68 sajcd • vol 59 • december 2012 cpd december 2012 1. true (a) or false (b): research has shown that very low birth weight has a severe impact on hearing. 2. true (a) or false (b): in developed countries like the usa hiv is included as a high risk factor for hearing loss. 3. true (a) or false (b): a study on neonates with very low birth weight showed that exposure to ototoxic medication was the most commonly occurring risk factor for hearing loss. 4. true (a) or false (b): context-specific risk factors are relevant for effective targeted hearing screening protocols. 5. true (a) or false (b): a study on neonates with very low birth weight revealed a statistically significant relationship between risk factors and distortion product otoacoustic emissions (dpoae) screening results. 6. true (a) or false (b): the relationship between language, mathematics and numeracy is well understood. 7. true (a) or false (b): internalisation refers to learning that occurs on a social plane. 8. true (a) or false (b): cognitive academic language proficiency (calp) typically precedes the development of basic interactive communicative skills (bics). 9. true (a) or false (b): research revealed that teacher expectations of learners’ achievement in low-income communities are typically low. 10. true (a) or false (b): owing to their cost-effectiveness, cochlear implants are used in high volumes worldwide. 11. true (a) or false (b): in the uk, individuals and families carry some direct costs for cochlear implant services. 12. true (a) or false (b): the first multi-channel cochlear implantation in south africa took place in 1989. 13. true (a) or false (b): the total cost for an adult cochlear implantation in south africa is less than for a child. 14. true (a) or false (b): a similar number of vowels are used in most spoken languages. 15. true (a) or false (b): a swahili screening test for speech in neurological disorders was developed for sole use by speech therapists. 16. true (a) or false (b): the swahili speech screening test included a swallowing assessment. 17. true (a) or false (b): the speech loudness of patients with parkinson’s disease and the control group differed significantly with the swahili speech screening test. 18. true (a) or false (b): stress and intonation patterns have an impact on the translation of english test items into isizulu. 19. true (a) or false (b): male participants often used the word ‘please’ during the translation of western aphasia battery (wab) test items. 20. true (a) or false (b): spatial release of masking (srm) refers to the improvement in speech perception as a result of spatial separation of speech and noise when listening with both ears. cpd questionnaires must be completed online via www.cpdjournals.co.za. after submission you can check the answers and print your certificate. the south african journal of communication disorders sajcd we are pleased to announce that the number of ceus per test has been increased to 5. 3 myrtle l. aron claire penn, ph.d (witwatersrand) head, department of speech pathology and audiology university of the witwatersrand, johannesburg professor myrtle lily aron retired this year after over thirty six years service to the profession of speech pathology and audiology in south africa. these four decades have been some of the most exciting and influential in the history of south africa and the development and growth of the profession during this time reflects the qualities, leadership and insight of a person particularly sensitive to the changing times and the needs of the country and its people. she was born in 1929 on the east rand, during the depression, and though she rarely makes reference to these difficult times, it is certain that her early childhood made her particularly sensitive to the needs of less privileged sectors of the population. she attended the university of the witwatersrand as a student in the sub-department of logopedics and its speech voice and hearing clinic under professor ρ de v pienaar, obtaining her ba logopedics in 1953. she continued to work in this department as an assistant supervisor until 1954 when she left for a year to work as a clinical speech therapist in the department of psychiatry at the university of toronto, canada. she returned to south africa and in 1956 embarked on her research for her master's degree which involved an investigation of the nature and incidence of stuttering among a bantu group of school-going children. this research, culminating in the award of a master of arts cum laude in 1959, was a seminal work in the area of stuttering and its measurement. still frequently cited in current stuttering tests, its findings as well as its rigorous attention to methodological issues placed south africa on the map in the field of stuttering. her research forj her doctoral degree which was awarded in 1964, was on the effects of the combination of trifluoperazine and amyloba'rbitcme on adult stutterers. while her research and teaching activities moved to other areas after this degree, her keen interest in the area of stuttering remained and was nowhere more evident than in the organization and planning of the department's jubilee international stuttering conference held at the university of the witwatersrand in 1986. while undertaking her research, she was employed in the subdepartment as a clinician and assistant supervisor (19561958) and then as a clinical lecturer and tutor (1959-1964). in 1964 she was awarded an ernest oppenheimer memorial trust award and a fullbright hayes travel grant in order to study in the field of audiology in the united states. she spent a year at the university of pittsburg and visiting training institutions in the united states and the united kingdom. on her return to south africa, she developed new courses in audiology and her influence in this aspect in the profession condie suid-afrikaansc tydskrif \ir kommitiiikitsirafirykiiiys, vol. 37, 1990 tinued to grow and develop. she was very active in the needs of the deaf in south africa and has written memory ndi#oη early intervention for the infant and young hearing impaired. she was a member of the audiological technical committee and steering committee on acoustics and noise abatement for the south african bureau of standards, and a fellow of the south african acoustics institute. her inaugural lecture, delivered in 1974, was entitled communication for the hearing impaired some plain talk, and presented some hard-hitting facts about the nature of deaf education in the country and some clear directions for its improvement. a significant step in her career and acknowledgement of her abilities came when the sub-department gained full status in july 1971 and became the department of speech pathology and audiology. shortly thereafter she was appointed as full professor and head of the department and director of the speech and hearing clinic, a post which she held until her retirement earlier this year. this acknowledgement of the department's independent status more or less coincided with the move of the department, previously housed in the library basement and then in yale cottage, to its present location the social sciences block. just as she was instrumental in creating the department spiritually, it is true to say that her role in the physical development of the new department was pivotal. she was involved in each step of its design and its construction and it has served as an impressive model for later student training facilities in this country. besides the many hundreds of undergraduate students who have passed through her hands and who will remember her lectures in a wide range of topics, she has been involved wit! the supervision of many postgraduate students. her keen inte rests in research methodology, together with her experience and her insights, both academic and emotional, were highl} valued by her postgraduate students. her involvement in the university and in broader issue: related to the community has been tireless. she stood on £ number of important university committees, including the boards of the faculties of arts and medicine. she resisted fre quent attempts by the university to change the faculty ο affiliation, and its close and lasting relationship to the arts faculty has been the hallmark of the course at wits and ofter the envy of other departments both locally and inter nationally. this close link with the humanities and with th« disciplines of psychology and linguistics particularly is a reflec tion of her attitude to life and particularly to rehabilitatior £ sash a 199c r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 claire penn other university committees on which she served during her career were the higher degreescommittee, the human ethics research committee, the executive committee of convocation, and the senate publications committee, as well as several scholarship awards committees. professor aron's long involvement in community issues has perhaps been nowhere more evident than in her efforts through the south african speech-language-hearing association to establish the two-year diploma course for speech and hearing therapy community workers. this course, which started at wits university in 1984, was the first of its kind in the world. its aim was to train persons who could identify and manage the communication problems of the broader community in south africa particularly in the rural'areas. this has proven to be very successful and at least 46 diploma graduates are now working in the field and providing a very important service to populations previously having no help. her own research and energy in this field has done a lot to establish the groundwork for this course and has provided directions for course content, training and employment opportunities. this has included field trips to gazankulu and the transkei where she has examined the need for essential services set up networks and set up long-term research plans. she is also a founder member of ruract (rural disability action group) and a member of the working group to consider an institute of urban primary health care based on the alexandra health centre. she was also requested to act as chairman of a coordinating committee of senior persons from the professions of occupational therapy, physiotherapy and speech therapy and audiology to explore and establish community rehabilitation education and training of rehabilitation workers in south africa. her efforts in this regard have been publicized internationally and have been presented at the international association of logopedics and phoniatrics congresses in tokyo (1986) and in czechoslovakia (1989). the course has been a model, not only for other professions but also for workers in other countries. it was also through her efforts that the unit for languageand hearing-impaired children was established at the university. now housed at the transvaal memorial institute this facility provides facilities for a number of preschool children who require a specially integrated approach to rehabilitation. for a long time the only such unit in the transvaal, it has provided an exceptional training and research facility for students and become a nationally recognized facility addressing a desperate shortage in this country. professor aron also instituted a long-term research programme on the development and maintenance of a computerized information retrieval programme of case data on communication disorders. this has been supported since 1975 by the human science research council and the programme has been extended to include case data on a national basis. this programme has successfully recently been transferred to the human sciences research council. in p'rofessional issues, professor aron has been active throughout her career. she was a student representative of the south african logopedic society in 1952 and the chairman of the first national speech therapy congress in 1953 as well as chairman of its academic activities committee. she has had many periods of chairmanship of the s a speech-languagehearing association (formerly the s a speech and hearing association) as well as editor of its journal (s a journal of communication disorders) and its monthly newsletter.she was elected as president of saslha in 1978. she has been regular chairman of standing committees of saslha to consider ethical, professional and training problems and is currently chairman of the research committee to promote and ' coordinate research in the field in southern africa. a bursary scheme administered by saslha was started in her name for students studying at universities in south africa a very fitting tribute for one who has so long been involved in student issues and concerns. she was a founder member of the council of allied medical professions and was appointed as first chairman of the professional board for speech therapy and audiology of the south african medical and dental council a position she has held from its establishment in 1976 until the present. by request of this board she drew up a memorandum on facilities and training for the j c de villiers committee of enquiry into further facilities for medical, dental and paramedical training in 1984. her international contacts have been very important for the professional in south africa and it is undoubtedly largely due to her efforts and her representation in washington dc in 1980, in tokyo in 1986, at meetings of the international association of phoniatrics and logopedics, together with contact with the american speechlanguage-hearing association from international participation. she has friends and colleagues all over the world and has lectured and travelled in sweden, denmark, britain, canada and the united states. the department and its graduates have an international reputation and the high quality of its training is world renowned. myrtle aron has been a leader in all fields of her profession. the hallmark of her contribution has been a clear and principled direction, a vision and an integrity. she has fought many battles, and has achieved widespread respect. she has done more than anyone to gain the profession its independent autonomous status. she has been an inspiration to all those she has taught and has set the highest standards for energy and dedication. her planned activities during her retirement thankfully mean continued involvement in many aspects such as teaching and research, and it is with gratitude that those of us who have to follow still have her direction, wisdom and experience vto' guide us. ' i list of publications of myrtle l. aron (not including abstracts, reviews, formal addresses, reports, ' memoranda, unpublished conference papers or commentaries) aron, m.l. stuttering therapy an integration of speech therapy and psychotherapy../. s.a. loi/opedic society, 4, 1, 3-8, 1957. bauman, s & aron, m.l. research needs in speech pathology. /. s.a loyopedic satiety, 6, 2, 1-5, 1960. aron, m.l. the nature and incidence of stuttering among a bantu group of school-going children../. speech and hearinq disorders (us). 27, 2, 116-128, 1962. ' x aron, m.l. the effects of the combination of trifluoperazine and amylobarbitone on adult stutters. medical proceedini/s, 11, 10, 227-237, 1965. / aron, m.l., bauman, s. & whiting, d. speech-therapy in the republic of south africa: its development training and organization of services. british /. disorders of "'communication, 2, 1, 78-83, 1967. the south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) myrtle l. aron aron, m.l. communication problems of the handicapped child. proceedings of the national conference on the hadicapped child, transoranje institute, pretoria, 1967. aron, m.l. the relationship between measurements of stuttering behaviour../. s.a logopedic satiety, 14, 15-34, 1967. aron, m.l. hearing screening and testing in infancy. public health, 72, 11, 335-341, 1972. aron, m.l. pierre de villiers pienaar (festschrift)../. s.a speech and hearing association. 20, 7-13, 1973. aron, m.l. approaches to the pre-school hearing impaired child. in proceedings of the national symposium on the organization of comprehensive autliological services in south africa. department of otorhinolaryngology, university of stellenbosch, cape, 3442, 1974. aron, m.l. communication for the hearing impaired some plain talk. inaugural lecture. witwatersrand university press, johannesburg, 1974. aron, m.l. language communication for the hearing impaired child: a perspective strategy. talk (royal national deaf children's society), 86, 19-22, 1978. aron, m.l. concepts underlying the develoment of a computer information retrieval programme for research in communication disorders. british j. disorders of communication, 16, 2, 89100, 1981. aron, m.l. the development of an information retrieval programme for various communication disorders. in proceedings of the 18th international association of logopedics and phoniatrics congress, washington, d c, august 1980, published as special edition by folia phoniatrica, 1981. anderson, d & aron, m.l. incidence and sex distribution of specific articulatory errors derived from a computerized information retrieval programme. humanitas. 9, 3, 365-374, 1983. aron, m.l. community work and speech therapy. in proceedings of the symposium on the role of the speech therapist in a multilingual society, pretoria july 1984. university of pretoria, 10-16, 1984. 5 aron. m.l. editor. the south african j. of communication disorders, 1971-1980, and 1984-1985. aron, m.l. community speech and hearing therapy: orientation and training. proceedings of the 20th congress of the international association of logopedics and phoniatrics, tokyo, japan: folia phoniatrica 1986. aron. m.l., smit, w. & allsopp, p. w1pcom manual for the computerized information retrieval programme of case data on communication disorders. department of speech pathology and audiology, university of the witwatersrand, johannesburg, 1986, isbn 0854949178. aron, m.l., lewis, r.e. & willemse ,j.l. the use of signs and the coding of prefix markers at a school for the deaf. s.a. jnl. communication disorders, 33: 64-72, 1986. aron, m.l. community-based rehabilitation for communication disorders. proceedings of the s.a. speech and hearing association national conference, pretoria, 1987. aron, m.l. data bank of communication disorders. research bulletin, 33-38, 1987. aron, m.l. opening keynote address of audiology congress. proceedings of the audiology congress, cape town, 1988. aron, m.l. communication rehabilitation for the hearing impaired adult with an acquired hearing loss. proceedings of the audiology congress, cape town. 1988. aron, m.l. rehabilitative procedures with the hearing impaired adult. proceedings of the 21st congress of the international association of logopedics and phoniatrics, prague, czechoslovakia. 1989. aron, m.l. implementation of community speech and hearing work in disadvantaged areas. proceedings of the 21st congress of the international association of logopedics and phoniatrics, prague, czechoslovakia, 1989. rosebank hearing aids extra strong to extra small!! suppliers of rexton, bosch, viennatone and microson hearing instruments. in-the-canal, in-the-ear, behind-the-ear, power body aids, tinnitus maskers, bone-conductors and cros instruments available. we have our own laboratory facilities on our premises 15 trupps centre 4 tyrwhitt avenue cnr jan'smuts avenue rosebank johannesburg p.o. box 2 1 1 0 parklands 2121 tel: (011) 8 8 0 4 5 8 4 / 5 fax (011) 8 8 0 7 3 1 1 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) this page is sponsored by the literary group (pty) ltd academic & medical booksellers johannesburg: campus bookshop 34 bertha street 2017 braamfontein westdene bookshop 7 ameshoff street 2017 braamfontein phone: (011) 339-1711 phone: (011) 339-3026 durban: logans westdene 660 umbilo road 1400 durban phone: (031) 253221 ext 22 cape town: westdene rondebosch 18 main road 7700 rondebosch phone: (021) 689-4112 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ^ p p t a n c e of deafness in deaf adolescents: a r e p e r t o r y g r i d s t u d y r t j a c q u e l i n e β a l l a n h n e b . s c . ( l o g o p a e d i c s ) . c a p e t o w n department of speech ^erapy, bjrag^anajhhospital, p.o. bertsham, 2013, ^ m < ! t d v investigated the acceptance and definition of deafness by deaf adolescents. a 6prtorv grid (rg) technique was administered to 27 moderate^ to profoundly r e p ired subjects attending orally directed schools. the responses ehciled indicated that t^siiblects ident'ified with neither deaf nor hearing persons, thereby denying their own rieafnms subjects also described deaf individuals (dis) negatively but maintained tivp self-concepts and displayed inadequate definitions of themselves and deafness^ ^ l d l s have distinct implications for the management of the di, with regard both to* assessment and therapy. results further demonstrated that the rg technique is an effective means to investigate the psychology of deafness. u w d i f s t o d i f ondersoek gehoorgestremde adolessente se aanvaarding en definisie van η nfietd 'n "repertory jid" (rg) tegniek is uitgevoer op 27 matig tot erg gehoort ™<ie. oroefnersote wat oraal georienteerde skole vir dowes bygewoon het. die response h^t aang^toon^ datdie proefpersone hulself nie met dowe of normaa horende netsone identifiseer nie aanduidend van ontkenning van hul gehoorgestremdheid. die nroeidersone he^ook "dowes" negatief beskryf, maar het positiewe selfkonsepte behou. c d e r h e t h u i e o o k swak o m s k n u g s van hulself en doofheid gedemonstreer. tterdie bevindinge h * duidelike implikasies vir die hantering van gehoorgestremdes wa be ef evaluasie en terapie. resultate het aangetoon dat die rg tegniek, effektiewehk aangewend kan word om die psigologie van doofheid te ondersoek. the disabled person has many adjustments to make. ultimately how he behaves will be influenced by his ability to i n t e g r a t e his handicap with the way in which he sees himself, sees others sharing his disability, and how he believes others, particularly tfiose closest to him, in a normal society view him and his handicap. . ... . u a number of studies examining adjustment to disability have shown that disabled persons do not identify themselves with others having s i m i l a r handicaps. for example, fransella' has found that stutterers see behaviours and characteristics typical of a "stutterer as unlike that f o ^ t h e d l a f individual ( d i ) there are many factors w h i c h influence how he is able to accept his deafness as an integral part of himself. these include his parents' reaction to the diagnosis of deafness, the philosophy of deaf education observed in the school he attends the reaction of peers to his deafness and his parents' ability to treat him and his siblings equally, particularly during a d o l e s c e n c e . furth believes this stage to be critical for acceptance of deafness and identification with the deaf community. h e maintains that in spite of a history of factors promoting denial of deafness, the di is nevertheless able to accept his handicap and hence identify with the deaf community. on the other hand, a number of authorities have emphasized the dangers of promoting separation between the deaf and hearing worlds. they argue that segregation is never complete. dis remain economically, financially and, to some extent, socially dependent on the hearing world. 4 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 jacqueline ballantine investigation of the extent to which dis do, in fact, accept their deafness at the critical stage of adolescence is a difficult task. measuring psychological parameters in dis by conventional psychological tests presents problems which can be mainly attributed to the dis linguistic and experiential limitations.7 this means that the norms of conventional tests, which were not originally intended for use with deaf populations, may prove ambiguous and invalid when used for interpreting scores obtained from dis. the repertory grid (rg) technique described by fransella and bannister2 appears able to overcome these difficulties. this technique is used to evaluate the psychological structure'of an individual's world as he defines i t . 6 the r g lends itself very well to investigation of di subjects for a number of reasons. test stimuli may be visually presented in the form of photographs thereby eliminating the need to simplify items to a linguistic level where the deaf subjects can understand them. very little linguistic load is placed on the subject allowing him to respond at his own level of competence. evaluation is achieved by means of a mathematically based model with no reference to norms standardized on "normal" or deaf populations. because of these advantages, the rg was selected as an appropriate technique for the present study, the two aims of which were: 1. to determine whether or not deaf adolescents identify with other dis, and hence accept deafness as an integral part of themselves, 2. to determine the way deaf adolescents describe the di, thereby gaining insight into their concept of deafness. m e t h o d o l o g y the subjects were 27 school children (10 male and 17 female) between the ages of 16 and 20 who were attending orally directed schools. all were prelingually deaf, having moderate to profound impairment. each subject intended to matriculate from high school and was following a conventional course of study. apart from deafness the subjects had no other physical handicap. a personal profile for each subject was developed from case histories detailing the home background, scholastic record, personality assessment and the nature of deafness. this information was obtained from school teachers and personal record files. the rg technique requires an interaction between what are termed "elements" and "constructs". in this study the elements were a set of ten full-face photographs of matriculant school children in uniform. there were five males and five females in the set. the children were not known to the subjects. similarly, there were ten constructs. two of these were supplied by the experimenter. these were "as i am" and "as a deaf person is". the other eight were elicited by presenting each subject with various combinations of three photographs (i.e. elements) and asking him to name some way in which two of the photographs appeared to be similar but nevertheless different in that respect from the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a c c e p t a n c e of deafness in adolescents 55 uη nhotoeraph. subjects were encouraged to answer in terms of t h e ahtv characteristics of the individuals in the photographs and not p e r s o n a h t y charac c h a r a c t e r i s t i c s . whatever c h a r a c t e r i s e was i n ' " t v he ubject was recorded as the emergent pole of the g , v e n ,t the opposite, as provided by the subject was recorded as c o n s p cit poleppthi p r o c e d u r e was repeated until eight constructs i v s n ellited to nfake a total of ten constructs with the two h a 'ηed constructs these constructs were now expressed as bi-polar provided constructs. _ u n f n e n d l o r h a s a m c e d t s " h a t a nice personality, and were then noted as personality " n e u t r a l " by a randomly selected group of e p n htaring i n d f v duals with the majority view prevailing. the s u b j e c t w e r e t h e n presented with all ten photographs and were r e q u i r e d ο i k t h e m from the one which was most like the emergent pole of e a c h instruct to that which was most unlike the emergent pole i.e that s c h was most like the implicit pole. this procedure was repeated for γ ί ten constructs and the ranked order of the constructs was recorded t h e ^ r ^ w e r e analysed using the ingrid 72 computer programme j o e c i a l l y designed for this purpose. this provided a set of product^ moment correlations expressing the degree of relationship between eacli construct and every other construct in the r g in addition wuhin each grid all the correlations of the constructs with construct 1 ( a s 1 am ) and with construct 2 ( " a s a deaf person is") were squared and summes this operation provided a measure of the extent to which a subject defined both himself and the d i . ? a e b l ^ p r s o v i d e s a summary of the constructs most frequently used by subjects to describe themselves and the d i . table i: c o n s t r u c t s u s e d m o s t frequently t o describe "self" and "the deaf individual" " t h e d e a f individual" u n h a p p y ( n e g a t i v e ) unlike self (neutral) u n e n t h u s i a s t i c ( n e g a t i v e ) unfriendly ( n e g a t i v e ) unhelpful ( n e g a t i v e ) angry ( n e g a t i v e ) u n e x c i t e d ( n e g a t i v e ) like self (neutral) friendly ( p o s i t i v e ) unintelligent ( n e g a t i v e ) happy (positive) n o t w o r r i e d (positive) w o r r i e d ( n e g a t i v e ) "self" friendly happy intelligent n o t a t r o u b l e m a k e r hearing n o t shy not angry not w o r r i e d popular has a nice personality deaf surprised confident ( p o s i t i v e ) ( p o s i t i v e ) ( p o s i t i v e ) ( p o s i t i v e ) ( p o s i t i v e ) ( p o s i t i v e ) ( p o s i t i v e ) ( p o s i t i v e ) ( p o s i t i v e ) ( p o s i t i v e ) (neutral) (neutral) ( p o s i t i v e ) die suid-afrikaanse t y d s k r i f vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 5 6 jacqueline ballantine two important findings emerge from table i. 1. eleven of the thirteen constructs most frequently used by subjects to describe themselves are positively rated. 2. of the thirteen constructs most frequently used by subjects to describe the di, eight were rated as negative, three as positive and two as neutral. this in effect means that whereas the subjects described themselves in positive terms, they nevertheless described the di in predominently negative terms. in addition, of the 27 subjects, 19 aligned themselves with neither deaf nor hearing persons (p < 0,05). only one subject aligned himself with hearing persons (p < 0,01) while another aligned himself with the di (p < 0,01). no definitive statement could be made about the other six subjects. the mean correlation between construct 1 ("as i am") and construct 2 ("as a deaf person is") was -0,0358. therefore the majority of subjects can be described as having placed themselves approximately equidistant from both deaf and hearing individuals. in addition, the relationship between subjects' acceptance of deafness and their self-definition and definition of the di was investigated. the measurement of acceptance of deafness was provided by the correlation between "self" and "the deaf individual" (i.e. constructs 1 and 2). it was found that subjects who defined themselves inadequately tended to be unaccepting of their deafness as part of themselves (p < 0,001). the same trend was also found among subjects who defined the di inadequately (p < 0,01). furthermore, those subjects who defined themselves inadequately also tended to define the di inadequately (p < 0,05). discussion this study has revealed three main findings about deaf subjects and their reactions to their handicap. 1. subjects identified with neither deaf nor hearing persons and described themselves as equally distant from each of these groups. this finding suggests that the subjects neither accepted their deafness nor conceptualized themselves to be hearing. this is contrary to reports in the literature which maintain that in spite of many influences in society promoting an attitude of denial by the di towards his deaf status, the di nevertheless is able to adjust to and accept his handicap.3 the findings of the present study suggest that these influences do predominate and serve as the basis for the di's denial of his disability. 2. subjects described the characteristics and behaviours typical of the di as unlike that of their own. furthermore, the di was described in predominantly negative terms, whereas the subjects described themselves positively. this finding is consistent with other rg studies investigating reactions of handicapped persons towards their disability.1 subjects have the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acceptance of deafness in adolescents 57 d e s c r i b e d the di as "unhappy", "unlike self", "unenthusiastic", " u n f r i e n d l y " and "unhelpful". o n the other hand, they have des c r i b e d themselves as "friendly", "happy", "intelligent", "not a t r o u b l e m a k e r " and "hearing". consequently subjects have seen themselves as distinct from the di, a finding that is logically consistent with their denial of deafness. in addition, they have seen themselves positively and rejected the di and therefore deafness. 3 the majority of subjects, who showed little or no identification with hearing or deaf persons, tended to have poorly developed descriptions of both themselves and the di. this trend shows that subjects defined both themselves and the di weakly. inadequate definition of the di is suggestive of inadequate definition of deafness and hence a lack of insight among subjects into the meaning of their disability. these findings have important implications concerning the status of the di's self-concept. in the present study, it has been shown that subjects described themselves in positive terms suggesting that subjects possessed positive self-concepts. these self-descriptions, however, were found to be inadequately defined and associated with a lack of insight into and rejection of deafness. this reaction indicates a denial of reality and the stability of such self-concepts must therefore be questioned. in summary, these findings suggest that subjects were experiencing an "identity crisis" concerning themselves, their deafness and how it affects their roles in relation to other deaf and hearing persons. such a trend has important implications for the adjustment of these subjects in the world dominated by hearing persons. as all subjects expressed intentions of securing jobs which will necessitate integration into the hearing world, this issue is crucial to their future adjustment and success. implications of t h e study implications of the present study appear to be two-fold. firstly, the study has shown that deaf adolescents in this sample have been unable to accept their disability. this is contrary to views expressed in current literature. furthermore, as furth 3 has advocated, promoting acceptance of deafness as the top priority in the management of the di, it appears important to incorporate the findings of the present study into both assessment and therapeutic tools for dealing with the di. secondly, this study has demonstrated that the rg provides an effective means for evaluating psychological parameters among deaf subjects. this applies not only to the field of research but equally to assessment and therapy. rgs have been shown to be effective as assessment and therapeutic tools in dealing with disorders ranging from stuttering to schizophrenia.2 in each of these areas, the psychology of die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 jacqueline ballantine the di has previously proved to be an intangible and elusive area of investigation. the rg provides a means of overcoming these difficulties. references 1. fransella, f. (1968): self concepts and the stutterer. british journal of psychology, 114: 1531-1535. 2. fransella, f. and bannister, d. (1977): a manual for repertory grid technique. academic press. 3. furth, h. (1973): deafness and learning — a psychosocial approach. california. 4. heider, g. m. (1967): adjustment problems of the deaf child. m. fusfield, i.s. (ed). a handbook of readings in education of the deaf and post-school implications charles c. thomas. 5. saflios-rothschild, c. (1970): the sociology and social psychology of disability and rehabilitation, random house, inc. 6. slater, p. (1972): notes on ingrid 72. st. george's hospital, london. 7. vernon, m. and mindel, e. (1978): psychological and psychiatric aspects of profound hearing loss. in rose, d. e. (ed.) audiological assessment, (2nd ed.) prentice-hall, inc., 128-130. the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) r e p u b l i c a h e a r i n g a i d c o n s u l t a n t s t p t y ) l t d . 7 3 2 m e d i c a l c i t y e l o f f c o r . j e p p e s t r e e t j o h a n n e s b u r g , t r a n s v a a l t e l e p h o n e 2 3 6 6 8 5 p . o . s o x 5 2 0 4 1 s a x o n w o l d 2 1 3 2 h e a r i n g aids. w e s p e c i a l i z e i n t h e supply and fitting of hearing a i d s for all hearing losses, especially for nerve deafness recruitment bone conduction cases. c r o s s a i d s : c r o s b i c r o s m u l t i c r o s etc. b o n e c o n d u c t i o n a i d s for body, earlevel, glasses (speciality by viennatone) b i n a u r a l f i t t i n g s we import and stock : viennatone, qualitone, microson, phonak hearing aids. m o u l d s : soft, hard, skeleton, vented, occluded etc. r e p a i r s : a l l aids supplied with a scientific performance report after repair. s p e c i a l p r i c e s for dealers and institutions. a c c e s s o r i e s : teacher pupil, parent child, individual audiotrainers, very reasonably priced. group a u d i o trainers. t v wireless infrared transistor receiver sets made by s e n n h e i s e r . audiometers: screening, diagnostic, research, e r a and electrocochleography c . o . r . and peep show. impedance bridges. manufacturers of sound proof booth and sound proof rooms. hearing a i d testing set by " f o n i x " u . s . a . phonak noise generator with different frequencies, pure tone and warble tone, for everyday's use. we repair and calibrate audiometers. sound level meters, calibrators. industrial noise consultants. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28,1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) post-laryngectomy t h e r a p y : a communication a p p r o a c h erna alant m a . ( l o g . ) ( p r e t . ) department speech pathology and audiology, university of the witwatersrand, johannesburg summary this article deals with the interpretation of post-laryngectomy therapy within the framework of communication. the communication approach towards rehabilitation emphasizes the necessity of incorporating verbal communication and non-verbal communication into the diagnostic and therapy procedures because of the close link between the two modes of communication. diagnosis and therapy are discussed in terms of communication skills, social and personal sensitivity and tension. throughout the article, the stress is on the therapist's creative role in the laryngectomy patient's construction of reality. opsomming die artikel handel oor die interpretasie van post-laringektomie terapie binne die raamwerk van kommunikasie. die kommunikasie benadering tot rehabilitasie beklemtoon die noodsaaklikheid van die interpretasie van verbale sowel as nie-verbale kommunikasie in terapie. die noue verband tussen verbale en nie-verbale kommunikasie in die algemene kommunikasiepatroon van die individu noodsaak dit. diagnose en terapie word bespreek in terme van kommunikasie vaardighede, sosiale en persoonlike sensitiwiteit sowel as spanning. dwarsdeur die artikel is die klem op die terapeut se kreatiewe rol in die laringektomie pasient se konstruksie van realiteit. communication is seen as the process of creating meaning intersubjectively;1'4 it is the way in which the individual interacts with the people and "things" around him in order to achieve a situation that makes sense to him. furthermore, meaning is achieved by using verbal and non-verbal means. verbal communication is usually taken to be the most important mode of communication, and it has therefore been the focus of rehabilitation procedures over a number of decades. 1 4 although one could not deny the importance of verbal interaction, it is important to interpret and diagnose a communication problem within the framework of the overall communication pattern of the individual.1 6 when dealing with the problem of the laryngectomy patient and the sudden trauma of "not being able to: speak", the therapist tends to start remediating on the. immediate problem which is vocal sound p r o d u c t i o n . 6 ' 1 0 | the communication process is disturbed because of a sudden inability of the individual to communicate vertjally as before, and because of the close link between verbal and non-verbal communication the loss of speech also impairs the patient's non-verbal means of expression.5 the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication and laryngectomy 101 interaction between the individual and his fellow-men changes, not only because of the different speech pattern and voice the patient has acquired in the process, but also because of the changed conceptions of 'self' and 'other' amongst all participants in the social situation. boone 6 stresses that rehabilitation starts when the surgeon tells the patient that he has cancer. this approach to laryngectomy therapy emphasizes the need for psychological counselling of the patient as well as his family. counselling does not only include talking about the operation, but also preparing the patient and his family for the varied consequences of the operation., the emphasis in laryngectomy therapy over the last decades was on counselling the patient and his family and applying techniques to re-initiate verbal communication (by means of esophageal speech, artificial larynx etc.). as dietrich and strom9 point out: we have a greater responsibility to the laryngectomee than just teaching him how to produce sounds or even simple words. the main concern is for the patient to be intelligible and that the quality of his speech should be socially acceptable in order for him to be able to go back to his previous work situation. although the above approach sounds logical, interaction is defined in terms of verbal communication (vc) only. the implication is that the patient has "lost speech" and should be able to interact without strain as soon as he can "speak again". the therapist will focus on counselling the patient on the physical difficulties he might have with his stoma etc. however, the influence that the problem will have on his general interaction with people on account of the different way in which they will perceive him, as well as his changed perception of himself, is neglected. also, the communication pattern of the individual (although he might be a good esophageal speaker) will be changed due to the intricate relationship between verbal and non-verbal communication. to concentrate only on verbal rehabilitation is thus not aiding the communication process to the fullest extent. the verbal communication of the patient will never be the same as before the operation, for example, stress patterns become more difficult, frequently there is a drastic reduction in the speech rate, pauses increase, pitch becomes lower. in order for the patient to communicate effectively, non-verbal communication (nvc) will have to be adjusted in order to support verbal communication. although one could argue that this might happen spontaneously, there is no guarantee that this will happen. further the therapist could facilitate this process. the communication approach towards therapy stems from the realization that a patient's social participation would be the basic focus of therapy and not merely the improvement of his/her verbal ability. this means that the therapist herself has to achieve understanding and awareness of the underlying sensitivities of the patient's situation in order to be able to rehabilitate communication. this, amongst other things, would imply that the therapist does not die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 102 erna alant approach the therapeutic situation in a clinical (technical) manner but rather attempts to situate the therapy within the life-world of the patient. let us now be more explicit about the criteria for evaluating the communication of a laryngectomy patient. the communication of a laryngectomy patient could be diagnosed according to communication skills, social and personal sensitivity and tension. communication skills this would include analysing his verbal and nonverbal communication skills as well as the way in which the patient combines both in daily interaction. verbal communication analysis speech: the articulation of the patient should be assessed as well as the air-intake method. berlin3 describes further criteria for evaluating speech production in laryngectomy patients by measuring the latency period between the air intake and the production, ability to phonate reliably on command, maintenance of an optimal duration of phonation, speech rate etc. language: this is important in that clear verbal expression can facilitate overall communication. bad speech habits, for example frequent repetitions, ungrammatical utterances could indeed impede communication.1 paralanguage: this is particularly important because esophageal speakers frequently have difficulty in maintaining sufficient loudness throughout conversations. pitch changes and intonation are also difficult due to frequent pauses and slowed speech. 1 5 nonverbal communication analysis: in this section the therapist would analyse what kind of nvc the patient uses, for example gestures, facial expressions, leg and foot movements and body shifts. she would also attempt to analyse the function of these nvc's in supporting verbal communication,2 completing the verbal messages, substituting for verbal communication or facilitating the actual production of esophageal s p e e c h . 1 2 this last aspect becomes increasingly important when evaluating excessive tension and effort in the production of esophageal speech. excessive tension might manifest itself in, for example facial distortion and body shifts. / / : / social a n d personal sensitivity j apart from verbal and nonverbal skills, effective communication also demands awareness or sensitivity to the needs of others as well as the needs of oneself.1 in the case of the laryngectomy patient this aspect is no less important than the actual improvement of communication skills. it is vital that the patient is aware of how others perceive the problem and how they define his communication problem. accordingly therapy should facilitate his reactions and responses in interpersonal the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication and laryngectomy 103 contacts.2 at the same time, the patient should be aware of what he wants to achieve and how this could be done realistically. social sensitivity would include-aspects like, the following: how aware is the patient of the social demands on him? does he frequently interact with people? is he ashamed of his stoma? does he tend to cover the stoma with cravats that are socially attractive but uncomfortable? to which extent is he changing his behaviour in order to be accepted by other groups? for example, does he identify and become actively involved in the local laryngectomy society or any other organization of this type? personal sensitivity could include the following: how aware is the patient of himself, his problem and its implications for his life style? can he still actively participate in the activities that he enjoys? can he initiate conversations? how expressive is he of how he feels and experiences his problem? how motivated is he to overcome the problem? it is difficult to be dogmatic about the distinction between social and personal sensitivity as they are interrelated. the therapist should, however, aim at devising criteria which could distinguish between a predominantly social or predominantly personal sensitivity. tension various authorities in the field of laryngectomy emphasize the importance of tension management in effective communication (good esophageal speech production).6' 1 0 ' 1 5 tension is important due to the influence on the performance of the cricopharyngeal muscle when producing esophageal speech. excessive tension could result in excessive stomal noise, audible intake of air, indigestion problems due to swallowing of air etc. it is important that the therapist identifies the way in which tension manifests itself in the patient. tension does not only hinder the effective production of esophageal speech, it also impedes overall communication on different levels, for example the individual's limited sensitivity towards others and himself. table i summarizes the diagnostic procedures: principles of rehabilitation from the diagnostic procedures three basic areas of rehabilitation emerge: improving communication skills the improvement of verbal and nonverbal skills entails the identification of ineffective verbal and nonverbal communication, behaviour change and the development of more effective communication strategies. in the laryngectomee's case this would include verbal rehabilitation including other verbal communicative aspects such as intonation, language etc. most of these aspects of therapy could be done by auditory training and self-monitoring. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 104 erna alant t en si on c op yi ng de vi ce s sh ou ld b e ev al u at ed ac co rd in g to v c a nd n v c t en si on a m ou n t r ef le ct ed in ov er al l v c an d n v c b eha vi ou r c om m un ic at io n sk il ls n on -v er b al f un ct io n c om pl et in g v c sy nc hr on iz in g f ee db ac k/ re in fo rc em en ts a tt en ti ve n es s p ro du ct io n of sp ee ch c om m un ic at io n sk il ls n on -v er b al t yp e f ac ia l ex pr es si on g es tu re s e ye c on ta ct p os tu re s l oc om ot io n p ar ak in es ic s p ro xe m ic s c om m un ic at io n sk il ls v er ba l p ar ala ng ua ge r hy th m i nte ns it y p it ch si le nc es a cce nt e m bo lo ph ia si a o no m ato p ei oa c om m un ic at io n sk il ls v er ba l l an gu ag e l an gu ag e st ru ct ur e us ed c om m un ic at io n sk il ls v er ba l sp ee h p ro du ct io n of sp ee ch s ou nd s se ns it iv it y s oc ia l a w ar en es s of th e n ee d s of ot he rs se ns it iv it y p er so na l i a w ar en es s of ow n n ee d s \ \ si tu ati on s oi γλ 1 s yn th es is d es cr ib ed ac co rd in g to se ns it iv it y an d co m m un ic ati on s ki lls the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication and laryngectomy 105 the reconstruction of non-verbal systems has until now received very little attention in therapy; this could partly be due to the fact that it is difficult to standardise non-verbal communication patterns as these do not seem to be as readily objectifiable as verbal speech patterns. it is important that the therapist therefore not only studies the personal non-verbal style of the patient, but also acquires sensitivity to the demands of the patient's new situation. the therapist thus helps the patient to enhance his/her non-verbal skills in order to compensate for the loss of verbal facility and so to 'complete' the verbal message. this can be done by using video tapes, slides or any other visual presentation that could facilitate the explanation and observation of non-verbal communication. by explaining how non-verbal means can contribute to more effective communication, the therapist can encourage the patient to experiment in order to change and improve his own pattern of interaction. increasing social and personal sensitivity in this part of therapy, the therapist should aim at making the patient more aware of himself and others. this could be done in conjunction with the identification and modification of verbal and non-verbal skills. therapy would focus on interpersonal perception and how behaviour could be interpreted meaningfully in order to enhance interaction and understanding. social perception would include the following: how do others perceive my problem, and how can i according to that facilitate interaction with them? personal perception would include: what does the patient find particularly difficult in situations and how can interaction in the situation be facilitated, thus how can i handle situations that are difficult for me? relaxation relaxation is included in many therapy programmes with laryngectomy patients. checklists could be used for identifying and improving relaxation. in accordance with the normal process of rehabilitation the first step will be the identification of tense areas, then on the basis of this, the formulation of a relaxation programme. the discussion on general versus specific relaxation is important here and should not be neglected.1 1 most patients have difficulty with specific relaxation without the background of general relaxation. on the whole long and cumbersome general relaxation programmes can be very discouraging and demotivating on account of the apparent concentration on techniques not directly related to communication rehabilitation. it is important to be able to incorporate relaxation in a way meaningful to the patient. the procedures suggested by jacobson 1 1 do not necessarily apply to all patients. the therapist should have the insight into relaxation therapy to compile a realistic relaxation programme for the die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 106 erna alant patient that will also facilitate relaxation in everyday life. techniques like breathing, counting and associations, together with physical relaxation could indeed be included in a relaxation programme that will not demand more than twenty minutes of the patient's time. as the patient becomes more familiar with relaxation, the aim would be to shorten this programme even more in order to facilitate its use in everyday life. relaxation therapy on its own is of little value unless the therapist is able to aid the patient in incorporating relaxation into his daily life in a way that is meaningful to him. what the writer has attempted to do should be seen as a tentative attempt to rethink the therapist's creative role in the laryngectomy patient's construction of reality. whether we like it or not, we, the therapists, are involved in much more than the technical reconstruction of vocal sounds: we are actually deeply involved in the reconstruction of our patients' everyday lives. and that this fact should be our focal point, constitutes the core of the present argument. references 1. alant, e. (1979): speech and language pathology and communication. ma thesis, speech therapy, speech science and audiology department, university of pretoria. 2. argyle, m. (1969): social interaction. methuen-london. 3. berlin, c. i. (1965): clinical measurement of esophageal speech. j. speech hear. dis. vol. 30, no. 2. pp. 174-183. 4. berlo, d. k. (1960): the process of communication holt, rinehart & winston: new york. 5. boase, p. h. (1964) & eisenson, j.: basic speech macmillan n.y. 6. boone, d. r. (1977): voice and voice therapy prentice-hall: new jersey. 7. cook, m. (1971): interpersonal perception. penguin: london. 8. damste, p. h. & de zaayer, c. & kuiper, f. d. & scholtens, b. (1978): het werken met gevorderde gelarymgectomeerden met behulp van een spraakbeoordelingslijst. logopedie en fonratrie vol. 50, no. 7/8 pp. 277-282. 9. diedrich, w. m. & strom, k. a. (1966): alaryngeal speech charles, c. thomas: springfield. 10. greene, m. (1980): the voice and its disorders, pitman medical: kent. 11. jacobson, e. (1976): you must relax, mcgraw-hill: new york. 12. kendon, a. (1972): some relationships between body motion and speech, in siegman, a. w. and pope, p. (eds.), studies in dyadic communication. pergamon press: elmsford. 13. nagel, r. f. (1963): against pre-laryngectomy counselling. j. speech hear dis., vol. 28. 1 14. perkins, w. h. (1977): speech pathology c. v. mosby & co: st. louis. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication and laryngectomy 107 15. rigrodsky, s. (1971): therapy for the laryngectomized patient. teachers college press: columbia. 16. silverman, f. h. (1980): communication for the speechless, prentice-hall: new jersey. 17. snidecor, j. c. (1969): speech rehabilitation of the laryngectomized, charles, c. thomas, springfield. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 25 die voorkoms en aard van gehoorprobleme en middeloorpatologiee by 'n groep swart stedelike kinders in graad i mirna nel, β log (pretoria)* willem odendaal, mb chb μ med (orl) (pretoria) marina hurter, β log (pretoria)* santie meyer, μ log (pretoria)* anita van der merwe, dphil (pretoria)* *departement spraakheelkunde en oudiologie, universiteit van pretoria departement oor-, neusen keelheelkunde, universiteit van pretoria opsomming die doel van die studie was om die aard en prevalensie van middeloordisfunksie by graad i stedelike swart kinders te bepaal. 146 kinders uit. 'n primere skool het 'n oor-,neusen keelondersoek, suiwertoonen immittansiemetings ondergaan. 92,8ψο van die ore was beide otologies en oudiologies normaal. die prevalensie van middeloorpatologie was 7,2ψο. die algemeenste middeloorpatologie was sereuse otitis media. uit die 292 ore het 18 ore met sereuse otitis media, 2 met 'n retraksie van die timpaniese membraan en slegs 1 met 'n perforasie voorgekom. abstract the aim of the study was to determine the type and the prevalence of middle ear dysfunction in grade 1 urban black children. 146 children attending a primary school received an ear, nose and throat examination as well as pure tone and immittance screening. 92,8ψο of these ears were otologically and audiologically normal. the prevalence of middle ear pathology was 7,2ψο. serious otitis media was the most common middle ear pathology (18 out of 292 ears testedj. only 2 retracted tympanic membranes and one perforation were noted. middeloorpatologie, en meer spesifiek otitis media, is 'n kindersiekte met 'n baie hoe voorkoms, veral by kinders i van ses jaar en jonger (mcshane & mitchell, 1979). otitis media toon 'n hoe voorkoms in gebiede waar mediese sorg ontoereikend is en die populasie onbewus is van die implikasies van die toestand (northern & downs, 1984). wilson (1985) se dan ook dat otitis media 'n hoe voorkoms het in gebiede waar daar| baie infeksies, ondervoeding en swak higiene voorkom. inlhierdie verband het verskeie oorsese studies al getoon dat in lae sosio-ekonomiese bevolkings 'n hoe voorkoms van middeloorpatologiee voorkom, en die bevolkingsgroepe sodoende hoerisikogroepe vir die siekte is (corth & harris, 1984; northern, 1978; wilson, 1985). indien otitis media chronies voorkom, veroorsaak dit 'n gehoorverlies, maar kan ook sekondere probleme veroorsaak, naamlik vertraagde taalontwikkeling (holm & kunze, 1969), ouditiewe perseptuele probleme (holm & kunze, 1969), verminderde intellektuele vermoens (downs, 1977), swak akademiese prestasies (gottlieb, 1979; kaplan, 1973) en gedragsen emosionele probleme (gottlieb, 1979). bess (1985) se dat "more than thirty studies covering approximately 3 500 children have agreed that a relationship exists between early fluctuating hearing loss and later decreased learning skills." (p.44.) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 die rede vir bogenoemde sekondere probleme kan waarskynlik toegeskryf word aan periodes van ouditiewe deprivasie wat veroorsaak word deur chroniese of herhaalde episodes van otitis media in die vroee kinderjare. "deprivation would seem to have at least two impacts: the retardation of language and learning potential and the direct effect on the auditory system itself." (glorig en gerwin, 1974, p.5.) uit die voorafgaande bespreking is dit dus baie duidelik dat otitis media so vroeg as moontlik opgespoor en behandel moet word ten einde die negatiewe sekondere gevolge te verhoed. dit is derhalwe belangrik dat hoerisikopopulasies geidentifiseer moet word, sodat konserveringsmaatreels getref kan word. die lae sosio-ekonomiese toestande van 'n groot deel van die swart stedelike bevolking in suid-afrika — maak van hulle ook 'n hoerisikobevolking. hulle het 'n hoe populasiegroei, swak behuising en ontspanningsgeriewe, 'n lae algemene gesondheidstoestand en 'n lae inkomste (morris, 1980). alhoewel daar nie 'n sosio-ekonomiese opname vir mamelodi beskikbaar is nie, word die gemiddelde sosioekonomiese omstandighede van die gebied ook as laag in vergelyking met ander rassegroepe in die omgewing gesien. die indikatore waarvolgens dit beoordeel word, is inkomste, opvoedkundige standaard en gesondheidstatus. werkloosheid, onstabiele gesinslewe en oorbehuising kom ook voor (morris, 1980; van der walt, 1987). © sasha 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 mirna nel, willem odendaal, marina hurter, santie meyer en anita van der μ min inligting is tot dusver bekend ten opsigte van die voorkoms van middeloorpatologie by swart stedelike kinders in s.a. (voogt, halama & van der merwe, 1986). eksperiment proefpersone 'n primere skool vir normaalhorende swart kinders is deur middel van 'n eenvoudige ewekansige steekproef geselekteer van die primere skole in mamelodi, naby pretoria. a1 die graad i kinders in die skool is in die eksperiment gebruik. 'we ting is gedoen by 500 hz, 1000 hz, 2000 hz en 4000 hz in them en downs, 1984). 'n onderwyseres is gebruik om & kinders te help kondisioneer vir toetsing en ook om a<tt 1\t op te tree. k analise van die data gehoorsensitiwiteit soos bepaal met suiwertoonsiftineto sing is as normaal beskou indien die proefpersoon respons gelewer het by 500 hz, 1 khz, by 20 db gp en 25 db gp ^ 4 khz volgens asha riglyne (aangehaal in northern p ! downs, 1984). n tabel 1: voorstelling van relevante gegewens omtrent die proefpersone in die geval van immittansiemetings behaal die persoon normale siftingsresultate as 'n tipe a-timpanogram, met η piek tussen +100 mmh ο en -100 mmh o, opgeteken word en 'n akoestiese refleks by 105 db gp of laer by 1000 hz ontlok word (asha riglyne, aangehaal in northern en downs, 1984; bess en mcconnell, 1981). 'n proefpersoon behaal afwykende siftingsresultate indien die refleks afwesig is selfs in die teenwoordigheid van 'n tipe a-timpanogram en/of 'n tipe as-, ad-, bof c-timpanogram verkry word (jerger 1970). resultate en bespreking ouderdom in jare manlik vroulik totaal 5 1 2 3 6 40 40 80 7 27 18 45 8 5 4 9 9 4 2 6 10 2 1 3 totaal 79 67 146 apparaat die apparaat wat vir die oor-neus-en-keelondersoek gebruik is, is standaardapparaat, naamlik 'n koplig, neusspekulum en otoskoop. 'n draagbare siftingsimmittansiemeter, die grason stadler, inc gsi 28a, is vir die immittansiesiftingsmetings gebruik. die meter is geyk volgens iso 1975 standaarde. die apparaat vir die siftingsuiwertoonondersoek was 'n madsen electronics ob40 draagbare oudiometer. die/oudiometer is volgens sabs 0154—1983 aangepas en volgens 1986 standaarde geyk. / toetsing is in 'n stil vertrek, weg van die klaskameren speelgrondlawaai, uitgevoer. prosedure die studie is in die vroee herfs uitgevoer voordat die voorkoms van boonste lugweginfeksies en gepaardgaande middeloorpatologie in voorkoms toeneem. elke kind het 'n oor-neus-en-keelondersoek ondergaan deur 'n oor-, neusen keelarts van die departement oor-, neusen keelheelkunde, aan die universiteit van pretoria. oormatige oorwas is verwyder sodat immittansiemetings suksesvol uitgevoer kon word. die otoskopiese bevindinge is aangeteken. siftingsimmittansiemetings is daarna uitgevoer. hierdie metings sluit timpanometrie, meting van statiese akoestiese immittansie en akoestiese refleksmetings in (northern en downs, 1984; bess en mcconnell, 1981). die akoestiese refleksmetings is ipsilateraal, by 'n 1000 hz en 105 db gedoen (northern en downs, 1984). daarna het die suiwertoonsiftingstoets gevolg. gehoorsiftabel 2: suiwertoonen immittansiesiftingstoetsresultate oudiometriese resultate aantal kinders ν = 146 % n o r m a le r e su l t a t e normale suiwertoonen immittansieresultate 106 72,6 a fw y k e n d e r e su l t a t e afwykende suiwertoonen normale immittansieresultate, d.w.s. sensories neurale betrokkenheid 0 0 a fw y k e n d e r e su l t a t e normale suiwertoonresultate maar afwykende immittansieresultate, d.w.s. middeloordisfunksie sonder 'n gehoorverlies 37 25,3 a fw y k e n d e r e su l t a t e afwykende suiwertoonen immittansieresultate, d.w.s. geringe gehoorverlies met 'n middeloordisfunksie 3 2,1 subtotaal 40 27,4 in tabel 2 word die oudiometriese siftingstoetsresultate vir die 146 kinders uiteengesit. uit tabel 2 blyk dit duidelik dat 72,6% van die kinders normale resultate in die oudiometriese siftingsondersoeke behaal het. hierdie betreklike hoe slaagsyfer is teen die v e r w a g t i n g in, omdat ander studies wat ook op lae sosio-ekonomiese populasies uitgevoer is, se normale resultate dikwels laer as 72,6% is, byvoorbeeld by die indo-chinese v l u g t e l i n g k i n ders is die slaagsyfer vir siftingsgehoortoetse 31,2% (corth harris, 1984) en by 'n spesifieke groep venda p l a t t e l a n d s e kinders in die dzanani distrik (oosthuizen, 1986) 48,3%· the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die v o o r k o m s e n aard van gehoorprobleme en middeloorpatalogiee by 'n groep swart stedelike kinders 27 en is daar ander studies van lae sosio-ekonomiese ^ l t s i e s in suidelike afrika wat ook 'n hoe persentasie p le resultate vertoon, byvoorbeeld 'n groep plattelandn 0 i v n d a kinders van tshikunda-malema 78% (meyer en s 6 den berg, 1985) en by graad i kleurlingkinders, van p 3 " terus buite pretoria, 86,4% (meyer, hurter & van rens1987) die 72,6% normale resultate van die swart stehehke bevolking, vergelyk dus goed met laasgenoemde twee studies, wat albei ook in suidelike afrika gedoen is. uit tabel 21 blyk dit duidelik dat 27,4% van die kinders in 1 of beide ore afwykende oudiometriese resultate vertoon daar is geen voorkoms van afwykende suiwertoon, en normale immittansiesiftingsresultate nie, dit wil se geen sensories neurale betrokkenheid is by die eksperimentele groep gevind nie. daar is egter 'n voorkoms van 25,3% wat normale suiwertoonsiftingsresultate, maar afwykende immittansiesiftingsresultate vertoon en wat daarop dui dat 'n moontlike middeloorpatologie teenwoordig is. slegs 2,1% van die kinders vertoon afwykende suiwertoonen afwykende immittansiesiftingsresultate wat waarskynlik dui op gevorderde middeloorpatologie by hierdie kinders. die hoer voorkoms van middeloorpatologie teenoor sensories neurale gehoorverlies stem ooreen met vorige navorsing van harvey en wilmot (1969). hulle navorsing dui daarop dat in die skoolgaande populasie, meer as sowat 70% van alle gehoorprobleme die gevolg is van middeloorpatologie. dit is opvallend dat 37 kinders uitvalle toon op slegs immittansiesiftingstoetsresultate, maar die suiwertoonsiftingstoets slaag. hulle toon dus tekens van middeloorprobleme, sonder dat hulle gehoorsensitiwiteit beduidend verswak het. hulle mag egter wel gehoorverliese kleiner as 20 db gp getoon het indien suiwertoondrempels bepaal is. dit bevestig brooks (1980) se stelling dat baie kinders met middeloorpatologie se gehoor as normaal beskou sou word indien immittansiemetings nie deel van die toetsbattery sou wees nie. altesaam 27,4% van die kinders vertoon uitvalle op die immittansiemetings. alhoewel die persentasie hoer is as die 14,9% van voogt, et al. (1986) se voorskoolse swart kinders, is die resultate nie direk vergelykbaar nie, aangesien die slaag/faal-kriteria in die 2 studies verskil. in tabel 3 word die aantal ore sowel as die % ore ten opsigte van die oudiometriese sowel as die otologiese resultate aangetoon. vir die diagnose van sereuse otitis media is van cantekin (1983) se algoritme gebruik gemaak. uit tabel 3 blyk dit dat 77,7% van die ore beide oudiologies en otologies normaal is. vier en veertig (15,1%) van die ore wat egter uitgeval het op die suiwertoon-en immittansiesiftingstoetse is egter ook otologies as normaal bevind sodat 92,8% van die populasie otologies normaal was. hieruit volg dat die prevalensie van middeloorpatologie 7,2% is. die tipe middeloorpatologie wat die algemeenste voorkom is sereuse otitis media (6,2%). slegs 1 perforasie het voorgekom. uit ander navorsing in verband met sereuse otitis media en perforasies blyk die volgende: die voorkoms van slegs perforasies onder navajo sk6olkinders was 14%, eskimo kinders 32%, alaskaanse kinders 17%, amerikaans-indiaanse kinders 6,5% en soshanguve kleuters 1,6% (northern, 1978; voogt, et al. 1986; howie, 1977; johnson en watrous, 1978). die voorkoms by die getoetse mamelodi kinders was slegs 0,3%. die voorkoms van sereuse otitis media by die mamelodi kinders (6,2%) is ook heelwat laer as in ander kinderpopulasies (johnson & watrous, 1978). oor die algemeen kan dus gese word dat daar nie in hierdie populasie kinders 'n hoe voorkoms van middeloorpatologie voorkom nie. die studie se resultate vergelyk redelik goed met die 3,6% otitis media soos verkry by 'n plattelandse venda kinderpopulasie (halama, voogt & musgrave, 1986). tabel 3: die otologiese diagnose in vergelyking met die oudiometriese siftingsresultate immittansie en suiwertoonresultate tipes diagnose van middeloortoestand immittansie en suiwertoonresultate tipes normaal afwykend immittansie en suiwertoonresultate tipes normaal retraksie sereuse otitis media chroniese otitis media: perforasie totaal ν = 292 % tipe a-timpanogram, teenwoordige akoestiese reflekse, normale suiwertoonresultate 227 0 0 0 227 77,7 tipe a-timpanogram met afwesige akoestiese reflekse, maar normale suiwertoonresultate 15 0 0 0 15 5,1 tipe b-timpanogram met afwesige akoestiese reflekse, maar normale suiwertoonresultate 0 0 15 1 16 5,5 lipe b-timpanogram met afwesige akoestiese _reflekse en geringe konduktiewe verlies 0 0 3 0 3 1,0 !ipe c-timpanogram met afwesige akoestiese _reflekse en normale suiwertoonresultate 19 0 0 0 . 19 6,5 1 ipe c-timpanogram met afwesige akoestiese reflekse en normale suiwertoonresultate 10 2 0 0 12 4,1 totaal 271 2 18 1 292 22,3 92,8 7,2 100 oie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 mirna nel, willem odendaal, marina hurter, santie meyer en anita van der merwe aihoewel die voorkoms van middeloorpatologie sekerlik ideaal gesproke kan verlaag, is die groep kinders in die lae sosio-ekonomiese omgewing nie 'n hoerisikogroep vir middeloorpatologie nie. wanneer die otologiese diagnose en die oudiometriese siftingsresultate vergelyk word, blyk die volgende: daar is swak ooreenstemming wanneer al die oudiometriese resultate normaal is, maar die akoestiese reflekse afwesig is. die teenwoordigheid van die akoestiese refleks as siftingskriterium (asha in northern & downs, 1984) word dus bevraagteken. swak ooreenstemming word ook verkry wanneer tipe c-timpanogramme veroorsaak dat die proefpersoon op die oudiometriese siftingstoets uitval. die ore word hoofsaaklik otologies as normaal verklaar. slegs twee ore, met 'n tipe c-timpanogram gee aanduidings van otoskopies waarneembare middeloorpatologie. hulle toon 'n retraksie van die timpaniese membraan weens 'n groter negatiewe middeloordruk as -200 mm h20. die ander 29 ore met tipe c-timpanogramme se negatiewe middeloordruk is minder as -200 mm h20, daarom is dit nog nie otoskopies as middeloorpatologiee gediagnoseer nie. volgens orchik, dunn en mcnutt (1978), verteenwoordig die ontwikkeling van negatiewe druk, in die middeloorruimte, 'n tussenfase in die ontwikkeling van sereuse otitis media. dit is dus belangrik dat hierdie kinders verder verwys word vir opvolgtoetsing sodat middeloorpatologiee gei'dentifiseer kan word indien die negatiewe middeloordruk nie opklaar nie. goeie ooreenstemming tussen die oudiologiese siftingsresultate en die otologiese diagnose is verkry in die geval van die tipe b-timpanogramme waar al die ore waarneembare middeloorpatologie soos sereuse otitis media of 'n perforasie vertoon het. gevolgtrekkings die prevalensie van slegs 7,2% middeloorpatologie by die groep graad 1 leerlinge was onverwags. die kinders is in lae sosio-ekonomiese omstandighede wat hulle teoreties 'n hoerisikopopulasie maak. die prevalensie van 7,2% is egter heelwat laer as ander verklaarde hoerisikopopulasies (corth & harris, 1984; northern, 1978). die oudiometriese suiwertoonsiftingsresultate toon aan dat geen kinders sensories neurale gehoorverliese vertoon nie, terwyl slegs 2,1% van die populasie 'n geringe konduktiewe gehoorverlies vertoon. die meeste kinders (25,3%) wat op die oudiometriese siftingstoetse uitval, vertoon slegs 'n middeloordisfunksie sonder dat hul gehoorsensitiwiteit beduidend be'invloed word. met betrekking tot die tipes patologiee kan die volgende gevolgtrekking gemaak word: dit is opvallend dat die middeloorpatologie wat die meeste voorkom, sereuse otitis media is. al die ore vertoon dan ook 'n tipe b-timpanogram met afwesige akoestiese reflekse en normale of afwykende suiwertoonsiftingsresultate. die voorkoms van sereuse otitis media is heelwat laer as die 20,5% van die amerikaans-indiaanse kinders (johnson en watrous, 1978). in die studie is slegs een perforasie. onder navajo skoolkinders was daar byvoorbeeld 'n voorkoms van 14% perforasies en by eskimo kinders 32% perforasies. dit blyk dus of die getoetse mamelodi kinders in terme van perforasies en sereuse otitis media nie as 'n hoerisikopopulasie beskou kan word in vergelyking met ander hoerisikopopulasies nie. dit is moontlik toe te skryf aan die gematigde klimaat in die pretoria omgewing in vergelyking met die klimaat waaraan die indiaanse en eskimo kinders blootgestel is wat moontlik kan lei tot verhoogde insidensie van boonste-lugweginfeksies en gepaardgaande middeloorpatologie. slegs twee ore met retraksie van die timpaniese membraan het tipe c-timpanogramme getoon. hulle toon retraksie, as gevolg van 'n negatiewe druk laer as -200 mm h 2 0 wat teenwoordig is in die middeloorruimte. die ander 29 ore met tipe c-timpanogramme se negatiewe druk is nie laer as -200 mm h2 nie, en daarom nog nie otoskopies waarneembaar nie. daar word aanbeveel dat 'n afwesige akoestiese refleks iri die teenwoordigheid van normale immittansiemetings en suiwertoonsiftingsresultate nie as aanduiding van 'n afwyking beskou word nie. in al die gevalle was die ore otologies normaal. ten slotte blyk dit dat die groep kinders, ten spyte van 'n lae sosio-ekonomiese omgewing, en die afwesigheid van gereelde oudiologiese sifting, nie 'n kommerwekkende hoe prevalensie-van middeloorpatologie vertoon nie. verwy sings bess, f.h. the minimally hearing-impaired"child. ear and hearing, 6, 4 3 4 7 , 1985. bess, f.h. en mcconnell, f.e. audiology, education and the hearing impaired child. st. louis: the cv mosby company, 1981. brooks, d.n. impedance screening in jerger, j. en northern, j.l. clinical impedance audiometry. massachusetts: american electromedics corporation, 1980. cantekin, e.i. algorithm for diagnosis of otitis media with effusion in stool, s.e. en bluestone, c.d. (eds): studies in otitis media, pittsburg otitis media research centre, progress report, 92, 6, 1983. corth, s.b. en harris, r.w. incidence of middle ear disease1 in indochinese refugee school children. audiology, 23, 27—37, 1984. 1 downs, m. theexpanding imperatives of early identification. |ln bess, f.h. (ed.): childhood deafness : causation~assessment and management. new york: grune en stratton, 1977. i glorig, a. en gerwin, k. detection of hearing loss and ear disease'in children. springfield iii: charles, c. thomas, 1974. gottlieb, m.i. chronic middle ear disease and auditory perceptual deficits. is there a link? clinical pediatrics, 18, 725—732, 1979. halama, a.r., voogt, g.r. en musgrave, g.m. prevalence of otitis media in children in a black rural community in venda (south afria). international journal of pediatric otorhinolaryngology, 11, 73—77, 1986. harvey, r.m. en wilmot, t.j. the incidence of deafness in childhood. journal of laryngology and otology, 83, 449—456, 1969. holm, v.a. en kunze, r.h. the effects of chronic otitis media on language and speech development. pediatrics, 43, 833—841. 1969. howie, ^ . m . acute and recurrent acute otitis media. in taffe, b.f. (ed.): hearing loss in children. baltimore: university park press, 1977. jerger, j. clinical experience with impedance audiometry. archives of otolaryngology, 92, .311—324, 1970. the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die voorkoms en aard van gehoorprobleme en middeloorpatalogiee by 'n groep swart stedelike kinders 2 9 northern, j.l. impedance screening in special populations — state of the art. in harford, e.r., bess, f.h., bluestone, c.d. en klein, j.o. (eds.): impedance screening for middle ear disease in children. new york: grune en stratton, 1978. northern, j.l. en downs, m.p. hearing in children. baltimore, maryland: the williams en wilkins company, 1984. oosthuizen, i. die aard en voorkoms van gehoorpatologiee in laerskole vir normaalhorende venda kinders. ongepubliseerde blogverhandeling, universiteit van pretoria, 1986. orchik, d.j., dunn, j.w. en mcnutt, l. tympanometry as a predictor of middle ear effusion. archives of otolaryngology, 104, 4 6 , 1978. van der walt, t.j. persoonlike mededeling. departement sosiologie, universiteit van pretoria, 1987. voogt, g.r., halama, a.r., van der merwe, c.a. immittance screening in black preschool children attending day-care centres. audiology, 25, 158—164, 1986. wilson, j. deafness in developing countries. arch. otolaryngology, 3, 5, 1985. the south african journal of communication disorders, vol. 35, 1988 johnson, j.s. en watrous. an acoustic impedance screening program with an american population in harford, e.r., bess, f.h., bluestone, c.d. en klein, j.o. (eds.): impedance screening for middle ear disease in children. new york: grune en stratton, 1978. kaplan, g.j. long term effects of otitis media: a ten year cohort study of alaska-eskimo children. pediatrics, 52, 577—585, 1973. mcshane, d. en mitchell j. middle ear disease, hearing loss and educational problems of american indian children. journal of american indian education, 7—11, 1979. meyer, s. en van den berg, c. die voorkomsfrekwensie van ooren gehoorpatologie by kinders in die afgesonderde gemeenskap van tshikunda-malema. die suid-afrikaanse tydskrif vir kommunikasieafwykings, 32, 71—75, 1985. meyer, s., hurter, m. en van rensburg, f. gehoorsiftingsresultate van 'n groep graad een kleurlingkinders. suid-afrikaanse tydskrif vir kommunikasieafwykings, 34, 43—47, 1987. morris, p. soweto. johannesburg: perskor, 1980. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) / new automatic hearing aid a truly advanced and innovative sound amplifier the a u t o m a t i c sound processor (asp) was developed especially for those people who have difficulty in hearing speech in noisy environments. for years, hearing aid wearers have avoided restaurants, theatres, church and parties because of the inability of an ordinary hearing aid to control background noises. the a s p. is simply and uniquely designed to normalize background noise so that speech is more easily understood. to be able to restore sound to even one human being makes your life especially important. 'd / , f to restore hearing... what a blessed talent to have medifix hearing system co. s u r g i c a l & m e d i c a l p . o . box 19 bedfordview 2008 south africa phone: ( 0 1 1 ) 5 3 4 1 8 8 / 9 cape p.o. box 52 lynedoch 7 6 0 3 phone: (024) 5 1 2 4 9 5 natal p.o. box 4 7 4 4 3 greyville 4 0 2 3 phone: (031) 2 9 4 0 5 0 ir] richards hearing systems tomorrow's technology for today's hearing problem r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sign language in south africa: some research and clinical issues claire penn phd (witwatersrand) robyn lewis ba (log) (rand), ba (soc. science) unisa, ltcl andrea greenstein ba (sp & η th) (witwatersrand) department of speech pathology and audiology, university of the witwatersrand abstract this article describes the variations of aspects of visual language of the deaf which have been well researched in other countries and which are hypothesized to exist in south africa. the results of a study conducted on the signing of a group of deaf school children in johannesburg are described. the signs used by these subjects for twelve lexical items differed from the signs said to be representative of the south african deaf community as a whole. research and clinical implications are presented. opsomming hierdie artikel beskryfdie variasie wat bestaan in aspekte van visuele taal van die dowe wat deeglik bestudeer is in ander lande en wat waarskynlik ook in suid-afrika bestaan. die resultate van 'n ondersoek na die gebarestelsel in 'n groep dowe skoolkinders in johannesburg word beskryf. die gebare van twaalf leksikale items wat hierdie kinders gebruik verskil van die tekens wat aanvaar word as verteenwoordigend van die suid-afrikaanse dowe gemeenskap as geheel. navorsing en kliniese gevolgtrekkings word aangebied. for the past two decades, sign language has enjoyed the increasing attention of researchers and clinicians alike. this field of study has been particularly active in america where, since stokoe's extensive research (1976,1978) there has been a widespread acceptance of sign language as the heritage of a distinct social minority — the deaf* community, with its own culture and norms. stemming from an increased consciousness of the rights of minority groups, the view of the deaf individual as 'bilingual' is an increasingly popular one. with regard to the south african position on sign language, the writers believe that two main issues need resolution. first, there is the need to determine the nature and variety of sign languages used by the south african deaf community and whether this is similar or distinct from more widely researched systems such as american sign language (asl). second, the implications of this research for deaf educators need to be considered. an attempt will be made to raise some issues relevant to these points. by way of a background to preliminary experimental evidence, some terminological and conceptual issues in sign language will be introduced. perhaps the most encompassing model of asl is the one proposed by woodward in 1972 who pointed out the notion of a "sign language continuum". this is represented schematically below (see fig. 1). the one extreme of the continuum is occupied by asl which is the visual gestural language used by the deaf in north america. it has a formal structure, it is systematic, rulegoverned and is strongly 'arbitrary' in that there is no resemamerican sign language english deaf pse hearing pse | manually coded english pidgin signed (mce) english (pse) examples i ι see i ' i 1 see ii , i : love ' i > signed english f 1 ,,·! fingerspelling i , etc. figure 1 american sign language continuum (after woodward, 1972). blance between the form of a symbol and the thing it stands for (klima and bellugi, 1979). derived from this formal language and the necessity for communication between deaf and normal hearing individuals, a pidgin sign language (psl) has developed naturally, incorporating elements of both english and asl. like any pidgin language, the reduction and mixing of two languages (in this case asl and english) result in new structures. as the continuum approaches pidgin signed english (pse), grammatical features of asl are replaced by english * the term "deaf' is used throughout this article to denote individuals with a severe or profound hearing loss. the south african journal of communication disorders, vol. 31 1984 @ sasha 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sign language in south africa: some research and clinical issues 7 features such as grammatical markers and word order (baker and cokely, 1980). it is of note that many writers mistakenly confuse pse with pure sign language. a further point of confusion arises when examining manually coded english (mce), another point on the sign language continuum. mce refers to the development of several codes which attempt to represent manually, spoken english syntax, and are hence distinct from either asl or psl. such systems include signed english, linguistics of visual english (love), seeing essential english (see) and the rochester method (usa) and the paget gorman system (u.k. and south africa). such manually coded systems had their origin in the increased awareness amongst educators that for the majority of severely and profoundly deafened children, the oral system alone has failed to teach functional english, either written or spoken, and that communication through a visual mode has many advantages (conrad, 1979). hence the notion of 'total communication' has evolved incorporating manually coded systems as well as lip reading, auditory training, speech teaching, etc. to summarize, there are discrete differences between asl, psl and mce, all of which need to be taken into account by the researcher and clinician dealing with the deaf. while sign language per se is a pure language found among deaf users, within educational contexts (i.e. where the deaf mingle with hearing individuals) there is a strong likelihood of observing psl or a manual system which has been formally introduced as an educational option. in south africa, there is clearly a wide variety of visual language being used by the deaf. according to axelrod (1983) the first people to bring a sign system to this country were the irish sisters over a century ago, but details regarding the nature of this sign language are unknown. due to the discrete educational policies at present existing in the country, many separate systems are probably in existence. for black school children a manual code based on the paget gorman system is used (i.e. al^deaf schools falling underj the control of the department of education and training use,this code). white deaf children by contrast, have to date not been permitted to use any signing system for formal education. the same situation exists for coloured and indian communities. the south african national council for the deaf, clearly riot unaware of the discrepancies in educational policies and the urgent need for sign language research, has recently established a communications committee to investigate the whole issue of sign language in this country. an attempt is being made to establish a 'uniform sign language system in south africa' (viljoen, 1982). a book, 'talking to the deaf (nieder-heitman, 1980) is currently being promoted as representative of signs used by the majority of deaf south africans. this is indeed a praiseworthy preliminary effort in a field so lacking in documentation but we believe that the stand taken is premature. first, little attempt has been made to describe the syntactic structure of the visual language presented in the text. second, there is no clear indication as to the research methods employed to establish the stated 'majority' representativeness of the signs. further, the source of many of the photographs is not local but an overseas one (the gestuno system). finally and most important, it would seem highly likely, in view of the preceding discussion that no single south african sign language exists. no one working within the deaf community of south africa, not least the deaf individuals themselves, can deny the existence of a seemingly rich spontaneous sign language which is used in at least some conversational contexts. what is at issue however is the potential variability of such visual language amongst different users. further, sign language as such, is clearly distinct from the manually coded systems used by some groups and undoubtedly shows considerable divergence according to culture, demography and sociological factors. languages develop, they are determined by history, by culture and by geography, and cannot be artificially constructed. in view of the above, it is, we suggest, essentially impossible and certainly unproductive to hypothesize the existence of a uniform sign language in south africa. as evidence for the above suggestions, some preliminary field work into the use of deaf sign language in south africa will now be described. preliminary experimental evidence the aims of this study* were first to describe the signs representing a number of lexical items used by deaf children attending a white residential school for the deaf in johannesburg in order to determine whether the use of these signs is standard within the school population, and second to determine whether these signs differ from those proposed to be the "standard" south african signs as described by nieder-heitman (1980). method forty deaf subjects ranging between the ages of 5-19 years were selected. subjects were congenitally deaf (loss of 80 db or more in the speech range) and were all boarders at the deaf school, thus ensuring that subjects interacted within the same educational and social environment. twelve lexical items were selected according to the following criteria: — 1) all items were required to appear in nieder-heitman's (1980) dictionary "talking to the deaf'. 2) lexical items were selected in terms of their frequency, use and relevance within the subjects' environment. 3) lexical items thought to be represented by highly iconic signs were eliminated in order to avoid the use of natural gestures. 4) nouns, verbs, adjectives and prepositions were selected. it has been suggested that the verb system of any language forms the core of every utterance (wilbur 1976, p. 439) and it is the nouns, prepositions and adjectives which expand the verb phrase into a meaningful language unit. three words for each part of speech were selected as follows: — nouns : dog, mommy, tree verbs : bathing, jumping, sitting adjectives : yellow, old, happy prepositions : on, in front of, to the results reported here are based on a research project undertaken in the department of speech pathology and audiology, university of the witwatersrand, by the third author. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 only single lexical items, out of syntactic context, were investigated. stokoe (1978) suggests that when encountering a new language one should commence by comparing vocabulary items. subjects were individually presented with a picture card and corresponding written stimuli representing the respective signs. all signing was video recorded and analysed according to the following variables:reported laterality age — dominant hand used — correspondence to south african signs (nieder-heitman 1980) data was analysed according to 3 cheremes (equivalent to the phonemes of spoken language) as described by stokoe in wilbur (1976, p. 441):tab (tabula) — location on or near the body where the sign is being made dez (designator) the configuration of the hands sig (signation) — the movement aspect of the hands. all data was tallied according to a percentage. the sign for each lexical item was interpreted as occurring in the majority of ss if it occurred in more than half the group. results table i represents the percentage of subjects using a standard sign together with an indication of their correspondence (or otherwise) with the "south african" sign. this table further demonstrates the dimensions along which the signs differ. results indicate that for the twelve lexical items an average of 75 % of the ss are utilizing a standard system of signs which differ from those described by nieder-heitman as representing the south african signs. the mean percentage of subjects utilizing the signs concurs with the findings of marcowicz (1972) who refers to a study by best (1972) which reported that 78.2 % claire penn, robyn lewis and andrea greenstein of deaf children within an oral school used sign language. the results of the present study also support suggestions in the literature that signs are non-uniform throughout the world (battison et al., 1976). it is of note that the subjects' signs for only two of the lexical items ('old' and 'happy') approximate the socalled hypothesized standard. for the other lexical items, there is a high level of agreement between ss for all except one item ('in front of) where considerable variation occurred. the fact that marked differences occurred between the standard signs used by the deaf subjects and the south african signs, reinforces the viewpoint that the signs of the subjects are not simply dialectal variations of the basic south african sign but completely different entities. six of the signs differed by all three cheremes from nieder-heitman's (1980) hypothesized standard and the remaining four signs by at least one chermee. such variation is further illustrated by the examples in figure 2. since an average of only 6.2% of the subjects used the signs from the manual, it is impossible to conclude that there is any close resemblance between the cheremic configurations of the deaf subjects' signs and those appearing in the manual, at least for the signs studied. the subjects appear to have their own unique system which is not idiosyncratic to each individual but is representative (to differing extents) of the group studied as a whole. certain variations did occur among the subjects but these occurred in a small number of subjects only and were close approximations to the more standard signs. the items on which there was somewhat wider variation were 'jumping', 'sitting' and 'in front of. the former two signs ('jumping' and 'sitting') showed variation from gross iconic gesture involving all four limbs to highly arbitrary signs (i.e. signs where there is no resemblance between sign and meaning (baker and cokely, 1980)). the variations observed as a function of these dimensions are illustrated below (see figure 3). it was possible to see a developmental trend in this data in that younger subjects in the group were more likely to use iconic variations for these two signs. though this could not be table 1 percentage of subjects using standard signs for the lexical items investigated sign percentage of subjects using a standard non-south african sign percentage of subjects utilizing a standard south african sign differences across the cheremic configurations ; occurring in the two sets of signs ; (x indicates where a difference occurs) j sign percentage of subjects using a standard non-south african sign percentage of subjects utilizing a standard south african sign tab (the location on or near the body where the sign is being made) dez (configuration of the hands) sig j (the movement ' aspect of the ' hands) dog 95% 0% x x x mommy 77,5% 12,5% a) x b) x tree 80% 10% a) x x b) x x x yellow 92,5% 0% x x x old ] 0% 92,5% / happy j 0% 92,5% bathing 80% 0% x jumping 70% 10% x x x sitting 90% 0% x x / x on 50% 27,5% x in front of extreme variation 2,5% x x x to 87o/o •0% x the south african journal of communication disorders, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sign language in south africa: some research and clinical issues 9 lexical sign used by subjects south african "standard" item (after nieder heitman, 1980) dog yellow figure 2 differences between signs used by subjects and those hypothesised to be the south african standard, for two lexical items. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 claire penn, robyn lewis and andrea greenstein iconic-arbitrary jumping hands in neutral position; jumping movement; legs involved sitting sitting movement by bending knees; hands not involved clenched fists bent elbows; bend elbows back as knees are bent hand in 'v' position move hand up and down (as if jumping) on back of opposite hand clenched fists; bent elbow twist wrist backwards figure 3 variations in signs used for lexical items "jumping" and "sitting" as a function of the iconicity-arbitrariness continuum statistically confirmed in the present study (due to the nature of the group studied) this suggested trend does support the idea that signs, just like spoken languge, develop along a specific route (wilbur, 1976). the variability characterizing the sign 'in front of might be explained in terms of the fact that the form of certain signs is dependent on context (klima and bellugi, 1974, p.41). for example according to these authors 'sitting in front of the class' may be signed differently from the 'boy stood in front of the girl'. since in the present study, the stimuli were not presented in a linguistic context, the subjects' own interpretations was not accounted for. this possibly accounts for the observed variations evident for this particular sign. further explanation for variation in certain signs undoubtedly comes from the observation made previously that when the deaf come into contact with hearing individuals, differing modifications of the sign may take place (i.e. a type of pidgin signing). as has been previously mentioned, the fact that the writers investigated only isolated lexical items limited the study in view of the fact that the syntax and rules of these signs could not be studied. however, certain features emerged within the signs used by subjects. these features correspond to those features which serve to make american sign language a syntactic linguistically sound language. they a r e : 1) iconicity and arbitrariness e.g. the signs 'jumping' and 'sitting'. 2) phonology (cheremes) e.g. the tab, dez and sig configuration evident in each sign. 3) symmetry and dominance. 4) the suggestion of a developmental pattern for certain signs. the results of this study have thus indicated that there appears to be a difference between selected signs used by the deaf subjects investigated a sub-group of the south african deaf population, and those signs proposed by nieder-heitman (1980) to be representative of all signs used by various ethnic groups in south africa. the variations that exist among these two sets of signs are not merely simple ones, but variations which are standard and arbitrary and which differ markedly from one another. discussion the above experimental evidence serves to illustrate that, at least for the sample tested, there is a lack of conformity with the signs included in the sign language system proposed to be representative of sign language users in south africa. it therefore seem logical to conclude that in other deaf populations in this country who stem from discrete language groups and educational backgrounds, a similar divergence from the hypothesized standard might exist. such a finding naturally awaits experimental confirmation but is certainly not unexpected in terms of the theoretical and research considerations discussed previously. it does, however raise some central and pressing clinical and research implications for the study of sign language and its variants in south africa. the current attempt to unify south african sign language systems (at different points on the sign language continuum) seems both scientifically and pragmatically questionable. rather what seems indicated is a nation-wide investigation of the existing dialectal variations in south africa and a systematic and academic attempt by linguists, sociologists, anthropologists and members of the deaf community to illustrate that the visual language used by the south african deaf is a unique set of phenomena, as arbitrary as rule-governed, as variable and as rich in cultural and linguistic heritage as any other sign system in the world. the implications arising out of this clearly have relevance to deaf educational policy in south africa. though the writers believe strongly in the benefits of a manual code as a supplement to teaching language to the deaf individual, this manual code will clearly have to depend on the existing lexicon and systems used by each individual deaf group in south africa. the systems which should be adopted will depend on a number of factors and may in fact be fairly similar, or at the other 'extreme, as diverse as the existing spoken languages in this country. hopefully it will not be political policies which will determine the eventual adoption of coding systems into educational programmes. rather, the prime concern should be the criterion of effectiveness to the deaf individual. we have a commitment to serve the community in the best way possible and to tliis end we hope that considerable efforts will be made in the future to investigate this promising yet essentially unexplored field of research. references axelrod, c. chaplain to the deaf, johannesburg. personal communication, 1983. baker, charlotte & cokely, dennis. american sign-language. t.j. publishers, 1980. battison, r.m. & jordan, i. king. "cross-cultural communication with foreigners" in sign and culture. william c. stokoe (ed.). maryland: linstok press 1980. conrad, r. the deaf school child. new york: harper & row, 1979. the south african journal of communication disorders, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sign language in south africa: some research and clinical issues 11 klima, edward, &bellugi, ursula. the signs of the language. harvard: harvard univ. press, 1979. markowicz, harry. "some sociolinguistic consideration of a.s.l." in sing and culture. william c. stokoe (ed.) maryland: linstok press, 1980. nieder-heitman, n. talking to the deaf. pretoria: government printers, 1980. stokoe, w.c.: "the study and use of sign language". sign language studies, 1976, 10, 1-36. stokoe, w.c. sign and culture. maryland: linstok press, 1978. viljoen, ds. editorial in the silent messenger. s.a. national council for the deaf, vol. 5(3), 1982. wilbur, r.b. "linguistics of manual language and manual systems". in communication assessment and intervention strategies. l.l. lloyd (ed.) baltimore: univ. park press, 1976. woodward, j. "implications for sociolinguistic research among the deaf." in sign language studies i, 1972. 1-7. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) danavox unique design, unrivalled technology and exceptional sound quality the 123 series is a completely new generation of small hearing aids combining an anatomically correct design w i t h the latest in technology. the 123 series offers the advantages of: modern, attractive design comfortable behind-the-ear fit convenient controls excellent sound quality and low distortion danavox high degree of reliability gain unaffected by changes in battery voltage d o w n to 1 volt very low battery consumption acoustimed hearing services 3rd floor bosman building eloff street johannesburg tel.: 337-2977 the south african journal of communication disorders, vol. 31 84 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 75 research note bonferroni's bound — a control of significance level errors in speech pathology and audiology research c v kass, ph d (witwatersrand) department of statistics university of the witwatersrand, johannesburg μ marks wahlhaus, μ a (log.) (witwatersrand) department of speech pathology and audiology university of the witwatersrand, johannesburg abstract many studies in behavioural sciences, such as speech pathology and audiology, involve statistical hypothesis testing. repeated tests are made, for example, of judge reliability in assessing the disorder, or within subject variability, or between subject comparisons over several measures of the disorder or types of treatment. if the error rate of the statistical test is only controlled for each individual test, the overall error rate is magnified and the chance of reporting a significant result where none exists, arises. this paper addresses this potential problem, by noting some common procedures that inherently guard against this pitfall, and suggesting a simple, albeit conservative, solution for other cases. opsomming talle studies in die gedragwetenskappe, soos spraakheelkunde en oudiologie, betrek statistiese hipotesetoetsing. herhaaldelike toetse word uitgevoer, byvoorbeeld, van die betroubaarheid van beoordelaars by die evaluering van 'n afwyking, of intervergelykings van proefpersone ten opsigte van metings van die afwyking of van die tipe behandeting wat toegepas is. indien die foutvoorkoms van die statistiese toets slegs vir elke individuele toets gekontroleer word, word die totale foutvoorkoms vergroot en ontstaan die moontlikheid dat 'n betekenisvolle resultaat opgeteken word waar daa/ in werklikheid geen resultaat bestaan nie. hierdie artikel spreek hierdie potensiele probleem aan deur sommige statistiese prosedures wat inherent teen hierdie valstrik waak, te vermeld en deur 'n eenvoudige, hoewel konserwatiewe oplossing vir ander gevalle aan die hand te doen. / overview the usual research in speech pathology, social, psychological and medical sciences typically advocates a significance level of 5% for reporting results-or theories as being established. that is, for example, if a new therapy is to be deemed better than an established regime, then the statistical analysis of an observed "improvement" (eg. a decrease in the frequency of stuttering) must show that such a result could not be ascribed to natural variation in the subject's stuttering frequency except with a 5% chance. in other words, if the stutterer was tested repeatedly (over many weeks) without the new therapy, only one time in twenty (equivalent to 5% of the time) would he show such a marked decrease in stuttering frequency as evidenced on the single test performed after the new therapy. i from the viewpoint of an individual researcher, a significant improvement of the 5% level is satisfactory as it protects her from advocating a new therapy that is no better than the existing one. an unhappy alternate interpretation is that if a hundred researchers all over the world decided to test this new therapy, then five of them could be expected to detect significant improvement even if the new therapy is ineffectual. this is a consequence of statistical testing in die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 modern times. similarly it is understood that for every hundred journal articles that use statistics and claim an improvement of some technique or difference between two approaches that are significant at the 5% level, it is expected that five such articles will be erroneous — although statistically there is no way of knowing which five they are, nor even if there are precisely five in error. for this reason researchers try to claim significant results at more extreme levels. that is, instead of using the 5% level (implying a one in twenty chance of claiming a false positive), the 1% (one in a hundred), 0.1% (one in a thousand) or more extreme level is used to indicate how small the chance is of an erroneous conclusion by the researcher. there is a problem in being too stringent, namely, if very small significance levels are used, false negatives increase; that is, the smaller the significance level the larger the probability of finding no improvement in a new therapy when in fact it really is efficacious. the above considerations are usually well known to the researcher. less understood are the implications when an individual researcher applies many statistical tests (in contrast to many researchers applying a single test as dis© sasha 1988' r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 76 g v kass and μ marks wahlhaus cussed above). some variations of this theme will now be discussed. one researcher applying many tests the previous example of testing a new therapy to decrease stuttering can be extended as follows: should the researcher consider the therapy to be conducive to reducing some stuttering behaviours but not others, she could subdivide the types of stutter into a number of auditory categories: gasp, glottal stop, laryngealization ... etc. if twenty categories were for instance decided upon the naive approach would be to apply twenty statistical tests, each at the 5% significance level. a simple extension of the original experiment in which the stuttered words are themselves categorised by the five initial phonemes [f], [s], [t], [m] and [h] and the twenty categories of stutter analysed within each of the five word types would result in one hundred statistical tests. in the latter case the analogy between a hundred researchers each employing one test, and the individual researcher applying one hundred tests, is complete. even if the new therapy is valueless, five of the behaviour/word-type combinations can be expected to show a significant decrease in frequency (i.e. clinical improvement); and further, one of these will even be significant at the 1% level. while publication of false positives due to many researchers working in isolation is accepted (that is, it is not expected of a researcher in south africa to anticipate other researchers in the country or throughout the world when performing her statistical tests, any more than they would take into account her research when performing theirs), it is believed that each researcher should include in her reckoning the other statistical tests that she herself performs, at least within a single research topic. failing "protection" in this way spurious significant results would likely be found. there are a number of ways of keeping the overall significance level (i.e. probability of type i error over several statistical tests) down to a pre-specified level, depending on the situation. one of the simplest and most versatile is to use boole's inequality (also known as the first bonferroni inequality), (feller 1968). in essence in its simplest form it states that if the number of tests to be performed is n, and the overall significance level to be contained is p, then each individual test should be performed at the p/n level. thus, in the first example above where the researcher was about to perform twenty (n = 20) tests each at the 5% (p = 5%) level, each test should have been performed at the 0.25% (p/n = 5%/20 = 0.25% = 1/4%) level, only then could any significant result be claimed to be truly meaningful at the 5% level. equivalently she would ensure that her overall error rate was at most 5% (i.e. overall probability of a type i error is at most 5%), by performing each individual test at the 1/4% level. similarly, if she wished to validly test all one hundred behaviour/word-type combinations at the overall 5% level of significance, each individual test could only be claimed to be significant if it attened the 0.05% (5%/100 = 0.05%) = (1 in 2000) level. such tests (at the 1/4% or 0.05% as appropriate) may be called modified 5% level tests that safeguard against the inflation of the probability of a type i error. indeed, without this modification it is almost sure (99.4%) that the type i error (i.e. claim a false positive) will be committed when performing a hundred tests each at the 5% significance level. one possible difficulty in using boole's inequality as described, is that the necessary statistical tables may not be easily accessible. thus, in the above example where a 0.25% significance level was postulated as providing the required protection, the critical values of the chosen test statistic at the 0.25% level may not be published in commonly used tables or appendices. a statistician may be able to provide a reference to superior tables, or a (possible complicated) procedure either to interpolate in tables or to access a computer approximation. some tables have been generated specifically for use with boole's inequality, eg. bailey (1977) gives tables so designed for use with the various forms of the t-test. another approach is to lower the necessary significance level to a value for which the required critical values are tabulated. this will induce a similar proportional reduction in the overall significance level. thus, for example, if the critical values of the 0.25% level are not available but ;hose for the 0.1% level are (i.e. reduced by a factor of 2.5 from 0.25% to 0.1%), then the use of the latter tables will cause a concomitant reduction in the overall significance level from 5% to 2% (since 5%/2.5 = 2%), a more stringent level. an example involving comparisons of variables suppose the researcher wishes to examine the association between ten visual behaviours (i.e. behaviours that can be observed by eye, eg. a jaw jerk, eye flutter, furrowed brow, ... etc) that are manifested during or just prior to a stuttered word. in this case it may be deemed appropriate to examine a matrix of pairwise comparisons, eg. a matrix of correlations or other measures of association or even 'distances' between pairs (as is used in cluster analysis). in the case of product-moment correlations a statistical package like sas (sas institute inc. (1985)) offers an overall test of whether or not all the pairwise comparisons can be considered insignificantly different from zero. unhappily, rejection of the hypothesis that all the comparisons do not differ significantly from zero, does not indicate which of the comparisons show a significant difference, and so the test, while valuable for certain problems, is incomplete as far as the hypothetical researcher into stuttering behaviours is concerned. j ι the global test can thus only indicate whether further analysis of the correlation severally may be profitable. if the global test is rejected at the 5% significance level, then individual tests may be performed. as before, use of boole's inequality is recommended. ' in the example of ten visual behaviours (or ten judges) there are 45 pairwise comparisons. thus each of the 45 tests should be executed at the 0.1111 % level (5%/45 = 0.1111 %), or perhaps more conveniently at the slightly lower 0.1% level. note that the procedure of considering these 45 tests each at the 0.1% level is a valid method for containing the overall significance level at most 5% for any such matrix of paired comparisons (eg. rank correlations) and not just product-moment correlations. in the field of speech pathology and audiology judge agreement is often a relevant research issue. the assessment inter-judge reliability poses problems with a similar structure to the example which has been examined, i.e. the association at stuttering behaviour. the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) bonferroni's bound — a control of significance level errors in speech pathology and audiology research 7 7 an example involving analysis of variance as a final example consider a researcher who measures stuttering frequency on a number of subjects before and after five different therapies (eg. a control group 'time heals' therapy, a fluency-based approach, a stuttering-modification approach, psycho-therapy treatment using psychopharmocological drugs). the null hypothesis that all these methods are equally effective (or equally ineffective) based on appropriate measures, is a standard analysis of variance problem. built into this technique are tests of all the alternative subhypotheses including those of one or two therapies being different to one, two, three or even all the other therapies. like the previous case of correlations examined above, rejection of the null hypothesis does not indicate which of the many alternative sub-hypotheses may be significant. again if the sub-hypotheses of interest (eg. the control group is worse off than any of the others, the drug therapy is better than the others, the last two are better than the first three, ... etc.) can be listed and numbered (let there be η of them) then boole's inequality can be invoked as before to give an overall significance level of p, by conducting each individual appropriate t-test and the p/n level. this approach is, however, only recommended if the number of sub-hypotheses of interest is fairly small (eg. up to η = 4 say). the reason for eschewing boole's inequality for larger η in this case is that more powerful tests have been developed although some require specialised statistical tables. these tests come in various forms and are under such headings as 'multiple range tests', 'multiple comparisons' and 'simultaneous testing procedures'. a discussion of the more popular tests may be found in winer (1971), while a comprehensive review including more modern procedures can be found in miller (1981). standard statistical packages such as sas (sas institute inc. (1985)) offer methods such as duncan's multiple range test, gabriel's multiple comparison procedure, tukey's studentized range test, among others, on request. conclusion it is clear from this study that each researcher should ensure that her overall significance level is controlled within an accepted bound, when performing multiple tests whether implicitly or explicitly. some statistical procedures and their associated computer programs contain such built-in protection, eg. analysis of variance. other techniques unfortunately do not normally provide such a safeguard, nor do the associated computer programs supply a caveat; theoni^and two-sample t-test and their non-parametric counterparts such as the wilcoxon test fall into this class. in these cases the use of boole's inequality as described in this paper is recommended. each researcher should be aware that performing many tests each at an accepted significance level, could lead to an unacceptable increase in the type i error; that is "discoveries" may be made which are, indeed, due merely to chance fluctuations. it is unfortunate that within the purview of behavioural research, the simple protection against this type of error outlined above, is not more widely used. references bailey, b.j.r. tables of the bonferroni t statistics journal of the american statistical association. 469—478, 1977. feller, w. an introduction to probability theory and its applications. wiley, new york, 1968. miller, r.g. simultaneous statistical inference. 2nd ed. springer, new york, 1981. sas institute inc. sas user's guide: statistics, version 5 edition. cary, nc, 1985. winer, statistical principles in experimental design. 2nd ed. mcgraw hill, new york, 1971. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) doit yourself insertion gain instrument if you have a suitable ibm compatible computer and if you are familiar with it, acoustimed can now offer you a "do it yourself" insertion gain instrument. we sell you a kit which you assemble yourself without any special tools. the equipment has all the features of the ha-2000 ii system but is in a less expensive housing and we save on installation costs. any support which you may need is given over the telephone or in our offices — saving you thousands of rands on the world's most versatile hearing aid analyzer. features: complex test signals fast pure tone sweep speech weighted signals transients, bursts, continuous signals built in signal synthesizer real time analysis time delay spectrometry "prescription" calculations are programmable auto-correlation for noise reduction signal averaging and spectrum averaging rms, peak and crest factor displayed linear response probe microphone data management with sophisticated data base program easy to use acodat programming language word processor with graphics facility mailing list programs invoicing programs calendar/scheduling program no other system offers all these features. write or call for a descriptive booklet. n b . this is a marketing experiment for which we have prepared two instruments. we reserve the ! right to request that you bring your computer to us for assembly, demonstration and instruction. i i i acoustimed (pty) ltd. 327 bosman building cor. eloff and bree streets johannesburg tel: (oil) 337-2977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) information for contributors the south african journal of communication disorders publishes reports and papers concerned with research, or critically evaluative theoretical, or therapeutic issues dealing with disorders of speech, voice, hearing or language, or on aspects of the processes underlying these. the south african journal of communication disorders will not accept material which has been published elsewhere or that is currently under review by other publications. all contributions are reviewed by at least two consultants who are not provided with author identification. form of manuscript. authors should submit four neatly typewritten manuscripts in triple spacing with wide margins which should not exceed much more than 25 pages. each page should be numbered. the first page of two copies should contain the title of the article, name of author/s, highest degree and address or institutional affiliation. the first page of the remaining two copies should contain only the title of the article. the second page of all copies should contain only an abstract (100 words) which should be provided in both english and afrikaans. afrikaans abstracts will be provided for overseas contributors. all paragraphs should start at the left margin and not be indented. major headings, where applicable, should be in the order of method, results, discussion, conclusion, acknowledgements and references. tables and figures should be prepared on separate 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should appear in the reference list. references should be listed alphabetically in triple-spacing at the end of the article. for acceptable abbreviations of names of journals, consult the fourth issue (october) of dshabstra cts or the worldlist of scientific periodicals. the number of references used should not exceed much more than 20. note the following examples: locke, j.l. clinical psychology: the explanation and treatment of speech sound disorders. j. speech hear. disord, 48, 339-341, 1983. penrod, j.p. speech discrimination testing. in j . katz (ed.) handbook of clinical audiology, 3rd ed., baltimore: williams & wilkins, 1985. van riper, c. the nature of stuttering. englewood cliffs, new jersey: prentice-hall, 1971. proofs. galley proofs will be sent to the author wherever possible. corrections other than typographical errors will be charged to the author. reprints. 10 reprints without covers will be provided free of charge. all manuscripts and correspondence should be addressed to: the editor, south african journal of communication disorders, south african speech and hearing association, p.o. box 31782, braamfontein 2017, south africa. inligting vir bydraers die suid-afrikaanse tydskrif vir kommunikasieafwykings publiseer verslae en artikels oor navorsing, of krities evaluerende artikels oor die teoretiese of terapeutiese aspekte van spraak-, stem-, gehoorof taalafwykings, of oor aspekte van die prosesse onderliggend aan hierdie afwykings. die suid-afrikaanse tydskrif vir kommunikasieafwykings sal nie materiaal aanvaar wat reeds elders gepubliseer is, of wat tans deur ander publikasies oorweeg word nie. alle bydraes word deur minstens twee konsultante nagegaan wat nie ingelig is oor die identiteit,van die skrywer nie. formaat van die manuskrip. skrywers moet vier.netjies getikte manuskripte in 3-spasi'ering en met bree kantlyn indien, en dit moet nie veel langer as 25 bladsye wees nie. elke bladsy moet genommer wees. op die eerste bladsy van 2 afskrifte moet die titel van die artikel, die naam van die skrywer/s, die hoogste graad behaal en die adres of naam van hulle betrokke instansie verskyn. op die eerste bladsy van die oorblywende twee afskrifte moet slegs die titel van die artikel verskyn. die tweede bladsy van alle afskrifte moet slegs 'n opsomming l 100 woorde) in beide engels en afrikaans bevat. afrikaanse opsommings sal vir buitelandse bydraers voorsien word. alle paragrawe moet teenaan die linkerkantlyn begin word en moet nie ingekeep word nie. hoofopskrifte moet, waar dit van toepassing is, in die volgende volgorde wees: metode, resultate, bespreking, gevolgtrekking, erkennings en verwysings. •tabelle en figure moet op afsonderlike bladsye verskyn (een bladsy per tabel/illustrasie). figure, grafieke en lyntekeninge moet oorspronklike weergawes wees en moet in swart ink op wit papier van 'n hoe gehalte gedoen word. letterwerk wat hierop verskyn moet eenvormig wees, professioneel gedoen word en daar moet in gedagte gehou word dat dit leesbaar moet wees na 'n 50%-verkleining in drukwerk. letterwerk by die illustrasie moet onder geen omstandighede getik word nie. verklarings of omskry wings moet nie in die illustrasie nie, maardaaronder verskyn. die byskrifte van tabelle moet bo-aan verskyn en die van figure onderaan. tabelle en figure moet in die volgorde waarin hulle verskyn, genommer word (met arabiese syfers). die hoeveelheid materiaal in die vorm van tabelle en illustrasies wat toegelaat word, word deur die redakteur bepaal (gewoonlik nie meer as 6 nie). verwysings. verwysings in die teks moet voorsien word van die skrywer se van en die datum, bv. van riper (1971). waar daar meer as twee skrywers is, sal et al. na die eerste skrywer voldoende wees. die name van alle skrywers moet in die verwysingslys verskyn. verwysings moet alfabeties in 3-spasiering aan die einde van die artikel gerangskik word. vir die aanvaarde afkortings van tydskrifte se titels, raadpleeg die vierde uitgawe (oktober) van dsh abstracts of the worldlist of scientific periodicals. die getal verwysings wat gebruik is, moet nie veel meer as 20 wees nie. let op die volgende voorbeelde: locke, j.l. clinical phonology: the explanation and treatment of speech sound disorders. j. speech hear. disord., 48, 339-341, 1983. penrod, j.p. speech discrimination testing. in j . katz (ed^handbook of clinical audiology, 3de ed., baltimore: williams & wilkins, 1985. van riper, c. the nature of stuttering. englewood cliffs, new jersey: prentice hall, 1971. proewe. galeiproewe sal waar moontlik aan die skrywer gestuur word. die onkoste van veranderings, behalwe tipografiese foute, sal deur die skrywer self gedra moet word. herdrukke. 10 herdrukke sonder omslae sal gratis verskaf word. alle manuskripte en korrespondensie moet gerig word aan: die redakteur, die suid-afrikaanse tydskrif vir kommunikasieafwykings. die suid-afrikaanse vereniging vir spraaken gehoorheelkunde, posbus 31782, braamfontein 2017. suid-afrika. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 43 gehoorsiftingsresultate van 'η groep kleurlingleerlinge santie meyer, m(log) (pretoria) marina hurter, b(log) (pretoria) felicity van rensburg, ba(log) (pretoria) departement spraakheelkunde en oudiologie, universiteit van pretoria. opsomming gehoorsifting wat bestaan het uit suiwertoon en immitansiesiftingsprosedures is uitgevoer op 201 graad i-leerlinge in twee laerskole in die kleurlingwoonbuurt, eersterust. 15,7% van die ore wat getoets is, het nie voldoen aan die kriteria vir gehoor binne normale perke nie. daar is gevind dat 2ψο sensories neurale gehoorverliese en 13,6ψο middeloortoestande vertoon. die kinders uit die lae sosioekonomiese omgewing vertoon 'n geringe verhoogde voorkoms van middeloorprobleme volgens die immitansiesiftingstoetse. as gevolg van die stremmende effek van selfs 'n geringe of fluktuerende gehoorverlies op opvoedkundige vordering, word gereelde oudiologiese dienste vir die skole aanbeveel. abstract auditory screening consisting of pure tone and immittance screening tests was carried out on 201 grade i pupils from two primary schools in the coloured residential area of eersterust. 15,7% of the ears tested did not comply with the criteria of hearing within the normal ranges. it was found that 2<vo exhibited sensory neural hearing losses while 13,6ψο displayed middle ear pathologies. immittance screening showed a slightly higher incidence of middle ear pathology in the lower socio-economic group than in the higher socioeconomic group. in view of the negative effect that even a slight or fluctuating hearing loss can have on school achievement it is recommended that audiological services be rendered regularly to these schools. "the ultimate goal in every country must be to act against all major causes of avoidable deafness. the first requirement ... is to identify ... communities that have an unacceptable amount of deafness." (wilson, 1985, p. 3.) in suid-afrika is daar nog maar net 'n begin gemaak om bogenoemde doelstelling te bereik, naamlik om hoerisikogemeenskappe te identifiseer. so is byvoorbeeld 'n besonder hoe voorkoms van ooren gehoorprobleme (22,5%) reeds by 'n groep kleurlinglaerskoolkinders ouer as 10 jaar gei'dentifiseer (pretorius, 1984). die resultate is verklaar na aanleiding van die algemene lae sosio-ekonomiese status (pretorius, 1984) by die groep kinders en al die faktore wat hiermee verband hou, byvoorbeeld maatskaplike probleme, ontoereikende mediese dienste, oorbevolking in huisvesting, onvoldoende verhitting tydens wintermaande (klein, 1978; van der walt, 1983) en afwesigheid van gereelde gehoorsiftingsprogramme by die skole (pretorius, 1984). bogenoemde ouderdomsgroep (ouer as 10 jaar) toon gewoonlik 'n laer voorkoms van ooren gehoorprobleme as jonger kinders (klein, 1978). dit is egter juis by die jonger kinders waar die teenwoordigheid van selfsi 'n geringe of fluktuerende gehoorverlies 'n nadelige effek op die kind se spraaken taalontwikkeling kan he (teele, klein en rosner, 1981; bess, 1985). die nadelige effek van selfs 'n geringe sensories neurale gehoorverlies tydens die taalaanleerperiode sowel as die effek op skolastiese prestasie is al deeglik beskryf (northern en downs, 1984; bess, 1985). terselfdertyd kry die negatiewe effek van middeloorpatologie toenemend meer aandie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 dag in die literatuur (bess, 1985). middeloorpatologie veroorsaak nie net verlaagde sensitiwiteit en dus verminderde stimulasie nie, maar in sommige gevalle ook foutiewe klankwaarneming. dit volg dus logies dat daar by die kinders onvoldoende taalen persepsieontwikkeling plaasvind (van der walt, 1983). dit veroorsaak uiteraard swak taalgebruik, 'n arm taalkennis en in sommige gevalle onbevredigende sosialisering (teele et al. 1981). veral in lae sosio-ekonomiese omstandighede word die probleme geaksentueer waar middeloorpatologie in wisselwerking tree met faktore soos wanvoeding, sosiokulturele ongelykheid, lae motivering en swak algemene gesondheid (lewis, 1976). in 'n samelewing wat toenemend meer staat maak op kommunikasie en prestasie is dit raadsaam om alle omstandighede nodig vir linguistiese, intellektuele en sosiale ontwikkeling optimaal te hou. alle kinders behoort geregtig te wees op vermoens wat nie beperk is deur ouditiewe deprivasie nie (ruben, 1985). deur die vroee identifikasie van kinders met gehoorverliese kan tydige hulpverlening die opvoedkundige en kognitiewe gevolge van gehoorverlies voorkom of verminder. op dieselfde wyse kan die ekonomiese gevolge van 'n gehoorverlies beperk word. indien die probleme ongei'dentifiseer bly, moet die kind soms in spesiale onderwys geplaas word. dit het groot finansiele implikasies vir die staat. net so sou 'n verlies aan mannekrag-inkomste as gevolg van onvoldoende beroepsopleiding van die gehoorgestremde finansiele implikasies vir die staat inhou (northern en downs, 1984). © s a s 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 santie meyer, marina hurter en felicity van rensburg in hierdie studie is gepoog om die voorkoms van ooren gehoorprobleme by graad i-leerlinge wat uit 'n lae sosio-ekonomiese omgewing kom, sowel as 'n groep wat uit 'n hoer sosio-ekonomiese omgewing kom, te bepaal. in beide gevalle is daar nie gereelde oudiologiese dienste vir die skole beskikbaar nie. dit is dus nie bekend of die populasie 'n hoerisikogroep vir gehoorverlies is nie. eksperiment: proefpersone: vir die doel van hierdie studie is twee laerskole in die kleurlingwoonbuurt, eersterust, geselekteer. in beide skole is al die graad i-leerlinge getoets. die een groep van 78 kinders was in 'n laerskool in 'n beter sosio-ekonomiese area. die tweede groep van 123 kinders was in 'n laerskool in 'n lae sosio-ekonomiese omgewing waar 'n groot aantal ouers werkloos was. die sosio-ekonomiese groepe is dus op grond van geografiese ligging verdeel waar een gebied hoofsaaklik sub-ekonomiese behuising gehad het en die ander 'n relatief meer gegoede area was waar baksteenhuise meer voorgekom het. apparaat: 'n oorondersoek is deur middel van 'n otoskoop uitgevoer. 'n madsen model tbn60 oudiometer sowel as 'n maico model ma-17 oudiometer is gebruik vir die suiwertoonsiftingstoetse. die oudiometer is voor die aanvang van die studie volgens iso 1964 standaarde geyk en daagliks psigoakoesties nagegaan. die impedansoudiometriese siftingsprosedures is deur middel van 'n american electro-medics timpanometer 85 ar uitgevoer. toetsomgewing: klankdigte fasiliteite was nie by die skole beskikbaar vir suiwertoonsiftingsoudiometrie nie. vertrekke weg van die klaskameraktiwiteite is vir die doel geselekteer. klankpeilmetings is deur middel van 'n briiel en kjaer klankpeilmeter 2203 en oktaaffilter 16b by oktaaffrekwensies gemaak, en dit het binne die toelaatbare norme vir suiwertoonsifting geval (ansi s3.6-1969 soos aangehaal deur bess en mcconnell, 1981). toetsafnemers: die oorondersoek en oudiometriese siftingsprosedures is deur 3 oudioloe van die departement spraakheelkunde en oudiologie, universiteit van pretoria, uitgevoer. 'n standaardtoetsprosedure is vooraf bepaal ten einde verskille in tegnieke te voorkom (northern en downs, 1984). prosedure: 1. •dataversameling: die volgende prosedures, soos voorgestel deur asha, naamlik guidelines for identification audiometry (1975 in ross en giolas, 1978) en middle ear screening criteria (1978 in bess en mcconnell, 1981) is ten opsigte van elke kind gevolg. — 'n otoskopie is uitgevoer met die doel om oormatige oorwas en otoree te identifiseer met die oog op suksesvolle uitvoering van siftingsimpedansoudiometrie. — die siftingsimmitansiemetings het daarna gevolg en het 'n akoestiese refleks by 100 hz en timpanometrie ingesluit. — hierna is die kind onderwerp aan die suiwertoonsiftingstoets. suiwertone is by 1000, 2000 en 4000 hz aangebied. volgens northern en downs (1984) is hierdie prosedure voldoende om middeloorpatologie en sensories neurale verliese in kinders te identifiseer. 2. dataverwerking: vir die verwerking van die rou data is die toetsgegewens wat by elke kind verkry is, afsonderlik in tabelvorm uiteengesit. in die tabel is daar teenoor elke oor van elke kind aangedui of die toets geslaagd was of gefaal het. die volgende kriteria vir slaag en faal is vir die suiwertoonen immitansiesiftingstoetse onderskeidelik toegepas. — suiwertoonsiftingstoetse: ten einde die toetse te slaag, moes die kind respondeer by 20 db gp by 100 en 2000 hz en by 25 db by 400 hz in albei ore (asha, 1975 in ross en giolas, 1978). indien daar nie 'n respons by enige van bogenoemde intensiteite ontlok kon word nie, het die kind nie die toets geslaag nie, en is 'n drempel vir die frekwensie bepaal en aangeteken. — immitansiesiftingstoetse: slaag/faal-kriteria soos voorgestel deur asha (1978 in bess & mcconnell, 1981), is gebruik. om die toets te slaag, moes 'n ipsilaterale akoestiese refleks teenwoordig wees by 1000 hz teen 105 db kdp, asook 'n timpanogram met 'n normale middeloordruk (jl 50 mm h2o) of met 'n geringe positiewe (+ 50 tot + 100 mm h2o) of negatiewe (-50 tot -200 mm h2o) middeloordruk. wanneer die middeloordruk afwykend is en die akoestiese reflekse teenwoordig of die middeloordruk normaal of gering positief of negatief of abnormaal is en die akoestiese reflekse afwesig is, slaag die persoon nie die toets nie (asha 1978 in bess en mcconnell, 1981). j — statistiese berekeninge: ' j 'n steekproefproporsie is vir 'n populasieproporsie gebruik; waar s = \j px̂ ~pi (binomiale distribusie) om te bepaal of daar' betekenisvolle verskille tussen groepe voorkom. 1 resultate: in tabel 1 word 'n aanduiding gegee van die aantal kinders en ore wat albei siftingstoetse geslaag het. uit tabel 1 blyk dit dat van die 201 kinders wat getoets is 76,6% op beide toetse slaag en 7,7% slegs in een oor aan al die vereistes voldoen. 84,3% van die ore van die kinders het dus tydens toetsing gehoordrempels binne normale perke en normale middeloorfunksionering getoon, terwyl 15,7% een of albei van die toetse gefaal het. the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gehoorsiftingsresultate van 'η groep kleurlingleerlinge 45 tabel 1: aantal kinders (en ore) wat albei siftingstoetse slaag hoer sosio-ekonomiese omgewing lae sosio-ekonomiese omgewing totaal kinders ore %ore kinders ore %ore kinders ore %ore ν = 78 n= 156 n= 123 ν = 246 ν = 201 ν = 402 aantal kinders waarvan beide ore toetsing slaag 62 124 79,5% 92 184 74,8% 154 308 76,6% slegs een oor slaag toetsing 12 12 7,7% 19 19 7,7% 31 31 7,7% totaal 136 87,1% 203 82,5% 339 84,3% alhoewel daar by die skool in die hoer sosio-ekonomiese omgewing 'n effens hoer slaagsyfer is as by die een in die lae sosio-ekonomiese omgewing, is die verskil gering (87,1% en 82,5% respektiewelik). hierdie betreklik hoe slaagsyfer, selfs by die kinders in die lae sosio-ekonomiese omgewing, is onverwags, aangesien studies op kinders van lae sosio-ekonomiese populasies (fay, 1972) en in lae-inkomstegroepe (northern en downs, 1984) dikwels 'n faalsyfer hoer as 15,7% toon. ten einde nou die aard van die ooren gehoorprobleme wat by die kinders van die studie voorgekom het, uit te lig, word die afwykende resultate van die gehoorsiftingsprogram aan die hand van afsonderlike tabelle bespreek. uit tabel 2 blyk dit dat slegs 2,2% van die ore wat getoets is die suiwertoonsiftingstoets faal, maar die immitansiesiftingstoets slaag. verder het 7 ore 'n geringe, een oor 'n gemiddelde en een oor 'n totale gehoorverlies vertoon. tabel 2: aantal ore wat die suiwertoonsiftingstoets / faal, maar die immitansiesiftingstoets slaag graad van lae sosio; hoer sosiosuiwertoonekonomiese ekonomiese totaal gehooromgewing omgewing (n = 402) verlies (n = 246) (n= 156) geringe gehoorc ' 9 7 verlies (26-40 db) 5 1 δ gemiddelde gehoorverlies 1 0 1 (42-55 db) totale gehoor0 1 1 verlies (96 db +) 0 1 1 totale aantal ore % 1,9% 2,2% totale aantal ore % 2,4% 1,9% 2,2% omdat die immitansieresultate in die gevalle normaal was, word die afleiding gemaak dat die afnames in gehoor te wyte is aan sensories neurale aantasting (fitzzaland en zink, 1984). die resultate by kinders in 'n hoer en in 'n lae sosio-ekonomiese omgewing verskil nie betekenisvol van mekaar op die 95% vlak van betekenis nie (p = 1,92% _+_ 2,16% en ρ = 2,44 jl 1,93%). verder vergelyk dit goed met die voorkoms in ander kinderpopulasies (2l k%) en is ook laer as die voorkomssyfer in 'n lae sosio-ekonomiese populasie — "inner city" kinders, nl. 19% (fay 1972; doster, 1972, aangehaal deur northern en downs, 1984). in tabel 3 word die aantal ore in beide die hoer en die lae sosio-ekonomiese omgewing ten opsigte van die afwykende immitansiesiftingsresultate aangedui. uit tabel 3 blyk dit dat 11,9% van die ore 'n middeloortoestand vertoon wat nie hul suiwertoongehoorsensitiwiteit bei'nvloed nie. dit is verder opvallend dat daar meer afwykende resultate in die lae sosio-ekonomiese omgewing as in die hoer sosio-ekonomiese omgewing voorkom — 13.8% teenoor 8,9%. die verskil is egter nie betekenisvol op die 95% vlak van betekenis nie (p= 13.82% _±_ 4,31% en ρ = 8.97% jl 4,49%). wat verder in die resultate in tabel 3 opval, is dat die grootste aantal ore wat die sifting gefaal het, normale tipe a-timpanogramme, normale std's, maar afwesige akoestiese reflekse vertoon. uit die 402 ore is dit 7,5%. die resultate is in ooreenstemming met die 30,4% ore met soortgelyke resultate in fitzzaland en zink (1984) se data. die verklaring hiervoor is nie duidelik nie, maar daar kan gespekuleer word dat die refleks sensitief is in die identifikasie van subkliniese toestande (fitzzaland en zink, 1984) of dat die refleksboog nog nie ten voile ontwikkel is nie (jerger, 1970). veral in laasgenoemde geval word die effektiwiteit van die insluiting van die akoestiese reflekse in die siftingsbattery bevraagteken. in die geval van tipe ben c-timpanogramme, maar normale suiwertoonresultate, vertoon die kinders met ander woorde nie gehoorverlies nie, maar wel 'n middeloorpatologie (jerger en hayes, 1980). die relatief hoe voorkoms van die tipe resultate is al by die ouderdomsgroep en jonger kinders opgeteken (jerger en hayes, 1980) en word hoofsaaklik aan buis van eustachius disfunksie of otitis media toegeskryf (jerger, 1970). die resultate moet egter in samehang met tabel 4 gesien word. in tabel 4 word die aantal ore met spesifieke timpanogram en akoestieserefleksresultate vir beide die hoe en lae sosioekonomiese omgewings uiteengesit. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) santie meyer, marina hurter en felicity van rensburg tabel 3 afwykende immitansiesiftingsresultate maar normale suiwertoonsiftingsresultate hoer sosio-ekonolae sosio-ekonototaal miese groep (n= 156) miese groep (n = 246) (n = 402) timpanogram akoestiese refleks aantal ore % aantal ore % aantal ore % a afwesig 7 4,5 23 9,3 30 7,5 β afwesig 4 2,6 9 3,7 13 3,2 ci afwesig 2 1,3 0 0 2 0,5 c 2 teenwoordig 1 0,6 1 0,4 2 0,5 c 2 afwesig 0 0 1 0,4 1 0,24 totaal 14 8,9% 34 13,8% 48 11,9% a = normale timpanogram met immitansiepiek by of naby ο dapa β = plat met geen duidelike piek ci = geringe negatiewe middeloordruk (-50 tot-200 dapa) c2 = negatiewe middeloordruk (kleiner as -200 dapa) tabel 4. afwykende immitansieen suiwertoonsiftingsresultate hoer sosio-ekonomiese lae sosio-ekonomiese totaal omgewing (n = 156) omgewing (n = 246) (n = 402) timpanogram akoestiese refleks aantal ore % aantal ore % % β afwesig 4 2,56 2 0,8 1,49 as afwesig 0 0 1 0,4 0,24 totaal 4 2,56 3 1,2 1,74 as = 'n timpanogram met verlaagde amplitude met 'n immitansiepiek by of naby ο dapa β = plat met geen duidelike piek uit tabel 4 blyk dit dat 1,74% van die 402 ore wat getoets is, op beide die suiwertoonen impedanssiftingstoetse uitval. in die geval is die verskil tussen die hoer en laer sosioekonomiese omgewings onbeduidend klein (p = 2,56% 2,48% en ρ = 1,22% ± . 1,37%). wat verder in die resultate van tabel 4 opval, is dat die grootste aantal ore (6 uit 7) tipe b-timpanogramme en afwegige akoestiese reflekse vertoon. uit vorige navorsing kan daar voorspel word dat hierdie middelooreffusie vertoon (bluestone, beery & paradise, 1973; orchik, dunn & mcnutt, 1978) en waarskynlik nie so vinnig sal normaliseer as die met tipe c-timpanogramme nie (fiellau-nikolajsen en lous, 1979). dit is ook moontlik dat hierdie kinders 'n gemengde gehoorverlies kan he (fitzzaland en zink, 1984). wanneer die resultate van tabel 3 en 4 gesamentlik bestudeer word, blyk dit dat daar uit die totale populasie 13,6% (tabel 3 = 11,9% en tabel 4 = 1,74%) moontlike gevalle van middeloorpatologie teenwoordig is (jerger, 1970). aangesien die bevindings nie gekontroleer is met 'n otoskopiese ondersoek deur 'n oor-, neusen keelarts nie, en daar ook nie 'n opvolgsiftingstoets uitgevoer is om vals positiewe resultate te verminder nie (fiellau-nikolajsen en lous, 1979), is hierdie syfer waarskynlik effens kleiner. wanneer hierdie resultate egter vergelyk word met ander hoerisikokinderpopulasies, blyk dit egter dat daar nie 'n kommerwekkende hoe voorkoms van oorof gehoorprobleme is nie. die % middeloorpatologie (of % prevalensiesyfers) wat in vergelykbare studies berig word, is in heelwat gevalle meer as in hierdie studie, byvoorbeeld: ouer kleurlingkinders : 22,5% (pretorius, 1984) meksikaanse kinders : 32% (berruecos, 1981) en kinders in kuwait : 31% (al-fadala en holmquist, 1984) wanneer dit egter vergelyk word met amerikaanse 4tot 6-jariges se voorkoms van slegs 3,5% middeloorprobleme, is dit hoog, en blyk dit duidelik dat meer aandag aan gehoorkonservering by hierdie groep kinders gegee moet word. gevolgtrekking uit die resultate van hierdie studie blyk dit dus dat daar 'n relatiewe hoe voorkoms (15,7%) van middeloorprobleme en moontlike sensories neurale gehoorverliese aanwesig is. alhoewel al die kinders wat op die gehoorsiftingstoetse uitgeval het, slegs in 'n geringe mate gehoorgestrem is, is daar al meer bewyse dat juis die kinders, spraak-, taal-, kognitiewe en skolastiese probleme ondervind (bess, 1985). by die groep word die kind met middeloorpatologie met en sonder gehoorverlies, die kind met 'n unilaterale sensories neurale verlies, sowel as die kind met geringe bilaterale sensories neurale verliese (bess, 1985) ingesluit. om dus te voorkom dat die sowat 16% kinders nie hul voile potensiaal kan bereik nie, is oudiologiese dienste in die gebied noodsaaklik. / soos bewys deur verskeie ander studies oor gehoorsiftingsprosedures by kinders (onder andere orchik en herdman, 1974) blyk dit ook uit hierdie studie'dat 'n kombinasie van suiwertoonen immitansiesiftingstoetse meer sensitief is vir die identifisering van ooren gehoorprobleme as die toepassing van slegs suiwertoonsiftingstoetse. the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gehoorsiftingsresultate van η groep kleurlingleerlinge 47 opsommend het hierdie studie 'n bydrae gelewer om hoerisikogemeenskappe vir ooren gehoorprobleme in suidafrika te help identifiseer. 'n verdere verantwoordelikheid rus op alle belanghebbendes om die inligting verder uit te brei en na aanleiding van die bevindings praktiese en kosteeffektiewe oplossings vir die probleme te formuleer (wilson, 1985). erkenning hierdie studie vorm deel van die "eersterus projek" van die departement spraakheelkunde en oudiologie wat deur die universiteit van pretoria befonds word. verwysings al-fadala, s., en holmquist, j. otoscopy and tympanometry in screening for middle ear disorders in children. scandinavian audiology, 13, 297-299, 1984. berruecos, p. identification of hearing problems in children using impedance measurements. in r. penha, en p. de n. pizarro, (reds.) acoustic impedance measurements. lissabon: universidade nova de lisboa, 1981. bess, f.h. the minimally hearing impaired child. ear and hearing, 6,43-47, 1985. bess, f.h., en mcconnell, f.e. audiology, education and the hearing impaired child. londen: the c.v. mosby company, 1981. bluestone, c.d., beery, q.c., en paradise, j.l. audiometry and tympanometry in relation to middle ear effusions in children. laryngoscope, 83, 594-604, 1973. fay, t.h. audiologic and otologic screening of disadvantaged children. in a. glorig en k. gerwin (reds,) otitis media. springfield, illinois: charles c. thomas, 1972. fiellau-nikolajsen, m., en lous j. prospective tympanometry in 3 year old children. archives of otolaryngology, 105, 461-466, 1979. fitzzaland, r.e., en zink, g.d. a comparative study of hearing screening procedures. ear and hearing, 5, (4), 205-210, 1984. jerger, j. clinical experience with impedance audiometry. archives of otolaryngology, 92, 311-324, 1970. jerger, j., en hayes, d. diagnostic applications of impedance audiometry: middle ear disorder; sensori-neural disorder. in j. jerger en j. northern (reds.) clinical impedance audiometry (2nd ed.). acton, m.a.: american electromedics, 1980. klein, j.o. epidemiology of otitis media. in e.r. harford, f.h. bess, c.d. bluestone en j.o. klein (reds.). impedance screening for middle ear disease in children. new york: grune & stratton, 1978. lewis, n. otitis media and linguistic incompetence. archives of otolaryngology, 102, 387-390, 1976. northern, j.l., en downs, m.p. hearing in children. baltimore, maryland: the williams & wilkins company, 1984. orchik, d.j., dunn j.w., en mcnutt, l. tympanometry as a predictor of middle ear effusion. archives of otolaryngology, 104, 4-6, 1987. orchik, d.j., en herdman, s. impedance audiometry as a screening device with school age children. the journal of auditory research, 14, 283-286, 1974. pretorius, a. aard en voorkoms van gehoorpatologiee in 'n laerskool vir normaalhorende kleurlingkinders. ongepubliseerde β logverhandeling. universiteit van pretoria, 1984. ross, n., en giolas, t. (reds.) auditory management of hearingimpaired children. baltimore: university park press, 1978. ruben, r.j. recurrent middle ear effusion affects preschool language and learning. audiology in practice, 1, (3), 5, 1985. teele, d.w., klein, j.o., en rosner, b. effects of persistent middle ear effusion (pmee) in development of speech and language. pediatric research, 15, 623, 1981. van der walt, m. sekere ouditiewe spraakpersepsie-vermoens by kinders, tydens 'n episode van otitis media teenoor 'n tydperk vry van die siektetoestand. ongepubliseerde μ log-verhandeling, universiteit van pretoria, 1983. wilson, j. deafness in developing countries. archives of otolaryngology, 111, 2-9, 1985. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) telos® a remote-control unit for in-the-ear hearing-aids an ultrasound transmitter for remote control of in-the-ear aids, now available for the siemens "cosmea" miniature aid. weighing merely 40 grams, in credit card format, it allows the user to adjust volume and tone inconspicuously. telos from siemens is the first of its kind world-wide. for more information write to: ro. box 1032 parklands 2121 name: address: code: telephone: s times 2/r telephone springs (011) 56-2617 johannesburg (011)29-6359 boksburg (011)52-3929 rosebank (011)880-3310 roodepoort (011)679-1155 bloemfontein (051)8-1111 pretoria (012)26-7874 telos professional service backed by siemens technolog^^j creative consultants 2 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'ν akoestiese ontleding van die glottale puls van sekere stempatologiese verskynsels emily groenewald m.a. (log) (pretoria) akoestiek afdeling, nasionale fisiese navorsingskboratorium, w.n.n.r., pretoria opsomming 'n uitgebreide akoestiese analise van die glottale golf-vorm van normale en patologiese stemme deur middel van 'n unieke opnametegniek en analiseproses is gedoen met die oog o p 'n kritiese evaluering van die toepassingsmoontlikhede van die metode en inligting wat verkry kan word. by die ondersoek is 15 normale en 17 abnormale stemme betrek. die abnormale groep sluit in toestande soos karsinoma, nodules, poliepe, papiloma, ventrikulere fonasie en stemlipverlammings. 'n fluktuasiefaktor of afwykingsfaktor vii elke parameter in 5 fonasiewyses van elke afwykende stem is bepaal. elke abnormale stem is individueel met die normale groep vergelyk en dit blyk dat die afwykingsfaktore verband hou met die graad en omvang van die patologie. aanduidings bestaan dat daar tipiese resultate vii spesifieke patologiese toestande mag wees en dit blyk dat die metode beslis potensiele waarde inhou vir die objektiewe evaluering en beskrywing van die stem, sow el as hulpmiddel in stemterapie. summary this research is concerned with an acoustic analysis of the glottal-wave shape of both normal and pathological voices using a unique recording technique and analysis procedure, and includes a critical evaluation of the practical feasibility of the method and the possible application of the resulting information. fifteen normal and seventeen abnormal voices were analysed during the investigation. conditions such as carcinoma, nodules, vibration of the false vocal cords, polyps, papillomas and vocal cord paralysis occur in the abnormal group. a fluctuation factor or abnormality factor was determined for every parameter of five phonation modes, for all abnormal voices. every pathological voice was compared with the normal group and it appears that the abnormality factor correlates with the degree and possibly t o some extent with the nature of the pathology. it appears that this method is potentially valuable for the objective evaluation and description of voices, particularly in the field of voice therapy. die menslike stem, soos in die larinks opgewek, is die produk van 'n delikate interaksie tussen verskillende anatomiese en fisiologiese faktore. moore 1 4 wys daarop dat larinkspatologiee dikwels met die meganisme van fonasie inmeng en smith1 8 kom tot die gevolgtrekking dat verskillende patologiee lei tot verskillende veranderings in die strukturele en fisiologiese faktore wat die stemkwaliteit bepaal. aangesien die glottale drukgolfpatroon die direkdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 90 emily groenewald te produk van die stemlipvibrasies is, kan daar verwag word dat veranderings in die fisiese toestand en werking van die stemorgaan in die golfpatroon gereflekteer sal word. onlangse navorsing dui daarop dat die akoestiese analise van die stem moontlik die eerste akkurate informasie aangaande patologiese veranderings in die larinks kan verskaf.23 normale stemlipvibrasie produseer 'n reeks relatief eweredige drukgolwe wat as 'n musikale of gelykmatige klank gehoor word. die eweredige klankgolwe word slegs opgewek wanneer albei stemlippe eweredig teen dieselfde frekwensie vibreer en albei stemlippe 'n redelike mate van periodisiteit handhaaf.1 3 die stemlippe is egter twee aparte onafhanklike vibrators wat elk funksioneer op grond van die inherente fisiologiese eienskappe daarvan. die stemlippe sou dus verskillend beweeg indien die fisiese eienskappe van die een stemlip verskil van die ander een. indien die gekombineerde werking van die twee afsonderlike stemlippe 'n reeks drukveranderings tot gevolg het wat na willekeur varieer in terme van tyd en/of amplitude, word die klank wat so geproduseer word as grof en skor waargeneem.13 verskeie ondersoeke wat in die verband gedoen is, bevestig die b e w e r i n g s . 1 , 4 , 2 5 van die vroegste studies op die gebied van patologiese stemlipvibrasies vestig die aandag op die asinchronisme in die vibrasiepatroon wat by die gevalle aangetref word en die gereelde vinnige fluktuasies in die golfpatroon van afwykende stemme. 2 2 verskeie studies is gedoen met betrekking tot die fluktuasies in amplitude en periode van die golfpatroon van normale en patologiese stemme. daar is gevind dat die fluktuasies normaalweg voorkom maar by afwykende stemme groter is as by normale stemme. 9 ' 1 0 ' 1 6 ' 1 7 ' 2 0 die resultate van 'n verskeidenheid akoestiese analises van patologiese stemme toon dat fluktuasies in die golfpatroon lei tot die persepsie van abnormale stemkwaliteit en verskeie navorsers wys daarop dat die fluktuasies verband hou met die aard, omvang en posisie van die patologie. 6 ' 1 1 · 2 5 'n literatuuroorsig in die verband bring egter bepaalde aspekte en moontlike tekortkominge onder die aandag. dit is onder meer opvallend dat ondersoeke beperk is tot die grondtoonfrekwensie en pulsamplitude of slegs een van die parameters.5 · 6 ' 1 8 in die meeste gevalle word ook slegs fonasie by 'n normale toonhoogte en luidheid ondersoek. uit die oorsig blyk ook dat baie min aandag tot op hede gegee is aan die moontlike waarde van analiseresultate as hulpmiddel by stemterapie. navorsers beklemtoon egter die noodsaaklikheid van die ontwikkeling van verbeterde tegnieke en instrumentasie vir die tipe ondersoeke. bogenoemde aspekte is by die studie in gedagte gehou. metode d o e l die doel van die studie is drieledig van aardlen kan as volg uiteengesit word: 1. 'n akoestiese ontleding van die glottale golfvorm van normale en patologiese stemme deur middel van 'n unieke opnametegniek en analiseproses. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η akoestiese ontleding van glottale puis 91 2. 'n kritiese evaluering van die opnametegniek en analiseproses. 3. 'n evaluering van die inligting wat verkry is, met die oog op moontlike toepassings.· s e l e k s i e v a n p r o e f p e r s o n e in die ondersoek is gebruik gemaak van 'n eksperimentele groep met 'n verskeidenheid van stempatologiee en 'n kontrole groep van normale stemme. die kontrole groep het bestaan uit 15 persone, 5 mans en 10 vroue, met 'n gemiddelde ouderdom van 30 jaar. die proefgroep het bestaan uit 17 persone, 11 mans en 6 vroue, met 'n gemiddelde ouderdom van 39 jaar. die seleksie is gedoen op grond van stemkwaliteit, dit wil se normale en afwykende stemkwaliteit en/of die fisiese toestand van die stem soos vasgestel met behulp van indirekte laringoskopie deur 'n onk-arts. basiese inligting in verband met elke spreker in die eksperimentele groep word in die ondergaande tabel weergegee. proefdiagnose op grond van ingeslag ouder-persoon nr. direkte laringoskopie geslag dom 1 akute laringitis μ 11 2 akute laringitis v 45 3 bilaterale stemlipedeem μ 28 4 bilaterale stemlipedeem μ 60 5 funksionele disfonie/unilaterale μ 49 stemlipnodule(?) μ 49 6 bilaterale stemlipnodules v 35 7 bilaterale stemlipnodules v 35 8 bilaterale stemlipnodules v 17 9 bilaterale stemlipverdikking v 40 10 bilaterale poliepagtige stemlipμ 55 verdikking μ 55 11 bilaterale papiloma en unilateμ 12 rale poliep μ 12 12 opgeklaarde larinkskarsinoom μ 47 13 unilaterale stemlipkarsinoom μ 37 14 gevorderde larinkskarsinoom μ 43 15 unilaterale stemlipverlamming (met 'n onderliggende verspreide tiroiedμ 42 klierkarsinoom) 16 unilaterale stemlipverlamming v 40 17 vals stemlipfonasie μ 65 tabel i: basiese inligting in verband met elke spreker in die eksperimentele groep. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 92 emily groenewald o p n am e-app a r a a t 'n nie-weerkaatsende uniforme pyp soos voorgestel en beskryf deur sondhi1 9 is gebruik om die glottale drukgolf te isoleer van die resonatoriese beinvloeding van die supraglottale ruimtes. 'n muirhead probusmikrofoon, tipe h-l 12, is 30 cm vanaf die pypopening in die nie-weerkaatsende pyp geplaas en gekoppel aan 'n bruel + kjaer mikrofoonkragbron, tipe 2801. die sein is versterk deur 'n w.n.n.r. -vervaardigde lynversterker, model l62 en op scotch 175 magneetband opgeneem met behulp van 'n briiel + kjaer fm-bandmasjien, tipe 7003. die uitgangsein van die bandmasjien is op 'n ossilloskoop (tektronix 7623a) vertoon en vergelyk met die direkte sein vanaf die lynversterker waardeur die uitgangsein van die bandmasjien gekontroleer is ten opsigte van oorlaaidistorsie. die uitgangsein van die lynversterker is ook verbind met 'n w.n.n.r. -vervaardigde ruisgenerator in kombinasie met 'n versterker, asook 'n stel akg 260 oorfone. die intensiteit van stemterugvoering deur die oorfone kon met behulp van die versterker verander word en met behulp van die ruisgenerator kon ruis tydens fonasie bygevoegword, soos gebruik is vir opnames van fonasie met verhoogde luidheid. o p n a m e m a t e r i a a l en p r o s e d u r e tydens die opnames is van die proefpersone verwag om in die pyp te foneer met die artikulators in 'n posisie soos vir [a], soos voorgestel deur sondhi19, is die neutrale vokaal gebruik omdat dit die mees uniforme toestand van die stemkanaal verseker. 2 ' 1 5 opnames van verskillende fonasiewyses is gemaak met die doel om meer inligting in verband met die stemlipbeweging onder verskillende omstandighede te verkry. opnames van fonasie by vyf verskillende fonasiewyses is geanaliseer naamliktoestand nommer beskrywing van fonasiewyse normaal, dit wil se normale toonhoogte en normale luidheid hoog, dit wil se verhoogde toonhoogte en normale luidheid laag, dit wil se verlaagde toonhoogte en normale luidheid / sag, dit wil se normale toonhoogte en verminderde luidheid hard, dit wil se normale toonhoogte en verhoogde luidheid. ι opnames van fonasiewyses 1 tot 3 is gemaak sonder versterkte stemterugvoering deur die oorfone en sonder ruis. vir die opname van fonasiewyse 4 is die stemterugvoering deur die oorfone tot 'n konstante mate verhoog the south african journal of communication disorders, vol. 24, 1977 1 2 3 4 5 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η akoestiese ontleding van glottale puis 93 om spontane luidheidsvermindering te bewerkstellig. vir die opname van fonasiewyse 5 is die versterking konstant gehou soos vir fonasiewyse 4, terwyl ruis geleidelik opgedraai is en vir ±2 sek by 75 db (a) gehou is. die opnameprosedure is gevolg deur 'n uitgebreide analiseproses waardeur spesifieke eienskappe van die glottale pulsreeks gemeet en vergelyk is. analise-apparaat die bruel + kjaer fm-bandmasjien wat vir die opnames gebruik is, is gekoppel aan 'n w.n.n.r.-ontwerpte digitale eindelose lus, model 2a. 'n spesiale fasiliteit van hierdie instrument is dat dit baie maklik is om 'n kort gedeelte van 'n spraakmonster (byvoorbeeld een glottale puis) akkuraat en herhaalbaar te selekteer. die geselekteerde gedeelte kan dan terselfdertyd op die ossilloskoop vertoon word en beluister word. die uitgangsein van die eindelose lus is vertoon op 'n hewlett packard ossilloskoop, model 1200 b, met behulp waarvan pulse geselekteer is. die monsters van die geselekteerde pulse is na 'n hewlett packard rekenaar, model 9820 a gevoer, waar die analise gedoen is. die verlangde inligting is uitgetik en die golfvorm en spektrum van elke geanaliseerde glottale puis is uitgeteken op 'n rekenaarbeheerde hp x-y registreerder, model 9862 a. analisemetode 'n literatuuroorsig van vorige navorsing het aangetoon dat afwykings van normale reelmatige pulsparameters die mees belowende aanduiding is van 'n stempatologie. die parameters wat by uitstek gebruik is vir die doel is die pulsamplitude en herhalingsfrekwensie. op grond daarvan is besluit om in die studie bogenoemde 2 parameters te ondersoek asook fluktuasies in die botoonpatrone. uit die aard van die saak is die frekwensie van botone nie belangrik nie aangesien dit veelvoude van die grondtoonfrekwensie is. die amplitudes van 'n bepaalde aantal botone is dus, benewens die herhalingsfrekwensie en pulsamplitude, deur die analiseproses bereken. die piek-tot-piek amplitude van elke puis is deur middel van 'n eenvoudige subroetine in die rekenaarprogram bepaal en uitgetik. die herhalingsfrekwensie van die puis is met behulp van die rekenaar bereken deur 'n eenvoudige outokorrelasieproses, waardeur opeenvolgende pulse met mekaar gekorreleer is. sodoende is die puls-tot-puls periode vasgestel en die onmiddellike frekwensiewaarde bereken en uitgetik. die analiseproses waardeur volledige inligting in verband met die amplitudes van die botone verkry is, is die fourieranalise. dit is 'n wiskundige proses, met behulp waarvan die suiwertoonkomponente waaruit 'n saamgestelde golf (soos in did geval die glottale golf) bestaan, bereken kan word. 3 an a l i s e p r o s e d u r e die analiseprosedure het daaruit bestaan dat 8 opeenvolgende pulse in die middelgedeelte van elk van die 5 fonasiewyses van elke normale en patologiese stem met behulp van bogenoemde analisemetode ontleed is. die nodige inligting in verband met fluktuasies in die piek-tot-piek amplitude, puls-totdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 94 emily groenewald puis periode en die onderskeie botoon amplitudes van opeenvolgende pulse by elke normale en patologiese stem is sodoende verkry en gestoor vir statistiese verwerking. resultate die statistiese verwerking van analiseresultate het ingesluit die berekening en normalisering van standaard afwykings, berekening van 'n gekombineerde standaard afwyking vir die normale groep en die berekening van 'n 95% betroubaarheidsvlak vir elke parameter van elke fonasiewyse. op grond van bogenoemde verwerkings is 'n fluktuasiefaktor of afwykingsfaktor vir elke afwykende stem bepaal vir elke parameter van elke fonasiewyse. elke patologiese stem is sodoende individueel met die normale groep vergelyk. 'n kwalitatiewe bespreking van die resultate die analiseresultate kan oorsigtelik as volg saamgevat word: (a) fluktuasies in die periode, piek-tot-piek amplitude en botoon amplitudes van die patologiese stemme toon wyer verspreidings as die van die normale stemme en hou verband met die omvang van die patologiese toestand. (b) alhoewel daar min of geen ooreenkoms tussen verskillende gevalle met dieselfde patologiese toestand in die beperkte eksperimentele groep gemerk kon word nie, toon die resultate in verskeie gevalle potensiele waarde as diagnostiese hulpmiddel: (i) die analiseresultate het in 3 gevalle gedui op patologiese toestande wat nie met behulp van 'n aanvanklike indirekte laringoskopie opgemerk is nie (proefpersone 5, 8 en 15); (ii) resultate kan moontlik dien as bevestiging van tentatiewe diagnoses soos in die geval van proefpersoon 17; (iii) die moontlikheid bestaan dat die reelmatigheid van die glottale pulsvorm 'n aanduiding van 'n verlammingstoestand kan wees soos by proefpersoon 16; (iv) dit is moontlik dat 'n onreelmatige aanwesigheid van afwykingsfaktore tipies kan wees van 'n laringitistoestand soos by proefpersone 1 en 2;en (v) daar is sterk aanduidings dat tipiese fluktuasiepatrone hoofsaaklik verband hou met die basiese histologiese of strukturele aard, omvang en implikasies van 'n patologie, en nie soseer met die spesifieke patologie nie. die bewering word gebaseer op resultate van proefpersone 4, 7, 10 en 11. (c) resultate in die studie kan moeilik direk vergelyk word met vorige navorsingsresultate, omdat die opnamemetode, analisemetode en statistiese verwerking van die resultate verskil van die in ander studies. daar bestaan egter wel algemene ooreenkomste, byvoorbeeld: (i) die bevinding dat fluktuasies wel voorkom in normale stemme, stem ooreen met bewerings van maeda et a l . 1 2 en zemlin;26 the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η akoestiese ontleding van glottale puis 95 (ii) die resultate van die studie toon aan dat fluktuasies meer algemeen is by patologiese stemme en bevestig bevindings van lieberm a n , 1 1 von leden en koike 2 3 en iwata en von leden ; 5 (iii) die bevinding dat die fluktuasies verband hou met die omvang van die patologie stem ooreen met bevindings van smith en lieberm a n , 1 8 lieberman,11 von leden en koike,2 3 iwata en von leden 5 en koike en markel;8 en (iv) die potensieel waardevolle rol van 'n golfvorm analise as hulpmiddel by diagnose en objektiewe evaluasie by terapie, word onderskryf deur navorsing van wechsler.24 (d) die resultate van die studie dui op die waarde van die meting van botoon amplitudes soos gevind is by proefpersoon 1 en 13 en dui op die waarskynlike waarde van metings van addisionele hoer botone soos by proefpersone 7 en 8. (e) resultate dui ook op die waarde van metings van verskillende fonasiewyses waardeur waardevolle inligting verkry kan word, soos gevind is by proefpersone 4, 7, 10 en 11. gevolgtrekkings daar kan, met verwysing na die doel van die navorsing 'n evaluasie gemaak word van die opnametegniek, analiseproses, asook toepassingsmoontlikhede van die metode, op grond van die resultate van die akoestiese analise van die golfpatroon. 'n evaluasie van die opnametegniek en analisemetode tydens die opnameprosedures van die studie is gevind dat die praktiese gebruik van die nie-weerkaatsende pyp uiters gerieflik en ongekompliseerd is, vir die verkryging van 'n gei'soleerde glottale golfpatroon. die metode het besondere praktiese voordele, maar daar bestaan ook moontlike nadele.3 verdere navorsing op die gebied behoort egter van waarde te wees. die analiseproses is basies bevredigend deurdat dit 'n groot hoeveelheid inligting verskaf. addisionele inligting in verband met amplitudes van botone blyk in sommige gevalle van groot waarde te wees.3 verdere ondersoeke in die verband kan ook moontlik waardevol wees. moontlike praktiese toepassings van die resultate en metode die resultate van die ondersoek bevestig bewerings dat puls-tot-puls fluktuasies in die glottale golfpatroon 'n objektiewe aanduiding kan wees van die flsiese toestand van die stemorgaan. dit impliseer dat sodanige inligting van groot waarde kan wees in 'n terapeutiese sowel as diagnostiese situasie. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 96 emily groenewald moontlike toepassings in 'n terapeutiese situasie die bevinding dat die fluktuasies in die golfpatroon feitlik in alle gevalle verband hou met die afwyking in die vibrasiepatroon, dui op die moontlikheid om, op grond van die analiseresultate, 'n objektiewe evaluasie en numeriese aanduiding van die stemafwykings te maak. die vordering al dan nie van 'n disfonie pasient kan moontlik sodoende objektief bepaal word. sodanige bepaling kan 'n waardevolle aanduiding van sukses in terapie wees en kan dien a motivering vir die pasient. dit kan ook moontlik 'n aanduiding wees van die wenslikheid al dan nie van die pasient se ontslag. die resultate van proefpersoon 12 waar 'n larinkskarsinoom met behulp van bestraling opgeklaar is, dui op die moontlikheid dat doeltreffendheid van bestralingsterapie deur middel van die metode bevestig kan word. die moontlikheid ontstaan ook dat die doeltreffendheid van chirurgiese behandeling ook op die manier opgevolg kan word. die objektiewe evaluasie of numeriese aanduiding van stemafwykings kan moontlik as basis dien vir 'n meer bevredigende en wetenskaplike beskrywing van abnormale stemkwaliteit. die gebrek aan wetenskaplike beskrywing van stemabnormaliteite, blyk duidelik uit die verwarrende en soms niksseggende subjektiewe beskrywings van stemkwaliteit op grand van subjektiewe ouditiewe persepsie wat algemeen in die literatuur aangetref word. 2 1 die resultate dui op 'n moontlike oplossing van die probleem, maar sal verdere ondersoeke na 'n korrelasie tussen die ouditief perseptueleen analise inligting vereis. moontlike toepassings in 'n diagnostiese situasie die analiseresultate dui op die potensiele waarde van sodanige inligting as diagnostiese hulpmiddel. op grond van die bepaalde studie waarby slegs 17 proefpersone betrek is, met 'n verskeidenheid van 10 verskillende patologiese toestande waarvan sommige unilateraal en/of bilateraal voorkom, is dit nie moontlik om betroubare gevolgtrekkings met betrekking tot tipiese resultate vir 'n spesifieke toestand, te maak nie. daar is enkele aanduidings van moontlike tipiese resultate, en dit lei tot die gevolgtrekking dat verdere navorsing in die verband van groot waarde kan wees. daar bestaan egter sterk aanduidings dat tipiese resultate verband hou met die struktureel-histologiese implikasies van 'n patologiese toestand en nie noodwendig met 'n spesifieke patologie nie. die bewering word gebaseer op grand van die resultate van proefpersone 4, 7, 10 en 11. dit impliseer dat 'n differensiaal-diagnose waarskynlik nie op grond van akoestiese analiseresultate gemaak sal kan word nie, maar dat die inligting waarskynlik wel as basis vir 'n siftingstoets gebruik sal kan word. , 7 die onteenseglike waarde van so 'n objektiewe en omvangryke akoestiese analise, blyk uit die feit dat in drie gevalle, waarby die probleem nie met behulp van aanvanklike indirekte laringoskopiese ondersoeke gediagnoseer kon word nie, 'n onderliggende patologie of oorsaak op grond van die analiseresultate vermoed en bevestig is. die gevalle waama verwys word is proefpersone 5, 8 en 15. in sulke gevalle waar die analiseresultate nie verband hou met die sigbare patologie nie, kan dit dui op die noodsaaklikheid van verdere laringale ondersoeke. die moontlikheid van 'n funksionele afwyking waarby geen patothe south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η akoestiese ontleding van glottale puis 97 logiese toestand bestaan nie, moet egter steeds in gedagte gehou word en verdere ondersoeke in die verband, byvoorbeeld 'n ondersoek na tipiese resultate by funksionele stemafwykings, kan van groot waarde wees. die metode van akoestiese analise wat in die studie beskryf is, is geskik vir praktiese gebruik in bogenoemde situasies. die moontlikheid bestaan ook dat die proses grootliks geoutomatiseer kan word. sodanige outomatisering sal meebring dat 'n akoestiese analise van stemme deur onopgeleide personeel uitgevoer kan word. dit is duidelik dat die metode verskeie dinamiese toepassingsmoontlikhede het en by uitstek geskik is as hulpmiddel in stemterapie. resultate van die ondersoek dui egter ook op groot leemtes en veld vir verdere navorsing in verband met die fisiologiese veranderings en akoestiese implikasies in geval van stempatologiee. bedankjngs die outeur wil graag dr l. p. c. jansen, mnr l. joffe en die personeel van die akoestiek afdeling van die n.f.n.l. bedank vir hul waardevolle hulp asook die w.n.n.r. vir die geleentheid om die navorsing te doen en vir die gebruik van die fasiliteite. dank gaan ook aan mev. l. hill en die personeel van die spraakterapie departement van die kalafong hospitaal vir die hulp wat verleen is tydens die opnames. verwysings 1. coleman, r. f. (1971): effect ofwaveform changes upon roughness perception. folia phoniatrica, 23. 2. flanagan, j. l. (1972): speech analysis, synthesis and perception. springer-verlag, new york. 3. groenewald, e. (1977): 'n akoestiese analise van die glottale puis van sekere stempatologiese verskynsels. ongepubliseerde verhandeling, universiteit van pretoria. 4. ishizaka, k. and isshiki, n. (1976): computer simulation of pathological vocal cord vibration. j. acoust. soc. amer., 60, no. 5. 5. iwata, s. and von leden, h. (1970): pitch perturbations in normal and pathologic voices. folia phoniatrica, 22. 6. koike, y. (1967): application of some acoustic measures for the evaluation of laryngeal disfunction. j. acoust. soc. amer., 42, no. 5. 7. koike, y. (1969): vowel amplitude modulations in patients with laryngeal diseases. j. acoust. soc. amer., 45, no. 4. 8. koike, y. and markel, j. (1975): application of inverse filtering for detecting laryngeal pathology. ann. otol. rhinol. laryngol., 84. 9. koshikawa, τ. and sugimuto, t. (1962): the information rate of the pitch signal in speech. proceedings of the stockholm speech communication seminar, stl-kth. 10. lieberman, p. (1961): perturbations in vocal pitch. j. acoust. soc. amer., 33. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 98 emily groenewald 11.. lieberman, p. (1963): some acoustic measures of the fundamental periodicity of normal and pathologic larynges. j. acoust. soc. amer., 35, 3. 12. maeda, s., fujimura, 0 . and sawashima, m. (1968): voice aperiodicity in terms of pulse shape and interval. report on the 6th international congress on acoustics, tokyo. 13. moore, g. paul. (1971): organic voice disorders. prentice-hall inc., englewood cliffs, n.j. 14. moore, p. (1968): otolaryngology and speech pathology. laryngoscope, 78. 15. mrayati, m„ guerin, n. and boe, l. j. (1976): a study of the input impedance of the vocal tract in the coupling of source and tract. acustica, 35, no. 5. 16. risberg, a. (1962): statistical studies of fundamental frequency range and rate of change. proceedings of the stockholm speech communication seminar. stl-kth. 17. siato, s„ kato, k. and teranishi, n. (1958): statistical properties of the fundamental frequencies of japanese speech voices. j. acoust. soc. japan, 14. 18. smith, w. r. and lieberman, p. (1969): computer diagnosis of laryngeal lesion. computers biomedical research. 2. 19. sondhi, μ. m. (1975): measurement of the glottal wave. j. acoust. soc. amer., 57, no. 1. 20. sugimoto, t. and hiki, s. (1962): on the extraction of the pitch signal using the body wall vibration at the throat of the talker. proceedings of the stockholm speech communication seminar, stl-kth. 21. takahashi, h. and koike, y. (1976): some perceptual dimensions and acoustical correlates of pathologic voices. acta-oto-laryngol. suppl. 338. 22. vonleden.h., moore, p. andtimcke, p. (1960): laryngeal vibrations: measurements of the glottic wave. part iii: the pathologic larynx. arch. otolaryngol., 71. 23. von leden, h. and koike, y. (1970): detection of laryngeal disease by computer technique. arch. otolaryngol., 91. 24. wechsler, enid. (1976): laryngographic study of voice disorders. speech and hearing work in progress, university college, london. 25. wendahl, r. w. (1963): laryngeal analog synthesis of harsh voice quality. folia phoniatrica, 15, no. 4. 26. zemlin, w. r. (1968): speech and hearing science anatomy and physiology. prentice-hall, inc., englewood cliffs, n. j. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ago u sum ed + oticon = the best in hearing • oticon hearing aids from the world's largest manufacturer of hearing aids • 14-day trial period plus free return period after purchase • regular servicing agreement which includes performance test on artificial ear and written report including performance curves • free repairs included in servicing agreement • special arrangements for pensioners and indigent cases • agents throughout the transvaal head office acoustimed (pty) ltd 302 sandown centre maud street sandown p.o. box 782131 sandton 2146 tel 784-0152 pretoria office acoustimed (pty) ltd 515 louis pasteur bidg schoeman street pretoria p.o. box 4424 pretoria 0001 tel 2-3202 also represented by hearing services 315 bosman bidgs cnr eloff & bree sts johannesburg p.o. box 9988 johannesburg 2000 tel 37-2978 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 . . „ γ α r h n p r η pragmatic aspects of comfoldi, n.s., cicone μ · > & « . f a g s . l s e g a l o w i t z (ed.), munication in bram-damaged pat ents. ^ y o r ^ l a n g u a g e junctions and brain organisa g o u t s . treasure of ma. new york, w.w. norton and _ £ ° τ 7 μ 1 9 & o'connor, j . k . pragmatic functions in aphasia j. comma, disord., 15, 337-346, 1982. holland, a.l. some practical considerations in aphasia rehabilitation.in m. sullivan and m.s. kommers (eds.), rationale for adult aphasia therapy. nebraska, university of nebraska medical center, 1977. holland, a.l. communicative abilities in daily living. baltimore, university park press, 1980. holland, a.l. observing functional communication of aphasic adults. j. speech hear. disord., 47, 50-56, 1982. holland, a.l. spontaneous recovery from stroke: an investigation of its earliest phases. paper presented at the academy of aphasia, minneapolis, minnesota, 1983. kazdin, a.e. assessing the clinical or applied importance of behaviour change through social validation. behaviour modification, 1, 427-452, 1977. kertesz, a. western aphasia battery. london, ontario canada, university of western ontario, 1980. linebaugh, c.w., kryzer, k.m., oden, s.e. & myers, p.s. reapportionment of communicative burden in aphasia: a study of narrative interactions. in r.h. brookshire (ed.), clinical claire penn aphasiology conference proceedings. minneapolis, mn, brk publishers, 1982. mueller, s.l. an investigation in social competence using clinical and societal profiles. ma thesis, university of california, santa barbara, 1983. penn, m.c. syntactic and pragmatic aspects of aphasic language. doctoral dissertation, university of the witwatersrand, johannesburg, south africa, 1983. prutting, c.a. pragmatics as social competence. j. speech hear. disord., al, 123-134, 1982a. prutting, c.a. observational protocol for pragmatic behaviours. developed for the university of california, santa barbara speech and hearing clinic, clinic manual, 1982b. prutting, c.a., & kirchner, d. applied pragmatics. in t. gallagher and c. prutting (eds.), pragmatic assessment and intervention issues in language. san diego, college-hill press, 1983. prutting, c.a., kirchner, d., hassan, p., & buen, p. a societal appraisal of pragmatic behaviours. unpublished manuscript, university of california, santa barbara, 1984. wertz, r.t., weiss, d., kurtzke, j.f., et al., a comparison of clinic, home and deferred treatment of aphasia. veterans administration cooperative study protocol, v.a. hospital, martinez, california, 1978. wertz, r.t. personal communication, v.a. hospital, martinez, california, 1984. wilcox, m.j. aphasia: pragmatic considerations. topics in language disorders, 3, 35-48, 1983. the profile of communicative appropriateness: a clinical tool for the assessment of pragmatics claire penn ph.d (witwatersrand) department of speech pathology & audiology, , university of the witwatersrand, johannesburg abstract i the profile of communicative appropriateness — a newly developed profile for the characterisation of pragmatics is described. the theoretical background to this profile is covered as well as its main components. its application to a group of eighteen aphasic patients is outlined, results suggesting that patient groupings on the profile could be predicted in terms of severity but not in terms of type of aphasia. explanations for this finding are discussed and the potential utility of this profile is suggested. 1 opsomming die profile of communicative appropriateness — 'n nuutontwikkelde profiel vir die karakterisering van pragmatiek word beskryf. die teoretiese rasionaal hieragter en die hoofkomponente van die profiel word behandel. die toepassing hiervan op 'n groep van agtien afatiese pasiente word omskryf resultate dui daarop dat die pasientgroeperings aanduidend kan wees van die erns van afasie maar nie van die tipe afasie nie. verduidelikings hiervoor en die potensiele bruikbaarheid van die profiel word bespreek. the clinical profile is a method of characterising language which has become increasingly popular in recent years. essentially " . . . a linguistic profile is a principled description of . . . those features of a person's . . . use of language which will enable him to be identified for a specific purpose." (crystal, 1982). the format of such a profile is the presentation of a wide range of variables simultaneously so that the clinician is able to see at a glance the communicative assets and deficits of a patient. the main purpose of such a profile according to crystal (1982) is to provide not only a comprehensive description of a patient's data but also an adequate basis for remedial intervention. it is not a standardized measure; nor is it an exhaustive linguistic description. the profile is, however, a compromise to the clinician faced with the realisation that language disability requires comprehensive and individual description. the amount of information contained on a profile is determined by the behaviours being measured © sasha 1985 the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) profile of communicative appropriateness : a clinical tool for the assessment of pragmatics as well as the purpose of the tool. however, it is imperative that the categories are clinically relevant i.e. that they can potentially distinguish patients with differing symptoms. the language behaviours which can be characterised by profile are numerous. crystal and his co-workers developed the larsp profile in 1976 to characterise expressive syntax and have subsequently introduced profiles to describe phonology, prosody and semantics (crystal, 1982). prutting has developed a profile (protocol), based on speech act theory designed to characterise pragmatic capabilities (prutting and kirchner, 1983). this paper will describe an alternative pragmatic profile, developed over some years viz. the profile of communicative appropriateness (pc a). the pca is a linguistic profile designed to characterize the communicative competence of a clinical subject. it was developed to identify the features of communication evading description by traditional methods. it is concerned primarily with language use beyond the sentence level and is based on a number of theoretical assumptions from the field of pragmatics. before a consideration of the pca and its application, this theoretical basis will be examined in further detail. theoretical background the field of pragmatics has been defined as the study of " . . .the rules governing the use of language in context" (bates, 1976). according to prutting (1982) "the context in which communication takes place is highly complex and includes multidimensional aspects of the environment". it takes into account the people present in the interaction, what was said before, the topic of conversation, the task of communication and the time and place of the interaction. i in figure 1 the main components of the communicative context are isolated viz. participants, codes, channels, setting and content. t h e c o m m u n i c a t i v e c o n t e x t c o n v e r s a t i o n a l m a x i m s figure 1 the realm of pragmatics although in the field of linguistics and in language pathology, there is at present what prutting (1983) calls a "paradigm shift" towards the field of pragmatics, the area is a complex one and as yet ill defined many linguists have declared a reluctance to incorporate such contextual factors into a model of language, their claim being that such considerations fall outside the realm of linguistics per se. on the other hand, there is ample evidence to suggest that many aspects of communicative competence are amenable to analysis and can be systematically described and related. these aspects have for the most part been dealt with largely independently in the literature and have different frameworks of analysis. aside from the work of bates (1976) there is as yet no cohesive theory of pragmatics which attempts to combine the study of language use into a unified whole. at this stage a discussion of pragmatics therefore probably necessitates a consideration of its component parts. central components selected for discussion here are reflected schematically in figure 1 viz. response to interlocutor, topic control, cohesion, fluency, sociolinguistic sensitivity and non-verbal commu· nication. to separate these particular aspects is a somewhat artificial exercise as there are many areas of overlap. the reasons for considering them separately are governed by their distinction in the literature their relative independence from a methodological perspective, but most important by their potential practical separation as useful areas for the characterization of pathological language. it is beyond the scope of this paper to present in any depth the scope and theoretical underpinnings to the aspects discussed. this has been described elsewhere (penn 1983a). presented here is merely an outline of the main components of communicative competence with their respective definitions. components of communicative competence probably the most important area of control which the normal speaker-hearer has over his language in real life is his competence with regard to discourse. most human communication takes place beyond a sentence level i.e. in dialogue or in conversations. appropriate response to an interlocutor thus involves knowledge of the rules of discourse and an understanding of the speaker's intention with regard to a particular utterance. coherence is a central feature of discourse i.e. the property that makes a discourse more than a collection of unrelated simple sentences. two aspects of coherence in discourse may be identified the first is related to control of topic or of semantic content. keenan and schieffelin (1976) define discourse topic as the proposition about which the speaker is either providing or requesting new information. the rules for topic cooperation are very complex including those for topic shifting, shading (expansion) and reintroduction. the notion of cohesion is the second major component of coherence. this refers to the way in which sentences are linked within a discourse. cohesion may be expressed through the syntax or vocabulary and includes components such as reference, substitution, ellipsis and conjunction, all of which have been discussed at length by workers such as halliday and hasan (1976). fluency is another aspect of communicative competence which has been examined in considerable detail by both linguists and speech pathologists. it is considered as a sensitive indicator of the potency of the communicative system. dalton and hardcastle (1977) point out that there are two possible ways to view fluency. the first emphasizes temporal and sequential aspects of speech and includes factors such as pauses and interruptions. the second meaning of fluency is derived from the context of language usage and includes adherence to the rules of language. clearly in characterizing communication, we are concerned with both aspects, though speech therapists have traditionally concerned themselves more with temporal and sequential aspects of fluency (penn, 1983b). the term sociolinguistic sensitivity coined by bates and johnston (1977) describes the speaker's awareness and sensitivity to the contextual features of his utterance and his ability to modify his message in terms of this context. the speaker who is sensitive to the die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 claire penn t .he situation will take into account the a communicatively competent speaker will also show good control and understanding of non-verbal transmission of messages. much has been written during recent years on this channel of communication (behrmann & penn, 1984). it includes areas such as kinesics, proxemics and paralanguage. the function of non-verbal communication changes according to context and the patient's specific abilities. non-verbal communication is in fact an important component of all aspects of communicative competence discussed previously. finally on a more esoteric level, there are certain properties of conversation which determine its overall qualitative level of appropriateness. in order to communicate effectively certain ground rules must be followed by the communicative participants. borrowing from kant, grice (1975) has suggested that four maxims apply in conversation: quantity, quality, relation and manner and that these are basic to the rules of cooperative discourse. by way of a summary of the preceding discussion, figure 1 illustrates the aspects discussed. it demonstrates the primacy of communicative context over the speaker's use of language and the basic influence of the cooperative principles of conversation. it also indicates the separate (but overlapping) areas of communicative competence discussed above. the pca reflects an attempt to capture such aspects for the purposes of clinical description and prediction. a clinically viable version of the pca is presented in figure 2. the six main areas of communicative competence are presented as well as the specific linguistic behaviours subsumed under each scale. the pca evolved from a study designed to investigate the expressive output of a group of adult aphasic patients. it is not the intention of this paper to describe the detailed outcome of this study. what seems important is a consideration of how the pca evolved and its utility in describing and separating out aphasic subjects. date person eliciting sample features of sampling unit of analysis / . t f v / / / contents request 2 ο reply % = = ο clarification request o s. gs acknowledgement s. ζ teaching probe others topic initiation topic adherence ° -s s topic shift ο £ lexical choice £ ε ο idea completion υ " idea sequencing others elipsis tense use c reference •2 lexical substitute forms -c relative clauses υ prenominal adjectives conjunctions others interjections repetitions > » incomplete phrases c ο false starts κ pauses word-finding difficulties others polite forms reference to interlocutor υ placeholders, fillers, stereotypes ts >» acknowl edgements self correction comment clauses sarcasm/humour (λ control of direct speech indirect speech acts others vocal aspects: intensity pitch rate intonation _ ο w 'ζ. quality ϋ .a non-verbal aspects: facial expression ι 3 s ι ζ ε head movement ι 3 s ι ζ ε body posture υ breathing social distance gesture and pantomime others total figure 2 profile of communicative appropriateness the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the profile of communicative appropriateness : a clinical tool for the pca and aphasia the pca evolved in a two-part study conducted over five years. in the first part (part a) the interactive language samples from a group of six aphasics were analysed syntactically using the larsp profile (crystal et al, 1976). this syntactic analysis was found not to identify the main communicative features clinically differentiating the subjects. among such features were factors relating to manner of production, control of content and control over rules of discourse. this led to the derivation of a taxonomy of behaviours designed to represent these aspects. as an audiotaped data base was the basis for analysis, non-verbal communication could not be considered in study a. in study β which employed videotaped analysis of the interactive language samples of fourteen subjects, a non-verbal scale was included. the pca thus measures three broad areas of communicative competence control of discourse (measured by scales α. β and c), fluency (scale d) and more global aspects of interactive communication (scales ε and f). a major concept underlying the pca is the notion of appropriateness the language behaviour of an individual may only be judged as being appropriate within the context of a communicative event. the term "appropriate" implies a societal framework of judgement based on the performance of the individual in a social context, rather than on his ability on an "all or none" measure ot language on a traditional test. in the writer's opinion, the perceived impact of an aphasic patient's difficulty can not be evaluated in terms of a score or a quantitative measure, but in terms of qualitative appropriateness. the issue of how to characterize appropriateness was considered in the present study which used, like holland (1982) and prutting the assessment of pragmatics 21 and kirchner (1983), a dichotomy rating of appropriate/inappropriate in study a. in study β a five-point rating scale was used. in study a, the task of the judges (six qualified and specially trained speech pathologists) was to rate each conversational turn in terms of its appropriateness for each aspect of the pca. a conversational turn was defined as one therapist-patient interaction. difficulties were experienced in analysing the data using statistical procedures for a number of reasons. firstly, the nature of the judgement proved too precise for the nature of the data under evaluation. secondly, the large number of judges, while providing valuable insight into the clinical utility of the tool, provided difficulties in the calculation of inter-rater agreement. as a result, in study b, a five-point rating scale was employed, illustrated in figure 2. two trained judges were required to rate the data of the subjects using the five point scale to evaluate each one minute chunk of language data (designated the conversational unit) in the sample of each of the subjects. inter-rater agreement (measured by means of cohen's weighted kappa coefficient (cohen, 1968) reached acceptable levels for each of the six scales. additional measures for each of the subjects included the administration of the boston diagnostic aphasia examination (bdae) (goodglass & kaplan 1972) holland's cadl (1980), and sarno's functional communication profile (1975). the approach to data analysis was essentially taxonomic making use of a technique known as hierarchical cluster analysis. this allows for the clustering of subjects on a particular measure on the basis of their similarity. the outcome of the cluster analysis can be portrayed schematically by means of cluster fields. in figure 3(a-f) the outcome of the cluster analysis on the separate scales of bdae severity rating (a) high high ο ο ) ο bdae severity rating (b) bdae severity rating (c) high (c 3 £ c 3 bdae severity rating (d) bdae severity rating (e) bdae severity rating (f) figure 3(a-f) clustering of the subjects on scales a-f of the pca in relation to appropriateness and severity ratings (study b) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 claire penn the pca in study β is demonstrated as a function of the subjects' the "la in y reveal that the subjects severity ratings on the buafc. clustered i n t o several distinct groups on the basis of appropriateness the size and the composition of the groups varying according to the scale. on the whole, results suggested a better retained competence for scales α, β, ε and f than for scales c and d. when results for all scales combined are viewed (figure 4) two broad subject splits can be identified — the appropriate group (consisting of eight subjects) and the inappropriate group (containing six subjects). these splits correlated broadly with severity (as measured on the bdae) and with performance on other measures of communication (see figure 5) but not with the subjects' syntactic capacities nor with type of aphasia. high med low 2 3 bdae severity rating figure 4 clustering of the subjects on all scales of pca in relation to appropriateness and severity ratings (study b) below median above median performance on fcp and/or cadl figure 5 comparison of subjects' performance on pca and other communication measures results thus suggest that the subjects showed differential retention of communicative skills as measured on the pca — a finding supported by goldblum (1983) who applied prutting's protocol to adult aphasics. further the results lend support to the idea that traditional methods of classification and assessment may need some reconsideration. possible explanation for results returning to the pragmatic framework presented in figure 1, the results of the present study suggest that within a given communicative context (whose participants, channels, code, setting and context are at least partially specified) aphasic patients' rules for communicating differed from those of normals and between individual subjects. no striking evidence was observed however which suggested that such differences reflected the use of a completely distinct set of rules within any particular group. rather, the patients' capabilities seem to lie on a continuum. discourse, fluency, sociolinguistic sensitivity and non-verbal aspects were assessed in terms of communicative appropriateness. results suggested that communicative competence is often well retained in aphasia and that difficulties pattern those of normals, occurring however with greater frequency. davis (1983) has suggested that "adult aphasia can be understood in part as a disturbance of normal processes". the effect of aphasia appears to be that of limiting or reducing the individual's capacity to apply the conversational maxims effectively. the maxims of quality and relation are properties of conversation concerned with basic truth conditions and. semantic content. control of such matters (particularly in scales a and b) was implicated in certain subjects. quality and manner of production (reflected on scales c and d) are also affected by brain damage. the behaviours measured on scales ε and f might be seen as those strategies employed by the subject to overcome the communicative difficulties imposed by his defect. the fact that there was a considerable degree of overlap between scales and between patients on the scales confirm that communication is after all a global process. the aphasic patient's control of communication and his adaptation to his difficulties reflects his overall communicative competence. utility of the pca with regard to the pca, the results of the study have indicated in a preliminary sense the potential clinical utility of the profile as a measure to characterise aspects of aphasic language use. 'it appears to have fulfilled many of the criteria suggested by crystal (1982) as being necessary properties of a linguistic profile: ι — it will provide at a glance a simultaneous appraisal of the patient's areas of strength and weakness in a communicative sense. — it may be used as a diagnostic or screening measure. for screening purposes only broad areas of communicative competence (e.g. control of semantic content) need be characterised. for diagnostic purposes an in depth appraisal of specific aspects (e.g. topic management) could be explored. — the pca is flexible and by no means finite. it provides an opportunity to code 'other' behaviours and also has a category for unanalysable features, (could not evaluate). further the conversational unit may be varied according to the interest and the needs of the examiner. it may be timeor turn-based. an additional flexible component of the pca is that it can be used to characterize interaction between a patient and any interlocutor, not necessarily his therapist. — although unlike other linguistic profiles developed on children, it is not graded, it does appear to provide a basis for remedial intervention in that it has generated many hypotheses regarding the direction of future therapy for those patients examined . in the present study. the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the profile of communicative appropriateness : a clinical tool for finally, although the pca emerged initially from the study of adult a p h a s i c ' l a n g u a g e , this certainly does not preclude its use with other l a n g u a g e i m p a i r e d populations. encouraging preliminary data has e m e r g e d from the application of the pca to a group of head injured subjects (irvine, 1984), a schizophrenic subject (cohen, 1984) and some hearing impaired children (sacks, 1984). further ongoing research exploring the usefulness of the pca in the area of learning disability, dementia and in the clinical supervision of students is being explored by the author. it is hoped that the next few years will see a burgeoning number of studies concerned with the refinement and broadened application of this apparently useful clinical tool. acknowledgements the writer is indebted to professor m.l. aron, head, department of speech pathology and audiology, university of the witwatersrand for her valuable supervision of the research on which this paper was based. for financial assistance, the writer is indebted to the human sciences research council and to the senate and council research committees of the university of the witwatersrand. references bates, e. language in context. new york, academic press, 1976. bates', e. & johnston, j.r. pragmatics in normal and deficient child language. short course presented at asha convention, 1977. behrmann, m. & penn, c. non-verbal communication of aphasic patient's. brit. j. dis. comm. 19, 155-168, 1984. cohen, j. weighted kappa: nominal scale agreement with provision for scaled disagreement or partial credit. psychological bulletin 70, 213-220, 1968. cohen, l. the communicative competence of a paranoid schizophrenic. undergraduate research report. dept. speech pathology & audiology, university of the witwatersrand, 1984. crystal, d., garman, m. & fletcher, p. the grammatical analysis of language disability. london, edward arnold, 1976. crystal, d. profiling linguistic disability. london, edward arnold, 1982. i dalton, p. hardcastle, w.j. disorders of fluency. london, edward arnold, 1977. the assessment of pragmatics 23 davis, g.a. aphasia and normal adult language processes. paper presented at asha convention, 1982. goldblum, g.m. aphasia: a societal and clinical appraisal of pragmatic and linguistic behaviours. unpublished m. a. dissertation. dept. speech. university of california, santa barbara, 1984. goodglass, h. & kaplan, e. the assessment of aphasia and related disorders. philadelphia, lea & febiger, 1972. grice, h.p. logic and conversation. in p. cole & j.l. morgan (eds.) syntax and semantics. speech acts vol. 3. new york, academic press, 1975. halliday, m.a.k. & hasan, r. cohesion in english. hong kong, longman, 1976. holland, a.l. communicative abilities in daily living. baltimore, university park press, 1980. holland, a.l. observing functional communication of aphasic adults. j. speech hear. dis., 47, 50-56, 1982. irvine, l. the communicative and cognitive deficits following closed-head injury. undergraduate research report, dept. speech pathology & audiology, university of the witwatersrand, 1984. keenan, e.o. & schieffelin, b.b. topic as a discourse notion: a study of topic in the conversations of children and adults. in c.n. li(ed.) subject and topic. new york, academic press, 1976. penn, c. syntactic and pragmatic aspects of aphasic language. unpublished doctoral thesis. university of the witwatersrand, 1983. penn, c. fluency and aphasia: a pragmatic reconsideration. s.a. j' comm. dis., 30, 3-9, 1983. prutting, c.a. pragmatics as social competence. j. speech hear dis., 47, 123-134, 1982. prutting, c.a. the pragmatics of language. s.a.j. comm. dis., 31, 3-5, 1984. prutting, c.a. & kirchner, d.m. applied pragmatics. in t.m. gallagher & c.a. prutting (eds.) pragmatic assessment and intervention issues in language. san diego, college hill press, 1983. sacks, j. some grammatical discourse features in the older hearing impaired child. undergraduate research report. dept. speech pathology & audiology, university of the witwatersrand, 1984. sarno, m.t. the functional communication profile. new york, institute of rehab. medicine, 1975. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) medical software and hardware specialities practice accounting packages rehabilitation aids patient history management computers and peripherals also available bureau facilities clinical computer concepts cc ck 85/03210/23 103 highlands north medical centre, cr. louis botha avenue & 3rd avenue, highlands north 2192. south africa. phone (011) 440-9412 for expert advice / the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 the provision of speech, language and hearing services in a rural district of south africa judith anne mckenzie rehabilitation unit tintswalo hospital abstract in this paper the delivery of a speech, language and hearing therapy (slht) service in a rural area is discussed. in the light of the need to relate the delivery of this service to principles of primary health care (phc) and community based rehabilitation (cbr), a brief theoretical background is given. obstacles to service delivery are then presented, followed by a description of some attempts to implement principles of phc and cbr. the author concludes that many challenges need to be faced in providing slht services that will benefit the majority of the population of south africa. opsomminc in hierdie artikel word die dienslewering van die spraak-taal-en gehoorterapeut in 'n plattelandse gebied bespreek. in 'n poging om die behoefte aan hierdie dienslewering in verband te bring met die beginsels van primere gesondheidsorg en gemeenskap gebaseerde rehabilitasie, word 'n kort teoretiese oorsig verskaf. probleme tydens die instelling van 'n diens word uitgelig. hierna word die rol van 'n spraak-taalen gehoorterapeut in 'n plattelandse gebied ondersoek, beide binne die rehabilitasie en die primere gesondheidsorg-span. die gevolgtrekking wat gemaak word is dat alhoewel die spraak-taal-en gehoorterapeut 'n belangrike rol het om te vervul in die platteland, hierdie rol gesien moet word in die lig van die gemeenskap se behoeftes. dit is egter 'n groot uitdaging vir spraak-taal-en gehoorterapeute om 'n diens te lewer wat tot voordeel van die meerderheid populasies in suid-afrika sal strek. the profession of speech, language and hearing therapy (slht) is under pressure in south africa to provide services to the majority of the population within a situation of transition. according to aron (1991) the linguistic, cultural and socioeconomic changes in the country will affect the nature, demand and delivery of our professional service. slht services within the public sector are delivered mainly through the health sector under the public service. therefore an examination of theoretical principles of health and rehabilitation policy is necessary in order to formulate how slht can rise to meet these demands. it is nonetheless insufficient to scrutinise the level of policy alone, since it is clear that practical realities dictate the way in which policy decisions can or cannot be carried out. newell (1989, p.80) in his discussion of district health systems stated that: although building blocks of a health service may be designed so that their general goals and form are consistent with a national standard, their expression in the field is not always the same. no countries are homogeneous; differences in structure, wealth, geography, disease pictures, and beliefs may influence how health services are delivered. ideally, this tier conforms to a national standard, and reflects accepted rules of accountability as viewed from the capital, but within each block there should be unique qualities as viewed from the bottom. the "block" that he identifies is the district. this paper can be seen as an attempt to take a view "from the bottom" that is the district level, at the implementation of slht services. it is with this in mind that the present paper is aimed at locating the practical experience of slht in a rural district in south africa within current demands for change arid in the light of theoretical principles. this paper will begin w;ith a discussion of some of the obstacles to providing an slht service in the rural district. this will be followed by a description of several projects which have been implemented in attempts to address these problems. the discussion of these projects will include an examination of the significance of each project with respect to the principles of primary health care (phc) and community based rehabilitation (cbr). in addition tliere is a need to clarify the principles of both-phc and cbr, which provide the guiding principles for the delivery of an slht service in the mhala district of gazankulu. before such a discussion can be meaningful, however, it is important to understand the physical and social background of the district and community under discussion. by relating practical experience to theoretical principles, the author aims to promote discussion of the ways in which the present model of service delivery of slht can be made more relevant to the present needs of south africa.it is clear that this is a major task and that the experience presented here is limited. moreover the issues which are raised, are complex and deserve much more considered debate than can be presented here. taking this into account, it is hoped that this paper can serve as a starting point for debate. sasi.ha th south african journal of communication disorders, vol. 39 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ision of speech, language and hearing services in a rural district of\sa 51 description of the mhala district, gazankulu and its community the mhala district of gazankulu is situated in the lowveld area of the eastern transvaal. the population of this area experiences a high degree of poverty and unemployment. despite the lack of documented studies, health authorities have concluded that there is a high degree of undernourishment in the area in both young and old (infraplan, 1992). the community rates lack of water as its major health problem with poor attitudes of health workers and problems with sanitation coming next (nethworc, 1992). the population of mhala is estimated at about 200 000 which is settled in 4 towns and 75 widely dispersed villages. the size of villages varies from 107 to 6 918 people [infraplan, 1992). in addition to this population, there has been an influx of refugees to the district from mozambique. this is estimated by local relief agencies as about 32 000 people (sr. agnes, 1992 personal communication1'. the proportion of the population with speech and hearing disorders is indicated by a survey conducted by the occupational therapy department of the university of the witwatersrand. this survey reveals a rate of 4.16 per thousand for speech disorders and 5.29 per thousand for hearing disorders in the mhala district (concha & lorenzo, 1988). health services in this district are provided by two hospitals (tintswalo, 266 beds in the north and matakwane, 178 beds in the south), two health centres, fourteen fixed clinics and one mobile clinic which serves ten visiting points on a fortnightly basis. there is in addition, considerable overlap with mapulaneng district which is serviced by mapulaneng hospital, and patients from both districts are seen in both hospitals (infraplan, 1992). in 1987, rehabilitation services were implemented at tintswalo hospital. at present the rehabilitation unit consists of one physiotherapist and two physiotherapy assistants, one occupational therapist and three occupational therapy assistants and one speech, language and hearing (slh) therapist and one slh community worker. a training programme for community rehabilitation workers (crws) was initiated in 1991 by the occupational therapy department of the university of the witwatersrand in consultation with the rehabilitation unit at tintswalo. at present nine students are in training who will be based in the community from 1993 (lorenzo, 1991). principles of phc and cbr the phc approach andj health care was formulated at alma-ata in 1978 at a joint world health organisation (who) and united nationsjchildren's fund (un1cef) conference. this approach is based on a definition of health that goes beyond the mere absence of disease, but also involves a state of physical, social and mental well-being (mckenzie, α., 1989). primary health care is defined as: essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the, spirit of selfreliance and self-determination (world health organisation (who) and united nations children's fund (unicef), 1978, p.110). the guiding principles of phc are: equitable distribution of health care resources and adequate quality care for all 1 sr. agnes, acornhoek catholic mission. a focus on preventive and promotive health services use of appropriate technology active community participation redressing of socio-economic equalities and use of a multisectoral approach (mckenzie, α., & mazibuko, 1989). in addition to these broad principles, the phc approach also identifies certain essential basic service components as follows: education concerning prevailing health problems and the methods of preventing and controlling them promotion of an adequate food supply and proper nutrition ail adequate supply of safe water and basic sanitation maternal and child aealth care, including family planning immunisation against the major infectious diseases prevention and control of locally endemic diseases appropriate treatment of common diseases and injuries provision of essential drugs (mckenzie, α., & mazibuko, 1989). the basic tenets of phc have been adopted in south africa as health policy. however buch (1989) has noted that the reality of the health care system is far from achieving these goals. he has argued that gross inequity still exists within the system, as indicated by the relatively low health budget for the homelands. preventive and promotive services are still not getting the priority they merit and community participation cannot be a reality in the absence of a broader political democracy. thus the present reality for slht services in south africa within the public sector is that we are operating within a phc policy which is inadequately funded and poorly implemented. slht services will need to take into account both the principles underlying present policy and the obstacles preventing successful implementation. at this point it is useful to consider the relationship between phc and rehabilitation. the declaration of alma-ata states that phc "addresses the main health problems in the community, providing promotive, preventive, curative and rehabilitative services accordingly" (who & un1cef, 1978, p. 112). thus it is accepted that rehabilitation is a component of primary health care. slht, as a component of rehabilitation services in general, can also fee accommodated within the phc model. while phc may provide an overall framework for delivery of slht services, we need to examine its implementation in rehabilitation more specifically. mclaren (1989) has argued that rehabilitation should not be merely seen as the last resort when medical treatment has failed. it should be seen as part of a comprehensive overall health strategy in which disability prevention should be a priority of phc. if this is the case then slht should be an integral part of phc strategy, together with other rehabilitation disciplines. the strategy proposed by the who for disability prevention and rehabilitation is community based rehabilitation (cbr). this approach defines rehabilitation as follows: it includes all measures aimed at reducing the impact of disabling and handicapping conditions, and at enabling the disabled and the handicapped to achieve social integration. rehabilitation aims not only at training disabled and handicapped persons to adapt to their environment, but also at intervening in their immediate environment and society as a whole, in order to facilitate their social integration. the disabled and handicapped themselves, their families and the communities they live in should be involved in the planning and implementation of services related to rehabilitation (who, 1981, p.39). what is striking about.this definition is its emphasis on the person with a disability within the social environment. thus cbr the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 judith anne mckenzie does not aim to develop the abilities of the person with a disability alone but also aims to change the society in which that individual lives so that the effects of disability can be minimised. cbr therefore, aims to deliver rehabilitation as defined above in a manner which builds on the resources of the community. rehabilitation occurs in the community insofar as is possible with referral to hospital where appropriate (mclaren, 1989). in order to obtain community involvement, education of the community is seen as vital. finally, it is acknowledged that the training of new levels of rehabilitation workers is necessary (mclaren, 1989). given the theoretical background, how does this apply to the district under discussion and the practical implementation of a slht service? as discussed above there are obstacles to the provision of phc services which must affect slht too. these obstacles will be discussed below. however, attempts have been made in the face of these obstacles to implement the principles of phc and cbr. examples of projects conducted by the slht service at tintswalo will be presented with a critical discussion of how they succeeded or failed in implementing these principles. obstacles to the implementation of the principles of phc and cbr 1. inadequate infrastructure and poverty. poor telecommunications and roads affect the delivery of slht services. community visits are time-consuming and arrangements have to be made well in advance in person or by letter. support structures and services for the disabled are very limited. thus, for example, the child with a mental handicap cannot be referred to an appropriate agency, but becomes the problem of the slh therapist. as noted previously there is a high degree of poverty in the mhala district. this means that clients for slht can not come in for regular therapy since they are unable to pay for transport costs. in addition, slht disorders can appear to be a trivial concern when one is struggling to survive. these issues relate to the phc principle of redressing social inequality and a multisectoral approach (mckenzie, α., & mazibuko, 1989). it will come asno surprise to the reader that there is much to be done in this regard. 2. training. the training of the slh therapist is not appropriate to the demands of the rural setting. specific skills related to the remediation of slh disorders cannot be used until the problems that prevent people from taking advantage of a slht service are addressed. therapy might thus be provided for eg., the cerebral palsied (cp) child, but if the mother can not bring the child in on a regular basis then the service is ineffective. the therapist needs to develop skills in working with the community in order to find more appropriate ways of dealing with slh disorders. the challenge lies in moving away from those clinical skills where s/he feels confident and secure, into the less certain waters of the community. the slh therapist is trained to deal with sophisticated equipment but is not trained to work in the setting where this equipment is not available. the inadequate budget of rural hospitals has been discussed previously. this is experienced in slht in the absence of audiometric equipment. the slh therapist will find that s/he has little experience of alternative and appropriate ways of testing hearing. in this instance, not only is training inappropriate, but also there is a lack of suitable appropriate technology. 3. community awareness. there is a lack of awareness in the community about the service that we provide. thus campaigns of awareness need to be conducted. the tension here is between raising awareness and developing the service in such a way that the increased demand can be dealt with. it is the impression of this author that this tension can be resolved to a certain degree by the manner in which awareness is raised. werner and bower (1982) have described two approaches to health education. the first is authoritarian and controlling and creates dependency and feelings of helplessness. the second is what they term "people-centred" learning. this helps people to become stronger and more self-reliant. if awareness campaigns for slht services are conducted in the first manner it is possible that the service might be overloaded, since people have not been encouraged to help themselves. they will depend on the service to do that for them. if the second approach is used it is possible that the service offered could be seen as one way to approach the problem once community efforts have failed. 4. the balance between hospital and community. there has been some difficulty in prioritising hospital and community services. how much time should be spent in the hospital and how much in the community? at present the rehabilitation service is between two models. institution based rehabilitation, which occurs within a hospital setting is the old model (mclaren, 1989). it is obviously a valuable service and it is what the slh therapist is employed at present to provide. however, as an attempt is made to implement cbr there is a necessity to be in the community more and more. support for working in the community from head offices and the posts for community work are lacking. description of projects attempting to implement principles of phc and cbr despite the obstacles noted above, attempts have been made within the rehabilitation service at tintswalo to implement the principles of phc and cbr". selected lessons from this for slht will now be discussed. 1. survey on stuttering. it was noted that very few stutterers were being referred to tintswalo hospital for treatment (five cases in three years). this led to the consideration that either stuttering was not perceived as a problem, or that it did not in fact occur in this community on any significant scale. it was in order to test this possibility that a survey of attitudes, knowledge and beliefs about stuttering was done in the acornhoek/timbavati area (mckenzie, 1992). the community rehabilitation worker students planned and carried out the survey as part of their training. a hundred and thirteen community members were interviewed: fifty-two of these were primary school teachers. the respondents were selected by means of stratified random sampling. the results can be summarised as follows: 1 91% of respondents knew what stuttering is 2 93% of respondents knew at least one person who stutters ! 3 86% of respondents believed that it is not infectious 4 77% of respondents believed that stuttering causes problems for the individual 5 87% of respondents believed that stuttering cannot be cured 6 68% of respondents believed that stuttering cannot be prevented 7 26% of respondents believed that stuttering is caused by rain falling on the child while still a baby 8 42% believed that it is hereditary or "in the person's nature". from the above, it is clear that stuttering is considered a problem in the community, but as long-as people believe that it cannot be prevented or cured, there is no reason to consider referral for speech therapy. however, it does appear that stuttering could be a problem for the individual. this was confirmed in an awareness campaign arising from the survey. it south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) provision of speech, language and hearing services in a rural district of sa 53 became apparent that many children were being heavily penalised in schools because of their fluency problems. in certain cases children who were able to achieve scholastically, had stopped coming to school because they were not able to cope with the punishment or teasing. the conclusion that can be drawn from the above is that the slh therapist is likely to have little success with either recruiting or treating individuals who stutter. even if stuttering therapy did take place the chance of success would be limited, given the prevailing beliefs and attitudes relating to stuttering. the definition of rehabilitation within cbr, emphasising the need to effect changes in the environment of the person with a disability is relevant here. the child who is penalised for fluency problems at school requires not only assistance with his/her speech but also an attempt to change the negative attitudes of the people around him/her. the strategy for effecting changes in attitude is community education. this forms an integral part of cbr. such education has been given to the teachers in report back sessions on the survey and in a subsequent workshop. teachers have stated that this education was useful to them, since they had not understood the problem previously. they suggested that the focus should now be placed on the parents. it is envisaged that this will be the next phase of the awareness campaign. the above example gives validity to the prominent place that community education is given within cbr this education should ideally be supplemented by appropriate and effective remediation of the fluency disorder. 2. workshop for disabled children. another feature of cbr is the involvement of families in the rehabilitation process, as discussed above. in 1989 a workshop for mothers of cerebral palsy (cp) and mentally handicapped (mh) children was run by the rehabilitation unit of tintswalo hospital (mckenzie, j & concar, 1991). the motivation to run the workshop arose from visits to a clinic of tintswalo hospital. since this clinic is 80 kilometres away from the hospital it was only possible to visit once a month. this resulted in lack of progress in the children and inadequate understanding of the mothers about the children's problems (mckenzie, j. & concar, 1991). the aim of the workshop was to provide a comprehensive educational programme addressing the mothers' and children's needs. thus the physiotherapy department gave input on handling and positioning the child. the occupational therapy department educated the mothers about play, toy making and activities of daily living. the slht department focused on feeding and communication.| assessments of each child were done by all members of the team together and home programmes were given involving all therapies. the programme did not only focus on rehabilitation techniques. there was health screening, and health education talks on nutrition and family planning were given. one of the most successful sessions was where mothers shared their feelings and experiences of having a disabled child. mothers were fully involved in this programme at every stage which was a valuable experience, as they became much more confident in handling their children. however, as this workshop was held at some distance from the village where they lived, it was not possible to involve other family members sufficiently. another important feature of this workshop to be highlighted was the significance of working as a rehabilitation team. this enabled the therapists to assess the person with a disability as a whole rather than from the point of view of their own discipline. this aspect was developed through combined assessment, where problems in order of priority for the mother were emphasised rather than those relating to specific disciplines. while the workshop itself was very successful according to parent and staff evaluations, the long term results are not satisfactory. the group continued to meet sporadically after that time but were unable to formulate any combined goals. there remained a great deal of dependency on the rehabilitation unit. ultimately the project was discontinued. possible reasons for this failure were discussed among rehabilitation staff. there was consensus that local community structures had been inadequately developed. the mothers continued to depend on the rehabilitation unit because there was little support for them in the community. the principle of cbr's building on local resources (mclaren, 1989) had not received due attention. in addition the rehabilitation effort had not been an integral part of the local phc programme and thus support was also lacking from this quarter. it appeared that this lack of support could be attributed to inadequate development of local community structures. one of the positive results of this effort was the selection for training as a crw of one of the mothers of a disabled child in this group. she is at present trying to revive the group. it will be interesting to see whether she, as a community member and a mother of a disabled child with specialised training will be more successful in this project. while this example and the previous one, look at approaches to already existing disability and ways of minimising its effects, the following example is concerned with prevention of disability as an integral part of the phc approach. 3. hearing screening. in the past, screening of hearing in creches and preschools has been conducted by the slht department. problems in covering all the schools due to lack of human resources were experienced. therefore it was decided that education of teachers about hearing loss should be undertaken, thereby encouraging appropriate referrals. teachers in creches were given input on the causes of hearing loss, how to identify the child with a hearing loss and where to refer such a child. this programme, however, was also unsatisfactory, for the following reasons. the slh team was acting in isolation from the phc team. thus the phc team did not understand our goals and the follow up medical treatment was not always satisfactory. referrals to the clinic were not always acted on by the parents because of lack of money and lackof community awareness of the problem. furthermore teachers felt that they were not in a position to motivate the parents to attend the clinic because their own knowledge was scanty. it was therefore decided to incorporate hearing screening as part of a comprehensive programme of health screening in creches. the screening programme is a joint venture of the health services development unit of the university of the witwatersrand and the rehabilitation unit and school health services of tintswalo hospital. health sciences students (medical, occupational therapy and physiotherapy students) were given the task of screening under the supervision of a trained member of staff. in liaison with the senior hospital staff, it was agreed that referrals from such screening would be seen free of charge at the hospital and clinic. creche teachers were consulted on how such a programme should be run. the clinic sister in the area where screening takes place was informed on that day and was given a list of those children who have been referred to the clinic. to date, the programme has not been formally evaluated but it is intended that this will be done soon. informally the response from teachers and nurses has been very positive. with respect to slht we have detected a marked improvement in the parents' response to referral, now that the first consultation is free of charge. the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 judith anne mckenzie such a screening programme is aimed both at preventing hearing loss from occurring and at detecting hearing loss early so that appropriate intervention can be taken. within the framework provided by mclaren (1989) it is clear that the slht service has been operating at the level of primary prevention in the programme by educating teachers. according to mclaren (1989) this entails preventing the occurrence of impairments, in this case hearing loss by education of key figures. the screening programme, however operates at the level of secondary prevention, where ear infections can be treated thereby preventing subsequent hearing impairment. it is clear that both levels need to be addressed. at present, screening only is being done and the education aspect needs to be incorporated into the programme. mclaren (1989) has argued that prevention should be included as a specific objective in phc programmes. this screening programme is aimed at meeting this objective with what appears to be some degree of success. conclusion the above discussion serves to illustrate the many challenges that the delivery of an slht service in a rural district poses. it is hoped that these will be taken up by the profession in a meaningful way so that the majority of the population of south africa can be better served. finally it needs to be noted that this cannot be achieved without the full participation of the community within the service: we must not fall into the trap of professional arrogance. as kaseje (1991, p.2) has warned: doctors and "medical experts" are like roosters they think the sun will not rise, that health will not happen if they do not crow. this attitude of medical arrogance needs to change and there must be more listening and trusting of the primary movers in phc, that is the community. acknowledgements the support of the rehabilitation unit at tintswalo hospital and the community rehabilitation worker training programme are gratefully acknowledged. the author also wishes to thank andrew mckenzie for his assistance in the preparation of this paper. references aron,-m.e. (1991). perspectives. the south african journal of communication disorders, 38, 3-11. buch, e. (1989). primary health care in south africa. nursing rsa, 4(11), 34-36. concha, m. & lorenzo, t. (1988). the prevalence of disability in a rural area of south africa. paper presented at the 2nd european congress for occupational therapists, portugal. infraplan (1992), survey commissioned by mhala health action group. kaseje, d.c.o. (1991). community empowerment: the key to health for all. paper presented at namibia national primary health care workshop. lorenzo, t. (1991). strides in community rehabilitation worker training in a rural area in south africa. world federation of occupational therapists bulletin, 2(4), 2-5. mckenzie, a. & mazibuko, r. (1989). what is primary health care? nursing rsa, 4(11), 30. mckenzie, j. & concar, a. (1991). report on a residential workshop for the mothers of cerebral palsy and mentally retarded children run by the rehabilitation unit of tintswalo hospital. communiphon, 299, 17-19. mckenzie, j. (1992). survey conducted on attitudes to stuttering in acornhoek, mhala district, gazankulu. unpublished. mclaren, p. (1989). rehabilitation and primary health care. paper presented at community rehabilitation meeting, gazunkulu. newell, k. (1989). the way ahead for district health systems. world health forum, 80-87. geneva: who. nethworc education project (1992). first community forum report. acornhoek. who/unicef. (1978). primary health care: report ofthe.international conference on primary health care, alma-ata, ussr. geneva. who. (1981). disability prevention and rehabilitation. technical report series 668. geneva. werner, d. & bower, b. (1982). helping health workers learn (pp. 1.11.30). palo alto ca: hesperian foundation. abacus h e a r i n g s e r v i c e s services available / dienste beskikbaar hearing aid assessment/ bepaling van gehoortoestelle maintenance / instandhouding manufacturers of 'in the ear' vervaardiging van 'in die oor' gehoorhearing aids, earmoulds, swimplugs apparate, oorstukkies, swemproppies repairs & servicing to all makes of herstel en diens van alle soort hearing aids gehoorapparate p.o. box 146276 brackengardens tel: (011) 867-1903 1 4 5 2 helping others to hear better ( 0 1 1 ) 8 6 4 1 9 2 0 / 1 the south african journal of communication disorders, vol. 3.9, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η spektrografiese ontleding van die vokale van afrikaanssprekende gehoorgestremdes santie meyer m(log) (pretoria) departement spraakheelkunde en oudiologie universiteit van pretoria opsomming die vokaalproduksie van 'n groep kongenitaal gehoorgestremde seuns is spektrografies ontleed. die dowe sprekers toon 'n gehoorverlies van 90db gehoorpeil ofswakker in die beste oor, terwyl die hardhorendes 'n gehoorverlies van 70-90db vertoon. resultate is met 'n normaalhorende groep vergelyk. die spektrografiese analise toon aan dat daar statisties betekenisvolle verskille tussen die dowes en normaalhorendes is ten opsigte van vokaalduur (dowes verleng die duur) die fundamentele frekwensie en eerste formantfrekwensie (dowes verhoog dit) en die tweede formantfrekwensie wat deur dowes verlaag word. die hardhorendes verskil ten opsigte van fundamentele frekwensie en die eerste formantfrekwensie van die normaalhorendes. die implikasies van hierdie bevindings word vir terapie bespreek. abstract the vowel production of eight profoundly deaf, ten severely hearing-impaired, and ten normal hearing subjects was subjected to spectrographic analysis and compared. results indicate significant differences between the profoundly deaf and normal hearing subjects in respect of vowel duration, fundamental frequency, and first and second formant frequencies. significant differences relating to fundamental frequency and the first formant frequency were observed between the severely hearing-impaired and normal hearing subjects. implications of these results regarding speech therapy for the hearing-impaired are discussed. the importance of the ability to correctly articulate vowels is not only that vowels are individual phonemic entities and serve as the basic building blocks of morphemes but also that: 1. vowels — particularly at their onset and their end convey to the listener crucial consonantal information; 2. they contain important prosodic information through variations in fundamental frequency, intensity, and duration. (monsen, 1976) die belang van die korrekte produksie van vokale vir suksesvolle kommunikasie blyk duidelik uit die aanhaling. die feit dat gehoorgestremdes se spraakkommunikasie dikwels oneffektief is, is tot 'n groot mate toe te skryf aan hul onvermoe om vokale akkuraat te produseer (markides, 1970). swak spraakverstaanbaarheid en spesifiek die onsuksesvolle vokaalproduksie kan verklaar word na aanleiding van die sensoriese omstandighede waaronder die gehoorgestremde spraak aanleer (monsen, 1983). die gehoorgestremde se afhanklikheid van visie, vibrasie, propriosepsie, terugvoering van horende volwassenes en die distorsie van die beskikbare gehoor in die aanleer van spraak, lei tot verskille in fonologiese organisasie. verder word die vokale geleer deur bewuste visuele, vibrotaktiele en ouditiewe nabootsing. die artikulasie van spraakklanke is dus stadig en aritmies. die gehoorgestremde kind boots ook die visuele beeld van die spraakklank na en ignoreer die tongbewegings wat nie sigbaar is nie. hul poog ook om die artikulatoriese terugvoer in die produksie van sekere klanke te verskerp om 'n meer spesifieke mikpunt te kan verkry (monsen, 1983). dit is gevolglik redelik duidelik waarom die vokaalproduksie afwykend is, tog is daar 'n gebrek aan basiese inligting ten opsigte van die aard van die afwykings spesifiek in afrikaans. hierdie studie poog om as vertrekpunt te dien in hierdie behoefte aan inligting. om vokaalproduksie egter sinvol te deurskou is dit van belang om 'n objektiewe metingswyse te gebruik omdat dit in die meeste gevalle selfs vir 'n opgeleide luisteraar moeilik is om die die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 oorsaak van 'n gehoorgestremde se spraakfoute te identifiseer (monsen, 1978). om die rede word vokale spektrografies ontleed. die parameters wat akoesties ontleed is, is die eerste twee formante wat die belangrikste leidraad in vokaalpersepsie is teenoor onder andere die fundamentele frekwensie en vokaalduur wat van sekondere belang is (monsen en engelbretson, 1983). daar is reeds in studies van amerikaanse engels aangetoon dat laasgenoemde twee parameters van belang is in die spraak van die gehoorgestremde en daarom is dit ook in hierdie studie ingesluit (monsen 1974, angelocci, kopp en holbrook, 1964). metode proefpersone agtien tienderjarige seuns met 'n kongenitale sensories-neurale gehoorverlies groter as 70db gehoorpeil in die beste oor is as proefpersone geselekteer. tien seuns het 'n ernstige (70-90db) gehoorverlies en 8 het 'n totale gehoorverlies (groter as 90db) vertoon. daar word vervolgens na eersgenoemde groep as hardhorendes en na laasgenoemde groep as dowes verwys. slegs seuns bo 15 jaar is geselekteer sodat hul laer fundamentele frekwensie akkurate spektrografiese metings kan verseker (huggins, 1980). al die proefpersone het oor 'n normale intelligensie beskik en geen ander fisiese afwykings getoon nie. almal is reeds op voorskoolse stadium met gehoorapparate gepas en daar is toe reeds met opleiding begin. verder is al die seuns se huistaal afrikaans en hulle is almal in 'n orale-ourale opleidingsprogram. tien normaalhorende seuns vergelykbaar met die gehoorgestremdes ten opsigte van intelligensie, ouderdom, huistaal en afwesigheid van enige ander fisiese of spraakprobleme is geselekteer om as kontrolegroep op te tree. materiaal en apparaat twaalf afrikaanse vokale is geselekteer, naamlik (i, y, ε, e, a:, φ, oe, 3, o:, a, a:, u). die vokale is in 'n kvk lettergreep met © sasha 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 santi meyer ( 9 ) as inisiele en (p) as finale konsonant geplaas. die konsonante is geselekteer met die oog op die geringste effek op die vokaalformante (angelocci et al., 1964) sowel as duidelikheid op die spektrogram en gemak van produksie vir dowes. ter wille van die natuurlikheid van die produksie is die toetswoord in sinskonteks geplaas. die opnames is gemaak deur middel van 'n nakamichi 550 en is spektrografies deur middel van 'η vii voice identification spectrograph ontleed. prosedure elke spreker het die 12 sinne in 'n toevallig geselekteerde volgorde gelees waartydens dit op band opgeneem is. die prosedure is na 'n tydsverloop herhaal wanneer die spreker die sinne in 'n ander toevallig geselekteerde volgorde gelees het. dit is ook 'n derde keer herhaal. hierna is die bande voorberei vir spektrografiese analises. van elke vokaal is 'n wyeband (300 hz) spektrogram verkry waar die eersteen tweedeformantfrekwensies sowel as elke vokaal se duur en fundamentele frekwensie bepaal is (meyer, 1984). resultate en bespreking die gemiddelde duur van die vokaalproduksie van normaalhorende en gehoorgestremde sprekers volgens figuur 1 is 'n eerste uitstaande kenmerk van die resultate dat die gemiddelde duur van die normaalhorendes se vokale opvallend korter is as die van die dowe sprekers. die dowes verleng hul vokale twee tot twee-en-'η-half keer relatief tot die gemiddelde vokaalduur van die normaalhorendes. hierdie verskil in vokaalduur is dan ook statisties betekenisvol op die 5%-vlak van betekenis (scheffe se meervoudige vergelykingstegniek) (steyn, smit en du toit, 1984). sprekers vokaal g e m · d u u r in m.sek. <0 80 120 160 200 210 280 duur in milusekondes figuur 1 die gemiddelde vokaalduur van normaalhorende, hardhorende en dowe sprekers alhoewel die gemiddelde duur van die hardhorendes se vokaalproduksie ook gering relatief tot die duur van die normaalhorendes verleng is, is die verskil nie statisties beduidend nie. die hardhorendes verskil ook betekenisvol op die 5%-vlak van betekenis van die dowes ten opsigte van vokaalduur (scheffe se meervoudige vergelykingstegniek) . 'n tweede opvallende eienskap van die resultate is dat die duur van die onderskeie vokale onderling verskil. dit blyk duidelik uit die resultate van die normaalhorende groep dat daar onderskei kan word tussen kort vokale (a, ce, u, i,) halflang (ε, a, o) en lang vokale (o: y, e, 0, a:) waarvan hul duur 63-72 ms, 81 ms en 112-150 ms onderskeidelik is. hierdie duurverskille word deur die hardhorende sprekers behou, want hul gemiddelde vokaalduur val in dieselfde kategoriee as die van normaalhorendes. in die geval van die dowe sprekers is die duurgrense van die verskillende vokale onderling nader aan mekaar. wanneer die vokale van die kortste na die langste vokaal gerangskik word, blyk dit egter dat die dowe sprekers tog ook sekere vokale korter as ander produseer. die halflang vokale verdwyn sodat die vokale in 'n groep met 'n relatief kort duur (a, 3, ε, ce, a, i, u) en 'n relatief lang duur (o:, 0, a:, y, e) verdeel. die dowe spreker se kenmerkende verlengde vokaalduur is reeds opgeteken (calvert, 1961). hierdie studie bevestig dat dit ook die geval is by die afrikaanssprekende dowe. alhoewel die dowe wel in staat is om vokaalduur waar te neem, is die produksie daarvan uitermate afwykend. 'n moontlike rede is dat die duur van vokale dikwels slegs 'n sekondere onderskeidende element is (monsen en engelbretson, 1983), of/en die dowe spreker nie die belang van die korrekte duur insien nie. daarbenewens kan dit moontlik ook die gevolg wees van die dowe spreker se moeisame spraakpogings omdat sy spraak dikwels onder bewuste beheer is (ling, 1976). in teenstelling met die dowe sprekers het die hardhorende sprekers in hierdie studie nie probleme met die korrekte beheer van vokaalduur getoon nie. die beskikbaarheid van meer gehoorreste het dus 'n ingrypende effek op die korrekte vokaalduur. 'n tweede kenmerk wat uit die resultate na vore kom, naamlik die onderlinge verskille in duur tussen die verskillende vokale, is algemeen in afrikaans beskryf (van wyk, 1977). die inherente duurverskille tussen soortgelyke vokale is deel van 'n normale spreker se linguistiese vermoe (monsen, 1974) waarmee betekenisverskille in afrikaans teweeggebring kan word, byvoorbeeld /pers/ (drukkery) teenoor /pe:rs/ (kleur). die feit dat die vokale in afrikaans in hierdie studie in kort, halflank en lank verdeel kan word, hou waarskynlik verband met die spesifieke linguistiese omgewing waarin dit geproduseer is. koopmans-van beinum (1980) het dieselfde in nederlands bevind, maar met die verskil dat die halflang vokale soos 'n kort vokaal in spontane spraak funksioneer. i i aangesien die duurverskil nie behoue bly in alle spraaksituasies nie, verklaar dit waarskynlik waarom die dowe sprekers nie so 'n onderskeiding in hul spraak tref nie. die meer uitgesproke verskille tussen lang en kort vokale bly egter in 'n mate in hul spraak behoue. die gemiddelde fundamentele frekwensie van die vokaalproduksie van normaalhorende en gehoorgestremde sprekers 'n eerste uitstaande kenmerk van die resultate in figuur 2 is die verskil in die gemiddelde fundamentele frekwensie tussen die normaalhorende en die gehoorgestremde sprekers. die gehoorgestremde sprekers se fundamentele frekwensie is ooglopend hoer as die van die normaalhorende groep. dit geld vir sowel die dowe as die hardhorende sprekers. hierdie verskille in gemiddelde fundamentele frekwensie is statisties betekenisvol tussen die normaalhorenthe south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η spektografiese ontleding van die vokale van afrikaanssprekende gehoorgestremdes sprekers vokaal fo gem. in h z . 100 110 120 130 u 0 150 gemiddelde fundamentele frekwensie in hz figuur 2 die gemiddelde fundamentele frekwensie (fo) van vokale soos deur normaalhorende en gehoorgestremde sprekers geproduseer de en beide groepe gehoorgestremdes. dit is bepaal deur 'n ewekansige blokontwerp (blokke is vokale) as variansieanalisetegniek. die twee groepe gehoorgestremdes, naamlik die dowes en hardhorendes, verskil egter nie betekenisvol van mekaar deur middel van sheffe se meervoudige vergelykingstegniek nie (steyn et al., 1984). i 1 i • ' i tweedens blyk dit dat vokale in figuur 2 verskil ten opsigte van die gemiddelde fundamentele frekwensie. wanneer die vokale gerangskik word van die met die laagste gemiddelde fundamentele frekwensie na die met die hoogste gemiddelde fundamentelefrekwensie kom daar redelike goeiej ooreenstemming tussen die drie groepe sprekers voor. by al die groepe is (a:, o, a) die vokale met die laagste gemiddelde fundamentele frekwensie en (0, y, i) die met die hoogste gemiddelde fundamentele frekwensie. die gemiddelde fundamentele frekwensie van normaalhorende manlike sprekers in hierdie studie vergelyk redelik goed met ander studies waar die sprekers in dieselfde ouderdomsgroep val. die gemiddelde fundamentele frekwensie van 126hz is vergelykbaar met schneiderman en kryski (1978) se sewentienen agtienjarige seuns se gemiddelde fundamentele frekwensie van 130hz en peterson en barney (1952) se volwasse manlike sprekers wat 'n gemiddelde fundamentele frekwensie van 132hz vertoon. die hoer gemiddelde fundamentele frekwensie van die dowe en hardhorende groep is ook in ooreenstemming met gepubliseerde navorsing in ander tale uitgevoer. die gemiddelde fundamentele frekwensie van angelocci et al., (1964) se 11-14-jarige seuns het met 43hz van die normaalhorendes verskil. in hierdie studie verskil die normaalhorende sprekers met 18hz van die dowes en 24hz van die hardhorendes. die geringer verskil in die resultate van hierdie studie is moontlik toe te skryf aan die feit dat angelocci et al. se proefpersone meer onstabiliteit van die fundamentele frekwensie toon as gevolg van hul ouderdom (11-14-jarige seuns) wanneer laringeale veranderings as gevolg van puberteit voorkom. aangesien beide groepe gehoorgestremdes 'n betekenisvol hoer gemiddelde fundamentele frekwensie as die normaalhorendes toon, kan die afleiding gemaak word dat dit die gevolg is van die teenwoordigheid van die gehoorverlies. die afleiding word dan ook ondersteun deur monsen, engelbretson en vermula (1979) se navorsing by gehoorgestremdes met vergelykbare graad van verlies as die sprekers in hierdie studie. the control of fundamental frequency is especially dependent upon the control of vocal fold tension and profound hearing impairment may hinder or prevent a speaker from learning the precise phonatory consequences of the muscular gestures which maintain or alter vocal fold tension in the production of speech. (monsen et al., 1979) die onvermoe om die fundamentele frekwensie te beheer, hou verband met die feit dat twee belangrike kwaliteite van fonasie, naamlik duur en intensiteit, beide waargeneem kan word deur vibrasie, maar nie fundamentele frekwensie nie. gehoor is dus nie so belangrik in die aanleer of beheer van eersgenoemde twee nie. toonhoogte ofte wel fundamentele frekwensie kan egter nie op enige ander wyse as deur middel van gehoor waargeneem word nie (monsen et al., 1979). die gevolgtrekking bied dan 'n gepaste verklaring veral vir die hardhorendes wat probleme toon met beheer van fundamentele frekwensie, maar nie enige moeite ondervind met die korrekte beheer van vokaalduur nie. alhoewel die gemiddelde fundamentele frekwensie van die gehoorgestremde sprekers afwyk van die norrnale, is dit interessant dat die vokale wat 'n relatief hoe en relatief lae fundamentele frekwensie by die normaalhorende groep toon, eweneens dieselfde eienskappe by die gehoorgestremdes toon. dit is 'n belangrike faset van vokaalproduksie in die sin dat die intrinsieke fundamentele frekwensie van die vokaal die struktuur van die spraakmeganisme reflekteer (koopmans-van beinum, 1980). alhoewel die volgorde ten opsigte van die gemiddelde fundamentele frekwensie by die gehoorgestremdes nie identies is nie, is daar 'n onderskeid tussen die vokale met 'n laer en die met 'n hoer fundamentele frekwensie wat vergelykbaar is met die normaalhorendes se resultate. die fundamentele frekwensie neig om te verhoog namate die vokaalhoogte toeneem. bespreking van die eersteen tweedeformantfrekwensies van normaalhorende en gehoorgestremde sprekers eerstens toon die resultate in figuur 3 dat 'n bepaalde vokaal in die geval van die normaalhorende sprekers in 'n spesifieke frekwensiegebied voorkom. die gemiddelde eersteen tweedeformantfrekwensie dui die verskil tussen die hoe en lae vokale sowel as die vooren agtervokale duidelik aan in hul ligging in figuur 3. die vokale waar daar veral opvallend oorvleueling voorkom, is (i), wat met (y) oorvleuel en so ook (e, 0) en (a, ce). hierdie vokale word egter slegs onderskei ten opsigte van die labiale modifikasie van die mondholte (van wyk, 1977) en die oorvleueling is dus verstaanbaar. slegs 'n geringe verlaging van die eersteen tweedeformantfrekwensies word deur lipronding veroorsaak. tweedens, in die geval van die hardhorende groep (figuur 4) is elke vokaal steeds opvallend in sy eie frekwensiegebied gelee, alhoewel die hoe en middelhoe voorvokale en die hoe en middelhoe agtervokale nie so ver van mekaar gelee is as wat by normaalhorendes die geval is nie. dit is duidelik dat daar meer oorvleueling van verskillende vokale se formantfrekwensies is. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 santi meyer hz 3250 3200 3150 3100 3050 3000 29s0 2900 2050 2600 2750 2700 2650 2600 2550 2500 2150 2100 2350 2300 2250 2200 2150 2100 2050 2 0 0 0 1950 1900 ism 1000 1750 1700 1650 1 6 0 0 1550 1500 u50 1400 1j50 1>00 1250 1300 1150 1100 10 50 1000 iso •00 • 50 t o o 750 700 650 600 if· : ι y : q i ? " . »© .> v * : » , ' (j ψ * τ • a η ' · * * mi 1 \ · ^ > * · λ i f • · . . y • % f ? f » «v t f 4 : . *3> jr * at γ « λ s · · •h { • «v 150 200 250 300 350 100 150 500 550 600 650 700 750 600 mo 900 mo hz eerste formant figuur 3 die eersteen tweedeformantfrekwensies van vokale geproduseer deur normaalhorendes hz 3250 3200 3150 3100 3050 3000 2950 2900 2850 2000 2750 2700 2650 2600 2550 2500 2150 2100 2350 2300 2250 2200 2150 2100 2050 2000 ί 9 5 0 1900 1050 ιβοο 1750 1700 1650 1600 1550 1500 1150 1100 1350 1300 1250 1200 1150 1100 1050 1000 950 300 050 000 750 700 650 600 550 « φ · , ι ® / © ? ® 4) . v « fc «· · t # . λ * . . * *® j· φ r" : $ 150 200 250 300 350 100 iso 500 550 600 650 700 750 βοο 850 soo »bo hz eerste f0rm4nt figuur 4 die eersteen tweedeformantfrekwensies van vokale geproduseer deur hardhorendes derdens, wanneer die resultate van die dowe groep bestudeer word (figuur 5) is die bogenoemde verskynsel nog meer opvallend. die gemiddelde eersteen tweedeformantwaardes is in" 'n klein frekwensiegebied na aan mekaar gelee. (die gemiddelde eersteen tweedeformantfrekwensies van die vokale van die drie groepe sprekers verskyn in die bylaag). laastens bied die statistiese verwerkings van bogenoemde formantfrekwensies interessante resultate. die gemiddelde eersteformantfrekwensie van die drie groepe sprekers verskil in elke geval betekenisvol van mekaar op die 5%-betekenispeil wanneer 'n ewehz 3250 3200 3150 3100 3050 3000 2950 2900 2850 2800 2750 2700 2650 260} 2550 2500 2450 2400 2350 2300 2250 2200 2150 2100 2050 2000 1950 1900 1850 1800 1750 1700 1650 1600 1590 1500 u 5 0 ; u00 ι 1350 1 1300 ! 1250 1 1200 1150 i 1100 1050 1000 950 900 650 600 550 150 200 250 300 350 400 450 500 550 600 650 700 750 800 850 900 680 mz e e r s t e formant figuur 5 die eersteen tweedeformantfrekwensies van vokale geproduseer deur dowes kansige blokontwerp as variansieanalisetegniek gebruik is, naamlik scheffe se paarsgewyse vergelykingstegniek (steyn et al., 1984). geeneen van die gehoorgestremde groepe se gemiddelde eersteformantfrekwensie is dus vergelykbaar met die van die normaalhorendes nie, en verder verskil hulle ook onderling. wanneer figure 3, 4 en 5 bestudeer word, blyk dit ook duidelik dat die eersteformantfrekwensies van die hardhorende groep hoer gemiddelde waardes toon as die van die normaalhorende groep, veral vir die voorvokale. dit is nog meer opvallend by die dowe groep. wat die tweedeformantfrekwensie betref verskil die normaalhorende groep betekenisvol van die dowe groep op die 5%-betekenispeil. verder verskil laasgenoemde sprekers ook betekenisvol van hardhorende sprekers op die 5%-betekenispeil. die verskil tussen die hardhorende en normaalhorende sprekers is egter nie statisties beduidend op die 5%-betekenispeil nie. die resultate is verkry deur middel van 'n ewekansige blokontwerp as variansieanalise-tegniek (scheffe se paarsgewyse vergelykingstegniek) (steyn et al., 1984). : i weereens is die bevindings ten opsigte van die verskille tussen die normaalhorendes en gehoorgestremdes duidelik wanneer figure 3, 4 en 5 bestudeer word. die gemiddelde tweedeformantfrekwensies van die normaalhorende groep sprekers toon opvallend heelwat hoer en laer waardes as die van die dowe groep. dieselfde waarneming kan gemaak worcl in die geval van die hardhorende en dowe sprekers. wanneer die gemiddelde formantfrekwensies van die dowe en hardhorende groepe met die van die normaalhorendes vergelyk word, is die beperkte omvang van die waardes opvallend. die frekwehsiegebied waarbinne die gemiddelde eersteformantfrekwensie by normaalhorendes gelee is, is 390hz (hoogste waarde 628hz en laagste waarde 238hz). hierteenoor is dieselfde waardes 433hz by die hardhorende sprekers (714hz en 281 hz respektiewelik) en 134hz by die dowes (657hz en 523hz). hieruit word die beperkte omvang van die eerste formant se frekwensiegebied by die dowes duidelik. wat verder in die verband opval, is dat die frekwensies the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η spektografiese ontleding van die vokale van afrikaanssprekende gehoorgestremdes 55 die eerste formant van die middel en agtervokale van normaalhorendes verteenwoordig. die bevinding ondersteun dus boone (1966) se opmerking dat die dowe spreker tydens vokaalproduksie sy tong te laag en ver na agter posisioneer. verder is die hoe voorkoms van neutrale vokale soos deur luisteraars in dowes se spraak gei'dentifiseer ook verstaanbaar aangesien die dowe heelwat verskillende vokale in die frekwensiegebied van die neutrale vokaal se eerste formant produseer (angelocci et al., 1964). die betekenisvolle groter frekwensiegebied waarin die hardhorendes se eerste formant voorkom, kan moontlik die gevolg wees van die hardhorende se poging om deur middel van die eerste formant tussen die vokale te onderskei. die eerste formant is vir hardhorende sprekers relatief duidelik hoorbaar en dit is moontlik dat hulle deur groot artikulatoriese/fisiologiese bewegings poog om op die wyse tussen vokale te onderskei — soortgelyk aan die sprekers van angelocci et al., (1964) wat vokaal verskille deur middel van die fundamentele frekwensie wou aanbring. die gemiddelde tweedeformantfrekwensie van die normaalhorende groep wissel oor 'n frekwensiegebied van 1754hz (2624hz van die hoogste vokaal na 870hz van die laagste vokaal). hierteenoor is dieselfde waardes van die hardhorendes 1082hz (2170hz van die hoogste na 1088hz van die laagste vokaal) en die dowes 393hz (1628hz en 1235hz respektiewelik). hieruit is dit duidelik dat die hardhorendes 'n redelike goeie omvang in die gemiddelde tweedeformantfrekwensie toon, maar dat die dowe se tweedeformantfrekwensie in die gebied van die neutrale (a) van die normaalhorende spreker gelee is. die bevinding verklaar weereens die hoe voorkoms van neutrale vokale in die dowe se spraak soos deur normaalhorendes beoordeel. die feit dat die gemiddelde eersteen tweedeformantfrekwensies van verskillende vokale so na aan mekaar gelee is en daar dus heelwat oorvleueling in die individuele waardes is, spreek dus vanself dat vokaalvervangings dikwels deur luisteraars gehoor word. daar kan ook uit die oorvleueling van waardes afgelei word dat die dowe sprekers nie akkurate plasing van die artikulators bemeester het nie — veral as die geringer mate van oorvleueling van die normaalhorendes in gedagte gehou word (angelocci et al., 1964). i die normaalhorende groep se gemiddelde eersteen tweedeformantfrekwensies toon veral van sekere vokale oorvleueling van waardes. dit is dan veral opvallend jin die geval van (i) en (y) en (e) en (0). die resultate is egter verstaanbaar aangesien lipronding in die produksie van hierdie vokale die enigste veranderlike is wat verskil (van wyk, 1977). j i gevolgtrekking na aanleiding van die bespreking van die resultate kom enkele implikasies vir die oudioloog na vore. ten opsigte van vokaalduur aangesien vokaalduur selfs vir 'n persoon met beperkte residuele gehoor waarneembaar behoort te wees (ling, 1976) en dus waarskynlik ook meer effektief gebruik behoort te word, moet redes vir die afwykende vokaalduur nagevors word. effektiewe terapiestrategiee moet beplan word sodat die dowe sprekers vokaalduur korrek kan aanwend. dit sal bydra tot meer effektiewe dekodering van die boodskap aangesien vokaalduur inligting bevat oor die suprasegmentele eienskappe van klem en dus ook spraakritme sowel as spraakspoed. dit verskaf ook inligting oor segmentele eienskappe, naamlik inligting ten opsigte van 'n aangrensende konsonant sowel as die inherente eienskappe van die vokaal self (monsen, 1976). ten opsigte van fundamentele frekwensie 'n belangrike aspek om in gedagte te hou is dat die gehoorgestremde, maar veral die dowe, nie in staat is om fundamentele frekwensie as gevolg van sy gehoorverlies effektief te reguleer nie. om die rede is dit dus sinvol om vir die spreker die ontbrekende inligting deur middel van 'n ander sensoriese kanaal aan te bied waarop hy wel die veranderings ten opsigte van fundamentele frekwensiebeheer kan waarneem. verskeie navorsers het bewys dat die beheer van fundamentele frekwensie effektief deur middel van die visuele kanaal aangeleer kan word — veral as die linguistiese belang van fundamentele frekwensiebeheer aangetoon word (phillips, remillard en pronovost, 1968). ten opsigte van die eersteen tweedeformantfrekwensies tydens vokaalaanleer is dit noodsaaklik dat die spraakopleier seker moet maak dat die dowe inligting sal verkry ten opsigte van tonghoogte en tongposisie. die inligting wat deur middel van die eerste en tweede formante oorgedra word, is of nie vir die gehoorgestremde beskikbaar weens die graad van sy verlies nie, of dit is so ondergeskik aan ander ouditiewe inligting dat hy dit nie benut nie. deur middel van spesifieke ouditiewe of taktiele strategiee kan hierdie inligting egter aan die dowe verskaf word sodat hy ook sy produksie daarvolgens kan rig (ling, 1976). bedankings die skryfster erken met dank die finansiele ondersteuning van die raad van geesteswetenskaplike navorsing. verwysings angelocci, α., kopp, g. en holbrook, a. the vowel formants of deaf and normal hearing eleven to fourteen year old boys. j. speech hear. disord., 29, 156-170, 1964. boone, d.r. modification of the voices of deaf children. the volta review, 68, 686-692, 1966. calvert, d.r. some acoustic characteristics of the speech of profoundly deaf individuals. ongepubliseerde d(phil) verhandeling, stanford universiteit, 1961. huggins, a.w.f. better spectrograms from children's speech: a research note. j. speech hear. res., 23, 19-27, 1980. koopmans-van beinum, f.j. vowel contrast reduction. an acoustic and perceptual study of dutch vowels in various speech conditions. amsterdam: academische pers b.v., 1980. ling, d. speech and the hearing impaired child: theory and practice. washington, d.c.: alexander graham bell association for the deaf, 1976. markides, a. the speech of deaf and partially hearing children with special reference to factors affecting intelligibility. br. j. disord. commun., 5, 126-140, 1970. meyer, s.e. die vokaalproduksie van die afrikaanssprekende gehoorgestremde. ongepubliseerde m(log) verhandeling universiteit van pretoria, 1984. monsen, r.b. durational aspects of vowel production in the speech of deaf children. j. speech hear. res., 17, 386-398, 1974. monsen, r.b. normal and reduced phonological space in the production of english vowels. j. phonetics, 4, 189-198, 1976. monsen, r.b. toward measuring how well hearing impaired children speak. j. speech hear. res., 21, 197-219, 1978. monsen, r.b. general effects of deafness on phonation and articulation. in hochberg, i., levitt, h., osberger, m.j. (eds.). speech of the hearing impaired. research, training and personnel preparation. baltimore: university park press, 1983. monsen, r.b. en engelbretson, a.m. the accuracy of formant frequency measurements: a comparison of spectrographic analysis and linear prediction. j. speech hear. res., 26, 89-97, 1983. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 santi meyer monsen, r.b., engelbretson, a.m. en vemula, n.r. some effects of deafness on the generation of voice j. acoust. soc. am., 66, 1680-1690, 1979. peterson, g. barney, h. control methods used in a study of the vowels. j. acoust. soc. am., 24, 175-184, 1952. phillips, n.d., remillard, w., bass, s. en pronovost, w. teaching of intonation to the deaf by visual pattern matching. am. annals deaf, 113, 239-246, 1968. schneiderman, c.r. en kryski, j.a. fundamental frequency change in preand post adolescent deaf males and females. j. am. audit. soc., 4, 64-68, 1978. steyn, a.g.w., smit, c.f. en du toit, s.h.c. moderne statistiek vir die praktyk. 3de uitgawe pretoria: j.l. van schaik, 1984. van wyk, e.b. praktiese fonetiek vir taalstudente: 'n inleiding. pretoria: heer drukkers (edms) bpk., 1977. bylaag die gemiddelde eersteen tweedeformantfrekwensies van die vokale van drie groepe sprekers vokale formante normaalharddowes horendes horendes dowes i fl 238 281 523 f2 2624 2170 1629 y fl 228 280 543 fl 2517 1959 1550 e fl 345 357 504 fl 2329 2098 1692 0 fl 331 357 520 (2 2264 2004 1548 ε fl 397 456 546 f2 1150 1952 1613 oe fl 475 537 541 (2 1300 1513 1354 3 fl 502 526 530 f2 1453 1572 1515 a fl 628 680 630 f2 1057 1202 1404 a: fl 575 715 657 f2 954 1213 1409 d fl 435 513 546 fl 873 1043 1209 0: fl 362 419 458 fl 1055 1137 1181 u fl 272 302 474 fl 870 1088 1235 the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gsi 28 auto tymp the gsi 28 auto tymp provides testing capability for tympanometry, ipsilateral and contralateral acoustic reflex testing and screening audiometry. selection of test sequence is as simple as pressing a button! the auto tymp is lightweight and compact so it can be easily moved from one location to another. an optional carrying case is available if more portability is required. t h e n e e d i e r w e s t d e n e o r g a n i s a t i o n ( p t y ) l i m i t e d in association with / in medewerking met hearing and acoustic instruments (pty) ltd lewis's hearing centre (pty) ltd engineered acoustic products noise control 1st floor, 74 george avenue, sandringham 2192. johannesburg, south africa. telex: 4-25028. p.o. 28975, sandringham 2131, south africa. tel: (011) 640-5017. cables: needlerog. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 43 indigenous healers and stuttering rozanne platzky and joan girson department of speech pathology and audiology university of the witwatersrand abstract traditional beliefs and attitudes of black south africans to stuttering were investigated. four indigenous healers (ihs) from different ethnic groups were interviewed about their beliefs as to cause and management of stuttering, as well as the outcome of their treatment. the data reveals varying degrees of concern about stuttering. the traditional beliefs of cause and management of stuttering show some similarities to current beliefs held by speech pathologists. implications in terms of direction in therapy, cooperation with ihs and future research in this field are discussed. opsomming die tradisionele opvattings en houdings van swart suidafrikaners ten opsigte van hakkel is ondersoek. onderhoude is met vier tradisionele genesers van verskillende etniese groepe gevoer om hulle geloofsoortuiginge te bepaal ten opsigte van die oorsaak en behandeling van hakkel, sowel as die resultate watgekry word met hulle behandeling. die data toon wisselende grade van besorgheid oor hakkel. die tradisionele geloof rakende die oorsaak en behandeling van hakkel stem ooreen met die huidige menings wat gehuldig word deur spraakpataloe. die implikasies van bevindinge word bespreek met behulp van terpeutiese riglyne, samewerking met tradisionele genesers en verdere navorsing. indigenous healers and stuttering an important aspect of stuttering in relation to research and therapy is the attitude^ of the stutterer himself and that of his associates toward his speech symptoms. (ammons and johnson, 194'4, p.39) although emotions and attitudes are highly individualistic, cultural beliefs and background will invariably influence them as "... culture is the indispensable factual background in relation to which the worker adapts his contribution to the situationj before him." (fenalson, 1952, p.4). culture implies meanings, ideas and values that constitute a way of life that pervades relationships, systems of belief and behaviour. it may be assumed therefore that culture will influence attitudes towards stuttering as well as its development and treatment. wendell johnson (1944), in his studies of american indians, was one of the first to investigate cultural influences on stuttering. he found no evidence of stuttering and no name for it was present in the languages of the groups studied. he interpreted this lack of a name as being the reason why stuttering did not exist, because it implied that stuttering was not significant in this culture. later analysis (wingate, 1972) identified methodological problems in johnson's research and his results were discredited. subsequent studies, cited by van riper (1971) found stuttering among population groups as diverse as the japanese and eskimo, leading him to conclude that stuttering exists universally. therefore, the cause is unlikely to be related to cultural attitudes. he does, however, cite kluckhohn (1954) who states that "... impressive differences in the degree and incidence (of stuttering) suggests cultural influences are operative." (van riper, 1971, p.9.) wingate (1972) attributes this to the differences in the importance and expectations of a child's speech, across cultures. this sentiment is reiterated by snidecor (1947), leith & mims (1975), leith (1986) and shames (1989) who identify cultural factors such as stress on speech performance, and child-rearing practices which are likely to influence the incidence of stuttering. having concluded that cultural beliefs influence the incidence of, and attitudes towards stuttering, and that these attitudes should be identified and explored in therapy, it is evident that the speech therapist needs to be familiar with the cultural beliefs of her clients. shames (1989) states that "... therapy becomes an intercultural collision of values, attitudes, expectations and definitions". owing to the disproportionate ratio of black speech therapists to blacks in south africa, one is faced with a situation where the majority of trained therapists are unfamiliar with the cultural backgrounds of their clients. current trends in therapy derive from america and europe with an orientation not designed to meet the needs of cultures as diverse as that of black south africans. the success of therapy may therefore be hindered by the denial of, or failure to acknowledge a client's cultural beliefs through lack of knowledge, and his being forced to conform to those proposed by modern theories. refuting beliefs about cause and treatment may serve only to aliendie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 ate the client (leith & mims, 1975). fenalson (1952) demands that any professional worker attempting to help others in areas of personal adjustment, needs to understand an individual in terms of his culture and its effect on his responses to life experiences. south african psychologists have become increasingly aware of the necessity to re-evaluate the therapy that they offer in terms of cultural appropriateness. holdstock (1979, p.119) goes as far as to say that "... professionals would never be able to satisfy the emotional needs of people", while the therapy that they offer is tailored to westernised cultures. it may be meaningless and ineffectual when applied to members of a culture so starkly different from it. the writers have, therefore, undertaken to study an aspect of the attitudes and perceptions of a sample of black people in south africa to stuttering. in order to attain an understanding of traditional cultural beliefs it was decided to focus on indigenous healers (ihs) for this information as they have been described as "... psychologist, physician as priest... tribal historian" (holdstock, 1979, p. 119). the ih is a highly respected member of the tribe, a reservoir of traditional beliefs and one who has the power to modify customs (hammond-tooke, 1989). he is that indispensable member of the society who is consulted by an estimated 70% of the black population of s.a. (mzinyathi, undated, p.144). in 1977 the soweto society for marriage and family life concluded that the majority of people in soweto believe in the power of the ih (holdstock, 1979). the world health organisation (who) estimated that ihs form the essential core of primary health workers for nine tenths of two billion rural dwellers in third world countries (holdstock, 1979). once urbanised, a black person may well consult an ih as hammond-tboke (1974) predicts that an urban diviner's clientele consists of traditionalists, professionals, middle-class blacks and even whites. ihs may, therefore, be considered a valuable source of information on cultural beliefs about stuttering as well as on the traditional treatment for stuttering. according to hammond-tooke (1989) there are two distinguishable types of healers, i.e. diviner and herbalist. the herbalist is one who has not been mystically called but is a master of medicines. he is one who has knowledge of plants and roots. the diviner, on the other hand has been described by hammond-tooke (1989, p. 104) as one "... clothed with power and knowledge ... called to the profession by the prompting of the ancestors". he, therefore, likens the diviner to a doctor, and the herbalist to a pharmacist. a diviner is consulted in the case of a longlasting illness in order to establish a cause and a remedy for the illness. the diviner was, therefore, considered to be the more suitable subject for this research report. south africa is moving towards a new political dispensation with revised health policies. the inclusion of the ih into these policies is now under debate. the role of the ih cannot be ignored as he is accessible to and consulted by the majority of the black people in south africa. it is estimated that there are between 100π000 and 200π000 ihs practising in s.a. today (freeman, 1992). in the best interests of the clients, krober (1990), therefore recommends fostering a spirit of co-operation between traditional healers and medical practitioners. holdstock (1979) agrees with this recommendation and admonishes members of the helping professions that"... although indigenous healing is as old as the civilisation of africa and at present rozanne platzky & joan girson time adhered to by countless numbers of individuals, people in the helping professions and academic community know next-to-nothing about it and acknowledge it even less" (holdstock, 1979, p. 118). there are those (motlana, 1992) who, on the other hand, are vehemently opposed to any co-operation. they perceive ihs as dangerous due to their lack of knowledge of physiology and anatomy. motlana (1992) criticises any attempt to co-ordinate traditional and modern practices as he feels that it traps the south african black person in a previous era while the rest of the community moves forward into a technologically advanced and sophisticated century. south african speech therapists cannot make an assessment about the efficacy of traditional methods until they have a knowledge of what they comprise. effective, efficient and meaningful therapy may then only be provided once the client's attitudes and expectations have been assessed. methodology aims the aims of this study were twofold: 1. to probe the cultural beliefs and attitudes of ihs to stuttering. 2. to investigate whether they treat stuttering clients and, if so, what this treatment would comprise. subjects because of time and other practical constraints the size of the sample had to be restricted to five subjects. an attempt was made to choose subjects reflecting the population of the ihs which is divided into the nguni, sotho, venda and tsonga groups (hammond-tboke, 1989). unfortunately, no venda subject was available. two subjects had rural, and three urban practices to reflect possible differences in approach. all subjects were diviners, as it was considered that they would be the more likely ihs to be consulted in the event of stuttering. ! all subjects were contacted through the african national healers association (anha), as freeman ;(1992) cautions against consultation with ihs who may not be authentic. for a description of the individual subjects please see table i. j ι procedure i i the survey was conducted through interviews because of the "richness and spontaneity of information" (oppenheim, 1966, p.32) which is obtained through this method of data collection. interviews yield a high response rate and decrease the number of "don't know" and "no answer" responses (young, 1966). the flexibility of an interview was felt to be particularly appropriate in this instance as english was not the home language of any of the subjects and it was therefore sometimes necessary to rephrase, explain and probe. interviews do not require reading or writing ability on the part of the subjects. this was an important consideration as according to the african national healers association (unpublished) not all ihs are literate. an interview is prone to a number of sources of error the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) indigenous healers and stuttering table 1. description of subjects 45 subjects professional name years in practice rural/ urban calling training experience 1. tsonga (female) mungome 22 r fell ill. couldn't eat. no improvement till consulted mungome who told her it was a calling. 8 months with mungome. communicated with ancestors in visions. specialist in childhood health problems. others infertility, insomnia due to witchcraft. ulcers. trains novices. 2. s. sotho (female) ngaka 22 r became ill. taken to ih. inaugurated via rituals slaughtering goats. drinking or smoking medicines. specialist in childhood disorders diarrhoea, vomiting, swollen feet, sores under tongue, nail biting, failure to speak. trains novices. 3. xhosa (male) igquira 7 u fell ill. untreatable by orthodox medicine. 1 year under ih. gained ability to communicate with ancestors and to predict events before they occur. treats mental disturbance, body sores, visual defects, stomach ache, female problems, birth difficulties. 4. zulu (male) inyanga 9 u fell ill. called to profession by his deceased grandfather. 1 year and still consults his trainer. throws bones to formulate diagnosis. ability to cure vd, nausea, vomiting and bewitching given as a few examples. and its scientific utility is limited. it does, however, offer a means to establish contact with the subjects and to assess the appropriateness of this source of information. question construction j the order and sequencing of questions was controlled (young, 1966). most questions were open-ended as these provide the best opportunity to obtain the maximum amount of information from each question. guidelines outlined in the literature (babbie, 1973) were followed in the construction of questions. pilot study following a pilot study, conducted with a southern sotho ih, several changes were made to the sequence and content of the questions. at the end of the interview the respondent asked if she could ask the interviewer some questions. this proved to be valuable as her questions provided insight into her frame of reference and beliefs about stuttering. this procedure was then incorporated into the interview framework. interviews it was felt that the respondents would feel more relaxed and discuss their thoughts and practices more openly in familiar surroundings. subjects 1 and 2, who practice in a rural area, were interviewed at a private residence of their choice in the area in which they live. the other three subjects were interviewed at the offices of the anha. the interviewer followed the subjects' lead in terms of where to sit, i.e. at a table or on the floor. none of the respondents could speak english well and they were, therefore, joined by a member of the african national healers association (not an ih himself) who acted as interpreter. kahn and cannel (1957) caution against the use of an interpreter as it creates a barrier in the establishment of a rapport between respondent and interviewer. in this case it was felt that the interpreter actually set the respondents at ease and facilitated more open responses. an interpreter should merely be a medium through which questions and answers are transmitted (young, 1966). in order to ensure this, sources of error such as prompting or leading the respondent's answers were discussed with the interpreter before the first interview. he showed a knowledge and understanding of the protocol for research. during the third interview, the interviewer became aware that the interpreter was leading the subject. when this interview was analysed by a sotho speaking speech therapy student her suspicions were reinforced. it was, therefore, decided to exclude this subject from the study. following this the process was rediscussed with the interpreter and he was reminded of his role before completing the remaining two interviews. none of the subjects was present at interviews other than their own and they were asked not to discuss their interviews with the other subjects. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 analysis of the data the contents of the interviews were reported upon as "... precise summaries of the data" (forcese and richer, 1973, p.213). as this research was descriptive, results were categorised according to the questions, tabulated, and discussed qualitatively in order to compare the salient features. results and discussion the subjects' views on stuttering, i.e. name, cause, management, outcome and attitudes are presented in table 2, and will be discussed below. name and description of stuttering all the ihs had names for stuttering, which corresponded with those found by aron (1966). si and s2 also gave alternate names. si (tsonga) originally spoke of treating "lilele", which from her description may or may not have referred to stuttering. however, when asked to translate "stuttering" she used the term "konkoretsa" and demonstrated this as syllable repetitions. it is interesting to note the similarity between this word and "korakoretsa" the term used by s2 (south sotho) as these two languages are not related. all the names used were onomatopoeic as are the names for stuttering in many languages, e.g. "tuhuhtuhuh" egyptian, "gimgeim" hebrew and "howdodo" ghana (van riper, 1971). the ih's descriptions of stuttering all corresponded with the description of characteristic stuttering symptoms, i.e. syllable repetitions, complete blocks and sound prolongations given by peters and guitar (1991). table 2. summary of data rozanne platzky & joan girson cause all 4 subjects identified stuttering as an inherited disorder, although s4 was originally undecided. authorities in the field of speech therapy have, over the years, researched heredity as a causative factor. theorists now seem to agree that certain constitutional factors may be inherited and predispose a child to stuttering (van riper, 1973; bloodstein, 1987). 52 and s3 gave additional causes which seem to have their roots in folklore, i.e. being left out in the first rains of spring or failure to inform the ancestors of the child's imminent birth. s2 gave witchcraft as another alternative. these have no parallel in the professional literature. diagnosis and management the subjects differed in their approaches to diagnosis and management. si believes there is no treatment for konkoretsa as it is hereditary. s2 treats according to the cause. where the cause is hereditary there is usually a sore under the tongue which she treats with medication. if the stutter is caused by being left out in the rain the child must be treated outside (as this is where the affliction took place) by inhaling smoke from the ashes of medicinal products. 53 manifests the same symptoms as the patient and through this, intuitively determines the cause and treatment. he may use prayer, ritual medication or fulfilment of the forgotten rituals. he also educates parents and siblings on ways to handle the stutterer. s4 communicates with the ancestors, then prepares medication from the dried tongues of certain animals which is rubbed into cuts in the throat. name description cause management outcome attitude of stutterer attitude of society si tsonga (lilele) konkoretsa syllable repetitions heredity (accumulation of coagulated milk in throat.) none medication none not a problem accepting status unaffected. 1 1 ] s2 south sotho kgakgametsa korakoretsa syllable repetitions prolongation visible and audible tension heredity baby left out in first spring rain medication prayer and ritual medication. parental counselling. slow speech easy prolongations problem low self esteem accepting status unaffected. j s3 xhosa thintitha syllable repetitions blocks heredity failure to inform ancestors of imminent child-birth whitchcraft prayer medication rituals parental counselling as with mental disorder slow speech big problem handicapping y accepting status unaffected / s4 zulu amalimi repetitive clicks (syllable repetitions) heredity medication applied to cuts on throat area. slow speech y big problem accepting status affected the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) indigenous healers and stuttering 47 outcome subjects 2, 3 and 4 were agreed that their treatment would not cure the stuttering but would lead to slower, improved speech. therapists in many parts of the world report programs based on slow easy speech as helpful for stutterers (peters & guitar, 1991). subject 2 claimed that "there will be some noticeable change in the child". when asked to demonstrate the change, she showed easy prolongations in place of the effortful blocking she had shown as symptomatic of stuttering. van riper (1973) and others, advocate modifying the symptoms of stuttering to easy prolongations. there is no objective proof that the ih's treatment of stuttering is as successful as reported. it is likely, however, that the treatment could bring relief to the patients, at least partially, through indirect suggestion. indirect suggestion forms part of any stuttering program. a patient seeking therapy, goes with an anticipation and expectation of relief from his stuttering. this strong faith and desperate need are able to bring about a certain amount of relief (van riper, 1973). van riper attributes the success of suggestion to the intermittent, variable, fluctuating nature of stuttering, spontaneous recovery and the fact that temporary fluency is easily established. whether or not any known medication has proved successful in treating stuttering is queried. van riper (1973) cites many experiments done to assess the efficacy of certain drugs but criticizes their methodologies. he concludes that placebos may produce the same effects as drugs, because the therapeutic value of drugs often comes from the patient's faith in his physician. van riper (1973) gives credit for success in therapy, to the therapist's love and concern for the patient, over any other factors. ihs provide "... warm, nurturent, total acceptance of their patients" (hammond-tooke, 1989, p. 147). this, coupled with a belief in their powers of healing and a need to be cured, may be effective in relieving some of the symptoms, e.g. tension, associated with stuttering. counselling parents also'plays a significant part in the therapy provided by speech therapists. the principle of guiding parents in terms of their speech and behaviour towards a stuttering child, is reported by some of the ihs. given the warm empathetic environment that an ih can provide, parents may discuss their anxieties and become open to suggestions regarding the treatment of their children (van riper, 1973). it is not uncommon for parents to report a dramatic cessation in stuttering once they have removed certain pressures from speaking situations (van riper, 1973). strategies, e.g. use of simple language, reducing time pressure, providing a fluency model and not calling attention to the stutter are some of the suggestions that peters and guitar (1991) make reference to in a summary of the parent counselling of theorists such as van riper, bloodstein and luper and mulder. s3 makes similar suggestions, e.g. "... they shouldn't shout at the child, they shouldn't speak fast to the child", and cautions that"... imitating him to tease him creates a big problem ... this shouldn't be done". the success of the ihs treatment may, in some cases, not be attributable to their efforts at all. research has indicated that 50-80% of children who stutter, recover before puberty, without any treatment (peters and guitar, 1991). although they commented that the methods of gathering this information were not entirely reliable, peters and guitar (1991) conclude that spontaneous recovery can occur. attitudes si did not feel that konkoretsa was a problem. the other three concluded that stuttering was a problem which would handicap the individual or cause him to develop a low self esteem. however, only s4 felt that the stutterer would be prevented from attaining a position of status such as a tribe leader. this duty requires proficient, confident speech which is beyond the reach of the stutterer. implications aron (1991) estimates that only a fraction of the more than 3 000 000 people in south africa who require speech therapy, receive it, due to the small number of speech therapists working in this country. as a solution she proposes a community based approach to speech therapy, i.e. training community workers to provide basic therapy and knowledge of when and to whom referrals should be made. ihs are already recognised and consulted by most black south africans. they may, therefore, provide the untapped resource needed to make services accessible to more people with communication disorders, one that includes anawareness of "linguistic and cultural forces that operate" on the individual (shames, 1989, p.74). co-operation between speech therapists and ihs in the treatment of stuttering appears viable, not to undermine or eradicate cultural beliefs, but to share information and establish a system of referral. the beliefs held by ihs have proven to be a fertile and accessible area and more research is indicated in ih's beliefs as to cause and management of other communication disorders, e.g. hearing loss, strokes and cerebral palsy were mentioned by these subjects; the outcome of treatment by an ih from the patient's perspective; interviewing greater numbers of ihs in order to generalize common trends in their beliefs about cause, management and attitudes to stuttering; a comparison of the views of rural and urban ihs. although no marked differences appeared in the views expressed by the subjects in this study, it must be noted that the two rural subjects lived relatively close to an urban area. possibly subjects living in more remote parts of the country might offer different ideas; the efficacy of modern stuttering therapies for black south africans. conclusion at a conference in geneva in 1987, the who resolved to develop traditional medicine in its member states as ihs constitute the most abundant health resource in many countries. in order to utilise and maximise this existing resource, the who has suggested national research strategies into traditional medicine (akerele, 1987). south africa too is scrutinising its national health policy in order to address primary health needs (aron, 1991). these could be satisfied by community workers familiar with the particular linguistic and cultural background of the community. the ih may be considered ideal die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 r o z a n n e p l a t z k y & j o a n g i r s o n in filling this role. this article is limited in terms o f its scope, i.e. only stuttering w a s investigated and only a small sample w a s used. however, it indicates that communication disorders are recognised and treated by ihs, and m o r e research into this field is necessary. further research m a y strengthen the conclusion that co-operation b e t w e e n ihs and speech therapists is possible as "... k n o w l e d g e and sympathetic understanding ... combine in o n g o i n g dialogue, with the interests o f the patient as the overriding concern" (hammond-iboke, 1989, p.155). a c k n o w l e d g m e n t s the writers w i s h to thank the following: 1. t h e a f r i c a n n a t i o n a l h e a l e r s a s s o c i a t i o n for assistance w i t h i n f o r m a t i o n a n d o b t a i n i n g subjects. 2. m r r a k a l u t a t h e interpreter. 3. t h e s u b j e c t s w h o p a r t i c i p a t e d w i l l i n g l y i n the r e s e a r c h a n d s h a r e d their k n o w l e d g e generously. r e f e r e n c e s -african national healers association. unpublished paper on research issues and the anha. akerele, o. (1987). the best of both worlds: bringing traditional medicine up to date. soc. sci. med., vol. 24, no. 2, 177-181. ammons, r. & johnson, w.(1944). studies in the psychology of stuttering. jsd, vol. 9, 39-393. aron, m. l. (1966). the nature and incidence of stuttering among a bantu group of school going children. jshd, vol. 21, no. 2, 116-128. aron, m. l. (1991). perspectives. south african journal of communication disorders, vol. 38, 3-11. babbie, c. r. (1973). survey research methods, california: wadsworth pub. co. bloodstein, o. (1987). a handbook on stuttering, chicago: national easter seal society. fenalson, a. f. (1952). essentials in interviewing, new york: harper & brothers. freeman, m. (1992). lecture on the traditional healer at witwatersrand medical school conference, may 20. forcese, d. p. & richer, s. (1973). social research methods, new jersey: prentice hall, inc. hammond-tooke, w. d. (1974). the bantu-speaking peoples of southern africa, (2nd ed.) london: routledge and kegan paul. hammond-tooke, w. d. (1989). rituals and medicines, johannesburg: a.d. donker. holdstock, t. l. (1979). indigenous healing in s.a.: a neglected potential. south african journal of psychology, vol. 9,118124. johnson, w. (1944). the indians have no word for it: stuttering in children. quarterly journal of speech, vol. 30, 330-337. kahn, r. l. and cannel, c. f. (1957). dynamics of interviewing, new york: john wiley and sons. krober, i. (1990). indigenous healers in a future mental health system: a case for co-operation. psychology in society, vol. 4, p.47-62. leith, w. & mims, h. (1975). cultural influences in the development and treatment of stuttering. jshd, 459-466. leith, w.r. (1986). treating the stutterer with atypical cultural influences. in the atypical stutterer, st. louis k. o. (ed.), orlando, florida: academic press. motlana, n. (1992). lecture on the traditional healer at the witwatersrand medical school conference may 20. mzinyathi, m. (undated). mental health care in s.a.: a personal psychological perspective, 143-145. oppenheim, a. h. (1966). questionnaire design and attitude measurement, london: heinemann educational books ltd. peters, t. j. & guitar, b. (1991). stuttering: an integrated approach to its nature and treatment. baltimore: williams & wilkins. shames, g. h. (1989). stuttering: an rfp for a cultural perspective. jfd, vol. 14, 67-77. smith, t. (1991). communicating quality: professional standards for speech and language therapists. britain: the college of speech and language therapists. snidecor, j. c. (1947). why the indian does not stutter. quarterly journal of speech. van riper, c. (1971). the nature of stuttering, new jersey: prentice hall, inc. van riper, c. (1973). the treatment of stuttering, new jersey: prentice hall, inc. wingate, μ. e. (1972). the evaluation and stuttering: ii environmental stress and critical appraisal of speech. in an analysis of stuttering: selected readings, l. l. emerick & c. c. η am re (eds.), illinois: interstate publishers and printers. young, p. v. (1966). scientific social surveys and research, 4th edition, new jersey: prentice hall inc. j appendix interview f o r m a t a) biographical information 1) n a m e , ethnic group. 2) h o w did you become an ih? 3) did you receive training? 4) for h o w m a n y years have you b e e n practicing as an ih? b) stuttering 1) tell m e about the w o r k you do. 2) have you ever b e e n consulted b y a patient with a speech problem? tell m e about this case. 3) do y o u k n o w what stuttering is? 4) w h a t w o r d do you use for stuttering? 5) have you ever treated a stutterer? cause m a n a g e m e n t o u t c o m e / 6) does your treatment differ if the patient is male or female? 7) would a stutterer's status b e affected because of the stuttering, e.g. could he be a tribe leader? 8) h o w w o u l d y o u rate stuttering: as a big, small or no problem? 9) do you have any questions that you would like to ask m e ? ^ the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) d i e w a a r d e van v o o r a f o p l e i d i n g d e u r d i e o u e r vir p e d o o u d i o m e t r i e by drieen v i e r j a r i g e kleuters. merisa lodewyckx b. ( l o g ) (pretoria) departement spraakwetenskap, spraakheelkunde en oudiologie universiteit van pretoria opsomming die verkryging van akkurate, betroubare inligting aangaande die gehoorvermoe van jong kinders is van besondere belang vir die oudioloog, maar word dikwels bemoeilik aangesien die kleuter nie goeie samewerking bied in die vreemde pedo-oudiometriese situasie nie. die oplossing hiervoor is grootliks gelee in die opleiding van die kind voor formele gehoortoetsing en meer spesifiek opleiding tuis deur die ouer. die doel van hierdie studie was om 'n voorbereidende program op te stel wat die ouer tuis met die kind kan uitvoer, voordat formele toetsing plaasvind. die waarde en effek van hierdie program in die pedo-oudiometriese situasie is geevalueer by 'n groep drieen vierjarige kleuters. resultate dui daarop dat laer en meer akkurate drempels, 'n korter toetstydperk, verminderde angs en beter samewerking verkry is by die kleuters wat vooraf opleiding ontvang het. die opleidingsprogram kan dus in die kliniese praktyk benut word as voorafopleiding vir pedo-oudiometrie. summary it is of great importance to the audiologist to obtain accurate, reliable information concerning the hearing sensitivity of the young child but this is often hampered by the infant's poor co-operation in the strange audiometric situation. the solution lies in the training of the child before formal hearing evaluation and more specifically in training by the parent at home. the aim of this study was to compile a training programme which the parent carries out at home, before formal testing of the child. the value and effect of this programme in pediatirc audiometry was evaluated in a group of three and four year old children. results showed that lower and more accurate thresholds, a short test time, reduced anxiety and better co-operation was obtained in infants that had received previous training. in clinical practice, the programme can be used for training of the infant before audiometry. een van die grootste probleme vir elke pediatriese oudioloog is die verkryging van definitiewe en betroubare oudiometriese inligting by die jong kind. inligting van hierdie aard is noodsaaklik vir die identifikasie van afwykings, vir seleksie van 'n toepaslike gehoorapparaat en die daarstelling van toepaslike opleidingsprogramme vir die indiwiduele kind. akkurate meting van gehoor by die volwassene is gebaseer op sy omvangryke ouditiewe ervarings en veral sy akkurate subjektiewe evaluasie van ouditiewe sensasie, asook sy vermoe om verbale instruksies te gehoorsaam. sodanige meting is nie by die jong kind moontlik nie. 3 dit het dus nodig geword om alternatiewe prosedures te ontwikkel wat geldige en betroubare meting van gehoorsensitiwiteit by die kind moontlik maak. operante kondisionering is een van die tegnieke wat groot toepassingsmoontlikhede vir kinderoudiometrie inhou. die prosedure van speloudiometrie is gebaseer op die beginsels the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) voorafopleiding en pedo-oudiometrie 115 van kondisionering en word die algemeenste gebruik in die verkryging van 'n suiwertoonoudiogram by die jong kind. in speloudiometrie vind kondisionering van 'n aangeleerde respons op 'n ouditiewe sein deur middel van die genotsbeginsel (spelaksie) plaas. aangesien speloudiometrie uiteraard 'n kondisioneringsproses is, staan die oudioloog voor die moeilike taak om die kind te kondisioneer om 'n stimulus (ouditief) te assosieer met 'n spesifieke respons (motoriese taak). die kondisioneringstaak word verder bemoeilik deurdat die kind opgelei moet word om betroubare response te lewer op suiwertone wat, soos dit uit die literatuur ook blyk, relatief onbekend en dikwels betekenisloos vir 'n jong kind is. verdere probleme ontstaan as gevolg daarvan dat gehoortoetsing plaasvind in 'n omgewing wat vir die kleuter onbekend is en dit wek dikwels angs en onsekerheid. verder, moet angstige kinders soms opgelei word om die oorfone te aanvaar, aangesien dit noodsaaklik is om elke oor afsonderlik te toets. 1 bogenoemde probleme beklemtoon dat die sukses en waarde van 'n volledige gehoorevaluasie afhanklik is van die betroubare samewerking van die kind. om samewerking te bewerkstellig is 'n kondisioneringsproses nodig voordat die kind se gehoordrempels formeel bepaal kan word. die waarde van 'n opleidingsperiode is deur verskeie outeurs beklemtoon. lowell en andere 4 beskou die voorafopleidingsperiode as die grondslag van drempelbepaling en beklemtoon dat alvorens onafhanklike en onderskeidende response tydens hierdie periode verkry word, geen poging tot drempelbepaling aangewend moet word nie. lowell gebruik •n visueel waarneembare klankbron, dit wil se die ouditiewe stimulus word gekoppel aan 'n waarneembare bron, in die opleidingsperiode. later word die visuele bron verwyder en die kind reageer slegs op die ouditiewe stimulus. variasie van die ouditiewe stimulus in terme van intensiteit en duur met die oog op respons veralgemening, vind ook in die opleidingsperiode plaas.4 o'neill en andere 6 gebruik hierteenoor 'n periode van semigestruktureerde spel voordat drempels bepaal word. die doel van hulle spelperiode is nie, soos die van lowell,4 om onderskeidende response te verkry nie, maar om die beste toetstegniek vir 'n bepaalde kind te selekteer. opleidingsperiodes tydens gehoortoetsing is dikwels tydrowend en die waarde daarvan kan in 'n mate bevraagteken word. die oudioloog is steeds vir die kind 'n vreemdeling en die toetssituasie bly onbekend en bedreigend. dus kan dit nooit met sekerheid aangeneem word dat die kondisioneringsproses bevredigend plaasgevind het nie. miller en polisar5 beklemtoon die feit dat die oudioloog die ouer(s) kan benut om die kind op te lei om konsekwent te reageer op ouditiewe stimuli. hulle is daarvan oortuig dat 'n intelligente, goed aangepaste en tegemoetkomende ouer uitstekende en waardevolle hulp kan bied deur tuis met die kind te oefen. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 116 merisa lodewyckx sodoende word die kind deur die ouer opgelei om die tipe respons, wat in die oudiometriese situasie verwag word, korrek uit te voer. sulke aanvullende oefening en kondisioneringstegnieke tuis kan volgens miller en polisar,5 die aantal besoeke aan die oudioloog noemenswaardig verminder. 'n moontlike oplossing vir 'n groot aantal van die genoemde probleme by gehoortoetsing van voorskoolse kleuters, is gelee in die benutting van die ouer(s) om die kind tuis reeds op te lei en te kondisioneer, voor formele gehoortoetsing plaas vind. dit is dan die doel van hierdie studie om (1) 'n opleidingsprogram op te stel wat aan ouers beskikbaar gestel word, voordat hul kind se gehoor formeel deur 'n oudioloog getoets word en om (2) die waarde van hierdie opleidingsprogram in pedo-oudiometrie te evalueer. eksperiment h i p o t e s e e n d o e l s t e l l i n g s die hipotese is gestel dat kleuters tussen drieen vierjarige ouderdom, wat 'n opleidingsprogram tuis ontvang het, beter sal reageer in 'n pedo-oudiometriese suiwertoon toetssituasie, teenoor soortgelyke kleuters wat nie vooraf opgelei is nie. om hierdie hipotese te bewys, is die volgende doelstellings nagestreef: 1. 'n opleidingsprogram is opgestel wat die ouer tuis met die kind uitvoer om hom/haar voor te berei op formele drempelbepaling. die doel van hierdie program was: (a) om die kind emosioneel voor te berei en te motiveer vir gehoortoetsing, sodat die angs en onsekerheid wat die vreemde omgewing, oudioloog en apparaat dikwels tydens gehoortoetsing by kleuters wek verminder sou word. ( b ) o m die kind, deur middel van eenvoudige, bekende "geraasmakers" op te lei om spesifieke, betroubare response te lewer op klankaanbieding, met ander woorde, om opleiding van stimulus-respons-samehang te verskaf. (c) om die kind op te lei om aanvanklik te reageer op 'n visueel waarneembare klankbron, wat later verwyder word, sodat die kind dan slegs op die ouditiewe sein moet reageer, met ander woorde operante kondisionering word bewerkstellig... / ( d ) o m stimulusveralgemening en -diskriminasie by clie kind te bewerkstellig deurdat die ouditiewe stimuli gevarieer word in terme van intensiteit, toonhoogte, duur en rigting. 2. die waarde van die opleidingsprogram in pedo-oudiometrie is ondersoek. 3. die program is verder geevalueer op grond van 'n bespreking met die ouer, asook 'n kort vraelys' wat deur die ouer voltooi is na uitvoering van die program. the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) voorafopleiding en pedo-oudiometrie 117 proefpersone twintig kleuters is gebruik as proefpersone en vir die doel van hierdie eksperiment het elke kind voldoen aan die volgende kriteria: — die kind was in die ouderdomsgroep drie tot vier jaar. — die kind was afrikaanssprekend en van 'n middel sosioekonomiese klas. — die kind het geen persoonlikheids-, fisiese of verstandelike afwykings gehad nie. — die kind het geen vorige ondervinding van gehoortoetsing gehad nie. — die kind het geen oorinfeksies, mangelontsteking, verkoue of griep onderlede gehad tydens toetsing nie. metode 'n voorbereidende opleidingsprogram wat die ouer tuis oor 'n periode van drie dae met die kind uitvoer, is opgestel. die doel en inhoud van hierdie program word kortliks bespreek: die program word oor 'n tydperk van drie dae uitgevoer. spesifieke instruksies en take is onder die opskrifte, dag 1; dag 2; en dag 3, uiteengesit. d a g 1: doelstellings: emosionele voorbereiding van die kind op die oudiometriese situasie, asook keuse van 'n toepaslike responsmedium vir die individuele kind. inhoud: die algemene prosedure wat tydens formele gehoortoetsing verwag kan word, word deur die ouer uitgebeeld in die vorm van 'n storie om die kind voor te berei op die vreemde oudiometriese situasie. die ouer moet ook op dag 1 'n spelaksie/respons kies wat telkens in die program gebruik sal word en waarvan die kind hou. ('n lys van moontlikhede word verskaf.) d a g 2 : doelstellings: motivering, stimulus-responssamehang en stimulusveralgemening. 'n bekende, visueel-waarneembare klankbron wat op bo-drempel vlakke aangebied word, word gebruik om die situasie betekenisvoller en interessanter te maak, sodat die kind meer gemotiveerd is om op die ouditiewe stimuli te reageer. stimulusrespons-samehang word bewerkstellig deurdat die kind 'n definitiewe assosiasie vorm tussen verlangde respons en ouditiewe stimulus. stimulusveralgemening word bewerkstellig deur variasie van stimuli in terme van duur en toonhoogte. inhoud: die ouer lei die kind op om die korrekte respons (waarop besluit tydens dag 1), uit te voer, elke keer as 'n klank aangebied word. vir hierdie doel word daar van 'n verskeidenheid klankbronne gebruik gemaak wat visueel waarneembaar is (die ouer staan voor die die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 118 merisa lodewyckx kind by klankaanbieding). 'n bekende klank word dus op bodrempelvlakke aangebied en dit word gevarieer in terme van duur en toonhoogte. d a g 3 : doelstellings: stimulusveralgemening, stimulusdiskriminasie en versterking. stimulusveralgemening vind plaas aangesien die stimuli weereens gevarieer het in terme van toonhoogte en nou ook in terme van lokalisasie (rigting) en intensiteit (luidheid). stimulusdiskriminasie word bewerkstellig aangesien daar slegs op die ouditiewe sein gereageer moes word, omdat die visuele bron verwyder is. versterking is beoog deurdat sosiale sowel as konkrete beloning verskaf word. inhoud: dieselfde klankbronne word op dag 3 gebruik, maar die verskil is nou dat die klankbron nie meer visueel waarneembaar is nie. stimuli word nou ook gevarieer in terme van intensiteit. die proefpersone is op 'n toevallige wyse verdeel in twee groepe van tien kinders elk. die kontrolegroep, bekend as groep a is onderwerp aan prosedure x en die eksperimentele groep, bekend as groep b, aan prosedure y. prosedure x behels: — 'n suiwertoondrempelbepaling deur middel van speloudiometrie — 'n tussenpose van drie dae — 'n tweede suiwertoongehoortoets deur middel van speloudiometrie prosedure y behels: — 'n suiwertoondrempelbepaling deur middel van speloudiometrie — 'n tussenpose van drie dae waartydens die kind tuis opleiding ontvang deur middel van die opleidingsprogram — 'n tweede suiwertoongehoortoets deur middel van speloudiometrie. die prosedure wat gevolg is by elke suiwertoondrempelbepaling by beide groepe, was kortliks as volg: — die oudioloog het die kind kortliks deur middel van die zenith neometer opgelei om hout blokkies in 'n kartondoos te gooi by aanbieding van 'n ouditiewe stimulus. — luggeleidingsdrempels is bepaal by 1 000 hz; 500 hz; 250 hz, 2 000 hz en 4 000 hz en 'n dalende-stygende metode van drempelbepaling is gebruik. — sosiale versterking tydens drempelbepaling is gebruik om korrekte response te versterk en na afloop van drempelbepaling by elke oor is 'n vorm van konkrete beloning gegee. tydens drempelbepaling is die volgende aspekte deur die oudioloog opgeteken: j (a) tydsduur van drempelbepaling] dit is gemeet met 'n stophorlosie. the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) voorafopleiding en pedo-oudiometrie 119 (b) die aantal foutiewe response wat die kleuter gelewer het. dit is elke keer aangeteken as die kind 'n respons lewer (blokkie ingooi) sonder dat 'n stimulus aangebied is. nadat suiwertoondrempels verkry is, is die gemiddelde suiwertoondrempel vir die regterasook linkeroor vir elke proefpersoon, bereken. na voltooiing van drempelbepaling is die volgende aspekte subjektief deur die oudioloog geevalueer en op die voorafopgestelde vorms aangeteken. — samewerking van die toetsling in die toetssituasie op 'n vyfpuntskaal. — angstigheid by die moeder op 'n driepuntskaal. — angs en onsekerheid by die toetsling op 'n driepunt-skaal. — aanvaarding van die oorfone deur die toetsling op 'n vierpuntskaal. slegs by die eksperimentele groep, waar 'n opleidingsprogram uitgevoer is, het die moeder 'n kort vraelys voltooi waarin sy die program evalueer. elke moeder is ook die geleentheid gegun om terugvoering aangaande die program aan die oudioloog te gee. resultate die resultate verkry by die tweede gehoortoets is vergelyk met die van die eerste toetsing om vas te stel of die opleidingsprogram die resultate van die tweede toetsing bei'nvloed het. die kontrolegroep is ook twee keer getoets ten einde te bepaal of, indien die tweede toetsing beter resultate gelewer het, dit aan oefening of aan die opleidingsprogram toegeskryf kan word. die twee groepe word dus vergelyk om te bepaal wat die invloed/effek van die opleidingsprogram is. vergelyking van gemiddelde suiwertoondrempels: om vas te stel of enige verbetering (verkryging van laer drempels) of verswakking (verkryging van hoer drempels) in gemiddelde suiwertoondrempels vanaf die eerste na die tweede toetsing plaasgevind het, is die volgende berekening by beide groepe gedoen: gemiddelde suiwertoon drempel by toets 1 minus gemiddelde suiwertoon drempel by toets 2 (sien tabel i). tabel i dui dat die gemiddelde verbetering in drempelwaarde by die kontrolegroep 0,01 db was wat nie statisties betekenisvol is nie, terwyl die verbetering by die eksperimentele groep 4,18 db was, wat statisties betekenisvol is op die 1% peil. die verbetering in gemiddelde drempelwaarde van die eksperimentele groep, vergeleke met die van die kontrolegroep is 4,18 0,01 = 4,17 db, wat statisties betekenisvol is op die 5% peil. hierdie waarde van 4,17 db, verteenwoordig dus die verbetering in drempelwaarde wat toegeskryf kan word aan die effek van die opleidingsprogram. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 120 merisa lodewyckx t a b e l i : verandering in gemiddelde suiwertoondrempels vir beide ore, vanaf die eerste na tweede toetsing d.w.s. gemiddelde suiwertoondrempel by toets 1 — gemiddelde suiwertoondrempel by toets 2 proefpersone groep a: groep b: 1 4 , 1 db 0 db 2 0 , 8 db -6,65 db 3 4 , 2 db 2,45 db 4 2,5 db 5 db 5 2 , 5 db 5,85 db 6 3,3 db 5,9 db 7 7,5 db 5,05 db 8 2,55 db 7,5 db 9 1 , 7 db 7,5 db 10 -2,45 db 9,2 db gemiddelde 0,01 db 4,18 db standaard-afwyking 3,607 4,38 standaard-fout 1,202 1,46 vefgelyking van tydsduur benodig vir drempelbepaling: tabel ii dui dat by elke proefpersoon in beide groepe die tydsduur benodig vir drempelbepaling by die eerste sowel as tweede gehoortoets opgeteken is en die verskil tussen die twee tydswaardes bereken is. by die kontrolegroep is die verskille tussen waardes verkry in die eerste en tweede toetsing betekenisvol op die 1% peil terwyl die verskille by die eksperimentele groep betekenisvol is op die 0,1% peil (meer betekenisvol). dit blyk duidelik uit tabel ii dat by beide groepe 'n korter tydsduur benodig was om drempels te bepaal by die tweede as by die eerste toetsing. die gemiddelde verskille in waardes! was vir groep a: 1,069 en vir groep b: 2,02. by toepassing van die t-toets vir onafhanklike steekproewe was gevind dat t = 2,000, wat betekenisvol is op die 5% vlak. alhoewel drempels dus by beide groepe vinniger bepaal kan word by die tweede gehoortoets, dui bogenoemde statistiese berekening dat drempels by groep β noemenswaardig vinniger bepaal kon word the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) voorafopleiding en pedo-oudiometrie 121 oh w ο ps ο oo 15 o, <l> "u o, ε <l> > a s "d ο a <d xi t-l 3 3 13 t/3 13 u 15 -*-* ο η j ω ca < η st d . fo u t 0, 58 7 0, 40 4 0, 35 7 st d . a fw . 1, 76 0 1, 21 3 1, 07 0 g e m . 7, 90 6 m in . 6, 85 7 m in . 1, 06 9 m in . ο t-h 9 ,9 3 m in . 7, 50 m in . 2, 43 m in . on 7, 57 m in . 6, 73 m in . 0, 84 m in . 00 6, 9 m in . 5, 63 m in . 1, 27 m in . 7, 62 m in . 7, 23 m in . 0, 39 m in . vo 4, 98 m in . 5, 47 m in . -0 ,4 9 m in . m 6, 63 m in . 7, 27 m in . -0 ,6 4 m in . ti7, 2 m in . 6, 62 m in . 0, 58 m in . ro 7, 65 m in . 5, 17 m in . 2, 48 m in . (n 11 ,5 3 m in . 9, 48 m in . 2, 05 , m in . t-h 9, 25 m in . 7, 47 m in . 1, 78 m in . pr oe fp er so ne ee rs te to et si ng tw ee de to et si ng v er sk ill e η ρ ο fa ω ps < < ω ζ < η 1/5 η ρ ο fa 00 3 ο i ζ δ ξ 11 < ω ps < < ω ζ < η £ fa < ω η pq οη w ο ps ο st d . fo u t 0, 31 7 0, 22 8 0, 31 4 st d . a fw . 0, 95 2 0, 68 3 0, 94 3 g e m . 9, 06 9 m in . 7, 04 9 2, 02 m in . ο t-h 6 ,8 0 m in . 6, 02 m in . 0, 78 m in . on 8, 97 m in . 7, 23 m in . 1, 74 m in . 00 9, 83 m in . 7, 38 m in . ί . 2 ,4 5 m in . 8, 92 m in . 7, 68 m in . 1, 24 m in . vo 10 ,2 2 m in . 7, 83 m in . 2, 39 m in . in 10 ,0 6 m in . 5, 67 m in . 4, 39 m in . ti9, 50 m in . 7, 63 m in . 1, 87 m in . ro 8, 55 m in . 7, 28 ι. m in . 1 1, 27 m in . (n 9, 42 m in . 7, 12 m in .r m ir 2, 3 m in . t-h 8, 42 m in . 6, 65 m in . 1, 77 m in . pr oe fp er so ne ee rs te to et si ng tw ee de to et si ng v er sk ill e die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 122 merisa lodewyckx tydens die tweede toetsing (dit wil se na uitvoering van die opleidings program) as wat die geval was by groep a. die opleidingsprogram veroorsaak dus dat die oudioloog drempels vinniger kan bepaal, omdat die kleuter reeds vooraf opgelei word om vinnig akkurate response te lewer. vergelyking van aantal foutiewe response: die aantal foutiewe response wat elke proefpersoon gelewer het by die eerste en tweede toetsing, is by beide groepe opgeteken en die verskille tussen die twee waardes is bereken. by die kontrolesowel as die eksperimentele groep was die verskille in die aantal foutiewe response verkry by die twee gehoortoetse, nie statistics betekenisvol nie. na toepassing van die t-toets vir onafhanklike steekproewe, kon daar afgelei word dat die opleidingsprogram nie die aantal foutiewe response by die eksperimentele groep statistics betekenisvol laat afneem het vanaf die eerste na die tweede toetsing nie, in vergelyking met die kontrolegroep. die opleidingsprogram het in hierdie opsig dus weinig effek gehad. subjektiewe waarnemings: sekere aspekte is, soos reeds genoem, na afloop van elke gehoortoets subjektief evalueer. tabelle is opgestel om hierdie gegewens saam te vat (sien tabelle i l i a en b). die kwalitatiewe resultate verkry uit hierdie subjektiewe evaluasie word bespreek. t a b e l i i i a. subjektiewe evaluasie van: angstigheid by die moeder e e r s t e t o e t s in g g r o e p a : e e r s t e t o e t s in g t w e e d e t o e t s i n g κ e e r s t e t o e t s in g b a i e a n g s t i g g e r i n g e a n g s t i g h e i d ' g e e n a n g s e e r s t e t o e t s in g b a i e a n g s t i g ; 1 e e r s t e t o e t s in g g e r i n g e a n g s t i g h e i d ! 1 1 4 e e r s t e t o e t s in g g e e n a n g s 4 the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) voorafopleiding en pedo-oudiometrie 123 t a b e l iii a. subjektiewe evaluasie van: angstigheid by die moeder groep b: tweede toetsing baie angstig geringe angstigheid geen angs baie angstig 2 geringe angstigheid 2 5 geen angs 1 t a b e l iii b. subjektiewe evaluasie van: angs en onsekerheid by die toetsing groep a: tweede toetsing: baie angs en onsekerheid gemiddelde angs en onsekerheid geen angs of onsekerheid e e r st e t o e t si n g baie angs en onsekerheid 2 e e r st e t o e t si n g gemiddelde angs en onsekerheid 2 3 e e r st e t o e t si n g geen angs of onsekerheid 3 groep b: tweede toetsing • baie angs en onsekerheid gemiddelde angs en onsekerheid geen angs of onsekerheid e e r st e t o e t si n g baie angs en onsekerheid 1 2 e e r st e t o e t si n g gemiddelde angs en onsekerheid 1 6 e e r st e t o e t si n g geen angs of onsekerheid die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 124 merisa lodewyckx samewerking van die toetsling in die toetssituasie is geevalueer op 'n vyfpuntskaal, naamlik baie swak; swak; gemiddeld; goed; baie goed. die samewerking van die proefpersone in die kontrole groep het nie wesenlik verander vanaf die eerste na die tweede gehoortoetsing nie. hierteenoor het daar by die eksperimentele groep blykbaar 'n verandering in samewerking ingetree. 'n algemene verbetering in samewerking het plaasgevind by die tweede toetsing. hierdie verbeterde samewerking wat by die eksperimentele groep voorkom, maar nie by die kontrole groep nie, kan moontlik toegeskryf word aan die positiewe effek van die opleidingsprogram. angstigheid by die moeder is geevalueer op 'n driepuntskaal naamlik baie angstig; geringe angstigheid en geen angs. tabel i l i a bevat hierdie gegewens. die resultate wat by die twee groepe verkry is, is baie ooreenstemmend. die verskil was egter dat 'n groter aantal moeders in die eksperimentele groep, wat by die eerste toetsing 'n mate van angstigheid getoon het, by die tweede toetsing geen angs getoon het nie. daar kan dus afgelei word dat die opleidingsprogram 'n geringe effek gehad het op die angsvlak van die moeders wat die kleuters in groep β vergesel het. angs-en onsekerheid by die toetsling is op 'n driepuntskaal geevalueer naamlik, baie angs en onsekerheid; gemiddelde angs en onsekerheid; geen angs of onsekerheid. in tabel i l l b word hierdie gegewens opgesom. beide groepe het 'n afname in angsvlak vanaf die eerste na die tweede toetsing getoon. daar bestaan moontlik wel 'n verskil tussen die twee groepe, aangesien 'n groter aantal proefpersone in die eksperimentele groep as in die kontrolegroep geen angs of onsekerheid getoon het by die tweede toetsing, vergeleke met die aanwesigheid van angs by die eerste toetsing nie. die opleidingsprogram het dus moontlik 'n positiewe effek op die kleuters, aangesien hulle minder onseker en angstig voorkom in die pedo-oudiometriese situasie na uitvoering van die program. die toetsling se aanvaarding van die oorfone is geevalueer op 'n vierpuntskaal naamlik, weier om die oorfone op te sit; bang en moet oorreed word om oorfone op te sit; aanvaar oorfone maar kom agterdogtig voor; aanvaar oorfone sonder probleme. / hier kon feitlik geen verskil opgemerk word tussen die twee groepe nie. by beide groepe het alle proefpersone die oorfone sonder enige probleme aanvaar by die tweede toetsing, vergeleke met die eerste gehoortoets. j evaluering van die program deur die ouer: dit het geblyk uit die vraelyste wat die ouers wat die program the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) voorafopleiding en pedo-oudiometrie 125 uitgevoer het, moes voltooi, dat al die ouers dit beoordeel het as aangenaam en maklik om uit te voer en dat hul kind daarby baat gevind het. verder kon die afleiding uit die besprekings gemaak word dat die meerderheid van die ouers die program as geslaagd en waardevol beskou as voorbereiding vir pedo-oudiometrie. bespreking dit het uit die literatuur geblyk dat geldige en betroubare oudiometriese resultate by kinders van uiterste belang is, en tog word die verkryging hiervan deur 'n groot aantal probleme wat in pedooudiometrie voorkom, belemmer. volgens verskeie teoritici en navorsers is die oplossing vir hierdie probleem moontlik te vinde in die opleiding van die kind voor formele toetsing.2' 4 ' 5 die resultate van hierdie studie dien as voldoende bewys dat die opleidingsprogram wat opgestel is, 'n waardevolle metode bied vir die opleiding van die kleuter voor formele gehoortoetsing. daar is statisties bewys dat laer en meer geldige drempels verkry kon word, nadat kleuters tuis opleiding deur middel van die program ontvang het. dit is ook bewys dat die oudioloog drempels vinniger kon bepaal nadat die kleuter tuis opgelei is. hierdie resultate stem ooreen met fulton e . a 2 se studie waarin gevind is dat kinders wat aanvanklik response gelewer het wat aanduidend was van 'n geringe gehoorverlies, na addisionele opleiding tuis, by hertoetsing, betroubare (dit wil se herhaalbare) response gelewer het op normale vlakke. die outeurs stel dan ook in hul studie voor dat: a home-training programme should be considered in clinical applications . . . the parent should be counselled and provided a written set of procedures for introducing auditory stimulus-response control.2 volgens 'n subjektiewe evaluasie kon die gevolgtrekking gemaak word dat die opleidingsprogram moontlik aanleiding gee tot beter samewerking van die toetsling in die toetssituasie, asook minder angs ten opsigte van die toetssituasie by die toetsling sowel as die vergesellende ouer. dit blyk verder uit die evaluasie van die program deur die ouers wat dit uitgevoer het, dat hul dit beskou as 'n waardevolle voorbereiding vir pedo-oudiometrie. miller en polisar5 is daarvan oortuig dat die ouer waardevolle hulp kan bied deur tuis met die kind te oefen sodat die kind opgelei word om die tipe respons, wat in die oudiometriese situasie verwag word, korrek uit te voer. sulke aanvullende oefening en kondisioneringstegnieke tuis kan volgens die navorsers, die aantal besoeke aan die oudioloog verminder.5 dit is dus duidelik dat hierdie opleidingsprogram 'n positiewe oplossing bied vir 'n groot aantal van die probleme wat die oudioloog ondervind in die pedo-oudiometriese situasie. die program kan in die kliniese praktyk benut word deurdat dit aan ouers beskikbaar gestel die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 126 merisa lodewyckx word, vir uitvoering drie dae voor die kind se gehoor formeel deur 'n oudioloog getoets word. sodoende sal die kind reeds tuis gekondisioneer en voorberei word sodat geldiger en meer betroubare resultate deur die oudioloog in pedo-oudiometrie verkry kan word. verwysings 1. frisina, r. (1973): chap, in jerger, j. (ed) modern developments in audiology. academic press, new york. 2. fulton, r. t., gorzycki, p. a. and hull, w. l. (1975): hearing assesment with young children. jshd 3, p. 397-404. 3. kendall, d. c. (1964): pediatrics and disorders in communication iii. the audiological examination of young children. the volta review, 66, p.734-740. 4. lowell, e . , rushford, g., hoverstein, g. and stoner, m. (1956): evaluation of pure tone audiometry with preschool age children jshd, 21, p.292-302. 5. miller, m. and polisar, i. a . (1964): audiological evaluation of the pediatric patient. charles c. thomas, illinois. 6. o'neill, j. oyer, h. j. and willis, j. w. (1961): audiometric procedures used with children. jshd 26, p.61-44. the south african journal of communication disorders, vol. 28,1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 85 direction of susceptance and conductance acoustic reflexes at high probe frequencies louise reynolds and lucille ρ morton department of logopaedics university of cape town abstract previous investigations have shown that for low probe frequencies (220 and 660 hz) the direction of susceptance and conductance reflexes is related to baseline transmission properties. previously documented reflex patterns, caused by the stiffening of the ossicular chain, are characterised by decreases in both components at 220 hz (-b-g) and increases in susceptance and decreases in conductance (+b-g) at 660 hz. in the present study, the direction of susceptance and conductance acoustic reflexes was investigated at a probe frequency of 1000 hz, where ears are expected to be less stiffness dominated than at the low frequencies, and for which there is little description of reflex patterns in the published literature. the pattern of ipsilateral susceptance and conductance reflexes from 30 normal ears was recorded across a wide intensity range at this probe frequency for three stimulus frequencies (0.5, 1 and 2 khz). reflexes were classified as either increases (+) or decreases (-) for each component, at threshold and at suprathreshold intensity levels. ears were grouped according to transmission properties at 1000 hz, and reflex patterns observed within each group of subjects were examined. patterns observed in these subjects at the 1000 hz probe frequency included: +b-g; +b+g; -b+g and -b-g. there appeared to be a relationship between baseline transmission and reflex patterns. further, patterns appear to be consistent with theoretical models of the effect of the acoustic reflex, particularly for ears where stiffness is significant in the baseline condition. the effect of the reflex for mass dominated systems requires further investigation. opsomming vorige navorsing het bewys 'dat vir laetoonfrekwensies (220 en 660 hz) die rigting van susseptansieen konduktansiereflekspatrone aan basiese t'ransmissie-eienskappe verwant is. vorige gedokumenteerde reflekspatrone, veroorsaak deur die verstywing van die osslkulere ketting, word gekenmerk deur verlagings in albei komponente by 220 hz (-b-g) en verhogings in susseptansielen verlagings in konduktansie (+b-g) by 660 hz. in die huidige studie, is die rigting van susseptansieen konduktansieakoestiese reflekse by toonfrekwensie van 1000 hz ondersoek, waar dit verwag is dat die ore minder stramheidoorheers sal wees as by die lae frekwensies. daar bestaan beperkte beskrywings in die gepubliseerde literatuur oor reflekspatrone. die patroon vir ipsilaterale susseptansie en konduktansiereflekse met 30 normale ore is vir 'n wye intensiteitsreeks aangeteken teen die toonfrekwensie vir drie stimulusfrekwensies (0.5, 1 en 2 khz). ! reflekse is geklassiflseer as^verhogings (+) of verminderings (-) van elke komponent, op drempelen bo-drempelintensiteitsvlakke. refleksie isgegroepeer volgens die transmissie-eienskappe by 1000 hz, en reflekspatrone waargeneem in elke groep is ondersoek. patrone waargeneem in die ore by die 1000 hz toonfrekwensie het die volgende ingesluit: +b-g, +b+g, -b+g en -b-g. 'n moontlike verwantskap is waargeneem tussen basislynkondisietransmissieen reflekspatrone. verder, blyk die patrone verenigbaar te wees met teoretiese modelle van die effek van die akoestiese refleks, in die besonder vir ore waarin stramheid betekenisvol in die basislynkondisie is. die effek van die refleks vir massa oorheersende stelsels vereis verdere navorsing. the effect of the acoustic reflex on admittance components (susceptance and conductance) is dependent on the baseline transmission properties of the middle ear at the particular probe frequency used in the immitance recording (feldman & williams, 1976). this has been clearly demonstrated for low probe frequencies by researchers such as feldman & williams (1976); lutman & martin (1979) and lutman, mckenzie & swan (1984). however, the effect of the acoustic reflex on susceptance and conductance measures for higher probe frequencies, where baseline transmission is either close to the natural frequency of the middle ear, or mass dominated, has not been fully discussed in the published literature. with the current availability of measuring devices which allow for the investigation of middle ear function across a wide frequency range, the clinical audiologist is now able to conduct acoustic reflex measures at a range of probe frequencies, but may encounter difficulty in the interpretation, given the varying effects of the reflex as being either an increase or decrease in each of the admitdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 86 tance components. having an expectation of the usual reflex pattern (increase of decrease in each of the components) in normal ears at higher probe frequencies, might assist the audiologist in reflex pattern interpretation. during acoustic reflex measurements the value of admittance components (susceptance (b) and conductance (g)) with the stapedius muscle at rest are compared to the values of these components with the acoustic reflex activated (wiley & block, 1979). the equipment used in many clinical investigations of the acoustic reflex baselines the admittance value measured at the probe tip in the resting state to zero, and then represents the admittance change associated with the activation of the reflex as an increase (+) or decrease (-) relative to zero. changes in middle ear admittance or impedance (or components thereof) caused by the reflex have the property of direction (+ or -) together with the properties of magnitude and shape. the direction of reflex patterns, at threshold and suprathreshold intensity levels of the reflex eliciting stimulus, for the components of admittance-have been investigated extensively using probe frequencies of 220 and 660 hz and in spite of different methodologies, similar findings are reported across studies. at a low probe frequency (220 hz) the normal ear is stiffness dominated (shanks, lilly, margolis, wiley & wilson, 1988). under these conditions, the reflex induced stiffness increase, is measured as decreases in both susceptance and conductance (-b-g), as shown by feldman & williams (1976) and lutman & martin (1977). increases in susceptance and decreases in conductance (+b-g) have been observed at a slightly higher probe frequency (660 hz) by the same researchers. at this probe frequency the middle ear system is still expected to be stiffness dominated, but with a significant contribution from the resistance component to overall impedance (shanks et al., 1988). the decrease in susceptance at 220 hz and the increase in susceptance at 660 hz are, however, both representative of the same phenomenon of stiffening of the ossicular chain. it is well established that the effect of the reflex results in an increase in negative reactance (stiffness), at least for these low probe frequencies (lutman & martin, 1979). the addition of negative reactance yields either increases or decreases in susceptance due to the complex relationship between the components of admittance and impedance, which rules that susceptance is not the direct reciprocal of reactance, and neither is conductance the direct reciprocal of resistance (van camp & creten, 1976). rather, a complex relationship exists between these components (berlin & cullen, 1980). in addition, when changes to reactance and/or resistance occur at the level of the tympanic membrane, these have a nonlinear relationship to impedance measurements made at the probe tip (margolis, 1981). to avoid this complexity, van camp & creten (1976) explain that immittance measures made in the clinical setting are •usually made in admittance (or components thereof). thus, although the reflex may be considered to cause an increase in negative reactance, the resulting susceptance measurement is more complex and is dependent on the baseline relationship between reactance and resistance. clinical measures in admittance quantities at the probe tip may therefore yield various patterns, depending on the baseline transmission properlouise reynolds & lucille ρ morton ties of the middle ear. little research has been reported on the effect of the reflex on admittance components, when recorded at probe frequencies above 660 hz. bennett & weatherby (1979) have investigated the effect of the reflex at a fixed stimulus intensity for a wide range of probe frequencies. the measures were made in admittance, but results were reported in impedance components. reynolds (1991), reporting on an exploratory investigation of the effect of the reflex using measures similar to those conventionally adopted in the clinical setting, found that for a higher probe frequency (1000 hz) the effect of the reflex was to increase both the admittance components (+b+g) at threshold for ears where the probe frequency was close to the resonant frequency. suprathreshold investigations of the acoustic reflex have indicated that the direction of the reflex may change at suprathreshold intensity levels. lutman & martin (1977); wilson & mcbride (1978) and lutman, mckenzie & swan (1984) have demonstrated the susceptance component when suprathreshold reflex patterns are compared to threshold reflex patterns for a 660 hz probe frequency. in these investigations, the susceptance reflex patterns shifted from an increase (+b) to a decrease (-b) with increases in reflex eliciting stimulus intensity. the phenomenon of direction change for the conductance component has not been reported in the published literature. however, reynolds (1991) found that direction changes occurred for the conductance component (+g at t h r e s h o l d b e c a m e -g at suprathreshold levels) at a 1000 hz probe frequency. this phenomenon suggests that the effect of the reflex at the higher probe frequency is to add negative reactance to the system, such that with stronger contractions of the acoustic reflex above threshold, reflex patterns resemble those seen at low intensities for stiffer systems (i.e., at lower probe frequencies). in order to provide an expectation for the clinical audiologist as to when to expect certain patterns of direction and direction change, an investigation of the relationship between baseline transmission properties and the direction of the reflex pattern at both threshold and suprathreshold levels was conducted in the present investigation. the aim of the present study was to relate baseline transmission properties to susceptance and conductance reflex patterns using a high probe frequency (1000 hz), and measured at the probe tip as is conventional in'clinical investigations. | methodology i subjects thirty subjects were chosen to represent a sample of normal young ears. subjects were required to be between the ages of 18 to 25 years; to have no known history of ear pathology; to have normal hearing thresholds (i.e. < 25 db hl) at the octave frequencies 250 to 8000 hz; air bone gaps of less than 10 db;,single peaked admittance tympanograms at a 226 hz probe frequency and present ipsilateral acoustic reflexes at 0.5, 1 and 2 khz stimuli recorded at a probe frequency of 226 hz. one ear was used from each subject' to allow for a wider spread of normal ears and prevent possible duplication of results, given the very small interaural differences reported in subjects by hall (1979) and creten, van de the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) direction of susceptance and conductance acoustic reflexes at high probe frequencies 87 heyning & van camp (1985). subjects were divided into 5 groups according to their transmission properties at 1000 hz determined by means of tympanometry at this probe frequency. the vanhuyse, creten & van camp (1975) system of tympanogram classification was used. subjects with similar transmission properties were grouped together. the division of subjects into groups is shown in table 1. in addition, an estimation of resonance by means of identifying the natural frequency using multiple frequency tympanometry (see below) was made for each subject. groups were also described in terms of the mean resonant frequency obtained. apparatus all audiometric evaluations were conducted using a gsi 16 clinical audiometer, with tdh-50p earphones and b71 bone vibrator. this audiometer is calibrated in db hl and meets the ansi s.26-1981 standard for audiometers. immittance measures were made using the gsi 33 version 2 middle ear analyser. this microprocessor based instrument meets the ansi s3.39-1987 standard for acousticimmittance instruments. the probe frequencies (including 1000 hz) are nominally set to 70 db hl (grason stadler instruction manual, 1989). ipsilateral reflex probe and stimulus tones are time m u l t i p l e x e d . for reflex m e a s u r e m e n t s either susceptance or conductance changes can be displayed at one time. the instrument was calibrated for the specific altitude of the test environment (98 meters above sea level) as recommended by lilly & shanks (1981). a calibration check following the manufacturer's instructions was carried out on each day of data collection. all testing was completed in a sound treated environment. procedure pure tone thresholds were determined according to standard audiometric procedure (yantis, 1985). baseline susceptance and conductance values in the uncontracted state were obtained from simultaneously recorded susceptance and conductance tympanograms obtained using a 1000 hz probe frequency. the pressure sweep for the tympanograms was in a positive to negative direction, pressure was varied at a rate of 50 dapa per second, between 1+200 and -300 dapa. the baseline susceptance and conductance values were recorded from the tympanometric peak pressures for each component. for n o t c h e d t y m p a n o g r a m s the central extremum was used for quantification. the recording of s u s c e p t a n c e and c o n d u c t a n c e values at tympanometric peak was selected in preference to ambient pressure due to this being a more stable measure (wilson, shanks & kaplan, 1984) and because the reflex was automatically recorded at tympanometric peak pressure. a decrease in pressure (change in pressure from positive to negative) at a low rate was used as these conditions yield less complex tympanometric configurations (margolis, van camp, wilson & creton, 1985). multiple frequency tympanometry was conducted for all ears in order to approximate resonance. the multifrequency tympanometry programme on the gsi 33 was used for this purpose. this programme consists of frequency sweeps (200 to 2000 hz) at +200 dapa and tympanometric peak (determined from the 226 hz admittance tympanogram). the frequency at which the difference between the susceptance value at +200 dapa and tympanometric peak is at a minimum is used as an approximation of middle ear resonance (funasaka & kumakawa, 1988). in order to ensure that an adequate approximation of resonance was obtained, susceptance and conductance tympanograms were recorded at this frequency to check for the 3b1g configuration. reflex growth functions were obtained ipsilaterally at the 1000 hz probe frequency using three stimulus frequencies (0.5, 1 and 2 khz). stimulus intensity ranged from levels below expected reflex thresholds (66 db hl) to the maximum output of the gsi 33 (110 db hl for 0.5 and 1 khz and 104 db hl for 2 khz). although the intensity of the reflex eliciting stimulus reached high levels, such intensity levels have previously been incorporated into studies investigating the effect of the reflex, such as that by lutman et al., (1984). a 4 db increment size was used. stimulus duration was kept constant at 1.5 seconds for each stimulus presentation (1.5 seconds being the default parameter for the gsi 33). for each of the s t i m u l u s frequencies susceptance recordings preceded conductance recordings and reflex eliciting stimuli were presented in an ascending manner. the amount of mmho change at each intensity level was recorded. this was classified as either an increase (+) or decrease (-) in the value of the component. this classification was made for each stimulus intensity level. analysis of the data the results obtained for the 1000 hz probe frequency were analysed within each of the subject groups shown in table 1 as suggested by sprague, wiley & block (1981) and greenfield, wiley & block (1985) as wide variability across subjects is reported when similar patterns are not grouped together first. this was considered important as trends in the data may obscure individual findings (block & wiley, 1986). the reflex patterns observed for each of the three stimulus frequencies were analysed together. this was in order to increase the pool of reflex patterns obtained from the subjects. reynolds (1991) reported that there was no significant difference between these three frequencies in terms of the reflex patterns observed, and no further investigation of any frequency effect was made in the present study. the distribution of reflex patterns at threshold and where direction changes at suprathreshold levels occurred, was recorded for each group of ears. threshold was defined as the intensity level at which both of the components demonstrated reflexes which met the gsi criterion of 0.09 mmho for the 1000 hz probe frequency. the range of reflex patterns was recorded and frequency counts made of the number of times subjects within each of the groups demonstrated the pattern. the results were presented in tabular form. results and discussion as the three stimulus frequencies (0.5, 1 and 2 khz) were pooled for each of the subjects in the present study, the total number of observations of reflex patterns is die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 88 louise reynolds & lucille ρ morton 90, that is three times the number of ears investigated. the total number of observations (n) in each group is also three times that of the number of ears allocated to the groups shown in table 1. the distribution of reflex patterns across the groups at threshold shown in table 2, indicates that a wider range of reflex patterns was seen at the 1000 hz probe frequency than is reported in the published literature. the range of patterns recorded at the subjects' reflex thresholds included: +b-g, +b+g, -b+g and -b-g. the threshold pattern can be seen to occur along a continuum, being determined by baseline characteristics and changing as the natural frequency of the system decreases. at suprathreshold intensity levels the direction of +b+g threshold patterns changed to +b-g, and threshold patterns of -b+g to those of +b+g at suprathreshold intensity levels. the theoretical continuum of results as a function of mass and stiffness characteristics and probe frequencies is illustrated in table 3. although the number of table 1. transmission propertie of ears at the 100 hz probe signal which formed the basis for the division of ears into 5 groups group 1: type 1 tympanograms (1b1g). all tympanometric peak β values larger than tympanometric peak g values and all β values positive n 9 mean resonant frequency = 120 hz type 1 tympanograms (1b1g). all tympanometric peak β values larger than tympanometric peak g values and all β values positive n 9 mean resonant frequency = 120 hz group 2: type 2 tympanograms (3b1g). all tympometric peak β values larger than g values and all β values positive η = 4 mean resonant frequency = 1062 'hz group 3: type 2 tympanograms (3b1g). all tympanometric peak β values smaller than typanometric peak g values and all β values positive η = 6 mean resonant frequency = 950 hz group 4: type 3 tympanograms (3b3g). all tympanometric peak β values smaller than tympanometric peak g values and all β values positive η = 7 mean resonant frequency = 707 hz group 5: type 3 tympanograms (3b3g) all tympanometric peak β values negative η = 4 mean resonant frequency = 650 hz table 2. susceptance and conductance reflex patterns at threshold and suprathreshold levels for each group, recorded for the three stimuli at the 1000 hz probe frequency. where the direction of the reflex pattern (b or g) changed at suprathreshold intensity levels relative to threshold reflex patterns, the threshold and suprathreshold patterns are named and separated by a semicolon reflex patterns for admittance components group 1 (n = 27) group 2 (n = 12) group 3 (n = 18) group 4 (n = 21) group 5 i (n = 12) j -b-g 1 5 | -b-g;-b+g j -b+g 1 2 1 -b+g;+b+g 2 4 +b+g 1 5 6 1 +b+g;+b-g 8 2 11 7 +b-g 18 10 2 5 table 3. continuum of results obtained in the present study indicating the relationship between reflex patterns at threshold and suprathreshold intensity levels and baseline transmission properties (mass dominance vs stifness dominance). stiffness dominated < — > mass dominated threshold +b-g +b+g +b-g -b+g -b+g ^-b-g -b-g suprathreshold +b-g +b+g -b+g the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) direction of susceptance and conductance acoustic reflexes at high probe frequencies 89 observations was too small to conduct any statistical analysis (fitz-gibbon & morris, 1987) it can be seen that the distribution of reflex patterns conforms to this continuum, with the majority of subjects in group 1 (higher natural frequency, therefore more stiffness dominated) showing the +b-g pattern, while the majority in group 5 (lower natural frequency, therefore more mass dominated) showing the -b-g pattern at both levels. thus as the natural frequency of the system moves from above the probe frequency to below it, one sees the progression of threshold reflex patterns from +b-g to -bg. this suggests that the patterns may occur in each subject, were the probe frequency to be shifted to frequencies above and below the ear's natural frequency. examples of each of the reflex patterns is shown in figure 1. the +b-g pattern was seen most commonly for ears which were stiffness dominated (groups 1 and 2). that is, the probe frequency was below the mean resonant frequency for both of these groups, which were 1200 hz and 1062 hz respectively. this pattern of +b-g is consistent with the findings of feldman & williams (1976) and lutman et al., (1984) who used 660 hz probe frequencies, at which many adult ears have similar transmission properties to those seen for these subjects in groups 1 and 2. this pattern at 660 hz has been related to an increase in stiffness when the reflex is activated (feldman & williams, 1976). the transmission properties for most of the ears demonstrating the +b-g pattern are possibly similar to the ears used in previous investigations at 660 hz, as they showed a fair contribution by negative reactance (stiffness) to overall impedance. this suggests that the effect of the reflex for the +b-g pattern at the 1000 hz probe frequency in the present study may also result from added stiffness when the reflex is activated. although the effects on impedance components were not investigated in the present study, the results do appear to be consistent with theoretical models of the effect of the acoustic reflex presented by lutman & martin (1979) and lutman (1984). j the +b+g pattern was clearly the most common pattern for ears in group 3 where the mean resonant frequency (950 hz) was just below the 1000 hz probe frequency. the +b+g patternl at threshold was also the most common pattern for ears in group 4 in which the transmission properties were slightly above resonance, but not significantly mass dominated. this suggests that where ears demonstrate transmission properties close to resonance, the +b+g pattern is expected. the +b+g pattern shifted to +b-g for several of the observations across groups 1 to 4. a sketch of this phenomenon is shown in figure 2. the direction change observed suggests that the effect of the reflex at suprathreshold intensity levels is to increase the amount of stiffness in the system. as the +b-g pattern at threshold in the present study is more commonly found for ears which are more stiff than those which show the +b+g pattern at threshold, it appears that the direction change to the +b-g pattern at suprathreshold levels is consistent with this addition of further stiffness at high intensities. these intensity related effects of the reflex are referred to in the theoretical models of the effect of the reflex (lutman & martin, 1979)., the -b+g pattern has not been reported previously. this occurred only in ears which demonstrated transmission properties which were above resonance as shown by the tympanometric shape at 1000 hz (groups 4 and 5). the mean resonant frequencies of these two groups was 707 hz and 650 hz respectively, and this pattern suggests that for ears with low resonant frequencies, the expected reflex pattern for high probe frequencies could be -b+g at threshold. the degree to which this pattern is expected appears to increase as the system becomes more mass dominated, as shown by this pattern being more' common for group 5 than for group 4. the -b+g pattern also showed a suprathreshold direction change (in some ears) to the +b+g pattern. a sketch of this is shown in figure 3. as with other direction changes discussed above, this direction change suggests that at higher intensities the effect of the reflex is to show added negative reactance, so that transmission approximates that usually seen for ears closer to resonance. because the effect of the reflex on reactance and resistance was not investigated directly, the patterns can only be simply related to patterns seen at lower probe frequencies. a more thorough investigation would be useful to relate measured admittance patterns to the effect on reactance and resistance. such an investigation would need to correct probe tip measures to the level of the tympanic membrane as there is a nonlinear relationship between impedance measures made at the probe tip and those corrected to the lateral surface of the tympanic membrane (margolis, reflex e x a m p l e s pattern s u s c e p t a n c e (b) c o n d u c t a n c e ( g ) + b g 0.09 0 2 ε ε -0.10 + b g ! 0 2 ε ε + b + g ^ ^ ^ ^ 0.12 0 ε ε 0.14 + b + g a ε 0 ε ε b + g -0.09 0 £ ε ε 0.11 b + g 1 0 £ ε ε b g -0.12 c 8 ε ε -0.13 b g c 8 ε ε figure 1. sketch of the reflex patterns obtained at 1000 hz probe frequency s u s c ep ta n c e ( β ) 0 c i § 0.16 1.09 α j^2.09 κ s u s c ep ta n c e ( β ) 0 c i § c o n d u c ta n c e ( g ) m m ho ο 0.72 α . 1.18 α 0.22 y v c o n d u c ta n c e ( g ) m m ho ο v -0.51 -087 c o n d u c ta n c e ( g ) 94 98 102 106 110 d b h l figure 2. sketch to show an example of the direction change in conductance (+b+g; +b-g) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 90 louise reynolds & lucille ρ morton 1981). such an analysis was beyond the scope of the present investigation which was simply to document reflex patterns at higher probe frequencies, recorded in a similar fashion to conventional clinical measures. the -b-g pattern was recorded only for ears which were clearly mass dominated at the 1000 hz probe frequency (group 5). this was interesting in that this pattern is the expected pattern also for ears which are clearly stiffness dominated, as shown by previous studies where the 220 hz probe frequency was extensively investigated (for example, feldman & williams, 1976; lutman et al., 1984). none of these patterns demonstrated the direction change at suprathreshold intensity levels found with the other reflex patterns. this is interesting in that there is less documented evidence of the effect of the reflex for mass dominated systems (lutman & martin, 1979) and it is possible that clearly mass dominated systems yield susceptance and conductance reflex patterns which do not reflect the added stiffness seen for ears with more stiffness in the baseline condition. as mentioned above, such conclusions cannot be drawn from the present investigation, but are discussed in more depth by reynolds (1993). in addition, this aspect of the effect of the acoustic reflex requires further investigation. conclusion thus it appears from the results of this study that the direction of reflex patterns is determined by the natural frequency of the system in relation to the probe frequency. at suprathreshold levels the effect of the increase in intensity is to increase the stiffness, which for some ears results in a change in reflex pattern. the changed pattern is one which is characteristic of systems with a slightly higher natural frequency, i.e., at suprathreshold levels normal systems may behave like more stiffness dominated systems but not like more mass dominated systems. the results also suggest that the continuum of reflex patterns may be seen in all normal systems provided that one has a sufficient range of probe frequencies. while further investigation of the effect of the reflex on underlying impedance components, particularly for mass dominated systems, is indicated these results do provide some guidelines to the clinical audiologist. reflex patterns need to be interpreted in relation to the ffl 0 . 0 8 0 . 1 1 0 . 1 4 lli ο ζ 2 α λ α . ω ο co c ί ε "v" ν d co 0 . 1 0 0 . 1 4 a 0 . 1 2 0 . 1 4 0 . 1 5 0 . 1 6 λ 0 . 1 6 lu ο ζ η α λ, λ α α ι -ο d α ζ ο ο £ ε ε 9 4 9 8 1 0 2 1 0 6 1 1 0 d b h l figure 3. sketch to show an example of the direction change in susceptance (-b+g; +b+g) natural frequency of the system and the probe frequency. thus high probe frequency reflex patterns cannot be interpreted with confidence without and indication of the natural frequency of the system. furthermore it would appear that the normal suprathreshold patterns can be explained by an increased stiffness occurring along a continuum, and that a departure from this may be abnormal. however, reflex patterns in abnormal systems need to be examined. this study formed part of a masters dissertation submitted to the faculty of medicine, university of cape town. references american national standards institute. (1981). specifications for audiometers (ansi s.26). new york, ansi. american national standards institute. (1987). specifications for instruments to measure aural acoustic impedance and admittance (ansi s3.39). new york, ansi. bennett, m.j. & weatherby, l.a. (1979). multiple probe frequency acoustic reflex measurements. scandinavian audiology 8: 233-239. berlin, c.i. & cullen, j.k. (1980). the physical basis of impedance measurement. in jerger, j. & northern, j (eds) clinical impedance audiometry (2nd ed), american electromedics corp. block, m.g. & wiley, t.l. (1986). acoustic-reflex growth for multitone complexes. journal of speech and hearing research 29: 92-98. creten, w.l., van de heyning, rh. & van camp, k.j. (1985). immittance audiometry: normative data at 220 and 660 hz. scandinavian audiology 14: 115-121. feldman, a.s. & williams, p.s. (1976). tympanometric measurement of the transmission characteristics of the ear with and without the acoustic reflex. scandinavian audiology 5: 43-47. fitz-gibbon, c.t. & morris, l. (1987). how to analyze data. newbury park, sage. funasaka, s. & kumakawa, k. (1988). tympanometry using a sweepfrequency probe tone and its clinical evaluation. audiology 27: 99-1008. grason-stadler. (1989) gsi33, version 2 middle-ear analyzer instruction manual 1733-0121, rev. 2, grason-stadler, inc. greenfield, d.g., wiley, t.l. & block, m.g. (1985). acoustic reflex dynamics and the loudness discomfort level. journal of speech and hearing disorders 50, 14-20. | hall, j.w. (1979). effects of age and sex on static compliance. archives of otolaryngology 105: 153-156. ! lilly, d.l. & shanks, j.e. (1981). acoustic immittance of an enclosed volume of air. in popelka, g.r. (ed) hearing assessment with the acoustic reflex grune and stratton. lutman, m.e. (1984). phasor admittance measurements of the middle ear i: theoretical aspects. scandinavian audiology 13: 253-264. ί lutman, m.e. & martin, a.m. (1977). the response of the acoustic reflex as a function of the intensity and temporal characteristics of pulsed stimuli. journal of sound and vibration 54(3) 345-360. lutman, m.e. & martin, a.m. (1979). development of an electracoustic analogue model of the middle ear and acoustic reflex. journal of sound and vibration 64 (1) 133157. lutman, m.e., mckenzie, h. & swan, r.c. (1984). phasor admittance of the middle ear ii: n o r m a l phasor tympanograms and acoustic reflexes. scandinavian audiology 13: 265-274 ' / margolis, r.h. (1981). fundamentals of acoustic immittance. in popelka, g.r. (ed) hearing assessment with the acoustic reflex. grune and stratton. / margolis, r.h., van camp, k.j., wilson, r.h. & creten, w.l. (1985). multifrequency tympanometry in normal ears. audiology 24: 44-53. moller, a.r. (1961). network model of the middle ear. journal of the acoustical society of america 33(2), 168=176. the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) d i r e c t i o n of s u s c e p t a n c e a n d c o n d u c t a n c e a c o u s t i c reflexes at h i g h p r o b e f r e q u e n c i e s 91 reynolds, l. (1991). two component acoustic reflex measures across a range of probe frequencies. presented at the south african speech, language and hearing association national audioly conference, durban, south africa, 16-18 october. reynolds, l. (1993). two component acoustic reflex measures as function of probe frequency. unpublished master dissertation, university of cape town. shanks, j.e., lilly, d.j., margolis, r.h., wiley, t.l. & wilson, r.h. (1988). tympanometry. journal of speech and hearing disorders 53 (4) 354-377. sprague, b.h., wiley, t.l. & block, m.g. (1981). dynamics of acoustic reflex growth. audiology 20: 15-40. van camp, k.j. & creten, w.l. (1976). principles of acoustic impedance and admittance. in feldman, a.s. and wilbur, l.a. (eds) acoustic impedance and admittance the measurement of middle ear function. williams & wilkins. vanhuyse, v.j., creten, w.l. & van camp, k.j. (1975). on the w-notching of tympanograms. scandinavian audiology 4: 45-50. wiley, t.l. & block, m.g. (1979). static acoustic-immittance measurements. journal of speech and hearing research 22: 677-696, 1979. wilson, r.h., & mcbride, l.m. (1978). threshold and growth of the acoustic reflex. journal of the acoustical society of america 63 (1) 147-164. wilson, r.h., s h a n k s , j.e., & k a p l a n , s.k. (1984). tympanometric changes at 226 hz and 678 hz across 10 trials for two directions of ear canal pressure change. journal of speech and hearing research 27:257-266. yantis, pa. (1985). puretone air-conduction testing. in katz, j (ed) handbook of clinical audiology (3rd ed) williams and wilkins. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the enigma of fluency: a single case study tessa goldsmith ba (sp & η therapy) (witwatersrand) denise anderson ba (sp & η therapy) (witwatersrand) department of speech pathology and audiology, university of the witwatersrand, johannesburg abstract the article deals with the relapse and maintenance of fluency skills in an adult stutterer following a "fluency-based" treatment programme. recordings of speech were made at relevant intervals throughout an eight month period. immediately after intensive treatment, fluency was established and rate and attitudes normalized. the deterioration of these behaviours and their re-instatement is described. opsomming die artikel handel oor die insinking en behoud van vlotheidsvaardighede in 'n volwasse hakkelaar na 'n "vlotheid-gebaseerde" terapie program. spraakopnames is met gereelde tussenposes gedurende 'n agt maande periode gedoen. spraakvlotheid is kort na die intensiewe behandelingsperiode bereik, terwyl spraakspoed and houdings genormaliseer is. die agteruitgang van bogenoemde gedragspatrone en die herinstelling daarvan word beskryf. one of the most perplexing aspects of the stuttering problem reflected by clinical experience and in the literature, is the relative ease with which most stutterers can become temporarily fluent. the novel conditions identified as inducing fluency in the speech of stutterers have been'explored, among others by bloodstein (1950), wingate (1969) and andrews, howie, dosza and/guitar (1982). several explanations have been proposed for the reduction in stuttering. bloodstein (1950) suggested that stronger or unusual stimulation could account for the change while van riper (1973) cited the distraction phenomenon as being responsible. perkins, rudas, johnson, michael and curlee (1974) hypothesized that fluency inducing conditions facilitate among other features, slowing of transitions, reduced grammatical complexity and decreased frequency of voice onset co-ordination. wingate (1969) concluded from his review of the literature that fluency is induced as a result of an alteration in the manner of vocalization. despite the simplicity of achieving immediate fluency, its permance remains elusive for the stutterer. remediation is a controversial issue as highlighted relatively recently by gregory (1979) in his description of the "speak-more-fluently" as opposed to the "stutter-more-fluently"paradigm. as regards the former, miller (1981) states that all fluency-based programmes have in common, decreased speech rate, fewer stress contrasts and continuous breath flow, which permit the stutterer more time to co-ordinate his systems of respiration, articulation and phonation for speech production. proponents of this approach to remediation are perkins et al. (1974), die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 © sasha 1984 schwartz (1976), shames and florance (1980), webster (1980) and goldberg (1983), among others. the establishment of fluency restricted to clinic situations is meaningless, unless satisfactory schedules for its transfer and maintenance are executed. according to boberg, howie and woods (1979) accounts of successful stuttering therapy are frequently reported before long term outcome is evaluated. the integration of fluency is compounded by the inevitability of the relapse phenomenon. although it has been alluded to frequently, relapse has seldom been investigated experimentally, particularly in relation to the subsequent reinstatement of the fluent response. documented treatment failure may facilitate the recognition of significant features relating to the relapse and maintenance of fluency. it is with this aim in mind that the present single case study is presented. description of subject the subject was a 19 year old male university student who had stuttered since early childhood. no family history of stuttering was reported. the subject stated that he was not initially concerned about his stuttering. he had received intermittent speech therapy for about ten years and occasionally, brief remissions had occurred. the most recent intervention included efforts at direct modification of the severe stuttering symptom and acceptance of this speech pattern. procedure measurement over the eight month intervention period, speech measurements were made at five intervals relevant to the therapeutic r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 tessa goldsmith and denise anderson process i.e. base-line, eight weeks post-onset intervention, at relapse, post-relapse and at follow-up (see figure 1). these measurements involved both the frequency of stuttering (percentage of syllables stuttered % ss) as well as speaking rate (number of syllables spoken per minute spm). only the former appears in figure 1 as this is regarded as the most explicit measure of speech progress. the speech sample consisted of two-hundred words of spontaneous speech and two-hundred words of oral reading. p o s t o n s e t r e l a p s e p o s t f o l l o w u p i n t e r v e n t i o n r e l a p s e t r e a t m e n t (in w e e k s ) figure 1 percentage syllables stuttered of spontaneous speech and reading samples over the 8 month period of therapy. the frequency of stuttering and the speaking rate were calculated according to the formulae suggested by andrews and ingham (1972). a general impression of prosody (including melody, inflection and stress) was formed on the basis of the speech samples. to establish the reliability of these measures, interjudge agreement was determined in terms of percentage concurrence. the authors listened simultaneously to the recordings and made independent judgements of the occurrences of these behaviours. dysfluency was defined as instances of part-word repetitions, whole word repetitions, interjections, revisions, tense pauses and dysrhythmic phonation (adams, sears and ramig, 1982). over the five recording periods, the mean percentage agreement for %ss was 88%, and 93% for spm. perceptions of prosody were discussed until consensus was reached. base line evaluation the subject stuttered on 20,4% of syllables during spontaneous, speech and 18,3% ss during reading. according to wingate's (1976) severity rating guide, he presented as a severe stutterer. his speech was characterised by predominantly tense syllable and sound repetitions, laryngealization, and extreme difficulty initiating phonation. stuttering occurred primarily on vowels, nasals, glides and on the first sound and syllable within words. associated secondary features included loss of eye-contact during the moment of stuttering, fidgeting and touching his body. avoidance and starter techniques, especially interjections, were frequently observed. he spoke at a normal rate of 196 spm (mean rate per minute has been defined as 200 ± 34 syllables, andrews and ingham, 1972) and was monotonous when he stuttered and when he was fluent (see table 1). to determine the optimal fluency inducer to be used as a basis for intervention, the subject's response was assessed under the conditions outlined by andrews et al (1982). fluency was induced by slowing speech rate and prolonging phonation. the subject obtained a low score on erickson's scale of communicative attitudes (1969) which is indicative of a positive attitude towards communication. it is clinically significant, relative to the severity of the stuttering symptom, that he also perceived his stuttering as mild in most speaking situations. this positive communicative attitude belies the fact that the subject reported few social interactions generally. intervention as mentioned above, slowing speech rate and prolonging phonation induced fluency in this subject. he was therefore enrolled in the stutter-free speech programme (shames and florance, 1980) which focuses essentially on these behaviours. he made a commitment to the intensive schedule of therapy and home practice. briefly, the aims of this programme are to establish speech that is free from stuttering and a selfperception that is compatible with this new speaking behaviour. the therapy programme is comprised of five overlapping phases, involving the principles of operant conditioning to shape forward moving speech with continuous phonation and controlled speech rate. the following alterations were made to shames and florance's (1980) original stutter-free speech programme: — delayed auditory feedback was excluded as the subject was able to achieve the target response through imitation of the clinician. , table 1 summary of speech measurements over the 8 month intervention period time of evaluation sample percentage syllables stuttered syllables per minute prosody i base-line evaluation speech reading 20,4 18,3 196 187 monotone monotone 8 weeks intervention speech reading 0 0 170 170 normal normal 10 weeks (relapse) speech reading 8,3 0 200 170 normal , normal 20 weeks (post-relapse) speech reading covert speech recording 1,2 0 6,5 179 164 174 normal normal 'normal 32 weeks (follow-up) speech reading covert speech recording 0,6 0 1,8 180 '175 190 normal normal normal the south african journal of communication disorders, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the enigma of fluency: a single case study 49 — non-verbal signalling (overt hand movement) was omitted during the self-monitoring phase as it was feared that it would become a distraction. establishment of voluntary control of speech was achieved within a three week period of intensive therapy for an hour a day. the subject moved smoothly through the transfer phase-experiencing stutter-free speech in all pre-planned contract activities. eight weeks post-onset intervention the subject was speaking with 0% syllables stuttered, normal prosodic features and at a rate of 170 syllables per minute (refer to table 1). approximately fifty percent of his speech was monitored and fifty percent unmonitored i.e. coincidental fluency. at this stage, the subject was enrolled into a group of adult stutterers, the aims of which were to provide peer support and the opportunity to practice monitored speech. ten weeks post-onset intervention (relapse) the newly learnt speech pattern was transient since the subject began to experience difficulty initiating phonation. marked laryngeal tension, infrequent tense repetitions, sporadic blocks and hesitations were observed. moreover, the subject was unable to reinstate monitored speech despite considerable effort and motivation. his speaking rate had increased to preintervention levels which obviated the previously established voluntary control. stuttering increased as a result but relative to the base-line evaluation, these instances were reduced in frequency, were less pronounced and involved less physical effort (refer to table 1). it seemed that the subject's success in the maintenance phase led to a false sense of security and reduced attention to monitored speech. this is compatible with the concept of "lucky fluency" (perkins, 1981). in addition, environmental events probably instrumental in maintaining the off-target behaviour included the subject's prolonged illness and mid-year examinations at that time. i / ι / i to reinstate the target response] the subject was encouraged to isolate the circumstances in which relapse occurred and the frequency and consequences of its occurrence. in addition to the strategies recommended by shames and florence (1980), intensive therapy was reintroduced and pre-planned contracts were rescheduled. the subject's awareness of his off-target behaviour was increased in an attempt to prevent further relapse. twenty weeks post-onset intervention (post-relapse) after the re-establishment of stutter-free speech throughout the talking day i.e. at 20 weeks post-onset intervention, a further evaluation was conducted. with the aid of 75% monitored speech and 25% unmonitored speech, the percentage of syllables stuttered was reduced to 1,2 % — within normal limits according to andrews and ingham (1972). the rate of speech was controlled at 179 spm. a comparison of these measures in relation to those conducted previously is contained in table 1. it is interesting to note that despite the deterioration in spontaneous speech, oral reading performance remained unaffected. fluency during oral reading was easier to establish at all phases largely because of the reduced propositionality and effective time planning it offers i (perkins, bell, johnson and stocks, 1979). the recency of the relapse highlighted the need for a more detailed description of the subject's reacquired fluency. ingham and packman (1978), howie, tanner and andrews (1981) and andrews and craig (1982) emphasize that a comprehensive evaluation of fluency requires overt and covert assessments of speech behaviour. in operant conditioning terms, the speech clinician and the clinic become the discriminative stimuli for fluency and thus an overt recording of speech would constitute a biased evaluation of improvement. the inclusion of a covert assessment involved the recording of a telephone conversation unbeknown to the subject. a comparison of the overt and covert recordings (contained in table 1) revealed a discrepancy i.e. more stuttering which was probably respresentative of the subject's speech in non-clinic situations. furthermore, the research of runyan and adams (1978, 1979) and runyan, hames and prosek (1982) has revealed that the speech of "successfully therapeutized" stutterers is perceptibly different from normal speakers i.e. 0% syllables stuttered and normal speaking rate do not alone constitute natural fluency. therefore, a perceptual evaluation of the fluency was conducted which focused on the parameters of rate, fluency, naturalness and prosody (ingham and packman, 1978). a spontaneous speech sample was video-recorded of six males aged between 18 and 25 years. three of these were normal speakers and three were "successfully therapeutized" stutterers, one of whom was the subject of the study. six speakers were chosen to provide a heterogenous matrix from which the identified subject could be objectively evaluated. the recordings were randomly presented to five unsophisticated judges, in the same session, who rated each speaker along rating scales developed for the parameters discussed above (see fig. 2). no case history information was provided so that the judges' ratings would not naturalness scale 1 2 natural unnatural fluency scale 1 2 i i 3 i 4 i severe mild stuttering stuttering fluent exceptionally fluent rate scale 1 2 i i 3 i 4 i extremely slow slow fast exceptionally fast prosody scale 1 2 i ι 3 i 4 i extremely monotonous expressive extremely monotonous expressive f i g u r e 2 r a t i n g s c a l e s f o r p e r c e p t u a l e v a l u a t i o n ( a f t e r i n g h a m a n d p a c k m a n , 1 9 7 8 ) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 tessa goldsmith and denise anderson be contaminated. while the ratings of all the speakers carry clinical and theoretical significance, only the identified subject will be discussed for the purposes of this paper. a mean score was computed for each speaker on each parameter. overall agreement was calculated in terms of percentage of agreement between judges and was found to be 90%. the judges perceived the subject as an unnatural speaker, with mild stuttering, slow speaking rate and monotonous speech (refer to table 2). the presence of these abnormal features aroused concern in view of adams and runyan's (1981) consideration of the subtle signs of fluency which they stress are important precursors to relapse. having detected these behaviours, additional maintenance strategies were introduced focusing on the more subtle areas of natural speech. through the use of audio-visual techniques, the subject's laboured rate, excessive monotone and instances of "microstutterings" (boberg et al. 1979) were modified. table 2 mean ratings of perceptual evaluation at relapse parameter subject ns1 ns2 ns3 sts1 sts2 naturalness 2 1 1 1 1 2 fluency 2 3 2 3 2 3 rate 2 3 3 3 3 2 prosody 2 3 3 3 3 1 ns normal speaker sts "successfully therapeutized" stutterer thirty-two weeks (follow-up) therapy contact was discontinued at this point as the subject was on a three-month vacation. subsequent to his return, i.e. eight months after the commencement of the intervention, a complete follow-up evaluation was conducted. as displayed in tables 1 and 3, the subject maintained fluency with normal rate and prosody in spontaneous speech and reading samples. in contrast to the previous evaluation, the present results of the overt and covert measures were consistent. in addition, the subject was now perceived as a natural speaker with normal fluency, and with normal rate and prosody relative to the matrix of normal speakers in the sample. table 3 mean ratings of perceptual evaluation at follow-up parameter subject ns1 ns2 ns3 sts1 sts2 naturalness 1 1 1 1 1 2 fluency 3 3 3 3 2 2 rate 2 2 2 2 2 2 prosody 2 3 2 3 2 2 ns normal speaker sts "successfully therapeutized" stutterer discussion although fluency was achieved and speech rate and attitudes normalised i.e. the ultimate therapy goals realised, the writers prefer to consider the clinical insights raised by the elusiveness of fluency. it is well documented that the establishment of fluency is a relatively uncomplicated procedure. however, the complexity of the client's integration of this fluency into his total life system together with the psychological adaptation involved, cannot be underestimated. intensive operant conditioning programmes frequently set 0% ss as the target for stutter-free speech (howie et al. 1981; goldberg, 1983). other programmes permit up to 2 and 3% ss as falling within the normal non-fluency range (hanna and owen, 1977). although the subject had achieved these criteria for fluent speech production, he nevertheless experienced a relapse in fluency. varying theoretical viewpoints have been proposed which might have accounted for the deterioration of the established response in this subject. prins (1970) has coined the term "stuttering overkill", which he sees as a by-product of intensive therapy schedules. the subject experienced a change in speech behaviour in three weeks and may not have been fully aware of how the fluency was established. webster (1980), in support of prins, blames the inadequate learning of fluency producing skills for the relapse and van riper (1973) points out that the habitstrength of the stuttering behaviour cannot be ignored. the presence of "lucky fluency" (perkins, 1981) is a common phenomenon experienced by many stutterers in the establishment of fluent speech. in this case, the subject felt over confident which led to a reduction in the intensity of monitored practice. subsequently "microstutterings" (boberg et al. 1979) developed which increased in magnitude and ultimately resulted in overt stuttering behaviour. clinicians who overlook the presence of these "microstutterings" may not have been sufficiently rigorous in the fulfillment of performance criteria and response contingencies and thus they may be a precipitator of relapse (shames, 1981). as illustrated by the subject of this study, lucky fluency is transient and carries with it speech that is not under the direct control of the speaker. collectively these correlates of relapse compound the integration of fluency. the effective management of relapse will determine the maintenance of fluency, which is described as "the perennial weak link in the therapeutic chain" (perkins, 1979, p. 119). i issues that face clinicians regarding relapse encompass its predictability, its prevention, its detection and its management. as researchers are unanimous that relapse is inevitable in adult stutterers, so they agree that clients should be informed of tlie likelihood of its occurrence at the outset of the therapeutic process (boberg et al. 1979; florance and shames, 1980; kamhi, 1982; perkins, 1983). sheehan (1979) suggests that relapses should be clinically induced so that the dread of them will be lessened when they occur. the clinician's ability to detect subtle signs of off-target behaviour will depend on the obtaining of a representative sample of speech behaviour, especially as clinic speech. performance alone is not a valid indication of therapy outcome. it is possible that the extent of this subject's relapse could have been minimized had more refined and detailed speech measures been conducted early on in the therapeutic process. andrews and ingham (1972) and andrews and craig (1982) advocate the use of non-clinic covert speech recordings in single case studies. despite the fact that covert assessment is / the south african journal of communication disorders, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the enigma of fluency: a single case study fraught with ethical problems, the discrepancy between the subject's overt and covert speech performance yielded valuable clinical direction. subtle signs of stuttering have been termed "tenuous fluency" by adams and runyan (1981). manifestations of such behaviour include the presence of monotone and rhythmicity, reduction in speaking rate, reduced vocal intensity and inappropriately placed pauses. at the time of the relapse, the subject of this study evidenced signs of all of the above-mentioned behaviours. in their article of 1981, adams and runyan contend that clients who show these signs of tenuous fluency are "good bets for relapse" (p. 215). this study demonstrates that focus on speech behaviour alone does not guarantee improved speech performance. concentrated work on aspects of psychological change is as relevant as are fluency instating procedures. "maintenance of attitude change has been shown to parallel maintenance of speech improvement" (dalton, 1983, p. 170). failure to confront these changes may give the client reason to return to his previous modes of speech behaviour. it became evident that this subject needed most support after the intensive period of therapy. at this point, the programme had to be directed specifically at his feelings about stuttering, his self concept, ideas about becoming a fluent speaker, and his perception of his role in therapy. these issues, as well as the behaviour change necessary for development of confidence to apply speech process control, occur primarily within the context of the clinical relationship. in recent years, perkins (1981, 1983) has argued strongly for the development and periodic re-evaluation of realistic goals for each client. this has emerged from his consideration of "fluency cost-effectiveness". in clients whose fluent speech is only realised through constant monitoring, the energy expended may not be commensurate with the reward of fluency. thus fluency may become a "tiring chore" for the stutterer. perkins (1983) makes the statement that "the expectation of permanent fluency is an expectation rarely realised" (p. 158). perhaps it is only possible if the patient constantly uses the skills he is taught. in his therapy programme, perkins (1981) thus establishes what he has termed "normal sounding speech" as opposed to "normal speech" behaviour. the distinction lies in the fact that normal speakers are not required to do anything special to achieve fluent speech. ^ carefully structured therapy programmes do not necessarily follow the smooth implementation their descriptions suggest. it is the work on motivation, frustration, impatience and disappointment, tolerance of fluency failure, resistance to transfer and failure to use the newly acquired fluency in previously stressful speaking situations which forms the essence of therapy. without these support skills, "clients will probably learn what to do to remain fluent without acquiring the facility to do it" (perkins, 1983, p. 158). conclusion this description was offered in order to capture the elusiveness of the fluent response in an adult stutterer. that it was eventually achieved is not tantamount to its permanence. ultimately it is the individual who chooses fluency. 51 acknowledgements the authors acknowledge south african inherited disorders association — cleft pals for their financial assistance. references adams, m. r. and runyan, c. m. stuttering and fluency: exclusive events or points on a continuum. journal of fluency disorders, 6, 197-218, 1981. adams, m.r., sears, r.l. and ramig, p. vocal changes in stutterers and non-stutterers during monotoned speech. journal of fluency disorders, 7, 21-35, 1982. andrews, g. and craig, a. stuttering: overt and covert measurement of the speech of treated subjects. journal of speech and hearing disorders, 47, 96-99, 1982. andrews, g. and ingham, r. j. an approach to the evaluation of stuttering therapy. journal of speech and hearing disorders, 15, 296-302, 1972. andrews, g. howie, p. μ., dosza, m. and guitar, β. e. stuttering: speech pattern characteristics under fluency inducing conditions. journal of speech and hearing research, 25, 208-216, 1982. bloodstein, o. a rating scale study of conditions under which stuttering is reduced or absent. journal of speech and hearing disorders, 15, 29-36, 1950. boberg, ε., howie, p. m. and woods, l. maintenance of fluency: a review. journal of fluency disorders, 4,93-116,1979. dalton, p. major issues for the therapist. in approaches to the treatment of stuttering. dalton, p. (ed.). croom-helm, london, 1983. erickson, r. l. assessing communication attitudes among stutterers. journal of speech and hearing research, 12,711-724, 1969. florance, c. and shames, g. stuttering treatment: issues in transfer and maintenance. seminars in speech, language and hearing, 1, 375-388, 1980. goldberg, s. a. the development of fluency through behavioral cognitive stuttering therapy. communicative disorders, 8, 89-107, 1983. gregory, η. h. controversial issues: statement and review of the literature. in controversies about stuttering therapy. gregory, h.h. (ed.). university park press, baltimore, 1979. hanna, r. and owen, n. facilitating transfer and maintenance of fluency in stuttering therapy. journal of speech and hearing disorders, 42, 65-76, 1977. howie, p. μ., tanner, s. and andrews, g. short and long term outcome in an intensive treatment program for adult stutterers. journal of speech and hearing disorders, 46, 104-109, 1981. ingham, r.j. and packman, a.c. perceptual assessment of normalcy of speech following stuttering therapy. journal of speech and hearing research, 21, 63-73, 1978. kamhi, a.g. the problem of relapse in stuttering: some thoughts on what might cause it and how to deal with it. journal of fluency disorders, 7, 459-467, 1982. miller, s. airflow therapy programs: facts and/or fancy. journal of fluency disorders, 7, 187-202, 1982. perkins, w. h. from psychoanalysis to discoordination. in controversies about stuttering therapy. gregory, h.h. (ed.). university park press, baltimore, 1979. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 perkins, w.h. measurement and maintenance of fluency. in maintenance of fluency. boberg, e. (ed.). elsevier, new york, 1981. perkins, w. h. learning from negative outcomes in stuttering therapy: ii. an epiphany of failures. journal of fluency disorders, 8, 155-160, 1983. perkins, w. h., rudas, j., johnson, l., michael, w.b. and curlee, r. f. replacement of stuttering with normal speech: iii clinical effectiveness. journal of speech and hearing disorders, 39, 416-428, 1974. perkins, w. η., bell, j., johnson, l. and stocks, j. phone rate and the effective planning time hypothesis of stuttering. journal of speech and hearing research, 22, 747-755,1979. prins, d. improvement and regression in stutterers following short term intensive therapy. journal of speech and hearing disorders, 35, 123-134, 1970. runyan, c. m. and adams, m.r. perceptual study of the speech of "successfully therapeutized" stutterers. journal of fluency disorders, 3, 25-39, 1978. runyan, c. m. and adams, m. r. unsophisticated judges' perceptual evaluation of the speech of "successfully treated" stutterers. journal of fluency disorders, 4, 29-38, 1979. tessa goldsmith and denise anderson runyan, c.m., hames, p. e. and prosek, r.a. a perceptual comparison between paired stimulus methods of presentation of the fluent utterances of stutterers. journal of fluency disorders, 7, 71-77, 1982. schwartz, m. f. stuttering solved. lippincott, philadelphia, 1976. shames, g. and florence, c. l. stutter-free speech: a goal for therapy. charles e. merrill, ohio, 1980. shames, g. relapse in stuttering. in maintenance of fluency. boberg, e. (ed.). elsevier, new york, 1981. sheehan, j.g. current issues on stuttering and recovery. in controversies about stuttering therapy. gregory, h.h. (ed.). university park press, baltimore, 1979. van riper, c. the treatment of stuttering. prentice-hall inc., new jersey, 1973. webster, r. l. evolution of a target-based behavioral therapy for stuttering. journal of fluency disorders, 5, 303-320, 1980. wingate, μ. e. sound pattern in "artificial" fluency. journal of speech and hearing research, 12, 677-686, 1969. wingate, m.e. stuttering: theory and treatment. irvington publishers inc., new york, 1976. the south african journal of communication disorders, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) information for contributors the south african journal of communication disorders publishes papers concerned with research, or critically evaluative theoretical or therapeutic issues dealing with disorders of speech, voice, hearing or language, or on aspects of the processes underlying these. the south african journal of communication disorders will not accept material that has been published elsewhere or that is currently under review by other publications. form of manuscript. authors should submit manuscripts including artwork, tabular material and photographs etc. in triplicate (the original and two copies). manuscripts should be double spaced with wide margins and should not exceed 20 pages. each page should be numbered and labelled with the author's name. page j should contain only the article title, name of author/s, highest degree and address or institutional affiliation. page 2 should contain only an abstract (100 words) which should be provided in both english and afrikaans. afrikaans abstracts will be provided for overseas contributors.. major headings, where applicable, should be in the order of method, results, discussion, conclusion, acknowledgements and references. tables and figures should be prepared on separate sheets (one per table/figure, unless two/more are to appear together). the first author's name should appear on the back of each page in pencil. the heading for tables appears above and for figures below. lettering should be uniform, profesionally done and large enough to be legible after a 50% reduction in printing. line drawings must be originals, in black ink on good quality white paper. tables and figures should be numbered in order of appearance (with arabic numerals). the amount of tabular and illustrative material allowed will be at the discretion of the editor (usually not more than 6). references. references should be cited in the text by surname of the author and date e.g. van riper (1971). use all authors' names the first time that the reference is used in the text. thereafter, et al. will suffice. references should be listed alphabetically in double-spacing at the end of the article. for acceptable abbreviations of names of journals, consult the fourth issue of dsh abstracts or the world list of scientific periodicals. the number of references should not exceed 20. note the following examples. van riper, c. the nature of stuttering. englewood cliffs, new jersey: prentice-hall, 1971. sharf, g.t. some relationships between measures of early language. j. speech hear. dis., 1972, 37, 67-74. crystal, d. clinical linguistics. disorders of human communications 3. arnold, g.e., winckel, f & wyke, b.d. (eds.). austria: springer-verlag, 1981. proofa. galley proofs will be sent to the author wherever possible. corrections other than typographical errors will be charged to the author. reprints. 10 reprints without covers will be provided free of charge. all manuscripts and correspondence should be addressed to: the editor, south african journal of communication disorders, the south african speech and hearing association. p.o. box 31782, braamfontein 2017, south africa. inligting vir bydraers die suid-afrikaanse tydskrif vir kommunikasieafwykings publiseer artikels oor navorsing, asook krities evaluerende artikels oor die teoretiese of terapeutiese aspekte van spraak-, stem-, gehoorof taalafwykings, of oor aspekte onderliggend aan hierdie afwykings. die suid-afrikaanse tydskrif vir kommunikasieafwykings sal nie materiaal aanvaar wat erens anders gepubliseer is, of wat tans deur ander publikasies oorweeg word nie. vorm van die manuskrip. skrywers moet die manuskrip, insluitend tekeninge, tabelle en fotos ens. in triplikaat (die oorspronklike en twee afskrifte( inhandig. die manuskripte moet dubbel-gespasieerd met bree kantlyne getik word en nie meer as 20 bladsye oorskry nie. elke bladsy moet genommer wees en die skrywer se naam dra. op bladsy 1 moet slegs die artikel se titel, naam van die skrywer/s, hoogste graad behaal en adres of naam van betrokke geaffilieerde instansie verskyn. op bladsy 2 moet slegs die opsomming (100 woorde) in afrikaans en engels verskyn. hoofopskrifte, waar van toepassing, moet in die volgorde metode resultate, bespreking, gevolgtrekking, erkenning en verwysings wees. tabelle en figure moet op aparte blaaie voorberei word, (een per tabel/figuur, tensy twee of meer saam moet verskyn). die eerste skrywer se naam moet in potlood op die keersy van elke bladsy verskyn. die opskrif vir tabelle moet bo-aan en vir figure onder-aan verskyn. lettertipes moet eenvormig, professioneel gedoen wees, en groot genoeg, om na 50% verkleining in druk, nog leesbaar te wees. lyntekentnge moet oorspronklik, in swart ink en op goeie kwaliteit wit papier gedoen wees. tabelle en figure moet in volgorde (arabiese syfers) genommer word. die hoeveelheid getabuleerde en geillustreerde material wat toegelaat word, word deur die redakteur bepaal (gewoonlik nie meer as 6 nie). verwysings. verwysings moet in die teks aangebring word deur die naam van die outeur en die datum te verstrek bv. van riper (1971). gebruik alle outeursname wanneer dit die eerste maal aangehaal word. daarna sal et al. voldoende wees. verwysings moet alfabeties gerangskik word aan die einde van die artikel en in dubbelspasieering getik word. voorbeeld: van riper, c. the nature of stuttering. englewood cliffs, new jersey: prentice-hall, 1971. sharf, g.t. some relationships between measures of early language. j. speech hear. dis., 1972, 37, 67-74. crystal, d. clinical linguistics. disorders of human communications 3. arnold, g.e., winckel, f & wyke, b.d. (eds.). austria: springer-verlag, 1981. vind die lys van aanvaarde afkortinge van name van tydskrifte in dhs abstracts (vierde uitgawe) of the world list of scientific periodicals. die aantal verwysings mag nie 20 oorskry nie. proewe. galeiproewe sal waar moontlik aan die skrywer voorgele word vir proeflees. onkoste van veranderinge (uitgesluit tipografiese foute) sal deur die skrywer gedra moet word. afdrukke. 10 afdrukke sonder buiteblaaie sal gratis aan die skrywer verskaf word. alle manuskripte en korrespondensie moet gerig word aan: die redakteur, die suid-afrikaanse tydskrif vir kommunikasieafwykings, die suid-afrikaanse vereniging vir spraaken gehoorheelkunde, posbus 31782. braamfontein 2017, suid-afr1ka. die suid-afrikaanse ydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a clinical rating scale of speech dysfunction in parkinson's disease thompson, alison k., b.a. (sp. & h.th.) (witwatersrand) speech therapy department, general hospital, johannesburg. summary the speech dysfunction of parkinson's disease is complex and individually variable owing to the interaction of muscle rigidity, tremor and disturbance of movement. eight speech dimensions which are characteristically disturbed in parkinson's disease are discussed with reference to available research findings. in order to provide a more detailed description of the speech than could be obtained by clinical notes alone, a speech rating scale has been developed, and is presented in summarized form for clinical use. incidence and progression of the speech dysfunction are considered in addition to the problems of assessment peculiar to the patient with parkinson's disease. opsomming die spraakdisfunksie van parkinson se siekte is kompleks en verskil van persoon tot persoon, as gevolg van die interaksie van spierstyfheid, tremor en versteuring van beweging. agt aspekte van spraak wat kenmerkend versteurd is in parkinson se siekte word bespreek met verwysing na die bevindinge van navorsing. 'n spraakgraderingskaal is ontwikkel om η meer volledige beskrywing van spraak te verkry as wat moontlik is met die gebruik van kliniese aantekeninge alleen en dit word opgesom vir kliniese gebruik. die voorkoms en ontwikkeling van die spraakdisfunksie word in oenskou geneem, asook die probleme by evaluasie wat eie is aan die pasient met parkinson se siekte. parkinson's disease is characterized by a combination of muscle rigidity, tremor and disturbance of movement. this disturbance may take the form of slowness of movement (bradykinesia), paucity of movement (hypokinesia) or difficulty in initiating movement (akinesia). the fact that this triad of symptoms occurs to a variable degree in any given patient means that each patient presents with his own individual pattern of both physical and speech dysfunction. speech disturbance, which is generally present to some degree, results from the inability to co-ordinate and integrate the various elements which comprise the motor-speech act. although laboratory techniques have been used to describe the different speech features of parkinson's disease objectively, these are neither practical nor available for everyday clinical use. furthermore, sarno1 8 notes that a patient's intelligibility rating does not necessarily correlate with the degree of motor impairment observed in the speech musculature or with an acoustic description of the speech production. the task of assessing the patient's speech therefore ultimately falls to the clinician who must use subjective judgements together with those recording techniques which are available. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol.25, 978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 alison thompson owing to the complexity and individual variation noted in the speech dysfunction of the parkinson's patient, it was felt that a consideration of each discrete speech dimension would lead to a better understanding of the precise nature and level of the patient's speech functioning than could be obtained from clinical notes alone. as speech performance is one index of the patient's general level of functioning, this information is of assistance in the formulation of decisions for ongoing medical management. research studies have provided data on the sequence of speech deterioration with progression of the disease.1' 5 ' 1 4 the course of the patient's speech deterioration can therefore be determined with the aid of a detailed speech assessment obtained at regular intervals. this article describes a clinical rating scale which has been developed to permit a systematic recording of eight speech dimensions which are characteristically disturbed in the parkinson's disease patient. the range of dysfunction pertaining to each speech dimension is discussed in some detail, thereby providing a base reference for applying the scales which are presented in summarized form for clinical use. whilst the scales cannot claim to be fully comprehensive, they provide a simple and practical means of recording clinical judgements for future reference. incidence and progression of speech dysfunction on subjective evaluation, reduced intensity of speech and monotony are frequently the earliest presenting signs of speech disturbance. laryngeal functioning is generally affected early in the disease process, followed by a deterioration in lingual, and finally labial functioning. canter5 demonstrated that in 17 patients tongue-tip involvement was typically greater than lip involvement. blonsky et al,1 investigated the speech of 100 patients with parkinson's disease using cinefluoroscopic techniques. the following incidence of dysfunction was found, (listed below in order of their presentation in the disease process): hoarseness 90 % vocal tremor 30 % lingual dysfunction 50 % labial dysfunction 30 % dysfluency/stuttering 20 % logemann et al'3 classified the voice and articulation defects of 150 patients by perceptual evaluation. they found that many patients had voice disorders in the presence of normal articulation but the converse was true in only one patient. voice disabilities appear to develop before articulation begins to degenerate. their analysis of the sequence of articulatory degeneration reveals' that deterioration progresses from posterior to anterior tongue positions of articulation. first phonemes affected are / k / and /g/, followed by / s / /z/, then / s / /z/, and then / c / / j/. last to be affected are / t / and / d / . jthe labial phonemes / p / / b / hi and / v / were affected after / k / and /g/, usually about the time that / c / and /'j/ deteriorated. the south african journal of communication disorders, vol. 25, 978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) rating scale of speech in parkinson's 4 1 v r e d o r t the following incidence of speech dysfunction: ι ney c f 8 q 0, voice disorders fi> (hoarseness, breathiness and roughness) articulation disorders 45 % rate disorders 20% n a s a l i t y , κ i n ? unimpaired speech 10 h rnnciderine that one might predict nasality in parkinson's patients owing ^ hp ditv and hypokinesia of the velum, it is noteworthy that this is not a characteristic feature of the condition. the logemann et a p incidence of if) % may reflect normal distribution factors. the relationship between the nature of speech disturbance and the natient who presents with either a predominance of tremor, rigidity or hradvkinesia is not clear. the relative interaction of these signs in the individual would appear to be responsible for the considerable variation in sneech disturbance noted between patients. the speed of speech which can be either abnormally fast or abnormally slow, provides a good example of this variability in presentation. factors influencing assessment there are several factors to be considered when assessing speech performance of the parkinson's disease patient. medication dopaminergic drugs, if well tolerated by the patient, generally result in improved speech."' 1 7 leanderson et al" obtained emg recordings of patients before and during l-dopa treatment. the untreated patient demonstrated a constant muscular hyperactivity which interfered markedly with articulation. a further finding was a disturbance in reciprocal muscular activation, manifested in a simultaneous contraction of opposing articulatory muscles. the primary action of l-dopa was a reduction in hypokinesia, thereby resulting in both improved speech and facial movement. however, from clinical experience, if the patient experiences dyskinesia as a side effect of dopaminergic drugs, then speech performance may once again deteriorate. the patient should be questioned as to his general fluctuation in functioning during the course of the day. stable control is not necessarily maintained, despite regular medication. the appearance of the on-ott reaction may cause marked fluctuation in speech functioning from hour to hour speech performance can be expected to deteriorate concomi t t a n t with a deterioration in the patient's general physical status. excess or deficiency of saliva in the mouth -has an indirect effect on speech performance. t h e untreated patient, plus those not on anticholinergic medication, have a tendency to drooling and slushy articulation. this is believed to be due to reduced effectiveness and frequency of swallowing rather than any excess in saliva secretion. 1 he die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 alison thompson majority of treated patients are placed on anticholinergic medication with the result that they complain of an abnormally dry mouth. this imparts a certain "thickness" of quality to the articulation. almost without exception, patients with this problem report increased difficulty with articulation as saliva secretion diminishes. in this regard, the normal stress reaction of the patient to examination adds to an already existing problem. emotional behaviour patients may also demonstrate a marked breakdown in performance as a result of stress. anxiety and self-consciousness create physical tension which exacerbates the rigidity, tremor and movement disturbance. the patient's speech frequently deteriorates as soon as he faces the clinician and anticipates that his performance is to be assessed. it is necessary to ensure that the patient is relaxed and adjusted to the environment before attempting any assessment. whilst the degree of breakdown under stress does afford valuable information in its own right, the clinician's primary aim is to obtain a rating of the patient's average functional speech ability. many patients are subject to depression which results in a general lack of spontaneity of speech plus poor motivation to strive for optimal functioning. anti-depressant drug therapy can alleviate the condition considerably, leading to an overall improvement in communicative behaviour. time of assessment factors such as fatigue and dosage schedule of drugs may cause significant fluctuation of performance during the day. this applies especially to therapy with l-dopa where performance (ability) may diminish markedly as the effect of the drug wears off and the next dose falls due. ideally, the patient should be interviewed at the same time of day for each subsequent assessment. this would in part help to control these factors. it is nevertheless essential to note the patient's physical and emotional state at the time of assessment. hearing as onset of parkinson's disease clusters around the middle years it follows that many patients will have some degree of presbyacutic hearing loss. the patient decompensates in his speech performance owing to a breakdown in his auditory monitoring skills. speech dysfunction may consequently be the result of a double pathological process' speech sample and assessment technique the parkinson's disease speech ratingscale is subject to the limitations of all rating scales. qualitative, subjective judgements are required which suggests that some experience with parkinson's disease speech is desirable in order to apply the scales 'most effectively. a rating scale of this nature cannot provide absolute quantitative values nor can it claim to the south african journal of communication disorders, vol. 25 978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ratingscale of speech in parkinson's 43 be equally efficient for the rating of all speech dimensions. some dimensions remain inherently more difficult to evaluate than others. an advantage of this type of scale for recording speech performance is that it focuses attention on each individual speech dimension. it is therefore possible to determine where the greatest changes occur as the disease progresses. generalized statements, such as "disturbed rhythm", provide very little useful information when one is faced with a patient for re-assessment. however, if the clinician has available past ratings of the speed of speech, degree of akinesia, and perseveration of phonemes within a word, he consequently has a meaningful delineation of the manner in which the rhythm was previously judged as being disturbed. recorded ratings are of particular reference value when a patient is assessed periodically over a number of years by several different clinicians. , clinically, it is desirable that assessment of speech in the parkinson s patient should be carried out on a spontaneous speech sample. as a rule, speech intelligibility is markedly more impaired in the spontaneous speech flow than it is in a restricted, formally induced sample. this discrepancy in performance has also been noted in the literature. 5 ' 1 s as soon as one seeks to control the patient's speech output in any way, performance alters. an assessment made on a formally induced sample is therefore a poor reflection of the patient's functional speech ability. a rating scale, as an assessment technique, is well suited for use with a spontaneous speech sample. t h e clinician engages the patient in conversation and waits until the patient has adjusted to the speaking situation before commencing the rating. t h e spontaneous sample also affords the clinician as much time as he requires in order to assess any single dimension. provided that the clinician marks his ratings out of the patient's direct line of vision this assessment technique would seem to have a minimally disruptive effect on the patient and, consequently, his speech performance. a d m i n i s t r a t i o n o f t h e r a t i n g s c a l e t h e patient should be comfortably seated in a quiet room. t h e basic information required from the patient should be obtained before starting the assessment. t h e patient is engaged in conversation on a subject of interest after having been instructed to disregard the clinician's note taking. once the patient has become adjusted to the speaking situation the clinician commences the speech assessment, discontinuing as necessary to maintain the patient in conversation. t h e clinician mentally focuses on each speech dimension placing a cross in the relevant place on the format. recording of ratings should be done out of the patient's direct line of vision. . . ^ t „ a gross clinical rating is required for each speech dimension. a rating ot u denotes no impairment whilst 1, 2 and 3 denote mild, moderate and severe impairment respectively. assess maximum vocal intensity last as the patient is more likely to feel die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol.25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 alison thompson confident and relaxed at this stage. test by asking the patient to shout a word such as "help!" or "hullo" as loudly as possible. the rationale behind this test should be explained in order to elicit the patient's full cooperation. in spite of this, reliable results may not be obtained. after the assessment has been completed, the patient should be asked to evaluate his performance in relation to his average speech performance over the previous few days. it may be helpful to obtain a similar evaluation from the spouse or other family member in order to confirm the reliability of the patient's subjective impression. s p e e c h d i m e n s i o n s articulation parkinson's disease is characterized by indistinct articulation. the complex disorder of muscle functioning results in irregular contraction of muscles and an inability to initiate the co-ordinated contraction of several muscles at any given time. there is a failure to move the articulators through the full excursion necessary for clear phoneme production. alternatively, the patient may perform the articulatory movement adequately but fail to initiate phonation simultaneously. the indistinct articulation therefore reflects a failure to complete articulatory and phonatory movements correctly rather than the absence of movement. sarno1 8 found that the type or degree of phonemic dysfunction does not necessarily correlate with limitations noted in movements of the oral musculature. conversely, canter,5 investigated the relationship between diadochokinetic rate and articulation in parkinson's subjects and found that diadochokinetic rates for both tongue tip'and the back of the tongue correlated strongly with clarity of articulation. the correlation of lip diadochokinetic rate and articulation was slightly lower but still highly significant. standard single-word articulation tests are unsuitable for testing the parkinson's patient. research indicates that these patients usually perform normally on such tests despite the fact that they clearly have articulatory deficiencies in connected speech. 5 ' 9 canter5 evaluated the articulation in the context of connected speech and found that the majority of errors involved the plosives. these tended to be produced with a fricative quality and were at times omitted in final word position. logemann et al1 3 confirmed these findings and noted that errors of / v / is/ and 111 resulted from reduced constriction of the air channel. / the indistinct articulation within connected speech in many patients with advanced disease makes it impossible to determine precisely which phonemes have been elided, distorted or omitted. in severe cases speech becomes unintelligible to the point where word junctures cannot be determined by the listener. the latter is unlikely to be entirely due to inadequate articulatory contacts. factors such as low speech intensity, rapid speed of speech flow and akinesia contribute further to the listener's difficulty. the south african journal of communication disorders, vol. 25, 978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ratingscale of speech in parkinson's 45 ,· «f the iaw and associated facial muscles frequently result in poor rigidity oi tn j a r t i c u l a t e d s o u n d t h r o u g h the mouth. this lack of p r ° j e c f u r t h e r confounds articulatory intelligibility and has led to a n s s n of the speech as "swallowed" or "mumbled". rate of speech rpt · „ n o s s i b l y the most variable feature of parkinson s disease speech writers have stressed the occurrence of slowed rate of speech whust others have emphasized the abnormally rapid rate.2'* canter 3 t i n t e d out that many parkinson's patients have a speech rate which alls p,?fhin the normal range. of 134 parkinson's patients assessed clinically at the johannesburg general hospital, 44 (32,8 %) were found to have some «lowine of speech rate whilst 42 (31,4 %) had an increase in their rate of speech the remaining 48 (35,8%) patients fell within normal limits. clearly both slowed and increased rates occur as a result of a complex interaction of the many defects of muscle contraction produced by the disease each individual patient has a certain consistency in his overall rate of speech. as the disease progresses the fast speaker may become slower however, the reverse is uncommon. the term "propulsive rate" has been used to describe the abnormally fast rate of speech. it suggests the uncontrolled nature of the speech flow, similar to the propulsive gait, where the sequence of movement, once initiated, cannot readily be inhibited. in severe cases of slowed rate of speech the patient can be seen to expend a great deal of effort in talking. the speech appears laboured, with difficulty in moving from one articula'tory posture to the next. t h e patient frequently adapts to his difficulty by "editing" his speech, using only the minimum number of words necessary for communication. akinesia of speech akinesia can be defined as the inability to change from one muscle contraction pattern to another, to initiate or maintain an action in the face of the necessity to change. _ akinesia, as it relates to speech, presents as an inability to initiate articulation a n d / o r vocalization at the beginning of a speech segment or as a perseveration of an articulatory movement within a word or segment. the frustrated attempt to initiate speech may last several seconds. once blocking of the speech musculature has been overcome, articulation frequently occurs propulsively over the ensuing speeeh segment·. this segment may consist of several words, phrases or sentences. abnormally long intervals occur between segments, reflecting the patient's inability to initiate each consecutive segment. these intersegmental intervals frequently appear inappropriately and not at the natural point within or at the end of a sentence. t h e intervals consist of a freezing or posturing of the articulators. t h e posturing may be either totally silent or else be accompanied by vocalization. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 alison thompson if the patient initiates vocalization successfully he generally sustains this until the blocking of the articulators is released for production of the intended utterance. the perseverative repetitions would appear to occur most commonly on phonemes or phoneme clusters in the initial word position, but can also be noted in the medial word positions. perseveration of articulatory postures gives a stuttering type quality to the speech. where speed of speech is also very rapid there can be cluttering with random omission of phonemes, syllables or even words. akinesia should not be confused with dyskinesia which occurs as a complication of dopaminergic medication. dyskinesia presents as random choreaform movements of all muscle groups. perioral dyskinesia is common. there is forced opening of the mouth with associated writhing and twisting of the tongue, lip, and cheek muscles whilst the patient is at rest. movements may be inhibited to a certain extent during the actual speech act. vocal intensity a subjective impression of overall reduced intensity is generally accepted as one of the earliest signs of speech disturbance in the parkinson's disease patient despite laboratory research by canter 3 ' 4 indicating that there is no difference in average conversational intensity levels between parkinson's patients and normals. whilst he supports the fact that th'e speech of a parkinson's patient is frequently perceived clinically as having inadequate intensity, he suggests that there must be parameters of speech loudness other than average intensity level which lead to this perception. greene and watson8 have attributed the reduced vocal intensity to impaired respiratory movements which result in weak and fluctuating subglottic pressure. the parkinson's patient also demonstrates reduced voluntary vocal intensity at both ends of the intensity range. 2 ' 4 there is an inability to phonate very loudly or very softly. the former appears to be due to rigidity of respiratory and laryngeal musculature whilst the latter reflects the failure to maintain the necessary balance between subglottic pressure and vocal fold tension required for very low intensity phonation. reduced intensity range can be tested by asking the patient to both whisper and to shout a word as loudly as possible. it is a difficult feature to rate clinically owing to the considerable individual variation in maximum intensity amongst normals as well as the patient's self-consciousness in producing his best attempt. ^ for these reasons the writer has not found it practical to'attempt a fine clinical rating of intensity range, but rather to note whether the range appears to be within normal limits or is clearly outside the normal range. speech decay owing to the rigidity of the respiratory, laryngeal and oral musculature there is a tendency to weak or absent phonation and articulation at the end of speech segments. in advanced cases, where speech is slow and the south african journal of communication disorders, vol. 25, 978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ratingscale of speech in parkinson's 47 laboured, speech decay may occur on the majority of words in the utterance. as the patient reduces effort, on approaching the end of a speech segment, the muscle rigidity prevents the fine control necessary to maintain phonation and firm articulatory contacts. described subjectively, the word endings appear to "trail off" and become inaudible. it would appear that maximum phonation times are reduced in the parkinson's patient although not all researchers are in a g r e e m e n t . 2 ' 4 ' 1 0 canter4 found that his patients were able to produce a sustained vowel for less than half as long as normal controls. speech decay, plus the poor phrasing of speech, may therefore be in part due to the inherent difficulty in sustaining phonation for an extended period of time. vocal quality rigidity and bradykinesia of the laryngeal musculature leads to incomplete adduction of the vocal folds. a hoarse, or harsh, breathy vocal quality is frequently the result. in some patients, this hoarse quality is constant and is superimposed on the entire speech flow whilst in others there is a random fluctuation between normal and hoarse quality. the latter case is due to continually alternating muscle tone and an inability to maintain the necessary fine motor co-ordination of the relevant muscle groups. previous research suggests that regular variability in intensity and/or frequency between adjacent vibratory cycles correlates well with perceptual judgements of vocal roughness or hoarseness. 1 2 ' 2 0 constant hoarseness should be distinguished from a fluctuating vocal quality which comprises episodes of hoarse speech interspersed with episodes of normal or near normal quality speech. t h e patient may present with either possibility at any given stage of his illness. as the disease progresses, the patient's vocal quality may change from fluctuating to constant hoarseness or vice versa. in advanced cases, the tendency is towards a constant forced hoarseness accompanied by marked speech decay. t h e parkinson's patient is, in practice, rarely seen to be totally aphonic. in some patients the development of aphonia may be delayed or prevented by suitable medical treatment. t h e patient may resort to whispering as an avoidance of effort, but this does not reflect his true phonatory potential. prosody dysprosody, or monotonous speech, relates to a lack of control over the stress and inflection variations natural to normal speech. it has been suggested that emphasis on stressed syllables and key words is reduced in parkinson's disease.7 dysprosody, together with reduced vocal intensity are frequently the earliest speech signs of parkinson's disease to be observed clinically. research indicates a lack of agreement as to the precise origin of the subjective impression of monotony. canter3 reports that reduced intensity die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol.25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 alison thompson variability (cf. stress) was not a feature of his parkinson's patients as compared to normals. he concluded that reduced use of stress is not responsible for the clinical impression of monotony and postulates that the reduced pitch range (cf. inflection) is at least partly responsible. dysprosody may not be entirely due to dysfunction of the peripheral speech mechanism. peacher1 6 thought that it reflected both central and peripheral disorders, whilst monrad-krohn14 considered it to be a central language disorder which impairs the melodic variations of speech. darley et al7 suggested that restricted range of movement was the most likely cause of the prosodic insufficiency. on clinical assessment, the patient's immobile face may well add psychological weight to the subjective impression of monotonous speech. the parkinson's patient may demonstrate a significantly higher modal pitch than normals, i.e. there is an increase in the average pitch level over the entire speech flow. subjectively, the patient appears to be speaking at a somewhat higher pitch than normal, quite apart from prosodic features which may or may not be intact. sarno1 8 and morley15 noted this trend as a result of perceptual evaluations. canter3 confirmed this clinical finding using frequency analysis. his patient group had a median fundamental vocal frequency of 129 hz on the average, whilst the median for the normal controls was 106 hz. clinically, an increased modal pitch is a difficult feature to assess. it can be identified far more readily in the male patient than in the female. this is due to the fact that there is a far greater permissible range for high modal pitch levels in the female than in the male. the phenomenon is probably attributable to a fairly constant rigidity of the entire laryngeal musculature. parkinson's disease speech rating scale emotional beka viour congruent confused lethargic depressed euphoric labile anxious unco-operative pitch other hearing saliva in mouth excessive normal reduced / effect on speech. pa tient s ra ting of: (a) fatigue level marked moderateminimal (b) physical status above average average below average the south african journal of communication disorders, vol. 25, 978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ratingscale of speech in parkinson's 49 current medication time of a ssessment time of last dos a ge notes a . articulation 0 — no impairment. 1 — mild impairment of articulation. occasional indistinct plosives. 2 — moderate impairment. some distortion of fricatives. plosives frequently indistinct. 3 — severe distortion of fricatives with multiple indistinct or omitted plosives. difficulty in detecting word junctures. b. rate of speech 0 — no impairment. (i) fast speech: 1 — slight increase in rate. 2 — speech flow moderately fast. 3 — speech flow rapid. or (ii) slow speech: 1 — slight decrease in rate. 2 — moderate slowing of speech flow. 3 — marked slowing of speech flow. speech laboured. c . akinesia of speech (i) initiation of segments: 0 — no impairment. 1 — occasional difficulty in initiating articulation a n d / o r vocalization. slight lengthening of intersegmental intervals. 2 — frequent difficulty in initiating articulation a n d / o r vocalization. silent posturing of articulators observable plus longer intersegmental intervals. 3 — severe difficulty in initiating vocalization and/or articulation. silent posturing results in lengthy intervals between speech segments. (ii) perseveration: 0 — no impairment. 1 — occasional single repetition of phonemes a n d / o r phoneme clusters. 2 — frequent repetition of phonemes and phoneme clusters within a word. perseverations consist of one or two repetitions. 3 — severe perseveration of phonemes and phoneme clusters. repetitions are varied and lengthy. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 alison thompson d . intensity 0 — no impairment. 1 — overall speech intensity slightly reduced. 2 — overall intensity moderately below the normal range. weak vocalization still audible. 3 — speech aphonic. e. speech decay 0 — no impairment. 11 mild decay of vocal intensity and articulatory contact at the end of speech segments. 2 — moderate reduction in vocal intensity and articulatory contact at the end of segments. 3 — speech decay severe. word endings frequently unintelligible owing to poor articulatory contact. weak/absent vocalization. f . vocal quality 0 — no impairment, (i) constant: 1 — slightly hoarse quality superimposed on entire speech flow. 2 — moderate hoarse quality. 3 — forced, hoarse quality. visible effort expended in vocalizing. or (ii) fluctuating: 1 — occasional fluctuation in vocal fold quality resulting in moments of hoarse quality interspersed in a speech flow of normal vocal quality. 2 — approximately 50 % of the speech flow is produced with normal quality. hoarse quality interspersed randomly over words, phrases or sentences. 3 — hoarse quality predominates, but moments of normal vocal quality are still detectable in the speech flow. / g . prosody 0 — no impairment. 1 — slight dysprosody. speech slightly monotonous. 2 — speech monotony pronounced, but some use of stress and inflection still evident. j 3 — severe dysprosody. speech produced in a flat, unvarying monotone. i the south african journal of communication disorders, vol. 25, j 978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ratingscale of speech in parkinson's 51 h. pitch 0 — no impairment. 1 — modal vocal pitch slightly above the normal range. 2 — moderately raised modal pitch. 3 — marked rise in modal pitch. maximum vocal intensity within normal limits reduced unreliable other ra ting of speech a ssessment sa mple by patient: below average average above average by family member: below average average above average ackno wledgements the author wishes to extend grateful appreciation to prof. h.e. reef, chief neurologist of the johannesburg general hospital, for his assistance and guidance with this project. thanks to dr. j. mcmurdo, medical superintendent of the johannesburg hospital, for his permission to publish. references 1. blonsky, e.r., logemann, j., boshes, b„ and fisher, h. (1975): comparison of speech and swallowing function in patients with tremor disorders and in normal geriatric patients: a cinefluorographic study. j. geront., 30, 299-303. 2. boshes, b. (1966): voice changes in parkonsonism. j. neurosurg. suppl., 24, 286-288. 3. canter, g.j. (1963): speech characteristics of patients with parkinson's disease: i. intensity, pitch and d u r a t i o n . / speechhear. dis., 28, 221-229. 4. canter, g.j. (1965 a): speech characteristics of patients with parkinson's disease: ii. physiological support for speech. j. speech hear. dis., 30, 44-49. 5. canter, g.j. (1965 b): speech characteristics of patients with parkinson's disease: iii. articulation, diadochokinesis, and overall speech adequacy: j. speech hear dis., 30, 217-224. 6. darley, f.l., aronson, a.e. and brown, j.r. (1969 a): differential diagnostic patterns of dysarthria. j. speech hear. res., 12, 246-269. 7. darley f.l., aronson, a.e., and brown, j.r. (1969 b): clusters of deviant speech dimensions in the dysarthrias. j. speech hear. res., 12, 462-496. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol.25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 alison thompson 8. greene, m.c.l. and watson, b.w. (1968): the value of speech amplification in parkinson's disease patients. folia phoniat., 20 250257. 9. hoberman, s.g. (1958): speech techniques in aphasia and parkinsonism. /. mich. st. med. soc., 57, 1720-1723. 10. kreul, e.j. (1972): neuromuscular control examination (nmc) for parkinsonism: vowel prolongations and diadochokinetic and reading rates. j. speech hear. res., 15, 72-83. 11. leanderson, r., meyerson, b.a. and persson, a. (1971): effect of ldopa on speech in parkinsonism: an emg study of labial articulatory function. /. neurol. neurosurg. psychiat., 34, 679-681. 12. lieberman, p. (1963): some acoustic measures of the fundamental periodicity of normal and pathologic larynxes. /. of acoust soc amer., 35, 344-353. 13. logemann, j., blonsky, e.r., boshes, b„ and fisher, h. (1972): the steps in the degeneration of speech and voice control in parkinson's disease. in parkinsons disease, siegfried, j. (ed.), 2 hans huber, switzerland. 14. monrad-krohn, g.h. (1957): the third element of speech: prosody in the neuro-psychiatric clinic. j. mental science, 103, 326-331. 15. morley, d. (1955): the rehabilitation of adults with dysarthric speech. j. speech hear. dis., 20, 58-64. 16. peacher, w.g. (1950): the etiology and differential diagnosis of dysarthria. /. speech hear. dis., 15, 252-265. 17. rigrodsky, s. and morrison, e. (1970): speech changes in parkinsonism during l-dopa therapy:. preliminary findings. /. amer geriat. soc., 18, 142-151. 18. sarno, m.t. (1968): speech impairment in parkinson's disease arch. phys. med. rehab. 49, 269-275. 19. webster, d.d. (1968): critical analysis of the disability in parkinson's disease. modern treatment, 5, 257-282. 20. wendahl, r. (1966): laryngeal analog synthesis of jitter and shimmer auditory parameters of harshness. folia phoniat, 18, 98the south african journal of communication disorders vol. 25, 978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) r e p u b l i c i ' i t t e l e p h o n e 2 3 6 6 8 5 " p.o. b o x 5 2 0 4 1 s a x o n w o l d 2 1 3 2 r e p u b l i c | h e a r i n g a i d c o n s u l t a n t s ( p t y ) l t d , 7 3 2 m e d i c a l c i t y e l o f f c o r . j e p p e s t r e e t i | | | | 1 i 1 1 i i i i i i j o h a n n e s b u r g , t r a n s v a a l hearing aids. we specialize in the supply and fitting of hearing aids for all hearing losses, especially for nerve deafness recruitment bone conduction cases. cross aids: cros bicros multicros etc. bone conduction aids for body, earlevel, glasses (speciality by viennatone) b i n a u r a l fittings we import and stock : viennatone, qualitone, microson, phonak hearing aids. moulds: soft, hard, skeleton, vented, occluded etc. repairs: all aids supplied with a scientific performance report after repair. special prices for dealers and institutions. accessories: teacher pupil, parent child, individual audiotrainers, very reasonably priced. group audio trainers. tv wireless infrared transistor receiver sets made by sennheiser. audiometers: screening, diagnostic, research, era and electrocochleography c.o.r. and peep show. impedance bridges. manufacturers of sound proof booth and sound proof rooms. hearing aid testing set by " f o n i x " u.s.a. phonak noise generator with different frequencies, pure tone and warble tone, for everyday's use. we repair and calibrate audiometers. sound level meters, calibrators. industrial noise consultants. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 23 the use of bliss symbols as a first step into literacy with four children with down syndrome erna alant centre for augmentative and alternative communication department of communication pathology, university of pretoria,pretoria abstract this study describes the use of bliss symbolics as a first step into literacy with four children with down syndrome in a preschool setting. initial stages of the intervention programme are discussed as well as the children's ability to read bliss symbols six months after commencement of the programme. symbol errors are analyzed and implications for further research discussed. opsomming hierdie studie beskryfdie gebruik van bliss-simbole as eerste stap tot geletterdheid by vier kinders met downsindroom in 'n voorskoolse opset.inisiele stadiums van die intervensieprogram is bespreek asook die kinders se vermoe om die bliss-simbole te lees ses maande na aanvang van die program. simboolfoute is geanaliseer en implikasies vir verdere navorsing bespreek. literacy is an important skill which facilitates the integration of disabled people into society. this is not only because of the print-dominant society we live in, but also because exposure to print enriches the individual's language and facilitates further conceptual and metalinguistic abilities (blackstone, 1989; koppenhaver & yoder 1992; van kleeck| 1992). traditionally children who had no or limited verbal expression were involved in speech/language programmes and not in reading programmes as it was believed that they did not have sufficient language skills to read (koppenhaver & yoder, 1992). a consequence of this has been limited exposure of cognitively handicapped children to reading instruction, particularly in cases where children have a specific language learning deficit, for example down syndrome (stoel-gammon, 1990). recently, however, researchers have opposed this view, for example, raver & dwyer (1986) who demonstrated a relationship between the reading and language ability of the 5 preschool mentally handicapped children involved in a conversational approach to teaching. they argued that although it was typically believed that reading instruction must be postponed until a child's expressive language is "ready", the results of their study did not support this assumption. apart from limited exposure to instruction, the success of teaching literacy to cognitively handicapped people has been limited. the reasons for this failure are multiple, including, poor teaching strategies (kuntz, carrier & hollis, 1978; raver & dwyer, 1986), children's limited language ability (hern, smith & fuller, 1992; stoel-gammon 1990), limited level of abstraction and poor concentration (jeffree, 1981; matson & mulick, 1991). wishart (1990:250) maintained that many professionals still hold outdated conceptions of the nature of down syndrome and of its developmental implications and indicated that "sufficient evidence has already accumulated to suggest that with the appropriate support and input, children with down syndrome in future generations will undoubtedly fare better than previously". the nature of the support needed, however, constitutes a major point of controversy which has led to a critical review of present methods used to enhance literacy development. the methodology of teaching literacy to cognitively handicapped individuals has focused mainly on the teaching of sight vocabulary in order to give entrance into as broad a vocabulary of written words as possible. the underlying assumption is that auditory and visual processing of the cognitively handicapped person are delayed and that they would not be able to cope with the complex skills of analyses and syntheses in reading (for example word attack skills). cognitively handicapped people will therefore learn to read in the same way as cognitively-able people although at a slower rate with little focus on word attack skills. the teaching of sight vocabulary limits the person's reading to a number of words which is, however, no longer sufficient. folk & campbell (1978) pointed out that trainers must find techniques that will allow trainable cognitively handicapped children to read recipes, newspaper items, movie schedules, vocation information, store signs and so forth. "the question is not whether trainable level students die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 erna alant are competent enough to acquire basic reading skills, but whether we as special educators are competent enough to teach them." (folk & campbell, 1978:322). alternative teaching strategies are particularly important in view of the heterogeneity in language performance found in cognitively restricted children where a single systematic pattern of language and cognitive development is highly unlikely ( miller & chapman, 1984). kangas & lloyd (1988:211) support this argument by stating " ..a model of child development may not be a sufficient framework for selecting goals of intervention for children and adults who experience severely disabling conditions and who are functioning at early levels with respect to developmental norms". wishart (1990) agrees with this notion and stresses that particularly in the case of down syndrome, early learning styles differ fundamentally from those seen in non-handicapped children. the pathways and processes used to process information by the child are thus at the basis of the different methods and systems in teaching language and literacy skills. mcnaughton (1992) discusses that processing differences occur between children who are ablebodied and those who have speech and physical impairments and hypothesizes that the different pathways make a difference to the way in which they process information and thus influence their learning to read. children who use a visual system instead of speech for communication may be able to compensate for the limitations they face in speech production domains. this suggests that severely communicatively handicapped children can get access to reading through a different symbolic pathway than that of normal children as this may provide an easier transition to normal orthography (romski, sevcik, pate & rumbaugh, 1985). various authors have suggested that "bridging" between pictures and print seem to be an effective teaching strategy with cognitively handicapped individuals (jeffree, 1981; mcnaughton, 1992). apart from the children learning to read words quicker, more reading fluency is achieved with resulting positive confidence with the task (jeffree, 1981). different symbol systems have been used to enhance literacy skills in cognitively handicapped children by providing a "bridge" to normal orthography, e.g., rebus, makaton, bliss. the use of bliss symbols for entrance into literacy have been propagated particularly in view of the extensive vocabulary and range of symbols available that can be combined to create new concepts (burroughs, albritton, eaton & montague, 1990; shepherd & haaf, 1992). although bliss has been used extensively with cognitively handicapped children, there is little doubt that these symbols are more difficult to learn than some of the other symbol systems e.g., pics and rebus (mizuko, 1987). this feature which refers to the more abstract nature of some of the symbols could be seen as part of the reason why this system is an appropriate bridge into literacy. the combination of symbols also creates the opportunity for analysis and synthesis skills to develop on a visual level before these skills are required in normal orthography. there have, however, not been any studies done on the association between analysis and synthesis skills on a conceptual level (for example, bliss) and reading ability. at most this relationship could be defined as loose, although the basic concept of analysis and synthesis in relation to reading is introduced before facilitating these skills in normal orthography. one could argue that the teaching of a conceptually based symbol system before teaching normal orthography could delay the actual reading process. superficially, this may seem to be the case, as the child will take longer before "reading" normal orthography. the extended world knowledge and exposure to concepts will, however, contribute to easier and more extensive access to reading once exposed to the process. similarly, it could be said that exposure to bliss symbols and normal orthography simultaneously could lead to cognitive overload as children may have problems in retaining two symbol systems (light & lindsay, 1991). as one system is conceptually based, while the other is letter based, however, they refer to two different functional systems which may facilitate information processing (underwood, 1978). the process of reading instruction with symbols can be described in three phases: phase 1, the teaching of symbols; phase 2, the sequencing of symbols; and phase 3, the fading of symbols to expose normal orthography only (kuntz et al., 1978). this study aims to describe the initial phase of teaching new symbols to four children with down syndrome, followed by a description of the sentence reading they were doing 6 months later. a qualitative description of symbol errors is made and discussed in order to shed some light on the symbol acquisition of the children. method the goals of this study were firstly to describe four cognitively handicapped children's ability to learn bliss symbols within a ten week period in order to use bliss symbolics as an entrance into literacy. the subgoals were threefold: firstly to study the process of learning bliss symbols in terms of recognition and labelling, secondly to investigate the children's conceptual ability in relation to symbols taught during this period and thirdly, to describe the children's bliss reading six months after the final training period. finally a qualitative description of the symbol errors is made. \ subjects: | j four children with down syndrome enrolled at a nursery school for disabled children in pretoria were included in the study. all the children were in the same class in the preschool specifically geared to the needs of children with down syndrome (see table 1 for a description of the subjects). table 2 gives more detail on the present communication abilities of the children. procedure: the bliss symbols were taught as part of the regular preschool curriculum. the teacher selected the symbols according to the theme for the particular period. the number of symbols used each period varied according to the need identified by the teacher (see table 3). the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the use of bliss symbols as a first step into literacy teaching of symbols: each theme was introduced in the same manner and the same school routine was used during the eight weeks of implementation. in the teaching of the symbols, particular steps were followed by the teacher which will be discussed below.all of these steps included teaching within a group setting.the daily routine during the eight weeks was as follows: with four children with down syndrome 25 * day 1: experiencing the concepts. all the children of the school went on an outing which was related to the theme of that week [see table 3 for an outline of the themes], the aim of the outings was to provide the children with the real experience and to bring them into contact with the actual objects.the teacher focused the table 1. description of subjects (n=4) characteristics subject 1 subject 2 subject 3 subject 4 chronological age [years & months] 7,2 5,7 5,5 3,7 mental age [years & months] 4,0 2,11 3,8 2,6 home language afrikaans afrikaans afrikaans afrikaans syndrome down down down down hearing normal normal normal normal previous exposure to bliss [months] 18 3 12 3 socio-economic status middle middle middle middle gender male male male female table 2. communication and visual perceptual abilities of the children evaluation measurement tools subject 1 subject 2 subject 3 subject 4 chronological age (ca) [ca:86 months] [ca:67 months [ca:65 months] [ca:43 months] receptive vocabulary *ppvt extremely poor extremely poor extremely poor receptive language *tacl sub tests: word'classes and relations grammatical morphemes elaborated sentences 1 *rdls comprehension 49-53 months 42-45 months 56-58 months 33 months 30-31 months 29-31 months 28-31 months 31 months expressive language *mlu j •predicted chronological age j >6 >58.3 months 2.00 26.9 months 5.6 55.2 months 1.9 26.1 months pragmatic behaviour •checklist of pragmatic behaviour. good average average poor cognitive development *dasi 2 developmental age 48 months 35 months 44 months 30 months visual perception •developmental test of visual perception •developmental test of visual motor integration 57.2 months 35.6 months 52.7 months not available ppvt: peabody picture vocabulary test; afrikaans translation by gouws (1975). tacl: test of auditory comprehension of language; afrikaans translation by kritzinger (1985). ca: chronological age. rdls: reynell developmental language scales (reynell & huntley, 1985). mlu: mean length of utterance; computation according to miller, 1981. pragmatic behaviour: good: 60-100% of communicative intents and conversational devices were observed; average: 30-60% poor: 0-30% dasi 2: developmental activities screening inventory (fewell & langley, 1984). developmental test of visual perception (frostig, 1963). developmental test of visual motor integration (beery, 1967). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 erna alant children's attention on concepts which were to be included in training and provided language stimulation throughout the outing. a video recording was made by one of the teachers, which was used in teaching later on in the week. no formal work was done on day 1, as the children left for home after the outing. no bliss symbols were thus introduced on day 1. * day 2:introduction of pictures, objects and symbols. on day 2 the class was introduced to the interest table. this table contained objects and/or toys of the vocabulary to be taught.the teacher and the children had an informal discussion about the objects and related it back to their outing. new concepts were explained, demonstrated and acted out where necessary, in order to highlight the meanings of the concepts. this table was displayed in the classroom throughout the day.after this the interest board was introduced containing the symbols and pictures.pictures were matched to the objects on the object table and then put onto the interest board, followed by the bliss symbol for that particular object/picture. the blissymbol-interest board was displayed in the classroom throughout the week.this procedure was followed with all the symbols to be taught. the bliss symbols were presented as follows: * global presentation of the bliss symbol on a flashcard * naming of the symbol * association of the symbol with the objects and pictures * identification of indicators [plural and action indicators] * as soon as all the new symbols were introduced, the teacher made short sentences with the bliss symbols and the children had to read them. new and old symbols were used in the sentences.the teacher also asked comprehension questions, where children had to match the correct picture to the sentence. drill practise: after the groupwork, the teacher worked with the children individually for approximately 10 minutes a day in order to reinforce the meaning of the symbols.the work done in school was sent home and it was expected of the parents to reinforce the sentences at home. the same procedure was followed for the remainder of the time period in which the theme was used.new symbols were introduced every day and objects/toys on the object board were added on a daily basis. testing of symbols for the study: * each child was tested individually on the different occasions at school. the symbols were taught over an extended period of 10 weeks, but due to school and public holidays the period of exposure varied for each theme. during this time some children were also absent for a number of days due to illnesses or personal reasons. see table 3 for detail about exposure time. * baseline testing (before intervention) : in the beginning of a new training period, each child was evaluated to determine if he/she was familiar with the concepts that were to be taught and whether he/she recognized or was able to label the bliss symbols that were going to be taught. three pictures or symbols were presented and the child was requested to point to the specific picture or symbol. as the speech of some of the children was unintelligible, the evaluation of the ability to label bliss symbols had to be adapted. the symbol was presented and the child was asked to label it or to match it with the picture. a choice of three pictures was given once again. items that were indicated by trial and error were repeated in order to increase reliability. at the end of each period of teaching, the same procedure was followed to evaluate the number of concepts learned as well as the children's ability to recognize and label newly taught symbols (middle evaluation). a final evaluation (two weeks after intervention stopped) of all the concepts and symbols taught since the begintable 3. symbols taught during each period period 1 period 2 period 3 period 4 theme: wild animals insects birds good habits period of exposure (days): 6 days 6 days 8 days 8 days bliss symbols: nouns elephant monkey lion giraffe rhinoceros hippopotamus bee butterfly grasshopper museum duck owl ostrich parrot dentist teeth hair vegetables fruit milk verbs swing sit run bath is fly jump swim y brush eat drink other big small on high fast i my the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the use of bliss symbols as a first step into literacywith four children with down syndrome 27 ning of the period was conducted to determine how much was retained over this period. finally, an analysis was made 6 months later to determine progress in terms of bliss reading. results and discussion figures 1, 2, and 3 represent the global results of all 4 c a n d i d a t e s over the eight weeks as regards their scores on the baseline, middle and final evaluations of the concepts introduced, ability to recognize and label bliss symbols. from this diagram it is clear that all four children showed an increase in their understanding of the concepts over the 8 weeks. it is interesting that two of the c a n d i d a t e s , subject 2 and 3, showed slightly less understanding (9% and 8%) in the final evaluation than in the middle evaluation. this decrease could be because concepts were not internalized well enough before proceeding to the new concepts resulting in the elimination from short term memory. from figure two it is evident that 2 candidates did not recognize any symbols before training started, while two candidates recognized 32% and 40% respectively. once again, it is clear that all the candidates scored better in the final evaluation. as in the previous figure, candidates 2 and 3 again showed a slight decrease (2% and 7 %) in performance from the middle to final evaluation. although a smaller decrease than in the conceptual evaluation, this could be explained against the background of information processing models, whereby recognition is seen as a much easier skill in the information processing process (light & lindsay, 1991). a similar pattern is observed in figure 3 where all the subjects showed an increase in the labelling of bliss symbols over the total period. although a labelling response was not only scored on a verbal level (the child could also label by matching the picture to the symbol), it was interesting to note that there was an increase of verbal labelling from one of the candidates. once again, however, subjects 2 and 3 as well as subject 1 in this case, showed a decrease in scores from the middle to the final evaluations. labelling, (being the most difficult of the three skills in terms of information processfigure 2. overall recognition of bliss symbols in baseline, medial and final evaluations. % 100 90 80 70 60 50 40 30 20 10 |= t/ i / 'a / / ̂ / / / i= |= a * / l / / 1 0 i 1 1 2 i 3 4 baseline medial final 40 97 100 0 95 93 32 100 93 0 84 96 subject baseline 7ζά medial i i 1 1 i 1 1 ii 1 final figure 1. overall conceptual performance of the subjects. subject • baseline έζά medial w final figure 3: overall labelling of bliss symbols in baseline, medial and final evaluations % 100 90 80 70 60 50 40 30 20 1 0 0 baseline medial final 29 95 8 2 baseline 7ζά medial i i i | i 1 1 1 1 1 final 0 95 85 i i / 29 100 83 subject 0 78 83 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 erna alant ing and production) was most affected by the two week time lapse before final testing. although bliss symbols have been criticized for being more difficult for children to learn than other symbol systems e.g., pics and rebus ( goosens, 1983; hurlbut, iwata & green, 1982), most of the children in this study were able to learn the different symbols. the retention of concepts and symbolic skills over eight table 4. qualitative description of subjects' symbol errors more complex less complex less complex more complex is λ φ say a 0 jump a r v grasshopper a a a r > run λ walk a eat a 0 a drink sit l λ ~ί chair | ^ eat <ol teeth brush / ι i * sit 1—ι fruit ^ vegetables duck χ bird x small v i h i s a a + ostrich χ / ν legs/walk father ^ ^ mother ^ ^ dentist j 4 w teeth w ball θ c i r c l e © d o vegetables 6 fruit ^ hair ' φ l i o n > i<r_ λά c j elephant λ ά ζ nose j on ν γ sit 1—grasshopper λλλ jump r\ similar le vels of complexity bee οbutterfly ( x ) duck χ λ jump high ν on v_ dentist 1 t w toothbrush 1 h-1 w s big ν i high v the / a/an \ j big h< i 1, a/an \ the / ' small ν i the / on v t the / •on v above • my j + i l i my man the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) use of bliss symbols as a first step into literacywith four children with down syndrome 29 weeks suggests that the programme provided the children with a stable and functional bliss reading skill (romski, sevcik & rumbaugh, 1985). analysis of symbol errors made by the four children table 4 represents the kind of errors the children made in terms of visual complexity (number of strokes and elements in the symbol; fuller & lloyd, 1987). from this table it is clear that from the 30 errors identified, 63% can be categorized as being visually less complex than the stimulus symbol, 30% can be categorized as visually more complex than the stimulus symbol and 7% stayed constant in terms of complexity. the visual simplifications may be interpreted against the visual perceptual difficulties of the children as all the children had some visual processing problems (refer table 2). it also can be an attempt at reducing complexity in order to reduce overload of the cognitive system (light & lindsay, 1991). this finding is in accordance with the research done by fuller & lloyd (1987) in which they found that complexity has a detrimental effect on the learning of symbols. it is, however, interesting to note that all the errors that were made were not reduction errors. 30% of the substitute symbols were more complex than the original stimuli. table 4 suggests that the meaning of the concept and the transparency of the symbol were the main criteria for selection of a symbol. for example, the symbol for jump is substituted with grasshopper. the symbol for grasshopper is a much stronger sign for indicating jumping as it has repetitive up and down movement (zigzag). the symbol for eat is substituted for drink and teeth. a strong semantic similarity exists between concepts for the child e.g., he eats with his teeth; on instead of sit. it could also be an indication that the children are unsure of the symbols and need more exposure in order to familiarize themselves with them. in particular, it is indicated that the children are confusing verbs and nouns, ignoring the indicators above the symbols. these features could be indicative of too little time spent explaining individual elements to the children or that the children are not grasping the meaning of abstract indicators. children often identified one characteristic or element of a symbol and then generalized it to another e.g., dentist became toothbrush; hair became lion. they were able to recognize the identifying elements, but were less successful in applying them to the correct combined symbol elements. this behaviour could be another attempt at reduction of stimuli (gist recall), although the children were aware that it needed to be combined with another element or symbol. goossens' (1983) findings that suggested that students with a moderate cognitive impairment and no memory problems had more problems with bliss symbols than other graphic representational systems (e.g., pics), also support the higher cognitive demands on the child when learning bliss symbols due to the symbols being less iconic in nature. from this table it is clear that complexity of symbols table 5: sentence reading after 6 months subjects 2 3 4 die by vlieg. [the bee flies.] 100% 100% 67% die by sit op die blom. [the bee sits on the flower.] 100% 83% 100% die sprinkaan spring. [the grasshopper jumps.] 100% 100% 67% die sprinkaan het voelers. [the grasshopper has tentacles.] . 75% 100% 75% die sprinkaan eet gras. [the grasshopper eats grass.] 75% 75% 100% die papegaai is baie mooi. [the parrot is very pretty.] 80% 80% 40% die eend swem i n ' d i e water. [the duck swims in the water.] 83% 100% 83% die volstruis hardloop vinnig. [the ostrich runs fast.] 75% 50% 75% die apie swaai. [the monkey swings.] 100% 67% 100% die apie is klein. [the monkey is small.] 100% 50% 100% die olifant is groot. [the elepha.nt is big.] 75% 100% 100% ek drink my melk. [i drink my milk.] 100% 100% 100% ek eet my groente. [i eat my vegetables.] 100% 50% 75% ek eet vrugte. [i eat fruit.] 67% 67% 67% ek borsel my hare. [i brush my hair.] 100% 75% 75% die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 erna alant (number of elements or strokes) is not sufficient in explaining the behaviour of the children and that the behaviour of the children can only be described when factors like iconicity, exposure time, and teaching strategy are also taken into account. bliss reading performance of the same children after 6 months of instruction table 5 represents the reading done in the classroom after six months' bliss instruction. one of the children left the school during this period, leaving three candidates. from this table it is clear that all three candidates could read the majority of bliss symbols correctly. although these scores do not reveal whether the child understands what he has read, it certainly reflects entrance into the process of reading. although the teacher's subjective evaluation revealed that the children understood what they were reading, a formal study on the children's reading comprehension ability would be of primary importance particularly in view of the proposal by nettelbeck & lally (1976) that cognitively restricted individuals have less efficiency in accumulating and holding signals in order to decode. conclusion generally the children had little difficulty in learning the bliss symbols. an increase in conceptualization, recognition and labelling was noted with all the children. as no controls were used, one cannot suggest that these increases are the results of the implementation of bliss symbols in the classroom. however, the changes indicate gains for the children over a period of eight weeks. one of the children's mode of labelling used during the project also changed from predominantly nonverbal to more consistent verbal labelling attempts which is consistent with other reports on the facilitating effect that aac systems can have on speech development (kangas & lloyd, 1988). the reading fluency in bliss symbolics obtained by the subjects also indicates that this process is worth investigating as an entrance into the process of reading and language enrichment. as most of the concepts introduced are concrete (low level of abstraction), a systematic approach towards extending their conceptual reading is necessary. some systematic planning needs to be done in order to determine at which point bliss symbols should be faded away. at present, however, indications are that extensive work on bliss symbolics needs to be done in order to give the children sufficient exposure to conceptual reading and to reinforce receptive skills. the symbol errors indicated that transparency as well as the complexity of symbols were important characteristics in understanding the errors made by the children. confusion between symbols of similar meaning occurred which could either indicate not enough exposure to particular symbols or that too many symbols were introduced too soon. when observing the overall success in recognition and labelling of bliss symbols, the last alternative seems unlikely. finally, it was clear that there were several symbol confusions that occurred due to the children not being able to remember the differentiating indicators of the bliss symbols (for example, chair instead of sit). this could indicate the necessity of more focus on element training in the bliss programme to ensure that the children learn to analyze and synthesize symbol elements in order to facilitate more extensive entrance into bliss reading. the use of bliss symbolics as an entrance into literacy highlights many issues in relation to the process of learning to read, particularly in severely handicapped children. these issues vary from the evaluation of the most effective way to introduce, extend and eventually fade the use of bliss symbols to the understanding of the information processing skills of the cognitively restricted person. in these ways, the use of bliss symbolics not only facilitates the children's language development, but also contributes to the development of new information regarding the process of reading acquisition. acknowledgements the assistance of enid moolman in the fieldwork and preparation of the study is highly appreciated. the co-operation of the teachers at the nursery group for children with language and hearing problems, university of pretoria, is also much appreciated. references beery, k.e. 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(1985) discrimination of lexigrams and traditional orthography by nonspeaking severely mentally retarded persons. american journal on mental deficiency, 90(2), 185-189. shepherd, t.a. & haaf, r. (1992). a comparison of two training methods of bliss symbols. paper presented at isaac conference, philadelphia. stoel-gammon, c. (1990). down syndrome. asha, 32, 42-44. underwood, g. (1978). strategies for information processing. london: academic press. van kleeck, a. (1992). language assessment and intervention in children. guest lecturer, department of speech pathology and audiology, university of pretoria. wishart, j. g. (1990). learning to learn: the difficulties faced by infants and young children with down syndrome. in w.i.fraser, (ed.); key issues in mental retardation research. london: routledge. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ο p l a y x a n d m s c h o o l r o o m m s h o p 6 l t h e r o s e b a n k m e w s 1 7 3 o x f o r d r o a d r o s e b a n k j h b . tests, programmes, books, teaching aids, journals and resources for child development speech & language learning disabilities special needs p h o n e 7 8 8 1 3 0 4 adult rehabilitation p o b o x 5 2 1 3 7 f a x : 8 8 0 1 3 4 1 social activities s a x o n w o l d f a x : 8 8 0 1 3 4 1 social activities 2 1 3 2 / the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) articulation in apraxia of speech beverley ann lister, b.a. (sp. & h. therapy) (witwatersrand) psychological and guidance services, transvaal education department, southrand, johannesburg summary in an attempt to show that aphasics with apraxia of speech have characteristic articulatory patterns, two aphasics with apraxia of speech, and one subject with articulatory problems related to his sensory aphasia, underwent articulation testing. a quantitative measure of distance between error sound and target sound showed that the types of aphasics did not differ on distance, and apraxics could therefore not be said to be closer to the target sound than a sensory aphasic. however, the more severe the communication disorder, the higher was the distance score. a qualitative analysis of the data revealed that the apraxics had substitutions of phonemes as their major error, whereas in the subject without apraxia, substitutions were as prevalent as other errors such as reversals, omissions, augmentations. aphasics with apraxia of speech may be said to show characteristic types of errors. opsomming in 'n poging om aan te toon dat afatiese persone met apraksie van die spraak karakteristieke artikulatoriese patrone het, het twee afatiese persone met apraksie van die spraak en een proefpersoon met artikulatoriese probleme verwant aan sy sensoriese afasie, artikulasietoetsing ondergaan. 'n kwantitatiewe meting van afstand tussen foutiewe klank en doelklank het aangetoon dat afatiese tipes op afstand nie verskil nie; daarom kan daar nie aangeneem word dat die apraktiese persoon nader aan die doelklank is as die persoon met sensoriese afasie nie. hoe erger die kommunikasiesteuring egter was, hoe hoer was die afstandtelling. 'n kwalitatiewe analise van die gegewens het openbaar dat waar die apraktiese persone se primere fout foneemsubstitusie was, by die proefpersoon sonder apraksie daarenteen substitusie net so algemeen voorgekom het as foute soos omkerings, elisies en toevoegings. daar kan aangeneem word dat afatiese persone met apraksie van die spraak karakteristieke foute begaan. in 1968, darley7 described the field of apraxia of speech as one in which terminological confusion abounded. eight years later it would appear that there has been no resolution of this confusion, this writer finding in the literature more than 15 different terms for the manifestations of an apraxia of speech. these include cortical dysarthria,1 phonetic disintegration,29 apraxia dysarthria,24 articulatory apraxia,11 oral apraxia,10 facial apraxia,12 verbal apraxia,3 2'3 3 sensory-motor impairment,2 5'2 8 pure motor aphasia,3 and afferent kinesthetic aphasia.20 these reflect the diverse modes of thinking among writers. it also reflects to some extent how apraxia, dysarthria and aphasia are inter-related and how some authors have found it difficult to differentiate one from the other, seeing aspects of one in the other, elg. apraxia dysarthria, afferent kinesthetic aphasia. apraxia often accompanies motor aphasia, 3 ' 1 0 ' 1 2 ' 3 3 and the writer is of the opinion that this may have contributed to the difficulty of separating at least these two from each other. dysarthria may also accompany journal of the south african speech and hearing association vol. 23. december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) articulation in apraxia of speech 61 apraxia9'24 and it has been reported that apraxia of speech is occasionally found with sensory aphasia.4'5'9 recently, apraxia of speech has been defined as a non-linguistic sensory-motor disorder of articulation characterized by impaired ' . . . capacity to program the positioning of the speech musculature and the sequencing of muscle movements for volitional production of phonemes.'26 this definition appears to be fairly comprehensive, and is the one accepted by the writer. martin,21 however, feels that apraxia of speech cannot be non-linguistic, while others 1 7 ' 3 4 prefer to think of apraxia as a purely motor disorder without sensory involvement. despite the disagreement and confusion in studies in apraxia of speech, certain characteristics do emerge as fairly well agreed upon in the literature: 1. there is absence of significant weakness, paralysis and incoordination of the speech apparatus.7 2. as a result of the disturbed motor speech programming,4'5 apraxics grope for the correct positions of the articulators7'8'9 and the result is often omission, substitution or distortion of the p h o n e m e s . 9 ' 1 7 ' 2 0 ' 2 8 3. errors are inconsistent,7'9 and are not 'blind', i.e. their articulation attempts usually approximate the desired sound closely.5'32 in order to describe to what extent errors do approximate the target phoneme, trost and canter32 calculated the distance of the error sounds of apraxics on a 4-feature system of place, manner, voicing and oral/nasal emission. however it is felt that this system of analysis could not give a true reflection of 'closeness' by virtue of the fact that on this scale voiced/voiceless, a two-dimensional category, is weighted equally with a manner or place category which has 6 alternatives in english. lecours and lhermitte19 carried out a similar analysis on the speech of jargon aphasics and found similar results to trost and canter,32 i.e. that jargon aphasics also closely approximated their target sound. the method of analysis of the data was probably a factor in these seemingly contradictory results. martin and rigrodsky22 further confused the issue by apparently considering the latter two experiments as being ones in which the same kinds of subjects (ss) were tested. canter,4 however, has claimed that aphasics with apraxia of speech are closer in distance to the target sound than sensory aphasics. the writer felt there was thus an indication for the need to study the articulation errors of both apraxics and aphasics without apraxia, using a common and more sensitive method of analysis. method hypotheses 1. apraxics of speech are closer in distance to the target sound than are aphasics with articulation problems other than apraxia of speech. 2. a qualitative analysis of speech utterances will reveal differences between apraxics and aphasics with other kinds of articulation trends. criteria for subject selection the limited number of ss available necessitated broad criteria of selection. all ss were required to be: • tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23. desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 beverley lister 1. aphasic, as diagnosed by a speech therapist and a neurologist and further assessed as such by the experimenter (e) and results of the boston diagnostic aphasia examination.14 2. physically able to undergo testing. 3. reported to have articulatory difficulties and/or an apraxia by their speech therapists. subjects three aphasic ss participated in the study. relevant information concerning the ss is tabulated in table 1. subjects mrs μ mrs κ mr g sex female female male age 45 25 68 handedness before at present right left right right right right previous occupation manicurist housewife self employed in mining field present occupation unemployed housewife unemployed level of education std 8 std 8 matric date of onset july 1974 may 1975 june 1972 therapy since july 1974 none at testing since july 1972 etiology vascular. arteriosclerosis in carotid artery hypercholesterolemia vascular. 1 occlusion, in branch of middle cerebral artery after childbirth. vascular./ embolus to left parietal cortex. history of high blood pressure, fibrillations. table i: relevant information from case histories of aphasic subjects. journal of the south african speech and hearing association, vol. 23, december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) articulation in apraxia of speech 63 apparatus and procedure the number of sessions with each patient varied in accordance with the severity of the problem. where the communication handicap was more severe it was necessary to have shorter, more frequent interviews, to reduce the element of fatigue. in addition the ε had to be fairly flexible in administering the tests in order that the ss would not become traumatized by failure. tests administered: a. the boston diagnostic aphasia examination14 as it gives a comprehensive profile of patients on all levels of higher cortical functioning. b. articulation tests. trost and canter32 used the templin-darley test of articulation.30 ε was of the opinion that the black and white pictures used in this test were not suitable for aphasic patients as they detracted from the clarity of the object depicted. in addition, many of the pictures depicted objects more common in america, or representing americanisms, e.g. gopher, sled. the test devised by ε consisted of 61 words, representing the 24 phonemes of english in initial, medial and final position. common monosyllabic words which could easily be portrayed were chosen. the clear, simple pictures were displayed on 4" by 3" cards. it was not possible to meet all the criteria in regard to certain phonemes in the medial position, and 2 or 3 syllabic words had to be used, e.g. medial /b/ = rabbit, medial /t// = matches. 59 of the words used appeared in the thorndike-lorge list of 30,000 common words.31 those not appearing were 'pram' and 'mealie', mealie being the south african word for maize which did appear in the list and pram a word which is in common use now, but might not have been in 1931 when the list was devised. it was felt that if certain stimulus conditions were found to be more favourable than others in eliciting responses, this could have important implications for therapy. in addition, the type of s and the influence of the stimulus conditions on them might reveal interesting findings. thus the articulation test was administered over 5 conditions: 1. naming the pictures. 2. naming the pictures with the word printed underneath in 1 inch black lettering. 3. naming the picture with the ε simultaneously presenting a related sentence auditorily with each picture. 4. naming the picture with the sentence presented auditorily and the word printed beneath. 5. naming the picture with the model given by ε i.e. on imitation. all responses were recorded on a national tape recorder (model r.q. 7065). the pictures were so arranged that initial, medial and final position phonemes were randomly distributed through the sample. each s was tested in the same order of conditions, i.e. the order listed above. the test was not given over more than two conditions in one session in order to control to some extent for practice effect. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 beverley lister in orcler to measure the degree of similarity or distance between any two phonemes, the phonemes were described in terms of their distance features and these features were then divided into 2 sections, those comprising manner of articulation (see figure 1) and those comprising place (see figure 2). it has been stated in the literature that place errors are the most common in the speech of apraxics.25'32 ρ t h c k b d v j g f θ s ν s ν 2 s ζ 1 r m 11 i) w y nasal + + + voice + + + + + + + + + + + + + + + continuant + + + + + + + + + + + + + delayed release consonantal + + + + + + + + + + + + + + + + + + + + + vocalic + + strident + + + + + + + + figure 1: distinctive features of manner of articulation of the consonant phonemes of english ρ t h v c k b d v j g f θ s ν s ν ζ ζ 1 r m η q w y coronal + + + + + + + + + + + + + anterior + + + + + + + + + + + + + + back high + + + + + + + + lateral figure 2: distinctive features of place of the consonant phonemes of english / two tables were then drawn up to calculate the difference between each phoneme. table ii shows distances of place and table iii shows distances of manner. from these tables, for example, the distance between /f/ and /0/ may be said to be 1 , i.e. /f/ is minus ( ) coronal, whereas /0/ is plus (+) coronal while they do not differ on other features of place. theylare also a distance of 1 apart on manner, as /f/ is + strident and /0/ strident.27 thus it was possible to quantitatively state the difference between error sound and target sound in the responses on the articulation tests. journal of the south african speech and hearing association, vol. 23 december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a r t i c u l a t i o n in a p r a x i a of s p e e c h ρ t h c k b d τ g f θ s s v \ 7 ν ζ 1 r m η ί w y y 2 3 1 1 1 2 3 1 1 2 3 3 1 2 3 3 1 4 2 2 3 1 2 0 w 0 1 1 3 3 0 1 3 3 0 1 1 3 0 1 1 3 2 2 0 1 3 0 q 3 4 2 2 0 3 4 2 0 3 4 4 2 3 4 4 2 5 3 3 4 0 η 1 0 2 2 4 1 0 2 4 1 0 0 2 1 0 0 2 1 1 1 0 m 0 1 1 3 3 0 1 3 3 0 1 1 3 0 1 1 3 2 2 0 r 2 1 1 1 3 2 1 1 3 2 1 1 1 2 1 1 1 2 0 1 2 1 3 3 5 2 1 3 5 2 1 1 3 2 1 1 3 0 ζ 3 2 2 0 2 3 2 0 2 3 2 2 0 3 2 2 0 ζ 1 0 2 2 4 1 0 2 4 1 0 0 2 1 0 0 * 1 0 2 2 4 1 0 2 4 1 0 0 2 1 0 ν 0 1 1 3 3 0 1 3 3 0 1 1 3 0 ν s 3 2 2 0 2 3 2 0 2 3 2 2 0 s 1 0 2 2 4 1 0 2 4 1 0 0 θ 1 0 2 2 4 1 0 2 4 1 0 f 0 1 1 3 3 0 1 3 3 0 g 3 4 2 2 0 3 4 2 0 v j 3 2 2 0 2 3 2 0 d 1 0 2 2 4 1 0 b 0 1 1 3 3 0 k 3 4 2 2 0 ν c 3 2 2 0 h 1 2 0 t 1 0 ρ 0 table ii: measures of distance in place of articulation between the consonant phonemes of english tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23. desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 66 beverley lister ρ t h v c k b d v j g f θ s s v i ζ ν ζ 1 r m η 1 w y y 3 3 1 5 3 2 2 4 2 3 2 3 3 2 1 2 2 2 2 3 3 3 0 0 w 3 3 1 5 3 2 2 4 2 3 2 3 3· 2 1 2 2 2 2 3 3 3 0 γ) 2 2 4 4 2 1 1 3 1 4 3 4 4 3 2 3 3 3 3 0 0 0 η 2 2 4 4 2 1 1 3 1 4 3 4 4 3 2 3 3 3 3 0 0 m 2 2 4 4 2 1 1 3 1 .4 3 4 4 3 2 3 3 •3 3 0 r 3 3 3 5 3 2 2 4 2 3 2 3 3 2 1 2 2 0 0 1 3 3 3 5 3 2 2 4 2 3 2 3 3 2 1 2 2 0 ν ζ 3 3 3 3 3 2 2 2 2 1 2 1 1 0 1 0 0 ζ 3 3 3 3 3 2 2 2 2 1 2 1 1 0 1 0 ι 2 2 2 4 2 1 1 3 1 2 1 2 2 1 0 ν 3 3 3 3 3 2 2 2 2 1 2 1 1 0 ϊ 2 2 2 2 2 3 3 3 3 0 1 0 0 s 2 2 2 2 2 3 3 3 3 0 1 0 θ 1 1 1 3 1 2 2 4 2 1 0 f 2 2 2 2 2 3 3 3 3 0 g 1 1 3 3 1 0 0 2 0 j 3 3 5 1 3 2 2 0 d 1 1 3 3 1 0 0 b 1 1 3 3 1 0 k 0 0 2 2 0 v c 2 2 4 0 h 2 2 0 t 0 0 ρ 0 table iii: measures of distance of manner of articulation between the consonant phonemes of english. 1 journal of the south african speech and hearing association, vol. 23, december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) articulation in apraxia. of speech 67 this method was chosen in preference to those described by some a u t h o r s . 1 6 ' 1 9 ' 3 2 as has been discussed, their measures were not felt to reflect distance adequately. a similar method to the one used in this study was used by martin and rigrodsky,2 3 but it was not utilised here because they did not differentiate between place and manner features, a distinction which ε felt might yield an important differentiating factor between aphasics with apraxia of speech and aphasics with other kinds of articulation problems. the distance scale could not be used when: 1. ss substituted a consonant cluster for a phoneme, e.g. klaisn/laisn. 2. ss omitted the target phoneme. 3. ss substituted an associated word for the target word e.g. bluu/yelsu. 4. when the s was obviously perseverating. 5. when ss used a jargon word which could not be related to the target word by e. when these words were eliminated from the data it was no longer possible to have a straight comparison of total distance scores in different categories, e.g. initial, medial and final, as there was an unequal number of words in the different groups. all scores were then converted to the percentage of incorrect features of the total number of possible features. the total number of features possible was the number of phonemes under consideration multiplied by the number of features used, i.e. 12 (see figures 1 and 2). scores could then be compared. the number of errors made varied between ss. to test whether aphasics with apraxia of speech are closer in distance to the target sound than are aphasics with articulation problems other than apraxia of speech (in this case a sensory aphasic, as diagnosed on the boston examination), ss were only compared on phonemes where both had made errors; thus mr g and mrs μ were compared on 31 utterances, mr g and mrs κ on 7, and mrs μ and mrs κ on 7 utterances. in accordance with hypothesis 2, all the data from the articulation testing were qualitatively assessed and occurrence of characteristics such as perseverations, reversals, word and sound substitutions, simplifications and augmentations were noted. results and discussion a. the boston diagnostic aphasia examination14 in terms of the classificatory system of the authors, the examination yielded the following profiles. 1. mr g: a profile of wernicke's aphasia with the 'most critical features. . . (of) impaired auditory comprehension and fluently articulated, but paraphasic speech', with reading and writing severely impaired as well. on the .. aphasia severity rating.scale he received a rating of 2, which is described as follows: ' . . . frequent failures to convey the idea, but patient shares the burden of communication with the examiner'.14 in this paper, mr g will be referred to as a sensory aphasic, and is understood to have articulatory problems not due to an apraxia of speech'. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 68 beverley lister 2. mrs m: a profile of conduction aphasia where the ' . . . outstanding speech difficulty is in the proper choice and sequencing of their phonemes, so that literal paraphasia constantly interferes with production'.14 repetition is impaired, auditory comprehension is high, and reading and writing scores are also somewhat depressed. mrs μ was also rated a score of 2 on the severity rating scale. goodglass and kaplan14 equate conduction aphasia with luria's afferent motor aphasia, which he describes as a disturbance of the ability to articulate and to use speech when primary oral movements are intact.2 0 luria feels that to consider the disorder of motor aphasia in relation to the motor disorder of apraxia is a progressive step and he in fact uses the term of apraxia specifically in connection with afferent motor aphasia. in this paper conduction aphasia14 and afferent motor aphasia20 will be referred to as an apraxia of speech. 3. mrs k: her profile also appeared to correspond with that of the conduction aphasia described above, although scores were less depressed and she received a severity rating of 4 — described as 'some obvious loss of fluency in speech . . . without significant limitation on ideas expressed of form of expression'.4 b. articulation tests distance measured between mrs μ and mr g over 31 utterances showed that there was only a small difference in the number of feature errors produced, mrs μ having 102 errors, while mr g had 106 errors. the difference between mrs κ and mrs μ was much large, despite the fact that both had been diagnosed as having apraxia of speech. the difference in the number of feature errors between mrs κ and mr g was 14, as opposed to the 11 point difference between mrs κ and mrs m, indicating that mr g and mrs μ were at a similar distance from mrs κ on feature errors. results are shown in table iv. from these results, it may be postulated that it is not the disorder itself which results in a farther or closer distance from the target sound, but the severity of the disorder. mrs κ had been rated as having only a mild impairment on the boston examination, whereas mrs μ and mr g had been rated equally on the severity rating scale. of interest were the similar and sometimes identical errors of the ss, e.g. mrs μ and mrs κ respectively: pig = b3k, p3k; soldier = jauku/saulda ; bucket = batst, batas; nest = mest, met; mrs μ and mr g: vase = fals, faz; mr g and mrs k: mouse = mau0; birthday = p30dsi, b30ds , / / these results appear to clarify, to some extent, distance scores. it was not closeness to the target that was the most important differentiating factor in articulation, for all could be demonstrated.as making similar errors, but it was the total number of words which contained errors directly related to severity that was important. individual scores show that for mrs κ the naming task was most difficult, and the cueing, especially involving some auditory stimulus, facilitated the correct response. she had the greatest number of errors in medial position and more journal of the south african speech and hearing association, vol. 23 december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) articulation in apraxia of speech 69 number of subject place manner distance total utterances mr. g 47 59 106 31 mrs. μ 54 48 102 mrs. μ 15 12 .27 7 mrs. κ 5 11 16 mrs. κ 5 8 13 7 mr. g 11 16 27 table iv: between s comparison of total distances of error sounds from target sound errors of feature of manner than of place. she experienced least difficulty in phonemes in initial position. see table v. naming picture picture and printed word picture and auditory stimulus picture word and auditory stimulus picture and imitation total initial ,49 0 0 0 1,85 ,47 medial 1,96 ,93 1,39 2,31 0 1,14 final 3,24 0 ,93 0 0 ,83 total % errors 1,92 ,31 ,47 ,79 ,62 no. feature errors = 26. comprising 6 place errors and 20 manner errors table v: total distance scores expressed as the percentage of incorrect features: mrs k. mrs μ also had greater difficulty in the naming task and responses on imitation were somewhat better than those following other forms of cueing. (see table vi). the latter seemed to facilitate responses more or less equally. the results over the different situational variables support the findings of johns and darley,17 who found that mode of stimulus presentation affected the articulatory performance of apraxics, as opposed to deal and darley9 who found that situational variables had no effect on phonemic accuracy. mrs μ also had more difficulty on phonemes in medial position. although most studies have reported that initial position is the most difficult for apraxics of speech, 5 ' 8 ' 2 9 ' 3 2 a study by la pointe18 did find, as did johns and darley,17 that no single position in a word was characteristically more difficult. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol 23. desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 beverley lister naming picture picture and printed word picture and auditory stimulus picture word and auditory stimulus picture and imitation total initial 12,18 7,35 4,4' 5,56 6,83 medial 17,26 1,04 3,92 6,37 7,8 7,8 final 1,96 5,09 3,7 1,56 2,3 2,97 total % errors 9,85 4,55 4,01 4,58 5,28 no. feature _ errors 166. comprising 83 place errors and 83 manner errors table vi: total distance scores expressed as the percentage of incorrect . features : mrs m. it is important to note that words in which medial position was tested were longer and had more syllables than those in which initial and final position were tested. it has been claimed that apraxics are negatively affected by word l e n g t h , 7 ' 9 ' 1 7 ' 2 8 and find polysyllabic words more difficult than monosyllabic.8 thus, scores in this area might have been a reflection of these factors, and not the position of the phoneme as such. however, by virtue of its position, a medial phoneme implies a transition from one phoneme to another, and is often in the position v c v. apraxics of speech.are felt to have difficulty in transitions in the co-ordinated sequencing of several articulators,3'5'2 8'2 9 and this would support the finding that a phoneme in the medial position presents more difficulty. mrs μ demonstrated the same number of place errors as errors of manner of articulation, while mrs k, as mentioned above, had more manner errors than those of place. these results are contrary to those of trost and canter32 and osgood and miron25 who considered errors of place to be most common. the limited number of ss and the fact that their results were dissimilar introduced a limitation with regard to drawing any conclusions from these results. an important factor in obtaining different results from those reported in the literature, is the different form of analysis used in this study. one point of difference is that voicing is considered an aspect of manner, whereas in pther studies, 1 6 ' 1 9 ' 3 2 it has been rated as a separate category. this in itself may have affected the results significantly. mr g's greatest difficulty occurred on the naming task, and on naming with an auditory stimulus, with the latter presenting slightly more difficulty,(see table vii) it appeared that his responses were often influenced by the sentence which the ε had given together with the presentation of the picture. the phonemes from the more significant words in the given sentence found their way into his response. the added cue of the printed word seemed to have the effect of overcoming this intrusion to some extent, as he concentrated on the journal of the south african speech and hearingassociation, vol. 23, december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) articulation in apraxia of speech 71 visual image. he had almost equal difficulty with phonemes, whether they occurred in initial, medial or final positions, with slightly more difficulty on final position. martin and rigrodsky22 emphasize the difficulty of final position for aphasics, but there is little other evidence of such findings in the literature. mr g had more place errors than those of manner, and this is consistent with findings of other studies of sensory aphasics.15'13 naming picture picture and printed word picture and auditory . stimulus picture word and auditory stimulus picture and imitation total initial 18,1 8,33 17,95 11,98 12,96 13,69 medial 26,04 9,9 29,17 11,9 9,72 14,7 final 30 4,17 27,56 5,1 8,3 14,79 total % errors 24,17 7,62 24,26 9,38 10,64 no. feature errors = 372. comprising 196 place errors and 176 manner errors table vii total distance scores expressed as the percentage of incorrect features: mr g. in analysis of types of errors produced, some trends emerged. mrs κ tended to reduce affricates, either to their fricative component or more often, to their stop component, e.g. d / d^. fricatives were sometimes complicated by making them affricates, e.g. +}lf , and she frequently made an error of voiced/voiceless, e.g. k/g, p/b, and z/s. nasals jmj, /n/ and /η/ were often confused. in terms of categories of stop, fricative, nasal, resonants, mrs κ was not observed to make confusion between categories, but only between phonemes within these categories, e.g. 1/r. the category of affricate, by definition, consists of both a stop and a fricative quality, and it was only between the categories of stop and fricative across affricate that mrs κ substituted phonemes across categories, e.g. +/ff . omissions were also present in her speech, e.g. zeba/zebra. in mrs m's responses, trends were less clear. although her errors tended to be within the categories mentioned above, she had frequent substitutions across categories, e.g. t/m, g/n, g/v, w/1, r/d. she also made errors of voiced/voiceless features, e.g. p/b, but these were not as frequent as some other errors. she had difficulty with nasals, which supported a finding of shankweiler and harris29 in their study of apraxics of speech. she also experienced difficulty with affricates and confusion among fricatives, as did mrs k. this difficutly with fricatives and affricates seems to be a finding which is well supported by other studies. 8 ' 9 ' 1 8 ' 2 9 mrs μ also demonstrated^omissions e.g. paem/praem, daef/dgsrasf as well as complication of sounds skr/s, t / / + , as mrs κ had done. an interesting phenomenon in mrs m's speech was the introduction of j\j and /r/ into a cvc structure, making it ccvc. it appeared that these phonemes were used tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23. desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 beverley lister as 'helpers' to facilitate the transition from a consonant to a vocoid. that these sounds may facilitate the transition is supported by the fact that /l/ and /r/ are the only two consonants which have vocoid properties. examples of the use of these are gault/gsut; droa/doa; krid^/ksidx plaet/az/maet/sz. examples of reversals of letters were /op/wot/ and d^aesb/ssldjs and perseveration of letters — mimiz/miliz; rariau/rsidrau. generally, the error demonstrated most frequently by the apraxics was one of substitution which is in agreement with the observations made by a number of workers.8'9'2 0 errors of augmentation of phonemes, and omissions were present to a lesser extent, while reversals and perseverations were relatively rare. anticipations were not observed in the apraxics. mr g's responses, however, were characterized by numerous neologisms, e.g. taundal/d^srasf; verbal paraphasias, e.g. donki/zebra; bluu/yebu; reversals, puus/suup; kenz/nest; ksit/rsik; and perseverations, e.g. faul, faub, fauzsl. he did not demonstrate perseverations on a phoneme level as mrs m. had done. anticipations which occurred were febfsun/tebfaun; paep/taep. he also showed omissions e.g. fesz/fe&z and augmentations, e.g. k'apst/kap. his substitution errors were both of the within and between category kind. he tended to pluralize a number of words, e.g. pigz/pig; b3dz/b3d; bolz/bol when there was only one object depicted. he frequently responded with the diminutive form of a word, e.g. praemi/praem; b3di/b3d; doki/dog; 0amzi/0am, which is interesting in terms of the theory of errors in aphasics being a reflection of acquisition in childhood. 1 2 ' 1 3 from the description of individual differences, the writer feels that what emerges as the differentiating factor between apraxics and the sensory aphasic (mr g) is not the distances between their errors and the target sound, but the fact that in the sensory aphasic the error of substitution is but one of many other characteristic errors, e.g. perseveration, whereas in the aphasic with apraxia of speech it is the major error. it is interesting to note, however, that aphasics with apraxia of speech, a so-called motor disorder, had poor scores on a test of oral stereognosis. this is perhaps an indication that the term sensori-motor would be more applicable. conclusion it did not appear that aphasics with apraxia of speech were closer in distance to the target sound than sensory aphasics, as suggested by canter.4/these findings might have been the result of the more subtle analysis utilize'd in this study, i.e. a distinctive feature system. it seemed that the differentiating factor between the apraxics and the sensory aphasic was not distance, but frequency of other errors such as perseveration, reversals and verbal paraphasias in the ss. the ss with apraxia of speech made errors,of substitution more frequently than other errors, while the sensory aphasic made as many substitution errors as those of perseveration, reversal, neologisms and augmentations. it would seem that it is not possible to use distance as a method of diagnosing different types of aphasics. journal of the south african speech and hearing association, vol. 23 december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) articulation in apraxia of speech 73 references 1. bay, e. (1964): principles of classification and their influence on our concepts of aphasia. in disorders of language. ciba foundation symposium. de reuck, a.v.s. & o'connor, m. (eds.). churchill ltd., london. 2. brain, lord (1965): speech disorders (2nd ed.) butterworths, london. 3. brown, j.w. (1972): aphasia apraxia and agnosia: clinical and theoretical aspects. charles c. thomas, springfield, illinois. 4. canter, g.j. (1969): the influence of primary and secondary verbal apraxia on output disturbances in aphasic syndromes. paper presented to the annual convention of the american speech and hearing assocition. 5. canter, g.j. (1973): dysarthria, apraxia of speech and literal paraphasia: three distinct varieties of articulatory behaviour in the adult with brain damage. paper presented to the annual convention of the american speech and hearing a ssociation. 6. darley, f.l. (1964): diagnosis and appraisal of communication disorders. prentice-hall, englewood cliffs, n.j. 7. darley, f.l. (1968): apraxia of speech: 107 years of terminological confusion. paper presented to the annual convention of the a merican speech and hearing association. 8. darley, f.l. (1970): apraxia of speech: definition, description and appraisal. paper presented to the annual convention of the american speech and hearing association. 9. deal, j.l. & darley, f.l. (1972): the influence of linguistic and situational variables on phonemic accuracy in apraxia of speech. j. speech hear. research. 15 (3) 639-653. 10. de renzi, e.; pieczuro, a.;& vignolo, l.a. (1966): oral apraxia and aphasia. cortex 2, 50-70. 11. eisenson, j. (1973): adult aphasia: assessment and treatment. appleton century crofts, new york. 12. espir, m.l.e.; & rose, f.c. (1970): the basic neurology of speech. salisbury press, oxford. 13. fry, d.b. (1959): phonemic substitutions in an aphasic patient. lang. & speech, 2, 52-61. 14. goodglass, h. & kaplan, e. (1972): the assessment of aphasia and related disorders. lea & febiger, philadelphia. 15. green, e. (1969): phonological & grammatical aspects of jargon in an aphasic patient: a case study. lang, and speech 12, 103-118. 16. hurwitz, l. (1974): a phonological investigation of jargon aphasia. unpublished research report, department of speech pathology and audiology,' university of the witwatersrand, johannesburg. 17. johns, d.f & darley, f.l. (1970): phonemic variability in apraxia of speech./. speech hear. research. 13 (3), 556-583. 18. la pointe, l.l. (1969): phonemic characteristics in apraxia of speech which aid in differentiation among articulation disorders in brain-injured adults. paper presented to the american speech and hearing association convention. 19. lecours, a.r. & lhermitte, e. (1969): phonemic paraphasias: linguistic structures and tentative hypothesis. cortex 5, 193-228. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23. desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 74 beverley lister 20. luria, a.r. (1966): higher cortical function in man. basic books, new york. 21. martin, a.d. (1974): some objections to the term apraxia of speech. j. speech hear. dis., 39 (1)54-63. 22. martin, a.d. & rigrodsky, s. (1974): an investigation of phonological impairment in aphasia. part i. cortex 10 (4), 317-328. 23. martin, a.d. & rigrodsky, s. (1974): an investigation of phonological impairment in aphasia. part ii. cortex 10 (4), 329-346. 24. nathan, p.w. (1947): facial apraxia and apraxic dysarthria. brain 70, 449-478. 25. osgood, c.e. & miron, m.a. (1963): approaches to the study of aphasia. university of illinois press, urbana. 26. rosenbek, j.c.; lemme, m.l.; ahern, m.b.; harris, e.h. and wertz, r.t. (1973): a treatment for apraxia of speech in adults. j. speech hear. dis., 38 (4), 462472. 27. schane, s.a. (1973): generative phonology, prentice hall, englewood cliffs, new jersey. 28. schuell, h. (1965): differential diagnosis of aphasia with the minnesota test, university of minnesota press, minneapolis. 29. shankweiler, d. and harris, k.s. (1966): an experimental approach to the problem of articulation in aphasia. cortex 2, 277-292. 30. templin, m.c. & darley, f.l. (1960): the templin-darley tests of articulation. a manual and discussion of the screening and diagnostic tests. bureau of educational research and service division of extension and. university services, university of iowa, iowa city, iowa. 31. thorndike, e. and lorge, i. (1952): the teacher's word book of 30,000 words. bureau of publications, teachers college, columbia university, n.y. 32. trost, j.e. and canter, g.j. (1970): subphonemic feature analysis of articulatory errors made by patients with verbal apraxia. paper presented at the american speech and hearing association convention. 33. wertz, r.t. and porch, b.e. (1970): effects of masking noise on the verbal performance of adult aphasics. cortex 6 (4), 399408. 34. wilson, a.k. (1908): a contribution to the study of apraxia. brain 31, 164-216. journal of the south african speech and hearing association vol. 23, december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) modern hearing aids (pty) ltd. for hearing aids — a comprehensive range comprising the latest microson directional models — unitron high level compression models — and electone economically priced models. ear moulds — we specialise in ear mould technology to the great benefit of our patients — we also supply instant mould kits to schools. audiometers — audiotone portable screening and diagnostic units at the best prices available. sound proof booths and earmuffs high quality locally manufactured products tv accessories — manufactured by ourselves we are at 165 jeppe str johannesburg tel: 23-9250 305 rand central and 133 central house 288 pretorius str pretoria tel: 2-1206 22-4855 tydskrif van diesuid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 7 the problem of stuttering (continued from page 5) references berry, m. developmental history of stuttering children. j. ped., 12: 209-217 1938. brutten, e. and shoemaker, d. the modification of stuttering. new jersey, prentice-hall, 1967. boberg, e., yendall, l., schopflocher, d., bo-lassen, p. the effects of an intensive behavioural program on the distribution of eeg alpha power in stutterers during the processing of verbal and visuospatial information. j. fluency dis., 8, 245263, 1983. conture, e. observing laryngeal movements of stutterers. in curlee, w. and perkins, w.h. (eds). nature and treatment of stuttering. san diego: college-hill, 1984. cullinan, w. and springer, m. voice initiation and termination times in stuttering and nonstuttering children. / speech hear. res., 23, 344-361, 1980. flannagan, b., goldiamond, i. and azrin, n. operant stutterin the control of stuttering behaviour through response contingent consequences. j. experimental analysis ofbehav., 1, 173-177, 1958. gregory, h. and mangan, j. auditory processes in stutterers. in lass, n. (ed) speech and language advances in basic research and practice, volume 7. new york: academic press, 1982. howie, p., woods, c. and andrews, j. relationship between covert and overt speech measures immediately before and immediately after stuttering treatment. j. speech hear. disorders, 47, 419-422, 1982. ingham, r. toward a therapy assessment procedure for treating stuttering in children. in gregory, h.h. (ed). stuttering therapy: prevention and intervention with children. memphis: speech foundation of america, 1984. kidd, k. genetic models of stuttering. j. fluency dis., 5,187-201, 1980. ludlow, c. and cooper, j. genetic aspects of speech and language. new york: academic press, 1983. meyer, s. and freeman, f. interruptions as a variable in stuttering and disfluency. j. speech hear. res., 28, 428-435, 1985a. meyers, s. and freeman, f. mother and child speech rates as a variable in stuttering and disfluency. j. speech hear. res., 2.8, 436-444, 1985b. moore, w.h. central nervous system characteristics of stutterers. in curlee, w. and perkins, w.h. (eds). the nature and treatment of stuttering. san diego: college-hill press. sheehan, j.g. theory and treatment of stuttering as an approachavoidance conflict. journal of psychology, 36, 27-49, 1953. sheehan, j.g. and costle, m. a reexamination of the role of heredity in stuttering. j. speech hear. dis., 42, 47-59, 1977. siegel, g.m. punishment, stuttering and disfluency. j. speech hear. res., 13, 677-714, 1970. skinner, b. the sciences of human behaviour. new york: appleton-century-crofts, 1953. wischner, g.j. stuttering behaviour and learning: a preliminary theoretical formulation. j. speech hear. dis., 15, 324-335, 1950. the application of the peabody picture vocabulary test — revised (ppvt-r) to non-mainstream children erna alant, d.phil (pretoria) s.m. beukes, ma (pretoria) department of speech pathology and audiology, university of pretoria. abstract this article focuses on the difficulties involved in diagnosing the communication of non-mainstream speakers within a south african context. various alternatives are discussed whereby tests can be made more relevant to this population. the revised version of the peabody picture vocabulary test is applied to a group of afrikaans-dialect speaking coloured children in order to determine the merits of standardizing the jest for this population. the test results are correlated with the accuracy scores on a story. the findings indicate the feasibility of the standardization of the ppvt-r for this population. opsomming die problematiek verbonde aan die diagnosering van nie-standaarsprekers se kommunikasie in 'n suider-afrikaanse konteks word onder die loep geneem verskeie alternatiewe benaderings waardeur die relevansie van toetse verhoog kan word, word bespreek. die hersiene weergawe van die peabody picture vocabulary test is op 'n groep nie-standaard afrikaanssprekende kleurling kinders toegepas ten eindediemerietevan toetsstandaardisasie vir hierdie teikengroep te bepaal. die toetsresultate word met die akkuraatheidstellings van 'n storie gekorreleer. die bevindings dui daarop dat standaardisasie van die ppvt-r vir hierdie populasie uitvoerbaar is. © sasha 1986 die suid-afrikaanse tydskrif vir kommunikasieafwykmgs, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 erna alant and s.m. beukes the difficulties involved in diagnosing the communication problems of the client speaking a non-standard or non-mainstream language have recently received much attention from speech and language pathologists (musselwhite, 1983; wiener, lewnau and erway, 1983; terrel and tertel, 1983). the reason for this widespread interest stems from the realization that very few reliable diagnostic tools are available for the evaluation of communication of non-standard-language speakers (saville-troike, 1973). various authors (erickson and omark, 1981; terrel and terrel, 1983; adler & birdsong, 1983) have expressed their concern with the effect that misdiagnosis (i.e. overcompensation or undercompensation for the language variety) could have on the client in terms of the provision of adequate clinical services. a result of the current awareness of'culturally fair' or 'non-biased' testing is the active search for alternative ways of enhancing diagnostic procedures. the functional approach to diagnosis has become prominent within this context in view of the current psycholinguistic and sociolinguistic theory (erickson and omark, 1981). the emphasis is on the child's natural communication, and contextual evaluations of interactive abilities are advocated. the value of tests as a supplement to functional assessments is stressed, as an integrated diagnosis essentially involves gaining information from more than one source. it is against this background that the limitations of traditional speech therapy tests for use with different populations are recognized and efforts are made to reduce or eliminate the cultural and socio-economic biases in these tests. the revision of the peabody picture vocabulary test (dunn & dunn, 1981) as well as the translation of the auditory comprehension of language (carrow-woolfolk, 1973) are examples of test adaptations aimed at facilitating diagnosis with different groups. the ppvt is described as 'culturally specific' and has a fault factor of at least three years according to taylor (1977), but the revised version has eliminated many of these cultural biases (adler and birdsong, 1983). in a recent article, vaughn-cooke (1983) discusses various ways in which tests can be modified or adapted for use with different groups, although each of these alternatives pose their own problems. the most uncomplicated procedure would be to standardize existing tests for use with a particular group. this approach could, however, lead to the difficulty of coping with 'low norms' in comparison with other groups. a second possibility would be the inclusion of a small percentage of minorities in the standardization sample, as was done in the revised peabody picture vocabulary test (ppvt-r). appropriate representation of a particular group could, however, still be a problem in that only a small percentage of minorities can be included in the standardization sample. a third alternative involves the modification of existing tests in order to make them appropriate for non-mainstream speakers. the difficulties entailed in the modification or revision of tests include inherent problems in providing a comparable form and content of the items that are being changed in order to adhere to the criteria of the original test (saville-troike, 1973; labov, 1972). another possibility would be to develop a new test for use with different groups. although perhaps the most relevant alternative, it is not always practical as expertise and substantial financial assistance is required for the standardization and development of a new test. the last alternative described by vaughn-cooke (1983) is the use of non-standardized language samples and criterion reference measures, as previously discussed. the lack of norms in these evaluations, however, complicates the differentiation between language pathology and the rules of non-standard language. the need for norm referenced techniques in the evaluation process is therefore explicit. vaughn-cooke (1983:33) concludes his review on a rather pessimistic note: "it is not an overstatement,to say that a crisis exists in the area of assessment for non-mainstream speakers. researchers, clinicians and test developers must intensify their efforts to overcome this crisis and meet the need of diagnosticians. diagnosticians do not need more evaluations of the assessment problem, nor do they need more 'interim' solutions. they need valid, reliable assessment tools." the diversity of the south african population emphasizes the relevance of the above statement to speech and language therapists working in this country. not only do therapists lack standardized communication assessment tools, but also descriptions of what constitutes a particular dialect or language variation. the differentiation between language differences and language pathology is further complicated for the therapist working in the afrikaans speech community because relatively little information is available as regards the characteristics, rules and functions of the varieties/dialects of afrikaans (webb, 1984). a sociolinguistic approach in determining the appropriacy of language use would assume that language is a social phenomenon (bartsch, 1982) which is to a large extent context sensitive and norm determined. the vernacular which the children in this study used is a non-standard variety of afrikaans with a set of rules and norms that differs from that of standard afrikaans in some respects. although geographically in close proximity to other afrikaans-speaking communities, this community is almost completely isolated from other afrikaans-speaking communities. sections of eersterust community are dialect speakers of afrikaans, including the lower socio-economic strata of this group which are particularly isolated from the greater afrikaansspeaking community. this isolation was confirmed in conversation with eersterust teachers who stated that many of the preschool children from the area where the research was conducted had never been outside their suburb. in view of the above, this study aims to develop a diagnostic tool for the evaluation of the receptive vocabulary of this community. a provisional translation of the ppvt-r into standard afrikaans was used as a basis for test modifications and adaptations to fit the needs of the community. ι as the ppvt-r was standardized on a sample that included minority speakers, it seemed to provide a logical starting 'point from which further research could be undertaken. although the revised edition had succeeded in eliminating many of the cultural biases, a translation of the test would not necessarily guarantee the same results. the aim of the research therefore centered around the appropriateness of the test items for this particular group of children. the choice of the ppvt-r was further enhanced by the exposure that the test has had in research and translations in other parts of the world (cox and jones, 1985). this contributed towards giving a more realistic idea of the difficulties that would be encountered when dealing with this test. apart fom qualitative analyses of the ppvt-r done in order to determine appropriacy of test material, the results were compared with receptive language scores obtained from another informal language assessment situation (refer appendix 2). as the ppvt-r the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) π * application of the revised version of the peabody picture vocabulary test (ppvt-r) to non-mainstream children is a test of receptive vocabulary it was hypothesized that both these tests should demonstrate some overlap in the ability being assessed. although no attempt could be made to validate the ppvt-r in this context, an association between these two measurements could indicate some potential in the use of these evaluation techniques with this population. method the 77 children included in the study were prospective schoolbeginners in the next year at nantes primary school in eersterust. twenty-four of these children had attended a preschool class at nantes primary school for six months, while the rest of the children had no pre-school experience. the latter were recruited through children attending nantes primary school who were requested to provide the names of relatives, friends and acquaintances who intended enrolling at the school in the following year. all those named by the children were included in the study. only children attending this particular school were tested as one of the aims was to conduct a longitudinal study whereby the same children would be evaluated at the end of their first school year. the children tested all came from the nantes area, which is one of the more deprived areas in eersterust. questionnaires were sent out to the parents of the children to determine their occupations and educational levels and the size of households as a measure of socio-economic status. the age of the children varied between 5,5 and 6,5 with the majority of the children between 5,5 and 6,0 years. all the children in the sample were afrikaans-speaking. the influence of english in this area is relatively small as it is a predominantly afrikaansspeaking community. table 1 gives a more specific description of the subjects used in the study. table 1: description of subjects variable description age y = 5,5 (sd:0,61) s e x y ' male female ί ι 38 39 educational level mother father 1 ± 7,05 (sd:1,39) y = 7,98 (sd: 1,64 pre-school training experience none 6 months 53 24 audiological screeening passed both tests failed both tests 62 15 size of households χ = 5,73 (sd:2,49) determine whether there would be any merit in standardizing the test for coloured children, particularly in view of the pictures, and concepts, used. the use of the ppvts existing norms and iq scores would be evaluated in terms of their appropriacy for this group. the children's performance on the afrikaans ppvt-r would then be correlated with the scores obtained from a comprehension story in order to compare achievements on different measuring techniques. the comprehension story used was that of the 'fox and the crab' (berry, 1969). this story was modified by alant (1984) for use with five and a half year olds in a comprehension situation. the story was lengthened for the purpose of testing by means of including more characters (factual material), while maintaining the basic story together with the inferences required to complete the ending. the story was recorded on video tape (with facial cues and gestures only in order to simulate stories or narratives occurring in normal communication). a nursery school teacher as well as the teachers of the beginners classes at the school were asked to view the tape and to evaluate it in terms of its appropriacy in terms of: — middle class biases to vocabulary and language structures; — cultural prejudice and content; — age appropriacy. some minor changes were suggested after which the story was rerecorded for use in the pilot and main study. procedure the children were occupied in a classroom where they were provided with toys and snacks. this gave the researchers the opportunity to familiarize themselves with the subjects before testing. each child was tested individually and sent home or to the pre-school class after the testing was completed. each was tested on the provisional translation of the ppvt-r. the prescribed procedure was used for the application of the ppvt-r. when, however, the child pointed to the wrong picture, the following procedure was used in order to determine whether the child responded incorrectly because he did not know the 'word' or because he did not understand the concept represented by the particular item. for eg.' step 1: show me . . . if wrong, then step 2. step 2: what is this? (researcher points to any other picture in order to avoid repetition of therapist's stimulus utterance). step 3: what is this? (researcher points to the target picture. the verbalization of the subjects was written down). the children also observed a pre-recorded video-taped story (4 minutes) after which some comprehension questions were asked based on the story. each child was tested individually and probing was used in order to facilitate the answering of the questions, (alant, 1984). materials the ppvt-r was translated by members of the eersterus-project of the department of speech therapy and audiology at the university of pretoria which consisted of speech therapists and a linguist. care was taken to keep the standard afrikaans word as close as possible to the original standard english with respect to semantic characteristics and difficulty and in terms of the visual clues of each test item. the peabody picture vocabulary tests-revised (ppvt-r) was provisionally translated into standard afrikaans (appendix 1) to the test situation all the children were tested in the same classroom of the school. although every possible effort was made to provide a pleasant atmosphere for the children, this more formal situation could have been threatening to some of them, particularly those children who had no pre-school experience (saville-troike, 1973). the use of researchers that were not from the area could also have influenced the children's behaviour (labov, 1972; adler & birdsong, 1983). however, the lack of suitably qualified people from the area necessitated a compromise in this regard (musselwhite, 1983; erickson & omark, 1981). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 erna alant and s.m. beukes data analysis peabody picture vocabulary test revised: the ppvt-r results were scored according to the manual of the test. only the raw scores were used in the analysis as the norms were not suitable for use with this population (taylor, 1977). the raw scores of the ppvt-r were then correlated with the findings of the responses to the questions asked on the comprehension story. all the error items were noted and the children's responses to the items were qualitatively analysed. accuracy of the answers to comprehension questions: four questions were asked, based on the story. these questions were ranked from easy to difficult i.e. from questions demanding immediate reproduction of facts to questions relating to answers based on inferences drawn from the story. the grading of the questions was first tested in alant (1984) and proved to be satisfactory in that the last questions were more demanding than those which preceded them. this was deemed important as easy questions could be motivating in the beginning of the interaction (refer appendix 2). probing: probing was used in order to prevent inhibited children being discredited for lack of understanding. although the effectiveness of probing with' these children could be questioned (labov, 1972; faeggans and farran, 1982) in view of their unfamiliarity with the context and communication situation, reinforcement of verbalizations could contribute to an increase of verbal behaviour (bolton, 1979). a probe was defined as a verbalization from the therapist.followed by a pause during which the child was allowed the opportunity to respond. probing was used when children did not respond or when they responded with 'don't know' or other short replies. non-directive probing was used at first followed by more direct probes depending on how many probes were necessary (refer appendix 2). statistical analysis descriptive statistics were used in order to examine the children's general performance on the ppvt-r and comprehension questions after which a qualitative description of errors was made. correlation coefficients were calculated to obtain a measure of association between the accuracy of responses and the ppvt-r (translated) for various levels of probing. results and discussion figure 1 reflects the general performance (raw scores) of the subjects on the ppvt-r (translated) and table 2 gives the mean and standard deviations for the group. 30· 3 25· & | 15r ζ ιο· 5raw scores 0-15 16-30 31-45 46-60 figure 1: frequency bar chart of the children's performance on the ppvt-r (afrikaans translation) table 2: descriptive statistics of the group's performance on the ppvt-r (afrikaans translation). mean sd std error min value max value of mean ppvt-r (raw 25,73 13,15 7,00 59,00 1,50 scores) from the above figure and table it is clear that the children obtained low raw scores on the ppvt-r, particularly in view of the required raw score of ± 62 stipulated for their age according to the american norms (dunn & dunn, 1981). vaughn-cooke's (1983) concern about the standardization of tests on different populations due to the problem of low norms seems to be relevant in the present study. the low scores on the test necessitate a qualitative analysis of the errors in order to determine the relevancy of the test items for this particular group of children. table 3 gives some indication of the common errors made on the first 25 items (the mean score for this group) while table 4 illustrates interesting differences between the children with and without pre-school training experience. table 3: common responses on some of the first 25 items. item % correct type of response 8: band (tyre) 37 wiel (wheel) 37%, tyre 26% 9: koei (cow) 61 bees (beast) 11% 10: lamp (lamp) 59 lig (light) 33%, globe 3% 15: verband (bandage) 62 voet (foot) 20%, bandage 4% 18: heining (fence) 33 hek (gate) 19%, planke (planks) 10%, fence 6% 22: seil (sail) 36 skip (ship) 36%, (om te) ry (to ride) 10% tables 3 and 4 clearly demonstrate the statement of leeman (1981) that direct translation of test items is problematic because of the different ways in which experience is conceptualized in different cultures and expressed in different dialects/languages. in spite of the revision of the ppvt-r to eliminate cultural biases, it is clear that many of the first 25 items of the provisional translation are biased against these non-mainstream dialectspeaking children. these items contain information and represent concepts that have little relevance to their dialect, culture and socio-economic status. | i item 18 shows that the word heining is relatively unknown to these children. many different responses to this item were recorded, ranging from hek (gate), planke (planks), fence, jaartdraad (yard fence) to stokke (sticks). the variety of lexical items used by these children suggests that the concept of a picket fence is unknown to them. further empirical investigation is necessary to determine what the dialect vocabulary item for fence is. another example in this regard is item 22 (om te) seil(sail) which is pictorially represented by a small sailing-vessel on water. the responses to this picture indicate that the vessel was recognized as a "ship", but that the function of the vessel as expressed in the verb is unknown to them. once again this can be seen as a result of their socio-economic status in that this item reflects information concerning a luxury of middle class lifestyle that goes beyond their immediate experience. the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the application of the revised version of the peabody picture vocabulary test (ppvt-r) to non-mainstream children 11 table 4: interesting differences in some responses between children with pre-school training and children with no pre-school training. children with pre-school training children with no pre-school training item % correct type of response % correct type of response 14: elmboog (elbow) 16: veer (feather) 17: leeg (empty) 19: ongeluk (accident) 26: gereedskap (tool) 27: vierkant (square) 32: koevert (envelope) 49: kraan (faucet) 88 100 80 96 60 100 84 100 hand 8%, arm 4% glas (glass) 12%, koppie (cup) 8% kar(re) (cars) 4% spanner 20% brief (letter) 16% 60 82 62 64 47 47 62 60 hand 40% blaar (leaf) 10% koppie (cup) 26%, glas (glass) 11% kar(re) (cars) 16% spanner 30% blokkie (block) 24% brief (letter) 38% pomp (pump) 40% the same argument holds in the case of item 10 where one third of the children were not able to connect the word lamp (lamp) with the pictorial representation. lig (light) was used as the appropriate lexical item in their dialect, although responses such as blomding (flower thing), glas (glass) and globe were also recorded. the deprived background of these children is presumably again the reason for the high frequency of lig. lig is a generic term for any electrical light appliance. these children obviously do not need to make distinctions between sophisticated electrical appliances. some significant differences occurred between those children who had pre-school training and those who had no pre-school training. the pre-school group exhibited a greater sensitivity for the standard afrikaans word than did the other group. this is presumably the result of exposure to the standard language variety in the formal school situation. more pre-schoolers for example knew the word gereedskap (tool) (item 26) and all of them knew the word kraan (faucet, tap) (item 49) as opposed to the other group of whom 40% used the word pomp (pump). once again socio-economic factors cannot be ignored here. the pictorial representation of this item shows a modern mixer-type bathroom tap of which these children presumably have little or no experience. . ι ι / • / ; one must bear in mind that these interesting differences reflect a greater knowledge of sociolinguistic norms on the part of the preschool group. as coetzee (1982) points out there are very few members of a speech community who know only their own dialect. the children without pre-school training presumably had less exposure to standard afrikaans which is reflected in their responses. they show a marked lack of sensitivity in comparison with the pre-school group who have had a greater exposure to standard norms. in other words these pre-schoolers' responses demonstrate their ability to choose between items from their dialect and the standard language. they demonstrate an awareness of the appropriate sociolinguistic norms in a specific diglossic context. in view of the errors made on this test in standard afrikaans by these dialect-speaking children, it is evident that a sociolinguistic approach is needed in compiling a revised translation for use within this specific group. a sociolinguistic dimension to compiling these test items would imply careful consideration of not only the linguistic form but also of the status of certain items in a particular speech community. to modify an existing test implies that the modified version has to die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 adhere to the same underlying principles in the selection of-items as the original test i.e. level of abstraction and nature of visual clues. this requirement necessitates a sociolinguistic approach in order to improve the reliability and in particular the validity of the test. in the last instance, the children's ppvt-r scores were compared with their performance on the comprehension questions (table 5). categories were not analysed when there were fewer than 10 cases per category, accounting for the absence of the other probing scores on the different questions. from table 5 it is evident that the ppvt-r scores correlated significantly with the accuracy of the responses on all the questions indicating a strong positive association between these two variables. this positive correlation suggests some common denominator between these two tests, although it could not be seen as a validation of the procedures as both these measurements evaluate different aspects of language (culatta, page and ellis, 1983). the correlation between these two tests could, however, be regarded as a positive indication for future standardization of the ppvt-r for this group of children. the findings of this study confirm the difficulties involved in the modification of existing tests in order to reduce or eliminate cultural biases. however, results indicate the feasibility of the standardization of the ppvt-r for this population. such standardization would involve the development of appropriate test items as well as the creation of local norms of this population (adler and birdsong, 1983) in order to facilitate continued assessment of children in the area. table 5: partial correlation between ppvt-r scores and accuracy of comprehension questions when probing is held constant. question probing level probability of exceedence question 1 probing 1 0,0189 question 2 probing 1 0,0474 probing 2 0,0009 probing 3 0,0056 question 3 probing 1 0,0041 probing 2 0,0079 question 4 probing 1 0,0001 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 erna alant and s.m. beukes acknowledgements r s ^ ^ f f s s r d x t e d assistance of the teachers and ch.ldren at the school .s hereby acknowledged. references adler, s. and birdsong, s. reliability and validity of standardized testing tools used with poor children. topics in language disorders, 3, 3, 76-87, 1983. alant, e. the development of a procedure for analysing communication of pre-school children. unpublished d.phil thesis, depart. speech therapy and audiology, university of pretoria, pretoria, 1984. bartsch, r. the concepts 'rule' and 'norm' in linguistics. in lingua, 58, 51-81, 1982. berry, m.. language disorders of children. englewood-cliffs, prentice-hall, 1969. bolton, r. people skills. englewood-cliffs, prentice-hall, 1979. carrow-woolfolk, e. test for auditory comprehension of language. new york: teaching resources, 1973. coetzee, a.e. 'n herorientering van die begrip standaardtaal en 'n voorstudie van die ontwikkeling van standaard-afrikaans gedurende die 20e eeu. in tydskrif vir geestewetenskappe, 22, 4, 271-289, 1982. cox, t. and jones, g. disadvantaged 11 year olds, oxford: pergamon press, 1985. culatta, b., page, j.l. and ellis, j. story retelling as a communicative performance screening tool. language, speech and hearing services in schools, 14, 2, 66-74, 1983. dunn, l.m. and dunn, l.m. peabody picture vocabulary test — revised american guidance services, circle pines, 1981. erickson, j.g. and omark, d.r. communication assessment of the bilingual bicultural child, baltimore, university park press, 1981. faegans, l. farran, d.c. the language of children reared in poverty, new york: academic press, 1982. labov, w. the logic of non-standard english. in giglioli, p. (ed), language and social context, new york: penguin, 1972. leeman, e.m. evaluating language assessment tests. in erickson, j.g. and d.r. omark (eds.): communication assessment of the bilingual bicultural child, 115-128, 1981. musselwhite, c.r. pluralistic assessment in speech-language pathology: use of dual norms in the placement process. language, speech and hearing services in schools, 14,1,29-38, 1983. saville-troike, m. bilingual education series: 2, arlington: center for applied linguistics, 1973. taylor, o. the sociolinguistic dimension in standardized testing. in saville-troike, m. (ed.), linguistics and anthropology, washington, d.c.: georgetown university press, 1977. terrel, s.l. and terrel, f. distinguishing linguistic differences from disorders: the past, present and future of non-biased assessment, topics in language disorders, 3, 3, 1-7, 1983. vaughn-cooke, b.f. improving language assessment in minority children, ash a, september, 29-33, 1983. wiener, f.d., lewnau, l.e. and erway, e. measuring language competency in speakers of black american english, j. speech hear. disord. 48, 76-84, 1983. webb, v.n. sosiolinguistiek en die spraakterapie. in beukes, 5.m. (ed.): the role of the speech therapist in a multilingual society. symposium papers. university of pretoria, department of speech therapy and audiology, 22-37, 1984. appendix 1 voorlopige vertaling van ppvt (revised) in afrikaans naam van toetsling: datum van toets: naam van toetsafnemer: lys: item nr woord 2 ' / 2 3 sleutel 3'λ 4 ' λ 6v2 1 . . . . (4) 2 . . . . (1) 3 bed . . . . (3) 4 . . . . (3) 5 . . . . (1) 6 . . . . (4) 7 . . . . (2) 8 . . . . (3) 9 . . . . (1) 10 . . . . (4) 11 . . . . (3) 12 . . . . (4) 13 . . . . (2) 14 . . . . (4) 15 . . . . ( 4 ) . 16 . . . . (1) 17 . . . . (3) 19 . . . . (2) 20 . . . . (2) 21 . . . . (4) 22 . . . . (1) 23 . . . . (2) 24 skil . . . . (3) 25 . . . . (1) 26 gereedskap . . . . (4) 27 . . . . (4) 28 . . . . (1) 29 . . . . (2) 30 . . . . (2) 31 . . . . (1) 32 . . . . (2) 33 . . . . (3) 34 . . . . (4) 35 . . . . (1) 36 . . . . (1) 37 . . . . (2) 38 (1) 39 . . . . (2) 40 . . . . (3) 41 (4) 42 . . . . (4) 43 (3) 44 (2) 45 . . . . (4) 46 (3) 47 (1) 48 (3) 49 (2) 50 (3) 51 (3) 52 (3)53 (1) 54 (2) 55 (4) 56 (2) 57 werktuigkundige (2) 58 (1) 59 teleurstelling (4) 60 (3) 61 (3) respons the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the application of the revised version of the peabody picture vocabulary test (ppvt-r) to non-mainstream children 62 katrol ο 63 teken ( ! ) 64 ( 2 ) 65 menslik (2) 66 neusgat 0 ) 67 geskil 0 ) 68 uitgeput (2) 69 wingerd (4) 70 seremonie (4) — 71 skottel •·· ( 2 ) — 72 voertuig (4) — 73 aardbol ( 3 ) — 74 liasseer (3) — 75 klamp (2) — 76 reptiel (2) — 77 eiland 0 ) — 78 spatel (3) — 79 samewerking (4) — 10 80 kopvel (4) — 81 loot (2) — 82 meerkat (2) — 83 sloop (4) — 84 balkon 0 ) — 85 halssnoer (3) — 86 verras (3) _ 87 buisvormig (1) — 88 slagtand (1) — 89 bout ( 3 ) — 12 90 kommunikasie (4) 91 skrynwerker (2) 92 afsondering (1) 93 opgeblaas (3) _ 94 kus (3) — 13 95 verstelbaar (2) — 96 breekbaar (3) 97 aanval (1) 98 toestel (1) — 99 piramide (4) 14 100 woed ( 4 ) 101 hys ( 0 102 boog (4) 103 lesing ( 4 ) 104 gehawend (4) 15 105 peinsend , (2) 106 o r n a m e n t . . . . (3) / 1 0 7 dissekteer j (3) 108 skakel (4) 109 swaarmoedig ( 3 ) 16 110 boogskutter (2) 111 deursigtig . . . (3) 112 stronk ·' ( ο ι 13 gereedskap ( 2 ) 114 sitrus -j ( 3 ) 115 voetganger .j (2) 116 parallelogram < ( ο ι 17 sluimeremd (3) 118 skiereiland (4) 119 bekleedsel (2) 120 versperring (4) 121 kwartet (4) 122 kalm (3) 123 slyp ( d 124 uitgeput (3) . 125 sferies (2) • 126 spuit (2) • 127 knaagdier (3) • 128 dor (4) 129 fasade 0 ) 130 konstellasie (4) 131 kornea (2) 132 handel (1) 133 bestyg (3) 134 filtrering (1) 135 verbruik (4) 169. 136 kaskade ( 4 ) — 137 loodreg ( 3 ) — 138 aanvul ο — 139 vrylating (3) — 140 vleuel ( 4 ) 141 toorn (3) — 142 stralend ( 4 ) 143 arrogant (2) — 144 vertrou (3) 145 rombus (3) 146 kontoere (2) 147 raaklyn ( ' ) 148 guur (4) 149 baan ( ' ) 150 gekluister (1) 151 haweloos (3) 152 jubelend (2) 153 skaai ( 4 ) 154 dut (2) 155 aas ( 3 ) 156 nooddruftig (2) 157 konveks ( ' ) 158 uitgeteer ( 2 ) 169 divergensie (4) 160 dromedaris (2) 161 optooi (2) 162 e n t o m o l o o g (3) 163 weerhou (1) 164 geriatries (1) 165 antropo'ied (3) 166 skim ( 4 ) 167 talm ( 2 ) • 168 fragiel 0 ) • . (1) obelisk 0 ) 170 gebosseleer (4) 171 ambulerend (2) 172 kelk ( 2 ) 173 soen (3) 174 koepel ( 4 ) 175 homunkulus (4) berekening van roupunt plafonitem minus foute roupunt the south african journal of communication disorders. vol. 33. 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 erna alant and s.m. beukes appendix 2 story unit 1 e.3 e.3 e.2 e.3 eendag// stap ou /e/tkals in die bos./ hy loop en spog te lekker,/ want hy kan tog 5 0 : vinnig hardloop.// toe hy nog so stap, sien hy vir olifant onder die boom staan.// "goeie more ou olifant" ss jakkals./ "kom ons hardloop reisies, dan kyk 0:ns wie van oris twee hardloop die vinnigste."// ou olifant dink toe so 'n bietjie en se toe "agge nee ou jakkals jy is gans te vinnig vir my."/ ou jakkals lag te lekker./ "ja ou olifant, ek sal jou sommer ve:r wen."// en so stap jakkals toe a a n . / / unit 2 toe jakkals nog so s t a p / sien hy vir skilpad./ "goeie more skilpad./ kom ons hardloop reisies dan kyk ons wie van ons twee is die vinnigste."/ skilpad dink toe so 'n bietjie/ en se: "agge nee ou jakkals jy is gans te vinnig vir m y . " / / ou jakkals lag te lekker. dis tog te lekker vir hom om te weet dat al die die re te bang is om teen horn reiseis te hardloop.// en so stap jakkals toe aan . . . / / unit 3 toe jakkals nog so stap, sien hy vir krap op die grond/ "goeie more ou krap. kom ons hardloop reisies, dan kyk ons wie van ons twee is die vinnigste."/ / ou krap dink toe so 'n bietjie . . / / en toe kry hy 'n bate goeie plan./ "goed ou jakkals, kom ons hardloop reisies dan kyk ons wie van ons twee is die vinnigste."// ou jakkals is stom geslaan./ hy kan nie glo dat krap teen hom wil reisies hardloop nie.// unit 4 die twee begin toe hardloop./maar net toe jakkals begin hardloop, spring krap op jakkals se stert en kl:ou daar vas./ jakkals hardloop baie vinnig tot by die wenpaal./ en toe hy by die wenpaal kom/ skud hy sy stert en kyk om om te sien waar die krap is.// huuu. . .en daar sienjakkals vir krap op die grond! "agou jakkals," se die krap toe "ek wag al lankal hier vir jou op die grond." verbal analyses: accuracy: question 1: who walked in the veld? 4 fox 3 = description of animal, no name 2 = wrong animal 1 = no response/did not understand question 2: whom did he meet there? 4 = all three correct 3 = two correct 2 = one correct 1 = none correct question 3: what was the clever plan of the crab? 4 = indication of relationship between action and intention 3 = repeat actions involved e.g. jumped onto tail and clung onto it 2 = partially correct repetition of actions e.g. hanged on tail 1 = no response/response out of context/do not know question 4: who do you think won the race and why? the why part of the question is scored only: 4 = in context explanation e.g. crab won because he made a clever plan 3 = in context, but concrete e.g. crab, because he jumped on the fox's tail 2 = vague, out of context e.g. fox, because he is faster 1 = no response/do not understand/do not know probing analyses: all the probes on each question were calculated and categorized according to the following scoring system: 3 = 11-15 probes 4 = 16-20 probes 1 — 4 1 — 4 1 = 0-5 probes 2 = 6-10 probes s = smile ε = eye widening/ eye narrowing f = frowning hn = head nod hs = head shake il = illustration italics = emphasized capital letters =stressed with more loudness i so: = the last sound prolonged / = pause (untimed duration shown by number of / / ) / / — longer pause the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 59 diagnostic reference data for the monaural brain-stem auditory evoked response (baer) cyril d govender μ (audiology) udw department of speech and hearing therapy university of durban westville abstract the objective of the investigation was to establish diagnostic reference data for the normal baer. baers were elicited from the target (r) ear using clicks presented at 70dbnhl. relevant latency and amplitude data were obtained from 60 selected normal hearing indian undergraduate females (n=30; τ age = 20.33gears) and male (n=30; τ age = 21.33 gears) students aged between 18 and 25 gears (x age =20.73gears). diagnostic reference data were established for the absolute latencies ofpeaks i to vi; relative latencies of peaks i-iii;iii-v and iv; absolute amplitudes ofpeaksland vand the relative amplitude ratio of peaks v:i. these results are discussed in terms of the literature and implications for clinical application and further research. opsomming die doel van hierdie ondersoek was om diagnostiese verwgsingsdata vir normale ouditief ontlokte breinstamresponse daar te stel. hierdie response is van die regteroor ontlok deur middel van klikgeluide wat bg 70dbngpaangebied is. toepaslike data vir latentheid en amplitude is vir 60normaalhorendeindier voorgraadsestudente verkrg. vroulike (n=30;τouderdom = 20.33jaar) en manlike (n=30;τouderdom = 21.33 jaar) studente, tussen die ouderdom 18 tot 25jaar (x ouderdom = 20.73jaar) is vir die doel van hierdie studie geselekteer. diagnostiese verwgsingsdata is verkrg vir die absolute latenthede van pieke i tot vi; relatiewe latenthede van pieke i-iu; ιιι-ven i-v; absolute amplitude van pieke i en v en die relatiewe amplitude-verhouding van pieke v:i. hierdie resultate is bespreek met verwgsing na die literatuur. die implikasies vir kliniese toepassing en verdere navorsing is ook aangedui. introduction during the past decade and a half, there has been a formidable increase in the use of specialised audiological test procedures in otoneurological diagnosis. since the initial description of a procedure from the human scalp (jewett & williston 1971), the measurement of the brain-stem auditory evoked response (baer) has become the most recent electrophysiological procedure to be integrated into testing protocols. this procedure subsequently had a major impact on the disciplines of audiology, otology and neurology, (schwartz & berry, 1985). the development of the baer was focused on two principal areas of application: i i. the evaluation and diagnosis of peripheral auditory problems and related pathology, and ii. the assessment of the neural integrity of the acoustic nerve and caudal levels of the brain-stem afferent auditory pathway (hecox & jacobson, 1984). however, despite the reported robustness and stability of the baer as a reliable assessment tool, it is critical to the effective use of this measurement to have diagnostic reference data that are collected within the individual laboratory or clinic. several investigators have reported on the myriad of variables that can potentially alter one or more of the important parameters of the baer, and hence lead to misinterpretation. it is, therefore, appropriately suggested by schwartz & berry (1985), that it is not advisable for any clinician to depend on published diagnostic reference data for interpreting baers. this emerges from the opinion that there is a lack of uniformity in baer die suid-afrikaanse tydskrif vir kommunikasieafykins, vol. 37 1990 measurement variables among investigators in various clinics and laboratories around the world. furthermore, although there is available information on diagnostic reference data on the normal baer (see table 1, adapted from schwartz & berry, 1985), such information is lacking in south africa for any age or population group. due to the absence of standard to specify recording parameters and methods used to measure the baer, (this is clearly seen in table 1 whereby the various clinics and or laboratories differ in their test protocols), it is imperative that any clinic, including the audiology clinic at the university of durban-westville establishes its own diagnostic reference data based on its own test equipment'and protocol. baer interpretation maybe confounded by the influence of various factors, viz. differences m: a. electrical and electromagnetic field variation between clinical/laboratory sites b. the use of different stimuli c. recording and analysis parameters d. electrode placement e. transducer type and f. transducer placement. the above differences may lead to small but significant changes in peak latency, amplitude and morphology. in addition a number of investigators (beagly & sheldrake, 1978; jerger & hall, 1980; and stockard et al. 1978) reported that there is a ftiarked sex effect on the normal baer. generally, females show shorter latencies and larger amplitudes than sasha 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 cyril d govender males. the difference is greater for peak v than for the earlier peaks, and also produces shorter ipls within females. the clinical implication of this differential effect is that it is advisable to establish separate reference data for males and females to avoid misinterpretations (hall, 1984). therefore a study designed to elicit and to examine the baer in a group of normal male and female subjects under controlled conditions would provide relevant information, leading to the establishment of suitable diagnostic reference data for the interpretation of baer in the audiology clinic at the university of durban-westville. method aim the aim of the study was to examine certain response characteristics of the baer obtained in a selected group of normal hearing indian male and female subjects. this would allow for the generation of diagnostic reference data for the interpretation of baer at the audiology clinic at the university of durban-westville. the response characteristics of the normal baer to be examined were as follows: a. absolute latencies of peaks i to vi b. relative (interpeak) latency (ipl) of peaks itii, iii-v and peaks i-v. c. peak to trough amplitudes of peaks i and v d. amplitude ratio obtained by comparing the absolute amplitudes of peak i and v. subjects a total of 60 randomly selected subjects (x age 20.7 years) comprising of 30 males (x age 21.3 years) and 30 females (x age 20.3 years) contributed relevant data fc*· the purpose of this study. all subjects had normal hearing thresholds of 026db for ac and bc for the test frequencies 250hz to 8000hz, srts which were within ±5db of the ptas, speech discrimination scores of 92% to 100% at 35dbsl, normal type a tympanograms, static compliance measures ranging between 0.28 and 2.5cc, and contralateral acoustic reflex thresholds of between 70dbsl and 90dbsl. subjects also had a negative history of neurological abnormalities, consuming known ototoxic drugs and of excessive noise exposure as evidenced in the pre-test case history questionnaire (govender, 1989). furthermore, all subjects were right-handed as determined by a standardised handedness questionnaire (lazarus, 1989), so as to select the right ear as the test ear. this was to ensure consistency in testing the same ear for all subjects. procedure all subjects were assessed in the supine position on a standard patient couch with appropriate head propping by using a pillow to minimize postural muscle activity around the head and neck regions (chiappa et al. 1979). subjects were en.couraged to relax and to fall asleep during the recording session as this would reduce myogenic activity from influencing the responses. therefore actual testing commenced only if subjects appeared to be relaxed or asleep. the electrode sites were cleaned of all debris with omni-prep skin preparing paste and were slightly abraded to assist in reducing skin resistance. self-adhesive silver-silver chloride electrodes were then arranged so that the electrical potential difference was measured between a pair of electrodes as suggested by schwartz & berry (1985). the positive electrode was placed on the high forehead just below the hairline, the negative electrode was placed on the ipsilateral mastoid, while the contralateral mastoid was used as the site for the ground electrode. prior to fixing the electrodes to the skin, standard eeg paste (colloidon) was applied between the surface of the electrode and the skin. the electrodes were then fixed firmly to the skin. the recording electrodes were connected to a high gain (104) differential, low noise, biological preamplifier (the cadwell quantum 84 preamplifier). the inter-electrode impedance was always below 3000ω before testing commenced. electrode activity was differentially filtered with a filter bandpass setting of 100hz to 3000hz, as suggested by the cadwell programme for baer testing. alternating click stimuli with a duration of loopsec were presented at a rate of 11.29 per sec at 70dbhl to the target right ear via a tdh-39 earphone, housed in an amplivox freefield audiocup. the headphone position was held constant for all subjects. the no-test left ear was masked with 60dbhl of broadband noise so as to prevent its participation in obtaining the monaural baer in the right ear. the sweep time was set at 1 so that each division on the monitor screen represented 1 msec. therefore, the baer was observed over a time frame of 10msec post-stimulus. a total of 2048 clicks was presented to ensure waveform build-up and clarity. the artifact rejection facility of the evoked potential system was switched on continuously so as to allow for automatic rejection of artifacts. all responses were recorded using the built in alps printer of the evoked potential system. all baers were elicited using the cadwell quantum 84 computer based, software run, auditory evoked response audiometer. testing was conducted in a electro-magnetically screened anechoic sound treated chamber meeting noise level requirements set by ansi (1977). the actual test run was initiated as soon as all test parameters ι were set. prior to any stimulus presentation, a control run was j done to allow for comparing and identifying of true responses. : at least two trials were done to ensure waveform repeatability ! and consistency. nb. see appendix 1 for a summary of the j baer test protocol used in this study. i i measurements made ! ι 1. absolute latencies. , the absolute latencies of peaks i to vi in msec were made from stimulus onset to the positive peak of each component wave of the baer. 2. relative or interpeak ipl latencies. the relative latencies in msec, of peaks itii, iii-v and i-v were recorded from the target (r) ear. these were automatically calculated by the computer of the evoked response system. 3. absolute amplitudes. peak to trough amplitudes of peaks i and v inmicrovolts were measured. these were measured from the-positive peak to the following negative trough of each of the named component waves of the baer. the south african journal of communication disorders. vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) diagnostic reference data for the monaural brain-stem auditory evoked response (baer) 61 4. amplitude ratio. this ratio was obtained by comparing the amplitude of peak v to that of peak i. the ratio was obtained by dividing the amplitude of peak i by that of peak v, as suggested by musiek & gollegly, (1985). analysis of data the data were analysed by using conventional statistical procedures which allowed for the generation of means, ranges and standard deviations. results table 2 summarises the statistical analyses made on the various latency and amplitude measurements obtained from the combined group (n=60). table 3 reflects a summary of the statistical analysis conducted for the various latency and amplitude measurements obtained among 30 female and 30 male subjects. this table was drawn up to specifically reflect the data for males and females separately. tables 2 and 3 therefore represent the diagnostic reference data related to the aim of the study. discussion table 2 provides a summary of the latency and amplitude measures made on the monaural baer elicited in 60 normal hearing young students. the diagnostic reference data reflected in table 2 is to be discussed in relation to previously published data under the following headings: a) absolute latencies table 2 reflects the overall group absolute latency values for peaks i to vi. the obtained range extends from 2.08 to 7.49 msec in response to clicks presented at 70dbnhl. the latency range for peaks i to v was 2.8 to 6.00 msec. beagley & sheldrake (1978), in reporting their "normative data" obtained from 5 male and 5 female subjects (age range 21-30 years) for peaks i to v show a similar latency range of 2.1 to 6.1 msec in response to clicks presented at 70dbsl. however, in comparing the findings of the above studies to those obtained in other clinics and laboratories (see table 1), it is evident that there are small variations between and among the values reported. these variations may be attributed to differences in intensity, polarity of clicks, repetition rates, filter setting and other aspects of test protocols used. the fact that these discrepancies between and among clinics and laboratories exist, highlights the need for each facility to generate its own diagnostic reference data. an examination of the individual studies reported in' table 1 reveals two major differences: laboratory/clinic 1 2 3 filter settings (hz) wave latency (ms) laboratory/clinic 1 2 3 filter settings (hz) i ii iii iv v i-iii iii-v i-v jewett'and williston, 60-75 ? ? 10-10,000 1.5 2.6 3.5 4.3 5.1 / ί ' 9 7 0 ) lev and sohmer, 65 ? 2 250-5000 1.5 2.5 3.5 5.0 (1972) picton et al. 60 ? 10 10-3000 1.5 2.6 3.8 5.0 5.8 (1974) starr and achor, 65 alt. 10 100-3000 1.6 2.8 3.8 4.8 5.5 (1975) stockard and rossiter, 60 ^ r a r . 10 100-3000 1.9 3.0 4.1 5.2 5.9 2.1 1.9 4.0 (1977) rosenhamer et al. 60 ? 16.6 180-4500 1.7 2.9 3.9 5.2 5.9 2.26 2.0 4.27 (1978) row, 60 ? 10 100-3000 1.9 2.9 3.8 5.1 5.8 1.97 1.97 3.94 (1978) gilroy and lynn, 75 ? 11 150-3000 1.55 2.67 3.60 4.69 5.40 2.05 1.9 3.83 (1978) beagley and sheldrake, 70 ? 10 250-3200 2.1 3.3 4.3 5.3 6.1 2.2 1.8 4.0 (1978) chiappa et al. 60 alt. 10 100-3000 1.7 2.8 3.9 5.1 5.7 2.1 1.9 4.0 (1979) schwartz and berry, 75 db rar. 11.1 75-1500 1.65 2.85 3.8 4.99 5.66 2.05 1.85 4.00 (1985) (nhl) 1 = stimulus intensity level in db 2 = stimulus polarity | 3 = repetition rate (cps) table 1: normative abr latency data across 11 laboratories. adapted from schwartz & berry, ( 1 9 8 5 ) . die suid-afrikaanse tydskrif vir kommunikasieafivykinijs, vol. 37. 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 2 cyril d govender i. some researchers did not always clearly define the reference intensity level for the clicks used, ie. whether the clicks were presented in dbsl, dbnhl, dbspl or dbhl. this aspect is considered important as it reflects on exactly how loud a click is presented. furthermore, it is well documented that there is a direct relationship between intensity level and the latency of the peaks obtained in the baer (rowe 1978, stockard et al. 1978), ie. as the intensity of the click increases, the latencies of the peaks decreases and vice-versa (moore 1983). it is, therefore, suggested that investigators clearly define the reference intensity levels used. this suggestion is supported by the american electroencephalic society guidelines for clinical evoked potential studies (1984). adherence to these guidelines would permit the uniform use of reference intensity levels and would allow for the comparison of reference data between and among clinics and laboratories. ii. investigators did not always clearly define the polarity of clicks used. baers are affected by the acoustic phase of clicks (gastone et al. 1987). rarefaction clicks evoke shorter peak i and v latencies (coats & martin 1977); although these vary considerably among subjects. condensation clicks, however, appear to delay peak i and v latencies (schwartz & berry 1985), while alternating clicks do not seriously compromise baers, but serve to enhance the clarity of the response (schwartz & berry, 1985). it is therefore recommended that investigators clearly define the acoustic phase of clicks used in the generation of "normal" reference data. this would facilitate the development of uniform procedures and hence allow for inter-facility comparison. it is conceivable that among the variables mentioned earlier, both variation in intensity reference levels and the polarity of clicks used, may principally account for the differences in normal values reported in table 1 and in this investigation. in considering the appearance of individual peaks, all six peaks except for peak iv were consistently elicited in this investigation. six subjects (2 males and 4 females) did not produce clear and measurable peak iv latencies. according to beagley & sheldrake (1978), peak iv tends to be a more labile peak while rowe (1978), states that it may, in some normal subjects be absent. this may be attributed to the fact that peak iv sometimes tends to fuse with peak v thereby making it indistinct (chiappa et al. 1979). peak i was consistently elicited in a latency range of 1.87 to 2.29 msec. this finding is consistent with picton's (1986), recommended range of 1.4 to 2.5 msec. the mean of 2.08 msec, however, appears to be slightly delayed when compared to the means reflected in table 1. among the other variables mentioned earlier, this may be attributed to variations in testing and measurement protocols used in the different laboratories and clinics, particularly to differences in intensity levels of click phases used. generally, the absolute latencies of peaks ii, iii, iv and v show close approximation with those presented by beagley & sheldrake (1978). however, in comparison with the other studies reflected in table 1, these latencies appear to be slightly delayed, but the inter-facility standard deviations show close agreement. this provides support for the claim that the baer is a stable and reliable measure at moderate to high intensity levels. the inspection of the peak v latency, which, according to schwartz &berry (1985) and stockard et al. (1978), should occur within 4.00 msec after peak i, reveals that the finding of this study is consistent with the above i.e. peak v (see table 1) had a mean latency period of 3.90 msec after peak i. according to several researchers, e.g. beagley and sheldrake (19 78), stockard et al. (1978) and picton (1986), peak v is the most consistent and prominent of the baers, and is probably most useful diagnostically. its appearance at a mean latency period of 6.00 msec in this study conforms well with findings reported by stockard & rossiter (1977), at 5.9 msec, rosenhamer et al. (1978), at 5.9 msec and of rowe, (1978) at 5.8 msec. furthermore, the standard deviation of the peak v latency as reported by all these researchers did not differ significantly from that of this study, i.e. a standard deviation of 0.23. clearly, peak v latency appears to be robust in character. it is reliable and stable even under varying measurement conditions. this contention is supported by the evidence presented in table 1. it is, therefore, not surprising to note that peak v (a rostral component of the baer) has received widespread clinical attention in differential diagnosis of otoneurologic disorders, as well as for the estimation of hearing sensitivity (schwartz & berry, 1985). the finding that there were some overall variations between this study and of those summarised in table 1, illustrates and highlights again the need for each clinic or test facility to establish its own diagnostic reference data. b) relative or inter-peak latencies table 2 also reflects the mean relative latency values obtained in the group of 60 normal hearing students. these include the values for the relative latencies of peaks itii; iii-v and peaks iv. crucial to the differential diagnosis of space occupying lesions, either intrinsic or extrinsic to the brain-stem, is the time difference between peaks. these time differences are reflected by the time intervals between the following: i. peaks itii as representing peripheral transmission time from stimulus onset to the ponto-medullary junction in the lower pons (stockard et al. 1978) ii. peaks iii-v as reflecting central transmission time from caudal pons to the midbrain (schwartz & berry, 1985) and | iii. peaks i-v as representing both peripheral and central transmission time from stimulus onset to the midbrain (schwartz & berry, 1985). , i peripheral transmission time is determined by middle-earj function, cochlea mechanics, cochlea transduction, synaptic; and cochlea nerve conduction velocity while central transmis-1 sion time is associated with fibre conduction velocity and syn-. aptic transmission of brain-stem tracts and nuclei (cornacchia et al. 1983). the mean relative latency values obtained in this investigation were as follows: peaks itii = 2.01 msec peaks iii-v = 1.88 msec ' . ·" peaks i-v = 3.90 msec these values coincide well with previously published data as reflected in table 1. furthermore, these values fit in well with the suggested values presented by,schwartz & berry (1985); these being ± 2 msec for peaks i-iii, and iii-v and ± 4 msec, for peaks i-v in normal hearing subjects. according to rowe the south african journal of communication disorders, vol. 37 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) diagnostic reference data for the monaural brain-stem auditory evoked response (baer) 6 3 (1978), these relative latency values should not vary between and among laboratories and clinics using the same rate of stimulus presentation. in summary, this investigation established relative latency values which are similar to those found in other clinics and laboratories having used a click stimulation rate of 10-12 clicks per sec (see table 1). the lack of variability in these measures between and among facilities using the same click rate, makes them robust measures of peripheral and central transmission time within the auditory system. therefore, the interpeak latency measures are suitable for assessing pathologies which may affect the transmission of auditory impulses in the peripheral and brain-stem part of the auditory system. c) absolute amplitudes in referring to table 2, two absolute amplitude measures were considered in this investigation. these were the absolute amplitudes of peaks i and v. the obtained values in μ ν were used for the computation of the more clinically acceptable amplitude measure, i.e. the amplitude ratio of peak v compared to peak i. table 2: summary statistics for absolute and relative latencies in milli-seconds and absolute and relative amplitude measurements in micro-volts of the monaural baer for the combined group. (n=60) baer measures statistical measures absolute latencies (msec) x range sd peak i 2.08 1.87-2.29 0.08 peak ii 3.02 2.17-3.37 0,18 peak iii 4.12 3.71-4.52 0.17 peak iv (n=54) 5.13 4.42-5.83 0.30 peak v 6.00 5.50-6.58 0.23 peak vi >'7.49 6.54-8.21 0.32 relative latencies (msec) ^peak i-iii 2.01 1.69-2.41 0.15 peak iii-v 1.88 1.48-2.41 0.18 peak i-v 3.90 3.45-4.37 0.22 absolute amplitudes (μν) peak i j 0.17 0.08-0.36 0.05 peak v |0.24, 0.08-0.50 0.08 relative amplitude (μν) peak v:i 1.50 0.55-3.85 0.67 n.b. for peak iv, combined group n=54 table 2 above reflects the diagnostic reference data for the various latency and amplitude measurements obtained from the combined group (n=60). 1 there is consensus among researchers, viz. schwartz & berry, (1985), rowe, (1978), and chiappa et al.(l979), that absolute amplitude measures are not normally distributed; are highly susceptible to myogenic activity and noise levels; are difficult to replicate, and are easily influenced by minor alterations in recording techniques. consequently, the measurement of absolute amplitudes do not enjoy the stability and reliability of their latency counterparts (schwartz & berry, 1985). in this study, the mean peak i amplitude value was ο. 17 μν and that of peak v was 0.24 μν. chiappa et al. (1979), presented a mean peak amplitude value of 0,28 μν and a mean peak v value of 0.47μν. stockard et al. (1978), published a mean value of 0,23 μ ν for peak i and 0,35 μν for peak v. it is not clear that there are no close approximations between and among reported measures. these reported variations in amplitude measures between and among normal hearers may be attributed to the present system of signal averaging and use of artifact rejection (fernandes, 1989). theoretically, a wanted evoked potential is extracted from ongoing eeg by signal averaging and the use of artifact rejection. that is, by increasing the signal-to-noise ratio. waveform and amplitude build up is, therefore, a product of time-locked averaging together with the rejection of other contaminating artifacts, e.g. myogenic and other cerebral activity. it has been found that consensus among researchers on how much of averaging and/or artifact rej ection is required before a response is judged as acceptable or not, is lacking. according to hyde (1985), the choice of the number of clicks presented for averaging is often "based on popular consensus rather than on quantitative rationale". due consideration has not been given to the influence of differences in "internal noise levels" among normal hearers when reference data are established. that is, some normal subjects may have higher internal noise levels, requiring longer periods of averaging with greater number of averages within a trial before eliciting an appropriate response than subjects who have lower internal noise levels (hyde, 1985). therefore a choice of either 1048,200 or 2048 clicks to elicit a suitable averaged response may not be appropriate for all normal hearers. furthermore, since the amplitude of a response is partly dependent on the number of averages that occur in a trial, it is reasonable to assume that response amplitudes will differ between and among individuals. this therefore may account for the variability in amplitude measurements that are reported in the literature. similarly, the use and control of artifact rejection to eliminate unwanted noise is not consistent in studies that have reported on normal amplitude values. it is therefore not surprising to find variations in the reported amplitude values between and among studies. the consistent and approriate application of signal averaging and management of artifact rejection needs to be given careful attention in future research. attention needs to be focused on decisions pertaining to the: i. actual number of averages required in a trail (i.e. 1048, 2000 or 2048 clicks) before a response is regarded as representative of a "true neurogenic" response. ii. use and control of artifact rejection so that the final response is truely representative of the baer without being contaminated by other artifacts. a reasonable course of action, is to set the artifact rejection limits so that little of the "well behaved" (low variance) activity is rejected, while all of the high variance (bursts of electromyogenic noise) activity is. this may be done by "tuning" the rejection level while observing the displayed activity, so that only about 5-10% of the good activity is rejected. perhaps, the manufacturers of evoked potential systems need to incor/» suid-afrikaanse tydskrif vir kommimikasirafityikhi/is. vol. .17, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 4 cyril d govender porate additional desirable features that will allow for the display of the input eeg during averaging, rejection of trails in which large voltage artifacts occur and an assessment of amplitude variability within an averaging run. the above may assist in establishing appropriate reference data for amplitudes which may be used routinely in baer interpretation. thereafter, such reference data should be applied widely to assess how otoneurologic pathologies influence the measures, and to document the obtained patterns for ongoing comparisons. d) relative amplitude the peak v:i amplitude ratio table 2 reveals, that the mean amplitude ratio obtained in this investigation was 1.50. this is consistent with the findings of chiappa et al. (1979); rowe (1978), and that of starr & achor (1975), who have all reported that a value greater than 1.00 be considered as normal. in order to detect abnormality, musiek et al. (1984), state that amplitude ratio should be less than 1.00. stockard et al. (1978), however, state that a complete absence of peak v in the presence of peak i is an indication of relative amplitude abnormality. differing in this opinion, starr & achor (1975), state that a peak v:i amplitude ratio ofless than 0,5 at 55 dbsl is abnormal. later in 1978, stockard et al. suggested that the peak v absolute amplitude value which is reduced by more than 3 sd from the normal mean, together with a peak i amplitude that is larger than peak v, and an inter-trial variation ofless than 10% are all necessary for the peak v:i amplitude ratio to be defined as abnormal. chiappa et al. (1979), agree with starr & achor (1975),in the looftheir 104 normal subjects displayed apeak i amplitude which was larger than peak v. the findings of this investigation are in part agreement with starr & achor (19 75), and with chiappa et al. (1979), since 12 subjects (5 females and 7 males) displayed peak i amplitudes which were larger than peak v, although the overall mean was 1.50. the observed differences in amplitude ratios appear to be due to normal variations that occur within and among normal individuals. this contention is in keeping with stockard et al.'s (1977), statement that "alterations of baer morphology in the absence of quantifiable latency or absolute amplitude abnormality are not considered abnormal per se, because of the variability of baer waveforms within and among normal individuals." however, schwartz & berry (1985), are of the opinion that there is a dearth of well documented literature concerning the use of the v:i amplitude ratio in a large pathologic population. they suggest that considerable research is needed on the confounding effects of such variables as stimulus polarity, repetition rates, filter characteristics, electrode sites etc., prior to the general use of this measure in clinical practice. the investigator concurs with the above recommendation. due consideration should also be given to inter and intra individual variations when examining amplitude data. furthermore, and improvement in signal averaging and artifact control may aid in resolving the issue of obtaining variable amplitude measures in normal hearers. separate diagnostic reference data for males and females in response to the suggestion made by several researchers, viz. stockard et al. (19 78), (19 79); jerger & hall (1980), and jerger & johnson (1988), that diagnostic reference data be established separately for males and females, the raw data was further treated to reflect this separation. table 3, reflects the means, ranges and standard deviations for the various baer measurements as obtained from 30 females and 30 males. on inspection and comparison of the mean absolute latency values obtained for the two groups, it is evident that for all six peaks, females tended to show shorter latency values than males. this is also evident for the peak i-iii and peak i-v relative latency values. the absolute and relative amplitude measures show no such differences, implying that there are no observable differences between sexes for these measures in this investigation. however, further research focusing on the appropriate use of signal averaging and artifact rejection may produce realistic amplitude measures in normal hearers. once this has been achieved, it is suggested that the effect of sex difference on amplitude measurements be reassessed. the question of whether there is a statistically significant sex difference effect on the normal baer, needs to be researched further. ι in the interim, the fact that there are observed latency differen-j ces between the sexes as seen in table 3, is supportive of the suggestion that separate diagnostic reference data be esta-i blished for the two sexes. the establishment of such data, would prevent the clinician from applying inappropriate sex| related reference data to interpret the baer. | / the south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) diagnostic reference data for the monaural brain-stem auditory evoked response (baer) 6 5 table 3: summary statistics for absolute and relative latencies in milli-seconds and absolute and relative amplitude measurements i n micro-volts of the monaural evoked baer in females (n=30) and males (n=30) baer measures (p=peak) statistical measures baer measures (p=peak) males (n=30) baer measures (p=peak) females (n=30) males (n=30) absolute latencies x range sd x range sd ρ i 2.06 1.87-2.19 0.07 2.11 1.92-2.29 0.10 ρ ii 3.02 2.71-3.29 0.14 3.4 2.79-3.37 0.14 ρ iii 4.08 3.71-4.52 0.18 4.16 3.87-4.50 0.16 ρ iv 5.10 4.42-5.83 0.37 5.17 4.58-5.52 0.21 ρ v 5.98 5.54-6.58 0.24 6.03 5.50-6.42 0.22 ρ vi 7.44 6.75-7.96 0.30 7.55 6.54-8.21 0.33 relative latencies ρ i-iii 2.00 1.74-2.41 0.16 2.03 1.69-2.37 0.15 ρ iii-v 1.87 1.48-2.41 0.18 1.87 1.56-2.29 0.17 ρ i-v 3.84 3.49-4.37 0.22 3.91 3.45-4.33 0.23 absolute amplitude ρ i 0.17 0.08-0.36 0.05 0.16 0.09-0.29 0.05 ρ v 0.25 0.09-0.44 0.08 0.22 0.08-0.50 0.08 relative amplitude ρ v:1 1.50 0.74-2.50 0.51 1.50 0.55-3.85 0.81 n.b. for peak iv: female no. = 26 male no. = 28 table 3 represents the means, ranges and standard deviations for the various baer measurements as obtained for the females and males respectively. conclusion diagnostic reference data were established for both the combined group (n=60) and separately for females and males. similarities an differences between this study and of those reported in the literature were noted and discussed. the similarities in absolute latency measures were attributed to close approximations between testing protocols used, whilst variations were primarily related jto, among other variables, differences in reference intensity levels and the polarity of clicks. despite the difference between this study and of those reflected in table 1, the absolute latency of peak v remained resistant to variations in stimulus, recording and "normal subject" variables. therefore this measure,appears to be robust and maybe reliably used in otoneurological diagnosis and for estimating hearing sensitivity. the relative latency values generated are consistent with those reported in the literature (see table 1), and this is attributed to the fact that click presentation rates used are similar, i.e. 10-12 clicks per sec., in each of the studies. it is therefore suggested that clinicians may confidently use these measures to assess otoneurological pathologies that may upset the conduction of impulses in the auditory periphery (e.g. multiple sclerosis), provided that the click rate used is 10 to 12 per sec. differences in amplitude measures between this study and among other studies were noted. these variations were, among other factors, attributed to the manner in which signal averaging and artifact rejection have been manipulated in obtaining the average baer. further research in this respect has been suggested. however, the relative amplitude value of 1.50 obtained in this study is consistent with those reported in the literature. this implies that the ra measure is less variable in normals and therefore, may be used as a more sensitive measure of brain-stem auditory function than absolute amplitude measures. in view of the demonstrated differences in reference data between and among clinics and laboratories, the writer is of the opinion that clinicians should exercise caution in using reference data established elsewhere, especially if reported testing protocols differ in stimulation, recording and normal subject variables, e.g. sex. the observation that there were differences between the sexes is strongly supportive of the suggestion that separate reference data be established for the sexes (stockard et al. 1978; jerger & hall, 19.80). this would allow for the accurate clinical interpretation of the baer obtained in the two sex groups. therefore it is recommended that each clinic generates its own reference data commensurate with its needs. furthermore, noting that this study fell short of giving due consideration to age-related data across the continuum, interaural latency differences, use of different repetition rates, stimulus intensity reference levels and click polarity, future research considering the above, needs to be conducted to extend the present reference data base. the need for consensus to be reached among researchers and clinicians with respect to test protocols used in bear testing cannot be overemphasized. perhaps, an international conference involving the various disciplines that use this test pror ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 6 cyril d govender cedure should be held, in order to formulate a standard guideline or protocol for the use of interpretation of the baer. this would facilitate inter-clinic and/or laboratory comparisons, and perhaps aid in resolving some of the controversies that exist in baer testing and interpretation. in the interim, it is important the researchers and clinicians clearly define the parameters of their test protocols in establishing reference data. in addition, such data should be applied within populations having known otoneurological pathologies to assess the 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j.t. jacobson(ed.), the auditory brain-stem response. san diego: college-hill press, 1985. musiek, f.e., kibbe, k., rackliffe, l., and weider, d.j. the auditory brain-stem response i-v amplitude ratio in normal, cochlear and retrocochlear ears. ear and hearing, 5, 52-55, 1984. picton, t.w. abnormal brain-stem auditory evoked potentials: a tentative classification. in r.q. cracco and i. bodis-wollner (eds.), frontiers of clinical neuroscience. evoked potentials, vol. 3. new york: alan r. liss inc, 1986. rosenhamer, h., lindstrom, b., and lundborg, j. on the use of click evoked electric brain-stem responses in audiological diagnosis, i. the variability of the normal response. scandinavian audiology, 7, 197-206, 1978. rowe, m.j. normal variability of the brain-stem auditory evoked response in young and old subjects. electroencephalography and clinical neurophysiology, 44, 459-470, 1978. schwartz, d.m., and berry, g.a. normative aspects of the abr. in j.t. jacobson (ed.), the auditory brain-stem response. san diego: college-hill press, 1985. starr,α., and achor, j. auditory brain-stem responses in neurological disease. archives of neurology, 32, 761-768, 1975. stockard, j.j., and rossiter, v.s. clinical and pathologic correlates of brain-stem auditory response abnormalities. neurology, 27, 316-325, 1977. , stockard, j.j., stockard, j.e., and sharbrough, f.w. non-pathologicl factors influencing brain-stem auditory evoked potentials.] american journal of electroencephalographic technology, 18,: 171-209,1978. ' ; r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 7 appendix i bear test protocol technical and procedural considerations stimulus : transducer electrodes evoked response audiometer electrode sites polarity repetition rate filter pass band sweep time time frame no. of clicks per trial no. of trials contralateral masking level of test ear stimulus artifact rejection i recording of responses / / test environment patient state clicks ιοομ sec. duration electrodynamic tdh-39p earphones housed in free field audio-cups. self-adhesive silver-silver chloride. cadwell quantum 84 positive fz high forehead negative ipsilateral mastoid ground contralateral mastoid alternating 11,29 per sec 100hz 3000hz 1 division = 1 msec 10 msec post-stimulus 2048 minimum-two to ensure waveform repeatability. 60dbhl kept constant at 70 dbnhl switched on by built in alps printer anechoic chamber electromagnetically screened low noise levels ansi (1979). appeared to be relaxed or asleep lying in a supine position on a standard patient couch. n.b.: a control run prior to stimulation was done to allow for comparing and identifying true responses. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) < */ * ν u v -sex m i<§ r' jspvs. •s t a l k i n g to p r o f e s s i o n a l s the needier westdeneorganisation p.o. box 28975 sandringham 2131 telephone (011) 485-1302/3/4/5' wm r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 signed lexical items in an afrikaans oral residential school for the deaf sonya warren, b(log) (pretoria) durban school, psychological centre, durban santie meyer, m(log) (pretoria) h.e.c. tesner, ma (pretoria) department of speech pathology and audiology, university of pretoria abstract the signs for 15 lexical items were video recorded and analyzedfor 40 congenitally deaf subjects (hearing loss greater than 91 db in the best ear) from an afrikaans oral residential school for the deaf a uniform and relatively arbitrary sign system was found to be in usage within the school. comparing these signs with the signs used in an english oral residential schoolfor the deaf, it became apparent that only certain signs for lexical items were similar. furthermore, a marked difference between the signs for lexical items used by the deaf in the afrikaans residential school and the "standard south african signs" were found. opsomming die gebare vir 15 leksikale items is op videoband geneem en ontleed vir 40 kongenitaal dowe leerlinge (gehoorverlies groter as 91 db in die beste oor) in 'n afrikaanse skool vir gehoorgestremdes. die leerlinge word deur middel van die orale metode opgelei. daar is bevind dat daar 'n eenvormige en relatief arbitrere gebaresisteem in die skool gebruik word. enkele van die gebare toon ooreenkomste met die wat in 'n soortgelyke skool waar engels die voertaal is, gebruik word. daar is ook enkele ooreenkomste tussen die gebare vir leksikale items van die dowes in die afrikaanse skool en die "standaard suid-afrikaanse gebare". sign languages as commonly used among the deaf, are highly structured and organized systems and thus allow for communication equal to spoken languages. a sign language1 consists of a lexicon, grammatical rules and semantic characteristics, which enables one to express ideas and satisfy communicative needs (bonvillian, orlansky and novack, 1978). signs serve as the lexicon of this visibly transmitted language. a single member of a lexicon is a lexical item (i.e. a sign) which in a spoken language would be a word. many different types of signs are in existence: local, provincial, standard, conservative and puristic (stokoe, 1976 as cited by caccamise, ayers, finch and mitchell, 1978). analogous to the structure of the phonological system of oral language, are four parameters: hand configuration, hand orientation, movement of the hand and location where these occur, which arise from the patterned movements of the hands (klima and bellugi, 1980). these parameters are combined simultaneously to form either iconic signs, which visually resemble the referent, or arbitrary signs, which bear little or no resemblance to the referent (orlansky and bonvillian, 1984). both iconic and arbitrary signs used by different signers are not only non-uniform throughout the world, but are not necessarily standardized within many countries (battison as cited by stokoe, 1980a). caccamise et al. (1978), state that the standardization can only occur through consistency of sign use, that is, through public and institutional acceptance of the same sign, for the same meaning, by different users. to obtain this 'consistency' of use is not easy and often proves impossible, owing to differing sociological, demographical 'and cultural factors present in a country (fisher, 1982). south africa is a country where the above-mentioned factors are especially apparent. a diverse cultural heritage, as well as demographic and politically induced separateness of its ethnic groups, emphasizes these differences (penn, lewis, greenstein, 1984). these ethnic groups have their own culture, each differing from the other. © sasha 1986 it can therefore be assumed that a sign system will develop among the deaf in each ethnic group. penn et al. (1984) hypothesize that those south african sign languages that exist, contain as rich a vocabulary and arbitrary a structure as any language. however, because sign languages differ just as much as spoken languages differ from one another (markowicz, 1977, as cited by musselwhite and st. louis, 1982) 'consistency' of sign use in this country would be virtually impossible. it has been proposed by lewis (1983) that because of south africa's discrete educational policies, the separate signing systems will reflect the social group of those who use them. a study in respect of the english deaf group in johannesburg was therefore carried out (greenstein, 1983), to determine whether or not uniform signs were used within an english oral residential school for the deaf, and whether or not there was a divergence from these signs from the proposed 'south african' signs of nieder-heitmann (1980). these signs2 in the book "talking to the deaf' are presently being promoted as being representative of the signs used by the majority of the deaf in this country (rousseau 1980). results indicate that uniform'signs were used in the english oral residential school, as hypothesized, and that 75% of these did indeed differ from nieder-heitmann's (1980) proposed sign system. by attempting to investigate the afrikaans deaf cultural group's use of sign, this study will.also aim at providing further information concerning the use of'uniform' south african signs. the purpose of this study is to determine whether or not certain lexical items in the sign lexicon used by the afrikaans-speaking deaf school child in an afrikaans oral residential school for the deaf, are uniform and consistently used within the school and to what degree this afrikaans sign lexicon differs from that of the english culture and the south african signs of nieder-heitmann (1980). in this way an indication of the degree to which a 1 such a language is american sign language (asl), a bona · fide language most widely used by the deaf in america. 2 these signs will be referred to as the south african signs. the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) lexical items in an afrikaans oral residential school for the deaf 57 consistently used uniform sign system exists within south africa, can be provided. method 1. aims the following aims were formulated: a . to describe the signs used by children in an afrikaans oral residential school for the deaf, determining whether or not the use of the signs described is uniform within the school. b. to determine whether or not the signs in the afrikaans residential school for the deaf, differ from those in use at the english oral residential school for the deaf, thus determining whether the nature of the signs is affected by the language culture group (greenstein, 1983). c. to determine whether or not the signs used within the school, differ from those proposed by nieder-heitmann (1980) to be the standard3 south african signs. 2. subjects for this study forty pupils aged 7 to 19 years were selected from an afrikaans residential school for the deaf. profound congenital hearing loss was present in all subjects (hearing level greater than 91 db in the best ear). the rationale for studying these subjects is based on evidence that they rely to a greater extent on non-verbal communication than subjects with more residual hearing (siple et al. 1978a). subjects with deaf parents were excluded from this study because these parents could influence the vocabulary used by the child. furthermore, subjects with other handicaps were also excluded because these handicaps could affect their signing abilities. the subjects selected for this study are presented in table 1. table 1: description of subjects variables age groups (years) 7-9 10-13 14-16 17-19 degree of loss: >91 db(hl) 10 / 10 10 10 onset of loss: congenital j10 10 10 10 hearing status of parents: normal 10 10 10 10 educational environment: afrikaans 10 10 10 10 residential status: boarders 10 10 10 10 secondary handicaps: none ! 0 0 0 0 intelligence: normal !10 10 10 10 sex: male ! 5 5 5 5 female ' 5 ' 5 5 5 3. material twelve of the fifteen lexical items were selected from those used by greenstein (1983) to compare the signs of the afrikaans and english deaf pupils. these are: nouns: hond, mamma, boom verbs: bad, spring, sit adjectives: geel, oud, bly prepositions: op, voor, na . . . toe in addition the following three emotive words were arbitrarily chosen: lag, kwaad, huil (warren, 1985) 3 standard = consistent use of signs (caccamise, ayers, finch and mitchell, 1978). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 4. representation o f test material a clear, colourful picture, representing each lexical item was used to elicit a response. below the picture was the printed form of the word in isolation as well as in a sentence in dark block lettering underneath the picture-word card (warren, 1985). 5. procedure a quiet, well-lit room in the school was used. instructions were given orally, in natural gestures and in sign, by the investigator. the subjects had to sign the word represented by the pictureword card. subjects were then individually tested to ensure that they could not influence one another's use of signs. subjects were filmed so that the whole body of the subject was video taped, capturing the total movement involved in producing the sign (warren, 1985). 6. scoring procedure for the analysis of data, the three parameters as described by stokoe (1980b) were used, namely: dez, sig & tab. in addition to these three classic parameters, orientation was analysed as a fourth parameter as suggested by battison, markowicz and woodward (1975, as cited by daniloff and vergara, 1984). orientation is important in sign formation, as it distinguishes between minimal pairs of signs. signs were analyzed according to: a. designation — dez — the distinctive handshape used to make the sign e.g. flat hand. a list of handshapes used by the subjects in this study were obtained from niederheitmann's book 'talking to the deaf (1980, p. 54) as a comparison of the signs of afrikaans subjects to the south african signs was being made, and a common classification system was needed. any handshapes used by the subjects, and not listed by nieder-heitmann (1980) were obtained from klima and bellugi (1980). b. signation — sig — the movement involved in making the sign, e.g. circular. c. tabulation — tab — the location where a sign begins and ends in relation to the signer's body. termed 'place of articulation' e.g. chest. d. orientation — orient — planes of the palms of the hand, e.g. palm up. results table 2 provides a clear description of the signs consistently used by the majority4 of afrikaans subjects — 50% being a significant majority according to penn and saling (1983 as cited by greenstein, 1983). fourteen of the fifteen signs have been described according to the four parameters dez, sig, tab (stokoe, 1980b) and orient (markowicz and battison, 1975 as cited by daniloff and vergara 1984). one sign, 'in front of is discussed in table 3, as no single sign is used by the majority for this lexical item. the percentage of subjects using the sign has been provided to indicate the extent to which each sign is used by the subjects. 4 signs used by the majority in the school will be referred to as uniform signs. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) , q sonya warren, santie meyer and h.e.c. tesner j o table 2: a description of the signs used by the majority of subjects in the afrikaans oral residential school for the deaf word % of ss dez sig tab orient dog (hond) 100% compressed hand opens and closes lower face vertical — unilateral opposite mommy* (mamma) 92,5% claw hand move hand across chest l-r, r-l chest vertical — toward body tree (boom) 95% cupped hands (bilateral) finger tips together move apart in a circular shape joining once more at wrists fingers wrist vertical — bilateral opposite yellow (geel) 85% broad u-hand wrist action opening of ear on same side vertical — unilateral opposite old (oud) 60% crooked fingers move finger slowly down cheek cheek on same side vertical — away from body happy* (bly) 57,5% flat hands (bilateral) clap hands together neutral vertical — bilateral opposite bath (bad) 95% spread hand rub hand in circular motion lower chest abdomen vertical — toward body jumping (spring) 72% v hand raise hand vertically from palm of opposite hand palm of opposite hand vertical — unilateral body sitting (sit) 77,5% fist hand move hand downward to strike palm of opposite hand palm of opposite hand vertical — unilateral opposite on (op) 72,5% flat hand move hand straight down neutral abdomen horizontal — palm down in front (voor) minority use — see table 3 to (na... toe) 50% first finger (bilateral) move 1st finger of dominant hand along side of opposite 1st finger side of opposite finger horizontal — p a l m down laugh (lag) 67,5 % clawed hand (bilateral) move hand l/r-r/l in front of lower face vertical — toward body cross (kwaad) 82,5% clawed hands (bilateral) no movement cheeks vertical — toward body cry* (huil) 85% v hand move fingers straight down cheeks cheeks vertical — toward body χ= 73% x = the average number of subjects using the sign system *signs considered to have a certain amount of iconicity as is evident from table 2, the sign for the lexical item 'dog' was the only sign consistently used by 100% of the subjects. ten of the fifteen signs were used by more than 70% of the subjects, while four of the signs, i.e. 'happy', 'to', 'laugh' and 'old' were used by 50% or more of the subjects. it was hypothesized that a sign system would be in use at the afrikaans oral residential school for the deaf. it is apparent from the results in table 2 that a certain uniform and largely arbitrary sign system is in existence within the school. it is considered uniform as most of the signs are consistently used by the majority of subjects. these signs which serve as a means of communication amongst the subjects, do not appear to be idiosyncratic to each individual signer, but have rather become a system commonly used by the majority of the subjects. this is in agreement with baker and cokely's (1980) proposal that the members of a community must agree on the meaning of symbols and the manner in which they are used for effective communication: it is apparent that the above-mentioned activities have taken place amongst the afrikaans subjects, owing to the fact that 73% (see table 2) of the subjects used the same signs for the representation of certain lexical items. / many of the signs in table 2 are also considered arbitrary as they do not visually represent the referent e.g. 'yellow'. however, baker and cokely (1980) state that degrees of arbitrariness exist where the sign, although largely arbitrary, has a certain degree of iconicity, i.e. relatively arbitrary. these signs are indicated in table 2 with the use of an asterisk e.g. 'mommy'. the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) signed lexical items in an afrikaans oral residential school for the deaf table 3: a description of signs used by a minority of the subjects word % of ss dez sig tab orient happy (bly) 22,5% flat hands (bilateral) clap hands together palm of opposite hand horizontal — palm down jumping* (spring) 15% flat hands (bilateral) raise hands upwards. simulate jumping movement of legs side of body horizontal — palm down sitting* (sit) 15% flat hands (bilateral) move hands downwards. simulate sitting movement by bending knees side of body horizontal — palm down on (op) 17,5% flat hand (bilateral) clap hands together palm of opposite hand horizontal — palm down in front of (voor) 42,5% a. 35% b. cupped hand move hand forward in semicircle away from chest chest neutral vertical — toward body in front of (voor) 42,5% a. 35% b. first finger point finger forward — wrist of dominant hand bangs against opposite wrist wrists vertical — away from body to* (na..toe) 27,5% a. 20% b. fist hand move hand outwards in bold movement chest vertical — unilateral opposite to* (na..toe) 27,5% a. 20% b. fist hand point finger in front neutral region vertical — unilateral opposite laugh* 15% flat hands (bilateral) hand hold stomach — slight move up and down neutral vertical — toward body cry* (huil) 10% first finger (bilateral) move fingers straight down cheeks cheeks vertical — toward body χ = 6% percentage of subjects using the iconic* signs χ = 15% percentage of subjects using the minority system of signs •an asterisk marks the signs that are largely iconic. ι table 3 indicates the signs which are neither idiosyncratic to just one individual signer, nor representative of a majority use, but are, however, used by a minority, i.e. less than 50% of the subjects. the description of sign follows the same format as that used in table 2, while an asterisk marks those signs that appear to be iconic. pertinent to table 3 is the fact that all the signs were used by a minority of subjects — appearing to be less than 30% in all cases except for 'in front of. for the lexical item 'in front of, two differing signs, each used by a minority of subjects (42,5% and 35% respectively) were elicited (see table 3). the sign for 'in front of (a), subjectively viewed, appears motorically easier and slightly more iconic than 'in front of (b). since the lexical items that could be influenced by the context e.g. 'on', were placed in an appropriate sentence, it is felt that the own interpretation of the context by the subjects did not influence the form of the sign. (for example, "he sits on the chair"). it therefore appears that two signs are in use at the afrikaans oral residential school for the deaf, for the lexical item 'in front of. an issue of importance is the fact that 50% of the signs — five of the ten in table 3 — are iconic e.g. 'sitting' — (indicated by an asterisk) while the remaining five are relatively arbitrary. although table 3 indicates minority use, at least 10% of the subjects used the sign in each case. it is therefore apparent that these signs are not idiosyncratic to each individual, but rather serve as a communication system. thus it is evident that within this oral school for the deaf a uniform sign system used by a majority, as well as certain signs by the minority, (x 15%) are in existence. the uniform system shows consistent use by 73% of the subjects. this is in accordance with lunde (as cited by stokoe, 1980a) who states that although oral schools emphasize speech reading and speech, the fact is that the deaf, as a group, use sign language amongst themselves. 2. differences in structure of the signs used in the english and afrikaans oral residential school for the deaf. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 sonya warren, santie meyer and h.e.c. tesner table 4: the variations across the four parameters which occur in the signs of the english and afrikaans subjects word dog mommy tree yellow old* happy* bathing jumping sitting on in front of to dez sig tab orient % afr ss 60% 57,5% 17,5% % eng ss 95% 77,5% 80% 92,5% 92,5% 92,5% 80% 70% 90% 50% extreme variations of english signs χ ι χ ι x 20% 87% the percentage of afrikaans subjects using the signs of the english subjects 13% * = signs are the same χ = variation in parameter table 4 is a comparison of the signs used by the majority of subjects in the afrikaans school and those used by the majority of subjects in the english school. the signs have been analyzed according to the parameters dez, sig, tab and orient. notable differences between the two sets of signs are indicated by a cross. the second to last column from the right indicates the percentage of afrikaans subjects using the signs that are used in the english oral residential school, while the last column in table 4 indicates the percentage of english subjects using each sign of the sign system, unique to the english oral residential school for the deaf. the sign for 'in front of could not be compared, as greenstein (1983) could also not determine a definite use of sign by a majority, for this lexical item. the' results in table 4 can be discussed after the division of signs has been explained. after researching the development of signs it was evident that there are differences between the younger and older subject's signs. greenstein (1983) noted that a development of ceftain signs (from the iconic to the more arbitrary forms) was evident. both the iconic and relatively arbitrary signs were treated as being part of a uniform system. in this study the signs were subdivided into the relatively iconic (developing signs, marked by an asterisk in table 3) and relatively arbitrary levels (see table 2). for comparison of the use of iconic and arbitrary signs by different age groups, the reader is referred to greenstein (1983) and warren (1985). although not proven, it is felt that the younger subjects will acquire the adult form of the sign (bornstein, 1978) (i.e. the more arbitrary uniform sign system). for this reason only the relatively arbitrary sets of signs are compared with greenstein's (1983) results. table 4 illustrates that only in two cases the same signs were used by the majority of english and afrikaans subjects; these were the signs for 'old' and 'happy'. the four signs 'dog', 'tree', 'sitting' and .'to' show a difference across all four parameters indicating an extreme variation for these lexical items in the two sets of signs. the remaining five signs 'mommy', 'yellow', 'bathing', 'jumping' and 'on' show at least one parametric variation. although the uniform signs of the afrikaans subjects for 'on' differed from the sign of the english subjects by three parameters, a minority of afrikaans subjects, i.e. 17,5% did use the sign used by 50% of the english subjects. similarly, 20% of the afrikaans subjects used the same sign for 'to' as was used by 87% of the english subjects. it must be noted that whereas the signs for 'on' and 'to' were used by a majority in the english school, they were only used by a minority in the afrikaans school. the sign for the lexical item 'jumping' used by the afrikaans subjects, was found to vary from the sign used by the english subjects, with 'palm up' as opposed to a 'palm down' orientation of the non-dominant hand (see appendix). although the three parameters dez, sig and orient correlated, the sign differed because of tabulation. the sign of the afrikaans subjects for 'bathing', differed only in 'movement' from the otherwise correlate english sign, while 'mommy' differed only through 'handshape' variation. it was hypothesized that the signs used by the majority of subjects in the afrikaans oral residential school for the deaf, would differ from the signs described to be of uniform use (of the majority) in the english oral residential school. the results therefore support the hypothesis that although both schools are using a uniform system of signs, the majority of these signs differ between the two schools. it has been said that children in a given school will invent and utilize signs not found elsewhere (cokely and gawlick, 1974 as cited by bornstein, 1978). bearing in mind that sign language has never been formally taught in white south african schools, it can therefore be expected that the pupils in both the english and afrikaans schools have devised their own system of signs. the fact that the english and afrikaans groups are representative of different cultures (baker and cokely, 1980) could explain these differences. furthermore, these differences could also be attributed to geographic areas. this is in accordance with markowicz (1980) who states that in different geographical areas different signs are sometimes used to represent the same thing. 3. differences in structure of the south african signs and the signs used in the afrikaans oral residential school for the deaf table 5: differences across the parameters occurring in two sets of signs word dez sig tab orient % afr ss dog x x x x mommy a) x x x b) x x x tree a) x x x x i b) x x x x j yellow x x x x 1 i •old 60% happy x 22,5% bathing x x x •jumping 72,5% sitting x x x x on x x x in front of a) x x x b) x x x x to x x x x percentage of afrikaans subjects using the south african signs / 13% * = signs are the same χ = variation in parameter a) and b) = two varying sa signs for the same lexical item. table 5 indicates the variations across the four parameters (i.e. dez, sig, tab and orient of signs) which occur between the south south african journal of communication disorders, vol 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) signed lexical items in an afrikaans oral residential school for the deaf a f r i c a n signs and the uniform signs used by the majority of subjects in the afrikaans oral residential school for the deaf. the analysis follows the same format as that of table 4. the far right hand column indicates the number of afrikaans subjects using the south african signs. for a detailed description of the differences in the two sets of signs refer to the appendix. in table 5 it is evident that, of the twelve signs used by the majority of afrikaans subjects, only two, namely 'jumping' •72,5%) and 'old' (60%) correlate exactly with the south african signs, for the representation of the same lexical items. the signs of the afrikaans subjects for 'tree' (b), 'dog', 'yellow', 'sitting', 'in front of (b) and 'to' show variations across all four parameters and therefore have no correlation with south african signs i.e. 'mommy' (a and b), 'tree' (a), 'bathing', 'on', 'in front of, while the sign for 'happy' is the only sign which correlates across three parameters with the south african signs. divergence is evident in the fourth parameter — orientation. the south african sign for 'happy' was, however, used by a minority (22.5%) of the afrikaans subjects, correlating across all four parameters because of orientation being 'palm down' as opposed to bilateral opposite which was used by the majority of afrikaans subjects. deaf culture — did not make consistent use of the signs proposed by nieder-heitmann (1980) to be representative of all signs used by various ethnic groups in south africa. the signs showed a marked difference from one another. this investigation therefore supports lewis' (1983) hypothesis that deaf populations in the country, who stem from discrete language and educational backgrounds, will exhibit divergence from the hypothesized standard sign system. this study is an important introductory contribution with regard to the investigation of the sign lexicon used by subjects in an afrikaans school for the deaf and adjunct to the study carried out by penn et al. (1984). with the exception of these results very little research is available regarding this specific sign system. it is an important research area as stokoe (1980b, ρ 126) states: 'sign languages generally and sign in particular make excellent objects for scientific study . . . for sign is a language which can make a deaf person a sharer in culture and also a member of a specific group with its own self awareness and pride.' this is specifically relevant in the demographically diverse multi-cultural situation in south africa.' the results of table 5 indicate that minority of subjects in the afrikaans oral residential school for the deaf are using the south african signs i.e. 13%. this clearly shows that within this school a sign system which differs from that of the proposed south african signs of nieder-heitmann (1980) is in existence. only one south african sign 'old' is used consistently by both english and afrikaans subjects and appears to be the only uniform south african sign of the twelve lexical items. rousseau (1980) describes the signs presented in niederheitmann's book as a systematized language system, incorporating the signs commonly used by the deaf in south africa. with these significant differences present it is evident that the validity of rousseau's (1980) proposal could be queried. furthermore, consistency is recognized as a critical factor, the basic premise upon which standardisation rests (caccamise et al. 1978). yet, it appears from the! above results that the south african signs are not consistently used by subjects to represent the lexical items tested. conclusions the findings support the hypothesis that a uniform and relatively arbitrary sign system is in existence within the afrikaans oral residential school for the deaf. the majority of subjects have a sign system which is not idiosyncratic, but is representative of the group studied as a whole. this is in accordance with literature where it is suggested that children in an oral school utilize a sign language amongst themselves (lunde as cited by stokoe, 1980b). although the white deaf population in this country are not taught sign language, they appear to 'turn quite naturally to their own language' (furth cited by markowicz, 1980). on comparison of the results of this study with an investigation carried out on english subjects in an english oral residential school for the deaf (greenstein, 1983) it was evident that single lexical items were similar. however, in most cases the signs of the afrikaans subjects were part of a sign system in existence within the afrikaans oral residential school, which is largely unique to the school. this is in accordance with cicoural (1978) who notes that a variety of sign forms emerge among signers of differing educational backgrounds. the results indicate that the subjects in an afrikaans oral residential school for the deaf — a subgroup of the south african references baker, c. and cokely, d. american sign language: a teacher's resource text on grammar and culture.!.j. publishers, inc., maryland, 1980. bonvillian, j.d., orlansky, m.d. and novack, l.l. developmental milestones, sign language acquisition and motor development. child development, vi. 54, 1435-1445, 1978. bornstein, h. sign language in the education of the deaf. in: i.m. schlesinger and l. namir (eds) sign language of the deaf. academic press, inc. new york, 1978. caccamise, f., ayers, r., finch, k., and mitchell, m. signs and manual communications systems: selection, standardization and development. american annals of the deaf vol 123, 887-901, 1978. cicoural, a.v. sociolinguistic aspects of the use of sign language. in: i.m. schlesinger and l. namir (eds.) sign language of the deaf. academic press, inc., new york, 1978. daniloff, j. and vergara, d. comparison between the motoric constraints for amer. ind. and a.s.l. sign formation. journal of speech and hearing research. no. 27, 70-76, 1984. fisher, s. sign language and manual communication. in: g.g. walter and r.l. whitehead. deafness and communication; assessment and training. williams and wilkins, baltimore, u.s.a., 1982. greenstein, a.l. signs used by pupils in an oral residential school for the deaf. unpublished thesis, university of the witwaterrand, johannesburg, 1983. klima, e. and bellugi, u. the signs of language. harvard university press, massachusetts, 1980. lewis, r.e. an overview of the research into the american sign language continuum and its relevance to south african sign languages and codes. an unpublished paper, university of the witwatersrand, johannesburg, 1983. markowicz, h. some sociolinguistic considerations of american sign language. in: w.c. stokoe. sign and culture. linstok press, maryland, 1980. musselwhite, c.r. and st. louis, k. communication programming for the severely handicapped: vocal and non-vocal strategies. college hill press, houston, texas, 1982. nieder-heitmann, n. talking to the deaf. government press, pretoria, 1980. orlansky, m.d. and bonvillian, j.d. the role of iconicity in early sign language acquisition. journal of speech and hearing disorders, vol. 49, 287-292, 1984. die suid-afrikaanse tydskrif vir kommunikasieafwykings vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 sonya warren, santie meyer and h.e.c. tesner penn c lewis, r. and greenstein, a. sign language in south africa: some research and clinical issues. south african journal of communication disorders, vol 31, 6-11, 1984. rousseau, g.j. foreword. in: n. nieder-heitmann. talking to the deaf government press, pretoria, 1980. siple, p., hatfield, n. and caccamise, f. the role of visual perceptual abilities in the acquisition and comprehension of sign language. american annals of the deaf. nov. 78, 852856, 1978a. siple, p. linguistic and psychological properties of american sign language: an overview. in: ρ siple (ed.) perspectives in neurolinguistics and psycholinguistics. a series of monographs and treatises. academic press, inc., new york, 1978b. stokoe, w.c. sign and culture. linstok press, maryland, 1980a. stokoe, w.c. the study and use of sign language. in: r.l. schiefelbusch. language intervention. university park press, baltimore, 1980b. warren, s. signed lexical items in an afrikaans oral residential school for the deaf. unpublished blog thesis, university of pretoria, pretoria, 1985. afrikaans subjects english subjects south african signs 100% 95% hond dez compressed hand (unilateral) 1st finger (unilateral) flat hand (unilateral) (dog) sig hand opens and closes finger moves from a central pat thigh with hand position to the centre of the throat tab centre of mouth centre of throat thigh orient vertical-unilateral vertical-toward body vertical-toward body face signer is required to look down while eliciting the sign 93% 77,5% mamma dez claw hand flat hand a b (mommy) m-hand flat hand sig move hand across chest move hand across chest tapping move across l-r or r-l l-r or r-l movement chest l/r and r / l tab chest chest — palm of the opposite palm of chest — point hand rests on chest opposite hand of contact is side of 4th finger orient vertical — toward body vertical — toward body vertical — horizontal — toward body palm up 95% 80% boom dez cupped hands (bilateral) spread/clawed hand a b (tree) spread hand spread handelbow bent sig finger tips together, move hand moves from side move hands move hand apart in a circular shape joining up and down from side to once more at wrists indicating the side ; outline of ; a tree 1 tab finger tips — wrists elbow rests in opposite shoulders — elbow rests on cupped hand abdomen back of opposite hand orient vertical — bilateral opposite vertical — toward body vertical — orientation bilateral changes as a opposite result of hand rotation face 87% 92,5% / geel dez u-hand y-hand 1st finger (yellow) sig wrist action of u-hand wrist action of y-hand tap 'opening' of ear on same side tab next to opening of ear on inside of opposite cup-hand 'opening' of ear on same side same side orient vertical-unilateral opposite horizontal-palm down vertical-toward body appendix: a description of the signs used by the majority of subjects in the afrikaans and english schools respectively together with a representation of the south african signs. south african journal of communication disorders, vol 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) signed lexical items in an afrikaans oral residential school for the deaf 63 afrikaans subjects english subjects south african signs 80% 92,5% oud* (old) dez sig tab orient face crooked finger move finger slowly down cheek cheek on same side vertical-palm away from body 57% 92,5% bly (happy) dez sig tab orient face flat hands (bilateral) clap hands together neutral region (abdomen) vertical-bilaterial opposite happy look flat hands (bilateral) clap hands together abdominal region vertical-appears bilateral opposite smile — happy look flat hands (bilateral) clap hands together abdominal region horizontal — palm down and up smile — happy look 95% 80% bad (bathing) dez sig tab orient face spread hand-unilateral rub hand in circular motion lower chest-abdomen vertical-toward body spread hand-unilateral rub hand up and down chest-abdomen vertical-toward body clawed fists (bilateral) rub hand up and down chest region vertical-toward body 72,5% 15% 35% 35% spring (jump) dez sig tab orient face a b v hand flat hands raised hand flat hands once, vertiare raised upcally from wards. jump palm of oppoup and down site hand (lower limbs) palm of opposite hand verticalhorizontaltoward body palms down a b v hand hands passive jumping jump up and movement down (limbs) hands at either side of body back of hands on opposite hand either side of body verticaltoward body v hand raise hand vertically from palm of opposite hand palm of opposite hand vertical-toward body 77,5% 15% 52,5% 22,5% sit (sitting) / / dez · 1 1 sig tab ! orient face a b fist hand flat hands move hand flat hands downward to move downstrike palm of ward. sitting opposite hand movement by bendingknees palm of opposite hand verticalhorizontal unilateral palms down opposite a b clenched fists, clenched fist bend elbows bend elbows bend elbows twist wrists back and bend back bend knees arms at side side of body of body verticalaway from body clenched fists — open thumb close fist by pushing down thumb side of body vertical — bilateral opposites 72% 50% op (up) dez sig tab orient face flat hand move hand straight down neutral— abdomen horizontal — palm down palm of flat hand clap palms together palm of opposite flat hand horizontal — palm down palm of flat hand clap palm of flat hand on back of opposite hand back of opposite flat hand horizontal — palm down "the only south african sign consistently used by english and afrikaans subjects. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 sonya warren, santie meyer and h.e.c. tesner afrikaa ns subjects english subjects south african signs 42% 35% variations voor dez a b in front cupped 1 finger extreme variation within compressed hand of) hand this sign compressed hand sig move hand point move hand across chest forward in finger forl-r or r-l semi-circle ward. wrist away from of dominant chest hand strikes wristof opposite hand tab chest neutral wrists chest orient verticalverticalverticaltoward body toward away from verticaltoward body body body face 50% 20% 87% na...toe dez a b (to) 1st finger 1st finger 1st finger 1st finger bilateral 1st finger sig move 1st point point finger join tips of fingers finger of finger join tips of fingers dominant hand along side of opposite 1st finger tab side of in front in front or l; r 1st finger of opposite hand opposite centre of body finger centre of body orient horizontal verticalvertical-unilateral opposite vertical-palm away palm down unilateral from body opposite face the use of signs and the coding of prefix markers by teachers at a school foi the deaf ι myrtle l aron, ph d (witwatersrand·) i robyn ε lewis, ba(log.) (witwatersrand) ba soc.science (unisa) j judy l willemse, ba (sp. & η therapy) (witwatersrand) department of speech pathology and audiology university of the witwatersrand, johannesburg abstract the use of aspects of an artificially devised manual code in a black schoolfor the deaf was examined. the encoding of prefixes, bound with the noun class system, in tswana as used by seven teachers was studied as well as the consistency of the teachers to code lexical items. results .indicated the absence of signed prefix markers, inconsistency in signing lexical items and much variability among teachers in the signs used. the educational and research implications are discussed. /'' opsomming die gebruik van aspekte van "n kunsmatig ontwikkelde gebarestelsel in 'n swart skool vir dowes, is ondersoek. die enkodering van voorvoegsels verbonde aan die naamwoordklasstelsel in tswana soos gebruik deur sewe onderwysers is bestudeer, asook die konstantheid van die onderwyser se vermoe om leksikale items te kodeer. resultate dui op die afwesigheid van voorvoegselgebare, onkonstantheid van leksikale gebare en baie variasie onder onderwysers t. o. v. die gebare wat hulle gebruik. die opvoedkundige en navorsingsimplikasies word bespreek. ^ ο sasha 1986 77^ south african journal of communication disorders, vol 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 7 gesproke en geskrewe taalvermoens van hulpklasleerlinge teruggeplaas in hoofstroomonderwys karen kleingeld, brenda louw en isabel c. uys departement kommunikasiepatologie universiteit van pretoria opsomming resente navorsing le toenemend klem op die rol van die spraak-taalterapeut by taalleergestremde hinders 'n ^^uegter • γ tn^z satuur eeidentifiseer betreffende die taalfunksionering van die ouer taalleergestremde kind in die skool. b ^ z i i ^ t l t ^ t z n van gesproke en geskrewe taalprobleme by leerlinge wat uit die hulpklas ter^geplaas ilnztroomonderwys, het as motivering vir hierdie studiegedien. die empinese studie is opagt-en-twintigafrikaa^en en^elsprekende stankerd twee oud-hulpklasleerlinge uitgevoer. die proefpersone se peil van taalen skolastiese l s s t s kwalitatief en kwantitatief ontleed en beskryf, dear die gebruik van die toets vir mondehnge taalproduksie r^die suidam.kaanse skryftaaltoets. die resultate van die studie toon dat 'n beduidende persentasie van die proefpersone z^^^zttas^obume ondervind en 'n agterstand in die vakke afrikaans en engels vertoon. betekenisvolle korrelasiesiscmn^toon tussen die proefpersone se gesproke en geskrewe taalvermoens en hulle taalvermoens en .ftofarte» prestasies d^bevindinge hou belangrike implikasies in vir die bantering van die taalleergestremde kind m die praktyk en zox voortgesette spraak-taalterapeutiese intervensie aan by hinders wat uit die hulpklas teruggeplaas is η zofstroomonderwys. verdere navorsing oor die taalvermoens van die ouer taalleergestremde kind word aanbeveel ter uitbreiding en bevestiging van die navorsingsresultate. abstract current literature emphasizes the role of the speech-language therapist with regard » l " ^ * ? ™ * gabled children a lack of research regarding the language abilities of the older language learning disabled child was however identified the possmjity of continued spoken and written language problems in aid class children who have been placed back into mair^tream edulion, served as a motivation for this research project the on twenty-eight afrikaans arid english speaking ex-aid class children. according to experiment performlein spoken and written language and scholastic skills were analysed and described tively, through the test for θ\αι language production and the south african written language that a significant percentage of the subjects evidenced spoken and written language problems and the school subjects afrikaans and english. meaningful correlations were found to exist between guage, and language skills dnd scholastic performance. implications for dealing with the language learning disabkdchdd ire discussed, l!continuation of speech-language intervention with aid class c^^n ^o w e ^ mainstream education, is strongly recommended. a need for further research with regard to the older language learning disabled child is expressed in order to support and expand these results. sleutelwoorde: taalleergestremde kinder s, hulpklas, gesprokeen geskrewe taalprobleme, geheeltaalbenadering, samewerkende dienslewering. inleiding die spraak-taalterapeut se rol in hulpverlening aan kinders met leerprobleme het toegeneem in samehang met navorsing oor die verband tussen taalen leerprobleme (hill & haynes, 1992). taal blyk onontbeerlik te wees vir die leerproses in die skool, met die gevolg dat taalprobleme aanleiding gee tot die ontwikkeling van leerprobleme (wallach, 1990). in die lig van bogenoemde behoort die spraak-taalterapeut dus as aktiewe lid van die multidissiplinere span op te tree in die voorkoming, identifisering en remediering van onderliggende taalprobleme by die taalleergestremde p'opulasie. leerlinge met ernstige leerprobleme word dikwels in die hulpklas, 'n aparte remedierende klas binne skoolverband, geplaas (haines, 1988). die doel van die hulpklas is om aan die kind met leerprobleme intensiewe remedierende hulp te verleen en akademiese vordering op 'n individuele grondslag te monitor. hulpverlening vind in spanverband plaas en die onderwyser, opvoedkundige sielkundige, spraak-taalterapeut, arbeidsterapeut en mediese dokter lewer insette om die skolastiese, taal, perseptuele en fisiese probleme wat saamhang met die hulpklasleerling se leerprobleem, te ondervang (itempelhoff, 1994). resente navorsing oor die taalvermoens van afrikaanssprekende hulpklasleerlinge toon aan d&t tot soveel as 94% van hierdie leerlinge geringe tot die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 karen kleingeld, brenda louw & isabel c. uys ernstige orale semantiese afwykings vertoon, wat negatief op skolastiese'prestasie kan inwerk (du plessis, 1992). dit is dus duidelik dat die spraak-taalterapeut wat in die skole werksaam is, aandag moet skenk aan taalprobleme wat by hulpklasleerlinge voorkom. hulpklasleerlinge kan gespesialiseerde onderrig egter slegs tot op negejarige ouderdom ontvang, waarna hulle teruggeplaas moet word in hoofstroomonderwys, ongeag of hulle leerprobleme opgelos is of nie (derbyshire, 1989). die verband wat uitgewys is tussen taal en leer vero'nderstel dat taalprobleme steeds by die nie-gerehabiliteerde oud-hulpklasleerlinge kan voorkom. opvolgstudies oor die verloop van taalprobleme bewys ook dat taalprobleme met tyd verander, maar bly voortbestaan (hill & haynes, 1992). aangesien onderliggende en onopgeloste taalprobleme dus steeds akademiese vordering kan beperk, kan die taak van die spraak-taalterapeut nie as afgehandel beskou word sodra die taalleergestremde kind gereed is om weer in die hoofstroom teruggeplaas te word nie. 'n leemte wat egter in die literatuur en in die praktyk gei'dentifiseer is, is navorsingsbevindinge met be trekking tot die spesifieke taalvermoens van leerlinge wat hulpklasonderrig ontvang het. omdat die taalleergestremde leerling wat in 'n hulpklas was aan 'n unieke hulpverleningsituasie blootgestel is, kan bestaande literatuur oor die taalvermoens van taalleergestremde leerlinge nie sonder meer op die oud-hulpklasleerling toegepas word nie. die implikasies wat die voortbestaan van gesproke en geskrewe taalprobleme by oud-hulpklasleerlinge vir spraak-taalterapeutiese dienslewering inhou, noodsaak dus verdere navorsing in hierdie verband. tbenemende klem wat tans in die onderwys op 'n voorkomende, eerder as 'n remedierende benadering geplaas word (williams, 1995), identifiseer 'n behoefte aan navorsing wat aanleiding kan gee tot voorkomende optrede in spraaktaalintervensie. verder fokus resente onderwysgerigte navorsing in suid-afrika op die insluiting van kinders met spesiale behoeftes in hoofstroomonderwys (naidoo, burden, topham & singh, 1996), wat die belang van spraaktaalterapeutiese navorsing by hoofstroom taalleergestremde kinders beklemtoon. aangesien 'n geheeltaalbenadering tot taalintervensie by leergestremde kinders voorgehou word, en geskrewe en gesproke taal as 'n eenheid binne hierdie benadering figureer (smith-burke, deegan & jaggar, 1991), stel die empiriese studie dit ten doel om die navorsingsleemte wat gei'dentifiseer is, binne die raamwerk van geskrewe en gesproke taal te ondersoek. resente navorsing oor die verband tussen gesproke en geskrewe taal by leergestremde kinders steun die belang van verdere navorsing oor spesifiek gesproke en geskrewe taal, ten einde onopgeloste vraagstukke wat steeds in die literatuur voorkom, aan te spreek (oosthuizen, 1994). metode doel die doel van die studie is om die gesproke en geskrewe taalfunksionering van 'n groep leerlinge wat hulpklasonderrig ontvang het, te beskryf deur: die aard van gesproke en geskrewe taalvermoens en skolastiese prestasies by die proefpersone te bepaal. die proefpersone se gesproke en geskrewe taalvermoens, asook taalvermoens en skolastiese funksionering te vergelyk. navorsingsontwerp die komplekse aard van gesproke en geskrewe taal, wat vir die doel van hierdie studie ondersoek is, leen hom tot die gebruik van 'n gekombineerde kwantitatiewekwalitatiewe ontwerp. 'n opname metode is as navorsingsontwerp gebruik, en kwantitatiewe (statistiese) en tabel 1. opsommende kenmerke van proefpersone kenmerke van proefpersone subgroepe aantal en % proefpersone (n = 28) moedertaal afrikaans engels 14 (50%) 14 (50%) ouderdom (jare-maande) 9-0 tot 9-11 10-0 tot 10-11 11-0 tot 11-11 3 (11%) 18 (64%) 7 (25%) geslag manlik vroulik 19 (68%) 9 (32%) intelligensiekwosient (osais) 9 5 9 9 100 109 110 119 120 en hoer 4 (14%) 14 (50%) 8 (29%) 2 (7%) geskiedenis van otitis media geen eenmalige episode herhaaldelik 19 (68%) 2 (7%) 7 (25%) aandag-eh konsentrasieprobleme . geen aandagafleibaarheid 19 (68%) 9 (32%) arbeidsterapie geen terapie ontvang terapie ontvang 21(75%) 7 (25%) spraak-taalterapie geen terapie ontvang terapie ontvang 20 (71%) 8 .(29%) ekstra remedierende onderrig geen ekstra onderrig ekstra onderrig ontvang 17 (61%) 11 (39%) tydsduur in hulpklas minder as 6 maande een jaar twee jaar 1 (4%) 18(64%) 9 (32%) rede vir uitplasing uit hulpklas opheffing van leerprobleem maksimum ouderdom 22 (79%) 6 (21%) tydsverloop sedert terugplasing in hoofstroom een jaar twee jaar drie jaar 8 (28%) 19 (68%) 1 (4%) the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gesproke en geskrewe taalvermoens van hulpklasleerlinge teruggeplaas in hoofstroomonderwys kwalitatiewe (beskrywende) analises van verkree data is aanvullend tot mekaar uitgevoer (leedy, 1 9 9 3 ) . resultate proefpersoonseleksie agt en twintig standerd twee leerlinge wat voorheen hulpklasonderrig ontvang het, is as proefpersoonpopulasie geselekteer uit staatsondersteunde afrikaanse en engelse laerskole in benoni en kempton park. kwotasteekproefneming (leedy, 1993) is gebruik in die verkryging van 'n proefpersoon-populasie van ongeveer 30 leerlinge, waarvan 50% deur afrikaanssprekende leerlinge en 50% deur engelssprekende leerlinge verteenwoordig moes word. opsommende kenmerke van die geselekteerde proefpersone word in tabel 1 weergegee. data-insameling die proefpersone is individueel deur middel van gestandaardiseerde gesproke (tmt en tolp) en geskrewe taaltoetse (sast en sawlt) deur die betrokke navorser geevalueer. die toetse is volgens voorgeskrewe standaard prosedures in die toetshandleidings op die proefpersone uitgevoer. by afrikaanssprekende leerlinge is die tmt (vorster, 1980a) en die sast (brink, 1976a) afgeneem, en by engelssprekende leerlinge die tolp (vorster, 1980b) en die sawlt (brink, 1976b). toetsresultate is volgens riglyne gestel deur die handleidings van die tmt/tolp en die sast/sawlt te ontleed. vraelyste oor huidige taalen skolastiese funksionering van die proefpersone is aan die klasonderwysers van die betrokke leerlinge verskaf. vraelyste oor die agtergrondsgeskiedenis van elke proefpersoon is aan die betrokke ouers oorgedra. die proefpersone se finale standerd-twee punte, asook alle ander relevante inligting is uit kumulatiewe verslagkaarte en skolastiese rekords versamel. dataverwerking dataverwerkingsprosedures wat uitgevoer is om elkeen van die doelstellings van die studie te bereik word in tabel 2 saamgevat. tabel 2. dataverwerking van toetsresultate die aard van proefpersone se gesproke en geskrewe taalvermoens en skolastiese vordering beskrywing van die proefpersone se gesproke taalvermoens uit die bestudering van die proefpersone se gesproke taalvermoens volgens die tmt en tolp word die gevolgtrekking gemaak dat proefpersone hoofsaaklik ondergemiddeld presteer in totale woorde, tipe-teken ratio, bywoorde, medewerkwoorde, sinstruktuur-verbeterings, woordkeuse-verbeterings, woordherhalings en abstrak-konkreetheidsindeks, en dat hierdie swak prestasies aanleiding gee tot 'n hoe persentasie ondergemiddelde prestasies in die vlotheid(50%), produktiwiteit(38,1%) en kompleksiteitskale (39,2%) (sien p r o d u k l j w i l a l t k a r r a k t h e l d i n h o u d k o m p i e k i r t f l i l v l o l h e l d t o t a a l n a s i e n s k a l e v a n t m t e n t o l p i % o n d e r g e m i d d e l d % g e m l d d e l d * b o g e m l d d e l d figuur 1: ondergemiddelde, gemiddelde en bogemiddelde prestasies van proefpersone in mondelinge taalproduksie 1 doelstellings 1 roudata statistiese verwerkings voorstelling van resultate 1 aard van gesproke en geskrewe taalvermoens en skolastiese funksionering * staneges tmt (vorster, 1980a) en tolp (vorster, /1980b) * staneges sast (brink, 1976a) en sawlt (brink, 1976b) * ordinale data vraelyste en skolastiese rekords * geweegde rekenkundige gemiddeldes * frekwensies * persentasies (leedy, 1993) * figure 1 tot 3 frekwensie verspreidingsdiagramme staafdiagramme 2 verband tussen gesproke en geskrewe taal en tussen taalvermoens en skolastiese prestasie * staneges tmt (vorster, 1980a) en tolp (vorster, 1980b) * staneges sast (brink, 1976a) en sawlt (brink, 1976b) * ordinale data vraelyste en skolastiese rekords: omgeskakel in kwantitatiewe vorm * spearman korrelasiekoeffisient vasstelling van betekenisvolle positiewe of negatiewe korrelasies tussen data (leedy, 1993) * tabel 3 * tabel 4 die suidafrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 figuur 1). dit blyk dus dat die proefpersone ten spyte van hulpklasonderrig steeds gesproke taalprobleme ondervmd wat verband hou met die lengte en kompleksiteit van huue uitinge, en dat hulle gesproke taal gekenmerk word deur mondelinge verbeterings wat vlotheid b^nvloed. m d bevindinge word ondersteun deur de koker (1981) se ondersoek na taalprobleme by leergestremde kinders. beskrywing van die proefpersone se geskrewe taalvermoens uit die beskrywing van die proefpersone se geskrewe taalfunksionering word die gevolgtrekking gemaak dat 27,4% van die proefpersone ondergemiddeld presteer in geskrewe taal volgens die sast en sawlt. in sinskompleksiteit en korrektheid het onderskeidelik 21,4% en 28,6% van die proefpersone swak presteer, maar die lae persentasie goeie prestasies (10,7%) wat in hierdie subtoetse behaal is, verklaar waarskynlik die waarneming dat sinskompleksiteit en korrektheid die swakste vertoon het in die gemiddelde stanege waardes wat vir elke subtoets vasgestel is. onderskeidelik 32,1%, 42,9% en 35,7% van die proefpersone het swak presteer in totale woorde, totale sinne en woorde per sin, wat op 'n algemene agterstand in hierdie geskrewe taalvaardighede dui (sien figuur 2). navorsing ondersteun die voorkoms van geskrewe taalprobleme, soos lae kompleksiteit en korrektheid, by taalleergestremde kinders (carlisle, 1994). samevattend dui die resultate oor die aard van die proefpersone se taalvaardighede daarop dat 'n beduidende persentasie van die proefpersone ondergemiddelde gesproke en geskrewe taalvermoens vertoon en dat meer proefpersone probleme ondervind in gesproke taalvermoens (33,2%) as in geskrewe taalvermoens (27,4%). gesproke taalfoute kan hoofsaaklik toegeskryf word aan ondergemiddelde tellings in vlotheid, produktiwiteit en kompleksiteit, terwyl beperkte sinskompleksiteit en korrektheid verantwoordelik was vir swak prestasies van die proefpersone in geskrewe taal. beskrywing van die proefpersone se skolastiese vordering vraelyste wat deur die onderwysers ingevul is dui daarop dat die proefpersone as 'n groep gemiddeld in die klaskamer funksioneer. spellingprobleme verteenwoordig die grootste karen kleingeld, brenda louw & isabel c. uys persentasie swak prestasies (35,7%) en probleme in wiskunde en geskrewe taal kom by onderskeidelik 25% en 26,2% van die proefpersone voor. in die geval van wiskunde het 'n groter persentasie van die proefpersone (26,8%) egter goeie prestasies vertoon. lees, algemene akademiese vaardighede (bv. vermoe om selfstandig te werk), mondelinge taal en algemene kommunikasie-vaardighede (bv. beantwoording van vrae) blyk die minste probleme by die proefpersone te veroorsaak (sien figuur 3). in die geheel gesien presteer die proefpersone dus gemiddeld in skolastiese vordering. 42,9% tot 46,4% van die proefpersone se prestasies in die vakke afrikaans en engels vertoon egter veral in die areas van spelling en skryfvermoens, byvoorbeeld korrektheid en kompleksiteit van sinne, 'n agterstand. hierdie bevindinge word deur bestaande navorsing ondersteun (stackhouse, 1992). vergelyking van die proefpersone se gesproke en geskrewe taalvermoens, asook taalvermoens en skolastiese vordering vergelyking van die proefpersone se gesproke en geskrewe taalfunksionering in tabel 3 word die subtoetse van die tmt en tolp en die sast en sawlt wat betekenisvolle verbande met mekaar vertoon, uiteengesit. 'n positiewe korrelasie is geidentifiseer in die vergelyking van die proefpersone se abstrak-konkreetheidsindeks in gesproke taal en die abstrak-konkrete inhoudskaal in geskrewe taal, asook tussen gemiddelde staneges in gesproke taal en gemiddelde staneges in geskrewe taal. 'n negatiewe korrelasie tussen woorde per t-eenheid in gesproke taal en woorde per sin in geskrewe taal is by die proefpersone aangetoon. die afleiding word gemaak dat daar 'n verband bestaan tussen die proefpersone se prestasies in gesproke en geskrewe taal in terme van abstrakte taalinhoud, en ook in terme van totale gesproke en geskrewe taalprestasie, soos bevestig deur catts (1991). vergelyking van die proefpersone se gesproke en geskrewe taalfunksionering met skolastiese vordering 'n uiteensetting van die gesproke en geskrewe taalprestasies van proefpersone wat betekenisvolle verbande met skolastiese prestasies vertoon, word in tabel 4 verskaf. t o t a l s w o o r d e w o o r d e p e r s i n k o r r e k t h e i d t o t a a l t o t a l e s i n n e s i n s k o m p l e k s i t e i t a b s t r a k k o n k r e t e i n h o u d s a s t s u b t o e t s e t o t a l e w o o r d e w o o r d e p e r s i n k o r r e k t h e i d t o t a l e s i n n e s i n s k o m p l e k s i t e i t a b s t r a k k o n k r e t e ir s a s t s u b t o e t s e [ ϊ ϋ % s w a k • • "it g e m i d d e l d % g o o d figuur 2: swak, gemiddelde en goeie prestasies van proefpersone in geskrewe taal figuur 3: prestasies van proefpersone in algemene skolastiese vaardighede the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gesproke en geskrewe taalvermoens van hulpklasleerlinge teruggeplaas in hoofstroomonderwys 11 subtoetse en nasienskale spearman korrelasiekoeffisient oorskrydingswaarskynlikheid (p-waarde) aard van korrelasie (op 10% peil van betekenis) gesproke taal tmt (vorster, 1980a); tolp (vorster, 1980b) geskrewe taal sast (brink, 1976a; sawlt (brink, 1976b) spearman korrelasiekoeffisient oorskrydingswaarskynlikheid (p-waarde) aard van korrelasie (op 10% peil van betekenis) totale aantal woorde totale woorde 0,154 0,212 geen betekenisvolle verwantskap woorde per t-eenheid woorde per sin -0,255 0,093 negatiewe verwantskap kompleksiteit-skaal kompleksiteit-skaal -0,054 0,39 geen betekenisvolle verwantskap korrektheidskaal korrektheidskaal -0,063 0,37 geen betekenisvolle verwantskap abstrak-konkreetheids-indeks abstrak-konkrete inhoudskaal 0,455 0,009 positiewe verwantskap gemiddelde staneges gemiddelde staneges 0,305 0,0571 positiewe verwantskap tabel 4: die aard van betekenisvolle korrelasies tussen gesproke en geskrewe taal funksionering by die proefpersone gesproke taal en skolastiese prestasie spearman korrelasiekoeffisient oorskrydingswaarskynlikheid (p-waarde) aard van korrelasie (op 10% peil van betekenis) gesproke taal en afrikaans 0,000 geen korrelasie gesproke taal en engels -0,500 0,24 negatiewe korrelasie gesproke taal en wiskunde 0,000 geen korrelasie gesproke taal en leervakke 0,500 0,24 geen korrelasie gesproke taal en lees 0,500 0,24 geen korrelasie gesproke taal en spelling 1,000 0,08 positiewe korrelasie gesproke taal en algemene akademiese funksionering' 0,500 0,24 geen korrelasie gesproke taal en algemene kommunikasiegedrag -0,500 0,24 negatiewe korrelasie gesproke taal en st 2 skolastiese vordering 1,000 0,08 positiewe korrelasie geskrewe taal en j skolastiese i prestasie : spearman korrelasiekoeffisient oorskrydingswaarskynlikheid (p-waarde) aard van korrelasie (op 10% peil van betekenis) geskrewe taal en afrikaans 0,000 geen korrelasie geskrewe taal en engels 0,500 0,24 negatiewe korrelasie geskrewe taal en wiskunde 0,000 geen korrelasie geskrewe taal en leervakke 0,500 0,24 geen korrelasie geskrewe taal en lees 0,500 0,24 geen korrelasie geskrewe taal en spelling 1,000 0,08 positiewe korrelasie geskrewe taal en algemene akademiese funksionering 0,500 0,24 geen korrelasie geskrewe taal en algemene kommunikasiegedrag -0,500 0,24 negatiewe korrelasie geskrewe taal en st 2 skolastiese vordering 1 1,000 0,08 positiewe korrelasie die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 karen kleingeld, brenda louw & isabel c. uys volgens die resultate kom beide positiewe en negatiewe korrelasies tussen gesproke en geskrewe taal en skolastiese prestasie by die proefpersone voor. die proefpersone se taalvermoens toon 'n positiewe verband met hul st 2 skolastiese vordering (hill & haynes, 1992) en spelling (lerner, 1993) en 'n negatiewe verband met prestasie in die skoolvak engels en algemene kommunikasiegedrag. bespreking 'n opsommende weergawe van die eksperimentele doelstellings en verbandhoudende resultate word in figuur 4 verskaf, en dien as raamwerk vir die bespreking van die navorsingsresultate. bespreking van resultate oor die aard van gesproke en geskrewe taalvermoens en skolastiese vordering uit die beskrywing van die resultate is dit duidelik dat die proefpersone uitvalle vertoon in gesproke taalvermoens. verskeie outeurs bevestig dat taalleergestremde kinders swakker gesproke taalvermoens vertoon as normaalpresterende kinders (lerner, 1993; klein & harris, 1986). wat die aard van orale taalproblematiek betref, ondersteun die huidige studie navorsingsbevindinge van de koker (1981), dat onderprestasies in alle subtoetse van die tmt voorgekom het by taalleergestremde kinders. die resultate van die proefpersone se gesproke taalvermoens dui daarop dat die meeste ontoepaslike gedrag voorgekom het met betrekking tot produktiwiteit en vlotheid van mondelinge taalproduksie. navorsers het ter ondersteuning hiervan bevind dat die gemiddelde lengte van iaitinge by taalleergestremde kinders opvallend laer is as die van nie-leergestremde kinders (oosthuizen, 1994) en dat die taalleergestremde kind minder doelmatige woorde in spontane verbale ekspressie produseer, wat dus produktiwiteit verlaag (derbyshire, 1989). welman (1986) bevestig die voorkoms van onvlotheid as een van die taalleergestremde kind se grootste probleme. die resultate van die ondersoek na die proefpersone se gesproke taalvermoens, toon dus dat 'n agterstand in gesproke taalvermoens ten spyte van hulpklasonderrig, steeds by 'n beduidende persentasie van die proefpersone voorkom en dus langdurig van aard is. aram, enkelman & nation (1984) het in ooreenstemming met hierdie resultate bevind dat gesproke taalprobleme wat voorskools gei'dentifiseer is, kan voortduur tot in adolessensie. geskrewe taal prestasies dui daarop dat die proefpersone oorwegend op 'n laag gemiddelde vlak funksioneer en dat 46,4% van die proefpersone waarskynlik aangewese is op ekstra hulpverlening vir die verbetering van geskrewe taalvermoens. hierdie resultate stem ooreen met resente literatuurbewyse wat die bestaan van geskrewe taalprobleme by taalleergestremde kinders ondersteun (carlisle, 1994). schumaker & deshler (1984) het bevind dat die probleme wat taalleergestremde kinders in geskrewe uitdrukkingsvermoens ervaar, tot in adolessensie voortduur. die huidige studieresultate bevestig dus vorige bevindinge oor die voorkoms van geskrewe taalprobleme by ouer taalleergestremde kinders. die empiriese studie toon verder dat 33,5% van die totale aantal foute wat deur proefpersone in die korrektheidskaal van die sast en sawlt gemaak is, direk toe te skryf is aan swak woordgebruik en foute in sinskonstruksie. lerner (1993) erken die voorkoms van woordvindingsprobleme in taalleergestremde kinders se geskrewe taal. moran (1988) wys egter daarop dat sintaktiese foute by taalleergestremde kinders eerder verband hou met aandagtekorte as met 'n beperkte kennis van sintaksis-reels. beperkte geskrewe taalkorrektheid kom waarskynlik ook voor opidat taalleergestremde kinders dikwels nie geskrewe take proeflees vir spelfoute en punktuasiefoute nie (buttrill, niizawa, biemer, takahashi & hearn, 1989). verskeie navorsers bewys die voorkoms van spelfoute en punktuasiefoute in die geskrewe taal van taalleergestremde kinders en bevestig dus die resultate van die huidige studie (hallahan & kauffman, 1991; gearheart & gearheart, 1989). dit blyk dus dat die bestaan van ekspressief geskrewe taalprobleme by die proefpersone nie ontken kan word nie, maar dat hierdie probleme nie opvallend by alle oud-hulpklasleerlinge wat as proefpersone gedien het, voorkom nie. die beskrywing van die studie-resulfate dui aan dat die proefpersone uitvalle in skolastiese funksionering vertoon en dat slegs 23% van die proefpersone daarin kon slaag om bo die standerdgemiddeld vir standerd-twee te presteer terwyl 38% van die proefpersone onder^die standerdgemiddeld presteer het. hierdie bevinding stem ooreen met literatuurbewyse oor die voorkoms van skolastiese probleme by taalleergestremde kinders (hill & haynes, 1992). die bevindinge impliseer verder dat skolastiese probleme wat by die proefpersone voorgekom het, nie in die hulpklas opgehef is nie, en dat addisionele rejnediering benodig word. beskrywing van die aard van skolastiese probleme wat deur die proefpersone ondervind word, dui daarop dat ongeveer 50% van die proefpersone ondergemiddeld presteer het in die skoolvakke afrikaans en engels. hierdie bevinding hou waarskynlik verband met die gesproke en geskrewe taalprobleme wat reeds by die proefpersone gei'dentifiseer is, aangesien prestasies in die skoolvakke afrikaans en engels hoofsaaklik op die evaluering van mondelinge, spelling, lees en opstelle berus (derbyshire, 1989). die resultate verkry uit die onderwysersvraelyste bevestig hierdie veronderstelling en toon aan dat spelling en ander geskrewe taalprobleme die grootste bydrae lewer tot ondergemiddelde skolastiese prestasies by die proefpersone. literatuur ondersteun die hoe voorkoms van skolastiese probleme, wat verband hou met geskrewe taal, by taalleergestremde kinders (stackhouse, 1992). 'n beduidende persentasie van die proefpersone behoort dus steeds in die areas van spelling en skryfvermoens in die vakke afrikaans en engels hulp te ontvang, omdat hierdie vaardighede en vakke 'n sentrale deel vorm van akademiese werk in sowel die primere as doelstelling 1 gesproke en geskrewe taalprobleme en skolastiese probleme | gesproke taal | geskrewe taal | | skolastiese funksionering ] • kompleksiteit • sinkompleksiteit • skoollakke: air, eng, wisk • vlotheid • korrektheid • spelling • produktiwiteit • geskrewe taal doelstelling 2 korrelasie tussen gesproke e n geskrewe taal, en taal en skolastiese funksionering jgesproke e n geskrewe taal | | taal e n skolastiese funksionring j • abstrakte taalinhoud · taal e n spelling • totale gesproke e n geskrewe taal · taal e n vordering in standerd 2 figuur 4: 'n skematiese voorstelling van die resultate the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) geskrewe taalvermoens van hulpklasleerlinge teruggeplaas in hoofstroomonderwys 13 die sekondere skoolfases. ondergemiddelde prestasies wat in wiskunde voorgekom het, stem ooreen met navorsingsbevindinge oor die voorkoms van wiskunde-probleme by taalleergestremde kinders (haylock, 1992). literatuur dui ter verdere ondersteuning van die studieresultate aan dat wiskunde-probleme wat deur taalleergestremde kinders ondervind word, by ouer kinders voortduur (maxwell & wallach, 1984). die afleiding word gemaak dat die leerprobleme wat deur die proefpersone ervaar is, van so 'n aard was dat dit nie ten voile deur hulpklasonderrig uitgeskakel kon word nie en dat hierdie kinders dus aangewese is op verdere hulpverlening op skolastiese gebied na uitplasing uit die hulpklas. samevattend dui die resultate van doelstelling 1 van die empiriese studie op die volgehoue aard van gesproke en geskrewe taalprobleme, sowel as beperkinge in skolastiese funksionering by 'n beduidende persentasie van die proefpersone. bespreking en verklaring van korrelasies tussen gesproke en geskrewe taalvermoens, en taalvermoens en skolastiese vordering resente literatuur ondersteun 'n geheeltaalbenadering tot geletterdheidsontwikkeling en lig so die verband tussen gesproke en geskrewe taal uit (smith-burke et al., 1991). volgens die empiriese ondersoek is 'n positiewe korrelasie tussen gesproke en geskrewe taal by die proefpersone gei'dentifiseer wanneer abstrak-konkreetheidsindeks in gesproke taal en abstrak-konkrete inhoudskaal in geskrewe taal, vergelyk word. in die bespreking van gesproke en geskrewe taal-toetsresultate is opgemerk dat die proefpersone oor die algemeen gemiddeld presteer het in gesproke en geskrewe abstrakte taalgebruik. hierdie bevinding is teenstrydig met literatuurbevindinge wat die voorkoms van abstrakte taalprobleme by taalleergestremde kinders beklemtoon (lerner, 1993). ongeag van die aard van die huidige proefpersone se abstrakte taalvermoens, blyk dit egter uit die resultate dat gesproke en geskrewe taalvermoens,' wat abstrakte taalgebruik aanbetref, verband hou. hierdie verband impliseer dat proefpersone wat wel gesproke abstrakte taalprobleme ondervind, waarskynlik ook geskrewe abstrakte taalprobleme sal vertoon, wat laangespreek moet word in s p r a a k t a a l t e r a p e u t i e s e intervensie ten einde die ontwikkeling van gepaardgaande skolastiese probleme te verminder. 'n positiewe korrelasie is ook tussen gesproke en geskrewe taal vasgestel wanneer gemiddelde staneges in gesproke taal en gemiddelde staneges in geskrewe taal vergelyk word. die veronderstelling word dus gemaak dat kinders met gesproke taalprobleme waarskynlik ook geskrewe taalprobleme sal ondervind en dat 'n verbetering in gesproke taal aanleiding sal gee tot 'n verbetering in geskrewe taal. verskeie navorsers ondersteun die voorkoms van 'n verband tussen gesproke en geskrewe taal (oosthuizen, 1994; catts, 1991). volgens maxwell & wallach (1984) word veranderinge in taalsimptome oor tyd veral sigbaar wanneer vroee gesproke taalprobleme in geskrewe taalprobleme gemanifesteer word. onderwysers is egter nie altyd bewus van die verband tussen gesproke en geskrewe taal nie, en skenk dikwels aandag aan die geskrewe taalprobleem sonder om ook die verbandhoudende gesproke taalprobleme aan te spreek (gearheart & gearheart, 1989). die resultate van die empiriese studie beklemtoon egter die belang van 'n geheeltaalbenadering in die behandeling van gesproke en geskrewe taalprobleme wat by die proefpersone gei'dentifiseer is. 'n negatiewe korrelasie is in die huidige studie tussen gesproke taal en geskrewe taal aangetoon wanneer woorde per t-eenheid in gesproke taal en woorde per sin in geskrewe taal, vergelyk word. horowitz (1990) wys daarop dat gesproke taal minder gestruktureerd en kompleks as geskrewe taal is, en dat die taalgebruiker meer selfbewus is in die gebruik van geskrewe as gesproke taal. geskrewe taal is dus meer gekontroleerd en akademies, en moet meer sorgvuldig beplan word (owens, 1992). hierdie sienings ondersteun resultate van die huidige studie, wat daarop wys dat die proefpersone wat lang sinne in gesproke taal gebruik het, korter geskrewe taalsinne vertoon het. gillam & johnston (1992) bevestig dat taalleergestremde kinders korter sinne in geskrewe as in gesproke taal gebruik. die resultate van 'n vergelyking tussen die proefpersone se g e s p r o k e en g e s k r e w e t a a l v e r m o e n s b e v e s t i g dus literatuurbewyse wat ooreenkomste, sowel as verskille tussen gesproke en geskrewe taal ondersteun (wallach, 1990). soos reeds genoem, kom reseptiewe en ekspressiewe taalprobleme wat taalleergestremde kinders se skolastiese prestasies beperk, tot in adolessensie voor (buttrill et al., 1989). die resultate van die studie bevestig dat 'n wisselwerking tussen taalprobleme en leerprobleme voorkom. volgens die resultate van die empiriese ondersoek is korrelasies by die proefpersone tussen die sekere areas van taal en skolastiese funksionering gei'dentifiseer. 'n positiewe korrelasie is aangedui tussen die proefpersone se gesproke en geskrewe taal en hulle spelling. navorsing oor spellingprobleme by taalleergestremde kinders het 'n verband tussen die kinders se taalvermoens en hulle spelling bepaal (kriegler, du toit & smart, 1990). die voorkoms van spellingprobleme by die proefpersone hou dus waarskynlik verband met die geskrewe taalprobleme wat reeds by die proefpersone gei'dentifiseer is. carlisle (1994) skryf die voorkoms van spellingprobleme toe aan gebrekkige linguistiese kennis, en wys daarop dat spellingprobleme aanleiding gee tot geskrewe taalprobleme omdat die taalleergestremde kinders korter en meer eenvoudige stories as kinders sonder spellingprobleme skryf. om korrek te kan spel word van die skoolgaande kind vereis om oordele oor gesproke en geskrewe taal te kan maak. beperkinge in metalinguistiese vermoens word dus aangevoer as een van die redes waarom taalleergestremde kinders spellingprobleme ondervind (owens, 1992). verdere navorsing word benodig om die presiese verband tussen ontwikkelende linguistiese en metalinguistiese vermoens, en spelling-ontwikkeling te ondersoek (carlisle, 1994). positiewe korrelasies is verder gei'dentifiseer tussen gesproke en geskrewe taal en standerd-twee skolastiese vordering by die proefpersone. die kontinuum van taalleerprobleme wat deur maxwell & wallach (1984) voorgestel is, word deur die korrelasie bevestig. die verband tussen taalvermoens en skolastiese funksionering wat deur die resultate gei'dentifiseer is, word algemeen in die literatuur aanvaar (hill & haynes, 1992). die korrelasies wat na aanleiding van doelstelling twee vasgestel is, bevestig dus 'n algemene verband tussen taalvermoens en skolastiese prestasie, ten spyte van die feit dat spesifieke skolastiese vaardighede nie 'n reglynige verband met gesproke en geskrewe taalfunksionering vertoon nie. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 gevolgtrekkings en aanbevelings die identifisering van gesproke taalprobleme by die proefpersone, en die verband wat in die literatuur uitgewys word tussen onderliggende gesproke taalprobleme en leesen skryfprobleme (gillon & dodd, 1995) impliseer dat verdere spraak-taalterapeutiese intervensie by oud-hulpklasleerlinge van die uiterste belang is. insluiting van hierdie kinders by die reeds oorvol program van die spraaktaalterapeut wat in die skole werksaam is, stel egter hoer eise wat werkslading aanbetref. die spraak-taalterapeut word dus genoodsaak om alternatiewe diensleweringsmodelle in te skakel by die evaluering en behandeling van ouer taalleergestremde kinders (wright, 1992). deur middel van samewerkende dienslewering (creaghead, 1994) moet die spraak-taalterapeut poog om deur samewerking met die ouers, onderwysers en ander professionele persone effektiewe intervensie te bewerkstellig by leerlinge wat uit die hulpklas teruggeplaas is in hoofstroomonderwys. gesproke en geskrewe taalprobleme wat in hierdie studie gei'dentifiseer is, behoort in 'n geheeltaalbenadering deur die spraak-taalterapeut aangespreek te word. deur middel van die geheeltaalbenadering maak die gefragmenteerde aard van afsonderlike hulpverlening vir gesproke en geskrewe taalprobleme, plek vir integrasie van die taalkomponente, om oordrag te vergemaklik en samewerking tussen intervensie-spanlede aan te moedig (norris & hoffman, 1993). spraak-taalterapeute is egter tans nie ten voile opgelei om lees, spelling, wiskunde of kreatiewe skryf te hanteer, en dus die taalleergestremde kind as geheel te beskou nie (oberstein, 1990). opleiding van die spraak-taalterapeut behoort verbreed te word om meer in-diepte opleiding oor geskrewe taalintervensie in te sluit. aansluitend hierby stel uys (1993) voor dat reeds gekwalifiseerde spraak-taalterapeute konferensies, werkwinkels en simposiums, maar ook modules van nuwe voorgraadse kursusse sal bywoon, om met nuwe raamwerke bekend te raak. uitbreiding van die spraak-taalterapeut se vaardighede op die gebied van geskrewe taalvermoens, sal hom/haar in staat stel om as aktiewe lid van die multi-professionele span wat taalleergestremde kinders in die skoolkonteks hanteer, te funksioneer. die spraak-taalterapeut kan deur middel van spansamewerking ook opvoedkundige personeel se bewustheid van die rol van die spraak-taalterapeut in geskrewe taalprobleme, verhoog (sanger, hux & gries, 1995). die interverwantskap wat tussen gesproke en geskrewe taal van die proefpersone uitgewys is, impliseer die belang van gesproke taal in geletterdheidsontwikkeling, en ondersteun dus vroee intervensie by kinders wat risikofaktore vertoon vir die ontwikkeling van spraaken taalprobleme (fletcher & foorman, 1994). vroegtydige bewusmaking van ouers en onderwysers van die ingrypende invloed van taalprobleme op skolastiese vordering, kan die stimulasie van voorgeletterdheidsvaardighede aanmoedig (schuele & van kleeck, 1987), wat die risiko vir die ontwikkeling van sekondere taalleerprobleme soos leesen skryfprobleme kan verlaag (scarborough & dobrich, 1990). 'n opvolgstudie oor die taalen skolastiese funksionering van oud-hulpklasleerlinge in die hoerskool, word in die lig van die resultate van die huidige studie en ter uitbreiding van beperkte literatuur oor die oud-hulpklaskaren kleingeld, brenda louw & isabel c. uys leerling in die hoerskool, aanbeveel (haines, 1988). ter aansluiting behoort die effektiwiteit van implementering van 'n samewerkende diensleweringsmodel vir opvolg en intervensie by die oud-hulpklasleerling en ouer taalleergestremde kind, ondersoek te word. na aanleiding van die groot persentasie wat taalleergestremde kinders van die spraak-taalterapeut se gevalsbelading uitmaak, word die uitvoering van kliniese navorsing met taalleergestremde kinders aanbeveel. aksie-navorsing sal die spraak-taalterapeut in staat stel om intervensieprosedures wat gevolg word met taalleergestremde kinders, voortdurend te evalueer en aan te pas by nuwe navorsingsbevindinge (wallach, 1990). behoeftes wat in die praktyk bestaan aan wetenskaplik verantwoordbare programme vir spraak-taalterapeutiese intervensie by taalleergestremde kinders, sal ook op hierdie wyse aangespreek kan word. die empiriese studie is van waarde vir die kliniese praktyk, omdat dit die basis daarstel vir opvolg-intervensie by die ouer taalleergestremde kind, asook vir verdere navorsing oor die taalen skolastiese funksionering van oud-hulpklasleerlinge. bevindinge oor die teenwoordigheid van gesproke en geskrewe taalprobleme by proefpersone wat uit die hulpklas teruggeplaas is in hoofstroomonderwys, hou belangrike kliniese en navorsingsimplikasies vir die spraak-taalterapeut in. dit blyk uit die empiriese studie dat die spraak-taalterapeut beide gesproke en geskrewe taalvermoens by taalleergestremde kinders behoort aan te spreek, ten einde effektiewe dienslewering moontlik te· maak, en die ontwikkeling van skolastiese probleme sover moontlik te beperk. toepaslike funksionering van die taalleergestremde kind in die klaskamersituasie sowel as in die sosiale konteks, word deur spraak-taalintervensie ten doel gestel. die rol van die spraak-taalterapeut in skole, asook die struktuur van hulpklasse, ondergaan tans ingrypende veranderinge om aan te pas by die nuwe suid-afrika konteks. die insluitings-beleid wat tans in die gauteng departement van onderwys voorgestel word (naidoo et al., 1996), impliseer dat hoofstroomleerlinge ook op tydelike basis by die hulpklas ingesluit moet word, sodat aandag aan spesifieke leerprobleme geskenk kan word. ter aansluiting by die gevolgtrekkings wat uit die huidige studie gemaak is, sal die spraak-taalterapeut se betrokke nheid by die taalleergestremde kind dus verder as die gei'dentifiseerde hulpklasleerling moet strek. die spraaktaalterapeut wat in die skole werksaam is, sal in die toekoms moet poog om alle taalleergestremde kinders deur middel van konsultasie met die hulpklasonderwyser, hoofstroomonderwysers en ouers (williams, 1995), by spraak-taalintervensie te betrek. erkenning hierdie artikel is gebaseer op die μ kommunikasiepatologie verhandeling k. kleingeld, gesproke en geskrewe taalvaardighede van kinders wat uit die hulpklas teruggeplaas is in hoofstroomonderwys, 1995, universiteit van pretoria, uitgevoer onder leiding van b. louw en i.c. uys. verwysings aram, d.m., ekelman, b.l. & nation, j.e. 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(1994). hulpklasse baat die intelligent» kinders. die beeld. 21 april, ρ 8. uys, i.c. (1993). kommunikasiepatologie: onderrig vir die toekoms. die suid-afrikaanse tydskrif vir kommunikasieafwykings, 40, 3-9. vorster, j. (1980a). handleiding vir die toets vir mondelinge taalproduksie. pretoria: suid-afrikaanse raad vir geesteswetenskaplike navorsing. vorster, j. (1980b). manual for the list for oral language production. pretoria: south african human sciences research council. wallach, g.p. (1990). magic buries celtics: looking for broader interpretations of language learning and literacy. topics in language disorders, 10(2), 63-80. welman, m.c.j. (1986). die doeltreffenheid van verbale ekspressie by taalleergestremde kinders. m.log.-verhandeliflg. universiteit van pretoria. williams, e. (1995). policy framework for the provision of professional services. support services workshop: johannesburg college of education. wright, j.a. (1992). collaboration between speech and language therapists and teachers. in fletcher, p. & hall, d. (eds): specific speech and language disorders in children: correlates, characteristics and outcomes. london: whurr publishers ltd. die suid-afrikaanse ydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 43 excess cerumen : failure rate of black and indian preschool children from durban on the middle ear screening protocol (mesp) daksha bhoola and rene hugo department of communication pathology university of pretoria abstract the aim of the study was to examine the failure rate of black and indian subjects within the excessive cerumen category of the middle ear screening protocol (mesp). the subjects included four to five year old black and indian children attending pre-schools in the durban central region. thus, a sample of 728 subjects (average age = 4.6 years), 312 black (135 male and 180 female) and 413 indian (223 male and 190 female) was screened using referral criteria based on a middle ear screening protocol (mesp). the results of the study indicated that a significant percentage of black (38,4%) and indian (49,9%) subjects failed, due to excessive cerumen. these results are discussed with reference to the literature. a cerumen management program has been outlined and recommended to be implemented in preschools in south africa. opsomming die doel van die studie was om ondersoek in te stel na die invloed van oormatige was op die faalkategoriee van 'n middeloorsiftingsprotokol. die proefpersone het bestaan uit vieren vyfjarige swarten indierkinders verbonde aan preprimere skole in die durban sentraalstreek. 'n totalegroep van 728proefpersone (gemiddelde ouderdom = 4.6jaar), waarvan 312 swart (135 manlik en 180 vroulik) en 413 indier (223 manlik en 190 vroulik) kleuters was, het 'n middeloorsiftingsprotokol ondergaan. die resultate van die studie dui daarop dat 'n betekenisvolle groot groep van die proefpersone -38.4% swart en 49.9% indier die siftinggefaal het as gevolg van oormatige was. hierdie resultate is bespreek aan die hand van relevante literatuur en opgevolg deur 'n voorgestelde was-hanteringsprogram wat moontlik sinvol in suid-afrikaanse kleuterskole geimplementeer kan word. key words: black and indian children, 4-5 years, cerumen management program, excessive cerumen, middle ear screening protocol. introduction the sancd (1990) classifies auditory dysfunction that occurs when the site is the external ear or middle ear, as conductive hearing loss. one of the commonest causes of conductive hearing impairment is the accumulation of cerumen in the external auditory meatus (eam) (northern & downs, 1984; martin, 1981; newby, 1979). total occlusion of the eam due to excessive or impacted cerumen is said to cause a threshold shift of about 45 70 db (chandler, 1964). in fact, bricco (1985) pointed out that impacted cerumen is regarded as an ear disease it can cause otitis externa, hearing loss, pain, itching and tinnitus (bullachanda & pears, 1992; roeser & crandell, 1991). furthermore, bricco (1985) stated that if cerumen impinges on the eardrum, a chronic cough may be triggered and persist until the cerumen is removed. myers and fueschel (1987) even related impacted cerumen to major psychiatric changes. bricco's (1985:241) investigation suggested "an association between the presence of impacted ear wax (cerumen) and subsequent middle ear or hearing problems, but a causal relationship is not inferred from the study". however, garber (1986) found that in some 30% of children, accurate diagnosis of acute otitis media (aom) requires cerumen removal. he stated that "you cannot assume that the heat of the middle ear infection will melt earwax : ceruminosis and acute otitis media can coexist". (garber 1986:151). the reasons for cerumen impaction are many. it may be due to increased secretory function of ceruminous glands, leading to more than normal production (mandour, el-ghazzawi, toppozoda & malaty, 1974) or failure of keratinocyte separation that occurs normally in the earcanal (robinson & hawke, 1990). anatomical abnormalities of the ear-canal, the improper use of cotton swabs, hearing aids, or a collapsed ear-canal have also been reported to obstruct extrusion of cerumen from the canal (ballachanda & peers, 1992). furthermore, the aggressive cleaning of soft wax by well-meaning parents can result in the wax becoming impacted against the tympanic membrane (bricco, 1985; newby, 1979; martin, 1981). in addition, ballachanda and peers (1992) stated that cerumen enlarges when it becomes soaked with water (e.g., after bathing, swimming) and can completely occlude the eam. thus, even the presence of excessive amounts of soft cerumen, poses a significant audiological problem since it can result in a mild conductive loss. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 it has been proven in studies on recurrent otitis media that mild and fluctuating conductive losses have negative effects on language and auditory function and on later educational achievements (gravel & wallace, 1992; boothroyd, 1982; northern & downs, 1984). this is equally true of excess cerumen and the negative consequences can be prevented through routine otoscopic examination of preschool children. in fact, the american food and drug administration (1977), cited by alpiner and mccarthy (1987), as well as asha (1990), identified excessive accumulation of cerumen as a condition that needed medical intervention. furthermore, american physicians are said to perform cerumen extraction on approximately 44 000 ears per year (sharp, wilson, ross & barr-hamilton 1990). according to burgess (1977), wax removal is done more than 40 000 times a week in the united kingdom. thus, otoscopic examination can "improve the timeliness of medical management for those in most urgent need." (roush 1990:367). the research design of the present study used a modified version of the revised asha (1990) protocol, referred to as the middle ear screening protocol (mesp). disorders of the outer and middle ear contribute to the conductive component of a hearing loss, which in many cases can be remediated with medical attention. it is possible that disease in the outer ear may spread to the middle ear and vice-versa (martin, 1981). therefore it is logical to include examination of the outer ear when considering middle ear disorders. it is for the above reasons, that the protocol used in this study, although being a middle ear screening protocol, is included in the examination of the outer ear. the mesp consists of three components; history, visual inspection and tympanometry. (refer to appendix a, table 1.) excess cerumen was identified using this protocol. martin (1991) stated that the problem of ear wax is a complex one and that no one wants to take the responsibility for the managing of it. in this regard two important questions needed to be answered: (i) "why haven't audiologists assumed the responsibility for cerumen management?" according to roeser and crandell (1991:52) a likely reason is that audiology's roots are in nonmedical institutions of higher education, where the philosophy is to avoid procedures that might be interpreted as "medical". moreover, in the early years of the profession, routine audiological protocols did not require placing objects in the earcanal. in fact, otoscopy was not performed or encouraged routinely. however, standard audiology protocols now require placing objects in the ear-canal and audiologists are familiar with the proper protocols to follow, as well as the possible contra-indications. the ear-canal is irrigated similarly to that of cerumen removal for caloric testing during electronystagmography. in addition, otoscopy is a mandatory prerequisite for proper audiological screening, evaluation and management. visual inspection of the ear-canal (otoscopy) is required in the asha screening guidelines (asha, 1989); moreover, the standard procedures in audiology manual developed by the veterans health services and research administration (vhsra, 1990) includes visual inspection of the ear as an audiological procedure. it is apparent that the above reasons are valid and that cerumen management should be the responsibility of the audiologist daksha bhoola & rene hugo in view of the new standard audiology protocols and the high frequency of occurrence in the population under study. (ii) should cerumen management be a part of audiology practice? asha (1990) defined the scope of practice in audiology to include : facilitating and conservation of auditory system function; preventing auditory system dysfunction; and selecting, fitting and dispensing amplification. in addition, asha (1996) included the following in the audiologist's scope of practice "otoscopic examination and external ear canal management for removal of cerumen in order to evaluate hearing or balance, make ear impressions, fit hearing protection or prosthetic devices, and monitor the continuous use of hearing aids". (asha, 1996:14). furthermore, the american academy of audiology (aaa) (1989:1), adopted a scope of practice statement that defines an audiologist as "a person who, by virtue of academic and clinical training and appropriate certification and/or licensure, is uniquely qualified to provide a comprehensive array of professional services related to the prevention, assessment and rehabilitation of auditory and vestibular impairments". in addition, "the audiologist is an independent practitioner, and may practice in a hospital, clinic, school, private practice or any other setting in which audiological services are relevant". in view of the limitations in providing comprehensive audiological services when excessive/impacted cerumen is present, both asha and aaa scope of practice statements give strong support and rationale for audiologists to engage in cerumen management. furthermore, considering the results of the present study on excessive cerumen in both race groups, it is time to recognize that audiologists can and should manage cerumen. it is evident from the results of the present study and the literature review presented above on the problem of excessive cerumen, that this is a serious problem in many countries, including south africa, and which needs urgent attention. the writer, therefore recommends a cerumen management programme which could be implemented in pre-schools and primary schools in south africa. 1 method research design i in order to realise the aim of the study, the methodology of research design used was the analytical (quantitative) survey method (leedy, 1989). aim the aim of the study was to examine the failure of black and indian preschool children within each category of the middle ear screening protocol (mesp). subjects a total of 728 randomly selected subjects (mean age 4,6 years), comprising 315 blacks (135 males, 180 females) and 413 indians (223 males, 190 females) contributed relevant data for the purpose of this study. available literature has indicated a paucity of information of middle ear the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) excess cerumen: failure rate of black and indian preschool children from durban on the middle ear screening protocol (mesp) disorders within the indian and black ethnic groups in south africa, which motivated the criterion of race. all subjects attended preschools located in the magisterial district of durban central. according to bess and humes (1990), children who reside in the inner city and attend day care centres are prone to suffer from outer and middle ear disorders. table 1 presents the subject characteristics of this study. all subjects were required to fall within the age range of 48-60 months inclusive (4-5 years) as a literature review has shown an increased prevalence of middle ear infection in this age range worldwide (davidson et al., 1988). 45 table 1 : subject characteristics n% mean age in years mean age in years black males females 315 (43) 135 (43 180 (57) 4,7 4,6 4.0-4,9 4.1-4,9 indian males females 413 (57) 223 (54) 190 (46) 4,6 4,6 4,2-5,0 4,0-4,8 total 728 data collection procedure screening. * immediate medical referral was made in cases of abnormally large canal volume (>1.0ml) estimates accompanied by low static admittance (<0.2ml) (when there was a reason to suspect a perforation of the tympanic membrane) (asha, 1990). * when tympanometric results were abnormal, (low static admittance (<0.2ml) and abnormal tympanometric peak pressure (< -200dapa)) rescreening was scheduled in 4-6 weeks from the date of the first screening. if the results were again abnormal, a medical referral was made. * normative data (table 2 of appendix a) based on the work of margolis and heller (1987) and asha (1978) were used for analysis of results in the procedures above. the pass-fail criteria are indicated in appendix a. * when a subject failed the first or second screening, the parents and school officials were informed by letter/report, of the test results and informed of a need for further evaluation. when medical review was indicated, parents were advised to consult with a general practitioner or their family doctor. a medical follow-up was requested from the attending doctor specifying his/her findings and treatment procedures for school records. data analysis procedures failure rate was computed in terms of percentages and numbers, and reflected in tables and graphs. the specific criteria for evaluation were as follows: all procedures for middle ear screening were completed on the same day, i.e., history, visual inspection and tympanometry for each subject. the screening was conducted on the school premises during school hours (08h0012h30). screening was scheduled for fall, i.e., between february and april 1992, to control for seasonal variations, since otitis media has its highest prevalence during the winter months (roust, 1990; sorensen, 1981). all subjects who met the subject1 selection criteria were included. the criteria included: race (black and indian), age (4-5 years old), and area of school (durban central region). * the teacher provided the biographical details as well as information pertaining to observable history of pain and ear drainage, wliich was recorded on the record form (appendix b). ; * following the collection of the above information, a visual inspection of the ear, head and neck was performed, using a welch-allen battery operated otoscope. otoscopic examination of each ear was conducted to identify, earcanal abnormalities, blood effusion, occlusion, inflammation, excessive cerumen, tumour or foreign material. each ear was then examined for eardrum abnormalities, and specifically for obvious inflammations, and severe retractions. * after visual inspection, typanometry was performed except when the earcanal was occluded with cerumen, or any other foreign material which prevented visual inspection of the tympanic membrane. according to asha (1990), excess cerumen is classified as soft or hard cerumen that totally occludes the ear canal and impacted wax. tympanometric measures were obtained using the grason-stadler 28a (grason-stadler, 1990), which was calibrated in january 1992, i.e., prior to (i) middle ear screening protocol (mesp) included history, visual inspection and tympanometry. the mesp consisted of two elements: outer ear tests and middle ear tests. (ii) failure on outer ear tests included: structural defects of the ear, head and neck ear-canal abnormalities, (i.e., bl to b9, refer to appendix b). (iii) failure on middle ear tests included: eardrum abnormalities tympanometry (iv) failure of a subject on any one of the categories, under outer ear and middle ear tests independently, was regarded as a fail. (v) failure of a subject on either ear on each category independently was regarded as a fail. (vi) both ears of a subject had to pass the three screening procedures in order for that subject to be regarded as a pass. the data were analysed in terms of failure rate of black and indian subjects within each category of the mesp. results were calculated using one subject as the statistical unit and classifying each subject according to the poorest result obtained in either ear. results the failure rate of black and indian subjects was computed within each category of the middle ear screening protocol. results in table 2 and figure 1 reflect the following failure rates for black, and indian subjects, within each category of the middle'ear screening protocol (mesp). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 daksha bhoola & rene hugo (i) history on history 0,3% (1) black and 0,5% (2) indian failed on otalgia, whereas 0,3% (1) black and 0,2% (1) indian failed on otorrhea. (ii) visual inspection visual inspection is divided into three subcategories, i.e., structural defects, earcanal abnormalities (eca) and eardrum abnormalities (eda). the results are as follows: * structural defects only one black (0,3%) failed on structural defects of the head. there were no failures in the indian group. * earcanal abnormalities (eca) there were no black or indian failures on occlusion bg categories. in the blood effusion category, 0,3% (1) blacks failed whereas no indians failed (b4). four point eight percent (15) blacks 2,2% (9) indians failed to inflammation (b6). of the 103 blacks, 32,7% and of the 188 indians, 45,5% failed due to excessive cerumen (b7) and 1,0% (3) blacks and 2,2% (9) indians failed to foreign material (b9). it is evident that a large percentage of indians (45,5%) and blacks (32,7%) failed due to excessive cerumen as compared to failure on any other category of earcanal abnormalities. furthermore, more indians (45,5) failed than blacks (32,7%) on excessive cerumen only. '' eardrum abnormalities (eda) there were no black or indian subjects failing due to severe retractions(b12). however, 1,0% (3) blacks and 0,5% (2) indians failed due to obvious perforations (b ) and 1,6% (5) blacks and 1,0% (4) indians failed due to obvious inflammation (b ). (iii) tympanometry on tympanometry measures, 1,0% (3) blacks and 0,5% (2) indians failed due to flat tympanogram (c ) and equivalent earcanal volume outside normal range (c ) ie. > 1,0cm3; 5,4% (17) blacks and 4,8% (20) indians failed due to low static admittance (c3), ie. <0,2cm3 and 8,3% (26) blacks and 10,4% (43) indians failed tympanometric peak pressure (c4) ie. <-200 dapa. failure rat· (%) 1 1 xj <5 118 bv j||\· h i ? j p a i a 2 b i b 2 s ! d * b s 5 e b π b l a c k ββ b1 β» btl β12 chcz ci c4 ^ indian figure 1 : failure rate (percentage) of black and indian subjects within each category of the mesp table 2 : failure rate (percentage and numbers) of black and indian subjects within each category of the middle ear screening protocol (mesp) middle ear screening protocol (mesp) outer ear tests middle ear tests subject history visual inspection subject structural defects ear-canal abnormalities ear-drum abnormalities tympanometry i a 2 b, b2 b3 b4 b5 b6 b7 b8 b9 b10 b u b12 c / c 2 c 3 et black 0,3 (1) 0,3 (1) 0 0,3 (1) 0 0.3 (1) 0 4.8 (15) 32.7 (0.3) 0 1.0 (3) 1.0 (3) 1.6 (5) 0 1.0 (3) 5.4 (17) 8.3 1 indian 0,5 (2) 0,2 (1) 0 0 0 0 0 2.2 (9) 45.5 (188) 0 2.2 (9) 0.5 (2) 1.0 (4) 0 0.5 (2) 4.8 (20) 10.4 (13) note: figures in parenthesis denote number of subjects failed. key for table 2 and figure 1 aj otalgia β j structural defect of the ear b3 structural defect of the neck b5 occlusion b7 excessive cerumen b9 foreign material b u obvious inflammation cj flat tympanogram (type b) cg static admittance (<0.2cm3) v b 2 " b 4 bsb„ β c 2 ottorrhea structural defect of the head blood effusion inflammation tumor . obvious perforation severe retraction equivalent ear-canal volume (> 1.0 cm3) tympanometric peak pressure (<-200 dapa) the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) excess cerumen: failure rate of black and indian f middle ear screening protocol (mesp) discussion with reference to table 2 and figure 1, it is evident that a large percentage of both indians (45,5%) and blacks (32,7%) failed due to excessive cerumen as compared to failure on any other category of earcanal abnormalities. furthermore, more indians (45,5%) than blacks (32,7%) failed on excessive cerumen. ruben and fishman (1981) also found that the problem of impacted cerumen was common in their study of american infants. six of the 21 hearing impaired infants examined, presented with cerumen, this being a significant finding (rubin & fishman, 1981). bricco (1985), in her study of children younger than 7 years of age, found that 10 percent (35) of the subjects failed the screening because of impacted cerumen. however, 4,63% of the school children screened by audiologists watkins, moore and phillips (1984) failed their screening because of excessive cerumen in the eam. roeser and crandell (1991) emphasised that the incidence of excessive or impacted cerumen in children aged 6-17 years, is approximately 10%. in a pilot study conducted on indian children, (house of delegates, 1990) 87,8% of the subjects failed the hearing and immittance screening protocol. they concluded that "the majority of pupils failed one or all three subtests due to the presence of impacted wax unilaterally or bilaterally (house of delegates, 1990:3)". comparisons between the results of this study and the studies cited above must be drawn with caution due to the differences in age range of subjects in each study. however, in a study conducted by mandour, el-ghazzawi, toppozada and malaty (1974) on histological and histochemical study of the activity of ceruminous glands in normal and excessive wax accumulation in subjects aged one to thirty years, they showed no difference in the normal control groups either in the two sexes or at different ages. there appears to be no available information on the relationship between race and excessive accumulation of cerumen. comparatively, results on all other categories of the mesp was found to be nojt significant for both black and indian subjects. the striking results on the excessive cerumen category therefore indicate an urgent need for cerumen management. conclusion and recommendations the study revealed a high prevalence of excessive cerumen in both race groups. several studies in the literature have noted a high prevalence. as discussed in the introduction, excessive cerumen can cause a mild to moderate (fluctuating) conductive hearing loss. furthermore, medical consequences of impacted cerumen include tinnitus, pain, fullness in the ear and loss of hearing. the implication of this result is that there is an urgent need for cerumen management programs to be implemented and established with preschool children. the desired result of any screening program is the proper referral and care of individuals with identified problems. furthermore, universities can actively promote training and participation by students in cerumen extraction processes as part of their course requirements. unless audiologists manage cerumen they will be unable to provide comprehensive services to as many as 25-30% of certain populations (asha, 1990). a strong case is put forward for the audiologist's responsibility in cerumen manageihool children from durban on the 47 ment. further research in this respect is suggested. it is further suggested that teacher-parent education and general public awareness on the harmful effects of excessive cerumen, prevention and treatment of cerumen through organized programs need to be developed. although audiologists currently receive some theoretical training and clinical experience that qualifies them to manage cerumen, specific training in cerumen removal should be conducted before they engage in this activity (roeser & crandell, 1991). according to asha(1991), each audiologist who intends to perform cerumen removal procedures must ensure that he/she has acquired the knowledge and skills necessary to do each task necessary to the procedure. asha (1991) has outlined the tasks to be performed, the necessary proficiencies and the knowledge and skills necessary to do each task are summarised in appendix c. asha (1991) also stressed that the training should take place through direct supervision by a qualified professional in a setting allowing the trainee adequate clinical experience. the writer is in agreement with asha (1991) and recommends that asha's suggestions be followed in the south african pre-schools. however, each practitioner should consider the following precautions or circumstances prior to undertaking these procedures: (a) obtain a ruling from the appropriate professional board(s) to determine whether there are any limitations on the scope of audiology practice which restrict the performance of these procedures. (b) check professional liability insurance to ensure that there is no exclusion applicable to cerumen management. (c) check medical policy, institution insurance coverage and delineation of practice privileges for the specific institution to ensure that there are no restrictions applicable to an audiologist performing these procedures. (d) know whom to contact if emergency medical assistance is needed. (e) obtain informed consent from parents/guardian/ caregiver to proceed with cerumen management and maintain complete and adequate documentation. the program that follows, is extracted and modified from the dallas (texas) independent school district program (disd) (roeser, adam & watkins, 1991). the program has been modified to suit the preschools in the south african context. program procedures figure 2 presents a flow chart outlining the program. otoscopy should be performed by an audiologist prior to audiometric screening. audiometric screening should only be performed if both earcanals are unoccluded. if either or both canals are occluded, written permission from the parents/guardian is obtained for earcanal irrigation. if the child has no previous otologic history and permission is obtained, the audiologist must then instill wax softening agents into the earcanal twice daily for four to five days and the ears must be checked otoscopically. if cerumen is removed by the wax softening agent, audiometric and immittances screenings should be done. ears that remain occluded, must be irrigated until clean by the audiologist with a water pik using lukewarm wadie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 daksha bhoola & rene hugo yes 1 proceed withaudiometry no figure 2: flow chart of procedures for cerumen management preschool program reference: roeser, adam & watkins (1991: 47) ter (35 -39°c, 96 -100°f). care must be taken to avoid extreme temperatures which may cause nausea and vomiting. a low pressure setting, no higher than 2 on a scale of 0-10 on the water pik, should be used to dislodge the cerumen. audiometric and immittance screening should be performed once the ears are clear. these procedures are in accordance with roeser, adam and watkins, (1991). the audiologist must consider the contraindication of irrigation when implementing the programme. garber (1986) suggested that irrigation is contraindicated: (a) in young children or infants, because perforations are more likely in this age group; (b) in patients with tympanostomy tubes; (c) when tympanic membrane is perforated; (d) when surgery of middle ear has been recent. the program offers several significant advantages: (a) each child with impacted cerumen receives treatment necessary to ameliorate the problem. at present, patients with impacted cerumen are referred to ent specialists or doctors. often, these referrals are not completed and audiometric status remains unchanged, which may affect academic, psychoeducational and psychosocial development (roeser et al., 1991). '(b) the program will represent a time and monetary saving for parents because completing a referral often means half a day out of class for the child, medical expenses, the loss of parents'working time and salary. (c) reduced case load for ent specialists and doctors. (d)cerumen management will increase accessibility of the public to audiological practices and widen the use of our services. the procedure does have some inherent risks. injury and infection to the external auditory canal, perforation of the tympanic membrane, exacerbation of chronic mid die ear disease and damage to the ossicular chain can result (brooks, 1980). however, if procedures are performed by trained staff and applied judiciously, these risks are minimal to nonexistent (roeser et al., 1991). the program represents a modest investment of financial resources by the school system and time of the health care staff. roeser et al. (1991) reported data on more than 2000 ears that were irrigated without complications. the benefits to patient care and increased professional independence far outweigh the potential risks (roeser & crandell, 1991). it must be stressed that the proposed program is only a guideline and not a protocol that needs strict adherence. the validity and reliability of the program need to be determined. acknowledgement this article is based on master in logopaedics by the first author and she wishes to thank professor rene hugo and cyril govender for their support and assistance in the supervision of this study. references alpiner, j.g. & mccarthy, p.a. (1987). rehabilitative audiology : children and adults. baltimore : williams & wilkins. american academy of audiology. (1989). scope of practice working draft. american food and drug administration. (1977). in alpiner, j.g. & mccarthy, p.a. (1987). rehabilitative audiology: children and adults. baltimore : williams and wilkins co. american speech-language-hearing association. (1978). guidelines for acoustic immittance screening of middle ear function. american speech-language-hearing association, 21:550-558 american speech-language-hearing association. (1989). guidelines for screening hearing impairment and middle ear in disorders (draft: for peer review). 31:71-77. american speech-language-hearing association. (1990). guidelines for screening for hearing impairment and middle ear disorders). american speech-language-hearing association, 32:17-24. ' american speech-language-hearing association. (1991). external auditory canal examination and cerumen management. american speech-language-hearing association, 35 : 65-66. american speech-hearing association. (1996, spring). scope of practice in audiology. asha, 38:12-15. ; american speech-language-hearing association. (1996, spring). scope of practice in audiology. asha, 38:12-15. ballachanda, b.b. & peers, c.j.. (1992). cerumen management: instruments and procedures. american speech-languagehearing association, 43-46. bess, f.h. & humes, l.e. (1990) audiology : the fundamentals. baltimore : williams & wilkins. boothroyd, a. (1982). hearing impairments in young children. englewood cliffs, new york : prentice hall. bricco, e. (1985). impacted cerumen as a reason for failure in hearing conservation programs. journal of school health. 55 (6) : 240-241. brooks, d.n. (1980). acoustic impedance testing for screening auditory function in school children. part 1 and 2. in maico audiological library series, 15:2-5. burgess, e.h. (1977). earwax and the right way to use an ear syringe. nursing times, 73:1564-1565. chandler, r.j. (1964). partial occlusion of the external auditory meatus: its effect upon air and bone conduction hearing acuity. laryngoscope, 74:22-36. davidson, j., hyde, m.l. and alberti, p.w. (1988). epidemiology wax softening agents (4-5 days) i repeat otoscopy i oil dissolved cerumen i irrigate earisl repeat otoscopy audiometry aud immitance the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) r . r u m e n · f a i l u r e r a t e of b l a c k a n d i n d i a n p r e s c h o o l c h i l d r e n from d u r b a n o n t h e ^fiddle e a r s c r e e n i n g p r o t o c o l (mesp) 49 f hearing impairment in children. scandinavian audiology, ι 10*13-20 s l u p p r v (1986) removing impacted cerumen : procedures g a f o r vour practice'. patient care, 20, pp. 151-153. grason-stadler. (1990a). tympanometry in just seconds. grason qtnriler inc : littleton. ^ η stadler (1990b). gsi28a special auto tymp : instruction manual grayson stadler inc : littleton rravel j s & wallace, i.f. (1992). listening and language at 4 years of age : effects of early otitis media. journal of speech and hearing research, 35:588-595. house of delegates, (1990). study on hearing and immittance screening of class 2 pupils at two primary schools. unpublished report, department of health service and welfare. l edy pd (1989). practical research :planning and design. (4tn 6 p t i n e w york : macmillan publishers. mandour, m.a., el-ghazzawi, f„ toppozada, h.h. & malaty, h.a_ (1974) histological and histochemical study of the activity of ceruminous glands in normal and excessive wax accumulation. the journal of laryngology and otology, 88:1075-1085. mareolis r.h. & heller, j.w. (1987). screening tympanometry : criteria for medical referral. audiology, 26:197-208 martin, f.n. (1981). medical audiology : disorders of hearing. new jersey : prentice-hall, inc. martin, r.l. (1991). an effective program for managing ear wax. the hearing journal, 44:37. mvers β & fueschel, s.m. (1987). pseudodementia in the mentally retarded. clinical pediatrics, 26:275-263. newby, h.a. (1979). audiology (4th ed). new jersey : prentice northern^ j.l. & downs, m.p. (1984). hearing in children (3rd ed). london : williams & wilkins. robinson, a.c. & hawke, w.m. (1990). cerumen impaction: the unravelling of a mystery. otolaryngology head and neck surgery, 103, 2, 195. . roeser, j.r. & crandell, c. (1991). the a u d i o l o g i s t s responsibility in cerumen management. asha, 33 : 43-48. rouser r.j., adams, r.m. & watkins, s. (1991). cerumen management in hearing conversation : the dallas (texas independent school district program. journal of bchool health, 61(l):47-49. roush j (1990). identification of hearing loss and middle ear disease in preschool and school-age children. seminars m hearing, 11(4):357-371. ruben r j. & fishman, g. (1981). otological care of the hearing impaired child. in mencher, g.t. and gerbe, s.e. (eds). early management of hearing loss. london : grune and stratton. sharp j f, wilson, j.a. & barr-hamilton, r.m. (1990). ear wax removal: a survey of current practice. british medical journal, 301:1215-1253. sorensen h. (1981). the post-winter prevalence of secretory otitis media in four-year old children, judged by tympano-metry. in penha r and pizarro, p.n. (ed). proceedings of the fourth international symposium on acoustic impedance measurement. universidade nove de lisboa : 63-67. south african national council for the deaf. (1990). prevention of hearing impairment : summary. genetics and disability prevention cc. . , . . . . veterans health services and research administration (1990). standard procedures in audiology. washington, d.c. : audiology and speech pathology service. watkins, s. moore, t.h. & phillips, j. (1984). clearing impacted ears. american journal of nursing, 84:1107.0 a p p e n d i x a t a b l e 1 rreferral criteria : m i d d l e e a r s c r e e n i n g p r o t o c o l ( m e s p ) i h i s t o r y (a) otalgia (b) o t o r r h e a ii v i s u a l i n s p e c t i o n of the e a r (a) structural dejfect of the ear, h e a d or n e c k (b) e a r c a n a l abnormalities b l o o d or effusion o c c l u s i o n i n f l a m m a t i o n e x c e s s i v e c e r u m e n , tumour, foreign material (c) e a r d r u m abnormalities o b v i o u s perforation o b v i o u s i n f l a m m a t i o n severe retraction iii t y m p a n o m e t r y (a) flat t y m p a n o g r a m and equivalent earcanal volume ( v c ) outside normal range, o c c u r r e n c e s in a 4 6 w e e k interval. modified from : a s h a (1990) a n d a s h a (1978) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 daksha bhoola & rene hug table 2 : interim norms (means and 90% ranges) for static admittance (peak y), equivalent earcanal volume (vcc) and tympanometric peak pressure (tpp) peaky cm3/ml* v ec cm'/ml* tpp dapa means 90% range means 90% range means 90% range children 0.05 0.2-0.9 0.7 0.4-1.0 100 -200 +100 the values were extracted from margolis & heller (1987) who employed an acoustic immittance screening instrument (226-hz) probe tone; pump speed -200 dapa/s that automatically compensated for earcanal volume by subtracting the admittance at 200 dapa from all values. normative values for children were obtained from preschool-aged children (3-5 years). *cm3 and ml are equivalent units (asha, 1990). modified : roush (1990) from asha (1978) appendix β pupil record form personal details reference no: name: sex: school d.o.b date of test: age: date of retest: race :, audiologist: daksha bhoola key: red = right ear; blue = left ear a. history first screen second screen a.l otolgia yes no yes no otorrhea yes no yes no b. visual inspection structural inspection of the b.l ear yes no yes no ' b.2 head yes no yes no i b.3 neck yes no yes no ' ear canal abnormalities b.4 blood effusion yes no yes no b.5 occlusion yes no yes no b.6 inflammation yes no yes no. b.7 excessive cerumen yes no yes no b.8 tumor yes no yes no b.9 foreign material yes no yes no eardrum abnormalities b.10 obvious perforation yes no yes no b . l l obvious inflammations yes no yes no b.12 severe retractions yes no yes no the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) excess cerumen: failure rate of black and indian preschool children from durban on the middle ear screening protocol (mesp) 51 first screen c. tympanometry c 1 tympanogram c 2 static admittance c.3 earcanal volume c.4 tympanometric peak pressure d. summary d.l history d.2 visual inspection d.3 tympanometry d.4 send letter to parent d.5 send letter to ent d.6 retest a <0,2 <0,4 <-200dapa as β 0,2-0,9 0,4-1,0 -200-+100dapa fail fail fail yes yes yes c ad >0.9 >1,0 +loodapa actual value r l pass pass pass no no no second screen c. tympanometry c . l tympanogram c.2 static admittance c.3 earcanal volume c.4 tympanometric peak pressure a <0,2 <0,4 200dapa as β 0,2-0,9 0,4-1,0 -200-+100dapa c ad >0.9 >1,0 +loodapa actual value r l d. summary d.l history d.2 visual inspection d 3 tympanometry d.4 send letter to parent d.5 send letter to ent d.6 retest fail fail fail yes yes yes pass pass pass no no no appendix c summary of tasks, i^roiiciency, iuiuwi task ! bugc auu ——1 — proficiency knowledge/skills needed inspect visually via hand-held otoscope or head-light (mirror)! and speculum the eac and tm for presence'of obstructing material, evidence of lesions or ongoing infectious process, evidence of anatomical anomalies that may affect the accuracy of immittance or caloric irrigations. visual inspection of the eac and tm. 1. knowledge of anatomy, physiology and pathophysiology of the eac and tm. 2. knowledge of common medical or post-surgical conditions of the eac, tm or middle ear that alter the appearance and/or function of the eac and/or tm. . 3. skill in the use of otoscopy. 4. skill in the interpretation of visual inspection of the eac and tm inspect the eac and tm visually via hand-held pneumatic otoscope or head light (mirror) and seigel scope for determining the mobility of the tm. determination of appropriateness of tm mobility. 1. knowledge of anatomy, physiology and pathophysiology of the eac and tm. 2. knowledge of common medical or postsurgical conditions of the eac, tm or middle ear that alter the appearance and/or function of the eac and/or tm. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 daksha bhoola & rene hug 3. skill in the use of otoscopy and pneumatic otoscopy. 4. skill in the interpretation of visual inspection of the eac and tm. inspect the eac and tm visually prior to and following caloric irrigation, immittance, ear mould impression, real ear acoustic measurements or noninvasive electrocochlegraphy for purpose of documenting status of the eac and tm after one of these procedures is performed. visual inspection of the eac and tm 1. knowledge of common medical or post surgical conditions of the eac, tm or middle ear that alter the appearance and/or function of the eac and/or tm. 2. skill in the use of otoscopy and pneumatic otoscopy. 3. skill in the interpretation of visual inspection of the eac and tm. determine if occluding material visualized in the eac is cerumen and if it can be removed comfortably and safely without the use of an operating microscope. recognizing cerumen versus other occluding versus other occluding materials, and determining its need for removal and the most effective method of removal 1. skill in the use of otoscopy and pneumatic otoscopy. 2. skill in the interpretation of visual inspection of the eac and tm. 3. skill in cerumen removal by a variety of techniques and equipment. determine if the procedure to be performed should be deferred, based on eac and tm inspection, and if referral to an otolaryngologist is indicated. determining the status of the eac and tm relative to the needs of the procedure to be performed. 1. knowledge of anatomy, physiology and pathophysiology of the eac and tm. 2. knowledge of common medical or postsurgical conditions of the eac or tm or middle ear that alter the appearance and/or function of the eac and/or tm. 3. skill in the use of otoscopy and pneumatic otoscopy. 4. skill in the interpretation of visual inspection of the eac and tm. 5. skill in cerumen removal by, e.g., use of cerumen loop and hand-held otoscopic device; use of cerumen loop, head mirror and hand-held speculum; use of material for softening and gentle water irrigation or a combination of these methods. establish appropriate protocol with medical personnel to handle eac abrasion or laceration that could result from cerumen removal. determining need for other medical service involvement in the care of the eac and tm. 1. knowledge of anatomy, physiology and pathophysiology of the eac and tm. 2. knowledge of common medical or t postsurgical conditions of the eac; tm or middle ear that alter the j appearance and/or function of the eac and/or tm. select appropriate method and remove occluding cerumen or refer to an otolaryngolist for removal once determining that: a. use of a microscope may be required; b. the cerumen is too close to the tm; c..the occluding material is not cerumen; d. the comfort or safety of the patient may be comprised determining if occluding material is cerumen and, if it is cerumen, determining if it can be removed safely and comfortably without the use of an oprating microscope. 1. knowledge of anatomy, physiology, and pathophysiology of the eac and tm. 2. skill in cerumen removal by a variety of techniques and equipment key : eac external auditory canal, tympanic membrane reference : asha (1991:66) the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 41 die bydrae van basiese navorsing in kliniese toepassings met verwysing na kogleere inplantings tania hanekom en johan j. hanekom departement elektriese, elektroniese en rekenaar-ingenieurswese universiteit van pretoria opsomming hierdie artikel bespreek die waarde van basiese navorsing soos toegepas op kogleere inplantings. die artikel is gerig op klinici en oudioloe wat in die veld van kogleere inplantings werk, ofwat in hierdie veld belangstel. die artikel gee ook 'n meer algemene inleiding tot modellering vir navorsers in die kliniese omgewing. dit gee 'n wegsprihgpunt vir kogleere inplanting navorsing en gee 'n oorsig oor die toepassing van basiese navorsing in nuwe ontwikkeling in kogleere inplantings. daar word gewys wat tot dusver bereik is en watter probleme nog bestaan. die rol van multidissiplinere navorsingspanne by die oplossing van hierdie probleme word bespreek. eksperimentele navorsing en modellering werk saam om probleme op te los en nuwe ontdekkings te doen. die belangrikheid van modellering as 'n gereedskapstuk vir basiese navorsing word beklemtoon. abstract this article discusses the value of basic research as applied to cochlear implants. the article is aimed at clinicians and audiologists who are working in the field of cochlear implants or who are interested in this field. the article also gives a more general introduction to modelling for researchers in the clinical environment. it provides an entry point to cochlear implant research and reviews the application of basic research to new developments in cochlear implants. it is shown what has been achieved so far and which problems still exist. the role of multidisciplinary research teams to solve these problems is discussed. experimental research and modelling co-operate to solve problems and make new discoveries. the importance of modelling as a tool for basic research is emphasized. sleutelwoorde: kogleere inplantings, elektriese stimulasie, modellering, multidissiplinere navorsing, basiese navorsing. inleiding daar is dikwels die persepsie dat 'n kloof bestaan tussen die werelde van die navorser en die klinikus. die klinikus mag voel dat navorsing soms isoteriese probleme aanspreek wat van min praktiese waarde is. daarenteen mag die navorser voel dat die klinikus nie genoeg begrip het van die onderliggende beginsels waarop sy of haar werk berus nie. hierdie artikel spreek hierdie probleem aan uit die oogpunt van die navorser. meer spesifiek, in hierdie artikel word menslike gehoor en kogleere inplantings (clark, 1993) gebruik as voertuig om te demonstreer watter basiese navorsing in hierdie veld nodig is en wat die praktiese impak daarvan vir die oudioloog en klinikus is. die artikel is dus gerig op lede van die mediese span wie se betrokkenheidby gehoor en kogleere inplantings primer klinies van aard is (spesifiek oudioloe en klinici). die doel is om te wys wat die rol en toepaslikheid van basiese navorsing is en ook om 'n begrip te vestig van die probleme wat navorsers aanspreek en die tegnieke wat hulle gebruik. 'n omvattende bronnelys word ingesluit as inleiding tot die literatuur in die veld. , die benadering wat in die artikel gevolg word, is om 'n beskrywing te gee van die aard van navorsing, asook die gereedskap en metodes wat navorsers gebruik en om die bydrae van basiese navorsing in neuroprostetiese rehabilitasie met spesifieke verwysing na kogleere inplantings in perspektief te stel. die artikel beklemtoon spesifiek modellering as 'n belangrike gereedskapstuk in basiese navorsing. die aard van navorsing navorsing in neuroprostetiese rehabilitasie kan in drie kategoriee verdeel word: kliniese navorsing, tegnologiese navorsing (ingenieurswese) en basiese navorsing. kliniese navorsing is gemik op (1) die habilitasie en rehabilitasie van gestremde persone (spesifiek gehoorgestremde persone in hierdie artikel) deur die keuse van geskikte hulpmiddels uit dit wat beskikbaar is, (2) toepassing van die hulpmiddels (bv. die inplantering van prosteses), (3) navorsing omtrent die beste maniere om hierdie hulpmiddels te gebruik (insluitende verbeterde kliniese prosedures), en (4) die ontwikkeling van effektiewe nasorg'programme. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 tania hanekom & johan j. hanekom hierdie aspekte word hoofsaaklik bedryf deur oudioloe en klinici en val buite die bespreking van hierdie artikel. tegnologiese navorsing in neuroprostetiese rehabilitasie word hoofsaaklik bedryf deur ingenieurs, maar dit behoort duidelik te wees dat dit nie in isolasie kan gebeur nie. ingenieurs ontwikkel nuwe hulpmiddels, dikwels na aanleiding van behoeftes wat gestel word deur gestremde mense of deur medici. behoeftes mag bestaan-lank voor die tegnologie ver genoeg ontwikkel het om die spesifieke probleem te kan aanspreek. kogleere inplantings is een van die suksesverhale van biomediese ingenieurswese. graham clark het in die vorige eeu reeds besef dat die tegnologie ryp was vir 'n tegnologiese oplossing vir doofheid. hoewel hy beskou word as een van die pioniers van hierdie tegnologie, het hy gebou op vorige navorsing (andreef, gersuni & volokhov, 1934; brummer & turner, 1975; house & urban, 1973; simmons, mongeon, lewis & huntington, 1964). 'n verdere bespreking van die proses betrokke by die ontwikkeling van nuwe tegnologie val buite die bestek van hierdie artikel. basiese navorsing gee die grondslag waarop die praktiese oplossing van probleme gebou is, maar dit kan die uiteindelike tegnologiese toepassing met baie jare vooruitloop. volta (1800) het byvoorbeeld reeds twee eeue terug die eerste keer met elektriese stimulasie geeksperimenteer. toepassings, of potensiele toepassings, gee rigting aan basiese navorsing. die doel van basiese navorsing is eerstens om 'n fundamentele onderbou te verskaf waarop kliniese toepassings en tegnologiese ontwikkeling baseer kan word. twee voorbeelde word gegee. eerstens, sonder die begrip van die elektriese stimuleerbaarheid van senuweeweefsel (bv. galvani, 1791; hodgkin & huxley, 1952), sou dit nie moontlik wees om die tegnologie van kogle§re inplantings te ontwikkel nie. tweedens, die diagnostiese hulpmiddels wat in die oudiologie gebruik word, spruit voort uit die groot hoeveelheid navorsing in die psigoakoestiek wat oor die afgelope eeu gedoen is (richards, 1976). basiese navorsing stel dus ten doel eerstens om 'n beter begrip te verkry van die fundamentele werking van die onderliggende biologie en fisiologie van 'n lewende stelsel en tweedens om die reaksie van die stelsel op spesifieke insette of stimuli te voorspel. binne die konteks van neuroprosteses is die nut van basiese navorsing dus om (1) die wetenskaplike kennis omtrent die werking van die normale en elektries-gestimuleerde biologiese stelsel uit te brei (bv. clark, shute, shepherd & carter, 1997; shannon, 1993), (2) die funksionering van prosteses te verbeter deur nuwe kennis omtrent die werking van die biologiese stelsel toe te pas gedurende die ontwerp van nuwe generasies tegnologiese hulpmiddels (bv. cords, reuter, issing, sommer, kuzma & lenarz, 2000), en (3) om die effek van elektriese stimulasie te verklaar vir verskillende inplantings wat op die mark beskikbaar is bv. (tye-murray, lyier, woodworth & gantz, 1992). hieronder word aangedui wat die navorsingsvrae omtrent kogleere inplantings is en watter gereedskap gebruik word by navorsing. eerstens word die probleem van kogleere inplantings kortliks geskets. die kogleere inplantingsprobleem kogleere inplantings kan vanuit beide 'n kliniese oogpunt en bio-ingenieurswese oogpunt beskou word as suksesvol (national institutes of health, 1995). die inplantings is veilig en betroubaar. kliniese prosedures en prosesse vir voorsorg, insorg en nasorg is gevestig. inplantings is voordelig vir die gebruiker, vir wie dit in kontak plaas met die klankomgewing. inplantings word ook as finansieel effektief beskou. daar is egter vele onopgeloste probleme, insluitend onvoorspelbaarheid van resultate (clark, 1996), groot interpasientvariasie in sukses (kou, shipp & nedzelski, 1994), baie gebruikers se lae spraakverstaanbaarheid in 'n normale spraakomgewing (kou, shipp & nedzelski, 1994; clark, 1996), meeste gebruikers se musiekpersepsie is swak (fujita & ito, 1999), sommige gebruikers het steeds balansprobleme (kou, shipp & nedzelski, 1994), baie gebruikers kan nie telefonies kommunikeer nie en sukkel in ruiserige omstandighede (hirsch, 1993). die ideaal is dat 'n gebruiker se inplanting onsigbaar van buite is, lang lewensduur het, lang batterylewe het en klankkwaliteit gee wat naby aan normale gehoor is. kogleere inplantings se ontwerp is gebaseer op drie onderliggende beginsels: (1) 'n senuweevesel kan geaktiveer of gestimuleer word deur elektriese stroom deur die vesel te laat vloei, (2) senuweevesels in die koglea is tonotopies gerangskik (greenwood, 1990) en (3) frekwensie-inligting word gekodeer in beide tydpatrone sowel as die plek van aktiwiteit in die cochlea (evans, 1978). die tonotopiese rangskikking van die senuweevesels in die koglea verwys na die rangskikking van senuweevesels volgens toonhoogte oor die lengte van die koglea. stimulasie van senuweevesels naaste aan die basis van die koglea is verantwoordelik vir persepsie van hoe toonhoogtes terwyl senuweevesels nader aan die apeks laer toonhoogtes waarneem. deur dus stroom deur die senuweevesels te laat vloei op spesifieke plekke in die koglea, kan verskillende toonhoogtesensasies geskep word. vokoder-tipe strategiee maak gebruik van hierdie idee (bv. die speak strategie, loizou, 1999). daarenteen fokus strategiee soos cis (loizou, 1999) op die behoud van tydpatrone. in teenstelling met akoestiese opwekking van senuwees in 'n normale koglea, word groot getalle senuweevesels gelyktydig geaktiveer tydens elektriese stimulasie (javel, 1990). een rede hiervoor is dat daar ongeveer 30 000 senuwees in die koglea is (allen, 1985) wat met slegs 16 tot 22 elektrodes geaktiveer moet word (clark, 1993; kessler, 1999). verder kan die stimulasiestrategiee wat gebruik word om klanklinligting oor te dra nie die tydof ruimtelike patrone waarvolgens die gehoorsenuweevesels akoesties geaktiveer word perfek namaak nie (javel, 1990; miller, abbas, rubinstein, robinson, matsuoka & woodworth, 1998). die stroomverspreiding om die elektrodes tesame met die stimulasiestrategie het waarskynlik 'n groot effek op die klanksensasie wat 'n persoon met 'n kogleere inplanting waarneem (clark, 1996). die uitdaging is dus om die verspreiding van die stimulasiestroom by die senuwees te beheer en om die stimulasiestrategie te optimeer in 'n poging om die natuurlike senuweeaktiveringspatrone in die koglea na te maak (rubinstein, wilson, finley & abbas, 1999). twee aanverwante navorsingsdoelwitte wat hieruit spruit, is (1) om metodes te vind om die verspreiding van die stimulasiestroom by die senuwees te beheer (bv. cords, reuter, issing," sommer, kuzma & lenarz, 2000) en om (2) die proses waarop die sentrale gehoorstelsel die inligting wat tydens stimulasie oorgedra word integreer, verwerk en interpreteer verder te ontsyfer (bv. hanekom & kriiger, 2001; zeng & shannon, 1999) sodat die stimulasiestrategie daarvolgens ontwerp the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die bydrae van basiese navorsing in kliniese toepassings met verwysing na kogleere inplantings 43 kan word. dis byvoorbeeld nog nie duidelik of tydof plekkodering dominant is nie (moore & sek, 1996). die gereedskap wat gebruik word vir basiese navorsing basiese navorsing in kogleere inplantings sluit in neurofisiologiese laboratoriumeksperimente, psigoakoestiese eksperimente met normaalhorende persone sowel as gebruikers van inplantings, en modellering van die perifere en sentrale gehoorstelsel, beide wanneer dit akoesties gestimuleer word en wanneer dit elektries gestimuleer word. om die navorsingsdoelwitte genoem in die vorige paragraaf te kan behaal, bv. om die verspreiding van die stimulasiestroom te beheer en om die sentrale verwerkingsprosesse in die brein te verstaan, is dit belangrik om die fisiese en biologiese beginsels met standaardmetodes te kan naspeur en te kan beskryf. analitiese navorsingstegnieke en prosedures in die neurofisiologie en psigoakoestiek is goed gevestig in standaardprosedures oor 'n tydperk van baie dekades. beskrywingstegnieke kom uit die domein van ingenieurs, fisici en wiskundiges. modellering ingenieurs skep dikwels wiskundige modelle om prosesse voor te stel en die effek van veranderings aan 'n stelsel te voorspel. 'n model is 'n wiskundige beskrywing vaii 'n natuurlike verskynsel in hierdie geval dus 'n wiskundige beskrywing van die werking van die sentrale gehoorstelsel of 'n wiskundige beskrywing van die gei'nplanteerde koglea. die ingenieur of natuurwetenskaplike skep dus 'n stelsel van wiskundige vergelykings waarmee die gedrag van die normale gehoorstelsel of van die elektriesgestimuleerde gehoorstelsel beskryf kan word. die vergelykings kan met analitiese metodes (bv. rubinstein, soma & spelman, 1985; siebert, 1970) of met numeriese metodes (bv. finley, wilson & white, 1990; rattay & aberham, 1993) opgelos word. numeriese oplossings word verkry met ' rekenaarsimulasies. modelle kan verder varieer vanaf streng biologiesgebaseerde modelle tot swartkassiemodelle. die term swartkassiemodel word dikwels deur ingenieurs gebruik vir 'n stelsel waarvan mens die inset en die uitset kan meet, maar geen kennis het oor wat binne-in die stelsel (die "swart kassie") sit nie. voorbeelde word hieronder gegee. streng biologiesgebaseerde modelle daarenteen inkorporeer soveel moontlik bestaande kennis oor die biologiese anatomie en fisiologie. sulke modelle mag byvoorbeeld die funksie van 'n spesifieke stelsel in die brein modelleer deur. 'n groot aantal senuwees te modelleer en dan hierdie senuwees saam te voeg in 'n groter struktuur (bower, 1990). meer spesifiek, in sulke modelle mag elke senuwee wat modelleer word beskryf word deur 'n volledige hodgkin-huxleymodel (hodgkin & huxley, 1952). die hodgkin-huxleymodel is een van 'n. aantal biologiesgetroue senuweemodelle en gebruik 'n hele aantal wiskundige vergelykings om die werking van 'n enkele senuweesel te beskryf. swartkassiemodelle beskryf bloot inset-uitsetdata deur 'n wiskundige vergelyking sonder die inagneming van die biologie. sommige senuweemodelle modelleer die senuwee bloot as 'n generator van senuweepulse (bv. gabbiani & koch, 1996). in die eenvoudigste vorm pas swartkassiemodelle bloot 'n kurwe aan die data en aanvaar geen begrip van die werking van die stelsel wat dit modelleer nie. swartkassiemodelle kan baie beperk wees in terme van die datastelle wat voorspel kan word. tussen streng biologiese modelle en swartkassiemodelle bestaan 'n hele kontinuum van modelle wat tot 'n mindere of meerdere mate bestaande kennis oor die biologie inkorporeer. sommige modelle ignoreer doelbewus bestaande kennis (dus is meer gei'dealiseerd as streng biologiesgebaseerde modelle) met die doel om randfaktore buite rekening te laat (soos byvoorbeeld variasies tussen mense) om te kan deurdring tot die kernbewerkings wat die stelsel wat ondersoek word, uitvoer. modelle word gekarakteriseer deur die modelstruktuur en die parameters. hierdie terme word met 'n voorbeeld verduidelik. om 'n sekere funksie (bv. diskriminasie van twee suiwer tone) uit te voer is 'n netwerk van neurone op 'n sekere manier aan mekaar geskakel. vir sommige stelsels in die liggaam is hierdie struktuur in minder of meer detail bekend, bv. struktuur van die piriforme korteks, die primere sentrum vir die verwerking van olfaktoriese inligting (bower, 1990), en die struktuur van die sentrale ouditiewe stelsel, (brugge, 1992; ehret, 1997). wanneer die struktuur van 'n model gedefinieer word, moet daar onder andere besluit word hoeveel neurone die model moet bevat, wat die aard van die sinapse (inhiberend of eksiterend) moet wees, en wat die plasing van die sinapse in die struktuur moet wees. die modelstruktuur kan afgelei word uit die anatomie (bower, 1990). nadat die struktuur bekend is, mag sekere parameters steeds onbekend wees. die eienskappe van die senuweemembraan (bv. hoe sterk dit reageer op 'n stimulus), die spoed waarteen senuwees aksiepotensiale gelei en die dikte van die senuwees is voorbeelde van modelparameters. bower (1990) gee 'n gedetailleerde voorbeeld van so 'n rekenaarmodel vir die piriforme korteks. modellering is dikwels 'n iteratiewe proses. gegrond op die navorser se begrip van die prosessering wat uitgevoer word in die stelsel wat gemodelleer word, bepaal die navorser 'n modelstruktuur. parameters vir die model moet dan gemeet word, of kan soms uit die literatuur verkry word. dikwels is dit nodig om modelparameters te skat en soms is dit voldoende as die skatting net naastenby reg is. met struktuur en parameters bekend, kan rekenaarsimulasies dan met die model uitgevoer word. die gedrag van die verskynsel wat gemodelleer word (die uitsette van die model), word tipies beskryf in terme van meetbare hoeveelhede soos byvoorbeeld die vuurtempo op enkelsenuwees, ruimtelike aktiveringspatrone op 'n aantal senuwees, gehoordrempels en drempels van frekwensiediskriminasie. dit is nodig dat die uitsette van 'n model ooreenstem met meetbare hoeveelhede sodat die werking van die model met fisiese metings bevestig kan word. as die model se gedrag goed is, m.a.w. die model kan gemete data getrou namaak (dit kan absolute waardes en tendense voorspel), gee dit vertroue dat die keuse van die struktuur goed was. soms word tendense reg voorspel, maar die groottes van die gemete data en voorspelde data stem nie ooreen nie. dit kan wees omdat die struktuur van die model reg is, maar die parameters foutief geskat of gemeet is. aan die ander kant kan dit gebeur dat die model hoegenaamd glad nie die gemete data kan voorspel nie, en dan is die eerste vermoede dat die modelstruktuur verkeerd is. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 'η belangrike vraag wat oor elke model beantwoord moet word is: kan,die model gemete data buite die datastel waarvoor die model geskep is, verklaar? indien nie, moet die model verder ontwikkel word. hoe meer datastelle 'n model kan verklaar, hoe meer vertroue kry die navorser dat die verwerking van die onderliggende stelsel verstaan word en dat die model se struktuur dus reg is. as voorbeeld, as 'n model geskep is om frekwensiediskriminasie van enkeltone te voorspel, maar dit kan ook die diskriminasie van komplekse tone voorspel, gee dit heelwat vertroue in die geldigheid van die model. soos modelle verder ontwikkel word, groei begrip van die stelsel wat gemodelleer word. waarvoor word modelle gebruik? modelle van die gehoorstelsel kan nie die effek van stimulasie of die gedrag van die gehoorstelsel perfek voorspel nie, omdat hulle 'n vereenvoudiging van die werklikheid voorstel. dit is byvoorbeeld onmoontlik om al die interpersoonvariasies in die aantal residuele senuwees in die kogleas van dowe persone in ag te neem. wat is die nut van modelle dan? 'n volmaakte voorstelling van die werklikheid is nie noodwendig noodsaaklik, of beskikbaar, om die funksionering van 'n stelsel te beskryf nie. kogleere inplantings is 'n goeie voorbeeld hiervan, omdat verbeterings aan die inplantings reeds suksesvol aangebring is op grond van onder andere modelleringstudies, ten spyte daarvan dat die funksionering van die gehoorstelsel nie volledig verstaan word nie (clark, 1996). as 'n model dus die belangrikste eienskappe van 'n stelsel so korrek kan voorspel dat die inligting bruikbaar is, is die model nuttig. heelwat modelle is byvoorbeeld geskep om psigoakoestiese data te voorspel vanuit neurofisiologiese data. sulke modelle het onlangs gewys dat ruis 'n positiewe rol speel in gehoor (bruce, white, irlicht, o'leary & clark, 1999; zeng, fu & morse, 2000). op grond hiervan is nuwe algoritmes voorgestel wat meer ruis sal bewerkstellig in vuurpatrone as gevolg van elektriese stimulasie (bruce, irlicht, white, o'leary, dynes, javel & clark, 1999; bruce, white, irlicht, o'leary & clark, 1999; rubinstein, wilson, finley & abbas, 1999; white, rubinstein & kay, 2000). modelle van die gei'nplanteerde koglea is ook geskep om die stroomverspreiding om die elektrodes te voorspel (finley, wilson & white, 1990; frijns, de snoo & schoonhoven, 1995; girzon, 1987; t. hanekom, 2001; rattay, leao & felix, 2000). hierdie modelle het gewys dat senuwees meer selektief gestimuleer kan word as die elektrodes nader aan die senuwees geplaas word. op grond van modelleringsdata soos hierbo en metings in die laboratorium (shepherd, hatsushika & clark, 1993) is nuwe elektrodes, soos naby-modiolus elektrodes (donnelly, cohen, xu, xu & clark, 1995; treaba, xu, xu & clark, 1995), en 'n elektrodeposisioneerder (cords, reuter, issing, sommer, kuzma & lenarz, 2001), ontwikkel. nog 'n belangrike gebruik van betroubare modelle is dat dit die navorser in staat stel om konsepte te toets in rekenaarsimulasies, eerder as om direk eksperimente op mense of diere te doen. eksperimentele navorsing eksperimentele navorsing sluit 'n wye veld in en is gerig op die fisiese kwantifisering van parameters waarvoor daar ontwerp moet word in neuroprostetiese toestelle. ekspetania hanekom & johan j. hanekom rimentele navorsing is nader aan die verwysingsraamwerk van die klinikus of oudioloog en sal nie hier in diepte bespreek word nie. slegs enkele navorsingsgebiede word ter illustrasie genoem. ingenieursaspekte wat tipies tydens basiese navorsing aangespreek word sluit in bioaanpasbaarheid, veiligheid en betroubaarheid van die materiale wat ge'inplanteer word (brummer & turner, 1975; clark, shepherd, patrick, black & tong, 1983; donaldson, donaldson & brindley, 1985; hambrecht, 1985; house & urban, 1973; lenhart, 1992; seldon, dahm, clark & crowe, 1994; van noordt & black, 1981); betroubaarheid van die stelsel (soma, 1986); korrosie van die elektrodemateriale (donaldson & donaldson, 1986; donaldson, donaldson & brindley, 1985; hanekom & hanekom, 1998; johnson & hench, 1977; shepherd,/murray, houghton & clark, 1985); vervaardiging van elektrodes, gei'nplanteerde elektronika en eksterne elektronika (clark, shepherd, patrick, black & tong, 1983; hanekom, hanekom & marais, 1998; lauridsen, giinthersen, bonding & tos, 1982); en betroubaarheid van elektronika en hermetiese verseeling (donaldson, 1988; soma, 1990). neurofisiologiese eksperimente is gerig op die bepaling van die biologiese stelsel se eienskappe en werking waarbinne die prostese moet funksioneer. in kogleere prosteses is kennis oor die werking van senuweevesels en die seinverwerking deur die senuweevesels en sentrale gehoorstelsel van primere belang. fisioloe het meettegnieke ontwikkel en metings gedoen op senuwees om die meganisme waarvolgens senuwees geaktiveer word na te speur (frankenhaeuser, 1956; hodgkin & huxley, 1952; schwarz & eikhof, 1987), om eienskappe van senuwees te meet (verveen, 1962), om senuwees se reaksie op elektriese stimulasie te meet (miller, abbas, rubinstein, robinson, matsuoka & woodworth, 1998; rattay, 1999; rubinstein, wilson, finley & abbas, 1999; shepherd, hatsushika & clark, 1993; stypulkowski & van den honert, 1984; van den honert & stypulkowski, 1984; van den honert & stypulkowski, 1987a; van den honert & stypulkowski, 1987b) en om skade aan senuwees as gevolg van elektriese stimulasie te bepaal (huang & shepherd, 1999; mccreery, agnew, yuen & bullara, 1992; shepherd, matsushima, martin & clark, 1994; tykocinski, shepherd & clark', 1997). i die doel met psigoakoestiese eksperimente is om die waarneembare effek van insette na die gehoorstelsel te kwantifiseer. psigoakoestiese hoeveelhede soos die toonhoogte of luidheid van 'n klank is persoonafhanklik en kan nie eenduidig en direk gemeet word nie. psigo-j akoestiese hoeveelhede word dus statisties bepaal nadat' proefpersone 'n voldoende aantal herhalings van 'n ekspe-1 riment voltooi het om 'n statisties beduidende resultaat te lewer. deur die psigoakoestiek van akoestiese en elektriese stimulasie te vergelyk (j.j. hanekom, 2000; shannon, 1993; zeng & shannon, 1992) kan meer geleer word oor die seinverwerking wat die gehoorstelsel doen en oor hoe om te werk te gaan om beter inplantings te ontwikkel. psigoakoestiese navorsing kan direk lei tot verbeterde algoritmes (clark, 1996) en verbeterde programmering van bestaande inplantings (hanekom & shannon, 1996). navorsing moet multidissipliner wees die bespreking hierbo wys dat multidissiplinere navorthe south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die bydrae van basiese navorsing in kliniese toepassings met verwysing na kogleere inplantings 45 singspanne nodig is om probleme effektief aan te spreek en nuwe tegnologie te ontwikkel. natuurwetenskaplikes soos ingenieurs, fisioloe, fisici, wiskundiges en dierkundiges beskik oor die eksperimentele en analitiese gereedskap wat nodig is om die suiwer wetenskaplike en tegnologiese aspekte ter sprake by basiese navorsing op die gebied van kogleere inplantings aan te spreek. elke lid van 'n navorsingspan kan nie 'n kundige wees op elke tersaaklike gebied nie. ingenieurs het 'n goeie teoretiese en tegnologiese onderbou en kan fokus op modellering, die ontwikkeling van meetgereedskap en tegnologie. fisioloe kan weer fisiologiese parameters meet op selle of diere in die laboratorium. kliniese en basiese navorsing het verskillende (maar aanverwante) doelwitte. in 'n multidissiplinere span word beide tipes navorsing gedoen, en al die lede van die span kan betrokke wees by alle navorsingsprojekte, maar tipies word kliniese en basiese navorsing afsonderlik bestuur deur 'n klinikus en 'n natuurwetenskaplike onderskeidelik. wat is reeds bereik met basiese navorsing? enkele voorbeelde word hier gegee van die impak van basiese navorsing op die ontwikkeling van kogleere inplantings. dit is in psigoakoestiese eksperimente bepaal dat die frekwensie waarteen gestimuleer word op 'n enkele elektrode net gediskrimineer kan word tot omtrent 300 hz, maar dat deur die plek van stimulasie te verskuif, 'n baie groter perseptuele verandering in frekwensie verkry kan word as 300 hz (dorman, smith, smith & parkin, 1994; shannon, 1983). ander navorsing het gewys dat die elektrodes gerangskik kan word in tonotopiese volgorde (dorman, smith, dunnavant, parkin & dankowski, 1990; nelson, van tasell, schroder, soli & levine, 1995). daarom is besluit om frekwensie te kodeer as plek van stimulasie in al die bestaande multikanaalinplantings (clark, 1996; kessler, 1999). in 'n verdere lyn van navorsing is aangetoon dat die elektries-gestimuleerde gehoorstelsel net so goed of beter vaar as die normale ι gehoorstelsel met take wat tydre/ solusie meet (shannon, 1983; shannon, 1989; van wieringen & wouters, 1999). hierdie lyn van navorsing het gelei tot strategiee wat daarop gemik is om die tydpatrone in spraak so getrou as moontlik in stimulasiegolfvorms na te maak, bv. die cis strategie (loizou, 1999). wat is huidige navorsingsvrae? ι daar is 'n te groot aantal navorsingsvrae wat tans aangespreek word om almal hier te noem. enkele belangrike vrae word genoem. kan stroomverspreiding rondom elektrodekontakte beperk word deur beter elektrode-ontwerpe (cords, reuter, issing, sommer, kuzma & lenarz, 2000)? hoeveel interaksie is daar tussen neurale kanale wat met verskillende elektrodes gestimuleer word (fu, 1997; hanekom & shannon, 1998)? is kanaalinteraksie belangrik vir spraakverstaanbaarheid (fu & shannon, 1999a; fu & shannon, 1999b)? is dit plekkodering of tydkodering, of 'n kombinasie van beide die meganismes waarmee die gehoorstelsel frekwensie kodeer (j.j. hanekom, 2000; moller, 1999)? hoeveel elektrodes is nodig vir effektiewe oordraging van inligting aan die elektriesgestimuleerde gehoorstelsel (fishman, shannon & slattery, 1997)? hoe belangrik is die relatiewe tydverskille waarmee elektries gestimuleer word op die verskillende kanale (carlyon, geurts & wouters, 2000)? waar presies word die elektriese gestimuleerde seine gegenereer (javel & shepherd, 2000)? wat is die invloed van die stimulasiegolfvorm se parameters op die klank wat waargeneem word (chatterjee, fu & shannon, 2000)? hierdie is maar 'n klein uittreksel uit vrae, waarvan die antwoorde kan lei tot verbeterings in kogleere inplantings. gevolgtrekking om die kogleere inplanting-navorsingsveld volledig aan te spreek is dit noodsaaklik dat basiese navorsing in parallel met kliniese navorsing gedoen moet word. kliniese navorsing konsentreer op die habilitering en rehabilitering van die dowe persoon, terwyl basiese navorsing gemik is op uitbreiding van die kennis en begrip van die werking van die normale en elektries-gestimuleerde gehoorstelsel sowel as die ontwikkeling en verbetering van die kogleere inplantingtegnologie. basiese navorsing behoort modelgebaseerd te wees. wiskundige modelle vorm 'n belangrike deel van die meetgereedskap van die navorser. buiten hul waarde om bestaande kennis op te som, dra modelle by tot begrip van die werking van die stelsel (bv. die gehoorstelsel). modelle help ook om gapings in die bestaande kennis bloot te le, hetsy dit in onbekende parameterwaardes of in begrip van die werking van die stelsel le. basiese navorsing het reeds gelei tot kliniese toepassings waaronder die kogleere inplanting een van die uitstaande suksesse is. 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(1999). psychophysical laws revealed by electric hearing. neuroreport, 10, 1931-1935. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) time to think of a think about working in the uk s p e e c h a n d l a n g u a g e t h e r a p i s t s a n d a u d i o l o g i s t s quality locums are looking for quality personnel in all grades and specialities for work in the uk. eligibility for a visa or work permit would be an advantage, but even if you are not eligible w e would still like to hear from you a s w e may be able to help. quality locums are the largest independent medical, c a r e and education agency in the uk and w e have branches in south africa and australia. w e need medical staff of all s p e c i a l i t i e s , s o c i a l w o r k e r s a n d t e a c h e r s urgently to fill full and part time positions throughout great britain and ireland. w e are experts at helping you to take advantage of the^>pportunities in the uk. w h y not call one of our managers today for an informal discussion. s o n j a l e w i s q u a l i t y l o c u m s c a p e t o w n re.: 0 2 1 4 6 2 5 3 5 7 fax: 021 4625390 email: qualitylocums@worldonline.co.za matt w a g n e r q u a l i t y l o c u m s d u r b a n tel: 0 3 1 4 6 9 2 0 9 8 email wagner@yebo.co.za the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mailto:qualitylocums@worldonline.co.za mailto:wagner@yebo.co.za cpd december 2011 1. true (a) or false (b): literacy can be defined as one’s ability to read and speak. 2. true (a) or false (b): literacy skills of south african grade 5 learners are better than those of learners in neighbouring countries. 3. true (a) or false (b): language problems of children learning in their l2 have the most significant impact on their achievement in mathematics. 4. true (a) or false (b): the noise level in a classroom has little or no impact on learners’ reading skills. 5. true (a) or false (b): teachers identified limited reading and writing opportunities as a barrier to learning written language. 6. true (a) or false (b): teacher-learner ratios can affect reading comprehension of learners. 7. true (a) or false (b): the home/social community can influence learners’ academic success. 8. true (a) or false (b): the acquisition of listening skills is important in acquiring phonological awareness. 9. true (a) or false (b): phonological awareness is a predictor of reading and writing success. 10. true (a) or false (b): classroom instruction in the home language is important during the foundation phase of schooling. 11. true (a) or false (b): the majority of teachers in the wium & louw study used english as the language for learning and teaching in classrooms. 12. true (a) or false (b): currently 30% of slts in south africa have an african language as first language. 13. true (a) or false (b): rhyming is a common occurrence in african languages. 14. true (a) or false (b): learning and teaching in a second language can have a negative emotional impact on the learner and teacher. 15. true (a) or false (b): language factors are the only contributors to academic success. 16. true (a) or false (b): academic language skills are usually acquired through casual conversation. 17. true (a) or false (b): in south africa, sufficient attention is paid to educational linguistics. 18. true (a) or false (b): white paper 6 (department of education, 2011) omitted the role of slts in the educational setting. 19. true (a) or false (b): parental beliefs about literacy can have an impact on writing skill development. 20. true (a) or false (b): teachers’ skills to facilitate language development in the classroom can be enhanced by cpd activities. special edition on education cpd questionnaires must be completed online via www.cpdjournals.co.za. after submission you can check the answers and print your certificate. the south african journal of communication disorders sajcd 2 7 'η vergelyking van die invloed van sekere kontekstuele faktore op die simptome van persone met verworwe verbale apraksie en verbale ontwikkelingsapraksie a. van der merwe, d.phil (pretoria) departement spraakheelkunde en oudiologie universiteit van pretoria r.j. grimbeek, m.sc (pretoria) departement statistiek universiteit van pretoria opsomming gegewens oor die individuele simptome van persone met verworwe verbale apraksie en verbale ontwikkelingsapraksie is van teoretiese belang vir die studie van verbale apraksie. deur die vergelyking van individuele simptome kan liggewerp word op simptoombeelde oftipes verbale apraksie en op die aard van die afwyking by verworwe verbale apraksie en verbale ontwikkelingsapraksie. in hierdie ondersoek wat deel uitmaak van die groter ondersoek waarin die effek van variasie in kontekstuele faktore op verbaal apraktiese spraak nagegaan word (van der merwe, uys, loots en grimbeek, 1987; 1988; vander merwe, uys,loots, grimbeek en jansen, 1989) is die simptome van vier persone met verworwe verbale apraksie en een per soon met verbale ontwikkelingsapraksie onderling vergelyk. die ouditiefwaarneembarefoute en afwykings in stemaanvangstyd, vokaalduur en uitingduur van die proefpersone is vergelyk. die resultate toon onder andere aan dat diefrekwensie van voorkoms van sekere simptome aanleidinggee tot individuele simptoombeelde, maar dat al die proefpersone die hoe voorkoms van simptome wat aanduidend is van die aard van die afwyking gemeen het. die proefpersoo'n met verbale ontwikkelingsapraksie het al die simptome gemeen met die groep, maar vertoon minder afwykings in temper ale vloei en uitingduur en meerklankvervangings. die teoretiese implikasies van die resultate word bespreek. summary data on the individual symptoms of patients with acquired apraxia of speech and developmental apraxia of speech is of theoretical significance in the study of this disorder. a comparison of individual symptoms may shed light on error patterns in apraxia of speech, the possibility of types of apraxia ofspeechand on the nature of the disorder. in this study which was part of the wider investigation into the effect of variation in contextual factors on apraxia of speech (van der merwe, uys, loots and grimbeek, 1987; 1988; van der merwe, uys, loots, grimbeek and jansen, 1989) the symptoms of four patients with acquired apraxia of speech and one subject with developmental apraxia of speech were compared. the auditorily perceived symptoms and the deviations in voice onset time, vowel duration and utterance duration of all the subjects were compared. the results indicated that the frequency of occurrence of certain symptoms created individual error patterns but also that all subjects had the high occurrence of symptoms which reflect the nature of the disorder in common. the subject with developmental apraxia of speech had 'all symptoms in common with the other subjects but exhibited less deviancy in the temporal flow of speech and in the duration of the utterance.^he presented with more sound substitutions than did the acquired group. the theoretical implications of the results are discussed. ι tydens die navorsing oor die invloed van sekere kontekstuele faktore op ouditief waarneembare foute, stemaanvangstyd, vokaalduur en uitingduur by verbale apraksie (van der merwe, uys, loots & grimbeek, 1987; 1988; van der merwe, uys, loots, grimbeek en jansen, 1989) was die analises gebaseer op groepresultate alhoewel aandag ook subjektief geskenk is aan die gedrag van individue binne die groep. die data van die individuele proefpersone is egter ook statisties onderling vergelyk en in die huidige artikel word hierdie resultate aangebied. analise van die individuele resultate was belangrik aangesien dit bekend is dat alle apraktiese persone nie alle simptome gemeen het nie (wertz, la pointe & rosenbek, 1984) en ook omdat 'n proefpersoon met verbale ontwikkelingsapraksie (voa) by die eksperimentele groep ingesluit was. gegewens oor die individuele simptome van proefpersone met verworwe verbale apraksie ( w a ) en voa is van teoretiese belang vir die studie van verbale apraksie. diagnostiese kriteria gegrond op sekere kenmerkende eienskappe van vva is vir die eerste keer geformuleer en in navorsing gei'mplimenteer deur kent en rosenbek (1983). hulle noem die volgende eienskappe van w a as kriteria: worstelende en soekende probeer-en-tref artikulasiebewegings en pogings tot selfkorreksie; disprosodie met geen verlengde periodes van normale ritme, klem en intonasie nie; foutonkonstantheid by herhaalde produksies van dieselfde eenheid; opsigtelike probleme in die inisiering van uitinge. dieselfde kriteria (tesame met ander kriteria wat die teenwoordigheid van afasie en disartrie uitskakel) is vir die seleksie van proefpersone in die huidige ondersoek gebruik. dit was reeds by seleksie duidelik dat nie alle simptome by al die proefpersone voorkom nie. die moontlikheid van verskillende tipes die suid-afrikaanse tydskrif vir kommunikasieafwykins, vol. 37 1990 s a s 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 a. van der merwe & r.j. grimbeek verbale apraksie is reeds van melding gemaak in die literatuur (rosenbek, kent & la pointe, 1984; deutsch, 1984). die huidige ondersoek kan moontlik 'n bydrae maak tot kennis van individuele foutpatrone van persone wat almal as verbaal aprakties gediagnoseer kan word. in die huidige ondersoek is daar ook vir die eerste keer sover bekend 'n sistematiese vergelyking in navorsing getref tussen die simptome van persone met w a en 'n kind wat gediagnoseer is as verbaal aprakties. die blote bestaan van voa word soms nog betwyfel (guyette en diedrich, 1981; aram, 1984). die meeste vooraanstaande navorsers erken egter wel dat verbale apraksie by die kind kan voorkom (wertz, et al, 1984; yoss & darley, 1974). die belangrikste struikelblok in die beskrywing van sodanige diagnostiese groep is die gebrek aan diagnostiese kriteria wat hoofsaaklik te wyte is aan onvoldoende navorsing en die beperkte siening van verbale apraksie wat hoofsaaklik gegrond is op die simptome van die verworwe vorm. die verskille tussen individuele kinders met voa en die gekombineerde voorkoms met ander probleme veral by die meer algemeen breinbeseerde kind, bemoeilik die diagnose en beskrywing van voa verder. jarelange verkenning in die praktyk dui op die bestaan van minstens drie groepe kinders wat as suiwer verbaal-aprakties beskryf kan word (van der merwe, 1985). die eerste is die groep wat nie-verbaal is, maar met goeie reseptiewe taal. die tweede is 'n groep wat spraakagtige uitings vertoon soos slegs vokaalproduksie en die derde groep kommunikeer wel verbaal, maar is onverstaanbaar. beide hierdie groepe beskik ook oor goeie reseptiewe taal vermoe. verdere navorsing word tans onderneem om hierdie groepe te verifieer. die kind wat in die huidige ondersoek ingesluit is, het by aanvanklike diagnose in groep 1, die nie-verbale groep geval. afgesien van die vraag of daar wel so 'n afwyking soos voa is, bestaan die vraag ook of die kern van die probleem by die kongenitale of verworwe vorms soortgelyk is. guyette en diedrich (1981) verwys in hul bespreking na die rasionaal dat dieselfde benadering in behandeling geskik sal wees vir beide w a en voa indien die kern van die probleem ooreenstem. sodanige waarneming is wel plaaslik gedoen. die terapieprogram vir voa wat daarop gemik is om die beplanning van spraak te fasiliteer en uit te bou is suksesvol bevind by aldrie bogenoemde tipes voa en ook by gevalle met suiwer w a (van der merwe, 1985). guyette en diedrich (1981:41) meld ook in hul oorsig van voa dat "it is believed that response to treatment is a strong argument in support of a diagnostic category". dit is die teoretiese uitgangspunt in hierdie artikel dat beide w a en voa afwykings in die vermoe van die brein is om spraak te beplan of te leer beplan (van der merwe, 1986). indien ooreenstemmende simptome wel gevind word by die proefpersone met w a en die persoon met voa sal dit nie alleen die aanvanklike diagnose van voa grootliks bevestig nie, maar dit sal ook 'n sterk aanduiding wees van die ooreenkoms in die onderliggende aard van die probleem. die beskrywing van die individuele foutpatrone van al die proefpersone sal ook bydra tot 'n beter gedefinieerde beeld van w a en voa. metode d o e l die doel van hierdie bepaalde komponent van die ondersoek is om die individuele verskille in die simptome van die proefpersone met verworwe verbale apraksie verder toe te lig en ookom te bepaal in watter opsigte die proefpersoon met verbale ontwikkelingsapraksie verskil van of ooreenstem met die ander vier persone met verworwe verbale apraksie. e k s p e r i m e n t e l e o n t w e r p die proefpersone, luisteraars, materiaal en prosedure van ondersoek is reeds volledig beskryf in die voorafgaande artikels (van der merwe et al, 1987, 1988, 1989) en slegs enkele belangrike aspekte sal hier herhaal word. die totale ondersoek het bestaan uit 'n perseptuele analise van die invloed van sekere kontekstuele faktore op die ouditief waarneembare foute van persone met verbale apraksie en uit 'n akoestiese analise van die invloed van dieselfde faktore op stemaanvangstyd (sat), vokaalduur en uitingduur. die kontekstuele faktore wat nagegaan is bestaan uit 'n sistematiese variasie in die klankstruktuur (foneemstruktuur) en die artikulasie-eienskappe (motoriese kompleksiteit) van onsineenhede waarin hierdie eienskappe volkome gekontroleerd is. die kriteria vir samestelling van hierdie materiaal word volledig beskryf in van der merwe (1986). die materiaal bestaan uit agt eenhede in vyf klankstruktuurgroepe en die eenhede in elke klankstruktuurgroep word verdeel in vier artikulasie-eienskapgroepe (van der merwe, et al, 1987). al die proefpersone het hierdie veertig eenhede ses keer agtereenvolgend herhaal na 'n kort oefenperiode waarin elke eenheid eers selfstandig geproduseer moes word. die uitings was dus selfge'fnisieerd en nie direkte nabootsings nie. die proefpersone het wel die uitings in 'n geskrewe vorm voor hulle gehad ten einde geheueprobleme sover moontlik te beperk. tydens die eerste stadium van die ouditiewe analise van die data is 'n lys saamgestel van alle spraakfoute wat voorgekom het by die vyf proefpersone. selfs al sou net een van die proefpersone 'n sekere simptoom vertoon, is dit in die lys opgeneem. foutkategoriee is verder in samewerking met twee medeluisteraars saamgestel (van der merwe, 1987). p r o e f p e r s o n e i vier persone met verworwe verbale apraksie en een persoon met verbale ontwikkelingsapraksie (voa) is in hierdie ondersoek gebruik. die volledige gegewens word aangegee in van der merwe et al, (1987). j ι die persoon met verbale ontwikkelirigsapraksie is aanvanklik slegs op 'n voorlopige grondslag ingesluit by die ondersoek vanwee die beperkte getal persone met 'n "suiwer" verworwe verbale apraksie wat opgespoor kon word. daar is later in samewerking met die statistikus besluit dat die resultate van hierdie proefpersoon in so 'n mate ooreenkom met die eksperimentele groep se resultate dat dit tesame daarmee verwerk kan word, 'n afgepaarde kontrolepersoon is ook vir die proefpersoon met voa geselekteer vir vergelyking van die akoesties geanaliseerde data. ten einde te verseker dat die proefpersoon met voa (proefpersoon 5) wel verbale apraksie vertoon, is die volgende kenmerkende eienskappe as seleksiekriteria gestel. — 'n diskrepansie tussen ekspressiewe en reseptiewe taalvermoe wat nie meer as ses maande agter sy chronologiese ouderdom is nie het voorgekom tydens die inisiele diagnose. the south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) vergelyking van faktore op simptome van persone met verworwe verbaleen verbale ontwikkelingsapraksie 29 'n onvermoe om willekeurige spraakbewegings uit te voer met gevolglike nie-verbaliteit het voorgekom. kommunikasie het deur middel van gebare geskied. proefpersoon 5 is op die ouderdom van vier as 'n geval met voa gediagnoseeren hy het sedert daardie tyd verbale apraksieterapie (van der merwe, 1985) ontvang. ten tyde van die ondersoek het hy reeds goed verstaanbaar gekommunikeer in vyf tot seswoordsinne. ten spyte van die goeie vordering tydens die ses jaar van behandeling het hy steeds simptome van verbale apraksie vertoon en veral die lengte van woorde wat gebruik is, was nog beperk. vir die vier persone met verworwe verbale apraksie is die kriteria van kent en rosenbek (1983) gestel. hierdie persone het onvlot spraakproduksie met probeer-en-tref artikulasiebewegings, pogings tot selfkorreksie, onkonstantheid in die foute by herhaalde produksie van dieselfde woord en disprosodie vertoon. hulle moes ook aan verdere kriteria voldoen om die teenwoordigheid van 'n gepaardgaande afasie of disartrie uit te skakel (van der merwe et al, 1987). a n a l i s e van d i e d a t a ten einde die mate van afwyking van die groepgemiddeld te bepaal, is similariteitsvektore (steyn, smit en du toit, 1984) vir die individuele proefpersone bereken. by die berekening van similariteitsvektore vir sat, vokaalduur en uitingsduur is die verskil tussen die gemiddelde foutwaardes van elke persoon en die groepgemiddeld bereken en die totaal van hierdie verskille is sodoende bekom. kleiner totale dui op kleiner afwykings vanaf die groepgemiddeld. by die berekening van similariteitsvektore vir ouditief waarneembare foute is die verskil tussen die rangnommer (bepaal op grond van frekwensie van voorkoms) van elke tipe fout van die groep en die rangnommer van elke tipe fout van die individu bereken. resultate ί m a t e van a f w y k i n g van die i n d i v i d u e l e p r o e f p e r s o n e v a n a f g r o e p g e m i d d e l d e s vir s a t , v o k a a l d u u r , u i t i n g d u u r en o u d i t i e f w a a r n e e m b a r e f o u t e in tabel 1 word die proefpersone gerangskik in volgorde van afwyking vanaf die groepgemiddeldes vir al die aspekte wat ondersoek is. persone wat eerste geplaas word wyk die meeste af van die groepgemiddeld en die wat laaste (vyfde) geplaas word, wyk die minste af. in die tweede gedeelte van die tabel word die finale rangorde van elke proefpersoon bepaal. die hoogste totaal toon die kleinste afwyking vanaf die groep en die kleinste totaal die grootste afwyking. die plasing van proefpersone by die verskillende aspekte wat ondersoek is, toon aan dat variasie in individuele simptoombeelde voorkom na gelang van die mate waarin 'n besondere aspek aangetas is. geen een van die proefpersone neem konstant die eerste of laaste of enige ander posisie in nie. proefpersone 1 en 2 wat in die finale rangorde die naaste aan die groepgemiddeld gepresteer het, vertoon nie konstant die kleinste verskil van die groep nie. proefpersoon 1 toon byvoorbeeld by vokaalduur die tweede grootste afwyking van die groep en proefpersoon 2 neem ook dieselfde posisie in ten opsigte van sat en uitingduur. tabel 1: proefpersone gerangskik in volgorde van afwyking vanaf die groepgemiddeldes vir sat, vokaalduur, uitingduur en ouditief waarneembare foute aspek wat ontleed is verskil meeste verskil minste van groep van groep 1 2 3 4 5 sat *pp 3 pp 2 pp 4 pp 5 pp 1 vokaalduur pp 4 pp 1 pp 5 pp 3 pp 2 uitingduur pp 5 pp 2 pp 3 pp 1 pp 4 ouditief waarneembare foute pp 5 pp 1 pp 2 pp 3 pp 4 proefpersone rangorde van proefpersoon binne die groep 1 2 3 4' 5 5 + 2 + 4 + 3 = 14x 2 + 5 + 2 + 5 = 14 1 + 4 + 3 + 3 = 1 1 3 + 1 + 5 + 3 = 12 4 + 3 + 1 + 1 = 9 1 — verskil minste 2 van groep 4 3 5 — verskil meeste van groep *pp = proefpersoon χ die persoon met die kleinste totaal het die meeste afgewyk van die groep proefpersoon 4 wat telkens tydens die vorige besprekings uitgesonder is (van der merwe et al, 1987, 1988, 1989), verskil volgens hierdie analise nie sover van die groep as wat verwag is nie. in die finale rangorde word proefpersoon 4 derde geplaas. die grootste afwyking vertoon hy by vokaalduur terwyl uitingduur die minste van die groepgemiddeld verskil. segmentele duur was dus in die besonder versteur, maar totale duur van die uiting is dieselfde as die gemiddeld van die groep. oorgangtye tussen klanke was dus korter. proefpersone 2 en 4 vertoon onderskeidelik ten opsigte van sat die tweede en derde grootste afwyking van die groep omdat hulle weinig sat-foute gemaak het. proefpersoon 3 het daarenteen besonder baie sat-foute en wyk daarom die meeste af van die groepgemiddeld. proefpersoon 1 presteer die naaste aan die groepgemiddeld. die aard van die sat-foute wat wel voorgekom het was by al die proefpersone dieselfde, naamlik te grootpositiewe tellings wat veroorsaak dat stemhebbende klanke as stemloos geperseptueer word. die sat-foute is deur al die proefpersone onkonstant gemaak en daar is bevind dat hierdie foute nie konteks-sensitief is nie. die foute tree dus onverwags en onvoorspelbaar in. die aard van afwykings in vokaalduur en uitingduur was dieselfde by al die proefpersone. in vergelyking met die kontrolepersone het al vyf die proefpersone verlengde vokaalduur en uitingduur vertoon. statistiese analises het ook aangetoon dat vokaalduur en uitingduur konteks-sensitief is en dat duur toeneem namate die kompleksiteit en lengte van die uiting toeneem. 'n subjektiewe vergelyking van duurafwykings by die verskillende klankstruktuurgroepe (s) van elke proefpersoon toon aan dat al die proefpersone konteks-sensitiwiteit vertoon. (kyk tabelle 4 en 5 in van der merwe et al, 1989). die suid-afrikaanse tydskrif vir kommunikasieafivy kings, vol 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 a. van der merwe & r.j. grimbeek die totale syfers (soos aangegee in tabel 1) waarmee al die proefpersone afwyk van die groep (9 tot 14) verskil minimaal en dit blyk dus dat nie een van die proefpersone radikaal van die groep verskil nie. die proefpersone vertoon dieselfde tipe simptome, maar individuele variasie in die mate waarin spesifieke aspekte aangetas is, kom voor. die finale rangordes in tabel 1 toon aan dat proefpersoon 5, die persoon met voa, die meeste verskil van die groep. dit is egter slegs ten opsigte van uitingduur en die ffekwensiepatroon van ouditief waarneembare foute wat proefpersoon 5 die meeste afwyk van die groep. wat sat aanbetref word proefpersoon 5 vierde geplaas en vertoon dus net 'n klein afwyking vanaf die groepgemiddeld. hierdie proefpersoon het ook soos die ander onkonstante sat-foute gemaak wat nie konteks-sensitief is nie en die vorm aanneem van te groot positiewe tellings. ten opsigte van vokaalduur neem proefpersoon 5 die derde posisie in en vertoon ook verlengde vokaalduur soos die persone met w a . vokaalduur is ook by proefpersoon 5 kontekssensitief. die enigste buitengewone resultaat was dat vokaalduur vir s5 wat 'n kvkvkvk-struktuur het, nie soos by die ander proefpersone meer afwykend was as vokaalduur van die ander klankstruktuurgroepe nie. 'n moontlike verklaring hiervoor is dat proefpersoon 5 geneig was om eenhede in s5 fonologies te verkort en spraakproduksie is dan aangepas by die korter en meer eenvoudige eenheid. proefpersoon 5 het net soos die ander proefpersone kontekssensitiwiteit in uitingduur vertoon. by s3 wat 'n kvkvkstruktuur het, het hy die grootste afwyking en die tweede grootste afwyking was by s5. klankstruktuurgroep 4 wat 'n kvk-struktuur het, vertoon die kleinste afwyking (kyk tabel 5 in van der merwe et al, 1989). hierdie patroon van kontekssensitiwiteit is dieselde as by die ander proefpersone. o u d i t i e f w a a r n e e m b a r e f o u t p a t r o n e van die i n d i v i d u e l e p r o e f p e r s o n e in tabel 2 word die frekwensie (en persentasie) van voorkoms vandie foutkategoriee by elke proefpersoon aangegee. uit die gegewens in hierdie tabel blyk dit dat die proefpersone alle foute gemeen het behalwe dat proefpersoon 1 geen foute gevolg deur selfkorreksie getoon het nie en proefpersoon 4 het geen veranderinge van struktuur getoon nie. die totale aantal foute toon aan dat wisselende hoeveelhede foute voorkom by die individuele proefpersone. dit verskaf 'n aanduiding van die graad van aantasting. ten einde 'n duideliker beeld te kry van individuele foutpatrone is die foutkategoriee gerangskik in dalende volgorde van voorkoms by elke proefpersoon. hierdie gegewens word aangegee in tabel 3. die rangskikking van foutkategoriee toon aan dat of distorsie (c) of afwykings in temporale vloei (d) die hoogste frekwensie tabel 2: die frekwensie (en persentasie) van voorkoms van die foutkategoriee by elke proefpersoon. foutkategoriee proefpersone a vervangings β verandering van struktuur c distorsie d ε afwyking in . _ , afwykings m temporale / , r , , . vlotheid vloei f g s e l f k o r r e k s i e m w y k i n f i n prosodie totale aantal foute 1 7 ( 1,6%) 27 ( 6,2%) 227 (52,0%) 169 (38,8%) 5 ( 1,2%) 0 ( 1 0%) ( 0,2%) 436 (100%) 2 11 ( 2,8%) 58 (14,6%) 94 (23,6%) 168 (42,2%) 8 ( 2,0%) 3 56 ( 0,8%) (14,0%) 398 (100%) 3 53 ( 8,5%) 74 (11,9%) 209 (33,5%) 158 (25,3%) 87 (14,0%) 14 29 ( 2,2%) ( 4,6%) 1 624 i (100%) 4 25 ( 4,0%) 0 ( o%) 57 ( 9,2%) 359 (58,0%) 15 ( 2,4%) 12 ( 152 1,9%) (24,5%) 1 , 620 ! (100%) 5 118 (27,4%) 82 (19,1%) 182 (42,4%) 38 ( 8,8%) 3 ( 0,7%) 3 4 ( 0,7%) ( 0,9%) 430 ' (100%) totaal 214 241 769 892 118 32 " 242 2508 tabel 3: rangskikking van foutkategoriee in dalende volgorde van voorkoms by elke proefpersoon -proefpersone rangskikking van foutkategoriee 1 c (52,0%) d (38,8%) β ( 6,2%) a ( 1,6%) ε ( 1,2%) g ( 0,2%) f ( 0%) 2 d (42,2%) c (23,6%) β (14,6%) g (14,0%) a ( 2,8%) ε ( 2,0%) v x { 0,8%) 3 c (33,5%) d (25,3%) ε (14,0%) β (11,9%) a ( 8,5%) g ( 4,6%) ' ' f ( 2,2%) 4 d (58,0%) g (24,5%) c ( 9,2%) a ( 4,0%) ε ( 2,4%) f .(/l9%) β ( 0%) s 5 c (42,4%) a (27,4%) β (19,1%) d ( 8, 8%) g ( 0,9%) ε ( 0,7%) f ( 0 , 7 % ) ^ / the south african journal of communication disorders, vol. 37 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) vergelyking van faktore op simptome van persone met verworwe verbaleen verbale ontwikkelingsapraksie van voorkoms vertoon by al die proefpersone. by drie van die proefpersone neem een van hierdie foute ook die tweede plek in. dit is slegs proefpersone 4 en 5 wat nie hierdie patroon volg nie. by proefpersoon 4 neem distorsie wel die derde plek in. afwykings in vlotheid (e), foute gevolg deur selfkorreksie (f) en/of afwykings in prosodie (g) neem by al die proefpersone die voorlaaste en/of die laaste posisie in. slegs by proefpersoon 4 neem veranderinge in struktuur (b) die laaste posisie in. al die proefpersone vertoon dus ook ten opsigte van die laagste voorkoms van spesifieke foutkategoriee ooreenstemmende foutpatrone. foutkategoriee a, β en ε neem by die meeste proefpersone die middelposisies in. dit is egter slegs by proefpersoon 3 dat afwykings in vlotheid (e) die derde hoogste frekwensie van voorkoms vertoon. proefpersoon 3 se spraak was baie meer onvlot en worstelend as die spraak van die ander proefpersone. proefpersoon 4 vertoon ook 'n individuele foutpatroon wat hom onderskei van die ander proefpersone. vanwee die besondere aantasting van proefpersoon 4 neem afwykings in temporale vloei (d) en waarskynlik as gevolg daarvan afwykings in prosodie (g) onderskeidelik die eerste en tweede plekke in. hy is dus die enigste persoon by wie distorsie nie een van die eerste twee plekke inneem nie. uit die gegewens in tabel 2 word dit duidelik dat hierdie persoon baie meer foute in bogenoemde twee aspekte het (359 by d en 152 by g) as die ander proefpersone. hy was ook die enigste persoon wat nie veranderinge in struktuur (b) vertoon het nie en hy het ook weinig sat-foute gemaak. proefpersoon 4 het wel die laagste voorkoms van distorsie-foute, maar die foute wat wel voorgekom het was ook onkonstante distorsies soos teenwoordig by die ander proefpersone. die bepaling van similariteitsvektore op grond van foutfrekwensiepatrone (bylae c) en die rangskikking van proefpersone in volgorde van afwyking van die groep (tabel 1) toon aan dat proefpersoon 2 die minste verskil van die groep terwyl proefpersone 1, 3 en 4 gesamentlik die middelposisie inneem. die mate waarin hierdie drie' afwyk van die groep stem dus ooreeri. die resultate ten opsigte van die ouditief waarneembare foute bevestig dus die resultate van die akoestiese ontledings naamlik dat al die proefpersone die meeste van die foute gemeen het maar dat individuele foutpatrone of simptoombeelde voorkom na gelang van die mate waarin 'n besondere aspek aangetas is. by al die proefpersone vertoon afwykings in temporale vloei of distorsie die hoogste voorkoms. al die proefpersone het dus hierdie kenmerk gemeen. die rangskikking van proefpersone in volgorde van afwyking vanaf die groepgemiddeldes in tabel 1, toon verder ook aan dat proefpersoon 5 die meeste verskil van die groep ten opsigte van die frekwensiepatroon van ouditief waarneembare foute. die verrassendste verskynsel is egter dat hierdie proefpersoon met voa wel dieselfde simptome gemeen het met die ander proefpersone. die gegewens in tabel 2 toon aan dat hy foute in elke foutkategorie vertoon het. geen ander spraakfoute kom by hom voor nie omdat alle foute van al die proefpersone tydens die analise van die data aangeteken is. die rangskikking van foutkategoriee in tabel 3 toon aan dat proefpersoon 5 ook soos twee ander proefpersone die hoogste voorkoms van distorsiefoute vertoon. die drie simptome (g, ε en f) met die laagste voorkoms het hy ook gemeen met die ander proefpersone. die enigste groot verskille in frekwensie van voorkoms van ouditief waarneembare foute is die hoe voorkoms van vervangingsfoute (a) en die relatief lae voorkoms van afwykings in temporale vloei. uit tabel 2 blyk dit dat proefpersoon 5 , 1 1 8 vervangings vertoon het in vergelyking met die ander proefpersone wat gewissel het van 7 tot 53. hy vertoon ook meer veranderinge in die struktuur van die eenheid. dit is moontlik dat hierdie twee probleme saamhang want tydens die ondersoek het dit duidelik geword dat proefpersoon 5 nie die struktuur van s5-eenhede kon onthou ofproduseer nie. hy was geneig om hierdie eenhede fonologies te vereenvoudig en/of te verkort. die lae voorkoms van afwykings in die temporale vloei van spraak by proefpersoon 5 is in ooreenstemming met die akoestiese bepaling van uitingduur. proefpersoon 5 vertoon minder afwykend as die persone met w a ten opsigte van beide hierdie aspekte. d i e i n v l o e d van k l a n k s t r u k t u u r o p d i e g e t a l o u d i t i e f w a a r n e e m b a r e f o u t e van d i e i n d i v i d u e l e p r o e f p e r s o n e die totale aantal ouditief waarneembare foute van al die proefpersone by die verskillende klankstruktuurgroepe word aangegee in tabel 4. in hakies word die rangorde van elke klankstruktuur aangedui. dit blyk duidelik dat variasie in die aantal foute by die verskillende klankstruktuurgroepe voorkom. die laagste voorkoms van foute by al die proefpersone is by s4 wat 'n kvk-struktuur het. die lae voorkoms van foute is deels te wyte aan die korter struktuur wat minder foute toelaat, maar die akoestiese analises van byvoorbeeld die eerste vokaal van al die klankstrukture het aangetoon dat dit nie die oorwegende faktor is nie. die konteks van die kvk-struktuur het 'n ooreenstemmende invloed gehad op al die proefpersone. dit is interessant dat dit ook die geval was by proefpersoon 5 want tydens die fasilitasie van verbaliteit by hierdie geval met voa, het hy die produksie van kvk-strukture eers 'n paar jaar na die produksie van kvkv -strukture bemeester. tabel 4: totale getal ouditief waarneembare foute van die vyf proefpersone by die verskillende klankstruktuurgroepe klankstruktuur 1 proefpersone 2 3 4 5 1 95(3) 98(5) 132(3) 124(2) 75(3) 2 65(2) 84(2) 109(2) 145(4) 66(2) 3 119(5) 88(3) 151(4) 154(5) 92(4) 4 . 52(1) 35(1) 76(1) 61(1) 37(1) 5 105(4) 93(4) 156(5) 136(3) 160(5) totale aantal foute 436 398 624 620 430 dit blyk verder uit tabel 4 dat s3 of s5 tot die meeste foute aanleiding gegee het by al die proefpersone behalwe proefpersoon 2. by hierdie persoon het s5 wel die tweede hoogste voorkoms van foute vertoon. die redes vir die hoer getal foute by hierdie klankstrukture is vroeer reeds volledig bespreek (van der merwe et al, 1987,1988). binne die konteks van die huidige bespreking is die belangrike punt dat die proefpersone, ingeslote proefpersoon 5, oorwegend ooreenstemmend gereageer het op variasie in die klankstruktuur van die uiting. dit is interessant dat ook by proefpersoon 5, s3 wat slegs een klank langer is as si en s2 (kvkvk teenoor kvkv) soveel meer foute tot gevolg het. dit wil dus voorkom asof die toename in kompleksiteit van die uiting meer probleme in die beplanning van spraak te weeg bring by die proefpersone met w a maar ook by die proefpersoon met voa. die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 a. van der merwe & r.j. grimbeek b e s p r e k i n g s l m p t o o m b e e l d e van p e r s o n e m e t v e r w o r w e v e r b a l e a p r a k s i e . die akoestiese-analise van sat, vokaalduur en uitingduur en die analise van ouditief waarneembare foute toon aan dat die proefpersone met w a die meeste van die groepe foute gemeen het, maar dat individuele simptoombeelde na vore kom na gelang van die varierende mate waarin verskillende aspekte aangetas is. die kollektie we voorkoms van sekere simptome lei dus tot die beeld van vaa, maar die besondere konstellasie van die simptome verskil skynbaar van persoon tot persoon. die analises het egter ook aangetoon dat beide klankdistorsie en afwykings in temporale vloei of een van hierdie twee groepe ouditief waarneembare simptome die hoogste frekwensie van voorkoms by al die proefpersone vertoon het. die hoe voorkoms van klankdistorsie by al die proefpersone bevestig die uitspraak van itoh en sasanuma (1984) dat klankdistorsie waarskynlik die kernsimptoom van verbale apraksie is. vroeer is distorsie nie gereken as 'n simptoom van verbale apraksie nie. dit is egter duidelik dat afwykings in die beplanning van spraak onder andere aanleiding kan gee tot onkonstante temporale en ruimtelike oorskreiding van die ekwivalensiegrense van spraakbewegings wat dan aanleiding gee tot klankdistorsie. die hoe voorkoms van afwykings in temporale vloei is ook in ooreenstemming met die aanvaarde aard van verbale apraksie. vloei van spraak word belemmer en simptome soos die afbakening van lettergrepe, stadige doelbewuste artikulasie en verlenging van klanke kom voor. die hoer frekwensie van voorkoms van sekere simptome by spesifieke persone gee aanleiding tot eiesoortige foutpatrone of simptoombeelde wat moontlik aanduidings is vanverskillende tipes w a . in die huidige ondersoek het minstens drie verskillende simptoombeelde by die persone met w a na vore gekom. proefpersoon 3 het groter afwykings in vlotheid as die ander proefpersone vertoon weens worstelende artikulasie. dit het voorgekom asof die inisiering van uitings vir haar besonder moeilik was. proefpersoon 4 daarenteen vertoon 'n hoe voorkoms van verlenging van die statiese periodes van artikulasie met baie min afwykings in vlotheid. dit het byna voorgekom asof sy spraakafwyking nader aan 'n disartrieseprobleem is as die van die ander proefpersone. die konstante distorsie en ander uiterlike tekens kenmerkend van disartrie was egter nie teenwoordig nie en die artikulasieverlenging was ook nie konstant teenwoordig nie. die subkortikale skade van hierdie persoon het moontlik aanleiding tot die besondere simptoombeeld gegee. kertesz (1984) het verbale apraksie by persone met subkortikale skade nagegaan en hy kom tot die slotsom dat die sogenaamde subkortikale sindroom grootliks ooreenkom met die kortikale sindroom. hy het by die subkortikale sindroom ook disartiese simptome gevind, maar het nie die konstantheid van die simptome nagegaan nie. proefpersoon 4 het egter kortikale en subkortikale skade gehad. proefpersoon 1 vertoon in teenstelling met bogenoemde twee persone die klassieke beeld van suiwer w a (itoh & sasanuma, 1984; wertz et al, 1984). proefpersoon 1 presenteer met die hoogste voorkoms van klankdistorsie en ook 'n hoe voorkoms van afwykings in temporale vloei terwyl sy 'n baie lae voorkoms en in baie gevalle die laagste voorkoms van die ander groepe ouditief waarneembare foute vertoon. die hoe voorkoms van klankdistorsie en afwykings in temporale vloei by hierdie besondere proefpersoon asook die feit dat een of beide van hierdie foute die hoogste voorkoms by al die ander proefpersone vertoon, is 'n sterk aanduiding dat hierdie groepe simptome die kenmerkende eienskappe van w a is en ook in aanmerking geneem moet word wanneer diagnostiese kriteria vir w a geformuleer word. navorsing met groter groepe is egter nodig om hierdie resultate te bevestig. v e r b a l e o n t w i k k e l i n g s a p r a k s i e as d i a g n o s t i e s e e n t i t e i t proefpersoon 5 wat op die ouderdom van vier jaar gediagnoseer is as 'n geval met voa en wat reeds tien jaar oud was ten tyde van die ondersoek, vertoon in die geheel gesien verrasende ooreenstemming met die proefpersone met w a . die similariteitsvektore toon aan dat hy wat die totale ondersoek betref die meeste van die groep verskil, maar wat die onderskeie aspekte betref verskil hy slegs ten opsigte van uitingduur en die frekwensiepatroon van ouditief waarneembare foute die meeste van die groep. hy het egter al die simptome gemeen met die groep. proefpersoon 5 vertoon soos die persone met w a onkonstante sat-foute wat ook die vorm aanneem van te groot positie we tellings, verlengde vokaalduur en verlengde uitingduur alhoewel laasgenoemde minder afwykend is as die uitingduur van die persone met w a . hy reageer ook dieselfde as die ander, proefpersone op variasie in die klankstruktuur van die uiting. wat die ouditief waarneembare foute betref het hy die groepe simptome met die hoogste en laagste voorkoms gemeen met die groep. die distorsiefoute wat by hom soos by twee ander proefpersone die hoogste voorkoms vertoon het, neem ook die vorm aan van onkonstante distorsies van klanke tydens herhaalde produksie van 'n uiting. die grootste verskille van die groep vertoon proefpersoon 5 ten opsigte van die hoe voorkoms van klankvervangings en die lae voorkoms van afwykings in temporale vloei. die grootste aantal klankvervangings was weens fonologiese vereenvoudiging van die langer eenhede (s5) wat moontlik verband hou met beperkte fonologiese geheue of 'n onvermoe om die lang uitinge te produseer. die feit dat dit onsineenhede was wat geproduseer moes word, speel waarskynlik ook 'n rol. dit is ook moontlik dat hierdie simptoom in samehang is met die totale beeld van vertraagde spraakontwikkeling. ι die lae voorkoms van afwykings in temporale vloei word bevestig deur die uitingduurmetings. ten opsigte van uitingduur vertoon proefpersoon 5 die grootste afwyking vanaf die groepgemiddeld omdat sy spraakspoed hoer is.'n moontlike verklaring vir hierdie verskynsel is dat alle spraak wat hy wel het doelbewus aangeleer is deur middel van die terapieprogram vir verbale ontwikkelingsapraksie (van der merwe, 1985). 'n belangrike grondbeginsel van die program is dat spraakuitinge doelbewus herhaaldelik geproduseer word sodat outomatisasie kan intree. alhoewel die proefpersone met w a dieselfde tipe behandeling ontvang het, is dit moontlik dat doelbewuste beplanning en inisiering van spraak in groter mate by hulle teenwoordig is en meer tyd in beslag neem. die afleiding kan nie sonder meer gemaak word dat alle kinders met voa vinniger spraakspoed as persone met w a vertoon nie omdat die spraak wat proefpersoon 5 het, die resultaat is van hierdie besondere benadering in behandeling. / die ooreenkoms in simptome van die persoon met voa en die ander proefpersone met w a bevestig nie alleen grootliks die bestaan van voa as 'n diagnostiese entiteit nie, maar ook die akkuraatheid van die aanvanklike diagnose van voa. by / the south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) vergelyking van faktore op simptome van persone met verworwe verbaleen verbale ontwikkelingsapraksie 33 proefpersoon 5 as vierjarige kind het die teenwoordigheid van 'n probleem in die aanleer van die beplanning van spraak daartoe gelei dat hy nie-verbaal was ten spyte van goeie taalbegrip. dit wil dus voorkom asof die diagnostiese kriteria van groep 1 voa (van der merwe, 1985) as korrek aanvaar kan word. in die literatuur word geen oorweging daaraan geskenk of die moontlikheid genoem dat voa kan presenteer as nie-verbaliteit nie. die diagnostiese kenmerke wat beskryf word sentreer om die aard van artikulasiefoute en orale apraksie (macalusohayes, 1978; aram, 1984; yoss & darley, 1974) en geeneen van hierdie beskrywings het nog bygedra tot 'n oplossing van die problematiek van die diagnose van voa nie. op grond van die resultate van die huidige ondersoek kan die volgende diagnostiese kriteria van voa by die kind wat wel verbaliteit verkry het, voorgestel word: — 'n diskrepansie tussen reseptiewe taalvermoe en ekspressiewe vermoe soos onder andere weerspieel in die lengte van woorde wat geproduseer kan word; — onkonstante distorsie van konsonante en vokale; — worstel ing by of 'n on vermoe in die produksie van u itinge wat vir die kind moeilik is om te produseer; — die onvermoe tot lang uitinge lei tot fonologiese verkorting. verdere navorsing met groot groepe kinders met voa moet egter eers uitgevoer word voor hierdie kriteria as korrek aanvaar kan word. die resultate van die huidige ondersoek laat egter min twyfel oor die bestaan van voa as 'n diagnostiese entiteit. die ooreenstemmende simptome van die proefpersone asook die feit dat proefpersoon 5 op dieselfde wyse as die persone met w a gereageer het op die variasie in kontekstuele faktore is verder ook sterk aanduidings dat die onderliggende aard van verbale apraksie in die kongenitale en verworwe vorms in belangrike opsigte ooreenkom. in die literatuur word 'n beperkte siening van die aard van verbale apraksie gehandhaaf soos weerspieel in die definiering van die afwyking. die algemeen aanvaarde definisie ;van darley, aronson & brown (1975: 255) beskryf verbale apraksie as: "an articulatory disorder resulting from impairment,due to brain damage, of the capacity to program the positioning of speech musculature for the volitional production of phonemes and the sequencing of muscle movements for the production of words." | hierdie beskrywing is waarskynlik volkome korrek en kan aanvaar word, maar die totale omvang van die motoriese beplanning van spraak en moontlike afwykings daarin word nie in die definisie weerspieel nie. die beplanning van spraak kan meer omvattend beskryf word as: — die herroeping van die onveranderlike kernmotorplan met ruimtelike en temporale spesifikasies van bewegings vir elke foneem, , — die daaropvolgende aanpassing van die kernmotorplan by die klankomgewing, koartikulasiemoontlikhede en die spoed van produksie binne die grense van motoriese ekwivalensie, — die temporale organisasie van struktuurbewegings en — die sistematiese vooruitvoering in volgorde van onveranderlike fonologiese eenhede met gespesifiseerde motorplan-subroe tines, — binne die invloed van kontekstuele faktore soos die lengte, klankstruktuur, bekendheid en motoriese kompleksiteit van 'n uiting (van der merwe, 1986). binne sodanige teoretiese raamwerk kan w a gesien word as 'n afwyking in een of meer van hierdie stadiums of komponente en voa as 'n onvermoe om een of meer van hierdie stadiums of komponente te realiseer. die nie-verbale apraktiese kind leer moontlik nie kernmotorplanne vir klanke aan nie of kan die kern nie aanpas by die klankomgewing nie of kan die agtereenvolgende beplanning en produksie van klanke in 'n woord nie behartig nie. sodanige teoretiese raamwerk is vanselfsprekend slegs hipoteties, maar dit is duidelik dat logiese verklarings vir die voorkoms van 'n kongenitale en verworwe vorm van verbale apraksie daarop gebaseer kan word. indringende gevallestudies van groot groepe kinders met voa sal in die toekoms meer lig werp op die diagnostiese kenmerke en die aard van die probleem by suiwer voa. k e r n s i m p t o m e e n g e a s s o s i e e r d e s i m p t o m e in die vorige artikels (van der merwe, et al, 1987; 1988; van der merwe et al, 1989) is kernen geassosieerde simptome ge'fdentifiseer op grond van konteks-sensitiwiteit. daar is gevind dat die ouditief waarneembare simptome met die hoogste voorkoms by al die proefpersone, naamlik klankdistorsie en afwykings in temporale vloei en ook sat-foute wat dui op temporale interartikulator wankoordinasie nie gereageer het op variasie in konteks nie en dus nie konteks-sensitief was nie. daarteenoor is gevind dat simptome soos klankvervangings, veranderinge in die struktuur van die eenheid deur weglatings en byvoegings van klanke en afwykings in vokaalen uitingduur toeneem met 'n toename in die lengte of motoriese kompleksiteit van 'n uiting. hierdie simptome is dus konteks-sensitief en die afleiding is gemaak dat hierdie geassosieerde simptome moontlik kompensatoriese strategies weerspieel terwyl die simptome wat nie konteks-sensitief is nie en deurentyd in dieselfde mate voorkom waarskynlik aanduidings is van die kern van die probleem en kernsimptome genoem kan word. die huidige ondersoek se resultate toon aan dat al die proefpersone, ingeslote proefpersoon 5, oorwegend ooreenstemmend reageerop die variasie in konteks. die kernsimptome en geassosieerde simptome stem dus by almal ooreen. indien die afleiding oor die verdeling van simptome as geldig aanvaar word en die feit dat al die proefpersone oorwegend ooreenstemmende patrone van konteks-sensitiwiteit vertoon bevestig grootliks so 'n afleiding, dan is die implikasie dat die kernsimptome en geassosieerde simptome by voa en w a ooreenstem. die aard van die kernsimptome versterk verder ook die uitgangspunt dat verbale apraksie 'n afwyking in die beplanning van spraak is. gevolgtrekking — die kollektiewe voorkoms van sekere simptome lei tot die beeld van w a , maar die besondere konstellasie van simptome op grond van frekwensie van voorkoms verskil van persoon tot persoon. — klankdistorsie en/of afwykings in temporale vloei van spraak wat aanduidings is van die kern van die probleem by verbale apraksie vertoon die hoogste frekwensie van voorkoms by al die proefpersone. — die frekwensie van voorkoms van sekere simptome gee aanleiding tot individuele simptoombeelde en hierdie simptoombeelde dui op die moontlikheid van tipes verbale apraksie. die suid-afrikaanse tydskrif vir kommunikasieafykins, vol 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 3 4 a . v a n d e r m e r w e & r.j. g r i m b e e k — die p r o e f p e r s o o n m e t voa ( p r o e f p e r s o o n 5) verskil i n t o t a a l die m e e s t e v a n die groep, m a a r w a t die o n d e r s k e i e a s p e k t e b e t r e f verskil hy slegs t e n o p s i g t e v a n u i t i n g d u u r e n die f r e k w e n s i e p a t r o o n v a n o u d i t i e f w a a r n e e m b a r e foute die m e e s t e v a n die groep. — p r o e f p e r s o o n 5 h e t al die s i m p t o m e g e m e e n m e t die groep e n die a a r d v a n die foute k o m o o k o o r e e n , m a a r die frekw e n s i e v a n v o o r k o m s v a n s e k e r e s i m p t o m e gee a a n l e i d ing tot ' n i n d i v i d u e l e s i m p t o o m b e e l d . — p r o e f p e r s o o n 5 is in t e e n s t e l l i n g m e t die p r o e f p e r s o n e m e t w a m e e r geneig o m die l a n g o n s i n e e n h e d e (s5) fonologies te v e r e e n v o u d i g e n v e r t o o n d a a r o m m e e r k l a n k v e r v a n g i n g s . h i e r d i e verskil k a n in s a m e h a n g m e t die totale b e e l d v a n v e r t r a a g d e s p r a a k o n t w i k k e l i n g w e e s . — h i e r d i e b e s o n d e r e p e r s o o n m e t v o a v e r t o o n m i n d e r p r o b l e m e m e t die t e m p o r a l e vloei v a n s p r a a k e n k l e i n e r afw y k i n g s i n u i t i n g d u u r as die p e r s o n e m e t w a e n d i t w i l v o o r k o m asof die s p r a a k w a a r o o r h y w e l b e s k i k m a k l i k e r vooraf b e p l a n w o r d a s w a t die geval is b y die p e r s o n e m e t w a . — h i e r d i e o n d e r s o e k o n d e r s t e u n die k o n s e p v a n v o a a s 'n d i a g n o s t i e s e e n t i t e i t e n bevestig o o k die d i a g n o s e v a n voa o p g r o n d v a n n i e v e r b a l i t e i t b y die k i n d m e t geen a n d e r b e k e n d e / o p s i g t e l i k e p r o b l e m e n i e . — die o n d e r l i g g e n d e a a r d v a n die p r o b l e e m b y v o a e n w a k o m in b e l a n g r i k e opsigte o o r e e n e n b e i d e k a n w a a r s k y n lik a s v o r m s v a n a f w y k i n g i n die b e p l a n n i n g v a n s p r a a k b e s k o u w o r d . — k o n t e k s s e n s i t i e w e s i m p t o m e e n s i m p t o m e w a t n i e kont e k s s e n s i t i e f is n i e k o m o o r e e n b y al die p r o e f p e r s o n e , i n g e s l o t e die p e r s o o n m e t voa. d i t w i l d u s v o o r k o m s asof k e r n s i m p t o m e e n g e a s s o s i e e r d e s i m p t o m e b y voa e n w a o o r e e n k o m . e r k e n n i n g s f i n a n s i e l e b y s t a n d v a n die r a a d vir g e e s t e s w e t e n s k a p l i k e n a v o r s i n g v i r h i e r d i e o n d e r s o e k , w o r d h i e r m e e e r k e n . v e r w y s i n g s aram, d.m. assessment and treatment of developmental apraxia: preface. seminars in speech and language, 5, 1984. darley, f.l., aronson, a.e. en brown ,j. motor speech disorders. philadelphia: saunders, 1975. deutsch, s.e. prediction of site of lesion from speech apraxia error patterns. in j.c. rosenbek, m.r. mcneil en a.e. aronson (reds.) apraxia of speech: physiology, acoustics, linguistics, management. california: college-hill press, 1984. guyette, t.w. en diedrich, w.m. a critical review of developmental apraxia of speech. in ν j. lass (red.). speech and language, 5,149, 1981. itoh, m. en sasanuma, s. articulatory movements in apraxia of speech. inj.c. rosenbek, m.r. mcneil en a.e. aronson (reds.). apraxia of speech: physiology, acoustics, linguistics, management. california: college-hill press, 1984. kent, r.d. en rosenbek, j.c. acoustic patterns of apraxia of speech. journal of speech and hearing research, 26, 231-249, 1983. kertesz, a. subcortical lesions and verbal apraxia. in j.c. rosenbek, m.r. mcneil en a.e. aronson (reds.). apraxia of speech: physiology, acoustics, linguistics, management. california: collegehill press, 1984. macaluso-haynes, s. developmental apraxia of speech: symptoms and treatment. in d.f. johns (red.) clinical management of neurogenic communicative disorders. boston: little, brown and company, 1978. rosenbek, j.c., kent, r.d. en la pointe, l.l. aparxia of speech: an overview of some perspectives. inj.c. rosenbek, m.r. mcneil and a.e. aronson (reds.). apraxia of speech: physiology, acoustics, linguistics, management. california: college-hill press, 1984. steyn, a.g.w., smit, g.f. en du toit, s.h.c. moderne statistiek vir die praktyk. pretoria: j.l. van schaik, 1984. van der merwe, a. terapieprogram vir verbale ontwikkelingsapraksie met moontlikhede vir ander spraakafwykings. publikasie van die universiteit van pretoria, pretoria: v&r, 1985. van der merwe, a. die motoriese beplanning van spraak by verbale apraksie. ongepubliseerde d.phil-verhandeling. universiteit van pretoria, 1986. van der merwe, α., uys, i.c., loots, j.m. en grimbeeck, r.j. die invloed van sekere kontekstuele faktore op die ouditief waarneembare foute by verbale apraksie. die suid-afrikaanse tydskrif vir kommunikasieafwykings, 34, 10-22, 1987. van der merwe, α., uys, i.c., loots, j.m. en grimbeek, r.j. ouditief waarneembare foute by verbale apraksie: aanduidings van die aard van die afwyking. die suid-afrikaanse tydskrif vir kommunikasieafwykings, 35, 45-54, 1988. van der mewre, α., uys, i.c., loots, j.m., grimbeek, r.j. en jansen, l.p.c. die invloed van sekere kontekstuele faktore op stemaanvangstyd, vokaalduur en uitingduur by verbale apraksie. die suid-afrikaanse tydskrif vir kommunikasieafwykings, 36, 2941, 1989. wertz, r.t., la pointe, l.l. en rosenbek, j.c. apraxia of speech in adults: the disorder and its management. orlando: grune & stratton, inc., 1984. yoss, k.a en darley, f.l. developmental apraxia of speech in children with defective articulation. journal of speech and hearing research, 17, 399-416, 1974. | the south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a phonological analysis of the expressive and receptive articulatory difficulties of an aphasic with apraxia of speech: a case study. aura kagan, b.a. (sp. & h. therapy) (witwatersrand). dept. speech pathology and audiology, university of the witwatersrand, johannesburg. summary the expressive and receptive phonological errors of an aphasic subject with mild apraxia o f s p e e c h were analysed in terms of a distinctive feature framework. the results indicated that errors could be characterized linguistically and t h a t such information could be of therapeutic significance. the relationship between articulation problems and ability to discriminate phonemes was investigated. although no direct relationship was found, discrimination errors followed linguistic trends demonstrated in t h e articulation errors. the findings of this study suggest that t h e traditional idea of apraxia as a non-linguistic and purely m o t o r disorder needs re-examination. opsomming die ekspressiewe en reseptiewe fonologiese foute van 'n afatiese proefpersoon met matige spraakapraksie is ontleed in 'n raamwerk van distinktiewe eienskappe. die uitslae dui aan dat foute linguisties gekaraktiseer kan word en dat die inligting dan van terapeutiese waaide k o n wees. die verwantskap tussen artikulasieprobleme en die vermoe om tussen foneme te diskrimineer is ondersoek. alhoewel daar geen direkte verwantskap gevind is nie, het diskriminasiefoute dieselfde linguistiese neigings getoon as die artikulasiefoute. die bevindings van hierdie studie dui aan dat die tradisionele begtip van apraksie as 'n nie-linguistiese en suiwer motoriese afwyking hersien behoort te woord. apraxia of speech has been considered to be a nonlinguistic disorder.27 for the purpose of this study, the term apraxia will be used as defined by de renzi et al,7 who refer to oral apraxia as . . the inability to perform voluntary movements with the muscles of the larynx, pharynx, tongue, lips and cheeks, although automatic movements of the same muscles are preserved. the possibility of the application of phonological theory to apraxia occurring within the aphasic syndrome is felt to be of interest, as much recent work in the field of aphasia has indicated that articulation errors can be systematically described and analysed in terms of phonological theory. • • • > it must be pointed out that there has been controversy as to the relevance of phonological theory in the field of aphasia. critchley,4 for example, concludes that: to trace any rigid plan underlying the pattern of articulatory disorders in aphasic patients is premature. spreen,3 3 however, points out that a phonological investigation of aphasia is valuable, as phonological errors, besides being of inherent linguistic interest, tend to confuse the study of higher-level speech functions. the writer was interested in undertaking a phonological analysis of apraxic errors based on articulation trends derived from recent work in the field of die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 aura kagan aphasia and phonology. some of this work has taken place within the framework of distinctive feature (df) theory.2' 2 1 ' 2 2 this theory, first proposed by jakobson et a l , 1 3 and later developed by chomsky and halle,3 has at its foundation the belief that the distinctive features making up the phoneme are the basic units of language. standel et a l 3 4 define distinctive features as . . . the smallest individual characteristic of a particular phoneme that can determine a difference between phonemes. blumstein,2 as well as martin and rigrodsky,23 found that the frequency of substitution errors made by aphasic subjects was inversely related to df distance. results of the latter study also revealed that errors on df oppositions formed a definite hierarchy. blumstein 2 also found that unmarked phonemes were substituted for marked phonemes more than vice-versa. the concept of 'markedness' in,phono logical theory is complicated and is defined differently within different theoretical frameworks. blumstein 2 introduces the idea of a hierarchical relationship between phonemes, the marked value being more complex than the unmarked or more basic value. she gives the example of the relationship between / ρ / and i b / where / ρ / is the unmarked member to which the feature (+ voice) is added in order to obtain / b / which is thus marked in relation to / ρ /. another interesting feature of the application of phonological theory to aphasia arises from jakobson's notions of the inverse relationship between childhood acquisition and aphasic dissolution of the phonological system.12 it was felt that it would be of value to investigate whether apraxic errors occurring within the aphasic syndrome could be analysed in terms of this theory. the writer was also interested in an analysis of the self-correction of articulation, as this presents us with an opportunity of observing phonological processing in action. in addition, self-correction embodies auditory discrimination, 5 ' 6 and thus the relationship between this analysis and the results of discrimination testing should be of interest. it is felt that the application of phonological theory to apraxia could further our knowledge of this disorder, as the usefulness of conventional tests of articulation appears to be limited, particularly in cases where the apraxic element is of a milder or more subtle nature. the rationale for this study was thus to investigate whether a phonological approach would yield more meaningful results than conventional articulation tests of production and discrimination in the description and analysis of apraxic articulatory errors. the writer felt that if this did prove to be the case, such an approach could be effectively used in the drawing-up of therapy programmes for these patients. / / method s u b j e c t (s) the s used in this study was an adult white male aged 45 years. severe aphasia involving apraxia developed as the result of the removal of infected braintissue. the infection set in after surgery to treat a subdural haemorrhage caused by trauma to the left cerebral hemisphere. the s had been receiving speech therapy for two years and had improved greatly during this time. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) phonological analysis of an aphasic with apraxia 25 the s selected fulfilled the following criteria: 1) he was diagnosed as aphasic by a speech therapist and a neurologist. this was further confirmed by a formal rating on the boston diagnostic test of aphasia.10 2) apraxic difficulties of a mild nature were experienced. a mild case was chosen as it was hoped that this would serve to highlight the value of a linguistic approach as compared to conventional testing. 3) dysarthria was ruled out as being etiologically related to the articulation problem. 4) the s had an adequate pre-morbid acquisition of speech and language. 5) hearing was within normal limits. a i m s 1) to investigate whether or not a df analysis would be more successful than conventional tests in the description and analysis of apraxic articulatory errors. 2) to observe whether linguistic trends emerge in apraxic substitution errors as tested on a nonsense-syllable repetition task. (see [4] in section on tests employed for the rationale behind the use of nonsense syllables.) in particular, to investigate: a) whether there is an inverse relationship between the number of errors and df distance between the target phoneme and substitution error; b) whether or not certain feature oppositions emerge as being more diffi. cult than others; c) if unmarked phonemes are substituted for marked phonemes more than vice-versa; d) whether certain phonemes are substituted more often than others, regardless of the particular target phoneme; e) whether attempts at self-correction move towards the target phoneme or if they are random. 3) to test discrimination of phonemes in nonsense syllables on a pointing task, in terms of findings on the nonsense-syllable repetition task. 4) to assess the value of a linguistic approach for therapy. t e s t s e m p l o y e d i n t h e s t u d y (construction, administrative procedures and scoring) 1. the boston diagnostic aphasia examination 1 0 in addition to obtaining a formal confirmation of the clinical diagnosis of aphasia and assessing the degree of articulatory difficulty, this test was used in order to obtain a profile of scores on various linguistic dimensions. administration followed the procedures laid down in the test manual. 2. the goldman-fristoe test of articulation.9 this was administered twice: a) conventionally, i.e. the s was required to name pictured objects and describe pictured situations, and b) the s had to repeat the names of objects or descriptions of situations after the experimendie suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 aura kagan ter, (e). (see 2 in results and discussion for the rationale behind the two administrations of this test). 3. spontaneous speech sample forty minutes of speech was elicited by requesting descriptions of pictures such as those from the boston diagnostic aphasia examination.10 the sample was recorded on a sony tape recorder (tc 350). 4. nonsense syllable repetition task nonsense syllables were included in the test battery because, as pointed out by martin and rigrodsky,21 they might be more representative of a 'purely phonological task' in that they exclude semantic factors. in addition, nonsense syllables have the advantage of being able to be systematically manipulated, e.g. each phoneme can be systematically tested in different positions and in the context of other phonemes. in order to facilitate the drawing up of the nonsense syllables as well as subsequent analysis, computer programmes were constructed based on the df chart proposed by chomsky and halle.3 this theoretical framework was chosen as it is considered to be one of the most comprehensive to date. 1 1 only the consonantal system was investigated, which means that the number of relevant distinctive features was limited to eight of the original thirteen proposed, viz: (± voice), (± continuant), (± nasal), (± strident), (± high), (± back), (+ anterior) and (± coronal). based on this, the following programmes were devised:a). all possible consonant contrasts grouped according to the df distance between them, with a list of the features on which the differences occurred. b). contrasts grouped in terms of features (e.g. all contrasts involving (± voice) in a hierarchy ranging from a difference of one distinctive feature upwards.) c). contrasts grouped in terms of particular phonemes (e.g. all contrasts involving / ρ /). d). contrasts grouped in terms of the order of differences (e.g. all contrasts involving (± coronal);(± coronal) + (± voice);(± coronal) + (± voice) + (± continuant). the nonsense syllables were constructed as follows: i. they consisted of 3 phonemes in cvc combinations. ii. initial and final consonants differed by at least three distinctive features (although in certain cases, contrasts of two distinctive features apart had to be used in order to avoid the formation of meaningful words). this was based on a finding by lecours and lhermitte^18 that the likelihood of phonological error on , a particular phoneme is directly related to the extent of its similarity to other phonemes in its immediate vicinity. iii. each phoneme was tested in the context of two vowels and two consonants (voiced-voiceless cognates). the feature (± voice) was chosen because it is felt that its positive and negative values represented a clear acoustic and articulatory distinction. specific vowels and consonants were chosen on the basis of avoiding the formation of meaningful words. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) phonological analysis of an aphasic with apraxia 27 it was hoped by the above procedure to control for the influence of contextual environment on the test-phoneme to some minimal extent. iv. each phoneme was tested in initial and final position. where possible, the consonants were merely reversed, keeping the vowel constant, in order that only one variable be manipulated at a time, viz: position. v. where possible, phonemes were tested in blends (in initial position only). the blends were those used by johnson, darley and spriestersb a c h 1 6 in their articulation test form, viz: /1 /, / s / and / r / . (see table i for an example of nonsense syllable manipulation.) initial position final position. blends /kov/; /kif/ /vok/; /fik/ /krov/; /kriv/ /klov/; /kliv/ /skov/; /skiv/ table i: example of the testing of the phoneme / k / . procedure for the testing of nonsense syllables: a) the entire nonsense syllable test was administered twice: (i) in the early morning and (ii) in the late afternoon, each administration involving several sessions. both the s and the ε felt that testing in this manner sampled performance at its best and at its worst. apraxia is, by its very definition, inconsistent.5' 6 it seems logical therefore, to include the inconsistencies as part of the data. it is felt that many studies in the field of apraxia can be criticised for not repeating test procedures more than o n c e . 6 ' 1 5 b) the s was required to repeat the nonsense syllables spoken by the ε. he was seated at right angles to the tester in such a manner as to obtain only auditory stimuli, as according to johns and darley,1 5 articulation proficiency is aided by the use of both auditory and visual modes of stimulation. c) all substitution errors were noted. the decision to use this type of error was based on findings of recent research,21 where it has been found that substitutions (or commutation errors) occurred most frequently in nonsense-syllable repetition tasks. d) the s's responses were noted by both the ε and an observer. wherever the two versions did not agree, the error was not included in the analysis. a tape-recorder was not used as this had been found to adversely affect the s's performance. for this same reason, the observer was a person familiar to the s. s c o r i n g a) responses were recorded phonologically and the results were tabled so as to give information about the df distance between the target phoneme die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 24, 77 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 aura kagan and substitution, as well as an indication of what these differences were. (see table ii.) a particular substitution had to occur at least twice before it was considered to be an error. a separate analysis of phoneme contexts and positions was felt to be beyond the scope of this study. these contexts and positions were included so that the phonemes could be tested under varied conditions. in this way, the results could not be attributed to variables external to the phoneme itself. target phoneme substitution v, cont. n, s . £l b. a. c. total ρ ρ m t * * * 2 1 total 1 1 1 key: v = voice, cont. = continuant, ν = nasal, s = strident, η = high, β = back, a = anterior, c = coronal table ii: example of the df distance between target phoneme and substitution, with the features on which the phonemes differ. in relation to table ii, a horizontal score tally gives the total df distance between the target phoneme arid substitution while a vertical score tally gives the number of times errors occurred on particular feature oppositions. b) the latter results were ranked and spearman's rank-order correlation test was performed between this result and that obtained by martin and rigrodsky 2 2 on a similar task. target phoneme 1st attempt 2nd attempt 3rd attempt ρ s f t phoneme contrasts df distance ρ s 3ρ f ? / ρ t 1 / in this example, attempts at self-correction moved towards the target phoneme in terms of df distance. table iii: example of the analysis of self-correction attempts. c) substitution errors were analysed in order to see whether voiceless and anthe south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) phonological analysis of an aphasic with apraxia 29 terior phonemes were used as substitutions more often than voiced and back phonemes. d) substitution errors were compared with the target phoneme in terms of whether unmarked features were substituted for marked features more than vice versa. analyses were done on three different sets of data: i) phoneme contrasts involving a df distance of 1, after blumstein's procedure.2 ii) phoneme contrasts involving a df distance of 1 but excluding all those involving the phoneme / ρ / . xn examination of the df chart of chomsky and halle,3 reveals that / ρ / is the only phoneme with one positive distinctive feature (excluding the feature [± consonantal] which is common to all phonemes used in this study). therefore, it is theoretically impossible for / ρ / to be substituted for by an unmarked phoneme; as such a phoneme would have no positive distinctive features. it was therefore felt that the inclusion of / ρ / may bias the results. iii) all phoneme contrasts. for this purpose, the marked phoneme of the pair was defined as the one with more positive distinctive features. both (ii) and (iii) represent extensions of the procedure used by blumstein.2 e) attempts at self-correction were analysed in terms of whether they moved towards the target phoneme or not. (see table iii.) general points regarding procedure: testing took place over approximately fourteen hours, involving thirty-eight sessions. testing sessions were short, the exact time involved depending on the s's reaction. the experimental procedure was made as flexible as was practical in order to elicit maximal performance. the test atmosphere was relaxed and informal so that variables such as test anxiety would not contaminate the results. this approach to testing has been supported by authorities such as schuell et a l . 3 0 although discrimination testing formed a large part of this study, it is not within the scope of this paper to discuss it in depth. a brief summary of procedures and results of discrimination testing can be found at the end of the following section. results and discussion 1. the boston diagnostic aphasia examination the s received a severity rating of 2, which, according to goodglass and kaplan, ,10 indicates that there are . . . frequent failures to convey the idea, but patient shares the burden of communication with the examiner. although it was difficult to give the profile a specific label as the scores did not fall into an easily recognisable stereotype, the use of a score profile is felt to be a great advantage of this test as it enables one to see the relationship between various areas of deficit. it is felt, however, that the test is lacking in the depth required die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 aura kagan for planning detailed therapy procedures. for example, the writer found it difficult to obtain an in-depth picture of the articulatory difficulties of the s. 2. the goldman-fristoe test of articulation neither this test nor the spontaneous speech sample are discussed in detail as they do not form the focus of the study, but were used to reveal the fact that conventional testing procedures were not always suitable for ascertaining the extent of the subtle articulation difficulty being experienced by the s. errors made in response to the conventional administration of the goldman-fristoe test9 were felt to berelated to naming difficulties rather than to articulation problems. for example, when shown a picture of a 'house', the s responded with: "building no, to live as usual i can't remember box . . ." when the test was modified in such a way that the s repeated the name after the e, he managed successfully in almost every case. 3. spontaneous speech sample surprisingly, only 5 substitution errors were noted in this forty-minute speech sample. possible explanations relate to the help afforded by semantic content, pictures which did not require much interpretative skill, and the relaxed, informal atmosphere of the test situation. as well as this, the s had the choice of production under his control. based on the results of the above two tests, it might have been decided that the s did not have phonological problems. however, the clinical observations that the s's articulatory performance did in fact break down under difficult conditions (e.g. when tired, upset, nervous, speaking to strangers or describing specific situations), indicated that more sensitive testing was required. 4. nonsense syllable repetition task (a) the relationship between number of errors and df distance. as seen in figure 1, there is an inverse trend in the relationship between error frequency 12 10 error 8 frequency 6 4 2 / 1 2 3 4 5 df distance figure 1: relationship between error frequency and df distance between target phoneme and substitution error. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) phonological analysis of an aphasic with apraxia 31 and df distance, confirming the results of the studies of blumstein 2 and martin and rigrodsky. 2 2 most errors occurred on a df distance of 1 and least on 5. according to blumstein,2an essential notion in df theory is that phonemes with a df distance of 1 are more similar . . . structurally, motorically and acoustically, as well as psychologically . .. than phonemes with a larger df difference. lecours and lhermitte18 in their measures of paradigmatic distance, based on five parameters, found that most substitution errors occurred between morphologically similar phonemic units. although it is difficult to compare the results of studies based on different theoretical frameworks, it is interesting to note the similarity of general tendencies. this leads the writer to believe that we are dealing with psychologically valid phenomena and not merely results determined by particular theories. although most errors did occur between similar phonemes in terms of the df framework of chomsky and halle, 3 this theory could not explain certain substitution errors with a larger df distance. some of these are better explained by the jakobsonian framework. 1 1 ' 1 3 it seems, for example, that in certain instances acoustic dimensions do function as superior explanatory tools, e.g. with / g / / b / ; / k / / p / ; / r ) / / m / , all have a df distance of 3 in terms of chomsky and halle's theory,3 but in terms of the jakobsonian df framework,11 labials and velars share the property of ( + grave) or 'low tonality', and are thus close in acoustic terms. the finding that substitution errors are not random, but are in most cases similar to the stimulus, leads the writer to feel, in common with martin,20 that apraxia of speech within the aphasic syndrome is a linguistic disorder and should as such be considered as an integral part of the aphasic impairment. this finding has important implications for therapy and suggests that the difficulties might be amenable to df therapy. (b) hierarchy of feature opposition difficulty: table iv indicates that certain features emerge as being more difficult than others. these results were correlated with those found by martin and rigrodsky. 2 2 the correlation was not significant ( r s = 0.38 ρ > 0.05). this serves as a reminder that care must be exercised before generalizing from the results of feature no. of errors rank coronal 11 1 anterior 7 2 back voice high 3 strident nasal continuant 5 4 3 1 4 5 6 7 table iv: hierarchy of difficulty on feature oppositions die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 aura kagan research to the individual patient. general trends are useful as an indication of what to expect, based on the average scores of many ss. they cannot predict with complete accuracy, the performance of any one individual. although the writer recognises the inconsistency of apraxic articulation errors, the fact that the phonemes were tested in different contexts at different times, makes it possible to draw tentative conclusions relevant to the planning of therapy for this patient. table iv presents a hierarchy of difficulty through which to work. the writer feels that these features themselves can be systematically analysed to give specific starting points for therapy. this point is discussed in detail at a later stage in this paper. (c) analysis of substitution errors: according to jakobson,12 phonological disintegration in the aphasic is an 'exact mirror-image' of phonological acquisition in the child. other authorities, such as critchley 8 disagree with this point of view. in order to investigate jakobson's hypothesis, one should select trends which have been well established as characteristic of the childhood acquisition of sounds. hyman1 1 feels that certain of the trends observed by jakobson are reliable, although the details have not always been supported by recent studies. he gives as examples, the acquisition of voiceless before voiced stops, as well as the acquisition of front before back consonants. if jakobson's theory 1 2 is valid, one would expect the aphasic to find voiceless and anterior phonemes easier than voiced and back phonemes, and would therefore predict that they would be used more frequently as substitutions. the results obtained indicate that voiceless stops were substituted more than their voiced cognates in every case (figure 2) and anterior phonemes were used as substitutions more frequently than back phonemes (figure 3). figure 2 also indicates that this trend applied to voiced-voiceless cognates other than stops. it is interesting to note that within the markedness theory of generative phonology, voiceless stops are 'universally less marked' than their voiced cognates. 1 1 18 16 frequency 14 of 12 occurrence 10 of 8 / errors 6 4 2 i « 1 » « 1 « « p-b t-d f-v k-g s-z c-j θ-8 voiced voiceless cognates figure 2: voiced compared to voiceless substitution errors the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) phonological analysis of an aphasic with apraxia 33 mean 8 frequency 6 of 4 occurrence 2 anterior* back** •anterior was defined as any phoneme with the feature ( + anterior) **back was defined as any phoneme with the feature ( — anterior) (both based on chomsky & halle's df chart3). figure 3: anterior ̂ compared to back substitution errors. (d) markedness analysis: figure 4 represents the trend for unmarked phonemes to be substituted for marked phonemes more than vice-versa, using three different manipulations of the substitution errors made by the s. theoretically these results are significant, as they lend credence to the idea put forward by chomsky and halle3 t h a t . . . unmarked features do not add to the complexity of a grammar. the writer agrees with blumstein2 that such results can be seen within the general trend in aphasia towards... simplification of the phonological system. contrasts with contrasts with contrasts df distance df distance involving df of 1 of 1 excluding distance of contrasts l and more involving /p/ key: v / x \ .'marked to unmarked i i : unmarked to marked figure 4: markedness analysis a comparison of substitution error to target phoneme die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 aura kagan 80 % 60 error 40 20 towards target phoneme away from target phoneme figure 5: analysis of self-correction errors (e) analysis of the process of spontaneous self-correction: the results in figure 5 indicate that in the majority of cases, attempts at selfcorrection move towards the target phoneme in terms of df distance. this is an interesting result as it appears to tap an ongoing phonological process rather than examining a static structure. the writer feels that these results indicate the applicability of distinctive features, which are an abstract concept, to a psychologically real process. in his efforts to reach the target, the s did appear to be using distinctive features. this is felt to be a striking example of the fact that the apraxic errors in this aphasic s could be linguistically characterised, and implies that linguistics, or more specifically, phonological theory, could be of use in planning therapy for him. the concept of a feature opposition chart as an aid to df therapy before discussing this procedure, it is felt that the use of df therapy in aphasia needs justification. much recent work in the field of articulation difficulties in children has been involved with an application of phonological theory. 2 4 ' 2 s > 2 6 most studies seem to be based on jakobson's idea that childhood acquisition of phonology can be seen in terms of the acquisition of feature contrasts. if one accepts jakobson's theory12, about the relationship between aphasia and childhood language, it is possible that the dissolution of the phonological system in aphasia could be viewed in terms of the loss of feature contrasts. the results of this study show that the apraxic errors of an aphasic patient can be usefully described and analysed within a df framework. it seems logical, therefore, to attempt to remediate within the same framework. it must be pointed out that there have been criticisms of this approach. walsh,35 for example, feels that distinctive features are too abstract to be clinically useful. based on the finding that most of this s's errors occurred on the feature (± coronal), a coronal feature opposition chart was devised as an aid to therapy. the chart is a representation of all possible contrasts involving (± coronal) in terms of chomsky and halle's theory.3 , the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) phonological analysis of an aphasic with apraxia 35 df distance c 1 p t ; b d ; f s ; v z ; m n . . 2 c + v 2 p d ; b—t; f-z; v s . 3 cont. ν str. η β a 3 ρ i ρ 1 b θ ρ η t m f 3 f 1 ν θ 4 ν str a cont cont β a a str cont str η 4 θ m p z b s t v d f p r θ m p z b s t v d f c g j k f r f 5 v-j j k i-t p r f r f 3 v j key: c=coronal v v o i c e cont. =continuant n = nasal str. = strident h=high β = back a = anterior table v: example of part of the coronal feature opposition chart. similar charts could be drawn up for any feature. the chart can be used to describe df distance as well as to see the effects of particular feature combinations. as previously noted, most substitution errors occurred between phonemes with a df distance of 1 and least between phonemes with a df distance of 5. therefore, when beginning distinctive-feature therapy, one would initially choose contrasts with a large df difference, gradually and systematically decreasing this until the patient can contrast differences of 1 distinctive feature. winitz 3 6 mentions a similar principle with reference to 'phonetic' distance. if df training is to begin with phonemes having a df distance of more than 1, it becomes necessary to analyse the effects of various features in combination with the coronal feature. for example, if at a df level of 2, the s makes least errors when the coronal feature is combined with voice, therapy could begin with this combination. looking at the chart for coronal plus voice (see table v), one can systematically select particular phoneme contrasts for inclusion in the df therapy programme. in general, one would work from greatest to smallest df distance. in addition, within eachdf level, one should work within a hierarchy of difficulty as presented by each individual case. an example of a hierarchy of difficulty, working from the greatest to the smallest df difference, would be the following: coronal, voice, continuant, strident, e.g. p z coronal, voice, continuant, e.g. p 1 coronal, voice, e.g. p d coronal, e.g. p—t die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 aura kagan a feature opposition chart can be used to represent both errors of articulation and discrimination. by marking the errors on the chart, one is provided with an instant visual indication of feature confusions. summary of the procedures and results of discrimination testing discrimination was first tested conventionally on a modified version of the d.ip. test. 3 2 modifications were made to those americanisms felt to be confusing for the s. the s made only 4 errors but as in the case of the repetition task, it was felt that deeper testing, using a phonological approach, would reveal the fact that difficulty was being experienced in this area. therefore, a discrimination task was devised which involved pointing to one of two visually presented nonsense syllables, following an auditory stimulus given by the e. nonsense syllables were devised in the same manner as that described in the repetition task. each contrast was tested twice and the order of presentation in terms of spatial cues within the contrasts was randomized. the two stimuli were identified by the ε before the contrast was tested so that errors could not be attributed to problems of visual recognition. the following discrimination tests were administered:a) the discrimination of phoneme contrasts with a df distance of 1 which were confused on the repetition task was compared to the discrimination of phoneme contrasts having an identical df distance not derived from articulation errors. the df distance of 1 was chosen because most errors occurred here. b) in terms of findings on the nonsense-syllable repetition task, the discrimination of all possible contrasts with a df distance of 1 was compared with the discrimination of all possible contrasts involving adf distance of 5. results for a) and b) were scored in terms of i) correct/incorrect from which a percentage of error was derived, and ii) reaction time (rt), defined as the time taken between the auditory stimulus being given by the ε and.the s's pointing to one of the nonsense syllables, irrespective of whether it was correct or incorrect. it was hypothesized that rt would be a function of the 'difficulty' or 'complexity' of the stimulus. rt was measured with a stopwatch and was calculated to the nearest 1/loth second. the mean (x), standard deviation (s.d.) and range of each set of rt scores was computed, the range being defined as χ — 1 s . d . 2 8 stimuli % error χ rt sd y range substitution error — target phoneme 40 1,82 ,33 1 , 4 9 2 , 1 5 other contrasts 29 1,75 ,33 1 , 4 2 2 , 0 8 table vi: a comparison between phoneme pairs derived from substitution errors with pairs not derived from substitution errors (all having a df distance of 1) the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) phonological analysis of an aphasic with apraxia 37 the results in table vi indicate that the s did find the discrimination of his errors slightly more difficult as indicated by a larger percentage error score and longer rt. however, this difference is not considered to be reliable, as the range of scores in both cases overlapped considerably.28 the difference between discrimination of phoneme pairs with a df distance of 1 compared to those with a df distance of 5 (table vii) appears to be reliable, as indicated by a larger difference in the percentage error score and rt as well as by the fact that the range of scores hardly overlapped.28 df distance «error χ rt sd range 1 26 1,22 ,24 0 , 9 8 1 , 4 6 5 3 1,81 ,40 1 , 4 1 2 , 2 1 table vii: a comparison between the discrimination of all phoneme pairs having a df distance of 1 with all phonemes having a df distance of 5 these two findings seem to be indicative of different aspects of discrimination. the results in table vi are felt to reflect the lack of a direct relationship between articulation and discrimination in this s. this is surprising in terms of the views put forward by authorities such as lieberman19 and ladefoged et a l , 1 7 who stress the direct relationship between articulation and auditory perception (although their theories tend to emphasize different aspects of this). the results in table vii are felt to indicate the existence of an indirect relationship between articulation and discrimination in the s. as can be seen, the trend for error frequency to be inversely related to df distance followed that found in the analysis of articulatory substitution errors, i.e. phoneme contrasts with a df distance of 1 resulted in more errors and a longer rt than phonemes with adf distance of 5. . conclusions articulation errors made by the s were able to be described and analysed within a linguistic framework which provides support for the view put forward by martin 2 0 that apraxia of speech is a linguistic disorder. this implies that apraxia could be considered an integral part of the aphasic breakdown, necessitating a linguistic approach to testing and therapy. johns and darley,15 on the other hand, feel that apraxia of speech requires a different therapeutic approach to that used in aphasia. the results of the df analysis on the nonsense syllable task appear to approximate the real-life performance of this s better than the results of conventional tests which were unable to tap the subtle phonological difficulties being experienced. the s did demonstrate problems of auditory discrimination, but these were not directly related to the articulation errors, according to the results of this die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 aura kagan study. the writer feels that, as yet, we do not have enough information to make emphatic statements about the lack of a one-to-one relationship between articulation and discrimination in apraxia. in order to do so, one should test discrimination of an error at the instant that it is produced. testing the discrimination of errors at a later stage has an inherent limitation in view of the inconsistent nature of apraxic errors. it does, however, seem that there is some involvement of auditory perceptual difficulty in this s, which should be taken into account when planning therapy. the writer agrees with the views of martin et a l 2 3 who feel that aphasia is characterized by an impairment of the interaction of several processes rather than impairment of an isolated aspect of functioning. although the use of feature opposition charts involves a great deal of work on the part of the clinician, its great advantage lies in the fact that it allows the patient to demonstrate his idiosyncratic phonological difficulties in great detail, which should lead to the planning of more effective therapy. further research may serve to refine these charts in order to make them more clinically practical. it should be pointed out that the proposed approach in this study need not be limited to apraxia of speech, but should prove useful in many cases involving multiple articulation disorders. references 1. aten, j. l„ johns, d. f. & darley, f. l. (1971): auditory perception of sequenced words in apraxia of speech. j. speech hear. res., 14(1) 131-143. 2. blumstein, s. (1973): some phonological implications of aphasic speech. in psycholinguistics and aphasia, goodglass, h. & blumstein, s. (eds.) the johns hopkins university press, baltimore. 3. chomsky, n. & halle, m. (1968): the sound pattern of english. harper & row, new york. 4. critchley, m. (1973): articulatory defects in aphasia: the problem of broca's aphemia. in psycholinguistics and aphasia, goodglass h. & blumstein, s. (eds.) the johns hopkins university press, baltimore. 5. darley, f. l. (1968): apraxia of speech: 107 years of terminological confusion. paper presented to the american speech and hearing association convention. / 6. deal, j. l. & darley, f. l. (1972): the influence of linguistic and situational variables on phonemic accuracy in apraxia of speech. j. speech hear. res., 15(3), 639-653. 7. de renzi, pieczuro, a. & vignolo, l. a. (1966): oral apraxia and aphasia. cortex, 2, 50-70. 8. fry, d. b. (1959): phonemic substitutions in an aphasic patient. lang. speech, 2, 52-61. 9. goldman, r. & fristoe, m. (1969): goldman-fristoe test of articulation. american guidance service, inc., minnesota. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) phonological analysis of an aphasic with apraxia 39 10. goodglass, h. & kaplan, e.'(1972): the assessment of aphasia and related disorders. lea & febeger, philadelphia. 11. hyman, l. m. (1975): phonology: theory and analysis. holt, rinehart & winston, u. s. a. 12. jakobson, r. (1968): child language, aphasia and phonological universals. mouton, the hague. 13. jakobson, r., fant, g. & halle, m. (1961): preliminaries to speech analysis. m.i.t. press. cambridge, massachusetts. 14. johns, d. f. (1970): application of experimental evidence in the treatment of apraxia of speech. paper presented to the american speech hearing association convention. 15. johns, d. f. & darley, f. l. (1970): phonemic variability in apraxia of speech./. speech hear. res., 13(3), 556-583. 16. johnson, w„ darley, f. l. & spriestersbach, d. c. (1963): diagnostic methods in speech pathology. harper & row, new york. 17. ladefoged, p., de clerk, j., lindau, m. & papcun, g. (1972): an auditory-motor theory of speech production. unpublished paper, u.c.l.a. working papers in phonetics, 22, 48-75. 18. lecours, a. r. & lhermitte, f. (1973): phonemic paraphasias: linguistic structures and tentative hypotheses. in psycholinguistics and aphasia, goodglass, h. & blumstein, s. (eds.). the johns hopkins university press, baltimore. 19. lieberman, p. (1972): speech acoustics and perception. the bobbsmerrill company, inc., u. s. a. 20. martin, a. d. (1974): some objections to the term apraxia of speech. j. speech hear. dis., 39(1), 54-63. 21. martin, a. d. & rigrodsky, s. (1974a): an investigation of phonological impairment in aphasia. part i. cortex, 10(4), 317-328. 22. martin, a. d. & rigrodsky, s. (1974 b): an investigation of phonological impairment in aphasia. part ii. cortex, 10(4), 329-346. 23. martin, a. d„ wasserman, ν. h„ gilden, l„ gerstman, l. & west, j. (1975): a process model of repetition in aphasia: an investigation of phonological and morphological interactions in aphasic error performance. brain language, 2(4), 434-450. 24. mcreynolds, l. v. & engmann, d. l. (1975): distinctive feature analysis of misarticulations. university park press, baltimore. 25. mcreynolds, l. v. & huston, k. (1971): a distinctive feature analysis of children's misarticulations. j. speech hear. dis., 36(2), 155166. 26. menyuk, p. (1968): the role of distinctive features in children's acquisition of phonology.speech hear. res., 11(1), 138-146. 27. rosenbek, j. c„ lemme, m. l„ ahem, μ. b„ harris, ε. h. & wertz, r. t. (1973): a treatment for apraxia of speech in adults. j. speech hear. dis., 38(4), 462-472. 28. saling, m. (1976): lecturer, department of psychology, university of the witwatersrand, johannesburg, personal communication. 29. schuell, h. (1966): some dimensions of aphasic impairment in adults considered in relationship to investigation of language disturbance in children. brit. j. dis. commun., 1(1), 33-45. die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 aura kagan 30. schuell, h„ jenkins, j. j. & jiminez-pab'on,(1964): aphasia in adults. harper & row, new york. 31. sankweiler,d.&harris,k: s.(1973): some phonological implications of aphasic speech. in psycholinguistics and aphasia, goodglass, h. & blumstein, s. (eds.). the johns hopkins university press, baltimore. 32. siegenthaler, β. m. & haspiel, g. s. (1968): discrimination by identification of pictures. pennsylvania state university speech and hearing clinic. 33. spreen, o. (1968): psycholinguistic aspects of aphasia./. speech hear. res., 11(3), 467-480. 34. standel, j. j., gardner, j. o. & hannah, e. p. (1974): distinctive feature analysis. in applied linguistic analysis, hannah e. p. (ed.). joyce publications, california. 35. walsh, h. (1974): on certain practical inadequacies of distinctive feature systems. / . speech hear. dis., 39(1), 32-43. 36. winitz, h. (1975): from syllable to conversation. university park press, baltimore. b o o k s o n speed ι and hearing c o n s u l t campus bookshop 34 bertha street, p.o. box 31361 braamfontein 2017 telephone 39-1711 westdene medio books 35/6 nedbank plaza, 175 beatrix street pretoria telephone 2-6336 logans university bookshop . . 227/9 francois road, durban telephone 35-4111 overseas publications obtained promptly. nationwide mail-order service. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) modern earing aid (pty) ltd for hearing aids — a comprehensive range comprising the latest microson directional models — unl· tron high level compression models. ear moulds — we specialise in ear mould technology to the great benefit of our patients — we also supply instant mould kits to schools. audiometers — audiotone portable screening and diagnostic units at the best prices available. sound proof booths and earmuffs high quality locally manufactured products tv accessories — manufactured by ourselves w e a r e a t 305 rand centra! 185 jeppe st johannesburg tel: 37-1774 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the iconicity of picture communications symbols for rural zulu children 40 the iconicity of picture communication symbols for rural zulu children lize haupt and erna alant* centre for augmentative and alternative communication university of pretoria abstract the purpose of this study was to investigate the iconicity of selected picture communication symbols (pcs) for rural zulu ten-year-olds. participants were presented with copies of a commercially available communication overlay without glosses. they were required to match a symbol with each of 36 spoken zulu labels. with both strict and lenient scoring criteria applied, 2.8% and 11.1% (respectively) of the symbols on the communication overlay emerged as iconic for participants. it was further established that the position of symbols on the overlay, the total frequency of selection of symbols, and gender did not influence results. an analysis of errors revealed that for some symbols many of the participants agreed on a single specific label, be it the target label or a non-target label; while for other symbols there were either many possible labels, or none. the term distinctiveness was coined to describe how well defined or specific were the evoked meanings triggered by a symbol in the viewers' minds. results suggest that participants did not make maximum use of the information provided by arrows in the symbols. this finding could be ascribed to the opaqueness of arrows and participants' lack of previous experience with these conventional cues in pictures, as well as the traditional oral nature of the zulu culture. key words: augmentative and alternative communication (aac), communication overlay, cross-cultural, iconicity, zulu, picture communication symbols (pcs), translation introduction it is often stated that good practice when first teaching symbols, is to select symbols that are easy to learn (fuller, 1997; lloyd & fuller, 1990; mirenda & locke, 1989). this strategy facilitates communication while at the same time ensuring success, which motivates the user. iconicity information can greatly aid clinicians in such a selection, since iconic symbols are easier to learn (fuller, 1987; fuller, 1997; lloyd & fuller, 1990; lloyd, fuller & arvidson, 1997; lloyd, loeding & doherty, 1985; luftig, 1983; luftig, page & lloyd, 1983; mizuko, 1987). furthermore, information about the iconicity of symbols is especially valuable in south africa because of widespread illiteracy. a literate communication partner can read the gloss (written text) that accompanies a symbol, but illiterate partners have to rely on the iconicity of symbols to guess their meaning. it is expensive and virtually impossible to train all possible communication partners in the use of the relevant symbol set/system, therefore the use of iconic symbols is more efficient. iconicity is defined as the degree to which an individual perceives visual similarity between a symbol and its referent (blischak, lloyd & fuller, 1997). factors influencing visual perception would probably influence a symbol's iconicity for a given viewer. such factors include the material on which symbols are printed (deregowski, 1980a,b); schooling (duncan, gourlay & hudson, 1973); thinking styles (retief, 1988; taylor & clarke, 1994; witkin, 1967); oral or literate background of viewer (ong, 1982) and previous experience with symbols (deloache, 1991). closer inspection of these factors reveals that they are all intertwined with culture. culture is 'a set of behaviours, institutions, beliefs, technologies and values invented and passed on by a group of individuals to sustain what they believe to be a high quality of life and to negotiate their environments' (taylor & clarke, 1994, p.-103). it therefore seems reasonable to assert that iconicity should be studied in the context of a culture, and that it cannot be taken for granted that results obtained from studying one group of people can necessarily be generalised to another. however, the iconicity of graphic representational systems has not previously been investigated in the context of any of south africa's many cultures. there is a need for culture-specific iconicity information in this country to enhance alternative and augmentative communication (aac) intervention for individuals with little or no functional speech (lnfs). kwazulu-natal is the province in south africa with the second highest disability prevalence rate (6.7%) (schneider et al., 1999). furthermore, the 1996 census showed that 22.9% of south africans are zulu mothertongue speakers (burger, 2000), making it one of the largest linguistic groupings in the country. picture communication symbols (johnson, 1981, 1985, 1992) is a set of aided, static communication symbols and is regarded as relatively iconic compared to other aided symbol sets and systems (mirenda ,& locke, . 1989; mizuko, 1987). although it originated in the usa, it is widely used all over the world, including south africa. an investigation into how zulu children relate to picture communication symbols (pcs) could yield valuable information on how to modify the'content, appearance or use of pcs to facilitate symbol learning and use. a review of iconicity literature revealed that one of two methodologies is normally used to determine the iconicity of symbols: either the participant is shown a the south african journal of communication disorders, vol. 49, 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) rouviere de waal, rene hugo, maggi soer and johann j kruger 41 symbol and asked to guess its meaning, or participants are required to match a spoken label with a symbol from a set of closed alternatives. it has been reasoned that such a forced-choice task might be easier than an openchoice task (musselwhite & ruscello, 1984), probably resulting in the best possible iconicity values. in a critique of their own study, mirenda and locke (1989) mentioned that communication overlays typically contain more than two symbols. they maintained that the inclusion of a larger number of symbols in iconicity tasks might yield more accurate results for intervention , purposes. in the light of this consideration it was decided to investigate iconicity in the context of a communication overlay. instead of presenting a participant with three to five symbols to choose from, an entire overlay was presented. the communication overlays designed by goossens', crain and elder (1996) can be photocopied directly from the manual, and are widely used unmodified in south africa. the use of a 36-matrix overlay from this collection therefore seemed appropriate for the present study. clearly such a task would differ from those in previous iconicity studies in four important ways. firstly, when participants are presented with a complete communication overlay, the set of alternatives is substantially larger than in previous studies, as has just been discussed^ secondly, all symbols are semantically related to the same theme and therefore possibly to each other, even if indirectly. thirdly, the 36 symbols comprising the set .of, alternatives will remain static across all 36 trials; and fourthly, each symbol will in time be the target symbol. these last two factors create the possibility that some participants may remember which symbols they had chosen for several consecutive trials and, in response to the next labels, narrow their selection down to those not yet chosen. the possibility that a combination of these factors might influence the iconicity values obtained should be kept in mind. ' due to the novel; methodology, the question arose as to what terminology should be used. transparency refers to 'the ease of identification of symbols when no additional cues, such as printed labels or verbal hints, are provided' (musselwhite & ruscello, 1984, p.437). in this study; however, an additional cue was provided in that the theme of the overlay was known. thus the traditional term {'transparency' could not be used. translucency on ! the ,, other . hand (typically determined by participants rating on a 5or 7point scale) · indicates the extent to which a symbol looks like its referent (blischak et al., 1997). no ratings were required from participants in the present study, so the term translucency would not apply either. it was decided that use of the more general term iconicity would be most accurate. method aim the primary aim of the study was to determine " how accurately typically developing rural zulu 10-yearolds could identify 36 picture communication symbols (pcs), presented thematically on a commercially available communication overlay, in response to spoken labels. the following objectives were formulated: to select a commercially available communication overlay, die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 49, which, contained no concepts that would be foreign to rural zulu children; to determine how accurately tenyear-old zulu children would select the correct symbol in response to its spoken label; to describe error patterns; and to investigate factors that could have influenced results, specifically total frequency of selection, position on overlay and gender research design the nature of the study was exploratory. an analytical survey was conducted in which 94 rural zulu mother-tongue speakers from nine schools were exposed to 36 pcs symbols in the context of a commercially available communication overlay. in response to a verbal zulu label they had to mark the symbol they thought best depicted that concept. sampling was purposive in the sense that schools were selected according to accessibility. at the selected schools however, all children that met the selection criteria were included in the study. the data was quantitative in nature and was therefore subjected to statistical analysis to obtain iconicity values. possible influences on results and error patterns were analysed qualitatively. participants participant selection criteria participants had to be zulu mother-tongue speakers between the ages of 10 and 11, with no indication of hearing loss or uncorrected sight problems. they had to be in either grade 4 or grade 5, to ensure comparable educational and experiential backgrounds; and should never before have failed a school year. in the absence of formal assessment of mental abilities, this criterion was included to control for severe learning and mental disabilities. description of schools the kwazulu-natal department of education and culture divides the province into 196 circuits. the twenty-two primary schools in the kranskop east circuit were targeted for this study. these schools are all located along three main routes, and three schools along each route, that would be accessible by sedan vehicle, were chosen in consultation with a physical planner from the kwazulu-natal department of education and culture pietermaritzburg region. permission to perform the study was obtained from the principal of each selected school, as well as the kwazulu-natal department of education and culture. the nine schools that were selected were all co-educational government-funded schools. none were boarding schools, which means that all the participants were indigenous to the kranskop area. none of the schools had facilities for learners with special educational needs. although the mother tongue of all participants was zulu, the official language of instruction at all schools was english. the kwazulu-natal department of education and culture classifies schools as deep rural, rural, peri-urban and urban, according to no set definitions. rural is simply described as far from any town, whereas deep rural means 'off the beaten track' (p. miiller, deputy chief education specialist in education management information services, personal communication, july 9, 2001). all schools in the sample r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) lize haupt and erna alant 42 were classified as rural or deep rural by the kwazulunatal department of education and culture. description of participants at the nine selected schools all children who met the selection criteria were identified. a population of 94 children were tested, of which 52 were female and 42 male. participants were between the ages of 10 and 11, and the mean chronological age was ten years and five months. procedure preparatory phase this phase included the selection and translation of a suitable communication overlay (goossens' et al., 1996), development of a test protocol, training of the research assistant and execution of a pilot study to pretest the validity of the translation and test protocol. the aim of the selection process was to minimise cultural distance between the concepts represented on the overlay and the experiential background of the target population. the basic content of the overlay had to form part of the world knowledge of children from the target population. the researcher was assisted in the selection process by a panel of three zulu judges each of whom had between four and 15 years' teaching experience in the kranskop area. to minimise the influence of linguistic factors on the performance of participants, the entire procedure was conducted in zulu. consequently all labels (the sentences/phrases accompanying the symbols on the overlay) had to be translated into zulu. the goal was to produce an ethnographic translation (brislin, 1980) and a process consisting of blind back-translation, a review committee and pre-test procedures (bracken & barona, 1991; retief, 1988) was followed. the translation process involved eight people, five of whom were zulu mother-tongue speakers with proficiency in english; and three of whom were english mother-tongue speakers with proficiency in zulii. all eight translators had previous experience with translation between the two languages. the final translations are presented in table 1. • a young zulu, adult served as research assistant. she had obtained her senior certificate and was at the time studying part time through unisa. additionally, she co-reared eight younger cousins and did pro work for two youth organizations in the kranskop area. she was selected for her proficiency in english and good rapport with young children. as an introduction to the training, the research assistant received general background information on the aims of' the study, and was presented with the communication overlay as well as the zulu and english phrases. thereafter the procedure was performed once on each of three children who met the selection criteria, but who were not included in the pilot or main studies·. these sessions were performed as part of training, and in order to develop a practical test protocol. during the first session the research assistant worked from a crude protocol designed by the researcher, and instructions were modified in consultation with the researcher where it seemed necessary. during sessions two and three the protocol did not change considerably, and the research assistant reported familiarity with the procedure. a pilot study was then performed in two phases. during the first phase the procedure was performed on ten participants who met the selection criteria, but who were not included in the main study. based on the results of this phase, minor adjustments were made to the protocol and translation. three modelled training items and three independent training items proved to be sufficient to train participants in the task, but it seemed necessary to add an instruction to scan through all the symbols before making a choice. such an instruction was added to the protocol. participants reported, that: the translation for the phrase 'let us put" on....' ('masendlale...') was too close to the translation for 'let us make the bed' ('asendlale umbhede'). consequently an alternative translation ('maseleke...'), that satisfied all the participants as well as the translators, was used, in the main study. the second phase of the pilot study entailed performing the procedure a second time on the same participants, one week after the first administration. results were compared in order to establish test-retest reliability. table 1: final translations of labels english phrase zulu translation what a mess! kwaze kwangcola! it looks like a bomb went off! sengathi kuqhume ibhomu! it is dirty. kungcolile. you need to change them. udinga ukuwashintsha." let us take it off. asikususe. help me, please. ngicela ungisize. it is finished. kuphelile. what is next? kulandelani? put it in the tub. faka kubhavu. let us make the bed. asendlale umbhede. hold this, please. ngicela ubambe lokhu. you need to pull. udinga ukudonsa. it is crooked. kugwegwile. j let us do it again. asiphinde futhi. ' fold it back. kugoqele emuva. . . , tuck it in. kushutheke. ; let us put on... maseleke... ...the sheets ...amashidi. ·, ι ...the blanket ...ingubo. ι ...the pillowcase ...iphilo. thank you. ngiyabonga. you are welcome. wamukelekile. < let me:.. . akengi... where is it? kuphi? put it here. beka lapha. puff it up. khukhumalisa. it is nice and soft. kuntofontofo. what do you think? ubona kanjani? it looks good. kubukeka kahle. / it looks bad. kubukeka kabi/ whoops! we! look at this. buka lokhu. we forgot. sikhohliwe. yes. yebo. no. cha. it is nice and clean. kuhlanzeke kahle. the south african journal of communicationdisorders, vol. 49, 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) rouviere de waal, rene hugo, maggi soer and johann j kruger 43 main study the researcher and research assistant visited the nine schools and included all children that met selection criteria at every school.. sessions were conducted with ten or less participants at a time (except in two cases where twelve children were included due to time constraints) and took between 45 minutes and one hour. each participant was issued with a recording booklet (containing 36 a4 facsimiles of the communication overlay and six facsimiles of the training overlay) and a felt tip marker. the training procedure consisted of six trials where participants were asked to indicate the written word on the training overlay that corresponded table 2: presentation order of symbols with the zulu word that the research assistant read out. participants were shown and told to visually scan the entire matrix before indicating the word. since children who experience problems with sight or hearing would have difficulty with this task, it served simultaneously as hearing and visual screening. during the testing procedure, zulu labels were read in an order that was determined before commencement of the study by drawing symbols randomly from a bag and assigning each number, accordingly. participants had to mark one label per page. every label was repeated once and the procedure was not timed. after the session each participant received a token. teachers were given information on aac in general and the aims of the study, as well as worksheets for their classes. they were asked nr label in english target symbol iv nr label in english target symbol iv nr label in english target symbol iv 1 what is next? c \ 1 2 3 • • • 14 13 it is * finished. / _ _ ν t ^^^ j 6 25 puff it up. φ ν / 47 2 it is nice and soft. f \ ο \ / 7 14 let us make the bed. f v ϊμ 67 26 what a mess! 1»"" * a w 14 3 no. 0 15 thank you. f— mr 40 27 it looks like a bomb went off. f \ 32 3 no. 0 15 thank you. 40 27 it looks like a bomb went off. 32 4 you need to change them.' f \ e l · · ^ ' j 4 16 ...the blanket. v. ^ 10 28 let us do it again. f s 1 5 whoops! / ν φ 46 17 let us put on... r \ < ' s 5 29 yes. f ν © i * j 12 6 κ we forgot. f f a ) v 1 y 22 18 ...the sheets. r j o 30 put it here. k λ 13 7 what do . you think? fe) 13 19 where is it? f / 5 31 you are welcome. t \ q 9 8 it is nice and clean. ^ i ·λ 8 20 look at this. β " ν j 1 32 ...the pillow case. a 21 9 let us take it off. f \ ^ j 8 21 tuck it in. f \ l £ ] 17 33 let me... 3 10 it is -crooked. f sl l l > k. 13 22 i it is dirty. 3 34 it looks bad. r \ φ 10 10 it is -crooked. 13 22 i it is dirty. 3 34 it looks bad. 10 11 you need to pull. ( \ ν j 81 23 fold it ' back. f \ 2 35 hold this, please. t ν. 37 12 put it in the tub. ft * 57 24 help me, please. ·\ 47 36 it looks good. 0 (nr = number; iv = iconicity value) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 49, 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) lize haupt and erna alant 44 to discuss the session with their pupils with the help of the worksheets, as a form of debriefing. data analysis paired t-tests were performed on the two sets of data from the pilot study in order to reveal possible significant differences between the performances of the same group of participants one week apart. the performance of males and females in the main study were compared in a chi-square test. descriptive statistics, includingfrequency distribution counts, mean and standard deviation were also used. possible influences on results and error patterns were analysed qualitatively. results and discussion the results are described and discussed according to the objectives of this study. the frequency of correct responses per label is presented. an analysis of errors is presented and discussed, and possible influences on correct responses are considered. frequency of correct responses per label missing data out of the total of 3,384 responses generated in this study ! (94 participants χ 36 trials), two symbols on one page were marked on five occasions, no choice was indicated on eight occasions, and the activity graphic in the top. right hand corner of the overlay was chosen on nine occasions. in order to focus on the most salient patterns in this study, it was arbitrarily decided to consider only those responses that were indicated by at least 20% of the participants (i.e. 19 participants or more). consequently the influence of the missing data was deemed negligible. iconicity values to aid in interpretation of the results, the number as well as iconicity value of each symbol are presented in table 2. the iconicity value represents the number of participants that chose a symbol in response to its target label. doherty, daniloff & lloyd (1985) used strict (iconicity values > 75%) and lenient (iconicity values > 50%) criteria for interpreting the transparency scores of amer-ind gestures. although the present study did not investigate pure transparency, these criteria were nevertheless deemed useful. in accordance with the above criteria, one symbol (symbol 11) was found to be iconic when the strict criterion was applied, and four symbols (symbols 11; 12; 14; and 25) when the lenient criterion was applied. note that symbol 5 achieved an iconicity value of 49% (n=46) and was one response short of being classified as iconic according to the lenient criterion. thus either 2.8% or 11.1% of the symbols on the communication overlay were iconic for the participants involved, depending on the criterion used. the average of 'correct' responses across all symbols was 17.75 (18.88%) with a standard deviation of 20.17. analysis of errors when the highest frequency responses were studied for each symbol, it became clear that for some symbols many participants agreed on a single specific label, be it the target label or a non-target label. for other symbols either many possible labels, or none of the labels, were indicated. the term distinctiveness was coined to describe how well defined or specific were the evoked meanings triggered by a symbol in the mind of a viewer. this term should not be confused with 'perceptual distinctness',, as described by fuller, lloyd, and stratton (1997), which refers to the degree to which the symbols in a group are clearly different or distinct from one another. . it is also important to note that 'distinctiveness' was not intended as an equivalent to 'iconicity'. whereas both terms concern the visual relationship between a symbol and its referent, they indicate different aspects of that relationship. iconicity pertains to the degree of visual similarity perceived, as demonstrated by the use of the three dimensions, transparency, translucency and opaqueness .(blischak et al., 1997). the term distinctiveness, as used in this study, relates to the specificity of visual similarity perceived i.e. whether participants perceive similarity to one referent, to many, or to none. since iconicity and distinctiveness are not opposing terms, a symbol can be classified by both terms simultaneously. such a classification will lead to all symbols falling into one of four orthogonal groups: distinctive and more iconic (many participants chose a certain symbol in response to its target label only); indistinctive and more iconic (many participants chose a certain symbol in response to its target label, however they also chose that symbol often in response to one or more other labels); distinctive and less iconic (few participants chose a certain symbol in response to its target label, however many of them chose that symbol in response to a certain non-target label); indistinctive and less iconic (few participants chose a certain symbol in response to its target label but they chose that symbol often in response to one or more other labels). 1 the symbols from the present study were distributed across these four orthogonal groups. to determine iconicity and distinctiveness two criteria were used. regarding the iconicity of a symbol, the criterion suggested by hoemann (1975) was used (iconicity values > 25%). admittedly this criterion is very lenient (lloyci et al., 1985), but since" this analysis was concerned with relative rather than absolute iconicity, it was considered appropriate. to describe distinctiveness, all response frequencies > 20% were investigated. note that this cuttable 3: distribution of symbols according to iconicity and distinctiveness more iconic (iconicity values > 25%) less iconic (iconicity values < 25%) ^ distinctive (only one response over 20%) numbers: 5; 12; 16; 25; 27; 35 numbers: 4; 7; 13; 15; 20; 26; 28; 31 indistinctive (more than one response over 20%, · or no responses over 20%) numbers: 11; 14 numbers: 6; 18; 32; 33; 1; 2; 3; 8; 9; 10; 17; 19; 21; 22;'23; 24; 29; 30; 34; 36 the south african journal of communication disorders, vol. 49, 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) rouviere de waal, rene hugo, maggi soer and johann j kruger 45 off point was arbitrarily selected and not statistically determined. the distribution of the symbols from the present study across these four orthogonal classifications is presented in table 3. although the variable 'distinctiveness' has never been investigated before, it was hypothesised that it would yield valuable information as to how participants viewed symbols. hence a discussion of symbols according to this classification follows, including only the most salient points. for a detailed discussion the reader is referred to haupt (2001). distinctive and more iconic six symbols (5, 12, 16, 25, 27, and 35) were classified as distinctive and more iconic. it seems that participants perceived a relatively strong visual relationship between these six symbols and their target referents, and to those referents only. it is hypothesised that of all 36 symbols included in the study these six will probably be the easiest to learn for rural zulu children. indistinctive and more iconic symbols 11 and 14 (the two symbols with the highest iconicity values) were classified as indistinctive and more iconic. it is evident that not only did participants perceive visual similarities between these symbols and their target referents, but also to other referents. it can be argued that the conceptual features of symbol 14 were exceptionally close to the theme of the overlay (making the bed). underlying similarities possibly existed between the label for this symbol and those for other symbols, making it a popular choice. it is postulated that the indistinctiveness of symbol 14 can therefore be ascribed to the context in which it was ν presented. had this symbol been presented in a group of unrelated foils like in most other iconicity studies, it probably would have scored higher on distinctiveness. the perceptual features of symbol 11 ('you need to pull') include a human figure in implied motion 'and an object linked to the figure by rope. one of the two non-target labels that were associated with this symbol by more than 20% iof participants also referred to physical motion ('let us take it off') and the selection of this symbol can therefore easily be explained. the other non-target label associated with this symbol referred to more abstract motion: from present to future ('what is next?'). the target symbol for this label (symbol 1) shows this motion with an arrow. it seems that participants preferred the symbol that implied motion by postural cues, to the symbol that included an arrow, suggesting the possibility that participants did not interpret the arrow as presenting information about movement. this phenomenon recurred throughout the analysis of error patterns and possible , causes are discussed later in the paper. another aspect to be considered is the fact that the label 'what is next?' is a question. three of the 36 symbols on the overlay contained question marks: symbols 1, 7 and 19; whereas symbol 11 did not. it is postulated that if participants recognised and optimally utilised'the question mark, they would have associated one of the three 'question mark symbols' with the label 'what comes next?'. the fact that they preferred symbol 11 may indicate that they did not interpret the question mark as indicating a question. distinctive and less iconic symbols 4, 7, 15, 28 and 31 were classified as distinctive and less iconic. symbol 4 intends to depict a change of colour, however it could also be interpreted as a change from clean to dirty, which would account for the confusion with the label 'what a mess!'. if this explanation were accepted, it would appear that participants did interpret the arrow in this symbol as indicating change. it seems once again that the clue afforded by the question mark in symbol 7 was lost since participants associated it with a label that was not in question form. to viewers that are unfamiliar with american sign language, symbols 13, 15 and 31 might be difficult to understand. symbol 15 shows two hands on the chin of a face. the label 'we forgot' was associated with this symbol, possibly because people who are shocked or surprised sometimes put their hands over their mouths. if this interpretation is accepted, participants once again did not use information afforded by the arrows pointing outwards. symbol 31 depicts two hands with empty palms turned upwards. if the hands were motionless in that position, it could be interpreted as showing that the hands are empty, possibly explaining why the label 'it is finished' was associated with this symbol. the arrows, however, imply movement away from the face, a clue that was presumably not interpreted as such by participants. symbol 28, depicted by two arrows pointing downwards, was associated with the label 'it is crooked'. the target label for symbol 28 is 'let us do it again'. the participants, instead of perceiving that the arrows indicated repetition, perceived them as two crooked lines. this finding confirms the hypothesis that participants did not interpret arrows in the symbols as indicating direction or movement. indistinctive and less iconic it is interesting to note that seven of the symbols in this classification (symbols 1, 3, 9, 19, 21, 23, 29) contain arrows. the evidence collected thus far seems to suggest that the arrows could have been a cause of the low iconicity and indistinctiveness. for example, none of the symbols indicated by this study as iconic contained arrows, and only five symbols containing arrows were not classified as indistinctive and less iconic (symbols 4, 13, 15, 20, 31). it has however already been postulated that the arrows in symbols 13, 15, 20 and 31 were not interpreted conventionally. only in symbol 4 was the arrow interpreted as indicating change. conversely it could be argued that in symbol 4 the form of the two objects stay the same and hence, unlike the other symbols containing arrows, only one attribute (colour) changes. the change is therefore highlighted, possibly contributing more to the target interpretation than the actual arrow. it seems that participants did not interpret arrows as indicating direction or change in any of the symbols except possibly one. two possible explanations for this phenomenon will be discussed. the arbitrary nature of arrows necessitates previous experience with it in order to be able to interpret it. it could be argued that children from rural areas are die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 49, 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) lize haupt and erna alant 46 • c o r r e c t r e s p o n s e s d t o t a l r e s p o n s e s 2 2 5 2 1 0 1 9 5 1 8 0 1 6 5 1 5 0 1 3 5 ο g 1 2 0 εγ 1 0 5 £ 9 0 7 5 6 0 4 5 3 0 1 5 0 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1 3 2 3 3 3 4 3 5 3 6 s y m b o l n u m b e r figure i: correct responses and total frequency of selection not afforded enough opportunity to experience and learn to interpret such western conventions. yet the participants in this study all attended school where encounters with such conventions could be expected. it seems possible that either the nature or the frequency of such encounters is not sufficient in some rural schools. another possible explanation entails the predominant oral nature of the zulu culture where print traditionally played· a minor role. through the widespread use of media such as television, newspapers and billboards however, most 'oral' cultures today have had some contact with print, resulting in 'secondary orality' (ong, 1982). although most zulu people therefore are confronted with print in one way or another, there is evidence that the contact has not been great enough to promote a bookish culture among them (duncan et al., 1973;. solarsh, 2001). the possibility therefore exists that the orality of the culture, albeit secondary orality, plays a role in this phenomenon. the same argument could be made for the fact that question marks were not interpreted as indicating a question. it is not possible at this stage to determine why participants did not interpret arrows and question marks conventionally, and more research is needed. however, this phenomenon should be kept in mind when a symbol set/system is introduced to this population. special training in the use of arrows and even conventional literacy symbols might prove beneficial (moolman .& alant, 1997). ' possible influences on results consistency between sessions in order to ensure that instructions for the test procedure were consistent across sessions, the instructions of 9 out of 13 sessions (70%) were played back to one of the translators following data collection. a checklist comprising all instructions from the test protocol was used to record which instructions were used and which were left out or modified for each session. consistency was calculated by dividing the number of instructions used correctly, by the total number of instructions required for each session. an average across sessions was then calculated. accordingly, consistency across sessions was 94% (range varied between 80% and 100%). total frequency of selection of symbols the methodology required only one choice per page, to ensure that all 36 symbols were available every time a participant had to make a choice. consequently the possibility existed for a single symbol to be chosen in; response to more than one label or to none. a frequencyi procedure showing how often each participant chose ι each symbol was performed on the data. theprocedure < revealed that participants commonly selected certain1 symbols two or three times, and that in one case a symbol was selected up to nine times. it was hypothesised that the more a symbol was selected, the higher the frequency of correct responses would be. to test this hypothesis, the frequency of correct responses per symbol and the total frequency of selection per symbol were plotted on the same chart and compared (figure i). • it is evident that there is no relationship between the two sets of data to support the hypothesis. it can be concluded that the frequency of correct response's was not a function of total frequency of selection of-symbols. position of symbols on communication overlay the possibility exists that participants were influenced in their choosing of-symbols by factors such as placement on the periphery or in the centre of the overlay. it was hypothesised that symbols on the periphery could draw more attention because of less the south african journal of communication disorders, vol. 49, .2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) rouviere de waal, rene hugo, maggi soer and johann j kruger 47 competing stimuli surrounding them. conversely it could be supposed that the four symbols in the centre of the overlay would draw more attention because viewers focus there first. a further possibility would be for participants to concentrate on the symbols in the top left quadrant of the overlay. fonseca and lassey (1964, in duncan et al., 1973) found that literate individuals preferred the top left quadrant of a page. a qualitative analysis was performed in order to reveal possible patterns visually. the analysis entailed shading the blocks of a matrix-36 with differing intensities to indicate higher and lower frequencies of selection as a function of position on the overlay. this was done once for the total frequency of selection and then again for frequency of correct responses. these results were then compared. the analysis revealed that symbols placed on the periphery, the centre and the top left quadrant of the overlay were not selected more often in total, nor more often-in response to the correct label. it seems that physical placement did not influence selection. another factor related to position could have influenced the choices of participants. to facilitate efficiency, the symbols on various communication overlays are consistently grouped according to grammatical categories namely social (pronouns, whwords, exclamation words and negative words), verbs, descriptors (adjectives and adverbs), prepositions and nouns (goossens', crain & elder, 1992). the key concept of each symbol's label serves as a basis for dividing the symbols intothese categories. symbols belonging to the same category are placed together so that they can be colour coded for easy access. each overlay is therefore roughly divided into five columns, with all social symbols placed to the very left of the overlay, followed by verbs, descriptors, prepositions, and nouns to the very right of the overlay. an informal quantitative analysis was performed in order to determine which of the categories was the most iconic. / although verbs were chosen most often on average, nouns were more often identified correctly, revealing that nouns were th'e most iconic symbols on the display. these results seem to confirm that of mizuko (1987) and bloomberg, karl|an and lloyd (1990). gender i . • · i a recent study in 'which the target population overlapped with that of the present study, revealed significant gender differences in thinking skills (solarsh, 2001). conversely, duncan et al. (1973) found that the rural zulu group they studied, performed': poorly on several measures of pictorial perception, regardless of gender, whereas results from rural tsonga, urban tsonga and urban zulu groups did reveal significant gender differences. they .hypothesised that in both tsonga groups and the urban zulu group, boys performed better than girls since it was more common for boys than for girls to attend school. however, very few children from the rural zulu group attended school leading to minimal exposure to western pictorial conventions for both genders, thus both genders performed poorly. the data of the present study was subjected to a chi square test in order to compare the number of correct responses given by boys and girls for every symbol. a significant difference was revealed for symbol 11 only, die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 49, χ2(1, ν = 94) = 9.7339, ρ = 0.0018. it seems that gender did not influence the accuracy of participants in identifying pcs symbols. these results agree with the findings of duncan et al. (1973), although a different explanation for the absence of gender differences may be offered. today it is equally likely for children from both genders to attend school. the fact that both genders generally have equal opportunities for exposure to pictures and symbols possibly explains the lack of difference in performance. conclusion the iconicity of the selected pcs symbols was generally low for the population studied. this finding serves as a reminder -that although pcs had been described as one of the most iconic symbol sets (mirenda & locke, 1989; mizuko, 1987), the meanings of these symbols are still not entirely guessable for the population studied. a factor that could have contributed to low iconicity in this population was the presence of arrows in many of the symbols. it might prove profitable to use a symbol set/system that employs more postural cues and fewer arrows. alternatively, clinicians must be aware that special training in the use of arrows might be needed. in future, investigation should be made into how rural zulu mother-tongue speakers interpret arrows and why. furthermore, the unmodified use of commercially available communication overlays containing pcs symbols clearly is not ideal in the south african context. many'of the themes of the overlays and the concepts depicted on them do not promote experiential equivalence with southern african cultures. it is suggested that clinicians choose themes that are relevant to their clients, and then compile communication overlays relating to those themes and the experiential background of the client. it has been mentioned that the presentation of an array of symbols all related to the same theme, might have had an influence on iconicity and distinctiveness values. yet symbols are most often used in such a context. it is therefore argued that whatever influence these factors had on the values obtained, the influence served to make the values more functional and socially valid. it is suggested, that this methodology be considered in future iconicity studies. the construct of "distinctiveness" could hold promise for the field of aac. it should be validated and its influence on the learnability of symbols investigated. furthermore, children's perceptions of indicators like arrows need to be explored in more depth. this study should be seen as a 'first step' towards understanding iconicity in the context of a specific culture, and it clearly shows the need for such research. it is hoped that it will be instrumental in motivating others to investigate the iconicity of graphic representational systems for south african cultures before headlong implementation. acknowledgements this article is the culmination of a thesis submitted by the first author, in partial fulfillment of the requirements of the masters degree in augmentative and alternative communication, under supervision of the r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) lize haupt and erna alant 48 second author. the financial assistance of the national research foundation (nrf) towards this research is hereby acknowledged. opinions expressed, and conclusions arrived at, are those of the author and are not necessarily to be attributed to the national research foundation. references blischak, d. m., lloyd, l. l., & fuller, d. r. (1997). terminology issues. in l. l. lloyd, d. r. fuller & η. h. arvidson (eds.), augmentative and alternative communication: a handbook of principles and practices (pp. 38-42). boston: allyn & bacon. bloomberg, k., karlan, g. r., & lloyd, l. l. (1990). the comparative translucency of initial lexical items represented in five graphic symbol systems and sets. journal of speech and hearing research, 33, 717-725. bracken, β. α., & barona, a. (1991). state of the art procedures, for translating, validating and using psycho-educational tests in cross-cultural assessments school psychology international, 72,119-132. brislin, r. w. (1980). translation and content analysis of oral and written materials. in h. c. triandis & j. w. berry (eds.), handbook. of crosscultural psychology: vol. 2. methodology (pp. 389-444). boston: allyn & bacon. burger, d. (ed.). (2000). south africa yearbook 2000/1. retrieved april 17, 2001, from http://www.gov.za/vearbook/rainbow.htm. deloache, j. (1991). symbolic functioning in very young children: understanding, of pictures and models. child development, 62, 736-752. deregowski, j. b. (1980a). illusions, patterns and pictures. london: academic press. deregowski, j. b. (1980b). perception. in h. c. triandes & w. lonner (eds.), handbook of cross-cultural psychology: vol. 3: basic processes (pp. 21-115). boston: allyn & bacon. doherty, j. e., daniloff, j. k., & lloyd, l. l. (1985). the effect of categorical presentation on amerind transparency. augmentative and alternative communication, 1, 10-16. duncan, h. f., gourlay, n., & hudson, w. (1973). a study of pictorial perception among bantu and white primary school children in south africa. (human sciences research council publication series no. 31). johannesburg, south africa: witwatersrand university press. fuller, d. r. (1987). effects of translucency and complexity on the associative learning of blissymbols by cognitively normal children and adults. 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(1999). the extent of moderate and severe reported disability and the nature of the disability experience in south africa. pretoria, south africa: community agency for social enquiry. solarsh, b. (2001). verbal solutions of rural zulu τ speaking children to problems encountered in everyday life. unpublished doctoral dissertation, university of pretoria, south africa. taylor, o. l., & clarke, m. g. (1994). culture and communication disorders: a theoretical framework. seminars in speech and language, 15, 103-114. witkin, h. a. (1967). a cognitive styles approach to cross cultural research. international journal of psychology, 2(4), 233-250. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 49, 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 information for contributors 1. nature of publication the south african journal of communication disorders publishes reports and papers concerned with research, and critically evaluative theoretical and philosophical conceptual issues dealing· with aspects of human communication and its disorders, service provision, training and policy. the south african journal of communication disorders will not accept material which has been published elsewhere or that is currently under review by other publications. 2. manuscript style and requirements • articles must he accompanied by a covering letter providing the author's address, telephone and fax numbers and email address. • articles must be on a4 pages in double spacing and in a font size of 12 • three print outs of the article must be submitted. • one exact copy of the article on disk must be submitted. filenames must include the first author's initials and a clearly identifiable key word and must he type-written on the last line of the last page of the reference list (for retrieval purposes only). • articles must not exceed 30 pages. • the title page of one must contain: • title of the article. • full names of the authors. • institutional affiliation. • abstract of the article in the language of the article. • the title page of the remaining two copies must not contain the authors names or institutional affiliations. • each article must contain an abstract of no more than 200 words. β all abstracts must be in english, irrespective of the language in which the article was written. • each article must provide 5-7 key words for indexing purposes. β all contributions are required to follow strictly, the style specified in the publication manual of the american psychological association (αρα pub. man., 2001). • headings are not numbered. the order of importance is indicated as follows: • main heading in capitals and bold print. • sub-headings in capitals, bold and italic print. • sub-subheadings in upper and lower case bold and italic print. • sub-sub-sub-heading in upper and lower case hold print. • major headings, where applicable, must be in the order of introduction, method, results, discussion, conclusion, acknowledgements, references. • all paragraphs should be indented. • all tables, figures and illustrations must he numbered . and provided with titles. • the title of tables, which appear above, and of figures, which appear below, must he concise but explanatory. • allow for 50-75% reduction in printing of tables, figures and illustrations. • each table, figure or illustration must appear on a separate page and be print ready. preferably not printed on colour printers. • do not include more than 10 tables, figures or illustrations. 3. references • references must be cited in the text by surname of the author and the date, e.g. van riper (1971). • where there are more than two authors, after the first occurrence, et al. may be used. • the names of all authors must appear in the reference list, which must he listed in strict alphabetical order in triple spacing at the end of the article. • all references must be included in the list, including secondary sources, (αρα pub. man. 2001). β only acceptable abbreviations of journals may be used, (see dsi-1 abstracts, october; or the world list of scientific periodicals). β the number of references should not exceed 30, unless specifically warranted. examples locke, j.l. (1983). clinical psychology: the explanation and treatment of speech sound disorders. j. speech hear disord., 48 339-341. penrod, j.p. (1985). speech discrimination testing. in j. katz (ed.), handbook of clinical audiology (3rd ed.). baltimore: williams & wilkins. davis, g. & & wilcox, m.j. (1985). adult aphasia rehabilitation: applied pragmatics. san diego, ca: collegehill. editing • articles must be corrected for grammar and style prior to submission. • the manuscript style of the article must be strictly according to the guidelines provided. • only articles complying with the above requirements will be accepted for review. reviewing system • the peer review of refereeing system is employed as a method of quality control of this publication. • peer reviewers are selected by the editor based on their, expertise in the field and each article is sent to two independent reviewers to assess the quality of the manuscript's scientific and technical content. • the blind peer review system is employed during which the names of the author/authors are not disclosed to the reviewers. • the editor retains the final responsibility for decisions regarding revision, acceptance or rejection of the manuscript. deadline for contributions. 30lh january each year queries, correspondence & manuscripts: should he addressed to the editor, south african journal of communication disorders , south african speechlanguage-hearing association, po box 5710, the-reeds, 0158, south africa copyright the copyright of all articles printed in the south african journal of communication disorders is reserved by the south african speech-language-hearing association (saslha) the south african journal of communication disorders, vol. 49 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) cybernetic functioning in stuttering ursula zsilavecz μ ( l o g ) pretoria department of speech science, speech pathology and audiology, university of pretoria summary the aim of this study was to evaluate different kinds of masking noise and daf, in order to identify the condition which would elicit the highest incidence of fluency in a group of stutterers. the study demonstrates that masking noise and daf can be effectively applied as an aid in a therapy programme, viz. noise can effectively be put to use so as to encourage and reinforce somesthesia. stuttering is viewed as defective functioning in the cybernetic system. opsomming hierdie studie evalueer verskeie tipes maskering sowel as vertraagde ouditiewe terugvoering om sodoende die tipe lawaai wat die hoogste persentasie vlotheid in 'n groep hakkelaars teweegbring, te identiflseer. hierdie studie poog ook om te bewys dat maskering en vertraagde ouditiewe terugvoering effektiewelik in terapieprogramme toegepas kan word, nl. om somestetiese terugvoering te versterk. hakkel word beskou as afwykende funksionering in die kubernetiese sisteem. in an attempt to obtain a better understanding of stuttering, a number of investigators have attempted to find the cause of the problem and an appropriate "cure". many of the theories offer reasonably adequate explanations for stuttering but cures posited only provide temporary relief from stuttering. the view that the stutterer may have a malfunctioning, or a defect in the auditory feedback system and the fact that noise had an ameliorative effect on the stuttering, resulted in the development of portable devices emitting masking noise or delayed auditory feedback (daf) in an attempt to eliminate stuttering. some researchers in the field of stuttering have cautioned that it is a much more complex matter than just investigating the auditory feedback system and applying masking noise or d a f to elicit a higher percentage of fluency. this view of stuttering is limited as it does not adequately account for the disruption of the motor sequences of stuttered words. yet researchers often advise the incorporation of masking noise and d a f as a part of the therapeutic programme. van r i p e r 1 4 sums up the situation in which attempts have been made to simply alter the auditory signals by using masking noise and d a f as a clinical procedure as follows: exchanging stuttering for deafness is no great bargain and we have found little permanent improvement as a result of masking itself. van r i p e r 1 3 emphasizes therapeutic procedures involving the retraining of speech monitoring by means 'of employing auditory signals which exclude the perception of the stutterer's own speech. by means of the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) c y b e r n e t i c functioning in stuttering 61 masking noise and d a f fluency can be manipulated and then reinforced. in view of previous research studies, the writer attempted to evaluate the influence of different types of masking noise and delayed auditory feedback on the speech of stutterers. the main aim was to identify the type of masking noise and/or delayed auditory feedback which would elicit the highest incidence of fluency in view of reinforcing normal motor patterns and enhancing somesthetic feedback. experimental design many different fragments and facets of information have to be brought together comprehensively to identify conclusively the most appropriate and successful type of masking device to be used in therapy as an aid so as to reinforce somesthesia. certain hypotheses can be postulated stemming from the results of previous research in this field. hypotheses the degree of fluency in stutterers can be increased by application of masking noise and daf. previous studies described devices which were developed in an attempt to ameliorate stuttering. devices were developed by trotter and l e s c h 1 2 , curlee and perkins4, dewar et al5 and van r i p e r . 1 4 . continuous masking noise and d a f elicits a higher degree of fluency than intermittent masking noise. van r i p e r 1 4 has determined that when stutterers are exposed to intermittent noise, they still tend to anticipate and expect to stutter; as a result, stuttering does in fact ensue and thus the frequency of stuttering is not diminished dramatically. these findings are in agreement with those of altrows and bryden.1 continuous masking noise obtained by using the bench model type edinburgh masker is more successful than continuous white noise as research has indicated that low frequency noise is more successful in masking the speaker's own voice (cherry and sayers3). white noise contains a wider spectrum of frequencies. persons with a severe stuttering problem will not necessarily have poorer oral perceptual abilities (jensen et al7). to a large extent previous research has been conducted in cases of severe neurological deprivation such as dysarthria or cleft palate. limited research has indicated that stutterers need not necessarily function poorly on oral perceptual tasks. subjects in view of evaluating various devices and techniques which can alter the auditory feedback signals it was necessary to select a group of subjects, representative of the population of stutterers. for the purposes of this study 14 subjects were chosen at random, all fulfilling certain criteria, thus forming a homogenous group, (see table i) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 ursula zsilavecz t a b l e i: the criteria set for the fourteen subjects d e g r e e of status subject a g e speech h o m e sex of oral defect language hearing status yrs mnths 1 21 4 v. severe afr. male normal normal 2 19 9 severe afr. male normal normal 3 37 6 severe eng. male normal normal 4 23 11 v. severe afr. male normal normal 5 20 10 severe afr. male normal normal 6 34 5 severe afr. male normal normal 7 23 2 v. severe afr. male normal normal 8 28 6 v. severe afr. female normal normal 9 30 1 v. severe afr. male normal normal 10 16 0 v. severe afr. male •normal normal 11 36 0 v. severe afr. male normal normal 12 24 6 v. severe afr. male normal normal 13 19 6 severe eng. male normal normal 14 27 9 severe afr. male normal normal e q u i p m e n t a n d a p p a r a t u s in order to compare and evaluate equipment and devices which could alter the auditory feedback signals, devices offering different kinds of auditory feedback were included in the study. equipment offering continuous masking noise including the edinburgh master (bench model — type cm3) and white noise, achieved by employing the maico, model ma.24 audiometer automatic intermittent noise was obtained by the edinburgh masker (portable model — type af1). d a f was achieved employing the 'artik,' device, similarly used in a study by martin and haroldson.8 the minimum intensity output used in the experiment was 100 db spl, for all the masking noise devices. the intensity required for d a f is the most comfortable loudness level. in the case of the study the intensity output, however, was also 100 db spl. both types of the edinburgh masker models produced a masking noise comprising a frequency of 150 hz. this meets with the requirements, discussed by cherry and sayers3, that effective masking noise comprises a low frequency — i.e. below 500 hz and that the intensity must be a minimum of 40 db above normal voice production level. the delay time of the 'artik' device was 0,13 seconds. the two tests included for oral-perceptual a b i l i t y a s similarly described by jensen et al 7 in their study were oral stereognosis and two-point discrimination. ten of the forms of the set of 25 developed by the national institute of dental· research (grossman6) were used for testing oral stereognosis. a vernier caliper, which was similarly adapted in the experiments by rutherford and mccall1 0 was used for the test of two-point discrimination.' in order to determine that all the equipment meets with the minimum the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) c y b e r n e t i c functioning in stuttering intensity required for effective noise the devices were calibrated with the briiel-kjaer sound pressure level meter. experimental design and procedure the investigator drew up a comprehensive and strict plan so as to ensure that all behaviour could accurately be accounted for. the investigator saw the subjects over a period of 5 weeks. a minimum time lapse of 4i hours has to be permitted before the next experimental situation so as to avoid carry over fluency. it also suited the patients better to come to the clinic once a week. initially a videotaped recording was made of each subject's spontaneous speech under normal feedback conditions. hereafter, each subject was exposed to one of the four different experimental conditions, which were also videotaped in a soundproof room. in order to elicit an adequate sample of spontaneous speech the investigator used the "job task" as described by johnson et al and van r i p e r 1 3 the subjects were required to discuss controversial subjects so as to elicit a minimum of 400 utterances or ± 10 stuttering moments (van r i p e r 1 3 ) . after each videotaped recording was analysed and evaluated according to the "profile of stuttering severity" (van r i p e r 1 3 ) . lastly, oral stereognostic ability and twopoint discrimination was evaluated on the 14 stuttering subjects. statistical analysis the methods employed to evaluate the results were the "wilcoxon signed-rank test", also known as the "one sample wilcoxon s test . the "sign test" was employed in evaluating the results obtained on test for oral stereognosis (siegel1 1). the information for statistical analysis was obtained from each profile for each experimental condition of the subjects. the investigator had to determine the category improvement of each characteristic on the "profile of stuttering severity" (frequency, tension, duration and avoidance-postponement behaviour) when compared to the same characteristic on the profile for the control situation. results a n d conclusions it was ascertained and proved that continuous masking noise and d a f elicited the highest incidence of fluency, in comparison to automatic intermittent masking noise. with regard to the evaluation of continuous masking noise and d a f , white noise and d a f elicited more fluency, than continuous masking noise emitted by the edinburgh masker — bench model. stuttering behaviour which was effected by masking noise and dal· was fequency of stuttering, duration of the stuttering moment and tension. postponement-avoidance behaviour was hardly effected in most cases of masking noise and daf. subjective observation confirms that masking noise and dah dedie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 ursula zsilavecz creases the incidence of stuttering but does not totally ameliorate stuttering behaviour, (see table ii) t a b l e ii: a summary of the effects of the four experimental conditions on the speech of the 14 subjects characteristics of stuttering continuous noise edinburgh masker (bench model) white noise d a f automatic intermittent noise frequency slight significant dramatic slight tension slight moderate significant slight duration slight moderate dramatic slight avoidancepostponement significant moderate dramatic no the investigator observed change in vocal intensity, vocal pitch and rate of speech when the subjects were exposed to the experimental conditions. drawling of speech also occurred. it is important to note that each subject exhibited a different and personal profile under each experimental condition, thus emphasizing that therapy programmes must cater for the individual's needs. from the results in this experiment it appears that persons with a severe stuttering problem tend to. make more errors in oral stereognostic testing, than normal fluent speakers. (for this experimental condition a group of normal fluent speakers was selected to match the stutterers, as no norms are available.) persons with a severe stuttering problem have good two-point discrimination ability, they fall within the norm determined by ringel and ewanowski9 for normal fluent speakers, i.e. 1,0 mm 2 , 0 mm. it appears that subjects who achieve a greater increase of fluency with masking noise and d a f do not necessarily have good oral perceptual ability. some subjects who did not show dramatic increase of fluency when using masking noise and d a f on the contrary had good oral perceptual ability. / it has become increasingly clear that a solution for stuttering does not merely lie in altering the auditory feedback of stutterers or is developing more level and sophisticated devices. on the contrary older methods of masking auditory feedback (such as white noise) have been proved more effective.: the findings in this study also support the view that somesthetic; feedback requires attention in therapy, as well as in future research!. supplying the person who stutters with a device which produces the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) c y b e r n e t i c functioning in stuttering s u f f i c i e n t high intensity noise to alter the perception of his own s d e e c h and elicit a higher incidence of fluency seems a very simple and easy way to solve the problem. unfortunately as soon as the stutterer switches off the masking device, stuttering once again increases. another disadvantage of these devices is that they do not elicit total fluency, nor are they comfortable to wear and they often elicit a negative reaction from listeners who treat a stutterer wearing a device as though he were hard of hearing. unfortunately only a limited amount of work has been done in this field and not much information is available. it is possible that stutterers tend to achieve poorer results on oral stereognosis because they are not used to employing this feedback system in speech production. from the results in this study and previous research it can be argued that a normal "fluent" speaker may also exhibit errors on this type of oral perceptual testing; the stutterer in turn may exhibit good results on oral perceptual testing. these types of tests may not truly be testing oral perceptual ability but merely tactile sensations. in other words, oral perceptual ability is not directly related to somesthesia but a separate feedback ability therefore stutterers as a group should generally compare well with "normal" fluent speakers. furthermore, this accounts„ for the phenomenon that stutterers can achieve a higher degree of fluency u n d e r specific circumstances — when given the opportunity, e.g. to use masking noise. the motor patterns required for fluent speech are available, but the stutterer has not learned to apply these in his normal speech production, as the change-over from auditory feedback to somesthetic feedback, which generally occurs during normal development has not taken place. once a higher degree of fluency has been elicited these normal motor patterns must be reinforced so that they can gradually become habitual. many "solutions" and therapy programmes fail, because these do not emphasize or reinforce awareness of normal use of fluent speech patterns. stuttering may well result from failure to learn the essential skills at the beginning of speech development. bluemel's2 comment aptly sums this up: speech which is poorly made is readily unmade. acknowledgements dr i c. uys and prof. i. s. hay, dept. of speech pathology and audiology, university of pretoria, for their invaluable guidance in preparing this study. prof. d. j. stoker, human sciences research council, pretoria, for helping with the statistical planning and analysis of the research. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 66 ursula zsilavecz references 1. altrows, i. and bryden, m. p. (1977): temporal factors in the effects of masking noise on the fluency of stutterers. journal of communication disorders, vol. 10, pp. 315-329. 2. bluemel, c. s. (1957): the riddle of stuttering, danville — illinois, the interstate publishing co. 3. cherry, e. c. and sayers, β. m. (1956): experiments on the total inhibition of stammering by external control and some clinical results. journal of psychosomatic research. vol. 1, pp. 223-246. 4. cur lee, r. f. and perkins, w. h. (1973): effectiveness of daf conditioning programme for adolescent and adult stutterers, beh. res. therapy. vol. 11, pp. 395-401. 5. bewar, a. et al (1976): automatic triggering of auditory feedback masking in stammering and cluttering, british journal of disorders of communication. vol. 11, 1, pp. 19-26. 6. grossman, r. c. (1967): methods of determining oral tactile experience. chap. 8. in symposium. bosma, j. f. (ed.), springfield, charles c. thomas publishers. 7. jensen, p. j. et al (1975): oral sensory-perceptual integrity of stutterers. folia phoniatrica. vol. 27, pp. 38-45. 8. martin, r. and haroldson, s. (1969): the effects of two treatment procedures on stuttering. journal of communication disorders. vol 2, pp. 115-125. 9. ringel, r. l. and ewanowski, s. j. (1963): oral perception, two-point discrimination. jshr. vol. 8, pp. 389-398. 10. rutherford, d. and mccall, g. (1967): testing oral sensation and perception in persons with dysarthria. in symposium. bosma, j. f. pp. 188-200. 11. siegel, s. (1956): nonpar'ametric statistics for the behavioural sciences. new york, mcgraw-hill. 12. trotter, w. d. and lesch, μ. m. (1967): personal experiences with a stutter aid. jshd. vol. 32, 3, pp. 271-272. 13. van riper, c. (1971): the nature of stuttering. englewood cliffs, n. j., prentice hall. 14. van riper, c. (1973): the treatment of stuttering. englewood cliffs, n. j., prentice-hall. the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a u d i o m e t e r s i m p e d a n c e m e t e r s light, portable, screening and clinical, manual and automatic phonic ear f.m. t e a c h i n g s y s t e m s w i t h phonak audio-input h e a r i n g a i d s needler westdene organisation (pty) ltd. p . o . b o x 2 8 9 7 5 s a n d r i n g h a m 2 1 3 1 j o h a n n e s b u r g t e l e p h o n e ( 0 1 1 ) 6 4 0 5 0 1 7 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28,1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 35 antisiperende labiale koartikulasie: 'n elektromiografiese studie by afrikaanssprekendes karin theron en anita van der merwe departement kommunikasiepatologie universiteit van pretoria malcolm baker departement neurologie 1 militire hospitaal pretoria opsomming die verskynsel van antisiperende labiale koartikulasie word bestudeer om inligting te bekom aangaande die motoriese beplanning van spraak deur die brein. die doel van die studie is om inligting te bekom in verband met die temporale omvang van antisiperende labiale koartikulasie, die verloop van koartikulasie vir uitinge wat bestaan mt twee geronde vokale geskei deur 'n nie-labiale konsonant en laastens die effek van 'n woordgrens op die aanvang van koartikulasie by normale afrikaanssprekende volwassenes. die metode het bestaan uit die opname van elektromiografiese aktiwiteit vanaf musculus orbicularis oris met 'n bipolere konsentriese naaldelektrode. die resultate dui daarop dat antisiperende labiale koartikulasie wel voorkom en dat die aanvang van lipronding toenemend vroeer intree namate die duur van die konsonantstring wat die geronde vokaal voorafgaan toeneem. by die ondersoek van antisiperende labiale koartikulasie m uitings wat bestaan uit twee geronde vokale wat deur 'n nie-labiale konsonant geskei word, is gevmd dat twee pieke van elektromiografiese aktiwiteit met 'n duidelike afname in aktiwiteit tussen die pieke voorkom. laastens is gevmd dat antisiperende labiale koartikulasie oor woordgrense kan voorkom. die resultate word bespreek aan die hand van verskiuende teoretiese modelle van spraakproduksie wat poog om die verskynsel van antisiperende labiale koartikulasie te verklaar. abstract anticipatory coarticulation sheds light on the planning of speech by the brain. the aim of this study is to gain information on the temporal extent of anticipatory labial coarticulation, the course of coarticulation for utterances consisting of two rounded vowels separated by ah intervening consonant without rounding specification and lastly the effect of word boundaries on the onset of coarticulation iri normal afrikaans speaking adults. the method consisted of the recording of electromwgraphic (emg) activity from musculus orbicularis oris using a bipolar concentric needle electrode. the results suggested that anticipatory coarticulation is* demonstrated by afrikaans speaking individuals and that the onset of liproundmg for a rounded vowel commenced earlier when the duration of the nonldbial consonantal string preceding the rounded vowel increased during the investigation of anticipatory labial coarticulation in utterances consisting of two rounded vowels separated by a nonlabial consonant, it was found that two peaks in emg activity with a pronounced decrease m activity between the peaks occurred. lastly it was found that anticipatory coarticulation can occur across word boundaries. the results are discussed in relation to different theoretical models of speech production which have been proposed to account for the phenomenon of anticipatory labial coarticulation. sleutelwoorde: antisiperende koartikulasie, elektromiografiese aktiwiteit, motoriese beplanning, teoretiese modelle van spraakproduksie beplanning van spraak word nog dikwels as 'n erisms", dat 'n spreker 'n volledige frase in gereedheid het hipotetiese en kontroversiele konsep beskou, omdat daar voordat dit geuiter word (hams 1984; borden & hams, nie 'n objektiewe meetinstrument bestaan wat beplanning 1984). antisiperende koartikulasie reflekteer die omvang kan meet nie. baie bewyse word egter aangevoer vir die van vooruitbeplanning van komende segmente (katz, voorafbeplanning van spraak. by normale sprekers 1988a; 1988b) en aangesien koartikulasie ekstern suggereer onbewuste woorden foneemomruilings, "spoongemanifesteer word, is dit meetbaar en word dit bestudeer die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 karin theron, anita van der merwe en malcolm baker om inligting te verskaf aangaande die grootte en aard van die eenhede wat as invoer vir die motoriese beplanning van spraak gebruik word (kent & minifie, 1977; lubker, 1981; lubker & gay, 1982; katz, machetanz, schonle & orth, 1990). studies aangaande antisiperende labiale koartikulasie is tot op datum in tale soos sweeds, russies, frans en engels uitgevoer, maar daar bestaan nog 'n leemte t.o.v. die bestudering van hierdie verskynsel in afrikaans. aangesien daar nog baie kontroversie in die literatuur bestaan omtrent sekere kernaspekte van antisiperende labiale koartikulasie is verdere studies nodig om hierdie aspekte te ondersoek en om die universaliteit daarvan te bepaal. verder is dit noodsaaklik om antisiperende koartikulasie by normaalsprekende persone te bestudeer, want eers wanneer 'n verwysingsraamwerk van normale koartikulasie daargestel is kan neuromotoriese afwykings, veral in die beplanning van spraak, binne hierdie raamwerk bestudeer word. antisiperende koartikulasie word as 'n inherente deel van die neuromotoriese beplanning van spraak beskou. die beplanning veroorsaak dat die artikulators geaktiveer word en sodoende kan 'n artikulatoriese doelwit van 'n komende segment bereik word voordat dit akoesties gerealiseer word (sussmann, marquardt, macneilage & hutchinson, 1988). borden en harris (1984) definieer koartikulasie as die temporale oorvleueling van artikulatoriese bewegings vir verskillende foneme. antisiperende labiale koartikulasie verwys spesifiek na die vroee aanset van kenmerke wat verband hou met labialiteit, bv. die aanset van ronding vir geronde vokale (lubker & gay, 1982). die temporale en ruimtelike aspekte van linguale, labiale, velere en mandibulere koartikulasie is al vanaf die 1960's bestudeer. die eksperimentele metode behels gewoonlik die kontrolering van een of twee iisiologiese aanduiders van neuromuskulere aktiwiteit, tesame met die ouditief waarneembare spraaksein. die iisiologiese metings word verkry deur bv. kineradiografiese ontleding (bv. verplasing van die tong of velum) of elektromiografiese (emg) metings vanaf die toepaslike agonisspier(e) verantwoordelik vir die artikulatoriese beweging (bv. die orbicularis oris vir lipronding) (sussmann et al., 1988; blair & smith, 1986). een van die aspekte van antisiperende labiale koartikulasie wat al dikwels bestudeer is, is die temporale omvang van die antisipering. deur die aspek te bestudeer word inligting ingewin aangaande die grootte en aard van die eenhede wat die brein gebruik in die motoriese beplanning van spraak, asook inligting aangaande die kontrole en ordening van die eenhede (lubker, 1981; lubker & gay, 1982; katz, 1988a; 1988b; katz et al., 1990). daar is tans twee opponerende sienings aangaande die temporale omvang van antisiperende labiale koartikulasie. die een groep navorsers meen dat 'n persoon labiale beweging vir 'n geronde vokaal beplan in verhouding tot die duur van die foneme wat dit voorafgaan (daniloff & moll, 1968; benguerel & cowan, 1974; lubker, 1981; sussmann & westbury, 1981). volgens hierdie navorsers kan antisiperende labiale koartikulasie 'n redelik wye omvang he. benguerel en cowan (1974) het gevind dat lipprotrusie vir franse geronde vokale soveel as ses konsonante voor die akoestiese aanset van die geronde vokaal voorkom. daniloff en moll (1968) het weer gevind dat lipronding in engels tot vier konsonante voor die akoestiese aanset van die geronde vokaal 'n aanvang neem. waar die bogenoemde navorsers die hoeveelheid konsonante bepaal het waaroor antisiperende labiale koartikulasie kan strek, het lubker (1981) die tydsverloop in millisekondes bepaal vanaf die aanset van emg aktiwiteit geassosieer met lipronding tot by die akoestiese aanset van die geronde vokaal. hy het gevind dat labiale emg aktiwiteit vir sweedse geronde vokale tot 600ms voor die akoestiese aanvang van die geronde vokaal kan begin (mcallister, lubker & carlson, 1974; lubker, 1981). die wye omvang van antisiperende labiale koartikulasie impliseer dat die brein 'n bespiedingsproses uitvoer op die uiting wat geproduseer gaan word. hierdie vermoe van die brein om so 'n bespiedingsmeganisme te implementeer tydens die motoriese beplanning van spraak is deur henke (in kent & minifie, 1977) gepostuleer in 'n spraakproduksiemodel wat as henke se bespiedingsmodel bekend staan. henke spesifiseer egter nie die temporale omvang van die bespiedingsgebeure nie en meen dat 'n komende kenmerk soos ronding deur εύ die foneme wat die geronde klank voorafgaan, geantisipeer sal word, solank die voorafgaande kenmerke nie antagonisties is t.o.v. die bepaalde kenmerk nie. die ander groep navorsers postuleer dat antisiperende koartikulasie nie so 'n wye omvang kan he nie en dat die aanset van die rondingsbeweging geassosieer met die geronde vokaal beperk is tot 'n relatief klein temporale venster van ongeveer 250ms (bell-berti & harris, 1979; 1981; 1982). hierdie aanname impliseer dat lipronding op 'n vasgestelde tyd voor die aanvang van 'n geronde vokaal 'n aanvang sal neem. die aanvang van die lipronding sal dus nie wissel na gelang van die lengte van die konsonantstring wat die geronde vokaal voorafgaan nie (gay 1979; bell-berti & harris, 1979; 1981; 1982). die kontroversie wat gegenereer word deur die opponerende sienings is van besondere belang in spraaknavorsing, aangesien dit verskillende verduidelikings van die motoriese organisasie van antisiperende koartikulasie gee (lubker & gay, 1982). die eerste siening impliseer dat die brein die motoriese kontroleprogram vir die aanset van labiale aktiwiteit versigtig beplan en aanpas by die duur van die konsonantstring wat die geronde vokaal voorafgaan. laasgenoemde siening onderskryf dus die werking van 'n bespiedingsmeganisme tydens die motoriese beplanning van spraak. die tweede siening postuleer die bestaan van 'n vaste en relatief konstante (dalk 250 ms) "tydsvenster" waar die brein nie genoodsaak word om enige fyn aanpassings t.o.v. temporale aanset te maak nie. wanneer 'n labiale rondingsbeweging benodig word, word dit op 'n vasgestelde tyd voor die geronde vokaal gei'nisieer en die duur van die voorafgaande konsonantstring is dus irrelevant (lubker & gay, 1982). nog 'n aspek van antisiperende koartikulasie wat dikwels bestudeer word, is die voorkoms van koartikulasie vanaf een geronde vokaal na 'n ander waar die twee vokale geskei word deur tussenkomende nie-labiale konsonante wat nie met ronding geproduseer word nie (v k n l v konteks). in sulke gevalle het albei bogenoemde, opponerende groepe navorsers gevind dat 'n keep in die elektromiografiese aktiwiteit voorkom. twee duidelike pieke in emg aktiwiteit met 'n totale staking of noemenswaardige vermindering in emg-aktiwiteit tussen die pieke word in die foneemkonteks onderskei. die keepverskynsel impliseer dat antisiperende labiale koartikulasie afwesig is in die vgkn]vg-konteks. indien antisiperende labiale koartikulasie kan voorkom oor the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) labiale koartikulasie: ' elektromiografiese studie by afrikaanssprekendes 37 f o n e e m s t r i n g e van t o t v y f o f s e s konsonante (benguerel & cowan, 1974) ontstaan die vraag hoekom dit nie volgehou kan w o r d in /vkv/-uitinge nie, waar v=/u/ en die vokale deur slegs een konsonant geskei word. navorsers wat meen dat antisiperende labiale koartikulasie beperk is tot 'n relatief klein temporale venster en dat die labiale rondingsbeweging dus op 'n vasgestelde tyd voor die aanvang van die geronde vokaal 'n aanvang neem, meen dat die keepof dubbele piekverskynsel (lubker & gay, 1982) bewys lewer vir hulle aanname. navorsers wat egter die werking van 'n bespreidingsmeganisme ondersteun, p o s t u l e e r dat die keepverskynsel slegs daarop dui dat idiosinkratiese aanpassings in beplanning nodig is, afhangende van die eerste vokaal in die segmentreeks (m.a.w. die vokaal wat die geronde vokaal voorafgaan) (sussmann & westbury, 1981). die afname in lipronding tydens die produksie van die konsonant voor die tweede geronde vokaal staan dus teenoor die werking van die bespiedingsmodel vir s p r a a k p r o d u k s i e soos voorgestel deur henke (in k e n t & minifie, 1977; bell-berti & harris, 1974; gay, 1979). 'n ander aspek van antisiperende koartikulasie wat al dikwels bestudeer is, is die invloed van 'n woordgrens op die aanvang van koartikulasie. sommige navorsers het gevind dat die woordgrens nie die aanvang van die rondingsbeweging bei'nvloed nie (daniloff & moll, 1968; benguerel & cowan, 1974; bell-berti & harris, 1982). ander het weer gevind dat sekere linguistiese grense wel 'n effek het (mclean, 1973). 'n spraakproduksiemodel, wat o.a. poog om die verskynsel van antisiperende koartikulasie te verklaar, is deur kozhevnikov en chistovich (in kent & minifie, 1977) voorgestel. die navorsers voer aan dat die invoereenheid vir die motoriese beplanning van spraak 'n artikulatoriese lettergreep is, wat bestaan uit enige hoeveelheid konsonante gevolg deur 'n vokaal, en dat die lettergreepgrens 'n beperking plaas op antisiperende koartikulasie. indien koartikulasie egter nie deur die woordof lettergreepgrens bei'nvloed word nie, kan die artikulatoriese lettergreepmodel van kozhevnikov en chistovich (in kent & minifie, 1977) nie sonder meer aanvaar word nie. 'n verdere afleiding wat gemaak kan word indien die woordgrens nie die aanvang van antisiperende koartikulasie bei'nvloed nie, is dat die brein se linguisties-simboliese beplanning van spraak afsonderlik van die motoriese beplanning van 'n uiting plaasvind (van der merwe, 1986). dit is dus duidelik dat daar 'n behoefte bestaan aan verdere ondersoek van sekerej aspekte van antisiperende labiale koartikulasie, aangesien daar steeds kontroversie in die literatuur heers oor die voorkoms en aard daarvan. verder is geen studies m.b.t. antisiperende labiale koartikulasie al met afrikaanssprekende persone uitgevoer nie en is dit dus nodig om hierdie verskynsel te ondersoek ten einde te bepaal of die voorkoms en aard daarvan universeel is. metode doelstellings die doel van die studie is om inligting te bekom aangaande spesifieke aspekte van antisiperende labiale koartikulasie by afrikaanssprekende normale sprekers, ten einde afleidings te maak aangaande die motoriese beplanning van spraak deur die brein. die volgende aspekte word ondersoek: ' die temporale omvang van antisiperende labiale koartikulasie. die doel is dus om te bepaal of die aanvang van labiale beweging, geassosieer met ronding, beplan word in verhouding tot die duur van die nie-labiale konsonantstring wat die geronde vokaal voorafgaan (wye omvang) en of die labiale rondingsbeweging telkens 'n vasgestelde tyd voor die aanvang van die geronde vokaal gemisieer word (beperkte omvang). hierdie aspek sal dus inligting verskaf aangaande die grootte en aard van die invoereenheid wat die brein gebruik in die motoriese beplanning van spraak. die verloop van elektromiografiese (emg) aktiwiteit vir uitinge wat bestaan uit twee geronde vokale wat deur 'n nie-labiale . konsonant geskei word (vgkn,v konteks). verskeie navorsers (gay, 1979; bell-berti & harris, 1982) het gevind dat antisiperende labiale koartikulasie in hierdie foneemkonteks afwesig is. laasgenoemde bevinding sal dus die werking van 'n bespiedingsmeganisme tydens die motoriese beplanning van spraak teenstaan. die effek van woordgrense op die aanvang van die labiale rondingsbeweging. daar word eerstens bepaal of antisiperende labiale koartikulasie oor woordgrense sal voorkom en of 'n woordgrens die voorkoms van antisiperende labiale koartikulasie gedurende die eerste woord van 'n tweewoorduiting inhibeer soos gepostuleer deur kozhevnikov en chistovich (in kent & minifie, 1977). vervolgens word bepaal of die aanvangsmoment van ronding bei'nvloed word deur die woordgrense vir uitinge waar 'n sekere konsonantkombinasie binne 'n woord en oor 'n woordgrens voorkom. navorsingsontwerp die onderskeie doelstellings het telkens dieselfde eksperimentele ontwerp. dieselfde respondente is vir al drie die ondersoeke gebruik. die ontwerp bestaan telkens uit een of twee eksperimentele materiaalgroepe met 'n kontrole materiaalgroep (guy, edgley, arafat & allen, 1987). die eksperimentele materiaalgroep verwys na uitings waarin 'n geronde vokaal voorkom. sekere handelings is met die eksperimentele, sowel as die kontrole materiaalgroep uitgevoer, waar die handeling telkens bestaan het uit die lees van 'n spesifieke uiting vanaf 'n kaartjie. die kontrole materiaalgroep verwys na uitings waarin daar nie 'n geronde vokaal voorgekom het nie. die1 kontrolie materiaalgroep was telkens soortgelyk aan die eksperimentele materiaalgroep, maar in die plek van die geronde vokaal het die kontrole materiaalgroep die hoe voorvokaal /i/, wat met lipstrekking geproduseer word, bevat. die kontrole materiaalgroep is ingesluit om te kontroleer dat labiale emg-aktiwiteit wat tydens die produksie van die eksperimentele materiaalgroep opgeteken word, wel voorkom a.g.v. die teenwoordigheid van die geronde vokaal. die onderskeie doelstellings en handelings toegepas binne die eksperimentele en kontrole materiaalgroepe verskyn in tabel 1. proefpersone die proefpersone het 5 normaalsprekende persone sonder enige geskiedenis van spraakof neurologiese afwykings ingesluit. die proefpersone moes oor normale gehoor en intelligensie beskik en tussen die ouderdomme 19 en 25 jaar wees. almal was sprekers van standaard afrikaans. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 karin theron, anita van der merwe en malcolm baker tabel 2 verskaf 'n opsommende weergawe van die kenmerke van die proefpersone. apparaat vir die opname van die elektromiografiese (emg) potensiale vanaf musculus orbicularis oris is gebruik gemaak van 'n bipolere konsentriese naaldelektrode wat gekoppel is aan kanaal 1 van 'n multikanaal elektromiograaf, medelec mystro ms25. daar is gebruik gemaak van 'n bipolere naaldelektrode, aangesien die tipe elektrode emg-aktiwiteit binne 'n baie klein gebied kan bepaal. die spraaksein is opgeneem deur 'n mikrofoon, pro 2 dynamic microphone met 'n impedans van 300u wat aan kanaal 2 van die elektromiograaf gekoppel is en 'n visuele voorstelling van die spraaksein tot gevolg gehad het. daar is spesiaal deur 'n tegnikus 'n spraakprogram vir opname van die akoestiese sein, gei'nstalleer. die medelec mystro ms25 besit 'n funksie vir die direkte stoor van resultate. die elektromiografiese aktiwiteit, op kanaal 1, en die visuele voorstelling van die spraaksein, op kanaal 2, is onder mekaar op die rekenaarskerm van die elektromiograaf vertoon (figuur 1). eksperimentele en kontrole materiaal motivering vir die keuae van apraakmateriaal eksperimentele materiaal die eksperimentele materiaal wat geselekteer is vir die uitvoering van die studie het bestaan uit onsinreekse wat opgestel is om aan die doel van die studie te voldoen. die reekse is elkeen vyf keer agtereenvolgend gese en die elektromiograaf is geprogrammeer om telkens die gemiddeld van elke uiting voor te stel vir beide die spraaksein en die emg-aktiwiteit. die gemiddeld van vyf herhalings verhoog die betroubaarheid van die resultate. al die materiaal is so opgestel dat die uiting met 'n stemhebbende klank begin en dat die konsonante wat die stemhebbende geronde vokaal voorafgaan, stemloos is. sodoende kon daar tydens data analise maklik op die visuele voorstelling van die spraaksein onderskei word tussen die konsonantstring en die aanvang van die geronde vokaal (figuur 1). kontrole materiaal die kontrole materiaal is opgestel om te bepaal of labiale emg-aktiwiteit, voorkom in segmentreekse wat nie 'n tabel 1: doelstellings en handelings toegepas binne die kontrole en eksperimentele materiaalgroepe. doelstellings eksperimentele kontrole materiaalgroep materiaal groep groep 1 groep 2 bepaling van die temporale omvang van /isu/ /is=>/ /isi/ antisiperende labiale koartikulasie in uitinge met /istu/ /isto/ /isti/ verskillende konsonantstringduur /istsu/ /istso/ /istsi/ /iststu/ /iststz)/ /iststi/ /ikststu/ /ikststo/ /ikststi/ bepaling van die verloop van elektromiografiese /usu/ /isi/ aktiwiteit in die v k . v -konteks g nl g /uku/ /iki/ bepaling van die effek van woordgrense op die /gistul/ /dis//tul9/ /gisti/ aanvang van die labiale rondingsbeweging /gistut/ /disti/ ! /gistup/ /dis/ /tutors/ ! /gistof/ /dis/ /tupa/ 1 /gistol/ 1 /gistom/ /dis/ /toils/ /dis//tol9/ 1 1 1 /dis/ /tomi/ 1 proefpersoon ouderdom geslag suiwertoondrempels dbl/dbr spreektaal 1 21 vroulik 5/10 afrikaans y 2 19 vroulik 10/10 afrikaans 3 24 vroulik 15/10 afrikaans 4 24 manlik 5/5 afrikaans 5 20 manlik 10/10 afrikaans tabel 2: gegewens omtrent die proefpersone the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) labiale koartikulasie: ' elektromiografiese studie by afrikaanssprekendes 39 g e r o n d e vokaal bevat nie. die kontrole segmentreekse is s o o r t g e l y k aan die wat in die eksperimentele ondersoek in kombinasie met 'n geronde vokaal gebruik word en is ook telkens vyf maal herhaal. indien hierdie betrokke s e g m e n t r e e k s e nie tydens produksie met lipronding g e p a a r d gaan nie, kan aanvaar word dat labiale e m g a k t i w i t e i t wat voorkom in die toetsmateriaal wat wel 'n geronde vokaal bevat, verband hou met die geronde vokaal alleen (figuur 2). kontrolemateriaal sal telkens na die e k s p e r i m e n t e l e materiaal beskryf word. beekryiving van spraakmateriaal spraakmateriaal om die invloed van die duur van die konsonantstring op die aanvang van labiale emg aktiwiteit te bepaal die konsonantreekse wat in die studie gebruik word om die invloed van die duur van die konsonantstring (konsonantstringtyd) op die aanvangsmoment van labiale emg-aktiwiteit (antisiperingstyd) te bepaal, is gekies n.a.v. 'n soortgelyke studie wat in sweeds uitgevoer is (lubker, 1981). die geronde vokale is egter gekies n.a.v. afrikaanse vokale wat in afrikaans gespesifiseer is t.o.v. ronding. die kontrole en eksperimentele materiaal om die invloed van die duur van die konsonantstring op die aanvang van labiale emg-aktiwiteit te bepaal, het bestaan uit onsin segmentreekse in die vorm: /v^kv,/. vj verwys na die hoe voorvokaal /i/ wat met 'n gespreide lipposisie geproduseer word en dus nie sal inmeng met labiale ronding nie. ko verwys na die konsonantstring bestaande uit 1-5 nie-labiale konsonante en v 2 verwys in die geval van die kontrolemateriaal na die hoe voorvokaal /i/ en in die geval van die eksperimentele materiaal na die geronde vokaal /z>/ of/u/. twee geronde vokale is ingesluit ten einde die hoeveelheid data te vermeerder en te bepaal of die twee geronde vokale 'n ooreenstemmende effek het. die spesifieke uitings wat vir die eksperimentele en kontrole materiaalgroepe gebruik is verskyn in tabel 1. spraakmateriaal om die verloop van emg-aktiwiteit te ondersoek vir uitings wat bestaan uit twee geronde vokale wat deur 'n nie-labiale konsonant geskei word (vjkjv konteks) die eksperimentele materiaal het telkens bestaan uit twee geronde vokale wat deur 'n nie-labiale konsonant geskei is. om te kontroleer dat labiale emg-aktiwiteit wel voorkom a.g.v. die voorkoms van die geronde vokaal en dat die konsonante /s/ en /k/ in die betrokke uitings nie met liprondingsaktiwiteit geproduseer word nie, is k2: kanaal 2 spraaksein x: konsonantstringtyd die stemlose deel van die uiting y: antisiperingstyd die afstand vanaf die aanvang van emg-aktiwiteit tot die akoestiese aanset van die geronde vokaal a: kursor 1 geplaas op die aanvang van die konsonantstring b: kursor 2 geplaas op die akoestiese aanvang van die geronde vokaal figuur 1: rekenaaruitdruk vanaf medelec mystro ms25 ter illustrasie van konsonantstringtyd, antisiperingstyd en optekenkanale. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 kontrole-uitings saamgestel. die spesifieke uitings wat vir die eksperimentele en kontrole materiaalgroepe gebruik is verskyn in tabel 1. spraakmateriaal om die invloed van woordgrense op die aanvang van labiale emg aktiwiteit te bepaal uitings is saamgestel wat as een of twee woorde uitgespreek moes word. die konsonantkombinasie/st/het beide binne 'n woord en oor 'n woordgrens voorgekom (benguerel & cowan, 1974). die uitings is telkens met 'n nie-labiale konsonant begin sodat daar tydens produksie van die klank nie met lipronding ingemeng word nie. uitings is telkens met die geronde vokaal /u/en/3/opgestel ten einde die hoeveelheid data te vermeerder en te bepaal of die twee geronde vokale 'n ooreenstemmende effek het. dit was egter moeilik om sinvolle uitings te vind wat aan die vereistes wat die metings stel voldoen. daar is gepoog om veral die uitings wat as twee woorde uitgespreek moes word sinvol te hou. twee van hierdie ses uitings was egter sinloos wat dus lei tot kunsmatige woordgrense. hierdie feit sal egter by die interpretasie van die resultate in gedagte gehou word. om te bepaal of die rondingsbeweging oor die woordgrens voorgekom het, m.a.w. of die beweging alreeds gedurende die eerste woord gei'nisieer is, is gebruik gemaak van groep β uitings, aangesien hierdie uitings as twee woorde uitgespreek is. twee van die uitings met die vokaal /u/ was ongelukkig onsinuitings, terwyl die res van die uitings sinvolle woorde was. daar kon dus so bepaal word of die rondingsbeweging oor die woordgrens van sinvolle en onsinuitings voorkom, of nie. om te bepaal of die karin theron, anita van der merwe en malcolm baker woordgrens die aanvang van ronding beduidend be'invloed het vir uitings wat onderskeidelik as een en twee woorde uitgespreek is, waar die konsonantkombinasie /st/ onderskeidelik binne die woord en oor die woordgrens voorkom" (benguerel & cowan, 1974) is gebruik gemaak van groep a en groep β uitings. eksperimentele materiaal: groep a /gistul/ groep β /dis/ /toeia/ /gistut/ /dis/ /toet3rs/ /gistup/ /dis/ /tupa/ /gistoff /dis//tofis/ /gistol/ /dis/ /tol3/ /gistom/ /dis/ /tomi/ kontrole materiaal: die kontrole-uitings is opgestel om te kontroleer dat die konsonante /g/, /d/, /s/ en itl wat die geronde vokaal voorafgaan nie met lipronding geproduseer word nie. die geronde vokaal wat in die toetsmateriaal voorgekom het, is vervang met die hoe voorvokaal ν wat met 'n gespreide lipposisie geproduseer word en dus nie met lipronding sal inmeng nie. die kontrole-uitings het dus bestaan uit die deel van die toetsmateriaal wat die geronde vokaal voorafgaan en die ho6 voorvokaal /i/, omdat slegs hierdie dele van die uitings vir analise gebruik is. die kontrole uitings was soos volg: /gisti/ /disti/ 4k 2 1 l / i s t s figuur 2: rekenaaruitdruk vanaf medelec mystro ms25 ter illustrasie van die afwesigheid van emgaktiwiteit tydens die produksie van 'n kontrole-uiting the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t · perende labiale koartikulasie: 'n elektromiografiese studie by afrikaanssprekendes prosedure vir opname 41 nie n a v o r s e r is bygestaan deur 'n neuroloog wat ervare • die uitvoering van elektromiografiese ondersoeke. 'n r nolsre n a a l d e l e k t r o d e is in die midlyn van die musculus nh'cularis oris, bekend as die agonis vir lipronding (bellr^ti & harris, 1979) geplaas. die elektromiografiese ktiwiteit geassosieer met lipronding van die spier is op k naal een van die elektromiograaf opgeneem. die skrofoon is op 'n afstand van 5-10 cm vanaf die spreker e mond geplaas en die spraaksein is op kanaal twee van die e l e k t r o m i o g r a a f opgeteken. die gemiddelde van die vyf duksies van elke uiting vir die elektromiografiese a k t i w i t e i t en die visuele voorstelling van die spraaksein is onder mekaar op die ingeboude rekenaarskerm vertoon. 'n g r o n d e l e k t r o d e op die persoon se linkerwang is gebruik om enige vreemde elektriese stroom te ontvang en gevolglike artefakte uit te skakel. die eksperimentele materiaal is op kaartjies van 10 χ 4 cm geskryf en die kaartjies is geskommel sodat e k s p e r i m e n t e l e materiaal wat dieselfde aspek toets nie ηά mekaar voorgekom het nie. hierdeur is gepoog om die moontlike invloed wat die woorde op mekaar kon he uit te skakel. die kontrole materiaal is eerste geproduseer en indien liprondingsaktiwiteit tydens die produksie van die kontrole materiaal teenwoordig was, is die persoon nie in die studie gebruik nie. dit het wel gebeur dat een persoon as gevolg van hierdie rede nie by die studie ingesluit is nie. die proefpersone is vooraf elkeen geleentheid gegee om die uitspraak van die uitinge te oefen. analise van data tydens analise van die resultate is elke persoon se data wat op 'n rekenaardisket gestoor is, herroep. die elektromiografiese aktiwiteit op kanaal een en die spraaksein op kanaal twee vir die betrokke uiting het dan onder mekaar op die rekenaarskerm verskyn. deur middel van twee kursors kon die navorser dan die tydsverloop tussen die verlangde punte meet. soos die kursors beweeg is, het die tydsverskil tussen die twee kursors in millisekondes op die rekenaarskerm verskyn. die amplitude van 'n sekere punt kon jook bepaal word d.m.v. die plasing van die kursor op daardie punt. die amplitude in u v vir 'n spesifieke plasirig het ook onder aan die rekenaarskerm verskjm. j i analise van data om die invloed van die duur van die konsonantstring (konsonantstringtyd) op die aanvang van labiale emg-aktiwiteit (antisiperingstyd) te bepaal vir elke uiting is die duur van die konsonantstring in millisekondes gemeet (konsonantstringtyd) deur die kursors op die begin en einde van die konsonantstring, m.a.w. die stemlose deel van die uiting te plaas. die analise is uitgevoer op kanaal 2, m.a.w. die spraaksein. vervolgens is die tydsverloop in millisekondes bepaal vanaf die aanvang van emg-aktiwiteit (kanaal 1) tot die akoestiese aanset van die geronde vokaal (kanaal 2) (antisiperingstyd). die begin van emg-aktiwiteit is beskou as die eerste duidelike uitwyking vanaf die basislyn soos beoordeel deur die navorser en die neuroloog (figuur 1). die verband tussen antisiperingstyd en konsonantstringtyd is bepaal deur staltistiese metodes soos by die verwerking van data beskryf word. die oogmerk was dus om te bepaal of antisiperingstyd wissel na gelang die duur van die konsonantstring wissel. analise van data om koartikulasie van een geronde vokaal na 'n ander te ondersoek (v^nlvg-konteks) by die analise van die data is die verloop van die emgaktiwiteit nagegaan. daar is gekyk of daar twee piekperiodes voorkom met 'n duidelike afname in aktiwiteit tussen die twee piekperiodes. indien twee piekperiodes onderskei kan word, is die maksimum amplitude in mikrovolt van die twee piekperiodes gemeet d.m.v. die kursors op die rekenaarskerm. soos die kursors beweeg is, het die amplitude in mikrovolt aan die onderkant van die skerm verskyn. die minimum amplitude van die keep tussen die twee piekperiodes is ook bepaal. die verloop van die emg-aktiwiteit is subjektief beoordeel deur die navorser en die neuroloog. analise van data om die invloed van woordgrense op die aanvang van labiale emg aktiwiteit te bepaal • die materiaal is so opgestel dat die konsonante wat die geronde vokaal voorafgaan stemloos is en dus maklik onderskeibaar is van die stemhebbende geronde vokaal op die visuele voorstelling van die spraaksein. die duur van die konsonantstring in millisekondes is bepaal asook die tydsverloop vanaf die aanvang van emgaktiwiteit tot die aanvang van die geronde vokaal. bogenoemde is gemeet vir beide groep a (uitings wat as een woord uitgespreek is) en groep β (uitings wat as twee woorde uitgespreek is). verwerking van data verwerking van data omdie invloed van die duur van die konsonantstring (konsonantstringtyd) op die aanvang van labiale emgaktiwiteit (antisiperingstyd) te bepaal puntediagramme is afsonderlik vir elke proefpersoon vir eksperimentele groep 1 en groep 2 uitings onderskeidelik, opgestel. na gelang van die data is daar onderskeidelik van linesre en paraboliese passings gebruik gemaak, waar daar van die kleinstevierkantmetode gebruik gemaak is. vir die lineere en paraboliese passings is die akkuraatheid van die passing weergegee deur die simbole r en r onderskeidelik, waar die terme telkens die fraksie van akkuraatheid voorstel (r of r = 1 stel dus 'n perfekte passing voor). 'n akkurate lineere passing impliseer dat y toeneem, namate χ toeneem. dit sou dus beteken dat antisiperingstyd toeneem na gelang konsonantstringtyd toeneem. 'n akkurate paraboliese passing impliseer dat y toeneem tot op 'n punt en daarna afneem, ten spyte van 'n toename in x. dit sou dus beteken dat antisiperingstyd 'n maksimum bereik, waarna dit nie verder toeneem nie. verwerking van data om die invloed van woordgrense op die aanvang van labiale emg-aktiwiteit te bepaal indien antisiperende labiale koartikulasie oor die woordgrens strek sal antisiperingstyd (y) groter wees as konsonantstringtyd (x) (figuur 3). 'n gepaarde t-toets die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 (eensteekproefgeval) is m.b.v. proc univariate en sas uitgevoer om te bepaal of daar 'n beduidende grootteverskil tussen die waardes van χ en y is. met behulp van die toets is 'n p-waarde verkry, en indien die waarde kleiner as 0,05 is, dui dit op 'n beduidende grootteverskil. 'n vyf persent peil van betekenis vir betekenisvolheid is dus gehandhaaf. 'n beduidende grootteverskil sou daarop dui dat antisiperende labiale koartikulasie al gedurende die eerste uiting van twee uitinge voorgekom het. in hierdie geval het antisiperende labiale koartikulasie dus wel oor die woordgrens voorgekom. vervolgens is bepaal of daar 'n beduidende verskil is tussen die antisiperingstye van uitinge waarin die konsonantkombinasie /st/ binne 'n woord voorkom en vir uitinge waar die spesifieke konsonantkombinasie geskei word deur 'n woordgrens. daar moet dus bepaal word of emg-aktiwiteit telkens min of meer op dieselfde punt in die woord 'n aanvang neem, vir uitings wat as een en twee woorde uitgespreek word. die verskil tussen χ en y is bereken vir beide die uitings wat as een en twee woorde uitgespreek is. die rede waarom die verskil bereken is, is ten einde te kompenseer vir die verskil in konsonantstringtyd van die twee groepe uitings. die verkrygde waardes word dan m.b.v. 'n gepaarde ttoets (eensteekproefgeval) geevalueer ten einde te bepaal of daar 'n beduidende verskil in antisiperingstyd tussen die twee groepe uitings bestaan. met behulp van die toets is 'n p-waarde verkry en indien die waarde dus groter as 0,05 is, is die verskil nie beduidend nie. 'n vyf persent peil van betekenis vir betekenisvolheid is weer gehandhaaf. indien die verskil nie beduidend is nie, impliseer dit dat die woordgrens in hierdie konteks nie die aanvangsmoment van labiale rondingsaktiwiteit be'invloed nie. antisipering begin dus op dieselfde plek in die uitings, ongeag of die uiting as een of twee woorde uitgespreek is. karin theron, anita van der merwe en malcolm baker beskrywing van resultate bepaling van die temporale omvang van antisiperende labiale koartikulasie die resultate van die verskillende proefpersone en segmentreekse met die geronde vokaal /u/ en !z>! word opsommender wys bespreek aangesien, daar konstant sekere tendense teenwoordig was. soos reeds genoem by die verwerking van data is daar telkens bepaal of'n linesre of paraboliese verband tussen χ en y bestaan, waar die xas telkens die duur van die konsonantstring in millisekondes aandui (konsonantstringtyd), en die y-as telkens na die tydsverloop vanaf die aanvang van emg-aktiwiteit tot die akoestiese aanset van die geronde vokaal (antisiperingstyd), ook in millisekondes, verwys. ter illustrasie van die paraboliese en lineere verband tussen χ en y word slegs figure 4 en 5 ingesluit, aangesien die resultate van die ander proefpersone deurgaans dieselfde tendens (paraboliese of lineere verband) getoon het. die roudata wat antisiperingstyd en konsonantstringtyd vir elke uiting en proefpersoon toon verskyn in bylae 1. 'n paraboliese verband tussen χ en y is twee keer verkry vir uitings van ekperimentele materiaalgroep 1 en een keer vir uitings van eksperimentele materiaalgroep 2. figuur 4 illustreer die resultate van proefpersoon 1 m.b.t. eksperimentele materiaalgroep 1 waar 'n paraboliese verband tussen χ en y bestaan. 'n paraboliese verband impliseer dat antisiperingstyd toegeneem het namate konsonantstringtyd toegeneem het, totdat laasgenoemde 'n maksimum bereik (in hierdie geval 524 ms), waarna antisiperingstyd weer afgeneem het. 'n lineere verband tussen χ en y is verkry in twee gevalle van eksperimentele materiaal groep 1 uitings en in drie gevalle van eksperimentele materiaalgroep 2 figuur 3: rekenaaruitdruk vanaf medelec mystro ms25 ter illustrasie van die voorkoms van antisiperende labiale koartikulasie oor 'n woordgrens the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) antisiperende labiale koartikulasie: 'n elektromiografiese studie by afrikaanssprekendes 43 tings. figuur 5 illustreer die resultate van proefpersoon χ1 waar 'n positiewe lineere verband tussen χ en y verkry •' vir eksperimentele materiaalgroep 2. 'n positiewe lineere v e r b a n d impliseer dat namate konsonantstringtyd (x) t o e g e n e e m het, a n t i s i p e r i n g s t y d (y) o o k t o e g e n e e m het. in twee gevalle (eksperimentele materiaalgroep 2 van proefpersoon 2 en eksperimentele materiaalgroep 1 van proefpersoon 4) kon daar nie 'n paraboliese of lineere verband tussen χ en y verkry word nie, maar met beskouing van die data is in beide die gevalle gevind dat antisiperingstyd wel toegeneem het, namate konsonantstringtyd toegeneem het tot op 'n sekere punt. a l h o e w e l d i t u i t d i e r e s u l t a t e b l y k d a t d i e a n t i s i p e r i n g s t y e v a n die v e r s k i l l e n d e p r o e f p e r s o n e vir dieselfde u i t i n g s v e r s k i l , t o o n a l d i e p r o e f p e r s o n e se resultate egter dat antisiperingstyd toeneem namate konsonantstringtyd toeneem. aangesien die verskynsel voorgekom het tydens die uitinge met die geronde vokaal lz>/ en /u/ kan afgelei word dat die twee vokale 'n ooreenstemmende effek het. antisiperingstyd het gewissel vanaf 144 ms vir die uiting /is z>/ (by proefpersoon 2) tot 950 ms vir die uiting /ikststu/ (by proefpersoon 3). al die proefpersone se antisiperingstye het vir eksperimentele materiaalgroep 2 egter 'n maksimum bereik en afgesien van 'n toename in konsonantstringtyd het antisiperingstyd na hierdie punt nie verder toegeneem nie. vir eksperimentele materiaalgroep 1 het slegs proefpersone een, twee en vyf se antisiperingstye 'n maksimum bereik. die maksimum antisiperingstye van die verskillende proefpersone het ook verskil. antlalperlngatyd (ma) 10001— 760 6 0 0 2s0 300 400 600 800 700 800 800 konsonantstringtyd (ms) antlalperlnoatyd (ma) + 800 + 800 + 800 + 800 400 + 400 200 300 400 600 800 700 konsonantstringtyd (ms) figuur 4: puntediagram van konsonantstring teenoor antisiperingstyd van eksperimentele materiaalgroep 1 vir proefpersoon 1. figuur 5: puntediagram van konsonantstringtyd teenoor antisiperingstyd van eksperimentele materiaalgroep 2 vir proefpersoon 1. tabel 3: gegewens aangaande verloop van emg-aktiwiteit in die vgk^vg-konteks. maksimum amplitude vir eerste piek in μ ν minimum amplitude tussen pieke in μ ν maksimum amplitude vir tweede piek in μ ν deurlopende emg aktiwiteit pp.1 /usu/ i 48 1 54 /uku/ 48 1 54 pp.2: /usu/ ! 60 0 75 /uku/ x pp.3: /usu/ 48,4 2 32 /uku/ x pp.4: /usu/ 40 0 44 /uku/ 27,8 1,99 22,8 pp.5: /usu/ 78 1 58 /uk 1 58 2 64 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 karin theron, anita van der merwe en malcolm baker bepaling van die verloop van labiale emgaktiwiteit in die vpjvfkonteks ter illustrasie van hierdie resultate word tabel 3 ingesluit. daar word telkens in mikrovolt aangedui wat die maksimum amplitude van die twee piekperiodes was, indien teenwoordig. verder word die minimum amplitude van die emg-aktiwiteit tussen die twee piekperiodes ook in mikrovolt aangedui. in die tabel word aangetoon dat deurlopende emg-aktiwiteit voorgekom het indien geen prominente pieke met 'n afname in emg-aktiwiteit tussen die pieke onderskei kon word tydens beoordeling deur die neuroloog en navorser nie. uit die resultate blyk dit dus dat die keepverskynsel by agt uit die tien uitings voorgekom het. daar is egter slegs van een intervokaliese konsonant gebruik gemaak en die konsonantstringtyd was dalk in die twee gevalle waar die keepverskynsel nie waargeneem is nie, korter as die tyd wat nodig is vir die spieraktiwiteit om te daal tot die basislyn vir die eerste /u/ en dan weer te styg vir die tweede /u/ (bell-berti & harris, 1982). daar word aanbeveel dat die verskynsel in die toekoms ondersoek word vir uitings waar meer as een intervokaliese konsonant gebruik .word, om te bepaal of die keepverskynsel konstant voorkom. bepaling van die effek van woordgrense op die aanvang van labiale emg-aktiwiteit tydens statistiese verwerking is die roudata van al die proefpersone vir eksperimentele materiaalgroep a en eksperimentele materiaalgroep β uitings gesamentlik verwerk. om te bepaal of antisiperende labiale koartikulasie oor woordgrense voorkom, is soos reeds genoem, gebruik gemaak van 'n gepaarde t-toets om te bepaal of die antisiperingstyd (y) groter is as konsonantstringtyd (x). indien ρ < 0,05 dan is y > x. daar is gevind dat ρ gelyk is aan 0.0001 en dus is y groter as x. die resultate impliseer dat antisiperende labiale koartikulasie telkens reeds gedurende die produksie van die eerste woord voorgekom het en wel voor die produksie van die laaste segment van die eerste woord. die voorkoms van die woordgrens het dus nie die voorkoms van antisiperende labiale koartikulasie gedurende die eerste woord oor die woordgrens gei'nhibeer nie. die verskynsel het konstant by al die proefpersone voorgekom vir die sinvolle en onsinuitinge. vervolgens is bepaal of daar 'n beduidende verskil is tussen die antisiperingstye van uitinge waarin die konsonantkombinasie /st/ binne 'n woord voorkom en uitinge waar /s/en/t/ geskei word deur 'n woordgrens. weer eens is die data van al die proefpersone gesamentlik verwerk. die p-waarde wat m.b.v. die t-toets verkry is, is 0,7982. aangesien die waarde groter as 0,05 is, dui dit daarop dat daar nie 'n beduidende verskil is tussen die antisiperingstye van die uitings wat as een of twee woorde uitgespreek is nie. antisipering begin dus op ongeveer dieselfde foneem voor die geronde vokaal, ongeag of die uiting uit een of twee uitings bestaan. die resultaat impliseer dat in twee uitings soos /gistul/ en /dis/ /tul / antisipering in albei gevalle bv. by die ν sal begin. die teenwoordigheid van 'n woordgrens bei'nvloed dus nie die aanvang van antisipering nie. die verskynsel het konstant by al die proefpersone voorgekom. bespreking van resultate die temporale omvang van antisiperende labiale koartikulasie die data van die huidige studie dui aan dat die aanvangsmoment van labiale emg-aktiwiteit (antisiperingstyd) wissel, na gelang die duur van die konsonantstring wat die geronde vokaal voorafgaan wissel. daar is gevind dat liprondingsaktiwiteit toenemend vroeer 'n aanvang neem, namate die duur van die voorafgaande konsonantstring toeneem. die antisiperingstye het gewissel vanaf 144 ms (proefpersoon 4) vir die uiting usui tot 950 ms (proefpersoon 3) vir die uiting /ikststu/. alhoewel die verskillende proefpersone se antisiperingstye vir dieselfde uitings verskil het, het almal se resultate getoon dat antisiperingstyd toeneem, namate konsonantstringtyd toeneem. in sommige gevalle (proefpersone een, twee, drie en vier) het dit voorgekom of van die proefpersone hul maksimum antisiperingstyd behaal het, aangesien daar op 'n sekere punt 'n afname in antisiperingstyd was, ten spyte van 'n toename in konsonantstringtyd. die feit dat antisiperingstyd in sommige gevalle op 'n sekere punt nie verder toegeneem het nie, ten spyte van 'n toename in konsonantstringtyd, kan dui op 'n moontlike temporale beperking vir antisiperende labiale koartikulasie. in die huidige studie verskil die maksimum temporale omvang wat behaal is van persoon tot persoon. die maksimum antisiperingstyd wat 'n persoon behaal het weerspieel dus moontlik die maksimum grootte van die beplanningseenhede wat die persoon gebruik in die motoriese beplanning van sy spraak, van watter aard die eenhede ook al mag wees. die bevindings aangaande die temporale omvang van antisiperende labiale koartikulasie kan gebruik word om sekere afleidings te maak aangaande die wyse waarop motoriese beplanning van spraak deur die brein geskied. die resultate van die huidige studie is in ooreenstemming met bevindings van ondersoekers wat meen dat antisiperende labiale koartikulasie 'n wye omvang kan he (daniloff & moll, 1968; benguerel & cowan, 1974; mcallister et al., 1974). die sterk positiewe verband tussen die duur van die nie-labiale konsonantstring en die aanvangsmoment van labiale emg-aktiwiteit, ondersteun die hipotese dat die aanvang van labiale ronding beplan word in verhouding tot die temporale omvang van die nielabiale konsonantstring wat die geronde vokaal voorafgaan. daar kan na aanleiding hiervan geredeneer word dat die brein soveel as bv. 950 ms (by proefpersoon 3) vooraf besef dat 'n geronde vokaal geproduseer gaan word. verder kom dit voor asof die brein ook bewus is van die feit dat daar geen aktiwiteit van die lippe vereis word in die intervokaliese periode nie, aangesien die konsonantstring nie-labiaal is. as gevolg hiervan kan vroee lipronding gei'nisieer word. die resultaat lewer dus bewys van die voorafbeplanning van spraak deur die brein en impliseer dat antisiperende labiale koartikulasie 'n bespiedingsmeganisme vir spraakproduksie reflekteer (lubker & gay, 1982). hierdie bevindings is dus in teenstelling met studies waar bevind is dat die aanvang van die rondingsbeweging temporaal gebonde is aan die akoestiese aanset van die geronde vokaal en nie bei'nvloed word deur die duur van die voorafgaande konsonantstring nie (bell-berti & harris, 1979;1982; gay, 1979). 'n moontlike verklaring vir die opponerende resultate the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) isiperende labiale koartikulasie: 'n elektromiografiese studie by afrikaanssprekendes 45 van die huidige studie teenoor die van bell-berti en harris (1979;1982) kan wees dat in die spraakmateriaal wat deur bell-berti en harris (1982) gebruik is, die konsonants t r i n g t y d nooit 420 ms oorskry het nie en 'n maksimum van vier i n t e r v o k a l i e s e k o n s o n a n t e g e b r u i k is. antisiperingstyd sou dus moeilik die duur van 420 ms oorskry. verder was antisiperingstyd soms in genoemde n a v o r s e r s se studie wel 300 ms en 400 ms soos blyk uit hul studie se puntediagramme. antisiperingstyd was dus nie konstant 250 ms (bell-berti & harris, 1982) nie. die omvang van antisiperende labiale koartikulasie kan ook gebruik word om modelle van spraakproduksie, wat poog om o.a. die v e r s k y n s e l van a n t i s i p e r e n d e koartikulasie te verklaar, te ondersoek. kozhevnikov en chistovich (in kent & minifie, 1977) postuleer dat die omvang van antisiperende koartikulasie die grootte van die eenheid wat in die beplanning van spraak gebruik word, reflekteer. na aanleiding van hulle resultate met russiese proefpersone, het hulle w a a r g e n e e m dat lipprotrusie vir konsonantkombinasies wat geronde vokale voorafgaan, begin met die eerste konsonant in die reeks. die navorsers het tot die gevolgtrekking gekom dat artikulatoriese bewegings georganiseer word in lettergrepe met die vorm van kv, kkv, kkkv ens. die lettergreep kan dus bestaan uit enige hoeveelheid konsonante, gevolg deur 'n vokaal. die basiese hipotese wat deur die kozhevnikov-chistovich teorie (in kent & minifie, 1977) gepostuleer word, is dat die motoriese beplanning van spraak onderbreek word by sekere intervalle, naamlik ηά die produksie van 'n vokaal. nadat 'n vokaal teegekom is, begin 'n nuwe beplanningseenheid. na aanleiding van hul bevindings het hulle 'n model, bekend as die artikulatoriese lettergreepmodel, gepostuleer wat poog om die verskynsel van antisiperende koartikulasie te verklaar. uit die resultate van die huidige studie blyk dit egter dat die rondingsbeweging in sommige gevalle alreeds voor of gedurende die eerste vokaal in die uiting 'n aanvang neem. die rondingsbeweging word dus alreeds voor die produksie van die eerste konsonant in die uiting gei'nisieer. die verspreiding van die rondingsbeweging tot die vokaal wat die eerste konsonant ih die reeks voorafgaan, is in ooreenstemming met die bevindings van sussman en westbury (1981), benguerel |en cowan (1974) en lubker (1981). die arikulatoriese lettergreep, bestaande uit 'n sekere hoeveelheid konsonarite wat deur 'n vokaal gevolg word, kan dus nie as die enigste basiese invoereenheid vir die motoriese beplanning van spraak aanvaar word nie. indien die omvang van antisiperende koartikulasie gebruik word as bewys van \ die grootte en aard van die beplanningseenhede van artikulasie, dan is lettergrepe in die vorm kv of selfs (k)°v (dit is enige hoeveelheid konsonante wat die geronde vokaal voorafgaan) nie die enigste moontlike invoereenhede nie (kent & minifie, 1977). die a r t i k u l a t o r i e s e l e t t e r g r e e p m o d e l van kozhevnikov en chistovich (in kent & minifie, 1977) word dus nie n.a.v. die resultate van die huidige studie ondersteun nie. nog 'n model soos gepostuleer deur henke (in kent & minifie, 1977) hipotetiseer dat die invoereenheid wat vir die motoriese beplanning van spraak gebruik word, uit groepe kenmerke bestaan. henke (in kent & minifie, 1977) postuleer dat elke foneem in 'n artikulatoriese reeks uit 'n groep artikulatoriese kenmerke bestaan. elke foneem het vir 'n bepaalde kenmerk 'n waarde van nul, plus, of minus. wanneer 'n spreker 'ή artikulatoriese reeks moet produseer, voer die brein 'n bespiedingsproses uit op die foneemstring. as 'n bepaalde foneem 'n plus waarde het t.o.v. 'n spesifieke kenmerk bv. ronding, en die segmente wat dit voorafgaan almal 'n nulwaarde het vir hierdie kenmerk, sal die kenmerk tydens produksie van die tussenkomende foneme geantisipeer word. die voorafgaande foneme sal dus die kenmerkwaarde van die komende foneem aanneem. hierdie beginsel geld slegs as die kenmerk nie onverenigbaar is met die kenmerke van die tussenkomende segmente nie, en staan bekend as henke se " c o m p a t i b i l i t y n o t i o n " (kent & minifie, 1977:124). uit die huidige resultate blyk dit dat die rondingskenmerk wel tydens die produksie van die voorafgaande konsonantstring wat 'n nul waarde m.b.t. die rondingskenmerk het, geantisipeer is. die rondingskenmerk is egter in sommige gevalle reeds deur die eerste vokaal in die reeks (/i/) aangeneem. die vokaal lil het egter 'n negatiewe waarde vir die rondingskenmerk. die feit dat labiale e m g a k t i w i t e i t alreeds g e d u r e n d e die /i/ waargeneem is, is dus 'n onverwagte resultaat indien die wyse van spraakbeplanning wat deur henke (in kent & minifie, 1977) voorgestel is, aanvaar word. die bevinding dat labiale emg-aktiwiteit alreeds gedurende die /i/ voorkom, is in ooreenstemming met die bevindings van ander navorsers soos benguerel en cowan (1974), lubker (1981) en sussman en westbury (1981). aangesien die kontrole uitinge nie ronding vertoon nie, kan aanvaar word dat die resultaat nie die gevolg van 'n artefak in die meting is nie. 'n moontlike verklaring vir die resultaat is voorgestel deur sussman en westbury (1981). hierdie navorsers aanvaar ook 'n bespiedingsmeganisme wat in die motoriese beplanning van spraak deur die brein gebruik word, maar volgens hulle siening noodsaak die vokaal wat die geronde vokaal voorafgaan dat daar aanpassings gemaak moet word. indien die voorafgaande vokaal biomeganies neutraal is t.o.v. lipronding, dan behandel die bespieder die segment as nog 'n neutrale segment in die reeks. as die voorafgaande vokaal antagonisties is t.o.v. ronding dan word temporale a a n p a s s i n g s ge'inkorporeer in die a n t i s i p e r e n d e rondingsbeweging, m.a.w. ronding begin vroeer as wanneer 'n neutrale vokaal teenwoordig is. die verloop van labiale emg-aktiwiteit in 'ν v^knlvg-konteks antisiperende labiale koartikulasie blyk afwesig te wees in reekse wat gespesifiseer word as geronde vokaal (v )nie-labiale konsonant (knl)-geronde vokaal (vg). in die huidige studie is in agt van die tien uitings, twee temporaal onderskeibare pieke van musculus orbicularis oris aktiwiteit gevind, en nie oordrag van die labiale emgaktiwiteit vanaf die eerste geronde vokaal oor die konsonantstring wat neutraal is t.o.v. ronding na die tweede geronde vokaal nie (figuur 14). die bevindings stem ooreen met die bevindings van gay (1979). n a v o r s e r s wat m e e n dat a n t i s i p e r e n d e labiale koartikulasie tydsgebonde is aan die geronde vokaal meen dat die keepof dubbele piek verskynsel (lubker & gay, 1982) bewys lewer vir die werking van 'n tydsgebonde meganisme in die motoriese beplanning van spraak (gay, 1979). die n a v o r s e r s d a a r e n t e e n w a t m e e n dat antisiperende labiale koartikulasie 'n wye omvang kan hs, meen egter dat die verskynsel slegs die noodsaaklikheid die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 karin theron, anita van der merwe en malcolm baker van idiosinkratiese aanpassings in beplanning, n.a.v. die aard van die eerste vokaal in die uiting, weerspieel (sussman & westbury, 1981). die keepverskynsel word ook gebruik om reedsgenoemde spraakproduksiemodelle te ondersoek. die verskynsel kan nie verklaar word as die bespiedingsmeganisme soos deur henke (in kent & minifie, 1977) gepostuleer, aanvaar word nie. volgens henke se model moes ronding ook gedurende die intervokaliese konsonant voorgekom het, aangesien die nie-labiale konsonant neutraal is t.o.v. die rondingskenmerk. dit lyk dus of die bespiedingsmeganisme in hierdie besondere geval nalaat om sy bespiedingsproses uit te voer. geen antisiperende labiale koartikulasie vind in die konteks plaas nie. die feit dat geen antisiperende koartikulasie in die konteks plaasvind nie, opponeer verder die aanname van (k)nv-eenhede as die basiese invoereenheid vir beplanning van spraak, soos gepostuleer deur kozhevnikov en chistovich (in kent & minifie, 1977), omdat volgens die navorsers labiale emg-aktiwiteit gedurende die eerste konsonant in die uiting 'n aanvang moes neem en volgehoii word oor die vokaal. dit sou wees omdat hierdie navorsers invoereenhede in die vorm van (k)nv aanvaar as die basiese invoereenheid in die motoriese beplanning van spraak. rondingsaktiwiteit het egter nie gedurende die konsonant voorgekom nie, soos blyk uit die resultate. die keepverskynsel het nie konstant voorgekom nie (in twee van die tien uitings afwesig) en is moontlik nie in genoeg diepte in die huidige studie ondersoek nie. daar is vir toetsing van die keepverskynsel gebruik gemaak van uitinge wat slegs een intervokaliese konsonant bevat in die vgkjvg-konteks. dit word aanbeveel dat die verskynsel in die toekoms in meer diepte ondersoek word deur gebruik te maak van uitinge wat langer intervokaliese konsonantstringe bevat. die effek van woordgrense op die aanvang van labiale emg-aktiwiteit in die huidige studie is gevind dat koartikulasie oor woordgrense kan voorkom. verder is gevind dat vir uitings waar 'n konsonantkombinasie /st/binne 'n woord en oor 'n woordgrens voorkom, die aanvangsmoment van ronding nie beduidend deur die woordgrens bei'nvloed word nie. die resultaat het vir beide die onsinvolle en sinvolle uitings wat as twee woorde uitgespreek is, gegeld. die resultate wat toon dat die woordgrens nie 'n beduidende effek op die aanvang van ronding het nie, is in ooreenstemming met die bevindings van daniloff en moll (1968), benguerel en cowan (1974) en bell-berti en harris (1982). die feit dat antisiperende labiale koartikulasie oor 'n woordgrens kan strek ondersteun die aanname van van der merwe (1986) dat die linguisties-simboliese beplanning en die motoriese beplanning van spraak deur die brein afsonderlik geskied. die brein skei dus moontlik taal en motoriek tydens die motoriese beplanning van spraak. die onbeduidende effek van die woordgrens op die aanvang van labiale emg-aktiwiteit is ook in stryd met die aanname van 'n artikulatoriese lettergreep met die formaat (k)nv as die basiese invoereenheid wat in die motoriese beplanning van spraak gebruik word. in die huidige studie is daar in 'n uiting soos /dis/ /t mi/ gevind — u , ί.λ—μλi f x \c2 a: kursor 1 geplaas op die eerste piek van emg-aktiwiteit b: kursor 2 geplaas op die tweede peik van emg-aktiwiteit figuur 6: rekenaaruitdruk vanaf medelec mystro ms25 ter illustrasie van die keepverskynsel. the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) labiale koartikulasie: ' elektromiografiese studie by afrikaanssprekendes 47 dat labiale emg-aktiwiteit al voor of gedurende die eerste ν begin en voortduur oor die woordgrens. volgens die aannames van kozhevnikov en chistovich (in kent & minifie, 1977) se artikulatoriese lettergreepmodel, behoort die l e t t e r g r e e p g r e n s die aanvang van labiale ronding ffe'inhibeer het (bell-berti & harris, 1979) en verder moes geen r o n d i n g al gedurende die /i/ voorgekom het nie. gevolgtkekking na a a n l e i d i n g van die resultate van die studie blyk dit dat nie die artikulatoriese lettergreep model van k o z h e v n i k o v en chistovich (in kent & minifie, 1977) of die bespiedingsmodel van henke (in kent & minifie, 1977) ten voile ondersteun word nie. sussman en westbury (1981) het egter 'n bespiedingsmeganisme vir die beplanning van spraak voorgestel wat deur die resultate van die huidige studie ondersteun word. hierdie navorsers meen dat 'n voldoende model van antisiperende koartikulasie 'n teoretiese beskrywing van 'n kenmerkbespiedingsmeganisme vir spraak moet bied wat aan sekere vereistes voldoen. eerstens moet die meganisme in staat wees om komende artikulatoriese kenmerke wat lank na die huidige opdragte voorkom, te antisipeer. tweedens moet die meganisme geen vaste tydsgebonde verhouding tot 'n fonetiese of abstrakte linguistiese entiteit soos 'n kenmerk of 'n foneem he nie. die feit dat gevind is dat die omvang van antisiperende labiale koartikulasie wissel na gelang konsonantstringtyd wissel, impliseer dat daar geen sodanige vaste tydsgebonde verhouding bestaan nie. derdens moet die meganisme se temporale program aangepas word om die biomeganiese vereistes van die perifere strukture, a.g.v. antagonistiese voorafgaande kontekste, te hanteer. die feit dat antisiperende labiale koartikulasie reeds gedurende die vokaal /i/ wat 'n negatiewe waarde t.o.v. ronding het voorkom, impliseer dat aanpassings gemaak word om die antagonistiese beweging van die lippe vir die /i/ te akkomodeer. vierdens moet die meganisme nie die bespiedingsvermoe gebruik wanneer 'n foneem met 'n spesifieke kenmerk bv. ronding, twee maal na mekaar voorkomjen geskei word deur 'n segment wat neutraal is t.o.v. hierdie kenmerk nie. die resultate van die huidige studie ondersteun ook hierdie aanname, aangesien antisiperende labiale koartikulasie afwesig was in die vgknlvg-|konteks. die model van sussman en westbury (19(81) verklaar egter net koartikulasie m.b.t. ronding, terwyl die beplanning van spraak alle eienskappe betrek.! dit sou dus nodig wees om ander tipes koartikulasie, bv. veler, mandibuler of linguaal, te bestudeer m.b.t. ander kenmerke bv. nasaliteit, strekking e.a. om sodoende 'n omvattende model vir die beplanning van spraak deur die brein te formuleer. die resultate van die studie ondersteun dus resultate van vele ander navorsers. uit die resultate van die huidige studie blyk dat afrikaaanssprekende persone dieselfde reageer m.b.t. die verskynsel van antisiperende labiale koartikulasie, as sprekers van ander tale. die bevinding dui daarop dat die wyse van motoriese beplanning van spraak 'n universele verskynsel is. verder dra die resultate van die studie by tot kennis aangaande antisiperende labiale koartikulasie en verskaf dit addisionele data aangaande di£ aspekte van koartikulasie waaroor daar steeds kontroversie bestaan. afleidings uit die resultate van alle navorsers m.b.t. die beplanning van spraak deur die brein is hipoteties en dit is moeilik om betroubare afleidings te maak as die geweldige kompleksiteit en wye omvang van spraakbeplanning in gedagte gehou word. verwysings bell-berti, f. & harris, k.s. (1974). more on the motor organization of speech gestures. haskins laboratories status report on speech research, sr-37/38, 73-77. bell-berti, f. & harris, k.s. (1979). anticipatory coarticulation: some implications from a study of liprounding. journal of the acoustical society of america. 65, 1268-1270. bell-berti, f. & harris, k.s. (1981). a temporal model of speech production. phonetica, 38, 9-20. bell-berti, f. & harris, k.s. (1982). temporal patterns of coarticulation: liprounding. journal of the acoustical society of america, 71, 449-454. benguerel, a.p. & cowan, h.a. (1974). coarticulation of upper lip protrusion in french. phonetica, 30, 41-55. blair, c. & smith, a. (1986). emg recording in human lip muscles: can single muscles be isolated? journal of speech and. hearing research, 29, 256-266. borden, g.j. & harris, k.s. (1984). speech science primer: physiology, acoustics and perception of speech. 2de uitgawe, baltimore: williams en wilkens. daniloff, r.g. & moll, k.l. (1968). coarticulation of liprounding. journal of speech and hearing research, 11, 707-721. gay, t. (1979). coarticulation in some consonant-vowel and consonant cluster-vowel syllables. in b. lindblom & s. oilman (reds.) frontiers of speech communication research. new york: academic. guy, r.f., edgley, c.e. arafat, i. & allen, d.e. (1987). social research methods. puzzles and solutions. allyn and bacon, inc. harris, k.s. (1984). coarticulation as a component in articulatory description. haskins laboratories: status report on speech research, sr-79, 19-36. katz, w.f. (1988a). anticipatory coarticulation in aphasia: acoustic and perceptual data. brain and language, 35, 340368. katz, w.f. (1988b). "methodological considerations" reconsidered: reply to sussman et al., brain and language, 35, 380-385. katz, w., machetanz, j., schdnle, p. & orth, u. (1990). akinematic analysis of anticipatoy coarticulation in speech of anterior aphasic subjects using electromagnetic articulography. brain and language, 38, 555-575. kent, r.d. & minifie, f.d. (1977). coarticulation in recent speech production models. journal of phonetics, 5, 115-133. lubker, j. (1981). temporal aspects of speech production: anticipatory labial coarticulation. phonetica, 38, 51-65. lubker, j. & gay, t. (1982). anticipatory labial coarticulation: experimental, biological and linguistic variables. journal of the acoustical society of america, 71, 437-448. mcallister, r., lubker, j. & carlson, j. (1974). an emg study of some characteristics of swedish rounded vowels. journal of phonetics, 2, 267-278. mclean, m. (1973). forward coarticulation of velar movement at marked junctural boundaries. journal of speech and hearing research, 16, 286-296. sussman, h.m., marquardt, t.p., mcneilage, p.f. & hutchinson, j.a. (1988). anticipatory coarticulation in aphasia: some methodological considerations. brain and language, 35,367379. sussman, h.m. & westbury, j.r. (1981). the effects of antagonistic gestures on temporal and amplitude parameters of aniticipatory labial coarticulation. journal of speech and hearing research, 22, 16-46. van der merwe, a. (1986). die motoriese beplanning van spraak by verbale apraksie. ongepubliseerde d.phil-verhandeling. universiteit van pretoria. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 karin theron, anita van der merwe en malcolm baker bylae 1 roudata wat konsonantstringtyd en antisiperingstyd vir die onderskeie uitings van die vyf proefpersone aandui uiting konsonantstringtyd (x) (ms) antisiperingstyd (y) (ms) proefpersoon 1 2 3 4 5 1 2 3 4 5 /isi/ 276 192 206 154 212 184 230 306 230 246 /istu/ 292 226 192 256 300 608 420 432 266 410 /istsu/ 442 404 404 464 600 780 490 852 284 632 /iststu/ 694 586 412 578 650 790 432 874 432 562 /ikststu/ 800 668 486 604 664 116 256 950 616 544 /1s3/ 276 424 208 166 158 520 144 190 164 348 /isto/ 458 316 194 220 198 714 206 238 290 342 /istsz>/ 574 476 388 254 560 886 206 248 166 704 /iststo/ 670 524 516 502 604 854 284 718 522 508 /ikststo/ 630 640 550 520 664 780 162 688 604 296 /gistul/ 230 218 216 170 188 366 144 514 200 414 /dis/ /tula/ 350 254 318 224 320 462 182 332 302 492 /gistut/ 238 410 216 190 192 400 184 326 234 292 /dis/ /tutdrs/ 320 488 304 254 300 518 186 390 528 334 /gistup/ 308 204 228 224 226 500 222 482 358 462 /dis/ /tupa/ 326 188 332 190 282 386 206 454 222 474 /gisz>f7 236 194 236 190 216 376 238 322 336 304 /dis//tofis/ 376 190 232 160 242 504 228 592 252 412 /gis=>l/ 334 168 98 190 224 548 198 392 238 384 /dis//tola/ 340 190 863 188 230 1002 222 242 280 416 /gisz>m/ 290 208 214 206 180 406 226 316 502 ι 396 the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 97 'η elektroglottograflese analise van sekere stemparameters: normatiewe aanduidings kobie cloete emily groenewald anita van der merwe departement spraakheelkunde en oudiologie universiteit van pretoria jean badenhorst departement statistiek universiteit van pretoria opsomming 'n omvattende stemevaluasie behels meer as net die evaluasie van perseptuele en organiese aspekte. vir 'n volledige stemevaluasie is dit belangrik dat verskeie objektiewe metings die diagnostiese battery aanvul. ten einde normatiewe riglyne vir sekere kwantitatiewe elektro-glottografiese metings vir die universiteit van pretoria se spraaknavorsingslaboratorium daar te stel, is 25 mans en 25 dames metperseptueel normale stemme, uit 'n ouderdomspektrum van 8 tot 80 jaar, ondersoek met betrekking tot gemiddelde fundamentele frekwensie, piek-tot-piek frekwensiefluktuasie, piektot-piek amplitudefluktuasie en harmoniek /ruis-verhouding. resultate dui aan dat al hierdie parameters sensitiefis vir verandering in stemproduksie as gevolg van veroudering, vokaalen luidheidsveranderinge. die waarde van die verkree data vir navorsing en die kliniese praktyk word bespreek. abstract a comprehensive voice evaluation comprises more than just the evaluation of perceptual and organic aspects. objective voice analysis should supplement the diagnostic battery. in order to obtain normative indications for the speech research laboratory at the\university of pretoria, 25 men and 25 women ranging in age from 8 to 80 years and with perceptually normal voices were tested with regard to fundamental frequency, cycle to cycle frequency fluctuation (jitter), cycle to cycle amplitude fluctuation (shimmer) and harmonic i noise ratio. results indicate that these parameters are sensitive to changes in voice production caused by ageing, changes in loudness and the production of different vowels. the implications of these results for research and clinical practice are discussed. 'n omvattende stemevaluasie behels meer as net die evaluasie van perseptuele en organiese aspekte. vir 'n volledige stemevaluasie is' dit belangrik dat verskeie objektiewe metings die diagnostiese battery aanvul (gould, 1988; glaze, bless & susser, 1990). stemlaboratoria, bestaande uit onder andere verskeie akoestiese meetinstrumente, het die afgelope dekade vinnig toegeneem (gould, 1988). die ideale stemlaboratorium verskaf optimale informasie vir diagnose en behandeling van 'n stempasient en kan gebruik word vir verdere navorsing om steeds meer gesofistikeerde pasientsorg te verseker (sataloff, spiegel, carroll, darby, hawkshaw & rulnick, 1990). die spraaknavorsingslaboratorium van die universiteit van pretoria beskik oor die nodige instrumentasie vir die uitvoer van elektroglottograflese (egg) metings, maar weens 'n gebrek aan normatiewe data is dit moeilik om hierdie tegniek sinvol aan te wend. hierdie behoefte aan norme blyk ook uit die literatuur. (wilcox & horii, 1980; hollien, 1987; colton & conture, 1990; fitch, 1990; glaze etal., 1990; sataloff et al., 1990). hierdie studie beoog dus die uitbreiding van stemanalisemetodiek deur die daarstelling van normatiewe riglyne vir egg-metings, vir gebruik met normale en patologiese stemme. die elektroglottograaf is 'n objektiewe, nie-indringende meetinstrument wat gebruik word om stembandaktiwiteit te ondersoek sonder veel ongemak of inmenging met fonasie (gould, 1988). dit meet die elektriese stroom tussen twee elektrodes aan weerskante van die larinks soos wat dit deur die nekweefsel en stembande beweeg (mcfarlane & watterson, 1991). die resultaat is 'n weerstandsgolfpatroon. normale stembandvibrasie produseer 'n reeks relatief eweredige weerstandsgolwe en word as 'n gelykmatige klank gehoor, ten spyte van minimale fluktuasie in die golfpatroon (mcfarlane & watterson, 1991). die s t e m b a n d e is 2 o n a f h a n k l i k e v i b r a t o r s wat elk funksioneer op grond van die inherente fisiologiese eienskappe (bv. stembandmassa, -spanning, spieraktiwiteit, neurale aktiwiteit en kardio-vaskulere die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 98 kobie cloete, emil betrokkenheid) daarvan. indien die gekombineerde werking van die twee afsonderlike stembande 'n reeks weerstandsveranderinge tot gevolg het wat varieer in terme van tyd en/of amplitude, word die stem as grof, skor of hees waargeneem (horii, 1980; hollien, 1987; orlikoff & kahane, 1991). akoestiese metings, naamlik piek-tot-piek frekwensiefluktuasie ("jitter") en piek-tot-piek amplitudefluktuasie ("shimmer") reflekteer onderskeidelik die stabiliteit en reelmaat van stembandvibrasie. lae piektot-piek frekwensiefluktuasie (ppff)-waardes dui dus op relatief hoe stabiliteit in die frekwensie van stembandvibrasie en lae piek-tot-piek amplitudefluktuasie (ppaf)-waardes dui op 'n hoe mate van reelmaat in die amplitude van stembandvibrasie (orlikoff en kahane, 1991). uit die literatuur blyk dit dat ppff en ppaf baie hoer waardes by growwe, skor, en hees stemme het. piek-tot-piek fluktuasies is ook baie groter in patologiese stemme as in normale stemme (horii, 1980; hollien, 1987; brown, morris & michel, 1989; linville, korabic & rosera, 1990). onlangs is 'n kwantitatiewe stemanalise-program vir die kay dspsonagraph (model 5500) beskikbaar gestel. hierdie program bepaal, m.b.v. 'n elektroglottograaf, outomaties gemiddelde fundamentele frekwensie (gem. fo), ppff, ppaf en gee 'n harmoniek/ruis-verhouding (wat 'n aanduiding gee van die hoeveelheid ruis of heesheid in die stem). navorsing dui daarop dat 'n akoestiese analise van die stem moontlik die eerste akkurate informasie aangaande patologiese verandering in die larinks verskaf (baken, 1987). veroudering impliseer nie noodwendig 'n patologiese toestand nie, maar normale anatomiese en fisiologiese verandering tree wel met veroudering in (hollien, 1987). veranderinge in perseptuele en akoestiese eienskappe in die verouderende stem kan aan ouderdomsverwante anatomiese en fisiologiese veranderinge op molekulere, sellulere en orgaanvlak toegeskryf word, wat dwarsdeur die hele liggaam plaasvind (aronson, 1985; chodzko-zajko & ringel, 1987; biever & bless, 1989; orlikoff, 1990a). volgens orlikoff (1990a) word die fonatoriese sisteem die meeste van enige komponent in die spraakmeganisme deur veroudering geaffekteer. dit blyk dus dat 'n behoefte aan bruikbare norme vir verskillende ouderdomsgroepe bestaan. metode doelstellings die doel van die studie is die uitvoering van 'n egganalise van spesifieke stemparameters van sprekers met perseptueel normale stemme, ten einde normatiewe riglyne daar te stel. die subdoelstellings is om die invloed van ouderdom asook vokaalen luidheidsveranderinge op die volgende stemparameters na te gaan: gemiddelde fundamentele frekwensie (gem. fo) by manlike en vroulike sprekers piek-tot-piek frekwensiefluktuasie (ppff) piek-tot-piek amplitudefluktuasie (ppaf) harmoniek/ruis-verhouding (h/r-verhouding) groenewald, anita van der merwe, jean badenhorst navorsingsontwerp hierdie studie behels 'n kruisseksie-opname (guy, edgley, arafat & allen, 1987) deur middel van die korrelatiewe navorsingstegniek (smit, 1983). 'n kwotasteekproef word gebruik om proefpersone te selekteer. proefpersone word sodoende in verskillende kombinasies van ouderdom en geslag georden, om 'n objektiewe beeld van die stemeienskappe van persone van verskillende geslagte, in spesifieke ouderdomsgroepe, langs 'n ouderdomskontinuum te verkry. hierdie tipe navorsingsontwerp het dan ook die voordeel dat veranderlikes onder natuurlike omstandighede bestudeer kan word en die ko-variasie tussen die onderskeie veranderlikes ondersoek kan word. informasie wat deur die opname-studie verkry word, kan na die hele populasie veralgemeen word (guy et al., 1987). hierdie tipe studie is dus voordelig om te gebruik vir die opstel van 'n normbasis. proefpersone kriteria vir die aeleksie van proefpersone: ouderdom: aangesien die beplande databasis vir 'n ouderdomspektrum opgestel word, is proefpersone binne die volgende vyf oudersomsintervalle ondersoek: 8 tot 10 jaar die kinders moet geen tekens van puberteit toon nie (glaze et al., 1990), aangesien spesifiek 'n prepuberteitsanalise van die stem gemaak word. 19 tot 23 jaar -hierdie post-puberteitsanalise van die stem behoort optimale stembandf u n k s i o n e r i n g te reflekteer, aangesien maksimum effektiwiteit in liggaamlike funksionering origeveer in hierdie tydperk plaasvind (orlikoff, 1990a). ; 30 tot 40 j a a r o r l i k o f f ( 1 9 9 0 a ) p o s t u l e e r dat liggaamlike funksionering toenemend vinniger begin afneem vanaf ongeveer dertigjarige ouderdom. deur hierdie groep in te sluit kan die aanvang van stemveroudering gemonitor word. 50 tot 60 jaar-hierdie kategorie word ingesluit om die status van stembandfunksionering te e v a l u e e r net voor w e r k l i k e veroudering begin intree. 70 tot 80 jaar:-na die sesde lewensdekade is dit moeilik om groepsgemiddelde op^persone toe te pas, selfs al vind normale veroudering plaas (orlikoff, 1990b). as gevolg van baie kontroversie in die literatuur (shipp & hollien, 1969; horii & ryan, 1981; hollien, 1987), blyk dit nodig te wees om aparte norme, spesifiek vir hierdie ouderdoms-groep, daar te stel. the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η elektroglottografiese analise van sekere stemparameters 99 ander faktore: 5 manlike en 5 vroulike proefpersone per ouderdomsgroep is geselekteer op grond van perseptueel normale stem. geen relevante mediese probleme mag teenwoordig wees nie. persone mag nie meer as 20 sigarette per dag rook nie, moet oor normale gehoor beskik, nie oormatig oorgewig wees nie en nie medikasie gebruik wat 'n uitdrogingseffek op die larinks het nie (orlikoff, 1990a; hollien, 1987; horii, 1980; fitch, 1990; baken 1987). materiaal die vokale /a:/ en hj word geselekteer vir hierdie studie. uit die literatuur blyk dit dat hierdie twee vokale die meeste vir egg-opnames gebruik word (childers & lee, 1991). die vokale /a:/ en /i:/ verteenwoordig die grootste moontlike fisiologiese omvang vir vokaalproduksie (fitch, 1990). aangesien persone met s t e m p a t o l o g i e d i k w e l s p r o b l e m e o n d e r v i n d met luidheidsveranderings, word elke vokaal ook met verhoogde luidheid geproduseer sodat 'n basis verkry kan word waarmee patologiese luidheidverandering vergelyk kan word. apparaat die volgende apparaat is gebruik vir die stemopnames: "portable electro-laryngograph" met elektrodes, electro-voice mikrofoon model 63ib, kay dsp sonagraph model 5500 en nec multisync ii vertoonskerm. die opstelling van die apparaat is gedoen soos voorgestel in die handleiding van die sonagraaf (kay elemetrics corp., 1989). die analise is met behulp van die outomatiese stemanaliseprogram, model 5625, van die dsp sonagraph gedoen. prosedure vir dataversameling die plasing van die elektrodes op die proefpersoon se larinks het volgens die prosedure, soos aanbeveel deur'mcfarlane en watterson (1991) en colton en conture (1990), geskied. optimale elektrodeplasing en opname-instellings is telkens getoets deur voorafgaande proefopnames (kay elemetrics corp., 1989). die vokaal /a/ en lil is op dieselfde wyse geproduseer, opgeneem en ontleed. elke vokaal is vir 2 sekondes geproduseer by normale gesprekstoonhoogte en -luidheid, gevolg deur 'n produksie van 2 sekondes teen verhoogde luidheid. elke uiting is 3 maal herhaal en afsonderlik ontleed, om sodoende die invloed van intrapersoonlike variasie te bekamp. prosedure vir data-analise die analiseprosedure by elke uiting, het bestaan uit die afbakening van ongeveer 100 siklusse van 'n stabiele, middelgedeelte van die lx-sein, soos op die skerm geposisioneer. (horii, 1980; linville et'al., 1990). die onderskeie parameters is dan outomaties bereken deur die aktivering van die stemanaliseprogram. die meting van gemiddelde fundamentele frekwensie fundamentele frekwensie word bepaal deur die vibrasiespoed van die stembande en bepaal die toonhoogte van fonasie. die gemiddelde fo is telkens bereken vir 'n periode van ongeveer 100 siklusse. die meting van ppfv lieberman (1963) definieer ppff ("jitter") as die s i k l u s t o t s i k l u s fluktuasie in fundamentele frekwensie. die stemanaliseprogram gebruik 'n manipuleerde vorm van koike se formule (kay elemetrics corp., 1989) om ppff te bereken. resultate word as persentasie (%) weergegee. die meting van ppaf ppaf ("shimmer") of soos horii (1980) dit definieer, siklus-tot-siklus amplitudefluktuasie, word in hierdie studie bepaal deur die verskil tussen die mees positiewe en mees negatiewe pieke te bereken (kay elemetrics corp., 1989). die verkree ppaf-waardes word in desibel (db) uitgedruk. die meting van harmoniek/ruis-verhouding die h/r-verhouding druk die verskil in db uit tussen die harmoniese en ruiskomponente in die afgebakende deel van die stemgolf. dus, hoe kleiner die v e r s k i l w a a r d e tussen die a m p l i t u d e van die harmoniese komponent en die amplitude van die ruis* komponent, hoe kleiner is die h/r-verhoudingswaarde. 'n klein h/r-verhouding dui op 'n hoe mate van ruis in die stem en word as heesheid gehoor (yumoto, 1988). prosedure van dataverwerking 'n variansie analise is op die finale data gedoen met behulp van proc anova en die sas-programpakket. hierdie analise het getoets vir enige betekenisvolle verskille tussen die verskeie veranderlikes. die peil van betekenis was bepaal by p<0.05. uit die data is statistiese gegewens aangaande die verskeie veranderlikes verkry om sodoende frekwensieverdelings, gemiddeldes, standaardafwykings, minimumen maksimumwaardes te bereken. uit die finale data is vertrouensintervalle ook opgestel vir verskeie veranderlikes. 'n 95% vertrouensinterval is gekonstrueer sodat met 95% sekerheid gese kan word dat hierdie interval wel die populasie-gemiddeld sal bevat (waar populasie beduie op die totale groep van persone waarop hierdie studie betrekking het). hierdie interval is gebruik om 'n skatting te maak van die onbekende populasiegemiddeld (steyn, smit & du toit, 1987; bowermann & o'connel, 1990). resultate en bespreking die resultate word beskryf en bespreek aan die hand van die onderskeie subdoelstellings. gemiddelde fundamentele frekwensie ouderdomsverwante verandering in gemiddelde fundamentele frekwensie van mans en vroue. die gem. fo van die mansen vrouegroep verskil statisties betekenisvol op 'n peil van 5%. die resultate vir die 2 groepe word dus afsonderlik verskaf. in figuur 1 word die gem. fo van mans in verskillende ouderdomsgroepe weergegee vir produksie van /a:/ en hj met normale en verhoogde luidheid. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 100 kobie cloete, emily groenewald, anita van der merwe, jean badenhorst gem. fo (hz) 350 η 300 250 2 0 0 150 1 0 0 50 0 1 8-10 i 19-23 i 30-40 i 50-60 i 70-80 /ay normaal 268.4 125.1 119.6 121.4 150.2 /ay hard 284.4 133 134 137.2 166.2 irj normaal 271.3 136.4 137.8 145.8 182.4 lij hard 294.1 146.4 153.6 166.4 196.1 ouderdomsgroepe flare) fonasie /a:/ normaal μ hard ""·"" fi:l normaal —θ μ hard figuur 1: die verandering in gem. fo van mans in verskillende ouderdomsgroepe tydens produksie van /a:/ en /i:/ met normale en verhoogde luidheid. 350 300 250 200 gem. fo (hz) 350 300 250 200 » v v ν λ ο 350 300 250 200 κ 150 100 50 0 0 1 i i 1 8-10 19-23 30-40 50-60 70-80 /a:/ normaal 291.5 250.1 221.1 233.3 200.6 /ay hard 305.8 253.9 226.2 239.7 216.6 /i:/ normaal 299.8 261.4 233.2 251.1 244.1 /i:/ hard 331.3 267.3 239.9 261.8 267.4 ouderdomsgroepe flare) fonasie 1 /a:/ normaal ·• /&/ hard 1 fr.l normaal μ hard figuur 2: die verandering in gem. fo van vroue in verskillende ouderdomsgroepe tydens produksie van die vokale /a:/ en /i:/ met normale en verhoogde luidheid. daar is 'n skerp daling in gem. fo na puberteit. slegs die 8-10 jaar groep verskil statisties, op 'n 5% peil van betekenis, van die ander ouderdomsgroepe. die verlaging in fo na puberteit, is die logiese gevolg van fisiese groei van die fonasiestruktuur. dit word gevolg deur 'n neiging tot verhoging in gem. fo met veroudering, wat moontlik toegeskryf kan word aan ouderdomsverwante veranderinge wat in die larinks plaasvind, bv. verdunning van die stembande a.g.v. atrofie, dehidrasie van die laringale m u k o s a , v e r m i n d e r i n g in die elastisiteit van die laringale ligamente, toenemende ossifikasie en kalsifikasie van die k r a a k b e n i g e strukture van die larinks en afname in sentrale senuweestelselkontrole (aronson, 1985; chodzko-zajko & ringel, 1987; orlikoff, 1990b). die gem. fo waardes verkry in die huidige studie korreleer met die resultate van ander navorsers (aronson, 1985; colton & casper, 1990; childers & lee, 1991). in figuur 2 word die gem. fo van vroue in verskillende ouderdomsgroepe weergegee tydens produksie van die vokale /a:/ en /i:/ met normale en verhoogde luidheid. figuur 2 vertoon 'n geleidelike verlaging in gem. fo van die vokale /a:/ en /i:/ vanaf die ouderdomsgroep 810 jaar tot by die ouderdomsgroep 30-40 jaar. hierdie verlaging in die gem. fo van vroue is nie so groot as die verlaging in gem. fo wat by mans in dieselfde tydperk voorkom nie. die laagste gemiddelde fo-waardes word deur die groep 70-80 jaar vertoon. die gemiddelde fowaardes van die verskillende ouderdomsgroepe verskil egter nie statisties, op 'n 5% peil van betekenis, nie. dit kom voor asof die invloed van veroudering nie e e n v o r m i g e gem. fo v e r a n d e r i n g e by alle vroue teweegbring nie, terwyl 'n styging in gem. fo by feitlik alle mans voorkom. uit die literatuur blyk baie kontroversie rondom die invloed van veroudering op die gem. fo van vroue (mcglone & hollien, 1963) en sommige navorsers (aronson, 1985), voel dat hierdie verskillende neigings nie verklaar kan word nie. hollien (1987) postuleer egter dat menopouse die omgekeerde van puberteit is. die neiging van mans se gem. fo om na die ouderdom van 50-60 jaar toenemend te begin styg en vroue se gem. fo wat neig om te daal, staan in1 die literatuur bekend as die "sentrale neiging" (orlikoff, 1990b) wat hollien (1987) se siening dat die menopciuse die omgekeerde effek as puberteit op gem. fo (het bevestig. j vokaalverwante verandering in gem. fo ^an mans en vroue ( soos dit blyk uit figure 1 en 2 is die gem. fo van /i:/ telkens hoer as vir /a:/. die /i:/ is 'n hoe, voorvokaal en produksie van hierdie vokaal behels dat die tong gelig word. met die oplig van die tong word die hioi'edbeen en larinks opwaarts getrek en die laringale spiere word gestrek. gevolglik verhoog die elastisiteit van die stembande en het hoer gem. fo waardes vir ivj tot gevolg (aronson, 1985). . ^ luidheidsverwante veranderinge in gem. fo van mans en vroue fonasie met verhoogde luidheid het telkens hoer gem. fo-waardes as normale fonasie tot gevolg. hierdie verhoging in gem. fo tydens harde fonasie kan gesien the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η elektroglottografiese analise van sekere stemparameters 101 word as die resultaat van veranderinge in o.a. subglottale lugdruk wat vir klankpeilvariasie benodig word. tydens harde fonasie kom die grootste gem. foverhoging by die 70-80 jaar voor. verskeie outeurs rapporteer 'n toename in die veranderlikheid van gem. fo van bejaardes wat toegeskryf kan word aan 'n verlies aan aanpasbaarheid as gevolg van 'n vermindering in spiertonus en -krag, ossifikasie en ander ouderdomsverwante veranderinge in die bindweefsel van die laringale kraakbeen. (hollien, 1987; colton & casper, 1990; orlikoff, 1990a; biever & bless, 1989; brown et al., 1989). piek-tot-piek frekwensiefl uktuasie statistics betekenisvolle verskille kom nie by die piek-tot-piek frekwensiefluktuasie (ppff) ("jitter")waardes van mans en vroue voor nie. om hierdie rede word die verkree resultate gekombineer en weergegee in figuur 3. 1 ppff (%) 0.7 0.6 0.5 / * 0.4 // ϊ / // 0.3 0.2 i\\ .y y 0.1 0 i i 8-10 19-23 30-40 50-60 70-80 /aj normaal 0.357 0.241 0.334 0.344 0.678 /av/hard 0.308 0.192 0.166 0.307 0.464 ivj normaal 0.334 0.20j1 0.235 0.344 0.542 lij hard 0.285 0.219 0.159 0.287 0.449 \ ouderdomsgroepe (jare) ! —— lay normaal ftu/ hard —*— /i:/normaal; b μ hard figuur 3:ppff-waardes van mans en dames in verskillende ouderdomsgroepe tydens produksie van /a:/ en /i:/ met normale en verhoogde luidheid. ouderdomsverwante verandering in ppff lae ppff-waardes reflekteer relatief hoe stabiliteit in stembandvibrasie. die groep 19-23 jaar verkry dan ook die laagste gemiddelde ppff-waarde vir /a:/ en /i:/, wat dui op die mees stabiele stembandvibrasie van al die ouderdomsgroepe. orlikoff (1990a) rapporteer dat liggaamsfunksionering maksimum effektiwiteit tussen 20-29 jarige ouderdom bereik. die lae ppff-waardes van die groep 19-23 jaar korrelleer dan ook met hierdie stelling van orlikoff. teen dertigjare ouderdom begin homeostatiese funksionering, sowel as kompensatoriese en regulatoriese kontrole in die liggaam afneem. ppff bereik dan ook 'n maksimum gemiddelde waarde (figuur 3) by die groep 70-80 j a a r en v e r s k i l s t a t i s t i c s betekenisvol, op 'n 5% peil van betekenis, van die ander ouderdomsgroepe. hierdie hoer ppff-waardes wat korreleer met 'n toename in ouderdom dui dus op 'n geleidelike verlies in stabiliteit in stembandvibrasie en word geassosieer met growwe, skor en hees stemme (hollien, 1987; horii, 1980; orlikoff, 1990a). alle bejaardes vertoon nie hoe ppff-waardes nie. hierdie verskynsel word in die literatuur verklaar aan die hand van die fisiese gesondheid van die proefpersone, veral wat betref kardiovaskulere gesondheid (biever & bless, 1989; brown et al., 1989; orlikoff, 1990b). orlikoff (1990a) vind dat gesonde, bejaarde mans se ppff ooreenstem met die ppff van mans in hul twintigerjare, terwyl bejaarde mans met aterosklerose baie hoer ppff-waardes as die gesonde jong en bejaarde mans vertoon. dit is dus duidelik dat sekere gesondheidsverwante faktore ppff-resultate kan bei'nvloed. dit/is verder ook bekend dat alle liggaamlike sisteme nie ewe vinnig verouder nie en dat laringale veroudering by sommige persone vinniger as by ander kan plaasvind (chodzko-zajko & ringel, 1987). by die opstel van normatiewe riglyne moet die wye omvang van ppff-waardes van bejaardes dus ingedagte gehou word en kan groepsgemiddelde nie sonder meer op die geriatriese populasie toegepas word nie. vokaalverwante verandering in ppff die verskillende vokale het nie 'n statisties betekenisvolle invloed op ppff nie, alhoewel dit voorkom asof /a:/ meer konstante resultate oplewer. hierdie resultate korreleer ook met die van wilcox & horii (1980). luidheidsverwante veranderinge in ppff uit die resultate van ppff blyk dit dat fonasie met verhoogde luidheid feitlik konstant laer waardes oplewer as fonasie met normale luidheid. glaze et al. (1990) postuleer dat luidheidsveranderinge teweeggebring word deur veranderinge in subglottale lugdruk en die mediale kompressie van die stembande wat gevolglik die stembandvibrasiepatroon verander deur verlenging van die geslote fase van stembandvibrasie. die v e r a n d e r i n g e wat in die s p r a a k p r o d u k s i e meganisme plaasvind vir harde fonasie kan dus moontlik bydra tot groter stabiliteit in die vibrasiepatroon van die stembande en lewer gevolglik laer ppff-waardes op. piek-tot-piek amplitudefl uktuasie geen statisties betekenisvolle verskille kom by die piek-tot-piek amplitudefluktuasie (ppaf) ("shimmer")waardes van die twee geslagte voor nie en daarom word mans en dames se resultate gekombineerd in figuur 4 weergegee. figuur 4 stel die verandering van ppaf met toename in ouderdom voor, vir die vokale /a:/ en /i:/ tydens produksie met normale en verhoogde luidheid. ouderdomsverwante veranderinge in ppaf die ppaf-waardes van die verskillende ouderdomsgroepe verskil nie statisties, op 'n 5% peil van betekenis, die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 102 kobie cloete, emily groenewald, anita van der merwe, jean badenhorst p p a f (db) 0.5 0.4 0.3 \ \ ' , 0.3 \ ' , 0.3 -g 0.2 * ' 0.2 ' • * * ' 0.1 0 ι — i 8-10 19-23 30-40 50-60 70-80 /a:/ normaal 0.288 0.232 0.353 0.343 0.444 laj hard 0.251 0.189 0.212 0.314 0.329 lij normaal 0.359 0.307 0.42 0.33 0.343 ivj hard 0.346 0.268 0.314 0.249 0.26 ouderdomsgroepe flare) ——/aynormaal ·•*•• /&:/ hard —»— flu normaal e μ hard figuur 4: ppaf-waardes van mans en dames in verskillende ouderdomsgroepe tydens produksie van l&'j en /is/ met normale en verhoogde luidheid. van mekaar nie. lae ppaf-waardes reflekteer 'n hoe mate van reelmaat in stembandvibrasie. die groep 1923 jaar behaal vir beide vokale /a:/ en iv.l die laagste ppaf-waardes wat dui op die mees reelmatige stembandvibrasie van al die ouderdomsgroepe. hierdie resultate korreleer met o r l i k o f f (1990a) se stelling dat maksimum effektiwiteit in liggaamsfunksionering ongeveer in die tydperk 20-29 jaar plaasvind. glaze et al. (1990) vind dat ppaf-waardes vir kinders 5-11 jaar buite die ppaf-waardes van volwassenes le. die groep 8-10 jaar van die huidige studie, vertoon ook hoer waardes by k i n d e r s op grond van voortdurende anatomiese en morfologiese struktuurveranderinge op hierdie ouderdom. tydens die maak van opnames vir die huidige studie is ook gevind dat opnames oor die algemeen moeiliker vir kinders as volwassenes gemaak word, a.g.v. moeiliker elektrodeplasing. 'n swak golfpatroon is ook in sommige gevalle verkry, wat die gevolg kan wees van meer vetweefsel in die nek wat algemeen by kinders voorkom (colton & conture, 1990; baken, 1987), maar ook die gevolg van swak elektrodekontak op die klein en hooggeplaaste larinks. hierdie veranderlikes dra moontlik by tot die hoer ppafen ppff-waardes wat vir kinders in die huidige, sowel as ander studies verkry is (colton & conture, 1990; glaze et al., 1990). net soos die geval by ppff, korreleer die hoer gemiddelde ppaf-waardes met 'n toename in ouderdom en dui op 'n geleidelike verlies aan reelmaat in stembandvibrasie soos wat 'n persoon verouder. hoe ppafen ppff-waardes is direkte korrelate van 'n growwe, skor en hees stem, en kan verwag word dat die verouderende stem toenemend grof, skor en hees sal klink. dit is egter nie altyd die geval nie. tydens die huidige studie behaal sommige bejaardes ppaf-waardes wat korreleer met die waardes van die groep 19-23 jaar. net soos die geval by ppff kan die afleiding gemaak word dat fisiese gesondheid met stemfunksie verband hou. alhoewel die proefpersone van die huidige studie gesond was, is faktore soos arteriosklerose en osteop o r o s e nie spesifiek g e k o n t r o l e e r nie. h i e r d i e veranderlikes, wat nie in dieselfde mate by die bejaarde proefpersone voorkom nie, kon ook moontlik bydra tot hoer ppaf(en ppff)-waardes (chodzko-zajko & ringel, 1987; brown et al., 1989; orlikoff, 1990b). vokaalverwante veranderinge in ppaf by vergelyking van ppaf-resultate van /a:/ en ivj blyk dit dat die vokaal /a:/ beter is om te gebruik vir die meting van ppaf as ivj, aangesien dit voorkom asof ivj meer onkonstante resultate oplewer as /a:/. hier kan onkonstante ppaf-resultate van ivj moontlik toegeskryf word aan die opwaartse verplasing van die larinks tydens produksie van ivj, aangesien die elektrodes spesifiek geplaas word vir produksie van die vokaal /a:/ en nie vir /i:/-produksie aangepas word nie. luidheidsverwante veranderinge in ppaf figuur 4 toon aan dat fonasie met verhoogde luidheid telkens laer ppaf-waardes as normale fonasie tot gevolg het. dit wil voorkom asof die veranderinge wat in die stemproduksie-meganisme vir fonasie met verhoogde luidheid plaasvind, bydra tot groter reelmaat in stembandvibrasie en gevolglik laer ppaf-waardes oplewer as normale fonasie. dit is dus duidelik uit huidige resultate dat stemluidheid gekontroleer moet word tydens metings. harmoniek/ruis-verhouding die h/r-verhoudingswaardes (h/r-verhouding) van mans en vroue verskil nie statisties betekenisvol, pp 'n peil van 5% betekenis, van mekaar nie en daarom is die resultate gekombineer en weergegee in figuur 5. figuur 5 stel die v e r a n d e r i n g in h / r v e r h o u d i n g met veroudering vir die vokale /a:/ en ivj tydens produksie met normale en verhoogde luidheid voor. | ι ouderdomsverwante veranderinge in h/rverhouding i in figuur 5 is dit duidelik dat h/r-verhoudiiigswaardes 'n dalende tendens met veroudering vertoon. die h/r-verhoudingswaardes verskil nie statisties, op 'n 5% peil van betekenis, vir die groepe 8-10, 19-23, 3040 en 50-60 jaar nie. die h/r-waardes van die 70-80 jaar groep, vir fonasie teen normale luidheid, verskil wel statisties betekenisvol van die ander groepe. in teenstelling met ppff en ppaf reflekteer 'n hoer h/rverhouding beter stembandfunksionering. volgens yumoto (1988) is die h/r-verhouding 'n goeie aanduiding van die graad van heesheid wat in die stem voorkom, aangesien die h/r-verhouding aandui in hoe 'n mate die harmoniese komponent deur die ruiskomponent in die stem verplaas word. uit figuur 5 wil dit dus voorkom asof ouderdomsverwante involusie van die laringale strukture heesheid tot gevolg kan he, en moontlik tot the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η elektroglottografiese analise van sekere stemparameters 103 25 22.5 20 17.5 15 12.5 10 h/r verhouding (db) 8-10 19-23 30-40 50-60 70-80 laj normaal laj hard ivj normaal ivj hard 17.9 19.5 17.3 18.2 17.5 18.5 17.8 16.6 17.6 18 18.4 18.5 15.4 15.4 17.8 17.9 13 14.3 14.8 15.5 ouderdomsgroepe flare) /a:/ normaal /i:/ normaal •·*·• /&:/ hard μ hard figuur 5: die h/r-verhoudingswaarde van persone in verskillende ouderdomsgroepe tydens produksie van la.il en liil met normale en verhoogde luidheid. perseptuele verskille tussen ou en jong stemme bydra (shipp & hollien, 1969; hollien, 1987). alle bejaarde persone behaal egter nie lae h/r-verhoudingswaardes in die huidige studie nie. soos in die geval by ppff en ppaf kan die afleiding gemaak word dat alle persone se laringale strukture nie diieselfde mate van involusie met veroudering ondergaan nie (chodzko-zajko & ringel, 1987), en dat heesheid eerder met patologie van die larinks as met veroudering verband hou. vokaalverwante verandering in h/r-verhouding ι soos dit blyk uit die resultate van ppaf, ppff en ook h / r v e r h o u d i n g , lewer die vokaal /a:/ meer konstante resultate op as iv.l. die meeste studies wat h/r-verhouding ondersoek, gebruik dan ook die vokaal /a:/ vir opnames (yumoto, 1988). luidheidsverwante verandering in h/r-verhouding uit figuur 5 blyk dit dat hoer gemiddelde h/rverhoudingswaardes telkens vir harde fonasie as vir normale fonasie behaal word. dit blyk dus 'dat harde fonasie telkens beter stemband-funksionering tot gevolg het as normale fonasie. aanduidings vir die daarstelling van 'n normatiewe basis die resultate van die gemiddelde fo-waardes vir mans en vrouens word o.g.v. die betekenisvolle statistiese verskille tussen die 2 groepe, afsonderlik beskou. hoewel slegs die 8-10-jaar-groep van die mans statisties, op 'n 5% peil van betekenis, van die ander ouderdomsgroepe verskil, word die gegewens vir die verskillende ouderdomsgroepe nogtans afsonderlik verskaf. dit word gedoen na aanleiding van vorige navorsingsbevinding wat daarop dui dat luisteraars perseptuele verskille tussen ouderdomsgroepe waarneem. (horii & ryan, 1981; biever & bless, 1989; brown et al., 1989). gegewens van gemiddelde fo-waardes, word verskaf in bylaag 1. 'n statistiese berekening van 95% vertrouensintervalle is nie vir die gem. fo-waardes gedoen nie, omdat die data vir mans en vroue nie gekombineer kon word nie en die groepe gevolglik te klein was. 'n normatiewe basis vir verskillende ouderdomsgroepe betreffende ppff-, ppafen h/r-verhoudingswaardes word verskaf in bylae 2, 3 en 4 respektiewelik. die resultate van mans en vroue kan gekombineer word omdat geen betekenisvolle verskil bestaan nie. die gegewens vir elke parameter is verkry deur statistiese berekenings van vertrouensintervalle, wat geld vir 95% van die populasie. aangesien die produksie van /a:/ deurgaans meer konstante en betroubare resultate gelewer het, is die waardes vir 'n normatiewe basis geselekteer. die verkree resultate van ppff-, ppafen h/r-verhoudingswaardes korreleer met die van ander navorsers en kan dus as betroubaar aanvaar word. (horii, 1980; kay elemetrics corp., 1989; brown etal., 1989; wilcox & horii, 1980; orlikoff en kahane, 1991; glaze et al., 1990). gevolgtrekkings uit die resultate van die huidige studie kan die volgende afleidings gemaak word: gem. fo-waardes van mans en vrouens verskil betekenisvol. gem. fo van mans vertoon 'n kurviliniere verloop met ouderdom, naamlik 'n betekenisvolle verlaging in gem. fo vanaf 8-10 jaar tot 3040 jaar, waarna geleidelike styging in gem. fo met verdere veroudering plaasvind. individuele verskille kom egter voor. die gem. fo van vroue verlaag ook vanaf die ouderdomsgroep 8-10 jaar tot en met 30-40 jaar, maar met toenemende ouderdom vind egter een van drie veranderinge plaas naamlik min verandering, 'n effense verlaging of eers 'n verlaging en dan 'n verhoging. geen statisties betekenisvolle verskille kom vir ppff, ppaf en h/r-verhouding van mans en dames voor nie. een normbasis kan dus vir mans en dames per ouderdomsgroep opgestel word. ppff en ppaf verhoog met veroudering terwyl die h/r-verhouding verlaag. individuele verskille kom egter, veral by die geriatriese populasie, voor. die vokaal /a:/ lewer meer konstante resultate op as die vokaal li:l vir ppff, ppaf en h/r-verhouding en behoort dus as basis vir ouderdomsnorme gebruik te word. fonasie met verhoogde luidheid veroorsaak hoer gem. fo-waardes, laer ppffen ppaf-waardes en hoer h/r-verhoudingswaardes as fonasie met normale luidheid. 'n normbasis vir die onderskeie parameters is daargestel op grond van die statistiese berekening van 95%-vertrouensintervalle, wat gebruik is om 'n skatting te maak van die onbekende populasiegemiddeld. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 104 k o b i e cloete, e m i l y g r o e n e w a l d , a n i t a v a n d e r m e r w e , j e a n b a d e n h o r s t s l o t die h u i d i g e s t u d i e is 'n k w a n t i t a t i e w e analise v a n sekere s t e m p a r a m e t e r s d.m.v. e g g . r e s u l t a t e v a n die studie dra b y tot die u p s p r a a k n a v o r s i n g s l a b o r a t o r i u m se b e s k i k b a r e a n a l i s e m e t o d i e k deur die daarstelling van 'n n o r m a t i e w e b a s i s (sien b y l a e s 1 tot 4) vir g e b r u i k i n die kliniese en navorsingsituasie. a l h o e w e l subjektiewe e v a l u a s i e v a n d i e s t e m s t e e d s n o o d s a a k l i k is, m o e t die s t e m o o k o b j e k t i e f g e a n a l i s e e r w o r d s o d a t perseptuele, o r g a n i e s e e n a k o e s t i e s e d a t a m e k a a r a a n v u l e n s o d o e n d e 'n m e e r o m v a t t e n d e d i a g n o s t i e s e e n t e r a p e u tiese m e t o d i e k d a a r s t e l . v e r w y s i n g s aronson, a.e. 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(1988). quantitative assessment of the degree of hoarseness. journal of voice, 1(4), 310-313. ι v e r s k i l l e n d e o u d e r d o m s g r o e p e t y d e n s n o r m a l e en h a r d e vokaal /a:/ o u d e r d o m s g r o e p g e m . fo ( h z ) m e t n o r m a l e fonasie g e m . fo ( h z ) m e t h a r d e ' fonasie vokaal /a:/ o u d e r d o m s g r o e p l a a g s t e w a a r d e h o o g s t e w a a r d e l a a g s t e w a a r d e h o o g s t e w a a r d e m a n s 8 1 0 19-23 3 0 4 0 5 0 6 0 70-80 237.3 99.2 108.3 8 4 . 4 111.2 290.7 150.4 126.6 167.5 181.6 2 4 0 . 8 103.7 125.9 9 4 . 9 122.9 3 1 0 . 2 9 164.1 140.7 191.4 ' 198.5 8 1 0 2 5 0 . 1 3 1 4 . 2 2 7 4 . 2 , 3 3 8 . 1 19-23 216.8 3 2 3 . 5 2 2 1 . 3 / 3 3 0 . 1 v r o u e 3 0 4 0 194.9 2 4 9 . 7 196.1 2 4 9 . 4 5 0 6 0 175.7 2 7 1 . 5 2 0 2 . 9 2 8 1 . 3 7 0 8 0 174.9 2 2 1 . 2 184.2 / 2 4 1 . 0 the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η elektroglottografiese analise van sekere stemparameters 105 bylae 2 normatiewe aanduidings vir die hoogste en laagste ppff-waardes ("jitter") vir persone in verskillende ouderdomsgroepe tydens normale en harde fonasie van /a:/ ppff ( %) met ppff (%) met harde normale fonasie fonasie vokaal ouderdomslaagste hoogste laagste hoogste groep waarde waarde waarde waarde 8-10 0.251 0.464 0.194 0.423 19-23 0.212 0.27 0.163 0.221 /a:/ 30-40 0.184 0.484 0.123 0.208 50-60 0.228 0.459 0.216 0.397 70-80 0.381 0.975 0.318 0.609 bylae 3 normatiewe aanduidings vir die hoogste en laagste ppaf-waardes ("shimmer") vir persone in verskillende ouderdomsgroepe tydens normale en harde fonasie van /a:/ ppaf (db) met ppaf (db) met harde normale fonasie fonasie vokaal ouderdomslaagste hoogste laagste hoogste groep waarde waarde waarde waarde 8-10 0.185 0.391 0.173 0.328 19-23 0.158 0.305 0.132 0.244 /a:/ 30-40 0.226 0.479 0.154 0.269 50-60 0.224 0.461 0.175 0.453 70-80 0.273 0.614 0.204 0.452 bylae 4 normatiewe aanduidings vir die hoogste en laagste h/r-verhoudingswaardes vir persone in verskillende ouderdomsgroepe tydens normale en harde fonasie van /a:/ h/r-verhouding (db) normale fonasie h/r-verhouding (db) vokaal ouderdomsgroep laagste waarde hoogste waarde laagste waarde hoogste waarde /a:/ 8 1 0 19-23 30-40 50-60 70-80 15.3 14.9 15.2 13.2 8.9 20.7 20.1 19.9 17.7 17.1 17.4 16.6 15.9 12.8 10.7 21.7 20.4 20.1 17.9 17.8 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) information for contributors the south african journal of communication disorders publishes reports and papers concerned with research, and critically evaluative theoretical and philosophical conceptual issues dealing with aspects of human communication and its disorders; service provision; training; and policy. the south african journal of communication disorders will not accept material which has been published elsewhere or that is currently under review by other publications. manuscript style and requirements manuscripts should be accompanied by a covering letter providing the author's address and telephone numbers. all contributions are required to follow strictly, the style specified in the publication manual of the american psychological assoc. 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(1983). clinical psychology: the explanation and treatment of speech sound disorders. j. speech hear. disord., 48 339-341. penrod, j.p. (1985). speech discrimination testing. in j. katz (ed.), handbook of clinical audiology (3rd ed.). baltimore: williams & wilkins. davis, g.a. & wilcox, m.j. (1985). adult aphasia rehabilitation: applied pragmatics. san diego, ca: college-hill. editing acceptable manuscripts may be returned to the author for revision. additional minor changes may also be made at this stage, but a note on the manuscript acknowledging each alteration made by the author, is required. the paper is then returned to the editorial committee for final editing for style, clarity and consistency. reprints: 10 reprints without covers will be provided free of charge. ι deadline for contributions: the preferred date is the 31st may each year, but papers will be accepted until 30th june by arrangement. | queries, correspondence & manuscripts: shiuld be addressed to the editor, south african journal of communication disorders, south african speech-language-hearing association, p.o. box 31782, braamfontein, 2017, south africa. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) inlicting vir bydraers die suid-afrikaanse tydskrif vir kommunikasieafwykings publiseer verslae en artikels wat gemoeid is met navorsing, of handel oor krities evaluerende, teoretiese en filosofiese konseptuele kwessies wat oor menslike kommunikasie en kommunikasieafwykings; diensverskaffing; opleiding en beleid gaan. die suid-afrikaanse tydskrif vir kommunikasieafwykings sal nie artikels aanvaar wat reeds elders gepubliseer is, of wat tans deur ander publikasies oorweeg word nie. manuskrip styl en vereistes: manuskripte behoort deur 'n dekkingsbrief vergesel te word wat die skrywer se adres en telefoonnommers bevat. daar word van alle bydraers verwag om die styl, soos gespesifiseer is in die "publication manual of the american psychological assoc. (3rd ed., 1983) (αρα pub. man."), nougeset te volg met volledige interne ooreenstemming. manuskripte moet getik, van hoe gehalte en in drievoud spasiering met wye kantlyne wees. vier kopiee van die manuskrip moet verskaf word. een hiervan moet 'n identiese skyfkopie van die artikel wees in "wordperfect" 5.1 (met 'n uitbreiding ,wp5). leername behoort die eerste skrywer se voorletters en 'n duidelike identifiseerbare sleutelwoord of afkorting daarvan in te sluit en moet op die laaste lyn van die bladsy van die verwsyingslys getik word (slegs vir naslaan doeleindes). as 'n reel moet bydraes nie 30 bladsye oorskry nie, maar langer artikels sal aanvaar word indien die addisionele lengte dit regverdig. op die eerste bladsy van twee van die afskrifte moet die titel van die artikel, naam van die skrywer(s), en instansie (of adres) verskyn. in ooreenstemming met die "αρα pub. man." se styl word daar nie van skrywers verwag om enige kwalifikasies te verskaf nie. op die eerste bladsy van die twee oorblywende afskrifte moet slegs die titel van die artikel verskaf word. die tweede bladsy van alle afskrifte moet slegs 'n opsomming (100 woorde) in beide engels en afrikaans bevat. afrikaanse opsommings sal vir buitelandse bydraers voorsien word. hoofopskrifte moet, waar van toepassing, in die volgende volgorde verskaf word: metode, resultate, besprekings, gevoljgtrekkings, erkennings en verwysings. alle paragrawe moet ingekeep word. tabelle en figure wat op afsonderlike bladsye (een bladsy per tabel/illustrasie) moet verskyn, moet vir referent doeleindes gekopieer word en slegs die kopiee moet inisieel verskaf word. figure, grafieke en lyntekeriinge wat vir publikasie gebruik word, moet egter oorspronklike weergawes wees en moet in swart ink op wit papier van 'n hoe gehalte wees. die oorspronklikes sal slegs verlang word nadat die artikel vir publikasies aanvaar is. letterwerk wat op bogenoemde verskyn, moet eenvormig wees, professioneel gedoen word en daar moet in gedagte gehou word dat dit leesbaar moet wees na 'n 50% verkleining in drukwerk. letterwerk by illustrasies moet onder geen omstandighede getik word nie. verklarings of legendes moet nie in die illustrasie nie, maar daaronder, verskyn. die opskrifte van tabelle (wat bo-aan verskyn), en die onderskrifte van figure, (wat onderaan verskyn), moet beknop, maar verklarend wees. numering moet deur middel van arabiese syfers geskied. tabelle en figure moet in die volgorde waarin hulle verskyn, genommer word. die aantal tabelle en illustrasies wat ingesluit word, word deur die redakteur bepaal (gewoonlik nie meer as 6 nie). verwysings verwysings in die teks moet voorsien word van die skrywer se van en die datum, b.v., van riper (1971). wanneer daar egter meer as twee skrywers is, moet daar na die eerste verskaffing van al die outeurs, van et al. gebruik gemaak word. in die geval waar daar egter ses of meer outeurs ter sprake moet et al 'van die begin af gebruik word. al die name van die skrywers moet in. die verwysingslys verskyn wat aan die einde van die artikel voorkom. verwysings moet alfabeties in trippel spasiering gerangskik word. al die verwysings moet in die verwysingslys verskyn, insluitende sekondere bronne, ("αρα pub. man." 1983, p. 13). slegs aanvaarbare afkortings van tydskrifte se titels mag gebruik word, (sien "dsh abstracts, october"; of the world list of scientific periodicals"). die aantal verwysings moet nie meer as 30 oorskrei nie, tensy dit geregverdig is. let op die volgende voorbeelde: locke, j.l. (1983). clinical psychology: the explanation and treatment of speech sound disorders. j. speech hear. disord., 48, 339-341. penrod, j.p. (1985). speech discrimination testing. in j. katz (ed.), handbook of clinical audiology (3rd ed.). baltimore: williams & wilkins. davis, g.a. & wilcox, m.j. (1985). adult aphasia rehabilitation: applied pragmatics. san diego, ca.: college-hill. rebigering manuskripte wat aanvaar is, mag na die skrywer teruggestuur word vir hersiening. addisionele kleiner veranderinge mag ook op hierdie stadium aangebring word, maar 'n nota ter aanduiding van alle veranderinge wat op die manuskrip voorkom, moet verskaf word. die artikel word dan aan die redaksionele komitee vir finale redigering van styl, duidelikheid en konsekwentheid teruggestuur. herbrukke: 10 herdrukke sonder omslae sal gratis aan die outeurs verskaf word. sluitingsdatum vir bydraes: bydraes word verkieslik teen 31 mei elke jaar verwag, maar artikels sal nog tot 30 junie vir aanvaarding oorweeg word. navrae, korrespondensie en manuskripte: moet geadresseer word aan die redakteur, die suid-afrikaanse tydskrif vir kommunikasieafwykings, die suid-afrikaanse spraak-taal-gehoor vereniging, posbus 31782, braamfontein 2017, suid-afrika. diesuid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 77 early communication functioning of infants with cleft lip and palate alta kritzinger, brenda louw and rene hugo centre for early intervention in communication pathology department of communication pathology university of pretoria abstract this study investigated the early communication functioning and hearing abilities of 44 infants with cleft lip and palate, ages 3 to 31 months old. the results revealed that 64% of the subjects had a history of recurrent otitis media with effusion and 33% displayed associated anomalies. 26% of the subjects had mild hearing losses and middle ear pathology at the time of data collection. the subjects as a group displayed average developmental levels for perceptual-cognitive, socio-personal and receptive language skills, but a limited phonetic repertoire and a statistically significant expressive language delay. the results indicated that the subjects experienced a motor developmental delay, but this was not statistically significant. the implications for early communication intervention are to conduct regular hearing measurements and to conduct regular parent-centered therapy with individualized home programmes. efforts should be directed towards expanding early communication intervention services to include all infants with cleft lip and palate in south africa. opsomming: hierdie studie het ondersoek ingestel na die vroe'e kommunikasie funksionering en gehoorvermoens van 44 babas met gesplete lip en verhemelte, tussen die ouderdomme van 3 tot 31 maande. volgens die resultate het 64% van die proefpersone 'n geskiedenis van herhaalde otitis media met effusie en 33% het geassosieerde afwykings vertoon. 26% van die proefpersone het 'n geringe gehoorverlies en middeloor-patologie vertoon ten tye van data-insameling. die proefpersone as groep het gemiddelde vlakke van ontwikkeling vertoon in die areas van perseptuele kognitiewe ontwikkeling, sosiaal persoonlike ontwikkeling en reseptiewe taalvaardighede. hulle het egter 'n beperkte fonetiese repertoire en 'n staties beduidende ekspressiewe taalagterstand vertoon. alhoewel daar bevind is dat die proefpersone 'n motoriese ontwikkelingsagterstand vertoon het, is dit egter nie staties beduidend van aard nie. die implikasies vir vroe'e kommunikasie intervensie is om sulke babas se gehoor gereeld te monitor en om gereelde ouer gesentreerde terapie met geindividualiseerde tuisprogramme uit te voer. pogings moet aangewend word om vroee kommunikasie intervensie dienste uit te brei om alle gesplete lip en verhemelte babas in suid-afrika in te sluit. i key words: cleft lip andlpalate infants, risk factors, early communication development, early intervention. j infants with cleft lip and lpalate are at-risk of developing communication delays or disorders not only due to the established risk of the cleft itself, but also due to biological and environmental risk factors during their critical period for language acquisition. known biological risk factors which can negatively impact on the communication development of this population include associated anomalies and hearing impairment. although hearing impairment relative to recurrent otitis media with effusion has been reported extensively (goldman, martinez & ganzel, 1993; scheurle, 1989), the risk for sensorineural hearing impairment appears to be under reported. it is generally accepted that the presence of anatomical malformations of the head and neck, which includes the population with clefts, indicates a risk for all forms of hearing impairment (asha, 1994). one reason for the under reporting of sensorineural hearing loss could be that stud!es on the communication «development of children with cleft lip and palate often exclude the cases with associated anomalies who could present with various forms of hearing impairment. environmental risk factors proposed to impact on the early development of infants with cleft lip and palate include early surgical intervention, disruption of parent-infant-interaction due to the trauma of the diagnosis, resulting in changes in early socialization, the effect of infant appearance on adult developmental expectations and family stress due to increased care giving needs of having an infant with a congenital malformation (savage, neiman & reuter, 1994). the presence of multiple risk factors in infants with clefting conditions is indicative of a heterogenous population with the possibility of displaying a variety of developmental disorders. when applying the transactional view of etiology as described by samerhoff (1986), another implication becomes clear. the effect of multiple risk factors die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 78 alta kritzinger, brenda louw and rene hugo early in life implies a complex reciprocal interaction over time between infants with cleft lip and palate and their environment, resulting in an ever-changing profile of their speech and language development. for example, the transactional interaction of biological risk factors within the infant with a cleft lip and palate can be seen as the physiological malformation of the speech and hearing mechanisms (lynch, 1986) impacting on the neuromotor encoding and auditory decoding skills of the infant (bzoch in russell & grunwell, 1993), which may contribute to the speech and language delay evidenced in these infants. intermittent attacks of otitis media as well as discrete environmental events such as surgery resulting in family stress, add to a developmental profile which changes not only as a result of development itself. the transactional view of etiology also explains why no single risk factor can be viewed as the cause of early delays in speech and lantable 1. description of subjects, n=44 16% 21% 16% 40% 5 b i l a t e r a l c l p 6 u n i l a t e r a l c l p β s o f t p a l a t e id p i e r r e r o b i n • s u b m u c o u s • c l e f t l i p & s p figure 1: differences in cleft types, n=44 feature description age gender birthweight neonatal intensive care feeding during neonatal period associated conditions·. associated anomalies other physical defects low birthweight other biological risks total: range: 3 to 31 months mean: 15 months 24 subjects female (54,5%) 20 subjects male (45,5%) pierre robin sequence, n=7 range: 2,25kg to 4,25 mean: 2,94kg all other subjects, n=37 range: 1,37kg to 5kg mean: 3,23kg 10 subjects in incubator (22,7%) 34 subjects without intensive care (77,3%) 11 subjects tube fed (25%) 7 subjects breastfed (15,9%) 26 subjects bottle fed (59,1%) 1 subject with down syndrome 1 subject with sensorineural hearing loss due to congenital syphilis 1 subject with heart defect 1 subject with bilateral polydactyly 1 subject with hernia 8 subjects <2.5kg (18,2%) 1 subject one of a twin 14 subjects with associated conditions (31.9%) 30 subjects without associated conditions (68,1%) age of cleft repair soft palate: mean: 3 to 23 months 5 months lip and hard palate: mean: 6 to 9 months 7 months pre-operative early communication intervention (eci) socio-economic status 3 low income families (6,8%) geographical representation 41 subjects received eci (93,2%) 3 subjects received no eci (6,8%) 41 middle income families (93,2%) 28 living in gauteng province (63,6%) 16 living outside gauteng province (36,4%) the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication functioning of infants with cleft lip and palate 79 -mage development in infants with cleft lip and palate and as a r e s u l t predictions of their developmental outcome cannot be accurate. in the light of the wide spectrum of risk factors intera c t i n g at different times during the development of infants with cleft lip and palate, early intervention is implem e n t e d as secondary prevention of speech and language delays. as preschool language development has shown to be the single best predictor of a child's school success (capute, palmer & shapiro, 1987), the aim of early interv e n t i o n is for comparable communication skills with peers a s young as possible. in spite of the known risk factors, l i m i t e d research has been conducted to provide a description of early communication profiles of infants with cleft lip and palate (savage et al., 1994). the ai*i of the study is to describe the early communication skills of a group of infants who attended an early intervention diagnostic clinic after being referred by the local cleft palate clinic attached to the university of pretoria or by professionals in private practice. methodology the research methodology took the form of a descriptive survey as discrete data was derived from observational situations during the chrib assessments. the subjects were recruited from the clinic for high risk babies (chrib) at the centre for early intervention in communication pathology, department of communication pathology, university of pretoria. chrib is a diagnostic facility of the early intervention programme for infants with disabilities or at-risk and their families and forms part of the centre's training activities and community service. anon-random non-probability sampling procedure was used to select the 44 subjects. description of subjects due to the descriptive nature of the research methodology, the characteristics of the subjects are discussed in detail as this information is viewed to be of importance in the interpretation of the results and the conclusions reached (savage, neiman & reuter, 1994). 44 infants with cleft lip and palate and cleft palate only served as subjects for the survey, displaying a variety of six different cleft types (see |figure 1). subjects with a cleft of the lip only were omitted from the study as they are generally not associated! with speech and language disorders (peterson-felzone, ;1989). an exceptional cleft type, namely a cleft of the lip and'soft palate with an intact hard palate, occurred in one subject. this subject presented with extremely low birth weight (1,37kg) and moderate prematurity (33 weeks gestation) as well. the age of the subjects depended on their referral to chrib, which were usually after their primary surgery was completed (see table 1). subjects with associated anomalies, such as the subject with down syndrome, were referred much earlier. the majority of the subjects (93%) had already received early communication intervention m the form of guidance and home programmes to the parents at the cleft palate clinic they were attending prior to their referral to chrib. the mean age of the subjects w a s 15 months which is considered as an ideal stage to conduct a comprehensive speech, language and hearing assessment and to continue with early communication intervention, as active team management usually decreases after primary surgery has been completed and clients may be lost for follow-up. according to table 1 the mean age of the subjects for soft palate repair was 5 months, while the mean age for lip and hard palate repair was 7 months. as indicated in table 1, the gender ratio displayed by the subjects does not reflect the accepted gender ratio of cleft lip and palate of twice as many males as females being affected. the omission of infants with a cleft lip only and the higher incidence of pierre robin sequence among females could be related to the gender differences found in the present study, i.e. slightly more females (54,5%) than males (45,5%) with cleft lip and palate. five of the seven subjects presenting with pierre robin sequence were female, which is in agreement with literature findings of a female bias among these children (amaratunga, 1989). the subjects' birth weight was recorded separately for the pierre robin sequence group and the rest of the subjects (see table 1). although the pierre robin sequence sample was too small to statistically compare them with the rest of the subjects, their mean birth weight of 2,94kg without prematurity should be noted. the subjects with pierre robin sequence displayed a lower mean birth weight than the rest of the subjects, as well as a lower birth weight compared to the general population in developed countries. (mean birth weight in developed countries: 3,4kg, ranging from 3,2kg to 3,8kg, according to turner, douglas & cockburn, 1988). the finding of a lower birth weight than the average among pierre robin se-. quence subjects can be compared to a study carried out by laitinen, heliovaara, pere and ranta (1994). this study also investigated the birth weight of pierre robin subjects and did not find a significant lower birth weight among them. the findings of the present study call for further research, as a better understanding of the characteristics of the pierre robin sequence population is of great clinical importance. apart from the subjects' birth weight, the need for incubator care also emphasizes the subjects' vulnerability for biological risk conditions. 22,7% of the subjects were kept in an incubator during the neonatal period. the listing of associated conditions in table 1 serves to provide a picture of the wide spectrum of major to minor associated anomalies and conditions present in 14 of the subjects. the characteristics of the subjects' feeding difficulties directly after birth, as shown in table 1, indicate that only 11 subjects required tube feeding. this implies that the subjects were referred for special care early enough to benefit from a jaw orthognathial suction and drinking plate (biitow, 1995), which resulted in successful bottle and even breast feeding. seven subjects succeeded in breast feeding, which is usually regarded as the least viable feeding option for infants with cleft palate. the last two items in table 1 concern the subjects' geographical and socio-economic backgrounds. 63,6% of the subjects lived in the gauteng province, a metropolitan area of which pretoria is one of the largest cities. most of the subjects were from middle income families, indicating that the study did not draw subjects from lower income families living in rural areas. this emphasises the inadequacies of tertiary health care to provide specialized services to infants with cleft lip and palate of families with limited resources to travel long distances to a cleft palate centre. at present the transformation of the national health system is to prioritize the development of primary health care suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 80 and community based rehabilitation services in the rural areas (anc, 1994). finally, the subjects' history of otitis media with effusion as a recurrent risk factor concerning their postnatal and later speech and language development, is presented in figure 2. 64% of the subjects had a history of recurrent otitis media with effusion. according to figure 3 they were treated either by the insertion of ventilation tubes or by medication. only 11% of the subjects received no treatment for otitis media, which implies that most of the parents were knowledgable about the management of middle ear infections. in summary, the subjects were between 3 and 31 months old and displayed a variety of cleft types which were already repaired at the time of data collection. their mean birth weight was within normal limits, but almost one third of the subjects either had associated anomalies and/or experienced biological risk conditions. recurrent otitis media with effusion occurred in almost two thirds of the subjects. most of the subjects were from middle income families living in a metropolitan area. assessment protocol and data collection each subject underwent a comprehensive assessment of their hearing abilities, prespeech and language skills and general development based on a communication assessment protocol for cleft palate infants developed by louw (1986) and adapted for chrib. the hearing assessment was carried out using sound field behavioural observation audiometry for subjects unalta kritzinger, brenda louw and rene hugo der 5 months developmental age and sound field visual response audiometry for subjects older than 5 months developmental age with narrow band noise as the test stimulus. immittance measurements were carried out for subjects of all ages. data on all hearing measurements were collected by a qualified audiologist with experience in pedoaudiometric procedures. normative data for different ages supplied by northern and downs (1984) was used to interpret the narrow band noise thresholds obtained from the subjects. subjects with abnormal middle ear measurements were referred to an ear, nose and throat specialist for follow-up. the subjects' prespeech and language skills and general developmental skills were elicited and observed in a controlled play context, involving the infant and a speechlanguage therapist with the infant's parents as onlookers. two qualified speech-language therapists with early intervention experience were involved in the data collection, one to elicit behaviour from the infant and the other to observe and record the data. infant behaviours such as vocalizations and verbalizations were recorded and used as descriptive data while other behaviours were recorded using a developmental scale, the developmental assessment schema (das) (anderson, nelson & fowler, 1978). data was analysed using descriptive statistics presented in the form of tables, pie charts and bar charts to provide means and ranges. the subjects' functioning on the das was statistically analysed using the friedman two-way analysis of variance test with bmdp 3s statistical software to determine significant differences between the 7 different subscales (level of significance: p_0.05). 32% 9% 23% 00 no otitis media 01-2x otitis media ® > 3 x otitis media 36% figure 2: history of otitis media, n=44 figure 3: treatment of otitis media, n=28 table 2. results of audiological assessment, n=44 normal thresholds elevated thresholds sensorineural hearing loss total hearing abilities 31 (72%) 11 (26%) 1 (2%) 44 normal middle ear pressure negative middle ear pressure / no test total middle ear functioning 15 (35%) 11 (26%) 17(40%) 44 the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication functioning of infants with cleft lip and palate 81 results and discussion the developmental profiles of the subjects are presented a c c o r d i n g to the assessment areas of hearing abilities, prespeech skills and the different subscales of the das (anderson, et al., 1978), i.e. expressive language, receptive language, personal-social, perceptual-cognitive, gross motor, fine motor, and self help skills. hearing abilities table 2 indicates that 72% of the subjects displayed normal narrow band noise thresholds while 26% of the subjects showed elevated thresholds relative to mild hearing losses. one subject had a serious sensorineural hearing loss associated with prenatal syphilis exposure as well as a history of recurrent otitis media. at the time of testing she had ventilation tubes and no immittance measurements were carried out. the narrow band noise thresholds of all subjects could be successfully determined by the proposed testing procedures. not all subjects, however, could be tested for middle ear functioning. no immittance measurements were obtained of 17 subjects, as 15 subjects had ventilation tubes inserted following recurrent attacks of otitis media and two subjects would not cooperate for the immittance testing procedures to be carried out reliably. although 64% of the subjects (see figure 2) had a history of recurrent otitis media with effusion, only 26% of the subjects evidenced negative middle ear pressure at the time of data collection. the relative small number of subjects found with abnormal middle ear functioning could be due to the treatment received prior to the testing (see figure 3). the results also reveal the intermittent nature of the disease, indicating that reliable data on the occurrence of middle ear pathology among the subjects could only be obtained when data on both the history of the condition as well as immittance measurements were collected. this approach is also advocated by grunwell, sell and harding (1993). it is therefore concluded that a far greater number of subjects experienced recurrent middle ear pathology than the 26% of subjects gleaned from the immittance measurements, j as indicated in table 2, 11 subjects evidenced both elevated narrow band thresholds as well as negative middle ear measurements. although not statistically analysed to establish a correlation, the results suggest that those subjects with abnormal middle ear measurements may have experienced some form of mild hearing loss. it is generally accepted that a conductive hearing loss of 15 to 40db may accompany the different forms of otitis media with effusion, such as serious otitis media, acute otitis media and chronic otitis media (zarnoch & northern, 1989). the results emphasize the recurrent periods of auditory deprivation the subjects experienced during the critical window of opportunity for early language acquisition. these findings are in agreement with the studies of blakely and brockman (1995) and russell and grunwell (1993) who also found varying hearing levels associated with recurrent attacks of otitis media with effusion throughout infancy and early childhood as characteristic of their subjects with cleft lip and palate. prespeech and speech development the majority of the subjects (80%) displayed a limited phonetic repertoire in comparison with normal developmental levels as indicated in table 3. observations revealed that the limited phonetic repertoires of the subjects were characterized by vowels and nasal fricatives, with a distinct absence of plosives and to a lesser degree, fricatives. these findings are in agreement with chapman (1991) who found the number of consonants produced by 12 to 14 year old infants with cleft palate to be between 1 and 8, whereas non-cleft subjects displayed phonetic repertoires of 2 to 16 consonants. the most frequently occurring consonants of these subjects were /m/, /n/, /h/ and /w/. it is interesting to note that despite the similar findings of limited phonetic repertoires, the subjects of the chapman study (1991) had unrepaired cleft palates, whereas the present study utilized subjects with repaired cleft lip and palates. although the mean age of the subjects for soft palate repair in the present study was relatively early, i.e. 5 months (see table 1) most of the subjects displayed a limited phonetic repertoire. o'gara and logemann (1988) also found limited phonetic repertoires in their subjects with early palatal repair in comparison with normal development, suggesting that speech developmental constraints early in life continue to have an effect even after palatal repair. due to the limited expressive language displayed by the subjects, some as young as three months old, it was not possible to identify the resonance features of the prespeech utterances of 55% of the subjects (see table 3). it was, however, possible to detect hypernasality, identified as nasal resonance on vowels and substitutions of oral plosives and fricatives for nasals, in the prespeech and speech patterns of 25% of the subjects. 20% of the subjects evidenced both normal phonetic repertoires as well as normal resonance features in their prespeech and speech development. russell and grunwell (1993) also found a percentage (12%) of their subjects with cleft lip and palate to demonstrate normal phonetic development. results of the subscales of the das (anderson et al. 1978) figure 4 provides the results of the 7 subscales of the das (anderson, et al. 1978). the results of the subject's receptive language development indicate that a total of table 3. prespeech development, n=44 limited normal total phonetic repertoire 35 (80%) 9 (20%) 44 hypernasality normal could not establish total speech resonance | 11 (25%) 9 (20%) 24 (55%) 44 die suid -afrikaanse tydskrif vir kommunikasieafwy kings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 82 alt a kritzinger, brenda louw and rene hugo 64% of the subjects demonstrated average skills. in comparison, the subjects' expressive language development indicates a marked delay, with only 32% subjects displaying normal development. table 4 provides the statistical analysis of the results, using the friedman two way analysis of variance test to perform multiple comparisons. this test demonstrated a significant difference between the results on the das expressive language scale (anderson, et al. 1978) and the other subscales, indicating a significant delay in the subjects' expressive language skills. the nature of the subjects' expressive language delay as assessed by the das (anderson, et al. 1978) includes delayed onset of vocalizations, babbling patterns, verbalizations, multiple word combinations as well as limited imitation skills. the subjects' delay in expressive language skills therefore includes more components of language abilities than the limited phonetic repertoires as discussed in the previous section. the present study therefore determined that the subjects displayed a delay in all components of expressive language development, indicating the extensive effects of the different risk factors on the subjects' early language development. the expressive language delay without a concurrent delay in receptive language development found in the subjects is in agreement with studies by louw (1986) and sherer and d'antonio (1995). louw (1986) found a communication developmental delay in subjects under 12 months of age and sherer and d'antonio (1995) found delays in expressive language development in their subjects with cleft lip and palate when compared with subjects without clefts. the subjects' age appropriate performance on personalsocial skills as measured on the das (anderson, et al. 1978) signifies no delay in their nonverbal communication interaction skills and personal attachment behaviours. a study by long and dalston (1982) extensively investigated the gestural communication skills of 12 month old infants with cleft lip and palate and compared them with a normal control group of subjects. the findings indicated that no significant differences existed between the two key: ε l: expressive language skills r l: receptive language skills p-s: personal-social skills p-c: perceptual-cognitive skills g m: gross motor skills f m: fine motor skills s h: self help skills • below β average mabove groups, demonstrating that infants with cleft lip and palate experience no delay in the development of their nonverbal expressive language skills. as receptive language ability and cognitive development are closely related in infancy (lahey, 1988), the subjects' average functioning on the perceptual-cognitive subscale of the das (anderson, et al. 1978) (see figure 2), is viewed as part of their language developmental profile. the subjects' language functioning in the present study was thus characterized by an incomplete phonetic repertoire, delayed expressive language development, but with age appropriate nonverbal communication interaction table 4. multiple comparisons performed for friedman two way analysis of variance test. critical ζ values indicating a significant difference: <3.04 for overall alpha of 0.5 (**). critical ζ values indicating a significant difference: <2.82 for overall alpha of 0.10 (*) figure 4: profile of development, n=44 comparisons ζ stat difference personal-social perceptual-cognitive 0.05 -1.00 personal-social , self help 0.89 18.00 personal social gross motor 1.53 31.00 personal-social fine motor 1.16 23.50 personal-social receptive language 2.42 49.00 personal-social expressive language 5.28** 107.00 perceptual-cognitive self help 0.94 19.00 perceptual-cognitive gross motor 1.58 32.00 perceptual-cognitive fine motor 1.21 24.50 perceptual-cognitive receptive language 2.47 50.00 perceptual-cognitive 1 expressive language 5.33** 108.00 self help gross motor 0.64 13.00 self help 1 5.50 fine motor 0.27 1 5.50 self help 1 receptive language 1.53 31.00 self help 1 expressive language 4.39** 39.00 gross motor fine motor 0.37 -7.50 gross motor receptive language 0.89 18.00 gross motor expressive language 3.75** 76.00 fine motor / receptive language 1.26 25.50 fine motor expressive language 4.12** 83.50 receptive language expressive language 2.86* 58.00 the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) early communication functioning of infants with cleft lip and palate 83 skills as well as average receptive language functioning and perceptual-cognitive skills. according to figure 2, 41% subjects displayed average gross motor, development, while most of the subjects (55 %) demonstrated average fine motor skills. although most subjects' gross motor skills were below average development, the statistical analysis did not reveal a significant difference between the various subscales to indicate a delay. not withstanding that research on the motor development of infants with cleft lip and palate is limited, savage et al. (1994) also suggest delayed motor development in 6 to 12 month old subjects as measured on the bayley scales of infant development. the results of the present study partly correlate with the findings of louw (1986) who determined delayed motor development in 44% of subjects, 0 to 12 months of age. the present study, utilizing older subjects, found fewer subjects (36%) functioning below average for motor development. longitudinal data is, however, needed to determine the developmental motor patterns of infants with cleft lip and palate. the last subscale of the das (anderson, 1978) deals with self help skills, i.e. skills related to feeding, dressing and toiletting. as a group the subjects displayed age appropriate developmental levels, indicating that feeding problems experienced before surgery were largely overcome by the time of data collection. in summary, the subjects' functioning on the 7 different subscales of the das (anderson, et al. 1978), were as follows: the majority of the subjects displayed age appropriate functioning in receptive language, perceptual-cognitive, personal-social and self help skills. their fine and gross motor skills evidenced lower levels of functioning, although these were not found to be statistically significant. the only developmental area in which the subjects as a group displayed a significant delay, was their expressive language skills. conclusion ι a characteristic communication developmental profile of the subjects emerged from the results. certain components of their language abilities revealed strong points, i.e. nonverbal communication interaction and receptive language skills, while an expressive language delay and a limited phonetic repertoire demonstrated their weak points. the subjects' communication profile should further be viewed against the broader developmental perspective of their age appropriate'cognitive and self help skills, but a slight delay in motor development was present. as the subjects had already benefitted from a communication intervention programme and sufficient management of middle ear pathology since birth, the results cannot be generalised, especially not to infants with cleft lip and palate from disadvantaged communities in south africa. in order to provide effective early intervention services in south africa for all infants with cleft lip and palate, further research is required. the effects of the risk factors associated with disadvantaged environmental circumstances on the communication development of these infants need to be determined. previous studies have extensively investigated the phonetic and phonological development of infants with cleft lip and palate (chapman, 1991; chapman & hardin, 1992; lohmander-agerskov, soderpalm, friede, persson & lilja, 1994; jansonius-schultheiss, 1989; o'gara & logemann, 1988; o'gara, logemann & rademaker, 1994; russell & grunwell, 1993), but much less focus was placed on the nature of these infants' language development. although the present study describes the nature of the subjects' expressive language delays, further research is required to provide clarity on the interaction between risk factors and language development. the study points to the need for widely available appropriate early intervention programmes for infants with cleft lip and palate. despite the dearth of research, however, some early language intervention programmes and protocols for infants with cleft lip and palate advocate a holistic approach and include all components of language development (langlois & nowak, 1990; lynch, brookshire & fox, 1993; scheuerle in bzoch, 1989). although these programmes are widely applied, they have to be adapted to meet the needs of the unique south african context. the current study provided a characteristic communication profile of the subjects as a group, but the diversity of the individual subjects should be emphasized. the presence of pierre robin sequence as a vulnerable group for hearing loss (handzic, bagatin, subotic & cuk, 1995), associated anomalies and malformations (sprintzen, 1988) and mental retardation among the subjects (cauettelaberge, bayet & larocque, 1994) calls for individualized language intervention programmes with full parental involvement and committed transdisciplinary teamwork. the incidence of associated conditions such as down syndrome and severe sensorineural hearing loss (see table 1) emphasizes the need for specialized knowledge in more than one field to meet the needs of infants with multiple disabilities. the intermittent hearing loss caused by recurrent otitis media with effusion which a number of subjects experienced, requires periodic monitoring of hearing at least every six months (asha, 1994). as a first attempt to describe a section of the cleft lip and palate population, the study provided useful information. expanded research is, however, necessary to provide information on which to base context relevant services. efforts must be directed towards expanding early communication intervention services to reach all infants with cleft lip and palate and their families. infants with cleft lip and palate represent a diverse population with various risk factors continuously influencing their communication development. they are particularly at-risk for expressive language delays. this poses great challenges for individualized early communication intervention services to them and their families. based on the results of the present study, the preferred approach is the implementation of regular early intervention sessions, commencing before surgery, fully involving the parents, with a curriculum emphasis not only on monitoring hearing abilities and facilitating expressive language development, but also on all components of language and general development. references amaratunga, n.a. de s. (1989). a comparative clinical study of pierre robin syndrome and isolated cleft palate. british journal of oral and maxillofacial surgery, 27, 451-458. anc. (1994). a national health plan for south africa. johannesburg: anc. anderson, d. nelson, j. & fowler, s. (1978). developmental assessment schema. in northcott, w.h. (ed.), curriculum die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 4 alta kritzinger, brenda louw and ren hugo guide: hearing impaired children (0-3 years) and their parents. washington, dc: the alexander bell association for the deaf, inc. asha. (1994). joint committee on infant hearing. 1994 position statement. asha, december, 38-41. blakely, r.w. & brockman, j.h. (1995). normal speech and hearing by age 6 as a goal for children with cleft palate: a demonstration project. american journal of speech-language pathology, 4(1), 25-32. butow, k-w. (1995). treatment of facial clef deformities. an illustrated guide. st. louis: ishiyalcu euro america, inc. capute, a. j., palmer, f.b. & shapiro, b.k. (1987). using language to track development. patient care, november, 60-71. cauette-laberge, l., bayet, b. & laroque, y. (1994). the pierre robin sequence: review of 125 cases and evolution of treatment modalities. plastic and reconstructive surgery, 93(5), 934-942. chapman, k.l. (1991). vocalizations of toddlers with cleft lip and palate. cleft palate cranio-facial journal, 28(2), 172178. chapman, k.l. & hardin, m.a. (1992). phonetic and phonological skills of two-year-olds with cleft palate. cleft palate craniofacial journal, 29(5), 435-443. goldman, j.l., martinez, s.a. & ganzel, t.m. (1993). eustachian tube dysfunction and its sequelae in patients with cleft palate. southern medical journal, 86(11), 1236-1237. grunwell, p., sell, d. & harding, a. (1993). describing cleft palate speech. in grunwell, p. (ed.), analysing cleft palate speech. london: whurr publishers ltd. handzic, j., bagatin, m. subotic, r. & cuk, v. (1995). hearing levels in pierre robin syndrome. cleft palate-craniofacial journal, 32(1), 30-36. jansonius-schultheiss, k. (1989). phonological development in two year old cleft lip and palate toddlers. proceedings: 6th international congress on cleft palate and related craniofacial anomalies, 29. jerusalem. laitinen,s.,heliovaara,a.,pere,a. &ranta, r. (1994). growth in children with pierre robin sequence and isolated cleft palate. acta paediatrics, 83, 1161-1164. lahey, m. (1988). language disorders and language development. new york: macmillan publishing company. langlois, a. & nowak, b.r. (1990). the first year of a child with cleft palate: an approach to facilitate communication development. infants and young children, 2(4), 34-50. lohmander-agerskov, α., soderpalm, e., friede, h., persson, e. & lilja, j. (1994). pre-speech in children with cleft lip and palate or cleft palate only: phonetic analysis related to morphologic and functional factors. cleft palate-craniofacial journal, 31(4), 271-279. long, n.v. & dalston, r.m. (1982). gestural communication in twelve-month-old cleft lip and palate children. cleft palate journal, 19(1), 57-61. louw, b. (1986). swart babas met gesplete lip en verhemelte: 'n morfofunksionele studie. unpublished d phil dissertation: university of pretoria. lynch, j.i. (1986). language of cleft infants: lessening the risk of delay through programming. seminars in speech and language, 7(3), 255-268. lynch, j.i., brookshire, b.l. & fox, d.r. (1993). a curriculum for infants and toddlers with cleft palate. developing speech and language. austin: pro-ed. northern, j.l. & downs, m.p. (1984). hearing in children. baltimore: williams & wilkens. o'gara, m.m. & logemann, j.a. (1988). phonetic analysis of the speech development of babies with cleft palate. cleft palate journal, 25(2), 122-134. o'gara, m.m., logemann, j.a. & rademaker, a.w. (1994). phonetic features by babies with unilateral cleft lip and palate. cleft palate-craniofacial journal, 31(6), 446-451. peterson-felzone, s.j. (1989). speech disorders related to craniofacial structural defects. in northern, j.l. (ed.), study guide for the handbook of speech-language pathology and audiology. toronto: b.c. decker inc. russell, j & grunwell, p. (1993). speech development in children with cleft palate. in grunwell, p. (ed.), analysing cleft palate speech. london: whurr publishers ltd. samerhoff, a.j. (1986). environmental context of child development. the journal of pediatrics, 109(1), 192-200. savage, h.e., neiman, g.s. & reuter, j.m. (1994). a developmental perspective on assessment of infants with clefts and related disorders. infant-toddler intervention, 4(3), 221-234. scherer, n.j. & d'antonio, l.l. (1995). parent questionnaire for screening early language development in children with cleft palate. cleft palate-craniofacial journal, 32(1), 7-13. scheuerle, j. (1989). stimulating language development in infants and toddlers with cleft palate. in bzoch, k.r. (ed.), communicative disorders related to cleft lip and palate. boston: little brown and company. shprintzen, r.j. (1988). pierre robin, micrognathia and airway obstruction: the dependency of treatment on accurate diagnosis. international anesthesiology clinics, 26(1), 64-71. turner, t.l., douglas, j. & cockburn, f. (1988). grains care of the newly born infant. edinburgh: churchill livingstone. zarnoch, j.m. & northern, j.l. (1989). audiologic manifestations. in northern, j.l. (ed.), study guide for the handbook of speech-language pathology and audiology. toronto: b.c. decker inc. the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 7 a tribute to professor myrtle aron lesley wolk, ph.d syracuse, university syracuse, new york professor myrtle aron is retiring from the department of speech pathology and audiology at the university of the witwatersrand after a long and illustrious career. she has attained outstanding recognition in the fields of speech pathology and audiology. her diverse interests and areas of expertise range from childhood and adult stuttering to the broad base of audiology. in addition to her status as a key figure in speech pathology and audiology in south africa, she has attained an international reputation as well. i write this tribute to professor aron from the perspective of student, colleague and friend. i have indeed been fortunate to know professor aron in all of these capacities, and i have valued her contributions to me, both professional and personal, on all of these levels. professor aron was an excellent teacher in the areas of audiology and research methodology. she is respected deeply for her knowledge and professional integrity. it was distinctly remarkable how she was able to keep abreast of current literature and trends in the field and impart these to her students, while at the same time organize the administrative workings of her department. the clinical training in her department ranks as clearly outstanding at an international level because she encouraged students to think independently and creatively, and to develop therapeutic plans without total reliance on a clinic supervisor. professor aron demanded high standards for both clinical and academic work. she encouraged students to be creative, flexible and, perhaps most importantly, to value their indep e n d e n c e and freedom to apply their knowledge and develop individual treatment regimens in order to best meet the needs of their patients. i also had the opportunity φ work with professor aron as a colleague at the university of the witwatersrand. my experiences as a lecturer there were all influenced to some extent by professor aron's overall guidance, approach to education, and devotion to our profession. she encouraged faculty members to work independently and take full responsibility for their lecture courses, yet was always open and available for advice and assistance. professor aron was a central figure in my professional training and#:areer development. finally, through many years of professional association, i have considered professor aron a friend, and i am grateful for the warmth and friendship built over time. she has an unusual ability to show personal interest and concern, and to provide invaluable guidance and support when needed. few teachers and administrators have exhibited the level of caring that professor aron has shown towards me. i deeply value her friendship at this level. professor aron is respected highly in south africa for her intellectual excellence, dedication to the profession, and the model of professionalism she provides. she has an insightful approach to problem-solving, and a deep perspective within the field. moreover, her wide-reaching dedication has also included a commitment to the training of both black and white south african students and to the treatment of children and adults with speech, language and/or hearing disorders, regardless of race or ethnic background. professor aron has been selfless in her contribution. retirement may be thought of as: a time of accomplishment, a time of satisfaction, a time of reflection, a time of sadness, a time of peace, a time of relaxation, a time of closure ... a time to move on to other things... on behalf of all the members of the south african speech and hearing association — those residing in and outside south africa and the members of the american speech and hearing association worldwide, i would like to wish professor aron a sense of fulfilment as she reflects on her contributions to the development of our profession in south africa. we wish her good luck, good health, and much happiness in her future. die suid-afrikaanse tydskrif vir kommunikasiafykins vol. 37. 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 professor m.l. aron 'n huldeblyk professor isabel uys departement spraakheelkunde en oudiologie universiteit van pretoria hoe fragmenteer 'n mens 'n kompleksiteit sonder om daaraan afbreuk te doen? hoe kan ek praat oor iemand soos professor aron sonder om chookie daarby in te sleep? 'n mulddimensionele, veelvlakkige mens is sy. 'n mens met wie altyd rekening gehou moet word dis sy. 'n stilte van haar kant af is 'n "op julle merke"-sein vir almal om haar. en dit is een van haar grootste bates, waarvoor sy waarskynlik nognooitgenoegerkenninggekry hetnie. sy laatnie dinge met haar gebeur nie, maar sorg dat dinge om haar gebeur tot voordeel van almal. dit is die boodskap van haar lewe vir ons as kollegas en vriende. as professionele leier het sy oorgeneem na die vestiging van die kursusse en die beroep. maar sy het gesorg vir erkenning, vir uitbouing en aanvaarding. was daar al ooit iemand wat met soveel toewyding dag vir dag kon stry vir spraakterapie en oudiologie in suid-afrika? sy deins nooit terug vir struikkelblokke en uitdagings nie en dikwels was dit al nodig om op 'n nie so subtiele manier die bul by die horings te pak. sy is braaf, ja. om hierdie eensame paadjie te loop is nie altyd maklik nie, maar dit is juis omdat sy as mens vrede gemaak het met haar eie kompleksiteit wat sy daartoe in staat was. een oomblik kan sy hoogs gesofistikeerd die koue wetenskaplike feite aanhaal, om net daarna met 'n nai'we humorsin te vertel hoe haar besonder intelligente hond die telefoon antwoord. sodra jou aandag goed afgetrek is, sou sy bewys lewer dat jou afleibaarheid nie 'n goeie professionele eienskap is nie. nie maklik nie, maar 'n waardevolle les. stres en "burn-out" het in ons beroep al mode geword. waarom het hierdie simptome nog nooit by haar kop uitgesteek nie? omdat haar beroep ook 'n roeping is, 'n lewenstaak wat sy met liefde, toewyding en entoesiasme uitvoer. dit is vir haar lekker om te werk en haar entoesiasme is aansteeklik. een van haar grootste bates in die beroep is haar vermoe om ander entoesiasties te maak en te inspireer nie net om iets te doen nie, maar om dit na die beste van jou vermoe te doen. dit is ook waar die vriendin inkom. professor aron kan jou aan die werk kry, maar chookie sal altyd lojaal bly, jou beskerm, help en ondersteun. sy gee krediet waar dit toekom en tel op as jy geval het. sy het die gawe van die spreekwoordelike ystervuis wat in watte toegerol is. nou het sy as departementshoof afgetree, maar soos ons al almal agtergekom het, is dit maar net een van die verantwoordelikhede wat sy verruil het vir 'n hele paar ander. nou het die tyd gekom vir die uitlewing van al haar ander belangstellings. gaan die oudioloog weer die spraakterapeut toelaat om na vore te tree? gaan die administrateur weer vir 'n rukkie plek maak vir die navorser? wat ook al gaan gebeur, ons gaan nog daarvan moet kennis neem. sy het nog soveel om by te dra en haar bydraes kan nie gei'gnoreer word nie. dit was my boodskap oor haar. maar ek het ook 'n boodskap vir haar. ons is reeds in die "op julle merke"-posisie. ek weet sy is "gereed". ons wag nou vir die "gaan"! the south afi icon journal of communication .disorders, vol. '37. 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 9 tribute to professor aron marcelle norman chairman, saslha professor aron has been involved with the south african speech-language-hearing association (saslha) since her days as a student speech therapist when our organisation was still called the s a logopedics society. she has held most portfolios in the organisation but her function as editor of the journal, chairman and in the past eight years as president, are the positions that we all best remember her in. her contribution to our profession has extended far beyond her role in the south african speech-languagehearing association, her position as professor of the department of speech pathology and audiology at the university of the witwatersrand and her chairmanship of the professional board for speech pathology and audiology with the south african medical and dental council (samdc). she has been involved in or responsible for every major change and advancement that has taken place within our profession. in addition, we have had to deal with frequent and very serious threats from many overseas speech and hearing associations who have attempted to have us barred from the international association for logopedics and phoniatrics (ialp). once again professor aron has represented us at these international meetings as well as at conferences in america and elsewhere where she has put our case and ensured our continued participation in and recognition by professional organisations around the world. it is said that no-one is ever indispensible but as far as saslha is concerned, professor aron is indeed indispensible. her knowledge is encyclopaedic and her memory frightening and she is the person we turn to for the confirmation of all major decisions and for the elusive details of history that professional groups often need to draw on. we know that professor aron is only retiring her position as head of department from the university of the witwatersrand and that she is certainly not giving up her involvement with saslha and the professional board but we felt that this was a fitting moment to pay her a long overdue tribute. her commitment to saslha and her profession of speech therapy and audiology on every level has been extraordinary. there can be few similar professions that have had one person who has played such a vital and profound role over such a long and unbroken time period. to have a permanent reminder of her role in saslha we have decided to dedicate this year's journal as a commemorative issue in her honour and we wish her much happiness in her retirement. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 professor aron: a personal message aura kagan the speech and stroke centre north york, ontario, canada although we have not had any contact over the past few years, prof. aron and the department have often been in my thoughts. the first thing that i would like to mention (and i am sure that you have heard this over and over again) is the high calibre of graduates from the wits speech-pathology department. toronto is a city of immigrants and thus one meets professionals from all over the world. the graduates of our department enjoy an excellent reputation which reflects well on the training we received. much of this is due to prof. aron's dedication and enthusiasm and i think that we all owe her a personal debt of gratitude. i think that you may be interested in some of the work that i have been doing and the unique agency in which i am involved. the speech & stroke centre north york was started approximately 10 years ago by pat arato. pat's husband suffered a stroke and after the rehabilitation phase was over, she realized that this relatively young man was not going to be able to return to work and that there were no long-term facilities available. although she had absolutely no professional training, she started encouraging individuals with chronic aphasia to join communication groups led by volunteers. in these early days, there was some help from one or two speech-pathologists, but volunteers had to rely largely on their own resources. pat soon realized that something wonderful was happening to the people attending the groups. they seemed to be gaining confidence in using the communication skills that they had and seemed to feel better about themselves generally. the centre grew from this small venture to the sophisticated operation that it is today. we have over 100 aphasic members with a staff of 4 speechlanguage pathologists (2.5 positions) and about 60 volunteers. we also have a full-time volunteer co-ordinator and clerical staff. the philosophy of the program is what is probably of most interest. what we feel makes this centre unique is the combination of the following factors: 1) focus on giving individuals with chronic aphasia an opportunity to communicate, i.e. concentrating on ways of facilitating the exchange of information so that the focus is on what is being communicated rather than on how it is communicated. in the process of doing this, we have developed expertise in training lay individuals in communication strategies that help get communication flowing within a group format. the idea is not to replace what speechlanguage pathologists do but rather to supplement this with what we feel is a much neglected aspect of our work with aphasic clients using our skills to help them to forget, albeit for a short while, that they are aphasic and to concentrate on exchanging information, feelings and opinions with other individuals in a natural non-institutional atmosphere. 2) functional approach. 3) integration of community and professional resources (volunteers receive professional training and on-going, daily supervision). we work in extremely overcrowded conditions and desperately need more space. because we provide long-term support, we do not discharge members and thus, in order to cope with the rapidly expanding waiting-list, we have recently opened our first satellite centre and hope to be opening more in the future. as is the situation everywhere, there is an acute shortage of funds and this is a major problem. activities in which i have been involved include: trying to formulate what we do so that we can share it with others. this is easier said than done as many of the variables we look at are in the psycho-social realm and are extremely difficult to measure. establishing credibility within the professional community at first, many professionals were wary about the concept of using volunteers, for obvious reasons. we now receive referrals from all the major hospitals in toronto and surrounding areas. in fact, our waiting list exceeds our present membership. we are also now an official training centre for the university of toronto and provide internships for students who are about to graduate. providing on-going professional education in the areas of aphasia. we have just had our 4th annual seminar and have also had numerous smaller events and open-houses inbetween. the feedback we have received has been extremely positive. some of the topics include: pragmatic and functional communication; the use of interactive drawing for establishing communication with expressively restricted aphasic adults; the challenge of generalization, and the art and science of aphasia therapy. speakers have included audrey holland, jon lyon, kevin reams, marianne simpson and sally byng. various research projects are underway, e.g. using new measures of functional communication to try and help document the type of change we see occurring in our aphasic members; developing our own measures to capture the psycho-social aspects relevant to the aphasic population and their families; investigating methods for formalizing our volunteer training so that other professionals can benefit from our experience as well as developing methodsto demonstrate that a volunteer has reached a certain level of proficiency. , i am fortunate to be working with a dedicated staff, two of whom are south africans. lorraine podolsky works parttime and rochelle cohen-schneider almost full-time. we all send greetings to you and invite you to visit us if you are ever in toronto. / r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 11 professor m.l. aron: continually in mind ... brenda jacks lewsen etobiooke, ontario canada prof aron to mask or not to mask, what to cook for supper, to prepare data for the statistician or read a book or, better still, browse through the latest gardening catalogue which got dumped on the doorstep. the list goes on ... prof you're wondering where this is all leading or what it could possibly have to do with you. please bear with me a little longer, because although you are entirely unaware of the fact, you are frequently involved with many of my daily decisions. over the years, i suppose, we all develop our own odd ways of dealing with decisions, or matters of principle, or prickly twinges of conscience. i always find myself in a witness box facing a jury. the members of my mental juries vary depending on the nature of the problems to be solved. here's an example when i've been particularly unreasonable with my kids i evoke the ire of the jury which includes my mother, of course, the occasional humanist and a well known canadian writer who feels strongly about children's rights. when it comes to professional or audiological issues the jury box is shared by my current director, sometimes a physician and naturally you, yourself. the temptations tp cut research corners, do sloppy audiometry, or to conduct corridor conferences about patients result in no-no responses of the conscience stirring variety. but rigour innovation, careful attention to detail whether at the audiometer or while supervising colleagues and my entire jury smiles benignly. the good news for me is that there is no retirement from doing jury duty in my head. the bad news is that it is a real pity that i am forever playing these mind games. it would be so much nicer to be able to discuss issues and kick ideas around with you, face-to-face, more often. this is a long and public way of saying that i'm thinking of you and looking forward to seeing you. 3 play m a n d • j schoolroom shop 6l the rosebank mews 173 oxford road rosebank jhb. play & schoolroom, specialists in the field of child education have been offering assistance to both professionals and parents for nearly thirty years. their expertise and advice range through preschool education, perceptual training, primary and remedial education and adult education. play and schoolroom are sole agents for learning development aids which include an excellent selection of materials of interest to the speech therapist. they also offer an interesting range of aids and books to foster and develop language and communicative skills. their stock of educational books and toys is exceptionally wide. you are invited to view their superb range in their new beautifully laid out showroom. phone 7 8 8 1 3 0 4 fax: 8 8 0 1 3 4 1 ι po box 5 2 1 3 7 s a x o n w o l d 2 1 3 2 die sidd-afrikaansc tydskrif \ir kom»wiiikttsictifirykiii/is. vol. 37. 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 professor aron : an appreciation hanna klein, b.a. (speech and hearing therapy) m.a. (clinical audiology) witwatersrand. mcst co-ordinator, department of continuing education national hospitals college of speech sciences london, united kingdom miss aron, as she then was, first appeared to me operating a strange machine at the international fair, held at wits, many, many years ago. overwhelming images of careers and artifacts, which were totally new, crowded in on my adolescent, impressionable mind. professor aron remained a particular image — small, determined, articulate: a professional woman espousing new concepts in a scientific mode. the image of this idealized woman remains to this day. an uncompromising figure of impeccable intellectual, political and academic integrity, professor aron has mothered endless streams of women into a profession that has continued to develop, change and enlarge its horizons. her great asset of intense loyalty and respect for all the peoples of southern africa has been the bedrock of my respect for her. guilt, at having deserted her framework of commitment to the provision of the most excellent services to all those in need of them, by living abroad, is all pervasive. is it any comfort to professor aron that her trainees are highly respected for the calibre of the wide range of contributions they have made to many aspects of communication disorders, in major centres all over the world? the department of speech pathology at wits must stand as a monument to her grit and determination that south african students would have access to facilities and training that matched any unit in the world. her ideas and practical skills flourished, and are now deployed with great enthusiasm, by many graduates, elsewhere, away from the nest of support and encouragement. but outside of the "department" and in addition to her standing within the university as a whole, professor aron is widely acknowledged and admired for her passionate, and long standing fight to keep sasha within the international arena of professional activity, despite some vicious orchestrations to misrepresent the position of south african speech therapists and audiologists, and their clients, within the south african context. i am proud to be a wits graduate. my professional development is due almost entirely to the vision, standpoint and influence of a true woman of worth. she made us believe through an outstanding training, that we could enhance the communication skills in all those deprived of them, through accurate observation, pertinent treatment,and the consideration, in the first instance, that all men, women and children were deserving of an equality of care and consideration. / 1'lic south african journal of'coiiniiiiuication disorders, vol. '.\7. 19u0 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 13 a personal tribute to prof. chookie aron marion fredman haifa, israel prof. chookie aron had more influence on my professional career than any other individual. it may even be that her influence on me was greater than on most of the students who have been under her supervision throughout the years. in 1950 when i started studying at wits, i could not decide which profession to choose. in my first year i took courses which would leave my options open for future study. i knew chookie previously and met her again on the campus. when i told her about my dilemma she suggested that i come to the speech clinic in the third basement of the library and discuss speech therapy with her. on my first visit i observed her treating a case and shortly after that my mind was made up. i qualified in 1954 and in 1958 emigrated to israel. in 1965 i was offered an american government research grant to carry out a project on adult aphasics. it was a wonderful opportunity to work towards an m.a. but as yet there was no speech therapy department in israel. so i turned to chookie and was accepted at wits for my degree under her supervision. during the four years that i carried out the project and wrote my thesis, i only visited south africa once or twice so that all my supervision was by correspondence. it is only due to chookie's endless patience and willingness to help that i graduated in 1970. her task not only involved supervising my work but included helping me borrow books from the wits library. this was no mean feat in the pre-computer-fax era! throughout the years chookie and i have been meeting and cooperating as delegates to the i.a.l.p. congresses where each of our countries need all the support they can get. our most recent encounter in prague was a truly historic one. we managed to see the city together three mon ths before the revolution which has changed the country considerably. i wish chookie a happy retirement. i know that she will continue to work for the benefit of the speech and hearing impaired community wherever she is needed. professor aron : a message from a distance marlene behrmann marlene carno jacobson danielle kaplan toronto, canada it is with feelings of the utmost respect, admiration and gratitude that we write this tribute from toronto to professor m.l. aron. | / for us, prof. aron was a mentor, teacher and a sensitive, caring person. she nurtured the development and advancement of speech-language pathology and audiology in the south african milieu over several decades, a singular accomplishment for one person. her vision of our field was constantly attuned to the changing needs of the country and she was instrumental in redirecting the focus of the discipline to accommodate such changes with remarkable flexibility. furthermore, she was able to foresee and anticipate the need for change, as manifest in her day-to-day activities and long-range plans. on the academic front, prof. aron insisted that students receive a broad, rich foundation, covering all facets of communication disorders, thereby enabling her graduates everywhere to succeed in diverse areas of specialty. while attending to the acute grass-roots needs of the profession and the country, prof, still saw the importance of a postgraduate program, which could ensure our participation internationally. her breadth extended still further: she implemented a database of tremendous scope, targeting the unique epidemiology of communication disorders in south africa; she also ventured beyond the academic ivory tower into the unknowns of rural health-care and at the same time, managed to maintain close and personal links with her many students and colleagues. as recipients of prof.'s generous spirit, continued interest and hospitality, we take this opportunity to pay tribute to a woman ahead of her time. prof, we salute you and wish you fulfilment of your many dreams and endeavours. die sitid-afiiktumsc ti/dskrif n'r kommunikasicafiqiuhuis, vol. 37. 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 reflections on prof. chookie aron margaret marks wahlhaus johannesburg the phrase "full circle" carries with it pleasing connotations of satisfying completeness. it is an apt description of professor aron's academic life and achievements. my nearly forty year's knowledge of chookie aron as a friend and colleague (we were both very young at the time) gives me a privileged perspective of the circles within circles which have gone up to make the interest and world of this remarkable person. i would write at length of the way that her interest in art and in music have been honed and rounded by her educated eye and ear and her commitment to do and find the best to enjoy and appreciate, whether in pottery, photography, piano performance, architecture, or the creation of beauty in her home and in her garden. but perhaps the full circle can best be highlighted by her involvement with the people of south africa. from her time as a student, chookie was concerned on an active and practical level with the people who had no voice, or muted voices a natural care for a speech therapist. her interest in the arts led her, through an involvement with the university of the witwatersrand's arts festival (which she chaired in a frantic but fulfilled final "logopedics" year) to work with union artists, a group which was established to give opportunities to black artists and musicians and was the inspiration of much of the artistic work enjoyed today. her master's dissertation, on stuttering in the black population, has become a source work in the field. all her interests in the arts, in the university where she had studied and taught, in the people of this country, and particularly in those who have communication disorders, culminated in her dedicated concern which led to the establishment of a course at the university of the witwatersrand, for the training of community workers in speech and hearing therapy. her enthusiasm and involvement have ensured attention for so many of the communicatively impaired people, particularly those in the rural and underprivileged areas of southern africa who would otherwise have no help. and so the circle of her life and interest is continuing, and her retirement is just a beginning of more commitment and involvement with the principles, standards and ethics of our profession, with the community workers, and with the urgent needs of the people of our land. as the work of a teacher can never be fully measured, so the influence of a person and teacher such as chookie aron can never be limited. the circles grow wider ... / ίίιι· south af'rir/iii foiini/if of coiiimiuiiaitioii disortlcrs, vol. 37. 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 31 die aard en voorkoms van middeloorpatologiee in laerskole vir normaalhorende blanke kinders carin cilliers, β log (pretoria)* deon ρ rossouw, mb ch β μ med (orl) (pretoria) santie meyer, μ log (pretoria)* marina hurter, β log (pretoria)* *departement spraakheelkunde, spraakwetenskap en oudiologie, universiteit van pretoria departement oor-, neusen keelheelkunde, universiteit van pretoria opsomming die doel van hierdie studie is om vas te stel wat die aard en voorkoms van middeloorprobleme by graad 1 en 2 blanke kinders is. siftingsoudiometrie is op 50 leerlinge (100 ore), in 'n hoe, en 50 leerlinge (100 ore) in 'n lae sosio-ekonomiese omgewing uitgevoer. alle leerlinge wat 'n eerste oudiometriese siftingsprosedure gefaal het, is aan 'n tweede siftingsprosedure onderwerp. uit die resultate blyk dit dat 19,5% uitgeval het op die oudiologiese siftingstoetse. 'n otologiese ondersoek het 8,5% van hierdie kinders geidentifiseer as kinders met middeloorprobleme. daar was nie statisties beduidende verskille tussen die verskillende sosio-ekonomiese groepe nie. abstract the aim of the study was to determine the prevalence of middle ear dysfunction amongst grade 1 and 2 white children. identification audiometry was performed on 50 children (100 ears) in a high, and 50 children (100 ears) in a low socio-economic area. all children failing the identification audiometric procedure were re-evaluated. the results indicated that 19,5% also failed the second audiometric screening. of these children 8,5ψο were identified as children with middle ear problems. there were no statistically significant differences between the two socio-economic groups. voor die ouderdom van ti'en jaar het ongeveer 75% van alle /'kinders een of meer aanvjalle van akute otitis media ondervind (m611er, 1985). juis aangesien daar so 'n hoe voorkoms van otitis media is, is vroee identifisering, soos by enige gehoorpatologie, van groot belang. die rede hiervoor is dat dit gevolge kan he wat deur vroee intervensie voorkom kan word. met ander woorde, kinders wat herhaalde aanvalle van chroniese otitis media in die vroee lewensjare gehad het, kan later as gevolg hiervan sekondere probleme toon. dit sluit onder andere in: vertraagde taalontwikkeling en versteurde taalvaardighede, ouditiewe perseptuele probleme, swak intellektuele vermoens, swak akademiese prestasie en gedragsen emosionele probleme (hugo, 1984; feldman en wilber, 1977; northern en downs, 1984). die rede vir die negatiewe sekondere gevolge van otitis media is dat kinders 'n wisselende graad van ouditiewe deprivasie ondervind, as gevolg van die fluktuerende aard van die toestand. sekere hoerisikogroepe is al geidentifiseer, byvoorbeeld die gesplete-lip-en-verhemeltepopulasie (mcwilliams, morris en shelton, 1984). daar is byvoorbeeld ook uitgevind dat die voorkoms van otitis media opvallend hoer in die laer sosio-ekonomiese groepe as in die hoer sosioekonomiese groepe is (klein,yl978). dit kan waarskynlik aan verskeie faktore toegeskryf word, byvoorbeeld oorbevolking, swak sanitere toestande, ontoereikende mediese die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 dienste, wanvoeding, sosio-kulturele ongelykheid, lae motivering en swak algemene gesondheid (lewis, 1976; klein, 1978). alhoewel daar reeds baie navorsing gedoen is ten opsigte van kindergehoorverliese in eerste wereldlande, byvoorbeeld swede, engeland en die verenigde state van amerika, bestaan daar 'n groot leemte ten opsigte van inligting oor derde wereldlande (wilson, 1985). suid-afrika, met die kenmerkende eerste en derde wereldomstandighede, vertoon ook 'n gebrek aan inligting ten opsigte van die prevalensie van ooren gehoorpatologie. geen studies in hierdie verband is al op die suid-afrikaanse kaukasiese groepe (waaronder die blankes gereken word) gedoen nie. hierdie studie is dus 'n poging om ten dele hierdie leemte te vul en vas te stel wat die voorkoms van middeloorpatologie onder suid-afrikaanse graad 1 en 2 blanke kinders is en ook om vas te stel of sosio-ekonomiese verskille wel 'n merkbare invloed uitoefen op die voorkoms van middeloorpatologiee. eksperiment proefpersone blanke kinders woonagtig in pretoria is geselekteer. die © sasha 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 carin cilliers, deon rossouw, santie meyer en marina hurter kinders is in graad 1 en graad 2. een groep besoek 'n skool wat in 'n lae sosio-ekonomiese gebied gelee is. die ander groep besoek 'n skool in 'n hoe sosio-ekonomiese area (van bergen, 1982). die kinders is deur middel van 'n gestratifiseerde ewekansige steekproef uit die 2 skole geselekteer. tabel 1: voorstelling van proefpersone ouderdom skool 1* skool 2** totaal 6 jaar 16 9 25 7 jaar 34 35 69 8 jaar 0 6 6 totaal 50 50 * skool 1: hoer sosio-ekonomiese status ** skool 2: laer sosio-ekonomiese status apparaat die otoskopiese ondersoek is deur middel van 'n welch allyn otoskoop en immittansiemetings deur middel van 'n grason stadler model gsi 28 auto tymp (geyk volgens 150-1975 standaarde) uitgevoer. die suiwertoondrempels is met behulp van madsen electronics ob40 (geyk volgens sabs 082 standaarde) bepaal en die agtergrondgeraas is met behulp van 'n bruel en kjaer 2204 klankpeilmeter gemeet. prosedure die eksperimentele metode is 'n tweegroepontwerp wat 'n tussengroep ontwerpmetode is (smit, 1983). al die proefpersone is in april en mei getoets aangesien klimaatverandering die resultate kan bei'nvloed wanneer boonste lugweginfeksies in die wintermaande die voorkoms van die middeloorpatologie verhoog (voogt, halama & van der merwe, 1986). klankpeilmetings is van 'n stil vertrek gemaak om te bepaal of dit geskik vir suiwertoonsiftingsdoeleindes is (barrett, 1985). in beide skole was die agtergrondgeraas in die vertrek binne die voorgestelde perke en dus geskik vir siftingsoudiometrie. 'n inisiele gehoorsifting is uitgevoer om kinders sonder middeloordisfunksie uit te skakel. hiervoor is al die proefpersone aan 'n otoskopiese ondersoek en siftingsimmittaiisiemeting onderwerp. slegs proefpersone wat nie die inisiele siftingstoets geslaag het nie, is aan opvolgtoetsing onderwerp. die opvolgtoetsing het bestaan uit 'n oor-, neusen keelondersoek, uitgevoer deur 'n oor-, neusen keelarts, siftingsimmittansiemetings en 'n suiwertoonsiftingsondersoek. data-ontleding die ondersoek van die timpaniese membraan is na aanleiding van die oor-, neusen keelarts se bevindings as volg geklassifiseer: i — normaal, ii — geskend (fibroties, atrofies, skleroties), iii — kliniese otitis media (cholestiatoma, timpaniesemembraan-perforasie, middeloor-effusie, atelektatiese otitis media, akute otitis media). siftingsimmittansiemetings se slaag/faalkriteria is soos volg (asha in barrett, 1985): klas i — slaag middeloordruk tussen + 100 en 200 dapa en 'n teenwoordige akoestiese refleks. klas ii — risiko abnormale middeloordruk en teenwoordige akoestiese refleks of middeloordruk tussen + 100 en 200 dapa en afwesige akoestiese refleks. hertoets na drie tot vyf weke. klas iii — faal middeloordruk abnormaal en afwesige akoestiese refleks. die kriteria vir normale en afwykende timpanogramme is volgens jerger (1970) ter aanvulling van bogenoemde kriteria gebruik. suiwertoonsiftingskriteria is as volg (asha in barrett 1985): volgens die standaarde moet proefpersone drempels he van: 20 db gp by 500 hz, 1000 hz en 2000 hz en 20 db of 25 db by 4000 hz. om te bepaal of die verskille tussen die twee groepe proefpersone statistics beduidend is, is daar varrdie volgende formule gebruik gemaak: pi p2 s/p]i-pj~ s/ϊ/οο+τ/ϊ00 waardes is op die^to peil van betekenis bereken. resultate tabel 2: die ore wat die inisiele en opvolgimmitansiemetings slaag/faal faal inisiele faal opvolgsifting sifting skool 1: 29/100 20/100 | ν = 100 (29 %) (20 %) skool 2: 24/100 19/100 ; ν = 100 (24 %) (19 %) ] totaal: 53/200 39/200 1 ν = 200 (26,5 %) (19,5) ! in tabel 2 word 'n vergelyking getref tussen die aantal pre wat die eerste sifting gefaal het en die wat die tweede sifting gefaal het. uit tabel 2 blyk dit dat 19,5% ore die tweede sifting gefaal het waar daar aanvanklik 26,5% ore gefaal het. daar het dus meer leerlinge gefaal tydens die eerste toetsing as tydens die tweede toetsing. hierdie verskynsel kan verklaar word as sou die middeloortoestande, wat in die eerste toetsing opgemerk is, ten tye van die tweede toetsing in sommige gevalle alreeds spontaan opgeklaar het^fprescod, 1978). hierdeur word oorverwysing dus verminder. brooks (1976) waarsku ook daarteen dat te veel waarde aan 'n enkele abnormale timpanometriese uitslag geheg word en beklemtoon ook die groot mate van spontane herstel wat voorkom. uit die resultate blyk dit verder dat die leerlinge in skool 1 the south african journal of communication disorders, vol 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die aard en voorkoms van middeloorpatalogiee in laerskole vir normaalhorende blanke kinders 33 in 'n geringe mate swakker gevaar het as die leerlinge in skool 2 op beide siftingstoetse. hierdie verskille is egter nie statisties betekenisvol nie (z = 0,8 < 2,52 maar > 2,57; ζ = 1,66 < 2,57 maar > 2,57). hierdie tendens is moeilik verklaarbaar aangesien daar verwag is dat leerlinge vanuit die hoer sosio-ekonomiese groep minder middeloorprobleme sou vertoon as leerlinge vanuit die laer sosio-ekonomiese groep. redes hiervoor kan wees dat daar miskien nie so 'n groot verskil in sosio-ekonomiese status onder blankes in pretoria is nie (badenhorst, 1987). verder beskik albei skole oor sowel skoolmediese dienste as oudiologiese dienste. ten spyte van die relatief lae sosio-ekonomiese gebied waarin die proefpersone van skool 2 woonagtig is, is dit so dat heelwat van die inwoners by ,groot industriee werksaam is wat goeie mediese fasiliteite bied. 'n laaste faktor wat die resultate kon be'invloed, is die ouderdomme van die kinders. leerlinge in skool 1 was effens jonger as die in skool 2. aangesien jonger kinders 'n groter voorkoms van middeloorpatologie vertoon, kon dit duidelik die rede wees hoekom die resultate van die twee skole nie beduidend van mekaar verskil nie. ten einde te bepaal of die proefpersone wat met die siftingstoetse uitgeval het, wel oor die patologiese middeloorfunksie beskik, is die resultate van die otologiese ondersoeke in verband gebring met die van die opvolgimmittansiemetings. resultate kan soos volg getabelleer word: tabel 3: die otologiese diagnose van die ore wat met die opvolgimmittansiemetings uitval opvolgsifting otologiese diagnose faal patologies normaal skool 1 ,n = 29 / 20/29 (69%) 11/29 (37,9%) 9/29 (31%) skool 2 ν = 24 19/24 (79,1%) 6/24 (25%) 13/24 (54,2%) totaal: (opvolgsifting) ν = 53 ! 39/53 (73,6%) ί 17/53 (32,1%) 22/53 (41,5%) totaal: (uit totale populasie) ν = 200 i 39/100 (19,5%) 17/200 (8,5%) 22/200 (11%) in tabel 3 word die ore wat met die tweede sifting faal, se otologiese diagnose uiteengesit. uit tabel 3 blyk dit dat 'n totaal van 39 uit 53 ore met die tweede sifting uitval (73,6%). van die 53 ore is slegs 17 as patologies geklassifiseer (32,1%). daar kan dus gese word dat 'n totaal van 17 ore, vanuit die aanvanklik getoetste populasie (8,5%), beide die opvolgtoetsing en otologiese diagnose gefaal het. wanneer hierdie persentasie vergelyk word met ander populasies van 'n gemiddelde sosio-ekonomiese status, is dit duidelik dat hier 'n hoe voorkoms van middeloorprobleme is. die volgende voorkomssyfers van otitis media is hier tersaaklik: 2% (amerika), 4,1% (rusland) en 1% (denemarke) (hinchcliffe in northern en downs, 1984). wanneer dit egter vergelyk word met die voorkoms onder hoerisikogroepe, byvoorbeeld indo-chinese vlugtelingkinders (68,8%), is die voorkoms laag (corth en harris, 1984). dit wil dus voorkom asof die voorkoms van middeloorprobleme by die groep graad 1 en 2 leerlinge van pretoria, hoer is as in ander gemiddelde sosio-ekonomiese status populasies, maar laer is as die insidensie in hoerisikogroepe. wanneer die voorkomssyfers van middeloorprobleme by skool 1 (11%) en by skool 2 (6%) bestudeer word, blyk dit dat die resultate van skool 2 effens beter is. op die 1% peil van betekenis is hierdie verskil egter nie statisties beduidend nie. die moontlike redes vir die bevinding is reeds genoem. tabel 4 : die otologiese diagnose van die ore wat met die opvoleimmittansiemeting slaag. opvolgsifting otologiese diagnose slaag patologies normaal skool 1 ν = 29 9/29 (31%) 1/29 (3,4%) 8/29 (27,6%) skool 2 ν = 24 5/24 (20,8%) 1/24 (4,2%) 4/24 (16,7%) totaal: (opvolgsifting) ν = 53 14/53 (26,4%) 2/53 (3,8%) 12/53 (22,6%) totaal: (uit totale populasie) ν = 200 14/200 (7%) 2/200 (1%) 12/200 (6%) in tabel 4 word die ore wat die tweede sifting slaag, se otologiese diagnose uiteengesit. uit tabel 4 blyk dit dat 'n totaal van 14 uit 53 ore, die tweede sifting slaag (26,4%). uit die 14 ore, is slegs 2 as patologies geklassifiseer tydens die otologiese ondersoek (14,3%), terwyl 12 ore (85,7%), normaal was. twee van die ore wat wel afwykend was volgens die otologiese diagnose is as normaal geklassifiseer tydens die opvolgsifting. die een oor het 'n herstelde perforasie gehad en die ander oor was atelektaties. dit gebeur met ander woorde relatief selde dat 'n persoon nie op oudiologiese siftingstoetse uitval nie, maar dan wel as patologies geklassifiseer word (1%). tabel 5: otologiese ondersoek timpaniese membraan totaal normaal 181/200 ν = 200 (90,5%) geskend 8/200 ν = 200 (4%) kliniese otitis media 11/200 ν = 200 (5,5%) in tabel 5 word die resultate van die otologiese ondersoek uiteengesit. uit tabel 5 blyk dit dat vanuit 'n aanvanklik getoetste populasie van 200 ore, 4% 'η geskende timpaniese membraan en 5,5% kliniese otitis media het. sou hierdie persentasies vergelyk word met resultate van soortgelyke die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 carin cilliers, deon rossouw, santie meyer en marina hurter studies, wil dit voorkom asof die prevalensie van middeloorprobleme hier relatief laag is. hier kan die studie van johnson (1970) as voorbeeld genoem word. in die betrokke studie is 3000 indiaanse kinders betrek. 'n voorkomssyfer van 7% gevalle met chroniese otitis media en 8% gevalle met tekens van vorige middeloorpatologie is gevind. in teenstelling hiermee toets fiellau-nikolajsen (1979) kaukasiese kinders en vind 'n baie lae voorkoms van 0,8% defekte van die timpaniese membraan. dit wil dus voorkom asof die proefpersone in hierdie studie, in vergelyking met 'n hoerisikogroep kinders, nie 'n abnormale hoe voorkoms van middeloorprobleme toon nie. tabel 6: sensitiwiteit en spesiwiteit: siftingsimmittansieresultate en otoskopiese ondersoek siftingstoets patologies normaal totaal positief negatief totaal 17 (a) 2 (c) 19 (a + c) 22 (b) 12 (d) 34 (b + d) 39 14 53 (a + b + c + d) sensitiwiteit: a/(a + c) 89,5% ' spesiwiteit: d/(b + d) (frankenburg in northern en downs, 1984) 35,3% in tabel 6 word die sensitiwiteit en spesiwiteit van die immittansiesiftingstoets bereken. dit is dus duidelik dat hoewel die sensitiwiteit hoog is (89,5%), is die spesiwiteit te laag (35,3%): die vraag ontstaan nou of die spesiwiteit van die immittansiesiftingstoets nie sal verbeter indien die akoestiese refleks nie as siftingskriterium gebruik is nie. die rede hiervoor is omdat so 'n groot persentasie kinders ten spyte van 'n tipe a-timpanogram, 'n afwesige akoestiese refleks toon en dus die siftingstoetsing faal. in so 'n geval kan die resultate soos volg getabelleer word: ' tabel 7: sensitiwiteit en spesiwiteit: timpanogramme en otoskopiese ondersoek siftingstoets patologies normaal totaal positief negatief totaal 14 (a) 2 (c) 16 (a + c) 16 (b) 12 (d) 28 (d + b) 30 14 44 (a + b + c + d) sensitiwiteit: a/(a + c) 87,5% spesiwiteit: d/(b + d) (frankenburg in northern en downs, 1984) 42,9% in tabel 7 word die sensitiwiteit en spesiwiteit van die immittansiesiftingstoets bereken waar reflekse nie as maatstaf gebruik word nie. die afleiding kan dus gemaak word dat die spesiwiteit van die immittansiesiftingstoets wel van 35,3 •ria 42,9 verbeter het, maar dat dit steeds baie laag is. dit is nogtans bemoedigend dat kinders wat middeloorprobleme toon selde nie deur middel van immittansiesiftingstoetse geidentifiseer kan word nie. gevolgtrekkings in teenstelling met die algemene opvatting dat daar 'n hoer voorkoms van middeloorprobleme in 'n laer sosio-ekonomiese gebied as in 'n hoer sosio-ekonomiese gebied sal wees (klein, 1978) het die studie dit as onwaar bewys. feitlik ewe veel leerlinge uit beide die hoe en lae sosio-ekonomiese omgewing faal die eerste, sowel as die tweede siftingsprosedure. redes hiervoor kan onder andere klein verskille in sosio-ekonomiese status onder blankes, goeie mediese en oudiologiese dienste ook in die laer sosio-ekonomiese gebied en die effens jonger ouderdomme van leerlinge in skool 2 wees. ten opsigte van die voorkoms van middeloordisfunksie (oudiometries bepaal) faal 'n totaal van 19,5% die eerste, sowel as die tweede oudiologiese sifting. word dit vergelyk met resultate van soortgelyke studies, wil dit voorkom asof die prevalensie van middeloordisfunksie by die 2 groepe kinders nie kommerwekkend hoog is nie. redes hiervoor kan die gereelde skoolmediese, sowel as oudiologiese dienste waaroor hierdie skole beskik, wees, 'n totaal van 17 ore (8,5%), vanuit die aanvanklik getoetste populasie, faal beide die opvolgtoetsing en die otologiese diagnose. verder was daar geen statisties beduidende verskille tussen die twee groepe persone nie. ten opsigte van die aard van die middeloorpatologie het 4% 'n geskende timpaniese membraan en het 5,5% kliniese otitis media. in vergelyking met ander studies wil dit voorkom asof hierdie proefpersone in vergelyking met hoerisikogroepe nie 'n hoe voorkoms van middeloorprobleme vertoon nie (johnson, 1970): dit blyk egter dat die voorkoms wel hoer is as ander kaukasiese populasies (fiellau-nikolajsen, 1^79). ten opsigte van 'n vergelyking tussen die mediese en oudiologiese resultate, blyk dit dat die sensitiwiteit van die immittansiemetings goed is, maar die spesiwiteit baie laag is (35,3%). indien akoestiese reflekse nie as siftingskriterium gebruik word nie, verbeter die spesiwiteit na 42,9%. hierdie studie verskaf belangrike inligting aangesien dit die eeitste keer is wat so 'n studie onder kaukasiers in suidafrika uitgevoer is. die voorkomsfrekwensie van 9,5% vir middeloordisfunksie soos in die studie verkry is, sal waarskynlik wissel in ander populasies, geografiese areas, ouderdomsgroepe, ensovoorts, maar 'n prevalensiesyfer vir 'n groep graad 1 en 2 blanke kinders is nou beskikbaar. ! verwysings i badenhorst, m.s. persoonlike onderhoud. departement stadsen streekbeplanning, universiteit van pretoria, 1987. barrett, k.a. hearing and immittance screening of school-age children. in katz, j. (red.) handbook of clinical audiology. baltimore: williams & wilkins, 1985. brooks, c.n. school screening for middle ear effusions. the annals of otology, rhinology and laryngology, suppl. 25(2), 223—2238 1976. corth, s.b. & r.w. harris. incidence of middle ear disease in indochinese refugee schoolchildren. audiology, 23, 27—37 1984. feldman, a.s. & l.a. wilber. acoustic impedance and-admittance. baltimore: williams & wilkens, 1977. fiellau-nikolajsen, m. tympanometry ι prediction of the magnitude of hearing loss in _preschool-children with secretory otitis media. scandinavian audiology, supplementum 17 6 8 7 2 , 1979. . / hugo, r. normatiewe evaluasie van otitis media as sekondere patologie. suid-afrikaanse tydskrif vir opvoedkunde 5 8 3 8 8 , 1984. the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die aard en voorkoms van middeloorpatalogiee in laerskole vir normaalhorende blanke kinders 35 jerger, j. clinical experience with impedance audiometry. archives of otolaryngology, 92, pp. 3 1 1 3 2 4 , 1970. johnson, r.l. a abbreviated impedance bridge technique for school screening. in feldman, a.s. & l.a. wilber (reds.) acoustic impedance and admittance. baltimore: williams and wilkens, 1970. klein, j.o. epidemiology of otitis media. in harford, e.r., f.h. bess, c.d. bluestone, j.o. klein (reds.): impedance screening of middle ear disease in children. new york: grune & stratton, 1978. lewis, n. otitis media and linguistic incompetence. archives of otolaryngology, 192, 3 8 7 3 9 0 , 1976. mcwilliams, b.j., h.l. morris & r.l. shelton. cleft palate speech. st. louis: the cv mosby company, 1984. miller, p. incidence and time course of otitis media in children. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 audiology in practice, 1(3), 1, 1985. northern j.l. & m.p. downs. hearing in children. baltimore: the williams & wilkens company, 1984. prescod, s.v. audiological handbook of hearing disorders. new york: litten education publishing inc., 1978. smit, g.j. navorsingsmetodes in die gedragswetenskappe. pretoria: haum opvoedkundige uitgewers, 1983. van berge, m.m. die sosio-ekonomiese status van woongebiede in pretoria. ongepubliseerde skripsie, universiteit van pretoria, 1982. voogt, g.r., halama, a.r. & van der merwe, c.a. immittance screening in black preschool children attending day-care centres. audiology, 25, 158—164, 1986. wilson, j. deafness in developing countries. archives of otolaryngology, 3(1), pp. 2 9 , 1985. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) new a m o m e n t of truth from amtronix οτι co ν 152 canal hearing a i d available in standard (modular) and custom made. the 152 comes standard with three audiological controls as shown in fig. a: a-gram control = low frequency adjustment (green arrow and dots). db hl control = output/gain adjustment (red arrow and dots). feedback control (fc) = high frequency adjustment (orange arrow and dots). volume control button (with o n / o f f fig. β shows minimum & maximum of function) red dot: right version. controls. blue dot: left version. battery compartment (below lid). sound outlet. vent opening (in custom version). state of the art technology for the year 1990 available from amtronix in 1988. the almost impossible made possible, thanks to oticon! 1. 2. 3. 4. computerized insertion gain optimizer features: * the sure way to the right results. * read in personal patient and audiogram data. * measure open ear and occluded ear gain. compare insertion gain curves and select hearing aid. * programme alternate test procedures; if needed. * get it right first time. the igo 1000 system offers you a compact, easy-to-use diagnostic and treatment package. * complete test capability. high resolution, full colour monitor and printouts. * high speed and extreme test accuracy. * ' efficient, easy-access storage of patient data. a modern, ergonomic design for maximum user comfort. diagnostic a u d i o m e t r y the friendly midimate 602 diagnostic audiometer for audiologists demanding capability, simplicity and efficiency. features: * brief automatic check at start-up. * fast menu-driven setup of your own test. * ; \ p r e p r ° g r a ; ™ a b l e t e s t s e t u p s f o r instant one-key retrieval of your favourite setups saves you time and trouble in the daily routine. ^ simple and logical multilingual menu-driven display dialogue makes the midimate 602 easy to learn and easy to use. ' transflective blacklighted display is easily readable under any lighting conditions while supertwist technology enlarges the viewing angle. / few operator controls all logically located on front panel for optimal operation convenience and accuracy. a m t r o n i x (pty) ltd., p.o. box 630, bedfordview 2008 phone (011) 6221743 telex 4-50033 amtron fax 6221306 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 3 the case for cognitive neuropsychological remediation marlene behrmann, ma (speech path.) (witwatersrand) sharon herdan, ba (sp. and h. therapy) (witwatersrand) department of speech pathology and audiology, university of the witwatersrand, johannesburg abstract developments in the field of cognitive neuropsychology have recently begun to have an impact on therapeutic approaches to aphasia. increasingly, clinicians have started adopting theoretical models of normal cognitive processing for the assessment and rehabilitation of individuals with acquired language deficits. this study describes and evaluates a single case, tested and treated within this framework. the subject, a surface dysgraphic, was assessed in detail pre-therapy and a deficit in lexical processing was diagnosed. treatment designed to stimulate the lexical route of writing was undertaken and post-therapy evaluation was conducted. the results revealed a significant improvement in the writing of both regular and irregular treated words with generalisation to certain untreated words. such improvement was shown to be a direct consequence of the intervention procedure. therapeutic findings strengthen the basis of cognitive processing models which, in turn, provide a streamlined clinical framework for the practitioner. opsomming resente ontwikkeling in die vakgebied van kognitiewe neuropsigologie begin om 'n invloed uit te oefen op terapeutiese benaderings tot afhsie. terapeute begin toenemend om teoretiese modelle van normale kognitiewe prosessering aan te wend vir die evaluering en rehabilitering van individue met verworwe taalafwykings. hierdie studie beskryfen evalueer 'n enkele geval wat binne hierdie raamwerk geevalueer en behandel is. voor die aanvang van die behandeling is 'n diepte-evaluasie op 'n pasient met oppervlakdisgrafie uitgevoer en 'n afwyking in leksikale prosessering is gediagnoseer. behandeling gerig op die stimulering van die leksikale roete van skryfvermoens is uitgevoer en die pasient is na afloop van die behandeling geherevalueer. resultate dui op 'n beduidende verbetering in die skryfvan beide reelmatige en onreelmatige behandelde woorde met veralgemening na sekere onbehandelde woorde. hierdie verbetering is bewys om 'n direkte gevolg van die intervensieprosedure te wees. terapeutiese bevindinge verstrek die basis van kognitiewe prosesseringsmodelle wat op hulle beurt 'n gerasionaliseerde kliniese raamwerk aan die klinikus verskaf. the'last decade has witnessed the rapid expansion of a discipline which has come to be called cognitive neuropsychology. this discipline postulates that an information-processing system, consisting of a number of modular subcomponents, underlies the normal execution of any cognitive activity (coltheart 1983, 1985).!these modular, domain-specific subcomponents function independently and are interconnected by a network of pathways. whereas all the subsystems function adequately in normals, they are susceptible to discrete disruption following brain damage. brain damage, thus, leads to observable dissociations between functions. such dissociations have been studied in detail and have evolved into a detailed description of the various patterns of acquired cognitive deficits (see coltheart 1980). the study of brain damaged patients within the cognitive neuropsychological paradigm has been informative on a number of levels. it has confirmed the existence of theoretically postulated dissociations and has lent credibility to the existing theoretical models, especially in the field of acquired dyslexia. a further benefit of such an approach has been in the clinical sphere. sophisticated diagnostic methods have evolved in order to assess the independent functioning of the modular subcomponents. additionally, and more recently, remediation programs designed to restore the malfunctioning subsystem, have been described in the literature (behrmann 1987; byng and coltheart 1986 and de partz 1986). the cognitive neuropsychological approach has facilitated the locating of a specific acquired deficit in precise terms and has then provided guidelines for formulating an individually tailored treatment program. according to hatfield (1983), this new orientation has made it possible to develop new methods which depend on a wellthought out theory of normal cognitive processing. a basic concern of the above cited remediation studies is methodological integrity. treatment studies have always been subject to methodological inadequacies and as such, results have been ambiguous and undefined. in many instances, it has been impossible to determine whether the positive findings were attributable to the treatment itself or to other co-occurring but non-specific causes such as spontaneous recovery or increased motivation (byng and coltheart 1986). the cognitive neuropsychological remediation studies, on the other hand, have been designed in such a way that the outcome of therapy may be unequivocally interpreted and as such, satisfy rigorous methodological criteria. the purpose of this paper is to describe a remediation study based on the cognitive neuropsychological theory of writing. in recent years, models of the normal writing process have become increasingly well developed and detailed investigations of the acquired dysgraphias have been underdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 © sasha 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 marlene behrmann and sharon herdan taken (margolin 1984; patterson and shewell 1987). despite the fact that such theoretical development has much potential for therapeutic application, there are remarkably few treatment studies in this area. the present study was designed to apply a model of normal writing to the remediation of an acquired agraphia. as in most current models of the normal writing process, the writing model adopted for this study includes two major routes (see figure 1). the phonological route involves the segmental translation from phonology to orthography spelling of words directly from the lexicon and are thus forced to rely on the phonological route whereby phonological segments are translated into orthographic representations (ellis 1984; hatfield and patterson 1983). the outcome of this is that irregular and homophonic spelling is adversely affected and since phoneme-grapheme conversion is used, resulting spelling errors are phonologically plausible for example, 'yacht' may be written 'yot'. previous studies (beauvois and derouesne 1981; hatfield auditory analysis w phonological non-lexical route 1 γ w lexical route r phonological representation: word recognition ι figure 1: simplified information processing model of two major routes for single word writing to dictation (after ellis 1984: patterson 1980.) through the application of rules of phoneme-to-graphemeconversion. this route may only be utilised to write regular words whose spelling conforms to the spelling conventions of the language. in addition, one may use this route for assembling the spelling of unfamiliar words or non-words which do not have prior entries in the lexicon. the second major route, the lexical route, involves an association between word spelling and its meaning. thus, the writer must recognise the phonological input of the dictated word and must access its semantic representation and orthographic form. this may only be achieved with words which have prior entries in the lexicon, i.e., are real words which have been encountered previously. the use of the lexical procedure is critical for spelling irregular words (which cannot be assembled through phoneme-grapheme conversion) and homophonic words (which are phonologically identical but differ in orthographic representation and semantics) (hatfield and patterson 1983; margolin 1984). surface dysgraphia is one of the patterns of deficit identified on the basis of models such as the one above. this problem, alternatively termed lexical or orthographic dysgraphia, arises from the defective functioriing of the lexical route. patients with this disorder have lost the ability to access the and patterson 1983) have focussed on the assessment and classification of acquired surface dysgraphia. beauvois and derouesne (1981), for example, reported that their subject; r.g. wrote almost all non-words correctly but that his real word spelling depended on the degree of orthographic ambi-, guity between sound and print. as words became less regular in their spelling pattern, so his performance dete-j riorated. hatfield and patterson's (1983) subject, t.p. alsoj spelled via the non-lexical routine. he too showed superior/ performance on regular compared with irregular words and many of his errors were phonologically plausible (e.g., laugh — laf). treatment of this disorder was undertaken by hatfield (1983) who described a positive therapy outcome for her surface dysgraphic subject. another study of surface dysgraphia treatment, undertaken by behrmann (1987), was devoted to the retraining of the subject's lexical route through the use of homophonic rather than irregular words. the subject benefitted from this intervention, showing marked improvement on treated homophones (from 49% to 67%). in addition, the subject improved on writing untreated irregular words (32% to 67% across two lists), implying that a broad, rather than a specific, change within lexical processing had been implemented. minimal improvement on untreated homophones was noted, suggesting that the the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the case of cognitive neuropsychological remediation 5 lexical route was not entirely restored or alternatively, word-specific learning is necessary for homophones. the subject of the present study, ccm, participated in the behrmann (1987) study and as is evident, did not achieve perfect scores on irregular word writing. she has subsequently participated in a second phase of the treatment program and the results of this phase are reported here. aims the aim of the present study was to investigate the efficacy of a treatment program conducted within a cognitive neuropsychological framework, on a subject with acquired dysgraphia. more specifically, this study was designed to investigate the subject's present use of the lexical procedure in writing to dictation, and to implement a therapy procedure to further enhance the use of the lexical route in writing. subject description a. case history ccm suffered a cerebro-vascular accident (cva) in june 1984, at the age of 53 years. a ct scan suggested that the cva involved the middle cerebral artery in the left temporoparietal region. clinically, no hemiplegia nor hemianopia were noted. ccm had a history of hypertension for which she was receiving medication at the time of the stroke. ccm, a high-school educated woman, was employed as a secretary pre-morbidly. although she is bilingual (english and afrikaans), she has resided in an english speaking environment for a long time and uses english almost exclusively. b. aphasia testing the western aphasia battery (kertesz 1980) was administered in may 1985 and revealed an aphasia quotient of 73 (cut-off point 93,8) and a pattern of deficits resembling conduction aphasia. her spontaneous speech was fluent with a mean length of utterance of 6,8 and a marked breakdown in repetition was observed, j ' the bishop and byng (1984) lexical understanding with visual and semantic distractors, in which ccm was required to match a printed! word with the correct picture, was administered. distractor pictures included a closely related semantic picture, a distant semantic distractor, a picture which is visually similar to the target and an unrelated picture. ccm's score of 39/40 was indicative of her preserved single word level semantic ability. relatively well preserved syntactic abilities were also observed as ccm scored 85% on the test of receptive grammar (trog) (bishop 1982). c. test of reading and writing: detailed testing of ccm's reading and writing have been described in the previous study (behrmann 1987). in sum, ccm demonstrated remarkably well-preserved reading skills at the single word level. she scored 100% on a lexical decision task in which she had to decide whether a string of letters constituted and english word or not. in addition, various word lists were given to her for oral reading. reading performance was good even on irregular words (mean 96%) which utilise the lexical route. similarly, her ability to use the non-lexical route (segmental translation from orthography to phonology) was good as she read 83% non-words correctly. neither imageability nor frequency played a significant role in her reading performance. ccm's superior reading ability was in marked contrast to her impaired writing. only on non-word writing did ccm perform relatively well (80%), suggesting the selective preservation of the non-lexical phonological writing route. results of several other writing tests (see table 1) revealed a significant difference in her ability to write regular compared with irregular words (bub and kertesz list, fisher exact test p<0.05). this result was not borne out on the roeltgen and heilman (1984) list (fisher exact test ρ = .21) possibly because this latter list is made up of low frequency words, and as such, it presents a potentially confounding interaction of variables. ccm scored poorly on the regular words of this list too, indicating a possible floor effect of this list. table 1: results of ccm's writing performance across various word lists test bub and kertesz (1982) regular words irregular words writing score 35/40 (88%) 15/30 (50%) roeltgen and heilman (1984) regular words irregular words 27/45 (60%) 23/45 (51%) homophone writing 93/138 (67%) non-word writing 24/30 (80%) ccm also performed poorly on homophone writing to dictation (67%). this task obligatorily requires the use of the lexical procedure in order to translate the ambiguous phonological input (for example /seil/) into the correct orthographic form (either 'sale' or 'sail' depending on intended meaning and context). the regular-irregular word discrepancy, together with her poor homophone writing suggested an impairment in the use of the lexical procedure for writing. this is further borne out by an analysis of the types of errors made by ccm. such an analysis revealed that writing was accomplished via the preserved phonological, non-lexical route for writing. most of her writing errors involved phonological conversion, for example tomb—• "toom", ocean —•"owshin", effort—• "evort", ritual—• "richell". certain errors suggested that ccm was using afrikaans rules of phoneme-grapheme conversion in her writing of english words. examples of this include contract—•"kontrak" and crime—•"krime". additionally, /w/ and ivl were confused, for example victim—•"wictim". these confusions are not surprising since ccm grew up in a bilingual community and was a fluent afrikaans reader and writer. in sum, the results of ccm's reading and writing testing indicates that orthographic knowledge for word recognition in reading is separate from the orthographic knowledge necessary for correct spelling in writing. while her reading was remarkably preserved, she displayed all the symptoms typidie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 marlene behrmann and sharon herdan cally associated with surface dysgraphia that is, a reliance on the phonological route in writing, a discrepancy between performance on regular and irregular words and impaired homophone writing. baseline measurement prior to instituting therapy, an adequate baseline measurement must be taken to serve as the basis for comparison of outcome and the evaluation of effectiveness of intervention (mcreynolds and kearns 1983). baseline stability and consistency are critical features which, when observed, rule out maturational and spontaneous recovery effects (vetter 1985). as therapy was to be directed to the restoration of the lexical route through the teaching of irregular words, further spelling assessment was carried out. this assessment was loosely based on the format used by byng and coltheart (1986) in the evaluation of their surface dyslexic patient. four hundred and fifty most frequent words, taken from francis and kucera (1982), constituted the baseline measure. owing to the possible confounding effect of frequency, words were divided into three frequency bandwidths for testing: (i) word 1-150 : frequency 69975 to 580 per hundred thousand (ii) word 151-300 : frequency 574 to 330 per hundred thousand (iii) word 301-450 : frequency 329 to 231 per hundred thousand. testing took place over three sessions during which fifty words from each bandwidth were assessed. overall, ccm wrote 359/450 (80%) words correctly. results across sessions were not statistically significant (chi squared = 1,43, ρ >0,5) and hence, stability of performance was observed (session 1 115/150 (77%); session 2 121/150 (81%); session 3 123/150 (82%)). a significant difference (chi square = 8,3, ρ <0,01) across frequency bands was noted with ccm scoring 87% for the most frequent items, 77% for the second group and 75% for the last frequent items. eighty six of the 91 incorrectly written words formed the basis of the therapy. the five words not selected comprised four words that had occurred more than once in the list and one americanised word which was felt not to be in ccm's repertoire. t h e r a p y ( a 1 ) (one week) selection of words (a and b) t p r e t h e r a p y measure ( t w o weeks : 3 baseline measures) treatment procedure the aims of treatment were a. to enhance the use of the lexical procedure in writing, through teaching ccm a group of irregular words, b. to ascertain whether the improvement would generalise to a set of untreated irregular words. c. to establish that the change (if any) that took place was a direct consequence of treatment. design in order to achieve the final aim, a multiple baseline design was used. whereas several functions were assessed pretherapy (semantics, syntax and writing), only one function was to be treated. if improvement was a specific consequence of the treatment program, only the treated function should improve. if, however, improvement resulted from a generalised change such as increased motivation or spontaneous recovery, all linguistic functions should be affected. in order to assess the generalisation of treatment, a crossover design of material was employed. this required that one set of words (a) be taught prior to a second set (b) so that one may evaluate the effect of therapy on β while a is taught and vice versa. to this end, the 86 incorrect words were randomly divided up into two groups, one of 44 words and one of 42 words. these two groups were matched for frequency. each group was further subdivided (a1 and a2, b1 and b2) so that shorter word lists could be taught during therapy. treatment took place for two one-hour sessions per week. each list of words was taught for two consecutive sessions and intra-therapy assessment was conducted at the end of two weeks when the entire group a had been taught. posttherapy evaluation was undertaken after both sets a and β had been covered. figure 2 below illustrates the methodology as well as the timing of treatment. i therapy (a2) 1 (one week) i two weeks i n t r a t h e r a p y measures i post-therapy measure ( t w o weeks : three baseline measures) ί t h e r a p y ( b 2 ) ~ « t h e r a p y ( b 1 ) (one week) ( 0 n e week) figure 2: methodological design and timing of ccm's treatment plan the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the case of cognitive neuropsychological remediation several critical issues were considered in devising specific therapy strategies. in order to retain word-specific representations, a holistic approach had to be adopted and therapy had to be directed to maintaining the link between semantics and the visual form of the word. this meant that the focus of therapy would be on each individual word as a whole item and sub-lexical or part-word processing would be de-emphasized. as ccm was surface dysgraphic but not surface dyslexic, tasks which relied on reading were limited so that the focus of therapy was on the writing, and not on the reading process. different exercises were employed in the initial and subsequent sessions. the first session involved showing ccm the target word and linking it to its meaning through the use of a dictionary. in those cases where it was possible, the word was represented pictorially. following this, ccm was required to copy the word out several times and then to spell it aloud orally so that practice in several modalities would strengthen the link between the word and its spelling. thereafter, she wrote the word to dictation. home practice was undertaken after each session and involved additional copying and picture-word matching tasks. the aim of these tasks was essentially to link the orthography to the semantics and to aid the memorising of the written form of the word. the second session involved correction and revision of the home exercises followed by a series of multiple choice tasks in which the subject selected the correct written form from several options. she then wrote the words to dictation and incorrect spellings were highlighted with coloured pens. finally, ccm was required to write the words to dictation. homework was given again. treatment of groups a2, b1 and b2 followed the same format as outlined for group al. practice at home was restricted to those words which were being taught at that particular phase of the program. post-therapy testing was conducted after a five day break from treatment. the post-therapy baseline testing included the re-administration of all words in lists a and β as well as all words written correctly at pre-therapy testing. the order of testing was the same as that of the pre-therapy assessment. results a comparison of ccm's performance preand post-therapy revealed a significant improvement in her spelling ability following intervention (cochran q test x2 = 38.7, ρ >0,001). table 2 illustrates the scores obtained during the preand post-therapy assessments. there was no significant difference in ccm's three post-therapy measures, indicating a stability in her performance across time (x2 = 0.99, p<0.5). the observed improvement was equally distributed across the three frequency bandwidths (see table 3), suggesting a broad rather than a frequency-specific effect of treatment. an evaluation of pre-, intraand post-therapy measures suggested that the final improvement noted was directly attributable to intervention. as can be seen from table 4. ccm obtained 91% correct spelling on the treated group a words at the intra-therapy measure compared with the pretherapy score (mcnemar's test x2 = 38, p>0.001). the untreated group β words were also markedly improved (60% correct) compared with the pre-therapy score (mcnemar's test x2 = 23, ρ >0.001). this suggests that a certain amount of generalisation had taken place from group a to group β at the intra-therapy stage. this was a pleasing, although not totally surprising result. specific carry-over from group a to group β words was seen on certain words, for example, she learned to spell 'which' in group a and generalised the 'wh' spelling to 'where' and 'while' in table 2: results obtained on baseline measures at pre-and post-therapy levels baseline 1 baseline 2 baseline 3 pre-therapy 115/150 (77%) 121/150 (81%) 123/150 (82%) post-therapy j 143/150 (95%) 139/150 (93%) 140/150 (93%) table 3: results obtained within frequency bandwidths at preand post-therapy testing words 1-50 words 151-300 words 301-450 pre-therapy 131/150 (85%) 116/150 (77%) 112/150 (75%) post-therapy 146/150 (97%) 143/150 (95%) 133/150 (87%) table 4: results of group a and group β words at pre-intra and post-therapy testing pre-therapy intra-therapy post-therapy group a words 0/44 (0%) 40/44 (91%) 41/44 (93%) group β words 0/44 (0%) 25/42 (60%) 35/42 (83%) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34,1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) marlene behrmann and sharon herdan group b. similarly, the correct spelling of 'effort' learned on group a was generalised to the correct spelling of effect in group β the generalisation from group a to group β cannot be totally accounted for on this basis, however, and it is s u g g e s t e d that even at this intra-therapy stage, the lexical route had been activated and was being utilised for writing untreated words. post-therapy testing on the now (treated group β words also revealed that further gains were made when spcific attention was paid to this group and a posttherapy gain of 23% over the intra-therapy score was noted in the group β score. there was no significant difference between group a intratherapy and post-therapy scores (mcnemar's text x2 = 0, ρ <0,5), indicating that ccm was able to retain the words learned even when no practice was allowed. in sum, the post-therapy results were encouraging on several counts: intra-therapy generalization was observed; further benefit was later noted on group b; and there was no decay on group a indicating some longer-term effect. however, in order to ascertain whether ccm had learned something specific about the treated words or whether she had gained a more general ability to spell any set of words, the bub and kertesz (1982) word list was re-administered. the results revealed a significant improvement in the writing of the irregular bub and kertesz words (mcnemar's test x2 = 3,3, ρ<0.01) and some additional improvement on the regular words from 35/40 (88%) to 38/40 (95%). this finding strongly suggests that the lexical route is functional and is processing words that have not been individually treated. in order to assess whether the observed change in writing was directly attributable to therapy and not simply a function of a non-specific variable, ccm's sentence comprehension was re-evaluated. since sentence comprehension bears no theoretical relationship to writing, no improvement in this area is expected. indeed, if improvement were noted, ccm's changes in writing ability might have been a result of diffuse variables rather than intervention per se. preand post-therapy scores on the test of receptive grammar were identical (85%), confirming that the intervention procedure had a specific effect on writing alone. likewise, no change in ccm's digit span was noted post-therapy, a finding which further confirms the specific effects of therapy. discussion the results of this study revealed stable post-treatment performance on writing (directly attributable to the intervention program) and statistically significant improvement on treated words with generalisation to untreated words. these findings suggest that it is possible to retrain writing through a whole-word technique in which the semantic and orthographic links are strengthened. the adoption of a model-based approach allowed the clinician to clearly define the nature of the underlying spelling deficit and then to -develop a remediation program suited to treating the disorder. the fact that the group β words showed some improvement in intra-therapy testing implies that the treatment of group a words did not merely act as a rote learning of a list of words. instead, it suggests that a more general spelling ability had been activated. it has been previously suggested that complete restoration of lexical processing may only be achieved through wordspecific attention and that the spread of generalization (behrman 1987) is minimal. this has largely been refuted in the present case since improved lexical processing was noted on group β words prior to its undergoing treatment and change on untreated irregular words (bub and kertesz list) was obtained. although the type of treatment program adopted in this study does not differ dramatically from traditional approaches to treatment in practical terms, it diverges in terms of its theoretical formulation. the present treatment approach is motivated by a fine-grained theoretical analysis of the subject's presenting deficits. it adopts a model of normal cognitive processing as the theoretical basis for isolating and identifying the locus of functional breakdown and for evolving a compatible treatment plan. unlike traditional forms of therapy, the present approach provides explicit pointers for remediating the underlying cause of the deficit. traditional forms of writing therapy do not always provide the same amount of certainty and specificity. they merely alert the therapist to the general direction which treatment should take (perkins 1985). therapy studies such as the one outlined here have an additional benefit. their results feed back into the theoretical model and either, if correct, confirm the practicality of the theory or, if incorrect, demand a modification of the model. to this end, therapy is dependent on theory and theory is enhanced and altered by therapy. it is suggested that this symbiotic relationship has much to offer clinicians working with brain-damaged subjects. although the therapy efficacy hypothesis was put to the test in a single subject and the results restricted in generalizability, the data contributes to the cumulative evaluation of the models used. further case replications are imperative, however, and further developments in this field are critically dependent on the widespread application of this therapeutic approach. references beauvois, m.f. and derouesne, j. (1981) lexical or orthographic agraphia. brain, 104, 21-49. i behrmann, m. (1987) the rites of righting writing: homophone remediation in surface dysgraphia. cognitive neuropsychology (in press). | bishop, d. (1982) trog: test of receptive grammar abingdon, oxon : thomas leach (for medical research council). | bishop, d. and byng, s. (1984) assessing semantic comprehension: methodological considerations and a new critical test. cognitive neuropsychology, 1, 3, 233-243. ι bub, d. and kertesz, a. (1982) deep agraphia. brain and language, 17, 146-165. byng, s. and coltheart, m. (1986) aphasia therapy research : methodological requirements and illustrative results. in e. hjelmquist and l.b. nilsson (eds.) communication and handicap. aspects of psychological compensation and technical aids. amsterdam : north holland publishing co., 1986. coltheart, m. (1980) varieties of acquired dysgraphia. unpublished paper, birkbeck college, university of london. coltheart, m. (1983) aphasia therapy research : a single case study approach. in c. code and d.j. muller.jeds.) aphasia therapy. london, edward arnold. coltheart, m. (1985) cognitive neuropsychology and the study of reading. in m.i. posner and o.s.m.-martin (eds.) attention and performance xi. lawrence erlbaum associates, new jersey. de partz, m.p. (1986) re-education of a deep dyslexic patient: rationale of methods and results. cognitive neuropsychology, 3, 149-177. / the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the case of cognitive neuropsychological remediation ellis, a.w. (1984) reading, writing and dyslexia : a cognitive analysis. london, lawrence erlbaum associates. francis, w.m. and kucera, h. (1982) frequency analysis of english usage lexicon and grammar. boston, houghton miffin and co. hatfield, f.m. (1983) aspects of acquired dysgraphia and implications for re-education. in c. code and d.j. muller (eds.) aphasia therapy. london: edward arnold. hatfield, f.m. and patterson, k.e. (1983) phonological spelling. quarterly journal of experimental psychology, 35a, 451-468. kertesz, a. (1980) the western aphasia battery. university of western ontario, london, canada. margolin, d. (1984) the neuropsychology of writing and spelling: semantic, phonological, motor and perceptual processes. quarterly journal of experimental psychology, 36a, 459-489. 9 mcreynolds, l.v. and kearns, k.p. (1983) single subject experimental designs in communicative disorders. university park press, baltimore. patterson, k.e. (1986) lexical but not semantic spelling. cognitive neuropsychology, 3, 3, 341-367. patterson, k.e. and shewell, c. (1987) speak and spell : dissociations and word-class effects. in m. coltheart, r. job and g. sartori (eds) cognitive neuropsychology of language. lawrence erlbaum associates ltd, london. perkins, w.h. (1985) from clinical dispenser to clinical scientist. seminars in speech and language, 6, 1, 13-20. roeltgen, d.p. and heilman, k.m. (1984) lexical agraphia. brain, 197, 811-827. vetter, d.k. (1985) evaluation of clinical intervention: accountability. seminars in speech and language, 6, 1, 55-64. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the performance of stutterers on selected central auditory tests gabrielle m. karr β .a. (sp, & h. therapy) (witwatersrand) psychological and guidance services, transvaal education dept., johannesburg summary the possibility of central auditory involvement in stutterers was investigated. five confirmed stutterers and five nonstutterers between the ages of 20 and 26 years served as subjects. the phonetically balanced cid w-22 auditory lists presented with ipsilateral and contralateral white noise broad band masking (at signal to noise ratios of 0 db and l o d b ) a n d the staggered spondaic word test were utilized. no significant differences between the groups were revealed, indicating intact functioning of both groups on these tests. possible reasons for this were postulated. response trends exhibited by all subjects were discussed. opsomming hierdie studie beoog om moontlike sentraal-ouditiewe betrokkenheid in hakkelaars te ondersoek. vyf gevestigde hakkelaars en vyf nie-hakkelaars tussen die ouderdomme van 20 en 26 jaar is as proefpersone gebruik. die foneties gebalanseerde cid w-22 ouditiewe lyste, aangebied met ipsilaterale en kontralaterale wit lawaai bree-band maskering (teen sein t o t ruis verhouding van 0 db en — 10 db), en die verspringende spondee woordtoets (vsw) is benuttig. geen merkbare verskille is tussen die groepe gevind nie."hierdie resultate dui ongeskonde funksionering betreffende hierdie toetse vir altwee groepe aan. moontlike redes hiervoor is gepostuleer. responsneigings van al die proefpersone is bespreek. many hypotheses concerning the etiology of stuttering have been postulated. sander25 summarized the causation areas of stuttering considered in the literature as those of reinforced behaviour, emotion and organicity. the latter model is relevant to the present study. within the framework of the possibility of an organic component in stuttering, a neurological involvement has been suggested. the orton-travis theory of cerebral dominance (1931) postulated that due to a lack of maturation in the cortical speech areas, intercerebral hemisphere conflict occurs cerebral dominance does not develop and stuttering'results.4 progress in testing methods and subsequent physiological findings led to the rejection of this theory. nevertheless an interest in it persists. jones9 using the wada-rasmussen sodium amytol technique, concluded that stutterers do exhibit intercerebral conflict for speech, but controversial findings have been reported. similarly, the performance of stutterers on dichotic tests, (which assess temporal lobe functioning11) is held in question. 9 ' 2 7 • 3 2 in addition, the hypothesis that stuttering is a sub-class of aphasia36 indicates that temporal lobe functioning in stutterers needs to be clarified. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) central auditory testing in stutterers 1 0 1 wolf and wolf8 suggested that a brainstem lesion results in stuttering and the performance of stutterers on the synthetic sentence identification test with an ipsilateral competing message (a test reported to be sensitive to brainstem lesions11 ) was reported to be inferior to that of nonstutterers.31 however, further investigation to support or refute the existence of brainstem lesions in stutterers, is indicated. the auditory cortex consists of the primary and secondary auditory areas. stimulation of the former produces the sensation of hearing non-verbal sounds,22 while stimulation of the latter evokes the sensation of hearing verbal signals17 and thus participate in speech decoding. the secondary auditory cortex, lying in the lateral convex portions of the temporal lobe, is thought to be responsible for the analysis and synthesis of acoustic stimuli and differentiates between simultaneously presented acoustic information.17 the interaction of the higher brainstem and the dominant tempero-parieto-occipital region enables speech comprehension.22 the secondary auditory areas and the post central and premotor articulation areas are connected by u-shaped structures and are within the subcortical gray matter of the cortex, 1 7 thus revealing the reality of neurological connections between the speech and auditory systems. a central disorder has been defined as an . . . impairment of the cerebral cortex and subcortical areas, probably to the level of the brainstem14 so that primary sites of a central auditory system (cas) lesion may be considered to be in the brainstem or in heschl's gyrus.11 this study is concerned with the functioning of these two areas in stutterers. lesions at these sites do not lead to impaired scores on conventional pure-tone or speech audiometric tests.5 · 1 1 the use of speech has been favoured in cas testing as the functions of discrimination and integration and the participation of the language processess are tapped.5 the probability rules of redundancy and predictability involved in speech perception had to be eliminated and thus the speech material utilized in cas tests had to be suitably selected. tests such as the speech with alternating masking index (swami)3s and fusion testss have been utilized in brain stem lesion testing and jerger11 suggests that individuals with brainstem involvement have greater difficulty with a complex monaural task than a dichotic task. the use of ipsilateral masking has been suggested as a factor which increases the complexity of speech identification tasks.5 dichotic tests have been used in evaluating temporal lobe functioning.35 a dichotic task may be viewed as one involving simultaneous sets of information being presented to each ear. the staggered spondaic word test (ssw) devised by k a t z 1 3 is partially dichotic and is reportedly a cas test sensitive to temporal lobe lesions.6 the performance of normals on dichotic tasks reveal superior right ear performance which is known as the right ear affect (rea), and reduced scores in the ear contralateral to a cas lesion have been reported on dichotic tasks.9 the ssw yields right and left ear scores and it may therefore reveal differences in ear performance in stutterers as compared to nonstutterers. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 1 0 2 gabrielle μ. karr methodology it was hypothesized that the performance of stutterers on a brainstem and/or temporal lobe cas test would be inferior to that of nonstutterers. inferior performance by the stutterers will be reflected by decreased ear difference scores as compared to the scores of the nonstutterers. s u b j e c t s . two groups of subjects (ss) were selected. group ε consisted of five stutterers. group c comprised five nonstutterers. criteria for subject selection. 1. age: all ss were between twenty and twenty-six years of age to exclude the possibility of the changing 'stuttering mechanisms' of adolescence, and in view of the documented reliability of the ssw with 11-60 year olds.6 2. home language: the home language of all ss is south african english — to prevent the influence of unfamiliarity with the language affecting performance. 3. intelligence: ss with average intelligence were utilized — to eliminate contamination by the suggested relationship between intelligence and auditory abilities.5 all ss were studying at post-matriculation levels. 4. handedness: only right handed ss were utilized as most stutterers are reportedly right handed 4 and in view of the theory that a correlation between ear, brain and hand dominance exists.26 5. peripheral hearing status: all ss were required to have pure tone thresholds within normal limits and no otological involvement at the time of testing. 6. sex: each group consisted of one female and four males, as the reported ratio of male to female stutterers at the american 'college' level has been found to be 1,6 3 , 4 : 1 . 3 0 7. neurological status: as the presence of gross-neurological lesions would have biased results, their absence in all ss served as a further selection factor. t e s t s a n d p r o c e d u r e selection procedures. (a) speech task (for group e): in order to be included in this study nonfluencies as described by johnson et a l 1 2 had to be present in the speech of group ε on a propositional task. (b) handedness test: a handedness test based on that of satz et a l 2 6 was administered. subjects had to be right handed to be included in this study. (c) pure-tone air-conduction threshold test: thresholds were established in the conventional manner. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) central auditory testing in stutterers 103 audiological tests. a. pretests: speech reception threshold test (srt): written responses were required for this and all subsequent tests in view of the speech difficulty of group e. speech discrimination test: half lists of phonetically balanced words, the cid word list w-22 (pb cid w-22) were utilized in obtaining speech discrimination scores at 50 db sl for each ear. testing and scoring were carried out in the conventional manner.2 0 b. central auditory tests: the order of presentation of the central tests was randomized to prevent fatigue and learning from influencing results. (a) phonetically balanced cid w-22 with contralateral and ipsilateral masking at signal to noise ratios of 0 db and lodb. it has been reported that ipsilateral masking with pbs is a test sensitive to central disorders18 and the use of monaural tasks in brain stem testing has been suggested.11 the sub-test, including contralateral masking thus served as a basis of comparison. results of previous investigations indicate a greater breakdown in speech discrimination at a signal to noise (sn) ratio of greater than 5 db than at 0 db.3 7 as complexity of central tests has been stressed5 a sn ratio of— 10 db was incorporated, while the sub-test at the sn ratio of 0 db was utilized to serve as a basis of comparison. all sub-tests were administered at 50 db sl. white noise was utilized as it has been reported to be the most effective form of masking noise for speech.20 pb cid w-22 half lists were utilized to prevent fatigue on the part of s. conventional instructions and scoring procedures were employed.2·2 0 (b) the staggered spondaic word test. the ssw, reportedly a test of temporal lobe functioning,6 was administered at 50 db sl to each ear. an american recording of the ssw test list ec was utilized which consists of four practice items and 40 test items. each test item consists of two overlapping spondees, one presented to each ear, arranged so that the last syllable of the first spondee and the first syllable of the second spondee overlap in time. the non-competing syllables form a third spondee. presentation of the first syllable alternates between the ears and is preceded by 'are you ready?' preceding the test is a recorded 1 000 hz tone in each channel allowing for calibration. katz's 6 system of weighting was employed in scoring the tests, but all faulty responses, e y · ' if minimal, were considered as errors.1 equipment audiological assessments were carried out in an i.a.c. acoustic suite (series 1600) utilizing the maico model ma-24 dual channel audiometer. the speech material was routed to this audiometer from a viking 88 stereo tape recorder. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 104 gabrielle μ. karr results and discussion no significant differences in performance between group ε and group c were found on both central tests utilized. nevertheless performance of all ss taken as one group revealed several trends. discussion of the trends and observations made on the brainstem test will be followed by that of the temporal lobe test. (a)pb cid w-22 with ipsilateral and contralateral masking at sn ratios of 0 db and 1 0 db. the following trends were noted for the ss, taken as one group: 1. ipsilateral masking sub-tests yielded significantly fewer correct responses than contralateral masking (p< 0,001), validating the former's greater complexity. a similar finding is reported for performance on the swami, a test reportedly sensitive to brainstem lesions.35 2. significantly fewer correct responses occurred when the masking, whether ipsilateral or contralateral, was 10 db sl louder than the speech signal as opposed to speech and masking of equal sls (p< 0,001). this supports the conclusion that discrimination scores decrease as the sn ratio decreases.10 3. no ear differences occurred on the contralateral masking sub-tests while significantly fewer correct responses in the left ear occurred under the conditions of ipsilateral masking (0,025 < ρ . < 0,05) indicating that performance in the right ear was similar for both contralateral and ipsilateral masking sub-tests, while in the left ear, inferior performance under the ipsilateral masking condition occurred. performance on the contralateral masking condition was similar to that of the right ear. thus the process of transmission and figure-ground differentiation for speech appears to be more efficient when stimuli are presented to the right ear, which connects, by way of its strong contralateral pathway, to the left hemisphere which is dominant for speech.15 the strong contralateral pathway from the left ear leads to the right hemisphere which is dominant for nonspeech sounds.21 masking may be considered as one type of non-speech sound. speech and noise may be differentiated at the brainstem, whereafter the speech is transmitted to the left (speech) hemisphere, but if the brainstem does not function in this process, differentiation may only occur at the cortex where the rate of spontaneous activity and^the quantity of discharged impulses are less than at the brain s t e m , ' 1 0 , 2 3 thus placing the speech message transmitted from the left ear at a disadvantage. if this latter suggestion is to be adopted however, the validity of this test as a brainstem test is to be questioned. other limitations of this test may serve as further factors querying its validity as a brainstem test. for example, the necessity for central tests to be complex tasks has been discussed. the mere addition of masking noise may not have increased the complexity of this task sufficiently for it to assess brainstem functioning. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) central auditory testing in stutterers 105 (b) the staggered spondaic word test. the following trends were noted for the ss taken as one group. 1. significantly more errors occurred on competing than non-competing syllables (0,025 < ρ <0,01) confirming the greater complexity of dichotically than monotically presented material. 2. while performance on non-competing syllables was similar for both ears, the left ear showed significantly greater difficulty for competing stimuli than the right ear (p = 0,05). under competing conditions the rea discussed earlier may thus be considered to have occurred and, as no differences between group ε and group c were evident, no difference in the dominance between the stutterers and non-stutterers in this experiment was seen to exist — casting doubt on the applicability of the orton-travis theory to these stutterers. it has nevertheless been claimed that the ssw is 'free' from laterality effects.6if this holds true, the true dichotic properties of the ssw are to be questioned. the present study does however indicate the presence of the rea in the ssw. the true dichotic properties of the ssw are to be further questioned however. familiarity and word probability introduce the variable of redundancy, and, in central testing the necessity of reduced redundancy has been stressed.5 although katz 1 3 felt the presence of this property to be advantageous to the test the reality of this contamination may have caused responses such as the following: stimulus: washtub response: washtime stimulus: batboy response: badboy the writer suggests that in the absence of the non-competing syllables, the ssw might be a 'truer' dichotic task. a further factor to consider is that in a dichotic task, when stimuli contrast by one phoneme, the rea occurs,21 but the competing syllables in katz's ssw differ in a multiplicity of phonemes. further, if a dichotic pair share no features, performance of normals and left-and right brain damaged subjects is similar.21 thus the importance of phonetic control in dichotic testing is highlighted. 3. three out of five subjects of both group ε and group c presented with scores inferiorto the average score (0,8) reported for an american group of comparable age on list ib of the ssw a predecessor of list ec, 1 4 with three ss in group ε and one s in group c falling more than one standard deviation from this average. this highlights the necessity of a south african standardization of the ssw. 4. error trends on the ssw were considered for all the ss as a group. it would have been of value to compare error trends between the groups in view of the finding that dominance for vowels and consonants differs between stutterers and non-stutterers.32 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 1 0 6 gabrielle μ. ka trends observed included: (a) reversals: (this is not considered an error 1 4 ). if the stimulus sequence is right non competing (rnc), right competing (rc) and left competing (lc), left non competing (lnc), the response sequence in a reversal is lc-lnc-rnc-rc. if one word leads another by 30-90 msecs, the latter word is perceived more clearly — this is known as the 'lag effect'16 and may have intervened in reversal responses. (b) omissions of both or either competing syllable: faulty attention, storage or output have been postulated as the cause hereof.21 the writer contends that the additional processes of perception and integration may intervene. (c) portmanteau terms: the competing stimuli were combined to form a single word, e.g. stimulus: (rc) white (lc) foot response: fight it has been suggested that on dichotic tests, errors produced by the dominant ear are the result of the interaction between the dominant and non-dominant ears.28 it is important to remember that in the ssw an re a for competing stimuli occurred. (d) substitutions, additions and omissions: competing condition: (i) vowel substitutions resulting in a non-meaningful spondee. (ii) additions, omissions or substitutions of a consonantal phoneme resulting in a meaningful spondee. (iii) additions, omissions or substitutions of a consonantal phoneme resulting in a nonmeaningful spondee. (iv) substitution of a syllable (possibly more familiar) resulting in a meaningful spondee. non-competing condition: fewer errors occurred on non-competing conditions nevertheless substitutions; omissions and additions of consonants and vowels were noted. from the above observations, it is evident that an in-depth analysis of errors on the ssw would entail not only phonemic but semantic considerations. the intervention of both these systems contaminates the dichotic task, as responses are not merely based on integration and storage abilities. the use of dichotic nonsense syllables may have eliminated this contamination16 although this, too, could involve unaccountable variables.13 the proposed central auditory test could utilize in dichotic presentation, stops (which are better identified, normally, in the right ear), / a / which shows right ear superiority and i i / which does n o t . 1 6 the utilization of right dominant sounds is hypothesized to be sensitive to left temporal lobe functioning. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) central auditory testing in stutterers 107 the ssw does incorporate a temporal element and includes the aspect of storage, which is important in central testing. 2 6 ' 2 8 nevertheless, it has been suggested that sentence use assesses the temporal nature of speech to a greater extent than word use. 2 9 it is important to bear in mind that temporal sequence perception is a function of the dominant hemisphere.3 in a natural sentence, however, two or three 'key words' may convey the sentence's meaning. to overcome this problem in auditory testing, the synthetic sentence identification test (ssi) was devised.29 in utilizing these sentence types in central auditory testing, a competing speech message was introduced, and it was concluded that the ssi presented with a contralateral competing message (ssi-ccm) is sensitive to temporal lobe lesions, while the ssi presented with an ipsilateral competing message (ssi-icm) is sensitive to brainstem lesions.11 familiar words were used however and the writer suggests that some probability factors may thus intervene in their perception. it is thus felt that a test containing strings of nonsense words presented dichotically should be considered, as the use of dichotic sentences with limited redundancy and controlled semantic value in central testing has been stressed.3 further factors which could account for the similar performance of the stutterers and nonstutterers in this study concern the 'nature' of stuttering, and include: 1. the possible existence of sub-populations of stutterers.2s' 3 3 2. the possibility of cerebral involvement other than temporal lobe or brainstem impairment, e.g. apraxia 8 , pyknolepsy34 or minimal cerebral dysfunction.24 3. the possibility of audiological involvement other than central impairment in stutterers, e.g. differing middle ear functioning7 or disturbed auditory monitoring.19 4. the possible aspects of validity of the emotional or behavioural theories of stuttering which have been postulated. conclusion the performance of stutterers and non-stutterers on pb cid w-22 auditory lists with ipsilateral and contralateral masking at signal to noise ratios of 0 db and 10 db and on the ssw were not significantly different. these results suggest the comparable functioning of the ss on the tests utilized. in accounting for these findings, the possibility of faults inherent in these tests, or of impairment in stutterers other than that of central auditory processes, must be considered. bearing in mind, however, the report of inferior performance of stutterers on the ssi-icm31 and the importance of the utilization of a test battery in audiological assessment,35 the inclusion of the ssi-icm for brain-stem lesions and the use of either the ssi-ccm or dichotic nonsense word sentences might have led to differential responses in the subjects. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 108 gabrielle μ. karr references 1. β alas, r. and simon, g. (1964): the articulation function of a staggered spondaic word list for anormal hearing population./. aud. res 4, 285-289. 2. berger, k. w. (1971): speech audiometry. in audiological assessment, rose, d. e. (ed). prentice-hall inc., n . j . 3. berlin, c. i. and lowe, s. s. (1975): temporal and dichotic factors in central auditory testing. in handbook of clinical audiology, katz, j. (ed). the williams and wilkins co., baltimore. 4. bloodstein, 0 . (1969): a handbook on stuttering. national easter seal society for crippled children and adults, chicago. 5. bocca, e. and calearo, c. (1963): central hearing processes. in modern developments in audiology, jerger, j. (ed). academic press inc., new york. 6. brunt, m. a. (1975): the staggered spondaic word (ssw) test. in handbook of clinical audiology, katz, j. (ed). the williams and wilkins co., baltimore. 7. butler, b.r. and stanley, p. e. (1966): the stuttering problem considered from an automatic control point of view. folia phoniat 18 33-44. 8. caplan, l. (1970): an investigation of some aspects of stuttering-like speech in adult dysphasic patients. unpublished research report, department of speech pathology and audiology, university of the witwatersrand, johannesburg. 9. dorman, m. f. and porter, r. j. jr. (1975): hemispheric lateralization for speech perception in stutterers. cortex, 11(2), 181-185. 10. findlay, r. c. and schuchman, g. i. (1976): masking level difference for speech: effects of ear dominance and age. audiology, 15(3), 232241. 11. jerger, j. (1973): diagnostic audiometry. in modern developments in audiology, jerger, j. (ed). academic press, new york. 12. johnson, w„ darley, f. l. and spriestersbach, d.c. (1963): diagnostic methods in speech pathology. harper and row, new york. 13. katz, j. (1962): the use of staggered spondaic words for assessing the integrity of the central auditory nervous system. /. aud. res 2 327-337. 14. katz, j. (1968): the sswtest: an interim report./. speech hear. dis 33(2), 132-146. 15. kimura, d. (1967): functional dominance of the brain in dichotic listening. cortex, 3(2), 163-178. 7 16. lowe, s. s„ cullen, j. k. jr., berlin, c. i., thompson, c. l. and willett, μ. e. (1970): perception of simultaneous dichotic and monotic monosyllables./. speech hear. res., 13(4), 812-822. 17. luria, a. r. (1973): the working brain. the penguin press, london. 18. milner, b. (1962): laterality effects in audition. in interhemispheric relations and cerebral dominance, mountcastle, v. b. (ed). the john hopkins press, baltimore. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) central auditory testing in stutterers 109 19. mysak, e. d. (1960): servo theory and stuttering. / . speech heardis., 25(2), 188-195. 20. newby, h. a. (1972): audiology. prentice-hall inc., new jersey. 21. oscar-berman, m., zurif, ε. b. and blumstein, s. (1975): effects of unilateral brain damage on the processing of speech sounds. brain and lang., 2(3), 345-355. 22. penfield, w. and roberts, l. (1959): speech and brain mechanisms. princeton university press, new jersey. 23. radionova, e. a. and vartanian, i. a. (1971): comparative description of the characteristics of normal activity at different levels of the auditory system./. aud. res., 11(3), 195-217. 24. saffer, d. (1976): personal communication. neurologist, baragwanath hospital, johannesburg. 25. sander, ε. k. (1975): untangling stuttering. a tour through the theory thicket. asha, 17(4), 256. 26. satz, p., achenbach, k„ pattishall, e. and tennell, e. (1965): order of report, ear asymmetry and handedness in dichotic listening. cortex, 1(4), 377-396. 27. slorach, n. and noehr, b. (1973): dichotic listening in stuttering and dyslalic children. cortex., 9(3), 295-300. 28. speaks, c„ gray, t., miller, j. and rubens, a.b. (1975): central auditory deficits and temporal lobe lesions. / speech hear. dis., 40(2), 192-205. 29. speaks, c. and jerger, j. (1965): method for measurement of speech identification./. speech hear. dis., 8(2), 185-194. 30. timmons, b. a. and boudreau, j. p. (1972): auditory feedback as a major factor in stuttering. / . speech hear. dis., 37(4), 476-484. 31. toscher, μ. m. and rupp, r. r. (1975): a study of the central auditory processes in stutterers using the synthetic sentence identification (ssi) test battery. asha, 17(9), 680. 32. tsunoda, t. and moriyana, h. (1972): specific pattern of cerebral dominance for various sounds in adult stutterers. / aud. res., 12(3), 216-227. 33. van riper, c. (1971): the nature of stuttering. prentice-hall inc., new jersey. 34. west, r. (1958): an agnostic's speculations upon stuttering. in stuttering: a symposium, eisenson, j. (ed). harper and row, new york. 35. willeford, j. a. (1969): audiological evaluation of central auditory disorders part ii. maico audiological library series, 6,5-7. 36. willis, c. (1975): stuttering and aphasia: some important similarities and some important differences. wmuj. ofsp. th„ 12(1), 11-12. 37. young, i.'m. and harbert, f. (1970): noise effects on speech discrimination score. / aud. res., 10(2), 127-131. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 29 die invloed van sekere kontekstuele faktore op stemaanvangstyd, vokaalduur en uitingduur by verbale apraksie a van der merwe, d phil (pretoria) i c uys, d phil (pretoria) departement spraakheelkunde en oudiologie universiteit van pretoria j μ loots, d sc (fisiologie) (pretoria) instituut vir sportnavorsing, universiteit van pretoria r j grimbeek, β sc (hons) (pretoria) departement statistiek, universiteit van pretoria l ρ c jansen, d sc (fisika) (pretoria) privaat praktiserende akoestikus opsomming die konsep van konteks-sensitiwiteit soos ontleen aan die koalisiemodel hougroot rrwontlikhede in vir die interpretasie van verbaal apraktiese simptome en vir 'n beter begrip van die aard van die afwyking. in hierdie ondersoek wat deel uitmaak van die groter ondersoek waarin die effek van variasie in kontekstuele faktore op verbaal apraktiese spraak nagegaan word (van der merwe, uys, loots en grimbeek, 1987; 1988), word die effek van die kontekstuele faktore, klankstruktuur en artikulasie-eienskappe op stemaanvangstyd, vokaalduur en uitingduur akoesties ontleed. vier persone met verworwe verbale apraksie en een persoon met verbale ontwikkelingsapraksie is as proefpersonegebruik. daar is bevind dat stemaanvangstyd nie konteks-sensitiefis nie. die stemaanvangstydfoute is nie ware vervangings met stemlose klanke nie, maar is onkonstante distorsies weens oorskryding van die kritiese temporale ekwivalensiegrense vir interartikulator-sinchronisasie. vokaalduur en uitingduur, is wel konteks-sensitief. namate die moeilikheidsgraad van die uiting toeneem, neem die afwyking in duur ook toe. die temporale eienskappe van verbaal apraktiese spraak kan dus ook soos die ouditief waarneembare foute op grond van kontekssensitiwiteit verdeel word in kernsimptome en geassosieerde simptome. / / ' abstract the concept of context sensiti dtyas borrowed from the coalition model has important implications for the interpretation of the symptoms of apraxia of speech and for a better understanding of the nature of the disorder. in this study which was part of the wider investigation into the effect of variation in contextual factors on apraxia of speech (van der merwe, uys, loots and grimbeek, 1987; 1988), the φα of two contextual factors namely sound structure and articulatory features on voice onset time, vowel duration and utterance duration was acoustically analysed. four subjects with[acquired apraxia of speech and one with developmental apraxia of speech were tested. findings indicated that voice onset time is not context sensitive. errors in voice onset time were not true substitutions with voiceless sounds but were inconsistent distortions due to an inability to keep interarticulator synchronization within the critical temporal boundaries of motor equivalence. vowel and utterance duration were found to be context sensitive. the deviation in duration increased with increased complexity of the utterance. as was the case with the auditorily perceived symptoms, the temporal characteristics of apraxia of speech can also be classified into core symptoms and associated symptoms based on their context sensitivity. sistematiese variasie in die kontekstuele faktore, klankstruktuur en artikulasie-eienskappe van 'n spraakuiting het 'n invloed op die ouditief waarneembare foute by verbale apraksie en aanduidings van die aard van die afwyking word daardeur verkry (van der merwe, uys, loots & grimbeek, 1987 en 1988). die vraag bestaan of variasie in hierdie kontekstuele faktore 'n akoesties aantoonbare invloed sal he op die temporale eienskappe van verbaal apraktiese spraak en of dit ook aanduidings van die aard van die afwyking sal verskaf. dit is bekend dat temporale versteurings een van die mees kenmerkende eienskappe van verbale apraksie is (kent & rosenbek, 1983; collins, rosenbek & wertz, 1983; itoh&sasanuma, 1984) en variasie in die graad en tipe aantasting sal moontlik waargeneem word met 'n variasie in bogenoemde kontekstuele faktore. akoestiese ondersoeke van die temporale eienskappe van verbaal apraktiese spraak waarvan verslag gedoen is in die literatuur is algemeen gemik op simptoombeskrywing (wertz, la pointe & rosenbek, 1984). stadige spraakspoed, verlengde vokaalduur en swak koordinasie van stemgewing met ander artikulasiegebeure word as kenmerkende simptome van verbale apraksie beskryf (blumstein, cooper, caramazza & zurif, 1977; freeman, sands & harris, 1978; kent & rosenbek, die suid-afrikaanse tydskrif vir kommunikadeafivykings, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 a va der merwe, i c uys, j μ loots, r j grimbeek en l ρ c jansen 1983). die konteks waarin hierdie eienskappe ondersoek is, is egter in geen van hierdie studies gekontroleer en gevarieer nie. die teoretiese belang van kontekstuele faktore is volledig bespreek in van der merwe et al. (1987). die konsep van kontekssensitiwiteit is ontleen aan die koalisiemodel wat groot moontlikhede inhou vir toepassing op verbale apraksie (kelso & tuller, 1981; kelso, tuller & harris, 1983). variasie in kontekstuele faktore stel differensiele eise aan die beplanning en uitvoering van gedrag en die effek wat hierdie variasie op die waargenome simptome het, kan insiggewende gegewens verskaf oor die aard van die afwyking. dit hou verder ook implikasies in vir die interpretasie van simptome en vir verdere navorsing. die resultate van die ondersoek waarin die invloed van kontekstuele faktore op die ouditief waarneembare foute by verbale apraksie (van der merwe, et al. 1987, 1988) nagegaan is, is die simptome van verbale apraksie wel in 'n nuwe en insiggewende perspektief gestel. dit wil voorkom asof die simptome van verbale apraksie op grond van kontekssensitiwiteit verdeel kan word in kemsimptome en geassosieerde simptome. in die huidige ondersoek wat deel uitmaak van die groter ondersoek waarin die effek van variasie in kontekstuele faktore op verbaal apraktiese simptome nagevors is, word die effek van sistematiese variasie op sekere temporale aspekte van verbaal apraktiese spraak akoesties ondersoek. metode doel die doel van die ondersoek is om te bepaal of sekere kontekstuele faktore in spraakproduksie, naamlik die klankstruktuur (foneemstruktuur) en die artikulasie-eienskappe (motoriese kompleksiteit) van 'n uiting 'n effek het op die volgende temporale aspekte van die spraak van persone met verbale apraksie: interartikulator-sinchronisasie soos waargeneem in stemaanvangstyd. segmentele tydsduur soos waargeneem in vokaalduur. die spoed van spraak soos waargeneem in die duur van die uiting. eksperimentele ontwerp. 'n tweegroepontwerp waarin die invloed van gekontroleerde stimuli op die temporale eienskappe van verbaal apraktiese spraak bepaal is deur vergelyking met die invloed op die spraak van afgepaarde kontrolepersone, is gebruik. die kontrolepersone is afgepaar met betrekking tot ouderdom, geslag en spreektaal. die proefpersone, materiaal en prosedure van hierdie ondersoek is reeds volledig beskryf in 'n voorafgaande artikel (van der merwe et al. 1987) en word dus nie hier herhaal nie. kortliks kan wel gemeld word dat vier persone met verworwe verbale apraksie en een persoon met verbale ontwikkelingsapraksie as proefpersone gebruik is. die kriterium is gestel dat 'n suiwer verbale apraksie vertoon moet word. wat die materiaal betref, is onsineenhede wat gekontroleer is in klankstruktuur en artikulasie-eienskappe ontwikkel (van der merwe, 1986). die vyf klankstruktuurgroepe (s) hetelkagt eenhede bevat wat in vier artikulasie-eienskapgroepe (a) verdeel is. vir die doel van die akoestiese analise is ses herhalings van vier eenhede in elke klankstruktuurgroep ontleed. apparaat vir die akoestiese analise. die akoestiese analise is uitgevoer in die forensiese akoestieklaboratorium van die suid-afrikaanse polisie. unieke apparaat wat ontwikkel is by die w.n.n.r. is vir die analise gebruik. hierdie apparaat wat skematies voorgestel word in figuur 1 is verkies bokant die spektrograaf (wat ook besktkbaar was) omdat dit die spraaksein op so 'n wyse kodeer op die ossiloskoop dat akkurate metings tot op die naaste millisekonde gemaak kan word. 'n sony tc 1552-bandopnemer voer die spraaksein na die digitale herhalingslyn model 2a. die beeld word vertoon op die skerm van 'n hewlettpackard 1200 b-tipe ossilloskoop. daar is na die spraaksein geluister met 'n w770-kopstuk. 1 oorfone figuur 1: skematiese voorstelling van die apparaat vir die akoestiese analise. the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) invloed van sekere ontekstuele faktore op stemaanvangstyd, vokaalduur en uitingduur 3 1 prosedure vir die akoestiese analise. opleiding in die tegniek van akoestiese metings en die hantering van die akoestiese apparaat is ontvang van 'n akoestiese ingenieur, 'n kenner op die gebied van sprekerherkenning en akoestiese analises, wat dele van die apparaat ontwikkel het vir die w.n.n.r. tydens die analises is alle probleemgevalle met hierdie persoon bespreek. die akoestiese metings is nie op al die eenhede toegepas nie, maar slegs op eenhede 1 tot 4 van elke klankstruktuurgroep. die aantal eenhede in elke klankstruktuurgroep is vir die akoestiese ontledings beperk omdat dit duidelik geword het tydens ontleding dat die addisionele data geen verskil sal maak aan die uitslag van die ondersoek nie. die akoestiese ontledings is ook tydrowend. elk van die twintig uitings wat akoesties ontleed is, is ses keer herhaal en die meting van hierdie honderd en twintig uitings het ongeveer twintig uur per persoon geduur. die data van twee van die drie engelssprekende dames wat as kontroles opgetree het, is nie volledig ontleed nie. nadat die analise van die eerste dame voltooi is, is steekproefontledings op die data van die ander twee gedoen. daar is bevind dat die resultate grootliks ooreenkom en op aanbeveling van jansen (1985) is die data van die eerste dame as kontrole vir die drie engelssprekende proefpersone gebruik. slegs ouderdom is in hierdie geval nie konstant gehou nie. jansen (1985) beskou die data van een normale spreker as verteenwoordigend van normale spraak in die spesifieke taalgroep. die data van die ander twee kontrolepersone is volledig ontleed. die spraakseinopnames van die kontrolepersone is eerste ontleed ten einde die tegniek volkome te bemeester alvorens die meer atipiese data van die proefpersone ontleed is. voor elke meetsessie is vorige metings op 'n steekproefbasis herhaal ten einde die akkuraatheid te kontroleer. dit het ook 'n oefengeleentheid gebied voordat die verdere metings voortgesit is. die drie akoestiese metings van elke uiting is agtereenvolgens gedoen omdat dit die mees betroubare en tydbesparende metode is. i / / die drie metings is direk vanaf die ossilloskoopskerm in millisekondes gedoen. die spraaksein is na die ossilloskoop gevoer soos uiteengesit in figuur 1. die gedeelte van die spraaksein wat in die digitale herhalingslyn se geheue ingelees en daar , vasgevang is, is voortdurerid herhaal. hierdie digitale herhalingslyn stoor 2,5 sekondes spraak vir analise. die spoed waarteen die beeld oor die skerm beweeg, kan verstel word van vyf tot twintig (of meer) millisekondes per divisie (wat aangebring is op die skerm) afhangende van die instelling wat die duidelikste beeld weergee by 'n spesifieke uiting. die ondersoeker kan ook terselfdertyd na die herhaling luister. die tydsbasis van die ossilloskoop is gekalibreer en die metings kan direk van die skerm af gedoen word deur die aantal divisies op die skerm te tel. hierdie getal is dan met die ingestelde aantal millisekondes per divisie van die ι tydsbasis vermenigvuldig om die tydsduur in millisekondes te verkry. die meting van stemaanvangstyd. meting van die stemaanvangstyd van die inisiele konsonante / b / en / d / is gedoen. die stemaanvangstyd word gemeet vanaf die begin van die ploffing tot by die aanvang van stemgewing vir die vokaal. dit word as 'n positiewe waarde genoteer. soms is daar 'n stemvoorloop en die meting word dan gedoen vanaf die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 36, 1989 die begin daarvan tot by die ploffing. in did geval word dit as 'n negatiewe waarde genoteer. tydens die meting van die eerste proefpersoon se data is bevind dat die norme van normale sprekers nie altyd voldoende riglyne verskaf vir eenvormige metings nie. daar is toe begin om 'n reeks sketse van atipiese voorbeelde saam te stel namate dit opgeduik het. by elke volgende probleemgeval is dan terugverwys na die reeks vir riglyne vir meting of die nu we voorbeeld is by die reeks ingevoeg. die ossilloskoopbeeld waarop die stemaanvangstyd gemeet is, word ge'illustreer in figure 2 tot 5. die metingspunte word ook aangedui. sat: -80 millisekondes (spoed: 20 millisekondes per divisie duur van beeld: 200 millisekondes) figuur 2: voorbeeld van 'n negatiewe stemaanvangstyd by 'n normale spreker. sat: + 10 millisekondes (spoed: 20 millisekondes per divisie duur van beeld: 200 milliesekondes) figuur 3: voorbeeld van 'n positiewe stemaanvangstyd by 'n normale spreker. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 a vail der merwe, i c uys, j μ loots, r j grimbeek e n l ρ c jansen sat: -176 millisekondes (spoed: 50 millisekondes per divisie duur van beeld: 500 millisekondes) figuur 4: voorbeeld van 'n negatiewe stemaanvangstyd w a t byna buite die normale perke val by 'n verbaal apraktiese spreker. sat: +40 millisekondes (spoed: 20 millisekondes per divisie duur van beeld: 200 millisekondes) figuur 5: voorbeeld van 'n positiewe, maar atipiese stemaanvangstyd by 'n verbaal apraktiese spreker. die meting van vokaalduur. die duur van die eerste vokaal / a / of h i is vanaf die ossilloskoopskerm in millisekondes gemeet. die meting van vokaalduur is oor die algemeen 'n betroubare prosedure wat minder probleemgevalle oplewer as stemaanvangstyd. die vokaal word aangedui deur 'n groot reelmatige kurwe met 'n lae frekwensie. die meting word vanaf die begin van die kurwe tot by die laagste punt waar die kurwe afplat, gedoen. die metingspunte van die vokaalduur word ge'fllustreer in figuur 6. vokaalduur: 164 millisekondes (spoed: 25 millisekondes per divisie duur van beeld: 250 millisekondes) figuur 6: voorbeeld van die vokaalduur van 'n normale spreker. die meting van die duur van die uiting. die duur van die kvkv en kvk (in die geval van klankstruktuur 4) gedeelte van die eenhede is gemeet. die meting van klankstruktuur 3 en 5 is beperk tot hierdie dele, omdat die roudata sodoende vergelykbaar is met die duur van klankstruktuur 1 en 2. die produksie van die langer eenhede deur die verbaal apraktiese sprekers het ook meestal die geheue van die digitale herhalingslyn, naamlik 2,5 sekondes, oorskry en dus meting van langer dele verhoed. die eerste metingspunt is die aanvang van die ploffing en die tweede punt is die laagste vlak wat bereik word by die afplatting van die kurwe van die tweede vokaal. die kvk duur is ook gemeet vanaf die aanvang van die inisiele ploffer tot by die einde van die ploffing van die finale konsonant. uitingduur: 920 millisekondes (spoed: 120 millisekondes per divisie duur van beeld: 1,2 sekondes) figuur 7: voorbeeld van die uitingduur van 'n verbaal apraktiese spreker. the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) invloed van sekere kontekstuele faktore op stemaanvangstyd, vokaalduur en uitingduur 33 dataverwerking die stemaanvangstyd, vokaalduur en uitingduur van ses herhalings van die twintig eenhede wat akoesties ontleed is, is vir elke proefpersoon en kontrolepersoon verkry. alvorens die invloed van die twee kontekstuele faktore bepaal kon tvord, is 'n gemiddelde foutwaarde vir elke persoon bereken. die metode van berekening word vervolgens beskryf. bepaling van die gemiddelde foutwaarde vir stemaanvangstyd. die stemaanvangstydwaardes van -180 millisekondes tot +15 millisekondes is aanvaar as die normale perke. in die literatuur word 'n positiewe telling van +25 millisekondes as die hoogste normale perk beskou. daar is egter waargeneem dat by 'n telling hoer as +15 millisekondes die klank reeds stemloos klink. jansen (1985) beskou ook 'n telling hoer as +15 millisekondes as afwykend en daar is op hierdie waarde as die hoogste normale perk besluit. die data van die kontrolepersone is dus nie vir hierdie spesifieke doel gebruik nie. verskeie metodes is oorweeg om 'n enkele stemaanvangstydwaarde wat die foutgrootte sal aandui oor ses herhalings, te bereken. daar is volstaan deur 'n gemiddelde foutwaarde vir die ses herhalings van elke eenheid te bereken. dit is gedoen deur die hoeveelheid millisekondes bokant 15 of onder 180 (laasgenoemde het nooit voorgekom nie) oor die ses herhalings bymekaar te tel en deur ses te deel. hierdie gemiddeldes vir elke eenheid en vir elke proefpersoon word aangegee in tabel 1. die klankstruktuurgroepe (si tot s5) en die artikulasieeienskapgroepe (al tot a4) word in die tabel onderskei soos wat dit aangegee vyord in tabelle 2 en 3. " bepaling van die gemiddelde foutwaarde vir vokaalduur en uitingduur. die gemiddelde foutwaarde (die mate van afwyking vanaf die normale) is op dieselfde wyse bepaal vir vokaalduur en uitingduur en dit word dus gesamentlik bespreek. i die gemiddelde duur in millisekondes van die ses herhalings / v a n elke eenheid by elke proefpersoon en kontrolepersoon is bereken. die verskil tussen hierdie twee waardes wat die mate van afwyking vanaf die j normale weergee, is bereken. die waardes van die proefpersone was in alle gevalle groter as di6 die suid-afnkaanse tydskrif vir kommunikasieafivykings, vol. 36, 1989 van die kontrolepersone behalwe by enkele kvk-uitings. hierdie verskille in millisekondes word vir vokaalduur weergegee in tabel 4 en vir uitingsduur in tabel 5. die klankstruktuurgroepe en artikulasie-eienskapgrciepe word ook in hierdie geval onderskei op die tabelle. statistiese prosedure om te bepaal of klankstruktuur en artikulasie-eienskappe enige effek het op stemaanvangstyd, vokaalduur en uitingduur. ten einde te bepaal of klankstruktuur en artikulasie-eienskappe enige effek het of sat, vokaalduur en uitingduur, is die verdelingsvrye variansie-analiseprosedure van friedman gebruik. hierdie analise is toegepas op die waardes in die kolomme en rye van tabelle 1,4 en 5. die uiteensetting van die rye en kolomme van die tabelle is volgens die riglyne wat by die ontwikkeling van die materiaal bepaal is. deur middel van die friedman-prosedure is vasgestel of die gemiddelde foutwaardes van die verskillende klankstruktuurgroepe (si tot s5) of die verskillende artikulasie-eienskapgroepe (al tot a4) betekenisvol van mekaar verskil. dit is globaal vir klankstruktuur en vir artikulasie-eienskappe bepaal en dit is ook vir die afsonderlike aen sgroepe bepaal. dit is essensieel om die invloed van klankstruktuur by elke artikulasiegroep afsonderlik te bepaal (dus vier vertikale vergelykings van die kolomwaardes in tabelle 1, 4 en 5) aangesien die artikulasieeienskappe van die uitings andersins ook 'n invloed op die waarde wat verkry word, sal uitoefen. dit geld ook vir die bepaling van die effek van artikulasie-eienskapgroepe (in hierdie geval is vyf horisontale vergelykings van die rywaardes gedoen). die invloed van die artikulasieeienskappe word dus by elke klankstruktuurgroep afsonderlik bepaal. die p-waardes toon die betekenisvolheid van verskille aan. resultate en bespreking resultate van stemaanvangstydmetings algemene beskrywing en bespreking. die meting van die stemaanvangstyd (sat) van ses herhalings van twintig eenhede deur die verbaal apraktiese sprekers wat in hierdie ondersoek gebruik is, dui daarop dat afwykende tabel 1: gemiddelde en totale stemaanvangstydfoutwaardee i n millisekondes klankstruktuur1 artikulasie-eienskapgroepe groepe • ' al a2 a3 a4 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 si eenhede: 1.1 1.2 1.3 1.4 si 0 0 4 0 0 0 0 0 0 4 3 0 12 0 1 2 0 0 0 0 26 s2 eenhede: 2.1 2.2 2.3 2.4 s2 1 0 1 0 1 3 0 2 0 1 1 0 24 0 1 9 0 9 0 1 54 s3 eenhede: 3.1 3.2 3.3 3.4 s3 10 2 5 0 0 0,5 0 0 0 13 2 0 5 0 1 4 0 2.0 0 0 26,5 eenhede: 4.1 4.2 4.3 4.4 5 1 0 0 3 1 0 0 0 0 5 0 11 4 0 4 0 11. "0 0. 45 s5 1 eenhede: 5.1 5.2 5.3 ,5.4 s5 1 5 19 6 0 2 0 0 0 0,5 0 2 0 0 1 0 7 0 0 42,5 totaal 63 26,5 27,5 68 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 a va der merwe, i c uys, j μ loots, r j grimbeek en l ρ c jansen stemaanvangstye (sate) voorkom by die meeste van hierdie sprekers. (kyk tabel 1 vir die gemiddelde sat-foute in millisekondes vir elke eenheid en vir elke proefpersoon en tabelle 2 en 3 vir voorbeelde van gemete waardes.) die resultate van hierdie studie stem in groot mate ooreen met die resultate van vorige ondersoeke na sat by verbaal apraktiese sprekers en addisionele waarnemings is ook gemaak (freeman et al. 1978; blumstein et al. 1977; hoit-dalgaard, murray & kopp, 1983; itoh en sasanuma, 1984; kent en rosenbek, 1983). tabel 2: die gemete sat-waardes van die ses herhalings van eenhede in die verskillende klankstruktuurgroepe in artikulasie-eienskapgroep 1 tabel 3: die gemete sat-waardes van die ses herhalings van eenhede in die verskillende artikulasie-eienskapgroepe in klankstruktuurgroep 1. freeman et al. (1978) wat 'n gevallestudie uitgevoer het, meld dat daar onder meer bepaal moet word of afwykende sat 'n algemene eienskap van verbale apraksie is en of die probleem idiosinkraties is. in die huidige ondersoek is bevind dat nie alle sprekers wat wel as verbaal aprakties geklassifiseer kan word, sat-foute maakof in dieselfde mate maak nie. proefpersoon 2 het slegs by artikulasiegroep 1 en in besonder by s5 sat-foute gemaak (kyk tabel 1). proefpersoon 4 het slegs by uiting 4. 3 'n gemiddelde sat-fout van vier. verder vertoon hy geen sat-foute nie. die ander drie proefpersone maak wel sat-foute. die feit dat nie alle verbaal apraktiese sprekers sat-foute maak nie, dui moontlik daarop dat interartikulatorsinchronisasie soos onder meer weerspieel in sat, beheer word deur 'n meganisme wat nie in alle verbaal apraktiese sprekers versteur is nie. afwykende sat is dikwels die residuele probleem van 'n verbaal apraktiese spreker (freeman et al. 1978). hierdie gegewens impliseer dat selektiewe aantasting van temporale interartikulator-sinchronisasie kan voorkom en dui dus daarop dat hierdie komponent van beplanning moontlik onafhanklik funksioneer. hoit-dalgaard et al. (1983) noem dat satby verbale apraksie onvoorspelbaar is en ook kent en rosenbek (1983) meld dat die sat-resultate van die individuele sprekers verskil. hulle vind egter afwykings by al die sprekers. die feit dat nie alle sprekers in hierdie studie sat-foute vertoon nie, kan ook daarop dui dat verskillende tipes verbale apraksie voorkom, met selektiewe aantasting van komponente van motoriese beplanning. die sat-foute wat waargeneem is, is in alle gevalle te groot positiewe sat tellings van +15 millisekondes of meer vir stemhebbende klanke (kyk tabelle 2 en 3 vir voorbeelde). die positiewe telling is die gevolg van 'n verlengde stemnalooptyd. sat-tellings van meer as +15 millisekondes bring mee dat die klank as stemloos waargeneem word. die materiaal sluit slegs stemhebbende klanke in en afleidings kan dus slegs hieroor gemaak word. in die literatuur word gerapporteer dat stemhebbende klanke meer algemeen stemloos gemaak word as wat stemlose klanke stemhebbend gemaak word (wertz et al. 1984: 52). die waarneming dat stemhebbende klanke ίέ groot positiewe tellings oplewer van ongeveer +15 tot +30 millisekondes, bevestig die resultate van ander studies (freeman et al. 1978;. blumstein et al. 1977). daar is verder ook bevind dat slegs 17 van die 600 uitings (dus 2,8%) positiewe tellings van 35 millisekondes of meer getoon het. 'n stemlose, bilabiale plosief se sat is + 35 tot + 1 5 0 millisekondes (blumstein et al. 1977). 'n ware stemlose klank is dus slegs in 'n minimum van die gevalle geproduseer. freeman etal. (1978) het gevind dat d a a r ' n oor-! vleueling in die sate van stemhebbende en stemlose klanke voorkom en dat ook stemlose klanke dus nie volkome korrek geproduseer word nie. die ίέ groot positiewe tellings wat waargeneem is, impliseer op 'n gedragsvlak dat die glottale sluiting temporaal vertraag is in verhouding tot die verbreking van die afsluiting deur die artikulators. daar is verskillende moontlike verklarings vir die verlengde stemnalooptyd of anders gestel, die vertraagde inisiering van stemgewing wat voorkom by verbaal apraktiese sprekers. vanuit die oogpunt van die bekende regressieteorie wat ook soms op verbale apraksie toegepas word (marquardt, reinhart & peterson, 1979) kan daar gepoog word om hierdie verskynsel te verklaar as moontlike regressie na 'n infantiele vorm van spraakproduksie. volgens kewley-port en preston (1974) dek die sate van beide stemhebbende en stemlose klanke 'n wye omvang by kinders op 'n leeftyd van ses maande. daarna volg 'n periode waarin die sat vir stemhebbende en proefpersoon uitingnommer gemete sat-waardes van die ses herhalings 1 1.1 1.2 1.3 1.4 0. +11 0 0 0 0 + 10 0 0 +10 0 + 9 + 10 +20 +12 +20 +24 +10 + 10 +18 +10 +11 +12 +24 2 1.1 1.2 1.3 1.4 + 6 0 0 1 1 6 2 0 6 4 + 6 0 0 + 6 3 4 7 0 0 0 4 0 0 + 8 0 0 0 + 6 0 0 + 6 3 1.1 1.2 1.3 1.4 +26 +24 0 +20 +10 +16 0 0 +10 +12 +12 +12 + 18 +46 +20 +26 +22 +26 + 16 +14 +14 +10 +12 +10 4 1.1 1.2 1.3 1.4 6 0 6 0 4 0 3 6 2 0 8 0 8 0 4 8 8 0 8 0 0 8 0 1 0 0 5 2 2 2 7 6 4 8 0 6 4 6 0 4 8 1 0 0 8 0 5 2 5 1.1 1.2 1.3 1.4 + 5 +10 + 9 + 5 +12 +10 + 6 +20 +20 +20 +20 +18 + 6 +10 +14 + 7 +20 +12 + 6 + 1 4 + 8 + 6 0 + 1 0 proefpersoon uitingnommei gemete sat-waardes van die ses herhalings 1 1.1 2.1 3.1 4.1 5.1 0 +11 0 0 0 0 + 14 +10 +19 +14 +15 +18 + 18 +15 +20 +36 +20 +40 + 15 +20 +26 +15 +28 + 8 + 10 +11 +12 +13 +30 +32 2 1.1 2.1 3.1 4.1 5.1 + 6 0 0 1 1 6 2 0 6 4 0 0 2 6 0 +12 0 +26 + 6 + 6 0 + 6 0 +10 0 +10 +18 +16 +10 +15 +120 +10 +10 +20 +17 3 1.1 2.1 3.1 4.1 5.1 +26 +24 0 +20 +10' +16 0 0 +20 +10 +10 + 7 +12 +10 +14 +40 +20 +10 0 + 5 0 +16 + 5 +10 +24 +34 +10 +12 +16 +22 4 1.1 2.1 3.1 4.1 5.1 6 0 6 0 4 0 3 6 2 0 8 0 8 4 6 0 8 0 6 0 4 0 0 4 8 1 0 1 3 2 1 0 0 3 6 7 6 4 0 7 2 6 0 6 0 1 0 1 1 2 6 8 1 3 6 1 2 6 8 8 0 1 0 0 5 1.1 2.1 3.1 4.1 5.1 + 5 +10 + 9 + 5 +12 +10 + 5 + 9 +20 +10 +10 +10 + 10 +12 0 +12 0 +11 20 +10 0 0 + 7 + 7 vervang met /t/ the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) invloed van sekere kontekstuele faktore op stemaanvangstyd, vokaalduur en uitingduur 35 stemlose klanke net tussen 0 en +20 millisekondes is. stemvoorlope kom glad nie voor nie. volgens bogenoemde outeurs en cooper (1977) wat die teorie ondersteun, is dit motories maklik om 'n stemhebbende klank met 'n kort (0 +20 millisekondes) nalooptyd te produseer. die ploffing lei tot 'n afname in lugdruk wat die stembande dan in staat stel om spoedig na die ploffing te begin vibreer. 'n lang stemnalooptyd vir stemlose klanke vereis volgens hul verklaring 'n addisionele neurale bevel en is dus moeiliker om te produseer. oppervlakkig beskou, verklaar hierdie ontwikkelings-teorie nie die groot positiewe tellings (+15 tot +35 millisekondes) nie want daarvolgens neig die verbaal apraktiese sprekers om stemhebbende klanke motories moeiliker te maak. die belangrike punt wat hier in gedagte gehou moet word, is dat stemgewing soms in terme van die norm te laat 'n aanvang neem of ge'inisieer word vir die korrekte produksie van 'n stemhebbende klank. dit sou dus sinvol wees om aandag te skenk aan die neurale inisiering van stemgewing en gegewens in hierdie verband na te gaan vir moontlike verklarings. glottale bewegings geskied sonder die bewussyn van die normale spreker maar daar is wel neuro-anatomiese (jiirgens & ploog, 1981; ploog, 1981), neuropatologiese (jiirgens & von cramon, 1982) en neurofisiologiese (aitken & wilson, 1979) gegewens wat aandui dat fonasie willekeurig beheer word. die fonasiekontrolestelsel is hierargies georganiseerd en die hoogste vlak is gesetel in die anterior limbiese korteks (ploog, 1981). skynbaar speel ander strukture wat essensieel is vir artikulasie (byvoorbeeld die sensories-motoriese korteks, talairius en serebellum) nie 'n rol by stemgewing nie (jiirgens & ploog, 1981). die feit dat die limbiese stelsel wat 'n rol speel by inisiering van motoriek (mogeson, jones & yim, 1980) ook willekeurige stemgewing beheer, is in die lig van die feit dat verbale apraksie beskryf word as 'n afwyking in willekeurige beweging, belangrik. moontlik kan 'n versteuring in die meganisme van willekeurige inisiering deur die limbiese stelsel, of versteurde interaksie met ander motoriese dele, die afwyking in temporale sinchronisasie en wel die vertraagde inisiering van stemgewing verklaar. dit is insiggewend dat geen stemvoorlope waargeneem is by die drie proefpersone wat sat-foute gemaak het nie. hierdie oevinding bevestig die resultate van freeman et al. (1978). antisiperende stemgewing het dus glad nie voorgekom nie, maar slegs vertraagde stemgewing. ί vanuit 'n ander perspektief (wat nie teenstrydig is met die verklaring hierbo nie, maar dit wel aanvul) kan die temporale sinchronisering van artikulatoriese beweging met glottale sluiting, as 'n jnotoriese doelwit wat die spreker moet bereik, beskou word. die ossilloskoopbeeld wat verkry is (wat moontlik gemaak word deur die besondere apparaat wat gebruik is) by proefpersone 3 en 5 werp moontlik verdere lig op temporale sinchronisering as 'n motoriese doelwit. by beide hierdie persone was daar in uitings met hoe positiewe sat-tellings, aanduidings dat ploffing en stemgewing onafhanklik plaasvind en nie gei'ntegreera is nie. die plotting het in baie gevalle gepaard gegaan met baie ruising wat soms verleng was en dan 'n onafhanklike aanvang van stemgewing. dit wil voorkom asof daar 'η bewustheid by hierdie twee verbaal apraktiese sprekers is van die twee komponente van die uiting, naamlik ploffing en stemgewing. daar is dus aanduidings van kennis van die komponente van die motorprogram, maar daar ontstaan blykbaar 'n probleem in die vooruitvoering daarvan. die probleem kan die vertraagde inisiering van stemgewing wees of die onafhanklike vooruitvoering van subroetines van bewegings. die temporale sinchronisering van spraakbewegings het egter kritiese temporale ekwivalensiegrense en die onafhanklike of vertraagde inisiering van subroetines van bewegings bring mee dat temporale wanpassing plaasvind met gevolglike distorsiefoute. die kritiese grense van temporale interartikulatorsinchronisasie is in groot mate onveranderlik en dit stel 'n hoe eis aan die spreker om die sinchronisasie wat binne millisekondes moet plaasvind, te beheer in vinnige opeenvolging. so 'n uitgangspunt verklaar ook deels die onkonstantheid in produksie wat ook waargeneem is. 'n belangrike implikasie van die onkonstant foutiewe stemgewing is dat dit 'n baie sterk aanduiding is dat dit onwaarskynlik is dat die vervangings met stemlose klanke die gevolg is van foutiewe klankseleksie of foutiewe ouditiewe persepsie van stemhebbendheid. dit is aan die ander kant 'n baie sterk aanduiding dat stemhebbend-stemlose klankvervangings die gevolg is van afwykende beheer van die produksie van stemhebbende klanke. veranderlikheid of onkonstantheid in die verskillende komponente van 'n beweging is 'n kenmerk van motoriek en ook spraakmotoriek. die mate van veranderlikheid neem af tydens ontwikkeling totdat 'n volwasse stadium bereik word wanneer bewegings steeds veranderlik is, maar binne die grense van motoriese ekwivalensie (turvey, fitch & tuller, 1982; kelso et al. 1983: 145). die afleiding kan dus gemaak word dat onkonstantheid in die bewegingspesifikasies, byvoorbeeld in temporale inter-artikulator sinchronisasie, 'n aanduiding is van 'n motoriese probleem en nie 'n afwyking in die fonologiese kennis van fonotaktiese reels nie. kennis van die toepaslikheid van 'n spesifieke foneem en die ouditiewe herkenning daarvan is waarskynlik meer stabiele vermoens wat berus op verworwe reels en is nie wisselend van moment tot moment nie. afleidings gegrond op 'n enkele produksie van 'n klank is dus nie verteenwoordigend van die ware vermoe of onvermoe van die verbaal apraktiese spreker nie. 'n enkele produksie van 'n stemhebbende klank wat toevallig stemloos klink, kan die luisteraar mislei en meebring dat die afwyking gei'nterpreteer word as 'n klankvervanging en dus afwykende klankseleksie wat aanduidend kan wees van 'n fonologiese beplanningsprobleem. 'n interessante bevinding wat die uitgangspunt in hierdie studie bevestig, is dat die sate slegs in 2,8% van die uitings die waardes van ware stemlose klanke, naamlik +40 millisekonde en hoer (cooper, 1977) bereik het. die "ververvangings" met klanke wat stemloos klink, is dus nie ware vervangings nie maar wel distorsie van die klanke. 'n verdere insiggewende bevinding is dat die sat-resultate van die proefpersoon met verbale ontwikkelingsapraksie volkome ooreenstem met die resultate van die ander proefpersone. proefpersoon 5 het ook onkonstant sat-foute gemaak en hy het die sat-kenmerke vertoon wat ooreenstem met die patroon van proefpersoon 3. dit wil dus voorkom asof dieselfde meganisme versteur word by kongenitale en verworwe breinskade wat aanleiding gee tot verbale apraksie. opsommend kom die sat-resultate daarop neer dat afwykings nie in dieselfde mate by alle proefpersone voorkom nie; dat die satfoute die vorm aanneem van hoe positiewe tellings van +15 tot +35 millisekondes; dat sat onkonstant foutief is en dat die resultate van die proefpersoon met verbale ontwikkelingsapraksie ooreenstem met die resultate van die ander proefpersone. die sat-foute word onvoldoende verklaar deur die regressieteorie of'n teorie waarin die foute aan ware klankvervangings of persepsieprobleme toegeskryf word. die resultate word meer sinvol verklaar as 'n onvermoe om interartikulatorsinchronisasie binne die kritiese grense die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 a va der merwe, i c uys, j μ loots, r j grimbeek en l ρ c jansen van temporale ekwivalensie te beheer en die bewegings temporaal georden vinnig te inisieer en gei'ntegreerd vooruit te voer. die invloed van die klankstruktuur van 'n uiting op stemaanvangstyd. ten einde te bepaal of variasie in die klankstruktuur van 'n uiting 'n effek het op die stemaanvangstyd van inisiele stemhebbende konsonante by verbaal apraktiese sprekers, is 'n tweerigting-variansie-analise toegepas op die gemiddelde satfoute van eenhede uit die verskillende klankstruktuurgroepe. die eenhede vanuit die verskillende artikulasie-eienskapgroepe is afsonderlik vergelyk. 'n p-waarde van kleiner as 0,0125 dui daarop dat daar betekenisvolle verskille (op die 5% peil van betekenis) tussen die gemiddelde foute van die eenhede voorgekom het. die p-waardes is almal groter as 0,0125 wat aandui dat daar geen betekenisvolle verskille tussen die gemiddelde satfoute in die verskillende klankstruktuurgroepe is nie. die feit dat sat nie betekenisvolle sensitiwiteit vertoon vir die klankstruktuur van 'n uiting nie, kan 'n aanduiding wees dat die beheer van sat 'n suiwer motoriese gebeure is. die motoriese prosesse wat nodig is om sat te beheer, vertoon dus 'n afwyking ongeag die uiting waarin dit moet plaasvind. die onkonstantheid in die sat-foute het reeds gedui op hierdie „ moontlikheid. dit wil dus op grond van hierdie ontleding voorkom asof sat nie konteks-sensitief is nie en 'n suiwer motoriese komponent van die afwyking in verbale apraksie vorm. die afwesigheid van konteks-sensitiwiteit dui moontlik ook daarop dat afwykings in sat 'n kernsimptoom van verbale apraksie weerspieel. die invloed van die artikulasie-eienskappe van 'n uiting op stemaanvangstyd. ten einde te bepaal of variasie in die artikulasie-eienskappe van uitings met dieselfde klankstruktuur enige effek het op sat, is 'n tweerigting-variansie-analise uitgevoer op die gemiddelde satfoute van eenhede uit die verskillende artikulasie-eienskapgroepe. alle p-waardes is bokant 0,0125 wat impliseer dat daar geen betekenisvolle variasie tussen die uitings in die verskillende artikulasie-eienskapgroepe is nie. die afleiding gegrond op hierdie analise is dus dat sat nie sensitief is vir die verskillende artikulasie-eienskappe wat in die materiaal teenwoordig is nie. dit wil dus voorkom asof die afwyking in interartikulator-sinchronisasie vir sat by die verbaal apraktiese spreker voorkom ongeag die artikulasieof klankstruktuur-eienskappe van die uiting. foute kom egter nie tydens elke uiting voor nie. die verbaal apraktiese spreker het skynbaar 'n probleem om hierdie aspek van spraakbewegings te beheer. resultate van vokaalduurmetings. algemene beskrywing en bespreking. wisselende grootte verskille tussen die gemiddelde vokaalduur van ses herhalings van die verbaal apraktiese sprekers en normale sprekers is waargeneem. hierdie verskille in millisekondes word aangegee in tabel 4. dit is insiggewend dat daar by sommige eenhede geen verskille waargeneem is nie. die uitings van die verbaal apraktiese sprekers was selfs in enkele gevalle 'n paar millisekondes korter as άίέ van die normale sprekers en die verskil word dan as nul aangegee. tydens die verwerking van die data is ook waargeneem dat indien die langste duur van die ses herhalings van die normale sprekers in berekening gebring word, daar kleiner verskille veral by s4 voorkom. dit is ook interessant dat daar groot verskille bestaan tussen die mate waarin die individuele sprekers afwyk van die normale sprekers. proefpersoon 4 vertoon die grootste mate van afwyking. hy het ook by die sat-metings anders gereageer as die ander vier proefpersone en dit wil dus voorkom asof hierdie spreker wat tog as verbaal aprakties gediagnoseer kan word, moontlik 'n ander tipe aantasting vertoon. proefpersone 1 en 5 vertoon die kleinste mate van afwyking ten opsigte van vokaalduur. die proefpersoon met verbale ontwikkelingsapraksie vertoon wel ook verlengde vokaalduur soos die ander proefpersone. dit is belangrik om daarop te wys dat alhoewel daar individuele verskille voorkom, die orde van die foute by die verskillende eenhede, ooreenstemming toon. die faktore wat in die materiaal gemanipuleer is, het dus 'n ooreenstemmende uitwerking op al die proefpersone. die foutgrootte by s4 is byvoorbeeld kleiner as by die ander strukture vir al die proefpersone. dit kom dus voor asof daar 'n gemeenskaplike probleem by die sprekers aanwesig is alhoewel individuele verskille voorkom. in die literatuur word oor die algemeen gerapporteer dat verlengde vokaalduur voorkom by die verbaal apraktiese spreker en dat dit 'n komponent is van algemene artikulasieverlenging wat kenmerkend is van hierdie sprekers (freeman et al. 1978; collins et al. 1983; kent & rosenbek 1983). die mate van afwyking word nie aangegee nie en die struktuur van die uitings is ook nie gekontroleer nie. kent en rosenbek (1983) meld wel dat die duur toeneem namate die lengte van die uiting toeneem. duffy en gawle (1984) het vokaalduur in kvkuitings ondersoek en het ook vokaalduur korter as die normale waargeneem. die moontlikheid bestaan dat die wisselende grootte foute wat in die huidige studie waargeneem is, verband hou met die variasie in die klankstruktuur en artikulasieeienskappe van die uiting. die resultate van die ondersoek in hierdie verband word vervolgens verskaf. • die invloed van die klankstruktuur van 'n uiting op ! vokaalduur. i ι ten einde te bepaal of die klankstruktuur van 'n uiting 'n effell het op vokaalduur, is 'n tweerigting-variansie-analise uitge-! voer op die data wat aangegee word in tabel 4. globaal gesien1 is daar uitgesproke betekenisvolle verskille tussen die mate' van afwyking in vokaalduur van die eenhede in die verskillende klankstruktuurgroepe. 'n p-waarde van 0,0000 is verkry. op grond van die beskikbare data kan die gevolgtrekking gemaak word dat die klankstruktuur van 'n uiting 'n effek het op die vokaalduur. vokaalduur vertoon dus konteks-sensiti; witeit. die betekenisvolle verskille wat hier waargeneem is, is tussen die vokaalduur van klankstruktuur 4 en die ander klankstrukture. die verskille tussen die ander klankstrukture is statisties nie betekenisvol nie. verbaal apraktiese sprekers vertoon feitlik normale vokaalduur in kvk-uitingsaferiengde segmentele duur is dus nie 'n primgre eienskap van verbaal apraktiese spraak nie (duffy & gawle, 1984; rosenbek, kent & lai pointe, 1984: 16). die mate van afwyking in vokaalduur het the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 37 invloed van sekere kontekstuele faktore op stemaanvangstyd, vokaalduur en uitingduur tabel 4: die verskil in millisekondes tussen die gemiddelde vokaalduur van die proefpersoon en die gemiddelde vokaalduur van die kontrolepersoon klankartikulasie-eienskapgroepe struktuurgroepe al a2 a3 a4 proefpersone 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 totaal totaal per persoon si eenhede: 1.1 1.2 1.3 1.4 1. 180 2. 539 3. 386 2697 4. 1017 5. 575 si 105 271 0 92 168 6 50 137 177 80 19 39 77 388 168 50 179 172 360 159 1. 180 2. 539 3. 386 2697 4. 1017 5. 575 s2 eenhede: 2.1 2.2 2.3 2.4 1. 97 2. 366 3. 731 2805 4. 1210 5. 401 s2 4 68 221 408 122 0 25 113 273 147 27 175 205 260 82 66 98 192 269 50 1. 97 2. 366 3. 731 2805 4. 1210 5. 401 s3 eenhede: 3.1 3.2 3.3 3.4 1. 222 2. 557 3. 832 3342 4. 1269 5. 462 s3 162 274 209 259 120 53 137 187 300 99 7 117 182 308 137 0 29 254 402 106 1. 222 2. 557 3. 832 3342 4. 1269 5. 462 s4 eenhede: 4.1 4.2 4.3 4.4 1. 84 2. 0 3. 199 545 4. 189 5. 73 s4 0 0 2 100 0 19 0 72 0 70 25 0 23 32 0 40 0 102 57 3 1. 84 2. 0 3. 199 545 4. 189 5. 73 s5 eenhede: 5.1 5.2 5.3 5.4 1. 304 2. 789 3. 860 3359 4. 1165 5. 241 s5 120 287 143 242 75 53 223 241 265 80 215 242 262 118 51 64 234 396 48 1. 304 2. 789 3. 860 3359 4. 1165 5. 241 totaal per persoon 391 900 575 1101 485 131 435 750 1015 396 158 546 729 1250 505 207 370 954 1484 366 totaal 3452 2727 3188 3381 toeneem. hul afleiding is dat die verbaal apraktiese spreker sensitiwiteit vir hierdie vlak van "fonologiese enkodering" behou. die spreker beskik dus nog oor die nodige kennis van linguistiese reels. die verskynsel dat vokaalduur verkort voor 'n stemlose plosief is 'n aangeleerde eienskap wat nie voorkom in die spraak van driejariges nie (disimoni, 1974). die feit dat hierdie verskynsel waargeneem word in die spraak van verbaal apraktiese sprekers is 'n verdere aanduiding dat die probleem nie bloot 'n regressie na 'n infantiele spraakproduksiewyse is nie. die invloed van die artikulasie-eienskappe van 'n uiting op vokaalduur. geeneen van die berekende p-waardes is onder 0,0125 nie, wat impliseer dat daar geen betekenisvolle verskille tussen die mate van afwyking in vokaalduur van eenhede in die verskillende artikulasiegroepe is nie. groot waardes is oor die algemeen verkry. die artikulasie-eienskappe wat in die materiaal gedek is, het dus geen statisties beduidende effek op die vokaalduur nie. die gegewens in tabel 4 toon egter aan dat die mate van afwyking van al en a2 meer verskil as wat byvoorbeeld al en a4 verskil. al vertoon die grootste mate van afwyking in vokaalduur en a2 die kleinste. daar is dus aanduidings dat eenhede met verskillende artikulasie-eienskappe nie homogene eise stel aan die spraakproduksievermoe van die verbaal apraktiese sprekers nie. ten einde duplisering te beperk sal die implikasies van hierdie gegewens bespreek word tydens die bespreking van die invloed van artikulasie-eienskappe op uitingduur. die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 36, 1989 toegeneem namate die lengte van die uiting toegeneem het (kyk tabel 4). dit kom dus voor asof die spreker segmentele duur verleng in langer eenhede wat hoer eise stel aan sy spraakproduksievermoe. dit word algemeen aanvaar dat laiiger uitings lei tot meer spraakfoute by die verbaal apraktiese spreker (rosenbek et· al. 1984:15; kent & rosenbek, 1983). die resultate van hierdie studie bevestig dus hierdie aanname. dit beantwoordj ook in groot mate die vraag of verlengde artikulasie 'n direkte gevolg is vanjlie neuromotoriese afwyking (kent, netsell & abbs, 1979). op grond van die huidige resultate skyn dit nie die geval te wees nie. verlengde segmentele duur is meerj waarskynlik 'n kompensatoriese strategie om die onderliggende neuromotoriese probleem te oorkom. die resultate impliseer verder ook dat die engelssprekende verbaal apraktiese sprekers (dit is nie bekend of die reel ook geld in afrikaans nie) sensitiwiteit behou vir die linguistiese reel dat vokaalduur verkort voor 'n plosief in die finale posisie van 'n woord "(duffy & gawle, 1984: 169). dit word weerspieel deur die feitlik normale vokaalduur wat waargeneem is by die kvk-eenhede wat almal plosiewe klanke in die finale posisie het. alhoewel dit meestal onsineenhede was, het dieselfde reel wat verwag word by betekenisvolle spraak by beide groepe (eksperimenteel en kontrole) sprekers in werking getree. die resultate van collins et al. (1983) wat die behoud van 'n reel vir duurverhoudlnge waargeneem het, word dus bevestig. collins et al. (1983) het bevind dat alhoewel vokaalduur verleng is, die duur wel soos by die normale spreker verkort word namate die lengte van die woord waarin dit voorkom, r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a van der merwe, i c uys, j μ loots, r j grimbeek e n l ρ c jansen tabel 5: die verskil in millisekondes tussen die gemiddelde uitingduur van die proefpersoon en die gemiddelde uitingduur van die kontrolepersoon klankstruktuurgroepe artikulasie-eienskapgroepe klankstruktuurgroepe al a2 a3 a.4 proefpersone 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 totaal totaal per persoon si eenhede: 1.1 1.2 1.3 1.4 1. 1750 2. 2290 3. 2230 8199 4. 1370 5. 559 si 700 613 407 267 166 234 464 497 57 30 .486 613 740 326 130 330 600 586 720 233 1. 1750 2. 2290 3. 2230 8199 4. 1370 5. 559 s2 eenhede: 2.1 2.2 2.3 2.4 1. 710 2. 2078 3. 2070 7296 4. 2225 5. 213 s2 80 290 490 716 60 10 574 547 603 0 230 464 390 446 70 390 750 643 460 83 1. 710 2. 2078 3. 2070 7296 4. 2225 5. 213 s3 eenhede: 3.1 3.2 3.3 3.4 1. 2183 2. 3256 3. 3657 12927 4. 2997 5. 834 s3 953 940 1440 647 207 564 1090 897 670 197 433 663 717 720 233 233 563 603 960 197 1. 2183 2. 3256 3. 3657 12927 4. 2997 5. 834 s4 eenhede: 4.1 4.2 4.3 4.4 1. 719 2. 827 3. 409 2400 4. 330 5. "115 s4 140 417 30 210 0 87 107 74 0 37 136 176 76 80 53 356 127 229 40 25 1. 719 2. 827 3. 409 2400 4. 330 5. "115 s5 eenhede: 5.1 5.2 5.3 5.4 1. 2084 2. 3584 3. 3540 12662 4. 2777 5. 677 s5 750 1404 893 427 307 527 993 1267 747 363 793 733 610 226 444 394 647 993 144 1. 2084 2. 3584 3. 3540 12662 4. 2777 5. 677 totaal per persoon 2623 3664 3260 2267 740 1442 3228 3282 2077 264 1648 2709 2656 2182 712 1753 2434 2708 3173 682 totaal 12554 10273 9907 10750 resultate van uitingduurmetings. algemene beskrywing en bespreking. die verskil in millisekondes tussen die gemiddelde uitingduur van die proefpersone en die kontrolepersone word weergegee in tabel 5. die groot verskille wat waargeneem is, impliseer dat al die proefpersone stadige spraakspoed vertoon. volgens die meeste navorsers is stadige spraakspoed kenmerkend van die verbaal apraktiese spreker (wertz et al. 1984: 71; kent & rosenbek, 1983; rosenbek et al. 1984: 15). die grootste verskille tussen die gemiddelde uitingduur van normale en verbaal apraktiese sprekers ten opsigte van klankstruktuurgroepe kom voor by s3 en s5. daarna volg si en s2 en die kleinste verskil is by s4. wat die verskillende artikulasieeienskapgroepe betref, kom daar ook verskille voor wat groter is as die verskille wat ten opsigte van artikulasie-eienskapgroepe by die vokaalduurmetings waargeneem is (kyk tabel 4).-· wat die individuele proefpersone aanbetref, word bemerk dat proefpersoon 4 nie soos in die geval van vokaalduur die grootste afwyking vertoon nie. dit is 'n interessante verskynsel, want dit impliseer dat segmentele duur meer verleng is as by die ander sprekers, maar die oorgange van een klank na 'n ander vind dus vinniger plaas. 'n verdere interessante waarneming is dat proefpersoon 5 sonder uitsondering die kortste uitingduur van al die proefpersone yertoon. dit was egter nie die geval by vokaalduur nie (kyk tabel 4) alhoewel daar ook 'n neiging tot 'n vokaalduur korter as die gemiddelde waargeneem is. die oorgange tussen klanke vind dus by proefpersoon 5 vinniger plaas as by enige van die ander proefpersone. proefpersoon 5 wat 'n verbale ontwikkelingsapraksie vertoon, was nie-verbaal tot op onger veer vierjarige ouderdom en het daarna met behulp van die terapieprogram vir verbale ontwikkelingsapraksie (van der merwe, 1985) spraakproduksie aangeleer oor 'n tydperk van ongeveer vier jaar. 'n moontlike verklaring vir die vinniger spraakspoed is dat alle spraak wat hy vertoon doelbewus aangeleer is. een van die grondbeginsels van die terapieprogram is die doelbewuste herhaalde produksie van eenhede met toenemende spoed. die proefpersoon het dus 'n bewustelik aangeleerde motorprogram vir alle klanke en is geleer om dit herhaaldelik willekeurig te herroeop in alle klankomgewings en in langer wordende uitings. 'n mate van outomatisasie het waarskynlik plaasgevind. die ander proefper-, sone moet moontlik in 'n groter mate spraak wat voorheen outomaties plaasgevind het, doelbewus herroep, inisieer en beheer. dit kan die gevolg wees van die effek van verworwe breinskade nadat spraak reeds aangeleer is en' die reaksie daarop. dit kan andersyds ook toegeskryf word aan die feit dat die vier volwassenes vir korter periodes dieselfde tipe behandeling as proefpersoon 5 ontvang het en tydens die ondersoek the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) invloed van sekere kontekstuele faktore op stemaanvangstyd, vokaalduur en uitingduur 39 nog stadige spraak en stadige inisiering vertoon het. die gebrekkige outomatisasie van spraak verklaar moontlik die stadiger spraakspoed wat veral in die oorgange tussen klanke voorkom. die afleiding kan dus nie sonder meer gemaak word dat kinders met verbale ontwikkelingsapraksie vinniger spraakspoed vertoon (indien hulle wel spraak kan produseer) as gevalle met verworwe verbale apraksie nie omdat die vermoens waaroor proefpersoon 5 beskik deur middel van hierdie spesifieke benadering aan hom geleer is. dit is belangrik om daarop te wys dat proefpersoon 5 se spraak steeds stadiger is as normaal en dat die konteks van die uiting dieselfde uitwerking op sy spraakspoed het as op die spraakspoed van die persone met verworwe verbale apraksie. die mate van afwyking is die grootste by s3 en s5. daarna volg si en s2 wat in mindere mate 'n afwyking vertoon. die geringste uitval is by s4. metbetrekking tot spraakspoed vertoon die verbaal apraktiese spreker wel oppervlakkig geoordeel regressie. daar is eksperimenteel bevind dat woordduur by die jong kind langer is as by die ouer kind en die volwassene (kubaska & keating, 1981). die onderliggende redes hiervoor kan egter verskil. motoriese vaardigheid in die manipulasie van die spraakstrukture speel onder meer 'n rol by spraakspoed en die jong kind kan moontlik weens beperkte vaardigheid spraak stadiger produseer. stadige spraakspoed is ook kenmerkend van disartrie en in hierdie geval word spoed beperk weens versteurde spiertonus en onwillekeurige bewegings. 'n verlaging in spraakspoed kan ook kompensatories wees of weens gebrekkige outomatisasie. daar is dus verskillende redes vir stadige spraakspoed en dit is 'n oppervlakkige afleiding indien aanvaar word dat die stadige spraakspoed 'n simptoom van regressie na 'n infantiele spraakproduksiewyse is. opsommend kom die; resultate daarop neer dat die verbaal apraktiese sprekers wat in hierdie studie ondersoek is, stadige spraakspoed vertoon wat wissel in die mate waarin dit afwyk van normale spraakspoed. die rol van variasie in die konteks van die uiting by die wisselende mate van afwyking, word vervolgens bespreek. ι j die invloed van die klankstruktuur van 'n uiting op uitingduur die berekende p-waardes toon aan dat daar beduidende verskille voorkom tussen die mate van afwyking in uitingduur van eenhede in die verskillende klankstruktuurgroepe. slegs by artikulasiegroep 4 het daar nie 'n beduidende verskil voorgekom tussen die klankstruktuurgroepe nie. die verskille wat waargeneem is, was tussen die eenhede in s4 en die in s3 en s5. betekenisvolle verskille is nie uitgewys tussen s4 en si en s2 nie, maar die numeriese totaalwaardes in tabel 5 toon tog aan dat si en s2 nie dieselfde invloed het op uitingduur as die ander strukture nie. dieselfde groepverdeling is waargeneem by vokaalduur (kyk tabel 4). die gevolgtrekking is dus dat die klankstruktuur van 'n uiting 'n invloed het op die mate van afwyking in uitingduur. 'n interessante verskynsel wat deur hierdie resultate aan die lig kom, is dat die byvoeging van 'n enkele klank by die klankstruktuur, meebring dat die produksie van die uiting meer problematies word vir die verbaal apraktiese sprekers. klankstruktuur 4 wat die minste foute tot gevolg gehad het (by alle akoestiese analises) het 'n kvk-struktuur terwyl klankstrukture 1 en 2 wat die tweede groep vorm 'n kvkv-struktuur het. daarteenoor het klankstrukture 3 en 5 wat die derde groep vorm onderskeidelik 'n kvkvken kvkvkvk-struktuur. die effek wat die byvoeging van 'n enkele klank het, is verrassend omdat die kvkv-struktuur byvoorbeeld slegs die byvoeging van 'n vokaal meebring. artikulatories gesproke vereis dit weinig addisionele artikulasiebewegings na die verbreking yan die afsluiting vir die finale plosief. fonologies gesproke is dit 'n klankstruktuur wat baie vroeg reeds in die spraak van die jong kind voorkom en die fonologiese beplanning van so 'n uiting behoort nie meer problematies te wees as die kvk-struktuur nie. 'n verklaring vir hierdie verskynsel word dus nie vanuit hierdie oogpunte verkry nie. 'n ander moontlike verklaring is dat die beplanning van 'n langer uiting meer kompleks is en meer tyd in beslag neem. klapp, anderson en berrian (1973) het'deur middel van 'n reaksietydstudie bevind dat dit langer neem om 'n tweelettergrepige woord te beplan as wat dit neem om 'n eenlettergrepige woord te beplan. die afleiding is dat dit langer neem om 'n meer komplekse motorprogram te beplan. die data in die huidige studie toon aan dat langer eenhede langer neem om te produseer. die feit dat korter eenhede teen feitlik normale spoed geproduseer word impliseer dus dat daar nie 'n primere motoriese probleem is wat lei tot stadige spraakspoed nie. dit is dus die beplanning van die langer uiting wat soveel meer tyd in beslag neem en nie die produksie daarvan nie. die moontlikheid bestaan ook dat die langer uiting op 'n ander wyse beheer word as die korter uiting wat minder kompleks is. die verbaal apraktiese spreker kan moontlik vanwee die verhoogde eise van 'n langer uiting, dit nie volledig beplan voor produksie nie en moet dan voortdurend tydens produksie beplan. schmidt (1982: 207) meld onder meer dat motories vaardige persone lang reekse bewegings vooraf kan beplan. die teenoorgestelde is dus moontlik, naamlik dat beperkte motoriese vaardigheid meebring dat net korter reekse vooraf beplan kan word. die beplanning van 'n langer eenheid is waarskynlik om verskeie redes meer kompleks. die byvoeging van addisionele klanke bring mee dat 'n groter getal kernmotorprogramme herroep moet word, die vereistes van ruimtelike en temporale adaptasie en koartikulasie neem toe en die groter getal bewegingspesifikasies moet in die korrekte volgorde vooruitgevoer word. meer opeenvolgende variasie in bewegings kom ook voor in langer uitings. dit is in die praktyk waargeneem dat k1v1k1v] -eenhede by verbaal apraktiese sprekers soos by die normaal ontwikkelende kind vroeer voorkom en meer korrek geproduseer word. die eenhede wat in hierdie studie gebruik is, is ki v1k1v2 en kivik2v2-eenhede wat toenemend meer variasie in die bewegingspesifikasies meebring. indien die mate van variasie in die klanke wat voorkom, wel 'rr rol speel behoort die data dit te reflekteer. hierdie moontlikheid word bevestig deur die resultate van die vokaalduurmetings (kyk tabel 4) waar die mate van afwyking by s2 groter is as by si. by die uitingduurmetings (kyk tabel 5) word hierdie moontlikheid egter nie bevestig nie. si toon 'n groter mate van afwyking as s2. dit wil dus voorkom asof die mate van variasie in die klanke in die eenheid nie die oorwegende rede is vir die verhoging in moeilikheidsgraad nie, maar eerder die getal klanke in die eenheid. laasgenoemde afleiding hou egter ook nie volkome stand nie. dit wil voorkom asof die lengte van die uiting nie die enigste faktor is wat die moeilikheidsgraad daarvan bepaal nie want s5 bevat twee klanke meer as s3 maar vertoon feitlik dieselfde die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 a va der merwe, i c uys, j μ loots, r j grimbeek en l ρ c jansen mate van afwyking in vokaalduur (kyk tabel 4) en 'n kleiner mate van afwyking in uitingduur (kyk tabel 5) as s3. die feit dat s5 fonologies meer kompleks is omdat meer klanke geselekteer en gekombineer moet word as by s3, bring dus nie mee dat die afwyking in uitingduur toeneem nie. die verbaal apraktiese spreker neem dus nie baie langer om dit te beplan as 'n uiting met vyf klanke soos in s3 nie. daar is verskillende moontlike verklarings vir die feit dat s3 feitlik dieselfde mate van afwyking vertoon vir vokaalduur en 'n groter mate van afwyking vir uitingduur as s5. tydens die ondersoek is subjektief waargeneem dat s5 meer ritmies geproduseer word deur die verbaal apraktiese sprekers as s3. dit kan wees dat die ritme van 'n eenheid bepaal word deur die klankstruktuur en dat sekere strukture meer ritmies is. keele en summers (1976:139) verklaar dat 'n ritmiese tydstruktuur vaardighede anders be'invloed as 'n arbitrsre tydpatroon. wanneer die tydreeling ritmies is, word die vaardigheid makliker aangeleer. dit word aanvaar dat die basiese eenheid van spraakritme die lettergreep is. klankstruktuur drie bestaan uit twee lettergrepe, maar 'n neiging is waargeneem by die verbaal apraktiese sprekers om die kvkv-gedeelte as 'n eenheid te produseer en die finale /f/-klank as 'n ge'fsoleerde eenheid. dit het moontlik meegebring dat die natuurlike spraakritme versteur is by s3. die versteuring in spraakritme bring dan mee dat die uiting meer afwykend word. 'n verdere moontlike verklaring wat by bogenoemde aansluit, is dat s3 problematies is omdat dit uit 'n kvkv-eenheid bestaan wat 'n duplisering is van die sogenaamde kv-eenheid van spraakprogrammering en 'n addisionele konsonant wat losstaande is. die kvkv-struktuur kom ook soos reeds gemeld vroeg voor in kinderspraak en het waarskynlik beperkte kompleksiteit. dit word dan as 'n eenheid geproduseer deur die sprekers. dit mag ook wees dat lettergreepvorming versteur is, maar dit is on waarskynlik want by s5 was daar geen probleme hiermee nie. by s5 vorm die kvkven die kvk-gedeeltes twee afsondenike eenhede wat deiae met redelike gemak geproduseer kan word terwyl die losstaande klank by s3 moontlik 'n groter mate van beplanning verg. die probleme wat die proefpersone ervaar het met die produksie van s3-eenhede kan moontlik ook die gevolg wees van die spesifieke klank wat in die finale posisie voorkom. die /f/ vereis akkurate aanpassing in lipbeweging en is minder veranderlik as baie ander klanke. die /f/ kom aan die ander kant ook voor in s5 maar moontlik werk die daaropvolgende /u/klank fasiliterend in op die /f/ in hierdie eenhede. die bewegings vir die /f/ in hierdie twee posisies en eenhede verskil. bogenoemde drie moontlike verklarings is die enigste wat voorgestel kan word op grond van die beskikbare data. opsommend kom die resultate daarop neer dat die klankstruktuur van 'n uiting 'n invloed uitoefen op die mate van afwyking in uitingduur. die lengte van die uiting speel 'n belangrike rol. kort uitings word feitlik normaal geproduseer wat die temporale eienskappe vokaalduur en uitingduur betref. die byvoeging van 'n enkele klank bring mee dat produksie meer afwykend is. die lengte van die uiting is egter nie die enigste faktor wat moeilikheidsgraad vir die verbaal apraktiese spreker bepaal nie. die moontlikheid bestaan dat die besondere klankstruktuur van 'n uiting, die inherente ritme daarvan en/ of die klanke wat daarin voorkom, ook 'n rol speel by die moeilikheidsgraad daarvan. die invloed van die artikulasie-eienskappe van 'n uiting op uitingduur. geeneen van die berekende p-waardes is onder 0,0125 nie, wat impliseer dat daar geen betekenisvolle verskille tussen die mate van afwyking in uitingduur van eenhede in die verskillende artikulasie-eienskapgroepe is nie. die p-waardes wat verkry is, is egter kleiner as die p-waardes vir vokaalduur. die kleinste waarde vir vokaalduur is 0,4010 terwyl die grootste p-waarde vir uitingduur 0,4202 is. die kleinste waarde is 0,0713 wat vir artikulasie-eienskapgroepe binne si verkry is. numeries is daar ook groot verskille tussen die totaalwaardes vir die verskillende artikulasie-eienskapgroepe (kyk tabel 5). dit wil voorkom asof daar tog verskille is tussen die mate waarin die uitingduur van eenhede in verskillende artikulasie-eienskapgroepe afwyk. 'n moontlike verklaring vir die feit dat die invloed op vokaalduur meer beperk is, is waarskynlik dat verlengde vokaalduur slegs 'n gedeelte van die invloed van artikulasie-eienskappe reflekteer. die data oor uitingduur reflekteer die totale invloed en is daarom meer opsigtelik. dit moet in gedagte gehou word dat die artikulasie-eienskappe wat in die eenhede binne 'n struktuurgroep verteenwoordig is, netminimaal verskil. uiting 1.1 en 1.2 en ook 1.3 en 1.4 verskil byvoorbeeld net met 'n enkele klank. dit is dus insiggewend dat hierdie klein verskille in artikulasie-eienskappe wel die groot verskil in totaalwaardes teweegbring. die totale afwyking in millisekondes vir a l is 12554 terwyl dit vir a3 9907 is (kyk tabel 5). die verskille tussen die artikulasie-eienskapgroepe word ook in groot mate gereflekteer in die totale vir die individuele sprekers. dit wil dus voorkom asof die artikulasieeienskappe van 'n uiting wel 'n invloed uitoefen op die duur daarvan en moontlik dus op die moeilikheidsgraad van 'n uiting. gevolgtrekkings daar kan tot die volgende gevolgtrekkings gekom word: interartikulator-sinchronisasie vir korrekte stemgewing is nie sensitief vir die klankstruktuur of artikulasie-eienskappe van 'n uiting nie. stemaanvangstydfoute kom onvoorspelbaar en onkonstant by die herhaling van 'n uiting voor. die gebrek aan konteks-sensitiwiteit en die feit dat nie alle proefpersone stemaanvangstydfoute vertoon nie, dui daarop dat interartikulator-sinchronisasie vir korrekte stemgewing 'n komponent van beplanning is wat onafhanklik van die ander komporiente funksioneer en dat sat-foute 'n kernsimptoom vanyverbale apraksie reflekteer. die sat-foute wat voorkom, is nie ware vervangings met stemlose klanke nie, maar is distorsies weens oorskryding van die kritiese temporale ekwivalensiegrense vir interartikulator-sinchronisasie. variasie in die klankstruktuur van 'n uiting het 'n effek op vokaalduur. vokaalduur is dus konteks-sensitief vir klankstruktuur. namate die moeilikheidsgraad van die uiting toeneem, neem die mate van afwyking in vokaal-. duur ook toe. die verlengde segmentele duur is dus nie 'n direkte gevolg van die neuromotoriese afwyking by die verbaal apraktiese sprekers nie. dit is waarskynlik 'n kompensatoriese strategie om die oriderliggende neuromotoriese probleem te oorkom. sensitiwiteit vir die temporale reel dat vokaalduur verkort voor 'n finale plosief, is behou. die verbaal apraktiese sprekers is dus in staat om temporale aanpassings in die kernmotorprogram te maak the south african journal of communication disorders, vol. 36, 1989, r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) invloed van sekere kontekstuele faktore op stemaanvangstyd, vokaalduur en uitingduur 41 o p g r o n d v a n k e n n i s v a n die b e t r o k k e t e m p o r a l e r e e l e n m e t die d o e i o m te k o m p e n s e e r . variasie i n die a r t i k u l a s i e e i e n s k a p p e w a t in die m a t e r i a a l v e r t e e n w o o r d i g is, h e t n i e ' n s t a t i s t i e s b e d u i d e n d e effek o p v o k a a l d u u r b y die g r o e p v e r b a a l a p r a k t i e s e sprek e r s n i e . d a a r is w e l a a n d u i d i n g s d a t v o k a a l d u u r s e n s i t i e f is vir die a r t i k u l a s i e e i e n s k a p p e v a n ' n u i t i n g . variasie in die k l a n k s t r u k t u u r v a n ' n u i t i n g h e t ' n effek o p die d u u r v a n die u i t i n g . n a m a t e die m o e i l i k h e i d s g r a a d , w a t b e p a a l w o r d d e u r die l e n g t e e n die k l a n k s t r u k t u u r v a n die u i t i n g , t o e n e e m , n e e m die m a t e v a n a f w y k i n g i n u i t i n g d u u r toe. d i e gevolgtrekking d a t v e r l e n g d e d u u r n i e ' n d i r e k t e gevolg v a n die a f w y k i n g is n i e , m a a r ' n k o m p e n s a t o r i e s e strategie, w o r d bevestig. sekere k l a n k s t r u k t u r e ( b y v o o r b e e l d kvkvke e n h e d e ) e n l a n g e r u i t i n g s w o r d verleng, w a a r s k y n l i k o m d a t die b e p l a n n i n g d a a r v a n m e e r k o m p l e k s is. d a a r is a a n d u i d i n g s d a t die a r t i k u l a s i e e i e n s k a p p e v a n ' n u i t i n g ' n invloed uitoefen o p die m a t e v a n a f w y k i n g i n u i t i n g d u u r , m a a r die effek is n i e s t a t i s t i e s b e t e k e n i s v o l b e v i n d n i e . die k o n s e p v a n k o n t e k s s e n s i t i w i t e i t soos o n t l e e n a a n die k o a l i s i e m o d e l h e t d u s o o k m e t b e t r e k k i n g t o t die t e m p o r a l e e i e n s k a p p e v a n v e r b a a l a p r a k t i e s e s p r a a k , die s i m p t o m e i n ' n i n s i g g e w e n d e p e r s p e k t i e f gestel d e u r die o n d e r s k e i d t u s s e n k e r n s i m p t o m e e n g e a s s o s i e e r d e s i m p t o m e a a n te t o o n . verd e r e a a n d u i d i n g s v a n die a a r d v a n die a f w y k i n g is o o k v e r k r y . die o n v e r m o e o m k o n s t a n t die kritiese t e m p o r a l e e k w i v a l e n s i e g r e n s e vir i n t e r a r t i k u l a t o r s i n c h r o n i s a s i e te b e r e i k , is s i g ' b a a r g e d e m o n s t r e e r d e u r die a k o e s t i e s e a n a l i s e v a n herh a a l d e u i t i n g e . die r e s u l t a t e v a n die o n d e r s o e k d u i v e r d e r o o k d a a r o p d a t dieselfde t w e e l e d i g e s i m p t o m a t o l o g i e , a a n g e t r e f w o r d b y verb a l e o n t w i k k e l i n g s a p r a k s i e . e r k e n n i n g s f i n a n s i e l e b y s t a n d v a n die r a a d vir g e e s t e s w e t e n s k a p l i k e n a v o r s i n g vir h i e r d i e o n d e r s o e k , w o r d h i e r m e e e r k e n . v e r w y s i n g s aitken, p.g. en wilson, w.a. discriminative vocal conditioning in rhesus monkeys: evidence for volitional control? brain and language, 8, 227-240, 1979.) blumstein, s.e., cooper, w.e.jzurif, e.b. en caramazza, a. the perception and production of voice-onset time in aphasia. neuropsgcholofita, 15, 371-383, 1977. collins, m., rosenbek, j.c. en wertz, r.t. spectrographic analysis of vowel and word duration .jou rnal of speech and hea ring resea rch, 26, 224-230;?1983. cooper, w.e. the development of speech timing. in s.j. segalowitz en f.a. gruber (reds.) language development and neurological theory. new york: academic press, 1977. di simoni, f.g. influence of consonant environment on duration of vowels in the speech of three-, six and nine-year-old children. journal of the acoustical society of america, 55, 362-363, 1974. duffy, j.r. en gawle, c.a. apraxic speaker's vowel duration in consonant-vowel-consonant syllables. in j.c. rosenbek, m.r. mcneil en a.e. aronson (reds.) apraxia of speech: physiology, acoustics, linguistics, management. san diego: college-hill press, 1984. freeman, f.j., sands, e.s. en harris, k.s. temporal coordination of phonation and articulation in a case of verbal apraxia: a voice onset time study. brain and language, 6, 106-111, 1978. hoit-dalgaard, j., murry, t. en kopp, h.g. voice-onset time production and perception in apraxic subjects. brain and language, 20, 329-339, 1983. itoh, m. en sasanuma, s. articulatory movements in apraxia of speech. in j.c. rosenbek, m.r. mcneil en a.e. aroirton (reds.) appraxia of speech: physiology, acoustics, linguistics, management. san diego: college-hill press, 1984. jansen, l.p.c. persoonlike onderhoud, forensiese akoestiek-laboratorium van die suid-afrikaanse polisie, pretoria, 1985. jiirgens, u. en ploog, d. on the neural control of mammalian vocalization. trends in neurosciences, 4, 135-137, 1981. jiirgens, u. en von cramon, d. on the role of the anterior cingulate cortex in phonation: a case report. brain and language, 15, 234248, 1982. keele, s. w. en summers, j.j. the structure of motor programs. in g.e. stelmach (red.) motor control: issues and trends. new york: academic press, 1976. kelso, j.a.s. en tuller, b. toward a theory of apractic syndromes. brain and language, 12, 224-245, 1981. kelso, j.a.s., tuller, b. en harris, k.s. a'dynamic pattern' perspective on the control and coordination of movement. in p.f. macneilage (red.) the production of speech. new york: springerverlag, 1983. kent, r.d., netsell, r. en abbs, j.h. acoustic characteristics of dysarthria associated with cerebellar disease. journal of speech and hearing research, 22, 627-648, 1979. kent, r.d. en rosenbek, j.c. acoustic patterns of apraxia of speech. journal of speech and hearing research, 26, 231249, 1983. kewley-port, d. en preston, m.s. early apical stop production: a voice onset time analysis. journal of phonetics, 2, 195-210, 1974. klapp, s.t., anderson, w.g. en berrian, r. w. implicit speech in reading reconsidered. journal of experimental psychology 100, 368374, 1973. kubaska, c.a. en keating, p.a. word duration in early child speech. journal of speech and hearing research, 24, 615621, 1981. marquardt, t.p., reinhart, j.b. en peterson, h.a. markedness analysis of phonemic substitution erors in apraxia of speech. journal of communication disorders, 12, 481-494, 1979. mogeson, g.j., jones, d.l. en yim, c.y. from motivation to action: functional interface between the limbic system and the motor system. progress in neurobiology, 14, 6997, 1980. ploog, d. neurobiology of primate audio-vocal behavior. brain research reviews, 3, 35-61. elsevier: north-holland bio-medical press, 1981. rosenbek, j.c., kent, r.d. en la pointe, l.l. apraxia of speech: an overview and some perspectives. in j.c. rosenbek, m.r. mcneil en a.e. aronson (reds.)apraxia of speech: physiology, acoustics, linguistics, management. san diego: college-hill press, 1984. schmidt, r.a. motor control and learning: a behavioral emphasis. illinois: human kinetics publishers, 1982. turvey, m.t., fitch, h.l. en tuller, b. the bernstein perspective: i. the problems of degrees of freedom and context-conditioned variability. in j.a.s. kelso (red.) human motor behavior: an introduction. london: lawrence erlbaum associates, 1982. van der merwe, a. terapieprogram vir verbale ontwikkelingsapraksie met toepassingsmoontlikhede vir ander spraakafwykings. publikasie van die universiteit van pretoria, pretoria: v&r, 1985. van der merwe, a. die motoriese beplanning van spraak by verbale apraksie. ongepubliseerde d.phil-verhandeling. universiteit van pretoria, 1986. van der merwe, α., uys, i.c., loots, j.m. en grimbeek, r.j. die invloed van sekere kontekstuele faktore op die ouditief waarneembare foute by verbale apraksie. die suid-afrikaanse tydskrif vir kommunikasieafivykings, 3, 10-22, 1987. van der merwe, α., uys, i.c., loots, j.m. en grimbeek, r.j. ouditief waarneembare foute by verbale apraksie: aanduidings van die aard van die afwyking. die suid-afrikaanse tydskrif vir kommunikasieafwykings, 35, 45-54, 1988. wertz, r.t., la pointe, l.l. en rosenbek, j.c. apraxia of speech in adults: the disorder and its management. orlando: grune & stratton, inc., 1984. die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 36, 1989 \ r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a legacy of sound advice and equipment philips hearing aids audiometers fm systems head office: 1005 cavendish chambers, 183 jeppe street p.o. box 3069, johannesburg 2000. tel: (011) 337-7537. philips r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) laryngeal trauma: a diagnostic case study* loren β schneider ba (sp & η thorapyr(witwatersrand) baragwanath hospital, johannesburg anthony traill phd (witwatersrand) department of linguistics university of the witwatersrand, johannesburg lesley wolk ma (speech pathology) (witwatersrand) department of speech pathology and audiology, university of the witwatersrand, johannesburg abstract this study investigates the physiological mechanism responsible for reappearance ofphonation in an aphonic subject with traumatic laryngeal damage. the battery of procedures involved spectrography, laryngographic analysis, fiberoptic laryngoscopy, tomography, lateral xerography and cinefluorography. results show that the subject's abnormal laryngeal anatomy facilitated a novel adductory mechanism for vocal fold vibration involving a type of sphincteric constriction between the arytenoid cartilages and the epiglottis. the value of a battery of diagnostic measures is highlighted. opsomming hierdie studie ondersoek die fisiologiese meganisme wat verantwoordelik is vir die herverskyning vanfonasie in « afonie geval met troumatiese laryngeale beskadiging. die ondersoek battery het spektrografie, laringografiese analise, fiberoptiese laringoskopie, tomografie, laterale xerografie en cinefluorografie ingesluit. resultate dui daarop dat die proefpersoon se abnormale larinks-anatomie 'n ongewone adduksie meganisme bewerkstellig het vir die stemband vibrasie, naamlik, 'n sfinkter vernouing tussen die aritenoide kraakbene en die epiglottis. die waarde van 'n metingsbattery vir diagnose word uitgelig. laryngeal injury was prevalent during the two world wars (luchsinger and arnold, 1965). post-war, the incidence decreased. today, we are again witnessing an acceleration of laryngeal injuries. this has been attributed to the sustained increase in motor vehicle accidents and rise in violent crimes, an inexorable fact of our present society (luchsinger and arnold, 1965). most interest in laryngeal trauma has been confined to medical literature. there is a paucity of research on laryngeal injury with regard to vocal rehabilitation by the speech clinician. a detailed investigation of recent literature reveals only one study viewing laryngeal trauma in relation to voice therapy (mitrinowicz-modrzejewska,j 1962). in this study, two cases of laryngeal trauma are discussed, and it is concluded that voice therapy is possible, even under highly adverse circumstances and following long periods of post-traumatic aphonia. however, differential diagnosis is essential before any treatment is undertaken. trauma results in disorders of variable type and degree, ranging from slight dysphonia to complete aphonia. the nature of the laryngeal damage must be determined, as treatment and prognosis will depend on the site and extent of structural involvement. different perspectives on subjective and objective measures have been highlighted in the literature. it is apparent that earlier clinicians were more dependent on subjective measures, whereas later writers have attempted to objectify evaluation. kelman, gordon, morton and simpson (1981) attribute this to the recent advent of electronic instruments for assessment of vocal behaviour. the advantages of the various objective measures have been emphasized by many writers. the inaccessibility of the phonatory mechanism renders fiberoptic and radiological techniques invaluable in diagnostic evaluation. for acoustic analyses of the speech waveform, writers have stressed the value of spectrography (kerr and lanham, 1973; rontal, rontal and rolnick, .1975) and laryngography (fourcin, 1974). a combination of subjective and objective evaluation is still felt to be optimal (aronson, 1980, p. 171). the major aim of this study was thus to use a multidimensional approach in an in-depth evaluation of the structural and functional components responsible for phonation in a case with laryngeal damage due to trauma. method subject the subject, m.p., is an english-speaking adult male, aged 24 years, who suffered a motorcycle accident in which his larynx was crushed by a wire stretched across the road. summaries of the pertinent post-traumatic medical events are presented in table 1. * this article is based upon the first'author's research report entitled "laryngeal trauma: a diagnostic case study" submitted to the department of speech pathology & audiology, university of the witwatersrand, johannesburg. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 sasha 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 loren β schneider, anthony traill and lesley wolk table 1 summary of post-traumatic medical events date event description of findings vocal history 15.01.78 motorcycle accident crushed tracheal cartilages and severe damage to larynx post-traumatic aphonia 30.01.78 tracheostomy; graft inserted around trachea 28.04.78 direct laryngoscopy; bronchoscopy; tracheal dilation left vocal fold moved poorly; right vocal fold normal; marked fibrosis and stenosis 07.05.78 subglottal t-tube insertion vocal cords immobile; ventricular cords moving 08.01.79 removal of t-tube; direct laryngoscopy vocal cords scarred and immobile; ventricular cords moving 01.05.79 direct laryngoscopy; granuloma removal vocal cords immobile; very narrow trachea voice therapy received, resulting in lowpitched, severely hoarse phonation 07.09.81 direct laryngoscopy; laser therapy (for anterior web and subglottal scarring) vocal cords not moving normally; scarring of left vocal cord voice therapy received, resulting in lowpitched, severely hoarse phonation 12.11.82 direct laryngoscopy; laser therapy oedematous vocal cords; some movement detected; ventricular cord closure; no web referred for further voice therapy. the vocal history is as follows: in january 1979 m. p. presented with post-traumatic aphonia. between march and october of that year he received voice therapy resulting in low-pitched, severely hoarse phonation. he reported a gradual improvement in voice quality over the next three years. after the medical examination and laser therapy in november 1982 he was referred for further voice therapy. at this stage it was suggested that nerve re-generation may have occurred to explain movement observed in the vocal cords (see table 1). procedure preliminary measures audiometric evaluation revealed hearing within normal limits bilaterally. oral peripheral examination revealed structural and functional adequacy of the oral peripheral 'mechanism 'for speech. voice evaluation a. subjective evaluation a voice sample was recorded including connected'speech, reading, selected speech sounds and counting at v'avying rates, loudness and pitch levels. aspects of respiration, phonation and resonance were analysed descriptively. a voice scale was completed in an attempt to confirm and objectify subjective evaluation. the buffalo voice profile (wilson, 1979) was selected for evaluation of vocal parameters as a baseline measure and was judged by two qualified speech therapists. the judges were naive as to the aims of the study and had had no previous contact with the subject. b. objective evaluation 1. indirect laryngoscopy indirect laryngoscopy was carried out by an ent specialist following the procedure of mirror laryngoscopy. 2. spectrography spectrographs analysis was performed on a kay sonagraph model 6061-b. broad and narrowband spectrograms were made as well as sections. the vowels la; j and [i:j] were used for analysis and sentences were used to supplement this data. 3. fiberoptic examination \ the flexible fiberoptic laryngoscope provides a means of visualising and identifying normal or abnormal laryngeal structure and regulation during'voice production. aronson (1980) states that this is the-only assessment technique which allows observation of 'the 'vocal folds during connected speech. fiberoptic exantifiatton was carried out, using a flexible fiberoptic nasokiryngoscope olympus type vf4a. several slides were takgn^f^elii7nx^duti0g^quief'fe$i>iration and sustained vowel'prdduction.-phonation'vvas' taipe recorded concurrently,1 allowing for correlation of slides with corresponding utterances. 4. laryngography the laryngograph is "an electrical impedance technique . . . for the direct examination of vocal fold closure, which does not -interfere with phonation" (fourcin, 1974). the laryngographic procedure described by wechsler (1977), was ' carried out, using the fourcin laryngograph and voicescope. the south african journal of communication disorders, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) laryngeal trauma: a diagnostic case study 15 m.p. was required to produce sustained phonation on the vowels [a:] and [i:] during level and rising pitches. a sentence was recorded to supplement the data. the output of the laryngograph and voicescope was simultaneously recorded on a mingograf inkjet recorder. 5. frontal tomography and lateral xerography many writers advocate the use of x-ray techniques in the diagnosis of voice disorders, for example, fletcher, shelton, smith and bosma (1960), who stress the need for research in this area. in traumatic cases, radiological measures aid in determining the extent of structural damage. for an anteroposterior view of the larynx, frontal tomograms were taken. for a lateral view of the larynx, lateral xerography was carried out. tomograms and xerograms were taken at rest and during sustained phonation. the audio signal was tape recorded to ensure that the exposure had coincided with phonation and for later spectrographic analysis. 6. cinefluorography cinefluorography is a technique using "electronic image in. tensification, in which motion pictures are taken from a fluoroscopic screen" (moll, 1960). one of the major advantages of this technique is in its application to the dynamics of connected speech. this allows the study of movement, rather than a single pose taken at one instant in time. a barium compound was introduced through the subject's nostrils into the pharynx to add clarity to the image, and he produced a few seconds of spontaneous speech and sustained vowel phonation to determine the exact locus and nature of his vibratory source. results subjective evaluation table 2 represents a summary of the parameters evaluated qualitatively by the investigators, from a recorded speech sample, and includes findings from the rated buffalo voice profiles. / / khz 3,0 η 2,5 2,0 1,0 οβ -\ table 2 summary of findings of subjective voice analysis respiration thoracic type of breathing; restricted capacity; poor respiratory control, as assessed through phono-respiratory tasks extracted from boone (1977, p. 85) loudness adequate volume in habitual phonation, but progressive decrease in loudness during sustained vowel production, which could be related to inadequate respiratory function pitch low habitual and optimum pitch levels; limited pitch range; no pitch breaks. quality hoarse; breathy; auditorily rough; diplophonic steadiness steady at habitual pitch level; unsteady when required to raise pitch level, possibly attributable to excessive tension. rate within normal limits, confirmed by raters (wilson, 1979, p. 88) resonance within expected range, confirmed by raters (boone, 1977, p. 98) overall vocal efficiency moderately impaired objective evaluation a. indirect laryngoscopy examination during quiet breathing revealed no significant variables in terms of the medical status of μ. p.'s laryngeal structures. assymmetry of the vocal cords was reported, with the left vocal cord situated at a higher level than the right vocal cord. during phonation a posterior movement of the epiglottis obstructed the view of the vocal cords, preventing any observation of their state during phonation. figure 1 narrow band spectrograms and acoustic sections of the sustained vowels [i:] and [a:]. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 loren β schneider, anthony traill and lesley wolk b. spectrographs analysis the broadband and narrowband spectrograms were analysed in terms of the following parameters: 1. fundamental frequency the fundamental frequency was measured at various places in connected speech. the figures obtained were averaged, yielding a fundamental frequency of 77 hz. this is well below the norm for males, i.e. 120 hz. (fry, 1979). 2. harmonic components in comparison to a normal spectrogram a relatively restricted range of harmonics was evident. as is illustrated in figure 1, in some parts of the narrowband spectrograms and on the sections, clear harmonics were evident with a good signal to noise ratio, while in others the signal to noise ratio was poor. nevertheless, during production of both [a:] and [i:] a sufficiently rich range of harmonics was always evident. 3. formant structure in normal phonation, the first four formants are usually clear (kerr and lanham, 1973). in m.p.'s case, the first three formants were present on most of the wideband spectrograms. however, the higher formants were noise excited. rontal et al (1975) state that clear formants depend on a lack of breathiness, normal periodicity and a good resonating system. despite the presence of breathiness and aperiodicity in m.p.'s voice, subjective analysis suggested that the resonatory system was adequate. 4. pitch range m.p. was able to achieve limited pitch variation of 34 hz. when asked to produce vowels on a series of pitches, from lowest through to highest. the highest and second highest pitched vowels he produced had a greater number of clear harmonics than the three lower pitched vowels, indicating that optimal vibratory adjustment occurred at a higher pitch. however, it required additional effort and discomfort for m.p. to raise his pitch to these levels. c. laryngographic analysis the parameters analysed were as follows: 1. lx: lx provides information concerning the mode of vibration of the vocal folds, and excludes supraglottal information. the following aspects of lx were assessed: a) regularity: in the normal larynx, the lx pattern is regularly repeated, through control of lung air pressure and laryngeal musculature (abberton, 1972). as can be seen in figure 2, m.p.'s lx behaviour was complex and highly irregular throughout the laryngogram. by contrast, the normal lx waveform represented in figure 3 is simple and completely regular, indicating a stable vibratory source. m.p.'s lx tracings exhibit gross cycle to cycle waveform changes, a condition which may be described (with a little licence) as "lx shimmer", indicating abnormal vocal fold vibration. b) shape: abberton (1972) describes three phases in the shape of a normal vibratory cycle: — a rapid closing phase (positive going), i.e. a rise in the waveform associated with the interval of greatest acoustic excitation of the vocal tract. — a slower opening phase (negative going), i.e. a decline in the waveform associated with the gradual parting of the vocal folds, as the subglottal pressure increases prior to abduction. — an open phase, i.e. a flat base corresponding to the interval when the vocal folds are out of contact and the glottis is abducted. the shape of m.p.'s lx waveform is thoroughly irregular in all these phases. given the abnormal anatomy of this case it would be unwise to speculate on the precise physiological correlates of the irregularities. however, it may safely be said that the lx tracings provide clear evidence of variability in the mass, adduction, abduction and probably tension of the vibratory source. 2. fx: fx is a display of fundamental frequency. as illustrated in the normal case in figure 3, fx takes the form of an even or smoothly varying line. throughout m.p.'s fx tracing, an abnormality, termed "jitter", was evident, i.e. small cycle to cycle pitch perturbations due to aperiodicity of the vibratory mechanism. figure 2 illustrates this. the amount of jitter and shimmer in a signal is directly related to the listener's perceptions of auditory roughness (wendahl, 1966) and in this case, the large amount of jitter and shimmer corresponded to the rough, hoarse voice quality evident in subjective evaluation. i fx lx figure 2 m.p. 's lx and fx tracings during the production of [i:]. the irregularity of the former would be produced by a highly variable vibratory source. the lack of smoothness of the fx trace reflects jitter. the south african journal of communication disorders, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) laryngeal trauma: a diagnostic case study 17 fx —• ^ ft, ft ft ft ft ft ft ft ft ft ft ft ft ft ft ft ft ft 'v ft ft ft ft ^ ft ft ft ft ft ft ft ft . >i \ \ \ \ · \ \ l > v \ \ v v \ v v : ·. \ : \ . \ ; ν ; \ \ : '< > \ \ \ · \ v v 1 \ ι i; " η ^ ^ ν η l ί u ν η ν v v η v i u u ι u ι ^ figure 3 normal lx waveform of an adult male. the simple and regular lx trace and the smooth fx trace contrast with those in figure 2. gx and lx \ • \ j rt j f^j l\ ft s a / \ w w ι gx and lx / ίκλ/' ν figure 4 two laryngographic tracings illustrating gx movements frequently observed prior to the onset of phonation (marked with an arrow). 3. gx: slower changes on the lx tracing are termed gx and they are primarily the result of gross movements of the entire larynx before, during and after phonation, brought about by the function of the extrinsic muscles. figure 4 illustrates the large gx movements that were frequently observable prior to the onset of phonation by m.p. although he does not have a normal laryngeal structure, these gx movements are precisely what could be expected from the independently observed laryngeal airway adjustments seen during lateral xerography and cinefluorography (see figure 4). d. fiberoptic analysis slides taken during fiberoptic examination were analysed descriptively at rest and during phonation, in order to determine the structural changes evident during phonation: 1. at rest figure 5 shows a clear view of one true vocal fold, both ventricular folds, the tips of the arytenoid cartilages and the cushion of the epiglottis. one ventricular fold is larger than the other, approximating the midline and obscuring one true vocal fold. slight asymmetry of the arytenoid cardie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 loren β schneider, anthony traill and lesley wolk tilages in relation to each other is evident. during examination, the left arytenoid and vocal fold appeared to be situated at a higher level than the corresponding structures on the right, confirming the findings of indirect laryngoscopy. figure 5 fiberoptic view of m.p. 's larynx taken at rest. the tips of the arytenoids are visible in the top part of the picture, one true fold and the two ventricular folds in the middle and the cushion of the epiglottis at the bottom centre. 2 during phonation of fi:] it was never possible to view the vocal folds during phonation as the rim of the epiglottis moved posteriorly, obscuring the view of the glottis, as is evident in figure 6. the posterior aspect of the arytenoids is visible below the epiglottis. during the examination, no vibration of the posterior aspect of the arytenoids was apparent during phonation. figure 6 fiberoptic view of m.p. 's larynx taken during phonation of [i:]. the rim of the epiglottis is visible in the foreground. in the background the posterior aspect of the arytenoid cartilages can be seen. the dark spot at the centre of the picture corresponds to the junction between the arytenoids. e. tomography because trauma and surgery had distorted m.p.'s laryngeal structures, conventional landmarks were missing, making it extremely difficult to estimate section depths for the tomograms. although tomograms were taken at several section depths, clarity did not result and it was not possible to reach any conclusions about the position of the vocal folds during phonation. f. lateral xerography xerograms selected for analysis were those taken at rest and during phonation. xerograms were analysed using overlay tracings, with bony landmarks as reference points. the cervical vertebrae were used as orientation points by which to align the tracings. in this case conventional grid measures were inapplicable because of the abnormal anatomy, for example, absence of the cricoid and thyroid cartilages. thus, anatomical changes were analysed descriptively, under the following parameters, selected from a list provided by berry, epstein, fourchin, freeman, maccurtain and noscoe (1982). the reader should consult figure 7 during the following discussion. structural changes between quiet respiration (solid lines) and phonation (dotted lines) in m.p. 's larynx. ι 1. epiglottis one of the major physiological changes evident between quiet respiration and phonation, was a pronounced and abnormal anterior rotation of the base of the epiglottis and a posterior tilting of its rim. although the mechanism underlying this movement cannot be stated precisely, it appears to be facilitated by the absence of the thyroid cartilage, which would normally obstruct any anterior movementof the root of the epiglottis. ' 2. hyoid bone during phonation, there was a marked displacement of the hyoid bone anteriorly. despite this anterior movement, the angle of the hyoid bone is maintained. the south african journal of communication disorders vol. 31 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) laryngeal trauma: a diagnostic case study 19 3. hypopharynx another major physiological change was an anterior and upward movement of the arytenoid cartilages towards the epiglottis, resulting in a marked expansion of the hypopharynx, both antero-posteriorly and supero-inferiorly. 4. vocal folds although the vocal folds were not clearly visible on the lateral xerograms, their presence could be inferred partly from the shape of laryngeal ventricles which were relatively distinct. two ventricles were visible, one directly above the other, suggesting that the true vocal folds were lying at different heights. this was consistent with superior displacement of the left vocal fold evident during indirect laryngoscopy and fiberoptic examination. during phonation these ventricles were elongated slightly as they moved anteriorly and slightly superiorly in consort with similar movements of the hyoid bone and arytenoid cartilages. it seems reasonable to assume, therefore, that the vocal folds also moved anteriorly and superiorly during adduction. 5. dimensions of the laryngeal airway anterior expansion of the entire laryngeal airway was evident during phonation, again in consort with the anterior movement of the other laryngeal structures mentioned. subglottally, a posterior expansion of the airway was also evident, probably due to air-pressure build-up during phonation. the most interesting physiological change from the rest position to phonation involved the articulation of the arytenoid structure relatively high up on the epiglottis. it is well known that generalisations about the precise physiology of phonation in connected speech cannot be made from lateral xerography, as this technique provides a static view. because of this m.p.'s phonatory mechanism was investigated using cinefluorography. g. cinefluorography the lateral cinefluorographioview of the larynx confirmed the postures evident on the lateral xerograms, i.e. anterior rotation of the base of the epiglottis from a vertical position at rest, through about 45° during phonation. from lateral xerography it was suspected that vibration between the rotated epiglottis and the arytenoids could have: occurred. however, the dynamic image provided by cinefluorography revealed no vibration between these structures. ! 1 / discussion the result of the xerographic and cinefluorographic investigations revealed that a number of unusual physiological adjustments were involved in m.p.'s phonatory mechanism. these included the extreme tilting of the epiglottis, the prominent expansion of the supraand subglottic airway and the hypopharynx, and the articulation of the arytenoids relatively high on the broad part of the epiglottis all undoubtedly due to the subject's abnormal anatomy. in the normal case the base of the epiglottis is attached to the inner aspect of the angle of the thyroid cartilage by the thyro-epiglottic ligament. in m.p.'s case the thyroid cartilage is missing, leaving the base of the epiglottis free to move in the anterior direction seen in figure 7. this in turn allows for an unusual rotation of the epiglottis relative to the arytenoid cartilages allowing them to articulate high up rather than at the level of the tubercle. the lack of cartilaginous support and the surgically architected airway dimensions are responsible for the expansions in the airway both suband supraglotally. the position adopted by the epiglottis during phonation prevented any laryngoscopic observation of the vibratory source. this emphasizes the contribution of x-ray techniques. however, it was possible to establish from fiberoptic examination that neither the epiglottis nor the posterior aspects of the arytenoids vibrated during phonation. it should be mentioned that this position of the epiglottis represented a clear physiological innovation in m.p.'s adductory mechanism that arose subsequent to the situation in 1979. earlier it was indeed possible to see into the larynx during phonation and to observe a narrowing of the laryngeal sphincter during attempts at phonation. the sequence of events suggests that the rotation of the epiglottis is directly involved in some way with the improved phonatory mechanism that developed. speculations as to what this role might be will be discussed at a later stage. while the x-ray data provided an invaluable perspective on these unusual physiological changes, they did not provide much useful information about the role of the vocal cords during phonation. at best they showed that the location of the cords changed during phonation and that they were probably elongated slightly as they shifted. whether the cords actually vibrated and, if so, in what manner, had to be investigated by other means, namely, spectrographically and laryngographically. the lx and fx tracings provide complementary information on the nature of the vibratory source. briefly, they show that the vibrations are irregular in terms of their periodicity and waveform. this permits the inference that there is no fine control over the vibratory source so far as bulk and tension are concerned. the complex and variable waveform shapes present a unique picture with double peaking on either the closing or opening phase. no straightforward physiological interpretation of these complexities is possible because of m.p.'s abnormal anatomy. however, double peaking normally suggests that more than one structure may be involved in the vibratory source and that these are variably present in adduction and abduction. typical candidates for this sort of complexity are the vocal cords together with the ventricular folds. in m.p.'s case this could be so, with the height discrepancies between the vocal cords adding yet another "level" to the structures involved in adduction. another structure that prima facie could be involved is the aryepiglottic adduction mechanism. indeed, the x-ray data may be readily interpreted as showing that m.p. was simply using a well-known site for the development of a pseudo-glottis (luchsinger and arnold, 1965). however, apart from the unusually high position of the adduction, this possibility does not seem likely. first, if the vibratory source is located at this ary-epiglottic sphincter, it is difficult to account for the complete lack of visible vibration of either part. neither the arytenoids nor the epiglottis could be seen to vibrate during either fiberoptic or cinefluorographic investigation. second, the location of the electrodes was not sufficiently high on the neck to detect impedance changes at the level of m.p.'s arydie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 loren β schneider, anthony traill and lesley wolk epiglottic sphincter. third, the spectrographic evidence strongly suggests that m.p.'s vibratory source was unlikely to involve the arytenoid cartilages or epiglottis. this evidence concerns the rich harmonic structure best seen on the acoustic sections in figure 1. the large number of modes of vibration (i.e. harmonics) most strongly suggests that the vocal cords are dominantly involved in m.p.'s vibratory source. there are no other laryngeal structures capable of vibrating in that many modes. while this vibratory behaviour is less than optimal, involving aperiodicity and noise, it is, nevertheless, the best evidence we have that m.p.'s cords retain the potential for complex harmonic motion. there is no independent evidence that the false cords are involved and so the double peaking on the lx waveform can be attributed to the uneven levels of the cords relative to one another and to the resulting asymmetrical adductory possibilities. we now return to the role of the physiological changes seen in figure 7. the question arises as to why these unusual supraglottal adjustments are necessary if m.p. is indeed using his true vocal cords for phonation. we suggest that they constitute m.p.'s adductory mechanism for the vocal cords in the absence of some of the parts of the normal mechanism. the fact that the changes are a pre-requisite for phonation, together with the observation that they directly affect the position of the cords on the xerograms suggests this is so. as to why the adduction mechanism should, in a sense, be so elaborate, we can only speculate that it represents a good example of transferred function in a larynx with extensive structural damage. m.p.'s control of the laryngeal sphincter is obviously not impaired and he has learnt to exercise a fine control over this highly efficient adductory mechanism in order to create conditions for vocal cord vibration. the findings of the measures carried out on this case cannot be generalised to other cases of laryngeal trauma. however, some comments concerning the use of a battery of diagnostic measures are apposite. no one measure used in this study provides a complete diagnosis on its own. rather, the value of each measure is highlighted, within the context of the battery as a whole. in evaluation of this subject, the objective analyses revealed acoustic displays of vocal parameters and the physiological mechanism responsible for phonation, and subjective analysis revealed the auditory quality of the phonation being produced by this mechanism. when m.p. was referred for further voice therapy at the end of 1982, it was clinically impossible to determine whether further therapy was indicated, and if so the nature of this therapy. it was only after a full battery of diagnostic measures was carried out, that it was possible to prognosticate. results of the investigation indicated that m.p. was in fact using the optimal phonation possible with his damaged laryngeal mechanism; a final goal for therapy (luchsinger and arnold, 1965). hence, no futher voice therapy was indicated. in conclusion, a battery of diagnostic measures (both subjective and objective measures) appears to be most valuable in the rehabilitative process of patients with vocal disorders. a dearth of research on laryngeal trauma within the realm of speech pathology exists. it is hoped that this study will promote further interest in this area. acknowledgement dr. m. said's generous assistance with the cinefluorography is gratefully acknowledged. references abberton, e. some laryngographic data for korean stops, j. int. phonetic assoc., 2, 67-78, 1972. aronson, a.e. clinical voice disorders, brian c. decker, new york, 1980. berry, r.j., epstein, r., fourcin, a.j., freeman, m., maccurtain, f. and noscoe, n. an objective analysis of voice disorders: part one, br. j. disord. commun., 17, 67-76, 1982. boone, d.r. the voice and voice therapy, prentice-hall inc., englewood cliffs, new jersey, 1977. fletcher, s.g., shelton, r.l., smith, c.c. and bosma, j.f. radiography in speech pathology, j. speech. hear. dis., 25, 135-144, 1960. fourcin, a.j. laryngoscopic examination of vocal fold vibration, in ventilatory and phonatory control systems, wyke, b. (ed.), oxford university press, london, 315-326. 1974. fry, d.b. the physics of speech, cambridge university press, 1979. kelman, a.w., gordon, m.t., morton, f.m. and simpson, i.c. comparison of methods for assessing vocal function, folia phoniatr., 33, 51-65, 1981. kerr, w. a. and lanham, l.w. anatomical and spectrographic analysis of the voice in disease: a report of five cases, journal of the south african speech and hearing association., 20, 81-107, 1973. luchsinger, r. and arnold, g.e. voice speech language, wadsworth publishing co., belmont, ca., 1965. 1 mitrinowicz-modrezjewska, v.a. posttraumatische stiminstorungen und ihre phoniatrische behandlung, folia phoniatr., 15, 15-22, 1962. i moll, k.l. cinefluorographic techniques in speech research, j. speech hear. res., 227-241, 1960. | rontal, c., rontal, m. and rolnick, m.i. objective evaluation of voice pathology using voice spectrography, ann. otol, rhinol. and laryngol., 84, 662-671, 1975. wechsler, e. laryngographic study of voice disorders, br. j. disord. commun., 12 , 9-22, 1977. wendahl, r.w. some parameters of auditory roughness, folia phoniatr., 18, 26-32, 1966. wilson, d.k. voice problems of children, the williams and wilkins co., baltimore, 1979. the south african journal of communication disorders, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) clark early language programme * carrow auditory-visual abilities test * communication training programme * fokes sentence builder * fokes sentence builder expansion * fokes written language programme * auditory discrimination in depth * developmental language lessons * developmental language stories * language rehabilitation programme * universal articulation programme * w o o d c o c k language proficiency battery * test for auditory * carrow elicited language cards * parts of speech * pea token test for children * trol therapy * remediation harty preschool speech and comprehension of language inventory * tr large picture ce-harmony-awareness * the personalized fluency conof vocal hoarseness * flulanguage screening test * here? posters * voice disoru e t h r u s t colour a n d shape posters * what's wrong here? posters * voice disorders * t h r u s t therapy * ν θ · n i l · π ί ! ΐ ι · π ϊ ΐ 1 · ι ί ΐ ] ^ β 0 α β υ ι α ρ υ c omprehensib k i t e s b j i m m i i i i j m o n scale • lindamood a b ^ ^ j μ · · · · · · · · · ^ β υ β ι τ ο ρ υ con ceptualization test * developmental syntax programme * weiss comprer e a d (pty) ltd. educational resources hensive a r t i c u l a t i o n ! a cognitive-linguist i tegy * the syntax gam γ velopmental scale * cards * pictures for language programm visual abilities test ' i ning programme * fok | fokes sentence b u i l d · written language pr indiscrimination in dep language lessons * guage stories * langu programme * univer test * infant learning ic intervention strae * birth to three des e q u e n c e p i c t u r e sounds * clark early ε * carrow auditoryicommunication trai-es sentence builder * er expansion * fokes ogramme 4 auditory ' ύ η * d e v e l o p m e n t a l developmental lana g e r e h a b i l i t a t i o n sal articulation programme * woodcock language proficiency battery * test for auditory age * r . a r r d ^ ^ ^ ^ ^ m ^ l ^ μ β β 1 e l i c i t e d language inventory * tr large picture cards ' parts of speech * peaceh a r m o n y a w ^ ^ ^ ^ ^ h w ^ i j i f t z t ^ ^ ^ ^ ^ ^ h a r e n e s s t o k e n t c z t ^ ^ ^ ^ ^ m k ^ ^ ^ w f o r c h i l d ren * personalized fluency control therapy · remediation of vocal h o a r s e n e s s ^ ^ ^ ^ r . j ι i t j f l u h a r t y p h f f i p h n n i s mi j • a n d language screening test * colour and shape posters * what's wrong here? posters * voice disorders ' tongue thrust therapy * vocabulary comprehension scale * lindamood auditory conceptualization test * dev e l o p m e n t a ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ j ^ ^ ^ ^ ^ ^ ^ ^ ^ j ^ ^ ^ ^ j ^ w p ^ ^ ^ ^ ^ ^ ^ l syntax pro gramme * comprehensive a r t i ^ h h f l y k p n m u t e st * infant l ^ ^ u u e m i u l u a c o g n i t i v e l i ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ q ^ ^ ^ ^ k h m a l j u l ^ ^ ^ ^ ^ ^ ^ l n g u i s t i c intervention strategy * the syntax game * birth to three developmental scale sequency picture cards λ pictures for sounds * clark early die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction methods results ethical considerations discussion conclusion acknowledgements references about the author(s) anél botha department of speech-language pathology and audiology, university of pretoria, south africa elizbé ras department of speech-language pathology and audiology, university of pretoria, south africa shabnam abdoola department of speech-language pathology and audiology, university of pretoria, south africa jeannie van der linde department of speech-language pathology and audiology, university of pretoria, south africa citation botha, a., ras, e., abdoola, s., & van der linde, j. (2017). dysphonia in adults with developmental stuttering: a descriptive study. south african journal of communication disorders 64(1), a347. https://doi.org/10.4102/sajcd.v64i1.347 original research dysphonia in adults with developmental stuttering: a descriptive study anél botha, elizbé ras, shabnam abdoola, jeannie van der linde received: 10 nov. 2016; accepted: 20 mar. 2017; published: 26 june 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: persons with stuttering (pws) often present with other co-occurring conditions. the world health organization’s (who) international classification of functioning, disability and health (icf) proposes that it is important to understand the full burden of a health condition. a few studies have explored voice problems among pws, and the characteristics of voices of pws are relatively unknown. the importance of conducting future research has been emphasised. objectives: this study aimed to describe the vocal characteristics of pws. method: acoustic and perceptual data were collected during a comprehensive voice assessment. the severity of stuttering was also determined. correlations between the stuttering severity instrument (ssi) and the acoustic measurements were evaluated to determine the significance. twenty participants were tested for this study. result: only two participants (10%) obtained a positive dysphonia severity index (dsi) score of 1.6 or higher, indicating that no dysphonia was present, while 90% of participants (n = 18) scored lower than 1.6, indicating that those participants presented with dysphonia. some participants presented with weakness (asthenia) of voice (35%), while 65% presented with a slightly strained voice quality. moderately positive correlations between breathiness and ssi (r = 0.40, p = 0.08) have been reported. in addition, participants with high ssi scores also scored a poor dsi of below 1.6, as observed by a moderate positive correlation between ssi and dsi (r = 0.41). conclusion: the majority of pws presented with dysphonia, evident in the perceptual or acoustic parameters of their voices. these results can be used for further investigation to create awareness and to establish intervention strategies for voice disorders among pws. introduction developmental stuttering (ds) is the most common type of stuttering, affecting approximately 1% of the adult population (watkins, smith, davis & howell, 2008). it is also a complex and multifactorial disorder as many different factors play a role (guitar, 2014). more specifically ds is related to abnormalities within the speech planning and production and auditory feedback during speech (ingham et al., 2004). during stuttering, there is abnormal functioning of the whole speech system, including the larynx (salihović, junuzović-žunić, ibrahimagić & beganović, 2009). abnormal functioning of the larynx may include excessive muscular tension and variable subglottal pressure, which could be caused by muscle incoordination of the respiratory tract. weaker laryngeal neuromuscular control and disturbances in respiratory and laryngeal control may also lead to voice problems (salihović et al., 2009). persons with stuttering (pws) often present with other co-occurring conditions such as anxiety, a low self-esteem and negative responses to their communication partners (erickson & block, 2013). these co-occurring conditions may complicate the communication process and affect the emotional well-being and quality of life of pws negatively (blood, blood, maloney, meyer & qualls, 2007). an individual’s feelings and attitudes can be as much part of the disorder of stuttering as his speech behaviours. at first, stuttering may result in unnoticeable, repetitive stuttering behaviours. as stuttering increases, feelings of frustration and shame may also increase, which result in tense and effortful speech that impede fluency (guitar, 2014). pws may have negative attitudes about themselves, which are derived from years of stuttering experiences, and they often project these attitudes on listeners. the relationship between stuttering and emotions varies among individuals who stutter. for some individuals, emotions may contribute to the aetiology of stuttering and for others, stuttering may evoke emotions such as frustration, fear and anger (guitar, 2014). a basic and powerful way to express one’s emotions and to convey messages is through the voice (frühholz, trost & grandjean, 2014). the human voice has been described as an embodiment of self in a social context, contributing to expression, perception and mutual exchange of self, consciousness, inner life and personhood (sidtis & kreiman, 2011). if pws present with negative emotions or anxiety as a result of different factors, including stuttering, it may negatively impact the voice characteristics, such as voice quality (pullin & cook, 2013). voice problems in pws may occur because of attempts to mask their stuttering by changing their pitch or volume to an inappropriate level, leading to a misuse in voice (cooper, 1979). yet, only cooper (1979) and salihović et al. (2009) have conducted studies to explore the voice quality of pws. however, few studies have explored the relationship between dysphonia and pws in the past. the world health organization’s (who) international classification of functioning, disability and health (icf) proposes that it is important to understand the full burden of a health condition. to determine the impact of the condition, information about the disorder and how it impacts the functioning of an individual needs to be determined. because only a few studies have explored voice problems in pws, the importance of conducting future research has been emphasised (salihović et al., 2009). from the gap in existing literature and the multimodality of stuttering, as well as the effect of stuttering on all the different areas of an individual’s life, the following research question is posed: what are the vocal characteristics of adults diagnosed with a developmental stutter? methods aim the study aimed to describe the vocal characteristics of adults with ds. setting and participants the study was conducted at the department of speech-language pathology and audiology, university of pretoria. a total of 20 adults who were able to speak either afrikaans or english as first or second language were selected to take part in the study. inclusion criteria required the participants to exhibit with a ds only, with no other co-occurring communication disorders. individuals who had any known speech, language, hearing disorders or syndromes, apart from stuttering, were excluded from the study. the participants had to be between the age of 18 and 60 years. anatomical and physiological changes of the vocal folds occur as individuals age and affect the acoustic output of the voice (xue & deliyski, 2001). therefore, participants over the age of 60 were excluded from this study. participants also had to be non-smokers as smoking has an evident effect on some acoustic voice parameters (banjara, mungutwar, singh & gupta, 2014). description of participants case histories indicated that all 20 participants were diagnosed with ds during their preschool years and have previously received or are still receiving stuttering therapy. none of the participants have been diagnosed with a voice disorder or are receiving voice therapy. the study included 7 (35%) women and 13 (65%) men. the average age of participants were 23.5 years (s.d. = 4.95). the home language distribution included 30% (n = 6) english, 25% (n = 5) afrikaans, 20% (n = 4) sepedi, 10% (n = 2) setswana and isizulu and 5% (n = 1) sesotho speakers. approximately a third (35%) of the participants reported to have an average daily intake of carbonated drinks of one to two cups per day and 10% an average intake of three to four cups per day. a few participants (10%) reported an alcohol consumption of one to two glasses per week, and only 5% indicated that they consume three to four glasses per week. only one participant reported to take anti-histamines for allergy-related conditions, and one participant zalascopyrin and celebrex for juvenile arthritis. five participants (25%) indicated that they regularly experienced symptoms of sinusitis. one participant (5%) reported endocrine illness and one (5%) presented with oesophageal reflux. participant 4 and participant 19 indicated that they had experienced a change in their voice quality over time, with participant 4 experiencing a weakness in the voice and participant 19 experiencing hoarseness. however, no voice problems were diagnosed in any of the participants, and they were not receiving treatment for their voice symptoms. voice and speech assessment protocol background questionnaire the background questionnaire consisted of questions about the participant’s background history as well as questions related to their voice and stuttering experiences. demographic information such as the participant’s language, race and marital status was also obtained through the questionnaire. the questionnaire used in the study by van wyk et al. (2016) was used as a guide to the questions used. acoustic voice analysis the computerized speech lab 4300 hardware system was used for the analysis and feedback of acoustic measurements. a comprehensive voice analysis was conducted by using the multi-dimensional voice program and the voice range profile software packages (kaypentax, 2008) to evaluate the voice quality of the participants. the parameters that were assessed included the jitter, shimmer, highest frequency, lowest intensity, noise-to-harmonics ratio and the fundamental frequency values of a phonated/a/sound (table 1). the voice range profile displays the vocal intensity range versus fundamental frequency (f0). table 1: description of acoustic parameters. the dysphonia severity index (dsi) is an index used to create an objective and quantitative link of the perceived voice quality. the dsi is an objective measure as no perceptual analysis is necessary to determine the index. the dsi ranges from +5 (i.e. no dysphonia are present) to -5 (i.e. a severely dysphonic voice). the smaller the dsi, the greater the severity of the dysphonia. while normal voice quality is evident when a positive dsi (1.6 and higher) is obtained (wuyts et al., 2000), the voice measurements that are used to calculate the dsi include the lowest intensity (i-low in db), highest frequency (f0-high in hz), maximum phonation time (mpt in seconds) and the jitter (%), (see equation 1): perceptual voice and speech analysis the perceptual voice and speech analysis of the clients was conducted through the analysis of a spontaneous speech sample and a recorded speech sample of the participants’ voices. the recordings were obtained through the participants who read either an afrikaans or english passage [na die wildtuin/rainbow passage (fairbanks, 1960)]. the instruments that were used included the grade of hoarseness, roughness, breathiness, asthenia, strain and instability (grbasi) 4-point scale (yamauchi, imaizumi, maruyama & haji, 2010) and the stuttering severity instrument (ssi-4; riley, 2009). the grbasi perceptual rating scale was recommended by the japanese society of logopedics and phoniatrics and the european research group for the use in clinical and research settings (yamauchi et al., 2010). the ssi-4 was used to determine the frequency, duration, physical concomitants and the severity of stuttering. based on these parameters, the ssi was determined as very mild, mild, moderate, severe or very severe (riley, 2009). a speech sample that was recorded during the voice assessment was used to determine the severity of stuttering. the ratings were performed after the voice assessment. a listener panel, consisting of three listeners, took part in the perceptual analysis. to increase the reliability and validity of the perceptual analysis, a blind rating was performed by the three listeners. all three listeners had normal hearing and were student researchers. voice handicap index the voice handicap index (vhi) measures the influence of voice problems on a patient’s quality of life. (maertens & de jong, 2007). the vhi is a 30-item self-administered questionnaire (subjective rating scale) that required from the participants to describe their voice and the effects of their voice on their life. the vhi consists of three subscales, which cover the areas of functional, emotional and physical aspects of voice disorders. the vhi was scored after the assessment by the researchers. the overall score was interpreted as mild, moderate or severe. data analysis: all data were analysed by means of descriptive statistics by using statistical software (stata). correlations between the ssi and the acoustic measurements, including the strength and direction (negative or positive) of a relationship between two variables, were evaluated using spearman’s rank correlation coefficients. correlations between the variables of 0.2 ≤ 0.39 were classified weak; 0.4 ≤ 0.59 were moderate; 0.6 ≤ 0.79 were strong; and 0.8 ≤ 1.0 were very strong (mukaka, 2012). pearson’s correlation coefficients were calculated between normal distributed variables, and the non-parametric spearman’s rank correlation coefficients for correlation between the non-normal variables. spearman’s rank and, where appropriate, point bi-serial correlation values were determined between ssi, dsi, vhi and the demographic variables. chi-squared tests were used to identify significant associations at 5% and 10% significance level between the categorical demographic variables, grbasi scores and ssi categories. results the stuttering severity of participants (n = 20) is depicted in table 2. the majority, 75% (n = 15), of participants presented with a very mild stutter, while only 10% (n = 2) presented with a severe stutter. the type of stuttering observed in participants consisted of syllable repetitions, 70% (n = 14), prolongations, 55% (n = 11), blocks, 55% (n = 11), and avoidance of words, 40% (n = 8). the estimated duration of the blocks in 40% (n = 8) of the participants was between 2 and 9 s, one full second in 25% (n = 5) of the participants and the remaining 35% (n = 7) presented with estimated duration of less than 1 s. no physical concomitants were observed in 65% (n = 13) of participants during moments of stuttering. however, very distracting sounds were observed in 15% (n = 3) of participants, distracting facial grimaces in 20% (n = 4) of participants and very distracting head movements in 20% (n = 4) of the participants. table 2: description of stuttering severity of participants (n = 20) according to the stuttering severity instrument. the vocal characteristics of the participants are presented according to perceptual analysis of voice, acoustic voice analysis and self-rating on the vhi. the consensus score across the grbasi scale (table 3) indicated that the perceptual results of many of the participants deviate from normal voice quality. some participants presented with a slight weakness (asthenia) of voice (35%), while the majority of participants (65%) presented with a slightly strained voice quality. table 3: consensus scores of participants (n = 20) across grade of hoarseness, roughness, breathiness, asthenia, strain and instability scale. in table 4 the results of the acoustic voice analysis are presented. the median and interquartile ranges (iqrs) are compared to the expected norms for each acoustic outcome and the correlations between them. table 4: acoustic analysis: descriptive statistics and norms. the jitter (p < 0.001), maximum frequency (p < 0.001), minimum intensity (p < 0.001), mpt (p = 0.001) and the dsi (p < 0.001) all presented with significant differences between the recorded medians and the norms. the shimmer, minimum frequency, maximum intensity and the s–z ratio are the only measurements whose medians fall within the norm or are relatively close to the norm. the median minimum intensity (65 db) is significantly louder than the norm of 40 db. the mpt is significantly lower than the norm of 20 s, indicating that most participants were not able to phonate the/a/sound for 20 s or more. only 15% of the participants were able to sustain phonation of the/a/sound for 20 s or more. the dsi results also indicated a significantly lower score when compared to the norm, indicating a moderate dysphonia in the participants. only two participants (10%) obtained a dsi score of 1.6 or higher while 90% (n = 18) of participants scored lower than 1.6. according to the self-rating of the vhi, 40% (n = 8) of the participants scored between 0 and 30 on the vhi, indicating a low level score. the majority of participants, 55% (n = 11), scored between 31 and 60, indicating a moderate level of handicap and only 5% (n = 1) greater than 60 points, indicating a severe level of handicap. the statements shown in table 5 were extracted from the vhi and represent the statements that received the highest scores from participants. table 5: voice handicap index statements with highest self-rating scores by participants (n = 20). in this study, participants with high ssi scores, also scored a poor dsi of below 1.6, as observed by a moderate positive correlation between ssi and dsi (r = 0.41). although the correlations given in table 6 are not all statistically significant, the directions of the correlations are of clinical significance. the jitter (r = -0.62) displayed a moderate to strong negative correlation with the dsi, implying that participants who scored poorly on this parameter also scored lower than 1.6 on the dsi. in contrast, maximum frequency (r = 0.40) showed a positive relationship with the dsi, indicating that participants with a maximum frequency showed lower than the norm also scored lower than 1.6 on the dsi. table 6: acoustic outcomes and correlations between the stuttering severity instrument, dysphonia severity index and voice handicap index and acoustic variables. spearman’s rank correlation coefficients were calculated for the grbasi scales and ssi, dsi, vhi and participant characteristics (table 7). moderate positive correlation was observed between breathiness and ssi (r = 0.40; p = 0.08). a moderate positive correlation between oesophageal reflux and vhi was noted (r = 0.45; p = 0.05), indicating that the participant with oesophageal reflux scored higher on the vhi. significant differences were observed between home language and the asthenia score (p = 0.024). it appears that sepedi and setswana speakers obtained a weaker rating of 1, compared to english and afrikaans speakers who were rated 0 for asthenia. further significant associations were observed between the strain score and weekly alcohol consumption (p = 0.042), as well as daily consumption of carbonated drinks (p = 0.022). the higher the daily consumption of alcohol and carbonated drinks, the higher is the perceived strain in voicing. no other significant associations between the perceptual evaluations and gender, marital status, medical history and excessive shouting were observed in this study. table 7: correlations between the stuttering severity instrument, dysphonia severity index and voice handicap index and grade of hoarseness, roughness, breathiness, asthenia, strain and instability scale. ethical considerations ethical clearance was obtained from the research ethics committee, department speech language pathology and audiology, university of pretoria, prior to data collection, with ethics clearance number: 2016/13024753/04498063/13042964. once written informed consent was provided, the comprehensive voice and speech assessment protocol was conducted. discussion the severity of ds in the current study ranged between very mild to moderate. supporting the outcomes of the current study, a previous study reported a mean stuttering severity in the mild to moderate range (blumgart, craig & tran, 2010). the perceptual analysis of voice has shown moderately positive correlations between breathiness and ssi (p = 0.08). during the reading activity and spontaneous speech sample, 25% of the participants displayed a breathy voice quality. a breathy voice is characterised by air loss through loosely or hypo-adducted vocal folds (ferrand, 2012). breathiness is often accompanied by low vocal intensity and a lower than optimum fundamental frequency level (ferrand, 2012). speech-language therapists often recommend the use of the easy voice onset technique to pws. if pws utilise this technique, they will not adduct their vocal folds as forcefully; therefore, an increased breathy voice quality may be audible (adler, hirsch & mordaunt, 2006). interestingly, the acoustic analysis of voice rendered significantly different mean values for jitter (p ≤ 0.001), maximum frequency (p ≤ 0.001), minimum intensity (p ≤ 0.001), mpt (p = 0.001) and the dsi (p ≤ 0.001) when compared to the norms. the study also indicated that a higher ssi score resulted in a higher dsi score (r = 0.41, p = 0.08). most participants were not able to sustain voicing for 20 s or more. mpt is often reduced in individuals with dysphonia (ferrand, 2012). the reduced mpt may emphasise the fact that the pws may struggle with prolongations of sounds and present with more dysphonic voices (bogaardt, speyer & zumach, 2008). reduced mpt also indicates decreased efficiency of the respiratory mechanism during phonation, causing inefficient use of air in pws (bogaardt et al., 2008). an interesting and unexpected finding was the significant difference between the norms and maximum frequency and minimum intensity and this should be explored in future research. poor jitter values were associated with a poorer dsi and higher vhi score. the jitter may be affected mainly because of lack of control of vocal fold vibration, in the moments of stuttering which may result in the presence of noise at emission and breathiness of the voice (amaro, schreiber & wertzner, 2005). participants who scored higher in the vhi also had a higher asthenia rating in the grbasi scale. asthenia refers to the degree of weakness of the voice. the weakness of the voice can be caused by an overuse of voice or using the voice ineffectively (ferrand, 2012). the pws may change the way they use their voice to compensate for the emotions, anxiety and stuttering symptoms experienced (guitar, 2014). the demographic variances have shown some significant differences between home language and the asthenia score (p = 0.024). it appears that sepedi and setswana speakers obtained a weaker rating of 1, compared to english and afrikaans speakers who were rated 0 for asthenia. a study by boyer and zsiga (2013) has indicated that depending on the geographical area, many of the setswana speakers who participated in their study reported to have post-nasal devoicing. the devoicing of some sounds in the african languages may have contributed to the weaker asthenia ratings. devoicing of sounds might also be interpreted as a weak voice (pinho, jesus & barney, 2009). a noteworthy association between a higher daily consumption of alcohol (p = 0.042) and carbonated drinks (p = 0.022) and higher perceived strain in voicing, was found. the use of excessive alcohol causes dehydration of the vocal folds and may also lead to irritation of the mucous membranes that line the throat (ferrand, 2012). a study by baek and bae (2013a, 2013b) also stated that the use of alcohol can reduce the flexibility and elasticity of the mucosa tissue of the vocal cords. as a result incomplete opening or closure of the glottis reduces clarity of the speaker’s pronunciation because of the air leak when speaking after drinking (geumran & muyungjin, 2013). this study is one of few studies that investigated the vocal characteristics of pws. this explorative study was conducted to identify whether an experimental study is warranted. it is therefore recommended that future research should use an experimental research design on a larger sample size, including a control group that are age and gender matched. further research should also be conducted in the paediatric population as a means to prevent voice disorders in pws by creating awareness and establishing good vocal habits. conclusion a few studies have explored voice problems in pws, and the characteristics of voices of pws are relatively unknown. the who’s icf proposes that it is important to understand the full burden of a health condition. because of limited research in this area and the importance and extent to which stuttering affects a person, the aim was to describe the acoustic and perceptual parameters of voice quality in adults with ds. results obtained from this study indicated that a higher ssi score resulted in a poorer dsi score. it has been found in the current study that the majority of pws presented with dysphonia. further investigation is warranted to establish prevention and intervention of voice disorders in pws. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions a.b. performed the collection of data and organisation of data collection venues and equipment and played a lead role in data analysis and writing of the article. e.r. performed the collection of data, organisation of data collection venues and equipment and writing of the article. j.l. provided guidance on data collection, data analysis and writing of the article, organisation of data collection venues and equipment. s.a. provided guidance on data collection and writing of the article, organisation of data collection venues and equipment. references adler, r.k., hirsch, s., & mordaunt, m. 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(2010). perceptual evaluation of pathological voice quality: a comparative analysis between the rasati and grbasi scales. logopedics phoniatrics vocology, 35, 121–128. https://doi.org/10.3109/14015430903334269 normal acoustic reflex amplitude growth and the influence of cochlear hearing loss juliette womersley b.sc(log) (cape town) lucille dickens b(log) (pretoria) department of logopaedics, university of cape town abstract the nature of acoustic reflex amplitude (ara) growth at ikhz and 2khz was investigated in normal hearing and cochlear disordered subjects subdivided into meniere's disease and heterogeneous pathology groups. statistical and graphical analyses revealed significant inter-group variation in ara growth rate. the normal and meniere's groups behaved similarly, while the heterogeneous group demonstrated a faster ara growth rate. the differential sensitivity of various measurement methods was examined. explanations were put forward to account for variability in ara data amongst cochlear disordered subjects. it was concluded that the clinical sensitivity of ara measurement was questionable. opsomming die toename van die akoestiese refleks amplitude (ara) by ikhz en 2khz is in normaalhorendes en proejpersone met kogliere letsels ondersoek. laasgenoemde is in meniere se siekte en groepe met 'n heterogene patologie onderverdeel. 'n betekenisvolle variasie tussen groepe m. b. t. die ara-groeitempo is d. m. v. statistiese en graflese analises bevind. ooreenkomste tussen die normale en die meniere se groepe is aangetref terwyl daar 'n toename in die ara-groeitempo van die heterogene groep was. verder is die sensitiwiteitsverskil van verskeie metingsmetodes ondersoek. ten einde die veranderlikheid in ara-data~tussen proefpersone met kogliere letsels te verantwoord, is verskeie verklarings gebied. die gevolgtrekking is gemaak dat die kliniese sensitiwiteit van die ara-meting bevraagteken is. the role of acoustic reflex measurement in determining the nature of sensori-neural hearing loss has been well established. traditionally the acoustic reflex threshold test, a static measure, and the reflex decay test, a dynamic temporal measure, are employed for this purpose (jerger, 1975). measurement of other dynamic properties such as amplitude and latency has not yet achieved the same clinical status. borg (1976) however, stated that such properties may contribute significantly to clinical diagnosis in impedance audiometry if they are proven to be pathology sensitive. acoustic reflex amplitude (ara) is defined as the change in acoustic impedance between quiescent and reflexive states. ara is intensity dependent: for pure tone stimulation it has a dynamic range of 20-30 db, representing the intensity range over which the reflex shows an amplitude growth (wilson and mcbride, 1978). the nature of ara growth in normal subjects has been variably reported in the literature. uliel (1980) and clemis and sarno (1980) reported a linear function while several other investigators have reported a curvilinear function (dallos, 1964; sprague, wiley and block, 1981; wilson and mcbride, 1978). inter-study variability in the description of normal ara growth could have resulted from a nonstandardised basis of amplitude measurement; sensation level (sl) versus hearing level (hl) measurement methods. sprague et al. (1981) employed both sl and hl in their data analysis and demonstrated an ara configuration difference accordingly. this lack of agreement between researchers is also evident in the literature on ara in the cochlear hearing loss population. uliel (1980) investigated an ascending-descending ara function in normal and cochlear disordered subjects, by hl measurement. the growth pattern characteristic of cochlear disordered subjects without concomitant loudness recruitment was similar to that of the normal group. in contrast, cochlear disordered subjects with concomitant loudness recruitment demonstrated a faster than normal © sasha 1985 amplitude growth. an increased growth rate was also repeatedly observed by clemis and sarno (1980) in meniere's disease subjects, at ikhz and 2khz. in contrast with these findings, petersen and liden (1972) and beedie and harford (1973) reported a slower growth rate in pathological ears of variable cochlear etiology, than in normal ears. both uliel (1980) and beedle and harford (1973) specifically investigated ears with loudness recruitment and thus the discrepancy in their respective findings is particularly notable. a further confusion is that jerger and hayes (1983) reported an abnormally slow growth rate to be characteristic of a retrocochlear group. these discrepancies indicate that the influence of cochlear pathology on ara has not been unequivocally established. furthermore, since uliel (1980) did not find an abnormal growth rate to be characteristic of alljcochlear disordered subjects, it is logical to suspect that the influence of cochlear disorder on ara might vary as a function of pathology. the need for further research on ara in the cochlear population is clear. however, results cannot be classified validly as "faster" or "slower" than normal, until "normal" growth has been unequivocally defined. further investigation in to the shape of the ara growth function in normal subjects is therefore also necessary. methodology aims the amplitude growth of the acoustic reflex was investigated at ikhz and 2khz, in normal hearing and cochlear disordered subjects with the aim of 1. describing the configuration of the ara growth function in normal hearing subjects for various measurement methods, namely: hl, sl, δ hl, and δ sl; the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) normal acoustic reflex amplitude growth and the influence of cochlear hearing loss 59 2. investigating the influence of cochlear dysfunction on the ara growth function. specifically, to investigate ara in a group of meniere's disease subjects, and a group of subjects with variable cochlear etiology, excluding meniere's disease; 3. examining the variable sensitivity of different measurement methods in distinguishing between the normal and pathological subject groups. subjects the subject sample in this investigation comprised three groups: a control group (a) of 16 normal hearing subjects (mean age 24 years; 38 test ears), an experimental group (b) of six subjects with meniere's disease (mean age 38 years; six test ears), and a further experimental group (c) of four subjects with variable cochlear etiology, excluding meniere's disease, (mean age 40 years, six test ears). this age limit of 20-50 years was imposed since ara data has been shown to be relatively stable across this age range (osterhammel and osterhammel, 1979). both sexes were represented. subjects were selected on the basis of case-history findings and audiologic results obtained by the author from a battery comprising pure tone air and bone conduction audiometry, impedance audiometry, the metz recruitment and rosenburg tone decay tests. table 1 summarises the specific criteria according to which subjects were differentiated into groups a, β and c. equipment a madsen electro-acoustic impedance audiometer (model z073a) which delivered a 220 hz probe tone was used. this was calibrated according to standards set out in iec publication 318. a hewlett packard moseley x-y plotter (model 7035a) was connected to the impedance meter. the x-axis was activated by depression of the pure tone stimulus interrupter switch on the impedance meter, resulting in a time-locked 2 second excursion. presentation of the 250 msec stimulus followed automatically but not immediately, allowing a baseline to be plotted before reflex elicitation. the impedance meter was set at sensitivity 2 and the range of the y-axis was calibrated such that 0.05 cc = 0.04 mv = 1 mm on the chart paper. an acoustic reflex was recorded as a relative deflection from the baseline, representing an increase in input impedance (refer to figure 1). experimental procedure tympanometry was performed on each test ear prior to experimental testing in order to determine the point of maximum compliance. the acoustic reflex testing was conducted by the contralateral stimulus mode at lkhz and 2khz. the starting point for stimulus intensity was subject specific: testing began at reflex threshold and table 1 summary of specific criteria for subject selection and grouping group a group β group c detailed case-history negative history of hearing difficulty, ear pathology, otologic surgery, noise exposure and ototoxic drug intake. positive history of cochlear sensori neural hearing loss, negative history of middle ear pathology and surgery, noise exposure, acoustic trauma, and ototoxic drug intake. positive history of meniere's disease and associated symptomatology, confirmed by an e.n.t. specialist. positive history of cochlear sensori-neural hearing loss, negative history of middle ear pathology and otologic surgery and meniere's disease. hearing thresholds no poorer than 25 db. no air-bone gap. between 25-75 db at speech frequencies. no air-bone gap. between 25-75 db at speech frequencies. no air-bone gap. tympanometry type-a tympanogram to rule out the presence of middle ear disorders. type-a tympanogram to rule out the presence of middle ear disorders. type-a tympanogram to rule out the presence of middle ear disorders. static compliance 0.55cc-1.5cc. ; 0.5cc-1.55cc. 0.5cc-1.5cc. reflex thresholds between 70-100 db at all frequencies. between 70-100 db at lkhz and 2khz, contralateral^. between 70-100 db at lkhz and 2khz, contralaterally. supra-threshold dynamic range minimum of 25 dbhl to allow for sufficient ara growth. minimum of 25 dbhl to allow for sufficient ara growth. minimum of 25 dbhl to allow for sufficient ara growth. metz test negative. positive: arsl < 60 db. arsl < 60 db. tone decay test — negative. negative. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 juliette womersley and lucille dickens ν ό d "5. ε, < φ cc u> 3 ο o < mv 0.04 mv = 1 mm 2 sec. excursion reflex amplitude figure 1 a sample reflex response at 95 dbhl, illustrating the configuration of reflex amplitude, a = interrupter switch depression: the distance between a and b represents the baseline before reflex elecitation. proceeded in 5 db increments up to 125 dbhl. in this manner a series of graphical figures (refer to figure 1) were obtained representing reflex amplitude at consecutive stimulus levels, for each test ear at both frequencies. analysis of results the graphical figures represented the raw data. the amplitude of each reflex was established by calculating the millimetre measurement from the lowest point of the positive deflection to the highest point representing the maximal increase in input impedance. millimetre measurements were converted to mv's according to the scale — 1 mm = 0.04 mv. mv scores used in data analysis were restricted to those at hearing levels (hl) and sensation levels (sl) at which a reflex response was common to all test ears. data were also tabulated separately for those normal subjects who demonstrated the broadest dynamic range of amplitude growth, thus forming a subgroup of the normal sample. the following analyses were performed: 1. graphical analysis mean ara functions for the three subject groups were graphically displayed with the aim of examining the influence of subject group and measurement method variables on the configuration of these functions. data for the subgroup of normal subjects was graphically displayed so as to examine the effect of dynamic range on function configuration. 2 . slope index measurement slope index values were calculated for each graphical figure, based either on the whole hl or sl stimulus range (100-125 dbhl or 0-25 dbsl) or based only on the final two hl or sl increments (120-125 dbhl or 20-25 dbsl); thus observed differences in overall or 'tail-end' function configurations could be quantified. ' 3 . statistical analysis the two-way analysis of variance statistic, with repeated measures on β (2-anova-rb), was used to establish whether a significant interaction existed between subject group (variable a) and stimulus level (variable b). the simple main effects (sme) and tukey's honestly significant difference (hsd) statistics were used to quantify further the variation in ara between subject groups at specific stimulus levels. all hl and sl data at lkhz and 2khz were converted to δ hl and δ sl data, by computing the mv difference between scores at consecutive stimulus levels. this data was analysed graphically with the aim of examining the influence of δ hl and δ sl measurement methods on inter-group trends. results and discussion normals the graphical representation of data from 38 test ears at lkhz and 2khz, over a 100-125 dbhl range and a 0-25 dbsl range, revealed that the nature of ara growth was neither mathematically linear or curvilinear (refer to figure 2). this finding contrasts with the relevant literature which has variably reported ara configurations in normal subject groups to be exactly linear (uliel, 1980; clemis and sarno, 1980) or curvilinear (dallos, 1964; sprague et al., 1981; wilson and mcbride, 1978). it is possible that this discrepancy between present and other research findings is a function of the small sample size and considerable variability in function configurations, that characterised this study. mv ν •ό q. ε < x φ φ cc ο ο < key χ = hl,1khz ο = sl,1khz • = hl,2khz δ = sl,2khz _ ι _ 100 105 10 15 db sl 110 115 db hl 20 25 120 125 figure 2 ara functions for normal subjects at lkhz and 2 khz for hl and sl data / the differential effect of measurement method on ara configuration was visually evident at 2khz but not at lkhz (refer figure 2). there was no difference between the hl-sl configurations at lkhz, whereas at 2khz an asymptotic function was characteristic of the sl but not the hl function. ^ the obtained 'tail-end' slope index values were as follows: hl 0.3 mv (lkhz) sl 0.3 mv (lkhz) hl 0.5 mv (2khz) / s l o.'l mv (2khz) these values substantiated the graphical findings: while there was no difference between the hl and sl values at lkhz, the sl index the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) normal acoustic reflex amplitude growth and the influence of cochlear hearing loss 61 mv ν ό "5. ε < x φ φ cc ο ΰ ) 3 ο ο < 30 dbsl 100-125 dbhl ° key: χ = 1 khz ο = 2κηζ _l _l _ l _l _1_ _ l 85 95 105 db hl 115 125 figure 3 a complete ara function for a sample of 10 normal subjects, with super imposed hl and sl ranges, at ikhz and 2khz at 2khz was reduced relative to the hl value, indicating an asymptotic function. this hl-sl configuration difference is in keeping with the findings of sprague et al (1981), and requires an explanation particularly in view of it's frequency selectively in this study. figure 3 illustrates an ara function for the subgroup of normal subjects who demonstrated a broad dynamic range (85-125 dbhl) at ikhz and 2khz. the superimposition of hl and sl ranges on the graphical figures reveals that the differences'in function configuration description (such as asymptotic versus non-asymptotic) can result from anal y s e s ^ different portions of a wide intensity range. this possibly explains discrepancy in descriptions reported in the literature: linear versus curvilinear. figure 3 illustrates further that the absence of an asymptotic sl function at ikhz was simply a function of the breadth of dynamic range underi investigation, namely 25 dbsl; an asymptotic function would have resulted had a 30 dbsl range been investigated. considerable variability was found in the rate and pattern of ara growth amongst normal subjects. this inter-subject variability was pronounced for hl measurement and relatively reduced for sl measurement, in keeping with the findings of petersen and linden (1972). a broad range of normal variability might obscure the clinical identification of mild or even moderate pathological deviance, and therefore it is implied that sl measurement offers a better prognosis for clinical sensitivity in ara testing, than hl measurement, by reducing this range. inter-group comparisons graphical representation of the function configurations for groups a, b, and c, for sl data at ikhz and 2khz revealed a marked trend; group c demonstrated a visually steeper ara function (faster ara growth rate), while groups a and β were similar regardless of stimulus parameters (refer to figures 4 and 5). this trend was also characteristic of hl data, at 1 and 2khz, although less pronounced. whole slope index values quantified and confirmed these findings: the highest values were consistently obtained for group c, indicating a faster ara growth rate in this group than in either groups a or β (refer to table 2). mv φ •ό α . ε < φ cc 3 ο ϋ < key χ = group α ο = group β δ = group c 15 20 25 0 5 10 db sl figure 4 ara functions at ikhz, for sl data, showing inter-group growth rate trends mv 5 key x = group a ο = group β δ = group c φ • σ 3 t 3 ε < χ φ φ cc • i 2 ο ο < 1 ' 5 10 15 20 25 db sl figure 5 ara functions at 2khz, for sl data, showing inter-group growth rate trends die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 juliette womersley and lucille dickens table 2 whole-slope index mv values for groups a, β and c group hl, 1 khz sl, 1 khz a 0,4 0,4 β 0,3 0,5 c 0,6 0,8 hl, 2 khz sl, 2 khz a 0,3 0,4 β 0,3 0,5 c 0,8 0,8 the 2-anova-rb statistic for hl and sl measurement at ikhz and 2khz, yielded significant f-ratio values (p<0.01, and ρ <0.05 for sl data at 2khz). the sme statistic indicated that significant variation within all subjects (variable a collapsed), existed at specific stimulus levels for ikhz and 2khz, these levels being more numerous for sl than hl data, and for 1 khz and 2 khz data. these findings suggest that the 1 khz stimulus and the sl measurement method were more sensitive to inter-subject variation, and therefore have greater potential clinical value. the tukey's t-test results quantified inter-group variability at the specific stimulus levels identified by the sme statistic. the similarity between groups a and β suggested by graphical and slope index analyses was confirmed: tukey's t values in the group a group β comparison never reached statistical significance. in contrast statistical significance was revealed in the group c — group a, and group c — group β comparisons, but only at specific stimulus levels. these statistical results suggest that the label of a 'faster than normal ara growth rate' in group c, is only valid at specific stimulus levels. the discussion that follows however, is based on overall trends of inter-group comparisons, since the implications arising from statistical analyses on a small subject sample may be misleading. the finding of a faster than normal ara growth rate in the heterogeneous pathology group (c) agrees with the research of clemis and sarno (1980) who found this to be characteristic of cochlear disordered subjects, but is contrary to the findings of petersen and liden (1972) and beedle and harford (1973) who found a slower growth rate in cochlear disordered subjects. the similarity in growth rate between groups a and β was unexpected since clemis and sarno (1980) repeatedly observed a faster than normal ara growth rate in meniere's disease subjects, as did sprague et al. (1981) in a single case of meniere's disease. the dissimilarity in ara growth rate between groups β and c was surprising in view of their common lineage both groups belonged to the cochlear population. this dissimilarity raises two issues for •discussion: firstly, the variability in ara data within the cochlear population requires an explanation, and secondly, the interpretation or meaning of a faster than normal ara growth rate must be questioned. clearly, a faster than normal ara growth rate cannot be interpreted as being indicative of cochlear pathology since subjects in the population have also yielded a slower than normal ara growth rate (petersen and liden, 1972) and a normal growth rate as shown in this study. the term 'recruitment' has been used by uliel (1980) and clemis and sarno (1980) in association with a faster than normal ara growth rate. the use of this term in this context does not agree with other research. beedle and harford (1973) specifically investigated cochlear subjects with concomitant loudness recruitment and found a slower ara growth rate. furthermore, in this study all experimental subjects demonstrated loudness recruitment on the metz test, however only those subjects in group c yielded the faster ara growth rate. an alternative interpretation of intra-cochlear variability and a faster ara growth rate, is based on the relationship between cochlear pathology and the neurological basis of the ara response system. evans (1982) states that damage to a cochlear fibre causes a broadening of its frequency threshold curve and a consequent increase in the rate at which adjacent cochlear fibres become activated as a function of increasing stimulus intensity. if this is an acceptable explanation of a faster ara growth rate, then it is implied that cochlear fibre functioning in the meniere's disease group was normal, since this group yielded an ara growth rate mapping that of normal subjects. no definitive statements can be made regarding the differential effect of cochlear pathology on hair cell morphology in groups β and c, however, the variability in state and stage of disease that is characteristic of meniere's disease patients (brackman, selters and don, 1982) may be of significance when contrasted with the profile of subjects in group c, all of whom reported a minimum 10 year history of bilateral hearing loss with no fluctuating symptomatology. it would be of interest in future research to specifically compare a group of subjects with known hair cell damage, with a group of 'early' stage meniere's disease patients who had shown symptom-reversability on glycerol testing (thus suggesting no permanent hair cell damage). audiogram configuration is another variable which may have contributed to the dissimilarity between groups β and c. five of the six meniere's subjects showed predominantly low frequency hearing loss whereas this was not characteristic of subjects in group c. future research may reveal that lower test frequencies (below ikhz) are more sensitive to meniere's disease and therefore elicit a faster ara growth rate in these subjects. mv 1.25 1.00 <1) t3 3 ε 0.75 < x α> α> a 0.50 ο <0 ο ο < 0.25 100-105 110-115 120-125 db δ hl χ ' figure 6 ara functions for δ hl data at 1 khz, illustrating the ascending-descending configuration similarity between groups β and c, relative to group a the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) normal acoustic reflex amplitude growth and the influence of cochlear hearing loss 63 these explanations put forward to account for intra-cochlear variability are tentative owing to the use of small sample sizes, and particularly in view of the degree of normal variability in ara data in this study. graphical analyses of δ hl and δ sl data suggested that groups β and c behaved similarly, in contrast with the trend revealed by hl and sl data (refer figure 6). this similarity manifested itself in an ascending-descending configuration which was riot characteristic of group a. the meaning of this configuration is not certain, however the implication is that δ hl and δ sl measurement methods were more successful than all other methods in distinguishing between normal and cochlear subjects per se. in view of this implication, it is possible that the intra-cochlear variability in this study was a deceptive consequence of measurement method and not a real phenomenon. this does not alter the intra-cochlear variability found within uliel's (1980) study and between other studies (clemis and sarno, 1980; petersen and liden, 1972; beedle and harford, 1973), which remains worthy of note and is as yet not successfully accounted for. conclusions the configuration of ara growth functions obtained for normal hearing subjects were shown to be influenced by the method of ara measurement, namely hl versus sl measurement. this variable determined which area of dynamic range of amplitude growth was analysed, and consequently determined the asymptotic versus nonasymptotic configuration difference. the same variable may also account for discrepancies in ara configuration description in the literature. if this hypothesis is correct then the implication is that a standardised methodological basis for ara is required, because without reliable normative data the relative influence of hearing impairment cannot be successfully determined. on the basis of hl and sl measurement methods, the meniere's disease group yielded an ara growth rate similar to that of normal subjects, while the heterogeneous pathology group showed a faster than normal ara growth rate. this intra-cochlear variability has also been found in other studies and suggests that ara measurement has a poor prognosis for-clinical sensitivity. this is implied since'faster than normal ara growth rate (positive result) might indicate cochlear disorder but a negative test result would not contraindicate cochlear disorder. δ hl and δ sl measurement methods distinguished, to a certain extent, between the normal and cochlear disordered subjects per se, and therefore offer a better prognosis for test sensitivity than either the hl or sl methods. it could be the purpose of future research, therefore, to examine and compare these and other alternative measurement methods with the aim of improving clinical sensitivity to the degree that would be necessary if ara measurement was to be included in the impedance audiometry test battery. references beedle, r.k., and harford, e.r. comparison of the acoustic reflex and loudness growth in normal and pathological ears. j. speech hear. res., 16, 271-281, 1973. borg, e. dynamic characteristics of the intra-aural muscle reflex. in acoustic impedance and admittance — the measurement of middle ear function. feldman, α., wilber, l. (eds.). the williams & wilkins co., baltimore, u.s.a., 1976. brackman, d.e., selter, w.a., and don, m. auditory evoked responses. in otolaryngology 1: otology, gibb, a.g. & smith, h. (eds.) butterworth & co., london, 1982. clemis, m.d., and sarno, c.n. the acoustic reflex latency test: clinical application. laryngoscope, 90, 601-610, 1980. dallos, p. dynamics of the acoustic reflex: phenomenological aspects. j. acous. soc. am., 36, 2175, 1964. evans, e.f. recent advances in cochlear physiology. in otolaryngology 1: otology. gibb, a.g., & smith, m. (eds.) butterworth & co., london, 1982. jerger, j. handbook of clinical impedance, chap. 7. american electro medics corp., new york, 1975. jerger, j., and hayes, d. latency of the acoustic reflex in eighth nerve tumour. arch. otolaryngol., 109, 1-5, 1983. osterhammel, p., and osterhammel, d. age and sex variations for the normal stapedial reflex thesholds and tympanometric compliance values. scand. audio., 8, 153-158, 1979. petersen, j. and liden, g. some static characteristics of the stapedial muscle reflex. audiology, 11, 97, 1972. sprague, b.h., wiley, t.l., and block., m.g. dynamics of acoustic reflex growth. audiology, 20, 15-40, 1981. uliel, s. acoustic reflex measurements and the loudness function in sensori-neural hearing loss. s.a.j. commun. dis., 27, 58-77, 1980. wilson, r.h. and mcbride, l.m. threshold and growth of the acoustic reflex. j. acous. soc. am., 63, 147-154, 1978. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) in close cooperation with the electro-acoustic department of siemens, one of the world's leading electrical and electronic engineering companies, r e p u b l i c 2 11h e a r i n g a l d consultants (pty) ltd »»)))) 187 jan smuts avenue lower rosebank offers hearing aids (opposite mupps) a n ( j school teaching tel.: 442-8691 . ^ equipment of the highest quality. the south african journal of communication disorders vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the effects of mandibular osteotomy on articulation and resonance delsa geffen m.a.(log.) (pretoria) psychological and guidance service, transvaal education department, johannesburg north. summary preand post-operative speech samples were studied in nine adult cases who received mandibular osteotomy. lateral cephalograms were taken during sustained production of selected sounds and trained listeners judged recordings. in most cases there was an improvement in the general quality of the speech. considering thai the functional relationships between the speech organs had altered, it would appear that some form of adaptation by the speaker had in fact taken place. opsomming preen postoperatiewe spraakvoorbeelde is bestudeer van nege volwasse gevalle wat mandibulere osteotomie ondergaan het. laterale kefalogramme is geneem tydens die volgehoue produksie van sekere klanke en opgeleide luisteraars het opnames geevalueer. in die meeste gevalle het die algemene kwaliteit van die spraak verbeter. gesien dat die funksionele verhoudings tussen die spraakorgane verander het, wil dit voorkom asof adaptasie wel by die spreker plaasgevind het. surgical correction of prognathic and retrognathic conditions of the mandible is being undertaken with increasing frequency throughout the world. mandibular osteotomy, in correcting an abnormal jaw relationship, brings about certain changes affecting the speech organs. there is a modification in the relative positions of the structures of the oral cavity. these include the palate, tongue, teeth and lips, all of which are involved in articulation. an alteration also takes place in the dimensions of the oral cavity, as well as in the size and shape of the orifice, resulting from the change in position of the teeth and lips. the aim of this study was to investigate the effects of. mandibular osteotomy on those speech parameters which are functions of the supralaryngeal cavities, namely articulation and resonance. although many maxillo-facial and oral surgeons have commented on the improvement of speech in their patients after correction of an abnormal jaw relationship,4' 7> 9' " few controlled studies have been published. goodstein et al3 studied five persons with mandibular prognathism, all of whom had deviant articulation. they found no significant change in the articulation of their subjects1 after mandibular osteotomy, but reported that voice quality improved. the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mandibular osteotomy and articulation 55 method nine adults requiring mandibular osteotomy for the correction of a malrelationship between the maxilla and the mandible were studied. two patients had received speech therapy during childhood for defective production of /s/, but without success. as research has indicated a direct relationship between the physiological processes of articulation and the acoustic properties of the sound produced,2 both of these aspects were investigated. auditory acoustic investigation a comparison was made between a pre-operative speech sample and a post-operative speech sample in each case. two short passages were selected, one in english and the other in afrikaans, containing all the phonemes of the language concerned. each subject was required to read the passage in his mother tongue. the post-operative speech evaluations were made between three and eleven months after the operation, the average time lapse being five-and-a-half months, thus ensuring complete recovery of the inferior alveolar nerve, recovery of mandibular movement and allowing the patients sufficient time to adjust to the altered structures so that their speech patterns could be considered stable. evaluations of the speech samples were made by five trained listeners. the recordings of each subject were played consecutively to facilitate comparison, but were presented in a random order with regard to preoperative and post-operative speech in order to prevent possible bias in the judgement. the listeners were asked to make comparative intrasubject judgements with regard to the articulation of the different sounds, paying particular attention to the production of /s/ as the accuracy of this sound is so readily disturbed by any dental irregularity.6 the listeners were also asked to consider any additional factors, such as resonance, and projection and quality of the voice. physiological investigation the place of articulation was studied by means of radiography. as cinefluorography was not available, lateral cephalograms were made during the sustained production of selected speech sounds. a narrow strip of ray-tec gauze, approximately 25 mm in length, was placed on the anterior section of the hard palate and another on the anterior part of the tongue, with the radiopaque thread running along the midline of each organ. a thin film of orabase paste was applied to the gauze to ensure adherence to the contours of the palate and tongue during articulation. in the case of english-speaking subjects, the sounds chosen were /θ, s, 1, i/; in the case of afrikaans-speaking subjects /s, 1, i/. in analysing the cephalograms, attention was paid to the salient points regarding the relationships of the organs.'0 the following measurements were taken for the consonants /θ, s, 1/:die suid-afrikaanse tydskrif vir kommunikasieafwykings. vol. 25. 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 delsa geffen a the distance between the upper and lower incisors on a horizontal plane. where a reversed relationship occurred, with the lower incisors anterior to the upper incisors, the distance is expressed as a minus quantity. λ β the distance between the upper and lower incisors on a vertical plane. where the incisal edge of the lower teeth was superior to that of the upper teeth, the distance is expressed as a minus quantity. c the distance, on a horizontal plane, posterior to the cutting edge of the upper anterior incisors, of the narrowest point of the constriction. where this point was doubtful or difficult to determine, the midpoint of the constriction was used.8 for the vowel / i / the horizontal and vertical distances between the upper and lower incisors were noted in the same way. the place of articulation was more difficult to evaluate as, in some cases, the highest point of the tongue was too far posterior to be marked on the cephalogram. to obtain an idea of the configuration and position of the tongue, the width of the air channel was measured (i.e. the distance between the palate and the tongue) at the following set points posterior to the upper anterior incisors: d 10 mm ε 15 mm f 20 mm results measurements obtained in the analysis of the cephalograms are given in table i. important points relating to the cephalograms and the listener judgements will be mentioned in individual cases. a comparison of the articulation of / s / as produced pre-operatively and post-operatively by all subjects, on both the auditory acoustic level and the physiological level, may be found in table ii. the general quality of the speech is also indicated. prior to surgery, case 7 sometimes held the mandible in a forward position when speaking, claiming that she found this more comfortable. an additional cephalogram was taken pre-operatively, viz. of the articulation of / s / with the mandible in the forward position. in cases 1, 8 and 9 the sound / l / was exaggerated when produced in isolation. as it was felt not to be a true reflection of that person's speech, those tracings were not analysed. p r o g n a t h i c m a n d i b l e case 1 cephalograms: the sounds were dentalized pre-operatively. postoperatively, the articulation was modified in accordance with the change in the mandible, and the sounds remained dentalized. listener judgement: both pre-operatively and post-operatively the articulation sounded further forward than normal. the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mandibular osteotomy and articulation 57 c ep ha lo m et ri c tr ac in g u. <n ο <ν ιη θ" ιη ο μσ\ # ιο μ"" ο # # # c ep ha lo m et ri c tr ac in g ω <n <n ιη ιο ο ιη •<f ο <ν η σ\ γμ" ιη # # # c ep ha lo m et ri c tr ac in g q <n <n ιη ιη θ" ιο η" οο η # # c ep ha lo m et ri c tr ac in g cq ο ο 1 •qιη ο ιο ο ο ιο ιη i τ μι <n # # c ep ha lo m et ri c tr ac in g < in 1 n 1 ο ιη <ν i ιo <ν ο π ο γ00 # # c ep ha lo m et ri c tr ac in g \ \ u ο <ν ττ γο ο γc ep ha lo m et ri c tr ac in g \ \ cq ο <ν μο γο ο ο c ep ha lo m et ri c tr ac in g \ \ < μι ιο ιο ο ο <ν οο ιη c ep ha lo m et ri c tr ac in g \ ιλ u γιη ο <ν ιη ο <ν οο ιη γ-" γσ\ tt σγ ο c ep ha lo m et ri c tr ac in g \ ιλ cq ο •q-1 -1 ,5 <ν i -0 ,5 ο i <ν -0 ,5 γι <ν i <ν i i ο 1 <n c ep ha lo m et ri c tr ac in g \ ιλ < <n 1 tt γι ιη ο ο τ <ν ο η ιη η" <ν μο ο tt c ep ha lo m et ri c tr ac in g > u ο m· οο ο c ep ha lo m et ri c tr ac in g > cq ο <n rc ep ha lo m et ri c tr ac in g > < γc ep ha lo m et ri c tr ac in g so un d m ea su re m en ts pr eop er at iv e p os top er at iv e pr eop er at iv e po st -o pe ra ti ve pr eop er at iv e p os top er at iv e pr eop er at iv e po st -o pe ra ti ve pr eop er at iv e po st -o pe ra ti ve pr eop er at iv e m an di bl e fo rw ar d po st -o pe ra ti ve p re -o pe ra ti ve p os top er at iv e pr eop er at iv e po st -o pe ra ti ve d is ta nc e m an di bl e m ov ed ο 00 00 ιη ο ιη i 1 c as e ο μ· ιη γοο ja w re la ti on sh ip pr eop er at iv el y p ro gn at hi c m an di bl e r et ro gn at hi c m an di bl e pr og na th ic m ax ill a fa ci al as ym m et ry i » ε .ο μ ο υ ο od ο ο . ιυ u c < ω _ι cq < η ιλ c ε υ w ε s υ ιλ 3 υ ν) γ-η c 1 1 = η die suid-afrikaanse tydskrif vir kommunikasieafwykings vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 delsa geff e n case 2 c e p h a l o g r a m s : this case was excluded from the cephalometric investigation as he wore a partial denture which was constructed from radiopaque material, with the result that the outlines of the tongue and palate could not be visualized on x-ray. listener judgement: in the pre-operative recording /s/ and / r / were defective and the consonant clusters were indistinct. in the postoperative recording both the accuracy of articulation and the quality of speech were much improved. case 3 cephalograms: pre-operatively the constriction for /s/ was pre-palatal. post-operatively there was a change in tongue position, corresponding to that of the mandibular teeth. judgement of listeners cephalogram of /s/ jaw place of relationship articulageneral articulation adjustment precase tion of quality adjusted in in tongue operatively /s/ /s/ of speech accordance posture with altered jaw position prognathic 1 remained no change yes no mandible defective 2 improved improved — 3 remained improved yes \ n defective 4 remained improved no slight acceptable 5 remained deteriorated no no acceptable 6 remained improved slightly yes defective retrognathic 7 remained deteriorated yes no mandible defective prognathic 8 improved improved yes 'yes maxilla facial 9 remained no change no, but no no asymmetry defective significant anatomical change table ii listener judgement and cephalograms for preand postoperative production of /s/. the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 59 m a n d i b u l a r osteotomy and articulation r i.ihgement: in the pre-operative recording the mid-alveolar l i s t c i s s o u n d e d pre-palatal. post-operatively the /s/ segment remained deviant, but the speech was generally "pleasing". k i l o g r a m s · the place of articulation remained the same post% p r a t e i y as pre-operatively, but slight variations occurred e.g. h ^ x ^ ^ o , was good on both recordings. postoperatively the resonance was greatly improved. s i a l o g r a m s : the place of articulation was virtually unchanged postnerativelv in spite of the alteration in the jaw relationship. s e n e r judgement: articulation was good in both recordings, but r e s o n a n c e was poorer post-operatively. case 6 . . cephalograms: both preand post-operatively the constriction for /s/ occurred anterior to the usual position. listener judgement: with regard to articulat.on the /s was el to be deviant in both recordings. the speech was generally better postoneratively, however. of the six patients who underwent surgery to correct a prognathic m a n d i b l e it may be seen that four distorted / s / pre-operatively. postot^erative'ly three of them altered the place of constriction for the sound iifaccordance with the changed mandibular position. in the case of the u b s who produced an acceptable /s/ post-operat.vely, the position of the constriction in relation to the maxillary incisors was maintained. vhe p ace of constriction in relation to the maxilla remained constant in the remaining two cases, who produced / s / correctly both pre ner s and post-operatively. in one case, however, a slight x s t m e m in ton£ie posture occurred, so that a narrower constriction the^ge^eral^quality of speech was maintained or improved in most cases. r e t r o g n a t h i c m a n d i b l e case 7 l^ase / . cenhaloerams· in the pre-operative cephalogram with the mandible held .n a'forward position, and in the post-operative cephalogram there was an extremely small orifice for the escape of air on / s / . l i s e n e r judgement: resonance was found to be best pre-operatively wuh the mandible in the natural position. the /s/ was defect,ve in all " a ^ n l y o n e subject with a r e t r o g n a t h i c mandible. her articulation remained the same but the general quality of her speech deteriorated post-operatively. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 delsa geffen prognathic maxilla case 8 cephalograms: pre-operatively, for the production of /s/, the lower incisors are in contact with the upper alveolar ridge. the tongue humps considerably at the point of constriction and then drops sharply anterior to this, probably to form a channel of sufficient width to conduct the air stream. post-operatively the mandibular incisors are in a lower position and there is thus more space behind the upper incisors and adjacent alveolar ridge. articulation takes place in a more anterior position and the superior surface of the tongue is flatter, with a gentle rise to form the constriction. listener judgement: / s / is deviant pre-operatively, but improved postoperatively. the speech generally and in particular the quality of the voice, is better post-operatively. following the operation in this case, the articulation of / s / was improved by an adjustment in the place of articulation, in addition to modification of the configuration of the tongue. facial asymmetry case 9. .. . cephalograms: the operation resulted in a comparatively small change in the relation of the lower teeth to the upper teeth. the articulation of / s / occurred far forward in the mouth in both cases. listener judgement: the / s / was deviant at times both pre-operatively and post-operatively. there was no significant difference in speech between the two recordings. with no significant anatomical change produced surgically, there was no change in articulation or resonance of this subject's speech. discussion and conclusions post-operatively, the anatomical structures are such that the person may have the potential for normal speech. the acoustic impression of his speech, however, will be determined by the complexity of muscular movements which he makes in relation to his oral morphology.1 in the limited number of subjects studied, certain effects on articulation and resonance were observed. in most cases there was an improvement in the general quality of the speech, which may be attributed to the creation of a more favourable oral environment for optimal resonance. this substantiates the finding that an increase of space between the dorsum of the tongue and the palate brings about a corresponding increase in the carrying power of the voice.5 pre-operatively the relationship between the jaws is such that the orifice of the mouth is basically on a horizontal plane. in the postoperative state, there is a greater space between the maxillary and mandibular teeth in the vertical dimension, through which speech may be emitted. the south african journal of communication disorders, vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mandibular osteotomy and articulation 61 in the subject with the retrognathic mandible the general quality of speech deteriorated post-operatively. surgery included a myotomy .of the anterior digastricus and the geniohyoid muscles, and the possibility of the deterioration of speech quality being related to a muscular change in the posture or support of the tongue warrants further investigation. with regard to articulation, when the place of production of the sound was adjusted in accordance with the new position of the teeth and jaw, no change occurred in the acoustic properties. such a change did occur, however, when the place of production was adjusted and, in addition, the posture of the tongue was modified. when the place of production remained the same, the acoustic properties of the sound changed. in view of the alteration of the jaw relationship, the maintenance of the place of articulation implies a marked change in the functional relationship between the speech organs. adjustments made by the speaker in adapting to the alteration in the oral morphology will either facilitate or restrict any changes perceived in his speech. the effects of oral surgery on the speech of the individual can therefore not be predetermined, and any generalizations should be made with caution. certain implications arise with regard to speech therapy for articulatory defects in persons with an abnormal jaw relationship. while defective articulation might be related to such an anomaly, surgical correction of the malrelationship will not necessarily result in normal articulation. this may be accounted for by the habitual patterns of muscular movements, maintained by the characteristic functioning of the various feedback systems of the individual. in two cases, where speechtherapy was attempted prior to surgery,, it was not successful. although this aspect was not included in the present investigation, it is suggested that the better functional relationship between the structures of the oral cavity post-operatively, may facilitate treatment. a ckno wledgements the writer wishes to thank prof. p.c. snijman, dean of the faculty of dentistry, university of pretoria, for his kind permission to utilize the facilities and equipment of the oral and dental hospital. appreciation is also extended to prof. j.g. duvenage, head of the department of maxillo-facial and oral surgery and to prof. j.e. seelige'r, head of the department of radiology, university of pretoria for their co-operation and assistance. references 1. bloomer, h.h. (1971): speech defects associated with dental malocclusions and related abnormalities. in handbook of speech pathology and audiology, travis, l.e. (ed.). appleton-centurycrofts, new york. die suid-afrikaanse tydskrif vir kommunikasieafwykings vol. 25. 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 delsa geffen 2. broad, d.j. and peterson, g.e. (1971): the acoustics of speech. in handbook of speech pathology and audio logy, travis, l.e. (ed.). appleton-century-crofts, new york. 3. goodstein, d.b., cooper, d. and wallace, l. (1974): the effect on speech of surgery for correction of mandibular prognathism. oral surg., 37, 846-849. 4. hogeman, κ. e. (1951): surgical-orthopaedic correction of mandibular protrusion. acta chir. scand. suppl. 159. 5. lawson, w.a. and bond, e.k. (1969): speech and its relation to dentistry. part iii. the effects on speech of variations in the design of dentures. dent. practit. 19, 150-156. 6. luchsinger, r. and arnold, g.e. (1965): voice — speech — language. wadsworth publishing co., belmont, california. 7. murphey, p.j. and byrd, d.l. (1966): correction of prognathia by oral surgery and orthodontic therapy. in current therapy in dentistry, goldman, h.m. et al. (eds.). c.v. mosby co., st. louis. 8. peterson, g.e. and shoup, j.f. (1966): a physiological theory of phonetics. j. speech hear. res. 9, 5-67. 9. simpson, w. (1974): the results of surgery for mandibular prognathism. brit. j. oral surg. 12, 166-176. 10. subtelny, j.d.„oya, n. and subtelny, j.d. (1972): cineradiographic study of sibilants. folia phoniat. 24, 30-35. 11. vig, p. (1967): adaptation to altered morphology — illustrated by two surgical cases. dent. practit. 17, 225-233. hearing aids — a comprehensive range comprising the latest microson directional models — unitron high level compression models. ear moulds — we specialise in ear mould technology to the great benefit of our patients — we also supply instant mould kits to schools. r tv accessories — manufactured by ourselves modern hearing aids (pty) ltd for we are at 305 rand central 165 jeppe st johannesburg tel: 37-1774 the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the edinburgh masker was pioneered by the stammering research unit at edinburgh university. t h e e d i n b u r g h m a s k e r is s u p p l i e d w i t h t h e c o n s e n t o f t h e p a t i e n t ' s d o c t o r o r t h e r a p i s t . the edinburgh masker is a new electronic device designed to alleviate stammering. the needier westdene organisation (pty) limited. in association with / in medewerking met hearing and acoustic instruments (pty) ltd. lewis's hearing centre (pty) ltd. engineered acoustic products noise control needier westdene house 33 durham street, raedene, johannesburg, 2192 telex· 8-3660 p.o. box 28975 sandringham, 2131 south africa tel 45-7262,45-6113/4 cables: needlerorg die suid-afrikaanse tydskrif vir kommunikasieafwykings vol. 25, 978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 33 criteria for managing audiometric data in occupational hearing conservation calum μ delaney department of logopaedics, university of cape town abstract hearing conservation programmes usually include hearing testing, although it is not always clear whether the aim of such testing is to identify individuals with a hearing disability, or those who show evidence of having been affected by noise. the requirements for hearing testing in both cases relate to three main considerations: the choice of frequencies at which hearing is assessed; the way in which this threshold data is quantified or otherwise managed; and whether this index is compared to some static limit, or to the individual's own baseline audiogram to assess hearing change. central to the assessment of hearing for the purpose of identifying individuals at risk for noise-induced hearing loss is a measure that is both sensitive and specific to the effects of noise. a case is made for a choice of frequencies around 4000 hz, the substitution of hearing loss configuration for the three-frequency average, and an emphasis on hearing change rather than status as a means of interpreting audiometric data for hearing conservation purposes. opsomming gehoor-konserverings-programme sluit gewoonlik gehoortoetsing in, alhoewel dit nie altyd duidelik is of die doel van sulke toetse is om die individue met gehoorafwykings of diegene wat deur lawaai geaffekteer is, te identifiseer nie. in beide gevalle is die vereistes vir gehoorevaluasie verwant aan drie hoofoorwegings: die keuse van frekwensies waarby gehoor getoets word; die wyse waarop die drempelgegewens kwantitatief of andersins verwerk word; en ofhierdie indeks vergelyk word met een ofander statiese limiet, of met die individu se eie basislyn-oudiogram om gehoorverandering te ondersoek. sentraal tot die evaluasie van gehoor, met die oog op identifikasie van risikogevalle virgehoorverlies wat deur lawaai veroorsaak word, is 'n meting wat beide sensitief en spesifiek is tot die gevolge van lawaai. daar bestaan oortuigende redes vir die keuse van frekwensies van om en by 4000 hz, die vervanging van die gemiddelde van drie frekwensies met gehoorkonfigurasie, en die klem op gehoorverandering eerder as gehoorstatus as wyse van interpretasie van oudiometriese data vir die doel van gehoorkonservering. most approaches to hearing conservation include the testing of hearing at some point. the aim of this is to monitor employees to identify those who show a deterioration of hearing in spite of;the wearing of hearing protection and attempts to reduce noise levels. however, the aspect of hearing deterioration that receives attention appears to suffer from a confusion of purpose that leads to a frustration of the probable intent of the hearing testing in the first place. that is, the prevention of noiseinduced hearing loss. "deterioration of hearing" may mean two things. one meaning may refer to the development of a hearing status that compromises an individual's ability to make use of his hearing for communicative and other purposes. the other meaning may be any change to hearing that may reasonably be attributed to noise exposure, regardless of what the subsequent effect of such change may be. conservation of auditory communication ability if the aim of preventing hearing deterioration is to conserve the individual's ability to use audition for communication, then measurement needs to concentrate on those hearing frequencies considered to be most important for the processing of speech information. speech sounds cover a range of frequencies from at least 100 hz to 8000 hz (fletcher, 1953), while the maximum level of the perceived spectra of summed speech ranges between 500 and 4000 hz (pascoe, 1978). due to the redundancy of information inherent in speech, normal hearing listeners are able to maintain the intelligibility of speech that has been lowpass filtered as low as 1600 hz (hirsch, reynolds & joseph, 1954), thus probably giving rise to the view that speech information in the frequency range 500 hz to 2000 hz is necessary and sufficient for adequate communication. interestingly the same study also found that eliminating all frequencies below about 1600 hz also had a similarly minimal effect on speech intelligibility. however, more recent work carried out with hearing impaired listeners (including noise-induced hearing loss) suggests that for these individuals speech information redundancy is reduced by the hearing loss and other auditory effects such as reduced frequency and temporal resolution (dreschler & plomp, 1985), as well as the die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 calum μ delaney confounding effects of competing noise (suter, 1985). these subjects show increased intelligibility in noise with an increased signal bandwidth (skinner & miller, 1983), particularly with the inclusion of frequencies above 2000 hz (sullivan, allsman, nielsen, & mobley, 1992). verschuure and van benthem (1992) found that subjects with steeply sloping audiograms performed better in noise when using hearing aids with high-frequency emphasis. a consistent finding across a number of studies is that the hearing loss at 2000 and 4000 hz is the best simple predictor of speech reception and speech intelligibility in noise (abel, krever, & alberti, 1990; smoorenburg, 1990; verschuure & van benthem, 1992). in evaluating hearing thresholds it is also necessary to establish a level beyond which hearing can no longer be considered to be satisfactory (i.e., when an individual is considered to experience some "disability"), and a way to relate the thresholds at different frequencies to that level. the most convenient measure to employ in quantifying hearing loss at several frequencies is some form of simple, or occasionally weighted, average of three or more frequencies. typically these include some of the octave frequencies from 500 hz to 4000 hz, and sometimes 3000 hz and 6000 hz (e.g., british standards institution, 1976; ward, 1983). this average is then related to a level beyond which the hearing is considered abnormal and an individual is expected to begin experiencing difficulty with his hearing. this level (the "low fence") is usually 25 db or 30 db (e.g., british standards institution, 1976; united states department of labor, 1983). examination of the sabs 083-1983 code of practice (1983) which specifies recommended procedures for hearing conservation in south africa suggests that the approach to hearing measurement in this standard has much in common with the aim of conserving hearing for communication purposes outlined above. it employs the average of the three frequencies 500, 1000, and 2000 hz as a measure of threshold, and defines an impairment as occurring when this average exceeds 25 db. further, the manner of specifying risk is in terms of the probability of the above impairment occurring as a consequence of exposure to a given level of noise, taking into account the age of the individual. rather than permit an assessment of the risk posed to an individual, the procedure for assessing risk seems intended to assess whether an individual with an impairment (as defined) can reasonably be assumed to have acquired that impairment as a consequence of his noise exposure. in other words, can the "blame" for the loss be attributed to the noise rather than something else (typically age)? in evaluating this approach an additional point is worth mentioning. this is the similarity between hearing conservation as outlined above and the current approach to compensation for noise-induced hearing loss in south africa, with respect to the use made of hearing measurement. the formula for the calculation of disability specifies impairment in terms of a threshold (the average of 500, 1000, and 2000 hz) worse than 25 db. (office of the workmen's compensation commissioner, 1988 and 1992). in examining the approach to compensation it is clear that its aim is to ensure that the impairment is sufficiently disabling to warrant compensation. the point to be made is that the specification of impairment is intended to reflect disability, and is primarily concerned with hearing status (rather than change), which is similar to the approach outlined above in respect of sabs 083. it is interesting to contemplate the extent to which considerations of compensation might have influenced the approach to hearing conservation. ward (1983) and noble (1988) have commented on the arbitrary nature of the assumptions underlying formulae for compensation, and it would be unfortunate were these to have influenced procedures for conservation. identification of the effects of noise on hearing the alternative approach to monitoring hearing deterioration is to do so for the purpose of identifying individuals who are being affected by their noise exposure. this is regardless of whether or not the loss has any disabling effect on the individual's ability to use his hearing for communication and other purposes. the aim in this approach is to devise a measure that is both sensitive (generates a minimum of false negatives), and specific (generates a minimum of false positives) to the effects of noise. this raises the question of what is known about the effects of noise exposure on hearing. robinson (1987) provided a useful synthesis of the data from studies on noise-induced hearing loss available at that time. robinson's treatment of the data was extensive and what follows is a summary of the most obvious trends. plots at different frequencies of hearing threshold level against the level of noise exposure for different durations of exposure showed that within ten years of exposure to noise levels greater than 85 db(a) most studies showed evidence of some degree of threshold elevation (to >10 db hl) at 4000 hz in 50% of their subjects. at 2000 hz this was the case for 25% of subjects, while at 1000 hz there was minimal threshold elevation even at the 25th percentile. additionally the effect of noise level was greatest at short exposure durations for 4000 hz (5 to 10 years), only becoming marked (but resulting in less affected threshold levels) at increasingly longer durations for 2000 hz and 1000 hz (at approximately 20 and 30-40 years respectively). growth curves of hearing loss at 4000 hz as a function of exposure duration at levels of 90 db(a) and greater showed a rapid growth in the first ten years of exposure, levelling off thereafter. similar curves at 2000 hz and 1000 hz showed a constant growth of hearing loss with exposure duration at progressively lower rates respectively. this was true of b o t h a s c r e e n e d otologically normal population and an unscreened typical population. rate of hearing loss at 4000 hz on first entry to noise varied between 1 and 9 db/year for exposure to noise levels of 85 to 100 db(a), depending on actual level· of exposure and individual variation. finally, in a study of the effect of age on hearing loss by robinson and sutton (1979), the results showed that a noticable effect at 4000 hz only became discernable after age 30 to 35 years. apart from confirming the generally accepted fact that 4000 hz is the hearing frequency most susceptible to damage by noise, the results of robinson's work suggest that the degree of hearing loss is greatest at this frequency, it shows the greatest change at increasing the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) c r i t e r i a for managing audiometric data in occupational hearing conservation 35 noise levels and it shows this change over the shortest duration i.e., most of the deterioration in hearing at 4000 hz occurs within the first ten years of exposure, and this deterioration can initially occur at a rate of up to 9 db/year. taken in conjunction with robinson and sutton's findings that the effect of age on hearing at 4000 hz is minimal before the age of 35 years, it is reasonable to suggest that change to hearing at this frequency can be attributed to noise alone in the first ten years of exposure to noise of persons under 35. monitoring of change to hearing at this frequency should therefore provide a sensitive indicator of susceptibility to noise. the next consideration is the way in which this measure should be utilised. given that noise can also affect other frequencies in the region of 4000 hz, for example 6000hz and 3000hz, an average of thresholds at several frequencies can be obtained. this is the case for example in the occupational safety and health administration (osha) hearing conservation amendment (united states department of labor, 1983) where the average threshold at 2000, 3000, and 4000 hz is used to assess susceptibility. (the frequencies used in the osha amendment are interesting, given the discussion on compensation versus conservation above. it is not clear whether the choice of frequencies is intended to reflect the effects of noise, or their effect on disability. a discussion of the amendment by suter (1984) suggested that considerations other than hearing conservation played a role in the choice finally decided upon). alternatively, a shift in threshold at any one of several frequencies can be used. the australian standard as 1269-1989 (standards association of australia, 1989) for example prescribes testing at 3000, 4000, and 6000hz as a minimum, and a threshold shift at any one of these frequencies as requiring further action. if it is a noise effect that is to be detected (rather than the presence of some form of disability) then it is important that a change to hearing at these frequencies be reacted to rather than the hearing reaching a certain pre-defined status. this is regardless of whether the change has resulted in' thresholds which are still considered normal, or whether the thresholds before exposure lay outside the normal range to begin with. the amount of deterioration of hearing considered significant is 10 db or greater in the osha amendment (united states department! of labor, 1983) and 15 db or greater in the australian' standard (standards association of australia, 1989).' at present the sabs 083 standard has no definition for "deterioration of hearing", even were either a three-frequency average or threshold shift at one of the specified test frequencies to be utilised for this purpose. audiometric configuration it is important to note that the studies incorporated in robinson's (1987) work examine the effects of noise on hearing thresholds in terms of measures of central tendency for certain populations. while this provides some information on how a noise-induced hearing loss might develop in an individual case, this data essentially obscures any individual variability that might occur. similarly, utilisation of threshold shift at isolated frequencies or in terms of an average at several frequencies may reduce the specificity of the measure by permitting hearing loss of other etiology to be misclassified as being noise-induced. examination of the audiometric data of individuals who have been exposed to noise suggests that the hearing thresholds of these individuals are poorer at 4000 hz and the frequencies in the vicinity of 4000 hz than at other frequencies. this conclusion is also indirectly supported by the data in robinson's (1987) work. importantly though the thresholds at 8000 hz, and 2000 hz and below, are noticably better than those at 4000 and 6000 hz. an important feature of utilising thresholds at the frequencies around 4000 hz as a measure of noise effect may be their level in relation to the thresholds at 2000 and 8000hz. that is, the depth of the "notch" in the audiogram at 4000 hz. thus it may be useful to consider audiometric configuration rather than averaged or isolated frequencies when developing a more specific measure of the effect of noise on hearing. as part of an earlier study (delaney, 1993) the author compared the audiometric data of just over 600 noise-exposed subjects from 6 different factories described in terms of three-frequency averages and in terms of audiometric configuration. three averages were obtained: 500, 1000 and 2000 hz; 1000, 2000, and the worst of 4000 or 6000 hz; and 2000, worst of 4000 or 6000, and 8000 hz. these averages were then grouped as falling below 26 db, between 26 db and 55 db (inclusive), and above 55 db. the audiometric configuration of each ear was categorised in terms of the depth of the "notch" as showing no noise-induced hearing loss (nihl); a possible nihl (a depth of at least 5 db on one side and 10 db on the other); and a probable nihl (a difference of at least 20 db between 2000 and 4/6000 hz and 15 db between 4/6000 and 8000 hz, or 15 db between 2000 and 4/6000 hz and 25 db between 4/6000 and 8000 hz). one of the aims was to assess the extent to which the numbers of individuals identified as having been affected by noise might differ when measured using the two different approaches. a summary of the results of this analysis for all six of the factories combined is presented in fig 1. from these results it can be seen that the number of ears showing an average hearing loss greater than 25 db (using any of the <0 cr < uj ω ξ <26 26-55 >55 <26 26-55 >55 <26 26-55 >55 .5, 1, 2khz 1, 2, 4/6khz 2, 4/6, 8khz average hearing loss (db) | | no nihl | | possible nihl i probable nihl figure 1. noise-induced hearing loss (nihl) component and severity of three-frequency-average hearing loss (<26 db, 26-55 db, and > 55 db), for three different three-frequency-averages. die suid-afrikaanse tydskrif vir kommunikasieafwykings', vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 calum μ delaney three averages) is less than the number identified as having a possible or probable noise-induced component to their hearing configuration. additionally, not all individuals with a three-frequency-average hearing loss show a noise-induced component to their hearing configuration, while a large number of subjects with normal three-frequency-average hearing do. the former finding may suggest that audiometric configuration may be a more specific measure of the effect of noise, while the latter may indicate that it is more sensitive. clearly these conclusions rest on the validity of the hearing configuration criteria used to identify a noise effect. the criteria were arrived at by examining the types of hearing configurations identified by experienced audiologists as showing possible or probable noise-induced hearing loss. however, these criteria may as easily be submitted to debate as any other criteria already employed in hearing conservation. additionally a reexamination in terms of individual audiometric configuration of the raw data from some of the studies already conducted might also provide some guidelines. conclusion this discussion attempted to show that an alternative approach to the management of hearing measurement data might provide a more sensitive and specific measure of the effect of noise on hearing, thus permitting the detection of individuals being affected by noise such that conservation measures can be implemented as rapidly as possible. it was also suggested that some of the confusion that exists concerning whether considerations of disability should enter into the identification of individuals susceptible to noise, and whether considerations of compensation should be allowed to influence conservation criteria, should be avoided. choice of frequencies for assessing the effects of noise, criteria for assessing the significance of hearing change, and whether or not hearing configuration is a better means for managing audiometric data is a matter for debate. however, a careful re-examination of the philosophy and purpose behind hearing measurement in the conservation of hearing may permit the development of a practice that better serves the aim of preventing noise-induced hearing loss. references abel, s. m., krever, ε. m., & alberti, p. w. (1990). auditory detection, discrimination and speech processing in ageing, noise-sensitive and hearing-impaired listeners. scand. audiol., 19, 43-54. british s t a n d a r d s institution. (1976). bs 5330-1976: estimating the risk of hearing handicap due to noise exposure. london: british standards institution. delaney, c. m. (1993). hearing measurement for noise control: an alternative approach to assessing noise risk. in m. j. crocker & ν. i. ivanov (eds.). proceedings of the noise-93 international noise and vibration control conference (vol. 2, pp. 243-248). st petersburg, russia: interpublish. dreschler, w. α., & plomp, r. (1985). relations between psychophysical data and speech perception for hearingimpaired subjects. j. acoust. soc. am., 78, 1261-1270. fletcher, h. (1953). speech and hearing in communication. princeton: van nostrand. hirsch, i. j., r e y n o l d s , e. g., & j o s e p h , m. (1954). intelligibility of different speech materials. j. acoust. soc. am., 26, 530-538. noble. w. (1988). evaluation of hearing handicap: a critique of ward's position. audiology, 27, 53-64. office of the workmen's compensation commissioner. (1988, 1992). personal communication. pascoe, d. (1978). an approach to hearing aid selection. hear. instruments, 29, 12-16. robinson, d. w. (1987). noise exposure and hearing: a new look at the experimental data (hse contract research report no 1). london: health and safety executive. robinson, d. w., & sutton, g. j. (1979). age effect in hearing: a comparative analysis of published threshold data. audiology, 18, 320-334. skinner, m., & miller, j. (1983). amplification bandwidth and intelligibility of speech in quiet and in noise for listeners with sensorineural hearing loss. audiology, 22, 253-279. smoorenburg, g. f. (1990). on the limited transfer of information with n o i s e i n d u c e d hearing loss. acta otolaryngol, suppl. 469, 38-46. south african bureau of standards. (1983). sabs 083-1983 code of practice for the measurement and assessment of occupational noise for hearing conservation purposes (amended). pretoria: south african bureau of standards. standards association of australia. (1989). as 1269-1989: hearing conservation. sydney: standards association of australia. sullivan, j. α., allsman, c. s., nielsen, l. b., & mobley, j. p. (1992). amplification for listeners with steeply sloping, high-frequency hearing loss. ear and hearing, 13, 35-45. suter, a. h. (1984). osha's hearing conservation amendment and the audiologist. asha, 26, 39-43. suter, a. h. (1985). speech recognition in noise by individuals with mild hearing impairments. j. acoust. soc. am., 78, 887-900. united states department of labor, occupational safety and health a d m i n i s t r a t i o n . (1983). o c c u p a t i o n a l noise exposure: hearing conservation amendment. federal register, 46, 9738-9785. verschuure, j., & van benthem, p. p. g. (1992). effect of hearing aids on speech perception in noisy situations. audiology, 31, 205-221. ward, w. d. (1983). the ama/aoo formula for determination of hearing handicap. audiology, 22, 313-324. the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die diagnosering van stamel as 'n vorm van ps1goneurologiese disfunksie i.e. uys. d.phil. (pretoria) dept. spraakheelkunde, universiteit van pretoria. opsomming die samestelling van 'n diagnostiese program vir stamel as 'n vorm van psigoneurologiese disfunksie word gebaseer op 'n teoretiese orientering ten opsigte van die simptomatologiese en etiologiese verband tussen hierdie twee sindrome. hierdie verband word met empiriese bevindings gestaaf. 'n omvattende diagnostiese program is saamgestel met die doel om al die verskillende simptome van psigoneurologiese disfunksie, sowel as meer spesifiek, die verbale kommunikasieprobleme van stamel, uit te lig. ten slotte word hierdie program ge-evalueer aan die hand van eksperimentele bewyse. summary the construction of a diagnostic programme for cluttering as a form of psychoneurological dysfunction is based on a theoretical orientation to the symptomatological and etiological relationship between these two syndromes. this relationship is confirmed by empirical findings. a comprehensive diagnostic programme is constructed with the purpose of eliciting all the different symptoms of psychoneurological dysfunction, as well as more specifically, the verbal communication problems of cluttering. finally this programme is evaluated according to experimental findings. wanneer 'n navorser poog om 'n sinvolle diagnostiese program vir enige afwyking saam te stel, moet so 'n program gegrond word op 'n aanvaarbare logiese teoretiese orientering. dit is egter nodig om eers 'n intensiewe studie te maak van alle relevante empiriese bevindings in verband met die afwyking wat tot so 'n teoretiese orientering kan lei. in die geval van stamel as 'n vorm van psigoneurologiese disfunksie (pnd) berus 'n sinvolle diagnostiese program op a) die bestaan van 'n simptomatologiese verband tussen stamel en pnd; b) 'n ooreenstemming in verband met die moontlike etiologiese faktore in beide gevalle; c) empiriese bewyse dat stamel wel 'n vorm van pnd is en dus as sodanig ondersoek moet word. die simptomatologiese verband tussen stamel en pnd 'n intensiewe literatuurstudie dui daarop dat pnd as 'n bree diagnostiese kategorie gesien moet word, en dat dit omvattend genoeg moet wees om voorsiening te maak vir al die uiteenlopende simptome. binne hierdie bree diagnosjourna of the south african speech and hearing association. vol. 23. december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) stamel en psigoneurologiese disfunksie 77 tiese kategoriee is 'n verskeidenheid van sindrome te vinde. dit is dus ook sinvol dat hierdie spesifieke simptoomkomplekse as sub-kategoriee herken en aanvaar sal word. daar bestaan egter so 'n massa publikasies oor pnd dat die student verblind word deur al die losstaande, veranderlike en veelvormige simptome en gewoonlik lei dit tot teoretiese mistasting en kliniese rondtasting. in 'n onlangse navorsingsprojek is gevind dat 'n kubernetiese beskouing veral vir die spraakterapeut van groot waarde kan wees, omdat dit nie maar weer lei tot die samestelling van 'n lys van bekende kenmerke nie, maar eerder aanduidend is van die verband tussen verskillende simptome.22 dit is juis in die kubernetika wat die verband tussen pnd en stamel gevind word. volgens navorsing wat reeds gedoen is op die gebied van stamel, is daar 'n merkwaardige ooreenkoms, op byna alle vlakke, met die beeld wat deur pnd geskep word.3' 2 0 ' 2 5 in hierdie gevalle is die spraakafwyking egter die middelpunt van die beskry wing van die simptoomkompleks, omdat die kenmerkendste of opvallendste simptome gesentreer is om spraak as kommunikasiemedium. murray11 het die kenmerkendste simptome van pnd as volg saamgevat: 1. hiperaktiwiteit 2. perseptuele — motoriese aantasting 3. emosionele labiliteit 4. algemene versteurings in ko5rdinasie 5. steurings van aandag 6. impulsiwiteit 7. steurings van geheue en denke 8. spesifieke leergestremdhede 9. steurings van spraak en gehoor 10. twyfelagtige neurologiese tekens en onreelmatighede van die elektroenkefelogram. 'n analise van die varierende simptome van stamel, veral in die lig van die bogenoemde lys van simptome, dui op die een of ander vorm van pnd. nie alle simptome, wat by verskillende stamelaars, as 'n groep voorkom, hoef as verpligtend beskou te word nie. in werklikheid kan alleenlik vier simptome as verpligtend vir die diagnose van stamel beskou word, naamlik: a) kort aandagspan en die daarmee gepaardgaande swak konsentrasievermoe; b) gebrek aan volkome bewustheid van die probleem; c) 'n buitensporige aantal herhalings in die spraak; d) 'n verswakte waarnemingsvermoe. die meeste simptome wat dikwels by stamelaars waargeneem word is egter opsioneel. hierdie simptome toon 'n groot omvang, van reseptiewe, tot integrasieen ekspressiewe probleme. simptome wat waarskynlik die opvallendste is, sluit in die ekspressiewe of motoriese manifestasies, soos buitensporige spraakspoed, artikulasie-afwykings en 'n algemene rusteloosheid of hiperaktiwiteit. die reseptiewe probleme is moeiliker waarneembaar, maar dra nogtans in 'n groot mate by tot die omvang van die probleem. hier word simptome soos tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23. desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 78 i.c,. uys perseptuele afwykings gevind, wat kan lei tot leesen spellingprobleme en gevolglik spesifieke skolastiese leergestremdhede. die algemeenste opsionele simptoom van stamel is waarskynlik 'n leesprobleem, wat vergelykbaar is met disleksie.25 gewoonlik word die probleem van 'n sentrale taalwanbalans of -onvermoe in verband gebring met 'n versteuring in die ontwikkeling en funksionering van die sentrale senuweesisteem. dit is op die gebied van hoer kortikale integrasie waar die merendeel van die probleme gemanifesteer word.1' 3 arnold1 be-. klemtoon die feit dat dit 'n afwyking is, wat die hoogste vlak van linguistiese formulasie en integrasie sal affekteer en bradford3 voeg daarby dat enige toestand wat die harmoniese organisasie van serebrale aktiwiteite bei'nvloed ook probleme in verband met die ontvangs en koordinasie van visuele en ouditiewe indrukke sal veroorsaak. dit sal weer die psigomotoriese stabiliteit van die persoon nadelig bei'nvloed. in hierdie geval sal die onderliggende pnd, of meer spesifiek, die swak gei'ntegreerde en onvolledige denkprosesse die oorsaak wees van die herhalende spraakpatroon, hersienings, huiwerings en stiltes, tussenwerpsels, artikulasie-afwykings, grammatikale verwarring eh leesen spellingprobleme.12 uit 'n kubernetiese studie van die simptomatologiese beskrywings van pnd aan die een kant, en stamel aan die ander kant, blyk dit dus asof daar 'n definitiewe verwantskap tussen die twee sindrome bestaan. 'n etiologiese ooreenstemming tussen stamel en pnd daar is 'n baie noue verband tussen pnd en stamel vasgestel deur eksperimentele bewyse, onder andere in verband met eienskappe van die senuweesisteem,1 3 sekere biochemiese en formakologiese aanduidings 9 ' 1 4 ' 2 6 en die omlyning van die betrokke neurofisiologiese g e b i e d e . 7 ' 1 0 ' 1 6 die volgende implikasie is dus voor die handliggend — dat in die .geval van stamel die funksionering (kwalitatief en kwantitatief) van senuwee-oordrastowwe, tesame met selen organisme sensitiwiteit, tot 'n wanbalans in die funksionering van die twee opwekkingsisteme (die retikulere en limbiese) kan bydra. die teorie, in verband met 'n verhoogde adaptasiepeil (stelling) in die retikulere formasie en 'n moontlike wanbalans in.die wisselwerking tussen die twee sisteme, is ook van toepassing gevind op stamel.22 in hierdie geval (waarskynlik as gevolg van striatum-betrokkenheid) is die kenmerkendste simptome in die .verbale kommunikasie-oordrag merkbaar. 1 9 ' 2 5 dit gebeur meestal dat ondersoekers pnd toeskryf aan kortikale wanfunksionering7 terwyl die probleem eerder in die retikulere formasie gesô ek behoort te word. dieselfde mening word gehuldig in verband met die striatum en "stamel. die geweldige omvang en wisseling van simptome kan alleenlik verklaar' word, indien die wisselwerking tussen die retikulere en limbiese sisteme in ag gene.em word. 1 empiriese bewyse in verband met stamel as 'n vorm van pnd in 'n onlangse navorsingsprojek22 is die hipotese gestel dat stamel een van . die vorms is wat pnd kan aanneem. stamel· is dan ook beskou as die manifes-. tasie van 'n, sentrale taalwanbalans,25 wat veral veruiterlik word in verbale journal of the south african speech and hearing association, vol. 23. december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) stamel en psigoneurologiese disfunksie 79 kommunikasie-afwykings. dit is toegeskryf aan afwykings in die koderingsprosesse, wat verbale uiting voorafgaan en al die verskillende kommunikasiekanale nadelig beinvloed. 'n spraakkubernetiese model is opgestel, waarvolgens 'n psigoneurologiese verklaring van die verskillende kenmerkende verbale kommunikasie-simptome moontlik is. omdat dit egter alleenlik moontlik was om die hipotese deur empiriese bevindings te bewys, is 'n omvattende, maar intensiewe interdissiplinere navorsingsprojek uitgevoer, waarin agt stamelaars, uit drie families, aan die volgende ondersoeke blootgestel is: 1. volledige neurologiese ondersoeke ' 2. elektroenkefalografiese ondersoeke 3. intelligensietoetsing 4. projeksietoetsing 5. persepsietoetsing 6. evaluasie van die kommunikasiesisteem en handeling (insluitende lees en spelling) 7. evaluasie van skolastiese prestasies 8. genetiese ontleding van familiegeskiedenisse met die oog op moontlike genetiese faktore. uit 'n kwalitatiewe analise van die toetsresultate, blyk dit dat al die agt proefpersone, in 'n mindere of meerdere mate, as persone met 'n psigoneurologiese disfunksie beskou kan word. al die verskillende simptome, wat by pnd voorkom is deur een of meer van die diagnostiese ondersoeke uitgelig by elkeen van die proefpersone. afdoende bewyse is dus gevind dat stamel 'n vorm van pnd is, met die kenmerkendste simptome gesentreer om spraak as kommunikasiemedium. kriteria vir die insluiting van toetse in die diagnostiese battery aangesien daar reeds bewys is dat stamel 'n vorm van pnd is, word die samestelling van 'n toetsbattery bepaal deur a) die vermoe van sekere toetse om al die verskillende simptome van pnd uit te lig b) die vermoe van sekere toetse om spesifiek die verbale kommunikasie abnormaliteite, kenmerkend van stamel, uit te lig. hier kan die diagnostikus gelei word deur die bevindings van vorige navorsers, tewete: russell, neuringer en goldstein17; schulman, kaspar en throne;18 francis-williams;4 joubert;7 weiss;25 goldschmidt;5 en vele ander. in die studie deur uys22 is 'n omvattende toetsbattery gebruik wat die volgende ondersoeke en toetse ingesluit het: genetiese ondersoek hierdie ondersoek dien alleenlik as aanduiding van familiale betrokkenheid. 'n tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 80 i.c. uys stamboom van elke familie word getrek, waarvolgens sekere afleidings, in verband met die voorkoms van stamel in families, gemaak kan word. gevalsgeskiedenis die gevalsgeskiedenis behoort so beplan te word dat dit nie alleenlik alle moontlike etiologiese faktore insluit nie, maar ook 'n evaluasie van die waargenome simptome van die pasient. aanduidings van familiale betrokkenheid kan hieruit verkry word. in bree trekke moet die volgende aspekte gedek word: voorgeboortelike geskiedenis; perinatale geskiedenis; postnatale geskiedenis; ontwikkelingsmylpale; familiegeskiedenis; akademiese prestasie; oorsake en simptome van die probleem. neurologiese evaluasie die neurologiese evaluasie kan in twee afdelings verdeel word, naamlik: 1. die elektroenkefalografiese ondersoek, waar 'n twaalf-kanaal eeg-apparaat beduidende resultate sal lewer. die bipolere metode van elektrodeplasing word aanbeveel. hoewel daar in menslike eeg-studies gewoonlik van drie eksperimentele toetse gebruik gemaak word7, is daar vir die diagnose van stamel alleenlik twee toetse noodsaaklik. photiese stimulasie vir die diagnose van epileptiese aanvalle word nie as noodsaaklik beskou nie. die „oe sluit-toets" stel die retilculere formasie en talamus in staat om alfa-sinchronisasie te bevorder en word dus aanbeveel.7 die hiperventilasie-toets veroorsaak sametrekking van die bloedvate en kan ook aanduidend wees van moontlike epilepsie.23 2. 'n lntensiewe neurologiese ondersoek behoort ingesluit te word sodat 'n kliniese evaluasie van die pasient moontlik is. in bree trekke moet die volgende aspekte hier gedek word: algemene neurologiese evaluasie; funksies van die dominante hemisfeer; funksies van die nie-dominante hemisfeer; funksies van beide hemisfere; motoriese funksies; sensoriese funksies; reflekse. psigometriese evaluasie die toetse wat in hierdie ondersoek gebruik word, kan in drie hoofgroepe verdeel word, volgens hulle vermoe om psigoneurologiese disfunksies aan te dui. intelligensie toetse. in die geval van afrikaanssprekende pasiente word die wechsler-bellevue intelligensieskaal vir volwassenes en die nuwe suid-afrikaanse intelligensieskaal vir kinders aanbeveel. vorige navorsing het reeds bewys gelewer van die diagnostiese waarde van hierdie intelligensietoetse.4'15'17'24 aan die hand van hierdie bevindings, word ook vir die diagnose van stamel 'n kwalitatiewe evaluasie van die resultate in die lig van die totale beeld aanbeveel. spesiale toetse vir visuele persepsie, visuele geheue, oog-hand-koordinasie en dus psigoneurologiese funksies: die volgende toetse kan hier van waarde wees, naamlik bender-gestalt, ellis visual designs, albasterbord-toets, grassi en draw a person. die bender gestalt en ellis visual designs kan mekaar in werklikheid vervang.2 in die toepassing van'die ellis visual designs kan die voorbeelde egter na 5 sekondes verwyder word, sodat die pasient op 'n geheuebeeld, dus integrasie van informasie, moet staatmaak. hierdie toets lewer dus journal of the south african speech and hearing association, vol. 23 december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) stamel en psigoneurologiese disfunksie 81 aanduidings van visuele geheuevermoens (integrasie), terwyl die bender gestalt veral waarneming van weergawe toets. die grassi kan as aanvullende toets vir volwassenes gebruik word, omdat die toets nie diskriminerend genoeg is vir die toepassing op kinders nie.2 1 persoonlikheidstoetse. vir persoonlikheidsmeting kan die rorschach, tematiese appersepsietoets (tat), draw a person (dap) en columbus picture analysis of growth towards maturity gebruik word. terwyl die rorschach bruikbaar is by volwassenes, is die columbus meer geskik vir kinders. al hierdie toetse het reeds bewys gelewer van 'n vermoe om psigoneurologiese disfunksies aan te d u i . 1 8 ' 6 sommige van hierdie toetse oorvleuel in 'n mate, maar kan ingesluit word waar sulke toetse vir meer as een doel gebruik word. met die uitsondering van die dap word die persoonlikheidstoetse vir die evaluering van persoonlikheid en die aanduiding van kompensatoriese meganismes gebruik. die ander toetse is weer nuttig vir die aanduiding van psigoneurologiese disfunksies. evaluasie van ouditiewe vermoens hierdie evaluasie berus op die resultate van twee groepe toetse. basiese ondersoeke is nodig vir die bepaling van die suiwertoondrempel, spraakontvangsdrempel en spraakdiskriminasievermoe. aangesien daar in die geval van pnd nie noodwendig perifere gehoorprobleme voorkom nie, kan die standaardprosedure by hierdie toetse gevolg word. spesiale ondersoeke na verskillende aspekte van ouditiewe vermoens is egter noodsaaklik in die diagnose van hierdie pasiente. aangesien daar nog 'n groot gebrek aan sulke toetse met afrikaanse norms bestaan, word die seashore measures of musical talents hiervoor aanbeveel. die fisiese dimensies van ouditiewe seine kan beskou word as die produk van frekwensie (psigies verteenwoordig as toonhoogte, terwyl die verskillende frekwensiesamestellings verteenwoordig word as timbre of toonkleur), intensiteits(psigies verteenwoordig as luidheid) en temporale faktore (psigies verteenwoordig as tydsduur, ritme en reekse). hierdie dimensies is almal ingesluit in die toets en kan aanduidend wees van psigoneurologiese disfunksies.8 hierdie toets bepaal hoofsaaklik twee aspekte van ouditiewe vermoens, naamlik: die waarneming en diskriminasie van toonhoogte, luidheid, ritme, tydsduur en timbre, sowel as ouditiewe klankgeheue. verbale kommunikasie-ondersoek aangesien daar geen gestandaardiseerde afrikaanse toetse bestaan vir die objektiewe meting van verbale kommunikasievaardighede nie, moet 'n ondersoekwyse ontwerp word wat met 'n redelike mate van sekerheid kwalitatief ontleed kan word. veral aangesien stamel hier ter sprake is, is dit noodsaaklik om hierdie aspekte meer volledig te ondersoek. 'n drieledige toets word aanbeveel vir die evaluasie van lees, skryf en spraak as 'n kommunikasiemedium. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 82 i.c. uys vir die leestoets kan die pasient eers 'n maklike leesstuk aangebied word waarmee sukses behaal kan word. dit sal egter die voorkoms van stamelsimptome na vore laat tree.2 5 hierdie stukke moet egter aangepas word by die pasient se ouderdom en akademiese stand. . . 'n moeilike leesstuk sal weer bepaal of enige disleksie-elemente teenwoordig is, terwyl die stamelsimptome sal afneem (met die verhoogde konsentrasie en bewustheid). die skryfvermoe kan getoets word deur van die pasient te verwag om 'n stuk van 'n gedrukte voorbeeld af te skryf, te skryf volgens diktee en 'n spontane skryftaak. hiermee word nie 'n volledige analise van die verskillende onvermoens beoog nie, maar alleenlik die vasstelling van ouditief-motoriese, visueelmotoriese en integrasie vermoens. die evaluasie van spraak as 'n kommunikasiemedium vereis nie inisieel 'n volledige linguistiese analise nie — eerder is van waarde 'n stel toetse om die verskillende vlakke van abstrahering (integrasie) en proposisionering te onderskei en sodoende stamelsimptome uit te lig. so kan die volgende take van die pasient verwag word: die beskrywing van 'n prent; storievertelling volgens 'n strokiesprent; storievertelling volgens een prent; spontane spraak. hierdie diagnostiese battery word as voldoende in omvang beskou, mits die ondersoekprosedure aan die volgende vereistes voldoen: a) die resultate moet 'n getroue weergawe van die pasient se beste pogings wees b) dit moet nie die pasient uitput nie . c) aangesien dit 'n multidissiplinere diagnostiese program is, behoort deskundiges op elke gebied die toetse af te neem. d) die omstandighede moet voldoen aan die vereistes van elke toets. evaluasie van die diagnostiese program hierdie diagnostiese program is getoets aan die hand van agt pasiente se resultate. in tabel 1 kan die vermoe van hierdie toetse, om al die verskillende simptome van pnd uit te lig, duidelik gesien word. die syfers in die kolomme is 'n aanduiding van hoeveel pasiente (uit agt) die spesifieke simptoom openbaar het. 'n evaluasie van die diagnostiese vermoe van die verskillende toetse, het die volgende gegewens aan die lig gebring: 1. die neurologiese ondersoeke het veral gedui op perseptueel-motoriese versteurings, twyfelagtige neurologiese tekens, en, in die geval van "die elektroenkefalogram ondersoek, onreelmatighede. 2. die intelligensietoetse is van groot diagnostiese waarde. perseptueel-motoriese versteurings, emosionele probleme, twyfelagtige neurologiese tekens en integrasieversteurings (denke en geheueversteurings) het veral uit hierdie toetsresultate geblyk. journal of the south african speech and hearing association, vol. 23 december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) stamel en psigoneurologiese disfunksie 83 simptome van psigoneurologiese disfunksie toetse h ip er ak ti w it ei t | pe rs ep tu ee lm ot or ie se aa n ta st in g e m os io ne le la bi lit ei t k ob rd in as ie ve rs te ur in gs a an da gs ve rs te ur in gs im pu ls iw it ei t d en ke -e n ge he ue . ve rs te ur in gs sp es if ie ke le er ge st re m dh ed e | sp ra ak ve rs te ur in gs g eh oo rve rs te ur in gs t w yf el ag ti ge ne ur ol og ie se te ke ns o nr ee lm at ig he de va n di e e e g . eeg 5 neurologiese ondersoek 1 8 3 2 2 1 8 wechsler/ n.s.a.i.s. 7 2 7 5 3 bender 5 7 3 6 2 4 1 8 ellis 3 7 2 3 2 3 5 8 dap. 3 4 7 3 1 1 7 grassi 1 1 albas terbord 7 2 1 1 5 5 rorschach/ columbus 1 5 4 1 2 4 tat. 7 2 2 oudiometriese ondersoek seashore 8 8 leestoets i 2 3 1 3 6 7 leestoets ii 3 1 3 6 5 skriftoets i 8 6 1 5 8 skriftoets ii 8 6 1 5 8 2 skriftoets iii 1 8 '7 1 5 8 spraaktoets i 1 8 spraaktoets ii 2 1 8 8 spraaktoets iii 2 1 8 8 spraaktoets iv 7 4 8 2 8 8 tabel 1: simptoomverspreiding na aanleiding van die toetsresultate. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23. desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 84 i.c. uys 3. toetse vir visuele vermoens is veral van diagnostiese waarde ten opsigte van perseptueel-motoriese versteurings, motoriese koordinasieprobleme, aandagsversteurings en twyfelagtige neurologiese tekens. dit blyk egter dat nie alle toetse vir visuele vermoens diagnosties ewe goed is nie. die grassi het opmerklik minder simptome aangedui as die ander en in 'n mindere mate ook die dap. die bender en ellis het geblyk die beste diagnostiese waarde te he. 4. persoonlikheidstoetse dui veral op emosionele versteurings en kompensasiemeganismes. in 'n mindere mate kan hieruit ook inligting in verband met integrasieprobleme en aandagsversteurings verkry word. die rorschach en columbus-toetse toon 'n beter diagnostiese vermoe as die tat. 5. toetse vir ouditiewe vermoens. die seashore toets is baie waardevol vir die bepaling van ouditiewe waarnemings-, diskriminasieen geheuefunksies. 6. leestoetse, veral waar dit verbind word met die ouditiewe en visuele funksies onderskeidelik, is aanduidend van integrasie-vermoens, spesifieke leergestremdhede en ook verskillende spraakafwykings. 7. die skriftoetse het veral aanduidings gelewer van perseptueel-motoriese versteurings, ko5rdinasie en integrasieprobleme, asook spesifieke leesonvermoens. 8. die spraaktoetse het, as gevolg van die gradering, gedui op integrasieprobleme, aandagsversteurings en hiperaktiwiteit. uiteraard het hierdie toetse die meeste inligting verskaf in verband met die voorkoms, verspreiding en aard van die verskillende spraakafwykings. alhoewel hierdie diagnostiese program dus toereikend blyk te wees vir die diagnose van stamel as 'n vorm van pnd, word dit in die vooruitsig gestel dat meer objektiewe metingstoetse van groter nut sal wees, veral met die oog op kwantitatiewe analises van resultate. daar is 'n groot behoefte aan gestandaardiseerde toetse met suid-afrikaanse norms. verwysings 1. arnold, g.e., (1970): an attempt to explain the causes of cluttering ' with the l.l.m.m. theory. folia phoniatrica. vol. 22, no. 4-5, 247-260. 2. aron, a.m. (1972): minimal cerebral dysfunction in childhood. j. comm. dis., vol. 5, no. 2, bl. 142-153. 3. bradford, d., (1970): cluttering. folia phoniatrica. vol. 22, no. 4-5, bl. 272-279. 4. francis-williams, j., (19 70): children with specific learning difficulties. pergamon press, n.y. 5. goldschmidt, p., (1970): a casuistic model of a logopedic assessment in private practice. folia phoniatrica. vol. 22, no. 4-5, bl. 289-300. 6. gunzberg, h.c., (1955): scope and limitations of the goodenough drawing test method in clinical work with mental defectives. j. clin., psycho., vol. 11, bl. 8-15. ! 7. joubert, m.j., (1969): psychoneurological dysfunction in school-going . children. ongepubliseerde proefskrif, universiteit van pretoria. journal of the south african speech and hearing association, vol. 23 december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) stamel en psigoneurologiese disfunksie 85 8. katz, j. (ed.), (1972): handbook of clinical audiology. the williams & wilkins co. baltimore. 9. krakowski, a.j., (1956): amitriptyline in treatment of hyperkinetic children: a double blind study. psychosomatics. vol. 6, bl. 355. 10. moruzzi, g. & magoun, h.w., (1949): brain stem reticular formation & activation of the e.e.g. electroencephalography & clinical neurophysiology. vol. 1, bl. 455. 11. murray, c.h. de c., (1969): verslag van die komitee van ondersoek na die opvoeding van kinders met minimale breindisfunksie. dept. van hoer onderwys, die statsdrukker, pretoria. 12. mussafia, m., (1970): various aspects of cluttering. folia phoniatrica. vol. 22, no. 4-5, bl. 337-346. 13. nebylitsyn, v., (1972): the basic properties of the nervous system. soviety science review. maart, bl. 113-120. 14. op't hof, j., (1973): die genetiese benadering tot leergestremdhede met spesiale verwysing na spesifieke leergestremdhede. referaat gelewer bu doe stogtomgslpmgres vam doe s.a. vereniging vir leeren opvoedingsmoeilikhede. 15. reitan, r.m. & boll, t.j., (1973): neurophysiological correlates of minimal brain dysfunction. annals new york academy sciences. vol. 205, bl. 65-88. 16. routtenberg, α., (1968): the two-arousal hypothesis: reticular formation & limbic system. psychological review. vol. 75, no. 1, bl. 51-80. 17. russell, e.w., neuringer, c. & goldstein, g., (1970): assessment of brain damage. a neuropsychological key approach. wiley-interscience, n.y. 18. schulman, j.l., kaspar, j.c. & throne, f.m., (1965): brain damage & behaviour. a clinical-experimental study. charles c. thomas springfield, iii. 19. seeman, m., (1965): sprachstorungen beikindern. v.e.b. verlag. volk und gesundheit, berlin-jena. 20. seeman, m., (1970): relations between motorics of speech and general motor ability in clutterers. folia phoniatrica. vol. 22, no. 4-5, bl. 376-380. 21. steyn, d., (1973): kliniese sielkundige, dept. spraakwetenskap, spraakheelkunde en oudiologie, universiteit van pretoria. persoonlike onderhoude. 22. uys, i.c., (1974): psigoneurologiese disfunksie: 'n tipering volgens sekere spraakpatologiese verskynsels. ongepubliseerde proefskrif, universiteit van pretoria. 23. van der merwe, h.p. (1973): persoonlike mededeling. neuroloog, h.f. verwoerd hospitaal, pretoria. 24. wechsler, d., (1949): manual wechsler intelligence scale for children. the psychological corporation, n.y. 25. weiss, d.a. (1964): cluttering. speech foundation series. prenticehall inc., englewood cliffs, n.j. 26. wender, p.h., (1971): minimal brain dysfunction in children. wileyinterscience, n.y. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustimed (pty.) ltd. (edms.) bpk. s o u t h a f r i c a n m a n u f a c t u r e r s of * audiometers and sound proof rooms * speech trainers and group systems * hearing aids and components we provide a repair service for all makes of hearing aids and manufacture all types of earmoulds including clear soft moulds. please w r i t e or call: acoustimed (pty) ltd., 302 sandowim centre, maud st., sandown 2196, johannesburg. p.o. box 782131, sandton 2146 radio telephone: dial 213361 ask for code 564, channel 4. journal of the south african speech and hearing association vol. 23. december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die m o e d e r k i n d v e r h o u d i n g by kinders met 'n gesplete lip en/of v e r h e m e l t e en minimale-breindisfunksie ronel steenekamp b . a . ( l o g ) ( p r e t . ) alberton kinderleidingkliniek, privaatsak x2805, alberton, 1450. opsomming die doel van hierdie studie is om die invloed van 'n fisies waarneembare afwyking en 'n fisies nie-waarneembare afwyking op die moeder-kind-verhouding na te gaan. die moeder-kind-verhouding by twee verskillende afwykings nl. gesplete lip en/of verhemelte en minimale-brein-disfunksie is bestudeer. die verhouding tussen die moeder en haar kind is 'n kritiese faktor in die algemene ontwikkeling van die kind. die kwaliteit van die verhouding kan 'n invloed he op latere verhoudinge wat die kind in sy lewe aangaan. daar is gevind dat pre-, perien postnatalegebeure hierdie verhouding kan bei'nvloed. 'n werkhipotese is gestel nl. dat die moeder-kind-verhouding betekenisvol swakker is by die ondersoekgroepe as die van die kontrolegroep. ten einde die hipotese te bewys is "the mother-child-relationship evaluation"-vraelys ingevul deur moeders met kinders met die genoemde afwykings. daar is egter gevind dat daar nie 'n beduidende verskil is in die moeder-kind-verhouding van moeders met kinders wat 'n gesplete lip en/of verhemelte het nie. moeders met kinders met minimale-brein-disfunksie, is egter geneig om did kinders te verwerp. summary the aim of this study is to investigate the influence of a physically observable defect and a non-observable defect on the mother-child relationship. mother-child relationships of two defects viz. cleft lip and/or palate and minimal brain dysfunction were studied. the relationship between a mother and her child is a critical factor in the overall development of the child. the quality of the relationship can influence the child's subsequent relationships. it has been found that preperiand postnatal events can influence this relationship. a working hypothesis was postulated viz. that the mother-child relationship is significantly weaker in the experimental groups than in the control group. to prove this hypotheses, the "mother-child-relationship evaluation" questionnaire was completed by mothers of children with the mentioned defects. however, it was found that there is no significant difference in the mother-child relationship in mothers of children with a cleft lip and/or palate. however, mothers of children with minimal brain dysfunction are inclined to reject these children. die verhouding wat bestaan tussen die moeder en haar kind met 'n gesplete lip en/of verhemelte of haar kind met minimale-breindisfunksie is van teoretiese en praktiese belang. die moeder-kindverhouding is 'n kritiese komponent in die aanpassing van elke kind op 'n latere stadium van sy lewe. die verhouding het egter ook 'n invloed op die kind se spraak en taalontwikkeling. enige teoretiese begrip van die kind met 'n gesplete lip en/of verhemelte of minimale-breindisfunksie en sy ontwikkeling, moet 'n studie insluit van die moeder se reaksie op die inisiele kennisneming van haar kind se probleem, hoe hierdie reaksie verander het met verloop van tyd, hoe hierdie reaksie the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) moeder-kind verhouding 109 bygedra het tot die kind se spraakvaardigheid asook die algemene aanpassing van die kind. die toepassing van hierdie kennis kom tot uiting in die beplanning van 'n remedierende program vir die kind. die spraakterapeut moet bepaal wat die houding van die moeder is t.o.v. haar kind met 'n gesplete lip en/of verhemelte of minimale-brein-disfunksie en of hierdie verhouding 'n invloed het op prognose of die spraakprobleem teenwoordig. hierdie verhouding moet dus in ag geneem word by die opstel van 'n terapieprogram. die doel van hierdie studie is dus om die invloed van 'n fisies waarneembare afwyking en 'n fisies nie-waarneembare afwyking op die moeder-kind-verhouding na te gaan. die vraag is of die moeder-kindverhouding by die kind met 'n gesplete lip en/of verhemelte of minimale-brein-disfunksie verskil in vergelyking met die moeder-kindverhouding by normale kinders. die verhouding tussen die moeder en kind is essensieel vir die voortbestaan en ontwikkeling van die kind. hierdie verbintenis tussen die moeder en haar kind is waarskynlik die sterkste verbintenis wat die mens aangaan. die aanvanklike verhouding is 'n kritiese faktor in die algemene ontwikkeling van die kind. meer spesifiek het dit 'n invloed op die intellektuele en verbaal-linguistiese ontwikkeling. die sterkte en kwaliteit van hierdie verhouding kan ook 'n invloed he op die latere verhoudings wat die kind in sy lewe aangaan. die houding van die moeder kan ook die kind se aanvaarding van homself en dus sy selfbeeld bei'nvloed. tydens die periode van swangerskap vind daar baie emosionele skommelinge plaas, positief en negatief. die moeder moet leer om haar verantwoordelikhede te verplaas van haarself na haar kind. sy moet tot aanvaarding kom van die swangerskap en besef dat sy moeder word. sy moet identifiseer met die fetus as integrale deel van haarself, maar ook van die fetus as individu. hierdie aanvaarding ontstaan tydens die beweging van die fetus in die uterus. die perinatale periode is 'n periode van uiterste sielkundige kwesbaarheid a.g.v. die fisiese en psigiese veranderinge wat plaasvind by die moeder en haar kind. die geboorte is die klimaks van die swangerskap. die moeder sien uit daarna om haar kind te aanskou. die geboorte is die finale resultate van haar konflikte a.g:v. angs en vrees vir swangerskap en geboorte. gebeure tydens die geboorteproses kan die moeder be'invloed in die ontwikkeling van 'n verhouding met haar kind. indien dit nie 'n normale geboorte was nie, kan die moeder skuldig voel omdat sy beheer verloor het tydens die geboorteproses. postnatale depressie kan hieraan toegeskryf word. die moeder benut dus nie die periode direk na geboorte om 'n verhouding met haar kind te ontwikkel nie weens die invloed van verdowingsmiddels op haar en haar kind en postnatale ongerief. die tydperk direk na geboorte word deur verskeie outoriteite as 'n uiters kritiese periode beskou in die ontwikkeling van die die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 110 ronel steenekamp moeder-kind-verhouding. die periode is baie kort en 'n komplekse interaksie bind die moeder en haar kind saam. tydens die periode verkry die moeder oogkontak met haar kind, sy streel en soen hom, borsvoeding vind plaas en sy praat met die baba ten einde sy aandag te behou. gedurende die eerste paar weke na geboorte word interaksie hoofsaaklik deur die huil van die baba bewerkstellig. die huil bring die moeder in die posisie waar visuele, olfaktoriese en taktiele stimuli van waarde is. glimlag word ook gebruik om die moeder naby die baba te hou. 'n glimlag is belonend vir die moeder, sy bly dus naby die baba en voorsien in sy behoeftes. glimlag het vertroeteling tot gevolg en versterk vertroeteling, daarom is dit een van die belangrikste reaksies in die moeder-kind-verhouding. vokalisasie word ook as 'n veranderlike in hierdie komplekse moeder-kind-interaksie beskou. tydens interaksie is die moeder altyd besig om met haar baba te praat of te vokaliseer. dit maak dus deel uit van haar stimulasie. haar houding sal die hoeveelheid spontane ,,gesprekvoering" bepaal. die baba se reaksie op haar vokalisasie sal ook bepaal hoeveel sy met die baba gaan praat. die moeder praat nie net met haar baba nie, maar moedig hom aan om ook met haar te praat. klaus & kennel3 voel dat kommunikasie beweging insluit. die baba beweeg in ooreenstemming met die volwassene se spraak. die moeder sal dus met die baba praat om reaksie uit te lok. sosiale interaksie ontwikkel geleidelik uit hierdie vroee verhouding met die moeder, namate die huil van die baba afneem en die tyd wat hy wakker is toeneem. daar is dus nou meer geleentheid tot speelinteraksie. een van die sterkste faktore in vroee sosiale interaksie is spontane spel. die baba sal baie meer babbel tydens spel, wat by die moeder die gevoel laat dat dit wat sy doen wel iets beteken. indien die moeder by die kind is in vreemde situasies, tussen vreemde mense, sal die kind weg beweeg van haar en die nuwe omgewing ondersoek. dit is belangrik dat die kind die moeder verlaat en leer omtrent die groter wereld. hy moet dus onafhanklik raak om te funksioneer as volwassene in die samelewing. die kind moet in interaksie verkeer met die lewelose omgewing en met ander lede van sy sosiale omgewing behalwe die moeder. die moeder-kind-verhouding moet nie hierdie eksplorasie verhoed nie. symonds9 onderskei tussen vier houdings wat by die moeder aahwesig kan wees t.o.v. haar kind nl. verwerping, oortoegeeflikheid, oorbeskerming en aanvaarding. aanvaarding teenoor verwerping word beskou as die fundamentele elemente van die verhouding. dit is die mate van aanvaarding wat die ander aspekte van die moeder se gedrag bepaal. aanvaarding of verwerping van die kind word deur verskillende outoriteite as 'n primere faktor in die etiologie van spraakprobleme beskou. | die geboorte van 'n kind is die hoogtepunt van die moeder se verwagtinge en omsluit haar toekomsdrome, daarom is die geboorte the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) moeder-kind verhouding 111 van 'n kind met 'n gesplete lip en/of verhemelte 'n skok vir elke moeder. die kind verskil van die beeld wat die moeder opgebou het tydens swangerskap. die voorkoms van die kind bei'nvloed die proses van eksternalisasie van 'n interne beeld wat gedurende die nege maande gegroei het. in plaas daarvan om die kind waarvan sy gedroom het te baar, het sy die een gebaar wat sy gevrees het sy sal baar. die gevolg kan verwerping of oorbeskerming wees. die moeder word dus oorweldig deur 'n konflik van positiewe en negatiewe gevoelens wat bewus of onbewus kan wees. verskillende vrae sal by die moeder ontstaan t.o.v. die uiterlike voorkoms van die kind, reaksie van die vader, familie en vriende, die oorsaak en oorerflikheid van die afwyking en finansiele probleme. die reaksie van die moeder op die vrae word bepaal deur die wyse waarop dit beantwoord word. hierdie antwoorde bepaal die langtermyn probleme waarvoor sy nou te staan kom. voor optimale ontwikkeling van 'n moeder-kind-verhouding kan begin, moet die moeder haar skuld-, angsen onsekerheidsgevoelens verwerk. die kritiese periode word dus nie benut nie a.g.v. angs omtrent die kind se toestand, gevoelens van mislukking en hulpeloosheid en fisiese skeiding van die moeder en haar kind. sommige moeders kan nie tot aanvaarding kom van die kind met sy afwyking nie. hulle verkeer vir maande in 'n toestand van selfverwyt en bejammering. as reaksie op haar negatiewe gevoelens teenoor haar kind, ontstaan skuldgevoelens wat die verhouding met haar kind van die begin af bei'nvloed. dit het oorbeskerming tot gevolg. die feit dat meeste babas met 'n gesplete lipen/of verhemelte nie geborsvoed kan word nie, dra ook by tot die emosionele konflik van die moeder. die baba moet versigtig gevoed word, in 'n spesiale posisie gehou word, meer toegelaat word om winde op te breek en meer gereeld gevoed word. die moeder moet spesiale voedingsmetodes gebruik wat die abnormaliteit van die kind beklemtoon. voeding is nie meer 'n tyd van plesier en vertroeteling nie. die herstel van die lip en prepalatale spleet sal plaasvind gedurende die eerste drie maande na geboorte en voor die kind drie jaar oud is, sal die palatale spleet herstel word. voordat die kind skool toe gaan, sal hy reeds twee, drie of vier operasies ondergaan het om die spleet bevredigend te herstel. elke operasie impliseer skeiding van die moeder, narkose, pyn van die orale omgewing en tydelike beperking van die bewegings van die hande en arms om manipulering van die operatiewe areas te voorkom. skeidingsangs ontstaan by die kind en die moeder tydens hierdie operatiewe tydperk. die moeder toon ook vrees t.o.v. operatiewe prosedures en gevolge. die moeder-kind-verhouding is die primere area van versteuring. hospitalisasie onderbreek roetine en die lewenssiklus van die kind. die spraak en psigolinguistiese vermoens van die kind is ook dikwels afwykend wat die gevolg is van orale onvermoens, maar ook weens 'n die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 112 ronel steenekamp gebrek aan stimulasie en die feit dat die kritiese periode nie ten voile benut is nie. die moeder is bewus daarvan dat spraakprobleme voorkom by die kind en daarom moedig sy nie die kind aan om te praat nie. daar word laer vereistes t.o.v. sy spraaken taalgebruik gestel. sommige moeders kritiseer van die begin af die kind se spraakpogings, wat by die kind die gevoel laat dat sy spraak onverstaanbaar is. hy kan ook voel dat hy nie sy moeder tevrede stel nie. hierdie spraakprobleme beklemtoon ook die kind se andersheid by die moeder en later by die kind self. die kind met 'n gesplete lip en/of verhemelte vereis voortdurende gespesialiseerde aandag en ondersoeke. dit vereis finansieel baie van die ouers ten koste van ander behoeftes. die moeder ondervind dus uiterste angs t.o.v. haar kind se probleme tydens die groeitydperk. die emosionele omgewing is dus gestrem van geboorte af en bly dikwels abnormaal tydens die opgroei van die kind. die moeder ervaar verskillende houdings van familie, vriende en vreemde persone weens die andersheid van haar kind, wat die normale ontwikkeling van 'n verhouding met haar kind strem. precht7 beweer dat abnormaliteite tydens swangerskap en geboorte 'n uiters belangrike faktor is in die etiologie van neurologiese abnormaliteite. hy vind dat tot 68% van kinders waar probleme preof perinataal voorgekom het, neurologiese abnormaliteite vertoon. volgens precht het 70% van hierdie neurologies gestremde kinders spiertremors getoon van alle liggaamspiere, asook hiperaktiwiteit, gedragsprobleme en emosionele onstabiliteit. hulle het ook op 'n later stadium leerprobleme getoon op skool. die geboorte van 'n premature baba kan beskou word as 'n psigososiale krisis wat 'n besliste emosionele invloed op die moeder het. sy moet eerstens die moontlikheid aanvaar dat sy haar kind kan verloor deur die dood. tweedens moet sy die gevoel dat sy nie 'n normale kind kan baar nie, aanvaar en verwerk. derdens moet sy na die inisiele skeiding, tydens die kritiese periode, 'n verhouding met haar kind opbou en vierdens moet sy aanpas by die bepaalde ontwikkeling van 'n premature baba. meeste van die moeders ervaar dus gevoelens van angs en skuld. die feit dat die moeder van haar kind geskei word, verhoog haar skuldgevoelens. die skeiding laat haar voel dat sy nie in staat is om na haar eie kind om te sien nie. die minimale-brein-disfunksie-sindroom, wat waarskynlik meestal die gevolg is van preof postnatale komplikasies, het 'n besliste invloed op die gedragspatrone van die kind, maar nie in so 'n mate dat die moeder professionele hulp verkry nie. so 'n kind kan die moeder egter uitermatig irriteer, wat oorangstigheid1, oorbeskerming of verwerping van die kind tot gevolg kan he. | die minimale-brein-disfunksie-sindroom kan in twee vorme voorkom nl. die hipokinetiese kind, wat ook dikwels hipotonies is, apaties, stadig en min drink en swak reageer op stimuli. aangesien hierdie the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) moeder-kind verhouding 113 kind minder huil as die normale kind, beskou die moeder hom as 'n "soet" kind. daar ontstaan dikwels by die moeder 'n vrees dat sy die slap baba kan seermaak. aangesien die kind swak reageer op stimuli, sal die moeder hierdeur bei'nvloed word. die moeder sal minder stimuli aan die kind bied, omdat hy minder stimuli bied en swak reageer op haar stimuli. die baba se slaperigheid, huiwerige bewegings en reaksies en uitdrukkinglose gesig, kan die ontwikkeling van 'n normale moeder-kind-verhouding bei'nvloed. meestal is hierdie kinders egter hiperaktiewe kinders, hipertonus kom voor, die baba huil baie, 'n lae drempel kom voor t.o.v. die mororefleks, hy word moeilik wakker, maar raak ook weer moeilik aan die slaap. die kind word moeilik getroos as hy begin huil. 'n lae frekwensie tremor word getoon. hy skrik maklik en kom angstig voor. voedingsprobleme word getoon. a.g.v. 'n swak suigrefleks en braking. baie angs is by die moeders teenwoordig. hulle voel dat hulle die kind mishandel en ontwikkel skuldgevoelens. die kinders is dus nie maklike deelnemers aan die moeder-kind-verhouding nie en die ontwikkeling van 'n gebalanseerde verhouding word bei'nvloed. precht7 het gevind dat die moeders nie bewus was daarvan dat hierdie simptome tekens is van minimale-brein-disfunksie nie. hierdie gedrag het by hulle kommer gewek en hulle gei'rriteer. hulle het hierdie simptome as deel van die kind se temperament en persoonlikheid beskou. die gedrag het die moeder se gedrag en vertroeteling van haar kind bei'nvloed. die moeders het nie 'n harmonieuse, positiewe houding teenoor hulle kinders geopenbaar nie. die moeders was bekommerd of hulle die kind korrek hanteer. die kind se gedrag het nie die moeder tevrede gestel nie en die gevolg was dat die moeder onrustig gevoel het. fisiese uitputting kom by die moeders voor, aangesien die kind uiters baie energie vereis van die moeder weens sy swak eeten slaappatroon en ontydige gehuil. die moeder is dus ongeduldig en gei'rriteerd wat haar verhouding met hierdie kind, sowel as ander kinders in die gesin en die vader bei'nvloed. dit lei tot rusies en wrywing. vyandigheid kan ontstaan teenoor die kind wat lei tot oortoegeeflikheid of verwerping. infantiliteit van die kind veroorsaak dat hy afhanklik bly van die moeder en wat daartoe lei dat sy die kind kan oorbeskerm. die moeder se emosionele houding, vyandigheid, angstigheid en depressie word oorgedra aan die kind as verwerping. die kind se reaksies is dan 'n terugvoering van die moeder se houding. verwerping word getoon in die kind se soeke na liefde en pogings om aandag te kry in so 'n mate dat hy nie belangstelling ontwikkel in die buitewereld nie. hierdie kinders toon kenmerkende ontwikkelingsprobleme, wat taalontwikkeling insluit, waarskynlik a.g.v. 'n vertraging in die maturasie van die dele van die brein wat betrokke is by motoriese koordinasie en taal. hierdie spraak en taalprobleme word getoon in vertraagde ontwikkeling, artikulasie afwykings, hakkel en stamel. sy die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 114 ronel steenekamp taalontwikkeling is egter nie net stadig nie, maar manifesteer deur sy lewe in sy lees en spelprobleme en swak woordeskat. hierdie probleme kan egter ook toegeskryf word aan 'n gebrek aan stimulasie tydens die kritiese periode en die houding van die moeder teenoor haar kind. uit hierdie literatuurstudie kan daar dus tot die gevolgtrekking gekom word, dat moeder-kind-verhoudings waarskynlik versteur kan wees by moeders met kinders wat 'n gesplete lip en/of verhemelte of minimale-brein-disfunksie het. tydens die ontwikkeling van hierdie versteurde moeder-kind-verhouding is die kind se linguistiese en taalontwikkeling ook bei'nvloed. spraak en taalafwykings by hierdie kinders kan dus ook aan hierdie versteurde moeder-kind-verhouding toegeskryf word, afgesien van organiese afwykings teenwoordig. eksperimentele ontwerp 1 . fflpotese-stelling 'n nulhipotese-stelling word t.o.v. elke groep gestel. hq daar is geen beduidende verskil tussen die moeder-kindverhouding van die onderskeie ondersoekgroepe en die kontrole groep nie. 'n werkhipotese word hierteenoor gestel. hi die moeder-kind-verhouding is betekenisvol swakker by die onderskeie ondersoekgroepe as die van die kontrolegroep. h 2 die moeder-kind-verhouding van die ondersoekgroepe is betekenisvol beter as die van die kontrolegroep. 2 . doelstellings die doel van hierdie ondersoek is tweeledig nl. — die bepaling van die aard van die moeder-kind-verhouding by moeders met 'n kind met 'n gesplete lip en/of verhemelte of minimale-brein-disfunksie teenoor moeders met normale kinders. — die berekening van die verband tussen bepaalde gesinsveranderlikes en die moeder-kind-verhouding. 3 . proefpersone kriteria van seleksie κ (a) die kontrolegroep / / die moeders in die kontrolegroep mag geen kind he met enige fisiese abnormaliteite of spraak-probleme nie. die swangerskap en geboorte van die betrokke kind moet relatief normaal verloop het, geen voedingsprobleme moet voorgekom het nie, 'n relatief normale ontwikkelingsverloop moet voorgekom het en geen gedragsafwykings mag getoon word nie, aangesien hierdie faktore is wat die normale ontwikkeling van die moeder-kind-verhouding kan bei'nvloed. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) moeder-kind verhouding 115 (b) die gesplete lip en/of verhemeltegroep die moeders moet een of meer kinders he met 'n gesplete lip en/of verhemelte met gevolglike sekondere probleme soos voedingsprobleme, spraak-afwykings, emosionele probleme, sosiale probleme, ortodontiese probleme en afwykings van gehoor. (c) die minimale-brein-disfunksiegroep die moeders moet een of meer kinders he met minimale-breindisfunksie d.w.s. die kind moet 'n preof perinatale geboortegeskiedenis toon. daar moet faktore aanwesig wees soos voedingsprobleme, die kind moet 'n huilerige baba gewees het, wat min geglimlag en vokaliseer het, met 'n vertraagde ontwikkelingsgeskiedenis. die kind moet hiperof hipo-aktief wees, gedragsprobleme toon, kort aandagspan asook emosionele onstabiliteit. sover moontlik is die kind deur 'n spesialis as 'n kind met minimale-brein-disfunksie gediagnoseer. die kind moet egter ook 'n spraakafwyking toon soos artikulasieof taalafwykings, hakkel, stamel of disleksie. omskrywing van die groepe twee ondersoekgroepe is gebruik nl. — twintig moeders, waarvan vyftien afrikaanssprekend was en vyf engelssprekend, met 'n kind met 'n gesplete lip en/of verhemelte. twaalf van hierdie kinders was seuns en agt dogters. — vier en twintig moeders, waarvan vyftien afrikaanssprekend was en nege engelssprekend, met 'n kind met minimale-breindisfunksie plus 'n spraakafwyking. twintig van hierdie kinders was seuns en vier dogters. een kontrolegroep is gebruik bestaande uit— — vier en dertig moeders, waarvan sewe en twintig afrikaanssprekend en sewe engelssprekend was, met normale kinders d.w.s. kinders sonder 'n fisiese-.of spraakgebrek. sestien van hierdie kinders was seuns en agtien dogters. verskeie gesinsveranderlikes is sover moontlik konstant gehou by al drie groepe. (tabel 1.) die gemiddelde ouderdom van die moeders, van al drie groepe, was 35 jaar, die gemiddelde aantal kinders wat die moeders gehad het, was drie kinders. die gemiddelde geboorte-orde van hierdie kinders was twee en die gemiddelde ouderdom van die kinders was sewe jaar. die sosio-ekonomiese klas van hierdie groepe is ook sover moontlik konstant gehou deur besonderhede te verkry van die beroep van die vader, sowel as die van die moeder asook die woonbuurt waar hulle woonagtig is. die moeders kom oorwegend uit 'n gemiddelde-sosio-ekonomiese klas. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 116 ronel steenekamp tabel i: g e s i n s v e r a n d e r l i k e s b e t r o k k e by die o n d e r s k e i e g r o e p e . standaard τ grade van beduidenveranderlike gemiddeld afwyking waarde vryheid heidsvlak gemiddelde ouderdom van moeder: kontrole 33,70 5,885 gesplete lip 34,30 5,292 0 , 3 7 52 0,712 m b d 35,33 3,931 1 , 1 8 56 0,243 gemiddelde aantal kinders: kontrole 2,50 0,896 gesplete lip 2,70 1,129 0 , 7 2 52 0,476 m b d 3,16 1,129 2 , 5 0 56 0,015* gemiddelde geboorte-orde: kontrole 1,73 0,898 gesplete lip 2,00 1,170 0 , 9 3 52 0,355 m b d 2,16 1,239 1 , 5 4 56 0,130 gemiddelde ouderdom van kind: kontrole 6,91 2,800 gesplete lip 6,90 4,621 0,01 52 0,991 mbd 7,37 3,005 0 , 6 0 56 0,550 *beduidend op die 5% vlak 4 . toetsmateriaal omskrywing van die toetsmateriaal die toetsmateriaal bestaan uit 'n vraelys nl. "the mother-childrelationship-evaluation"-vraelys. die vraelys is opgestel deur robert m. r o t h 8 en gepubliseer deur die western psychological services, california. die vraelys verskaf 'n meetinstrument vir die bepaling van moeders se houdings teenoor hulle kinders. dit evalueer die moeder-kind-verhouding objektief in terme van vier houdingskale te wete: aanvaarding (a)—12 items oorbeskerming (ob) — 12 items oortoegeeflikheid (ot) — 12 items verwerping (v) — 12 items twee pole word weergegee in hierdie vraelys nl. aanvaarding teenoor nie-aanvaarding. oorbeskerming, verwerping en oortoegeeflikheid is vorme van nie-aanvaarding. die houding van die moeder kan 'n positiewe en negatiewe karakter toon. dit is moontlik dat 'n moeder vyandig voel teenoor haar kind en die kind aanvaar. i hierdie vraelys is vertaal in afrikaans, taalkundig nagesien en deur 'n sielkundige aan die universiteit van pretoria goedgekeur as 'n betroubare weergawe van die oorspronklike. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) moeder-kind verhouding 117 kriteria van keuse die "mother-child-relationship-evaluation"-vraelys (mcre) is gekies aangesien dit die enigste vraelys beskikbaar is wat gebaseer is op medinnus en johnson 4 se teoretiese model wat verwerping teenoor aanvaarding asook oortoegeeflikheid en oorbeskerming as 'n houding teenwoordig by die moeder insluit. verder voldoen die vraelys ook aan die statistiese kriteria van betroubaarheid en geldigheid. 5 . prosedure verkryging van proefpersone name en adresse van kinders met genoemde afwykings is verkry van die kliniekhoofde aan die spraaken gehoorkliniek van die universiteit van pretoria, van die spraakkliniek by die h. f. verwoerdhospitaal in pretoria, 'n remedierende onderwyseres in pretoria en 'n chirurg in pretoria. name van moeders met normale kinders is verkry van 'n privaat creche in pretoria en 'n staatsdepartement in pretoria. toepassing . die vraelyste is onder verskillende omstandighede aan die moeders oorhandig en ingevul. sommige moeders het die vraelys ontvang van die terapeut betrokke by hulle kinders se spraakterapie, die vraelyste is by die kliniek ingevul of tuis. sommige van die vraelyste is aan die moeders persoonlik oorhandig en tuis ingevul, ander vraelyste is aan die moeders gepos nadat hulle telefonies gekontak is. alle moeders kon egter nie gekontak word nie; vraelyste is dus slegs uitgepos. die voltooide vraelyste is weer aan die betrokke terapeute oorhandig of aan die ondersoekster self. vraelyste wat uitgepos is, is teruggepos. nasien en berekening van skale elke stelling word bereken in terme van 'n vyfpuntskaal. regs van elke stelling word die skale aangegee nl. ss (stem sterk saam), s (stem saam), ο (onseker), v (verskil) en sv (sterk verskil). die nommerwaardes 5 4 3 2 1 bokant die response is die individuele roupunte vir elke respons. regs van elke stelling is die letters a-ob-ot-v-vd. hierdie letters identifiseer die houdingsskale. ten einde die roupunt te bereken van die houdingskale van bv. verwerping (v) word al die nommerwaardes van die respons ge'identifiseer deur die letter v, op te tel. dieselfde metode word gevolg vir oorbeskerming (ob), oortoegeeflikheid (οτ), aanvaarding (a). hoe hoer die skaaltelling, hoe sterker is die houding. hoe laer die skaaltelling, hoe swakker is die houding. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 118 ronel steenekamp statistiese verwerking die data is verwerk met behulp van die universiteit van pretoria se ibm 370 rekenoutomaat. die "statistical package for the social sciences" (spss) rekenaarprogram is vir die doel gebruik. die volgende subprogramme is betrek: — berekening van die beduidendheid van verskille tussen die groepe (t-toets). — produk-moment-korrelasie. die statistiese formules wat betrekking het op bogenoemde berekenings word deur nie et al 6 volledig bespreek. resultate agt en sewentig vraelyste is terugontvang en verwerk. hiervan was 34 van toepassing op die kontrolegroep, 24 op die minimale-breindisfunksiegroep en 20 op die gesplete verhemeltegroep. (die bevindings word in tabel 2 tot 6 weergegee.) 1 . die aard van die moeder-kind-verhouding dit blyk dat daar 'n statistics beduidende verwerpingsingesteldheid teenwoordig is by die moeders met kinders met minimale-breindisfunksie en 'n spraakafwyking. alhoewel nie statistics beduidend nie, neig hierdie moeders ook om hulle kinders te oorbeskerm. hierdie resultate kom ooreen met die van ander studies. aangesien hierdie kinders uiters baie energie vereis a.g.v. hulle swak eeten slaappatroon, ontydige gehuil, hiperof hipoaktiwiteit, emosionele onstabiliteit en swak aandagspan, kan daar by die moeder 'n vyandigheid ontstaan teenoor die kind wat daartoe lei dat die moeder die kind verwerp. infantiliteit van die kind veroorsaak dat hy afhanklik bly van die moeder wat daartoe lei dat sy hom oorbeskerm. precht7 bevestig hierdie resultate in sy studie "the mother-child interaction in babies with minimal brain damage" (sien tabel 2). daar kan tot die gevolgtrekking gekom word dat daar nie 'n beduidend nie (sien tabel 3). hierdie resultate kom ooreen met die kinders en moeders met gesplete lip en/of verhemeltekinders nie. daar is egter 'n neiging tot oorbeskerming, maar dit is nie statistics beduidend nie (sien tabel 3). hierdie· resultate kom ooreen-met die van g o o d s t e i n . 1 ' 2 goodstein vind ook geen beduidende verskil in die gesindheid van moeders met kinders met 'n gesplete lip en/of verhemelte nie en moeders met normale kinders nie. die neiging tot oorbeskerming by die moeders kan verklaar word deur palmer se semantiese teorie. hy beweer datj 'n semantiese fout ontstaan a.g.v. die "gesond-siek" digotomie. die moeder beskou dus haar kind met 'n gesplete lip en/of verhemelte as 'n ,,siek" kind en neig om hom te oorbeskerm. ι ι the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) m o e d e r k i n d v e r h o u d i n g 1 1 9 2 . die verband tussen die bepaalde gesinsveranderlikes en die moeder-kind-verhouding d i e v e r b a n d is o o k b e r e k e n t u s s e n d i e h o u d i n g v a n d i e m o e d e r e n d i e b e p a a l d e g e s i n s v e r a n d e r l i k e s v i r d i e d r i e g r o e p e g e s a m e n t l i k . d i t i s g e d o e n v o l g e n s p e a r s o n s e p r o d u k m o m e n t k o r r e l a s i e t e g n i e k ( s i e n t a b e l 4 ) . tabel ii: b e d u i d e n h e i d van verskille in die m o e d e r k i n d v e r h o u d i n g tussen die k o n t r o l e g r o e p e n die m i n i m a l e b r e i n d i s f u n k s i e g r o e p veranderlikes gemiddeld standaard afwyking τ waarde grade van vryheid beduidenheidsvlak oorbeskerming: kontrole mbd 34,47 37,75 6,881 6,589 1,82 56 0,074 verwerping: kontrole mbd 32,05 35,00 4,445 5,927 2,16 56 0,035* oortoegeeflikheid: kontrole mbd 31,88 33,83 5,068 6,844 1,25 56 0,217 aanvaarding: kontrole mbd 36,44 36,37 5,685 6,398 0,04 56 0,967 'beduidend op die 5% vlak. tabel iii: b e d u i d e n h e i d v a n verskille in die m o e d e r k i n d v e r h o u d i n g tussen die k o n t r o l e g r o e p e n die g e s p l e t e lip e n / o f v e r h e m e l t e g r o e p veranderlikes gemiddeld standaard afwyking τ waarde grade van vryheid beduidenheidsvlak oorbeskerming: kontrole gesplete lip 34,47 38,05 6,881 7,097 1,82 52 0,074 verwerping: kontrole gesplete lip 32,05 34,65 4,445 6,556 1,73 52 0,090 oortoegeeflikheid: kontrole gesplete lip 31,88 33,15 5,068 5,153 0,85 52 0 , 3 8 2 aanvaarding: kontrole gesplete lip 36,44 35,55 5,685 14,796 0,59 52 0,559 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 120 ronel steenekamp tabel i v : v e r b a n d tussen b e p a a l d e g e s i n s v e r a n d e r l i k e s e n die m o e d e r k i n d v e r h o u d i n g vir die drie g r o e p e g e s a m e n t l i k ( n = 78). veranderlikes oorbeskerming r verwerping γ oortoegeeflikheid γ aanvaarding r ouderdom van moeder 0,0910 ρ = 0,214 0,0738 ρ = 0,260 0,0491 ρ = 0,335 0,0504 ρ = 0,331 aantal kinders 0,0061 ρ = 0,479 0,0416 ρ = 0,359 0,0295 ρ = 0,899 0,0448 ρ = 0,348 geboorte-orde 0,0429 ρ = 0,354 0,0509 ρ = 0,329 0,0441 ρ = 0,351 0,1143 ρ = 0,159 ouderdom van kind 0,0991 ρ = 0,194 0,2645 ρ = 0,110 0,0439 ρ = 0,351 0,0673 ρ = 0,279 beroep: vader * *0,2885 ρ = 0,005 •0,2141 ρ = 0,030 0,1463 ρ = 0,101 * 0,2103 ρ = 0,032 beroep: moeder 0,0613 ρ = 0,297 * *0,2862 ρ = 0,006 0,1463 ρ = 0,101 0,1155 ρ = 0,157 * 'beduidend op die 1% vlak. •beduidend op die 5% vlak. tabel v : v e r b a n d tussen b e p a a l d e g e s i n s v e r a n d e r l i k e s e n d i e m o e d e r k i n d v e r h o i i d i n g b y d i e m i n i m a l e b r e i n d i s f u n k s i e g o e p ( n = 2 4 ) veranderlikes oorbeskerming γ verwerping γ oortoegeeflikheid ...r.. aanvaarding r ouderdom van moeder 0,1830 ρ = 0,196 0,1792 ρ = 0,201 0,1918 ρ = 0,185 0,2057 ρ = 0,167 aantal kinders 0,1519 ρ = 0,239 0,2598 ρ = 0,110 0,0356 ρ = 0,434 0,1233 ρ = 0,283 geboorte-orde * 0,3620 ρ = 0,041 * 0,3433 ρ = 0,050 0,2580 ρ = 0,112 *0,3975 ρ = 0,027 / 0,0619 ρ = 0,387 ouderdom van kind 0,0686 ρ = 0,375 ; 0,1904 ρ = 0,186 0,1110 ρ = 0,303 *0,3975 ρ = 0,027 / 0,0619 ρ = 0,387 beroep: vader 0,0226 ρ = 0,458 0,3205 ρ' = 0,063 0,0254 ρ = 0,453 0,0524 ρ = 0,404 beroep: moeder 0,2576 ρ = 0,112 ] *0,4326 ρ ' = 0,017 "0,3571 ρ = 0,043 0,2568 ρ = 0,113 'beduidend op die 5% vlak. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) moeder-kind verhouding 121 tabel vi: die verband tussen bepaalde gesinsveranderlikes en die moederkind-verhouding by die gesplete lip en/of verhemelte groep (n = 20) veranderlikes oorbeskerming r verwerping γ oortoegeeflikheid r aanvaarding r ouderdom van moeder 0,2966 ρ = 0,102 0,2110 ρ = 0,186 0,0311 ρ = 0,448 0,2163 ρ = 0,180 aantal kinders 0,3108 ρ = 0,091 0,2340 ρ = 0,160 0,1457 ρ = 0,270 0,0263 ρ = 0,456 geboorte-orde 0,2346 ρ = 0,160 0,0824 ρ = 0,365 0,1048 ρ = 0,330 0,0563 ρ = 0,407 ouderdom van kind 0,3500 ρ = 0,065 *0,3966 ρ = 0,042 0,0360 ρ = 0,440 0,1494 ρ = 0,265 beroep: vader 0,2449 ρ = 0,149 0,1667 ρ = 0,241 0,0174 ρ = 0,471 0,1532 ρ = 0,260 beroep: moeder 0,1244 ρ = 0,301 0,1490 ρ = 0,265 0,1210 ρ = 0,306 0,1546 ρ = 0,258 uit bogenoemde resultate kan afgelei word dat die veranderlikes, ouderdom van die moeder, aantal kinders, geboorte-orde en ouderdom van die kind geen invloed het op die houding van die moeder nie. dit is egter in teenstelling met ander literatuur wat hierdie veranderlikes as belangrik beskou in die ontwikkeling van die moeder-kind-verhouding. 'n positiewe verband bestaan egter tussen die beroep van die vader en oorbeskerming en verwerping (nie-aanvaardingsdimensies) by die moeder. daar bestaan 'n negatiewe verband tussen die beroep van die vader en aanvaarding deur die moeder van haar kind. hier kan dus afgelei word dat daar 'n groter ingesteldheid tot nieaanvaarding bestaan by moeders wat getroud is met mans in die sogenoemde laervlakberoepe. 'n positiewe verband is ook gevind t.o.v. die beroep van die moeder en volgens hierdie bevindings blyk dit of moeders wat huisvrouens is, in 'n groter mate geneig is om hulle kinders te verwerp as werkende moeders. daar is 'n negatiewe verband tussen die geboorte-orde van die kind en oorbeskerming sowel as verwerping by kinders met minimalebrein-disfunksie (sien tabel 5). dit wil se hoe laer die kind met minimale-brein-disfunksie in die geboorte-orde voorkom, hoe minder word hy oorbeskerm of verwerp deur die moeder. hierdie neiging word bevestig deur 'n positiewe verband tussen die geboorte-orde van die kind en aanvaarding van die kind. dit toon aan dat hoe laer die kind in die geboorte-orde voorkom, hoe meer die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 122 ronel steenekamp word hy deur die moeder aanvaar. eersgeborenes met minimalebrein-disfunksie sal dus meer oorbeskerm en verwerp word en minder aanvaar word as latere kinders. precht7 beweer dat moeders met kinders wat minimale-breindisfunksie toon, die simptome van hulle kinders as deel van die kind se temperament en persoonlikheid aanvaar. die kind word dus aanvaar, maar sy gedrag stel die moeder nie tevrede nie. die moeder raak fisies uitgeput en gei'rriteerd a.g.v. hierdie gedrag van die kind, wat daartoe lei dat sy die kind verwerp. die infantiliteit van die kind gee aanleiding tot die moeder se oorbeskerming. medinnus en johnson 4 beweer dat moeders 'n baie sterker band met hulle eerste kinders opbou en dus baie meer betrokke is by die gebeure rondom die kind as latere kinders. fisieseof gedragsafwykings by eersgeborenes sal dus 'n baie groter invloed he op die moeder se houding teenoor die kind. 'n positiewe verband is ook gevind t.o.v. die beroep van die moeder en 'n nie-aanvaardingsingesteldheid. dit blyk dat moeders wat huisvrouens is, in 'η groter mate geneig is om hulle kinders te verwerp, wat moontlik toegeskryf kan word aan die feit dat sy vir baie langer periodes blootgestel is aan die kind met minimale-brein-disfunksie se gedrag. sy is ook geneig om oortoegeeflik te wees teenoor die kind. hierdie neiging kan toegeskryf word aan die feit dat daar aan die moeders gese word dat die kind nie beheer oor sy gedrag het nie en dat sy dit nie kan verander nie. sy gee dus makliker toe aan sy versoeke en ontoelaatbare gedrag. die ouderdom van die kind toon wel 'n beduidende verband met verwerping by kinders met 'n gesplete lip en/of verhemelte (sien tabel 6). hoe ouer die kind met 'n gesplete lip en/of verhemelte is, hoe groter is die verwerping. hierdie resultate dui daarop dat die moeder, namate die kind ouer word, hom meer verwerp. dit word bevestig deur goodstein.1 goodstein verklaar dit soos volg: . . . the effects on parental adjustment of having a child with this type of physical handicap in the home are not immediately evidenced, but rather develop with time. baie van die probleme by die kinders, soos spraakprobleme, ortodontiese probleme, chirurgiesof ander sekondere probleme is nie aan die moeder bekend by geboorte nie, maar word belangriker namate die kind ouer word. gepaardgaande emosionele en sosiale afwykings wat manifesteer in swak skoolprestasie en leerprobleme kan die moeder se verwerpingsingesteldheid versterk. 1 / ] gevolgtrekkings , daar kan nie tot die gevolgtrekking gekom word dat daar 'n beduidende verskil in die moeder-kind-verhouding van moeders met minimale-brein-disfunksie of gesplete llip en/of verhemelte kindes teenoor moeders met normale kinders is nie, aangesien bogenoemde resultate nie beduidend genoeg is nie. dit kan die gevolg wees van die the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) moeder-kind verhouding 123 feit dat die groepe nie groot genoeg was nie en 'n normale verspreiding nie voorgekom het nie. die moontlikheid bestaan ook dat die "mother-child-relationshipevaluation"-vraelys nie sensitief genoeg is om verskille aan te toon in die houding van moeders met kinders met spesifieke abnormaliteite teenoor moeders met normale kinders nie. goodstein1 en moll & darley5 het ook gevind dat 'n enkele vraelys of toets nie voldoende is om ingesteldhede by ouers met kinders met spesifieke abnormaliteite teenoor ouers met normale kinders waar te neem nie. daar kan egter wel afgelei word dat moeders met kinders wat minimale-brein-disfunksie toon, geneig is om hierdie kinders te verwerp. die verwerpingsingesteldheid van die moeders kan 'n bydraende faktor wees in die spraakafwykings wat by die kinders voorkom. as gevolg van die moeder se verwerping, is die kind voortdurend gefrustreerd, maar hy mag nie uiting gee aan die gevolge daarvan nie. die kind moet hierdie aggressiewe gevoelens onderdruk en leer dus dat spraak 'n suksesvolle wapen is. die feit dat daar geen statisties beduidende verskil gevind is in die houding van die moeders met gesplete lip en/of verhemelte kinders nie, kan waarskynlik toegeskryf word aan die feit dat die moeders reeds die afgelope aantal jare hulp ontvang vanuit 'n multidissiplinere raamwerk. die nulhipotese word dus aanvaar nl. dat daar geen beduidende verskil tussen die moeder-kind-verhouding van die onderskeie ondersoekgroepe en die kontrolegroep is nie. die werkhipotese ( h : en h 2 ) word dus verwerp nl. dat die moeder-kind-verhouding betekenisvol swakker of beter is by die onderskeie ondersoekgroepe as die van die kontrole groep. daar is ook gevind dat sommige gesinsveranderlikes wel 'n invloed kan he op die moeder-kind-verhouding veral by moeders met kinders wat 'n gesplete lip en/of verhemelte het of minimale-brein-disfunksie. aanbevelings dit word aanbeveel dat, indien daar in verdere navorsing in die verband belangstel word, 'n battery toetse uitgevoer word eerder as 'n enkele toets, aangesien 'n enkele toets slegs een fasset toets en daar wel verskille op ander vlakke kan voorkom. in verdere navorsing behoort daar veral klem gele te word op die moeder-kind-verhouding by kinders met minimale-brein-disfunksie, aangesien hierdie studie wel 'n verwerpingsneiging uitgewys het by moeders met kinders wat minimale-brein-disfunksie toon. slot in die algemeen kan tot die gevolgtrekking gekom word dat die evaluering van die moeder-kind-verhouding met behulp van die "mother-child-relationship-evaluation"-vraelys van min waarde was die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 124 ronel steenekamp in 'n poging om die moeders van kinders met minimale-breindisfunksie of 'n gesplete lip en/of verhemelte en hulle verhouding met die kind beter te verstaan. dit het egter wel aan die lig gebring dat moeders met kinders wat minimale-brein-disfunksie het, nie hulle kinders bevredigend aanvaar nie. hierdie resultate beklemtoon weereens die belang van 'n multidimensionele benadering in behandeling van hierdie kinders. verwysings 1. goodstein, l. d. (1960a): personality test differences in parents of children with cleft palates. j. speech. hear. res. 3. p. 39-43. 2. goodstein, l. d. (1960b): mmpi differences between parents of children with cleft palates and parents of physically normal children. j. speech. hear. res. 3. p. 31-37. 3. klaus, μ. h . & kennel, j. h. (1976): maternal infant bonding c. v. hosby st. louis. 4. meddinus, g. r. & johnson, r. c. (1969): child and adolescent psychology: behaviour and development. wiley & sons. ny. 5. moll, k. l. & darley, f. l. (1960): attitudes of mothers of articulatory impaired and speech retarded children. j. speech. hear. dis. 25. pp. 377-384. 6. nie, ν. h. (1975): statistical package for the social sciences. mcgraw hill. · 7. precht, m. f. r. (1963): the mother child interaction in babies with minimal brain damage (a follow-up study). in determinants of infant behaviour vol. 2. foss (ed). butler and tanner ltd. g. b . 8. roth, m. r. (1961): the mother child relationship evaluation western psychological services. california. 9. symonds, p. (1949): dynamics of parent child relationships. bureau of publications ν. y. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) philips hearing aid services a division of s.a. philips (pty) ltd. hearing aids amplaid audiometers group teaching systems p h i l i p s hearing aid services head office 1005 cavendish chambers, 183 jeppe street, p.o. box 3069, johannesburg. p h i l i p s fib2399 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) i n t r o d u c i n g ... t y m p a n o s c o p e t h e i m p e d a n c e m e t e r t h a t u s e s a n o t o s c o p e a s t h e p r o b e ... b y madsen electronics 1 s t in impedance • automatic • fast • portable • printout • diagnostic • screening • otoscopy • tympanometry — from +200 to -300 mm hjo • reilex — ipsilaieral in real lime contact kan southcott or richard anderson at amtronix (pty) ltd p.o. box 630 bedtordview 2008 phone 61s-7647/8/9 performs all tests automatically — complete lest lakes only 10 seconds each ear — weighs only 15 lbs. (7 kg) — ibm size card lot r?asv nlirig — results correlate with marisra'i 1 lical instrument — pass •' lail para m el era adjustable — pressure finely control led r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e acquisition of some dimensional adjectives by both n o r m a l a n d l a n g u a g e i m p a i r e d children susan gail wright, b . a . ( s p . & h . therapy) ( w i t w a t e r s r a n d ) psychological and guidance services, transvaal education department, johannesburg north-west, johannesburg. summary the main aim of this study was to assess various predictions made by h. and e. clark with respect to the acquisition of certain dimensional adjectives. in addition, the performance of children with impaired language skills was compared with that of children with normally developing language. eighteen subjects in the age range 3,3 to 4 years were divided into two groups; those with adequate language (c group) and those with impaired language (e group). the dimensional adjective pairs of "length", "tallness" and "width" were investigated on comprehension tasks of increasing dimensionality. a qualitative analysis of the data, for both c and ε groups, revealed findings supporting the predictions concerning the order of dimensional adjective acquisition in terms of semantic complexity, the acquisition of the unmarked pair member before the marked member, and the acquisition of the concept of polarity before dimensionality. a quantitative analysis of the data revealed significant differences between the c and ε groups on a few tasks only. implications for the researcher and speech therapist are considered. opsomming die hoofdoel van hierdie studie was om die verskillende voorspellings van h. clark en e. clark, met betrekking tot die verwering van sekere dimensionele byvoeglike naamwoorde, te ondersoek. daarbenewens is die prestasie van kinders met ontoereikende taalvermoens vergelyk met di6 van kinders met normaalontwikkelende taal. agtien proefpersone, vanaf 3,3 tot 4 jaar, was verdeel in twee groepe; di6 met voldoende taal (groep c) en di6 met ontoereikende taal (groep e). die pare dimensionele byvoeglike naamwoorde van "lengte" en "breedte" is ondersoek m.v. begripstoetse van toenemende dimensionaliteit. 'n kwalitatiewe analise van die gegewens vir albei groepe, het voorspellings aangaande die verwerings volgorde van dimensionele byvoeglike naamwoorde, gebaseer op semantiese ingewikkeldheid, ondersteun — naamlik, die verwerwirig van die ongemerkte deel van die paar voor die gemerkte lid en van die begrip van polariteit v66r dimensionaliteit. 'n kwantitatiewe analise van die gegewens het betekenisvolle verskille tussen groep c en ε op slegs 'n paar take aangedui. die implikasies vir die navorser en spraakterapeut is bespreek. the relationship between cognition and language has long been a topic of discussion and presents a controversial area of study. the importance of a conceptual basis for language development is particularly evident when reviewing recent literature concerning the early acquisition of language.4 within this field, attempts have been made to investigate the nature of the acquisition of dimensional adjectives. 2 ' 1 3 as before, results have revealed varying degrees of disagreement and an integrated overview of this subdivision has yet to be achieved. the present study was undertaken with a view to researching various proposals put forward by the existing theories. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 128 susan wright "most of language is composed of relational t e r m s " 1 1 of which dimensional adjectives form a sub-set. h . clark,7· 8 · 9 in researching the progression and nature of the acquisition of spatial and temporal expressions, has provided a theoretical framework which is widely discussed in the literature.1 2· 1 7 his hypotheses generally appear to be considered noteworthy and comprehensive, although perhaps not fully explanatory. h. clark9 bases the evidence for this thesis on the "strong correspondence between the properties of spatial terms and the properties of man's innate perceptual apparatus". he postulates the existence of a perceptual space, or p-space, and a linguistic space, or l-space; thus supporting the notion of a connection between cognition and language. the properties of l-space are predicted to be identical to those of p-space; thus forming his correlation hypothesis.9 biological and physical environments place constraints on the way in which objects may be described in space.9 these constraints are determined by p-space properties, which make varying demands on man's perceptions. an area which is easily perceptible may be considered a "positive" perceptual direction as opposed to a "negative" one. similarly, linguistic forms may differ in complexity;, the more complex term is "marked" with respect to the less complex term. the "positive" or "unmarked" term may be comprehended more easily than the "negative" or "marked" t e r m . 9 the complexity hypothesis is inherent in this proposal. dimensional adjectives are divided into adjective pairs defining the dimensions of size, length, distance, tallness, height, depth, width, breadth, and thickness.8 these pairs comprise big-small, long-short, far -near, tall-short, high-low, deep-shallow, wide-narrow, broadnarrow, and thick-thin. in terms of the "markedness" theory,9 the first member of each pair is "unmarked" and the second "marked". this theory is further supported by e. clark5· 6 in her advancement of the semantic feature hypothesis (sfh). sfh predicts that the child does not randomly decide which of the two meanings to attribute to the antonym pair, but rather operates systematically by selecting the member of the pair which is linguistically simpler or "unmarked" before he acquires the "marked" term. to date, research findings concerning "markedness" have been contradictory.2· u · 1 3 the notion of "markedness" is prominent in another aspect of h. clark's theory concerning the sequence of acquisition/of the dimensional adjective pairs. he proposes that the pairs differ in their conditions of application according to the nature of their dimensionality.9 the fewer dimensions an adjective presupposes, the less complex the adjective will be, and therefore the less "marked". adjective pairs involving only one dimension will be acquired before those involving two or three dimensions.9 other authorities have found support for this prediction.1· 3 h. clark8 therefore proposes that the intrinsic properties of the the south african journal of communication disorders, vol. 28,1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acquisition of dimensional adjectives 129 antonym pairs could affect their sequence of acquisition. he suggests that the child first uses the terms in a nominal, non-comparative sense only. here the appropriate dimension is indicated disregarding polarity; for example, both "long" and "short" mean "having length". the child gradually begins to distinguish between the terms and to use them comparatively. bartlett2 has failed to find support for these predictions concerning polarity. her data suggests that the concept of polarity is acquired before the concept of dimensionality. as soon as stimuli varied along a number of dimensions, judgements relating to one polar feature were more difficult. little research has been carried out to investigate this particular prediction. in conclusion, the correlation and complexity hypotheses, proposed by h. clark8' 9 make various predictions concerning the acquisition of dimensional adjectives. research findings have supported or rejected these predictions to varying degrees. literature concerning the comprehension of dimensional adjectives in children with impaired language skills is scarce. although leonard, bolders and miller 1 4 believe that these children tend to be delayed in terms of semantic relations, many questions remain unanswered. does the pattern of dimensional adjective acquisition in these children match that of children with adequate language skills? is there a difference in performance, on dimensional adjective comprehension tasks, between children with receptive and expressive language impairment? further investigation is therefore indicated. m e t h o d this study aimed to assess various predictions of h. clark's theories and the sfh proposed by e. clark, with respect to the acquisition of certain dimensional adjectives. the comprehension of these adjectives by children with delayed language skills was compared to that of children with normally developing language skills. h y p o t h e s e s 1. the acquisition of dimensional adjectives, in ss with normal language skills, follows a particular developmental sequence determined by the semantic complexity of the terms:— "long-short" to "tall-short" to "wide-narrow". 2. the unmarked member of a dimensional pair is acquired before the marked member of the pair, in ss with normal language skills. 3. the concept of polarity is acquired before the concept of dimensionality, in ss with normal language skills. 4. on examination of h 1 ; h 2 and h 3 in relation to language impaired ss, a difference exists in the acquisition of dimensional adjectives by language impaired ss. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 130 susan wright 5. a difference exists between the performance of ss with receptive and expressive language impairments with regard to the acquisition of various dimensional adjectives. s u b j e c t s eight children with adequate language skills and eight children with delayed language skills, ranging in age from 3,3 to 4 years, were selected. the mean age of both the c and ε ss was 3,6 years. subjects were selected according to certain criteria:— 1. within an age range of 3,3 to 4 years, children with normally developing language are reported to be able to differentiate between the members of the dimensional adjective pairs under investigation.13 evidence that the acquisition of these adjectives continues after 4 years,2 suggests that the chosen age range will provide an opportunity to study the progression in development of the structures at this stage. 2. both c and ε groups comprised seven male ss and one female s as this reflected the ratio of males to females attending the speech clinics visited. this incidence is supported in the literature. 1 5 3. the ε ss were diagnosed by a speech therapist as having delayed language skills (receptive or expressive) for their age. they had all been attending speech therapy for at least six months. the c ss were each considered, by mothers and nursery school teachers, to have adequate language skills for their age. in addition, an objective measure was used to assess language skills. the verbal comprehension scale a section of the reynell developmental language scale 1 6 was administered to all ss. this test acted as a screening device during the selection of c ss. in the ε group, ss with a receptive language delay were separated from those with a purely expressive delay. 4. all ss were required to have attended a nursery school for a minimum of six months in order to control for the influence of schooling. each ε s was paired with a c s of same sex and a similar age from the same nursery school to control further for possible differences in the schooling environments. 5. all ss were required to come from middle to upper-middle class homes in an attempt to ensure similar environmental stimulation. 6. all ss were judged as being of normal intelligence and to have no primary behavioural or emotional involvement. 7. ss were required to have adequate hearing. t e s t m a t e r i a l s : the ss' levels of comprehension of various dimensional adjectives was the purpose of this study and a pertinent task was thus devised. three pairs of dimensional adjectives were chosen for this study, each pair representing one of the three dimensions of length, tallness and width. the properties of these adjectives are displayed in table i. the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acquisition of dimensional adjectives 131 t a b l e i : summary of dimensional adjective properties proposed by h . clark.9 "long-short" "tall-short" "wide-narrow" extent or number of point of position dimensions verticality reference + extent 1 ego (primary) + extent 3 • ground level (primary) + extent 2 secondary edge although the pair implying width involves only two dimensions, it will be more cognitively and semantically complex than that of tallness, involving three dimensions, since it refers to the secondary feature of a reference object. the perception of a secondary feature, rather than that of a primary feature, is necessarily more complex. these particular dimensional adjective pairs were therefore chosen because of their varying complexities. the unmarked members of the dimensional pairs are, according to h. clark9 "long", "tall" and "wide". the marked pair members are "short", "short" and "narrow" respectively. n a t u r e o f t h e s t i m u l i a n d t h e e q u i p m e n t u s e d the stimuli consisted of object pairs which were varied systematically along certain dimensions according to the relevant dimensional adjective pair and the complexity of the task required. 1. to assess the acquisition of features of polarity, apart from the acquisition of dimensionality, only the relevant dimension was varied, that is the objects differed along only a single dimension; one pair differed in length (strings of beads), one in tallness (cardboard human figures) and one in width (cardboard strips). 2. to assess the acquisition of features of dimensionality it was necessary to use objects which varied along at least two dimensions to determine if the child was able to extract the relevant dimension from the properties of the stimulus.2 the dimensions were varied systematically so as to determine the effect of different dimensional features on the acquisition of the relevant dimension. doubledimensional stimuli consisted of a combination of two adjective pairs. multi-dimensional stimuli consisted of various combinations of all the adjective pairs simultaneously. table ii presents the materials used with respect to the relevant dimensions. t e s t p r o c e d u r e each s was tested individually in a quiet room with limited distractions. testing, with a few exceptions, was carried out in the nursery school as this had the advantage of familiarity of environment of the child. each s was tested during a single session lasting approximately forty minutes. inconsistencies found when examining die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28,1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 132 susan wright table ii: description of doubleand multi-dimensional stimuli stimulus pairs task no. l e n g t h (+primary) t a l l n e s s (+primary) w i d t h (+secondary) long short tall short wide narrow ό _j cardboard flags two strips of paper 1 2 3 4 long short short long long short short long ι— m ζ a —1 : r ζ ο c/3 ζ u_l s ο i i i cardboard dogs cardboard trees 1 2 3 4 tall short short tall tall short short tall —1 > 1— 1— ζ m co co cd ^ ο ο two strips of paper cardboard houses 1 2 3 4 wide narrow narrow wide wide narrow narrow wide s σ —i :r s _j green blocks 1 2 3 4 long long short short short short long long long short long short short long short long 1— m ζ a —1 x ζ ο c/3 ζ u_l ξ ο •ή pink blocks 1 2 3 4 tall tall short short short short tall tall tall short tall short short tall short tall 2 ' 1— f— ζ m od oo ξ blue blocks 1 2 3 4 wide wide narrow narrow narrow narrow wide wide wide narrow wide narrow narrow wide narrow wide s σ —i x d d ; for example, task 1 for the adjective pair "long-short" involved the contrasting of two flags of the dimensions:— (1) "long-tall" (2) "short-short". m-d; for example, task 1 for the adjective pair "long-short' involved the contrasting of two blocks of the dimensions: (1) long/tall/wide (2) short/short/narrow. various research results concerning the field of acquisition of dimensional adjectives could be attributed to their varying methodologies.2' 1 3 the task type of this study was based on that used by bartlett2 since her method of eliciting responses indicating comprehension'appears to exclude variables such as cognitive complexity. a pair of objects was placed in front of the s who was asked to "give me the (object)", where " " was one of the dimensional adjectives and (object) was the name of the stimulus, for example "give me the long dog". two pre-test tasks ensured the s's understanding of the directions. each object pair was presented twice; once when the unmarked adjective of the pair was asked for and once when the marked adjective was required. objects were presented to each s in random order, within the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acquisition of dimensional adjectives 133 the adjective pair categories, except for the requirement that no object pair was presented twice in succession. scoring consisted of correct/incorrect marking to promote statistical analysis. information to aid in a qualitative analysis was also recorded. results two types of analyses were applied to the data. a quantitative analysis, the mann-whitney u-test for independent samples, 1 0 determined whether a statistically significant difference existed between the various measures obtained for the c and ε groups. significance at a 0,05 level for a one-tailed test was determined. a qualitative analysis in the form of descriptive evaluation of the findings obtained by both groups highlighted trends in the findings. the results are discussed within a framework provided by the hypotheses. overall test results are presented in table iii. the results of the statistical test are presented in table iv. table iii: number and percentag^of correct responses obtained by ε and c subjects α length tallness width ο th o long short ( + ) ( ) tall short (+) ( ) wide narrow ( + ) ( ) s in g l e ε c 7/87,5% 6/75% 13/81% 8/100% 7/87,5% 15/94% 4/50% 5/62,5% 9/56% 7/87,5% 5/62,5% 12/75% 6/75% 2/25% 8/50% 5/62,5% 5/62,5% 10/62,5% d o u b l e ε c 24/75% 18/56% 42/66% 27/84% 24/75% 51/80% 13/41% 15/47% 28/44% 27/84% 20/62,5% 47/73% 11/34% 5/16% 16/25% 21/66% 15/47% 36/56% m u l t i ε c 27/84% 13/41% 40/62.5% 32/100% 26/81% 58/91% 16/50% 13/41% 29,45% 22/69% 20/62,5% 42/66% 9/28% 3/9% 12/19% 14/44% 13/41% 27/42% ( + ) = unmarked term, ( ) = marked term. 1. sequence of acquisition of dimensional adjective pairs the obtained percentages indicate that there is a distinct sequence of acquisition in the comprehension of the three dimensional adjective pairs across all tasks for single-, doubleand multi-dimensional stimuli; that is, length to tallness to width. h j may therefore be accepted. the ε group also demonstrates a similar sequence in the acquisition of the dimensional terms. this sequence is not particularly well-defined for the single-dimensional terms. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28,1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 134 susan wright table iv: results of the mann-whitney u-test comparing c and ε group performance category dimension /adjective pair u implications (e ss) sequence of acquisition of dimensional adjective pairs single length tallness width double length tallness width multi length tallness width 36,5 | not significantly 40,5 v different or 38 j delayed. sequence of acquisition of dimensional adjective pairs single length tallness width double length tallness width multi length tallness width 46,5 not delayed. *49 1 delayed in adjective *55,5 j acquisition. sequence of acquisition of dimensional adjective pairs single length tallness width double length tallness width multi length tallness width *58,5 delayed. 41,5 not delayed. *52 delayed. order of acquisition of adjective pair members single length + tallness + width + double length + tallness + width + multi length + tallness + width + 36 η 36 44 32 28 j not significantly >• different or delayed. order of acquisition of adjective pair members single length + tallness + width + double length + tallness + width + multi length + tallness + width + 34 45 48,5 40,5 48,5 *53,5 ^ not significantly ί delayed. delayed for marked term. order of acquisition of adjective pair members single length + tallness + width + double length + tallness + width + multi length + tallness + width + *52 1 delayed for marked and *54,5 j unmarked term. , \ not significantly s j delayed. *51,5 delayed for marked term. sequence of acquisition of polarity and dimensionality length single double multi tallness single double multi width single double | multi 36.5 ί not significantly 45.6 j delayed on these tasks. *58,5 delayed when task complex sequence of acquisition of polarity and dimensionality length single double multi tallness single double multi width single double | multi 40,5 not delayed. *49 delayed on doublelevel. 41,5 not delayed. sequence of acquisition of polarity and dimensionality length single double multi tallness single double multi width single double | multi 38 "i not delayed. / "55,5 > delayed in the acqiiisi'52 j tion of dimensionality. ( + ) = unmarked term, ( ) = marked term ; * indicates a statistically significant result with u 3= 49. on comparing the c and ess on their; task performance ess do not show any uniform significant delay across all the comprehension tasks of the adjective pairs, as expected. significant differences were obtained on double-dimensional tasks of tallness and width, and on the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acquisition of dimensional adjectives 135 multi-dimensional tasks of length and width indicating a delay of the ε group in these areas. h 4 , in relation to h 1 ; may therefore only be partly accepted. 2. order of acquisition of adjective pair members many of the findings relating to the css' performance, indicate only a slight discrepancy between the acquisition of unmarked and marked terms (in favour of the unmarked term). only width reveals a more decisive difference between the acquisition of the pair members. however, the writer feels that h 2 may be accepted for reasons considered in the discussion. findings for the ess generally reveal a superiority in the comprehension of the unmarked terms. the only statistically significant difference, between the c and ess, in the acquisition of unmarked and marked terms exists on the multidimensional task involving length. the acquisition of the marked term of width for doubleand multi-dimensional tasks was also significantly different. h 4 , in relation to h 2 , may only be partly accepted. 3. sequence of acquisition of polarity and dimensionality here, the ss' performance on single-dimensional adjective tasks (representing polarity), and doubleand multi-dimensional adjective tasks (both representing a different degree of dimensionality) were considered. findings, for the css, involving tallness and width support h 3 since task difficulty increases from singleto doubleto multidimensional tasks. the ess' performance suggests a similar progression of difficulty for all adjective pairs. the ess do not show any general significant difference from the css across dimensional tasks involving length or tallness. significant differences were found to exist on measures of width. although, both c and ess appear to experience increasing difficulty with increasing dimensionality, the ess demonstrate a significant delay in the acquisition of width, especially for doubleand multi-dimensional tasks. h 4 , in relation to h 3 , may therefore only be accepted for the dimensional adjective pair of width. 4. ess' performance in terms of the presence of a receptive or depressive language delay the ε group was divided equally into ss with receptive and purely expressive language impairment by the language pre-test. 1 6 these two sub-groups were compared on their comprehension of the adjective pairs under all the different task conditions: on application of the statistical test, the groups do not show any significant differences with regard to the acquisition of various dimensional adjectives. h 5 is therefore rejected. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28,1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) susan wright discussion sequence of acquisition of dimensional adjective pairs the results obtained by both c and ess did indicate a progression in acquisition from length to tallness to width across all dimensional tasks. this finding therefore supports the trend in the literature.2 , 9 in trying to explain why some adjective pairs should be acquired later than others, it appears to be reasonable to assume that these pairs involve a greater semantic complexity and are thus more difficult to learn. if cognition and language are linked, as suggested in the literature, it is possible that semantic complexity would imply cognitive complexity. these more complex terms would then be acquired later on the developmental scale at a stage when the child's innate cognitive processes are more evolved. a comparison between the abilities of c and ess does not produce such conclusive results. ess appear to be performing on a similar level as css on tasks involving singledimensions. if doubleand multi-dimensional tasks are more complex than single-dimensional tasks,9 this finding could indicate that ess are operating at a less complex level and therefore fail to perform as adequately as css when more demanding tasks are introduced.. if this reasoning is correct, ess may be assumed to be significantly delayed in dimensional adjective acquisition due to their inability to cope as efficiently as css, with the adjective pairs under varying task conditions. these findings would therefore support predictions made by leonard et a l . 1 4 order of acquisition of adjective pair members both c and ess demonstrate superior comprehension of the unmarked member, as opposed to the marked member, of the dimensional adjective pairs. for css, however, there is frequently only a slight discrepancy between the acquisition of unmarked and marked terms across all the dimensional tasks. this could be explained by the relative stability of the adjective pairs in the ss' repertoires; a decisive discrepancy would only be evident during the initial stages of adjective pair acquisition.8 it is evident that findings for unmarked and marked terms become more discrepant when the components of width are involved in the various combinations. this finding could be related to h j suggesting that the adjective pair width is the last acquired in the sequence and is therefore still particularly unstable in the css' repertoires. findings for the ess could also be related to h j ; ess are still in the process of acquiring all the dimensional adjectives. preference for the unmarked term would thus be more decisive at this stage of incomplete acquisition and is apparent during all dimensional tasks of varying complexities. a comparison of the abilities of c and ess reveals only isolated occurrences of a significant difference appearing to highlight a trend in the findings only in that they are evident in the more complex doublethe south african journal of communication disorders, vol. 28,1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acquisition of dimensional adjectives 137 and multi-dimensional tasks. this could be related to h 4 , involving h 1 ; where a significant difference between ε and css was found on these tasks. reduced stability of the pairs in the ess repertoires, as compared to the css, could explain the delay in the ess discrimination between these unmarked and marked terms. these results only partly support predictions made by leonard et a l . 1 4 sequence of acquisition of polarity and dimensionality css demonstrated the acquisition of the concept of polarity prior to that of dimensionality for tallness and width. the absence of increasing difficulty with increasing dimensionality for length could be explained by the relative stability of this term in the css' repertoires (as suggested by h i ) . these findings fail to support the general trend in the literature stating that the comprehension of dimensional features is acquired before that of polarity features.9 they support contradictory research findings obtained by bartlett. 2 results for the ess suggest increasing difficulty with increasing dimensionality for all adjective pairs. it appears that, in this study, bartlett's prediction2 can be extended to implicate language impaired ss. the finding of a significant delay only in the acquisition of width, especially for doubleand multi-dimensional tasks, on comparing the abilities of c and ess could be explained in terms of h 4 , in relation to h j . width, which is the most semantically complex of the adjective pairs studied,5 was found to be significantly delayed for the ess, particularly on the more complex tasks. it is therefore logical that ess should differ significantly from css in this area whereas the difference is not as marked for the other less complex adjective pairs. although both groups show a trend towards the acquisition of polarity before dimensionality, ess are significantly delayed in their acquisition of both of these features. predictions made by leonard et a l 1 4 are only partly accepted since the ess were not significantly delayed in all aspects of this semantic area. conclusions the hypotheses based on predictions made by h. clark8' 9 and sfh, 5 ' that is h i and h 2 , are supported by the data. the prediction could also, according to these findings, be extended to implicate ss with language impairment. h 3 , based on bartlett's p r o p o s a l 2 is accepted thus implying the rejection of the sfh prediction. the findings indicate that the proposal could also describe the performance of language impaired ss. h 4 , in relation to h 1 ; h 2 and h 3 , may be partly accepted indicating significant differences between c and ess' performance in isolated areas only. h 5 is rejected implying similar performance by the ess irrespective of the type of language impairment. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28,1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 138 susan wright implications further research in this area is obviously necessary before broad conclusions may be drawn. research could tend towards the establishment of norms for the acquisition of dimensional adjectives, the investigation of the acquisition of other dimensional adjectives, the expression of these adjectives, or the analysis of comparatives in terms of deductive reasoning.7 in devising a therapy programme it appears to be important to consider the normal sequence of development. this study highlighted certain areas: 1. teaching should progress from less complex to more complex terms. 2. the unmarked member of the pair should be taught before the marked member, since this appears to be a less complex term. 3. the terms should be taught in terms of polarity features before further dimensionality is introduced. tasks should be graded in terms of dimensionality; that is, singleto doubleto multidimensional tasks. dimensional adjectives influence the child's perception of his world and could thus affect corresponding areas of language and perception. acknowledgements the writer thanks: mrs. f. schmaman of the department of speech pathology and audiology, university of the witwatersrand, for her supervision. references 1. anglin, j. m. (1970): the growth of word meaning. m.i.t. press, london. 2. bartlett, e. j. (1976): sizing things up; the acquisition of the meaning of dimensional adjectives. j. child lang., 3, 205-219. 3. bierwisch, m. (1970): on classifying semantic features. in bierwisch, m. and heidolph, κ. e. (eds.), progress in linguistics. mouton & co., the hague, paris. 4. brown, r. (1976): a first language the early stages. (2nd edition). penguin books ltd., england. 5. clark, ε. v. (1973): what's in a word? on the child's acquisition of semantics in his first language. in moore, τ. e. (ed.), cognitive development and the acquisition of language. academic press inc., new york. 6. clark, ε. v. (1974): some aspects of the conceptual basis for first language acquisition. in schiefelbusch, r. l. and lloyd, l. l. (eds.), language perspectives —' acquisition, retardation and intervention. university park press; baltimore. 7. clark, η. h . (1969): linguistic processes in deductive reasoning. psych. review, 76, 4, 387-404. , the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acquisition of dimensional adjectives 139 8. clark, η. h . (1970): the primitive nature of children's relational concepts. in hayes, j. (ed.), cognition and the development of language. wiley, new york. 9. clark, η. h . (1973): space, time, semantics and the child. in moore, τ. e. (ed.), cognitive development and the acquisition of language. academic press inc., new york. 10. connolly, t. g. and sluckin, w. (1971): an introduction to statistics for the social sciences. (3rd edition). the macmillan press ltd., london. 11. donaldson, m. and wales, r. (1970): on the acquisition of some relational terms. in hayes, j. (ed.), cognition and the development of language. wiley, new york. 12. friedman, w. j. and seely, p. b. (1967): the child's acquisition of spatial and temporal word meanings. child develop., 47, 4 , 1103-1108. 13. klatzky, r. l., clark, ε. v. and macken, m. (1973): asymmetries in the acquisition of polar adjectives: linguistic or conceptual? j. experimental child psych., 16, 32-46. 14. leonard, l. b., bolders, j. g. and miller, j. a. (1976): a n examination of the semantic relation reflected in the language usage of normal and language disordered children. j. speech hear. res., 19, 371-392. 15. menyuk, p. (1971): the acquisition and development of language. prentice-hall inc., englewood cliffs, new jersey. 16. reynell, j. (1969): reynell developmental language scale. n . f . e . r . publishing co. ltd., england. 17. townsend, d. j. (1976): do children interpret "marked" comparative adjectives as their opposites?. j. child lang., 3, 385-396. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28,1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) professional resources for communications specialists r e a d i n g a n d l a n g u a g e a r t s l a n g u a g e d e v e l o p m e n t a s s e s s m e n t m a t e r i a l s b a s i c s k i l l s ο » for information or free catalogues call read ( p t y ) l t d . / ( e d m s ) b p k . t e l : johannesburg 3 9 6 3 7 8 · pretoria 4 4 4 2 4 2 d u r b a n 6 6 6 6 9 · c a p e t o w n 2 2 0 9 4 7 pietermaritzburg 5 8 0 7 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the needs of teachers of children with hearing loss within the inclusive education system 23 the needs of teachers of children with hearing loss within the inclusive education system catherine van dijk, rene hugo and brenda louw department of communication pathology, university of pretoria abstract in south africa, the current movement towards the inclusion of children with disabilities, including children with hearing loss, is likely to have far-reaching consequences for both teachers and learners. undoubtedly, needs will arise from teachers during the transition, especially in the areas pertaining to the audiological and educational management of children with hearing loss. therefore, a descriptive research design was developed comprising of a questionnaire survey followed by focus group interviews to determine teachers' needs. the questionnaire survey explored the needs of 664 teachers while focus group interviews were conducted with 19 teachers of children with hearing loss. teachers were mostly from special schools as only a very small number of children are educated outside these establishments. findings revealed that, although participants realised the importance of various aspects of development of the child with hearing loss, they generally did not realise the importance of receiving support from an educational audiologist. key words: children with hearing loss, educational audiologist, educational audiology, inclusion, needs of teachers, teacher support. introduction "...because of the invisible nature of the (hearing) impairment, and the general lack of understanding regarding the full impact of hearing impairment upon learning, there is always a need for individuals to work for the child, to ensure that his or her needs as a learner with hearing impairment are not marginalized or overlooked." (english, 1995 pl2). the education of all learners in south africa, including children with hearing loss, has undergone profound changes since the end of the apartheid era in 1994. the educational system changed from a racially segregated system to a non-racial inclusive system. prior to 1994, specialised education was characterised by the following (education white paper no. 6, 2001): • education and support were predominantly provided for / a small percentage of learners with disabilities within / special schools or classes; • where provided, specialised education and support were rendered on a racial basis, with the best human, physical and material resources reserved for the white population; j • most learners with disabilities were either excluded from the system or were mainstreamed by default; • the curriculum and educational system as a whole, generally failed to respond to the diverse needs of the learner population with disabilities and this resulted in massive numbers of academic failures; and • although attention was given to the schooling phase with regard to "special needs and support", the other levels or bands of education were seriously neglected. the government is in the process of rectifying the abovementioned injustices to learners with disabilities and proposes an inclusive education system which aims to "... promote education for all and foster the development of inclusive and supportive centres of learning that would enable all learners to participate actively in the education process so that they could develop and extend their potential and participate as equal members of society" (education white paper no. 6, 2001 p5). the south african education white paper no. 6 (2001) states that the inclusive education system will have a variety of different placements ranging from ordinary schools to special schools/resource centres with the goal of uncovering and addressing barriers to learning, and recognising and accommodating the diverse learning needs among learners. the inclusive education system will have a wider spread of educational support services that will be created in line with what learners with their specific disabilities require. schools will be divided into three categories: ordinary schools, full-service schools and special schools/resource centres. however, these three categories of placement are by no means an attempt to revert to the previous education system of separation of children with disabilities from other regular children. the difference lies in the placement strategy: learners are classified according to their need for support and not according to their physical limitations. the current movement toward inclusion of children with disabilities, including those with hearing loss, is likely to have far-reaching consequences for teachers, parents and learners (keith & ross, 1998). more specifically, the teacher, in order to successfully fulfill his/her role, will have to confront many challenges related to the audiological and educational management of children with hearing loss (english, 1995). the rationale for this statement is based on the complexities and/or characteristics related to the disability of a hearing loss (johnson, benson & seaton, 1997). children, except those exclusively immersed in signing environments, learn language primarily through the auditory pathways (english, 1995; lynas, 1994). therefore, a hearing loss often negatively impacts on the development of these children's auditory, language, speech, communication, literacy, academic, and psychosocial skills within the inclusive environment (johnson et al., 1997). children with hearing loss who are primarily educated within a signing environment will also be affected by the transition to an inclusive education system due to, amongst other reasons, communication barriers that may exist between them and their hearing peers and teachers (moores, 1996). the educational audiologist is uniquely skilled in manathe south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 catherine van dijk, rene hugo and brenda louw ging the effects of hearing loss on the child's educational development, and is a crucial member on the educational team. the educational audiologist, as specialist in the management of children with hearing loss, is able to offer a wide range of support and assistance to teachers as well as to these children in the inclusive education system (johnson et al., 1997). when teachers receive appropriate educational audiology services, they are enabled to provide quality education that strives to maximize the full potential of every child with hearing loss (english, 1995). the responsibilities of the educational audiologist continues to evolve and mature in response to changing educational trends and evolving government policy (english, 1995). the most recent guidelines for audiology services in schools as proposed by the american speech-language-hearing association are prevention of hearing loss, conservation of hearing, assessment, habilitation and amplification of the child with hearing loss, education and training of the educational team, assistance and support to the child and family, monitoring and follow-up of clients, and research in the field of educational audiology to stay abreast of new trends. (asha, 1993). it is understandable that transition to an inclusive system will not be successful without additional research and training efforts. as a possible first step in this process, it is important to determine the opinions, ideas and plans of teachers for children with hearing loss within the inclusive education system. more specifically, the needs of teachers of children with hearing loss have to be determined in order to seek solutions to provide support to teachers in their new role. supporting the teacher through educational audiology services will enhance the quality of education for all children with hearing loss (english, 1995; johnson et al., 1997; webster & wood, 1989). method aims and objectives the aim of the study was to determine the needs of teachers of children with hearing loss regarding their audiological and educational management within the inclusive education system. in order to achieve this aim, the following objectives were formulated: • to determine and describe the needs of teachers regarding their knowledge of educational audiology, and • to determine and describe the needs of teachers regarding the audiological and educational management of children with hearing loss. research design the research design was a qualitative paradigm that was descriptive and contextual in nature (leedy & ormrod, 2001; mouton & marais, 1996; schurink, 1998). a qualitative analysis of teachers' needs regarding the management of children with hearing loss within the inclusive education system, made it possible to determine their current needs. by means of quantitative analysis, findings could be interpreted in terms of their generalizability to the whole population of teachers of children with hearing loss in south africa. the primary research protocol comprised of a descriptive survey by questionnaire followed by supplementary focus group interviews (stewart & shamdasani, 1990). the use of a combination of research methods had the potential of enhancing the quality of data collection and reducing the chance of, bias (berg, 1998). utilising different methods enabled the formation of a comprehensive depiction of the needs of teachers of children with hearing loss within an inclusive education system. selection and description of participants the procedures for selection and the description of schools and teachers follow. selection and description of schools all 35 schools currently providing for children with hearing loss in the nine provinces of south africa were identified from a list obtained from the deaf federation of south africa (deafsa, 2001a) and were included in the questionnaire survey (see appendix a). all these schools were targeted, to ensure that the results obtained were representative of teachers of children with hearing loss in south africa (reid & gough, 2000). schools that focused exclusively on the pre-school phase were excluded. these schools were excluded because they are primarily privately owned and may not be directly affected by plans for the transition to an inclusive education system (education white paper no. 6, 2001). two gauteng schools on the list of 35 schools were purposefully (leedy & ormrod, 2001) selected for participation in the focus group interviews. purposeful selection facilitated analysis of differences between pre-determined heterogeneous groups (morgan, 1997) namely, schools that mainly promote spoken language and schools that mainly promote sign language. questionnaires (see appendix b) were sent to 32 of the total of 35 schools, thereby excluding the three schools used during the pilot study and in the focus group interviews, in order to avoid data-contamination (neuman, 1997). after completion of the survey, 27 of the 32 schools (84%) returned their questionnaires. of the total number of schools providing for children with hearing loss in south africa, 27 of the 35 schools (77%) participated in the survey. the schools in the survey represented all eight provinces that had schools for children with hearing loss, namely: eastern cape, free state, gauteng, kwazultinatal, limpopo, mpumalanga, north west, and western cape. this sample was a very good statistical representation of tlie total population of schools in south africa (huysamen, 1998).; table 1 provides a description of the schools included in the questionnaire survey. (refer to page 24) selection and description of teachers the procedures for selection are described followed by, a description of the participants. participants in the questionnaire survey y·' the participants had to be employed as teachers by any of the schools mentioned above in order to ensure that they had teaching experience with children with hearing loss and that they were familiar with the educational-setting in south africa. questionnaires were sent to 664 of the total population of 769 teachers of the 32 schools, thereby excluding the participants die suid-afrikaanse tydskrifvir kommunikasieafivykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the needs of teachers of children with hearing loss within the inclusive education system 2 5 table 1: description of schools participating in the questionnaire survey (n=32) province school nature of communication educational teachers number of school instructional audiologists educating learners approach posted at school children with hearing loss with hearing loss eastern cape 1 hearing loss sign language 0 38 300 2 hearing loss & visual impairment sign language 1 35 120 3 regular school & unit for hearing loss oral-aural 0 5 40 4 hearing loss total communication 1 vacancy 11 110 free state 5 hearing loss & visual impairment sign language 1 vacancy 16 160 6 hearing loss & visual impairment sign language 0 20 210 gauteng 7 hearing loss, visual impairment & physical impairment total communication 2 14 40 8 total communication 1 16 102 9 1 vacancy 22 170 10 hearing loss sign language 1 25 161 11 oral-aural 0 35 189 kwazulu-natal 12 hearing loss 1 vacancy 20 150 13 total communication 1 14 108 14 1 18 265 15 2 28 240 16 1 vacancy 30 275 17 sign language 1 27 241 18 0 3 12 19 bilingual/bicultural 1 25 99 limpopo 21 hearing loss & visual impairment 1 16 189 / / / 23 hearing loss, visual impairment & physical impairment sign language 1 vacancy 21 197 24 hearing loss 1 23 240 22 oral-aural 0 2 36 mpumalanga 20 hearing loss, visual impairment & cognitive impairment total communication 0 6 60 northern cape no schools providing for children with hearing loss to date north west 25 hearing loss sign language 0 7 60 26 hearing loss total communication 0 30 300 western cape 27 hearing loss total communication 1 30 200 28 hearing loss oral-aural 1 15 70 29 hearing loss total communication 2 15 200 30 hearing loss oral-aural 1 13 84 31 hearing loss total communication 1 29 150 32 hearing loss oral-aural 2 55 506 total: 664 teachers 6215 learners the south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 catherine van dijk, rene hugo and brenda louw used during the pilot study and focus group interviews. a return rate of 364 (55%) completed questionnaires was achieved. this return rate is considered good as the general return rate for mailed questionnaires is usually in the region of 20% (berg, 1998). three hundred and sixty four of the total population of 769 teachers (47%) providing for children with hearing loss in south africa participated in the questionnaire survey. the sample consisted of 75 of the 165 teachers (45%) who mainly promote spoken language, and 289 of the 604 teachers (48%) who mainly promote sign language. it was concluded that the sample was representative of the total population of teachers providing for children with hearing loss in south africa considering the following (huysamen, 1998): • participants represented all eight provinces that have schools providing for children with hearing loss in south africa; • participants represented 77% of all the schools providing for children with hearing loss; • participants from the sub-groups representing the two communication instructional approaches were represented nearly equally percentage-wise; and • a large number of completed questionnaires (n=364) were received from participants. figure 1 provides a summary of the description of participants included in the questionnaire survey. male (21%)' female (79%) 20-30 years (14%)~2 31-40 years (32%) gender age oiler (1%) sign language (1%)" sepadi (1%) tswana (3%) eng & afr sotho(7%; xhosa (11%) zulu (20%) english (27%) afrikaans (25%) other(1%) signedengiish(1%)· afrikaans (10%!aig &afr (10%) english (31%) home language medium of language instruction no response (1%)specialised deyee(2%j; no preparation (18%) every 3 months (4%)η every 6 months ( 5 % ) " > v p every 2 years-v \ \ \ ~ n o in-service (12%) / \ \ i \ (30%) annually(23%) "^-monthly (26%) 4-5% years (6%)-, 0-1'/» years 2-314 vears j f j f c s l , (13%) n m t f l j p > 5% years ' (72%) in-service training experience other combinations (4%) ί pre-school (4%)vocational (10%) no response (4%) 41-50 learners (9%) 11-20 learners (27%) phases taught teacher/learner ratio figure 1: description of participants in the questionnaire survey (n=364) participants in focus group interviews participants were randomly selected from both the junior and senior phases to ensure representativeness during the focus group interviews (leedy & ormrod, 2001). two focus groups were conducted with each selected school, totaling four separate focus group interviews. one school was representative of teachers mainly promoting spoken language and the other school represented teachers who mainly promote sign language. five participants were randomly selected from the junior phase of a school (ranging from preschool to grade 6) for the first focus group interview. for the purposes of the second focus group interview, five participants were randomly selected from the senior phase of a school (ranging from grade 7 to vocational phase). these selection procedures allowed for a more equal distribution of participants among the teaching phases. the selection of five teachers per focus group interview was regarded as a sufficient number of participants, because according to morgan (1997), a smaller number of participants are required if the participants have a high level of involvement with the topic and a smaller group allows the researcher to exercise more control over the active involvement of each participant. furthermore, five teachers were selected for each focus group interview, because findings from the pilot study revealed this to be a desirable number of participants for active focus group participation. teachers who met the selection criteria and acted as participants in the focus group interviews, are described in figure 2. / ' data collection instruments a questionnaire (see appendix b) and focus group interviews served as data collection instruments for the study. qualifications specialised training die suid-afrikaanse tydskrifvir kommunikasieafivykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the needs of teachers of children with hearing loss within the inclusive education system 27 male (5%) . "^female (95%) gender english ( " k l ^ n s afrikaans (89%) 20-30 yearn (5%)-, 31-40 years/ ;"~λ (30%) ~ f \ >. >51 years v(33%) ^41-50 yeare (32%) age univi -i degn ·· f \ j βί&ί. ~\/vhigher diploma1 honours (74%) home language qualifications specialised . —^ diploma ( no specialised — diploma (79%) specialised training 0-5% years (10%) 6-10% yeare —f \ (11%) 21-30% year / (16%) x & f y/*-11-20% year! (63%) every 6 months,—• (26%) —monthly j (48%) every 3 mont~nquu£| (26%) 1 ^ j ™ in-service training vocational (5%), pre-school(11%)>̂ y flb^j senior (31 %)^§ibj|l ik intermediate / / (53%) experience phases taught figure 2: description of participants in focus group interviews (n=19) the questionnaire a questionnaire, as a data collection instrument, was compiled for this study and considered the most advantageous for the following reasons (berg, 1998; neuman, 1997): • a wide geographical area (in this case the whole of south africa) could be included in the survey; • questionnaire surveys are more time-effective, since a large number of responses can be obtained in a limited period of time; ° questionnaire surveys are more cost-effective in comparison with face-to-face contact with participants; and • a questionnaire is completed in privacy, and participants are therefore more likely to express their true opinions and views. ' however, the main disadvantage of a mailed questionnaire is that there tends to be a poor response rate (neuman, 1997). this limitation was acknowledged, and guidelines in the literature were followed in order to facilitate a good response rate. these guidelines included, telephonic contact with principals prior, during and after the survey, sending questionnaires by courier services, and supplying postage-paid, self-addressed envelopes that were registered at the post-office, to ensure that these parcels could be tracked within the postal system (berg, 1998; neuman, 1997). the questionnaire was comprised of 30 questions distributed across 12 pages, and consisted of three sections. although a 12-page questionnaire seemed lengthy, most of the questions were closed-ended. therefore, the duration for completion (approximately 20 minutes) was considered as being within reasonable limits (berg, 1998). appendix c depicts the development and description of the questionnaire in terms of the content included and the rationale for inclusion. focus group interviews the use of focus group interviews were regarded as an important data collection instrument in the current study for the following reasons (morgan, 1997; stewart & shamdasani, 1990): • some of the quantitative results obtained from the questionnaire survey could be qualitatively interpreted; • concentrated amounts of data, on precisely the topic of interest could be extracted; • new ideas and creative concepts could be stimulated; • complex behaviours and opinions could be more clearly studied; and • participants could be made stakeholders in the research process, when they were given a chance to freely voice their feelings and suggestions. the most common disadvantage of utilising focus group interviews is that the small numbers of participants included in focus group interviews limits the generalisation of findings to the larger population (stewart & shamdasani, 1990). there: fore, this data collection method was not used in isolation in this study, but was combined with a questionnaire survey in order to make findings more generalizable. the focus group interview consisted of two topics to guide the participants during the focus group interviews (stewart & shamdasani, 1990). the first topic of discussion was: "how do you feel about the inclusive education system and children with hearing loss?". this topic remains controversial internationally amongst many teachers of children with hearing loss (english, 1995; moores, 1996). by obtaining participants' views on issues such as the challenges they foresee, and the solutions they suggest, determination of the role of the educational audiologist in attempting to address these challenges will be aided. the second topic discussed was: "how do you feel about the role of a hearing therapist (audiologist) in the inclusive education system?". by determining teachers' need for support and the challenges of current service delivery by the educational audiologist, appropriate service delivery can be planned. the duration of focus groups interviews was approximately 30 minutes each and was conducted on the school premises on separate days during in-service training time. audio recordings were made of the focus group interthe south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 catherine van dijk, rene hugo and brenda louw views, in order to facilitate written transcriptions. in addition, the researcher made notes of distinct nonverbal behaviour, such as frowning, gesturing or winking, that aided the interpretation of the content of the audiocassette recordings at a later stage (stewart & shamdasani, 1990). data analysis the data analysis procedures are described. data analysis of the questionnaire survey analysis of questionnaire data' included quantitative analysis where percentages and frequencies of responses were determined, as well as qualitative analysis, where responses were described in detail. data obtained from the questionnaire survey were analyzed by means of descriptive statistics in order to describe and summarise the collection of scores obtained. descriptive statistics physically reduce large amounts of data and facilitate the drawing of conclusions about them (bless & higson-smith, 1995). raw data transferred onto spreadsheets were analyzed by means of computer software, namely sas/stat® (version 8) from the sas institute. responses to open-ended questions were abstracted into main ideas in order to categorise answers of all the participants into more manageable units (berg, 1998). data analysis of focus group interviews analysis of data obtained from the focus group interviews was qualitative in nature. the cut-and-paste technique described by stewart and shamdasani (1990) was used in order to analyze and interpret data obtained from the focus group interviews. this technique has four distinct steps that are critical in order to establish the dependability of data recording and analysis (reid & gough, 2000). the first step includes the recording of data. during the second step, the researcher identified units from the transcript that were relevant to the research aims (stewart & shamdasani, 1990). these units were underlined by means of a word processing program. in step three, the researcher reread the transcript and then identified by selecting themes that corresponded with those of the questionnaire items. the units relating to these themes were colour-coded according to the themes and were then cut and pasted into their respective classifications using a word processing program. these sorted themes provided the basis for further categorisation of content (stewart & shamdasani, 1990). finally, during step four, units that supported each theme were further categorised in order to form an interpretative representation of responses. these excerpts were numbered and were presented within a format that clearly captured the findings of each theme (stewart & shamdasani, 1990). ethical concerns research ethics define what is legitimate and moral during research procedures (neuman, 1997). according to strydom (2002), ethical issues can be divided into harm to participants, informed consent, deception of participants, violation of privacy, researcher competence, cooperation with collaborators, and release of findings. the researcher attempted to conduct herself ethically in each of these areas. participants were not harmed in a physical and/or emotional manner during the research (strydom, 2002). participants were disadvantaged if they chose not to participate in the research, and this was clearly stated to them. a covering letter accompanied by an informed consent form was provided to all participants, explaining the aims of the research, the procedures to be followed, and that participation in the study was entirely voluntary (strydom, 2002). therefore, participants were not coerced or manipulated into volunteering, and had to give informed consent in order to participate in the research project (berg, 1998). participants were also free to withdraw from the research whenever they chose to do so (strydom, 2002). the researcher ensured that participants were not deceived in any way as to the goal of the study, the purpose, the experiences that they were subjected to, or the use of the data accumulated, as these were clearly stipulated these points in a covering letter (strydom, 2002). it was essential that the researcher acted with the necessary sensitivity where privacy of participants was concerned. therefore, respondents were not requested to reveal their names. in addition, the participants were assured of the confidentiality of their responses by removing any element from the research records that may have indicated the participant's identity (berg, 1998). the researcher assured all parties involved of her competence, skill and thorough preparation to undertake the investigation at hand (strydom, 2002). the research design, data collection instruments, and procedures were reviewed by experienced research supervisors prior to the main study. prior to conducting the fieldwork, permission to carry out the research was obtained from the relevant authorities, namely: research ethics committee: faculty of humanities, university of pretoria by submitting a research proposal prior to the intended study. permission was also obtained from the various departments of education, the school principals, as well as; the participants (strydom, 2002). | questionnaires were distributed and completed during break-time so as not to interfere with regular school duties. focus group interviews were conducted after school hours during a time allocated for in-service training so as not to have caused interference with participants' regular school hours. : the participants were informed that the information obtained from the research would only be used for research purposes and would not be misused or used to cause any harm to the reputation of individual participants or to the professional groups involved (neuman, 1997). after completion of the research, a summary of findings was made available to the departments of education as well as the schools that participated in the research (strydom, 2002). results knowledge of educational audiology averages of the results were determined in order to obtain a broad overview of the findings of both sub-groups of die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the needs of teachers of children with hearing loss within the inclusive education system 2 9 table 2: knowledge of educational audiology areas of knowledge participants who mainly promote spoken language(n=75) participants who mainly promote sign language (n=289) should have knowledge requires support to obtain this knowledge should have knowledge requires support to obtain this knowledge hearing loss 85% 68% 68% 58% negative impact of a hearing loss 92% 73% 66% 64% maximising residual hearing 87% 47% 73% 42% participants on the questionnaire survey. the data is set out in table 2. some excerpts from the focus group interviews are provided in the text. hearing loss and the negative impact of a hearing loss participants of both sub-groups, namely teachers who mainly promote spoken language and teachers who mainly promote sign language, strongly recommended, that teachers have knowledge of the various aspects of hearing loss, but, a smaller number of participants, indicated that teachers required support in the acquisition of this knowledge. the teachers' need for knowledge of the various aspects of hearing loss were confirmed by two excerpts from the focus group that reveal teachers' awareness of the importance of knowledge on hearing loss. "... hearing aids are of the utmost importance, a child cannot afford to be sitting in class without an aid for even one single day..." (participant mainly promoting spoken language). "... we would have liked to know more about it (annual audiograms of pupils) ...we do know how the audiogram works, but if we could compare it with the results of the previous year... if we knew how..." (participant mainly promoting sign language) furthermore, participants who mainly promote sign language, indicated less need than the other sub-group for the acquisition of knowledge and support in the various aspects of hearing loss. j participants of both sub-groups, namely teachers who mainly promote spoken language and teachers who mainly promote sign language, recommended that teachers should have knowledge about the negative impact of a hearing loss on the various areas of development. the teachers' high regard for knowledge about the negative impact of a hearing loss is supported by focus group comments: "... our children have a big problem with abstract thinking... with maths... they experience many difficulties... they don't have insight, they are extremely bound by their concrete world..." (participant mainly promoting spoken language); "... ever so often he is embarrassed, because he didn 't do his work or know what was going on, because he didn't hear..." (participant mainly promoting sign language). an overview of results indicated that participants who mainly promote sign language indicated less need (66% vs 64%) than the other sub-group for the acquisition of knowledge and support with regard to the impact of hearing loss. further statistical analysis regarding knowledge about hearing loss and the negative impact of a hearing loss revealed that some of the variables rendered chi-square (χ2) values greater than the critical value based on ρ < .05 variables that were considered included: gender, age, teaching experience, medium of language instruction, highest educational qualification, specialised training in hearing loss, in-service training as well as the teacher/learner ratio in the classroom. chi-square values greater than the critical value indicated that these variables significantly influenced the participants' need for support in learning about hearing loss. however, none of these variables significantly influenced the participants' need for support in learning how to address the negative impact of hearing loss. participants who mainly promote spoken language, with no specialised training in hearing loss, indicated a greater need for support in learning about the classification of the types of hearing loss than participants who had received specialised training. participants who mainly promote spoken language and that have received in-service training less frequently than once per month, indicated a greater need for support in learning about audiograms and fm systems. participants who mainly promote sign language that had more than 20 learners in their classrooms indicated a greater need for support in learning about the trouble-shooting of a hearing aid. maximising of residual hearing participants of both sub-groups, namely teachers who mainly promote spoken language and teachers who mainly promote sign language, recommended (87% and 73% respectively) that teachers have knowledge about how to maximise residual hearing. however, very few participants (47% and 42% respectively) indicated that teachers required support in the acquisition of this knowledge. two excerpts from the focus group interviews confirm that teachers value knowledge on maximising residual hearing: "...the physical environment of the child should provide for his hearing impairment..." (participant mainly promoting spoken language); "...then you first have to send him back to the hostel to get his hearing aids... many of the older children have that don't-care attitude about their hearing aids..." (participant mainly promoting sign language). statistical analysis of variables and the maximising of residual hearing revealed chi-squar values greater than the critical value which indicated that the variables a significantly influenced the participants' need for support in learning how to maximise residual hearing. the south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 catherine van dijk, rene hugo and brenda louw participants who mainly promote spoken language and who had diplomas, indicated a greater need for support in learning about the advocacy of fm systems in the school setting, than participants with higher qualifications. participants who mainly promote spoken language, with no specialised training in hearing loss, indicated a greater need for support in learning about the instruction of speech-reading skills to children with hearing loss than participants with specialised training. participants who mainly promote spoken language, with more than ten learners in their classrooms, indicated a greater need for support in learning about the enhancement of classroom acoustics. participants who mainly promote sign language and who had diplomas as their highest qualifications, indicated a greater need for support in the acquisition of knowledge in various areas. these areas included, how to advocate the use of fm systems in the school setting, the enhancement of correct listening skills, as well as knowledge in the instruction of speech-reading skills. participants who mainly promote sign language, with more than 20 learners in their classrooms, indicated a greater need for support in learning about the instruction of speech-reading skills. participants who mainly promote sign language who had received in-service training less frequently than once per month, indicated a greater need for support in learning about the identification of noise levels, as well as learning about the encouragement of continual hearing aid use. audiological and educational management of the child with hearing loss averages were calculated in order to condense findings of both sub-groups of participants as obtained from the questionnaire survey. these averages are presented in table 3. the findings in table 3 are discussed in terms of the most outstanding features, and items viewed similarly by participants were grouped together. some focus group excerpts are presented. speech production skills from table 3 it is clear that participants of both sub-groups strongly recommended that teachers take various intervention steps in order to develop the speech production skills of the child with hearing loss. the majority of participants of both sub-groups, namely teachers who mainly promote spoken language and teachers who mainly promote sign language recommended (80% and 60%) respectively that teachers receive professional support in order to develop the speech production skills of the child with hearing loss. participants' recommendations for the development of speech production skills are echoed in the following excerpts from the focus group interviews: "... we want them (the educational audiologists) to...motivate the children to speak, it will be a great help if there is someone to monitor each child..." (participant mainly promoting spoken language); "... they (the educational audiologists) could help...with the pronunciation and forming of words in subjects, where they have to know big words..." (participant mainly promoting sign language). results revealed that participants who mainly promote spoken language generally indicated a greater need for support (80%) in the development of speech production skills than did participants who mainly promote sign language. language, communication, literacy and academic skills results indicated that participants of both sub-groups strongly recommended that teachers take various intervention steps in order to develop skills in language, communication, literacy and academics. however, only an average to belowaverage amount of support in these areas of development was deemed to be required. excerpts from the focus groups highlighted participants' commitment to the development of language skills: "... we are specifically trained to know where language starts, in other words, we know a small little thing such as eye contact... is a form of language..." (participant mainly promoting spoken language); "... definitely in the area of sign language they (the educational audiologists)... can make more contributions in terms of planning the language lessons..." (participant mainly promoting sign language). the development of communication skills was highlighted in | the knowledge of development participants who mainly promote spoken language (n=75) participants who mainly promote j sign language (n=289) j should take various intervention steps requires support to execute these steps should take various intervention steps requires support to execute these steps , speech production skills 78% 80% 75% 60% language skills 90% 53% 74% 45% communication skills 92% 57% 77% 45% / literacy & academic skills 90% 59% ' 76% , 48% psychosocial well-being 97% 17% 92% 21% ι i table 3: audiological and educational management of the child with hearing loss die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the needs of teachers of children with hearing loss within the inclusive education system 31 following focus group excerpts: "... he may get discouraged, because of his communication it is an obstacle between him and the other (hearing) children..." (participant mainly promoting spoken language); "... if teachers at schools for the deaf are making use of sign language interpreters why can't the audiologist also make use of them? ... it would make it much easier for the child" (participant mainly promoting sign language). the importance of developing literacy skills and academic achievement were highlighted by the following excerpts from the focus group interviews: "... with subjects you must zoom-in individually, you must explain the terminology... because their vocabulary is poor, their world experiences are poor..." (participant mainly promoting spoken language); "...if they (the educational audiologists)...can overcome that bridge between sign language and written language, they will be worth their weight in gold..." (participant mainly promoting sign language). psychosocial well-being both sub-groups indicated the importance of intervention in developing the child's psychosocial well-being. in contrast, only a very small percentage specified a need for support in doing so. emphasis on the development of psychological wellbeing can be seen in the following excerpts from the focus group interviews: "... he needs to have a solid foundation, because if he's not emotionally strong, he'll drop out..." (participant mainly promoting spoken language); "... ever so often he is embarrassed, because he didn't do his work or know what is going on, because he didn't hear... he will also feel left out from the deaf community..." (participant mainly promoting sign language). statistical analysis of the results regarding the educational management of hearing loss, revealed that some of the variables rendered chi-squared values greater than the critical value. findings reveal that both sub-groups of participants who had diplomas, indicated a greater need for support in the development of language within activities of social interaction, than'participants with higher qualifications. both sub-groups of participants who have received in-service training less frequently than once per month!, indicated a greater need for support with articulation skills when planning speech production activities. finally, both sub-groups of participants who have received in-service training less frequently than once per month, indicated a greater need for support in providing opportunities for socialising and expression in the classroom. discussion knowledge of educational audiology participants' knowledge of educational audiology, as well as their need for support in the acquisition of this knowledge, is crucial in addressing the specific needs that may arise from the sensory impairment of children with hearing loss (easterbrooks & radaszewski-byrne, 1995; flexer, 1993). hearing loss and the negative impact of a hearing loss participants of both subj-groups strongly recommended that teachers have knowledge of the various aspects of hearing loss, as well as on the negative impact of a hearing loss on the various areas of development. in contrast, a smaller number of participants felt that teachers required support in the acquisition of knowledge in these two areas. these findings may indicate that participants generally did not realise the advantages of receiving support from a professional such as an educational audiologist (english, 1995; johnson et al., 1997). furthermore, participants who mainly promote sign language indicated less need for the acquisition of knowledge and support in the various aspects of hearing loss as well as the various areas of impact relating to hearing loss than the other sub-group. the literature substantiates these findings, which can be explained by the .differences in the communication instructional approaches followed by the two sub-groups (lynas, 1994; moores, 1996). participants who mainly promote sign language were less interested in acquiring knowledge in the various aspects of hearing loss, such as the anatomy and functioning of the auditory mechanism, the aim and interpretation of an audiogram, the purpose and functioning of an fm system and hearing aid, et cetera. reasons for their disinterest can be found in the education system. participants who promote sign language often view knowledge in the aforementioned areas as approaching the hearing loss as a pathology, whereas they tend to regard hearing loss as a social identity and a sub-culture that does not necessarily have to be corrected (deafsa, 2001b; lynas, 1994; moores, 1996). teachers who mainly promote sign language generally do not regard hearing loss as a condition that needs to be habilitated or which negatively influences all areas of development (deafsa, 2001b; lynas, 1994; moores, 1996). furthermore, the acquisition of sign language is not negatively affected by the presence of a hearing loss (moores, 1996). maximising of residual hearing participants of both sub-groups recommended that teachers have knowledge about the maximising of residual hearing. however very few participants indicated that teachers required support in the acquisition of this knowledge. this finding may imply that participants generally did not realise the importance of receiving support from a professional such as an educational audiologist when maximising a child's residual hearing (english, 1995; johnson et al., 1997). audiological and educational management of the child with a hearing loss providing support to participants in the audiological and educational management of the child with hearing loss is essential in order to ensure that all facets of the child with hearing loss are developed (sanders, 1988). teachers should develop all the relevant areas in order to ensure that the child reaches his/her full potential as a scholar and a human being (sanders, 1988). information about the differences between the two sub-groups' need for support in the audiological and educational management of the child with hearing loss is crucial in order to plan for appropriate support structures in the inclusive education system. speech production skills the majority of participants of both sub-groups recommended that teachers take various intervention steps and the south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 catherine van dijk, rene hugo and brenda louw receive professional support in order to develop the speech production skills of the child with hearing loss. results revealed that participants who mainly promote spoken language generally indicated a greater need for support in this development area than did participants who mainly promote sign language. these findings are supported by the literature (jamieson, 1994; lynas, 1994; moores, 1996; paul & quigley, 1994; sanders, 1988) and this, once again, relates to the differences in the communication instructional approaches followed by the two sub-groups. it is well known that teachers who mainly promote spoken language are primarily concerned with inter alia, the child's development of speech production skills in an oral environment or in inclusive settings as this is often a prerequisite for educational success (jamieson, 1994; paul & quigley, 1994; sanders, 1988). on the other hand, teachers who mainly promote sign language tend to focus on the development of sign language skills, and the development of speech production skills is usually not a priority (lynas, 1994; moores, 1996). therefore participants who mainly promote spoken language would indicate a greater need for support in the development of speech production skills. more specifically, the results revealed that participants of both sub-groups strongly recommended professional support in order to acquire knowledge about various speech instructional approaches as well as support to subsequently apply the most suitable approach. these findings are confirmed by a recent study among south african teachers of children with hearing loss, which indicated that the majority of teachers experienced speech instruction as a difficult task, and that they felt incompetent in their ability to address deficits in speech production (isaacson, 2000). in addition, both sub-groups of participants recommended that teachers monitor changes in speech intelligibility. changes in the quality of articulation, voice, pitch, et cetera, should be monitored, in order to target the appropriate sounds that the child with hearing loss is learning to pronounce correctly (froehlinger & bryant, 1981). however, results indicated that only a small number of participants in both sub-groups recommended professional support in order to monitor changes in the child's speech intelligibility. these findings may indicate that participants were of the opinion that they had sufficient skills in this area. a study among south african teachers found, however, that teachers often neglected to monitor the changes in speech intelligibility and rarely completed phonetic inventories for each child (isaacson, 2000). the fact that participants did not indicate a need for support in this area cannot be seen to indicate that they hadsufficient skills. for these reasons, educational audiologists should promote more awareness regarding the development of speech production skills. together with speech-language therapists, they are the most suitable professionals to offer the teachers support in the areas of speech assessment and intervention (english, 1995; johnson et al„ 1997; sanders, 1988). in order to address speech deficits in children with hearing loss, the teacher will need essential information on the child's phonological repertoire, as well as audiological information such as the type and degree of hearing loss, response with amplification, speech discrimination performance, listening skills, and the child's speechreading skills (johnson et al., 1997). the educational audiologist should provide varying degrees of support in the development of speech production skills that will depend on the communication instructional approach followed by the teacher. language, communication, literacy, academic skills and psychosocial well-being participants of both sub-groups strongly recommended that teachers take various intervention steps in order to develop language skills, communication skills, literacy skills, academic achievement and psychosocial well-being in children with hearing loss. in contrast, participants of both sub-groups indicated that they required only an average to below-average amount of support in the development of these skills. participants' failure to recommend support proportional to the intervention steps, may indicate that they did not realise the benefits of receiving support from a professional such as an educational audiologist in developing the language, communication and literacy skills, and in the academic achievement and psychosocial well-being of the child with a hearing loss (english, 1995; johnson et al., 1997). it is evident that educational audiologists need to advocate the range of their services to teachers, and the benefits of receiving this support in educating children with hearing loss in the inclusive educational setting. teamwork and support should be implemented in schools to benefit the whole of the educational team. it should clearly be demonstrated that the services of educational audiologists are for all teachers and children with hearing loss, regardless of the communication instructional approach followed. conclusion results indicated various needs of teachers of children with hearing loss as well as differences between the two subgroups of participants' need for support in various areas. determining these differences is crucial in order to plan for appropriate service delivery that will benefit teachers of both sub-groups and ultimately ensure that the child with hearing loss develops his/her full potential. i this study indicated a definite lack of knowledge among teachers with regard to educational audiology principles' in spite of their in-service training. it becomes clear that teachers require further training and professional support in the development of auditory, language, speech, communication, literacy, academic, and psychosocial skills (johnson et al., 1997) in order to deliver appropriate and effective services to children with hearing loss in the inclusive education system. south africa consists of a unique combination of developed and developing contexts, and this limits the relevance of educational audiology service delivery models applied in developed countries such as the usa and european countries (fair' & louw, 1999). adaptations to the services delivered by educational audiologists should be made to overcome specific south african problems and issues. these problems and issues include overcrowded classrooms and limited staff resources, the lack of parental involvement, the absence of adequate financial resources, increasing poverty, the rising htv/aids pandemic, and challenges associated'with diversity in culture and language (penn & reagan, 1995; viljoen & molefe, 2001). the literature confirms the importance of teachers die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the needs of teachers of children with hearing loss within the inclusive education system 33 receiving the support of an educational audiologist when including the child with a hearing loss. educational audiologists are specialists in the field of hearing loss and the impact of hearing loss on a child's ability to be educated among hearing peers (english, 1995; johnson et al., 1997). furthermore, the educational audiologist assumes the role of family and community liaison agent which considers the child as a unique human being within his/her social context, and therefore links the child's significant others to the educational team, in order to ensure the applicability of the child's intervention programme, thereby increasing the success of outcomes (johnson et al., 1997). only by working together as a team can the successful inclusion of children with hearing loss be achieved in south africa. as part of this team, the educational audiologist and his/her services to children with hearing loss, should be recognised: "audiologists, as professionals who are experts in the management of hearing in an educational setting, can have an enormous impact on the future of children with all types and degrees of hearing problems. indeed, thorough and insightful audiologic management can make the difference between one child with hearing loss becoming an independent, contributing citizen and another child living life on the fringe " (flexer, 1993 p.204). acknowledgements this article is based on a doctoral thesis entitled "an educational audiology service delivery model: needs of teachers of children with hearing loss", written by the first author in partial fulfillment of the requirements for a d phil degree in communication pathology at the university of pretoria, south africa under the promotership of prof r. hugo and the co-promotorship of prof b. louw. references american speech-language-hearing association. 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(1989). special needs in ordinary schools: children with hearing difficulties. london: cassell. appendix a list of schools that provide for children with hearing loss in south africa (n=35) eastern cape efata school for the blind and deaf greenwood primary school reubin birin school for the hearing impaired st thomas school for the deaf free state bartimea school for the deaf and blind thiboloha school for the deaf and blind gauteng dominican school for the deaf filadelfia secondary school katlehong school for the hearing impaired mc kharbai school for the deaf t 1 v.. sizwile school for the deaf sonitus school for the hard of hearing st vincent school for the deaf transoranje school for the deaf kwazulu-natal durban school for the hearing impaired fulton school for the deaf indaleni school for the deaf kwa thintwa school for the deaf ι kwa vulindlebe school for the deaf st martin de porres comprehensive school j vn naik school for the deaf 1 vuleka school for the deaf | limpopo bosele school for the blind and deaf | nelsonskop centre for the hearing impaired tshilidzini school for the deaf yingisani school for the deaf mpumalanga silindokuhle school for the mentally retarded, blind and deaf northern cape no schools to date north west north west secondary school kutlwanong school for the deaf western cape de la bat school dominican grimley school for deaf children / dominican school for deaf children mary kihn school for partially hearing pupils noluthando institute for the deaf nuwe hoop centre for the hearing impaired die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the needs of teachers of children with hearing loss within the inclusive education system appendix β 35 dear teacher, please • complete all the questions • share your knowledge and opinions in detail • place a cross in the appropriate block • more than one block may be crossed where appropriate • all responses will remain highly confidential • any identifying information will be removed from the final report section a: teacher information 1. what is your gender? male female 2. what is your age? 20-30 years 31-40 years 41-50 years 51 years and older 3. what is your home language? afrikaans english sotho zulu xhosa sign language other specify: 4. what is the highest educational qualification you have obtained? 5. have you had any special training in working with children with hearing loss? yes 5.1 if yes, please specify your training: in-service training special diploma/certificate special degree 6. / approximately how long have you been involved with children with hearing loss? 0 1 years 2 3 years 4 5 years more than 5 years section b: information regarding teaching practices i 7. which phases do you teach? . / pre-school foundation intermediate senior vocational/ gr r gr 3 gr 4 gr 6 gr 7 gr 12 technical 8. what is the total number of learners you teach? 9. what medium of language instruction do you use at your school? 0-10 11-20 ' 21-30 31-40 41-50 more than learners learners learners learners learners 50 learners afrikaans english sotho zulu xhosa sign language other specify: 10. what method of communication do you use with your learners? oral-aural sign language total communication bilingual/bicultural the south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 catherine van dijk, rene hugo and brenda louw 11. have teachers at your school received any specific in-service training in terms of managing the child with a hearing loss? (e.g. any workshops, seminars, hands-on demonstrations) yes 11.1 if yes, indicate how often training takes place: every 2 years annually every six months every three months every month 12. do you think in-service training benefits you? yes no explain your answer: section c: the teacher in the future inclusive educational system dear teacher, please • the following questions require your opinion on: what you think the skill of a teacher of children with hearing loss in the future inclusive educational system should be, and whether you think the teacher will require support from a professional person who is knowledgeable in these areas ° remember you can tick more than one answer where appropriate knowledge of the child with hearing loss 13. in which of the following areas should a teacher in an inclusive educational system have basic knowledge and support in? please tick off your choices in both columns el: teacher should have basic knowledge thereof teacher requires support from a professional to obtain this knowledge understand the process of communication interaction i know about the different communication options available, namely oral-aural, sign language, total communication and the bilingual/bicultural method i know the structure and working of the ear i 1 i be able to interpret a child's audiogram (hearing graph) know the purpose and working of an fm system ( know the purpose and working of a hearing aid know how to inspect a hearing aid and detect the problem when it is not working know the common causes of hearing loss know the types of hearing loss associated with these common causes know the factors that can further damage hearing know the impact a hearing loss will have on a child's ability to be educated / / none of the above-mentioned die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the needs of teachers of children with hearing loss within the inclusive education system 37 14. a teacher in an inclusive educational system should know that hearing loss can impact negatively on the following areas of the child and he/she will require support in the following areas: please tick off your choices in both columns el: teacher should know a hearing loss can negatively impact on this area teacher requires support to obtain knowledge on the negative impact of the hearing loss on this area language development speech production communication skills literacy skills academic achievement psychosocial development none of the above-mentioned 15. if a child in an inclusive class has been identified with a hearing loss, the teacher should have knowledge of the following in order to enhance the child's ability to hear and he/she will require support in the following areas: please tick off your choices in both columns el: teacher should have basic knowledge thereof teacher requires support from a professional to obtain this knowledge identify noise levels inside and outside the classroomtry to reduce noise levels inside and outside the classroom suggest to the relevant authorities at school that the classroom should have more absorbent surfaces such as carpets and curtains to enhance the sound quality in the classroom suggest to the relevant authorities at school that the child could benefit from the use of an fm system in class encourage the child to wear his/her hearing aids at all times teach the child the correct listening behaviour in class teach the child speech-reading (lip-reading) skills none of the above-mentioned language of the child with hearing loss 14./ which of the following steps should a teacher in an inclusive educational system have to take in order to address a child's delayed language skills (due to hearing loss) and in which of the following areas will he/she require support? please tick off your choices in both columns kl: teacher should take these steps teacher requires support from a professional to execute these steps use the hierarchy of normal language development to plan activities for language development " take into account the child's unique level of language functioning when talking to the child take into account the child's unique level of language functioning when planning the content of teaching material modify and/or adapt teaching materials, teaching techniques, and the classroom environment to meet the language needs of the child have knowledge of different language instructional approaches such as: fitzgerald key, natural approach, etc. and apply the best suited approach for the child emphasise language across all contexts in the school practise language within activities of social interaction take into account that some children may have additional language problems such as: phonological processes, second language confusion, etc. that need to be addressed none of the above-mentioned the south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 catherine van dijk, rene hugo and brenda louw speech of the child with hearing loss 17. which of the following steps should a teacher in an inclusive educational system have to take in order to address a child's deficits in speech production (due to hearing loss) and in which of the following areas will he/she require support? please tick off your choices in both columns et teacher should take these steps teacher requires support from a professional to execute these steps use the hierarchy of normal speech development to plan activities for improvement of speech intelligibility take into account the child's unique physical ability to produce sounds with his/her mouth when planning activities for improvement of speech intelligibility obtain information on the child's ability to pronounce all the sounds monitor and document changes in the faulty sounds that the child is learning to pronounce correctly have knowledge of different speech instructional approaches such as: analytical, whole, formal, multisensory, etc. and apply the approach best suited for the child take into account that some children may have additional speech problems such as: stuttering, voice problems, etc. that need to be addressed none of the above-mentioned communication of the child with hearing loss 18. which of the following steps should a teacher in an inclusive educational system have to take in order to address a child's communication difficulties (due to hearing loss) and in which of the following areas will he/she require support? please tick off your choices in both columns et teacher should take these steps teacher requires support from a professional to execute these steps expose the child to interactional experiences so that he/she is more motivated to communicate and can develop his/her communication skills apply communication repair strategies when communication breakdowns occur in class have knowledge of the communication options available to the child, either the oral-aural, sign language, total communication or bilingual/bicultural method use one of the above-mentioned communication options in class none of the above-mentioned literacy skills of the child with hearing loss j i 19. which of the following steps should a teacher in an inclusive educational system have to take in order to address a child's poor literacy skills (due to hearing loss) and in which of the following areas will he/she require support? j please tick off your choices in both columns e*3: teacher should take these steps teacher requires support from a professional ! to execute these steps j ensure that the child has acquired the basics of language before proceeding with literacy instruction identify the origin of the reading and writing errors made by the child, such as auditory discrimination problems, language problems, etc address the origin of the reading and writing errors made by the child have knowledge of different literacy instructional approaches such as: top-down or bottom-up, etc. and apply the best suited approach for the child none of the above-mentioned y die suid-afrikaanse tydskrifvir kommunikasieafivykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the needs of teachers of children with hearing loss within the inclusive education system 39 academic achievement of the child with hearing loss 20. which of the following steps should a teacher in an inclusive educational system have to take in order to address a child's poor academic achievement (due to hearing loss) and in which of the following areas will he/she require support? please tick off your choices in both columns et teacher should take these steps teacher requires support from a professional to execute these steps tailor the child's learning experience to his/her cognitive, physical, socio-emotional, and cultural level modify the curriculum of the subject by controlling the vocabulary and syntax none of the above-mentioned psychosocial development of the child with hearing loss 21. which of the following steps should a teacher in an inclusive educational system have to take in order to address a child's troublesome psychosocial development (due to hearing loss) and in which of the following areas will he/she require support? please tick off your choices in both columns et teacher should take these steps teacher requires support from a professional to execute these steps promote the child's confidence in class encourage acceptance and respect from the child's hearing classmates monitor the child's social adjustment and integration in class and intervene when necessary give opportunity for socialising and expression in class none of the above-mentioned service delivery and the child with hearing loss 22. which of the following persons should a teacher in an inclusive educational system involve during teamwork in order to successfully plan the child's educational programme? please tick off your choices in the column g2 teacher will need these person(s) on the team / ' the child with hearing loss ' the parents the speech therapist | the hearing therapist (audiologist) the social worker j the psychologist j the occupational therapist1 others, specify: none of the above-mentioned the south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 catherine van dijk, rene hugo and brenda louw 23. which one of these persons will you choose to co-ordinate the team and to liaise with other team members in order to assist the teacher of a child with hearing loss? please tick off one choice in the column κ the child with hearing loss the parents the teacher must do it himself/herself the hearing therapist (audiologist) the speech therapist the social worker the psychologist the occupational therapist none of the above-mentioned 24. if a professional who specialises in children with hearing loss can provide support to the teacher in the inclusive education system, which of the following methods of support will benefit the teacher? please tick off your choices in the column el: teacher will benefit from the following method(s) of support a once-off training session regular workshops continuous in-service training hands-on assistance when needed none of the above-mentioned 25. if a professional who specialises in children with hearing loss can provide support to the teacher in an inclusive educational system, which one of these service delivery models would you recommend? please tick off one choice in the columnel: the school employs one full-time professional to conduct services at the school the school utilises a private professional from outside the school to conduct part-time services at the school the school employs one full-time professional who receives part-time assistance from another private professional in order to conduct services at the school none of the above-mentioned. specify your own suggestion: j open-ended questions dear teacher, provide detailed explanations of your answers 26. what main duties do you think should a hearing therapist (audiologist) have at a school? 27. do you feel that the teacher in an inclusive educational system can benefit from the support of a hearing therapist (audiologist)? yes 27.1 explain your answer: die suid-afrikaanse tydskrifvir kommunikasieafykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the needs of teachers of children with hearing loss within the inclusive education system 28. what is the biggest challenge that may face a teacher of children with hearing loss in an inclusive educational system? 29. what possible solution(s) can you suggest for the above-mentioned challenge? 30. do you think that children with hearing loss will benefit from the future inclusive educational system? yes 31. explain your answer: thank you for your time and your valuable contribution towards this research project! the south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 catherine van dijk, rene hugo and brenda louw appendix c development and description of questionnaire content section questions topic justification section a: five close-ended questions & 1 open-ended question questions 1 to 6 biographic information of participants questions were included on participants' personal characteristics such as: gender; age; home language; qualifications; specialised training; and experience in order to describe the participants included in the study, as well as to draw correlations during data analysis. section b: seven closeended questions & 1 open-ended question questions 7 to 12 information regarding teaching practices questions requested information with regards to teaching practices and included: the educational phases taught; number of learners; medium of language instruction; method of communication instruction; and in-service training in order to describe the schools included in the study, as well as to draw comparisons during data analysis. section c: fifteen closeended questions & 5 open-ended questions question 13 knowledge of the various aspects of hearing loss and the need for support to determine whether participants realised the importance of having knowledge in these areas, in order to successfully educate children with hearing loss in the inclusive educational system. in this question provision was also made for determining participants' need for support in order to acquire this knowledge, as teachers will benefit from the support of an educational audiologist in order to acquire knowledge of the child with a hearing loss (johnson, benson & seaton, 1997). question 14 knowledge of the areas that hearing loss impacts on and the need for support to determine whether participants had knowledge of all the areas that hearing loss impacted on. participants' need for support in obtaining knowledge in order to be able to address the negative impact of the hearing loss was also probed in this question. teachers may benefit from the support of an educational audiologist in addressing the negative impact of the hearing loss on the child's ability to be educated (johnson, benson & seaton, 1997). the following items were included: language development; speech production; communication skills; literacy skills; academic achievement; and psychosocial development. these areas english (1995); johnson, benson & seaton (1997); moores (1996); and sanders (1988) could be negatively impacted by a hearing loss. question 15 knowledge of the steps to be taken in order to develop the child's residual hearing and the need for support to obtain this knowledge to determine whether participants had knowledge of all the steps required to optimally develop the child's residual hearing. participants' need for support in order to obtain knowledge on how to develop a child's residual hearing was also included, because teachers may benefit from the support of an educational audiologist in this regard. (johnson, benson & seaton, 1997). question 16 knowledge of the steps to be taken in order to develop the child's language skills and the need for support to determine whether participants had knowledge of all the steps required to develop the child's language skills. participants' need for support in order to develop the child's language skills, was also included. ι 1 question 17 knowledge of the steps to be taken in order to develop the child's speech production skills and the need for support to determine whether participants had knowledge of all the steps required to develop the child's speech production skills. participants' need for support, in order to develop the child's speech production skills, was also included. j 1 question 18 knowledge of the steps to be taken in order to develop the child's communication skills and the need for support to determine whether participants had knowledge of all the steps required to develop the child's communication skills. participants' need for support in order to develop the child's communication skills was also included. question 19 knowledge of the steps to be taken in order to develop the child's literacy skills and the need for support to determine whether participants had knowledge of all the steps required to develop the child's literacy skills. participants' need for support, in order to develop the child's literacy skills, was also included. question 20 knowledge of the steps to be taken in order to promote the child's academic achievement and the need for support to determine whether participants had knowledge of all the steps required to promote the child's academic achievement. participants' need for support in order to promote the child's academic achievement was also included in this question. this was included. die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the needs of teachers of children with hearing loss within the inclusive education system 4 3 appendix c continued section questions topic justification question 21 knowledge of the steps to be taken in order to develop the child's psychosocial well-being and the need for support to determine whether participants had knowledge of all the steps required to develop the child's well-being. participants' need for support, in order to develop the child's psychosocial well-being was also included. question 22 information on the selection of relevant team members for the inclusive educational system to determine which team members participants wanted to include during teamwork in the inclusive educational system. the following items were included: the child with hearing loss; the parents; the speech therapist; the educational audiologist; the social worker; the psychologist; the occupational therapist; and an option to add a person not mentioned. working with other team members is as crucial part in the success of educating the child with a hearing loss (johnson, benson & seaton, 1997). literature suggests that of all the team members involved, the child with a hearing loss, and the parents/guardians should always be involved (english, 1995). question 23 information on the selection of a team co-ordinator for teamwork in the inclusive educational system to determine participants' opinions on which person they thought should fulfil the role of team co-ordinator during teamwork in the inclusive educational system. the following items were included: the child with hearing loss; the parents; the teacher; the educational audiologist; the speech therapist; the social worker; the psychologist; or the occupational therapist. according to literature, any of these persons, except the child, can function as a team co-ordinator (english, 1995 and benson & seaton, 1997); question 24 information on the selection of methods available for teacher support in the inclusive educational system to determine participants' opinions on what methods of support they thought could benefit teachers in the inclusive educational system. the following items were included: once-off training session; regular workshops; continuous in-service training; and hands-on assistance when needed. all of these methods of support have their benefits, but, arguably, continuous in-service training may provide the most benefit to teachers, due to the higher frequency of such training sessions (english, 1995). / / / question 2 5 information on the selection of an educational audiology service delivery model for use within the inclusive educational system to determine participants' opinions on what educational audiology service delivery model they thought could benefit teachers in the inclusive educational system. the following items were included: the school-based system; the contractual agreement system; and a combination of the two systems. these three options were identified as the main educational audiology service delivery systems found in school settings, and were therefore included (johnson, benson & seaton, 1997). question 26 i i knowledge of the functions of an educational audiologist to determine (1) whether participants had knowledge of the roles and responsibilities of the educational audiologist in the school setting; (2) to determine participants' opinions on what they thought the roles and responsibilities of the educational audiologist within the inclusive educational system should be. if teachers have knowledge of the roles and responsibilities of the educational audiologist, they will be more frequently inclined to utilise this support and, as a result, the child with hearing loss will benefit from these support services (johnson, benson & seaton, 1997). question 27 1 information on the necessity and advantages of receiving support from the educational audiologist when including a child with hearing loss to determine whether (1) participants had knowledge of the advantages of receiving support from the educational audiologist in the inclusive educational system, (2) participants' opinions on what they thought the advantages of receiving support from the educational audiologist in the inclusive educational system should be. if teachers have knowledge of these advantages they will be more frequently inclined to utilise this support with resulting benefits for the child with a hearing loss. (johnson, benson & seaton, 1997). the south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 catherine van dijk, rene hugo and brenda louw appendix c continued section questions topic justification question 28 information on the challenges faced by teachers when including the child with hearing loss to determine participants' opinions on what they thought the challenges might be when educating the child with hearing loss in an inclusive educational system. the transition toward an inclusive educational system will undoubtedly present challenges to teachers that need to be identified. question 29 information on the possible suggestions to address these anticipated challenges to explore participants' suggestions on how to overcome the challenges they identified in question 28, as suggestions may be incorporated in a proposal for an educational audiology service delivery model. question 30 information on the advantages or disadvantages of including the child with hearing loss to determine participants' opinions on what could be the advantages or disadvantages of the inclusive educational system for the child with a hearing loss. some potential disadvantages could be addressed by an educational audiologist. the advantages identified may highlight the possible success teachers may have when educating the child with hearing loss. die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) information for contributors nature of publication the south african journal of communication disorders publishes reports and papers concerned with research, and critically evaluative theoretical and philosophical conceptual issues dealing with aspects of human communication and its disorders, service provision, training and policy. the south african journal of communication disorders will not accept material which has been published elsewhere or that is currently under review by other publications. manuscript style and requirements preparation of manuscript articles must he accompanied by a covering letter providing the author's address, telephone and fax numbers and e-mail address. articles must be typed on a4 pages in double spacing and in a font size of 12. three print outs of the article must be submitted. one exact copy of the article on disk must be submitted. filenames must include the first author's initials and a clearly identifiable key word and must he type-written on the last line of the last page of the reference list (for retrieval purposes only). articles must not exceed 30 pages. title page the title page of one must contain: title of the article. full names of the authors. institutional affiliation. abstract of the article in the language of the article. the title page of the remaining two copies must not contain the authors' names or institutional affiliations. abstracts and key words each article must contain an abstract of no more than 200 words. all abstracts must be in english, irrespective of the language in which the article was written. each article must provide 5-7 keyf words for indexing purposes. i body of article j all contributions are required to follow strictly, the style specified in the publication manual of the american psychological association (αρα pub. man., 2001). | headings are not numbered. the order of importance is indicated as follows: j main heading in capitals and bold print. sub-headings in capitals,!bold and italic print. sub-subheadings in upper and lower case bold and italic print. sub-sub-sub-heading in upper and lower case bold print. major headings, where applicable, must be in the order of introduction, method, results, discussion, conclusion, acknowledgements and references. all paragraphs should be indented. tables, figures and illustrations all tables, figures and illustrations must be numbered and provided with titles. the title of tables, which appear above, and of figures, which appear below, must he concise but explanatory. allow for 50-75% reduction in printing of tables, figures and illustrations. each table, figure or illustration must appear on a separate page and be print ready. preferable not printed on colour printers. references references must be cited in the text by surname of the author and the date, e.g., van riper (1971). where there are more than two authors, after the first occurrence, et al. may be used from the start. the names of all authors must appear in the reference list, which must be listed in strict alphabetical order in triple spacing at the end of the article. all references must be included in the list, including secondary sources, (αρα pub. man. 2001) only acceptable abbreviations of journals may be used, (see dsi-1 abstracts, october; or the world list of scientific periodicals). the number of references should not exceed much more than 30, unless specifically warranted. examples locke, j.l. (1983). clinical psychology: the explanation and treatment of speech sound disorders. j. speech hear disord., 48 339-341 penrod, j.p (1985). speech discrimination testing. in j. katz (ed.), handbook of clinical audiology (3rd ed.). baltimore: williams & wilkins. davis, g. & wilcox, m.j. (1985). adult aphasia rehabilitation: applied pragmatics. san diego, ca: college-hill. editing articles must be revised for grammar and style prior to submission. the manuscript style of the article must be strictly according to the guidelines provided. only articles complying with the above requirements will be accepted for review. reviewing system the peer review of refereeing system is employed as a method of quality control of this publication. peer reviewers are selected by the editor based on their expertise in the field and each article is sent to two independent reviewers to assess the quality of the manuscript's scientific and technical content. the blind peer review system is employed during which the names of the author/authors are not disclosed to the reviewers. the editor retains the final responsibility for decisions regarding revision, acceptance or rejection of the manuscript. deadline for contributions 30th january each year queries, correspondence & manuscripts address to: the editor, south african journal of communication disorders south african speech-language-hearing association p.o. box 5710 the reeds 0158 south africa copyright the copyright of all articles printed in the south african journal of communication disorders is reserved by the south african speechlanguage-hearing association (saslha). do not include more than 10 tables, figures or illustrations. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 3 5 stuttering: can research unravel the riddle? m. marks wahlaus, ma (log) (witwatersrand) department of speech pathology and audiology university of the witwatersrand, johannesburg abstract in spite of decades of research on stuttering there are few unequivocal findings. several reasons for this are offered and discussed. particular attention is paid to the lack of one accepted definition of stuttering. other issues concern the unit of stuttering, inter and intra-stutterer variability, the overt and covert features of stuttering, objective and subjective measures in stuttering research and the sampling of material for study. these are some of the problems which pertain to study of the nature of stuttering. they apply also to research on therapy, which presents additional challenges to the researcher. opsomming ten spyte van dekades van navorsing oor hakkel, is daar weinig onomwonde bevindings. verskeie verklarings vir hierdie verskynsel word verskafen bespreek. spesifieke aandag wordgeskenk aan diegebrek van een aanvaarde definisie van hakkel. andergeskilpunte wat bespreek word is die eenheid van hakkel, inter en intra-hakkelvariasie, die overte en koverte kenmerke van hakkel, objektiewe en subjektiewe metings wat in hakkelnavorsinq aanqewend word en die keuse van spraakmonsters wat bestudeer word. hierdie is sommige van die probleme in die studie van die aard van hakkel. dit is ook van toepassing op navorsing oor terapie, wat addisionele mtdagings aan die navorser bied. the phrase "the riddle of stuttering" coined by bluemel in 1937 has been frequently quoted to denote the manifold difficulties concerned with stuttering. van riper questions it as being simplistic: "we do not like the term because it implies a pat verbal answer and because it fails to do justice to the complexity of the disorder, j / i stuttering is more than a riddle. it is at least a complicated multidimensional jigsaw puzzle, with many pieces still missing.'j i van riper (1982), p. 1 i to those working with this difficult disorder, it seems that it might well be described in the way winston churchill explained russia in 1937 as "a-riddle wrapped in a mystery inside an enigma". the lack of final answers is in no way due to a paucity of research efforts. curlee & perkins (1984) summing up the status of understanding of stuttering in the middle of the 1980's believe that "after so many years and so much work, it may seem somewhat discouraging that our knowledge base on stuttering will rarely support unequivocal inferences or conclusions." (preface). this theme is continued by perkins' carpenter analogy where he likens the observations about stuttering to individual pieces of lumber lacking the final design to give meaning to them (1985), and by other contemporary writers such as zimmerman, who as recently as 1984 talks in terms of the "lack of progress in coming to an understanding of stuttering and its treatment." (1984, p. 131), echoing an earlier stated view that there was a need for a unifying conceptual die suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 37, 1990 framework of stuttering (zimmerman et al. 1981). there are still no definitive answers to the questions what is stuttering? what causes it? what is the cure (a word which therapists still eschew)? these are the naive, but basic verbalizations of the issues which have constantly plagued speech therapists and the stutterers with whom they work. it is the belief of the writer that the first of these questions is the most fundamental, and the answer to it the sine qua non. the other areas, those of cause and treatment, are dependent on it. if research cannot determine or uncover what stuttering is, it is axiomatic that there can be no more than speculation about its cause or causes; if any etiological factors are presumed, it is important to know on which of the facts, or observations, about stuttering they are made, and how far the jump had to be made before the causal conjecture was made. as far as remediation is concerned, the results of therapy for a condition which cannot be absolutely defined,cannot be absolutely predictable "what stuttering is and w h a t can be done to bring about its modification are inexorably linked together" (brutten 1975, p. 201). the "facts" about stuttering are the proven data. most of these have been derived from rigorously controlled studies, which are valid, reliable and replicable. it is the view of the writer that these data are scarce. for the few studies which give positive results, there are many which purport to test the same aspects, yet produce contradictory findings. to the question of why research on stuttering has not provided definitive facts, many answers may be mooted. adams (1976) discussed some common problems in the design and © sasha 1990' r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 μ. marks wahlhaus c o n d u c t of experiments i n stuttering when he considered what he described as circular definitions of hypothetical constructs, operational definitions that lack denotative specificity, research methods based on invalid assumptions about stuttering and omitted or inappropriate measurement of speech rate in operant studies of stuttering (pp. 3-9). his thinking on these problematic issues, many of which are still unresolved, is acknowledged. it is the purpose of this paper to suggest some possible reasons why results of research on stuttering are so conflicting, and why findings of what is ostensibly the same aspect are often so disparate. the discussion centres around the nature of stuttering, and stresses the issue of definition. difficulties in defining stuttering to the intelligent but naive observer it must be puzzling to find that what is an articulation defect is an articulation defect (or was, before the head of phonology emerged from the linguistic waters); that what is cleft palate speech is cleft palate speech; but that what is stuttering, is not necessarily, or not always, stuttering. the literature abounds in non-confirmed or contradictory findings. while these are often attributed to individual differences between stutterers, or to the concept that there may be different sub-groups of stutterers, much of the conflict and confusion has as its genesis the fact that there is not unanimity among researchers as to what constitutes stuttering. to date, there has not been one definition which has received universal acceptance. the direct relationship between understanding the nature of an event and being able to define it is self-evident. if authorities do not agree about what stuttering is, it is little wonder that results of studies conflict. if there is not common cause as to what constitutes stuttering, workers may be studying different things and considering them the same. the fact that, after all the years of investigation and theorizing, there is no one accepted definition of stuttering which appears to this writer to be the most dominating reason for the disparity in research findings, and for the lack of conclusions. if one researcher takes as his operational definition (and that concept brings its own hazards) that stuttering is present if a speaker repeats, another says that stuttering is present if the speaker repeats or prolongs and yet another that stuttering is present if the observer says it is, each will interpret the findings of the identical study in a different way, and come to different conclusions about the results. it would be surprising if, over the years, some definitions did not become more accepted than others. the definitions which seem to have withstood some tests of time are those implied in johnson's description of types of nonfluencies (1961) and wingate's "standard" definition (1964). it is probable that these have been used in research because of their purely descriptive nature. a researcher can relate to terms such as wholeor part-word repetitions (johnson 1961), and "... audible or silent repetitions or prolongations in the utterance of short speech elements, namely: sounds, syllables, and words of one syllable." (wingate, 1964), (even though there can, and has been controversy over the term "voluntary" which he uses to preface this description). it is easier to mark a sound, syllable or word as being stuttered on with this directive in mind, than it would to mark a word "improperly patterned in time" (van riper, 1963). that there are problems concerning definition is not new. van riper explains some of the different concepts underlying the various definitions. by virtue of the insights he gives, his views are given verbatim: "some of the definitions are merely statements of the authors' points of view with respect to the cause or nature of the disorder ... some definitions are so broad that they fail to provide proper limitations... conversely, there are definitions which are so restrictive that they exclude many persons who would be commonly called or would call themselves stutterers... other definitions are frankly descriptive lists of behaviors, overt and covert, shown by different stutterers... finally, there are the definitions consisting of descriptions of phenomena which seek to identify the essential speech characteristics that differentiate stuttering behavior from other phenomena with which it could be confused." van riper (1982), pp. 11-12 it is the opinion of the writer that many of the problematic issues surrounding definition of stuttering can be dealt with within the frame of the molecular approach to stuttering as espoused by brutten & shoemaker (1967) and brutten (1975). it would seem that a detailed description of the observable behaviours which constitute stuttering would go far in lessening the confusion. this view endorses wingate's (1964) opinion: "any definition of stuttering which treats inadequately with speech characteristics contains a serious fault, for such features are the sine qua non of stuttering... it seems evident that, in essence, we must be content for some time to come with a 'phynotypic' definition of stuttering; that is, a definition which sticks to observable facts about stuttering and excludes hypothetical predilections. it seems to me that a definition such as this is prerequisite to pursuing further rational and reasoned inquiry into the nature of the disorder." wingate (1964), p. 484-485 several experimenters have paid attention to this issue. adams (1976) considered that it was necessary to conceive of specific behaviours, stating that "... it seems reasonable to assert that phrases like a moment or instance of stuttering are virtually useless to the researcher interested in replications..." believjing that "so long as precision and replication remain integral parts of scientific and scholarly inquiry, generaf and vague definitional terminology ought to be avoided" (pp. 4-5). | i from the foregoing discussion, it can be seen that lack of con-' census about a definition of stuttering reflects researchers' diversity of perceptions about the nature of stuttering; and that what one investigator considers to be a stuttering event may not be a stuttering event for another investigator. this lack of agreement about the most basic issue that which is to be studied seriously hampers the advancement of knowledge based on scientific study. t h e unit of stuttering ^ allied to the previous discussion of definition is the issue of what comprises the unit of stuttering.^it has been relatively easy to assume that a person is stuttering on a word, and most research is carried out with this assumption. this has come to be questioned by observant clinicians, and by research finthe south african. journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) s t u t t e r i n g : can research unravel the riddle? 37 dings that the fluency of stutterers can be different to that of non-stutterers. the writer has questioned whether the unit of stuttering is, indeed, the word, or whether the stutter is waiting, beneath insecure fluency "like garp's 'undertoad' " to arrest the stutterer (marks wahlhaus, 1986). wingate (1986) asks whether words per se represent the true focus of stuttering occurrence appropriately. he feels that saying that stuttering occurs on words "... or even in relation to words ..." is essentially a surface description which reflects what he considers to be only a first level of observation. he acknowledges that we have been limited to this descriptive reference, and should be cognizant of the limitations (p. 25). the fact that researchers are not sure, not only of w h a t the stutter is, but w h e r e it is, provides another area of potential misunderstanding among researchers. interand intra-stutterer variability if there is one feature which either implicitly or explicitly dogs the footsteps of experimenters, it is that of individual differences between stutterers. hard on its heels, is the factor of intrastutterer variability. researchers attempt to cope with these problems in different ways. in group design studies there are often attempts to limit variability by, for example, excluding female stutterers, or using the same proportion of male to female stutterers which are reported in the general population. some investigators restrict the age range of their subjects, other intelligence, others family history. a factor which is often controlled for is that of severity. attempts are often made to introduce different types of controls, depending on the variables to be studied. some researchers feel confident in generalizing their findings from a large number of subjects. taking individual differences into consideration, a caveat regarding generalizing must always be recognized. an alternative to group study design is the single subject, or single subjects, design. this has received scientific status within / h e behavioural sciences] having been given particular impetus with behaviour modification studies. with these designs, the researcher is able to control for the inter-subject variability, but has to take cognisance of the differences within the same subject. this is of particular relevance to stuttering where, for example, adaptation has to be taken into consideration when stuttering change is examined, or when a subject's mood changes have to be controlled for before the effects of a treatment can be assessed (aron,-1964). working within this structure, researchers are explicitly aware of their inability to generalize from their results. there does, however, seem no doubt that detailed study of one, or of a series of idividuals, adds to the corpus of knowledge on stuttering. when intra-subject investigations are considered, it is of value to keep in mind the question of consistency. studies have been directed to finding out more about the tendency of stutterers to stutter on the same word as on a previous utterance or reading. the writer found the advanced stutterers which she studied longitudinally to have behavioural consistency over time (marks wahlhaus, 1990). nevertheless, investigators should take into consideration that there is variation in a stutterer's speech under different conditions, and that findings about the nature of the one person's speech could differ form one time to the next, depending on the1 conditions of testing. overt and covert features of stuttering in his text on the nature of stuttering, van riper (1982) uses the term "phenomenology" to introduce two chapters, the one being further detailed in terms of "overt features" and the' other, "covert reactions". many speech pathologists would disagree with wingate's (1964) relegation to a subsidiary statusof his definition of associated features, "... of a more or less general or vague nature which include such things as indications or report of excitement, tension, personal reactions, feelings of attitudes." (p. 488). exclusion of covert reactions in research on stuttering is not always considered as desirable, and studies have been oriented towards the facet only, not only within the field of speech pathology, but in allied disciplines such as psychology. defining and controlling these less tangible variables present particular difficulties when conducting research in this area, with particular difficulties inherent in measurement systems. it seems that the safeguard which should be taken is an explicit awareness of the subjectivity of these features. objective and subjective measures in stuttering research measurement in behavioural research is fraught with difficulties. with developing technologies, objective measures are becoming more viable. at times objectivity is gained at the expense of meaningfulness. glottographic findings of laryngeal function may prove to be of interest in terms of physiology and possibly etiology, but do not contribute significantly to the applied aspect of speech therapy. core findings about the nature of stuttering cannot be overestimated; however, the researcher must recognise the level of his research, and the practical implications and applications of it. the more tried and tested means of assessing and describing stuttering are those which involve some type of human judgement. many considerations have to be made when this type of assessment procedure is used in stuttering research. some of these involve the number of judges, their professional or lay standing, their experience with stuttering which can involve the question of training. there are conflicting ideas in the research reports concerning the way judge agreement should be assessed, taking into account the varied results of interand intra-judge agreement under different conditions of experimentation, as well as different statistical procedures to establish agreement (marks wahlhaus, 1979, 1990). motivated decisions have to be made as to the presentation of the material to the judges. these include such objectives as to whether this is to be done visually, auditorally, or both; whether the stutters are to be considered in isolation or in the speech context; whether the judging situation is to be rigorously experimental or more clinical, among others. attention is drawn here to these aspects, as the writer believes that if these important considerations are not taken into account, results of studies involving judges cannot be compared or collated, and that failure to control for these factors can compound the confusion of findings of studies which purportedly examine the same aspects, but in fact, do so in different ways. die suid-afrikaanse tydskrif vir kommunikasieafivykinys, vol. 37. 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 μ. marks wahlhaus sampling of material for study a factor which needs to be taken into account when studies are carried out on stuttering, is the source of the stuttering data. clinical experience has shown that many stutterers show differing severity when they read and when they speak; from a molecular point of view, therapists observe that some behaviours can be present in one condition and not in the other. yet, very many studies use stutters collected from a corpus of read material (understandably, as the reading situation is more easily controlled than conversation), and explicitly or implicitly identify these with the "stutterer's speech". even more marked than the difference between speaking and reading, is the clinically realised difference between both of these and many stutterers' speech performances when under stress, for example, when talking on the phone. van riper (1982) discusses at some length his observations and views of the way speech is disrupted by stress, within the context of his view of stuttering as a disorder of timing (pp. 437-443), but there is little experimental evidence on this issue. it would be of interest to study specifically the stuttering behaviours manifested by speakers while talking under this type of stress, particularly to see if the same behaviours are present in all situations but more frequently in the stressed situation, or if different and more bizarre responses are evidenced when the stutterer is faced with a situation which has more difficult communication demands. as part of a larger study, the writer studied this aspect and found that, in several instances, the telephone situation did indeed evoke more abnormal behaviours than were evidenced in speaking or reading (marks wahlhaus, 1990). another aspect which should receive more experimental attention is the varied way in which a person stutters on words beginning with different phonemes. as has been pointed out above, recent thinking is challenging the concept that stuttering is necessarily "on" words, or even sounds. until it is proved that word beginnings and initial phonemes are not the stuttering focus, attention must be paid to them. clinical experience has demonstrated that many stutterers manifest different behaviours depending on the articulatory and phonatory features of individual sounds. as early as 1935 johnson & brown reported on stuttering in relation to various speech sounds (1935), as did brown (1938), in one of his often-quoted studies. these studies gave rise to theoretical speculation concerning the reason for the influence of various sounds on stuttering, but there has been little definitive research on this topic. a particular lack is noted within the molecular framework, which seems particularly suited for an investigation of this type. if different behaviours are manifested with the production of words beginning with different phonemes, this cannot be ignored when stuttering behaviours are studied. ideally, stutters on words beginning with the same phoneme should be compared, rather than stutters on words beginning with any phoneme. the consideration of stuttering on different phonemes has particular relevance for therapy. additional problems for research into therapy the difficulties presented above have dealt specifically with studies of stuttering behaviour. there are additional hazards encountered by the researcher who is interested in research on etiology and therapy facets, which are not within the purview of this paper.therapy, in particular, brings its own special difficulties when research is undertaken, including a multitude of patient and therapy variables. this probably explains in part the scarcity of documented research on therapy with stutterers. conclusions what has gone before has highlighted some of the confusions which are still very real in the study of stuttering. there is a need to separate what is conjectured from what has been proved, and for an awareness of how great the quantum leap there often is between theory and fact, and fact and therapy. there is an even more basic need to ensure that the facts, the data about stuttering, are unequivocal, and that each n e w piece of research can be seen as placing a valid and reliable block on the . structure which will lead to an understanding of the distressing disorder of stuttering. references adams, m.r. some common problems in the design and conduct of experiments in stuttering. journal of speech and hearing research, 41, 3-9, 1976. aron, m.l. the effects of the combination oftrifluorperazine and amylibarbitone on adult stutterers. ph. d. thesis, university of the witwatersrand, 1964. brown, s.f. a further study of stuttering in relation to various speech sounds. quarterly journal of speech, 24, 390-397, 1938. brutten, c j. stuttering: topography, assessment, and behavior-change strategies. in j. eisenson (ed.), stuttering: a second symposium. new york: harper and row, 1975. brutten, c.j. and shoemaker d j. the modification ofstutteriny. englewood cliffs, prentice hall, 1967. curlee, r.f. and perkins, w.h. (eds.) nature and treatment of stutteriny: new directions. san diego: college-hill, 1984. johnson, w. measurements of oral reading and speaking rate and disfluency of college-age male and female stutterers and nonstutterers. journal of speech and hearing disorders, monograph supplement 7, 1-20, 1961. johnson, w. and brown, s.f. stuttering in relation to various speech sounds. quarterly journal of speech, 21, 481-496, 1935. marks wahlhaus, m.judges' agreement on auditory and visual aspects o( stuttering journal ofthe south african logopedic society, 26,318, 1979. | marks wahlhaus, m.here island. paper presented at the international conference on stuttering. university of the witwatersrand, 1986. ι marks wahlhaus, m. the consistency of stuttering beha viours oyer time. ph.d. thesis (submitted), 1990. ; j perkins, w.h. horizons and beyond: confessions of a carpenter. seminars in speech and language, 6, 233-244, 1985. j van riper, c. speech correction: principles and methods (4th edn). new york: prentice hall, 1963. i van riper, c. the nature ofstutteriny (2nd ed). englewood cliffs: prentice hall, 1982. ' , wingate, m.e. a standard definition of stuttering. journal of speech and hearing disorders, 29, 484-489, 1964. wingate, m.e. adaptation, consistency and beyond: i. limitations and contradictions. journal of fluency disorders, 11, 1-36, 1986. zimmerman, g.n. articulatory dynamics of stutterers. in r.f. curlee and w.h. perkins (eds). nature and treatment ofstutteriny: new directors. san diego: college-hill, 1984. zimmerman, g.n., smith. a. and hanley, j.m. stuttering in need of a unifying conceptual framework. journal of speech and hearinq research, 46, 25-31, 1981. ' / ' / the south african journal of communication disorders vol. 37 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 55 the nature and management of communication disorders in a rural area : the role of the community speech and hearing therapy workers marguerite schneider department of speech pathology and audiology university of the witwatersrand, johannesburg abstract six hospitals where community speech and hearing therapy workers (cws) are working in gazankulu were visited. firstly, data were collectedfrom records, reports and case files over an 18 month period to determine the nature and prevalence of the communication disorders seen by the cws. secondly, the cws were interviewed about their work situation, organisation of their time and intervention strategies used with communicatively disordered people in order to evaluate the efficacy of their work. methodological issues requiring consideration when undertaking this type of research are discussed. the results are discussed in terms of the implications for course modifications as well as policy decisions within the profession of speech and hearing therapy. opsomming ses hospitale in gazankulu waargemeenskapspraak-engehoorterapiewerkers (g ws) werksaam is, is besoek. die aard en voorkoms van die kommmunikasieprobleme wat deur die gwbehandel word, is bepaal, deur data uit verslae, rekords en gevalsleers oor 'n periode van 18 maande te versamel. verder is daar onderhoude met die gws ten opsigte van hul werksituasie, tydsbenutting en behandelingstrategie gevoer, met die doel om werksejfekktiwiteit te evalueer. metodologiese aspekte wa t in hierdie tipe studie oorweeg moet word, word bespreek. die resultate word in terme van die implikasies vir die modifikasie van die kursus sowel as die beleidsbesluite in die spraak en gehoorterapieberoep, bespreek. it is estimated that 8 -10% of the south african population have a communication disorder (aron, 1984; penn, 1978). this figure is borne out by estimates of communication problems in other parts of the world (van riper&emerick, 1990). if one looks at the percentage of communicatively impaired people who have access to speech and hearing therapy services it becomes apparent that in south africa (aron, 1984; drew, 1982) and indeed in the developing world generally (goerdt, 1989) there is a dearth of speech and hearing services, especially in rural areas (aron, 198|4). this is also true for most health and rehabilitation services in south africa (price, 1986; donald, 1991). faced with this problem the department of speech pathology and audiology at the university of the witwatersrand implemented the two year diploma in community speech and hearing therapy in 1984. by the end of 1991, 58 students had qualified as community speech and hearing therapy workers (cws). the diploma course is "intended to train students to operate quite differently from students in the degree course. in the former the emphasis is on preventive and promotive work, equipping students to follow the principles of community work so that they can function within a primary health care model. in the degree course students concentrate on detailed, in-depth curative work with a strong research orientation" (diploma course review, 1991, p.2). the implication is that the cws should be based in the community and would only be involved in the "provision of elementary speech and hearing therapy" (south african medical & dental council, (samdc) 1985). 1 the implementation of this course, with a clear emphasis on community work, was not accidental but was coherent with a world wide move towards developing appropriate health and rehabilitation services which would overcome shortages of person power. this movement lead to the concepts of primary health care (phc) (walt & vaughan, 1981) and community based rehabilitation (cbr) (helander, nelson, mendis & goerdt, 1989) both of which advocate the use of midand primarylevel workers to ensure a more accessible and more cost effective health and rehabilitation service (helander et al„ 1989; walt & vaughan, 1981) as well as a strong emphasis on promotive and preventive services (walt & vaughan, 1981). delaney and malan (1984) have pointed out that in order to "develop a professional identity that has relevance to our situation and which will ultimately permit a professional practice which bears a direct and meaningful relationship to the population it serves,... a comprehensive understanding of the requirements of both the patient and clinician populations is necessary" (p. 76). they have suggested that this understanding will feed into the development of appropriate training. this point is echoed a number of times in the diploma course reviews written by staff of the department of speech pathology and audiology (review, 1991) in which the following issues have been highlighted. firstly, there is not sufficient information concerning the nature and prevalence of communication problems in areas of south africa other than the white middle class communities. this prevents the achievethc south african journal of communication disorders, vol. 39. 1992 sasi.ha 1shi2 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 marguerite schneider ment of the necessary, comprehensive understanding of the patient population highlighted by delaney and malan (1984). secondly, there has not been any formal evaluation undertaken to assess the efficacy of the cws in dealing with communication problems. there is an annual workshop held at the university of the witwatersrand to which qualified cws are invited (review, 1986). this forum has provided the university staff with much valuable information concerning the nature of the problems (both communication disorders and workplace issues) facing the cws but it is limited in that it does not provide detailed information about the nature of the communication disorders nor evaluate the cws in their workplace. the need for further information on communication problems and for an evaluation of the cws work provided the impetus for the present study. the implementation of the diploma course was not without controversy. the criticisms levelled at the implementers, but apparently not formally documented, included fears of the courses being a second rate qualification aimed largely at blacks, because the need for services is greatest in the black areas. furthermore, the danger of setting up such a course is that it then becomes too easy for the rest of the profession to ignore the need for changing the profession to meet the needs of south africa. these criticisms raise important issues which require careful debate but which is beyond the scope of this paper. it is an easy matter to see a need. it is a more complex matter to determine a feasible methodology which will provide the necessary information in an acceptable manner. the adoption of the phc and cbr approaches has led to a move away from using traditional methodologies for the evaluation of these approaches. miles (1991) has described this development in pakistan where lack of baseline data, trained research assistants and limited access to updated literature has encouraged the use of innovative and unorthodox methodologies which produce meaningful results for the communities concerned. miles (1991) has made the further point that there are "complex multi-causal relations discernible in rehabilitation studies" which require "flexible and holistic approaches" (p.2). in a similar vein, feuerstein (1986) has described a participatory evaluation methodology where the "approaches are ... tailored to suit the real contexts of development programmes, and the abilities and technical levels of the participants" (p.ix). the two methodological approaches described above form one end of a spectrum of "social, non-traditional" (miles, 1991) research methods which move from strongly community-based, participatory approaches through to more externally controlled epidemiological approaches. both ends of the spectrum have their advantages and disadvantages. the participatory model allows for strong community involvement in the research and therefore enhances the commitment of the community to the research and its findings (feuerstein, 1986). however, the source of data (eg. records, files) is often problematic as there are inconsistencies and gaps in the records . especially if these are not seen as a priority (miles, 1991). the uses of epidemiological research include determining the extent of health problems in the community, developing the basis for prevention programmes, and evaluating the effectiveness of preventive or therapeutic programmes (yach & botha, 1986). yach and botha (1986) have listed three types of epidemiological study, viz. descriptive, analytical and intervention. a descriptive study aims to quantify the size or extent of a health problem; an analytical study looks at why a health problem exists; and an intervention study is used to assess the effectiveness of a treatment or modification. in ideal circumstances, health planning should start with a descriptive study, move on to an analytic one and end with an intervention study (yach & botha, 1987). this process should also be applied to the field of rehabilitation. a well documented method of doing descriptive studies is the survey method (yach & botha, 1987) which provides a well structured method for data collection. miles (undated) has provided an insightful and critical review of the "uses and abuses of surveys in service development". she has stated that disability surveys are often undertaken by outside agencies as health planners believe that these will help in the development of services for disabled people. her criticisms are that there is already sufficient relevant data for planning purposes and that further data should be obtained through the existing services and notbefore services are set up. furthermore, she has noted that "surveys can be wasteful or even counter productive (and) service development should take priority" (p. 1). having set out the history and aims of the diploma course and having outlined a number of methodological considerations, i will now contextualise the present study. the purpose of the study is to address the needs discussed above : the need for further information concerning the nature and prevalence of communication disorders and the need for a formal evaluation of the work of the qualified cws. the information obtained could then be used in modifying the diploma course where necessary as well as informing rehabilitation policy development. method in view of the methodological issues discussed above, it was necessary to use a methodology which incorporated aspects of both descriptive study and participatory evaluation methods. the descriptive study method (yach & botha, 1986) was used for looking at the nature and prevalence of communication problems; and aspects of participatory research (feuerstein, 1986) were used for evaluating the efficacy of the cws, viz. the use of tape recorded interviews and discussions, observations and perusal of written information such as records, case files and departmental reports. the interviews and discussions were used as a means of involving the cws in the evaluation process so that the results would then be more meaningful and useful to them. the study does not fall into the category of 'wasteful surveys' as described by miles (undated) as it started from the existing service.this however, was not unproblematic as it provided information only on those disorders .presenting themselves to the cws and not the comprehensive information that would have been provided by a full) survey. furthermore, although the term 'prevalence' is used, it is used in a broad sense and not in a strict epidemiological sense (gerber, 1990). this is recognised as a limitation. the advantage of limiting the source of data to those disorders presenting them1 selves to the cws is that all the records could be included without having to take a sample. aims the aims of this study are twofold: 1. to determine the nature and prevalence of communication disorders seen by the cws in a rural area 2. to evaluate the efficacy of cws in a rurakarea. the choice of gazankulu as the rural area for study was made because of two factors. firstly, the wits rural facility, an extension of the university of the witwatersrand, is situated on the border of gazankulu, which makes this site accessible. secondly, there were at the time of the study, 13 cws working at 6 hospitals in gazankulu, the tsonga / shangaan homeland the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the nature and management of communication disorders in a rural area 57 situated in the north eastern transvaal, south africa. there were two cws based at each hospital except for one hospital which had 3 cws. this is also the hospital which has had a speech and hearing service since 1986 when one of the first cws to qualify started working there. at the remaining hospitals the speech and hearing services had only been in existence for 18 months prior to the collection of the data. all the cws are tsonga speakers and many of them also speak northern sotho. a pilot study was conducted to ascertain the feasibility of obtaining the necessary information from the hospital records, reports and case files. the records of one of the hospitals were examined and it was clear from this that the records kept by the cws would be a useful data collection source. following this a meeting was held with the cws in gazankulu to discuss the study and its aims and to obtain their consent to participate in the study. data collection this took place during two days spent at each of the 6 hospitals. all records and reports for all cases seen by the cws at the hospital, schools and outreach clinics were collected and photocopied for later data analysis; therapy files were perused to determine the type of therapy being given; and therapy and assessment sessions were observed. formal interviews of the cws were tape recorded for later transcription. the interview included a set number of areas for discussion as well as any other issues which arose outside of these. the areas covered dealt with the organisation of their work and time allocation for various functions (eg. travelling, therapy, ward rounds, community education), problems encountered in the management of various disorders, strengths and weakness of the training and issues of career development and professional advancement. any queries which i had from looking at the records were clarified during the time spent with the cws. a number of problems was highlighted during the data collection. the records kept by the cws lacked consistency in terms of the data given, for example, information concerning age, and diagnosis, was often omitted. hence there was a number of cases that had to be categorised as 'unspecified' in terms of age and diagnosis. there were records of disorders seen at a school or outreach clinic but no indication was given of the total number of people screened. if this was the case in only one or two instances for a hospital the average number of people screened at the other clinics and schools by the same hospital, was taken. lastly, there were some diagnostic categories (eg. speech disorders, hearing) which are very broad and require further clarification. | definitions of categories can be seen in appendix a. despite these shortcomings the data obtained were sufficiently· precise to allow clear trends to emerge. the data could have been improved if regular visits to the cws during the 18 month period had been undertaken to assess and advise on record keeping. this however was not possible due to geographical distances involved. the time scale chosen for the study was the 18 month period starting in january 1990, the time at which most of the hospitals started providing speech and hearing therapy services, and ending in july 1991. all the data was collected during august and september 1991 by me. as the records from all the hospitals showed similar trends the data from all the hospitals were pooled and analyzed in the following manner: 1. for the hospital records (inand out-patients) the number of cases of each disorder seen was calculated relative to the total number of cases seen giving a proportional figure 2. for the clinics and schools, sufficient information was available on the total number of people screened and the number of these with a disorder allowing for a prevalence rate to be calculated. the data were analyzed for three age groups: birth to 10 years, 11 to 16 years and above 16 years. this division was used to capture the differences between the high risk younger age group [high risk for hearing disorders especially middle ear infections (mcpherson & holborow, 1981 1983; who, 1992) and speech and language delays]; the lower risk adolescent group; and the adult group [at risk for the whole gamut of acquired communication disorders]. a fourth category, 'unspecified', was used for all the record entries which did not provide ages. results 1. the nature and prevalence of communication disorders a) hospitals. table 1 shows the types of disorders seen at the 6 hospitals (including both inand out-patients) and the proportion of each type of disorder relative to the total number table 1: type of problems and proportion of each relative to the total number of patients seen in β hospitals in the period january 1990 to july 1991 type of problem number of cases percentage relative to total ν = 2305 hearing 1040 45.1 hearing rechecks 167 7.3 speech 90 3.9 cerebral palsy 71 3.1 mental retardation 66 2.9 aphasia 58 2.5 speech & language 41 1.8 hearing aid fitting 37 1.6 learning problem 34 1.5 other 25 1.1 mr + cp 17 0.8 voice 15 0.7 closed head injury 14 0.6 stuttering 14 0.6 unspecified assessments 8 0.3 cleft palate 6 0.3 non-verbal 4 0.2 learning rechecks 3 0.1 filling forms 579 25.0 key: mr = mental retardation cp = cerebral palsy the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 marguerite schneider of patients seen during the period january 1990 to july 1991. from the table it is clear that hearing disorders are the most common types of disorders seen by the cws at the hospitals. these include conductive, middle ear problems as well as sensori-neural problems. speech disorders, cerebral palsy (cp), mental retardation (mr), adult acquired aphasia, speech and language disorders (predominantly in children), and "learning problems", a category the cws use to signify children not coping at school, form the bulk of the remaining disorders. voice, stuttering, closed head injury, and cleft palate are not common problems. of the total number of cases seen, 25% comprised people who came for "completion of forms". these forms are for disability grants or, more commonly, application forms for a teacher training college which requires candidates to provide information on their hearing and vision status. most of these occurred at one hospital. finally, as expected, the child (birth to 10 years) and adult groups (older than 16 years) yielded the greatest numbers of disorders. not only were patients of the "one off" category seen, but a number of patients was seen for therapy at the hospital. these were ward in-patients with aphasia or dysarthria, as well as some outpatients, mainly stutterers and speech and language impaired children. very few patients however, attended regularly for therapy. b) outreach clinics. these include visiting points, where there is no building and without a nurse in permanent attendance, and clinics where there is a clinic building with a nurse in attendance. table 2 gives details of the types of disorders seen in the clinics as well as the total number of disorders relative to the total number of people screened. the number of people screened refers to three hospitals only out of the five who do clinic visits, as they were the only ones who provided information concerning the total number of people screened as well as details of the types of disorders. in terms of ages the majority of the people screened were young children, adult table 2: types of problems and their percentage relative to the total number of problems seen at the outreach clinics of 3 hospitals women and elderly people. hearing disorders made up 90% of the disorders seen with otitis media and impacted wax being the most common of the hearing disorders. there are a number of possible reasons for this high proportion of hearing disorders. the first relates to procedural aspects. the cws screen for hearing rather than for communication disorders generally. furthermore, the screening involves an otoscopic examination together with a few questions regarding speech, language and hearing status. secondly, this high proportion reflects the reality of disadvantaged rural areas where otitis media is clearly a significant problem (who, 1992; mcpherson & holborow, 1981-1983; brobby, 1989). c) schools. only preschools and primary schools were visited, and usually the lower classes were screened. there was often a scattering of children from the higher classes who were referred by the teachers for assessment following educational talks on communication disorders. table 3 summarises the results of school screening carried out in 38 schools. this involved only 4 of the hospitals as one hospital did not provide the necessary information for inclusion in the analysis and the last hospital does not have a policy of regular school visits. of the total number of children screened 20.16% showed some type of disorder. once more, hearing disorders account for over 90% of these. however, unlike the findings from the clinics, impacted wax accounted for 76.44% and otitis media for only 10.35% of the hearing disorders. 2. evaluation of cws efficacy many issues were raised by the cws but as they are not central to this paper they will not be presented. of significance, however, the following observations were noted from the discussions, interviews and the records. a) the cws are hospital based and go out into the community from this base. they are not community based. their 'going out into the community' involves them in activities such as the giving of educational talks, screening, and some, but table 3: total number of problems seen at 38 schools (4 hospitals) and the percentage of the different types of problems relative to the total number of problems total number of people seen 12 154 total number of people seen 12 154 total number screened 6799 1 total number of problems 1 471 percentage of total = 12.10% total number screened 6799 1 total number of problems 1 471 percentage of total = 12.10% total number of problem 1371 i percentage relative to total | number = 20.jl6% type of problem number of cases percentage of total number of problems, ν = 1471 total number of problem 1371 i percentage relative to total | number = 20.jl6% type of problem number of cases percentage of total number of problems, ν = 1471 type of problem number of cases percentage otitis media 629 42.76 impacted wax 1048 76.44 ι impacted wax 557 37.87 otitis media 142 10.35 painful ears 70 4.76 foreign body 49 3.57 foreign body 56 3.81 painful ears 34 2.48 otitis externa 51 3.47 speech & language 33 2.41 other 42 2.86 other 30 2.19 for hearing test 31 2.11 otitis externa 15 1.09 perforations 24 1.36 for hearing test 8 / 0.58 speech & language 10 0.68 mental retardation 0.44 mental retardation 1 0.07 perforation 6 0.44 the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) re and mangement of communication disorders in a • imal follow up of cases in their homes. the main focus of ^ ' " e d u c a t i o n a l talks is on hearing and hearing disorders as 'hev have identified this as a high priority need. 1 b) in all but one of the hospitals, two days a week are spent • the hospital and three days a week in the community. t r a n s p o r t is a big issue as the cws often have to share transr t with other health workers and therefore, have to fit their p°ogrammes into the time frames of the other workers. if there fs no available transport they do not go out. at the hospital the cws see people referred from the doctors, nurses and other rehabilitation workers within the hospital as well as patients referred after school and clinic visits for a full assessment. these assessments were not done at the visits due to shortage of time. teachers, clinic nurses and individuals in the community also referred people to the hospital. c) the cws work together with other rehabilitation workers, viz. physiotherapy (ptas) and occupational therapy assistants (otas) on specific cases such as adult aphasic people and cp children. however, they do not have properly structured rehabilitation teams except in one hospital. at the last hospital there is a well functioning rehabilitation team comprising occupational therapists, one speech and hearing therapist and two cws, otas and ptas. the work organisation of this hospital differs from the other hospitals in that they do not focus on school and clinic visits but instead, as a rehabilitation team, develop community rehabilitation projects such as support groups for mothers of cp children. it was apparent that this hospital also had a more overtly formulated policy regarding the prioritisation of needs. an example of this is their decision to target children as their main focus of work. it is important to note that this was not the only hospital with degreed therapists. d) the cws commented on a number of issues which are important to note. the first deals with the issue of whether they should do therapy. the cws reported that they need to do therapy as they are faced with many cases requiring individual or group therapy. however, as the samdc scope (1985) specifies basic management of communication disorders, at one time it was thought to be inappropriate to teach the cws how to do therapy. although this attitude is no longer held, a number of qualified cws have missed out on this training. they reported that this affects their credibility as they are unable to deal with a disorder comprehensively once it has been identified. a second issue relates to their confidence concerning the knowledge that they acquired on the course. many of the cws said that they felt most competent dealing with hearing screening and testing but lacked confidence in dealing with language disorders. this is borne out by my observations of their work in which language assessments and therapy were rudimentary with an emphasis on motor speech work (eg. tongue exercises, oral peripheral examinations) and vocabulary enrichment. these issues have implications for the course structure and teaching methods. lastly, all the cws raised the issue of the lack of career structure for their qualification which makes them feel very insecure in terms of their jobs and professional status. they also expressed frustration concerning the lack of credits for the diploma courses as this excludes them from entering the four year degree course midstream. discussion 1. the nature and prevalence of communication disorders the most common disorders seen were hearing disorders. there are two aspects to consider when explaining this occurrence. the first is that indeed this does reflect a real situation rural area 59 where hearing disorders form a large part of the communication disorders in disadvantaged rural areas. this is borne out by research on the prevalence of hearing disorders in the developing countries which have shown high occurrences of hearing disorders (who, 1992; mcpherson & holborow, 1981 -1983) although little indication isgiven in these studies of the occurrence of hearing disorders relative to speech and language disorders. many of the cases of hearing disorders seen in the present study included chronic otitis media with resulting complications such as language delay as well as sensori-neural hearing losses. brobby (1989, p. 152) has stated that "otitis media continues to be one of the most common diseases confronting the practising paediatrician and ent surgeon in the third world and it has important economic and health care implications". this is a real problem which requires decisions in terms of management, for example, by following the suggestions made by mcpherson and holborow (1981 1983) that primary and mid-level workers be taught simple but effective methods for treating chronic middle ear disorders. impacted wax was also a common disorder diagnosed. this category was used when a dark mass of wax was observed otoscopically to be obscuring the tympanic membrane. the literature on hearing impairment in developing countries (e.g., mcpherson & holborow, 1981 1983)mention the occurrence of this problem but does not give indications of its prevalence. in most studies it seems, the wax is cleared out before further testing is done, thereby implying that it is not a serious disorder. this is indeed the case as the loss is usually of the order of20 40db hl (silman & silverman, 1991) and conductive in nature so the medical implications are not serious. however, as the prevalence was high in the school age population this disorder should not be rejected as insignificant. if a child is already at risk because of poor nutrition and poor family circumstances, and in addition has a bilateral hearing loss of 40db hl, impacted wax becomes a disorder requiring serious attention. at present the cws instil drops for impacted wax assuming that it will eventually be expelled naturally. however, the efficacy of this approach has not been proven, so an intervention study to assess this is required (yach & botha, 1986). the second aspect to consider is that more of the cws time was spent doing hearing screening and assessments than screening and assessments of speech and language disorders. the first reason for this could lie in the time factor in that screening for hearing disorders using an otoscopic examination together with a few relevant questions is much more cost effective in terms of the number of people screened than speech and language screening. however, it is doubtful whether this type of hearing screening can pick up any disorder other than middle and outer ear diseases. therefore, a development of this screening should involve some form of pure tone screening to identify sensori-neural hearing losses. the use of the liverpool screening audiometer which is a "simple, hand-held device for screening audiometry in developing countries" (mcpherson & knox, 1992) could be added to the screening protocol. a second reason for more time being spent on hearing screening could relate to comments made by the cws during the discussions, interviews and observations during data collection. the cws lack confidence in their ability to assess and remediate language disorders. they do not have access to standardised assessment procedures for tsonga children and it seems that they find it difficult to put into practice general language development principles that were taught to them in relation to english. the lack of adequate knowledge of black south african languages on the part of the lecturers makes this the south african journal of communication disorders, vol. 39 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 marguerite schneider a difficult problem to overcome. this highlights the need for research to develop these assessment procedures and to determine the extent of the speech and language disorders. the cws all commented that there were many children with language disorders but that they were not seeing many of them. the cws did feel confident doing articulation assessments and therapy but one queries whether this is a high priority in the disadvantaged rural areas. other disorders such as cp and mr are common disorders seen by the cws as indicated by table 1. the diagnosis of mr was made on the basis of case history factors (eg. having failed the first year of school three times), a brief assessment of speech and language development and where possible an assessment by the only psychologist working in gazankulu. at one of the hospitals the cws mentioned that there were over 700 names of mr children waiting for some form of intervention. this is clearly an area which has to be addressed although not by the cws alone. an interesting disorder to consider is that of stuttering. it is a well-recognised speech pattern as indicated by the fact that maiiy of the black languages have a word to describe it (ttiriel, 1992). however there was a very low occurrence of this disorder in the cws case load. the explanation given by the cws is that it is not seen as a disability in the tsonga culture and therefore does not get referred for treatment. 2. evaluation of the efficacy of cws from the data presented in the tables 1, 2 and 3 it is clear that there is a need for speech and hearing services in the disadvantaged rural areas. in terms of whether the cws are being effective in their work or not, the evidence points to a positive answer. there was a notable increase in the number of cases seen from the beginning of january 1990 to july 1992. this implies a certain awareness concerning the use of speech and hearing services developing in the community generally, as well as within the health and education sectors. a further pointer to the efficacy of the cws can be found in the observations of their work. at one of the hospitals the cws had met with the local remedial teacher to develop a management policy for mildly mr children. as there are no facilities for these children they decided to enrol them in local schools but with prior discussions with the teachers involved regarding the problem and its classroom management. although it is clear that the cws are providing an effective service, there are many areas which require further development such as the assessment and management of language disordered children. lastly, i will address the issues raised by the cws concerning the career structure for the diploma and their frustrations at not being able to move onto the degree course easily. firstly, it is clear that these people are not based in the community and i will go further to say that they seem well placed in the hospital. the reasons for this are that they are trained in a highly specific area of knowledge and skill and because of that should deal with specific problems relating to their knowledge: it does not seem feasible that a cw in speech and hearing therapy can deal effectively with community development issues such as sanitation, water, and nutritional needs, as well as specific communication disorders. thus i propose that the cws be viewed as mid-level workers providing a service to patients referred by primary level workers, such as the community based rehabilitation workers (crws) or facilitators (crfs), being trained at tinstwalo hospital, eastern transvaal, and alexandra health centre near johannesburg (cornielje, undated).the cws would then provide a secondary level rehabilitation service based at a hospital or school. they would still work closely with the community and the crws/crfs in terms of back and forth referrals, and education concerning communication problems. an example of this would be a child seen by the crw for a suspected hearing loss. the crw would refer the child to the cw for a full hearing assessment and hearing aid fitting after which the child would be followed up in the community by the crw. the degreed speech and hearing therapist would provide the tertiary level of service where the cws could send patients they are unable to treat because of limited knowledge. this concept of limited knowledge relates to the idea that mid-level workers should be taught more about fewer disorders so that they become effective therapists in the disorders they see most of the time and less effective for the disorders they see infrequently. this idea is based on the assumption that there is information about which disorders are most prevalent in the various areas of south africa. this study presents information on one disadvantaged rural area only. the data given in table 1 suggest a reduction of training input on cleft palate and voice problems and an increased input for language disorders if one is training cws for the gazankulu area. finally, the issue of career structure and lack of mobility from the diploma to the degree course, demands brief attention. the insecurity of the cws is an important factor to recognise. they themselves provided examples of other health care professionals who were trained and after a few years of service were told that their professional category did not have any further role. bearing this in mind, i propose that the profession of speech and hearing therapy should take a serious look at its structure and start finding creative means to ensure good career structures and mobility from one level of worker to another. an example of how this could be done is by training all potential cws and degree therapists on a 2 or 3 year degree or diploma which would have as a focus, the development of strong clinical skills for all the major disorder types. any student who wished to expand her/his knowledge and develop a strong research, academic and managerial ability would go on with one or two years of study. these thoughts could be taken even further with the application of a similar concept to the movement of crw/ crfs from a primary level of service provision to a more specific secondary level of service provision, be it in speech and hearing, occupational or physiotherapy. conclusions ! the cws are providing a useful and effective service in dealing with communication disorders in a disadvantaged rural area. through their services the need for further development of these services has become apparent, a point clearly made by miles (undated). the onus is now on the profession of speech and hearing therapy to address the issue of the development of appropriate service provision in a creative way, looking at the needs of the patient and clinician populations, and integrating this information into relevant training for all levels of service provision. acknowledgements / i thank the cws in gazankulu for their open and welcoming attitude and for sharing their ideas with me.. the financial assistance of the institute for research development of the human sciences research council towards this research is hereby acknowledged. opinions expressed in this publication and conclusions'arrived at are those of the author and do not necessarily represent the views of the institute for research development or the human sciences research council. the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) nature and management of communication disorders in a rural area 61 references aron, m. l. (1984). introduction. in m. aron, & l. le roux, (eds.), proceedings of the sasha conference on community work. johannesburg, 1 5 . brobby, g. w. (1989). personal view...strategy for prevention of deafness in the third world. tropical doctor, 19, 152 154. cornielje, h. (undated). the community based rehabilitation course at the alexandrahealth centre: initial findingsfrom a recent evaluation. unpublished mimeograph, alexandra health centre, south africa. delaney, c., & malan. k., (1984). community speech and hearing therapy: some questions before answers. in m.aron, & l. le roux, (eds.), proceedings of the sasha conference on community work in speech and hearing therapy. johannesburg, 73 84. donald, d. r. (1991). training needs in educational psychology for south african social and educational conditions. s. afr.j. psychol, 21, 38 44. drew, m. (1982 october). editorial. sasha communiphon, 1-6. feuerstein, m. (1986). partners in evaluation: evaluating development and community programmes with participants. london: macmillan & talc. gerber, s. ε. (1990). prevention: the etiology of communicative disorders in children. englewood cliffs, new jersey: prentice-hall. goerdt, a. (1989). manpower for community-based rehabilitation programmes. international meeting on human resources in the field of disability. tallin, 14 22 august. united nations office at vienna centre for social development and humanitarian affairs. helander, e., mendis, p., nelson, g., & goerdt, a. (1989). training in the community far people with disabilities. geneva: world health organisation. mcpherson, b.&holborow, c.(1981 -1983). study of deafness and ear disease in west africa the gambian hearing health project. london: the commonwealth society for the deaf. mcpherson, b. & knox, e. (1992). test-retest variability using the liverpool screening audiometer in a field environment. brit. j. of audiology, 26, 139 141. miles, m. (1991). effective use of action-oriented studies in pakistan. intern. j. of rehab. research, 14, 25 35. miles, s. (undated). the uses and abuses of surveys in service development planning for the disabled in the case of lesotho. unpublished mimeograph, save the children fund, uk, regional organiser. penn, c. (19 78). speech pathology and audiology in south africa -past, present and future perspectives. in l. lanham, & k. prinsloo, (eds.), language and communication studies in south africa. cape town: oxford university press. price, m. (1986). health care as an instrument of apartheid policy in south africa. health policy and planning, 1, 158 170. department of speech pathology and audiology. (1986 & 1991). review report on the undergraduate two-year diploma in speech and hearing therapy (community work). unpublished mimeographs. johannesburg: university of the witwatersrand. south african medical and dental council. (1985,9 august). samdc regulations defining the scope ofthe profession of community speech and hearing workers. government gazette. silman, s. & silverman, c. a. (1991). auditory diagnosis: principles and applications. san diego, california: academic press. turiel, r (1992). an investigation into the beliefr and attitudes of south african indigenous healers with regard to causes and management of stuttering. unpublished undergraduate research report, department of speech pathology and audiology, university of the witwatersrand. van riper, c. & emerick, l. (1990). speech correction 8th ed. englewood cliffs, new jersey: prentice-hall. walt, g. & vaughan, p. (1981). an introduction to the primary health care approach in developing countries: a review with selected annotated references. ross institute of tropical hygiene publication no. 13, london: london school of hygiene and tropical medicine. world health organisation, (1992). formulation of guidelines for management of programmes for the prevention of deafness. meeting held in new delhi, 9-10 september, 1991. geneva: who. yach, d. & botha, h. j. l„ (1986). epidemiological research methods. part ii. descriptive studies. sa medical j., 70, 766 772. yach, d. & botha, h. j. l., (1987). epidemiological research methods. part vii. epidemiological research in health planning. sa medical j., 72, 633 636. a p p e n d i x a description of the categories used i n the analysis of the d a t a table 1 categories: ι only the ambiguous categoriesj are described. hearing = any type of hearing disorder, conductive or sensorineural [ hearing recheck = recheck after diagnosis of otitis media or impacted wax to note any improvements after treatment speech = any articulation type of disorder although it is possible that some of the children diagnosed as having speech problems might well have additional language ones learning problem = when a child fails at school or is reported to be having difficulties by the teacher a rather broad category other = any disorder not included in the categories non-verbal = when a child does not appear to verbalise at all learning rechecks = when child with a learning problem returns for a recheck table 2 and 3 categories: as these disorders were identified from a hearing screening and not a full speech, language and hearing screening the categories are predominantly concerned with hearing disorders. only the ambiguous categories are described. otitis media = red tympanic membrane and/or runny ears painful ears = as reported by the patient otitis externa = itchy ears and/or sores on the pinna other = any disorder not included in the categories for hearing test = when a hearing loss is suspected the person is referred to the hospital for a hearing test perforations = as observed on otoscopic examination; usually these are quite distinct for them to be observed by the cws speech and language = broader than for table 1 as here it includes any disorder eg. stuttering the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) performance of saenglish 1st language l speakers on central auditory processing test 15 the performance of south african english first language child speakers on a "low linguistically loaded 'central auditory processing test protocol nicole g. campbell* and wayne j. wilson* * department of communication pathology, university of pretoria, pretoria, south africa *school of health and rehabilitation sciences, university of queensland, brisbane, australia abstract the lack of standardized tests for central auditory processing disorders (capd) in south africa (sa) led to the formation of a sa capd taskforce, and the interim development of a" low linguistically loaded\ "capd test protocol using test recordings from the 'tonal and speech materials for auditory perceptual assessment disc 2.0'. this study compared the performance of 50 sa english first language child speakers (aged 8 to 12 years of age) on this protocol, with the previously published american normative data ofbellis (1996, 2003). results with respect to predicted pass criteria as calculated by mean-2sd cutoffs, suggested that the sa speakers performed of a lower level than the american speakers by an average of 5.3% per ear for the two pair dichotic digits test, 1.9 db for the masking level difference test, 8.8% per ear for the frequency pattern test humming report, 14.5% per ear for the frequency patterns test verbal report, and 39.7%> per ear for the low pass filtered speech test. consequently, the bellis (1996, 2003) data was not considered appropriate for immediate use as normative data in sa. instead, the preliminary data provided in this study was recommended as interim normative data for sa english first language child speakers until larger scale sa normative data can be obtained. introduction this study served as a direct follow-on from the saleh, campbell and wilson (2003) study published on pages 19 to 25 of this edition of the south african journal of communication disorders. whereas the saleh et al. (2003) study investigated the performance of south african (sa) english first and second language adult speakers on the " low linguistically loaded" capd test protocol selected by the sa central auditory processing disorder (capd) taskforce, the present study investigated the performance of sa eriglish first language child speakers on selected tests from the same test protocol. / methodology aims following on from the sa capd taskforce's proposed" low linguistically loaded" interim capd test protocol, and the resulting need for sa specific normative data, this study used a comparative research design (leedy δΐ ormrod, 2001) to: obtain preliminary normative data from sa english first language child speakers, on four tests of capd suitable for use in the proposed test protocol. determine if the performances of the sa english speakers differed from the previously reported american normative data ofbellis (1996, 2003). subjects fifty child subjects (10 each from the 8, 9, 10, 11 and 12 year old age groups) were conveniently sampled from four mainstream primary schools in the gauteng region. the children were recruited by approaching the principals of the schools. permission was obtained from the principals to send letters home with the children that outlined the aim of the study, the test procedures as well as a request for volunteers to participate in the study. the sample size for each age interval was based on the minimum sample size required for utilizing the means procedure of the sas program (sas institute inc., 1999) and the time limitations of the study. the subjects all spoke sa english as their first language (based on the first language leant at school, and the first language used in general day-to-day living) and were all of the same ethnic background, namely white english first language speakers. they had no developmental or learning disabilities, no known medical history of adverse neurological or medical conditions, and normal pure tone thresholds and acoustic immittance results (hall & mueller, 1997; martin & clark, 2000). all criteria, except the pure tone and acoustic immittance requirements, were confirmed by subject and parental report only. materials and apparatus a subject information sheet and letter of consent were used to explain the purpose and nature of the study. a biographical questionnaire, a welchallyn 3.5 v hal otoset otoscope, an audiometer (interacoustic ac30 audiometer with telephonic tdh-50 earphones), an acoustic immittance meter (gsi 28a middle ear analyzer), a compact disk player (single disc philips portable ax1000), and the cid w-l list of spondees (presented live voice), were used to ensure the subjects had no history or peripheral hearing deficits that could adversely affect the capd testing. the same audiometer and compact disk player, and the 'tonal and speech materials for auditory perceptual assessment disc 2.0' (wilson & strouse, 1998), were used to obtain the capd test data. of all the tests available on the 'tonal and the south african journal of communication disorders, vol. 50, 2003 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) nicole g. campbell and wayne j. wilson 16 disc 2.0' (wilson & strouse, 1998), only the following four tests were used: the two pair dichotic digits test (a low linguistically loaded dichotic speech test), the low-pass filtered speech test (a monaural low redundancy test), the frequency patterns test (a temporal patterning test), and the speech masking level difference test (a binaural interaction test). the two pair dichotic test was selected, as this task was more challenging than the use of single digits, yet simple enough for young children (bellis, 1996, 2003). the remaining three tests were selected as the child age norms for these tests were better defined than for other tests of capd (bellis, 1996, 2003). all tests were suitable for inclusion in the" low linguistically loaded"capd test protocol as recommended by the sa capd taskforce (south africa central auditory processing taskforce, 2000, 2001). it must be noted that the low-pass filtered speech test recording used in this study was from the 'tonal and speech materials for auditory perceptual assessment, disc 2.0' (wilson & strouse, 1998). this recording used monosyllabic words from list 3 of the northwestern university auditory test no. 6 (n. u. no. 6), spoken by a female, and low-pass filtered with a 1500hz cutoff at 115 db/octave (wilson, zizz, shanks & causey, 1990). the low-pass filtered speech test recording used by bellis (1996, 2003) was from auditec, st louis. this recording used monosyllabic words from list 3 of the northwestern university auditory test no. 6 (n. u. no. 6), spoken by a male, and low-pass filtered with a 1000hz cutoff (bellis, 1996,2003). all testing was conducted in a sound-treated test booth and all audiometric equipment and test environments complied with the south african bureau of standards specifications. procedures on arrival for testing, the parents of each subject completed the informed consent and pre-test questionnaire forms, and each subject underwent otoscopic, pure tone, speech reception and acoustic immittance testing. subjects who met the selection criteria were then tested on the selected capd tests from the 'tonal and speech materials for auditory perceptual assessment disc 2.0' (wilson & strouse, 1998). both the order of test presentation, and the order of ear testing (where appropriate), were randomized. the test procedures used were as per those described by saleh et al. (2003) on pages 21 to 22 of this e d i t i o n of the south african j o u r n a l of c o m m u n i c a t i o n d i s o r d e r s , with the following modifications: 1) each subject was familiarised with the test stimuli prior to the tests being applied. for the twopair dichotic digits, each subject was asked to repeat sequences of four digits spoken live voice by the examiner. for the low-pass filtered speech and speech masking level difference tests, the test-words were read to each subject by the examiner and their meaning discussed. for the frequency pattern test, each subject was asked to verbally label and hum patterns as hummed by the examiner. each subject was also informed that the accent of the recorded s p e e c h m a t e r i a l was a m e r i c a n , and that the pronunciation of some of the words differed slightly from t h e sa p r o n u n c i a t i o n . w h i l s t s i m i l a r familiarisation techniques were used by bellis (1996, 2003), their use in the present study was primarily to counter the possible linguistic bias resulting from assessing sa english first language speaking children using capd test materials recorded in american english (wilson & strouse, 1998). 2) stimulus presentation levels were set to 50 dbsl relative to the average pure tone threshold at 0.5, 1 and 2 khz. these levels were different from that of saleh et al. (2003) and bellis' (1996, 2003) use of 50 dbsl relative to the 1000 hz threshold, 50 dbsl relative to spondee threshold, or 50 dbhl, depending on the test involved. table 1 summarises the differences in presentation levels between this study and those used by bellis (1996, 2003). the reason for the different levels was that the normative data being generated by this study was used in a subsequent doctoral study by campbell (2003) where spondee thresholds were not measured. 3) the frequency pattern test was presented twice. for the first presentation, each subject had to say the patterns back. for the second presentation, each subject had to hum the patterns back. the same frequency patterns and protocol were used for each response format. data collection and analysis all subject responses were recorded manually and scored off-line. group performances on each capd test were described using means and standard deviations. comparisons with the normative data of bellis (1996, 2003) were completed using mean-2sd cut-off values only. these mean 2sd values were used as they were the only values provided by bellis (1996, 2003) (her report did not report sample sizes, subject selection criteria, or raw data). | results and discussion ' table 2 shows the results obtained for the sa english first language child speakers, and the related bellis (1996, 2003) american normative data, on the capd tests assessed. compared to the american normative data (using the mean-2sd values only), the table 1. differences in the test procedures employed by this study and by bellis (1996, 2003). test audiometer settings used in current study audiometer settings used by bellis (1996, 2003) the two pair dichotic digits test 50 dbsl relative to the spondee threshold of the better ear the frequency patterns test 50 dbsl relative to the average pure tone threshold at 500, 1000 and 2000 hz of the better ear 50 dbsl relative to the 1000 hz threshold of the test ear the low-pass filtered speech test 50 dbhl die suid-afrikaans e tydskrif vir kommunikasieeafwykings, vol. 50, 2003 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) performance of sa english 1st language l speakers on central auditory processing test 17 table 2: sa english first language speaking child data (mean ± sd and mean 2sd), and bellis1 (1996, 2003) american normative data (mean 2sd only, in bold) age in years test dichotic digits test frequency pattern test verbal frequency pattern test • humming low-pass filtered speech speech mld test (db) ear r(%) l(%) r(%) l (%) r(%) l(%) r(%) l (%) 8 (n=10) mean ± sd mean-2sd bellis 87.0 ±7.5 71.9 75 77.3 ±8.8 59.7 65 49.4 ± 14.5 20.4 42 50.2 ± 12.9 24.5 42 56.8 ±8.8 39.2 42 56.4 ±9.7 37.0 42 43.5 + 13.1 17.2 70 37.5 ±15.5 6.5 70 5.2 + 1.1 2.9 5.5 9 (n=10) mean ± sd mean-2sd bellis 88.0 ±7.4 73.1 80 82.0 ±7.9 66.2 75 64.0 ±9.6 44.9 63 64.0 ±7.7 49.1 63 67.2 ± 6.2 54.8 63 68.2 ±6.3 55.6 63 49.5 ±9.3 31.0 68 50.5 ± 12.6 25.4 68 5.8 + 0.8 4.1 5.5 10 (n=10) mean ± sd mean-2sd bellis 93.3 ±3.6 86.2 85 90.0 + 8.2 73.7 78 73.6 ±8.5 56.7 78 72.6 ±6.0 60.7 78 77.0 ±4.3 69.3 78 75.8 + 5.2 65.4 78 52.5 + 11.6 29.3 72 54.0 ±8.8 36.5 72 5.4 ±0.9 3.7 5.5 11 (n=10) mean ± sd mean-2sd bellis 94.3 ±6.1 82.0 90 92.0 ±5.1 82,0 88 80.0 ± 4.6 81.8 78 81.2 + 5.7 70.8 78 82.4 + 5.7 69.9 78 82.8 ±4.6 71.0 78 57.0 ±9.5 38.0 75 55.0 + 8.2 38.0 75 5.8+1.7 2.4 5.5 12 (n=10) mean + sd mean-2sd bellis 93.5 ±4.6 84.3 90 92.8 ±5.1 82.6 90 82.4+10.7 61.0 80 79.6+11.4 56.8 80 84.8 ±9.2 66.4 80 82.4 ±8.3 65.9 80 69.0 ±7.8 53.5 78 67.9 ±7.1 53.8 78 6.2 ± 1.2 3.7 5.5 r right l left than bellis' (1996, 2003) american normative data for all tests except the right ear score of the 10 year olds on the two pair dichotic digits test. ranking the mean-2sd scores of the sa english first language child speakers showed that they performed most like their american english speaking counterparts on the two pair dichotic digits test (averaging 5.3% lower/ear), followed by the speech masking level difference test (averaging 1.9 db lower), the frequency pattern test humming report (averaging 8.8% lower/ear), the frequency patterns test verbal report (averaging 14.5% lower/ear), and lastly the low-pass filtered speech test (averaging 39.7% lower/ear). the most likely factor to have influenced the two pair dichotic digits, the low pass filtered speech, and the speech masking level difference test scores, was the american english accent of the test recordings. whilst thesejtests were chosen because of ,tlieir relatively low linguistic load, there was still sufficient load to disadvantage the sa english first language child speakers. an a c c e n t m i s m a t c h was not e n o u g h , however, to explain the much poorer mean-2sd scores obtained by the sa english first language child speakers on the low-pa'ss filtered speech test. this effect was more likely to^have resulted from the different cd recordings used by this study and those ofbellis (1996, 2003). it is possible that the words on this study's 'tonal and speech materials for auditory perceptual assessment, disc 2.0' (wilson & strouse, 1998) recording may harder to recognise (bellis, 1996, 2003). the lower scores were of particular concern when considering the very low (<20%) scores obtained by the 8 year old group, and the generally low scores (<40%) obtained by the 9 to 11 year old groups. overall, these results suggest that the 'tonal and speech materials for auditory perceptual assessment, disc 2.0' (wilson & strouse, 1998) recording of the low-pass filtered speech test should be approached with caution when assessing sa english first language child speakers. similarly, an accent mismatch also cannot explain the lower mean-2sd scores obtained by the sa english first language subjects on the frequency patterns test on both the verbal and humming report. further research is needed to identify the reasons for these differences, although the better scores obtained on the humming report suggest a possible influence of the maturity level of the corpus callosum (bellis, 2003). similar to the performance on the low-pass filtered speech test, the very poor scores obtained by the 8 year old group on the frequency patterns test for verbal report, suggest that the frequency patterns test on the 'tonal and speech materials for auditory perceptual assessment disc 2.0's' (wilson & strouse, 1998) should also be used with caution in this younger age group. conclusions preliminary normative data was obtained for sa english first language child speakers on four tests of capd selected from the 'tonal and speech materials for auditory perceptual assessment disc 2.0' (wilson & strouse, 1998). each test was chosen because of its suitability for use in the" low linguistically loaded"test protocol proposed by the sa capd taskforce. on average, the sa english first language child speakers performed worse than the bellis (1996, 2003) american data (as calculated by comparing mean2sd cutoffs). as a result, the bellis (1996, 2003) a m e r i c a n n o r m a t i v e data was not c o n s i d e r e d appropriate for immediate use in sa. instead, the sa data provided in this study was recommended for use as preliminary normative data for sa english first language child speakers, until larger scale sa normative data can be obtained. in particular, the subjects lower scores on the low-pass filtered speech test contained on the 'tonal and speech materials for auditory perceptual assessment disc 2.0' (wilson, & strouse, 1998), suggest that this test should be approached with caution when assessing south the south african journal of communication disorders, vol. 50, 2003 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) nicole g. campbell and wayne j. wilson 18 limitations of this study are noted and the results cannot be generalized beyond the subject, stimulus and recording parameters used. note: the 'tonal and speech materials for auditory perceptual assessment disc 2.0' (wilson, & strouse, 1998) is available from professor richard wilson phd, audiology (126), va medical centre, mountain home, tennessee 37684, ph +1 423 926 1171 ext 7553, fax +1 423 232 6903, email r i c h a r d . w i l s o n 2 @ m e d . v a . g o v o r wilson.richard@mtn-home.va.gov. professor wilson does not charge a formal price for the cd, as it was produced by usa veterans affairs. he has requested that you send a "donation (postal order)" of us$50100 to his research fund the east tennessee state university (etsu) foundation. references bellis, t. j. (1996). assessment and management of central auditory processing disorders in the educational setting: from science to practice. san diego: singular publishing group. bellis, t. j. (2003). assessment and management of central auditory processing disorders in the educational setting: from science to practice (2nded.). san diego: singular publishing group. campbell, n. g. (2003). the central auditory processing and continuous performance of children with attention deficit hyperactivity disorder (adhd) in the medicated and nonmedicated state. u n p u b l i s h e d d o c t o r a l dissertation. university of pretoria, pretoria. hall, j. w., & mueller, h. w. (1997). audiologists' desk reference. san diego: singular publishing group. leedy, p. d., & ormrod, j. e. (2001). practical research: planning and design (7th ed.). upper saddle river, new jersey: merrill prentice hall. martin f. n., & clark, j. g. (2000). introduction to audiology (7th ed.). boston: allyn and bacon. sas institute inc. (1999). sas/stat user's guide version 8. cary, nc: sasinstitute inc. saleh, s., campbell, n. g., & wilson, w. j. (2003). the performance of south african english first and second language adult speakers on a" low linguistically loaded" central auditory processing t e s t p r o t o c o l . south african journal of communication disorders, 50, 19-25. s o u t h africa c e n t r a l a u d i t o r y p r o c e s s i n g disorder taskforce. (2000). sa capd taskforce business plan. unpublished document. pretoria, south africa. s o u t h africa c e n t r a l a u d i t o r y p r o c e s s i n g disorder taskforce. (2001). sa capd taskforce: an update. unpublished document. pretoria, south africa. wilson, r.h., & strouse, a. (1998). tonal and speech materials for auditory perceptual assessment disc 2.0. tennessee: department of veterans affairs. wilson, r. h., zizz, c. α., & sperry, j. l. (1994). masking level difference for spondaic words in 2000-msec bursts of broadband noise. journal of die suid-afrikaanse tydskrif vir kommunikasieeafwykings, vol. 50, 2003 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mailto:richard.wilson2@med.va.gov mailto:wilson.richard@mtn-home.va.gov 49 tentative age-related norms for high frequency electric bone conduction audiometry g r voogt department of otorhinolaryngology medical university of southern africa η s schoeman department of mathematics and statistics medical university of southern africa abstract from 172 male and female patients aged 7 71 years old and admitted in one month to a tuberculosis hospital, 150 had their highest audible electric bone conduction (ebc) frequency evaluated, prior to the commencement of any medical treatment. various problems in establishing high frequency norms are discussed and from the results of this study tentative agerelated highest frequency ebc norms are suggested. possible clinical applications of evaluating the highest audible c frequency is suggested. opsomming van 172 manlike en vroulike pasiente met ouderdomme 7-71 jaar oud wat in een maand opgeneem is in 'n tuberkulosehospitaal, is 150 se hoogste hoorbare elektriese beengeleidingsfrekwensie bepaal, voor die aanvang van enige mediese behandeling. verskeie probleme in die daarstelling van hoefrekwensie-norme word bespreek en uit die resultate van hierdie studie word tentatiewe ouderdomsverwante hoogste hoorbare elektriese beengeleidingsfrekwensienorme voorgestel. moontlike kliniese toepassings van die bepaling van die hoogste hoorbare elektriese beengeleidingsfrekwensie word voorgestel. \ key words: highest audible frequency, electric bone conduction, age, sex, norms. introduction as early as 1876 galton showed interest in establishing the upper frequency hearing limits for humans, by using such crude instrumentation as whistles in his examinations (galton, 1876). ! the interest in compiling high frequency normative data dates way back to 1929, when dr. harvey fletcher's original reports on high frequency normative studies were published. at that time he reported that the data was very uncertain and varied greatly amongst individuals (fletcher, 1929). since those early years immense progress has been made in design and development of audiometers, testing procedures and calibration of the equipment. however, different researchers still reported widely differing data for high frequency hearing thresholds and thus also normative data (sivian & white, 1933; dadson & king, 1952; rudmose, 1961; zislis & fletcher, 1966; harris & myers, 1971; and northern, downs, rudmose, glorig & fletcher, 1972). thus reports on high frequency audiometry originated from research investigations but no clinical applications were suggested. 1 recently many investigators have shown renewed interest in high frequency audiometry as more and more possible clinical applications have become evident. jacobson, downs and fletcher (1969) applied high frequency audiometry for the early detection of ototoxicity; corliss, doster, simonton and downs (1970) for detecting noise-induced hearing damage; fletcher, cairns, collins and endicott (1967) for detecting hearing loss due to meningitis; rosen and olin (1968) for detecting hearing loss related to coronary heart disease. in all cases only air conduction stimulation was used. as no normative threshold data existed, much use was made of baseline threshold data to which any changes in hearing, subsequent to diseases or treatment, was compared. methods of testing, instrumentation and calibration of instrumentation also differed widely (northern et al., 1972). until 1988 high frequency audiometry was mostly restricted to studies involving sensori-neural disease processes, thus the interpretation of high frequency threshold changes have remained largely conjectural. bone conduction audiometry has been restricted to the frequency range of 250 hz to 6 khz, because bone vibrator quality is poor die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 g r voogt and η s schoeman at higher frequencies. this latter problem was largely overcome in 1984 by the development of the "electric boneconduction" audiometer which works by electro-stimulation via mylar coated electrodes on the skin over the mastoid (tbnndorf & kurman, 1984), which has excellent testretest reliability (okstad, laukli & mair, 1988) and can test up to 20 khz. despite all these developments, various factors still prevent the establishment of proven, reliable high frequency normative threshold data. consider that to calibrate a standard air conduction audiometer a 6 cm3 iec 303 coupler has to be used and the audiometer output calibrated to iso 389 (1985) standards, l b calibrate an air conduction audiometer which can test up to 20 khz, eg., the demlar 20k, a special coupler supplied by the manufacturer of this audiometer should be used. when an "electric bone-conduction" audiometer, eg., the audimax 500 has to be calibrated, the electric output must be connected to a simulated load supplied by the manufacturer of the audimax. thus there appears to be no hard and fast standard of calibration for these very different types of audiometers. in evaluation of clinical testing, further problems re use of high frequency audiometry surfaced. when comparing hearing thresholds on the same subjects using a demlar 20k and an audimax 500, okstad et al. (1988) found that this does not result in equivalent air conduction and bone conduction thresholds at all frequencies. schechter, fausti, rappaport and frey (1986) found that factors such as age, gender, different equipment, different testing procedures, headphone placement, ear canal acoustics, etc., all interact to give a great degree of intersubject variability in the high frequency hearing range. tonndorf and kurman (1984) and okstad et al. (1988) found that the normative electric bone conduction (ebc) threshold curves are relatively flat up to a variable cut-off frequency, after which there is a very sharp fall of thresholds over the subsequent 2 or 3 khz. this sharp fall indicates the point of highest audible frequency at hearing threshold level. however, it still does not indicate the real highest frequency at which the subject may be able to hear at higher stimulus intensities. furthermore, in audiometric testing the stimulus intensity scale is logarithmic, while in ebc testing it is linear. consider further that the conventional frequency scale is also logarithmic, while in ebc testing it is linear. therefore it would appear that by keeping the stimulus intensity constant and at the maximum of the audiometer, while measuring the highest audible frequency, it would lead to a more finely determined and therefore more accurate test result. recently a considerable amount of research was done on high frequency hearing and thresholds. frank (1990) examined high frequency air conduction thresholds in adults 18-28 years old; frank and dreisbach (1991) tested for repeatability of high frequency air conduction thresholds in adults 19-27 years old; schechter et al. (1986) and stelmachowicz, beauchaine, kalberer and jesteadt(1989) worked on age-related high frequency air conduction thresholds; okstad et al. (1988) compared high frequency air conduction and bone conduction thresholds in adults 20-24 years old. the differences in testing equipment, methodology and subjects result in considerable difficulties when attempting direct comparison of their results. there was found to be reasonable agreement on high frequency air conduction thresholds and norms, but not much on high frequency bone conduction. in an effort to try to establish some kind of high frequency ebc hearing norms, utilizing the suggested method of measuring the highest audible ebc frequency, a group of subjects of differing age and sex were tested at the maximum stimulus intensity of the ebc audiometer. the results may possibly then also shed more light on the pattern of loss of high frequency bone conduction hearing with increasing age and the possible effects that gender may have on this pattern. methodology all 172 patients admitted over a period of one month to a tuberculosis hospital, whether for treatment or followup examinations, (and statistically not a representative sample of the population) had their highest audible frequency evaluated at the maximum stimulus intensity of the audiometer (120 electro-stimulation units which compares to about 60 db spl). the audiometer used was an audimax 500, which essentially measures ebc hearing up to 20 khz. the highest audible ebc frequency was determined by increasing and decreasing the stimulus frequency in 100 hz steps. the point of highest audible ebc frequency was defined as that level at which the subject indicated he could just barely detect the sound, this level being crossed in three runs consecutively. as no effective masking is available, the test results indicated the hearing binaurally. the hospital is built on a vast expanse of open field, resulting in very quiet surroundings. the hearing tests were performed in a large and unused dental examination room which is situated a considerable distance away from the main hospital buildings, resulting in an extremely quiet test environment. the subjects included different indigenous races, male and female, with age ranging from 7 to 71 yrs old. from these subjects, 22 had to be excluded because they displayed poor hearing/no hearing in the 8-20 khz range, had middle ear problems (determined by standard audiometry and impedance tests), were previously treated with ototoxic drugs or had previous exposure to occupational industrial noise (determined by examining case :histories and questioning subjects). the subjects were grouped into ten year age intervals, mainly to be able to compare the results with those from other researchers at a later stage. each subject was tested twice, on consecutive days, in order to make sureithat the test results had test-retest repeatability, differences not exceeding 200 hz. the average of the two measurements on each subject was then considered as the highest audible ebc frequency. these test results were then cross referenced with age and gender. results figure 1 shows a plotting of the mean values of the highest audible ebc frequencies, calculated from the raw data, for males, females, and males and females together, set out in ten year age groups. although males showed slightly higher mean values than females for all age groups, (see fig. 1) this difference between the two sexes was not statistically significant. consequently, the data for males and females were lumped together. statistical data from the test results for males and females together are displayed in table 1. the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) i t e n t a t i v e age-related norms for high frequency electric bone conduction audiometry prom ibble 1 a definite but gradual decrease is observed 51 • mean highest audible ebc frequency with increasing 1 1 1 the youngest age group constituted one subject only, w?o c o u l d hear right up to 18,4 khz. this is followed by a e d u c t i o n through the older age groups down to 11,15 khz γ the s e c o n d last group. the last (oldest) group constituted only one subject aged 71 years old. this subject s h o w e d a repeatable highest audible ebc frequency of 16,4 khz. figure 2 shows the mean, standard deviation and range of highest audible ebc frequency, set out in ten year age groups, for all the subjects together, except for the youngest and oldest age groups which were excluded because of one s u b j e c t only in each of these two age groups. discussion from the results of this study it would appear that the highest audible ebc frequency decreases linearly with increasing age. this decrease cannot be ascribed to being infected by mycobacterium tuberculosis or to being previously treated with any of the four standard antituberculosis drugs (rifampicin, isoniazid, pyrazinamide and e t h a m b u t o l ) as neither has any effect on hearing (tteale, goldman & pearson, 1994). if it is assumed that this is a result of sensory presbycusis due to hair cell loss in the basal cochlea (schuknecht, 1955), then it would appear that presbycusis possibly starts at a very early age and follows a distinct linear pattern of reduction in highest frequency hearing with increasing age. this phenomenon appears to affect males and females of all age groups in exactly the same way, as no statistically different gender discrepancies could be established. this differs from the findings of stelmachowicz et al. (1989) who found a small but statistically significant difference, males showing a 4,4db poorer threshold. this may be ascribed to differences in type of auditory stimulation (air conduction vs. bone conduction) used in these two studies. the finding of a gradual decrease in highest audible frequency with increasing age is in agreement with the finding of stelmachowicz et al. (1989) of a monotonical increase in high frequency threshold as a function of age. as a direct result of this linear pattern it would be a fairly easy matter to establish age-related norms for highest frequency ebc hearing. a complicating factor was the wide variation in highest audible frequency within each age group, which resulted in the normative curve being quite wide on both sides of the mean threshold line, as figure 1: mean values of highest audible ebg frequencies. table 1: statistical data by age group. figure 2: mean, stand, dev. and range of highest audible ebc. j highest audible ebc frequency (khz) ten-year age group η median mean st. dev. range ten-year age group η median mean st. dev. min. max. 1 1-10 yr 1 18,40 18,40 * 18,40 18,40 2 11-20 yr 9 16,60 16,67 1,17 15,50 18,20 3 21-30 yr 50 16,00 15,78 2,23 13,55 19,40 4 31-40 yr 42 14,50 14,21 1,84 12,37 17,40 5 41-50 yr 34 13,60 12,90 1,88 11,02 17,20 6 51-60 yr 9 11,00 11,36 1,71 9,65 13,80 7 61-70 yr 4 11,00 11,15 1,04 10,11 12,40 8 71-80 yr h 16,40 16,40 * 16,40 16,40 die suid -afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 g r voogt and η s schoeman depicted in fig. 2. despite this drawback, the data would result in a more clearly defined and perhaps more usable tentative norm for clinical use. follow-up studies utilizing much larger groups of subjects may result in the formulation of much tighter norms. until then, using a baseline ebc audiogram against which any later audiograms can be compared, seems to be the better option. the megor advantage appears to be that this method of testing, i.e., determining only the highest audible ebc frequency, is a quick and easy one to apply, as only one parameter, that of highest audible frequency at maximum stimulation intensity, needs to be examined in each patient. there could therefore be the opportunity for excellent applications in high frequency hearing screening and quick monitoring of the early effects of ototoxic drugs and perhaps also the early detection of noise induced hearing loss. the major obstacle still remains the fact that ebc thresholds reflect the hearing of both ears simultaneously, as there is as yet no reliable method of masking available on ebc audiometers. in ototoxicity monitoring, however, it would be a lesser problem as ototoxic drugs usually affect both ears equally and simultaneously. conclusion we have managed to establish some kind of tentative norms for age-related bilateral highest frequency ebc hearing. it is also suggested that this quick and easy method of measuring the highest audible ebc frequency be used for screening purposes and possibly also for ototoxic and noise damage monitoring. a larger study on a representative group of subjects may provide a much tighter set of norms and if a reliable method of masking ebc could be found, clinical norms for unilateral highest audible ebc hearing could then also be established. until then, using a baseline ebc audiogram against which any later audiograms can be compared, seems to be the better option for clinical use. references corliss, l.m., doster, m.e., simonton, j. & downs, m.p. (1970). high frequency and regular audiometry among selected groups of high school students. j. sch. health, 40, 400-404. dadson, r.s. & king, j.h. (1952). a determination of the normal threshold of hearing and its relation to the standardization of audiometers. j. laryngol. otol., 66, 366-378. fletcher, h. (1929). speech and hearing. van nostrand, new york. fletcher, j.l., cairns, a.b., collins, f.g. & endicott, j. (1967). high frequency hearing following meningitis. j. aud. res., 7,223-227. frank, t. (1990). high-frequency hearing thresholds in young adults using a commercially available audiometer. ear hear, 11(8), 450454. frank, t. & dreisbach, l.e. (1991). repeatability of high frequency thresholds. ear hear, 12(4), 294-295. galton, f. (1876). whistles for determining the upper limit of audible sound in different persons. south kensington museum conferences. harris, j.d. & myers, c.k. (1971). tentative audiometric threshold levels standards from 8 to 18 khz. j. acoust. soc. am., 49, 600601. jacobson, e. j., downs, m.p. & fletcher, j.l. (1969). clinical findings in high frequency thresholds during known ototoxic drug usage. j. aud. res., 9, 379-385. northern, j.l., downs, m.p., rudmose, w., glorig, a. & fletcher, j.l. (1972). recommended high-frequency audiometric threshold levels. j. acoust. soc. am., 52(2), 585-595. okstad, s., laukli, e. & mair, i.w.s. (1988). high frequency audiometry: comparison of electric bone-conduction and airconduction thresholds. audiology, 27,17-26. rosen, s. & olin p. (1968). hearing loss and coronary heart disease. arch. otolaryngol., 88, 251-253. rudmose, w. (1961). the suprahigh-frequency audiometer. tracor, incorporated, austin, itexas. schechter, a.m., fausti, s.a., rappaport, b.z. & frey, r.h. (1986). age categorization of high-frequency auditory threshold data. j. acoust. soc. am., 79(3), 767-771. schuknecht, h.f. (1955). presbycusis. laryngoscope, 65, 402-119. sivian, l.j. & white, s.d. (1933). on minimal audible sound fields. j. acoust. soc. am., 44, 257. stelmachowicz, p.g., beauchaine, k.a., kalberer, a. & jesteadt, w. (1989). normative thresholds in the 8to 20-khz range as a function of age. j. acoust. soc. am., 86(4), 1384-1391. iteale, c., goldman, j.m. & pearson, s.b. (1994). the association of age with the presentation and outcome of tuberculosis: a fiveyear survey. j.ar.d., 6(4), 7-10. ibnndorf, j. & kurman, b. (1984). high frequency audiometry. ann. otol. rhinol. laryngol, 93, 576-582. zislis, τ & fletcher, j.l. (1966). relation of high frequency thresholds to age and sex. j. aud. res., 6, 189-198. / the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sajcd 51 speech-language assessment in a linguistically diverse setting: preliminary exploration of the possible impact of informal ‘solutions’ within the south african context j barratt, k khoza-shangase, k msimang   department of speech pathology and audiology, school of human and community development, university of the witwatersrand, johannesburg joanne barratt katijah khoza-shangase kwandinjabulo msimang corresponding author: j barratt (joanne.barratt@wits.ac.za) speech-language therapists (slts) working in the context of cultural and linguistic diversity face considerable challenges in providing equitable services to all clients. this is complicated by the fact that the majority of slts in south africa are english or afrikaans speakers, while the majority of the population have a home language other than english/afrikaans. consequently, slts are often forced to call on untrained personnel to act as interpreters or translators, and to utilise informally translated materials in the assessment and management of clients with communication impairments. however, variations in translation have the potential to considerably alter intervention plans. this study explored whether the linguistic complexity conveyed in translation of the western aphasia battery (wab) test changed when translated from english to isizulu by five different first-language isizulu speakers. a qualitative comparative research design was adopted and results were analysed using comparative data analysis. results revealed notable differences in the translations, with most differences relating to vocabulary and semantics. this finding holds clinical implications for the use of informal translators as well as for the utilisation of translated material in the provision of speech-language therapy services in multilingual contexts. this study highlights the need for cautious use of translators and/or translated materials that are not appropriately and systematically adapted for local usage. further recommendations include a call for intensified efforts in the transformation of the profession within the country, specifically by attracting greater numbers of students who are fluent in african languages. keywords: interpretation, linguistic diversity, speech-language therapy, translation, western aphasia battery s afr j cd 2012;59(1):34-44. doi:10.7196/sajcd.51 the south african healthcare system is plagued with challenges, including but not limited to shortages of skills and equipment and staff retention difficulties. over and above these, there is the challenge of providing an efficient and equitable service to patients from diverse cultural and linguistic backgrounds (mosdell, balchin & ameen, 2010). the issue of cultural and linguistic diversity poses considerable challenges in the provision of speech-language therapist (slt) services since the majority of graduates are english or afrikaans speakers with little or no knowledge of other official languages and/or cultural backgrounds of their patients (gerber, 2009; bornman, sevcik, romski & pae, 2010). although english is used as the language of instruction in the majority of schools, tertiary institutions, the work place, and in healthcare settings, 92% of the total south african population are reported to have a home language other than english (statistics south africa, 2003). isizulu, the language of investigation in the current study, is reported as the mother tongue of 23.8% of the south african population. language rights of all south african citizens are firmly entrenched in, inter alia, sections 6, 29, 30 and 31 of the constitution of the republic of south africa, act 108 of 1996. given the south african government’s attempts to address language rights through changes in national policies, a higher emphasis needs to be placed on the development of culturally and linguistically suitable and reliable speech and language assessment tools (khoza, ramma, mophosho & moroka, 2008; bornman et al., 2010) with equal focus on the use of interpreters in slt engagements. this need is substantiated by research which illustrates that cross-linguistic healthcare consultations have the potential to affect the efficacy and appropriateness of intervention (swedley, stith & nelson, 2003) as well as patient satisfaction (foley, 2005). despite some preliminary attempts to translate assessment batteries into local languages (e.g. mosdell et al., 2010), difficulties continue to be incurred as a result of the range of languages spoken in south africa. consequently, one of the proposed ‘solutions’ to mitigating the negative effects of language barriers in cross-linguistic consultations has been to employ trained translators or interpreters to act as mediators. the differences between translation and interpretation may be subtle, yet may have far-reaching effects on the consultation. spiggle (1994) states that translation refers to either written or verbal communication in the second language having the same meaning when written or spoken in the first language, while interpretation relates to a deduction of information, and may refer to assessing intentions and inferences, making sense of experience and behaviour, and seeing or understanding a phenomenon in one’s own terms by grasping its essence (spiggle, 1994). many researchers prefer the use of the term adaptation as opposed to translation or interpretation as there is an acknowledgement that there is a requirement for adaptation in culture, content and wording, over and above the simple translation of a test (geisinger, 1994). davidson (2001) claims that interpretation is always contextual; however in institutional settings, such as hospitals, interpretation may be defined by social and behavioural norms. davidson (2001) asserts that in the medical setting, clinicians usually judge the patients’ physical and verbal signs for social and moral relevance in order to make a diagnosis, and the current authors argue that an untrained interpreter may not look for such cues during a mediated consultation. moreover, in speech-language assessments, untrained interpreters may not be aware that subtle changes or inaccuracies in understanding or production can indicate an impairment that requires intervention. adaptation of test materials compounds this issue to a further degree. despite the fact that south african legislation, as indicated by the policy on language services (2011) for the department of health (department of health, 2011), promotes the use of interpreters in healthcare settings, few trained interpreters are available in the public healthcare sector (penn, 2007). as a result, most therapists rely on untrained interpreters and translators during assessments and therapy sessions. in hospital settings, nurses, cleaners, general assistants, and family members are frequently called upon to translate or interpret for patients who do not speak and/or understand english. this observation is confirmed by elderkin-thompson, silver and waitzkin (2001), who report that bilingual individuals with no formal training as translators frequently translate for patients who are non-english speaking. much meaningful information may be lost since the person translating may not have an understanding of terms used, may use the notion of direct translation or translate the message differently, thus creating confusion and changing the meaning of the item to be translated (elderkin-thompson et al., 2001). previous research has also shown that ad hoc interpreters can commit many errors of interpretation such as omitting important information as a result of limited vocabulary during translation (flores, laws, mayo, zuckerman, abreu, medina & hardt, 2003). it can thus be anticipated that results obtained from mediated slt assessments may be compromised, leading to incorrect diagnoses, particularly where untrained translators or interpreters are used. in speech-language therapy this challenge is more complex because how communication occurs is a crucial aspect, not just what is communicated as in most other healthcare setting scenarios. owing to the limited focused research on this challenge within the south african context, the ad hoc arrangements made during assessment and management of clients from linguistically and culturally diverse populations creates translation and adaptation difficulties which arguably influence the normative interpretation of assessment measures, and consequently management plans. despite the availability of frameworks and guidelines for adapting or translating test measures (e.g. geisinger, 1994), as well as published guidelines for working with interpreters, anecdotal evidence suggests that these are infrequently followed by slts in the south african context; this is believed to have a negative impact on speech-language therapy service provision as a whole. one of the populations with whom slts commonly work is the neurologically impaired adult population. van schoor, van niekerk and grobbelaar (2001) reported that south africa is rated among the highest in the world for casualty admission rates secondary to motor vehicle accidents. global statistics reveal that south africa has among the highest hiv/aids infection rates in the world, with an estimated 410 000 new infections in 2010 (statistics south africa, 2010). mochan, modi and modi (2003) show a relationship between hiv infection and cerebrovascular accidents as a result of vascular abnormalities, coagulation disorders and cardio-embolic disease. this high incidence of stroke concurs with the findings of the southern africa stroke prevalence initiative (saspi) project team (2004), who report an incidence of cerebrovascular accidents of 243 per 100 000 people. as a result of the above-mentioned factors, it can be assumed that in south africa the number of patients with speech, language and/or cognitive-linguistic impairments as a consequence of neurological impairment is high, resulting in an increased need for speech-language therapy assessment and intervention. one commonly used formal english assessment tool for speech-language and cognitive-linguistic assessment of the neurologically impaired adult population is the western aphasia battery (wab) (kertesz, 1982). this tool includes subtests relating to content, fluency, auditory comprehension, repetition, naming, reading, writing and calculation (kertesz, 1982), and thus assesses areas of functioning in which patients with traumatic brain injuries also experience difficulty (kennedy & yorkston, 2000). formal assessment measures provide a baseline for intervention, which may be compromised when a patient’s first language is not english. this becomes abundantly clear in a multilingual context like south africa where the majority of formal assessment measures available are written in english and standardised in different settings. as a result, ad hoc translators are often used in clinical encounters, and this may influence the assessment findings in a number of ways. the untrained individual’s lack of familiarity with the speech materials presented and compromised competence with the language that the clinician speaks may influence the accuracy of translation. translators who are neither competent in english nor the language being translated may not perform as well as native speakers of that language. hence, slts need to take cognisance of these factors and how their lack of knowledge of the native languages of their clients can negatively affect the accuracy of assessment results, preventing them from fully meeting their clients’ needs. this heightened awareness should range from case history taking to the actual assessment to the test material used in the assessment, and therefore more emphasis should to be placed on development of assessment and intervention materials in all languages. in response to this need within the south african slt profession, the current study explored whether differences existed in the translation of the wab by five first-language isizulu speakers. in a multilingual context, it is well documented that many of the formal speech-language assessments are inappropriate for first-language english speakers, and indeed speakers of other languages. it is therefore crucial for all avenues to be explored in order to appropriately adapt or develop the most accurate and efficient assessment tools for the african continent. methodology prior to the study being conducted, permission was obtained from the university of the witwatersrand non-medical ethics committee (protocol number: h090404). aim to determine whether the linguistic complexity of the test items of the wab changed when translated from english to isizulu. objective to determine whether differences existed in the translation of the wab from english to isizulu when translated by five first-language isizulu speakers. research design a comparative qualitative research design was employed in order to determine whether similarities and differences existed within the data rather than starting with predefined concepts (ovretveit, 1998). data collection the initial part of the study involved translating the wab from english to isizulu in order to investigate whether the syntax and semantics as well as item complexity and familiarity changed during translation. this translation was performed by the third author (km – translator 1). another translation was then performed by a senior lecturer from the department of african languages (all – translator 2). the two sets of translations were compared and one set was agreed upon for use as a baseline comparative set. for the purpose of this study, the translation made by km was chosen to be the baseline for comparison. this choice was based on the fact that she had detailed knowledge on the test material being used for translation, as well as the purpose for which the assessment tool was established. furthermore, while the translations made by both translator 1 and translator 2 were considered to be accurate, translator 1’s choice of words was thought to be less academic/formal, and therefore more familiar to the participants. once the wab had been translated, the three subtests deemed by the researchers to comprise the most complex linguistic features were identified: the subtests of auditory verbal comprehension, sequential commands and spontaneous speech. these were then utilised in the second phase of the study where verbal translations were conducted with the five participants (tables 2 4). data collection took place with each participant individually in a quiet private consulting room at the university speech and hearing clinic. the researcher dictated each item of each of the subtests individually, and the participants were instructed to verbally translate these from english to isizulu. these translations were digitally audio-recorded and later transcribed. participants five first-language isizulu speakers were recruited using convenience sampling. the choice of isizulu speakers was based on the fact that this is the most widely spoken african language in south africa (stats sa, 2003), and represents the most commonly spoken african language at the university speech and hearing clinic. furthermore, both the second and third authors are first-language isizulu speakers. inclusion criteria stipulated that all participants needed to be over the age of 18 years, be first-language isizulu speakers, and should consider themselves to be proficient in english as per self-report. table 1 provides a description of the participants. all participants were provided with information letters and consent forms in both english and isizulu prior to the commencement of data collection. where the participants were unable to read, the researcher verbally explained the study to them in isizulu and verbal assent was accepted in lieu of written consent. ethical considerations were guided by the principles of the south african medical research council (south african medical research council, 2003). table 1. personal characteristics of the participants participant age gender occupation highest level of education languages spoken place of origin/birth translator 1 22 female speech and hearing therapist ba speech and hearing therapy isizulu, english, afrikaans newcastle translator 2 38 female senior lecturer phd (african languages) isizulu, english johannesburg 1 56 male gardener grade 11 isizulu and english rural kwazulu-natal 2 52 female nursing sister diploma in nursing isizulu and english pietermaritzburg 3 23 female student 3 years at university studying law isizulu and english pietermaritzburg 4 38 female cleaner grade 9 isizulu, english and sotho newcastle 5 34 male painter & fixes air conditioners grade 12 isizulu, english and sotho soweto data analysis and trustworthiness of findings data were analysed qualitatively using comparative analysis. each translation was transcribed and back-translated from isizulu to english. thereafter, each translation was compared against the baseline translation. furthermore the translations were compared with each other so as to identify differences in translation across the five participants. trustworthiness of findings was accounted for by means of back-translation of the baseline wab, as well as independent validity checks of two of the five participants’ translations to eliminate bias. results results are presented in accordance with the aims of the study. results of the translations of the most linguistically complex subtests of the wab are depicted in table 2 (tables 2 4 are placed at the end of the article to facilitate the flow of the article). comparison of translations made by the researcher and african languages lecturer (all) initially, the translations made by the researcher and the all were compared. while some differences relating to sentence structure and vocabulary were noted, these appeared to be mainly dialectal in nature and did not affect the overall linguistic complexity of the test items. the reasons behind these differences appeared to pertain to the all’s more formal and academic use of isizulu, while the researcher’s choice of words was more colloquial. within the subtest of auditory verbal comprehension, a few changes to structure and complexity of the questions were noted. an example of this can be seen in the translation of the question ‘is the door closed?’ in english this phrase consists of the structure copula determiner noun adjective, whereas in isizulu the structure changes to adjective noun which is translated to ‘uvaliwe umnyango?’ although the structure of the question changes, the meaning remains the same, and when translated back into english the question stays the same. similarly, by translating the question ‘are you wearing red pyjamas?’ to isizulu (‘ugqoke izimpahla zokulala ezibomvu?’) the sentence structure changes to ‘are you wearing pyjamas that are red?’ this indicates that the meaning does not change, although the length of the question increases. this was also noted in the phrase, ‘do you eat a banana before you peel it?’(‘uhluba ubhanana ngaphampi kokuba uwudle?’). in this phrase the noun phrase (np) is followed by the verb phrase (vp) in english. however, in isizulu the vp is followed by the np, further indicating that the structure of the question changes, yet does not compromise the meaning of the question. when translated back to english, the phrase reads as ‘do you peel a banana before you eat it?’ in the subtest of spontaneous speech, differences were also noted. the researcher translated the phrase ‘what is your occupation?’ to ‘usebenza laphi?’ which, when translated back into english means ‘where do you work?’ this implies that the response obtained could refer to place of occupation but not the type of occupation. some differences were also noted in the translation of the auditory verbal comprehension subtest. for example, the researcher translated the command ‘shut your eyes’ as ‘vala amehlo’ whereas the all translated it as ‘chimeza’. both of these translations are accurate representations of the english command as a patient would perform the command correctly if translated either way. the only important difference in the two translations is that the translation made by the researcher can be back-translated into english as ‘close your eyes’ whereas the translation made by the all would be translated to english as ‘shut your eyes’. another difference was noted in the command ‘point to the chair’. people from the more rural parts of kwazulu-natal and those who have formally studied isizulu tend to use the word ‘isihlalo’ as used by the all, for ‘chair’. however, the researcher translated the word ‘chair’ as ‘isitulo’. the word ‘isitulo’ is a ‘borrowed word’ taken from the afrikaans word ‘stoel’ and is used more commonly in more urban areas, whereas ‘isihlalo’ is the more authentic version of the word ‘chair’ in isizulu. in some instances, the word order of the sequential commands changed. an example of this is seen in the command ‘point to the comb with the pen’, which was translated to ‘ngepeni, khomba ikama’, meaning ‘with the pen, point to the comb’. although this change did not compromise the overall meaning of the command, it has the potential to affect a patient’s understanding of the command and may also change the sequential order in which they carry out more complex commands. most of the changes that were noted from the initial translation of the wab were concerned with structure and vocabulary. since the all had studied isizulu at both an undergraduate and postgraduate level, her translations were more formal as opposed to the more colloquial translations by the researcher. this implies that level of education may play an influential role on translation. these effects of education may also be true for the patient population. this is of significance to slts since the risk of misdiagnosis of communication impairments may be increased by failure to ensure effective translation of assessment materials or by assessing the patient in a language that he/she does not understand (stolk, ziguras, saunders, garlick, stuart & coffey, 1998). this suggests that slts should be cautious in their interpretation of assessment findings elicited through informally mediated consultations. comparison of verbal translations made by the five participants the results of this aspect of the study have been tabulated in table 2. based on these results, it was noted that many more discrepancies were noted across the translations, specifically those concerning vocabulary used, as well as sentence structure and semantics. table 2. translation of the auditory verbal comprehension subtest of the wab wab command translation by translator 1(km) and translator 2 (all) participant zulu translation english translation is your name smith? 1: igama lakho usmith?   2: igama lakho usmith? 1 igama lakho ungusmith na? is your name smith? 2 igama lakho usmith? is your name smith? 3 igama lakho usmith? is your name smith? 4 igama lakho usmith na? is your name smith? 5 igama lakho usmith? is your name smith? is your name brown? 1: igama lakho ubrown?   2: igama lakho ubrown 1 uwu mr brown? is your name brown? 2 igama lakho ubrown? is your name brown? 3 igama lakho ubrown? is your name brown? 4 igama lakho ubrown? is your name brown? 5 igama lakho ubrown? is your name brown? is your name (real name)? 1: igama lakho u (real name)?   2: igama lakho u (real name)?   1 igama lakho u(real name) na? is your name (real name)? 2 igama lakho u(real name)? is your name (real name)? 3 igama lakho u(real name)? is your name (real name)? 4 igama lakho u(real name)? is your name (real name)? 5 igama lakho u(real name)? is your name (real name)? do you live in toronto? 1: uhlala toronto?   2: uhlala toronto na? 1 uhlala etoronto? do you live in toronto? 2 uhlala etoronto? do you live in toronto? 3 uhlala etoronto? do you live in toronto? 4 uhlala etoronto na? do you live in toronto? 5 uhlala etoronto? do you live in toronto? do you live in windsor? 1: uhlala ewindsor?   2: uhlala ewindsor na? 1 uhlala ewindsor? do you live in windsor? 2 uhlala ewindsor? do you live in windsor? 3 uhlala ewindsor? do you live in windsor? 4 uhlala ewindsor? do you live in windsor? 5 uhlala ewindsor? do you live in windsor? wab command translation by translator 1(km) and translator 2 (all) participant zulu translation english translation are you a man or a woman? 1: uyindoda noma umuntu wesifazane?   2: uyindoda noma umuntu wesifazane? 1 umuntu wesilisa noma wesifazane? are you a male or female? 2 uyindoda noma umuntu wesifazane? are you a man or a woman? 3 uyinkosikazi noma indoda are you a woman or a man? 4 ungumuntu wesifazane noma umuntu wesilisa? are you a female or a male? 5 ingabe uyindoda noma umfazi? could you be a man or a woman? are you a doctor? 1: ungudokotela?   2: ungudokotela na? 1 ungudokotela? are you a doctor? 2 ungudokotela? are you a doctor? 3 uwudokotela yini? are you a doctor? 4 ungu-doctor are you a doctor? 5 igabe uwudokotela? could you be a doctor? am i a man or a woman? 1: ngiwumuntu wesifazane noma wesilisa?   2: ngiyindoda noma umuntu wesifazane? 1 nguye umuntu wesifazane? is she the female here? 2 mina ngowesifazane? am i a woman? 3 lo, uyindoda noma wumuntu wesifazane? is she a male or female? 4 ungumuntu wesifazane noma wesilisa? are you a man or a woman? 5 ngigabe ngiyindoda noma umfazi? am i a man or a woman? are the lights on in this room? 1: ugesi uyakhanya yini la-endlini?   2: ugesi uyakhanya kulelikamelo na?   1 kukhanyiswe la endlini? are the lights on in this room? 2 uyakhanya ugesi kuleligumbi? is the light on in this room? 3 kuyakhanya kulendlu noma akukhanyi? are the lights on in this room or not? 4 i-light ikhanyisiwe kulendlu? are the lights on in this room? 5 ama-light ngabe ayakhanya kuleli-room? are the lights on in this room? is the door closed? 1: umnyango uvaliwe?   2: uvaliwe yini umnyango? 1 umnyango uvaliwe? is the door closed? 2 umnyango uvaliwe? is the door closed? 3 umnyango uvaliwe? is the door closed? 4 umnyango uvaliwe? is the door closed? 5 umnyango uvaliwe? is the door closed? is this a hotel? 1: isehotela la?   2: isehotela lapha? 1 ihotela leli? is this a hotel? 2 ihotela leli? is this a hotel? 3 kusehotela la yini? is this a hotel? 4 ihotela leli? is this a hotel? 5 ihotela leli? is this a hotel? is this a therapy room? 1: i-therapy room yini le?   2: igumbi lokuhlolela leli? 1 indawo yokuhlolela le? is this an assessment room? 2 i-therapy room le? is this a therapy room? 3 kuse-therapy room yini la? is this a therapy room? 4 lena i-therapy room? is this a therapy room? 5 igabe igumbi lokongela leli? could this be an assessment room? are you wearing red pyjamas? 1: ugqoke amapyjama abomvu yini?   2: ugqoke izimpahla zokulala ezibomvu? 1 ugqoke ama-pyjama abovu? are you wearing red pyjamas? 2 ugqoke ama-pyjama abovu na? are you wearing red pyjamas? 3 ugqoke ama-pyjama abovu yini? are you wearing red pyjamas? 4 ugqoke i-pyjama lokulala elibovu? are you wearing sleeping pyjamas that are red? 5 ugqoke ama-pyjama abovu? are you wearing red pyjamas? will paper burn in fire? 1: iphpha lingasha emlilweni?   2: iphepha lingasha yini emlilweni? 1 iphepha lingasha emlilweni? can paper burn in fire? 2 iphepha liyasha yini emlilweni? does paper burn in fire? 3 amaphepha ayasha yini emlilweni? can papers burn in fire? 4 iphepha liyavutha na? is paper burning? 5 igabe iphepha liyasha emlilweni? can paper burn in fire? wab command translation by translator 1(km) and translator 2 (all) participant zulu translation english translation does march come before june? 1: inynaga ka-march ifika kuqala kuneya-june?   2: inynaga ka-march ifika kuqala kuneya-june?   1 kuyenzeka lenyanga ka-march ifike ngaphambi kwa-june? does it happen that the month of march comes before june? 2 u-march ufika ngaphambi kwa-june? does march come before june? 3 yikuphi okuqamuka phambili, u-march noma u-june? what comes first march or june? 4 inyanga ka-march ifika kuqala kuno-june na? does the month of march come before june? 5 igabe u-march ufika before u-june? could march come before june? do you eat a banana before you peel it? 1: uyawuhluba kuqala yini ubanana ngaphambi wokuthi uwudle?   2: uyawuhluba kuqala yini ubanana ngaphambi wokuthi uwudle? 1 uyawudla ubanana ungakawuhlubi? do you eat a banana before you’ve peeled it? 2 ubanana uwudla ungaka wuhlubi na? do you eat a banana before you peel it? 3 udla ubanana ngoba usuwuhlubile yini? do you eat a banana because you have peeled it? 4 udla ubanana kuqala before uwuhluba? do you eat a banana first before you peel it? 5 igabe uyalidla ibanana ngaphambi wokuthi ulihlubile? can you eat a banana before you peel it? does it snow in july? 1: liyakhithika yini ngo-july?   2: liyakhithika yinii ngo-july? 1 kuyenzeka likhithike ngo-july? can it snow in july? 2 liyakhithika ngo-july? does it snow in july? 3 kuyakhithika yini ngo-july? does it snow in july? 4 liyakhithika ngo-july? does it snow in july? 5 liyasnowa na ku-july? does it snow in july? is a horse larger than a dog? 1: ihhashi likhulu kunenja?   2: ihhashi likhulu yini kunenja? 1 kuyenzeka ihhashi libel’khulu kunenja? can a horse be bigger than a dog? 2 ihhashi likhulu kunenja yini? is a horse bigger than a dog? 3 yini enkulu, inja noma ihhashi? what is larger, a dog or a horse? 4 ihhashi likhulu kunenja yini? is a horse larger than a dog? 5 igabe ihhashi likhulu na kunenja? is a horse larger than a dog? do you cut the grass with an axe? 1: uyabusika yini utshani ngembazo?   2: uyabusika yini utshani ngembazo? 1 uyakwazi ukuthi ngembazo ugence utshani? can you cut grass with an axe? 2 utshanii ubugunda ngembazo yini? do you cut grass with an axe? 3 uma usika utshani, usika ngembazo na? when you cut grass, do you use an axe? 4 ugangamula utshani ngombese? can you cut grass with a knife? 5 igabe usika utshani ngembazo? do you cut the grass with an axe? variations in translation relating to vocabulary as evident in table 2, much of the vocabulary used in the subtest may be considered inappropriate for assessment in south africa. this concurs with the findings of mosdell et al. (2010), who also found that test items in the boston naming test and the cookie theft test were both linguistically and culturally biased, affecting the reliability of the tests when used in the south african context. over and above the effect that culturally inappropriate vocabulary may have on the responses obtained from a patient, the nature of the vocabulary may be altered by the translator if he/she has limited vocabulary in his/her own language and/or in english. for example, when looking at nouns such as smith, brown, windsor and toronto, it may not be easy for a second-language speaker of english to relate to such words, and may thus affect the results of the testing procedure. anderson (1992) recommends that materials used during assessments and therapy should be culturally and linguistically sensitive so as to appropriately guide patient management. vocabulary such as ‘hotel’ and ‘snow’ in the wab may be inappropriate to use in a country such as south africa, especially in the government healthcare context, since many people in this context may not be familiar with the concept of a hotel. similarly, many people in south africa have never seen snow before or heard what it is called in languages other than their own. for this reason it may be difficult to comment on when it snows because of the fact that they do not have any experience on which to base this. the wab was standardised in new york and therefore the expected response for the absurdity question ‘does it snow in july?’ is ‘no’. however, in south africa it is quite possible to have snow in certain parts of the country at this time of year. this is therefore clinically relevant as a patient may then be thought to be presenting with impaired comprehension because of the fact that he answered the question incorrectly. the word ‘axe’ is also considered inappropriate for use in a south african assessment battery. this is due to the fact that some patients may be unfamiliar with the name of this object and therefore may have difficulty in answering the question. for example, participant 4 translated ‘do you cut grass with an axe?’ as ‘unganqamula utshani ngombese?’ meaning ‘can you cut grass with a knife?’ this may be due to the fact that she does not have the vocabulary to make a connection between the english word ‘axe’ and the isizulu word ‘imbazo’. implications of this mistranslation which leads to changed meaning entirely are considerable and have direct impact on test scoring as well as eventual diagnosis. errors in translation of syntax and/or semantics word order is an aspect that may be altered during translation and may have negative effects on slt assessments. berndt (2001) states that verbal short-term memory is frequently affected in patients with neurological impairments. therefore a change in sentence structure may have a negative effect on the neurologically impaired patient’s ability to comprehend an instruction. from the subtest of auditory verbal comprehension (table 2), a number of semantic differences in translation were apparent. participant 3 translated the question ‘are the lights on in this room?’ as ‘are the lights on in this room or not?’ similarly, participant 3 changed the nature of the question ‘does march come before june?’ to ‘what comes first, march or june?’ and translated ‘is a horse larger than a dog?’ to ‘what is larger, a dog or a horse?’ in all of these instances, patients with neurological impairments may have difficulty in responding accurately since the nature of the question has been changed from one which requires a yes/no response to a forced alternative, and the processing requirements being assessed have also been simplified. in the questions ‘are you a man or a woman?’, ‘are you a doctor?’ and ‘is this an assessment room?’, participant 5 consistently asked the question by saying ‘could you/this be a woman/doctor/therapy room?’ this increases the level of complexity of the question and requires a degree of reasoning in formulating an answer, which may be difficult for the neurologically impaired patient, or the patient’s reasoning may be difficult for the slt to follow. in the question ‘am i a man or a woman?’ participants 1, 2, 3 and 4 all changed the nature of the semantics, thus posing the questions ‘is she the female here?’, ‘am i a woman?’, ‘is she a male or a female?’ and ‘are you a man or a woman?’ respectively. another change in semantics can be seen in the question ‘will paper burn in a fire?’ where participant 4 translated it to ‘is paper burning?’, thereby altering the meaning conveyed in the question and the expected response. these examples not only reveal the impact on complexity of the stimuli, but also highlight the influence of informal translation on validity of the instrument. the only semantic differences in the spontaneous speech subtest (table 3) were in the question ‘what is your occupation?’ this may be because few people use the term ‘occupation’ when they speak about work, but tend to use the word ‘job’ or ‘work’, and may explain participant 2’s translation to ‘where do you work?’ which resulted in a change of semantics. in the same question, participant 4 mistook the meaning of the word ‘occupation’ for the meaning of ‘address’ in the question ‘what is your occupation?’, thereby completely altering the meaning of the question. table 3. translation of the spontaneous speech subtest of the wab wab question translation by translator 1(km) and translator 2 (all) participant zulu translation english translation how are you today? 1: unjani namhlanje?   2: unjani namhlanje? 1 unjani namhlanje? how are you today? 2 unjani namhlanje? how are you today? 3 unjani namhlanje? how are you today? 4 unjani namhlanje? how are you today? 5 unjani namhlanje? how are you today? have you been here before? 1: usuke weza lapha ngaphambilini?   2: usuke weza lapha ngaphambilini? 1 ukewaba-la? have you been here before? 2 waka wafika-la phambili? have you been here before? 3 wakeweza-la ngelinye ilanga? have you been here previously? 4 ukewaba-la phambilini? have you been here before? 5 usuke waza la-phambilini? have you been here before? what is your name? 1: ubani igama lakho?   2: ubani igama lakho? 1 igama lakho ungubani? what is your name? 2 ubani igama lakho? what is your name? 3 ubani igama lakho? what is your name? 4 ubani igama lakho? what is your name? 5 ubani igama lakho? what is your name? what is your address? 1: lithini ikheli lakho?   2: lithini ikheli lakho? 1 ikheli lakho lithini? what is your address? 2 lithini ikheli lakho? what is your address? 3 lithini ikheli lakho? what is your address? 4 ithini i-address yakho? what is your address? 5 la ohlalakhona, i-address where you stay, what is your address? what is your occupation? 1: usebenza laphi?   2: usebenza msebenzi muni? 1 usebenza msebenzi muni? what is your occupation? 2 usebenza kuphi? where do you work? 3 wenza msebenzi muni? what is your occupation? 4 ilokunjana yakho…. address? participant thought occupation was address, therefore unable to translate the question. 5 igabe uwenza msebenzi muni? what is your occupation? tell me a little about why you are here? 1: ngitshele kabanzi ukuthi yini ekubeka la-namhlanje.   2: ngitshele kabanzi ukuthi yini ekubeka la-namhlanje.   1 awuthi ukungitshela fahla ukuthi ubekwayini la. tell me briefly why you are here. 2 ongitshele kancane ukuthi ufunani la. please tell me a little about why you are here today. 3 awungitshele ukuthi namhlanje uzeleni la? please can you please tell me why you are here today? 4 ngitshele kancane ukuthi yini uze-la namhlanje. tell me a little about why you came here today. 5 ngitshele kabanzi ukuthi yini ula-namhlanje. tell me a little why you are here. analysis of the subtest of sequential commands (table 4) revealed that in the command ‘point with the pen to the book’ participants 2 and 3 changed the word order to ‘khomba ibuku ngepeni’ and ‘khomba incwadi ngepeni’ respectively, meaning ‘point to the book with the pen’, thus changing the sequential nature of the command. furthermore, participant 4 translated the same command to ‘khomba ikamu ne-ball peni’ meaning ‘point to the comb with the pen’ thus changing the semantics of the command. similarly, in the command ‘point to the window then to the door’, participants 1 and 4 both translated the command as ‘point to the window and the door’, and in the command ‘point to the pen and the book’, participants 3 and 5 both translated the command to ‘point to the pen and then point to the book.’ these errors in translation affect the expected sequential order of the response and consequently patients may be misdiagnosed as having auditory memory impairments and/or sequencing problems incorrectly. in the command ‘point to the comb with the pen’, participants 1 and 4 translated this as ‘point with the pen to the comb’ which, although it maintains the semantics of the command, changes the complexity. similarly, the command ‘with the book, point to the comb’ yielded errors in translation, where participant 2 translated it as ‘point with the comb to the book’, thus changing the semantics, and participant 4 translated it as ‘on the book point to the book’ thus providing a nonsensical command. the command ‘put the comb on the other side of the pen and turn over the book’ was problematic for almost all of the participants because of the increasing complexity of the command, with only participant 5 giving an accurate translation of the command. an important factor highlighted by berndt (2001) is that most neurologically impaired patients have impairments related to sentence comprehension tasks, especially with semantically reversible sentences that are syntactically complex. this implies that a patient who already presents with a neurological impairment may have marked difficulties in answering a question with complex semantics and syntax, especially where translation is necessary; where inaccurate translations are performed, the assessment process is therefore severely hampered. table 4. translation of the sequential commands subtest of the wab wab command translation by translator 1(km) and translator 2 (all) participant zulu translation english translation raise your hands 1: phakamisa izandla zakho   2: phakamisa izandla zakho 1 phakamisa isandla raise your hand 2 ngicela uphakamise izandla please raise your hands 3 phakamisa izandla zakho raise your hands 4 phakamisa izandla zakho raise your hands 5 phakamisa isandla sakho raise your hand shut your eyes 1: vala amehlo   2: chimeza 1 vala amehlo close your eyes 2 chimeza amehlo shut your eyes 3 vala amehlo akho close your eyes 4 vala amehlo close your eyes 5 vala amehlo akho close your eyes point to the chair 1: khomba isitulo   2: khimba isihlalo 1 khomba isitulo/isihlalo point to the chair 2 khomba isitulo point to the chair 3 khomba isitulo point to the chair 4 khomba isitulo point to the chair 5 khomba isitulo point to the chair point to the window, then to the door 1: khomba ifasitela bese ukhomba umnyango   2: khomba ifasitela bese ukhomba umnyango   1 khomba efasteleni nase mnyango point to the window and the door 2 khomba ifasitela mese ukhomba umnyango point to the window and then to the door 3 khomba ifasitela bese ukhomba umnyango point to the window and then to the door 4 khomba ifasitela nomnyango point to the window and the door 5 khomba ifasitela bese ukhomba umnynago point to the window and then point to the door point to the pen and the book 1: khomba ipeni nencwadi   2: khomba ipeni nencwadi   1 khomba ipeni nebuku point to the pen and the book 2 khomba ipeni nebuku point to the pen and the book 3 khomba ibodwe bese ukhomba ibuku point to the pot and then to the book 4 khomba i-ball peni nebuku point to the pen with the book 5 khomba ipeni bese ukhomba incwadi point to the pen and then point to the book point with the pen to the book 1: ngepeni khomba incwadi   2: khomba ngepeni encwadini 1 khomba ngepeni ebukwini point with the pen to the book 2 khomba ibuku ngepeni point to the book with the pen 3 khomba incwadi ngepeni point to the book with the pen 4 khomba ikamu ne-ball peni point to the comb and the pen 5 khomba ngepeni encwadini point with the pen to the book point to the comb with the pen 1: ngepeni khomba ikamu   2: khomba ikamu ngepeni 1 khomba ngepeni ekamini point with the pen to the comb 2 khomba ikamu ngepeni point to the comb with the pen 3 khomba ikamu ngepeni point to the comb with the pen 4 khomba ngepeni ekamini point with the pen to the comb 5 khomba ikamu ngepeni point to the comb with the pen with the book point to the comb 1: ngencwadi, khomba ikamu   2: ngencwadi, khomba ikamu 1 ngencwadi, khomba ekamini with the book point to the comb 2 khomba ikamu ngebuku point with the comb to the book 3 ngebuku khomba ikamu with the book point to the comb 4 ebukwini pointa ibuku on the book point to the book 5 ngencwadi, khomba ikamu with the book point to the comb wab command translation by translator 1(km) and translator 2 (all) participant zulu translation english translation put the pen on top of the book then give it to me 1: beka ipeni phezu kwencwadi bese unikeza mina   2: beka ipeni phezu kwencwadi bese unikeza mina   1 awuthathe ipeni ulibeke phezu ebukwini bese unikeza mina take the pen and put it on top of the book and give it to me 2 beka ipeni phezu kwebuku mese uletha la-kimina put the pen on top of the book and then give it to me 3 beka ipeni lakho phezu kwencwadi bese unikeza mina put your pen on top of the book and then give it to me 4 thatha i-ball peni ulibeke phezu kwebuku mese unikeza mina take the pen and put it on top of the book and then give it to me 5 beka ipeni phezu kwencadi bese unikeza yena put the pen on top of the book and then give it to her put the comb on the other side of the pen and turn over the book 1: beka ikamu ngale kwepeni bese uphendula incwadi   2: beka ikamu kuloluhlangothi lwepeni bese uphendula incwadi   1 thatha ikamu ulibeke enxenyeni ethile kwincwadi bese uvala ibuku take the comb and put it on the other side of the book and then close the book 2 beka ikamu kulelelinye icela lepeni mese uvala ibuku put the comb on the other side of the pen and then close the book 3 beka ipeni ngalelinye icala bese ulibeka phezu kwencwadi put the pen on the other side and put it on top of the book 4 beka i-ball peni phezu kwekamu bese ngiyayiphendula bese unikeza mina put the pen on top of the comb and then i will turn it over and give it to me 5 beka ikamu kuloluhlangothi lwencwadi bese uphendula incwadi put the comb on the other side of the book and then turn over the book discussion as illustrated in this preliminary study, numerous differences and errors in translation may occur when untrained translators are used, and these have the potential to alter the responses obtained from the patient. this may result in misdiagnosis and consequently inappropriate intervention. while it is also not possible to fully identify the characteristics that make one translator more accurate than another, there are a number of factors that can be identified from the current study. the following factors need consideration when translations are conducted from english to isizulu: the impact of isizulu as a tonal language on translation stress and intonation patterns impact substantially on the semantics of spoken language in isizulu. this implies that lexical tone can be used to attach different meanings to words which share the same phonemic content (kuun, zimu, barnard & davel, 2005). the effects of this were noted, for example, during the transcription of participant 4’s question ‘am i a man or a woman?’ which was translated to ‘ungumuntu wesifazane noma wesilisa?’ as a result of the intonation patterns of the language, stress can be placed in different places on the word ‘ungumuntu’ thereby changing the meaning of the sentence. the subtle difference between ‘ungumuntu’ (is she/he) and ‘ungumuntu’ (are you) will affect the patient’s response. this is an important consideration since the ability to accurately detect intonation is a cognitive function involving the right hemisphere (kuun et al., 2005); therefore it has significance in the assessment of a neurologically impaired individual.   the impact of gender on translation although the sample size was small, it was observed that generally the male participants translated the test items with the closest level of accuracy to the original stimuli. it is unclear why the males in this study consistently gave more accurate translations than the females; however, this finding is of interest given that in most clinical encounters, females are more likely to be requested to assist with translation when a language barrier exists. within the south african context, females dominate the nursing profession, and they are also the ones who most often take the role of caregivers. this reality is also confirmed by friedland and penn (2003), who state that it is typical within the south african healthcare sector for nurses and cleaning staff, who are predominantly female, to act as translators in cross-linguistic encounters. interestingly, on a few occasions in the current study, female participants used the carrier phrase ‘please’ during translation of test items. for example, in the spontaneous speech subtest, both participants 2 and 3 translated ‘tell me a little about why you are here’ to ‘please tell me a little about why you are here’. similarly in the sequential command ‘raise your hands’, participant 2 translated this to ‘please raise your hands’. while the sample is too small to draw definitive conclusions as to why this occurred, it is possible that the female participants, because of their ‘nurturing’ nature attempt to establish a rapport with the ‘patient’ during the process of informal translation. this use of the carrier phrase may also be related to cultural norms in isizulu which may dictate subservience on the part of females in general societal functions and engagements. the impact of education on translation based on the current findings, it was evident that level of education also appears to play a role in the type of translation. participant 4 has the lowest level of education. a number of variations were noted in the translations made by this participant compared with the other translators, with the most significant variation being in the translation of ‘what is your occupation?’ owing to the fact that participant 4 may not have had extensive exposure to formal english because of her level of education, she was unable to understand the term ‘occupation’, but instead interpreted it as ‘address’. ercikan (1998) states that a translation made by an interpreter must reflect not only the meaning of the original item, but should also maintain the same relevance, intrinsic interest and familiarity of the item content. furthermore, ercikan (1998) argues that if this is not done, what the item measures may be altered. the current authors agree with this statement as evidence from the current study provides some support for it. a further example of the impact of education on translation can be seen in the subtest of auditory verbal comprehension, where participant 4 was unable to provide the correct term for the object ‘axe’, indicating that she did not have sufficient vocabulary to make the translation. however, having said this, the participant with the highest level of education did not always translate the test items with the closest degree of accuracy. when the impact of level of education on translation was discussed with all, she revealed that ‘reasons’ for translation also play a role in how translation is done, and this may not necessarily be related to level of education. furthermore, she reported that translating items for a ‘language assessment’ may pose significant challenges for the translator and requires a higher level of precision than ‘routine’ translation. therefore, despite the fact that in the south african context english is learned at school by the majority of the population and it can be argued that level of education may give a translator access to a greater vocabulary or to a greater degree of bilingualism, it may not necessarily improve their ability to make translations without changing the inherent meaning, especially in cases where the purpose of the translation has not been explicitly described. the role of multilingualism and language exposure on translation the number of languages that a translator is able to speak appears to play a role in the type of vocabulary that is used during translation. this was observed, for example, in the subtest of auditory verbal comprehension when the question, ‘are the lights on in this room?’ was posed. participants 1, 2 and 3 translated this sentence correctly. however, participants 4 and 5 substituted the isizulu word ‘ugesi’ with the english word ‘light’. this can possibly be explained by looking into where the participants are from. participant 4 is from newcastle in kwazulu-natal, where isizulu is the dominant language, but many people from different backgrounds live there, and a number of languages are spoken. the same applies to participant 5 who is from soweto. therefore, it is understandable that they would not use the authentic isizulu term, ‘ugesi’ for ‘lights’. nevertheless, it is unlikely that this translation would negatively influence the response elicited. the use of ‘borrowed’ english words during translation may also be related to age, in that the younger participants are more likely to have had more exposure to english as a result of being born during a time when more people were educated with english as a medium of instruction, and also having had more exposure to english on television. conclusion although this study employed a small sample size, it has effectively highlighted some of the potential dangers associated with non-formal and non-systematic use of informal translators in the translation of formal speech-language assessment tools. one may argue that the wab is not the most frequently used assessment tool, yet the authors believe that similar results would have been obtained had another formal test been translated, given that the nature of the differences in translation were mostly related to vocabulary and semantics. the findings suggested that test items may be affected by the language, culture, gender and level of education of the translator. this concurs with the findings of mosdell et al. (2010); however, at this point these factors cannot be considered as definitive because of the preliminary nature of the study. these factors therefore warrant more in-depth attention in future studies where bigger sample sizes can be used. while the effects that translation may have on the process of assessment of language impairments are undeniable, the solution to this is less clear. as slts we can continue to motivate for the employment of formal trained translators/interpreters, yet issues associated with the diversity of cultures and languages in the south african context may not be notably reduced in the presence of a translator. while the goal of employing a translator in cross-cultural consultations would be to reduce the effects of language barriers on the accurate assessment of speech and language impairments, this study produces evidence that mediated consultations may in fact be more complex in speech-language therapy than in general health communication, and warrant a different type of solution. efforts to develop and standardise assessment tools in african languages, coupled with increasing the numbers of slts who speak african languages, need to be intensified as it appears these would be the most reliable and logical ways of ensuring that appropriate and effective slt service delivery is achieved within this context. acknowledgement. the authors would like to thank dr i j mhlambi from the department of african languages, university of the witwatersrand, for her active participation in the current study.   references anderson, n. b. 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(2001). mechanical failures as a contributing cause of motor vehicle accidents: south africa. accident analysis and prevention, 33 (6), 713-721. doi:10.1016/s0001-4575(00)00083-x 6 9 kurrikulumontwikkeling vir spraak-taalterapi oudiologie: basis en beginsels s.r. hugo, d. phil (pretoria) i.c. uys, d. phil (pretoria) departement spraakheelkunde en oudiologie universiteit van pretoria opsomming tuur nie langer voldoen aan die multikulturele, 'h ^lor^sonta^e beroepstruk natiewe opleidmgsmoontlikhede soos diploma-oplddingv^mn^^serti^cmtn^n nodig omte besin oor die instelling van alter gerigte magisteropleiding. in samehang hierje het berlp.z^ en beroepsgemeenskapsdiens en konsultasie η veel groter rol in ΐίιζτζζι behoon ^ ^ — abstract ekenaargeletterdheid, bestuursfunksies te speel as wat tans die geval is. ^ ΐ ϊ β ί o f c u r u l u m d e v d o p m e n t f o r « the multicultural, multilingual rsa context. it is therefore necessaru to inv^tim^ah f0''01^^0'1'1^structure ^ n o l°n0er adequate in needs. these may include diploma trainingfor techniaans certifirafe nrn alternative educational options to accommodate current directed masters courses. it is also apparentthattk^ofessionctifan^ wor^lers and professionally the point where aspects such as computer literacy, mmi^em^fiukti^^mmmimh αηί^ audiologist have extended to curriculum thin is the case at present. ^ementfunawns, community work and consultation should play a greater role in the inleiding >' ! zlxzi^' l f a t l v e i n ™akms thin«s ^ tolim^t t 0 m h e c a u s e o f o u r o w n b e n m n e 3 l e a hierdie stalling is verteenwo'ordigend van die algemene gees wat tans m d l e beroep van spraakheelkunde en oudiolog e kottek v s e g t e r , ° ° k t 6 k e n e n d v a " t w e e belangrike kontekse, te wete die universiteitswese in die a l g e m e e n en die suider-afrikaanse samelewing in die besonder teen hierd raamwerk is dit seker nie vreemd dat die behoefte van kurriku lumontwikkehng vir die opleiding van spraak-taalterapeute en oudioloe so sterk na vore gekom het nie. ? die fundamentele vraag wat beantwoord moet word is· wat is die spesifieke beroepsen opleidingsveranderinge wattn 'n ' opleidingskurrikulum vervat moet word? kurr1kuleringsveranderinge· internasionale gesigspunte ' kridesep11^ γ ^ 1 9 8 ° " 1 9 9 ° d e k a d e w o r d ^ e n m e r k deur kritiese evaluas,e van sowel die beroep as die bestaande opleida"aimrds w a t c ' e u r i t i ' d d e ' v 3 n o m n ' b u s o p n a m e s data o o r die stand van spraakterapie en oudiologie a s beroep ingesamel het. die opleiding is dan geevalueer in terme varuhe die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 37, 1990 beroepseise. sodoende is verskeie voorgraadse en nagraadse kursusse, asook voortgesette onderrig geweeg in terme van relevansie van 'n ontwikkelende en veranderende beroep hyman, 1986; shewan, 1988; terrizzi, 1988). uit die britse literatuur blyk dit ook dat oplossings vir diensleweringspros e v i n d k a n w o r d deur die behoefte aan diens en die voorsiening van diens vas te stel (enderby & davies, 1989). relevante demografiese gegewens in verband met die stand van die beroep dui op klemverskuiwings wat leemtes met betrekking tot beroepsen bestuursfiinksies laat. dit is veral die internasionale menseregteverdrae en die standpunte van die gesondheidsorganisasie wat nuwe insigte gebring en orientasieveranderinge laat plaasvind het. opsommenderwys kan die volgende riglyne vir verandering aangestip word: 5 vir ongeveer twee dekades word die behoefte aan spraakterapie en oudiologie as 'n enkel-professie bepleit (feldman 1981). alhoewel daar geleidelike verandering in die opleidingsprogramme te bespeur is, is die algemene tendens vir die vsa steeds om eerder as oudioloog of spraakterapeut te kwalifiseer, te registreer en te werk. demografiese bevindings dui egter aan dat die gevallebelading in die praktyk deskundigheid op beide gebiede vereis en noop die aanvaarding van stellings soos: «true specialization grows 0 savsg 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 s.r. hugo & i.c. uys out of generalist training" (feldman, 1981: 942). * daar is vir baie jare reeds 'n behoefte om 'n beroepskorps daar te stel wat spraakterapie en oudiologie tot 'n onafhanklike beroep kan lei. alhoewel die oorgrote meerderheid spraakterapeute en oudioloe steeds by instansies soos skole en hospitale diens lewer, is daar tans 'n omskakeling na privaat praktyk te bespeur (shewan, 1988). hierdie oorskuiwing word deur asha ondersteun maar hulle beklemtoon ook die feit dat opleiding hierby aangepas moet word. * verwant aan die bogemelde punt, is 'n behoefte dat spraakterapeute en oudioloe onmiddellik na opleiding (met toetrede tot die beroepslewe) oor al die nodige beroepsen bestuursvaardighede sal beskik om onafhanklik en toerekenbaar in die privaat praktyk op te tree. opleidingsprogramme moet dus voorsiening maak dat studente daardie kritiese korpus van kennis en vaardighede bekom voor toetrede tot die beroep (feldman, 1981; lingwall, 1988). * juis as gevolg van die veranderende werksomstandighede het dit nodig geword om spraakterapeute en oudioloe vakinhoudelik meer omvangryk voor te berei op hulle beroepsfunksies (flower, 1984). in die basiese opleiding moet aandag geskenk word aan die kwantiteit en kwaliteit van die teoretiese en kliniese opleiding, die verhouding tussen fundamentele geesteswetenskaplike en natuurwetenskaplike inhoude; die verhouding tussen basiese en toegepaste wetenskappe; die verhouding tussen akademiesteoretiese en kliniese opleiding (terrizzi, 1988). * feldman (1981) identifiseer die behoefte aan voortgesette onderrig en veral kliniese magistergrade en doktorsgrade. opleidingsinstansies moet ook voortgesette onderrig aan oudstudente, wat nie noodwendig graad-kwalifikasies is nie, as 'n verpligting beskou omdat die vakgebied so vinnig ontwikkel (hyman, 1986; shewan, 1988). * een van die grootste behoeftes wat deur verskeie ondersoeke gei'dentifiseer is, is die onkunde oor bestuursfunksies wat tans by spraakterapeute en oudioloe bestaan (foxman, 1988; gelatt, 1988; griffin, 1988; holley, 1988). die aanbeveling word gemaak dat veral die bemarking van dienste aandag moet geniet, omdat dit al hoe meer deel word van die eise wat aan lewensvatbare beroepe gestel word. * verskeie behoeftes het ontstaan as gevolg van politieke druk in samehang met tegnologiese ontwikkeling. die belangrikste hiervan is: die behoefte aan rekenaargeletterdheid. die rekenaar word al hoe meer onontbeerlik in die beoefening van spraakterapie en oudiologie. gedurende 1984 het ongeveer 27% spraak-taalterapeute en oudioloe rekenaars gebruik; en 'n opname in 1988 dui op 'n styging na amper 58%. dit is interessant dat die reke. n a a r i n 1986 hoofsaaklik vir bestuursfunksies (administrasie, rekordhouding en woordverwerking) aangewend is, terwyl die 1988-opname aantoon dat rekenaars tans hoofsaaklik vir diagnostiese en behandelingsdoeleindes gebruik word. opleiding in rekenaargebruik word derhalwe al hoe meer 'n noodsaaklikheid (hyman, 1986; shewan, 1988). die betrokkenheid by minderheidsgroepe. reeds in 1985 het asha die standpunt ingeneem dat hulp verleen behoort te word aan persone in uiteenlopende sosiale, kulturele, ekonomiese en linguistiese populasies. alhoewel opleiding van terapeute uit minderheidsgroepe vanaf 1987 spesiale aandag geniet, is daar huidiglik in die vs a slegs 3% geregistreerde spraaktaalterapeute en oudioloe uit hierdie bevolkingsgroepe. opnames toon egter dat terapeute al hoe meer betrokke raak by die hantering van minderheidsgroepe (cole en massey, 1985; hyman, 1986; shewan, 1988). die betrokkenheid by spesiale groepe as gevolg van die ontwikkeling van die wetenskap. as gevolg van die identifikasie van kommunikasieafwykings by spesifieke groepe soos taalleergestremdes, vigslyers, verskeie neuropatologiee en selfs bejaardes (met die toename in hierdie populasie), brei die spraakterapeut en oudioloog se werksomvang skielik uit. opleidingsinstansies moet derhalwe voorsiening maak vir die voortgesette onderrig van persone wat in die verlede gekwalifiseer het ten einde hulle vaardighede na die nuwe toepassingsvelde uit te brei. kurrikuleringsveranderinge: nasionale vertrekpunte dit is opmerklik dat die plaaslike literatuur 'n byna identiese weerspieeling van oorsese veranderinge aandui. dit is egter te verstane omdat die vsa-model vir baie dekades al aangepas en toegepas is in die rsa. juis hierdie basis behoort in 'n evaluasie van bestaande opleiding bevraagteken te word. soos delaney en malan (1984:75) dit stel: "this foreign model has been modified to provide our south african model. this is not to sag that a foreign model modified on the basis of limited information is necessarily inadequate, but rather that it is important that we be aware that this is the situation." 'n eiesoortige probleemsituasie dra by tot die noodsaaklikheid van 'n rsa-opleidingsmodel. ten eerste is dit die kenmerke van die ontwikkelende land wat eiesoortige aanpassings vir dienslewering en opleiding noodsaak. penn (1986) bevraagteken die relevansie van opleiding in hierdie omstandighede, i omdat daar tans 'n "ongesonde status en beeld van die beroep 1 as oorwegend 'n luukse bestaan" (uys, 1987). in samehang ' hiermee bepleit aron (1984(a) en 198 7) veranderinge in opleiding en dienslewering om aan hierdie behoeftes van, onder andere, minderbevoorregting, armoede, onkunde en selfs ongeletterdheid te voldoen, deur alternatiewe opleiding binne die raamwerk van gemeenskapsgebaseerde benaderings aan te bied. sy staan ook die opleiding van primere sorgpersone voor. j fourie (1984) ondersteun hierdie siening dat aanpassing by j die eise van 'n derde wereldland die opleiding en aanstelling van semigekwalifiseerde persone onder toesig noodsaak. daarenteen meen morgan, geraghty, dawber, motshei, drew, motshei en segal (1984) dat 'n gemeenskapsorientasie nie aan 'n afs. nderlike kursus, of 'n afsonderlike groep werkers met anc er funksies toegese behoort te word nies maar dat 'n gemeenskapsorientasie geinkorporeer behoort te word in die opleiding van spraakterapeute en oudioloe. die implikasies van hierdie voorstelle is eerstens dat die tradisionele benadering tot opleiding (die identifikasie van patologie in die individu en die rehabilitasie van die idividu) en dienslewering (die uitvoering van die praktyk binne die raamwerk van institusionele strukture, bv. hospitale, skole, ens.) ontoepaslik is. voorbereiding van die spraakterapeut en y the south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kurrikulumontwikkeling vir spraak-taalterapie en oudiologie: basis en begin se is 71 oudioloog om by toetrede tot die praktyk onafhanklik toerekenbare diens te lewer, plaas 'n hoe premie op opleiding veral met betrekking tot omvattende primere, sekondere en tersiere voorkoming en konsultasie (uys, 1985). die tweede implikasie is dat spraakterapeute en oudioloe 'n navorsingsinset sal moet lewer en dus 'n sterker akademiese opleiding in wetenskapmetodologie sal moet ontvang om hulle voor te berei op sinvolle navorsing (uys, 1986; 1987). 'n kompliserende faktor wat die eise van 'n onwikkelende land verder verhoog is die geografiese kenmerke van die rsa. die uitgestrektheid van plattelandse gebiede en die groot bevolkingsamevloeiing ver van sentrale gebiede is vroeg al as 'n besondere kenmerk van dienslewering gei'dentifiseer. reeds in 1966 onderstreep pienaar die behoefte aan "properly conducted surveys at regular intervals over large areas" en "clinics, mobile and otherwise established in ... country districts" (in morgan et al. 1984: 111). in opleiding stel dit die eis dat klem gele moet word op gemeenskapsdiens, konsultasie, en veel eerder generalisasie as spesialisasie. noodwendig hang geografiese kenmerke nou saam met die beskikbaarheid van dienste. in 1984 was daar na beraming reeds 'n tekort aan 4,494 spraakterapeute en oudioloe in die rsa (fourie, 1984). in 1986 het die tekort gestyg tot oor die 5 000 en volgens projeksie (met inagneming van die bevolkingsgroei) sal daar in 2000 'n tekort aan minstens 10 000 wees (gestremdheid in die republiek van suid-afrika, 1987(a), (b), (c)). dit het verder aan die lig gekom dat bykans alle dienste uitsluitlik gerig is op die identifikasie, diagnose en behandeling van bevoorregte, stedelike blankes, dat dienste aan die ontwikkelende plattelandse bevolkingsgroepe totaal ontoereikend is en dat voorkomingsdienste feitlik nerens beskikbaar is nie (gestremdheid in die republiek van suid-afrika, 1987(c); aron, 1984(a)). verskeie aanbevelings is reeds gemaak om hierdie probleem te oorkom, naamlik: i die verhoging van studentetalle uit alle bevolkingsgroepe /by bestaande opleidingsinstansies (uys, 1984). die instelling van opleidingskursusse by ander (addisionele) universiteite, met veral die oog op opleiding van persone uit asier-, kleurlingen swart-bevolkingsgroepe. daar is tans ongeveer 4 kleurling-, 25 asieren 4 swartspraakterapeute en oudioloe geregistreer (gestremdheid in die republiek van suid-afrlika,-1987(c)). met inagneming van die bevolkingstoename van hierdie drie groepe, is die opleiding van spraakterapeute en oudioloe uit hierdie groepe noodsaaklik (penn, 1986; crossley, 1987). die aanpassing van opleidingskursusse met die oog daarop om terapeute in staat te stel om groter pasientgetalle te hanteer deur alternatiewe spraakterapeutiese en oudiologiese benadering (morgan et al. 1984; hugo & louw, 1987), konsultasie (uys, 1985) en die gebruik van ondersteuningsdienste (enderby & davies, 1989). die multikulturele, veeltalige bevolkings van die rsa skep 'n behoefte in terme van die omvang en kwaliteit van die bestaande dienste. die opleiding en kwalifikasies van spraakterapteute en oudioloe kan, met spesiale verwysing na hulle rol in 'n meertalige, multikulwele gemeenskap, gekritiseer word. die opleiding voldoen huidiglik beslis nie aan al die eise wat deur hierdie samelewing gestel word nie (uys, 1984). die habilitasie en rehabilitasie van kommunikasieafwykings is anders as ander terapiee in die opsig dat kommunikasie beide die middel en die doel in behandeling is. die spraakterapeuten oudioloog moet nie slegs oor 'n diepgaande kennis van die taal van die pasient beskik nie, maar ook 'n goeie begrip van die sosiokulturele eienskappe van die betrokke bevolkingsgroep he (aron, 1984 (b); crossley, 1984). verskeie voorstelle word voorgehou ter oplossing van hierdie probleem: om basiese konsepte van swarten indiertale in te sluit in die opleiding van spraakterapeute en oudioloe. om inligting in verband met sosiokulturele verskille in te sluit in die opleiding van spraakterapeute en oudioloe (crossley, 1984; segal & drew, 1984). om in spanverband navorsing te doen oor hierdie verskille en verskynsels, sodat norme vir kommunikasiegedrag op alle vlakke vasgestel, en diagnostiese en behandelingsmateriaal ontwikkel kan word (aron, 1987; webb, 1984). om van spraakterapieen oudiologie-assistente, of tolke gebruik te maak in dienslewering (uys, 1984). om spraakterapeute en oudioloe vanuit hierdie groepe op te lei (penn, 1986). hierdie behoefte aan verandering, om opleiding en dienslewering aan te pas by die rsa-konteks, is ook reeds deur die outeurs gei'dentifiseer in 'n navorsingsprojek. dit blyk uit vraelyste wat aan 'n verteenwoordigende populasie van spraak-taal-gehoorterapeute gestuur is, asook uit onderhoude wat met die persone gevoer is, dat 73% aanpassing van die opleiding by rsa-omstandighede voorstaan, terwyl 62% voorstanders is van verandering in opleiding om voorsiening te maak vir klemverskuiwing met betrekking tot die beroepsfunksies (hugo & uys, 1988). die voorafgaande inligting skets op 'n gekondenseerde wyse enkele van die vraagstukke rondom opleiding en meer spesifiek die probleem van kurrikulering vir spraakterapie en oudiologie. indien dit die probleem is wat is die oplossings? tentatiewe oplossings vir kurrikulums kurrikulumontwikkeling is die "doelgerigte en sistematiese opbou van die kurrikulum en die voortdurende evaluering, herevaluering en vernuwing daarvan" (kachelhoffer, 1987: 14). indien die inligting in die voorafgaande paragrawe as vertrekpunt gebruik word, is dit duidelik dat die bestaande opleiding van spraak-taalterapeute en oudioloe in die rsa redelik indringend verander moet word. hierdie veranderinge sal natuurlik ook in samehang met die eiesoortige karakter van die inrigting waar die opleiding aangebied word, moet ontwikkel. daar is egter twee belangrike fundamentele aspekte wat as basies tot enige kurrikulumontwikkeling gesien kan word. die beroepstruktuur en opleiding ten eerste is dit vir die internasionale aanvaarding van beroepsbeoefenaars belangrik dat die aard en kwaliteit van opleiding sodanig sal wees dat professionele erkenning maklik die suid-afrikaanse tydskrif vir kommunikasieafivgkings, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 7 2 s.r. hugo & i.c. uys plaasvind en uitruiling van studente 'n praktiese moontlikheid sal wees. derhalwe is 'n vierjarige beroepsgerigte baccalaureusgraad met hoofvakke spraak-taalpatologie en oudiologie 'n minimum vereiste vir registrasie as spraakterapeut en oudioloog. dit kan dan gevolg word met 'n magisteren doktorsgraad vir bykomende kwalifikasie en spesialisasie. 'n ander vorm van professionele graadopleiding vir registrasiedoeleindes moet egter oorweeg word. dit is die moontlikheid van 'n tweeof driejarige, beroepsgerigte magistergraad in spraak-taalpatologie of oudiologie, met as voorvereiste enige algemene baccalaureusgraad. hierdie opleiding sou 'n verintensifisering van die basiese opleiding beteken met gevolglike registrasie as of spraakterapeut of oudioloog. die voordeel van sodanige opleiding is dat dit volwasse en gemotiveerde studente sal lok wat waarskynlik uit 'n spesifieke beroepsopset (bv. skole vir gehoorgestremdes of serebraalgestremdes), 'n spesifieke belangstelling in die kommunikasiegestremde ontwikkel het. kurrikulering en beroepsfiinksies wanneer die jaarboeke van opleidingsinstansies bestudeer word, is dit duidelik dat opleiding by universiteite tans grootliks 'n afwykinggerigte (bv. hakkel, breinbesering, ens.) benadering volg. dit beteken dat hoofsaaklik twee van die beroepsfunksies, diagnose en terapie, uitvoerig onderrig word, dikwels ten koste van die meeste ander beroepsfunksies. die resultaat hiervan is 'n onewewigtige kurrikulum wat nie met die huidige beroepseise tred hou nie. ten einde 'n kurrikulum te ontwikkel wat 'n funksionele holistiese basis het, is dit nodig om alle beroepsfunksies te lys en te definieer. hierdie funksies word in tabel 1 uiteengesit. tabel 1: beroepsfunksies van spraak-taalterapeute oudioloe ten tweede is dit so dat omstandighede in die rsa dui op die ondervoorsiening van dienste in die algemeen, maar spesifiek ook met betrekking tot diens aan ander kultuurgroepe, ander taalgroepe, die geriatriese en die plattelandse bevolking. dit is derhalwe duidelik dat die verhoging van basiese graadopleiding alleen nie die antwoord op hierdie probleem sal wees nie. die oplossing hiervoor is die instelling van ander vorms van diens wat dienooreenkomstig ander tipes van opleiding benodig. dit word visueel voorgestel in figuur 1, en bestaan in essensie uit die volgende: graadopleiding aangebied deur universiteite vir die kwalifikasie van terapeute wat kan optree as probleemoplossers, toesighouers, konsultante en spesialiste. diploma-opleiding aangebied deur technikons vir die kwalifikasie van terapeutiese assistente en spraaken gehoorgemeenskapswerkers wat gemoeid sal wees met die aanbieding van roetine/tegniese aspekte van kommunikasiepatologie. sertifikaatprogramme aangebied deur diensleweringsorganisasies vir die kwalifikasie van gemeenskapsrehabilitasiewerkers. sentrale klinieke . spesialis spraakterapeute en oudioloe ' (nagraadse spesialisasie)\ opleiding: universiteit gedesentraliseerde klinieke spraakterapeute en/of oudioloe (baccalaureusgraad, en ma in spraak-taalpatologie of oudiologie) opleiding: universiteit gemeenskappe> semi-gekwalifiseerdes spraaken gehoorgemeenskapswerkers (gediplomeerdes) opleiding: technikon gemeenskapsrehabilitasiewerkers (sertifikaatprogramme) opleiding: diensleweringsorganisasies beroepsfunksie omskrywing 1 sifting aktiwiteite wat uitgevoer word ten einde uit 'n grootpopulasie te differensieer tussen persone wat normale kommunikasie het en diegene wat vollediger bestudeer moet word om vas te stel of hulle 'n spesifieke afwyking het. 2 voorkoming aktiwiteite wat uitgevoer word ten einde die aanvang, ontwikkeling en komplikasie van 'n kommunikasieafwyking te elimineer en/of te inhibeer. 3 gemeenskapswerk aktiwiteite wat daarop gerig is om 'n diens aan en deur die gemeenskap te lewer ten einde kommunikasieafwykings te voorkom, te diagnoseer en te behandel. 4 terapie 5 evaluasie figuur 1: opleidingsmodel vir die beroepstruktuur aktiwiteite wat poog om kommunikasiegedrag te modifieer. hier kan drie tipes aktiwiteite onderskei word: gerig op verwerking van elemente van normale kommunikasie * gerig op verwerwing van kompensatoriese prosedures in gevalle van onherstelbare afwykings * gerig op verandering van weerstand teen kommunikasieverbetering. aktiwiteite wat ten doel het om 'n kommunikasie-afwyking te beskiyf of om beslissings aangaande hulpverlen ing te maak. die doel hiervan is: * om aanwesigheid en graad van afwyking te bepaal * om die afwyking te beskryf * om die stappe ter oplossing aan te dui * om verwysingsraamwerk vir intervensiegevolge te stel(prognose) * om aan ander professies die implikasies van die afwyking aan te toon. the south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kurrikulumontwikkeling vir spraak-taalterapie en oudiologie: basis en beginsels tabel 1 vervolg 73 6 beraad 7 bestuur 8 konsultasie 9 navorsing 10 onderrig dienste gebied aan die kommunikasieafwykende en/of sy familie (en belangrike omgewingsindividue) gerig op die oplossing of vermindering van probleme wat met die kommunikasieafwyking verband hou of daaruit spruit. hierdie dienste vul terapie aan ten opsigte van: * beraad aan die kommunikasieafwykende om ander vorms van professionele hulp te soek en te aanvaar * beraad aan familielede ten einde terapie te steun en hulle kommunikatiewe rol aan te dui. aktiwiteite wat uitgevoer word om menslike finansiele, fisiese en inligtingshulpbronne te benut ten einde die onderneming (ondernemings wat met die kommunikasieafwykende gemoeid is) se doel witte aan te wend. dit sluit in bestuurfunksies soos beplanning, organisasie, koordinering en beheer. aktiwiteite wat daarop gerig is om aan ander professionele persone 'n diens te lewer ten bate van die kommunikasieafwykende. aktiwiteite wat daarop gerig is om tot grondige en akkurate kennis en insig van normale en afwykende menslike kommunikasie te kom. die opleiding en opvoeding van persone in normale en afwykende menslike kommunikasie in terme van kennis, vaardighede en gesindhede wat daarme.e verband hou. in^fabel 1 is gepoog om alle beroepsfunksies, ongeag die spesifieke arbeidsterrein, en toepaslik op so wel spraakterapeute as oudioloe, uit te spel. uiteindelik sal dit noodwendig van die spesifieke werkgewer en werksomstandighede afhang watter funksie/s die meeste beklemtojon word, maar vir kurrikulumontwikkeling is dit nodig om alle fasette in die sillabus te be trek. ! i beroepstruktuur en beroepsfunksies aangesien die voorgestelde beroepstruktuur, sowel as die gedifferensieerde opleiding van verskeie faktore afhanklik is, kan daar tans slegs pro-aktiewe voorstelle gemaak word oor die versoening tussen opleiding, struktuur en funksies. die funksies (bv. sifting, behandeling, voorkoming ens.) benodig. die eerste kwalifikasie in spraak-taalterapie en oudiologie sal daarenteen weer 'n algemeen gemiddelde kennis en vaardigheid met betrekking tot alle funksies as voorvereiste stel. namate'styging in die hierargie plaasvind, kan 'n stygende tendens in indiepte-kennis met betrekking tot bestuur, konsultasie, onderrig ens. 'n voorvereiste wees, terwyl spesialisasie deur navorsing, 'n getande profiel aan opleidingsomvang kan verskaf. kurrikulum quo vadis? alles is al vantevore bedink. die noodsaak is weer daaraan te dink. dit is 'n algemeen geldige stelling. die voorafgaande bespreking lig enkele belangrike tendense uit waarvoor toegelaat moet word in kurrikulumontwikkeling. kurrikulumontwikkeling is egter nie 'n horisontale groei nie maar vind veelvlakkig plaas. op die makrovlak sal daadwerklik gekyk moet word na die verskillende vlakke van opleiding (insluitend technikons en diensleweringsinstansies) sodat mindere en andersoortige kwalifikasies as voorvereiste vir omvattender en meer koste-effektiewe dienslewering daargestel kan word. mesovlakverandering betrek die spesifieke departemente en sluit in kursuskurrikulering. hier is dit essensieel dat die onderskeie departemente kursusse ontwikkel wat eerstens aan die universele behoeftes van die beroep voldoen, maar tweedens toelaat vir die spesifieke karakter van die bepaalde universiteit en die geografiese gemeenskap wat die universiteit bedien. daar moet veral ook aandag gegee word aan die rol wat nagraadse onderrig, ondersteuningsprogramme en voortgesette onderrig binne die bree kursuskurrikulum speel. wat die mikrovlak betref, moet volledig besin word oor sillabustemas, en lesingeenhede, maar sinvolle beplanning hier sal van waarde wees indien dit in samehang met onderrigdidaktiek en personeelorganisasie gedoen word. die uiteindelike sukses van kurrikulumontwikkeling is in die laaste instansie in die hande van diegene wat die onderrig moet aanbied. dit beteken dat hoe eise aan dosente en ander opleiers gestel sal word. van hulle sal kwaliteite vereis word soos aanpasbaarheid, deeglike vakkennis, hoe intelligensie, entoesiasme, bereidwilligheid om te leer en te groei, en selfs enkele nie-vakverwante vaardighede en gesindhede. hierdie vereiste eienskappe is in elk geval kenmerkend van toegewyde en professionele spraakterapeute en oudioloe. daar is derhalwe geen twyfel nie dat die beroepslui met gemak sal kan voldoen aan die uitdagings wat kurrikulumontwikkeling stel. alhoewel dit met die eerste oogopslag mag voorkom asof alle kurrikulums slegs swaarder gelaai word met vakinhoud, is dit glad nie die geval nie. grondliggend aan die opleiding is andersoortige opleidingsorientasies en opleidingsmetodieke. klemverskuiwing met betrekking tot die gewig van insette oor die funksies sal die verskillende struktuurvlakke onderskei. dit word aanvaar dat al die funksies in 'n meerdere of mindere mate op elke beroepsvlak ter sprake moet kom. basiese riglyne kan egter voorgestel word. basisvlakwerkers sal waarskynlik beperkte kennis en vaardigheid met betrekking tot sekere van verwysings aron, m.l. introduction. in m.l. aron en l. ie roux (reds) proceedings of the conference on community work in speech and hearing therapy. savsg, 1-5, 1984(a). aron, m.l. community work in speech therapy. in s.m. beukes (red.) simposiumreferate: die rol van die spraakterapeut in 'n meertalige samelewing. universiteit van pretoria, 10-16, 1984(b). die suid-afrikaanse tydskrif vir kommunikasieafins, vol. 37 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 7 4 s.r. hugo & i.c. uys aron, m.l. community-based rehabilitation for communication disorders. in w. smit en s. meyer (reds.) nasionale konferensieverrigtinge. savsg (ongenommer), 1987. cole, p.r.j want to shape my own future. how about you? asha, 28(a), 41-42, 1986. cole, l. en massey, a. minority student enrolment in higher education institutions with communicative disorders programs. asha, 27(6), 33-37, 1985. crossley, s. language remediation in an indian community. in s.m. beukes (red.) simposiumreferate: die rol van die spraakterapeut in 'n meertalige samelewing. universiteit van pretoria, 38-61, 1984. crossley, s. how to train clinicians to work with culturally different clients. communiphon, 280, 2-11, nov./des. 1987. delaney, c. en malan, k. community speech and hearing therapy: some questions before answers. in m.l. aron en l. ie roux (reds.) proceedings of the conference on communitg work in speech and hearing therapg. savsg, 73-84, 1984. enderby, p. en davies, p. communication disorders: planning a service to meet the needs. british journal of disorders of communication, 24, 301-331, 1989. feldman, a.s. the challenge of autonomy. asha, 23(12), 941945, 1981. flower, r.m. deliverg of speech-language pathology and audiology services. baltimore: williams en wilkens, 1984. fourie, h.p. maatskaplike behoeftebepaling. in s.m. beukes (red.) simpodum-refer ate: die rol van die spraakterapeut in 'n meertalige samelewing. universiteit van pretoria, 2-9, 1984. foxman, c.a. speak with sense. asha, 30(9), 46-47, 1988. gelatt, p.j. the business of grantseeking. asha, 30(9), 43-45, 1988. gestremdheid in die republiek van suid-afrika: hoofverslag 1, pretoria: departement van gesondheid en bevolkingsontwikkeling, 1987(a). gestremdheid in die republiek van suid-afrika: gehoorgestremdheid 8, pretoria: departement van gesondheid en bevolkingsontwikkeling, 1987(b). gestremdheid in die republiek van suid-afrika: spraakgestremdheid 10, pretoria: departement van gesondheid en bevolkingsontwikkeling, 1987(c). griffin, k.m. quality sells, asha, 30(9), 48-51, 1988. holley, s.c. president's page asha, 30(9), 37-38, 1988. hugo, s.r. en louw, b. ouergesentreerde interaksieterapie. in w. smit en s. meyer (reds.) nasionale konferensie-verrigtinge, savsg, (ongenommer), 1987. hugo, s.r. en uys, i.c. kurrikulering van spraakheelkunde en oudiologie. in referategelewer tgdens die oudiologiekontires. savsg, 190-201, 1988. hyman, c.s. the 1985-omnibus survey. implications for strategic planning. asha, 28(4), 19-22, 1986. kachelhoffer, p.m. kurrikulumontwikkeling: riglyne aan kurrikulumkomitees. up-dosent, (1), 14-20, 1987. lingwall, j.b. report: evaluation of the requirements for the certificates of clinical competence in speech-language pathology and audiology. asha, 30(9), 75-78, 1988. morgan, r., geraghty, s., dawber, α., motshei, f., drew, m., motshei, m. en segal, d. an alternative approach to speech therapy. in m.l. aron en l. ie roux (reds.) proceedings of the conference on community work in speech and hearing therapg. savsg, 1 ιοι 20, 1984. penn; c. guest editorial. communiphon, 274:2, 1986. segal, df. en drew, m. argument for a community oriented approach to language therapy. in s.m. beukes (red.) simposiumreferate: die rol van die spraakterapeut in 'n meertalige samelewing. universiteit van pretoria, 88-92, 1984. shewan, c.m. 1988-omnibussurvey: adaptation and progress in times of change. asha, 30(8), 27-32, 1988. terrizzi, a.m. status report on undergraduate education in communication sciences and disorders. asha, 30(5), 31-33, 1988. uys, i.c. spraaken gehoorheelkunde in 'n meertalige samelewing. in s.m. beukes (red.) simposiumreferate: die rol van die spraakterapeut in 'n meertalige samewelinq: universiteit van pretoria, 88-93, 1984. uys, i.c. 'n medekonsultasiemodel vir spraaken gehoorterapie in die rsa. in i.s. hay en i.c. uys taalverskeidenheid en taalpatologie. pretoria: universiteit van pretoria, 1985. uys, i.c. gas redaksioneel. communiphon. 280, 1-2, 1986. uys, i.c. navorsing: 'n diens aan en deur die klinikus. in w. smit en s. meyer (reds.) nasionale konferensie-verrigtinge. savsg, (ongenommer), 1987. webb, v.n. sosiolinguistiek en die spraakterapie. in s.m. beukes (red.) simposiumreferate: die rol van die spraakterapeut in 'n meertalige samelewing. universiteit van pretoria, 23-27, 1984. the south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) information for contributors the south african journal of communication disorders publishes reports and papers concerned with research, or critically evaluative theoretical, or therapeutic issues dealing with disorders of speech, voice, hearing or language, or on aspects of the processes underlying these. the south african journal of communication disorders will not accept material which has been published elsewhere or that is currently under review by other publications. all contributions are reviewed by at least two consultants who are not provided with author identification. form of manuscript. authors should submit four neatly typewritten manuscripts in triple spacing with wide margins which should not exceed much more than 25 pages. each page should be numbered. the first page of two copies should contain the title of the article, name of author/s, highest degree and address or institutional affiliation. the first page of the remaining two copies should contain only the title of the article. the second page of all copies should contain only an abstract (100 words) which should be provided in both english and afrikaans. afrikaans abstracts will be provided for overseas contributors. all paragraphs should start at the left margin and not be indented. major headings, where applicable, should be in the order of method, results, discussion, conclusion, acknowledgements and references. tables and figures should be prepared on separate sheets (one per table/ figure). figures, graphs and line drawings must be originals, in blackink on good quality white paper. lettering appearing on these should be uniform and professionally done, bearing in mind that such lettering should be legible after a 50% reduction in printing. on no account should lettering be typewritten on the illustration. any explanation or legend should not be included in the illustration but should appear below it. the titles of tables and figures should be concise but explanatory. the title of tables appears above, and of figures below. tables and figures should be numbered in order of appearance (with arabic numerals). the amount of tabular and illustrative material allowed will be at the discretion of the editor (usually not more than 6). references. references should be cited in the text by surname of the author and date, e.g. van riper (1971). where there are more than two authors, et al. after the first author will suffice. the names of all authors should appear in the reference list. references should be listed alphabetically in triple-spacing at the end of the article. for acceptable abbreviations of names of journals, consult the fourth issue (october) of dsh abstracts or the world list of scientific periodicals. the number of references used should not exceed much more than 20. note the following examples: locke, j.l. clinical psychology: the explanation and treatment of speech sound disorders./ speech hear. disord., 48, 339-341, 1983. penrod, j.p. speech discrimination testing. in j. katz (ed.) handbook of clinical audiology, 3rd ed., baltimore: williams & wilkins, 1985. van riper, c. the nature of stutteriny. englewood cliffs, new jersey: prentice-hall, 1971. proofs: galley proofs will be sent to the author wherever possible. corrections other than typographical errors will be charged to the author. reprints. 10 reprints without covers will be provided free of charge. all manuscripts and correspondence should be addressed to: the editor, south african journal of communication disorders, south african speech and hearing association. p.o. box 31782, braamfontein 2017, south africa. inligting vir bydraers die suid-afrikaanse tydskrif vir kommunikasieafivykinys publiseer verslae en artikels oor navorsing, of krities evaluerende artikels oor die teoretiese of terapeutiese aspekte van spraak-, stem-, gehoorof taalafwykings, of oor aspekte van die prosesse onderliggend aan hierdie afwykings. > die suid-afrikaanse tydskrif vir kommunikasieafivykings sal nie materiaal aanvaar wat reeds elders gepubliseer is, of wat tans deur ander publikasies oorweeg word nie. alle bydraes word deur minstens twee konsultante nagegaan wat nie ingelig is oor die identiteit van die skrywer nie. formaat van die manuskrip. skrywers moet vier netjies getikte manuskripte in 3-spasiering en met bree kantlyn indien, en dit moet nie veel langer as 25 bladsye wees nie. elke bladsy moet genommer wees. op die eerste bladsy van 2 afskrifte moet die titel van die artikel, die naam van die skrywer/s, die hoogste graad behaal en die adres of naam van hulle betrokke instansie verskyn. op die eerste bladsy van die oorblywende twee afskrifte moet slegs die titel van die artikel verskyn. die tweede bladsy van alle afskrifte moet slegs 'n opsomming (100 woorde) in beide engels en afrikaans bevat. afrikaanse opsommings sal vir buitelandse bydraers voorsien word. alle paragrawe moet teenaan die linkerkantlyn begin word en moet nie ingekeep word nie. hoofopskrifte moet, waar dit van toepassing is, in die volgende volgorde wees: metode, resultate, bespreking, gevolg trekking, erkennings en verwysings. tabelle en figure moet op afsonderlike bladsye verskyn (een bladsy per tabel/illustrasie). figure, grafieke en lyntekeninge moet oorspronklike weergawes wees en moet in swart ink op wit papier van 'n hoe gehalte gedoen word. letterwerk wat hierop verskyn moet eenvormig wees, professioneel gedoen word en daar moet in gedagte gehou word dat dit leesbaar moet wees na 'n 50%-verkleining in drukwerk. letterwerk by die illustrasie moet onder geen omstandighede getik word nie. verklarings of omskrywings moet nie in die illustrasie nie, maar daaronder verskyn. die byskrifte van tabelle moet bo-aan verskyn en die van figure onderaan. tabelle en figure moet in die volgorde waarin hulle verskyn, genommer word (met arabiese syfers). die hoeveelheid materiaal in die vorm van tabelle en illustrasies wat toegelaat word, word deur die redakteur bepaal (gewoonlik nie meer as 6 nie). venvysinys. verwysings in die teks moet voorsien word van die skrywer se van en die datum, bv. van riper (1971). waar daar meer as twee skrywers is, sal et al. na die eerste skrywer voldoende wees. die name van alle skrywers moet in die verwysingslys verskyn. verwysings moet alfabeties in 3-spasiering aan die einde van die artikel gerangskik word. vir die aanvaarde afkortings van tydskrifte se titels, raadpleeg die vierde uitgawe (oktober) van dsh abstracts of the world list of scientific periodicals. die getal verwysings wat gebruik is, moet nie veel meer as 20 wees nie. let op die volgende voorbeelde: locke, j.l. clinical phonology: the explanation and treatment of speech sound disorders./ speech hear. disord., 48, 339-341, 1983. penrod, j.p. speech discrimination testing. inj. katz (ed.) handbook of clinical audioloyy, 3e ed., baltimore: williams & wilkins, 1985. van riper, c. the nature of stuttering. englewood cliffs, new jersey: prentice hall, 1971. proewe: galeiproewe sal waar moontlik aan skrywers gestuur word. die onkoste van veranderings, behalwe tipografiese foute, sal deur die skrywer self gedra moet word. herdrukke. 10 herdrukke sonder omslae sal gratis verskaf word. alle manuskripte en korrespondensie moet gerig word aan: die redakteur, die suid-afrikaanse tydskrif vir kommunikasieafivykinys. die suid-afrikaanse vereniging vir spraaken gehoorheelkunde, posbus 31782, braamfontein 2017", suid-afrika. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) immediate echolalia and the interactive behaviour of autistic children ingrid van zyl b.(log) (pret) erna alant d.phil (pret) isabel c. uys d.phil (pret) department speech pathology and audiology, university of pretoria this research examined whether echolalia and interactive behaviour in autistic children could function within a communicative system. four autistic children were videotaped individually in interaction with a familiar adult. a categorical system was designed whereby the children s interactive behaviour could be rated. it was found that the immediate echolalia is far more than a meaningless repetition of words the utterances are relevant, displaying the conveyance of meaningful information and the maintenance of social interaction. conclusions were drawn on the facilitation of communication through modification and expansion of immediate echolalia. opsomming , , ., . . , , , . die doel van hierdie ondersoek is om vas te stel ofeggolalie en interaksiegedrag in outistiese kinders binne η neer individuele video-opnames van die interaksie van vier outistiese kinders met 'n bekende volwassene is gemaak. η kategoriese sisteem is ontwerp vir die beoordeling van die kinders se interaksiegedrag. bevindings dui daarop dat onmiddellikeeggolalie meer is as slegs die vtelslose herhaling van woorde. die uitinge is meestal relevant en dui op die oordrag van betekenisvolle informasie en die behoud van sotiale interaksie. gevolgtrekkings word gemaak oor die fasilitasie van kommunikasie deur die modifikasie en uitbreiding van onmiddellike eggolalie. of the language abnormalities which are quoted as primary criteria in the diagnosis of autism, immediate echolalia is the most frequently cited characteristic of autistic children who have some verbal expressive ability (prizant & duchan, 1982). echolalia is generally defined, by many authors (fay, 1980; hurtig et al., 1982; wing, 1976) as the meaningless and automatic production of words, without understanding, that are an exact or partial copy of those originally spoken by another person. i there is a certain controversy surrounding the significance of immediate echolalia for the autistic child. behaviourally orientated researches consider echolalia as an undesirable symptom of the language behaviour of autistic children (koegal et al., 1974). they consider echolalia as a communication disorder in itself and therefore advocate its extinction or replacement through the use of behaviour modification procedures (lovaas, 1977). i a recent trend in research has been to consider immediate echolalia in terms of how it may function for autistic children (prizant & duchan, 1982). fay (1973), suggests that immediate echolalia enables the autistic child to maintain social interaction in the face of a severe comprehension problem. philips & dyer (1977), hypothesize that immediate echolalia is a late onset form of normal imitative functioning in young children and that with the appropriate intervention programme, the echolalia becomes useful to the child and gives him access to an experience with the complexities of grammar. considering the diversity of views held in relation to immediate echolalia and how it may function for autistic children, it is of contention that these children, who have a severe language problem are attempting to communicate and interact socially with other people to the best of their limited capabilities. during the past few years (schuler, 1980) much work has been carried out on the pragmatic die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 aspects of language. emphasis has shifted away from a purely structural view toward a more functional approach. prizant & duchan (1982) analyzed immediate echoic utterances according to gaze behaviour and other non-verbal components such as general body orientation and manipulation of objects. seven distinct categories of echolalia were derived and a function was attributed to each structural category, namely: non-focussed; turn-taking; declarative; rehearsal; self-regulatory; yes-answer; and request function. however, a functional approach does have certain limitations in that it requires an interpretation of the autistic child's communication intent in a particular situation. contextual cues (e.g. the reaction of the listener) are frequently used as indicators of the function of a particular verbalization (dore, 1978). one is often inclined to interpret verbalizations according to one's own perspective. schuler (1980) emphasizes, that in judging the relevance of verbalizations one should guard against over-interpretation. these overinterpretations become even more tempting when observed speech behaviours resemble our own speech. consideration of the conflicting views of researchers in relation to the function of immediate echolalia for the autistic child and the limitations of a functional approach has led to this research. the main focus of this study is to determine whether immediate echolalia can function within a communication system. echoic and non-echoic utterances are viewed within a framework where the initiation of utterances, turn-taking, and the segmental features of the utterances are considered to determine the relevance of the autistic child's utterances; analyzing the echoic and non-echoic behaviour in natural communicative interactions considering situational factors and nonverbal behaviours co-occurring with the production of echoic utterances. © sasha 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 ingrid van zyl, ema alant and isabel uys method aims to determine whether the verba, utterances, in particular the immediate echoic responses of autistic children have communicative relevance as described by prizant and duchan (1982). to construct a categorical system whereby interactive behaviour and immediate echolalic responses of autistic children can be analyzed as relevant or irrelevant in communication. subjects a preliminary study was carried out by the examiner to select suitable subjects and to clarify the procedural aspects of the experiment. the 4 subjects who participated in the experiment were selected from the unica school for autistic children in pretoria. each subject had to be diagnosed as autistic by a professional evaluation team comprising two psychiatrists; a clinical psychologist; a speech clinician; the principal of the unica school and one teacher. the department of national education (1971) requires that each child admitted to the unica school must fulfil the four essential criteria of the autistic syndrome (rutter, 1974): — onset of the disorder prior to thirty months of age; — disturbances of language and communication; — persistent, ritualistic and compulsive behaviour; — disturbed social relationship each child must also display a minimum of seven of the 14 core symptoms noted by clancy et al. (1964) which are most persistently present in the syndrome of infantile autism and are regarded as the major manifestations of the disease. to qualify for participation in the experiment, each child had to demonstrate that at least 25 % of all verbal productions were echoic responses (prizant and duchan, 1982). study was on functional communication rather than the relationship between this and cognition. procedure during interaction with the children it was noted that they did not make contact with the examiner. therefore the resident speech clinician participated as the interlocutor in the experiment. the structured activities designed to elicit verbal responses from the children during the interaction with the interlocutor, were selected according to a preliminary study. the same activities were used for all four subjects. although this may seem inappropriate due to the wide age and mental status range, these activities were recommended by the resident speech clinician and the children's teachers, since eating and drinking activities are enjoyed by children of all ages. data collection was extended over a three day period for each child with a one day interval. each child was videotaped in interaction with the interlocutor on two occasions, each 30 minutes in length, to ensure that a reliable sample of the child's communicative abilities was obtained. the situation involved direct interaction between the interlocutor and the child. during the interaction the interlocutor was directed to interact/communicate with each child as naturally as possible and to indirectly encourage the child to communicate by eliciting the child's interest in the activities provided. analysis: categorical system a preliminary study indicated that the categorical system described by prizant & duchan (1982) was highly complex and subjective in the interpretation of the function of immediate echolalia. therefore the examiner constructed a categorical system for the purpose of analyzing the relevance and irrelevance of the children's utterances, including their echolalic responses based on interpretation table 1 criteria for subject selection criterion subject 1 subject 2 subject 3 subject 4 mental status griffiths mental development scales 24 months non-testable 29 months 36 months age 5:8 8:3 8:5 11:1 previous therapy none * — auditory perception receptive and expressive language stimulation * — auditory perception receptive and expressive language expansion none language afrikaans afrikaans afrikaans afrikaans * during speech therapy echoic utterances were accepted but not encouraged by the speech clinician. .table 1 presents a number of the criteria used during subject selection. the age of the subjects was not deemed a significant factor since the study was focussed on the relevance of the interactive behaviour and particularly, immediate echolalia, and not on the performance of a specific age group. although reference is made to the mental status of each subject, this too was not considered a significant factor. the focus of the of behavioural aspects co-occurring with the children's utterances (see table 2). x due to the complex nature of the categorization procedures, data analysis was restricted to 20 utterances in each interaction. the first 20 utterances of each interlocutor — child interaction were selected since the children displayed excellent co-operation and attention at the beginning of each interaction. the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) immediate echolalia and the interactive behaviour of autistic children table 2 categorical system for analyzing the relevance of utterances 27 1 initiation:a spontaneous, original utterance created by the child and not an echoic response. 2. delayed echolalia: a repetition of stored utterances which the child has heard some time before, in a new and usually inappropriate context (fay, 1980). 3. turn-taking: smooth interchanges between the child and the interlocutor (prutting, 1982); each utterance in this category is also coded according to whether the turn was:verbal: indicating that the utterance is not accompanied by any non-verbal behaviour. verbal and non-verbal: indicating that the child's verbal response is accompanied by one or more of the following non-verbal behaviours: — eye contact with the interlocutor — gaze behaviour at the object, — head movements, — smiling, and — deliberate gestural actions; 4. relevance: the child's utterance is either designated as a self-directed or as an other-directed response; self-directed: a self-directed utterance is used by the child to monitor his action, or to focus control on his actions or used for planning what he will do next (tough, 1977). other-directed: an other-directed utterance is directed at the interlocutor by the child for demonstrating the actions he requests, instructing, forward planning, and anticipating collaborative action (tough, 1977). the relevance of the utterance is coded by a positive or a negative rating. a positive rating indicates that the child's utterance displays communicative intent. indicators of communicative intent: any of the following behaviour associated with the verbal response: eye contact with the interlocutor. according to argyle (1973), eyes provide crucial information about where the person is looking, and the area around the eyes is extremely expressive. one looks to obtain information and to send signals; this is all concerned with the flow of information needed to perform the social skills of interacting. appropriate gaze behaviour at the object. direction of gaze shows the direction of that person's attention (argyle, 1973). deliberate and voluntary actions. hand movements especially, play a role in social interaction. their principle function is as illustrators accompanying speech, and augmenting it when verbal skills are inadequate (argyle, 1973). the echoic response is functionally relevant to the task, or to the child's self-directed utterance, or to the interlocutor's utterance indicating communicative intent. a negative rating indicates that the child's response is irrelevant and a purely meaningless repetition; devoid of any indication of communicative intent. 5. linguistic segmental features: the utterance is rated according to whether the child changes or exactly repeats the linguistic segmental features of the model utterance. „ • ' changed: the child uses some of the interlocutor's words or either adds, deletes, or substitutes elements and is therefore not an exact repetition of the model utterance (prizant and duchan, 1982). same: the child gives an exact, complete or partial repetition of the interlocutor's model utterance. 6 non-segmental features: the non-segmental features of "the child's echoic response are rated according to the similarity in intonatioh, stress, speaking rate, duration, and voice to the model utterance. linguists recognize that timing, pitch and stress and other non-segmentals are integral to the meaning of utterances. changed: the child varies one or more of the non-segmental features of the model utterance. same: the child produces an exact repetition of the non-segmental features of the model utterance. in each subcategory, changed or the same, the echoic response is coded as being either a complete or an incomplete repetition:a complete repetition indicates that the child repeats the entire model utterance, an incomplete repetition indicates that the child echoes only a part of the model utterance. raters used to control observation the utterances were analyzed independently by the examiner and the resident speech clinician to objectify observations. after being trained on the significant features of the categorical system, the resident speech clinician viewed the first video-recording of interaction with each child. the interjudge reliability was measured by comparison of the results obtained by the examiner and the resident speech clinician. non-parametric statistical procedures were used due to the small number of subjects used in the experiment. results interjudge reliability non-parametric statistical procedures determined that a high agreement (97,34%) existed between the paired judgements of the examiner and the second judge, indicating that the categorical system designed by the examiner was a practical and easy to use scale. the reliability of this analysis procedure therefore seems to be high. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 ingrid van zyl, erna alant and isabel y s categorization of the utterances figure 1 represents a summary of the data obtained from the categorization of the autistic children's echoic and non-echoic utterances. it demonstrates a tendency for a greater occurrence of immediate echolalia (61,2%), followed by initiation (36,9%) and only a token usage of delayed echolalia (1,9%). there is a marked difference between verbal versus verbal and non-verbal turn-taking; verbal and non-verbal turns being the most prevalent (81,9%). it can be seen that other-directed utterances had a higher rate of occurrence (85%) than self-directed utterances (15%), but for both these categories most utterances were rated as relevant. it is interesting to note that 87,5% of the other-directed utterances were rated as relevant whereas only 66,7% of the self-directed utterances were relevant; suggesting (tentatively) that other-directed utterances are more likely to be rated as relevant than are self-directed utterances. e s 1 ζ 100 90 80 70 60 50 40 30 20 10 utterances turn-taking re1.evance j m 1 immediate initiation delayed verbal verbal & echolalia echolalia non-vertial 100 g 90 υ 8 80 2 ε £ 8 70 3 u 60 oc ο 60 8 1 50 η 2 ε η • β 40 •g υ ε £ ε 30 do 2 υ ο 20 i 3 10 £ linguistic segmental features non-segmental features changed same changed incomplete complete incomplete complete figure 1 categorization in percentages of the autistic subjects' echoic and non-echoic utterances. the data shows that the linguistic segmental features of the immediate echolalic utterances were mostly rated as the same (83,8%), rather than as changed (16,2%). the non-segmental features of the immediate echolalia were more often rated as changed with only an incomplete repetition of the model utterance (75%). the incidence of the use of the same non-segmental features with a complete repetition of the model utterance was minimal (3,5%). the data presented in figure 1 initiated the calculation of the infor'mation in figure 2. the relevance of the children's utterances is reviewed including a more specific analysis of the relevance of the immediate echolalia. echoic and non-echoic utterances viewed together had a higher incidence of being rated as relevant (84,4%) in comparison to only 15,6% of these utterances being rated as irrelevant. a more specific analysis of the immediate echolalia showed a large difference berelevanee of the utterances % relative to the total no of utterances relevance of the immediate echolalia % relative to total no of immediate echoic utterances subject 1 \z/a relevant i | irrelevant subject 2 subject 3 subject 4 figure 2 analysis of the relevance of the utterances tween the ratings of relevance and of irrelevance. of the immediate echolalia, 82,6% was relevant whereas only 17,5% was rated as irrelevant. specific analysis of each individual subject's performance was carried out and summarized into a single table (table 3) indicating jeach subject's performance as a percentage relative to the total number of utterances. a brief comparison of the subjects' performances according to the data in table 3 indicates that subject 4 has the highest initiation of original utterances (55%), followed by 40% immediate echolalia and only 5% delayed echolalia. of these utterances, 95% were rated as relevant and 100% of the immediate echolalia was rated as relevant. it is interesting to note that subject 4 had the highest mental status for all four subjects (36 months) and was the oldest subject. subject 2's performance shows very little initiation (17,5%), no delayed echolalia and a high incidence of immediate echolalia. subject 2 was, at the time of the study non-testable and mental status could not be determined. subject 1 and 3 display the same general tendencies of more initiation than delayed echolalia and the majority of utterances being immediate echolalia (55% and 67,5% respectively). they also show a high rate of relevant utterances and relevant immediate echolalia. the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) immediate echolalia and the interactive behaviour of autistic children t&ble 3 performance of subjects on each category 29 4. initiation delayed echolalia turn-taking 3.1 verbal 3.2 verbal and non-verbal relevance 4.1 self-directed 4.2 other-directed + + linguistic segmental features 5.1 changed 5.2 same non-segmental features 6.1 changed — complete — incomplete 6.2 same — complete — incomplete immediate echolalia rating % relative to the total number of utterances subject 1 the range of the four subjects' performances indicates interesting tendencies as well as variance among their performances. in the category of initiation, subject 2 scored 17,5% whereas subject 4 scored 55%, pointing out that a large variance exists in the intersubject performance. this could1 possibly be related to the variance between these subjects' mental ages. the average of the 4 subjects' performances in initiation (36,9%) is therefore not indicative of the individual scores. a broader inspection of subject 2's and subject 4's overall performance shows that subject 2 has 82,5% immediate echolalia compared to subject 4's:40% rating; a difference of 42,5%. however, in the case of relevance both these subjects (2 and 4) have the highest percentage of utterances rated as relevant, that is 90% and 95% respectively. therefore the apparent difference in performance in production of the type of utterance does not necessarily affect the rating of relevance of the subjects' utterances. a relatively small range of performance exists between the four subjects' production of delayed echolalia, the highest score being 5% (subject 4) and the lowest rating 0% (subjects 2 and 3). the category of turn-taking indicates a wider range of performance among the subjects. subject 1 has 42,5% verbal turns compared to 57,5% verbal and non-verbal turns. the remaining subjects show a much greater difference between these two sub-categories with a higher incidence of verbal and non-verbal turns. for example, subject 2 has 2,5% verbal turns compared to 97,5% verbal and non-verbal turns. the data supports a general tendency of a greater percentage occurrence of verbal and non-verbal turns. in the category of relevance there is a small range between the subjects' performances indicating a general tendency for a greater prevadie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 42,5 2,5 42,5 57,5 7,5 2,5 70,0 20,0 subject 2 17,5 0 2,5 97,5 5,0 5,0 85,0 5,0 subject 3 32,5 0 7,5 92,5 20,0 10,0 55,0 15,0 subject 4 55,0 5,0 20,0 80,0 7,5 2,5 87,5 2,5 % relative to the individual total no of immediate echoic utterances 22,7 77,3 13,5 77,3 4,6 4,6 55,0 0 100,0 15.2 48,4 6,1 30.3 82,5 29,6 70,4 7,4 74,1 3,7 14,8 67,5 12,5 87,5 0 100,0 0 0 40,0 lence of other-directed utterances (85%) and the large majority of both self-directed and other-directed utterances being rated as relevant (84,4%). there is a degree of variance between the subjects' performances in the category of linguistic segmental features. subject 2 produced all his immediate echolalia with the same linguistic segmental features of the model utterances. subject 3 produced the greatest change in the linguistic segmental features (29,6%) of the model utterances. there is however a general tendency for the four subjects to display the same linguistic segmental features of the model utterance. characteristic for all the subjects is the general tendency for nonsegmental features of the immediate echoic utterances to be more often changed and incomplete repetitions of the model utterance. the percentage production of immediate echolalia differs among the subjects. subject 2 produced the most immediate echolalia (82,5%) whereas subject 4 produced the least immediate echolalia (40%), but both subjects have the highest ratings of relevance, that is 84,9% and 100% of their immediate echolalia was rated relevant respectively. subject 1 who produced the most verbal (only) turns (42,5%) produced the least relevant immediate echolalia (68,2%). however comparison of the individual subject's relevant and irrelevant immediate echolalia indicates a general tendency of a greater percentage occurrence of relevant immediate echolalia. discussion the general attitude toward autistic immediate echolalia is to view it as an automatic and meaningless repetition of words, and not as r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 ingrid van zyl, erna alant and isabel ljys the child's attempt to initiate and sustain social contact (fay, 1980) or to communicate his intentions. the high occurrence of immediate echolalia is coupled with the finding that 85% of these echoic responses were rated as relevant, meaningful and an attempt at communication within their limited capabilities. in response to, "gaan jy nou saamwerk?" subject 4 replied "saamwerk", while smiling and making rare eye contact with the interlocutor. subject 4 changed the non-segmental features of the model utterance and made a statement of the word he echoed and did not copy the questioning tones of the model utterance. he clearly displayed his intention to the interlocutor through the manipulation of an immediate echoic response accompanied by non-verbal cues of eye-contact and smiling. in the interaction analyzed by the examiner, the children always responded to a question or a statement directed at them by the interlocutor. acceptance and expansion of echoic behaviour appeared to reinforce the autistic child's turn-taking echoes and utterances. important non-verbal communication co-occurred with the otherdirected utterances providing indicators of intent whereby the utterances could be rated. these responses can be interpreted in terms of attention, need for interpersonal feedback and an attempt at sustaining the flow of interaction (argyle, 1973). a comparison of the individual subjects' performance shows some interesting differences. a brief comparison shows subject 4, the oldest subject producing the most initiation, less immediate echolalia and no delayed echolalia; whereas subject 2 displayed the least initiation, no delayed echolalia and the most immediate echolalia. this suggests that subject 4 has more advanced language skills as shown by his ability to produce more initiated utterances and fewer echoic responses supporting the view of carr, schreibman and lovaas (1975) that immediate echolalia may be an early stage in the development of normal language functioning. of great importance is the fact that a very small difference existed between these two subjects in relation to the relevance of their echoic and non-echoic utterances; subject 2 displayed 90,0% relevance and subject 4, 95,0% relevance. this suggests that the relevance of the autistic child's echoic and non-echoic utterances is not necessarily dependent on the child's level of speech and language development. subject 3 produced the greatest change in the linguistic segmental features of the model utterance, using some of the interlocutor's words and adding elements to indicate his own meaning. prizant and duchan (1982) view this type of immediate echolalia as probably the most intentional and least automatic response and an example of intentional mitigation. subject 3's performance may be influenced by the fact that he received speech therapy to expand receptive and expressive language and had a mental status of 29 months. the examiner recognizes that analysis of the child's utterances alone is a limitation of the study. analysis of the interlocutor's utterances would provide interesting and relevant information related to the type of response made by the child. however, a brief survey of the interlocutor's utterances shows that when the interlocutor repeated a child's relevant immediate echoic response and the child echoed the interlocutor, the child's second echo was more likely to be rated "as irrelevant. this suggests that the speech clinician should take care not to inhibit the child's relevant utterances by producing meaningless repetitions of the child's echoes. implications for diagnosis and treatment the findings of this study should be regarded within the greater framework of diagnosis and treatment of the autistic child. as previously cited, behaviourally orientated researchers (koegal, lovaas and schreibman, 1974) consider echolalia a communication disorder and advocate the extinction or replacement of echolalic behaviours through the use of behaviour modification procedures (lovaas, 1977) the findings of this study dispute a non-functional view of immediate echolalia. the consideration of immediate echolalia as having communicative intent must form an integral part of diagnosis and therapy. the clinician should guard against regarding a high occurrence of echoic utterances in the child as indicating less meaning than a higher occurrence of non-echoic utterances, but should rather view echolalia as possibly a necessary stage of language development for verbal autistic children (philips and dyer, 1977). according to prizant & duchan (1982), indiscriminate extinction of all forms of immediate echolalia is ill-advised because of the functions that echolalia may serve for autistic children. individual differences do exist and each child has a certain potential to learn to communicate. different therapeutic procedures should be used to treat, for example, a child who has been predominantly echolalic for some years than those used to treat a child who displays comprehension and communicative intent with the echoic utterances he produces. the latter child needs to accept and exploit immediate echolalia and learn to relate the repetitions to aspects of the environment and communicative interactions (prizant & duchan, 1982). references argyle, m. the psychology of interpersonal behaviour. penguin books ltd, harmondsworth, great britain, 1973. argyle, m. social interaction. tavistock publications ltd, london, great britain, 1973. carr, e., et al. control of echolalic speech in psychotic speech. j. abnor. child psycho., 3, 331-338, 1975. clancy, h., et al. the diagnosis of infantile austism. develop. med. child neuro., 11, 432, 1969. de c. murray, c.h., a report of the committee of enquiry into the treatment, education and care of autistic children. department of national education, government print, pretoria, rsa, r.p. 26/72, 1971. dore, j. requestive, systematic nursery school conversation. in: campbell, r. and smith, r., (eds.), recent advances in the psychology of language. plenum press, new york, 1978. fay, w.h. on the echolalia of the blind and of the autistic child. j. speech hear. disord., 38, 478-489, 1973. i fay, w.h. aspects of language. in: fay, w.h. and schuler, a.l., (eds.) emerging language in autistic children. language intervention series, vol 5, edward arnold ltd, london, great britain, 1980. hurtig, r., ensrud, p, and tomelin, b. the communicative function of question production in autistic children. j. autism develop. disord., 12, 57-69, 1982. koegal, r., lovaas, o.i. and schreibman, l. a behaviour modification approach to the treatment of autistic children. j. autism child. schizoprenia. 4, 111-116, 1974. lovaas, o. the autistic child: language development through behaviour modification. halstead press, new york·;' 1977. philips, g. and dyer, c. late onset echolalia in autism and allied disorders. br. j. disord. commun., 12, 47-59, 1977. prizant, b.m. and duchan, j.f. the functions of immediate echolalia in austistic children. j. speech-hear. disord., 47, 241-249, 1982. prutting, c.a. pragmatics as social competence. j. speech hear. disord., al, 123-134, 1982. the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) therapy programme with spastic dysphonia a single case study 31 rutter, m. the development of infantile autism. j. psychol. med. 9, 147-163, 1974. schuler, a.l. aspects of communication. in: fay, w.h. and schuler, a.l., emerging language in autistic children. language intervention series, 5, edward arnold ltd, london, great britain, 1980. tough, j. the development of meaning: a study of children's use of language. george allen and unwin ltd, london, great britain, 1977. wing, l. early childhood autism: clinical, educational and social aspects. a wheaten and co., exeter, great britain, 1976. a stuttering therapy programme with spastic dysphonia a single case study ingrid meyers ba (sp & η th) (witwatersrand) speech therapy department baragwanath hospital denise anderson ba (sp & η th) (witwatersrand) department of speech pathology and audiology, university of the witwatersrand, johannesburg abstract this study was motivated by reported similarities in vocal tract dynamics in stuttering and spastic dysphonia. the effects of a stuttering therapy programme with an adult with spastic dysphonia were observed. subjective and objective measures obtained preand posttherapeutically included a qualitative analysis, laryngographic tracings, and fiberoptic examinations. results showed subtle improvements on all measures suggesting improved laryngeal behaviours. findings are discussed in relation to therapeutic utility. opsomming die motivering vir hierdie ondersoek is gebasseer op die ooreenkomste t.o.v. die dinamiek van die vokale gang tydens hakkel en spastiese disfonie dieuitwerkingvan 'nterapieprogram vir hakkel wat uitgevoer is op 'n pasient met spastiese disfonie, is waargeneem. subjektiewe en objektiewe metings is vooren na-terapeuties van laringografiese afdrukke, fiberoptiese ondersoeke en van 'n kwalitatiewe anahse verkry. resultate dui op 'n subtiele verbetering op alle metings, wat verbeterde laringale werking aandui. die bevindinge word bespreek t. o. v. kliniese bruikbaarheid. of all the human voice disorders, the syndrome of adductor spastic dysphonia has remained the most mysterious, the most poorly understood, and the most resistant to effective treatment, (boone 1972; aronson 1980; reich and till 1983). spastic dysphonia is a rare disorder and literature on the subject is limited, which has led to some confusion with regard to treatment (wolk, 1980). yet most authorities agree on its poor response to therapy procedures. the disorder, first described by traube in 1871 is characterized by "a strained, creaking, choked vocal attack and a tense squeezed voice accompanied by extreme tension of the entire phonatory system." (luchsinger and arnold 1965). various terms have been used to describe the disorder of spastic dysphonia. it has been referred to as 'glottal spasms', 'stammering of the vocal cords' and 'laryngeal stuttering', and has been parallelled to the disorder of stuttering by mccall (1975) and salamy and sessions (1980). stuttering is a more common disorder, and the age of onset and sex distribution are well defined. the two disorders can, however be likened in terms of their variability, development and course, etiological controversy and history of therapeutic failure with high rates of symptom relapse (ingham and andrews 1973; aronson 1980; salamy and sessions 1980). perhaps the abnormality in the physiology of the larynx for stuttering and spastic dysphonia could be considered a major similarity. mccall (1975) found that similarities between spastic dysphonia and the stuttering block included muscle spasms, disturbed muscle tone and involuntary movements e.g. tremor, with normal laryngeal structures evident on laryngologic examination. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 the past decade has brought about a dramatic transition in the theoretical foundation and purpose in the treatment of stuttering. based on the factors which induce fluency in stutterers, remediation has shifted to manipulation of phonation utilizing behaviour modification techniques as a vehicle for establishing fluency (shames and florance 1980). common to all 'fluency-based' programmes are smooth initiation of phonation, decreased rate and continuous phonation and breath flow which facilitates co-ordination of the vocal folds concurrent with the execution of articulatory gestures (miller 1982). schwartz (1976) felt that it was the reduction in stress on the cords which facilitated their laxing and lengthening and enabled their greater bulk to vibrate. the literature on spastic dysphonia does not reflect the same advances regarding treatment approaches. while some authorities have described similar techniques to those constituting 'fluency-based' programmes, no-one has as yet integrated these techniques into a unified therapy programme. in view of the limited investigations into the field of spastic dysphonia, and of the need to explore new avenues for treatment, the writers decided to investigate the effects of a fluency-based programme (developed for stutterers) by shames and florance (1980) on a subject with spastic dysphonia. method subject the subject, s, was an english speaking adult male, aged 34 years whose profession involved much public speaking. his voice problem © sasha 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) an investigation of non-standard english syntax in 12-year old c o l o u r e d children karen c. malan ( b . s c . logopaedics, u . c . t . ) tygerberg hospital, cape town summary non-standard english (nse) syntactic constructions occurring in the natural spdech, behaviour of a group of 20 12-year old coloured children were identified and analysed. three syntactic classes were isolated as having contained nse constructions used significantly by the group: auxiliary/copula verb forms, number-verb agreement and tense. a bi-dialectal sentence repetition task was then adminstered to the same group and to a matched group of white children, in which the two groups were compared on their ability to reproduce sentences containing (1) nse constructions used significantly by the coloured group, and (2) the standard english (se) forms of these constructions. results indicated that while coloured ss were able to reproduce many of the se constructions, their overall performance on these items was significantly inferior to that of white ss. conversely, their repetition of nse items was significantly superior to that of white ss. the implications of these findings for the clinical language assessment of coloured children were discussed. opsomming die voorkoms van nie-standaard engelse (nse) sintaktiese konstruksies in die natuurlike spraakgedrag van 'n groep van 20 twaalfjarige kleurlingkinders is gei'dentifiseer en geanaliseer. drie sintaktiese kategoriee bevattende nse konstruksies wat betekenisvol deur die groep gebruik is, is gei'soleer: hulpwerkwoord/kopula werkwoordvorme, werkwoord-getal ooreenstemming en tydsvorme. 'n sinsherhalingtaak is vervolgens in twee dialekte aan dieselfde, sowel as 'n soortgelyke blanke groep kinders, gestel. die twee groepe is vergelyk t.o.v. hulle vermoe om sinne bevattende (1) nse konstruksies en (2) standaard engelse (se) vorme van bogenoemde konstruksies, te produseer. resultate het getoon dat terwyl die kleurling groep instaat was om se konstruksie te produseer, hulle algemene prestasie t.o.v. hierdie items, betekenisvol swakker was as di6 van die blanke groep. die kleurling groep se herhaling van nse items was egter betekenisvol beter, as die van die blanke groep. die implikasies van die bevindinge t.o.v. die kliniese taalevaluasie van kleurlingkinders word bespreek. recent sociolinguistic research into the language differences of children from economically disadvantaged and culturally-different sub-communities has necessitated a re-evaluation of current approaches to the assessment and diagnosis of language 'disorders in these children. while procedures for the identification and treatment of language deviance and delay are well described in the literature, there is evidence of increasing concern among speech and language professionals that these procedures may be inappropriate, or at least inadequate, where the child concerned is one from a dialectal sub-community whose language manifests certain phonological, lexical or syntactic differences from that of ' the standard language of the larger community1' 1 4 ' 1 5 the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) non-standard syntax of coloured children 69 two major factors have formed the basis for this concern. 1. firstly, there is a lack of documented information on the language norms prevailing in many linguistic sub-communities. without this knowledge, it is difficult to differentiate between socially induced language differences and true language pathology. 2. secondly, the commonly-used measures of linguistic behaviour are based on the norms of a "standard" language, and hence run the risk of indicating language deviance or delay in a child who may simply be using rules which conform to his own dialect. research in the field of sociolinguistics provides some indications as to how these shortcomings might be overcome. in particular, the notions of socio-cultural constraints on language use and "communicative competence"9 have implications for both the sampling of language data and assessment of the dialectally-different child. recent advances in the study of language as a social phenomenon have indicated that an adequate structural description of a speaker's language cannot be provided without consideration of the effects of socio-cultural factors on the speaker's language use. 6 ' 7 ' 9 ' 1 0 ' 1 6 these include such factors as the attitude of speakers toward their language varieties, the roles and status of speakers, the relative formality of the situation or topic of the message, all of which may have a systematic effect on a speaker's linguistic competence in that they will affect his choice of speech style or his use of one particular syntactic form over another. evidence of systematic variation in language use as a function of contingencies in the linguistic and social environment has led to the suggestion that it is part of a speaker's knowledge or competence of his language that he "knows" implicitly which linguistic rules to apply in which social contexts. this in turn has led to a reformulation of the traditional, chomskian notion of linguistic competence to a more broadly defined "communicative competence" which includes not only a speaker's knowledge of the rules of grammar, but also the ability or competence for the appropriate uses of language in different contexts.3· 9 · 1 0 the integral role of socio-cultural factors in language use afforded by this definition has important implications for the sampling of linguistic data from dialectally-different children. it makes clear that the type of speech behaviour obtained in sampling will vary greatly according to the setting and circumstances in which it is elicited. it means that in order to obtain reliable data concerning the natural speech behaviour of children, the language clinician must know a great deal about the contextual variables which govern speech production and control for them accordingly. the notion of competence for use of language has further implications for the use with dialectally different children of assessment tests based on elicted imitation (ei). more specifically, it has helped to explain the differences in performance found between children from different dialectal communities on these tasks. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 karen malan sentence repetition or ei tasks have been widely used by investigators of child language and speech clinicians alike as a means of determining the capacity in young children developing language, for comprehension and expression.8' 1 7 • 1 3 they are based on the premise that a child will correctly reproduce only those sentence structures which are a part of his linguistic competence: 1 7 where an item is beyond his level of competence, the child is said to filter the sentence he hears through his own productive system, to reproduce it using the rules he knows.5 sociolinguists who adopted ei tasks as a source of information on the language behaviours of non-standard english (nse) speakers, found evidence that a similar type of "rule-filtering" occurred with much older (adolescent) speakers of nse dialects.1 0' 1 3 l a b o v 1 0 and baratz,2 in separate studies, found that when adolescent black nse speakers in the united states were given standard english (se) sentences to repeat, the majority tended to re-encode the sentences into nse form in their responses. thus, for example, given the sentence "i asked alvin if he knows how to play basketball", the majority of speakers repeated it as "i asks alvin do he know how to play basketball". 1 0 in terms of hymes 9 notion of communicative competence, these speakers might be said to have hacf the tacit knowledge for the se rule, in that the meaning of the sentence was preserved in their responses, yet did not show the ability or competence for use of the se construction. furthermore, baratz's2 findings indicated that white english speakers were significantly superior to black speakers in repeating se sentences, while black speakers were far superior to whites in repeating nse constructions. it was concluded from these findings that the language assessment of nse-speaking children should include measures of their knowledge of nse in addition to their knowledge of se. however, current language tests based on the ei technique, including the carrow elicited language inventory5 and the northwestern syntax screening t e s t , 1 1 fail to account for the influence of dialectal differences on performance. they are based solely on se norms, and hence are liable to score grammatical complexity as being absent when in fact it may be present, but its dialect is not that of the test instrument.1 it was the contention of the present study that an effective approach to the language assessment of the dialectally-different child requires: 1. knowledge of the linguistic forms used in the dialect of the child's community, and v •*' 2. the availability of assessment tools which are sensitive to the dialectal variations present in the child's language. the need to meet these requirements was seen to be particularly relevant to the language assessment of children from the englishspeaking "coloured" community of cape t o w n 1 8 . that the speech of this group is characterized by certain phonological, lexical and grammatical differences is clearly apparent to the outside observer. yet the lack of documented information on its linguistic forms1 4 make ! the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) non-standard syntax of coloured children 71 it unclear as to whether there can be said to be a distinct pattern of the language spoken in this community, while at the same time, our measures of language proficiency are based on the norms of a white, middle-class, "standard" english speaking population, and hence of questionable validity to this group. this study attempted a partial fulfillment of these needs, by investigating the presence of nse syntactical constructions in, the language of coloured children, and the implications of these for the use with the coloured child of one type of assessment tool — viz. test based' on elicited imitation. m e t h o d a i m s 1. the elicitation and analysis of samples of natural speech behaviour from a group of 12 year old english-speaking coloured children, to identify the significant presence and/or trends of nse language patterns. 2. administration of a bi-dialectal sentence repetition task to the same group of coloured children and a matched group of white children, in which the two groups are compared on their ability to reproduce sentences containing: (a) nse syntactic constructions used significantly by the coloured group, and (b) the se forms of these constructions.s u b j e c t s part i: ss comprised a group of 20 coloured school-children, of which 10 were boys and 10 girls. ages ranged from 12.0 to 13.0 years. all ss came from english-speaking homes and attended english-medium classes at their schools. all were from low socio-economic status families, as determined by parental occupation. all were judged by their teachers to possess average intelligence and normal speech, hearing and language abilities. ss were representative of 2 broad areas of the cape peninsula. part ii: a matched group of 20 english-speaking white schoolchildren, judged to be representative of white south african sespeaking children, was added to the experimental population. these were matched to the first group by applying the same criteria with regard to age, sex, home-language, intelligence and speech, hearing and language abilities. parental occupations fell within the range of the middle socio-economic group. p r o c e d u r e part i: language samples were obtained from each of the 20 coloured ss in recorded sessions, in which ss were interviewed by a coloured die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 karen malan experimenter (e). language was elicited in 3 stimulus situations: 1. unstructured conversation with the e. 2. responses to a set of questions related to 5 stimulus photographs. to ensure consistency in the method of eliciting language and to ensure a minimum number of utterances from each s, five directions were supplied for each of the 5 enlarged photographs. these were constructed (after l e o n a r d 1 2 ) so as to elicit present, future, past and future conditional tenses. 3. conversation with the ε on 4 topics, each generated by a prescribed set of questions. each session was recorded onto tape by the writer. language samples from each child were transcribed for the purpose of isolating nse constructions used by each s. these were then categorized according to grammatical class for examination of possible trends of nse usage. a manipulation of the chi-square formula was used to determine which nse constructions were used significantly by the group as a whole. these comprised the "critical constructions" to be used in part ii of the study. part ii: for each of the 'critical' nse constructions, a nse sentence containing that construction was devised, as well as a corresponding se sentence containing the standard form of the construction. these sentences, randomized for presentation, formed the basis of the sentence repetition,'task administered approximately 2 weeks later to the same group of '''coloured" ss as well as the control group of white ss. the task was administered to the coloured group by the same coloured ε used in part i, while the writer served as ε for the white group. ss were seen individually by the es. responses were recorded in writing immediately, as well as tape recorded, to ensure accuracy. repetitions were scored in two categories according to whether the critical construction of a sentence was "repeated verbatim" by the s or "altered to opposite dialect". chi-square analyses were used to determine for each group, which se and nse sentences were "repeated verbatim" by a significant number of ss in the group, and which were "altered to opposite dialect". also, chi-square analyses were used to compare the responses of the two groups to se and nse sentences. t-tests for independent samples were used to determine whether a significant difference existed between the two groups in the total number of verbatim repetitions of (1) se and (2) nse sentences. / • /' i results and discussion i part i using the chi-square formula to (determine the frequency of occurrence of nse constructions which would be necessary to yield a significant chi-square value, it was determined that above 14 (p < the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) non-standard syntax of coloured children 73 0.05), nse constructions were used by a significant number of ss. the 7 constructions which fell above this point were: (1) absence of the auxiliary " a r e " . (2) absence of copula " a r e " . (3) absence of auxiliary "have". (4) absence of 3rd person singular present tense marker (-s) (5) absence of regular past marker (-ed). (6) simple present replacing future conditional tense. (7) simple future replacing future conditional tense. these constructions were grouped together with the remaining nse constructions in context of the syntactic class to which they belonged. a total of 9 syntactic classes were found to contain nse constructions; for purposes of the present article, however, only those classes containing nse forms used significantly by the group (the "critical constructions") are presented. auxiliary/copula verb forms. certain forms of 'be' and ' h a v e ' — " a r e , " "has" and "have" — were deleted in present tense constructions (see table i). a single tendency may underlie all of the items listed in table i, in that absence of auxiliary/copula forms occurred only for those forms of 'be' and ' h a v e ' which in se are contractible. the se contraction rule removes all but the final segments of these auxiliaries in present tense forms. it seems that coloured speakers may be applying the contraction rule, and then applying a further rule for deletion of the segments remaining after contraction. furthermore, deletion occurred most frequently in instances where the preceding subject was a pronoun. taken together, these factors suggest that where contraction is expected in se, coloured dialect may delete, and that the probability of deletion is greater when the subject is a pronoun. table i: non-standard auxiliary/copula verb forms in coloured children no. non-standard english construction example no. of ss i absence of forms "to be"· (1) + auxiliary "are" in present progressive forms (are + -ing) (2) + copula "are" in simple present (s-cop.-o) they fighting we five in the family 20 16 ii absence of forms "to have" (1) auxiliary have in present perfect " h a s " + past participle η—"have" + past participle she got a pencil in her hand i got two uncles 3 18 + indicates nse constructions used significantly by the group. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 74 karen malan number-verb agreement nse forms in this category are listed in table ii. these forms may all be indicative of a single tendency among ss to eliminate number distinction in verbs and demonstrative pronouns. this tendency appears to be a simplifying process, but may be directly related to the influence of afrikaans syntax: (1) there are no inflected verb-endings for the 3rd person singular in afrikaans; hence the same verb form is used for all persons. by eliminating 3rd person singular present tense markers, coloured english speakers achieve a similar simplicity of form. (2) ss use of english "is" and "was" regardless of number, reflects a similar pattern to afrikaans where there is only one present tense form of the verb "to be" ("is") and one past tense form ("was"). (3) the use of singular demonstratives with plural nouns may be similarly explained, since there is no plural form for demonstratives in afrikaans. table ii: non-standard number-verb agreement in coloured children no. non-standard english construction example no. of ss i absence of 3rd person singular present tense markers: (1) + /s/ suffix (2) "has" and "does" my mommy say she think . . . it just have to be like that 18 7 ii plural subject takes singular form of "be": (1) present tense (2) past tense (3) "there + be + plural np subject their clothes is dirty the cops was fighting there is leaves on the floor 8 2 13 iii plural noun takes singular demonstrative one of that stones 6 tense (1) present tense forms were used pervasively, and replaced several more complex tense constructions. in particular, the simple present replaced past, future land future conditional tenses. it seems that coloured english speakers tend to omit the morphological endings which mark the contracted forms of these tenses (-ed, '11, a n d ' d respectively). it should not be inferred from this tendency, however, that ss we're insensitive to past, future and conditional tenses, since instances were found in the speech of the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) non-standard syntax of coloured children 75 nearly every s where the full forms of these tenses were used. furthermore, where reduction to the present tense occurred, it may have been directly related to phonological environment: for example, formation of the regular past in se involves simply the addition to the verb base of /t/ or id/, both sounds which tend to be lost in certain kinds of word-final consonant clusters, whether part of a past tense formation or n o t . 1 6 (2) the simple future was frequently used in place of the future conditional tense — possibly indicative of a preference to use a more tangible form of the verb, rather than the abstract conditional construction. table iii: non-standard tense usage in coloured children no. non-standard english construction example no. of ss 1 simple present tense replaces: e: what did you do? 17 (1) + simple past e: what did you do? 17 (1) + simple past s: i clean our pigeonhok (2) + future conditional e: what would you like 16 (2) + future conditional to do when you grow up? s: i like to travel around the world (3) simple future e: what will happen 13 (3) simple future next? s: the people buy it from them 11 simple future replaces: + future conditional e: what would you do? s: i'll take my friend's part 19 numerous further nse constructions were found in the categories of negation, question forms, adverbials, adjectives, pronouns and prepositions. since none of these categories contained nse forms used by a statistically significant number of ss, they have been omitted from discussion for purposes of the present article. from the preceding discussion, it seems evident that the nse forms produced by coloured ss cannot be considered without reference to the structural linguistic and socio-cultural factors which may have entered into their realization. it was seen that many of the nse forms might be considered the result of grammatical "interference" from afrikaans, to which the ss under study can be assumed to have had considerable exposure, afrikaans being the dominant language of the coloured community. the possible influence of phonological environment on certain of the forms was also referred to. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 76 karen malan a third consideration was that certain nse forms might be seen as reductions to a simpler form. certain of the nse constructions coincide at least in superficial form to stages in the language development of children in a se community. this is true of the forms used by ss comprising morpheme omission — omissions which are also found, interestingly, in many american nse dialects. brown4, however, has stressed that it should not be concluded from this that these forms constitute "immature" versions of se. he proposes that many morphemes, by virtue of the fact that they are frequently redundant to the meaning of an utterance, may be especially vulnerable to deletion. he finds no evidence that the 'misconstructions' of certain dialects are simpler than the standard constructions, merely that they are different. finally, it was evident from the preceding linguistic analysis that the use of nse forms by ss was not categorical. thus, for nearly every nse construction used, instances could be found in which the se form of that construction was used. for this reason, the syntactical differences shown by coloured ss should not be taken to indicate the consistent presence or absence of certain features, but might rather be viewed as a matter of differences in relative usage. in this regard, it should be noted that certain of the nse forms outlined above may be detected in the colloquial speech of many white south african english speakers (a case in point being the omission of auxiliary/copula "are"). it seems probable that there are social constraints which govern the probability of occurrence of nse forms in white south african english as opposed to coloured english. it is likely that the prestige value attached by white speakers to the standard form of the language serves to constrain their use of non-standard variants except in their most casual, unmonitored speech. and equally likely that the more a coloured speaker strives towards the values of the highest status societal group, the more his language will tend towards the standard variety. these factors would make it doubtful as to whether a standard pattern of non-standard usage could be said to exist in the coloured community. the variability shown by ss in this study in their use of nse forms appears to support this view. it is suggested, therefore, that rather than forming a separate dialect with distinct nse forms, so-called coloured english might be seen as part of a spectrum of south african english, which has at its one extreme white, middle-class se, and at the other extreme the dialectal variations of the coloured lower-class. in this view, coloured english forms part of the same continuum as se, sharing the vast majority of its rules, yet containing certain extensions and modifications of these rules which may be variably applied depending on factors in the linguistic and social context. , part ii i results of statistical analyses on the sentence repetition task are the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) non-standard syntax of coloured children 77 discussed in relation to the following questions which this part of the study aimed to explore: would coloured ss reproduce sentences containing se constructions used irregularly by them? or would they produce sentences conforming to the nse syntactical patterns identified in part i? results of chi-square analyses indicated that coloured ss showed considerable facility at reproducing verbatim many of the se constructions. it seems likely that the relative formality of the testing situation in this part of the study, as well as the nature of the task itself, both of which were conducive to a more careful and monitored style of speech, may have served to favour application of the standard rule in this task for some ss. in spite of these constraints, however, some proportion of coloured ss showed a tendency to re-encode each of the se constructions into nse form in their responses — indicating that they had decoded the sentence, then re-encoded it in the form they might have used in formulating the sentence themselves. would the repetition of certain nse forms be restricted to coloured ss, or might white ss show a similar tendency to produce nse forms? results indicated that, in general, when given se sentences, white ss repeated them verbatim, and that when given nse sentences, they re-encoded the sentence in terms of their own se rules to produce it in se form. however, given the constructions "auxiliary ' a r e ' " and "copula ' a r e ' " , in either se or nse, white ss showed some tendency to apply the nse rules in their responses. although this tendency was not statistically significant in either case, it seems that the rules for auxiliary and copula deletion are not necessarily peculiar to the speech of coloured children, but may be a part of the white child's linguistic behaviour as well. would the ss in each group be consistent in their "translations" from the unfamiliar dialect? examination of responses by each s in the two groups to se and nse sentences indicated that ss from both groups were consistent in their responses, in that when they translated a given sentence to their own dialect, all applied the same se or nse rule in their responses. this result appears to provide evidence for the validity of nse forms as representing a structured, yet different set of rules. if the nse forms used by coloured ss were a matter of random, unordered variation, one would not have expected consistency among the nse responses. could one group be said to be significantly superior to the other at repeating (1) se and (2) nse sentences? results of t-tests used to compare the total number of verbatim repetitions by each group to each of the 2 sentence types revealed that coloured ss were significantly superior to whites at reproducing correctly nse items, and that white ss were significantly superior to coloured ss in reproducing se sentences. the main trends of the results of part ii may be summarized as follows. while coloured ss showed considerable facility at reproducing die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 78 karen malan se forms which they had used irregularly in their spontaneous speech, their overall performance on se items was significantly inferior to that of white children. this was due to the fact that for each se item, a proportion of coloured ss reformulated the item to produce the nse rule in their output. that these reformulations showed a consistent pattern across all ss appears to provide evidence of the structured, rule-governed nature of the nse forms. furthermore, the performance of coloured ss was significantly superior to that of white ss when given nse sentences to reproduce, while conversely, their performance on se items was significantly inferior to that of white ss. while these findings must be considered preliminary, the indication is that coloured children may perform interiorly to white children on ei tests which have se as their criterion of correctness. the results would appear to justify the inclusion in current ei tests of measures of the clinical coloured child's ability to reproduce nse syntactic forms in addition to se forms. if a coloured child suspected of having a language disorder failed to reproduce a se construction, yet correctly reproduced the nse form of this construction, and if his alterations were similar to those of his age-peers within his community, we might assume that he is not language delayed/deviant, but using a wellordered though different rule. conclusion the analysis of speech samples obtained from coloured ss revealed the presence of numerous nse syntactic forms in their natural speech behaviour of which those involving auxiliary/copula verb forms, number-verb agreement, and tense were predominant. examination of this data indicated that the use of nse forms was not consistent, but rather a matter of relative usage of certain features, the occurrence of which could not be considered without reference to both structural (linguistic and phonological) and social contextual determinants. the second stage of the study was concerned with the question of whether the nse forms identified in the speech of coloured ss might produce differential effects on their performance in ei tasks as compared with the performance of white children. .results of a bi-dialectal sentence repetition task administered to white and coloured ss indicated that the overall performance of coloured ss on se items was significantly inferior to that of white ss, while their performance on nse items was significantly superior to that of white ss. these findings led to a suggestion for the reformulation of currently used ei tests in the clinical situation, to include additional measures of the coloured child's ability to reproduce nse syntactical constructions. the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) non-standard syntax of coloured children 79 references 1. adler, s. (1979): poverty children and their language: implications for teaching and treating. new york: grune and stratton inc. 2. baratz, j. (1969): a bi-dialectal task for determining language proficiency in economically disadvantaged negro children. child development 40, 889-901. 3. bloom, l. & lahey, m. (1978): language development and language disorders. new york: wiley. 4. brown, r. (1973): a first language: the early stages. penguin books. 5. carrow, e. (1974): carrow elicited language inventory. austen, texas: learning concepts. 6 cazden, c. b. (1972): the situation: a neglected source of social class differences in language use. in j. b. pride and j. holmes (eds) sociolinguistics. penguin books. 7. cazden, c. b. (1972): child language and education. new york: holt, rinehart & winston, inc. 8. ervin, s. m. (1964): imitation and structural change in children's language. in ε. h. lenneberg (ed) new directions in the study of language. cambridge, mass.: m.i.t. press. 9 hymes, d. (1972): competence and performance in linguistic theory. in j. b. pride & j. holmes (eds) sociolinguistics. penguin books. 10 labov, w. (1972): language in the inner city: studies in the black english vernacular. philadelphia: university of pennsylvania press. 11. lee, l. (1969): northwestern syntax screening test. evanston: northwestern university press. 12. leonard, l. b. (1972): what is deviant language? journal of speech and hearing disorders 37(4), 427-446. 13. menyuk, p. (1971): the acquisition and development of language. englewood cliffs, n. j.: prentice-hall inc. 14. penn, c. (1978): speech pathology and audiology in south africa — past, present and future perspectives. in l. w. lanham and k. p. prinsloo (eds) language and communication studies in south africa. cape town: oxford university press. 15. severson, r. a. & guest, κ. e. (1970): toward the standardized assessment of the language of disadvantaged children. in f. williams (ed) language and poverty: perspectives on a theme. chicago: markham publishing co. 16. shuy, r. w. (1972): language problems of disadvantaged children. in j. w. irwin and m. marge (eds) principles of childhood language disabilities. englewood cliffs, n. j.: prentice-hall inc. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 80 karen malan 17. slobin, d. i. & welsh, c. a . (1973): elicited imitation as a research tool in developmental psycholinguistics. in c. a . ferguson and d. i. slobin (eds) studies of child language development. new york: holt, rinehart & winston inc. 18. whisson, m. g. (1971): the coloured people. abe bailey institute of international studies, university of cape town, rondebosch. the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 49 vokaalreels by dowes santie ε meyer department of speech pathology and audiology university of the witwatersrand opsomming alhoewel die bepaling van reelmatighede in spraakproduksie belangrik vir terapiebeplanning is, is dit nie altyd identifiseerbaar in die spraak van die dowe nie. die doel van die studie was om te bepaal of die normaalhorende luisteraar in staat is om die dowe se spraakreels te identifiseer. sewe dowes met 'n kongenitale, sensoriesneurale gehoorverlies het ses toetsvokale in woorde vyfkeer herhaal wat deur derdejaarstudente in oudiologie in 'n geslote-keuseformaat beoordeel is. twee luisteraars moes saamstem in 70% van die beoordelings dat 'n spesifieke vokaalgehoor is. uit die beoordelingsmatrikse blyk dit dat die luisteraars wel in staat was om konstanthede te identifiseer. die interluisteraarkorrelasies wissel van r=0.49 tot 0.89, wat impliseer dat die luisteraars nie altyd saamstem in hulle beoordelings van 'n spesifieke vokaal nie. die bevinding het implikasies vir die oudioloog in terme van spraakevalusie. abstract although the establishment of patterns in speech production is important for therapy planning they are not always identifiable in the speech of the deaf. in this study the object was to ascertain whether the normal hearing person was capable of identifying rules of speech. seven deaf speakers with a congenital, sensorineural hearing loss repeated six test words five times which were rated by third year audiology students in a closed set format. two listeners were required to agree in 70 % of the cases that a specific vowel was heard. the rating matrixes showed that the listeners were able to identify consistencies. the interlistener correlations varied from r=0.49 to 0.98, implying that the listeners did not always agree in their judgements regarding a specific vowel. in'terms of speech evaluation the findings pose implications for the audiologist. word. spraakreels ontwikkel waarskynlik by die gehoorgestremde (daar word hier spesifiek na die persoon met 'n binourale kongenitale ernstige tot totale sensoriesneurale gehoorverlies verwys) op dieselfde wyse as by die normaalhorende. die omgewingsleidrade wat deur die gehoorgestremde gebruik word, sal waarskynlik van die normaalhorende verskil in die sin dat visuele en slegs gedeeltelike ouditiewe inligting (meestal lae frekwensieinligting) beskikbaar en dus benutbaar is (boothroyd, 1978). daar kan verder verwag word dat die gehoorgestremde se reseptiewe leidraadsisteem uitgebrei en gemodifiseer sal word soos in die geval van die normaalhorende kind, afhangende van die gehoorgestremde se omgewing en sy vermoe om spraak uit die omgewing, te gebruik (fry, 1978). hy ontwikkel dus 'n sisteem wat as konstanthede of reelmatighede in sy spraak gei'dentifiseer kan word, ofte wel spraakreels. dit is egter 'n kontensieuse hipotese want daar is navorsers wat beweer dat daar nie sprake van 'n reelgebaseerde sisteem in die dowe se spraak is nie as gevolg van die hoe mate van variasie in produksie (harris et al., 1985). hierteenoor beweer ander outoriteite dat daar nie bewys kan word dat die uitings op 'n lukraak wyse en dus sonder enige plan, geskied nie (monsen, 1974; ten spyte van uitgebreide navorsing en verbetering in die spraakopleidingstegnologie word die spraak van die dowe steeds gekenmerk deur swak verstaanbaarheid (gold, 1980). nogtans wordjspraakverbetering by dowe kinders aangemoedig en look deur hul begeer om onafhanklike funksioneringj in die bree samelewing te vergemaklik (ling, 1976; manilal, 1992). voortgesette pogings tot beter begrip van die spraakproduksie van die dowe en dus meer effektiewe spraakevaluasie en -terapie bly 'n navorsings-prioriteit. afgesien van die swak spraakverstaanbaarheid, word die dowe se spraakpogings ook deur 'n hoe mate van produksie-onstabiliteit of intrapersoonsvariasie in herhaling van dieselfde uitings, gekenmerk (harris, rubin, spitz & mcgarr, 1985; metz, schiavetti, sitler & samar, 1990; osberger, 1987). desnieteenstaande is daar aanduidings dat sprekers konstante verskille tussen sekere uitings aanbring (monsen 1976). hierdie konstante verskille kan as spraakpatrone of spraakreels1 beskou spraakreels is die produksiereels waarvolgens spraakklanke op dieselfde, konstante wyse uitgespreek word en op 'n konstante wyse van ander spraakklanke verskil (verwerk uit grunwell, 1982). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 santie ε meyer monsen, 1976). die verskil in mening is nog nie besleg nie veral aangesien dit vir die spraakopleier2 so problematies is om hierdie spraakreels te identifiseer. die reelmatighede in die produksie van die dowe se spraak is soms deur die normaalhorende luisteraar identifiseerbaar maar in vele gevalle nie. selfs waar die dowe se spraakproduksie deur middel van die internasionle fonetiese alfabet (ifa) getranskribeer word, is die gevaar dat die spreker se komplekse reelsisteem vereenvoudig word deur die transkripsie (parker & rose, 1990). verder is die onakkurate segmente dikwels moeilik artikulatories spesifiseerbaar en dus moeilik verteenwoordigbaar met 'n ifa-simbool (abberton, hazan & fourcin, 1990). dit is dus moontlik dat die dowe reelmatighede in sy eie spraak gebruik wat nie deur die normaalhorende luisteraar identifiseerbaar is nie. die teenwoordigheid en die aard van spraakreels is egter vir die klinikus van groot belang met die oog op die ontwikkeling van rehabilitasiestrategie. terapie is tradisioneel nie dieselfde vir 'n persoon met 'n konstant foutiewe reel, die met variasie in produksie van dieselfde klank en die persoon met geen spraakklankreel nie. die prognose vir terapie sal ook verskillend wees in die geval van 'n individu met geen spraakreel nie en vir die persoon waar daar alreeds 'n foutiewe reel vasgele is (stoel-gammon & dunn, 1985). dit is derhalwe duidelik dat die identifikasie van die dowe se spraakreels, indien enige, belangrik is. tot op hierdie stadium is die probleem dat daar nie 'n klinies bruikbare metode is om die spraakreels te identifiseer nie. die studies wat die reelmatighede aangetoon het, het dit slegs vanuit 'n teoretiese oogpunt benader, instrumentele analises gebruik wat nie vir die klinikus beskikbaar is nie, byvoorbeeld elektromiografiese studies en nie gepoog het om die spraakreels van 'n individu aan te toon nie (byvoorbeeld monsen, 1976; huntington, harris & sholes, 1968). een van die redes is dat slegs enkele klanke ondersoek is en in die meeste gevalle is die studies net op die fonetiese vlak van spraakproduksie, met ander woorde in betekenislose eenhede, uitgevoer (metz, 1980; huntington et al., 1968). die gebruik van die spraakreels as 'n kommunikasiemedium, waar spraakklanke betekenisonderskeidend aangewend word (op die fonologiese vlak), word nie op die wyse ondersoek nie. 'n tradisionele fonologiese ontleding (byvoorbeeld grunwell, 1982) is onbevredigend aangesien die swak spraakverstaanbaarheid van die dowe spreker transkripsie van die spraak feitlik onmoontlik maak. 'n tradisionele "artikulasietoets" het verskeie probleme (ling, 1976) waarvan een is dat die onkonstantheid in die dowe se produksie nie in ag geneem word met die enkele ontlokking van 'n foneem in 'n spesifieke konteks nie. om die spraakreels dus te kan bepaal, moet die metode vir die spraakopleier uitvoerbaar wees en ook in staat wees om die konstanthede, indien teenwoordig in die spraakproduksie van die dowe, uit te lig. die studie het dus ten doel om te bepaal of daar reelmatighede in geselekteerde uitinge van die afrikaanssprekende dowe deur luisteraarsbeoordelings geidenti2 spraakopleier verwys na die persoon wat die spraakopleiding van die dowe doen. dit kan die oudioloog of die onderwyseres indie skool vir dowes wees. fiseer kan word. deur spesifieke spraakvoorbeelde van die dowes op 'n herhaalde wyse te ontlok en luisteraars die voorbeelde te laat beoordeel, kan bepaal word of die dowes foneme konstant produseer en of luisteraars ooreenstem ten opsigte van die foneme wat hulle hoor. metode proefpersone die twee groepe proefpersone, naamlik dowe sprekers en normaalhorende luisteraars word afsonderlik bespreek. dowe sprekers die proefpersone moes verteenwoordigend wees van dowes waar slegs 'n gehoorverlies voorkom het dat die omgewing se spraakreels spontaan aangeleer kon word. hulle moet dus geen ander probleme as slegs 'n ernstige (71-91db) en uitermatige (>91 db) kongenitale sensoriesneurale gehoorverlies openbaar nie en verby die aktiewe periode van spraaken taalaanleer wees (bess & mcconnell, 1981). seuns in standerd agt, nege en tien met ernstige en uitermatige kongenitale sensories-neurale gehoorverliese is in 'n afrikaanse skool vir dowes gei'dentifiseer. die seuns met 'n normale intellektuele vermoe volgens hul skoolprestasie en vorige ik-toetsing en met horende afrikaanssprekende ouers wat sedert kleutertyd 'n skool vir dowes bygewoon het, is vervolgens geselekteer. sewe proefpersone het aan die vereistes voldoen. hulle het 'n gemiddelde spraakverstaanbaarheidskaaltellingvantussen 1.5 en 3.8 op 'n vyf-punt-skaal (meyer, 1984) behaal met een as onverstaanbaar en vyf as volkome verstaanbaar gestel. die skaaltelling is bereken deur die gemiddeld van ses beoordelaars. normaalhorende luisteraars vrywillige studente in hul derde jaar van die ib.log.graad aan die universiteit van pretoria is as beoordelaars van die spraakuitings gebruik. hulle is reeds opgelei om bree transkripsies van abnormale spraak te doen. die studente (ouderdom wissel van 20 tot 22 jaar), beskik oor normale gehoor en het slegs beperkte indien enige blootstelling aan die spraak van dowes gehad. dertien van die studente het afrikaans as moedertaal, terwyl een haarself as tweetalig beskou. 1 apparaat 'n sony stereo cassette corder tc-158 sd bandopnemer met twee sher-o-dyne model 533samikrofone is vir die opname van die spraakvoorbeelde in 'n stil, vertrek by die skool gebruik. die perseptuele beoordelings is in die taallaboratorium van die universiteit van pretoria gedoen. die taallaboratorium is to^gerus met 'n tandberg model is-10 apparaat. elke luisteraar het vir die ouditief perseptuele beoordelings 'n tdk d 60 band ontvang wat deur middel van 'n individuele kopstuk (tandberg tlh 12) en na gelang van persoonlike luidheidsvoorkeur beoordeel moes word, 'n enkele luisteraar het 'n phillips d-6280 bandspeler vir die beoordelings gebruik. the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) vokaalreels by dowes tabel 1: gehoorgestremde sprekers en eienskappe vir seleksie spreker ouderdom graad van verlies oorsaak van verlies aanvang ouderdom: diagnose ander probleme ik spraak verstaanbaarheid een 17 jr 6 mnde uitermatig onbekend kongenitaal 11 mnde geen 123 1.5 twee 17 jr 3 mnde uitermatig onbekend kongenitaal 17 mnde geen 105 1.8 drie 16 jr 11 mnde ernstig onbekend kongenitaal 30 mnde geen 93 2.7 vier 19 jr uitermatig waardenburg kongenitaal 32 mnde geen 101 2.5 vyf 19 jr 9 mnde uitermatig onbekend kongenitaal 24 mnde geen 122 1.8 ses 18 jr 6 mnde uitermatig onbekend kongenitaal 18 mnde geen 100 3.8 sewe 20 jr 1 mnd uitermatig onbekend kongenitaal 24 mnde geen 114 1.5 materiaal vir die ontlokking van die spraakvoorbeelde in 'n poging om die spraakreels van die dowe op 'n klinies toepasbare wyse te bepaal, is daar verskeie vereistes gestel, naamlik: ο die eksperimentele taak en die materiaal wat gebruik word, moet geskik vir die dowe spreker wees, ο verskeie herhalings van die spraakvoorbeelde moet versamel word sodat reelmatighede of produksiestabiliteit, bepaal kan word, ο die woordstruktuur moes eenvoudig wees sodat dit met gemak deur 'n dowe gelees en uitgespreek kan word. daar is besluit om kvk-woorde te gebruik. die kvkwoorde wat geselekteerj is, is minimale pare om op 'n gekontroleerde analitiese wyse te bepaal of geselekteerde kontraste inderdaad afwesig of teenwoordig is. slegs die toetsvokaal is 'gevarieer en die konsonante is as lb-tl konstant gehou. die konstante klankomgewing is belangrik in die perseptuele beoordelings sodat die beoordelaars nie enige addisionele inligting kry wat die beoordeling van die toetsklank bei'nvloed nie. elke woord is vyf keer herhaal sodat daar van elke vokaal in 'n spesifieke kontekstuele omgewing vyf produksies is. ο dit is nie moontlik om alle spraakreels te bestudeer nie en daarom is slegs vokale geselekteer. vokale is geselekteer na aanleiding van die volgende kriteria: slegs enkelvokale is oorweeg, aangesien die dowe duurverskille in vokaalproduksie, selfs al is die produksie abnormaal, behou en duurverskille in afrikaans kontrasterend gebruik word, byvoorbeeld man teenoor maan (meyer, 1984). die abnormale hoe voorvokaal [y] is ook uitgelaat aangesien die vokaal dikwels as ongerond uitgespreek word en dus as [i] of [θ] realiseer (meyer, 1984). slegs vokale wat in die [b-t] klankomgewing voorkom is verder ingesluit en om die rede is [ae] weggelaat. vokale moes ook verteenwoordigend wees van die afrikaanse vokale en is dus geselekteer om hoe, neutrale en lae, sowel as voor-, middelen agter-vokale in te sluit, naamlik /a, i, u, ε, a, o/ (wissing, 1982; de villiers & ponelis, 1987). die woorde vir die vokaalontleding is: boet, bot, bad, bed, bied en bid. ο aangesien verskeie faktore 'n effek op die duur van klanke het, byvoorbeeld die spraakspoed, die posisie van die woord in 'n sin, die betekenis van die woord, klem van die woord in die sin (nickerson, stevens, boothroyd & rollins, 1974, lehiste, 1970), is alle toetswoorde in dieselfde sin geplaas, naamlik "ek het gese". ο die toetssinne is individueel op wit 10 x 20 cm kaarte aangebring waarop die toetswoord in donker en onderstreepte font verskyn. 'n swart en wit lyntekening wat die woordbetekenis illustreer, is telkens op die kaart aangebring om sodoende die betekenisvolheid van die woord te verseker. optekening van data die beoordelaars het 'n geslotekeuseantwoordblad ontvang waarop hul response aangeteken moet word. die responsmetode is geselekteer aangesien die sprekers as gevolg van hul swak verstaanbaarheid besonder swak sou vaar op 'n onbeperkte-keuse-responswyse (osberger, 1992). die alternatiewe is geselekteer om die korrektheid van die volgende fonetiese kontraste te evalueer, naamlik vertikale tongposisie of tonghoogte (bied/bad; boet/ bad), horisontale tongposisie (bied/boet; bed/bot), lipvorming (bied/ buut; bid/ bot; bed/bot) en duur (bat/ baat; bed/beet; bot/boot). daar was met ander woorde 10 moontlikhede waaruit die luisteraar 'n keuse moes maak sowel as 'n vraagtekenkategorie. die vraagteken-kategorie is ook ingesluit om inligting te verkry wanneer die spreker se distorsie nie 'n bekende identifiseerbare vorm aanneem nie (owens, talbott & schubert, 1968). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 santie meyer prosedure prosedure vir dataversameling 1) 'n stil vertrek is geselekteer sodat die agtergrondgeraas op die opnames so laag moontlik vir die versekering van akkurate analises is. 2) die doel van die eksperiment is kortliks aan elke proefpersoon verduidelik en die eksperimentele taak is uiteengesit. 3) die kaarte met toetsstimuli is omgekeerd op die tafel voor die spreker geplaas en die mikrofone is ongeveer 20 sentimeter regs, voor die spreker se mond op 'n tafel geplaas om die effek van die kamerakoestiek sover moontlik te beperk. 4) daar is dan oorgegaan om die voorbeelde van die toetssinne aan die spreker voor te hou om te verseker dat hy begryp wat van hom verwag word. 5) die sprekers is daarna gevra om die woorde op die kaarte op 'n natuurlike wyse te lees. wanneer die ondersoeker seker was dat die spreker weet wat van hom verwag word en dat hy die opdrag kan uitvoer, is tot die oudio-opnames van die eksperimentele sinne oorgegaan. prosedure vir die perseptuele ontleding 6) 7) 8)' al die beoordelaars is opgelei vir die luistertaak deurdat die navorser twee sprekers se spraak saam met die groep beoordeel het. die beoordelaars het elk hul eie oudioband ontvang waarop die toetssinne van 'n spesifieke spreker gekopieer is met 'n vel papier waarop 'n beperkte keuse van elke toetsitem aangebring is. 'n voorbeeld van die toetsitems is : "ek het bad, baat, boet, bot, boot, biet, beet, bid, bed, buut ? gese." elke spreker se sinne is deur twee luisteraars beoordeel. elke luisteraar is slegs vir die ontleding van een spreker se uitinge gebruik om te voorkom dat daar 'n orde-effek voorkom deurdat die beoordelaars die daaropvolgende sprekers beter beoordeel as gevolg van hul blootstelling aan die navorsingstaak (mcgarr, 1983). analise van data 9) 'n punt is aan elke korrekte foneembeoordeling toegeken. 'n vervangingstelling word ook bereken deur die aard van die beoordelaars se "foutiewe" response (die beoordelings wat nie die mikpuntfoneem bevat nie) te ondersoek. indien dieselfde foneem vir 70 of meer persent waargeneem is, is dit as die vervangingsfoneem beskou. 10) die beoordelaarsresponse is ook nagegaan om 'n kontrastelling op te teken (boothroyd, 1985). die kontraste naamlik tonghoogte of vertikale tongposisie (hoog, middel, laag), horisontale tongposisie (voor, sentraal, agter) , duur (kort, lank) en lipstand (de villiers & ponelis, 1987; wissing, 1982) is ondersoek. die kontraste lewer 'n totaal van 40 (vier kontraste, vyf herhalings, twee luisteraars) moontlike korrekte response per proefpersoon per foneem. 11) die response is verder in die vorm van 'n beoordelingsmatriks vir elke spreker opgestel met die doel om patroonmatigheid in die luisteraarsresponse visueel voor te stel. 12) die interluisteraar-korrelasiekoeffisient is .93 wat dui op betroubare luisteraarsbeoordelings (downie & heath, 1971). resultate resultate van die luisteraarsbeoordelings van die dowes se vokaalproduksie as 'n groep. in tabel 2 word die vokaal wat deur die luisteraars waargeneem is horisontaal en die teikenvokaal vertikaal in die beoordelingsmatriks se selle ingevul. die getal in die selle is die frekwensie waarmee elke teiken-/ waargenome vokaalpaar voorgekom het. die persentasie korrekte produksie sowel as die persentasie waarmee 'n spesifieke vokaal as vervanger gebruik word, word ook verskaf. elke vokaal is deur 14 luisteraars beoordeel. beskrywing van die resultate van die vokaalbeoordelings van die dowes as 'n groep. uit tabel 2 is dit duidelik dat die ses toetsvokale met 'n verskeidenheid vokale vervang word. die sprekers behaal 'n persentasie korrekte produksie van slegs 46.6%!. die tabel 2. beoordelingsmatriks van die gehoorgestremdes se vyf herhalings van die vokale. waargenome foneem a a: i y e: ε β 3 ο: u totaal 1 % korrek 1 a 51 2 0 1 0 7 9 0 0 0 70 72.9' i 14 3 11 1 1 30 9 0 1 0 70 15.7 ε 14 9 4 2 34 7 0 0 0 70 48.6' a 16 1 0 0 0 5 41 0 1 6 70 58.5 d 13 6 2 2 0 1 1 19 1 25 70 x 27.1 u 8 8 1 4 0 0 2 6 1 40 70 57.1 totaal 116 20 23 12 3 77 69 25 4 y 71 420 46.6 % vervang 15.5 4.8 2.9 2.9 .7 10.2 6.7 1.4 .95 7.4 53.4 g ω ω β a α ja f8 the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) vokaalreels by dowes vokale wat die meeste korrek3 geproduseer word is /a/ (73%), /a/ (59%) en ivj (57%). hierdie foneme, sowel as die hi, word ook algemeen as vervangingsvokale gebruik. dit is verder opvallend dat selfs die beste geproduseerde vokale (/a/ teen 73%) 'n relatief lae persentasie korrekte produksie behaal het. die vokaal wat die meeste probleme opgelewer het, is die /i/ waar die sprekers slegs 16 % behaal. bespreking van die resultate van die vokaalbeoordelings van die dowes as 'n groep. die beoordelingsmatriks (kyk tabel 2) illustreer die swak produksie van vokale duidelik. vokale word deur ten minste drie ander vokale vervang. die swak vokaalproduksie van die dowe spreker is alreeds deeglik in verskeie tale gedokumenteer (angelocci, kopp & holbrook, 1964; meyer, 1984; odendaal, 1981; suonpaa & aaltonen, 1981). die huidige studie bevestig dan ook die resultate waar 'n maksimun persentasie korrekte vokaalproduksie van slegs 47% verkry is. die prestasie is egter beter as in ander studies wat ook op afrikaanssprekende proefpersone uitgevoer is. meyer (1984) verkry byvoorbeeld 33% en odendaal (1981) 21%. die verskil is egter waarskynlik aan die aard van die beoordelingstaak toe te skryf. in hierdie studie is van 'n geslote-keusetaak gebruik gemaak terwyl die ander studies die luisteraars 'n vrye keuse in die beoordelings gegee het. dit is bekend dat die prestasie in 'n geslote-keusetaak beter as in 'n vrye keuse is (osberger, 1992). oor die algemeen blyk dit dat die lae en die sentrale vokale meer dikwels korrek uitgespreek word en dat die voorvokale meer dikwels probleme oplewer (gold, 1980) soos ook in die huidige studie die geval is. die verklaring wat hiervoor voorgehou word, is dat dowes geneig is om hul tonge laag en na agter in die mondholte te hou. daar word gemeen dat dowes die tongstand verkies omdat dit taktiele leidrade verskaf (boone, 1966). die tongplasing het uiteraard 'n negatiewe effek op die voorvokale se resonansiepatrone. j /wanneer die hoorbaarheid van die vokaalformantfrekwensies in gedagtejgehou word, kan die beter produksie van /a/ en ivj verklaar word. beide die vokale se eerste en tweede formante is in 'n relatief lae frekwensiegebied gelee (meyer, 1984). die sentrale /a/ vokaal se relatief geslaagde produksie is ook in ooreenstemming met vorige studies. daar word algemeen gemeen dat die ontspanne natuurlike tongposisie /a/ 'n maklik produseerbare vokaal maak. die relatief ongeslaagde produksie van /a/ (slegs 27% korrekte produksie is behaal) is nie duidelik nie. dit is 'n vokaal waar beide die eerste en die tweede formante in die frekwensiegebied onder 1000 hz gelee is (peterson & barney, 1952) en dus hoorbare leidrade vir die produksie behoort te bied. nogtans berig owens et al. (1968) dat dowes die vokaal dikwels foutief waarneem. daarbenewens is dit ook 'n vokaal wat sigbare leidrade in die vorm van lipronding bied, wat ook korrekte produksie kan bevorder. daar is egter verskeie ander studies wat die dowes se probleme met die vokaal aantoon (meyer, 1984; odendaal, 1981). die swak produksie van ν is egter nie onverwags nie, 3 korrek moet gelees word as "korrek identifiseerbaar" aangesien die spraak van al die sprekers die kenmerkende afwykings van die dowe vertoon. 53 en is ook al in vorige studies en in ander tale bevind (geffner, 1980; meyer, 1984; odendaal, 1981). die hoe voortongposisie verskaf min taktiele leidrade (boone, 1966) en die hoe tweede formantfrekwensie maak die vokaal moeilik hoorbaar (meyer, 1984; peterson & barney, 1952). die spreker het met ander woorde min inligting tot sy beskikking om sy produksie van die vokaal te rig, wat tot die swak produksie aanleiding gee. alhoewel duurversteurings dikwiels in die vokaalproduksie van die dowe se spraak voorkom (parkhurst & levitt, 1978), was dit nie 'n opvallende kenmerk van die huidige studie nie. daar is spesifiek net kort vokale vir die navorsingstaak geselekteer, en die luisteraars het slegs met uitsondering 'n lang /a:/ (4.7%), /e:/ (.7%), en /o:/ (.95%) in plaas van kort vokale gehoor. dit is steeds moontlik dat die sprekers hul toetsvokale verleng, maar dat dit nie as lang vokaal relatief tot die res van die sin gehoor word nie, aangesien die totale uiting se duur verleng is. dit is dan ook reeds opgeteken dat die dowe spreker, ten spyte van algemene verlenging van vokale, die relatiewe duur van sy vokale behou (meyer, 1984). die laaste opvallende bevinding is dat alle vokale nie ewe veel as vervangingsvokale gebruik word nie. die id en die /a/ word algemeen as vervangingsvokale gebruik. die id word hoofsaaklik as die vervangingsvokaal van die ν gebruik. beide vokale is voorvokale en het 'n relatief lae eerste formant. die tweede formant van die id is egter laer as die van die /i/ (meyer, 1984) wat dit waarskynlik makliker hoorbaar maak. die /a/ daarenteen, word vir 'n wye verskeidenheid vokale as vervanging gebruik sodat daar nie so 'n duidelike patroon voorgekom het nie. wat egter opvallend is, is dat /a/ eerder as die neutrale vokaal ibi as "algemene" vervangingsvokaal gebruik word. afgesien van die /a/ se hoorbaarheid soos reeds genoem, bied die middellae tongposisie moontlik taktiele terugvoeringsleidrade wat produksie vergemaklik. die vervangingspatroon het veroorsaak dat die tradisionele vokaalneutraliserings (levitt, stromberg, smith, & gold, 1980) nie in die groep sprekers se spraak opgeval het nie. die bestudering van die data van die groep as geheel, het interessante patrone na vore gebring met die uitstaande indruk dat die dowe spreker oor swak vokaalproduksie beskik. die samevoeging van die groepsdata verskuil egter die moontlikheid van enige hoorbare patroonmatigheid in die vokaalproduksie van die individuele dowe spreker. in 'n poging om die individuele patroonmatigheid na te gaan, sal die beoordelingsmatrikse van die sprekers afsonderlik bestudeer word. resultate van die luisteraarsbeoordelings van individuele dowe sprekers in tabel 3 word die vokaalbeoordelingsmatriks vir spreker een aangetoon. die vokaal wat deur die luisteraars waargeneem is, is horisontaal en die vokaal wat die spreker geproduseer het of die teikenvokaal, vertikaal in die beoordelingsmatriksselle ingevul. die getal in die selle is die frekwensie waarmee elke teiken-/ waargenome vokaalpaar voorgekom het. elke vokaal is deur twee luisteraars beoordeel en die persentasie korrekte beoordelingvir elke vokaal asookdie persentasie korrekte beoordeling vir al die vokale gesamentlik word aangetoon. die asterisk by 'n selinskrywing toon aan dat 'n luisteraar in al vyf beoordelings dieselfde vokaal gehoor het. die persentasie waarmee 'n spesifieke vokaal as vervangingsvokaal gebruik is, word ook aangegee. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 santie ε meyer tabel 3. vokaalbeoordeling van spreker een waargenome foneem tabel 5. vokaalbeoordeling van spreker drie waargenome foneem a v v α £ α v j4 •ρ* β a 1 y e: ε 9 d o: u korrek a 1 y e: ε 9 0 ο: u korrek a 3 6 10 a 10* 100 i 7 3 0 i 1 1 5* 3 10 ε 10* 100 a 0) ε 3 5* 2 50 9 1 9* 90 0) α £ a 10* 100 d 2 8* 20 α 0) j4 •ρ* d 2 8* 20 u 10* 100 0 u 10* 100 % vervang 1.7 0 0 0 16.7 15 0 0 13.3 % vervang 0 0 6.6 0 8.3 8.3 0 0 13.3 % korrekte vokaalproduksie: 53.3% beskrywing van die resultate van die vokaalbeoordelings van spreker een uit tabel 3 blyk dit dat die die spreker 'n persentasie korrekte vokaalproduksie van 53 % behaal het en dat die luisteraars /ε/, h / en /u/ korrek kon hoor. hulle het egter met goeie eenstemmigheid 'n foutiewe maar reelmatige produksie van /i/ as /ε/ en /o/ as /u/ gehoor. die spreker het met ander woorde slegs drie in plaas van die ses vokale in sy foneemskat. die vokale wat hy korrek produseer, word ook as vervangingsvokale vir die ander gebruik. in tabel 4 word die vokaalbeoordelingsmatriks vir spreker twee afsonderlik aangetoon. die uiteensetting is soos in tabel 3. beskrywing van die resultate van die vokaalbeoordelings van spreker twee. uit tabel 4 blyk dit duidelik dat die luisteraars nie enige ander vokaal as /a/ konstant kon hoor nie. die spreker maak met ander woorde nie enige verskil in die produksies van /a/, /i/, /a/ en h i soos deur die luisteraars waargeneem nie. dit is ook interessant dat /ε/ en /u/ vir 'n geringe aantal herhalings as korrek waargeneem is maar dat 'n groot tabel 4. vokaalbeoordelings van spreker twee waargenome foneem a v v α a α . · » α •ρ* β % korrekte vokaalproduksie: 63% aantal van die produksies ook as /a/ gehoor is. in plaas van ses foneme gebruik die spreker slegs een foneem. dit is dus nie onverwags dat hy slegs 23% korrekte vokaalproduksie behaal nie. in tabel 5 word die vokaalbeoordelingsmatriks vir spreker twee afsonderlik aangetoon. die uiteensetting is soos in tabel 3. beskrywing van die resultate van die vokaalbeoordelings van spreker drie. uit tabel 5 blyk dit die luisteraars /a/, /u/ en /a/ konstant korrek kon hoor. die enigste ander vokaal wat 'n konstant hoorbare patroon gegee het, is h i wat as /u/ gehoor is. die ander vokale is as verskillend gehoor, en die spreker behaal 'n relatief hoe persentasie korrekte produksie, naamlik 62%. dit was egter interessant dat die luisteraars nie dieselfde inligting uit die uitings verkiy het nie. die vokaal /ε/ is konstant korrek gehoor deur die een luisteraar en ook as die konstante vervangingsklank vir die ν gehoor (aangedui met *). die ander luisteraar het egter nie tabel 6. vokaalbeoordelings van spreker vier waargenome foneem ' i ' korrekte vokaalproduksie: 27% a 1 y e: ε a d o: u korrek a i y e: ε θ d ο: u korrek a 10* 100 a 7* 3 ΐο i 9* 1 0 i 1 1 5 3 10 ε 6 3 1 30 re ik en fo n ee m ε 1 5* 4 50 9 8* 1 1 0 re ik en fo n ee m 9 10* 100 , d 9* 1 0 re ik en fo n ee m d 2 1 5* y / 2 50 u 6 1 3 30 u 2 2 5* 1 10 % vervang 63.3 0 0 0 0 1.6 0 6.6 1.6 % vervang 0 0 10 0 10 15 8.3 0 3.3 korrekte vokaalproduksie: 48% the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) vokaalreels by dowes 55 dieselfde konstante inligting uit die /i/ en id uitings verkry nie, want sy het die vokale, hoofsaaklik lyl of/a/ gehoor. in tabel 6 word die vokaalbeoordelingsmatriks vir spreker twee afsonderlik aangetoon. die uiteensetting is soos in tabel 3. beskry wing van die resultate van die vokaalbeoordelings van spreker vier. uit tabel 6 blyk dit duidelik dat die luisteraars slegs in die geval van /a/ en lal die vokale as korrek kon hoor. die ander vokale is egter nie as patroonmatig waargeneem nie. verskeie vokale is met lal vervang, terwyl id en hi ook dikwels in plaas van ander foneme gehoor is. van die ses toetsvokale wil dit voorkom asof die spreker lal tabel 7. vokaalbeoordelings van spreker vyf waargenome foneem a i y e: ε a d o: u korrek a 8* 2 80 i 5 3 2 0 ε 8 2 20 a 7* 1 2 20 d 4 6 0 u 2 8 0 % vervang 43.3 33.3 0 0 3.3 0 0 0 0 % korrekte vokaalproduksie: 20% tabel 8. vokaalbeoordelings van spreker ses waargenome foneem a i y e: ε a d ο: u korrek a 10* 100 i 10* 100 ε 8 2 20 a 5* 5* 50 d 10* 100 u 1 9* 90 % vervang 0 13.3 0 0 0 0 1.6 0 8.3 % korrekte vokaalproduksie: 76.6% opsigte van die id wat met redelike goeie konstantheid met die lil vervang is nie. daar was egter 'n verskil in opinie tussen die luisteraars oor die korrektheid van die lal. die een het gemeen dat die vokaal korrek uitgespreek is terwyl die ander dit as 'n konstante vervanging met ivj gehoor het. die spreker gebruik vier in plaas van die ses toetsvokale. hy tref geen onderskeiding tussen ν en id nie en sy produksie van lal is nie duidelik nie. hy behaal 62% korrekte vokaalproduksie. in tabel 9 word die vokaalbeoordelingsmatriks vir spreker twee afsonderlik aangetoon. die uiteensetting is soos in tabel 3. kontrasteer met voorvokale wat deur id verteenwoordig word en agtervokale wat deur h / verteenwoordig word. die lal word as algemene vervangingsfoneem aangewend. ten spyte van die beperkte foneemskat behaal die spreker 47% korrekte produksie. j in tabel 7 word die vokaalbeoordelingsmatriks vir spreker twee afsonderlik aangetoon. die uiteensetting is soos in tabel 3. i | beskrywing van die resultate van die vokaalbeoordelings van spreker vyf. uit tabel 7 blyk dit dat die luisteraars net een vokaal, naamlik die /a/, korrek kan identifiseer. die /a/ word dan ook as algemene vervangingsfoneem gehoor. die spreker kontrasteer lal en lul skynbaar deur middel van 'n duurverskil, waar die lul met 'n langer duur uitgespreek word. daar is egter geen ander duidelike patroon wat uit die data na vore kom nie en hy behaal slegs 20% korrekte produksie. in tabel 8 word die vokaalbeoordelingsmatriks vir spreker twee afsonderlik aangetoon. die uiteensetting is soos in tabel 3. beskrywing van die resultate van die vokaalbeoordelings van spreker ses. uit tabel 8 blyk dit dat die luisteraars eenstemmig was ten opsigte van die korrektheid van die produksies van vier van die vokale. daar is ook nie onduidelikheid ten beskrywing van die resultate van die vokaalbeoordelings van spreker sewe. uit tabel 9 blyk dit dat die luisteraars slegs die id en die lul as korrek beoordeel het. hulle was ook eenstemmig dat die spreker nie enige onderskeid tref tussen lil en id nie en ook nie tussen hi en lul nie. die ander beoordelings vertoon nie 'n duidelike patroon nie. hy behaal dan ook slegs 40% korrekte produksie. tabel 9. vokaalbeoordelings van spreker sewe waargenome foneem a i y e: ε a d o: u korrek a 5 1 4 50 i 1 8* 1 0 ε 1 2 7* 70 a 5 5 50 d 2 1 7 0 u 1 2 7* 70 % vervang 0 6.7 5 5 28.3 3.3 0 0 11.7 % korrekte vokaalproduksie: 40% die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 santie ε meyer bespreking van die resultate van die vokaalbeoordelings van individuele dowe sprekers. die individuele beoordelingsmatrikse van die sprekers toon dat daar groot individuele verskille ten opsigte van die persentasie korrekte vokaalproduksie, wat wissel van 20 tot 62 persent, bestaan. alhoewel die luisteraars nie in staat was om al ses vokale in enige van die sprekers se spraakmonsters te identifiseer nie, kon hulle vier by spreker ses teenoor slegs een by spreker twee hoor. nog 'n interessante verskil tussen die verskillende sprekers was die vokale wat die luisteraars as korrek kon identifiseer. die /a:/ is deur 5 sprekers (sprekers twee, drie, vier, vyf en ses) die /u/ deur vier (sprekers twee, drie, vier en ses) en /a/ deur drie (sprekers een, drie, en vier) korrek gebruik. die ander vokale was korrek deur een (/i/, h/) of twee (/ε/) sprekers (sprekers een en sewe) gebruik. dit dui ook net weer op die individuele patrone in die vokaalproduksie by die sprekers. die verskil in die vervangingsvokale wat die luisteraars kon hoor, was ook opvallend tussen die sprekers. die vokale wat as vervangingsvokale gebruik is, was in die meeste gevalle die vokale wat die spesifieke spreker ook korrek kan produseer. dit gee dan outomaties aanleiding tot individuele verskille soos in die vorige paragraaf verduidelik is. alhoewel daar aanvaar word dat dowes nie dieselfde foute vertoon nie, lewer die studie 'n bydrae ten opsigte van die klem wat op individuele foutpatrone geplaas word. groepsdata soos in verskeie studies (gold, 1980; odendaal, 1981) en soos in tabel 2 verskaf, verbloem die individuele foutpatrone wat in die dowes se spraak na vore kom wanneer die individuele data bestudeer word. dit lei tot die foutiewe aannames dat "dowe spraak" nie ook individuele patrone vertoon nie. die individualiteit van 'n spreker se fonologiese stelsel is van groot belang in terapie. oster (1991) noem dat 'n afwykende produksie sistematies en stabiel oor tyd kan wees en dat dit die realisering van 'n afwykende reel kan wees. indien terapie gegee word sonder bewustheid van bestaande kontraste in die kind se spraak en dus bestaande verbindings tussen die fonetiese realisering en die abstrakte linguistiese vlak, kan dit tot die verval van die kind se sisteem en tot 'n afname in verstaanbaarheid lei. dit is verder belangrik om daarvan bewus te wees dat dit nie raadsaam is om op slegs 'n enkele uiting staat te maak om die dowe se produksiekennis te evalueer nie. die variasie in die beoordelings van die sprekers het duidelik uit die beoordelingsmatrikse geblyk. dit is duidelik dat sommige vokale op 'n lukraak wyse geproduseer word, soos blyk uit die /a/ van spreker sewe. die variasie in produksie sou nie uit 'n enkele spraakvoorbeeld duidelik geword het nie. 'n laaste opmerking ten opsigte van die luisteraarsbeoordelings is dat dit wil voorkom asof luisteraars nie dieselfde "perseptuele strategiee" gebruik in die beoordeling van die spraak van die sprekers nie. (wanneer 'n luisteraar telkens in elk van die lyste dieselfde vokaal gehoor het wanneer die spreker 'n spesifieke toetswoord geproduseer het, is dit met 'n asterisk in die matrikse aangetoon.) daar is uiteraard niks vreemd omtrent die beoordelings waar 'n spreker 10 in die selinskrywing ontvang het nie. dit impliseer slegs dat beide luisteraars die geproduseerde vokale as korrek beoordeel het. wanneer een luisteraar egter konstant 'n spesifieke vokaal hoor, terwyl die ander luisteraar konstant 'n ander vokaal hoor (kyk spreker 6, vokaal hi) of verskeie ander vokale hoor (kyk byvoorbeeld spreker 4, vokaal /ε/) kan daar moontlik van verskillende luisterstrategiee gepraat word. om die aspek verder te ondersoek is die interluisteraarsbetroubaarheidskoeffisient van die kontrastellings van die twee luisteraars wat elke spreker beoordeel het, ondersoek. resultate van die interluisteraarsbetroubaarheidskoeffisient van die kontrastellings van die luisteraars in tabel 10 is die interluisteraarsbetroubaarheidskorrelasiekoeffisient vir die twee luisteraars bereken deur die kontrastellings vir die vyf herhalings van elke van die ses toetsvokale teenoor mekaar te stel. beskrywing van die interluisteraarsbetroubaarheidskoeffisient van die kontrastellings van die luisteraars uit tabel 10 blyk dit dat die korrelasiekoeffisiente wissel vanaf 0.49 tot 0.98. die rede waarom daar so 'n goeie korrelasie in sommige en so 'n swak korrelasie in ander gevalle bestaan, kan net oor gespekuleer word, veral gesien in die lig van die interluisteraarkorrelasie van 0.93. luisteraarsbeoordelings is tradisioneel die metode van keuse vir die evaluasie van afwykende spraak (kearns & simmons, 1988). dat dit moeilik vir selfs 'n hoogs opgeleide luisteraar is om die spraak van die dowe te beoordeel, is algemeen bekend (monsen, 1978). dit is problematies om die oorsaak van die fout te onttrek omdat spraak nie 'n eenvoudige liniere string simbole is nie, maar 'n ingewikkelde gekoartikuleerde kode. die feit dat die twee luisteraars egter nie dieselfde kontrastellings behaal nie, dui op verskillende luisterstrategiee. dit is moontlik dat sekere luisteraars van die kontraste wat in die spreker se spraak voorkom, suksesvol kan benut, terwyl dit nie vir 'n ander luisteraar duidelik genoeg is om te benut nie. die abnormaliteit in die spraak van die spreker verbloem moontlik die kontras vir so 'n luisteraar. ! dit is immers bekend dat die luisteraar, selfs 'n opgeleide fonetikus, nie 'n spraakanalise kan doen sonder om deur konvensionele terminologie en linguistiese ondervinding beinvloed te word nie (clark & yallop, |l990). in die geval van hierdie luisteraars, slegs opgelei om bree fonetiese transkripsies te doen, sou bogenoemde invloed tabel 10. korrelasie-koeffisient vir vokaalbeoordelings van elke spreker se twee luisteraars luisteraars van korrelasie-koeffisient spreker 1 .93 spreker 2 •74 spreker 3 .49 spreker 4 . .56 / spreker 5 .98 spreker 6 .76 spreker 7 .71 the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) vokaalreels by dowes 57 moontlik nog sterker kon wees. die luisteraars wat vir die studie geselekteer is, is waarskynlik tiperend van die persone wat vir die dowe se spraakopleiding verantwoordelik sal wees en die bevindings is dus van belang vir die spraakopleier. in teenstelling met die hipotese van individuele luisterstrategiee, is harris et al. (1985) van mening dat luisteraars, hetsy gesofistikeerd of ongesofistikeerd, nie oor 'n spesiale strategie beskik om dowes se vokale te dekodeer nie. die studie spreek egter nie spesifiek die resultate van individuele luisteraars aan soos die huidige navorsing nie. die feit dat luisteraars in hierdie studie in die beoordeling van dieselfde spreker se uitings verskil, bevestig die hipotese dat daar moontlik van verskillende luisterstrategiee sprake is. wanneer die uitings waaroor hulle saamstem bestudeer word, kom interessante inligting na vore en dit word vervolgens verskaf. resultate van die ooreenstemming in die luisteraarsbeoordelings van die dowe sprekers se segmentele produksie in tabel 11 word die resultate van die twee luisteraars se beoordelings van elke spreker weergegee. wanneer sewe van die tien beoordelings ooreengestem het, word die resultaat as 'n duidelike patroon in die produksie van die uiting beskou. wanneer al die beoordelings egter tussen slegs twee segmente gewissel het met ongeveer ewe veel beoordelings in elk is dit ook aangetoon soos byvoorbeeld in die geval van die a/u-inskrywings. indien die luisteraars se beoordelings oor 'n aantal selle verspreid was, is daar nie 'n hoorbare konstantheid in die produksie van die spesifieke foneem nie. beskrywing en verklaring van die ooreen-stemming in die luisteraarsbeoordelings van die dowe sprekers se segmentele produksie uit tabel 11 blyk dit duidelik dat daar sekere foneme is wat meer dikwels deur die luisteraars korrek waargeneem kon word as ander. die /a/ is 'n mikpuntfoneem wat deur vyf of ses van die sewe sprekers gebruik is. die vokale /i/ en hi lewer opvallend dikwels probleme. die luisteraars kon selde hoor dat 'n spreker die mikpuntfoneme konstant korrek gebruik. j dit val verder op dat die sprekers nie een dieselfde vervangingspatroon vertooh nie. alhoewel daar ooreenkomste tussen die sprekers is, is daar nie by enige twee sprekers presies dieselfde mikpuntfoneme wat korrek gebruik word of wat met dieselfde foneem vervang word nie. dit is ook duidelik uit tabel 11 dat die sprekers sommige van die kontraste van die korrekte mikpuntfoneem behou het, byvoorbeeld in die geval van /i/ is die vervangingsfoneem /ε/. beide die teikenen die vervangingsvokaal is voorvokale alhoewel die plek van vonning nie korrek is nie. die individualiteit van die sprekers se segmentproduksie blyk duidelik uit die bespreking. die sprekers het patroonmatigheid getoon en mikpuntfoneme op 'n konstante wyse gerealiseer sodat beide beoordelaars oor ten minste 70% van dieselfde foneem se realiserings saamgestem het. dit dui op die gebruik van kontraste op 'n sistematiese wyse. die individualiteit van die sprekers se foutpatrone is waarskynlik te wyte aan hul individuele sensoriese en omgewingsomstandighede. gevolgtrekking die resultate van die studie toon aan dat dit wel moontlik is om spraakreels in geselekteerde uitinge van die afrikaanssprekende dowe deur middel van luisteraarsbeoordelings te bepaal. uit hierdie studie het daar belangrike feite na vore gekom. eerstens het dit geblyk dat die luisteraars se segmentbeoordelings aangetoon het dat die groep dowe sprekers se produksie in 'n groot mate ooreenstem met wat reeds in die literatuur berig is. die lae voorkoms van korrek gei'dentifiseerde foneme is reeds in verskeie studies aangetoon en is weer in die studie bevestig. tweedens was dit duidelik dat sekere mikpuntfoneme met konstantheid gerealiseer word terwyl dit nie by ander die geval is nie. dit was ook opvallend dat die dowes individuele verskille getoon het ten opsigte van die vokale wat hulle korrek kon produseer en die vokale wat hulle as vervangingsvokale gebruik. derdens is daar bevind dat daar verskille tussen luisteraars na vore getree het. die verskille toon aan dat die luisteraars, indien hulle dieselfde produksie moet beoordeel, nie noodwendig dieselfde foneem identifiseer nie. die metode wat hier gebruik is, het beperkinge aangesien die monsters nie spontane spraak is nie en die linguistiese vaardigheid van die spreker nie bepaal word nie. die verstaanbaarheid van die uitings sal bei'nvloed word deur die sintaktiese en leksikale probleme wat nie op die wyse gei'dentifiseer word nie (boothroyd, 1985). deur egter die uitings te beperk, te laat herhaal en op 'n toetsfoneem spreker 1 spreker 2 spreker 3 spreker 4 spreker 5 spreker 6 spreker 7 aantal korrek a geen a a a a a geen 5 i ε a geen geen a/a: i ε 1 ε ε geen geen ε a i ε 3 a a a θ a a a/u a/ε 3 3 u i a u geen a/a: 3 u 1 u u geen u geen a: u u 4 tabel 11. konstanthede identifiseerbaar in elke gehoorgestremde spreker se vokaalproduksie deur twee luisteraars. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 santie meyer geslotekeusebasis te beoordeel, kan die spraakopleier 'n idee vorm of'n segment op 'n konstante wyse uitgespreek word en die 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(ed). intelligibility in speech disorders. theory, measurement and management. amsterdam: john benjamins publishing co. oster, a-m. (1991). phonological assessment of eleven prelingually deaf children's consonant production. speech transmission laboratoryquarterly progress and status report, 2-3, 11-18. j owens, e., talbott, c.b. & schubert, e.d. (1968). vowel discrimination of hearing-impaired listeners. journal of speech and hearing research, 11, 648-655. | parker, a. & rose, h. (1990). deaf children's phonological development. in: grunwell, p. (ed). developmental speech disorders. edinburgh: churchill livingstone. i parkhurst, b. & levitt, h. (1978). the effect of selected prosodic errors on the intelligibility of deaf speech. journal of communication disorders, 11, 249-256. peterson, g. & barney, h. (1952). control methods used in a study of the vowels. journal of the acoustical society of america, 24, 175-184. stoel-gammon, c. & dunn, c. (1985). normal and disordered phonology in children. baltimore; md: university park press. suonpaa, j. & aaltonen, o. (1981). intelligibility of vowels in words uttered by profoundly hearing-impaired children. journal of phonetics, 9, 445-450. wissing, d.p. (1982). algemene en afrikaanse/generatiewe fonologie. johannesburg: macmillan. the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 17 the development of a screening schedule for use by teachers to describe the communication abilities of children with severe disabilities anna-marie wium and erna alant centre for augmentative and alternative communication department communication pathology university of pretoria abstract the study developed a screening schedule for teachers to describe the communication abilities of children with severe disabilities teachers were trained in the use of such an assessment procedure. both the schedule as well as the training were evaluated. results indicated that ike schedule can be regarded as adequate for future use as teachers found it easy to use and applicable to their situation. scoring the schedule requires more practise and training as this is a more advanced skill. specific issues had an effect on the results, e.g., the teachers'familiarity with the type of disability observed, their qualifications and experience. opsomming 'n siftingsskedule vir onderwyseresse is ontwikkel wat die kommunikasievaardighede van kinders met erge gestremdhede beskryf. die onderwyseresse moes opleiding ontvang om die skedule te gebruik. daar is gevind dat die skedule geskik is vir toekomstige gebruik aangesien dit maklik is om te gebruik en toepaslik is vir die klaskamer. gradenng word beskou as η gevorderde vaardigheid wat meer ervaring en opleiding verg. aspekte wat die resultate beinvloed het, was die onderwysers se bekendheid met die tipe gestremdheid, hulle kwalifikasies en tot 'n mindere mate hulle ondervindmg met erg gestremde kinders. key words: screening schedule, teachers, children with severe disabilities, augmentative and alternative communication. introduction the increasing need for service delivery to all children with severe disabilities (csd) necessitates the use of teachers to facilitate the children's general interaction. teachers are ideally suited to assess their childrens' capabilities as they are familiar with their individual needs and skills. in this context, the transdisciplinary method of intervention whereby the teacher is trained to fulfil certain intervention functions in the classroom can be a most effective way of dealing with the'severely disabled population (hogg & raynes, 1978). as assessment can be seen as the beginning of the intervention process, teachers should also be trained to perform this task. researchers such as skuy, westaway, makula and perold (1988) have found teachers valuable, parsimonious and accurate in rating students' performances in psychometric testing. the use of teachers in the communication assessment of csd becomes especially relevant as they are able to functionally assess students during daily class routines. a functional assessment can thus be described as an assessment method aimed at describing the child's performance in real life contexts. this approach to assessment is of the utmost importance when working with the majority of children with severe disabilities as they experience difficulty in learning new tasks due to the severity of their cognitive and/or physical disabilities. it is therefore important that the tasks used in the assessment process should be relevant and applicable to daily routines to facilitate the children's increasing independence. which evaluative procedure should be used if teachers are involved in the assessment process? a very limited choice of non-verbal tests are available, e.g., the nonspeech test (huer, 1983), and are for exclusive use by speech and language therapists. many speech and language therapists who work with csd make use of tests which were developed to test language in depth. the problem is that many of the children with severe disabilities are unable to speak which makes it very difficult to obtain reliable results. the need for an aac assessment schedule to describe the skill areas of functioning relevant to aac which could be used by teachers of csd is evident. however, various issues must be taken into account in the development of such an assessment schedule. firstly, the level of impairment in csd often necessitates the use of an augmentative system for more effective communication. the variation in symptoms of the child with severe disabilities clearly indicates that more than one skill area can be involved. it is therefore important to assess all skill areas involved in augmentative communication, such as communication, cognitive, motor, sensory and social/emotional skills. successful intervention should not take only abilities into account, but should also focus die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 on needs (beukelman & mirenda, 1992) secondly the heterogeneity of this population means that every^ child has unique problems, abilities and needs. a schedule has to address the development of an individual programme. thirdly, the characteristics of the child with severe disabilities such as his inconsistent behaviour, passivity, short attention span, anti-social behaviour (durant, 1990) and motor problems (bergen, 1990), make it necessary to observe such behaviour during ordinary functional routines as was recently proposed by asha (1992). researchers such as light (1989) as well as mirenda and iocono (1990), regard functional communication as an integral part of all areas of development particularly in the areas of social, emotional and cognitive development which must therefore also be accommodated in the assessment process of csd. fourthly, for a schedule to be effective for use in the classroom, it needs to be easy to administer and time effective. the development of such a screening schedule for teachers of csd has various advantages in that its use would enable teachers to describe their students' problems, it would help them to know when to refer to specialised services if necessary, and lastly, they would be able to draw up an individualised program plan for each child which enables them to monitor progress. it is against this background that the present study was conducted to investigate the use of an aac screening schedule for use by teachers. method aims anna-marie wium and erna alant apart from their subjective evaluation on the ease of use of the schedule, the results of their assessment were compared to those done by a group of three experienced aac specialists to assess their ability to identify items and to score them. the results obtained by this group was, considered as a norm or a reference to guide the training of observation skills. research design a small group, experimental design was used, which involved elements of the single subject, multiple-baseline design (using replication across 12 subjects). this is similar to the study described by light, dattilo, english, gutierrez and harts (1992). in this referred study of light et. al (1992), data was presented for each individual subject. data for the evaluation of changes that had occurred in the teachers as a result of the training in observation skills were collected five times in total for each of the 12 teachers and then compared to a norm. this was done for reliability as it is recommended by barlow and hersen (1984) that at least four baselines be collected for convincing results in this type of design. the general flow of events in the design of this study encompassed the following: firstly the development of the schedule which, in turn, was evaluated for ease of use in a pilot study with a sample of eight teachers. after the schedule had been refined, the main study trained twelve teachers to use it. the results were processed and analyzed. to describe the application of a schedule to identify the communication abilities of csd as used by teachers of children with severe disabilities (csd). more specifically the following aspects of implementation will be highlighted: the evaluation of the ease of use of the schedule the identification of questions in the schedule which were poorly phrased and thus poorly understood by the teachers the identification of problematic questions which were difficult to score teachers used the schedule to functionally assess the abilities of three children with severe disabilities (cases a, β and c) and were then asked to evaluate the schedule. materials used the schedule which was used to document observation skills of the teachers was designed to cover 47 items of five skill areas associated to aac. they are the communication, cognitive, motor, sensory and social/emotional skill areas. the questions were formulated in user-friendly terms and examples of these can be seen in tables 1 and 3. the schedule has to be completed by observing four functional tasks. each task needs to be rated on a six-point rating scale (0-5). in order to guide the teacher, the rating scale is categorized as poor, sub-average and average which has to be selected prior to attributing a specific score. table 1 has a summarized description of the schedule1. table 1: description of schedule description of schedule rating scale schedule had to be completed by observing and scoring four functional tasks. five skill areas of functioning related to aac were included and were desribed by 47 questions (items): 1. communication skills: (e.g. "to what extent does he want to communicate with others?") 2. cognitive skills: (e.g. "how well does he search for a hidden object?") 3. motor skills: (e.g. "how well can he reach with his right arm?") 4. sensory skills: (e.g. " how well does the child see for communication purposes?") 5. social/emotional skills: (e.g. " how well does he make eye contact during communication?") six-point rating scale was guided by three categories: poor: 0 1 sub-average: 2 3 average: 4 5 the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h p d e v e l o p m e n t of a screening schedule for use by abilities of children with severe disabilities data collection procedure training was conducted as a workshop according to nciples r e c o m m e n d e d for adult training (wium, 1994). tvaining took place at the centre for augmentative and alternative communication (caac), dept. communicaf r n pathology, university of pretoria, over a two-day period the content and procedure of training are described table 2. data collection procedures are highlighted. tfcble 2: training procedure and data collection teachers to describe the communication data analysis procedures 19 the focus of this study was to.develop an aac assessment schedule which involved two aspects: firstly, the schedule had to be evaluated and secondly, the ability of the teachers to identify (recognize) the various items and to score them in the schedule had to be described. evaluation of the schedule by the teachers: the teachers evaluated the ease of use of the schedule by cornday 1:descriptive information of teachers: teachers from schools for children with severe disabilities in the pretoria area registered for the workshop. each received a folder consisting of handouts, three unused schedules and each of the three above-mentioned questionnaires. these teachers had to have a minimum experience of six months with children with severe disabilities. the seats were arranged in a semi-circle facing the researcher/trainer in order to encourage interaction amongst the trainees. each seat was numbered according to their anti-clockwise position from 1-12 (from right to left) for material to be distributed and collected. pre-training knowledge of skill areas: prior to training, teachers completed an open-ended questionnaire which recorded their untrained knowledge of the five skill areas to be assessed in aac as well as their expectations of the course. these questionnaires were collected after completion. introductory and background information on a functional assessment was presented by means of audio-visual material (overhead projector and transparencies). the schedule (see table 1) was introduced and the questions as well as the instructions for scoring were read through with them and demonstrated. teachers were required to score every item in every observation. the assessment schedules were not collected until the teachers had scored four children and had calculated the results. pre-training observation skills (al): firstly they were shown a video (a) of an autistic child (noted as observation al). after three consecutive viewin'gs, they were requested to complete the schedule. the use of the schedule specifies that four functional tasks should be observed and documented. this first documentation was regarded as task 1 on the schedule. after completion of the first observation, questions were answered and the scoring of some of the items was compared within the group as part of the discussion regarding their problems. pre-training observation skills ( b l ) : they were then shown a second video (b) of a cei-ebral palsied child (noted as observation bl) three times consecutively and they were required to complete the schedule as for task 2 on the schedule (see appendix a). the same procedure as in observation a1 was followed after training. again teachers required that scores of some items be compared. these were then discussed in the class. training in the completion of the schedule was conducted by means of video material of children with severe disabilities. atraining video of a young, non-ambulatory, cognitively high-functioning child was shown (as many times as needed) and scored by all teachers. the child was severely communicatively disabled but demonstrated all precursors to communication while playing with a speech-language therapist during therapeutic prone standing. open discussion of all items in the schedule was continuously encouraged. teachers scored this child as the third of the four tasks on their schedules. scoring of these items were compared and discussed by the group. practical demonstrations and role play were used to demonstrate the items in the schedule. day 2: at the beginning of the second day handouts for the specific day were distributed. the previous day's work was reviewed, questions answered and handouts were discussed. another training video of a non-verbal child was then shown as many times as necessary. the child identified pictures and symbols and the teachers had to score this video as well. the training video was discussed and scores compared. teachers have now completed the four tasks on the schedule and could then learn to calculate the results. each teacher had to calculate her four observations (al, bl, task 3 and task 4), and present the results as a graph. the completed schedules were then collected. documentation of tasks 3 and 4 were not used for the research but merely to train teachers in the use of the schedule, the various skill areas and to calculate the results. post-training observation skills (a2): after tea, the first video (a) was again shown (as often as necessary) and scored on an unused schedule as observation a2. questions were again answered and several scores compared. post-training observation skills (b2): the second video (b) was then shown (as often as necessary) and then scored as observation b2. questions were again answered and several scores compared. post-training observation skills (c): a third video (of an unfamiliar child) was then shown and also scored. this observation was documented as observation c. results were compared and questions anwered. the second schedule (with the results of documentation after training), were then collected. post-training evaluation of schedule: teachers had to complete a closed-ended questionnaire to evaluate the schedule. post-training knowledge of skill areas and evaluation of the training: they also had to complete the open-ended questionnaire after training to assess the change that had occurred in their knowledge of the skill areas. comments and recommendations regarding the training were also given. at the end of day 2 teachers received certificates of attendance. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 pleting a closed-ended questionnaire. responses were calculated as percentages and displayed as a distribution graph. comments and recommendations were tabled. evaluation of the items in the schedule: the approach followed emphasised the different interpretations given to the same set of data, and focused on the ability to observe the items listed in the schedule from the observation of video cases as well as an evaluation of their ability to score the items. the ability to identify items described in the schedule was evaluated by using the data obtained from the schedules completed during training. all correct responses were given a value of 1 and all errors a value of 0 which implied that they could or could not identify the skill. responses were considered as correct when the teachers' responses were the same as the norm (which was established by three aac experts prior to the main study). a distribution of all 0's and l's was calculated before (al and b l ) and after (a2, b2, c) training for all teachers and presented in two graphs. four types of results were observed. they are summarised in table 3. the results of both observations a and b, before (al, bl) and after (a2,b2) training, were calculated as percentages and visually presented in figures 3 and 4. questions in the schedule which caused confusion ( 1 0 ) , or where no gains were made (0 0), should be altered to be better understood or should be specifically focused upon in training. on the other hand, questions where existing knowledge (1 1), or gained knowledge (0 1) were observed, could be regarded as adequate for future use. evaluation of scoring this information was obtained by assessing the margin of error exhibited for each question. therefore all scores from the completed schedules were compared to a norm (the value of which was allocated by a specialist team prior to training), and then statistically analysed.. this analysis was done by obtaining the root mean square (rms) (kirkpatrick, 1974) of the deviations from the norm for all 5 observations (al, bl, a2, b2, c), and then comparing them. this information in turn determined not only the magnitude of errors per question, but also the degree of complexity of each case. the deviations from the norm were calculated by subtracting the teacher's score from the norm. the rms's of these deviations were then used as basis of assessing the questions: the larger the deviation from the norm, the less accurate the observation. an overall impression of suitable questions can be obtained by anna-marie wium and erna alant considering the distribution of the deviations. this is presented in fig. 7, where the number of cases (expressed as a percentage of the total number), was grouped in intervals of 25% of the deviation from the norm. the accuracy of teachers' observations as they deviated from the norm was calculated for the individual questions for all three cases (a,b,c). the scores documented before training were compared with those after training and indicated questions to be changed. in calculating an average error per question for all cases (a,b,c) observed, an indication of problematic questions could be obtained. questions with a >1.5 variation were considered as those questions which elicited poor scoring accuracy and should therefore be changed or receive more attention in future training. questions with a <1.5 accuracy were considered adequate for future use. results and discussion the schedule was evaluated from two perspectives: the teachers evaluated it for ease of use content and structure of the schedule were evaluated by identifying questions (items), that proved to be difficult to assess. evaluation of the schedule by teachers the data from this evaluation was obtained from a closed-ended questionnaire and the results are presented as a distribution graph. the results describing the ease of use of the schedule are presented in figure 1 below. from figure 1 it is clear that in general the teachers regarded the schedule as good or very good, and easy to use. none of the teachers evaluated any aspect on this questionnaire as poor or unacceptable although they had these options to choose from if they wanted to. the instructions for use as well as the questions within the schedule were regarded as clear, and its appearance was well received. the length of the schedule for classroom use was considered acceptable (the alternative options to choose from were "too long" or "too short") which actually reflects the optimum choice. in general, the schedule was evaluated very favourably by the teachers and they thought that it would be of great future use to them. j evaluation of content versus structure of the sched ule the problematic questions in the schedule were identified by using a two-level approach: ] table 3: four types of results for identification of items (0-1): gains made by training in ability to identify a function. the number of teachers who could not identify the function before training but could do so afterwards. a decrease of errors after training made by the group indicates that they had gained in observation skills regarding their ability to identify functions. (0-0): no gains made. this implies that the teacher could not identify the function before training and neither could she do it after training. ίβ^ββλη^ϋίβλ existing knowledge. these results imply that the teacher could identify the function before as well as after training. e^bp^blie^pllll^llillii incorrect the teacher identified the correct function before training but could not do so after training. the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the development of a screening schedule for use by abilities of children with severe disabilities firstly, it was established whether teachers could recognise the particular skill (described by the item in the schedule) as exhibited by the student thus whether the skill was displayed. secondly the accuracy with which teachers could score (rank) their observation on a six-point rating scale was investigated. it was necessary to differentiate between these two aspects in assessing a particular item to prevent confusion. it is much less difficult to identify an item (skill) as present or absent by attributing a positive (1) or negative (0) value than to scale (score) it from 0 5. scoring could be considered a more advanced skill which requires extensive training. the data (collected before and after training), was used to measure the success with which teachers could recognise items in the schedule as well as to identify questions where items were unreliably scored on a rating scale. recognition of items for all items and for individual cases the questions of concern are those where the item could not be recognised correctly after training. a summary of correct and incorrect answers (after training) was comteachers to describe the communication 21 piled, and is presented in figure 2. from this figure it is clear that after training approximately 31% of the items were identified incorrectly, while 69% were correctly recognised as being present or absent. it is significant to note that the fact that they could identify 69% of the questions before training, could imply that the questions in the schedule were formulated in a user friendly manner and that most people could understand it without any training. an analysis of the schedule for cases a and β together may be misleading, therefore cases a and β were studied separately. these results are presented in figures 3 and 4, where the results obtained prior to training were also included. four classes of answers could therefore be distinguished and are presented in table 3. general analysis of individual cases the sum of the first two categories in the correct group (1:1, 0:1), corresponds with the "correct" class in figure 2, while the latter two can be regarded as being equivalent to the "incorrect" class in that figure. from figure 3 it is apparent that for case a, a total of 65.7% (45.7% + 20.0%) is correct after training, compared with 69.3% for both cases. s c h e d u l e ease of feraphing ease of arithmetic ease of scoring ease of assessment tv clear understood questions understood instructions length appearance c o m p a r i s o n of o b s e r v a t i o n s e v a l u a t i o n o f q u e s t i o n s conect 69% inconect 31% figure 1: teachers' evaluation of the schedule c o m p a r i s o n o f o b s e r v a t i o n s p r e & p o s t t r a i n i n g : c a s e a incorrect 22.5% correct 45.7% correct/incorrect 11.7% incorrect/correct 20.0% figure 2. total of all questions c o m p a r i s o n o f o b s e r v a t i o n s p r e & p o s t t r a i n i n g : c a s e β incorrect 15.4% correct 57.3% correct/incorrect 11.7% incorrect/correct 15.6% figure 3. difficult questions in observation a figure 4. difficult questions in observation β die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 in figure 4, the total of correct items in case β amounts to 72.9% (57.3% + 15.6%), or a difference of 7,2% between the two cases. . it is also important to evaluate the impact of the training: for case a (figure 3), the correctness of answers improved for 20% of the answers, and decreased for 11.7% of the answers (a net gain of 8.3%). for case b, (figure 4), a net gain of 3.9% was recorded which is much less than for case a. (a) questions litems in the schedule that the teachers found difficult to recognise the results were finally used to identify individual questions where teachers found it difficult to recognise the presence or absence of a skill. these results are presented in figures 5 and 6 and should be looked at as a pair in order to distinguish different patterns in shading. particular attention should be paid to the darker and solid areas as these represent correctly identified items, while the lighter areas represent incorrect observations. it is obvious when observing figures 5 and 6, that there is a marked difference in the patterns between cases a and b. questions which were poorly identified in case a were much better identified in case b, and vice versa. a good example of this is where question no. 7 was poorly identified by 9 (75%) of the teachers in case a but only by 2 (16%) in case β after training. this shows that the teachers understood the questions but that they might have had other difficulties, e.g., unfamiliarity with the case presented (which is discussed later). by studying figures 5 and 6 specific questions were identified as difficult. all the questions which could not be identified by more than 25% of the teachers after training, were regarded as difficult and are listed in table 4 below. it was only after all these questions were listed (see table 4), that similarities could be detected which in turn identified problematic questions. questions which were repeatedly regarded as difficult in both cases a and b, consist of 12% (6 out of 47) of the total number of questions. these questions (all ab or ba responses), were labelled as problematic and are numbers 21, 26, 31, 33, 38 and 39. these questions need more attention during training by more demonstrations and explanations. the motor skill area seems to be relatively difficult as 2/3 of the questions in this skill area are listed as difficult, which also includes half of the problematic questions on this list. this indicates that teachers found the terminology and assessment of anna-marie wium and erna alant c o m p a r i s o n o f o b s e r v a t i o n s p r e a n d p o s t t r a i n i n g : c a s e a 12 10 c 8 ο s 1 6 h. h) ο 4 2 11 ι τ υ y c o m m u n i c a t i o n • incorrect [g cor/incorrect ρ ί cognitive m o t o r s e n s o r y s o c i a l ] incor/correct gg correct figure 5. difficult items to identify in observation a c o m p a r i s o n o f o b s e r v a t i o n s p r e a n d p o s t t r a i n i n g : c a s e β c o m m u n i c a t i o n ^cognitiv^^ m o t o r >4 s e n s o r y ̂ "^socfef • incorrect m cor/incorrect m incor/correct g c o r r e c t figure 6. difficult items to identify in observation β a c c u r a c y in s c o r i n g s u m m a r y o f d i s t r i b u t i o n o f e r r o r s 10% 15% 20% p e r c e n t a g e of q u e s t i o n s 25% figure 7. categorised results of the distribution of errors the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the development of a screening schedule for use by abilities of children with severe disabilities motor skill area difficult. the majority of teachers in this study had not yet worked with physically disabled hildren and therefore had no knowledge of this skill area. this is therefore not a reflection on the schedule, but more on the teachers' experience. (b) teachers' accuracy in scoring (rating 0-5) the items in the the schedule the data obtained from the completed schedules also provided information on the questions which elicited poor scoring. teachers scored their observations which were compared with the norm, on a scale from 0 to 5. the size of the deviation from the norm indicated their ability/inability to score a specific item, e.g., when the teachers' scores deviated more than two numerals on a scale from 0-5 then their scoring ability was considered as poor. when their scores deviated one numeral (on a scale 0-5), then teachers to describe the communication 23 their scoring ability was considered as inconsistent. an overall impression of suitable questions can be obtained by considering the distribution of the deviations. this, is presented in figure 7, where the number of cases (expressed as a percentage of the total number), was grouped in intervals of 25% of the deviation from the norm. from figure 7 it is clear (when adding the number of questions in the two intervals of deviations between 26% and 75% from the norm), that there is a large percentage (45%) of questions in this section. also, none of the questions deviates more than 200% (2 numerals on the scale 0-5), from the norm. it must be made clear that the term % might be misleading and should be regarded as a unit (e.g., 100% deviates in fact 1 score from the norm). a more detailed account of the specific problematic questions was obtained when the average error per question was calculated and it became clear that 12,7% of the questions deviated more than 150%. the specific questions are table 4: difficult questions to identify no question prior tu training after training co mmunication skills 1 how well does he respond to his name being called? a 3 to what extent does he look at preferred item to indicate choice? a 7 how well does he make sounds? a a. 11 how well does he use questions? β β 12 how well does he use yes/no responses? β β 15 how well is his speech understood by others? β β co gnitive skills 18 how well can he imitate movements after a model? a a 21 how well does he follo.w a one-step command/request ? ab ab 23 how well does he use jan object for what it is meant for? a a mc >tor skills 26 how well is the student positioned for function? β ba 28 how good is his muscle tone? (floppy/very stif!/mixed=0, normal=5)? β β 30 how well can he reach with right arm (range of motion)? β β 31 how well can he reach with left arm (range of motion)? ab ab 33 how good is the fine co-ordination in his dominant/user hand? ab ab 34 to what extent are uncontrolled movements (arms/legs) present? (normal=5) a a se nsory skills 36 how well does he visually attend to a task? • a a 38 how well does student visually follow moving object? (tract) ab ab 39 how well does student visually select a preferred choice? (scan) ab ab μ cial/emotional behaviour 45 how often does self-stimulation occur? a a 46 how well does he make eye contact during communication? β a = case a; β = case β; ab = both cases a and β die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 lematic to score^han any other^ ^ w a ^ ^ ^ ^ t m v r r s n g w s t s in accordance with finds t s a m f a n " i e l d y k e (1988), who stated that the assessor should be skilled. when the scoring of the individual skill areas was studied, it became dear tha the teachers were too broadly trained in the skill areas to be tested with such a relatively fine measuring instrument. however, the repeated use of the rating scale is useful for monitoring progress in the classroom. in general, the items in the schedule were not significantly better scored after training. scoring is considered an advanced skill which requires more training. problematic questions in the schedule when both the ability to identify the items as well as the scoring of the schedule are taken into account, six questions were found to be difficult, of which four were found in the motor skill area of the schedule. of these only one question needs to be rephrased. difficult questions require specific attention in future training. conclusions the results indicated that the schedule is adequate for future use as teachers found it easy to use and the questions were adequately phrased. the training of teachers in the use of this schedule, however, needs to focus more on unfamiliar skill areas depending on the experience of the teacher (e.g., teachers who work with children with only cognitive disabilities would need more familiarisation with the motor skill area as their children are not physically disabled). the scoring routine of the schedule should be considered as an advanced skill which may need more practise and further training. the results obtained in this study highlight various issues which could have had an effect. this study showed that some children are more difficult to assess for specific teachers than others. two important factors which have to be kept in mind are: the teachers' familiarity with the disability: the majority of teachers in this workshop were unfamiliar with physically disabled children as they were used to working with primarily cognitively disabled children. the terminology applicable to the motor skill area was therefore especially at risk. this was pointed out as two thirds of the questions regarded as difficult occurred in the motor skill area. the effect of familiarity with the anna-marie wium and erna alant disability observed could be seen in their ability to identify items as well as in scoring. furthermore, the fact that the items which were poorly identified, and the items poorly scored did not match each other, supports the notion that the questions in the schedule are not so much poorly phrased, but that teachers were less familiar with certain skill areas due to their experience with specific disabilities. these results underline the complexity of assessing the severely disabled child (culp & carlyle, 1988), and also the fact that it is not easy to learn to observe objectively and in depth. it is therefore essential that future initial training workshops train a specific group of teachers with a familiar disability, as more reliable results could be obtained. additional disabilities can be introduced with more advanced follow-up courses in order to make teachers better observers. secondly, the severity of the disability: in addition to the above, teachers were also not familiar with the severity of the disabilities observed. the majority of teachers who attended this workshop had not been exposed to severely physically disabled children as their own . students were mainly severely or moderately cognitively disabled. familiarity in the use of the schedule and the ability to observe depends on repetition (stevens, 1978). this also became clear during training where it was observed that the more experienced and skilled teachers became in the use of the schedule , the less time was required to complete it and the more accurate their scoring became (as was continually noted in observation of case c). perhaps the most significant contribution of the schedule and the training was the effect it had on the selfconfidence of the teachers. the results in figure 1 indicated they felt confident of their ability to apply the schedule in future. this study has provided teachers with a screening tool as well as training in the use of the tool. the ability to effectively assess students by using the schedule made teachers feel efficient and in control. practise and continual use of the schedule will_ make them feel even more confident and efficient in assessment. this implies that teachers who are able to use the schedule effectively, become empowered to perform their role as teachers more successfully. most importantly in this study, the issue of a transdisciplinary approach was addressed. one of the problems in aac service delivery was that the responsibility of assessment had largely been considered as that of the professional speech therapists (hogg & raynes, 1987). such measures resulted in it being an exclusive service in this country, focusing on the community with the table 5: questions poorly scored no description of question skill areas 2 to what extent does he want to communicate with others? communication 6 how well can he point to an object (finger or hand)? communication 34 are any uncontrolled movements present? motor 36 how well does he visually attend to a task? sensory 41 how well does he attend auditory? sensory 45 how often does self-stimulation occur? social/emotional the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) l o o m e n t of a screening schedule for u s e b y the d e ^ o f children with severe disabilities a i ' ancial resources to afford it. this study provides a ! p n i n g instrument w h i c h can b e used b y a m u c h crroup of people, w h i c h in turn makes the service ΐ £ ι ι ^ β γ γ ν of aac more available and accessible to those work with children with severe disabilities. the f this schedule enables teachers to identify probγ δ β ° to refer to a specialised multi-disciplinary t e a m when necessary, to plan communication objectives and to monitor progress. this in turn results in more effective service delivery where problems such as limited manpower and funding are addressed. a c k n o w l e d g e m e n t s this study was funded b y the university of pretoria. r e f e r e n c e s american speech-hearing-language association (1992). (joint committee for the communicative needs of persons with severe disabilities). guidelines for meeting the communication needs of persons with severe disabilities. asha, j4w), barlow d & hersen, m. (1984). single-case experimental designs: strategies for studying behaviour change. oxford: pergamon press. . . . bereer a f presperin, j. & tallman, t. (1990). positioning for function: wheelchair and other technologies. new york: valhalla rehabilitations communications. beukelman, d.r. &.mirenda, p. (1992). augmentative and alternative communication: management of severe communication disorders in children and adults. baltimore: paul brookes publishing co. cuip, d. & carlyle, m. (1988). partners in augmentative teachers to d e s c r i b e the c o m m u n i c a t i o n 25 communication training. tuscon, arizona: communication skill builders. durant, v.m. (1990x severe behaviour problems: a functional communication training approach. london : the guilford hogg, j. & raynes, n. (1987). assessment in mental handicap: a guide to assessment practices, lists and checklists. london: croom helm. huer, m.b. (1983). the non speech ifest for receptive/expressive language. don johnston developmental equipment, inc, usa. kirkpatrick, e.g (1974). introductory statistics and probability for engineering, science and technology. in w.j. fabrycky, & j.h. mixe (eds.). new jersey: prentice-hall. light, j. (1989). toward a definition of communication competence for individuals using augmentative and alternative communication systems. aac, 5(2), 137-142. light, j., dattilo, j., english, j., gutierrez, l. & harts, j. (1992). instructing facilitators to support the communication of people who use augmentative communication systems. journal of speech and hearing research, august, 35, 865-875. mirenda, p. & iocono, t. (1990). communication options for persons with severe and profound disabilities: state of the art and future directions. journal of american speech and hearing, 15(1), 3-21. salvia, j. & yseldyke, j.e. (1988). assessment in special and remedial education. boston: houghton millin company. skuy, m., westaway, m., makula, n. & perold, c. (1988). development of a screening instrument for the identification of pupils with impairments. south african journal of education, 8(1), 45-49. stevens, m. (1978). observe then teach: an observational approach to teaching mentally handicapped children. london. edward arnold. wium, a.m. (1994). the development of a screening schedule for' teachers to describe the communication abilities of children with severe disabilities. unpublished m. log. thesis. university of pretoria. 0 play i x a n d m s c h o o l r o o m ! s h o p 6 l t h e r o s e b a n k m e w s 1 7 3 o x f o r d r o a d 1 r o s e b a n k j h b . tests, programmes, books, teaching aids, journals and resources for child development speech & language learning disabilities special needs p h o n e 788-1304 adult rehabilitation ^ s s i s w n i n social activities s a x o n w o l d f a x : 8 8 0 1 3 4 1 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 sonya warren, santie meyer and h.e.c. tesner afrikaa ns subjects english subjects south african signs 42% 35% variations voor dez a b in front cupped 1 finger extreme variation within compressed hand of) hand this sign compressed hand sig move hand point move hand across chest forward in finger forl-r or r-l semi-circle ward. wrist away from of dominant chest hand strikes wristof opposite hand tab chest neutral wrists chest orient verticalverticalverticaltoward body toward away from verticaltoward body body body face 50% 20% 87% na...toe dez a b (to) 1st finger 1st finger 1st finger 1st finger bilateral 1st finger sig move 1st point point finger join tips of fingers finger of finger join tips of fingers dominant hand along side of opposite 1st finger tab side of in front in front or l; r 1st finger of opposite hand opposite centre of body finger centre of body orient horizontal verticalvertical-unilateral opposite vertical-palm away palm down unilateral from body opposite face the use of signs and the coding of prefix markers by teachers at a school foi the deaf ι myrtle l aron, ph d (witwatersrand·) i robyn ε lewis, ba(log.) (witwatersrand) ba soc.science (unisa) j judy l willemse, ba (sp. & η therapy) (witwatersrand) department of speech pathology and audiology university of the witwatersrand, johannesburg abstract the use of aspects of an artificially devised manual code in a black schoolfor the deaf was examined. the encoding of prefixes, bound with the noun class system, in tswana as used by seven teachers was studied as well as the consistency of the teachers to code lexical items. results .indicated the absence of signed prefix markers, inconsistency in signing lexical items and much variability among teachers in the signs used. the educational and research implications are discussed. /'' opsomming die gebruik van aspekte van "n kunsmatig ontwikkelde gebarestelsel in 'n swart skool vir dowes, is ondersoek. die enkodering van voorvoegsels verbonde aan die naamwoordklasstelsel in tswana soos gebruik deur sewe onderwysers is bestudeer, asook die konstantheid van die onderwyser se vermoe om leksikale items te kodeer. resultate dui op die afwesigheid van voorvoegselgebare, onkonstantheid van leksikale gebare en baie variasie onder onderwysers t. o. v. die gebare wat hulle gebruik. die opvoedkundige en navorsingsimplikasies word bespreek. ^ ο sasha 1986 77^ south african journal of communication disorders, vol 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) -fhe use of signs and the coding of prefix markers by teachers at a school for the deaf 65 the objective of deaf education has always been to teach the child the language of his culture — the culture of the hearing society in which he must live (bornstein, 1978; lewis 1984). this objective has pertained irrespective of the mode of communication used in in teaching deaf children. the long standing conflict between the use of oralism and manual communication still prevails although there has been a shift over the last twenty years in most education institutions for the deaf towards the use of manual communication often within a total communication framework. this shift has come about largely due to the apparent failure of oralism and oral education to teach spoken language and the increased use, interest and research into sign languages. total communication embraces an eclectic philosophy, which includes the combined use of a sign language system, manual coding, fingerspelling, speech, auditory training, speech reading, amplification, cueing and any other means whereby the child is taught to encode and decode language. a true natural sign language, which is the visual-gestural language of a deaf community, has its own lexicon, "phonological" and syntactic structure which is systematic and rule-governed. its basic encoding unit is the word represented by a sign. inflectional marking is distinguished by spatial temporal dimensions. nonmanual signs, such as stylised facial expression, also denote syntactic forms, such as question-type and subordinate clauses. (klima & belugi 1980; liddell, 1980; stokoe, 1978). it is expected that existing "natural" sign languages in south africa would show great divergence from each other due to the diverse ethnic, demographic and politically induced separation of social groups as well as differences in the spoken mother tongues. natural sign language plays a central role in maintaining the culture and ethnocentricity of deaf communities and is bound to the whole culture on one hand and physical constraints of the users on the other (stokoe 1978; cokeley and baker 1980; erting 1981). manual coding differs from natural sign in that it has been artifically devised by educationalists to represent the syntax of spoken language. in addition, some codes represent the morphological structure of the language in varying degrees (crystal et al. 1976; evans 1982). however, it is important to note that /tlie more reputable and widely used of these codes supplement the natural sign language, rather than replacing it. in order to relate sign language to coding, woodward (1972) suggested a sign continuum, with natural sign language at one end and the contrived sign systems at the other. a pidgin sign language occurs between the two extremes and incorporates elements of both signing and coding — it derives from the necessity for communication between deaf and hearing individuals. manual codes (mc) are used in educational settings and never as the home language of deaf people. examples of mcs include:signed english, manual english, seeing essential english (see) and signing exact english (see2), the rochester fingerspelling method and the paget-gorman sign system (pg). the latter system was developed in england and is of significance in south africa. it was first introduced at the kutlwanong school for the deaf in bophuthatswana some twenty-five years ago. no doubt it changed its form over the years of usage and undoubtedly provided part of the framework for the text talking to the deaf developed by nieder-heitmann past principal of kutlwanong school for some years. this text has now been introduced into all black schools for the deaf in southern africa. teaching staff are trained to use talking to the deaf by means of short courses and videotape (van der merwe, 1986). i the book talking to the deaf consists of 1500 signs which are claimed to be representative of signs used by the majority of deaf south africans. there is no empirical evidence or published data to support this claim. penn et al. (1984) provide preliminary evidence to show that these signs are not used by all deaf groups. the relationship of the nieder-heitmann (n-h) signs to natural sign languages is therefore much in question. the south african black languages are heavily morphological, being characterised by a noun class system and extensive agreement based upon that system. prefixes on the noun stem indicate noun class and number. th e prefix determines the form of the agreement morphemes of the other sentence constituents, all of which must be brought into agreement with the determining head noun (cole, 1982). although the n-h code makes some provisions for manually coding the syntax of black languages, this does not extend to the noun class system. according to gustason (1983) an effective code increases the input of morphological markers, word endings and other structural elements. it appears relevant and necessary to explore whether the use by teachers of the recently introduced dictionary of signs — talking to the deaf (nieder-heitmann, 1980) incorporates adaptations such as prefix markers intrinsic to tswana, the spoken language of the area. one black school for the deaf was selected for studying this. method aims of this study (1) to determine whether the teachers in a black school for the deaf are encoding certain prefixes of the tswana language, and if so, what form of coding they are using. (2) to examine the consistency with which the teachers are reproducing there prefix markers. (3) to ascertain whether the sign for a lexical item (noun) remains the same when used in isolation and in context by each teacher subject. (4) to note whether there is any influence of the signs from the original paget-gorman system on the signs used by the subjects for lexical items. seven subjects (a,b,c,d,e,f & g), all teachers at a black school for the deaf were selected. in addition, twenty-one pupils at the school were used to simulate a communicative interaction between teacher and pupil. the teacher subjects (ts's) were required to be native tswana speakers and to have taught at the school for at least two years so as to be familiar with the signing methods in use. all the ts's were teaching standards 1-5, in order to ensure that a sign system was used in the classroom, and that the test items were appropriate and meaningful. the pupils used to simulate a classroom situation were congenitally deaf, their home language was tswana and they had attended the school for a minimum of two years. they were therefore familiar with the signing system used during this time period. a national wv361 portable videocamera was used to record each ts's performance on the tasks. five tswana nouns, each from a different noun class and in singular and plural forms were selected. these nouns appear in talking to the deaf (nieder-heitmann 1980). the nouns selected were: noun class 1 moruti (teacher) noun class 2 mollo (five) noun class 3 leru (cloud) noun class 4 segokgo (spider) noun class 5 podi (goat) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 66 these lexical items were chosen for their frequency of use and relevance within the teaching situation. due to time limitations noun classes la, 6, 7, 8 and 9 were excluded. classes 1 to 4 take both singular and plural prefixes. multi-syllabic words in class 5 do not take a singular prefix (cole, 1982). this class was included . to ascertain whether coding of the singular occurs in spite of the absence of a prefix. as the plural prefixes of class 4 and 5 nouns are the same, it would be of interest to note whether they were coded differently. in addition, the object pronouns of each class were included in the test material as their grammatical form corresponds to the noun prefix. the object pronouns are as follows:noun class 1 ke a mo rata (i like him/her) noun class 2 ke a ο besa (i light it) noun class 3 ke a le bona (i see it) noun class 4 ke a se bolaya (i kill jt) noun class 5 ke a e gama (i milk jt) each ts was required to sign the selected nouns in the following forms: (1) singular — in isolation: moruti (teacher). (2) singular — in context: ke rata moruti (i like the teacher). (3) singular pronoun: ke a mo rata (i like him/her). (4) plural in isolation: baruti (teachers) (5) plural in context: ke rate baruti (i like the teachers). (6) plural pronoun: ke a ba rata (i like them). the subjects were video recorded signing the five nouns to the examiner (e) alone, and to three pupils. this was to ascertain whether the ts's would convey the prefix markers in an instructional setting with more deliberation. the nouns were signed in isolation and in context to see if they changed in form with varied syntactic contexts. at the end of the study the ts's were also required to complete a questionnaire concerning their awareness of the noun class system in tswana, and their need to convey such information to their pupils. in addition, information which might influence the ts's proficiency in sign usage was tapped, namely: teaching qualifications, length of teaching experience at the school, method of sign instruction, and perception of consistency of sign usage at the school. a questionnaire was also completed by the school principal, concerning the school's policy to signing, how the noun class system should be taught and the instruction of teachers in the system. analysis of data the signed nouns will be described, using the nieder-heitmann (n-h) code as reference. in addition, the paget-gorman signs will be considered in order to compare this original code with n-h and the ts's variations of the n-h code. each signed noun produced by the ts's was recorded as the same as the n-h system, or a variation (v) or as a totally different sign (d) to the n-h system. the variations or the different signs from the n-h were arranged in terms of the three cheremes described by stokoe (1976): a) dez (designator) — the configuration of the hands, b) tab (tabula) — the location on or near the body while the sign is made, (c) sig (signation) — the movement aspect of the hands. in addition, the signed noun in isolation (condition "a") was compared to its use in a syntactic context (condition "b") and described as the same (s) or different (d). myrtle l. aron, robyn e. lewis and judv l w „ 1 " w'"emse two graduate speech therapists acted as raters to analys sample of the teachers' signs to assess the accuracy of tl^ * v ' d e ° and categorization of all the signs as determined bv o r , a n a ' y s i s authors. e o f 'he results 1. signed nouns a. description of signs table 1 provides a description of the responses recorded denotes whether the signs used were the same as described^ nieder-heitmann (1980), or a variation thereof — the variaf ^ used are described in the table. table 2 provides a summa °of the data in table 1 and indicates the percentage scores of whethe the responses were nieder-heitmann signs, variations thereof totally different signs. it can be seen from both table 1 and table 2 that consistency i n signing between the ts's is minimal. only for the nouns "moruti" and "mollo" is there some overlap, where two ts's used the same variation. other variations are used exclusively by each ts however, many of the variations are minimal, differing in a single chereme. it can be noted from table 2 that a large percentage of signed nouns used are variations of the n-h signs (x80%). there was one occurrence of "moruti" which was totally different, and four occurrences for "podi". it is interestingto note that all ts's used the sign "preacher" rather than "teacher" (moruti). stokoe and kuschell (1979) note the significance of cultural factors in language and this may be an example of such cultural factors. comparing tables 1 and 3 it is clearly evident that the p-g signs differ extensively from both n-h and the ts's variations. reference will be made in the discussion, to the significance of the lack of similarity between the p-g and the teacher variations, although a study of the pupil's use of natural sign as compared with p-g would be of significant interest. b. consistency of use in isolation as compared to use in context there were two occurrences out of a total of seventy in which the signed nouns were different when used in isolation and context. the influence of syntactic context did not appear to affect the formation of the sign. however, as only a single syntactic context was used, this finding must be viewed with caution. writers such as stokoe (1976), and klima and bellugi (1980) have illustrated much variance in signing in context. signs may vary in terms of spatial and temporal dimensions. c. consistency of use in the demonstration of signs by the ts's to the ε as compared to the use of signs to pupils. there was also high consistency (80%) for the two situations. native users of sign language belong to a diglossic community, implying varieties of signing used by the same speaker under different conditions, particularly when addressing deaf or hearing individuals. as the ts's are not native users of sign, and only use it in the educational setting, this may explain the non-variance. ii prefix markers signed prefix markers were not used by the ts's for any of the test items. this fining indicates that no manual means exist in the signing system for coding the variety of noun classes in tswana. this was substantiated by the ts's answers to the questionnaire. five ts's reported that the noun class system is not taugn formally, but is deduced by the pupils from the written form. τ 1 s written form is recorded on a wall-chart, used for learning dn the school principal was uncertain as to how the noun pretixe the south african journal of communication disorders, vol. 33, r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) n>« nh the coding of prefix markers by teachers at a school for the deaf u s e of sign s anu 67 13v • t on of the variations with dez, tab and sig formations of the lexical items used by the teacher subjects as compared to f»ble 1 ^ ^ e r h e i t m a n n reference signs ( ii) variations: bilateral: th&l-f positioned approximately 3cm apart, b of hands face body. 1. unilateral 2. bilateral: not symmetrical 1-h; 1-f points up, th & 2-f slightly apart point horizontally 2-h: as for n-h sign. 3. bilateral: th & 1-f further apart, ρ faces body 4. unilateral: 1-f and then tab sig no. of subjects using signs in the 2 situations ts to ε ts to pupils neck/throat 2. mollo (i)n-h sign: (ii) variations: 3. leru (i) n-h sign: (ii) variations: bilateral: spread-h, ρ faces body 1. unilateral 2. compressed-h 3. compressed-h 4. unilateral: compressed-h 1-h:side of face 2-h as for n-h sign chest neck and chest. chest 5. — bilateral: spread-h; b. of hand faces floor abdomen level with forehead i 1. — 2. unilateral: flat-h; ρ faces floor. 3. cupped-h; p. faces floor 4. unilateral: flat-h; p. faces floor 5. unilateral: clawed-h; p. faces floor 6. unilateral: p. faces floor 7. unilateral: flat-h p. faces floor 8. unilateral: flat-h above head above head. move hands apart from midline to edge of neck indicating collar. 1 (e) 2 (f&g) move hands across from 2 (a;c) 1 (a) one side of neck to the other 1-h stationary 0 1 (b) 2-h: move hand across from one side of neck to the other move hands apart from 2 (c:d) 2 (c:d) midline to edge of chest. move 1-f across neck, then 1 (f) 1 (f) flat-h down chest. move hands up and down and repeated tapping movement of fingers indicating flames. tapping movement of fingers against th no up and down hand movement. tapping movement of fingers against th only upward hand movement. 2 (a:g) 2 (a:g) 1 (b) 2 (c:e) 1 (d) 1 (f) move hands apart from 0 midline, using pronounced semi-circular movements along a horizontal plane. hands positioned adjacent 1 (a) each other and move in same direction across body moves hand shorter 1 (b) distance along horizontal plane; very slight semicircular movements. very slight semi-circular 1 (c) hand movement. moves hand shorter 1 (d) distance along horizontal plane; very slight semicircular movements. moves hand along horizon1 (e) tal plane: initial semicircular movements very slight. moves hand along horizon1 (f) tal plane; rapid and very slight semi-circular movement. 1 (g) fingers move independently 0 1 (b) 2 (c:e) 1 (d) 1(f) 0 1 (a) 1 (b) 1 (c) 1 (d) 1 (e) 1 (f) 0 1 (c) d" suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 68 myrtle l. aron, robyn e. lewis and judy l. willemse 4, segokgo (i) n-h sign: unilateral: clawed-h; level with nose slow vertical movement 0 0 p. faces floor. from centre/neutral position to position level with nose; then slight horizontal movement, fingers move rapidly as if typing. (ii) variations: 1. bilateral chest hands across at wrist; 1 (a) 1 (a) no vertical movement of hands; fingers move in unison tapping against th. 2. — — hands move diagonally 1 (b) 1 (b) from side of chest to above head. 3. — neck/throat slight horizontal hand 1 (c) 1 (c) movement absent. 4. — — hand moves across chest: 1 (d) 0 no vertical movement of hand upwards. 5. cupped-h. — no finger movement; 0 1 (d) no vertical movement of hand upwards. 6. — — rapid vertical movement; 1 (e) 1 (e) slight horizontal movement absent. 7. — chest no vertical movement 1 (f) 1 (f) of hand upwards. 8. b. of hand faces body — vertical movement begins 1 (g) 1 (g) in upper chest region, slight horizontal movement absent. 5. podi (i) n-h sign: unilateral; fist-h; neck/throat hand moves from chin a 1 (g) 1 (g) knuckles face away short distance vertically from body downwards, indicating beard. (ii) variations: 1. th, 1-f and 2-f together — hand moves from chin in 1 (a) 1 (a) semi-circle outwards. 2. bilateral; not r.h. top of head r.h. — stationary 1 (c) 0 symmetrical l.h.-neck/throat l.h. rapid movements up r.h. — v-h and down from chin. l.h. — th, 1-f and 2-f together. i 3. same as 2. same as 2. r.h. — stationary 0 1 (c) ! l.h. — one slow movement i down from chin. 4. th (on top of chin) — slow downward movement 1 (e) 1(e) 1 and 1-f (under chin) against chin twice s. same as 4. — rapid downwards 1 (f) 1 (f) movement against chin. key: f — finger th — thumb b — back ρ — palm 1-f — first finger 2-f — second finger 3-f — third finger 1-h — first hand 2-h — second hand r.h. — right hand l.h. — left hand flat-h — flat-hand spread-h — spread-hand compressed-h — compressed hand cupped-h — cupped-hand clawed-h — clawed-hand fist-h — fist-hand v-h — v-hand the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) he use of signs and the coding of prefix markers by teachers at a school for the deaf 69 ble 2 signed nouns used by each teacher subject in terms of whether they are nieder-heitmann signs, variations thereof, or totally τ 3 * different from the nieder-heitmann sign, and number and percentage of occurrence within each category in both situations across all nouns. situation sign n-h v d tss situation moruti mollo leru segokgo podi no/10 % no/10 % no/10 % a + v v n-h n-h v v v v v v 2 20 8 80 — — β + d v v v v v v v d d — — 7 70 3 30 c + v v v v v v v v v v — — 10 100 — — d + v v v v v v v v d d — — 8 80 2 20 ε + n-h n-h v v v v v v v v 2 20 8 80 — — f + v v v v v v v v v v — — 10 100 — — — v n-h v v n-h 5 50 5 50 _ + n-h n-h v v n-h x 9 13 56 80 5 7 key: — = ts demonstration to e; + = ts demonstration to group of pupils; n-h v = variation of n-h sign; d = totally different from n-h sign = nieder-heitmann sign; table 3 description of paget-gorman signs within dez, tab and sig formations (nieder-heitmann 1980) sign dez tab sig teacher (moruti) (no sign for preach/er) 1-h: 1-f pt up, tl & 2nd finger pt horizontally. 2-h: compressed hand 1-h level with shoulder 2-h-side forehead 1-h: extend tl & 1 finger outwards. 2-h-twist wrist to open hand fire: (mollo) (unilateral) 5 point-hand, (fingers & thumb pt upwardstraight & seperate from one another) side of chest move all digits simultaneously & independently of one another cloud (leru) unilateral, spread-hand, palm faces floor forehead vibrate hand vertically segohgo (spider) unilateral clawed hand p. faces floor shoulder hand lowers vertically, one hand length moving digits independantly podi (goat) 1-h; l f & 4-f up; 2-f & 3-f on th. palm faces floor. 2-h: 1-f on side 4-f. 1-h & th on side 2-f 1-h 1-h: shoulder 2-h: lower v2h. breadth closing th & 1-f. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 myrtle l. aron, robyn e. lewis and judy l. willemse table 4 description of the nieder-heitmann object pronoun sign across the cheremic configurations, and variations thereof sign dez tab sig n-h sign: unilateral; 1-f points diagonally downwards. side of body (same side as ! hand involved) stationary variations: dez 1: bilateral dez 2: f points straight or diagonally upwards. tab 1: f points to front of body. tab 2: f points above head. sig 1: hand moves across body, sig. 2: m table 5 description of the nieder-heitmann plural sign across the cheremic configurations, and variations thereof sign dez tab sig n-h sign: unilateral: th and 1-f meet. side of chest below shoulder of opposite side. move hand across chest from" shoulder on same side to lower position below shoulder of opposite side. variations: tab 1: mid-chest area. tab 2: lower face/neck area. tab 3: side of body opposite face. tab 4: mouth tab 5: shoulder of same side. sig 1: no movement of hand from shoulder of same side to other shoulder. sig 2: hand moves from midline of chest to opposite shoulder. sig 3: hand moves from shoulder to midline of chest. were taught to the pupils, but believed the teachers used the written mode. a single ts stated that she finger-spelled the prefixes and another emphasized the role of lip-reading. five ts's stated that no instruction had been given to them on how to convey noun classes. (the remaining two ts's appeared to miscomprehend the question, and responded inappropriately). ill the object pronoun and plural forms as indicated above the noun prefixes for both structures were not distinguished through manual means. they were illustrated purely as lexical items by their respective n-h signs or variations thereof, as were the singular nouns. the most interesting variations occurred for the object pronoun. the n-h sign does not account for a location shift, according to the direction in space appropriate to the person or object being referred to. however, in the variations used by some ts's (see table 4) it appears that there was an attempt to increase the morphological information. this is in accordance with pronominalisation in american sign language as well as various mce systems (gustason 1980). the n-h sign employs the non-manual component of eye direction — the signer is required to look at his hand when signing; presumably to indicate who is being referred to. this was observed in only two of the ts's. the n-h plural sign and variations thereof are described in table 5. it can be seen that there was a great deal of variation in both the tab and the sig cheremes. signs changed position in front of the body, in close conjunction with the context sign (schlesinger, 1978), and this principle was clearly seen operating here. a general trend was that the formation of the plural marker was less discrete in syntactic context than in isolation. iv results of the questionnaire put to teacher subjects 1) a single ts had a diploma in special education — the others had only a general primary teacher's diploma. evans (1982) feels that professional education of teachers of the deaf should provide for instruction in manual communication during a specialised period of study. 2) the period of service at the school ranged from 6 to 12 years. this suggests that all the ts's had been exposed to a signing system which differed from n-h for several years prior to its introduction. it would thus be expected that some confusion with the "old' system would arise, particularly if it is used by the children as their natural sign system. 3) the ts's stated they had been taught "the signs" by the more exerienced teachers at the school, as well as from the pupils and by using the text talking to the £><?a/(nieder-heitmann 1980). it appears that in-service training is the present mode of teacher instruction. all the ts's and the school principal acknowledge the variability in the signs used and cite the following reasons: (a) the recent change in the sign system (b) the fact that natural sign is still used by the older pupils who "do not understand the new signs" | (c) the n-h system is in its "first phase" of development and is limited. , discussion ' this study serves to illustrate the difficulty experienced (by hearing educators, in learning a prescribed manual code. the results obtained are further confirmed by du plessis (1985) who observed similar variation in the signing of the n-h code by teachers in several schools for the black deaf. the explanations given to him by the teachers as to why their signing was inaccurate, are similar to those given by the ts's in this study. his subjects believed that:the manual (talking to the deaf) was obsolete, the varied groups using signs in the republic were not consulted when it was compiled, and that the signs are probably based on those used by whites. the children are confused by the introduction of 'new' signs, andit is not a bona fide sign language and is unfit to use for communication. as a manual code, designed to teach the syntax of spoken tswana, the n-h code appears to have few attributes of the more popular codes, namely:to supplement already existing signs and to increase the input to the child of vocabulary and morphological markers, as well as other structural elements (gustason 1980). the south african journal of communication disorders, vo 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) he use of signs and the coding of prefix markers by teachers at a school for the deaf 71 there is universal support for initial mother-tongue education (unesco 1953, cited by reagan, 1986), so that many educators of the deaf are advocating the use of natural sign language as the medium of instruction in schools. in the multicultural, multilingual and multiethnic population of south africa it is postulated that there would be much linguistic diversity in deaf communities. little research has been carried out on the lexical, syntactic and cheremic nature of these languages (lewis, 1984; reagan, 1986; morgan, 1986). languages originate when people come together to form a society. the entire socio-cultural context of language users must be considered (erting 1981;stokoe 1979). as in the united states, south african languages probably also underwent development. american sign language (asl) was "creolised" from imported french signs, the indigenous signs of america and the sign languages which developed on school campuses where deaf children intermingled. the language was restructured on lexical, syntactic and cheremic levels and became more arbitrary (woodward, 1978, cited by morgan, 1986). this phenomenon probably occurred in south africa, which might explain the transition from the p-g code, to the present varied signs used. this creative construction of sign languages meets the communicative needs of its users, as with spoken languages. several educators in south africa may find virtue in the similarities between the apparent varied number of sign languages used in south africa and even asl and gestuno to meet their principal needs (viljoen, 1982) but this is spurned by the deaf (jones, 1982), and they violate current research findings (battison & jordan, 1980). if manual codes are devised by educators to teach spoken language, it seems logical that they should resemble the natural language as closely as possible. quigley and paul (1984) differentiate between manual code in their natural form and those that are artificially invented. in its natural form, a manual code uses the lexicon of the natural sign language of each deaf community and does not artificially invent signs for words or counter-act the existing signs. empirical research is likely to reveal varied lexicons for deaf groups in south africa (penn et al., 1984). / / conclusion no signs for encoding the morphological structures of tswana were evident in this study. although [most of the ts's in this study showed awareness of having to convey the noun class system in the classroom, a manual form for such instruction is not used. the efficacy of encoding the syntax of a spoken language, in order to aid the deaf child to acquire competence, is yet to be proved (quigley & paul 1984). some studies have shown that deaf children have similar receptive competence of inflectional markers to their hearing peers, when the markers are manually encoded. these children are suprerior to those using oralism only (bornstein et al., 1978). however, writers such as cokeley and baker (1980) question the advisability of supplying too many sensory stimuli simultaneously. they also state that few hearing individuals (teachers) may be sufficiently competent to sign all the spoken elements of language while speaking. the possible limitations of attempting to faithfully represent the structure of a highly inflected language such as tswana should be borne in mind. further research into the advisability of devising a manual code to teach the noun class prefixes of black language is required. wilbur (1976: 451) states ... no matter what the drawbacks are of any of these systems... there is strong-evidence that manual communication in any form is itself a more effective teaching medium than a straight oral approach. the writers express their concern at the dearth of empirical research into south african signing systems. the department of education and training has pioneered the use of total communication for teaching language to deaf black children. however, for this method to be truly effective, the most appropriate sign system should be selected. this can only be done with reference to the vast body of literature on signing and by studying current trends overseas. psycholinguists, with a background of knowledge in manual communication, should together with other related workers, research in the rich heritage of deaf culture and sign language in this country. references battison, r; jordan and king, i. cross cultural communication with foreign signers. fact and fancy. sign language studies, 10, 53-68, 1980. bornstein, h. sign language in education of the deaf. sign language of the deaf. psychological, linguistic and sociological perspectives, schlesinger, i.m. and namier, l. (eds). academic press, inc., new york, 1978. cokeley, d. and baker, c. american sign language: a teacher's resource text on grammar and culture tj publishers inc., maryland, 1980. cole, d.t. an introduction to tswana grammar. (4th impression) longman penguin southern africa, cape town, 1982. crystal, d., fletcher, p. and garman, m. the grammatical analysis of language disability. a procedure for assessment and remediation. edward arnold ltd., london, 1976. du plessis, j.c.l. report on black education: sign languages. in biennial council meeting reports. sa national council for the deaf october 24-25, 1985. erting, c. an anthropological approach to the study of communicative competence of deaf children. linstok press, maryland, 1981. evans, l. total communication. structure and strategy. gallaudet college press, washington d.c., 1982. gustason, g. and rosen, r. effective sign communication for instructional purposes. in using signing exact english in total communication. gustason, g. and zawolkow, ε (eds) modern signs press, 1980. gustason, g. manual english and american sign languages: where do we go from here? in language in sign: an international perspective on sign language. kyle, j.g. and woll, b. (eds). croom helm., kent, 1982. jones, a. letter addressed to the national council for the deaf on behalf of the adult deaf association, durban, natal, 1982. klima, e. and bellugi, u. the signs of the language, harvard university press, massachusetts, 1980. lewis, r.e. an overview of the research into the american sign language continuum and its relevance to south african sign languages and codes. in proceedings of the conference of the linguistic society of south africa, pretoria, july, 356-403,1984 liddell, s.k. american sign language system, monton, 1980. morgan, r.z. sign language in south african black communities implications for future research. unpublished dissertation submitted to the department of linguistics, faculty of arts, university of the witwatersrand, johannesburg, 1986. nieder-heitmann, n. talking to the deaf, government press, pretoria, 1980. penn, c., lewis, r. and greenstein, a. sign language in south africa: some research and practical issues. the south african journal of communication disorders, 31, 6-11, 1984. quigley, s.p. and paul, p.v. language and deafness, college-hall press, inc., san diego, california, 1984. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 myrtle l. aron, robyn e. lewis and judy l. willemse reagan, t.g. sign language diversity in south africa: a preliminary investigation, with implications for the education of the deaf. unpublished proposal for a research project, 1986. schlesinger, h.s. the acquisition of signed and spoken language. in deaf children: developmental perspectives. liben, l.s. (ed). academic press, inc., new york, 1978. stokoe, w.c. the study and use of sign language. sign language studies. 10, 1-36, 1976. stokoe, w.c. sign and culture, linstok press, maryland, 1978. stokoe, w.c. and kuschel, r. a. a field guide for sign language research, linstok press, maryland, 1979. van der merwe, a.j. deputy director — special education, department of education and training, pretoria, personal communication, march, 1986. viljoen, s.w. communication skills project — editorial, silent messenger, south african national council for the deaf, v 5 no 3, july/august, 1982. wilbur, r.b. the linguistics of manual language and manual systems. in communication assessment and intervention strategies. lloyd, l.l. (ed). university park press, baltimore, 1976. woodward, j. implications for sociolinguistic research among the deaf. sign language studies, 1, 1-17, 1972. an intonational analysis of deaf speech: a case study marguerite schneider, ma (applied linguistics) (reading, u.k.) department of speech pathology and audiology, university of the witwatersrand, johannesburg abstract the intonation of an english speaking congenitally deaf adult was analysed using the framework set out by crystal (1969) for normal spoken english. the analysis revealed a deviant and deficient intonation system. the main features of this system included, firstly, an excessive use of tone units resulting in unintentionally emphatic sounding speech; secondly, inaccurate and inconsistent use of both the grammatical and accentual junctions of tonicity; and thirdly, a deficient tone system with additional abnormal use of the tones which formed the subject's tonal repertoire. this paper highlights the need for both phonetic and phonological analyses in order to obtain a true indication of a speaker's performance. opsomm1ng die intonasie van 'n kongenitaal dowe engelssprekende volwassene is geanaliseer deur 'n raamwerk te gebruik wat deur crystal (1969) vir standaard engelse spreektaal opgestel is. die analise het 'n qfwykende en gebrekkige intonasiesisteem aan die lig gebring. die belangrikste kenmerke van hierdie sisteem is eerstens, 'n oormatige gebruik van tooneenhede wat spraak wat onopsetlik beklemtoon klink tot gevolg het; tweedens, onakkurate en inkonsekwente gebruik van beide die grammatika en aksentsfunksies van toon; en derdens, 'n gebrekkige toonstelsel met addisionele abnormale gebruik van die tone wat die proefpersoon se toonrepertoire gevorm het. die noodsaaklikheid van beide fonetiese en fonologiese analises vir die vasstelling van 'njuiste aanduiding van 'n spreker se prestasie word deur hierdie ondersoek sterk na vore gebring. introduction the congenital handicap of hearing impairment affects the normal development of intelligible speech (ling, 1976). intelligible speech is a function of both segmental and non-segmental aspects of phonology. in other words, in order to produce intelligible speech a person must have mastered the individual phonemes as well as the intonation system of his/her language. (in addition, intelligible speech requires the mastery of syntactic, semantic and pragmatic aspects of language, but discussion of these areas is beyond the scope of this paper.) normal hearing children develop basic intonational contrasts before they acquire the finer phonemic distinctions which are to be fitted into the intonation 'envelope' or pattern (bruner, 1975; crystal, 1979). phonemic errors and segmental phonological systems of hearingimpaired speakers have been thoroughly investigated in the literature (ling, 1976; stark, 1979; dodd, 1976). however, it is not only the phonemic problems which render the speech of the hearing-impaired largely unintelligible. abnormal prosody also plays a large role in this process (john and howarth, 1965; phillips et al. 1968; silverman and calvert, 1978; king and parker, 1980). until recently the prosodic features of deaf speech were described in a rather impressionistic manner using labels such as 'monotonous voice' and 'laboured speech' without much formal analysis to justify these. it is only recently, with the advent of © sasha 1986 visual display aids (eg. laryngoscope and visispeech as described by king, parker, spanner and wright, 1982) that researchers have been able to analyse and describe the prosodic features of deaf speech in an objective manner, as well as compare them to the norm (martony, 1968; nickerson and stevens, 1973; nickersonet al. 1976; phillips et al. 1968; king and parker, 1980). i i stark (1979) summarises the typical prosodic features found in the speech of the deaf. these include: 1 —errors in timing —excessive word and sentence duration —errors in rhythm —intonation problems such as too little pitch variation (monotonous voice) or excessive pitch variation. however, there is no indication as to whether these features are used to mark meaning contrasts. in other words, are these features used on a phonological level as well as on a phonetic one? if one of the aims of deaf education is to teach effective verbal communication, it is imperative that deaf speakers be taught to make meaning contrasts both by phonemic and intonational means. in order to develop appropriate teaching goals and methods we need to establish not only the phonemic systems used by deaf speakers but also their intonational systems or lack of them. the south african journal of communication disorders, vol 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 49 what do cochlear implants teach us about the encoding of frequency in the auditory system? johan j. hanekom department of electrical, electronic and computer engineering university of pretoria abstract this article explores the coding of frequency information in the auditory system from the viewpoint of what has been learnt from cochlear implants. cochlear implants may provide a window on central auditory nervous system function by creating the possibility to separate place and temporal information. an existing model of frequency discrimination in the acoustically stimulated auditory system is extended to include electrical stimulation. to be able to predict frequency difference limens for acoustic stimulation, an important assumption is that one spike per stimulus cycle is available, which may be provided by the existence of a volley principle. it is shown that to predict frequency difference limens for electrical stimulation of the auditory system, it must also be assumed that electrical stimulation causes desynchronization at a central auditory nervous system integration centre. with these assumptions, the model predicts the degradation in frequency discrimination that occurs for electrical stimulation. finally, it is shown that cochlear implants have not yet proven conclusively that either rate-place coding or temporal coding is predominant in the auditory system. opsomming hierdie artikel ondersoek die kodering van frekwensie-inligting in die ouditiewe stelsel vanuit die oogpunt van wat geleer kan word uit kogleere inplantings. kogleere inplantings kan 'n venster gee op die verwerking wat in die sentrale ouditiewe stelsel plaasvind, deurdat dit die moontlikheid skep om pleken tydinligting te skei. 'n bestaande model van frekwensiediskriminasie in die akoesties-gestimuleerde ouditiewe stelsel word uitgebrei om elektriese stimulasie ook in te sluit. om frekwensiediskriminasie vir akoestiese stimulasie te voorspel is die belangrike aanname dat een aksiepotensiaal per stimulussiklus beskiikbaar is, nodig. dit kan bewerkstellig word deur die werking van 'n sarsiebeginsel. dit word aahgetoon dat frekwensiediskriminasie vir elektriese stimulasie voorspel kan word deur die verdere aanname dat elektriese stimulasie desinkronisasie veroorsaak by 'n sentrale integrasiesentrum. gegee hierdie aannames, kan die model die verswakking in frekwensiediskriminasie vir elektriese stimulasie voorspel. laastens word dit aangetoon dat kogleere inplantings nog nie bo alle twyfel kon bewys dat of plek-tempo-kodering of tydkodering van frekwensie die dominante meganisme in die ouditiewe stelsel is nie. key words: frequency discrimination, electrical stimulation, cochlear implants, interspike interval, phase-lock coding, rate-place coding. ; introduction a long-standing question about frequency analysis in the auditory system is how frequency information is represented: is frequency coded as a temporal code or as a place code (moller, 1999) or as both? pure tones are represented as both rate-place information (rate-place coding) and temporal information (phase-lock coding) in the discharge patterns of auditory nerve fibres and the central auditory nervous system, but the extent to which the auditory system uses either representation is unknown. rate-place coding is a spectral analysis mechanism whereby the auditory system may combine firing rate information from nerves originating from different places in the cochlea to determine the stimulus frequency. this method of coding of frequency operates over the entire stimulus frequency range, but is usually presumed to be dominant for the coding of high frequencies (above about 5000 hz) (kim & parham, 1991; moore, 1973). phase-lock coding is a temporal mechanism, wherein the auditory system presumably uses the synchronization of neural discharges to individual cycles of periodic stimuli as a cue to determine the frequency of a pure tone. phaselock coding is usually presumed to operate primarily at lower frequencies, since phase-locking is progressively lost as stimulus frequency increases above about 2500 hz. no phase-locking is observed above 5000 hz (johnson, 1980; rose, brugge, anderson & hind, 1968). it is possible that both coding mechanisms operate in parallel over a large range of frequencies. so far, neither die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 johan j. hanekom neurophysiological studies in animals, nor psychoacoustic experiments in humans have been able to determine to which extent the central auditory system uses either mechanism alone or both mechanisms simultaneously to determine the frequency of a pure tone (moller, 1999; johnson, 1980). whilst previously this may have been regarded as a purely academic question, the development of cochlear implants has made it important to understand how information is coded in the auditory nervous system. this knowledge will influence the stimulation strategies used in cochlear implant speech processors. specifically, we need to know what information transmitted to the electrically stimulated cochlear nerve is perceptually significant. two strategies used in current cochlear implant systems reflect two different approaches. in the spectral peak (speak) strategy (loizou, 1999), which is based on the rate-place mechanism, spectral peaks are extracted and presented to electrodes that are arranged tonotopically. in contrast, the continuous interleaved sampling (cis) strategy (loizou, 1999) uses high pulse-rate stimulation to conserve temporal waveform information. moller (1999) reviews the roles of temporal and rateplace coding of frequency. he presents convincing arguments in favour of the phase-lock code. his arguments are based on the robustness of the code and on the effects of various kinds of pathology on the impairment of frequency discrimination and pitch perception. it is well established that frequency tuning in the auditory system is a function of sound intensity (moller, 1999; johnstone, patuzzi & yates, 1986). the location of maximal vibration of the basilar membrane shifts at higher intensities. however, the perception of pitch of pure tones is relatively insensitive to changes in intensity over large intensity ranges. some models conjecture that it is not the spectral peaks, but rather the complete spectral profile, or the edges of the spectral profile that are used in frequency discrimination (moore & glasberg, 1986). moller (1999) argues that these are just as sensitive to intensity. moller also reviews data that suggests that impairment of spectral analysis in the cochlea does not affect speech discrimination noticeably, which suggests that spectral analysis might not be important for speech perception. cochlear implants provide the opportunity to study the coding of frequency by the rate-place code and by the phaselock code separately. the perception of frequency as encoded in the rate-place code alone may be studied by using a fixed stimulation frequency and varying the site of stimulation in the cochlea. to explore the role of phaselock coding alone, stimulation at a fixed position in the cochlea may be used while varying the frequency of stimulation (townshend, cotter, van compernolle and white, 1987; blarney, dooley, parisi & clark, 1996; dorman, smith, smith & parkin, 1994). this article further explores the coding of frequency in the phase-lock code, using neurophysiological and psychoacoustic data from auditory electrical stimulation as instrument. one motivation for this study stems from the strong arguments by moller (1999) in favour of phaselock coding, but the way in which frequency information should be encoded in cochlear implants is also of interest. approach a modelling approach is taken here. note that the models described below are mathematical models of neural processing that were simulated on computer, and that no real neurons were used. a recent model of frequency discrimination in the acoustically stimulated auditory system (hanekom & kruger, 2001) is extended to include the electrically stimulated auditory system. this model provides satisfactory predictions of frequency discrimination in the normal (acoustically stimulated) auditory system. if, in addition, it is found that the extended model can predict psychoacoustic data for the electrically stimulated auditory system, strengthening the arguments in favour of a phase-lock code for frequency may be possible. the applicability to cochlear implant stimulation strategies will be explained in the discussion. a short motivation for using a modelling approach is provided. the current model predicts psychoacoustic data from neurophysiological data. apart from being useful to summarize current knowledge, models build understanding of the signal processing that the auditory system has to perform. models also assist in revealing gaps in our knowledge, whether it is in unknown parameter values, or in our understanding of the signal processing. models are of necessity idealizations of reality. it is, of course, always possible to build complex models with many free parameters that will be able to model any given set of psychoacoustic data. however, simple models with few free parameters that can accurately predict trends in psychoacoustic data builds confidence that the signal processing that the central auditory nervous system performs is understood. plausible models of acoustic frequency discrimination data should account for the absolute values of frequency difference limens (af's) and explain the origin of the bowl shape of the curve of the weber fraction (aft f) plotted as a function of frequency (e.g. moore, 1973; sek & moore, 1995), without the need to manipulate many free parameters to fit the psychoacoustic data. several models exist to explain psychoacoustic frequency difference limens (af's) for the acoustically stimulated auditory system. these models are based on either the extraction of frequency directly from one or more neural spike trains (i.e. a temporal approach) (goldstein & srulovicz, 1977; javel & mott, 1988) or the rate-place code (javel & mott, 1988), or both mechanisms simultaneously (siebert, 1970; srulovicz & goldstein, 1983). one recent model (hanekom & kruger, 2001) is examined in this article and extended to incorporate auditory electrical stimulation data. j the model is based on the following. a listener's ability to discriminate between two signals is limited by neural noise, i.e. the random nature of the neural spike train (siebert, 1970). siebert was first to propose the notion that the difference limen in a discrimination task (e.g. frequency or intensity discrimination) is equal to the standard deviation in estimating the magnitude of the stimulus variable (e.g. frequency or intensity). the implication is that estimators may be designed to extract a stimulus variable from its noisy neurally encoded form. the difference limen can then be evaluated by calculating estimation variance. based on these ideas, goldstein and srulovicz (1977) proposed a temporal model of frequency discrimination in which frequency is encoded in inter-spike intervals only. they demonstrated that with the combination of a small number of fibres, sufficient information is available to account for perceptually measured frequency discrimithe south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) what do cochlear implants teach us about the encoding of frequency in the auditory system? 51 nation thresholds. an extension of their 1977 model (srulovicz & goldstein, 1983) accounts for a wider range of psychoacoustic phenomena. the more complex extended model incorporated both temporal and rate-place cues. like moller (1999), they concluded that phase-lock coding is a more likely mechanism than rate-place coding for the frequency discrimination task. wakefield and nelson (1985) extended the temporal model of goldstein and srulovicz (1977) to include intensity effects. based on moller's (1999) strong arguments in favour of a phase-lock code for frequency, and the success of the simple inter-spike interval based model of goldstein and srulovicz (1977) in predicting the shape and magnitude of frequency discrimination thresholds, a new model of frequency discrimination was presented in hanekom and kriiger (2001). this model used a particularly simple description of the statistics of phase-locking, which enabled the authors to construct an optimal estimation mechanism by which frequency information can be extracted from one or more neural spike trains. the objective of the extension to this model is to include the statistics of spike trains evoked by electrical stimulation in order to make predictions about frequency discrimination thresholds in cochlear implants. the statistics of spike trains that result from electrical stimulation are quite different from acoustically evoked spike trains, as will be discussed later. it should be noted that this paper does not present any hypotheses about the central representation of pure tones. the emphasis is on the interpretation of the frequency discrimination performance of an optimal estimator, presumably located somewhere in the central auditory nervous system, given the statistics of acoustically and electrically evoked spike trains. method the phase-lock model of hanekom and kriiger is extended to incorporate electrical stimulation. this is a mathematical model of neural processing which may be simulated on computer. this model has been considered / i n more detail in hanekom and kriiger (2001) and is only briefly outlined here. the proposed extension for electrical stimulation is simple and detail is provided. estimator structure phase-locking is the tendency of nerve spikes (action potentials) to cluster around multiples of the stimulus cycle at a preferred phase (a specific time relative to the onset of the stimulus cycle). it is assumed that these clusters have gaussian distributions (javel and mott, 1988) of which the variance depends on the amount of phaselocking. perfect phase-locking occurs when spikes always occur at the same phase. when spikes are also entrained to the stimulus (i.e. spikes occur at each stimulus cycle), calculating the stimulus frequency perfectly is very simple. thus, the distribution of the spikes around the preferred stimulus phase is a source of noise. it is assumed that the auditory system can combine spike trains from a number of fibres to obtain a single spike train that has one spike per stimulus cycle. this idea is essentially the same as the volley principle of wever (1949). javel (1990) speculated that the great redundancy in auditory nerve fibre innervation of the inner hair cells may exist to ensure that a spike occurs on every stimulus cycle. superimposing a number of spike trains results in clusters of spikes, with cluster centres spaced approximately 1 if apart. if spike trains from more fibres are superimposed, estimates of the cluster centres become more accurate, resulting in more accurate estimates of the actual stimulus period. this is on the condition that fibres fire on exactly the same preferred phase, which is not necessarily true. different fibres, tuned to slightly different frequencies, will all phase-lock to the stimulus, but each at its own preferred phase (javel, 1990). neurons have been found in the cochlear nucleus that may be able to implement a volley principle by combination of several auditory nerve inputs (moller, 1999). to achieve this, the integration centre has to compensate for differences in the preferred firing phase. the auditory system may achieve this by variation in fibre length and variation in the strength of synapses (cook & johnston, 1999). in the current implementation of the model, spike trains were not combined explicitly. it was assumed that one spike per stimulus cycle was available. under this condition, measurements of inter-spike intervals used to estimate frequency are just noisy measurements of the actual period of the stimulus waveform. the problem of obtaining a good estimate of the stimulation frequency from these noisy measurements can be solved with an estimator that is often used in engineering applications, the kalman filter (kalman, 1960). number of fibres combined at high intensities, the combination of spike information from just a few nerve fibres will ensure the availability of one spike per stimulus cycle. at lower intensities, the combination of more nerve fibres is required to account for human frequency discrimination data. the probability of missing cycles decreases as the number of fibres to be combined increases. it is estimated from simulations that the current model requires the combination of around 100200 fibres to ensure one spike per stimulus cycle at all frequencies for acoustical stimulation. model of phase-locking for acoustic stimulation at high stimulation intensities, for fibres with characteristic frequency (cf) at or close to the stimulus frequency, spikes may occur on each stimulus cycle for low frequencies (lower than about 1000 hz), although this is usually not so and cycles are often missed (rose, brugge, anderson & hind, 1968). spikes can be very scarce at low intensities or when the stimulus frequency is far from the cf of a fibre. it is assumed in the current model that the central processor integrates spike train information from a restricted area in the cochlea where the strongest activity is found. this corresponds to the average localized synchronized rate (alsr) model of sachs and miller (1985). thus, for a stimulus well above threshold as used in the current model, it is assumed that the most strongly stimulated fibres fire at their maximum rates. a further assumption is that spikes cluster around a specific phase of the stimulus cycle according to a gaussian distribution. the distribution of spikes is gaussian with standard deviation die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 johan j. hanekom which is a curve fit to the synchronization index data in dynes and delgutte (1992) as shown in figure 1. secondly, the degree of entrainment is much higher for electrical stimulation than for acoustic stimulation. spikes may occur on each stimulus cycle for low frequencies (below 1 khz) (javel & shepherd, 2000; javel, 1990). thirdly, there is no frequency selectivity for electrical stimulation (there is no basilar membrane filtering), so that all areas activated by the electrical stimulus generate action potentials, regardless of the stimulus frequency or the cf of the stimulated site. in addition, the statistical independence among spike trains in different fibres is lost, so that many fibres fire exactly in phase (javel, 1990; o'leary, tong & clark, 1995). lastly, synchronization increases with stimulus intensity (shepherd & javel, 1999). spike latencies become smaller for more intense stimuli, and spike latencies are shorter for pulsatile stimuli than for sinusoidal stimuli. the probability of firing is a function of the stimulus strength, but the slope of this function is very steep (van den honert & stypulkowski, 1987) so that for pulsatile stimulation at just around 6 db above threshold, neurons fire at their maximum (entrained) rate. it is assumed that fibres are stimulated well above threshold, so that a value of g/a)-l is used for electrical stimulation in the current model. combination of fibres for electrical stimulation if spike trains are combined according to a volley principle, then presumably the auditory system must compensate for differences in the preferred firing phase of different fibres as explained before. fibres fire exactly in phase in electrical stimulation. any mechanism that compensates for differences between fibres in acoustic stimulation some important differences exist between neural synchronization to acoustical and electrical stimulation. first, electrically stimulated fibres exhibit phase-locked responses with a much higher degree of synchronization (shepherd & javel, 1999; javel, 1990; van den honert & stypulkowski, 1987; hartmann, topp & klinke, 1984). this is demonstrated in period histograms where the peak is much narrower for electrical stimulation than for acoustic stimulation (e.g. javel, 1990). thus phase-locking occurs on a very precise phase of the stimulus signal (hartmann, topp & klinke, 1984). for high frequencies (4-8 khz), phase-locking is weaker (dynes & delgutte, 1992). the fibre still discharges regularly, but many stimulus cycles may be skipped, similar to the acoustic case. phase-locking is maintained at high frequencies (10 khz) for electrical stimulation, unlike acoustical stimulation which demonstrates no phase-locking above 5 khz. the synchronization index for electrical stimulation is described by ° ' ® = γ τ ζ τ <4> + \3500 / the south african journal of communication disorders, vol. 47, 200 2nfatcc0s( g(f,a) } ( 1 ) where g(f,a) is the synchronization index, k is a scaling factor used to fit neurophysiological data, f is the stimulus frequency, and a is the stimulus intensity. this equation was derived in hanekom and kruger (2001). the synchronization index g(f,a) is a function of both frequency and intensity. g(f,a) may be written as the product of two factors, g(f,a) = g/f) g/a), where a is intensity in db sl and fis frequency in hz. g/β and g/a) characterize the variation of the synchronization index with variation in frequency and intensity of the pure tone stimulus respectively. for acoustic stimulation g/f) is given by ι + \3500j and g/a) is given by 1.1 a°m g/a) = 0.6 (3) v0.5(a 0 3 ) 2 i p + k equation 2 and equation 3 are curve fits to typical values of the synchronization index as a function of frequency and intensity respectively. in equation 3, if is a sensitivity constant that controls the threshold of the model fibre, while η is a tuning constant that takes on a maximum value of 1 when the model fibre has cf at the stimulus frequency. model of phase-locking for electrical frequency ( h z ) figure 1. synchronization index as a function of frequency for electrical and acoustic stimulation. the solid curve (electrical stimulation) was calculated from equation 4. the dotted curve (acoustic stimulation) was calculated from equation 2. open squares are data from johnson (1980) and open circles are data from javel and mott (1988) for acoustic stimulation. filled circles are data for sinusoidal electrical stimulation from dynes and delgutte (1992). r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) what do cochlear implants teach us about the encoding of frequency in the auditory system? 53 stimulation may in fact disperse spikes around the preferred phase in electrical stimulation as measured at a central integration centre. so for electrical stimulation, it is assumed that phase-locked spike trains arriving at the central integration centre are desynchronized relative to each other. it is assumed that the central integration centre still generates one spike per stimulus cycle, but with larger variance in spike position around the preferred phase than for the acoustic case. the spike position variance is a function of the number of spike trains combined. it is assumed that the spike trains arriving at the central integration centre are statistically independent, so that the spike variances add. if it is assumed that spike trains from around 200 fibres are combined, the spike variance around the preferred phase will be two hundred times larger for electrical stimulation than for acoustic stimulation. thus an = v200 ^k -ί-τarccos ( g i ^ ° · 5 ) ( 5 ) 2 π/ ctjc/j is used for electrical stimulation, with g/β as given in equation 4. as further motivation for this argument, it is noted that injuries to the auditory nerve cause increases in neural conduction time (and thus temporal dispersion of neural activity). it is known that injuries to the auditory nerve affect speech discrimination ability more than cochlear injuries (moller, 1999). implementation of the estimator and simulations stimulus of duration τ many (typically 200) times and calculating the standard deviation of the frequency estimate at a specific time. this time was either at the end of the interval τ or after 50 observations of inter-spike intervals, as will be explained in the discussion. values of af were obtained as a function of stimulus frequency for both acoustic and electrical stimulation. the equations describing the model were coded in matlab, a computer language designed for doing mathematics. simulations were run on a pentium ii personal computer under the windows 95 operating system. results af/f as a function of frequency for acoustic stimulation figure 2 shows the normalized frequency difference limen (af/f) as a function of frequency for acoustic stimulation as predicted by the model. for comparison, af/f for electrical stimulation is also shown. frequency discrimination data for acoustic stimulation as measured by sek and moore (1995) are plotted on the same axis. the shapes of the two curves for acoustic stimulation are very similar, and both reach minima at 500 hz. the absolute values of af/f as predicted by the model correspond well to measured values across the entire frequency range, except at 10000 hz. af as a function of freq uency for electrical stimulation derivation of the kalman filter equations falls outside the scope of this article, but details may be found in hanekom and kriiger (2001). the discussion below is intended to elucidate the principles. essentially, to apply the kalman filter, the modelling equations for the generation of spikes must be obtained in a certain format (the state space format, which is often used by engineers). this is relatively simple for the problem stated 'here. once this has been done, the noisy measurements of the actual stimulus period may be applied as input to the kalman filter. from an implementation viewpoint, the kalman filter is then simply a set of equations solved iteratively to provide an estimate' for the input frequency at each time instant. i spike trains from single fibres were computer generated using the> model. estimates were obtained for frequency by observing the spike train from a single modelled fibre under the assumption that one spike per stimulus cycle was available. spikes were placed according to a gaussian distribution with standard deviation σ η . for acoustic stimulation, g/f) of equation 2 was used in equation 1 to calculate ση, while g/f) as in equation 4 was used in equation 5 for electrical stimulation. the frequency difference limen af was then obtained by assuming it to be equal to the standard deviation in the frequency estimate, following siebert (1970) and several other authors after him. the standard deviation in the frequency estimate was obtained by repeating the pure tone c ω j ω ο c ω ι— ω τ3 ω ν "to ε ιο ζ figure 3 shows the frequency difference limen (af) as a function of frequency for electrical stimulation as predicted by the model. simulation predictions are not shown as the 0 . 0 8 0.04 0.02 0.01 0.008 0.004 0.002 0.001 -ι 1 100 200 500 1000 2000 5000 8000 frequency(hz) figure 2. values of the frequency difference limen af expressed as a proportion of frequency (aflf) are plotted as a function of the frequency of a pure tone stimulus on logarithmic axes. filled squares are model predictions for acoustic stimulation, while open circles are the perceptual frequency discrimination data of sek and moore (1995). filled circles are model predictions for electrical stimulation. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 johan j. hanekom weber fraction af/fin this figure, as the measurement data was available as af. frequency discrimination data as documented in pfingst (1988) and ibwnshend et al. (1987) are plotted on the same axes. the shapes and slopes of the model prediction and the psychoacoustic data are similar. the absolute values of af as predicted by the model are smaller than measured values across most of the frequency range. at high frequencies, model predictions may be an order smaller than the psychoacoustic data. to bring the model and data into closer agreement, larger standard deviations may be used for spike position jitter. alternatively, higher stimulus intensities shift the measured curves downwards (pfingst, 1988). unfortunately, it is unknown at which stimulus intensities the data were measured. discussion justification of assumptions the current model rests on two important assumptions. first, it was assumed that the auditory system has some way to ensure one spike per stimulus interval across the entire frequency range. this assumption idealizes known neurophysiological data. more than one spike may occur per stimulus cycle in acoustic stimulation (rose, brugge, anderson & hind, 1968) and multiple spikes may occur in electrical stimulation (javel & shepherd, 2000). both phases of the electrical stimulation waveform may evoke spikes (van den honert & stypulkowski, 1987) and multiple spikes per phase may occur at higher frequencies of pulsatile stimulation (javel & shepherd, 2000). because of the way that the current model was formulated, it is a requirement that there is only one spike per stimulus cycle. the kalman filter will regard more than one spike per stimulus interval as a source of noise. if a small percentage of cycles have either more than one spikes per cycle, or some cycles are skipped, the dominant inter-spike interval is still the period of the stimulus waveform and the central estimator will make the correct estimate (although with larger standard deviation in the estimate). with many cycles not conforming to the one spike per cycle assumption, the central estimator may make an incorrect estimate of the input frequency. a higher likelihood exists that this will happen for electrical stimulation, as spikes may occur on both phases of the stimulus waveform. nonetheless, the model may still explain the observed frequency difference limens, because frequency discrimination measurements are differential and do not measure the absolute frequency perceived. the close correlation between the predicted and measured frequency discrimination thresholds suggests the possibility that a central representation of the pure tone exists that is equivalent to the one spike per stimulus interval assumption. this, however, is not what the model intended to prove. rather, the intention was to show that frequency discrimination thresholds could be explained by spike position jitter in a phaselocked response. this is discussed further in the sequel. the second assumption was that, because many fibres fire in phase as a result of electrical stimulation, the net result at the central auditory estimator would be a desynchronization of spike trains, rather than improved synchronization. it is unknown whether data exist which supports this hypothesis. available data seems to refute this notion. the cochlear nucleus (cn) exhibits greater response diversity than the auditory nerve (o'leary, tong & clark, 1995). some fibres display phase-locking to the stimulus, while the responses of other fibres are more complex. cn fibres that do phaselock exhibit very little temporal dispersion of spikes for electrical stimulation (javel & shepherd, 2000). however, as it is not known what the central representation of frequency is, to search for spike trains at the cn output that exhibits larger spike position jitter for electrical stimulation than for acoustic stimulation may be fallacious. it is known that temporal information on the auditory nerve is gradually transformed into a rateplace code at higher levels of the central auditory system, possibly at the level of the cn (rhode and greenberg, 1992). many auditory afferents carrying a phase-lock code converge on cn cells. these fibres should provide at least one spike per stimulus cycle on the input to a cn neuronal assembly. the possibility exists that the phase-lock code may then be transformed directly into a rate-place code without the need for fibres firing at rates up to 5000 hz. so, not enough is known to be able to prove or disprove the second assumption. neither assumption is unrealistic in terms of biological implementation and the results justify the two assumptions to some extent. as a final comment, the possibility that the model predictions only hold for frequencies below 5000 hz needs to be pointed out, as no phase-locking is observed at higher (acoustic) stimulation frequencies. ν ~ 1000 ^ 500 c (u ε ω ο c ω l_ ω ifc > ο c ω ^ cγ ω 100 50 10 100 300 600 1000 3000 6000 10000 f r e q u e n c y ( h z ) figure 3. values of the frequency difference limen δf are plotted as a function of the frequency of electrical stimulation., on logarithmic axes. filled circles are model predictions for electrical stimulation. open circles and open diamonds are perceptual frequency discrimination data from two studies (for sinusoidal electrical stimulation) as reported in pfingst (1988). open squares are data for pulsatile electrical stimulation (townshend et al., 1987). the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) what do cochlear implants teach us about the encoding of frequency in the auditory system? 55 the origin of the shape of the af/f frequency curve the af obtained is primarily a tradeoff between two parameters of the model: the number of observations and the spike jitter around the preferred phase of the stimulus cycle. to account for psychoacoustic data below 500 hz, stimulus duration γ is limited to 100 ms so that the number of observations decreases with lower frequencies, which results in a growth in af/f at lower frequencies consistent with psychoacoustic data. this choice for τ is consistent with known auditory integration times (eddins & green, 1995). at these frequencies, af/f is determined primarily by the number of observations available. at higher frequencies the number of observations in the 100 ms time interval grows. it was found that the number of observations needs to be close to n= 50 to achieve the same af/f values as the psychoacoustic data for acoustical stimulation. larger ν results in little further decrease in aflf. at higher frequencies (above 500 hz), the spike jitter becomes a systematically growing percentage of the stimulus period. this plays the primary role in the growth of aflf at these frequencies. what do cochlear implants teach us about the coding of frequency in the auditory system? psychoacoustic data from cochlear implants seem to refute the idea that temporal coding mechanisms are utilized by the central auditory system to extract frequency information from the neural spike train, as the frequency difference limens are much poorer than for normal-hearing listeners, even though there is much more synchronization to the stimulus waveform in electrical stimulation. the current model demonstrates (with reasonable assumptions) that a central auditory estimator that uses interspike intervals to calculate frequency may fare worse with electrical stimulation than with acoustic stimulation. this is consistent with psychoacoustic data. so at least the .current model indicates ,'that we cannot rule out temporal mechanisms as a mechainism for frequency coding. it is known that cochlear implant signal processing strategies based on preserving the temporal pattern (e.g. cis) are generally more successful than strategies based on vocoders (e.g. speak) (loizou, 1999), which supports the argument in favour jof phase-lock coding. also, recent studies have shown that fewer channels in a speech processor can lead to equally good or better speech discrimination (fishman, shannon & slattery, 1997), but if fewer than 4 to 6 channels are used, performance drops. the interpretation is that the actual number of independent information channels in an implant is probably not more than 4 to 6. also, because higher stimulation rates can be achieved with fewer activated electrodes (shannon, adams, ferrel, palumbo & grandgenett, 1990), the temporal characteristics of the signal are preserved better. thus, evidence suggests that good spatial resolution is not achieved in cochlear implants, but also that preservation of the temporal waveform is important in cochlear implants. conversely, it has been shown in many pitch discrimination or electrode discrimination experiments (nelson, van tasell, schroder, soli & levine, 1995; pfingst, holloway, zwolan & collins, 1999), where a fixed stimulation frequency was used on various electrodes, that cochlear implant users can discriminate between electrodes. furthermore, pitch estimation experiments show that implant users can assign pitch to electrodes in a systematic fashion (dorman, smith, smith & parkin, 1994) which follows the tonotopical arrangement of the cochlea. spikes are entrained to the stimulus in electrical stimulation (javel, 1990), so if the phase-lock code was the only mechanism operating in frequency discrimination or pitch perception, stimuli on all electrodes would have had the same pitch. so electrode discrimination and pitch estimation experiments provide convincing arguments in favour of the rate-place code. it is concluded that cochlear implants have not yet provided the final answers to the question of the coding of frequency in the auditory system. implications for cochlear implants it is far easier to get high temporal resolution in electrical stimulation than it is to get high spectral resolution. current spread from electrodes limit spectral resolution (krai, hartmann, mortazavi & klinke, 1998). new electrode designs may limit current spread (cords, reuter, issing, sommer, kuzma & lenarz, 2000), but certain physical limitations on electrode design remain. for example, maximum safe levels of charge density exist (shannon, 1992). on the other hand, there are no basic technological limitations on increasing the stimulation rate. however, neural threshold adaptation may occur for high stimulation rates (above 400 pulses per second per channel), which suggests that higher stimulation rates may not be beneficial and may even degrade speech recognition performance (javel & shepherd, 2000). still, the success of temporal pattern based strategies for cochlear implants like cis is encouraging and warrants further study. conclusions (1) to be able to predict frequency difference limens for acoustic stimulation, an important assumption is that one spike per stimulus cycle is available, which may be provided by the existence of a volley principle. the volley principle may be implemented by the cochlear nucleus, where neurons have been found that can improve temporal precision by combination of a number of auditory nerve inputs (moller, 1999). (2) an additional assumption is required in order to predict frequency difference limens for electrical stimulation of the auditory system. it is assumed that because many fibres fire on exactly the same phase of the electrical stimulation waveform, desynchronization results at a central auditory nervous system integration centre, which in turn leads to degradation in frequency discrimination. (3) psychoacoustic data from cochlear implants show that both mechanisms for the coding of frequency information in the auditory system are equally likely. thus, though cochlear implants may provide a tool to solve this problem, they have not yet provided the final answer to the question of coding of frequency in the auditory system. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 johan j. hanekom references blarney, p.j., dooley, g.j., parisi, e.s., & clark, g.m. (1996). pitch comparisons of acoustically and electrically evoked auditory sensations. hearing research, 99, 139-150. cook, e.p. & johnston, d. (1999). voltage-dependent properties of dendrites that eliminate location-dependent variability of synaptic input. journal of neurophysiology, 81, 535-543. cords, s.m., reuter, g., issing, pr., sommer, α., kuzma, j. & lenarz, t. 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(1968). patterns of activity in single auditory nerve fibres of the squirrel monkey. in a.v.s. de reuck & j. knight, hearing mechanisms in vertebrates. london: j & a churchill ltd. sachs, m.b. & miller, m.i. (1985). pitch coding in the auditory nerve: possible mechanisms of pitch sensation with cochlear implants. in r.a. schindler & m.m. merzenich (eds.), cochlear implants. new york: raven press. sek, a. & moore, b.c.j. (1995). frequency discrimination as a function of frequency, measured in several ways. journal of the acoustical society of america, 97, 4, 2479-2486. shannon, r.v. (1992). a model of safe levels for electrical stimulation. ieee transactions on biomedical engineering, 39,424426. shannon, r.v., adams, d.d., ferrel, r.l., palumbo, r.l., & grandgenett, m. (1990). a computer interface for psychophysical and speech research with the nucleus cochlear implant. journal of the acoustical society of america, 87, 905-907. shepherd, r.k. & javel, e. (1999). electrical stimulation of the ausditory nerve: ii. effect of stimulus waveshape on single fibre response properties. hearing research, 130, 171-188. siebert, w.m. (1970). frequency discrimination in the auditory system: place or periodicity mechanisms? proceedings of the ieee, 58, 723-730. srulovicz, p. & goldstein, j.l. (1983). a central spectrum model: a synthesis of auditorynerve timing and place cues in monaural communication of frequency spectrum. journal; of the acoustical society of america, 73, 1266-1276. ; townshend, b., cotter, n., van compernolle, d., & white, r:l. (1987). pitch perception by cochlear implant subjects. journal of the acoustical society of america, 82, 106-115. i van den honert, c. & stypulkowski, p.h. (1987). temporal response patterns of single auditory nerve fibers elicited by periodic electrical stimuli. hearing research, 29, 207-222. ι wakefield, g.h. & nelson, d.a. (1985). extension of a temporal model of frequency discrimination: intensity effects in normal and hearing-impaired listeners. journal of the acoustical society of america, 77, 613-619. wever, e.g. (1949). theory of hearing. new york: wiley. the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 93 community based education in speech pathology and audiology at the university of durban-westville in an under served community* glen w jager department of speech and hearing therapy university of durban-westville abstract in south africa there is increasing awareness both in academic and clinical domains of the inadequacy of education and training of health personnel, in preparing graduates to meet the service needs of the disadvantaged majority. a feasibility study is reported in which the regular curriculum of final year speech, language therapy i audiology students was adapted to provide a more relevant, more appropriate learning experience. this comprised a community based action research programme in a zulu peri-rural community. a qualitative critical analysis of the project is presented, in an attempt to identify factors that could be likely to hinder and promote the greatly needed process of curriculum transformation within the university; and in the process of strengthening the role that the university can play in meeting the needs of the community it serves. opsomming daar is 'n toenemende bewuswording in suid afrika, op beide die akademiese en kliniese gebied ten opsigte van die ontoereikende opvoedkundige en gesondheidspersoneel, om gegradueerdes voor te berei om aan die diensverskaffmgseise van die minderbevoorregte meerderheid te voldoen. 'n vatbaarheidsstudie word uiteengesit waarin die normale kurrikulum van finalejaar spraaktaalterapieen oudiologiestudente aangepas is om 'n meer relevante en toepaslike leersituasie daar te stel. dit het 'n praktiese gemeenskapsgebaseerde navorsingsprogram· in 'n peri-landelike zulugemeenskap behels. 'n kwalitatiewe kritiese analise van die projek is voorgestel, in 'n poging om faktore te identifiseer wat aanduidings verskaf om die nodige prosesveranderings van die kurrikulum in die universiteit te bewerkstellig, asook die bef^lemtoning van die rol wat die universiteit kan speel om te voldoen aan die gemeenskapseise. the development of health personnel able and willing to serve the community by providing health care, promoting healthij preventing disease and caring for those in need is a major and formidable task for educators. | h. mahler, director-general of the world health-organisation (who), (cited by lipkin, 1989a). vative community based; problem based medical education; in current thinking about the role of the university in the community it serves; and in increasing commitment to the principles of primary health care (phc) as defined in the world health organisation report on the international conference on primary health care at alma-ata (1978). 2 background 1 introduction in south africa, in both academic and clinical domains, there is increasing awareness of the'inadequacy of education and training of health personnel in preparing graduates to meet the service needs of the disadvantaged majority. this is reflective not only of the current political changes but also of progressive thinking in education; in international trends towards innoin order to contextualise this growing concern with the inadequacies of the status quo in health personnel education, the paradigms, to which dynamic influences can be attributed, must be expanded. 2.1 educational background the educational concepts of a participatory, interactive, problem solving, teaching/learning paradigm are * the original version of this paper was presented at the third international symposium on the role of universities in developing areas, 7-9 july 1993, university of the azores at ponta delgada, s. miguel, in conjunction with the university of california, los angeles, and ben-gurion university, beer-sheeva. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 94 glen w. jager not new, nor are they restricted to the discipline of eduhealth for all, is to implement the principles of phc. cation. since classical times, following the thinking of based as it is on a biopsychosocial model of health, phc, socrates, there has been an acknowledgement of the encompasses social, psychological as well as physical significance of self discovery. this has formed the badimensions of well-being. a fully comprehensive apsis for theorists such as bruner (1966), and rogers proach to health care is thus implied, and focuses, inter (1969) (lipkin, 1989b). the problem based learning alia, on the attainment of basic needs. people, and their approach, which is based upon the case study method right to choose and to decide about their own health, (fraser 1931) used at the harvard law school and the need to be respected and accounted to by sensitive, comdiscovery learning approach, was developed at the passionate service providers. they need to take control mcmaster university (schmidt, 1989), to provide stuof their health; they need relevant, appropriate, acceptdents with the skills and attitudes that would foster in „ able, accountable health services, accessible to them them an ethos of life long learning. for at least two where they live (who, 1978). decades, some medical educators have been exploring and developing this methodology as a means of address2.3 the role of the university in transing the challenges of the information explosion and the formation of the health service deficiencies of traditional health personnel training, which foster an attitude of passive, examination driven south african policy makers and health personnel learning, which ceases upon graduation with the end of ; "are faced with the challenge of meeting the people's examinations (lipkin, 1989b). around the world, more needs by redistribution of resources; different models than twenty medical schools from diverse political and of service; and by new and relevant skills and technosocial systems, have participated in the common experilogies. to achieve these goals, awareness of and sensiment of implementing this approach, since it was pio' tivity to the diversity of cultures, and the needs of the neered at m c m a s t e r university (lipkin 1989b). ethnically rich south african population, are essential. nonetheless, contingent upon the paradoxical context it is at this level that the dynamic role of the university of the traditional assumption that teachers in tertiary in the transformation process becomes apparent. not institutions need no training in teaching skills and only should relevant skills be identified and taught; methodologies, the impact of such ideas on other disciappropriate, new technologies developed; and attitudes plines is only recently being felt in any significant way modified; but also new and appropriate models of servin south african universities. ice must be developed and validated. furthermore, the at the university of durban-westville (udw) changuniversity has a.critical role to play in the development ing policies, which are dynamically impacting on proof appropriate policies. without policy change, transgressive thinking, are producing a rigorous demand not formation at other levels remains superficial and inefonly for maximally effective teaching methodologies, but fective. supported and informed by appropriate realso for a radical review of curricula. the university has search, which is a major goal of a university, transforcommitted itself to a creative, social redress programme mation, through development of appropriate models and to address the inequity of the past, in relation to stupolicies, becomes a viable reality, dent selection policies. in order to reflect a representative ethnic distribution across the student population, 2.4 background to the project it has been necessary to abandon traditional entry criteria, based solely upon matriculation results, to enit was within this framework that the intersure that educationally disadvantaged people have acdisciplinary health group at the university of durbancess to tertiary education. academics are thus chalwestville (udw), together with concerned academics lenged to develop effective and relevant teaching and from other health related tertiary academic institutions learning strategies. in the region, established the natal institute of community health education (niche). this is a tripartite 2:2 health service background partnership between communities, service organisations and tertiary academic institutions, which is primarily in south africa it is not only educationally that the aimed at changing the training of health personnel, majority of people have been disadvantaged, but it is socialisation is a critical part of health personnel edualso in terms of basic needs and health care. it has cation (friedman, 1991; lipkin, 1989b; schmidt, 1989). been acknowledged that the who goal of health for all the aims, therefore, are to expose the providers of the by 2000, is beyond reach (csd/swo report, 1992). service to appropriate models of care, and acceptable health and health care, therefore, are central issues in role models at a stage early enough to ensure the critical demands of the present climate in the counsocialisation to appropriate models of service. particitry. over the past decades, health care in south africa, pants collaborate in an interdisciplinary, community has reflected the principles of the biomedical model, in based, problem based, integrated teaching, research and which health is perceived as the absence of disease service initiative, in which the teaching methodologies (capra, 1983). this has resulted in a hospital and clinic are participatory, self directed student centred learnbased, curative service delivery system. the interacing with an emphasis on process, and skill development, tion of this system with the reality concerning inequirather than on content based, lecture centred learning, table resource allocation that has favoured urban fa a second, smaller initiative, specific to udw, is an cilities (medical research council, 1991), has led to a interdisciplinary research project,, designed to investisituation where vast numbers of rural people have had gate the implications of components of the same comlittle or no access to health care. the only possible opmunity based initiative; to use the findings to impact tion for developing a strategy to pursue the goal of upon curriculum and institutional transformation in the y the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) community based education in speech pathology ί university of durban-westville in an under served faculty of health sciences and health related departments. the feasibility study that is presented here, was located in the context of the above. in 1992, in the department of speech and hearing therapy, it was not possible to alter the curriculum in any significant manner, but in acknowledging the principles and aims described, the staff agreed that the need for more appropriate educational experiences was urgent, and relevant to present students as well as to future groups. it was considered to be of critical importance to evaluate the feasibility of implementing such a programme. the current timetable and the speech pathology curriculum were adapted, therefore, to allow for the introduction of an integrated, community based component that would, as far as possible, reflect the principles of both phc and an emancipatory (grundy, 1987), student centred teaching strategy. one day a week during the academic year (i.e., 20% of the final year curriculum), the final year class and a lecturer spent the day in a peri-rural community of approximately 67 000 people at kwa dedangendlale in the valley of a thousand hills, 40 kilometres from durban. it is situated in kwa zulu-natal, on the eastern seaboard of south africa. the black population is zulu speaking and mainly poor. it is served by a socio-medical phc project, the valley trust, established in 1951. so great are the needs of disadvantaged communities in south africa, however, that even in the context of a highly successful phc project such as this, the reality is that basic needs are still inadequately met, and that there is virtually no paramedical service. 3 description of the programme the programme comprised a number of components from both the theoretical and practical courses which were co-ordinated to provide a cohesive programme. i 3.1 purpose of the programme j there were two major goals of the programme: 1) to investigate the feasibility of decentralised community based student centred learning, that reflects the aims of niche (described above), by reviewing the extent to which academic standards can be maintained | ii) to sensitise students to, and to facilitate the development of appropriate skills for community based service, by exposure to third world conditions. 3.2 components of the programme 1) research design module. the programme commenced with a ten hour course on practical aspects of designing and implementing a research project. evaluation of this module was based upon the written report of research projects undertaken by the students. 2) seminar module. in the 20 hour seminar module, students presented topics1 that had been selected to develop familiarity with the literature; to stimulate their own thinking; and to provide them with a relevant theoretical background. the starting point of this module was a global, first world profile of the profession of audiology at the mmunity 95 speech, language pathology and audiology (slp&a). the purpose of this was to identify paradigms and international, current trends, including phc, that would provide them with a framework for analyzing, applying and understanding professional issues when operating in third world conditions; and to facilitate understanding from the outset, that the implementation of phc principles in no way implies a lowering of standards nor a "second class" service. other topics related to theoretical aspects of social issues such as poverty; to discipline specific and methodological issues; and to the implementation of phc. the purpose of this module was to allow the students to identify within themselves, insights and resources that they would be bringing to the programme from their three years' experience of a traditional first world, eurocentric curriculum; and to obtain an initial recognition of the limits and inadequacies of such a curriculum for the conditions they were about to experience. 3) field visits. upon completion of the seminar module, visits to kwa dedangendlale commenced. the phc manager of the service organisation of the valley trust project, a medical doctor with an epidemiological background and vast phc experience, worked closely with the departmental lecturer and the students throughout the programme. as students from many disciplines visit this area, the programme was planned to involve as many disciplines as possible, e.g. nursing, medicine, occupational therapy. students from other disciplines moved in and out of the programme for short periods of either one or six weeks: these were involved as much as possible in the programme to allow students of different disciplines the opportunity of working together on common projects; to learn to understand each other; and to recognise common difficulties and constraints. the objectives were few, and simply formulated to provide maximum flexibility that would allow students and staff to develop the programme iii response to the needs of the community, and to negotiate the course of the programme in collaboration with them. through experiential, participatory, reflective learning methods, appropriate insights and skills were targeted. both small group and plenary workshops were utilised for preparing students who could not speak zulu, for communicating with the zulu speaking community people; for the development of research projects; and for planning intervention and service. contacts took place at schools; in the local court house, in a first aid station and in people's homes. 3.3 the field visit programme 1) orientation. in order to ensure that the community people were protected as much as possible from blunders by inexperienced students, the orientation was focused upon the following : the community, through interview and focus groups with community health workers; teachers; and with key members of the valley trust staff • living conditions and the work of community health workers through home visits with them • the socio-medical project through input from the valdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 96 ley trust staff • methodological and cultural issues relating to cross cultural, people centred, facilitative communication through workshops and role play.' 2) input concerning slp&a. contact with the chws and the teachers commenced by discussion concerning their conceptualisation of the discipline and the services available: people were asked to provide input concerning their understanding of slp&a • students then interacted with them to provide more accurate information. 3) identification of community needs. using the shared framework concerning the nature of the discipline of slp&a, community members were asked to identify their needs relative to this. (as there is a long established socio medical project working on basic needs, these were not the focus of the current programme.) 4) negotiation of a research topic. based upon the identification of needs, students were required to negotiate a research topic, with either the chws or the teachers, that would be of relevance in some way, in addressing an expressed need. as the students' final year research project was integrated into the community practicum, it was required to be of benefit to the community. it was therefore required to include an action phase that would provide a service to the community, thus integrating the goals of research and service with those of teaching. they were permitted to develop topics of their own interest, on condition that they were agreed by either the teachers or the chws. they were encouraged, however, to choose the simplest topics possible, due to the challenging complexities of the task, viz.: that an entire class was required to run their projects in a particular community; that they would therefore be obliged to be working in the context of a language not known to them; and that there were no available precedents of linking the research project to teaching and service in this way. 5) preparation for visits. workshops were used to enhance cultural sensitivity; cross cultural, cross linguistic communication; and facilitative methods to ensure dialogue and participation. methods used were experiential and participatory learning; brainstorming; role play; and reflective review techniques. 6) planning. all aspects of the programme were carefully planned by both staff members and the students. i) the ten research proposals (appendix 1) were discussed in a group, so that the students were exposed to, and participated actively in the development of all the projects, thus expanding their practical research experience. the planning for these was detailed, and included discussion of relevance, accountability, acceptability, participation and action, as well as logistical factors, and academic and design issues. ii) group data collection was used in order to maximise the research experience for the students and the the south glen w. jager chws; and to use the research experience for providing hands-on community work. for this, the projects were grouped together in themes. very careful planning, therefore, was critical to achieve this in the time available. three days were targeted across three weeks, but due to unforeseen difficulties data collection was extended to five days. iii) after individual analysis of the data, action programmes were designed to be of some benefit to the community. although these focused to a large extent on the transfer of information and skills, identified needs of individuals were met as far as possible. iv) implementation of the intervention programmes was planned together, by the students. this was a major challenge because of constraints in terms of available resources. 7) staff and student responsibilities. initially the staff took a directive role, taking responsibility for introducing the students to relevant concepts and issues: they initiated and modelled the methods and techniques used. supervisory and monitoring functions became their primary responsibilities as the programme progressed. the students gradually assumed the responsibility for directing the planning and implementation of the programme after the first six weeks. their responsibilities involved identifying and effectively utilising the minimal human and service resources available; identifying human contact chains to overcome the lack of the telephone service; time management; and meeting the needs of all parties in so far as possible, in a relevant, appropriate manner. 4 evaluation in an integrated, problem based, experiential teaching initiative such as the above, traditional student evaluation methods are inappropriate. as this was primarily a feasibility study, implying the need for programme evaluation, it was critical that the evaluation procedure should be sensitive to the nature of the experience. this was discussed by staff and students,j both informally and in a workshop session. a procedure that would reflect as far as possible, all aspects of the discussion, was then designed by the departmental lectjurer. this was presented to and accepted by the students and the valley trust staff member. it was agreed that the feasibility of the study would be determined to a great extent by the evaluation of the students: both by tiheir own self-evaluation of the initiative as a learning experience, and by external evaluation of their performance. it was therefore necfessary to determine the students' subjective perceptions ofboth the experience and their performance; and to identify indicators of performance that could be used in a more objective evaluation protocol. 4.1 the evaluation procedure 1) significance of the experience to students. as the students believed strongly that their experience should be shared, they agreed as a group, that the programme should be documented and published. they agreed to write personal descriptions of the significance of the experience to them (appendix 3), and they mancan journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) community based education in speech pathology and audiology at the university of durban-westville in an under served community 97 dated the departmental lecturer to write the paper. the need for open, frank disclosures was stressed, but the students indicated that this would not be a problem, as the nature of the experience had made them feel quite comfortable about this. the descriptions were written without consultation, in order to identify individual, personal perceptions. it was left to them to identify themselves or not as preferred. 2) evaluation ef students'participation and input to the project. as the students had been responsible as a group for a large part of the activities of the programme, it was agreed that it would be necessary to obtain an evaluation of the contribution made by each student, on dimensions of responsibility (list 3) and leadership (list 4) to his/her own project (list 1); to the other students' projects and to the programme as a whole (list 2). this was done by means of a rating scale (1-5) with categories agreed by the students and staff (appendix 2). both staff members also rated each student. 3) questionnaire: student's evaluation of the programme. anonymously, students completed detailed questionnaires that provided information concerning the nature of their perceptions, evaluations and recommendations; and concerning the strength of their opinions. they were requested to provide as much negative information as possible, as this would be the most valuable part of the exercise for developing the programme. 4) interviews: assessment of student performance. in lieu of a traditional, formal final assessment of performance within the context of the placement, the departmental lecturer interviewed each student for approximately twenty minutes, at the end of which a negotiated percentage mark was given. the following format was used. , i) initial presentation by students. the students were asked in advance to review the experience and to identify significant issuesjand indicators of insight and performance. they were asked to present whatever they believed would demonstrate their insight and ability; and to evaluate the experience, their input, their development and their performance. i ii) students' recommendations. recommendations and motivations for improving the programme were sought, to provide another dimension to the evaluation procedure and to provide input into the development of the programme. iii) marking overall performance. students then provided and motivated a percentage mark. at this point i assigned (but did not disclose), a mark based upon my observations and evaluation of the student's role and performance in relation to the entire process; the general trend of his/her profile as indicated on the class rating matrix; and based upon the student's performance in the above interview. after the student's motivation, i facilitated discussion to substantiate and to probe further, to allow the student to reformulate or reiterate the evaluation. at this point, both the student and i reflected further on our marks, to permit us to modify them, after which the student discussed his/ her final mark. i then gave input concerning my mark and my evaluation, after which a final mark was agreed. 5) research projects : academic evaluation of written research report. students' performance on these projects would be a particularly clear indicator of success. although they were required to be accountable; to have an action phase; and to be participatory if at all possible, they would nonetheless, have to meet required academic standards. this aspect was measured by the usual practice of evaluation by two departmental internal examiners not immediately involved in the programme, and an external examiner from a university with a strong academic focus. 6) final examination: academic evaluation of performance in course major. departmental examinations in speech pathology in the final year reflect the full course of four years of study, with three, three-hour written papers and a 30 minute clinical interview with evaluation by a panel of all the departmental academic and clinical staff and an external examiner. a similar examination schedule applies to audiology, but as this component of the curriculum was not altered it will not be discussed. 7) career: programme impact on choice. the medical education literature (e.g., schmidt, 1989) suggests that one reliable indicator of success of a problem based, community based approach to education, is the chosen career path of the student after graduation. students whose attitudes have been positively altered by conscientisation and whose skills for third world models of service delivery have developed, are more likely to choose phc types of posts than those who have not received positive benefits from the exposure. in order to tap this source of information therefore, students were asked before and after exposure to the programme to provide information about their preferred career choices, given that all things would be equal. 4.2 evaluation results 1) the written descriptions were all extremely positive. the only negative comments related to initial reservations and anxieties. 2) the ratings providing information concerning students' perceptions to the programme indicated diverse levels of evaluation. seven students (n=13) used a narrow rating band, at the higher end of the scale, for all students for responsibility for own projects. five used this high, narrow rating band for contribution to total project; four for responsibility for total project; and three for leadership role for total project. two of the students consistently used this narrow band on all four lists, and two did so on three lists. others made use of the full range of ratings, all of which reflected the ratings of the two staff members involved, indicating consensus and the ability of students to evaluate their own and other's work. 3) the questionnaires were extremely positive in favour of the experience, in that no responses fell below die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 98 glen w. jager the second highest category, and most were at the highest level. such strong positive results raise the question that students might not have felt free to provide negative information. this, however, was not the case, as the students provided detailed critiques as well as detailed motivations for their opinions. in the former, all students provided clearly negative comments, together with constructive recommendations for modification. 4) the student interview corroborated and developed the conclusions reached, concerning the questionnaire information. although some students lower in the range tended to reflect inadequate insight, which led to an inflated mark, and some appeared to underestimate their performance, the general pattern was one of maturity and insight. the negotiated marks ranged from 53% to 78% with a median of 67% and a mean of 66.5%. only two of the students were led to lower their marks and three were led to raise them. for the others, which differed from mine by only two or three points, a compromise was agreed halfway between the two marks. 5) the research projects were passed by all students, and the departmental staff received a congratulatory letter on the success of the programme from the external examiner. the marks ranged from 54% to 76% with a median of 64.4% and a mean of 64%. 6) in the final examinations all students except one, passed. the unsuccessful student was one who had consistent difficulties, and one of two students who had received student ratings of making little contribution to the total project and of some reliance on the efforts of others for own project. the external examiner commented favourably on the quality of the answers on the examination paper that specifically related to, and reflected the principles of the programme. 7) career choices differed markedly before and after the programme, with changes from 9 to 2 for hospital based posts, and from 1 to 3 for community clinics, in favour of a shift from 0 to 6 for community based posts (figure 1). these reflect the students' comments that they felt able to deal with the challenges of community based experience and that they perceived the need for and significance of providing services at this level of care. 5 discussion both the major goals of the programme were achieved. a clear answer was obtained to the question of feasibility of decentralised student learning. academic standards are imminently maintainable as evidenced by the 100% pass rate on the research projects; by the sensitivity and range of the negotiated marks which reflected evaluation of performance levels on other, more traditional evaluation procedures; and by indications derived from the comments of the external examiner concerning a pattern of positive qualitative differences in the component of the written examination based upon the programme. the other goal of sensitising students by exposure to third world conditions and of facilitating the development of appropriate skills was also clearly achieved as reflected by evaluations by students and staff and by the changes of attitudes and self-confidence reflected in the shifts in career choices. the reality of the students' competence was affirmed by subsequent clinical events, such as a highly successful screening initiative in a school in an entirely different, first world context. for the first time in the history of the department, the organisation and planning of such an initiative was left entirely to the students: the role of the staff being one of observation and monitoring only. the screening proceeded smoothly and efficiently while the students remained calm and competent throughout. clearly they had been able to extrapolate and apply the lessons of the valley programme to the new context, thus substantiating their comments on the value of the experience not only to service delivery in a phc model, but also to first world service delivery. from the programme in kwa dedangendlale it was also possible to identify the potential role of speech, language pathology and audiology in a phc model of service delivery. although in the limited exposure we could do little more than touch upon such issues, it was very clearly possible to work in a language and culture different from our own, and to have a place in phc service delivery. we were not able to develop relevant models of service delivery. this will be a continuous process that must take place over a number of years. there were strong indications, however, of the importance of an interdisciplinary context and of developing skills and delivery models appropriate to, and relevant, to service needs. the benefit to the community of an ad hoc service was indicative of the future role that could be played by speech, language and hearing therapists in such a context. although the programme reported was little more than a feasibility study, its impact on those involved was significant. the community people we worked with have reported that they have gained both knowledge hospital h h ^ ^ ^ ™ ™ ^ 2 special school j ^ ® community clinic h ^ s community based s l h t gggj g e n e r a l p h c η 0 2 4 6 8 / 1 0 12 number o f s t u d e n t s ^ aftnr before figure 1. student career choice before and after programme the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) community based education in speech pathology and audiology at the university of durban-westville in an under served community 9 9 and some skill relating to a broader range of health problems; but most of all they have rated as most significant, their role in teaching future health professionals about the reality of life and the lack of health care in their community. they too are aware of the inadequacies and points of failure, but they are convinced of the value of the programme, and are committed to working towards strengthening it. the ownership of the user community for this programme has grown, so that more and more, they are directing the programme by the ever increasing clarity of the articulation of their needs and expectations. people in neighbouring communities are urging us to expand our activities to them. students who have now graduated, continue to seek forums for the presentation of the initiative. they are convinced of their role in sharing their experience and their insights, in contributing to transformation, and in recruiting colleagues. they believe they should continue to work for a service that will meet the needs of all people; and to agitate for relevant changes in the infrastructure of the health system. academics are committed to developing the programme and involving all disciplines, despite the enormous challenges of collaborating with and working with so many academics and professionals who have been accustomed to working independently. 5 .1 lessons learnt it has been possible to identify factors that could be likely to hinder and promote the greatly needed process of curriculum transformation within the university. such factors are thus critical in the process of strengthening the role that the university can play in meeting the needs of the community it serves. 1) the challenge. it became very clear that the nature of community work, that is based upon the principles of the who definition of comprehensive phc, is both slow moving and demanding. integral components of participation and development imply dimensions that are new to many health personnel and academics, whose training was based on the mechanistic paradigm of the medical model (capra 1993). the contingent service delivery model demands anj urgency for action directed towards a curative outcome for individuals. the phc approach, on the other hand, demands a more equal, facilitative, participatory model of service, based on the principles of identification of needs and resources and on the provision of options. inherent in this approach is the development of capacity to facilitate the active participation of the "client". the challenges of re-orientation, conscientisation and skill development in both students and staff, result in anxiety and insecurity, as they venture out of the safety of the hospital and the clinic to risk (a) failing to meet the academic and educational needs of the students and (b) exposing disadvantaged community people to inexperienced students. 2) the need for time. one lesson that emerged from the programme in 1992 and that has been reinforced subsequently, is that the process is slow initially. while students continue to experience a sense of impatience, there must be sufficient time to plan, to develop skills, to reflect and negotiate. in this time, while the relationship with the community is being developed, and the direction of the programme is being negotiated to meet the needs of all concerned, time must be spent on developing students' skills. they need to learn, inter alia, how to communicate in a language most of them do not speak, with people from a different culture, who are mainly uneducated.2 they must learn to negotiate, not inform; they must learn to abandon professional jargon; they must learn to facilitate client participation, not act "upon" their clients. all this takes time, humility, sensitivity and respect; and while students continue to feel a sense of impatience, they need to continue to prepare and plan, for they have not yet learnt the necessary lessons and skills! 3) the potential for success. another critical lesson from the experience is the reassurance that if undertaken carefully, this period of skill development, planning, and negotiation, is richly rewarded. suddenly the process speeds up and the anxiety gives way to a sense of the richness of the experience, which continues to grow throughout the year. in the feasibility study, inadvertently, inadequate time was scheduled for planning in the action phase. although impatient and anxious initially, the students themselves recognised the inadequacy of the first contact during the action phase, and immediately requested additional time from the staff members, as they acknowledged that the need for careful planning was as great as in the early preparation phase. this time, however, although severely constrained by time, there was no impatience and certainly no frustration. instead a note of c a u t i o n a r y admonishment towards the staff could be detected. 4) factors hindering and promoting the transformatory programme. promotive factors identified are the following: the clear indications that academic standards could be maintained while adding new dimensions of accountability, relevance and capacity development • the strong positive conviction concerning the feasibility and value of the programme which replaced initial scepticism, anxiety and frustration. hindering factors identified are the following: lack of human resources, which impacts upon all other hindering factors, presents as the most significant single obstacle lack of adequate, thorough preparation and planning, action concerning goals, methods, co-ordination, development of skills and utilisation of resources • attempts to hasten the process and to take short cuts time tabling difficulties that prevented common starting and ending dates for students from different departments 5.2 reflections on the role of the university in disadvantaged communities after initiating an integrated interdisciplinary programme in a disadvantaged community, it appears that the university's role could realistically be to impact upon die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 100 glen w. jager change directly within the community. by the sharing of skills and resources and by strengthening the initiatives of the community, it is possible for the university to contribute directly to development. indirectly too, by transforming the curriculum for educating health personnel, the university can facilitate the development of appropriately trained health personnel who, in the long term, will contribute to transformation of the health system and health service delivery in the country by their sensitivity and accountability to all the people of the country. in south africa, however, the role that the university can play is even more significant than this, for it can, and should be at the vanguard of profound change. it is not enough to provide a community service, even one that is enabling; nor is it enough to alter the attitudes and skills of health personnel and other professionals of the future. changes in health personnel education must be parallelled by policy change. not one of the students who would prefer a community based post has been able to find one. the infrastructure of the health services have remained unchanged. the threats of further privatisation and elitism continue to flourish. the significance of the university's role in health, therefore, is not only the development and validation of appropriate models of service delivery, but the development and implementation of policy informed by relevant accountable research. it is only through informed policy change and the development of appropriate models of service that profound transformation can occur. it is imperative therefore, that the university has a comprehensive, well co-ordinated, integrated programme of teaching research and service that will inform policy change and implementation, to address the challenge of development, with a strong focus on a meaningful programme of social redress. parallelling the inequities in the health service, are the inequities in education which continue to deny university access to the historically disadvantaged people of the country. it is not enough that the disadvantaged communities are served by sensitised health personnel from other communities: they are rightly demanding that their own people have easy access to university education and that they are served by adequately educated health personnel form their own communities. for this to become a reality, universities must be proactive in impacting upon education of disadvantaged communities at every possible level, from pre-school to adult education. to do this, every aspect of life must be addressed, including socio-economic conditions. the university with the richness of a multiplicity of departments, is well placed to lead in sensitisation to the need, and in addressing the challenges. by adopting and implementing the principles of the multi-sectoral approach to phc, the university will become accountable to the community it serves, and integral to the process of transformation and so will meet its social and moral obligations of contributing to development of the communities it serves. although education cannot transform the world, the world cannot be transformed without education. prof. j. reddy. vice chancellor and rector, university of durban-westville (1991). installation address. 6 conclusion in this paper, an integrated teaching, research and service programme has been described. the aims of the study which were to provide alternative skills and to sensitise students to third world conditions; and to investigate the feasibility of final year speech, language, hearing therapy students working in a disadvantaged community with people of a different culture, in a language not known to the students, were both achieved. by linking an academic module and a research commitment to a clinical service practicum, it was possible to provide an experiential learning component, introducing an alternative model of service delivery of relevance, not only to people living in third world conditions. a qualitative analysis of the programme indicated that lack of resources and lack of co-ordinated and adequate planning could seriously compromise such a programme, which is challenged by the need for profound attitude change. potentially promotive factors relate to the indicators of success which suggest that academic standards are imminently maintainable; and to the strong positive impact on those involved. reflections relating to the role of the university focused on the development of appropriate models of health care and policy in transforming not only the health service, but also education and socio-economic conditions of community life. the multi-sectoral perspective of phc was cited as providing the integrative cohesion that will render the university accountable to the community and integral to the processes of transformation and development. notes 1 the list of topics, materials used and other information are available from the author. 2 according to the government census of 1985, 50% of south africans over the age of 20, and 79% in rural areas, are functionally illiterate. (medical research council, 1991, p.18.) ι acknowledgements | ι the c o n t r i b u t i o n made by the people of kwa dedangendlale, the community health workers, thei students, members of the staffs of the valley trust and the department of speech and hearing therapy are warmly appreciated. in exploring new models of learning jand service provision, we have attempted to establish relationships in which participants all assume the roles of both teaching and learning. in such a context, although i take responsibility for the opinions expressed, i acknowledge the invaluable contribution of all concerned, to a profoundly enriching experience and i thank them all for contributing so much to our common learning. i acknowledge all those who have commented on the draft of this paper, and particularly the former students who have shared the experience. their comments on the paper have been particularly helpful. although the feasibility study reported was not funded, the subsequent pilot programme is part of broader initiatives, described in the paper, which are being funded by the w κ kellogg foundation, battle creek, michigan and the international development research centre, ottawa, canada, respectively. the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) community based education in speech pathology and audiology at the university of durban-westville in an under served community 101 correspondence should be addressed to: glen jager, niche academic co-ordinator, c/o idhig f2-416, university of durban-westville, private bag x54001, durban 4000. phone (031) 820-2905 fax (031) 820-2925 references bruner, j. (1966). toward a theory of instruction. new york: norten. capra, f. (1983). the turning point: science, society and the rising culture. london: collins. csd/swo report (1992, october). "health for all" out of reach. csd/swo bulletin, 3-4. fraser, c. (1931). the case study method of instruction. new york: mcgraw-hill. friedman, i. (1991, november). the education of health personnel for primary health care: current practise and prospects for the future in south africa. paper presented at the symposium: training of health personnel, medical research council, cape town. grundy, s. (1987). curriculum: product or praxis. lewes, east sussex: falmer. katz, f.m. & fulop, t. (eds.). (1978). personnel for health care. geneva: who. lipkin, m. (1989a). toward the education of doctors who care for the needs of the people: innovative approaches in medical education. in h.g. schmidt, m. lipkin, m.w. de vries, & j.m. greep (eds.), new directions for medical education: problem-based learning and community-oriented medical education. new york: springer-verlag. lipkin, m. (1989b). preface. in f.m. katz & t. fulop (eds.). personnel for health care. geneva: who. medical research council. (1991). changing health in south africa: towards new perspectives in research. menlo park, ca: h.j. kaiser family foundation. rogers, c. (1969). freedom to learn. columbus, oh: merrill. sached trust. (1985). right to learn. durban: sached. schmidt, h.g., de vries, m.w. & greep, j.m. (eds.). (1989a). new directions for medical education: problem based learning and community oriented medical education. new york: springer-verlag. schmidt, h.g. (1989). how effective are problem-based, community-oriented curricula: experienced evidence. in h.g. schmidt, m.w. de vries & j.m. greep (eds.), new directions for medical education: problem based learning and community oriented medical education. new york: springer-verlag. walsh, w.j. (1978). the mcmaster programme of medical education, hamilton, ontario, canada: developing problem solving abilities. in h.g. schmidt, m. lipkin, m.w. de vries, & j.m. greep (eds.), new directions for medical education: problem-based learning and community oriented medical education. new york: springer-verlag. world health organisation. (1978). report on the international conference on primary health care at almaata, ussr, 6-12 september. geneva: who. appendix 1: research projects appendix 2 : student rating information 1 screening for loss and middle ear disease among black, rural infants and pre-nursery children in the ,4-36 months age group. | 2 feasibility of an alternative hearing screening protocol for pre-schoolers inl a black rural community. 3 hearing screening of rural black schoolchildren 6-14 years old in the inkazimulo lower primary school, at the valley of a thousand hills. 4 prevalence of hearing impairment in black class i underachievers in inkazimulo lower primary school. 5 communication disorders: beliefs and practices in a zulu community. 6 teacher attitudes and knowledge of stuttering held by primary school and high school teachers in the kwa nyuswa community. 7 acquired neurogenic communication disorders service need identification using community health workers in the kwa nyuswa area. 8 prevalence of hearing impairments and the feasibility of selected hearing screening tools for the elderly, black zulu speaking population of nyuswa. 9 the applicability of the draw a man test as used by speech-language therapists, to black children in a rural area. 10 the use of communicative intents by a group of black south african preschool children in the valley of a thousand hills. class evaluation of individual students' contribution to the valley trust experience instructions: 1 on the attached form, against each student's name, including your own, give your rating using the scale given below, to signify your perception of the following: list 1: responsibility taken for own project list 2: contribution made to total project list 3: responsibility taken for total project list 4: leadership role taken for total project 2 please do not identify yourself in any way 3 please complete independently and honestly notes to be completed by one student only • each student will get a separate form i will collate all responses on to separate lists i.e., 1-4, so please ensure accuracy scale: 1 = minimal mainly depends on others 2 = little frequently depends on others 3 = meaningful but does not undertake extra 4 = significant input is above average 5 = outstanding input is outstanding die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 102 glen w. jager appendix 3 : examples of students' descriptions 1 "the man who has never had to face adversity has yet to learn what he is made of' (anon). i believed that each day at campus was a day of facing adversity; of rising to the challenge and meeting the stresses of speech and hearing therapy. i guess i still believe this; however, from a changed perspective. when i'm on the brink of a nervous breakdown i just cast my mind back to my experiences in the valley of a thousand hills. this is written more from a personal level than an academic level, since it was my personal self that was so deeply affected by what i've observed and learnt over the year. to hear about poverty, to read about poverty has no real impact until you stare it straight in the face. the ongoing, painful adversity these people have to face leaves one totally shaken. this has been the first shocking awakening i've experienced in my short life a life previously so safe and cocooned! reality struck and left its mark. i've taken so many things for granted my three hot meals a day, a switch that will give me light, a tap that provides water people in the valley of a thousand hills are deprived of these basic needs needs which i believe are a right not a privilege. i have learnt such valuable lessons over these few months. for example, when we visited one home, walking over one hill to the next, the rugged terrain would leave me out of breath and dying for a thirst quencher and then i saw a young girl of approximately 11 years carrying a crate of cold drinks on her head 12 heavy bottles! she also had to walk over those hills! i've had to learn about mothers and fathers unemployed trying desperately to provide for their numerous children... however, a striking feature was the hospitality and friendliness of these people to us strangers, together with their sense of pride! there was no sign of (rightly placed) bitterness or hostility! another important lesson! i had no idea of the extent of poverty and its effects! there are so many other ignorant people out there people who may have the power to help in their own little way! people need to become aware of the poor socio-economic situation in these rural communities! awareness can lead to action! one way of action is through primary health care a topic i've become quite familiar with thanks to my experiences in the valley of a thousand hills, where i learnt about the dedicated work of the community health workers; and also thanks to valley trust and dr. irwin friedman for broadening my horizons! this year we were pioneers in conducting research in the valley! it was a starting point! it has also made me realize that may be through our profession we'd be able to ease the burden of these people! if only a little. i've also learnt of the importance of multi-disciplinary work there is no way we can work in isolation and be effective there has to be input from all sides! in addition, we as professionals/academics have to get rid of this "big chip on the shoulder" called arrogance! as paulo freire said "transformation is only valid if it is carried out with the people, not for them..." in essence, from: martin luther king: i have the audacity to believe that people everywhere can have three meals a day for their bodies, education and culture for their minds, and dignity, equality and freedom for their spirits. i believe that what self-centred men have torn down, other-centred people can build up. i still believe that one day humanity will bow before the altars of god and be termed triumphant over war and bloodshed and nonviolent redemptive goodwill proclaim the rule of the land and the lion and the lamb shall lie down together and every man shall sit under his own vine, and fig tree, and none shall be afraid. i still believe that we shall overcome. nobel peace prize acceptance speech. if the ignorant are educated, if the powerful act, if those who are status-bound lose their arrogance... maybe we will overcome. 2 the valley trust experience... whew!... how do i begin to describe it?! a roller-coaster ride: where i learnt about life, values, prejudice, politics, morals and about myself up every hill, down every dip and around every hairpin bend on the route. i've learnt about community: the concept; and phc what that term does and does not compass; i've acquired to a certain extent cultural sensitivity and tolerance of others' values, life styles and practices. i've learnt about the essence and value of communication, and being an effective communicator. ι most importantly i've been forced to "see" what i've been "looking at" ... a great many people in south africa have been deprived of essential services. a vast amount of work needs to be done. it is extremely encouraging to witness the community projects that a!re operating in the valley of a thousand hills knowing that each small step that is taken here, is a great step for the rest of south africa. ' thank you for the experience! the feeling has been incredible! research: "it was never easy, but together we made it!" the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 37 the manifestation of middle ear pathology in an elderly group ν j cilliers, β log (pretoria) a van der merwe, d phil (pretoria) μ hurter, β log (pretoria) department of speech pathology and audiology, university of pretoria ο nel, mb chb (pretoria) department of otorhinolaryngology, university of pretoria abstract there is a lack of clarity in the literature regarding the manifestation of the structural changes due to aging in the middle ear and the pathology which occurs in the elderly. in order to determine the incidence and manifestation of middle ear problems in an elderly group, acoustic immittance measurements and otoscopy were carried out on 94 subjects over the age of 65 years. thirty eight percent of all the subjects tested had abnormal tympanometry results in one or both ears. these abnormal results were due to either pathologies which were medically diagnosed, or other unidentified factors such as possible structural changes in the middle ear as a result of increased age. otoscopy and acoustic immittance measures should always be carried out as part of the test battery for the elderly. opsomming in die literatuur is daar geen duidelikheid oor die manifestasie van strukturele veranderinge in die middeloor weens veroudering en middeloorpatologie by die geriatriese bevolking nie. ten einde die insidensie en manifestasie van middeloorprobleme by 'n geriatriese groep na te gaan, is akoestiese immittansiemetings en otoskopiese ondersoeke uitgevoer op 94 proefpersone oor die ouderdom van 65 jaar. agt en dertig persent van al die proefpersone het abnormale timpanometriese resultate in een of beide ore vertoon. die abnormale resultate was die gevolg van verskillende middeloorpatologiee wat gediagnoseer is asook onge'identifiseerde faktore soos moontlike strukturele veranderinge in die middeloor weens veroudering. otoskopiese ondersoeke en akoestiese immittansiemetings behoort deel uit te maak van die toetsbattery vir geriatriese persone. many physical and behavioural changes differentiate the elderly population from younger persons (wofford, 1981). these physical changes include structural changes, specifically in the middle ear, such as degeneration of muscles and the stiffening of ossicular joints. there is no consensus in the literature as to the significance of these structural changes. such changes could have an effect on the functioning jof the middle ear and should be detectable through acoustic immittance measurements. there is also a lack of clarity in the literature as to whether these structural changes] lead to an increase in middle ear pathology (chermack, 1981). some studies have examined acoustic immittance measurements in the elderly. blood and greenburg (1977) examined the static acoustic immittance measurements in persons between the ages of 50 and 70. they found a significant decrease in values and concluded that there was a need for a different set of norms to be used when testing people over 70 years of age. nerbonne, bliss and schow (1978) investigated the static acoustic immittance measurements in subjects between the ages of 20 and 79 years. they found a slight but non-significant tendency for values to decrease with age. they recommended, however, that further study is neccessary in subjects over 79 years of age. degeneration of middle ear muscles results in an increase in acoustic reflex thresholds (chermack, 1981). however, studies by gelfand and piper (1981) indicated that there was no difference between the acoustic reflex thresholds of an elderly population with normal hearing and that of a young population with normal hearing. these studies have only investigated single aspects such as static immittance measurements or acoustic reflexes. the optimal use of acoustic immittance measurement is achieved when all three tympanometric parameters are assessed, viz. tympanometric peak pressure, tympanometric shape, as well as static immittance (margolis and shanks, 1985). it is also still uncertain whether there is an increase in middle ear pathology due to the structural changes. turner (1982), states that middle ear pathology is common among older patients. he found perforations of the tympanic membrane, otitis media with effusion, usually resulting from upper respiratory infection of influenza and otosclerosis. otitis media often occurs because of eustachian tube dysfunction (meyerhoff and paparella, 1978). eustachian tube dysfunction in the elderly is frequently a result of the degeneration of the veli palatine muscles (chermack, 1981). the literature indicates therefore that middle ear pathology does in fact occur in the elderly. there is no indication of the incidence of the pathology or whether the incidence is significant. these shortcomings in the literature have important implications for the audiologist. firstly, if these structural changes in the middle ear have a significant effect on immittance measurement, a different set of acoustic impedance (immittance) norms would be necessary for the elderly. secondly, if these structural changes lead to an increase in pathology, the audiologist should identify potential disdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 © sash 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 orders for referral, as many of these problems can be remedied medically or surgically (turner, 1982). thirdly, a significant incidence of middle ear disorders can motivate the inclusion of acoustic immittance measurement in the test battery for the elderly. the need for further study in this field is evident. the goals of this study are, firstly, to determine how structural changes in the middle ear affect acoustic immittance measurement. this evaluation will include tympanometric peak pressure, tympanometric shape, static immittance and acoustic reflexes. secondly, this study will examine the incidence of middle ear pathology within the test group (cilliers, 1987). methodology goals the goals of the study are: — to determine the types of tympanograms which occurred most frequently in a specific group of elderly subjects. this can supply information regarding the influence of age on the tympanogram. — to relate the acoustic immittance results to the diagnosis of pathology in order to determine whether the results are influenced by pathology or other factors such as structural changes due to aging. — to determine what effect aging has on the static immittance values and, if this varies significantly from the prescribed norms, a different set of norms for the elderly should be considered. — to record the presence or absence of acoustic reflex measures in the group of elderly subjects. experimental design a one-group design was used for this study. the same group of subjects was subjected to the test battery and each subject underwent the same procedure. subjects criteria for selection — age: the subjects had to consist of persons over the age of 65 years as sixty-five was accepted for medical-legal purposes as the start of "old age". many physiological [changes occur in this age group. these include structural changes of the auditory system (wofford, 1981). — health: all the subjects had to be capable of undergoing acoustic immittance testing and an otoscopic examination. i /' i — sex: the subjects could be either male or female. this is essential as some research claims that there is a difference between static immittance values of males and females (jerger, jerger and mauldin, 1976). therefore • both male and female subjects were selected for this study. selection of subjects ninety-four people from three old age homes in pretoria were randomly selected for this study. the ages of persons in the experimental group varied between 66 and 95 years of age. there were 11 male subjects and 83 female subjects. ν j cilliers, a van der merwe, μ hurter and ο nel the age spread and sex of the subjects are presented in table 1. table 1: the age-spread and sex of subjects used for this study age of subjects no of subjects sex of subjects male female 65—69 years 5 0 5 7 0 7 4 6 0 6 7 5 7 9 27 2 25 8 0 8 4 34 5 29 8 5 8 9 14 3 11 90 + 8 1 7 apparatus acoustic immittance data were obtained on each subject with a calibrated (to standard -iso 389, 1979) grason stadler gsi 28a auto tymp, utilizing a 226 hz probe tone. acoustic reflex measures were obtained at 500, 1000, 2000 and 4000 hz. experimental procedure each subject tested underwent the following procedure: a short interview was carried out to obtain personal information, viz. name and date of birth. a preliminary visual examination of the external auditory canal had to be carried out to determine whether immittance measurement could be obtained. immittance measurements cannot be carried out if fluid is running from the ear canal or if there is an obstruction (meyer, hurter and van rensburg, 1987). the acoustic immittance protocol was then carried out. the probe was placed in the ear canal and an airtight seal was obtained. the test sequence proceeded automatically. the pressure sweep began at + 200 dapa and proceeded in a negative direction until it reached -400 dapa. the ear canal volume in ml, immittance peak in ml, and the pressure peak in dapa were recorded (margolis and shanks, 1985). acoustic reflex measures were then obtained ipsilaterally at 500, 1000, 2000 and 4000 hz in db hl (hearing level), i i i an otoscopic examination was then carried out by a clinical assistant in otorhinolaryngology in order to determine the presence of any middle ear pathology. / data analysis since all the acoustic immittance measures were carried out on the gsi 28a, the norms were used as set out in the instruction manual. — static immittance: the normal range is 0,3 ml to approximately 1,8 ml. a static immittance peak which falls between these two ranges indicates normal mobility of the middle ear system. — pressure peak: for most applications a normal pressure range of -150 dapa to +100 dapa is used (margolis and shanks, 1985). however, strict rules for a normal middle the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the manifestation of middle ear pathology in an elderly group 39 ear pressure indicate a pressure range of -50 dapa to + 50 dapa (brooks, 1981). — tympanometric shape: — type a tympanogram has static immittance values of between 0,3 ml and 1,8 ml and has a pressure peak at or near 0 dapa although a range between -150 dapa and + 100 dapa is considered normal (hodgson, 1980; margolis and shanks, 1985). — type ad signifies a tympanogram with an unusually high static immittance peak of 1,8 ml or more. peak pressure is usually at or near 0 dapa (hodgson, 1980; margolis and shanks, 1985). — type as denotes a tympanogram with reduced amplitude of 0,2 ml or less. the pressure peak is usually at or near 0 dapa (margolis and shanks, 1985). — type β tympanogram is flat, typified by the absence of a pressure peak (hodgson, 1980; margolis and shanks, 1985). — type c tympanogram has a negative tympanometric peak pressure, usually smaller than -150 dapa (hodgson, 1980, margolis and shanks, 19^5). — acoustic reflex measures: the reflex usually occurs between 70 and 90 db hl above the hearing threshold in normal;hearing people (wiley and block, 1985). data processing for the analysis of the data obtained in this study descriptive statistical techniques were used. the aim of descriptive statistics is to sum up and condense the measurable characteristics of results obtained. the following techniques were used: percentages and frequency tables. i resijlts j / / · i the results are presented in the sequence outlined according to the goals of this study. the types.of -tympanograms which occurred table 2 presents a summary of the salient data obtained iq this study. it shows the number of subjects with normal acoustic immittance results bilaterally, with abnormal acoustic immittance results unilaterally and with abnormal immittance results bilaterally. the types of tympanograms which occurred' are indicated as well as the number of ears which presented each type of tympanogram. table 2 also shows the various types of pathology which were diagnosed. of the 94 subjects tested 58 (62%) had type a tympanograms bilaterally. type a tympanograms are associated with normal middle ear function. this pattern reflects normal mobility and peak pressure (hodgson, 1980). twenty three of the subjects (24%) had abnormal results unilaterally and 13 subjects (14%) had abnormal results bilaterally. therefore 38% of all the subjects tested had abnormal acoustic immittaijce results in one or both ears. these results are extremely high, compared with a study by jerger (1976). jerger found that the highest incidence of abnormal tympanometric results (31%) occurred in the age group 2 to 5 years. it was suggested th t̂ tnis age group is the highest risk group for otitis media. jerger found that there was a gradual decrease in abnormal results with an increase in age. ) with reference to the number of ears tested in this study 188 ears were examined in total. of these 139 (74%) yielded type a tympanograms. of the remaining ears 38 (26%) presented type as tympanograms. type as denotes a tympanogram with a reduced amplitude characteristic of ossicular fixation, tympanosclerosis and some forms of otitis media (margolis and shanks, 1985). the type as tympanogram therefore predominates over the other abnormal tympanograms in this elderly group. this differs from findings in children where tympanograms associated with otitis media, eg. type β and type c tympanograms, occur most frequently (hodgson, 1980). the reason that the type as tympanograms occurred more often in the elderly group could be due to the calcification and ossification of the joints between the ossicles in the middle ear (kahane, 1981). there were 3 type β tympanograms. type β tympanograms occur in the presence of middle ear effusion and other spaceoccupying lesions of the middle ear. they can also occur in cases of tympanic membrane perforation and impacted cerumen (hodgson, 1980; margolis and shanks, 1985). most of these pathologies associated with type β tympanograms can be remedied medically or surgically and therefore can be identified and referred for further treatment (turner, 1982). there were 5 ears with type c tympanograms. this type of tympanogram is often an indication of eustachian tube dysfunction or otitis media (hodgson, 1980; margolis and shanks, 1985). of all the ears tested tympanograms with no peak were recorded in 3 ears. this could indicate a perforation or impacted cerumen (margolis and shanks, 1985). correlation between the acoustic immittance results and the types of pathology diagnosed the question as to why this high percentage of abnormal acoustic immittance results occurred was posed and thus the acoustic immittance results are discussed in terms of the different types of pathology which were identified. this is also presented in table 2. type a tympanograms of the 139 ears which yielded type a tympanograms 96 were diagnosed as having normal middle ear function. forty of the remaining ears with type a tympanograms were diagnosed as having cerumen, ear canal collapse or both. although cerumen and ear canal collapse can affect pure tone audiometric results (wofford, 1981), they do not necessarily affect acoustic immittance results (randolph and schow, 1983; wofford, 1981). this could explain why type a tympanograms occurred. a further 2 ears that presented a type a tympanogram were diagnosed as having healed perforations in the tympanic membrane. a mildly scarred tympanic membrane can result in increased mobility in the tympanic membrane (jerger, anthony, jerger and mauldin, 1976). in these 2 cases it appears as though the healed tympanic membrane had not necessarily affected the tympanometric results. the south african journal of communication disorders, vol. 35, 1988 . r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 ν j cilliers, a van der merwe, μ hurter and ο nel ό <u a. si bo js "o λ <3 ο, <υ α si <υ λ "ό α <3 4) u 4) υ α <3 s <λ 3 ο υ < ν ο ξ <3 η ty pe s of p at ho lo gy d ia gn os ed su rg er y on ty m . m em . 7—1 ty pe s of p at ho lo gy d ia gn os ed o tit is m ed ia 7—1 ν ty pe s of p at ho lo gy d ia gn os ed r ep ai re d m em br an e 7—1 7—1 ty pe s of p at ho lo gy d ia gn os ed c er um en + re tr ac te d m em br an e 7—1 ty pe s of p at ho lo gy d ia gn os ed pe rf or at io n 7—1 τ—i ty pe s of p at ho lo gy d ia gn os ed c er um en + ty m pa no sc le ro si s 7—1 ty pe s of p at ho lo gy d ia gn os ed ty m pa no sc le ro si s \ 7—1 ty pe s of p at ho lo gy d ia gn os ed c er um en + ea r ca na l co lla ps e ν ν co τ—i ty pe s of p at ho lo gy d ia gn os ed ea r ca na l co lla ps e <n τ—1 7—1 τ—i co ν c er um en im pa ct io n co 7—1 c er um en l£> 7—1 7—1 7—1 τ—1 n or m al ο 00 l£> 7—1 co 7—1 oo n o. o f ea rs l£> τ—1 τ—1 co ν oo 7—1 τ—1 co 1 ο ν ν ν cm ty pe o f ty m pa no gr am ty pe a ty pe a ty pe a s ty pe β ty pe c n o pe ak ty pe a s ty pe β t yp ec n o pe ak n o. o f su bj ec ts oo in co ν on or m al a co us tic im m itt an ce re su lts bi la te ra lly a bn or m al ac ou st ic im m itt an ce re su lts un ila te ra lly a bn or m al ac ou st ic im m itt an ce re su lts bi la te ra lly die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the manifestation of middle ear pathology in an elderly group 41 one ear with a type a tympanogram was diagnosed as having otitis media. it should be noted that a peak pressure of -119 dapa was recorded. this could imply that the peak pressure norms that were used, viz. a pressure range of -150 to + 100 dapa, are not sensitive enough to identify all cases of otitis media. type as tympanograms thirty eight of the ears tested yielded a type as tympanogram. of these 21 were diagnosed as having normal middle ear function, 5 were diagnosed as having cerumen, 1 had impacted cerumen, 3 had ear canal collapses, 5 had both cerumen and ear canal collapses, 2 had tympanosclerosis and 1 ear had had surgery to the tympanic membrane. the percentage of ears with type as tympanograms that were diagnosed as normal is 55. this implies that factors other than pathology influenced the tympanometric results. structural changes due to aging such as stiffening of the tympanic membrane and ossicular joints could have resulted in the type as tympanogram (wofford, 1981). the possibility that structural changes due to aging may have affected the tympanometric results, has important implications for the audiologist, as there will be a high percentage of abnormal tympanograms with no evidence of middle ear disorder. this implies that the occurrence of a type as tympanogram does not always indicate the presence of middle ear pathology among the elderly. impacted cerumen can cause a type as tympanogram (margolis and shanks, 1985). this accounts for the single case of cerumen impaction which yielded as type as tympanogram. ear canal collapse and cerumen do not necessarily influence the acoustic immittance results (randolph and schow, 1983; wofford, 1981). there were 13 ears with type as tympanograms that were diagnosed as having cerumen, ear canal collapse or both. these tympanometric results could therefore be caused by factors other than pathology. structural changes due to aging can /cause stiffening of the middle ear system, which could result in / type as tympanograms. there were also 2 ears which had tympanosclerosis and 1 case of surgery to the tympanic membrane that yielded type as tympanograms. according to margolis and shanks (1985), both of these diagnoses could] result in a type as tympanogram. type β tympanograms there were 3 ears with type β tympanograms. one was diagnosed as having a perforated tympanic membrane and the third had a retracted tympanic membrane and cerumen. all three of these types of pathology correlate with the acoustic immittance results (margolis and shanks, 1985). referral for further medical attention is essential in these cases (turner, 1982). type c tympanograms of the 5 ears which yielded c tympanograms 2 had otitis media. the remaining 3 ears all had an ear canal collapse. an ear canal collapse cannot influence tympanometric results (wofford, 1981). the type c tympanogram could therefore be caused by eustachian tube dysfunction. tympanograms with no peak three ears with tympanograms which had no peak were diagnosed. perforated tympanic membranes were found in 2 of the ears. the third ear had cerumen and an ear canal collapse. no peak is registered in tympanometric measurement when the pressure that is required for the measurement of the middle ear function cannot be built up (hodgson, 1980). both the perforations and the ear canal collapse could result in no pressure being built up. there is therefore a correlation between the tympanometric results and the presence of pathology. the effect of aging on static immittance values in order to determine the effect of aging on the static immittance values a correlation was drawn between the two. table 3 gives the mean and median static immittance values as a function of age. table 3: correlation between age and mean and median static immittance results in millilitres (mp) age in years mean median 6 5 6 9 0,61 mp 0,65 mp 7 0 7 4 0,75 mp 0,65 mp 7 5 7 9 0,53 mp 0,4 mp 8 0 8 4 0,58 mp 0,4 mp 8 5 8 9 0,38 mp 0,4 mp 90 + 0,55 mp 0,5 mp the results show that there is a significant decrease in both the mean and median static immittance values in the subjects of 75 years and older. this decrease does not, however, continue with an increase in age. there is in fact, a slight increase in the static immittance values of subjects over 90 years of age. this tendency contrasts with the findings by blood and greenburg (1977). they found a significant decrease in static immittance values. their study examined subjects between the ages of 50 and 70 years. the fact that their population was considerably younger than the population used in this study may explain the resulting difference in findings. the tendency for static immittance values to decrease slightly and then level off as was observed in this study, correlates with findings by nerbonne, et al. (1978). they found a slight but non-significant tendency for values to decrease with age. their subjects ranged in age from 20 to 79 years. they did recommend that further study of individuals over 79 years of age was necessary. this study examined subjects between the ages of 65 and 95 years, but the results did not differ from those found by nerbonne, et al. (1978). a separate set of static immittance norms for the elderly is not necessary, as the mean and median values for all the age groups fall within the normal range of 0,3 mp — 1,8 mp. acoustic reflex measures table 4 presents the percentage of subjects as well as the percentage of ears with absent acoustic reflex measures. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 ν j cilliers, a van der merwe, μ hurter and ο nel table 4: percentage of subjects and ears with absent and present acoustic reflexes percentage of ears percentage of subjects acoustic reflexes present 48% 29% acoustic reflexes absent 52% 71% the acoustic reflex is usually elicited at 70—90 db hl above pure tone threshold. the most likely cause of the absent reflexes is an increased pure tone threshold. most elderly people have a sensory neural hearing loss due to presbycusis. since pure tone audiometric testing was not carried out, the exact cause of the absent acoustic reflexes is unknown. the possibility exists that the absent reflexes could also be the result of the degeneration of the middle ear muscles. all the muscles in the body degenerate with increasing age. the muscles in the middle ear should not be an exception. discussion of results the manifestations of outer and middle ear pathology outer and middle ear pathology occurred in 38% of all the ears tested. this high occurrence can partially be explained as a function of increased age. the type of pathology which occurred most frequently was excessive cerumen which may obstruct the external auditory canal partially or completely (cohn, 1981). copious secretion of wax occurs in individuals of all ages; marshall (1985), however, indicates that excessive cerumen is more common among older people. an overaccumulation of cerumen can result in a conductive hearing loss and abnormal acoustic immittance results, depending on the degree of obstruction (wofford, 1981). excessive cerumen can also influence ear mould impressions for hearing aids. twenty two percent of all the ears tested were diagnosed as having cerumen, and of these, 64% had type a tympanograms. the acoustic immittance results indicate that even a total occlusion of the ear canal due to cerumen impaction does not always result in abnormal tympanograms. the impaction may, however, influence the results, and this implies that an otoscopic examination should always be carried out prior to acoustic immittance testing in an elderly group. excessive cerumen can be treated quickly and successfully. ear canal collapse or stenosis occurred in 17% of all the ears which were examined. although ear canal collapse can occur in any age group, it is usually associated with old age which causes a loss of elasticity in the dermis. the cartilaginous portion also becomes more flexible (wofford, 1981). the external auditory, canal closes when an earphone is placed over it; this can result in a mild to moderate conductive hearing loss (randolph and schow, 1983). a type a tympanogram can occur with reduced ear canal volume measurements. this correlates with the findings of this study where 64% of the ears diagnosed as manifesting an ear canal collapse had type a tympanograms. the remaining 36% had additional factors which affected the results. in order to prevent incorrect interpretation of audiometric testing, otoscopy and tympanometry should always be performed prior to audiometric testing. a collapse of an ear canal during audiometric testing can be prevented by using circuaural or postaural cushions (marshall and grossman, 1982). there were 3 cases of otitis media diagnosed and 1 case of retracted tympanic membrane, indicative of an early stage of otitis media (cohn, 1981). the development of otitis media is most frequently related to eustachian tube dysfunction. the eustachian tube maintains middle ear ventilation and facilitates the clearing of foreign material as well as providing immunological defence (cohn, 1981). eustachian tube dysfunction is often associated with old age because the veli palatini muscles which open the eustachian tube may degenerate or atrophy. kahane (1981), says that degeneration of all the muscles occurs with old age. otitis media may therefore be caused indirectly by increased age. however, it is also possible that these subjects have a history of otitis media, and thus the condition is not as a result of old age. otitis media cannot always be detected through pure tone audiometry. it can yield a conductive hearing loss. otoscopy and acoustic immittance testing can detect the presence of otitis media. as mentioned previously, a type β or c tympanogram usually occurs (hodgson, 1980) and this correlates with the tympanometric results obtained in this study. it is therefore essential that these examinations be carried out as part of the test battery for the elderly. otitis media is therefore not exclusively associated with the very young, but can also occur among the elderly. there were 3 ears with perforated tympanic membranes. tympanic membrane perforation can result from excessive effusion, the erosive effect of middle ear lesions such as cholesteatomas or an external trauma (wofford, 1981). in the 3 cases diagnosed in this study, the most likely cause was excessive effusion. a perforation may affect the audiometric results, depending on the size of the perforation (wofford, 1981). a perforation can be identified through otoscopy and acoustic immittance measurement. if the 3 cases identified in this study had perforations due to excessive effusion, the possibility exists that the otitis media was caused, by a eustachian tube dysfunction. the eustachian tube dysfunction, as mentioned earlier, could be the result of increased age. tympanosclerosis and healed perforations occurred in 4 ears. tympanosclerosis and healed perforations may result after tympanic membrane rupture and healing (wofford, 1981). tympanosclerosis can include stiffening of the tympanic membrane, tympanic mucosa, ossicular ligaments1, tendons of the stapedius and tensor tympani muscles and fixing the malleus andincus in the epitympanic area. a scar·! red tympanic membrane is indicative of a healed perfora-; tion. the most likfely cause of a healed perforation is effusive otitis media. j it is essential that the persdn with evidence of a healed per-j foration undergoes regular ,'otoscopic examinations and1 acoustic immittance testing to detect the recurrence of otitis 1 media. / / it is evident; therefore, that much of the pathology which occurs in' elderly individuals could be as a result of increased age. otoscopy and acoustic immittance testing are essential for the diagnosis of most of these disorders and must therefore be carried out prior to pure tone audiometric testing. repeated testing is necessary to detect the recurrence of otitis media. the nursing staff who work in old age homes could also be trained to identify symptoms related to outer and middle ear disorders for early identification and referral. the effect of structural changes due to aging on, the acoustic immittance measurements eleven percent of abnormal acoustic immittance results the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the m i f e s t a t i o n of middle ear pathology in an elderly group were diagnosed as having no middle ear disorders. this implies that there are factors other than a middle ear pathology which resulted in the abnormal acoustic immittance results. one of the possible causes of these abnormal results could be attributed to structural changes to the middle ear system. kahane (1981), noted that the structure of the adult laryngeal cartilages changes with increasing age. calcification or ossification caused stiffening of the laryngeal joints. these changes do not only occur in the larynx, but occur in all the joints of the body including those in the middle ear. it seems possible, therefore, that a stiffening of the middle ear system could cause abnormal acoustic immittance results. fifty five percent of the type as tympanograms which occurred had a diagnosis of normal middle ear condition. abnormal results could also have been caused by a history of pathological conditions which are no longer evident, but which have caused a permanent effect on the middle ear system. since biological changes are known to occur with increasing age, it is unlikely that the middle ear should remain unaffected. these non-pathological changes which influence acoustic immittance measures have important implications for the audiologist. there will thus be a percentage of abnormal tympanograms with no middle ear disorders in the testing of the elderly. although this percentage is not high enough to warrant separate static immittance or tympanometric norms for the elderly, it nevertheless should be taken into consideration. > it is also of interest that the static immittance values decreased in subjects over 75 years of age. this decrease did not continue with an increase in age. in addition, these values increased slightly in the age group over 90 years. the mean and median static immittance values of each age group fell within the normal range, i.e. 0,3 ml — 1,8 ml. conclusion \ in this group of elderly subjects, acoustic immittance results indicating a normal middle ear system (type a tympanogram) occurred most frequently. of these normal acoustic immittance results, 43 earsjwere, however, medically diagnosed as having excessive cerumen, ear canal collapse, healed perforations or otitis media. these diagnoses do not necessarily influence acoustic immittance measurements. thirty-eight percent of the subjects had abnormal tympanograms in one or both ears. of these tympanograms indicating middle ear dysfunction; eight ears presented with type β or c tympanograms or had no peak, confirming the medical diagnosis of conditions such as otitis media. two of the ears had type c tympanograms but there was otoscopically no indication of middle ear pathology. these results could indicate a eustachian tube dysfunction possibly caused by degeneration of the veli-palatini muscles. of the abnormal tympanograms, type as, indicating reduced amplitude, occurred most often. this was otoscopically verified in 45% of the cases where a diagnosis of pathology such as tympanosclerosis or impacted cerumen occurred. however, 55% of these type as tympanograms had no evidence of middle ear disorder. these results could therefore be due to unidentified causes such as non-pathological changes, associated with old age, which lead to a stiffening of the middle ear system. the fact that there was a correlation between the decrease in static immittance values and an increase in age up to 90 years of age, seems to indicate that aging had an effect on the results. otoscopy and acoustic immittance measures should be carried out as part of the test battery for the elderly. identification of pathology, which may influence further audiometric testing, eg, ear canal collapse, is essential as the effect of these disorders on audiometric testing can be prevented. middle ear pathology increases the total hearing loss in the elderly. there is a high incidence of sensory neural hearing loss in the aged. the conductive component of the hearing loss can be remedied medically or surgically. the audiologist therefore has an important role to play in the identification ot these conductive components. the last few decades have seen a rapid increase in the number of people over 65 years. the elderly can no longer be ignored, but must be recognised for the contribution they make to society. there is a shift in the orientation of the field of audiology towards the evaluation and rehabilitation of the elderly. the audiologist plays an important role in the identification and referral of individuals who have pathological conditions in the outer and middle ear. references blood, i. & greenburg, h. acoustic admittance of the ear in the geriatric person. journal of the american audiological society, 2, 185—187, 1977. brooks, d. impedance measurement in the elderly. in r. penha & p. de ν pizarro (eds.) proceedings of the fourth international symposium in acoustic impedance measurement. lisbon: lissabon universidade, nova de lisboa, 1981. chermack, g. handbook of clinical audiological rehabilitation. illinois: charles c thomas, 1981. cilliers, n.j. the manifestation of middle ear pathology in an elderly group. unpublished b.(log.) dissertation, university of pretoria, 1987. cohn, a. etiology and pathology of disorders affecting hearing. in f.n. martin (ed.) medical audiology disorders of hearing. new jersey: prentice-hall, inc., 1981. gelfand, s. & piper, n. acoustic reflex thresholds in young and elderly subjects with normal hearing. journal of the acoustical society of america, 69, 2 9 5 2 9 7 , 1981. hodgson, w.r. basic audiological evaluation. baltimore: williams and wilken co., 1980. jerger, j.f. clinical experience with impedance audiometry. in j.l. northern (ed.) selected readings in impedance audiometry. new york: american electromedics corporation, 1976. jerger, j.f., anthony, l., jerger, s. & mauldin, l. studies in impedance audiometry iii. middle ear disorders. in j.l. northern (ed.) selected readings in impedance audiometry. new york: american electromedics corporation, 1976. jerger, j.f., jerger, s. & mauldin, l. studies in impedance audiometry i. normal and sensori-neural ears. in j.l. northern (ed.) selected readings in impedance audiometry. new york: american electromedics corporation, 1976. kahane, j.c. anatomic and physiological changes in the aging peripheral speech mechanism. in d.s. beasley and g.a. davis (eds.). aging communication processes and disorders. new york: grune & stratton, 1981. ' / margolis, r.h. & shanks, j.e. tympanometry. in j. katz (ed.) handbook of clinical audiology. baltimore: williaps and wilken co., 1985. marshall, l. audiological assessment of older adults. seminars in hearing, 6, 2, 1 6 1 1 7 5 , 1985. marshall, l. & grossman, m.a. management of ear canal collapse. archives of otolaryngology, 108, 3 5 7 3 6 1 , 1982. meyer, s., hurter, m. & van rensburg, f. gehoorsiftingsresultate van 'n groep kleurlingleerlinge. the south african journal of communication disorders, 34, 43—47, 1987. meyerhoff, w.l. & paparella, w.m. diagnosing the cause of hearing loss. geriatrics, 33, 95—98, 1978. nerbonne, m., bliss, a. & schow, r.l. acoustic impedance values in the elderly. journal of the american audiotory society, 4, 5 7 5 9 , 1978. randolph, l.j. & schow, r.l. threshold inaccuracies in an elderly clinical population: ear canal collapse as a possible cause. journal of speech and hearing research. 26, 54—58, 1983. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 turner, j.s. treatment of hearing loss, ear pain and tinnitus in older patients. geriatrics, 37, 1 0 7 1 1 8 , 1982. wiley, t.l. & block, m.g. overview and basic principles of acoustic immittance measurements. in j. katz (ed.) handbook of ν j cilliers, a van der merwe, μ hurter and ο nel ι clinical audiology. baltimore: williams & wilkens co., 1985. wofford, m. audiological evaluation and management of hearing disorders. in f.n. martin (ed.) medical audiology disorders of hearing. new jersey: prentice-hall inc., 1981. talking to professionals i'hc needier westdene organisation p.o. box 28975 sandrinaham 2131 telephone (oil) 485-1302/3/4/5 technimark 560 the south a frican journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abr audiometry: application to the paediatric population susan helfand ba (sp & η th) (witwatersrand) rachel yifat ma (sp path) (tel aviv) department speech pathology and audiology, university of the witwatersrand, johannesburg abstract this study examines the relationship between auditory brain stem, behavioural observation and impedance audiometry in a paediatric population. particular reference is made to the strengths and weaknesses of auditory brainstem audiometry applied to this age group. results indicate that in some cases diagnosis of hearing loss is made primarily on the basis of this test, while in other cases the test serves as an excellent check on behavioural and impedance audiometry. opsomming die verhouding tussen ouditiewe breinstamoudiometrie, gedragswaarneming en impedans-oudiometrie is in 'n pediatriese groep ondersoek. verwysing word gemaak na die voordele en nadele van breinstamoudiometrie vir hierdie ouderdomsgroep. resultate dui daarop dat vir sommige pasiente die diagnose van 'n gehoorverlies uitsluitlik berus op die uitslag van hierdie toets, terwyl dit in ander gevalle dien as 'n aanduiding van die betroubaarheid van gedragswaarneming en impedans-oudiometrie. the impact of abr audiometry has increased rapidly over the past five years (hecox & jacobson, 1984). many more centres have introduced auditory nerve and brainstem evoked responses in addition to traditional behavioural procedures as a means of diagnosing hearing loss in infants and children (levi et al, 1983). initial validation procedures for auditory brainstem response (abr)* audiometry i.e. the degree to which the auditory brainstem potentials are able to accurately predict auditory impairment, were undertaken in the adult population (hecox & jacobson, 1984). finitzo-hieber (1982) cites her research, where impairments predicted by abr were confirmed by pure tone audiometric results, stating that, the agreement between abr and pta was generally good with abr/pta discrepancies among subjects never greater than one category. in other words, while abr could and did predict normal hearing in the presence of a mild loss, this discrepancy/error did not occur for moderate or greater impairment and a loss was never called severe to profound that was in fact normal or even mild in degree (sohmer & feinmesser, 1974 and pratt & sohmer 1978 cited by levi et al, 1983). hecox and jacobson (1984) also, using the pta as the validating reference criterion, report serious discrepancies in less than 1% of cooperative adults. therefore, whilst the use of click stimuli in routine abr testing does not allow for the prediction of information concerning the entire audiometric configuration, a methodological limitation generally accepted, one would usually still be able to identify patients in need of long term follow up (hecox & jacobson, 1984). recent studies have attended specifically to the use of abr testing in the difficult-to-test population, namely the very young and multihandicapped. cornacchia et al, (1982), comparing brainstem evoked response audiometry and behavioural audiometry in 270 infants and children (divided into those with and without reliable audiograms), found a higher agreement between the two methods in the former group but concluded that abr (using the term bsera) * suggested nomenclature at the international conference on standards for auditory brainstem response testing, cited by. sohmer, h. (1984). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 audiometry was reliable and enabled many diagnostic mistakes to be avoided. levi et al., (1983) conducting a similar, but two part study where both infants and neonates were studied, state that abr audiometry gave an earlier indication of the presence or absence of hearing and of hearing threshold. they recommended the use of abr as early as possible, particularly for the "high risk" infant. the purpose of this work was to analyze in more detail our own paediatric abr clinical data. specifically the aims were to examine and gain a better understanding of the relationships between abr, behavioural and impedance testing in this population group. method subjects during the period 1982-1983, forty-five children under the age of two years, were tested at the speech and hearing clinic, university of the witwatersrand. two years was taken as the arbitrary age cut-off point for the purpose of the study. fourteen children in this group were assessed with abr audiometry in addition to the conventional procedures and constitute the population under study. the children were referred by a variety of medical and educational sources for suspected or queried hearing loss. since abr testing was not administered routinely to all clinic patients in this age range, the majority of the children were those with associated problems or "at risk" infants. see table 1 below for a detailed description of the subjects (ss). as table 1 illustrates, eight of the ss had definite associated problems or "at risk" factors for hearing loss. in the remaining ss no "at risk" factors could be identified. procedure retrospective analyses of assessment reports took note of the results of three procedures: behavioural, impedance and abr audiometry. 1. behavioural observation audiometry (boa) all ss had been tested behaviourally in a sound field setting using © sasha 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 66 susan helfand and rachel yifat table 1 description of subjects subjects sex age associated problems at risk factors 1 μ 6 weeks — family history 2 f 5 months — 3 μ 5 months — 4 μ 7 months — 5 μ 8 months — 6 f 10 months downs syndrome 7 μ 16 months — 8 μ 18 months — 9 f 20 months pierre robin syndrome 10 f 20 months mental retardation 11 f 20 months reyes syndrome 12 μ 22 months cerebral palsy 13 f 22 months post meningitis 14 μ 24 months family history the methods reported by downs and sterrit (1967) cited and summarized by levi et al., (1983). essentially this is based on the use of higher intensity stimuli for younger infants: neonates 90-100 db hl; 6 week-old infants 50db hl (to which a gross motor reaction is expected); 4-5 months 30db hl; and 7-9+ months 10-20db hl (to which the expected response is a turning of the head to the source of sound). responses were categorized according to the following general descriptive categories: absent responses, queried responses and expected responses. in some cases a more detailed description of the expected responses was possible in terms of the intensity range. 2. impedance audiometry (imp) where available these results were described according to tympanometric configuration and acoustic reflex results. tympanograms were classified according to jerger's classification (jerger, 1970 cited by northern, 1984). reflexes were described as being absent or present at normal or elevated hearing levels. 3. abr audiometry (abr) abr testing had been conducted at both the national institute of personnel research and at the speech and hearing clinic, university of the witwatersrand. the test was carried out in an electrically shielded, sound-attenuated room. all children were sedated and slept through the entire test. the responses were elicited by clicks of rarefaction polarity with an electrical duration of 100 micro sees, delivered through a tdh-39 earphone monaurally. stimulus rate was 11.1/sec. electrodes were placed as follows: vertex (ev = active electrode); earlobe (er = reference electrode); and forehead (eg = ground electrode). the electrical signals were fed into a pre-amplifier, filtered through a band-pass,filter (150-3000hz), amplified by a lownoise wide band amplifier and then averaged. averaging was initiated at stimulus onset and continued for 10 ms. the averaged signals were printed on an x-y plotter. the procedure for threshold estimation was as follows: stimulus intensity was decreased in 5-10 db steps until no identifiable peak v was obtained. for the purpose of this study only the presence of peak v was used to estimate thresholds (chiappa, 1983). the site of impairment was not identified as the results for each individual were not compared to a normal latency intensity curve (hecox and jacobson, 1984). results results are discussed as follows: — agreement between boa and abr audiometry — agreement between impedance and abr audiometry — agreement among all three tests: boa, impedance and abr audiometry. agreement between boa and abr as can be seen in table 2 these infants (with the exception of subjects 10 & 12) had either normal or severe to profoundly impaired hearing, with no associated problems. this observation is consistent with the findings of gornacchia et al., (1982) who found in their group of children without associated problems (group a) that there was increasing agreement between boa and abr in those classified as profoundly deaf or no/mild hearing loss. specifically they noted that when audiograms revealed a hearing loss of at least 70 db in the frequencies of the speech range, the correlation between these two tests was perfect. ss 10 & 12 reflect how gross threshold 'estimates' (i.e. notjeompletely frequency specific) from behavioural testing were more or less in agreement with the extent of loss suggested by abr jaudiometry, despite the many queried responses. agreement between behavioural and abr test results should however take into account frequency specific responses. < | i as can be seen in table 3 agreements between abr.and boa in these subjects is generally poor. as in the case of group β ss in the study by cornacchia et al., (1982) these children were those with associated brain damage and/or behavioural problems, which render behavioural test results less reliable, especially in cases with severe handicaps. specific test results in this group are examples of how critical the contribution of abr testing was for clarifying the peripheral auditory status. in subject 6 where severe retardation may have confounded any impression of auditory functioning, abr results ensured that the problem of a concomitant severe hearing handicap was recognized and followed up much earlier. / in subject 11, a child with multiple problems, normal results as reflected on abr testing excluded a hearing problem and she could thus be referred accordingly. while these examples illustrate the serious discrepancies that may occur between the two tests, subject 14 is a good example of partial discrepancy between the two tests. here, / the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abr audiometry : application to the paediatric population table 2 results of boa and abr in subjects reflecting good inter-test agreement subjects age associated problems boa abr i 6 weeks expected responses normal bilateral 3 5 months no responses severe-prof, s/n loss bilateral 4 7 months expected responses normal bilateral 7 16 months responses to low freq. only (70db hl) severe-prof, s/n loss bilateral 8 18 months sat l:95db hl r:85db hl severe-prof, s/n loss bilateral 10 20 months queried retardation response to 40-65 db hl many responses queried mild/mod s/n loss bilateral 12 22 months cerebral palsy lx:response at 70db hl many queries. 2x:response at 50-60db hl lx:severe loss bilateral 2x:mod. mixed loss bilateral 13 22 months post meningitis response at 90db hl severe-prof, s/n loss bilateral sat = speech awareness threshold s/n = sensori-neural severe-prof. = severe-profound table 3 results of boa and / / abr in cases reflecting inter-test discrepancy. / subjects age associated problems boa abr 2 5 months . prematurity response to medium intensity. many responses queried. normal bilateral 5 8 months expected responses ' mild cond. loss bilateral 6 10 months downs syndrome queried responses severe/prof, s/n loss bilateral 9 20 months pierre robin syndrome queried responses mild cond. loss bilateral 11 20 months reyes syndrome all responses queried normal limits bilateral 14 24 months family history responses at 60db hl severe/prof, s/n loss bilateral cond. — conductive s/n = sensori-neural severe/prof. = severe-profound die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 68 susan helfand and rachel yifat table 4 results of impedance and abr audiometry subjects age associated problems imp abr 1 6 weeks — bilateral type a normal bilateral 2 5 months premature bilateral type a ars at normal hls normal bilateral 3 5 months — severe-profound loss bilateral 4 7 months — bilateral type a ars at normal hls normal bilateral 5 8 months — bilateral type a ars at normal hls mild loss bilateral 6 11 months down syndrome grommets severe-profound loss bilateral 7 17 months — grommets severe-profound loss bilateral 8 18 months — grommets severe-profound loss bilateral 9 21 months pierre robin syndrome bilateral type β mild loss bilateral 10 22 months query retardation grommets mild-moderate loss bilateral 11 24 months reyes syndrome bilateral type a ars at normal hls normal bilateral 12 22 months cerebral palsy 1 χ bilateral type β 2 χ grommets severe-profound loss bilateral moderate loss bilateral 13 20 months post meningitis profound loss bilateral 14 24 months family history type a bilateral ars present up to ikhz, absent from 2-4 khz severe-profound loss bilateral key: ar acoustic reflex hl = hearing level behavioural testing gave the impression of a less severe loss than that indicated on abr, and probably yielded information about low frequencies that is not available with the use of the 'broad-band' click stimulus which reflects high frequency fibre activity (hecox & jacobson, 1984). , agreement between abr and impedance audiometry robier et al., (1983) discuss the value of using precise acoustic impedance measures to rule out middle ear effusion before administering electro-physiological tests to reveal sensori-neural deafness. levi et al., (1983) include impedance together with abr audiometry as a check on behavioural observation audiometry. neither of these studies, however, specifically examine the relationship between acoustic reflex threshold and abr measures. a comparison of the results of these two tests revealed how they may complement each other. it was possible to observe, in subjects 2 and 11, how abr results were able to lend support to the suggested normal hearing observed on the acoustic reflex subtest. in these cases, the presence of the reflexes at normal hls was ambiguous in the light of the queried behavioural responses. furthermore, in subject 14, while absent abr tracings suggested a severe to profound loss, the pattern of reflex threshold results.obtained (absent in the higher but present in the lower frequencies), suggested some hearing in the lower frequencies. since it is known that correlations between abr prediction of hearing loss and audiometric thresholds suggest that abr best approximates hearing thresholds at high frequencies (2-4 khz), and poorly reflects the integrity of hearing at less than 500 hz (galambo and hecox 1978, jerger and mauldin, 1978, cited by hecox and jacobson, 1984), acoustic reflex the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abr audiometry : application to the paediatric population 69 measures in this case, gave us information about possible residual hearing, otherwise unavailable from isolated standard abr testing. agreement among abr, impedance and boa in general the findings of the results of these infants reflected a familiar phenomenon facing the audiologist, namely that inter-test results are not always in perfect agreement. it is clear that where agreement is perfect the diagnosis of the extent and type of loss can be made more definitely, and that as agreement lessens diagnoses are made more tentatively. extending this to abr audiometric interpretation the use of adjunctive audiological information is crucial if one is to use abr results to effectively diagnose and manage, in particular the paediatric and unco-operative patient (hecox & jacobson, 1984). subject 12 best illustrates how the integration of results from all three tests avoided the possibility of a critical diagnostic error. on initial assessment abr together with boa results gave the impression of a bilateral severe hearing loss, while impedance results indicated the presence of some conductive component. subsequent to the medical treatment of the middle ear condition, abr and boa results together reflected a mixed but predominantly mild-moderate rather than severe loss, which was managed accordingly. although this is an isolated case it illustrates effectively how the exclusive use of abr audiometry cannot accurately predict permanent hearing loss. this is an important consideration when dealing with the paediatric population where the incidence of middle ear pathology is at its highest. conclusions there is no end to the combinations of the types and extent of hearing losses that an audiologist may encounter. certainly the small size and age range of this sample does not allow finite conclusions about the relative importance of abr, behavioural and impedance testing in the overall audiological test battery. nevertheless, closer inspection of the results and relationships between these tests provides an appreciation of the strengths and weaknesses of the use of abr audiometry in the paediatric population. j assuming that the abr threshold is a reliable indicator of the hearing threshold of a subject (sohmer & feinmesser, 1974; pratt & sohmer, 1978 cited by levi at al., 1983) five of the subjects in the study were diagnosed on the basis of abr results alone. these subjects were those with associated brainjdamage and/or behavioural disorders which made them less amenable to behavioural testing, and those where the presence of gronimets prevented the use of objective impedance measurements. in'these two instances abr testing enhanced earlier diagnoses of the peripheral auditory status and thus appropriate habilitation measures. in the remaining nine subjects, particularly those with normal hearing or severe losses in the absence of associated problems, abr audiometry served as an excellent check on both behavioural and impedance test results. of particular interest was the fact that the acoustic reflex sub-test served as a useful complement to abr results, at times providing information about possible residual low frequency hearing, which is not available from standard abr testing. while the ultimate validation of these abr test results would depend on follow-up audiograms, as was included in the study by levi et al., (1983), these results suggest nevertheless that abr audiometry can be seen as a logical component of paediatric testing. acknowledgement the authors wish to thank brian mallinson, chief researcher, nipr, human sciences research council, who assisted with some of the abr audiometric testing. references chidppa, k.h. evoked potentials in clinical medicine. raven press, 1983. cornacchia, l., viglian, e. and arpini, a. comparison between brainstem evoked response audiometry and behavioural audiometry in 270 infants and children, audiology, 21, 359-363, 1982. finitzo-hieber, t. auditory brainstem response: its place in infant audiological evaluation, seminars in speech, language and hearing, 3 (1), 76-87, 1982. levi, h., tell, l., feinmesser, m., gafni, m. and sohmer, h. early detection of hearing loss in infants by auditory nerve and brian stem responses, audiology, 22, 181-188, 1983. hecox, k. and jacobson, j.t. auditory evoked potentials. in hearings disorders, second edition, northern, j.l. (ed.). little brown and company, 1984. northern, j.l. impedance audiometry. in hearing disorders, second edition, northern, j.l. (ed.). little brown and co., 1984. robier, α., lemaire, m.c., garreau, b., polyet, m.j. martineau, j., delvert, j.c. and reynaud, j. auditory brain stem responses and cortical auditory evoked potentials in difficult to test children, audiology, 22, 219-228, 1983. sohmer, h. nomenclature and technical considerations of the short latency evoked potential. in international conference on standards for auditory brainstem response testing, starr, a. rosenberg, c., don, m., hallowell davis (eds.) edizioni techniche, milan, italy, 1984. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustimed's ha-2000 dynamic real ear insertion gain analyser represents a giant leap into the future now you can do true free-field tests without background noise interference right in your consulting room. test dynamic hearing aid performance in-situ with wide band signals (or even recordings of real speech), analyze a.g.c. characteristics or distortion components. the actual measurement time can be less than one hundredth of a s " 327 bosman building, 99 eloff street, johannesburg 2000. south africa. p.o. box 9988, johannesburg 2000. south africa. tel: 011-337-2977 w r i t e t o d a y a n d l e a r n h o w e a s i l y y o u c a n g e t h a 2 0 0 0 w o r k i n g for y o u . ha-2000 is supplied read\ complete with a fully progi micro-computer system and software for insertion gain specification. is this the ultimate in-situ analyser? acoustimed (pty) ltd the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a therapy programme for pre-school language impaired children* linda narun, m.a. (sp. path.) (witwatersrand) department speech pathology & audiology, university of the witwatersrand, johannesburg sum mar y this study aimed to establish effective language programmes for pre-school language impaired children based on psycholinguistic principles. eight language-impaired children 6 males and 2 females between the ages of 3 and 6 years, were the subjects. language samples were transcribed and subjected to syntactic analysis; semantic aspects were also considered and programmes developed for each subject, based on the information obtained from the language analyses. a developmental.sequence was adopted as the basis for therapy a 'slot-method' was used in which language was taught as rule-operated behaviour principles of discrimination learning were adopted for teaching some aspects of grammar · auxiliary verbs are reported in detail as this was the most universal error and difficult to teach. the role of imitation in language learning and therapy is discussed. opsomming hierdie studie beoog om doeltreffende taalprogramme vir voorskool se taalgestremde kinders, gebaseer op psigolinguistiese beginsels, daar te stel. die proefpersone was 8 gestremde kinders, 6 seuns en 2 dogters, tussen die. ouderdomme van 3 en 5 jaar. laalmonsters is getranskribeer en sintakties ontleed; semantiese aspekte is ook in ag geneem. programme, gebaseer op die gegewens verkry van die taalontledings, is vir elke proefpersoon opgestel. 'n ontwikkelingsvolgorde is as grondslag vir terapie aanvaar. η „01eul metode is gebruikvir die aanleer van taal as reelbeheerde gedrag. beginsels van disknminasie-aanleer is gebruik om sekere aspekte van grammatika aan te leer. slegs hulpwerkwoorde word uitvoerig bespreek. foute in hulpwerkwoorde was die mees algemene verskynsel en die_moeilikste om vir die kind aan te leer. die rol van nabootsing in die aanleer van taal en in taalterapie word bespreek. in the early years of life, communication occurs primarily through verbal language. the knowledge of, and ability to handle, the mother tongue is of prime importance if any further linguistic codes are to be learnt. any difficulty with verbal language must consequently affect all other aspects of communication. we are becoming aware of increasing numbers of young children who exhibit difficulties in acquiring the basic symbolic communication system. because of the importance of early language learning, it is imperative that more effective methods of intervention be developed. while many studies have been conducted on language acquisition,1'4'8'1 2'1 9' comparatively few have con* this paper is based on an m.a. dissertation submitted to the department of speech pathology and audiology, university of the witwatersrand, johannesburg 1976. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 linda narun cerned themselves with the practical application of this data to the therapeutic situation. lee1 0 describes the situation thus: psycholinguists have not studied atypical language development to any great extent nor have they suggested how to approach clinical problems in language acquisition. the further step of making psycholinguistic information useful and applicable to clinics is going to have to be taken by clinicians themselves. the aim of the study was to devise effective therapy programmes based on current psycholinguistic theory. while psycholinguistic research has added much to therapy programmes, language acquisition is still not fully understood, and so advances may not be as great as the volume of literature would have one believe. rees17 describes several theoretical bases which might be used in deciding the sequence of language therapy. one of these is the developmental sequence basis, which was adopted for the present study. according to rees, there are two implications inherent in this approach. firstly, the disordered language must be evaluated against what is expected. secondly, the child's language goes through predictable stages. during therapy, the child should be taken through these stages, rather than getting him to imitate an adult model. this approach may incorporate syntactic and semantic development. the present study attempted to utilise both aspects, but emphasis was laid on syntactic development. while many aspects of the grammar were diagnosed and treated, this article will deal primarily with the auxiliary verb to be, and sentence types dependent on its correct usage. in addition, factors which appear to influence language learning will be discussed. ingram5 demonstrates that there is a point at which structural aspects can be taught. he states that the problems that language deviant children manifest with the verb to be, are related to performance rather than competence. he found that these children not only had difficulty in acquiring the form, but also in supplying it when required. however, the sequence of development was the same as for normal children, albeit at a slower rate. thus, in terms of therapy, data on normal acquisition can be used. confirming brown's4 findings on the acquisition of is ingram5 suggests first teaching the contractible copula, and then the uncontractible copula, the contractible verbal auxiliary, and lastly, the uncontractible verbal auxiliary. this order is also based on the relative frequency of occurrence of these verb forms. the importance of the auxiliary verb seems to lie in its necessity as a structural component, without which fully grammatical sentences are not possible. according to lee,1 0 the elaboration of the verb is one of the most difficult aspects of the english language, because of the introduction of the auxiliary verb. she states that each auxiliary carries a meaning which is superimposed on the meaning of the main verb. however, with regard to the progressive form, brown,4 makes it clear that its semantics is not clearly understood. ', thus, while errors involving the verb to be were viewed predominantly as syntactic errors, it was felt important to make them as meaningful as possible so that acquisition would be facilitated. journal of the south african speech and hearing association. vol. 23. december j 976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) therapy for language impaired children 5 the syntactic realisation of question and negative sentences, is dependent upon a knowledge of the auxiliary verb. the syntactic development of these sentence types has been described fully.9 however, the semantic development is understood less w e l l , although brown4 stresses that the development of the w/2-question is highly dependent on semantic and cognitive features. similarly, bloom1 criticised klima and bellugi-klima's9 study on the grounds that it only considered syntactic development. she has identified three semantic features of negation i.e. non-existance, rejection and denial. a detailed discussion of these features will not be undertaken here. when devising therapy programmes, however, semantic features must be taken into account. method eight children, two females and six males, between the ages of three and six years, diagnosed at the speech and hearing clinic, university of the witwatersrand, johannesburg, as having language learning problems, acted as the subjects in the study. all subjects had normal hearing. in addition, no subject demonstrated any degree of retardation or severe brain injury. detailed diagnostic procedures were undertaken with each subject and, from the information obtained, individual therapy programmes devised. these diagnostic procedures were repeated afregular intervals. any change required in the therapy plan was made, so that diagnosis was on-going throughout the time period allowed for therapy. spontaneous speech samples of each subject (s) were tape-recorded. language was elicited in an informal situation, where the experimenter (e) exposed ss to meaningful objects and pictures. immediately following assessment interviews, the tapes were transcribed, so that contextual information could be considered in doing the analysis. together with the sentence produced by the s, the sentence he was attempting was also noted. at times it was difficult to determine exactly what the s had intended to say. it was here that contextual information was utilised in deciding the semantic intention of the sentences. without this information utterances cannot be adequately analysed or interpreted.2'4 sentences were assessed using theories of transformational grammar as advocated by jacobs and rosenbaum.7 however, it was often necessary to compare the s's performance with developmental sentence types described by various authorities.1 0'1 2'1 3 therapy morehead and johnson15 have pointed out that most programmes in speech pathology use learning theory as a basis for instruction. within this type of approach, the case is presented with a model sentence, is asked to repeat it and given immediate reward. most speech and language therapy is structured for direct immediate experience and the unstable changes that occur with the use of this technique are well-known to therapists and generally referred to as "carry over problems.15 tydskrif van die suid-afrikaanse vereniging vir spraak en geoorheelkunde. vol. 23. desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 linda narun the approach utilised in this procedure hoped to avoid the problems inherent in a behaviourist model, by attempting to teach language as a system of rule-operated behaviour. regarding language in this framework, it is hypothesised that language deviant children do not extract the rules governing the grammar of the language, as opposed to the normal developing child who somehow learns the semantic restrictions of various linguistic categories. the aim of therapy, therefore, was to enable the ss to extract and abstract syntactic rules and generalise these rules to novel and creative situations. thus, the child was not reinforced for a repetition of a model sentence, but rather for being able to generate novel sentences utilising rules taught in therapy. in this way, a 'cognitive' rather than 'behaviourist' approach is used. following the initial diagnosis, a therapy programme was devised for each subject. therapy was conducted over a six month period, during which time each child was seen twice weekly. an attempt was made in devising the therapy programme to establish at what point during the acquisition of syntax, the child had made an incorrect hypothesis in the learning of syntactic rules. each programme was devised to stimulate the child at the point at which he failed to establish correct phrase structure rules and to enable him to 'releam' parts of the grammar which were dependent on the acquisition of these earlier rules. a 'slot method' was employed in an attempt to demonstrate the rule that the s had failed to acquire. it was felt that if imitation of a constant structure could be established (where the syntactic structures and semantic relations were held constant) the s might abstract the rule operating and generalise it to new creative utterances. thus the basic structure of the sentence was held constant and the lexical item of one category varied in order to demonstrate the rule which gave rise to the underlying meaning of the sentence. the subject was presented with many sentences illustrating one aspect of a sentence before any response was demanded. in utilising the slot method, stimulation was not only through the auditory modality, but through the visual modality as well. therefore, verbal stimuli were always associated with visual stimuli, arranged sequentially, in an attempt to heighten awareness of auditory sequencing of a sentence. in some instances it was difficult to apply the slot method utilising visual stimuli as described above. an example of this was in the teaching of the present progressive construction. when teaching this construction the therapist and the s carried out the continuous action in unison with the verbal counterpart. when acquiring the phonological system children learn the difference between phonemes rather than discreet features. this theoretical framework was utilised in teaching aspects of syntax. in the case of tenses, an attempt was made to demonstrate the difference between, for example, an action that was ongoing and one that had already taken place. therefore, the child carried out the activity "johnny is jumping" while he verbalised it, and afterwards said "johnny jumped", indicating that the activity had already occurred. alternatively, the future tense was used preceding the introduction of the present progressive. in this way, the different tenses were semantically and syntactically contrasted. journal of the south african speech and hearing association, vol. 23, december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) therapy for language impaired children 7 data was evaluated qualitatively rather than subjected to a statistical analysis. the linguistic performance of language impaired children tends to be inconsistent. the nature of these inconsistencies is important and forms an integral part of making therapeutic decisions. in evaluating the efficacy of therapeutic procedures, initial and final language samples were compared. results the primary aim of this study was to investigate a method of therapy. however, the diagnostic procedures undertaken prior to the development of therapeutic programmes in themselves yielded interesting results. in addition, the therapy programmes depended on these results, so that the diagnostic findings will also be reported. the results confirm those of morehead and ingram,14 who found that a significant discriminating factor between language impaired and young normal children is the restricted ability of deviant children 'to develop and select grammatical and semantic features which allow existent and new major lexical categories to be assigned to larger sets of syntactic frames.' morehead and ingram see these restricted sentences and sentence types as being reflective of a cognitive deficit. an example of the restricted sentence types used by the ss in this study are vvft-questions. no subject used all possible wft-word questions. the only two types used by most subjects with any consistency were where and what. the study analysed many aspects of syntax, e.g. prepositions and prepositional phrases, pronouns, articles. however, as stated earlier, only auxiliaries will be discussed and to a lesser extent sentence types dependent upon their realisation. diagnostic results all ss demonstrated errors in the use of the auxiliary verb system. the use of the present progressive construction fee + ing confirmed previous observations by lee,10 in that the inflection -ing was never omitted, but the auxiliary was always omitted. according to her, in the course of normal development -ing emerges very early and is later followed by the auxiliary: the language,impaired child, therefore, seems to follow the normal course of verb acquisition, but in a typically delayed manner. brown4 in comparing adam and eve's performance on the auxiliary with labov's work, found that the normal child may omit auxiliaries (or copulas) which can be contracted but not those which cannot be contracted. however, on the rare occasions that the auxiliary was used by some ss, the findings of brown (on normal children) were not demonstrated. these language impaired children, only used contracted auxiliaries (and copulas). these isolated examples of the usage of the auxiliary, did not appear to reflect the child's competence to handle this node for two reasons: (i) the sentences in which the auxiliary appeared, seemed to be imitated forms i.e. stock sentences which the mother may often have used, e.g. i'm big, i'm good. all examples seemed to be of this type, (ii) within the samples, auxiliaries were used very infrequently and in restricted sentence types, i.e. declarative sentences almost exclusively. tydskrif van die suid-afrikaanse vereniging vir spraak en gelioorheelkunde. vol. 23. desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 linda narun menyuk13 has pointed out that, although all developing behaviour is inconsistent, the normal child tends to use the correct construction with greater frequency than the incorrect construction. in contrast, the language impaired child in this study used the incorrect construction with far greater frequency. in addition, brown" has stressed that frequency must be assessed together with diversity of type. the results of this study demonstrate the very restricted occurrence of this verb. by attaching -ing to the verb, the child has marked the class, as well as the continuing action. the semantic loading of be is very low and the child communicates no more meaning by using it. as the child uses language to communicate his cognitions, he cannot be expected to use a linguistic form until he understand i t . 1 9 as brown" has pointed out, the young child using socalled 'telegraphic' speech can be understood very easily. including functors does not really add significantly to the child's message. however, the normal child very quickly incorporates functional words into his utterances, whereas the language impaired child fails to do so. auxiliaries are but one example of this failure. it seems possible that auxiliaries and their development are related to"the cognitive deficit postulated earlier. therefore, because this verb has so little meaning, therapy should attempt to make it more meaningful. t h e r a p y r e s u l t s the verb to be proved to be a very difficutl construction to teach and took a great deal of time. lee1 0 has suggested that more meaning can be brought to this verb by teaching questions and negatives first, where the necessity for the verb is more easily demonstrated. if this procedure had been adopted, therapy time required may have been significantly reduced. however, having taught it in this manner an interesting result was observed. once the ss could use this verb correctly, questions and negative transformations spontaneously improved. no s had to be given therapy specifically dealing with these two transformations. why this occurred, is difficult to explain. however, it confirms that the ss did not have difficulty with questioning or negation per se, but with the syntactic structure involved in the formulation of these sentence types. this does not, however, explain how the child was able to transpose the auxiliary and the subject by merely acquiring the auxiliary verb. errors involving the verb to be were the most frequent, in that this verb was deviant in all ss and only very infrequently was it used correctly. it was the base line of therapy with all ss, because of its universal nature and because so many other constructions were affected by it. at the end of the sixmonth period allowed for therapy, five of the eight ss handled this'node quite competently. the remaining three subjects experienced difficulty in generalising the auxiliary to new situations. after many repetitions of the construction, they were able to imitate it, but had difficulty in generating new utterances. it would seem that these subjects had difficulty in abstracting and generalising the rule governing auxiliaries. again this particular difficulty seems to indicate a cognitive deficit in these particular ss. ι general discussion the verb to be both as an auxiliary and a copula proved to be a difficult journal of the south african speech and hearing association, vol. 23, december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) therapy for language impaired children 9 construction to teach. lee1 0 suggests that because it has a low semantic value, its acquisition is difficult. it is the therapist's task to increase the meaning of this node if it is to be adequately taught. the method employed in this experimental procedure i.e. the use of contrastive tenses together with the appropriate actions did seem to highlight this verb. therefore, this broadly syntactic approach was successful in that the children incorporated the structure into their utterances. this led to the correct usage of many sentence types. after many repetitions of this construction, ss were able to imitate it. immediately following these repetitious presentations, the ss were able to produce it spontaneously. for those ss who encountered difficulty the problem arose when they used this construction at a later time, when not specifically stimulated. it was thus the 'carry-over' and 'generation' of sentences involving the present progressive construction which invariably proved to be the point of difficulty. an attempt was made when teaching all aspects of language not to reward imitated utterances, but. rather the child's attempt to produce a spontaneous utterance, thereby reducing the role of imitation in the learning process. however, it is extremely difficult to avoid imitation, and invariably it becomes an inherent part of the teaching programme. bricker & bricker3 make it clear that imitation is one of the more powerful language training tools and the parameters need to be studied if this process is to be used efficiently in training. from the discussion on the auxiliary verb, it can be seen that the ability to imitate a given construction, does not imply that the child is able to use it. ruder and smith 1 8 demonstrated that what is important is that both comprehension and imitation training are required to achieve production, and it is not significant which is done in the initial stages of therapy. the language impaired children studied, and in particular the three subjects whose improvement was minimal, had difficulty in imitating. the normal developing child imitates parents and siblings on verbal and non verbal tasks with ease and pleasure. the ss experienced difficulty on all levels of imitation, and had to be 'taught' to do what is usually spontaneous behaviour. it may prove fruitful to view this inability of the language impaired child from a piagetian point of view. piaget16 regards all symbolic play and mental imagery as being derived from motor imitation, so that the language impaired child's inability to imitate may be representative of a cognitive deficit. if so, language intervention should begin with motor imitation tasks and only later proceed to verbal material. viewing child language syntactically, is limited in that it does not account for the possible restricted nature of the utterances. therefore while five ss were considered to be 'syntactically rehabilitated' (three children still displayed syntactic errors), it must be emphasised that attention was not paid to what the ss did not express. consequently, the language may not have been semantically diversified. as ingram6 states tydskrif van die suid-afrikaanse vereniging vir spraak en geoorheelkunde. vol. 23. desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 linda narun . . . we may have to shift from worrying about how correctly these children speak to what they have to say. in doing such, we need to face the problems of whether or not teaching syntax will help cognitive development. . . the diagnosis and treatment of w/2-questions illustrates this point. syntactic form of questions improved as a result of the acquisition of the auxiliary. note was not made of the change (if any) that occurred in the type of questions asked. developmentally, some w/2-questions emerge before others. it is the task of the therapist to diagnose and treat any deficits which may occur on this, the semantic level. therefore, in order for any therapy programme to be successful, language must be considered at all levels i.e. phonological, syntactic and semantic. although five ss are described as rehabilitated, this must be regarded tentatively as an assessment of rehabilitation can only be made longitudinally. marge11 outlines five secondary goals of a language programme. one of these is " . . . provision of a linguistic foundation for the further development of language skills, such as reading and writing." the ε feels that in many ways an assessment of rehabilitation is false, unless the therapist is sure that the child will cope in the educational and social fields. the language pathologist must not only ensure that the child is talking, but that the development of secondary symbolic systems, which are dependent on language, is adequate. if our therapy programmes do not facilitate future learning, we must accept lenneberg's assertion that language intervention should be left as late as possible so that maturation can occur (cited by marge11). any programme developed to aid a language impaired child should attempt to isolate these possible future difficulties and provide treatment for them as early as possible. clearly, this area requires a great deal more research and it is possible that the child may require many programmes rather than one focused only on his linguistic abilities. references 1. bloom, l. (1970): language development: form & function in emerging grammars; cambridge, massachusetts & london, england, the m.l.t. press. 2. bloom, l. (1973): one word at a time; the hague, paris: mouton. 3. bricker, w.a. & bricker, d.d. (1974): an early language training strategy. in language perspectives acquisition, retardation and intervention; eds., schiefelbusch, l. & lloyd, l.l. baltimore: university park press. 4. brown, r. (1973): a first language: the early stages. cambridge, massachusetts: harvard university press. 5. ingram, d. (1972a): the acquisition of the english verbal auxiliary & copula in normal and linguistically deviant children. papers & reports in child language. stanford |university. 6. ingram, d. (1972b): the acquisition1 of questions & its relation to cognitive development in normal & linguistically deviant children — a pilotstudy: papers and reports on child language; stanford university. journal of he south african speech and hearing association. vol. 23 december 976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) therapy for language impaired children 11 7. jacobs, r.a. & rosenbaum, p.s. (1970): readings in english transformational grammar. massachusetts, toronto, london. ginn & co. 8. jakobson, r. & halle, m. (1971): fundamentals of language. the hague, paris: mouton. 9. klima, ε .s. & bellugi-klima, u. (19 66): syntactic r egularities in the speech of children. in child language: a book of readings. eds. baradon, a. & leopold, w.f. engelwood cliffs, new jersey, prentice hall, 1971: 412-423. reprinted from psycholinguistic papers; eds. lyons, j. & wales, r.j. 10. lee, l.l. (1974): developmental sentence analysis. evanston: northwestern university press. 11. marge, m. (1972): general problem of management and corrective education. in principles of childhood language disabilities; eds. irwin. j.v. & marge, m. new york; appleton-century-'croft, meredith corp. 12. mcneill, d. (1970): the acquisition of language. the study of developmental psycholinguistics: new york, harper & row. 13. menyuk, p. (1969): sentences children use. cambridge, massachusetts: m.l.t. press. 14. morehead, d.m. & ingram, d. (1973): the development of base syntax in normal and linguistically deviant children./. speech hear. research, 16: 330-352. 15. morehead, d.m. & johnson, m. (1972): piaget's theory of intelligence applied to the assessment and treatment of linguistically deviant children. papers & reports on child language. stanford university. 16. piaget, j. (1972): language & thought from the genetic point of view. in language in thinking. ed. adams, p. penguin books ltd. 17. rees, n.s. (1972): bases of decision in language training./. speech hear. dis., 37, 283-304. 18. ruder, k.f. & smith, m.d. (1974): issues in language training. in language perspectives acquisition, retardation and intervention. eds. schiefelbusch, r.l. & lloyd, l.l., baltimore, london & tokyo: university park press. 19. slobin, d.l. (1970): universals of grammatical development in children. in advances in psycholinguistics eds. flores d'arcais, g.b. & levelt, w.j.m., amsterdam, london: north holland publishing co. tydskrif van die suid-afrikaanse vereniging vir spraak en geoorheelkunde vol. 23. desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) philips hearing aid services a division of s.a. philips (pty) ltd. if portable 1 audiometers1 group teaching i i p h i l i p s hearing aid services head office 1005 cavendish chambers, 183 jeppe street, p.o. box 3069, johannesburg. / philips i ( j w t ) « 9 2 3 ( journal of the south african speech and hearing association. vol. 23. december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) auditory function in a group of adults infected with hiv/aids in gauteng, south africa 17 auditory function in a group of adults infected with hiv/aids in gauteng, south africa katijah khoza & eleanor ross department of speech pathology and audiology university of the witwatersrand abstract numerous international studies have demonstrated a relationship between hiv/aids and auditory function. the aim of this study was to explore this relationship in a group of adults infected with hiv/aids attending an outpatient clinic in a hospital located in gauteng, south africa. the prevalence of hearing loss; the type, degree and configuration of the hearing loss; the relationship between the hearing symptoms and the progressive stages of the disease, and the type of onset of hearing problems were examined. the results of the study indicated a prevalence rate of hearing loss which was as high as 23% in the sample surveyed. the types of hearing loss included conductive and sensorineural, while the degree of severity ranged from slight to profound in nature. the configuration of the hearing loss was not frequency-range-specific, and the degree of severity did not seem to worsen with the progression of the hiv/aids disease. however, there did seem to be an increase in the occurrence of sensorineural hearing loss with the deterioration of patients' immunological status. analysis of patients' audiological results along with their case history data suggested that their hearing loss may have been caused by opportunistic infections and/or their treatments. these results are discussed in terms of their implications for the clinical management of patients with hiv/aids; education of team members; and policy formulation.· key words: immune cell count; aids; ototoxic; serology; hearing loss introduction the acquired immune deficiency syndrome (aids) and the human immunodeficiency virus (hiv) that causes it seem to j have arguably created more challenges to science and! medicine than any other single disease. moreover, the aids epidemic is now in its third decade and would seem to have become one of the most important public health problems in south africa (south african department of health, 2000). hiv is reported' to cause a total breakdown of the body's natural immune system by reducing the immune cell count (bankaitis, 1996). such a reduction leads to the development of various diseases,, which does not occur similarly in all patients infected with the virus. bankaitis (1996) reports that many of the patients with the virus remain, asymptomatic and maintain normal immune cell count for long periods of time, and they are therefore described as falling outside the documented clinical definition of aids. for patients to be diagnosed with aids, they must either have an extremely low thelper lymphocyte count or a cd4+ blood; count (below 200 /mm3 of blood) or present with at least one aidsdefining condition. the american center for disease control and prevention (cdc) classifies hiv infected patients into three distinct groups according to their cd4+ blood count, where patients with cd4+ count greater than 500/mm3 are classified as asymptomatic (stage 1), patients with1 cd4+ count between 200 and 499/mm3 as symptomatic (stage 2), and patients with cd4+ count less than 200/mm3 as having full blown aids (stage 3) (bankaitis, 1996; chandrasekhar, connelly, brahmbhatt, shah, kloser, & baredes, 2000). from the first diagnosis of hiv/aids and throughout most of the epidemic the concern of most people has been to sustain life by preserving the immune system and fighting off primary, life-threatening infections. however, as a result of recent advances in treatment, the focus of therapy has shifted to a more rehabilitative approach with the emphasis on enhancing quality of life (friedman & noffsinger, 1998). in addition to treating life-threatening infections there is an increasing awareness of the need to consider the impact of hiv/aids on cognitive, motor, and sensory domains, with hearing changes being a potential presentation at any stage*of the disease (larson, 1998). • as early as 1987 sooy reported on abnormal audiologic findings of thresholds worse than 25db hl, with a high frequency sloping configuration on pure tone audiometry in patients with aids. more recently, a study of black female hiv positive patients in a south african hospital reported that the most prevalent degree and type of hearing loss found was slight to mild and sensorineural in nature (fuzani, 1999). chandrasekhar et al. (2000) reported that the high frequencies of 4000 hz and 8000 hz were significantly elevated relative to other frequencies. such results are in line with those reported by sooy (1987) that indicate worsening hearing loss in high frequencies. with regard to otologic symptoms, contradictory research findings, mostly from american studies, have been reported. for example, rosenberg, schneider, and die sid-afrikaansetydskrif vir kommunikasieafwykings vol. 49, 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) katijah khoza and eleanor ross 18 cohen (1985) reported a total absence of otologic symptoms in american patients who presented with head and neck manifestations of the disease, while booth (1997) noted an increasing trend in the number of people living with hiv/aids who presented with otologic symptoms. lalwani and sooy (1992) maintained that ear related manifestations of hiv/aids occur to a lesser degree relative to other head and neck complaints. these discrepancies in findings could be attributed to different methodological steps employed in these studies. the management of hiv/aids, which involves medications such as azidothymidine (azt) and radiation treatment, has been reported to have an adverse effect on the auditory function of individuals infected with hiv/aids (bankaitis & larson, 1998; schountz, 1998). however, more recently, chandrasekhar et al. (2000) reported that the sensorineural hearing loss detected in their outpatient subjects did not correlate with their routine hiv/aids medications used. despite these contradictory findings, changes in audiological function attributable to hiv/aids, and the medications used to treat the condition and its. associated opportunistic infections, are likely to increase the demand for audiologists to work with patients with hiv/aids. whilst it is evident that a cure for aids, does not appear to be imminent, treatment strategies have been improving rapidly suggesting that 'long-term therapeutic protocols for the management of infections are likely to be developed in the near future (tshabalala-msimang, 1999). regensberg and maartens (1999) stated that the drugs currently available have significantly improved the prognosis and quality of life for patients living with hiv/aids thereby allowing them to continue to be productive members of society. improved hearing and enhanced communication have the potential of contributing positively to the patients' quality of life, and hence ensuring their ability to remain productive members of society. while hearing loss related to hiv/aids is receiving increasing attention in the international literature, the reported prevalence rates may not necessarily apply to south africa. in view of the increase in the number of south africans who are reported to be infected (south african department of heath, 2000), as well as the researcher's clinical experience, and review of audiology records of patients with hiv/aids at the research site, it was hypothesized that hearing loss might be the presenting problem in some cases of undiagnosed hiv infection. real, thomas, and gerwins (1987) support the hypothesis that sensorineural hearing loss may in some cases be the presenting complaint of undiagnosed hiv infection. furthermore, because the head and neck region has been reported as a common anatomical site for medical conditions associated with hiv/aids (rosenberg et al., 1985), audiologists, as part of the head and neck team, need to contribute to the theoretical knowledge about audiological manifestations of hiv/aids. such knowledge may increase the likelihood of appropriate assessments leading to accurate diagnoses and management (noffsinger & friedman, 1996). for these reasons, this study was conducted. methodology aim of the study the aim of the study was to explore the auditory function in a group of adults infected with hiv/aids attending a hospital outpatient clinic in gauteng, south africa. the six specific sub-aims were to determine the prevalence of hearing loss in the sample; to assess the type, degree, configuration and symmetry of the hearing loss; to determine the relationship between the hearing symptoms and the progressive stages of hiv/aids; to explore the nature of onset of hearing loss (e.g. sudden vs. gradual/progressive onset); to determine the relationship between the nature of onset of sensorineural hearing loss and the severity of the hearing loss; and lastly, to relate the hiv/aids signs and symptoms of each subject to the nature of the hearing loss. research design the study was exploratory in nature. the design utilised was non-experimental and observational in nature with no control group and non-randomization of subjects (mccall, 1990). the aim was to determine whether there was a relationship between hiv/aids and auditory function. the subjects' age, clinical stage of the hiv/aids, and co-occurring diseases (e.g. tb, syphilis, middle ear pathology) were the independent variables, while the audiological measures (otoscopy, impedance audiometry, pure tone audiometry, abr) were the dependent variables. description of subjects subject selection criteria the south african population that is predominantly infected with hiv/aids is unique in that it includes mineworkers (who are exposed to noise in the workplace), and hiv/aids co-occurs with diseases such as tb and syphilis (south african department of health, 2000). the treatment of hiv/aids, the opportunistic infections and co-occurring symptoms may impact on hearing (bankaitis & schountz, 1998; larson, 1998). it was therefore difficult to specify selection criteria without excluding" almost all patients attending the hiv/aids clinic. as this was an exploratory study which endeavoured to represent the south african hiv/aids population, it was considered undesirable to isolate the impact of hiv/aids on hearing. such a sampling1 procedure has disadvantages relating to the presence of confounding variables e.g. ototoxic drugs for tb, noise exposure, syphilis, etc. however, inclusion and documentation of such variables in the hiv/aids population might yield important information. consequently, the subject selection criteria were: > subjects' hiv/aids status needed to have been confirmed by serology studies. > subjects needed to be between the ages of 18 and 55 years. there are reported age differences in presentation of the virus (matkin, diefendorf, & erenberg, 1998). > subjects were not to have presbycusis. presbycusis could confound the results since it also presents as a sloping high frequency sensori-neural hearing loss ' (snhl) (katz, 1994). the south african journal of communication disorders, vol. 49, 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) auditory function in a group of adults infected with hiv/aids in gauteng, south africa 19 > the subjects had to be alert, oriented, able to provide informed consent, and to participate in an audiological assessment. sampling procedure a convenience sampling technique was utilised in recruiting subjects for the study. subjects volunteered to have their hearing status evaluated in response to notices that were posted at the hiv/aids clinic inviting them to participate in the study, and in response to the researcher's verbal explanations of the purpose of the project at this clinic. subject description a total of 150 subjects, including both males and females, comprised the research sample. a profile of the subjects is set out in table 1. the subjects spanned all three cdc stages and were also categorised into four age groups as depicted in table 1. inspection of the subjects' data revealed demographic similarities between them and the general south african population infected with hiv/aids (crewe, 1999; tshabalala-msimang, 1999). firstly, crewe (1999), supported by tshabalala-msimang (1999) maintains that women have the highest hiv prevalence rates in .the country. the gender bias in the prevalence rates of the disease was also evident in this sample, with a much higher number of participants in the study being female. secondly, the distribution of subjects across the different age ranges mirrors those of the country. most subjects were between 20 and 45 years of age, which is the most vulnerable age group for hiv/aids (tshabalala-msimang, 1999). table 1. demographic and medical profile of all subjects in the study (n = 150) factor sub-category number age ranges (years) 18-25 26-35 36-45 46-55 19 77 45 9 gender male female 54 96 ethnic group black white coloured indian 147 2 1 0 cd4+ count (/mm3) (cdc stages) asymptomatic (stage 1) > 500/mmj symptomatic (stage 2) 200 499/mm3 aids (stage ,3) < 200/mm3 38 (25%) 52 (35%) 60 (40%) hearing status κ 1 1 1 normal: stage 1 stage 2 stage 3 abnormal: stage 1 stage 2 stage 3 35 39, 41 total: 115 (77%) 3 " 13 19 total: 35 (23%) tinnitus j present •absent 34 (23%) 116 (77%) vertigo ! i present absent 14 (9%) 136 (91%) symmetry of hearing loss (n=35) i unilateral bilateral 10 (29%) ' · . 25 (71%). type of onset of hearing loss sudden gradual 16 19 type of hearing loss conductive sensorineural mixed 4 21 10 possible aetiology of hearing loss • meningitis oto/syphilis otitis media ' encephalitis tb treatment 9 13 14 1 2 hearing status and possible aetiological factors i •subjects with possible causal factors (i.e. tb, syphilis) but normal hearing (n = 115) subjects with possible causal factors and abnormal hearing1 (n = 35) 14 (12%) (14 of the 115 subjects with normal hearing) 32 (91,42%) (32 of. the 35 subjects .with hearing loss) noise exposure ' present absent 23 (15%) . 127 (85%) die suid-afrikaanse.tydskrif vir kommunikasieafwykings. vol. 49, 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) katijah khoza and eleanor ross 20 testing procedures the testing procedure was conducted in four phases: phase i prior to commencement of the study, permission to conduct the research project was obtained from the university of the witwatersrand medical ethics committee for research on human subjects, the hospital superintendent and relevant heads of departments. thereafter, the researcher discussed details regarding the project with the medical team at the hiv/aids clinic, and enlisted their co-operation in informing their patients about the study. informed consent was obtained from all individuals volunteering to participate in the study. a case history form (available on request from researchers) was used to record the case history, audiological data, and medical variables that could have an impact on the results of the study. case history form the devised case history form consisted of the following sections: > demographic information: information obtained included subjects' ethnic group, age and gender and was used to determine the representative nature of the sample. > history of noise exposure: information on noise exposure was obtained to differentiate between hearing loss that was noise-induced versus hiv/aids related. the data gathered included the length of time the subject was exposed to noise, the type of noise, and the intensity of the noise as per subjects' report. chronic and consistent exposure to noise causes hearing loss particularly in the high frequencies, generally seen as a dip at 4000 hz (katz, 1994). > history of tinnitus and vertigo: tinnitus and vertigo are associated with hearing loss (katz, 1994), and the subjects were asked if they experienced these symptoms which were described by the researcher. > hearing status: information on family history of hearing impairment, previous audiologic assessments, time since onset and nature (sudden, gradual) of onset, progression of the hearing loss, current hearing status, and laterality of the hearing loss was obtained from subjects. such questions form part of the audiologic evaluation (bess & humes, 1990; schuknecht, 1993). > medical history: the subjects' medical records were reviewed to obtain information on the following: • the clinical or serological evidence of syphilis as this disease is known to cause hearing loss (darmstadt & harris, 1989). • case history factors that may have contributed to a hearing loss e.g. history of prior ear disease; head trauma; use of ototoxic drugs; diseases such as tb, cancer, etc. (katz, 1994; lalwani & sooy, 1992). • treatment history that could contribute to hearing loss. two major forms of such treatment are radiation therapy and azt (bankaitis & schountz, 1998; larson, 1998). the • the different cdc categories (asymptomatic stage; symptomatic stage; and full-blown aids) (bankaitis, 1996). case history information was obtained by interviewing each subject prior to the audiologic evaluation. individuals who were literate in english completed parts of the case history form (except for the medical information) on their own. the medical history information (e.g. medical diagnosis, serology information cd4+ count, ent diagnosis, etc) was obtained from the medical records for all subjects. phase ii following infection control measures proposed by kemp and roeser (1998), basic audiological information was obtained via otoscopy, tympanometry, and pure tone audiometry for each subject. hearing thresholds were obtained by both air conduction and bone conduction so as to differentiate between conductive and sensorineural hearing loss as per katz's protocol (1994). the objective of the otoscopic evaluation, using a welch allyn otoscope, was to examine the subjects' ears for the presence of impacted wax, otitis externa, possible otitis media, perforated tympanic membranes, collapsed ear canals, presence of any growths and so forth (friedman & arnold, 1993). findings were then confirmed by the otolaryngologists at the hospital. impedance audiometry in the form of tympanometry assessed the status and integrity of middle ear functioning. tympanometry has been reported to be superior to routine otoscopy in correctly predicting the absence or presence of middle ear effusions (silman & silverman, 1991). the use of both assessment procedures in a complementary fashion was deemed necessary for this study as the results were combined to provide valuable redundant information to facilitate accurate diagnoses (wiley & fowler, 1997). phase iii auditory brainstem response (abr) measurements were obtained for subjects with sensorineural hearing loss (snhl) in order to determine possible retrocochlear involvement (hall, 1992; hood, 1998). it was acknowledged that the abr should be used in a test battery approach rather than in isolation to determine site of auditory pathology. the test battery includes otoacoustic emissions, speech discrimination measures, loudness balance tests, metz test-acoustic reflex, short increment sensitivity index, tone decay, and acoustic reflex decay (katz, 1994). however, these site of lesion tests were not performed because of the lack of appropriate testing tools at the time of the study. therefore the abr, which has been documented as an objective and sensitive tool for assessing the neural intergrity of the auditory pathway was utilised (hall, 1992; hood, 1998). hall's (1992) protocol was-adopted for. abr testing for neurodiagnosis of eighth nerve or auditory brainstem· dysfunction. responses · were collected three times for each ear so as to ensure reliability of the measurement procedures and that the artefacts were of acceptable levels. the criteria for determining abnormal abr were those advocated by hall (1992), hood (1998), silman ind silverman (1991), and spehlmann (1985). south african journal of communication disorders, vol. 49, 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) auditory function in a group of adults infected with hiv/aids in gauteng, south africa 21 speech testing was not one of the tests selected to form part of the test battery due to the paucity of s t a n d a r d i s e d word lists for the multilingual south african population. in addition, it was envisaged that there could be poor performance on speech tests because of differences in dialect, word-meaning, and word familiarity levels. such problems have been reported by wilson, jones, and fridjhon (1998) who maintained that subjects' educational level may influence their linguistic performance. phase iv this phase involved re-inspection of the data for the subgroup with abnormal hearing. all persons whose hearing loss was not directly attributable to hiv/aids, but rather to confounding variables such as ototoxicity and diseases such as meningitis were excluded. the purpose of this exercise was to try to establish the number of subjects where there might be a direct link between hiv/aids and impaired hearing function. data analysis procedures and statistical following consultations with statisticians it was concluded that the nature of the data collected precluded inferential statistical analysis, and therefore descriptive statistical analyses were performed. each subject was classified as either having normal or abnormal hearing following the audiological evaluation. normal hearing was regarded as responses at and better than 25 db hl, with abnormal results being thresholds worse than 25db hl (katz, 1994; silman & silverman, 1991). the degree of hearing loss was determined using silman and silverman's (1991) classification of "magnitude of hearing impairment". this classification system, supported by katz (1994), advocates that impaired hearing function begins at an average hearing level of 25 db hl. abnormal hearing was further categorized into type of hearing loss; • normal hearing s a b n o r m a l hearing figure 1: the prevalence of hearing loss in hiv/aids subjects (n = 150) die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 49, 2002 severity; and the nature of onset of the hearing loss. all case history factors were recorded and analysed along with the audiological results in order to obtain a comprehensive evaluation. the aibnormal hearing results were then group matched to the different cdc stages to determine relationships between hearing loss and stages of hiv/aids. furthermore, the data were examined to establish if there was any relationship between the nature of onset (sudden or gradual) of snhl and the severity of the hearing loss. results and discussion according to the research literature, auditory abnormalities have been reported in persons with varying degrees of hiv infection, in both symptomatic and asymptomatic patients (bankaitis & keith, 1995; bankaitis, 1996; chandrasekhar et al., 2000; fuzani, 1999). similar findings were obtained in the present study and have particular relevance to the field of audiology. the results are discussed in accordance with the sub-aims of the study. the prevalence of hearing loss of the 150 subjects tested, 115 (77%) had normal hearing, and 35 (23%) presented with a hearing loss as depicted in figure 1. thus 23% of subjects had both otologic and audiological symptoms that included tinnitus, vertigo, and hearing losses with varying nature and severity. these results appear to be consistent with some internationally published studies on otologic and audiologic manifestations of hiv/aids (bankaitis, 1996; bankaitis & keith, 1995; birchall et al, 1992; chandrasekhar et al, 2000). the general trend reported in the american literature suggests that the prevalence of otologic manifestations of hiv/aids is relatively small (sooy, 1987), with the exception of flower (1991) who reported auditory abnormality prevalence rates in adults with aids to be as high as 75%. this difference in results could be related to variations in subject selection criteria, sample sizes, and the otologic versus audiologic nature of the studies. more recently, booth (1997) reported an increase, in the united states, in the number of patients with otologic symptoms associated with aids. birchall, wight, french, and smith (1992) reported hearing loss (not type-specific) on pure tone testing in 39% of patients who were hivpositive and syphilis-negative with no neurological symptoms, while sooy (1987) described hearing impairment greater than 25db hl on pure tone testing in 49% of the subjects. a surprising finding was that in the presence of these abnormal audiologic findings in sooy's study, the speech discrimination scores were reported to have consistently been above 82% for all patients evaluated, with the majority of the patients obtaining scores that were better than 90%. consistent with the aforementioned studies, the current study also reported the presence of otologic disease in some subjects who presented with head and neck symptoms. however, this finding differs from those studies (marcusen & sooy, 1985; rosenberg et al, 1985) reporting a total absence of otologic signs in the adult population. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) these studies concluded that while there was an extremely low incidence of otologic disease in adults, there was a much higher incidence in the paediatric population. the high incidence of conductive hearing loss in paediatric patients was attributed, in part, to the high incidence of serous otitis media which occurred in up to 80% of cases (smith & canalis, 1989). rosenberg, schneider, and cohen (1985) reviewed medical records of 102 adult patients with aids and found that although 71% of the patients had symptoms localised in the head and neck, none had otologic signs and symptoms. similar results were reported by marcusen and sooy (1985) who also could not find any otologic findings in 165 aids infected patients they evaluated. lalwani and sooy (1992) maintain that otologic manifestations associated with hiv/aids do occur but are less common than other head and neck complaints. methodological differences such as retrospective case reviews (rosenberg et al., 1985) versus prospective evaluations of subjects (marcusen & sooy, 1985) could have contributed to the contradictory findings. the high incidence of hearing loss in the studied sample provides strong support for the view that audiologists should be involved in the assessment and management of patients with hiv/aids (larson, 1998). the type, degree, configuration, and symmetry of the hearing loss type of hearing loss katijah khoza and eleanor ross 22 as can be seen in figure 2, snhl was the most commonly occurring type, while conductive hearing loss (chl) was the least frequent. of those with a snhl 11 (52%) were possibly cochlear, and 10 (48%) were possibly retrocochlear; and 10 (29%) had mixed hearing loss (mhl) as indicated in figure 2. these results concur with the literature in that any type of hearing loss i.e. conductive, sensory/neural, or central hearing loss may be seen in hiv/aids (chandrasekhar et al., 2000; friedmann & noffsinger, 1998). however, the current results differ from the documented prevalence rates of types of hearing loss (friedmann & noffsinger, 1998; gold & tami, ί 998; lalwani & sooy, 1992). the most common otologic problems reported were serous otitis media and recurrent acute otitis media, and were predominantly related to eustachian tube dysfunction implying that conductive hearing loss was the most common. in this study, chl was the least common type of problem seen. there were slightly lower rates of occurrence of snhl (between 20 and 50%) reported by gold and tami (1998). the higher incidence in the current study could be related to sampling differences in that subjects with syphilis were excluded from some of the international studies. degree of hearing loss subjects had varying degrees of hearing loss as illustrated in figure 3. mild hearing loss (34%) was most common, followed closely by the profound hearing impairment (27%). table 2 indicates that of the subjects 70 8 6 0 1 i 50 j 3 ι ο 8 40 & 30 u) ro φ 2 0 ο φ ο1 0 -j 0 11 60 49 29 2 0 c h l s h l m h l t y p e s of h e a r i n g l o s s figure 2: types of hearing loss in the group of subjects with hearing loss (n = 35) key: rpta = right ear pure tone audiometry lpta = left ear pure tone audiometry mhl = mixed hearing loss chl = conductive hearing loss shl = sensorineural hearing loss the south african journal of communication disorders, vol. 49, 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) function in a group of adults infected with hiv/aids in gauteng, south africa 23 • φ ο c φ 3 ο ο ο φ σ> re c φ ο φ ο . 40 35 30 25 20 15 10 5 0 s / m μ m / s e s e m 23 20 7 7 17 27 ι • 34 10 7 : io 17 21 ! d e g r e e of h e a r i n g l o s s figure 3: degree of hearing loss in the subjects with hearing loss (n = 35) key: rpta = right ear pure tone audiometry s = mild hearing loss μ = moderate hearing loss se = severe hearing loss with snhl, most of them (67%) presented with a severe to profound hearing loss. these results differ from those reported in the literature where severity ranged from mild (fuzani, 1999) to severe (sooy, 1987), with little mention of profound hearing loss. sooy (1987) reported that subjects presented with hearing losses greater than 25db, typically ranging between 30 and 50db hl at 8000 hz. the degree of hearing loss reported in this study suggests that audiologic management of patients with hiv/aids should commence promptly so that early intervention can.be instituted, thereby preventing further deterioration of hearing thresholds over time. lpta = left ear pure tone audiometry s/m =mild to moderate hearing loss m/se = moderate to severe hearing loss ρ = profound hearing loss 1997). these results suggest that all frequencies may be affected equally or to varying degrees. previous studies, however, e.g. chandrasekhar et al. (2000), gold and tami (1998), and lalwani and sooy (1992) reported a sloping high frequency hearing loss, mostly snhl. aetiology of the hearing loss could be a contributory factor to the differences noted. symmetry of hearing loss as can be seen from table'3, of the 35 subjects with hearing losses, 29% had unilateral hearing impairment while 71% presented with bilateral hearing loss, suggesting that hearing loss can be unilateral or bilateral in adults with hiv/aids. the high prevalence of bilateral hearing loss among subjects suggests that . hearing impairment probably occurs more frequently and with greater severity than anticipated in the patients with hiv/aids. bilateral hearing loss has been reported to table 2. type of onset of hearing loss in subjects with hearing loss (n = 35) configuration of hearing loss no typical pattern of configuration of hearing loss could be established. of the subjects with a hearing loss, only 14% presented with a sloping/high frequency hearing loss. the remaining 86% presented with flat and/or irregular audiograms, which related well to the possible causes of hearing loss (e.g., meningitis and otitis media which do not only affect high frequencies but low and mid frequencies as well) (booth, sudden onset gradual/progressive onset total = 16 total = 19 > 13 (81 %) severe to profound snhl > 3 mild-moderate hearing loss > 2 (10%) severe snhl > 7 (37%) mild-moderate snhl > 10 (53%) conductive and mixed die sid-afrikaansetydskrifvir kommunikasieawykings vol. 49, 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) katijah khoza and eleanor ross 24 impact more severely on communication than unilateral hearing loss, and therefore requires prompt diagnosis and management (katz, 1994; silman & silverman, 1991). early intervention in terms of medical management and/or amplification would enhance patients' communication abilities, and faciltate compliance with any verbally prescribed medical treatment. hence, enhanced communication could potentially improve not only the social, academic, and vocational quality of the patients' life, but also their general health. the relationship between hearing loss and the progressive stages of hiv i aids as illustrated in figure 4, there was a trend towards an increase in the number of occurrences of snhl from stage 1 (asymptomatic) to stage 3 (fullblown aids), but there was no definitive relationship to the 3 cdc categories for chl and mhl. these findings are supported by evidence which suggests a relationship between audiological manifestations and the progression of the hiv/aids disease (birchall et al., 1992; chandrasekhar et al., 2000; lalwani & sooy 1992). the increase in the occurrence of snhl with advanced stages of the disease in the current study may be attributed to the progressive decline in the immunologic status which increases susceptibility to the neurotropic nature of the disease and to opportunistic infections, which have been found to cause hearing loss (friedmann & arnold, 1993; real et al., 1987; schuknecht, 1993). type of onset of hearing symptoms as indicated in table 2, similar numbers of subjects presented with sudden and with gradual onset of hearing loss. several studies have reported sudden onset of snhl in patients with hiv/aids (real et al., 1987; timon & walsh, 1989). smith and canalis (1989) reported that snhl can occasionally be of a sudden onset but is commonly rapidly progressive. chandrasekhar et al. (2000) also reported similar findings with 3% presenting with sudden onset, 21% with gradual onset, while the largest number demonstrated intermittent onset. type of onset of snhl and its relationship to degree of the hearing loss as further indicated in table 2, sudden onset of hearing loss occurred most frequently in subjects who presented with severe to profound snhl, while gradual onset was mostly found in subjects who presented with conductive and/or mixed hearing losses. real et al. (1987) suggested that sudden snhl (temporary or permanent) was frequently caused by viral agents, in as many as 33% of cases. the relationship between hiv/aids signs and symptoms and the nature of the hearing loss detailed descriptive analysis of the audiologic evaluation results together with the documented case history information where medical diagnoses had been confirmed by ear, nose and throat specialists revealed the following: > patients who presented with snhl had documented medical histories of meningitis (aseptic; cryptococcal; and viral); infections (syphilis and otosyphilis; encephalitis); and histories of ototoxic medication used in the treatment of tb and other opportunistic infections. three patients had possible noiseinduced hearing loss due to industrial noise exposure. > patients who presented with chl and mhl figure 4: hearing loss and its relationship to the cd4+ count in the subjects with hearing loss (n = 35) key: chl = conductive hearing loss ' mhl = mixed hearing loss : shl = sensorineural hearing loss 1 = stage 1 of hiv/aids (asymptomatic) 2 = stage 2 of hiv/aids (symptomatic) 3 = stage 3 of hiv/aids (aids) the south african journal of communication disorders, vol. 49, 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) auditory function in a group of adults infected with hiv/aids in gauteng, south africa 25 had a history of chronic suppurative otitis media, and otitis media with effusion. the above results are consistent with the welldocumented causes of hearing loss in the population with hiv/aids (friedmann & arnold, 1993; smith & canalis, 1989). it has been reported that decreased cellmediated immunity, recurrent viral· infections, nonmalignant lymphoid hyperplasia of the adenoids, nasopharyngeal tumours," sinusitis, or allergic autoimmune reaction to hiv can all lead to poor eustachian· tube function and middle ear effusions (friedmann & arnold, 1993; gold & tami, 1998; lalwani & sooy, 1992). chandrasekhar et al. (2000) reported that 23% of adults with hiv presented with otitis media which is highly uncommon in adults who are hiv-negative, and thus suggest that conductive hearing loss can be expected as a presenting problem .in hivinfected patients. the causes of snhl (which involve the central nervous system (cns) and the sensory end organs) in hiv/aids include cranial neuropathy due to meningitis (aseptic, cryptococcal, and viral) or lymphoma; viruses (cytomegalovirus; hepatitis b; herpes simplex and syphilis -otosyphilis and neurosyphilis; herpes zoster; and toxoplasma) which are conditions reported to be more common in patients with hiv than in healthy individuals; ototoxic drugs used in the treatment of opportunistic infections and neoplasms; and intracranial events, such as encephalitis and haemorrhage (bankaitis & schountz, 1998; booth, 1997; friedmann & arnold, 1993; larson, 1998; real et al., 1987; schuknecht, 1993; smith & canalis, 1989). in this study, meningitis and syphilis were the two major possible causes of snhl with encephalitis and ototoxicity being minor causes. the three types of meningitis (aseptic, cryptococcal, and viral) reported, all have an effect on the auditory system (schuknecht, 1993). cryptococcal meningitis is an opportunistic infection that has its primary focus in the lung with spread mainly to the meninges (schuknecht, 1993). this infection causes similar tissue damage both iri people with and without hiv infection, with the exception that table 3: summary of case history data for subjects with hearing loss (n=35) factor sub-category number percentage cd4+ count (/mm3) asymptomatic (stage 1) >' 500/mm3 3 9 symptomatic (stage 2) 200 499/ mm3 13 37 aids (stage 3) < 200/mm3 19 54 . type of hearing loss conductive hearing loss 4 11 sensorineural hearing loss 21 60 mixed hearing loss 10 29 type of onset of sudden 16 46 hearing loss gradual 1954 symmetry /of hearing unilateral 10 29 loss j bilateral 25 71 possible aetiology of . meningitis 9 26 hearing loss * oto/syphilis 13 37 ί otitis media 14 40 s encephalitis 1 3 , • tb treatment 2 9 possible site of lesion cochlear 11 52 of snhl (n=21) ι retrocochlear 10 1 48 degree of snhl mildmoderate 7 . 33 (n=21) severe-profound 14 67 . tinnitus present 16 46 absent 19 54 vertigo present 9 26 absent 26 74 noise exposure present 6 17 1 absent 29 83 note: * % scores do not add up to 100% as some subjects presented with more than one possible aetiological factor die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 49, 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) in people with hiv, the damage tends to be more extensive and destructive (larson, 1998). booth (1997) reports cryptococcal meningitis as being increasingly associated with sudden onset snhl with the incidence as high as 27%. the hearing loss is reported to be mostly retrocochlear in nature. in the current study, of the 3 subjects with cryptococcal meningitis, one subject had a possible cochlear site of lesion, while the other two subjects had possible retrocochlear lesions. real et al. (1987) reported that the organism in cryptococcal meningitis has been found in both the cochlear and vestibular nerves, and in the end organs, with severe damage to the organ of corti. they further report that neuronal loss with good hair cell preservation can also be found. thus they suggested that hearing loss due to cryptococcal meningitis could be either cochlear or retrocochlear in nature. syphilis and otosyphilis have been linked to sudden or gradual onset of snhl (schuknecht, 1993). research has suggested that otosyphilis affects the cochlear (booth, 1997; friedmann & arnold, 1993; smith & canalis, 1989). in contrast, the current study had four patients with possible retrocochlear lesions. it could be speculated that such a finding was possibly related to difficulty in diagnosing otosyphilis (friedmann & arnold, 1993)", which might lead to an incorrect diagnosis, especially if a differential diagnosis has not been done to exclude other systemic processes that occur in the hiv/aids population. retrocochlear lesions may also be possible since hiv changes the course of syphilis by hastening the development of neurosyphilis with resultant neural hearing loss (smith & canalis, 1989). ototoxicity can occur in this population since the patients' drug regimen often involves potentially ototoxic medications. however, this issue requires more research as bankaitis and schountz (1998) reported that experimental antiretroviral drugs (with undocumented or unknown side effects) could contribute to hearing loss, while chandrasekhar et al. (2000) reported no correlation between sensorineural hearing loss and routine medications. medical histories of normal hearing subjects vs. subjects with hearing losses: of the total of 150 subjects evaluated, 115 subjects presented with normal hearing thresholds. in phase iv of the study, it became evident that the major differentiating factor between the two groups (normal hearing group and the hearing impaired group) was the presence of opportunistic infections. subjects with normal hearing had no opportunistic infections and other possible causes of hearing loss, except in 12% of the subjects. there was, however, strong evidence suggesting that hearing loss, in this study, was probably due to opportunistic infections and their treatment rather than from hiv/aids alone. of the 23% of subjects with hearing loss, almost all presented with a history of opportunistic infections and other aetiological factors associated, with hearing loss in patients with hiv/aids. hence, the hearing loss in hiv/aids subjects may not be solely attributable to hiv/aids but to a combination of factors. katijah khoza and eleanor ross 26 conclusion numerous internationally published studies have demonstrated a correlation between hearing loss and hiv/aids (bankaitis, 1996; birchall et al., 1992; chandrasekhar et al., 2000; gold & tami, 1998; sooy, 1987). findings from the present exploratory-descriptive study conducted on a local south african sample also revealed a relationship between hiv/aids and auditory function. the estimated prevalence of hearing loss among adults attending an hiv/aids clinic in a government hospital in-gauteng was around 23%. the hearing loss occurred at any stage of the disease with varying degrees of severity and types. in addition, it is suggested that a diagnosis of hiv/aids be suspected if a patient presents with a sudden hearing loss, with no clear aetiology, as it could be the first symptom in some undiagnosed hiv/aids patients. results from the present study have the potential to contribute toward enhancing audiological assessment and management of patients infected with this virus, particularly in the current era of financial constraints across services in provincial hospitals. however, these results need to be considered in relation to issues identified in the project's research design and analysis. by ensuring that appropriate management in the form of correct hearing aid fitting where progression of the hearing loss is known or suspected, regular rechecks of hearing status for possible adjustment of hearing aid settings so as to ensure maximum benefit from amplification, and visual training where hearing aids are of no or little benefit to patients, audiologists will be contributing enormously towards providing efficacious care to patients with hiv/aids. in conclusion, the results from the present study suggest that the audiologic presentation of patients with hiv/aids is consistent with their immunocompromised status. susceptibility to opportunistic infections increases chances of quantifiable audiological sequelae. references bankaitis, a.e. 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(2000). otologic and audiologic evaluation of human immunodeficiency virusinfected patients. american journal of otolaryngology, 2/(1), 1-9. the south african journal of communication disorders, vol. 49, 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) auditory function in a group of adults infected wi crewe, m. (1999, november). aids, activism and the role of the universities. paper presented at the conference of the social, demographic, and development impact of aids: commonwealth universities respond, durban, south africa. darnstadt, g. l., & harris, j.p. (1989). luetic hearing loss: clinical presentation, diagnosis, and treatment. american journal of otolaryngology, 10:410. department of health. (2000). hiv/a1ds/std strategic plan for south africa 2000-2005. rsa. friedmann, i., & arnold, w. (1993). pathology of the ear. london: churchill livingstone. friedman, j.l., & noffsinger, d. (1998). hearing loss associated with hiv/aids: social, cultural, and political issues. seminars in hearing, 19, 205214. fuzani, p. (1999). the type, degree and prevalence of hearing loss in black female hiv positive patients at various clinical stages of infection in south africa. undergraduate unpublished report, university of the witwatersrand, johannesburg. gold, s., & tami, t.a. (1998). otolaryngology manifestations of hiv/aids. seminars in hearing, 19, 165-175. hall, j.w. (1992). handbook of auditory evoked responses. boston: allyn & bacon. hood, l.j. (1998). clinical applications of the auditory brainstem response. san diego: singular publishing. jacobson, j.t., & northern, j.l. (1990). diagnostic audiology. boston: allyn and bacon. katz, j. (1994). handbook of clinical audiology. baltimore: williams & wilklns. kemp, r.j., & roeser, r.j. (1998). infection control for audiologists. seminars in hearing, 19(2), 195203. lalwani, a.k., & sooy, c.d. (1992). otologic and neurologic manifestations of acquired immunodeficiency syndrome. the otolaryngological clinics of north america, 25(6), 1183-1198. larson, c.r. (1998). \ htv-1 and communication disorders: what speech and hearing professionals need to know. london: singular publishing inc. ' marcusen, d.c., & sooy, c.d. (1985). otolaryngologic and head and neck manifestations of acquired immunodeficiency syndrome (aids). laryngoscope, 95, 401-405. hiv/aids in gauteng, south africa 27 matkin, n.d., diefendorf, a.o., & erenberg, a. (1998). children: hiv/aids and hearing loss. seminars in hearing, 19, 143-153. mccall, r.b. (1990). fundamental statistics for behavioral sciences (4th ed). new york. noffsinger, d., & friedman, j. (1996). audiology and the person with hearing loss associated with hiv/aids. audiology today, 8(6), 12-13. real, r., thomas, m., & gerwins, j.m. (1987). sudden hearing loss and acquired immunodeficiency syndrome. otolaryngology head and neck surgery, 97, 4099-4120. regensberg, l., & maartens, g. (1999). antiretroviral therapy in adults. modern medicine of south africa, 30-38. rosenberg, r.a., schneider, k.l., & cohen, n.l. (1985). head and neck presentations of acquired immunodeficiency syndrome. otolaryngology head neck surgery, 93, 700-705. schuknecht, h.f. (1993). pathology of the ear (2nd ed). london: lea & febiger. silman, s., & silverman, c.a. (1991). auditory diagnosis: principles and applications. san diego: academic press. smith, m.e., & canalis, r.f. (1989). otologic manifestations of aids: the otosyphilis connection. laryngoscope, 99, 365-372. sooy, c.d. (1987). the impact of aids on otolaryngology head and neck surgery. advances in otolaryngological head & neck surgery, 1, 1-28. spehlmann, r. (1985). evoked potential primer: visual, auditory, and somatosensory evoked potentials in clinical diagnosis. boston: butterworth. timon, c.i., & walsh, m.a.' (1989). sudden hearing loss as a presentation of hiv infection. journal of laryngology and otology, 103, 1071-1072. tshabalala-msimang, m.e. (1999). overview of the national hiv sero-prevalence survey of women attending public antenatal clinics in south africa: national hiv/aids statistics/ 13th international aids conference, south african department of health, rsa. wiley, t.l., & fowler, c.g. (1997). acoustic immittance measures in clinical audiology. san diego: singular publishing. wilson, j.w., jones, b., & fridjhon, p. (1998). use of the nal-ab wordlists as a south african english speech discrimination test. the south african journal of communication disorders, 45. die sid-afrikaansetydskrifvir kommunikasieafwykings vol. 49, 2002 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the production of coherent narrative texts by older language impaired children. s h a r o n t u c h , β a . (sp. & h. therapy) (witwatersrand) speech therapy department, transvaal memorial hospital for children, johannesburg. summary a group of 4 language-impaired children, 9 years old, and a group of 4 control children with n o language problems were compared on an aspect of 'communicative competence' their ability t o produce coherent narrative texts (sequences of sentences) which were semantically coherent and appropriate to the situational context. a test was devised by t h e writer, comprising stories presented t o the children through a number of sensory modalities. the narrative texts elicited from the 2 groups were compared on a number of measures of semantic cohesion and measures of general semantic content (or appropriateness t o t h e situational c o n t e x t ) . the performance of the languageimpaired children appeared t o be inferior to the control group on all the measures of semantic cohesion and general semantic c o n t e n t , supporting the hypothesis that the language-impaired group would perform inferiorly t o the control group on an aspect of 'communicative competence'. the implications of t h e study's findings for the diagnosis and t r e a t m e n t of expressive language problems in the older child were discussed. opsomming 'n groep van 4 9-jarige kinders met taalprobleme is vergelyk met 'n kontrole-groep van 4 kinders ten opsigte van 'n aspek van 'kommunikatiewe vermoe'. ten einde hierdie aspek te ondersoek is hulle vermoe om saamgestelde verhalende paragrawe te produseer, ontleed. hierdie paragrawe moes ook toepaslik met betrekking t o t die situasie wees. die ondersoeker het vervolgens 'n toets saamgestel, bestaande uit stories wat deur verskeie sensoriese modaliteite aan die kinders meegedeel is. die verkree response van beide groepe is vergelyk ten opsigte van 'n aantal maatstawwe van semantiese samehang en maatstawwe van algemene semantiese inhoud (of toepaslikheid t o t situasieleidrade). resultate verkry uit evaluasie van semantiese samehang en semantiese inhoud het getoon dat die groep van kinders met taalprobleme swakker presteer het as die kontrole-groep. hierdeur word die hipotese, dat kinders met taalprobleme ondergeskik is aan kinders met normale taalontwikkeling ten opsigte van 'kommunikatiewe vermoe', dus gestaaf. die waarde van bevindinge verkry uit die studie vir die diagnose en behandeling van ekspressiewe taalprobleme in die ouer kind, word vervolgens bespreek. linguistics has had an increasing influence on work in language pathology over recent years. currently, diagnosis and treatment of expressive (and receptive) language problems of the child during the initial years of,language acquisition as well as the older child (beyond the first 5 years of language acquisition) has been conducted largely within the linguistic framework of 'grammatical competence' with its emphasis on the grammaticality of single sentences. however, there appears to have been a growing feeling amongst language clinicians that this approach towards diagnosis and treatment of expressive language disorders might not be adequate for expressive language problems in the older child. whereas the younger child is largely expected to be only 'grammatically competent', the older child should be able to produce the south africa journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) coherent narrative texts by older children 43 not only single grammatical sentences but coherent sequences of sentences if he wishes to communicate effectively with others in his environment. this ability appears to require both greater linguistic and cognitive skill and might be deficient in older children, who, having passed the period of early language acquisition, may by this time have acquired 'grammatical competence' at the single sentence level. recent developments in modern linguistic theory appear to offer both a conceptual framework as well as a method of analysis with which to evaluate such an ability and to remediate possible deficits in this ability. growing dissatisfaction expressed by a number of linguists 1 0 , 1 9 with modern linguistic theory's notion of 'grammatical competence' has led to the introduction of (1) a new conceptualisation of 'competence' — 'communicative competence' as well as (2) a method of analysis with which to investigate this new conceptualisation of 'competence' 'discourse analysis'. each of these will be considered briefly. modern linguistic theory, largely based on the generative model of language put forward by chomsky,4 has recognised that the world of modern linguistics comprises 2 parts — 'linguistic competence' and 'linguistic performance'. 'linguistic performance' has been conceptualised as the native speakerlistener's actual production and understanding of an indefinite number of isolated context-less grammatical sentences, generally never spoken nor heard before. 'linguistic competence' has been conceptualised as the set of rules which characterizes the native speaker-listener's abstract, underlying knowledge of his language which permits the 'linguistic performance' discussed above.17 modern linguistic theory until recently has aimed to concern itself exclusively with the formulation of the rules of this particular conceptualisation of 'competence' which will hence be termed 'grammatical competence'.13 criticism has been levelled by certain linguists10·19against linguistic theory's notion of 'grammatical competence' as this characterization of 'competence' makes possible 'performance' which does not approximate performance in actual speaking situations. in order to communicate effectively with others in his environment, it does not suffice for the listener-speaker to produce (and understand) an indefinite number of isolated sentences. in addition, he must be able to produce (and understand) connected discourse defined by harris8 as. . . sentences spoken or written in succession by one or more persons in a single situation, these sentences being appropriate to their situational context. in order to account for this ability to produce sentences appropriate to their verbal and situational context, certain linguists1 0·1 9 have recognised the need to supplement the restricted notion of 'grammatical competence' with an additional conceptualisation of 'competence' 'communicative competence' and 'performance' has been reconceptualised as the actual application of 'communicative' and 'grammatical competence' in real-life speaking situations.20 as 'communicative competence' involves the ability to produce sentences appropriate to their verbal and situational context, the data used for analysis can no longer be the corpus of isolated context-less sentences used for the investigation of 'grammatical competence'. the data used must necessarily be die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 sharon tuch 'connected discourse' as defined above by harris.8 the term designated for this type of analysis is 'discourse analysis'. (the terms 'discourse' and 'text' will be used interchangeably). discourse analysis concerns itself with the .. . isolation of linguistic features which differentiate a coherent (connected) sequence of sentences a text from an agglomerate of sentences.6 the majority of work on text cohesion (relation between sentences) 7 has dealt with the syntactic aspects of intersentence dependence or relation and has considered different syntactic types of intersentence relation. amongst these are the two types of intersentence relation investigated in the present study: (1) the use of 'anaphora', when one element in a sentence refers back to an earlier sentence and (2) the use of conjunctions. however, there has been growing realization that the consideration of semantic, in addition to syntactic, aspects of intersentence relation is essential if the problem of text cohesion is to be successfully resolved.8 gleason 8 in his discussion of semantic cohesion in narrative texts stated that the most important aspect of semantic ('deep' in gleason's terminology) cohesion is the chain of events which 'forms the backbone of the narrative'. gleason's scheme, the 'event line' has been adapted for the semantic analysis in the present study. research into the child's development of this aspect of 'communicative competence' (as well as other aspects of 'communicative competence') has been limited. since 1960, investigations9 1 3 > 1 4 1 s have focused on the development of the structure of the single sentence and did not consider the ability to produce coherent sequences of sentences. piaget,16 despite the fact that he has not worked within a linguistic framework, did investigate in a portion of his work the development of communication skills the child's ability to produce coherent sequences of sentences appropriate to the situation. piaget's work is considered to have relevance for the present study for the following reasons :(1) it has provided a certain amount of information on the development, with age, of the ability to produce sequences of sentences — the progression from 'egocentric' to 'socialised' language. (2) piaget isolated the features of 'egocentric language', a number of which were considered in the evaluation of the ability in this study.6 (3) his work provided a perspective on factors which might account for deficits in this ability.s while a limited amount of research has been done (notably by piaget16 and flavell5) on the development of communication skills, no research to the author's knowledge has been conducted within a linguistic framework into the ability of normal or language-impaired children to produce coherent sequences of sentences appropriate to the situational context an aspect of 'communicative competence.' the present study aimed to investigate this aspect of 'communicative competence' in both normal and language-impaired older children. the study was undertaken with a view to: ' (1) providing a more comprehensive framework for the diagnosis and treatthe south african journal of communication disorders. vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) coherent narrative texts by older children 45 ment of expressive language problems in the older child a framework which would incorporate 'communicative competence' in addition to 'grammatical competence'. (2) suggesting a method of analysis with which to evaluate an aspect of 'communicative competence' 'discourse analysis'. (3) offering a test which might be used to appraise an aspect of 'communicative competence'. methodology aim to compare two groups of 9-year-old children, a language-impaired and a normal group, on an aspect of 'communicative competence' their ability to produce narrative texts which are semantically coherent and appropriate to the situational context. • more specifically the study aims to compare the two groups on: (1) their ability to provide the chain of events which according to gleason 8 'forms the backbone' of the stories presented to them. this involves the appraisal of general semantic content (or appropriateness to the situational context) as well as an appraisal of the most important aspect of semantic cohesion.8 (2) their use of two types of intersentence relation, which contribute to the semantic cohesion within a text. (a) their use of conjunctions which are semantically appropriate as well as their use of conjunctions acquired later in the developmental sequence of language acquisition. (b) their anaphoric use of pronouns with non-ambiguous referents. subjects two groups of subjects (ss) were used, an experimental group (e grp.) and control group (c grp.). each group comprised 4ss, 3 girls and 1 boy. all ss came from monolingual english-speaking home environments. the ε grp. comprised ss diagnosed by a speech-therapist or remedial teacher to have language problems of a predominantly expressive nature. the ss were attending either private remedial schools or 'pilot' (remedial) classes in government schools. the criteria for the selection of the ε grp. were (1) age ε ss were required to be between 8% to 9v< years of age. this particular age range was selected as it was believed, on the basis of work done by piaget,16 and a pilot study carried out by the present author, that children should by this age have acquired the particular aspect of 'communicative competence' investigated in the study. (2) intellectual functioning all children were required to be of average intellectual functioning, judged on the basis of a full scale i.q. assessment range of 100-110. i.q. tests had been carried out recently at the schools. this was considered necessary as c. chomsky3 found that the stage of language acquisition reached by children was related to i.q. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 sharon tuch (3) socio-economic level all ε ss appeared to be from middle-class backgrounds in terms of the areas where they lived and the occupational status of their fathers (all white-collar workers — professional or in important business positions e.g. managers or directors). it was considered necessary to use ss from middle-class backgrounds in view of the work done by bernstein1· on the effect of lower-class backgrounds on children's language. it was originally required that ε ss had no visual perceptual difficulties. this was considered to be of importance as a portion of the test used by the writer involved picture interpretation. however, it was not possible to obtain ss with exclusively language problems. all ε ss were reported in their remedial assessments to have visual perceptual difficulties largely with regard to their perception of form rather than pictures per se. it was recognized that, if their performance on the portion of the test involving picture interpretation was inadequate, the influence of visual perceptual difficulties rather than linguistic factors could not be ruled out. three of the four ss had received speech therapy, two of whom were still receiving speech therapy. the fourth ε s had only recently been diagnosed to have a language problem. the varied amount of speech therapy received by the ε ss did not appear to be a critical factor as all the ε ss were still considered to have language problems. the c grp. comprised ss reported by their teachers to have no language problems or problems of any nature. these ss were all attending the same government school. the following variables were considered in the matching of the c and ε grps:(1) age; (2) sex; (3) intellectual functioning; (4) socio-economic background. test used in view of the unsuitability of available tests to assess children's ability to produce narrative texts, the present author devised her own test, following a pilot study which cannot be elaborated on in the present article. the test comprised:— (1) 4 different picture sequences (of 6 pictures each) each relating a story. (2) 2 verbal stories. the stories were presented in three different ways, distinguished in terms of the sensory modality of input or combination thereof. each presentation of a story was followed by the elicitation of a narrative text from the child about the story. the three types of stofy presentation were: (1) input through the visual modality two picture sequences were presented to the child. ; (2) input through the auditory modality another two stories were recounted verbally (auditorily) to the child. (3) input through a combination of the visual and auditory modalities — a further two picture sequences were presented to the child, accompanied the south african journal of communication disorders vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) coherent narrative texts by older children 47 by a verbal description of the sequence of events depicted in the picture sequence. the reasons for varying the nature of the input in the presentation of the stories were the following: (1) it was postulated that the demands imposed by the different modalities were not entirely the same. an investigation of the effect of modality on performance was considered of value. (2) information about events contained in a narrative text is originally received through a number of possible modalities. it was thus believed that stories presented through different modalities or combinations thereof would elicit discourse which was more representative of real-life spoken discourse than the presentation of stories through a single modality. all stories were intended to be of a comparable nature in view of the writer's intention to determine the effect of different modalities on performance without the interference of the variable of story content. the following factors were considered:(1) the nature of the content (stories depicted every-day events). (2) the number of main events per story. (3) the nature of the relationship between main events (causal or temporal). (4) the number of pictures per picture sequence. (5) the number of sentences and the nature of the syntax of the sentences in the auditory stories. pictures were designed to be as clear and non-ambiguous as possible. factors considered by the writer to ensure the clarity of the pictures were (1) picture size (2) background the reduction of distracting background detail and (3) realism. "thus any possible pictorial misinterpretation by the children could not be attributed to the lack of clarity of the pictures. procedure (1) testing of each of the eight ss was conducted individually during a single 30-minute session under quiet conditions with only the tester (the writer) and the subject present in the room. (2) instructions were provided and a trial picture story was presented to the child (not analysed) in order to ascertain that the child "understood the task required of him and to familiarise him with the test . situation. (3) the tester then presented the 6 stories, each followed by the elicitation of a narrative text about the particular story presented. the stories used in a particular modality were the same for each child. (4) the order of modality presentation was varied systematically for each child to eliminate a practice effect. (5) the child was given as much time as he required before telling the story in order to elicit narrative texts to the best of the child's ability. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24,1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 sharon tuch (6) all four auditory stories were pre-recorded on a tape recorder to ensure uniformity in the presentation of stories. (7) the narrative texts of the children were recorded on a second taperecorder. (8) though six narrative texts (two per modality) were elicited from each child, three narrative texts (one per modality) were analysed for each child in view of time limitations. the three particular texts analysed were selected randomly but were the same for all ss. (9) the three narrative texts, were analysed and scored in terms of a number of measures and the scores for the two groups on these measures were compared (see measures below). the influence of modality was investigated only for measures of the ability to provide the chain of events: it was believed that the performance on this measure might be most affected by different sensory modalities. (10) a descriptive rather than inferential statistical analysis of the results was carried out: the results were not considered to lend themselves to a reliable inferential statistical analysis in view of the 'open-ended' responses of the children. measures u s e d a n d their scoring the following measures were used: i. measures of the ability to provide the chain of events which 'forms the backbone of the narrative' stories presented to the children. these measures were suggested by gleason's concept of the 'event line'. measures of this ability were divided into two categories:(a) measures of the ability to provide the general semantic content of the story presented, i.e. measures of the ability to respond appropriately to the situational context the story-stimuli presented. (b) measures of the ability to provide a semantically (or logically) coherent narrative text. only those deviations in content which affected the semantic cohesion of the narrative text were recorded here. it was necessary to distinguish these two categories as deviations in content affecting not only semantic accuracy but also, the logic of the story resulted in a greater disturbance of meaning and appeared to suggest possible difficulties at the higher cognitive level of logical thinking or'reasoning. the three stories presented to the children were each broken down into a number of main events, the omission of which would alter either the content or both the content and semantic cohesion of the text. (children were not required to provide the prpcise wording of the main events outlined but to convey rather the 'idea' of these events.) the three narrative texts of each child were analysed in terms of the following: (a) measures of content consisted of the total number of (1) main events omitted per story, and (2) number of inaccuracies concerning the main events per story. it was considered necessary to include this latter measure as children, on occasions provided a main event with an inaccuracy concerning a particular aspect of the event, which altered to the south african journal of communication disorders vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) coherent narrative texts by older children 49 some extent the content of the story. (3) the number of additional events provided per story were noted. these events described very concrete aspects of the situation portrayed in the story and were of no relevance to the story, they tended to obscure the main events of the story. (b) measures of semantic (or logical) cohesion consisted of (1) the number of main events omitted, affecting story logic per story, (2) the number of inaccuracies affecting logic per story, and (3) the frequency of incorrect verbal sequencing of main events per story. these instances of incorrect sequencing disturbed the semantic cohesion of the text. scoring of the above measures: for each child: for each of the measures (a) (1), (a) (2), (b) (1) and (b) (2) a percentage was established for each story and a mean percentage for all three stories was computed. for measures (a) (3) and (b) (3) a frequency score was established (e.g. no. of additional events) for each story and then a mean frequency score was tallied. for each group: for each of measure (a) (1), (a) (2), (b) (1) and (b) (2) a group mean percentage was calculated on each story modality and then a grand group mean percentage for all three modalities together was established. for each of measures (a) (3) and (b) (3) a group mean frequency was tallied for each story modality and then a grand group mean frequency for all three modalities together was established. grand group means for all six measures were compared for all the modalities together. group means for all six measures were compared on each modality. ii. measures of two types of intersentence relation contributing to the semantic cohesion of the text: (a) conjunctions, and (b) personal pronouns with non-ambiguous referents were used. both types of intersentence relation contribute to the syntactic in addition to the semantic cohesion within the text. however in the present study only the semantic aspects of intersentence relation were considered. (a) the use of conjunctions to link sentences within the text: conjunctions were divided into two main categories: — conjunctions which manifest themselves early in the developmental sequence of language acquisition 'and', 'then' and 'so' used with the semantic intent of 'then' rather than 'therefore'. — conjunctions which manifest themselves later in the developmental sequence causal conjunctions ('because' and 'so' used to denote 'therefore'), time conjunctions ('when' and 'until') and other later-developing conjunctions ('but', ' i f ' , ' in case', 'in order to'). 1 2 other later developing conjunctions could not be considered in the study as the nature of the stories was not conducive to their use. the following two measures were used in the analysis of children's use of conjunctions: (1) number of later developing conjunctions used semantically appropriately. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 sharon tuch this measure-suggested by flavell5 was considered of importance as the laterdeveloping conjunctions express more complex relations (than early-developing conjunctions) between the sentences which they link. their use within a text would thus enhance the semantic cohesion of the text. it was postulated on the basis of the work of flavell5 and piaget1 6 that the ε grp. would use a smaller percentage of these later developing conjunctions semantically appropriately. (2) number of conjunctions used semantically inappropriately. this measure was considered necessary as a failure to observe the semantic restrictions governing the use of particular conjunctions would lead to a disruption of the semantic cohesion (or continuity) within the text. it was postulated on the basis of lee's w o r k 1 2 that the ε grp. would use a higher proportion of conjunctions in a semantically inappropriate manner than the c grp· scoring of the two measures of conjunction use. a percentage for each of the two measures was established for each child on the basis of his three narrative texts. group mean percentages on each measure were obtained and compared. (b) the use of pronouns with non-ambiguous referent. the second type of intersentence relation considered was the anaphoric use of personal pronouns i.e. personal pronouns said to substitute for an earlier occurring noun phrase (np) in a preceding sentence of the text. the writer chose to investigate an aspect of anaphoric pronoun use which was of importance for semantic cohesion the anaphoric use of personal pronouns with non-ambiguous referents (a measure suggested by piaget1 6). this refers to the use of a pronoun only when the earlier occurring np, to which it is intended to refer, is not to be confused with other earlier occurring nps. ambiguous anaphoric use of personal pronouns is more likely to occur when there are two or more human participants in the text of the same sex; or when there are two or more non-human nouns in the text, both singular and plural. the following was investigated: (1) ambiguous use of human personal pronouns ('he', 'him', 'his' or 'she', 'her') in two of the three stories analysed per child; (2) ambiguous use of non-human personal pronouns ('it' or 'them') in two of the three stories analysed. it was postulated on the basis of work done by piaget1 6 and flavell5 that the ε grp. would use a higher proportion of personal pronouns ambiguously than the c grp. scoring of ambiguous pronominal use. each child's stories were scored in terms of1 ι (1) number of ambiguous human personal pronouns in two stories, (2) number of ambiguous non-human personal pronouns in two stories, and the south african journal of communication disorders vol. 24,1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) coherent narrative texts by older children 51 (3) number of ambiguous personal pronouns,which was computed as a percentage on the basis of scores (1) and (2). mean group percentages for (3) were then obtained and compared. results and discussion. before presenting the results it should be pointed out that conclusions about the significance of differences between the two groups could not be drawn as an inferential statistical analysis was not carried out. it must also be mentioned that, though included in certain tables, consideration of the performance of individual ss was not possible in this present article. results, for each measure will be presented and discussed. i. measures of the ability to provide the chain o f e v e n t s o f the s t o r y . a comparison of the two groups' performance on measures of semantic content and semantic cohesion — all modalities being considered together. while the disparity between the two groups was small on certain measures, scores for the two groups appeared to indicate that (1) the ε grp. performed inferiorly to the c grp. on all measures of semantic content resulting in their texts being less appropriate to the situational context (or stories presented.) (2) the ε grp. performed inferiorly to the c grp. on all measures of semantic cohesion, the presence of these deviations in semantic cohesion casting greater doubt on the higher cognitive processes of reasoning or logical thought of these children. the two groups performance will be compared firstly in terms of (a) measures of semantic content and then in terms of (b) measures of semantic cohesion (see table 1). (a) measures of content: (1) the grand mean percentage of events omitted by the ε grp. of the total number of events per story was 13,6» for the ε grp as compared with 2,5% for the c grp. the ε grp thus showed a tendency to omit more events of a story than the c grp. (2) the grand mean percentage of inaccuracies concerning the main events of the total number of events per story was 9,5% for the ε grp. and 2,3% for the c grp. these results appear to indicate a greater tendency in the ε grp to provide events with inaccuracy. (3) the mean frequency of additional events per story was 0.5 for the ε grp. and 0 for the c grp. the disparity between the two groups was small but considered noteworthy in view of the presence of these events in the ε grp's texts as compared with their total absence in the c grp's texts. the presence of these events in the texts of the ε grp. seems to indicate that the ε grp. tended to be more 'concrete-bound' than the c grp and experienced difficulty on occasions in extracting the main (salient) events of the story from the concrete background occurrences within the story (a more abstract cognitive function). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 sharon tuch measures visual auditory visual & auditory all modalities together ε c ε c ε c ε c percentage of events omitted of the total no. of events per story 14% 16% 4% 11% 3,5% 13,6% 2,5% percentage of inaccuracies about events of the total no. of events per story 25% 7% 3,5% 9,5% 2,3% frequency of additional events per story ,75 ,25 ,33 . percentage of events omitted affecting semantic cohesion of the total no. of events per story 756 16% 1% 3,5% 10% 1,2% percentage of inaccuracies affecting semantic cohesion of the total no. of events per story 18% 6% frequency of incorrect sequencing per story ,5 ,25 ,25 table 1 ε and c group means on semantic measures of content and cohesion by modality and all the modalities together. (b) measures of semantic (or logical) cohesion: (1) the grand mean percentage of omissions of events affecting logical cohesion of the total number of main events per story was 10% for the ε grp. and 1,2% for the c grp. the ε grp thus omitted a greater proportion of events affecting the logical cohesion of their stories. (2) the grand mean percentages of inaccuracies affecting the semantic cohesion of the story of the total number of events per story was 6% for the ε grp as compared with 0% for the c grp. while the disparity in percentage between the two groups on this measure was small, it did appear that the ε grp tended to provide a greater proportion of inaccuracies affecting the logical cohesion of their stories as compared with the c grp. (3) the grand mean frequency of incorrect sequence per text was 0,25 for the ε grp and 0 for the c grp. the disparity in frequency between the two groups was again small; however, it was considered noteworthy that there was a total absence of incorrect verbal sequencing in the c grp, whereas there were a number of these instances in the ε grp's stories. the south african journal of communication disorders vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) coherent narrative texts by older children 53 the effect of modality. an in-depth comparison of the performance of the groups on the different story modalities was not made in view of the limited number of texts (one text) per modality for each s. on the basis of the brief comparison made, the reliability of which is recognised to be uncertain, it was apparent that the ε grp performed inferiorly to the c grp on each modality. this appears to indicate that the inferior semantic performance of the ε grp as a whole was not modality dependent. it was, however, of interest that the largest differences between the two groups occurred in the visual modality where the ε grp performed inferiorly to the c grp on all the semantic measures used for the analysis. this appeared attributable in part to the visual perceptual difficulties which the children reportedly experienced. in addition, the interpretive (perceptual-cognitive) demands appeared to be greater in this modality as compared with the audi-, tory modality and the combination of the visual and auditory modalities where the salient events had already been extracted for the child in the verbal (auditory) presentation. the finding appears to have important implications for the language therapist working with language-impaired children the therapist should consider the possibility of visual in addition to language problems with such children. factors postulated to account for the inferior performance of the ε grp on the above semantic measures. (1) difficulty in the gaining of meaning from the different modalities of input — visual and auditory: in order to gain meaning from these modalities, the following skills are necessary (a) perceptual skills (auditory and visual), (b) verbal comprehension (for auditory modality) and (c) cognitive skills the ability to extract only the salient (main) events of the story and the logical and temporal relations between these events. the ε grp may have experienced difficulty in the gaining of meaning from the modalities of presentation due to deficits at one or a number of these levels which appear to be interrelated aspects of cognition. piaget16 attributed deficits in perceptual and cognitive skills (which appeared to be reflected in some of the children's misinterpretation and distortion of events) to the child's generalised cognitive 'egocentrism' his being a 'prisoner of his own point of view.' (2) difficulty in expressing meaning which the child has in fact grasped: it is possible that in certain instances the ε ss were able to grasp the salient events of the story and the relations between them, but had difficulty in providing the events accurately and in the correct sequence due to expressive language difficulties involving syntax and/or vocabulary. in addition, piaget16 maintains that the child up to 7—8 years of age tends to omit events and provide them in the incorrect sequence due to his failure to consider the listener's point of view ('egocentric language') which piaget considered to be a further manifestation of the child's generalised cognitive 'egocentrism', his functioning at a less mature cognitive level. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 sharon tuch it is postulated by the writer that an interaction of both the above groups of factors (linguistic and cognitive) might have accounted for the inferior performance of the ε grp on the above semantic measures (of content and cohesion). it is recognised that the relative contribution of these factors may have varied for individual ε ss. ii measures of the use of 2 types of intersentence relation (a) use of conjunctions. (1) the mean percentage of later developing conjunctions used semantically appropriately of the total number of conjunctions used was 20,5% for the ε grp and 33% for the c grp. (see table ii). the ε grp thus used a lower mean percentage of later developing conjunctions semantically appropriately as compared with the c grp. as the later developing conjunctions establish more com. plex and intimate relationships between the sentences of a text, the semantic cohesion of the ε grp's texts thus appeared to be somewhat reduced in relation to the cohesion of the c grp's texts. two factors, one or both of which (as in the case of semantic measures of content and cohesion) may be operative, are postulated to account for the lower percentage of later developing conjunctions found in the ε grp: (i) a cognitive factor piaget 1 6 maintains that the use of causal and logical conjunctions (the majority of later developing conjunctions being logical and causal) in children's spontaneous language develops as children begin to grasp the actual causal and logical relationships expressed by these conjunctions. the lack of causal and logical conjunctions was considered by piaget to be a feature of the child's 'egocentric language'.6it is possible that the ε grp had not mastered to the same extent as the c grp these logical and causal relationships and were thus cognitively delayed in relation to the c grp. (ii) linguistic factors — it is possible that the ε grp did have a non-linguistic (or cognitive) understanding of these causal and logical relationships but did not have the linguistic means (vocabulary of conjunctions and/or syntactic ability) to express these relationships. it would appear that the process of subordination, involved in the use of most later-developing conjunctions,12 imposes greater syntactic demands on the child as subordination involves the linking of units which are constituents at different levels, whereas co-ordination (involved in the use of early conjunctions) involves the linking of units which are constituents at the same level. it is believed that future investigation of the use of later-developing conjunctions may be carried out even more effectively using stories which provide greater scope for the utilisation of these conjunctions. the south african journal of communication disorders vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) coherent narrative texts by older children 55 ss *see across el 44 e2 16 e3 22 e4 0 χ egrp 20,5 ci 40 c2 20 c3 36 c4 35 x c grp 33 * later-developing conjunctions used semantically appropriately as a percentage of the total no. of conjunctions (early and late-developing) used. table ii later developing conjunctions used semantically appropriately as a percentage of the total number of conjunctions used by s and group (2) the percentage of conjunctions used semantically inappropriately of the total number of conjunctions used was 10% for the ε grp and 1% for the c grp (see table iii). while it is difficult to comment on the magnitude of the differences between the 2 groups, it is apparent that the ε grp used a higher proportion of conjunctions in a semantically inappropriate manner as compared with the c grp. as semantic errors in conjunction use disrupt the semantic cohesion or continuity of the text, the higher proportion of semantically inappropriate conjunctions in the ε grp. was responsible for reduced semantic cohesion within their texts. semantic errors in conjunction use in the ε grp. occurred for both earlier and later-developing conjunctions and would reflect the ε grp's failure on occasions to observe the semantic restrictions governing the use of these conjunctions e.g. the conjunction 'then' can be used to link two sentences only when the action described in the sentence preceding the conjunction is complete (not ongoing) prior to the action contained in the sentence following the conjunction. this finding of greater semantic inappropriateness appeared to be in agreement with l e e 1 2 who die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 sharon tuch ss percentage inappropriate el 8% e2 0% e3 22% e4 10% xegrp 10% ci 0% ' c2 5% c3 0% c4 0% xc grp 1,25% table iii conjunctions used semantically inappropriately as a percentage of the total number of conjunctions used by s and group. reports that. . . some children in clinical language training show difficulty learning the semantic constraints of conjunction selection and will make inappropriate choices. β a measure of the anaphoric use of personal pronouns with non-ambiguous referents:the mean group percentage of pronouns used ambiguously (i.e. with two possible referents) of the total number of personal pronouns used anaphorically in the texts investigated was 13,5% for the ε grp and 1% for the c grp. it is evident that the ε grp used a greater percentage of pronouns ambiguously as compared with the c grp. the greater occurrence of ambiguous pronominal usage in the ε grp reduced to some extent the semantic cohesion of their texts as well as their communicative efficacy as compared with'the c grp. again two factors, one or both of which may be operative, are postulated to account for this greater tendency in the ε grp. to use pronouns with ambiguous referents: ' a cognitive factor piaget16 maintains that the use of pronouns with non-explicit referents is a feature of 'egocentric' language. according to piaget, 'egocentric' language declines as a function of the child's the south african journal of communication disorders. vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) coherent narrative texts by older children 57 cognitive development and is replaced by 'socialised' language. it is thus possible that the ε grp, at 9 years of age, were still using pronouns with ambiguous .referents in view of cognitive delay. a linguistic factor it is possible that the ε grp do consider the listener's point of view (and are thus not cognitively delayed in this regard) but are unable to express this consideration in view of other more important linguistic and cognitive demands imposed by the discourse situation. flavell5 recognised that seemingly 'egocentric' language might not be attributable to a failure to consider the listener's point of view per se but rather to deficits in linguistic skills. further investigation of ambiguous pronominal use may be enhanced by consideration of the following points: (1) demands on the ability to use pronouns with non-ambiguous referents may be increased by the use of stories involving more than two participants of the same sex or more than two non-human nouns (singular or plural). (2) the use of auditory stories or visual stimuli no longer present in the testing situation is likely to increase the speaker's need to be explicit in his use of pronouns the listener is less able to extract the appropriate referent in the absence of pictures. general discussion and conclusion in view of the few deviations on all measures it appeared that the normal 9-year-old group were 'communicatively competent' and that the languageimpaired grp of the same age failed to exhibit the 'communicative competence' required for their age level. the ε grp's inferior performance on the measures used to investigate an aspect of 'communicative competence' appeared to be most comprehensively accounted for by the perspective furnished by piaget,16 and flavell:5 an interaction between both linguistic (semantic and syntactic) and cognitive deficits, the relative contribution of which may have varied for individual ss. the findings of the study would suggest that at least certain language impaired children exhibit deficits on an aspect of 'communicative competence' which impair their communication with others in their environment. while the value of diagnosis and treatment of expressive problems in terms of 'grammatical competence' is recognised, it is believed that this approach needs to be supplemented with the concept of 'communicative competence' for the following reason: an approach to expressive language problems in the older child in terms of 'grammatical competence' alone might not be able to detect and hence remediate deficits beyond the single sentence level. thus it cannot ensure the child's communicative efficacy, effective communication being to some extent dependent on the ability to produce coherent sequences of sentences. furthermore, such an approach might lead to premature dismissal of children from language therapy as rehabilitated in terms of 'grammatical competence', when, in fact, they still have difficulty in terms of 'communicative competence' which warrants attention. it is further believed that such an approach could also be utilised in the appraisal of aphasic language. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 sharon tuch the present study appears to have a further implication for the approach to expressive language problems in the older (and possibly younger) language-impaired child. the study focused largely on semantic ability (the ability to express meaning) as this ability appears to be crucial for effective communication or 'communicative competence'. all the language-impaired ss investigated showed deficits in this ability. despite the report that the ε ss were predominantly expressively impaired, the difficulty in their expression of meaning appeared to be the result, not only of linguistic deficits, but possibly of the interaction between linguistic and perceptual-cognitive deficits. currently, diagnosis and therapy for expressive language problems focuses largely on linguistic deficits involving syntax and to some extent vocabulary, which only partially accounts for the ability to express meaning. the findings of the study appear to suggest the need for (a) greater emphasis on the ability to express meaning and (b) a more global approach considering both linguistic and cognitive factors even in the diagnosis and treatment of what seem to present as predominantly expressive language problems. discourse analysis appeared to be a necessary tool for the investigation of the particular aspect of 'communicative competence' considered in the study; it facilitates the examination of aspects of semantic cohesion which could not be investigated at the single sentence level, except possibly for the use of conjunctions which was nevertheless considered to be more profitably investigated in discourse where there is scope for the conjoining of a greater number of sentences. a consideration of the child's discourse rather than single sentences, lends itself also to the investigation of other features which are of importance for effective communication, though not included in the present study: (a) syntactic cohesion established through a number of types of intersentence relation, e.g. ellipsis, tense continuity and the anaphoric use of the determiner 'the' and pro-forms (e.g. pro-verbs, pro-adjective); (b) the ability to produce grammatical sentences in discourse rather than at the isolated sentence level; (c) fluency in a discourse situation. the test devised was considered to be of value as it enabled an appraisal of the aspect of 'communicative competence* investigated in the study and proved to be sensitive to deficits in this aspect of 'communicative competence'. it is recognised, however, that a more complex test of a similar nature might have been more appropriate for the age level investigated and revealed even greater differences between the two groups. this can be ascertained only with future research. the test also provided a controlled situation for the investigation of an aspect of 'communicative competence': the content of the children's narrative texts could be evaluated against the content of the stories presented. the test makes it possible to establish the influence of modality of input on this aspect of 'communicative competence' which could have both diagnostic and therapeutic value. the test also enabled an appraisal of what the writer considers to be 'integrated linguistic functioning' — the ability to gain meaning and then express that meaning, which requires substantial cognitive and linguistic integrity. this integrated linguistic functioning would appear to be the hallmark of 'communicative competence'. finally, it is believed that the test (or picture and auditory stories the south african journal of communication disorders vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) coherent narrative texts by older children 59 of a similar nature) could be utilised therapeutically to promote the development of both cognitive and linguistic skill. in conclusion, further research employing larger samples of ss and a greater number of texts per s appears advocated to investigate the aspect of 'communicative competence' as well as its development with age. as the judgement of 'communicative competence' is ultimately the listener's, the ratings of other speech therapists and untrained listener's of children's 'communicative competence' should be obtained. also, children should be required to provide information to a listener who is ignorant of this information: this would most likely increase the need on their part to communicate effectively and hence enable a more accurate appraisal of this ability. references 1. bernstein, b. (1962): social class, linguistic codes, and grammatical elements. language & speech, 5,221-240. 2. brown, r. (1973): a first language the early stages. george allen & unwin, london. 3. chomsky, c. (1970): stages in language development and reading exposure . harvard educational review, 42 (1), 1 -33. 4. chomsky, n. (1973): current issues in linguistic theory. mouton, the hague. 5. flavell, j. h. (1968): the development of role-taking and communication skills in children. wiley, new york. 6. ginsburg, h. & opper, s. (1969): piaget's theory of intellectual development. prentice hall, new jersey. 7. hasan, r. (1968): grammatical cohesion in spoken and written english, i. (programmes in linguistics and english teaching, paper 7) longman, london. 8. hendricks, w. 0 . (1973): essays on semiolinguistics and verbal art. mouton, the hague. 9. hunt, k. w. (1970): syntactic maturity in school children and adults. monographs of the society for research in child development. 35(1), serial no. 134. 10. hymes, d. (1972): on communicative competence. in sociolinguistics. pride, j. b. & holmes, j. (eds). penguin. 11. johnson, d. j. & myklebust, h. r. (1964): learning disabilities. grune & stratton, inc., new york. 12. lee, l. (1974): developmental sentence analysis. northwestern university press, evanston. 13. lyons, j. (1973): introduction. in new horizons in linguistics, lyons, j. (ed). penguin, middlesex. 14. menyuk, p. (1964): syntactic rules used by children from preschool through first grade. child development, 35,533-546. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sharon tuch 6 0 15 o'donnell, r. c., griffin, w. j. & norris, r. c. (1967): syntax of kindergarten and elementary school children: a transformational analysis. national council of teachers of english, report no. 8. champaign, illinois. 16. piaget, j. (1926): the language and thought of the child. routledge & kegan paul ltd., london. 17. pit corder, s. (1973): introducing applied linguistics. penguin education, middlesex. 18. saling, m. (1976): personal communication. senior lecturer, department of psychology, university of the witwatersrand, johannesburg. 19. wales, r. & campbell, r. (1973): the study of language acquisition. in new horizons in linguistics, lyons, j. (ed.), penguin, middlesex. 20. young, d. n. (1971): a sociolinguistic analysis of some aspects of discourse structure in newspaper texts with proposals for pedagogic application. master's dissertation, department of linguistics, university of edinburgh. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction research method and design results ethical considerations discussion conclusion acknowledgements references about the author(s) esedra krüger department of speech-language pathology and audiology, university of pretoria, south africa alta kritzinger department of speech-language pathology and audiology, university of pretoria, south africa lidia pottas department of speech-language pathology and audiology, university of pretoria, south africa citation krüger, e., kritzinger, a., & pottas, l. (2017). breastfeeding and swallowing in a neonate with mild hypoxic-ischaemic encephalopathy. south african journal of communication disorders 64(1), a209. https://doi.org/10.4102/sajcd.v64i1.209 original research breastfeeding and swallowing in a neonate with mild hypoxic-ischaemic encephalopathy esedra krüger, alta kritzinger, lidia pottas received: 10 oct. 2016; accepted: 20 mar. 2017; published: 22 may 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: specific breastfeeding and swallowing characteristics in neonates with hypoxic-ischaemic encephalopathy (hie) have not yet been well described in the literature. considering the relatively high incidence of hie in resource-poor settings, speech-language therapists should be cognisant of the feeding difficulties in this population during breastfeeding. objective: to systematically describe the breastfeeding and swallowing of a single case of a neonate diagnosed with mild hie from admission to discharge. method: a case study of a 2-day old neonate with mild hie in a neonatal intensive care unit at an urban teaching hospital, is presented. data were prospectively collected during four sessions in a 12-day period until the participant’s discharge. feeding and swallowing were assessed clinically, as well as instrumentally using a video-fluoroscopic swallow study. results: after parenteral feeding, nasogastric tube feeding commenced. breastfeeding was introduced on day 6, as it was considered a safe option, and revealed problematic rooting, shallow latching, short sucking bursts, infrequent swallowing, and a drowsy state of arousal, with coughing and choking. no penetration or aspiration was identified instrumentally. after 13 days, the neonate was breastfeeding safely. conclusion: although the pharyngeal stage of swallowing was intact, symptoms of oral stage dysphagia were revealed using a combination of clinical and instrumental measures. breastfeeding difficulties were identified, exacerbated by poor state regulation, which lead to prolonged hospitalisation. the case study highlights the unexpected long duration of feeding difficulties in an infant with mild hie and indicates further research. introduction hypoxic-ischaemic encephalopathy (hie) describes abnormal neurologic behaviour in the neonate because of a hypoxic-ischaemic event (groenendaal & de vries, 2015). organ dysfunction, specifically of the heart, lungs, gut, kidneys and the brain, is associated with hie (thyagarajan et al., 2015). hie is referred to as a possible neurological cause of dysphagia (dodrill & gosa, 2015; garg, 2004; rybak, 2015). according to sarnat and sarnat observations (1976), as well as other hie grading systems such as the hie score (thompson, van der elst, molteno & malan, 1997) or the modified sarnat encephalopathy grading (horn, 2013; shalak, laptook, velaphi & perlman, 2003), infants with hie may be at risk of early feeding problems. this may be because of a weak or absent rooting and sucking reflex, which is distinctive of all three hie stages [mild (i), moderate (ii) and severe (iii)] (horn, 2013; shalak et al., 2003). infants with neurological conditions may have significant feeding difficulties (genna, levan fram & sandora, 2013). according to tamminen, verronen, saarikoski, göransson and tuomiranta (1983), infants with neonatal encephalopathy because of hypoxia-ischemia, or birth asphyxia as it was previously named, may show breastfeeding difficulties. inadequate muscular control in the infant’s oral area may be related to neurological deficits such as asphyxia (wolf & glass, 1992). a condition such as hie may also impact the infant’s ability to achieve a correct latch-on for breastfeeding (walker, 2017). neurologic impairment in infants may furthermore inhibit state regulation, which may negatively influence an infant’s ability to feed successfully (wolf & glass, 1992). furthermore, gastrointestinal tract impairment, and specifically necrotising enterocolitis (nec), is also a concern following hie (thyagarajan et al., 2015), which may further complicate feeding in this population. infants with neurological impairment are likely to be more disorganised than neuro-typical infants as they are influenced by hospital procedures, medication, and are often separated from their mothers, which may affect their ability to breastfeed (genna et al., 2013). central nervous system involvement such as hie is considered to be a known aetiology of dysphagia in infants (arvedson & brodsky, 2002), but globally, literature describing the specific early breastfeeding and swallowing characteristics in neonates with hie is scarce. limited published data exist on the incidence of hie in sub-saharan africa (horn, 2013). hie has a range of reported incidences, but occurs approximately 1–5 per 1000 live births according to three studies in the united kingdom, australia and sweden (horn, 2013). research in south africa reported incidences of 8.3/1000 and 3.6/1000 (bruckmann & velaphi, 2015; horn, 2013). because of the relatively high incidence of hie in south africa, speech-language therapists (slts) will encounter infants with hie in their caseloads and will be required to be skilled in addressing feeding difficulties that may arise in this population. infants with neurological conditions such as hie may have various issues with feeding including muscle tone disturbances, inadequate coordination, hampered function of certain nerves or neuromuscular units, inappropriate state regulation and limited endurance for feeding (genna et al., 2013). these challenges may influence early breastfeeding, but an infant may adapt over time, depending on the severity of the neurological condition (walker, 2017). the benefits of exclusive breastfeeding for infants have been documented well and are recommended for the first 6 months of life in high-income as well as lowto middle-income countries for all infants (kramer & kakuma, 2001; victoria et al., 2016). breastfeeding challenges that may arise from infants with neurological involvement may include sucking and swallowing difficulties, poor weight gain, separation from the mother in the first week of life, as well as maternal grief and shock at having an infant with a disorder (walker, 2017). the slt being a central team member of an in-patient feeding and swallowing team should address the mentioned issues in affected families (arvedson & brodsky, 2002; walker, 2017). slts, therefore, require an understanding of the profile of the feeding characteristics of neonates with hie in order to render comprehensive services to this population and their families. the following research question was, therefore, posed: what are the early breastfeeding and swallowing characteristics including the feeding difficulties of a neonate with hie in neonatal care? a description of the breastfeeding and swallowing characteristics in a case of hie in a neonate over a period of 12 days is presented. a clinical description may contribute to the dearth of research on the early oral feeding attempts in infants with hie in south africa and abroad. the findings may also assist slts to identify the feeding difficulties in neonates with hie that may lead to longer hospitalisation. research method and design aim the aim of this study was to systematically describe the breastfeeding and swallowing of a neonate diagnosed with hie over a period of 12 days until discharge from the hospital. design a case study was used, and data were collected prospectively. an in-depth description of a single case over time is presented (leedy & ormrod, 2014). setting data were collected in the neonatal intensive care unit (nicu) and high care unit of an urban tertiary hospital in pretoria. neonates diagnosed with hie and deemed suitable candidates, receive whole body therapeutic hypothermia for 72 h. intermittent kangaroo mother care is provided after completion of therapeutic hypothermia. neonates in the nicu and high care unit are provided with neurodevelopmental supportive positioning on warm tables and incubators. the hospital encourages exclusive breastfeeding and expressed breast milk (ebm) by cup as an alternative. participant an inborn post-term male neonate of 2 days old, diagnosed with hie by a paediatrician, and receiving therapeutic hypothermia, was purposefully selected for this study. characteristics of the infant and mother are shown in table 1. table 1: maternal and infant characteristics. according to table 1, the neonate’s highest hie score (thompson et al., 1997) was 4, indicating mild hie, on day 1. no congenital anomalies or metabolic disorders were diagnosed. therapeutic hypothermia is the standard of care for infants with hie globally (tagin, woolcott, vincer, whyte & stinson, 2012). according to the literature, an infant is diagnosed with hie by a medical doctor when the following criteria are met (martinez-biarge, diez-sebastian, wusthoff, mercuri & cowan 2013; volpe, 2012): arterial cord blood gas indicative of metabolic acidosis (ph < 7.1), depressed apgar scores (<7 at 5 and/or 10 min), the presence of neonatal encephalopathy (depression of level of consciousness, usually with respiratory difficulty, abnormal muscle tone, disturbed cranial nerve function especially impaired feeding and often the presence of seizures) and the need for resuscitation. as further indicated in table 1, the neonate was exposed to hiv and received nevirapine, but it was too early to suspect the presence of hiv encephalopathy. the neonate’s mother was of advanced age and received limited antenatal care in comparison with the minimum of four antenatal appointments prescribed for mothers with hiv (national department of health, 2015). mothers who are hiv positive in this hospital setting are counselled about exclusive breastfeeding during antenatal care and at birth as per national department of health (2015) guidelines. both mother and infant receive antiretroviral treatment, and viral loads are monitored to ensure safe breastfeeding. materials well-known literature on paediatric dysphagia and standard parameters of feeding such as coordination of sucking, swallowing and breathing, respiration during feeding and swallowing (arvedson & brodsky, 2002; pereira, sacher, ryan & hayward, 2009; wolf & glass, 1992) were used to compile a data collection sheet and to select relevant information from the hospital file. certain components of the oral motor and feeding assessment checklist (arvedson & brodsky, 2002) were extrapolated for the data collection sheet. this checklist obtains relevant history of the infant and mother, includes a pre-feeding observation of the infant at rest, including a physical examination (such as muscle tone and respiration), as well as observations of non-nutritive sucking and a feeding session at the breast. the hie score (thompson et al., 1997), calculated by the paediatrician, was obtained from the hospital file. the preterm infant breastfeeding behavior scale (pibbs) (nyqvist, rubertsson, ewald & sjöden, 1996) was used to monitor the progress of breastfeeding. the pibbs may be used with full-term infants and was designed as a breastfeeding monitoring tool for use by mothers or clinicians (da costa, van den engel-hoek & bos, 2008; nyqvist, 2013). a video-fluoroscopic swallow study (vfss) was performed using a sysco 19’ version multi diagnosteleva fd (philips, netherlands) screening machine. the contrast liquid used during the vfss was a commercially prepared non-ionic x-ray contrast solution. the contrast liquid was presented in a nuk™ bottle using a narrow nuk™ teat (birth to 6 months) with a small hole. a data collection sheet was compiled for the interpretation of the vfss, which included a checklist compiled from arvedson and brodsky (2002), as well as the penetration aspiration scale (pas) (rosenbek, robbins, roecker, coyle & wood, 1996). the pas is an eight-point classification system to quantify the penetration and aspiration events during vfss (rosenbek et al., 1996). the pas was conceptualised for use with adults, and thus far, data are only available for use in the adult population (arvedson & brodsky, 2002), but has been used in a study on the paediatric population (masarei, wade, stat, mars & sommerlad, 2007). procedure the participant’s feeding was clinically evaluated daily by the first author (esedra krüger), an slt registered with the health professions council of south africa (hpcsa), experienced in assessment of feeding and swallowing in neonates. the assessments were completed during typical feeding sessions in the nicu once the participant was deemed ready for oral feeding by the managing paediatrician. multiple data collection entries were made to allow for capturing of follow-up data. information on the neonate’s medical treatment from admission, as well as his progress, was obtained from the hospital file. the neonate was treated daily, by providing parent guidance and oral stimulation, by a hospital-based slt (arvedson & brodsky, 2002). the pibbs (nyqvist et al., 1996) was completed daily from the commencement of oral feeding on day 6, during direct observation of breastfeeding. direct observation is the least intrusive method of observing breastfeeding while not disrupting the infant’s behaviour (nyqvist et al., 1996). the researcher stood near the mother in a position that provided a clear view of the neonate’s face and chin, according to the description by nyqvist et al. (1996). the neonate was instrumentally assessed on day 13 using vfss, according to recommendations by arvedson and brodsky (2002). the lateral projection view was used, as it yields the most valuable information when studying the paediatric population (arvedson & brodsky, 2002; dematteo, matovic & hjartarson, 2005). the vfss was conducted by two hospital-based slts registered with the hpcsa who has experience in vfss in infants, in conjunction with a radiologist and a radiographer based at the hospital. analysis clinical assessment data were systematically collected by the researcher via observation, without being involved in treatment of the participant (meline, 2010). the clinical assessment data were interpreted using normative data available for full-term infants (arvedson & brodsky, 2002; walker, 2017). the vfss recording, which allowed a frame by frame analysis, was analysed by a panel of two slts experienced in interpretation of vfss in infants. the panel was blinded to the results of the clinical feeding assessments conducted by the researcher. results the results are described chronologically according to the occurrence of events in the participant’s 14-day stay in the hospital and are depicted in figure 1. figure 1: chronological events from admission to discharge. rooting and sucking reflexes were reported to be absent by the paediatrician upon the participant’s admission to the nicu. during the initial clinical assessment on day 2, with a weight of 3.79 kg, the neonate was still receiving whole body therapeutic hypothermia (figure 1). at the scheduled feeding time, he was lethargic, and difficult to rouse, presented with hypotonia, and was unresponsive to stroking on and around the mouth. non-nutritive sucking could not be elicited, although minimal jaw and tongue movement were perceived. no ebm was available yet, and the participant received only parenteral nutrition. the participant received ebm 3-hourly via nasogastric tube (ngt) on the following day after therapeutic hypothermia (day 3). on day 6, the participant was breathing room air, saturating well (>95%) (wolf & glass, 1992) and weighing 3.72 kg. the participant was physiologically stable, with his condition improving, while being cared for in the high care unit positioned in side-lying in an open bassinet. he was deemed ready to commence oral feeding by the paediatrician and the hospital-based slt. the participant was positioned cradled in his mother’s arm for all breastfeeding attempts, which is a comfortable position for most feeders (wolf & glass, 1992). communication interaction between the mother and the participant during all feeding sessions could be described as inadequate with limited eye contact. the results of the pibbs are presented in table 2. table 2: breastfeeding results according to the preterm infant breastfeeding behavior scale. on day 6, the participant displayed some rooting, but showed shallow latching onto only the nipple, and stayed latched onto the breast for less than 1 min (see table 2). single sucks and occasional short sucking bursts of two to four sucks were observed. occasional swallowing was noticed, but coughing and choking were present. the participant was predominantly in a drowsy state before and during feeding. premature fatiguing, as well as hiccupping and yawning, were observed. the breastfeeding session lasted approximately 41 min, and the infant received ebm via the ngt to complete the feed. ebm via cup feeding was attempted by hospital staff when his mother was not available to breastfeed. the infant received intervention by the slt daily. information available from the participant’s hospital records indicated that cup feeding was successful, however, the daily slt intervention records indicated otherwise. the participant was in the quiet-sleep stage at the scheduled feeding time on day 7. he presented with closed eyes and showed no body movements even with repeated attempts at waking him for the feeding. no rooting or latching could be elicited during breastfeeding, and no swallowing was noticed. ngt feeding continued supplemental to breastfeeding, and a vfss was scheduled for the following week. during the vfss on day 13, no penetration or aspiration was identified. no residue was left on the posterior pharyngeal wall, the valleculae or the pyriform sinuses. however, the qualitative analysis revealed poor bolus formation and delayed oral transit time, which may be indicative of oral stage dysphagia (arvedson & brodsky, 2002). on day 13, the participant had regained his birth weight at 3.82 kg and was mainly breastfed, although a ngt was still in situ. the participant was awake and alert before and during feeding. he showed obvious rooting, latched deeply onto the whole nipple and some of the areola, and stayed latched onto the breast for approximately 11 min. repeated long sucking bursts (>10 sucks per burst), and repeated swallowing, indicative of successful feeding, were observed. the participant was discharged home the following day. the participant and his mother continued with antiretroviral treatment. validity and reliability the outcome measures used in the study are published and deemed valid and reliable tools to use for the assessment of infant feeding. the reliability and validity of the pibbs was considered satisfactory and increased the rigour of this study (da costa et al., 2008; nyqvist et al., 1996). the vfss is referred to as the ‘gold standard’ for examining swallowing (arvedson & brodsky, 2002), which contributed to the validity of the results. the use of two blinded raters for the vfss increased the reliability of the vfss findings. ethical considerations ethical clearance was obtained from the hospital, as well as from the faculties of health sciences and humanities of the university of pretoria prior to data collection. voluntary informed consent was requested from the mother on behalf of her infant to participate in the study and for the medical file to be perused. the mother was informed that she may withdraw her infant from the study at any time without her usual care at the hospital being affected. the participant received intervention from a hospital-based speech-language therapist from the day of the first assessment. data were handled confidentially and will be stored electronically and in hard copy according to institutional guidelines for a period of 15 years. discussion a neonate with mild hie and hiv exposure, as well as feeding difficulties, was presented. weight loss was minimal, and the participant regained his birth weight at the last assessment prior to discharge. problems with rooting and latching onto the breast were identified while the participant was treated for septicaemia and after receiving therapeutic hypothermia and continuous positive airway pressure (cpap) in the nicu. the infant presented with hypotonia initially. muscle tone problems may lead to incorrect alignment, which may contribute to feeding difficulties (wolf & glass, 1992). the participant received parenteral and tube feeding initially. feeding difficulties requiring tube or intravenous feeding are signs of cerebral depression that may likely correlate with future neurological dysfunction (genna et al., 2013). successful latching-on and breastfeeding require an intact central nervous system (radzyminski, 2005). sucking and swallowing were not optimal for breastfeeding between birth and day 13. he was hospitalised for 14 days, mainly because of an inability to complete all feeds orally, and possibly because of reduced endurance (short sucking bursts and staying on the breast less than a minute). breastfeeding sessions may have been prolonged as the mother was motivated for her son to breastfeed and was able to dedicate time to breastfeeding. the required daily volume of feeds per day was ensured with ngt feeding. successful breastfeeding was not established until the second week after birth. infants with neonatal encephalopathy because of hypoxia-ischemia may show difficulty starting to breastfeed (tamminen et al., 1983). the participant was his mother’s fourth child, and her advanced age and prior child-rearing experience may have contributed to successful feeding after 13 days. evidence also exists that an infant’s ability to increase his or her intake at the breast develops over time (nyqvist, 2001; walker, 2017). although no clinical symptoms of oral stage dysphagia, associated with hiv, were observed, the participant’s hiv exposure may have contributed to problematic feeding. hiv exposure in itself is linked with subtle neurodevelopmental difficulties (le doaré, bland & newell, 2012), which may likely influence feeding in a young infant. a neonate with mild hie may present with absent rooting and sucking reflexes initially (thompson et al., 1997), which was true in this case. however, rooting and sucking remained inadequate for breastfeeding well into the first week of the participant’s life. an absent rooting reflex may not impact an infant’s feeding functionally, but short sucking bursts may be related to swallowing difficulties (wolf & glass, 1992). the participant’s state was drowsy before and during feeding. quiet-alert, drowsy or active alert may be the optimal states to feed a neonate (arvedson & brodsky, 2002). although the drowsy state is labelled as being one of the optimal states for feeding, there may only be one specific state for a particular infant that is ideal for feeding (wolf & glass, 1992). state is also related to an infant’s neurological and medical status (wolf & glass, 1992). cerebral depression may cause reduced alertness and a lower level of consciousness in infants (genna et al., 2013). in this study, it appears that state regulation may have affected the participant’s ability to feed successfully. the instrumental assessment of swallowing revealed no aspiration, penetration or residue. however, clinical signs of aspiration, such as coughing and choking, which may also be signs of stress (arvedson & brodsky, 2002), were observed on day 6, while the vfss was only conducted on day 13. the participant received intervention from the slt during this period, which may have contributed to the improvement in the coordination of the oral and pharyngeal stages of the swallow seen on the vfss. further research is required. the vfss during the second week revealed mild symptoms of oral stage dysphagia, which is similar to the findings in the clinical assessment of breastfeeding. from this case presentation, it is clear that feeding in a neonate with hie and hiv exposure, was not only affected because of the absence of rooting and sucking reflexes, but also because of the neonate’s inability to maintain an appropriate state for feeding. the participant’s state may have been influenced by the diagnosis of hie, and his medical status, namely the provision of cpap and therapeutic hypothermia in the first days of life as well as treatment of septicaemia (wolf & glass, 1992), and the fact that he was a post-term infant, or even a combination of these factors. post-term infants (>42 weeks gestation) may often be lethargic and may have difficulty sustaining sucking (walker, 2017). because of a relatively high incidence of hie in south africa, slts working in hospitals are required to provide the earliest feeding intervention to this population of infants. this case study outlines early salient features of the breastfeeding and swallowing of a neonate with hie with hiv exposure. although hie is not a new diagnosis in an slts case load, this case study provides a novel description of the unique feeding profile that may be found in infants with hie, namely, difficulty establishing breastfeeding initially because of poor latching, inadequate sucking and mild oral stage dysphagia. these difficulties coupled with hiv exposure and inadequate state regulation may have led to a longer hospitalisation and separation from the participant’s mother. as oral motor control, muscle tone and the infant’s state are interrelated, a deviation in any of these areas will likely influence the others and may lead to dysfunction in feeding (wolf & glass, 1992). furthermore, separation of an infant and mother leads to increased stress in both and negatively influences breastfeeding (smith, 2013). in many instances, infants with mild hie may escape the attention of the slt with a large caseload, unlike the moderate or severely involved infant with hie. the long duration of feeding difficulties after the initial recovery of mild hie in the participant was unexpected. this case study highlighted the fact that feeding difficulties and prolonged hospital stay may be the result in a case of mild hie and hiv exposure, and should, therefore, form part of the slts caseload. according to gagne-loranger, sheppard, ali, saint-martin and wintermark (2016), newborns with mild neonatal encephalopathy may require more thorough monitoring as their outcomes have been less well studied. the fact that the present study describes only one case, limits the generalisation of the findings to other infants with hie. the study presented in-depth data on one case, which may point to the need to investigate the population of infants with hie as a group. a larger scale investigation of the feeding characteristics of infants with hie may therefore be valuable in order to assess the impact of hie on infants’ initial feeding attempts, feeding practices used during therapeutic hypothermia, as well as neonatal communication development of this population. the influence of hiv exposure on neonates’ early feeding skills also requires further research, as this case study cannot provide clarity on the influence of the participant’s hiv exposure on the resultant feeding outcomes of the participant. because of the design of this study, it is also not clear what the influence of intervention by the hospital-based slt was on the participant’s outcome. future research may be directed towards the feeding intervention and neuro-developmental supportive care infants with hie receive in neonatal care. the findings of this study may lead to slts’ improved understanding of the complexity of the feeding of even the mildly affected infants with hie who also have hiv exposure. conclusion the specific breastfeeding difficulties, oral stage dysphagia and inadequate state regulation in this case study of a neonate with mild hie and hiv exposure were presented in order to contribute to data on feeding characteristics of infants with hie. even though being diagnosed as having mild hie, the participant’s problematic feeding led to prolonged hospitalisation. neonates with hie and hiv exposure may have unique feeding profiles. the early involvement of the slt in the treatment of feeding difficulties in infants with mild hie was highlighted. further research investigating the feeding and communication development of infants with hie is required. acknowledgements the authors would like to express their gratitude to prof. wilma de witt and the department of paediatrics, university of pretoria, as well as the staff at the department of speech therapy and audiology, steve biko academic hospital. competing interests the authors declare that they have no financial or personal relationships that may have influenced them in writing this article. authors’ contributions e.k. was the principal investigator, collected and analysed the data, and wrote the article. a.k. and l.p. assisted in design of the project and contributed to the article. references arvedson, j.c., & brodsky, l. 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( s p . & η . t h . ) ( w i t w a t e r s r a n d ) psychological and guidance services, cape education department, cape town summary this study describes the communicative performance of a severely hearing-impaired adolescent. the experimenter taught the subject how to play russian backgammon. the subject conversed with, and afterwards taught his mother, speech therapist, and a peer how to play the game. each dyad played the game once. videotape recordings were made of each dyadic situation. the channels of communication, both verbal and nonverbal, used by each speaker, were determined. a relational communication coding scheme, involving the analysis of requests and subsequent responses, was applied to the data. results indicate that the hearing-impaired adolescent, though not always able to hold a dominant position in a dyadic situation, was capable of expressing the same types of control as normal adults. moreover, the types of control expressed varied as a function of each contextual setting. whenever the subject did hold a dominant position, the combined verbal plus nonverbal channel was his predominant mode of communication. these findings suggest that a sociolinguistic approach provides important information regarding a hearing-impaired adolescent's communicative performance. opsomming hierdie studie beskryf die kommunikasiegedrag van 'n erg gehoorgestremde adolessent. die navorser het die proefpersoon geieei om 'n spel te speel. die adolessent het met sy moeder, 'n spraakterapeut en 'n jeugdige van dieselfde ouderdom gesels en hulle later geleer hoe om die spel te speel. elkeen van die tweetal het die spel eenkeer gespeel. videobandopnames is gemaak van elke tweegesprek. die verbale en nie-verbale kommunikasieklee, deur elke spreker gebruik, is vasgestel. 'n kommunikasie koderingskema, wat die ontleding van versoeke en daaropvolgende response behels, is gebruik om die gegewens te analiseer. resultate het aangedui dat die gehoorgestremde adolessent alhoewel hy nie altyd 'n dominante posisie gedurende 'n tweegesprek kan handhaaf nie, nogtans instaat was om dieselfde tipe beheer as normale volwassenes, te openbaar. die tipe kontrole het verskil as 'n funksie van elke situasie. wanneer die adolessent wel 'n dominante posisie beklee het, was gesamentlike verbale en nie-verbale kommunikasiewee, sy vernaamste kommunikasiewyse. hierdie bevindinge dui daarop dat 'n sosiolinguistiese benadering belangrike inligting verskaf aangaande 'n gehoorgestremde adolessent se kommunikasiegedrag. most research dealing with the language of the hearing-impaired has focused on syntax. results across all studies indicate a retardation in linguistic performance.1' 6 ' 2 4 these findings, however, do not reflect or predict how the hearing-impaired use their language for communication. communication is . . . the transmission of a message from one person to another.21 thus, it is an interpersonal, interactive process . . . realized, not only through verbal codes, but also through a matrix of complexly integrated coding mechanisms in a communicative context.22 the natural method of communication among the congenitally hearingimpaired is by means of signs, and most hearing-impaired parents use die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28,1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 ann russell sign language with their young hearing-impaired children. 1 7 most hearing-impaired children, however, have hearing parents who, traditionally, have been discouraged from using manual communication. in an attempt to determine the relative effectiveness of oral versus manual methods of communication, most studies 7 · 1 3 have compared hearing-impaired children of hearing-impaired parents, who use a manual method of communication, with hearing-impaired children of hearing parents, who use oral language. it has been found that hearing-impaired children of hearing-impaired parents, who use a manual method have superior communication skills.21 recently, a number of investigators 8 ' 2 6 have utilized a sociolinguistic approach to describe the semantic-pragmatic component of language in the spontaneous communication of hearing-impaired preschool children. the results have revealed a clear difference between the development of a linguistic (semantic) and a communicative (pragmatic) ability: the former ability appeared to be delayed whereas the latter was age appropriate. sociolinguistic research has investigated the ways in which children talk to adults and to one another. 2 ' 1 6 very little information, however, has been published regarding the ways in which hearing-impaired adolescents communicate. if the goal of education is to prepare them to communicate effectively in society, then information about their communicative abilities is essential. adolescence, being the age between 12 and 21 years, 2 3 is a period during which the adolescent has to learn appropriate social roles. 2 5 role relationships are implicitly recognized by the way individuals interact with each other. mishler 1 9 ' 2 0 proposes that questionsustained discourse reflects the role relationships between speakers, particularly along the dominance-submission dimension. for example, in hierarchical relationships, such as a teacher-pupil relationship, it is common for the dominant person to control the dialogue by asking questions and issuing commands.5 the subordinate person does not have these privileges, but rather . . . 'is expected to respond to the imposed tasks'. 5 adolescence is a time of flux,11 and, during this period, an adolescent manifests both dominant and submissive traits in his/her struggle to establish a sense of identity. 2 3 hearing-impaired adolescents, how. :ever,-have, been ,described.as "timid.", 1! ."-passive", " s h y " 1 8 and .--. "more introvertive and submissive than those with normal h e a r i n g " . 1 2 this study represents a sociolinguistic analysis of the communicative performance of a severely hearing-impaired adolescent in three conversational settings: with his mother, his speech therapist, and a peer. in addition, each dyad will be involved in a game of russian backgammon: an interpersonal communicative task selected from the literature.1 01 5 the writer will attempt to answer the following questions: how does a severely hearing-impaired adolescent use his/her existing language to communicate? has a severely hearingthe south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication of a hearing-impaired adolescent. 5 impaired adolescent the requisite skills for successful interpersonal interaction? what is his/her style of interaction in a dyadic situation along a dominant-submissive dimension? can a severely hearingimpaired adolescent express control or authority in a social interaction? if so, in what specific ways is control accomplished? which channel(s) of communication will be used? m e t h o d o l o g y aim to describe the communicative performance of a severely hearingimpaired adolescent. a total description of an adolescent's communicative abilities would be so detailed as to defy analysis. for the purposes of this study, therefore, the complexity of this process was reduced by analysing it within a sociolinguistic framework, in which primary emphasis was given to the interrogative units. an interrogative unit has been defined as "three successive utterances": (1) the question, (2) the response from a second speaker, and (3) the confirmation from the initial questioner.1 9. subject (s) description the s used in this study was a white, south african, english-speaking, congenitally severely hearing-impaired male, aged 17 years. the s was fitted with 2 hearing aids and has had a consistent history of hearing aid usage, as well as speech and hearing therapy, since 18 months of age. the oral method was used extensively and intensively in the home, both parents having normal hearing. occasionally, however, natural gesture was used to facilitate interpersonal communication. at 6 years, he was enrolled as a day student at a school for the deaf. he has not failed an academic school year, and his teachers feel that his intelligence falls within the normal range. status of the s's communication behaviour at the time of testing hearing. pure tone audiometry revealed a fairly flat, severe sensori-neural hearing loss in the s's left ear. the pta was 87 db (iso 1964). there was no response in his right ear for all frequencies at the limits of the audiometer. speech audiometry revealed an aided speech reception threshold of 30 db and a speech discrimination score of 76% at 60 db. the s's speech was characterized by a number of inconsistent articulation errors, and therefore his speech was regarded as being fairly intelligible by his speech therapist at the clinic. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 ann russell his voice was fairly high-pitched and monotonous with a densasal quality. his receptive language ability was better than his expressive ability, but both areas were restricted. an analysis of his expressive language revealed an output of predominantly 3 to 4 word utterances; specific syntactic errors related to marking of tense, plurality, and possessives; inconsistently correct determiner and pronoun usage; ellipsis of large segments, inconsistent tense shifting; and poor cohesion. in terms of pragmatics, he was able to use the informing and ritualizing functions, and express his feelings, in certain situations. participant selection participants were selected in accordance with the following criteria. a. they were required to be well known to the s. b. english was required to be their home language. t c. none of the participants had played russian backgammon before. in accordance with the above criteria, the s's mother (m), speech therapist at school (t), and best friend (p), who also attended the school for the deaf, were selected. thus, one participant was selected out of each of the following primary social relationships: parent-child, teacher-pupil, and friend-friend.4 procedure (1) the experimenter (e) taught the s how to play a game known as russian backgammon. as far as possible, the ε used a verbal plus gestural and/or manipulative channel of communication to describe each item of game-information. once the s had been taught how to play the game, the ε played the game once with him to observe whether or not he had understood the rules of the g a m e . 1 4 (2) the test procedure the ε ushered each dyad, that is, the s and one participant, into a room and they were asked to discuss (i) television watching; (ii) school; (iii) extra-mural; and (iv) holiday activities as naturally as possible. it was suggested that the participant initiate the conversation by asking the s if he had watched "tv last night". each dyad was told that when they had finished discussing the 4 activities, the s was going to teach the participant how to play a game. as soon as the instructions had been given to the dyad, the/e left the room and began videotaping their , interaction through^a one-way mirror. using a sony video recorder^ testing was complete as soon as the dyad had finished playing the game. the dyadic interactions were evenly spaced over a period of 8 days and all testing took place in the afternoon when the ambient noise level was low. s each dyadic interaction was orthographically transcribed by the ε from the video recordings. the south african journal of communication disorders, vol. 28, 1981' r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication of a hearing-impaired adolescent. 7 analysis of the data the analysis procedure was applied to the entire length of each conversation and explanation of the rules, as well as the first 5 minutes of each game. approximately 25 minutes was analysed for each dyad. the channels of communication used by the s and each participant rating of the nonverbal aspects of communication used by the s and each participant was done by the ε and a qualified speech therapist who was familiar with the informal gesture system used at the school for the deaf. the ε and the rater independently analysed each utterance. the symbols v, g/m, or vg/m were written on the transcription sheets next to each utterance to denote whether the verbal (v), gesture and/or manipulative (g/m), or verbal plus gesture and/or manipulative (vg/m) channel of communication had been used. the ε and the rater then compared their analysis. where there were discrepancies, the videotapes were replayed until exact agreement was reached. the coding and mapping procedures all questions (and commands) on the transcript sheets were located and marked " q " . any utterance following a question (or command) was marked " r " , as it might be a response to i t . 1 9 if the third speaker, in a sequence of 3 successive utterances, was the same person as the questioner, then the third utterance was counted as a confirmation and marked " c " . 1 9 nonverbal modes of communication, viz., gesture and/or manipulation of game material which served as questions, responses, or confirmations was also included. the interrogative units, consisting of successive question-responseconfirmation (q-r-c) — utterances were then "mapped" on the transcript sheets as follows: . q τ : who brings you supper? r s : we just help ourselves c τ : oh sometimes the ror c-utterance in one interrogative unit (iu) also included a question. this question then initiated a second iu which was connected to the first through the fact of their having this utterance in c o m m o n . 1 9 if the question was through the r-utterance, the connection was referred to as arching; if it was through the c-utterance, it was referred to as chaining.1 9 arching and chaining were "mapped" on the transcript sheets as follows: , q μ : did you watch tv last night? -r s : yes chaining ^ c / q μ : how much did you watch? a r c h i n g < ^ r / q s : how much? ~c/r μ : hm -c s : a little bit die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 ann russell the analysis procedure the mapped units of dialogue were then analysed. the ε worked through each successive q-r-c-utterance in 7 scans. scan 1: the q-utterances were analysed in terms of various categories, such as, request for permission, statement in request form,3 etc. each type of question was tabulated and a count made. scan 2: commands were analysed in terms of their being "single" or "multiuttered". scan 3: the r-utterances were analysed to ascertain whether the initial question or command was accepted, rejected, or evaded. scan 4: the r-utterances were analysed to ascertain whether they contained a question, thereby initiating a second iu, referred to as an arched iu series. scan 5: the c-utterances were analysed to ascertain whether they contained a question, thereby initiating a second iu, referred to as a chained iu series. scan 6: a chained iu series was further analysed to ascertain whether the r-utterance in the first iu was accepted, rejected, or evaded. scan 7: the questions and commands were analysed to ascertain whether they were dominant (d) or submissive (s) bids. a d bid was based on the rationale that the speaker assumed he had the power to make such a demand. an s bid was based on the rationale that the speaker was dependent upon the responder.3 every d and s bid, response, and iu was tabulated and a count made. the numerical scores for each interaction were then transferred from the transcripts to a score sheet. reliability of the coding, mapping, and analysis procedures was obtained for each dyad. the first 5 minutes of each game was analysed for realiability by the ε and a qualified speech therapist. interreliability agreement for these 3 procedures was 73%. the following areas were then investigated: (1) the styles of interaction: the ratio of d or s bids. (2) the manner in which control or authority were expressed. • according to bedrosian and prutting,3 a speaker can express control in any one of the following ways: (a) when the majority of his bids (either d or s) is accepted; (b) when the listener is not allowed to respond to the bids due to multi-uttered questions/commands, a statement following, the bid, the speaker answering his own question, or when n o r e s p o n s e is expected; (c) by the use of arching; and (d) by the use of chaining only when all of the bids in the iu series are accepted. ; the e, therefore, examined the scoreisheets to ascertain: (i) the types of control, and i (ii) the frequency with which they were expressed by the s and each participant. | the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication of a hearing-impaired adolescent. 9 (3) the channels of communication used by the s and each participant. only 3 different communication channels were considered: a verbal (vocalization only); a gestural (hand movements in the air) and/or manipulative (touching game materials), and a verbal plus gestural and/or manipulative. the s's and each participant's use of these channels was evaluated. the above procedures were used to analyse the speech used by the s and each participant (a) while conversing; (b) during the s's explanation of the game; and (c) whilst playing the game. results a n d discussion o f results ( 1 ) the s's style of interaction following the previously mentioned mapping and coding procedures,3 the frequencies of d and s bids, responses, and interrogative units were tallied for the s and all of the participants in each interaction (see table i for an example of how s interacted with his mother). conversational setting while conversing with his μ, t, and p, the s made 0, 8, and 1 d bid, respectively. the μ, t, and p, however, made 24, 66, and 7 d bids, respectively. therefore, it can be said that they held the dominant positions during their conversations with the s. the above results correspond with those obtained by mishler, 2 0 who found that adult-initiated conversations have a higher number of d bids than those initiated by children. explaining the game while explaining the game to his m, the s and his μ both offered 17 d bids. therefore, neither held the dominant position. during his explanation of the game to his τ and p, however, the s offered 19 and 37 d bids, respectively, while τ and ρ offered 9 and 3, respectively. thus, it can be said that the s held the dominant position during his explanation of the game. playing the game while playing the game, the s made more d bids than any of the participants. therefore, he held the dominant position each time he played the game. the overall results indicate that the s held a dominant position in 5 out of 9 settings (55,5% of the time), a submissive position in 3 out of 9 settings (33,3% of the time), and neither a dominant nor a submissive position in one setting (11,1% of the time). thus, by being able to hold both a dominant and a submissive position, the s manifested both dominant and submissive traits. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 ann russell i i i i i i i i i i i i i | m m | ' i i i i i i i i i i i i i i i ι i | tt co ι—ι rj rj νηνόοονν i i' ι ι ι ι — i i i i i i r ι i i i i i i |<n | i i i r ι i i i i i oo co co rj i i i i i i i i i ii i i ii i i i i i i i i ii i i i i coco ι ηίλνγ̂ γ̂ νοήνρ -"(ninoninmr-r-'-hs©'· i i i ii i i i i i i i i i i i i i i i i i i i ι (ν <n co 1-h (ν t-i1 i i i " i l m r " h i ~ i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i i ii i ii i i i i i i i i i i i i i i i i i i i i i i i i § ! q c 5 η ή f c flj g ssi.l ι ε s « s &&|u l ^ s f s s l λ u. (λ 0) -̂ ιλ s ο ο ^ vj μ μ mm 3 3 -= α,2 ω ρ ρ ο cr cr2 (λ go η u< u< ο-υ ω ο 3 β ° 0 ™ ίι " α ό 1 s .2 3 1 τ-1 (λ (λ ι » § £ ! s er.2 j • 8 " l s β ^ ι ε s > ι·_ u c 3 ffl q ^ i s q ^ s s " s "v, » sjis'c g-os s ο ο e (a (λ 1) ... a s s: ζ i »·§ ξ< £ ^ ό 1 8 ° : co c c _ co ο q s s d • s ^ s s i s-b χι ·κ uxj-ϊ « υ -si, ^(ϋ ^ ο υ ω j3 υ .2 α ΐλ ω co υ > y ω< the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication, of a hearing-impaired adolescent. 11 ( 2 ) expression of control s expressed all types of control while interacting with his μ, t, and p. the types of control expressed, however, varied as a function of each communicative task. for example, the s used chaining while conversing with all the participants. mishler 2 0 found that adults took control of a conversation through questions that served to chain succeeding units together. therefore, by using chaining, the s was attempting to take control of each conversation in an adult-like manner. ( 3 ) channels of communication used by the s and each participant table ii indicates that while conversing with his μ, t, and p, the s used the v channel more frequently than the g/m or vg/m channels. table ii also indicates that the s used the vg/m channel more frequently than the v or g/m channels while explaining and then playing the game. on average, the s used the vg/m channel 84% of the time. table ii also indicates that whenever the s held a dominant position, he used the vg/m channel of communication. this indicates the relative efficiency of a combined oral-manual compared to an oral — or manual — only mode of communication.2 1 table ii: predominant channels of communication used by the subject and each participant in each contextual setting channels of communication most frequently used dyad s μ s τ s ρ conversing v v* v v* v vg/m* explaining vg/m + v vg/m* vg/m vg/m* g/m playing vg/m* vg/m vg/m* vg/m vg/m* g/m * indicates the dominant speaker in each dyadic interaction + indicates that neither speaker held the dominant position in the dyadic situation. g e n e r a l discussion the results of this study seem to suggest that a sociolinguistic analysis provides important information regarding a hearing-impaired adolescent's communicative performance. for example, although the s's linguistic abilities were poorer than those of the participants', he was able to use his limited linguistic abilities to hold a dominant position in a social situation. the fact that he was able to hold both a dominant and a submissive position while interacting with the participants is significant. firstly, it indicated that he was aware of the social significance of his communicadie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 ann russell tive performance. dittmar 9 found that the average 15-year-old, with normal hearing, was just as aware of the social significance of his communicative abilities as an adult. therefore, the s's communicative performance was appropriate for his age. secondly, pervin 2 3 has stated that adolescents manifest both dominant and submissive traits in their search for a sense-of identity. these traits are reflected in the s's style of interaction. thus, the s's style of interaction also confirms that his communicative performance is age appropriate. finally, the overall results of this study reveal a distinct difference between the s's linguistic ability and his communicative performance: the former ability appeared to be restricted whereas the latter was age appropriate. implications clinical implications are: (1) the use of a sociolinguistic analysis as part of a test battery in assessing the communicative behaviour of the hearing-impaired. (2) the use of a therapeutic programme aimed at improving specific verbal, as well as non-verbal, interpersonal communication skills. implications for future research lie in: (1) the determination of the efficacy of this analysis procedure and its applicability to a diversity of language disorders and populations. these include (a) handicapped children, adolescents, and adults. this procedure has potential for use with the motorically, intellectually, as well as the audiologically impaired. (b) a large population of hearing-impaired adolescents in an attempt to assess its effectiveness with the mildly, moderately, and profoundly hearing-impaired. (2) comparing the communicative performance of (a) institutionalized and non-institutionalized hearing-impaired adolescents; and (b) hearing-impaired adolescents of hearing parents with hearingimpaired adolescents of hearing-impaired parents. references / 1. bamford, j. and mentz, l. 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(1978): the "natural history" of a research project: an illustration of methodological issues in research with deaf children. chapter 2 in deaf children: developmental perspectives. liben, l. s. (ed.) academic press, inc., new york. 18. minski, l. and shepperd, m. j. (1970): non-communicating children. butterworth and co., ltd., london. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 ann russell 19. mishler, e. g. (1975): studies in dialogue and discourse: an exponential law of successive questioning. language in society, 4, 31-51. 20. mishler, e. g. (1975): studies in dialogue and discourse: ii. types of discourse initiated by and sustained through questioning. journal of psycholinguistic research, 4, 2, 99-212. 21. moores, d. f. (1974): nonvocal systems of verbal behaviour. chapter 15 in language perspectives-acquisition, retardation, and intervention. schiefelbusch, r. l. and lloyd, l. l. (eds.) university park press, baltimore. 22. muma, j. r. (1978): language handbook: concepts, assessment, intervention. prentice-hall, inc., englewood cliffs, new jersey. 23. pervin, l. a . (1970): personality: theory, assessment, and research. john wiley and sons, inc., new york. 24. quigley, s. p., power, d. j., and steinkamp, m. w. (1977): the language structure of deaf children. the volta review, 79, 73-84. 25. schmitt, p. j. and mercaldo, d. j. (1978): training personnel for hearing-impaired adolescents. the volta review, 80, 5: 359-377. 26. skarakis, e. a . and prutting, c. a. (1977): early communication: semantic functions and communicative intentions in the communication of the preschool child with impaired hearing. american annals of the deaf, 122, 4: 382-391. 27. stuckless, e. r. (1976): manual and graphic communication. the volta review, 78, 4: 96-101. the south african journal of communication disorders, vol. 28,1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) philips hearing aid services a d i v i s i o n of s . a . p h i l i p s ( p t y ) ltd. hearing aids amplaid audiometers group teaching systems philips hearing aid services h e a d o f f i c e 1 0 0 5 c a v e n d i s h c h a m b e r s , 1 8 3 j e p p e s t r e e t , p . o . b o x 3 0 6 9 , j o h a n n e s b u r g . philips die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28,1981 fib2399 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a filtered speech test for an aging population * hanna klein, m.a. (audiology) (witwatersrand) sub-department of communication studies, university of the witwatersrand, johannesburg summary a filtered speech test was presented to sixty males and females above the age of sixty years. thirty of these subjects had complained of, and demonstrated clinically, a high frequency hearing loss for pure-tones. thirty subjects, who had never complained of a hearing loss, but who nevertheless were found to have mild-to-moderate high frequency hearing losses, were included as a control in the study. the ability to discriminate among phonetically-balanced words where certain frequencies had been filtered out deteriorated with age, although those subjects in the control group performed better than those in the experimental group. however both groups showed poorer ability to discriminate with the right ear, than with the left, or with both ears. the results seemed to indicate a particular retrocochlear involvement in an aging population. opsomming 'n gefiltreerde spraaktoets is aan sestig mans en vroue oor die ouderdom van sestig jaar voorgele. dertig van hierdie proefpersone het gekla oor 'n hoe frekwensie-gehoorverlies. hierdie toestand is ook klinies bevestig. dertig proefpersone, wat nooit oor 'n gehoorverlies gekla het nie, maar by wie geringe tot gemiddelde frekwensie-gehoorverlies nietemin gevind is, is as kontrole in die studie ingesluit. die vermoe om te diskrimineer tussen foneties-gebalanseerde woorde waar sekere frekwensies uitgefiltreer is, het met ouderdom versleg, alhoewel die proefpersone in die kontrolegroep beter as die in die eksperimentele groep gepresteer het. altwee groepe het egter 'n swakker vermoe vertoon om met die regteroor as om met die linkeroor, of met altwee ore, te diskrimineer. uit die resultate blyk dit dat daar 'n spesifieke retro-cochlieere betrokkenheid onder die bejaarde ouderdomsgroep bestaan. a common aspect noted in the texts dealing with the problems induced by the aging process, is the apparent deterioration in the communication process, and the subsequent withdrawal from social intercourse. many workers in the field have indicated that such deterioration may be related to sensory degeneration in general, and auditory disturbance in p a r t i c u l a r . 1 ' 1 ' ' 1 5 ' 2 2 a survey of the more recent literature specifically related to the auditory problems of the aged, indicates that a sensori-neural loss demonstrated by pure-tone audiometry is only one of the many audiological features that may be demonstrated clinically in the a g e d . 1 2 ' 1 6 ' 1 7 in fact, research in the areas of anatomy, physiology, and especially neurology and its allied fields, have led us to view the condition of presbycusis as an extremely complex auditory disturbance * this paper. is based on an m.a. dissertation submitted to the department of speech pathology and audiology, university of the witwatersrand, johannesburg, 1976. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 88 hanna klein that may manifest itself in any, or all of the areas along the auditory pathway, from the pinna to the temporal cortex.4' 8> 1 3 > 1 8 ' 2 4 where speech signals have been distorted in terms of intensity, time and frequency, the amount of information that is conveyed by the auditory pathway to the brain is thus reduced2' 6 the normal reduction of cortical cells due to aging may limit the ability of the aged person to integrate the cues on a distorted speech test.5 matzker20 was a pioneer in the field of filtered speech tests. his study showed that normal subjects make few, if any, errors on tests of dichotic integration using a filtered speech test, whereas those with brain.stem lesions make many. in addition, he also noted how poorly the presbycusic patient performed on these tests. whereas the task of speech discrimination of phonetically-balanced words in quiet conditions is considered to give minimal information with regard to the functioning of the retrocochlear pathway, the same test used in conjunction with modifications, such as the introduction of noise, or the filtering out of crucial speech frequencies, may serve to provide more detailed information about the ability of the patient to discriminate and integrate speech c u e s . 2 ' 1 7 the introduction of a complex listening task with the aged requires careful and controlled presentation and analysis. while neurological deficits may account for a reduction in performance on complex speech tests, one has to bear in mind such psychological factors as fatigue, motivation, memory span, etc., which may mitigate against a favourable performance on such tasks.17' 21> 2 5 palva and jokinen 1 7 ' 2 1 have devised a test to determine the effects of aging on the discrimination of filtered speech. the present study was modelled on their experiments. the aim of this study was therefore to investigate certain aspects of the function of the retrocochlear pathway of the aged person, using a test of filtered speech. method subjects thirty subjects (ss) were selected on the basis of the following criteria: 1. sixty years of age, or older. 2. male and female (no predetermined sex ratio was stipulated in advance, but was dependent on the chronological sequence of referral of suitable subjects to the speech and hearing clinic, university of the witwatersrand, within the experimental period). 3. no previous or ongoing severe general illnesses. 4. negative history regarding the taking of ototoxic drugs. / 5. gradual and progressive hearing loss of recent onset. 6. negative history of noise exposure, as a result of an occupation or hobby. 7. negative history of early otological problems. table i details the number and age of subjects in the experimental group (eg). a control group was included in this study to investigate whether or not there was any difference between a group who had been referred, or self-referred, journal of the south african speech and hearing association vol. 23 december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) filtered speech for the aged 89 male female mean age total no. 60-69 years 6 6 65.5 12 70-79 years 5 9 74.2 14 80-89 years 1 3 82.5 4 total • 12 18 74.0 30 table i. number and age of subjects in the experimental group. for an audiological assessment, and those people in the same age range who had never sought professional help, in their ability to discriminate filtered speech sounds. thirty ss were selected to match those in the experimental group for all the variables mentioned above, with the exception of a hearing loss of gradual or recent onset. table ii depicts the number and age of ss in the control group (cg). male female mean age total no. 60-69 years 6 6 63.8 12 70-79 years 5 973.8 14 80-89 years 1 3 81.5 4 total 12 . 18 73.0 30 table ii. number and age of subjects in the control group. the pilot study in view of the findings in the literature that normal ss are able to complete a test of distorted speech with few or no errors,21 it seemed essential to ascertain how people of differing ages performed on the test of filtered speech. the results thus obtained would serve to verify the accuracy of the results obtained on the test of filtered speech with the aged ss in this study, or they would demonstrate that the errors obtained were merely artefacts. thirty ss, ranging in age from 15-58 years, both male and female, were tested, in order to determine the validity of the filtered speech test. as far as possible unsophisticated listeners were selected for this aspect of the study. men and women who had not received a higher education were favoured over those who had; and only those who had no history of ear disease, medical problems or hearing loss were selected. table iii below indicates the number of ss included in the pilot study group (pg) for the filtered speech test. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23, desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) filtered speech for the aged male female mean age total no. 15-24 years 3 3 20.8 6 25-29 years 3 3 27.3 6 30-39 years 3 3 32.7 6 40-49 years 3 3 43.3 6 50-59 years 3 3 55.2 6 total 15 15 31.7 30 table 111. number of subjects in the pilot study group. preparation of material for the filtered speech test in order to standardise the presentation of the filtered speech test to all the ss, seventy-five words were recorded onto a master tape recorder nagra iii, using a tape-scotch-avi77 tenzar at 7!/2ips. a beyer mi60 200 ohm microphone was used. the following procedure was employed: preceding the recording of the words to be filtered, a 1 000 hz tone was recorded onto track one of the tape for thirty seconds for calibration purposes. the same was repeated for track two. the vu meter was set at zero decibels for calibration purposes. twenty five words each was recorded by the experimenter (e) onto channel one and two of the tape, and a further twenty-five words were recorded onto both channels simultaneously. the words were taken from the cid w-22 lists 2 and 3. no carrier phrase was used, so that minimum cues were given to the subjects. two madsen electronic speech filters were placed in the same sound-proof booth, i ac series 1604a-act, as a maico ma24 audiometer. the filter feeding the left channel of the audiometer was set up to filter out all the frequencies in the speech spectrum except those of bands 480-640 hz and 1 920-2 560 hz. using the same recording material described above, the following tape was constructed: the first word was directed to the right ear through teletronic tdh 39 earphones at bands 480-640 hz and 1 920-2 560 hz. the second word was directed to the left ear through the earphone at bands 480-640 hz and 1 920-2 560 hz. the third word was directed to both ears simultaneously, the right ear hearing the word through the earphones at 480-640 hz, and the left ear hearing the same word through the earphone at 1 920-2 560 hz. each band is too narrow for adequate discrimination. this is obviated by presentation of both frequency bands to each ear in the monaural test, and presentation of one band to each ear in the binaural t e s t . / ' 2 0 ' 2 1 a 5 second interval was left between each word recorded, and the condition was repeated twenty five times using different words. in order to verify that the filter had indeed filtered out, and maintained the desired frequencies in the speech spectrum, the resident sound engineer of the clinic analysed the frequency of certain words chosen at random; using the kay-sona-graph 6061-b. spectographs indicated that the words were not in fact being filtered as desired, and so the filters were adjusted, and the tapes remade until the spectographic analysis indicated that the desired frequency cut-outs had been obtained.14 journal of the south african speech and hearing association, vol 23, december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) hanna klein 91 presentation of material for the filtered speech test the ss were seated in a sound-proof double suite booth, (i.a.c. 1600 act series) using the same earphones as previously described. before placing the earphones on the s's head, the ε gave the following instruction for this particular test: you are now going to hear some single words through these earphones. the words do not sound like english words because i have treated them in a special way, so that they are now distorted. you will probably not understand the words you are going to hear, but i want you to guess what they are. please do not keep quiet, rather take a guess as to what the word is. you will hear the word first in the right ear, then a different word in the left ear, and then another word in both ears. this will be repeated. the tape recording of these words will last about ten minutes. the instructions were repeated until the ε was sure the s understood, and six trial words were presented by the ε seated at the maico ma24 audiometer in the second partition of the suite. all test words were then presented at 40db above srt for each ear. all errors were phonetically transcribed for each condition, and the percentage of errors was computed. in order to determine the degree of peripheral hearing loss in the aged ss, and that hearing for puretones was normal in the pilot study group, an audiogram for each s, and their speech reception threshold, was obtained in the usual manner, prior to the administration of the test for filtered speech. results and discussion there were no significant differences between the sexes for the three test conditions for the right ear, left ear and the binaural presentation, for any of the three groups. however significant differences existed between the pg, cg, and eg in relation to scores obtained for the filtered speech test for the three test conditions. the following tables demonstrate these differences among the means. from the inspection of table iv it may be seen that the ss in the pg. scored significantly better for the three test conditions than either the eg. or cg. the significance value for the difference between the means for the three groups was p=0.05. ear pilot study group experimental group control group filtered speech right ear (fsr) 86.4 38.0 50.5 filtered speech left ear (fsl) 86.6 42.5 52.1 filtered speech binaural (fsb) 85.7 38.5 53.9 table iv. mean percentage scores for the filtered speech test for right and left, and both ears, for pg., eg. and cg. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23, desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 92 hanna klein table v demonstrates the mean scores for filtered speech for the three conditions for the age groups ranging from 15-89 years. age groups ear 15-24 25-29 30-39 40-49 50-59 aged group 60-69 70-79 80-89 right ear 92.0' 89.4 81.5 83.17 75.5 eg cg 44.1 59.4 36.6 47.3 33.5 44.4 left ear 92.0 89.1 82.0 86.17 77.6 eg cg 47.1 61.2 39.6 42.9 33.5 41.0 both ears 91.5 89.9 83.0 82.17 78.3 eg cg 44.1 63.2 33.2 43.3 34.7 45.7 table v. mean percentage scores for filtered speech for the right and left ears, and the binaural condition for the pg, cg and eg. inspection of table v once more indicates that all ss in the pg. scored significantly better than the cg. who in turn scored significantly better than the eg. for all three conditions. however it may be observed that there is a deterioration in the scores for all three conditions as the age increases; and this is so even for the pg. the results obtained in this study, which demonstrate the poorer performance with an increase in age, correspond very closely to the results obtained by palva and jokinen.21 it is interesting that none of the ss in the pg scored 100% for the filtered speech test, under any condition. these results accord closely with the studies cited by palva and jokinen.17' 2 1 ' from the results presented in table v, and those presented by palva and jokinen, l 7 ' 2 1 ' i t may be concluded that a 'normal population group' will score up to the 75th percentile for the filtered speech test, and an aged group score considerably below this level. it may be noted that in the latter two age groups studied, the difference between the means for the filtered speech conditions are less than those in the younger age groups. figure 1 details the relationship between age and scores obtained by the pg., and cg. for the three test conditions. although there are no significant differences among the three test conditions for filtered speech, it may be seen that the right ear for all three groups is slightly inferior to the left ear, and both ears. jokinen and palva17 found that their subjects, who ranged in age from 60-89 years, showed poorer discrimination in the right ear for the filtered speech test, and this score was worse than that in the left ear, and both ears, although not significantly so. figure 2 details the relationship between age and scores obtained by the pg. and eg., for, the three test conditions. it may be seen that although similar trends exist for the three test conditions in the eg., the scores are significantly poorer than those for pg. and cg. it would seem that the hearing defect which is present in this group is so severe journal of the south african speech and hearing association, vol. 23, december 19 76 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) filtered speech for the aged 93 both ears left ear right ear 40.00 60.00 age figure 1: mean percentage scores for filtered speech for the pilot group (age 15-59) and control group (age 60-85). § s left ear right ear figure 2: mean percentage scores for filtered speech for the pilot group (age 15-59) and experimental group (age 60-85). tydskrif van die suid-afrikaanse vereniging vir spraak-en gehoorheelkunde vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 94 hanna klein that it affects all aspects of hearing ability in a more debilitating manner, than the 'normal' loss of hearing which occurs in the cg. filtered speech tests have been used to diagnose the presence of lesions in the higher auditory pathway. 2 ' 5 ' 2 0 a lesion in the auditory cortex should produce poor speech discrimination scores in the contralateral ear. where both ears respond in the same manner, and the binaural test gives similar results in both ears, one may conclude that the lesion is not at a cortical level, and in fact is probably at the brain-stem level.21 as pointed out before, the poorer responses obtained for the ss in the eg. and cg. for the right ear although not significant at the 95% confidence level, nevertheless concurred with the study by palva and j o k i n e n . 1 7 ' 2 1 they felt that the poorer scores in the right ear, giving an asymmetrical pattern to the response set, indicate that the contralateral hemisphere was not functioning as well as it did for younger people. they did not detail the exact level of the auditory pathway implicated, but because of the asymmetrical response, assumed that it must be higher than brain-stem. the better responses for the binaural condition may be due to the fact that binaural stimulation activates more neurons than monaural stimulation, and this allows greater facility for interpretation of the incoming signal. all ss in the eg. and cg. were right handed, and this would indicate a left-hemisphere dominance. irrespective of the semantic connotations of the stimulus word, it has been found that in right-handed people, the best score for complex speech tests is found at the right ear.9' 2 6 it is therefore interesting to speculate as to why the aged demonstrated poorer responses for what may be assumed to be their dominant ear. if, during aging, there is a loss of neurons, and the transmission ability in the auditory nerve is reduced because of wear and tear, it may be that the dominant route to the contra-lateral hemisphere is no longer able to transmit complex signals as effectively as the ipsilateral ear. although the dominant hemisphere has been shown to be responsible for the encoding of language and its related s y s t e m s 2 ' 1 9 ' 2 6 it may be that in the aged system the stimuli from the left ear are able to travel more easily to the left hemisphere via the right hemisphere and its connections to the left hemisphere, than through the contralateral pathway which may be reduced in efficiency. the intrinsic neural noise may be greater in the contra-lateral than ipsilateral pathway, and this may also contribute to reduced transmission in the auditory system.3 a bigger sample size may in fact have caused the differences between the right and left ear in the older groups to become significantvin addition, a detailed phonemic analysis of the type of errors made in this test may lead to greater insight as to which area is being tested since it seems that certain phonemes are mediated by either the right and/or the left hemisphere.7'27 conclusion it would seem that while pure-tone audiometry may indicate the integrity of the peripheral auditory pathway, complex speech tests may give more detailed information in regard to the function of the retrocochlear pathway. many workers have been concerned with the function of the cortex in interpreting journal of the south african speech and hearing association, vol. 23, december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) filtered speech for the aged 95 auditory signals in the aged. the conclusion which has emerged from the majority of studies has been that speech tasks under varying conditions of complexity are not correctly interpreted by the aged, as they are by younger ss who display no evidence of hearing loss. the inclusion in this study of a pilot group who ranged in age from 15 to 58 years for the filtered speech test, showed that indeed, for these tasks, younger people perform in a superior manner to people above the age of 60 who do not necessarily demonstrate a severe hearing loss. the rationale for the poorer performance of the aged ss has been attributed to a reduced number of neurons in the central nervous system, lengthening of the synapse time along the higher auditory neural pathways, and the interference of intrinsic neural noise with signal interpretation. 3 ' 1 0 ' 2 3 ' 2 8 distortions due to peripheral auditory difficulties are thus being transmitted by inefficient neural fibres in the retrocochlear pathways to a cortex where there are a reduced number of neurons. the rate of conduction is reduced and the signal may decay before it reaches the original target area. the scores obtained by the experimental group in the filtered speech test were significantly poorer than those obtained by the control group. it would seem that whatever process is responsible for the interpretation of filtered speech is more affected in the former group. since an ear asymmetry has been noted in this study, it has been suggested that the filtered speech test is sufficiently sensitive to test that area of the auditory pathway where decussation has occurred, since cortical dominance seems to be implicated where ear preference is noted.1 7' 2 1 the enigma is that there is a left-ear, rather than a right ear dominance, although all ss in the study were right-handed. it has been tentatively postulated that the dominant pathway suffers from extreme wear and tear with age, and in later years the ipsilateral pathway may invoke more efficient neural transmission. acknowledgement the writer would like to express her sincere gratitude to professor m.l. aron, head, department of speech pathology and audiology, university of the witwatersrand, johannesburg, for assistance with this project. this study was supported by the ernest oppenheimer post-graduate fellowship, awarded by the university of the witwatersrand, johannesburg. references 1. agate, j. (1970): the practice of geriatrics. 2nd ed., heinemann medical books, london. 2. berlin, c.i. & lowe, s.s. (1972): temporal and dichotic factors in central auditory testing. in handbook of clinical audiology. (ed.) katz, j., williams and wilkins co. baltimore. 3. berruecos, p. (1970): binaural temporal integration in presbycusis. int. audio., 19,309. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 96 hanna klein 4. bocca, e. (1958): clinical aspects of cortical deafness. laryngoscope, 12, 301. 5. bocca, e. (1967): distorted speech tests. in sensori-neuralhearing processes 'anddisorders. (ed). graham, b. little, brown and co., boston. 6. carhart, r. (1973): updating special hearing tests in otological diagnosis. archives otolaryngology, 97, 88. 7. cole, r.a., & scott, β. (1974): towards a theory of speech perception. psychol. rev., 81, 348. 8. covell, w.p. (1952): histologic changes in the aging cochlea. j. gerontology, 7, 173. 9. curry, f.k.w. (1975): a comparison of left-handed and right-handed subjects on verbal and non-verbal dichotic listening tasks. cortex, 3, 345. 10. de quiros, (1964): accelerated speech audiometry. translation of the beltone institute for hearing research, 17, 5. 11. donahue, w. (1968): psychologic aspects. in the care of the geriatric patient. (ed.) cowdry, e.v. 3rd edit. the c.v. mosby co. st. louis. 12. fisch, l. (1973): special senses: the aging aduitory system. in testbook on geriatric medicine and gerontology. (ed.) brocklehurst, j.c. churchill, livingstone, edinburgh. 13. gacek, r.r., & schucknecht, i. (1969): pathology of presbycusis. int. audiol, 8, 199. 14. grieve, r.l. (1975): personal communication. 15. helander, j. (1968): some problems in the determination of the degrees of senility. in geriatric audiology (ed.) liden, g. almqvist and wiksell, stockholm. 16. jerger, j.f. (1960): audiological manifestations of lesions in the auditory nervous system. the laryngoscope, 70, 417. 17. jokinen, k., & palva, a. (1970): presbycusis. v. filtered speech test. acta oto laryngologica, 70, 232. 18. kirikae, i. (1969): auditory function in advanced age with reference , to histological changes in the central auditory system. int. audiol., 8, 221. 19. luria, a.r. (1966): higher cortical functions in man. tavistock publications. london. 20. matzker, j. (1959): two new methods for the assessment of central auditory functions in cases of brain disease. ann. otol, rhinol, laryngol., 63,1185. 21. palva, α., & jokinen, k. (1975): the role of the binaural test-in filtered speech audiometry. acta otolaryngologica, 79, 310. 22. pfalz, r., & treeck, h. (1973): why does inner-ear deafness usually commence with low intensity tones? j. audiological technique, 12, 2. 23. schonfield, d., trueman, v. & kline, d. (1972): recognition tests of dichotic listening and the age variable. j. gerontology, 27, 487. 24. schucknecht, h.f. (1967): the effect .of aging on the cochlea. in sensori-neural hearing processes and disorders. henry for. hospital international symposium. (ed.) graham, a.b., little, brown and co. boston. journal of the south african speech and hearing association vol. 23 december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) filtered speech for the aged 97 25. smith, r.a., & prather, w.f. (1971): phoneme discrimination in older persons under varying signal-to-noise conditions./. speech hear. res., 14,630. 26. studdert-kennedy, m., shankweiler, d. (1970): hemispheric specialization for speech perception. j. acoustical society of america, 48, 579. 27. studdert-kennedy, m., shankweiler, d. (1972): auditory and phonetic processes in speech perception: evidence from a dichotic study. cognitive psychology, 3,455. 28. willeford, j.a. (1971): the geriatric patient. in audiological assessment. (ed.) rose, d.e. prentice-hall, inc. new jersey. * portable audiometers * clinical audiometers * bekesy audiometers * impedance audiometers * era/ecog audiometers * train-ears * speech training equipment * rf phonic ear systems * hearing aids the leaders for sales and service needler westdene organisation (pty.) ltd. p.o. box 28975 sandringham 2131 phone: 45-7262 45-6113/4 tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 7 3 2 m e d i c a l c i t y εi o f f cor. jeppe s t r e e t q l | 1 1 i i 1 i i i i i j o h a n n e s b u r g , transvaal r e p u b l i c | ' h e a r i n g a i d c o n s u l t a n t s t p t y ] l t d . i11')))))) j/ii s a x o n w o l o 2 1 3 2 travelling audiometer noise generator. a p r e c i s i o n i n s t r u m e n t m a d e by phonak germany. a) as noise generator with the detachable loudspeaker: here is an ideal noise generator for quick check of patients, especially for babies and children. either with sinus tone or warble (pulsing sinus tone). frequency: 10002000 4000. test intensity from 35 to 90 db. b) travelling audiometer: with the headphones. this is an excellent quick-check screening audiometer with the frequencies 500 1000 2000 4000 6000. the noise absorbing headset allow testing even in noisy surroundings without a sound proof booth. other models available with different and more frequencies. please write to, or telephone oiir mr. siebold, for more details or demonstration. journal of the south african speech and hearing association vol. 23 december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pg2-5.html editorial contextually relevant resources in speech-language therapy and audiology in south africa – are there any?* abstract in this editorial introduction we aim to explore the notion of contextually relevant resources. we argue that it is the responsibility of speech-language therapists (slts) and audiologists (as) working in south africa to develop contextually relevant resources, and not to rely on the countries or cultures where the professions originated to do so. language is often cited as the main barrier to contextually relevant resources: most slts and as are aware of the need for more resources in the local languages. however, the issue is not as straightforward as translating resources from english into other languages. the challenges related to culture, e.g. formal education and familiarity with the test situation, have to be considered, as well as the population on which norms were obtained and the nature of vocabulary or picture items. this paper introduces four original research papers that follow in this edition of the journal, and showcases them as examples of innovative development in our field. at the same time we call for the further development of assessment materials, intervention resources, and contributions to the evidence base in our context. we emphasise the importance of local knowledge to drive the development of these resources in innovative and perhaps unexpected ways, and suggest that all clinicians have an important role to play in this process. keywords: resources, development, speech-language therapy, audiology, culture ‘the responsibility to provide culturally appropriate material for our work lies within the countries to which the profession has extended.’ (watson, 2006, p. 154). around the world, the professions of speech-language therapy (slt) and audiology (a) face challenges that have been well documented: services for people with communication difficulties often have low priority in health care systems; the professions straddle education and health and are not always fully understood by each sector; resources are limited; the professions are relatively small and relatively new (enderby & emerson, 1995; hartley, 1998; nippold, 2010; swanepoel, 2006). in south africa these challenges are especially intense: there are an insufficient number of slts and as to provide services to all people; the qualified slts and as do not represent the linguistic and cultural diversity of the country’s population and are unequally distributed between the private and public sectors; the burden of infectious disease is high; health priorities often centre on saving lives rather than improving quality of life; and the research/evidence base is lacking for the context (penn, 2007). along with these challenges come opportunities. in this journal and others, much has been made of the need for the professions of slt and a to transform and develop their practice, and to make our research and practice relevant for the local context (kathard, naude, pillay & ross, 2007). one way in which the professions can start to meet these challenges is through the development of contextually relevant resources tailor-made for the local context. in this paper we explore what is meant by contextually relevant resources and practices, why developing and disseminating such resources is important, and what has already been done towards this goal, and finally we suggest ways to participate in this process. this editorial introduction grew from discussions about the papers that were submitted and accepted for publication in sajcd this year. in a seeming coincidence, each of these has innovation and development of resources and practices for the south african context as a linking theme. rogers, de wet, gina, louw, makhoba and tacon (this issue) describe the translation of the vertigo symptom scale into afrikaans, and its ability to differentiate between patients with and without vertigo. strasheim, louw and kritzinger (this issue) describe the development of a locally relevant neonatal communication intervention tool for use by clinicians in the neonatal nurseries of public hospitals in south africa. uys and van dijk (this issue) developed a music perception test for adult hearing aid users. finally, crewe-brown, stipinovich and zsilavecz (this issue) detail communication difficulties in individuals who have experienced mild traumatic brain injury, from a spouse’s perspective. this last study focused on communication in everyday contexts and explored ways in which communication can be evaluated in the absence of formal assessment procedures and functional rating scales. rather than being a coincidence, this group of papers may serve to highlight the need for development of locally relevant resources and the way in which local researchers are rising to this challenge. before describing what is meant by contextually relevant resources, it may be helpful to provide an overview of our current context. the current context: speech language therapy and audiology in south africa south africa has experienced major socio-political changes over the past 20 years. in 1994, the first democratic government was elected into power, and transformation of all sectors – health, welfare, education – began. the impact of apartheid in south africa prior to 1994 cannot be underestimated, and many of today’s pressing social issues (e.g. poverty, illiteracy) are linked to its legacy. for example, black and coloured south africans experienced great educational disadvantages that continue to have major consequences today: an estimated 15 million people cannot read or write, and one in every five south africans over the age of 20 years has not received formal education. high rates of migration, overcrowded living conditions, family violence, teenage pregnancy and substance abuse contribute to family and social difficulties in many communities (kagee, 2008). in line with its progressive constitution, south africa aims to provide all of its citizens with equal access to quality health care and education. but transformation is an ongoing process, not without challenges: despite a high incidence of hiv/aids and tuberculosis (tb), the south african public health system is characterised by sub-optimal provider-to-client ratios and insufficient material resources. education has been described as being in crisis, with national benchmarking studies suggesting that reading and writing is not being effectively taught in our schools (mullis, martin, kennedy & foy, 2007). the professions of slt and a have also changed considerably since 1994 in response to the changing milieu. swanepoel (2006) describes attempts to ‘improve imbalanced service delivery, redress teaching programmes and focus … research endeavours on the specific needs of the contexts’ (p. 264). moodley, louw and hugo (2000) describe the failure of traditional institution-based models of service delivery to reach the majority of people, especially those disenfranchised and disadvantaged, who may need our services the most. services are now focused on the community and delivered within a primary health care framework, in an attempt to address the needs of the population. in addition, the role of the slt and a in schools is being redefined. a special edition of this journal is due towards the end of the year, and will have education as its focus. south africa has a diverse multicultural and multilingual population. of an estimated 47 million people, 79% are black, 9% are coloured, 9% are white, and 2.5% are of indian/asian origin. officially there are 11 languages, but many more unofficial languages and dialects are spoken. the most widely spoken languages in the country are isizulu (23.8%), isixhosa (17.6%) and afrikaans (13.3%) (statistics south africa, 2005). however, the majority of slts and as working in the country are white englishor afrikaans-speaking; as a result, speakers of the indigenous languages have invariably been under-served (penn, frankel, watermeyer, & muller, 2009). the majority of health interactions are mediated by a third party, and more than 80% of these interactions between clients, a third party and health professionals take place across linguistic and cultural barriers (penn et al., 2009). in a small-scale survey of slts working in the western cape, pascoe, maphalala, ebrahim, hime, mdladla, mohamed & skinner (2010) found that a considerable proportion of slts are able to offer therapy in only english or afrikaans – even when working with children for whom these are second or third languages. there is a fundamental challenge here: ethical guidelines suggest that an individual should not be denied intervention because of a language mismatch with the clinician, but slts or as may not be competent to offer intervention in all languages. a study by jordaan and yelland (2003) attempted to determine how south african slts provide language intervention for multilingual language-impaired children. the results indicated that the majority of slts were providing language therapy to multilingual children in the child’s second language only – usually english. the authors attributed this to parental insistence and a lack of another common language between the slt and child. what is meant by contextually relevant resources (and why are they important)? contextually relevant resources are any tools (assessments, intervention programmes, guidelines and norms) that are available for slts and as to use with a specific population in a specific setting, and that have been developed with that population and setting in mind. many of the assessments and therapy resources in use in south africa today have been developed by clinicians and researchers in countries such as australia, the uk or the usa, and are used here in the absence of contextually relevant resources, sometimes with adaptations that make them more appropriate. in the case of standardised assessments, these will be accompanied by a set of norms against which clinicians can compare the performance of the specific individual they have assessed on a given day. this assessment procedure and comparison against norms requires a number of assumptions on the part of the clinician-assessor: firstly that the test was administered in the exact way described in the manual, and secondly that the individual-client whose performance is compared with the norms comes from the same population as that from which the norms were obtained. the first point is more easily addressed in our context, but to address the second may not be possible, and therefore results must be treated with caution. stanczak, stanczak and awadalla (2001) found that typical sudanese adults attained scores on the arabic version of the expanded trail making test that were similar to those attained by us adults with brain damage. this suggests that simply translating the language of a test does not make it appropriate for another population group, as the culture and context of the target population needs to be considered to avoid misinterpretation of results. in another study, boivin (1991) found that children in zaire performed significantly below the norms of age-matched american children on a number of non-verbal assessments widely held to be ‘culture-fair’ measures of cognitive abilities. he suggested that even supposedly ‘culture-fair’ assessments have to originate from somewhere, in this case that of western psychological research and theory, which has several fundamental underpinnings and assumptions about the way the world works that may be inappropriate when used elsewhere. in south africa, wilson and moodley (2000) determined that the use of the cid w22 wordlist (a speech discrimination test developed in the usa and widely used by south african audiologists) was problematic because normal-hearing, first-language south african english speakers performed more poorly than their us counterparts on whom the norms are based. pahl and kara (1992) assessed 60 typically developing children in south africa using the renfrew word finding scale, a test which has been developed and standardised in the uk. even though the south african children were first-language speakers of english with no language difficulties, a significant proportion of the children’s test scores fell in the range suggesting language difficulties. it is widely acknowledged that assessment is the cornerstone on which intervention should be built. if assessment is inappropriate or inaccurate and does not take cultural variation and the potential for cultural bias into account, assessment results will not be accurate and intervention may be inappropriate at best or harmful at worst (carter, lees, murira, gona, neville & newton, 2004). since it is the ethical and professional responsibility of slts and as to provide an equitable and quality service to all, the importance of using culturally fair assessment tools cannot be overemphasised. similarly, using inappropriate assessment tools in research can confound results and lead to biased conclusions. irrespective of the languages involved, it is clear that translation of a test does not necessarily make it suitable for use in another setting with a different culture. not only assessment but intervention too should be appropriate for the culture. vocabulary, stereotypical concepts, high-frequency words, body language and gestures differ between cultures and languages. it may be necessary to look at the language structure of words in different languages, because some intervention strategies commonly used with one language may not be applicable when used with another. for example, cuing words using the initial consonant sound as for english (greenwood, grassly, hickin & best, 2010) may not work well with languages such as isixhosa or sesotho, which typically begin with a vowel sound (gxilishe, 2004). we know that intervention is more valid when it is relevant and culturally acceptable, and therefore it must be tailored specifically to the culture of the individual and the community culture (hartley, murira, mwangoma, carter & newton, 2009). there is growing recognition of the necessity for developing or adapting assessment tools and procedures to match the needs of the populations. carter et al. (2004) emphasise the need to develop culturally appropriate materials that meet the needs of a specific culture, and to take cultural variation and potential cultural bias into consideration. in their kenyan-based study they found that the following factors should be taken into account by clinicians assessing or treating children from a culture different to their own: the influence of culture on performance, familiarity with the testing situation, the effect of formal education, and picture recognition. gladstone, lancaster, umar, nyirenda, kayira, van den broek & smyth (2009) described a qualitative methodology using focus groups to identify contextually important concepts and developmental milestones when creating a developmental assessment tool for malawian children, rather than simply translating and adapting available ‘western’ tools. the results from their focus groups identified social milestones and social intelligence as important aspects of development for the community, which would have been neglected in a ‘western’ test. local knowledge local knowledge refers to the ‘unique locally-available knowledge, innovations, technologies, practices, resources and their utilisation for improved livelihoods, beliefs and their contribution to the wellbeing of communities’ (nhemachena, chakwizira, dube, maponya, rashopola & mayindi, 2011, p. 2). authors such as pillay (2003), kathard et al. (2007) and joubert (2010) have variously described the origins and flawed epistemologies of the slt, a and occupational therapy (ot) professions in south africa. essentially, in these (and other) professions, ways of working have been developed in the western world that may not be appropriate for other cultures and contexts. joubert (2010), writing about ot, a profession that shares much in common with ours, describes ‘a coming of age … a stage now when [we] have used [our] resilience to really change those flaws of the past … now recreating a new and more robust and appropriate africanised epistemology’ (p. 26). kathard (2005) describes a troubled and contradictory professional identity, but suggests that the way we view ourselves as professions is not set in stone and is in the process of transforming. we believe that the innovative development work described in the journal signals a coming of age in our professions, although clearly there is much more to be done. local knowledge must be valued and used to inform the development of contextually relevant resources. to illustrate this, we use the case of isixhosa phonology. while there is a substantial amount of research surrounding children’s speech sound acquisition in english, most of this has been conducted with children in europe, north america and australia. to date, there is no tool available to comprehensively assess isixhosa phonology. there are standardised assessments of children’s speech that have been developed in other parts of the world, e.g. the goldman-fristoe test of articulation (goldman & fristoe, 1986). using the picture stimuli from this test with isixhosa-speaking children would be helpful in providing some insight into the child’s difficulties and can be used to provide some qualitative information. in the survey by pascoe et al. (2010), it was found that western cape slts rely largely on informal assessments when evaluating children’s speech. they make adaptations to formal assessments, as well as using other informal assessments of their own design. more than 50% of therapists indicated that they make adaptations to formal tests to better suit the population, e.g. translating the assessment and using more contextually relevant pictures. these slts will often omit items or sections of formal assessments that are not appropriate for their clients, and will administer tests in non-standardised ways, e.g. repeating instructions or test items. however, the isixhosa phonemic inventory contains consonants that do not occur in english and may not be elicited by these pictures. the clinician would need to know what the correct vocabulary items/names were and what the correct production of the names are. s/he would need to know what the vowel and consonant inventory of isixhosa looks like to know whether the child’s inventory was complete or not. once this information was gathered s/he would need to know whether the child’s speech was acceptable/typical for the child’s age: what are the typical processes used in isixhosa and when do they appear/disappear? these processes might not be the same as for english, given that the language structures are different, e.g. isixhosa does not typically have closed syllables and therefore final consonant deletion would not be expected. this illustration shows not only the need for development of resources, but also the need for development of local knowledge to drive the process. it illustrates that starting from a blank page may in fact be easier than trying to adapt something that has been developed for an entirely different population, in a different place, speaking a different language. gxilishe (2004) conducted a study in the western cape, looking at the acquisition of clicks by isixhosa-speaking children. he found that at the onset of speech (approximately 1 year of age) isixhosa-speaking children begin using three basic clicks. such studies are important in advancing our knowledge of speech and language development in the local context; however, further research is needed. contextually relevant resources – what has been done (and where is it hiding)? this edition of sajcd showcases some original research around the development of locally relevant resources. the two audiology papers (rogers et al., this issue; uys et al., this issue) add to a small but growing body of research in the field of south african audiology. panday, kathard, pillay and govender (2007, 2009) as part of an ongoing larger project have described the development of isizulu speech materials for use in speech audiometry, and khoza, ramma, mophosho, and moroka (2008) have examined alternative ways of carrying out speech audiometry with bilingual tswana/english speakers. while much of the research in audiology focuses on development of assessment materials, there is also work that has focused on development and evaluation of interventions (e.g. pienaar, stearn & swanepoel, 2010) and culturally relevant local knowledge regarding hearing impairment (de andrade & ross, 2005). in this issue, the paper by strasheim and colleagues focuses on the development of an early intervention tool applicable to the local context. both slts and as participated in the first phase of the study, which aimed to identify specific needs regarding clinical resources for use in neonatal nurseries. participants noted that culturally appropriate instruments were needed specifically for parent guidance and staff/team training. in response, the next phase of the study focused on development of a neonatal communication intervention programme for parents, the aim of which was to inform parents about prematurity and ways of developing early communication development. handouts were written in english and isizulu. the final phase of the study saw the piloting of the programme with two therapists. in education, wium, louw and eloff (2010) developed a continuing professional development (cpd) programme for educators to support them in their teaching of literacy and numeracy. other studies that have focused on development of slt assessments include fouche and van der merwe (1999), who described the development of a sepedi speech intelligibility test, and buitendag, uys and louw (1998), who evaluated the suitability of the afrikaanse reseptiewe woordeskattoets (afrikaans receptive vocabulary test). watt, penn and jones (1996) examined the ecological validity of a test battery for evaluating communicative effects of closed head injury. the study (this issue) by crewe-brown and co-authors details the communicative difficulties faced in their daily life by individuals with mild traumatic brain injuries (mtbis). using a case study approach, the authors show the value that ‘significant others’ can bring to understanding and supporting the individual with mtbi, an approach that could have far-ranging applicability in our context. in this section we have highlighted some of the work that has been done in our fields, rather than carrying out an exhaustive review. our survey focused on studies that have been published, but there is a wealth of unpublished work that has been carried out by undergraduate students for their final-year projects or by postgraduate students. the old adage ‘publish or perish’ may be particularly pertinent here, not only to individual academic careers but also to the professions as a whole: we have to share what we have done in order to advance our knowledge. numerous authors have urged us to carry out more research and publish our findings: swanepoel (2006) calls for more studies in the local context to determine the prevalence of hearing loss and accurately describe the status of services currently available for those with hearing impairments in south africa. without this information, swanepoel argues, legislative support and associated funding will not be forthcoming. penn (2007) decries the lack of quality, local research and urges all slts and as – and especially clinicians – to carry out research. while our agenda may be to develop local knowledge and resources, we should not be limited to publishing our work in local journals only, since many of the issues relevant to our context will have relevance for other developing settings, and there is worldwide interest in the unique languages and mix of cultures of our country. re-inventing the wheel or borrowing from our friends? indigenous knowledge can be effectively combined with external or scientific knowledge during the innovation process. hartley et al. (2009) reviewed the literature related to service development for individuals with communication difficulties in developing contexts. they suggest that western techniques and interventions cannot be rolled out to african countries without appropriate adaptation because of cultural and language differences; environments and climates and stages of social development. however, they also noted that ‘with cooperation, flexibility and humility, nations could work together to their mutual advantage using the underlying principles learnt in the west, together with local knowledge to develop appropriate training and services (p. 279)’. while it may be necessary to start from a blank page, free of assumptions, there is of course much valuable information and many lessons to be learnt from resources and knowledge developed elsewhere. publishing or presenting work at conferences is a valuable way to share resources and knowledge through a common forum which could advance the development of such assessments in a systematic manner and ensure that new slts and as or those setting up services would not have to ‘re-invent the wheel.’ joubert (2010) acknowledges the importance of developments around the world and suggests that it would be ‘both naïve and foolish not to prepare south african occupational therapists to be able to work anywhere in the world. it is however of foremost importance that they are competent in dealing with the particular health needs of south africa’s diverse population where the need for appropriate health care is greatest’ (p. 22). we believe the same is true for south african slts and as, whether working in education or health. priorities and next steps in south africa there is a great need to develop contextually relevant resources for our professions. clinicians in the study by pascoe et al. (2010) noted that an assessment tool in the most dominant languages in the western cape would be of value to them, and they suggested that this would increase their level of confidence when working with multilingual children. there is also a need for intervention resources and studies on the south african population in order to build an evidence base for the different approaches used. it may be that the natural order of this development is for assessment materials to be most needed and developed first, followed by the intervention tools and then the systematic evaluations thereof. but clinicians should be driven by their own needs. what is it that is needed to maximise our role? how can we add more value and relevance to the work we do with individuals with communication and swallowing difficulties? we should not only look to others to meet these needs, but should use our own knowledge, that of our colleagues and that of the clients we serve to move forward in this task. there is nothing wrong in starting small: modifying wordlists, devising new protocols and reflecting on our daily practice – all are valuable beginning points. we must collaborate with each other at a national level and share the gains we make. a national project under the leadership of associate professor shajila singh of the university of cape town focuses on the development of materials in the indigenous local languages and aims to encourage such collaborations and develop knowledge of the process. this is not a project for academics only, but also for all slts and as, as well as colleagues working in disciplines such as linguistics and psychology. in essence, our answer to the question posed in the title of this paper is: yes – there are contextually relevant resources for slts and as. however, as for mahlalela-thusi and heugh (2010), who examined the development of textbooks in the indigenous languages in southern africa, there is a great need for development of more resources, and further work to improve quality of the resources available for local populations. further, these resources need to be published and shared so that we can build on what has been done. this paper has aimed to move away from mere rhetoric and focus on the practicalities of our challenge. our hope is that all slts and as – especially clinicians who bemoan the lack of suitable resources – will be inspired to start innovating, collaborating and sharing. the papers that follow showcase some of the varied ways in which this can be done. acknowledgements. the authors gratefully acknowledge the support of lucretia petersen, and helpful comments from two anonymous peer reviewers. michelle pascoe vivienne norman department of health and rehabilitation sciences university of cape town *this title is adapted from the title of a paper by mahlalela-thusi and heugh (2010) entitled ‘terminology and school books in southern african languages: aren’t there any?’ references boivin, m.j. 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(1996). speech-language evaluation of closed head injured subjects in south africa: cultural applicability and ecological validity of a test battery. south african journal of communication disorders, 43, 85-92. wilson, w.j., & moodley, s. (2000). use of the cid w22 as a south african english speech discrimination test. south african journal of communication disorders, 47, 57-62. wium, a.m., louw, b., & eloff, i. (2010). speech-language therapists supporting foundation phase educators with literacy and numeracy in a rural and township context. south african journal of communication disorders, 57(1), 14-22. 8 5 speech-language evaluation of closed head injured subjects in south africa: cultural applicability and ecological validity of a test battery nola watt, claire penn and dilys jones department of speech pathology and audiology university of the witwatersrand johannesburg abstract this paper addresses the communicative outcome of a group of closed head injured (chi) subjects in south africa. communicative outcome is evaluated on one test battery currently used for medico-legal assessments in south africa. it was found that a number of the tests were sensitive to breakdown in this sample, but that the demographic factors of first language and pre-injury education significantly affected performance on some tests. many test performances were significantly related to return to work, thus confirming the importance of communicative skills in the workplace, and the speechlanguage pathologist's role in vocational assessment and rehabilitation. opsomming hierdie verslag spreek die gevolge van geslote hoofbeserings by 'n groep suid-afrikaanse proefpersone aan. 'n spesifieke toetsbattery wat tans in suid afrika vir regsmediese evaluasies gebruik word, het gedien as instrument om die proefpersone se kommunikasievermoens te ondersoek. sommige toetse was sensitiefvir kommunikasie uitvalle maar sekere demografiese faktore, b.v. moedertaal en opvoedkundige peil voor die hoofbesering, het die proefpersone se prestasie op sommige toetse be'invloed. baie van die toetse het 'n duidelike verband getoon met die proefpersone se vermoe om terug te keer werk toe. die belangrikheid van kommunikasie-vermoens binne die beroepskonteks en die spraak-taalterapeut se rol in beroepsevaluering in rehabilitasie word dus bevestig. key words: closed head injury; communicative outcome; ι introduction j speech-language pathologists in the medico-legal field are called upon daily to describe and quantify communicative deficits as a result of: closed head injury (chi). these clinicians, however, have little empirical or policyrelated guidance as to which tests are indeed sensitive to breakdown in the south africian population, and how performance may be affected by certain demographic and cultural factors, for example, educational level. this is important to know when one considers the vast discrepancies in such socio-economic indicators in south africa. further, the medico-legal professional is required to prognosticate, beyond a reasonable doubt, whether or not the patient will be able to return to work. again, this is currently taking place with little scientific insight regarding which communicative skills are most important in the workplace, and which tests are most useful to measure them. the above difficulties faced by the south african speechlanguage pathologist are highly significant in the light of the extremely high incidence of chi in south africa, cited as 316/100 000 (nell & brown, 1990), approximately 50% higher than abroad. in addition, dwindling insurance and return to work third party payouts demand that professionals ensure that they are using culturally appropriate and functionally valid tests in order to ensure the strongest possible case for their clients. this study was hence aimed at determining the sensitivity of a test battery already used by a practice involved in medico-legal assessments in south africa, the effects on performance of early demographic and injury variables, and which test performances were most closely related to return to work. in order to contextualise the results of this study, previous research documenting communication breakdown following head injury will be discussed, as well as the impact of early variables on test performance and research documenting the relationship between communicative skills and vocational success. 1. communicative breakdown following closed head injury there has been much debate in the literature regarding the nature and mechanisms underlying communication breakdown following chi. early studies in the 1970's and early 1980's assessed and classified the communicative breakdown using traditional aphasia tests. the incidie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 86 dence of classical aphasic syndromes found within the chi population ranges from 2% (heilman, safran & geschwind, 1971) to 30% (sarno, 1988). hartley and levin (1990) point out that the lower incidence of classical aphasias tends to be associated with samples of consecutive cases of head injury, which contain a wide range of severity levels, while higher incidences have been reported in samples of chi admissions to rehabilitation centres, which are likely to be mainly severe injuries. a number of specific linguistic deficits have also been found to occur relatively often in the absence of a classical aphasic syndrome, and have been termed "subclinical aphasia" (sarno, 1988). the most common deficit is anomia, measured usually on a confrontation naming task such as the boston naming test (heilman, safran & geschwind, 1971; levin, grossman & kelly, 1976). verbal fluency tasks have also been found to be sensitive measures of anomia (walsh, 1991). in addition, impaired auditory comprehension, particularly of complex commands as measured by the token test, has been found to occur relatively often (levin et al., 1976; sarno, 1988; kreutzer, gordon, rosenthal & marwitz, 1993). more recently, the focus of chi assessment has shifted to the investigation of more naturalistic forms of language use, these being discourse and pragmatics. it is not surprising that the use of such different tests has led to the identification of very different types of communication impairment. one of the earliest studies which investigated the discourse of chi individuals found it to be characterised by impoverished productivity in terms of the number of words produced, the rate of speech, and the percentage of syllables in mazes (wyckoff, jensen & lapointe, 1984). the amount of content was also consistently reduced in comparison to controls, and the subjects used fewer cohesive ties per communication unit. the researchers summarise these findings by describing chi discourse as limited in "quantity, efficiency and connectivity" (wyckoff, jensen & la pointe, 1984). other studies investigating discourse have confirmed deficits in the following areas: discourse cohesion (mentis & prutting, 1987; liles, coelho, duffy & zalagens, 1989);" discourse superstructure and story grammar elements (chapman, culhane, levin et al., 1992; liles et al., 1989); coherence (chapman et al., 1992; glosser & deser, 1990); and productivity (hartley & jensen, 1991; mentis & prutting, 1987; liles et al., 1989). within the realm of pragmatics, deficits have been found to occur in all three of the nonverbal, interactional and propositional aspects of communication (hartley, 1990). nonverbal deficits in the paralinguistic features of speech fluency, rate of speech and voice quality (marsh & knight, 1991), fluency (hartley & jensen, 1991) and prosody (milton, prutting & binder, 1984) have been found. the interactional aspects of communication have also been found to be significantly affected after chi. in particular, inappropriate turn-taking behaviours have been noted (milton, prutting & binder, 1984; coelho, liles & duffy, 1991), as well as deficits in "partner-directed behaviour" (marsh & knight, 1991). mcdonald (1993) demonstrated significant difficulties in the chi individual's ability to meet the informational needs of their listeners. similarly, irvine (1984) demonstrated disrupted interpersonal skills on scale a (response to interlocutor) on penn's (1985) profile of communicative appropriateness. finally, researchers have demonstrated difficulties in the propositional the sou nola watt, claire penn and dilys jones aspects of communicative interaction following chi. these include difficulties in topic selection, maintenance, relevance and quantity of verbal output (milton et al., 1984; ehrlich, 1988; penn & cleary, 1988). at this point, it seems to be important to gather information about how a south african sample of chi individuals perform on a battery of tests in order to confirm patterns of breakdown, as well as which tests appear to be most sensitive in measuring this breakdown. 2. impact of early variables on outcome/ test performance given the fact that about 88% of the south african population is not first language english speaking, and that about 25% are illiterate (central statistical services, 1994), understanding the impact of demographic factors on test performance is of paramount importance in south africa. in most outcome studies, researchers have attempted to identify factors in the head-injured patient's past and related to the injury itself that can account for the outcomes they describe. few studies, however, have investigated the impact of these effects on communicative outcome. it is only very recently that a systematic discussion of the possible effects of such factors on test performance has been made and preliminary investigations carried out (coelho, 1995). the need for this empirical information in south africa is great, particularly in the light of our multicultural and multilingual society, with such a large disparity in socio-economic status among its inhabitants. it is almost impossible to comment on test performance without it. 3. impact of communicative deficits on return to work (rtw) return to work following head injury abroad, and particularly in south africa is a major concern as insurance and other resource allocations for chi individuals diminish. however, few outcome studies have included the assessment of the impact of communication difficulties on the chi patient's ability to return to work. in the studies which have assessed this relationship, researchers have used widely differing measures of communicative functioning, from standardised aphasia tests to questionnaire items, thus making comparison and generalisation difficult. also, researchers have tested their subjects at different times-post-onset.those testing in the acute stage have measured the prognostic value of early language breakdown on later vocational performance (i.e., communicative functioning as a predictor of future performance), while those who have tested breakdown in the chronic stage measure the relationship between communicative and vocational performance at the same time (i.e., communicative functioning as an indicator of outcome). this is useful in that it allows researchers to make hypotheses as to which deficits are affecting performance at the time of testing. testing in the acute stage of recovery, dresser, meirowsky, weiss et al.(1973) found that the early presence of aphasia was a significant predictor of future unemployment. similarly, najenson, groswa'sser, mendelsohn and hackett (1980) found the early presence of aphasia to have an important influence on rehabilitation outcome, and a significant effect on vocational functioning on follow-up. / african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) speech-language evaluation of closed head injured subjects in south africa: cultural applicability and ecological validity of a test battery 87 considering communication breakdown as a late indicator of outcome, brooks, mckinlay, symington et al. (1987) found that ratings of communicative impairment by relatives or significant others were significantly related to failure to return to work. two particular communication deficits, the ability to carry on a conversation and to understand a conversation, were highly significant. in a metaanalysis of the predictors and indicators of work status, crepeau and scherzer (1993) were able to compare five studies which investigated the relationship between communicative abilities and return to work, and found their results to be relatively homogeneous with communicative abilities having a moderate correlation with return to work. however, they stress that due to the differing measures used in the various studies, it was difficult to come to a closer understanding of exactly what fosters a strong relationship between communication and return to work. it appears that no detailed study correlating performance on a battery of communication tests and vocational status has been carried out to date. also, it is only recently that speech-language pathologists have begun working in close collaboration with the vocational rehabilitation team in attempting to evaluate systematically the communicative requirements of the workplace (fraser & baarslag-benson, 1994). the aim of this study, therefore, was to evaluate a particular communication test battery, developed and currently used by a speech therapy practice in south africa, in terms of the following three aspects: 1. sensitivity to breakdown in the chronic stage of recovery; 2. effects of early demographic and injury variables on test performance; and, 3. the relationship between test performance and occupational status. methodology a group of fifty chi subjects who had been evaluated for medico-legal purposes, was selected based on the following criteria: | 1. the subjects had to speak! english as a first langauge, or at least with enough proficiency not to require an interpreter during testing. this limited the cultural diversity of the sample, but aimed to ensure greater test validity; i 2. the subjects had to be of working age at the time of testing; j 3. sufficient information had to be available regarding all the communicative functioning, demographic and injury-related variables, and occupational functions for data analysis. the medico-legal reports of the subjects who fulfilled these criteria were reviewed in detail, and the relevant data was captured on a data recording form, and transferred into a computerised database devised by the first author (watt, 1996). the aim of this form was to provide a standard method of analysing the reports and recording the data. it includes 197 variables, including demographic information of age at onset, time since onset, gender, preand postinjury educational levels, preand postinjury occupational types and status; injury-related information of severity, cause of injury and surgical procedures; and early postinjury variables, e.g., therapy received. the form was designed to be similar to that designed for the model systems database for traumatic brain injury that has been established in the united states of america (dahmer, schilling, hamilton et al., 1993) in order to make it comparable to international databases and yet feasible in a country with fewer resources for detailed assessment and data gathering. table 1 summarises the demographic, injury and early post-injury factors investigated in this study. the communication parameters included on the form are comprehensive in scope and reflect the assessment battery (detailed in table 2) of the speech-language pathologists who conducted the medico-legal assessments. this battery was devised on the basis of substantial experience with a wide range of medico-legal assessments (>200), and taps a range of cognitive and linguistic domains, including hearing, motor speech abilities, receptive language, expressive language, reading, writing, verbal reasoning, and pragmatics. the battery utilises a mixtable 1: characteristics of the sample characteristic percentage age at onset mean: 29y lomo sd: 12y lomo time since onset mean: 3y 5mo sd: l y 5mo gender male 74 female 26 first language english 62 afrikaans 16 zulu/xhosa 8 sotho 6 other european 8 pre-injury matriculation 50 education certificate or less . post secondary 50 school training or qualifications pre-injury manual worker 12. occupational clerical/technical 22 type professional/executive 40 type student 26 pre-injury competitively employed 74 occupational full time status full-time student 26 injury severity mild 18 moderate 12 severe 70 therapy received speech-language 24 post-injury occupational 20 physio52 cognitive 6 counselling 2 vocational 2 social services 2 die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 88 nola watt, claire penn and dilys jones ture of standardised as well as modified, adapted, and novel or clinician-constructed items that have been developed over time in an attempt to meet the unique needs of the south african head injured population. this appears to have been essential in the face of a shortage of relevant materials, and too great a dependence on inappropriate overseas tools. the form does not record exact test scores, as these are table 2: outcome on the communicative test battery task missing adequate not adequate mild moderate severe hearing 39 11 2 3 6 motor speech dysarthria ope dysphagia voice fluency 34 28 40 34 28 16 22 10 16 22 6 14 5 6 9 4 7 4 6 13 6 1 1 4 reception token test celf(ambiguities) . celf(relationships) tolc (ambiguities) normal conversation rhcb (alternate word meaning) rhcb (verbal humour) 5 9 12 26 2 28 43 18 19 15 14 42 12 2 27 22 23 10 6 10 5 11 12 12 3 6 8 2 10 8 7 6 2 2 6 2 4 1 1 expression word-finding1 verbal fluency narrative discourse procedural discourse syntax1 paraphasias1 perseverations1 serial speech 2 3 3 2 1 1 1 1 14 12 25 40 44 42 45 48 34 35 22 8 5 7 4 1 13 17 9 5 5 5 1 13 12 10 2 2 3 8 6 3 1 1 reading2 comprehension drawing inferences memory 2 11 16 31 12 17 17 27 17 7 10 7 9 13 7 1 4 3 writing3 letter formation spelling 2 4 20 28 28 18 26 11 1 4 1 ! 3 ! verbal4 reasoning speed arithmetic 4 3 27 22 19 25 18 13 1 10 1 2 ! pragmatics5 topic control relevance turn-taking quantity eye contact gesture posture 1 2 1 1 1 28 31 37 29 38 42 45 22 18 13 19 11 7 4 6 8 5 5 3 12 9 7 13 11 4 4 4 1 1 1 key: 1: assessed in spontaneous speech 2: assessed using the tolc inferences subtest and/or an informal fable task 3: assessed in spontaneous writing task 4: assessed in clinician-constructed verbal arithmetic task 5: assessed in spontaneous speech the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) speech-language evaluation of closed head injured subjects in south africa: cultural applicability and ecological validity of a test battery 89 often not reported in medico-legal reports, which usually describe the performance qualitatively and interpret the test scores. hence the researchers classified performance on a five point scale according to whether it was above average (1), average (2), intact but slow or showing mild difficulties (3), moderate difficulties (4), and marked or severe difficulties (5), on the basis of the medico-legal report. this appeared to be the most appropriate way of capturing the data. a measure of inter-rater reliability was calculated to ensure that the data-capturer was able to extract this information reliably. an independent speech pathologist completed the "communication" section of the database form for one fifth of the sample, and inter-rater reliability was calculated using cohens's kappa, a stringent measure of agreement that corrects for chance agreement (howell, 1992). the following mean kappa values were obtained: per subject 0.62; per construct: motor speech 0.86, receptive language 0.62, expressive language 0.81, reading 0.87, writing 1, verbal reasoning 0.6, pragmatics 0.73. these values indicate "substantial" to "almost perfect" levels of agreement (landis & koch, 1977) and suggest that the data was recorded sufficiently reliably from the medico-legal reports. the data was analysed according to the three aims. frequency counts were used to organise the group data, while relationships between variables were calculated using cross-tabulations and chi squared analysis. when sample sizes were small, fisher's exact probability test was used (siegel, 1956). the five point rating scale describing communicative performance was collapsed into two categories, namely adequate (ratings of 1 and 2) and inadequate (ratings of 3, 4 and 5) in order to be compatible with 2 x 2 contingency tables. this system is similar to the cut-off systems employed by kreutzer, gordon, rosenthal and marwitz (1993). » results and discussion / 1. sensitivity of the test battery table 2 describes the communicative performance of the subjects on the communication test battery. the column labelled "missing" indicates the number of subjects for whom data on a particular test was missing. this figure reveals how the test batteries used changed according to the needs of the patient. hearing the occurrence of a hearing loss as a result of the head injury in 22 % of this sample is substantially higher than that reported by giles and clark-wilson (1993) of 6 to 8 % of all hospital trauma admissions. it is significant that despite this high incidence, few, if any, had been referred to an audiologist before the time of the medico-legal assessment, which took place a mean of three years postinjury. reception it would appear from table 2 that the receptive battery used is indeed sensitive to breakdown in comprehension in this sample as over half of the subjects manifested difficulties on the revised token test, the subtest used from the clinical evaluation of language function (celfxprocessing relationships and ambiguities) and the right hemisphere communication battery (rhcb) verbal humour subtest. just under half manifested difficulties on the test of language comprehension (tolc) inferences subtest and the alternate word meanings subtest of the rhcb. the most discriminative test on which the most subjects performed poorly was the revised token test, which is considered to be fairly specific and highly diagnostic of comprehension difficulties (howieson & lezak, 1992). this finding confirms previous reports of the prevalence of a specific linguistic deficit in auditory comprehension in the absence of traditional aphasia following closed head injury. it is interesting to note that few of the subjects appeared impaired in spontaneous conversation. this illustrates the ease with which comprehension difficulties may be masked in conversational exchanges, very often the only medium on which other professionals base their referral to a speech-language therapist. expression the profile of communicative performance on the expressive tests clearly indicates which tests are sensitive to breakdown in this south african chi sample. nearly 70 % exhibited word finding difficulties in connected speech, which confirms previous repots (thomsen, 1975; levin, grossman & kelly, 1976; sarno, 1984), although these authors relied more on confrontational naming tasks for diagnosis. poor verbal fluency measures also confirm the previously cited sensitivity of this procedure (walsh, 1991). the narrative discourse task was the third measure which appeared to be very sensitive to breakdown. although discourse analysis was not detailed, this finding confirms others' results (kaplan, 1987; liles et al., 1989; hartley & jensen, 1991). reading the assessment of reading appeared to be well justified by the poor performance of the individuals, particularly for deeper level comprehension such as drawing inferences from the text. this is what is referred to as intratextual processing (ulatowska, chapman & johnson, 1992) such as making inferences on the tolc or recognising the moral of a fable. as with auditory comprehension, these results highlight the importance of assessing deeper comprehension abilities which would otherwise be missed in basic comprehension tasks. verbal reasoning regarding verbal reasoning abilities, the results indicate that tests of arithmetic ability, particularly those which are verbally mediated and require understanding of verbal concepts, are highly sensitive to breakdown following head injury. there was a dissociation between speed of processing and arithmetic ability on these tasks. this was characterised by very quick and impulsive calculations with incorrect answers by some and extremely slow working with ultimately correct answers by others. this has implications both for therapy and for vocational placement. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 90 nola watt, claire penn and dilys jones pragmatics the pragmatic categories included in the data recording form did not appear to be very sensitive to breakdown in this sample. this may have reflected insufficiently detailed pragmatic analysis. although there were subjects who manifested difficulties on all of the parameters described, none of these were very great, the most sensitive measure being that of topic control (44% had difficulties), quantity of verbal output (38%) and relevance (36%). the presence of these difficulties does confirm previous reports of pragmatic breakdown following head injury (milton, prutting & binder, 1984; penn & cleary, 1988). interesting significant relationships between the non-verbal behaviour of eye contact and the pragmatic behaviours of topic control and relevance were found. a possible explanation for this may be that eye contact is essential for gaining important cues from the listener which help to regulate and monitor turns and relevance. in summary, it appears that the communication test battery used for this sample was sensitive enough to detect breakdown in performance in nearly all communicative spheres. most of the difficulties experienced by this group confirm previous studies and indicate that such difficulties are persistent, even up to a mean of three years post-injury. these findings have great implications for the role of the speech-language pathologist in the rehabilitation of this clinical population. 2. early predictors of communicative performance the impact of early demographic and injury related variables on communicative test performance was assessed. table 3 highlights the relationships that were found to be significant at alpha=0.05. the subjects' first language was found to be the most significant factor affecting communicative performance. this indicates that first language european language speakers (i.e., english, afrikaans and other european languages e.g., german) performed significantly better than subjects whose first langauge was an african language. this does not necessarily mean that these tests have no place in a south african test battery, as a number of these tests were also significantly related to occupational outcome (see below). however, it does mean that therapists must be aware of this factor, as well as which tests are not affected by first language (e.g., pragmatic functioning) and therefore to include these for valid testing. it is striking how small an impact injury severity had table 3: significant predictors of communicative outcome (df=l except for severity where df=2) test gender first language education severity hearing 0.034 * dysarthria 4.24x10s ** ope problems 0.016 * token test 0.031 * understanding normal conversation 0.033 * ; narrative discourse 0.040 i " · i procedural discourse 0.050 * ι 1 reading: comprehension 5.47xl0"3 ** 0.015 * reading: drawing inferences x2=4.41 * . • reading: memory 0.044 writing: letter formation x2=4.11 verbal reasoning: arithmetic x2=5.09 * significant at 0.05 ** significant at 0.01 the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) speech-language evaluation of closed head injured subjects in south africa: 9 1 cultural applicability and ecological validity of a test battery particularly interpersonal aspects of communication, on general communicative functioning in the chronic stage of recovery. severity of injury was significantly related only to motor speech abilities as manifested in dysarthria and ope difficulties. it appears that, as far as the speechlanguage pathologist is concerned, injury severity may have less of a role to play, particularly in expressive and receptive language, than other cultural factors such as first language and pre-injury education. 3. relationship between communicative performance and rtw performance on each of the communicative tests was correlated with the occupational status of the subjects, i.e., employed or unemployed. table 4 highlights the significant relationships found between test performance and return to work. these results show that adequate performance on at least one test in nearly every communicative domain was significantly related to the ability to return to work. this is encouraging regarding the communicative domains tapped in the assessment as well as the tests used for this purpose. the importance and value of the revised token itest appears to be underscored by the very strong relationship between performance on this test and return to work. since, as mentioned previously, the token test has been described as relatively specific to, and therefore strongly diagnostic of langauge comprehension difficulties (howieson & lezak, 1992), this finding can confidently be interpreted as confirming the essential role of high level language comprehension abilities within the functional context of the workplace. the strong relationship between the reading measures and return to work is possibly related to the nature of the sample, the majority of the subjects having been employed in clerical or professional capacities in which reading is essential. these results reveal the high premium placed on literacy in the vocational context. surprisingly, none of the pragmatic parameters were significantly associated with whether or not the subject was able to return to work. this is a counter-intuitive result, as many authors suspect that poor pragmatic skills, table 4: communicative tests significantly related to rtw (df=l) : construct 1 test ; x 2 value motor speech ope 6.148 * reception token test 13.500 *** expression narrative discourse 4.627 * reading comprehension 9.52 *** \ inferences ' \ 5.110 * memory 7.77\ ** verbal reasoning speed 5.101 * * significant at 0.05 ** significant at 0.01 *** significant at 0.005 would have severe vocational consequences after head injury (hartley, 1995; sarno, 1988). it was, however, found that poor turn-taking abilities and abnormal quantity of verbal output were significantly associated with the downgrading of those who had returned to work (x2 values of 5.109 and 7.670; alpha=0.05). in other words, a significant number of the working subjects who presented with these symptoms had been downgraded at work, either in terms of the time commitments of the job (e.g., part time v. full-time) or the employment conditions (e.g., competitive v. sympathetic employment). these findings add more empirical weight to the importance of communicative skills in the workplace, and thus address an important gap in the literature. they also provide convincing support for the functional appropriateness of the tests in this communicative test battery, particularly for the medico-legal assessment, as well as the role of the speech-language pathologist in the vocational rehabilitation team for chi individuals. summary and conclusions these results have important clinical implications for the south african speech pathologist involved in the assessment of chi individuals. they indicate that communicative breakdown is pervasive and persistent following closed head injury, affecting particularly high level linguistic abilities, and that there are a number of tests available, both standardised and non-standardised, which are sensitive to this breakdown. clinicians must, however, be aware of how the south african cultural and socio-economic milieu affects performance on some of these tests, and interpret their results accordingly. they should also be sure to include tests in their battery appear to be less affected by such variables (e.g., verbal reasoning tasks and pragmatic skills evaluation). in addition, these results highlight the integral importance of communication skills in the workplace, and how poor performance on a number of tests is significantly related to a failure to return to work. there is a need for the development of policy guidelines by the profession as a whole to guide the continued development and fine-tuning of a sensitive, valid and reliable test battery for the assessment of communicative breakdown following chi. it is evident that at the present time south african clinicians are using vastly different assessment tools with little empirical basis for their test selection. results such as these may have relevance in the setting up of such guidelines. such a policy may also then have implications for the clinician's dealings with insurance companies, providing therapists with greater empirical and political support for their evaluation procedures, results and prognoses. a number of implications for future research also emerge from these finding. firstly, the study should be expanded and replicated with a larger number of subjects, particularly of the smaller groups represented here, such as the first language african language speakers. in doing so, the methodology of this study has implications for the possible compilation of a national database for head injury in south africa such as that set up abroad (dahmer et al., 1993). a necessary precursor to such a database would be consensus regarding a common minimal test battery for all participating speech therapists and, again, die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 92 nola watt, claire p e n n a n d dilys jones the issue of policy guidelines governing such decisions is applicable here. the empirical confirmation of the importance of communicative skills in the workplace also has implications for further research. while these results confirm the importance of specific communicative skills, such as comprehension, expression and reading, in successful vocational o u t c o m e , further r e s e a r c h is n e c e s s a r y to determine whether the pattern of demands differs across different occupations. atool for measuring the communicative demands of a specific workplace is currently being developed at the university of the witwatersrand, which will be used by clinicians to conduct on-site j o b skill assessments. in conclusion, this study has highlighted the areas of persistent w e a k n e s s in communicative functioning of a group of chi subjects in south africa. tests sensitive to this breakdown have been identified, as well as which test performances are affected by demographic factors such as pre-injury educational level and first langauge. in addition, test performances most closely related to successful reintegration in the workplace have been identified. these results support the role of the speech-language pathologist in the long-term rehabilitation of c h i individuals particularly in the occupational sphere. r e f e r e n c e s brooks, n., mckinlay, w., symington, c., beattie, a. & campsie, l. (1987). return to work within the first seven years of severe head injury. brain injury, 1, 5-19. central statistical services (1994). october household survey statistical release. p0317. chapman, s.b., culhane, k.a., levin, h.s., harward, h., mendelsohn, d., ewing-cobbs, l., fletcher, j.m. & bruce, d. (1992). narrative discourse after closed head injury in children and adolescents. brain and language, 43, 42-65. coelho, c.a. (1995). discourse production deficits following traumatic brain injury: a critical review of the recent literature. aphasiology, 5, 409-429. coelho, c.a., liles b.z. & duffy, r.j. (1991). analysis of conversational discourse in head injured adults. journal of head trauma rehabilitation, 6, 92-99. crepeau, f. & scherzer, p. (1993). predictors and indicators of work status after traumatic brain injury: a meta-analysis. neuropsychological rehabilitation, 3, 5-35. dahmer, e.r., schilling, m.a., hamilton, b.b., bontke, c.f., englander, j., kreutzer, j.s., ragnarsson, k.t. & rosenthal, m. (1993). a model systems database for traumatic brain injury. journal of head trauma rehabilitation, 8, 12-25. dresser, α., meirowsky,, α., weiss, g., mcneel, m., simon, g. & caveness, w. (1973). gainful employment following head injury. archives of neurology, 29, 111-116. ehrlich, j .s. (1988). selective characteristics of narrative discourse in head-injured and normal adults. journal of communication disorders, 21, 1-9. fraser, r.t. & baarslag-benson, r. (1994). cross-disciplinary collaboration in the removal of work barriers after traumatic brain injury. topics in language disorders, 15, 55-67. giles, g.m. & clark-wilson, j. (1993). brain injury rehabilitation. a neurofunctional approach. london: chapman and hall. glosser, g. & deser, t. (1990). patterns of discourse production among neurological patients with fluent language disorders. brain and language, 40, 67-88. hartley, l. (1995). cognitive-communicative abilities following brain injury. a functional approach. california: singular • publishing group. hartley, l.l. (1990). assessment of functional communication. in d.e. tupper and k. d. cicerone (eds). the neuropsychology of everyday life: assessment and basic competencies, (chap. 6). boston: kluwer academic publishers. hartley, l. & jensen, p. (1991). narrative and procedural discourse after closed head injury. brain injury, 5, 267-285. hartley, l. & levin, h. (1990). linguistic deficits after closed head injury: a current appraisal. aphasiology, 4, 353-370. heilman, k.m., safran, a. & geschwind, n. (1971). closed head trauma and aphasia. journal of neurology, neurosurgery and psychiatry, 34, 265-269. howe, j.r. & miller, c.a (1975). midbrain deafness following head injury. neurology, 91, 50-60. howell, d.c. (1992). statistical methods for psychology. belmont california: duxbury press. ' howieson, d.b. & lezak, m.d. (1992). the neuropsychological evaluation. in s. c. yudofsky and r. e. hales (eds). the american psychiatric press textbook of neuropsychiatry. (2nd ed.) (chap. 5). washington: american psychiatric press, inc. irvine, l. (1984). the communicative and cognitive deficits following closed head injury. unpublished undergraduate research report. university of the witwatersrand, johannesburg. kaplan, d. (1987). discourse production in closed head injury. unpublished master's dissertation. university of the witwatersrand, johannesburg. kreutzer j.s., gordon, w.a., rosenthal, m. & marwitz, j. (1993). neuropsychological characteristics of patients with brain injury: preliminary findings from a multicentre investigation. journal of head trauma rehabilitation, 8, 47-59. landis, j.r. & koch, g.g. (1977). the measurement of observer agreement for categorical data. biometrics, 33, 159-174. levin, h.s., grossman, r.g. & kelly, pj. (1976). aphasic disorder in patients with closed head injury. journal of neurology, neurosurgery and psychiatry, 50, 183-193. liles, b., coelho, c., duffy, r. & zalagens, m. (1989). effects of elicitation procedures on the narratives of normal and closed head-injured adults. journal of speech and hearing disorders 54, 356-366. marsh, n.v. & knight, r.g. (1991). behavioral assessment of social competence following severe head injury. journal of clinical and experimental neuropsychology, 13, 729-740. mcdonald, s. (1993). pragmatic language skills after closed head injury: ability to meet the informational needs of the listener. brain and language, 44, 28-46. mentis, m. & prutting, c.a. (1987). cohesion in the discourse of normal and head-injured adults. journal of speech and hearing research, 30, 88-98. milton, s., prutting, c. & binder, g. (1984). appraisal of communicative competence in head injured adults. in r. brookshire (ed.). clinical aphasiology conference proceedings (pll4-123). minneapolis: brk publishers. najenson, t., groswasser, z., mendelsohn, l. & hackett, p. (1980). rehabilitation outcome of brain-damaged patients after severe head injury. international rehabilitation medicine, 2, 17-22 nell, v. & brown, d.s.o. (1990), epidemiology of traumatic brain injury in johannesburg: morbidity, mortality and etiology. health psychology unit technical report no. 1: unisa and hsrc. penn, c. (1985). the profile of communicative appropriateness: a clinical tool for the assessment of pragmatics. south african journal of communication disorders, 32, 18-32. penn, c. & cleary, j. (1988). compensatory strategies in the language of closed head injured patients. brain injury, 2,3-17. sarno, m.t. (1984). verbal impairment after closed head injury. report of a replication study. the journal of nervous\and mental disease, 172, 475-479. sarno, m.t. (1988). head injury: language and speech deficits. scandinavian journal of rehabilitation medicine. suddi 17 5 5 6 4 . ' ' siegel, s. (1956). nonparametric statistics for the behavioral sciences. new york: mcgraw-hill book company, inc. thomsen, i.v. (1975). evaluation and outcome of aphasia in patients with severe closed head trauma. journal of neurology, neurosurgery and psychiatry, 38, 237-254. ulatowska, η. k., chapman, s.b. & johnson, j. (1992). depth of information processing for discourse in aphasic and elderly patients. unpublished research. walsh, k.w. (1991). understanding brain damage. a primer of neuropsychological evaluation. (2nd ed.) melbourne: churchill livingstone. watt, n.j. (1996) predictors and indicators of outcome following closed head injury in south africa. unpublished master's dissertation. university of the witwatersrand, johannesburg. wyckoff, i.h., jensen, p.j., & lapointe, l. (1984). narrative and procedural discourse following closed head injury. itechnical paper presented at asha convention: san francisco, california. the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) information for contributors the south african journal of communication disorders publishes reports and papers concerned with research, and critically evaluative theoretical and philosophical conceptual issues dealing with aspects of human communication and its disorders, service provision, training and policy. the south african journal of communication disorders will not accept material which has been published elsewhere or that is currently under review by other publications manuscript style and requirements manuscripts should be accompanied by a covering letter providing the author's address and telephone numbers. all contributions are required to follow strictly, the style specified in the publication manual of the american psychological assoc. (3rd ed., 1983) (apapub. man.), with complete internal consistency. four copies of triple-spaced high quality type-written manuscripts with numbered pages, and wide margins should be submitted. they should be accompanied by one identical disc copy of the paper. filenames should include the first author's initials and a clearly identifiable keyword or abbreviation thereof and should be typewritten on the last line of the last page of the reference list (for retrieval purposes only). as a rule, contributions should not exceed much more than 30 pages, although longer papers will be accepted if the additional length is warranted. the first page of two copies should contain the title of article, name of author(s), and institutional affiliation (or address). in accordance with the apapub. man. style (1983, p.23) authors are not required to provide qualifications. in the remaining two copies, the first page should contain only the title. the second page of all copies, should contain only an abstract (100 words), written in english and afrikaans. afrikaans abstracts will be provided for overseas contributors. major headings where applicable should be in the order of method, results, discussion, conclusion, acknowledgements, references. all paragraphs should be indented. tables and figures which should be prepared on separate sheets (one per page), should be copied for review purposes and only the copies sent initially. figures, graphs, and line drawings that are used for publication, however, must be originals, in black ink on good quality white paper, but these will not be required until after the author has been notified of the acceptance of the article. lettering appearing oh these should be uniform and professionally done, allowing for|a 50% reduction in printing. on no account should lettering be typewritten on the illustration. any explanation or legend should appear below it and should not be included in the illustration. the titles of tables, which appear above, the figures, which appear below, should be concise but explanatory. both should be numbered in arabic numerals in order of appearance. the number of illustrative materials allowed, will be at the discretion of the editor (usually about 6). references references should be cited in the text by surname of the author and the date, e.g., van riper (1971). where there are more than two authors, after the first occurrence, et al. after the first author will suffice, except for six or more when et al. may be used from the start. the names of all authors should appear in the reference list, which should be listed in strict alphabetical order in triple spacing at the end of the article. all references should be included in the list, including secondary sources, (αρα pub. man. 1983, p. 13). only acceptable abbreviations of journals may be used, (see dsh abstracts, october; or the world list of scientific periodicals). the number of references should not exceed much more than 30, unless specifically warranted. examples locke, j.l. (1983). clinical psychology: the explanation and treatment of speech sound disorders. j. speech hear. disord., 48 339-341. penrod, j.p. (1985). speech discrimination testing. in j. katz (ed.), handbook of clinical audiology (3rd ed.). baltimore: williams & wilkins. davis, g.a. & wilcox, m.j. (1985). adult aphasia rehabilitation: applied pragmatics. san diego, ca: college-hill. editing acceptable manuscripts may be returned to the author for revision. additional minor changes may also be made at this stage, but a note on the manuscript acknowledging each alteration made by the author, required. the paper is then returned to the editorial committee for final editing for style, clarity and consistency. reviewing system the peer review of refereeing system is employed as a method of quality control of this publication. peer reviewers are selected by the editor based on their expertise in the field and each article is sent to two independent reviewers to assess the quality of the manuscript's scientific and technical content. the blind peer review system is employed during which the name of the author/ authors are not disclosed to the reviewers. the editor retains the final responsibility for decisions regarding revision, acceptance or rejection of the manuscript. reprints: 10 reprints without covers will be provided free of charge. deadline for contributions: the preferred date is the 31st may each year, but papers will be accepted until 30th june by arrangement. queries, correspondence & manuscripts: should be addressed to the editor, south african journal of communication disorders, south african speech-language-hearing association, p.o. box 600, wits, 2050, south africa. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) inligting vir bydraes die suid-afrikaanse tydskrif vir kommunikasieafwykings publiseer verslae en artikels wat gemoeid is met navorsing, of handel oor krities evaluerende, teoretiese en filosofiese konseptuele kwessies wat oor menslike kommunikasie en kommunikasieafwykings, diensverskaffing, opleiding en beleid gaan. die suid-afrikaanse tydskrif vir kommunikasieafwykings sal nie artikels aanvaar wat reeds elders gepubliseer is, of wat tans deur ander publikasies oorweeg word nie. manuskrip styl en vereistes: manuskripte behoort deur 'n dekkingsbrief vergesel te word wat die skrywer se adres en telefoonnommers bevat. daar word van alle bydraers verwag om die styl, soos gespesifiseer is in die "publication manual of the american psychological assoc. (3rd ed., 1983) (apapub. man."), nougeset te volg met volledige interne ooreenstemming. manuskripte moet getik, van hoe gehalte en in drievoud spasiering met wye kantlyne wees. vier kopiee van die manuskrip moet verskaf word. een hiervan moet 'n identiese skyfkopie van die artikel wees. leername behoort die eerste skrywer se voorletters en 'n duidelike identifiseerbare sleutelwoord of afkorting daarvan in te sluit en moet op die laaste lyn van die bladsy van die verwysingslys getik word (slegs vir naslaan doeleindes). as 'n reel moet bydraes nie 30 bladsye oorskry nie, maar langer artikels sal aanvaar word indien die addisionele lengte dit regverdig. op die eerste bladsy van twee van die afskrifte moet die titel van die artikel, naam van die skrywer(s), en instansie (of adres) verskyn. in ooreenstemming met die "apapubl. man." se styl word daar n i e van skrywers verwag om enige kwalifikasies te verskaf nie. op die eerste bladsy van die twee oorblywende afskrifte moet slegs die titel van die artikel verskaf word. die tweede bladsy van alle afskrifte moet slegs 'n opsomming (100 woorde) in beide engels en afrikaans bevat. afrikaanse opsommings sal vir buitelandse bydraers voorsien word. hoofopskrifte moet, waar van toepassing, in die volgende volgorde verskaf word: metode, resultate, besprekings, gevolgtrekkings, erkennings en verwysings. alle paragrawe moet ingekeep word. tabelle en figure wat op afsonderlike bladsye (een bladsy per tabel/illustrasie) moet verskyn, moet vir referent-doeleindes gekopieer word en slegs die kopiee moet inisieel verskaf word. figure, grafieke en lyntekeninge wat vir publikasie gebruik word, moet egter oorspronklike weergawes wees en moet in swart ink op wit papier van 'n hoe gehalte wees. die oorspronklikes sal slegs verlang word nadat die artikel vir publikasies aanvaar is. letterwerk wat op bogenoemde verskyn, moet eenvormig wees, professioneel gedoen word en daar moet in gedagte gehou word dat dit leesbaar moet wees na 'n 50% verkleining in drukwerk. letterwerk by illustrasies moet onder geen omstandighede getik word nie. verklarings of legendes moet nie in die illustrasie nie, maar daaronder, verskyn. die opskrifte van tabelle (wat bo-aan verskyn), en die onderskrifte van figure, (wat onderaan verskyn), moet beknop, maar verklarend wees. numering moet deur middel van arabiese syfers geskied. tabelle en figure moet in die volgorde waarin hulle verskyn, genommer word. die aantal tabelle en illustrasies wat ingesluit word, word deur die redakteur bepaal (gewoonlik nie meer as 6 nie). verwysings verwysings in die teks moet voorsien word van die skrywer se van en die datum, b.v., van riper (1971). wanneer daar egter meer as twee skrywers is moet daar na die eerste verskaffing van al die outeurs, van et al. gebruik gemaak word. in die geval waar daar egter ses of meer outeurs ter sprake is moet et al. van die begin af gebruik word. al die name van die skiywers moet in die verwysingslys verskyn wat aan die einde van die artikel voorkom. verwysings moet alfabeties in trippel spasiering gerangskik word. al die verwysings moet in die verwysingslys verskyn, insluitende sekondere bronne, ("αρα pub. man." 1983, p. 13). slegs aanvaarbare afkortings van tydskrifte se titels mag gebruik word, (sien "dsh abstracts, october"; of the world list of scientific periodicals). die aantal verwysings moet nie meer as 30 oorskry nie, tensy dit geregverdig is. let op die volgende voorbeelde: locke, j.l. (1983). clinical psychology: the explanation and treatment of speech sound disorders. j. speech hear. disord., 48, 339-341. penrod, j.p. (1985). speech discrimination testing. in j. katz (ed.), handbook of clinical audiology (3rd ed.). baltimore: williams & wilkins. davis, ga. & wilcox, m.j. (1985). adult aphasia rehabilitation: applied pragmatics. san diego, ca.: collegehill. resensering resensering deur vakkundiges word toegepas as 'n metode van kwaliteitskontrole van hierdie publikasie. resenseerders word deur die redakteur geselekteer op grond van hulle spesialiskennis en elke artikel word na twee onafhanklike resenseerders gestuur om die kwaliteit van die manuskrip se wetenskaplike en tegniese inhout te beoordeel. die naam van die outeur/outeurs word nie aan die resenseerder bekend gemaak nie. die redakteur behou die verantwoordelikheid vir die finale beslissings aangaande wysigings, aanvaarding of afkeuring van die manuskrip. redigering 1 manuskripte wat aanvaar is, mag na die skrywer teruggestuur word vir hersiening. addisionele kleiner veranderinge mag ook op hierdie stadium aangebring word, maar 'n nota ter aanduiding van alle veranderinge wat op die manuskrip voorkom1, moet verskaf word. die artikel word dan aan die redaksionele kbmitee vir finale redigering van styl, duidelikheid en konsekwentheid teruggestuur. j herdrukke: 10 herdrukke sonder omslae sal gratis aan die outeurs verskaf word. sluitingsdatums vir bydraes: bydraes word verkieslik teen 31 mei elke jaar verwag, maar artikels sal nog tot 30 junie vir aanvaarding oorweeg word. navrae, korrespondensie en manuskripte: moet geadresseer word aan die redakteur, die suid-afrikaanse tydskrif vir kommunikasieafwykings, die suid-afrikaanse spraak-taal-gehoor vereniging, posbus 600, wits 2050, suidafrika. the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'ν oudiovisuele analise van woorddeelherhalings by hakkelaars maggi van wyk b.a. (log) (pretoria) skoolsielkundige dienste, posbus 1360, kempton park, 1620. opsomming 'n oudiovisuele analise van woorddeelherhalings wat in spraakopnames van 18 hakkelaars voorgekom het, is gemaak. hierdie gedragsvorm is 'n belangrike diagnostiese kriterium van hakkelspraak. buiten die voorkomsfrekwensie is veral ook die aard en plek van voorkoms van onderbrekings belangrike faktore in die diagnose van hakkel. kliniese waarnemings beklemtoon dat die woorddeelherhalings van hakkelaars van die van nie-hakkelaars onderskei kan word deur o.a. tempoverskille, onreelmatigheid, gebrek aan oorgangsformante, die gebruik van die schwa-vokaal en die voorkoms van benaderingsgedrag. ouditiewe parameters asook spektrogramme is gebruik om die hipotese te bevestig dat die tempo van woorddeelherhalings verskil van die tempo waarteen die vloteenhede van spraak geuiter word. ook is hierdie herhalings opmerklik onreelmatig en het die verlangde oorgangsformante nie by herhalingseenhede voorgekom nie. dit is egter nie die schwavokaal wat gebruik word nie en dit is onwaarskynlik dat die herhalings dien as benadering tot die verlangde oorgang. hierdie bevindings is van belang vir die differensiaaldiagnose tussen hakkelspraak en normale onvlotheid. summary an audio-visual analysis was conducted on the repetitions of parts of words which occurred in the recorded speech of 18 stutterers. this behaviour manifestation is an important diagnostic indication of stuttering. not only the frequency of interruptions, but also their nature and place of occurrence, are important factors in the diagnosis of stuttering. clinical observations stress that the stutterer's repetitions can be distinguished from those of nonstutterers with relation to differences in tempo, irregularity, lack of formant transitions, the use of the schwa vowel and the occurrence of approximation. auditory parameters as well as spectrograms were used to confirm the hypothesis that the tempo of repetition of parts of words differs from the tempo at which the fluent units of speech are uttered. these repetitions are also notably irregular and necessary formant transitions do not occur in the case of the units which were repeated. however, it was not the schwa vowel which was used, and it is uolikely that the repetitions served as an approximation of the desired transition. these findings are of importance for the differential diagnosis between stuttered speech and normal nonfluency. die bydraes ten opsigte van hakkel in die literatuur skep dje indruk van groot meningsverskille en duidelike uiteenlopendheid/hoewel daar reeds baie beskrywings van hakkel gegee is, bv. die baie omvattende beskrywing deur wingate,32 kom hierdie beskrywings oorwegend daarop neer dat hakkel beskou kan word as onderbrekings in die vlotheid van verbale uiting. die frekwensie van onderbrekings belemmer kommunikasie,5 maar dit blyk ook uit baie beskrywings dat veral die aard en plek van voorkoms van hierdie onderbrekings belangrike faktore in die diagnose van hakkel is. nie alle onderbrekings van spraakvloei kan as hakkel beskou word nie. the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) oudiovisuele analise van woorddeelherhalings 65 vlotspraak is hierargies-gefntegreerde gedrag: hierargies, omdat dit odgebou is uit verskillende elemente op die klank-, lettergreep-, woorden sinsvlakke28 en ge'fntegreerd, omdat hierdie elemente so ingeskakel is dat oorgangsvlotheid gemanifesteer word. hierdie oorgangsvlotheid word egter onderwerp aan aanvaarbare onderbrekings soos pouses, ritmiese patroonvorming, tempoveranderinge, intonasieen klempatrone en tussenwerpsels wat dui op onstabiliteit op die supramorfemiese vlakke. beskrywings gegee deur boehmler,7 webster en brutten,30 peters en giles21 en van riper28 dui daarop dat onstabiliteit wat op morfemiese vlakke manifesteer as hakkel gediagnoseer word. hoewel hakkel baie meer behels as die definisies gegee deur bg. persone, kan hierdie simptome as die kerngedrag van hakkel beskou word. webster en brutten30 skryf die meningsverskille toe aan die konglomeraat van gedragsvorme wat voorkom by hakkelaars en lewer dan ook 'n pleidooi aan ondersoekers om 'n noukeurige analise te maak van komponente gedragsvorme wanneer hakkel bestudeer word. die verklaring vir die verskynsel dat gevestigde hakkelaars nie dieselfde merkbare simptome vertoon nie,9 kan moontlik gesoek word in die primere en sekondere gedragsvorme waarin die hakkelmoment gedifferensieer kan word. hierdie stelling steun brutten en shoemaker8 se siening dat die hakkelaar se self-gedifferensieerde, "onwillekeurige" gedrag in die primere en sy "willekeurige" gedrag in die sekondere kategorie val. meeste waarnemers stem saam dat hakkelgedrag met tydsverloop verander. die gevestigde hakkelaar toon 'n groot verskeidenheid gespanne worstelings en morbiede emosionele reaksies wat min verband hou met sy vroeere hakkelgedrag. hakkelteoriee is dikwels in konflik met mekaar omdat hulle gebaseer is op die aard van die afwyking nadat dit alreeds ten voile ontwikkel het. aangesien sekondere gedrag verskillend ontwikkel by verskillende persone, sal navorsing wat gebaseer is op hierdie gedragsvorme lei tot verwarring.28 dit dien as motivering waarom 'n gedragsvorm wat min of meer universeel by hakkelaars van alle ouderdomme voorkom, bestudeer moet word. montgomery en cooke20 noem dat woorddeelherhalings een van die universeel herkenbare simptome van hakkel is. dit is een van die kerngedragsaspekte van hakkel, aangesien dit een van die primere kenmerke is wat die ontwikkelende hakkelaar onderskei van die nie-hakkelaar. daarom is woorddeelherhalings as studieterrein in hierdie navorsingsprojek geneem. herhalingsgedrag by hakkel vlotheid word versteur wanneer 'n spraakeenheid deur die een of ander onderbreking geskei of verwyder word van die res van die uiting.6 hierdie onderbrekings kan verskeie vorms aanneem soos bv. tussenwerpsels, herhalings (van klanke, lettergrepe, woorde en frases); hersienings, verlengings, gebroke woorde (pouses en eksplosiewe vrylatings) en selfs onvolledige of onvoltooide s i n n e . 7 ' , 5 ' 4 herhalings is een van die basiese onderbrekings wat voorkom in die spraak van die hakkelaar en word gekenmerk deur 'n duplikasie van sekere spraakelemente. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25. 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) maggi van wyk die_belang van herhaling as diagnostiese kriterinm herhalings is 'n belangrike diagnostiese kriterium, aangesien hakkel herken kan word aan onderbrekings op morfemiese vlak, terwypnie hakkelende spraak gekenmerk word deur onderbrekings op suoramorx v i t r if is veral op *** 1. die onderskeiding tussen aanvangshakkel en normale onvlotheid by kmders. aanvangshakkelaars toon konsekwent lettergreepen klankherhalings, asook klankverlengings, terwyl woorden fraseherhalings eerder kenmerkend is van die normale onvlotheidsperiode m<32 2. die verskil tussen hakkel en onvlotheid in nie-hakkelaars se spraak· veral boehmler7 het hier gedui op die diagnostiese belang van lettergreepen klankherhalings. die feit dat sheehan2 4 persentasiegewys bewys het dat sodanige herhalings by uitstek op die bestaan van hakkel dui terwyl woorden fraseherhalings meestal by nie-hakkelaars voorkom) beklemtoon nie alleen die diagnostiese waarde van hierdie gedragsvorm nie, maar onderskryf ook wingate33 se siening dat herhalings d™ ondaengl f ΐ ϊ y a , " ά ϊ k e m 8 e d r a g v a n h a k k e l vorm. ander outoriteite onderskryf ook hierdie bev.ndings en dui aan dat fraseherhalings, tussenwerpsels en pouses aanvaarbare onderbrekings van normale spraak die omvang en aard van herhalinpsgehrao id™ h f i s t u p e r , i n 5 h i e r v a " ί d k e e r s t e n s n o d i g o m ooreenstemmings te ldentifiseer. relatiewe waardes en verskille sal eers daarna geidentifiseer en duidelik word.3' navorsingsresultate dui reeds op sekere'ooreen emas s n e f e r e o n i a p r r i e r h a l i r ; g s b v " d p e s e n p l e k v a n v o o r k o m s · sowel as sekere onderske.dende eienskappe bv. duur.3' verder kan die aard van herhalingsgedrag ook reeds gekoppel word aan die erns van hakkel l8<23 daar bestaan egter nog 'n dringende behoefte aan die bestudering van die aard van kerngedrag as diagnostiese kriterium.28 kliniese bevindings o l t e z z t ^ v o , 8 c n d e v e r s k y n s d s ^ herhalingsgedrag fs i n t v t k i l l e ; b ° n r f s l m a t i g , h e i d : g e b r e k a a n oorgangsformante, gebruik van die schwa-vokaal; moonthke benaderingsgedrag; staking van lugvloeistaking van fonasie; skielike staking (teenoor geleidelike afname by die vvf w i η·[ t ) ; e " k ° " p ° u s e s t u s s e n herhalings. dit is veral die eerste toeligttng verdien ^ ^ ^ ^ w ° r d e " " a d e r e l s ! . m ™ m p 0 ^ v e d v u l c l i g e wo^ddeelherhalings. reel'matigheid in die tempo van uiting is kenmerkend van vlotspraak. so sal selfs 'n konstante tempo in die herhalings van nie-hakkelaars as aanvaarbare onderbrekings beskou kan word.^dit is egter wanneer die tempo van herhalings merkbaar verskil van die normale spoed van lettergreep uiting dat dit as aanduidend van hakkel beskou word.28 hoewel daar al navorsing gedoen is oor die duur van herhalings,2 4'3' is dit nog nie s t i t i n g n i f d u u r ^ ^ ° ~ m m e 8 n d e vloteenhefe™ the south african journal of communication disorders vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) oudiovisuele analise van woorddeelherhalings 67 2. die onreelmatigheid van woorddeelherhalings. 'n ander onderskeidende kenmerk van herhalingsgedrag by die hakkelaar is onreelmatigheid. 2 8 ' 2 9 van riper meen dat hierdie veelvuldige onreelmatige herhalings verband hou met die hakkelaar se onvermoe tot tydsberekening in sy spraakuiting. beech en fransella5 onderskryf hierdie teorie. kliniese waarneming dui daarop dat hierdie soekende gedrag be'invloed kan word deur faktore soos tydsdruk, wat hierdie onreelmatigheid tot gevolg kan he. 2 6 3. gebrek aan oorgangsformante by woorddeelherhalings. by vloeiende spraak word oorgangsvlotheid op die fonemiese vlak deur koartikulasie bewerkstellig.9 in die geval van herhalings by nie-hakkelende spraak kom die nodige oorgangsformante en lugvloei voor, terwyl beide ontbreek by herhalings van hakkelaars.28 hierdie verskynsel is deur stromsta25 deur middel van spektrogramme bewys. 'n verdere verwante verskynsel is van riper28 se vermoede dat die motoriese programmering belemmer word, omdat die hakkelaar sy artikulators tydens herhalings in 'n onnatuurlike posisie plaas. sheehan2 4 bewys dat 43,6% van die herhalings verkeerde klanke bevat. dit word verklaar op grond daarvan dat die hakkelaar dit te moeilik vind om die hele woord aan te durf en dus net woorddele probeer uitspreek wat die voorkoms van oorgangsformante onnodig maak.6 verskeie skrywers beklemtoon dat hakkel as 'n fonetiese oorgangsprobleem beskou kan word. 1 ' 3 3 die beskouing verskaf 'n verfyning in analise wat meer spesifiek die essensiele aard van die hakkelmoment spesifiseer. dit is egter nie maklik waarneembaar nie en soms kan dit slegs deur middel van spektrogramme uitgelig word.25 4 die gebruik van die schwa-vokaal by woorddeelherhalings. die feit dat kliniese bevindings daarop dui dat die schwa-vokaal gebruik word tydens herhalingsgedrag word o.a. deur sheehan,24 van riper28 en montgomery en cooke2 0 verklaar. navorsing bewys egter dat alleenlik in 25 % van gevalle die schwa gebruik word. 2 0 ' 2 4 in hierdie gevalle is die verlangde formantoorgange en koartikulasie dus afwesig. na aanleiding hiervan meen montgomery en cooke2 0 dat die voorkoms van die schwa in die inisiele herhaling van veelvuldige herhalings wel van riper28 se teorie in verband met soekende of benaderingsgedrag kan bevestig. dit is duidelik dat verdere navorsing in verband met hierdie verskynsel noodsaaklik is. 5. woorddeelherhalings as 'n vorm van benadering tot die verlangde fonetiese oorgang. by veelvuldige herhalings lyk dit, oppervlakkig beskou, asof dieselfde lettergreep oor en oor herhaal word. by nadere ondersoek blyk dit egter dat varierende artikulasieposisies voorkom, wat kan dui op soekende of benaderingsgedrag.30 montgomery en cooke20 kan benadering nie bevestig nie, omdat veelvuldige herhalings nie genoegsaam voorgekom het in hul proefpersone se spraak nie. dit is dus 'n faset wat verdere navorsing vereis. die suid-afrikaanse tydskrif vir kommunikasieafwykings vol.25. 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 68 maggi van wyk hoewel die term "lettergreepherhalings" meestal gebruik word in die literatuur, was dit nie geskik vir gebruik in hierdie ondersoek nie lettergreepherhalings" sluit noodwendig ook een-lettergrepige woorde in en lg. herhalings kan ook as normale onvlotheid voorkom 3 1 die term woorddeelherhalings" is gekies om te verhoed dat verwarring by analise ontstaan. die term het in hierdie studie die betekenis van die herhaling van η lettergreep of kleiner eenheid van 'n woord.31 om hierdie rede word "vlotlettergreep" ook vervang met die term "vloteenheid." spraakanalise m.b.v. die spektrograaf hoewel daar nie 'n meer sensitiewe analiseerder van spraak is as die oor self nie,1 word die klankspektrograaf as hulpmiddel tot ouditiewe analise gebruik, aangesien dit spraak na sigbare patrone verander wat as verwysing dien vir korrekte en foutiewe artikulatoriese bewegings in aaneenlopende spraak.16 op spektrogramme kan daar ook afsonderlike sowel as aaneenlopende segmente waargeneem word 1 daar word dus van 'n oudiovisuele analise gebruik gemaak aangesien modaliteite elk op eie wyse betekenisvolle leidrade aangaande spraakdimensies verskaf. talle ondersoekers bevestig dat spektrografiese analise waardevolle inligting aangaande spraakkenmerke van spraakafwykings kan verskaf.20 2 5 ' 2 2 ' 2 8 f metode h i p o t e s e die hipotese word gestel dat woorddeelherhalings by hakkel verskil van die ooreenstemmende vloteenheid en van nie-hakkelspraak in verskeie opsigte nl.: 1. die tempo van die herhalings verskil van die normale spoed van uiting van die ooreenstemmende vloteenheid. 2. die hakkelaar se veelvuldige woorddeelherhalings vind plaas teen η onreelmatige tempo. 3. die verlangde oorgangsformante verskyn nie by die woorddeelherhalings nie. 4 g e b r u t ^ 3 v ° k a a l w ° r d d c u r h a k k e l a a r s b y woorddeelherhalings 5. die veelvuldige herhalings is 'n vorm van benadering tot die verlanede oorgang. b y / p r o e f p e r s o n e y agttien proefpersone is gebruik. hulle is geselekteer op grond van die teenwoordigheid van woorddeelherhalings in hul spraak. ouderdom of geslag is me in ag geneem nie. a1 die,proefpersone was reeds vooraf deur η paneel spraakterapeute as hakkelaars gediagnoseer. volwassenes is ook gebruik, aangesien beide kinders en volwassenes wat as hakkelaars gediagnoseer is, se spraak proporsioneel meer woorddeelherhalings toon.7 the south a frican journal of communication disorders. vol. 25. 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) oudiovisuele analise van woorddeelherhalings 69 die voorwaarde was dus dat die proefpersone hierdie universele kerngedrag moes toon. geen ander spraakverskynsels of gedragsvorme wat by individuele proefpersone mag voorgekom het, het 'n rol gespeel nie. proefpersone: ouderdomme (jare) manlik vroulik 0 5 1 5 1 0 3 1 1 1 1 5 2 2 1 6 2 0 1 20 25 4 bo 25 3 ' 1 a p p a r a a t bandopnames is gemaak in 'n klankdigte kamer met 'n nagra 111 no. bh 67884 bandopnemer en mikrofoon. vir die ontlokking van spontane spraak, is t.a.t. en c.a.t. kaarte gebruik.15 spektrogramme is gemaak met 'n voice identification incorporated model 700. p r o s e d u r e s ses-minuut opnames van spontane spraak is van die agttien hakkelaars gemaak volgens die voorskrifte van johnson, darley en spriestersbach15 — "the job task". hierdie prosedures is ook aangepas vir kinders. die t.a.t. en c.a.t.-kaarte is gebruik vir spraakmonsters wat meer emosionele betrokkenheid van die sprekers geverg het. die maak van spektrogramme: altesaam 305 spektrogramme is van die herhalingsgedeeltes gemaak. betroubare prosedures is gebruik om die spektrogramme te maak en te analiseer. hier kan verwys word na hulp en aanwysings van kopp en green, 1 6 kopp, kopp en angelocci;17 potter, kopp en kopp2 2 se geskrifte. om te bepaal of die woorddeelherhalings reelmatig of onreelmatig plaasvind. dit het berus daarop dat die duur van die herhalingseenhede, asook die duur van die vloteenheid met behulp van 'n konstantheidsfaktor bereken is. die duurverskil is dan in vier kategoriee ingedeel. om te bepaal of die verlangde oorgangsformante by die eerste of enigste herhalingseenheid voorgekom het. in hierdie geval is gebruik gemaak van die eerste, tweede en derde formantposisies; die bandopnames (ouditiewe modaliteit) en die formantpatrone, om te bepaal of die verlangde oorgangsformant definitief, onwaarskynlik of glad nie voorgekom het nie. die formantpatrone is in ag geneem, omdat klanke wat gekombineer word mekaar be'invloed. dit word getoon in die oorgange van hierdie formantpatrone. hierdie oorgangsbewegings is belangrik by die herkenning van geproduseerde klanke en dit moet dus ook in ag geneem word by beoordeling.22 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol.25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 7 0 η. , . maggi van wyk om_te_ bepaal of die schwa-vnkggihy die eerste of enipste hprh»ii™ die beoordelmg was gegrond op die formantgebiede sowel as die ouditiewe beeld die koeffisient van die voorkoms van hierdie verskynsel by die verskillende kategoriee van elke proefpersoon afsonderlik en "ok die somtotaal van elke kategorie is bereken. " f e r i n e en ook g m j ^ p a a l o f d i e o p e e n v o l g e n d e h e r h a l i n g s v a n e l l ^ r r a ^ p ^ i n g n b e o a t o g j s i g t d l e v e r l a n g d e a r t i k u l a t o r i e s e ^ ^ h t ^ t f f ^ ook volgens n dne-punt skaal beoordeel, gegrond op die posisies van die spil (tweede formantbalk) van die herhalingsen vloteenhede. die spil verander die meeste in posisie en die spil van klanke koppel ook o p ' n bestendiger wyse. dit is dus die belangrikste formant om dop te hou by die identifisering van klankpatrone en kombinasies.22 die koeffisient van die voorkoms van hierdie verskynsel by die verskillende kategoriee van elke proefpersoon afsonderlik en ook die somtotaal van elke kategorie is bereken. deur die toepassing van 'n toets vir 'n verhouding is daar by al vy bogenoemde tabulerings bepaal of een van die kategoriee statisties betekenisvol verskil het van die ander. die waarde word jenoem die /z/resultate en bespreking tabel i bevat die ontleding van 315 spraakpogings, waarvan 41 (13%) geklassifiseer is as om van dieselfde duur te wees. by 274 (87 %) het die duur verskil van die van die ooreenstemmende vloteenheid. by 18 gevalle h v m ' ^ v a n , d i f h e r h a l i " g s e e n h e i d 16 31 msek. korter en oy μ u ι a ) i t 3i msek. langer as die van die vloteenheid. 107 gevalle het n duur van meer as 31 msek. korter en 114 (36 %) 'n duur van meer as 31 msek. langer getoon. 'n totaal van 70% d l ^ t w ^ d r i ' i % e k e n i s v 0 1 ° p d i e 5 % b e t e k e n i s ' p e i l geneem indien > i t 3 2 ? n i ? e h t e k e n i w o l o p ΐ 6 v 7 0 p e i l g e n e e m i n d i e n d i e waarde a 3,29. dit dui op n uiters betekenisvolle verskil. in die ontleding is 'n /zawaarde van 13,072 bereken, en daar is dus op 'n 0,1 % betekenlspeh gevind dat die woorddeelherhalings in tempo baie betekenisvol v s het van die ooreenstemmende vloteenhede. ook is gevind dat hierdie duurverskille groot was, aangesien die duurverskille by 70 % gevalle meer as 31 msek. was hoe groter die verskil in duur tussen die herhaltngsd i t t m o o n h w v l ° t e e n h e i d ' h o e opmerklik is die abnormalitei fn lu s t e r t " n w a a r ° m w o o r d d e e l h e r h a , i n g s uitgesonder word deur die luisteraar.2* daar is nie 'n statisties betekenisvolle verskil gevind tussen herhahngseenhede wat van korter en van langer duur was nie, aanges en n /zawaarde van 1,39 bereken is. montgomery en cooke2» skryf h!e die the south african journavof communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) oudiovisuele analise van woorddeelherhalings 71 geval a β c d ε f g η i j κ l μ ν ο ρ q r van dieselfde duur < 8 msek 1 4 1 1 4 3 1 van korter duur 16-31 msek totaal persentasie gewys >31 msek 41 13% 18 6 % 22 4 1 3 6 5 4 4 4 3 2 3 24 8 2 5 3 4 van langer duur 16-31 msek 107 10 1 4 2 2 1 1 2 3 1 3 4 1 >31 msek 35 34% 24 3 3 6 17 7 1 2 3 1 6 6 6 6 13 3 7 114 11% 36% tabel ι 'n vergelyking van die tempo van die eerste herhalingsuiting met die uiting van die o o r e e n s t e m m e n d e vloteenheid. verskil toe aan die duur van die inisiele konsonant. hulle het. bevinc1 dat d s d u u r van hierdie konsonant van die gehakkelde woord 20 msek. of meer langer was as die van die ooreenstemmende konsonant van die z z o o r d hierdie bevindings stem ooreen met die hipotese wat aanvanklik gestel is. r^prpkinp van resultate soos getihii w r in tahelle ii. ill en iv bv"76~eevalle het twee herhalings per spraakpoging voorgekom 36 is d e u r d d e herhalings voorafgegaan en 17 deur vier. as gevolg van hierd.e t i a s i e moes die groepe aisonderlik ontleed w o r d ^ by d.e groepe ^ drie en vier herhalings per spraakpoging is die verskil bepaal tussen die met die laneste en die met die kortste duur. . b y d i e ^praakpogings wat deur twee sowel j ^ r d n e woorddeelherhalings voorafgegaan is, is daar op die 0,1 £ ^ sevind dat daar 'n beduidende duurverskil t u s s e n d . e herhahngseenhede vooreekom het. by eg. is 'n /z/-waarde van 8,603 bereken en by lg. 5,833. d a a r t s e g t e r n i e 'n statisties betekenisvolle verskil verkry tussen die s t a l e aanfal wat van korter duur was en die wat van langer duur was nie. ^ ^ ^ e mln gevalle voorgekom het waar vier herhalings die vlotuiting voorafgegaan het, o m statisties te ontleed, blyk dit dat dieselfde neiging as by die vorige gevalle voorkom. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol.25. 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 maggi van wyk geval van dieselfde duur msek d 16-31 korter uur msek langer d 34-5i korter uur msek langer d 62,5-'; korter uur 8 msek langer d >78 korter uur msek langer a β c d ε f g η i j κ l μ ν 0 ρ 0 r 2 1 1 1 1 1 2 2 1 1 2 1 1 1 1 1 1 1 1 1 1 1 1 1 1 3 6 2 1 1 1 1 1 4 3 1 5 2 5 3 3 1 3 1 totaal 0 4 11 7 2 5 3 21 23 /ο 0% 5% 15% 9% 3% 7% 4% 28% 30% tabel ii 'n vergelyking van die duur van woorddeelherhalings by gevalle waar daar twee herhalings per spraakpoging voorgekom het. gevan dieduur duur duur ^ duur geselfde 16-31 msek 34-55 msek 62,5-78 msek > 78 msek val duur korlangkorlangkorlangkorlangί 8 msek ter er ter er ter er ter er a 1 1 3 4 β 1 1 c d 1 1 2 1 ε • 1 1 1 2 5 f g η 1 1 i 1 j j 1 κ 1 l μ 1 / 1 ν 2 0 • 1 ρ 1 0 r to0 0 1 taal 0 0 1 1 3 4 2 12 13 0/ /ο 0% 0% 3% 3% 8% 11% 6% 33% 36% tabel iii 'n vergelyking van die duur van woorddeelherhalings by gevalle waar daar drie herhalings per spraakpoging voorgekom het. the south african journal of communication disorders, vol. 25. 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) oudiovisuele analise van woorddeelherhalings geval a β c d ε f g η i j κ l μ ν 0 ρ 0 r van die selfde duur < 8 msek du 16-31 korter ur msek langer du 34-55 korter ur msek langer du 62,5-78 korter ur msek langer du >78 korter ur msek langer geval a β c d ε f g η i j κ l μ ν 0 ρ 0 r 1. 2 3 •1 7 1 1 1 totaal 1 2 4 10 0/ /ο 6% 12% 24% 59%· tabel iv 'n vergelyking van die duur van woorddeelherhalings by gevalle waar daar vier herhalings per spraakpoging voorgekom het. uit tabelle ii en iii blyk dit dat by die meeste gevalle nl. 58 % en 69 % gevalle onderskeidelik, die duurverskil meer as 78 msek. was. by alle gevalle was daar 'n duurverskil van meer as 16 msek. die veelvuldige herhalings van hakkelaars word dus opmerklik onreelmatig geuiter, wat van riper se kliniese indruk van hakkelspraak bevestig i.t.m. die normale onvlothede van nie-hakkelaars wat glad, reelmatig en teen dieselfde tempo as die res van hul lettergrepe geuiter word.28 montgomery en cooke het ook by 62 % van pare monsters wat hulle ontleed het η verskil in tempo van produksie opgemerk.20 dit bevestig ook die hipotese wat aanvanklik gestel is. die voorkoms al dan nie van die verlangde oorgangsfornimtbyjie^gmg of enipste woorddeelherhaling wat die vlotuiting voorafgaan (sien tabel daar is gevind dat die verlangde oorgangsformant by 30% gevalle wel voorgekom het, by 64% was dit onwaarskynlik en by 6 h was die moontlikheid nie uitgesluit dat dit wel die verlangde oorgang was me statisties is op die 0,1 % betekenispeil gevind dat dit onwaarskynlik is dat die oorgangsformant van die eerste of enigste woorddeelherhaling ooreenstem met die verlangde formant van die vloteenheid.-aangesien η /z/-waarde van 5,99 bereken is. dit bevestig van riper se hipotese. hierdie bevinding word ook nog onderskryf deur waarnemings van die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25. 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 74 maggi van wyk geval ja moontlik onwaarskynlik a 4 3 58 β 3 1 9 c 1 0 7 d 1 0 12 ε 5 0 24 f 6 2 4 g 4 0 3 η 9 0 4 i 1 2 8 j 1 1 3 κ ' 1 1 1 l 1 0 10 μ 32 0 15 ν 8 2 6 ο 0 1 8 ρ 10 3 11 0 4 1 9 r 3 1 9 totaal 94 18 201 % 30% 6% 64% tabel v die voorkoms van die verlangde oorgangsformant by die eerste of enigste woorddeelherhaling wat die vlotuiting voorafgaan. agnello1 en montgomery en cooke.2 0 dit is dus moontlik dat die formantafwykings reflekteer dat die konsonant van die gehakkelde woord geproduseer was met 'n abnormale stand van die artikulasie organe. daarom is die artikulatoriese (en dus akoestiese) verloop vanaf hierdie stand na die nodig vir die produksie van die verlangde vokaal ooreenstemmend versteur. die outeurs hipotetiseer dus dat die abnormale formantoorgange die gevolg is van afwykende artikulasie van die konsonant eerder as wat dit die gevolg is van foutiewe oorgangsdinamika.20 daar word ook weer verwys na die bevindinge van stromsta,25 aangaande die gebrek aan formantoorgange as diagnostiese middel vir die identifisering van hakkelaars. hierdie bevinding bevestig die hipotese wat aanvanklik gestel is. aangaande die gebruik van die schwa-vokaal deur hakkelaars by hul woorddeelherhalings. daar is gevind dat by 22 % gevalle die schwa-vokaal wel geproduseer is, wat goed ooreenstem met montgomery en cooke se bevinding van 25 %.20 verder was dit by 51 % van gevalle onwaarskynlik, terwyl daar by 27 % wel die moontlikheid bestaan het dat die schwa geproduseer is. statistics is op die 0,1 % betekenispeil gevind dat dit onwaarskynlik is dat die schwa-vokaal gebruik is by die eerste of enigste woorddeelherhalings van hierdie hakkelaars. hierdie bevinding is teenstrydig met die verwagte resultate asook met van riper se kliniese indruk:2" almost universally the schwa vowel can be heard in the stutterer's abortive speech attempts. hierdie teenstrydigheid kan verklaar word aan die hand van die feit dat the south african journal of communication disorders vol. 25. 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) oudiovisuele analise van woorddeelherhalings 75 geval ja moontlik onwaarskynlik a 21 15 28 β 2 2 7 c 3 2 2 d 4 1 8 ε 11 11 4 f 2 3 1 g 0 1 6 η 0 2 11 i 4 1 5 i .2 0 2 κ 1 .1 0 l 3 1 6 μ 2 12 30 ν 1 5 8 ο 1 4 4 ρ 4 6 14 0 2 6 3 r 1 4 8 totaal 64 77 147 /ο 22% 27% 51% t a b e l vi 'n beoordeling van die voorkoms van die schwa-vokaal b y die eerste of enigste woorddeelherhalings van spraakpogings waar 'n neutrale vokaal nie verlang word nie. geval ja moontlik onwaarskynlik a 2 0 4 β 0 0 5 c 0 0 3 · d 0 0 4 ε 0 0 4 f 0 0 4 g 1 0 0 η 1 0 3 i 0 2 2 j 0 1 2 κ 0 0 1 l 0 0 1 μ 0 0 5 ν 1 0 2 ο 0 0 4 ρ 0 1 2 0 1 0 2 r 0 0 0 totaal 6 4 48 /ο 10% 7% 83% t a b e l vii die voorkoms van benaderingsgedrag. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 76 maggi van wyk die vorige bewerings grootliks gebaseer was op kliniese indrukke as 'n deeglike analise. hierdie indrukke reflekteer die natuurlike neiging van 'n luisteraar wanneer hy vokaalsegmente van kort duur teenkom, soos by deelwoordherhalings of oor die algemeen wanneer onsekerheid teengekom word, om tot die gevolgtrekking te kom dat die neutrale vokaal geuiter is.20 die voorkoms van benaderingsgedrag by 83% het dit geblyk dat dit onwaarskynlik is dat daar van benaderingsgedrag sprake is. by 69 % het definitiewe benaderingsgedrag voorgekom en by 7 % gevalle was dit moontlik. t.s.v. die relatief min spraakpogings met genoeg woorddeelherhalings om hierdie eienskap te ondersoek, soos die geval met montgomery en cooke 2 0 se ondersoek, is daar statisties op die 0,1 % betekenispeil gevind dat dit onwaarskynlik is dat die veelvuldige herhalings 'n wyse van benadering tot die verlangde oorgang van die vlotuiting is. hierdie bevinding korreleer dus nie met die hipotese wat gestel is nie en ook nie met van riper se kliniese indruk nie.28 gevolgtrekkings buiten die voorkomsfrekwensie van onderbroke woorde, is daar ook nog ander eienskappe waarvolgens 'n diagnose van hakkel gemaak kan word. die bevinding van hierdie studie is dat die tempo waarteen hakkelherhalings geuiter word verskil van die van normale onvlothede en ook dat eg. opmerklik onreelmatig is. kliniese waarnemings het getoon dat tydsberekening 'n belangrike faktor is in die voorkoms van hakkel. so bv. bei'nvloed tydsdruk die hakkelaar se spraak. die hakkelaar vertoon soekende gedrag-gedrag wat daarop gerig is om die regte tydsberekening vir woorduiting te bewerkstellig.26 dit is dus moontlik dat hakkel ontstaan as gevolg van 'n biologiese onvermoe om op morfemiese vlak motoriese patrone temporaal te bemeester. aangesien daar geen reelmatigheid ten opsigte van tempoverskille voorgekom het nie, word die indruk geskep dat hierdie gedrag onwillekeurig is, soos webster en brutten dit ook stel.30 hoewel daar gevind is dat die verlangde oorgangsformante nie by die woorddeelherhalings van hakkelaars voorkom nie, is dit egter ook nie die schwa-vokaal wat gebruik word nie. die veelvuldige herhalings is ook nie 'n poging tot benadering van die verlangde oorgang nie. die artikulatoriese model voorgestel deur henke1 9 kan moontlik gebruik/word om die abnormale temporale aspek en die ongewensde oorgangsformant waarmee die hakkelspasma gei'nisieer word, met mekaar in verband te bring. die toevoer van die model is 'n string foon-grootte segmente wat elk gespesifiseer is i.t.v. 'n stel artikulatoriese mikpunte. laasgenoemde stel 'n beperkte reeks saam wat onderskeidelik gevarieer word in tyd. hulle is vorme en posisies van die articulators. hoewel die artikulators na hierdie spesifieke mikpunte beweeg, mag hulle moontlik nie bereik word nie. die posisies wat bereik word hang af van die artikulasiestande wat the south african journal of communication disorders vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) / oudiovisuele analise van woorddeelherhalings 77 voorheen deur die artikulators ingeneem is en van die tydreeling van opeenvolgende toevoerings. henke stel ook 'n vooruitbeskouing van toekomstige toevoereenhede voor, wat 'n verwagting van koartikulasie van sekere eienskappe toelaat, wanneer dit nie in konflik is met die gespesifiseerde mikpunte van meer onmiddellike eenhede nie. daar kan dus tot die gevolgtrekking gekom word dat woorddeelherhalings nie alleen 'n essensiele eienskap is wat algemeen by hakkelaars opgemerk word nie,2 8 maar dat dit ook sekere distinktiewe eienskappe bevat wat veroorsaak dat die luisteraar dit juis uitsonder as hakkelgedrag. d i e w a a r d e v a n d i e s t u d i e e n m o o n t l i k e a a n b e v e l i n g s spraakkenmerke wat van belang is vir die differensiaaldiagnose tussen hakkelspraak en normale onvlothede is deur hierdie studie bevestig. naamlik dat woorddeelherhalings onreelmatig geuiter word en nie teen dieselfde tempo as die vlotuiting nie, en ook die afwesigheid van die verlangde oorgangsformant by die inisiele herhaling. hierdie was vroeer slegs kliniese indrukke. 2 8 ' 2 5 dit impliseer terapeuties dat daar met die afbraak van die hierargiese gedragsvorme van hakkelaars begin moet word by die willekeurige sekondere gedrag. aangesien die primere gedragsvorme onwillekeurig is,30 mag die volgende tegnieke van waarde wees: tegnieke wat ontspanning meebring onder andere johnson se bonstegniek, verlengde spraak en ligte kontakte deur die artikulators.1' metodes wat die hakkelaar met die tydsberekening van spraakpogings help, kan ook met sukses in terapie aangewend w o r d . 2 ' 3 ' 2 7 die volgende aspekte mag interessant wees om verder na te vors: aangesien dit nie die schwa is wat oor die algemeen deur hakkelaars gebruik word in hulle inisiele herhalings nie, kan dit van waarde wees om te bepaal watter klank dan wel die meeste gebruik word. navorsing word benodig aangaande verdere aspekte van belang vir differensiaaldiagnose28 nl: of lugvloei by hakkelherhalings wel onderbreek word en of skielike fonatoriese stakings dit vergesel; of pouses by normale lettergreepherhalings baie korter is as die van gehakkelde herhalings. daar kan ook nog dieper ingegaan word op die kwessie van benadering. dit mag interessant wees om te bepaal of die fonetiese samestelling van die vloteenheid 'n rol speel by die korter of langer duur van die herhalingseenheid. daar is bevind dat daar wel tot duidelike resultate en gevolgtrekkings gekom kan word deur 'n enkele komponente gedragsvorm van die konglomeraat te selekteer en dit te analiseer.30 daar is ook bevind dat spektrografie nie alleenlik 'n waardevolle hulpmiddel is by eksperimentele ondersoek nie, maar dat dit ook van diagnostiese belang is om spektrografiese ontledings van spraakmonsters te maak. sodoende word spraakkenmerke van spraakafwykings uitgelig, wat nie bloot deur die ouditiewe bepaal kan word nie. hierdie siening word gesteun en bevestig deur stromsta,25 van riper,28 montgomery en cooke 2 0 en potter, kopp en kopp.2 2 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol.25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 78 maggi van wyk verwysings 1. agnello, j.g. (1975): measurement procedures in speech, hearing and language, university park press. 2. barber, v. (1939): chorus reading as a distraction in stuttering, studies in the psychology of stuttering xv, j. speech dis., 4,371-383. 3. barber, v. (1940): rhythm as a distraction in stuttering, studies in the psychology of stuttering xvi, j. speech dis., 15, 29-42. 4. barr, h. (1940): a quantitative study of the specific phenomena observed in stuttering, j. speech dis., 5, 277-280. 5. beech, h.r. en fransella, f. (1966): research and experiment in stuttering, pergamon press, oxford. 6. bloodstein, o. (1961): the development of stuttering iii. theoretical and clinical implications, j. speech hear. dis., 26, nr. 1, 67-81. 7. boehmler, r.m. (1958): listener responses to non-fluencies, j. speech hear. res., 1, 132-141. 8. brutten, g. en shoemaker, d. (1971): a two factor learning theory of stuttering. in handbook of speech pathology and audiology, travis, l. (ed.). appleton century crofts, new york, bis. 1035 1072. 9. dalton, p. en hardcastle, w.j. (1977): disorders of fluency and their effects on communication, billing and sons ltd london. 10. davis, d.m. (1939): the relation of repetition in the speech of young children to certain measures of language maturity and situational factors, part i, j. speech dis., 4, 308-318. 11. flanagan, j.l. (1972): speech analysis synthesis and perception, 2nd edit. universitatsdriickerei, wiirzburg. 12. froeschels, e. (1952): the significance of symptomatology for the understanding of the essence of stuttering, folia foniatrica, iv, 217-230. 13. helmreich, h.g. en bloodstein, o. (1973): the grammatical factor in childhood disfluency in relation to the continuity hypothesis, j. speech hear. res., 16, 731-738. 14. jakobson, r., fant, g. en halle, m. (1963): preliminaries to speech analysis: the distinctive features and their correlates, m.i.t. press. 15. johnson, w., darley, f.l. en spriestersbach, d.c. (1963): diagnostic methods in speech pathology, harper & row, new york. 16. kopp, g. en green, h. (1948): visible speech, volta'review, feb., 60-62. 17. kopp, g.a., kopp, h.g., angelocci, a. (1967): visible speech manual, wayne state university press, detroit. 18. minifee, f.d. en cooker, h.s. (1964): a dysfluency index, j. speech hear. dis., xxix, 189-193. , 19. moll, k.l. en daniloff, r.g. (1971): investigation of the timing of velar movements during speech, part 2, j. acoustical soc. america, 50, nr. 2. the south african journal of communication disorders vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) oudiovisuele analise van woorddeelherhalings 79 20. montgomery, a.a. en cooke, p.a. (1976): perceptual and acoustical analysis of repetitions in stuttered speech, j. commun. dis., 9, 317330. 21. peters, r. en giles, m. (1965): stuttering in relation to syntactical and phonemic structure of the english language, kongresverslag van die internasionale vereniging vir logopedie en foniatrie, 11, 321-323. 22. potter, r.k., kopp, g.a., kopp, h.g. (1966): visible speech, dover publications inc., new york. 23. sander, e.k. (1963): frequency of syllable repetition and stutter judgements, j. speech hear. res., vi, 19-30. 24. sheehan, j.g. (1974): stuttering behaviour: a phonetic analysis., j. commun. dis., 7, 193-212. 25. stromsta, c. (1965): a spectrographic study of dysfluencies labelled as stuttering by parents, kongresverslag van die internasionale vereniging van logopedie en foniatrie, ii, 317-318. 26. uys, i.c. (1973): 'n biologies-gefundeerde hipotese in verband met die ontstaan van hakkel, tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, 20, des. 47-58. 27. van dantzig, m. (1940): syllable-tapping, a new method for the help of stammerers, j. speech dis., 5, 127-131. 28. van riper, c. (1971): the nature of stuttering, prentice hall inc. 29. van riper, c. (1972): speech correction: principles and methods, prentice-hall inc. 5th edit. 30. webster, l. en brutten, g. (1972): an audiovisual behavioral analysis of the stuttering moment, behaviour therapy, 3, 555-560. 31. wingate, m.e. (1976): stuttering theory and treatment, irvington publishers inc., new york. 32. wingate, m.e. (1964): a standard definition of stuttering, j. speech hear. dis., xxix, 484-489. 33. wingate, m.e. (1969): stuttering as phonetic transition defect, j. speech hear. dis., xxxiv, 107-108. 34. yairi, e. en clifton, n. (1972): dysfluent speech behaviour of preschool children, high school seniors, and geriatric persons, j. speech hear. res., 15, 714-719. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol.25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aids for • the development of perception • the acquisition of speech and language skills • the improvement of motor co-ordination plus • helpful texts for therapists • educational toys, books and equipment • records for auditory training • catalogues on request • large variety of tests available new arrivals: • learning to listen • two sound lottos • "listen what is that?" play and schoolroom 8 tyrwhitt avenue, rosebank (adjoining the constantia cinema) telephones: 788-1304 p.o. box 52137, saxonwold, 2132 ο m the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aspects of cohesion, tense and pronoun usage in the discourse of the older language-impaired child hilary berger, b.a. (sp. & h. th.) (witwatersrand) speech therapy department, transvaal memorial hospital for children, johannesburg. aletta sinoff, b.a. (sp. & h. th.) (witwatersrand) department speech pathology and audiology, university of the witwatersrand, johannesburg. summary aspects of the discourse of 5 language-impaired children and 5 children with no language impairment, aged approximately 9 years, were compared. a film and a story sequence were utilised to elicit narratives on which, measures of cohesion, tense and pronouns were appraised. measures of cohesion refer to the ability to indicate appropriately the relations of meaning with regard to situational context. measures of tense include aspects of tense range and tense continuity. measures of pronouns refer to the anaphoric use of pronouns with non-ambiguous referents. the group of language-impaired children was found to be significantly poorer on measures of cohesion and pronominal usage than the normal children, whereas a significant difference between the two groups was not revealed on measures of tense. possible factors accounting for these findings were discussed and' implications for the diagnosis and therapy of the older language-impaired child were considered. opsomming aspekte van die uitinge van 5 taalversteurde kinders en 5 kinders sonder taalversteuring van ongeveer 9 jaar, is vergelyk. 'n film en 'n storie-reeks is gebruik om 'n vertelling te ontlok waarvolgens maatstawwe van kohesie, tyd en voornaamwoorde geevalueer is. maatstawwe van kohesie verwys na die vermoe om die verhouding van betekenis met betrekking tot situasie konteks toepaslik aan te dui. maatstawwe van tydsvorme sluit in aspekte van die omvang van tydsvorme en die aaneenskakeling van tydsvorme. maatstawwe van voornaamwoorde verwys na die anaforiese gebruik van voornaamwoorde met ondubbelsinnige verwysings. die groep taalversteurde kinders het beduidend swakker presteer ten opsigte van maatstawwe van kohesie en voornaamwoord gebruik as die normale kinders terwyl geen beduidende verskil uitgewys is tussen die twee groepe kinders met betrekking tot tydsvorme me. moontlike faktore verantwoordelik vir hierdie bevindinge is bespreek en imphkasies vir diagnose en terapie van die ouer taalversteurde kind is oorweeg. • recent research in child language has indicated the need to view pragmatics. this has highlighted the importance of accounting for 'reallife'., communication situations, for example, the appropriateness of utterances with reference to the context in which they are produced and understood. 6 ' 2 0 ' 24<28 application of this to the field of language pathology suggests a number of implications for the diagnosis of and therapy for language disorders. an examination of aspects of pragmatics is afforded by discourse, that is, the sentences spoken or written in succession by one or more persons in a single situation.14 the concept of cohesion may be considered as central to discourse. it refers to the relation of meaning expressed in discourse and the appropriate linking of these relations.12 semantic cohesion is described as die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, j978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 η. berger & α. sinoff characterizing the 'backbone' of narratives and is formed by appropriately relating the chain of events.'4 syntactic cohesion refers to the linguistic forms used to indicate appropriately the interrelationships between utterances and draws partly from the syntax and partly from the vocabulary.12 description of the language of the older child, that is, the child from five years of age, is limited.22 research in this area has focused on the understanding and production of isolated sentences with an emphasis on the adequacy of syntactic form and to some extent semantic a s p e c t s . 9 ' i 0 ' 1 7 however, language beyond the single sentence within a context has received less attention. the importance of accounting for these aspects is aptly stated by cazden:8 a child's manifest verbal behaviour or performance has both grammatical and pragmatic aspects. thus, a consideration of discourse becomes particularly relevant in examining the child's communicative ability. the discourse of the older clinical child deserves attention, as it has been stated that these children lack the ability to . . . talk coherently and to the point.24 a study conducted by t u c h 2 7 investigated this aspect in the narratives of a group of 9-year old language-impaired and normal speaking children. results revealed the language-impaired group's failure to convey logicality resulting in incoherent narratives. thus the clinical child may be competent on a sentence level, but may manifest difficulty with the expression of inter-sentence relations in discourse. two syntactic forms which rely on inter-sentence relations in discourse, and have relevance for the clinical child, are tense and pronouns. research on both these aspects has dealt largely with the acquisition p r o c e s s . 7 ' i 5 ' , 8 ' l 9 ' 2 1 ' 2 9 with reference to tense, emerging linguistic forms indicating the relationship of events in time have been viewed together with the child's cognitive development.'' 4 ' 5 a consideration of the scope of tense reveals that the linguistic forms of the present and past tense are closely related to aspect, that is, the view of the verbal action either as in progress — the progressive aspect, or as completed — the perfect aspect.2 5 this results in a number of complex tense forms. these tenses are acquired later than the simple tenses in the developmental sequence.4 only a small proportion of studies in this area make reference to the older child. in terms of acquisition of tense use, it appears that from approximately six to seven years of age, the child's ability is comparable to that of the adult.5 this however does not account for the specific handling of tense beyond the single sentence level, for example, the reporting of direct speech in discourse. hendricks14 uses the term "intersentence concord" to refer to the consistent use of the same tense of the main verbs in the sentences comprising a narrative. this affords an examination of tense continuity or the extent of tense shifts. research on pronouns has indicated) that the child of nine years has mastered the various features of pronoun selection on a sentence level, such as person, gender and number, as well as the grammatical rules that the pronominalization process is subject t o . 1 8 ' 1 9 ' 2 9 however there has the south african journal of communication disorders. vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aspects of discourse in language impairment 5 been little research carried out on the use of pronouns in discourse aspects of pragmatics such as role-playing have to be taken into consideration in a discourse situation where, for example, a child is required to realize that if there are two male participants in a narrative pronominalization of both after the initial naming will cause confusion aspects of pronoun usage in discourse which contribute to cohesion are anaphoric pronouns which function as replacements for co-referential noun phrases (np's) in preceding clauses. the pronoun as a reference item functions as a deictic, that is, it refers to an np or to knowledge shared by the speaker and listener.'6 for cohesive purposes the identification of the pronoun must be specific. for example, "john went to town. he bought shoes". the pronoun "he" is an anaphoric pronoun as it replaces the np "john"; or; "for he is a jolly good fellow". in this case the speaker and listener should be able to identify "he" from their mutual knowledge of the context for the identification of "he" to be specific. application of the measurement and characterization of aspects of discourse has received little attention. thus the present report aims to examine the older language-impaired child's discourse, and proposes parameters which are relevant for such an analysis. methodology aim to examine aspects of the communicative ability as revealed by discourse, of a group of older language-impaired children and to compare the communicative ability of this group with that of non language-impaired children of the same age range. specifically, to compare the two groups on the following measures:measures of cohesion the ability to relate the chain of events such that the relation of meaning is expressed.1 2'1 4 this involves a consideration of appropriateness to situational context, the logicality and sequence with which events are recounted, as well as fluency. measures of tense the appropriate use of complex tenses, as well as tense range and tense continuity. measures of pronouns the anaphoric use of third person pronouns with non-ambiguous referents. subjects two groups of subjects (ss) comprising an experimental (e) group of 5 language-impaired children and a control (c) group of 5 non languageimpaired children were used. age range was from 8,4 to 9,6 years. the ε ss had language problems predominantly of an expressive nature as assessed by the speech therapists attached to the two remedial schools from which the ss were selected. ss were receiving speech therapy at the time of testing. all ss came from white english-speaking, middle-class south african homes. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 η. berger & α. sinoff ss in the ε and c groups met the following criteria for subject selection:(1) age:the older child was selected as, according to piaget,23 there is a decline in egocentric language from 8 years of age, and children begin to be more explicit in their narrative. this aspect was relevant for the study of pronouns in discourse and cohesion. secondly, by 8 years of age, features of tense have been acquired on the single sentence level,5 but the extent of competence in discourse has not been explored. (2) intelligence:the intelligence of all ss was considered to be within normal limits. for the ε group, iq scores on the new south african individual scale were obtained from the case-files at the respective remedial schools. exact scores were unavailable for the c group, however all c ss were judged by their teachers to be of average intelligence. t a s k s the data to be analysed was derived from the retelling of a film or story sequence. this was felt to be a close approximation to a 'real-life' discourse situation. also, children tend to talk more when presented with this type of stimulus as compared with pictures or a toy.8 the following tasks were therefore administered :(1) one sequence (1 minute 15 seconds) was selected from a film of the "three stooges", and presented audio-visually. in terms of investigating the child's anaphoric use of third person pronouns (he; him; they; them; it) with non-ambiguous referents, the film sequence was required to have more than 2 male actors with equal interaction. this was aimed at creating a potentially ambiguous situation where there were 2 or more referents of the same sex. (2) one story sequence presented auditorily. this task was devised particularly for analysis of tense use. results from a pilot study carried out by the writers revealed that a film sequence (such as that described in (1) above) required relating events that have occurred in the immediate past, and therefore would not be sufficiently taxing for assessing complex tense use. thus a story sequence was devised which contained some later developing conjunctions,1 8 for example, since; when; while; unless; if; after; before, and temporal adverbs — all of which require the use of more complex tenses. the story was tape-recorded to ensure that presentation to each subject was consistent. / to control for memory span, the number of events in the film and story sequence was limited to 7. p r o c e d u r e i all ss were tested individually by 2 experimenters (the writers e l and e2). testing was carried out in 2 rooms — 1 room where the film and story sequences were presented by el and a second room, where the narratives the south african journal of communication disorders vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aspects of discourse in language impairment 7 were recorded by a 'naive' listener (e2). the following is an explanation of the procedure followed for each s: (1) a period of casual conversation between the s and experimenters preceded the presentation of tasks. this was aimed at creating a relaxed atmosphere in an attempt to control for the influence of the testing situation on communication. (2) the instructions for the film and story tasks included the information that the s was retelling the sequences to a listener who was unfamiliar with the content (e2). this was aimed at approximating a 'real-life' situation which requires that the speaker be explicit rather than rely on the listener's previous knowledge of the content of the sequences. (3) e l presented the film first, followed by the story. after the presentation, the s was required to retell the narrative to e2 who had not been present during the task presentation. a methodological point of significance was the use o f " . . . tell m e . . " as part of the instructions to each subject. this prevented the influence of the tense used in the instructions on the tense of the s's narratives.5 during the s's discourse, e2 acknowledged his comments with the expression of "mm" and nodding of the head so as to approximate a natural speaker-listener effect. the s's narratives were tape-recorded and transcribed on both tasks the scoring system devised by the writers was then applied to the protocols measures of cohesion, tense and pronouns were analysed on the film task; measures of cohesion and tense (but not pronouns) were analysed on the story task. measuring and scoring system. the measures of aspects of communicative ability may be divided into 3 main sections following the aim of the study. (i) measures of cohesion (ii) measures of tense (iii) measures of pronouns each of these measures and the scoring system used is outlined below. (4) (5) (i) measures of cohesion this represents an appraisal of the ability to relate appropriately the chain of events such that the relation of meaning is expressed 12>'< measures of this ability were divided as follows:(a) semantic content this was measured by:(a) number of main events. the film and story, sequences were each divided into 7 main events. the number of events reported by each s on each task was tallied. the requirement was that the event be mentioned irrespective of its position in the narrative or its grammaticality. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol.25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 η. berger & α. sinoff (b) number of inaccuracies of content. this was felt to detract from the general cohesiveness of the narrative. the number of inaccurately reported events on each task was tallied. (b) semantic cohesion (a) sequencing of events and logicality. this measure was derived from piaget's work2 3 on the "egocentric" language characterizing children's narratives. this measure refers to the ability to express appropriately casual relations, that is, the "how" of events; the ability to order events in the correct time sequence; and the ability to recount all parts of a narrative into a meaningful whole. this was measured by:(1) the number of events related logically and in sequence ( + log seq). the number of events related logically and in sequence in each narrative were tallied as (+ log seq). the following example is an extract from a c s's narrative to illustrate this measure:"it was about a cow and they're trying to milk it and they're using its tail and it didn't give milk . . . " (2) the number of errors in logic and sequence (— log seq). the number of errors in logic and sequence in each narrative were tallied as (— log seq). errors were evident where events were listed without any form of logical, temporal or casual connection such that no interrelationship was implied, and where narratives lacked specificity and events were omitted. the following example is an extract from an ε s's narrative to illustrate this measure:"then they try, they milk the cow — so, so then on it was a hole in one side and went into his face". with regard to both (1) and (2), the ability to express the semantic relations of the original story was considered together with the use of appropriate syntactic forms in the expression of these relations. (b) fluency. this measure was based on the categories applied by haynes and hood 1 3 when analysing fluency changes as a function of linguistic complexity. these were: interjections; part-word, word and phrase repetitions; revisions; incomplete phrases and tense pauses. the number of times when dysfluency was felt to affect the cohesiveness of the narrative was tallied. this was determined according to a subjective evaluation by e l and e2. from the measures of semantic content and semantic cohesion, a general appraisal of cohesion was obtained. protocols were scored independently by the writers, and cotcurrence was reached in the majority of instances. where there was a discrepancy, the writers reviewed the narratives. ( i i ) measures of tense (a) tense range this was measured by:| (a) the number of complex tenses used appropriately. the number of appropriate present and past forms, of the progressive, perfect and the south african journal of communication disorders vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aspects of discourse in language impairment 9 perfect progressive were tallied. in addition, the variety of present and past tense forms was qualitatively examined. the following example is taken from a c s's narrative on the story task and illustrates the appropriate use of the present and past progressive tenses: "sam's class was going to the zoo. they were very excited. when sam came into the class, the teacher said to him: "why are you so dirty". sam said: "while i was playing soccer, another boy tripped me . . ." (b) tense continuity this was measured by:(a) the number of inappropriate tense shifts of a main verb. this measure determined the extent of tense shifting before or after the reporting of direct speech. a score was obtained by tallying the number of inappropriate tense shifts of a main verb. the following example is taken from a c s's narrative to illustrate this: ". . . and he did it about three times and nothing happened. so he says: "try again", and then it went into his face, and he says: "that's a nice flavour". the verb "says" in both instances is in the present tense instead of the past tense. from a consideration of aspects of complex tense use and tense continuity, a measure of tense in discourse was obtained. ( i l l ) measures of pronouns (a) ambiguous pronoun usage this was measured by:(a) the number of nonindexed pronouns — that is, where there was no referent corresponding to the pronouns. the number of nonindexed pronouns was tallied. the following example is taken from an ε s's narrative to illustrate this measure:"when he brought a cow into the house and he wanted to milk it so he didn't know . . ." one is unable to determine to whom the "he" refers. (b) ambiguous pronouns that is, where the identity of the referent corresponding to the pronoun was ambiguous. the number of instances when this occurred was tallied. the following example is taken from an ε s's narrative to illustrate this measure: "the man went flying... and then the other man said: 'i'll show you how'. . . . and then he took the long . . . then he pulled, then he said: "what's wrong". there are two possible referents for "he", that is, 'the man' and 'the other man', resulting in ambiguity. (c). incorrect reference of the pronoun that is, where identity of the referent was incorrect. this was based on the experimenters' knowledge of the content of the narrative. from a consideration of each of the above measures, a general measure of ambiguous pronoun usage in discourse was obtained. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 η. berger & α. sinoff statistical treatment of data due to the 'free production' nature of the discourse tasks, the ε and c groups' narratives could not be directly compared.2 6 thus a co-variate for each task had to be identified. the co-variate selected was the number of words on the film task, and the number of sentences on the story task. the spearman rank order correlation test was used to correlate each of the measures with the co-variate. where correlations were significant, i.e., where the co-variate influenced the scores obtained, the scores were divided by the co-variate. a mann whitney u test for significance was then carried out to compare the ε and c groups on each measure. results a significant difference between the ε and c groups was found on measures of semantic cohesion and ambiguous pronoun usage. the groups did not differ significantly on measures of semantic content, tense range and tense continuity (table i). measures of cohesion film task story task semantic content number of main events number of inaccuracies 7,5 8,5 4,5 8 semantic cohesion ( + log seq) ( l o g s e q ) fluency 3 x 3 x 6 1 x 3 x 2,5 x measures of tense tense range the number of complex tenses used appropriately 11,5 10 tense continuity the number of inappropriate tense shifts of a main verb 11 5 measures of pronouns / / measures of ambiguous pronoun usage 4 x not analysed values represent the mann whitney u scores obtained on each measure. x — significant differences between the ε and c groups (p = 0,05). (+ logseq) — the number of events related logically and in sequence. (— log seq) — the number of errors in logic and sequence. ι table 1. summary table of significant differences between the ε and c groups on measures of cohesion, tense and pronouns. the south african journal of communication disorders vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aspects of discourse in language impairment 11 d i s c u s s i o n o f r e s u l t s measures of cohesion on measures of semantic content, the ε and c groups did not differ significantly, demonstrating the ability to include the relevant features in their narratives. the significant difference between the groups on measures of cohesion related to the manner in which the events were related. the ε groups' narratives were characterized by more errors affecting logic and general sequence. with this group events were merely listed resulting in incoherent narratives which the ss were unable to communicate effectively. in contrast, the c group scored higher on the number of events related logically and in sequence, thus producing coherent stories. contributing to the ε ss' incoherence, was their dysfluency in relating the narratives. this created discontinuity and reduced the speaker's communicative efficiency. measures of tense from table i it can be seen that the ε ss did not experience difficulty with aspects of tense use in discourse. however with regard to aspects of tense range, a qualitative difference between the two groups was found. this manifested in the variety and range of simple and complex tenses used. for example, all ss utilised simple tenses, however the ε ss used fewer complex tenses than the c ss. generally the ε ss used a small variety of tense forms, specifically in terms of complex tense usage. for example, no ε s used the present progressive, present perfect, and perfect progressive tenses, although these were used by all c ss. results on tense continuity revealed a small number of tense shifts characterizing the narratives of both groups. an in-depth analysis of the narratives revealed that all instances of tense shift of a main verb occurred either preceding or following the reporting of direct speech. this was illustrated by the substitution of present tense for past tense. for example: " . . . and some stones fell on top of his head and then the fat one says: 'try again' and then another man came over . . ." a consideration of the appropriateness of the tasks employed for measuring tense range and tense continuity indicated that the story task was more revealing of aspects of tense range than the film task. it seems that this was related to the presence of temporal conjunctions and adverbs ('since' and 'while' in the example below) in the story task which implied complex tense usage. this is illustrated in the following example taken from a c s's narrative on the story task: "sam's class wanted to go to the zoo and they had been looking forward to it since the beginning of the term . . . his teacher said: 'why are your clothes so dirty'. so he said: 'while i was playing soccer somebody came and tripped me . . ." with regard to tense continuity, the film task was more appropriate than the story task. since the film contained direct speech only, ss tended to die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol.25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 η. berger & α. sinoff recount as much of this as possible. this therefore provided the context for tense shifts to occur. measures of pronouns a significant difference between the ε and c groups was found on measures of ambiguous pronoun usage. the ε ss used more non-indexed pronouns in their narratives than the c ss, that is, the ε ss violated the rule of referring to an np and appeared to rely on presupposed mutual knowledge shared by the speaker and listener. for example: "you see, he was sitting on the floor, and then he said that, then he said: 'wait a minute' — because he wanted to try and get him up". both groups demonstrated a certain amount of difficulty with explicit reference to pronouns. where there were two possible referents for a pronoun, ss did not use the pronouns specifically. for example: "the one man was sitting on the floor and the other tried to get him onto the bed and they were trying to get it out and he comes and he cuts their trousers and he hit him and he went flying onto the top bunk." g e n e r a l d i s c u s s i o n . from the above results, it is apparent that the ε group's discourse was inferior to that of the c group, in that the ε group's narratives demonstrated poor semantic cohesion and restricted syntactic forms in comparison to the c group. it is interesting to note'that restricted forms were seen not only in terms of smaller tense range and less explicit reference in pronouns, but also on other aspects (not directly analysed) such as vocabulary, length of np, for example, "the other man with the straight hair" versus "the man", and overall length of narrative. the c group's narratives reflected what could be described as "richness" as compared with the ε group's. this is illustrated in the following examples taken from an ε and c s's narratives:e s: "alright you see, the man brought this cow in and then they didn't know, they were pumping like water . . ." c s: "there was the three stooges and one of the big fat ones brings in the cow and then he says 'how do we milk the cow?' so another one of the three stooges takes the bottle and he puts it down and he says: 'give', and the cow is supposed to give milk and it doesn't so he goes to the back and he pulls its tail like you do with a water pump . . ." cognitive, linguistic and social factors can be considered in recounting for the differences in the communicative ability of the ε arid c groups: cognitive factors" ' two modes of style characteristic of the young child's egocentric language23 were identified in the ε group's narratives. these were juxtaposition and syncretism. for example ss tended to list events and did not link them in the causal, temporal and logical relationship conveyed in the task. according to bates,3 a particular level of cognitive maturity is required to transform information received into a meaningful the south african journal of communication disorders vol 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aspects of discourse in language impairment 13 message. since the ε ss were, according to their age, past the stage of 'egocentricity', some form of cognitive immaturity/delay may be suggested to account for their performance. linguistic factors in accounting for the results obtained, it is important to consider the characteristics of verbal discourse. firstly, it is produced in a situational context and not in isolation. this requires expression of semantic relations appropriate to the context. secondly, the linguistic formalisation of the semantic relations requires syntax which extends beyond the syntactic structure of a single sentence. it seems then that discourse places great demands on linguistic processing as well as cognitive capacity. it is possible that the ε group were unable to cope'on this level. social factors social factors, such as the ability to role-play, are important for effective communication. according to flavell," ellipsis and indefinite pronouns in a message are evidence of a basic failure on the part of the child to keep the listener's role in mind while communicating to him. this suggests that the ε group's increased use of ambiguous pronouns as compared with the c group may be related to their inability to role play. j in summary, it seems that the child's communicative ability in discourse should be viewed in the context of a combination of cognitive, linguistic and social factors. conclusion the present research has shown that a consideration of language beyond the single sentence level is relevant as it has highlighted differences between the ε and c groups. this implies the need for diagnosis and therapy of expressive language disorders in the older child to be considered with reference to discourse. failure to consider this may result in subtle language errors going undetected. it may also lead to the premature dismissal from therapy of children who demonstrate competence on the sentence level, but who have a more complex linguistic difficulty. it has been reported that children with a history of language disorders frequently have learning difficulties in later schooling2 — further highlighting the value of viewing language within a discourse framework. discourse appears to be a useful tool for assessing a broad range of language function as it taps semantic and syntactic aspects. specific discourse situations could be devised to evaluate and teach aspects important for effective communication. in therapy, the child's attention could be drawn to semantic relations as well as the appropriate expression of these relations. areas such as nonfluency, logical sequencing of events, appropriate use of pronouns in terms of indexing pronouns for reference and eliminating ambiguities, and abilities such as role-playing could be considered in a therapy program. situations such as having two or more actors of the same sex could be utilised to teach the use of pronouns. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 η. berger & α. sinoff it would seem that future research specifically directed to the application of discourse in diagnosis and therapy of the older language-impaired child would be of value. a ckno wledgements the writers would like to express their sincere thanks to ms c. penn, lecturer, dept. of speech pathology and audiology, university of the witwatersrand, johannesburg, for her guidance and help. references 1. antinucci, f., and miller, r. (1976): how children talk about what happened. 7. child lang., 3(2), 167-189. 2. arnold, g. (1969): patterns of predictive significance in preschool children with gross delay in speech and or language development. paper at the convention of the american speech and hearing association, chicago, illinois. 3. bates, e. (1976): language and context: the acquisition of pragmatics. academic press, new york. 4. beilin, h. (1975): studies in the cognitive basis of language development. academic press, new york. 5. bronckart, j., and sinclair, h. (1973): time, tense and aspect: cognition. int. j. cognitive psychol., 2, 107-131. 6. campbell, r., and wales, r. (1970): the study of language acquisition. in new horizons in linguistics, lyons, j. (ed.), penguin 242-260. 7. cazden, c.b. (1968): the acquisition of noun and verb inflections. child development, 39, 433-438. 8. cazden, c.b. (1972): the situation: a neglected source of social class differences in language use. in sociolinguistics. pride, j.b., and holmes, j., (eds.), penguin, 294-313. 9. chomsky, c. (1969): the acquisition of syntax in children from5to 10. research monograph no. 57 cambridge, massachusetts: the m.i.t. press. 10. cromer, r.f. (1970): "children are nice to understand": surface structure clues for the recovery of deep structure. brit. j. psychol., 61, 397-408. 11. flavell, j.h. (1968): the development of role taking and communication skills in children. john wiley and sons inc. n.y. 12. halliday, m.a.k. and hasan, r. (1976): cohesion in english. longman group ltd., london. , 13. haynes, w.o. and hood, s.b. (1978): dysfluency changes as a function of the systematic modification of linguistic complexity. j. commun. dis., 11, 79-93. 14. hendricks, w.o. (1973): essays on semiolinguistics and verbal art. mouton, the hague. the south african journal of communication disorders vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aspects of discourse in language impairment 15 15. herriot, p. (1969): the comprehension of tense by young children. child development, 40(1), 103-110. 16. huxley, r. (1970): the development of the correct use of subject personal pronouns in two children. in advances in psycholinguistics. flores d'arcais, g., and levelt, w., (eds.), w. amsterdam north hollard pub. co. 17. kessel, f.s. (1970): the role of syntax in children's comprehension from ages six to twelve. monographs of the society for research in child development, 35. 18. lee, l. (1974): developmental sentence analysis. northwestern university press, evanston. 19. lees, r.b. and klima, e.s. (1969): rules for english pronominalization. in modern studies in english. reibel, d.a. and schane, s.a. (eds.). prentice hall inc. new jersey. 20. limber, j. (1976): unravelling competence, performance and pragmatics in the speech of young children. j. child lang., 3, 309318. 21. menyuk, p. (1969): sentences children use. the m.i.t. press, cambridge. 22. palermo, d.s. and molfese, d.l. (1972): language acquisition from age five onward. psychological bulletin, 78(6), 409-428. 23. piaget, j. (1926): the language and thought of the child. routledge and kegan paul ltd., london. 24. pit corder, s. (1973): introducing applied linguistics. penguin. 25. quirk, r., and greenbaum, s. (1976): a university grammar of english. longman group ltd., london. 26. saling, m. (1977): lecturer, department of psychology, university of the witwatersrand. personal communication. 27. tuch, s. (1976): an aspect of "communicative competence" in older language impaired and normal children — their ability to produce coherent narrative sequences of sentences. unpublished research report, department speech pathology and audiology, university of the witwatersrand, johannesburg. 28. van der geest, t„ gerstel, r., appel, r„ and tervoort, b. th. (1973): the child's communicative competence. mouton, the hague. 29. waryas, c.l. (1973): psycholinguistic research in language intervention programming: the pronoun system. j. psycholing. res., 2(3), 221-237. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) self contained 3track instrumentation tape recorder for scientific analysis igap four speed recorder: 1 5 , 7 ϊ ι 3 j e n d 1 ϊ i n / 8 · t w o d i r e c t recording t r a c k s a n d o n e f m t r a c k . applic a t i o n a s a precision sound level m e t e r w h e n a m e a s u r e m e n t microphone is c o n n e c t e d . specifications (typical values) unbalanced line input, impedance 100 kft. 10 mv for mpl (maximum peak level). line output at mpl, 1 v into 10 ki2 loudspeaker amplifier 1 w performance obtained by recording: frequency response, 20 db below mpl, 15-in/s 25 hz 35 khz * 1 , 0 d b ; 7 j i n / s 25 hz 20 khz * 1 , 0 db; 33 i n / s 25 hz 10 khz a 1,5 db; 1i i n / s 25 hz 3,5 khz a 1,5 db; at 1i i n / s recording from 2,5 hz and transposition for restitution. signal-to-noise ratio at 15 in/s, linear 57,db, asa a weighted ccir 64 db and nab 62 db distortion at mpl = 320 n w b / m . h 3 < 1,5% crosstalk attenuation at 10 khz a 50 db phase fluctuation a 12° between tracks at 7 i i n / s and 10 khz ^ fm-track at 15 and 7 j in/s: carrier frequency 17 khz maximum frequency deviation * 4 5 % peak-to-peak input voltage 2 v frequence response 0 hz to 4 khz 3 db signal-to-noise ratio 44 db speed stability at 15, 7 i and 33 in/s: * 0 . 1 % wow and flutter, din 45 507 weighted peak-to-peak value, 15 i n / s * 0 , 0 5 % , / 7 1 i n / s ±0,07%, 33,in/s 0,12%, 1i i n / s * 0 . 2 5 % , / ναβααπηιξηξξι vitaphone (pty) ltd v . p o b o x 4 6 3 7 , j o h a n n e s b u r g t e l : 3 7 1 4 5 4 / 5 5 t h f l o o r , c a p e y o r k h o u s e 2 5 2 j e p p e s t r e e t , j o h a n n e s b u r g t e l e x : 8 2 1 6 3 s a the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 15 assessment of speech intelligibility in five south-eastern bantu languages: critical ^ considerations marlene carno jacobson, ph.d (witwatersrand) department of speech pathology and audiology, university of the witwatersrand, johannesburg anthony traill, ph.d (witwatersrand) department of linguistics, university of the witwatersrand, johannesburg abstract this paper examines criteria underlying the development of tasks and materials for the measurement of speech intelligibility in five southeasternbantu languages. the chief considerations include utterance length, word familiarity and structure, and phonetic balance. it is established that the foundation research necessary for devising materials in south-eastern bantu languages on the same basis as those of fnelish has not yet been conducted. salient properties of the relevant african languages include multilingualism, dialectal variation, vocabulary differences between rural and urban speakers of the same language, borrowed words, the simple vowel systems, the fairly elaborate consonant systems prosodic features, certail syllable structure characteristics, and noun morphology. a rationale for the use of two measures of intelligibility is presented, while the need to adapt many criteria characterising english materials is demonstrated. opsomming . hierdie referaat ondersoek die kriteria wat onderliggend is aan die ontwikkeling van take en materiaal vir die meting van spraakverstaanbaarheid in vyf suid-oosterlike bantoe tale. die hoofoorwegings sluit lengte van uiting, woordbekendheid en -struktuur. en fonetiese batons in. dit is bevestigdat die basiese navorsing wat benodig is vir die saamstel van materiaal in suid-oostelike bantoe-tale nog nie op dieselfde basisas eneels eedoen is nie opvallende kenmerke van die relevante afrika-tale is veeltaligheid, dialektiese variasies, verskille in woordeskat tussen landelike en stedelike gebruikers van dieselfde taal, leenwoorde, die eenvoudige vokaalsisteme, die betreklik uitgebreide konsonantsisteme, nrosodiese kenmerke, sekere eienskappe van lettergreepstrukture, en naamwoordmorfologie. 'n rasionaal vir die gebruik van twee verstaanbaarheidsmetings is aangebied en die noodsaak om kenmerkende kriteria vir engelse materiaal aan te pas, word ook uitgewys. the present paper explores the range of issues confronted on undertaking research which sought to measure the speech intelligibility levels of a series of surgically-treated oral cancer patients each of whom spoke one of five south-eastern bantu languages (viz. jacobson, 1986). the problem was approached by critically "dissecting" the notion of intelligibility in an effort to extract salient properties and, thereafter, by extrapolating applicable criteria of intelligibility measures to the set of phonetico-linguistic conditions characterising these languages. as such, the major concerns underlying speech intelligibility in the present paper are two-fold. the reconciliation of these two aspects forms the rationale for the choice of designated measures of intelligibility, and is represented in the materials themselves. i nine members of the south-eastern bantu family of african languages are recognised and have developed as educational media and literary languages in south africa (south africa, 1985): | 1. nguni languages: zulu, xhosa, swazi, and ndebele, among a total of twelve nguni languages. 2. sotho languages: southern sotho, northern sotho and tswana, among a total of eleven sotho languages. 3. tsonga. 4. venda. the present paper happens to deal with the nguni and sotho groups of indigenous languages, each of which is sub-divided to form dialect clusters. it was coincidental that the languages spoken by the randomly selected subjects of the study reflect the five most frequently spoken bantu languages in south africa, namely, zulu, xhosa, northern sotho, southern sotho, and tswana. in view of the number of dialects, some of which are poorly known, certain dialects have been raised to standard forms by taking into account various factors, such as the prominence of a die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 leader, or tribe size (ziervogel, louw, ferreira, baumbach & lombard, 1967). a second major feature of this group of languages is the profound multilingual situation which characterises speakers of the bantu languages of south africa. no materials appear to have been published previously in the relevant african languages for the specific purpose of measuring intelligibility. speech discrimination word lists used in audiology (e.g. baragwanath hospital, 1977) and phonetic inventories (e.g. hillbrow hospital, 1981) did not meet those requirements deemed fundamental to the study concerned, namely, clear evidence of the formulation of a set of criteria for item selection, taking into account previous research on intelligibility. speech intelligibility is the property of speech communication involving meaning, and is the quality or state of being comprehended or understood. a signal is intelligible to a listener, and for a speech signal to have intelligibility, both a speaker and a listener must be involved (lehiste & peterson, 1959). hence, because both speech production and speech perception are involved, distinctly more complexity is implied than is suggested by the use of superficially related terminology, such as articulation, recognisability, identifiability, and discriminability, which do not necessarily pertain to speech communication, consider meaning, or take full account of the listener. numerous factors determine this "communicative effectiveness". in the main, these are the social context, message content, the stimulus signal and the medium used for signal transmission, the speaker and his speech mechanism, and the characteristics of the listener. speech intelligibility is employed by numerous disciplines (e.g. speech pathology, audiology, and acoustical engineering), each of which places differential emphasis on these major elements of the communication process. in the research on which this paper is based, the emphasis was on speaker characteristics with an attempt being made to control all other parameters as closely as possible, so that non-speaker parameters could serve © sasha 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 • ii thic naner seeks to determine l a r g e l y as constants^ es^ntially^ thus ̂ ^ ^ intelligibility in a optimal message content in oraer valid fashion. . λΐηο feature of speech inteuigibility is its performance ^ ^ ^ υ 0 * γ a „ d " y m a n 1981). as such, it supersedes several related criteria and models' which capture a more limited scope. these include qualitative, perceptually-based tools used for differential diagnosis (e.g. darley, aronson & brown, 1975), the evaluation of individual components of speech production, such as defective articulation (e.g. prather, 1960), phonation, or resonance, and models which systematically evaluate the anatomical or physiological locus of disturbance along the vocal tract, such as the "point-place system" of rosenbek and lapointe (1978). the inclusive nature of the concept of intelligibility is further exemplified by its pertinence to different speech-disordered groups (e.g. the cerebral palsied, alaryngeal speakers, cases of congenital orofacial malformations, among numerous others), despite the varying nature of the pathological elements of the speech production process. the concept of intelligibility is therefore sufficiently flexible to house a range of speech production variables, varying in combination and degree. it is thereby possible for each clinical population to bring to research its associated symptomatological milieu and still be investigated under the broad umbrella of intelligibility. the potential information offered by intelligibility data is diverse, depending on both task selection and on the level of analysis undertaken: the more detailed the analysis, the richer and more versatile the applications of the data. in the literature, the analysis and presentation of intelligibility data assume a variety of forms: 1. simple percentages of intelligibility reflecting the number of discrete units perceived correctly. 2. analysis of perception-production confusions to form matrices (e.g. nichols, 1976). 3. analysis of the distance between produced and perceived phonemes (in words) in terms of distinctive features: manner, place or voicing differences. 4. breakdown into analysis of vowel and consonant intelligibility, once the basic word intelligibility scores have been computed. 5. the determination of the patholect for a particular clinical population, or the pattern of phonemic confusions for a particular clinical group. 6. combination of inteuigibility measures with other measures such as speech rate, for example "intelligible words per minute" (iwpm) and "unintelligible words per minute" (uwpm) — yorkston and beukelman (1981). 7. description of auditory or perceptual characteristics of the speech. 8. development of a classification system for recognition of different groups demonstrating a particular speech disorder. 9. development of an intelligibility measure which reflects severity of involvement such as shriberg and kwiatkowski's (1982) percentage consonants correct (pcc), which is, however, defined as "a measure of articulatory proficiency". methods of assessment of surgically-treated oral cancer patients apparently sample the range of procedures generally employed in the examination of intelligibility in english-speaking pathological populations. the range of methods described in current and older research is extensive. however, whereas older research glosses informally through accounts of intelligibility, current research appears to aim at greater qualitative and quantitative specificity, marlene carno jacobson and anthony traill with certain intelligibility materials even being designed for particular clinical populations and the ranges of severity within them. standardised word lists frequently constitute the materials of speech intelligibility assessment, e.g. the cid w.22 phonetically balanced (pb) word lists (hirsh, davis, silverman, reynolds, eldert & benson, 1952), as employed in numerous studies (e.g. skelly, 1973); the consonant-syllable nucleus-consonant words (lehiste and peterson, 1959), as selected and adapted by tikofsky (1970), for example, for use with dysarthrics; the fairbanks (1958) test of phonemic differentiation (a "rhyme" test), as used by kipfmueller and prins (1971), for example; the word lists of black (1957), as used by yorkston and beukelman (1981), for example; and moses' (1969) monosyllabic word lists (as cited by nichols, 1976). standardised sentence materials (e.g. the cid "everyday sentences") have also been utilised in examining the construct and criterion validity of various intelligibility procedures (schiavetti, metz and sitler, 1981). finally, standardised phonetically balanced passages of reading, such as "my grandfather", "the rainbow passage" and "arthur the rat", (fairbanks, 1960), have been employed as elicitation material for intelligibility measurement (e.g. piatt, andrews, young and neilson, 1978). however, the use of read material introduces a prerequisite of patient literacy, which was inappropriate in the research concerned. a further batch of materials includes those designed for specific clinical populations, such as the glossal and labial word lists for surgically-treated oral cancer patients (e.g. skelly, 1973). in contrast, other research methods are individualistic from the viewpoint of the researcher, for example, the use of read sentences from early reading books in the case of deaf school-leavers (kyle, conrad, mckenzie, morris & weiskrantz, 1978), picture description (markides, 1978), and spontaneous speech samples (weiss, 1978, cited by schmidt, 1984). under the latter circumstances, the properties of the spoken material are clearly far less stringently controlled. as mentioned above, no similar spectrum of formalised materials exists in the languages under consideration. nonetheless, within the above range, certain themes and issues pertaining to the choice and characteristics of materials recur with remarkable regularity, thereby illustrating the origins of useful criteria for devising appropriate intelligibility measures. these may be categorised in terms of three key components: i a. the composition of speech materials, which takes into account the message to be communicated, its length, complexity,! and spontaneity. i b. the form of response required of the listener, in order that he may register his reaction to or understanding of the message, either by written or spoken means. c. the choice of general procedural characteristics influencing the reliability and validity of the assessment, such as the manner in which stimuli are presented, and the selection of judges. the first component, the composition of spoken materials, is the chief area of interest in the present paper. the second component extends beyond the focus selected for the present discussion. only isolated aspects of the third component are relevant here: irrespective of the nature of the materials that are selected, or the manner in which the listener responds to the signal, the mass of methodological details pertaining to stimulus presentation and listener characteristics is largely independent of the language of the speaker and thus warrants routine consideration. such factors the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a s s e s s m e n t of speech intelligibility in five south-eastern bantu languages: critical considerations 17 include the decision to pre-record the speech stimuli or to present hese live whether to use the same stimuli repeatedly, the selection of suitable carrier phrases, and details of judge selection and training. certain aspects of judge selection are, however, incorporated in the discussion below. furthermore, this review proceeds from overriding linguistic properties of the five languages, largely of a general, sociolinguistic nature — with implications at a semantic level, and progresses towards the enumeration of more specific, phonetic, phonological and morphological characteristics. all of these considerations affect the choice of individual word items. key considerations in devising appropriate materials a. composition of speech materials 1. utterance length while single words regularly form the basis of speech intelligibility scores, researchers frequently comment that singleword performance does not permit the evaluation of several critical parameters of speech, such as the effects of juncture, rhythm and stress patterns, and rate control (e.g. griggs, 1958). furthermore, the addition of context requires less fine discriminations of the listener (miller, heise & lichten, 1951). as such, there appears to be a demand for the development of formal materials suitable for studying the intelligibility of connected speech and its intrinsic prosodic properties. towards meeting this need, schiavetti, sitler, metz and houde (1983) recently established two formulae for calculating contextual speech intelligibility on the basis of single-word intelligibility scores. in spite of the above-mentioned criticism, nichols (1976) reports that excellent correlations exist between pb scores and sentence intelligibility scores for esophageal speakers: " . . . hence, word intelligibility measures may be used as estimates of connected speech abilities with confidence". hodson and paden (1982) cite research with phonologically-impaired children demonstrating that essentially the same processes were revealed by single-word elicitation procedures as by both delayed sentence imitations, and by connected speech samples. this work therefore plays down, to some extent, the presumed effects of utterance length. yorkston and beukelman (1978) support the above findings noting that mean intelligibility scores for sentences were not different from scores derived from single-word tests. however, for transcription tasks, there was an interaction between severity and intelligibility score's on sentences versus words, that is, the most intelligible speakers tended to score higher jon sentence transcriptions, while the least intelligible speakers received higher scores on single words. the same researchers also found that various measurement techniques, including bojth sentences and single words, tended to rank speakers similarly. beukelman and yorkston (1979) confirmed the close relationship between both single-word and sentence intelligibility, and the amount of information transferred between a speaker and a listener. interestingly enough, piatt, andrews, young an<i neilson (1978) concluded that intelligibility of pbs was an excellent measure for assessing speech competence after finding good correlations with assessments of the recognisability of individual phonemes. it is clear, however, that the above correlations are mostly calculated on the basis of standardised english materials. as such, extrapolation of these results to other languages is uncertain. in summary then, the first issue encountered was whether to establish speech intelligibility levels based on single words and/or connected speech. in view of the property of context, it is logical that connected speech would automatically reflect the semantic, morphological and phonological characteristics of a language. therefore, the following discussion pertains chiefly to the development of singleword intelligibility materials, although a range of sociolinguistic characteristics of connected speech is highlighted simultaneously. die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 33, 1986 2. word familiarity/frequency a chief dimension along which word item selection for formal lists may be restricted, is that of vocabulary or work familiarity (e.g. cid w.22 word lists). schultz (1964) examines the criterion of high familiarity of cid w.22 words, analysing the relationship between stimulus and response familiarity, and concludes that although the required educational level of the listener is lowered, certain unique patterns and problems arise (schultz, 1964). most researchers still agree, however, that the greater the frequency of the word, the more likely it is of being intelligible (e.g. black 1952). this phenomenon has been explained in terms of "set" or "expectancy" (ibid. 1952). in english, word familiarity is usually controlled by consulting thorndike's list of word frequencies (1932, cited by hirsh et al. 1952) or that of thorndike and lorge (1952, cited by lehiste and peterson, 1959). in the african languages under consideration, only one study, of a most preliminary nature, has investigated word frequency per se (viz. gowlett & rassmann, 1979), in one language. this study considers the 367 most common words in southern sotho, while griesel (1979) lists common zulu vocabulary items for instruction of learners of the language. such research provides cursory guidelines regarding word frequency in african languages, and gives rough clues as to culturally relevant items in other bantu languages. it appeared therefore that word familiarity was a significant consideration but its implementation would be constrained by the paucity of formal indices of word frequency. as such, this criterion would have to be borne in mind informally when formulating materials. several interrelated phenomena further complicate the application of the principle of word familiarity to south-eastern bantu languages, exerting their influences predominantly on the choice of vocabulary items appropriate for single-word intelligibility testing. these include the factors of multilingualism, vocabulary differences between urban and rural speakers of a language, mutual intelligibility in the face of dialectal variation, and the prevalence of borrowed words. a. multilingualism a prime factor colouring the "purity" of the bantu languages spoken by the subjects of the research under consideration, that of the judges, as well as native speakers who were consulted, is the phenomenon of multilingualism (e.g. wilkes, 1978). this is a normal condition among black south africans, particularly in the industrial cities and border areas, such as the western transkei, where xhosa and southern sotho co-exist, and eastern transvaal, where tsonga, pedi and zulu overlap (lanham, 1978). in fact,' in such multilingual communities, a "pure" northern or southern sotho, tswana, zulu, or xhosa speaker has long since disappeared, although a pure form of his language is still used in certain rural areas (wilkes, 1978). lanham (1978) cites the example that it is expected that an nguni speaker will have a good control of a sotho language if a substantial proportion of the immediate speech community speaks sotho. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 marlene carno jacobson and anthony traill one subject of the research under discussion a nursing sister illustrates an apparently normal occurrence. she was ra.sed and educated speaking southern sotho, and married a swaz. speaker. after undergoing her professional training in port elizabeth for a year and had to learn to speak xhosa^she currently lives in a zulu-speaking community in an east rand urban area, delivers lectures in zulu, speaks english at home to her husband, converses with other sotho speakers in zulu, but feels that her zulu may be marred by a trace of sotho "intonation". she also feels that after twenty-five years of speaking zulu predominantly, her zulu is better than her sotho. this history presents a difficult decision in terms of the choice of language for administration of intelligibility tests. finally, the inherent subjectivity of autobiographical reporting must be considered. subjects also claimed that whilst living in their townships surrounding johannesburg, they had found themselves combining snatches of several languages. this would appear directly attributable to the multilingual milieu in such areas. hence, it seems that in addition to possession of a language medium for education or rearing, there is an urbanisation of original, "pure" forms and the development of "city dialects". the degree of this mixing, the levels on which it occurs, to what extent it takes place systematically and whether or not it differs from speaker to speaker and occasion to occasion, are but a few of the questions of which the answers can only be guessed at, for the simple reason that no researcher has as yet made any attempt to investigate these fields with their wealth of sociolinguistic phenomena (wilkes, 1978: 110). while on the one hand, there is the urban black demonstrating an extensive multilingual repertoire, there is on the other, the rural black with his associated vocabulary. in the study under consideration, the source of subjects covered both rural and urban areas, while judges were likely to be urbanised. as such, it was important to take both elements into account in compiling materials, by locating shared linguistic features and by avoiding both extremes as much as possible, so that all items were acceptable to both types of speakers. b. dialectal variation while all standards are to some extent idealisations, persistent difficulties arise in devising materials due to the prevalence of dialectal variation in the south-eastern bantu languages. although more than a dozen bantu dialects have been investigated, many others have hardly been described. far more than half of the dialects of which the nguni and sotho languages are composed, are as yet undescribed (wilkes, 1978). to what extent these dialects are (still) characterised by deviant or distinctive systems, or have had to make way for other (more dominant) systems, will become clear only when a comprehensive survey of all the south african bantu language dialects is carried out (wilkes, 1978). in the practice of compiling word lists, it was difficult at times to know whether the native speaker being consulted was in fact speaking an unstandardised dialect or not. furthermore, native speakers frequently disagree on lexical issues, and therefore, without actually consulting a vast range of native speakers, which was beyond the scope of the study, the information provided to the researcher had to be treated cautiously. word lists is the influence of english and afrikaans. in many dictionaries numerous entries representing such influences, are labelled "borrowed words". the large english-afrikaans vocabulary of sotho and the phonological principles by which loan words have been incorporated, have been described by kunene (1963, cited by lanham, 1978). van wyk (1978) notes that english words were borrowed in the "educational, technical, commercial and industrial spheres", i.e. in those spheres where english is used extensively by blacks. afrikaans loans on the other hand are drawn from practical spheres, such as clothing, farming, labour, household implements and foodstuffs. the ratio between english and afrikaans loan words varies in the different languages, depending upon the proximity to either predominantly afrikaans or english-speaking communities (van wyk, 1978). in drawing up suitable lists of word items, the familiarity of borrowed words to the range of speakers of the relevant languages would be inestimable. thus, unless these are extremely common, these should be omitted wherever possible in preference to more indigenous words. conversely, in the urban areas speakers of non-standard varieties of the south-eastern bantu languages would find certain standard forms beyond even their passive lexical knowledge. it would therefore seem desirable to avoid selecting word items characterising either extreme, i.e. borrowed or esoteric indigenous words. the methodological implications of the above factors for word familiarity complicate the task of devising single-word materialsconsiderably. their recognition is nonetheless helpful in constraining the selection of word items along appropriate dimensions. it is pertinent too to consider the control of word familiarity in direct relation to both listeners (judges) and speakers (subjects). for both groups it would be desirable that the language used for test administration is that spoken in the home during childhood, as well as that comprising the vernacular during schooling. furthermore, in order to avoid the uncontrollable complications resulting from speaker unfamiliarity with word items, an auditory model for imitation should be provided by a proficient speaker of the language who is also familiar with the test materials, ι the problematic influence of word familiarity, compounded by the fact that the subjects of the present research did not all speak the same language, could arguably be obviated through the'use of a single, cross-linguistic task comprising nonsense words, additionally spanning a progression in phonetic complexity. such a task would thereby tap phone recognisability, or, viewed differently, articulatory efficacy. however, (i) such a task would be of limited clinical significance — the production of phonemic distinctions is of greater interest than the capacity for articulatory agility — which is linguistically meaningless; (ii) it is most probably that only through production of linguistically meaningful units (i.e. words) that it can be established whether target phonemes are recognisable, in spite of phonetic distortion or allophonic variation; ·-' (iii) linguistic variety within the subject sample was not sufficiently problematic that articulatory capabilities of subjects and inferences regarding articulatory functioning would be irretrievable. c. borrowed words a further factor contributing to the difficulty of item selection for 3. word length single-word intelligibility materials in english have mostly comthe south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a s s e s s m e n t of speech intelligibility in five south-eastern bantu languages: critical considerations 19 nrised m o n o s y l l a b l e s , as is evident from the original pb-50's ieean 1948), cid w.22 pb word lists (hirsh et al. 1952) and the f a i r b a n k s rhyme test (fairbanks, 1958). this is perhaps due to the well-documented finding that the greater the number of syllables c o n t a i n e d in an english word the more intelligible the word is likely to be (e.g. black, 1952). in the relevant african languages, monosyllables are comparatively infrequent. therefore extracting the criterion of fewest possible syllables per word is perhaps inappropriate, as the effects of multisyllabic words on intelligibility may not be the same as in english. in the nguni and sotho languages, the criterion of monosyllabicity is virtually impossible to conform to as trisyllables and bisyllables, respectively, comprise the canonical forms of lexical items, while monosyllables are comparatively infrequent (cole, 1955)'· (the canonical forms of lexical entries for nguni verbs are frequently bisyllabic when constituting singular imperatives, but these items contain some undesirable redundancy, as is discussed later). monosyllables are therefore insufficiently representative of the relevant languages to constitute an admissible criterion for the word structure of single-word intelligibility materials. nonetheless, the reasoning behind the use of monosyllabic english words perhaps implies that words should have as few syllables as possible. in the absence of verb prefixal and suffixal formatives, verb stems in the nguni and sotho languages are very commonly bisyllabic (cvcv shape). in the nguni languages, this bisyllabic word structure represents the singular imperative form and some pronouns. in the sotho languages, nouns also have a cvcv structure, whereas nguni nouns mostly have a vcvcv structure due to the noun class prefix always beginning with a vowel. there are very few productive noun suffixes in the south-eastern bantu languages. the bantu languages are also syllabic tone languages (i.e. each syllable in a word has its particular tone value). the pattern of the syllable is mostly open, t a k i n g a jcv form (consonant/consonant combination + vowel), but sometimes there is a no word-initial consonant (e.g. "a-ba-ntu": people zulu). in the sotho languages it is not uncommonl to have a cvc syllable shape, w h e r e t h e final c o n s o n a n t is the syllabic nasal, / d / . t h e fact that the final consonant always has] the same identity, is possibly a source of phonemic redundancy. taking into account the present considerations regarding word structure, it is apparent that xhosa and zulu vocabulary items of vcvcv form comprise nouns, while in the sotho languages, the cvcv form demonstrates grammatical variety, including nouns, verbs and pronouns. from a grammatical point of view therefore the nature of bisyllabic nguni words is more restricted than that of sotho, and the exclusive selection of singular verb imperatives would add considerable redundancy to the stimuli in terms of both tonal cues and the identity of the final vowel, which would always be / a / . however, the difference is not seen as significant because the phonological properties of the different word classes are homogeneous in major aspects, and are therefore of no specific interest. the presence of syllabic liquids and nasals in the sotho languages (e.g. / r / and / m / ) results in several words of a cv structure, which are bisyllabic, and words of a cvcv structure, which are trisyllabic (e.g. "rre" : father, "mmini" : dancer — tswana). in view of the fact that such syllable structures are characteristic, these two forms would have to be included in the respective sotho word lists. 4. phonetic balance the principle of phonetic balance, which probably embodies the most stringent form of the notion of "phonetic composition representative of the language" (egan, 1948), dictates that the relative frequencies of occurrence of component speech sounds in a language, that is, their distribution in normal speech, should be reflected in any word list. in english pb materials, the phonetic composition (balancing) is based on dewey's frequency count of english sounds in a sample of 100000 words (dewey, 1923, cited by egan, 1948). tobias (1964) states that phonetic balance is not a meaningful criterion for construction of word lists. he offers the rationale that dewey's phonetic analysis of the relative frequency of english speech sounds was almost completely of written material. tobias also observed "startling differences" in phonetic structure between any one pb list and any other. he states that although egan's original pb-50 lists are not well-balanced phonetically, they are diagnostically superior to the cid w.22 lists in which the balance is far better. he concludes that since discriminationtesting based upon the pb-50 lists is useful, phonetic balance could not be playing much of a role. nonetheless,the suggestion to consider the frequency of particular phonemes when devising materials, is pertinent. no indices of phoneme frequency are known to exist in the relevant african languages. it would seem desirable nonetheless to represent all the phonemes in each language in order to access the manner in which these were articulated by subjects and perceived by judges. an arbitrary decision would be necessary regarding the number of times each phoneme should appear in the relevant word list. table 1: consonant and vowel phonemes of five south-easteni bantu languages (*) combined with certain phonetic variants due to constitution of a cluster or nasal compound (c) or dialect (d). abbreviations: z. zulu; x. xhosa; n.s. northern sotho; s.s. southern sotho; t. -tswana. ζ. x. n.s. s.s. τ. 1. /p·/ /pv lb / ibl ibl /m/ /mft/ /»/ lil lil ejective stop aspirated stop murmured stop voiced stop implosive stop nasal murmured nasal glide voiceless fricative voiced fricative labiodentals j^j _ voiceless fricative /v/ voiced fricative [wf1] ejective affricate [„v] voiced affricate die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) marlene carno jacobson and anthony traill alvbolars / t,/ ejective stop /th/ /rf/ /d/ /β/ / * / / * / /δ/ /η/ /nft/ /γ/ /!/ /tl/ /tlv /dtj/ /te'/ /te h/ aspirated stop murmured stop voiced stop voiceless fricative voiced fricative lateral fricative voiced lateral fricative nasal murmured nasal trill lateral liquid * ejective lateral stop c aspirated lateral stop voiced lateral affricate c ejective affricate · aspirated affricate labio-alveolars /$s/ fricative /ps'/ ejective affricate /psh/ aspirated "double" alveopalatals /f/ voiceless fricative / y voiced fricative /p/ nasal /ph/ murmured nasal /j/ glide /tjh/ aspirated affricate /tj·/ ejective affricate ity murmured affricate /dy voiced affricate palatals /c' / ejective stop /c*v aspirated stop [pc'] voiceless stop /is/ murmured stop [ηί] voiced stop labiopalatals /fj/ fricative /φ// voiceless fricative /β}/ voiced fricative /pj'/ ejective "double" /pjh/ aspirated "double" /b}/ aspirated "double" velars /k·/ /kh/ /x/ /*/ /•)/ /kx'/ . /kxh/ /**·/ • / * / [ g ] ejective stop aspirated stop • voiceless fricative voiced fricative nasal • ejective affricate • aspirated affricate • ejective lateral affricate • murmured stop • voiced atop 10. clicks /// //h / in ii ii si /π/ε/ /nk// /!/ /ih/ in'· i it el frig/ /r,k>/ iii i 111*1 11 hi 1*111 /1//8//,]*///11. vowels /a/ it i /e/ m h! lol /u/ voiceless dental aspirated dental nasalised dental delayed voice dental fully voiced denta] preceding naaal+volceless voiceless alveopalatal aspirated alveopalatal nasaliaed alveopalatal delayed voice alveopalatal fully voiced alveopalatal preceding nasal+voiceless voiceless lateral aspirated lateral delayed voice lateral nasalised lateral fully voiced lateral preceding nasal+voiceless glottals ihl voiceless fricative voiced fricative table 1 contains the phonemic inventories of zulu, xhosa, northern sotho, southern sotho and tswana, based on the works of brown (1971), cole (1955), doke (1931), doke and mofokeng (1957), jordan (1966), khumalo (1981), mabille and dieterlen (1961), ziervogel et al. (1967), ziervogel, louw and taljaard (1981), and ziervogel and mokgokong (1975). these inventories are presented in order to identify the phonemic constituents of the south-eastern bantu languages and to informally observe differences from english. to capture subtle phonetic differences between ostensibly similar articulations belonging to different languages (e.g. / b / in zulu as compared to the sotho languages), finer phonetic specifications are incorporated within the phonemic description (viz. / b / versus / b / : murmured versus voiced / b / ) . the purpose of depicting certain phonetic variants, comprising members of consonant clusters or nasal compounds; is that clusters are particularly complex and therefore most taxing phonetically — quite conceivably affecting intelligibility. for this reason they would add an additional dimension of complexity to intelligibility word lists. in table 1 elements of clusters or nasal compounds are marked with a "c". 1 dialectal variants are incorporated in table 1 too, primarily to mark alternative correct productions which could be misconstrued as errors, and for the sake of completeness. these are marked with a "d". in conducting a single-word intelligibility task, dialectal variation would need to be taken into account and should not incur penalty. for example, in northern sotho, the labio-alveolar fricative, /#e/ , may also be produced as /te/ , or / h / , or / f / )ziervogel et al. 1967). certain segments appear only within ideophones in the canonical forms cited above. an ideophone is an onomatopoeic word form with its own morphology, phonology and prosodic rules (kunene, 1978). in view of these properties, the controversial definition of ideophones (wilkes, 1978), and their frequent appearance within a particular grammatical structure, such as "ho re . . ." (southern sotho), from which it may be indivisible, it would seem unwise to consider ideophones as word items. this view would hold irrespective of whether an ideophone contained a required phoneme. the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a s e s s m e n t o f speech intelligibility in five south-eastern bantu languages: critical considerations 21 tensive range of consonants in each of the above languages ared to english, has implications for the length of word lists c ° uwould be desirable to include all consonants more than once for reliability purposes. m d a r i s o n of the phonemes of zulu, xhosa, southern sotho, u r t h e r n sotho and tswana, reveals language-specific trends rtable 1)· the vast repertoire of clicks, voiced and voiceless f lives λ / and / y , and murmured forms o f / b / , / d / , and l are characteristic of zulu and xhosa. xhosa also has an extended range of palatal phonemes, depicted orthographically as " t y " and "dy", and the ejected velar affricate a w . in addition any zulu fricatives are pronounced as affricates in xhosa, for example, "inhloko" is "intloko", and "insimu" is pronounced "intsimi". particular to the sotho group of languages are the alveolar trill, / r / the aspirated lateral stop, / t l h / , the voiced alveopalatal fricative, μ , and the labio-palatal "double" phonemes (affricate-like, generally characterised by two virtually simultaneous, non-adjacent places of articulation), /f s /, / , /pw, and / w · members of the latter group tend to be dialectal in tswana. characteristic of northern sotho are the labio-alveolar phonemes, /to/, ,/ps·/ and fysw tswana contains marked dialectal variation, which influences the production of alveolar and alveopalatal affricates, and also leads to the non-lingual voiceless fricative also being produced as either / ( / or / h / . all five languages display phonemic aspiration, ejection of consonants, and the palatal nasal phoneme, μ . as a group these therefore show a variety of airstream mechanisms in speech: glottalic ingressive and egressive, velaric, as well as pulmonic airstream mechanisms. where vowel phonemes are concerned, south-eastern bantu languages have five to seven pure vowels as a rule, no central vowels, and no diphthongs. the nguni languages, xhosa and zulu, both have five basic vowel phonemes with one variant each of / e / and / o / , acting in complementary distribution as a result of adjacent vowel influence. the sotho languages, southern sotho, northern sotho and tswana, have seven basic vowels and four additional phonetic variants (ziervogel et al. 1967). b. response formats j the formalised materials discussed above require that the listener's response consists of' repetition, transcription, written completion of a word with one letter, or completion of multiplechoice response formats. it would appear though that transcription or stimulus repetition serves as the closest means of reflecting the listener's actual perceptions. although multiplechoice formats have excellent quantifiability and recognised usefulness, analysis of such tasks indicates that these may well test identifiability rather than intelligibility. the listener's "perceptions" are structured to fit a particular framework and real perceptions may be ignored. furthermore it has been demonstrated that multiple-choice response formats may be graded in difficulty by systematically altering the information provided to the judges, while keeping the stimulus constant (yorkston & beukelman, 1980). in this instance there is an inverse relationship between the number of selection options and inteuigibility (ibid.). the influential effects of various response formats with specified options suggest that these may contaminate the results of intelligibility tests and are best avoided. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 where test materials comprise connected speech, rating scales are commonly used to capture gradations of speech intelligibility. these clearly demand a different type of subjectivity to that of the procedures described previously, in that they rely on appraisals rather than the listener's actual comprehension of speech. however, the appropriateness of different rating scales deserves judicious consideration to ensure the selection of valid indices of speech intelligibility (cf. schiavetti, metz & sitler, 1981). many of the issues concerning response formats are examined by yorkston and beukelman (1978). these researchers conclude that it may be beneficial to take advantage of the task hierarchy that apparently exists among quantification procedures, instead of relying on a single measurement technique to quantify speech across the entire performance range. however, this suggestion would appear more suited to clinical practice than research, as in the case of the latter, a standard methodology is necessarily implemented. the nature of redundancy the foregoing discussion reveals various factors which could increase the redundancy of the speech signal during intelligibility testing. these include the offer of options in identifying stimulus words, the use of linguistic context, the exclusive selection of singular verb imperatives, and an increase in the number of syllables per stimulus word (certainly for english). however, redundancy in a word inteuigibility task is an undesirable feature in that it meddles with the attempt to measure "absolute" inteuigibility. meyerson, johnson and weitzman(1980)comment on the contribution of redundancy to the intelligibility glossectomees, reporting a 50 per cent discrepancy in intelligibility scores based on single words versus connected speech. in the present south-eastern bantu languages, there is likely to be some degree of redundancy in single words existing independently of that contained in connected speech, largely due to the multisyllabic, tonal nature of words in these languages. as such redundancy is potentially introduced at the word level in the form of semantic and grammatical tonal cues. these properties, in conjunction with fairly consistent syllable shapes and sequences, conceivably provide supplementary cues to single-word intelligibility stimuli. on a morphological level, furthermore, many single words in the bantu languages are polymorphic, with all prefixes and some suffixes showing grammatical tone. in this regard, it is noteworthy that in zulu, for example, noun prefixes are composed of only three vowels and seven consonants (westphal, 1973). this limited range could possibly aid the listener's decision when the noun stem is doubtful. on the other hand, noun stems are so varied that it is uncertain whether the class prefix effectively contributes any redundancy to the speech signal, in spite of its tonal characteristics and phonetic composition. it would seem, nonetheless, that if grammatical tone does add redundancy to work items, this would operate in the case of nouns predominantly. in attempting to eliminate all the above-mentioned potential sources of redundancy in a word inteuigibility task, the syllable composition of the words would probably need to be restricted to being as short but as representative as possible, the noun class prefix would have to be limited to only one syllable, and the use of options in the response format would be rejected. conclusion a detailed account has been presented of paramount considerations in resolving the issue of task and material selection r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 marlene carno jacobson and anthony traill for the measurement of intelligibility in five south-eastern ban u languages. the final outcome of the effort to attain maximally vthd measures was therefore arrived at under the following restrictive circumstances: 1. t h e a b s e n c e o f a d e w e y t y p e i n d e x o f r e l a t i v e p h o n e m e frequency; . 2. the absence of a thorndike-lorge-type index of word frequency for languages other than southern sotho; 3. the absence of standardised passages of reading; 4. the paucity of intelligibility materials for english-speaking glossectomees to act as guidelines for the development of materials in african languages. the decision was made to couple two complementary tasks: a single-word task, which may be viewed as a "molecular-intensive" or detailed analytical measure, while rating of a spontaneous speech task comprises a "molar-extensive" or global measure (hollenbeck, 1978), and may be regarded as a "molar taxonomy", as it combines a "a number of features, actions, directions, and objects of behaviour" (sackett, 1978: 25). this decision was determined by three factors which receive elaboration below: the specific research objectives, the emergency of two distinctive genres of intelligibility measures, and the limitations of any single measure of intelligibility in isolation. firstly, in considering the purpose of the research, there was dual interest in "how well speech was understood", which indexes overall speech effectiveness, as well as in specific error patterns. it seems logical that there be an underlying commonality to both processes and one would predict that the number of errors relates closely to the understandability of contextual speech. however, two discrete tasks were deemed necessary: it could not be assumed that the percentage word intelligibility based on unstandardised materials would accurately parallel the level of spontaneous speech intelligibility; neither could it be assumed that a word list, assembled on the basis of strict criteria such as phoneme position and syllable structure, would reflect the properties of everyday speech and vocabulary. the use of spontaneous speech samples was therefore important for the criterion validation of an unstandardised work intelligibility task. hence, a word intelligibility task incorporating the phoneticophonological properties of the relevant language was desirable in that 1. phonemes could be included in a controlled and structured manner; 2. the lack of context normally provided by syntax would allow evaluation of each phoneme in a minimally redundant form; 3. a numerically specific index of the percentage of intelligible words could be computed; 4. words are the work-horse of intelligibility materials in english, and serve as highly accessible units of speech for a researcher who is not a fluent speaker of a foreign language. similarly, a spontaneous speech task was desirable in that 1. ratings of performance on such a task could tackle the construct of speech intelligibility directly as everyday connected speech would be typified, providing a reasonable approximation of the normal communication process; 2. the task promotes the linguistic style and vocabulary of the subject and thereby captures a congruent communicative whole. isolated words, in contrast, are in danger of falling peripheral to either the judge's or the subject's vocabulary, despite careful item selection. the particular method whereby spontaneous speech samples may be evaluated, constitutes a separate methodological decision which lies outside the scope of the present paper. the lists of single words in zulu, xhosa, northern sotho, southern sotho and tswana, appear in appendixes 1-5. as far as possible, these were formulated and items selected according to the following criteria: 1. vocabulary items should be familiar to both rural and urban speakers of the relevant language. 2. the word structure should be highly representative of the particular language in question. a scan of common vocabulary items in nguni and sotho languages, combined with the notion of shortest word having least redundancy, suggested that it was most appropriate to include bisyllables in the sotho languages where the simplest uninfected nouns and verbs have a cvcv (nasal) structure, and trisyllables in the nguni languages where nouns of a vcvcv structure predominate because of the pre-prefix. although cvcv verb imperatives are readily available in the nguni languages, the final v is always / a / which acts to increase the redundancy of stimuli in that the final vowel is always given. 3. all consonant phonemes in each language should be included twice in the list, once as the first consonant in a word and secondly, in an intervocalic position. 4. within the scope of these criteria, the number of items presented to the judges was restricted to as few as possible by eliminating the least satisfactory items. this represented an attempt to increase both reliability and validity. the least satisfactory items in the research were those of doubtful conversational familiarity. it was hoped that the remaining items would constitute sufficiently long tests and that these would be more reliable, comprehensive and valid than lists that would have been any shorter. 5. rigorous balancing of vowel phonemes was not undertaken due to the stringency of primary requirements already mentioned. an attempt was made, however, to keep the frequency of different vowel phonemes equivalent within each word list. secondly, the above exposition of intelligibility and related issues reveals two distinguishable categories of assessment methods: the first category, comprising formalised procedures, displays a certain stringency of both item selection (the maximal units of which are sentences), and procedural design (which facilitates quantification and error analysis). however, english procedures of this nature are at times of questionable validity, in terms of the definition of intelligibility provided earlier in this paper, as these could be more accurately regarded as exercises in stimulus discriminability. in the case of south-eastern bantu languages, materials of this nature could be formulated through the informal application of principles such as word familiarity, word length, and phonetic balance. | ι in contrast, less formalised procedures, in that either the material or the assessment procedure itself is irregular, perhaps represent more valid appraisals of intelligibility. these procedures generally have, as a minimal unit, the sentence, and usually consist of either read or spoken samples of connected speech. hence, these demonstrate high face validity in representing overall speech behaviour, which is of prime interest. however, in this instance, the validity of the listener's task or tool of judgment may be questionable in relation to the construct of speech intelligibility. / these observations suggest that both formal and less formal procedures have merits and demerits, and probably represent complementary entities, which are most effective in unison. thirdly, as demonstrated by english materials, although the above range of intelligibility measures and procedures is vast, in most cases, only a portion of overall speech performance is r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a s s e s s m e n t of speech intelligibility in five south-eastern bantu languages: critical considerations 23 c a p t u r e d by a single measure, which furthermore, cannot be employed to describe performance across the entire severity range: as all measures have both a ceiling and a floor effect, these are sensitive to performance changes in only a limited range. these limitations underscore the strength of any single measure of intelligibility in research which is combined with at least one other intelligibility task, or the event of intelligibility comprising only one measure within a battery of measures of speech production, where such a battery also incorporates acoustic, articulatory, and physiological studies. additional measures then serve as concurrent validation procedures. if "the observer's perception and subsequent judgment represents the final validity for the identification and measurement of disordered speech" (young and downs, 1968: 6), the present paper comprises a preliminary step in the direction of reflecting this criterion, that is, intelligibility, among speakers of southeastern bantu languages. a ckno wled g ε me nts the human sciences research council, pretoria, and the senior bursary fund, university of the witwatersrand, johannesburg, are gratefully acknowledged for their generous financial support of the doctoral research on which this paper is based. inhlanzi igazi ixhegu iqanda umeqo izinyo insimu uqhotho iviki iphepha iconsi umpompi igeja umgqomo iwashi indlebe idlelo induku umshado inantshi ilanga inzule i jaha amakha ingiqi isiklabhu igceke ingqondo uxamu phonemic transcription /inti andzi/ /igazl/ /i//hcgu/ /i!anda/ /uml!d/ /iziro/ /ints imu/ λι! hot\v /ufudu/ /ivik'i/ /iph'pha/ /i/onts 'i/ /ump -̂ mp i/ /ig'd ψ/ /izi<wu/ /um!gjrao/ /imbuzi/ /iwa ji/ /indl;>.e»v /iliklo/ /induk u/ /um fad o/ /inant j"'i/ /ila^a/ /indzule/ /id^aha/ /amakha/ / i rji ι i / /isiki 'abu/ /i/gek'r./ /irj'.gondo/ /u//amu/ gloss fish blood old man an egg a jump field shrivelled thing; homeless person tortoiae week paper drop of liquid a tap a plough sheep barrel; drum; "round person" goat a vatch pasture a stick a wedding naartjie fruit sun; day type of indigenous cow strapping fellow perfume, scent lazy person sheep courtyard mind; brain leguaan appendices igxathu /i//gathu/ stride (n) ingxangxa / if)//gar)//ga/ a green-striped frog appendix 1 : zulu word list igxolo /i//§.ilo/ bark of tree orthography phonemic gloss icici /i/i/i/ earring transcription. ipapa /ip 'ap 'a/ porridge idada /idada/ duck umunwe /umunwe/ a finger ungcede / /uo/gede/ common little bird appendix 2 : xhosa word list unyawo /upawo/ leg orthography phonemic gloss inxele /in//eie/ left-handed person transcription isifo /isifo/ sickness inzala /indzala/ progeny; interest (on capital) itiye /it 'ΐτε/ tea indlovu /indtpvu/ elephant incwadi /in/wadi/ a book indyebo /inre co/ treasure; plenty inyoni /ipdni/ bird ityhefu /ic h,-fu/ poison (n) umhambi /um ̂ambi/ traveller intyelo /inc'rio/ information ugogo /ueogo / grandmother intlahla /inti'aia/ shiny, glossy appearance ithanga /ithana/ pumpkin ibhokwe /ibokw 't·/ goat ingxoxo a conversation irafu /ixafu/ tax, hut-tax, poll tax iqhude /i!hudt/ a cock igronya /iiopa/ sack-cloth, coarse cloth; sack ihhashi / i fia j i / horse ikrele /ikx 'εΐε/ stabbing assegai, sword, sickle indlovu /indlovu/ elephant ihashe /ihaje/ horse, mount; abcess imvubu /im»vubu/ hippo imvubu /im<4vu£u/ hippopotamus inhlanhla /int* 'anti a/ luck indoda /indoda/ man, husband /uzip o/ intsimi /ints 'imi/ arable field, garden uzipho /uzip o/ nail i ihlombe /iiambe/ shoulder imfene /im<ff 'ene/ baboon uhala /uhala/ a cotton thread amanzi /amandzi/ water bus ikhaya /ik ha3a/ home, residence, dwelling, domicile ibhasi /ibasi/ bus ikhaya cat ityiphu /ic'ip hu/ domestic fowl ikati /ik 'at 'i/ cat ityiphu /utf'ani/ isidlo /isitjo/ meal, feast utshani /utf'ani/ grass /isitjo/ education ikratshi /ikx 'at/'i/ arrogance imfundo /im*fundo/ education ikratshi /ikx 'at/'i/ i a pond ithanga /ithaoa/ pumpkin; thigh; outpasture; outfarm, ichibl /i/hibi/ i a pond ithanga outkraal ikhehla /ikheia/ a man beginning to go grey food ubisi /ufcisi/ (sweet) milk ukudla /uk'uija/ food r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 marlene carno jacobson and anthony traill orthography phonemic transcription icici /i/i/i/ ixesha /i//tja/ ucango /u/apo/ incoko /in/ok'o/ ixhego /i//hego/ igqira /ilgixa/ ingxowa / i/gowa/ umfundi /umff'undi/ izonka /izonk'a/ iphepha /iphcpha/ uluvo /uluvo/ ingcambu /io/gambu/ impompo /imp'omp'3/ iqhosha /i! hoja/ ubhaqo /uba!o/ ibuzi /ifcuzi/ iceba /i/e&a/ ijokwe /id^ok'we/ ugcado /u/gad 3/ uvuyo /uvujo/ iwatahi /iwatj'i/ ihlobo /iio£o/ itshintshi /itj'inti'i/ utolo /ut'oi3/ idama /i<1ama/ inyosi /iposi/ isingci /ieincgi/ ushenxo udladla /uljalja/ ingwiqi /i>)wi!i/ igatya /igac 'a/ umhambi /umtambi/ iqands /i!anda/ ichibi /i/hifci/ igxalaba /i//gala&a/ inxele /in//clc/ umnqwazi /umn!wazi/ ingwanqwa /i η!w an!a/ icangci /i/arygi/ inkcazo /ink/azy uncipho /un/ip h y inkxvaleko /ink//walek 'ο / umngqusho /umqkiu/o/ ingqumbo / i>)! gun bo / injini /ind^ini/ ijaji / itĵ ad̂ i/ umgcini /um/gini/ umgodi /urngô i/ ingoti /irjgozi/ inkqu /irjklu/ unoqho /uno1ho/ iaixa /isi//a/ ungwebi /umgwcm/ appendix 3 : northern sotho word list taebe /te' ebe/ pudi /p 'udi/ dijo /di^o/ gloss something circular; earning; small group . time, period; watch, clock . door (not a doorway); cell in a honeycomb • conversation old man • doctor, medicine-man, witch-doctor bag, pouch, sack, pocket pupil, scholar, reader, disciple, student • loaves of bread • paper; page • feeling, senaation; view, opinion; impression • root • button, buckle; coin; seashell discovery rat councillor; splinter jar a roast • joy· gladness, rejoicing watch, clock summer change (n) arrow dam, reservoir bee mane leeway granary a gulp, swallow clause; branch traveller egg; large bead pool, pond, lake shoulder, shoulder-blade left hand; left-handed person cap, hat step piece of corrugated iron; metal sheet memorandum; explanation decline, decrease misery eamp anger engine judge one who keeps deep excavation, mine; a hole danger; misfortune, accident, injury reality clothes-peg bunch; handful (of grasa, corn flowers) those who judge • ear orthography noka kgogo topa toro bjala botse ngaka nyala tsea hlogo tlala khuta phiri motho p6hap6ha tshipi tlhaba psinya holla dinku ngwana motse nnosi tehwene sego kofi hwile fase gohle legong tshwane leho ' swiri maswi pholo ngwaga robja monna haka jase patsi kgomo 11a nnyane mpheng gomme thunya kua sebopsa ngwe lefaega ipehina phonemic transcription /nok 'a/ /kx 'οϊο/ /t ops/ /toro/ /p3ala/ /bots e/ /oak 'a/ /moo/ /psla/ /tj'ea/ /ioio/ / tl 'ala/ /khut 'a/ /phiri/ /motho/ /pjhapjha/ /tj'ipi/ /tlhaba/ /ps 'ipa/ /foia/ /dii'jk 'u / /^wana/ /mots e/ /aoji/ /tj 'wene/ /i+iele/ /ap'a/ /sets/ /k'ofi/ /hwile/ /fase/ /roie/ /le*ov /tshwane/ /lets/ /«fcsiri/ /ma<j>ai/ /pholo/ /twa^a/ /rop̂ a/ /morla/ /f-aka/ /d^aae/ /pat f i/ /wet j 'we/ /kx 'omo/ /la/ /p/hatl'a/ /pane/ /mp he /xome/ /thupa/ /kua/ /sebop j 'a/ /me/ /na/ /rjwe/ /lefje*a/ /ipjhina/ river chicken pick up dream; prickly pear plant; beer beautiful doctor maater, owner; one, other (adj.) to marry, give dowry take, receive, get hold, take on; marry head hunger hide hyena, wolf person applaud, clap iron; bell slaughter, to stab a person defaeeate! child village, town baboon body stomach; skipping rope; sky between two clouds calabash coffee has passed away; dead under, below, down everywhere wood, timber pretoria spoon, ladle lemon ox year break, break off (paaaive of "roba") man · to hook on overcoat i coat i fall toward; to fail in (causative of "wela") ! heard of cattle ^ cry; mourn; ring; strike (a bell) play a musical instrument; bellow; yelp; mew; whistle to break (into pieces); break in (to burgle); smash small, little, miniature a handle and; furthermore cauae duat; blossom; ache; explode -·over there creature my / our mother i, me another faacea of diarrhoea; a coward enjoy, be happy he south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a s s e s s m e n t of speech intelligibility in five south-eastern bantu languages: critical considerations 25 phonemic transcription /mokx'wa/ /dirapfa/ . squtherh flotho l i s t phonemic ianscripti01 /pita'a/ /buk'a/ /thipha/ /noma/ /leino/ /k 'olol/ /kx 'aut'a/ /hemp e/ /ict'o/ /tahela/ /iitsha/ /nt j"'a/ /pjhatl'a/ /net 'e/ /moho/ /lei \ra/ /kx'aba/ /phiri/ /mat he/ /φ» ana/ /di^>/ /me/ /dutl 'a/ /diha/ /foia/ /haok'a/ /tl'atl'a/ /tlhok'a/ /j wa]a/ /ta'oie/ /tshwtpha/ /mots o/ /!a!a/ /mona/ /tj 'otj'a/ /tjnlo/ /motjhi/ /kx'wa*a/ /^ak'a/ /sits'a/ /madi/ /pjhana/ /pj 'atl'a/ /t'oaa/ /b^arats a/ /porwa/ /la/ /pjhehs/ /ab^wa/ /md-kx'0/ /iata 'wa/ lefjwa /lefjwa/ die suid-afrikaanse tydskrif mokgwa dimpsa pitsa buka thipa nana leino koloi kgauta hempe qeto tahela ntsha ntja pjhatla nnete mmoho leqhwa kgaba phiri ma the ngwana dijo eheshe dutla diha fohla hanka tlatla tlhoka shwaya tsohle tshwepha motsho qaqa monna tjotja tjhello motjhi kgwahla jaka sitsa madi pjhanya pjatla tosa bjaratsa nyorwa 11a pjheha abjwa mookgo hlatswa • manner, custom, habit • dogs gloss pot, vessel book knife meat tooth wagon, car gold; a big gold or silver bead shirt the end, conclusion; decision to cross (a road); to cut meat; to live; to pour to take out, to aend, tp eontribute dog; despised person; dysentry of children; very heavy stone to spesk much, to tell; to break into pieces truth together; on one side ice to be besutiful; to dress well; a spoon; to have a nice action hyena saliva child, infant; tooth of a baby; charm used for frightening birds away food; crops violence; type of tree to leak, trickle out, drip to cause to fall; to throw, to cast down, to put into trouble to peel; to enlarge s hole to walk proudly to shine; a wooden dish (for meat) hardened ear-wax; to shout 'to prick, to sting, cause a rash all, everything to twist, entwine black to be plain, evident r man, husband jto continue raining jdamage sustained through fire not anywhere to run; to become atrong, firm; to shrivel up to go and live in a foreign place to give, to grant, to favour with blood; beer to speak, to say to boil well to stretch out, to raise to crunch, to smash to become thirsty weep, cry, emit a sound, bellow to have diarrhoea, to be purged; to act in a cowardly manner to divide, hand out, distribute tears (n) to wash vir kommunikasieafwykings, vol. 33, 1986 orthography nku kgafa nna mme tshwara kgomo yaka repha appendix 5 mantswe mollo kgopa tlase podi taie tshimo thuto ruri koko moagi ngaka nyals rwele jala tshups lwana tshweu tshwara gagwe nkgvana dinku yaalo mow a yona leswe puo tau kobo sejo nama rre gotlhe pitsi tshipi khudu phutha tlhaba kgopho phepha fofs wesi tefo senya rragwe rrunidi phonemic transcription /ik'u/ /kx'afa/ /na/ /m/ /tshwara/ /kx omo/ /jak'a/ /rt-pha/ nnye nnetlane nkga tlhwaya (tsebe) 11a : tswana word list /msnta we/ /molo/ /kx'op'a/ /tl'ase/ /p'odi/ /ts'ie/ /tsh imo/ /thut'o/ /ruri/ /k'ok'o/ /moaxi/ /oak'a/ /pala/ /rwele/ /d^ala/ /tsnjps/ /lwana/ /ts weu/ /tshwara/ /gagwe/ /t}kx 'wons/ /dirjku/ /jsalo/ /mowa/ /jona/ /leswe/ /puo/ /t'au/ /kobo/ /sed^o/ /nama/ /rt/ /x3tlhe/ /p'its'i/ /tship'i/ /khudu/ /•ε/ /phutha/ /tlhaba/ /kx'opho/ /phepha/ /fofs/ /wesi/ /t'efo/ /sepa/ /raxwe/ /midi/ /n·/ /netl'ane/ /nkx1 a/ /tlhhwajs/ /la/ gloss sheep • tax, hut-tax-duties • i, myself; to be; continually mother of; and, also, indeed to seize, to get hold of, to capture a herd of cattle it seemed that to become loose, old • words • fire snail; to trip up, stumble, offend, vex, displease down a gost locust a garden lesson, education true grandmother a builder a doctor to marry hss worn plant:· wesvil fight, quarrel, strive with each other white hold his, hers a water pot, calabash sheep like that air it dirty, nasty apeech lion a kaross; blanket food meat father, my fsther entirely, all a horse; a zebra iron, metal tortoise my mother to gather, collect to slaughter, stab β small bush with edible fruit clean fly! own; alone payment spoil) his father mealie little something to emit s smell to listen carefully cry r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 orthography phonemic transcription gloss lwantsha /lwantsha/ cause to quarrel or strive with each other lotswa /lot] 'ws/ be required, demanded, asked foi „pho /mpho/ gift sekhi /sekhi/ a species of thorny bush supa /supa/ to show, point; seven aeba /stba/ to whisper, to backbite aga /axa/ to build; live, dwell fitlha /fitlha/ to arrive; to bury, hide kgakge /kx'akx'e/ wonder, astonishment maswi /majwi/ milk, sweet milk taoma /te'oma/ to hunt dikgwa /dikx'wa/ clumps of bush mmini i /mini/ dancer bonnye /bope/ smaller setshaba /setjhaba/ nation tlhatsa /tlhata'a/ vomit gotlha /xotiha/ rub a aurface aonyo /mopo/ dew; mist references baragwanath hospital, department of speech therapy and audiology. speech discrimination testing materials: zulu and sotho. soweto, 1977. beukelman, d.r. and yorkston, k.m. the relationship between information transfer and speech intelligibility of dysarthric patients. journal of communication disorders, 12, 189-196, 1979. black, j.w. accompaniments of word intelligibility. journal of speech and hearing disorders, 17, 409-418, 1952. black, j.w. multiple-choice intelligibility tests. journal of speech and hearing disorders, 22, 213-235, 1957. brown, j.t. setswana-english dictionary. third edition. botswana book centre (u.c.s.s.a.), 1971. cole, d.t. an introduction to tswana grammar. london: longmans, green and co., 1955. darley, f.l., aronson, a.e. and brown, j.r. motor speech disorders. london: saunders, 1975. doke, c.m. text-book of zulu grammar. second edition. london: longmans, green and co., 1931. doke, c.m. and mofokeng, s.m. textbook of southern sotho grammar. cape town: longmans, green and co., 1957 egan, j.p. articulation testing methods. laryngoscope, 58, 955991, 1948. fairbanks, g. test of phonemic differentiation: the rhyme test. journal of the acoustical society of america, 30(7), 596-600, 1958 fairbanks, g. voice and articulation drillbook. second edition, new york: harper and row, 1960. gowlett, d.f. and rassman, e.f.a. word-frequency count for southern sotho prose literature. african studies, 38(2), 107133, 1979. griesel, g.j. die invloed van 'n kwantitatiewe taaltonleding op leerstofseleksie by die onderrig van zoeloe as tweede taal. master's dissertation, university of natal, pietermaritzburg, 1979. griggs, t. from articulation tests towards formulas for intelligibility. language and speech, 1, 194-221, 1958. hillbrow hospital, department of speech therapy and audiology. phonetic inventories: zulu and southern sotho., johannesburg, 1981. hirsh, i.j., david, h. silverman, s.r., reynolds, e.g., eldert, e. and benson, r.w. development of materials for speech audiometry. journal of speech and hearing disorders, 17, 321-337, 1952. marlene carno jacobson and anthony traill hodson, b.w. and paden, e.p. targeting intelligible speech: a phonologic approach to remediation. san diego: collegehill press, 1982. hollen'oeck, a.r. problems of reliability in observational research. in sackett, g.p. (ed.) observing behaviour vol. ii; data collection and analysis methods. nichd mental retardation series, baltimore: university park press, 1978. jacobson, m.c. speech intelligibility and articulatory dynamics of reconstructed oral cancer patients. ph.d. thesis. university of the witwatersrand, johannesburg, 1986. jordan, a.c. a practical course in xhosa. cape town: longmans, 1966. khumalo, s.j.m. zulu tonology. master's dissertation. university of the witwatersrand, johannesburg, 1981. kipfmueller, l.t. and prins, t.d. consonant intelligibility: reliability and validity of a speech assessment procedure. journal of speech and hearing research, 14, 559-564, 1971. kunene, d.p. the ideophone in southern sotho. marburger studien zur afrika und asienkunde. berlin: verlag von dietrich reimer, 1978. kyle, j.g., conrad, r., mckenzie, m.g., morris, a.j.m. and weiskrantz, b.c. language abilities in deaf school leavers. teacher of the deaf, 2, 38-42, 1978. lanham, l.w. an outline history of the languages of southern africa. in l.w. lanham and k.p. prinsloo (eds.), language and communication studies in south africa. cape town: oxford university press, 1978. lehiste, i. and peterson, g.e. linguistic considerations in the study of speech intelligibility. journal of the acoustical society of america, 31(3), 280-286, 1959. mabille, a. and dieterlen, h. southern sotho-english dictionary. revised by paroz, r.a. revised and enlarged eighth edition. basutoland: morija, 1961. markides, α., assessing the speech intelligibility of hearing impaired children: oral reading versus picture description. teacher of the deaf, 2, 185-189, 1978. meyerson, m.d., johnson, b.h. and weitzman, r.s. rehabilitation of a patient with complete mandibulectomy and partial glossectomy. american journal of otolaryngology, 1, 256-261, 1980. miller, g.a., heise, g.a. and lichten, w. the intelligibility of speech as a function of the context of the test materials. journal of experimental psychology, 41, 329-335, 1951. nichols, a.c. confusions in recognising phonemes spoken by esophageal speakers: i. initial consonants and clusters. journal of communication disorders, 9, 27-41, 1976. piatt, l.j., andrews, g., young, m. and neilson, p.e). the measurement of speech impairment of adults with cerebral palsy. folia phoniatrica, 30, 50-58, 1978. i prather, e.m. scaling defectiveness of articulation by direct magnitude estimation. journal of speech and hearing research, 3(4), 380-392, 1960. rosenbek, j.c. and lapointe, l.l. the dysarthrias: description, diagnosis and treatment. in d.f. johns (ed.), clinical management of neurogenic communicative disorders. boston: little, brown, 1978. sackett, g.p. measurement in observational research. in g.p. sackett (ed.), observing behaviour, vol. ii: data collection and analysis methods. nichd mental retardation series. baltimore: university park press, 1978. / schiavetti, n., metz, d.e. and sitler, r.w. construct validity of direct magnitude estimation and interval scaling of speech intelligibility: evidence from a study of the hearing-impaired. journal of speech and hearing research, 24, 441-445, 1981. schiavetti, n., sitler, r.w., metz, d.e. and houde, r.a. prediction of contextual speech intelligibility from isolated (continued on page 28) / the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) v new automatic hearing aid a truly advanced and innovative sound amplifier the automatic sound processor (asp) was developed especially for those people who have difficulty in hearing speech in noisy environments. for years, hearing aid wearers have avoided restaurants, theatres, church and parties because of the inability of an ordinary hearing aid to control background noises. the a.s.p. is simply and uniquely designed to normalize background noise so that speech is more easily ' understood. * to be able to restore sound to even one human being makes your l life especially important. to restore hearing... what a blessed talent to have medifix (pty) ltd. surgical & medical cape p.o. box 19 , p.o. box 52 bedfordview lynedoch 2008 7603 south africa phone: (02234) 442 phone: (oil) 53-4188/9 or (02231)93442 /7λν natal p.o. box 47443 greyville 4023 phone: (031) 236164 | r | r i c h a r d s hearing systems tomorrow's technology for today's hearing problem r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 (continued from page 26) word intelligibility measures. journal f speech and hearing research 27, 623-626, 1984. schmidt s intelligibility and the child with multiple articulation deviations. in h.a. winitz (ed.), treating articulation disorders: for clinicians by clinicians. baltimore: university park press, 1984. schultz, m.c. world familiarity influences in speech discrimination. journal of speech and hearing research, 7, 395-400. shriberg, l.d. and kwiatkowski, j. phonological disorders iii: a procedure for assessing severity of involvement. journal of speech and hearing disorders. 47, 242-256, 1982. skelly, m. (ed.) glossectomee speech rehabilitation. springfield, illinois, charles c. thomas, 1973. south africa 1985: official yearbook of the republic of south africa. eleventh edition. johannesburg: chris van rensburg, 1985. tikofsky, r.s. a revised list for the estimation of dysarthric single word intelligibiliy. journal of speech and hearing research, 13, 59-64, 1970. tobias, j.v. on phonemic analysis of speech discrimination tests. journal of speech and hearing research, 7, 98-100, 1964. van wyk, e.b. language contact and bilingualism. in l.w. lanham and k.p. prinsloo (eds.), language and communication studies in south africa. cape town: oxford university press, 1978. westphal, e.o.j. syllable and sound change in southern bantu languages. journal of the south african speech and hearing association, 20, 22-41, 1973. marlene carno jacobson and anthony traill wilkes, a. bantu language studies. in l.w. lanham and k.p. prinsloo (eds.), language and communication in south africa, cape town: oxford university press, 1978. yorkston, k.m. and beukelman, d.r. a comparison of techniques for measuring intelligibility of dysarthric speech. journal of communication disorders, 499-512, 1978. yorkston, k.m. and beukelman, d.r. a. a clinician-judged technique for quantifying dysarthric speech based on single word intelligibility. journal of communication disorders, 13, 15-31 1980. yorkston, k.m. and beukelman, d.r. communication efficiency of dysarthric speakers as measured by sentence intelligibility and speaking rate. journal of speech and hearing disorders, 46, 296-301, 1981. young, m.a. and downs. t.d. testing the significance of the agreement among observers. journal of speech and hearing research, 11, 5-17, 1968. ziervogel, d., louw, j.α., ferreira, j.α., baumbach, e.j.m. and lombard, d.p. handbook of the speech sounds and sound changes of the bantu languages of south africa, unisa handbook series no. 3e. university of south africa, pretoria, 1967. ziervogel, d., louw, j.a. and taljaard, p.c. a handbook of the zulu language. third edition. pretoria: j.l. van schaik, 1981. ziervogel, d. and mokgokong, p.c. groot noord-sotho woordeboek. pretoria: j.l. van schaik, 1975. kritiese beoordeling van evaluasietegnieke van toepassing op gesplete-lip-en-verhemeltebabas brenda louw, d.phil (pretoria) isabel c. uys, d.phil (pretoria) departement spraakheelkunde en oudiologie, universiteit van pretoria, pretoria. opsomming die verkryging van 'n klinies geldige en 'n voorskrywende proflel van 'n baba se kommunikasiefunksionering verg noukeurige seleksie van ondersoekmetodes en meetinstrumente wat aangewend word. voorgestelde evaluasietegnieke wat van toepassing is op swart gesplete-lip-enverhemeite-babas word teen die agtergrond van 'n kritiese oorsig van die evaluasieproses beoordeel in terme van navorsingsen kliniese toepassingswaarde. vyf-en-twintig swart babas met gesplete verhemelte onder die ouderdom van twaalf maande het asproefpersone gedien. riglyne vir toepassing van die voorgestelde evaluasiemodel deur middel van direkte dienslewering deur die spraakterapeut en deur middel van konsultasie-as-voorkoming in 'n multi-kulturele gemeenskap word verskaf. / abstract the obtaining of a clinically valid and prescriptive profile of the communication function of infants calls for an accurate selection of the research methods and measuring instruments to be used. suggested evaluation techniques applicable to black cleft lip and palate infants are judged and evaluated within the framework of a critical review of the evaluation process in terms of research and clinical applicability. twenty-five black cleft lip and palate infants under the age of twelve months served as subjects. guidelines are supplied for use of these techniques through direct services provided by the speech pathologist and through consultation -asprevention in a multi-cultural society. © sasha 1986 the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) teacher support an exploration.html teacher support – an exploration of how foundation-phase teachers facilitate language skills anna-marie wium department communication pathology, university of pretoria brenda louw professor emeritus: department communication pathology, university of pretoria correspondence to: a wium (anna-marie1.wium@ul.ac.za) abstract the role of speech-language therapists (slts) has been redefined by white paper 6, which emphasises the role of support to both teachers and learners. slts have expert knowledge and skills pertaining to communication and language, and therefore have much to contribute to the process of learning in teaching. this article builds on a previous article published in the 2010 edition of the journal, which reported on the process of supporting teachers to facilitate listening, language and numeracy skills in semi-rural and urban (township) contexts. in this follow-up article the focus is on the qualitative findings obtained from a specific section of the larger study. where the overall study made use of a mixed methods approach to evaluate the process of providing support, and reported on the entire continued professional development (cpd) programme, this article focuses specifically on the qualitative data collected when the cpd programme addressed the facilitation of language. this article explores how the strategies were used in the classrooms, and the benefits of the support provided. the data discussed in this article were obtained from questionnaires, focus groups, and critical self-evaluation by teachers, as well as a research diary used by the programme facilitator. the results show that both the participants and their learners benefited from the support provided. the participants reportedly for the first time were able to meet curriculum outcomes which previously had been omitted, and showed an increased ability to plan their lessons. several teachers experienced changes in their teaching practices and could reflect on their practices, which contributed to their professional development. these teachers became more empowered. learning in the classroom was enhanced through increased participation of all learners, and enjoyment of the strategies. keywords: language, literacy, collaboration, numeracy, teachers, support, speech-language therapist speech-language therapists (slts) have expert knowledge and skills regarding language acquisition and literacy, which place them in a position to support teachers with the implementation of the revised national curriculum statement (rncs) (department of education, 2002). this article builds on a paper published in the 2010 edition of this journal (wium, louw & eloff, 2010) which focused on the development of a continued professional development (cpd) programme researched using a mixed methods approach. the focus was on the process of supporting teachers to facilitate listening, language and numeracy skills, whereas this article concentrates specifically on the language component of the overall study. this article explores how the teachers facilitated language skills in their classrooms as a result of strategies learnt in a cpd programme, and how they experienced the support provided. such findings provide guidelines to slts who have to provide support to teachers in schools. this article firstly discusses the collaborative roles of slts in education contexts and the interrelationship between listening, language and literacy. such information was used to develop the workshop material to support teachers in the facilitation of language skills as described by the rncs. the content of the cpd programme is briefly described in appendix a. background in south africa the performance of learners in literacy and numeracy is alarmingly poor. the implication is that the majority of learners in south africa are currently not receiving quality education, which can be considered as a violation of their constitutional rights. attempts to facilitate literacy and numeracy learning, particularly in the early grades, need to be improved. research by girolametto, weitzman, lefebvre and greenberg (2007) indicated that many teachers in care centres in the usa lack the knowledge to facilitate emergent literacy skills. such findings may also apply to the south african context, as formal qualifications for teachers of grade r learners have not been a requirement until 2011 (motshekga, 2010). the need for teacher support in the implementation of the curriculum has become a national priority (department of education, 2008; motshekga, 2010), which slts can provide by using a collaborative approach, particularly in the literacy learning area. collaborative roles of the slt in education contexts white paper 6 (department of education, 2001) outlines the government’s strategy to transform the current education system to make it more efficient, equitable and just. this document also specifies that slts should play consultative and collaborative roles in district and school-based support teams and support both teachers and learners who experience barriers to learning. white paper 6 requires slts to provide training, mentoring, monitoring, and consultation to facilitate literacy and numeracy. with regard to literacy, teachers need to understand the complex nature of language and also how to facilitate it in the classroom. the support of young learners who experience barriers to learning is essential because communication is central to the social, emotional, and academic development of young children (department of education, 2008). in terms of supporting learners slts should focus on the prevention of communication disorders (including literacy development problems), and provide language programmes in schools for the whole classroom as a group. such preventive strategies are aligned with recommendations made by the american speech and hearing association (asha) (2001), which require slts to provide foundation-phase learners (grades k 3) with suitable intervention for literacy development and to address reading and writing skills in older learners. child language development is an interdisciplinary field of knowledge that is shared by teachers and slts because language is the foundation for developing competence in reading, writing, listening, and speaking. language deficits may delay the acquisition of these four modes of communication, resulting in barriers to learning (owens, 2004). teachers and slts should work as a collaborative team to prevent and overcome such barriers, and to share their knowledge and skills to this effect. teachers are primarily responsible for the teaching of reading and writing, whereas slts attend to the cross-modal literacy-language connection between all four modes of language, as these may affect one another. in south africa many learners have to acquire oral and written language skills in their home language as well as english (motshekga, 2010); this implies that learners who require support in the development of language will need to be supported in both their home language and in english. the inter-relationship between listening, language, literacy and numeracy language is the foundation for learning (owens, 2004), and is an integral part of ‘literacy’ in the foundation-phase curriculum (motshekga, 2010). the four language systems shown in table i are integrated in the rncs as listening, speaking, reading, viewing, writing, thinking, and reasoning, as well as language structure and use (department of education, 2002). each of these language systems is associated with either receptive or expressive modes of communication (johnson & roseman, 2003). language is not restricted to the oral modality, but also includes the visual modality (johnson & roseman, 2003). learners developing written language awareness discover that print is a highly organised system that reflects oral language and guides them to an understanding of the alphabetic principle (justice & ezell, 2002), which relates to literacy in the rncs. the national curriculum: literacy in order for learners to develop language and communication skills (department of education, 2002), they firstly have to listen attentively and respond critically to information. the rncs requires learners to communicate confidently and effectively in a spoken language in a wide range of situations. it is essential that learners learn to read and view information for enjoyment, and respond critically to the aesthetic, cultural and emotional values in texts. the rncs requires learners to read and write different kinds of texts, but also to use language to think and reason. learners are required to become competent in language structure and use and in doing so they have to use the sounds, words, and the grammar of a language to create and interpret texts. the development of language and communication skills is therefore critical for effective learning. provided that the curriculum has been properly implemented, learners should be able to read and write and perform basic mathematical calculations by the end of grade 3. an outcomes-based education (obe) approach is integral to the rncs. it requires a skills-based, problem-solving, co-operative approach to teaching and learning. teachers firstly have to decide on which skills and concepts they would like their learners to acquire, and then create suitable contexts in which such skills can be facilitated in the classroom. within an obe approach teachers plan in teams in order to equip learners with similar skills across the grade. such group planning ensures that the standard of education is the same, and teachers need to agree on what to teach and the activities required (department of education, 2008). learners from low socio-economic schools (ses) require a variety of experiences to facilitate the natural transition from oral language used at home to functional literate language used in school. children living in poverty are at risk for learning disorders, and need support. the current context education in south africa is complex, as several challenges are encountered across contexts by both teachers and learners (rembe, 2005). the poor performance of learners in south africa can often be attributed to the fact that 40% of children in south africa come from extremely impoverished backgrounds with limited access to learner support materials in their homes. access to printed material in shared reading experiences, as well as parental beliefs about literacy, have been identified as having an effect on writing. learners raised in poor communities mostly have limited exposure to printed material and subsequently may have very different attitudes to, and experiences of, the printed text from those of their peers (nancollis, lawrie, & dodd, 2005). locke, ginsborg and peers (2002) reported that preschool children who were raised in impoverished environments in the uk performed at lower levels in oral language assessments than the general population, which put them at risk for delayed written language skills. learners from low ses often experience difficulty in making the shift from the language used at home to the abstract and decontextualised language used in the classroom (justice & kaderavek, 2004). these learners may therefore require more support than their counterparts (department of education, 2008). inadequate oral language development may result in poor academic performance (figure 1), which points to a link between language and literacy. with reference to figure 1, emergent literacy involves both written language awareness and phonological awareness (justice & ezell, 2001), which in turn are based on normal oral language (particularly vocabulary development). in turn, age-appropriate oral language development is required for the development of reading competence, and therefore oral language proficiency is regarded as predictive of reading achievements as well as other written language achievements at a later stage. figure 1 shows that adequate print-related language (e.g. familiarity with books and visual symbols) is required for continued oral language development (justice, skibbe, & ezell, 2006). a similar reciprocal relationship exists between phonological awareness and reading, as each facilitates and is facilitated by the other (justice, skibbe & ezell, 2006). learners’ language learning is a crucial precursor to literacy. poor literacy development contributes to later problems in language. the link between language and literacy language is essential for the acquisition of literacy and numeracy because it is the foundation for speaking, reading, writing, and spelling. for emergent literacy to develop, learners need to firstly develop meta-linguistic skills (johnson & roseman, 2003) to identify and analyse specific sounds to allow them to read or write. phonological development (including phonological awareness) (figure 2) provides the bridge between language and literacy whereas higher-level phonological skills (e.g. sound manipulation and substitution) facilitate written language development in terms of reading and spelling (johnson & roseman, 2003). similarly, adequate language development is required to facilitate the language required for numeracy. the american speech hearing association (asha)’s position statement (2001: 16) advocates that ‘... children need to experience reading, spelling, and writing for authentic communication purposes in which vocabulary, grammar, and discourse skills converge.’ learners who do not have adequate and age-appropriate listening and language skills when entering formal education may be at risk for academic failure (justice & kaderavek, 2004). this, in turn, may cause problems such as low self-esteem, social maladjustment, and inability to support themselves financially. it is therefore important to prevent academic failure by ensuring that learners acquire such skills as early as possible to allow them to become academically competitive when going to school. lessing and de wit (2008) were of the opinion that the teachers’ own lack of conceptual knowledge of language and the sub-skills required for literacy acquisition were at the root of their use of outdated teaching practices such as rote learning (e.g. drilling and chanting). such outdated teaching practices do not facilitate learning. teachers should aim instead for the development of meta-linguistic skills, which are required for learners to identify and analyse specific sounds to allow them to read or write (johnson & roseman, 2003). it appears that learners from the most disadvantaged homes may be further challenged by the inadequate teaching practices prevalent in their classrooms. teachers need to be supported to develop an understanding of the underlying concepts of language for learning, and to develop strategies and skills to facilitate the four language systems included in the rncs in order for learners to develop literacy skills. the specific cpd programme was part of a research study that covered several topics, and this particular article focuses on the language component of the entire research project. the topics were repeated in two contexts over a period of 2 years within an action research approach (stringer, 2007). such support was based on a three-pronged approach that consisted of a workshop (training component), the implementation of the skills in the classroom (practical component), and a mentoring component which provided the teachers with feedback on lesson plans and portfolio assignments (wium, louw, & eloff, 2010). the results obtained demonstrate how the facilitative strategies (e.g. the use of stories, songs, and art within a theme) were used to facilitate language. these activities were combined with reading and writing activities in the classroom, which were submitted as portfolios. method aim of the research and objectives the aim of the research was to describe the outcomes of a particular cpd programme for foundation-phase teachers for the facilitation of language skills. to this end the research focused on how the participants (teachers) facilitated language development in their classrooms following the support provided, and how the participants valued the support provided to themselves and their learners. in this article the term ‘participant’ refers to the teachers who participated in the research, and ‘learners’ to the learners in classrooms (grades r 3). study design an action research (stringer, 2007) approach was used to determine how the participants facilitated language in their classrooms as a result of a specific cpd programme. this section of the research was originally included as part of the overall project that performed programme evaluation with mixed methods research (wium, et al., 2010). each research cycle collected data with questionnaires prior to and following the workshops, which was followed by a period of practical implementation with the completion of portfolios. these portfolios displayed evidence of lesson planning and practical implementation of strategies in the classrooms, as well as self-reflection. at the conclusion of each cycle a focus group was conducted to evaluate the support provided, as well as the implementation of the strategies learnt. this research cycle was repeated in both contexts. throughout each cycle the programme facilitator continually reflected on the entire process in a research diary. the context as mentioned in the previous article (wium, et al., 2010), the research was repeated in two contexts: a semi-rural context and an urban (townships and informal settlements) context. many learners in south africa are educated in a language which is not their first language, or by teachers who speak a different language from the language of learning and teaching (lolt) (wium, 2010). the research was conducted in a context where northern sotho is the dominant language, which explains why 63% of the participants (n=96) used this language as home language (l1). the other major languages represented as being the participants’ l1 included tswana (11%), isizulu (11%), and to a lesser extent other official african languages of south africa (excluding english and afrikaans). of the teachers 61% used northern sotho as the lolt, whereas 33% used english as lolt in the semi-rural context compared with 25% in the urban township context. in both these contexts setswana and isizulu were used as lolts to a lesser extent. the cpd programme was presented in english as it is the language used for support by the gauteng department of education (gde), and also the language used in higher education (ministry of education, 2001). the aim of the cpd programme was to make the participants aware of the language skills required for learning, and to provide them with strategies to facilitate language development in the lolt in relation to the rncs. participants the sampling process is discussed according to the criteria for selection, selection procedure and sample size. criteria for section of the participants the selection of the schools to be supported was determined by the gde as they aimed to redress past inequities. all participants included in this study were required to meet the following criteria: • all had to be appointed full-time in teaching positions in the foundation phase (grades r, 1, 2 and 3) at schools in the targeted contexts. • only teachers who wanted to participate of their own free will were included. they were made aware that participation was voluntary and that they should not have been coerced by their superiors or peers. those teachers who did not want to participate in the programme were excluded. • participants were expected to feel comfortable with the use of english as medium of instruction. an introductory letter of invitation to the schools alerted the teachers to the fact that the cpd programme would be provided in english, which allowed them to make informed decisions with regard to their participation in the research. selection procedure twelve schools from a semi-rural area and 12 schools from an urban/densely populated area (including township schools and schools from informal settlements) were selected by the gde. a total number of 24 low ses in the tshwane region were targeted for this project over a period of 2 consecutive years. • each of the selected schools was required to identify one teacher from each grade level in the foundation phase who had volunteered to participate. the intention was for these participants to go back to their schools to share their knowledge and skills with the wider community. • a similar procedure of volunteerism was used for compiling the focus groups. by using a nested design, the participants in the focus groups were already included in the original sample. only one representative from each school was required to participate in the focus groups. sample size each grade level (grades r 3) was represented by 12 participants, totalling 48 per annum. the entire sample consisted of 96 participants, which was considered sufficient to serve the purpose of this specific study and was representative of foundation-phase teachers in both contexts (leedy & ormrod, 2010). as only one primary programme facilitator was available to conduct the workshops, a group of 48 participants per workshop was regarded as manageable. this number was considered sufficient to allow for possible attrition later in the programme. all the participants in the semi-rural context were female, whereas two of the participants in the urban context were male. the focus groups each consisted of 12 participants (one representing each school per context), as this number is considered an adequate size for this purpose. it was also a representative sample (25%) of the entire group that was trained, and allowed for attrition. sampling method the sample was selected by means of stratified random sampling, which is a probability sampling method (leedy & ormrod, 2010). each participating school identified one individual from the list of volunteers in each grade level of the foundation phase (e.g. grades r, 1, 2, and 3), so that four participants from each school enrolled for the programme. the qualitative strand obtained data from the entire sample (96) with questionnaires and portfolio assessments, but also used a nested design (onwuegbuzie & dickinson, 2007) for the focus group. the participants who volunteered to participate in the focus groups originated from the entire sample and were therefore similar to those in the rest of the study. the sample was fairly homogeneous in terms of contexts, grade levels represented, and the teachers’ experience in teaching, although not in terms of qualifications and language, and can therefore be considered as a cross-section of the population (leedy & ormrod, 2010). data collection methods the researchers wanted to understand how the participants implemented the strategies, as well as their impression of the benefits obtained from the support provided. this required various forms of qualitative data (leedy & ormrod, 2010). data collection material data were obtained from open-ended questions via questionnaires, focus groups, critical reflection in portfolios, and a research diary completed by the researcher. open-ended questions allowed respondents to express themselves freely and to make suggestions. although open-ended questions were useful to obtain additional information that could add to the understanding of phenomena, they were kept to a minimum as they take longer to complete and therefore could be a cause of non-response. the questions, instructions and layout of the questionnaires were formulated based on guidelines obtained from the literature (mcmillan & schumacher, 2010). a language editor reviewed and edited the questions, and two experts in the professional field, as well as a statistical advisor, scrutinised the various questionnaires to ascertain their validity as a measuring instrument, and to identify any potentially imprecise or ambiguous terms. pretesting determined the clarity of instructions as well as questions, and the time for completion. focus groups were used to evaluate the workshop in terms of the participants’ impressions/feelings about the workshop, and to obtain their experiences in implementing the strategies. in addition, information was obtained on how the participants regarded their own individual levels of skill in implementing the strategies at the end of the 3-week implementation period. the focus group schedule was compiled according to specific criteria obtained from the literature. categories of questions included opening questions, introductory questions, transition questions, key questions, ending questions, and ‘putting the parts together’. the focus group plan was reviewed with experts and then pilot tested prior to use. two experts in the professional fields of slt and education scrutinised the schedules to assess the expected responses, which increased the likelihood of both content and construct validity. the portfolio assessments were used to evaluate the participants’ applied knowledge and to monitor the implementation of strategies. it was assumed that implementation of the strategies learnt would increase the participants’ competence in planning their lessons and facilitate language for learning. the aim of the research diary was to document the research process and to reflect on issues arising. it provided insight regarding factors that could affect the outcomes of the programme. data entries were used to share ideas on the process with experts and colleagues, but also to observe ‘real world’ processes. questions could be answered about methods used. such continued reflection resulted in changes being made; therefore this process could be associated with evidence-based research. data collection process the data used in this article were obtained from questionnaires, self-reflection sheets in portfolios, focus groups and diary entries in a research journal. questionnaires were handed to participants prior to and following training, and were collected by hand after completion. the four participants from each school were required to implement the strategies in the classrooms for a period of at least 3 weeks following the workshops. at the end of the implementation period, they were required to engage in self-reflection (guided reflection) and to include the self-reflection sheets in their portfolios. the focus groups met within 4 6 weeks of the workshop to establish the value of the learning experience and to monitor the implementation of the strategies taught. in addition, diary entries were made throughout the process to reflect on the process. such diary entries were included as data. credibility all the qualitative data analysed were reviewed by inter-rater agreement of coding with 80% accuracy. focus groups were conducted in both contexts. at the end of each focus group meeting, the assistant moderator verbally summarised the responses to questions (as documented from the completed summary sheet). member checking was done immediately when these summaries were presented to the group for approval, thereby increasing the trustworthiness of the data. after the participants had departed, the researcher and the assistant moderator met to reflect on the procedures, the participation, and outcomes of the session. they compared notes and confirmed the key ideas. the researcher further reflected on the focus group shortly afterwards with entries in the research diary. thick descriptions within the context were created and rich data from several data sources (diary entries, focus groups, questionnaires and portfolio reflections) were triangulated, which increased the credibility. data analyses content analysis (qualitative research) provided a clear description of classroom practices and the experiences of the trainees following the support provided (leedy & ormrod, 2010). the focus group transcriptions, diary entries and open-ended questions from questionnaires were qualitatively analysed with atlas-ti (thomas muir scientific software development, 2003 2004) (qualitative descriptive analysis). such software allowed for counting of the occurrence of the codes (enumeration) to determine the prominence thereof. items coded were then grouped as categories and themes within the logic model framework of input, process, output and outcomes. where the overall project reported previously (wium, et al., 2010) focused on the process of providing support, this article concentrates on the outcomes of the component that facilitated language skills. in the overall study all items coded were quantitised by using a binary scale to categorise the data as either positive or negative (supporting the item, or refuting it), which allowed a comparison of quantitative and qualitative data within a mixed methods approach. the interpretation of the inferences was subjected to a validation process before final conclusions could be drawn. results and discussion the binary classification used to interpret the data in the overall project is used in this article as it reflects how the strategies were implemented in the classroom, and the benefits obtained from the support provided. in terms of the former, the following themes can be identified: increased competence in meeting curriculum outcomes, working in themes, and language issues. the benefits of the cpd programme are discussed in terms of the benefits to the teachers (e.g. improvement in lesson planning, working in a theme and language issues), and for the learners (e.g. increased participation of all learners, and enjoyment). selected extracts and quotes obtained from the qualitative data are provided in italics in the discussion of the results. implementation of strategies in the classroom meeting curriculum outcomes the benefits obtained from the support by the teachers included an increased ability to address the curriculum outcomes through the implementation of specific strategies. perceptions of increased competence with the implementation of strategies to facilitate language learning became evident from the following quotes: ‘i took many things out of that story. i made a song, made a poem, and then they must do the plurals, the opposites, segmentation, and then i also stated the new vocabulary. it takes maybe two weeks … on one story. which is [why] i forgot about the assessment.’ (line 28, focus group 1) ‘that any story can teach learners all the learning outcomes.’ (line 20, reflection and self-evaluation of teachers) the use of stories allowed the participants to integrate various assessment standards within a single activity, which is in accordance with the principles of obe. the support also integrated literacy with other learning areas, e.g. life skills, where values such as respect for animals could be taught. ‘a told us how much the story has made an impact on her class. previously she taught numeracy through counting (rote counting). now she makes sure that the story introduces the numbers and concepts within a more meaningful manner (line 22, diary entry 18, pilot focus 2) t: ‘when we tell the story, animals (some learners do not respect animals), when i tell them about animals; they see that they have to respect the animals.’ f: ‘was that because of the story or why did they learn to respect animals?’ t: ‘the story that i was telling – they have changed. i think they have changed.’ (line 42, pilot focus group) in both contexts it became evident during role-play activities conducted in the workshops that some participants at first did not clearly understand how to construct a story or how to hold the attention of learners when reading a storybook. this may be because either they have not used this strategy before, or possibly because having to use english (which was an additional language for all participants) in the role play activity, which could have inhibited their ability to express themselves freely. in general, the participants reported that the use of a story with pictures, as well as book reading, yield satisfactory results as their learners were able to listen attentively and to retell the story. the inference is that the implementation of the story and the use of pictures enhanced the learners’ receptive and expressive language skills. t: and even that one of … the sequencing. when i was just telling them the story, so that they listen and then afterwards, they could tell the story. they were able to sit and listen and then afterwards they could tell us the sequence.’ (line 46, focus group 1) support in lesson planning support in lesson planning had particular value to the participants. prior to the support provided, many of the participants did not understand the value of integrating various activities around a central theme in order to enrich the learners’ conceptual language base and understanding of vocabulary. the participants agreed that using a central theme helped them to plan their lessons. t1 ‘yes it helped me with planning of the lesson.’ (line 191, focus group 3 (b)) t2: ‘most of our teachers had problems with planning our lessons. or creating los. i am so perfect now. i can now use the one lo and apply it to another – we kill two los.’ (line 284, pilot focus group 1) strategies to be used within a central theme, e.g. stories and role play, relate to the functional approach to language learning and increase linguistic awareness (owens, 2004). working within a central theme in general the songs and nursery rhymes supported and expanded vocabulary pertaining to the original theme of the story, and highlighted semantic and syntactic forms (paul, 2007). songs and rhymes supported by transparent gestures or accompanied by movements, as well as role play, allowed for repetition of vocabulary, but also provided the opportunity for multimodal experiences that could facilitate learning. such strategies provided a ‘script’ for learning language, as learners were encouraged to fill in parts that have purposefully been left out once the learners have become familiarised with the story, song, or rhyme. ‘i was thinking that if all the teachers were attending workshops like these, lots of things were going to change at our schools – involving the negative attitudes of teachers for learners who have barriers, and teachers themselves who don’t realise that they are barriers themselves for the learners. because they don’t want to apply new strategies in their lessons.’ (refer to hu 46, line 33. testimonials of learner support teachers) a few participants complained that they found it difficult to match the story with a rhyme and/or a song within a specific theme. they complained about how difficult it had been to design a good story that encompassed all the different elements stipulated in the assignment. (line 17 in diary entry 18, focus group 2) it is possible that the participants had followed a fragmented approach in the past where such activities were conducted in isolation, as was the case with the previous transmission approach to learning. in this case these participants may have benefited from more peer support or mentoring. a central theme was instrumental in the creation of a meaningful context that facilitated understanding and allowed for the use of a variation of intervention activities. themes allowed the learners in class to incorporate new learning into existing frameworks and to gain familiarity with concepts (allowing them to express these in language), as well as to develop understanding. apart from providing activities for listening and speaking, teachers were required to encourage reading and writing within the general theme of the week. the use of a theme integrated the thread of language throughout the curriculum in all classroom activities. such activities within specific themes allowed for cultural diversity and various learning styles, and therefore created an optimal learning environment for learners. language issues some of the participants reported that the use of prepositions was difficult to implement when the lolt was an african language. they explained how they made use of different ways to express the use of prepositions. t: ‘i also struggled, so i looked at the story and tried to implement the strategies. but some of the things we do not do in n sotho. like … prepositions, and … adjectives!’ (line 97, focus group 2) t: ‘we say ka-ga-re (inside), kamorago (behind). e-kamogare. e-mogauswe, e-kamorage (sing-song style).’ (line 109, focus group 2) these participants tended to use archiforms (e.g. use of one member of a word class to represent all members) to refer to several positions in space and augmented the meaning with different hand gestures. such use of prepositions relates to the typical language use of additional language speakers, although in this case archiforms were used by some of the participants when communicating with learners in their l1. some participants reported on their learners’ limited vocabulary, which did not include a wide range of prepositions, and that learners often use a single preposition to represent several others. they reported that they refer to positions in space in a similar manner as their learners do, because they do not expect their learners to understand them if they express themselves differently. such practices did not allow for conceptual growth or for an expansion of vocabulary and therefore these participants’ lack of insight and/or limited proficiency in the lolt could be regarded as barriers to learning. the importance of language modelling (paul, 2007) needs to be emphasised in future programmes because learners need an adult as ‘knowledgeable other’ (in this case the teacher) to provide them with the relevant insights within cultural and social exchange. it should be noted that these teachers’ limited insight into what language consists of and how it can be facilitated can be attributed to several reasons which are rooted in the south african context (e.g. inadequate prior training of teachers who were trained under the previous dispensation, and the lack of formal qualifications). increased insight in meta-language was noted as some participants also complained that subject-specific vocabulary and terminology do not necessarily exist in indigenous languages, which required of them to explain such concepts through the use of gestures, or by making use of more elaborate descriptions. f: ‘but then you explain it with gestures? you can also explain “kagare” as being “behind”?’ (line 109, focus group 2) benefits of the programme the inferences indicated that 95% (n=288) of all items coded in terms of the benefits of the programme were positive, but these results are discussed separately as benefits to the participants and the learners. benefits of the cpd programme to the participants the results indicated that 96% of the 137 items coded were positive; this included the participants’ perception of changes that occurred in their teaching practices, and their ability to reflect on their practices, as well as their empowerment. ‘it has empowered me enormously and i am highly skilled to deal with learners’ problems with sound-right strategies, and confident to approach any learning problem and to assist my colleagues with pride.’ (line 128, un-tabled open questions, forms 2 & 3) evidence of ‘empowerment’ (n=17) is related to the fourth of five levels of knowledge acquisition described by miller & watts (1990), where learners become knowledgeable to the extent of training their peers. in this case, it resulted in some of the participants training their colleagues (and was therefore coded as ‘training of others’). coenders, terlouw and dijkstra (2008) reported on the successful preparation of teachers for a new science curriculum by having them develop and use curriculum materials, as it created ownership and strengthened their pedagogical content knowledge (pck). even though a small sample (n=7) was used in their study, these findings resonate with findings in this study where teachers had to prepare lesson plans for assessment. moreover, as the participants came to realise that they all shared similar problems, a network of support was established between schools. they also came to realise that others are in the same boat, and that they need to support one another as teachers. networking was also established (line 42, diary entry 25). a sense of collegiality appeared to have developed between the participants through sharing experiences, which verifies the value of group and peer learning. benefit to the learners the effect of the programme on the learners is described by information obtained from secondary data on participants’ perceptions of the effect of the strategies on their learners. in general the participants were positive (94%, n=132) about the effect the strategies had on their learners, which is promising as gilmore and vance (2007) found a positive correlation between teachers’ overall rating of attentive listening and learners’ verbal comprehension test scores. research to determine the impact of programmes on learners’ performance is limited. the current study reported perceived gains made by learners, but these findings were subjective. the effect of cpd programmes on learners’ performance needs further investigation. increased participation of all learners all the participants (100%, n=34) testified to the increased ‘participation of the learners’ when using the newly acquired strategies and activities, especially from learners who had been excluded in the past or would not participate. they particularly reported how learners participated in songs and listened to, and retold the stories. ‘learners can tell the stories with the pictures. even the learners who struggle, they can tell the story.’ (line 35, focus group 1) the learners were all able to retell the story and to participate in the songs using gestures and actions. such participation in these activities allowed learners to sufficiently internalise the language to eventually participate through the verbal medium. enjoyment of lessons a particular attribute of the programme was the element of ‘enjoyment’ that was experienced (100%, n=19) across contexts, and is illustrated in figure 3. because the learners enjoyed the new activities and participated in the classroom, the participants (teachers) responded positively and expressed their excitement about the outcomes. enjoyment of learning experiences facilitated learning in both the learners and the participants. ‘these strategies provide the language development. the classes are so much fun … sometimes i look at my class and i cannot believe the difference. the children, they all enjoy the lessons so much. sometimes i feel as if i just want to cry.’ (line 46, diary entry 16 on focus group 1) the continued reflection by both the participants and the researcher on the entire process led to their professional and personal growth. the results indicated that the strategies for language facilitation were experienced as positive (83% of the items coded, n=18). a summary of the results with regard to the implementation of the strategies and the benefits of the support provided are summarised in table ii. negative findings negative findings were related to the ‘process’ component of implementing the cpd programme, particularly the use of portfolio assignments with lesson planning, which were met with resistance as it added to the participants’ workload and put them under pressure. t: ‘implementation is very good, the problem is this assignment. to know … to write it. but it helps us. it really helps us. when we start planning again for those … or your … compiling everything. but i don’t like the assignment.’ (line 12, focus group 2) the participants also complained about time constraints in completing the portfolio assignments or implementing the strategies. such complaints were attributed to busy schedules, high workload, and low intrinsic motivation, which could be related to limited support from the school or a negative school culture. t: ‘yeah, because of lack of time. we have been so busy.’ (line 303, focus group 1) t: ‘in the week it is difficult. i think we should work on it for another two weeks.’ (line 161, focus group 1) t1: ‘it has been so hectic, since the schools closing.’ t2: ‘busy, very busy.’ a-m: ‘with what?’ t: ‘with meetings, some of the workshops.’ (line 15, focus group 2) sustainability of the cpd programme this cpd programme was one example of support provided to teachers and the question remains whether it had any long-term effect as it has not yet been researched. the complex nature of education as a contested context (mcmillan & schumacher, 2010; motshekga, 2010) requires a better understanding from slts working in the education environment (o’connor & geiger, 2009). informal feedback received from the district facilitators 2 years after their training suggested that the lesson-planning format, where groups of grade-level teachers planned their lessons together around a central theme, was still practised in some of the schools, possibly because an integrated thematic approach is supported by the gde as it is part of an obe approach. once, when working in a different context from the research, the programme facilitator encountered members of learner support teams (lsts) (who did not attend the original workshops), using the workshop handout as a resource, which indicated that the strategies and materials were discussed and shared with other colleagues. the message has spread to a wider community, which had been the original intention from the start, but this could also cause problems and be limiting. an initial introduction to the facilitation of language by means of a workshop, as well as follow-up support, is required to ensure quality and generalisation of principles. teacher development is not a ‘quick fix’ for existing problems, but is an ongoing process over time. information and skills need to be repeated and reflected on continually to bring about behaviour change. each learning experience provides a scaffold for future learning. while this cpd programme yielded positive benefits the long-term outcomes remain unknown. limitations of the research in terms of data collection, high levels of non-response were evident in the open-ended questions in the questionnaires, as well as in the critical reflections included in the portfolio assessments. training venues more central to the schools could have limited late arrivals and subsequent non-response in questionnaires. factors such as participants not being familiar with reflective practices, limited language proficiency in english, literacy levels, timing and logistics could have contributed to non-response in portfolio assessment. in some instances a negative school culture impacted on the participants’ motivation to complete the portfolio assignments. it is further acknowledged that working in close proximity with teachers over a prolonged period of time could have increased the possibility of over-involvement and subjectivity. the focus group meetings were conducted, transcribed, coded, and analysed by the course facilitator (also the researcher), which could have increased the possibility of subjectivity in the interpretation of results, despite several measures taken to prevent this. because the participants were not a homogeneous group (in terms of qualifications, literacy levels, prior knowledge, age, and language proficiency), it is possible that the pace of training was too fast for some, while appropriate for others. these factors also impacted on the completion of questionnaires and portfolio assignments. as the workshop material was prepared mainly in english, the participants were required to transfer their knowledge to the lolt, which hampered optimal learning. more examples are required in the lolt. district facilitators who are proficient in the lolt need to become more actively involved in the preparation of the workshop material, and need to be trained as co-trainers to bridge the language divide. it is also possible that less information provided in the workshops would have allowed more time for review, which could have increased the effectiveness of the training. as research informs practice, the limitations of the research also provide indicators for practice. indicators for the practices of slts • since it is not practically possible for a single slt to effectively support every teacher in an entire district, it is essential for slts and district facilitators to collaborate. district facilitators are required by the gde to support teachers in the implementation of the curriculum. they are responsible for the daily support of teachers and therefore need to be supported in their efforts to provide ongoing in-service training in literacy-related skills. • in a consultative and collaborative capacity, the slt can provide advice and support with cpd activities related to listening and language facilitation on an ongoing basis. in a collaborative model of support slts need to provide staff development activities to increase theoretical content knowledge and skills (king, strachan, tucker, duwyn, desserud, & shillington, 2009) as basis for pedagogical content knowledge. in turn, district facilitators are often proficient in the lolt and can contribute to the support process by using code switching to bridge the current language divide in workshops for teachers where slts are from a different language background. such a collaborative support programme needs to be developed as action research (burton & bartlett, 2005; onwuegbuzie & dickinson, 2007) as it will have to be adjusted over time to accommodate various topics and be tailor-made for specific contexts. • a once-off workshop by itself may be useful to introduce new ideas, but its effect is temporary (massel and goertz in roberts, 2002). a ‘cluster model’ of support as an alternative to large-group support may be more effective. the results of this study indicated that the participants preferred group learning and discussing issues and experiences in small groups while sitting around a table. group learning (cluster model) may be a more suitable support model for these particular contexts (killen, 2007). in an attempt to establish a balance between quantity and quality in training, the questions that need to be answered are whether cluster support contributes significantly more to the competence of teachers than large-group workshops and whether it warrants the costs. the advantages and disadvantages of such a cluster model (where small groups will be trained in short sessions over an extended period) as opposed to ‘once-off’ large-group training should be investigated. the effect of such small-group support could be determined by means of a case study design where both quantitative and qualitative methods are employed (roulstone, owen, & french, 2005). • reflective practices are inherent to the obe approach, but have not yet become familiar practice and need to be addressed in future programmes. dunst and trivette (2009) developed the participatory adult learning strategy (pals) which included ‘trainer-guided reflection’ to promote child literacy, communication and language learning practices to parents and slts, which could be further explored for use with teachers. continual reflection on their practices, together with practical experiences, will provide the basis for more effective professional growth for teachers and therapists. • the teachers in this study expressed a need for the slt (course facilitator) to observe their teaching and to provide individual feedback, which was beyond the scope of the research. in school-based support, the slts may want to support teachers through co-teaching and constructive feedback. however, effective collaboration requires that both parties understand their individual roles, and that slts take account of the educational environment. collaboration between slts and teachers cannot be taken for granted when these two professions are brought together as they stem from different disciplinary specialisation and knowledge bases. allen (in forbes, 2008: 153) is of the opinion that ‘collaboration with other professionals is a complex knot of relationships which has to be learned and worked at. it cannot be assumed that by issuing an enjoinder to collaborate, and by placing people together, that the outcomes will be positive.’ it is necessary to identify each discipline’s individual knowledge base and approaches, as well as the new knowledge, skills and approaches required to work together in supporting young learners in south african classrooms. with literacy and numeracy as central focus, the unique contribution of each profession needs to be determined in order to facilitate collaboration in schools. forbes (2008: 141) based a similar line of enquiry on the ‘analytic modes of knowledge’ described by gibbon, limoges, nowotny, schwartzman, scott, & trow (1994), which appears potentially useful as a starting point. however, more contextually relevant information is required for the south african context. conclusion the results showed that the provision of cpd activities regarding language learning can be effective as the majority of the participants implemented the strategies in class and valued the new skills acquired. teachers, as well as learners, reportedly enjoyed the strategies and learnt from them. in view of the relationship between language and literacy, it is imperative that teachers and slts work as a team towards a common goal of supporting learners in learning. as team members they need to show mutual respect and show an ability to work towards similar outcomes (o’toole & kirkpatrick, 2007). the results show that the support of teachers is beneficial for both teaching and learning, and that slts have an important role to play in the process. acknowledgement. the authors wish to acknowledge the support of the shuttleworth foundation for supporting the fieldwork. references asha (2001). roles and responsibilities of speech-language pathologists with respect to reading and writing in children and adolescents (guidelines). rockville, md: asha. burton, d., & bartlett, s. 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(2010, 6 july 2010). statement by the minister of basic education, mrs angie motshekga, mp, on the progress of the review of national curriculum statement. retrieved on 17 august 2011 from http://www.education.gov.za. nancollis, a., lawrie, b.a., & dodd, b. (2005). phonological awareness intervention and the acquisition of literacy skills in children from deprived social backgrounds. language, speech, and hearing services in schools, 36, 325-335. o’connor, j., & geiger, m. (2009). challenges facing primary school educators of english second (or other) language learners in the western cape. south african journal of education, 29, 253-269. o’toole, c., & kirkpatrick, v. (2007). building collaboration between professionals in health and education through interdisciplinary training. child language teaching and therapy, 23(3), 325-352. onwuegbuzie, a.j., & dickinson, w.b. (2007). mixed methods research and action research: a framework for the development of pre-service and in-service teachers. academic exchange. retrieved on 20 december 2008 from http://asstudents.unco.edu/students/ae-extra/2007/6/indxmain.html. owens, r.e. (2004). language disorders: a functional approach to assessment. boston, ma: allyn & bacon. paul, r. (2007). language disorders: from infancy through to adolescence (3rd ed.). st. louis, mo: mosby. rembe, s.w. (2005). the politics of transformation in south africa: an evaluation of education policies and their implementation with particular reference to the eastern cape province. grahamstown: rhodes university. roberts, j. (2002). district development: the new hope for educational reform. johannesburg: joint education trust. roulstone, s., owen, r., & french, l. (2005). speech and language therapy and the knowles edge standards fund project: an evaluation of the service provided to a cluster of primary schools. british journal of special education, 32(2), 78-85. stringer, e.t. (2007). action research (3rd ed.). los angeles, ca: sage. thomas muir scientific software development (2003-2004). atlas-ti: the knowledge workbench v5.0. berlin, germany: thomas muir scientific software development. wium, a.m. (2010). the development of a support programme for foundation phase teachers to facilitate listening and language for numeracy. pretoria: university of pretoria. wium, a.m., louw, b., & eloff, i. (2010). speech-language therapists supporting foundation phase teachers with literacy and numeracy in a rural and township context. south african journal of communication disorders, 57(1), 14-22. table i. the four language systems that children have to acquire aural system (language by ear) oral system (language by mouth) print system (language by eye) written system (language by hand) receptive language heard words expressive language spoken words receptive language printed words expressive language written words fig. 1. the link between language and literacy development. fig. 2. the relationship between listening, language, literacy and numeracy. fig. 3. the role of enjoyment in the programme. table ii. summary of the results obtained in the outcomes component area assessed results positive implementation of strategies 70% (n=125) positive benefits of the programme: learners 94% (n=132) participants 96% (n=137) enjoyment 95% (n=19) appendix a. workshop to facilitate language the training component of the cpd programme addressed the following topics: • what is language? as introduction to the cpd programme an explanation of language and why it is important was provided. there was a brief discussion on the aspects and the elements of language, and how it can be facilitated through the use of a variety of relevant activities and strategies (owens, 2004). • a balanced approach to facilitating reading and writing. current evidence (justice & kaderavek, 2004) regarding the acquisition of literacy skills suggests a balance of both contextualised and decontextualised (discrete) skill intervention as best practice. this specific programme supported a ‘balanced approach’ to the facilitation of literacy (justice & kaderavek, 2004), which creates opportunities to develop an understanding of the language and then uses this understanding as the basis to teach discrete skills within a phonics-oriented, code-based approach (justice, et al., 2006). such a balanced approach to literacy encompasses both the ‘top-down’ (whole language) and ‘bottom-up’ (phonetic) approaches and is most appropriate in the foundation phase where the focus is on facilitating literacy. the teachers were shown how language develops along a continuum, from oral language learnt in the home through concrete operations, to the decontextualised language required for written language used in school. in order to facilitate language and literacy skills teachers need to be aware of a balanced approach to facilitating reading and writing, and how to use central themes to facilitate the four language systems (listening, speaking, reading and writing) in an integrated manner. • the use of a theme in integrating the four language systems: the training component of the cpd programme made use of group activities where the teachers planned the use of songs, rhymes, and craft activities, together with listening, reading and writing exercises within a central theme. such an integrated thematic approach (ita) created several language-rich experiences and allowed the learners to not only develop the vocabulary related to a specific topic, but to integrate skills across the curriculum (department of education, 2002). 62 community work project in gazankulu: a community-based training experience melissa a. bortz, barbara schoub department of speech pathology and audiology, university of the witwatersrand, johannesburg, south africa judy mckenzie rehabilitation unit, tintswalo hospital, acornhoek, gazankulu abstract speech pathology and audiology students at the university of the witwatersrand participated in afield trip to learn about rural community work. in collaboration with rehabilitation workers at tintswalo hospital, gazankulu, projects in pre-school language stimulation, aphasia assessment and intervention, and hearing screening were undertaken. projects adhered to community work principles. these were successful in terms of both providing a service to the community and teaching students principles and practice of community work. opsomming spraakheelkunde en audiologie studente van die universiteit van die witwatersrand het aan 'n plattelandsgemeenskapswerkprojek, as deel van hul onderrig, deelgeneem. projekte in voorskoolse taalstimulasie, afasie-evaluasie en terapie engehoorsifting, is in samewerking met die rehabilitasie-werkers van tintswalo hospitaal in gazankulu onderneem. die projekte het aan die beginsels vangemeenskapswerk voldoen. hierdie projekte was suksesvol, beide in terme van dienslewering aan die gemeenskap en die opleiding van die studente in die beginsels en praktyk van gemeenskapwerk. the discipline of epidemiology has been concerned with prevention of disease and is used to study relationships between people, their diseases and the agents that cause, prevent or cure their disease in the environment (kibbel & wagstaff, 1991). when considering prevention of communication disorders from an epidemiological perspective, prevention usually occurs at three levels, primary, secondary and tertiary (gerber, 1990). primary prevention is aimed at the promotion of good health by reducing the incidence of disease or where the occurrence of a communicative disorder can be eliminated, for example, by mass public education; secondary prevention is the early detection and treatment of a communication problem and aims at reducing the prevalence of disease while tertiary prevention is rehabilitation where traditionally speech and hearing therapists have focused their attention (butler, 1989; gerber, 1990). gerber (1990) does not deny that rehabilitation is necessary but has suggested that it would be positive "for humankind were we to have more primary and secondary prevention" (gerber, 1990, p. xiv). primary prevention can be instituted by means of primary health care which the who-unicef meeting (1978) cited by walt and vaughan (1981, p. 1) has declared is essential health care based on practical, scientifically sound and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self-reliance and self determination. one of the methods currently used to institute primary health care is community work, which de vries (1984) believes is an effective means of promoting health through collective action to prevent disease. according to the calouste gulbenkian foundation (1973) community work is essentially concerned with affecting the course of social change through analysing social situations and forming relationships with different groups to bring about change (1973). j currently south africa's population is estimated at approximately 35 million people. in 1978 penn reported that although few incidence studies had been conducted in south africa those performed, indicate that 8-10% of the population have a communication difficulty. based upon these ifigures there could, currently, be as many as 3,5 million people with disorders of communication. drew (1982, p. 1) has contended that "there are vast sections of the population who do not receive even the most basic speech therapy and audiological care" and according to aron (1984), if one takes into account the number of speech, language and hearing therapists working, it appears that only approximately 138 000 patients are receiving any form of treatment. a possible reason for this is that speech and hearing therapy students are "not only drawn from the privileged sections of the population, but tend to operate within these sections" (drew, 1982, p. 1). in addition, adler (1979) has asserted that speech and hearing therapists tend to treat patients "in rather centralised geographic locations" (p. xiii). / the department of speech pathology and audiology at the university of the witwatersrand (wits) has been attempting to sasi.ha 1992 th south african journal of communication disorders, vol. 39 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) community work project in gazankulu deal comprehensively with the lack of speech and hearing personnel by the training of different tiers of workers who would nrovide services to broader spectrums of the community than currently occurs. (see model presented in figure 1). in addition, wits is striving to make the training of the four year degree in speech therapy and audiology more appropriate for the south african population. one of the methods that has been utilised, is community therapy so that "students can be made aware of the needs of different sectors of the community" (segal, 1982, p. 17). therefore, at present, community work principles are incorporated into all aspects of student training. one of the methods used to achieve this, is the use of regular field trips into the community to carry out speech, language and hearing based projects. the field trip that is to be described took place in the mhala district of gazankulu, a rural community with a population of approximately 200 000 people. most of the inhabitants live in villages of which there are 75, although there are also four towns. villagers have limited access to farming land and water needed for drinking and irrigation purposes. there is a high rate of unemployment and poverty, with people who are employed, being paid at the rate of between r2,00 and r5,00 per day (wits rural facility, 1991). because of limited employment opportunities, many people become migrant labourers, causing a breakdown in traditional family structure and culture. in addition, a large number of mozambican refugees have recently settled in this area, causing further strain on existing resources. medical facilities of this region consist of a 266 bed hospital (tintswalo), two health care centres, 10 permanent clinics and one mobile clinic. at tintswalo two occupational therapists (ots), a social worker, a part-time speech and hearing therapist, two community workers in speech and hearing, three assistants in occupational therapy, and two in physiotherapy, work together as a rehabilitation team. 63 in response to the need for making rehabilitation more accessible and affordable, the tintswalo rehabilitation team, in conjunction with the occupational therapy department of the university of the witwatersrand, is engaged in the process of training community rehabilitation workers at tintswalo hospital (unit for the development of rehabilitation strategies, 1992). the community rehabilitation workers are representatives selected from different villages in the mhala district and trained in basic principles of speech therapy, physiotherapy and occupational therapy and their application. the field trip was a joint project planned by the tintswalo rehabilitation team and the department of speech pathology at wits, and integrated with tintswalo's community rehabilitation worker training programme. the project was based upon methods used in speech and hearing such as hearing screening and community work principles, which "refer to various intervention approaches by a professional practitioner to help a community engage in conscious collective action in order to respond to social problems" (mitchell, 1987, p. 109). according to the calouste gulbenkian foundation (1973, p. 21), community work comprises certain characteristic steps which the field trip was designed to incorporate: 1) study the situation 2) establish rapport and a network of communication links with the community 3) gather information, analyse the relationship between community wants and needs and identify alternative ways of meeting needs 4) create some basis of organisation and of resources, work on the programme, modifying procedures and objectives as experience grows 5) review and develop progress to determine the next steps. in speech and hearing therapists: 4 tear university degree course (prevention, promotion, χ rehabilitation and research n concerning communication impairment) community workers in speech and hearing theradv: 2 year diploma course (prevention, promotion and rehabilitation of communication impairment) community-based rehabilitation workers: }"2 year situ rehabilitation training with general disability figure 1: proposed model for personnel involved in treatment of communication problems. (department of speech pathology and! audiology, university of the witwatersrand). the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 melissa a. bortz, barbara schoub & judy mckenzie mitchell (1987) has reported that the final stage of a community work project is evaluation which is the process by which the participants in a project assess the extent to which the project has met its objectives. cooper and heenan (1980) believe that evaluation should be carried out on an ongoing basis while the project is in progress, and a concluding evaluation session should be held in which the overall project is evaluated in terms of the extent to which it has met the stated expectations and goals. the field trip aim the purpose of the field trip, for the wits students was to learn community work principles and experience conditions in rural areas. the aim of the field trip for the tintswalo rehabilitation team was to engage in speech and language projects they had identified as necessary but had not carried out due to lack of adequate personpower. for the community the purpose of the field trip was to receive language and hearing services. participants three staff members and 14 students from wits participated in the three selected projects for the field trip, together with members of the tintswalo rehabilitation team and community rehabilitation workers. all participants in the field trip were divided into the three selected projects discussed below. p l a n n i n g feasibility and organizational details were discussed at a planning.workshop held in gazankulu with members of staff from the tintswalo rehabilitation team, from the community rehabilitation worker training programme and from the department of speech pathology and audiology, wits. this took place a month before the field trip. three projects were selected to be undertaken by participants in the field trip. these were new projects selected for the field trip according to needs previously identified in the community by the tintswalo rehabilitation team. the selected field trip projects were: 1. a language stimulation project consisting of wits students and staff and a community worker in speech and hearing which aimed to educate childminders at local creches about the development of language and the importance of language stimulation and play. 2. a stroke rehabilitation project whose objectives were for wits staff and students to train student community rehabilitation workers about speech and language problems associated with stroke. a further objective was to devise relevant and appropriate assessment and management procedures for aphasic patients in this setting. 3. a hearing screening and education project aimed at identifying hearing problems by conducting hearing screening at three schools. in addition, this group would be used to provide information about hearing loss and management to teachers and members of a self help group that had deaf members. the month between the planning workshop and the field trip was used to organise such practical details as transport from wits to tintswalo, and in gazankulu; and accommodation for wits students and other participants in the language stimulation group. to the writers' knowledge this is one of the first occasions that a project of this nature, combining the fields of community work and speech and hearing has taken place, and there are no recognised evaluation procedures or standardised measures for projects of this nature. therefore, much of the work undertaken was exploratory, which the reader should bear in mind, for the remainder of the article. implementation the duration of the field trip was four days with projects being carried out for three days and the fourth day being used for each group to discuss and evaluate their project.for a detailed timetable of the trip, see appendix. 1. language stimulation project the aim of this project was for wits staff and students and members of the tintswalo rehabilitation team to provide information about language development, stimulation and play to childminders belonging to a support group in gazankulu. background information. the tintswalo rehabilitation team coordinates a support programme for childminders at local creches and has organised an association called hlangavani creche teachers support group whose aim is: 1) to provide support and training for childminders in the region, through the running of workshops by training associations such as the montessori society of child centered education. childminders are generally untrained and often work on a voluntary basis. 2) to assist with fundraising for creches in this region. reynolds (1989) has contended that in societies such as the one being described, adults tend not to play with their children as play is regarded as being undignified. in addition, it has been noted by members of the tintswalo rehabilitation team that parents tend to perceive feeding and day-care rather than preschool education, to be the primary functions of creche. members of the tintswalo rehabilitation team, based on their professional knowledge, considered that the time the children spent at creche could be maximally utilised by engaging in such activities as play. childminders had also agreed to this when receiving information regarding the importance of play, at regular interactions between them and members of the tintswalo rehabilitation team. thus, the need for a programme, in the form of a workshop, dealing with language stimulation and play had been identified by childminders and the tintswalo rehabilitation team. j the childminders were notified about the proposed .workshop by one of the ots from the tintswalo rehabilitation team, who organised accommodation for them. eight 'childminders attended the workshop which was facilitated by six wits students, a staff member and a community worker in speech and hearing. the aim of the facilitators was to increase the childminders' motivation to learn and act on this learning, as suggested by brookfield (1986). in order to obtain maximal benefit and participation, members were divided into two equal groups from the second day of the programme. the same format was adopted for both groups. location. the workshops were held at: 1. pfukani creche which has an enrolment of 30 children and primarily caters for the children of tintswalo hospital staff. a number of disabled children also attend this creche. 2. hluvukani creche which is a community-creche catering for 250 children, mostly refugees. this creche is assisted by operation hunger. the programme was conducted in english at pfukani creche as all participants could communicate in english. at hluvukani creche, however, as two caregivers did not understand english, all input was translated by a member of the group who was fluent in both english and tsonga. the comthe south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) community work project in gazankulu 65 munity worker in speech and hearing, although fluent in both languages, was not used as the translator, as her role in this group was that of facilitator. the programme. according to twelvetrees (1986, p. 21) certain basic methods are followed in community work, that is, "to study the situation, establish rapport and gather information" and in accordance with this, the functioning of the two creches and the interaction of childminders with the children were observed by the facilitators on the first day. this observation confirmed the need, previously identified, to provide childminders with information about language stimulation. it was apparent that childminders were not allowing children to play, and that they were providing much information at inappropriately high levels: eg. teaching three to six year old shangaan speakers approximately 15 new english words in the space of 10 minutes, by having them imitate the childminder. this was particularly true at pfukani creche. based on the information obtained, the facilitators prepared an educational programme consisting of talks and activities such as role play and poster presentations. information was to be provided on language and its development, language stimulation, the importance of play and how to incorporate this into a creche programme. this programme was implemented on the second and third day of the field trip with techniques such as role-playing, modelling and problem solving exercises being used to demonstrate principles and methods of the programme, rather than lecturing to childminders on the specific topics. the example noted at the observation, of the childminders attempting to teach english vocabulary by imitation, was used to demonstrate the difficulty of learning a language in this way, by the facilitators using the same ineffective methods of teaching a foreign language, hebrew, to the childminders.an example of one of the subjects addressed in the workshop was effective story telling. this was demonstrated through role-play followed by a discussion with the facilitators and childminders on the principles of story telling. childminders were then asked to role-play telling a story to the workshop. finally, the childminders were given the opportunity of telling the story to children in the creches. other similar role-plays and discussions were held over the two days to demonstrate other principles of language stimulation and play such as teaching body parts and singing. posters were also used to explain the sequence of language development. evaluation evaluation was carried out on an ongoing basis in accordance with the evaluation procedures, previously described by cooper and heenan (1980). in the ongoing evaluation it was noted by the facilitators that the childminders participated enthusiastically in all activities and had acquired new and more effective skills in stimulating language development, in such activities as teaching vocabulary or songs. when teaching vocabulary childminders attempted to introduce only one or two new words into an activity. they would explain the word, for example, a particular object, by showing it to the children, describing it, enumerating its uses and allowing the children to play with it. in addition, the childminders displayed an ability to generate and expand on what they had been taught, for example by the incorporation of songs that the children knew, into a story. this resulted in the exposure of the children to more varied activities and input. in the formal evaluation session held at the end of the third day, the childminders described the workshop positively and said that it had benefitted them. examples provided of what they had learned were that they had not realised that children learn through play or that language learning is a gradual procedure. the success of the project, which was manifest both in terms of the increase in skills and the positive evaluation of participants can be seen as consistent with the principles of community work, that is language stimulation had been identified as a need, and therefore the childminders were motivated to carry out the programme as it served their needs and their potential for becoming self-sufficient, as advanced by segal (1982). the students also evaluated the workshop positively. the students at hluvakani creche found that the translation of the proceedings from english to tsonga slowed down the process of giving information. however, they reported that this was extremely valuable in terms of exposing them to the inherent problem of not always speaking the same language as the client, so common in south africa. the community worker in speech and hearing commented on the positive changes she had seen taking place in the childminders interaction with their pupils. her feedback was of particular value as she had experienced the childminders' previous lack of knowledge regarding language stimulation and play, while during the workshop she was able to view a constructive change in this. she expressed concern that these skills should be maintained and therefore implemented long term evaluation of this project by involving the tintswalo rehabilitation team and the hlangvani creche teachers support group. 2. the stroke rehabilitation project the aim of the project was to assist community rehabilitation workers in the practical aspects of identifying and assessing aphasia and planning suitable intervention procedures. formal standardised aphasia tests for this population are not available, therefore a further aim was to develop basic identification and assessment procedures, suitable for use by the community rehabilitation workers. participants. pairs, consisting of a wits student and a community rehabilitation worker visited individual clients in the community rehabilitation workers' villages. a wits staff member and a tintswalo rehabilitation team member provided transport for the pairs and consulted with each pair when necessary to assist in evaluation. the programme. at the planning workshop, the following timetable was proposed. on the first day stroke patients who had previously been referred to members of the tintswalo rehabilitation team or community rehabilitation workers, were to be observed in their homes. on the basis of these observations an aphasia evaluation and home therapy programme was to be devised, on the second day. the assessment was to be carried out with patients and its effectiveness assessed on the third day, and finally, on the fourth day, the home therapy programme was to be initiated and its success evaluated. due to the considerable distances between villages however it was not practical to keep to this proposed timetable. this difficulty had not been foreseen initially. in addition, the implementation of the therapy programme on day four could not be carried out as many of the previously identified stroke patients did not present with aphasia, or were too frail and ill to receive therapy. the programme for day one was implemented as planned. the observations of the stroke patients in their homes revealed that many of the patients were not aphasic. it was also realised that it took considerably longer than had been anticipated to transport pairs to their locations, in some instances up to two hours per pair. one of the reasons was that no maps or street names are available for the different villages and time was the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 66 melissa a. bortz, barbara schoub & judy mckenzie spent in asking directions from local residents. on day two an aphasia assessment was devised for those stroke patients who appeared to present with aphasia. broad areas were to be examined, for example, how to test receptive and expressive language, using objects and stimuli available in the patients' homes. this was successfully implemented on the third day. also on this day, where appropriate, suggestions were made to families on how to communicate more effectively with their aphasic family member. at the request of the community rehabilitation workers the remainder of the day was used to assist them with other patients they had identified with communication problems such as mentally retarded or dysarthric children. implications it was invaluable for wits students to see patients in their home environments as this helped them to understand the overwhelming physical difficulties handicapped patients in rural areas have to contend with, eg. the uneven and eroded terrain that patients have to negotiate when going to the toilet. in addition, they were able to observe the close involvement of the extended family and neighbours in caring for the patient. this highlighted the need for the community rehabilitation worker to provide the family and community with education about stroke and management of the communication problems of the patient. it was particularly valuable for wits staff and students, as members of a training institution, to experience the importance of community rehabilitation workers. this was evidenced in terms of their ability to relate to the patient and the family. it was clear that the shared community origins were most valuable in that the community rehabilitation workers understood the language, local customs and the needs of their community, which endorses segal's observations (segal, 1982). furthermore, the presence of community rehabilitation workers in the villages, has made integrated assessment and management programmes across disciplines, available in the homes of patients otherwise deprived of access to rehabilitation, which is available only in places far from their homes. as mentioned in an earlier section, community rehabilitation workers receive training in basic assessment and treatment principles of physiotherapy, occupational therapy and speech therapy. the benefit of this broad training gives them an integrated perspective of aphasia in relation to the patient's other disabilities, and helps them to treat patients holistically. this is a perspective which is often difficult for members of different paramedical professions to appreciate. this project was successful too, in that the wits students imparted specialist skills to the community rehabilitation workers to allow them to provide services to their own communities. according to wagstaff (1984, p. 11) "primary health care advocates ... team work and the responsible delegation of tasks for which necessary training has been given". from the experience of teaching students it is clear that there is a common misconception that community work must of necessity be carried out within groups. this project helped students to realise that community work can be carried out on a one to one basis. students also learned about the need to be flexible when undertaking community work, as they observed how programmes had to be modified due to circumstances that could not be predicted, for example, the small number of patients who had aphasia, necessitated a change to the programme. the assessment procedure was successful in identifying the presence or absence of aphasia. however, as few of the patients exhibited aphasia, it was not possible to demonstrate to the community rehabilitation workers the full evaluation of aphasic symptoms, such as perseveration or word finding difficulties. furthermore, due to the fact that there were so few aphasics, and that these were mostly elderly and many years post stroke, intervention procedures could not be demonstrated. 3. hearing screening and education project background information. this project took place in the village of croquet lawn following an incidence study undertaken by the tintswalo rehabilitation team in 1990, in which numerous patients with hearing loss were identified. in addition two deaf members belong to a self-help group that undertakes sewing and agriculture, with the purpose of obtaining an income which has been established in this area. it should be noted that self-help is a strategy that most typifies community work and aims'to assist people in learning how to deal with their problems according to mitchell (1987). aims. the aims for this project included hearing screening of children in the village pre-primary and primary school and diagnostic testing of pupils with known hearing losses in the high school. in addition educational talks providing information to teachers on such topics as hearing loss, basic ear hygiene and management of the hearing impaired child in the classroom were held. a final aim of this project was a talk to members of the self-help group to discuss deafness, causes of hearing loss and communication with the hearing impaired. this was conducted in oral and sign language. participants. a staff member and four students from wits; a community worker in speech and hearing; and a community rehabilitation worker from croquet lawn were to administer this project. the programme. hearing screening of the pre-primary school took place on the first day of the project while the primary school was screened on the second day. otoscopic examinations preceded the screening. as there was no electricity, a liverpool screening audiometer and peters audiometers were used. screening levels were 50db at 500 and 1000hz and 30db at 2000 and 4000hz on the liverpool audiometer due to high levels of ambient noise and 35db at 500, 1000, 2000 and 4000hz on the peters audiometer. in addition on the second day, diagnostic audiometry was administered to pupils at the high school who had previously been identified as having hearing problems. thorough pure tone testing as suggested by green (1985) was attempted but was not possible due to the fact that portable audiometers were used and no sound proof booths were available. educational talks were delivered to teachers and members of the self-help group on the third day of the project, on the topics mentioned above. both talks incorporated a discussion on the role of jthe community rehabilitation workers as regards identification, monitoring and referral of patients with hearing problems in the community. results. all the aims of this project were achieved. otoscopic examinations revealed a high incidence of impacted wax. referrals for removal of this were made to the local clinic or to the community worker in speech and hearing, who has a great deal of experience with wax removal. children with suspected ear infections were referred to the local clinic for treatment and children who failed the hearing screening, where there was no evidence of impacted wax or ear'infection, were referred to tintswalo hospital for further diagnostic testing. evaluation. this project was successful in that the following was achieved: hearing screening was successful in identifying children who had ear problems arid needed treatment or referral. a positive outcome was that the students learned to apply their screening skills,in a rural community and they reported bethe south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) community work project in gazankulu 67 coming more proficient in otoscopic examination. this project was also successful in emphasising the importance of the community rehabilitation worker and tintswalo rehabilitation team in providing follow up for identified hearing problems. the importance of being appropriately prepared and of identifying community resources prior to embarking on such a project, was highlighted by participants in this project. for example, it was important to know before the field trip that there was no electricity in the pre-primary and primary schools, and that therefore it would be necessary to use batteryoperated audiometers. in addition, participants learned how to adapt basic procedures for the situation, for example, diagnostic testing with a portable audiometer. summary and conclusions when evaluating the results of the field trip it is important to remember that it lasted four days. within that time, change was seen, but it is not yet clear whether there can be any long term effects in such a short time. results and conclusions should thus be seen in the light of this. the specific objectives of the three projects were achieved with the exception of implementing aphasia assessment and intervention. this was due to factors that could not have been anticipated such as the fact that not all stroke patients had aphasia. during the exposure to community work, participants learned the importance of being flexible and of being able to adapt to existing conditions. the successful working relationships between speech and hearing therapists, community workers in speech and hearing, and community rehabilitation workers, as well as occupational therapists, was proved to be particularly appropriate for the context of the field trip. in addition, results of the field trip indicated that a coordinated team such as the one used, provided an integrated and effective community service. a large part of the success of this service can be attributed to the fact that follow up of referrals was made possible by the existing infrastructure of the tintswalo rehabilitation teams and community rehabilitation workers. it would have been irresponsible to undertake community work projects without providing the necessary follow up services. as regards the aims of the various participants of the field trip, the tintswalo rehabilitation team considered the field trip successful as the projects were planned according to their identified needs and provided the personpower to undertake them. the community benefitted in that they received necessary language and hearing services.the wits students and staff, on the other hand gained an insight and increased proficiency for community work from this field trip. much of the value was derived from the reality of the aims and the work done. this trip did not merely provide an opportunity for 'rural tourism'. finally, this project achieved, to a certain extent, an objective of community work which is to enable the communities to acquire the skills and confidence to tackle problems which are necessary to ensure thatconcrete changes are brought about in the community (twelvetrees, 1986). acknowledgements the writers gratefully acknowledge the assistance of ms. m. schneider for participating in this project under laborious circumstances. the assistance of the students is also warmly appreciated. references adler, s. (1979). poverty children and their language: implications for teaching and treating. new york: grune and stratton. aron, m. a. (1984). introduction. proceedings of conference on communitg work in speech and hearing therapg. johannesburg: university of the witwatersrand. brookfield, s. d. (1986). understanding and facilitating adult learning. milton keynes: oxford university press. butler, j. (1989). child health surveillance in primary care: a critical review. london: her majesty's stationery office. the calouste gullbenkian foundation. (1973). current issues in communitg work. a study by the communitg workgroup. london: routledge & kegan paul. cooper, s., & heenan, c. (1980). preparing, designing and leading workshops: a humanistic approach. boston: cbi publishing, de vries, g. (1984). community work in health. proceedings of conference on communitg work in speech and hearing therapg. johannesburg: university of the witwatersrand. drew, μ. e. (1982). editorial. south african speech and hearing association newsletter, 250, 1-6. gerber, s. e. (1990). prevention: the etiology of communicative disorders in children. englewood cliffs, new jersey: prentice hall. green, d. s. (1985). pure tone air-conduction testing. in j. katz (ed.), handbook of clinical audiology (3rd ed.). (pp. 98-109).baltimore: williams and wilkins. kibel, m. a. & wagstaff, l. a. (1991). child health for all: a manual far southern africa. cape town: oxford university press. mitchell, w. (1987). social work with communities. in b. w. mckendrick (ed.), introduction to social work in south africa. pinetown: owen burgess. penn, c. (1978). speech pathology and audiology in south africa past, present and future perspectives. in l. w. lanham & k.p. prinsloo (eds.), language and communication studies in south africa: current issues and directions in research and inquiry. cape town: oxford university press. reynolds, p. (1989). childhood in crossroads: cognition and society in south africa. claremont: david phillip. segal, d. (1982). community-based therapy: some preliminary suggestions. south african speech and hearing association newsletter. 251. 15-18. twelvetrees, a. (1986). communitg work. london: macmillan education. unit for the development of rehabilitation strategies. (1992). report on the training of communitg rehabilitation worker students. unpublished document. tintswalo hospital, gazankulu. wagstaff, l. a. (1984). the need to work in the community. proceedings of conference on communitg work in speech and hearing therapy. johannesburg: university of the witwatersrand. walt, g. & vaughan, p. (1981). an introduction to the primary health care approach in developing countries. a review with selected annotated references. ross institute of tropical hygiene publication no 13. london. wits rural facility. (1991). introduction to the mhala region of the eastern transvaal. unpublished document. wits rural facility. address correspondence to ms. m. bortz, department of speech pathology and audiology, university of the witwatersrand, private bag 3, wits, 2050, south africa. the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 68 melissa a. bortz, barbara schoub & judy mckenzie appendix 3 proposed programme for field trip to gazankulu, 1 5 september,! 992. projects 1. language stimulation 2. stroke rehabiliation 3. hearing screening and education day 1 observe at creches observe at stroke patients' homes screen hearing at pre-primary school day 2 implement programme devise aphasia evaluation and home therapy programme screen hearing at primary school. diagnostic audiometry at high school. day 3 implement programme and evaluate implement assessment, evaluate and counsel families educational talks to teachers and self-help group. day 4 institute home therapy programme evaluation of field trip by prticipants the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the effect of intracranial pressure on the performance of an aphasic subject: a case history michelle shapiro b . a . ( s p . & h . t h e r a p y ) ( w i t w a t e r s r a n d ) speech and hearing therapy department. baragwanath hospital. summary a battery of tests involving the language modalities of speech, comprehension, reading and writing were administered to an aphasic subject who presented with a predictable fluctuation in intracranial pressure. results revealed a consistency in performance in the two situations, across all modalities. the subject's performance was found to be of a concrete nature, demonstrating a cognitive deficit concomitant with his linguistic impairment. opsomming .'n battery toetse wat toetsing van die taalmodaliteite van spraak, begrip, lees en skryf insluit is uitgevoer op 'n afasiepatient wat gepresenteer het met 'n vooispelbare fluktuasie van intrakraniale druk. resultate het konstantheid van gedrag in die twee situasies t.o.v. alle modaliteite aangetoon. die pasient se gedrag was konkreet van aard, wat dui op die kognitiewe ontoereikendheid wat met 'n linguistiese afwyking gepaardgaan. the performance of aphasics has been studied under the influence of alerting and tranquillizing drugs, fatigue induced by exercise, relaxation training, influence of motivating instructions and scheduling effects.18 one variable that has been given little consideration as to its potential influence on measurement of aphasic patients' communicative skills is intracranial pressure. the present study was concerned with the effects of changes in intracranial pressure on an aphasic subject's expressive and receptive language, reading and writing skills. schuell, jenkins, and jiminez-pabon2 2 consider aphasia to be a general deficit that crosses all language modalities and which may or may not be complicated by other sequelae of brain damage. marie and goldstein1 6 believe that the principal form of the mental process is "symbolic activity", put into operation as "abstract" schemes, and that every disease of the brain is manifested, not so much by loss of the ability to carry out specialized processes as by a depression of this symbolic function or abstract orientation, (p. 19). having stated these definitions it is opportune to pose two questions as yet unresolved in the literature. is the aphasic patient impaired in his thinking because of a deficit in the language, or is he impaired in language because of a "primary, adventitiously acquired" deficit in thinking?1 0 a second question posed by eisenson 1 0 is particularly relevant to this study. compared with his premorbid potential, is the aphasic an intellectually impaired person and so, at best, one who will continue to be linguistically impaired in that he will not recover fully his capacities for dealing with high-level abstract propositions?10 (p. 1224). throughout the literature a general viewpoint emerges suggesting that the higher mental functions are formed in the process of ontogenesis, die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 82 michelle shapiro passing through several successive stages. 1 1 ' 1 2 · 1 6 piaget 1 2 does not emphasize individual differences in intelligence, but has evolved a description of the general form of thought. his theories depict the optimum capabilities of thought at a given period in development. at successive stages in their development, the structure of the higher mental functions does not remain constant, but performs the same task by means of different, regularly interchanging systems of connections.1 6 therefore, it can be concluded that reading, writing, receptive and expressive speech have different psychological compositions at different stages in development. m e t h o d o l o g y a i m the primary aim of the study was to determine the effect of intracranial pressure changes on the communicative skills (reading, writing, receptive and expressive language) of an aphasic subject. the performance of the subject with variation in intracranial pressure (i.c.p.) was attained by testing the patient in the morning; that is, when the pressure had been built up after approximately eight hours sleep. in the afternoon the lower pressure recordings were made; that is, when the pressure had dropped after the day's activities in the upright position. if no change is evident in the performance of the subject at high and low intracranial pressure, the writer will attempt to determine the possible contribution of a cognitive deficit to his linguistic impairment. it was hypothesized that the communicative skills will be improved when the intracranial pressure is at a higher level; and the converse; that is, that there is a detectable decline in performance when the pressure is lower. s u b j e c t the subject used in this study was an english-speaking male, aged forty-nine years, who sustained an injury to his head when he fell six years before. a linear tempero-parieto-occipital fracture of the left hemisphere and a contrecoup lesion of the right frontal lobe was noted. a subdural haemorrhage developed on the left side. within a week his head swelled and due to the excessively high i.c.p. he had to undergo an emergency, life-saving operation in which a haemotoma was removed. a bone flap was removed to provide adequate decompression. however, the decompression site became progressively more swollen, and a communicating hydrocephalus developed. as a result the i.c.p. rose to a danger level. the subject became semi-comatose, and in order to reduce this pressure, surgery was performed in which a ventriculo-atrial shunt was inserted. however, the opposite effect now occurred. pressure manometry revealed a damped (low) i.c.p. system (5 ml h 2 0 compared with the normal 130 ml h 2 0 ) with minimal rises in' pressure with coughing, valsalva the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) i n t r a c r a n i a l pressure and aphasia 83 manoeuvre, speaking and posture. to ensure adequate circulation of blood through the brain a higher i.c.p. was required. two further operations were performed. firstly, a stellon prosthesis was sutured to the bone and periosteum, thus separating the i.c.p. from the barometric (atmospheric) pressure and hence creating a closed system. in the second operation, an "on-off" switch to the ventriculo-atrial shunt and an i.c.p. transducer were inserted. pressure recordings were made with the valve switched " o n " and "off'. in order to determine the relationship between the subject's i.c.p. and level of brain functioning, the relationship between the i.c.p. and fluid volume was established. a stress curve was used to act as a standard for the interpretation. this is represented in figure 1. in a normal subject, the cerebo-spinal fluid (c.s.f.) pressure is set to a steady level by externally induced forces, mainly from the respiration and less so from the heart. to obtain figure 1, controlled amounts of c.s.f. were first removed and then ringer lactate solution added, with a pause at each station to allow the newly induced level to adjust spontaneously to a steady state, thus introducing three dimensional parameters of volume, pressure and 20 18 16 14 12 volume/ml 10 8 2 2ml units ringer lactate ^ key: = functioning before shunt/plale was inserted = present status (with plate) = normal functioning = hydrocephalic patient (the status of the subject before the valve was inserted). figure 1. a diagramatic representation of the subject's i.c.p. functioning with an increase in cerebro-spinal fluid volume. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 84 michelle shapiro time.2· 3 2 ml of fluid is injected at a time by means of a lumbar puncture and the rise in pressure is monitored. as can be seen in a normal subject each time 2 ml is injected, the pressure rises. however when a certain pressure is reached through stress or some other deviation, any increase in pressure can prove to be dangerous. the human copes with this by what has been termed restoring forces that oppose the distortion and reduce the pressure. the restoration appears to depend essentially on the overall elasticity of the system. therefore, each stress curve. is likely to be individual specific and pathology specific. in the aphasic subject, by comparison, the shunt was originally overacting or overdraining and as a result the subject's opening pressure was about 5 ml h 2 0 . with the insertion of the plate the subject's opening pressure rose 5 ml h z o which is better than his previous one but below the normal opening pressure. originally with an increase of volume, the pressure rose but then fell back to its original level. after a few increases in volume a further increase in volume did not result in a pressure increase. the supine position facilitates the flow of blood to the brain. upon rising in the morning the i.c.p. of the subject is at its optimum; that is approximating normal levels. physiologically, this forms the basis for the improved functioning in the morning: the subject reported better performance in his speaking, reading, writing and comprehension. owing to the valve function the i.c.p. reduces as the day progresses and consequently his performance declines.1 in this study the writer attempted to assess the reported changes in the subject's higher mental functions; that is, expressive and receptive speech, reading and writing skills. tests the battery of tests administered to assess the possible performance changes consisted of standardized and non-standardized tests. the standardized tests chosen had either test — retest reliability or equivalent forms in order to permit unbiased repeated examination of the same patient during conditions of high and low i.c.p. the aphasic tests used which adhere to these criteria include the boston diagnostic aphasia examination, 1 4 the shortened version of the token test 6 and the reporter's test. 7 the neale reading analysis2 0 and picture story language t e s t 1 9 are also standardized tests. these were included in the battery, as reading and writing form part of/higher cortical functioning. the abovementioned tests can be quantitatively and qualitatively analysed. the tests compiled by p e n n 2 1 were also included in the battery to assess the subject's competence with respect to complex sentences. finally, expressive samples of speech were analysed according to crystal, fletcher and garman's 4 language assessment, remediation and screening procedure (larsp). the procedure was used to provide a description of the subject's syntactic output. the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) i n t r a c r a n i a l pressure and aphasia 85 to confirm the trends which emerged from the aforementioned battery, the wechsler intelligence scalefor children — revised (wisc-r) was administered to assess the subject's verbal and non-verbal performances.2 4 testing procedure with the exception of the wisc, each test or equivalent form of the test was administered on two separate occasions, with a week's interval. an hour was scheduled for each session to reduce the possibility of the subject becoming fatigued during the assessment period. testing extended over ten days. one assessment was scheduled to be held in the morning at 8.30;.that is, at the time of higher i.c.p. the second assessment was scheduled for the afternoon at 3.30 the following week. order of scheduling, that is, morning first, afternoon s e c o n d ; and afternoon first, morning second, was randomly determined. (refer table i.) an attempt was made to present approximately half the tests first in the morning and the other half first in the afternoon. table i: the testing procedure name of test order of administration name of test morning (8,30 a.m.) higher i.c.p. afternoon (3,30 p.m.) lower i.c.p. \ boston (first i) 1st 2nd 5 boston (second i) 2nd 1st shortened version of the token test 2nd 1st reporter's test 1st 2nd complex sentences (comprehension and recall) 2nd 1st description of an orange/ banana 1st 2nd how to attach a plug/ change a tyre 2nd 1st description of a picture (from boston test) 1st 2nd neale reading analysis 1st 2nd picture story language test 2nd 1st die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 86 michelle shapiro results no marked difference in the subject's performance with higher and lower i.c.p. was evident from the battery of tests administered. (see table ii.) on the boston diagnostic aphasia examination, the z-score profiles of aphasia subscores revealed a picture of "conduction aphasia" but showed little variation between measurements at higher and lower i.c.p. on the shortened version of the token test, the subject performed better at times of lower i.c.p. on all parts of the test. penn's comprehension subtest 2 1 involved asking the subject questions about specific aspects of complex sentences presented orally. the subject displayed a consistent confusion of the deep relationship for each type of complex sentence as well as for sentences containing more than one embedding. the confusion of the deep relations was apparent at both the high and low i.c.p. performances, although the frequency of occurrence differed. twenty-seven sentences were administered at each sitting, with a corresponding seventy-two questions. the subject's comprehension performance was found to be better at higher i.c.p. the larsp profiles revealed consistent performance of the subject at high and low i.c.p. in terms of the length of the sample; mean sentence length; distribution of the structures on the clause, phrase and word levels; number of expansions; and error types. the results of the complex sentence-recall subtest were analysed qualitatively and indicated a better performance at low i.c.p. on the reporter's test, no difference was found in the performance of the subject at high and low i.c.p. results from the neale reading analysis revealed little change in performance at high and low i.c.p. on equivalent forms of the test. (form β and form c.) the subject performed equally poorly at high and low i.c.p. on the picture story language test. on the abstract-concrete scale the subject obtained a score of " 6 " which falls within level ii; that is, the "concrete-descriptive" level. the wisc-r was administered only once, in the afternoon, to ascertain the relationship between the subject's verbal and non-verbal performances with respect to an age equivalent. results revealed that he was functioning verbally on an 8 year 11 month level and non-verbally on an 11 year 10 month level. / discussion the results of this study did not support the hypothesis that there is an improvement in performance at the time of higher i.c.p. the subject's performance was consistent throughout the testing period regardless of the state of i.c.p. although an improvement in the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) intracranial pressure and aphasia t a b l e ii: summary of the subject's performances at higher and lower i.c.p. task administered high i.c.p. low i.c.p. the boston diagnostic aphasia examination + + the shortened version of the token test + complex sentences: comprehension + complex sentences: recall + description of an orange/banana + instructions: how to attach a plug/change a tyre + + reporter's test + + neale reading analysis + + picture story language test + + + improved performance deteriorated performance + consistent performance comprehension performance was found with higher i.c.p., the amount of change was not marked. due to the fact that the neurosurgeon confirmed a physiological basis for improved performance, and the fact that the subject reported improved performance with higher i.c.p., it was important on the basis of the results to investigate the possibility of another factor contributing to the consistency in the subject's performance throughout testing. it was for this reason that the writer attempted to determine if the subject presented with a cognitive deficit concomitant with his linguistic impairment. goldstein 1 3 states that there is a change in an aphasic's behaviour in the ability to employ an abstract attitude. the essence of change is in a tendency towards concretism.9 (p. 1224.) in piaget's theory, the concrete-operational period takes place in the normal child between the ages of seven and eleven years, whereas the formal operational period (which he considers to be the final period of intellectual development) begins at about twelve years of age and is consolidated during adolescence. 1 1 , 1 2 inhelder and piaget 1 5 state that both the syntax and the semantics of die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 88 michelle shapiro language involve structures of classification, (p. 2.) as the subject performed poorly in both these areas, one would hypothesize that he experiences difficulty in "classification", and therefore, can attribute his poor performance to an underlying cognitive impairment. an analysis based on the fact that not all word classes are understood in the same w a y , 1 3 revealed that the subject experienced more difficulty understanding nouns than adjectives on the shortened version of the token test 6 at lower i.c.p. however, de renzi and vignolo8 assert that the nouns used in the token test, are, in fact, nouns which have the function of adjectives ("square" for example, identifies an attribute of the token, as does "red"). they forward a possible explanation for the difference in error count; namely, that shape is a more abstract concept than colour or size, and that geometrical conceptions and their linguistic equivalents are learned later than size and colour discrimination in childhood. this confirms the finding that the subject was operating at a concrete rather than an abstract level. the subject's poor performance at high and low i.c.p. on the complex sentence-comprehension subtest illustrated clearly his inability to understand the meaning of complicated logico-grammatical combinations which express certain abstract relationships. in analysing the six larsp profiles of expressive speech it was found that the subject only used three subordinate clauses in the samples, and no instances of more than one subordinate clause in a particular utterance was evident. davelaar5 cited bernstein who found a correlation between the amount of subordinate clauses that children use and the level of cognitive development. h e suggested that a greater number of subordinate clauses implied a more advanced level of cognitive development. the subject was unable to repeat sentences on both presentations of the complex sentence-recall subtest. luria and h u t t o n 1 7 postulate that the difficulty experienced in repeating as opposed to speaking, naming and understanding is due to the fact that repeating is an artificial task requiring certain abstractions that are not present in normal speech activity. they, therefore, assumed that the inability to repeat words or sentences is associated with an impairment of complex forms of abstract speech behaviour. results of the reporter's test revealed a breakdown in the subject's ability to provide all the necessary information for a third person to reproduce the examiner's performance. this could be attributed to an impairment in cognition. a contemporary linguistic view is that writing is a parallel or alternative form of language to speech, and that reading, like listening, involves a direct "decoding to meaning", or comprehension.2 3 on the neale reading analysis the subject obtained accuracy scores equivalent to a 7,1 and 8,6 year old respectively with high and low the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) i n t r a c r a n i a l pressure and aphasia 89 i c p., rate of reading scores of 6,11 and 7,2 years respectively and comprehension scores of 8,2 and 8,7 years respectively. on the picture story language test (written) the subject's performance on both presentations of the test ranged between that of a 6 year old and an 11,5 year old. as the results of this study revealed age equivalent scores between 6 and 11 5 years and qualitative interpretations revealed that the subject was performing on a concrete level, the writer administered the wisc-r to ascertain the relationship between the subject's verbal and non-verbal performances. results of the wisc-r revealed that the subject is functioning at an 8,9 year old level verbally and at an 11,83 year old level non-verbally. the overall results, therefore, indicate that all language modalities of the subject are impaired to about the same degree, and that the data is compatible with the assertion that there is a strong common factor underlying the impairments in each specific modality. performances at all language modalities were strongly tied to concrete situations. conclusion the quantitative and qualitative analyses of the battery of tests administered to the subject disproved the hypothesis that the communicative skills of the subject would be improved when his i.c.p. was at a higher level. however, the results illustrated that the subject was performing in the concrete-operational stage of piaget's theory thus supporting the possibility that there is a definite factor contributing towards the consistency in the subject's performance throughout testing; namely, a cognitive deficit concomitant with his linguistic impairment. acknowledgements the author wishes to thank ms. b. jacks, clinical tutor and ms c penn lecturer, in the department of speech pathology and audiology of the university of the witwatersrand for their invaluable guidance and support, as well as mr. k. l. allen, the neurosurgeon, and the subject who participated in this study. references 1. allen, k. l. (1980): personal communication. 2 allen, k. l. (1971): a study of the pressure of the cerebrospinal fluid in man by remote monitoring through the skull symposium on bio telemetry. pretoria. 3 allen, k. l. and goldman, ν. i. (1967): phasic pressure characteristics of the cerebrospinal fluid system south africa journal of surgery, 5(4), 151-158. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 90 michelle shapiro 4 crystal, d., fletcher, p. and garman, m. (1976): the grammatical analysis of language disability: a procedure for assessment and remediation. edward arnold. 5. davelaar, e. (1977): formal operational reasoning and its relationship to complex speech patterns and tentative statement use. language and speech, 20, 73-79. 6. de renzi, e. and faglioni, p. (1978): normative data and screening power of a shortened version of the token test. cortex, 14, 41-49. 7. de renzi, e. and ferrari, c. (1978): the reporter's test to detect expressive disturbances in aphasics, cortex, 14, 279-293. 8. de renzi, e. and vignolo, l. a . (1962): the token test to detect receptive disturbances in aphasics. brain, 85, 665-691. 9. eisenson, j. (1971): aphasia in adults: basic considerations. in handbook of speech pathology and audiology. travis, l. (ed.), appleton-century-crofts. 10. eisenson, j. (1973): adult aphasia: assessment and treatment. appleton-century-crofts. 11. flavell, j. h. (1963): the developmental psychology of jean piaget. litton educational publishing. 12. ginsburg, h. and opper, s. (1969): piaget's theory of intellectual development: an introduction. prentice-hall. 13. goldstein, k. (1948): language and language disturbances. grune and stratton. 14. goodglass, h. and kaplan, e. (1972): boston test for aphasia in the assessment of aphasia and related disorders. lea and febiger. 15. inhelder, b. and piaget, j. (1964): the early growth of logic in the child: classification and seriation. routledge and kegan paul. 16. luria, a. r. (1967): higher cortical functions in man. basic books. 17. luria, a . r. and hutton, j. t. (1977): a modern assessment of the basic forms of aphasia. brain and language, 4, 129-151. 18. marshall, r. c., and tompkins, c. a. and phillips, d. s. (1980): effects of scheduling on the communicative assessment of aphasic patients. / . comm. dis., 13(2), 105-114. 19. myklebust, h. r. (1965): development and disorders. of written language: picture story language test. vol. 1./ grune and stratton. / 20. neale, m. d. (1966): neale analysis of reading ability. st. martin's press. 21. penn, c. (1974): a linguistic approach to the detection of minimal language dysfunction in aphasia. / . 5. a. speech & hear assoc. 21, 3-20. ; 22 schuell, h . , jenkins, j. j. and jimenez-pabon, e. (1964): aphasia in adults. harper and row. 1 the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) i n t r a c r a n i a l pressure and aphasia 91 23. smith, f. (1975): relation between spoken and written language! in foundations of language development: a multidisciplinary approach. vol. 2. lennenberg, ε. h. and lennenberg, h. (eds.) academic press. 24 wechsler, d. (1974): wechsler intelligence scale for childrenrevised. the psychological corporation. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 43 a preliminary investigation of the pragmatic abilities of a group of language disordered children lindy rosen, bsc (logopaedics) (cape town) rosemary keen, μ sc (london) department of logopaedics university of cape town, cape town abstract the communicative acts, conversational acts, and breakdown repair abilities of six language-disordered children with a syntactic age of ±3 years old as determined by the larsp (crystal, fletcher, garman: 1976) were investigated. sampling of each subject involved two separate naturalistic interactions with a familiar adult and a language disordered peer. the data obtained from the transcriptions were analysed in terms of linguistic and nonlinguistic behaviours on the communication profile by wollner and geller (1982). specific patterns of deficit and strengths were observed and these trends were related to recent literature in this area. the study emphasises that there is as much heterogeneity in the pragmatic skills as in the other communication skills of language disordered children, although this is due to some extent to the limitations of assessment in naturalistic settings. it also indicates individual areas of pragmatic deficit that require remediation. opsomming die kommunikasiehandeling, gesprekshandeling en herstelmoontlikhede van uitvalle by ses kinders met taalsteurnis, met 'n sintaktiese ouderdom van ± 3 jaar volgens die larsp (crystal, fletcher, garman: 1976), is ondersoek. taalmonsters van elke toetspersoon is verkry deur twee aparte naturalistiese interaksies met 'n bekende volwasse en 'n taalversteurde klasmaat. die data wat verkry is van die transkripsies is geanaliseer in terme van linguistiese en nie-linguistiese gedrag deur die gebruik van "the communication profile" van wollner en geller (1982). bepaalde patrone van uitvalle en sterkpunte is opgemerk en hierdie neigings is vergelyk met onlangse literatuur oor hierdie aspek. die studie beklemtoon dat daar net soveel heterogeniteit in die pragmatiese vermoens van taalversteurde kinders voorkom, as in ander kommunikasie-vermoens, alhoewel dit in '« sekere mate te wyte is aan beperkings van ondersoekmoontlikhede in 'n naturalistiese opset. die studie dui ook op individuele aspekte van pragmatiese uitvalle wat remediering vereis. introduction bates (1976) introduced pragmatics into the field of speech therapy and defined it as 'the rules governing the use of language in context.' subsequent authors, e.g. savich (1983), prinz (1982), prutting &{ kirchner (1983), confirm this description. the study of pragmatics then considers com^rnunicative intentions, presuppositions, social context variables and social organisation of discourse. communication is thus much more than issuing and receiving a message. it deals with issuing a message in the most appropriate form for conveying intended meanings to a particular person for particular effects. muma (1975) verifies that both speaker and listener are activeparticipants in the conversational game. donahue (1983) discusses this familiar metaphor used to illustrate a model of conversational turntaking as a network for reciprocal obligations. she compares the conversational game to that of tennis and notes how conversation is governed by grice's (1975) co-operative principle, whereby both partners agree to work at keeping the conversational ball in play. she explains that just as the most skilled tennis player occasionally misses the ball or does not manage to get it over the net, so too, conversational partners can have communication breakdowns. both partners are then obliged to work at reintegrating the dialogue. co-operative listeners are expected to signal to the speakers when a remark is not understood and speakers are then obliged to revise or repeat the initial utterance. when one player is more skilful than another, the superior player is expected to compensate by assuming greater responsibility for keeping the game going (donahue, 1983). this can be seen in children as young as three or four years old who modify their speech when speaking to babies as opposed, to adults (shatz & gelman (1973) and sachs & devin as cited by fey, leonard & wilcox (1981)). hymes, as cited by roth & spekman (1984a), states that in addition to learning the phonologic, semantic and syntactic rules of language, the child must master the rules that underlie how language is used for the purpose of communication. a developmental sequence of pragmatic acquisition has been described by several authors. wiig & semel (1986) cite various perspectives from which this development can be viewed, while ochs & schieffelin (1979) document the following trends: the child's move away from reliance on the immediate context towards greater reliance on nonsituated knowledge; the child's expanding knowledge of conversation for carrying out particular social acts. creaghead (1982) comments that the current interest in pragmatic development has led to the identification of communication deficits in children which had previously been overlooked or considered outside the realm of speech therapy. numerous studies have recently been carried out on pragmatics in language-disordered children. research has revealed significant conflicting data. gallagher & darnton (1978) and brinton and fujiki (1982) report that the language disordered child uses his language in a qualitatively different way from the normal. in contrast van kleeck & frankel (1981) found that the language disordered children they studied used the linguistic devices they investigated in a manner essentially the same as normal children with a similar developmental trend emerging in their.subjects. die suid-afrikaanse tydskrifvir kommunikaeafivykings, vol 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 lindy rosen and r o s e m a r y keen prutting & kirchner (1983) state that simply because the child does not possess linguistic and structural sophistication does not necessarily imply that he does not acknowledge the partnership and meet the obligation of conversation. even if the child does not give the exact linguistic response, he may, for example, be aware that an answer is required. they conclude that, given the restricted range of linguistic options available to the disordered communicator, he may be forced to rely on pragmatic strengths (e.g. repetition of the previous utterance) to engage in co-operative conversation to sustain interaction. prutting & kirchner (1983) describe a group of children who display pragmatic assets which allow them to attain a higher level of communicative competence in the context of otherwise limited linguistic ability. donahue (1983) also cites various studies portraying the young language disordered and older learning-disabled child as eager to fulfil his conversational responsibility while compensating for linguistic inadequacies. it was donahue (1983) who likened'these children to tennis players who have a limited set of strokes and seem to hover on the edge of the interaction, watching for an easy opening into the game. she stresses that by seeking out opportunities for participating that provide nonlinguistic and contextual support, the child gives the appearance of keeping the conversational ball in play but simultaneously he is quite adept at avoiding situations that demand linguistic complexity and conversational initiative. the young language impaired child is thus described by savich (1983) and donahue (1983) as adopting an unassertive style which contributes to a cycle of social and linguistic delay in the child as he develops. as prinz (1982) points out, preliminary evidence indicates that the developmental course in pragmatics precedes greater variation and differentiation in expressive and receptive language skills. it also seems apparent that the non-verbal system of communication assumes a very important integrating role in the social-cognitive development process (prinz 1982). clearly the individual pragmatic behaviours of language disordered children should become part of the language assessment protocol. roth & spekman (1984a) emphasise that whereas the development of formalised pragmatic assessment tools must await a clearer delineation of a normal developmental sequence, it is possible to draw on available empirical and theoretical literature to construct an organisational framework for analysing performance in this area. they stress, however, that assessment in the area of pragmatics is still very much in the experimental stages and that our knowledge of normal developmental sequences\is far from complete. part of the framework for analysing pragmatic skills is the communicative setting. gallagher (1983) cites studies by stark and tallal of language development in normal and specifically language impaired children that have demonstrated that there are several major contextual parameters that seem important for language assessment. familiarity seems to be one of the most important factors, with more social and complex play occurring if young children are familiar with each other (doyle, connolly & rivest, cited by gallagher, 1983). craig (1983) reports that skilled clinicians of language impaired children can increase the frequency with which the child has opportunities for experiencing conversational demands and rules for obtaining representative samples of language use for analysis. : another part of the framework for analysing pragmatic skills is the assessment tool. the literature describes various profiles that have recently emerged for the purpose of analysing and explaining pragmatic abilities of children and adults with varying communicative disorders. the majority of the sources are designed for use with children (dore, gearhart & newman (1978), corsaro (1979), and wollner & geller (1982)) in contrast to penn's profile of communicative appropriateness (1985) that was specifically designed for adults with a degree of linguistic and structural sophistication required of participants. while it is important to study normal non-verbal communication in children for further development of assessment material, prinz (1982) advises that it is also necessary to study language disordered children's use of their limited language skills to determine the characteristics of the cycle of delay to provide guidelines for the determination of global therapy goals on a pragmatic basis. with this in mind, the experimenters chose to obtain samples of conversations from language disordered children for analysis using the available assessment profiles and data on normal and disordered pragmatic development to determine the ways in which pragmatic skills are used by these children, thereby providing information that could possibly be of use in their remediation. method the aim of the study was to determine the range and frequency of conversational acts, communicative acts and response to communication breakdown used by a group of language impaired children in two different communicative settings. these three aspects of pragmatic behaviour were the areas covered by wollner & geller's communication profile (1982) which was identified as being the most appropriate of the available assessment material for the subjects of this study. subjects a group of six english-speaking children was selected from fourteen children at the language unit attached to the department of logopaedics at the university of cape town. all these children had been accepted into the language unit according to strict admission criteria. of relevance here is that their intelligence was within the normal range (assessed by a clinical psychologist); hearing was within normal limits (assessed by an audiologist); there was no severe emotional or behavioural disturbance (assessed by a child psychiatrist), and their language was significantly delayed or deviant in production (at least a year's delay on the larsp) (crystal, fletcher & gar j man 1976). their ages ranged from 4.1 years to 4.11 yearsj with a mean of 4.6 years. \ the ss all had an expressive syntax rated on the larsp as' stage iii merging into stage iv, i.e. a language age of approximately 3 years. there were equal numbers of males and females to reduce any language variations that may occur with sex difference. none of the ss had had therapeutic intervention for pragmatics. data collection the ss were videotape-recorded (national camcorder video camera) and audio-tape-recorded (phillips tape recorder) in two separate naturalistic settings of approximately 10 minutes each in the language unit (lu): ' i — semi-structured interaction between the lu's speech therapist and each s the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a preliminary investigation of t h e p r a g m a t i c abilities of a group of language disordered children 45 ii — unstructured interaction between each s and a lu peer with a similar expressive language age. the usual lu play and toy material was made available in both settings. roth & spekman (1984b) note that meaningful, familiar contexts are essential for spontaneous language sampling, as are the provision of motivating activities. these authors state that the ideal assessment process should involve a variety of contexts and that this can be fulfilled by varying communicative partners. the adult partner in interaction i was able to control to some extent in the semi-structured interaction the potential for a variety of communicative and conversational acts and examples of communication breakdown, whereas the interaction between each pair of language impaired children was entirely spontaneous. analysis of the data each interaction was transcribed according to ochs's (1979) criteria for transcription. the identified behaviours were then analysed in detail as linguistic and non-linguistic behaviours in both communicative settings on the following profile: 1. communication profile (wollner & geller, 1982) (appendix 1) this profile evolved from wollner and geller's interest in describing the salient features of the communication performance of a group of language impaired children (wollner & geller, 1982). 1.1 communicative acts this section of the profile is an adaptation of the work done by dore, gearhart & newman (1978) in their profile of illocutionary forces which emerged from the study of normal 3 year-olds in a nursery school setting and involved the same naturalistic sampling as the present study. the'communicative acts that the child achieves by using language are grouped into those that convey content, that regulate conversation and that express attitudes. each category is divided into subtypes, for example, communicative acts conveying content can be requests, comments, responses or performatives. definitions for each type are provided in appendix 2. the non-linguistic communicative acts identified on the profile are the gestures, intonation patterns, facial expressions and/or vocalizations that either substitute for linguistic behaviour or are required by the listener for comprehension of the verbal message. 1.2 conversational acts this section is an adaptation of corsaro's profile on turn taking abilities (corsaro(1979)) which was designed for use in adult/child and peer/peer exchanges in children from 2 vi to 5 years. wollner & geller (1982) identified three main functions within this section: topic initiation, topic extension, and topic termination. definitions of these can be found in appendix 3. 1.3 communicative breakdown wollner & geller (1982) state that the ability to repair and to signal communication breakdown is often more critical for the language impaired child than it is for normals, as language die suid-afrikaanse tydskrifvir kommunikasieafivykins, vol. 36, 1989 impaired children are more often participants in communicative failure or disruption. the two types of behaviour in this section are those concerned with repair offered by the speaker and requested by the listener (appendix 1). wollner & geller (1982) note the following advantages of use of this profile: provision is made for conveyance of communicative acts via nonlinguistic devices as well as linguistically. information is included in the profile that can be applied to prelinguistic communicative development as well as to more sophisticated language development. this is very suitable for language disordered children with a young language age. statistical treatment of data the frequency of behaviours on the communication profile completed for each subject were computed and subjected to x2 analysis of significance of difference to determine whether any of the subjects was significantly different from his/her peers in any of the pragmatic jsehaviours, and whether any of the behaviours was used significantly more or less than any of the others by any of the subjects. results and discussion the results of this investigation reveal that the six subjects used a wide range of conversational acts, communication acts, and responses to communication breakdown, although some behaviour categories were not exhibited by every subject. there were, however, many significant differences between the frequencies of use of the various pragmatic behaviours, and also many significant differences between the subjects. several trends could be identified and these generally conform with those described in the literature. table 1: range of communicative acts for all subjects in interactions i and ii subjects a β c d ε f total requests i 1 3 11** 1 3 5 24 ii 2 5 11* 4 3 14** 39 comments i 6 >15 25 15 6 24 44** 110 ii 13 >15 25 11 22 25 31 127* responses i 45 58 57 93** 54 52 359** ii 18 10 8 12 17 7 72 performatives i 0 0 0 3 5* 2 10 ii 1 10** 0 3 1 3 18 organizational devices i 2 2 3 6 3 13* 29 ii 14 24 3* 17 14 24 96* expressives i 3 7 7 8 10 1 36 ii 2 4 1 1 1 3 12 others i 46 19 25 26 29 8 153 ii 89** 16 7 16 23 13 164** sub-totals i 103 104 118 143 128 125 721 ii 139 94 41** 75 84 95 528 total 242 198 159 218 212 220 1249 ** p<0.01 *p<0,05 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 lindy rosen and r o s e m a r y keen table 1 exhibits the wide range of behaviours used by each subject in both interactions. it is clear, however, that in interaction i, responses were used significantly more than any other category by all the subjects as a group (p <0.01), and that performatives were barely used. in fact three subjects never used any at all. in interaction ii it is comments, and o t h e r s ' that were used significantly more than all the other categories (p <0.01) except organizational devices by all the ss as a group, and expressives as well as performatives that were hardly used at all by most of the ss. these results are not unexpected when considering the level of language development of the ss and the nature of the interactions. rees (1978) and creaghead (1982) document a pragmatic trend in language-impaired children of having a limited range of communication intents in comparison to normally developing children and the tendency for limited use of a variety of speech acts in that kind of partnership. table 2: variation w i t h i n linguistic responses for all subjects in interaction i and ii subjects a β c d ε f total acknowledgements i 17 0 3 2 0 0 22 ii 0 0 0 4 1 1 6 response to question i 0 41* 40* 85** 42* 43* 251** ii 0 0 1 6 3 0 10 clarification i 9 16 9 3 0 8 45 ii 16 10 3 2 12 6 49 totals i 26 57 52 90 42 51 318 ii 16 10 4 12 16 7 65 ** p<0.01 *p<0,05 if one looks at the subcategories of by far the largest category of communicative acts (responses in interaction i) and separates these into linguistic and non-linguistic responses, it becomes clearer why this form of interaction was so frequently used. table 2 shows that for every child except subject a, linguistic responses to questions were significantly the most predominant form of response, although the level of significance varied (p<0.01 and p<0.05) (subject a, in fact, used linguistic responses to questions least of all of his response types.) remembering that their communicative intents are usually limited, these language impaired subjects used this means of keeping the conversational b^ll in play, taking turns where required by modifying the adult's interrogative into a declarative sentence. their non-verbal responses were occasionally indicative of a failure to comprehend the question form. table 3: linguistic/non-linguistic responses for all subjects in interactions i and π subjects a β c d ε f total linguistic i 26 57* 52* 90** 42* 51* 318 "ii 16 10 4 12 16 7 65 non-linguistic i 19** 1 5 3 12 1 41 ii 2 , 0 4 0 1 0 7 totals i 45 58 57 93 54 52 359** ii 18 10 8 12 17 7 72 ** p < 0 01 * p < 0 05 there were other means by which the subjects in this study fulfilled their communicative obligations with limited linguistic skills. when the communicative function of non-linguistic behaviours such as symbolic noise or gesture was clear, these were included in the relevant subcategory in part i of the profile. it turned out that all of these except two (both descriptions), were responses to questions. table 3 indicates the ratio of linguistic to non-linguistic communicative acts used by each subject as responses in both interactions. significantly more linguistic behaviours were used by all the children except subject a in interaction i (p<0.05 or 0.01) where subject a used significantly more non-linguistic responses (p<0.01). these findings correlate with a specific pragmatic disability as described by prutting & kirchner (1983) and by shavakis & greenfield (1982) who state that even when the child acknowledges the partnership of a communicative action and is relatively sensitive to his obligation as a participant, what continues to interfere with his communication are higher level linguistic operations. table 4: variation w i t h i n the "other" category for all subjects in interactions i and π. subjects a β c d ε f total unintelligible i 36 17 20 20 24 16 123** ii 53 16 3 9 21 10 112** incomplete utterance i 1 2 0 0 0 1 4 ii 4 0 0 0 0 0 4 laughter i 4 0 5 0 2 1 12 ii 12 0 4 / 1 1 1 19 screaming i 2 0 0 0 2 0 4 ii 12 0 , 0 1 0 2 15 symbolic noise i 3 0 0 6 1 0 10 ii 8 0 0 5 1 0 14 totals i 46 19 25 26 29 8 153, ii 89** 16 7 16 23 13 164 (no response) 22 j i 3 0 0 7 11 1 22 j ii 0 0 0 2 0 0 2 ι ** p<0.01 * ρ <0.05 there were more non-linguistic strategies used by the children that become evident when the content of the category of o t h e r s ' is looked at in table 4 which is seen to contain several non-linguistic communicative acts in addition to the nonlinguistic entries in the other categories. the o t h e r ' category on wollner & geller's (1982) profile was found to be inadequate for this study in providing space for unintelligible and uninterpretable utterances only. it was therefore modified by combining unintelligible and uninterpretable and adding linguistic and non-linguistic subcategories that were found to be used by the subjects in ways that could not easily be itemized elsewhere on the profile. the additions are shown in table 4. the fact that in interaction ii the category of o t h e r ' was used considerably more than any other category and highly significantly more (p<0.01) than four of the other categories (see table 1) is now explained. within this category are a large number of unintelligible utterances that could not be categothe south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 47 a preliminary investigation of t h e p r a g m a t i c abilities of a group of l a n g u a g e disordered children rized as any other communicative act nor did they specifically introduce or extend the topic of conversation. they served instead to perpetuate the interaction. subject a produced the largest number of unintelligible utterances, and it is interesting that he used more of these in interaction ii, while all the others used more in interaction i where they were responding to an adult. it was also subject a, who was the least advanced linguistically on the larsp profile (crystal, fletcher & garman (1976), who used symbolic noise, laughter and screaming more than the other children, and this behaviour could be included in those back-channel behaviours that fey & leonard (1983) describe as serving to maintain social contact, and at the same time avoiding taking the conversational floor. if one adds exclamations to these behaviours (the only entry within the expressive category for all the subjects) it is apparent that all the children used this black-channelling as a means for fulfilling their social responsibility. referring again to table 1, subject c used highly significantly more requests than his peers in interaction i (<0.01) and significantly more than any of the others (p <0.05) except subject f who used the most in interaction ii. subject c, however, also used significantly fewer organizational devices (p<0.05) than the rest in interaction ii and in fact his total number of 159 communicative acts is considerably smaller than all the other children whose totals ranged from 198 to 242 acts. table 5: variation w i t h i n organizational devices for all subjects in interactions i and ii subjects a β c d ε f total attention-getters i 0 0 1 1 1 11 14 ii 10 22 2 3 10 19 66* speaker selection i 0 0 0 0 0 0 0 ii 0 0 0 2 0 0 2 boundary markers , i , 2 2 2 5. 2 2 15 ii 4 2 1 12 3 5 27 / politeness markers 1 1 i 0 0 0 0 0 0 0 ii 0 0 0 ' 0 1 0 1 totals [ i 2 2 3 6 3 13 29 ii 14 24 3 17 14 24 96 * p> 0.05 j the children in this study used one organizational device much more than any other. the bulk of the entries for interaction ii in the organizational device category in table 5 are attention-getters (used significantly more than other organizational devices by all the children as a group in interaction ii), indicating the importance of this behaviour in the subjects' repertoire of communicative skills in certain communicative contexts. in interaction 1 the attention of the adult was focused exclusively on the child, and all the subjects, were aware of this, while in interaction ii both children's attention was focused primarily on themselves in play, with one or other child being content occasionally to play alone without involvement with the other member of the dyad. attentiongetters were therefore necessary to re-initiate the communicative interaction. mctear (1985) & ochs, schieffelin & piatt (1979) discuss how lexical attention-getters are used by children as young as two years old. mueller (1972) showed that the frequency of occurrence of attention-getter increases with age, and found it to be a function of the child's developing communicative competence. in contrast, only one of the six children, subject e, employed a politeness marker, and this child used it only twice in spite of numerous potential occasions for him and the other subjects. leonard, nippold, & anastopoulous (1982) elaborate on the emergence of politeness markers and relate them to the ability of the child to adopt the perspective of the other person, but there is no available information on this skill in language impaired children. if one compares the total number of utterances produced by each subject in each interaction in table 1, it is only subject a who apparently talked a lot more in interaction ii. it seems he is therefore the only child who conformed with fey, leonard & wilcox's (1981) language impaired subjects who spoke more frequently with their peers than with others, but this observation must be viewed in the light of the fact that he produced many more non-linguistic utterances than the other subjects (see table 4). table 6: topic initiation & extension for all subjects i n interactions i and ii subjects a β c d ε f total initiation i 0 0 2 1 3 12 18 ii 12 13 7 9 16 15 71 total 12 13 9 10 19 27 90 extension i 37 94 88 96 88 90 493 ii 27 64 26 57 46 91 311 total 64 158 114 153 134 181 804 although all six subjects used more responses as communicative acts than comments with the adult, and reversed this trend in the interaction with their peer (see table 1), it is apparent in table 6 that when the subjects' interactions are looked at as conversational acts, all the children were extenders of topics rather than initiators in both interactions. this appears not to conform with the above findings about comments being dominant in interaction ii, but if one considers that topic extension includes more than responses, it is clear there is no anomaly. the subjects were in fact confirming the findings of several authors including donahue (1983) who reports that the stronger communicative partner generally assumes responsibility for maintaining the dialogue, and siegel, cunningham and van der spuy cited by fey & leonard (1983), who describe how, in interaction with familiar adults, language impaired children are less likely to iniate interaction. table 7 shows the variety of ways in which the subjects extended the topics in both interactions. it is clear that the majority of extensions at a highly significant level (p<0.01) occurred for all the children as a group in both interactions as topic relevant extensions when they were related to the content of the previous speaker's act, but went further by adding to it. further, these topic relevant extensions were used considerably more in interaction i by each subject. subject d was the only subject who used more acknowledgements than topic relevant extensions in interaction i, although subject b's use of each was almost equal. wollner & geller (1982) stress the important notion that the child's ability to sustain the topic die suid-afrikaanse tydskrif vir kommunikasieafivykin/js, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 lindy rosen a n d r o s e m a r y keen with relevant contributions over extended turns depends on the conversational partner and the partner's sensitivity to the child's cognitive and linguistic level. table 7: variation w i t h i n topic extension for all subjects in interactions i and π. subjects a β c d ε f total acknowledgements i 5* 33 17 56 28 27 166 ii 6 2 0 17 5 9 39 topic relevant i 20 35 45 32 45 63 240** ii 7 19 11 30 21 52 140** topic shift i 0 1 2 0 1 0 4 ii 1 24** 4 2 0 4 35 off topic i 1 3 4 2 4 0 14 ii 3 8 0 0 0 3 14 resume topic i 1 1 0 0 0 0 2 ii 1 5 0 2 7 15 30 clarification request i 0 1 6 1 0 0 8 ii 0 2 6 2 2 2 14 clarification response i 9 17 11 3 7 0 47 ii 7 3 4 2 10 6 32 totals i 36 91 85 94 85 90 481 ii 25 63 25 55 45 91 304 ** p < 0 01 *p<0,05 all the children except subject c used more comments than verbal responses in interaction ii (see table 1) and all the subjects initiated more topics in interaction ii than in interaction i (see table 6). these findings support those on fey, leonard & wilcox (1981) who found that the language impaired subjects they studied became more assertive when interacting with other language impaired children. one child, subject f, used almost the same number of comments and responses with the adult, and many more comments than the other children in both interactions (see table 1). he was also the only child who initiated as many topics as those he extended (see table 6). it is important to note that this child was the oldest and most advanced linguistically on his larsp profile (crystal, fletcher & garman (1976)). \ when the subjects were asked for clarification of their utterances, it was more frequently by the adult in interaction i, but in interaction ii, all the children except subject a signalled a need for repair (see table 7). table 8 shows that subject a was also the only child who responded to a request for clarification with a nonverbal response in either interaction, and his only other attempt to repair was by repetition of his unintelligible utterances without attempting to modify them but all of them utteranced without attempting to modify them but all of them except subject d also attempted some other means of clarification, with subject β producing a wide repertoire. the children were generally very tolerant of clarification requests, and occasionally responded with up to four successive clarification attempts. they also requested acknowledgement after their clarification responses to ensure that their message had been understood. gallagher (1977) also found that regardless of language age, no subject ignored requests for clarification, although the responses were dependent on the level of his structural knowledge. donahue, pearl & bryan (1980) on the other hand, report the trend that language impaired children are less likely to initiate repair of communication breakdown and hence appear to be less co-operative communication partners. this is confirmed in the present study if the latter authors' finding refers to requests for clarification (see table 7). table 8: responses to clarification requests for all subjects in interactions i and π. subjects a β c d ε f total no repair i 2 4 0 1 0 0 7 ii 4 1 0 0 0 1 6 repetition i 2 4 5 2 3 0 16 ii 3 1 3 2 4 4 17 syntac/semantic revision i 0 1 3 0 2 0 6 ii 0 0 0 0 5 0 5 paraphrase i 0 0 1 0 0 0 1 ii 0 0 0 0 0 0 0 part repetition i 0 2 0 0 1 0 2 ii 0 • 1 0 0 0 0 1 unintelligible i 0 1 0 0 1 0 2 ii 0 0 0 0 0 0 0 multiple repetition i 0 2 0 0 0 0 2 ii 0 0 0 0 1 0 1 incomplete clarification i 0 1 0 0 0 0 . 1 ii 0 0 0 0 0 0 0 request acknowledgement i 0 2 2 0 0 0 4 ii 0 0 1 0 0 1 2 non-verbal clarification i 5 0 0 0 0 0 5 ii 0 0 0 0 0 0 0 ! totals i i 9 17 11 3 7 0 47 ii 7 3 4 2 10 6 32 it is worth noting that all six subjects differed significant! ly frifm all of their peers in at least orte type of communicative act. ifhis serves to remind us of the heterogeneity of the com-, municative behaviour of language impaired children, but may also be due to the sampling procedure of this study. roth &1 spekman (1984a) discuss various limitations of assessment in naturalistic settings. they comment on how analysis of the data is always limited to what a child produces, that the mere absence of a particular communicative intent or failure to initiate new topics cannot necessarily be seen as an indication that such a skill is not part of the child's repertoire, and that the presence of a particular communicative behaviour may not be demonstrated with sufficient frequency to assess its adequacy. these limitations apply to assessment within a variety of naturalistic settings, and the results from the present investigation should be considered in this framework. the relevance of these comments can be highlighted, for example, by the results obtained regarding politeness markers which may well have been used more by these children in settings with less familiar communicative partners. the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a preliminary investigation of t h e p r a g m a t i c abilities of a group of l a n g u a g e disordered children 49 a f u r t h e r c o m m e n t h a s b e e n m a d e b y f e y , l e o n a r d & wilcox ( 1 9 8 1 ) w h o s t a t e t h a t i n c o n v e r s a t i o n , e a c h p a r t i c i p a n t b r i n g s a c o m b i n a t i o n of p e r c e p t u a l , social, cognitive a n d linguistic skills to t h e task. t h e y w a r n a g a i n s t v i e w i n g a n y of t h e s e v a r i a b l e s i n i s o l a t i o n . g a l l l a g h e r ( 1 9 8 3 ) c o n f i r m s t h i s o p i n i o n a n d i n t r o d u c e s i s s u e s of p e r s o n a l i t y t h a t n e e d to b e c o n s i d e r e d i n d i s c u s s i n g a c h i l d ' s c o m m u n i c a t i v e c o m p e t e n c e . she a l s o cites e x t e n s i v e e v i d e n c e t h a t suggests t h a t t h e r e is a significant i n t e r r e l a t i o n s h i p b e t w e e n l a n g u a g e u s e v a r i a b i l i t y a n d e v e r y a s p e c t of p h y s i c a l c o n t e x t t h a t p r o b a b l y c a n , b u t w i l l n o t n e c e s s a r i l y , effect a p a r t i c u l a r c h i l d ' s l a n g u a g e u s e ( g a l l a g h e r 1 9 8 3 ) . s h e c o n c e d e s , h o w e v e r , t h a t s a m p l i n g a c r o s s a l i m i t e d n u m b e r of c o n t e x t u a l e n v i r o n m e n t s m e e t s t h e p r a c t i cal r e q u i r e m e n t of efficiency ( g a l l a g h e r 1 9 8 3 ) . c o n c l u s i o n r e s u l t s of t h e p r e s e n t i n v e s t i g a t i o n serve t o e m p h a s i s e t h e h e t e r o g e n e i t y t h a t e x i s t s i n c h i l d r e n w i t h l a n g u a g e d i s o r d e r s a n d i n p r a g m a t i c t r e n d s a s t h e y r e l a t e t o s y n t a c t i c developm e n t . t h e s t u d y a l s o h i g h l i g h t s t h e v a r i e t y of p r a g m a t i c abilities d i s p l a y e d b y t h e l a n g u a g e d i s o r d e r e d c h i l d r e n s t u d i e d a n d exemplifies b o t h p a t t e r n s of s t r e n g t h a n d w e a k n e s s e s a s exhib i t e d b y t h e m a n d a s r e p o r t e d i n t h e l i t e r a t u r e . it h a s b e e n e s t a b l i s h e d h e r e t h a t t h e s e c h i l d r e n u s e a v a r i e t y of comm u n i c a t i v e a c t s a n d n o n l i n g u i s t i c c o m m u n i c a t i o n t o comp e n s a t e for l i m i t e d l i n g u i s t i c skills a n d t h a t t h e y u n d e r s t a n d t h a t c o m m u n i c a t i o n is a s y m b o l s h a r i n g s y s t e m t h a t r e q u i r e s c o o p e r a t i v e p a r t n e r s . i d e n t i f i c a t i o n of e a c h c h i l d ' s p a t t e r n s of i n t e r a c t i o n w i t h i n t h e b o u n d a r i e s of t h e s a m p l i n g p r o c e d u r e s u s e d i n t h e s t u d y a d d s t o t h e a s s e s s m e n t d a t a for t h e i n c o r p o r a t i o n i n t o t h e t h e r a p y g o a l s for i n c r e a s i n g t h e o v e r a l l effectiven e s s of t h e c h i l d ' s c o m m u n i c a t i o n . a c k n o w l e d g e m e n t s s i n c e r e t h a n k s a r e e x t e n d e d to t h e s p e e c h a n d h e a r i n g ther a p i s t a t t h e l a n g u a g e u n i t a t g r o o t e s c h u u r h o s p i t a l for h e r c o o p e r a t i v e p a r t i c i p a t i o n i n t h e s t u d y , t o t h e c h i l d r e n a t t h e l a n g u a g e u n i t w h o w e r e t h e s u b j e c t s i n t h e i n v e s t i g a t i o n , a n d to t h e t e a c h i n g m e t h o d s u n i t a t t h e u n i v e r s i t y of c a p e t o w n for t h e i r v i d e o t a p e r e c o r d i n g service. / r e f e r e n c e s bates, b. language and context: the acquisition of pragmatics. new york: academic press incorporated, 1976. brinton, b. and fujiki, m. a comparison of request response sequences in the discourse of normal and language disordered children. journal of speech and hearing disorders, 47(1), 57-62, 1982. | corsaro, w. a. the development of social cognition in preschool children: implications for language learning.topics in language disorders 1(2), 77-95 1979. craig, h.k. applications of pragmatic language models for intervention. in t.m. gallagher and c a prutting (eds), pragmatic assessment and intervention issues in language. california: college hill press, 1983. creaghead, n. children with disorders of pragmatics in jv irwin (ed), pragmatics: the role in language development. california: fox point publishing ltd, 1982. crystal, d„ fletcher, p., and garman, m. the grammatical analysis of language disability: a procedure for assessment and remediation. london: edward arnold, 1976. donahue, m. learning disabled children as conversational partners. topics in language disorders, 15, 25-37, 1983. donahue, j., gearhart, m., & newman, d. conversation competence in learning disabled children: responses to uninform'ative messages. applied psycholinguistics, 1, 387-403, 1980. dore, j., gearhart, m., and newman, d. the structure of nursery school conversation. in κ nelson (ed), children's language, vol 1. new york: gardner press, 371-372, 1978. fey, m., and leonard l. pragmatic skills of children with specific language impairment. in t.m. gallagher and c a prutting (eds), pragmatic assessment and intervention in language. california: college hill press, 1983. fey, m., leonard, l„ and wilcox, k.^speech style modifications of language impaired children. journal of speech and hearing disorders, 46, 91-96, 1981. gallagher, t.m. revision behaviours in the speech of normal children developing language. journal of speech and hearing research, 20, 305-318, 1977. gallagher, t.m. pre-assessment: a procedure for accommodating language use variability. in t.m. gallagher and c aprutting (eds), pragmatic assessment and intervention issues in language. california: college hill press, 1983. gallagher, t.m. darnton β a. conversational aspects of the speech of language disordered children: revision behaviours. journal of speech and hearing research, 21, 118-135, 1978. grice, h.p. logic and conversation. in p. cole and j. morgan (eds), studies in syntax and semantics, speech acts (3). new york: academic press 1975. leonard, l., nippold, m., and anastopoulous, a. development in the use of and understanding of polite forms in children. journal of speech and hearing research, 25, 193-202, 1982. mctear, m.f. children's conversations. oxford: blackwell publishers, oxford, 1985. mueller, e. the maintenance of verbal exchanges between young children. child development, 43(3), 930-938, 1972. muma, j.r. the communication game: dump and play. journal of speech and hearing disorders, 40, 296-307, 1975. ochs, e., and schieffelin, b. (eds). developmental pragmatics. new york: academic press 1979. ochs, e. transcription as theory. in ε ochs and b. schieffelin (eds), developmental pragmatics. new york: academic press, 43-72 1979. ochs, e„ schieffelin, b., and piatt, m. propositions across utterances and speakers. in e. ochs and b. schieffelin (eds), developmental pragmatics. new york: academic press, 251-268, 1979. penn, c. the profile of communicative appropriateness. a clinical tool for the assessment of pragmatics. south african journal of communication disorders, 32, 18-25, 1985. prinz, p. development of pragmatics: multiword level. in j v irwin (ed), pragmatics the role in language development. california: fox point publishing ltd, 1982. prutting, c., and kirchner, d. applied pragmatics in τ μ gallagher and c a prutting (eds) pragmatic assessment and intervention issues in language. california: college hill press, 1983. rees, n. pragmatics of language: applications to normal and disordered language development. in r. schiefelbusch (ed), bases of language intervention. baltimore: university park press 1978. roth, f.p., and spekman, n.j. assessing the pragmatic abilities of children: part 1: organizational framework and assessment parameters. journal of speech and hearing disorders, 42, 211.1984(a). roth, f.p., and spekman, n.j. assessing the pragmatic abilities of children: part 2. guidelines, considerations and specific eva. luation procedures./ournai of speech and hearing disorders, 49, 12-17, 1984(b). savich, p. improving communication competence the role of metapragmatic awareness. topics in language disorders, 15 47, 1983. shavakis, e„ and greenfield, p. the role of new-old information in the verbal expression of language-disordered children. journavof speech and hearing research, 25, 462-467, 1982. shatz, m., and gelman, r. the development of communication skills: modifications in the speech of young children as a function of the listener. monographs of the society for research in child development. 38-47, 1973. van kleeck and frankel, t.l. discourse devices used by language disordered: a preliminary investigation. journal of speech and hearing disorders, 46(3), 250-257, 1981. wiig, e.g. and semel, e. language assessment and intervention for the learning disabled. 2nd edition. ohio: charles merrill publishing company, 1986. wollner, s. and geller, e. methods of assessing pragmatic abilities, in j.v. irwin (ed), pragmatics the rale in language development. california: fox point publishing limited, 1982. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 lindy rosen and r o s e m a r y keen appendix 1 communication profile part 1 child's name sima gerber wollner context: elaine geller dates: i. communicative acts* speaker listener 1. convey content ling non-ling** ling non-ling requests 1. action or object 2. information 3. permission 4. clarification b. comments 1. labels 2. descriptions 3. attributions 4. rules 5. explanations c. responses 1. acknowledgements 2. to questions 3. clarifications d. performatives 1. claims 2. jokes 3. protests 2. regulate conversation organizational devices 1. attention getters 2. speakers selections 3. boundary markers 4. politeness markers 3. express attitudes expressives 1. express emotions 2. exclamations 4. other a. uninterpretable b. unintelligible total communicative act! summary · speaker yes no 1. the child expresses a range of communicative act types. 2. the child uses non-linquistic devices to communicate acts. 3. the child conveys communicative acts clearly. 4. the child uses a variety of forms to express communicative act types. 5. the child uses appropriate forms to express communicative act types. 6. the child uses direct/indirect forms to express communicative act types. * (adapted from the work of dore, gearhart & newman, 1978.) ** (non-linguistic includes gaze, gesture, intonation, facial expression and vocalization.) communication profile part ii child's name sima gerber wollner context: elaine geller dates: ii. conversational acts* speaker listener ling non-ling ling non-ling 1. initiate interaction/ topic a. establish joint attention/ activity/reference. 2. extend interaction/ topic a. acknowledgement b. topic relevant c. topic shift d. off topic e. resume topic f. clarification request g. clarification response 3. terminate interaction/ topic summary speaker yes no 1. the child initiates topics/interaction. 2. the child initiates topics in an appropriate way 3. the child extends topics/interaction. 4. the child extends topics with appropriate/relevant conversational contributions. 5. the child uses a variety of conversational acts to extend topic. 6. the child extends topics/interaction over successive turns * (adapted from the work of corsaro, 1979) the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a preliminary investigation of the p r a g m a t i c abilities of a group of language disordered children 51 appendix 2 definitions of communicative acts 1. convey content a. requests involve soliciting information or actions. 1. requests for action/object involve the speaker directing the listener to perform an action, e.g., gimme ride. 2. requests for information involve the speaker obtaining solicited information from another participant, e.g., what did you watch on tv? 3. requests for permission involve the speaker seeking permission to perform an action, e.g., can i go out? 4. requests for clarification involve the speaker seeking clarification of another person's remark, e.g., what did you say? b. comments include descriptions and/or identification of observable events in the environment and statements which report facts or sta'te rules. 1. labels involve identification of objects, events, persons, etc., e.g., that's a car. 2. description predicate information about events, properties or locations of people or objects, e.g., it fall down. 3. attributions report a speaker's beliefs about another person's internal state, e.g., it's too hard for him. 4. rules state procedure, definitions, "social rules" or facts, e.g., we don't fight in school. 5. explanations involve the speaker stating reasons, causes, or justification for someone's behaviour, e.g., i hit him because i don't like him. c. responses involve the speaker providing solicited in-' formation to another speaker's prior remark or the acknowledgement of another speaker's prior utterance. 1. acknowledgements involve the speaker recognizing another participant's prior remark using verbal fillers which merely accompany the interaction without providing new/or additional information, e.g., right or yeah. 2. responses to questions involve the speaker providing the solicited information to a wh-question or yes/no question. 3. clarifications involve clarification of the speaker's previous remark usually in direct response to a clariy fication request. j d. performatives accomplish acts and establish facts by being said. | 1. claims involve the speaker establishing his rights, e.g., that's mine; i go, first. 2. jokes involve the speaker causing some humorous effect by stating incongruous information which is usually false, e.g., we throwed the soup in the ceiling. 3. protests involve thejspeaker expressing some objections to another individual's behaviour, e.g., stop that, no. 2. regulate conversation a. organizational devices accompany an interactional exchange and control the conversation flow and maintain personal contact with the other speaker(s). 1. attention getters involve the speaker attempting to ι gain the listener's attention, e.g. hey, jonn. 2. speaker selection involve labelling the next speaker's turn, e.g., you go, your turn. 3. boundary markers are used to mark openings, closings, or shifts in the conversation, e.g., hi-bye, oh, or bye the way. 4. politeness markers involve the explicit use of polite forms, e.g., thank you, please. 3. express attitudes a. expressives involve the conveying of feelings or attitudes. 1. express emotions involves the speaker conveying emotions, feelings or attitudes, e.g., i hate you. 2. exclamations involve the speaker expressing feelings or attitudes through the use of non-propositional language forms, e.g., wow, yuch! (adapted from the work of dore, gearhart & newman, 1978) appendix 3 definitions of conversational acts 1. initiate interaction/topic a. establish joint attention/activity/reference refers to any act which encourages a focused interaction by at least two participants in terms of a specified activity or a specified content. 1. non-linguistically child shows or offers a toy to the adult; e.g., child points to his milk. 2. linguistically, the child says hey, look at this, or wanna play with play-doll? 2. extend interaction/topic a. acknowledgement is a non-linguistic or linguistic act which is a response to a previous act but doesn't go beyond in terms of content. here, we can include responses to ves/no auestions, as well as responses to nonrequests. for example, child a: i like popeye. child b: right. b. topic relevant acts are related to the content of the previous speaker's act and go beyond or add to the previous act in terms of content. these can be thought of as further contributions to the conversation. for example, mother: look at big bird. child: big bird has feathers. c. topic shift is any act which takes place during a focused interaction where there is a direct attempt to change the topic. in our system, unlike corsaro's. these may or may not be marked formally i.e., l^et's do this now. d. off-topic acts occur within a focused interaction, are not relevant to the topic, and are usually initiated without a formal marker. e. resume topic is any act which refers back to a previously introduced topic. f. clarification requests are acts which call for the clarification, confirmation, or repetition of a preceding act. these usually take the form of interrogatives. for example, what did you say? or what do you mean? g. clarification responses are acts which are direct reactions to clarification reauests. the clarification responses do not go beyond the information or behaviour requested. 3. terminate interaction/topics this refers to any act which leads to the end of a focused interaction. a. non-linguistically, this might involve a physical movement away from the interaction or no response. b. linguistically, it might involve verbal cueing to terminate the interaction, e.g., child: bye-bye child: no more book (adapted from the work of corsaro, 1979) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 36, 1989 \ r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) -2play rirk and • j schoolroom have moved to bigger and better premises at shop 6l the rosebank mews 173 oxford road rosebank jhb. play & schoolroom, specialists in the field of child education have been offering assistance to both professionals and parents for nearly thirty years. their expertise and advice range through pre-school education, perceptual training, primary and remedial education and adult education. play and schoolroom are sole agents for learning development aids which includes an excellent selection of materials of interest to the speech therapist. they also offer an interesting range of aids and books to foster and develop language and communicative skills. their stock of educational books and toys is exceptionally wide. you are invited to view their superb range in their new beautifully laid out showroom. phone 788-1304 po box 52137 (as before) sax0nw0ld fax: 880-1341 2132 the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) therapy programme with spastic dysphonia a single case study 31 rutter, m. the development of infantile autism. j. psychol. med. 9, 147-163, 1974. schuler, a.l. aspects of communication. in: fay, w.h. and schuler, a.l., emerging language in autistic children. language intervention series, 5, edward arnold ltd, london, great britain, 1980. tough, j. the development of meaning: a study of children's use of language. george allen and unwin ltd, london, great britain, 1977. wing, l. early childhood autism: clinical, educational and social aspects. a wheaten and co., exeter, great britain, 1976. a stuttering therapy programme with spastic dysphonia a single case study ingrid meyers ba (sp & η th) (witwatersrand) speech therapy department baragwanath hospital denise anderson ba (sp & η th) (witwatersrand) department of speech pathology and audiology, university of the witwatersrand, johannesburg abstract this study was motivated by reported similarities in vocal tract dynamics in stuttering and spastic dysphonia. the effects of a stuttering therapy programme with an adult with spastic dysphonia were observed. subjective and objective measures obtained preand posttherapeutically included a qualitative analysis, laryngographic tracings, and fiberoptic examinations. results showed subtle improvements on all measures suggesting improved laryngeal behaviours. findings are discussed in relation to therapeutic utility. opsomming die motivering vir hierdie ondersoek is gebasseer op die ooreenkomste t.o.v. die dinamiek van die vokale gang tydens hakkel en spastiese disfonie dieuitwerkingvan 'nterapieprogram vir hakkel wat uitgevoer is op 'n pasient met spastiese disfonie, is waargeneem. subjektiewe en objektiewe metings is vooren na-terapeuties van laringografiese afdrukke, fiberoptiese ondersoeke en van 'n kwalitatiewe anahse verkry. resultate dui op 'n subtiele verbetering op alle metings, wat verbeterde laringale werking aandui. die bevindinge word bespreek t. o. v. kliniese bruikbaarheid. of all the human voice disorders, the syndrome of adductor spastic dysphonia has remained the most mysterious, the most poorly understood, and the most resistant to effective treatment, (boone 1972; aronson 1980; reich and till 1983). spastic dysphonia is a rare disorder and literature on the subject is limited, which has led to some confusion with regard to treatment (wolk, 1980). yet most authorities agree on its poor response to therapy procedures. the disorder, first described by traube in 1871 is characterized by "a strained, creaking, choked vocal attack and a tense squeezed voice accompanied by extreme tension of the entire phonatory system." (luchsinger and arnold 1965). various terms have been used to describe the disorder of spastic dysphonia. it has been referred to as 'glottal spasms', 'stammering of the vocal cords' and 'laryngeal stuttering', and has been parallelled to the disorder of stuttering by mccall (1975) and salamy and sessions (1980). stuttering is a more common disorder, and the age of onset and sex distribution are well defined. the two disorders can, however be likened in terms of their variability, development and course, etiological controversy and history of therapeutic failure with high rates of symptom relapse (ingham and andrews 1973; aronson 1980; salamy and sessions 1980). perhaps the abnormality in the physiology of the larynx for stuttering and spastic dysphonia could be considered a major similarity. mccall (1975) found that similarities between spastic dysphonia and the stuttering block included muscle spasms, disturbed muscle tone and involuntary movements e.g. tremor, with normal laryngeal structures evident on laryngologic examination. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 the past decade has brought about a dramatic transition in the theoretical foundation and purpose in the treatment of stuttering. based on the factors which induce fluency in stutterers, remediation has shifted to manipulation of phonation utilizing behaviour modification techniques as a vehicle for establishing fluency (shames and florance 1980). common to all 'fluency-based' programmes are smooth initiation of phonation, decreased rate and continuous phonation and breath flow which facilitates co-ordination of the vocal folds concurrent with the execution of articulatory gestures (miller 1982). schwartz (1976) felt that it was the reduction in stress on the cords which facilitated their laxing and lengthening and enabled their greater bulk to vibrate. the literature on spastic dysphonia does not reflect the same advances regarding treatment approaches. while some authorities have described similar techniques to those constituting 'fluency-based' programmes, no-one has as yet integrated these techniques into a unified therapy programme. in view of the limited investigations into the field of spastic dysphonia, and of the need to explore new avenues for treatment, the writers decided to investigate the effects of a fluency-based programme (developed for stutterers) by shames and florance (1980) on a subject with spastic dysphonia. method subject the subject, s, was an english speaking adult male, aged 34 years whose profession involved much public speaking. his voice problem © sasha 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 ingrid meyers and denise anderson began at the age of twenty and since that time he has received treatment in the form of psychotherapy, medication and tradmonal voice therapy, all of which have provided little relief from the disorder. no farruly history of spastic dysphoria has been reported. s s voice was characterized by breaks in phonation caused by an intermittent strained-strangled and highly tense voice with reduced modal pitch and voice intensity. reflex actions of phonation were intact and thus laughing and coughing were carried out normally. the symptoms became more prominent as the communicative demands of speech were increased. procedure pre-1ntervent10n voice measures pre-intervention samples were obtained over two days prior to the initiation of treatment. these samples were analyzed subjectively and objectively. all measures were obtained in a sound proof recording room, in the phonetic laboratory, department of linguistics at the university of the witwatersrand, johannesburg. the three voice samples included: (1) sustained phonation of (i:) for 5 sees. (2) reading the first paragraph of the fairbanks rainbow passage (fairbanks 1940). (3) a spontaneous speech sample. a) subjective evaluation the voice was recorded on the uher 4200 stereo tape recorder. two independent raters judged the severity of the voice samples. a rating scale adapted from aronson et al. (1968) and wilson (1979) was utilized for the qualitative analysis (see appendix i). severity was measured by classifying the subject's voice on a severity continuum based on aronson et al (1968). the two raters who rated blind as to whether the recordings were preor post-therapeutic, calculated the frequency of occurrence of strained, squeezed, staccato or effortful phonation (aronson 1980) for both reading and spontaneous speech. this constituted a measure of percentage and strained-strangled syllables (%ss), which was to be used as an equivalent of percentage stuttered syllables used for stutterers. this has been found to be a good indicator for treatment effectiveness (perkins et al. 1974). finally, a speaking and reading rate was calculated by counting the number of syllables spoken in one minute. this was to constitute a measure of syllables per minute (spm), which is necessary for determining the desired rate to be reached in the therapy programme (shames and florance, 1980). b) objective evaluation the following measures were obtained by the principal phonetician in the department of linguistics, university of the witwatersrand: i) laryngographic tracings. wechsler (1977) writes that laryngographic tracings provide a qualitative description of the voice, and show preferred qualitative estimates of vocal fold regularity. using a fourcin laryngograph and voicescope, the laryngographic procedure was carried out in the manner described by wechsler (1977) and kelman (1981). hirano (1981) writes that tracings should be obtained from both the steady position of sustained vowels, and the transitional phases of phonation. the output of the laryngograph and voicescope was simultaneously recorded on a mingograf inkjet recorder. each laryngograph was segmented into phonation stretches of 100 m/sec. the stretches were analyzed according to preselected categories from the features presented by wechsler (1977) and kelman (1981), and a frequency count based on visualizing these categories was used (see appendix ii). ii) fiberoptic examination. this measure was employed to observe the laryngeal behaviours directly during connected speech. aronson (1980) and chapey and salzberg (1981) maintain that fiberoptic examination is the only means by which one can observe and describe vocal fold behaviour, as well as co-ordinate the visual and auditory aspects of voice production. a flexible fiberscope connected by a c-mount adaptor to a type 4az olympus omi camera was used for the fiberoptic examination. the tape recorder was prepared to run concurrently with the examination so as to record all utterances. the vocal folds were examined at rest, during deep breathing and during a spontaneous speech sample. they were also examined during the prolongation of (i:) at a comfortable loudness and pitch level. the audio tape recordings corresponding to each slide, derived from the fiberoptic examination, were transcribed and two independent raters judged the perceptual characteristics of each slide. intervennon programme the intervention was carried out daily by one of the writers over a 3-week period. the programme employed was the 'stutter-free' speech programme (shames and florance 1980). based on the principles of operant conditioning to modify behaviour, the programme involves five overlapping stages which are systematically scheduled. the client is taught to deliberately control the rate of speech and to control the segmenting of speech acts so that there is continuous phonation and airflow between and within words. continuous phonation with normal rate and prosody become the goals for treatment. monitored speech is emphasized and the new speaking skills are transferred into the patient's entire talking day by moving up a situation hierarchy. unmonitored speech eventually replaces monitored speech (shames and florance 1980). the following alterations were made to shames and florance's (1980) original 'stutter-free' speech programme: j — the desired parameter of fluency was exchanged with that of efficient voice. | — the passive airflow technique, described by schwartz (1976) was used to assist s. in initiating phonation. the rationale for, and nature of the treatment programme was explained to s., and both reading and speaking were practised at varying rates of speech. a home programme was included as an adjunct to the therapy programme. post-intervention measures over the two days immediately after the therapy programme, both subjective and objective evaluations were carried out following the identical procedures to that of the pre-intervention evaluation. results interrater reliability was high for all measures (93-100%). the overall severity of the voice and the samples corresponding to the fiberoptic slides were discussed until some agreement was reached. the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a stuttering therapy programme with spastic dysphonia a single case study 33 subjective evaluation a ) qualitative analysis and overall vocal severity: table 1 indicates that while there was some improvement in the reading passage, the improvement was not marked. however, there was an overall improvement for the speech sample and prolonged vowel. table 1 indicates a summary of the results obtained for all three voice samples preand post-therapeutically. table 1 mean ratings from the preand post-therapy qualitative analysis of 10 vocal parameters rated on a 7 pt. equal interval rating scale with 1 = normal and 7 = deviant, as well as overall severity of the vocal pattern. vocal parameter /i:/ reading 30 sees. spontaneous speech vocal parameter pre post pre post pre post 1) laryngeal tension 6 1 7 5,5 7 3 2) laryngeal tone rough/hoarse 4 1,5 2,5 3 3 3,5 3) voice tremor 6 4 3 3,5 4,5 4 4) intermittent strain-strangle 3 1 5,5 5 5 2,5 5) constant strain-strangle 2 1 2 1 2 1 6) loudness 4 1 1 1,5 2 1,5 7) pitch 5,5 3,5 2,5 3 4,5 2,5 8) pitch breaks 4 1 3 1 3 1 9) rate ' 1,5 2 1,5 5 10) overall vocal efficiency 4,5 2 7 5 7 2 overall severity moderate mild severe moderate moderate mild table 2 preand post-therapeutic frequency count of strained syllables (%ss); total number of syllables and rate of speech in spm for reading and spontaneous speech. reading 30 sec. spontaneous speech pre post pre post %ss. 14,8% 8,6% 15,4% 0% total syllables 128 |128 84 63 rate (spm) 200 j160 190 150 b) frequency of strained vocal behaviours (%ss) and rate of speech (spm): table 2 indicates a reduction in %ss post-therapeutically, as well as a reduction in overall rate of speech for both the reading and speech samples. objective evaluations a) laryngographic analysis: a summary of the results for the prolonged (i:), reading and spontaneous speech samples on each category of the laryngograph is presented in table 3. a frequency count for each type of waveform per phonation stretch is expressed in terms of a percentage. table 3 preand post laryligographic measures for prolonged /hi, reading and spontaneous speech, (n = total number 1 ι waveform category prolonged /i:/ reading spontaneous speech 1 ι waveform category n=23 pre n=23 post η=101 pre n=126 post n=35 pre n=50 post a) variability per phonation stretch 13% 4,3% 70,3% 71,4% 77,1% 64% b) shape of lx: i) double/multi peaked base ii) irregular rise iii) double/multi peaked peak iv) irregular decline ι ν) exaggerated gradual decline vi) sustained amplitude reduction 13% 0% 0% 0% 0% 86,9% 26% 4,3% 4,3% 4,3% 0% 0% 16,8% 1,9% 18,8% ' 8,9% 36,6% 43,5% 22,2% 3,7% 42,8% 40,5% 33,5% 31,7% 14,2% 2,8% 25,7% 14,2% 40% 34,2% 16% 8% 28% 34% 28% 30% c) shimmer 8,7% 4,3% 58,4% 59,2% 62,8% 56% d) fx i) jitter ii) abnormal fx drops 13% 8,7% 4,3% 0% 44,5% 27,7% 43,6% 26,1% 40% 28% 42% 25% 1 e) vocal fry 0% 0% 22,7% 23,8% 17,1% 24% die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 ingrid meyers and denise andersoi the most noticeable change for all three voice samples can be seen in the amplitude of the wave forms. table 4 indicates the change in average amplitude preand post-therapeutically. table 4 changes in average amplitude of waveforms preand post-therapeutically. prolonged /i:/ reading spontaneous speech pre post pre post pre post average amplitude in mm. 10mm 25mm 10mm 16mm 13mm 17mm b) fiberoptic examination: normal, symmetrical vocal folds were evident at rest and during deep breathing preand post-therapeutically. both the true and false vocal folds remained abducted. figures la and b indicate the physiological alteration of the vocal folds for the prolonged vowel preand post-therapeutically. •il» figure la figure lb figure la & lb. the physiological alteration of the vocal folds 'during the prolonged ihl pre(a) and post(b) therapeutically. figure la reveals that pre-therapeutically the vocal folds were tightly adducted with the false folds approximating one another in an asymmetrical fashion. the left fold was tensed, had more bulk and was more adducted than the right fold. figure lb shows that posttherapeutically the true cords were not tightly adducted and a chink was visible along their inner border. the false folds approximated but were symmetrical. on subjective evaluation, the vowel in fig la was perceived as having a tight, strained hoarse quality, while in fig. lb, it was perceived as having a breaking quality. figure 2b w ψ i / figure 2a figures 2a & 2b. the vocal folds during the production of the word /i2wd/ pre and post therapeutically respectively. figures 2a and b reveal an alteration in the physiology of the vocal folds for spontaneous speech preand post-therapeutically. in fig. 2a pre-therapeutically, total arrest of the glottis was apparent, where the false folds were tightly adducted iri the midline, and obscured the view of the true vocal folds. tension was evident posteriorly as adjustments in the arytenoid cartilages were made. subjectively, a tight squeezed, laryngealized quality was evident. posttherapeutically, less tension in the glottis was present. the true cords were not tightly adducted and a visible chink was present between the cords. while the false folds approximated they did not adduct. this was perceived as having a laryngealized quality on subjective evaluation. finally, table 5 summarises the results obtained from both the subjective and objective evaluations after the therapy period. table 5 overall summary of preand post-therapeutic measures for all three voice samples. subjective evaluation laryngograph tracings fiberoptic examination / reading + + spontaneous speech + + + + + prolonged /i:/ + + + + + + key: -r = slight improvement + + = improvement the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a stuttering therapy programme with spastic dysphonia a single discussion the results of the study indicated some improvements on all three voice samples for both subjective and objective measures posttherapeutically. the improvement was most evident in a reduction in adductor spasms, strained strangled phonation and overall vocal tension. subjectively, the voice was judged as less tense, and a reduction in %ss was evident on the reading and speech samples. the reduction in exaggerated gradual decline and increase in wave form amplitude on the laryngographic tracing seemed to indicate less tension and freer vibration of the vocal cords (traill 1984). the fiberoptic examination revealed a chink between the true folds which were not adducted as tightly as they had been previously. izdebski, dedo, shipp and flower (1981) write that the characteristic identified as overpressure (i.e. strain) is typical of spastic dysphonia, and thus the reduction in strain observed in this study could be considered a positive index of treatment outcome. lerman (1980) found that in spastic dysphonia, the over adducted vocal folds impeded the airflow, thus disrupting the delicate balance between airflow and glottic resistance which is necessary to produce acceptable phonation. the reduced rate of speech inherent in this therapy programme seemed to induce voluntary control over the adductor laryngeal muscles which facilitated the co-ordination of the muscles for phonation. sustained phonation and easy initiation of phonation were found to eliminate the tight adduction in the cords and the effortful forced phonation in this study. adams (1975) and schwartz (1976) feel prolonged speech facilitates glottal vibration by integrating sub-glottal air pressure, glottal resistance, supraglottal pressure, correct timing, smooth initiation and maintenance of airflow. stuttering occurred when this integration was disturbed. this imbalance was observed in the present study which further lends support to the similarity in vocal fold physiology of stuttering and spastic dysphonia, and to the applicability of a 'fluency based' programme with an adductor spastic dysphonia client. the study also showed that behaviour therapy can be applied to consciously manipulate vocal cord behaviour, thus supporting the views held by boone (1977), and mowrer and case (1982). a rough laryngeal tone was still noted on the post-therapy subjective evaluation for reading and spontaneous speech. this was confirmed by the laryngographic tracings and the presence of false fold approximation on the fiberoptic examination. boone (1977) writes that a rough vocal quality is caused by aperiodic vibration, and ventricular phonation may be causjed by the ventricular folds lying in close contact with the superior surfaces of the true cords. traill (1984) feels that the interference of the false folds above alters their tension and interferes with their movement. these perceptive characteristics showed up as irregular lx waveforms on the laryngographic tracings, where shimmer, jitter and irregular peaks and declines were still observed post-therapeutically. wechsler (1977) found that shimmer, jitter and irregular fold vibration could occur in normal speakers but horii (1980) found these features were more extensive in pathological speakers. the high percentage of the above three features on the laryngographs of this subject, indicated some pathology to be remaining in the voice. the writers contend, that while the 'fluency-based' programme was effective in altering the mode of laryngeal vibration, it did not sufficiently reduce the contribution of the false folds during phonation which resulted in the harsh ventricular vocal quality. since the technique employed in this study has been effective in modifying both true and false fold activity in stutterers, perhaps further practice is needed with the techniques in spastic dysphonia. vocal tremor was still evident post-therapeutically on the subjective assessment of all three voice samples. the writers speculate die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 case study 35 that irregular waveshapes, particularly the irregular base or rise in the laryngographic tracings, may be related to the tremulous vocal quality. the maintenance of the tremor in this subject is interesting since mccall (1975) noted that tremor in the voice of stutterers decreased when the mode of phonation was altered to induce fluent speech. the writers feel that the laryngeal adjustments necessary for maintaining continuous phonation might have caused the tremor, due to the novel mode of phonation to which the larynx had been subjected. perhaps further practice with the therapy technique might have reduced the amount of vocal tremor. an alteration in modal pitch occurred on the post-therapeutic measures. pre-therapeutically, a drop in the fx tracing of the laryngograph coincided with a tight, strained voice and exaggerated gradual abduction of the vocal cords. aronson et al. (1968) found that a low modal pitch coincided with hyperadducted vocal cords in more severe forms of spastic dysphonia. these features were more prevalent in the subject prior to therapy and his voice disorder was judged as being more severe. post-therapeutically, a reduction in the percentage of fx drops and exaggerated gradual decline on the laryngographic analysis were evident. a decrease in %ss and overall vocal severity was noted on subjective evaluation. thus, the subject's symptomatology confirmed the findings of aronson et al. (1968) that in milder forms of spastic dysphonia, fleeting moments of strained harshness are evident with the pitch not being severely affected. the results of this study indicate some discrepancy across the different voice samples, as well as in the subjective and objective evaluations. the prolonged vowel showed a greater improvement than the reading and speech samples which is an interesting finding, since studies on spastic dysphonia have indicated that the voice deteriorates in the contextual, communicative functions of speech (boone 1977; aronson 1980). in addition, studies have shown that the voice deteriorates when voiced voiceless transitions need to be made (dedo and shipp 1980). various factors could have been related to the discrepancy between the subjective and laryngographic results for reading and spontaneous speech. progress in therapy was slow and the phase of transfer had not yet been reached. boone (1977) maintains that with spastic dysphonia, much time must be spent in working on environmental factors to allow the patient to phonate in a normal, relaxed way in various environmental situations. the discrepancy on the reading and speaking analysis may have been the result of the subject's difficulty in maintaining the continuous phonation on reading throughout the therapy programme. the phase of mow-up included in the stutter-free speech programme has been found to be essential with stutterers (shames and florance 1980). regression after treatment might occur and therefore the need for longer treatment to maintain fluency in stutterers has been emphasized (perkins et al 1974; shames and florance 1980). wechsler (1977) found that in voice disorders, when the larynx appeared to have improved, but no improvement on lx waveforms was noted, further treatment and long-term follow-up was indicated lest relapse occurred. the findings of this study lend support to wechsler (1977) since improvement was evident subjectively, but little change was determined on the laryngographic waveforms. boone (1977) feels that long-term follow-up procedures are essential in spastic dysphonia which has such a high rate of symptom relapse. conclusion a 'fluency-based' therapy programme conventionally used for stutterers was found to be effective in altering the vocal behaviours of r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 ingrid meyers and denise anderso a spastic dysphonic client. the writers feel that the therapy resulted in a reduction of vocal fold hyperadduction. this is in agreement with perkins (1971) as cited by reed (1980) stating that regardless of etiology, therapy for spastic dysphonia could be based on a functional analysis of vocal fold behaviour, where the knowledge of laryngeal function is used to achieve a more efficient voice. acknowledgements the writers wish to thank prof. a. traill, department of linguistics, university of the witwatersrand, johannesburg, for his assistance, guidance and time in conducting the objective measures. references adams, m.r. vocal tract dynamics in fluency and stuttering. in vocal tract dynamics and dysfluency. webster, l.m. and furst, l.c. (eds.), speech and hearing institute, new york, 1975. aronson, a.e. clinical voice disorders: an interdisciplinary approach, thieme. stratton, new york, 1980. aronson, a.e., brown, j.r., litin, e.m., and pearson, j.s. spastic dysphonia i: voice neurologic and psychiatric aspects. j. speech. hear. disord., 33, 203-218, 1968. boone, d.r. the voice and voice therapy, 2nd. ed., prentice hall, new jersey, 1977. chapey, r. and salzberg, d. the speech clinician's use of fiberoptics in indirect laryngoscopy. j. comm. disord., 14, 87-90, 1981. dedo, h.h. and shipp, t.s. spastic dysphonia: a surgical and voice therapy treatment programme. college hill press, houston, 1980. fairbanks, g. voice and articulation drillbook. harper and brothers, new york, 1940. hirano, m. clinical examination of voice. springer verlag, new york, 1981. horii, y. vocal shimmer in sustained phonation. j. speech. hear. res. 23, 202-209, 1980. ingham, r.j. and andrews, g. behaviour therapy and stuttering: a review. j. speech. hear. disord., 38, 405-441, 1973. izdebski, k.: dedo, h.h.; shipp, m.d. and flower, m. postoperative and follow-up studies of spastic dysphonia patients treated by recurrent laiyngeal nerve section. otolaryngol. head. neck surg. 89, 96-101, 1981. kelman, a.w. vibratoiy patterns of the vocal folds. folia phoniat. 33 (2), 73-100, 1981. lerman, j.w. disorders of phonation and their management. ear, nose and throat j. 59, 62-72, 1980. luchsinger, r. and arnold, g.e. voice speech language. wordsworth publishing co., california, 1965. mccall, g.n. spasmodic dysphonia and the stuttering block. in vocal tract dynamics and dysfluency webster, l.m. and furst, l.c. (eds). speech and hearing institute, new york, 1975. miller, s. airflow therapy programmes. facts and/or fancy. j. fluency dis. 7, 187-202, 1982. mowrer, d.e. and case, j.l. clinical management of speech disorders. aspen systems corporation u.s.a. 1982. perkins, w.h.: rudas, j.; johnson, l.; michael, w.g. and curlee, r.f. replacement of stuttering with clinical effectiveness iii. j. speech, hear. disord., 39, 416-428, 1974. reed, g.g. voice therapy: a need for research. j. speech hear disord., 45 (2), 157-171, 1980. "reich, a. and till, j. phonatory and manual reaction time of women with idiopathic spasmodic dysphonia. j. speech hear. disord., 26 (1), 10-17, 1983. sal amy, j.n. and sessions, r.b. spastic dysphonia. j. fluency dis 5, 281-290, 1980. schwartz, m. stuttering solved. j.b. lipincott, philadelphia, new york, 1976. shames, g.h. and florance, c.l. stutter-free speech. charles e. merrill, columbus, ohio, 1980. traill, a. personal communication. department of linguistics, university of the witwatersrand, johannesburg, 1984. wechsler, e. a laiyngographic study of voice disorders. brit. j. dis. comm. 12, 19-22, 1977. wilson, d.k.: voice problems of children 2nd ed. williams and wilkins, baltimore, 1979. wolk, l. spastic dysphonia: a case report s.a.j. commun. disord., 2, 3-18, 1980. appendix 1 reading and spontaneous speech scale parameter 1) laryngeal tension normal 1 2 3 4 5 6 7 extremely tense 2) laryngeal tone normal 1 2 3 4 5 6 7 exceptionally harsh/hoarse 3) tremor in contextual speech none 1 2 3 4 5 6 7 exceptional 4) voice stoppages none 1 2 3 4 5 6 7 excessive 5) intermittent strain-strangle none 1 2 3 4 5 6 7 excessive 6) constant strain-strangle none 1 2 3 4 5 6 7 excessive 7) loudness normal 1 2 3 4 5 6 7 exceptionally loud/soft 8) pitch normal 1 2 3 4 5 6 7 exceptionally high/low 9) vocal inflections normal 1 2 3 4 5 6 7 monotonous 10) pitch breaks to higher pitches none 1 2 3 4 5 6 7 excessive 11) rate normal 1 2 3 4 5 6 7 exceptionally fast/slow, 12) overall vocal efficiency ' efficient 1 2 3 4 5 6 7 inefficient 13) naturalness • natural 1 2 3 4 5 6 7 unnatural i i i appendix 2 ! summary of categories analyzed on laryngographic analysis adapted from'boone (1977), horii (1980) and traill (1984). lx waveform provides information on vocal fold vibratory a) cycle. a) regularity maintenance of a stable vibratory pattern. b) waveshape provides a basis for observing the nature of/ contact and separation time of the vocal folds. c) shimmer changes in adjacent wave amplitudes. fx waveform vocal pitch. a) jitter cycle to cycle variations in frequency. cor' responds with shimmer on lx. shimmer and jitter b) correlate with rough/hoarse voice. b) abnormal fx drops exaggerated drops in fx tracing. the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) philips hearing aid services a d i v i s i o n of s . a . p h i l i p s (pty) ltd. hearing amplaid audiometers earmark systems philips hearing aid services head office 1005 cavendish chambers, 183 jeppe street, p.o. box 3069, johannesburg. t i suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 3 9 die invloed van otitis media op die sentrale ouditiewe vermoens van kinders met sensoriese integrasieprobleme lidia olivier, b.log (pretoria) brenda louw, d.phil (pretoria) rene hugo, d.phil (pretoria) departement spraakheelkunde en oudiologie universiteit van pretoria opsommjng otitis media word in die resente literatuur in verband gebring met spraaken taalprobleme, gedragsprobleme en leerprobleme. beperkte navorsing is egter tot op hede uitgevoer om die invloed wat otitis media op die sentrale ouditiewe vermoens uitoefen, te bepaal. die doel met hierdie studie is om te bepaal of otitis media wel 'n invloed op die sentrale ouditiewe vermoens van kinders met sensoriese integrasieprobleme uitoefen. dertien persone wat gediagnoseer is as kinders met sensoriese integrasieprobleme, is as proefpersone geselekteer. hulle is in twee groepe ingedeel, naamlik agt proefpersone met 'n geskiedenis van otitis media (groep a) en vyf proefpersone sonder 'n geskiedenis van otitis media (groep b). 'n toetsbattery is saamgestel vir die evaluering van die sentrale ouditiewe vermoens en is op die proefpersone uitgevoer. in die geval van groep a was die resultate afwykend in elke subtoets in die sentrale toetsbattery wat op 'n moontlike breinstambetrokkendheid dui. groep β het normale resultate in bykans al die toetse verkry. die resultate dui daar op dat ehroniese otitis media wel 'n invloed op die sen trale ouditiewe vermoens van die proefpersone het en wel in terme van onvoldoende breinstamfunksionering. implikasies vir navorsing en behandeling is bespreek. abstract in recent literature otitis media is linked to speech and language problems, behavioural problems and learning disabilities. until recently limited research has been done in order to determine the influence of otitis media on the central auditory abilities. the aim of this study was to determine whether otitis media has an influence on the central auditory abilities of children with sensory integration problems. thirteen persons diagnosed as children with sensory integration problems were selected as subjects. theg were divided into two groups, namelg eight subjects with a history of otitis media (group a ) and five subjects without a history of otitis media (group b). a test battery was compiled for evaluation of the central auditory abilities and was used on the subjects. in terms of group a deviating results were obtained on every subtest of the central auditory test batiery which indicated a possible brainstem involvement. group β obtained normal results in more or less all the ίtests. the results therefore suggest that chronic otitis media has an influence on the central auditory abilities, i.e. in terms of insufficient brainstem functioning. implications for research and treatment were discussed. otitis media is tans 'n populere navorsingsonderwerp, hoofsaaklik as gevolg van die jomvattende invloed wat dit op die kind kan uitoefen (gottlieb, zinkus & thompson, 1979). dwarsdeur die literatuur word otitis media in verband met spraaken taalprobleme, gedragsprobleme en leerprobleme gebring (gottlieb et al. 1979). alhoewel otitis media ook in verband gebring word met die sentrale ouditiewe vermoens, is daar tot op hede nog beperkte navorsing in hierdie verband uitgevoer. in die lig daarvan dat die sentrale ouditiewe vermoens 'n belangrike rol in sensoriese integrasie speel, en deur 'n verband tussen otitis media en sentrale ouditiewe prosessering te bepaal, kan nuwe inligting, oor veral die invloed van otitis media, maar ook die rol van die oudioloog by die kind met sensoriese integrasieprobleme, beskikbaar gestel word. otitis media is 'n kindersiekte met 'n baie hoe voorkoms, veral by kinders van sesjaar en jonger (mcshane & mitchell, 1979). teenstrydighede ten opsigte van die invloed van otitis media op kinders kom egter i in die literatuur voor en navorsingsbevindinge kan hoofsaaklik in twee groepe verdeel word die suid-afrikaanse tdskrif vir kommunikasieafins, vol. 37 1990 (paradise, 1983). die eerste groep navorsers toon aan dat kinders wat wel 'n geskiedenis van otitis media het, maar van wie die gehoo'r normaal was tydens toetsing, geen of slegs 'n geringe agterstand toon in terme van sintaksis, taalbegrip, leesvermoe en woordeskat (owrid, 1970). die tweede groep navorsers het bevind dat otitis media wel 'n negatiewe invloed op taalontwikkeling, veral in terme van taalinhoud en -vorm het (blager, 1982; sak & rubin, 1982). volgens paradise (1983) kan hierdie geskilpunt in die literatuur verklaar word uit leemtes in die navorsing. diagnose van otitis media in vroeere lewensjare is ten eerste nie baie betroubaar nie. tydens toetsing vertoon sommige proefpersone otitis media en kan daar dus nie akkurate inligting met betrekking tot hulle ontwikkeling bekom word nie. slegs beperkte steekproewe is gewoonlik gebruik en die betroubaarheid van die studies word in baie gevalle betwyfel (paradise, 1983). as daar egter in gedagte gehou word dat otitis media soms gepaard gaan met 'n geringe konduktiewe gehoorverlies, is dit 'n logiese afleiding dat dit wel 'n invloed op die normale όπιο savsg 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 0 lidia olivier, brenda louw, rene hugo wikkelingsverloop van die kind moet uitoefen. die negatiewe sekondere gevolge van otitis media kan verklaar word op grond van die wisselende graad van ouditiewe deprivasie wat ondervind word. studies het aangetoon dat die eerste vyf lewensjare veral belangrik is vir breinmaturasie (webster, 1983). die eerste vier lewensjare is ook die kritieke periode van taalaanleer (rubin, 1984). dit is in hierdie tyd, maar veral gedurende die eerste twee lewensjare dat otitis media by kinders voorkom (northern & downs, 1984). gehoor is noodsaaklik vir die ontwikkeling van die ouditiewe bane in die perifere en sentrale ouditiewe sisteem. 'n fluktuerende konduktiewe verlies as gevolg van otitis media kan 'n negatiewe invloed op die ontwikkeling van die ouditiewe funksie, sowel as op kognitiewe en kommunikasievaardighede uitoefen (hornsby, 1984). die ontwikkeling van ouditiewe prosessering word ook nadelig bei'nvloed deur otitis media, aangesien die ouditiewe boodskappe nie die sentrale senuweestelsel akkuraat bereik nie (zinkus, 1982). afwykings in sentrale prosessering, versteuring in ouditiefvisuele integrasie, leesprobleme en ouditiewe persepsieprobleme word dus in verband gebring met die herhaaldelike.voorkoms van otitis media, (gottlieb, 1979; zinkus, 1982). webster (1983) is ook eens dat 'n chroniese konduktiewe gehoorverlies in die vroee lewensjare tot 'n permanente sentrale ouditiewe afwyking kan lei. otitis media kan dus 'n invloed op die sentrale ouditiewe vermoens van kinders uitoefen. die ouditiewe sisteem, en in die besonder die sentrale ouditiewe sisteem, is veral in die geval van kinders met sensoriese integrasieprobleme van belang as 'n sensoriese modaliteit vir die persepsie van ouditiewe invoer. normaalweg word die sensoriese inligting, afkomstig van die ouditiewe sisteem, met die sensoriese invoer van ander sensoriese modaliteite, naamlik die vestibulere sisteem, taktiele sisteem, propriosepsie en die visuele sisteem gei'ntegreer sodat daar toepaslik daarop gereageer kan word. die interpretasie en integrasie, asook toepaslike reaksie op sensoriese stimuli, staan bekend as sensoriese integrasie. die proses word deur die sentrale senuweestelsel teweeggebring deurdat 'n massa sensoriese inligting gefiltreer, georganiseer en gei'ntegreer word, sodat dit gebruik kan word in die ontwikkeling en uitvoering van die brein se funksies (ayres, 1973). 'n wanfunksie ten opsigte van sensoriese integrasie beteken dat die vloei van sensoriese inligting deur middel van die sensoriese modaliteite nie voldoende geprosesseer en georganiseer word nie. sodoende kan die individu nie presiese inligting oor homself en sy wereld beleef nie (ayres, 1973). dit strem die individu in die ontwikkeling van hoer breinfunksies en -kan, onder andere, tot die volgende simptome lei: hiperaktiwiteit; afleibaarheid; gedragsprobleme; spierwankoordiriasie; taalen spraakprobleme, asook leerprobleme. navorsing toon egter dat sensoriese integrasieprobleme tot leerprobleme kan lei en in baie gevalle nou verwant is aan leerprobleme (ayres, 1973). baie van die simptome van kinders met sensoriese integrasieprobleme stem ooreen met die simptome van leergestremde kinders, bv. ouditiewe prosesseringsprobleme, asook verskeie uitvalle ten opsigte van taalfunksies (ayres, 1973). in die geval van kinders met leerprobleme word hierdie probleme veral in verband gebring met die simptome en gevolge van otitis media. zinkus (1982) dui ook aan dat kinders met leerprobleme 'n hoer voorkoms van otitis media (25 36%) as normale kinders (13 17%) toon, veral as hulle probleme verwant is aan ouditiewe vaardighede. aangesien otitis media wel 'n invloed op kinders met leerprobleme het, en wel veral in terme van hulle sentrale ouditiewe vermoens, kan daarverwag word dat otitis media ook 'n invloed kan he op die sentrale ouditiewe vermoens van kinders met sensoriese integrasieprobleme. die bepaling van die verband tussen otitis media en die sentrale ouditiewe vermoens kan nuwe lig op die etiologie en simptomatologie van sensoriese intregrasieprobleme asook op die implikasies van otitis media werp. insluiting van die oudioloog in die span wat die kind met sensoriese integrasieprobleme hanteer, kan tot voorkoming van die nadelige invloed van otitis media op die sentrale ouditiewe vermoens, en gevolglik die algehele funksionering van die kind, lei. metode doel die doel van die studie is om die invloed van otitis media op die sentrale ouditiewe vermoens van kinders met sensoriese integrasieprobleme te bepaal deur: — die sentrale ouditiewe vermoens van twee groepe kindersmet sensoriese integrasieprobleme, naamlik die met en die sonder 'n geskiedenis van otitis media te peil — intergroepsooreenkomste en -verskille tussen die twee eksperimentele groepe te bepaal. — intragroepsooreenkomste en -verskille tussen die proefpersone in elke eksperimentele groep te bepaal. navorsingsontwerp 'n beskrywende navorsingsplan is gebruik aangesien dit intra en intergroepsvergelyking, waarvolgens die gestelde navorsingsvrae beantwoord kan word, moontlik maak (steyn et al. 1984). ι protfpersoonseleksie \ i die proefpersone het dertien kinders met sensoriese integrasieprobleme ingesluit. die dertien proefpersone is met behulp van 'n vraelys geselekteer uit die totale aantal afijikaanssprekende kinders met sensoriese integrasieprobleme wat terapie ontvang by 'n privaat arbeidsen spraakterapiekliniek. agt kinders met 'n geskiedenis van otitis media (groep a) en vyf sonder 'n geskiedenis daarvan (groep b) is op 'n eenvoudige ewekansige wyse geselekteer. die proefpersone moes oor normale perifere gehoor beskik en tussen die ouderdomme 6 en 10,5 jaar wees. tabel 1 verskaf 'n opsommende weergawe van die kenmerke van die proefpersone. ' / the south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) invloed van otitis media op sentrale ouditiewe vermoens van kinders met sensoriese integrasieprobleme tabel 1: algemene beeld van proefpersone w a t in hierdie ondersoek ingesluit is 41 * normale timpanogram dit wil se normale "compliance" en middeloordruk. + geen sluiting verkry. het reeds 22 maal buisies in beide ore gekry. eksperimentele groep proefpersoon geslag ouderdom gemiddelde gehoordrempel timpanogram groep a l r kinders met sensoriese 1 v 8j omnde 0 db 0 db normale tipe a* integrasieprobleme met 2 μ 7j 5mnde 13,3 db 10 db normale tipe a 'n geskiedenis van 3 μ 9j 9mnde 5 db 3,3 db normale tipe a otitis media 4 μ 6j 4mnde 6,6 db 6,6 db normale tipe a 5 μ 6j 4mnde 10 db 11,6 db geen sluiting"1" 6 v 6j 1 omnde 0 db 0 db normale tipe a 7 μ 7j 2mnde 3,3 db 3,3 db normale tipe a 8 v 7j l m n d 0 db 0 db normale tipe a groep β kinders met sensoriese 9 μ 9j 6mnde 0 db 3,3 db normale tipe a integrasieprobleme 10 v 7j 5mnde 8,3 db ' 3,3 db normale tipe a sonder 'n geskiedenis 11 μ 6j 6mnde 0 db 0 db normale tipe a van otitis media 12 v 8j l l m n d e 0 db 0 db normale tipe a 13 μ loj 6mnde 8,3 db 8,3 db normale tipe a prosedure data-insameliny 'n volledige gehoorevaluasie is op elke proefpersoon uitgevoer. vir hierdie doel is 'n gsi-10 oudiometer en 33 middle ear analizer gebruik asook telephonies tdh-50 oorfone met mx41/ar kussings. die oudiometer is op 1989-01-10 gekalitabel 2: sentrale ouditiewe sisteem toetsbattery breer en voldoen aan die vereistes van sabs 0154-1979. die eksperimentele toetsbattery was daarop gemik om die sentrale ouditiewe sisteem te evalueer en word in tabel 2 verskaf. toets motivering vir insluiting by toetsbattery a perifere gehoorevaluasie: 1 suiwertoontoetsing 2 spraakontvangsdrempel 3' spraakdiskriminasie ill stilte 4 timpanometrie β toetse vir sentrale ouditiewe prosessering 5 akoestiese refleksdrempelbepaling 6 sintetiese sinsidentifikasie (ssi) ssi-pi ssi-ikb (ipsilaterale kompeterende boodskap 7 maskeringsvlakverskiltoets (mw-toets) met suiwertone as stimulus met spondeewoorde as stimulus 8 simultaneous binaural median-plane localization test (sbmpl-test) i 1 normale perifere gehoor is 'n voorvereiste vir die uitvoering van sentrale ouditiewe toetse (musiek, 1985). 2 word as basis gebruik waarvolgens die intensiteit vir aanbieding van ander toetsstimuli bepaal is. 3 deur middel van die bepaling van spraakdiskriminasie in stilte by 4-5 intensiteite is die fg-pi-funksies (fonetiesgebalanseerde woordelysprestasie-intensiteitsfunksie) bepaal, om dit te kan vergelyk met die ssl-pi-funksie (sintetiese sinsidentifikasieprestasie-intensiteitsfunksie) om tot differensiaaldiagnose by te dra. 4 'n objektiewe meting van middeloorfunksie om die moontlikheid van middeloor-betrokkenheid uit te skakel. 5 vergelyking van ipsilaterale en kontralaterale reflekse verskaf waardevolle inligting vir moontlike identifikasie van breinstamletsels (hall, 1985). 6 ssi-pi versus fg-pi verskaf inligting vir 'n differensiaaldiagnose tussen kogleare retro-kogleare en sentrale ouditiewe senuweestelselletsels (jerger & hayes, 1977 in rintelman, 1985). differensieer verder tussen sentrale letsels (breinstam versus temporale lobletsels). 7 verskaf inligting oor laer breinstamfunksionering (noffsinger et al. 1985). 8 verskaf inligting oor algemene breinstamfunksionering. die suid-afrikaanse tydskrif vir kommuniksieawykins, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 2 lidia olivier, brenda louw, rene hugo dat a-analise response van die proefpersone is deurentyd op toetsvorms aangeteken. die data is daarna in terme van die volgende kriteria beoordeel: akoestiese reflekse die akoestiese reflekse is beoordeel in terme van: normaal, verhoog, afwesig en verlaag. indien die akoestiese refleks (ipsilateraal en kontralateraal) tussen 80-100 dbsp voorgekom het, is dit as normaal beskou (fria et al. 1985 en metz, 1946 in northern et al. 1985). enige refleks wat hoer as loodb intree, is as 'n verhoogde refleks beskou en enige refleks laer as 60db as 'n verlaagde refleks. sintetiese-sinsidentifikasietoets die ssi-pi-funksie versus die fg-pi-funksie is beoordeel in die lig van jerger & hayes se kriteria (rintelman, 1985). die resultate van die ssi-ikb en ssi-kkb is volgens die kriteria van jerger & jerger (1975) soos aangedui deur musiek en pinheiro (1975) beoordeel. figuur 1: staafkaart van akoestiese reflekse in figuur 1 word die ipsilaterale en kontralaterale refleksresultate uiteengesit. dit blyk duidelik uit die voorstelling dat groep a en β normale ipsilateral^ reflekse vertoon het. maskeringsvlakverskiltoets die resultate van die maskeringsvlakverskiltoets is in terme van afwykend en normaal beoordeel. die normale maskeringsvlakverskilwaarde by 500hz, dit wil se, die verskil in drempelwaardes met aanbieding van die toetsstimuli in (0/0)en uit (0/180)-fase is 10-15db (noffsinger et al. 1985). 'n vermindering in die maskeringsvlakverskilwaarde, dit wil se, minder as lodb word as afwykende resultate beskou. simultaneous binaural median-plane localization test twee beoordelings is gemaak, naamlik normaal of afwykend. die vermoe om die klank waar te neem met .'n interourale intensiteitsverskil van o-lodb is beskou as normale resultate. onvermoe om die klank sentraal waar te neem of sentrale waarneming van die klank met groot interourale-intensiteitsverskille, dit wil se, groter as 10-15db is as afwykende resultate beskou (jerger, 1960). resultate resultate word bespreek in dieselfde volgorde as wat die toetsbattery uitgevoer is. akoestiese reflekse in terme van die kontralaterale reflekse het groep a normale, verhoogde en afwesige kontralaterale reflekse vertoon. in geval van groep β het normale-kontralaterale reflekspatrone voorgekom. / the south african journal of communication disorders, vol. 37, 1990 akoestiese reflekse ipsilaterale & kontralaterale reflekse normaal verhooq ι verlaaq afwesiq i pel met o.m i pel sonder o.m kontra met o.m kontra sonder o.m 100% 100% 37.5% 100% 0% 0% 25% 0% 0% 0% 0% 0% 0% 0% 37.5% 0% η ipsi met o.m ϋ § 1 ipsi sonder o.m ted kontra met o.m ^ m kontra sonder o.m figuur 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) invloed van otitis media op sentrale ouditiewe vermoens van kinders met sensoriese integrasieprobleme 4 3 sintetiese sinsidentifikasietoets (ssi) in hierdie geval is twee metings gemaak, naamlik: 'n vergelyking tussen die fg-pi-funksie en die ssi-pifunksie — vergelyking van ssi resultate in die teenwoordigheid van 'n ipsilaterale kompeterende boodskap asook 'n kontralaterale kompeterende boodskap. fg-pi versus -pi die gemiddelde van die resultate word aangetoon in figure 2a en 2b. 10 i s 2 0 30 intensiteit in db -fg-pi-funksie ssi-pi-funksie figuur 2(a): ssi-pi-fi»nksie versus fg-pi-funksie: groep a , db 70 i 15 20 25 intensiteit in db -fg-pi-funksie -ssi-pi-funksie figuur 2(b): ssi-pi-funksie versus fg-pi-funksie: groep β figuur 2(a) toon dat die proefpersone in groep a se resultate op die fg-pi-funksie binne normale perke was. die spraakdiskriminasievermoens van die proefpersone het telkens 100% gebly met 'n verhoging in intensiteit nadat die persentasie maksimum korrekte spraakdiskriminasie bereik is. die ssi-pifunksie is heelwat swakker en verloop onder die fg-pi-funksie. dit vertoon ook telkens 'n sogenaamde "roll-over" (jerger en hayes, 1977 in tintelman, 1985). groep β vertoon afwykende resultate (figuur 2(b)) van die ssipi-funksie in die sin dat die ssi-pi-funksie onder die fg-pifunksie verloop en telkens 'n sogenaamde "roll-over" vertoon (jerger & hayes, 1977 in rintelman, 1985). hierdie resultate is egter in 'n mindere mate afwykend in vergelyking met groep a se resultate. in geval van groep β was die fg-pi-funksie ook binne normale perke. / / / 2 0 1 0 s/r verhouding sonder o.m. met o.m. figuur 3(a): resultate van ssi-ikb (links) 80% 20% 2 0 1 0 s/r verhouding sonder o.m. m e t o.m. figuur 3(b): resultate van ssi-ikb (regs) uit hierdie figure is dit duidelik dat beide groep a en β afwykende resultate vertoon het. groep a se resultate is egter in 'n meerdere mate afwykend in vergelyking met die van groep b. maskeringsvlakverskiltoets figuur 4 is 'n voorstelling van die resultate wat in die maskeringvlakverskiltoets vir suiwertone en spraak verkry is. resultate maskeringsvlakverskiltoets verskil in drempelwaardes 20 1 6 suiwer tone spondee-woorde proefpersone 1 spondee-woorde ssi-pi versus ssi-kkb die resultate van die ssi-ikb word deur die volgende figure voorgestel. figuur 4: resultate van die maskeringsvlakverskiltoets die suid-afrikaanse tydskrif vir kommunikasieafivykinfls, vol. 37, lij^,^. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 4 lidia olivier, brenda louw, rene hugo dit blyk dat daar in terme van beide die suiwertoonen spraakstimuli afwykende resultate by al die proefpersone in groep a verkry is. hulle resultate is afwykend aangesien die verskil in responsdrempels wat verkry is by die aanleiding van die toetsstimuli en die kompeterende boodskap in fase (0°/0°) en uit fase (0°/180°) lodb en minder was. normale response is by groep β verkry, dit wil se die verskil in responsdrempels met die aanbieding van die suiwertoonen spraakstimuli en die kompeterende boodskap in en uit fase was lodb en meer. simultaneous binaural median-plane localization test figuur 5 is 'n voorstelling van die resultate wat verkry is. sbmpl-resultate figuur 5: resultate van die sbmpl-toets uit hierdie voorstelling blyk dit dat die proefpersone van groep a se resultate in 'n groot mate van die van groep β verskil. groep a het meestal 'n onvermoe getoon om die klank sentraal waar te neem of dit is wel sentraal waargeneem met groot interourale intensiteitsverskille. groep β se resultate was heeltemal normaal. bespreking van resultate dit wil voorkom asof die eksperimentele vraag of herhaaldelike otitis media in die vroee lewensjare 'n invloed op die sentrale ouditiewe vermoerjf van persone met sensoriese integrasieprobleme uitoefen, deur die verkree resultate beantwoord is. uit die resultate blyk dit duidelik dat daar in die geval van groep a, die proefpersone met 'n geskiedenis van otitis media, oor die algemeen swakker resultate in die sentrale ouditiewe toetsbattery gelewer het in vergelyking met groep β wat bestaan het uit proefpersone sonder 'n geskiedenis van otitis media. in terme van die akoestiese refleksmeting dui verskeie outeurs (northern et al. 1985; griessen & rasmussen 1970 in hall, 1985) aan dat afwesige of verhoogde kontralaterale reflekse met gepaardgaande normale ipsilaterale reflekse 'n aanduiding van breinstampatologie is. dit blyk dus dat die proefpersone in groep a se resultate 'n aanduiding van moontlike breinstampatologie kan wees. volgens northern et al. (1985) kan dit verklaar word op grond van die teenwoordigheid van 'n letsel of wanfunksionering in die area waar die breinstambane kruis. die ongekruisde bane bly intakt en het dus normale ipsilaterale reflekse tot gevolg. in die geval van die proefpersone in groep β (proefpersone sonder 'n geskiedenis van otitis media) was die resultate deurgaans normaal. die resultate van die akoestiese refleksmeting word deur die ssi-toetsbattery geverifieer. die resultate van die fg-pi-funksie versus die ssi-pi-funksie dui daarop dat die fg-pi-funksie se resultate in geval van die proefpersone in beide groep a en β binne normale perke geval het. die ssi-pi-funksie het in die geval van die proefpersone in groep a, asook in die van groep b, onder die fg-pi-funksie verloop en 'n sogenaamde "roll-over" vertoon. die proefpersone in groep a se prestasie in die ssi-pifunksie was egter heel wat swakker as die van die proefpersone in groep b. jerger & hayes (1977) in rintelman (1985) het bevind dat, indien die ssi-pi-funksie onder die fg-pi-funksie verloop, dit 'n aanduiding van 'n sentrale afwyking in die kontralaterale oor is. in hierdie studie was die resultate afwykend in beide ore van al die proefpersone in groepe a en b. die teenwoordigheid van 'n sentrale betrokkenheid by die vergelyking van die ssi-pi-funksie en die fg-pi-funksie dui egter nie die spesifieke area van wanfunksionering aan nie. in die geval van die ssi-ikb versus ssi-kkb dui die resultate daarop dat die ssi-kkb in die geval van al die proefpersone binne normale perke was. met betrekking tot die ipsilaterale kompeterende boodskap (ssi-ikb) het al die proefpersone afwykende resultate vertoon. net soos in die geval van die fgpi-funksie versus die ssi-pi-funksie was die resultate van die proefpersone in groep a in 'n meerdere mate afwykend in vergelyking met die van die proefpersone in groep b: jerger (1981) het aangetoon dat in die geval van kinders met onvoldoende breinstamfunksionering die prestasie in die ssi-kkb binne normale perke val, terwyl die ssi-ikb afwykende resultate vertoon. in die verband verklaar jerger & jerger (1974): "for brainstem patients, the ssi procedure shows poor performance of icm and relatively good performance for ccm. the icm deficits are observed on the contralateral ear and ccm performance is within normal limits on both ears." (1974, p. 342). i wat interessant is, is dat die proefpersone in groep β met betrekking tot die ssi-toetsbattery swakker gepresteer het. toetsresultate met betrekking tot die res van die sentrale toetsbattery was binne normale perke. die swakker prestasie in die ssi-toetsbattery kan in die lig van die volgende verklaar word: kinders met normale gehoor leer taal aan eerstens deur die ouditiewe sisteem. lees is 'n sekondere taalvaardigheid wat afhanklik is van visueel-ouditiewe integrasie in die breinstam, soos gevind in studies van birch & belmont, kahn !&, birch & bartholomeus en doehring in 1976 (musiek & pinheiro, 1985). kinders met sensoriese integrasieprobleme ondervind probleme met visuele-ouditiewe integrasie. volgens ayres (1983) speel die breinstam 'n sentrale rol in normale sensoriese integrasie. die breinstam organiseer alle sensoriese informasie deur middel van inhibisie, fasilitasie en sintese om sodoende 'n volledige interpretasie van alle sensoriese stimuli te maak. dit help die brein om op een tipe sensoriese invoer te fokus, terwyl die res gei'nhibeer word. in die geval van die ssi-toetsbattery was nie net al die proefpersone se vermoe om die visuele stimuli met die ouditiewe stimuli te integreer, aangetas nie, maar ook die vermoe om die pf imere stimuli te kan isoleer deur middel van inhibering van moontlike waarneming van die kompeterende boodskap. laasgenoemde twee aspekte is volgens ayres (1983) kenmerkend van kinders met the south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) invloed van otitis media op sentrale ouditiewe vermoens van kinders met sensoriese integrasieprobleme 4 5 sensoriese integrasieprobleme en dit kan dus 'n bydraende faktor wees tot die swakker prestasie in die ssi-toetsbattery in hierdie studie. laastens wat die ssi-.toetse betref, moet daarop gewys word dat die proefpersone in groep a se prestasie in die ssi-toetsbattery swakker was as die van die proefpersone in groep b. dit kan waarskynlik die gevolg wees van die herhaalde otitis media in die vroee lewensjare wat moontlik 'n invloed op breinstamfunksionering gehad het. die maskeringvlakverskiltoets bevestig ook die bevindinge tot dusver. die proefpersone in groep a se resultate was afwykend in geval van beide die suiwertoonen spraakstimuli in die sin dat die responsdrempels wat verkry is by die aanbieding van die toetsstimuli en kompeterende boodskap in fase (0°/ 0°) en uit fase (0°/180°), lodb en minder was. normale response deur die proefpersone in groep β is verkry, dit wil se die verskil in responsdrempels met die aanbieding van die suiwertoonen spraakstimuli en die kompeterende boodskap in en uit fase was lodb en meer. volgens verskeie outeurs soos sweetow & reddel (in willeford, 1985) hou die maskeringsvlakverskiltoets belowende resultate in indien 'n breinstamafwyking vermoed word tydens die toetsing van leergestremde kinders. die maskeringsvlakverskiltoets se resultate in hierdie studie bevestig ook die moontlikheid van 'n breinstamletsel of onvoldoende breinstamfunksionering. aangesien daar geen ander veranderlikes as otitis media was nie, kan daar 'n korrelasie tussen die voorkoms van otitis media en die afwykende resultate op die maskeringsvlakverskiltoets bepaal word. bogenoemde resultate word verder bevestig deur die sbmpltoetsresultate wat ook op 'n algemene breinstamdisfunksie dui. die proefpersone in groep a was nie in staat om die klank sentraal waar te neem nie; of die klank is sentraal waargeneem met groot interourale-intensiteitsverskille (meer as lodb). stephens (1976) het gevind dat persone met 'n breinstamletsel afwykende resultate in die sbmpl-toets toon. in die lig van die verkree resultate in die sentrale toetsbattery blyk dit duidelik dat daar 'njmoontlike breinstamletsel of wan..funksionering in die geval van die proefpersone in groep a voorkom. aangesien die proefpersone in groep β se resultate op die sentrale ouditiewe toetsbattery (met uitsluiting van die ssi-toetsbattery) binne normale perke was, ontstaan die vraag waarom die proefpersone in groep a dan beduidend swakker presteer het op die toetsbattery. aangesien otitis media die enigste veranderlike is wat die twee eksperimentele groepe onderskei, noodsaak dit 'n diepgaande ondersoek na die moontlike rol wat otitis media in die sentrale ouditiewe gehoorvermoens kan speel, veral met betrekking tot breinstamfunksionering. verskeie menings oor die rol van otitis media in die sentrale ouditiewe vermoens van leergestremde kinders, word in die literatuur voorgehou. gottlieb et al. (1979) toon 'n duidelike verband aan tussen otitis media en die sentrale ouditiewe vermoens, asook die visuele integrasievermoens van leergestremde kinders. volgens zinkus (1982) toon verskeie leergestremde kinders sentrale ouditiewe probleme in bv reeksgeheue; diskriminasie en sluiting. dit is die gevolg van onvoldoende prosessering van ouditiewe invoer, alhoewel die kind se kognitiewe funksie intakt is. identifikasie, diskriminasie en organisasie wat die basis van die ouditiewe leerproses vorm, kan dus in die geval van hierdie kinders afwykend wees. johnson (1981) meen dat leergestremde kinders met sentrale ouditiewe prosesseringsprobleme ook hoerisiko-gevalle is vir otitis media. die fluktuerende gehoorverlies wat tydens periodes van otitis media voorkom, het dus moontlik 'n beplande invloed op die sentrale ouditiewe vermoens van die leergestremde kind (zinkus, 1982). die fluktuerende gehoorverlies lei tot onvoldoende ouditiewe invoer tydens die vroee lewensjare. aangesien die vroee lewensjare die kritieke tyd is vir spraaken taalontwikkeling, asook vir maturasie van, onder andere, die ouditiewe sisteem, is dit logies om tot die gevolgtrekking te kom dat otitis media wel 'n invloed op die maturasie van die ouditiewe sisteem het. dit kan lei tot latere onvoldoende ouditiewe prosessering wat die grondslag van sentrale ouditiewe probleme vorm. die moontlike invloed wat otitis media in die sentrale ouditiewe vermoens kan speel, word verder toegelig deur diere-eksperimente. studies deur webster en webster (1977, in zinkus, 1982) toon dat 'n konduktiewe gehoorverlies tydens kritieke periodes van breinmaturasie tot morfologiese veranderinge in sekere neurone van die ouditiewe nuklei kan lei. volgens webster (1983) is die ouditiewe sisteem afhanklik van omgewingsinvoer en kan daar dus duidelik strukturele veranderinge plaasvind as gevolg van 'n chroniese konduktiewe gehoorverlies in die vroee lewensjare. in 'n studie met muise is ook aangetoon dat 'n herhaaldelike konduktiewe gehoorverlies tydens kritieke postnatale periodes tot anatomiese en fisiologiese veranderinge in die breinstam lei. volgens katz & wilde (1985) het verskeie navorsers ook tot soortgelyke gevolgtrekkings oor die invloed van otitis media op die sentrale ouditiewe sisteem gekom (holm & kunze, 1969; northern & downs, 1978; rubin & rapin, 1980). dit blyk dus duidelik uit die literatuur dat die herhaaldelike konduktiewe gehoorverlies wat tydens chroniese otitis media voorkom, 'n invloed op die maturasie van veral die breinstam en uiteindelik op die sentrale ouditiewe gehoorvermoens het. katz & wilde (1985) is dit ook eens dat die sogenaamde ouditiewe deprivasie-effek die mees logiese verklaring is vir die uiteindelike langtermyninvloed wat otitis media op die sentrale ouditiewe vermoens het. sensoriese deprivasie speel uiteindelik 'n bydraende rol in terme van afwykende vermoens in die organisering en strukturering van inligting (ayres, 1983). voldoende stimuli is beskikbaar, maar onvoldoende prosessering vind plaas, aangesien die struktuur wat noodsaaklik is vir optimale prosessering nie voldoende ontwikkel het nie as gevolg van sensoriese deprivasie tydens kritieke stadia van ontwikkeling. indien hierdie studie se resultate in verband met bogenoemde verklaring gebring word, kan die gevolgtrekking gemaak word dat die proefpersone in groep a se swakker prestasie in die sentrale toetsbattery moontlik te wyte is aan vroee ouditiewe deprivasie waf veroorsaak is deur otitis media. die sensoriese deprivasie kon gelei hettotonvoldoende maturasie van veral die breinstam soos gemanifesteer in die verkree resultate van die studie. die resultate van hierdie studie het dus nie net op die korrelasie van otitis media en die sentrale ouditiewe probleme van die proefpersone in groep agedui nie, maar veral op die korrel; sie tussen otitis media en die breinstamfunksionering van die proefpersone in groep a. volgens zinkus (1982) kan chroniese otitis media egter nie gesien word as die enigste oorsaak van alle sentrale ouditiewe probleme nie. die etiologie van sentrale probleme kan dikwels nie gedefinieer word nie. katz & wilde (1985) toon aan dat alhoewel tumors en ander sentrale letsels in kinders kan voorkom, sentrale ouditiewe toetse by kinders meestal uitgevoer word in die lig van moontlike ouditiewe prosesseringsof leerprobleme. die doel met die suid-afrikaanse tydskrif vir kommunikasieafun/kint/s, vul. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 6 l i d i a o l i v i e r , b r e n d a l o u w , r e n e h u g o s e n t r a l e t o e t s i n g b y k i n d e r s is d u s n i e o m die l o k u s v a n ' n letsel te b e p a a l n i e , m a a r e e r d e r o m die f u n k s i o n e r i n g e n m a t u r a s i e v a n die v e r s k i l l e n d e d e l e v a n die s e n t r a l e o u d i t i e w e s i s t e e m te e v a l u e e r . i n die lig v a n h i e r d i e s t u d i e b e v e s t i g die v e r k r e e r e s u l t a t e l a a s g e n o e m d e stelling d e u r d a t d a a r a a n g e t o o n is dat h e r h a a l d e l i k e o t i t i s m e d i a w e l 'n i n v l o e d h e t o p die s e n t r a l e o u d i t i e w e v e r m o e n s v a n p r o e f p e r s o n e m e t s e n s o r i e s e i n t e g r a s i e p r o b l e m e e n w e l i n t e r m e v a n o n v o l d o e n d e b r e i n s t a m f u n k s i o n e r i n g . g e v o l g t r e k k i n g s e n a a n b e v e l i n g s a l h o e w e l die s t e e k p r o e f v a n h i e r d i e s t u d i e b e p e r k w a s , d u i die r e s u l t a t e d a a r o p d a t c h r o n i e s e otitis m e d i a w e l ' n i n v l o e d h e t op die s e n t r a l e o u d i t i e w e v e r m o e n s v a n k i n d e r s m e t sensoriese i n t e g r a s i e p r o b l e m e . d i e r e s u l t a t e w a t m e t die s e n t r a l e t o e t s b a t t e r y b y die p r o e f p e r s o n e m e t 'n g e s k i e d e n i s v a n otitis m e d i a v e r k r y is, d u i o p a f w y k e n d e r e s u l t a t e m e t b e t r e k k i n g tot die s e n t r a l e o u d i t i e w e v e r m o e n s , e n w e l i n t e r m e v a n onvold o e n d e b r e i n s t a m f u n k s i o n e r i n g . in die geval v a n die proefpers o n e s o n d e r g e s k i e d e n i s v a n otitis m e d i a , is n o r m a l e r e s u l t a t e i n al die t o e t s e v e r k r y , b e h a l w e i n geval v a n die ssi-toetsbatt e r y w a a r g e r i n g e a f w y k e n d e r e s u l t a t e d e u r die p r o e f p e r s o n e v e r t o o n is. l a a s g e n o e m d e r e s u l t a t e k a n egter v e r k l a a r w o r d i n die lig v a n die v i s u e e l o u d i t i e w e i n t e g r a s i e p r o b l e m e w a t k i n d e r s m e t s e n s o r i e s e i n t e g r a s i e p r o b l e m e o n d e r v i n d . i n t e r m e v a n i n t r a g r o e p k o r r e l a s i e s h e t d i e s e n t r a l e t o e t s b a t t e r y se res u l t a t e n i e g e d u i o p 'n b e d u i d e n d e verskil t u s s e n p r e s t a s i e v a n m a n l i k e e n v r o u l i k e p r o e f p e r s o n e in die t o e t s b a t t e r y n i e . ' n g r o t e r s t e e k p r o e f k a n m o o n t l i k geslagsverskille a a n die lig b r i n g . v a n u i t 'n k l i n i e s e o o g p u n t b l y k die r e s u l t a t e v a n h i e r d i e s t u d i e v e r a l v a n b e l a n g te w e e s . d a a r w o r d n i e n e t i n l i g t i n g o o r die i n v l o e d v a n otitis m e d i a o p die s e n t r a l e o u d i t i e w e v e r m o e n s v a n k i n d e r s m e t s e n s o r i e s e i n t e g r a s i e p r o b l e m e b e s k i k b a a r gestel n i e , m a a r o o k i n l i g t i n g o o r die rol v a n die o u d i o l o o g b y die k i n d m e t s e n s o r i e s e i n t e g r a s i e p r o b l e m e . i n s l u i t i n g v a n die o u d i o l o o g i n die m u l t i d i s s i p l i n e r e s p a n w a t die k i n d m e t sens o r i e s e i n t e g r a s i e p r o b l e m e h a n t e e r , k a n d e u r v r o e e i d e n tifikasie e n suksesvolle i n t e r v e n s i e tot die v o o r k o m i n g v a n die n a d e l i g e i n v l o e d v a n otitis m e d i a lei. v e r w y s i n g s ayres, a.j. sensory integration and the child. los angeles: western psychological services, 1973. ayres, a.j. sensory integration and learning disorders. los angeles: western psychological services, 1983. blager, f.b. 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(ed.): central auditory processing disorders of speech, language and learning. baltimore:' university park press, 1983. willeford, j. a. sentence tests of central auditory dysfunction. in katz, j. (ed.): handbook of clinical audioloyy. baltimore: williams & wilkens, 1985. / zinkus, p.w. "psychoeducational and sequelae of chronic otitis media." seminars in speech, language and heariny, 3, 305312, 1982. ' / the south african journal of communication disorders, vol. 37 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 3 segmental speech timing at the phoneme and syllable levels in english and afrikaans speaking white south african children carol l oosthuizen, ph d (cape town) department of otorhinolaryngology university of stellenbosch abstract two aspects of segmental timing were acoustically measured in the speech production of30 english and 30 afrikaans speaking white south african children. these were votand medial stop closure duration in vcv nonsense syllables. in addition, medial vowel duration in cvc nonsense syllables was measured in english speakers. comparisons were made between younger (mean age 4.25 years) andolder (meanage 6.5 years) subjects in each language group. graphical statistical methods revealed certain trends in the data. english speakers employed shortand long-lag votfor voiced and voiceless stops while afrikaans speakers used two short-lag categories. contextually determined right-to-left timing effects were identified which were in agreement with the literature, with different rates of acquisition of medial stop closure duration rules being observed between the language groups. opsomming twee aspekte van segmentele tydreeling in die spraakproduksie van 30engels en 30 afrikaanssprekende blanke suid-afrikaansekinders is akoesties gemeet. dit was stemaanvangstyd en tydsduur van mediale plosiewe sluiting in vkv onsinlettergrepe. tydsduur van mediale vokale in'kvk onsinlettergrepe is ook in engelssprekendes gemeet. vergelykings is ook gemaak tussenjonger (gemiddelde ouderdom 4.25 jaar) en ouer (gemiddelde ouderdom 6.5 jaar) proefpersone in elke taalgroep. dit is bevind dat engelssprekendes gebruik maak van kort en lang vertraging in stemaanvangstyd vir stemhebbende en stemlose plosiewe, terwyl afrikaanssprekendes twee kort vertragingskategoriee gebruik. regs-tot-links konteksgebonde neigings wat in segmentele tydreeling geidentifiseer is, het met die literatuur ooreengestem terwyl verskillende tempo's van verwerwing van reels vir tydsduur van mediale,plosiewe tussen die taalgroepe waargeneem is. temporal aspects of speech production have been highlighted by kent (1976) as possibly "j., the most critical factor in skilled motor performance." (ρ 43δ[) the development of speech timxiflg is thought to reflect neuromaturation of the speech mechanism and has important implications for many branches of the study of communication disorders. kent points out that phonetic judgments are only gross indicators of motor speech devejppment and that more sensitive parameters of motor skills, such as the acquisition of segmental timing rules, continue to develop after children have acquired the basic phonological system. some developmental patterns in segmental timing have been demonstrated (inter alia, by kewley-port & preston, 1974; disimoni, 1974 a,b,c; tingley & allen, 1975;menyuk&klatt, 1975; gilbert, 1976; gilbert & johnson, 1978; smith, 1978; macken & barton, 1979; flege, mccutcheon & smith, 1987) but the still inadequate body of research on the subject precludes a comprehensive description._ development in the various levels of speech timing has not been fully investigated. cooper (1977) identified three levels on which children learn control of speech timing: 1. the phonetic-phonemic level, such as voice onset time (vot), i.e the time taken from the release of a stop plosive closure to the onset of voicing for the post-consonantal vowel. die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 36, 1989 2. the syllable level, comprising rules for the timing of sounds within syllables. this can be illustrated by a temporal compensation rule which states that a longerthan-average vowel must be followed by a shorter-thanaverage consonant. 3. the sentence level. both children and adults seem to preplan the timing of segments within utterances, e.g. the longer the utterances, the shorter the individual segments. a fourth level of speech timing may be added (dalton & hardcastle, 1977), viz.: 4. the prosodic level, i.e. transition smoothness between intonation units. it is not yet known whether measures of timing variables in very young children would predict later motor speech performance. the intriguing question of whether or not there is a relationship between speech timing development and speech disorders has only been addressed in a preliminary way with regard to articulation disorders (weismer & elbert, 1982), phonological disorders (catts & jensen, 1983; smit & bernthall, 1983), cleft palate (forner, 1983), hearing impairment (stark, 1972), delayed language development (bord & wilson, 1980) and stuttering (inter alia, disimoni, 1974c; ® sasha 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 carol l oosthuizen starkweather et al. 1976; starkweather & myers, 1979; oosthuizen, 1986; adams, 1987; mcknight & cullinan, 1987). a description of normal development should be the precursor to the study of timing problems in speech disorders. no normative study of speech timing in south african children has yet been published and this report represents a limited attempt to explore a vast subject. most white south african children speak english or afrikaans, which have been the two official languages since 1925. owing to historical and geographical influences, south african english is a dialect which differs from forms of english found in other countries (lanham, 1967). afrikaans is a germanic language which was derived from dutch. it cannot be assumed that the findings of studies of speech timing using speakers of other english dialects or germanic languages can automatically be applied to speakers of south african english or afrikaans. separate investigations are merited which might eventually yield valuable insights into the relationships between the development of speech timing, dialect and language. the three aspects of expressive speech timing which form the topic of this report fall within the phonetic-phonemic and syllable levels. they are syllable-initial vot, syllable-medial stop closure duration and syllable-medial vowel duration. these segmental timing elements were studied in the speech of english and afrikaans speaking white south african children and formed part of a larger study directed toward the speech of stutterers (oosthuizen, 1986). they will be discussed as three separate experimental procedures carried out on the same subjects, experiment three using english speaking subjects only. experiment one. aim the aim of experiment one was to identify normal trends for vot production of syllable-initial stop plosives in the experimental groups. vot is an important dimension of segmental timing, since it i s a valid measure to differentiate phonemic voicing categories in many languages. most studies of vot production in children have employed very small subject samples, nevertheless some developmental trends have emerged. kewly-port and preston (1974), studying american english children (n3), found that, initially, short-lag vots predominated with a gradual increase in longlag vots. those findings were confirmed by macken and barton (1979) who noted that their 4 subjects had reached adult contrast values by 2.4 years. however, a small sample of canadian english children failed to demonstrate adult / t / values by three years (gilbert 1976). in reviewing the literature, kent (1976) concluded that vot attains adult stability around eight years of age. ί. method subjects 30 english and 30 afrikaans speaking white south african children from monolingual homesin the cape peninsula were divided into younger and older age groups (see table 1). the subjects had no known medical or neurological disorders, nor any history of communication problems and had passed hearing screening tests. table 1: subject groupings w i t h mean ages in years and months subgroup (n-15) mean age age range 1. older english speakers 6,10 yrs 6,5 to 7,6 2. older afrikaans speakers 6,9 yrs 6,4 to 7,10 3. younger english speakers 4,4 yrs 4,0 to 5,0 4. younger afrikaans speakers 4,1 yrs 3,1 to 4,8 procedures for data collection four productions of each of the following cvc nonsense syllables were elicited from each subject and recorded on audio tape: /paf/ /baf/ /taf/ /daf/ the subjects "were tested individually in a quiet environment. the syllables were used in a story context by an adult native speaker of each language, following a procedure described by hawkins (1973), after which deferred imitations were elicited from the children. data analysis storage oscilloscopic displays of the first three clear, isolated productions of each of the syllables for each subject were obtained using an electronic memory (biomation model 1015) and tektronix 510 3n oscilloscope. judgment of speech segmental boundaries in the display followed the guidelines laid down by shoup and pfeifer (1976) and segments were measured in milliseconds. the vot of each production was classified as falling into the short-, long-lag, or voicing lead categories. in their seminal study of adult native speakers of eleven languages, lisker and abramson (1964) identified three categories of vot values: prevoicing (voicing lead): -125 to zero msecs ι short-lag: zero to /25 msecs ι long-lag: /60 to /100 j it is n o w generally accepted that a vot boundary of approx[ imately /35 msecs separates the shortand long-lag categories in english (cooper, 1977), a figure which corresponds witli the perceptual boundary. j statistical treatment 1 owing to the small number of subjects (15) in each subgroup, and given the exploratory nature of the study, graphical statistical methods were applied. multiple box plots were used to display the central tendency and spread of the mean, the range, maximum and minimum scores for each production of each syllable. results and discussion ^ figure 1 shows summary box plots illustrating the relative vot values for the /paf/-/baf/ cognate pair in the four experimental groups. comment on the distribution refers to the interquartile distance, chosen as a measure of spread, and the median, chosen as a central value. these parameters were / the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) segmental speech timing at the phoneme and syllable levels 5 regarded as preferable to the standard deviation or arithmetic mean, since many of the distributions were asymmetrical; they have the additional advantage of being little affected by outlying scores. outlying scores are represented on the distribution by asterisks in a vertical column. results for the /taf/-/daf/ cognate pair (not shown) were comparable and are included in the comments. ker (1974). this relative reduction of vot for voiceless syllable initial stop plosives reflects the local dialect, since the older english speakers' scores were comparable to adult data obtained in an unpublished pilot study. speculation regarding the various influences on the local dialect which could affect segmental timing would be premature as ideas in this regard are currently under review (lass, personal communication 1986). older older younger younger • 8 0 enorsh speakers afrikaans speakers english speakers alrikaans speakers i v o t i n m s e c s • 5 0 ' .40 +30 +20 +10 0 -10-20" 3 0 " 4 0 5 0 6 0 ψ figure 1 summary box plots showing vot values for the /paf/-/baf/ cognate pair in the four groups of subjects. a few extreme prevoicing scores have been omitted in older afrikaans speakers. while there was a degree of overlap between vots for voiced and voiceless cognate pairs, older english speakers made clearer distinctions between them than did their afrikaans peers. south african english appears to be a two category dialect employing shortand long-lag vot contrasts for voiced and voiceless stops respectively. afrikaans speakers appeared to use two sets of unaspirated stops for 'voiced' and voiceless' sounds all of which fell into the short-lag category, a finding which provides documentary evidence of a feature which is familiar to afrikaans phoneticians (de villiers, /1967). older english speakers sho lag vots on voiceless stops ved a greater trend toward longthan did younger ones. this is in agreement with the reported developmental findings, that children have to learn to lengthen vot. afrikaans speakers did not show vot lengthening for voiceless stops with age, since they did not employ the long-lag category. analysis of multiple box plots of the range (not shown) indicated increased variability of vot on voiceless stops with age in the case of english speakers. this was attributed to the inherent scope of the long-lag category, which permits a wide variety of acceptable scores. most afrikaans speakers showed decreased variability of production with age; which agrees with previous findings (eguchi and hirsch, 1969; disimoni, 1974a, 1974b; tingley and allen, 1975; zlatin and koenigsknecht, 1976). however, some individuals showed increased variability for voiced stops owing to the development of voicing lead as a stylistic variant. in the case of the south african english children, the means for long-lag vot were considerably smaller than those reported in the literature for american english children, yet they fell into the adult long-lag range identified by abramson and lisexperiment two disimoni (1974a, 1974b), studying american english children, found that the influence of phonetic context on segmental durations appeared between three and six years of age and approached, but did not yet reach adult levels, by nine years. in vcv syllables, the stop closure durations of both voiced and voiceless stops were found to be greater in / i / t h a n in / a / environments. the present experiment set out to determine whether similar trends characterized the speech of south african children. procedures for data collection for experiments 2 and 3. t w o randomized word lists, each containing eight nonsense syllables and yielding three nonconsecutive productions of each syllable by each subject were audio recorded. in experiment 2 these were vcv syllables: /apa/ /aba/ /ata/ /ada/ /ipi/ /ibi/ /iti/ /idi/ the task was one of imitation of an adult speaker, recorded in the case of older subjects and live voice presentation for younger subjects, the syllables being preceded by a carrier phrase. the preconsonantal vowels were stressed in experiment 2. data analysis t w o measures were taken from each production of each syllable, viz. whole syllable duration and the closure phase of the medial stop plosive. results and discussion figures 2 5 contain summary multiple box plots illustrating the central tendency and spread of stop closure duration scores for the experimental syllables in the four groups. nonsense syllables idi ibi ata slop closure 129 • duration in msecs 109 figure 2 summary box plots showing the central tendency and spread of stop closure durations i n vcv syllables in older english speakers. die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 carol l oosthuizen stop 159 closure duration in msecs 124 η 532nonsense syllables u bl ill figure 3 summary box plots showing the central tendency and spread of stop closure durations in the vcv syllables in older afrikaans speakers. 223slop closure 157cbratlon in maeca 12490.35 7 2 24:0 • aba id bl ata apa kl ty 1 τ τ figure 4 summary box plots showing the central tendency and spread of stop closure durations in vcv nonsense syllables in younger english speakers. slop 201 closure duration in msecs 163 η 48.0 • nonsense syllables idi ibi ata apa figure 5 summary box plots showing the central tendency and spread of stop closure durations in vcv syllables in younger afrikaans speakers. sistent with the results of acoustic studies (schwartz, 1969; disimoni, 1974a; suen and beddoes, 1974; smith, 1978) as well as a physiological study by butcher and weiher (1976). schwartz (1969) attributed the shorter stop closure duration prior to / a / to coarticulation, the earlier consonant release compensating for the greater distance to be covered in order to reach the low vowel position compared with the high one. in contrast to canadian english adults (suen & beddoes, 1974) the south african children showed greater mean'stop closure duration differences between cognate pairs for alveolar sounds than for bilabials. perhaps this place-of-articulation effect results from relatively poor motor capabilities of the tongue tip in children. the younger south african english speakers had a mean closure duration difference between voiced and voiceless stops of 16,7 msecs, which is far below the values reported by smith (1978) for american english children of comparable ages. these discrepancies probably reflect dialectal differences, although methodological factors cannot be discounted. there appeared to be a developmental trend in the direction of lengthening of medial stop closure duration of voiceless stops. this voicing distinction seemed to be acquired earlier in both vowel environments in afrikaans speakers compared with english speakers. a second age-related trend, which was also interpreted as reflecting a developmental pattern, was toward lengthening of medial stop closure duration in the high vowel environment. variability of timing production was greater amongst younger speakers compared with older ones, confirming the reported trend in the literature. whole syllable durations did not decrease with age, however. another unexpected finding was that of greater whole syllable durations in english than in afrikaans speakers. this cannot simply be attributed to longer vots in the english group. vot lengthens with age, yet whole syllable durations were longer in younger than in older speakers. since stop closure durations per se, which included transitions, did not differ between the language groups, it seems that the english speakers may have been using longer vowels than did their afrikaans counterparts. the final vowel is generally thought to exert most influence on medial stop closure duration (anderson, 1975), but there is conflicting evidence regarding the influence of the preceding vowel (schwartz, 1969; butcher & weiher, 1976). since both vowels were the same in each syllable, it is not possible to determine which was affecting medial stop closure durations. j the lack of consistent age related trends for whole syllable duration is in agreement with kubaska and keating (1981) who observed that, provided that the positions of words in utterances were controlled, and once children had reached the two-word utterance stage of development, word durations did not change much over time in american english children (n3). experiment three no differences emerged between the older language groups with respect to stop closure duration trends. both groups showed longer medial stop closure durations for voiceless compared with voiced stops. stop closure durations were also longer in / i / than in /a/environments. these findings are conthis experiment was performed on english speakers only, since final voiced stops and fricatives do not normally occur in afrikaans (combrink & de stadlef, 1987). vowels which precede voiced stops have been, shown to be approximately 100 msecs longer than those preceding final the south african journal of communication , disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) segmental speech timing at the phoneme and syllable levels 7 voiceless stops in adult speech (house & fairbanks, 1953; peterson & lehiste, 1960). naeser (1970), smith (1978) and krause (1982) have demonstrated similar trends in 2-3 year old american english children. the phenomenon has also been identified in older children by disimoni (1974b) who indicated that development was in the direction of vowel lengthening for voiced consonants rather than shortening for voiceless consonants. this experiment was aimed at determining the trends characterizing the english speaking subgroups in terms of medial vowel duration relative to the consonant environment in cvc nonsense syllables. data collection and analysis the word lists contained these cvc nonsense syllables: /pip / / p a p / /sis/ /sas/ /bib / /bab/ /ziz/ /zaz/ measures were taken of vowel and whole syllable durations. results and discussion figures 6 and 7 show summary box plots indicating vowel durations for the eight syllables in the two subgroups. results showed that vowels were longer in sibilant than in stop plosive contexts as well as in voiced compared with voiceless consonant environments. 231 vowel 191 duration in msecs nonsense syllables zaz ziz pip k a 30.0figure β summary box plots showing the central tendency and spread of vowel durations in cvc syllables in older english speakers. contrary to other reports (reviewed by kent, 1976), segment durations did not decrease with age. however, an age-related trend was identified in the increasing differential vowel duration relative to both voicing and manner-of-articulation of the voiced consonant context. decreasing variability of performance with age was found on measures of whole syllable duration. general discussion the segmental phonetic level of speech timing, which would include vot, is considered by dalton and hardcastle (1977) to be dependent on aerodynamic coordination. the relatively late development of long-lag vot in speakers of those languages which use it might be attributed to its greater neurovowel 214duration in msecs nonsense syllables zaz ziz pip pap bib bab τ figure 7 summary box plots showing the central tendency and spread of v o w e l durations in cvc syllables in younger english speakers. physiological complexity, compared with short-lag vot (cooper, 1977). however, lisker (1975) suggested that vot was influenced by an interaction between biological restraints and phonological rules. the general decrease in mean segment duration which has been reported as a function of age (smith, 1978; kent & forner, 1980) and the development oflong-lag vot might largely reflect increasing neuromuscular capabilities. it has been proposed (suen & beddoes, 1974) that the relatively late development of longer stop closure durations for voiceless stops reflects the increased muscular effort required to produce them. this argument is challenged by the cross-language findings in the south african children, the relatively early development of longer closure durations in afrikaans speakers suggesting that phonological considerations may be important. it seems that certain elements of speech timing are singled out for this kind of development in the age group studied, probably on the basis of their phonological significance. this issue of the relative contribution of biomechanical and phonologically-programmed influences on segmental speech timing is further complicated by the probable lack of a simple one-to-one relationship between the underlying phonological segmental length specification and the observable phonetic duration. allen (1973) has suggested that sources of variation would include speech tempo, biological restraints (such as j a w mass) and aerodynamic factors. conclusion in the main, the segmental timing trends identified in the south african subjects agreed with those reported in the literature, i.e.: 1. increasing vot for voiceless stops as a function of age in english speakers. 2. longer medial stop closure durations in vcv syllables when the stop was voiceless and in high vowel environments. a developmental trend toward the acquisition of differential stop closure durations were observed. 3. longer medial vowel durations in cvc syllables in voiced and voiceless sibilant consonant environments and a developmental trend in this regard in english speakdie suid-aftikaanse tydskrif vir kommunikasieafivykings, vol. so, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 carol l oosthuizen south african english was identified as a two-category language employing shortand long-lag vots for voiced and voiceless stops respectively. afrikaans speakers appeared to use two short-lag categories with random voicing lead on voiced stops in some subjects. the fact that there were mixed findings regarding decreasing variability of production as a function of age may be attributed to the relatively small age gap between the older and younger groups of subjects. differences between speakers of the two languages with respect to rate and, to a lesser extent, degree of acquisition of anticipatory contextual timing effects highlighted the importance of comparing cross-language data when interpreting research results in this area of study. the research findings on segmental timing effects in the connected speech of adult speakers (chrystal & house, 1988) suggest that due 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' weismer, g. and elbert, m. temporal characteristics of the "functionally" misarticulated /s/in 4 6-year-old children./. speech hear. res., 25, 275-287, 1982. zimmermann, g.n. and sapon, s.m. note on vowel duration seen cross-linguistically. j. acoust. soc. am., 30, 152-153, 1958. zlatin, m.a. and koenigsknecht, r.a. development of the voicing contrast : a comparison of voice onset time in stop perception and production./. speech hear. res., 19, 93-111, 1976. the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 57 use of the cid w22 as a south african english speech discrimination test wayne j. wilson and selvarani moodley department of speech pathology and audiology university of the witwatersrand abstract south africa currently lacks a pre-recorded south african english (sae) specific speech discrimination test. in the absence of such a test, the sae speaker recording (tygerberg recording) of the american (usa) english (ae) cid w22 wordlists in combination with the original american cid w22 normative data is the most widely used alternative. the reliability and validity of this method, however, has never been formally assessed. this study assessed the performance of 15 normal hearing, female, first language sae speakers on the first two full-lists of tygerberg cid w22 recording at 20, 30, 40, 50, 60 and 70 dbspl, and compared their scores to the american cid w22 wordlist normative data. overall, the south african subjects performed worse than the original american normative data at the lower presentation intensities (<50 dbspl). use of the tygerberg cid w22 recording with the original american cid w22 normative data for near threshold assessment of sae speaking subjects was therefore concluded to be problematic. use at suprathreshold intensities (> 40 dbspl), however, was considered a viable option. these results reiterate the need for large scale, south african specific normative studies for the cid w22 wordlists if they are to continue their role as the dominant speech discrimination wordlists in south africa. key words: special discrimination, cid w22 wordlists, american (usa) english, south african english. introduction the cid auditory test w22, from the united states of america, represents the most widely used, basic audiological speech discrimination test in south africa. the test's popularity appears to be due mainly to its widespread use in the usa only, however, as opposed to any formal research demonstrating the validity and reliability of its use in the south african context. these factors, support for and criticisms against the cid w22, and the general problems of applying a non-south african specific speech discrimination test to the southj african population have been discussed previously (wilson, jones & fridjhon, 1998). the cid w22 was originally designed as an improvement on the psycho-acoustic laboratories phonetically balanced 50 word lists (pal-pb 50) speech discrimination test. it improved phonetic balance (lehiste & peterson, 1955), equality of difficulty between lists (brewer & resnick, 1983) and degree of familiarity (brewer & resnick, 1983; hirsh et al., 1952). the test consists of 4 lists of 50 monosyllabic words with six randomizations of each list. the words were originally chosen on the basis of being representative of north american (usa) english, with all but one of the chosen words appearing on the thorndike "list of most frequently used words" (hirsh et al., 1952). the chosen words were also checked for phonetic balance according to studies of syllable-consonant-vowel distribution in american english (ae) (hirsh et al., 1952). whilst originally created as 50 word full-lists, users of the cid w22 wordlists recognised almost immediately the benefits of reducing test time by administering 25 word half-lists (martin & forbis, 1978; edgerton & danhauer, 1979). these shorter lists remain in widespread clinical use despite being prone to higher variability (and therefore poorer reliability) and exacerbation of the already difficult phonetic balance problem (ostergard, 1983). the original cid w22 standardisation information was obtained on 15 normal hearing, ae speakers. all four lists were randomly presented at 10 db intervals from 20 dbspl to 70 dbspl. the resultant group "performance-intensity" plot is shown in hirsh et al. (1952) and represents the averaged performance of the subjects on all four full-lists at each presentation intensity. the actual scores obtained are not given and are extrapolated from the hirsh et al. (1952) plot. the success of the cid w22 wordlists in the usa lead to their introduction and widespread use in south africa. in an attempt to make these standardised cid w22 wordlists more suitable for the south african english (sae) speaking population, a sae speaker recording of the original wordlists was made at tygerberg hospital in the western cape. technical information on the tygerberg cid w22 recording is not available. what is known is that the recording is comprised of the 4 original american wordlists of 50 words each, all read by a south african adult male who is a first language speaker of sae. each word is preceded by the carrier phrase "say the word", the inter-stimulus interval die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 wayne j. wilson and selvarani moodley is 4 seconds and serves as the subject's response period. it must be noted at this stage that a popular alternative to the tygerberg cid w22 recording is to present the wordlists via monitored live voice (mlv). whilst the mlv presentation may provide a partial solution to speakerlistener accent mismatch, it has been widely criticised for its poor test-retest reliability (carhart, 1965; brandy, 1966; kreul, bell & nixon, 1969 and northern & hattler, 1974) and the inherent problem of comparing results using monitored live voice to standardisation information obtained using recorded versions of the test (mendel & danhauer, 1997). the recorded version of a test keeps the tester voice constant therefore improving test-retest reliability and allows valid comparisons to standardised normative data. because of this, testing using the tygerberg recording was preferred in this study. south african normative data for the tygerberg recording of the cid w22 has not been published. as a result, the performance of sae speaking subjects on the tygerberg recording, whether it be half-list of full-list performance, is typically compared to the original ae subject, averaged full-list normative data for the original american cid w22 recording. such comparisons add obvious reliability and validity problems to the already stretched reliability and validity of using an american designed and standardised test on south african subjects. formal assessment of the reliability and validity of using the tygerberg cid w22 wordlist recording with the original american cid w22 normative data to assess first language sae speakers is needed if this protocol is to remain the dominant speech discrimination test protocol in south africa. methodology aims this study aimed to: 1. measure the performance of 15 female, first language south african english (sae) speakers on the first two full lists, and the resultant first four half-lists, of the sae recorded version (tygerberg recording) of the cid auditory test w22 at stimulus intensities of 20, 30, 40, 50, 60 and 70dbspl. 2. compare the sae speaker results to the original american cid w22 wordlist normative data. 3. compare the performance of the south african subjects only, between full-lists and between half-lists at each presentation intensity, and within full-lists and half-lists between each adjacent presentation intensity. 4. comment on the suitability of using the tygerberg recording of the cid w22 wordlists, with comparison with the original american cid w22 normative data, to assess first language sae speakers. subjects subject selection criteria subjects were selected using a convenience sampling technique. for acceptance into the study, subjects were required to conform to the following criteria (as confirmed by audiometric testing and self-report): (i) aged 17 40 years. this controlled for the well-recognised effects of paediatric and geriatric age ranges on performance on speech discrimination tasks (hall, 1983). (ii) female gender. this criterion was included for ease of subject selection, as it was deemed unlikely that a sample balanced for gender could easily be obtained, (iii) english as first-language, (iv) resident in gauteng, south africa as according to fuller (1987), subjects for research in the area of speech audiometry should be native to the local area, (v) hearing thresholds < 5dbhl at 250, 500,1000, 2000,4000 and 8000 hz in the test ear. (v) no significant history, past or present, of: hearing impairment; speech or language impairment; tinnitus; ear infections; noise exposure; or; family history of hearing problems, (vi) no previous knowledge of, or experience regarding the cid w22 wordlists. subject description an initial sample of 18 female, first language sae speaking subjects, all resident in the gauteng area, was obtained. three subjects were excluded on the basis of pure tone threshold criteria. the final 15 subjects ranged in age from 18.6 to 31.4 years, with a mean age of 23.9 ± 4.4 years. educational levels included two subjects with secondary school education and 13 subjects with or receiving tertiary level education. the better ear only was tested in each subject with a final 8 right and 7 left ears tested. test environment, equipment and recorded material testing was conducted in a two-room soundproof booth at the university of the witwatersrand speech and hearing clinic in gauteng. a one-way mirror enabled observation of subjects during testing. the tygerberg cid w22 wordlists were presented via an aiwa audiocassette player coupled with a grason stadler gsi16 audiometer. presentation was through tdh39 headphones with mxar41 cushions. measurement procedures and data collection subjects first filled in a case history questionnaire. pure tone air conduction thresholds for 250-8000 hz were then obtained for both ears using a standard hughson-westlake test procedure. if all selection criteria were met, the subject's better ear was chosen for speech testing. speech discrimination testing was conducted using the first two of the four tygerberg cid w22 pre-recorded full wordlists at 20,30,40,50,60 and 70 dbspl. administration; of all four full-lists at each intensity was not conducted as1 it was thought that this would lead to unacceptably high, levels of test duration and subject fatigue. all testing was. conducted by a final year ba (speech and hearing therapy) student who has had clinical training in audiometric procedures, under the supervision of an audiologist registered with health professions council of south africa. the speech discrimination testing followed a similar protocol to that used by the central institute for the deaf to normalize the original cid w22 wordlists (hirsh et al., 1952). the two full-lists were split and presented as four half-lists at each of the six presentation intensities in a pseudo-randomised order to prevent a particular list from occurring several times in succession. the same set of instructions was given to all subjects through the headphones: "you are going to hear sentences. i want you to repeat the last word of each sentence." the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) use of the cid w22 as a south african english speech discrimination test 59 subjects' responses were recorded and scored on-line by the tester. an all-or-none scoring procedure was used where the subject had to perceive the entire word correctly in order to receive credit. a correct response obtained a score of 2% for the full lists and 4% for the half-lists. subjects were allowed to rest at their request at any time during the test procedure in order to reduce fatigue (mendel & danhauer, 1997). data analysis south african english speakers' scores for the two full and four half-list tygerberg cid w22 wordlists were visually compared to the original american, averaged scores on the american cid w22 full-lists [as extrapolated from the graphs provided in hirsh et al. (1952)]. descriptive differences were identified. the south african subjects' scores on the tygerberg cid w22 wordlists were then analysed for differences between: mean scores on the two full-lists, for each presentation intensity separately, using two-tailed t-tests for dependent samples at the 5% significance level. mean scores on the four half-lists, for each presentation intensity separately, using one-way repeated measure anova and tukeys honest significant difference analyses at the 5% significance level. mean scores between each adjacent pair of presentation intensities (20-30,30-40,40-50,50-60 and 60-70 dbspl), for each full-list and half-list separately, using repeated wilcoxon matched pairs analyses at the 1% significance level. score variances between presentation intensities for each full and half-list separately, and between full and halff u l l l i s t 1 f u l l l i s t 2 30 40 50 d b s p l half-list 1 1 half-list 1 2 20 30 40 50 60 70 d b s p l 20 30 40 50 60 70 d b s p l half-list 2 1 half-list 2 2 ο +—i 20 30 40 50 60 70 d b s p l figure 1. plots of south african english speakers' mean scores (diamonds) with error bars (2 s.d) for each tygerberg recording cid w-22 full-list and half-list, and the original american english speakers' mean scores (squares) for the american cid w-22 full-list. die suidl-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 wayne j. wilson and selvarani moodley lists for each presentation intensity separately, using within-groups f test analyses at the 1% significance level. results south african english speakers' versus american english speakers' scores figure 1 displays a plot of the sae speakers' mean scores on the tygerberg cid w22 full-lists 1 and 2, and their respective half-lists 1-1, 1-2, 2-1 and 2-2, at the 20, 30, 40, 50, 60 and 70 dbspl presentation intensities. all plots are superimposed on the extrapolated normative data for the ae speaker mean scores averaged over the four american cid w22 full-lists (hirsh et al., 1952). in general, the sae speakers' performance on the tygerberg cid w22 wordlists was poorer than the ae speakers performance on the american cid w22 wordlists at the lower presentation intensities (< 50 dbspl), but was equivalent at the higher presentation intensities (> 40 dbspl). on closer visual inspection, the sae speakers' scores were: more than two standard deviations lower than the ae speakers' mean scores for half-list 2-1 at 20 dbspl. approximately two standard deviations lower for fulllists 1 and 2, and half-lists 1-1 and 1-2 at 20 dbspl. between one and two standard deviations lower for halflist 2-2 at 20 dbspl and for full-list 1, and half-lists 11, 1-2 and 2-1 at 30 dbspl. less than one standard deviation lower for full-list 2 and half-list 2-2 at 30 dbspl and all lists at 40 dbspl. approximately equal for all lists at 50,60 and 70 dbspl. south african english speakers' scores table 1 shows the mean + one standard deviation scores for 15 female, first language sae speakers on the tygerberg cid w22 full-lists 1 and 2, and their respective half-lists 1-1,1-2, 2-1 and 2-2, at the 20,30,40, 50, 60 and 70 dbspl presentation intensities. the t-test for dependent sample results for differences between the sae speaking subjects' full-list scores, conducted separately for each presentation intensity, showed no significant differences (p<0.05). table 2 shows one-way repeated measures anova and tukeys honest significant difference (thsd) test results for differences between the sae speaking subjects half-list scores, conducted separately for each presentation intensity. results showed a significant difference (p<0.05) between the first half of list 1 (1-1), and the second half of list 1 (1-2) and list 2 (2-2) at 40dbspl only. note that a significant (p<0.05) anova result was observed at the 60 dbspl presentation intensity, but the associated thsd analysis showed no significant differences. wilcoxon matched pairs test results for differences between sae speaking subject scores on each pair of adjacent presentation intensities (20-30, 30-40, 40-50, 5060 and 60-70 dbspl), conducted for each full and half-list separately, showed significant differences (p<0.01) for all comparisons, except between 60-70 dbspl for all full and half-lists. f test analysis for differences in variance between sae speaking subjects scores, between presentation intensities (dbspl) within each full and half-list, showed the following significant differences (p<0.01): (20, 30, 40) > 50 > (60, 70) for full-list 1. 30 > (20, 40) > 50 > (60, 70) for full-list 2. (20,30,40,50) > (60,70); and (30,40) > 50 for half-list 1-1. (20, 30, 40) > 50 > (60, 70) for half-list 1-2. (20,30,40,50) > (60,70); and 30 > (20,50) for half-list 2-1. 30 > (20, 40) > (50, 60, 70) for half-list 2-2. f test analysis for differences in variance between sae speaking subjects scores, between each full and half-list, within each presentation intensity, showed the following significant differences (p<0.01): half-list 1-1 > half-list 2-2 at 40 dbspl. half-list 1-1 > (half-list 1-2, half-list 2-2) at 50 dbspl. half-list 1-1 > (half-list 1-2, half-list 2-1) at 60 dbspl. (half-list 1-1, half-list 2-2) > (half-list 1-2, half-list 2-1) at 70 dbspl. whilst these differences have implications for the anova and thsd analyses of the half-list scores above, the differences were not considered to be in excess of those tolerable by the anova (lindman, 1974). discussion the qualitative finding that the sae speakers' scores on the tygerberg cid w22 wordlists were generally worse than those of the original ae speakers' scores on the dbspl 20 30 40 50 60 70 full-list 1 9.2 + 10.8 53.3 + 13.8 80.1 ±10.8 95.2+4.7 98.5 + 2.2 99.1 ±1.8 full-list 2 10.7 ±8.5 51.6 ±21.7 83.6 ± 9.3 95.9 ±4.0 98.7 + 1.6 99.2 ±1.7 ' half-list 1-1 7.7+12.1 47.2 ± 15.9 73.9+15.9 92.8 ±7.4 97.6 ±3.6 98.4+2.9 half-list 1-2 11.2 ±10.7 53.9+16.5 86.4 ±9.3 97.6 + 3.6 99.5 + 1.4 99.7 + 1.0 half-list 2-1 10.1+8.0 45.9 ±21.7 80.5 + 14.3 95.5 ±5.4 99.5 ± 1.4 99.7 ± 1.0 half-list 2-2 12.5 + 10.9 53.1 + 23.9 86.7 ±7.5 96.0 + 3.7 97.9 ± 2.6 98.7 + 2.5 i table 1: south african english speakers' mean +one s.d. speech discrimination scores on the tygerberg cid w22 full-lists 1 and 2, and their respective half-lists 1-1,1-2, 2-1 and 2-2. the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) use of the cid w22 as a south african english speech discrimination test 61 american cid w22 wordlists, indicates that the use of the tygerberg sae recording of the cid w22 wordlists with the original american cid w22 wordlist normative data cannot be applied to the sae speaking population without significant modification. specifically, the differences between the sae and ae speaking subjects on their respective cid w22 wordlists occurred at presentation intensities below 50 dbspl. this suggests that both groups were able to hear their respective cid w22 wordlists equally well at the higher presentation intensities, but the american subjects were able to extract more information from their american wordlists at the lower presentation intensities, due most probably to their greater familiarity with ae. these findings are consistent with the previous finding of sae speakers' performance on the australian english nal-ab wordlists (wilson, jones & fridjhon, 1998). analysis of the sae speakers' scores alone showed several useful findings. the finding that the mean scores showed only two significant differences (p<0.05) when compared within presentation intensities between lists (half-list 1-1 scores were lower than those of half-lists 1-2 and 2-2 at the 40 dbspl presentation intensity only) suggests two things. generally, it suggests that the two tygerberg cid w22 wordlists and their four half-lists were of equal difficulty for the sae speaking subjects at all but one of the tested presentation intensities. specifically, it suggests that halflist 1-1 may be a more difficult half-list at 40 dbspl. the possibility that half-list 1-1 could be a problematic list was further supported by the finding that this half-list had a significantly greater variance (p<0.01) than the other halflists at the higher presentation intensities (> 30 dbspl). such interpretations must be approached with caution, however, as whilst the absolute differences in the mean and variance values were statistically significant, their clinical impact is of somewhat less value due to the small size of the absolute differences observed. the sae speakers' scores also showed a significant improvement (p<0.05) with each increase in presentation intensity from 20 to 60 dbspl, within each tygerberg cid w22 full and half-list, as would be generally expected in a /normal performance intensity function. the absence of ' significant differences between the 60 and 70 dbspl presentation intensities provides evidence of the beginning of a ceiling effect at these intensities. table 2: anova and tukeys hsd results for sae speakers' speech discrimination scores on e tygerberg cid w22 wordlists for half-lists 1-1, 1-2, 2-1 and 2-2. dbspl anova thsd 20 p=0.38 30 p=0.18 40 p<0.001 l-l<(l-2,2-2) 50 p=0.06 60 p<0.05 70 p=0.06 the significant decrease (p<0.05) in the sae speakers' score variances with increases in presentation intensity is remarkably similar to previous findings of sae speakers' performance on the australian nal-ab wordlists (wilson, jones and fridjhon, 1998). this finding, again, suggests a more equal ability between subjects to overcome any problems with non-sae english, in this case ae, when given a high enough presentation intensity, and only partly agrees with ostergard's (1983) findings that variability in speech discrimination scores tend to decrease for extreme scores and increase for mid-range scores. minor limitations to this study include the young, adult, female composition of the sample and the lack of control over right versus left ear selection. with no reports, to the authors' knowledge, of significant female/male or right/left ear performance differences in the literature for any of the monosyllabic word tests, these points were not considered to have had any significant impact on this study's findings. a more significant limitation was prerequisite that the sample should be first language sae speakers, and the predominance of tertiary level education. davis (1983) (cited in lutman, 1987) demonstrated a relationship between socio-economic status and type of occupation and performance in speech audiometry, with higher education level implying that a certain level of linguistic competence and even sophistication affects the results. it might therefore be predicted that a more representative sample of the sae speaking population would not have performed as well as the more educated sample used in this study. finally, it must be noted a significant factor affecting any interpretation of speech discrimination results is the large amount of variability inherent in speech audio me trie testing. mendel and danhauer (1997) warn that a margin of 16-20% should be allowed for erroneous scoring alone, because of errors in the scorer's perception. similarly, thornton and raffin (1978), ostergard (1983) and green (1987) state that a single score obtained for a particular wordlist is only an indicator of a range of scores in which the true score is likely to lie. this inherent variability in speech audiometry diminishes its accuracy in all uses generally and the strength of the descriptive results of this study specifically. conclusions the similarities observed between the sae and ae speakers on their respective pre-recorded cid w22 wordlist recordings makes the current south african practice of using the tygerberg sae recording with the original american normative data a valid option for the speech discrimination assessment of sae speakers, under restricted conditions. the tygerberg cid w22 recording with the american normative data is most suitable for use at suprathreshold intensities (> 40 dbspl) where the fewest differences were observed. use at or near threshold (< 50 dbspl) however, where the most differences were observed, should be approached with caution and reliance on these wordlists for site of lesion purposes should be avoided. in view of the generally equivalent performance of the sae speakers within the tygerberg cid w22 full and half-lists (a high "test equivalency"), this recording's general test reliability and validity could be quickly and easily improved by replacing the american normative data with large south african normative data-bases. despite this study's findings, the over-riding need for a die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 wayne j. wilson and selvarani m o o d l e y sae specific speech discrimination test remains. whilst the t y g e r b e r g c i d w 2 2 w o r d l i s t s w i t h t h e a m e r i c a n normative data was shown to have some validity and reliability in sae speakers, significant limitations exist in its use, and the continued use of non-south african tests must be seen as an interim measure only. in view of similarities between the performance of sae and ae speakers on their respective cid w22 wordlists in this study, and similar findings in other wordlists (wipi and n u c h i p s ( m e h l , 1 9 9 2 ) a n d n a l a b w o r d l i s t s (wilson, jones and fridjhon, 1998)), there is now a small but growing body o f literature that can provide some of the groundwork needed to assist in the development of the long awaited sae specific speech discrimination test. r e f e r e n c e l i s t brandy, w.t. (1966). reliability of voice tests of speech discrimination. journal of speech and hearing research, 9: 461-465. brewer, c.c. & resnick, d.m. (1983). a review of tests of speech discrimination. seminars in hearing, 4: 205-220. carhart, r. (1965). problems in the measurement of speech discrimination. archives of otolaryngology, 82(9): 253-260. edgerton, b.j. & danhauer, j.l. (1979). clinical implications of speech discrimination lasting using nonsense stimuli. baltimore: university park press. fuller, h. (1987). equipment for speech audiometry and its calibration. in m. martin (ed.), speech audiometry. london: taylor and francis ltd. green, r. (1987). the uses and misuses of speech audiometry in rehabilitation. in m. martin (ed.), speech audiometry. london: taylor and francis ltd. hall, j.w. (1983). diagnostic applications of speech audiometry. seminars in hearing, 4: 179-204. hirsh, i.j., hallowell, d., silverman, s.r., reynolds, e.g., eldert, e. & benson, r.w. (1952). development of materials for speech audiometry. journal of speech and hearing disorders, 15:321337. kreul, e.j., bell, d.w. & nixon j.c. (1969). factors affecting speech discrimination test difficulty. journal of speech and hearing research, 12(2): 281-287. lehiste, i. & peterson, g.e. (1959). linguistic considerations in the study of speech intelligibility, journal of the acoustic society of america, 31: 280-286. lindman, h.r. (1974). analysis of variance in complex experimental design. san fransisco: w.h. freeman. lutman, m.e. (1987). speech tests in quiet and noise as a measure of auditory processing. in m. martin (ed.) speech audiometry (chapter 3). london: taylor & francis ltd. martin, f.n & forbis n.k. (1978). the present status of audiometric practice: a follow up study. asha, 20: 531-541. mendel, l.l. & danhauer, j.l. (1997). audiological evaluation and management and speech perception assessment. san diego: singular publishing group inc. northern, j.l. & hattler, k.w. (1974). evaluation of four speech discrimination test procedures on hearing impaired patients. journal of auditory research, (suppl): 1-37. ostergard, c.a. (1983). factors influencing the validity and reliability of speech audiometry seminars in hearing, 4: 221240. thorton, a.r. & raffin, m.j. (1978). speech discrimination scores modelled as a binomial variable. journal of speech and hearing research, 21(3): 507-518. wilson, w., jones, b. & fridhon, p. (1998). use of the nal-ab wordlists as a south african english specific speech discrimination test. south african journal of communication disorders, 45: 77-86. the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 3 future trends in language intervention: addressing cultural bias in service delivery* anne van kleeck professor program in communication sciences and disorders department of speech communication university of texas at austin austin, texas 78712 usa abstract in this paper the cultural biases in a widely-used language intervention approach the hanen early language parent program that trains parents to he conversational partners with their language-delayed children, are explored. in many respects this program represents tye best of current clinical practice. it is empirically and theoretically grounded in recent research on parent-child interaction; studies have documented its efficacy; and it is a family-centred approach. and yet, in clinical practice, it does not work with all families. not surprisingly, these families are often from nonmainstream backgrounds. potential reasons for the lack ofeffectiveness with some families become apparent as research on patterns of language socialization in a wide variety ofcultures is reviewed. this review reveals that all of the basic premises of this program rest on culturally relative beliφ and values. specifically considered are cultural variation in (1) aspects of social organization related to interaction, (2) the value of talk, (3) how status is handled in interaction, (4) beliefs about intentionality, and (5) belief about teaching language to children. suggestions for incorporating this information into clinical services with nonmainstream families are offered. opsomming die kulturele bevooroordeling van die "hanen early language parent program" word ondersoek. hierdie program is tans algemeen ingebruik en verteenwoordig die beste in huidige kliniese riglyne. dit is 'n taalopleidingsbenadering wat ouers oplei asgespreksgenote vir hul kinders met vertraagde taalverwerwing. die program is empiries en teoreties gebaseer op onlangse navorsing in ouer-kindinteraksie; verdere studies lewer bewys van die effektiwiteit van die program; en dit is 'n gesinsgesentreerde benadering. kliniesegebruik van die program dui egter daarop dat dit nie opgesinne buite die hoofctroomagtergrond, van toepassing isnie. potensiele redes vir diegebrek aan effektiwiteit met sekere gesinne word uitgelig, wanneer die patrone van taalsosialisasie van verskillende kulture nagegaan word. die gevolgtrekking word gemaak dat die basiese grondbeginsels van hierdie program op kultuur verwante waardes en beginsels berus. kulturele verskille bestaan, veral ten opsigte van (1) aspekte van sosiale organisasie wat verband hou met interaksie, (2) die waarde van gesprek, (3) bantering van status in inter aksie, (4) beginsels ten opsigte van intensionaliteit en (5) waardes aangaande taalopleiding vir kinders. voorstelle word gemaak vir die implimentering^van hierdie inligting in die dienslewering aan nie-hoofstroom gesinne. ι when i entered the field of communication disorders as an undergraduate in 1970, we called ourselves speech pathologists. we had no courses on children's language development or language disorders, indeed, language had not yet entered our realm. in the fall of 1973,1 entered a masters program at columbia university and there met lois bloom. lois had been a practising speech-pathologist for a number of years and was inspired to do doctoral work because her clinical experience had led her to the realization that there was more to children's communication disorders than their difficulties with speech. when i met her, she had just published her pioneering work, language development: form and function in emerging grammar (1970). other than some diary studies done by linguist * this paper was delivered as the sixth p. de v. pienaar memorial lecture held in the senate house, university ofwitwatersrand, on 20 july 1992. parents, it was one of the very first in depth, comprehensive studies of early language development. her work, along with that of psychologist roger brown (1973) among others, was to revolutionize the field of communication disorders by adding language to its purview. the national association of professionals in communication disorders in the united states was renamed in 1977 to reflect this change the american speech and hearing association became the american speechlanguage-hearing association. now, twenty years later, i sometimes find myself in absolute awe at how far we have come in our understanding of children's language development and language disorders. there are now dozens of journals and hundreds of books devoted, in part or full, to scholarship in this area. armed with the vast amount of knowledge spawned by twenty years of vigorous research and clinical practice, we are more effective than ever in assisting children who have difficulty in acquiring that most basic and die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 39, 1992 ® saslha r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 anne van kleeck essential of human capacities language. i like to remind myself from time to time of this rich and rewarding history, of how far we have come, and of how much better we are currently doing. i like to remind myself because it helps balance another feeling that frequently surfaces that of being overwhelmed. overwhelmed because, as we learn more, the task of pulling that knowledge together into a cohesive whole becomes increasingly daunting. and clinical practice that does not at least attempt to deal with the whole, is, in my opinion, completely missing the mark. i feel overwhelmed, too, because as we learn more, we simultaneously become aware of how much more we need to understand. the complexity seems to multiply exponentially. one is never allowed to rest, it seems, with knowledge hard-gained.new issues continually beg attention: and, because we care about providing the very best service delivery, we cannot ignore them. i'd like to focus my talk today on an issue, or rather, a complex set of issues, that began as an uncomfortable stirring for me about three years ago. it is only recently, however, that the faint rumblings of something being amiss in my thinking has worked its way into a more conscious awareness of what might lie at root. let me provide a little background. in 1989,1 was awarded a training grant by the united states department of education to prepare specialists to work with handicapped infants and toddlers and their families. these funds were made available to fill a need created by a federal law passed in 1986, public law 99-457 (now p.l. 101-476), which mandated that states put in place a plan to provide services to families with handicapped children from birth to three years of age. previous legislation (public law 94-142) had required services for children above three years of age. public law 99-457 further specified that services must be familycentered, meaning that families would not only be closely involved in all assessment and intervention, but that they would also determine priorities for their child's services. they would, in effect, be equal team members. to work effectively with families, a clinician must respect individual family structure and interaction patterns. to do so, the need for cultural sensitivity becomes glaringly apparent. as i have worked with my grant project director, ann thomas, in developing course work and in setting up an infant/ toddler assessment team in our university clinic, i have come to realize that implementing family-centered services may be difficult for deeper reasons than the mere fact that change is always difficult. for me, the process of implementing familycentered services has forced into consciousness some points at which the values of our mainstream culture, of our profession, and of family-centered services for nonmainstream families may be in conflict. if we are to take the next step in providing even more efficacious services, we need to grapple openly with these sources of conflict. resolving these conflicts will hopefully result in changes that not only acknowledge the complexity posed by cultural diversity, but begin to offer more concrete guidance for our thinking about language assessment and intervention with children from non-mainstream families. given the multicultural nature of both of our societies, this issue seems as relevant to south africa, in essence if not in details, as it is to the united states. the mainstream cultural values in the united states that are particularly relevant to the discussion at hand include (a) the high value placed on verbal/literate skills, (b) our democratic ideal of equal opportunity for all, beginning with equal access to education and extending to maximizing the potential for upward mobility of all citizens, and (c) the value placed on individual choice. as we translate these cultural values into professional values, we find (a) a high value placed on facilitating the very "best" verbal/literate skills possible in all children we serve, and (b) that our notion of "best" is determined by those skills we know will foster the best chances for academic success, and, by implication, for lifelong success. the introduction of family-centered services addresses the third cultural value of individual choice families should be able to choose not only the kind of services they prefer from all options available, they should also have the final word on the goals to be focussed upon and the procedures that should be used to facilitate reaching those goals. a current, widely used intervention program reflects these values directly. first of all, it rests on the basic premise that one should attempt to get children to be as communicative as possible. the adult-child interaction patterns determined in research to best foster children's communicative attempts and subsequent language development provide the basis of the program. and finally, it is family-centered in that the interaction patterns are directly taught to the language delayed child's parents. the program, the hanen early language parent program, was developed by ayala manolson in toronto, canada (l 985). i'd like to focus on the hanen program to illustrate the pressing need for speech-language pathologists to become aware of the cultural biases it entails. this is not done to denigrate this program we have used it fruitfully in our clinic for years. the program is focussed on exactly because it does, in my mind, represent the best of current clinical practice. a careful analysis of the program's underlying cultural biases, however, uncovers dramatically the need for far more cultural sensitivity in our clinical practice than is presently the norm. the hanen early language parent program is based largely on the clinical work of jim macdonald, who in turn has grounded his ideas in an ever-growing body of basic research on adult-child interaction (e.g., macdonald, 1989). this program works directly with the parents (both mother and father whenever possible) to foster the interaction patterns within the family that will promote communication development. it is aimed at parents of children who are either preverbal or at the earliest stages of verbal development. several sets of parents are brought together in weekly three-hour meetings for eight to ten weeks. program objectives are taught via workbooks, lectures, demonstrations, training videotapes, videotapes of the parents in the group interacting with their own children, group discussion, role playing and homework assignments. to make the current videotapes, all parents enrolled in the program are videotaped at home interacting with their own children at three different junctures once before, once during and once after the program so that specific implementation can be discussed. the interaction strategies are based upon those that research has found ( l ) to best promote language development, and (2) to be lacking or infrequent in the interaction of parents with their language delayed children. the strategies are focussed one at a time, and include, sequentially, observing your child (to accurately assess the child's current communication level), following your child's lead (including talking at his or her level), responding supportively to the child's attempts at communication, fostering the child's turn-taking skills, prompting the child to a higher level of communicative performance, and designing play activities to provide communication opportunities (see girolometto, greenberg, & manolson, 1986, for further program description and a summary of supporting research). when i was first trained in this program by ayala manolson several years ago, i felt that the field of speech-language pathology was finally beginning to implement practices that took into account far more of the complex puzzle of factors that are involved in a child's language development. this direct work the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) futuretrends in language intervention with parents on the interactional foundation for language development was a far cry from the behavior modification programs that permeated the field in the 1970's, when clinician's were busy "flipping pictures and pitching tokens" (constable, 1986, p. 211) in pursuit of that elusive "is verb-ing" form. it also moved us beyond the subsequent application of the semantic and pragmatic revolutions when we were attempting to create meaningful contexts in our therapy rooms, but were not yet fully acknowledging that children are a part of a family system. hanen, and programs like it, have provided a much needed family-centered option for facilitating language development. a systematic clinical tool, it fosters parent-child interaction patterns that encourage children's communicative behavior and, consequently, their communicative development. the hanen program is well grounded both theoretically and empirically, and is often very effective. however, in our clinical experience, it does not work with all families. not surprisingly, these families are often from minority cultures. why doesn't it work? perhaps because many nonmainstream cultural values and beliefs that impact interaction patterns are at odds with those the hanen program attempts to foster. indeed, the empirical and subsequent theoretical underpinnings of the hanen program are based in large part on north american psycholinguistic research that has focussed almost exclusively on the white middle class. this fact is often unmentioned in these studies, a phenomenon ochs andschieffelin (1984) refer to as "the invisible" culture of child language studies. because the cultural biases of these studies have remained largely implicit, we have often assumed they illuminate natural rather than cultural behaviors (ochs & schieffelin, 1984, p. 284). in the following discussion, patterns of language socialization in a wide variety of cultures will be explored.in particular, i will consider cultural relativity regarding ( l ) aspects of social organization related to interaction, (2) the value of talk, (3) how status is handled in interaction, (4) beliefs about intentionality, and (5) beliefs about teaching language to children. as will be seen in this discussion, all of the basic premises of the hanen program rest on culturally relative social organization, beliefs, and values. ι social organization issues related to interaction the hanen program makes two basic asssumptions about social organization that impact on both how and with whom interaction with young children occurs. the first assumption is about caregiving, which impacts "who talks to small children, in what contexts, and about what topics" (schieffelin & eisenberg, 1984, p. 387). the hanen program is a parentprogram. it assumes that the young child's parents are the primary caregivers. however, caregiving arrangements vary in different cultures. in many cultures, siblings are the primary caregiver, particularly after the baby to be cared for has become mobile. this is true, for example, among the western samoans (ochs, 1982), the kikuyu of eastern africa (leiderman & leiderman, 1974), the gusii of kenya (levine & levine, 1966). it is also common in many american subcultures, including hawaiian, native american, black, and mexicanamerican and other hispanic communities (werner, 1984). the hanen program focus on parent interaction skills would clearly be of less value in such cultures. a second assumption of the hanen program related to social organization has to do with turn-taking. the hanen program assumes that interaction with young children will be primarily dyadic, a predominant pattern in mainstream western culture. however,, multiparty interaction dominates in die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 39, 5 many cultures for example, with the basotho (demuth, 1986), the kaluli (schieffelin, 1979), the samoans (ochs, 1982), and mexican-americans (briggs, 1984; eisenberg, 1982). value of talk let's consider the basic cultural value that undoubtedly accounts for the very existence of speech-language pathology the value of talk. to consider different cultural perspectives on the value of talk, i'd like to look at (1) the amount of talk that is valued, (2) the role of talk in teaching in general, (3) the relative value of verbal skills compared to other types of skills, and (4) the role of verbal skills in children's display of knowledge. 1 amount of talk. regarding amount of talk, a fairly high degree of verbosity in children is valued in our mainstream culture. indeed, an entire line of social science research views reticence as a social deficiency (see daly & mccroskey, 1984), and points out the negative perceptions held in our culture toward reticent children and adults alike. for example, as compared to their more talkative peers, reticent children are viewed by their teachers as significantly less likely to do well in all academic areas and less likely to have positive relationships with other students (mccroskey & daly, 1976). indeed, quietness in the classroom may lead to a speech-language pathology referral. crago (1990b) reports of a principal who was asked to compile a list of children who had speech and language problems. of the 90 children in her school, she listed 30 names and next to several of them noted, "does not talk in class" (p. 79). because mainstream adults value children's talk, they work to elicit it during interactions with children. this mainstream value is sometimes held in other cultures as well. bambi schieffelin studied a traditional nonliterate people in papua new guinea, the kaluli, and found that adults in that society also believed it important to elicit speech from children (schieffelin & eisenberg, 1984). the basotho also highly regard children's ability to interact with others. "indeed, teaching one's child how to talk is seen as one of the major responsibilities of mothers, other caregivers, and the community at large" (demuth, 1986, p. 54). a sesotho proverb loosely translated as "a quiet person will perish" captures the importance of verbal ability in this society (demuth, 1986). such a view is clearly not universal, however. in the working class black community studied by heath (1983), the adults did not ask children questions in order to keep the conversation going, nor did they consider children to be appropriate conversational partners. ward (1971) describes her early attempts at data collection in another black community in rural louisiana. "for the first two months of this project attempts to elicit spontaneous speech from the children met with defeat, with or without the tape recorder. the readiness to show off, the constant flow of speech, the mother-child interaction so common in middle-class children were nowhere in evidence. the children appeared to speak as little to their parents as to the investigator. one twenty-eight month male spoke three words in as many months" ( p. 15). quite to the contrary of our mainstream pattern of socializing children to interact with adults, many cultures value quietness in children. many groups believe that children should speak only when spoken to, such as the kipsingis (harkness, 1977) and luo (blount, 1972; 1977) of kenya, western samoans (ochs, 1982), and the tamil of malaysia (williamson, 1979). and this is true not only in nonindustrialized or third world cultures but in many north american sub-cultures that have been studied as well, such as rural louisiana blacks (ward, 1971) and many american indian groups (crago, 1990b; dumont, 1972; john, 1972; 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 anne van kleeck scollon & scollon, 1981). furthermore, children in many groups are often socialised to a generalised attitude regarding the value of silence. for example, the japanese (clancy, 1986; fischer, 1970) and other asian/pacific groups (see cheng, 1989, for a summary), who have immigrated to the united states in vast numbers in the past decade, often view a quiet child as a good child. this value is also held by the evergrowing chicano population in the united states, as well (coles, 19 77). in many native american cultures, children are taught to be silent in the presence of an adult, especially an unfamiliar adult (blanchard, 1983). indeed, navajo mothers view loquaciousness in a child as discourteous, self-centered, and undisciplined (freedman, 1979). the extreme variation in the value of talk even within the american culture is dramatically illustrated in a study conducted by birdwhistell (1974). he compared the median amount of talk per day in philadelphia jewish homes and in pennsylvania dutch homes (an agricultural group that has eschewed modern technology). the jewish families talked between six and twelve hours a day; the pennsylvania dutch, for two and one half minutes! from a rather different perspective, the scollons provide an example of the extreme differences in cultural expectations regarding children's talk. among the northern canadian athabaskans they studied, "children who do not begin to speak until five years of age or older are interpreted as growing up respectfully, not as being language-delayed'" (scollon & scollon, 1981, p. 134). indeed, our profession's very definition of a learning disability is stood upon its head in the comment made by an inuit teacher in martha crago's study. one of crago's research subjects was a very verbal little boy, whom she considered to be very bright. crago described this child to an inuit teacher and asked her reaction. the teacher said, "do you think he might have a learning problem? some of these children who do not have such high intelligence have trouble stopping themselves. they don't know when to stop talking" (crago, 1990b, p. 80). of course, social values associated with the talkative-reticence continuum are not as clear cut as this discussion might imply. the scollons (1981) discuss how the degree of volubility and degree of intimacy are related in an opposite fashion in north american mainstream and native athabaskan cultures. for mainstream speakers, they suggest, volubility is associated with social distance and taciturnity is acceptable in intimate relationships (that talk is not needed may indeed be a sign of intimacy). for the athabaskans, the opposite is true. they can be very talkative when they know each other well, but are quite reticent with people they have just met. 2 how teaching is accomplished. because our mainstream culture values talk, teaching is often accomplished with a great deal of talk. heath (1989) describes how mainstream adults engage in frequent verbal explanation with children. they intervene in a task being taught to offer step-by-step explanations, and children are afterwards often asked to recount the task verbally. such a teaching style is typical of what hall (1976) refers to as "low-context cultures". in contrast, "highcontext" cultures rely much more heavily on the physical context, and hence nonverbal contextual cues, to convey information. learning is accomplished primarily by observation; teaching by demonstration. westby and rouse (1985) note that hispanic and native american groups in the united states operate much more as high-context cultures in comparison to the anglo mainstream culture. children in lowcontext cultures are encouraged to ask questions; those in more high-context cultures are not. in specific studies, ward found that children's information-seeking questions were ignored among the rural louisiana blacks she studied (1971), and the inuit children studied by crago were also discouraged from asking questions (1990). 3 skills valued. heath (1989) ties a tendency to teach by demonstration with "societies that marshal children's efforts toward spatial, kinesthetic, musical, and interpersonal competence as prior or at least of equal merit with linguistic competence" (p. 342). so, once again, verbal skills are not always valued above all else, as they often seem to be in our mainstream culture. 4 display of knowledge. a final aspect of the value of talk within a given culture has to do with how knowledge is displayed, and by whom. scollon and scollon (1981) discuss the dimensions of spectatorship/exhibitionism in relation to dominant and subordinate roles. they explain how in our mainstream culture, the dominant person is the spectator and the subordinate person the exhibitionist. as such, the notion of display of knowledge is related to how status is handled in a culture, a topic i will discuss in the next section. in other cultures, such as the athabaskans the scollons studied, the dominant person is the exhibitionist rather than the spectator. in our mainstream culture, adults often elicit verbal displays of knowledge from their children. they often do this by asking children questions to which they, the adults, already have the answers. the children are nonetheless expected to perform their "exhibitionist" role and respond to these known-information or, as they are sometimes called, "test" questions. this verbal display of knowledge figures predominantly in the school setting as well. in many other cultures, requesting children's verbal display of knowledge is either not used or is used for different purposes. heath (1983) found that the adults in the black working class community she studied only rarely asked known information questions. when they did, the purpose was to chastise the child. heath (1989) summarizes several unpublished studies of mexicanamerican showing that adults refrain from asking children known-information questions, except in teasing exchanges. other groups not prone to using test questions in interaction with their children include the inuit studied by crago (1990b) and the rural louisiana blacks studied by ward (1971). ward, in fact notes, "such children are not expected to exhibit any range of manners, skills, or special knowledge" (p. 53). in these various nonmainstream cultures, children are expected to be spectators and learn by observation. how status is handled in interactions i in the hanen program we ask parents to respond to all [the child's attempts to initiate interaction, to follow the child's lead to facilitate conversation, to use simple language and to expand the child's communicative attempts so that the child will have the opportunity to learn from responses, and to iise questions to confirm or clarify. each of these suggestions rests upon underlying assumptions assumptions not always shared by other cultural groups. let's consider them by looking at how various cultures deal with (1) who initiates adultchild interaction, (2) who directs adult-child interaction, (3) who adapts to whom, and (4) who carries the burden of understanding. 1 who initiates adult-child interaction. in mainstream culture, while adults are certainly allowed to initiate interaction with children, children are also encouraged to initiate interaction with adults. we witness this primarily by observing how responsive adults are to children's initiations, intentional or otherwise. indeed, researchers have written entire articles on the positive impact of caregiver contingent social responsiveness to infants on their children's subsequent the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) futuretrends in language intervention 7 subsequent acquisition of communicative competence (e.g., dunst, lowe, & bartholomew, 1989-90; goldberg, 1977). but once again, this is clearly not a universal phenomenon. the rural blacks studied by ward (1971) paid more attention to a child when the child was not talking than when she or he was. in the black community studied by heath (1983), the adults did not tend to ask many questions in order to keep an interaction going with a child. indeed, these minority cultures and others, such as mexican-americans (discussed by heath, 1989), do not believe that a child should initiate a conversation with an adult. some cultures, such as the japanese, will even anticipate a child's needs in order to foster passivity (caudill & weinstein, 1969). 2 who directs the interaction. it is often the case that the person who initiates an interaction also directs it. schegloff (1972), for example, found that the person who speaks first in a conversation also tends to control the topic. likewise, in mainstream parent-child interaction, the parent follows the child's lead. in other words, the adult talks about what the child is doing or saying. snow refers to this as semantic contingency, and reviews numerous studies providing evidence that this interaction strategy facilitates language acquisition (1979,1981). the temporal characteristics of contingent responses are also important, as has been demonstrated in work with mother-infant dyads. numerous studies have found that most maternal responses to infant vocalizations occur within one second (beebe, jaffe, feldstein, mays, & alson, 1985; schaffer,collis&parsons, 1977;stella-prorok, 1983)andthat response delays of longer than one second interfere with the infant's perception of contingent relationships (millar, 1972; millar & watson, 1979;ramey&ourth, 1971; todd & palmer, 1968). temporal delays in adults' responses have also been found to completely disrupt conversations with 2-year-olds, because the children stopped responding (stella-prorok, 1983). obviously, both semantic contingency and such a quick response requires careful attention to the infant by the adult.1 other cultures do not allow children to direct topics (e.g., rural louisiana blacks studied by ward, 1971), and may believe it is the adult's role to issue directives and the child's role to obey them (louisiana blacks, the inuits studied by crago, 1990b). in many societies, 'parent-child interaction is not characterized by adult semantic contingency. this is true of the westehi samoans (ochs] & schieffelin, 1984), the kaluli (schieffelin & eisenberg, 1984); the gusii of kenya (levine, 1977), and rural louisiana and carolina blacks in the united states (heath, 1983; ward, 1971). 3 who adapts to whom: assuming the perspective of the child in making semantically, contingent responses is one way in which mainstream parents make rather extensive accommodations to the child. such accommodations are in part determined by how status is handled in a culture. in our mainstream culture, persons of higher status are expected to adapt to those of lower status hence, adults adapt to children. as ochs and schieffelin (1984) note, it is a pattern that extends beyond adult-child interactions and is also observed in widespread material accommodations, such as baby clothes and 1 the scallons (1981) discuss one instance of timing differences in interaction that between the athabaskans they studied and north american mainstream culture. the pause time between turns in conversation is slightly longer for athabaskans, although perhaps only a half second longer. the impact on interaction between these two groups, however, is dramatic. the mainstream speakers give adequate pauses for the other to take a turn within their own culture, but it is not long enough for the athabaskan culture. hence, the mainstream speakers do all the talking and the athabaskan never gets a chance. food, and miniaturization of furniture and toys. additional common behavioral accommodations include "baby-proofing" a home, and putting the baby in a quiet place to facilitate sleep. these scholars suggest that "these accommodations reflect a discomfort with the competence differential between adult and child" (p. 287). in interaction, one way that this competence gap is reduced is for the adult to simplify his or her speech to better match the lesser verbal competence of the child. this simplified speech is known by many names "motherese" (newport, gleitman, & gleitman, 1977), "baby talk register" (e.g., brown, 1977), and "child-directed talk (cdt)" (van kleeck & carpenter, 1980) or "child-directed speech (cds)" (snow, 1986). this simplified, reduced, redundant, acoustically distinct input to young children has been extremely well-documented in a variety of middle-class industrialized cultures (see snow, 1986, for a review that relates this simplified register to language acquisition). fischer (1970) notes that the japanese parents seem even more disposed to these speech simplifications than mainstream americans. but such modifications are not solely found in modern, industrialized societies. they have been found to characterize parent-child interactions among the kipsingis in kenya (harkness, 1977) and the kwara'ae of the solomon islands (watson-gegeo & gegeo, 1986a & b). in other cultures, persons of lower status are expected to adapt to those of higher status. this particular cultural value may be manifested in interactions with infants and young children by a lack of child-directed talk simplifications on the part of adults. this is the case with the western samoans studied by ochs (1982). heath also found a lack of such adult adaptation in the working-class black community she studied (heath, 1983). it is not simply the case that cdt modifications are either present or absent in most cultures. schieffelin and ochs (1986) discuss how there is a continuum'of accommodation both across and within cultures. within cultures, variability in the existence or degree of cdt modifications may occur as a function of who is talking to the child, the reason for the interaction, the setting, and the development level of the child. in mainstream american culture, some studies have documented that fathers and siblings do not simplify their talk to babies as much as mothers do (e.g., andersen & kekelis, 1986; bellinger & gleason, 1982;gleason&greif; 1983;mannle&tomasello, 1987). a study by gollinkoff and ames (1979), however, found that fathers did adjust their speech as much as mothers, although they produced half as many utterances and took fewer turns in a free play situation. in japan, mothers simplify far more in private than they do in public (clancy, 1986). the basotho use such modifications when their intent is to amuse or pacify the infant or young child, but they do not use them when talking seriously or reprimanding (demuth, 1986). the luo make no such modifications from birth until about 9 months of age, then make them extensively until the baby's first word at about 14 months. after 14 months, they are used to get attention, but not after attention has been gained (blount 1972). 4 who carries the burden of understanding. lacking an adult facility with the linguistic system, children are frequently difficult to understand. as with other accommodations, mainstream adults have strategies to attempt to deal with an unintelligible or partially intelligible child. they may ask clarification questions (e.g., sachs, 1983) or they may expand the child's utterances. brown (1977) suggests that expansions are communication checks that in effect ask the child, "is this what you mean by what you just said?" (p. 13). wells (1982) offers a different interpretation of expansions. wells found die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 39,1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 anne van kleeck that expansions in mother-child interaction were contextually determined. they rarely occurred when the dyad was alone, but were frequent when the mother-child dyad was in a group. the expansions seemed to serve as a way of explaining to others outside the mother-child dyad what the child might be intending to say. in either case, it is clearly the adult who carries the burden for making the child understood. ochs and schieffelin (1984) explain how status is handled differently among the western samoans. here persons of lesser status have the responsibility for making themselves clear. as such, adults do not expand children's utterances. a lack of expansions in adults' speech to children has been found in other cultures, as well, including the rural louisiana blacks studied by ward (1971) and the kipsingis of kenya studied by harkness (1977). interestingly, while mothers in ward's study did not imitate or expand the speech of their children, they did repeat and expand their own speech. beliefs about intentionality some components of the hanen program rest on cultural assumptions about intentionality. parents in the program are asked to freely interpret a child's intended meanings and provide labels for preverbal children and expansions for children in the early stages of language development. let's look at the assumptions underlying these suggestions regarding (1) other intentions and (2) when intentionality begins. 1 others intentions. many behaviors characteristic of mother-child interaction in american mainstream culture make it appear that adults in our culture believe that one person can interpret another's intentions. mothers often interpret internal states of infants as they engage in "conversation" with them (e.g., snow, 1977). with older children, nonconventional forms are often accepted as words, and mothers often provide the label they believe the child is intending to produce. indeed, this occurs with many unintelligible or partially intelligible utterances (ochs, 1982). not all cultures however, believe that one can know what another thinks or feels. ochs and schieffelin (1984) discuss this as underlying the lack of adult interpretation or expansions of children's communicative attempts among the kaluli. it is interesting to note that this same adult behavior, a lack of expansions, can stem from two quite different sources. recall that the samoans, also discussed by ochs and schieffelin, did not expand children's utterances for status reasons. 2 when intentionality begins. cultures also vary regarding when they begin treating children as intentional. in our mainstream culture, we treat children as intentional from birth. this is done by engaging the infant in "conversational dialogue", often by interpreting prelinguistic behaviors (e.g., lock, 1981; ryan, 1974; shorter, 1978). such social "conversations" are common from birth among the kwara'ae as well. however, they are clearly not universal. among the northern new mexico hispanics studied by briggs (1984), a child is not treated as intentional until she or he is one year of age. a similar type of pattern among mexican-american families in california was noted by eisenberg (1982). in western samoa, sibling caregivers begin treating babies as intentional once the baby is mobile (ochs, 1988). neither the kaluli of papua new guinea (ochs & schieffelin, 1984), the luo (blount, 1972), nor american blacks studied by heath (1983) direct much input to prelinguistic babies. navajo mothers are silent with their infants (freedman, 1979). language teaching beliefs the hanen program clearly espouses engaging young prelinguistic and beginning language users in a conversation-like exchange which is structured so that the child can be an "equal" participant. the goal is to get children to communicate as frequently as possible, but directive techniques for eliciting language are strongly discouraged.fostering equal participation in a conversation as a method of facilitating language acquisition is also a culturally determined phenomenon. in addition to conversation, other culturally sanctioned methods of facilitating language acquisition include direct teaching by eliciting imitations from children and a "look and listen" approach in which children are expected to learn by observation. direct teaching. the use of direct teaching as a general method of facilitating language acquisition is actually a fairly widespread phenomenon, found both in american minority cultures and a variety of other cultures. it is also not entirely unheard of in american mainstream culture. for example, this method is used to train young children to use politeness routines such as "please" and "thank you", general greetings such as "hello, how are you?" and "i'm fine", and holiday routines, such as "trick or treat" (gleason & weintraub, 1977). snow (1977) noted that adults began to expect children not only to respond, but to make appropriate responses by the time the children were 18 months old. appropriate responses were elicited by the mothers via direct instruction in three contexts soliciting the names of people, correcting mislabelings, and eliciting polite forms. indeed, politeness prompts have been found in other american cultures, including the working-class americans in south baltimore (miller, 1982) and mexicanamericans in california (eisenberg, 1982). in mainstream culture, direct teaching is mainly restricted to politeness routines. in many other cultures, it is used far more frequently. the literature abounds with examples of groups found to rely heavily on direct teaching devices to socialize children into the language of their culture. of non-american cultures, direct teaching has been reported of the kaluli after the child produces his or her first word (schieffelin & eisenberg, 1984), the samoans (ochs, 1982), for sons at about 4 years of age among the kugu-nganychara, an australian aboriginal tribe (von stunner, 1980), the kwara'ae (watson-gegeo & gegeo, 1986a & b), the wolof of senegal (wills, 19 77), and the wogeo of new guinea (hogbin, 1946). demuth (1986) reports on the very prominent use of direct teaching prompts to young children among the basotho. in america, direct teaching was found to be used extensively by the working class families in south baltimore studied by peggy miller (1982). it was also reported to be a device used among the northern new mexico1 hispanics studied by briggs (1984) once children reached about 14 months of age and mexican immigrant families in california studied by eisenberg (1982). eisenberg (1990) suggests that prompting routines, in which the caregiver tells the child what to say to someone else, are most common when conversations are multiparty. while this is true for the kaluli, kwara'ae, and mexican-americans studied, in miller's study of working-class families in south baltimore, interactions were mostly dyadic. as widespread as this practice of encouraging children to imitate language is, there are some cultures in which the imitation of others' speech is actively discouraged, as in italy (ervin-tripp & mitchell-kernan, 1977). interestingly, although the hanen program explicitly discourages parents .from using direct prompts to get children to talk, they strongly recommend that parents imitate their children, both verbally and nonverbally. research has documented that the amount that a child imitates is correlated with the amount of imitating his or her parent does. that is, highly imitative parents have highly imitative, more linguistically advanced children (folger & chapman, 1978; masur, 1989; the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) futuretrends in language intervention 9 snow, 1989). these findings are presaged by fortes study of the tallensi in ghana (1938), who noted that adults frequently imitated the babblings of children and expected the children to repeat in return. blount (1972) noted that mutual imitation was characteristic of luo parent-child interaction when the children were between 9 and 14 months old. so, while not advocating direct teaching, the hanen program accomplishes basically the same thing indirectly by asking parents to imitate their children. it gets children to imitate. observation. a number of cultures believe that language, as with other skills, is acquired by observation. as such, the ability to learn language is not tied to any overt production of speech. this has been reported of the inuit in northern canada studied by crago (1990b), the rural louisiana blacks studied by ward (1971), and the athabaskans studied by the scollons (1981). multiple approaches. while some cultures may exhibit a strong tendency to emphasize one of the foregoing methods of teaching language to children, the kwara'ae seem to believe that the best and fastest way to teach children language is multifaceted. in their culture we witness, first of all, lots of talk to children: talk that contains many simplifications. the kwara'ae encourage child initiations. they also use routines and direct teaching to facilitate language development. language socialization research: implications for slps using the hanen program rees and gerber (1992) provide an apt conclusion to the foregoing discussion of how cultural beliefs and values shape interaction in the opening sentence of their recent article. "for practitioners whose fascination with language has led them to language disorders as a field of study and a professional commitment, language in use has turned out to be of bottomless complexity and, yet, of central importance" (p.15). of central importance, indeed! the task before us now is to apply this growing body of information in a manner that makes our clinical interventions ever more effective. several ways in which we might begin to do so are 'offered below. \ become aware of our• own cultural biases. first and foremost, professionals must begin to consciously recognize their own "invisible culturej' (crago, 1992) and hence their own cultural biases. cheng (|1989) states that "it is of utmost importance that service providers make a critical examination of their world view, values, beliefs, way of life, communication style, learning style, cognitive study, and personal life history" (pp. 7-8). rice (1986) provides the concrete example of tolerance for dirt. while this may on the surface seem irrelevant to implementing the hanen program, one of my graduate classes had a long discussion about how they felt about visiting a family who had very different cleanliness standards from their own. as a visiting clinician recounted her uncontrollable squeal in reaction to a rat on the floor in one home, one student openly admitted that she simply could not tolerate such a situation. obviously there are many, many more biases we unconsciously harbor that could potentially interfere with our effective service delivery as professionals. uncovering them is not a simple task. just as children are socialized into a given culture, professionals are likewise socialized into a professional culture. and in many ways, asking professionals to become self-aware is in itself a cultural violation, since it has clearly not been a part of their professional socialization. "what is missing, or else minimally encountered, in both graduate programs and staff development training is a focus upon the person who is the helper" (krill, 1990, p. 12). and yet, the need for selfawareness among professionals has become glaringly apparent to me as we have begun working with families of handicapped infants and toddlers. 2 become cross-cultural communicators. much of the research i have reviewed poignantly points out the very different ways in which interaction may be structured and interpreted, even among people who speak the same language. to be effective, clinicians clearly need to be aware of these potential differences. in massively polyglot societies such as the united states, it is clearly unreasonable to expect clinicians and educators to be fluent in vast numbers of languages. in working with families who speak different languages from ourselves, knowledge about other cultural communication patterns would help by at least attenuating potential cultural barriers to communication. 3 -learn about each family's communication patterns. a danger inherent in the type of review provided here is that it can rather ironically lead to stereotyping members of various cultural groups. ochs (1986) reminds us that "cross-cultural differences turn out to be differences in context and/or frequency of occurrence" (p. 10). furthermore, the caveat to remember that cultural trends do not ever define all members of a culture are voiced over and over again in the literature. we are asked to pay heed to the fact that no culture is a monolith (schieffelin & ochs, 1986b); that "variation exists in communities, families, and individuals" (crago, 1992, p. 30); that there is "tremendous individual variation within each group" (miller, 1982, p. 14); "that what may appear to the outsider as one cultural group (e.g., asians) with one set of practices may, in fact, have numerous subgroups with substantially different belief systems, political and economic histories, and cultural patterns of communication" (crago & cole, 1991, p. 111). perhaps this warning is best summed up by rice who says, "each child's family constitutes a cultural entity" (1986, p. 267). how do we go about ascertaining the structure of communication within any particular family? westby (1990) offers many suggestions on ethnographic interviewing as one technique. obviously, observing the family interacting is also invaluable (e.g., andrews & andrews, 1990). 4 culturally situate the notion of a disorder or delay. saville-troike notes that "any study of language pathologies outside one's own speech community must include culturespecific information on what is considered 'normal' and 'aberrant' performance with the other group" (1982, p. 9). for example, matsuda (1989) discusses how in most asian cultures, only physical disabilities are considered to be disabilities. in this case, a serious delay in other domains of development may be denied, and the sensitive clinician would need to be aware of such a tendency to deal with families holding such beliefs. from a quite different perspective, there may sometimes be a tendency to see a disorder where none in fact exists if the communication patterns of the culture are taken into account. we might, for example, diagnose as languagedelayed a reticent native american or asian-american child (crago & cole, 1991). however, here we must be extremely careful not to go to the opposite extreme and "conclude that there is no disorder when one indeed exists" (harris, 1985, p. 43). 5 make instruction culturally congruent. andrews and andrews (1990) suggest that intervention with families will be efficacious only if they are fitted to current family structure. supporting, if somewhat tangential, research can be found in school studies. when school instruction is made culturally congruent, children from minority cultures are shown to be die suid-afrikaanse tydskrif vir kommunikasieafwykins, vol. 39,1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 anne van kleeck competent learners and communicators (e.g., erickson & mohatt, 1982; heath, 1982; hu-pei au, 1980; kawakami & hu-pei au, 1986; vogt, jordan & tharp, 1987). and, the reverse is also true penalization results from discontinuities between home and school cultures (e.g., boggs, 1985; durnate & ochs, 1988; erickson, 1987; heath, 1983; philips, 1983; tharp et al., 1984). 6 offer parents option to learn code-switching. schools are institutions that reflect and reinforce values and beliefs of the mainstream culture. we know that mainstream interaction patterns best prepare children for the school environment, and best ensure their continued academic success (see heath, 1983, for example). while we should certainly begin our interventions by gearing them to current family structure, we would likely be trying to move the family in a clearly specified direction toward mainstream patterns of interaction. a failure to do so might diminish the nonmainstream child's chances for academic success an outcome that would clearly violate our own basic equal opportunity cultural value. how can we reconcile this dilemma? we want on the one hand to respect the family as it is. that entails accepting all of their values and beliefs, including those that impact upon communication patterns. and yet, the child's chances for success are also of paramount importance to us. our only choice, it seems to me, is to discuss this matter with parents in an open and honest manner. it would then be their choice, not ours, regarding whether or not they wished to pursue a parent training such as that offered by the hanen program. the goals of the program, including its cultural biases, would then be explicitly chosen or eschewed by the family rather than unconsciously imposed by the professional. if our mainstream patterns of interaction with young children are simply too much at odds with the values of the family we are serving, we might alternatively suggest that mainstream interaction patterns be taught and practised in a very constrained context. the final decision on whether or not they wish to become bi-cultural, however, must rest with the family and must also be genuinely supported by the clinician. 7 have clinician act as language socializer. there may be instances where the family is unwilling or perhaps unable to socialize their own child in a manner that will facilitate success in our mainstream culture. a program such as hanen would obviously be an inappropriate intervention for them. in such cases, however, the clinician could offer the option of serving as a representative of the dominant culture. as such, the clinician would work directly with the child to foster the child's ability to code-switch from nonmainstream to mainstream patterns of interaction (rice, 1986). crago (1992), however, suggests that the code-switching option would work more successfully when children's metalinguistic skills are better developed, which generally occurs in the middle childhood years. crago's caution seems relevant if the clinician were to teach such code-switching to the child as a consciously implemented set of rules. it seems entirely possible, however, to foster code-switching skills in much younger children if conscious approaches are not employed. as such, the clinician could use a mainstream pattern of interaction with the child, who would gradually internalize this new interactional system, even though it differed from patterns of interaction with her or his parents. 8 inform teachers about their children's culturally determined patterns of interaction. as the classroom collaborative model of service delivery continues to gain in popularity in the united states, the opportunities for slps to impact a child's communicative experiences in the classroom increase exponentially. clearly, children will benefit if teachers are made aware of the culturally determined differences in their interaction patterns. this is an obvious role the slp can serve. conclusion as westby (1990) noted, "traditional educational and therapeutic intervention models have not been effective with minority populations" (p. 110). and yet, in the next decade, as much as one-third of the caseload of audiologists and slps in the united states will be children from black, hispanic, and native american cultures (cole, 1989; crago, 1990a; shewan, 1988). if our services are to be effective, we must find ways to make them more culturally sensitive. the foregoing discussion of the hanen early language parent program offers but one example of the kinds of cultural biases to be found in even the very best of current clinical interventions. just as we have much to leam from research on language socialization in nonmainstream cultures, so toocan we learn from the nonmainstream families we serve. to quote the mexican novelist carlos fuentes from his recent cultural history of spain and latin america: people and their cultures perish in isolation, but they are born and reborn in contact with other men and women, with men and women of another culture, another creed, another race. if we do not recognize our humanity in others, we shall not recognize it in ourselves. from the buried mirror by carlos fuentes (1992) references anderson, e. &kekelis, l. 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(1977). culture's cradle: social, structural, and interactional aspects of senegalese socialization. unpublished doctoral dissertation, university of texas at austin. the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 49 geskrewe en gesproke afrikaanse sintaktiese vermoens van hardhorende kinders enid slabber, b(log] (pretoria] rene hugo, d.phil (pretoria) brenda louw, d.phil (pretoria) departement spraakheelkunde en oudiologie, universiteit van pretoria opsomming die doel van hierdie ondersoek is om 'n moontlike verband tussen ekspressiewe geskrewe en gesproke sintaktiese vermoens van gehoorgestremdes te ondersoek. vyf afrikaanssprekende gehoorgestremde proefpersone is gebruik. in die evaluering van sintaktiese vermoens is daar gekyk na die gebruik van 7 sinstrukture asook na woordvolgorde. uit die resultate blyk dit dat meer komplekse sinstrukture tydens die proefpersone se gesproke as geskrewe taal voorgekom het. die persentasie korrekte sinstrukture wat gebruik is, is egter groter in geskrewe as in gesproke taal, alhoewel die persentasie nogtans betreklik laag is. meer woordvolgordefoute is tydens geskrewe as gesproke taal gemaak. in die gebruik van die geevalueerde sinstrukture het daar egter meer woordvolgordefoute in gesproke as geskrewe taal voorgekom. die gevolgtrekking is bereik dat daar wel 'n verband tussen die gehoorgestremde proefpersone se geskrewe en gesproke sintaktiese taalvermoens is, maar heelwat verskille het ook voorgekom. navorsing op hierdie gebied le egter nog braak, en die huidige studie kan as vertrekpunt dien vir verdere navorsing. abstract' the aim of this research report is to examine the relationship between the expressive written and spoken syntactic abilities of hearingimpaired children. 5 afrikaans speaking hearing-impaired subjects were used. in the evaluation of syntactic abilities, 7 syntactical structures as well as word order, were evaluated. from the results obtained, it appeared that more complex sentence structures were used in spoken than in written language. the percentage structures used correctly, was higher in written than in spoken language, although the percentage was relatively low. more errors of word order occurred in written than in spoken language, but subjects evidenced more word order errors in spoken than in written language, when using more complex sentences. the conclusion is made that a relationship between written and spoken syntactic abilities of hearing-impaired subjects does exist, but differences were abo evidenced. the study can be used as a "starting point" for further research. vir normale taalverwerwing 1. inleiding normale gehoor is essensieel en gevolglik vertoon gehoorgestremde kinders deurgaans taalprobleme (reseptief en ekspressief) wat op verskillende taalvlakke en in verskillende grade manifesteer en hulle kommunikasievermoens nadelig be'invloed (davis en hardick, 1981). wanneer daar na kommunikasie verwys word, sluit dit enige wyse in waardeur die persoon sy voorgenome boodskap oordra. die uitdrukking van 'n boodskap kan deur middel van gebare, gesproke of geskrewe taal plaasvind. ekspressiewe taal (hetsy geskrewe of oraal) is vir die gehoorgestremde kind 'n probleem wat oorkom moet word ten einde die beperking op kommunikasievermoens op te hef of te verminder. hierdie feit is algemeen bekend, maar wat die verband tussen die twee ekstreme vorme, naamlik geskrewe en gesproke taal is, en wat die implikasies daarvan vir die spraakterapeut/oudioloog in die evaluering en behandeling van die gehoorgestremde kind is, is vrae wat nog beantwoord moet word. navorsingsbelangstelling is gerig op sowel geskrewe en ''esproke taalvermoens van gehoorgestremdes, maar outeurs bestudeer geskrewe en gesproke taal gewoonlik apart. beperkte navorsing is uitgevoer in terme van 'n vergelyking van geskrewe en gesproke taalvermoens (arnold, crossley en exley, 1982; power en wilgus, 1983). beskikbare data dui egter dat daar op alle taalvhkke beide ooreenkomste en verskille tussen gesproke en geskrewe taalvaardighede van gehoorgestremde kinders gevind is (arnold, crossley, exley, 1982; power en wilgus, 1983; myklebust, 1965). die doel van hierdie artikel is om die ekspressiewe geskrewe en gesproke sintaktiese vaardighede van gehoorgestremdes te bestudeer. sodoende word gepoog om 'n moontlike verband tussen die twee modaliteite te bepaal, en om die verkree inligting as moontlike riglyn tydens die evaluering en behandeling van die sintaksis van gehoorgestremdes aan te wend. * voetnoot * die gebruik van gebaretaal as kommunikasiemiddel deur gehoorgestremde kinders word erken maar word nie in hierdie ondersoek in berekening gebring nie aangesien slegs die geskrewe en gesproke vorms van afrikaans as verskynsel by gehoorgestremde kinders ondersoek word. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 © sasha 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 enid slabber, rene hugo en brenda louw 2. metode 2.1 proefpersoonseleksie tydens die seleksie van proefpersone is die standerd 4 a en b en standerd 5 a en b klasse van 'n bepaalde skool vir hardhorendes gebruik. op grond van bepaalde kriteria is 5 proefpersone uit 'n aantal van 70 kinders geselekteer, deur die leers van die 70 leerlinge na te gaan. die onderwyseres, spraakterapeut en sielkundige se menings is ook ingewin, om sodoende geldigheid van seleksie te verseker. die relevante kenmerke van die 5 kinders wat uiteindelik geselekteer is, word in tabel 1 aangedui. tabel 1: beskrywing van die relevante eienskappe van die geselekteerde proefpersone kriteria vir seleksie proefpersoonnommer 1 2 3 4 5 skoolplasing sonitus taal afrikaans geslag manlik dra van gehoorapparaat saktipe graad van gehoorverlies (gemiddelde suiwertoondrempel) linkeroor (db) 95 95 95 100 75 regteroor (db) 80 90 95 80 100 intelligensie gemiddeld invloed van stimulasie dagskolier meervoudige gestremdheid geen kongenitale gehoorverlies ja normaalhorende ouers ja ouderdomme in jare en maande 12.8 13.1 12.0 12.8 12.0 2.2 materiaal 'n toets vir die evaluering van afrikaanssprekende gehoorgestremde kinders se ekspressiewe geskrewe en gesproke taalvermoens is opgestel, aangesien geen bestaande toetse aan die gestelde vereistes voldoen het nie. 2.2.1 teoretiese basis waarop die toets berus die benadering tot taalontwikkeling en taalafwykings wat deur bloom en lahey (1978) voorgestel is, word aangehang. hiervolgens bestaan taal uit drie komponente, naamlik taalinhoud, taalvorm en taalgebruik. die komponente wat deur bloom en lahey (1978) gedefinieer word, bied 'n raamwerk vir die evaluering van taalontwikkeling, en kan sinvol in die samestelling van die toets gebruik word. taalgebruik is egter nie in hierdie ekspriment geevalueer nie, aangesien dit moeilik toetsbaar is in geskrewe taal. in die bree kan die basis waarop die toets berus skematies (sien figuur 1) voorgestel word. 2.2'.2 toets vir die evaluering van afrikaanssprekende gehoorgestremde kinders se ekspressiewe geskrewe en gesproke vermoens. die toets vir die evaluering van afrikaanssprekende gehoorgestremde kinders se ekspressiewe geskrewe en gesproke vermoens, het beide geskrewe en gesproke taalvorm (sintaksis, morfologie en fonetiek) en taalinhoud (produktiwiteit, woordsoorte, aard) geevalueer, asook aanvullende inligting oor taalvermoens verskaf. 'n volledige uiteensetting van die toets met al sy onderafdelings word in bylae a verskaf. hierdie artikel verskaf egter net 'n bespreking van die sintaktiese vermoens van die proefpersone aangesien quigley, montanelli en wilbur (1976) meen dat sintaktiese vermoens beskou kan word as 'n verteenwoordigende weerspieeling van die gehoorgestremde kindysej vlak van ekspressiewe taalfunksionering. in die evaluering van sintaktiese vermoens, is twee aspekte, naamlik sinstrukture en woordvolgorde bestudeer. a) sinstruktuur hierdie afdeling omsluit die gebruik van die ingebedde sin, newe en onderskikkende sin, vraagsin, ontkenningsin, passiewe sin, onvoltooide sin, korrekte tydvorm van die sin en die gebruik van die direkte rede. hier word dus gekyk na die verskillende sinstrukture wat die gehoorgestremde kind korrek kan gebruik (arnold 1978; bunch 1979; powers en wilgus, 1983; steinkamp en quigley, 1977; pressnell, 1973;': ivimey, 1976; wilbur, goodhart en montandon, ,1983). b) woordvolgorde met foutiewe woordvolgorde word enige omruilings van1 twee of meer woorde, of slegs een woord wat in 'n verkeer-' de posisie in die sin gebruik word, bedoel. woordvolgorde is belangrik, aangesien dit 'n invloed het op die sinstruktuur en sintaktiese korrektheid daarvan. aangesien gehoorgestremdes geneig is om probleme met woordvolgorde te he, is dit ook by hierdie studie ingesluit (myklebust, 1965). 2.2.3 ontlokkingsprosedure ,· ^ beide geskrewe en gesproke taalvaardighede is afsonderlik ontlok deur prentbeskrywingstake. duidelike mondelinge instruksies is aan die proefpersone verskaf om 'n storie oor die voorgehoue prente te skryf en verbaal te vertel. 2.2.4 analise-prosedure sintaksis is geevalueer deur die strukture in elke sin te the south african journal of communication disorders, vol.34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) geskrewe en gesproke afrikaanse sintaktiese vermoens van hardhorende kinders 51 beoordeel ten opsigte van die frekwensie van voorkoms, korrekte woordvolgorde, weglating, vervanging of byvoeging van woorde in spesifieke sinstrukture gebruik. woordvolgorde is kwantitatief sowel as kwalitatief geevalueer en volgordefoute word met die strukture in die res van die sin in verband gebring. sodoende kan 'n duideliker beeld verkry word van wanneer die woordvolgorde in 'n sin verkeerd is, byvoorbeeld altyd saam met die gebruik van 'n voegwoord of voorsetsel, ensovoorts. 2.3 prosedure — vyf proefpersone is geselekteer op grond van gestelde kriteria. — 'n voorstudie is met 'n enkele proefpersoon uitgevoer en aanpassings op grond van die resultate wat verkry is, is gemaak. — by die toepassing van die finale weergawe van die toets op vyf proefpersone is geskrewe taalvaardighede eerste geevalueer om proefpersone sodoende meer op hulle gemak te stel. — gesproke taalvaardigheid is een week later geevalueer, sodat die herhalingseffek uitgeskakel kon word. 3. resultate en bespreking die verkree resultate van die proefpersone se geskrewe en gesproke sintaktiese vermoens word vervolgens bespreek. 3.1 sinstrukture die gegewens in verband met die tipe sinstrukture wat deur die proefpersone tydens die gesproke en geskrewe taal gebruik is, word in tabelle 2, 3 en 4 weergegee. tabel 2 verskaf 'n uiteensetting van die geevalueerde sinstrukture wat deur die proefpersone tydens gesproke en geskrewe taal gebruik is. in tabel 3 word opsommende inligting'aangaande die geevalueerde sinstrukture vervat. tabel 4/dui die voorkoms van persentasie foutiewe sinsvorme tydens gesproke en geskrewe taal aan. tabel 2: geevalueerde sinstrukture wat deur die proefpersone tydens gesproke en geskrewe taal gebruik is j sinstrukture i geskrewe taal gesproke taal a β c a β c ingebedde sin 0 0 0 0 ' 0 0 onderskikkende sin 6,3 20 0 2 100 0 neweskikkende sin 16,5 84,6 0 12,7 77 7,6 vraagsin 1,3 0 0 3 ' 100 0 ontkenningsin 6,3 80 0 9,8 40 10 passiewe sin 1,3 0 100 0 ι 0 0 direkte rede 1,3 100 0 17,6 5,6 5,5 a — persentasie sinstrukture gebruik β — persentasie sinstrukture korrek gebruik c — persentasie foutiewe woordvolgorde uit tabel 2 word afgelei dat die sinstrukture wat die meeste voorgekom het tydens geskrewe taal, die neweskikkende tabel 3: opsommende inligting aangaande sinstrukture geskrewe taal gesproke taal totale aantal sinne gebruik 79 102 totale persentasie geevalueerde sinstrukture 32,9% 45,1% persentasie t-eenhede nie geevalueer 67,1% 54,9% persentasie korrekte sinstrukture 65,4% 43,5% persentasie woordvolgordefoute in die gebruik van geevalueerde sinstrukture 3,8% 6,5% tabel 4: voorkoms van persentasie foutiewe sinsvorme tydens gesproke en geskrewe taal foutiewe sinsvorme % voorkoms in geskrewe taal % voorkoms in gesproke taal onvoltooide sinne tyd-vorm foutief 3,8 1,3 2 0 (16,5%), onderskikkende (6,3%) en ontkenningsinne (6,3%) was. ingebedde sinne kom glad nie voor nie, terwyl direkte rede, vraagsinne en passiewe sinne slegs 'n voorkomsfrekwensie van 1,3% getoon het. die sinstrukture wat die grootste persentasie korrekte voorkoms getoon het, was direkte rede (100% korrek), ontkenningsinne (80% korrek) en neweskikkende sinne (84,6% korrek). slegs 20% van die onderskikkende sinne is korrek gebruik. volgens tabel 3 bestaan 32,9% van die uitinge uit die sewe tipes sinstrukture wat in tabel 2 genoem word en daarvan is 65,4% korrek gebruik, terwyl slegs 3,8% van die bepaalde sinstrukture woordvolgordefoute getoon het. volgens tabel 2 is die sinstruktuur wat die hoogste voorkomsfrekwensie van die sewe tipes strukture getoon het tydens geskrewe taal neweskikkende sinne (16,5%). hierdie waarneming kan moontlik verklaar word deur die feit dat geen variasie in sinsvorm vereis word nie, en dit dus 'n minder komplekse sinstruktuur as die met 'n laer voorkomsfrekwensie is (heider en heider, 1940). die ingebedde, onderskikkende en passiewe sinne vereis egter 'n variasie in sinstruktuur, byvoorbeeld woordvolgorde, en dit is dus 'n meer komplekse sin (russel et al. 1976). powers en wilgus (1983) meen dat ingebedde, onderskikkende, passiewe, ontkenningsen vraagsinne almal 'n vorm van komplekse sinstrukture is, en die verkree resultate van hierdie studie stem dus ooreen met die van powers en wilgus (1983). 'n totale persentasie van 45,1 van alle sinne wat tydens geskrewe taal gebruik is, was van die sewe sintipes wat vir die ondersoek uitgesonder is. hiervan is 43,5% korrek gebruik. die hoe persentasie direkte-rede-sinne wat gebruik is, kan moontlik verklaar word op grond van die feit dat die direkte rede die taalvorm is wat elke dag tydens kommunikasie gebruik word. dit lyk asof die gehoorgestremde proefpersone in die direkte-rede-styl wat vir hulle bekend is, praat of 'n storie vertel. geen variasie in sinsvorm is nodig tydens direkte rede nie, wat ook moontlik verder bydra tot die hoe voorkoms hiervan. neweskikkende (12,7%) en ontkenningsinne (9,8%) kom daar waarskynlik met 'n hoe persentasie die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 voor omdat geen variasie in sinsvorm vereis word nie. neweskikkende sinne sluit ook die gebruik van die voegwoord "en" in, en volgens schwartz en solot (1980) is "en" een van die eerste en mees algemene voegwoorde wat deur die gehoorgestremde kind gebruik word. volgens schmitt (1970) is die gehoorgestremde kind nie geneig om passiewe sinne, ontkenningsinne of enige ander sinne wat variasie in vorm vereis, te gebruik nie. simmons (1962) meen ook dat die gehoorgestremde min buigbaarheid toon ten opsigte van sinstrukture, en die afwesigheid van sinne soos die passiewe vorm of ingebedde sin in die resultate kan moontlik hieraan toegeskryf word. die produksie van saamgestelde sinne is vir die gehoorgestremde kind moeilik en daarom word kort eenvoudige sinne gebruik, wat die klein persentasie (2%) onderskikkende sinne van die resultate verklaar (lewis en wilcox, 1978). pressnell (1973) is van mening dat die gehoorgestremde se bemeestering van sintaksis in gesproke taal vertraag is, en sy bevindinge word gestaaf deur huidige bevindinge. 'n vergelyking van die proefpersone se geskrewe en gesproke taal na aanleiding van die resultate wat in tabelle 2, 3 en 4 verskaf is, dui op die volgende ooreenkomste: — die resultate van beide die geskrewe en gesproke taal het getoon dat ingebedde sinne nie deur die proefpersone gebruik is nie. dit is aan die kompleksiteit van die sinstruktuur toegeskryf, asook aan die feit dat die sintaktiese reels vir hierdie struktuur nog nie bemeester is nie. tyack (1981) is van mening dat 'n kind met taalprobleme, probleme sal he met komplekse sinne, en dat die kind die reels van eenvoudige sinstrukture sal toepas wanneer hy met komplekse sinne in aanraking kom. die afleiding word dus gemaak dat gehoorgestremdes vertraagde taalverwerwing vertoon. — slegs 1,3% van die sinne in geskrewe taal was passiewe sinne en 0% tydens gesproke taal; dus 'n baie lae voorkomsfrekwensie van die passiewe struktuur. volgens power en quigley (1973) en wiig en semel (1980) toon die gehoorgestremde 'n groot agterstand met betrekking tot die verwerwing van die passiewe sinsvorm en die huidige resultate bevestig hierdie bevindinge. — neweskikkende (12,7% en 16,5% onderskeidelik) en ontkenningsinne (9,8% en 6,3% onderskeidelik) kom in sowel gesproke as geskrewe taal relatief baie voor in vergelyking met ander tipe sinstrukture, waarskynlik omdat dit nie sulke komplekse sinstrukture is nie en geen variasie in sinsvorm vereis word nie. heider en heider (1940) het bevind dat die gehoorgestremde tydens geskrewe taal 'n groter aantal eenvoudige sinne gebruik, (wat dus geen variasie in sinsvorm vereis nie), maar volgens die verkree resultate blyk dit die geval vir geskrewe sowel as gesproke taal te wees. di'e volgende verskille is tydens die vergelyking van die geskrewe en gesproke taal van die proefpersone opgemerk: — meer onderskikkende (6,3%) en neweskikkende (16,5%) sinne is in geskrewe as gesproke taal (2% en 12,7% onderskeidelik) gebruik. 'n moontlike verklaring hiervoor is dat meer tyd benut kan word tydens geskrewe taal om die sinstruktuur te beplan, terwyl gesproke taal vereis dat die spreker sy boodskap vinenid slabber, rene hugo en brenda louw nig moet beplan en verbaliseer. volgens northcott (1977) word die gehoorgestremde kind in gespreksituasies met kort, grammatikaal korrekte sinne deur sy ouers en onderwysers gestimuleer, wat dan moontlik aanleiding gee tot die gebruik van eenvoudige sinne in gesproke taal. tydens opleiding in die skool word daar heelwat aandag aan geskrewe taal gegee, wat dus ook 'n moontlike invloed op verkree toetsresultate kon he. — meer ontkenningsinne is in gesproke taal as in geskrewe taal gebruik (9,8% teenoor 6,3%), waarskynlik omdat alle kinders in die alledaagse lewe te doen kry met sinne wat ontkenning of negatiwiteit oordra (byvoorbeeld in die skool of tuis sal woorde soos nie, moenie en nee, dikwels gebruik word). hierdie ontkenningsinne word dan weer deur die gehoorgestremde kind tydens gesproke taal gebruik. hart en rosenstein (1966) is ook van mening dat die gehoorgestremde kind se taal sy linguistiese opvoeding wat hy van sy ouers en onderwysers ontvang, reflekteer. — meer vraagsinne (3%) en meer direkte rede (17,6%) is in gesproke taal as geskrewe taal (1,3% en 1,3% onderskeidelik) gebruik. in 'n skoolopset word die beantwoording van vrae dikwels van die gehoorgestremde kind vereis, en omdat vrae 'n persoon in staat stel om meer inligting van sy luisteraar te verkry, kan die hoe voorkomsfrekwensie van vraagsinne tydens gesproke taal moontlik met hierdie stelling verklaar word. die direkte rede is 'n taalstruktuur wat tydens alledaagse kommunikasie gebruik word, en dit wil dus voorkom asof die gehoorgestremde kind hierdie bekende struktuur ook in sy gesproke taal toepas; met ander woorde, direkte rede word nie herlei tot indirekte rede nie, aangesien die direkfe-rede-struktuur meer bekend is vir die gehoorgestremde kind. hierdie verklaring sluit dus weer eens aan by hart en rosenstein (1966) se bewering, soos vroeer vermeld. — tydens geskrewe taal is die direkte rede 100%'korrek gebruik, maar tydens gesproke taal is dit slegs in 5,6% van die gevalle korrek gebruik. hierdie diskrepansie kan moontlik toegeskryf word aan 'n tekort aan ouditiewe toevoer tydens gesproke taal, wat dan die lae persentasie korrekte gebruik van die direkte-redestruktuur verklaar. tydens kommunikasie deur middel van skryftaal is visuele toevoer egter die belangrikste sisteem wat as kontrolemeganisme dien, en dit bied 'n moontlike verklaring vir die 100% korrektheid wat voorkom (myklebust, 1964). 1 — tydens gesproke taal is onderskikkende en vraagsinne 100% korrek gebruik, terwyl slegs 2% en 0% onderskeidelik van hierdie sinstrukture tydens geskrewe taal korrek gebruik is. aangesien geskrewe taal eers vanaf 'n latere ouderdom aangeleer word, kan verkree resultate moontlik op grond hiervan verklaar word. / ' — tydens gesproke taal kom daar by 6,5% van die geevalueerde sinstrukture woordvolgordeprobleme voor, teenoor die 3,8% in geskrewe taal. volgens wiig en semel (1980) dui woordvolgordefoute op 'n subtiele prosesseringsprobleem by die gehoorgestremde se taal. schwartz en solot (1980) beweer dat die gehoorgestremde se woordvolgordegebruik beter in gesproke the south african journal of communication disorders, vol.34,1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) geskrewe en gesproke afrikaanse sintaktiese vermoens van hardhorende kinders 53 taal as in geskrewe taal sal wees, aangesien mislukkings voorkom kan word deur die gebruik van pouses. dit lyk egter asof die gehoorgestremde proefpersone in hierdie eksperiment nie in staat is tot die produksie van korrekte woordvolgorde nie, as gevolg van 'n onsekerheid omtrent korrekte woordvolgorde of 'n swak bemeestering van interne taalreels (schwartz en solot, 1980). — foutiewe sinsvorme (tabel 4) het telkens meer tydens geskrewe (3,8% en 1,3% onderskeidelik) as gesproke taal (2% en 0% onderskeidelik) voorgekom. die gehoorgestremde kind is nie daartoe in staat om die korrekte grammatika wat hy tydens gesproke taal aanwend in geskrewe taal toe te pas nie (bastable in arnold, crossley en exley, 1982). wanneer die resultate van geskrewe en gesproke taal samevattend beskou word volgens die inligting in tabelle 2, 3 en 4 vervat, word opgemerk dat die sewe sinstrukture wat geevalueer is, 32,9% van die sinstrukture wat tydens geskrewe taal gebruik is, uitmaak teenoor die 45,1% tydens gesproke taal. dit lyk dus asof daar meer komplekse sinstrukture in gesproke as in geskrewe taal voorkom. tydens geskrewe taal is 65,4% van die sinstrukture egter korrek gebruik, teenoor die 43,5% tydens gesproke taal, dit wil se meer van die komplekse sinstrukture word in gesproke taal gebruik, maar 'n groter aantal korrekte sinne kom tydens geskrewe taal voor. hierdie huidige resultate stem dus nie ooreen met die van arnold, crossley en exley (1982) se bevinding dat die gehoorgestremde meer foute tydens die skryf van sintaktiese eenhede maak as wanneer hulle praat nie. die verkree resultate stem egter ooreen met die van kretschmer en kretschmer (1978) wat noem dat die gehoorgestremde relatief min komplekse sinne in beide geskrewe en gesproke taal gebruik. resultate word verder ondersteun deur die bevindinge van navorsers soos ivimey (1976); wilbur, goodhart en montandon (1983) en bunch (1979). 3.2 woordvolgorde die tweede afdeling in die evaluering van sintaksis, is woordvolgorde. foute wat deur die proefpersone gemaak is met betrekking tot woordvolgorde, word in tabel 5 uiteengesit. ! tabel 5: resultate ten opsigte van proefpersone se woordvolgordefoute geskrewe taal gesproke taal % foute % foute % woordvolgordefoute gemaak in alle t-eenhede 5,1 4,0 % woordvolgordefoute gemaak tydens sinstrukture geevalueer (raadpleeg tabel 3) 3,8 6,5 volgens tabel 5 kom woordvolgordefoute by 5,1% van alle sinne in geskrewe taal voor, en by 3,8% van die sewe geskrewe sinstrukture s o o s igeevalueer (kyk ook tabel 4). twee verledetydsinne, asook by passiewe sinne. die woordsoort wat die grootste voorkoms van woordvolgordeprobleme veroorsaak, is die werkwoord. uit 'n kwalitatiewe analise blyk dit dat die voornaamwoord "wat" verwarring veroorsaak aangesien woordvolgordefoute ook in teenwoordigheid hiervan voorkom. tydens gesproke taal het die proefpersone by 4% van alle sinne woordvolgordefoute vertoon, en woordvolgordefoute by 6,5% van komplekse sinstrukture (tabel 5). kwalitatiewe analise van die resultate dui daarop dat woordvolgordefoute tydens die gebruik van die direkterede-struktuur, 'n neweskikkende sin, verledetydsvorm, en 'n ontkenningsin voorkom; dit wil se, meestal die sinne wat variasie in sinsvorm vereis en dus meer kompleks is. soos reeds vroeer genoem, het navorsing bewys dat die gehoorgestremde kind probleme met komplekse sinstrukture ondervind (heider en heider, 1940; simmons, 1962). uit tabel 5 blyk dit dus dat meer probleme met woordvolgorde tydens geskrewe taal (5,1%) as in gesproke taal (4%) voorkom. 'n moontlike verklaring hiervoor is dat geskrewe taal eers aangeleer word op 'n heelwat later stadium as die gesproke taal, en dus is die gehoorgestremde kind nog nie so vaardig in korrekte ordening van woorde as byvoorbeeld tydens gesproke taal wat elke dag vanaf geboorte gehoor word nie (alhoewel tot 'n beperkte mate by die gehoorgestremde kind). verskeie navorsers op die gebied van kindertaalontwikkeling huldig die mening dat die posisie van woorde in 'n sin belangrik is ten opsigte van betekenisvolheid en dat woordvolgorde reeds op 'n vroee stadium van taalontwikkeling 'n meganisme is wat betekenis uitdruk (sinclair en bronckart, 1972; brown, 1973; bloom, 1970). volgens brown en bellugi (1964) is dit moontlik dat die normaal horende kind normale woordvolgorde behou, omdat hy bepaalde semantiese verhoudings daardeur wil uitdruk. moontlik kan hierdie genoemde stelling dan ook dien as motivering waarom minder woordvolgordeprobleme tydens gesproke taal deur die proefpersone gemaak is as. tydens geskrewe taal. tydens die gebruik van meer komplekse sinstrukture (tabel 2), is daar egter 6,5% woordvolgordefoute in gesproke taal; teenoor die 3,8% tydens geskrewe taal gemaak. die moontlikheid is reeds genoem dat die gehoorgestremde kind tydens geskrewe taal meer tyd gegun word om die sinstruktuur te beplan as tydens gesproke taal, en daarom die kleiner persentasie woordvolgordefoute in komplekse geskrewe sinstrukture. celliers (1981) is van mening dat die kommunikasiewaarde van woordvolgorde vir normaal horende kinders op verskillende taalontwikkelingstadiums verskil, en aangesien die gehoorgestremde meestal 'n agterstand toon in die verwerwing van taal (presnell, 1973), kan ons verwag dat hierdie aspek nie vergelykbaar sal wees by die twee groepe nie. pressnell (1973) beweer dat die gehoorgestremde kind se bemeestering van sintaksis in gesproke taal vertraag is, en dit word dan bevestig deur die hoe persentasie woordvolgordefoute in die gebruik van komplekse sinstrukture. 'n verdere verklaring vir bogenoemde verskynsel mag wees dat die gehoorgestremde kind nie werklik oor die nodige begrip vir komplekse sinne beskik nie, en dus verward raak in die gebruik daarvan. dit is ook moontlik dat die toepaslike sintaktiese reels nog nie bemeester is nie. foute met woordvolgorde is gemaak tydens die gebruik van wanneer die navorsing (celliers, 1981) van normaal horendie suid-afrikaanse tydskrifvir kommunikasieafwykings, vol 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 enid slabber, rene hugo en brenda louw des se woordvoigordegebruik met die van die gehoorgestremde kind vergelyk word, kan woordvolgordeprobleme aan die hand van die volgende verklaar word: — dit is moontlik dat die gehoorgestremde kinders nie die semantiese betekenis van uitinge volkome insien nie, en daarom is woordvolgorde nie vir hulle so belangrik nie. — 'n tweede moontlikheid is dat die gehoorgestremde kinders nie oor die sintaktiese vermoe beskik om te weet wat die korrekte woordvolgorde is nie. — dit blyk ook moontlik te wees dat die kommunikasiewaarde van woordvolgorde vir die gehoorgestremde kinders nie van soveel belang is nie. — laastens bestaan die moontlikheid dat die gehoorgestremde kinders 'n agterstand vertoon met betrekking tot die ontwikkelingsverloop van woordordereels, aangesien soveel foutiewe sinstrukture ook tydens hierdie eksperiment waargeneem is (celliers, 1981). 4. samevatting 'n vergelyking van die proefpersone se geskrewe en gesproke sintaktiese vermoens het op die volgende ooreenkomste gedui, naamlik: — die resultate van beide die geskrewe en gesproke taal het getoon dat ingebedde sinne nie deur die proefpersone gebruik is nie. — slegs 1,3% van die sinne in geskrewe taal was passiewe sinne en 0% tydens gesproke taal; dus 'n baie lae voorkomsfrekwensie van die passiewe sinstruktuur, wat ooreenstem met bevindinge van powers en quigley (1973). — neweskikkende (12,7% en 16,5% onderskeidelik) en ontkenningsinne (9,8% en 6,3% onderskeidelik) kom in sowel gesproke as geskrewe taal relatief baie voor in vergelyking met ander tipes sinstrukture. die volgende verskille is tydens die vergelyking van geskrewe en gesproke sintaktiese vermoens opgemerk, naamlik: — meer onderskikkende (6,3%) en neweskikkende (16,5%) sinne is in geskrewe as gesproke taal (2% en 12,7% onderskeidelik) gebruik. — meer ontkenningsinne is in gesproke taal as in geskrewe taal gebruik (9,8% teenoor 6,3%). — meer vraagsinne (3%) en baie meer direkte rede (17,6%) is in gesproke taal as geskrewe taal (1,3% en 1,3% onderskeidelik) gebruik. — tydens geskrewe taal is die direkte rede 100% korrek gebruik, maar tydens gesproke taal is dit slegs 5,6% van die gevalle korrek gebruik. i — tydens gesproke taal is onderskikkende en vraagsinne 100% korrek gebruik, terwyl slegs 2% en 0% onderskeidelik van hierdie sinstrukture tydens geskrewe taal korrek gebruik is. — tydens gesproke taal kom daar by 6,5% van die geevalueerde sinstrukture woordvolgordeprobleme voor, teenoor die 3,8% in geskrewe taal. die persentasie woordvolgordefoute gemaak in alle t-eenhede is egter 5,1% in geskrewe taal, teenoor die 4,0% in gesproke taal. op grond van die resultate van hierdie ondersoek as geheel kan die volgende gevolgtrekkings gemaak word, naamlik: — meer komplekse sinstrukture het tydens die proefpersone se gesproke taal voorgekom as wat in geskrewe taal gebruik is. — die persentasie korrekte sinstrukture wat gebruik is, is egter groter in geskrewe taal as in gesproke taal, alhoewel nogtans betreklik laag. — meer woordvolgordefoute is tydens geskrewe as gesproke taal gemaak. — die diskrepansie wat tussen die resultate van gesproke en geskrewe taal voorkom, mag 'n direkte gevolg van die onderrigwyses van die proefpersone wees waar gesproke taal as kommunikasiemedium aangeleer word en geskrewe taal bloot as 'n meganiese funksie aangeleer word. kretschmer en kretschmer (1978) se bevinding dat die gehoorgestremde kind min komplekse sinstrukture in gesproke en geskrewe taal gebruik, ondersteun dus die resultate van hierdie studie. aangesien dit blyk asof die gehoorgestremde proefpersone 'n onvermoe ten opsigte van die gebruik van komplekse sinstrukture toon, word aanbeveel dat meer blootstelling van die gehoorgestremde kinders hieraan nodig is. aangesien gehoorgestremde kinders in 'n voorgeskrewe skoolprogram opgeneem is en blootstelling in 'n groot mate bepaal word deur die kurrikulum wat gevolg word, is dit 'n belangrike faktor wat in aanmerking geneem moet word. die gebruik van komplekse sinstrukture en die korrektheid van woordvolgorde in die taal van gehoorgestremdes is egter 'n navorsingsgebied wat verdere indringende aandag moet geniet. / j 5. slot i ι die inligting wat tydens hierdie studie verkry is, hou belangrike implikasies in vir die evaluering en behandeling van die gehoorgestremde kind, deurdat meer insig omtrent die gehoorgestremde se gesproke en geskrewe sintaktiese vermoens verkry is. navorsing op hierdie gebied le egter nog braak, en die huidige studie is die eerste poging in afrikaans om die verband tussen geskrewe en gesproke sintaktiese vermoens uit te lig. waardevolle riglyne vir die evaluering en behandeling van gehoorgestremde 'kinders is egter vekry. die studie kan dus as vertrekpunt dien vir verdere navorsing. verwysings arnold, p. 1978. the deaf child's written english can we measure its quality? journal british association of teachers of the deaf, 2 (6), 196-199. the south african journal of communication disorders, vol.34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) geskrewe en gesproke afrikaanse sintaktiese vermoens van hardhorende kinders 55 arnold, p., crossley, e. and exley, s. 1982. deaf children's speaking, writing, comprehension of sentences. the journal of auditory research, 22, 225-232. bloom, l. 1970. language development : form and function 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of deaf and hearing children. physiological monographs, 52, 42-102. ivimey, g.p. 1976. the written syntax of an english deaf child: an exploration in method. british journal of disorders of communication, 11 (2), 103-120. kretschmer, r.r and kretschmer, l.w. 1978. language development and intervention with the hearing impaired. baltimore: university press. lewis, t. and wilcox, j. 1978. the perceptual use of semantic rules by normal hearing and hard-of-hearing children. journal of communication disorders, 11, 107-118. myklebust, h.r. 1964. the psychology of deafness, new york, grune and stratton. myklebust, h.r. 1965. development and disorders of written language. (volume 1) picture story language test, new york: grune and stratton. northcott, w.h. 1977. curriculum guide. hearing impaired-children and their parents, washington: alexander graham bell association for the deaf, inc. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 power, d.j. and quigley, s.p. 1973. deaf children's acquisition of the passive voice. journal of speech and hearing research, 16, 5-11. powers, a.r. and wilgus, s. 1983. linquistic complexity in the written language of hearing-impaired children. the volta review, 85 (4), 201-210. pressnell, l.m. 1973. hearing-impaired children's comprehension and production of syntax in oral languag e. journal of speech and hearing research, 16, 12-21. quigley, s.p., montanelli, d.s. and wilbur, r.b. 1976. some aspects of the verb system in the language of deaf students. journal of speech and hearing research, 19, 536-550. russel, w.k. quigley, s.p. and power, d.j. 1976. linguistics and deaf children, washington: alexander graham bell association for the deaf, inc. schmitt, p.j. 1970. deaf children's comprehension and production of sentence transformations and verb tenses. unpublished doctoral dissertation, university microfilms, ann arbor, michigan. schwartz, e.r. and solot, m. 1980. response patterns characteristic of verbal expressive disorders. language, speech and hearing services in schools. 11, 139-144. simmons, a.a. 1962. a comparison of the type token ratio of spoken and written language of deaf and hearing children. the volta review, 64, 417-421. sinclair, h. and bronckart, j.p. 1972. svo a linguistic universal? a study in development phsycholinguistics. journal of experimental child psychology, 14 (3), 329-348. steinkamp, m.w. and quigley, s.p. 1977. assessing deaf children's written language. the volta review, 8, 7-13. tyack, d.l. 1981. teaching complex sentences. language, speech and hearing services in schools, 12, 49-56. wiig, e.h. andsemel, e.m. 1980. language assessment and intervention for the learning disabled, columbus, ohio: charles e. merrill publishing company. wilbur, r., goodhart, w. and montandon, e. 1983. comprehension of nine syntactic structures by hearing-impaired students. the volta review, 85 (7|, 328-345. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 enid slabber, rene hugo en brenda louw bylae toets vir die evaluering van afrikaanssprekende gehoorgestremde kinders se ekspressiewe geskrewe en gesproke taalvermoens a. taalvorm 1. sintaksis a) sinstrukture 3. fonetiek sinstrukture geskrewe taal gesproke taal ingebedde sin aantal woordvolgorde foutief korrek onderskikkende sin aantal woordvolgorde foutief korrek neweskikkende sin aantal woordvolgorde foutief korrek raagsin aantal woordvolgorde foutief korrek ntkenningsin aantal woordvolgorde foutief korrek direkte-rede-sin aantal woordvolgorde foutief korrek passiewe sin aantal woordvolgorde foutief korrek taalkorrekte foutiewe tipe verlanggelewerposimedia woord woord fout de klank de klank sie in of skrifof skrifwoord simbool simbool geskrewe taal gesproke taal b. taalinhoud 1. produktiwiteit aspekte van taalinhoud geskrewe taal gesproke taal geevalueer gesproke taal a) totale aantal woorde b) totale aantal t-eenhede c) woorde per t-eenheid 2. woordsoorte geskrewe taal gesproke taal woordsoorte a β c d a β c d werkwoord hulpwerkwoord van tyd modale hulpwerkwoord koppelwerkwoord selfstandige naamwoord voegwoord voorsetsel voornaamwoord bywoord lidwoord a — aantal β — byvoeging c — vervanging d — weglating 3. aard van taalinhoud t-eenheid nommer 1. 2. 3. 4. 5. ^ foutiewe sinsvorme geskrewe taal gesproke taal 1. 2. 3. 4. 5. ^ onvoltooide sinne tyd — vorm foutief 1. 2. 3. 4. 5. ^ b) woordvolgorde 6c 7. 8. t-eenheid nommer t-eenheid nommer geskrewe taal gesproke taal 9. 10. 11. 9. 10. 11. 2. morfologie 12. 13. morfologiese verbuigings geskrewe taal gesproke taal 14. 15. 16. 17. 18. 19. * aantal * byvoegings * vervangings * weglatings 14. 15. 16. 17. 18. 19. geskrewe taal gesproke taal the south african journal of communication disorders, vol.34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) geskrewe en gesproke afrikaanse sintaktiese vermoens van hardhorende kinders 57 20. 21. 22. 40. opsommend: aard van taalinhoud geskrewe taal gesproke taal 23. vlak 1 24. vlak 2 25. vlak 3 26. vlak 4 27. 2 8 · c. aanvullende inligting 29· a) behoud van tema 30· b) herhaling van vorige idees 31· c) selfkorreksie 32. d) gebruik van selfstandige naamwoorde in plaas van voor33. naamwoorde 34· e) gebruik van inleidende en slotsinne 35· f) vooronderstelling 36. 37. algemene inligting omtrent taalvorm 38 3 g' algemene inligting omtrent taalinhoud opmerkings needier westdene has been active in the south african hearing market for more than 20 years and therefore fully understands your specific requirements in the areas of: testing of hearing ability improvement of hearing ability prevention against industrial noise supplying specialised electromedical equipment and tools for / spe'ech therapists, ent's and others. maintenance ^ n d repair to and calibration of all equipment supplied by needier westdene (and certain other suppliers). contact us first for: — professional ladvice and guidance — competitive quotes for products and consumable items — the best preand post-sales support. the needler westdene organisation c.c. (ck87/02503/23) p.o. box 28975 sandringham 2131 r.s.a. tel: 011-640 5017 member/lid: dr. s.j. van tonder, phd., mbl. general manager/algemene bestuurder die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) s designed and manufactured in south africa the phantom series combines the flexibility of behind-the-ear hearing aids with the acoustic advantages and cosmetic appeal of in-the-ear hearing aids. a unique construction technique allows various models to be tried and tested in an individually made shell. clip-in modules are inserted with no special tools in a few seconds and it is even possible to make acoustic modifications to the earmould for controlling in-situ performance — including "open" earmoulds. m a n u f a c t u r e d by: a c o u s t i m e d (pty) l t d 327 b o s m a n b u i l d i n g cor. eloff a n d bree streets j o h a n n e s b u r g tel: (011) 337-2977 the south african journal of communication disorders, vol. 3, 198 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die voorkomsfrekwensie van ooren gehoorpatologie by kinders in die afgesonderde gemeenskap van tshikunda — malema santie meyer m(log)(pret.) carlin van den berg b(log)(pret.) departement spraakheelkunde en oudiologie universiteit van pretoria opsomming hierdie navorsing het ten doel die bepaling van die aard en voorkoms van ooren gehoorpatalogie by 'n afgesonderde gemeenskap in venda. honderd drie-en-vyftig kinders is aan 'n siftingsprosedure wat uit 'n oor-, neusen keelondersoek, impedans en suiwertoonsiftingsoudiometrie bestaan, onderwerp. uit die resultate blyk dit dat 15,2 % van die getoetste populasie ooren gehoorprobleme het. die patologie wissel van middeloorpatologie (13,4%) tot sensories-neurale patologie (1,8%). dit wil dus voorkom asof die voorkoms van ooren gehoorprobleme onder hierdie bevolking relatief laag is. dit bevestig vorige navorsing wat bevind dat die algemene gesondheid van hierdie bevolking goed is. abstract the aim of this research was to determine the incidence of ear and hearing pathology in an isolated community in venda. one hundred and fifty three children were subjected to a screening procedure that consisted of an ear, nose and throat examination, impedance and pure tone screening tests. the results suggested that 15,2% of the population had ear and/or hearing pathology. this pathology ranged from middle ear conditions (13,4%>) to sensory neural conditions (1,8%). from these results it appears that the incidence of ear and hearing problems in this population is relatively low. this confirms previous research that states the good health conditions of this community. die verskeidenheid van etniese groepe in suidelike afrika bied 'n unieke geleentheid vir die bestudering van siektetoestande byvoorbeeld ooren gehoorpatologiee wat geassosieer word met die lewenstyl en omgewing (van staden, 1983). in die verband is 'n stam van ongeveer 1 000 persone wat steeds die tradisionele lewenswyse van hul voorvaders behou, in die noordelike dele van die republiek van venda gei'dentifiseer, in 'n afgelee gebied wat as tshikunda-malema bekend staan (van staden, 1983)/ die algemene gesondheidstoestand van hierdie mense is uitsonderlik goed, veral as die afwesigheid van gereelde mediese dienste in ag geneem word (breighton 1983, van staden, nel en van zyl, 1982). die persone blyk ongeaffekteer te, wees deur siektes wat normaalweg geassosieer word met 'n gesofistikeerde lewenstyl en vesellose dieet, byvoorbeeld hoe bloeddruk en artritis (van staden, 1983, breighton, 1983). aangesien dit bekend is dat otitis media 'n hoe voorkoms toon in gebiede waar mediese sorg ontoereikend is en die populasie onbewus is van die implikasies van die toestand (northern en downs, 1984), ontstaan die vraag of dit ook die geval by hierdie vendastam 'n ondersoek na die voorkoms en aard van ooren gehoorpatologie is veral van belang as in gedagte gehou word dat selfs 'n geringe tydelike gehoorverlies, soms deur otitis media veroorsaak kan word. hierdie gehoorverlies kan 'n negatiewe effek op die ontwikkeling van kommunikasieen akademiesevermoens uitoefen (howie, 1977, downs, 1977), en dus 'n verminderde lewenskwaliteit tot gevolg he. verder kan die resultate van so 'n studie 'n belangrike bydrae lewer in die daarstelling van 'n basislyn van die voorkoms van ooren gehoorprobleme wat latere navorsers as verwysing kan gebruik (van staden, 1982). dit is veral ook van belang in die geval van tshikunda-malema se inwoners wat waarskynlik veranderinge in lewenstyl en eetgewoontes sal vertoon as gevolg van die moontlikheid van ontwikkeling van sekondere industriee in die toekoms van die gebied (breighton 1983). 'n moontlike uitvloeisel van die resultate is die inisiering van 'n gehoorkonserveringsprogram wat deur die lede van die gemeenskap self in stand gehou kan word. metode vir die doel van hierdie studie is kinders geselekteer wat in die tshikunda-malemagebied van venda woonagtig is. elke kind is aan 'n oor-, neusen keelondersoek sowel as 'n suiwertoonen impedanssiftingstoets onderwerp. deur hierdie drie prosedures te gebruik word effektiewe identifikasie van ooren gehoorprobleme verhoog (fisch, 1981). proefpersone kinders tussen die ouderdom van een en twaalf jaar is getoets omdat die grootste frekwensie van ooren gehoorpatologie voor die ouderdom van 12 jaar voorkom. kinders in hierdie ouderdomsgroep wat vrywillig by 'n gesondheidskliniek aangemeld het, is aan die siftingsprogram onderwerp. deur konkrete beloning is gepoog om soveel as moontlik kinders te motiveer om vir toetsing aan te meld. honderd drie-en-vyftig kinders is gevolglik getoets. in tabel 1 word die proefpersone in terme van geslag en ouderdom voorgestel. apparaat die apparaat wat vir die oor-, neusen keelondersoek gebruik is, is standaardapparaat, byvoorbeeld 'n koplig, neusspekulum en otoskoop. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 © sasha 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 santi meyer en carlin van den berg tabel 1 voorstelling van proefpersone ouderdom manlik vroulik totaal 1 1 6 7 2 2 1 3 3 2 6 8 4 4 6 10 5 9 5 14 6 8 10 18 7 11 6 17 8 7 9 16 9 3 13 16 10 10 8 18 11 9 9 18 12 5 3 8 totaal 71 82 153 die apparaat wat in die gehoorsiftingsprosedure gebruik is, is 'n madsen model tbn 60 suiwertoonoudiometer. die oudiometer is volgens iso 1964 standaarde geyk en daagliks tydens gebruik psigo-akoesties geyk. die impedansoudiometriese siftingsprosedures is deur middel van 'n damplex d175 impedansmeter uitgevoer. die elektriese voorsiening is van 'n kragopwekker verkry. vir pedo-oudiometriese toetsing van kinders wat nie deur middel van die suiwertoonsiftingsprosedure getoets kon word nie, is van 'n zenith neometer en geykte geraasmakers gebruik gemaak. toetsomgewing klankdigte fasiliteite was nie vir suiwertoonsiftingsoudiometrie beskikbaar nie. 'n vertrek, weg van die kliniek-aktiwiteite, is vir die doel geselekteer. die vertrek was bevredigend vir siftingsdoeleindes. toetsafhemers oudiometriese toetsing is deur 'n volledige oor-, neusen keelondersoek deur 'n oor-, neusen keelarts voorafgegaan. daarna is oudiometriesesiftingsprosedures, volgens 'n voorafbepaalde prosedure, deur twee ervare oudioloe uitgevoer. as gevolg van die taalprobleem is daar van 'n tolk gebruik gemaak vir die gee van instruksies en verkryging van die gevalsgeskiedenis. prosedure dataversameling elke proefpersoon wat vir toetsing aangemeld het, het die volgende prosedure deurloop: 'n tolk verkry inligting ten opsigte van 'n geskiedenis van ooren gehoorprobleme van die ouers. in die geval van die ouer kinders, is die inligting van die kind self, verkry. — hierna ondergaan die kind 'n oor-, neusen keelondersoek. oorwas word verwyder sodat impedansoudiometrie suksesvol uitgevoer kan word. die otoskopiese bevindinge word aangeteken. — die proefpersoon ondergaan dan 'n impedansoudiometriese ondersoek. hierdie toetsing sluit in timpanometrie, meting van statiese compliance en akoestiese reflekse. hierna volg die suiwertoonsiftingstoets. indien die kind te jonk is vir suksesvolle kondisionering vir die uitvoering van die suiwertoontoets, is van gedragsobservering met aanbieding van geraasmakers, gebruik gemaak. dataverwerking vir die verwerking van die rou data is die toetsen ondersoekgegewens wat by elke kind verkry is, afsonderlik in tabelvorm uiteengesit. die gehoor is as normaal beskou indien die proefpersoon response gelewer het by 500 hz, 1khz en 2khz by 20 db gp en 25 db gp by 4khz (northern en downs, 1984). die proefpersoon slaag dus die suiwertoonsiftingstoets by hierdie drempelwaardes. gedragsobservering daarenteen, was subjektief van aard. die baba moes bevredigende lokaliseringsresponse op stimuli lewer (northern en downs 1984). in die geval van impedansoudiometrie, slaag die proefpersoon die siftingstoets indien 'n tipe a-timpanogram en 'n refleks by 105 db gp of laer verkry word (harford et al. 1978). vir die klassifikasie van die resultate van proefpersone met sereuse otitis media, is van die prosedure van cantekin (1983) gebruik gemaak. akute otitis media en chroniese otitis media is deur die oor-, neusen keelarts gediagnoseer. resultate en bespreking van die 153 kinders (306 ore) wat getoets is, kon 15 kinders (30 ore) nie suksesvol deur middel van die suiwertoonen impedansoudiometriese prosedures getoets word nie, (tabel 2). 'n totaal van 138 proefpersone (276 ore) is dus suksesvol deur middel van albei toetsprosedures getoets. label 2 kinders wat nie suksesvol deur middel van die toetsprosedures getoets kon word nie ouderdom aantal nie getoets deur middel van ouderdom aantal impedans suiwertoon 1-3 jr 9 2 9 4-12jr 6 2 6 totaal 15 4 15 soos verwag kan word was meer kinders in die jonger ouderdomsgroep (nege kinders) onsuksesvol getoets, teenoor die viertot twaalfjariges waar ses nie suksesvol getoets kon word nie. dit is verder ook belangrik om op te merk dat geen een van die kinders deur middel van die suiwertoontoets toetsbaar was nie, maar dat 'n oordeel ten opsigte van middeloorfunksionering wel deur middel van die impedansresultate gemaak kon word. impedansoudiometriese resultate kan dus 'n bydrae lewer wanneer geen samewerking vir suiwertoontoetsprosedures verkry kan word nie. (northern 1978). uit die resultate blyk dit duidelik dat met toename in ouderdom daar 'n geleidelike styging in die persentasie van normale oudiometriese resultate is. daar is egter 'n enkele uitsondering naamlik die sewejariges, waar die resultate op 'n afname in normale ooren gehoorfunksionering dui. dit kan in verband gebring word met' harvey en wilmot (1969) se bevinding, naamlik dat daar 'n geringe toename van middeloortoestande tussen vieren negejariges voorkom. die hoer voorkoms van ooren gehoorprobleme by hierdie groep word verklaar na aanleiding van die boonste lugweginfeksies wat dikwels op die ouderdom voorkom. vanaf elfjarige ouderdom is daar opvallend minder afwykende resultate. dit stem ook ooreen met die resultate van vorige navorsers (weber, mcgovern en zink, 1967). voorkoms van afwykende suiwertoonen/of 1mpedanss1ft1ngsoudiometriese resultate' waar figuur 1 'n beeld gee van die voorkoms van resultate wat binne normale perke vir suiwertoonen impedanssiftingsproseduy the sourh african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pie voorkomsfrekwensie van ooren gehoorpatologie by die afgesonderde gemeenskap van tshikunda-malema 73 % 100 90 80 70 60 50 40 30 20 (d ε 3 ~ (λ ε 2 o u a ep = ·§ ϋ ο ελ ^ ιό ο α ft. ο 10 0 1 3 10 11 12 5 6 7 8 9 ouderdom in jare figuur 1 voorkoms van normale suiwertoonen impedansresultate res is, word die voorkoms van afwykende resultate in tabel 3 en 4 weergegee. in tabel 3 word die proefpersone met 'n sensoriesneurale betrokkenheid aangedui, terwyl tabel 4 die proefpersone met middeloorpatologie weergee. tabel 3 proefpersone wat suiwertoontoetsing faal, maar impedanstoetsing slaag (3 kinders) ouderdom van elke proefpersoon ore met afwykende suiwertoonresultate suiwertoongemiddeld in afwykende ore in db ouderdom van elke proefpersoon ore met afwykende suiwertoonresultate links regs 3 jaar 2 30 30 8 jaar 2 50 65 12 jaar / / / 1 i 25 (hoe frekwensie verlies) totaal % 5 1,8% tabel 4 die voorkoms van afwykende impedansoudiometriese resultate ouderdom van proefpersone in jare afwykende resultate ouderdom van proefpersone in jare faal st faal imp faal st slaag imp aantal ore getoets % 1-3 4 5 6 7 8 9 10 11 12 2 2 3 7 9 6 7 6 2 2 5 2 2 2 4 2 5 7 14 6 9 8 2 0 18 16 26 32 32 32 32 36 36 16 22,2 12,5 19,2 21,9 43,8 18,8 28,1 22,2 5,5 0 totaal 42 15 57 276 20,7 uit tabel 3 is dit dus duidelik dat vyf ore die suiwertoonsiftingstoets gefaal het, maar die impedanssiftingstoets geslaag het. hierdie resultate impliseer normale middeloorfunksionering maar verminderde gehoorsensitiwiteit wat op 'n sensories-neurale gehoorverlies kan dui. die driejarige kind vertoon binouraal suiwertoondrempels van 30 db wat op 'n geringe gehoorverlies dui. hierdie kind was egter moeilik kondisioneerbaar en die moontlikheid dat hy wel oor normale gehoor beskik, is goed. die kind het moontlik nie op sy drempel gereageer nie, maar eers op 'n hoer vlak. die agtjarige kind vertoon 'n matige binourale gehoorverlies terwyl die twaalfjarige slegs 'n geringe monourale hoe frekwensie gehoorverlies vertoon. 'n gebrek aan bevredigende agtergrondsinligting maak die oorsake van hierdie gehoorverliese moeilik bepaalbaar. uit tabel 4 blyk dit duidelik dat 20,7% van die populasie een of ander vorm van middeloorpatologie vertoon, terwyl slegs 1,8% (tabel 3) 'n sensories neurale betrokkenheid vertoon. die hoer voorkoms van middeloorpatologie teenoor sensories-neurale gehoorverliese stem ooreen met vorige navorsing. hierdie navorsing dui daarop dat meer as sowat 70% van alle gehoorprobleme, as gevolg van middeloorpatologie, in die skoolgaande populasie voorkom (harvey en wilmot, 1969). dit is verder opvallend dat meer kinders (42) slegs uitvalle op die impedanstoetsresultate toon, teenoor kinders (15) wat uitval op beide suiwertoonen impedanstoetsresultate. hierdie bevinding bevestig die stelling van brooks (1980) dat 'n beduidende aantal kinders met middeloorpatologie se gehoor as normaal beskou sou word, indien impedansoudiometrie nie deel van die toetsbattery sou wees nie. vyftien ore vertoon egter uitvalle op beide suiwertoonen impedansoudiometriese resultate. hierdie resultate kan op 'n gevorderde middeloorpatologie of 'n gemengde gehoorverlies dui. tabel 5 geslag van kinders met afwykende oudiologiese resultate st suiwertoon imp = impedans seuns dogters aantal met afwykende toetsresultate 20 20 totale aantal kinders getoets 67 71 % 30 (29,9%) 28 (28,2%) tabel 6 die aard van ooren gehoorpatologie diagnose aantal uit 276 ore getoets persentasie middeloorpatologie: sereuse otitis media akute otitis media chroniese otitis media — perforasies — cholestiatoom subtotaal sensories-neurale patologie subtotaal 29 2 5 1 10,5 0,7 1,8 0,4 middeloorpatologie: sereuse otitis media akute otitis media chroniese otitis media — perforasies — cholestiatoom subtotaal sensories-neurale patologie subtotaal 37 13,4 middeloorpatologie: sereuse otitis media akute otitis media chroniese otitis media — perforasies — cholestiatoom subtotaal sensories-neurale patologie subtotaal 5 1,8 totaal 42 15,2 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 74 santi meyer en carlin van den berg uit tabel 5 blyk dit dat feitlik ewe veel seuns (29,9%) as dogters (28,2%) afwykende oudiologiese toetsresultate vertoon. hierdie resultate stem dus nie ooreen met die navorsing van klein (1978) wat bevind het dat spesifiek otitis media, betekenisvol meer by seuns as dogters voorkom nie. aard van die ooren gehoorprobleme alhoewel die inligting uit tabelle 2 en 3 aandui dat 62 ore as afwykend beskou word, dui tabel 6 daarop dat slegs 42 ore gehoorpatologie vertoon. dit kan verklaar word aan die hand van die wyse waarop die groep met sereuse otitis media geklassifiseer is, na aanleiding van die voorstel van cantekin (1983). daar is dus van beide die otoskopiese ondersoek en impedanstoetsresultate in tabel 6 gebruik gemaak. die resultate in tabel 3 is slegs op grond van die impedanstoetsresultate saamgestel. die beskikbare data is geklassifiseer deur die slaag /faal-kriteria van die impedans en otoskopiese ondersoeke met mekaar in verband te bring (cantekin 1983). sodoende kon sereuse otitis media ge'identifiseer word. suiwertoonen impedanstoetsresultate is saam met die otoskopiese ondersoek gebruik vir identifikasie van sensories-neurale gehoorverliese. in die geval van akute otitis media, perforasies en cholestiatome is daar hoofsaaklik op die otoskopiese ondersoek staatgemaak. uit tabel 6 blyk dit duidelik dat 15,2 % van die venda-kinders wat getoets is, oorof gehoorpatologie vertoon. middeloorpatologie kom voor by 13,4% van die getoetste kinders. hierdie persentasie is opvallend laag wanneer dit met die hoer voorkoms van middeloorpatologie onder ander etniese kindergroepe vergelyk word. aangehaal uit corth en harris (1984) is die voorkoms van middeloorpatologie onder getoetste populasies: alaska 27%, eskimo 15%, indo-chinese vlugtelingkinders 68,8%. die voorkoms van slegs perforasies onder navajo-skoolkinders was 14%, eskimo-kinders 32%, alaskaanse kinders 17% en amerikaans-indiaanse kinders 6,5% (northern 1978, howie 1977, johnson en watrous 1978). slegs 1,8% van die getoetste vendakinders toon perforasies. die voorkoms van sereuse otitis media by die venda-kinders (10,5%) is ook heelwat laer as die 20,5% van die amerikaanse indiane (johnson en watrous 1978). dit is verder nodig om in gedagte te hou dat hierdie studie tydens venda se wintermaande uitgevoer is. die moontlikheid bestaan dus dat die voorkoms van ooren gehoorprobleme (15,2%) kan afneem indien die toetse in die somermaande herhaal word (klein 1978). opsommend wil dit dus voorkom asof die voorkoms van ooren gehoorprobleme by hierdie groep venda-kinders laag is. die stam kan dus nie as 'n hoe risiko-groep vir ooren gehoor-patologie beskou word nie. gevolgtrekking verskeie faktore wat bydraend is tot 'n hoe voorkoms van middeloorpatologie is al ge'identifiseer byvoorbeeld onder andere sosioekonomiese status, behuising, voeding, stedelike en landelike omgewing, klimaat, gebrek aan mediese dienste (klein 1978, corth en harris 1984). die verklaring van die hoe voorkoms van otitis media by die inheemse noord-amerikaanse bevolkingsgroepe word hoofsaaklik aan die lae sosio-ekonomiese status en faktore wat hiermee verband hou, toegeskryf (klein, 1978). in die geval van die venda-kinders is die sosio-ekonomiese status laag, (van nieuwenhuizen en oosthuizen, 1984), maar ten spyte daarvan is die vendas, soos reeds genoem, baie gesond (van staden, 1983). daar kan dus verwag word dat die voorkoms van ooren gehoorprobleme laag sal wees. dit is egter moontlik dat 'n lae sosio-ekonomiese status, soos deur 'n westerse industriele gemeenskap beoordeel, nie op die tradisionele lewenswyse van die venda van toepassing gemaak kan word nie. geld speel 'n relatief onbelangrike rol en hierdie mense is tot 'n groot mate selfonderhoudend, en afhanklik van die natuur vir hul daaglikse voedselbehoeftes. behuising in lae sosio-ekonomiese groepe is dikwels beknop en ontoereikend (klein, 1978). dit blyk egter nie die geval by die venda te wees nie. behuising is 'n hut wat van hout, klei en dekgras gebou is. die man woon in sy eie hut, terwyl die vrou en haar kinders (gemiddeld drie kinders) hul eie hut bewoon (van staden, nel en van zyl, 1982). voeding is 'n verdere faktor wat die voorkoms van middeloorprobleme verhoog. kinders wat geborsvoed word vertoon 'n laer insidensie van middeloorprobleme (klein 1978). volgens crous (1984) word die venda kind dikwels tot op twee jaar of selfs langer geborsvoed. hierdie faktor mag dus bydraend tot die relatief lae voorkoms van ooren gehoorprobleme wees. die feit dat die persone in 'n landelike omgewing woonagtig is, (klein, 1978) en die klimaat deur die jaar gunstig is, (temperatuur is nie laer as gemiddeld 15 °c nie) (van nieuwenhuizen en oosthuizen, 1984) dra waarskynlik by tot die venda se goeie algemene gesondheid, en dus die relatief lae voorkoms van ooren gehoorprobleme. · westerse mediese dienste, bjyk onvoldoende te wees aangesien die venda-gebied slegs drie tot vier keer per jaar deur mediese spanne besoek word. hierdie afgelee groep mense vertoon nogtans goeie algemene gesondheid en die voorkoms van ooren gehoorprobleme is waarskynlik om die rede ook laer as wat verwag sou word, 'n hoer voorkoms is verwag, as navorsing wat met inheemse amerikaanse rassegroepe gedoen is, in ag geneem word (johnson en watrous 1978). | i die lewenstyl en eetgewoontes van die inwoners van tshikiindamalema sal waarskynlik in die toekoms, as gevolg van westerse invloede, verander. dit is van belang dat die invloed van die' verandering op die aard en voorkoms van ooren gehoorpatologie, met die oog op 'n gehoorkonserveringsprogram gemonitor wiord. aanbevelings vir verdere navorsing 'n vergelykende studie waar die voorkoms van ooren gehoorprobleme van die landelike venda-kind met die voorkoms van ooren gehoorprobleme onder die stedelike swart kind vergelyk word. bepaling van voorkoms van ooren gehoorprobleme onder die volwassenes van tshikunda-malema. die voorkoms van ouderdomsdoofheid kan bepaal word.. bedanking die skrywers bedank die hans snijkers instituut vir die geleentheid wat daargestel is om hierdie navorsing te kon doen. the souh african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die voorkomsfrekwensie van ooren gehoorpatologie by die afgesonderde gemeenskap van tshikunda-malema 75 verwysings breighton, s. third world rheumatology. in carson dick, w. en moll, j.m.h. (eds) recent advances in rheumatology nr (3). edinburg; churchill-livingstone, 1983. brooks, d.n. impedance screening. in jerger, j., northern, j.l. clinical impedance audiometry (tweede uitgawe). massachusetts: american electromedics corporation, 1980. cantekin, e.i. algorithm for diagnosis of otitis media with effusion. in stool, s.e. en bluestone, c.d. (eds) studies in otitis media pittsburgh otitis media research centre, progress report. 92, 6, 1983. corth, s.b. en harris, r.w. incidence of middle ear disease in indochinese refugee school children. audiology, 23 27-37 1984. crous, j.m. lektrise, departement huishoudkunde en dieetkunde. persoonlike mededeling, 1984. downs, m. the expanding imperatives of early identification. in bess, f.h. childhood deafness: causation, assessment and management. new york: grune & stratton, 1977. fisch, l. development of school screening audiometry brit. j. audiology, 15, 87-95, 1981. harford, e., fox, j., clemis, j. impedance audiometry for identification of conductive component in school children. in harford, e.r., bess, f.h., bluestone, c.d., klein, j.o. (eds) impedance screening for middle ear disease in children. new york: grune & stratton, 1978. harvey, r.m. en wilmot, t.j. the incidence of deafness in childhood. j. laryngology otology, 83, 449-456, 1969. howie, v.m. acute and recurrent acute otitis media. in jaffe, b.f. (ed) hearing loss in children. baltimore: university park press 1977. johnson, j.s., watrous, b.s. an acoustic impedance screening program with an american indian population. in harford, e.r., bess, f.h., bluestone, c.d., klein, j.o. (eds), impedance screening for middle ear disease in children. new york: grune & stratton, 1978. klein, j.o. epidemiology of otitis media. in harford, e.r., bess, f.h., bluestone, c.d., klein, j.o. (eds) impedance screening for middle ear disease in children. new york: grune & stratton, 1978. northern, j.l. impedance screening in special populations state of the art. in harford, e.r., bess, f.h., bluestone, c.d., klein, j.o. (eds). impedance screening for middle ear disease in children. new york: grune & stratton, 1978. northern, j. en downs, m. hearing in children (derde uitgawe) baltimore: williams & wilkins, 1984. van nieuwenhuizen, e.f.j, en oosthuizen, j.s. sosio-ekonomiese opname in tshikunda-malema (venda) 'n tussentydse verslag. universiteit van pretoria: instituut vir bedryfs en ontwikkelingsosiologie. departement sosiologie, 1984. van staden, d.a. kennismaking met tshikunda-malema geneeskunde, 1, 37-39, 1982. van staden, d.a. health and disease in a traditional-living tribe in southern africa. ecology of disease, 2, 149-150, 1983. van staden, d.a., nel, w„ van zyl, m.l. groep a b-hemolitiese streptokokke in 'n tradisionele swart gemeenskap. s a med j., 62, 569-570, 1982. weber, h.j., mcgovern, f.j., zink, d. an evaluation of 1 000 children with hearing loss. j. speech hear. disord 32 343-354, 1967. ' ' d l e suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 37 knowledge and attitudes of a group of south african mine workers towards noise induced hearing loss and the use of hearing protective devices elise kahan and eleanor ross department speech pathology and audiology university of the witwatersrand abstract the study aimed to explore the knowledge and attitudes of a group of mine workers regarding noise induced hearing loss and the use of hearing protective devices. these aims were investigated via a questionnaire administered in a group setting to 55 underground mine workers. the main finding that emerged from the study was that respondents were poorly informed regarding the fact that noise was a health hazard. furthermore, the knowledge that respondents did possess, appeared to have been derived from the personal experience of working in noisy environments for many years, rather than from educational input. contrary to expectations, respondents did not view deafness as a status symbol but rather as a negative attribute. consequently, they were motivated to protect themselves from hearing impairment and to be educated about hearing and the effects of noise. the mine workers complained about discomfort when wearing hearing protective devices as well as feelings of insecurity due to inhibition of communication and the inability to hear warning signals. for these reasons, noise protection was mainly worn in situations perceived as noisy by workers themselves. these results are discussed in terms of their implications for the clinical practice of audiology; hearing conservation in the mining industry; further research; and the training and education of speech-language pathologists and audiologists. opsomming daar is met hierdie studie gepoog om die kennis en standpunte van 'n groep mynwerkers aangaande gehoorverlies, veroorsaak deur geraas, en die gebruik van gehoorbeskermende apparate te ontgin. die doelwit is ondersoek deur middel van 'n vraelys wat 'aan 'n groep van 55 ondergrondse mynwerkers uitgedeel is. die vernaamste bevinding wat deur die studie opgelewer is, was dat proefpersone nie voldoende ingelig is aangaande die feit dat geraas 'n gesondheidsrisiko inhou nie. verder isj die kennis waaroor proefpersone beskik het blykbaar verkry uit persoonlike ondervinding van jarelange werk in geraasomgewings eerder as deur middel van opvoedkundige insette. in teenstelling met verwagtinge het proefpersone doofheid nie as statussimbool beskou nie, maar veel meer as 'n negatiewe eienskap. hulle is gevolglik gemotiveer om hulself te beskerm teen gehoorbeskadiging en om ingelig te word betreffende gehoor en die gevolge van geraas. die mynwerkers het gekla oor ongerief wanneer hulle gehoorbeskermende apparate moes dra en ook oor gevoelens van onsekerheid asgevolg'van inhibisie van kommunikasie en die onvermoe om waarskuwingseine te hoor. om hierdie redes is geraasbeskerming hoofsaaklik gebruik in situasies wat deur die werkers self as raserig beskou is. hierdie resultate is bespreek in die lig van implikasies vir die kliniese praktyk van oudiologie; gehoorbeskerming in die mynnywerheid; verdere navorsing; en die opleiding en opvoeding van spraaktaalterapeute en oudioloe. hearing loss due to occupational noise exposure has been estimated to be the most prevalent industrial disease (sataloff & sataloff, 1987). the physiological and psychological effects of noise on humans have been recognised for centuries (miller & silverman, 1984). in fact, the first known reference to noise induced hearing loss (nihl) was found in the medical literature of the sixteenth century (howse, 1987). in addition, a steady increase in the intensity and prevalence of noise in both living and working conditions has been noted since the industrial revolution (sataloff & sataloff, 1987). moreover, as modern technology has become more sophisticated, greater recognition of the effects of noise on hearing has occurred. "noise adversely affects the quality of life and strong links exist between noise levels and accident rates. recognition of this causal relationship has prompted legislation which, in turn, has been instrumental in the design and institution of hearing conservation programmes" (kielblock, 1986, p.2). legislative acts which have either directly or indirectly affected industrial hearing conservation programmes include the factories, machinery and building work act (1941), the machinery and occupational safety act (1983) and the mines and works act (1956) which was amended in 1964 and 1989 and amalgamated in 1991 to form the minerals act no. 50 of 1991. acdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 elise kahan & eleanor ross cording to a notice in the star newspaper, may 1994, a commission of inquiry into safety and health in the mining industry was being planned. the purpose of this inquiry was to investigate all aspects of the legal regulation of health and safety in the mining industry as defined in the minerals act, no. 50 of 1991; and to make recommendations to the state president on improvements to the existing regulations. this commission of inquiry formed part of the national health plan for south africa (1994) formulated by the african national congress (anc). against this historical and legislative backdrop, noise has been defined as "any unwanted auditory, electric or other signal, a signal that interferes with the detection and discrimination of sound and sound having aperiodic waveform" (sheeley, 1985, p. 1079). "noise is capable of producing a hearing loss in two ways: the hearing loss could result from acoustic trauma (e.g., an explosion), or it could be produced from chronic exposure to noise" (miller & silverman, 1984, p.101). noise induced hearing loss typically begins in the high frequencies (especially 4000 hz) and progresses to involve speech frequencies with continuing exposure (jackler & kaplan, 1994). effects of noise on hearing may be divided generally into three categories: temporary threshold shift, permanent threshold shift and acoustic trauma (miller & silverman, 1984; guignard, 1973 in melnick, 1985). temporary threshold shift (tts) refers to a short-term elevation in the threshold of hearing which recovers gradually following the noise exposure. permanent threshold shifts (ptss) are those hearing changes which persist. ptss which result from acoustic trauma or a single encounter with very destructive noise do exist but are relatively uncommon. more frequently, hearing loss produced by the effects of noise exposure is a result of accumulation of noise exposure which is repeated on a daily basis over a period of years. studies conducted by the chamber of mines research organisation (comro) clearly show that noise induced hearing loss occurs frequently in numerous instances due to workers' excessive exposure to noise. these studies were first started by comro in 1974 and the first industry wide studies followed in 1979 (leger, 1985). according to south african labour statistics, at the end of 1993 there were 676,380 people employed in the mining and quarrying industry. it is difficult to calculate the number of these workers exposed to noise. it has, however, been pointed out by the national institute of occupational safety and health (niosh) that the number of workers exposed to noise in the mining industry far exceeds the number exposed to noise in the majority of other industries (kielblock, van rensburg, frans & marx, 1991). for this reason, formal hearing conservation programmes have been introduced in the mining industry. the fundamental objective of any hearing conservation programme (hcp) is to protect workers from suffering permanent hearing impairment as a result of excessive exposure to noise at their place of work (miller & silverman, 1984; kielblock, 1986; sataloff & sataloff 1987). personal protection by means of hearing protective devices (ear-muffs or insertable plugs) is the most common form of hearing conservation in the south african mining industry to date (kielblock, 1986; shearer, 1992; kielblock & van rensburg, 1988). in order for hearing conservation programmes to be effective, it is therefore imperative that those at risk wear appropriate hearing protection correctly and consistently. as early as 1961 maas (cited in newby & popelka, 1985) reported on a study by an insurance company in wisconsin, which found that only 22.5% of the 1,148 plants polled, indicated success in encouraging workers to accept ear protectors for a period of six months or more. reasons for not utilizing ear protection included discomfort, headaches, interference with hearing, and getting used to noise so that it was not regarded as bothersome. by the next decade, the situation did not seem to have improved greatly as mass (1975) revealed a failure rate of more than 50% of hearing conservation programmes conducted in the united states. one of the primary reasons for this failure rate appeared to be the fact that workers did not perceive noise as a health hazard. another feature of the resistance to avoiding noise exposure stems from anecdotal evidence on the "macho" image which some men feel the need to display. wearing ear protectors is perceived as a sign of weakness (lipscomb, 1988). more recently, kielblock (personal communication, 1994) hypothesized that a possible reason for south african mine worker's reluctance to wear hearing protective devices might be related to the positive status of mine workers. as noise is part of the mine workers' job, he suggested that noise induced hearing loss represents an emblem of pride for the mine worker in that it provides proof that he has worked on the mines. stewart (1988) highlights a further factor which is likely to influence mine workers' attitudes towards the use of hearing protective devices . he explains that the sound levels of all sources of noise to which workers are exposed, fall well below the pain threshold which is about 140dba. furthermore, in view of the fact that typical noise induced hearing loss does not interfere with speech discrimination, at least not during the early stages, the noise hazard is usually not perceived as real. kielblock & van rensburg (1988) studied a group of 480 novices and returners to the south african mining industry in order to explore the relationship between workers' perceptions of noise as a health hazard and their willingness or reluctance to wear hearing protectors. they found that more than 80% of their respondents did not perceive noise as a 'problem' in their jobs, while the most experienced workers were capable of identifying the most noisy work categories. permanent hearing loss, as a sequel to prolonged exposure to noise, was regarded as a health hazard by only 16% of the respondents. the need for hearing protection in noise was recognised in 65% of cases, but 47% of respondents were averse to protecting their own hearing, since they felt that they would not be able to hear anything while wearing hearing protectors. the attitude of the mine workers towards noise as a health hazard thus appeared to contribute to the high failure rate of the hearing conservation programmes. kielblock & van rensburg (1988) concluded that invariably the value of education (as a means of influencing attitudes) is under-estimated. they emphasize that the challenge to education is to convince employees that noise which is not painful can still lead to hearing loss which is not apparent at first. in other words, employees should be educated to regard noise as a hazard similar to more obvious hazards such as heat, the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) k n o w l e d g e and attitudes of a group of south african mine workers towards noise induced hearing loss and the use of hearing protective devices electricity and falls of ground. despite the important findings yielded by this study, it must be borne in mind that the researchers asked r e s p o n d e n t s only three questions in order to minimise disruptions to work routine and productivity on the mine. the present research project endeavoured to extend and build on kielblock & van rensburg's pioneering research efforts by surveying a broader range of knowledge and attitudes held by mine workers, towards noise induced hearing loss and the use of hearing protective devices. the opportunity to conduct the study, was provided by a diamond mine situated in the northern transvaal.' according to the 1993 annual report, the mine in question retained a five star safety grading in 1993, but safety performance deteriorated. the progressive disabling-injury incidence rate rose from 0,32 per 200,000 man hours worked in 1992, to 1,33 per 200,000 man hours worked in 1993. a revised safety management programme was formulated and is currently being implemented on the mine in order to reverse this adverse trend. the loss-control co-ordinator in charge of implementing the programme expressed the view that the research project would fulfil a vital need by providing important information which could hopefully be embedded in the revised safety management programme. furthermore, before the mine management embarked on a time-consuming and costly educational programme with their large workforce, it seemed advisable to first obtain more facts on workers' attitudes. it was hoped that a survey of mine workers' knowledge and attitudes towards noise-induced hearing loss and the use of hearing protective devices, would not only improve existing guidelines for hearing conservation programmes with this section of the population, but also contribute knowledge and understanding to a relatively neglected research area. moreover, the central focus of health policy in south africa is currently on primary health care as articulated in the african national congress's publication: a national health plan for south africa (1994). hearing conservation, as a form of preventive medicine, falls within the ambit of primary health care, thus underscoring the relevance and appropriateness of the present study to the south african context. moreover, the fact that a commission of inquiry into safety and health in the mining industry, was being held at the time the research project was conducted, further underlined the timeliness of the study. methodology aims of study 1. to investigate mine workers' knowledge of noise as a health hazard. 2. to explore the attitudes of these mine workers towards hearing loss; and , 3. to examine their attitudes towards wearing hearing protective devices. subjects criteria for selection: 1) subjects were required to be males between the ages of 24 and 45 years. this criterion was adopted be39 cause writers such as jerger & jerger (1981) maintain that auditory sensitivity of subjects in this age range is unlikely to have been affected by exposure to noise, use of ototoxic drugs or to degenerative effects associated with age. however, it is recognised that this assumption is open to question. 2) subjects were required to present with normal hearing. "according to the law employees working in noise levels above 85db must have hearing tests at least once per year" (noise: a safety steward's manual, 1991, p.49). the advantages of this procedure is that it allows the workers to be transferred to quieter jobs before their hearing is significantly affected. the disadvantage is that managers may transfer workers to jobs with lower remuneration or dismiss workers on the pretext that they must be repatriated for medical reasons. in view of these possible consequences of hearing impairment, persons who had sustained a hearing loss were excluded from the study as it was felt that this factor might have influenced their employment experiences and consequently biased their responses to the questionnaire. 3) the third subject selection criterion was literacy i.e., the ability to read and write english, so as to prevent incorrect information being collected due to a lack of understanding of the research instrument. 4) the final criterion was that all subjects were required to be working underground, so that they would be exposed to similar environmental conditions, altered by type of work only. subject sample after obtaining permission from the management of the mine as well as the co-operation of the national union of mine workers, 55 miners employed at the mine in question, were recruited for participation in the study. assistance was sought from the medical and loss control specialists employed at the mine to ensure that all subjects met the selection criteria. a non-probability, convenience sample was used. according to bless & achola (1990 p.75) this sampling procedure consists of taking all cases on hand until the sample reaches the desired size. for practical reasons as well as safety considerations, the subject sample comprised all workers who belonged to the same shift and worked on the same level underground on the day on which the study was conducted. the level chosen by the mine management accommodated 60 persons working in different categories e.g., drillers, operators, mechanics and helpers. of these 60 persons, 55 met the subject selection criteria. unfortunately, for reasons of confidentiality, it was not possible to obtain information from the mine regarding the levels of noise to which these different categories of workers were exposed. description of subjects the sample comprised 55 male mine workers. the ages ranged from 25 to 45 years with a mean age of 36.6 years. the home languages of the subjects were: sotho 47.3%, zulu 5.5%, pedi 14.5%, shangaan 1.8%, afrikaans 16.4%, english 1.8% and xhosa 10.9% with 1.8% unknown. extent of work experience ranged from 3 years to 28 years with a mean of 13 years and 8 months. the categories of jobs worked included: helpdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 elise kahan & eleanor ross ers 50.9%, machine drillers 7.3%, operators 12.7% and mechanics 24.1%. while 18.2% of the respondents mentioned that they had previously suffered from external or middle ear pathologies e.g., otitis media, the vast majority, namely 81.8%, had experienced no problems with their ears. all subjects had been audiometrically assessed as having normal hearing. research design in order to investigate the aims of the study, a survey research design was employed. in terms of the size of the mining population, its demographic spread and restrictions of time and resources, the use of a short questionnaire, personally administered, in a group setting to a sample of mine workers, was believed to be the most appropriate methodological tool for this study. description of the questionnaire a 6-page questionnaire comprising 27 questions was constructed which could be completed in 15-20 minutes. the instrument was drafted in english and a speaker of fanakalo was availaible for the benefit of respondents who came from diverse language backgrounds. the introductory letter provided assurance of confidentiality and anonymity and explained the purpose of the questionnaire. according to bailey (1987) these factors often determine whether or not respondents co-operate in filling in the questionnaire honestly and completely. included with the covering letter was an informed consent statement which complied with the guidelines laid down by the committee for research on human subjects, university of the witwatersrand. the questionnaire was made up of the following sections: a) demographic questions; and b) knowledge and attitudinal questions that examined: i) knowledge of noise induced hearing loss and the use of hearing protective devices. ii) attitudes towards noise induced hearing loss and the use of hearing protective devices; and iii) perceptions of the extent of service provided by the mines in the area of hearing conservation. these two sections are described separately as follows: demographic information the aim of the first eight questions was to obtain a socio-demographic profile of the respondents by soliciting biographical information on age, home language, type of work engaged in, and duration of work experience, as well as to identify anyone who had experienced ear or hearing problems in the past. questions which investigated knowledge of and attitudes towards noise induced hearing loss, hearing conservation and services the present study aimed to identify the knowledge and attitudes of mine workers towards noise induced hearing loss and the use of hearing protective devices. in view of the fact that english was the second language of the respondents targeted in the study, the majority of questions were formulated in a closed-ended format to facilitate ease of completion. the rationale for inclusion of the various items in the questionnaire was based on guidelines laid down by the national union of mine workers, relevant legislation, as well as the literature on hearing conservation. according to "noise: the safety steward's manual" of the national union of mine workers (num) (1991), the minerals act states that if it is not possible to bring the noise levels down to below 85db, management is obliged to implement a hearing conservation programme. the first step involved in achieving this goal is the requirement that management signpost all noisy areas. question 1 therefore endeavoured to ascertain whether respondents had previously observed these noise warning signs. questions 2, 3 and 4 investigated workers' knowledge and perceptions of noise in their working environments and its effects. these questions related to findings in the literature that workers apparently lack information and are uneducated about noise and its effects on hearing (kielblock & van rensburg, 1988; leger, 1985; shearer, 1992; noise: the safety steward's manual, 1991). management is further obliged to carry out hearing tests on every worker annually. if the noise level exceeds 105db, hearing tests must be conducted every six months. questions 5 and 6 therefore aimed at obtaining information on the frequency of hearing tests conducted on respondents. the publication "noise: the safety steward's manual" (1991, p.30) states that "workers don't know the results of their hearing tests." hence question 7 probed whether results of hearing tests had been explained to the mine workers. question 8 then explored whether respondents had been given information on the effects of noise on hearing. question 9 explored respondents' motivation to learn about noise and hearing, and question 10 investigated the manner in which respondents wished to obtain information on these topics. j question 11 aimed to investigate respondents' attitudes towards a hearing loss. kielblock (personal communication, 1994) suggested that one of the weaknesses of hearing conservation programmes was respondents' lack of education. he also hypothesised that they perceived a hearing loss as a sign that they were mine workers and therefore a symbol of pride. management, is expected, according to the sabs 0831983 code of practice for the measurement and assessment of occupational noise for hearing conservation purposes, to train workers on how to use hearing protection. hence question 12 inquired whether respondents wore any hearing protective devices. questions 13 and 14 focused on reasons for use or non-use of hearing protectors and question 16 attempted to ascertain whether training had been given in the use/ storage, cleaning and replacement of such devices. it is suggested in "noise: the safety steward's manual" (1991) that management give each worker the opportunity to try out a number of different types of hearing protection. question,15 therefore endeavoured to ascertain whether workers had in fact been given a choice of hearing protective devices. the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) k n o w l e d g e and attitudes of a group of south african mine workers towards noise induced hearing loss and the use of hearing protective devices questions 17 and 19 investigated respondents' attitudes towards hearing conservation programmes and were based on the hypothesis that if the mine workers viewed hearing loss as a positive attribute (kielblock, personal communication, 1994) or if they were uneducated about the connection between noise and hearing loss (kielblock & van rensburg, 1988; shearer, 1992; leger, 1985) then they would most likely view a hearing conservation programme as being unnecessary and hence not request that one be started on the mine. question 18 enquired if the mine already had a hearing conservation programme in place. the final item, that is, question 20, used an openended format which allowed respondents the opportunity to express any other views or comments on the topic under discussion. research protocol data analysis data were analysed using descriptive statistics derived from the sas computer package, and presented in the form of tables and bar charts. statistical procedures adopted were univariate analyses, which provided frequency distributions, means and ranges. cross-tabulations of certain variables were also carried out, as well as chi-square analyses to determine differences between sub-groups on certain items. open-ended questions were analysed qualitatively according to themes expressed by the respondents. results and discussion results of the study are presented according to the order in which items appeared in section β of the questionnaire1. submission of questionnaire to the human ethics research committee in accordance with the code of ethics for research on human subjects (university of the witwatersrand), the questionnaire was submitted to the relevant university committee to ensure that informants' physical, social and psychological welfare was protected and their dignity and privacy respected. pilot study the adequacy of the research instrument and the practical possibilities of carrying out the project were assessed in a pilot study. the questionnaire was submitted to a member of the mine management as well as a num official for approval before the pilot study was carried out. four underground mine workers from the mine were the subjects in the pilot study. these men were excluded as subjects in the field study. although an official from the mine had informed the researcher that all the mine workers were able to read and write english, the pilot study revealed that different workers demonstratejd different levels of understanding. it was therefore decided to utilize the services of a fanakalo interpreter employed at the mine in order to enhance understanding of the questionnaire by respondents. j j the field study x the study was conducted in a group setting underground in the workshop area. the researcher was present to answer any queries and two speakers of fanakalo were available if subjects needed clarification or translation of any questions or words. both translators had been briefed previously on the need to adopt a neutral, objective stance and to keep as close as possible to the original phrasing of questions so as to avoid biasing respondents' answers. singleton, straits & straits (1993, p.262) state that "interviewers must be trained to be sensitive to the way in which they may wittingly or unwittingly affect their interviewees' responses". recognition of the noise warning sign the mine workers' knowledge was explored by eliciting information on the percentage of respondents who recognised the noise warning sign, as well as the proportion who understood what the sign meant. the vast majority of respondents i.e., 53 (96.4%) of the 55 persons in the sample recognised the sign, while a similar proportion i.e., 52 (94.5%) understood the meaning of the sign. these results indicated that the notices at the shaft head, advising persons to wear hearing protectors when entering a noise zone, as well as the appropriate noise warning symbols, prominently displayed at all entrances and exits of noise zones i.e., areas where noise exposure was greater than 85dbhl, were effective in that the mine workers had seen them and understood why they had been erected. the implication of these findings is that the mine was carrying out the guidelines on noise warning signs laid down by the sabs and that these notices were being effectively seen and understood. respondents who felt they worked in noisy conditions the majority of respondents i.e., 42 (76.4%) felt they worked in a noisy place. a survey conducted by the chamber of mines suggests that the majority of underground day shift workers are exposed to an equivalent noise level of loodba or more (van rensburg, schutte, strydom, jooste & schoeman, 1980). the results obtained from the present study appeared to validate the statement made by the chamber of mines. according to sabs 083-1970, the hearing of 120 out of every 1000 workers will be impaired within five years if exposed to noise levels of this intensity. these figures imply that unless the hearing conservation programmes are successful or there is greater noise control engineering, there is likely to be a large number of workers presenting with hearing losses and an extensive hearing impairment liability for mine management in the form of compensation claims. 1 copies of the questionnaire are available from the second author, dept. of speech pathology and audiology, university of the witwatersrand, p.o. wits, south africa, 2050. die suidafrikaanse tydskrif vir kommunikasieafwykings, vol. , 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 elise kahan & eleanor ross respondents who felt that working in noise affected hearing a total of 52 (94.5%) of the respondents felt that working in noise affected hearing. these results illustrate that the workers were aware of the dangers of noise. however, on further questioning to ascertain why the workers thought that noise affected hearing, many miners stated that they did not know the reason but realised that noise influenced hearing due to personal experience. some of the statements furnished by respondents which highlighted this point included the following: "because i can feel it afterwards." "the noise hurts my ears and i can't hear my friends on the way back from work." "self-experience." another common response was that when working in noise, the noise blocked out all other sounds including the sounds of people talking. these findings suggested that much of the workers' knowledge appeared to be derived from the personal experience of working in a noisy environment. this is understandable if one considers that the mean number of years worked on the mine, was 13 years 8 months. the majority of these workers felt that they worked in a noisy environment and sabs 083-1970 states that noise levels of 100 dba can cause 120 out of every 1000 workers to become hearing impaired within five years. the emphasis on prevention in the new government health care policy (a national health plan for south africa, 1994, p. 19) would appear to underscore the need for workers to be educated about the dangers of noise rather than learn about noise through physically experiencing its effects. in this respect professionals who have been trained in the field of audiology could fulfil a vital educational role by supplementing the valuable services currently provided by personnel from other disciplines involved with hearing conservation on the mines. respondents'perceptions of changes in their hearing status since working on the mine when respondents were asked about the stability of their hearing, 34 (61.8%) stated that they felt their hearing had remained the same, while 21 (38.2%) perceived their hearing to have deteriorated. this finding suggests that in 38.2% of the cases the hearing protection was either not effective or not being used. information on table 1. respondents' perceptions of their hearing status since working on the mines. cross tabulated with the use of hearing protective devices, while working perceived hearing status was cross-tabulated with data regarding the use of hearing protective devices while working, and the results depicted in table 1. the findings show that 22 (40%) of the respondents who wore their hearing devices compared with the 12 (21.9%) who did not wear these devices while working perceived their hearing to have remained the same, while 19 (34.5%) of respondents who wore their hearing protective devices and the 2 (3.6%) who did not use these devices perceived their hearing to have deteriorated. the findings imply that although 40% of respondents were wearing their hearing protection and finding their hearing to be the same, 34.5% stated that they were wearing their hearing protection and the hearing protection devices were not efficacious, i.e., conserving their hearing. a chisquared analysis indicated significant differences between these sub-groups (x21=4,543; ρ < 0.05). however, the data only represent workers' perceptions of their hearing status. in order to obtain more scientific data, one would have to correlate respondents' perceptions with audiometric test results. regularity of hearing tests all the respondents reported that their hearing was tested annually, prior to going on vacation. this finding demonstrates that the regulations laid down in the sabs 083-1983 were being effectively implemented at the mine in question. explanation of results table 2 shows the percentage of mine workers who stated that the results of their hearing tests had been explained to them. the majority of workers namely, 38 (69.1%) reported that they had not had the results explained to them. these data were cross-tabulated with the workers' home language. it is of interest to note that the majority of respondents who had had the results of their hearing test explained to them were afrikaans first language speakers. this finding may indicate that due to language barriers the results of the hearing tests are table 2. respondents who had/did not have their hearing test results explained to them, cross tabulated with their first language | yes no remained the same 40,0% 12,9% deteriorated 34,5% 3,6% total 74,5% 16,5% the south yes no unknown sotho 5,5% 40,1% 1,8% pedi 3,6% 10,9% 0 xhosa 1,8% 9,1% 0 ' afrikaans 12,8% 3,6% 0 english 1,8% 0 shangaan · 0 1,8%·' 0 zulu 1,8% x%% r 1,8% unknown 0 ,· 1,8% 0 total % 27,3% 69,1% 3,6% / journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) knowledge and attitudes of a group of south african mine workers towards noise induced hearing loss and the use of hearing protective devices not explained to all workers. one possible way of dealing with language barriers could be for translators to be available to explain the results of the hearing tests to the workers. indeed, the effective use of a system of interpreters and translators could play a vital role in ensuring the success of hearing conservation programmes. such a system could firstly, educate the workers about their individual hearing as well as about hearing in general; and secondly, inform workers, so as to empower them to make their own decisions about their hearing i.e., whether they needed to be transferred to a quieter job or whether they should choose a different type of hearing protection device. as kielblock (1986) states: "the success of any hearing conservation programme hinges primarily on education and personal relevance." the explanation of the workers' hearing test results could go a long way towards fulfilling both these criteria. 43 attitudes towards the view that deafness is a positive status symbol for mine workers fig 3 demonstrates that the majority of respondents either disagreed or strongly disagreed with the statement that deafness is a positive status symbol for mine workers. there was only 1 (1.9%) respondent who strongly agreed and 2 (3.7%) who responded neutrally. this finding implies that the majority of the mine workers in the sample did not feel that deafness was a positive status symbol. this result appears to refute the idea expressed by kielblock to the researcher personally, that part of the challenge to a hearing conservation programme was the positive attitude of mine workers towards a hearing loss. however, the present research respondents who had been educated about the effects of noise on hearing fig 1 indicates the percentage of respondents who had been advised about the effects of noise on hearing. a total of 31 (56.4%), reported being informed; however, 24 (43.6%) were not informed. this percentage suggests that many workers were not receiving sufficient education/ information. kielblock (1986) maintains that this lack of education is the reason why programmes fail. it would therefore appear to be vitally important to enhance the educational side of hearing conservation programmes. respondents who requested information about noise and hearing fig. 2 shows that a large number of respondents namely 34 (61.8%) indicated a desire to learn more about noise and hearing. this finding may be due to the results obtained from question 3 i.e., that respondents' knowledge about noise and hearing had been derived primarily through personal experience rather than educational input. it would therefore be interesting to pose this same question to novice mine workers with limited work experience and compare results with those obtained from miners with longer work histories. ι medium of information requested for learning about the effects of noise on hearing this item probed the manner in which respondents wished to be informed about the effects of noise on hearing. the majority of respondents indicated a preference for video, while the remaining respondents were equally divided between a personal talk or a group talk. these results provide important information on'how to supplement existing hearing conservation programmes with additional input that will reach the workers and, hopefully, make the programmes more effective. through the medium of film/video, group talks and personal talks, and with the help of professionals in the field of noise and hearing, it is possible to educate and motivate respondents so as to improve the chances of hearing conservation programmes being successfully implemented. a ί ζ m ο a. 50.4% 43.6% y e s n o figure 1. respondents who had or had not been told about the effects of noise on hearing (n=55) cd < 60% ο 6 1 . 8 % γ • 9 . 1 % y e s n o u n k n o w n figure 2. respondents who requested information about noise and hearing. (n=55) % m ο a. m s t r o n g l y a g r e e figure 3. attitudes towards the view that deafness is a positive status symbol for mine workers. (n=55) die suidafrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 elise kahan & eleanor ross project was conducted on a relatively small convenience sample which precludes generalisation of the results to the broader population of mine workers. it is therefore suggested that the research be replicated on a larger, more representative sample and results compared. use of hearing protective devices while working the majority of mine workers i.e., 41 (74.5%) stated that they used hearing protection while working. reasons for the use/non-use of hearing protection while working mine workers' attitudes were examined by eliciting explanations for wearing or not wearing their hearing protective devices. qualitative responses included the following: "to protect the ear; to prevent deafness." "only when they are compulsory, when they are not compulsory noise can't be bad for you." "only when in loud noise." "depends where one is working, the noise is not very bad everywhere." from the above statements it appears that the majority of respondents wore hearing protection in noise that they considered to be dangerous for them. however, one is not sure whether or not respondents' definitions of loud noise meant noise greater than 85 dba as recommended by the sabs. this implies that workers may have had hearing protection available to them but may still have been exposing themselves to harmful noise due to incorrect judgement of the noisy situation. the only way to prevent this phenomenon from occurring seems to be via education. it would seem that workers need to be informed about what noise level is harmful and given an example/model of harmful noise intensity which they can use to assess whether or not they are in a hazardous noise zone. reasons for not wearing hearing protective devices while working, included the following: "inhibits communication." "can't hear warning signals." "uncomfortable." "causes skin irritation." "machines only come sometimes, so not so noisy." these examples indicate that the majority of reasons for not wearing hearing protection centred firstly, around the lack of comfort and secondly, the inability to "hear the hanging talk". with regard to the first aspect, comfort is one of the issues constantly addressed by employers, employees and manufacturers of hearing protective devices. it is also indirectly addressed in the sabs 083-1983 code of practice which states that workers must be provided with a choice of hearing protective devices. with regard to the second aspect, jones (1994, p.29) explains that "hanging talk is referred to by mine workers as a sort of primordial whisper as tiny fractures spread rapidly through the ground. the only other natural alarm is the scuttling of rats as they abandon miners to their fate." similar concerns have been found among workers who have to wear hearing protection world-wide (sataloff & sataloff, 1987; miller & silverman, 1984; kielblock, 1986; leger, 1985). the view that hearing protective devices inhibit communication is challenged and defended in various studies. kryteri, 1946, in leger (1985) found slight improvements in signal and speech intelligibility from wearing hearing protection. schroder, van rensburg, schutte & strydom (1980), also endorse the above view. endruweit & hach (1977), state that hearing protection improves speech communication in noisy environments; however, adaption is necessary and varies from person to person. kielblock (1986) explains that with hearing protection one hears better, but differently. wilkins & martin (1982) challenge some of these assumptions by saying that wearing hearing protection did not have any major effect on recognition of artificial warning signals such as sirens and alarms in the sample that they studied; however, the perception of environmental warning sounds was reduced. abel, alberti & riko (1982), showed that hearing protection did not have any effect for individuals with normal hearing but when individuals suffered from hearing loss, hearing protective devices reduced speech intelligibility considerably. taking all these points into consideration, it would seem that hearing protective devices do serve a purpose. nevertheless, they are not without faults, even allowing for proper induction, instruction and adaption. furthermore, as kielblock (1986) points out, hearing protection devices should be seen as an interim measure only until more effective noise reduction strategies can be implemented. in other words, noise intensity should be reduced at the source via quieter machinery rather than minimising noise for the receiver via hearing protective devices. whether respondents were given a choice of hearing protective devices analysis of data revealed that 27 (50,9%) of respondents reported not being given a choice of hearing protective devices. the publication entitled: "noise: a safety stewards manual" (1991) states that management must give each worker a number of different types of hearing protection to try out. kielblock (1986) states that one of the reasons many hearing conservation proputting them on storing them cleaning them when to replace y e s n o figure 4. training received on use of hearing protective devices. (n=55) / the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) knowledge and attitudes of a group of south african mine workers towards noise induced hearing loss and the use of hearing protective devices 45 g r a m m e s fail is the lack of choice of hearing protective devices. it is therefore recommended that all workers be provided with a choice of hearing protective devices. training received in the use of hearing protective devices fig 4 shows that the majority of the respondents stated that they did not receive training in any of the four areas i.e., inserting and removing; storing; cleaning; and replacing hearing protective devices. some of the workers in the study claimed that one of the reasons for not using their hearing protection was due to skin irritation or sores allegedly caused by these devices. proper instruction in the above four areas, especially storing, cleaning and replacing may help in alleviating some of these complaints, thereby helping workers to protect their ears as well as preventing them from experiencing unnecessary irritation and pain. moreover, the generally hot, dusty conditions which prevail in many underground mining areas and which tend to cause mine workers to perspire profusely, further underscores the need for proper cleaning and storage of hearing protective devices. hence instruction in the use and care of hearing protectors could probably be more cost effective for the mine than treating ear infections and paying hearing compensation claims. this type of educational strategy could also improve the success rate of hearing conservation programmes. views regarding a hearing conservation programme the vast majority of the respondents i.e., 52 (94.5%) felt that a hearing conservation programme was necessary and requested that the mine should start one. these results imply that these mine workers were motivated and therefore, if a comprehensive, integrated hearing conservation programme was started and properly implemented, there appeared to be a good chance of success being achieved. the publication entitled, "guidelines for the implementation and control of a hearing conservation programme in the south african mining industry" (1988) spates that the success of many hearing conservation programmes hinges on the extent of voluntary participation which in turn, stems from personal conviction. the mine workers in this study displayed an attitude conducive to the successful implementation of a hearing conservation programme. many respondents i.e., 39 (70.9%) realised that although the mine had implemented legislative guidelines in terms of hearing conservation, the mine had nevertheless, not implemented a comprehensive hearing conservation programme as defined in the questionnaire i.e., a programme which teaches mine workers, union officials and management how to reduce noise levels, how to conserve or save workers' hearing and how to prevent hearing loss. for this reason many of the respondents i.e., 39 (70.9%) correctly stated that the mine did not have a hearing conservation programme. although the mine had installed noise warning signs, issued free hearing protective devices, provided hearing tests every year and covered the topic of hearing in some ten minute lectures, these factors do not constitute a comprehensive, integrated hearing conservation programme. views articulated by the majority of respondents also highlighted the mismatch between what providers and recipients of a hearing conservation programme perceive as an adequate programme. the respondents who stated that the mine did have a hearing protection programme incorrectly assumed that the safety measures which had been legislated,for, and which were being carried out, constituted a comprehensive hcp. additional comments the respondents were given the opportunity to express any further comments. this item was formulated as an open-ended question. the following are examples of some of the responses furnished: "less noise on the mine." "give feedback on results." "would like more information on hearing protective devices." "if my hearing is becoming worse, who do i complain to? will i lose my job?" "would like to see a hearing conservation programme implemented on the mine." "would like to know if the mine has a hearing conservation programme." "would like a hearing test to be done every 6 months and the doctor must look inside the ear to see that there is no irritation, dirt or sore." "there is a lot of noise in the working place like the machines and fans. the mine must try to reduce the noise." "would like more training about ears, noise and hearing." these verbatim responses indicated that the mine workers in the study appeared to be lacking knowledge and were motivated to obtain help, guidance and assistance. the reason for this was probably due to their experience of working in noisy conditions and experiencing the effects of noise. conclusions the main finding that emerged from the study was that, in terms of knowledge, respondents were poorly informed regarding the fact that noise was a health hazard. furthermore, respondents' knowledge appeared to have been derived from the personal experience of working in noisy environments for many years rather than from educational input. contrary to expectations expressed by kielblock (personal communication, 1994), the majority of respondents did not view deafness as a status symbol and therefore did not have a positive attitude towards a hearing loss. they were motivated to protect themselves against deafness and to be educated about hearing and the effects of noise. furthermore, the mine workers' demonstrated positive attitudes towards wearing hearing protective devices in situations which they themselves perceived as noisy. they also complained about lack of comfort when wearing the devices as well as feelings of insecurity due to the inhibition of communication and the inability to hear warning signals. these were the primary reasons furnished by workers for only wearing these devices in situations perceived as noisy by the miners themselves. it is important to note that this study was conducted on a relatively small, unrepresentative, non-probability, convenience sample, which precludes generalisation die suidafrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 elise kahan & eleanor ross across the mining industry as a whole. nevertheless, the findings from the study do have implications for clinical practice of audiologists; hearing conservation in the mining industry; further research; and the training and education of speech-language pathologists and audiologists. clinical practice of audiologists the study highlighted the need for audiologists to play a vital role in the area of education and worker empowerment to help ensure successful hearing conservation programmes. according to the national health plan (1994), health policy in south africa advocates a primary health care (phc) approach which incorporates health programmes and services that emphasize both prevention and rehabilitation, and identify high-risk and under-served occupational groups. the audiologist would appear to be ideally equipped with knowledge and understanding in the area of hearing and noise induced hearing loss, to ensure that health policy and related legislation benefit at risk groups such as the mining population. hearing conservation in the mining industry findings from the study clearly show that there is more to a successful hearing conservation programme than simply implementing the safety regulations for hearing supplied by the sabs. the implication is that although mines such as the one where the study was conducted, appear to be making a concerted effort to conserve hearing, there is a need to establish comprehensive hearing conservation programmes which incorporate all the factors mentioned in both the guidelines for the implementation and control of a hearing conservation programme in the south african mining industry (1988), as well as the publication entitled "noise: a safety steward's manual" (1991). in particular, it is recommended that: (1) greater use be made of audiologists in the education of mine workers regarding noise as a hearing hazard. (2) results of hearing tests be explained to miners. (3) workers be provided with a choice of hearing protective devices. (4) mine workers be given training in the insertion, removal, cleaning, storage and replacement of hearing protective devices. research results from the present study cannot be generalised due to the relatively small convenience sample used. it is therefore recommended that the study be replicated on a larger, more representative sample which would more realistically reflect the mining populations' knowledge and attitude towards hearing loss and the use of hearing protective devices. other recommendations for future research include the following: similar questions as the ones posed in the present study questionnaire could be put to a group of novice mine workers to see if similar results are obtained. knowledge and attitudes towards noise induced hearing loss and the use of hearing protective devices could also be related to audiometric assessments of respondents. similar studies on the knowledge and attitudes of workers towards noise induced hearing loss and the use of hearing protection devices, could be carried out with other at risk occupational groups in commerce and industry e.g., airline pilots and construction workers. training and education of speech-language pathologists and audiologists at present the training curricula of speech-language pathologists and audiologists seem to focus largely on the theory underpinning noise induced hearing loss and the principles of hearing conservation. it is recommended that more opportunities be provided for students to acquire the practical experience of educating various occupational groups regarding the hazards of noise, and of actively implementing hearing conservation programmes in the community, particularly in high noise-risk industries. acknowledgements the authors wish to express their sincere appreciation to brad taurog for his assistance with creating the figure diagrams. references a national health plan for south africa. 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(1984). occupational hearing conservation. englewood cliffs: prentice hall. noise. a safety steward's manual. (1991). national union of mine workers. j o h a n n e s b u r g : learn and teach publications. newby, h.a. & popelka, g.r. (1985). audiology. 5th ed. englewood cliffs, new jersey: prentice-hall inc. sataloff, r.t. & sataloff, j. (1987). occupational hearing loss. new york: marcel dekker, inc. schroder, h.h., van rensburg, g.a.j., schutte, p.c. & strydom, n.b. (1980). noise and hearing conservation in the gold mining industry. johannesburg: chamber of mines. shearer, s. (1992). the sound of silence. goldfields review 1991 1992. (pp.65-70), johannesburg: goldfields. sheeley, e.c. (1985). glossary. in katz, j. (ed.). handbook of clinical audiology. third edition. baltimore: williams & wilkins. singleton, r.a., straits, b.c. & s t r a i t s , m.m. (1993). approaches to social research. new york: oxford university press. south african labour statistics. (1993). pretoria: central statistical services. stewart, a.p. (1988). the comprehensive hearing conservation program. in lipscomb, d.m. (ed.). hearing conservation in industry, schools and the military, (pp. 203-230), london: taylor and francis. van rensburg, a.j., schutte, pc., strydom, n.b., jooste, p.l.& schoemann, j.j. (1980). the personal noise doses of different workers in the gold mining industry. johannesburg: chamber of mines. (unpublished paper). wilkins, p.a. & martin, a.m. (1982). the effects of hearing protection on the perception of warning sounds. in alberti, p.w. (ed.). personal hearing protection in industry. new york: raven press. a p p e n d i x acts and related guidelines sabs code of practice for the assessment of noise exposure during work for hearing conservation purposes. sabs 0831970, south african bureau of standards: pretoria. sabs code of practice for the measurement and assessment of occupational noise for hearing conservation purposes. sabs 083-1983 as amended 1986 and 1989, the council of the south african bureau of standards: pretoria. the factories, machinery and building work act (1941). pretoria: government printers. the machinery and occupational safety act (1983). pretoria: government printers. the mines and works act no. 27 (1956) (amended 1964 and 1989). pretoria: government printers. the minerals act no. 50 (1991). pretoria: government printers. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 myrtle l. aron, robyn e. lewis and judy l. willemse reagan, t.g. sign language diversity in south africa: a preliminary investigation, with implications for the education of the deaf. unpublished proposal for a research project, 1986. schlesinger, h.s. the acquisition of signed and spoken language. in deaf children: developmental perspectives. liben, l.s. (ed). academic press, inc., new york, 1978. stokoe, w.c. the study and use of sign language. sign language studies. 10, 1-36, 1976. stokoe, w.c. sign and culture, linstok press, maryland, 1978. stokoe, w.c. and kuschel, r. a. a field guide for sign language research, linstok press, maryland, 1979. van der merwe, a.j. deputy director — special education, department of education and training, pretoria, personal communication, march, 1986. viljoen, s.w. communication skills project — editorial, silent messenger, south african national council for the deaf, v 5 no 3, july/august, 1982. wilbur, r.b. the linguistics of manual language and manual systems. in communication assessment and intervention strategies. lloyd, l.l. (ed). university park press, baltimore, 1976. woodward, j. implications for sociolinguistic research among the deaf. sign language studies, 1, 1-17, 1972. an intonational analysis of deaf speech: a case study marguerite schneider, ma (applied linguistics) (reading, u.k.) department of speech pathology and audiology, university of the witwatersrand, johannesburg abstract the intonation of an english speaking congenitally deaf adult was analysed using the framework set out by crystal (1969) for normal spoken english. the analysis revealed a deviant and deficient intonation system. the main features of this system included, firstly, an excessive use of tone units resulting in unintentionally emphatic sounding speech; secondly, inaccurate and inconsistent use of both the grammatical and accentual junctions of tonicity; and thirdly, a deficient tone system with additional abnormal use of the tones which formed the subject's tonal repertoire. this paper highlights the need for both phonetic and phonological analyses in order to obtain a true indication of a speaker's performance. opsomm1ng die intonasie van 'n kongenitaal dowe engelssprekende volwassene is geanaliseer deur 'n raamwerk te gebruik wat deur crystal (1969) vir standaard engelse spreektaal opgestel is. die analise het 'n qfwykende en gebrekkige intonasiesisteem aan die lig gebring. die belangrikste kenmerke van hierdie sisteem is eerstens, 'n oormatige gebruik van tooneenhede wat spraak wat onopsetlik beklemtoon klink tot gevolg het; tweedens, onakkurate en inkonsekwente gebruik van beide die grammatika en aksentsfunksies van toon; en derdens, 'n gebrekkige toonstelsel met addisionele abnormale gebruik van die tone wat die proefpersoon se toonrepertoire gevorm het. die noodsaaklikheid van beide fonetiese en fonologiese analises vir die vasstelling van 'njuiste aanduiding van 'n spreker se prestasie word deur hierdie ondersoek sterk na vore gebring. introduction the congenital handicap of hearing impairment affects the normal development of intelligible speech (ling, 1976). intelligible speech is a function of both segmental and non-segmental aspects of phonology. in other words, in order to produce intelligible speech a person must have mastered the individual phonemes as well as the intonation system of his/her language. (in addition, intelligible speech requires the mastery of syntactic, semantic and pragmatic aspects of language, but discussion of these areas is beyond the scope of this paper.) normal hearing children develop basic intonational contrasts before they acquire the finer phonemic distinctions which are to be fitted into the intonation 'envelope' or pattern (bruner, 1975; crystal, 1979). phonemic errors and segmental phonological systems of hearingimpaired speakers have been thoroughly investigated in the literature (ling, 1976; stark, 1979; dodd, 1976). however, it is not only the phonemic problems which render the speech of the hearing-impaired largely unintelligible. abnormal prosody also plays a large role in this process (john and howarth, 1965; phillips et al. 1968; silverman and calvert, 1978; king and parker, 1980). until recently the prosodic features of deaf speech were described in a rather impressionistic manner using labels such as 'monotonous voice' and 'laboured speech' without much formal analysis to justify these. it is only recently, with the advent of © sasha 1986 visual display aids (eg. laryngoscope and visispeech as described by king, parker, spanner and wright, 1982) that researchers have been able to analyse and describe the prosodic features of deaf speech in an objective manner, as well as compare them to the norm (martony, 1968; nickerson and stevens, 1973; nickersonet al. 1976; phillips et al. 1968; king and parker, 1980). i i stark (1979) summarises the typical prosodic features found in the speech of the deaf. these include: 1 —errors in timing —excessive word and sentence duration —errors in rhythm —intonation problems such as too little pitch variation (monotonous voice) or excessive pitch variation. however, there is no indication as to whether these features are used to mark meaning contrasts. in other words, are these features used on a phonological level as well as on a phonetic one? if one of the aims of deaf education is to teach effective verbal communication, it is imperative that deaf speakers be taught to make meaning contrasts both by phonemic and intonational means. in order to develop appropriate teaching goals and methods we need to establish not only the phonemic systems used by deaf speakers but also their intonational systems or lack of them. the south african journal of communication disorders, vol 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) international analysis of deaf speech: a case study 73 crystal (1969) has established a detailed and comprehensive account of normal prosodic systems and intonation in english. he defines prosodic features as those "vocal effects constituted by variations along the parameters of pitch, loudness, duration and silence" (crystal, 1969: 128). the primary prosodic features include pitch, loudness and duration, while the secondary ones include rhythmicality and pause, which both involve combinations of the three primary features. these features allow the following prosodic systems to be distinguished. tone, which involves pitch movement pitch range, which involves relative pitch levels tempo, which involves relative speed loudness, which deals with changes along a soft/loud continuum relative to the preceding utterance — rhythmicality, which allows for the description of speech along the rhythmic/arhythmic dimension — pause, which deals with the use of pause within the stream of speech. these systems function across both monosyllabic and polysyllabic stretches of speech (crystal, 1969: 140). crystal (1969) distinguishes two functions of intonation. the first is the ability to impart attitudinal information, such as a puzzled or questioning attitude with rising intonation, a neutral attitude with falling intonation, and an ironic or sarcastic attitude with a flat intonation. the second function of intonation is grammatical, such as in the placement of the tonic or nuclear stress on the adjectives in "a blue pen, not a red one" but on the nouns in "a blue car, not a blue pen". in these two examples the second stress in the utterance has its placement determined by the placement of the first stress. all grammatical functions of intonation will also entail an expression of attitude, whereas an attitudinal function of intonation will not necessarily involve a grammatical function. intonation involves three aspects or components, namely tone units, tone and tonicity. these three aspects are described below. a) tone units: these are the most easily identified and defined. crystal (1969) defines the tone unit as having one peak of prominence in the form of a nuclear pitch movement followed by a tone unit boundary which is indicated by two phonetic factors: there is a perceivable pitchjchange, the direction of which is determined by the nuclear tone, and ii) there are junctural features at the end of every tone unit, normally in the form of a very slight pause, often accompanied by variations, such as in length and aspiration used in the production of j the final phonemes. without a nucleus the tone unit is incomplete. on a semantic level the tone unit can be seen as corresponding to a 'sense group', on a syntactic level to a clause (usually), on a physiological level to a 'breath group' (crystal, 1969: 205). b) tone: this component of intonation describes the direction of pitch movement of the nucleus or nuclear syllable of the tone unit. three groups of tones are identified by crystal (1969): i) simple tones include falling, rising and level tones which are undirectional. ii) complex tones include all nuclei "where there is a change in direction of pitch movement within a syllable" (crystal 1969: 217). complex tones include fall-rise, rise-fall, rise-fall-rise and fall-rise-fall, the first two being the more common. the syllable with the first element of the tone is more prominent phonetically than the syllable with the second or third element. iii) compound tones are "combinations of two kinetic elements of different major phonetic types acting as a single tonal unit (crystal, 1969:218). the two main types are fall + rise and rise + fall, where the "two elements of a complex tone have in effect been separated to allow a larger stretch of utterance to fall under the semantic range of the nucleus" (crystal, 1969: 218). as for complex tones, the compound tones have one element which is more prominent phonetically than the other, this usually being the first. when used together with the pitch range system one finds tones being produced with a narrow, wide or normal pitch range resulting in different meanings. in his data on normal intonation of english, crystal (1969) found that simple falling tones were by far the most commonly occurring tone type. c) tonicity: this involves the placement of the nuclear tone within the tone unit. tonicity has two functions: the accentual and grammatical functions. the accentual function is governed by non-linguistic situational factors and is unpredictable from the grammar. it serves to highlight the most relevant part of the 1 sentence. the grammatical function is "largely or wholly predictable from the context immediately preceding the tonic word" (crystal, 1969: 263), as in alternative contrasts such as for the utterance "are you going by train or by car" where the tonic placement on any other words than train and car would, in most contexts, render the sentence ungrammatical. in english it is generally the case that the nucleus falls on the last lexical item in the tone unit. the aim of this paper is to analyse, using the framework described above, the intonation of a congenitally deaf adult in order to establish whether she is using intonation in a systematic manner or not. the second aim, arising out of the first, is to establish the nature of this system, if there is one. methodology 1. the subject (m): a) description μ is a 23 year old female whose mother-tongue is english. she has a profound, bilateral sensori-neural hearing loss of congenital origin with unknown cause. the pure tone average for the frequencies 500 hz, 1000 hz and 2000 hz is 98 db for both ears. μ has worn bilateral hearing aids since the age of two and a half. m's parents and siblings are all hearing. b) education: μ attended schools advocating an oral approach. she has a higher national certificate in maths, statistics and computing and is employed as a computer programmer. c) speech characteristics: m's speech is mostly intelligible. she has some consistent segmental errors mainly involving consonants. these include: — weak fricatives — unreleased final plosives — some nasalisation — intrusive schwa. it was decided to choose a subject who had reasonably good segmental ability so that the intonational factors could be more easily isolated. 2. data collection and analysis: about 20 minutes of informal conversation between μ and the writer was recorded on a cassette recorder. the tape was then transcribed orthographically. only m's utterances were analysed in terms of prosodic features. the following features were marked: — tone unit boundaries — stress — tonicity — pitch range — nuclear tones — pauses and rhythm. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 74 marguerite schneider appendix a gives a list of the symbols used in the transcription. counts were made of the occurrence of the various features and percentages were calculated from these. results and discussion once the data had been analysed it became apparent that μ was using a consistent intonation system which involved a number of idiosyncratic combinations of features. this is illustrated in detail below. the intonation system used by m: 1. tone units: table 1 summarises m's use of tone units. μ used a total of 567 complete, intelligible tone units, and 10 incomplete ones. the average length of the tone units was 3,7 words, and 81,1% of the tone units were between one and five words in length. crystal (1969) found that the average number of words per tone unit was five and that 80% of all tone units had lengths between one word and seven words. therefore, μ used shorter tone units on the whole, although the significance of the difference has not been established statistically. table 1: the use of tone units by μ number of complete intelligible tone units 567 total number of words 2157 average number of words per tone unit 3,7 percentage of tone units which ranged from 1 to 5 words 81,1% percentage of tone units which ranged from 6 to 10 words 18,9% number of minor sentence tone units 43 number of minor sentence tone units expressed as a percentage of the total 7,5 % number of incomplete tone units 10 it would seem that μ was in fact using too many tone units and as a result too many nuclear tones were marked. this overuse of nuclear tones, in turn, results in the loss of the functions of tonicity, namely to highlight new information and mark grammatical contrasts. the following are some examples of the excessive use of tone units. m: but we stayed in / a very simple / accommodation / m: it used to be / a stable / for horses / m: |"i've been tof dartmoor / 'once before / m: 'it's . fields / and country / — 1 all around / all the above examples would have been single tone units rather than separate ones in the speech of a hearing speaker with only the last item stressed or highlighted. μ is clearly not using tone units to delimit sense-groups. rather, she has segmented the sense groups inappropriately into phrases. a phonetic variation on the excessive use of tone units was the use of glissando which involves glides and also causes accentuation. for example: 'gliss' μ: i 'use it "mainly for 'going' to worlc/ 'gliss' m: say '"twenty-'five de'grees"f cefitigrade / in the above examples μ used glissando rather than separate tone units with a similar result. one way of overcoming the loss of functions of tonicity would be to devise an alternative means of marking these. in other words, it is possible that μ is using an idiosyncratic or abnormal way of marking the limits of sense-groups. in fact, the data suggest that μ used the tone system, rather than tone units, to serve this function. this hypothesis will be discussed in detail in the section on tone. another effect of m's excessive use of tone units is the fact that some tone units sound complete on an intonational level, but on a syntactic and semantic level they are incomplete. for example, in m: and the elms / t: and that's w h a t . . . 'gliss' m: a ''lot of elms / . 'get 'it / m's first utterance seems incomplete in all respects except for the presence of a tonic on "elms". the literature on the speech of the deaf makes reference to sentences being broken up into unusual breath-groups (hudgins and numbers, 1942, cited in stark, 1979), and to the presence of inappropriate pauses between words in mid-phrase (stark, 1979). a large amount of breath is used for each phrase thereby reducing the number of words or length of phrase per breath (nickerson and stevens, 1973). therefore it would seem that the use of too many tone units, (or to put it in another way, the use of tone units which are shorter than normal) seems to be a recognised feature of deaf speech. the explanation for this could be due to what ling (1976: 12) describes as "a lack of coordination between the articulators and the breath-voice system". 2. tonicity: tonic placement can be either final or non-final in the tone unit. out of a total of 395 tonic markings, 293 were final and 102 nonfinal. this represents 74% and 26% of the total respectively. tonic placement was only counted for those tone units which were larger than one word, and furthermore, it was decided to look at sense-groups rather than solely the tone units. this was felt to be justified as the excessive use of nuclear tones, not necessarily marking tonicity, would have yielded confusing results. | as mentioned above, it seems that μ uses an idiosyncratic system for marking prominence (see below for further discussion). ι as the above percentages indicate, μ used mostly final tonic placement. crystal (1969) suggests that the normal pattern is about 90% final and 10% non-final placement. therefore it would seem that μ followed the normal trend except that she tended to use non-final placements more than might have been expected. the following examples illustrate firstly, final and secondly, nonfinal tonic placement. 1. 'gliss' m: we 'went up on the "thursday' after'noon / 'gliss' m: — it was ''really a con'verted' stable / 'gliss' m: 'never came ''back the same' way / 2. m: we | "climbed . to the top hill / — m: 'they have the "highest welsh 'mountains / m: there are higher ones 'there / ^ μ did not use correct tonic placement in all cases. of the final placements, 76% were correct and 24% incorrect. some examples of incorrect final placement are given below. 3. 'gliss' m: and "three 'people' . | slept / on the |' two mattresses / 4. m: 'we went for | this 'easter weekend / the south african journal of communication disorders, vol 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) an international analysis of deaf speech: a case study 75 the underlined syllables indicate the tonic placement in question. in example 3 the tonic placement should have been on "three" and "two" to indicate the meaning contrast. there is no contrast meant between "slept" and "mattressess". in example 4 a more natural accent would have been to put the tonic placement on "this". example 3 demonstrates the grammatical function of tonicity where the placement of the tonic is determined by the preceding grammatical context. example 4 demonstrates the accentual function of tonicity which is independent of grammatical context. however, m's placement of the tonic does not show correct use of these functions. it seems therefore that μ has some but not full control of the rules governing tonic placement. of the non-final tonic placements, 81% were correct, 7% should have been final placements, and 12% were used correctly in that they were non-final but were placed on the wrong non-final item in the tone unit. μ: i 'went up to the 1 north t yorkshire dales / — in the above example "yorkshire" is made prominent when it need not be as no contrast is being made between "yorkshire dales" as opposed to some other "dales". the tonic placement would have been more appropriate on "dales" making it a final placement. an example where the use of non-final placement was correct but the non-final item chosen was incorrect, is the following: m: which "is / | "right up / — the 'north 'west part of 'yorkshire / in this utterance, if the non-final tonic placement is to be used, it would be more appropriate on "west" rather than "part", as the important information is the fact that it is the "north-west" and not the "north-east" part. a further example is m: y o u t 'don't . 'see anybody / 'gliss' we "hardly see any people / where the tonic should have been placed on "any" rather than "see" in the second utterance. m's use of tonicity mostly on lexical items rather than grammatical ones follows the normal pattern, in that 98% of tonic placements were on lexical items and 2% on grammatical ones. in crystal's (1969) data, 93% of tonics were placed on lexical items and 7% on grammatical ones. most of the placements of tonics on grammatical items in the data for| this project occurred in final position, and were generally correct, as the following examples show. 'gliss' m: we 'went up on the ''thursday 'after'noon / we 'drove up / infears / erm — 'gliss' it "took all 'afternoon' to getf up there / the tonic placement on the second "up" is quite appropriate in the context. the first "up" should not have a tonic and should be part of the same tone unit as "in cars". 'gliss' m: "where we' slept / 'gliss' 'was — "sectioned' off / — , in the above example, the placement of the tonic on "off" seems to fit correctly in the context. therefore, with regard to tonicity, the data indicate that μ is not fully in control of tonic placement. there is little literature concerning the placement of tonics by deaf speakers. stark (1979:239) in her summary of the features of deaf speech, mentions that 'word accents are misplaced and normally unaccented syllables are accented'. this statement refers to word stress rather than die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 sentence stress, the concern of tonicity. there were very few instances of incorrect word stress in the present data. two notable examples were the placement of the stress on the first rather than the second syllable of "certificate" and on the second syllable of "anyway" rather than the first. a later instance of "anyway" was produced with the correct stress. the lack of reference to tonicity in the literature on deaf speech reflects the fact that research has concentrated on the phonetic level and has not looked at the phonological use of these features. 3. tone: tonal aspects on intonation deal with the direction of pitch movement which occurs on the nucleus or tonic. crystal (1969) indicates that falling tones are the most commonly used, with rising tones being second in frequency of use. table 2 shows the distribution of tone types in m's speech. table 2: tone types in m's speech type number percentage of total falling \ full nuclear 82% sub-nuclear 18% 388 73% rising / full nuclear 81% sub-nuclear 19% 16 3% fall-rise v full nuclear 94% sub-nuclear 6% 86 16% fall + rise \ + / full nuclear 92% sub-nuclear 8% 42 8% in the above discussion it was suggested that μ had devised an idiosyncratic system to mark the limits of sense-groups. this was necessary because she used an excessive number of nuclear tones and thereby lost the ability to delimit sense-groups using tone unit boundaries. in analysing the placement of tonics in the data, the tone units were grouped into sense-groups, and the tonic for the sense-group, rather than for the individual tone units, was then determined. therefore the tones used by μ were classified as full nuclear when they were considered to be the nuclear tone of the sense-group, and sub-nuclear when they were not. crystal (1969) suggests that falling tones occur on about 51% of nuclei, and rising tones on about 20%. the other tone types seem to occur in relatively similar proportions. in the data for this subject falling tones were used far more and rising tones far less than expected. this could be a function of the sample type (i.e. informal conversation) as, for example, reading produces many more rising tones. falling tones are considered to be the most basic of the tones and are the first to be used by normal hearing children learning their mother tongue (crystal, 1979). it is also the falling tone which carries the least attitudinal information in english, being the neutral, unmarked form (crystal, 1969). therefore, if, due to the handicap of deafness, μ has not developed a full, normal intonation system, it is not surprising that the falling tone is far more common in the present data than expected. the following are some examples of full nuclear falling tones: r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 76 marguerite schneider 'gliss' m: — 'cause there's a "lot of 'other' traffic / — of the h61iday 'traffic / m: erm it's 'so quiet / m: — the 'whole building / 'gliss' m: a'bout — as "big as 'this' r6om / μ: i 'haven't. 'got a 'very good sleeping bag / i'm going to 'buy a | better one / l i t e r / the following examples show the use of falling tones in subnuclear positions: m: it was 'just 'like — you 'could 'imagine it / being a stible / m: the do6r / was . divided / in two / in the examples given below it will be noticed that the full nuclear tonic is in fact a falling tone produced with a narrow pitch range. m: f'that is about / 'gliss' "three and a half 'thousand feet' high / 'gliss' m: but we "get"' very 'wrapped'. 'warmly 'wrapped!ύρ / for reasons that will be discussed below, it is assumed that the narrowed falling tone is a variant of the falling tone, and that the narrowing could be seen as merely a phonetic realisation of the falling tone, just as one finds intra-person variations in phonemic productions. furthermore, narrowing can be related to a common observation in the literature that the speech of deaf speakers has a tendency to be monotonous (stark, 1979). if one did an analysis of the semantic contexts associated with the use of either variant, then it is possible that the falling and narrow falling tones might be used in different contexts. however, that is not within the scope of this paper. the tone types which occurred with most frequency after the falling tone were the fall-rise complex tone and fall + rise compound tone. both these tones were produced with a narrow pitch range on the rising component, not an entirely abnormal feature as crystal (1969) describes these tones as having a more prominent first component. the complex tone occurred about twice as often as the compound tone. a further look at the data indicates that comparison of m's use of these two tones with normal usage is not really valid as they seem to be used for different purposes. it was observed that i) the compound tone ( \ + / ) tended to occur predominantly as a nuclear tone in non-final position, ii) the complex tone (\ / ) tended to occur as a nuclear tone in final position, and iii) the use of the complex tone was much more frequent than the use of the compound tone (i.e. final tonic placement occurred more frequently than non-final placement). therefore, the distribution of these tones was analysed in more detail. the results show that, of the complex tones, 94% occurred as a full final nuclear tone, while only 6% occurred as sub-nuclear tones. furthermore, the tones which occurred in sub-nuclear position also marked final tonic placement within their tone units. the following examples show the use of this tone. m: wet work for people / 'gliss' like the "national trust / 'gliss' or — a "local' council / 'gliss' or a "nature' . council / 'gliss' m: a "lot of 'dead' elms / mi^'what we do / is vdjuntary / the first two examples show full nuclear tones and the third a subnuclear tone. (it should be noted that, in giving these examples, the correctness or incorrectness of the tonic placement is not at issue). similar results were observed with the occurrence of the compound tone, namely that 92% occurred as non-final full nuclear tones, while only 8% occurred as non-final sub-nuclear tones. the examples presented below demonstrate the use of the compound tone, the first two being non-final full nuclear tones and the last being a non-final sub-nuclear tone. m: 'there's no traffic 'warden / on saturdays / m: but i's 'very unlucky that afternoon / — m: it 'would've 'cost. 'about seven 'seventy pence / for the three hours i was . away / m: well i've parked my bike / there / m's purpose in using these tones seems to be to mark the end of sense-groups which normally would be marked by the use of tone unit boundaries. furthermore, μ uses the complex and compound tones for the same phonological function, thereby giving them the status of allophonic variations of the same tone in complementary distribution. however, μ does not only use the complex and compound tones to delimit sense-groups. she also uses the simple falling and narrow falling tones to fullfil this function. in the data, falling and narrow falling tones tended to be used for shorter sense-groups than the other tones, but this was not an important trend. finally, as table 2 indicates, μ used few instances of rising tones and no instances of complex and compound tones other than the fall-rise and fall + rise discussed above. therefore the use of tone types by μ has proved to be quite systematic in nature. however, it is not a normal system, in that μ seems to be using the three main tones of her system more as variations of one tone than as separate tones phonologically. this would indicate that μ has a very small range of tone types with which to mark meaning contrasts in terms of attitude. however, this assumption would need to be checked by analysing the semantic use of these tones; in other words, is μ marking different attitudes with these tones? it seems unlikely that she is, as her tone system functions to delimit sense-groups rather than to mark attitude contrasts. ; t in summary, the most important characteristics of m's intonation system are the following: | 1. an excessive number of tone units which do not correspond to the notion of tone units delimiting sense-groups; ι 2. an inconsistent ability to mark grammatical contrasts arid to highlight new information by means of varying tonic placement within the tone unit; 3. a very small tonal system which seems to be undertaking the function of delimiting sense-groups rather than marking attitude contrasts. the prediction is that, on a semantic level, μ will have a reduced ability to mark or express meaning contrasts usually indicated, in part, by variations in number of tone units, tonicity and tone. for example, crystal (1969) suggests that a haughty attitude is partly expressed by the use of non-simple tones, a puzzled attitude by a relatively high number of tone units and extremely stable tonicity and an amused one by a low number of simple falls. therefore it would be interesting to investigate the ability of deaf speakers to express these attitudes and the means by which they express them. the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) an international analysis of deaf speech: a case study 77 conclusion the intonation system which has emerged from the analysis of m's speech is deviant and deficient in nature. although μ has a number of normal features on a phonetic level, she does not use them in the normal manner to mark phonological contrasts. in that sense her system is deviant. the tone system used by μ includes basically one tone type with a number of phonetic variants, and in that way it is deficient. therapeutic intervention would aim at remediating both of these factors, using for example, visual display aids to teach different tone types and correct placement of the tonic. the aims of this paper have been achieved, and in addition, the hypothesis that was put forward has been shown to be correct for the speech of one congenitally hearing-impaired adult. one cannot generalise from one case, but it is not unlikely that other hearing-impaired speakers will use intonation systematically with a deviant and deficient system, although their individual systems might not have the same characteristics of m's system. an important factor arising from the analysis is the need to analyse the use of intonation not only in terms of the phonetic features but also in terms of how those features are used phonologically. in other words, assessment aimed at establishing therapeutic goals necessitates both a phonetic and phonological description of speech. this was highlighted by the fact that on a phonetic level, μ used at least three different tone types, but on a phonological level they functioned as a single tone. acknowledgements i wish to thank professor david crystal of the department of linguistic science, university of reading, reading, england, for his help and guidance in the analysis of the data. references bruner, j. the ontogenesis of speech acts,j of child lang. 2,1-19, 1975. crystal, d. prosodic systems and intonation in english, cup, 1969. crystal, d. prosodic development, in fletcher, p. and garman, m. (eds) language acquisition, cup, 1979. dodd,b. the phonological system of deaf children, j: speech hear disord., 41, 185-198, 19[76. john, j.e.j, and howarth, j.n. the effects of time distortions on ι the intelligibility of deaf children's speech, lang, and speech 8, 127-134, 1965. [ king, a. and parker, a. the relevance of prosodic features to speech work with hearing-impaired children, in jones, t.m. (ed) language disability in children, assessment and remediation, mip press ltd. 1980. king, α., parker, α., spanner, m. and wright, r.a. speech display computer for use in schools for the deaf, royal national institute for the deaf, london, 1982. ling, d. speech and the hearing impaired child: theory and practice, washington: the alex. graham bell assoc. for the deaf, 1976. martony, j. on the correction of voice pitch level for severely hard of hearing subjects, amer. annals of the deaf, 113,195202, 1968. nickerson, r.s. and stevens, k.n. teaching speech to the deaf: can a computer help? ieee transactions on audio, and electroacoustics, au-21. 5, 1973. nickerson, r.s., kalikon, d.n. and stevens, k.n. computeraided speech training for the deaf, j. speech hear disord., 41, 120-132, 1976. phillips, n.d., remillard, w., bass, s. and pronovost, w. teaching of intonation to the deaf by visual pattern matching, amer. annals of the deaf. 113, 239-246, 1968. silverman, s.r. and calvert, d.r. conservation and development of speech, in davis, h. and silverman, s.r. (eds) hearing and deafness, 4th ed, holt, rinehart and winston, 1978. stark, r, speech of the hearing-impaired child, in bradford, l.j. and hardy, w.g. (eds) hearing and hearing-mpairment, grune and stratton, 1979. appendix a: symbols used for the transcription \ = falling tone / = rising tone v / = fall-rise tone \ + / = fall + rise tone η = narrow pitch range = short pause — longer pause ' o r 1 1 = stress (extra loudness as opposed to pitch movement) t = raise in pitch 'gliss' " '' = glissando / / = tone unit boundary syll = tonic syllable referred to in examples die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 103 editing a scientific journal on communication disorders in south africa: a unique challenge* brenda louw department of communication pathology university of pretoria abstract the aim of this article is to describe the challenge of editing a scientific journal in the field of communication disorders in the south african context. an overview of the development of the journal and the current editorial policy is described. the distinctiveness and uniqueness of the journal is highlighted. a discussion of the problems encountered and the challenges posed by the future is supplied. in conclusion the question is posed of whether a scientific publication of this nature is relevant and justifiable. it is concluded that such a publication is indeed important and has the right of existence. opsomming die doel van die artikel is om die uitdaging te beskryf wat die redaksie van 'n wetenskaplike tydskrif in die vakgebied van kommunikasiepatologie in die suid-afrikaanse konteks hied, 'n oorsig van die geskiedkundige ontwikkeling van die tydskrif en die huidige beleid word bespreek. die onderskeidende en andersoortige aard van die tydskrif word uitgelig enprobleme in die redaksie en produksie van die tydskrif word ge'identifiseer. uitdagings en moontlike oplossings vir die bestaande probleme word aangespreek. ten slotte word die relevansie van 'n wetenskaplike publikasie van hierdie aard bevraagteken. die gevolgtrekking word bereik dat so 'n publikasie wel bestaansreg het. writing and publication are important in developing the scholarly base of speech-language therapy and audiology. scholarly journals serve as archives of research data, contain literature reviews, and other types of materials that contribute to the scientific base of a discipline or that have broad and lasting clinical relevance. because knowledge is ever-changing and advancing, the facts and findings published at any one point in time may become dated or proven incorrect. nevertheless, the hallmark of a scholarly publication is that it represents the current state of art or science at the time of publication (asha, 1993). the practice of the profession of speech-language therapy and audiology in south africa has been reflected and supported by it's own scholarly journal over the years. the editing of this scientific journal poses unique challenges to the editor. the aim of this article is to describe these challenges by supplying an overview of the south african journal of communication disorders, describing the distinctiveness and uniqueness of the journal, identifying the problems encountered and providing possible solutions in meeting these problems. the aim of the south african journal of communication disorders is to publish papers or reports concerned with research, and critically evaluative theoretical and philosophical conceptual issues dealing with aspects of human communication and its disorders, service provision, training and policy. it serves as the scientific mouthpiece for local members of the profession and mirrors the professional and theoretical trends within the local context by publishing both research and review articles. a historical overview indicates that the profession of speech-language-therapy and audiology has been practiced in south africa since the late 1930's. prof. pierre de villiers pienaar initiated the training of speech-language-therapists and audiologists at the university of the witwatersrand in 1937, and the course is currently taught at five universities in south africa (uys, 1993). the south african journal of communication disorders was first published by the south african speech, language, hearing association (saslha) in 1953 and the fortieth volume appeared in 1993. the journal is published annually. throughout the forty years of publication the journal has undergone three title changes, from "journal of the logopaedic society" to "journal of the south african speech and hearing association" to the current title, reflecting changes within * this article is based on a paper of the same title presented at the international conference on biomedical periodicals, beijing, china, june 16-18, 1994. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 104 the field and the association. the current title reflects the underlying paradigmatic shift of the profession in the south african context. the editorial policy is published in every issue and employs the peer review system (strayhorn, mcdermott & tanquay, 1993). peer review has become an important aspect of quality control in scientific publications. peer reviewers are experts in the topic of a submitted manuscript who are considered "peers" of the authors, and who are selected by the editor to assess the quality of the manuscript's scientific and technical content. the editor remains responsible for decisions regarding rejection, revision, or acceptance of publication (glass, 1994). this process of refereeing, or editorial peer review, increases the credibility of a journal by assuring that only scientifically sound research is published (weller, 1987). although the south african journal of communication disorders is comparable to other journals in the field published in the united kingdom, australia and the united states of america, it is distinctly different from these publications and has a unique character. the distinctiveness and uniqueness of the journal is embedded in the fact that two distinct, yet integrated, fields of speech-language pathology and audiology in which training is done, are represented by the journal, leading to diverse topics and research methodologies reflecting the differing nature of the two fields. in addition articles are published in the two (up till 1993) current official languages of south africa, english and afrikaans, thus rendering the journal to be bilingual. south africa represents a multilingual, multicultural society and articles increasingly reflect the diversity of the communication disorders and underlying issues encountered in this context. circulation figures of the journal are limited (approximately 800) which is ascribed to the fact that there were 980 speech-language therapists/audiologists registered with the south african medical and dental council in 1993, of whom approximately 650 are members of saslha and subscribe to the journal as part of their membership. this differs greatly from, for example, the membership figures of the american speechlanguage hearing association (aslha), with an approximate membership of 70 000 (asha, 1994). members of aslha selectively subscribe to the various journals published by their association. lastly, the uniqueness of the journal is related to geographical and political factors, as south africa has been relatively isolated from international contact (aron, 1991). this has led to limited international contributions and has characterized the journal with a unique south african perspective. it is therefore clear that the journal is distinct from others published in the field internationally, and in order to retain this uniqueness and to be truly representative of the context in which it appears, the editor is faced with exciting challenges. the challenges facing the editor of the south african journal of communication disorders are twofold, those relating to the general problems of scholarly journals and those stemming from the distinctiveness of the journal. according to leslie (1989) scholarly journals have numerous problems. although many scientific journals the south brenda louw are published, only very few can be labelled as quality journals due to various reasons, e.g., some lack central focus, others are too focussed and reject submissions if the content does not fit prescribed research agenda. a central problem to scholarly journals is manuscript review (leslie, 1989). the need for peer review is generally conceded, but the operation of the system is fraught with controversies e.g., conflicts of interest, importance of articles, masking of identities during peer review, and reviewer bias (grassman, 1986; siegelman & whicker, 1987; glass, 1994). leslie (1989) expressed the opinion that the time to examine these problems, and to search for an implement solutions is at hand. he poses the following question: do we have the courage to begin this important work? (leslie, 1989, p. 128). the answer is yes, as these problems are being addressed internationally by conferences, task groups and public actions in order to improve the quality of journals and to develop the editing process of scholarly journals into a profession (glass, 1994). when confronted by leslie's (1989) question and international developments, it is clear that the problems of the south african journal of communication disorders need to be identified and solutions proposed to ensure the continuation of the forty year old tradition of the journal. in response to these challenges and developments, the author who is the current editor of the journal, conducted a critical appraisal of the publication process of the the south african journal of communication disorders and of literature relating to editorial and publication issues. the following eightpro&iems were identified and addressed. many of the problems relate to the distinctive nature of the journal, as discussed earlier. firstly the language in which articles are written poses a problem. for example, articles written in afrikaans are not accessible to all subscribers. to write a scientific manuscript in a second language is problematic and professional translation is costly and does not usually convey the exact meaning of the author. imminent political changes, however, may designate english as one of the official languages which could necessitate changes in editorial policy. i the number of speech-language therapists and|audiologists from different linguistic and cultural backgrounds is increasing and will hopefully lead to anj increased research on communication disorders in the various cultural and linguistic groups as well as in intercultural research, which is urgently needed in the field. designating the publication of all articles in one language, namely english, will make information reasonably accessible to most professionals in the field, as opposed to publishing articles in the author's first language. abstracts may then be published in the author's first language or in a chosen second language. this implies that the editor would need to make use of additional resources in editing the second language abstracts, but would emphasize the distinctive nature of the journal. secondly, although south africa represents a multilingual, multicultural society and poses unique challenges to service delivery, the south african journal of communication disorders has not adequately developed χ ican journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ing a scientific journal on communication disorders in south africa: a unique challenge a distinct local character. the journal has been modelled on journals published by the american speech-language hearing association. a possible solution could be to increase the journal's scholarly impact by specifically developing the multilingual, multicultural aspects (as mentioned above) and developing the perspective of the profession contextualized in an intersectoral, transdisciplinary context of an integrated health care system. such an approach would provide a truly distinctive character to the journal. it could also contribute to the procuring of funding if the journal took on a new, strongly developed unique character, with a definite transformatory human rights perspective. this is consistent with the theoretical paradigm underlying the discipline, namely that the communication of an individual is always viewed in the context of social systems. thirdly, few professionals are willing to serve on the editorial board. professionals appear to be willing to act as reviewers, but not to become involved on any other level of management of the journal. this may be attributed to the "burn-out" phenomena within the profession (swidler & ross, 1993). according to weller (1987) journal quality is affected by the editorial staff. the implications of a limited editorial board are an increase in the editor's responsibilities regarding the peer review process, placement decisions, and the lack of a support mechanism on both a technical and emotional level. a proposed solution to this pressing problem is that the editor actively recruits members for an extended editorial board by clearly stating the advantages of being involved in the publication process of a scholarly journal. master degree level students could be motivated to serve as editorial staff members by expounding the benefits of being actively involved in the development of the data basis of the field of speech-language pathology and audiology. lastly, the editor can approach employers to recognize the importance of and benefits of employees participating in the editorial process of the journal, by crediting the individuals for promotion purposes, research grant or subsidy applications. fourthly, as mentioned previously, the circulation figures of the journal are limited, implying small financial gain and reader audience] increasing circulation figures may serve as a solution to both financial problems and the reader audience. this can be affected by recruiting student members and an active public relations drive of the saslha and the journal!itself. increased international contact may encourage new contributors, but the relevance of such contributions and the unique local character of the journal must not be compromised. fifthly, given the limited circulation figures, it follows that the source of contributors to the journal is also very limited. five universities offer undergraduate training in the field, thus contributors from the academia are a small group. relatively few professionals in clinical practice contribute to the journal, mainly due to two reasons. the workload created by the imbalance that exists between professional and communicatively disordered in the south african context (uys, 1993), allows for little time allocated to conducting scientific research and the writing of articles. secondly, only a small corps of professionals in the field actively conduct research, and even fewer are prepared to devote time to writing articles on conceptual issues related to the fields of speech-language pathology and audiology. a viable solution is to publish articles based on outstanding student research reports. this not only reflects the current development and interest at the various training centres, but also makes interesting research findings available and contributes to the data base of local research. in giving this guidance to student researchers the journals are contributing to a genre of graduates with the skills and attitudes relevant to a "culture" of publishing. according to silverman (1988) clinical research needs to be encouraged as it is beneficial to both the communicatively handicapped population and to members of the profession. the communicatively handicapped population can benefit by the publication of clinical research results as the sharing of information by professionals leads to higher quality services. professionals benefit from conducting clinical research as it allows them to satisfy a requirement of the profession's code of ethics; reduces "burn-out"; and improves clinical effectiveness (silverman, 1988). the questions, answers and implications of empirical and clinical research must, however, be communicated to potential consumers before they can have impact on the quality of services for the communicatively handicapped. according to silverman (1988) reporting information in professional journals is the most effective manner to reach large audiences. different kinds of incentives can be created by institutions to encourage clinical investigations and clinical researchers can be accommodated to enable them to conduct research. the editorial board of the journal can take the initiative and approach institutions in this regard to ensure a constant flow of articles to be submitted for publication. according to yoder wise (1992) writing is a professional commitment that requires planning and dedication. scholarly journals need to strive to help authors in their development of manuscripts in order to create an important body of knowledge in a discipline (yoder wise, 1992). sixthly, the peer review process employed by the journal poses many problems. according to yoder wise (1992) publication in a peer-reviewed journal should be a mark of distinction. this system is, however, fraught with problems (siegelman & wicker, 1987; oxman, 1991; abdellah, 1990). two striking aspects of peer review are that it is based almost entirely on uncompensated voluntary work, and that the peer review system itself has only recently come under scientific scrutiny. although peer review is viewed as a major facet of the evaluation of science, it is subject to human error. this pillar of science merits scientific research to refine the process and to develop a stricter application of scientific standard (glass, 1994). the editorial board thus needs to keep abreast with recent international trends of article reviewing and select peer reviewers with care to ensure that the peer review system is practiced optimally (leslie, 1989; strayhorn, mcdermott & tanquay, 1993; lightdale, 1992; grassmann, 1986). in addition to the problems of peer review as identified in the literature, the context in which this journal is published, leads to additional problems such as the limited corps of reviewers available and the fact that not all reviewers are able to effectively review a scientific article in a second language. certain criteria are, however, used as an aid to the peer review process in an attempt to increase the creddie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 106 brenda louw ibility of the journal by assuring that only scientifically sound research and review articles of scientific quality are published (oxman, 1991; weller, 1987). seventhly, funding for the journal is problematic due to the current financial climate in south africa and the limited sources of saslha. the journal receives a grant from the foundation for education, science and technology with saslha having to bear the brunt of the costs. funding determines the continuation of a publication to a large extent and alternatives will need to be found if the tradition of the journal is to be continued. recruiting an increased number of advertisements could increase the journal's income to assist in publication costs. the financial challenge is partially met by desk top publishing, which necessitates disk copies of the submitted articles and ensuring that the articles which are accepted for publication, are print ready. printing from "print ready" software reduces the printing costs dramatically and shortens the printing process. desk top printing, however, creates another editorial problem. in the south african context, papers tend to be submitted in grossly unedited forms. due to the limited source, mentioned earlier, competition is minimal and papers are accepted and then have to go through a long editorial process before being "print ready". a possible solution to this problem may be the expansion of the information for contributors which is contained in each issue of the journal and strict adherence to these guidelines by the authors. the editor should also retain the right to refuse publication of an accepted article if the set requirements of editorial care are not met.' eighthly, the post of editor of the south african journal of communication disorders is a voluntary one and financially uncompensated, which implies that the editor practices this portfolio in a part-time capacity, while usually employed in another full-time post. the demands of editing are great and according to weller (1987) the quality of a journal is affected by the continuity of good editors. in order to meet these challenges scholarly journals must provide editors with sufficient resources to do their jobs. according to leslie (1989, p. 126) the solution is to have the journal sponsor, whether a professional, academic, research organization or university (or a combination of these) provide editors with time, money, personnel, and equipment. if the publication of scholary work is important, it deserves this kind of commitment (leslie, 1989). the editor must actively campaign for these benefits in order to function appropriately. effective editorial management can make an important contribution to the continuity and quality of the journal. maintaining quality and standards of the journal in the given circumstances requires a concentrated effort to continue the international recognition the journal currently enjoys and to diligently carry out administration adequately so as to maintain international listing and abstracting of the journal. according to weller (1987) the quality of a journal is determined by the following factors the editorial staff, contributors, and refereeing process, the visual aspects of the journal and the continuity of good editors and authors (weller, 1987). by being aware of and addressing these contributing factors, the journal editor can function in an accountable fashion and ensure a quality product. despite the wide range of problems identified in publishing the south african journal of communication disorders, it appears that many solutions can be implemented to minimize, and even overcome these deterrents to a successful publication. conclusion: the ultimate challenge posed to the editor of the south african journal of communication disorders is whether a scientific publication in the fields of speechlanguage pathology and audiology is at all relevant in the south african situation? the alternative to a scientific publication is a more informal dissemination of clinical information. according to silverman (1989) this can be done by means of newsletters, study groups and informal communication between clinicians. another possible solution could be to abandon the discipline of specific journals that tend to lead to fragmentation in the south african context. instead, other disciplines such as e.g., occupational therapy, physiotherapy, psychology, general medical practice, could be involved to promote the concept of a transdisciplinary approach in meeting the needs of the people in an integrated health care system. based on the following argument it is concluded that the publication of the south african journal of communication disorders is indeed important and needs to be continued in the future. publishing articles in a peerreviewed journal is a mark of distinction. the time and effort invested in the publication process by the author, the reviewers and the editor is justified to help create an important body of knowledge in the field (yoder wise, 1992). this is specifically true of the south african situation in which a dirth of knowledge still exists regarding communication disorders and service delivery in the local context. research on the needs of the culturally and linguistically diverse population of south africa is needed in order to make clinical applications and to increase the effectiveness and accountability of service delivery. by publishing articles on issues dealing with communication disorders, service provision, training and policy the scientific journal supports the profession of speech-language pathology and audiology in taking responsibility for shaping its own future (cole, 1986; uys, 1993). j i acknowledgements the author wishes to thank glen jager, previbus editor of the south african journal of communication disorders, and prof. rene hugo for their valuable contribution in peer-reviewing this article. the financial assistance received from the centre for science development, hsrc and the university of pretoria is acknowledged with appreciation. references abdellah, f.g. 1990. peer review the only answer to highquality research? journal of professionalnursing, 6, pp 70-75. / aron, m.l. (1991). perspectives. the sokth african journal of communication disorders, 38, pp'. 3-12. ' asha. (1993). the publication process. a guide for authors. asha, 37, pp 142-144. asha. (1994). changing courses midstream. asha, 38, pp 38-39. the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) e d i t i n g a scientific j o u r n a l o n c o m m u n i c a t i o n d i s o r d e r s i n s o u t h africa: a u n i q u e c h a l l e n g e 107 cole, p.r. (1986). i want to shape my own future. how about you? asha, 28, pp. 41-42. glass, r.m. (1994). peer review and quality control in biomedical p u b l i c a t i o n . international conference on biomedical periodicals, abstracts, p. 1. grassmann, w.k. (1986). is the fact that the emperor wears no clothes a subject worthy of publication? interfaces, 16, pp 42-51. leslie l.z. (1989). manuscript review: a view from below. scholarly publishing, 20 pp. 123-128. lightdale, c.j. (1992). the editor : professor or journalist? gastrointestinal endoscopy, 38, pp 193-194. o x m a n , a.d. (1991). agreement among reviewers of review articles. journal of clinical epidemiology 44, pp. 91-98. siegelman, l. & whicker, m.l. (1987). some implications of bias in peer review: a simulation based analysis. social science quarterly, 68, pp. 494-509. s i l v e r m a n , f.h. (1988). speech language pathology and audiology. columbus: c ε merrill publ. co. strayhorn, j., mc dermott & j.f. tanquay, p. (1993). an intervention to improve the reliability of manuscript reviews for the journal of the american academy of child and adolescent psychiatry. american journal of psychiatry, 150 (6), pp. 947-952. swidler, m. & ross, e. (1993). burn-out: a smouldering problem among south-african s p e e c h l a n g u a g e pathologists? the south african journal of communication disorders, 40, pp. 71-84. uys, i.c. (1993). kommunikasiepatologie: onderrig vir die toekoms. die suid-afrikaanse tydskrif vir kommunikasieafwykings, 40, pp. 3-10. weller, a.c. (1987). editorial policy and the assessment of quality among medical journals. bulletin of medical library association, 75, pp. 310-316. yoder wise, p. (1992). from manuscript to publication. journal of continuing education in nursing, 23, p. 51. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) information for contributors the south african journal of communication disorders publishes reports and papers concerned with research, and critically evaluative theoretical and philosophical conceptual issues dealing with aspects of human communication and its disorders, service provision, training and policy. the south african journal of communication disorders will not accept material which has been published elsewhere or that is currently under review by other publications. manuscript style and requirements manuscripts should be accompanied by a covering letter providing the author's address and telephone numbers. all contributions are required to follow strictly, the style specified in the publication manual of the american psychological assoc. (3rd ed., 1983χαρα pub. man.), with complete internal consistency. four copies of triple-spaced high quality type-written manuscripts with numbered pages, and wide margins should be submitted. they should be accompanied by one identical disc copy of the paper; (1) in wordperfect 5.1 (with an extension .wp5). filenames should include the first author's initials and a clearly identifiable keyword or abbreviation thereof and should be typewritten on the last line of the last page of the reference list (for retrieval purposes only). as a rule, contributions should not exceed much more than 30 pages, although longer papers will be accepted if the additional length is warranted. the first page of two copies should contain the title of the article, name of author(s), and institutional affiliation (or address). in accordance with the αρα pub. man. style (1833, p.23) authors are not required to provide qualifications. in the remaining two copies, the first page should contain only the title. the second page of all copies, should contain only an abstract (100 words), written in english and afrikaans. afrikaans abstracts will be provided for overseas contributors. major headings where applicable should be in the order of method, results, discussion, conclusion acknowledgements, references. all paragraphs should be indented. tables and figures which should be prepared on separate sheets (one per page), should be copied for review purposes and only the copies sent initially. figures, graphs, and line drawings that are used for publication, however, must be originals, in black ink on good quality white paper, but these will not be required until after the author has been notified of the acceptance of the article. lettering appearing on these should be uniform and professionally done, allowing for a 50% reduction in printing. on no account should lettering be typewritten on the illustration. any explanation or legend should appear below it and should not be included in the illustration. the titles of tables, which appear above, and figures, which appear below, should be concise but explanatory. both should be numbered in arabic numerals in order of appearance. the number of illustrative materials allowed, will be at the discretion of the editor (usually about 6). references references should be cited in the text by surname of the author and the date, e.g., van riper (1971). where there are more than two authors, after the first occurrence, et al. after the first author will suffice, except for six or more when et al. may be used from the start. the names of all authors should appear in the reference list, which should be listed in strict alphabetical order in triple spacing at the end of the article. all references should be included in the list, including secondary sources, (αρα pub. man. 1983, p.13). only acceptable abbreviations of journals may be used, (see dsh abstracts, october; or the world list of scientific periodicals). the number of references should not exceed much more than 30, unless specifically warranted. examples locke, j.l. (1983). clinical psychology: the explanation and treatment of speech sound disorders. j. speech hear disord 48 339-341. penrod, j.p. (1985). speech discrimination testing. in j. katz (ed.), handbook of clinical audiology (3rd ed.). baltimorewilliams & wilkins. davis, g.a. & wilcox, m.j. (1985). adult aphasia rehabilitation: applied pragmatics. san diego, ca: college-hill. editing acceptable manuscripts may be returned to the author for revision. additional minor changes may also be made at this stage, but a note on the manuscript acknowledging each alteration made by the author, is required. the paper is then returned to the editorial committee for final editing for style, clarity and consistency. reprints: 10 reprints without covers will be provided free of charge. j ι deadline for contributions: the preferred date ii the 31st may each year, but papers will be accepted until 30th june by arrangement. j queries, correspondence & manuscripts: shiuld be addressed to the editor, south african journal of communication disorders, south african speech-language-hearing association, p.o. box 600, wits, 2050, south africa. 1 the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) inligting vir bydraers die suid-afrikaanse tydskrif vir kommunikasieafwykings publiseer verslae en artikels wat gemoeid is met navorsing, of handel oor krities evaluerende, teoretiese en filosofiese konseptuele kwessies wat oor menslike kommunikasie en kommunikasieafwykings, diensverskaffing, opleiding en beleid gaan. die suid-afrikaanse tydskrif vir kommunikasieafwykings sal nie artikels aanvaar wat reeds elders gepubliseer is, of wat tans deur ander publikasies oorweeg word nie. manuskrip styl en vereistes: m a n u s k r i p t e behoort deur 'n dekkingsbrief vergesel te word wat die skrywer se adres en telefoonnommers bevat. daar word van alle bydraers verwag om die styl, soos gespesifiseer is in die "publication manual of the american psychological assoc. (3rd ed., 1983) (αρα pub. man."), nougeset te volg met volledige interne ooreenstemming. manuskripte moet getik, van hoe gehalte en in drievoud spasiering met wye kantlyne wees. vier kopiee van die manuskrip moet verskaf word. een hiervan moet 'n identiese skyfkopie van die artikel wees in wordperfect 5.1 (met 'n uitbreiding .wp5). leername behoort die eerste skrywer se voorletters en 'n duidelike identifiseerbare sleutelwoord of afkorting daarvan in te sluit en moet op die laaste lyn van die bladsy van die verwsyingslys getik word (slegs vir naslaan doeleindes). as 'n reel moet bydraes nie 30 bladsye oorskry nie, maar langer artikels sal aanvaar word indien die addisionele lengte dit regverdig. op die eerste bladsy van twee van die afskrifte moet die titel van die artikel, naam van die skrywer(s), en instansie (of adres) verskyn. in ooreenstemming met die "αρα pub. man." se styl word daar nie van skrywers verwag om enige kwalifikasies te verskaf nie. op die eerste bladsy van die twee oorblywende afskrifte moet slegs die titel van die artikel verskaf word. die tweede bladsy van alle afskrifte moet slegs 'n opsomming (100 woorde) in beide engels en afrikaans bevat. afrikaanse opsommings sal vir buitelandse bydraers voorsien word. hoofopskrifte moet, waar van toepassing, in die volgende volgorde verskaf word: j metode, resultate, besprekings, gevolgtrekkings, erkennings en verwysings. alle paragrawe moet ingekeep word. tabelle en figure wat op afsonderlike bladsye (een bladsy per tabel/illustrasie) moet verskyn, moet vir referent-doeleindes gekopieer word en slegs die kopiee moet inisieel verskaf word. figure, grafieke en lyntekeninge wat vir publikasie gebruik word, moet egter oorspronklike weergawes wees en moet in swart ink op wit papier van 'n hoe gehalte wees. die oorspronklikes sal slegs verlang word nadat die artikel vir publikasies aanvaar is. letterwerk wat op bogenoemde verskyn, moet eenvormig wees, professioneel gedoen word en daar moet in gedagte gehou word dat dit leesbaar moet wees na 'n 50% verkleining in drukwerk. letterwerk by illustrasies moet onder geen omstandighede getik word nie. verklarings of legendes moet nie in die illustrasie nie, maar daaronder, verskyn. die opskrifte van tabelle (wat bo-aan verskyn), en die onderskrifte van figure, (wat onderaan verskyn), moet beknop, maar verklarend wees. numering moet deur middel van arabiese syfers geskied. tabelle en figure moet in die volgorde waarin hulle verskyn, genommer word. die aantal tabelle en illustrasies wat ingesluit word, word deur die redakteur bepaal (gewoonlik nie meer as 6 nie). verwysings verwysings in die teks moet voorsien word van die skrywer se van en die datum, b.v., van riper (1971). wanneer daar egter meer as twee skrywers is, moet daar na die eerste verskaffing van al die outeurs, van et al. gebruik gemaak word. in die geval waar daar egter ses of meer outeurs ter sprake is moet et al. van die begin af gebruik word. al die name van die skrywers moet in die verwysingslys verskyn wat aan die einde van die artikel voorkom. verwysings moet alfabeties in trippel spasiering gerangskik word. al die verwysings moet in die verwysingslys verskyn, insluitende sekondere bronne, ("αρα pub. man." 1983, p. 13). slegs aanvaarbare afkortings van tydskrifte se titels mag gebruik word, (sien "dsh abstracts, october"; of the world list of scientific periodicals"). die aantal verwysings moet nie meer as 30 oorskry nie, tensy dit geregverdig is. let op ble volgende voorbeelde: locke, j.l. (1983). clinical psychology: the explanation and treatment of speech sound disorders. j. speech hear. disord., 48, 339-341. penrod, j.p. (1985). speech discrimination testing. in j. katz (ed.), handbook of clinical audiology (3rd ed.). baltimore: williams & wilkins. davis, g.a. & wilcox, m.j. (1985). adult aphasia rehabilitation: applied pragmatics. san diego, ca.: college-hill. redigering manuskripte wat aanvaar is, mag na die skrywer teruggestuur word vir hersiening. addisionele kleiner veranderinge mag ook op hierdie stadium aangebring word, maar 'n nota ter aanduiding van alle veranderinge wat op die manuskrip voorkom, moet verskaf word. die artikel word dan aan die redaksionele komitee vir finale redigering van styl, duidelikheid en konsekwentheid teruggestuur. herdrukke: 10 herdrukke sonder omslae sal gratis aan die outeurs verskaf word. sluitingsdatum vir bydraes: bydraes word verkieslik teen 31 mei elke jaar verwag, maar artikels sal nog tot 30 junie vir aanvaarding oorweeg word. navrae, korrespondensie en manuskripte: moet geadresseer word aan die redakteur, die suid-afrikaanse tydskrif vir kommunikasieafwykings, die suid-afrikaanse spraak-taal-gehoor vereniging, posbus 600, wits 2050, suidafrika. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 53 the development of a model for geodesic learning: the geodesic information processing model caroline m. leaf, brenda louw and isabel uys department of communication pathology and audiology university of pretoria abstract the perception of ̂ arnin^n order* copew learning how to learn and self-directed inquiry as essential life-skills for the speech-language therapist are discussed. opsomming hierdie artikel voer aan dat alternatiewe benaderings tot die huidige tradisionele leermetodesessensieel isindier^nderriginhgtingsontplotting te han rnnteen self-gerigte navraag as essensiele lewensvaardigheid wat sisteme, * bewerkstellig in respons op veranderende situasies m p z z p me t s ^ m ^ p ^ z alternatiewe diensleweringsmodel, naamlik die geodetiese inligtingsproses^ r ^ ^ w ^ ^ j z van geodetiese filosofie val. die implikasies van hierdie alternatiewe benadermg vir die spraak-taalterapeut word ten slotte bespreek. key words: geodesic learning, mind mapping approach introduction j humans are biologically" designed to survive and the single greatest competitive advantage is the ability to learn (jensen, 1995: iv). traditional perceptions of learning the ability to learn, individually, in groups, in organisations and as a country, is a critical factor in the progress and development of society as a whole. traditionally, definitions of learning have been based on behaviouristic, mechanistic and cognitive theories (glasser, 1986; knowles, 1990). this has led to the assumption that learning is the internalisation of external knowledge, and is under the control of a single internal source of self-regulation, namely executive self-regulation (iran-nejad, 1990). this viewpoint defines learning as a growth process dependent on internalising events into a "storage" system that corresponds to the environment (knowles, 1990). therefore, most traditional learning theorists view learning as a process by which behaviour is changed, shaped or controlled, with an emphasis on growth and cognitive development (knowles, 1990; glasser, 1986). however, these assumptions undermine the creative and multimodal nature of learning, limiting learning to the simple incremental learning of facts and definitions, which in turn is responsible for the achievement and motivational problems many students experience (glasser, 1986; iran-nejad, 1990; gardner, 1985; knowles, 1990; jensen, 1995). it appears that behaviouristic and cognitive theories are too narrow to explain the complexity of the learning process as their primary focus is on concept attainment to the exclusion of concept formation or invention (glasser, 1986; jones, 1968, in knowles, 1990). furthermore, it needs to be acknowledged that that everyone learns in different ways, and that it is consequently necessary to explore alternative die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 ways of facilitating learning that will allow individuals to realise their natural potential. current traditional learning systems that propose to stimulate learning in the "whole" child, tend to favour predominantly linguistic and mathematical intelligences as opposed to a more pluralistic approach (jensen, 1995). this is a consequence of the prevailing philosophy of current traditional educational systems and therapeutic institutions which indicates that "intelligence" or "potential" is a single general capacity that enables the individual to achieve in all situations. research has, however, indicated that the traditional type of approach to developing learning potential , which is based on the i.q., piagetian and information processing movements, is product versus process oriented and does not develop the whole person in their full capacity (irannejad, 1990; gardner, 1985; jensen, 1995). many educators and philosophers concur that the most important goal of therapy and education is to facilitate thinking. hence an approach to learning is needed that moves away from viewing learning as a process of controlling, changing or shaping behaviour, to one that views learning as competency development. consequently, an alternative approach that focuses on the dynamics of the thought processes and the pluralistic nature of the intelligences of the human mind has arisen, and which is termed the geodesic movement (leaf, 1997; gardner, 1985; iran-nejad, 1990). the paradigm shift in speech-language therapy and audiology the paradigm shift that is occurring in the perception of learning is parallelled in the field of speech-language therapy and audiology, and has resulted in a paradigm shift in the professional self-concept and role played by the speech-language therapist. this paradigm shift has emerged in response to the increasing awareness of the inefficiency of traditional approaches in meeting needs of clients, with alternative service delivery models proposed to provide a more accountable service to clients (paulbrown, 1992; simon, 1987; leaf, uys & louw, 1990; lewis 1994). one of the communication needs stressed in the alternative service delivery literature is the need to integrate communication skills with academic material with the emphasis on the learning process (paul-brown, 1992). this is due to the academic environment requiring competent communication skills both oral and written as prerequisites for school success (johnson, 1987). a student's successes and failures are bound up in the way they share and create meaning through language. speech-language therapists therefore need to broaden their role to promote overall learning success, and in this way, provide a more accountable service to clients. speech-language therapists need to become more involved in facilitating the language and communication skills needed in the learning process in the classroom. this change therefore implies an evolution. according to johnson (1987:225), "the evolution from "speech-language therapist" to "communication and learning instructor" has been the result of adopting an educational versus a medical model, through integrating communication instruction into the students natural learning environment, and through collaborating with other educators". this entails the use of classroom and curriculum based service delivery models where the basis for the content of treatment would be the the south caroline m. leaf, isabel uys & brenda louw concepts and vocabulary from the academic curriculum. this implies a consultative role for the speech-language therapists allowing for their background and abilities to be utilised to a greater extent. not only can speech-language therapists provide direct therapy, but they can also provide input on the communication and social difficulties exhibited by the pupils as observed in the naturalistic learning environments, as well as about the process of language and learning in general (thurman & widerstrom, 1990). humanism versus behaviourism the development of humanistic psychology (founded in 1963) carries this trend of thought further in that the image of man is recast from a passive, reactive recipient to an active, seeking, autonomous and reflective being (rogers, 1969, in knowles, 1990). according to rogers (1969, in knowles), learning is seen as having a quality of personal involvement; as being self-initiated; as pervasive; as evaluated by the learner; and finally, as having meaning as its essence. this view is expanded by maslow (1970, in knowles, 1990) who identifies the goal of learning to be self-actualisation. jourard argues that "the learner has the need and the capacity to assume responsibility for his own continuing learning" (1972, in knowles, 1990). this humanistic view of learning has been formulated into a theory by glasser (1986) which he calls "learning control theory". learning control theory is a biological theory of how humans function as living creatures. it has as its basic premise the contention that all behaviour is an attempt to satisfy needs that are built into the genetic structure of the brain, and thus all motivation is internal, as opposed to external as claimed by behaviourists and cognitists. control theory contends that it is impossible to force or bribe a person into doing quality work. that is, learning is not a process of shaping change in behaviour, rather it is an internally motivated creation of meaning (glasser, 1986). iran-nejad (1990) elaborates on this idea by defining learning as the creative reconceptualisation of internal knowledge. he further proposes that there are two different sources of internal self-regulation; one that controls the sequential conscious aspect of learning,! and another that controls the simultaneous non-conscious aspect. furthermore, to extend the domain of learning beyond simple incremental memorisation, both sources of self-regulation have to be activated. ' ! both the behaviouristic and cognitive theories, wliich utilise computers and mechanistic processes as analogies, define learning as a change in behaviour that is largely controlled by an external source, and that will result in an accrual of knowledge facts. by contrast, humanistic theories, which have the functioning of the human brain as their analogy, define learning as an internally motivated and controlled process that results in the recreation of conceptual knowledge with the emphasis on meaning. behaviouristic and cognitive theories emphasise the educator, the agent of change who presents stimuli, and reinforcement for learning and designs activities to induce change. a humanistic approach, by contrast, emphasises the person in whom the change occurs, and learning as the act or process by which behavioural change, knowledge skills and attitude are reconceptualised. in this, a humanistic approach to learning appears to be a more accurate description of human functioning than a behavy african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the development of a model for geodesic learning: the geodesic information processing model 55 iouristic and cognitive approach. extensive research has been conducted in the fields of contemporary neuroscience and neuropsychology and has led to the identification of the brain's preferred way to learn, confirming the latter statement (glasser, 1986; gardner, 1985; iran-nejad, 1990; jensen, 1995; knowles, 1990; 1986; lozanov, 1978; dhority, 1991; springer & deutsch, 1989; diamond, 1988). however, behaviouristic and cognitive theories tend to dominate the philosophy of learning institutions with what are believed to be negative effects on the learning abilities of students and clients and the realisation of their potential. the adoption of predominantly behaviouristic and cognitive philosophies is possibly due to a lack of integration between research on the brain and standard education practices. in addition, the behaviouristic and cognitive theories provide neat ways of "measuring" and "packaging" students and clients into controlled environments, and are thus convenient to educationalists and learning institutions. the humanistic approach recognises the complexity and individuality of human nature, and consequently the complex and involved task of facilitating learning. this approach is not as convenient or controllable. cremin (1981, in knowles, 1990) indicates that the revolution in learning that began in the twentieth century and is continuing into the twenty-first century may be as fundamental as the original invention of formalised learning institutions. a strong case for the adoption of alternative approaches to learning is made by capra (1982, in knowles, 1990). he argues that "we are trying to apply the concepts of an outdated world view the mechanistic world view of cartesian-newtonian science to a reality that can no longer be understood in these terms. we live in a globally interconnected world, in which biological, psychological, and environmental phenomena are all interdependent. to describe this world appropriately, an ecological perspective is needed that the cartesian world view cannot offer" (capra, 1982, in knowles, 1990: 19). capra further argues that a fundamental change is needed in thoughts, perceptions and values, and thus, attitudes. the beginnings of this change are visible in x most areas and are likeljj to result "in a transformation of unprecedented dimensions, a turning point for our planet as a whole" (capra, 1982-, in knowles: 19). thus, a paradigm shift is needed in order to create new learning systems that focus on the development of potential which is achieved through teaching how to learn and not what to learn. there are many reasons for a paradigm shift in learning, not the least of which is that in the usa more than 40% of school-going children are diagnosed as having some kind of learning problem (jensen, 1995; thornburg, 1991, in jensen, 1995; simon, 1987). however, it is felt that this percentage is in fact higher, closer to 90% than 40%, and that the reason for this high percentage is the system within which pupils are being "educated". the current educational system is producing "educational casualties" (simon, 1987), rather than innovative lifelong learners. this constitutes a major problem because learning is an ongoing process that crosses all walks of life, and the application of traditional behaviouristic and cognitive learning systems is not preparing children for life (knowles, 1990). according to mitchell (1986, in buzan & dixon, 1976), society needs a more extended view of what normal human potential is, implying that high achievers are the norm and not the exception. this involves a totally new and broader approach to the perception of learning, and, therefore, of educating and remediating. in summary, it appears that traditional approaches to education and therapy are based on the i.q., piagetian and classical information processing theories of learning. these approaches all focus on a certain kind of logical or' linguistic problem-solving; ignore neurobiology; do not deal with higher levels of creativity; and finally do not consider the ethnography of learning. the result of such approaches is less than optimal as, according to research, 7090% of students are underachieving , many of whom require additional support in the form of therapy (iran-nejad, 1990; bloom, 1984). bloom (1984, in iran-nejad, 1990) states that for more than thirty years students have been memorising facts and definitions without understanding them. sizer (1984:84) indicates that "students are all too often docile, compliant and without initiative, painting a picture of considerable passivity towards academic learning and school". a non-intelligent learning culture of not thinking has thus resulted, producing students who do not take responsibility for their learning, and who are reliant on external sources to do their thinking for them. the geodesic movement the geodesic movement by contrast, focuses on the symbolic vehicles of thought, namely the activities and products of the human mind such as language, mathematics, visual arts and gestures (gardner, 1985; irannejad, 1990: allport, 1980; hinton & anderson, 1981). the geodesic movement moves away from the search for general problem-solving devices and horizontal structures such as memory, attention and perception, and focuses more on vertical components, hence providing a more molar and molecular analysis of the nervous system (allport, 1980). this approach is not entirely new, as facets of the mind were already recognised in ancient greek philosophy, and it can thus be seen as a type of rejuvenated faculty psychology. the geodesic movement does not merely focus on the linguistic, logical and numerical symbols of piagetian, i.q., and information processing theories , but also focuses on a full range of symbol systems encompassing musical, bodily, spatial and personal symbol systems, and is consequently multimodal (gardner, 1985: leaf, 1997). each symbol system can be viewed as an independent functioning cluster of intelligences making up that particular symbolic domain, and, although separate, the domains do interact in the thinking process (gardner, 1985). the geodesic is biologically oriented and is based on brain organisation and maturational capacity. thinking is perceived to consist of a number of special purpose devices, or clusters of abilities presumably dependent on neural "hard-wiring" in the brain (allport, 1980). furthermore, cognitive accomplishments may occur in a range of domains some of which are universal, such as the logical-mathematical domain which forms the basis of experimentation in the i.q., piagetian and information processing movements (feldman, 1980). some are culturally specific such as reading which is important in some cultures and not in others. within each domain there are steps ranging from novice to expert, making the movement developmental. however, there are great inter-individual differences in the speed at which an individual passes through the stages from novice to masdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 tery in the different domains. in contrast to piaget's theory, success at negotiating one domain does not invoke the other domains (feldman, 1980). the development of domains is dependent on internal genetic factors as well as on external cultural factors (gardner, 1985). therefore the geodesic movement represents a shift from cognitive theories of knowledge to cognitive theories of how the nervous system functions. (iran-nejad, 1990; hinton & anderson, 1981). this development suggests that simultaneous learning in diverse local sites and subsystems of the nervous systems is the rule for learning, as opposed to one-thing-at-a-time rule of traditional approaches. according to iran-nejad (1990), if previously unrelated local sites in the brain, representing domains, are stimulated simultaneously in a brain-compatible way, they will combine in configurations previously not experienced and result in higher levels of functioning. this simultaneous learning hypothesis, which is central to the geodesic movement, suggests that more than active conscious control is needed to think, learn and release potential. it implies that another kind of control must be operating on the non-conscious level, and both types of control are needed in effective learning. this control is called dynamic self-regulation, and is simultaneous, implying that simultaneous functioning is a prerequisite for learning as opposed to the other way around as in traditional approaches. furthermore, dynamic self-regulation operates on the non-conscious level, yet will impact the conscious level through a process of attention delegation, which is the power to contribute to the learning process even though not conscious (iran-nejad, 1990). this simultaneous, non-conscious process permits individuals to engage in multimodal encoding, unencumbered by potential interference from one-modality-at-atime executive encoding which is characteristic of many learners exposed to traditional approaches, and results in a cautious literal attitude to learning. learning in the traditional mode becomes increasingly analytical, intentional and potentially very sequential because the learner is using the rehearsal-memorisation strategy of allocating immediate attention to every physical item of the task over and over again, without regard for the powerful contributions of spontaneous, tacit and explicit attention-delegation processes of dynamic internal self-regulation. the geodesic approach represents a way of creating a more thinking-orientated approach to learning. a fundamental tenet underlying geodesic learning is that a mediator cannot cause learning in an individual, learning must be created by the learner. thus the mediator should structure the environment to facilitate the learning process (feuerstein, 1980). within the alternative geodesic approach, with the altered perception of learning, is the implication of an expanded role for the speech-language therapist working in educational settings. traditionally the speech-language therapist has employed a clinical model of intervention focusing on the oral linguistic aspects of language * (simon, 1987; paul-brown, 1992). this latter approach has led to a focus on deficits and remediating deficits a symptomatic approach. for example, viewing syntax, semantics, pragmatics and auditory processing as separate variables while ignoring the reading and writing aspects of communication leads to fragmented services that drill splinter skills (simon, 1987; paul-brown, 1992). in the field of education, specifically simon (1987) postucaroline . leaf, isabel uys & brenda louw lates that well-meaning traditional speech-language approaches have actually ended up creating "educational casualties" as a consequence of segregating and labelling students, leading them to become addicted to 1:1 attention. this has led to the development of passive attitudes towards learning by falling into patterns of "learned helplessness" due to believing their "disabled" labels (johnson, 1987). alternative service delivery approaches have consequently emerged in response to the increasing awareness of the inefficiency of traditional approaches to communication, with immediate impact on the role of the speech-language therapist. thus, the most significant implication arising out of the literature related to the development of lifelong innovative learners with proficient communication skills, concerns the need to move from teaching and facilitating specific skills to the teaching of strategies to enable students to attain mature language repertoires and communication competence with adequate problem-solving skills (thornburg, 1991, in jensen, 1995; derry, 1990). the speech-language therapist, with a background in language, communication, psychology, speech and hearing science, linguistics, and learning theory, is eminently qualified to become involved in the integration of a geodesic approach to the process of learning and intellectual development, which indicates the expanded role for the speech-language therapist working with learning problems (paul-brown, 1992). as discussed, speech-language therapists should view themselves as language specialists concerned with the prevention and remediation of communication difficulties by focusing on the process of learning and intellectual development (thornburg, 1991, in jensen, 1995). the speech-language therapist is seen to play an important role academically in assisting with adapting the child's academic instruction so that he can achieve to the best of his ability (committee on language, speech and hearing services in schools, 1983, in johnson, 1987). this implies that a complex relationship exists between language used for learning and intellectual development and language used for communication, highlighting the need for a paradigm shift in the perception of learning. in view of the foregoing, research highlighting and emphasising the necessity of a learning paradigm change is needed if educational institutions are to facilitate the development of innovative lifelong learners that can make a contribution to society. ι the overall objective of the research on the geodesic information processing model, and its application, the mind-mapping approach (mma) (leaf, 1990; 1997), is therefore to create and explore an alternative system to the traditional learning system. the mind-mapping approach (mma), is believed to provide a better way to assist learners teachers, therapists, pupils and clients alike in becoming innovative lifelong learners. this is because the theoretical base of the mma incorporates the principles inherent in the philosophy of geodesic learning, which is the suggested alternative philosophy upon which the perception of learning should be based,, and which falls within the realms of a humanistic approach. the mma framework provides a basis for bridging the gap between the unique individual learner and the design and delivery of the learning experience. the latter is in contrast to traditional educational and institutional systems of facilitating learning and communication, which are based on unnatural behaviouristic, mechanistic and cogthe south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the development of a model for geodesic learning: the geodesic information processing model 57 nitive philosophies which undermine the complexity and hence the potential of human nature. in view of the complex nature of learning, intellectual potential and communication, approaches of a more geodesic nature need to be adopted by educationalists and s p e e c h l a n g u a g e therapists in learning institutions in order to increase the efficacy of service delivery (simon, 1987). this implies a paradigm shift from traditional behaviouristic and cognitive approaches to geodesic approaches to learning and communication (gardner, 1985; dhority, 1991; jensen, 1995). this paradigm shift can be facilitated by practical frameworks incorporating geodesic principles. the mmais viewed as a framework of this nature. _ this theoretical model also serves as a foundation lor the expansion of the concept of the mind-map (leaf, 1990; leaf, uys & louw, 1993). the expanded view of mindmapping views the mind-map as the key which accesses the non-conscious levels of the brain. the mind-map is seen to directly access and influence the thought processes serving to unlock the potential of the brain. hence the mind-map will be shown to be the creative symbolic visualisation of the raw material of consciousness, that is, the synchronised electrical-chemical reactions of the neurons. it is the purpose of this paper to explain the development of the theoretical model, the geodesic information processing model in terms of its operation and theoretical assumptions. the importance of a theoretical base in the development and application of an alternative approach to facilitating a creative learning process in students and clients is stressed. the concepts inherent in the geodesic information processing model are general geodesic principles and can therefore be extrapolated and used in therapy and education . the mma and the expanded conception of the mind-map do, however, provide a framework that incorporates all geodesic principles in a practical way, and will be discussed in ensuing papers. explanation of the geodesic information processing model i in this section, the components of the geodesic information processing model and their operation will be described. orientation i 1 the geodesic information processing model was developed to explain the thinking process invoked by using the geodesic techniques of the mma. the emphasis of the mmais to capitalise on the natural multimodal functioning of the brain in order to reconceptualise useful knowledge and develop potential. the four components of a geodesic approach, namely metacognition, cognition, neuropsychology and symbolism, are incorporated into the geodesic model. the theoretical underpinnings of the development of the model have been derived from contemporary brain research: the work of iran-nejad (1990) on the two-source theory of self-regulation; lozanov's (1975, 1978) development of suggestopeadia; gardner's (1980, 1985) research on symbolic systems and the multiple intelligence theory; contemporary metacognitive and cognitive research, specifically on the role of the non-conscious (flavell, 1978); and finally symbolic system1 approaches to information processing which use the brain as the analogy for the mind (hinton & anderson, 1981). the geodesic information processing model is presented in schematic form in figure 1. this is accompanied by a gestalt overview of its operation followed by an in-depth explanation and discussion of its components and their operation. an overview of the operation of the geodesic information processing model the geodesic information processing model (figure 1) is a hypothetical model that traces the information processing pathway from the input which can be internal, external or both to the output whilst using a geodesic framework such as the mma. it is, however, postulated that this model can be extrapolated to explain any approach that strives to facilitate the processing of information within an environment that follows the natural laws of functioning of the brain. as the result of an internal or external input, or both, information begins to be processed (see figure 1). if the geodesic framework, the mma is utilised, specific metacognitive module(s) will be activated by a patternmatching process. this will result in the activation of the processing systems of the specific metacognitive module^) to be involved in the task. in order for the processing system to operate, metacognitive action (see figure 1), needs to be instituted, that is, the interaction of declarative, procedural and conditional knowledge executed by dynamic self-regulation. this will lead to the selection of the function to be carried out, facilitated by the activation of existing descriptive systems to assist in the reconceptualisation of the new knowledge, and the cognitive process will begin. at this point, active and dynamic self-regulation interact. the quality of this interaction is controlled by the geodesic nature of the mma. the cognitive domain (see figure 1), has to match the processing system already selected, and therefore the cognitive requirements of content, form and use will need to be met before quality processing can continue. if the cognitive requirements are fulfilled, then the cognitive function^) will be selected to carry out the cognitive task to completion. in order to operationalise the cognitive function^), cognitive action begins. finally, the result of the information processing will be expressed through a symbolic format which is known as the output. the evidence of the newly reconceptualised knowledge is visually available on the mind-map, and represents the overt evidence that thought has taken place. the geodesic information processing model (figure 1) is divided into four components, namely the metacognitive, cognitive, symbolic and neuropsychological components. the operation and interaction of each of these components is now discussed. the metacognitive component description the metacognitive component comprises seven metacognitive module's (see figure 1), each of which can be broken down into processing systems. each processing system is made up of functions that realise the potential die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 caroline . leaf, isabel uys & brenda louw the southafrican journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the development of a model for geodesic learning: the geodesic information processing model knowledge. 59 of that processing system. this realisation of the potential of a processing system is made possible by its computational capacity, the activation of the metacognitive domain. the seven metacognitive modules the metacognitive modules represent the knowledge base of the mind, categorised into seven groups based on the multiple intelligence theory (gardner, 1981, 1985). these seven are not exhaustive but are seen to be representative of the range of human knowledge and intellectual potentials (gardner, 1985; kline, 1990). the seven modules are the linguistic, logical /mathematical, visual/spatial, musical, interand intrapersonal, and kinaesthetic domains of knowledge. according to gardner (1985), owing to heredity, early training or both, some individuals will experience greater development within some domains of knowledge than others, but every normal individual should develop each domain to some extent. in life, these domains of knowledge (called metacognitive modules in the current model because of the metacognitive and information processing perspective) work in harmony, and so their autonomy may be invisible. however, gazzaniga (1977, in gardner, 1985) argues that they function as independent units each with their own cognitive characteristics. it is therefore proposed that the integrative cognitive nature of the mma facilitates the interaction of these modules. when these modules interact, higher order thinking is produced because the net result of the interaction between modules improves the quality of interaction within modules. strength in the sum of the parts is the fundamental principle of this modular perspective. the quality of higher cortical functions is influenced by the harmonious interaction of modules which is facilitated by creating environments that tap the abilities of all the modules, as opposed to just one or two, as is the case with traditional approaches. synchronised interaction is facilitated within multimodal frameworks such as the mma. i it should be noted that in figure 1 (the geodesic information processing model), the expansion from the metacognitive level to the cognitive level, to the symbolic level is shown only in the linguistic metacognitive module. however, it is proposed that each metacognitive module follows this selfsame expansion within its domain of metacognitive knowledge component | mma | e x e c u t e r dynamic s e l f r e g u l a t i o n monitoring ] oper ates i proce sys ssin3 tem regulation goal s e t t i n g figure 2: the metacognitive domain the processing systems and their functions a metacognitive module is further subdivided into processing systems which (see figure 1) are the result of a whole system of functions. these are represented neurologically by interrelations of different parts of the brain, based on luria's (1980) conception of functional systems. each metacognitive module has its own specific processing systems, which are represented across both hemispheres in the brain. the processing systems are made up of functions which are locally represented in specific areas of either the left or right hemisphere of the brain. for example, the linguistic metacognitive module has various different processing systems such as reading, writing, communicating and listening. each of these, in turn, can be divided into their functions. thus, for the processing system of reading, the function could be reading to find the key concept, or reading a complex technical manual, or reading a novel for pleasure. each of these functions requires different cognitive approaches and is made up of various different steps termed cognitive actions which will operationalise the cognitive task. the metacognitive domain the computational capacity a computational capacity exists at the core of each metacognitive module which is unique to that particular metacognitive module, and on which its complex realisations are based. from the repeated use of, interaction among, and elaboration of the various computational devices, forms of knowledge will eventually flow that could be termed useful, thus contributing to intelligence. these forms of knowledge have the potential to be involved in symbol systems, and will ultimately be expressed on the symbolic level. more specifically, these computational capacities, which are unique to each of the metacognitive modules, are termed the metacognitive domains. a metacognitive domain comprises declarative, procedural and conditional knowledge with its executor being dynamic self-regulation. each processing system operates under the direction of the metacognitive domain for that particular metacognitive module. figure 2 illustrates this relationship schematically. an example of the interplay in the metacognitive domain a hypothetical example of the dynamic interplay between the declarative, procedural and conditional knowledge components, and their executor dynamic self-regulation as invoked by the mma would involve the following. initially an externallyor self-imposed goal is established (the equivalent of internal or external input). the existing metacognitive knowledge concerning this particular objective leads to the conscious metacognitive experience (interaction between active and dynamic self-regulation) that the objective may be difficult to achieve. this metacognitive self-regulation, combined with additional metacognitive knowledge, results in the selection and use of the cognitive strategy (termed cognitive act on the schema) of asking quesdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 caroline . leaf, isabel uys & brenda louw tions of oneself or knowledgeable other people. the answers arising from this exercise stimulate additional metacognitive experiences about the success of the task, which represents the interaction between active and dynamic self-regulation. these experiences, guided by relevant metacognitive knowledge (declarative, procedural and conditional), investigate the cognitive strategy (cognitive act) of surveying, to establish whether it forms a coherent whole which provides a solution to the problem. this overview may result in the identification of difficulties with consequent activation by metacognitive knowledge and experience (active and dynamic self-regulation) of the same or different cognitive strategies. this interplay continues until the symbolic representation is achieved, which is the final creation of the mind-map. the activation of the metacognitive module metacognitive action in order to activate a metacognitive module, the components of the metacognitive domain (declarative, procedural and conditional knowledge) need to interact. this interaction results in metacognitive action, and is orchestrated by dynamic self-regulation. the quality of the interaction of the metacognitive domain determines the eventual output. in the creation of the mind-map, all three types of knowledge need to be considered when selecting the concepts, as well as when representing these in an associated way. the process of creating the mind-map enhances the interaction of declarative, procedural and conditional knowledge, resulting in metacognitive action. when metacognitive action occurs, the process of cognition begins. as mentioned earlier, 90 per cent of learning takes place on the non-conscious level (gardner, 1985; iran-nejad, 1990). the rationale for this is that "intelligent" learning is creative and multisource, and hence takes place on the non-conscious level (iran-nejad, 1990). traditional approaches assume that learning occurs under active conscious executive control, namely from a single source termed metacognition (iran-nejad, 1990; dhority, 1991). as a result effortful attention (iran-nejad, 1990) is viewed as the single most important regulator of learning (bereiter, 1985). this limits the domain of learning. in the current study, based on a literature review on the non-conscious and self-regulation, metacognition is redefined as occurring on the non-conscious level (irannejad, 1990; dhority, 1991; lozanov, 1978; flavell, 1978). these authors postulate the notion that external and internal stimuli are far too complex to manage or hold with only the mechanisms of our conscious attention. hence the non-conscious level is not viewed as simply containing the unattended or unimportant percepts, but as the level where the complex mental activity occurs. a structure for the non-conscious level is postulated, thus providing a broader definition of metacognition. by implication, 90 p.er cent of learning is taking place when metacognitive action is in process, and hence this is the level that should be targeted in intervention and mediation. the activation of the non-conscious stores triggers metacognitive action. the mma can be seen as this trigger. by implication, the mma focuses at the root level of the learning process, and therefore predominantly on the non-conscious. conversely, the cognitive functions that have been activated by metacognitive action, and that are orchestrated by active and dynamic self-regulation, only represent approximately 10 per cent of the learning and reconceptualisation of knowledge process (reddy, 1979, in iran-nejad, 1990; lozanov, 1975). the neurobiological level of metacognitive action on a biological level, modular columns of neuronal cells ascending from the cortex to the subcortex to the limbic system across the left and right hemispheres, represent the metacognitive modules and functional systems (see figure 1) (feldman, 1980). metacognitive action is represented as the distributed parallel activation of dendritic interconnections from the cortex to the limbic system across both hemispheres. the neuropsychological level of metacognitive action pattern recognition on a neuropsychological level, metacognitive action can be perceived as the activation of the descriptive systems (goldberg & costa, 1981), or organisational codes. the number of descriptive systems activated is dependent on the complexity of the cognitive task. these will be used to reconceptualise new descriptive systems based on pattern recognition. the mind-map's pattern structure facilitates the pattern recognition process, as well as making it available to introspection, and in this way more efficient use of the descriptive systems can be made. the interaction of active and dynamic self-regulation active self-regulation occurs on a conscious level, which implies that conscious introspection can occur. this is the result of the interaction of dynamic and active selfregulation (see hypothetical example above). according to iran-nejad (1990), this interaction has important implications for learning because the quality of this interaction distinguishes between effective and ineffective approaches to learning. therefore, active and dynamic self-regiilation have to interact in order to produce cognition. once the cognitive process is instituted, active and dynamic self-regulation should continue to interact, and the nonconscious will impact on the conscious level through attention delegation. this will lead to "quality learning". however, if active self-regulation starts to operate at the expense of dynamic self-regulation, which can occur if the facilitation is brain-antagonistic (jensen, 1995), as in traditional approaches, then the quality of learning lessens and learning becomes more rote-like. a single-source theory of self-regulation implies that the central executive must monitor constructive change by directly allocating attention to the source of change (reddy, 1979, in iran-nejad, 1990). the two-source alternative (iran-nejad, 1990) implies that active allocation of attention is neither sufficient nor always necessary. an activated descriptive system (the result of metacognitive action) can influence a cognitive task, even though it may be outside conscious awareness. therefore the activated descriptive system will still influence higher mental functions or cognitive tasks and strategies being used to complete a goal be it of a communicative or academic nature. this is known as attention-delegation power, which is the the southafrican journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) development of a model for geodesic learning: the geodesic information processing model 61 power to continue an ongoing contribution to internal r e c o n s t r u c t i o n even after t h e executive spotlight moves on to another site (iran-nejad, 1990). the most direct source of interaction between active and dynamic self-regulation occurs when specific attention is allocated to the components (iran-nejad, 1990). these are the declarative, procedural and conditional knowledge components of the metacognitive domain in the information process model. it is postulated that this interaction is enhanced by the mma due to its metacognitive nature. this process is evidenced during the act of creating a mind-map, where essentially declarative, procedural and conditional knowledge is stored. in the selection of a concept, metacognitive action sequences are established which indicate the associative relationships in a deductive and inductive way, therefore analogically. thinking on this level is considered to be deep processing as the metacognitive level is actively involved. if the incorrect concept is selected due to lack of comprehension or the attempt to learn in a rote fashion, incorrect action sequences will be stored, which will affect recall. this is easily rectified by reviewing the networked patterned nature of the mind-map. in this way the metacognitive components (which have become conscious by their visual symbolic expression on the mind-map, and therefore regulated by active self-regulation) will be activated. however, the metacognitive action sequences are governed by the non-conscious level (anderson, 1986, in springer & deutsch, 1989), and therefore dynamic selfregulation, and will be activated on a non-conscious level. hence, in order to rectify the incorrect action sequences, active and dynamic self-regulation have to meet and interact. it is this interaction that becomes a primary focus of the mma because, as already stipulated, the quality of interaction will distinguish between effective and ineffective approaches to learning. it is hypothesised that the mma improves' the quality of the interaction because it accesses the cognitive and metacognitive levels in its construction. figure 3 illustrates the relationship between active and dynamic self-regulation and metacognition and cognition. therefore, the metacognitive nonconscious is the highest level of thought, where qualitative, intelligent and useful knowledge is reconceptualised. traditional forms of stimulation will result in only partial activation of this level, arid hence the lack of activation of potential. j the cognitive component description the cognitive component of the geodesic information processing model represents what is traditionally assumed to be metacognition, that is, "thinking about thinking" (flavell, 1978). in the model (see figure 1), this level represents the level on which slow, conscious control of the thought process occurs. it is under the control of the central executive and is inherently sequential. the cognitive process begins after metacognitive action is instituted, when dynamic and active self-regulation interact. the cognitive process when metacognitive action is instituted, cognition (see figure 1), orchestrated by active and dynamic self-regulation, begins, the interaction between the two being of paramount importance. on the cognitive level, the metacognitive action is carried out to completion. this completive action is constantly enhanced by the use of the mma framework. in order to complete the metacognitive action, the cognitive process will be instituted on the product of the metacognitive action. this is the process that is instituted as the mind-map is being made. these action sequence steps include the following: • attention allocation and delegation; • perception through all the sensory modalities; • the decoding (analysis) of the incoming information (this involves the analysis of existing appropriate descriptive systems already called up when metacognitive action began) in preparation of the new reconceptualisation of knowledge; • the process of problem-solving, which includes reasoning, both deductive and inductive, resulting in inferences and judgements being made, and cause-effect relationships being established; • the organisation of the resultant reconceptualisations into appropriately associated and categorised networks; and finally • the synthesising (encoding) of information that will be effectively stored in memory (flavell, 1978; gardner, 1985; iran-nejad, 1990; jensen, 1995; dhority, 1991; hart, 1983; hand, 1986). these cognitive processes occur within each of the cognitive domains which delineate the processing systems already activated on the metacognitive level, namely listening, speaking, reading and writing, in the case of the linguistic module. each cognitive domain has various requirements that have to be fulfilled in order to create useful knowledge. these requirements (bloom & lahey, 1978, in leaf, 1997) include: somemetacognition (non-conscious) point at which active • dynamic vself-regulatiori cognition (conscious) rtwe • figure 3: the interaction between active and dynamic self-regulation die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 caroline . leaf, isabel uys & brenda louw thing to communicate (content); a structure for the communication (form); and, finally, a communicative intent (use). the next phase of the mma information processing model proposes that the cognitive process operates within each cognitive domain selected for the specific task at hand, if the cognitive requirements of useful knowledge have been fulfilled. each cognitive domain is divided into cognitive functions, corresponding to the functions on the metacognitive level, which are further subdivided into cognitive actions. in this way the cognitive act operationalises the cognitive task. an example of cognition in action level is therefore the evidence that thinking and processing of information has occurred. this is expressed through a symbolic vehicle that is representative of the metacognitive module. for example, the linguistic metacognitive module can be expressed symbolically as oral expression, reception, written expression or reading, or all of these (see figure 2.1). the mind-map facilitates and represents all four forms of expression. from the symbolic level, judgements of a person's thinking, learning, intellectual potential and communication skills are made. this implies judgements as to the effectiveness of cognitive and metacognitive skills. this occurs because metacognition influences cognition which in turn influences the symbolic output. in selecting the cognitive domain (see figure 1) (processing system) of writing, the cognitive function may be to write down a selected concept onto the mind-map. this is cf1 (cognitive function 1) in figure 1. cf1 would then be made up of various cognitive acts (ca1, ca2 etc) which are the steps involved in carrying out cf1. thus, ca1 in this case would be the analysis of the phonemes that would afterwards have to be written. this involves the posterior parts of the left temporal zone (luria, 1978). ca2 would involve the motoric expression of the lingual sound (luria, 1980) in order to make the contents of the sound clear. this involves the inferior portion of the left post-central gyrus (luria, in leaf, 1990). ca3 is the transferring of phonemes into letters involving the spatial arrangement of the graphemes, which involves the parietal-occipital part of the cortex (luria, 1980). ca4 involves the sequencing of phonemes and graphemes while writing, which involves the pre-motor zone (luria, 1980). finally, ca5 will involve the positioning of the word on the mind-map to fit into the associative network. thus ca5, in this case, moves onto the symbolic level namely level three on the information processing model. the symbolic component the symbolic component comprises the expressive level of the cognitive action, which is in turn influenced by the metacognitive component. functioning on the symbolic figure 4: a schematic representation of the neurobiological arrangements of the metacognitive modules the neuropsychological component the last component of the geodesic information processing model is the neuropsychological component, which deals with the relationship between brain function and behaviour (see figure 1) (tollman, 1988, in leaf, 1990). this component is the link between the biological and cognitive levels. in order to fall within the realms of being geodesic, the brain-function-behaviour relationship cannot be overlooked (dhority, 1991). according to the model, the metacognitive modules are represented biologically as modular columns of neuronal cells ascending from the cortex to the limbic system across both left and right hemispheres. it is postulated that there are seven neuronal columns representing the seven metacognitive domains, as illustrated in figure 4. as the result of input, electrical activity will flow across the columns. the more synergistic the input, the more synchronised the flow between the two hemispheres. it is postulated that when this occurs, larger areas of the brain will be utilised more efficiently. it is believed that this synchronised synergistic flow will result in the metacognitive action being activated. thus, the reserve capacities will be mobilised. in contrast, input from traditional approaches will result in reduced unsynchronised flow between the hemispheres resulting in only active self-regulation and effortful cognition occurring. the metacognitive domain is represented biologically as the distributed parallel activation of dendritic interconnections and synapses within the neuronal columns of the modules across both hemispheres (cook, 1984, in springer & deutsch, 1989). neuropsychological^, this results in pattern detection (pribram, 1971, in leaf,1997; hart, 1983, in leaf, 1997), which is the calling up of existing descriptive systems to facilitate reconceptualisation of knowledge. the cognitive component is represented as localised activation of neural connections in either the left or right hemisphere, because the processing systems at this'' stage are more specific (springer & deutsch, 1989). finally the symbolic component is represented as parallel activation of the modules involved across both hemispheres because the symbolic expression is the result of synery the southafrican journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the development of a model for geodesic learning: eristic action. „ , , therefore the geodesic information processing model rovides speculation as to the type of thinking that is induced when working within a geodesic framework. it traces the processing of information from the metacognitive level through to the symbolic output. there are various assumptions upon which this model is based. a n e x a m i n a t i o n of these assumptions and their theoretical underpinnings is of relevance, as they lead to a redefinition of the non-conscious level, metacognition, cognition and learning. these redefinitions are pivotal in the explanation of the effectiveness of a geodesic approach to intervention and education. in the ensuing discussion, an overview of the eight assumptions of the model is presented. this is followed by a more detailed explanation. the eight assumptions of the geodesic model: an overview there are eight assumptions underlying the geodesic information processing model (see figure 1 and table 1). the first of these assumptions deals with the metacognitive component of the model. it is assumed that metacogthe geodesic information processing model 63 nition is the root of the thought process controlling the cognitive process and ultimately the symbolic output. furthermore, the key to unlocking intellectual potential occurs when the metacognitive level is activated effectively. it is postulated that traditional approaches, which are not geodesic, do not take full advantage of the metacognitive potential of the brain, and that the full spectrum of metacognition is thus overlooked. within a geodesic approach such as the mma, it is assumed that the metacognitive level is more adequately activated. the second assumption postulates that metacognition is the non-conscious level. this implies that the majority of complex higher cortical functioning and learning occurs outside conscious awareness (reddy, 1979, in iran-nejad, 1990; derry, 1990). the way that metacognition is conceptualised within the geodesic information processing model provides a structure for understanding and analysing the non-conscious level. the third assumption deals with the concept of selfregulation and relates to the metacognitive and cognitive components of the geodesic information processing model. traditionally, this is the conscious executive control of thought which forms part of the definition of metacognition (costa, 1984). according to slife, weiss and bell table 1: the assumptions and theoretical underpinnings of the geodesic information processing model level assumptions theoretical underpinnings metacognition 1. metacognition is the non-conscious level that accounts for the bulk of learning 2. the metacognitive structure of the non-conscious: (1)metacognitive modules (2) metacognitive processing systems (3) metacognitive domains 3. the interaction of active and dynamic self-regulation is the operating system of effective thought processing. automaticity research multi-source self-regulation theory modular theory suggestopaedia multiple intelligence theory lurian theory metacognitive research descriptive system theory 4. the cognitive component is the level on which conscious sequential thought occurs. 5. memory enhancement, as part of the cognitive process, is contextual and content based specific to each module. self-regulation theory cognitive research taxon and local memory memory enhancement research ! i 6.1 synergy between the hemisphers releases potential. 6.2 metacognitive results in the activation of descriptive systems through the process of pattern recognition and feedback creating open systems. 6.3 the brain is a modular system of interlinked functional systems. 6.4 the limbic system needs to be activated in order to reconceptualize useful knowledge. 6.5 the processing of information occurs in a parallel simultaneous fashion on a nonconscious level, and in a sequential way on a conscious level. hemisphericity research topographic inhibition theory descriptive systems pattern recognition feedback modularity theory cognitive-emotive theory suggestopaedia pdp theory modular theory 7. the capacity to express and communicate using some symbolic vehicle. symbolic system modular theory 1 8. intelligent learning is the reconceptualization of descriptive systems leading to new knowledge. self-regulation theory suggestopaedia die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 caroline . leaf, isabel uys & brenda louw (1985 in iran-nejad, 1990), self-regulation refers to the planning, monitoring and checking activities necessary to orchestrate cognition. iran-nejad (1990) however, argues that this type of self-regulation, termed active self-regulation, is only part of the self-regulation process, accounting for the learning of a functional knowledge base. overreliance on this active self-regulation results in rote learners and reduces learning potential (iran-nejad, 1990). it is proposed that an additional form of self-regulation, termed dynamic self-regulation, is required to overcome the inherent limitations of active self-regulation (iran-nejad, 1990). dynamic self-regulation is rapid, spontaneous, multimodal and co-ordinates the simultaneous as opposed to the sequential aspects of the learning process (iran-nejad, 1990). it is the interaction of these two types of self-regulation that will lead to more effective learning (iran-nejad, 1990, 1991). within the geodesic information processing model, the interaction of the two types of self-regulation is viewed as the operating system of effective thought processing. this interaction triggers metacognitive action (see figure 1). the fourth assumption deals with the cognitive component, which is responsible for the conscious sequential aspect of learning. the activation of the cognitive process is reliant on its interaction with metacognition. this in turn is orchestrated by the interaction of active and dynamic self-regulation. therefore, according to the geodesic information processing model, the conscious awareness, or the "thinking about thinking" aspect of the thought process is a more advanced level of cognition and not metacognition, as described in traditional definitions. the fifth assumption, also dealing with the cognitive component, is that memory enhancement is part of the cognitive process. therefore, although memory is stored on the non-conscious metacognitive level, the actual enhancing of the memory process is facilitated by various techniques that are consciously created on the cognitive level and expressed on the symbolic level. the sixth assumption of the geodesic information processing model is concerned with the neuropsychological component (see figure 1). research has indicated that the most effective way of releasing the potential of the brain is through stimulating a synergistic wholistic and complementary pattern of processing between the two hemispheres (springer & deutsch, 1989). this will allow the natural, wholistic pattern-discrimination ability of the brain to function. priibram (1971, in leaf, 1997) argues that the brain extracts meaning through wholistic multisource pattern discrimination rather than through single facts or lists. the human brain is not designed for linear unimodal thought, but operates by simultaneously going down many paths (hart, 1983, in leaf, 1997). hart (1983) stresses the importance of presenting and assimilating information in larger patterns before the details. thus, a geodesic framework will need to utilise formats of presenting and assimilating information that allow synergistic multimodal pattern discrimination to occur. the techniques of the mma, specifically the mind-map, are assumed to stimulate multisource pattern discrimination that is brain-compatible (leaf, 1990; leaf et al., 1993). the seventh assumption of the geodesic information processing model deals with the symbolic component (see figure 1). the symbolic component is the expression of the metacognitive action, which is operationalised through the cognitive process. the symbolic component deals with the capacity of human beings to express and communicate meanings through using some symbolic vehicle (allport, 1980). it is assumed that the symbolic component reflects the thought processing of the person, and is the medium through which the thought process can be manipulated. the eighth assumption, relating to all four components of the geodesic information processing model, indicates that intelligent learning is the result of the reconceptualisation of knowledge (iran-nejad, 1990). the reconceptualisation of knowledge is the end result of the thought process invoked by a geodesic framework such as the mma. this is in contrast to traditional perceptions of learning which view learning as the incremental internalisation of external knowledge (reddy, 1979, in irannejad, 1990; costa, 1984). this latter definition cannot account for the complex creative process involved in intelligent learning and limits learning to the development of a factual knowledge base. implications of the geodesic information processing model arising out of the ideas presented in the current paper, are various implications for the speech-language therapist. these include the following :learning is the reconceptualisation of knowledge as opposed to the internal incrementalisation of facts. traditional philosophy limits the domain of learning to the simplistic internalization of externally available knowledge resulting in predominantly rote-type learning of facts and definitions (iran-nejad, 1990). most of the factual information taught within traditional environments has questionable value in terms of lifeskills, and therefore lacks in quality and usefulness (glasser, 1986). learning is an interactive multimodal process system, not a sequential accrual system which is only a sub-function. it is thus limiting and inhibiting to design education and therapeutic intervention around simple behaviouristic one-thing-at-a-time stimulus response. this is not congruent with biological theories of brain functioning, which indicate that the genetic structure of the brain results in behaviour being the attempt to satisfy needs, and is thus proactive, not reactive and stimulus bound (glasser, 1986). if the alternative perception of geodesic learning discussed in this paper is adopted, then the emphasis will move from the memorising of facts, information and formulas, which are readily available in both books and computer software, to processes and skills. for instance, preferred activities would be writing a play, as opposed to a grammatical writing lesson; or using co-operative groups to solve problems, or to understand a process as opposed to learning photostatted notes off by heart for a test. the idea is to immerse learners in multimodal stimulation using as many varied learning opportunities as possible. the focus would then be on the process of how to learn, which is recreating knowledge, and would therefore avoid simple incrementalisation of existing facts. the reconceptualisation of knowledge would enable students and clients to develop their ability to use what is learned, not just to know what it is. a further consideration is that special'education environments dealing with children with learning difficulties are usually characterised by a passive-acceptant approach the southafrican journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) development of a model for geodesic learning: the geodesic information processing model (feuerstein, 1980). familiar simple subject matter is offered at a slower pace with emphasis on reproducing material a simple incrementalisation of facts (feuerstein, 1980; king & goodman, 1990). this results in learning environments lacking any creativity, the facilitation of higher levels of thinking or the independent performance of higher level functions the reconceptualisation of knowledge. in order to raise children with learning difficulties to higher levels of development, a passiveacceptant approach must be replaced by a proactive geodesic approach. according to this approach, the individual is an open system capable of mental and emotional modification (feuerstein, 1980; jensen, 1995). a proactive geodesic approach will encourage children with learning difficulties to be actively involved in normal education environments and society. this requires a process of integration facilitated by the professional in the learning environment, who needs to recognise that language, learning and communication do not exist in a vacuum (paulbrown, 1992; marvin, 1987). instruction to facilitate language, learning and communication skills should be presented in natural environments requiring communication (johnson, 1987). as school is normally the natural environment for most school-going children, communication skills need to be integrated with academic content. thus, if the professional, specifically the speech-language therapist who has expertise in language and communication, works directly in the classroom where the problems occur, strategies can be provided for pupils to better understand academic material and classroom instructions (paulbrown, 1992). viewed functionally, speech-language therapists are not "re-mediating" or "re-habilitating" communication, language and learning disabilities, but are attempting to proactively assist in the mediation of a school communication system for them. in this way, the passive reactive incrementalisation of existing facts can be replaced by the active recreation of knowledge. learning environments need to be ecologically congruent and authentic with; an emic perspective, in order to facilitate effective language, learning and communication the majority of learning needs to be contextually embedded as realistically as is possible (johnson, 1987). this is because "the brain is actually very poor at learning large amounts of material from books. it is naturally good at learning in the locations and circumstances of everyday life" (jensen, 1995: 333). knowledge is more easily reconceptualised into useful! knowledge that can be utilised when it is associated with a,novel experience, or location or feeling, or some type of hook that will tie it in with the content. therefore neither the traditional "stand and deliver" context of teaching nor the isolated 1:1 therapy model are authentic, ecologically congruent or emic as the focus is on the teacher and therapist delivering content or remediating an identified "deficit". rather, the learner needs to be guided to discover the meaning of the content. furthermore, language, learning and communication are active creative processes. whether the focus is on speaking, listening, reading, or writing, language and communication involve the creation of meaning and making sense (king & goodman, 1990). a curriculum or therapeutic approach that fragments language, communication and learning into small, abstract pieces with the expectation that if the parts are mastered, the whole will eventually be mastered, inhibits learning and communication (schory, 1990). the opposite perspective is a whole language perspective where the learning direction is from the whole to the parts, (king & goodman, 1990; schory, 1990), and therefore falls within the realms of a geodesic approach. according to schory (1990), children pass a crucial test, before school, suggesting that they are spontaneously proficient learners, because they master in a few years one of the most complex systems of rules known, their mother tongue. they also become quite proficient in the knowledge of the world around them (iran-nejad, 1990). by contrast, "only a few children in school ever become good at learning in the way we try to make them learn. most of them get humiliated, frightened and discouraged. they use their mind, not to learn, but to get out of the things we tell them to do to make them learn" (holt, 1964: vii). bereiter (1985, in iran-nejad, 1990) indicates that there is a complex relationship between the multisource nature of learning and the environment in which this learning is fostered. a young child's learning environment is multisource, creative and natural with the various sources that contribute, operating simultaneously. it facilitates a balance between active and dynamic self-regulation to occur. this is in contrast to the less than authentic traditional learning environments of later life that foster a climate of encoding facts in an increasingly analytic and sequential way. this fosters an over-reliance on untrained or incorrectly-trained active self-regulation at the expense of dynamic self-regulation, which results in training children out of the natural way of learning (holt, 1964, in iran-nejad, 1990). therefore, the more wholistic, natural and meaningful the learning environment, is the more ecologically congruent and authentic it will be. this will ultimately result in more effective language, learning and communication skills. educationalists and therapists have a responsibility to change learning environments such that predominantly dynamic self-regulation operates with active self-regulation playing a minor role (iran-nejad, 1990; king & goodman, 1990; schory, 1990). this can be done by applying the principles of the philosophy of geodesic learning which have authentic ecological environments built into their methodology. geodesic approaches have to have authentic learning environments in order to work. by adopting geodesic approaches such as the mma, the practical application of the geodesic model, authentic learning environments will automatically be created. further research is needed to explore geodesic learning environments that foster a climate of authentic learning. in summary, transformation of learning in the in the schools of the future will need to consider the neuropsychological aspects that allow the interaction of dynamic and active self-regulation which will facilitate innovative learning. learning is a process of active research initiated and controlled by the learner. learning as a process of active research means that one's learning intentions need to be changed from those aimed at optimizing the conditions for encoding and retrieval under other-regulation to optimising the conditions for understanding and personal growth under selfregulation (iran-nejad, 1990). the latter implies that cooperation between teachers, therapists and pupils is required in the development of any course or therapy purporting to meet their needs. thus the learners take die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 66 caroline . leaf, isabel uys & brenda louw responsibility for their learning and the quality of their work in co-operation with the facilitator (glasser, 1986). this is in contrast to traditional philosophy of education and institution-based rehabilitation (ibr) which identifies the teacher and therapist as being solely responsible for what is learned, and how, when, why and if it is learned. currently, however, in the field of speech-language pathology, there is a move away from institution-based rehabilitation to community-based rehabilitation as a result of the increasing awareness of the inefficiency of traditional approaches, and the recognition of the social interactive nature of language (paul-brown, 1992). this is evident in the whole body of literature on alternative service delivery models designed to meet more efficiently the needs of clients with communication, language and learning problems (paul-brown, 1992; lewis, 1994; schory, 1990; king & goodman, 1992). if learners are guided into taking responsibility for their learning, then this will lead to learning that is based on curiosity, need and relevance, and thus the motivation becomes intrinsic. hence, the classroom and therapy room becomes focused on learning and not maintaining control. teachers and therapists have authority, and are content specialists, but learners also have the right to be respected and given an opportunity to learn. according to jensen (1995) and iran-nejad (1990), students in a fullyimplemented geodesic learning environment will rarely have behavioural, motivational and learning problems because they are fully engaged, curious, engrossed, challenged and excited about learning. students need to play a major role in the decision about what they have to learn and how this can be done; that is, learners need to take a higher level of responsibility for their own learning (schory, 1990; king & goodman, 1990). thus the learner needs to self-monitor and self-evaluate with the facilitator, with the emphasis on teaching the student how to assess the process and not just the end result of the process, the product (glasser, 1986). the learners and facilitators should engage in continual constructive examination of how to improve the process of learning. this can be done by the teacher and/or speech-language therapist orally making decisions and solving problems concerning her own reading, writing, communication or learning activity in order to demonstrate the problem-solving process (schory, 1990). this is especially important for the language-learning disabled students who frequently experience difficulty solving problems related to language, learning and communication (damico, 1987). finally, comparative studies should be conducted between self-regulated students in geodesic environments and other-regulated students in traditional environments in terms of problem-solving, research skills, thinking skills and general life skills in order to compare the differences in performance and learning potentials. there is research of this nature in the literature, but concerning predominantly suggestopaedic techniques (dhority, 1990; lozanov, 1978). there are, however, relatively few programmes that offer the unique combination of the mma, and it is felt that geodesic methods need to be used as wholistically as possible within a system's theory approach as opposed to componentially within a traditional approach to education. thus, true geodesic systems need to be created and studied scientifically in order to create the body of evidence that is lacking in traditional learning approaches. furthermore, this body of evidence will underscore the pitfalls of the traditional environments in education and therapy that were created, with relatively minimal scientific basis, (gardner, 1985: jensen, 1995; iran-nejad, 1990; knowles, 1990), as well as supporting the intimation made by gerber (1987) that traditional environments "de-educate" students turning them into rote-learning "junkies". in addition, the speculation that behavioural, motivational and learning problems will decrease in fully operating geodesic systems (jensen, 1995; iran-nejad, 1990) needs scientific and documented research as this has profound implications for students. this is because the ability to take a proactive role in initiating and controlling the learning process allows personal effort and ability to take on a determining role. according to glasser, (1986) persons who see themselves in control of a given situation make a greater effort to achieve success then those who do not. language-learning disabled pupils in particular need to be allowed to have a sense of control over their own learning processes in order to overcome the passiveacceptant and learned helplessness that comes from repeated failure and being continually guided (feuerstein, 1980). when a teacher or therapist continually corrects and guides students' efforts, they prevent them from taking charge of their own learning. this leads to overdependency on others and decreased confidence in one's own abilities (marvin, 1987). thus, the languagelearning disabled child needs to be shown how and allowed to take control of the language, learning and communication situation in and out of school. intelligence is pluralistic and in every individual there is a unique blend that determines their individuality. the multiple intelligence theory (gardner, 1985) challenges the prevailing concept of intelligence as a single general capacity that enables individuals to perform in all situations. according to gardner (1985) every normal human being is born with seven different intelligences. of these, one will be dominant and one secondary and this contributes to individualistic learning styles. if this does not conform to the dominant traditional teaching style, which emphasises verbal and mathematical intelligence, then individuals are at a disadvantage. thus, learning environments and facilitators need to recognise that intelligence is made up of different capacities, not just mathematical and linguistic, which results in a diversity of learning styles requiring highly individualised programmes and consequently, "freedom within structure". furthermore, i.q. testing, which is based on the single unitary concept of intelligence, cannot predict or determine potential as these tests are based on mathematical and linguistic intelligences alone. i.q. testing can only predict how well a student can play the "school game", and may erroneously label a student, limiting aspirations. successful teaching and therapy need to reinforce and affirm the different ways in which individuals learn. facilitators of learning need to incorporate situations where students have opportunities for the creative exploration of their individual interests and talents while also learning valued skills and concepts through multimodal means. information needs to be presented in numerous ways offering students many opportunities to succeed. therefore, manipulation and actual experience, moving, the southafrican journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) development of a model for geodesic learning: the geodesic information processing model 67 the hing and doing should be part of the learning process, τ rning environments need to help students to identify h i r areas of strength and to develop these so that they η become active contributors in society in their future. the more authentic the environment, the more effective t h e generalisation of skill mastery and problem-solving erformance will be. in addition, learning is more effective if a process (for example: learning plan) and opennded product structure (for example: therapy objectives, course outline) is applied, as opposed to a close-ended (traditional) product structure alone. within the field of s p e e c h l a n g u a g e pathology, the whole-language approach (schory, 1990) is evidence of this idea being practiced. the suggested geodesic methodology provides a broader framework enabling neuropsychological concepts to be incorporated into the whole-language approach, enhancing its effectiveness. the practical application of facilitating the seven different intelligences in learning environments is currently available in the literature (campbell et al., 1992, in leaf 1997). what is needed is scientific research incorporating these applications into geodesic frameworks such as the mma, and into learning environments in order to demonstrate their success. the learning approach needs to be transdisciplinary requiring facilitators, directors and therapists to assume interchangeable roles and responsibilities following the needs of the child, the family and the community a geodesic approach requires pupils, therapists, teachers and parents to commit to teaching and learning from each other by working together. this approach involves a collaborative and consultative methodology and as such, can be considered transdisciplinary (thurman & widerstrom, 1990). a transdisciplinary approach falls within the realms of systems theory which allows any social system to be conceptualised as a system of learning resources, or an interdependent learning community (knowles, 1990). a wholistic learning syst'em is a complex of elements in mutual interaction. | therefore, to account for wholism and interdependence, there has to be co-operative interaction between all the people within the system. the key issue, however, is the interchangeability of roles required and hence a transdisciplinary as opposed to interdisciplinary approach is essential for a truly geodesic learning environment to be created. in order to operationalise the above implication, collaborative and consultative skills have to be included in any training of teachers and therapists (all types) (simon, 1987). this would also include systems theory training which emphasises community-based learning systems. future research needs to explore the benefits of transdisciplinary principles within wholistic geodesic learning environments such as those created when using the mma, specifically the advantages of such an approach to the community as a whole. resources are readily available in every environment, and thus a primary research focus is to identify these and introduce learners to them. systems need to be put into effect where all resources within a community are explored and utilised in an organised interactive way within a geodesic framework. it is now recognised that services are most successful when teams of professionals and families collaborate forming partnerships. a transdisciplinary approach involves a collaborative consultative methodology involving both professionals and the community. teachers and therapists play different roles in a geodesic as opposed to traditional learning environments historically, the classroom teacher provided the student with the curriculum material to be learned, and the speech-language therapist provided the student with remediation strategies for specified communication difficulties (simon, 1987). however, the most important objective of a geodesic model such as the mma is adapting the child's academic instruction so that he can achieve to the best of his ability. many students are not successful learners and the differences between the educational experiences of students from different racial, linguistic and socio-economic backgrounds has led to many revisionist movements, which fall within the realms of geodesic philosophy, and which share the common goal of changing what does not appear to work. one direct result of this change is the re-discovery of the role language-proficiency plays in the education process (simon, 1987). here, the speech-language therapist, who is a language expert, can be extremely effective in mainstreaming into the classroom. this implies changed roles for both the speech-language therapist and the teacher who would need to work together in a consultative and collaborative manner in order to take advantage of their combined expertise. this whole-language approach (schory, 1990) would change the focus from the identification and fixing of deficits to the purpose and nature of learning. a teacher or therapist in a geodesic learning environment is a facilitator of learning. this implies that teachers and therapists are managers of the process of learning as opposed to content-transmitters. being a content resource or a content specialist should be a secondary role to that of being a facilitator of learning. according to knowles (1990) and glasser (1986), being a process manager as opposed to a content planner and transmitter requires relationship building, needs assessment, involvement of students in curricular planning, linking students to learning resources and encouraging student initiative. this idea is developed within the whole-language approach (schory, 1990; king & goodman, 1990) which provides a distinct philosophy as well as practical ideas on how to implement glasser (1986) and knowles' (1990) postulations. in order to operationalise the different roles of the teacher and therapist within the geodesic environment, classroom and curriculum-based models which utilise the concepts of collaboration and consultation have to be developed. classroom-based language and communication intervention has the distinct advantage of allowing the speech-language therapist to use the pupils' academic programmes as the basis upon which to build language intervention because pupils can stay in their classrooms and thus be present when important content information is given (schory, 1990). under such a system, known as the whole-language approach (schory, 1990), the speechlanguage therapist would be able to monitor the development of oral language skills within a more natural setting than a therapy room; there could be a more frequent exchange of information between the teacher and speechlanguage therapist regarding the specific needs of each language-learning disabled child resulting in improved die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 68 caroline . leaf, isabel uys & brenda louw language-learning experiences; there would also be the opportunity to provide teachers with suggestions for incorporating all the varied forms of oral language within their lessons;' the speech-language therapist could mediate the communicative interaction between the teachers and pupils; and finally the speech-language therapist could assist in the implementation of the mma methodology initially as an expert consultant, and thereafter as a partner in a collaborative process. in this way the teacher and therapist together become facilitators of language, communication and learning. in summary, a facilitator of learning allows learners to work, learn and grow at their own pace, not according to the teachers' and therapists' preset time-table. the facilitator will allow for new and different ways to solve problems without the traditional limits. the facilitator will supply the resources that will enable the learner to find the meaning enabling them to focus on the process and not the product. the so-called "language-learning disabled population" can become innovative thinkers if their learning is facilitated within a geodesic environment using geodesic methodology recognising the possible neurological constraints of the language-learning disabled population, it is believed that within environments using geodesic frameworks such as the mma many of the problems of the language-learning disabled pupil can be overcome enabling them to become innovative lifelong learners. research (jensen, 1995; buzan, 1991; dhority, 1991; gardner, 1985) suggests that the brain thrives on novelty, challenge and enrichment, and therefore it is only logical and fair to put all types of learners into an environment that takes advantage of the natural functioning of the brain. according to feuerstein (1980), restricting the level of requirements of the language-learning disabled child by simplifying the environment and reducing challenges, will lower levels of motivation, aspiration and achievement. thus, in order to empower children with language-learning disabilities to reach higher levels of development, the traditional passive-acceptant approach must be replaced by an active approach to learning. according to this approach, the individual is an open system capable of mental and emotional modifiability. therefore, low levels of achievement are reversible and it is possible to learn efficiently if the proper effort is invested in diverse and integrated ways (feuerstein, 1980; jensen, 1995; gardner, 1985). in order to operationalise this implication, learning environments need to change, from being passive-acceptant to active-modification. entire new global systems need to be created that will allow all learners, whether language-learning disabled or not, to develop their potential together. a geodesic system of learning will focus on individuals and developing them; and not on fitting the individual into a system. separate schools for learning disabled students are not necessary, they are in fact making the situation worse. individual help can be given when required, but within the system. therefore the child with language-learning disabilities should be mainstreamed and not protected within isolated educational frameworks (simon, 1987). according to feuerstein (1989: 166), "the ultimate purpose is to bring him satisfaction, not by isolating him and avoiding confrontation, but rather by providing tools for the daily struggle with a normal environment in which he may achieve satisfaction". the philosophy 6f the geodesic information processing model, and its practical application, the mma, which is an active modification approach, has faith in the exceptional child's ability to change and grow, and accordingly great effort is invested in offering him many choices, as well as providing "tools" for change for example: the mind-map and the mma strategies. in addition, a system of "pull-out" programmes within the mainstream (simon, 1987) could be created for students with special needs. instead of the traditional approach which primarily teaches content more slowly, these should focus on the processes and values of learning, for instance, how to spell, rather than lists of rote spelling words; how to learn; mind-mapping; communication skills; and finally social skills (jensen, 1995). learning in a world of continuing accelerating change is a process of ongoing enquiry within the field of speech-language pathology and audiology, the increased awareness of the inefficiency of traditional approaches has led to the emergence of alternative treatment approaches. the alternative service delivery models (paul-brown, 1992) have been the result of speech-language therapists being required to serve a wider range of persons who present with a greater variety of communication disorders (lewis, 1994). this has resulted in a paradigm shift in the professional self-concept of and role played by the speech-language therapist. this necessitates the ability to learn to understand, guide, influence and manage these transformations or paradigm shifts. learning activity should be deformalized and replaced by flexible diversified models, such as the mma, based on the geodesic information processing model, in order to move learning into the twenty-first century (unesco, 1972, in ltfa, 1996). it therefore becomes an imperative task for individuals, institutions and society as a whole to learn about the process of learning in the attempt to overcome the maintenance effects of conditioned traditional paradigms, and to foster a climate of change, as well as to deal with the education and therapy crises, it is believed that the basic training of therapists and teachers needs to change to adopt a geodesic philosophy which allows for more flexible and diversified models to be created and implemented. the training of facilitators and, pupils or learners within geodesic philosophies such as the mma has to aim at changing attitudes in order to create global changes in traditional learning philosophies. this will have long-lasting effects on the skill level of application in teachers and therapists and their pupils and clients, and by implication, on the educational and therapeutic environments in which learning is facilitated. furthermore the institution of training programmes to achieve the objective of creating global changes to geodesic systems for education and therapy needs to recognise the complex interrelationship between the diverse institutional learning environments in order to be successful. if the philosophy of systems theory (von bertalanaffy, 1968 in leaf, 1997), which visualises the complex interaction of systems and sub-systems, is adopted, then geodesic frameworks such as the mma could be applied withthe southafrican journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the development of a model for geodesic learning: • the larger framework of lifelong learning. the systems theory could therefore provide the principles of creating infrastructures within which geodesic frameworks could be implemented for education and therapy on all levels of learning. for instance knowles (1990) visualises an infrastructure for a lifelong learning resource system based on systems theory that emphasises the need to teach the community as a whole how to learn. the role of geodesic frameworks such as the mma in such an infrastructure is that of providing the "how" of the implementation of facilitating geodesic learning environments. thus, the systems theory (von bertalanaffy, 1968 in leaf, 1997) provides the infrastructure for the creation of geodesic learning environments, and programmes such as the mma provide the methods of training and facilitation within the geodesic learning environment. it is proposed that future research should concern itself with the interaction of the creation of geodesic infrastructures and the programmes providing the methods of facilitating geodesic learning. therefore the results of this study, and those of other similar research, need to be integrated with systems theory to create long-term and long-lasting changes that will ultimately equip learners with innovative lifelong learning skills. further research regarding the manner in which the attitudes of teachers, therapists, parents, pupils, and all those conditioned in to the traditional system can be enlightened in order to change their perceptions of their roles as learners. the purpose of "educating" and "remediating" is to facilitate innovative life skill learning competencies students should be excited about learning as it is a natural neuropsychological law that the brain is designed to learn. in a geodesic environment, students learn about life, they learn from each other, they learn what is in the curriculum and in therapy objectives, and they are ready to become lifelong learners that can contribute to society by applying geodesic philosophies, lifelong learning competencies can be developed. the geodesic information processing model and the practical application, the mma, focuses on the learner, not the content. the organisation of lesson and therapy objectives within the mma is based around creating conditions optimal for learning. it allows immersion into an integrated, thematic and interdisciplinary curriculum. this is in contrast to traditional formats of education and institution type therapy that emphasize learning one thing at a time so that a subject is divided into small chunks, and then sub-divided again and again. each day a micro chunk of the whole is presented out of context, for instance, "introduce unit a, learn it, take a test on it; now go to unit b" (jensen, 1995: 301). rather should one learn in an integrated thematic way. according to jensen (1995: 303), "our brain is designed to learn multi-path, in order, out of order, on many levels, with many teachers, in many contexts and from many angles. we learn with themes, favourite subjects, issues, key concepts, questions, trial and error and application. the thematic approach urges you to follow threads that weave through your student's world instead of a single subject or text book". this is the philosophy of the geodesic information processing model. the actual structure of the mind-map, the "tool" of the mma, promotes this geodesic information processing model 69 type of thinking because it creates patterns of meaning. therefore practical applications of geodesic philosophy such as the mma provide a strategic approach that can assist in the facilitation of innovative learners with good life-skills. conclusion the central thesis of the current paper is to change the perception of the traditional view of learning as a "mosaic of educational and therapeutic programmes conducted by a plethora of largely unconnected institutions" (knowles, 1990:17), into a lifelong learning resource system or learning community. this implies that learning should be viewed as an internal construction process controlled by the learner, as opposed to the internalisation of external facts from an external source such as a therapist or teacher. the geodesic model is seen to provide an alternative approach or system as well as a theoretical base to the perception of learning. the geodesic information processing model is also an attempt to develop a theory to explain why a geodesic framework such as the mma (not explained in this paper) invokes more effective thought processing than traditional behaviouristic approaches to education and therapy. the key issue in the geodesic information processing model of the current research is the intimate interaction and interdependence of metacognition and neuropsychology. the model proposes that metacognition is the nonconscious level, elevating metacognition to the level where most learning (approximately 90%) occurs. this is the highest level of thought, where thinking begins. the model then proposes that cognition is the next level of thought, the level of conscious thinking responsible for approximately 10% of learning. both levels need to be fully activated according to the ratio of their responsibility in order for learning to be effective and result in usefully reconceptualised knowledge. if methodologies and systems are used that are incompatible with natural neuropsychological laws, then the cognitive level will be predominantly activated, with limited intermittent involvement of the metacognitive non-conscious level. this will result in inefficient rote-type learning with a product orientation as opposed to process orientation. it is believed that geodesic methodologies such as the mma (leaf, 1997), are neuropsychologically based and will thus activate metacognition and cognition in the correct way . in contrast, traditional methodologies stimulate predominantly cognitive processes with concomitant learning limitations. furthermore, the mind-map itself is viewed as the "tool" which directly accesses and trains the metacognitive non-conscious. the emphasis of the mma is on the facilitation of improved language, learning and communication through a strategic versus skill-based approach communication, language and learning are seen as being controlled by metacognition , which will in turn influence information processing and thus the effectiveness of communication, language and learning oral or written. in other words, strategies are being facilitated at the root level and once automatized, will have a more effective result in terms of generalisation than if fragmented skills are trained. "throughout history only a few people have benefited from the growing corpus of scientific knowledge which permits the development of human potential. inequality die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 caroline μ. leaf, isabel uys & brenda louw of human beings was not determined genetically. they all have more or less the same potentiality , the same capacity to think" (van der vyver & capdeveille, 1990:6). therefore, every effort should be made to develop this potential of individuals. everyone should be allowed the opportunity to learn how to learn. acknowledgements the current article is based on the d.phil, research of c. leaf. the financial assistance of the centre for science development towards the research is hereby gratefully acknowledged. references allport, d.a. (1980). patterns and actions: cognitive mechanisms and content specific in claxton, g.l. (ed), cognitive psychology: new directions. london: routledge & kegan paul. dhority, l. (1991). the act approach: the artful use of suggestion for integrative learning. bremen, west germany: pls verlag gmbh, an der weide. diamond, m. (1988). enriching heredity: the impact of the environment on the brain. new york: free press. feldman, d. (1980). beyond uniuersals in cognitive development. norwood, n.j.: ablex publishers. feuerstein, r. (1980). instrumental enrichment: an intervention programme for cognitive modifiability. baltimore, maryland: university park press. flavell, j.h. (1978). metacognitive development in scandura j.m. & brainerd, c.j. (eds) structural / process / theories of complete human behaviour. the netherlands: sijthoff & noordoff. gardner, h. (1985). frames of mind. new york: basic books. glasser, m.d. (1986). control theory in the classroom. new york: harper & row. goldberg, e. & costa, l.d. (1981). hemisphere differences in the acquisition and use of descriptive systems. brain and language, 14 144-173. hinton, g.e. & anderson, j.a. (1981). parallel models of associate memory. hillsdale n.j.: erlsbaum. holt, j. (1964). how children fail. new york: pitman. iran-nejad, a. (1990). active and dynamic self-regulation of learning processes. review of educational research, 60 (4) 573-602. jensen, e. (1995). brain-based learning and teaching. south africa : process graphix johnson, j.m. (1987). a case history of professional evolution from slp to communication instructor. journal of childhood communication disorders, 11 (4) 225-234. king, d.f. & goodman, k.s. (1990). whole language learning, cherishing learners and their language. language, speech and hearing sciences in schools, 21 221-229. kline, p. (1990) everyday genius. arlington, v.a.: great ocean publishers. knowles, m. (1990) the adult learner: a neglected species. houston: gulf publishing company. leaf, c.m. (1990). mind-mapping: a therapeutic technique for closed head injury. unpublished masters dissertation, university of pretoria. leaf, c.m. (1997). the mind mapping approach: a model and framework for geodesic learning. unpublished d.phil dissertation, university of pretoria. leaf, c.m., uys, i.c. & louw, b. (1993). mind mapping: a culture and language free technique. south african journal of communication disorders, 40 35-43. lewis, r. (1994). report back on the workshop: speech / language / hearing therapy in transition. communiphon, 308 6-7. lozanov, g. (1978). suggestology and outlines of suggestopedy. new york: gordon and breach science publishers. luria, a.r. (1980). higher cortical functions in man (2nd ed). new york: basic books. paul-brown, d. (1992). professional practices perspective on alternative service delivery models. asha bulletin, 12. schory, m.e. (1990). whole language and the speech. language pathologists. language, speech and hearing services in schools, 21 206-211. simon, c.s. (1987). out of the boom closet and into the classroom: the emerging slp. journal of childhood communication disorders, 11 (1-2) 81-90. thurman, s.k. & widerstrom, a.h. (1990). infants and young children with special needs a developmental and ecological approach. 2nd (ed) baltimore: paul h. brookes publishing co. van der vyver, d.w. & de capdeveille, b. (1990). towards the mountain: characteristics and implications of the south african upptrail pilot project. journal of the society for accelerative learning and teaching, 15 (1 & 2) 59-74. the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) employment in the uk for a working holiday or permanent position, b b t is second to n o n e . join the hundreds of speech and language therapists we secure locum and long term positions for each year. our excellent reputation allows us to offer assignments throughout the uk, many of which are in the leading establishments in the state and private sectors. our dedicated team can guide you through the registration procedures prior to arrival and once in the uk, provide you with all the support you require. you will find our experience invaluable in ensuring your time is a complete success and the overall package unbeatable. contact sean ridgwell in london today for an initial discussion and our free information pack, or send your details, so that we can contact you. γ b e r e s f o r d b l a k e τ η 0 μ a s i. τ d toll free-0800 998 154 fax: 09 44 171 233 8004 e-mail: recruit@bbt.co.uk 14 buckingham palace road, london sw1w 0qp, england. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mailto:recruit@bbt.co.uk r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) undergraduate clinical training in neonatal assessment and neonate-caregiver interaction in sa 5 clinical training of undergraduate communication pathology students in neonatal assessment and neonate-caregiver interaction in south africa alta kritzinger and brenda louw clinic for high risk babies (chrib), centre for early intervention in communication pathology (ceicp), department of communication pathology, university of pretoria abstract developing an undergraduate clinical training module in early communication intervention (eci) that provides sufficient opportunity for students' learning experiences, and that allows contextually relevant and ethically accountable services to clients, as well as the dissemination of the latest scientific findings to both students and clients, poses a significant challenge. the article describes the development of a clinical training block and the development of an appropriate instrument for the assessment of neonatal communication skills that was used in this student practical. a qualitative research approach, employing a series of formative assessments, was used to refine the instrument. the results indicated changes in the content and use of the neonatal assessment instrument regarding the approach to infant and caregiver risk assessment; caregiver beliefs about neonatal capabilities; newborn state observation; caregiver training; language, cultural and age barriers; collaboration with nurses; kangaroo mother care; involvement of caregivers during the assessment; and adolescent mothers. the results confirmed the need for the ongoing refinement of an instrument to ensure quality training of students in the difficult field of neonatal assessments and neonate-caregiver interaction. the results also highlighted to the importance of initiating eci services before birth in communities at risk for infant neglect and abuse, and the close relationship between eci service delivery and student training. introduction early communication intervention (eci) has evolved as an important and new field within speechlanguage pathology and audiology internationally. the field was introduced to speech-language pathology curricula in south africa following the south african speech-language hearing association (saslha) position statement on eci (louw, 1997) and decisions taken by the different departments at the u n i v e r s i t i e s which offer s p e e c h l a n g u a g e p a t h o l o g y and a u d i o l o g y p r o g r a m m e s . t h e university of pretoria started formal clinical training in eci in 1990 when the (clinic for high risk babies (chrib) was establishedj(kritzinger & louw, 2002). since the introduction of eci in south africa, its training has been influenced by changes in the profession that were prompted by the political and societal transition in the country. during the past decade, various authors jwithin the field of speechlanguage pathology andi audiology in south africa have advocated a transformation in tertiary teaching programmes in order to meet the demand of providing speech-language services to all those who require intervention (kritzinger, louw & hugo, 1995; moodley, louw & hugo, 2000; pillay, kathard & samuel, 1997). in this regard, the importance of tertiary education as the only basis for effective and high standard services (uys, 1993), and the ideal that teaching should anticipate and react to the needs of clients, was emphasized (uys & hugo, 1997). furthermore, the implementation of appropriate service delivery models based on community needs and resources (fair & louw, 1999; tuomi, 1994) and a s t r o n g e m p h a s i s on p r e v e n t i o n and e a r l y intervention was proposed (hugo, 1998; louw, 1997). eci training has also been influenced by changes in tertiary level teaching approaches, characterized by learner-centredness, relevance, integration, critical and creative thinking, and a holistic approach to learner assessment (gultig, lubisi, parker & wedekind, 1998). the new education approach moved away from formal lectures to outcomes-based education, and represents a radical departure from a rigid separation between a contentbased education component and a training arena that involves the gaining of skills (le grange & reddy, 1998). the implications for eci curriculum design are that the traditional dichotomy of theoretical knowledge and its application in practice should be viewed as an integrated process, attempting to create authentic learning experiences both in the classroom and in clinical settings. consequently, the outcomes of authentic learning experiences in eci involve c o n s i d e r a b l y more than the a c c u m u l a t i o n of knowledge, and include the achievement of relevant skills, as well as shaping learners' attitudes and values regarding families requiring eci, their communities, the collaborators in the process and the advancement of the field of eci in south africa. since learning, teaching and assessment are inextricably linked in an outcomes-based education curriculum, the centrality of learners and their knowledge, experiences and needs should also be reflected in the assessment procedures that are selected (gultig et al., 1998). although several components of a coherent assessment system are described in outcomes-based education, the element of formative assessment appears to be particularly a d v a n t a g e o u s for c u r r i c u l u m d e s i g n in eci. formative assessment can be conducted while the learning process takes place and may be used to influence and inform both the learning process as well as the teaching process. the learner is provided with 1 based on a poster presentation at the 4 l h graz symposium on developmental neurology, may 22 to 24, 2003, austria. the south african journal of communication disorders, vol. 50, 2003 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) alta kritzinger and brenda louw 6 guidance in the form of self-assessment and feedback through peer-assessment and teacher-assessment. since learners themselves are regarded as sources of knowledge, this kind of assessment also guides the teacher's planning and allows for the critique of outcomes, methodology and materials (gultig et al., 1998; le grange & reddy, 1998). f o r m a t i v e assessments can therefore be used to develop an eci curriculum responsive to the needs of the learners as well as the needs of the clients requiring eci services, which can increase the standard and effectiveness of eci training and the services that are provided. since many infants and young children in south africa are at risk for developmental delay, neglect and abuse due to low birth weight and poverty related factors (central statistical services, 1997), the newborn period offers a unique opportunity to i n t e r v e n e e a r l y in o r d e r to p r e v e n t a d v e r s e developmental outcomes in infants. whilst the mothers and their newborn infants are still in hospital after delivery and in the beginning stages of postnatal attachment, the first few days of an infant's life are important to provide information to caregivers and to p o s s i b l y p r e v e n t n e g l e c t , a b u s e and d e l a y e d development. by demonstrating the remarkable communication interaction capabilities and listening skills of newborns to the caregivers, they may also be alerted to the importance of responsive interaction to facilitate the infants' early development. at the same time, students can be trained in the complex field of n e o n a t a l a s s e s s m e n t s and n e o n a t e c a r e g i v e r interaction by applying a neonatal assessment instrument upon which inferences of a newborn infant's communication behaviour can be made and demonstrated to the mother in order to enhance the infant's communication development. developing an undergraduate clinical training module in eci that provides sufficient opportunity for students' learning experiences in contexts of increased complexity, that allows the provision of contextually relevant and ethically accountable services to clients, as well as the dissemination of the latest scientific findings to both students and clients, poses a significant challenge to curriculum developers. the main aim of the article is to describe how a specific clinical training block was developed as part of a module in the eci curriculum. central to the development of the clinical block was the design of an appropriate clinical tool for the assessment of neonatal communication skills by undergraduate students. the sub-aim is therefore to describe the p r o c e s s of c l i n i c a l l y t r a i n i n g u n d e r g r a d u a t e communication pathology students in a public hospital outside pretoria in neonatal assessment and neonate-caregiver interaction by using the neonatal communication assessment instrument (kritzinger, 1994; see appendix a). method students' written reports on the clinical application of the assessment instrument during their annual practical training were analysed by means of a series of formative evaluations (fouche, 2002; gultig et al., 1998; mitchell, 1991). as the aim of the research was to evaluate processes, practices and outcomes in order to d e c i d e on m o d i f i c a t i o n s of the neonatal communication assessment instrument, a formative evaluation process was used. the formative evaluation process involved comparing the students' reports with the stated outcomes of the training module in order to identify limitations in the assessment instrument (le grange & reddy, 1998). since the initial design of the instrument in 1994, the neonatal assessments carried out annually by each cohort of students in the same p u b l i c h o s p i t a l was followed by a formative evaluation process and the application of changes to the i n s t r u m e n t , thereby creating a c o n t i n u o u s feedback loop in order to refine the neonatal communication assessment instrument and its clinical application. participants neonatal assessments have formed part of an e c i p r a c t i c a l b l o c k at t h e d e p a r t m e n t of communication pathology, university of pretoria since 1995 (see a p p e n d i x b). the formative evaluation process was conducted during the period of 1995 to 2002 and between 6 and 40 second year students were annually involved as participants in the study (see table 1). the students were informed that their written reports on their learning experiences with neonatal assessments would be used in a research project in order to refine the assessment instrument and to improve the authenticity of the learning experience. students who gave individual informed consent to participate in the research were requested to submit their reports once marks had been allocated following completion of the module. the average age of second year students was 20 years. while all the second year s t u d e n t s were r e q u i r e d to p a r t i c i p a t e in the compulsory training module, which required themjto learn and gain experience in the use of the neonatal communication assessment instrument, but only some students agreed to participate in the study (see table 1). . 1 ' ι i tablel. numbers of students completing the i training module and participating in the { study. ι year students students completing the module acting as participants 1995 36 7 1996 30 6 1997 36 8 1998 34 9 / 1999 39 10 2000 43 χ ' 9 2001 47 42' 2002 44 , 39 total 309 121 a phenomenological approach was employed as a qualitative research strategy to develop and refine the neonatal communication assessment instrument. in addition, a naturalistic method of study was used to describe the meaning of experiences recorded by students during their practical training (fouche, 2002). die suid-afrikaanse tydskrif vir kommunikasieeafwykings, vol. 50, 2003 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) undergraduate clinical training in neonatal assessment and neonate-caregiver interaction in sa 7 materials a comprehensive neonatal communication assessment instrument which includes the following components, was compiled (see appendix a): β prenatal, perinatal and environmental risk factors (kritzinger et al., 1995). a checklist was used to determine the mother-infant dyad risk profile. this p a r t i c u l a r risk assessment is intended for neonates born at term, and although the perinatal risks associated with infants born preterm and with low birth weight are not expected, it is still important to identify prenatal and perinatal conditions that may possibly increase an infant's risk for communication delay (rossetti, 2001). θ mother-infant communication interaction (klein & briggs, 1987). since the earliest interactions between a mother and neonate set the stage for communication development (billeaud, 1998), the quality of neonate-caregiver interaction should be assessed in order to intervene as early as possible. © neonatal states (brazelton, 1984). a neonate's state of alertness depends on physiological and environmental factors that should be utilized as a lens through which samples of b e h a v i o u r obtained during the assessment are interpreted (rossetti, 2001). ο feeding behaviour (wolf & glass, 1992). sine early feeding difficulties have been found to be predictive of later communication development (kritzinger, 1994) and are considered to be one of the risk factors for communication disorders (rossetti, 2001) an assessment of the manner and quality of the feeding process is imperative, ο precursors to language content, form and use. early interactive abilities and listening skills of newborns suggest that they are "prewired" for communication, and are related to the neonates' f u t u r e c o m m u n i c a t i o n d e v e l o p m e n t in content/form/use interactions (lahey, 1988; / o w e n s , 2001). thesejneonatal abilities should be / assessed as they enable infants to participate actively in reciprocal, interaction with their mothers. the absence of these typical behaviours in term newborns should be investigated further in order to identify risks for communication disorders and hearing impairment as early as possible. j θ precursors to cognition. since cognitive and communication development'are closely related, it is important to assess the early adaptive behaviours displayed by neonates (owens, 2001) in order to obtain a comprehensive sample of neonatal communication skills. the assessment instrument was designed for neonates from birth to 28 days old, and their mothers, and the assessment was based on the presence or absence of neonatal and caregiver behaviours, observed or elicited by the examiner. the instrument was used to assess the communication skills of neonates born at term, to assess the mother-infant interaction and to provide the mother with feedback on her infant's communication c a p a b i l i t i e s and r e a d i n e s s for c o m m u n i c a t i o n interaction. the mothers and their newborn infants resided in the 40-bed maternity ward of kalafong hospital, a large tertiary care hospital situated on the outskirts of pretoria. the hospital is utilized by the university of pretoria as a training site for students from different disciplines. the students' training block in the maternity ward of this hospital formed part of a prevention programme for speech-language and hearing problems in neonates. validity and reliability in order to enhance the face validity of the neonatal communication assessment instrument the tool was structured in such a way as to measure the different a s p e c t s of n e o n a t a l c o m m u n i c a t i o n behaviours accurately (kritzinger, 1994). based on a literature review and the careful consideration of different theoretical models, content validity was adhered to by including an adequate sample of items that represent the concept of neonatal communication abilities and ensuring that all the items actually describe this central concept. the assessment instrument appeared to be reliable since independent administrations over the years by students yielded c o n s i s t e n t r e s u l t s of n e o n a t a l c o m m u n i c a t i o n behaviours (de vos & fouche, 1998). data collection and analysis the written reports of each cohort of students were collected every year and the data was analyzed and interpreted using the huberman and mile's approach to data analysis in qualitative research (poggenpoel, 1998). the reports contained written descriptions of observations and reflections on the learning experiences. using the different components of the neonatal communication assessment instrument and the outcomes of the training module as guidelines, the large volumes of data were condensed, clustered and displayed according to themes. as a result of this process the assessment instrument was continually adapted and the latest version is presented in appendix a. since the first author was also the on-site clinical instructor during the training module, her own observations and theoretical guidelines served as multiple methods of data collection in order to increase the reliability of observations (de vos, 1998). although the first author became part of the process, care was taken to avoid influencing the participants' opinions written in their reports. after the practical brief on-site discussions were held with the students in order to facilitate reflection on the theoretical and clinical implications of their learning experiences. the d i s c u s s i o n s were c o n d u c t e d by e l i c i t i n g comments from the students and responding to their remarks and not by informing them what they were supposed to have gained from the practical. in order to interpret the participants' reports accurately, careful analysis of the data was necessary. this p r o c e s s i n v o l v e d c l o s e s c r u t i n y of the participants' use of terminology and language that often revealed their inexperience with the subject matter. the displayed data was interpreted according to themes by means of inductive abstraction and generalization (poggenpoel, 1998). the south african journal of communication disorders, vol. 50, 2003 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) alta kritzinger and brenda louw 8 results and discussion the results indicated the need for changes in the content and use of the neonatal communication assessment instrument regarding the following themes: • the approach to infant and caregiver risk assessment risk assessment has traditionally been the s t a r t i n g p o i n t for the early i d e n t i f i c a t i o n of communication disorders and hearing impairment (rossetti, 2001; kritzinger, 2000). initially, only biological risk factors in the mother and infant were considered in compiling a risk profile of the caregiver-infant dyad. the most prevalent biological risk factors identified over the years were adolescent mothers, multiparous mothers with four or more children, maternal hiv/aids and low birth weight in the infants. all of these risk factors may be associated with poverty conditions that can negatively impact on the mother's ability to care for the infant or to stimulate the infant's development sufficiently (rossetti, 2001). the identification of these four biological risk factors in the mother-neonate dyads, led to the inclusion of environmental risk factors, such as maternal educational level, employment, and quality of housing (samerhoff, seifer, baldwin & baldwin, 1993) in the assessment instrument (see appendix a). it became clear that an integrated approach to the risk assessment of the caregiver-infant dyad should be followed, since the different risk factors are interrelated (garbarino & ganzel, 2000). furthermore, it became clear that positive n e o n a t e c a r e g i v e r interaction and the mothers' enthusiastic responses to the information they received should be viewed as protective factors for further development of the infant (osofsky & thompson, 2000). although long-term predictions based on early assessment results of infants are not possible (rossetti, 2001), it is important to identify risk and protective factors in order to support and encourage parents to continue to enhance their infants' d e v e l o p m e n t , e s p e c i a l l y when an a s s e t b a s e d approach to intervention is followed (ammerman & parks, 1998). as a result of the increased awareness of the m u l t i p l e r i s k factors and the c o m p l e x i t y of interactions between risk factors and protecting factors affecting the communication development of newborns in kalafong hospital, the need for a longterm prevention programme became clear. in order to design such a contextually relevant programme, caregiver views on neonatal behaviours needed to be considered. • caregiver beliefs about neonatal capabilities u n d e r s t a n d i n g c a r e g i v e r p e r c e p t i o n s regarding neonatal capabilities is crucial if they are to be successfully incorporated in eci. the eci client base at kalafong hospital consists mostly of women living in a nearby township and surrounding areas, and who utilize the state-subsidized health care services provided at the hospital. many of the caregivers, even though they were m u l t i p a r o u s mothers, believed that their newborn infants were not able to see and hear at birth and that they acquire these abilities only after a few months. the implications of these perceptions could be that mothers are not responsive to their infants or that they may not attribute meaning to their young infants' early communicative signals. louw and avenant (2002) identified beliefs and perceptions regarding infants, communication interaction styles in families and child rearing patterns in different cultures in south africa as factors influencing caregivers' responses to early intervention services. since these beliefs represent the reality for the mothers and their communities, it is important to deal with the beliefs in a sensitive manner and not to judge the mothers or their perceptions. the finding that mothers were unaware of their newborns' c a p a b i l i t i e s led to the active involvement of the mother in the assessment process (brazelton, 1984) and demonstration to her that the infant had a preference for her voice instead of the assessor's voice, responded to all kinds of sounds, made eye contact and imitated facial movements. depending on the students' skills to elicit and demonstrate responsive interaction with the neonates (salmon, rowan & mitchell, 1998), the mothers usually responded with surprise, and their increased interest in their infants could still be observed at the end of an afternoon's session. although the long-term benefits for the neonates' communication development was beyond the scope of the current research project, the prevention programme for speech-language and hearing problems in neonates in the maternity ward of kalafong hospital, suggested the need for a multilevel framework for eci public service delivery in south africa. consequently a conceptual framework was developed, incorporating c o m m u n i t y b a s e d and institution-based models of service delivery, with a strong focus on p r e v e n t i o n of c o m m u n i c a t i o n disorders in young children. the framework, illustrated in table 2, includes the basic components of an early intervention service delivery system (fair & louw, 1999) but also indicates the different contexts where caregivers and their young infants may be identified, what the various professional functions in these contexts may entail and who are the different collaborative partners for information exchange. lastly, the framework makes provision for the long-term follow-up of young children and their caregivers at different levels of care, beginning in the antenatal period, where expectant mothers may be alerted to the importance of their unborn children's future communication and literacy development, and advancing through the neonatal and postnatal periods to the toddler years. as indicated in table 2 the shaded portion highlights the neonatal period when the practical block described in this article is undertaken every year in the maternity ward of kalafong hospital. / • language, cultural and age barriers south africa's multicultural and multilingual populations lead to barriers in service delivery, and present a challenge to eci clinicians to communicate effectively with their clients,(louw & avenant, 2002). the students and mothers often did not share the same die suid-afrikaanse tydskrif vir kommunikasieeafwykings, vol. 50, 2003 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) undergraduate clinical training in neonatal assessment and neonate-caregiver interaction in sa 9 table 2. conceptual framework for early communication intervention public service delivery in south africa service delivery model according to child's age context where caregivers can be reached functions of professional involvement collaborative partners forinformation exchange before infant is born: communitybased antenatal care clinic at primary health care centre raising awareness of: normal communication and literacy development importance of stimulation pregnant mothers community nurses speech-language therapists / early interventionists neonatal period: institution-based maternity ward in hospital neonatal intensive care unit determine neonate's risk profile screen neonate's communication and hearing abilities facilitate interest in neonatal communication abilities and developmental needs train mother to stimulate early development mothers and fathers extended family members nurses in maternity ward speech-language therapists / early interventionists audiologists postnatal period: communitybased immunization clinic at primary health care centre serial screening of communication skills identify risks and provide intervention reinforce interest in stimulating infant's communication and early literacy development advocacy for education parents / secondary caregivers community nurses speech-language therapists / early interventionists audiologists toddler years: communitybased day care centre nursery school provide intervention for children with communication delays train parents for ongoing stimulation of child's communication development facilitate the implementation of a language and literacy-based preschool curriculum to ensure school readiness parents secondary caregivers nursery school teachers speech-language therapists / early interventionists audiologists l a n g u a g e , or p r e s e n t e d with limited language proficiency of a shared language and no interpreters were available in the maternity ward. the caregivers often presented with low functional literacy as well. the age difference between some of the caregivers and.students was often a communication barrier as people from certain cultural traditions are accustomed to impart knowledge from the old to the young, and not vice versa. these aspects remain challenges, but as the student-caregiver, interaction relied on the demonstration of the newborn's capabilities, which invariably elicited positive reactions from the caregivers, an atmosphere conducive to improved communication could bei created. the advantage for f u r t h e r eci t r a i n i n g in a m u l t i c u l t u r a l and multilingual context was that students had already been exposed to some problem-based learning experiences in clinical situations early in their curriculum. © kangaroo mother care kangaroo mother care is currently viewed as best practice for all neonates in all contexts (power, 2002). although kalafong hospital runs a very successful kangaroo mother care programme for premature infants (van rooyen, pullen, pattinson, & delport, 2002), the practice did not include the fullterm neonates in the maternity ward. as a result of the students' previous exposure to kangaroo mother care in another module, and i having seen its application with premature infants in the kangaroo mother care unit of the same hospital, it was clear that the benefits of this neonatal care technique could not be ignored in communities where abandonment and neglect of infants occurs. this technique has proven to benefit the health of the neonate, lactation and mother-infant attachment, which forms the basis of communication development (hann, malan, kronson, bergman & huskisson, 1999; kritzinger & louw, 1999). in collaboration with the nursing staff, kangaroo mother care was introduced to the mothers of term neonates, especially those with low birth weight and/or small for gestational age infants, and to adolescent mothers in the maternity ward. the training advantage was that students were able to identify a need and apply their knowledge of recent scientific findings in order to find a practical solution in a real world clinical context. • newborn state observation identifying the six different newborn states (brazelton, 1984) is a basic skill to be achieved when conducting neonatal assessments. since healthy newborns are mostly in an alert state during the first 60-90 minutes after birth, and then mostly in a sleeping state (rossetti, 2001), it proved to be difficult to find the infant in a quiet alert state to conduct an interactive communication assessment. since the students were not experienced in eliciting and maintaining alert states in the infants, it was often not possible to administer the complete the south african journal of communication disorders, vol. 50, 2003 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) alta kritzinger and brenda louw 10 assessment instrument. in order to improve the students' skills in identifying the neonatal states, additional time was allocated to prepare for the practical block and to watch video material on neonatal behaviour in clinical seminars. β collaboration with nurses since an orientation to teamwork represents one of the principles of practice in eci, the aim was to include the contributions of multiple disciplines (guralnick, 1997). to integrate and sustain the eci services initiated by speech-language therapists in the activities of the maternity ward, the value of building trusting relationships between nurses and therapists was shown to be beneficial to the prevention programme. the students commented on the nurses' willingness to offer assistance and to introduce them to the mothers. the implications of these positive interactions with the nurses were that students were introduced to collaborative work with members of the health team at an early stage in their training (briggs, 1997; moodley et al., 2000). β adolescent mothers s i n c e t h e p r e v a l e n c e of a d o l e s c e n t pregnancies in south africa is high (department of health, 1997) this group of caregivers deserves special attention in eci. the students became acutely aware of the parenting risks for adolescent mothers (osofsky & thompson, 2000; rossetti, 2001) as they shared the same stage of life with these mothers. it was clear that there were personal gains as well as academic advantages for the students in training adolescent mothers who were often disinterested in their infants and lacked basic knowledge about infant d e v e l o p m e n t . the s t u d e n t s r e p o r t e d that the a d o l e s c e n t m o t h e r s often c o m m u n i c a t e d more spontaneously with them than some of the older mothers. © training of caregivers during the assessment caregiver training is the cornerstone of eci (rossetti, 2001) and should be a priority skill to be achieved in student training. since the students were still at a junior level of training (second year) and a fair amount of academic preparation was involved in the application of the assessment instrument, a caregiver-training package was developed which they could use with their beginner's skills. the training package consisted of a poster translated into three languages, namely english, setswana and afrikaans, and a brochure which could be used to reinforce information about newborn auditory, visual, feeding and communication interactive capabilities, and developmental needs. the training package may be used to facilitate the process of eci or serve as a. model that can be adapted to suit different contexts. the application of the caregiver-training package acted as one of the underpinnings for the students' further clinical training in providing familycentered eci services and learning experiences where increased learner responsibility was required. practical block in neonatal assessment and neonate-caregiver interaction as part of a module in the eci curricul um t h e r e s u l t s of t h e s t u d y led to t h e development of a learner-centered practical block in n e o n a t a l a s s e s s m e n t a n d n e o n a t e c a r e g i v e r interaction in which the neonatal communication assessment instrument was an integral component. the practical block, supported by three preparatory clinical seminars, was a small component of the entire eci curriculum, where the outcomes allowed for a gradual increase in the students' responsibility to manage their own learning experiences, from the protected environment of the classroom to the various clinical settings. simultaneously, the outcomes of the eci curriculum facilitated a systematic decrease in supervisor support and clinical instruction over the four years of study (see appendix c). the shaded area i n d i c a t e s the scope, e s s e n t i a l k n o w l e d g e and outcomes of the practical block in the second year of study, which was described in the article. the content and clinical training component of the practical block in n e o n a t a l a s s e s s m e n t and n e o n a t e c a r e g i v e r interaction was dynamic and was adjusted annually in response to student assessment of the learning experiences, new developments in the field and new texts that were published. the outcomes of the practical block were based on a set of characteristics relating to the practical training in the eci c u r r i c u l u m at the d e p a r t m e n t of communication pathology, university of pretoria, and these features are presented as follows: 1. outcomes are demonstrations of competence and students are expected to use essential knowledge and carefully planned learning experiences in clearly defined performance contexts to achieve the desired competencies for each learning unit/module. 2. learning tasks and outcomes become increasingly more complex as students progress over the four years of study. 3. the outcomes of the junior years of study act as enabling outcomes or stepping-stones to the ultimate outcomes in the final year of study. 4. students accumulate learning experiences during every year of study and use all the prior knowledge, skills and developing professional conduct in each new learning task, resembling a spiral of learning. , 5. the scope of praxis increases over time to include different service delivery contexts, and provides various opportunities for rich learning experiences. 7. t h e r e is a g r a d u a l i n c r e a s e in l e a r n e r responsibility for managing own learning experiences with a gradual decrease in supervisor support and clinical instruction over the four years of study. ^ 8. the ultimate goal is for students to use their knowledge, skills and professional conduct to be innovative, competent, adaptable and self-motivated in eci service delivery in south africa. (based on killen, 1999; spady, killen & rand, 2000) figure i was compiled to demonstrate that authentic learning experiences in eci clinical training depend on a carefully designed curriculum as well as a contextually appropriate service/delivery model, as presented in appendix c and table 2. since the aim of clinical training was carefiilly designed learning experiences in a real world context, an interdependent relationship existed between the curriculum and service delivery that anticipated and responded to eci client needs. die suid-afrikaanse tydskrif vir kommunikasieeafwykings, vol. 50, 2003 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) undergraduate clinical training in neonatal assessment and neonate-caregiver interaction in sa 11 carefully d e s i g n e d p r a c t i c a l b l o c k w i t h i n the eci c u r r i c u l u m figure i: interdependent components of authentic learning experiences in eci clinical training conclusion the results confirmed the need for the ongoing refinement of an instrument to enhance the quality training of students in the difficult field of n e o n a t a l a s s e s s m e n t s and n e o n a t e c a r e g i v e r interaction. it appeared that it was not only essential to design a valid and reliable assessment instrument, but also to develop appropriate strategies and techniques to administer the assessment tool in specific contexts. there is a dearth of clinical training instruments with relevant procedures in eci that can be u s e d in the s o u t h a f r i c a n c o n t e x t . t h e development of the content and procedures of the neonatal communication assessment instrument was an attempt to bridge the gap between theory and practice in learning, and to present a clinically proven tool in an accessible format. the development of the training block represented one of the enabling steps in the spiral of learning created by the entire eci curriculum over four years of study. the results also emphasized the importance of the relationship between clinical teaching in eci and the needs of the communities that provide these rich learning experiences. in order to maintain a prevention focus, it is most important to initiate eci services not only from birth onwards, but also from before birth in those communities at risk for infant neglect and abuse. therefore, authentic learning experiences for studentsj should be comprehensive, contextually relevant, ethically accountable and d i s s e m i n a t e t h e l a t e s t s c i e n t i f i c f i n d i n g s appropriately. such learning experiences must be supported by a carefully designed curriculum and guided by a conceptual framework of service delivery. this report illustrated how state of the art and advanced theory on neonatal development could be translated to practical applications in a clinical block in order to make a difference at the level of mothers and their newborn infants in kalafong hospital. references ammerman, α., & parks, c. 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(1992). feeding and swallowing disorders in infancy. tucson:'therapy skill builders. die suid-afrikaanse tydskrif vir kommunikasieeafwykings, vol. 50, 2003 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) undergraduate clinical training in neonatal assessment and neonate-caregiver interaction in sa 13 rt λ ω χι do .3 ώ £ c <2 6 s s cd •ό 9 1 js .52 a, > μ m ο u α ε β <υ υ μ ξ 'β μ β 4» β wi ό wi α> ο f .2 ο » 5 £ « § ^ ^ .2 » e •c ο\ ο ξ s « 5 = s s ·ξ s a β τ a ϋ μ ο β ° 2 •<ο 2 3 3 > " s c ^ ίο 1/3 § i αϊ rj "s s >, ο, 2 ο» μ λ a a j* s ο the south african journal of communication disorders, vol. 50, 2003 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a l t a k r i t z i n g e r and b r e n d a l o u w 1 4 c ® « β 3 β ϊ ·« s 2 § s •s b ό s h e i s ; ε * g 5 * i ο s η s a. ζ v ,q ό t+h 3 ο s β * b ι « !3 •u & 2 e c .2 u w w c ο ω ω > λ a ω β £ \ s -α u s ο g > 2 s β β tts — ο s u h s i s £ · § j2 * ο ΐ ο λ g < ε is 3 s | i j η ιέ 2 ΰ γ ω ~ = si c 's ή — ο ° μ μ μ c 3 ·3 ω.® λ β s s "π c δ i c § δ 1/3 κ e s . s g s c-a oc ^ 9 s" s 5 s , h ω •c ·2 δ ο s i ο ω ε c 3 ^ κ 1 ε2 5 'ξ ο β 3 " & 1 ε i 1 s δ ο -5 -α υ υ ο ο w y £ e a q ο m £ 3 a «> c .3 a g • j cd .2 -5 c 2 w "5? λ " ο m •α on w · sj no ω s s < s i s 3 · ? s3 "> ' 9 •o β ο λ £ ^ 3, ω — ^ % ή -§ ch ο c γw is μ οο ο ο „ os -η -ο ο -η £ ta w ?> « £ .5; (d ο κ t 3 « q ζ m p •sf ο ι 'c bo ι c js cd 00 ί ^ λ ^ c on on c on ο o t ' c (n , ^ s q £ υ (j £,«8 's . 2 3 c .1, 3 ο ο _ β ο «· cd t-< ω s i •β 9 <3 _ • '3 u 3 ω ο β u .ο ω" a °>·3 3 ^ c § ι . ^ (+η £ δ § ° a •§ i 1 s § c3 w u = i · | j | a l i g a g s '£ §) 3 i i | 1 ° δ ° ,ο ο ϋ ϊ g o f i « . •s ω ο «s w · s p i ^ j , ^ „-h s ce < ο s ο • —ι ίλ la i s «2 i ^ ο a 2 cd c λ •-· u -• c 00 ω .3 3 ε -s α ca die suid-afrikaanse tydskrif vir kommunikasieeafwykings, vol. 50, 2003 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the verbal and nonverbal communicative abilities of pre-adolescent stutterers monica bucher ba (sp. & h. therapy) (witwatersrand) transvaal education department psychological and guidance services melissa bortz ba (sp. & h. therapy) (witwatersrand) department of speech therapy & audiology coronation hospital, johannesburg denise anderson ba (sp. & h. therapy) (witwatersrand) department of speech pathology and audiology university of the witwatersrand, johannesburg abstract the aim of this study was to investigate and describe some aspects of the verbal and nonverbal communicative competence of six pre-adolescentstutterers. a communication inventory was used to assess competence in relation to four communication functions and two contexts. the sample obtained was transcribed and analyzed in terms of nonverbal and verbal behaviours, including morpheme length and paralinguistic features. the results indicated that the subjects were, on average, incompetent in all areas of communication. correlations were made to stuttering frequency and attitudes to stuttering and sensitivity to communication. diagnostic and therapeutic implications are discussed. uittreksel die doel van die studie was om aspekte van die verbale en nie verbale kommunikasie vermoe van ses pre-adolessente hakkelaars na te vors en te beskryf. 'n kommunikasie inventaris is gebruik om die vermoe in verband met vier kommunikasie funksies en twee kontekste te bepaal. die materiaal is neergeskryf en ontleed in verband met die verbale en nie verbale opdragte, ook met morfeem lengte en parataalkunde kenmerke insluit. die resultate toon dat die proefpersone gemiddeld nie in staat was tot al die aspekte van kommunikasie nie. korrelasies is gemaak tussen hakkel frekwensies en houding en sensitiwiteit vir kommunikasie. diagnostiese en terapeutiese verwysings is bespreek. shames and florance (1980) report on a stutterer who said, "i recall many times that i had been in restaurants and wanted to order something of my choice and anticipated stuttering and would select something else from the menu because it was easier to say that word at that moment" (p. 4). this reveals a marked communication impairment in that it distorts the stutterer's ability to "share" in a social manner, which is what the very word "communication" means (cherry 1978; wood 1981). communication, according to myers and myers (1976) is at the core of our humanness. alant (1979) feels that it expresses social reality. communication may take place by verbal or nonverbal means. verbal communication is defined by wiig and semel (1976) as "the exchange of ideas, intentions, or information by speakers using a common language" (p. 323). abercrombie's (1968) statement that man speaks with his vocal organs, but converses with his whole body, indicates, however, that the mechanical act of speech is only meaningful in its interaction with nonverbal communication. communication does not simply mean "fluent verbal communication" or "adequate nonverbal communication", but rather, effective verbal and nonverbal communication in particular situations (alant 1979). @ sasha 1984 recently the focus of language research has been expanded to include language usage in social contexts. much current research in speech pathology is conducted within a pragmatic functional framework. there is however, a dearth of literature on stuttering within this paradigm. dalton and hardcastle (1977) feel that the major effect of stuttering on communication may perhaps be the sheer absorption that stutterers have in their speech problem. this possibly results in little opportunity to develop adequate communication skills, leading to unspontaneous, inappropriate and insensitive use of language. as barbara (1972) points out, the stutterer's immediate reaction is usually "what have i said? was it clear? were they able to understand me?" nonverbal communication would express this fear to the listener as it is an accurate and spontaneous transmitter of communicating emotions and conveying information about the person (argyle 1975). luper and mulder (1964) describe the most severe communicative impairment of the stutterer as that in which the stutterer refuses to talk for fear of stuttering. stuttering interferes considerably with communication. , muma (1978) states that by the pre-adolescent stage, pragmatic skills should have been acquired. features of communicax the south african journal of communication disorders, vol. 31 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the verbal and nonverbal communicative abilities of pre-adolescent stutterers 23 tion that children should be familiar with and use by the middle of primary school, include a fluid flow of initiating and responding to ideas, and a simultaneous use of verbal and non verbal means within an interpersonal framework of communication. as regards the latter, it is interesting to note that stuttering has been described as an interpersonal disorder by both sheehan (1968) and van riper (1978). therefore it is important to investigate the pre-adolescent stutterer's use of communication. the present study aims to describe some aspects of the verbal and nonverbal communication performance of a group of pre-adolescent stutterers in order to determine whether they demonstrate inadequate or delayed socialverbal communication skills; and whether stuttering behaviour, attitudes to stuttering and sensitivity to communication are related to communicative competence. methodology subjects (ss) six male pre-adolescent stutterers were used. this represents the smallest sample size possible for non-parametric withingroup studies (saling 1983). description of subjects the subjects were phase iii or iv stutterers (bloodstein 1969) within the nine to ten year old age range. none of the subjects had received previous communication skills training. all were monolingual english speakers. materials 1. communication inventory: the let's talk inventory for adolescents (wiig 1982) was used to assess selective aspects of social-verbal communicative competence of subjects in terms of four communication functions, ritualising, informing, controlling and feeling, in relation to two contexts — peer and adult. 2. attitude to stuttering: j the iowa scale (johnson, darley and spriestersbach 1963) was used for this purpose. 3. sensitivity to communication: alant's personal and social sensitivity scales (1979) were used to assess the subjects' sensitivity to communication. procedure j the ss were assessed individually in the same sound treated room with the same seating arrangements. a video recorder was used to ensure that all ss's responses were accurately recorded for later analysis. the video equipment (national vhs) was placed on the other side of a one-way mirror to make the interaction as natural as possible. testing cpnditions were kept constant to ensure that the environment did not affect subject-examiner interactions. ( the attitude to stuttering and sensitivity to communication scales were administered after the communication inventory, so as to ensure no affect on communication behaviour. the data obtained from the communication inventory was rated by two speech pathologists in terms of a) verbal and b) nonverbal behaviours. the latter rating is an extension of wiig's original procedure, and was devised by the writers. a) verbal communication analysis the verbal behaviours, including paralinguistic features, a morpheme count, communicative competence and related stuttering symptomatology were analyzed in the following way: paralinguistic features'. these were assessed by one of the writers (e) and an independent rater (r) for each s along eight parameters, according to a four point rating scale: 1 — poor; 2 — fair; 3 — adequate; 4 — good. the parameters included rhythm, pitch, intonation, intensity, stress, rate, pausing and embolophrasia. morpheme analysis: the segments were scored to reflect the mean length of utterance (mlu) in morphemes (wiig 1982), for the functions and contexts. this score reflects "syntactic-semantic" complexity. as wiig (1982) pointed out, length does not always reflect verbosity, but may reflect word-finding efforts, circumlocutions, and topical discontinuity. these factors are often very prevalent in stutterers' communication. communication competence: competence was scored as a factor of intent (functions) and register (contexts), and related to the norms established by wiig (1982) and compared as percentages. speech act association scores were also computed to assess the ss' receptive communicative competence. related verbal stuttering behaviours: stuttering behaviours were analyzed in terms of frequency and severity according to a four-point rating scale based upon johnson et al. (1963). the ε and r independently rated the scores for each s on each item of the inventory, according to the following: 0 — no evidence of verbal stuttering behaviour. 1 mild stuttering behaviour, but not interfering with communication. 2 — moderate stuttering behaviour, consisting of a single severe symptom or two mild examples, thus interfering somewhat with verbal communication. 3 — severe stuttering behaviour characterized by two or more examples of severe stuttering, interrupting the smooth flow of verbal communication. b) nonverbal communication analysis the writers devised a nonverbal communication analysis that borrowed from several researchers (argyle 1972; friesen et al. 1979; johnson et al. 1963; knapp 1978; ling and ling 1974). eight movements (see table 1) formed the data-base and were rated according to the following categories by two raters: (i) nonverbal stuttering behaviour (secondary stuttering). (ii) nonverbal behaviour distracting from communication. (iii) nonverbal behaviour complementing communication. the rating consisted of marking down the presence of a movement in the sequence in which it occurred in the "speech act" of "moment" of stuttering" that is, while listening to the stimuli and before, during and after speaking (bales 1960; van riper 1973 and 1978). this would determine how stuttering was related to nonverbal communication and which behaviours detracted from or complemented communication. the speech act or "single interaction" was defined as the "smallest discriminable segdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31. 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 monica bucher, melissa bortz and denise anderson table 1 movements forming the basis for analysis behaviour description of movement head movements these were described as deviations of the head from a midline position, the face facing forward. gaze direction of gaze was considered as looking at partner, looking down or up, or to the side, or at the stimuli. facial expression this included facial configurations which displayed affect. facial extremities were defined as scalp, ears and temples. posture this included any change in general posture as well as varying positions in the trunk and shoulders and lower extremities. it was also the general category under which illustrators and manipulators were considered. illustrators and gestures these were movements which accompanied speech and illustrated what was being said verbally. they may have been present in all parts of the body. shrug this category was defined by the writers and involved a more subtle shoulder movement accompanying speech. manipulators these were either (i) self manipulators which included movements on various parts of the body, for example, finger scratching the palm of the hand, or (ii) object manipulators which were similar actions involving inanimate objects. lower extremities this involved any movement occurring in the upper or lower leg/legs or the ankle. ment of verbal or nonverbal behaviour" (bales 1960, p. 37). for a movement to be considered for analysis, both raters had to have agreed as to its placement within a particular category. the modified iowa scale (johnson et al. 1963) and personalsocial sensitivity scales (alant 1979) were then scored for each s and were related to each other and to communicative competence. statistical procedure the following non-parametric, descriptive statistical procedures used by wiig (1982) to analyze verbal behaviour, were extended, for the present study, to nonverbal behaviour as well. using the raw scores obtained by the group for each communicative function and context, a measure of central tendency (mean), ranges of scores, rankings from highest/best scores to lowest/worst scores and predominant scores, were calculated. inter-rater reliability for the verbal analysis was calculated as a percentage of agreement. results and discussion inter-rater reliability for the verbal analysis was found to be high (88%). communication inventory a) verbal analysis the results revealed that the subjects' verbal communicative abilities were on average ineffective. paralinguistic incompetence was demonstrated in the features of rhythm, pitch, rate and pausing (table 2). as expected with stutterers, rhythm was shown to be generally uneven, although two subjects presented with rhythmical speech patterns as a fluency facilitator. pitch was predominantly monotonous. the speech rate was judged to be slower than normal; pausing prior to speech onset and hesitations during speech production were prevalent in two of the subjects. johnson et al. (1963) suggested that these factors may be due to the fact that the stutterer proceeds apprehensively and cautable 2 overall paralinguistic competence for all ss' expressed as predominant scores, mean scores and rankings feature predominant score mean rank rhythm 2 1,7 7 pitch 1 1,5 8 intonation 3 2,8 4 intensity 4 3,8 1 stress 4 3,5 2 rate 1 1,9 6 pausing 2/3/4 2,7 5 embolophrasia 4 3,2 3 code 4 good 3 adequate 2 fair i 1 poor ; ι tiously as if looking for trouble. the feature of embolophrasia e.g. "er" and "um" and word repetitions was used as part of the stuttering symptomatology by two subjects. the other paralinguistic parameters were found to be largely unaffected by the stuttering. these results confirmed bloodstein's statement in 1969, that what can be identified as stuttering, is not only evident in the fluency impairment, but also in certain paralinguistic parameters and that these features are not always confined to discrete moments. results of the morpheme count (as shown in tables 3 and 4) revealed that the subjects used longer utterances when addressing adults, than when addressing peers. this is in accordance with what wiig (1982) found with normal speakers ̂ however, the subjects generally scored below the norms. they tended to use simple statements, with little elaboration. dalton and hardcastle (1977) described some stutterers, who cut down their utterances to the bare minimum, simplifying an argument to the point they felt they could make easily. one subject used extended utterances. however, this still rendered the commuthe south african journal of communication disorders, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the verbal and nonverbal communicative abilities of pre-adolescent stutterers 25 nication ineffective, mainly as a result of circumlocutions and rambling. the subjects in this study therefore did not appear to have learned the principle expounded by wood (1981) that one must say just enough, but not too much. table 3 morpheme analysis related to the two contexts context mean peer adult 8,6 9,7 table 4 morpheme analysis related to the four functions function predominant score ritualizing informing controlling feeling 1 1 ϊ | above norm same as norm | below norm for verbal competence, both norm relations (wiig 1982) and overall percentages were analysed on the communication inventory. in table 5 it can be seen that, with respect to the contexts, the subjects performed most effectively in relation to the peer context. table 5 verbal competence on inventory: stuttering frequency context ®/o peer adult 79 60 table 6 summary of the mean percentage and predominant scores for ss' communicative com. petence on all fourjcommunication functions wi' thin both contexts function context predominant „, score / 0 ritualizing informing controlling feeling peer, adult peer adult peer adult peer adult ! τ 53 i 83 • 61 1 78 1 62 ί 85 j 62 code | above norm same as norm | below norm wiig (1982) pointed out that this was to be expected in relation to the norms. thus, the stutterers tended to follow the normal trend of effectiveness, although when related to the normative data, they functioned below average for both peer and adult contexts. as can be seen from table 5, the stuttering behaviour was shown to be considerably worse in the adult context. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31 1984 in terms of the functions of communication (table 6), the subjects performed least effectively on the ritualising function, in relation to both contexts. the informing function revealed a considerably better performance in the peer context than in the adult context, although wiig (1982) reported that both contexts should have been acquired. the stuttering severity (tables 7 and 8) appeared to be least severe in relation to the ritualising function and most severe in relation to the informing function. table 7 stuttering analysis using predominant scores related to the four functions function predominant score ritualizing 0 informing 3 controlling 2 feeling 1 code 0 no stuttering 1 mild stuttering 2 moderate stuttering 3 severe stuttering table 8 stuttering analysis using predominant scores related to the two contexts context predominant score peer adult 0;1 2;3 code 0 no stuttering 1 mild stuttering 2 moderate stuttering 3 severe stuttering this may be related to the propositionality level associated with the different functions, since, as eisenson (1975) pointed out, stuttering increases when meaningfulness increases. the controlling function revealed the poorest scores in relation to the norms of all four functions. this too, may be due to the higher propositionality of speech involved (eisenson 1975). the subjects scored most effectively on the feeling function in terms of percentages and in relation to the normative data, yet they still scored below the norm. this may be related to the high personal sensitivity scores of the subjects revealing that they were possibly more in touch with their own feelings. thus the results indicated that the subjects did not perform according to the average standard described by wiig (1982). wiig suggested that this could be related to secondary emotional reactions interfering with the communication learning process. b) nonverbal analysis the subjects did not use nonverbal communication to either enhance or detract from verbal communication, across pragmatic functions. this indicates a delay, as wood (1981) stated that pre-adolescents should have basic pragmatic skills. seconr ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 monica bucher, melissa bortz and denise anderson dary stuttering did vary according to functions when related to propositionality. thus infrequent stuttering was found for ritualising as this function contains little propositionality. an increase in both the amount and severity of secondary stuttering behaviours was found for the informing function as this implies propositionality. the most frequent amounts of stuttering were found for the controlling function, where propositionality is high. this function also requires skill which, according to hopper and naremore (1978), adults often do not acquire. stuttering was decreased for the feeling function. this was possibly because this function was the last to be assessed and the subjects were more relaxed and familiar with the test situation. table 9 summary of the comparison of scores of nonverbal stuttering (st) distracting (d) and complementing (c) behaviours (percentages were calculated relative to the frequency of occurrence of the functions) st % d % c % head movements 4 31 6 46 3 23 gaze 4 22 6 33 8 44 facial expression 5 50 3 30 2 20 posture 4 31 6 46 3 23 gesture and illustrators 3 50 3 50 shrug 3 100 manipulators 3 30 7 70 lower extremities 2 8 9 82 as illustrated in table 9, limited effective communication occurred for head movements. nodding was the only frequent complementing head movement observed, particularly during listening and speaking. this correlated with knapp's (1978) statement that the head nod is probably the most familiar nonverbal act which maintains conversation. distracting head movements and secondary stuttering behaviour also detracted from effective communication. secondary stuttering head movements occurred during speaking as a release from a block as well as before stuttering as a starter. a close relationship between head movements and gaze was noted. eye contact is an important facet of face to face communication which occurs during listening and speaking, just before or after a thought unit is completed (knapp 1978). gaze acts were present on the complementing-checklists indicating adaptive eye contact. however maladaptive gaze patterns were also noted indicating evasion of social contact and interaction. facial expression is the second most commonly occurring stuttering symptom according to bloodstein (1960). it was found in these subjects in the form of lip pursing before and during stuttering, resulting in ineffective communication. high counts of shifting were present before and during speaking making posture one of the most distracting categories of nonverbal behaviours observed. argyle (1977) states that posture is less well controlled than other nonverbal clues and is often an indicator of leakage, that is concealing information from the other interactor. gestures accompanying speech illustrate what is being said verbally (knapp 1978). generally the presence of illustrators was tentative and indicative of ineffective communication. a high percentage of restless or repetitive leg and foot acts formed part of the stuttering pattern. at other times these movements distracted from the communicative process. in summary nonverbal behaviours were detracting from, rather than complementing verbal communication. secondary stuttering exacerbated ineffective communication. attitudes to stuttering the subjects demonstrated an average mean score of attitudes to stuttering on the iowa scale. nevertheless, the predominant scores revealed positive attitudes to stuttering. these positive attitudes did not correlate with the ineffective verbal and nonverbal communication parameters found. this may be a feature of pre-adolescence since the pre-adolescent stutterer has not yet experienced the accompanied social pressures and may therefore not have developed the negative attitudes so common in adults (dalton and hardcastle 1977). sensitivity to communication on the personal social sensitivity scale (alant 1979), the subjects demonstrated high scores on the personal dimension and low scores on the social dimension. the high personal rating probably indicated that the subjects were involved in the encoding function and tended to be selfcentred and absorbed in their stuttering, without considering the other communicators or decoding function. the low social rating probably pointed to the fact that the subjects were not involved adequately in the interaction, revealing their incompetence in their communication and lack of awareness of others. this correlated with the ineffective interactive communication found in this study, and showed that the stutterers did not comply with the prerequisites for high social sensitivity described by alant (1979). conclusions the results of this study revealed that the ss' communication abilities were on average ineffective. this led to ineffective communication and poor social interaction. thus, speech therapy with stutterers of this age group should focus on both fluency and remediation of communication. the ineffective conversation was demonstrated a) within all communication functions, particularly in the controlling function, and in relation to the adult context more than the peer context, b) in the shorter mean morpheme length and simple utterances used, with little elaboration, c) by certain paralinguistic features being of poor quality — uneven rhythm, monotonous pitch, slow rate, pausing before and during utterances, and poor intonation at times. the paralinguistic incompetence could be directly related to the stuttering pattern, while the communicative incompetence in terms of intent and register, and morpheme length may also be related to the stuttering. behaviours complementing communication were present, but in limited amounts. contrary to this, large and varied amounts of distracting nonverbal behaviours were found. these were exacerbated by the nonverbal stuttering actions, which constituted part of the communication problem. the nonverbal skills were not complementing verbal behaviour for pragmatic purposes. pragmatic patterns emerged for secondary stuttering which seemed to relate stuttering to propositionality. the south african journal of communication disorders, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the verbal and nonverbal communicative abilities of pre-adolescent stutterers 27 attitudes to stuttering were shown to be generally positive, which contradicts the hypothesis that poor communication results from poor attitudes. this may be related to the preadolescent age, when social pressure has been minimal. therefore, it seems worthwhile to introduce therapy at this age, as this population seems to have a positive attitude towards communication that is uncharacteristic of older stutterers. however, the low interactive communication sensitivity and poor communication skills indicate that although the ss' were intensely aware and sensitive to their own communication, they had low social sensitivity. in conclusion it must be recognised that therapists must deal with much more than the speech of stutterers in order to give them "the tools needed to help them rejoin the human race" (van riper 1978, p. 6). references abercrombie, d. paralanguage, chapter 2, in laver, j. and hutcheson, s. (eds.): communication in face to face interaction, middlesex, penguin books ltd., 1968. alant, e. speech and language pathology and communication, master of arts, university of pretoria, 1979. argyle, m. bodily communication, london, methuen and co. ltd., 1975. argyle, m. nonverbal communication in human social interaction, in hinde, r. a. (eds.): nonverbal communication, great britain, cambridge university press, 1977. barbara, p.a. communication in stuttering, chapter 22, in emerick, l.l. and hamre, c.e. (eds.): an analysis of stuttering: selected readings, illinois, the interstate printers and publishers inc., 1972. bloodstein, o. a handbook on stuttering, chicago, national easter seal society for crippled children and adults, 1969. bloodstein, o. the development of stuttering i. changes in nine basic features, j. speech hearing dis. 1960, 25, ,219-237. j cherry, c. on human communication: a review, a survey and a criticism, (3rd ed.), england, the mit press, 1978. dalton, p. and hardcastle, e.j. disorders of fluency, london, edward arnold ltd., 19717. eisenson, j. stuttering as a perseverative behaviour. chapter i vi, in, eisenson, j. (ed.): stuttering: a second symposium, new york, harper and row publishers, 1975. erickson, r.l. assessing communication attitudes amongst stutterers, j. speech hear. res. 1969, 12, 711-724. hopper, r. and naremore, r.j. children's speech a practical introduction to communication development, second edition, new york, harper and row publishers inc., 1978. johnson, w., darley, f.l. and spriestersbach, d.l. diagnostic methods in speech pathology, new york, 1963. knapp, m.l. nonverbal communication in human interaction, second edition, new york, holt, rinehart and winston, 1978. luper, h.l. and mulder, r.l. stuttering: therapy for children, englewood cliffs, new jersey, prentice hall inc., 1964. muma, j.p. language handbook concepts, assessment, intervention, englewood cliffs, new jersey, prentice hall inc., 1978. myers, g.e. and myers, m.t. the dynamics of human communication: a laboratory approach. (second edition), mcgraw-hill book company, 1976. saling, m. personal communication, senior lecturer, dept. of psychology, university of the witwatersrand, johannesburg, 1983. shames, g.h. and florance, c.l. stutter-free speech: a goal for therapy, columbus, ohio, charles e. merrill publishing co., 1980. sheehan, j. stuttering as a self-role conflict. chapter v, in, gregory, h.h. (ed.): learning theory and stuttering therapy, evanston, northwestern university press, 1968. shuter, r. understanding misunderstandings, exploring interpersonal communication, new york, harper and row, 1979. van riper, c. speech correction: principles and methods, sixth edition, englewood cliffs, new jersey, prentice hall inc., 1978. wiig, e.h. let's talk inventory for adolescents, manual, columbus ohio, charles e. merrill publishing company, 1982. wiig, e.h. and semel, e.m. language disabilities in children and adolescents, columbus, ohio, charles e. merrill publishing company, 1976. wood, b. children and communication, second edition, englewood cliffs, new jersey, prentice hall inc., 1981. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) siemens quality hearing aids and school teaching equipment from r e p u b l i c h e a r i n g c o n s u l t a n t s ( p t y ) ltd new address: 187 jan smuts avenue lower rosebank (opposite thrupps) telephone: 442-8691 the south african journal of communication disorders, vol. 31 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'ν palatografies-fotografiese ondersoek van die afrikaanse konsonantklanke h.e.c. tesner m.a. (pret.) e.c. naude m.a. (log) (pret.) departement spraakwetenskap, spraakheelkunde en oudiologie, universiteit van pretoria. opsomming die konsonantartikulasie van een afrikaanssprekende proefpersoon is palatografiesfotografies ondersoek om vas te stel wat die ko-artikulatoriese invloede van verskillende vokaalomgewings op die artikulasiekontakpunt van besondere konsonante is. afleidings word gemaak met betrekking tot die stabiliteit van-die artikulasiepunt vir die verskillende konsonante. die verslag word afgesluit met enkele terapeutiese riglyne en aanbevelings vir verdere navorsing. summary consonant articulation of an afrikaans-speaking subject was researched in a palatographicphotographic study in order to establish the co-articulatory effect of different vowel contexts on the place of articulation of specific consonants. deductions are made as to the stability of place of articulation of the different consonants. certain guidelines for therapy are given as well as suggestions for further research. die palatografiese tegniek is een van die oudste eksperimentele hulpmiddels tot die beskikking van die fonetikus wat artikulasie bestudeer. ten spyte hiervan is hierdie tegniek nog nooit uitgebreid toegepas om die invloed van varierende vokaalkontekste op die plasing vir konsonantartikulasie in afrikaans te bestudeer nie. dit word in die fonetiese wetenskap aanvaar dat spraak op artikulatoriese vlak streng gesproke nie segmenteerbaar is nie. nogtans is die praktiese waarde van 'n afsonderlike beskouing van konsonantklanke goed bekend by onderwysers in die fonetiek sowel as by spraakterapeute. meerdere kennis oor die gedrag van die artikulators vir klanke in verskillende omgewings kan ons begrip van artikulasie as 'n dinamiese proses slegs verbreed. hierdie fisiologies-georienteerde kennis moet tesame met 'n linguisties-georienteerde beskouing van die distinktiewe klankeienskappe toegepas word. metode slegs een proefpersoon is by die studie betrek. die palatum is bestuif met 'n mengsel van houtskoolen sjokoladepoeier en na elke artikulasie is 'n kleurfoto van die monddak met 'n "polaroid cu-5 land camera" geneem. die kamera is voorsien van 'n ringflits en 'n mondspieel van verchroomde staal. hibitane is as ontsmettingsmiddel gebruik. die konsonante wat by die studie betrek is en die klankomgewings waarin hulle geproduseer is, verskyn in tabel i. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol.25, 978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 h.e.c. tesner & e. naude iti idi ili ini iri i r i isi izi itu u t u uti θ t a idu u d u udi a d o ilu ulu uli a 1 a inu u n u uni a n a u r u uri a r a i r u u r u u r p i j i iqi iki ixi isu usu usi a s a izu uzu uzi a ζ a i j u u j u u j i i p i u j i u u p i it]u u n u uri" iku u k u uki a k a ixu uxu uxi a χ a igu ugu ugi 3 c u ici a g a j a uci t a b e l i. die konsonante wat by die studie betrek is en die klankomgewings waarin hulle geproduseer is. die iru-kombinasie is nie in die tabel verteenwoordig nie, omdat geen bevredigende fotografiese beeld van die produksie verkry kon word nie. verwerking van resultate: elke foto is vir ontledingsdoeleindes onderverdeel soos in fig. 1. met behulp van hierdie verdeling is die volgende metings geneem: 1. afstand van aanraking vanaf voortande. 2. antero-posterior breedte van aanraking. 3. unilaterale area van aanraking links. 4. unilaterale area van aanraking regs. voorbeelde van hierdie metings verskyn in tabelle ii en iii. bostaande metings is uit praktiese oorwegings na grafiekpapier oorgedra wat terselfdertyd 'n duideliker voorstelling van die artikulasiekontak gegee het en dit maklikergemaak het om aanrakingsareas numeries te verwerk. hierdie metode het die kwantitatiewe vergelyking van gegewens vir verskillende klanke moontlik gemaak. (sien grafiek 1). c β α β c 4 5 _ 3 _ 2 1 s p i e e l b e e l d v a n bo t a n d e bo t a n d e figure 1. 1 the south african journal of communication disorders. vol. 25. 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) afrikaanse konsonantklanke 19 iti c β a β c m » u l r grafiek 1 klanki-i i-u u-u u-i θ omgewings t 0-1,50 0-1,75 0-1,50 0-1,67 0-2 r 1,50-2 1,33-1,67 1,50-1,75 1,25-1,50 verklaring: die eerste letterwaarde vir elke klankomgewing dui op die afstand van aanraking vanaf die voortande. die afstand tussen die twee letterwaardes vir elke klankomgewing reflekteer die anteroposterior breedte van die aanraking. raadpleeg fig. 1. tabel 11. afstand van aanraking vanai vooriandc en unteroposierior breedte van aanraking vir [t] en [rj. i i a a links regs i.inks regs 1 a 1 a 1 a 1 a 2 β 2 b,50 2 a 2 a t 3 β,25 3 b,75 3 b,75 3 b,50 t 4 β,50 4 c,50 4 c 4 c 5 c 5 c,50 5 c 5 c,50 6 c 6 c,50 6 c,25 6 c75 1 c,50 1 c,50 1 c,50 1 c,50 2 a 2 a 2 c.50 2 c,50 r 3 b,50 3 b,50 3 a,50 3 a 4 b,25 4 b,50 4 β 4 c 5 b,50 5 c,25 5 c 5 c,50 6 6 6 6 t a b e l 111. laterale aanraking. die standaardafwyking van die area van aanraking vir elke konsonantklank in die verskillende klankomgewings is bereken om η aanduiding te gee van die stabiliteit van die artikulasiekontakpunt. dit word in tabel iv weergegee. die suid-afrikaanse tydskrif vir kommunikasieafwy kings vol.25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 h.e.c. tesner & . naude gemiddelde standaardafwyking t: 34,8 8,37 γ: 53,6 17,3 k: 9,6 3,9 d: 31,2 7,6 s: 71,6 6,4 x: 14,8 6,9 1: 33,8 9 z: 75,6 11,2 g: 10,8 5,7 n: 42 12,4 j : 60,4 19,7 r: 34,5 5,1 q : 14,8 5,5 tabeliv. m e t i n g s w a a r d e s . bevindings uit die grafieke is vir elke klank bereken watter klankomgewing die artikulasiekontakpunt die verste na voor plaas. (sekere klanke is nie by hierdie berekenings ingesluit nie, t.w. die ruisklanke [s j,[z ] en [ j ] asook [ s 1 en [c]). die klarikomgewings vir elke klank is vervolgens in volgorde van voor na agter geplaas (tabel v). t iti utu uti itu θ t θ d idu idi udi ad udu 1 ili ale ilu uli ulu η unu uni ini θηθ inu r θ γ θ uru iri uri γ 3 γ 3 iru uri iri uru 13 'ζμ a g a uqu iqu uqi k uki aka iki uku iku x ixi θχθ uxu ixu uxi g 'g' 3g3 ugu igu ugi tabel v. volgorde van voor na agter. uit tabel v blyk dit duidelik dat geen konstante patroon na vore tree nie. 'n kwalitatiewe ontleding van die gegewens lei tot die volgende tentatiewe gevolgtrekkings: die klankomgewing [i-i| blyk in die meeste gevalle vir 'n verplasing na voor verantwoordelik te wees. daarna volg die omgewing [s-a]. die omgewing [u-u] verskuif die kontakpunt in die meeste gevalle na agter. hier moet weer daarop gewys word dat uitsonderings voorkom wat die patroon versteur. ' wat die area van laterale kontak betref, is die klankomgewings vir elke klank weereens gerangskik in volgorde van breed na smal (tabel vi). the south african journal of communication disorders vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) afrikaanse konsonantklanke 21 t iti itu u t u uti a t a d udi idi idu u d u a d a 1 ilu ulu ili a l a uli η ini uni in u u n u a n a r uri iri a r a u r n γ i r u θ γ θ i r i u r i uf u s isi usi a s a usu isu ζ izu uzi izi uzu s z a j i j " i / i "ji u j u a j a q '13" u r j i i r j u u q u a q a k uki iki iku uki a k a x uxi ixi ixu uxu " a x a g igu igi ugi ugu a g a t a b e l vi. volgorde van breed na smal. ook hier is geen konstante patroon uit te wys nie. dit lyk of enige klankomgewing wat [i] bevat, verantwoordelik is vir die breedste laterale aanraking. die smalste laterale aanraking word in die meeste gevalle veroorsaak deur die omgewing [θ-θ], gevolg deur [u-u]. die ondersoek het baie duidelik getoon dat die grootste laterale aanraking voorkom by die frikatiewe [s],[z] en [j], indien die velere klanke uitgesluit word, lyk dit of die ratelklank tesame met die tikklank gekenmerk word deur die kleinste laterale aanraking. dit is ook opvallend dat hierdie twee klanke met besondere klein mediale aanrakings geartikuleer word. interessant van hierdie proefpersoon is dat artikulasiebewegings deurgaans 'n besondere sterk neiging na regs toon. hierdie patroon het egter geen hoorbare invloed op die akoestiese resultaat van die spraakproduksie nie. die laterale neiging is duidelik waarneembaar in die onderste voorbeeldgrafieke van [s]. die stabiliteit van die artikulasiekontakpunt in verskillende klankomgewings toon 'n wye variasie (tabel iv). die velere klanke word hier buite rekening gelaat omdat moontlike verskuiwings van die area van aanraking na agter nie deur hierdie metode opgeteken kan word nie. die volgorde van mees stabiel na minste stabiel verskyn in tabel vii. r s d t 1 ζ η r j" s t a n d a a r d 5,1 6,4 7,6 8,37 9 11,2 12,4 17,3 19,7 tabel vii. volgorde van mees na minste stabiel t.o.v. area van artikulasiekontak. bespreking 'n ernstige tekortkoming van hierdie studie is dat slegs een proefpersoon daarby betrek kon word. die metode is egter duur en omslagtig. ten spyte van hierdie tekortkoming kan daar tog sekere nuttige aanwendings van die bevindings in terapie gemaak word. in terapie vir addentale artikulasie sou dit volgens hierdie gegewens sinvol wees om aanvanklik die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 h.e.c. tesner & . naude konsonant artikulasie in die [u-u] omgewing vas te le, aangesien hierdie omgewing die kontakpunt na agter verskuif. die mate van motoriese vaardigheid en akkurate plasing wat vir die produksie van [r] vereis word, word beklemtoon deur die groot mate van stabiliteit van artikulasiekontakpunt en die besondere klein anteroposterior area van aanraking. in die geval van 'n persoon wat afsluitingsklanke met 'n bree stootbeweging artikuleer (hoewel die akoestiese resultaat vir klanke soos [t] en [d] bevredigend kan wees) sal 'n bevredigende [r] onwaarskynlik wees. die wisselende areas van aanraking vir die verskillende klankomgewings wys net weer op die noodsaaklikheid van 'n program waarin artikulasie van 'n klank in stelselmatig wisselende klankomgewings geoefen word. dit geld by uitstek vir die [n] en die [j'| (die [r], wat ook 'n groot mate van wisseling t.o.v. artikulasiekontakpunt openbaar, is nie 'n foneem in afrikaans nie). 'n interessante waarneming met betrekking tot [n] is dat hierdie klank wat in afrikaans in 'n groot mate onderworpe is aan ko-artikulatoriese bei'nvloeding deur konsonante skynbaar ook in 'n groot mate deur vokale bei'nvloed word. hierdie studie is in vele opsigte 'n ideale onderwerp vir meer gesofistikeerde bestudering met behulp van nuwe elektropalatografiese tegnieke. aangesien hierdie tegniek nog nie in suid-afrika beskikbaar is nie, sal data wat bostaande bevindings verwerp of bevestig, waardevol wees. books on speech and hearing c o n s u l t campus bookshop 34 bertha street, p.o. box 31361 braamfontein 2017 telephone 39-1711 westdene medio books 35/6 nedbank plaza, westdene medio books 175 beatrix street pretoria telephone 2-6336 / logans university bookshop . . 227/9 francois road, durban • telephone 35-4111 overseas publications obtained promptly. nationwide mail-order service. the south african journal of communication disorders vol. 25. 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the ie-30a system from audio analysis ivie spst sushi v i i c e s t e e i c n e 0 u s l y c o m p ' e t e f r e ^ e n c y spectrum of sounds, 2) portable, hand held, rechargeable battery or mains oderated complete w,th precision microphone, batte^charter and c a s n g c a s e 3) two memories, individual store spectrum pattern. 4) may be used to generate voice prints. 5) contains precision sound level meter with digital readout 6) output for oscilliscope, chart recorder, etc. for further information contact: colosseum acoustics 95. kerk street, johannesburg. phone 23-4541 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die meting van middeloorfunksie van die normale menslike oor: 'n timpanometriese ondersoek i . s . h a y , m.a. ( a u d . ) (wash.) departement spraakwetenskap, spraakheelkunde en oudiologie, universiteit van pretoria opsomming nege-en-veertig normaalhorende proefpersone (96 ore) is onderwerp aan 'n timpanometriese ondersoek met 'n grason-stadler otoadmittansmeter. timpanogramme van konduktansie (g) en susseptansie (b) is gelyktydig geregistreer met meetfrekwensie 220 hz en daaina met 660 hz en oorkanaal drukverandering is in 'n positiewe sowel as negatiewe rigting toegepas. sodoende is vir elke oor 8 timpanogramme verkry waarvan die statiese gen b-waardes bereken is. statiese admittansie (y) en impedansie (z) is volgens die standaardmetode bereken asook die fasehoek ( 0 ) . die resultate het getoon dat enige van die gen b-timpanogramme gebruik kan word vir die bepaling van middeloordruk. die rigting van die drukverandering het verskille by indiwiduele ore opgelewer, maar geen betekenisvolle verskille ten opsigte van die gemiddelde waardes nie. die vorm van die timpanogramme bewys dat vals positiewe resultate veral by 660 hz moontlik is aangesien normale ore 'n redelike mate van tipe d-timpanogramme openbaar. die studie gee aanduidings van die moontlikheid dat timpanometrie o.a. by groot positiewe en negatiewe druk in die oorkanaal, inligting kan verskaf aangaande middeloorfunksie. summary forty-nine normal hearing subjects (96 ears) were subjected to a tympanometric investigation using a grason-stadler otoadmittance meter. conductance (g) and susceptance (b) tympanograms were recorded simultaneously using probe-tone frequencies 220 hz and 660 hz. tympanograms were recorded with ear canal pressure variation in a positive and negative direction. this gave a total of eight tympanograms for each ear which were used to obtain static values for g and b. from this data static admittance (y) and static impedance (z) and phase angle ( 0 ) were calculated using the standard formulae. the results indicated that any of the g and β tympanograms could be used for determining middle-ear pressure. the direction of pressure change gave slightly different values of middle-ear pressure for some individual ears but there was no significant difference across subjects. the shape of the tympanograms proved that false positives are possible, especially using the 660 hz probe t o n e , since a considerable number of normal ears displayed type d tympanograms. this research provides indications that tympanometry could furnish information relating to middle-ear function when considering results at great positive and negative pressure levels. sedert metz in 1946 die meting van sekere aspekte van die impedansie op normale en patologiese ore gepubliseer het, het verskeie publikasies van navorsers in europa en die v.s.a. die lig gesien. binne twee jaar na die publikasie in amerika van die kliniese toepassing van timpanometrie in 1970 het timpanometrie 'n baie populere kliniese tegniek geword.4 vandag word die tegniek die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 i. s. hay wereldwyd toegepas en dit word beskou as redelik betroubaar en maklik uitvoerbaar. in die meeste kommersieel-beskikbare apparaat word daar slegs gebruik gemaak. van een aspek van impedansie, nl. die reaktiewe komponent en omdat die oor by 220 hz styfheid beheerd is, word slegs die 'compliance' (omgekeerde van die styfheid) gemeet. die reele komponent van impedansie (akoestiese weerstand) word as so laag beskou vir die menslike oor dat dit nie gemeet word nie. metings deur zwislocki en feldman15 het egter bewys dat waardevolle inligting tog bekom word indien die weerstandskomponent ook gemeet word. hierdie navorsers het egter in 1970 slegs impedansmetings gemaak en dit was eers in 1974 dat feldman3 met behulp van die grason-stadler otoadmittansmeter timpanometrie bestudeer het gebruikmakende van beide reele en reaktiewe komponente van admittansie (die omgekeerde van impedansie) beide by 220 hz en 660 hz. die gebruik van hierdie lae en hoe frekwensies het reeds getoon dat die hoer frekwensies (660 hz of 800 hz) besonder gevoelig is vir oordrom-abnormaliteite. alberti en jerger1 het dit egter duidelik gestel dat geen addisionele inligting bekom word deur by 800 hz te meet nie aangesien die w-tipe timpanogram by feitlik alle soorte middeloorpatologiee voorkom by 800 hz. hulle het egter net 'compliance' gemeet en het dus nie 'n geheelbeeld verkry soos feldman3 nie. die doel van die huidige ondersoek was om (as deel van 'n reeks ondersoeke) die normale menslike oor te onderwerp aan timpanometriese ondersoeke met behulp van die otoadmittansmeter terwyl die konduktansie en susseptansie gelyktydig gemeet word, om die beurt by 220 hz en 660 hz. in 'n tweede fase van die reeks ondersoeke sal soortgelyke metings uitgevoer word op proefpersone met bewese middeloorpatologiee. aangesien daar tot dusver slegs twee publikasies3.5 in hierdie verband verskyn het, word hierdie navorsing as belangrik beskou. metode p r o e f p e r s o n e as proefpersone het opgetree studente en personeel van die departement spraakwetenskap, spraakheelkunde en oudiologie van die universiteit van pretoria. proefpersone is geselekteer op grond van normale gehoor (gehoorpeil nie groter nie as 15 db i s ο by 250 tot 4 000 hz) en normaal verklaar deur 'n otoloog. nege-en-veertig proefpersone (96 ore) is gebruik. die ouderdomme het gewissel tussen 18 en 33 jaar met 'n gemiddelde ouderdom van 20 jaar 10 maande. a p p a r a a t vir die meting van die twee komponente van die admittansie is gebruik gemaak van die grason-stadler otoadmittansmeter model 1720. twee hewlettpackard tipe 7035b x — y registreerders is respektiewelik gekoppel aan die uitgange van die otoadmittansmeter sodat die twee komponente van die admittansie gelyktydig gemeet kon word. horisontale beweging op die registreerthe south african journal of communication disorders, vol. 24, 977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) timpanometriese ondersoek van middeloorfunksie 63 ders is bewerkstellig deur hulle te koppel aan die otoadmittansmeter se lugdruksisteemse uitgangwatvirhierdie doel beskikbaar is. sodoende is beweging na regs verteenwoordigend van druktoename in 'n positiewe rigting en na links van druktoename in 'n negatiewe rigting. yking van alle apparaat het daagliks geskied volgens voorskrifte van die vervaardigers. korreksies vir hoogte bo seespieel en temperatuur is aangebring op alle admittansiewaardes verkry. o n d e r s o e k m e t o d e metings met die otoadmittansmeter het 8 timpanogramme opgelewer. vir elke oor wat getoets is, is 'n timpanogram vir akoestiese konduktansie, g, en akoestiese susseptansie gelyktydig verkry by beide 220 hz en 660 hz, beide in die positiewe en negatiewe rigting van druk verandering. metings is in beide rigtings uitgevoer ten einde vas te stel of daar betekenisvolle verskille na vore kom wat die vorm van die timpanogramme betref. statiese waardes van g en figure 1. verspreiding van middeloordruk as 'n funksie van meetfrekwensie en admittanskomponente g en b. gg dui aan timpanogram drukverandering in rigting -300 na + 300 mm water §§ dui aan drukverandering in rigting +300 na-300 mm water. g: konduktansie. b: susseptansie. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 i. s. hay β is gebruik vir die berekening van die komplekse admittansie y deur middel van die formule y2 = g 2 + b 2 . die akoestiese impedansie, z, is bepaal deur die formule ζ te gebruik. die fasehoek, 0 , is bepaal deur die formule 0 = tan te gebruik. resultate middeloordruk die verspreiding van die resultate van middeloordruk (die drukwaarde waar die timpanogram se piek voorkom) word vir die linkeren regteroor vir al die meettoestande en rigting van drukverandering op fig. 1 vooigestel. vir al die toestande het meer as 80% van die metings tussen 2 0 en +20 mm waterdruk geval. gemiddelde middeloordrukwaardes vir die verskillende meettoestande en rigting van drukverandering word in tabel i aangegee. die laaste kolomme.gee die algehele gemiddeldes en hiervan kan afgelei word dat die gemiddeldes vir beide ore feitlik 0 mm waterdruk is. die feit dat die linkeroor se gemiddelde drukwaarde positief is en die regteroor s'n negatief, is hier van minder belang omdat beide waardes so klein is. rigting van drukverandering negatief na positief positief na negatief gemiddeld rigting van drukverandering negatief na positief positief na negatief gemiddeld linkeroor (n = 47) rigting van drukverandering negatief na positief positief na negatief gemiddeld g 220 hz 4 , 9 1 ( 5 9 / + 2 4 ) 8 , 3 6 ( s 3 / + 2 3 ) 6 , 6 4 ( 5 6 / + 2 0 , 5 ) g 660 hz 1,14 ( 4 6 / + 2 7 ) 0,17 ( 5 4 / + 3 0 ) 0,66 ( 5 0 / + 2 7 ) β 220 hz 0,70 ( 5 9 / + 2 5 ) 0,87 ( 5 2 / + 2 5) 0,79 ( 5 5 . s / + 2 5 ) β 660 hz 0,34 ( 4 6 / + 50) 0,34 ( 5 3 / + 4 7 ) 0,34 ( 4 9 , 5 / + 3 0 , 5 ) gemiddeld 0 , 6 8 ( 5 9 / + 5 0 ) 1 , 7 5 (—54/+47) 1 , 2 1 5 ( 5 6 / + 3 0 . 5 ) negatief na positief positief na negatief gemiddeld regteroor (n = 49) negatief na positief positief na negatief gemiddeld 7 , 9 3 ( 1 0 0 / + 1 9 ) 1 1 , 4 9 ( 1 0 0 / + 20) 9 , 7 1 ( 1 0 0 / + 1 7 ) 2 , 2 4 (—100/+29) 3 , 7 9 (—103/+36) 3 , 0 2 ( 1 0 1 . 5 / + 2 5 ) 3 , 4 2 (—100/+33) 5 , 8 8 (—100/+27) 4 , 6 5 (—100/+30) 6,71 ( 1 0 0 / + 5 0 ) / / 4,57 ( 9 4 / + 4 6 ) 5,64 ( 9 7 / + 4 8 ) 1 , 7 2 (—100/+50) 4 , 1 5 (—103/+46) 2 , 9 4 (—101,5/+ 48) tabel i gemiddelde middeloordrukwaardes vir timpanogram-optekening van g 220 hz, g 660 hz, β 220 hz en β 660 hz vir drukverandering in beide rigtings. die verspreiding word in hakies aangegee. the south african journal of communication disorders, vol. 24, 977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) timpanometriese ondersoek van middeloorfunksie 65 die rigting van drukverandering het skynbaar 'n geringe invloed op die middeloordrukwaardes uitgeoefen. in alle gevalle is die gemiddelde waarde 'n meer negatiewe of minder positiewe waarde as die rigting van drukverandering van positief na negatief was en andersom, vir die teenoorgestelde rigting van drukverandering. vir indiwiduele proefpersone was dit nie altyd die geval nie. hierdie verskille is egter so klein dat dit nie kliniese waarde kan he nie. die groter verspreiding van die regteroor (fig. 1 en tabel i ) is die gevolg van relatief groot negatiewe middeloordrukwaardes van twee proefpersone, nl. 1 0 0 mm-waterdruk vir proefpersoon 32 en 8 0 mm-waterdruk vir proefpersoon 40. beide proefpersone se oudiogramme was binne normale perke. jerger6 beskou die normale perke as ± 50 mm-waterdruk terwyl bluestone (soos gemeld in harford4 ) gevind het dat 5 0 mm-waterdruk kan dui op 'n abnormale middeloor. s t a t i e s e a d m i t t an se n i m p e d a n s w a a r d e s statiese konduktansie, g, en susseptansie, b, van die middeloor is verkry deur die verskil te bereken van die waardes vir die middeloor in die gespanne (+ of 3 0 0 mm-waterdruk) en die ontspanne (drukwaar timpanogram 'npiekvorm) toestande. indien die gen b-waardes by + en 3 0 0 mm-waterdruk verskil het, is die gemiddelde van die twee waardes geneem. die hoogte van die piek is dus die statiese waarde.13 daar bestaan 'n verskil van opinie oor wysheid van hierdie metode van meting en daar is navorsers wat verkies om die hoogte van die timpanogram te bepaal by atmosferiese druk aangesien hulle voel dat dit die waarde van g en β bepaal wat in die praktyk geld.7 by die meting van hierdie waardes op proefpersone met normale gehoor, soos in"die huidige studie, is daar nie 'n groot verskil tussen die twee metings, nl. by die maksimum van die timpanogram of by atmosferiese druk nie. die gemiddelde waardes van g, β, υ, ζ en 0 word in tabel ii angegee. resultate gepubliseer deur feldman3 en jacobson et al.s word in tabel iii saamgevat. 'n vergelyking van hierdie resultate en die van die huidige ondersoek toon dat laasgenoemde resultate heelwat hoer is. by nadere ondersoek blyk dit dat' die metode wat feldman3 gebruik het om die statiese gen b-waardes te meet, verskil van die van die huidige ondersoek se metode. feldman het die gen b-waardes by atmosferiese druk gemeet en nie by die piek van die timpanogram soos by hierdie ondersoek die geval was nie. die verskil is veral opmerklik by 660 hz. 'n groter ooreenkoms word egter gevind indien die impedans-waardes van die huidige ondersoek vergelyk word met die resultate van zwislocki en feldman soos gemeld in lilly10 en die van feldman3 soos aangedui in tabel iv. die ooreenstemming is hier merkwaardig. die relatief klein verskil in meetfrekwensie kan geignoreer word. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) i. s. hay /̂ s 00 /"s 00 νο m /"s ·> ν κ <3\ <3\ co t> ο, rr> α ιη co in f ν κ ο 00 γm ^ θ\ τ 1 so <3\ ii ο ν ο i in ι ο ι in i so <3\ ii so so cs 00 •ψ. -η γ<"1 co co m vo. ο" ο" 85 ο„ 00 £ ο ο" co m vo. ο" ο ' χ, t3 s i3 s i3 in 13 νο co 00 νο in ε 1 ο ο 00 γο" ε ν νο „ ο , ο σν ορ ri • ω ο ε ο 7 ο νο 00 «7 σν ορ ri • ω ο ο co i 00 i 00 i ^ i οο" i ° £ ο" 8 " ιη <3\ i ο <ν 1 ιη ο" ct ο" ο" m i 00 m ο • 00 • νο 00 m ο • cs <3\ <3\ 00 m ο • νο" ν ε 3 °ί> • £ s m σ\ -ο τ 1 -3 7, 3 ,6 — — 6ι <3\ ο i νο i i in i -3 7, 3 ,6 — — 6ι <3\ vo vo ο co ci m νο. -3 7, 3 ,6 — — 6ι ii •ψ. γ ί ci m νο. ο. 00 ζ ο" ct ο" ο i t-l ο 2 γο νο co 00 <3\ γο •<-» ο ο 00 00 σ\" οβ ο · pc ν νο ο γο οβ ο · pc ε § 7 3 7 i ο -χ ri 00 i in i 00 i cs ο 2 ο {g ο s " ιη " σ\. vo i co 1 in ο ' ο ο" ο in q ο •ψ νο 00 σ\ τ}· in ν νο γο in ε £ οο σ\ 0 0 vo τ 1 q ι ο ri m i | ^ i co i co 1 1 ^ rvo vo (sf _γ ιη ο" ^ co i co 1 1 ^ ii νο. co_ 00 £ lh ct ct ο" ο ο t-| in υ σ\ ο νο in λ ιη <3\ ro" •s j ν ^ r. 00 ο ^ ο 00 •s j ε £ 9 ιη cs 1 § ρ-, ιη ^ 1 σ\ ι vo 1 1 ο 00 i 00 i ^ i ^ 1 σ\ ι vo 1 1 ο ρ: σ\ ^ 1 σ\ ι vo 1 1 ο <ν ο ο" ό ο ' ο vo 1 ο ε ο ε̂ ο ε 1 i ο υ 13 μ t-l 00 ο cq * ν ό <υ •o c λ > -sl μ <a ο js c ω ν ΐλ e c3 ό <υ α, ε α λ •ο μ cq c μ -*-> α, ω s3 3 3 u <α .. &0 <υ c c α c3 ce +j υ ι * c ο r ί ι ! £ 2 00 ce c c '-β λ 5 g ιλ ο, > .a q ό, 2 * ω ο ' 13 ο 2 « § 2 ο ε j ω « < η the south african journal of communication disorders, vol. 24, 977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) timpanometriese ondersoek van middeloorfunksie 67 jacobsonet al. s ( n = 6 0 ) f e l d m a n 3 (n=100) hay (n =96) 220 hz 660 hz 220 hz 660 hz 220 hz 660 hz g (mmho) 0,28 1,7 0,15 1,95 0,301 2,602 β (mmho) 0,58 0,83 0,50 1,30 0,803 1,573 tabel iii gemiddelde waardes van konduktansie, g, en susseptansie, b, vir normale ore impedansie (akoest. ohm) frekwensie zwislocki & feldmanls (n = 66) feldman3 (n = 100) hay (n = 96) 220/250 hz 660/750 hz 1530/—74,1° 521/—41,6° 1856/—69,5° 409/—31,0° 1482/—68,8° 439/—35,2 tabel iv gemiddelde impedanswaardes vir normale ore die vorm van die timpanogram afleidings word van die vorm van die timpanogram gemaak met die oog op die diagnose van middeloorpatologie. in hierdie ondersoek is slegs normaalhorendes gebruik om te poog om normatiewe waardes vas te stel. die variasie wat die vorm van die timpanogram betref, is egter so groot dat feitlik alle vorms wat by verskillende patologiee voorgekom het, waargeneem is. hiervan kan afgelei word dat daar ook vir die normale oor toestande bestaan wat timpanogramme lewer met vorms wat foutiewe diagnoses moontlik maak. tabel v gee die klassifikasie (volgens jerger,6 liden et al.8> 9 ) van die timpanogramvorms wat in hierdie studie verkry is. die getalle dui op die aantal ore wat binne elke kategorie val. die resultate dui daarop dat vir beide g en β by 220 hz byna 80% van die timpanogramme 'n a-konfigurasie het. verhoging van die meetfrekwensie na 660 hz gee vir g 'n toename in die aantal ore wat timpanogramme van die ap-konfigurasie het, d.w.s. 'n meer gedempte sisteem. die effek van frekwensieverhoging op b-timpanogramme, is die toename in die aantal ore met den e-konfigurasie. hierdie konfigurasie word verklaar deur liden et al.9 deur te verwys na die feit dat 660 hz nader aan die resonansfrekwensie van die middeloor is en dat die susseptansie daar hoog is sodat met die oorgang van positiewe na negatiewe druk, die trommelvlies vmmg heen en weer beweeg. 'n ander siening is die van harford,4 nl. dat die d-konfigurasie moontlik die gevolg is van 'n losgekoppelde incudostapediale gewng sodat verandering in die kanaaldruk om en by atmosferiese druk tot gevolg kan he 'n gedeeltelike ontkoppeling van die benige ketting. liden et al.9 het gevind dat 8% van die 182 proefpersone met normale gehoor, tipe d-timpanogramme gelewer het, en hierdie resultaat word bevestig deur hierdie ondersoek (kyk tabel v β 220 hz). vir g 660 hz en β 660 hz word tipe d-timpanogram in 13% en 26% respektiewelik verkry. liden.et a l 9 verbind tipe d met littekens op die trommelvlies. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 68 i. s. hay — » ο ιο ο ο fs \ο η ^ ιο •ί· ιο ο rs 00 fs ν /-ν os κ ο vo vo ο ο 46 47 32 28 ο ο rs ό σ> ο ii ζ βί χ co ιο 00 69 73 m ο ο •τ 00 vo ο j ν s ο rs fs ο t̂ os t̂ ο ο •τ ο ο \ο ο 00 ο ο cn ο ο η ο 00 rs νο ο rs ο ιο ν s ο fs fs 00 ο fs ίιο /-ν os •τ ο vo ο rs fs m ο fs ο ο ii ζ \ο •ί· fs ιο ο fs •τ ο μ ο μ υ η fs \o m νο ο 1· ο χ ν s •τ t̂ m ο rs ο ο rs fs ο rs fs ο m ο f̂ l ο ο fs fs 1· ιο ο fs ο ο η ο m 1· ο ν s 1 m fs ο ο •τ rs ο «ο /-ν rο m fs ο ιο ο ζ •τ rs fs ό ο ο ιο ο ο μ ο .5 1-1 ο ο μ ο .5 1-1 η m m ο •τ ο ο ο μ ο .5 1-1 ν ε ο 1· fs m ' νο ο ιο ο rs rs rs rs ο 1· ο •τ m ο ο ο•τ 00 ιο ο 1 ο ο1 t ip e t im pa no gr . vi < < «ρ η u q ω < .s s ό j ο > c < •u •o 3 = g-s ^ t-h u ω 2 « ό ' s ε ε ε .2 ι ξ π rt υ λ ι ε + υ s υ <υ > ^ > crt •ο s rt υ 2 ό ό 'ε ο αο 3 •s > ab c ο .a s 2 ό ό ι e = 1 5 rt (λ s s a 5 «1 γλ ω 3 — 60 ia 1-2 ε π c „ c e ta η u * c 3 2 -s c .2 ο o s u ο ο λ (τ) (τ) ε u .· • ~ o. a s i a a ό rt ε λ ό u, top ed ο ο > ο e c .5 .ire ο s rt o. .§ η s o. u g ο η ε·5 υ « "2 ε α s 3 ε 5 ε ω ^ ολ ·° .s -a s s μ μ ο © ο ο ο ο ε .ε c c ο ό co (q μ > > 60 60 ω ω .5 .2 ' f t f t s s c c ό ό ω ω c c 0/5 (λ α α δ μ 3 ^ — hh fch . s s q q < < < β u q ω μ <υ οο <υ , ό c <υ > <υ •3 τλ c <υ ,ορ ~ο > ο > ε η 1-4 οο ο c η α, <υ •3 α η £ η α ζ <υ 1-4 ο α α < > η-ι η η < η r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) timpanometriese ondersoek van middeloorfunksie 69 die implikasies van bogenoemde resultate, is dat foutiewe diagnoses gemaak kan word deur tipe d-timpanogramme te koppel aan dislokasie van die benige ketting, veral by 'n meetfrekwensie van 660 hz. hierdie feit word verder gestaaf deur die werk van van huyse et al. 1 4 wat 'n wiskundige verklaring voorle vir die mof w-patroon. volgens hulle kom die patroon voor wanneer daar die regte kombinasie van druk, admittansie en frekwensie bestaan: timpanogram tipe ag kom wel voor by alle toestande, maar veral by g 220 hz, β 220 hz en g 660 hz. slegs een oor het 'n tipe a-timpanogram gegee by β 660 hz, maar daar moet gemeld w ord dat by hierdie toestand ongeveer 26 ore tipe d gegee het waaronder ingesluit was timpanogramme met pieke wat vergelykbaar was met tipe ag. timpanogram tipe β is nerens waargeneem nie, hoewel heelwat van die aqtipes timpanogramme baie plat verloop het met 'n geringe piek of hoogtepunt. timpanogram tipe c het wel in enkele gevalle voorgekom (tabel v) en in een geval met 'n middeloordrukwaarde van minder as 1 0 0 mm h 2 o. hoewel al die ore deur 'n onk-arts as normaal gesertifiseer is, kan daar tog 'n paar ore gewees het met 'n geringe disfunksie van die buis van eustachius. ook wat tipe ε betref, is enkele ore gevind met hierdie tipe timpanogram veral vir toestand β 660 hz. hierdie tipe word deur liden et al.9 gekoppel aan dislokasie van die benige ketting. die afleiding kan gemaak word dat timpanogramme van g 660 hz en β 660 hz meer vals positiewe resultate gaan oplewer as g 220 hz en β 220 hz 4 die timpanogram kan dus nie sonder meer gebruik word om middeloorpatologie aan te dui nie. beskouing van die korrelasie tussen die timpanogramtipe en die uiterste gevalle van absolute admittanswaarde (tabel vi) gee 'n duidelike beeld van 'n verband tussen hierdie waarnemings. die proefpersone met lae admittanswaardes het feitlik deurgaans 'n tipe a2"(gedempte) timpanogram gegee, terwyl diegene met 'n hoe admittansie 'n tipe d-timpanogram opgelewer het. hierdie korrelasie bestaan ook vir die konduktansieen susseptansie-waardes. timpanogram-tipe admittansie (220 hz) konduktansie (220 hz) susseptansie (220 hz) proefpersoon nr. (linkeroor) ( x = ,860 ) ( x = ,27) ( x = ,74) 9 a2 ,468 ,17 ,39 11 a2 ,404 ,14 ,34 13 • a 2 ,503 ,20 ,44 42 a 2 ,232 ,07 ,20 35 a2 ,382 ,11 ,33 7 d 1,768 ,43 1,55 15 d 1,571 ,64 1,28 30 d 1,785 ,60 1,51 37 d 2,020 ,61 1,72 41 d 1,817 ,69 1,51 tabel vi timpanogram-tipe en hoogste en laagste admittanswaardes by 220 hz die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 i. s hay 'n verskynsel wat opmerklik was, was die verskil wat daar soms bestaan het, tussen die g-sowel as b-waardes by 'n druk van —300 mm en + 300 mm h2 0 . dit word veronderstel dat beide hierdie druktoestande 'n harde wandholte skep wat 'n meting is van die ekwivalente volume gelyk aan die volume van die eksterne meatus met uitskakeling van die middeloor.4 die rigting van die drukverandering het in die meeste gevalle nie verskil gemaak wat die gen b-waardes by 3 0 0 en + 300 mm h2 o-druk betref nie. die verwagting was dat 'n positiewe druk in die oorkanaal groter gof b-waardes tot gevolg sou he aangesien die trommelvlies na binne geforseer word, maar dit was nie altyd die geval nie. tabel vii gee 'n aanduiding van die aantal ore waar die verandering in g en β met druk kleiner was by —300 mm as by + 300 mm water. hieruit kan afgelei word dat vir g 660 hz was die verandering in g in 11% van die ore kleiner vir 'n druk van —300 mm as vir +300 mm-waterdruk in die oorkanaal. a a n t a l o r e g 220 hz β 220 hz g 660 hz β 660 hz regteroor 1 6 42 1 linkeroor 6 1 35 0 totaal 7 ' 7 77 1 tabel vii aantal ore waarvan die verandering in g en β kleiner was by 'n oorkanaaldruk van 3 0 0 mm as by 'n druk van + 300 mmwaterdruk by g 220, β 220 en β 660 hz is daar slegs enkele ore gevind wat genoemde verskynsel openbaar, met ander woorde, in die meeste ore is die omgekeerde waar, nl. dat 'n groot positiewe druk in die oorkanaal 'n kleiner verandering in g en β gee as 'n groot negatiewe druk. hierdie resultaat stem in 'n mate ooreen met metings wat deur mcpherson et al.1 1 op marmotte uitgevoer is. meting van middeloorimpedansie met veranderde middeloordruk, het getoon dat by 200 hz en +300 mm-waterdruk in die middeloor, die impedansverandering groter is as by —300 mm-waterdruk. (dit moet onthou word dat +300 mmwaterdruk in die middeloor soos deur mcpherson gebruik, ooreenstem met +300 mm-waterdruk in die oorkanaal). mcpherson et al. 1 1 se resultaat by 200 hz stem ooreen met die resultaat van hierdie ondersoek by 220ήζ. hul resultaat by 600 hz gee dieselfde verandering in impedansie by +300 mmen —300 mm-waterdruk in die middeloor, terwyl daar in hierdie ondersoek gevind is dat vir g 660 hz, die verandering in admittansie groter is (vir 80% van die ore) vir +300 mm-waterdruk in die oorkanaal as vir 3 0 0 mm-waterdruk. hierdie toestand kom vir die marmot (volgens mcpherson et a l . 1 1 ) alleen voor by hoe frekwensies, bv. by ιοκηζ. j die verskille by die maksimum positiewe en; negatiewe druk, het waarskynlik te make met die verandering in die meganiese eienskappe van die middeloor the south african journal of communication disorders, vol. 24, 977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) timpanometriese ondersoek van middeloorfunksie 71 wanneer die stelsel ver na binne of ver na buite geforseer word deur hoe drukwaardes.11 'n groot negatiewe druk in die eksterne oorkanaal het tot gevolg die gedeeltelike ontkoppeling van die incudostapediale gewrig (dus groter wrywing en kleiner g) tesame met 'n groter gespannenheid van die trommelvlies en membraan van die ovale venster. 'n groot positiewe druk in die eksterne oorkanaal vergroot die koppeling van die gewrig (groter g) en vergroot die gespannenheid van die membrane met 'n verdere moontlikheid dat die wyse van beweging van die stapes verander soos met groot klankdruk.2 gevolgtrekkings die doel van die studie was om 'n waardebepaling te maak van die waardes van konduktansie, g, en susseptansie, b, soos gemeet op proefpersone met gehoor binne normale perke. verder moes daar vasgestel word of die rigting van drukverandering by die bepaling van die timpanogram van belang was en of die gebruik van 220 hz sowel as 660 hz as meetfrekwensie van waarde is by die bepaling van normale waardes. die volgende gevolgtrekkings kan gemaak word: die g, β, υ, ζ en 0 waardes in hierdie studie verkry stem in 'n groot mate ooreen met die verkry in ander studies,3'5 > 1 5 hoewel daar toegelaat moet word vir die feit dat die piek op die timpanogram waar g en β gemeet is, verskil van hierdie studie. wanneer daar by die piek gemeet word (soos in hierdie studie) is die waardes van g en β en dus y groter as wanneer die meting by atmosferiese druk gemaak word soos in die studies van feldman3 en jacobson et al.5 die meettoestand (g 220, g 660, β 220, β 660) en rigting van drukverandering in die oorkanaal het min invloed op die meting van middeloordruk. daar was wel 'n opmerklike verskil by indiwiduele proefpersone, maar nie sodanig dat dit diagnostics van betekenis sou wees nie. dit is miskien te verwagte dat 'n meganiese stelsel soos die middeloor effens gevoelig sal wees vir die rigting van drukverandering in die oorkanaal veral by die drukwaardes waar optimum beweeglikheid verkry word. ook by die bepaling van g en β het die rigting van die drukverandering in die oorkanaal geen noemenswaardige invloed gehad nie. die vorm van die timpanogram wat aanduidend is van die beweeglikheid van die middeloor bevat by die normale oor tipes van feitlik al die tipes wat verteenwoordigend is van sekere middeloorpatologiee. die gebruik van die vorm van die timpanogram vir diagnostiese doeleindes moet dus baie versigtig geskied. feldman3 waarsku ook hierteen en meld dat 'n trommelvlies met geneesde perforasies 'n beeld kan gee van 'n baie beweeglike sisteem wat die teenwoordigheid van otosklerose kan verbloem. die gebruik van beide die 220 hz en die 660 hz meettoon is veral van waarde wat die vorm van die timpanogram betref. ookhier moet egter 'n waarskuwing gerig word wat die gebruik van hierdie inligting vir diagnostiese doeleindes betref aangesien die voorkoms van tipe d (mof w-patroon) by proefpersone met normale gehoor redelik aansienlik is (26% van 100 normale ore by β 660 hz die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 i. s. hay en 13% by g 660). die toestand g 220 hz blyk meer betroubaar te wees omdat dit die hoogste persentasie (84%) as tipe a gediagnoseer het en die laagste persentasie (0%) as tipe d. die toestand β 660 hz het die laagste persentasie (56%) as tipe a gediagnoseer en die hoogste persentasie (26%) as tipe d. hieruit kan afgelei word dat daar wel met voordeel van die gebruik van gtimpanogramme gebruik gemaak kan word. die timpanogramme van g 220 hz, β 220 hz, g 660 hz en β 660 hz gee gesamentlik 'n beeld van die middeloorfunksie wat nie moontlik is met slegs β 220 hz en β 660 hz timpanogramme wat gewoonlik met kommersieel-beskikbare vapparaat geregistreer word nie. afleidings wat gemaak kan word van die gen b-waardes met die oordrom in die gespanne toestand (±300 mmwaterdruk) kan moontlik van diagnostiese waarde wees, maar hierdie aspek moet verder ondersoek word. verwysings 1. alberti, p. w. r„ jerger, j. (1974): probe tone frequency and the diagnostic value of tympanometry. arch. otolaryngol., 99, 3, 206-210. 2. bekesy, g. von, (1960): experiments in hearing. mcgraw hill, new york. 3. feldman, a. s., (1974): eardrum abnormality and the measurement of middle ear function. arch otolaryngol., 99, 211-217. 4. harford, e. r„ (1975): tympanometry. in handbook of clinical impedance, jerge.\ j. (ed.). american medics corp., new york. 5. jacobson, j. t., kimmel, b. l., en fausti, s. α., (1975): clinical application of the grason-stadler oto-admittance meter. asha, 1, 11-16. 6. jerger, j. (1970): clinical experience with impedance audiometry. arch. otolaryngol., 92, 311-324. 7. jerger, j. (1976): suggested nomenclature for impedance audiometry. in selected readings in impedance audiometry. northern, j. l. (ed.). american medics corp., new york. 8. lid£n, g., petersen, j. l., bjorkman, g. (1970): tympanometry.arch. otolaryngol., 92, 248-257. 9. liden, g., harford, e., hallen, o. (1974): automatic audiometry in clinical practice. audiology, 13,126-139. 10. lilly, d. j. (1972): acoustic impedance at the tympanic membrane. in handbook of clinical audiology. katz, j. (ed.). baltimore, williams & wilkins co. 11. mcpherson, d. l., miller, j. m., axelsson, a. (1976): middle ear pressure: effects on the auditory periphery./. acoust. soc. amer., 59, 135-142. 12. miller, j. m., holmquist, j. (1974): an animal model for study of eustachian tube and middle ear function.scarttl audiol., 3, 63-68. 13. northern, j. l. (1975): clinical measurement procedures. in handbook of clinical impedance audiometry. jerger, j. (ed.). american medics corp., new york. the south african journal of communication disorders, vol. 24, j 977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) timpanometriese ondersoek van middeloorfunksie i 73 14. van huyse, v. j., creten, w. l., van kamp, k. j. (1975): on the w-notching of tympanograms. scand. audiol., 4,45-50. 15. zwislocki, j., feldman, a. s. (1970): acoustic impedance of pathological ears. amer. sp. hear. assoc., monogr. no. 15. our rang ε ft service m e y m e q i m i e i train-ears audiometers hearing aids sound-proof rooms all speech therapy requirements for meedilek w e s t i e m e ( m m s o t m fftvj) l t i telephones: 45-7262 45-6113/4 telegrams: "needlerorg" telejt: 83660 needier westdene mouse 33 durham street raedene johannesburg die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24,1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) f@r © the development of perception ® the acquisition of speech and language skills ® the improvement of motor co-ordination ® helpful texts for therapists © educational toys, books and equipment φ records for auditory training ® catalogues on request © large variety of tests available ply ο play an κ 8 tyrwhitt avenue, rosebank (adjoining the constantia cinema) telephones: 788-1304 p.o. box 52137, saxonwold, tvl. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 3 dysphagia evaluation and management: clinical training, clinical competency and speciality recognition* bonnie j.w. martin** programme director: the evelyn trammel voice and swallowing center director : rehabilitation services department, saint joseph's hospital of atlanta atlanta, georgia, united states of america key words : dysphagia, swallowing disorders, speech-language pathologist, training, intervention an increasing number of speech-language pathologists have become involved in the evaluation and management of patients with swallowing disorders. approximately sixty percent of practicing speech-language pathologists in health care settings throughout the united states are involved in dysphagia intervention according to the 1993 asha omnibus survey (asha ,1995). it has been estimated that nearly 15 million americans suffer from disorders of deglutition that potentially alter their quality of life, rehabilitation potential and survival (simmons, 1986). in addition to increased patient demand impacting on the growing number of clinicians involved with dysphagic patients, consumers (e.g., patients, families, physicians, etc.) have also begun to recognize dysphagia management as a clinical science and the value added patient care service. the majority of dysphagic patients seen in hospitals and skilled nursing facilities have concomitant communication problems that may include disorders of voice, motor speech, language or cognition (martin & corlew, 1990). from a continuity of care arid cost perspective it follows that the speech pathologists! traditionally trained in the function of the neurologic system and vocal tract, also treat the functionally impaired upper aerodigestive tract comprised of structures common to the communication process (martin & corlew, 1990)1 however, speech-language pathologists have met with several challenges in their attempts toward dysphagia intervention with the often medically complex, multisystem involved patient. these challenges include the following: 1. inadequate educational and clinical preparation at the undergraduate and graduate level; 2. lack of methods for completing and measuring clinical competency in the areas of dysphagia management; 3 special patient populations (i.e., pediatric, ventilator dependent, head and neck surgical, tracheotomized) warrant acquisition of specific skills obtained in facilities not available to many student clinicians; 4 most employment opportunities in medical settings require dysphagia training and experience. because only a handful of accredited university programs in the united states offer courses in swallowing function and disorders, clinicians have sought other training alternatives that include conferences and workshops presented by colleagues who have self-acquired clinical experiential expertise, journals and books, or through observation of practicing dysphagia clinicians in medical settings. however, the body of clinicians maintain the sentiment that these methods fail to sufficiently meet the knowledge base and experience required to clinically or instrumentally manage dysphagic patients. these challenges have not only surfaced in the clinical area of dysphagia, but have also presented in other areas of clinical science with expanding knowledge bases. the end result has been the development of specialty recognition programs in specific areas of clinical practice by the american medical association. in addition, health care professions such as dentistry, pharmacy, physical therapy, occupational therapy, and nursing have also implemented specialty recognition programs that encompass competency training, measurement and methods for recognition. the primary incentive of these programs was not to embellish the concept of specialty practice in an age when general practitioners are becoming the preferred health care model, rather to "... ensure the welfare, safety, comfort, and quality of care of the public consumer" (report on the asha ad hoc committee on specialty recognition, 1994). even though the health care reform activities in the united states (e.g., shift to highly managed medical care) has limited the patient's options in their selection of health care providers, specialty recognition provides a vehicle for all consumers, including the individual patient, payers, and in some cases employers to identify clinical professionals with specialty skills that best meet their health care needs. the american-speech-language-hearing association is no exception to the professional organizations that have witnessed an expanding scope of practice among its members because of the evolving body of information that has resulted as an outgrowth of clinical research, experience ** dr. bonnie martin was an invited guest of saslhaand presented workshops on dysphagia at various venues during 1995 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 bonnie j.w. martin and technological advancements. the legislative council (lc) of asha approved a position statement explaining that the scope of practice in the profession has expanded and involves a "... broad range of services offered within the profession" (lc 6-89). position statements and clinical guidelines were developed for several areas of practice that were also submitted to and adopted by the lc. the clinical areas encompassed in these documents included assessment and management of oral myofunctional disorders (asha, 1991a), learning disability (asha, 1991b), language learning disorders (asha, 1982a), minority language populations (asha, 1983b; 1985), mental retardation (asha, 1982b), cognitive communication impairments (asha, 1988), balance system assessment (asha, 1992a), electrical stimulation for cochlear implant selection and rehabilitation (asha, 1992b), cerumen management (asha, 1992d) and dysphagia (asha, 1992e; asha 1991a; asha 1991b; asha 1982a; asha 1982b; asha 1983b; asha 1988; asha 1992a; asha 1992b; asha 1992d; asha 1992e). continued technical advances obviated the need for additional guidelines in the areas of augmentative and alternative communication (asha, 1991c), neurophysiologic intraoperative monitoring (asha, 19920, tracheoesophageal iistulization procedures (asha, 1992c), and vocal tract visualization and imaging (asha, 1992g; asha 1991c; asha1992f; asha 1992c; asha 1992g). most of the position statements and guidelines describe the range of proficiencies, knowledge bases and competencies required for provision of services by a clinician in the specific area of clinical practice (report of the asha ad hoc committee on specialty recognition, 1994). concurrent with the efforts to detail position statements and practice guidelines in specialty areas of the profession, special interest divisions were approved (lc 35-86) in 1987 and implemented in 1991 in an attempt to provide a structure in which asha colleagues with similar clinical and research interests could interact and exchange information. the development of the special interest divisions were one part of a two part initiative established by the ad hoc committee on specialty recognition report in 1986 (lc 35-86). in 1992 the dysphagia special interest division 13 was formed, and grew to be the largest division in the association in 1995. the division has a steering committee that meets periodically, and the entire division is invited to assemble annually at the national convention of asha. a quarterly newsletter is also published that informs the division members of current clinical and research activities in the area of dysphagia, and offers a forum for professional interchange. the second part of the ad hoc committee on specialty recognition report (lc35-86) included development of a plan to recognize individuals demonstrating a particular expertise in an area(s) of clinical practice. several models were developed and considered by the association. in 1992 at the association's convention in san antonio, texas, the ad hoc committee on specialty certification consulted with the special interest divisions' board of coordinators and with selected sids at their membership meetings. the issue of specialty certification was addressed and the study of specialty certification was endorsed. in the context of the dysphagia special interest division 13 membership meeting, participants expressed verbal support of the specialty certification initiatives, but there continued to be concern regarding the limited educational and clinical opportunities available at the graduate level in university speech pathology programs that would assist clinicians in achieving specialty certification in the area of dysphagia. in an attempt to address the issue of limited formal training opportunities raised by the sid 13 members, a task force of the division was formed whose charge was to devise a suggested graduate core curriculum for accredited speech-language pathology programs in colleges and universities throughout the united states. the format of the curriculum includes a basic graduate level lecture course with practical lab and observations, as well as suggestions to instructors for reference materials and clinical practicum. in addition, an advanced level course structured and recommended for individuals who desire further training in swallowing and research in dysphagia was also included. recommended clinical contact hours for the post-graduate clinical fellowship year were suggested. the recommended core curriculum will be reviewed by the sid 13 membership and forwarded to the educational standards board (esb) of asha. this initiative represents a critical step forward toward the enhancement of the theoretical and working knowledge of entry level dysphagia clinicians. in addition to graduate core curriculum and cfy contact hours, the specialty task force also recognized the need for speech pathologists to be able to demonstrate basic clinical competencies in the work setting prior to treating the often medically and behaviourally complex dysphagic patient. dysphagia management often involves relatively invasive methods that have not been traditionally utilized by clinicians in the field of speech-language pathology. also, treatment recommendations and methods can impact directly on the medical status, nutrition, and safety of the patient. further, the health care industry, including third party payers, will demand improved functional outcomes that can only be provided by highly competent dysphagia clinicians. therefore, the task force endorses that the specific work setting establish basic clinical competencies for dysphagia clinicians that may be very specific to the environment and needs of a particular patient population. at the evelyn trammell voice and swallowing center of saint joseph's hospital of atlanta, a model clinical competency training program has been devised and implemented that encompasses training modules, direct observations, supervised and independent contact hours and continuing education vehicles in the areas of swallowing assessment and treatment. in addition, if clinicians will practice in highly specialized areas of the hospital, such as critical care units, the clinician must meet clinical competencies that relate to the medically complex and unstable patient (martin, martin & cobb, 1993). dysphagic patients, particularly those in the critical care setting often present with multisystem dysfunction that impact upon their communication and swallowing status. the physiologic implications of 'whole body sick' on communication and swallowing functions, however, are often poorly understood and neglected when evaluating and planning dysphagia treatment. speech pathologists are traditionally trained in the neurologic and respiratory systems as they relate to speech, voice and language. however, knowledge of body multisystem influences on speech and swallowing abilities is often incomplete. swallowing and swallowing therapy methods have been shown to produce changes in the respiratory system, and these the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 3. 4. provides the highest probability that future changes in the clinical services in a particular area can be accommodated in changes in the competency verification mechanisms applied to the discipline; the model places the burden of responsibility for development and maintenance of the recognition program in the hands of the practicing clinicians (report of the asha ad hoc committee on specialty recognition, 1994). dysphagia evaluation and management: clinical training, clinical competency and speciality recognition changes must be recognized and considered in planning safe and appropriate dysphagia treatments (martin, 1991; martin, corlew, wood, olson, et al., 1993; martin, haynes, mcconnel, o'connor, haring & bouis, 1994; martin, logemann, shaker & dodds, 1993a; martin, logemann, shaker & dodds, 1993b; nishino, yonezawa & honda, 1985; selly, flack, ellis & brooks, 1986; smith, wolkove, colacone & kreisman 1987). further, dysphagia clinicians often evaluate and treat patients in the critical care units who undergo continuous cardiopulmonary monitoring. one purpose of these visual monitoring devices is to allow attending clinicians to modify their treatment plans based on the physiologic responses of the patient during the treatment sessions. this is troubling because the dysphagia clinician typically has not been trained in the basic interpretation of these physiologic visual signals, and leads to intimidation and incompetency in treating the critical care patient. also, the functional status of critical care patients and their ability to tolerate swallowing therapy will vary linearly with their medical status. therefore, the dysphagia clinician should become familiar with the clinical significance of relevant laboratory values, vital signs, pharmacological agents, pulmonary and radiographic tests that are typically reported in the patient's medical record. competency training by dysphagia clinicians in these specialty skill areas has been incorporated into saint joseph's model because of the highly specialized tertiary nature of the facility. the competency training has resulted in elevation of the dysphagia clinicians' clinical insight, skill and confidence when providing care to the medically unstable dysphagic patient. this expertise allows the clinician to begin treatment at an early stage in the patient's recovery, and expedites their return to safe oral intake. demonstration of competency should not only be expected by health care department directors and supervisors, but will be demanded and respected by physicians, patients, family members and other consumers (martin, martin & cobb, 1993). the consumer affairs division of asha also discovered through consumer advocacy group conferences in 1990 and 1992 that consumer groups "strongly supported specialty designations in the j professions as guidance for consumers in selecting providers of services", and appeared to uphold asha's ongoing exploration of the need for a specialty recognition program that goes beyond demonstration of basic clinical competencies as described above (report of the asha ad hoc committee on specialty recognition, 1994). the 1994 report of the ad hoc committee on specialty recognition contains a practitioner-driven model that has been selected as the proposed method for implementing specialty recognition within the asha (report of the asha ad hoc committee on specialty recognition, 1994). the model includes four salient features that highlight maximum participation by practitioners in the field for the development and maintenance of the specialty recognition program, and minimal participation by the central structure of asha: 1. consumer need for recognition of a specialty area can be well defined and justified; 2. practitioners involved in the delivery of services can be responsible for defining the knowledge, skills, and experience requisite to the delivery of services in the specialty area; l the proposed plan as described by the ad hoc committee on specialty recognition maintains a firm commitment to a broad-based practice by the majority of membership, and the concept of nonexclusionary specialty recognition is emphasized throughout the proposal. the plan provides a mechanism by which an individual can be recognized for specialty education experience and expertise, yet assumes that most practitioners will continue to provide broad-based clinical services. the specialty recognition plan is degree independent (report of the asha ad hoc committee on specialty recognition, 1994). because the responsibility for developing the components of the plan has been left to the members of the organization, an additional specialty recognition task force was formed by the dysphagia special interest division 13 in 1995, and a proposed specialty recognition program plan was devised. a draft of the dysphagia proposal will be presented to interested members of asha at the national convention in orlando, florida in december, 1995. the proposed program is highly competency based, and incorporates objective methods for competency measurement. in the plan proposed by the ad hoc committee on specialty recognition, a formal petitioning group submits the final dysphagia specialty certification plan to a clinical specialty board (csb), and a commission on dysphagia would be formed if the group's application has met the specialty recognition standards. the specialty commission on dysphagia would be responsible for maintaining the professional process for accepting, reviewing, maintaining, and renewing applications for recognition by dysphagia clinicians (report of the asha ad hoc committee on specialty recognition, 1994). while the dysphagia specialty certification program is in its infancy proposal stage, it represents a hallmark initiative toward the insurance of exemplary quality dysphagia care by recognized professionals who could potentially serve as clinical competency instructors to novice clinicians in the field. improved quality of care, patient outcomes and cost containment result from reductions in variability of practice and increases in standardization of specialty patient care. a comprehensive graduate core curriculum, clinical competency training and specialty recognition are modalities that will ultimately lead to improvement in the standard of care for dysphagic individuals provided by speech-language pathologists. the expanding scope of practice in the field of speech-language pathology is not unique to the united states. professional associations of clinicians from other countries will likely meet similar challenges with the issues of ensuring appropriate education, clinical competency, quality outcomes and specialty recognition. they will need to face these challenges with opportunity by tailoring methods and vehicles to meet the needs of their swallowing practitioners and health care consumers. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 references american speech-language-hearing association (1982a, november). language learning disorders. asha, pp. 937944. american speech-language-hearing association (1982b, august). serving the communicatively handicapped mentally retarded individual. asha, pp. 547-553. american speech-language-hearing association (1983b, september). social dialects (and implications). asha, pp. 23-27. american speech-language-hearing association (1988, march). the role of speech-language pathologists in the identification, diagnosis, and treatment of individuals with cognitivecommunicative impairments. asha, p. 79. american speech-language-hearing association (1991a, march). the role of the speech-language pathologist in assessment and management of oral myofunctional disorders, asha (suppl. 5), p. 7. american speech-language-hearing association (1991b, march). learning disabilities: issues on definition. asha (suppl. 5), pp. 18-20. american speech-language-hearing association (1991c, march). augmentative and alternative communication. asha (suppl. 5), pp. 9-12. american speech-language-hearing association ad hoc committee on advances in clinical practice (1992a, march). balance system assessment. asha (suppl. 7), pp. 9-12. american speech-language-hearing association ad hoc committee on advances in clinical practice (1992b, march). electrical stimulation for cochlear implant selection and rehabilitation. asha (suppl. 7), pp. 13-16. american speech-language-hearing association ad hoc committee on advances in clinical practice (1992c, march). evaluation and treatment for tracheoesophageal fistulization/ puncture. asha (suppl. 7), pp. 17-21. american speech-language-hearing association ad hoc committee on advances in clinical practice (1992d, march). external auditory canal examination and cerumen management. asha (suppl. 7), pp. 22-24. american speech-language-hearing association ad hoc committee on advances in clinical practice (1992e, march). instrumental diagnostic procedures for swallowing. asha (suppl. 7), pp. 25-33. american speech-language-hearing association ad hoc committee on advances in clinical practice (1992f, march). neurophysiology intraoperative monitoring. asha (suppl. 7), pp. 34-36. bonnie j.w. martin american speech-language-hearing association ad hoc committee on advances in clinical practice (1992g, march). vocal tract visualization and imaging. asha (suppl. 7), pp. 37-40. asha omnibus survey, personal communication from herb bauma, asha, february 27, 1995. martin, b.j. w. (1991). the influence of deglutition on respiration. doctoral dissertation, northwestern university. martin, b.j.w., & corlew, m.m. (1990). the incidence of communication disorders in dysphagic patients. journal of speech and hearing disorders, 55, 28-32. martin, b.j.w., corlew, m.m., wood, h., olson, d., et al. (1993). the association of swallowing dysfunction and aspiration pneumonia. dysphagia, 9 (1). martin, b.j.w., logemann, j.a., shaker, r., & dodds, w.j. (1993a). normal laryngeal valving maneuvres during three breath hold maneuvres: a pilot investigation. dysphagia, 8, pp. 11-20. martin, b.j.w., haynes, r., mcconnel, f.m.s., o'connor, α., haring, k., bouis, h. (1994). breathing and swallowing interrelationships. dysphagia research society meeting, mclean, virginia, october 14, 1994. martin, b.j.w., logemann, j.a., shaker, r., & dodds, w.j. (1993b). the coordination between respiration and swallow: respiratory phase relationships and temporal integration. journal of applied physiology, 76 (2), pp. 714-123. martin, b.j.w., martin, e., cobb, r. (1993). critical care competencies for dysphagia clinicians. short course presented at the annual meeting of the american speechlanguage-hearing association, anaheim, california. nishino, r., yonezawa, r., & honda, y. (1985). effects of swallowing on the pattern of continuous respiration in human adults. american review of respiratory disease, 132, pp. 12191222. report of the asha ad hoc committee on specialty recognition, august, 1994. selly, w., flack, f„ ellis, r. & brooks, w. (1986). respiratory patterns associated with swallowing: parti. the normal adult pattern and changes with age. age and ageing, 18, pp. 168172. simmons, k. (1986). dysphagia management means diagnosis, exercise, re-education. journal of the american medical association, 255, 3209-3210, 3212. smith, j., wolkove, n., colacone, α., & kreisman (1987). coordination of eating, drinking and breathing in adults, chest, 96, pp. 578-582. ο x m play a n d s c h o o l r o o m i i ο x m shop 6l the rosebank mews 173 oxford road rosebank jhb. i phone 788-1304 fax: 880-1341 tests, programmes, books, teaching aids, journals and resources for child development speech & language learning disabilities special needs adult rehabilitation social activities po box 52137 saxonwold 2132 the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 harsha kathard, mershen pillay, michael samuel and vijay reddy genesis of self-identity as disother: life histories of people who stutter harsha kathard*, mershem pillayi, michael samuel 0 amd vijay reddyd •division of communication sciences and disorders, university of cape town, south africa $sheik khalifa hospital, abu dhabi, united arab emirates ° school of educational studies, university of kwazulu natal, south africa nhuman sciences research council, pretoria, south africa abstract this paper explores the processes shaping self-identity formation as disother and the actions of participants who stutter. it illuminates the experiences of adults who stutter using a biographical, narrative, life history methodology. the participants were seven south african adults of diverse racial, social and economic backgrounds from kwazulu natal, south africa. five males and two females were invited to participate via purposive and convenience sampling processes. their stories of living with stuttering in their life worlds over time were constructed via biographical interviews using personal, social and temporal lenses typical of life history methodology. the interviews were audio-recorded and transcribed. the data were analysed at two levels using a combination of strategies. the first level entailed a narrative analysis that was represented as research stories for each participant. the cross-case and thematic analysis of research stories constituted the second level analysis of narratives. the findings explain the complex and interrelated personal and social processes over time which contribute to the genesis of self-identity formation as disother. social inscriptions of difference occurred in immediate home, school and work contexts over time via multiple processes such as labelling, norming, judging and'teasing. personal processes included discoveries of difference via critical events, repeated reinforcement of difference, self-judgement and temporal burdening. furthermore, the actions participants took in negotiating stuttering were examined. the implications of the findings and limitations of the study are presented. key words: self-identity formation, disother, people who stutter, life history. introduction this paper illuminates the processes shaping self-identity formation as disother of participants who stutter and their actions in relation to their self-identity, using a narrative life history methodology. the term "disother", constructed by pillay (2003), was appropriated in this paper to refer to an individual's understanding of himself as problematically different because he/she stuttered. the term was derived from two sources. firstly, the term "other" refers to instances when an individual manufactures himself as problematically different in a particular context (boehmer, 1995). it carries a meaning of an individual feeling he/she has intrinsically less value. secondly, the prefix "dis" refers to instances where the individual feels different, threatened, destabilised and disempowered on the basis of his disorder, in this instance, the disorder being the stutter. the rationale for this study emerged from two central concerns. firstly, there has been limited research on the personal and social dimensions of the stuttering experience. quesal (1989) challenged the professions' researchers for a lack of engagement with the core psychosocial and personal concerns of people who stutter (pws) in an article aptly titled "have we forgotten the stutterer?" he argued cogently that as a consequence of difficulties in quantifying psychosocial factors these issues were being interpreted as a lack of reality, that is, if we can't count or measure it, it does not exist. over time, the importance of personal experience research has been recognised and research on varied dimensions has gathered gradual momentum (corcoran & stewart, 1998; crichton-smith, 2002; die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 51, 2004 kathard, 2003; petrunik & shearing, 1983; sue-o'brien, 1993). research on dimensions of self and stuttering viz. on selfconception and self-esteem has been a source of professional research interest over time (green, 1997; green, 1999; kalinowski, lerman & watt, 1997; van riper, 1982; yovetich, leschied & flicht 2000; zelen, sheehan & bugenthal, 1954). while these studies have examined varied dimensions of selfconcept, they have not researched the processes shaping selfidentity formation over time. furthermore, they differ methodologically from this study because they relied on quantitative methodologies to understand varied relationships between self-conception and severity (green, 1999) and assessments of self-esteem (yovetich, leschied & flicht, 2000). green (1999) however, suggested that complex relationships between environmental, personal and behavioural factors influencing the self-conception of children could be enhanced by drawing on experience histories of pws. this study expands the methodological toolbox by introducing narrative biographical methodology in exploring self-identity formations over time. secondly, the profession of speech-language pathology has the responsibility of intervening with pws and requires a relevant personal experience knowledge base to inform intervention. adults who stutter, like all people with communication disorders, present a challenge to the clinician'because they bring a lifetime of experiences into the clinical relationship. interaction with the client's life experience is an important prerequisite for intervention (bloodstein, 1995; van riper, 1982). the limited research thus far could be attributed to the methodological tradition of the profession that has relied r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) genesis of self-identity as disother: life histories of people who stutter 5 primarily on positivist, quantitative and experimental designs (mowrer, 1998; perkins, 1997; pillay, 2003). silverman (2001, p. 4) provides a succinct critique of how the research outcomes within a positivist frame have (not) served clinical practice: the fact remains that people seeking help with stuttering problems are just that people. and the information that therapists have from those conducting research and writing books i.e. the means, standard deviations, etc. simply don't address that fact very well. the method of science with all its assumptions about reality from a human perspective including the need for objectivity of the so-called observer, linearity of experience and the uses of inferential and descriptive statistical analyses to interpret observations simply can not, at this point in space-time, generate information completely useful to modify behaviours of multitasking, complexly functioning human beings. personal, more than impersonal, knowledge is required to inaugurate, modify, stabilise and maintain behaviour change. narrative methodologies are robust ways of researching experience (plummer, 2001) because stories best facilitate researchers' understanding of experiences (clandinin & connelly, 2000). sacks (1995, p. 25) explained the value of the self-story in understanding how people live with an impairment/ disorder and the actions they take, "ask not what disease the person has, but rather what person has the disease." the answer to the first question is a monological chart (about disorder/ impairment). the answer to the second question will always be a story. unlike disease, no two people will have the same story. he proposed that the study of identity and disease/disorder could not be separated in personal experience research. researchers therefore should attend to the important "who am i?" question as a basis for understanding how the person makes sense of his/her worlds and how he/she acts. life history methodology1 is useful in exploring selfidentification formations because it admits the personal, temporal and social dimensions of experience. it attends to the critical temporal dimension 'of self-identity formations by considering the changing life cycle of the individual to be taken as'a single unit of study (hatch & wisniewski, 1995). it foregrounds the connection! of the experience to social circumstances and positions the participant as an active storyteller, thereby allowing for an explanation of social action from a personal perspective. : there are many theoretical debates about the notion of self-identity which are beyond the scope of this paper. therefore, the theoretical frame adopted in this study is presented here. self-identities only become identities when people internalise them (mishler, 1999). therefore, the concept of self-identity must be differentiated from roles and role-sets. while people may have many roles, identities are sources of meaning that actors construct for themselves through processes of individuation. although identities may coincide with roles, identities are stronger sources of meaning (castells, 1997). self-identities are always in a state of process, of "becoming" (mishler, 1999). the term "formation" was chosen to reinforce the process orientation of the self, past, present and future. it shifts away from the stage model of development which have traditionally enforced a rigid, orderly universal ά fuller explanation of the application of life history methodology can be found in kathard 2003. and progressive understanding of self-identity formations. identities have the capacity to be stable or flexible over time (valsiner, 2002). the process of narrative self-identity formation occurs by drawing together the overlapping cognitive, emotional, temporal, · relational, macro-structural, cultural, institutional, and moral dimensions, i.e. the personal and social influences (somers, 1994). social psychology theorists (howard, 2000) have emphasised issues of ethnicity, gender, class, age, disability, race, and geography in shaping self-identity formation. societies are multiple, fluid and changing and it is within this relational social matrix that self-identities form. within the relational matrix, the impairment/bodily dimensions (in this instance stuttering) are socially interpreted. in traditional medical science, disorders have been studied without the self. the notion of self-as-embodied however, humanises the body and dissolves the traditional boundaries between body/impairment, self and society. when impairment or disorder exist, people with disabilities (pwd) are constructed as an epistemological "other" (perry, 1996) at the social interface. goffman's (1963) theory on spoiled identity has been used to understand experiences of disability or "otherness". a person who is stigmatised is a person whose social identity or membership to some social category, calls into question his or her full humanity the person is devalued, spoiled or flawed in the eyes of others. "othering" (fine, 1998) does not occur only on the basis of impairments, but also on dimensions of race, gender, sexuality, class or education. however, in research with disability there has been a tendency for the emergence of neat, clean and categorical understandings of identity foregrounding disability. such understandings mask the complexity of identity formations in pwd. in the light of such social complexity the moral impulses of self-identity formations must be understood against the backdrop of societal norms and values. frank (2002) emphasised the importance of listening to the moral impulse of the self-story because self-identity formations are reflective of the social-moral debate i.e. who am i? and what it means to be good or bad in a society. it would also seem important to explore how participants negotiate stuttering in relation to their selfidentity formations. "i act because i am" suggests that the actions of individuals should be linked with their identity formations. it was also of value to understand why people act as they do and to guard against limiting understanding to universalist, essentialist notions (somers, 1994), for example expecting that all pws will act the same way. this stance makes provision for participants with impairment to be understood as agentic (frank, 2002), in contrast to passive, pathology-based stereotypic views. method aims the aims in this paper have been extrapolated from a larger study. in the study, the self-identity trajectories as able/potential and self-identity as disother emerged i.e. participants understood themselves as able and as disother. this paper is limited the south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 harsha kathard, mershen pillay, michael samuel and vijay reddy to the exploration of processes of self-identity formation as disother and thus the aims were: 1. to explore the processes over time shaping self-identity formation as disother of participants who stutter. 2. to illuminate the actions of participants in the context of their self-identity formations as disother. participants participants in the main study were required to be adults (over 18 years of age) who had stuttered since early childhood, as the intention of the study was to explore the experiences of stuttering over their life courses. they had to be willing to share their stories in a voluntary capacity and indicate their commitment to participate in a process requiring prolonged engagement. furthermore, they were required to have information rich stories (plummer, 2001), and english as a functional language of communication. the researcher was english-speaking and because the interview process required close and interpretive communication, it was felt that a shared language between participants was essential. participation was invited through a combination of purposive and convenience sampling procedures. participants were recruited via local hospitals, private practices, the university, and the local stuttering self-help group. of the 10 people sampled, 7 met the criteria for selection. the profiles of participants are summarised in table 1. the information reflects the status of the participants at the time of the study. the severity of stuttering was determined by participants' self-rating of stuttering severity at the time of the interview. data production the data was produced via interviews with each participant. at the outset,the nature of the research process, voluntary participation and withdrawal, communication (for example, conversational repair strategies, formality of the conversation) and confidentiality were discussed. the management of power imbalances inherent in the research context was negotiated with participants with the intention of developing a respectful research relationship (measor & sykes, 1992). the process commenced after participants had a full understanding of the research process and had consented in writing. a semistructured, open-ended life history interview schedule was constructed to support the interview. in narrative research, the researcher features as an instrument (hany, 1996) and it was necessary for the researcher to be reflexive and critical (peshkin, 2001) about how she was influencing the data production process. this process was monitored by peer critique and reflective memo-writing (charmaz, 1995). in particular, the researcher had to be cognisant of the need to be non-judgemental and to appreciate the uncertain nature of the interview process. a panasonic mini-cassette tape-recorder (rq-l30) was used to record all interviews. the interview process unfolded differently with each participant. in general, the initial session was used to establish rapport and to place the interview within the context of the study. in subsequent sessions, participants were asked to relate their stories beginning with their early experiences of stuttering and how they acted. a strict temporal line was not pursued because participants moved back and forth through their experiences. the process was deliberately open to allow participants to select the issues and events they felt were most important. the researcher probed these aspects further using matrix-type probing techniques to explore critical interfaces between the personal, temporal and social dimensions of experience. it was necessary to constantly monitor the potential for power imbalances in the interview and to create a discursive space in which participants felt comfortable in sharing their stories. the interview process was considered to be an interpretive conversation (josselson, 1995; fine, 1998) in which the researcher and participants were engaged in a process of joint meaning-making. this conversation required an empathetic listening and "sensing" and "connecting" (kathard, 2003) with participants. each interview lasted for approximately two hours and the total interview time for participants ranged from 6 hours to 10 hours. participants were each interviewed an average of three times. table 1: biographical profiles of participants participant gender age residential area race severity of stuttering therapy occupation / education | gareth male 65 durban white mild yes retired architect; , university hennie male 29 pinetown white moderate to severe yes accountant; university siyanda male 32 inanda black moderate no director: arts association; high school: standard nine thabo male 19 ashdown black severe yes university student kumari female 36 shallcross indian mild no accountant; university ' sagren male 32 pinetown indian moderate yes manager; university nontokozo female 20 umlazi black severe yes university student die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ^ genesis of self-identity as disother: life histories of people who stutter 7 data analysis each interview was transcribed verbatim from audio-tape recordings for each participant. the accuracy of the transcriptions was checked by the researcher and a research assistant to ensure the actual words spoken were correctly transcribed especially when speech intelligibility was influenced by a stutter. the written transcripts constituted the data and were subjected to analysis. given that the written transcription can never be a faithful copy of the interview (kvale, 1996), the researcher interacted with the written transcriptions as well as the audio recordings and memos. the data analysis was conducted at two levels. the first level entailed a representational narrative analysis (freeman, 1996; polkinghome, 1996). in narrative analysis, the raw data are configured by means of a plot into a story, thereby moving from elements to stories to explain a particular end. the product reflects a temporal ordering in which each part is given meaning via its reciprocal relationship with other parts, before and after, and to the whole. the plot facilitates the composition of events into a story (polkinghome, 1995) by: • clarifying the meaning events have as contributors to the story; • providing criteria for the selection of events/issues to be included; • delimiting the temporal range which marks the beginning and end of the story; • providing temporal ordering and unfolding of events leading to a conclusion. this level of analysis was represented as a research story for each participant. the second level of analysis involved a mixed strategy (reddy, 2000) of grounding the analysis within the individual case as well as constant comparisons across cases. an iterative strategy of analysis was used (charmaz, 1995). the researcher moved backwards and forwards between the interview data, i research stories and emerging categories on a continuous basis to generate constructs and themes. two processes of validation were used in the study viz. substantive and ethical validation. substantive validation was concerned with issues of trustworthiness and goodness of interpretive research (angen, 2000) and required consideration of issues like suitability of methodological choices, credibility, dependability and authenticity trail (creswell & miller, 2000; lincoln & guba, 1985). in contrast, ethical validation was concerned with the moral issues the researcher must entertain. this study utilized lincoln and guba's (1985) guidelines to enhance substantive and ethical validity. • member checking was used during the interview process to confirm technical details, obtain clarity on particular issues and to verify the researcher's interpretation of the story. participants also had access to the transcripts and were provided with two versions of their research stories. they were invited to comment on the trustworthiness of the representation of their stories and their comments were taken into consideration in further revision of their research stories. • prolonged engagement (plummer, 2001) ensured that the data was collected in a rigorous manner. this engagement included a few indepth interviews which totalled several hours as well as ongoing consultation with participants over time, extending over a year. • peer debriefing and critique was done by two research colleagues with speech-language pathology backgrounds, and one researcher with life history research experience. they were familiar with the study and provided guidance throughout the research process to ensure that it was rigorous, fair and thorough. • thick descriptions of empirical data were provided and represented as research stories. thick descriptions capture detail, density and depth to create a sense of verisimilitude so that the statements and stories can bring the experience to life. the reader then feels as if he/she could experience the events being described (charmaz, 1995; plummer, 2001). • procedural dependability was ensured via an audit trail analogous to a fiscal audit. all aspects of the research process were monitored by two peers (life history researchers) external to the study to confirm that the research process was systematic and rigorous. ethical validation addressed potential power imbalances during the research process. the fairness criterion (lincoln & guba, 1985) attempted to ensure that the interview process was fair, that voices were not demeaned, silenced and that the potential power held by the researcher or participant was restrained. the research study received ethical clearance from university authorities and informed consent was obtained from participants after clarifying issues of confidentiality, voluntary participation, withdrawal, risks and benefits. member checking, open communication and self-critique characterized the interaction to enhance ethical validity. a counseling support system, external to the research process, was available if participants felt the need for support. as every research process has potential to touch the participant in some way, there was a vigilant effort to reduce harm (frank, 2001). results and discussion the presentation is arranged in relation to the aims of the study. the data are represented as excerpts from the biographical research stories of participants. the emerging issues included: ·. discovering difference and the emergent self-identity as disother ° processes of strengthening, reinforcing and sedimenting self-identity formation as disother • negotiating self-identity as disother (action) discovering difference and emergent self-identity as disother all participants in this study began to stutter during the preschool years with the onset of stuttering occurring before 6 years of age and with differing degrees of severity. the primary intention was to examine the circumstances through which participants began to discover themselves as different. critical incidents and contexts for discovering difference i remember the first day i discovered the stutter. this happened when i was in grade two, about seven years old. i was the south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 harsha kathard, mershen pillay, michael samuel and vijay reddy table 2: incidents and events leading to the initial discovery of self as different participants critical events and primary contexts age: discovering difference age: onset of stuttering siyanda school: teacher punished him for not speaking on cue 8 3 kumari home: child abused by alcoholic father, was silent and then stuttered. she understood stuttering as a sign of fear and disempowerment 4 4 gareth home: parents' extreme concern at a young age about speech fluency 4 3 sagren home: early concern at home about poor speech development 3 3 thabo school: mocked by class mates when unable to read 7 4 nonthokozo school: critical incidents of feeling different within a new school environment and referral for treatment 13 5 hennie school: high school years: adolescent identity questioning 12 5 reading a book in front of the children in class. i was very shy and nervous and as a result i started stuttering suddenly. the children started to laugh. at that moment i wished the ground would just open so i could get under it and die. i was so very hurt that i nearly cried too. at first i didn 't even know what the stutter was. i didn't even know why they were laughing. that was the beginning of my nightmare. before that day i knew nothing of the stutter. no one at home said anything about it. (thabo) at home, the way we spoke, with our stutter, wasn't a problem. outside home it was a different story. i was about eight years old. we went to school in umlazi, an african township, in the 1970s and the rules were strict. one of the english teachers asks a question. if you don't know the answer then you stand up. he asks me a question. i am in the process of a stutter. i am trembling and i can't get it out. he hits me. that is my first memory when i was punished for not answering a question on time because of the stutter. i broke the rules. (siyanda) i started to stutter when i was young, around three or four years old. i was a very sensitive little chap and remember my parents worrying about my speech. i knew something was wrong. i suspect it was bad from early on. they said the usual fatherly and motherly thing like "slow down, take your time". i was aware of the stuttering at that stage but i don't think i was too troubled by it... at the time, on some occasions there were these verbal collisions at home. my parents, both of staid english backgrounds, were a difficult match. so, a degree of collision took place.! when these mws were on, for me, a sensitive little boy, it was like the end of the world. i don't know how it was for my older brother. those collisions made more of an impact on me then, than did my faulting speech. (gareth) i started talking very late, when i was four years old. girls normally speak early but i didn't. there was a reason for this which only i know. my family wondered what was going wrong. they thought i might have a problem with my ears or tongue or brain. they were wrong. it was fear, a gruesome, monstrous, all-consuming fear that silenced me. i never spoke for four years. when i did, it came out ssssstuttering. fear caused my stuttering. the fear was like venom, which spread quickly to every part of me, every crevice of my mind, body and spirit. a deep-seated ugly, emotional fear. i tried hard to shrug off but it still lurked in me, unrelenting. what caused this fear? the man of the house, my father. (kumari) i always had a small stutter but the problem started in high school in 1982. my parents sent me to a convent boarding school. this was a very big change for me. i didn't want to go there. everything was so strange. the school was run by white german nuns. the nuns were very strict. we follow rules. they spoke english. we were black, zulu speaking girls but only allowed to speak english. you couldn't go off the school premises. i was free before. wake up early. walk in a straight line. behave like girls. sleep early. i was sad and out-of place and the stutter became very severe. from a hiccup i went to having big, long blocks. (nontokozo). the narratives revealed that the contexts for discovering difference were their homes and schools, their immediate living contexts. parents, teachers and peers drew attention to stuttering as being different to normal and as a disorder by reacting to it in a negative way. the incidents ranged from casual correcting to mocking and had variable impacts on participants who then began to create initial understandings of themselves | as different. although these critical incidents were varied in nature across participants, they remained robust and were imprinted in participants' memories. as a consequence, they had a pervasive influence on participants' discoveries of themselves as different and began to shape their self-identity as disother. the social processes and interpretations of stuttering were not consistent between and within stories. for example, siyanda's and thabo's experiences of stuttering at home were different to that of school. in kumari's story the trend was reversed. these experiences highlighted that stuttering was not interpreted and acted on uniformly across contexts and that there were multiple interpretations of stuttering within a single life experience. however, it was also apparent that despite the varying and competing interpretations'of stuttering, participants eventually gained an understanding of themselves as different by their adolescent years. the negative interpretations were die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) genesis of self-identity as disother: life histories of people who stutter 9 conveyed to them through a variety of social responses which suggested that it was wrong to stutter that they had broken rules that they were different. there was variation in the ages at which participants discovered themselves as different (table 2). while five participants in this study began to understand themselves as different at an early age, 3 to 8 years of age during the primary school years, two (hennie and nontokozo) were aware of their speech being different but did not attach strong meaning to themselves as different until adolescence. this trend suggested uneveness in their biographical circumstances and that varied contexts and processes contributed to initial shaping of their self-identity as disother. importantly, the onset of their stuttering i.e. the presence of impairment and the development of a self-identity as disother did not coincide. stuttering in itself was therefore not sufficient to begin to construct themselves as different. the impairment/disorder must receive a (negative) social interpretation to shape one's self-identity as disother. fertile ground for discovering difference: complex realities and vulnerable selves the stories also revealed that for some participants (gareth, sagren, kumari, nontokozo) the circumstances for discovering difference were complex. within these realities, participants were potentially vulnerable and "powerless" to varying degrees. kumari in particular, attributed her silence and subsequent stutter directly to her sense of vulnerability and fearfulness as a child in an abusive environment. she explained stuttering as a symptomatic manifestation of fear of her abusive father. similarly, gareth had a heightened sense of being vulnerable and "at-risk". a similar set of circumstances emerged in sagren's story. siyanda, thabo and nonthokozo were relatively powerless in difficult school contexts. biographical suicide (samuel, 1998) describes nontokozo's context of feeling vulnerable. there was a devaluation and obliteration of her history as she was ̂ expected to take on the values of a powerful and dominant new system alien to her. in this context she felt vulnerable and "less than". these interplay of circumstances contributed to an exacerbation of stuttering through which she formed her selfidentity as disother. | the participants' "fragility" amid these difficult home and school environments created fertile ground to develop a selfidentity as disother. it is possible that another child, such as their siblings, with a different personal makeup, may not have been influenced in a similar way in the same situation. it is equally possible that the same child in another context might not have been as vulnerable. hence, the combinations of their vulnerable "at risk" selves embedded in difficult social contexts contributed to their early understandings of being different. reinforcing, strengthening and sedimenting self-identity at school... the threesome, the principal, the nurse and the school inspector. society watchdogs! we knew what they were looking for, all the misfits, all the problems. maybe they would forget about me. then they start: come to the front when we call your name and problem: mcdonald and hastings headlice, smith can't see well, lovemore cripple, blake stutterer. i just want to disappear into the ground. is this all they know about me? hey, remember i came second. they fill out the forms. i remain silent. powerless. they make it unbearable. everyone knows i am a stutterer but this is a painful public display. when you are young the last thing you want anyone to say is that you are different or you have a problem. nothing came of that incident but i did eventually get to therapy. she tried to help but i hated it because it intruded on all the joys... my sport and all that stuff... i was just fed up with it... just relax, relax... it didn't do me any good. it just emphasised my difference and that i didn 't speak well. (gareth) at high school i was still being teased. i could never say my name or answer a question without being stuck. there was the one time when we were all assembled at the beginning of the year so they could place us in new classes. the teacher calls the names of each child. she calls my name. silence. i have a block at the end the numbers don't tally and the principal wants to know where the problem is. the teacher whispers to him that i stutter. he announces loudly that she must ask me questions everyday so i get used to speaking. i am sure he was trying to help but i felt really embarrassed and it made the situation worse forme. (sagren) the teachers at school noticed my speech. everyone knew the problem. they didn't say anything. they left me to finish what i was saying. it got bad so they arranged a speech therapist for me. i went to therapy at the convent attached to the school. i was happy to go. she taught me to prolong the first word to make my speech fluent. the girls in class would laugh at me so i stopped doing it. they thought this new speech was funny. i stopped going to therapy after a few months. (nonthokozo) workplace... they are hard-nosed business executives. they are the allknowing, economically-driven, powerful, white and rich men. i am going to help get them richer. if you area rep, people don't specifically buy your product but they buy you. it's all about the packaging and presentation. how do i then sell my product. my product is me. i have to sell me in this business i want to own. i'm not really marketable because of the stutter and that's the problem. they will never take someone who stutters seriously. as soon as i stutter they will think i don't know my stuff (hennie) media... the interviewer wasn't knowledgeable and she didn't listen. sagren and i answered the questions. she interpreted the answers and produced a ghastly newspaper article. it conveyed the picture that we were sort of imbecilic and groped for words and had veins sticking out of our necks. of course our veins stick up! but she just conveyed us as poor, poor people with a problem. i read it and didn't like it. although it was redone it still conveyed us as a breed of poor fellows. it was her story and she heard very little of ours. since then i decided i won't talk to the media. (gareth) ongoing social inscriptions of difference: school, media and professional: authorising difference the contexts in which participants continued to strengthen their self-identities as disother over time included the home, school and work contexts. these repeated incidents provided the south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 harsha kathard, mershen pillay, michael samuel and vijay reddy impetus for strengthening their otherness. the media was implicated because it publicly portrayed negative images of pws and stuttering. the school as context was significant because participants spent, a minimum of twelve years at school. here their self-identity as disother was reinforced by negative experiences which included: identifying and authorising one as different; judging, evaluating, punishing and teasing within the school community; negative evaluations by teachers and "low marks" for oral work; referrals for treatment by school authorities. the school as community, as an ann of society, repeatedly inscribed stuttering as a problem over time. within a foucauldian (1977) interpretation, the school, among its other functions, also performed the task of surveillance via processes of scanning and detecting it identified problems like stuttering. in cataloguing difference, it drew attention to a "pathology/abnormality" as part of a broader social function. as a symbol of authority in society, the school had named and authorised the problem. while it may be argued that these processes served in the interests of helping children, the stories also revealed how they simultaneously foregrounded problems and difference by formalising and authorising difference thereby generating heightened awareness of norm deviations. in this regard, schools transmitted and sustained a dominant social discourse of stuttering as a problem. in nontokozo, gareth and hennie's stories, schools collaborated with health professionals e.g. nurses, speech therapists to treat stuttering. whilst professional intervention was a means of helping the pupil, it also served to cast stuttering formally into the realm of a disorder and reinforced disotherness through various professional processes. thabo aptly stated, "it is where they will ask: what is wrong with you?" participants had a problem (stuttering) for which there was an official and formal mechanism for treatment. professional interventions are social processes (pillay, 2003), knowledge of which filtered into schools, homes and communities and had potential to reinforce disotherness. these processes occurred repeatedly over time in contexts of daily living. prominent in all their stories were their negative experiences at school. critical transitions: colonising oneself experiencing the moment of stuttering. the funniest thing is you will never know until it's upon you. then you know. oh! my god. there's a block. i didn't know the block was coming. bump and you fall and the block happens. it's a devil of a job to get going again. (gareth) then it happens. out of the blue it takes me by surprise because you don't know exactly when it will pop... you 're not in control of your mouth and that is really annoying me. (hennie) i try to control the stutter but i can't. i try to control the stutter but i can't. takes so long... i ///////////// erer kn... knerer ererererererer erer that i... since you don't understand what i said. i can see by the questioning confused look on you face that you don't understand. here i go again. i can't look at your face. it is so embarrassing. yes. i know what i want to say. i break the contact. you wait. try to guess in your mind. you don't know what i want to say. i continue the struggle since i started it. more than a minute has passed. i stop. try again. finally, it's out. this is only part of what happens. the outside. nothing comes out or too much all at once but you still don't know what i am saying. what goes on inside me is worse. very very bad. the block disability because it takes so long for a word to come out. it happens again and again. (thabo) participants' experiences of the moment of stuttering varied over time. their experiences could be summarised as uncertainty and loss of control, extended and repeated moments of struggle and a feeling that communication was in jeopardy. a constellation of negative emotions accompanied the event. similar reports of suffering have been documented by corcoran and stewart (1998) and sue-o'brien (1993). as this bodily/ impairment experience of stuttering unfolded in a judgemental social world, the experience of "self-out-of-control" emerged and formed the personal layer of experience that contributed to the shaping of their self-identity as disother. self-judging stuttering is standing between me and my dream of becoming a top-class business consultant. i am at the stage where i am really, really fed up. i am at a stage, where i say, if my speech doesn't improve dramatically, then my life is a misery. it comes from the pressure i place on myself when i fail. i just think gee! i sound dof. really dof. i don't even like the sound of my voice when i am fluent. (hennie) when i reached my final year at school, the speech flow was better, but the rest of me, inside, was still an empty hollow. i was detached, isolated and lonely. i had friends, but no best friends because rangini went to another school. my self-esteem was low. rockbottom. i was fashioned out of fear. iam nothing. (kumari) the humiliation is what you suffer because you look stupid. i feel a halfwit. then, you have to pick up the pieces. the whole thing is just so embarrassing. i am not so sure always what people think but i don't want to embarrass them either. (gareth) while social processes were constantly operational, they became influential as participants engaged in personal interpretations of external values and judgements. the personal processes shaping self-identity as disother were therefore critical in the self-identity formation process. there was progression from discovering oneself as different because one stutters to judging oneself as problematically different. the critical transition from "i have a stutter" to "i am a stutterer" and "i am less than" unfolded variably for participants and via different contextual realities reinforcing unevenness between participant experiences. for few participants (thabo and kumari) initial insults and incidents had instantaneous effect and resulted in immediate self-judging and a critical transition to understanding oneself as disother. for most participants this process was more gradual and reinforced by repeated incidents over time. eventually all participants "colonised" themselves, as the dominant and (silent) discourses in school and at home were gradually appropriated into their value systems. hence, all participants discriminated and devalued themselves by borrowing and internalising the oppressive social discourse. temporal burdening the genesis of self-identity as disother occurred over time for all participants. although single incidents remained impordie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) genesis of self-identity as disother: life histories of people who stutter 11 tant in shaping the self-identity formation, temporal burdening was crucial in reinforcing and sedimenting self-identity as disother. kumari's feeling of being a vulnerable child in the presence of an adult male is a good example of the cumulative nature of self-identity formation "i am a little girl in the presence of my boss, a man. i carry the past with me". similarly, thabo's feeling of discomfort in the university classroom occurred as a consequence of an aggregation of past experiences. sagren's story also illuminated the cumulative nature of self-construction as he suggested "take away my memories and much of this problem will be resolved." selfidentity as disother, therefore could be understood as a temporal memory of a burdened self, accumulating suffering over time. multiplicities and intersections of self-identity formations i was always uncomfortable in male company... with male teachers, bosses, my father and father-in-law. i stutter the most in these situations. i was most uncomfortable with white males even if i didn't stutter. (kumari) primary school in umlazi was harsh and we were caught in a vicious cycle with no words. you didn't do your work. ten strokes. come to school late. twelve strokes. the punishment was too heavy. it was not just strict. it was unfair. the situation got bad. we were isolated, reserved and we were punished often. the trouble was not only because of the stutter. at home, we had a broken family. we go home and we see our parents fighting. my father used to beat my mother and we watch. helpless. speechless. this happened for about five years from standard one and standard five. all this stuff put together had a negative impact. we are very silent and in pain. eventually, we just drop out of school in standard five. we were about twelve years old. (siyanda) i entered university and everything was strange. i war just too scared to talk with my stutter and because they were white lecturers. i had never met white people before. i only saw them on/tv. (thabo) j x the participants' formation of self-identity as disother was not based neatly on theirj experience of stuttering but had also been shaped by their multiple positions in society. for example, issues of race, gender and age were indelibly interwoven suggesting that self-identity formations occurred at multiple intersections. the experience of stuttering therefore couldn't be understood solely,on the basis of impairment. kumari's self-identity as other included the collective influences of gender, age, race and stuttering. thabo raised the issues of race and his sense of being other as a black person reared within an apartheid context in south africa. siyanda's early experiences of stuttering began with the classroom and playground incidents. however, he let life slip in and proceeded to share other life-changing experiences which combined to shape his experience of stuttering. he placed these "extraneous experiences" at the centre of his story of stuttering in childhood. his self-identity occurred at multiple intersections as a vulnerable child at home in his "broken family", as poor, as a school dropout and as one who stutters. his "otherness" therefore was not constructed solely on the basis of stuttering. his self-identity as disother was embedded within this complex reality and received meaning within it. negotiating self-identity as disother we spoke only when answering questions and then we just sit down. we were shy guys. (siyanda) i was so hurt. i decided not to speak in class so i don't reveal my weakness. i didn't say a word for two years in class. (thabo) i get so angry when they tease. i have to show them who i am. boomboomboom. i fight. that is only response we have to show that we are irritated. angry! when we are so angry, we can't cough it up. in the classroom we are silent. (siyanda) my stuttering became severe. i war just afraid. stuck stuck. afraid. the only good thing was my best friend rangini. we were well-suited to each other because we were quiet and we silently blended into the background, remaining unnoticed. i was quiet especially in the class because i didn't want them to notice there war something wrong with me. (kumari) on occasion i even try to speak louder than usual, almost shouting to keep fluent, but i feel quite stupid. i would do anything to be a bit fluent but these attempts always failed me. (gareth) pass as normal there are two broad ways in which participants negotiated their self-identities as disother stuttering. firstly, they chose strategies to "normalise" as a primary strategy by remaining silent, concealing the stutter by using a range of techniques and "blending in" to achieve compliance. secondly, they were angered and "fight back". all strategies were contextdependent and fluid. thabo and siyanda chose to be silent in the classroom so that their problems would not be discovered. thabo remained silent and compliant for two years to feign normality and this strategy served a self-protective function. on the playground, repeated teasing, a severe stutter and sense of disempowerment reinforced his silence and consequently threatened his potential social relationships. he felt lonely, isolated, rejected and disconnected which reinforced his selfidentity as disother. sagren, kumari, thabo and siyanda followed similar patterns in the classroom to different degrees. they used strategies of blending in and compliance to reduce attention to their stuttering. for example, they were well-behaved in class and followed rules for games without protesting. when they spoke, they also chose to conceal their stutter using a variety of self-taught techniques or formally-learned strategies. these fluency-inducing strategies were used with varying degrees of success throughout their life paths. gareth suggested that he had difficulty using slow and controlled speech which did not suit his personality but continued to use it because any bit of fluency was welcome. sagren and thabo also used a combination of spontaneous and self-learned concealment strategies to cope with difficult moments. however these strategies frequently failed to conceal the stutter which increased their sense of disempowerment and reinforced their disothemess. the strategies of silence and concealing, blending and compliance can collectively be explained as strategies to "pass as normal" (goffman, 1963; petrunik & shearing, 1983). having realised their disothemess and the disruptive effects of stuttering, participants attempted to become "normal" as a the south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 harsha kathard, mershen pillay, michael samuel and vijay reddy means of creating order at the communicative interface. silence was often the first and preferred strategy as it served to reduce the disruption and also became a self-protective function preventing one from being discovered as different or abnormal. other strategies entailed concealing the stutter and attempting to establish fluent speech. concealing is linked to "ordering" as in situations of dis-order, of disruptive communication, participants conceal stuttering to establish interactional order (petrunik & shearing, 1983). one way of achieving this order was to feign fluency or by using any strategy that created order and hence pass as normal. disavowal that's one of the strange things, both my mother and father shouldn't like to talk about these topics... a sticky topic to talk about. the teachers did the same thing. they wanted to avoid the situation. i think it was also because they didn 't want to take time to listen to me. it was better for them to pretend, to say nothing. (sagren) the actions of parents and significant others also shaped how participants negotiated stuttering. parents and significant others were often in conflicting states between accepting them for who they are as pws and yet wanting to make them "right" or normal for society. the first set of strategies involved correcting the stutter via "lay" or professional strategies. a second set of strategies was disavowal, which occurred at school and/or at home. there was a "silent" acknowledgement of the problems associated with stuttering but these were not openly discussed. participants explained this as a cultural phenomenon in south africa during a historical period when it was uncommon for parents or teachers to talk to children about their (the children's) problems. they contrasted disavowal with the more recent and current situation in south africa (2000 to 2004), where the emphasis had shifted to disclosing and talking openly about problems. the value of disavowal was interpreted differently by participants in different contexts i.e. it was both useful and not useful. sagren and kumari suggested that the lack of direct support at home fostered a greater sense of vulnerability and disempowerment, contributing to their disotherness. in the school environment, some teachers also used a strategy of disavowal that participants responded to differently. sagren, for example, suggested that teachers excluded him from having to deliver oral speeches that would have been difficult (for him and them) to manage. he also suspected that disavowal might have been used as a strategy by those teachers who did not want to take the time to listen to him which served to isolate him and reinforce his self-identity as disother. for others (kumari, gareth, hennie and thabo), disavowal drew attention away from the problem, allowing everyday routines to continue. society's penalties for stuttering, evident here as a cloak of silence, can be harsh and intolerant (ross & deverell, 2004) and contributed to reinforcing a self-identity as disother. implications, recommendations and limitations this study has illustrated the potential of life history research to generate knowledge of a personal nature. the consequence of introducing self-identity into the research dialogue is that it breathes life and people into research thereby admitting subjectivity as a cornerstone of knowledge production. life history methodology extends personal focus by highlighting the importance of understanding temporal and social dimensions of experience therefore contributing to understanding the "wholeness" of experience. the individual stories illuminate the variation and fluidity in the formation of self-identities and offers alternative interpretation to linear, stage model theories of stuttering development that have long been challenged by van riper. he contested the inadequacy of sectioning and categorising data and suggested "when adequate longitudinal data are available the concept of phases or stages will be completely discarded. human beings have ways of slipping through meshes of all categories. we are tired of wielding empty nets" (van riper, 1982, p. 92). biographical research aspires to address this concern and it is recommended that research of this nature be expanded. this study has produced knowledge of personal dimensions and therefore may have relevance and application for clinicians in many settings as they deal with the complex and multiple realities of their clients' lives. it is recommended that clinicians extend their roles beyond that of technicians (ross & deverell, 2004) and connect with the richly woven fabric of self-identity, social realities, value systems, emotions, family circumstances, personal choices and events in their clients' lives. to this end, engagement with the complex lives of pws are emphasised in narrative-based interventions (dilollo, niemeyer & manning, 2002). moreover, this study revealed that despite the multiple biographical contexts and experiences of participants, the genesis of the self-identity as disother was robust for all participants. society's role in creating disability must receive critical consideration. societies which value "order" (marotta, 2002) and "normality" contribute to shaping how pws are constructed and responded to as other. disability activists barnes, mercer and shakespeare (1999) have therefore insisted that impairment in itself does not produce disability. society contributes to producing disability by constructing and texturising issues of impairment within a discourse of negativity. therefore, interventions at a societal level are recommended. snyder (2000) has argued that unless societies are more accommodating and understanding of pws, professional interventions will fail to make a significant difference in their lives. j as an important first step to addressing the social processes contributing to disability it is recommended that the professions' knowledge base is interrogated to uncover its' inherent prejudices and dominant stereotypical attitudes towards people who stutter. the theoretical base of the profession is grounded within in a deficit medical model (pillay, 2003), and it has been established that speech pathologists have negative stereotypes of pws which are resistant to change (snyder, 2001). therefore, changing professional attitudes may be an important first step. further to this the role of schools, media and general public in creating disability must also be addressed. the actions taken by participants have traditionally been understood as secondary aspects/behaviours of stuttering (guitar, 1998). in this study actions emerged as identity management strategies. all people who stutter will live die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) is of self-identity as disother: life histories of people who stutter 13 differently by virtue of their historical, cultural, social and personal contexts and they act in varied ways in the interests of their identity management. therefore, clinicians are encouraged to understand the actions of pws in relation to their self-identities. the unfolding self-identity trajectories in some stories demonstrate that understanding difference may occur early in life. although the dominant literature on the young child who stutters does not routinely address issues of emotions and attitudes (guitar, 1998), the results of this study point to participants' vulnerability and the pervasive effects of traumatic early experiences. interventions should be cognisant of early processes shaping self-identity formation and consider the appropriate nature of intervention with young children. in addition the issues of race, power and life circumstances must be foregrounded in understanding and intervening with complex lives. a significant limitation of the study was that the researcher was unable to interview additional participants due to time and human resource constraints. for example, it would have been useful to interview participants who had been reared in rural areas and who those who had no access to formal education. there were some pws who met some criteria for selection but were unwilling to share their stories because they did not know or trust the researcher. in this regard, life history methodology is restrictive because it can only access understanding of those who are willing to share stories. a further limitation was that was that participants did not participate fully in the second level analytical process and therefore the analysis was generated primarily by the researcher. a comprehensive review of limitations of the study is available (kathard, 2003). conclusion this study explored the processes of the self-identity formation as disother and the actions of participants who stutter using a biographical, narrative life history methodology. the findings indicated that a complex set of personal and social processes operate in shaping self-identity as disother over time. the initial shaping of sejf-identity as disother began with participants' understanding themselves as different through a variety of critical events. multiple social processes in their immediate home, school and work contexts reinforced their self-identities as disother. the personal, bodily experience of stuttering coupled with processes of self-judging, resulted in participants making a critical transition from discovering themselves as different to attaching meaning to themselves as "less than". the actions they took were context-dependent and served in the interests of their identity management. there was unevenness in how the trajectory of disother unfolded for each participant over time and the process was influenced by their biographical circumstances. the study makes a case for developing personal and experiential knowledge on 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(1954). selfperceptions in stuttering. journal of clinical psychology, 10, 70-72. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) http://www.mnsu.edu/dept/comradis/isad4/ http://www.stuttering.advocate.net/paper.html real partner helps you reach l i r i l 9 5 3 , t w o y o u n g m e n w o r k e d t o g e t h e r t o c o n q u e r o n e o f m a n k i n d ' s final f r o n t i e r s m t . e v e r e s t . it's t h e s o r t o f a c h i e v e m e n t t h a t c a n o n l y c o m e f r o m a g r e a t p a r t n e r s h i p . a t w i d e x w e a r e d e d i c a t e d t o b u i l d i n g r e l a t i o n s h i p s t h a t b r e a k n e w f r o n t i e r s in m a n a g i n g h e a r i n g loss. since t h e l a u n c h o f t h e w i d e x c h a l l e n g e in 2 0 0 3 , w e h a v e s u p p o r t e d six audiologists in e x p l o r i n g u n c h a r t e r e d t e r r i t o r y t o shift local i g n o r a n c e a b o u t h e a r i n g loss. o u r p a r t n e r s h i p s w i t h a u d i o l o g i s t s r e v e a l e d : • n e w insights f r o m u r b a n i n f o r m a l s e t t l e m e n t s w i t h r e g a r d t o t h e a w a r e n e s s o f d e a l i n g w i t h h e a r i n g loss • t h e p o t e n t i a l r o l e o f r u r a l kgotlas w i t h e d u c a t i n g local c o m m u n i t i e s a b o u t h e a r i n g loss • c u r r e n t a t t i t u d e s a n d b e h a v i o u r s w i t h i n c o r p o r a t e e n v i r o n m e n t s w i t h r e g a r d t o d e a l i n g w i t h h e a r i n g loss » r e l e v a n t g u i d e l i n e s t o assist p a r e n t s w h o h a v e c h i l d r e n w i t h h e a r i n g loss a l l t h e s e d i s c o v e r i e s a n d insights i n t o o u r local c o m m u n i t y w i l l in s o m e small w a y c o n t r i b u t e t o shifting t h e h u r d l e o f i g n o r a n c e a n d f e a r a b o u t h e a r i n g loss. b y w o r k i n g t o g e t h e r a n d s h a r i n g d i s c o v e r i e s w e c a n r e a c h n e w h e i g h t s a n d a c h i e v e m o r e in c o n q u e r i n g p u b l i c i g n o r a n c e a b o u t h e a r i n g loss. if y o u a r e i n t e r e s t e d in c o n q u e r i n g t h e c h a l l e n g e o f p u b l i c i g n o r a n c e a b o u t h e a r i n g loss w i t h s p e c i a l i s e d , social r e s e a r c h p r o j e c t s , p l e a s e c o n t a c t pk n a g i n o r b r e n d a n m c g u i r k at w i d e x . w e w i l l r e v i e w y o u r a p p l i c a t i o n w i t h o u r 2 0 0 5 i n t a k e o f a p p l i c a t i o n s . if y o u call us at ( 0 3 1 ) 5 6 3 4 4 2 5 w e w i l l also s h a r e o u r d i s c o v e r i e s o v e r t h e past t w o y e a r s w i t h y o u . v j j i d e x hear the difference r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pg13-18.html the development of a neonatal communication intervention tool esedra strasheim alta kritzinger department of communication pathology, university of pretoria brenda louw department of audiology and speech-language pathology, east tennessee state university correspondence to: e strasheim (esedra1@gmail.com) abstract neonatal communication intervention is important in south africa, which has an increased prevalence of infants born with risks for disabilities and where the majority of infants live in poverty. local literature showed a dearth of information on the current service delivery and roles of speech-language therapists (slts) and audiologists in neonatal nurseries in the south african context. slts have the opportunity to provide the earliest intervention, provided that intervention is well-timed in the neonatal nursery context. the aim of the research was to compile a locally relevant neonatal communication intervention instrument/tool for use by slts in neonatal nurseries of public hospitals. the study entailed descriptive, exploratory research. during phase 1, a survey was received from 39 slts and 2 audiologists in six provinces. the data revealed that participants performed different roles in neonatal nurseries, which depended on the environment, tools, materials and instrumentation available to them. many participants were inexperienced, but resourceful in their attempts to adapt tools/materials. participants expressed needs for culturally appropriate and user-friendly instruments for parent guidance and staff/team training on the topic of developmental care. during phase 2, a tool for parent guidance titled neonatal communication intervention programme for parents was compiled in english and isizulu. the programme was piloted by three participants. suggestions for enhancements of the programme were made, such as providing a glossary of terms, adapting the programme’s language and terminology, and providing more illustrations. slts and audiologists must contribute to neonatal care of high-risk infants to facilitate development and to support families. keywords: developmental care, early communication intervention, neonatal communication intervention, neonatal nursery, public health context comprehensive management in the neonatal nursery includes not only medical treatment of the infant but also developmental care and the provision of guidance, counselling and information to the family who are part of the decision-making process regarding the infant’s care (asha, 2005). a programme that has shown positive results for premature infants is the newborn individual developmental care and assessment programme (nidcap) (als et al., 2004). this programme requires specialised training based in the usa, which makes it inaccessible to most south african professionals. kangaroo mother care (kmc) has been shown to be a safe alternative for third-world countries, where 96% of the world’s premature infants are born (bergman, linley & fawcus, 2004). the effectiveness and safety of kmc is well established (bergman, malan & hann, 2003) and it is regarded as an important developmental care practice for developing, as well as developed, contexts (bergman et al., 2004). in south africa’s public health sector, early communication intervention (eci) services to neonates are less developed and less comprehensive in comparison with those of a developed country such as the usa (kritzinger, louw & hugo, 1995). while the role of the speech-language therapist (slt) in the neonatal intensive care unit (nicu) is clearly described in international literature (asha, 2005; rossetti, 2001; ziev, 1999), currently no guidelines for service delivery in the nicu in the south african context exist (de beer, 2003). slts who are employed in south african provincial hospitals are often faced with difficult working conditions, such as lack of community awareness of services, inadequate instrumentation and tools, insufficient services of trained interpreters and limited literacy of caregivers (fair & louw, 1999). the diversity of language and culture in south africa poses a challenge for slts in providing family-centred early intervention services (louw & avenant, 2002). current health care policies in south africa prioritise care of mothers and young children, as can be seen in legislation that emphasises the provision of free primary health care to children under the age of 6 years (national health act, 2003). although eci may be regarded as a component of services to women and young children, it is still not a health care priority in south africa. the undervalued perception of eci is not only due to the hiv/aids pandemic, but also to the limited knowledge about the benefits of eci, a shortage of eci facilities and early communication interventionists, an insufficient referral system and poor teamwork (kritzinger, 2000). in a study conducted by h. louw (2007) regarding eci service delivery in public hospitals in four provinces in south africa, it was concluded that some of the high-risk infants and families were still not receiving linguistically appropriate services. a shortage of qualified and trained interpreters was also identified (h. louw, 2007), which presents an obstacle to effective eci service delivery in public hospitals. south africa has 11 official languages, of which isizulu is the most commonly spoken (24%) with english in 5th place (8%) (population census key results, 2001); english is the language most commonly spoken by slts. language differences may pose a considerable barrier to effective understanding between professionals and families (madding, 2000). h. louw (2007) found that only 11% of the respondents in her study worked with trained interpreters at their hospitals. since the multilingual nature of the south african population creates barriers to service delivery, it necessitates different approaches to intervention. the shortage of slts who can provide eci and initiate prevention campaigns (fair & louw, 1999) and the insufficient number of therapists in the public hospital context result in large caseloads. another challenge to eci in south africa is a dearth of apparatus and materials for the assessment and treatment of high-risk and at-risk infants. h. louw’s findings (2007) indicated that 93% of community service slts employed in mpumalanga, western cape, kwazulu-natal and gauteng in the public health sector expressed the need for more culturally and language-appropriate materials specifically designed to address the unique needs of the south african community. the results confirm the earlier findings of kritzinger et al. (1995) that there are limited diagnostic tools developed from a speech-language pathology and audiology perspective for neonatal assessment and management. in south africa, poverty is a characteristic of the majority of the neonatal population requiring eci. poverty in itself may not be the direct cause of developmental problems in young children, but family conditions such as malnutrition, inadequate prenatal care, exposure to infectious diseases and toxicants in utero, unsafe living conditions, living with parents who are addicted to alcohol or drugs and inadequate educational opportunities are all common in circumstances of poverty (thompson, 1992). certain risk conditions associated with communication disorders, such as low birth weight, cerebral palsy, fetal alcohol spectrum disorder and hiv/aids, also have a higher prevalence in south africa than in developed countries (kritzinger, 2000; swanepoel, 2004). the high prevalence of conditions affecting young children is of significance to slts, as these conditions can be related to many developmental disorders but more specifically to communication delays and disorders (kritzinger, 2000; rossetti, 2001). asha (2004) states that slts have the responsibility to fulfil eci roles using practices that are based on research, family-centred, culturally and linguistically appropriate, developmentally appropriate and collaborative. the execution of these responsibilities and functions is dependent upon a well-developed theoretical and clinical foundation. evidence-based practice is a framework for clinical decision making that entails the integration of best research evidence with clinical expertise and patient values (johnson, 2006). according to louw (2007), basing clinical decisions on scientific research is fundamental to ethical practice in eci. in order to fulfil the roles and responsibilities in neonatal communication intervention effectively, the slt requires certain tools. local research already provides guidelines to useful training strategies. gani (2004) found materials based on the hanen programme (pepper & weitzman, 2004) to be useful in training a group of caregivers in communication stimulation in a care centre, and a positive effect on caregiver-child interaction patterns was determined. best practice in developmental care in neonatal nurseries needs to be encouraged and facilitated, which necessitates the development of appropriate tools for the local context. asha (2005) urges speech-language pathologists to develop culturally appropriate programmes that meet the needs of ethnically and linguistically diverse families. culturally and contextually appropriate tools and programmes for neonatal communication intervention therefore need to be developed for the south african context, in order to serve the unique high-risk population in south africa in an effective and ethical manner. the unique contextual reality of south africa should be taken into account. to be contextually relevant, tools should be based upon an expressed need within a given context. if based on western models of communication stimulation, these tools should be adapted appropriately for the south african context. because of the diversity of cultural groups in south africa, overseas tools and programmes cannot merely be translated (visser, 2005). the interdependent relationship between culture and language must be carefully considered during cross-cultural service delivery, otherwise the tool will still not be suitable even once translated (pakendorf, 1998). it may also be beneficial to consider other adaptations in order to bridge additional challenges such as limited literacy among caregivers. according to louw, shibambu and roemer (2006), literacy issues may be overcome by using visual sources such as pictorial illustrations and demonstrations, as written materials are not necessarily viewed as important, especially by individuals with low literacy levels. to propose a solution to address the dearth of tools in the public health context, a survey was conducted to determine the perceptions of slts and audiologists providing services in provincial hospitals in south africa. the aim of the survey was to investigate the role of slts in the neonatal nurseries and to identify participants’ needs in terms of neonatal communication intervention instruments/tools. this information was utilised to compile a preliminary instrument/tool based on the selection of one of the perceived needs of the participants. method aim the overall aim of this study was to compile a locally relevant neonatal communication intervention instrument/tool for use by slts in the neonatal nurseries of public hospitals. the following objectives were formulated in order to reach the main aim: • to describe the perceptions of slts and audiologists providing eci services in provincial hospitals in south africa regarding their role in the neonatal nurseries • to identify participants’ needs in terms of neonatal communication intervention instruments/tools • to select and justify a specific need of the participants in terms of neonatal communication intervention instruments/tools in the public hospital context • to compile a preliminary instrument/tool based on the selection of one of the perceived needs of the participants • to pre-test the completed instrument/tool and make changes, if necessary. research design for the purpose of this study a descriptive, exploratory study within the quantitative and qualitative frameworks of research design was selected. ethical considerations ethical clearance to conduct the study was obtained from the research ethics committee of the faculty of humanities, university of pretoria. all participants gave written informed consent. data were treated with confidentiality and no identifying information of the participants or their hospitals was reported. participants all the participants in this study had to provide eci to infants in a neonatal nursery such as an nicu, a neonatal high-care ward or a kmc ward, as this study specifically focused on the participants’ needs regarding neonatal communication intervention. permission was obtained in writing from 6 of the 9 provinces contacted, namely gauteng, kwazulu-natal, eastern cape, north west, northern cape and mpumalanga. the departments of health of the free state, western cape and limpopo provinces did not respond within the time constraints of this study, which further reduced the population available for the research. the provincial health departments were requested to provide statistics regarding the number of slts and audiologists employed at the hospitals in their province, as well as to provide each hospital’s contact details. the potential participants targeted for the study were contacted telephonically at the hospitals to explain the aim of the study and discuss participation. all participants who responded were included in the study. questionnaires were sent to 175 slts and audiologists in public hospitals in the six provinces. a total of 41 slts and audiologists returned a completed questionnaire, a return rate of 23%. the responses obtained are therefore not representative of speech-language therapy and audiology services in the public health sector in south africa. the majority of participants worked mostly at district or regional hospitals, as well as at community outreach clinics. they mostly provided eci in neonatal high-care units and kmc units of their hospitals. most participants appeared to be inexperienced in providing neonatal communication intervention services. they may have been without supervision, as most participants were the only slts/audiologists employed at their hospital and had limited access to interpreters and assistants. the participants’ characteristics are displayed in table i. research process the research was conducted in two sequential phases. data collection: phase 1 a self-designed questionnaire was selected as the data collection tool to conduct the survey. a pilot study was conducted to pre-test the questionnaire which provided recommendations to enhance its efficacy and practicality. the questionnaire was e-mailed or faxed to the potential participants during phase 1 of the study. the first section gathered biographical data, which was used to describe the participants and to interpret the data from other sections of the questionnaire. the following section enquired about the service delivery regarding eci in the hospital, task allocations, contexts for eci (nicu, neonatal high care, kmc) and the participants’ functions and roles in terms of assessment and intervention with the infant, parents or staff. the questionnaire enquired about the participants’ needs in terms of service delivery, their perceptions of culturally appropriate and user-friendly tools, and their needs in terms of tools regarding assessment, intervention directed at the parents/caregivers and intervention directed at the staff/team. data analysis: phase 1 frequency distribution was set up from the raw data to obtain an overall view of the data (maxwell & satake, 2006). descriptive statistics were used to examine the data and to graphically display the data (maxwell & satake, 2006). the qualitative data were presented as detailed textual descriptions, and phase 1 included direct quotations from participants (fossey, harvey, mcdermott & davidson, 2002). method: phase 2 the needs analysis in phase 1 informed the type and the format of the tool, which was compiled during phase 2. the tool could therefore only be compiled after the results of phase 1 were obtained. for this reason, the instrument/tool was pre-tested in a pilot study as part of phase 2 and presented in the results. the evaluation of the training tool entailed descriptive data, which were analysed according to recurring themes. validity in this study slts’ and audiologists’ perceptions of their roles, their competence, work satisfaction and their needs were constructs that could not be measured directly. the construct validity could therefore be influenced by the participants’ subjective opinions and by the wording of questions in the questionnaire. the content of the questionnaire was reviewed by a statistician to determine whether the questions were relevant and appropriate for statistical purposes. the construct and content validity of the questionnaire were determined by making use of a pilot study, and certain changes were implemented according to the recommendations made. because of the small sample size, the results of this survey were not representative of the perceptions of all slts and audiologists employed in government hospitals. therefore no attempt will be made to generalise the findings. reliability the questionnaire was piloted to determine whether any items were misleading or unclear, which could result in participants misinterpreting some items. the pilot study therefore also contributed to the reliability of the questionnaire. the data collection procedures were described in detail, contributing to the repeatability of the study and thereby increasing its reliability. results and discussion: phase 1 participants’ roles in the neonatal nursery figure 1 illustrates that some participants performed roles in the nicu that require specialised equipment, such as hearing evaluation and video-fluoroscopy. video-fluoroscopic instrumentation is not readily available at all hospitals and is usually only found in tertiary or academic hospitals because of the costs involved, which explains why few participants performed this role. this finding can be explained by the fact that most of the participants were employed at district or regional hospitals that would not have specialised equipment such as video-fluoroscopy. participants appeared to be performing multidimensional professional roles relating to screening and assessment, which is attributed to their awareness of the risks of development problems in the areas of attachment and communication development in infants with low birth weight and preterm birth. the majority of the participants reported that they fulfil a number of roles in direct intervention with infants and parents, as seen in figure 2. most slts were the only slt/audiologist employed in their department and had large caseloads, which possibly did not leave time to engage in discharge planning and planning of follow-up services. because patients come from a wide geographical area and have limited finances and transport to return to the hospital or clinic, regular follow-up services are a problem area in the south african public health sector (fair & louw, 1999). given the nature of the south african context, the roles performed by the participants need to be expanded and adapted to meet local needs to improve neonatal communication intervention service delivery. according to figure 3, most participants appeared to be aware of the impact they might have in this context through teamwork, as this is preferred practice because of the benefits for the infant, the family and the slt. early intervention in the nicu should follow a transdisciplinary team approach (rossetti, 2001). however, in-service training of staff members was not yet performed by all facilities, and their service delivery was limited by poor attendance of ward rounds. ziev (1999) describes this function as an opportunity to learn from others and to become a familiar face among team members, as well as to request referrals based on infants’ symptoms or histories. as mentioned earlier, many participants were the only slt/audiologist employed in their department, which may have limited the time available for them to attend neonatal ward rounds as they may have been involved in other paediatric or adult ward rounds, clinics or consultations. this is problematic as many participants had limited experience, which resulted in missed opportunities in the neonatal nursery. two of the participants in this study were qualified as audiologists only. only one of the two audiologists performed hearing screenings, which is ascribed to the fact that hearing screening equipment is not readily available in government hospitals (theunissen & swanepoel, 2008). both audiologists worked as part of a team and consulted with other team members in accordance with asha’s guidelines for audiologists (2008b). current literature emphasises the importance of ongoing audiological and medical monitoring of any child who demonstrates risk indicators for delayed onset or progressive hearing loss for at least 3 years (northern & downs, 2002). interestingly, both audiologists also assisted in discharge planning and planning of follow-up treatment/management after discharge, while only half of the larger group of 39 slt participants performed this role. this may be due to a lack of infant follow-up clinics at many district or regional hospitals. families need information, consistent encouragement, reassurance, and positive feedback regarding their competency and ability to cope with the birth and hospitalisation of their critically ill newborn (northern & downs, 2002). participants’ needs in the neonatal nursery an overview of the needs of the slts as determined in phase 1 was compiled in table ii. the 5 most frequently indicated needs are highlighted, namely tools for parent guidance (4 topics), a tool for staff and team training (1 topic) and an assessment tool (1 topic) (2 needs in 4th place). eci services are required to be family-centred, as well as culturally linguistically responsive (asha, 2008a). neonatal communication intervention services therefore cannot be effective without culturally appropriate tools. an urgent need for culturally appropriate materials for use in the neonatal nurseries of provincial hospitals was identified. participants were aware of the importance of providing culturally sensitive services, but were hampered by the dearth of tools and materials that could be utilised in clinical practice. phase 1 demonstrated that participants performed different roles in neonatal nurseries, which were determined by the environment, tools, materials and instrumentation available to them. although many participants were relatively inexperienced, they were resourceful in their attempts to develop and adapt tools and materials. the fact that these self-developed and adapted tools are not research-based compromises the quality of services and precludes best practice. the participants expressed a need for culturally appropriate and user-friendly instruments specifically for parent guidance and staff/team training. these descriptive findings justified the compilation and development of a locally relevant instrument/tool for use in public hospitals’ neonatal nurseries. results and discussion: phase 2 the compilation of a neonatal communication intervention tool a tool regarding parent guidance with the topic of developmental care was selected as the tool to be compiled, as this was a need indicated by the majority of the slt participants. most participants were also involved in services directed at parents/caregivers in the neonatal nursery. the ‘neonatal communication intervention programme for parents’ aimed to provide slts in local public hospitals with a programme to educate and guide parents/caregivers of infants in the neonatal nursery regarding developmental care, early reciprocal interaction and appropriate stimulation of their infants. adult-learning principles were utilised in the compilation of the programme. guidelines to teach adult learners consider mature learners as independent and self-directed (kaufman, 2003). the researcher formulated an aim as well as outcomes for the programme (popich, 2003). the structure and sequence of the programme as conceptualised is illustrated in figure 4. the programme is divided into four sections, which include an introduction with ‘warm-up time’ and definitions, information on the behaviours of the neonate, information on how parents may respond to these behaviours, and a conclusion that informs parents of options for follow-up services and provides time for reflection and questions. informal terminology was used to make the language more accessible to the parents/caregivers. the term ‘baby’ is used in the programme instead of ‘infant’ as this is the term most commonly used by south african parents in conversation (popich, 2003). it was decided that the programme should consist of a microsoft powerpoint presentation and a handout for parents. the powerpoint presentation was provided in two different formats as it allows each clinician to select a method that is conducive to his/her working environment. some slts and audiologists in public hospitals have limited technical resources, and the powerpoint presentation was therefore provided on a compact disc as well as transparencies. handouts were provided to parents during the programme to generalise and reinforce the newly learnt information as well as to actively involve each parent during the presentation. the handout included photos and images to manage literacy barriers. the content of the handout was translated into isizulu by a private translation service to address language barriers. isizulu was selected as it is the home language of almost a quarter of south africans and is the language most spoken in south africa (population census key results, 2001). the programme was pre-tested in a pilot study, which concluded that the programme was enjoyed by the parents who received the training. it was further determined that the content was appropriate but that the programme should be more concise and shorter so as to be more user-friendly. the parent handout was deemed suitable for the training. certain suggestions for enhancements of the programme were made during the pilot study, such as providing a glossary of terms with definitions for therapists to use and adapting the programme’s language and terminology. clinical and theoretical implications the current research identified and attempted to fulfil a need expressed by slts and audiologists. the study managed to achieve the aim of compiling a programme for slts for use with parents and caregivers in the neonatal nurseries in south african provincial hospitals. this study highlighted the role of the slt and audiologist in terms of prevention of communication delays and disorders. this research is an example for slts and audiologists in the public health sector on how to use adult education principles in parent training to prevent communication delays and disorders in infants. the programme could also be used for raising awareness of eci services within a certain community. south africa has an increased prevalence of infants at risk for communication disorders (kritzinger, 2000), and marketing of eci among the general public, as well as health care workers, should therefore be a priority of local slts working in the public health sector. according to asha (2008a) eci services must promote children’s participation in natural environments, which include community settings outside the home environment, where children without disabilities participate. community work increases the existing professional knowledge on diverse communities within south africa, which presents therapists with the opportunity to implement prevention programmes such as adult training (popich, 2003). this study emphasised involvement in community work and not only in the lives of individual families. the research could be used as an example of caregiver training within a specific community in order to reach more infants and toddlers in need of eci services and to improve the current services in communities. this study highlighted information on the roles of slts and audiologists in the neonatal care of high-risk infants in the public health sector. this research gathered valuable information regarding the roles and responsibilities of slts and audiologists in local nicu, neonatal high-care and kmc nurseries. it can therefore be used to guide future attempts to compile local guidelines for slts in the nicu. conclusion the study complied with the guiding principles for best practice in eci (asha, 2008a) as it aims to be family-centred, culturally and linguistically responsive and developmentally supportive, to promote children’s participation in their natural environments, to be comprehensive, co-ordinated and team-based, and is based on evidence. this research therefore contributed to neonatal care of high-risk infants in south africa. the increased prevalence of infants at risk for communication disorders in south africa (kritzinger, 2000) necessitates early interventionists to become involved in clinical and research efforts to develop eci services for provincial hospitals. slts and audiologists not only have an essential role to fulfil in the neonatal nursery, but also have an ethical responsibility to develop creative solutions for challenges arising from service delivery in the south african public health context. slts and audiologists must contribute to neonatal care of high-risk infants to facilitate their optimal development. acknowledgements. the authors would like to thank the professionals who participated in this study and who are committed to early communication intervention. the corresponding author (esedra1@gmail.com) may be contacted for more information about obtaining the ‘neonatal communication intervention programme for parents’. authors’ note. since the article was accepted for publication, saslha has adopted revised guidelines for early communication intervention, which include specific guidelines on neonatal communication intervention. the document may be obtained from the ethics and standards committee (2011). guidelines: early communication intervention. www.saslha.co.za references als, h., duffy, f.h., mcanulty, g., rivkin, 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(1992). developmental risk factors and poverty. in t. thompson & s.c. hupp (eds.). saving children at risk: poverty and disabilities. newbury park: sage publications. visser, c. (2005). die toepaslikheid van ’n afrikaanse vertaling van die ‘scan-c: test for auditory processing disorders in children – revised’ vir voorskoolse leerders. unpublished m. communication pathology dissertation, university of pretoria. ziev, m.s.r. (1999). earliest intervention: speech-language pathology services in the neonatal intensive care unit. asha, may/june, 32-36. fig. 1. speech-language therapists’ indication of their roles regarding screening and assessment of the high-risk infant (n=39). fig. 2. speech-language therapists’ roles in intervention specifically directed at the infant and parents/caregivers (n=39). fig. 3. speech-language therapists’ roles in intervention specifically directed at staff and team members (n=39). fig. 4. structure and content of the programme. table i. characteristics of the participants professional qualifications slt – 49% slt & audiologist – 46% audiologist – 5% provinces where employed eastern cape – 5% gauteng – 8% kwazulu-natal – 25% mpumalanga – 29% northern cape – 28% north west – 5% years of experience in government sector 1 year or less – 25 participants 2 years – 6 participants 3 years – 3 participants 5 years or more – 6 participants contexts of service provision clinics/community health centres – 26 participants (participants indicated more than one working context) district/regional hospital – 30 participants tertiary/academic hospital – 12 participants other – 1 participant wards where ei was provided nicu – 14 participants neonatal high-care unit – 23 participants kangaroo mother care ward – 20 participants number of slps and/or audiologists in the department 1 – 15 participants 2 – 10 participants 3 5 participants 4 or more – 11 participants trained interpreters or assistants at their disposal yes – 10% no – 90% table ii. speech-language therapists’ needs (n=39) need no. of responses ( n =39) no. who indicated need % hierarchy 1 14 assessment tools neonate’s communication development 36 15 41.6 9 feeding 34 15 44.1 8 mother-child communication-interaction 33 16 48.4 7 neonatal nursery environment 33 19 57.5 3 parent guidance tools neonatal nursery environment and staff 36 24 66.6 1 paediatric dysphagia and feeding therapy 34 18 52.9 5 over-stimulation, identifying infant’s stress cues 35 19 54.2 4 developmental care 35 19 54.2 4 kangaroo mother care (kmc) 35 8 22.8 14 communication interaction with infant 35 12 34.2 11 developmental milestones and follow-up after discharge 34 9 26.4 12 normal communication development 36 9 25.0 13 staff/team training tools developmental care 36 23 63.8 2 kmc & eci 35 13 37.1 10 role of the slt in the neonatal nursery 36 19 52.7 6 highlighted sections indicate the most frequently mentioned needs. 59 a new look at cochlear mechanics carole a jardine department of speech pathology and audiology university of the witwatersrand abstract the spectacular discovery of otoacoustic emissions has led to a plethora of cochlear mechanic models, all attempting to explain the active, nonlinear processing of the cochlea suggested by these recordable responses. these hypothetical proposals have been largely based on animal experimentations, mathematically-based theorems, and observations in simulated environments. none have been irrevocably validated although there is much circumstantial evidence expounding their feasibility. advances in electron microscopy, mechanical engineering, histological examination techniques together with the technology enabling us to measure these emissions, have radically altered the current views on the assumptions of auditory mechanics. this paper briefly contrasts the previously established cochlear theories proposed by doyens such as helmholtz (1857) and von bikisy (1936) with current perspectives advanced by cell biologists and biophysicists. however, the exact nature of cochlear processing still remains a mystery. as numerous chasms of knowledge about audition are being filled, so even more questions are posed in a seemingly eternal quest for the answer! opsomming hierdie indrukwekkende ontdekking van otoakoustiese emissies het gelei tot 'n oormaat kogleere-werkingmodelle wat almal gepoog het om die aktiewe nie-lineere prosessering van die koglea wat deur optekenswaardige response voorgestel word, te verklaar. hierdie hipotetiese voorstelle is grotendeels op diere-eksperimente, wiskundig gefundeerde stellings en waarnemings in gesimuleerde omgewings gebaseer. nie een hiervan is onweerlegbaar bekragtig nie, alhoewel daar heelwat omstandigheidsgetuienis bestaan wat die uitvoerbaarheid daarvan verklaar. vooruitgang op die gebied van elektromikroskopie, meganiese ingenieurswese, histologiese ondersoektegnieke, tesame met die tegnologie wat die meting van hierdie emissies moontlik 'maak, het die algemene opvattings oor die aannames van ouditiewe funksionering radikaal verander. hierdie artikel vergelyk die voorheen opgestelde kogleere teoriee wat voorgestel is deur doyens soos helmholtz (1957) en von bekisy (1936) kortliks met die huidige perspektiewe wat deur bioloe en biofisici daargestel is. die presiese aard van prosessering bly egter'nog steeds 'n geheim. namate talryke leemtes in die kennis van gehoor nog aangevul word, word selfs meer vrae gestel in 'n oenskynlik nimmereindigende soeke na die antwoord! abbreviations used in text oae otoacoustic emissions eoae evoked otoacoustic emissions dpoae distortion product otoacoustic emissions bm basilar membrane ihc inner hair cell ohc outor hair cell rl reticular lamina ocn oliviocochlear nucleus atp adenosine triphosphate introduction "few areas of audiology have advanced as rapidly as cochlear physiology and biophysics have over the past decade. the advance began with the shock realisation that existing knowledge and accepted concepts could not explain the response of the cochlea to sound and in particular otoacoustic emisssions. our very understanding of both the physical basis of hearing and the nature of hearing impairment was challenged". (grandori, cianfrone and kemp, 1990, viii) as early as 1948, gold (cited in rossi, 1990) inarguably stated that the inner ear itself was a vibratory body and could therefore produce sound since it did not exist in a vacuum. however, instrumentation to measure this response had been slow to develop and his statements were largely ignored in favour of an exclusively sound-receiving cochlear, until the discovdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 carol a jardine ery of otoacoustic emissions (oae) by david kemp (1978). prior to this breakthrough, the ear was viewed as a passive transducer of sound and the idea that it could produce its own energy was inconceivable. kemp (1978) changed this perspective radically when he presented his discovery of a response measurable within the closed external acoustic meatus, more than 5 milliseconds after excitation. he termed these responses "cochlear echoes" (kemp, 1978, p. 1386) also referred to as "kemp echoes" (johnstone, patuzzi & yates, 1986, p. 147) and currently called " o t o a c o u s t i c e m i s s i o n s " (probst, antonellia & pieren, 1990, p.117; glattke & kujawa, 1991, p.29; and numerous others). upon his discovery, kemp (1978) hypothesized that there could be an augmentation of energy from the cochlea which would result in a secondary disturbance of the middle ear and eardrum. by doing so, he implied that some active processing was occurring in the cochlea causing a major upheaval in the last decade of audiology. since then, the traditional model proposed by von bekesy (1936 cited by zemlin, 1982) more than fifty years ago, has been expanded, manipulated, modified and at times rendered obsolete in the attempt to explain these oae. contemporary theories all aim to decipher the active, nonlinear, frequency selective processing of the cochlea. each model has its own unique orientation often based on examination of isolated aspects of cochlear physiology. unfortunately, none have been undeniably verified from research nor have these specialised viewpoints been amalgamated to form a cohesive model yet. indeed, it would seem that the process of audition is one of the most poorly understood physiological systems in medicine today. otoacoustic emissions using a signal averaging technique, a specially constructed acoustic probe and a broadband click stimulus, kemp (1978) recorded the well-documented, large initial middle ear response (0 5ms post stimulus) due to reflection of acoustical energy from the ear canal and tympanic membrane, as well as a much smaller response (5 62ms post stimulus) the hypothetical cochlear echo. responses of a 1.5 cc coupler with similar impedance characteristics to the human ear was compared to the human ear response as illustrated in figure 1. he found that both showed rapid deterioration of response to almost zero approximately 6ms post stimulus. however, the reappearance of a significant but much smaller response at about 10ms post stimulus was unique to the human ear and found consistently amongst normal hearing subjects, and subsequently known as evoked otoacoustic emissions (eoae) (kemp, 1978). such evidence led to speculations about the active function of the cochlea. distortion product otoacoustic emissions (dpoae) were subsequently discovered a year later (kemp, 1979). distortion products are usually generated by systems which are nonlinear (probst et al., 1990). stimulation of the acoustic system by two primary frequencies f ; and f2 will undergo intermodulation distortion and a response is generated at frequencies other than the primary ones but at specific mathematifigure 1. comparison between responses recorded in a coupler (a) and an adult human ear (b) showing the much smaller response at about 6ms poststimulus amplified in (c) (after glattke & kujawa, 1991, p. 31). cally-predictable frequencies ie. f, + f2, ft f2 and the most robust at 2ft f2 (probst et al., 1990; glattke & kujawa, 1991). nonlinearity of the cochlea is strongly suggested by this distortion of the signal. ι the third type of oae differs from the previous two in that it is generated in the absence of any evoking stimuli and known as spontaneous otoacoustic emissions (soae). they are measurable in approximately 40% of normal hearing people (bright & glattke, 1986 cited in glattke & kujawa, 1991) and are also thought to be representative of the active processes occurring in the cochlea. 1 the growth in technology together with the discovery of oae has thus led the way towards a more objective, in situ measurement of the non-linear, active role of the cochlea and refocussed the attention of biologists, physiologists and audiologists. cochlea as source of emissions there was initial speculation that this response could be due to protracted reflections within the middle ear structures (kemp, 1978) but glattke & kujawa (1991, p.29) refuted this concept because (a) the time delay of more than 6ms is sufficient time for a sound wave to travel more than 6 feet; (b) the duration of the response is much longer than either the duration of the stimulus of the time for the middle ear response to decay; and finally (c) the stimulating clicks produced well-defined, the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a new look at cochlear mechanics 61 frequency specific waveforms. johnson and elbering (1982) in examining the clinical utility of oae verified the cochlea as the source of these emissions by selecting two pathologies of known cochlear origin, that of aspirin toxicity and mumps. a moderate reversible salicylate-induced cochlear hearing loss was traced from pre-ingestion to two days following completion of the drug course. the initial bilateral emissions were reduced during the hearing loss but recovered fully after the drug was excreted suggesting to the researchers that the cochlea had recovered sufficiently. to ensure that these emissions were not an artifact of middle ear mechanisms, they tested a subject with complete anacusis in the right ear due to mumps. emissions could not be measured in the right ear, even in the presence of normal recordings in the left. these experiments led the authors to believe that the oae was of cochlear origin. this paper aims to briefly outline the basic anatomy of the cochlea and the classic theory of cochlear mechanics, before examining current models focusing on the macro-functioning of wave propagation, the cochlear cellular responses, and finally the biochemical activity within the ohc. historical perspective as early as 1857, helmholtz (cited in zemlin, 1982) proposed his resonance theory of hearing where he described the transverse fibres of the bm as being a bank of resonators. then von bekesy (1960 cited in clopton, 1986) was the first to formalise the one-dimensional travelling wave of the cochlea after extensive observations and experimentations spanning over half a decade (kim 1986), for which he was awarded the nobel prize in medicine and physiology in 1961 (zemlin, 1982). he postulated that spatial analysis of frequency information occurred as a result of the differential masses and stiffnesses along the length of the bm, each locus acting as a bank of resonators in a sense, but longitudinally coupled together by soft tissue (clopton, 1986). hydrodynamic forces within the fluids of the inner ear lead to displacement of the bm, and a shearing force between the rl and the tectorial membrane resulted in bending of the stereocilia; and electromechanical transduction (lim, 1986; nuttall, 1986). this view was supported by zwislocki (1946 cited in dancer 1992) and subsequent scrutinies and analyses have verified this very acceptable theory. yet, with the improvements in observation and model construction techniques, it appears that this macromodel of cochlear mechanics is now insufficient. the discrepancy between the broadly tuned data of the bm and the sharply sensitive auditory nerve was still confusing (johnstone et al., 1986). subsequently evans and wilson (1975 cited in clopton, 1986) suggested that there was a "second filter" to sharpen the frequency selectivity of the cochlea. the nature of this second filter has been open to much conjecture, with ideas ranging from microresonance of the bm to the gradient differences of the bm displacements (pickles, 1982). however, this concept of a second filter has generally been dismissed as being unnecesarry especially with the currently available experimental data (kim, 1986). indeed, lechner (1993) cautions against the use of passe models of bm motion because many models were based upon eclusively visual and often faulty observations. an example of such an occurrence is von bekesy's examination of longitudinal and radial fibres in the bm wherein he described that the incision of the bm resulted in openings in the shape of a cone (zemlin, 1982; lechner, 1993). one needs to bear in mind that several hours had elapsed between his observations and death of the tissue. voldrich (1978) repeating these experiments soon after cell death, found that the shape was in fact more radial, only becoming conical 24 hours following death the shape having far-reaching consequences in mathematical calculations. furthermore, nuttall (1986) highlights the poor instrumentation sensitivity used by von bekesy requiring intensity of at least 140dbspl (johnstone et al., 1986). therefore, a plethora of models was based on incorrect observations of a cadaver basilar membrane (von bekesy, 1960 cited in lechner, 1993) or following drainage of the scala tympani during preparation of an animal cochlea (dancer, 1992). active macromechanics in the cochlea the fundamentals of the travelling wave theory are generally still felt to hold true, that the cochlear is able to perform broad frequency analysis via differential displacement of the basilar membrane (neely & kim, 1986). nevertheless, the prevailing travelling wave theory has many limitations. it implies a cochlea which is a passive transducer to sound but if this was the case, it would be too highly damped to permit the sharp frequency selectivity to occur (clopton, 1986). the linear system model also implies that one could predict the response to a click from a previously measured frequency response to tone stimulation (eggermont, 1993, p. 177), but this does not hold true and indeed, geisler and sinex (1983 cited in eggermont, 1993) found that one could not even predict the response of a high intensity stimulus from that of a low intensity one. such inexplicable evidence, together with the discovery of oae and the ability of the cochlea to give rise to harmonic and intermodulation distortion and generate the dpoae, suggests that: the previously accepted anatomical and physiological processes were wholly inadequate to explain nonlinearity of the cochlea (eggermont, 1993) and that the inner ear was not as simple as first proposed by von bekesy in 1960 (kim, 1986, p.105). kemp tentatively suggested that at very low levels of stimulation, there may be hyperexcitation at certain frequencies resulting in a recoil of the bm at "localised impedance discontinuities" (1978, p. 1386) and the generation of the cochlea echo (1978). this postulation highlighted the possibility of the cochlea producing its own energy, sufficient to be transmitted retrograde through the middle ear and be generated within the ear canal. by constructing various cochlear models, several researchers have acknowledged the presence of 'some active element' to explain its fine tuning characteristics (neely and kim, 1986). contemporary theories expounding the mechanically active cochlea tend to agree with this axiom and imply that the travelling wave is amplified by initiating or supplementing existing motion in the bm. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 carol a jardine subsequent experimentation culminated in davis (1983) presenting a revolutionary new model of cochlear mechanics in which "an active process increases the vibration of the basilar membrane by energy provided somehow in the organ of corti" (p. 79). he termed this active process "the cochlear amplifier: (p.80) but subsequent researchers have referred to it as "negative impedance" and "negative damping" (neely & kim, 1986. p.1479), or "positive feedback" (de boer, 1983, p.571). effect of 1 2000 ht — cochlear amplifier 1 bekesy wave and envelope : / / » c / uj ο d t1 4 1 ^ t t ^ ^ / it j π / 2 phow s < v i . / \ \ x \ ii λ x vv « apex 1 f bote • k 16 1 12 10 8 6 4 mm i distance from stapes figure 2. the classic travelling wave and its envelope is presented together with the cochlear amplifier. note the frequency difference in amplitude peaks between the two (after davis, 1983, p. 82). the cochlear amplifier acts as a high-q (good frequency resolution) acoustic resonator according to davis (1983), such that it increases the sensitivity to lowthreshold stimuli, and sharp-tuning curves of a narrow segment of the bm. figure 2 illustrates a travelling wave with its envelope to which is added the effect of this cochlear amplifier. it is interesting to note that the tip of the cochlear amplifier does not correspond with the maximum displacement of the travelling wave. this theorem has since been corroborated by johnstone, patuzzi & yates (1986) who generated travelling wave envelopes with increasing intensity and found that at high intensities, the maximum displacement shifted half an octave lower than the stimulating frequency citing this as another example of the nonlinear property of the cochlea. the well-documented frequency differences between the noise exposure and its resultant temporary threshold shifts (about one-half octave) may be used as further substantiating evidence (davis, 1983, p.81). from a hydrodynamic perspective, kim,siegel & molnar (1979) on the other hand, proposed that the sharply tuned curves could occur as a result of negative damping along the crest of the travelling wave. by constructing a passive model of the cochlea, they observed a diffuse spread of energy through the fluid and assumed the total amount of energy entering the oval window was absorbed by the partition. in a contrasting active model, they constructed a negative damping partition just basal to the characteristic frequency, and hence energy in the form of eddy currents (according to neely & kim, 1986) is released from this point of the partition, resulting in an increase in energy equivalent to 40db which was sharply focussed. excessive gain at this point on the cochlear partition causes spontaneous oscillations of the hair cells thought to be the source of soae (neely & kim, 1986). neely & kim (1986) in an attempt to combine the mechanical and hydrodynamic properties of the cochlea into a single cohesive model, suggested that the cochlear amplifier not only occurs as a result of bm displacement but that the loci of maximum displacement coincides with the greatest pressure difference between the two fluid-filled compartments. they imply that this pressure differential acted as a selective tuner. von bekesy (1960 cited in zemlin, 1982) also reported observing an eddy current at the locus of maximum displacement during his experiments. active cellular responses although the mechanics of nonlinearity differ, there appears to be a consensus amongst researchers that "the bm vibration is very sharply tuned ... and is the predominant determinant in the major responses of the eighth nerve e.g., sensitivity, sharpness of tuning and many nonlinear functions" (johnstone et al., 1986, 148). despite these different theories, researchers believed that the ohc were responsible for this active process in the cochlea (clopton, 1986), and davis (1983) and bronwell (1990) postulated that it may be the energy source for the oae measurable in the external ear canal. noise, drugs (glattke & kujawa, 1991, p.30), anoxia and mechanical insults (davis, 1983, p.81) result in damage to ohc which then compromises the sensitivity (harrison and evans, 1979) and selectivity (sellick et al., 1982 cited in bronwell, 1990) of the cochlea, and can therefore be assumed to diminish or obliterate oae recordings a fact which has been verified through subsequent clinical trials. davis ( 1 9 8 3 ) a c k n o w l e d g e s that the active mocromechanism of the cochlea is very poorly 'understood and this has been the source of much debate. the motile properties of ohc are well accepted and it is popular to suggest that the lengthening or shortening of ohc could either move the rl and bm further] apart or closer together in order to deform the organ of corti and thereby produce the nonlinear response of the cochlea. caution against such simplistic explanations is voiced by de boer (1990). through a series of mathematical computations based upon the 'sandwich model' (refer figure 3), he proved that the motility of ohc would be unable to provide sufficient pressures to overcome the bm impedance and initiate motion. through observations and experimentations on the , cat cochlea, khanna, ulfendahl & flock (1990) assumed that the sharply tuned curves of the bm were sourced by the ohc. in subsequent research, khanna et al. (1990) were able to observe that the vibration amplitude and tuning characteristics for the ohc and the bm were different and concluded that they were independently controlled. the large vibration amplitude of the ohc suggested that the ohc-induced movement in the bm and bony shell of the cochlear and not vice versa previously^ supposed. such observations give the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a new look at cochlear mechanics 63 rl bm © t t rl bm j'prl © rl bm © figure 3. the "sandwich model" showing a filling of scala media (p3) with the organ of corti, and two wedges on either side, the scala vestibuli (p2) and tympani (pi) (after de boer, 1990, p.4). credibility to what was previously a revolutionary statement, even in this information era. moreover, they found that the vibration amplitudes at the level of the rl were maximal in the hensen cells, decreasing towards the ihc. the steepness of the slope, i.e. the tuning curve was sharpest in the third row of ohc, and shallowest in both the hensen's cells and ihc. this led the experimenters to conclude that the ohc drove the rl. the vibrations of the bm were small compared to that of the ohc and rl and it would seem that the primary source of energy lies in movement of the ohc carrying the rl with it. in a sense, de boer (1990) colludes with khanna et al. (1986) by refuting the possibility of bm movement. this evidence is in sharp contrast to that of the stereocilia bending due to the mechanical motions o f t h e b m . j for a closer examination of the role of rl mechanics, zwislocki (1986) constructed a model with nonlinear coupling of the rl and tectorial membrane. he noted that nonlinearities observed were similar to those of the auditory nerve firing patterns. at low intensity levels, there was little or no distortion, at slightly higher intensities there was splitting of the peaks, and at even higher intensities, there was a phase shift initially of the order of 90° and later 180°. he suggested that this nonlinearity could be due to the relative change in shearing movements between the tectorial membrane which is coupled to the ohc cilia and rl showing startlingly similar results after observing the rectified waveform of his construction. active micromechanical responses at a molecular level, the active mechanisms are less well understood but seem to have some basis in the contractile elements within the ohc. active lengthening and shortening of the ohc by stimulation of its actin filaments, have been demonstrated by several researchers in response to acoustic stimulation, drugs such as caffeine and potassium (slepecky, ulfendahl & flock, 1988; ulfendahl, flock & khanna, 1990) and electric currents (zenner, reuter, plinkert & gitter, 1990). most recently, it has been suggested that these changes can also be induced by mechanical activity, such as that observed in the movement of the cochlear partitions (kim, 1986; ulfendahl et al., 1990). kim (1986) therefore concluded, that it was important to examine the ohc whilst still within an intact organ of corti. by isolating the temporal bone from a guinea pig, they induced ohc shortening by applying caffeine. not surprisingly, the ohc did indeed shorten, and it appeared that the caffeine triggered the release of calcium ions (a substance known to trigger contractile activity in other muscles) (slepecky et al., 1988; zenner, 1990). moreover, the vibration amplitude of the organ of corti, and tuning of the mechanical response was sharper in the presence of caffeine. such conclusions led the experimenters to believe that the ohc were capable of influencing the mechanical response of the organ of corti and therefore played a much more active role in frequency selectivity, non-linearity and tuning frequency of the cochlea than previously supposed. zenner et al. (1990) reports that ohc activity can also be stimulated by electric currents. using a photodiode, they noted the longitudinal movements within the cylindrical cell body of the ohc, that there is shearing of the stereocilia via a lateral sliding of the cuticular plate and simultaneous movement of both the bm and rl in the same direction. the motion of these stereocilia will cause ohc coupling with the ihc via the tectorial membrane and is termed the "fast motile response" (zenner et al., 1990). it is unlikely that this response is due merely to the actin myosin interaction because of the short latency of the response according to ashmore and bronwell (1986 cited in slepecky et al., 1988). zenner et al. (1990) hypothesized that the displacement of the cuticular plate with the stereocilia may amplify the signal through closer coupling to the ihc via the tectorial membrane. the sharp focusing of these fast responses is thought to be responsible for the sharp tuning curves. an alternative explanation was suggested by kim (1986) in that these apically generated fast responses resulted in an oscillatory motion of the stereocilia. the idea of a bidirectional movement of the stereocilia has been revolutionary and illustrated through the examination of turtle hair cells (fettiplace, 1985 cited in nuttall, 1986). using this information, kim (1986) proposed that the forward transduction motion forms a feedback loop with the reverse motion. similar thoughts were expressed by clopton (1986) who felt that the voltage changes due to the stereocilia bending in one direction would result in greater excitation than in the other but does not suggest any specifics other than it may be sourced by the differential stiffness of the stereocilia depending upon direction of motion. however, other experimenters speculated that the asymmetrical arrangement of stereocilia at the apical ends of the ohc may account for the non-linearity of the cochlea (khanna et al., 1990, p23). a second, slower, motile mechanism of the ohc is also described wherein there is a slow depolarisation of ohc. shortening of the ohcs are observed, as is a reduction in the distance between the bm and rl. the origin of this response is thought to lie in the contraction of actin and myosin elements in the lateral wall of die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 carol a jardine figure 4. schematic diagram of an outer hair cell illustrating proposed origins of the fast and slow motile responses and the apical areas rich in subcisternae (sc) (after kim, 1986, p. 110). the ohc (zenner, 1986) unlike the actin-independent fast motile responses. kim (1986) hypothesized that this slow motile response was responsible for the slow change in length of the ohc. figure 4 illustrates the anatomical origins of these fast and slow responses suggested by kim (1986). there is much uncertainty over whether the fast, motile responses or the slower secondary ones give rise to the selectivity, nonlinearity and sensitivity of the cochlea although much research has been focused on the existence of efferent feedback loops. efferent fibres from the oliviocochlear bundle are thought to control the fast, amplifying and selective action of the cochlea. efferent control a source of nonlinearity contralateral masking is able to suppress ipsilateral dpoae (puel, rebillard & pujol, 1990), and soae (kujawa & glattke, 1989). siegel & kim (1982) found that stimulation of the contralateral fibres arising from the oliviocochlear bundle (which synapse mainly with the ohc) could alter the strength of the distortion products suggesting ohc involvement in the generation of otoacoustic emissions. already in 1962 (fex cited in warren iii & lieberman, 1989) reported that the cochlear efferent system, arising from the oliviocochlear nucleus (ocn) could inhibit activity in the auditory afferent fibres. a schematic diagram of the anatomical •pathway of the efferent fibres can be found in figure 5. however, warren iii et al. (1989, p.98) report that it had not been conclusively proven that this efferent system arose from the ocn only and they highlight three methods where contralateral sound can influence responses to the ipsilateral stimulus: 1. mechanical propagation of the acoustic stimulus via bone conduction to the contralateral cochlea; figure 5. the cochlear efferent system originating from the oliviocochlear nucleus in the superior olivary complex. 2. some neural feedback system of which there could be three possibilities: (a) via the middle ear reflex muscles (stapedius and tensor tympani); (b) the oliviocochlear efferent system and (c) autonomic efferents to blood vessels within the spiral lamina: 3. there may be humoral agents released when the ear is acoustically stimulated and which travel via the circulatory system to the opposite side. the idea of accoustic crosstalk was eliminated since the intensity of the sound was always less than the level required for contralateral excitation. likewise, the likelihood of blood circulating agents was also discounted because of the time necessary to travel to the opposite cochlea. the three remaining neural feedback systems appear to be the most feasible explanation. both warren iii et al. (1989) and puel et al. (1990) in theirjstudies severed the stapedius and tensor tympani muscles to ensure that the middle ear muscles did not participate in this phenomenon. finally, through a process of elimination warren iii et al. (1989) state that the oliviocochlear system is the most likely originator of the efferent feedback loop since they argue unconvincingly that when there is removal of the cervical synpathetic system, there is a decrease in the n1 action potential (hultzcrantz et al., 1982 cited in warren iii et al., 1989) suggesting to them that the autonomic nervous system was in fact used to enhance auditory sensitivity an idea first suggested by beickert et al., 1956 (cited in zemlin, 1982) although to date, there is still no empirical evidence. warren iii et al. (ibid) therefore attributed this feedback process to the inhibitory cochlear efferents innervating the ohc and originating from the ocn in the central auditory pathway. they further postulate that the medial ocn was responsible for this action because they comprise large, myelinated nerves whereas the lateral ocn consists of largely small, unmyelinated neurones from experiments comparing myelinated and unmyelinated responses to electrical excitation (gifford & guinam, 1987). the idea of a closed feedback loop system and cochlear the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a new look at cochlear mechanics efferents to modulate ohc motility is also proposed by puel et al., (1990), kim (1986) and bronwell (1990). animal observations by lieberman (1988 cited in warren hi et al., 1989 and in froehlich, collet, valatz & morgon, 1993) show that auditory afferent stimuli can excite the efferent fibres arising from the medial ocn i.e. large, unmyelinated efferents leading to the ohc (warr et al., 1986 cited in dannhof & bruns, 1993). moreover, these medial ocn efferent fibres could inhibit activity in the contralateral auditory efferent fibres (lieberman 1988 cited in warren iii et al., 1989). johnstone et al. (1986) suggested that these efferents were used to return the stereocilia to its normal position after being bent in an excitatory manner by the movement of the bm (p. 151). in another paper with rajan (1983), he also noted the protective effects of stimulating the efferent system during tts and cited this as evidence of their role in the feedback loop. the high frequency selectivity of the bat has always sparked interest and its efferent innervation was of particular interest to xie, henson, bishop & henson (1993). they identified a greater number of ohc terminals in areas known to be associated with sharp frequency tuning and selectivity in the bat. in study of mammals such as the cat (lieberman & brown, 1986) and the guinea pig (hashimoto & kimura, 1987), the trend is towards a greater density of efferent terminals in the basal and middle regions with less in the apical regions. a comparison of vibration responses of the third and fourth turn in the guinea pig cochlea show that there is a sharper tuning in the more basal ends (khanna et al., 1990) an observation confirmed by using in vivo measurements of the cat cochlea (lieberman, 1982 cited in neely & kim, 1986). a relationship between greater frequency sensitivity and efferent terminal density is therefore implied by these observations (xie et al., 1993). not only is there a regional variation in efferent innervation, but also differences across the rows of ohc noted by several researchers (fex et al. 1982; simmons et al. 1990; fex & altschuler 1984). initially, the density of efferent fibres along the first row of ohc was thought to be a consequence of developmental patterns but it has been suggested that this is not so. the population density may be relatejd to amount of synaptic activity and possibly areas of sharp tuning (xie et al., 1993). however, this in sharp contrast to findings by khanna et al. (1990) who found that the vibration amplitude and frequency response was sharpest in the third row of ohc. however, xie et al. (1993) acknowledges that the role of efferent terminals are still unclear and subject to much conjecture. a lone voice amongst this excitement about efferent feedback loops is that of dolan & nuttall (1989) who suggested that there may be no feedback loop or efferent control system since they observed changes in ihc potentials following contralateral stimulation to be constant in amplitude and instantaneous in activation. they remark that such a feedback system would not be able to be activated within such a short latency and with such constant magnitude. cochlear biochemistry i the bending of the cilia is thought to generate an electric current (depolarisation) along their apical ends 65 which controls the release of neurotransmitter vesicles at the base of the hair cell (clopton, 1986) and supposedly initiates firing of the auditory nerve (nuttall, 1986). this characteristic of the ohc in which they are capable of bending in both directions with force distinguishes it from skeletal muscle in which contractions can only be directed in a single direction, whilst the relaxation phase is passive and does not exert force (bronwell, 1990). lim (1986) is more specific, and suggests that the stereocilia bending in the excitatory direction only will result in the initiation of neural impulses. nevertheless, depolarisation of drug-induced contractions result in an increase in intracellular ca2 +. nuttall (1986) speaks about the "gating of ions" (p.29), or a physical channel through the cell membrane permitting the passage of ions through. zenner (1986) demonstrated that by bathing the hair cells in variable ionic concentrated fluid could result in motile responses of the hair cells therefore suggesting as nuttall (1986) does, that extracellular ions are responsible for motility of the cilia. ikeda & takasaka (1993) more specifically reported that the i n c r e a s e in i n t r a c e l l u l a r c a 2 + was due to transmembrane influx of calsium from the surrounding endolymph and release from the apical cisterns and hensen's cells. contradictory evidence is presented by slepecky et al. (1988) in a study of the effects of tetracaine, a local anaesthetic when they found that it inhibited potassium and calcium-induced contractions in muscle but it did not affect contractions of the ohc when applied extracellularly. this led them to the believe that the increase in cellular calcium was of intracellular origin and did not arise from an influx through the permeable cell membrane. kim (1986) postulated that this slow response was mediated in the area between the cuticular plate and the ohc nucleus an area characterised by a large number of these subsurface cisternae. the finding of gamma a m i n o b u y t y r i c acid (eybauling et al., 1988 cited in dannhof et al., 1993) and acetylcholine receptors (zenner et al., 1990) at the synapses of the ohc, suggested that efferent nerves could stimulate release of inositol-trisphosphate which would control the release and uptake of calcium ions into the cytoplasm and modulate ohc contractions. recent discovery of other neurotransmitters such as choline acetyltransferase and glutamatee decarboxylase present in all ohc efferents and along the entire cochlea (dannhof et al., 1993) suggested that they perform a similar function. it is unlikely that the fast motile responses required the mediation of intracellular ca 2 + (zenner et al., 1987 cited in ikeda & takasaka, 1993) because of its relative independence of adenosin triphosphate (atp) involvement (kachar et al., 1986 cited in slepecky et al., 1988). de boer (1990) speculates that mechanical energy within the scala media or tectorial membrane could be released into the organ of corti, or that the energy source could be electrical or even chemical, and idea that appeals to neely and kim (1986) as well. they guessed that the source of this e n e r g y was electrochemically obtained from the surrounding endolymph. atp is necessary in all biological systems as an energy source necessary for the maintenance of the system. an active cochlea implies that energy needs to be added to the system and schacht (1986) reasons die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 66 carol a jardine that there is no evidence that the cochlea differs from any other system in the body, and that atp is formed through energy metabolism procedure called oxidative phosphorylation. atp is a phosphate compound whose molecular bonds are rich in energy which can be released when required (mcgilvery & goldstein, 1979). bronwell (1990) strongly disagrees with schacht (1986) stating that "the movements result from direct conversion of electrical potential energy to mechanical energy come from experiments that demonstrate movements even after cellular stores of atp are depleted" (p.84). by so doing, he is specifically stating that the physiology of the cochlea is very different to any other body system by not requiring atp. he states that atp is produced in stria vascularis and used to drive peripheral cells and not ohc specifically. davis (year unknown, cited by schacht, 1986) was the first to present his "battery theory" where he cites stria vascularis as being the source of this energy and for this reason schacht (1986) surmises that the cochlea has an unusually low metabolic rate in comparison to other sensory systems because of the contribution of stria vascularis although the exact relationship has yet to be elucidated. four years later, bronwell suggested that the stria vascularis is the source of a silent current of potential energy (1990) and it is this current that stimulates the motility of the ohc. ohc are therefore indirectly fueled by atp via the stria vascularis. return to the passive model lechner (1993).correctly states that the activity of the intact bm is still unclear. dancer (1992), from a review of the literature also suggests the re-examination of the bm. if the cochlea is as active as suggested by the previous research, clopton (1986) argues that such an undamped system would be highly unstable and would have a long release time with oscillations continuing for several seconds. this instability is acknowledged by bronwell (1990) who rationalises that it is these very oscillations which will trigger soae. by comparing the latency between the cochlear microphonic and the input stimulus obtained via direct measurements and those calculated from the zwislocki travelling wave theory, dancer (ibid) was able to conclude that measurements were significantly smaller than those calculated, as illustrated in figure 6. he concluded that the bm was stimulated as a whole immediately and that the bm acted as a helmholtz resonator at least at frequencies below the characteristic frequency, a theory subscribed to more than a century before. however, he is sceptical about the use of the onedimensional longwave model proposed by zwislocki (1948 cited in zemlin, 1982) because the expectations of a long latency required by this model are not met by the short experimental measurements. they concluded , that this bank of resonators was a passive phenomenon until the point of characteristic frequency of the bm, where ohc are thought to contribute towards some actiye p r o c e s s i n g s u p e r i m p o s e d upon a passive hydromechanical phenomenon. clopton (1986) also subscribes to this view, in which the passive role of bm resonance is coupled with the active but independent resonation of the tectorial membrane and hair cells. lizard hair cells were examined cochlear distance, mm figure 6. time taken for a wave to traverse the length of a guinea pig cochlea. theoretically calculated times ( ) are contrasted with actual latencies ( • • • • ) (after dancer, 1992, p. 305). by peake & ling (1980) and they found that the bm vibrated as a whole in response to acoustic stimuli and no travelling wave was generated. using a newly developed piezopolymer transducer to measure bm displacement, lechner (1993) constructed a hydromechanical model of the ear and concluded from his observations that the longitudinal stiffness of the bm could provide differential response characteristics, seemingly providing more experimental evidence that perhaps these traditional theories were not to be discarded so quickly. kolston, viergever, de boer & diependaal (1989) criticise the assumption of active elements in the cochlea since it was based on observed broad mechanical tuning together with the fine frequency selectivity of the neural responses. in comprehensive cochlea model based on an anatomical evidence, kolston et al. (1989) suggest that the bm is divided into an arcuate and pectinate zone (refer figure 7). the motion of the arcuate zone was influenced by the subtectorial j space | organ of corti arcuate zone j pectinate zone bm figure 7. schematic diagram showing the division of the basilar membrane (bm) into an arcuate and pectinate zone (after kolston et al., 1989, p. 134). the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a new look at cochlear mechanics 67 organ of corti and tectorial membranes. they postulated that the supporting cells in the pectinate zone acted as feedback mechanisms to the ohc to enable them to control their impedance and consequently indirectly controlling bm motion. this theory is interesting in that it is able to suggest a function for the supporting cells as well which up to now has been speculated to be purely supportive and nutritive (engstrom, 1982). this theory is also able to explain the contrast between broad tuning measured in the cochlea and the sharpness of the acoustic nerve response (johnstone et al., 1986). the authors argue that the probes utilised measured average bm response, largely the response of the pectinate zone. their conclusion is that sharp frequency selectivity of the cochlea can exist without the use of active elements, if the effect of the arcuate zone were to be taken into account. data from khanna & leonard (1982 cited in neely & kim, 1986) speculate that there is a linear relationship between bm displacement and excitation of hair cells at levels near threshold. de boer (1983) then extended this idea by suggesting that nonlinearity only becomes evident at high intensities. this idea correlates well with the hypothesis that only excessive gain of the amplifier would generate soae (neely & kim, 1986). several theories subscribe to the coexistence of a passive and active element in the cochlea, but differ in their division of the roles be it along the threshold of frequency continuum. and so ... despite this wealth of data about the ohc, what about the inner hair cells (ihc). spoendlin (1969 cited in engstrom et al., 1982) reports that 90 95% of the afferent nerve fibres innervate the ihc. moreover, most of the auditory information carried by the auditory nerve arise from the ihc (pfingst, 1986). the purpose of the ihc seems to be to detect the stimulus and mimic the characteristics of the acoustic nerve (de boer, 1983; nuttall, 1986). how the jstereocilia of these cells are displaced is still questionable although there are postulations that it may be through the viscous forces of the surrounding fluids (nuttall, 1986) or influence from the active mechanical ohc. brown & nuttall (1984 cited in nuttall, 1986) found that the ohc has sufficient active energy to set the inner hair cell cilia in motion. the exact nature of the coupling between ohc and ihc is still one of the most perplexing question in auditory physiology since it has been generally accepted that there is no direct mechanical coupling via the tectorial membrane. nevertheless, lim (1986) in his detailed review of the microanatomy of the cochlea reports on the existence of ihc imprints on the basal surface of the tectorial membrane. he acknowledges that these are not as distinct and consistent in appearance as those of the ohc but at the same time states that the possibility of ihc (especially those at the apical end) coupling to the tectorial membrane albeit loose should not be ignored. such evidence suggests that there could be mechanical coupling of ohc responses to the ihc. by anatomically contrasting the ihc and ohc, a number of differences between these two sensory structures can be noted, most markedly the innervation system (greater number of afferents ihc), tectorial membrane coupling and location along the bm (lim, 1986, p. 142) . ihc tends to be located on the immobile portion of the bm whilst ohc are found on the lateral, more mobile portions. this suggests that the ohc could be responsible for the active mechanics of the cochlea whilst the ihc acts as the passive transducer. the role of the supporting cells in auditory perception has also been questioned although evidence is still scanty. traditionally, they have been considered to provide a supporting framework, form a boundary between the endolymph and perilymph, formation of the tectorial membrane and phagocytosis of cell debris (engstrom et al., 1982; oesterle & dallos, 1989). oesterle & dallos (1986) found that both alternating and direct current were compared and the amplitude of the currents were found to be dependent upon the cell location. the closer the cell was situated to the ihc, the larger the direct current component. they postulated that their role could be in the regulation of neurotransmitter concentration in the intercellular spaces (p.231). in a subsequent paper on the same subject, the experimenters concluded that the potentials measured in the supporting cells arise from the electric currents generated by the hair cells and also show a reflection of the tuned responses of the hair cells. conclusions research in the area of cochlear micromechanics is still ongoing although much information has been gained through the discovery of otoacoustic emissions. recording of spontaneous and evoked emissions revived the concept that the cochlea could be active, whilst the discovery of distortion product emissions confirmed the presence of nonlinearity in the cochlea. the third problem facing biophysicists was the high frequency selectivity of the ihc and viii nerve when compared to the broad tuning curves of the bm. subsequent research has focussed mainly on the resolution of these three aspects of cochlear physiology. there is a wealth of fragmentary experimental data examining isolated cochlear behaviour under certain conditions, but the assimilation of this data into a cohesive cochlear model is still elusive. a major problem lies in the construction of a mechanically active cochlear model which is intrinsically unstable hampering investigators (de boer, 1983, p.572) as well as the limited in vivo measurements possibly causing the seemingly contradictory data. regardless of these difficulties, there seems to be increasing concensus over several issues: (a)that non-linearity exists at several levels the basilar m e m b r a n e , the m e c h a n i c a l t r a n s d u c t i o n into potentials and between the hair cell potentials themselves (eggormont, 1993); (b)that there is an active process occurring within the cochlear (davis, 1983) primarily mediated by the outer hair cells (kim, 1986); (c) that the origin of the emissions are the electromotility of the ohc (bronwell, 1990) as observed by the obliteration of these responses following noise-exposure, salicylate ingestion and other insults; (d)that the efferent feedback loop (xie et al., 1993) and in particular the neurotransmitters (zanner et al., die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 68 carol a jardine 1990) play a critical role in this. such observations would explain the sharp tuning curves of the cochlea and the presence of otoacoustic emissions and the pivotal role the ohc plays. nevertheless, some authors have cautioned against the quick dismissal of the traditionally held theories of hearing and suggest the presence of some crucial passive response of the cochlea occurring concomitantly (dancer, 1992). there is an overwhelming mass of experimental data on cochlear mechanics and each publication brings with it a new dimension. this paper serves merely to highlight the current trends, but this arena is eternally in a state of flux. undoubtedly, the cochlea is truly a sensitive, selective and secretive instrument! references bronwell, w.e. 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(1986). functional structure of the organ of corti: a review. hearing research, 22, 117-146. mcgilvery, r.w. & goldstein, r. (1979). biochemistry: a functional approach, 2nd edition, wb saunders co., japan. neely, s.t. &kim, d.o. (1986). a model for active elements in cochlear biomechanics, journal of acoustical society of america, 79, 5, 1472-1480. nuttall, a.l. (1986). transduction and frequency tuning in hair cells. seminars in hearing, 7, 1, 27-44. oesterle, e. & dallos, p. (1986). intracellular recordings from supporting cells in the organ of corti. hearing research, 22, 229-232. j oesterle, e. & dallos, p. (1989). intracellular recordings from supporting cells in the guinea-pig cochlea: ac potentials, journal of acoustical society of america, 86, 3, 1013-1032. peake, w.t. & ling, a. (1980). basilar membrane motion in the alligator lizard: its relation to tonotopic organisation and frequency selectivity, journal of acoustical society, of america, 67, 1736-45. ' pfingst, b.e. (1986). encoding of frequency and level information in the auditory nerve. seminars in hearing, 7, 1, 45-64. ' pickles, j.o. (1982). an introduction to the physiology of hearing, academic press, london. probst, r., antonellia, c. & pieren, c. (1990). methods and preliminary results of measurements of distortion product otoacoustic emissions in normal and pathological ears. in f. grandori, g. cianfrone & d.t. kemp (eds): cochlear mechanisms and otoacoustic emissions, advances in audiology. basel, karger, 7, 117-125. puel, j.l., rebillard, g. & pufol, r. (1990), active mechanisms and cochlear efferents. in f. grandori, g. cianfrone & d.t. kemp (eds): cochlear mechanisms and otoacoustic emissions, advances in audiology. karger, 7, 156-163. rajan, g. (1990). crossed cochlear influences, on monaural temporary threshold shifts, hearing research, 12, 185-197. rossi, g. (1990). intracochlear mechanisms involved in the generation of delayed evoked otoacoustic emissions. in f. grandori, g. cianfrone & d.t. kemp (eds): cochlear mechanisms and otoacoustic emissions. advances in the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a new look at cochlear mechanics 69 audiology. basel, karger, 7, 180-187. schacht, j. (1986). biochemistry of cochlear function and pathology. seminars in hearing, 7, 1, 101-115. siegel, j.h. & kim, d.g. (1982). efferent neural control of cochlear mechanics? olivocochlear bundle stimulation affects cochlear biomechanical nonlinearity. hearing research, 6, 171-182. simmons, d.d., manson-gieseke, l., hendrix, t.w. & mccarter, s. (1990). reconstructions of efferent fibres in the postnatal hamster cochlea, hearing research, 15, 113122. slepecky, n., ulfendahl, m. & flock, a. (1988). effects of caffeine and tetracain on outer hair cell shortening suggest intracellular calcium involvement. hearing research, 32, 11-22. ulfendahl, m., flock, a. & khanna, s.m. (1990). cochlear mocromechanics from isolated cells to the intact hearing organ. in f. grandori, g. cianfrone & d.t. kemp (eds): cochlear mechanisms and otoacoustic emissions. advances in audiology. basel, karger, 7, 27-34. voldrich, l. (1978). mechanical properties of basilar membrane. acta otolaryngologica, 86, 331-335. warren iii, e.h. & lieberman, m.c. (1989). effects of contralateral sound on auditory nerve responses: i. contributions of cochlear efferents. hearing research, 37, 89-104. xie, d.h., henson, m.m., bishop, a.l. & henson, o.w. (1993). efferent terminals in the cochlea of the mustached bat: quantitative data. hearing research, 66, 81-90. zemlin, w.r. (1982). speech and hearing science anatomy and physiology, 2nd edition, prentice-hall inc, new jersey. zenner, h.p., zimmerman, u. & schmitt, u. (1985). reversible contraction of isolated mammalian cochlear hair cells, hearing research, 18, 127-133. zenner, h.p. (1986). motile responses in outer hair cells, hearing research, 22, 83-90. zenner, h.p., reuter, g., plinkert, p.k. & gitter, a.h. (1990). fast and slow motility of outer hair cells in vitro and in situ. in f. grandori, g. cianfrone & d.t. kemp (eds): cochlear mechanisms and otoacoustic emissions. advances in audiology. basel, karger, 7, 35-41. zwislocki, j.j. (1986). are nonlinearities observed in firing rates of auditory nerve afferents reflections of a nonlinear coupling between the tectorial membrane and the organ of corti?. hearing research, 22, 217-221. address correspondence to: c jardine, department of speech pathology and audiology, university of the witwatersrand, ρ ο wits, 2050. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 acoustimed p.o. box 9 9 8 8 hearing services joh—urg offices in melville and johannesburg tel: 337-2977 fax: 337-5579 tinnitus maskers tinnitus is usually experienced as a ringing, hissing or buzzing sound in the ear or in the head. it is commonly associated with a mild hearing loss in the high frequencies. according to the american tinnitus association almost 5% of the american population suffers from tinnitus in its severe form and millions more are afflicted to a lesser degree. we have no reason to believe that the situation is any different in south africa. surveys have shown that the most effective source of relief is a tinnitus masker. acoustimed's tinnitus masker is an in-the-canal device which uses a specially designed amplifier module capable of amplifying up to 20000hz. for high frequency tinnitus the masker can be adjusted to provide as much as 70db spl of masking noise at frequencies above 6000hz. our experience with tinnitus masking has shown that a high frequency masker can provide effective masking with least awareness of the masking noise. in exceptional cases the masking noise is inaudible. the presence of a masker interferes with the acoustic characteristics of the ear canal causing, in effect, a mild high frequency hearing loss. all maskers must, therefore, provide some acoustic gain in the region of 3000hz even if the patient's hearing is completely normal. where necessary the masker will additionally compensate tor the hearing loss which is typically associated with tinnitus. because each masker is custom-built it is necessary to determine the nature of the tinnitus and obtain a reasonable prognosis prior to manufacture. for this purpose we use a number of instruments including a computer program which simulates multi-frequency tinnitus. for more information please telephone 337-2977 or 726-2430. registered hearing aid acousticians: d. a. smith d. christodoulides l. williams the south african journal of communication disorders, vol. 40, 199 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 53 die verband tussen gesproke en geskrewe taal van leergestremdes idillette qosthuizen, brenda louw en isabel uys departement kommunikasiepatologie, universiteit van pretoria opsomming die ondersoek het dit ten doel gehad om die verband tussen gesproke taal, geskrewe taal en fonologiese prosessering te bepaal. die empiriese opname is deur middel van 'n beskikbaarheidseleksie op nege afrikaanssprekende taalleergestremde leerlinge in graad-twee uitgevoer. ooreenkomstig voorafbepaalde doelstellings is gesproke taalparameters, geskrewe taalparameters en fonologiese prosesseringsparameters geidentifiseer. die proefpersone se peil van funksionering op die onderskeie parameters, sowel as die verwantskap tussen die parameters is kwalitatief en kwantitatief ontleed en beskryf. die resultate van hierdie empiriese opname toon dat betekenisvolle korrelasies tussen gesproke taal, geskrewe taal en fonologiese prosesseringsvaardighede by die betrokke taalleergestremde proefpersone voorgekom het. abstract the aim of this study was to explore the interrelationship between spoken language, written language and phonological processing. the empirical study was administered on nine afrikaans-speaking, language-impaired children in grade two by means of accidental sampling. conformable to predetermined objectives, spoken language parameters, written language parameters, and phonological processing parameters were identified. the subjects' level of functioning with regard to each parameter, and the interrelationship between these parameters were qualitatively and quantitatively analysed and described. the results of this study indicated significant correlations between spoken language, written language and phonological processing abilities of the selected language impaired subjects. sleutelwoorde: taalleergestremdheid, gesproke taal· i geletterdheid, geletterdheidsontwikkeling en voorlopers tot geletterdheid is tans van die mees kontensieuse onderwerpe binne die vakgebied van spraak-taalpatologie. 'n herorientasie in navorsers en beroepslui se siening van geletterdheid het gedurende)die afgelope eeu en veral gedurende die afgelope dekade plaasgevind. voor 1970 is leesprobleme as 'n uitval in visueel-perseptuele prosesse beskou. johnson en myklebust (1967) het egter die grondslag gele vir die perspektief dat leesprobleme, en gevolglik ook skryfprobleme, 'n taalgebaseerde uitval is en nie noodwendig 'n refleksie van kognitiewe of visueelperseptuele beperkinge nie (kamhi & catts, 1991). hierdie verandering in siening van navorsers en beroepslui bring mee dat taal as vertrekpunt vir die ontwikkeling van gesproke en geskrewe taalvermoens beskou word. die verandering stel opnuut uitdagende en opwindende eise aan die spraak-taalterapeut. juis vanwee die spraak-taalterapeut se besondere kennis van taalontwikkeling en taalprobleme, speel lede van hierdie beroep η kardinale rol in diagnose en intervensie van die kind met gesproke en geskrewe taalprobleme. die suid-afrikaanse vereniging vir spraak-taal-gehoor (savstg) (1990: 2) ondersteun die standpunt dat die spraaktaalterapeut 'n belangrike rol speel tydens diagnose en intervensie van beide gesproke taalprobleme en geskrewe geskrewe taal, fonologiese prosessering. taalprobleme. dit blyk dat vanwee die feit dat die spraak-taalterapeut 'n onmiskenbare rol by beide gesproke en geskrewe taal speel, dit noodsaaklik geword het om weg te beweeg van 'n diskrete-puntbenadering waar gesproke taal alleen aangespreek word, 'n breer en dus holistiese benadering word aanbeveel waar die kind in totaliteit gesien word en beide gesproke en geskrewe taalprobleme as uitvloeisel van 'n onderliggende taalprobleem behandel word. die noue interaksie tussen gesproke en geskrewe taalprobleme bestaan en die feit dat die spraak-taalterapeut gevolglik albei di£ komponente tydens diagnose en intervensie by die leergestremde kind behoort aan te spreek, impliseer dat groter eise en hoer vaardigheidsvlakke aan beroepslui gestel word. dit is van kardinale belang dat navorsing oor taalprobleme, en die gevolg van taalprobleme, voortgesit moet word sodat resente bevindings by die bestaande databasis gevoeg kan word (klecan-aker & kelty, 1990). as gevolg van ontwikkeling in die vakgebied, ontstaan daar voortdurend nuwe vraagstukke wat navorsing vereis. nuwe kennis moet voortdurend by bestaande kennis gevoeg word, sodat die spraak-taalterapeut 'n teoretiese basis kan formuleer wat as grondslag kan dien vir effektiewe diagnosering en intervensie by die taalleergestremde kind. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 idilette oosthuizen, brenda louw en isabel uys in die lig van resente navorsingsbevindinge word die spraak-taalterapeut gekonfronteer met vraagstukke soos wat die spesifieke aard van die verband tussen gesproke en geskrewe taalprobleme werklik is (stackhouse, 1990). dit is vir verantwoordbare beroepsoptrede noodsaaklik dat die spraak-taalterapeut kennis moet dra van hierdie vraagstukke. vanwee die.noue verwantskap tussen gesproke taalfunksionering en geskrewe taalfunksionering kan gesproke taal en geskrewe taal nie as sodanig in isolasie benader word nie. in die verlede is die rol van die spraak-taalterapeut afgebaken en beperk tot evaluering, diagnose en intervensie van gesproke taalprobleme. hierdie fragmentariese beskouing het tot gevolg gehad dat daar tans 'n leemte in kennis oor die spesifieke verwantskap tussen gesproke en geskrewe taal bestaan. bo en behalwe dat gesproke taal en geskrewe taal as interafhanklike vaardighede beskou word, word daar tans gespekuleer oor die invloed van fonologiese prosessering op beide hierdie vaardighede. daar word in resente publikasies (stackhouse, 1990; kamhi & catts, 1991) gehipotetiseer dat gesproke en geskrewe taalprobleme moontlik die manifestasie van dieselfde onderliggende fonologiese prosesseringsprobleem is. stackhouse (1990) beskryf pertinent die moontlikheid van spraak-, leesen spelprobleme as verskillende manifestasies van dieselfde onderliggende fonologiese prosesseringsprobleem. waar kinders met gesproke en geskrewe taalprobleme presenteer, ontstaan die vraag of 'n onderliggende fonologiese prosesseringsprobleem kan bydra, of selfs die primere oorsaak van beide gesproke taalprobleme en geskrewe taalprobleme, kan wees. indien laasgenoemde wel die geval is, impliseer dit dat 'n verbetering in fonologiese prosesseringsvermoens 'n verbetering in beide die gesproke taalvaardigheid en geskrewe taalvaardigheid teweeg sou kon bring. die behoefte om meer inligting oor die spesifieke aard van die verwantskap tussen gesproke en geskrewe taal te verkry, asook of 'n onderliggende faktor, naamlik fonologiese prosesseringsprobleme 'n oorsaak van beide gesproke taalprobleme en geskrewe taalprobleme is, is in die literatuur geidentifiseer (van kleeck, 1990 en 1992; kamhi & catts, 1991). dit blyk egter sinvol te wees om resente vraagstukke rakende gesproke en geskrewe taalprobleme binne die leergestremde populasie te ondersoek, aangesien leergestremde kinders 'n hoe-risikopopulasie is om met beide gesproke en geskrewe taalprobleme te presenteer (reid, hresko & swanson, 1991; klecan-aker & kelty, 1990). reid et al. (1991) ondersteun die standpunt dat navorsing oor die leergestremde populasie ten spyte van uitgebreide studie steeds geregverdig word. hul meen dat beperkte aandag aan basiese navorsing en aan die ontwikkeling van teoriee geskenk word, en dat navorsing oor leergestremdheid uiters swak georganiseer is. daar word voorgestel dat intensiewe gekoordineerde wetenskaplike navorsing sal bydra tot die oplossing van fundamentele probleme rakende leergestremdheid (reid et al., 1991). nye, foster en seaman (1987) beklemtoon die belang van navorsing, asook die waarde van intervensie by die leergestremde populasie. hul motiveer hul siening deur wetenskaplik te bewys dat taalleergestremde kinders se taalfunksionering merkwaardige verbetering getoon het nadat 'n intensiewe taalintervensieprogram met hulle gevolg is. dit blyk dat die taalvaardigheidsvlakke van die taalleergestremde kinders betekenisvolle verbetering getoon het, en dat navorsing op hierdie spesifieke populasie soveel te meer sinvol blyk te wees wanneer daar na hul vorderingsmoontlikhede gekyk word. beroepsfunksies van die spraak-taalterapeut impliseer die hantering van kommunikasieafwykings (uys, 1993), kommunikasie-afwykings sluit onder andere taalprobleme in wat presenteer op beide gesproke taalvlak en geskrewe taalvlak. wanneer fonologiese prosesseringsvaardighede as voorvereiste vir effektiewe funksionering op geskrewe taalvlak en gesproke taalvlak beskou word (stackhouse, 1990), word fonologiese prosessering onomwonde deel van kommunikasie-afwykings wat onder andere deur die spraak-taalterapeut hanteer word. alhoewel die spraak-taalterapeut as lid van die transprofessionele span betrokke is by evaluering, diagnose en intervensie van leergestremde leerlinge, word die spraaktaalterapieberoep as sodanig met kommunikasieafwykings (wat kommunikasie-afwykings van leergestremdes insluit) geassosieer. die doel van hierdie studie is gevolglik om meer inligting in te win aangaande die aard van die verband tussen gesproke en geskrewe taalvermoens van leergestremde leerlinge aangesien dit waardevolle kliniese riglyne vir evaluering, diagnosering en intervensie by die leergestremde populasie verskaf. meer effektiewe bemoeienis rakende gesproke en geskrewe taalprobleme kan uit die beskikbaarheid van hierdie inligting voortvloei. metode as agtergrond tot die ondersoek is doelstellings geformuleer. doel die doel van die ondersoek is om die funksionering van 'n groep taalleergestremde leerlinge in onderskeidelik gesproke taalfunksionering, geskrewe taalfunksionering en fonologiese prosessering te ondersoek asook om die aard van die verband tussen gesproke taalvermoens, geskrewe taalvermoens en fonologiese prosesseringsvermoens te bepaal. die volgende subdoelstellings is geformuleer om die doel te bereik: 1. identifikasie van die onderskeie gesproke taalparameters, geskrewe taalparameters en fonologiese prosesseringsparameters. i 2. bepaling van proefpersone se peil van funksionering op die onderskeie parameters. 3. ondersoek na die verwantskap tussen die onderskeie parameters. navorsingsontwerp hierdie studie is in die vorm van 'n kwalitatiewe en kwantitatiewe gestruktureerde beskrywende opname uitgevoer (leedy, 1989). / proefpersone proefpersone is d e u / m i d d e l van die beskikbaarheidseleksie (leedy, 1989) gekies en het aan die volgende kriteria voldoen: the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ο) s> bo φ 73 ci φ ο μ >. pq τ 3 2 ι 's ϊη u 00 α * .2 ο. 0q φ γ" i* fe φ 00 φ 3 ft φ λ xi tη φ ώ φ ·γη 2 α. s 0 1 ft φ cq -β p j e verband tussen gesproke en geskrewe taal van leergestremdes afrikaans moet die moedertaal of dominante taal wees. ' fyj o r m ale visuele en ouditiewe vermoens moet voorkom. 3 s e r e b r a l e gestremdheid mag teenwoordig wees. 4 spesifieke leergestremdheid moet by alle proefpersone gediagnoseer wees. 5 p r o e f p e r s o n e moet graad twee skoliere wees in 'n skool ' vir buitengewone onderwys. g p r o e f p e r s o n e moet oor ' n gemiddelde o f bo-gemiddelde intelligensie beskik. 'n ibtale aantal van nege proefpersone is in hierdie empiriese studie betrek. die inligting vir proefpersoonbeskrywing word volledig in tabel 1 saamgevat. materiaal enapparaat die apparaat en materiaal word in drie afsonderlike afdelings bespreek, naamlik: 1. meetinstrumente om gesproke ttial te evalueer meetinstrumente wat geselekteer is om gesproke taal te evalueer word opsommend in tabel 2 weergegee. 2. meetinstrumente om fonologiese prosessering te evalueer aangesien daar nog geen gestandaardiseerde toets bestaan wat fonologiese prosesseringsvermoens evalueer nie, het die navorser na deeglike literatuurverkenning (van kleeck, 1992; stackhouse, 1990) 'n eie toets ontwerp (vergelyk bylae a), wat spesifiek die segmentering van die akoestiese stroom evalueer. die toets bestaan uit drie subtoetse, naamlik subtoets een wat die segmentering van 'n sin in sy afsonderlike woordkomponente evalueer, subtoets twee wat die segmentering van 'n woord in sy afsonderlike sillabes evalueer en subtoets drie wat die segmentering van 'n woord in sy afsonderlike klankkompohente evalueer. die subtoetse is so geformuleer dat verskillende klankkombinasies wat in afrikaans voorkom, deur die subtoetse gedek word. ! i 3. meetinstrumente om geskrewe taal te evalueer meetinstrumente wat geselekteer is om geskrewe taal te evalueer word opsommend in tabel 3 weergegee. opname prosedures die prosedure is soos volg toegepas: 1. data-insamelingsprosedure die volgende prosedure is gevolg: toestemming is van die skoolhoof verkry om die betrokke empiriese studie op die graad twee leerlinge uit te voer. " 'n profielblad met identifiserende inligting rakende alle proefpersone is deur die navorser vir elke proefpersoon voltooi. 1 55 φ s => a ο ο 5"® vh φ β fls « ύ s a ο cu w ^ i—i « bfl i l l λ s ® > 2 ω rt ci • s 3 -μ '3 ^ s h i-i ο ĵ +j φ bo bo bj δ ft ci cη μ g cq bo ϋ ci ci 3 ο a-s a nj o j u1 ϋ ci i φ φ .g -aϊ co < j ο 2 ci •γη ιa bo ci ••e β •a bj 73 ci bj < ci φ δ h£ φ φ i — i α φ λ ft μ < 3 3 tf ο (ν (ν co (ν ο ο 00 ιο ο ο (ν 00 00 (ν 00 <35 (ν ο 00 κ κ κ die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 proefpersone is aan spraak-taalterapeute en 'n remedierende onderwyseres toegeken vir uitvoering van diagnostiese toetsing. spesifieke voorskrifte is gevolg ten opsigte van uitvoering van toetse. akkurate beskrywing van data is op gefotostateerde vorms aangeteken. 'n statistikus is geraadpleeg vir dataverwerking. idilette oosthuizen, brenda louw en isabel uy 2. data-analise om doelstelling een te bereik is alle veranderlikes in dj data-definisie gedefinieer (vergelyk bylae b) e* gekategoriseer onder gesproke taalparameters, geskre^ taalparameters en fonologiese prosesseringsparameters om die tweede doelstelling te bereik is die volgend stappe beplan (leedy, 1989): 6 tabel 2: meetinstrumente wat geselekteer is om gesproke taal te evalueer evaluasie-area meetinstrument motivering vir keuse van toets bron i taalinhoud * peabody picture and vocabu lary test (ppvt) (vertaald( afrikaanse weergawe) * die ppvt gee 'n verbale intelligensiekwosien! wat effektief met verbale tellings, soos gemeet deur die jsais (madge, 1981) of ssais (madge, 1983) vergelyk kan word. die ppvt is verder geselekteer aangesien die afrikaanse reseptiewe woordeskattoets (arw), nog nie beskikbaar is nie. * oorspronklike samesteller -lloyd, 1959 * test for auditory comprehension of language (tacl-r) (vertaalde afrikaanse weergawe) * inligting met betrekking tot die proefpersoon se reseptiewe taal word in 'n kort tyd verkry. inligting behels naamlik woordklasse en relasies, grammatikale morfeme en uitgebreide sinne. 'n ouderdomspeil word verkry wat intertoetsrelasies en interproefpersoonrelasies vergemaklik. * oorspronklike samesteller -carrow-woolfolk, 1985 ii taalvorm * die afrikaanse semantiese taal-evalueringsmedium (ast) -subtoets 2: woorddefinisies * die ast is 'n resente toets wat ekspressiewe uitinge (woordbeskrywing) op 'n maklike en informele wyse evalueer. die omskakeling van die roupunt na 'n ontwikkelingsvlak word op 'n tabel afgelees, en langdradige verwerkings van resultate word gevolglik daardeur uitgeskakel. deur middel van die ouderdomsvlak kan effektiewe interproefpersoon en intertoetsrelasies afgelei word. * pretorius, 1989 * toets vir mondelinge taalproduksie (tmt) * die tmt verskaf metings vir 16 fasette van taalproduksie wat saam produktiwiteit, sintaktiese kompleksiteit, korrektheid, vlotheid en inhoud dek. stanege-tellings kan effektief in statistiese vergelykings gebruik word. * vorster, 1980 i iii taalgebruik * pragmatiek-evaluasie * hierdie vraelys bestaan uit 'n kort en bondige metode waardeur verskeie aspekte van pragmatiek geevalueer word. direkte terapieleidrade word verder deur die vraelys verkry. die roupunt uit 20 kan effektief met di6 van ander leerlinge vergelyk word. * creaghead, 1984 ,' iv ouditiewe prosessering * pendulum die volgende areas word getoets, naamlik -ouditiewe storiegeheue, •ouditiewe opeenvolgende geheue, ouditiewe sluiting, ouditiewe analise en ouditiewe sintese. * die pendulum is gekies aangesien die toets maklik uitvoerbaar is. 'n pertinente ouderdomsen standerdpeil word ook verkry, wat effektief in statistiese vergelykings gebruik kan word. tallal (1980 in stackhouse, 1990) beklemtoon ook die verband tussen leesen ouditief-perseptuele probleme, met die gevolg dat ouditiewe prosessering noodwendig deel van die toetsbattery moet uitmaak. "struwig, 1984 / / y the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) verband tussen gesproke en geskrewe taal van minimumen maksimumwaarde word vir alle * n nderlikes bepaal. hprlikes met negatiewe tellings word omgeskakel * v e r a o s i t i e w e tellings sodat hoer toetstellings, beter n a l s i e by die toetsling impliseer. η s k a l e r i n g vind plaas m e t ander woorde, alle * raiiderlikes word getransformeer na 'n nul-eenv t e r v a l s k a a l sodat alle veranderlikes met mekaar m g e l y k b a a r kan wees, en toetsresultate word op 'n u litatiewe wyse beskryf om sodoende die moontlike v e r b a n d e en verklarings vir die verbande uit te wys, al dan nie. om die derde doelstelling te bereik, is die volgende stappe beplan (leedy, 1989): • pearson se parametriese korrelasietegniek word toegepas om sodoende die korrelasie-koeffisient te bepaal. • na aanleiding van die waarde van pearson se korrelasiekoeffisient kan daar bepaal word of betekenisvolle verbande tussen gesproke taalparameters, geskrewe taalparameters en fonologiese prosesseringsparameters bestaan, al dan nie. • s p e a r m a n se nie-parametriese korrelasietegniek word toegepas om sodoende die korrelasiekoeffisient te bepaal na aanleiding van die waarde van spearman se korrelasiekoeffisient wat rangordekorrelasies bepaal. resultate en bespreking die resultate word vervolgens aangebied. leergestremdes 57 i. identifikasie van onder skeie parameters op gesproke taalvlak, geskrewe taalvlak en fonologiese prosesseringsvlak die toepaslike veranderlikes word vir die doel van die studie in tabel 4 weergegee. //. uiteensetting van proefpersoonfunksionering op die onderskeie parameters die parameters wat 'n betekenisvolle verskil met kronologiese ouderdom van die groep proefpersone aandui, word in tabel 5 saamgevat. iii. bespreking enverklaring van die aard van die korrelasies wat tussen gesproke taalparameters, geskrewe taalparameters en fonologiese prosesseringsparameters geidentifiseer is die aard van die korrelasies tussen gesproke taalparameters, geskrewe taalparameters en fonologiese prosesseringsparameters word in tabel 6 saamgevat. alhoewel outeurs verskil oor die spesifieke aard van gesproke taaluitvalle, geskrewe taaluitvalle en fonologiese prosesseringsuitvalle by taalleergestremdes, asook oor die verband tussen hierdie vaardighede, is outeurs en navorsers dit eens dat taalleergestremde leerlinge 'n hoerisiko-populasie is, omdat hulle met uitvalle op hierdie tabel 3: evaluasie-areas en meetinstrumente wat geselekteer is om geskrewe taal te evalueer areas wat geevalueer word meetinstrument motivering vir keuse van toets en afleidings wat gemaak kan word uit die verkree toetsresultate bron i. leesvermoe individuele diagnostiese leestoets (prosalees en begrip) inligting word verkry aangaande 'n leerling se visuele begrip, aangesien hul self'n voorgeskrewe stuk moet lees en daarna mondelinge antwoorde op vrae moet gee. inligting word ook verkry aangaande 'n kind se visuele storiegeheue. grove & hauptfleisch (1984) een-minuutleestoets inligting aangaande die kind se leesspoed word verkry. afleidings kan gemaak word m.b.t. hul sintesevermoe en begrip. leerlinge met 'n hoe ik is geneig om hulself te korrigeer. transvaalse onderwysdepartement (ongedateer) ii. spellingvermoe k3 skolastiese toets bo en behalwe inligting oor 'n leerling se spellingvermoe kan afleidings gemaak word aangaande die kind se begrip van stillees. transvaalse onderwysdepartement (ongedateer) ipv spellingtoets inligting aangaande die leerling se spellingvermoe word verkry in terme van woorde wat progressief moeiliker gegradeer is. universiteit van wes-kaapland (ongedateer) tod taaltoets 1 inligting word verkry aangaande stillees-begrip. inligting word met betrekking tot spelling en begrip verkry aangesien vrae skriftelik beantwoord moet word. transvaalse onderwysdepartement (ongedateer) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 idilette oosthuizen, brenda louw en isabel uy c ο t-pa σι in σι 13 £ σι in σι 13 £ μ § ο 1 i * 2 m 5 °° « os ο ή μ a ο i i * ο η m a °° ο ή ο i ι * ο η in s 0 0 <s os ο ή ο i i * ο η in s 0 0 <s os ο ή μ «§ ο i i * ο t in αο « os ο .-η ο i i i t in co gj υ 3 os 00 os to 'c ο φ t h cl, os 00 os co x s φ t h cl, ο ο ο ο ο ο 00 00 00 00 00 αϊ os os os os os os t-l t-l th th th t-l th* if if φ φ ω ω φ ^ •+5 co co 03 03 co iq th th u u u £ £ £ i ? £ £ £ £ cl, cl, co (η φ .3 £ ce bo tφ φ & cl, pl, ζ * φ ce £ φ bo ce a α ce j φ bo ce a c ce j «τ-ο c ο c φ s s t-co β '-β φ φ § ω co β ce . ce " 11) o jg ce "ε &h > 13 c ce φ ce bo tφ φ * cn ce φ co α cd φ ce w φ >>2 ο i •s * cd tdu > 2 ® . 2 ® co s co β c φ 2 λ s φ je a ^ ο φ ο 13 φ bo ce a α cd j φ bo ce a α ce j ω bo ce a α cd hj «τ-ο α ο φ * cd bo th φ φ 2 ω « s φ 2 <2 ce φ μ s ^ ο φ ο ^ "ί « th i co < ώεη. c c φ cd β s φ η χ! « λ s >> cd κ 0 3 ο -υ -s tn th t co < φ λ a ^ ο φ ο ^ is ce co < φ μ a ^ ο φ ο 2 >»"ΐ3 jh cd th • co < ω λ s ^ ο φ o ^ b ce ο • t-£ « 13 in < ρ ρ ρ ρ ρ ρ ρ s s § § § § § e-i ε-ι ε-ι ε-ι ε-ι εη ρ φ φ _φ φ φ 'ω *0q '3 's '3 '3 "3 λ λ λ μ λ λ λ "3 λ ρ 3 ρ ρ 9 13 13 13 13 13 13 13 ο ο ο ο ο ο ο t h t h t h t h t h t h t h j5* j5* α . α , 3 "ce "ce "ce 13 "ce ce cd ce cd ce ce cd ε-ι ε-ι ε-ι ε-ι ε-ι ε-ι η φ ω ω φ φ φ φ bo bo bo bo bo bo bo β β β .β β _β β • t-l *·-ι "•η •η "ω φ φ " φ φ " φ "ω 13 13 13 13 13 13 13 β β β β β β β ο ο ο ο ο ο ο § s § § § § t h t h t h t h t h t h t h 'ρ 'ρ 'ρ 'ρ v co cq co cq co co αϊ -μ φ ω φ ω ω ω φ β β β β a ο 13 th φ 13 ρ ο 03 13 β ce -μ co th c :φ •t-l 03 ο ^ λ φ '«3 β bo a a ι •s a m a φ r 3 0 0 'φ cq m ο bo-s κ 3 £ cc a p φ § • s g φ μ 'φ co φ ρ 92 κ 3 id cο a ρ a a •fn a (μ ω ο cο β ω 13 13 th ο i a ρ a co λ ce a φ ο -μ •9 cο β ω 13 13 th ο i ω 13 th ο ο β ce ce φ̂ ω xi β ω φ t-ω α. φ 13 th ο ο β ce ce "ω 13 13 a ω ο ω xi β φ φ •2 ^ ce th i β ω λ ω ^ ι φ α. & u ω α, φ 13 th ο ο ι pa φ xi β ω ω tφ ο. ω co th ο ί? ω xi β φ ω tφ ο. φ 13 th ο ο i tφ * ω 13 φ bo $ a ^ i -c ο β ο fa co a 03 cd φ tcq cd ο o< ft φ ^ ω t-μ co φ ο ui £ λ ω s s s 2 ce o. s δ ο ' φ ftl s s 2 ο a χ χ χ χ χ χ χ χ χ χ χ χ χ χ χ χ x β ce is > γ3 φ h u φ· h i δ -1 ^ φ λ > 00 a ο fc ο (μ the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die e verband tussen gesproke en geskrewe taal van leergestremdes 59 c ο t-pa ο ο ο ο ο ο ο ο ο 00 00 00 00 00 00 00 00 00 σι σι σι σι σι σι σι σι σι τ-ι τ-ι τ-ι τ-ι τη τ-ι τ-ι τ-ι τ—i tt li tt tn" tn" tn" φ . t j φ φ φ 8 8 ' " 8 8 2 cq co co cq υι αϊ 01 co co lh μ, tu u th u (ν £ £ £ £ ί? £ is i? •ψ 00 σ ι t-® . <§§ ® m > s" 5 1 co ® t 3 •a i i ® £ β β β φ φ φ αϊ ΐω tt ti tn" φ φ φ " 3 > o. 0 0 -s "β > rt β ό φ il lit qpa qpa a φ β s η φ φ ε—< ε—< ε—< § § § ε—< ε—< ε—< ω λ τ 3 ο >73 & φ i " φ τ 3 β ο >φ •fl ω •3 τ 3 ο >-j3" 73 £ φ υο c •fl "φ τ 3 β ο § >ε-ι ε-ι § § b b φ φ 3 -9 1 τ 3 ο >73 & φ i " φ τ 3 β ο >τ 3 ο >73 £ φ υο β τ 3 ο >α. 73 £ φ υο β φ φ φ r o r o _© ε-ι ε-ι ε-ι •3 -s β β ο ο 53 § >>-03 co -w -w φ φ β s ε-ι ε-ι § § ε-ι ε-ι · ® *03 μ τ 3 ο >73 £ φ υο β 1 β ο § >φ μ τ 3 ο >ο. 73 £ φ ω β 1 β ο § >φ ε-ι ε-ι 53 § ε-ι ε-ι φ -t-l co λ τ 3 ο >α. co λ τ 3 ο >ο. 73 & & β "φ τ 3 β ο >φ co j>> φ cs •a 6: ce £ φ ω .β "φ τ 3 β ο >φ a co β •*» a i i s co φ 73 ce φ xi ω ce φ tο 3 ρ β β φ w ω β φ α. cο ι φ ο ο μ cο ρ? φ ο co φ φ co ο a 2 " φ ρ 73 β φ 5 73 ce ^ q ο η οι αϊ ΐω φ φ φ 2 ο ΐω 03 ΐω bo bo bo β β β " β έ χ φ φ φ οι 03 οι οι οι 03 φ φ φ οι οι ΐω ο ο ο £ £ £ φ φ φ οι ΐω οι φ φ φ •a •a •a ο ο " ο " ο ο β β β ο ο ο fa fa >φ -μ φ a ce tce -e· φ μ τη -s β ce th u β ce > ω β u μ co φ pa λ λ uu i β « co ce φ >co ce 2 o. .3 13 φ xi β φ φ φ xi β φ φ >φ α, co •a β ce > t2 2 η φ xi β φ φ >φ ο. co ω β α, >£ t-φ ο. co ω β φ ή 'ο ο "ο > β ο φ xi β φ φ >φ ο. 03 ω β χ φ ^ φ ΐ φ 6 ρ λ i co β •fn cο φ xi β φ ® η εη 3 λλ >φ α. co β5 χ φ φ ΐ φ > φ co ρ φ λ 73 th ο i tφ α. co ω α 73 χι th ^ 73 th ο i φ φ tφ ο. co ω β 1 φ ο β φ pa φ •a φ φ ε̂ tφ ο. μ φ τ3 β φ xi φ φ t7* ο λ i λ ce th β χ ! ο < λ φ ce th cl, 73 φ ο ο. τω co φ φ hj ω β φ α, cο ω β φ ο. cο α, "β φ χ! β φ ΐω φ φ 73 co ο tcl, "β φ χ! φ φ cc φ β β β ® i« ^ φ 69 β β ο •c λ φ a « i i f cο ? φ χ! ce φ τ3 th ο ο ^ β ce > ω β χ φ β φ φ cο φ ce a β •t-l φ 73 th ο ο > ω β χ φ β φ φ cο φ »η ε φ > -w φ η $ h ce β 01 δ ο ι φ & 2 s ω 3 « g ο. β ce ^ is i ί φ > ί 9 β „ ce ο ^ a ο fc (μ (μ co (μ (μ w (μ co (μ (μ 00 (μ σ ι (μ ο co co ιη •ψ co (μ w co w die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 idilette oosthuizen, brenda louw en isabel uy vlakke presenteer (reid et al., 1991; klecan-aker & kelty, 1990; stackhouse, 1990; van kleeck, 1992). volgens die resultate van di6 studie toon slegs ses van die 35 gei'dentifiseerde parameters 'n betekenisvolle verskil op 'n 5% en 10% betekenispeil met die kronologiese ouderdom van die groep proefpersone. hierdie verskille is van so 'n aard dat dit die implikasie het dat die spesifieke groep proefpersone bo hul kronologiese ouderdom presteer met betrekking tot begrip vir woordklasse en verhoudings, begrip vir grammatikale morfeme, totale aantal woorde per t-eenheid (tmt: vorster, 1980), woordherhalings per t-eenheid (tmt: vorster, 1980), stillees-begrip, en segmentering van 'n sin in afsonderlike woorde. bogenoemde resultate is egter teenstrydig met navorsingsresultate en menings van outeurs wat beweer dat taalprobleme 'n sentrale deel van leergestremdheid, en gevolglik ook van taalleergestremdheid uitmaak (asha, 1982; klecan-aker & kelty, 1990). hierdie a-tipiese resultate bevestig egter die siening van nye et al. (1987) wat beweer dat taalleergestremde kinders se taalfunksionering 'n merkwaardige verbetering kan toon nadat intensiewe taalintervensieprogramme met hulle gevolg is. die vraag ontstaan nou egter of die tydstip waarop vroee intervensie toegepas is, moontlik die funksionering van die proefpersone kon bei'nvloed. die proefpersone in hierdie studie is reeds vanaf driejarige ouderdom in die kleuterafdeling van die betrokke skool ingeskakel. tydens hierdie pre-geletterdheidsfase het die proefpersone reeds spraakterapie, fisioterapie en/ of arbeidsterapie ontvang. die proefpersone het intensiewe langtermyn terapie in die kritieke taalaanleerperiode ontvang. die trans-professionele insette op voorskoolse vlak kon moontlik tot die proefpersone se voordeel gestrek het, aangesien taalopleidingsprogramme soos in hoofstroomonderwys toegepas word, nie noodwendig kompenseer vir die verlies aan stimulasietyd, wat leerlinge met uitvalle wat eers op skoolvlak geidentifiseer is, ondervind nie (cole, 1982). alhoewel verskeie outeurs die waarde van vroee intervensie beklemtoon (asha, 1988; louw, 1990), bestaan daar tans verskille tussen outeurs rakende die siening of hoe-risiko-kinders eventueel met spraaken/of taalprobleme gaan presenteer, al dan nie. menyuk, liebergott, schultz, chesnick en ferrier (1991) het bewys dat daar nie 'n verskil bestaan tussen die taalontwikkeling en kognitiewe ontwikkeling van hoe-risiko-kinders (premature babas) en nie-hoe-risiko-kinders (voltermyn-babas) wat as proefpersone in hul studie gedien het nie. aram, hack, hawkins, weissman en borawski-clark (1991) het bewys dat meer nie-hoe-risiko-kinders (voltermyn-babas) met spraaken taalafwykings presenteer, as kinders in die hoe-risiko-groep. aangesien daar tans meningsverskille in die literatuur en navorsing bestaan rakende die invloed van vroee intervensie op latere ontwikkeling, kan daar nie sonder meer aanvaar word dat die a-tipiese resultate van die proefpersone op van die gesproke taalparameters, geskrewe taalparameters en fonologiese prosesseringsparameters, nie die resultaat is van vroee intervensie nie. oosthuizen (1994) is van mening dat vroee intervensie wel die proefpersoonfunksionering positief bei'nvloed het, in die opsig dat vroee inkortings van spraaken taalontwikkeling, voorlopers vir latere leerprobleme kan wees (aram & nation, 1980). indien die vroee ingryping deur die trans-professionele span nie noodwendig as primgre rede vir die proefpersone se funksionering aangevoer kan word nie, moet hul insette noodwendig die uitkoms van die leerprobleme minimaliseer (nye et al. 1987). aard van die korrelasies wat tussen gesproke taalparameters, geskrewe taalparameters en fonologiese prosesseringsparameters geidentifiseer is. volgens tabel 6 toon die proefpersone se taalbegrip vir woordklasse en relasies 'n positiewe verband met beide stillees-begrip, asook met die vermoe om sinne in afsonderlike woorde te segmenteer. die positiewe korrelasie wat statisties by die genoemde parameters geidentifiseer is, kan moontlik gei'nterpreteer word in die lig daarvan dat begrip vir woordklasse en relasies verband hou met die tipe begripsvrae wat aan die proefpersone gestel is, nadat hulle die stillees-leesstuk voltooi het. indien die proefpersone nie goeie begrip getoon het vir die betekenis van woordklasse en relasies nie, kon hul moontlik 'n inkorting gehad het om sinne in afsonderlike woorde te segmenteer, aangesien die sin eerder as 'n geheelboodskap gei'nterpreteer is, as bestaande uit 'n aantal individuele woorde. alhoewel die verband tussen fonologiese prosessering en gesproke taalfunksionering by hierdie groep proefpersone geidentifiseer is, word verdere navorsing steeds benodig om vas te stel of fonologiese prosessering die oorsaak van gesproke taalfunksionering is, soos deur stackhouse (1990) beweer word. dit blyk dat die proefpersone se vermoe om uitgebreide sinne te begryp 'n positiewe verband met begripsvermoe van 'n prosaleesstuk aangetoon het. hierdie resultate kan moontlik verklaar word na aanleiding daarvan dat indien die proefpersone nie oor die vermoe beskik om 'n enkele uitgebreide sin soos byvoorbeeld: "die man praat met die dogtertjie se ma wat in die kar sit" te verstaan nie, hulle nie begrip sal toon vir 'n prosaleesstuk, wat uit 'n hele aantal uitgebreide sinne saamgestel is nie. woorddefinieringsvermoe het 'n negatiewe korrelasie met leesspoed en fonologiese prosessering getoon. hierdie prestasie kan moontlik verklaar word op grond van die medium (ouditief of visueel) waardeur die proefpersone getoets is, naamlik dat gesproke taal in hierdie geval deur die ouditiewe medium (ouditiewe opdrag), en geskrewe taal deur die visuele medium (geskrewe leesstuk) geevalueer is. dit blyk dat die spesifieke meetinstrument wat gebruik word, die resultate kan bei'nvloed. die negatiewe korrelasie tussen verbale ekspressie en die vermoe om sinne in individuele woorde te segmenteer kan moontlik verklaar word op grond daarvan dat verbale ekspressie in hierdie geval deur die proefpersone se woorddefinieringsvermoe bepaal is. die fonologiese prosesseringsvaardigheid daarenteen, word geevalueer deur vooraf geformuleerde sinne wat deur die remedierende onderwyseres aan die proefpersoon gestel is, waarvan die fonologiese, morfologiese en sintaktiese sinstrukture nie noodwendig aan die proefpersoon bekend is nie. hierdie resultate bevestig die standpunt van stackhouse (1990) en van kleeck (1992), naamlik dat taalleergestremde leerlinge met fonologiese prosesseringsprobleme kan presenteer. dit blyk dat die proefpersone 'n omgekeerde verband toon tussen die totale aantal woorde wat in ekspressiewe taal gebruik word en stillees-begrip. taalleergestremde leerlinge toon dikwels ernstige en permanente uitvalle in die begrip en gebruik van meer abstrakte taal (myers & the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) verband tussen gesproke en geskrewe taal van leergestremdes 61 0 ο ο -*-» a ο ό h φ ό 9 ο 0) χ » •a ο ο α ο 0) a £ •3 α 0) ό ·ρ4 9 ό » 42 1 ε 0) 0) a 2 α ft, «ο ι-ί w a st at is ti es be du id en d op 'n 5 % p ei l +0 ,0 31 3 st at is tie s be du id en d op 'n 1 0% p ei l va n be te ke ni s +0 ,0 74 2 +0 ,0 54 7 +0 ,0 54 7 +0 ,0 74 2 +0 ,0 74 2 +0 ,0 54 7 f on ol og ie se pr os es se ri ng spa ra m et er va n be te ke ni s g es kr ew e ta al pa ra m et er x g es pr ok e ta al pa ra m et er x x χ x b es ki yw in g va n m ee ti ns tr um en t pa ra m et er b eg ri p vi r te st f or a ud it or y c om pr eh en si on o f l an gu ag e (t a c l -r ) w oo rd kl as se v er ta al de a fr ik aa ns e w ee rg aw e (c ar ro w -w oo lfo lk , 19 85 ) en v er ho ud in gs b eg ri p vi r te st f or a ud it or y c om pr eh en si on o f l an gu ag e (t a c l -r ) gr am m at ik al e v er ta al de a fr ik aa ns e w ee rg aw e (c ar ro w -w oo lfo lk , 19 85 ) m or fe m e to ta le a an ta l to et s 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"fi φ μ die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 idilette oosthuizen, brenda louw en isabel uyg α a ο 3 « a jg "o μ « m a ο i tn v a !β is α ν α ρ 1— 09 « μ v £5 g s s ο «ι j j ts 4) β fl ο 2 «3 fa a α s • £ g fl) η δ rt u •ίί-βί $ λ β a ® • -μ λ ο it h ! h α α α) δ 2 ® a w ο χ χ χ χ χ χ χ χ χ χ χ χ χ χ χ χ χ χ χ χ χ χ χ χ χ χ a ja ο μ u a jg ο μ φ μ μ •fn • s i 00 "β co μ 2 8 » * tf μ ib h ο ο τ-η (ν τ-η ι—ι > > co oj co τ-η co ο ο θ" ο* •ψ co co ο 00 co a,® a «•a λ 8 s w h <h « c :0) α ο ο go -μ -μ > > 1—' '—· ι> l> (ν (ν (ν (ν ο ® θ" θ" 10 os i—l •ψ co co 0 0 0 0 00 ο •ψ ο <n co co t-h in <n ο ο ο ο a ja ο μ ν a ο ο μ ν •β ιη (β « •fn ιη a ϊ > > •—· ν / co co (ν 00 (ν ιο ιο ο t> t> ο" ο" ιο co 00 00 in 00 ο 00 co co 00 0 0 a .2 fl rt 5 :φ a ® s ® & φ α ο ο go -μ -μ t-h i n i l 1-1 > > ο ο 00 co co cjl cj1 co co co •ψ 0 0 0 co 00 th <n 05 co 00 00 co 0 0 ω ! * co hj η 3 β ν ν a jgο μ 9) φ λ 1 •β ιη 1 ν a ee ί3 0η 3 ιη λ bo φ -β s ο > α 73 ® c r 1 § > φ α · 3 ' 6 φ ε-ι ^ ^ β φ φ ft m ό ο ^ s α ι ' 5 * ce φ α* * s ce ® ά ® 2 ® ® 73 tφ α. φ -β ιη ο s· ο co £ ^ β >-. φ s ® ι > φ 0 φ _ φ s ^ β s 3 ft φ s ι φ ιο s φ 3 ® μ c c φ ο , q. (β η φ ce φ ^ β β ο " φ i l l φ * •s φ bs s a g ο _ ο· α m a 3 ® ο < τ3 μ ce ih φ ft co ,-ν bp co 5 ^ rt φ b o 0 s § —i ' 2 t3 β s 2 ο 5 ο· to ο ί-α, β φ • d φ φ χ co ε-ι ^ ^ β fts a l β > ij5 3 s g s <! λ — β £ 0 3 η φ ό φ s ιο a β s u φ φ φ φ ιο eh is t® ^ ft ce s3 co β φ bo— -y β φ s m s ® i to φ λ tsi φ ° cd :φ 3 ο φ α λ f 15 i φ φ -μ β φ β ο ft .2 ι ί3 μ φ > αϊ bo β ν φ ^ 2 ® js.g φ c-2 i ι :φ & ο φ φ >· αϊ β rs φ αϊ :φ φ 2 * η 'ή ε > 3 co β bo ο β ,® c ο3 j . s β τ-η ο ιο •co 1 u3 φ β ίο κ φ φ 5 (ν ιο β ε ό 9 c φ > φ φ 3 2 c ο ® i bo ? β φ •μ ^ φ τι ft φ oj τ) α ο _ s ώ ιο .s s "s ό ο !> > ι* c φ i s ι ι gs -θ λ β ^ φ α bo ® β φ a μ ft φ oj ί3 ιο β "" c— φ j f β > β 5 φ -τ3 β s ο. i i , a φ s3 •9 "β co φ φ " β s § oj c3 φ s •3 i φ a ό φ ti. φ φ ce > ^ φ « > β ϋ w * the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) verband tussen gesproke en geskrewe taal van leergestremdes die tfammill, 1990). tydens evaluering van die proefpersone b e g r i p ' v a n ' n stillees-leesstuk word beide konkrete en s® t r a k t e taal as deel van die toetsinhoud voorgele. die 2 ole is dat 'n diskrepansie tussen die toetsprestasies van die p r o e f p e r s o n e op hierdie onderskeie twee vaardighede kan bestaan, aangesien spontane gesprekvoering deur middel van konkrete taal kan geskied, terwyl die stilleesb e g r i p s t o e t s uit beide konkrete en abstrakte taalelemente kan bestaan. dit blyk dat die proefpersone se funksionering 'n n o s i t i e w e verband tussen die gemiddelde aantal woorde wat hul gebruik het, en hul begrip vir 'n prosa-leesstuk a a n g e t o o n het. hierdie korrelasie blyk sinvol te wees want hoe groter die woordeskat van die proefpersone is, hoe meer woorde behoort hulle in die prosa-leesstuk te begryp. v a n w e e die positiewe aard van die korrelasie, bei'nvloed hierdie twee vermoens mekaar wedersyds. dit blyk dat die proefpersone se gesproke taalvermoe 'n verbetering sal toon indien g e s k r e w e taal 'n v e r b e t e r i n g toon en o m g e k e e r d . volgens die resultate van die empiriese ondersoek blyk dit dat daar 'n positiewe verband bestaan tussen die aantal mede-werkwoorde wat die proefpersone per t-eenheid (tmt: vorster, 1980) gebruik en spoedleesvermoe, asook tussen die aantal mede-werkwoorde wat die proefpersone per t-eenheid (tmt: vorster, 1980) gebruik en die proefpersone se vermoe om sinne in onderlinge woorde te segmenteer. 'n moontlike verklaring vir die positiewe korrelasie tussen die aantal mede-werkwoorde wat die proefpersone per t-eenheid (tmt: vorster, 1980) gebruik het en hul spoedleesvermoe, kan wees dat werkwoorde dikwels die kernwoord van 'n sin vorm. 'n goeie leser lees gevolglik nie noodwendig elke woord in die sin, om die voile boodskap te begryp nie (leaf, 1994). aangesien die proefpersone goeie begrip vir mede-werkwoorde toon, en hul spontane spraak as sodanig gekenmerk word deur die gebruik van mede-werkwoorde, kan hul spoedleesvermoe moontlik hierdeur bevoordeel word, deurdat hul in staat is om die mede-werkwoorde en werkwoorde in 'n leesstuk of individueel, te lees en te begryp. 'n moontlike interpretasie van die geidentiflseerde positiewe korrelasie wat bepaal is tussen die aantal mede-werkwoorde wat die proefpersone per t-eenheid (tmt: vorster, 1980) gebruik het en hul vermoe om sinne jin onderlinge woorde te segmenteer, kan wees dat die gebruik van werkwoorde en mede-werkwoorde alreeds 'n hoer linguistiese vaardigheid impliseer as met die gebruik van selfstandige naamwoorde (myers & hammill, 1990). aangesien die proefpersone alreeds hierdie vlak van linguistiese v a a r d i g h e i d bemeester het, is hul in staat om te begryp dat 'n sin uit afsonderlike woordkomponente bestaan wat eventueel 'n kommunikasieboodskap weergee. volgens hierdie ondersoek (tabel 6) blyk dit dat 'n negatiewe korrelasie geidentifiseer is tussen die aantal woorde wat die proefpersone per t-eenheid (tmt: vorster, 1980) weglaat en leesspoed en die aantal woorde wat die proefpersoon per t-eenheid (tmt: vorster, 1980) weglaat en begrip vir 'n prosa-leesstuk. dit blyk dat hoe minder woorde die proefpersone per t-eenheid (tmt: vorster, 1980) weggelaat het, hoe beter hul leesvermoe was. hoe beter 'n persoon se taalvaardigheid ontwikkel het, hoe minder sal weglatings van woorde in spontane spraak plaasvind. aangesien 'n persoon met min of geen weglatings van woorde in spontane spraak, alreeds 'n gevorderde vlak van linguistiese ontwikkeling bereik het 63 (myers & hammill, 1990), blyk dit moontlik te wees dat die genoemde vaardigheid verband kan hou met leesspoed, aangesien leesspoed ook 'n bepaalde vlak van linguistiese en visueel-perseptuele maturasie vereis. net so kan die aantal woorde wat 'n proefpersoon in spontane spraak weglaat met begrip vir 'n prosa-leesstuk verband hou. hoe beter 'n persoon se woordeskat ontwikkel is, hoe minder woorde sal hul in spontane spraak weglaat, en hoe beter kan hul begrip moontlik vir 'n prosa-leesstuk wees, aangesien hul bekend is met 'n goed ontwikkelde woordeskatkennis. alvorens die proefpersone in staat kan wees om selfkorreksies in spontane spraak te kon toepas, moes hul noodwendig tot 'n gevorderde vlak van linguistiese oordeel ontwikkel het, om tussen korrekte en foutiewe uitinge te kon diskrimineer. net so verg die vermoe om woorde in afsonderlike klankkomponente in te deel 'n gesofistikeerde a a n v o e l i n g vir die k o m p o n e n t e w a a r u i t 'n w o o r d saamgestel is (van kleeck, 1992). volgens die resultate (tabel 6) blyk dit dat daar 'n positiewe verband bestaan tussen die proefpersone se abstraheringsvermoe en hul spellingvermoe en die proefpersone se abstraheringsvermoe en hul vermoe om woorde in afsonderlike sillabes te segmenteer. die rede dat die proefpersone se abstraheringsvermoe met beide hul s p e l l i n g v e r m o e en hul v e r m o e om w o o r d e in afsonderlike sillabes te segmenteer geassosieer word, kan moontlik verklaar word na aanleiding van die verskillende ontwikkelingstadia wat alreeds in 1953 deur piaget beskryf is (myers & hammill, 1990). die vermoe om op 'n abstrakte vlak te funksioneer impliseer 'n gevorderde vlak van kognitiewe en linguistiese funksionering. die resultate van die studie lewer voldoende bewys dat daar 'n verband tussen gesproke taalfunksionering, geskrewe taalfunksionering en fonologiese prosessering by die proefpersone bestaan. verskeie verklarings kan aangevoer word vir die geidentiflseerde korrelasies, naamlik vlak van linguistiese maturasie, bewussyn van fonologiese struktuur van taal, modaliteitsvoorkeur (visueel of ouditief) en die tipe voorkennis wat benodig word alvorens 'n bepaalde vaardigheid uitgevoer kan word. net so impliseer 'n goed ontwikkelde spellingvermoe, asook die vermoe om woorde in afsonderlike sillabes te segmenteer, dat die proefpersoon reeds 'n bewussyn gekweek het van die onderliggende fonologiese strukture w a a r u i t taal b e s t a a n (van k l e e c k , 1992). die geidentiflseerde korrelasies hou dus beide verband met hoer taalfunksies, naamlik abstraheringsvermoe en die vermoe om taal in onderlinge eenhede te segmenteer. volgens die resultate (tabel 6) blyk dit dat daar 'n positiewe korrelasie bestaan tussen spellingvermoe en die vermoe om sinne in afsonderlike woorde te segmenteer. hierdie resultate bevestig die siening van outeurs (stackhouse, 1990; kamhi & catts, 1991) dat geskrewe t a a l v e r m o e en fonologiese p r o s e s s e r i n g s v e r m o e interverwant is. hierdie korrelasie hou moontlik verband daarmee dat spellingvermoe as sodanig, 'n vermoe impliseer wat die analise en sintese van grafo-foneme behels (westby & costlow, 1991). hierdie vermoe hou verband met die vermoe van die proefpersone om sinne in afsonderlike woorde te kan segmenteer. beide hierdie vermoens hou verband met 'n eksplisiete kennis van taal, naamlik 'n bewussyn van die fonologiese kennis, sowel as 'n aanvoeling vir foneem-grafeem en alfabetiese kennis (westby & costlow, 1991). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 idilette oosthuizen, brenda louw en isabel uys dit blyk dat daar 'n positiewe verband is tussen begrip vir 'n prosa-leesstuk en die vermoe om 'n sin in afsonderlike woordkomponente te segmenteer (tabel 6). die positiewe korrelasie wat tussen begrip vir 'n prosa-leesstuk en die vermoe om sinne in afsonderlike woordkomponente te segmenteer verkry is, dui eerstens daarop dat, indien die proefpersone 'n voorgeskrewe stuk self gelees het en vrae rakende die leesstuk korrek beantwoord het, hul ook vaardig is om sinne in afsonderlike woordkomponente te segmenteer. hierdie korrelasie kan moontlik verklaar word deurdat beide hierdie parameters met geheue verband hou (grove & hauptfleisch, 1984; van kleeck, 1992). in 'n poging om vrae rakende die prosa-leesstuk te kan beantwoord, moes die proefpersone oor 'n goeie visuele storiegeheue beskik, net so moes die proefpersone oor goeie ouditiewe geheue beskik tydens die fonologiese prosesseringstoets, aangesien 'n gesproke sin op ouditiewe vlak herroep moes word, alvorens die sin in woordkomponente verdeel kon word. gevolgtrekkings en aanbevelings die resultate van hierdie ondersoek lewer voldoende bewys dat daar betekenisvolle korrelasies tussen gesproke taalfunksionering en geskrewe taalfunksionering van die proefpersone bestaan. hierdie inligting noop die spraak-taalterapeut om die grense van haar dienslewering in heroenskou te neem, in die opsig dat gesproke taalprobleme nie in isolasie aangespreek kan word nie. 'n moontlike oplossing vir hierdie probleem kan die volgende insluit: die opleiding van die spraak-taalterapeut behoort verbreed te word na 'n in-diepte-opleiding rakende intervensie van alle kommunikasievaardighede wat beide gesproke en geskrewe taalprobleme impliseer. 'n noue trans-professionele benadering behoort gevolg te word, waar die spraak-taalterapeut, remedierende onderwyseres, arbeidsterapeut en opvoedkundige sielkundige as span saam die taalleergestremde kind hanteer. die proefpersoonresultate lewer bewys van die verband tussen fonologiese prosessering met beide gesproke en geskrewe taal. alhoewel die resultate van di6 studie 'n korrelasie tussen fonologiese prosessering en gesproke en geskrewe taalfunksionering bewys het, kan daar nie sonder meer aangeneem word dat fonologiese prosessering die onderliggende oorsaak vir gesproke en geskrewe taalfunksionering is, soos deur stackhouse (1990) beweer word nie. die korrelasie wat in die empiriese studie tussen fonologiese prosessering en gesproke en geskrewe taal bepaal is, noodsaak die spraak-taalterapeut om fonologiese prosessering as deel van die toetsbattery van geletterdheidsfunksionering by die taalleergestremde kind te implementeer. aangesien geen gestandaardiseerde evalueringsmedium tans bestaan om fonologiese prosessering in afrikaans te evalueer nie, behoort toekomstige navorsing daarop gerig te wees om die ontwikkeling van 'n gestandaardiseerde toetsbattery vir fonologiese prosessering daar te stel. in die lig van die voorafgaande gevolgtrekkings word die volgende aanbevelings geformuleer, naamlik: alhoewel die resultate die korrelasie tussen fonologiese prosessering en geletterdheidsfunksionering by die proefpersone bevestig, word verdere navorsing steeds benodig om te bepaal of fonologiese prosessering as basiese voorvereiste vir geletterdheidsfunksionering beskou kan word, soos hipoteties deur stackhouse (1990) beweer word. die ontwerp en ontwikkeling van kultuurvrye gestandaardiseerde evalueringsmedia, waardeur fonologiese prosessering volledig geevalueer word, behoort daadwerklike aandag in navorsing te geniet. evalueringsmedia behoort dus voorsiening te maak vir die multikulturele en multilinguistiese opset in die rsa. daar word aanbeveel dat fonologiese prosessering by intervensie van die taalleergestremde kind ingesluit word om as deel van kommunikasievaardighede aangespreek te word (catts, 1991). aangesien resente publikasies, asook bevindinge van di£ empiriese studie, die noue verwantskap tussen gesproke en geskrewe taal erken en bevestig, behoort die kurrikulum waarvolgens spraak-taalterapeute opgelei word in heroenskou geneem te word, om te verseker dat in-diepte kennis rakende intervensie van geskrewe taalprobleme as deel van die opleidingsprogram realiseer. navorsing binne die multikulturele en multilinguistiese domein word aanbeveel, sodat wetenskaplik gefundeerde intervensiebeplanning kan geskied met betrekking tot die hantering van geletterdheidsfunksionering en fonologiese prosessering van die bevolking van die rsa. alhoewel hierdie studie die evaluering van gesproke taal, geskrewe taal en fonologiese prosessering beklemtoon, behoort verdere navorsing daarop gerig te wees om terapeutiese hulpverleningsprogramme daar te stel. hierdie programme behoort daarop gerig te wees om habilitasie en rehabilitasie van gesproke taalprobleme, geskrewe taalprobleme en fonologiese prosesseringsprobleme van taalleergestremde leerlinge te bewerkstellig. bibliografie american speech-language-hearing association ](1988). prevention of communication disorders: position statement. american speech and hearing association, 30(3), 90.| american-speech-language-hearing association (committee on language learning disabilities) (1982). 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(1984). handleiding van die pendulum-toets vir ouditiewe persepsie en konseptualisering. pretoria. transvaalse onderwysdepartement. (ongedateer). een-minuutleestoets; k3 skolastiese toets; tod taaltoets. transvaalse onderwysdepartement: pretoria. universiteit van wes-kaapland. (ongedateer). ipv: spelevalueringstoets. kaapprovinsie: universiteit van weskaapland. uys, i.c. (1993). kommunikasiepatologie:. onderrig vir die toekoms. die suid-afrikaanse tydskrif vir kommunikasieafwykings, 40, 3-9. van kleeck, a. (1990). emergent literacy: learning about print before learning to read. topics in language disorders, 10(2), 25-45. van kleeck, a. (1992). "language assessment and intervention in children: an overview and special focus on preliteracy." saslha: workshop. department of speech pathology and audiology. university of pretoria. vorster, j. (1980). toets vir mondelinge taalproduksie. pretoria: raad vir geesteswetenskaplike navorsing. westby, c.e. & costlow, l. (1991). implementing a whole language program in a special education class. topics in language disorders, 11(3), 69-84. bylae a fonologiese prosesseringstoets s u b t o e t s 1 s e g m e n t e r i n g v a n sinne in w o o r d k o m p o n e n t e 1. sy sit die brood op die tafel. (antwoord: 7) i 2. water tap uit 'n kraan. (antwoord: 5) 3. die druiwe is op die stoof. (antwoord: 6) 4. die olifant, perd en kat word deur die zebra gejaag. j (antwoord: 10) j 5. sy voer die b a b a m e t die lepel. (antwoord: 7) 6. die e m m e r is vol klippe. (antwoord: 5) 7. die seuntjie drink. (antwoord: 3) 8. h y spring op sy fiets. (antwoord: 5) 9. die gogga eet blare. (antwoord: 4) 10. die skoene kos baie geld. (antwoord: 5) 11. h y speel gholf. (antwoord: 3) punte behaal maksimum punte 11 s u b t o e t s 2 s u b t o e t s 3 s e g m e n t e r i n g v a n w o o r d e s e g m e n t e r i n g v a n i n s i l l a b e s w o o r d e i n k l a n k e 1. vurk (antwoord: 1) 1. j a s (antwoord: 3) 2. kwas (antwoord: 1) 2. prop (antwoord: 4) 3. piesang (antwoord: 2) 3. huis (antwoord: 3) 4. sjokolade (antwoord: 4) 4. glas (antwoord: 4) 5. b o o m (antwoord: 1) 5. trein (antwoord: 4) 6. knoop (antwoord: 1) 6. gras (antwoord: 4) 7. vliegtuig (antwoord: 2) 7. swem (antwoord: 4) 8. seep (antwoord: 1) 8. boks (antwoord: 4) 9. spons (antwoord: 1) 9. berg (antwoord: 4) 10. vingers (antwoord: 2) 11. rok (antwoord: 1) 12. stryk (antwoord: 1) 13. masjien (antwoord: 2) 14. neus (antwoord: 1) 15. skryf (antwoord: 1) 16. mielie (antwoord: 2) 17. skrik (antwoord: 1) 18. pleister (antwoord: 2) 19. sleutels (antwoord: 2) 20. wolke (antwoord: 2) punte behaal m a k s i m u m punte 20 punte b e h a a l : m a k s i m u m punte die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 66 bylae β: data-definisie idilette oosthuizen, brenda louw en isabel u y s nommer van beskrywing van veranderlik gebied waarin kolomme veranderlike roupunt kan voorkom veranderlike 1 respondentnommer 1-9 01 veranderlike 2 kaartnommer 1 02 veranderlike 3 verstandsouderdom (ppvt) 067-149 03-05 veranderlike 4 intelligensiekwosient (ppvt) 070-126 06-08 veranderlike 5 subtoets 1 minimum (tacl-r) 069-097 09-11 veranderlike 6 subtoets 1 maksimum (tacl-r) 083-119 12-14 veranderlike 7 subtoets 2 minimum (tacl-r) 082-113 15-17 veranderlike 8 subtoets 2 maksimum (tacl-r) 095-119 18-20 veranderlike 9 subtoets 3 minimum (tacl-r) 066-119 21-23 veranderlike 10 subtoets 3 maksimum (tacl-r) 070-999 24-26 veranderlike 11 woorddefinisie minimum (ast) 084-120 27-29 veranderlike 12 woorddefinisie maksimum (ast) 089-125 30-32 veranderlike 13 kronologiese ouderdom (mnde) 097-122 33-35 veranderlike 14 tbtale woorde (tmt) 1-9 36 veranderlike 15 woorde per τ eenheid (tmt) 1-9 37 veranderlike 16 tipe tekenratio (tmt) 1-9 38 veranderlike 17 bywoorde (tmt) 1-9 39 veranderlike 18 voorsetsels (tmt) 1-9 40 veranderlike 19 medewerkwoorde (tmt) 1-9 41 veranderlike 20 weglatings (tmt) 1-9 42 veranderlike 21 vervangings (tmt) 1-9 43 veranderlike 22 verplasings (tmt) 1-9 44 veranderlike 23 onvoltooid (tmt) 1-9 45 veranderlike 24 sinstruktuurverbetering (tmt) 1-9 46 veranderlike 25 woordkeuseverbetering (tmt) 1-9 47 veranderlike 26 woordherhaling (tmt) 1-9 48 veranderlike 27 benoemings (tmt) 1-9 49 veranderlike 28 onsin (tmt) 1-9 50 veranderlike 29 abstrak/konkreet (tmt) 1-9 51 veranderlike 30 creaghead pragmatiek vraelys 00-25 52-53 veranderlike 31 analise 1 minimum (pendulum) 076-152 64-56 veranderlike 32 analise 1 maksimum (pendulum) 079-155 57-59 veranderlike 33 sintese 1 (pendulum) 080-152 60-62 veranderlike 34 sintese 2 (pendulum) 083-155 63-65 veranderlike 35 storiegeheue 1 (pendulum) 084-152 66-68 veranderlike 36 storiegeheue 2 (pendulum) 087-155 69-71 veranderlike 37 opeenvolgende geheue 1 (pendulum) 076-116 72-74 veranderlike 38 opeenvolgende geheue 2 (pendulum) 079-119 75-77 , veranderlike 39 respondentnommer 1-9 01 veranderlike 40 kaartnommer 2 02 veranderlike 41 sluiting 1 000-132 . 03-05 ί veranderlike 42 sluiting 2 072-135 06-08 1 veranderlike 43 1-minuut spoedtoets (tod) 01-16 09-10 veranderlike 44 spelling (ipv spellingtoets) 01-16 11-12 | veranderlike 45 skriftelike taal (k3 skolastiese toets) 01-16 13-14 ; veranderlike 46 prosalees en begrip (grove en hauptfleisch) 01-16 15-16 veranderlike 47 stillees en begrip (tod taaltoets) 01-16 17-18 veranderlike 48 verbaal (ik toets) 078-114 19-21 veranderlike 49 nie-verbaal (ik toets) 086-128 22-24 veranderlike 50 totaal (ik toets) 087-121 25-27 veranderlike 51 fonologiese prosessering subtoets fonologiese 00-10 28-29 . • veranderlike 52 prosessering subtoets 2 fonologiese prosessering 00-19 30-31 veranderlike 53 subtoets 3 0-5 / 3 2 * alle subtoetse en toetse waarna verwys word, is onderskeidelik in tabelle 2 en 3 volledig bespreek en uiteengesit. the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 7 the effect of guessing on the speech reception thresholds of children asoka moodley, b.ed (hons) med (audiol.) f.c.p. county service for the sensory impaired audiology education department, lincolnshire county council lincolnshire, united kingdom abstract speech audiometry is an essential part of the assessment of hearing impaired children and it is now widely used throughout the united kingdom. although instructions are universally agreed upon as an important aspect in the administration of any form ofaudiometric testing, there has been little, if any, research towards evaluating the influence which instructions that are given to a listener have on the speech reception threshold obtained. this study attempts to evaluate what effect guessing has on the speech reception threshold of children. a sample of 30 secondary school pupils between 16 and 18 years of age with normal hearing was used in the study. it is argued that the type of instruction normally used for speech reception threshold in audiometric testing may not provide a sufficient amount of control for guessing and the implications of this, using data obtained in the study, are examined. opsomming spraakoudiometrie is 'n wesenlike aspek van die totale evaluering van gehoorgestremde kinders en word tans uitgebreid in die verenigde koninkryk aangewend. daar word universeel saamgestem dat instruksies van wesenlike belang is in die uitvoering van alle vorme van oudiometriese toetsing. beperkte navorsing is egter tot op hede uitgevoer om die invloed van die instruksies, wat aan die luisteraar verskaf word op die spraakontvangsdrempel te peil. hierdie studie poog om die uitwerking van raai op die spraakontvangsdrempel van kinders te evalueer. 'n steekproefvan 30 hoerskoolleerlinge tussen die ouderdomme van 16 tot 18jaar, met normale gehoor, is in die studie benut. daar word beweer dat die tipe instruksies wat standaard gebruik word in die bepaling van die spraakontvangsdrempel, nie voldoende beheer uitoefen oor raai nie. die implikasies daarvan word ondersoek met behulp van die data wat in die studie verkry is. in performing speech audiometry it is common to obtain two measures of speech performance: the speech reception threshold (srt) and the speech ^discrimination score. the srt is .similar to the hearing threshold level for pure tones, because it is the lowest level at which the individual can just hear and repeat 50% of the test words. the discrimination score determines the person's ability to understand speech by measuring his capacity to distinguish the various phonemes of oral language at comfortable levels of loudness. ι in general the speech reception threshold and the pure tone average of the speech frequencies serve as a reliability check on each other, and should correspond closely. it has been suggested (carhart & porter, 1971) that averaging the pure tone thresholds at 500hz and lkhz, minus 2db, adequately predicts the srt from most audiometric configurations. in clinical practice the audiologist considers that agreement between speech reception threshold and pta of ± 6db is within acceptable limits (oslen & matkin, 1979). when one measure deviates substantially from the other, it can be an indication that results are suspect, and that both pure tone and speech audiometry should be repeated. within the last thirty years, speech reception threshold (srt) testing has come to play a prominent role in audiometry, makdie suid-afrikaanse tydskrif vir kommunikasieafwykins, vol. 37 1990 ing it one of the major audiometric tests available for the assessment of hearing. consistent with the magnitude of importance attached to the srt has been the great amount of research concerning numerous procedural variables that have been shown to influence the magnitude of srt obtained for a given subject. these include: 1. the form of the verbal stimuli used for the measurement of srt (harris, 1965). 2. the degree of sophistication a listener possesses with regard to vocabulary (farrimond, 1962). 3. the degree of familiarity the listener has with the test stimuli (oslen & matkin, 1979, wilson & margolis, 1983). 4. the use of live voice versus recorded presentation (beattie, forrester & ruby, 1977). although instructions are universally agreed upon as an important aspect in the administration of any form of audiometric test, little, if any, research has been directed towards evaluating the influence which the instructions that are given to a listener have on the speech reception threshold obtained. this study was concerned mainly with the possible influence that the factor of guessing, which is encouraged in essentially all suggested instructions for the speech reception threshold sash a 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 8 asoka moodley (chalklin & ventry, 1964; harris, 1965; martin, 1975; newby, 1972), may have on the resulting threshold for speech. this interest was fostered by the writer's observation that although all subjects are given similar instructions for the srt, which include encouragement to guess on items of which they are uncertain, considerable variability seems to exist in the degree of guessing which actually takes place among individuals. given this situation, it seems feasible to assume that those persons inclined to guess in an "aggressive" fashion, might obtain srt decidedly different from the srt obtained from those who choose not to engage in any guessing. the aim of this study was therefore to attempt to quantify the extent, if any, to which the factor of guessing may conceivably influence the magnitude of the srt. subjects subjects for the study included 30 secondary school pupils, made up of 15 boys and 15 girls. the average age of the boys was 16.9 years and the average age of the girls was 17.2 years. the average age of the group as a whole was 17.5 years. the age range for the group was 16.2 years 18.5 years. more details of the sample are shown in table 1. to qualify as a subject each pupil had to be: 1. between 16 and 18.5 years of age. 2. not have any prior knowledge of the srt procedure. 3. possess air conduction pure tone thresholds of 20db hl, or better, in the test ear at the octave frequencies from 250-4000hz. table 1: number, age and sex of subjects taking part in study age in years sex no. mean range boys 15 16.9 16.3 18.4 girls 15 17.2 16.2 18.5 boys & girls 30 17.5 16.2 18.5 method each pupil was seen initially to determine whether or not he or she qualified for the study. information concerning age and familiarity with the srt was ascertained initially. pupils meeting these two qualifications were then given both pure tone and srt tests in one ear randomly selected for examination. air conduction pure tone thresholds were obtained in the test ear at octave frequencies from 250-4000hz. after the completion of pure tone testing, srts were obtained in the same test ear. each pupil was administered the srt procedure under two separate conditions. in condition 1 the srt was obtained with the subjects being instructed n o t to guess on any items of which they were unsure. for condition 2 subjects were required to make a response for every spondee word presented. these two conditions were counterbalanced among subjects to control for any possible learning effects. before formal testing began each subject was familiarised with the test item by having the individual read each of the 35 spondee words. instructions were then given to each subject based on the instructions offered by (hopkinson, 1972). minor modifications in these instructions were made to reflect the differences in the test procedures to be used with each of the two test conditions. the instructions for condition 1 are given below. "words will be presented to you that have two parts: words like baseball, mushroom, and eardrum. the words will get softer and softer. just repeat each word after you have heard it. repeat each word you feel you have heard correctly. do not guess if you feel unsure of a word. are there any questions?" the same instructions were used for condition 2 with the appropriate modifications: "words will be presented to you that have two parts: words like baseball, mushroom, and eardrum. the words will get softer and softer. just repeat each word after you have heard it. it is important that you make an attempt at every word, even those of which you are uncertain. please respond on every test item, even if it is a guess. are there any questions?" test materials and procedure speech reception thresholds were obtained using commercially available tapes of the central institute for the deaf (cid) auditory test w / l . this consists of a list of 36 spondaic words, such as daybreak, birthday. six lists of w / l are available, each list being a different scrabbling of the same 36 words. the w / l recording attenuates the spondee lodb relative to the carrier phrase "say the word". this means that the carrier phrase has been recorded approximately lodb above the average level of the words. all pure tone and speech audiometry was conducted in a well carpeted room, measuring 15 χ 18 feet, free from extraneous noise and where the recorded ambient noise was no more than 40dba at various intervals during the course of the testing. all signals were generated by a kamplex τ a 155 diagnostic audiometer and transduced to each subject via tdh-39 earphones mounted in mx41/ar cushions. procedures described by (martin & pennington, 1971) with a 5db increment were utilized for establishing each srt. j the srt for each subject was obtained using a descending! method, rather than an ascending method. speech signals were presented at a comfortable level above threshold to fami j liarise the listener with the words and the task. the level was | then decreased in 5db steps, presenting one to three words at i each level decrement until a word was missed. at this point the ' stimulus level was raised lodb and then lowered in 5db steps, i presenting 3-6 spondees with each change in stimulus level. ' the level at which 50% of the spondees were correctly repeated was recorded as their speech reception threshold (srt). results the mean piire tone results obtained for the group of 30 subjects included in the study as well as the pure tone averages are presented in table 2. / mean pure tone values obtained as a function-o'f sex revealed some difference in auditory acuity between male and female subjects; the thresholds generally were better for female subjects for all frequencies tested, with the greatest difference between male and female subjects occurring at 2000hz and / the south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the effect of guessing on the speech reception thresholds of children 4000hz. these findings are in good agreement with results obtained by an investigation by corso (1968), where statistically significant differences in threshold values were found between male and females, which are similar to those found in this study. the mean srts obtained under conditions 1 and 2 are presented in table 3. these results are in good agreement with the pure tone data, with females yielding slightly better srts under both test conditions. an overall threshold difference in srt of 8.40 was observed between conditions 1 and 2, with condition 2 yielding the best srts. similar difference values were observed for the male and female subjects under these two test conditions. chalklin & ventry, 1964; siegenthaler & smith, 1961) has generally concluded that variables such as practice in hearing spondees at or near threshold, live voice versus recorded test stimuli, and use of two or five db increment in the measurement of the srt, have no strong clinical implications, since these variables were found to influence the srt by magnitudes of only l-2db. however, other research by (tillman & jerger, 1959) on familiarization with the test stimuli, has demonstrated that when a factor influences the srt by an amount greater than this, it then becomes clinically relevant. therefore, the implication is that the 8.40db difference found to be associated with guessing in the present study, makes it important that this variable be controlled in some fashion during the administration of the srt. the srt data obtained under conditions 1 and 2 were subject to a two-way analysis of variance procedure (winer, 1971). this was done to determine whether any statistically significant differences in srt existed between these two conditions as a function of sex and type of instructions, or as a result of any interaction between these variables. the analysis indicated a significant f value for sex (p < 0.05) and type of instructions for the srt (p < 0.01), while no significant interaction was observed between these two variables. the significant f value for the factor of sex is to be expected, due to the superior auditory acuity possessed by the female subjects in this investigation. the strong significance of the f ratio for the type of instructions clearly indicates that the factor of guessing will influence the srt obtained by a magnitude which is statistically and clinically significant. discussion the results of this study may be of relevance in the determination of the frt in a clinical environment, and may also be of use to teachers of the hearing impaired in their routine audiological assessment of hearing impaired children. previous research dealing with other variables associated with the· administration of the table 2: mean pure tone are also included the type of instruction normally used for the srt in audiometric testing may not provide a sufficient amount of control for guessing. although no formal investigation has been conducted to determine the precise extent to which individuals engage in guessing while undertaking the srt test, personal experience would suggest a considerable amount of variability in the amount of guessing that individuals actually engage in during the test. some children will guess on spondee items when they have heard little, if any, of the acoustic information in a given word, while others are prone not to engage in any guessing and will respond to the test stimuli only when they are relatively confident that they have heard the word presented. these extremes exist even though a common set of instructions, which encourage guessing, are used during testing. there seems to be too much latitude in the manner in which a given individual reacts and responds to currently used instructions for the srt: relative to the variable of guessing. this allows for two different individuals with identical hearing acuity to conceivably obtain significantly different speech reception thresholds, and also makes it potentially possible for a given person to obtain two significantly different speech reception thresholds, all because of the degree to which guessing occurs during the testing. this suggests that some modification in the instructions should be considered that will provide for more control of this impor-frt (tillman & jerger, 1959; thresholds in db hl for the 15 males and 15 females in this study. standard deviations males females combined frequency (hz) (n = 15) sd (n = 15) sd (n = 30) sd i 250 1 4.00 ± 9.1 0.66 ± 7.04 1.68 ± 8.60 500 4.00 ± 9.86 0.66 ± 7.04 1.68 ± 8.34 1000 1.34 ± 12.46 2.00 ± 9.42 0.34 ± 10.98 2000 4.00 ± 14.54 2.00 ± 12.08 1.00 ± 13.48 4000 6.66 ± 17.6 0.66 ± 12.22 3.00 ± 15.34 pure-tone average (500hz ik 2k) 3.12 ± 9.20 1.56 ± 6.40 0.78 ± 8.14 table 3: mean srt in db hl for male and female subjects in the study under condition 1 (no guessing) and condition 2 (guessing required). difference values are also given. standard deviations are provided. condition 1 sd condition 2 sd difference sd cond 1 cond 2 males (n = 15) females (n = 15) , combined (n = 30) 2.66 ± 8.12 2.80 ± 5.60 0.06 ± 7.40 6.26 ± 7.04 10.66 ± 5.22 8.46 ± 6.48 3.60 ± 1.84 7.86 ± 2.32 8.40 ± 2 . 1 2 the south african journal of communication disorders, vol. 37: 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 asoka moodley tant factor. serious consideration should be given to adopting a set of instructions that is similar to the instructions given to the subjects in this study during condition 1 or 2. listeners should be presented with a situation where they have a very clear and definite responses pattern specified. for example, if an individual is instructed not to guess at any time and to respond only when he/she is absolutely sure of a given test stimulus, guessing will be essentially controlled. no practical means of totally controlling guessing with absolute certainty is available, but this does not seem to be a serious limitation. another important reason for the control of the guessing variable relates to the agreement observed between the speech reception threshold (srt) and the pure tone audiogram (pta). numerous researchers (jerger, et al. 1959; tillman & jerger, 1959; carhart & porter, 1971) have investigated the agreement between these two indexes and have found it to be very close for listeners in which valid audiometric data have been obtained. generally the srt should be within ± 5db of the pta for a given ear. because of the stability of the agreement between the srt and the pta, it has been used as an important index of the validity of the data obtained on each of these two tests. in this study the ptas of the 30 subjects agreed more closely with the srts obtained under condition 1, where no guessing was allowed. this comparison resulted in a mean pta of 0.78 db hl and a mean srt of 0.06db hl. if better agreement between these two indexes is desired, the results of this study suggest that consideration should be given to the elimination of guessing during the attainment of the speech reception threshold (srt). references beattie, r., forrester, p., & ruby, b. reliability of the tillman-oslen procedure for determination of spondee threshold using recorded and live voice presentations.jourwaz ofthe american audiological society, no. 2, 159-162, 1977. carhart, r. & porter, l.f. audiometric configuration and prediction of threshold for spondees./o«ra«/ of speech and hearing research, 14, 486-495, 1971. chalklin, j. & ventry, i. spondee threshold measurement: a comparison of 2 and 5db methods. journal of speech and hearing disorders, 27, 47-59, 1964. corso, j. proposed laboratory standard of normal hearing. journal of the acoustical society of america, 30, 14-23, 1958. farrimond, t. factors influencing auditory perception of pure tones and speech. journal of speech and hearing research, 5, 194204, 1962. harris, j. speech audiometry in a. glorig ed. audiometry; principles and practices. williams and wilkins, baltimore, m.d., 1965. hopkinson, n. speech reception threshold inj. j£at£-ed. handbook of clinical audiology, williams & wilkins, baltimore, m.d., 1972. jerger, j., carhart, r., tillman, t., & peterson, j. some relations between normal hearing for pure tones and for speech .journal of speech and hearing research, 2, 126-140, 1959. martin, f.n., & pennington, c.d. current trends in audiometric practices. a.s.h.a. 13, 671-677, 1971. newby, h. audiology, prentice hall, 1972. oslen, w.o., & matkin, n.d. speech audiometry. in rintleman, w.f. (ed.) hearing assessment. baltimore: university park press, 1979. siegenthaler, b., & smith, d. speech reception^thresholds by different methods of test administration .journal of the acoustical society of america, 33, 1802, 1961. tillman, t., & jerger, j. some factors affecting the spondee thresholds in normal hearing subjects. journal of speech and hearing research, 2, 141-146, 1959. wilson, r.h., & margolis, r.h. measurements of auditory thresholds for speech stimuli, principles of speech audiometry, konkle, d.f. & rintelmann, w.f. (ed), page 79-126, 1983. winer,b. statistical principles on experimental design, mcfiraw hill. new york, 1971. the south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language of the english-speaking coloured child rosanna m1lste1n, β .a. (sp. & h. therapy) (witwatersrand) 105-21 66 ave., forest hills, ν. y. 11375 summary the language deficient language different controversy in the language of the coloured child was investigated while at the same time examining coloured english. the ss comprised 20 nine-year old english speaking coloured children, 9 boys and 11 girls. language samples were obtained through direct questioning according to halliday's language functions. from these samples, the non-standard language structures used by a significant number of the ss were isolated, and examined. it was established that the ss had competence for all these structures except that of relative sentences. possible reasons for this were postulated. a sub-aim of the study was to comparc the ratings of coloured teachers and a group of speech therapists and university students of non-standard sentences used by the ss. based on the findings, several implications for speech therapy were discussed. opsomming die twispunt „taalafwyking" teenoor ,,taalverskil" in die taal van die kleurlingkind is ondersoek, asook terselfdertyd kleurlingengels. die proefpersone was twin tig nege jarige engelssprekende kleurlingkinders, 9 seuns en 11 dogters. taalmonsters is verkry deur direkte vrae volgens halliday se taalfunksies. daardie taalstrukture wat nie standaard is nie en wat deur 'n betekenisvolle aantal proefpersone gebruik is, is van hierdie monsters geskei en noukeurig ontleed. daar is vasgestel dat die proefpersone vaardigheid in al hierdie strukture,'behalwe in relatiefsinne, getoon het. moontlike redes hiervoor word gepostuleer. 'n sekondere doel van hierdie studie was om die beoordelings van kleurlingonderwysers teenoor die van 'n groep spraakterapeute en universiteitstudente te vergelyk met betrekking tot daardie sinne wat deur die proefpersone gebruik is en nie standaard is nie. die implikasies wat die bevindinge vir spraakterapie inhou, word bespreek. south africa is both a multi-racial and a multi-lingual society. any profession concerned with speech and language must take cognizance of this and must include all the subcultures into its sphere of interest and investigation. this will ensure better understanding, communication and interaction among the members of society. the coloured people may be viewed as one such subculture, and thus warrant investigation as have done the negroes and puerto ricans. from the point of view of the speech therapist and linguist, the study of such cultures and subcultures offers a wealth of linguistic data which can serve to improve the efficiency of the disciplines. in studying the english of coloured children, it is important to bear in mind the standard version of the language, i.e., standard english (se). speakers whose dialects vary from the standard version have been labelled either as being defective or as being linguistically different.2 this conflict stems from the tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23. desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 rosanna milstei language deficient language difference controversy. according to the language deficient, viewpoint, the speakers are seen as using an inferior language, a "restricted code" 5 ' 6 together with its concomitants of concreteness, depressed verbal performance, and low conceptualization. 5 ' 6 ' 1 4 ' 2 8 ' 2 9 ' 3 5 ' 3 8 the proponents of the language difference standpoint suggest that the language is highly organized, rule governed and systematic, and is in no way inferior.1'9'42 the differences that occur are merely in the surface structure.26 in this study, when discussing the language used by the coloured child, the term non-standard will be alternated with "error", both of which will imply avariation, rather than a mistake. from the above it can be seen that in testing, it is important to tap not only what is overt viz. performance, but also what is known and understood about the particular linguistic code viz. competence. this is important as it will determine to an extent the severity of the "error", the approach in therapy, and if in fact, there is to be therapy at all. competence cannot be directly observed and is thus difficult to assess.3'41 linguistic competence is of little use if the speaker is unable to use his language. this suggests the value of assessing communicative competence7 and the change in language as it is used to fulfill different functions. halliday 1 5 ' 1 6 discusses several such functions of which three will be investigated in this study. in the representational or textual function, language is used to express propositions about something. this imaginative or ideational model serves to relate the child to his environment in his own way. through the interactional or interpersonal model, the language is used to establish and maintain social relations.15'16 these categories may be theoretical but if they do exist, they are ripe for exploration and may have important implications for the linguist and speech therapist. in particular, they indicate the importance of taking into account the context and meaning when evaluating language. methodology aims the main aim of this study is to investigate certain aspects of the language of the english-speaking coloured child. this is done with a view to examining the language deficient language different controversy. implicit in this aim are several sub-aims: to examine the possible change in language as it is used in different language functions. the language functions to be examined are those discussed by halliday1 5'1 6 and are a) representational b) imaginative and c) interactional. 1 to investigate the possible "concreteness" in the language of the coloured child. this area is closely allied to the language deficiency hypothesis. to differentiate the "errors" made by the group as a whole as,opposed to those made idiosyncratically by individual children. these may then be characteristics of coloured english. to evaluate the in-depth testing of language using both expressive language and structured language tests. journal of the south african speech and hearing association, vol. 23, december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language of the english-speaking coloured child 15 to compare coloured speakers' ratings of the children's language with those of a combined speech therapist and university population group. it is important to determine whose judgement to take into account when labelling a child's language "incorrect". to compare "errors" found with those reported in the literature on other english-speaking minority groups e.g. puerto ricans, negroes. hypothesis the language of the english-speaking coloured child is riot inferior to se but is an organised, rule-ordered language. the child is able to express and understand meaning in his environment and is thus not seen as language impaired. subjects 20 ss were used, 9 boys and 11 girls. the ss were drawn from two english medium coloured schools in johannesburg and were all in std.2. the mean age was 9 years 4 months and the ages ranged from 8 years 5 months to 9 years 8 months. the ss were selected by the teachers according to several criteria. 1. they had to be approximately between 8 years 6 months and 9 years 6 months. by this age children have acquired all the basic sentence structures and have not yet been influenced by the jargon of the peer group.27 2. they had to be of average intelligence and must not have failed at school. the experimenter (e) did not want the factor of intelligence to interfere but at the same time did riot want a biased population. for the purposes of this study, scholastic achievement was felt to be an adequate criterion. 3. the ss had to have no speech, hearing or language problem. the ε did not want their performance to be masked by any of the above. 4. the ss had to come from english-speaking homes and although variables of parental education and socio-economic status could not be controlled for, the above criteria made for a sufficiently homogeneous group. tests used these were designed in two parts: 1. the elicitation of language samples within representational, imaginative and interactional functions of language. 2. tests of those areas in which the ss had used non-standard variations of the language. no standardised tests were used as these were not felt to be appropriate for the sample being tested. the use of standardised tests has led to confusion regarding accurate descriptions of the different language of the culturally different child.40 tydskrifvan die suid-afrikaanse vereniging vir spraak en gehoorheelknde vol 23, desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 rosanna milstei test i a series of questions was used. these were similar to those used by lawton.28 there were three categories of questions, corresponding to the three language functions being tested'. toys were used to elicit the language which included a goblin, snake, sequence cards, jigsaw puzzles and two telephones. the first questions tapped the representational function of language. questions such as the s's name, age and address were started with, progressing to a more abstract level e.g. 'why should people not steal?' in the imaginative functions, the ss were required to talk about the rubber goblin and snake. they also had to answer the questions 'what would you do if you had a space ship?' or 'what you do if you were a fairy?', depending on their sex. for the interactional function, another s was called in and the two ss had to have a telephone conversation. they were also given a puzzle which they had to complete together. the questions were designed to elicit equal amounts of language for each of the three categories. this type of directed, structured language eliciting was felt to be better suited to the population being tested than some of the conventional methods u s e d . 6 ' 2 9 ' 3 0 ' 4 4 test ii this was designed to assess the competence in those areas of test i in which the ss had used different versions of the language. performance may be affected by certain variables e.g. memory factors, and the interference of physical or psychological processes.32 thus competence cannot be inferred from performance but must be separately investigated. only those areas which were "failed" by a significant number of the group were tested. eight areas were examined and the materials used were sentences, pictures on 17 χ 10 cm cards a boy, dog, car, train and lion. in each subtest, there were five items except for subtest 8, which had seven items. subtest 1 passives: the ss had to point to a picture corresponding to a passive sentence.23 there was a choice of four pictures so as to reduce the chance ^ factor. ss were then given an explanation of the passive, focusing on the object, and had to construct two passive sentences from the two action situations e.g. "the car hits the train" this is demonstrated "starting with the words 'the train' say what happened to the train". in these, the objects used were such as to yield no semantic cues.37 thus in the above example, either the-train or the car could have been the subject. subtest 2 relative sentences: the ss had to answer questions about relative sentences e.g. "the girl the boy saw was tall". "who was tall?" two types of embedded sentences were used: a) one embedded sentence in the underlying p-marker e.g. the cat that caught the mouse had a long tail b) one embedded sentence in the underlying p-marker but in the surface structure it is centreembedded e.g. the children the fish saw swam quickly.12 the sentences used were controlled for syllable length and here too, as far as possible yielded no semantic cues.37 journal of the south african speech and hearing association, vol. 23, december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language of the english-speaking coloured child 17 subtest 3 prepositions: the ss had to say whether the sentences were correct or incorrect, this method being referred to as sentence identification. they also had to say whether the picture presented corresponded to a sentence they were given e.g. given a picture of a car having driven into a tree, they had to say whether the sentence "the car drove in the tree" was right or wrong. subtest 4 pronouns: the ss had to point to one out of four pictures which corresponded to a.sentence. sentence identification was also used here e.g. i'll buy me a house. subtest 5 modal:the ss had to identify sentences as well as construct questions with "can", "will" and "do". even though the test words were given, it was felt that their competence would be demonstrated if they could use them correctly in a sentence. subtest 6 incomplete sentences: sentence identification was used here. subtest 7 agreement of v with ν of np and vp: sentence identification was required here. subtest 8 tense: the ss had to identify sentences and had to listen to a short story and fill in the correct word at the end e.g. would/will. the incorrect sentences used in the tests were either contrived, based on the ss' "errors", or they were actual sentences used by the ss. administration of the tests test i each s was seen individually for about 30 minutes and these interviews were tape recorded. the interview commenced with the representational function and although questions such as name, age and address yielded language data, they also served to relax the ss. the questions were asked in the same order for all ss. the imaginative function was tapped next, followed by the interactional function. here the responses were both tape recorded and written by the ε which served as a double check. test ii the second session took place one month later and the ss were seen individually for about 30 minutes. they were told they were going to play different sorts of speech games. the subtests were presented in the same order for all ss and the instructions were given at the start of each subtest. analysis and statistical procedures test i the language samples were transcribed from the tape recorder and a list was compiled of all the "errors" made by the ss. context was at all times referred to, following lee and canter.30 from this list, a table was drawn up listing the language classes and the number of "errors" made in each class by each s in each of the three categories. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheekunde vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 rosanna milstein using the information from the table, a chi squared test was used to determine which "errors" were made significantly by the group as a whole as opposed to individual "errors". the same test was used to determine whether all three language functions were equally affected for the ss. the chi squared test was chosen as the data being dealt with was ordinal and appeared to have directionality.34 a further table was compiled, listing the transformations the ss should have h a d 2 0 ' 2 1 and those which were present in their language samples. the chi squared test was used to establish which transformations were omitted by a significant number of the group. test 11 the ss were given scores out of 5 for the subtests. the results were tabulated, showing the number of "errors" made by each s for each subtest. the totals were subtracted from 100 to get a score of "incorrect". the chi squared test was used to determine which of the subtests were failed by a significant number of ss. teachers' ratings a list of 40 sentences used by the ss which were judged incorrect by the e, and 10 correct control sentences were given to 20 english-speaking coloured teachers and to 20 speech therapists and university students. the sentences had to.be rated as being 'acceptable', 'unacceptable', or 'not sure', if used by a nine-year old. the ratings of the two groups were compared and the pearson product moment correlation coefficient was used to establish the relationship. results and discussion results of test 1 in analysing the language samples of the ss, it was established that certain nonstandard versions were used by the group while others were idiosyncratic. this was ascertained using the chi squared test where x 2 = 33,92; df -22; ρ = 0,05. six language classes were isolated as having contained non-standard structures in the group. using the value of ε where ε = total number of errors i.e. the extotal number of cases pected values, it was found that above 11,52 the non-standard structures were used significantly by the group as a whole. the six language classes which fell above this point were "errors" of agreement, tense, prepositions, pronouns, incomplete sentences and modals (seefigure 1.). / discussion of the six "errors" agreement this involved mainly the np-v relationship e.g. "in the morning, she brush it out". other "errors" involved the relationship between v and ν of vp and np auxiliary. this was also found by ganes 1 3 in her study of the written english of coloured teacher trainees. this has also been noted in negro dialects where there are no obligatory morphological endings.3'10 tense this structure involved the substitution of one tense for another. the present tense was used for the past, conditional, progressive and future. future journal of the south african speech and hearing association, vol. 23, december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language of the english-speaking coloured child 19 h i j k l m n o p q r s t u v w language classes key: a = agreement b = tense c = preposition d = pronouns e = incomplete sentence f = modal g = word order h = clumsy figure 1: representation of the frequency of errors per language class in descending order tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde. vol. 23. desember 1976 i = determiner q = plurals j = k = auxiliary r = participles j = k = conjunction s = interrogative reversals 1 = got/my t = "to" m = do u = adj/adv η = vocabulary v = double negative 0 = semantic over elaboration w = miscellaneous ρ = copula r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 rosanna milstein tense was also used for conditional and the past tense was substituted for the future. the main "errors" were the use of future for conditional tense e.g. in response to "what would you do if you had r100?" "i will put it in the bank". it would appear that this substitution implies an inability to move out of the concrete functioning. it seems that the only areas of operation are those that are definite and tangible viz. past, present and future. some authors have reported that in negro dialects, conditionality is represented in word order change but this was not found in the protocols of this study.3 with regard to the use of present for past this may be due to the influence of the afrikaans historical present which is also evident in dialects of s e . 1 , 2 5 prepositions there were several substitutions found in this language class but it was only those which confused semantic understanding that were considered. these "errors" would be indicative of deficient conceptual relations and thus warrant attention e.g. a frequent substitution was in/at e.g. "i live in 20 north avenue". this does not impair meaning at all. in contrast, the sentence, "she was thankful for her parents (for giving her the gift)" implies a confusion of "to" and "for" as prepositions and it is this type of factor that necessitates deeper investigation. pronouns three types of non-standard versions were found. the least aberrant was that of omission and this occurred seldom. the use of the accusative pronoun for the reflexive was predominant e.g. "i'll buy me a house." this seemed to occur only in the first person.1 a further variation which was considered within this language class was where in a sentence, either the identical np was not deleted or the pronoun was redundant e.g. "my mother, she goes to town." adler1 has referred to this as "subject expression". fasold 1 0 refers to it as pronominal apposition where a pronoun is used in apposition to the ν of np. he feels that the length of the modifying material which intervenes between the noun and the pronoun affects the acceptability — the more intervening material, the more acceptable. this may be related to the entry and re-entry of participants in a narrative.10 incomplete sentences in most cases, the first np of "it" was absent. labor24 feels that these sentences cannot be considered incorrect as the child must have understood what was said in order to give an appropriate but incomplete response. this makes clear the importance of context in evaluating the language. modals these were frequently deleted and occurred mainly in the context of "got" e.g. "see, this man got a gun". 'got' was not regarded as incorrect unless it was substituted for the main verb of the sentence e.g. got/received,./ the above structures were discussed as they were found to be used by the majority of the group and thus may be seen as characteristic of coloured english. non-standard variations were also used by individuals and although they are of interest, they cannot be discussed here. language functions it was found that the three language categories were differentially affected by the "errors". using the chi squared test, where x 2 = 5,99; df = 2; ρ = 0,05 it was found that representational language had a significant number of non-standard structures x2' = 12,08. both imaginative and interactional language were not affected by the "errors", imaginative language journal of the south african speech and hearing association, vol 23 december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language of the english-speaking coloured child 21 having x 2 = 0,005 and interactional language x2 = 12,57. it can be seen that interactional language was not affected significantly. these results should however be viewed with reservation as although the test was designed to elicit equal amounts of language for each category, it is possible that unequal amounts were obtained, making the results less comparable. transformations that were omitted. the protocols were judged against a format of transformations passive, negatives, relative sentences, adjectives, pronouns, prepositions and adverbs. it was found that the ss did not use passives, relative sentences and adverbs significantly as a group. this was established using the chi squared test where x 2 = 3,84; df = 1; ρ = 0,05. passives and relative clauses were included in test ii but adverbs were omitted as it was felt that the area was too vast to be included in the confines of the study. results of test ii relative sentences. this subtest was failed by the group as a whole. this was ascertained through the chi squared test where x 2 = 3,84; df = 1; ρ = 0,05. there thus appears to be a defect in the competence for relative sentences. the ss did not, as suggested by strohner43 rely on syntactic information but rather on strategies. a possible explanation for this may be the age of the ss. it would be of interest to test for the evidence of this structure in an older child. passives. although these were not used spontaneously, the ss appeared to have the competence as they were able to understand and generate passive sentences. this may be due to the fact that the passive is learned late and memory may be involved in its production. in addition production lags behind comprehension and this may have been operative here too. 1 2 modals. this was well coped with, suggesting the "errors" made in test i were merely performance "errors" and were brought about by other factors e.g. phonological rules, rather than by a lack of competence in these areas. tense. here too ss coped well, suggesting that the "errors" were purely on a performance level. however it was felt that there was no semantic differentiation between e.g. should/shall. when asked the difference between these two words, some ss said there was no difference, others stating the difference by giving two sentences without going into the meaning. it is difficult to draw any conclusions from this but a possible explanation may be an inability to express subtle differences between the words, a difficulty manifested by all nine-year olds. a control group would have been useful here to evaluate whether this difficulty was culture specific or age group specific. prepositions. the "errors" seemed to be purely on a performance level and the ss appeared to have the conceptual meanings of the prepositions used incorrectly. pronouns. these were well managed indicating that the ss had the competence for these but broke down on a performance level. incomplete sentences. as mentioned earlier, these were not deficient in meaning, and the fact that the competence is there is borne out by the fact that ss were able to recognise and correct these sentences. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 rosanna milstein agreement. there appeared to be the competence for agreement between np-v and v and ν of np but the breakdown is on a performance level due to extraneous variables e.g. phonological rules. thus all errors were surface structure "errors" except for relative sentences. (see table 1.) total total x2 = 3,84 language classes correct incorrect df = 1, ρ = 5% · passives 91 9 1,26 relative sentences 59 41 5,93 prepositions 87 13 ,46 pronouns 78 22 ,1 modals 95 5 2,46 incomplete sentences 85 15 ,21 agreement 83 17 ,05 tense 69,3 30,7 1,66 table i. summary of results for competence sub-test (test ii) teacher rating. as this was designed to examine the similarity or difference of the two groups' ratings, correlations were established for each of the three ratings. using the pearson product moment correlation, correlations of ,89 ,83 and ,59 were established for the three ratings respectively. this means that there was a high level of agreement between the two groups for sentences that were clearly 'acceptable' or 'unacceptable'. however, there is some disparity between the two groups on their ratings of.sentences of which they were not sure. this may be because the group of coloured teachers were more definite about their decisions, perhaps because they were familiar with both the language used in the sample sentences and the nine-year old group. the other group found it difficult to visualize how a nine-year old speaks and were thus 'not sure' more often. discussion concreteness of language. the language of the ss and their responses to the questions were felt to have been fairly concrete and situation bound. this feature was noted in various forms. it could be seen in the ss' relating of their journal of the south african speech and hearing association vol. 23 december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language of the english-speaking coloured child 23 experiences, the story telling and in the syntax where frequently, structures implying concrete notions were used e.g. future for conditional tense. however, even though these factors may have been evident, it is incorrect to attribute them to the language of the coloured child. the language of nine-year old se speakers has not been examined and thus no statements, other than tentative ones, can be made about the language of the coloured child. furthermore, the concreteness of language must not necessarily be pinned to the speaker but rather to the factors operative at the time of testing. most obvious here is the influence of the testing situation on the language of the ss. variables in testing situation. it is inevitable that the race of e, as well as her age and authority, had an effect on the verbal output.4 0 " . . . the power relationship in a one-to-one confrontation between adult and child are too asymmetrical."24 this may have rendered the language more formal and possibly more concrete. it has been found that the greater the difference in status between the tester and s, the more the s strives to use standard forms. 1 1 ' 2 6 ' 4 0 had a different tester been used, perhaps of the same race, maybe even the same or closer age group, the ss may have given a truer representation of coloured english, along with even more non-standard structures. in addition, the poor performance may be due to a lack of understanding of the instructions. weener40 says that the ability to process natural language is directly related to the degree to which phonetic, syntactic and semantic features of a message match those same features of the speaker's own dialect. influence of afrikaans. there is yet another possible explanation for the nonstandard structures in coloured english the influence of another language, in this instance, afrikaans. although the ss were drawn from englsih-speaking homes and schools afrikaans is the dominant language of the coloured population (one english speaker to eight afrikaans speakers33). all the ss have been in contact with afrikaans speakers, speaking either afrikaans or non-standard english. the influence of one language on another has been defined differently by various authors. 8 ' 1 7 ' 1 9 features of the one language impinge on the other, and the interference is said to be in the language performance 4 the more similar the two languages, the more interference there is.3 9 this would seem to apply to the case in point, as the english used by afrikaans speakers is closer to that used by english-speaking coloureds than a completely different language e.g. afrikaans. additional aspects. a further observation that was made based on the protocols of the ss was a frequent use of sentences beginning with 'and', 'but', 'then' and 'because'. the commencement of sentences with 'and' and 'but', also found by templin44 may be viewed as misuse of conjunctions. it is possible that the ss did not have the concepts and semantic meanings of these words and thus used them at the beginning of sentences. two factors invalidate the above statement. the first is that both these words were used correctly in the language of the ss, implying that the competence for their meanings and uses does exist. secondly, these words are frequently used by speakers of se, possibly those of a lower socio-economic status. on heuristic observation, this has •frequently been noted in the language of all races, and thus must be judged with reservation. on the other hand, the frequency of the usage of these words tydskrifvan die suid-afrikaanse vereniging vir spraak en gehoorheelkunde. vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 rosanna milstein may be illustrative of a deficiency31 and may.be indicative of a limited vocabulary. it may be a further manifestation of the stilted, concrete nature of language which, as mentioned above, may have been partially caused by the test situation. the frequent use of 'jus' within the sentences is common in less formal speech, but may also be indicative of loss for words'. once again, judgement here must be made with reservation. conclusions from the above, there are several conclusions and implications which can be drawn, all which aid in dealing with the coloured child, be it in the form of speech therapist, teacher or research worker. broadly speaking, it would seem that the language of the english-speaking coloured child cannot be seen as inferior or deficient. it appears to serve adequately the communicative needs of the child, allows him to express himself and meaning in his environment and can be said to be deficient no more than any one language can be said to be inferior to another. in contrast, coloured english may be viewed as a different language which is how labor24 refers to the language of lower class speakers. yet, whatever the label given, there still exists an intercultural communication problem, especially when adjudged by speakers of se. implications for speech therapy there are specific implications for both testing in therapy and for the actual administration of therapy. testing. it seems, as mentioned earlier, that the method used to tap the ss' language is appropriate to the coloured population. although no spontaneous speech was directly attained, direct probing elicited sufficient language for linguistic analysis. this method of direct questioning is felt to be beneficial in a test situation where the s is not outgoing but even so, it must be tactfully handled in order not to intimidate the child. in the language samples obtained it was frequently difficult to distinguish between what was directly elicited and what was spontaneously given by the child. this would further seem to indicate the comparability and efficacy of using a structured means for getting a language sample. in addition, the linguistic content should be adapted to the child's system, thus ensuring that he understands what is required of him.3 6 further, in evaluating responses, context must be taken into account.19 this is particularly important when dealing with a culture different from that of the therapist. the therapist can no longer take for granted meanings of words used by children under test and must actively investigate the environment. this makes clear the shortfalls of using traditional tg methods for analysing and evaluating the language of coloured children. at all times semantics must be referred to, the relations of the linguistic occurrences to the rest of the child's world, and only in this way will their language be interpreted correctly and fairly. it can also be seen that it is important to probe deeper than performance as it is very often influenced by extraneous variables. thus an attempt must be made to tap competence as well as performance. therapy. the conclusion that the language, of the coloured child is different, · as opposed to deficient, throws a different light on therapy. several suggestions journal of the south african speech and hearing association, vol. 23, december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language of the english-speaking coloured child 25 have been made regarding this issue. it has been suggested that because the language is not deficient, it should be the avenue through which the child is taught the new or target language.4 the mother tongue which is used initially by the child should be used as much as possible in teaching the new language as this will promote better understanding, more carry-over between home and therapy, and the break from home will be minimized.8 the acceptance by the therapist of the child's language is of utmost importance22 and the therapist cannot be glib in admonishing a child's use of language and proclaiming it incorrect. this may result in the child's seeing himself as illogical and incorrect, and the psychological factors involved may be permanently damaging. the child will react to his failure and what may have originally been a language problem may grow into a learning and emotional one. yet another implication for the speech therapist is that she must not only accept the language of the child but must understand it and if necessary, endeavour to use i t . 7 ' 1 8 "such use, should among other gains, foster better social acceptance of the clinician by the child."2 this is important as the therapeutic relationship plays a large role. in addition, an understan ding ot the s child's culture, his needs and values14 and the dynamics operative in therapy are expedient in the successful dealing with the child, especially if he belongs to a different subculture to that of the therapist. in actually teaching structures, the therapist must determine the cause of the "errors". if the child is lacking in competence, therapy will be geared to its training if however the "error" is on a performance level only, the child will need less instruction and his attention may merely be drawn to the standard production if the "error" is related to the factors in his knowledge e.g. phonological system, there is little reason to teach the child the structure without taking into account its determinants. the findings with regard to the differential occurrence of non-standard structures within different language functions are also of interest to the speech therapist. this may give an indication as to which language functions should be started with and which may be used to facilitate carryover. the high correlation that existed between the ratings of the children's sentences by the teachers and the group of speech therapists and university students indicates that to an extent, an incorrect structure is universally incorrect, regardless of the culture or status of the judge. for the speech therapist, it means that the opinions and judgements of the teachers can be relied on. this does not mean that no further investigation need be done but does imply that the teachers of the children are reliable referrants. in the area of coloured language, the field is wide open to investigation. studies controlling many of the independent variables may lead to the isolation of factors pertinent to and influential in the understanding, description or treatment of children. the variation of language within the group as a whole may be of interest e.g. the change of language with race, sex, status and age. it would be of interest to see if at any age, competence for relative sentences is acquired. these investigations would surely have invaluable implications for the speech tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde. vol 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 rosanna milsteiri therapist. just as it was of interest to see what the coloured teachers rated correct and incorrect, so would it be enlightening to determine what the coloured children themselves term correct or incorrect. do these evaluations differ with status in the community? above all, norms are required for age groups, sex, status, all of which may validate the work with these children or refute therapy on the grounds that the reference points have been unrealistic. references 1. adler, s. (1971): dialectal differences: professional and clinical implications./ speech hear. dis. 36(1), 90-100. 2. adler, s. (1973): social class bases of language: a re-examination of socioeconomic, sociopsychological and sociolinguistic factors. asha (1)3-9. 3. baratz, j.c. (1969): language and cognitive assessment of negro children: assumptions and research need.^s/w 11 (2) 87-92. 4. baratz, j.c. (1970): should black children learn white dialect? asha 12(9)415417. 5. bernstein, b. (1959): a public language; some sociological implications of a linguistic form .brit j. sociol. 10, 311-326. 6. bernstein, b. (1962): social class, linguistic codes and grammatical elements. lang. speech 5, 221-240. 7. cazden, c.b. (1972): child language and education. holt, rinehart and winston, inc. 8. crothers, e. and suppes, p. (1967): experiment in second-language learning. academic press inc. 9. destefant, j.s. (1973): black english. in language, society and education: a profile of black english. destefano, j.s. (ed.) charles a. jones publishing company. 10. fasold, r.w. and wolfram, w. (1973): some linguistic features of negro dialect. in language, society and education: a profile of black english. destefano, j.s. (ed.) charles a. jones publishing company. 11. fishman, j. (1964): guidelines for testing minority group children. /. soc. issues 20 (2) 129-145. 12. gaer, e.p. (1967): children's understanding and production of sentences. . /. verb. learn. verb. behav. 8, 289-294. 13. ganes, g. (1967): an analysis of errors in the written english of 28 coloured teacher-trainees. unpublished research report, department of phonetics and linguistics, university of witwatersrand, johannesburg. 14. ginsberg, h. (1972): the myth of the deprived child. prentice hall inc. 15. halliday, m.a.k. (1973): explorations in the functions of language. edward arnold ltd, london. 16. halliday, m.a.k. (1970): language structure and language function. in new horizons in linguistics, lyons, j. (ed.) penguin books ltd. 17. halliday, m.a.k. (1968): the users and uses of language. in readings in the sociology of language, fishman, j.a. (ed.). mouton and-co printers, the hague. 18. honeyford, r. (1972): class talk. brit. j. dis commun. 7(2) 206-211. 19. hymes, d. (1971): competence and performance in linguistic theory. journal of the south african speech and hearing association, vol. 23, december 19 76r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language of the english-speaking coloured child 27 in language acquisition: models and methods, huxley, r. and ingram, e. (eds.). academic press inc. london. 20. jacobs, r.a. and rosenbaum, p.s. (1967): grammar 1. ginn and company, u.s. 21. jacobs, r.a. and rosenbaum, p.s. (1967): grammar 2. ginn and company, u.s. 22. johnson, k.r. (1970): blacks. in reading for the disadvantaged: problems of linguistically different learners, horn, t.r. (ed.) harcourt, brace and world, inc. 23. kessel, f.s. (1970): the role of syntax in children's comprehension from ages 6-12. monogr. soc. res. child. developm. 35(6). 24. labor, w. (1973): the logic of nonstandard english. in language, society and education: a profile of black english, destefano, j.s. (ed.). charles a. jones publishing company, u.s. 25. labor, w. and cohen, p. (1973): some suggestions for teaching standard english to speakers of nonstandard urban dialects. in language, society and education: a profile of black english, destefano, j.s. (ed.). charles a. jones publishing company, u.s. 26. labor, w. and cohen, p. (1973): systematic relations of standard and nonstandard rules in the grammar of negro speakers. in language, society and education: a profile of black english, destefano, j.s. (ed.). charles a. jones publishing company, u.s. 27. lanham, l.w. (1975): personal communication. professor, department of phonetics and linguistics, university of the witwatersrand, johannesburg. 28. lawton, d. (1969): social class, language and education. routledge and kegan paul ltd. london. 29. lawton, d. (1964): social class language differences in group discussions. lang. speech 7(3) 183-204. 30. lee, l.l. and canter, s.m. (1971): development sentence scoring: a clinical procedure for estimating syntactic development in children's spontaneous speech. / speech hear. dis. 36(3) 315-340. 31. leonard, l.b. (1972): what is deviant language? j. speech hear. dis. 37(4) 427446. 32. lyons, j. (1970): chomsky. fontana modern masters, london. 33. mainwaring, k. (1962): the contribution of the coloured people to culture in south africa. in understanding one another. s.a. institute of race relations. 34. mccall, r.b. (1970): fundamental statistics for psychology. harcourt, brace and world, inc. u.s. 35. mcdavid, r.i. (jnr) (1966): dialectal differences and social differences in an urban society. in sociolinguistics, bright, w. (ed.) mouton and co. publishers, the hague. 36. patterson, s. (1953): colour and culture in south africa. routledge and kekan paul limited, london. 37. penn, c. (1972): a linguistic approach to the detection of minimal language dysfunction in aphasia. unpublished research report, department of speech pathology and audiology, university of witwatersrand, johannesburg. ' tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde. vol. 23, desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 rosanna milstei 38. riessman, f. (1962): the culturally deprived child. harper and brothers publishers, new york. 39. saville, m.r. (1970): language and the disadvantaged. in reading for the disadvantaged: problems of linguistically different learners, horn, t.r. (ed.) harcourt, brace and world, inc. u.s. 40. severson, r.a. and guest, k.e. (1972): toward the standardised assessment of the language of disadvantaged children. in language and poverty: perspectives of a theme, williams, f. (ed.) markham publishing company, chicago. 41. shriner, t.h. and miner, l. (1968): morphological structures in the language of disadvantaged and advantaged children. in/. speech hear. res. 11(3) 605-610. 42. shuy, r.w. (1972): the sociolinguist and urban language problems. in language and poverty: perspectives on a theme, williams, f. (ed.) markham publishing company, chicago. 43. strohner, h. and nelson, k.e. (1974): the young child's development of sentence comprehension: influence of event probability, nonverbal context, syntactic form and strategies. child developm. 45(3) 567-576. 44. templin, m.c. (1957): certain language skills in children. university of minnesota press, minneapolis. 45. (1968): the use of vernacular languages in education: the report of the unesco meeting of specialists, 1951. in readings in the sociology of language, fishman, j.a. (ed.) mouton and co. printers, the hague. books on speech and hearing johannesburg: campus bookshop 34 bertha st braamfontein 724-8541 westdene services 76 king george st hospital hill 724-9345 logan's university bookshop 229 francois road durban telephone 354111 westdene services 604 eagle bldg murchies passage west street telephone 24403 westdene services sanso centre adderley street cape town telephone 411061 • westdene services shop 35 / ground floor nedbank plaza beatrix street arcadia telephone 26336 pietermaritzburg: logan's university bookshop nedbarik plaza scottsville telephone 41580/41588/41589 literary services (pty) ltd durban: cape town: pretoria: journal of the south african speech and hearing association, vol. 23, december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) , | | \ 7 3 2 m e d i c a l c i t y i t l t l l l l l l 1 e l o f f cor. jeppe s t r e e t β · | | 1 | 1 1 ι ii ii johannesburg, transvaal r e p u b l i c 7 ' ' i i i i 11 i i i i i t e l e p h o n e 2 3 6 6 8 5 h e a r i n g a i d 1 , 1 hi -.o. .*» b2o4, c o n s u l t a n t s cpty) l t d . '· saxonwold 2132 hearing aids. we specialize in the supply and fitting of hearing aids for all hearing losses, especially for nerve deafness recruitment bone conduction cases. cross aids: cros bicros multicros etc. bone conduction aids for body, earlevel, glasses (speciality by viennatone) binaural fittings we import and stock :— viennatone, qualitone, microson, phonak hearing aids. moulds: soft, hard, skeleton, vented, occluded etc. repairs: all aids supplied with a scientific performance report after repair. special prices for dealers and institutions. accessories: teacher — pupil, parent — child, individual audiotrainers, very reasonably priced. group audio trainers. tv — wireless infrared transistor receiver sets made by sennheiser. audiometers: screening, diagnostic, research, era and electrocochleography c.o.r. and peep show. impedance bridges. manufacturers of sound proof booth and sound proof rooms. hearing aid testing set by "fonix" u.s.a. phonak noise generator with different frequencies, pure tone and warble tone, for everyday's use. we repair and calibrate audiometers. sound level meters, calibrators. industrial noise consultants. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the renfrew word finding scale : application to the south african context jenny pahl meenakumari b. kara department of speech and heanng therapy university of durhan-westville, durban abstract the renfrew word finding scale (renfrew, 1988) was administered to 30 indian (group a) and30 white (group b) durban english speaking children aged between eight and nine years to determine its suitability for assessment of expressive vocabulary. mean scores for both groups were statistically compared to the british norms in terms of mean raw scores and mean mental age. mean scores for groups a and β were compared to each other. item analyses were carried out to obtain further information regarding possible lexical characteristics for each group and common problems with certain items. both groups performed significantly poorer than expected according to the british norms. group a was significantly lower than group b, thus indicating the test's unsuitability for use with these population groups in its present form. opsomming die "renfrew word finding scale" (renfrew, 1988) is op 30 indier (groep a) en 30 blanke (groep β) engelssprekende kinders tussen die ouderdomme agt en negejaar, woonagtig in durban, getoets om hierdie toets se toepasbaarheid vir die bepaling van ekspressiewe woordeskat vas te stel. die gemiddelde tellings vir beide groupe is statistics vergelyk met die britse norme ten opsigte van gemiddelde routellings en gemiddelde verstandsouderdom. gemiddelde tellings vir group a en β is ook met mekaar vergelyk. itemanalise is uitgevoer om verdere inligting aangaande moontlike leksikale kenmerke vir elke afionderlike groep, sowel as gemeenskaplike probleme van sekere items te verkry. beide groepe het beduidend swakker as wat verwag was, ten opsig van die britse norme presteer, en groep a was beduidend laer as groep b. die resultate dui dus daarop dat die huidige toets nie toepaslik is vir hierdie populasie groepe nie. the,introduction of the new dispensation in south africa has resulted in many changes opportunity for the admission ethnic groups within the school to its society, including the and integration of different system. this integration has implications for speech therapists, who will increasingly be required to provide services to people of language and cultural backgrounds different from their own. at present the framework for this service, both theoretical and practical, is primarily euro-american in nature (taylor,/1986), and not always appropriate to the south african context. an important part of the speech therapist's provision of services is assessment, which is aimed at differentiating between those people presenting with a communication problem and those whose communication is adequate. according to malan (1981), recent sociolinguistic research concerning normative differences in the language of children has necessitated a reevaluation of the current approaches to the assessment and diagnosis of language disorders in south africa. she has stressed the importance of obtaining normative information pertaining to specific communities because the commonly used measures of linguistic behaviour are based on the norms of the mainstream language. this has great significance in differentiating between true language pathology and language difference or variation. by failing to make the distinction, a difference could be perceived as a disorder, which would constitute a misdiagnosis, and could result in inappropriate and unnecessary tljerapy (anderson, 1984). the need for appropriately norm-referenced techniques in the assessment process is therefore explicit (alant & beukes, 1986). the acknowledgement of cultural factors contributed to the differencedeficit controversy concerning language. the deficit theory holds in america, for example, that "black" english is inferior to standard or "white" english. in contrast, the difference theory (e.g., labov, 1968; baratz & povitch, 1967, cited by williams 1970) holds that all languages and dialects are equal. the use of standardised tests in the assessment process can provide useful and reliable information, but in the south african situation it is frequently fraught with problems. one of the acknowledged major limitations of standardised tests is that of test bias. adler (1979) has outlined ways in which tests can be biased towards culturally different children, including the bias of linguistic aspects, the bias of non-linguistic factors, a culture-specific verbal style being required by the test, and bias due to the test's being outside the general experience of the testee. jensen (1980) discussed test bias in terms of the content validity of test items and the standardisation population. a test user, such as a speech therapist, may subjectively evaluate the appropriateness of the test according to these aspects, and may judge the test itself as culturally biased. such subjective judgments should be investigated. in the multilingual and multicultural south african conthe south african journal of communication disorders, vol. 39, 1992 ® sasi.ha 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 jenny pahl & meenakumari b. kara text, there are obviously many problems encountered by speech therapists in assessment in general and in particular, when using standardised tests. the implications of these difficulties include the provision of inadequate or inappropriate services, especially when working with people from different cultural backgrounds. alant and beukes (1986) have stressed that the limitations of standardised tests for use with different populations should be recognised, and effort should be made to reduce or eliminate the cultural and socioeconomic biases in these tests. this can be done by renorming existing tests, adapting test items or developing local norms (see, for example the discussion about this by vaughn-cooke, 1983). an aspect of communication frequently assessed by speech therapists is language development. the content component, one of three language components proposed by bloom and lahey (1978), encompasses meaning or semantics (owens, 1988). in this paper, the focus will be on an important subcomponent of language content, vocabulary. the acquisition of vocabulary, which is an integral aspect of language development, is never complete (rees, 1980) and a person's lexicon continues to expand throughout life (owens, 1988). jensen (1980) has stated that the acquisition of word meanings is highly dependent on the context in which the words are encountered. furthermore, vocabulary is not acquired by rote memorisation or formal instruction, but through generalisation, discrimination, education and inference. the child thus acquires the vocabulary of his/her cultural group (jensen, 1980). many researchers have documented the gradual (leonard & fey, 1979) but rapid and extensive acquisition of vocabulary (john & goldstein, 1964; owens, 1988). effective communication is dependent upon the retrieval of lexical items coding this knowledge from stored memory. according to wiig and semel (1984), in attempts to recall a word from long term memory, several processes are necessary. these include the selection of concepts and relationships to match the ideas, attitudes and feelings to be expressed; and the selection of vocabulary equivalents for the targeted concepts and relationships. the speech therapist is frequently concerned with the assessment of vocabulary development in children, for which (s)he uses standardised tests. although various tests are available, few if any have been standardised for the language and dialect groups in south africa. the renfrew word finding scale (rwfs) developed by renfrew (1968) in britain is one such test, that is widely used by speech therapists in durban for assessing expressive vocabulary. such assessment is valuable in identifying language difficulties in children (cottrell, montague, farb & thorne, 1980), but if cultural influences and differences are not considered, such testing can be problematic. since the first edition of the rwfs, published in 1968, there have been two revisions with the third edition having been published in 1988 (renfrew, 1988). a survey of the literature reveals that there are no reported studies on the application of this test to different cultural and ethnic groups in south africa. from the above, it appears that the relevance of the british norms and individual test items is questionable and should be examined to ensure accurate assessment of expressive vocabulary. the purpose of this study was thus to investigate the suitability of this british test of expressive vocabulary for a group of english speaking indian and white children between eight and nine years of age in durban. methodology aims the primary aim of this study was to obtain information on the performance of english speaking indian (group a) and white (group b) children to determine the suitability of the rwfs by comparing the performance of both groups with the british norms; and by comparing the results of the two groups to identify possible cultural and ethnic group influences on test performance. the secondary aim was to carry out a qualitative and quantitative item analysis to investigate the suitability of the test items, and to explore the possibility of specific vocabulary characteristics of both groups. subjects 1. description of subjects. the subjects were 30 south african indian (group a) and 30 south african white (group b) children, 15 males and 15 females in each group. the subjects ranged in age from eight to nine years. 2. subject selection criteria. renfrew(1968; 1972; 1988) selected subjects for the standardisation of the rwfs on the basis of the criteria that all children should be between the ages of three and nine years; be from english speaking homes; and have normal speech and language abilities. the same criteria were utilised in this study with the following modifications. due to practical limitations, subjects in this study were between eight and nine years of age. this age range was chosen as it was predicted that, as this level is the highest chosen by renfrew (1988), the subjects would be able to attempt all items included in the test, thereby providing the maximum amount of information regarding the suitability of items. equal numbers of boys and girls were chosen in each group to note if there were significant differences in scores obtained due to the sex variable, as renfrew (1988) indicated a sex difference with regard to scores obtained. any subject who had failed a year at school was excluded from the study. all subjects were required to be judged by their teachers as being of normal intelligence and as having normal speech and language abilities. although renfrew (1988) did not control for the class variable, subjects for this study were chosen from the middle socioeconomic group to exclude a possible source of differences. adler (1979) has noted that values relating to class cultures are reflected in linguistic interactions between children and their families, which could lead to class differences in linguistic development. apparatus the standardised test materials of the rwfs (1988) were used. the rwfs is utilised to assess children's ahlility to use words in a picture naming task. the test consists of 45 black and white line drawings on separate cards requiring 50 naming responses, which are scored on a recording form. ι procedure | all subjects at each of the schools were tested in the same room in the respective schools with only the subject and examiner present. the rwfs was administered with the examiner seated at a table next to the subject in a single session, lasting 10-15 minutes. administration and scoring procedures as outlined in the test manual were utilised. if the child was unable to recognise a picture or a targeted part, therefore, suitable explanations were given (renfrew, 1988, p.6). a modification to this procedure was to use all test items, as opposed to beginning at the starting points (items 17 and 26) for the age groups under study, in order to achieve the aim of evaluating the suitability of test items. analysis of data 1. after administration of the test, a raw score representing the total number of correct responses, was obtained for each subject according to the scoring procedures outlined in the the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) renfrew word finding scale: application1 >to the south african context 71 rwfs manual. using informal inspection, the mean raw scores for groups a and β were compared to the norms. the raw scores were converted to derived age level scores (referred to as mental age in this study for convenience) and mean mental ages were calculated for males and females in each group. 2. to determine if there were significant differences and variations between mean scores obtained by each group and the standardised british norms due to differences in sex, ethnic group and the interaction between these two variables (k. c. ryan, personal communication, april, 1991), a two-way analysis of variance (anova) was calculated. further, to identify differences within the ethnic groups (south african indian, white, and british), the tukey test, hsd (honestly significant difference) which is a q post hoc test, was done. 3. to check for significant differences between mean mental age and mean chronological age for groups a and b, the student's t-ratio test for correlated data was used. further, a ttest was used to determine if there was a significant difference between the mean mental age scores obtained by the south african groups. 4. quantitative and qualitative item analyses were carried out on the responses of the subjects on the rwfs in an attempt to obtain information about their familiarity with the items as well as characteristics of south african indian english (saie) and south african english (sae). adler (1979, p.88) has suggested the use of this procedure with different ethnic groups to "compare a child's linguistic performance to both standard and peer group norms". this will provide information concerning the difficulty of the item (downie & heath, 1974). results 1. informal inspection of groups a and β scores in comparison to british norms. the average raw scores of both groups a and β were equivalent to the scores obtained by younger children in the standardisation sample. group a (indian) obtained scores equivalent to the 5.6 to 6.0 year old age level, which is approximately 2.6 to 3.0 years below mean ca, while group β (white) obtained scores equivalent to the 7.0 to 7.6 year old age level, which is approximately 1.6 to 2.0 years below mean ca. 2. statistical comparison of the performance of the south african groups to the british norms. these results are presented in table 1. a significant difference (p<.05) in performance on the rwfs between the south african and british populations was found due to the ethnic group variable (see table 1). the results of the post-hoc test revealed that a significant difference occurred between the three ethnic groups. the sex variable was not found to be significant (p> .05) in all ethnic groups, and the combined effects of ethnic table 1: anova for scores obtained by groups a and β compared to the standardised scores on the rwfs (1988) source ss ms df f p-value p-level ethnic group 1372.422 686.211 2 53.51 0.000 ρ < .05 sex 25.600 25.600 1 1.996 0.161 ρ > .05 ethnic group and sex 0.067 0.033 2 0.003 0.997 ρ > .05 key: ss sum of squares ms mean squares df degree of freedom f f value p-value probability values p-level probability level table 2: comparison of mean ma to mean ca scores on the rwfs for groups a and β group mca j . mma m-d sd-d df t p-value p-level a males 8.6 6.0 2.6 0.83 14 11.26 0.000 ρ < .05 females 8.7 6.1 2.6 1.10 14 7.973 0.000 ρ < .05 β males 8.6 j 7.4 1.2 1.09 14 3.345 0.005 ρ < .05 females 8.9 7.4 1.5 1.03 14 3.744 0.002 ρ < .05 key: mca mean chronological age df degrees of freedom mma mean mental age t t value m-d mean difference p-value probability values sd-d standard deviation difference p-level probability level table 3: comparison between group a and group β for mean ma scores on the rwfs m-d sd-d df t p-value p-level a to β females -1.293 1.260 14 -3.975 0.001 ρ < .05 a to β males -1.387 1.215 14 -4.419 0.001 ρ < .05 key: m-d mean difference sd-d standard deviation difference df degrees of freedom t t value p-value probability values p-level probability level the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 jenny pahl & meenakumari b. kara group and sex were not significant (p>.05). 3. statistical comparison of mean ma and mean ca scores for groups a and b. it can be seen in table 2 that there were significant differences (p<.05) between ca and ma scores for both group a and group b, as indicated by the results of the student's t-test. in group a (indian), male and female subjects scored a mean ma of 2.6 years lower (6.0 and 6.1 respectively) than their mean ca (8.6 and 8.7 respectively). in group β (white), males scored a mean ma of 1.2 years lower than their mean ca (8.6), and females scored a mean ma of 1.5 years lower than their mean ca (8.9). only six subjects in all obtained ma scores higher than their ca scores. the results of the t-test comparing the ma scores of group a to those of group β presented in table 3 indicated a significant difference (p<.05) between the groups. group a performed poorer than group β for both sexes. 4. quantitative and qualitative item analysis. for the purposes of the present study it was necessary to determine an arbitrary/subjective cut off point to categorise responses to items as appropriate or inappropriate. those items correctly named by 50% or more of the subjects were classified as appropriate and those items correctly named by less than 50% of the subjects were categorised as inappropriate. these results are presented in figure 1. subjects in group a responded appropriately to 35 items and inappropriately to 15 items while in group β subjects responded appropriately to 42 items and inappropriately to 8 items (see figure 1). items one to 25 were easily named by both groups with the exception of item 18 (suitcase) for group a (indian). items 26 to 50 reflect variable levels of difficulty for the subjects. seven items (spout, 120 %age correctly identified 1 2 3 4 5 8 7 8 9 10 11 12 13 14 16 18 17 18 19 80 2 1 2 2 2 3 24 2 6 rwfs items i group a i group β %age correctly identified 2 8 27 2 8 2 9 3 0 3 1 32 3 3 34 36 38 37 38 3 9 4 0 4 1 4 2 4 3 4 4 4 6 4 8 4 7 4 8 4 9 6 0 rwfs items i group a i group β figure 1: percentage of correct responses given by subjects to each item on rwfs cuff, flame, wick, sling, spire/steeple and hinge) were inappropriately responded to by both groups. discussion the performance of the two south african groups was significantly lower than the british norms. it appears that differences attributed to the different cultural and ethnic backgrounds of south african whites and indians play a significant role in the acquisition of vocabulary. this is consistent with adler's (1971) observation that the patterns of behaviour unique to specific cultural groups are derived from their ethnic heritage. it therefore appears that ethnic group membership has diverse effects on naming. the suitability of the rwfs for south african indian and white children is therefore questionable. the implication of only six subjects (10%) obtaining scores equal to or above their chronological age levels, is that all the remainder have expressive vocabularies not commensurate with ca. another measure of selecting children requiring therapy because of poor expressive vocabularies, is to consider those whose test performance falls below the 25th percentile, or below the middle fifty percent range (renfrew, 1988). in the present study, 26 subjects from group a, and 13 subjects from group β could, using the british norms, be diagnosed as having expressive vocabulary problems and could require therapy. all subjects however were judged by their teachers as having normal language abilities, although the subjects were not tested specifically for language problems. the performance of the subjects scoring below the 25th percentile on the rwfs therefore should be viewed as either different or defective. depending on the theoretical perspective of individual speech clinicians, either view can be adopted. if the deficit theory is adopted, the presence of a language disorder is suggested which would require intervention. thus, according to manickam (1985, p.35) "although the individual may be functioning adequately in his [sic] socio-cultural environment, he [sic] is still viewed as being deficient with regard to the norms and is considered a candidate for an intervention programme". on this basis of incorrectly identifying children for therapy, the test itself does not appear to be a suitable assessment procedure. in contrast, results of this study seem to support the difference theory which indicates that because the norms for the rwfs were not established for the population groups investigated, the test norms are inappropriate for these groups. furthermore, as stated by adler (1979, p.95), and pertaining to this particular test, "unless a particular test has been standardised on a given group of culturally different people, it is to be expected that the scores of the culturally different will be lower than normal". it seems that because this test wjas standardised on the british population, and because test items were selected with that population in mind, subjective judge; ments of its being biased and unfair when used on other population groups would be correct. the rwfs does not appear to be sensitive to dialectal and cultural differences of south african indian and white groups. the need for investigation before making subjective judgements about test suitability is however vital. although the effect of the sex variable was not found to be statistically significant, the mean scores of .males in both groups was one point higher than the mean scores for females. such a difference is consistent with renfrew's (1990) scores and with her suggestion that a number of items are more familiar to boys than girls (e.g.tools). a further aim of the study was to investigate the relevance of specific test items. difficulty with apparently unclear drawings was noted with "diver" "lighthouse" "hinge" "sling" the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) renfrew word finding scale: application to the south african context 73 "thermometer" and "pod" (items 40,28,50,47,45, and 44 respectively). as the test is not one of picture recognition, perhaps these items should be more clearly represented in pictures. frequent incorrect responses were noted for some items, for example, "nail" for "screw" and "bandage" for "sling". on some items, cultural differences appeared to influence naming responses. the item "spire/steeple" (see item 48 in figure 1) was correctly named by nearly half of the white children, but was not correctly named by any children in the indian group. this lexical item thus seems to present a problem to both groups, but especially to the latter group. a lexical item used consistently differently by the two groups of subjects was "suitcase" (see item 18 in figure 1). in group a, 87% of subjects incorrectly identified the picture as "bag" whereas in group b, 97% of subjects correctly identified it as "suitcase" or "case". this would seem to indicate a lexical difference between south african indian english and south african english speakers. in testing, the speech therapist should thus be careful not to assume that target lexical items should be identical among all english speakers. overall, the test does not appear to be suitable for use with south african indian or white children between eight to nine years of age. for the indian group, scores were so different from the british standardisation sample that it does not seem that the test could be used to differentiate between language difficulties and normal language. for the white group, however, the test could possibly be modified for use. one means of accomplishing this, is to reorder items in terms of level of difficulty as was found to be necessary for the new zealand edition (c. renfrew, personal communication, may, 1991). an overview of the items as represented in figure 1 suggests that reordering item numbers 30, 27, 43, and 31 ("cuff' "spout" "wick" and "drill" respectively) towards the end of the test might be a solution. conclusion the present study was aimed at investigating the suitability of the rwfs for south african indian and white children ages ranging from eight to nine years. this aim was achieved by comparing the performance of the south african children to the british standardisation population. results revealed significant differences in mean scores between populations due to ethnic group membership as seen on the anova and the ttest. furthermore, comparisons of mean mas between group a and group β also revealed a significant difference which could be indicative of cultural differences between these groups, as confirmed by an examination of the responses on the item analysis. in its present form the rwfs is not suitable for use as a standardised language tool for assessing expressive vocabulary by south african speech clinicians for the populations investigated. the test could possibly be modified by reordering the sequence of items for the white group, but such modifications do not seem possible for the indian group. acknowledgements sincere appreciation is extended to the directors of education in the house of delegates and natal education departments for granting permission to conduct the fieldwork in the schools concerned. references adler, s. (1971). dialectal differences : professional clinical implications. journal of speech and hearing disorders, 36, 90-95. adler, s. (1979). poverty children and their language : implications for teaching and treating. new york : grune and stratton. alant, e. & beukes, s. m. (1986). the application of the revised version of the peabody picture vocabulary test (ppvt-r) to non-mainstream children. the south african journal of communication disorders, 33, 8-9. anderson, j. (1981). considerations in phonological assessment. in j. erickson & d. omark (eds.), communication assessment of the bilingual bicultural child. baltimore : university park press. bloom, l. & lahey, μ. (1978). language development and language disorders. new york : john wiley & sons. cottrell, a. w., montague, j., farb, j. & thorne, j. m. (1980). an operant procedure for improving vocabulary definition performances in developmentally delayed children .journal of speech and hearing disorders, 55, 90-102. downie, ν. m. & heath,.r. w. (eds.). (1974). basic statistical methods. new york : harper and row. jensen, a. r. (1980). bias in mental testing. london : methuen. john, v. p. & goldstein, l. s. (1964). the social context of language acquisition. merrill-palmer z>uarterly, 10, 265-275. leonard, l. b. & fey, μ. e. (1979). the early lexicons of normal and langauge disordered children : developmental and training considerations. in n. j. lass (ed.), speech and language : advances in basic research and practice vol 2. new york : academic press. malan, k. c. (1981). an investigation of non-standard english syntax in 12 year old coloured children. the south african journal ofcommunication disorders, 28, 68-80. manickam, l. (1985). an investigation into the performance of normal english speaking south african indian adults on the peabody picture vocabulary test (dunn, 1965). unpublished b. speech and hearing therapy research project, university of durban-westville. owens, r. e. (1988). language development :an introduction. (2nd ed.). columbus : charles e. merrill. rees, n. s. (1980). learning to talk and understand. in t. s. hixon, l. d. shriberg, & j. h. saxman (eds.), introduction to communication disorders. englewood cliffs, n.j. : prentice hall. renfrew, c. e. (1972). word finding vocabulary scale. (2nd ed.). oxford : c. e. renfrew. renfrew, c. e. (1988). word finding vocabulary scale. (3rd ed.). oxford : c. e. renfrew. renfrew, c. e. word finding vocabulary scale. (new zealand edition). oxford : c. e. renfrew. taylor, o. (1986). treatment of communication disorders in culturally and linguistically diverse populations. (ed.). california : collegehill. vaughn-cooke, f. b. (1983). improving language assessment in minority children. asha,25, 29-33. wiig, ε. h. &semel, ε. μ. (1984). language assessment and intervention for the learning disabled. london : charles e. merrill. williams, f. (ed.). (1970). language and poverty. chicago : markham. the south african journal of communication disorders, vol 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) spastic dysphonia: a case r e p o r t lesley wolk, b . a . ( s p & η t h e r a p y ) ( w i t w a t e r s r a n d ) department of speech pathology and audiology, university of the witwatersrand, johannesburg. summary an in-depth investigation of a 55-year-old woman with spastic dysphonia was performed. the findings from otological, neurological and psychological investigations assisted in making a differential diagnosis and served to provide evidence for the etiology of this disorder. subjective-perceptual evaluations of the voice revealed a strained, harshbreathy voice quality with frequent breaks in phonation, a variable pitch and visible tension in the face and neck muscles. objective spectrographic evaluations revealed much turbulence, ill-defined harmonics, a breakdown in formant structure, rapid pitch fluctuations and evidence of diplophonia, which was confirmed on a fiberscopic examination. post-treatment spectrographic evaluations indicated an improved phonatory ability with significant improvement in the above parameters. results are discussed in terms of the etiology and symptomatology of this disorder; and clinical implications for diagnosis and treatment are considered. opsomming 'n 55-jarige vrou met spastiese disfonie is in diepte ondersoek. die bevindings van otologiese, neurologiese en sielkundige ondersoeke het bygedra tot 'n differensiele diagnose en het ook gedien om bewyse te verskaf vir die etiologie van hierdie afwyking. 'n gestremde grof-ruiserige stemkwaliteit met frekwente onderbrekings in fonasie, veranderlike toonhoogte en sigbare stremming in gesigen nekspiere blyk uit subjektiefperseptuele evaluasie van die stem. objektiewe spektografiese evaluasies bring baie omstuimigheid, vaag bepaalde harmoniese tone, 'n afbraak in formant struktuur, vinnige wisseling van toonhoogte en bewyse van diplofonie aan die lig. dit is bevestig deur 'n fiberskopiese ondersoek. 'n verbeterde fonetoriese vermoe met opmerklike vooruitgang in die bogenoemde parameters blyk uit spektografiese evaluasies wat na behandeling opgeneem is. resultate word bespreek in die lig van die etiologie en simptomatologie van hierdie afwyking en kliniese implikasies vir diagnose en behandeling word oorweeg. spastic dysphonia has long been recognized as the most mysterious and the most poorly understood of all voice disorders. it is a rare disorder and literature on the subject is limited, which has led to some confusion with regard to differential diagnosis and treatment. spastic dysphonia was first described by traube in 1871.6 since then many terms have been used to describe the disorder. aronson, brown, litin and pearson, 1 for example, prefer the term 'spasmodic' dysphonia to avoid the confusion that arises from the use of the term 'spastic', which implies a specific neurological disorder. it is often referred to as 'stammering of the vocal cords' or 'laryngeal stuttering' because of the similarity between the glottal symptoms of spastic dysphonia and the oral ones of the stutterer. for the. purpose of this paper, the term 'spastic dysphonia' will be used. the onset of this disorder is reported to be relatively abrupt and to die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 lesley wolk occur almost exclusively in middle age, with women being affected slightly more frequently than m e n . 1 6 ' 2 5 berendes has defined 'spastic dysphonia' as a disorder of phonation which is characterized by a strained, creaking and choked vocal attack, a tense and squeezed voice sound . . . accompanied by extreme tension of the entire phonatory system (cited in f o x , 1 2 p.275). he further noted that the disorder disturbs primarily the communicative function of speech, with other expressive functions of the voice (such as laughing, speaking to oneself or to animals) remaining intact. spastic dysphonia represents the most extreme form of overadduction of the vocal folds. there is effortful voice production, intermittent voice stoppage, a reduced vocal range and inappropriate change in pitch, quality and/or volume. 1 0 the patient may complain of 'a choking sensation' or a 'tightness of throat'. 7 several visible features as described, such as flushing of the face and frowning accompanying the vocal spasm and tic-like contractions of the neck muscles.1 , 2 ' 8 severe contractions of the thoracic and abdominal musculature accompany the laryngeal spasm and is probably a compensatory forcing response for overcoming the resistance to exhalation created by the glottal closure. these frustrated vocal efforts result in a pronounced alteration of pneumophonic (phonatory-breath) control. 1 1 ' 1 6 a basic controversy seems to emerge from the literature, reflecting two divergent schools of thought about the etiology of the disorder. one point of view, typified by brodnitz,6 suggests that spastic dysphonia is a psychogenic voice disorder, a form of conversion hysteria. here spastic dysphonia is seen as one of two extreme forms on the continuum of functional voice disorders: functional aphonia being the one extreme of hypofunction, and spastic dysphonia representing the extreme of hyperfunction. both disorders are interpreted as the physical manifestations of a deep-rooted emotional conflict.4' 1 3 luchsinger and a r n o l d 1 6 propose that this voice disorder may be explained as the intrusion of a subcortical primitive mechanism of phonation after the regular cortical phonatory system has become inhibited by the unconscious withdrawal of a shattered personality from the threats of daily life. in opposition to this point of view are others exemplified by robe, brumlik and m o o r e , 2 5 who claim that spastic dysphonia is a manifestation of disordered function of the central nervous system. this organic view was later advocated by aronson et al 2 who feel that spastic dysphonia has a neurologic substrate and may be related to the essential tremor syndrome. in view of the diversity of opinions regarding its etiology and intervention strategies, further research in this area seemed to be indicated. furthermore, the literature on this subject has been derived mainly from subjective-perceptual evaluations and qualitative descriptions. little attempt has been made to delineate the acoustic characteristics of spastic dysphonia or to describe the nature of the disorder by other objective means. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) spastic dysphonia 5 in this paper, the author's intention is thus (a) to highlight the clinical picture of a case with spastic dysphonia and repaired cleft of the soft palate, (b) to attempt to delineate some of the acoustic parameters in this disorder of spastic dysphonia, and (c) to present some practical implications for diagnosis and treatment. case b a c k g r o u n d vocal history: mrs. g, aged 55 years, was first seen at the speech and hearing clinic, university of the witwatersrand, johannesburg in june, 1979. she was referred by an ear, nose and throat (ent) specialist who reported a dysphonia with no organic pathology evident upon laryngeal examination. she reported that she suffered from a period of chronic laryngitis and experienced a sudden onset of voice difficulty approximately twelve months prior to the initial assessment. she stated that ί find difficulty getting out my words, especially if i'm a bit agitated. . . . i try to force my words out and i get so cross with myself'. she complained of no pain apart from some discomfort in the laryngeal region, fatigue of the upper chest muscles and severe tension in the abdominal area as she forces the air for speaking. she reported that conversational speech, telephone calls, reading long passages and supervising others at work were difficult situations for her, and that her voice deteriorated when she was agitated, angry or upset. there was evidence of moderate depression and extreme anxiety at the time of initial assessment. no previous speech assessments or treatment were reported. medical history: she was born with a cleft of the soft palate which was not repaired until recently (lips and hard palate were not affected). mrs. g. reported that although she has always had 'a nasal problem' related to the cleft, it never worried her. recently she decided to undergo surgery as she hoped that this would correct her voice problem. the velar cleft was successfully repaired in april, 1979. according to mrs. g, some improvement in her voice was noted in the immediate post-operative period, but a gradual deterioration has since occurred. she has undergone no other surgery, apart from a gynaecological operation in 1962. psychological and family history: mrs. g. described several significant 'family stress' factors which may be associated with the onset of her voice problem. no family history of speech, language or hearing problems was reported. she has been working for a major oil company for twelve years. at present she holds a senior position as a sub-accountant and appears to achieve job satisfaction. she has tended to avoid social contact since the onset of her voice difficulty. she described herself as a tense person and a perfectionist both at work and at home. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 lesley wolk clinical observations mrs. g. presents as an attractive, well-groomed, intelligent middle-aged woman. from an informal assessment, she displayed a reserved, controlled introvert-type personality. she exhibited traits of conscientiousness, keen awareness and discharge of her responsibilities. she maintains an upright, rigid posture with general body tension. extreme tension of her facial muscles, forehead and lips was noted to occur during speech; reflected in much frowning and facial contortions (while this is typical to spastic dysphonia,1 it may also be associated with inadequate velopharyngeal closure). these informal observations are consistent with damste 9 who characterizes patients with spastic dysphonia as reliable persons with strong sense of duty and a rigid personality, sensitive and easily hurt (p. 173). examinations c a r r i e d o u t examinations were carried out by an ent specialist, a neurologist and a psychologist respectively, in order to assist in making a differential diagnosis and to further provide evidence for the etiology of this disorder. results are summarized in table 1. table i : summary of findings from otological, neurological and psychological examinations. e x a m i n a t i o n f i n d i n g otological — no evidence of anatomical or functional disorder of larynx — normal vocal cord movement (indirect laryngoscopy) — no abnormality of tongue — slight nasal escape — difficulty in phonating neurological — no major neurological deficits apart from: — increased reflexes in upper and lower limbs — slightly awkward digital movements. — normal eeg — normal emi scan psychological — evidence of marital tension — strong sense of duty; rigid personality y — various sources of , emotional conflict the neurological findings seen in table i, bear some relationship to the findings of critchley8 and aronson et al1 which suggest evidence of hypertonus and hyperreflexia in patients with spastic dysphonia. no conclusions can be drawn in relation to the e e g findings as inconsistent results are reported in the literature. robe et a l 2 3 found that 90% of their subjects showed abnormal e e g recordings; whereas the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) spastic dysphonia 7 aronson et al 1 found that 17 out of 22 patients showed normal e e g recordings, mild dysrhythmic activity in four others and independent spike foci in one patient. the findings from otological, neurological and psychological investigations seem to provide some support for the theory proposed by aronson and his co-workers.1 , 2 it is their belief that perhaps the type of personality described, superimposed on the 'unstable' motor system may be the adequate combination for the development of the disorder. they further suggest that these patients may have a basic predisposition or instability of innervation within the motor system, which is manifested through dysphonia when life events or personality abnormalities precipitate the symptoms. currently, d a m s t e 1 0 has found no evidence to assume that one single organic factor can be held responsible for causing spastic dysphonia. he contends that organic factors contribute in bringing the patients to a disadvantaged position. this, together with other external, constitutional and personality factors may trigger the 'pathologic defense system' of which he feels the symptoms of spastic dysphonia are a part. assessment o f communicaion b e h a v i o u r the assessment of communication behaviour was carried out by the author over a period of 3 months. this included a hearing assessment, an oral peripheral examination, a speech and language assessment. results are summarized in table ii. overall intelligibility thus appeared to be impaired by jerky rhythmic patterns, disturbed intonation patterns, periodic breaks in phonation and the frequent substitution or insertion of glottal stops. for the purpose of this paper, only a more detailed discussion of the acoustic impedance measurement will be included. acoustic impedance measurement studies have shown that middle ear muscle contraction precedes vocalisation by 65-100 ms or coincides with i t . 2 0 ' 2 6 the findings of recent studies provide evidence for a high incidence of apparent middle ear dysfunction in patients with spastic dysphonia.1 9 the use of acoustic impedance measurement has thus been advocated in order to further assess this phenomenon. briefly, the procedure used involved stimulating the acoustic reflex with sound stimuli at a 20 db suprareflex threshold level for approximately 30 seconds. the madsen z070 electroacoustic impedance bridge was used to observe the changes in middle ear impedance secondary to reflex contraction of the tympanic muscles. the focus in data analysis was concerned with certain dynamic response characteristics of the middle ear muscles as evidenced by the acoustic impedance measurements. particular attention was given to (1) on-time, (2) steady-state and (3) off-time characteristics of the acoustic reflex die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 lesley wolk table ii: summary of findings from an assessment of communication behaviour. hearing (a) pure-tone audiometry — normal (b) acoustic impedance audiometry — apparent abnormalities in middle ear muscle function (see below) oral peripheral examination (ope) — structural and functional adequacy of lips, teeth and jaw, tongue and hard palate. — slight asymmetry of soft palate and uvula. — soft palate is short — oropharynx is slightly shallow with excess width — nare constriction — adequate velopharyngeal closure since cleft repair — slight nasal escape (on plosives). speech — minimal articulation errors related to history of congenital velar cleft: — substitution and insertion of glottal stops. — distortion of fricatives (e.g. /s,z/). — substitution of voiceless sounds for their voiced cognates. language — normal response. a qualified audiologist acted as a second observer to provide a measure of reliability. the findings revealed normal tympanograms peaking at zero pressure level (mm w/s) bilaterally, and acoustic reflexes within normal limits. three types of apparent abnormalities in the middle ear muscle function were observed: 1. an apparent abnormality in the steady-state portion of the acoustic reflex was observed at 4 000 hz in both ears i.e. reflex contraction of the middle ear muscles was not sustained for the duration of acoustic stimulation at 4 000 hz. instead, the muscles apparently contracted briefly at the onset of stimulation and again at the cessation of stimulation. however, in view of the fact that this phenomenon only occurred at 4 000 hz, which has been found to occur in some normal subjects, 1 4 no conclusions can be drawn. 2. an abnormality in the off-time characteristics of the acoustic impedance response was noted to occur at 1 000 hz in the right (r) ear and at 500 hz in the left (l) ear. this refers to a prolonged time involved in the return to the baseline, which mccall 1 9 feels might be suggestive of a problem in muscle relaxation. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) spastic dysphonia 9 3 there was evidence of possible tremor or shivering of the middle ear muscles at the following frequencies: 250 hz, 1 000 hz and 2 000 hz in the (r) ear, and 250 hz, 500 hz and 1 000 hz in the (l) ear. it is important to mention at this point, that these results may be affected by the presence of the velar cleft, as a high incidence of middle ear pathologies in cleft palate patients is well documented in the literature.3 nevertheless, the results discussed above are consistent with those of mccall 1 9 who found similar results in his patients with spastic dysphonia. the observation of possible difficulty in muscle relaxation and tremor of the middle ear muscles might add further support to suggest neurogenic involvement of the extrapyramidal motor system in this p a t i e n t . 1 9 damste 9 has further suggested that the combined activity of vocal cords, velum and middle ear muscles in normal speech, might serve to explain that all three may be affected simultaneously when there is a supernuclear excitation inhibition disorder. assessment o f v o i c e d i s o r d e r : subjective-perceptual evaluations an analysis of the tape recorded speech sample and general observations from the initial assessment revealed the following: 1. a disturbance of respiratory control and a lack of pneumophonic co-ordination. this is reflected by a predominant use of thoracic and clavicular breathing, shallow inhalations, jerky movements and a difficulty in sustaining phonation. 2. a variable pitch in conversational speech and a difficulty in regulating the pitch level. 3. a reduced intensity level. 4. a harsh voice quality with periodic breaks in phonation, accompanied by visible tension of the muscles in the face and neck. a glottal stroke was heard at the onset of phonation. there was evidence of apparent breathiness throughout all phonation. 5. the reflex actions of phonation were intact. thus, coughing, laughing and crying were carried out normally. singing, talking to herself and her pet cat were reported by her to facilitate improved phonation. this was confirmed by the clinician who listened to tape recordings of her speaking in these situations at home. objective evaluation — spectrographs assessment spectrographic analyses were carried out as a diagnostic tool in an attempt to gain further insight into the nature of this disorder. a kay sonagraph model 6061-b (kay elemetrics 6, pine brook, n.j.) was used to produce type b/65 spectrograms from the tape recordings of conversational speech. the data in this study were derived from broad-band and narrow-band spectrograms. practically, it was not possible to analyze spectrographically all utterances recorded during the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 lesley wolk diagnostic evaluations. thus only a few utterances from the spontaneous speech sample taken at the initial assessment, were randomly chosen. the analysis of spectrographic data was descriptive in nature. for the purpose of this paper, only a few of these utterances were selected in order to highlight the major findings. the spectrographic representation for the utterance 'and when i asked him' is illustrated in figure 1. on the broad-band spectrogram (fig. la) there is evidence of much breathiness and ill-defined harmonics. sections were taken during the steady-state of the vowel, which showed that the filter function is operating in such a way as to dampen the harmonics. spectral energy is entirely missing where formant 1 (fl) was expected. while f2 is present, there is no evidence of f1 and f3. this finding may be explained by a reduced driving force from the lungs, resulting in a reduced subglottal pressure at the vocal cords; 1 5 or possibly inadequate adjustment of the vocal folds which would also affect the range of harmonics. it can be noted in figure la that there are bursts of energy which probably occur after the initial glottal attack or 'laryngeal spasm'. the narrow-band spectrogram (fig. lb) confirms the breathiness evident on the broad-band spectrogram, reflecting a lack of vocal cord approximation. this is illustrated by a sporadic and inconsistent occurrence of harmonics. figure la. broad-band spectrogram showing utterance /and wen ai a:skt him/. n o t e : some of the noise evident is from the tape-recording. and wen ai ' a:skt him figure lb. narrow-band spectrogram showing utterance /and wen ai a:skt him/. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) spastic dysphonia 1 1 the scale magnified narrow-band spectrograph^ representation of the ,,iterance ί asked my husband' is illustrated in figure 2. marked fluctuations in pitch can be seen on the vowel /a:/ in 'asked', with a relatively high fundamental frequency (±200 hz). there is a rise in oitch from 250 hz to 350 hz (100 hz in approximately 24 ms) indicating that pitch change is very rapid. it seems then, that rapid pitch fluctuations in this patient give rise, at least in part, to the perceptual effect of harshness.2 8 i ψ. t figure 2. scale-magnified narrow-band spectrogram showing utterance /ai a:skt mai tvizbond/. figure 3 represents the utterance 'how did the voice sound?' an examination of the scale magnified narrow-band spectrogram (fig. 3) alerted the author to another diagnostic feature which was hardly available during periodic subjective-perceptual evaluations. the harmonic structures represent the characteristic picture of diplophonia, which is clearly illustrated on the vowel /aw/ in 'sound'. here it can be seen that the harmonic at 1250 hz bears no relationship to the harmonic starting at 1000 hz and moving down to 800 hz. similar pitch fluctuations to those discussed in figure 2 are evident. it is interesting to note that there are simultaneous rising, falling and level pitches, indicating that the vocal cords are vibrating in at least two distinct modes at the same t i m e . 2 7 at the level pitch, the rate of vibration is maintained, whereas at the falling pitch there is a slowing down of the vocal fold vibration. it can be concluded therefore that in this case of diplophonia, there are (a) different modes of vibration and (b) different rates of vibration for each mode. b o o n e 5 has stated that diplophonia is frequently a symptom of general hyperfunctional usage of the vocal mechanism (p. 173). this diagnostic evaluation would thus seem to correlate significantly with the general diagnostic picture of spastic dysphonia and the frequent use of glottal stops resulting from the cleft palate. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 lesley wolk aw 31 /aw/ r figure 3. scale-magnified narrow-band spectrogram showing utterance /haw did after obtaining valuable diagnostic information from the spectrographic data discussed above, it was decided to extend the objective evaluation as a measure of therapeutic success. spectrographic analyses were carried out two months after the onset of treatment and at the end of treatment. the patient was treated for a total period of four months. utterances were again chosen randomly from taperecorded spontaneous speech samples. for the purpose of this discussion, spectrographic analyses carried out during the course of treatment will not be discussed in detail. they reflected a steady progression towards improved phonatory ability. figure 4 represents the utterance 'there were three factors', which was taken from a sample at the end of treatment. here it can be seen that there is some evidence of breathiness, although this is considerably reduced when compared with the utterance 'and when i asked him' in figure 1. the harmonics are clearly defined and there is no evidence of diplophonia. similar results were obtained from several other utterances analyzed spectrographically after treatment. the fact that the characteristic of 'diplophonia' was not evident on subjective-perceptual evaluations, leads one to assume that it may in fact be a symptom commonly associated with spastic dysphonia, but one which might have previously been overlooked because of the reliance upon subjective evaluations. da vsis sawnd/. v •mnaak / δ ε a w3: eri: fsekt3z figure 4. post-therapy scale-magnified narrow-band spectrogram showing utterance /δε3 w3: eri: fiektsz/1. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) spastic dysphonia 13 p i h p r s c o p i c j ^ a m i n a t i o n : r t t j i z ^ ^ t r u m e n t a t i o n such as the flexible fiberoptic nasolaryngoscope (fiberscope) provides a means for making direct observations of laryngeal behaviour during voice production. the entire procedure was carried out in the department of phonetics and general linguistics, university of the witwatersrand, tohannesburg 2 7 the fiberscope was connected by a c-mount adapter to a camera. a diagnostic fiberoptic light source provided necessary illumination the fiberscope was inserted into one nostril until the tip of the scope reached a level slightly rostral to the superior margin of the epiglottis, which allowed for observation of the patient's vocal folds and laryngeal structures. a tape recorder uher 4200 report stereo ic with an m816 directional microphone, was prepared to run concurrently with this examination so as to record all utterances which could then be carefully examined with its corresponding slide. the patient was asked to (1) breathe at rest, (2) sustain voicing on the vowel /i:/, (3) converse with the investigator and (4) read a passage from a book. a review of the slides revealed the following findings: 1 the vocal cords were normal at rest, as illustrated in figure 5. at the onset of phonation for the vowel li:l there seemed to be a tight sphincteric closure, which subsequently disappeared and continued as normal voicing. during connected speech, there was evidence of an inconsistent picture, variable in the attitude of one vocal fold to the other, i.e. the two vocal folds did not lie equal to each other; one fold appeared larger and thicker as if it was pulled slightly over the other vocal fold. this is clearly illustrated in figure 6. 2. 3. figure 5. subject's laryngeal figure 6. subject's laryngeal bebehaviour during quiet breathhaviour during connected speech ing, showing that the vocal cords (voicing), are normal at rest. (note that the two vocal cords are not lying symmetrically to each other. the (r) fold is larger and thicker, as if it is pulled slightly over (l) fold. this picture of asymmetry was seen repeatedly in connected speech.) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 lesley wolk there was a general picture of 'shuddering' or 'laryngeal spasms' as expected for this voice disorder. throughout all conversational speech and reading tasks, a slight 'chink' in the vocal cords was evident, which would account for the continual breathy escape. overall results thus served to confirm the diagnosis of 'diplophonia' noted on the spectrographic assessment; and to validate the information obtained from subjective-perceptual evaluations. in summary, subjective-perceptual evaluations of the voice revealed a strained, harsh-breathy voice quality with frequent breaks in phonation, a variable pitch and visible tension in the face and neck muscles. objective spectrographic evaluations revealed much turbulence, illdefined harmonics, a breakdown in formant structure ('filtering-out' of formants), rapid pitch fluctuations and evidence of diplophonia which was confirmed on the fiberscopic examination. post-treatment spectrographic evaluations indicated an improved phonatory ability. there was a minimum turbulence, clearly defined harmonics, increased energy, increased sub-glottal pressure and an absence of diplophonia; giving rise to a less breathy, less harsh, less choked voice quality. this was combined with improved pneumophonic co-ordination, reduced tension of the face and neck muscles, an elimination of glottal attacks and a better adjusted social personality. conclusions a n d implications it seems premature to make a general assumption that a patient with spastic dysphonia is suffering either from a psychogenic disorder or a neurologic one. as aronson et al 1 proposed, the issue must be resolved on the basis of findings that can be established for each particular patient. the author has thus postulated that in this single case, the onset of spastic dysphonia may be attributed to long term vocal misuse in compensation for the velar c l e f t , 1 8 ' 2 1 possibly precipitated by the physical trauma of 'secondary laryngitis'1 6 and the cleft repair operation, combined with the psychological stresses of life which occur during middle age. furthermore both the neurological and psychological findings in this study might point to an underlying organic or psychogenic predisposition. this explanation is supported by cooper 7 who recently concluded that: the onset and development of incipient spastic dysphonia and spastic dysphonia are due to long term/vocal misuse, with psychological or physical trauma often being the'catalyst (p. 173). an extension of this may lead one to postulate that in this single case, both the congenital velar cleft and the predisposition for the occurrence of spastic dysphonia may be related to a single common constitutional or embryological factor. ι clinical implications 1 the spectrographic analyses and fiberscopic examination carried out in this study served to provide an accurate diagnosis of the voice disorder the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) spastic dysphonia 15 and an evaluation of voice improvement both during and after treatment. most authors agree that the overall prognosis in patients with spastic dysphonia is p o o r . 5 , 7 currently however, it is still felt that the combination of voice therapy with psychotherapy offers the best chances for i m p r o v e m e n t . 4 , 6 several voice therapy techniques have been advocated, some of which were found to be useful in the treatment of this patient. these include procedures such as physical relaxation, respiration training and the correction of pneumophonic c o o r d i n a t i o n ; 7 , 1 0 , 1 3 the yawn-sigh technique, humming and vowel exercises, froeschel's chewing method, the elimination of hard glottal attacks and the use of a hierarchy analysis to assist the patient in recreating those environments where relaxed phonation is best a c h i e v e d . 5 , 2 5 e m g biofeedback has recently been proposed as an effective adjunct to traditional therapy methods for hyperfunctional voice disorders.2 2 its applicability and effectiveness in patients with spastic dysphonia, however, is still uncertain, so that further investigation into this area seems to be indicated. the findings of this study point to an important implication regarding habilitative procedures employed in the treatment of cleft palate children. there seems to be a tendency in some cases to overlook the vocal dimension in the treatment of these patients, focusing mainly on the improvement of velopharyngeal closure and increased flexibility of the articulators. luse, heisse and f o l e y 1 7 showed that all their cleft palate cases had a spasm of the hypopharynx prior to rehabilitation, indicating excessive hypopharyngeal and laryngeal tension. they thus contend that cleft palate quality can be eliminated by reducing-tension in the laryngeal and pharyngeal areas, so that the manner of phonation or vocalisation would seem to be the starting point for rehabilitation. while this study was concerned primarily with an evaluation of the vocal parameters, it would be of interest and probably essential to further investigate speech breathing in patients with spastic dysphonia. further research employing spectrographic analyses and fiberscopic examinations, working optimally within a team approach, would be of value in the evaluation and rehabilitation of a variety of voice disorders. acknowledgements the author wishes to thank mrs. m. wahlhaus, senior lecturer and ms. c. penn, lecturer, in the department of speech pathology and audiology of the university of the witwatersrand for their invaluable guidance and support, and mr. a. traill, senior lecturer of the department of phonetics and general linguistics for his valuable assistance in the spectrographic and fiberscopic testing of this patient. the author also acknowledges the human sciences research council for its financial assistance. die suid-afrikaanse tydskrif vir kommnikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 lesley wolk references 1. aronson, a. e . , brown, j. r., litin, ε. m. and pearson, j. s. (1968): spastic dysphonia i. voice, neurologic and psychiatric aspects. j. speech hear. dis. 33, 203-218. 2. aronson, a. e., brown, j. r., litin, ε. m. and pearson, j. s. (1968): spastic dysphonia ii. comparison with essential (voice) tremor and other neurologic and psychogenic dysphonias. j. speech hear dis. 33, 219-231. 3. arora, μ. m. l., sharma, v. l., gudi, s. p. and balakrishnan, c. (1979): acoustic impedance measurements and their importance in cleft palate patients. the j. laryngol and otol. 93, 443-445. 4. bloch, p. (1965): neuro-psychiatric aspects of spastic dysphonia. folio phoniat. 17, 301-364. 5. boone, d. r. (1971): the voice and voice therapy. prentice-hall, inc. englewood cliffs, new jersey. 6. brodnitz, f. s. (1976): spastic dysphonia. ann. otol. 85, 210-214. 7. cooper, m. (1973): modern techniques of vocal rehabilitation. charles, c. thomas publishers, springfield, illinois. 8. critchley, m. (1939): spastic dysphonia; ('inspiratory speech'). brain. 62, 96-103. 9. damste, p. h. (1977): spastic dysphonia; untieing or cutting the knot. o.r.l. 39(3), 173. 10. damste, p. h. (1978): spastic dysphonia: an interpretation of the symptoms. communicative disorders in audio journal for continuing education. 3(5) may. bradford, l. j. (ed) grune and stratton, inc., new york. 11. dedo, η. h. (1976): recurrent laryngeal nerve section for spastic dysphonia. ann. otol. 85, 451-459. 12. fox, d. r. (1969): spastic dysphonia: a case presentation. j. speech hear. dis. 34, 275-279. 13. greene, m. c. l. (1964): the voice and its disorders. pitman medical publishers, co., ltd., 2nd edition. 14. jerger, j. (ed). (1973): modern developments in audiology. 2nd edition academic press inc. a subsidiary of harcourt, brace jovanovich. publishers. 15. ladefoged, p. (1967): three areas of experimental phonetics. chapter 1. oxford university press. ely house, l o n d o n ' 16. luchsinger, r., and arnold, g. e. (1965): voice-speech-language. belmont, california. wordsworth. 17. luse, e., heisse, j. and foley, j. (1964): the vocal approach in the correction of cleft palate speech.[folio phoniat. 16, 123-129. 18. marks, c. r., barker, k. and tardy; μ. e. (1971): prevalence of perceived acoustic deviations related' to laryngeal function among subjects with palatal abnormalities. cleft palate j. 8(2) 201-211. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) spastic dysphonia 17 19. mccall, g. n. (1973):. acoustic impedance measurement in the study of patients with spasmodic dysphonia. j. speech hear. dis. 38(2), 250-255. 20. mccall, g. n. and rabuzzi, d. d . (1973): reflex contraction of middle ear muscles secondary to stimulation of laryngeal nerves. j. speech hear res. 16, 56-61. 21. mcdonald, ε. t. and koepp-baker, h. (1951): cleft palate speech. an interpretation of research and clinical observations. /. speech hear dis. 16, 9-20. 22. prosek, r. α., montgomery, α. α., walden, β. e. and schwartz, d. m. (1978): emg biofeedback in the treatment of hyperfunctional voice disorders. j. speech. hear. dis. 43(3), 282-294. 23. robe, e . , brumlik, j. and moore, p. (1960): a study of spastic dysphonia: neurologic and electroencephalographic abnormalities. laryngoscope. 70(3), 219-245. 24. saito, s., fukuda, h., kitahara, s. and kokawa, n. (1978): stroboscopic observation of vocal fold vibration with fiberoptics. folio phoniat. 30(4) 241-244. 25. segre, r. (1951): spasmodic aphonia. folio phoniat. 3, 150-157. 26. shearer, w. m., and simmons, f. b. (1965): middle ear activity during speech in normal speakers and stutterers. j. speech hear. res. 8, 203-207. 27. traill, a. (1979): senior lecturer in the department of phonetics and general linguistics, university of the witwatersrand, johannesburg. personal communication. 28. wendahl, r. w. (1963): laryngeal analog synthesis of harsh voice quality. folio phoniat. 15, 241-250. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) we invite you to talk to the firm who supplied the equipment you were originally trained on for all your hearing and acoustic requirements. audiometers train ears hearing test rooms hearing aids phonic ear f.m. radio systems speech therapy equipment needler westdene organisation (pty) ltd p.o. box 28975, , phone: 011 45?7262 sandringham, 01145-6113/4. johannesburg, 2131. i the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 45 ouditief waarneembare foute by verbale apraksie: aanduidings van die aard van die afwyking a van der merwe, d phil (pretoria) departement spraakheelkunde en oudiologie, universiteit van pretoria i c uys, d phil (pretoria) departement spraakheelkunde en oudiologie, universiteit van pretoria j μ loots, d sc (fisiologie) (pretoria) instituut vir sportnavorsing, universiteit van pretoria r j grimbeek, β sc (hons) (pretoria) departement statistiek, universiteit van pretoria opsomming baie vrae bestaan nog oor die aard en oorsake van diesimptome van verbale apraksie. tydens 'n ondersoek na dieinvloed van kontekstuele faktore op die ouditief waarneembafe~foute by verbale apraksie (van der merwe, uys, loots en grimbeek, 1987) is simptome wat aanduidings verskaf-van'die aard van die afwyking waargeneem. hierdie simptome word verder geanaliseer in hierdie artikel. die frekwensiferttipe foute by herhaalde produksie van onsineenhede wat sistematies gevarieer is in klankstruktuur en artikulasie-eienskappe is nagegaan by vier persone met verworwe verbale apraksie en een persoon met verbale ontwikkelingsapraksie. daar is onder andere waargeneem dat suiwer verbale apraksie gekenmerk word deur distorsie van klanke wat soms soos vervangings klink, afbakening van lettergrepe en veranderinge in die struktuur van 'n eenheid met veral 'n neiging om dit te vereenvoudig na 'n kv-eenheid of duplisering daarvan. daar is moontlik 'n onderliggende onvermoe om die kritiese ekwivalensiegrense en bewegings te handhaaf, klanke vinnig en onveranderlik vooriiit te voer en om spraak vooruit te beplan. abstract / many questions on the nature and causes of the symptoms of verbal apraxia still exist. in the investigation of the influence of contextual factors on auditorily perceived symptoms of verbal apraxia (van der merwe, uys, loots and grimbeek, 1987) symptoms indicative of the nature of the disorder were recorded and these are further analysed in this article. the frequency and nature of mistakes made during repeated productions of nonsense units which are systematically varied in sound structure and articulatory features were determined in the speech of four patientsj with acquired verbal apraxia and one patient with developmental verbal apraxia. the most prominent indications were that pure verbal apraxia is characterised by sound distortions whica are..sometimes perceived as substitutions, intersyllabic pauses and changes in the sound structure of units manifesting a tendency/o amplify and change the structure to a cv-unit or reduplication thereof. there possibly is an underlying inability to keep movements within the critical boundaries of motor equivalence to quickly and invariantly feed sounds forward and to preplan speech. navorsing oor verbale apraksie is in die verlede hoofsaaklik gerig op simptoombeskrywings en die kenmerkende simptome van suiwer verbale apraksie is mettertyd gei'dentifiseer. daar was aanvanklik geen eenstemmigheid oor die simptome van die afwyking nie en die suiwer vorm is selfs nog gedurende die vroee tagtigerjare deur sommige navorsers nie onderskei van broca afasie en fonemiese parafasie nie (martin, 1974; keller, 1978; miceli, gainotti, caltagirone & masullo, 1980; guyard, sabouraud & gagnepain, 1981). die implikasie van hierdie verwarring was dat simptome van afasie aan verbale apraksie toegeskryf is en sodoende is kennis en navorsing oor hierdie omstrede en komplekse afwyking benadeel. die oortuiging dat daar wel 'n suiwer vorm van verbale apraksie is, het mettertyd meer algemeen posgevat en in 1983 stel kent en rosenbek en ook collins, rosenbek en wertz kriteria vir die seleksie van hul verbaal apraktiese proefpersone ten einde te verseker dat 'n suiwer vorm van verbale apraksie ondersoek word. hierdie kriteria kom opsommend daarop neer dat die sprekers onvlot spraak, pr6beeren-tref-artikulasiebewegings, pogings tot selfkorreksie, onkonstantheid in die foute by herhaalde produksie van dieselfde woord en disprosodie vertoon, maar fraselengte en grammatikale vorm is normaal of byna normaal. deur te verseker dat die afwyking in sy suiwer vorm ondersoek word, word die weg gebaan om die aard van verbale aprakdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 © sasha 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46· a van der merwe, i c uys, j μ loots en r j grimbeek sie werklik bloot te le deur navorsing. talle vrae oor die aard van verbale apraksie bestaan tans nog. verbale apraksie word algemeen in definisies as 'n afwyking in spraakprogrammering beskryf, maar in werklikheid is daar baie min bekend oor wat spraakprogrammering werklik behels. darley, aronson & brown (1975 : 255) definieer verbale apraksie as: "... an articulatory disorder resulting from impairment, due to brain damage, of the capacity to program the positioning of speech muscalature for the volitional production of phonemes and the sequencing of muscle movements for the production of words". programmering word in hierdie definisie dus beperk tot posisionering van strukture en die volgordebepaling van bewegings. dit is ook nie duidelik in die definisie of die programmeringsprobleem 'n afwyking in die beplanning van die aksie is of ' η afwyking wat intree tydens die uitvoer van die beweging nie. la pointe (1982 : 7) definieer verbale apraksie as: "... a neurogenic phonologic disorder resulting from sensori-motor impairment of the capacity to select, program and/or execute in coordinated and normally-timed sequences, the positioning of the speech musculature for the volitional production of speech sounds". in hierdie definisie word onderskei tussen seleksie, programmering en uitvoering. die implikasie hiervan is dat programmering nie seleksie insluit nie. dit is ook nie volkome duidelik wat gekoordineer moet word nie. buckingham het reeds in 1979 die vaagheid van terme soos programmering, wankoordinering en volgorde gekritiseer. die onsekerheid oor wat spraakprogrammering of beplanning behels en wat die aard van 'n afwyking daarin is, hang nou saam met die vraag oor die stadium van spraakproduksie wat defek is by verbale apraksie. tydens spraakproduksie is daar waarskynlik sprake van fonologiese en in 'n volgende stadium van motoriese beplanning van 'n uiting. die fonologiese eienskappe van 'n uiting is 'n linguistiese komponent van spraakproduksie. navorsers met 'n linguistiese orientasie is van mening dat spraak en taal interafhanklik en onafskeidbaar is (jakobson, fant & halle, 1967; martin, 1974) en die fonologiese komponent verteenwoordig die tussenvlak tussen spraakproduksie (fonetiese aspekte) en taal (edwards & shriberg, 1983). differensiele aantasting van of taal of spraak is dus volgens die unguis nie moontlik nie (martin, 1974). vanuit so 'n uitgangspunt is verbale apraksie as 'n fonologiese probleem beskou en in die literatuur het die dispuut oor die aard van die afwyking dan ook hoofsaaklik gesentreer om die vraagstuk van verbale apraksie as 'n "motoriese teenoor 'n fonologiese probleem (martin, 1974; aten, darley, deal & johns, 1975; kent & rosenbek, 1983). wesenlik handel dit dus oor die skeiding van linguistiese (fonologiese) en motoriese gedrag. in hul bespreking oor die kwessie van verbale apraksie as 'n motoriese teenoor 'n fonologiese probleem, se kent en rosenbek (1983: 245) dat minstens sommige van die foute: "... do not seem to fall in the domain of phonology because as the term is commonly understood, phonology is not intended to explain the details of timing and coordination in speech". hulle se verder ook dat hulle nie daarop aanspraak maak dat verbale apraksie slegs 'n motoriese probleem is nie en dat dit montlik is dat beide tipes probleme saam voorkom. in die bogenoemde definisie van la pointe (1982) omseil hy die twispunt deur dit 'n fonologiese afwyking te noem, maar dan 'n beskrywing te gee van die motoriese probleme. itoh en sy medewerkers (itoh, sasanuma & ushijima, 1979; itoh & sasanuma, 1984) wat intensiewe ondersoeke oor die temporale versteuring van spraakbewegings by verbale apraksie gedoen het, stel dit onomwonde dat verbale apraksie na hul mening 'n afwyking in programmering van spraakmotoriek is. volgens hierdie navorsers is distorsie van klanke die kernsimptoom van verbale apraksie en is dit die gevolg van temporale versteurings van spraakbewegings. vroeer is algemeen aanvaar dat klankvervangings die kenmerkendste simptoom van verbale apraksie is (shankweiler & harris, 1966; la pointe & johns, 1975; keller, 1978; wertz, la pointe & rosenbek, 1984: 52). dit is waarskynlik omdat die gevalle wat ondersoek is, ook gepaardgaande broca afasie en/of fonemiese parafasie en dus ware klankvervangings vertoon het en omdat bree fonetiese transkripsies gebruik is om die spraakfoute te beskryf (itoh & sasanuma, 1984). op grond van hierdie transkripsiemetode word distorsies dus as vervangings beskryf. deur gebruik te maak van eng fonetiese transkripsies, soos in hierdie studie beskryf word, kan distorsiefoute beter nagegaan word. tydens die ondersoek na die invloed van sekere kontekstuele faktore op die ouditief waarneembare foute by verbale apraksie (van der merwe, uys, loots & grimbeek, 1987) is simptome waargeneem wat aanduidings verskaf van die aard van die afwyking maar wat nie in daardie artikel volledig aangegee is nie. die doel van die huidige artikel is om hierdie addisionele waarnemings te beskryf en te wys op die implikasies wat dit inhou vir 'n beter begrip van die aard van verbale apraksie. heelwat ander persept'uele studies oor die simptome van verbale apraksie is in: die verlede uitgevoer (la pointe & johns, 1975; johns & darley, 1970, dunlop & marquardt, 1977). hierdie studie is egter uniek in die sin dat die materiaal volkome gekontroleer'd is in klankstruktuur en artikulasie-eienskappe, 'n eng transkripsiemetode gebruik is wat ook voorsiening maak vir'die voorkoms van klankdistorsie en vier agtereenvolgende herhalings van die onsineenhede ontleed is. hierdie faktore bring mee dat die waarnemings binne hoogs gekontroleerde ' toestande kan plaasvind en ruimte gelaat word vir volledige beskrywings van gedrag. metode χ doel om te bepaal wat die frekwensie en tipe verbaal apraktiese foute is wat voorkom by herhaalde produksies van onsinhede wat sistematies gevarieer is in klankstruktuur en artikulasie-eienskappe ten einde aanduidings te verkry van die aard van die afwyking by verbale apraksie. the south african journal of communication disorders, vol 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ouditief waarneembare foute by verbale apraksie: aanduidings van die aard van die afwyking 47 eksperimentele ontwerp die proefpersone, luisteraars, materiaal en prosedure van hierdie ondersoek is reeds volledig beskryf in die voorafgaande artikel (van der merwe et al. 1987) eri word dus nie hier herhaal nie. kortliks kan wel gemeld word dat vier persone met verworwe verbale apraksie en een persoon met verbale ontwikkelingsapraksie as proefpersone gebruik is. die kriterium is gestel dat 'n suiwer verbale apraksie vertoon moet word. wat die materiaal betref, is onsineenhede wat gekontroleer is in klankstruktuur en artikulasie-eienskappe ontwikkel (van der merwe, 1986). die volgende vyf klankstruktuurgroepe (s), het elk agt eenhede bevat en elke eenheid is vier keer herhaal: struktuurgroep 1: κι vi k1 v2 struktuurgroep 2: κι vi k2 v2 struktuurgroep 3: κι vi k2 v2 k3 struktuurgroep 4: κι vi k2 struktuurgroep 5: κι vi k2 v2 k3 v3 k4 en κι vi k2 v2 k3 v2 k4 vir die analise van die data is 'n lys saamgestel van alle spraakfoute wat voorgekom het by die vyf proefpersone. hierdie foute is geklassifiseer in die volgende sewe foutkategoriee: a. vervangings b. verandering van die struktuur van die eenheid c. klankdistorsie d. afwykings in temporale vloei e. afwykings in vlotheid f. spraakfoute gevolg deur selfkorreksie g. afwykings in prosodie die tipe foute in elke foutkategorie verskyn volledig in die bylae van die vorige artikel en in tabelle 1 tot 7 van hierdie artikel. j 7 die somtotaal van elke vjerskillende tipe fout oor vier herhalings van 'n spesifieke eenheid is bepaal vir elke proefpersoon. die totale aantal kere wat 'n spesifieke fout in elke klankstruktuurgroep voorkom, is daarna bereken en hierdie totale word in tabelle ljtot 7 aangegee. 'n analise van die data het getoon dat artikulasie-eienskappe nie 'n statisties aantoonbare effek het op die tipe foute wat voorkom nie (van der merwe, 1986; van der merwe et al. 1987) en daarom word slegs die tipe foute by die verskillende klankstruktuurgroepe bespreek. resultate en bespreking afwykings in temporale vloei het die hoogste frekwensie van voorkoms, naamlik 35,6% vertoon en daarna distorsiefoute (30,7%), verandering van struktuur (9,6%), afwykings in prosodie (9,6%), vervangings (8,5%), afwykings in vlotheid (4,7%) en foute gevolg deur selfkorreksie (1,3%). elk van hierdie foutkategoriee word vervolgens bespreek. vervangings die opsommende gegewens in tabel 1 toon aan dat vervangings met eenheidskonsonante (konsonante wat in die doelwiteenheid teenwoordig is) die meeste voorkom. dit is veral by s3 en s5 wat oor die algemeen die meeste foute tot gevolg gehad het, waargeneem. by klankstruktuur 5 is daar 75 vervangings met eenheidskonsonante maar daar is geen sodanige foute by si en s4 nie. 'n vervanging met 'n eenheidskonsonant impliseer dat die volgorde van klanke in die eenheid foutief is. dit weerspieel dus klank volgordeningsprobleme en nie seleksieprobleme nie. klankstrukture 3 en 5 is die langste eenhede en stel dus die hoogste eise met betrekking tot die volgordening van klanke asook geheue vir die klanke wat voorgekom het in die eenheid. die spreker selekteer dus die korrekte foneem, maar kombineer dan die doelwitklanke in die verkeerde volgorde. hierdie simptoom kan as 'n fonologiese probleem geklassifiseer word omdat dit 'n afwyking in fonologiese beplanning weerspieel. dit is egter belangrik om daarop te wys dat die probleem nie konstant teenwoordig was nie. tydens herhaalde produksie van dieselfde uiting was die eenheid soms korrek en soms nie. dit is onwaarskynlik dat fonologiese kennis so labiel kan wees en die simptoom' weerspieel dus waarskynlik nie 'n afwyking in fonologiese kennis nie maar eerder 'n probleem wat ontstaan tydens produksie. 'n vraag wat ontstaan, is of die beeld van die uiting soos wat die ondersoeker dit geproduseer het nie vervaag in die geheue van die verbaal apraktiese spreker en dan lei tot foutiewe volgordening van konsonante en vervangings met eenheidskonsonante nie. dit is egter nie die geval nie, want dit was 'n algemene verskynsel dat die eerste herhalings foutief was, maar die laaste een dan weer korrek. die persoon behou dus 'n beeld van wat geproduseer moet word, maar by herhaalde produksie is dit onkonstant korrek. die feit dat die uiting soms korrek is dui sterk daarop dat die tabel 1: vervangingsfoute by die verskillende klankstruktuurgroepe: klankstrukvervangingsfoute tuurgroepe konsonant vokaal eenheidsnie-eeneenheidsnie-eentotaal klank heidsklank klank heidsklank 1 0 8 1 16 0 25 (11,7%) 2 3 3 1 15 0 22 (10,3%) 3 19 14 0 2 2 37 (17,3%) 4 0 4 0 0 0 4 ( 1,9%) 5 75 24 7 16 4 126 (58,8%) totaal 1 9 7 53 9 49 6 2 1 4 (45,3%) (24,8%) (4,2%) (22,9%) (2,8%) (100%)^ die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 a van der merwe, i c uys, j μ loots en r j grimbeek spreker 'n duidelike beeld het van wat verwag word en ook oor die nodige kennis beskik om die uiting fonologies te beplan, maar nie altyd in staat is om dit korrek vooruit te voer vir produksie nie. die vervangings met eenheidskonsonante het meestal meegebring dat 'n besondere klank herhaal word in die eenheid. guyard et al. (1981) het dieselfde simptoom waargeneem by gevalle met broca afasie en gepaardgaande verbale apraksie en hulle interpreteer dit as 'n vereenvoudiging van die reeks. die duplisering van klanke bring waarskynlik fonologiese en motoriese vereenvoudiging mee en dit is dus op grond van so 'n verduideliking nie moontlik om die simptoom as 'n motoriese of 'n fonologiese probleem te klassifiseer nie. dit is belangrik om daarop te wys dat dit veraljproefpersone 5 en 3 was wat vervangings vertoon het. in die geval van proefpersoon 5 kan die probleem moontlik verband hou met die feit dat hy 'n verbale ontwikkelingsapraksie het en dat hy moontlik 'n besondere probleem met volgordening van klanke het. die simptome wat hy openbaar, stem egter heeltemal ooreen met die simptome van proefpersoon 3. dieselfde tipe vervangings het by beide voorgekom. proefpersoon 4 het ook dikwels vervangings vertoon terwyl dit selde voorgekom het by proefpersone 1 en 2. klankvervangings is dus nie 'n kenmerkende simptoom van verbale apraksie_nie. indien die oorsprong daarvan wel suiwer fonologies (dit wil se linguisties-simbolies) is, impliseer die lae voorkoms daarvan (8,5% van alle foute) by slegs sommige verbaal apraktiese sprekers dat die fonologies gebaseerde simptome nie 'n integrerende deel van verbale apraksie is nie. vervangings met nie-eenheidsklanke, wat moontlik op foutiewe seleksie van klanke dui, het in mindere mate as vervangings met eenheidsklanke voorgekom. die hoogste frekwensie was ook by klankstrukture 3 en 5. hierdie vervangings kan ook as paradigmatiese foute beskryf word omdat dit foutiewe seleksie vanuit 'n interne "stoor" van foneme impliseer (jakobson, 1971; keller, 1978). vanuit hierdie gesigspunt is vervangings met nie-eenheidsklanke suiwer fonologies gebonde probleme. die besondere eise van die langer eenhede veroorsaak dat hierdie probleme intree. 'n nadere ondersoek van die spesifieke klanke wat vervang word, werp egter 'n ander lig op sommige van die vervangings met nie-eenheidskonsonante. die ibl is byvoorbeeld herhaaldelik vervang met iml. hierdie klanke is artikulatories verwant en die moontlikheid is nie uitgesluit dat die iml in werklikheid 'n distorsie in die produksie-eienskappe van ibl is nie. die luisteraars het moontlik die klank dan as 'n iml geperseptueer. vokaalvervangings is ook by hierdie groep sprekers waargeneem. dit bevestig die resultate van keller (1978) wat ook vokaalvervangings by persone met broca afasie en gepaardgaande verbale apraksie gevind het. slegs nege vokaalvervangings met eenheidsklanke het voorgekom en sewe daarvan was by s5. dit wil dus voorkom asof dit 'n ongewone verskynsel is by verbale apraksie en dat die persoon bewus is van die vokale in die uiting en die posisie daarvan. die volgordening van konsonante is dus 'n groter probleem. die vokaalvervangings met nie-eenheidsklanke was in die meeste gevalle vervangings van hi vir id en lo:l vir hi. oppervlakkig beskou, dui dit op fonologiese seleksieprobleme, maar daar is 'n paar aanduidings dat 'n groot persentasie van hierdie vervangings in werklikheid die gevolg van probleme in motoriese programmering is. daar is in die eerste plek waargeneem dat dieselfde vervangings by al die proefpersone voorgekom het. dit impliseer dat 'n gemeenskaplike probleem of eienskap tot die simptoom aanleiding gee. vanuit die oogpunt van 'n gemerktheidsanalise dui bogenoemde vervangings op vereenvoudiging na laer gemerkte vokale (keller, 1978). die bewegings word dus sistematies vereenvoudig. dit kan ook wees dat die artikulatoriese grense (ruimtelik en temporaal) tussen hierdie vokale nie streng afgebaken is deur die sprekers nie en dat geringe afwykings in die kritiese bewegingspesifikasies daartoe gelei het dat die luisteraars die afwykings as vervangings perseptueer terwyl dit in werklikheid 'n vorm van distorsie is. die onkonstante aard van die vervangings dui ook daarop dat dit die gevolg is van klankdistorsie en waarskynlik weens 'n oorskryding van die kritiese artikulasiegrense tussen klanke. 'n eenheid soos idokd is byvoorbeeld afwisselend geproduseer as /doke:, doki, dcfe/. dit is dus onwaarskynlik die gevolg van 'n afwyking in fonologiese klankseleksie. lettergreepvervangings het slegs voorgekom by s3 en s5. indien aanvaar word dat hierdie klankstrukture die moeilikste vir die verbaal apraktiese spreker is om te produseer, is lettergreepvervangings moontlik 'n ernstiger afwyking. dit het egter selde voorgekom by die verbaal apraktiese sprekers. opsommend kom die resultate daarop neer dat klankvervangings wel voorkom by verbaal apraktiese sprekers, maar nie in dieselfde mate by almal nie. die meeste vervangings kom voor by s5 wat die langste klankstruktuur het. dit wil dus voorkom asof vervangings konteks-sensitief is (van der merwe et al. 1987). vervangings is egter nie 'n prominente simptoom van verbale apraksie nie want slegs 8,5% van al die foute was klankvervangings. die vervangings wat wel voorkom is waarskynlik nie weens 'n fonologiese beplanningsprobleem nie, want dit kom onkonstant voor tydens herhaalde produksie. dit is ook nie weens 'n geheueof fonologiese herroepings-probleem nie want die laaste van die herhalings was soms fonologies die mees korrekte. dit wil wel voorkom asof daar 'n probleem is in die onveranderlike vooruitvoering van foneme in die korrekte volgorde. daar is veral 'n neiging om konsonante te vervang met eenheidskonsonante wat dus 'n afwyking in klankvolgorde is. moontlik word die fonologiese en motoriese komponente van die produksie van die eenheid sodoende vereenvoudig. vervangings met nie-eenheidskonsonante en vokale kom ook voor maar by 'n nadere ondersoek van die artikulasieeienskappe van die spesifieke klanke blyk dit dat hietdie vervangings meer waarskynlik distorsies van die doelwitklank is wat luisteraars perseptueer as vervangings. verandering van struktuur van eenhede / 'n totaal van 241 (9,6%) foute is in hierdie foutkategorie aangeteken. die hoogste persentasie (38,2%).foute het by s3 en s5 voorgekom (kyk tabel 2). dit is interessant dat dieselfde getal foute by altwee klankstrukture voorgekom het. die gevolgtrekking dat die lengte van 'n uiting nie die enigste faktor is wat die mate van afwyking bepaal nie (van der merwe et the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ouditief waarneembare foute by verbale apraksie: aanduidings van die aard van die afwyking tabel 2: verandering van struktuur by die verskillende klankstruktuurgroepe verandering van struktuur van eenhede klankstruktuurgroepe totaal verandering van struktuur van eenhede si s2 s3 s4 s5 totaal byvoeging van κ in mediale posisie 29(12,0%) (eenheidsklank) 1 13 15 29(12,0%) byvoeging van κ in mediale posisie 32(13,3%) (nie-eenheidsklank) 2 7 7 5 11 32(13,3%) byvoeging van κ in finale posisie 6 (2,5%) (eenheidsklank) 4 2 6 (2,5%) byvoeging van κ in finale posisie 5 (2%) (nie-eenheidsklank) 2 2 1 5 (2%) byvoeging van v (eenheidsklank) 0 (0%) byvoeging van v (nie-eenheidsklank) 2 2 32(13,3%) weglating van κ 4 23 5 32(13,3%) weglating van v 7 7 (2,9%) byvoeging van lettergreep 1 4 5 (2%) weglating van lettergreep 2 9 11 (4,6%) weglating van alle konsonante en 1 (0,4%) slegs vokaalproduksie 1 1 (0,4%) omruiling van klanke 1 1 (0,4%) struktuur verander na kv 2 2 (0,8%) struktuur verander na kvkv 17 2 19 (7,9%) struktuur verander na kvk 0 (0%) struktuur verander na kvkvk 1 1 2 4 (1,6%) struktuur verander na kvkvkv 1 1 3 5 (2,0%) struktuur verander na kvkvkvk 1 1 (0,4%) struktuur verander na ander struktuur 2 8 18 32 60(24,9%) afbreking binne geslote lettergreep 5 8 4 17 (7%) totaal 12 28 92 17 92 241 (5%) (11,6%) "(38,2%) (7%) (38,2%) (100%) nege keer voorgekom) of enkelklanke. die struktuur is soms verleng en dit het meegebring dat dit in werklikheid moeiliker gemaak is. geen strategiee om die uiting te vereenvoudig kan hierin gevind word nie en die indruk word gewek dat die spreker nie die eenheid kan onthou nie. in baie gevalle was die laaste herhalings egter nader aan die doelwituiting wat die moontlikheid aandui dat die kombinasie van foneme en/of die onveranderlike vooruitvoering daarvan problematies is by langer uitings. 'n verder interessante verskynsel is die afbreking binne geslote lettergrepe wat by s3, s4 en s5 voorgekom het. die redenasie kan moontlik geopper word dat dit eerder as afwykings in temporale vloei geklassifiseer moet word. dit was egter die afbakening van lettergrepe binne die uiting wat verander is. die kvk-eenhede is byvoorbeeld verander na kv-k en die kvkvk-eenhede na kvkv-k. hierdie verskynsel dui ook daarop dat die vooruitvoering van 'n kv-, of kvkv-eenheid wat 'n duplisering is, makliker of meer natuurlik is en dat die uiting sodoende vereenvoudig word. verandering van struktuur het by al die proefpersone voorgekom, maar daar was individuele gedragspatrone wat baie interessante inligting aan die lig gebring het. proefpersoon 2 het 'n feitlik konstante getal foute by al die strukture vertoon behalwe by s4 waar daar minder was. proefpersone 3 en 5 het dieselfde tipe foute vertoon en beide het veral by s3 en s5 foute gemaak. proefpersoon 1 het onverwags by s4 foute vertoon en proefpersoon 4 het geen foute gemaak nie. die huidige data wat verkry is, kan slegs in beperkte mate met die bevindinge van ander navorsers vergelyk word. la al. 1987) word dus deur hierdie analise bevestig. by s3 is die struktuur 17 keer vereenvoudig na 'n kvkv-struktuur en 18 veranderings na ander strukture soos veral 'n kvkkvkstruktuur het voorgekom. dit wil dus voorkom asof die struktuur van s3 moeilik is vir die verbaal apraktiese spreker. dit is waarskynlik so dat die, herbeplande struktuur makliker vooruitgevoer kan word. die verandering na 'n kvkv-struk/tuur is ondersteuning vir die teorie dat die kv-eenheid die natuurlike eenheid van spraakprogrammering is (jakobson, 1971: 21), maar die verandering na 'n kvkkvk-struktuur is in opposisie met die teorie1. laasgenoemde is wel 'n duplisering van die kvk-eenheid wat min afwykings tot gevolg gehad het. die feit dat die klankstruktuur herbeplan en selfs verleng (kvkkvk is langer as kvkvk) word, dui daarop dat die sprekers wel die uiting fonologies en morfologies kan beplan en dus nie 'n probleem het op hierdie vlak van beplanning nie. die herbeplande uitings voldoen ook aan die fonotaktiese reels van afrikaans en engels. veranderinge in die klankstruktuur van 'n uiting moet dus nie sonder meer as 'n afwyking in linguisties-simboliese beplanning beskou word nie. dit is wel moontlik dat sodanige simptome so 'n afwyking kan weerspieel, maar binne die konteks van al die gedragspatrone van die sprekers, is so 'n verklaring minder aanvaarbaar. daar moet in gedagte gehou word dat hierdie sprekers verstaanbaar verbaal kan kommunikeer en dus die uitings linguisties kan beplan. die produksie van die uitings is egter stadig en met hoorbare distorsie van die klankeienskappe. die klankstruktuur van s5 is in die meeste gevalle verkort deur byvoorbeeld die weglating van 'n lettergreep (dit het die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 a van der merwe, i c uys, j μ loots en r j grimbeek pointe en johns (1975) het ook klankvolgordefoute waargeneem. preposisionering van klanke in 'n woord is in beide studies gevind. hierdie navorsers en ook trost en canter (1974) vind dat metatese feitlik nooit voorkom nie. dit bevestig die huidige resultate want slegs een geval hiervan is waargeneem (kyk tabel 2 — omruiling van klanke). hulle bevind ook dat slegs 'n klein persentasie van die foute van verbaal apraktiese sprekers, klankvolgordefoute is. die data van hierdie ondersoek is nie op presies dieselfde wyse en met dieselfde doel ontleed as die data van la pointe en johns (1975) nie en verdere vergelykings is nie sonder verdere ontleding van die versamelde data moontlik nie. hierdie resultate kom dus daarop neer dat die klankstruktuur van 'n uiting wel 'n invloed het op frekwensie en tipe veranderinge in die struktuur van die uiting. die grootste getal veranderinge in klankstruktuur het voorgekom by s3 en s5. enkele van die simptome soos die verlenging van die struktuur van s5 kan as 'n probleem in fonologiese beplanning beskou word. die ander simptome soos die sistematiese vereenvoudiging van s3en s5-eenhede dui daarop dat die sprekers wel in staat is tot fonologiese herbeplanning van die uiting en kennis het van fonotaktiese reels. die verbaal apraktiese sprekers ondervind moontlik 'n probleem in algemene motoriese beplanning en sistematiese vooruitvoering en verander die struktuur dan na 'n vorm wat makliker geproduseer kan word. hierdie vorm stem ooreen met die sogenaamde eenheid van spraakprogrammering (volgens die meeste teoretici) naamlik die kv-lettergreep of 'n duplisering daarvan. distorsie die voorkoms van die verskillende vorms van distorsie by die verskillende klankstrukture word aangegee in tabel 3. distorsie het voorgekom by al die klankstrukture en die persentasie van voorkoms verskil nie baie nie. die hoogste persentasie is 26,6% by si en die laagste is 14,3% by s4. dit wil dus voorkom asof die klankstruktuur van 'n uiting nie 'n groot rol speel by die voorkoms van distorsie nie. distorsie is waarskynlik 'n kenmerkende simptoom van verbale apraksie wat voorkom ongeag die eienskappe van die uiting. aangeteken. 'n klankvervanging is ook aangeteken indien 'n klank vervang is met 'n klank wat artikulatories on verwant is daaraan. die onderskeid tussen distorsie en klankvervangings is egter soms 'n probleem. geen vorige navorsing is hieroor gedoen wat as riglyn gebruik kan word nie. elektromiografiese, spektrografiese en ander metodes wat spraakbewegings kan ontleed, moet in die toekoms gebruik word om distorsie by verbale apraksie na te vors. die vorm van distorsie met die hoogste. voorkoms is versteuring van stemhebbendheid wat meebring dat 'n klank nie met sekerheid herken word as stemhebbend of stemloos nie. hierdie resultaat van die ouditiewe analise bevestig dat die onvermoe tot interartikulator-sinchronisasie (tussen die glottis en artikulasiestrukture) vir korrekte stemgewing een van die prominentste en kenmerkendste probleme van die verbaal apraktiese spreker is. die syfers in tabel 3 toon aan dat meer foute in stemhebbendheid van klanke by si, s4 en s2 voorkom as by die ander strukture wat andersins meer probleme tot gevolg gehad het. die moontlikheid bestaan dat die sprekers poog om stemhebbendheid te beheer en dat die poging toeneem in intensiteit by die moeiliker en langer uitings. dit bring dan mee dat minder sat-foute voorkom by die langer en moeiliker klankstrukture. ander vorms van konsonantdistorsie het ook voorgekom en het 20,3% van die distorsiefoute uitgemaak. die meeste van hierdie foute het voorgekom by s3 en s5. die langer uitings bevat meer klanke wat foutief geproduseer kan word, maar dit het ook die /f/-klank bevat wat baie van die foute tot gevolg gehad het. vorige navorsers het ook bevind dat frikatiewe moeilik is vir verbaal apraktiese sprekers (shankweiler en harris, 1966; la pointe en johns, 1975; trost en canter, 1974; wertz et al. 1984: 52). dit is dus 'n kombinasie van faktore wat meebring dat meer konsonantdistorsies voorkom by s3 en s5. dit is interessant dat s3 ook in hierdie geval meer foute meebring as s5. die lengte van die eenheid is dus ook met betrekking tot die getal konsonantdistorsies nie die enigste bepalende faktor nie. ϊ tabel 3: distorsie by die verskillende klankstruktuurgroepe: distorsiefoute klankstruktuurgroepe stemhebbendheid konsonant — ander vokaal verandering van vokaaleienskappe lettergreep of eenheid j 1 totaal j 51 52 53 54 55 127 55 44 64 35 7 18 67 12 52 62 50 48 32 64 9 4 5 , 2 ' 2 0 1 5 0 4 205 (26,6%) ' 128 (16,7%) ' 169 (22%) 110 (14,3%) 157 (20,4%) totaal 325 (42,2%) 156 (20,3%) 256 (33,3%) 22 (2,9%) 10 (1,3%) 769 (100%)' die distorsies wat waargeneem is tydens die ondersoek het onkonstant voorgekom. 'n besondere klank of meer klanke binne 'n uiting is soms tydens die herhaalde produksies foutief geproduseer. die mate van distorsie het ook gevarieer. die verandering in die klankeienskappe was soms net waarneembaar terwyl dit by 'n volgende herhaling soms in so 'n mate afgewyk het dat dit byna soos 'n klankvervanging! geklink het. in sommige gevalle, wanneer die klank suiwer en vlot geproduseer is, is klankvervangings wel as sodanig distorsie van vokale het 33,3% van al die distorsiefoute uitgemaak. dit het by al die klankstrukture voorgekom. die laer voorkoms van vokaaldistorsie teenoor konsonantdistorsie bevestig die resultate van shankweiler en harris (1966). distorsie is onderskei van veranderinge in die vokaaleienskappe (2,9%) wat in werklikheid 'n'vorm van diftongisering was. in laasgenoemde geval is daar moontlik 'n onvermoe om die kritiese artikulatoriese konfigurasie te behou of om stemgewing en/of tongbeweging te onderbreek terwyl the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 51 a van der merwe, i c uys, j μ loots en r j grimbeek daar na die posisie van die volgende klank beweeg word. die ander vorms van vokaaldistorsie is moontlik weens 'n onvermoe om die kritiese ruimtelike konfigurasie te bereik. distorsie van 'n lettergreep en eenheid het slegs 1,3% van die totale aantal distorsies uitgemaak en was met 'n enkele uitsondering beperk tot s3 en s5. distorsie van enkele klanke binne 'n uiting is dus die meer algemene verskynsel by verbale apraksie. 'n teorie wat die verskynsel van distorsie by verbale apraksie verklaar, moet ook die feit verklaar dat slegs enkele klanke binne 'n uiting aangetas word, dat hierdie aantasting onkonstant plaasvind en dat meer distorsie voorkom by uitings met 'n besondere klankstruktuur. die mees algemene oorsaak vir klankdistorsie is spiertonusen spierkoordinasieprobleme soos wat voorkom by disartrie (darley et al. 1975; itoh en sasanuma, 1984). soortgelyke probleme is nie waargeneem by verbaal apraktiese sprekers nie (shankweiler en harris, 1966) en kan dus nie die voorkoms van distorsie verklaar nie. die moontlikheid dat klankdistorsie by verbale apraksie deur een of ander vorm van 'n perseptuele probleem veroorsaak word, behoort ook oorweeg te word. dit is egter nie duidelik hoe 'n ouditiewe of oraal-sensoriese terugvoeringsen/of persepsieprobleem of selfs 'n interne terugvoeringsprobleem tot onkonstante distorsie van klanke kan aanleiding gee nie. dit is meer waarskynlik dat 'n perseptuele en terugvoeringsprobleem konstant teenwoordig sal wees ( en 'n konstante probleem veroorsaak) en nie sensitiwiteit vir kontekstuele faktore sal vertoon nie. die konteks van 'n uiting soos byvoorbeeld die klankstruktuur het wel implikasies vir die beplanning en produksie van spraak. reaksie op die konteks en in hierdie geval die voorkoms van distorsie, is dus meer waarskynlik 'n aanduiding dat distorsie voorkom weens 'n versteuring in die beplanning en/of produksie van spraak. > xdie verlies van die ouditiewe beeld van die kritiese akoes/ tiese konfigurasie van 'n klank is 'n meer aanneemlike verklaring as 'n terugvoeringsof perseptuele probleem, maar dit sou waarskynlik ook aanleiding gee tot 'n konstant teenwoordige probleem. dit behoort ook nie konteks-sensitiwiteit te vertoon nie. j itoh en sy medewerkers 1(1979, 1984) wat die eerste navorsers was wat distorsie by verbale apraksie as 'n eienskap van verbale apraksie in die literatuur beskryf het, beskou distorsie as die gevolg van temporale wansinchronisasie tussen die bewegings van verskillende artikulators. dit is wel 'n redelike verklaring vir die aspek wat hulle ondersoek het, naamlik die temporale wansinchronisasie van velere en ander artikulasiebewegings. dit lei dan tot ontoepaslike nasalering of denasalering van klanke en soms gevolglike foutiewe identifikasie van klanke. dit is egter ook moontlik dat ruimtelike faktore tot distorsie aanleiding gee. soos reeds aangedui, vereis akkurate spraakproduksie dat die kritiese ruimtelike konfigurasie by herhaling bereik moet word en dat die natuurlike mate van ekwivalensie (hughes & abbs, 1976) nie oorskry word nie. sekere klanke is ruimtelik baie naby verwant en die oorskryding van die kritiese ruimtelike ekwivalensiegrense kan meebring dat daar distorsie van die klank is of selfs dat dit as 'n ander klank waargeneem word. tydens die ondersoek is waargeneem dat die mate van distorsie voortdurend wissel. die kritiese grense van ekwivalensie is dus telkens in wisselende mate oorskry. hierdie grense is dus te plasties by die verbaal apraktiese spreker. opsommend kom die resultate daarop neer dat die klankstruktuur van 'n uiting nie 'n groot rol speel by die voorkoms van distorsie nie. die vorm van distorsie met die hoogste voorkoms is versteurings van stemhebbendheid. minder vokaaldistorsies as konsonantdistorsies is waargeneem. distorsie kom onkonstant by herhaling van dieselfde uiting voor. die mate van distorsie varieer ook. hierdie feite en ook die feit dat konteks-sensitiwiteit wel voorkom, lei tot die afleiding dat distorsie voorkom weens 'n probleem in die beplanning van die temporale en ruimtelike dimensies van beweging. die kritiese ekwivalensiegrense word dan telkens in wisselende mate oorskry. afwykings in temporale vloei die aspekte wat geklassifiseer is as afwykings in temporale vloei het te doen met die ouditief waarneembare tempo van vooruitvoering van spraak. ongeveer dieselfde persentasie afwykings in temporale vloei is waargeneem by si, s2, s3 en s5 terwyl s4 baie minder foute vertoon (kyk tabel 4). in die produksie van s4 is die vokale, soos reeds met die akoestiese analises bevind, selde en minimaal verleng en afbakening in lettergrepe is minder waarskynlik. dit is interessant dat s5 minder foute opgelewer het as si, s2 en s3. daar is waargeneem dat die proefpersone die eenhede in s5 ritmies geproduseer het en moontlik het die inherente ritme van hierdie klankstruktuur temporale vloei gefasiliteer. afwykings in temporale vloei klankstruktuurgroepe verlenging van vokaal verlenging van konsosonant artikulasieverlenging stadige doelbewuste artikulasie lettergrepe kom afgebakend voor totaal 51 52 53 54 55 48 39 49 15 22 0 7 22 22 1 32 32 32 21 32 6 4 0 4 8 127 124 120 2 123 213 (23,9%) 206 (23,1%) 223 (25%) 64 (7,1%) 186 (20,9%) totaal 173 (19,4%) 52 (5,8%) 149 (16,7%) 22 (2,5%) 496 (55,6%) 892 (100%) tabel 4: afwykings in temporale vloei by die verskillende klankstruktuurgroepe die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ouditief waarneembare foute by verbale apraksie: aanduidings van die aard van die afwyking 52 die verlenging van vokale het 19,4% van die totale getal afwykings in temporale vloei uitgemaak in teenstelling met 5,8% verlengings van konsonante. volgens crompton (1980) is die duur van vokale meer veranderlik en die verbaal apraktiese sprekers was meer geneig om dit te verleng. die konsonante wat wel verleng is, is in s3 en s4. 'n nadere ondersoek van die data bring 'n baie interessante verskynsel aan die lig. die vier sprekers met verworwe verbale apraksie het almal die finale konsonant van die kvk-eenhede (s4) en die tweede konsonant in kvkvk(s3) eenhede verleng (in gevalle waar verlenging wel voorgekom het). die feit dat dieselfde verskynsel by die vier proefpersone voorkom, impliseer dat die beplanning en vooriiitvoering van hierdie klankstrukture sekere eise stel wat op 'dieselfde wyse oorkom is. die verlenging van die finale konsonant by s4 is verrassend want oor die algemeen het die minste foute by hierdie klankstruktuur voorgekom. daar moet egter in gedagte gehou word dat die eenhede agtereenvolgend geproduseer is en moontlik is die finale klank verleng terwyl die volgende uiting beplan is. die kvkvk-struktuur kan verdeel word in 'n kvken vk-gedeelte en in hierdie geval is dit ook soos by die kvk-eenhede, die tweede konsonant wat verleng is. die vraag ontstaan of dit nie die besondere klank is wat aanleiding gee tot verlenging nie. klankstrukture 2 en 5 bevat egter ook die klanke wat verleng is (/k/ en /t/) maar by hierdie strukture vind verlenging baie minder (sewe en een keer) plaas. die besondere klankstruktuur van s3 en s4 is dus die faktor wat aanleiding gee tot die verlenging van konsonante. die artikulasieverlenging wat waargeneem is, verwys in hierdie studie na verlenging van alle klanke. dit het net by proefpersoon 4 voorgekom. akoestiese analises (van der merwe, 1986) het aan die lig gebring dat die duur van die uiting in mindere mate afwyk as vokaalduur. by hierdie persoon is die oorgange tussen klanke en dus die spoed van vooruitvoering nie stadiger as by die ander proefpersone nie, maar die statiese periode van artikulasie is verleng. die verlenging het minimale sensitiwiteit vir klankstruktuur vertoon en is dus 'n konstante verskynsel wat ook blyk uit die 32 foute by si, s2, s3 en s5. hierdie simptoom is moontlik die gevolg van die besondere letsel van proefpersoon 4, naamlik in die linkerperifere parietale gebied en in die posterior-been van die capsula interna wat onder meer deel uitmaak van die afferente sensoriese bane na die talamus en van die basale ganglia (chusid, 1973: 13; 153—159). sensoriese terugvoering tydens spraak is moontlik as gevolg van die letsel onvoldoende en die persoon kompenseer deur segmented duur te verleng. so 'n verklaring is aanvaarbaar indien aanvaar word dat sensoriese terugvoering nodig is vir spraakvorming of vir die beheer van spraak onder buitengewone omstandighede soos 'n programmeringsprobleem. stadige doelbewuste artikulasie het voorgekom by proefpersone 2 en 3 en is slegs 22 keer waargeneem. stadige doelbewuste artikulasie is 'n subjektiewe waarneming deur 'n luisteraar in teenstelling met die ander foute wat ouditief duidelik identifiseerbaar is. om 'η werklik akkurate beskrywing daarvan te gee en om die verskil hiertussen en artikulasieverlenging te bepaal, sal 'n spektrografiese ontleding van groot waarde wees. proefpersoon 3 het ook afwykings in inisiering vertoon en dit is moontlik dat die stadige doelbewuste artikulasie 'n minder ernstige simptoom is van 'n inisieringsafwyking wat daartoe lei dat die spoed van vooruitvoering stadig is. dit kan ook 'n kompensatoriese reaksie wees op die algemene probleem in programmering. die grootste afwyking in temporale vloei is die afbakening van lettergrepe en dit het by al die proefpersone voorgekom en by al die eenhede met meer as een lettergreep. dit is wel twee keer waargeneem by s4 waar proefpersoon 1 die eenheid tydens twee van die vier herhalings geproduseer het as (du k/. die afbakening van lettergrepe is ook deur vorige navorsers (kent en rosenbek, 1982 en 1983; trost en canter, 1974) waargeneem. kent en rosenbek (1982) spreek die mening uit dat hierdie simptoom 'n aanduiding is dat die beplanning van spraak in onafhanklike lettergreep-eenhede plaasvind omdat die spreker nie groter eenhede kan hanteer nie. lettergreepvooruitvoering vind dus plaas. dit is 'n logiese verklaring vir die simptoom, maar die vraag ontstaan of die eenhede werklik onafhanklik beplan is en of slegs die vooruitvoering en produksie in lettergreep-eenhede plaasvind. deur die voorkoms van koartikulasie en adaptasie by die klankomgewing na te gaan, sal moontlik 'n antwoord op hierdie vraag verkry word. hierdie resultate dui dus daarop dat verskillende vorms van afwykings in temporale vloei voorkom en dat die njeeste hiervan nie sensitiwiteit vir die klankstruktuur van die uiting vertoon nie. die verlenging van konsonante het wel meer probleme met die vooruitvoering van s3 en s4 uitgelig. die het net by die sprekers met verworwe verbale apraksie voorgekom. die resultate toon aan dat sekere simptome (soos artikulasieverlenging) meer individueel is terwyl ander (soos die afbakening van lettegrepe en vokaalverlehging) by al die sprekers voorkom. kent en rosenbek (1983) het ook individuele variasie in die vorms van temporale vkrsteuring waargeneem. die algemene indruk is dat die waarneembare simptome waarskynlik kompensatoriese aksies in reaksie op 'n onderliggende probleem in die motoriese programmering van spraak is. j i afwykings in vlotheid i probleme om spraak te inisieer word as een van die kentabel 5: afwykings in vlotheid by die verskillende klankstruktuurgroepe klankstruktuurgroepe 51 52 53 54 55 totaal onvlot herhaling 17 (14, vassteking (bv. glottale afsluiting) 4 5 9 2 11 afwykings in vlotheid 31 (26,3%) vassteking met hoorbare worstelgedrag 25 (21, stadige worstelende artikulasie 15 9 45 (38,1 totaal 12 (10,1%) 23 (19,5%) 27 (22,ί ' 19 (16,1 37 (31,4 118 (100%) the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ouditief waarneembare foute by verbale apraksie: aanduidings van die aard van die afwyking 53 merkendste eienskappe van verworwe verbale apraksie beskryf (wertz et al. 1984; kent en rosenbek, 1983; collins et al. 1983). volledige simptoombeskrywings word egter nie verskaf nie. wertz et al. (1984: 76) se wel dat probleme in inisiering gekenmerk word deur "false starts and restarts". in die huidige ondersoek is vier tipes simptome waargeneem wat geklassifiseer kan word as afwykings in vlotheid (kyk tabel 5). die simptome kan ook beskryf word as afwykings in inisiering. stadige worstelende artikulasie wat die grootste persentasie (38,1%) van die totale aantal afwykings in vlotheid uitmaak, het slegs by proefpersoon 3 voorgekom. die meeste van die foute in die ander drie subkategoriee is ook gemaak deur proefpersoon 3. die afwykings in vlotheid het slegs 4,7% van die totale aantal foute uitgemaak en is skynbaar nie 'n tipiese probleem van die groep verbaal apraktiese sprekers nie. dit is moontlik dat hierdie sprekers anders sal reageer in spontane spraak. die meeste afwykings in vlotheid het voorgekom by s3 en s5. rosenbek (1980) se ook dat meer afwykings in vlotheid by langer eenhede voorkom. 'n interessante verskynsel is dat proefpersoon 3 meer gevalle van stadige worstelende artikulasie by s4 as by die ander klankstrukture vertoon het. die data is nagegaan vir enige tendense wat hierdie verskynsel kan verklaar. die enigste moontlike verklaring is dat die vooruitvoering van die kvk-struktuur moontlik moeilik is omdat dit nie die natuurlike eenheid van programmering is nie. daar is verskillende moontlike oorsake vir die herhalings, vasstekings en worstelende artikulasie wat by verbale apraksie voorkom. daar kan 'n onvermoe wees om die bewegings temporaal te orden en vooruit te voer of sensoriese terugvoering en interne terugvoering kan moontlik swak gekoordineer word met programmering. dit kan ook 'n ware inisieringsprobleem wees en die spreker is dan nie in staat om te begin beweeg nie. laasgenoemde word soms beskryf as 'n ideomotoriese apraksie (rosenbek, 1980). 1 . opsommend kom die resultate daarop neer dat daar aandui7 dings is dat vlotheid en inisiering wel in 'n mate kontekssensitief is. meer afwykings in vlotheid het by die langer uitings, naamlik s3 en s5,' voorgekom en proefpersoon 3 het meer stadige worstelende artikulasie by die kvk-struktuur vertoon. die verbaal apraktiese sprekers vertoon nie in dieselfde mate afwykings irl vlotheid nie. ι spraakfoute gevolg deur selfkorreksie spraakfoute gevolg deur selfkorreksie het meer by s5 en s3 as by die ander klankstrukture voorgekom (kyk tabel 6) en dit was teenwoordig by al die proefpersone/behalwe by proefpersoon 1. dit was slegs verbetering van klankseleksiefoute wat voorgekom het en proefpersoon 1 het baie min hiervan vertoon. ongeveer dieselfde getal klankveranderinge en lettergreepveranderinge het voorgekom. in die geval van klankveranderinge was dit meestal suksesvol en by lettergreepveranderinge meestal onsuksesvol. die feit dat klanken lettergreepveranderinge voorgekom het, dui daarop dat die verbaal apraktiese sprekers bewus is van foutiewe klankseleksie en poog om dit te verbeter. dit was ook die geval by proefpersoon 5. dit is opvallend dat geen ander vorms van selfkorreksie, byvoorbeeld van distorsies, voorgekom het nie. die sprekers is dus nie bewus van die groot getal distorsiefoute nie of is bewus van hul onvermoe om dit te verbeter. in 'n sekere sin bevestig hierdie bevindinge die standpunt van itoh en sasanuma (1984) dat distorsie die kernsimptoom van verbale apraksie is. selfkorreksie by verbaal apraktiese sprekers is nog nie formeel ondersoek nie en net beperkte vergelykings met ander studies kan getref word. deal en darley (1972) het wel die vermoe om foute te voorspel by verbaal apraktiese sprekers nagegaan en gevind dat hulle daartoe in staat is, maar dat meer foute gemaak word as wat voorspel is. die proefpersone was ook in staat om sommige van hul foute te herken. afwykings in prosodie afwykings in prosodie verwys in hierdie studie net na simptome soos oormatige of afwykende klemen intonasiepatrone en momentele afwykende stemkwaliteit. afwykings in prosodie is ook deur ander navorsers waargeneem (kent en rosenbek; 1982, 1983). dit word beskryf as disprosodie en verwys in besonder na stadige spraakspoed, verlengde segmentele duur en lettergreep-afbakening. hierdie aspekte is in hierdie ondersoek afsonderlik bestudeer. tabel 7: afwykings in prosodie by die verskillende klankstruktuurgroepe klankstruktuurgroep totaal si s2 s3 s4 s5 totaal aantal foute 53 (21,9%) 57 (23,6%) 48 (19,8%) 46 (19%) 38 (15,7%) 242 (100%) klankstruktuurgroepe spraakfoute gevolg deur selfkorreksie klankstruktuurgroepe klankverandering lettergreepverandering totaal klankstruktuurgroepe suksesvol onsuksesvol suksesvol onsuksesvol totaal si 1 0 1 2 4 (12,5%) s2 2 1 1 1 5 (15,6%) s3 3 0 2 3 8 (25%) s4 0 0 1 0 1 (3,1%) s5 6 2 2 4 14 (43,8%) totaal ' 12 (37,5%) 3 (9,4%) 7 (21,9%) 10 (31,2%) 32 (100%) tabel 6: spraakfoute gevolg deur selfkorreksie by die verskillende klankstruktuurgroepe die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 a v a n d e r m e r w e , i c u y s , j μ l o o t s e n r j g r i m b e e k die prosodiese aspekte wat in hierdie studie nagegaan is, is nog slegs in beperkte mate deur andere ondersoek. kent en rosenbek (1983) het wel op grond van spektrografiese analises waargeneem dat daar min variasie in piekintensiteit oor 'n aantal lettergrepe by verbaal apraktiese sprekers is. die beoordeling van die aspek in hierdie studie was nie in soveel diepte nie. daar is wel waargeneem dat die afwyking in prosodie dikwels vererger het wanneer die proefpersoon die uiting by herhaling korrek kon se. prosodiefoute het, afgesien van 'n enkele uitsondering by proefpersoon 1, slegs by proefpersoon 2, 3 en 4 voorgekom en glad nie by proefpersoon 5 nie. die afwykings in prosodie het by al die klankstrukture voorgekom (kyk tabel 7). dit is dus 'n konstant teenwoordige probleem wat nie konteks-sensitief is nie. dit wil voorkom asof alle afwykings in prosodie nie by alle verbaal apraktiese sprekers voorkom nie. hierdie probleme moet egter met akoestiese tegnieke ondersoek word alvorens enige betroubare afleidings gemaak kan word. gevolgtrekkings die resultate van hierdie ondersoek dui daarop dat verbale apraksie 'n afwyking is wat gekenmerk word deur: — distorsie van klanke wat soms soos vervangings van klanke klink; — afwykings in temporale vloei met veral die afbakening van lettergrepe en verlenging van klanke; —/veranderinge in die struktuur van 'n eenheid met veral 'n neiging om dit te vereenvoudig na 'n kv-eenheid of duplisering daarvan; — vervangings met eenheidsklanke van veral konsonante; —/afwykings in die vlotheid van spraak; -4 pogings tot selfkorreksie van klankvervangings; en τafwykings in die prosodiese eienskappe van spraak; al die simptome kom nie in dieselfde mate by al die-verbaal apraktiese sprekers voor nie. 'n verdeling van die simptome op grond van konteks-sensitiwiteit dui daarop dat distorsie van klanke, lettergreepafbakening en ook onkonstantheid in produksie, kernprobleme van verbale apraksie weerspieel. vervangings, byvoegings en weglatings wat konteks-sensitief is, is moontlik geassosieerde simptome en kompensatoriese strategiee om die kompleksiteit van 'n uiting te verminder. dit wil voorkom asof die verbaal apraktiese spreker 'n onderliggende onvernioe het om konstant die kritiese temporale en ruimtelike ewivalensiegrense van spraakbewegings te bereik, spraakklanke viiinig en onveranderlik vooruit te voer en om spraakuitings—vooruit te beplan. die verbaal apraktiese spreker is wel bewus van sy probleem en poog om die spraakuitings te vereenvoudig. die resultate van hierdie ondersoek dui verder ook daarop dat verbale apraksie voorkom na verworwe breinskade, maar dat 'n aangebore onvermoe om spraak te beplan, wel ook kan bestaan. erkennings geldelike bystand van die raad van geesteswetenskaplike navorsing vir hierdie ondersoek, word hiermee erken. verwysings aten, j.l., darley, f.l., deal, j.l. en johns, d.f. comment on a.d. martin's "some objections to the term apraxia of speech". journal of speech and hearing disorders, 40, 416—420, 1975. buckingham, h.w. explanation of apraxia with consequences for the concept of apraxia of speech. brain and language, 8, 2 0 2 2 2 6 , 1979. chusid, j.g. correlative neuroanatomy and fanctional neurology, 15de uitgawe, los altos, california: lange medical publications, 1973. collins, m., rosenbek, j.c. en wertz, r.t. spectrographic analysis of vowel and word duration. journal of speech and hearing research, 26, 2 2 4 2 3 0 , 1983. crompton, a. timing patterns in french. phonetica, 37, 205—234, 1980. darley, f.l., aronson, a. en brown, j. motor speech disorders. philadelphia: saunders, 1974. deal, j.l. en darley, f.l. the influence of linguistic and situational variables on phonemic accuracy in apraxia of speech .journal of speech and hearing research, 15, 639—653, 1972. dunlop, j.m. en marquardt, t.p. linguistic and articulatory aspects of single word production in apraxia of speech. cortex, 13, 17-29, 1977. edwards, m.l. en shriberg, l.d. phonology: applications in communicative disorders. california: college-hill press, 1983. guyard, h., sabouraud, o. & gagnepain, j. a procedure to differentiate phonological disturbances in broca's aphasia and wernicke's aphasia. brain and language, 13, 19—30, 1981. hughes, o.m. en abbs, j.h. labial-mandibular coordination in the production of speech: implications for the operation of motor equivalence. phonetica, 33, 199—221, 1976. itoh, m., sasanuma, s. en ushijima, t. velar movements during speech in a patient with apraxia of speech. brain and language. 7, 227-239, 1979. itoh, m. en sasanuma, s. articulatory movements in apraxia of speech. in j.c. rosenbek, m.r. mcneil en a.e. aronson |reds.| apraxia of speech: physiology, acoustics, linguistics, management. california: college-hill press, 1984'. jakobson, r., fant, c.g.m. en halle, m. preliminaries to speech analysis. massachusets: mit press, 1967. jakobson, r. studies on child language and aphasia. paris: mouton, 1971. , ^ johns, d.f. en darley, f.l. phonemic variability in apraxia of speech. journal of speech and hearing research, 13, 556—583, 1970. keller, e. parameters for vowel substitutions in broca's aphasia. brain and language, 5, 265—285, 1978. kent, r.d. en rosenbek, j.c. prosodie disturbance and neurologic lesion. brain and language, 15, 259—291, 1982. kent, r.d. en rosenbek, j.c. accoustic patterns of apraxia1 of speech. journal of speech and hearing research, 26, 231—249, 1983. ' • la pointe, l.l. en johns, d.f. some phonemic characteristics i in apraxia of speech. journal of communication disorders, .8, 2 5 9 2 6 9 , 1975. i la pointe, l.l. apraxia of speech and its management. ongepubliseerde referaat voorgedra by die agste jaarlikste kursus in gedragsneurologie en neuropsigologie, florida, v.s.a., 1982! martin, a.d. some objections to the term apraxia of speech. journal of speech and hearing disorders, 39, 53—64, 1974. \ " , miceli, g., gainotti, g., caltagirone, c. en masullo, c. some aspects of phonological impairment in aphasia. brain and language, 11, 159-169, 1980. rosenbek, j.c. apraxia of speech — relationship to stuttering. journal of fluency disorders, 5, 233—254, 1980. shankweiler, d.p. en harris, k.s. an experimental approach to the problem of articulation in aphasia. cortex, 2, 277—297, 1966. trost, j.e. en canter, g.j. apraxia of speech in patients with broca's aphasia: a study of phoneme_production accuracy_ and error patterns. brain and language, 1, 63—79, 1974. van der merwe, a. die motoriese beplanning van spraak/by verbale apraksie. ongepubliseerde d.phil-verhandeling. universiteit van pretoria, 1986. van der merwe, α., uys, i.c., loots, j.m. en grimbeek, r.j. die invloed van sekere kontekstuele faktore op die ouditief waarneembare foute by verbale apraksie.' die suid-afrikaanse tydskrif vir kommunikasieafwykings, 34, 10—22, 1987. wertz, r.t., la pointe, l.l. en rosenbek, j.c. apraxia of speech in adults: the disorder and its management. orlando: grune & stratton, inc., 1984. \ the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e comprehension o f deictic terms in normal a n d l a n g u a g e i m p a i r e d children michelle mentis, b . a . ( s p . & η . t h : ) ( w i t w a t e r s r a n d ) department speech therapy and audiology, groote schuur hospital, cape town summary this study examined the comprehension of four pairs of deictic terms in a group of language impaired children and compared their interpretation of these terms with those of non-language impaired children of the same age range. each group was comprised of ten subjects within the age range of 9,6 to 10,6 years. two tasks were administered, one to assess the comprehension of the terms here, there, this, and that and the other to assess the comprehension of the terms, come, go, bring and take. the results showed that while the non-language impaired subjects comprehended the full deictic contrast between the pairs of terms tested, the language impaired group did not. a qualitative analysis of the data revealed that the language impaired subjects appeared to follow the same developmental sequence as normal children in their acquisition of these terms and responded by using the same strategies that younger non-language impaired children use at equivalent stages of development. furthermore, the language impaired subjects appeared to comprehend the deictic terms in a predictable order based on their relative semantic complexity. opsomming hierdie studie ondersoek die verstaanbaarheid van vier pare diektiese terme in 'n groep taalversteurde kinders en vergelyk hulle interpretasie van hierdie terme met die van normale kinders in dieselfde ouderdomsgroep. elke groep is saamgestel uit tien proefpersone in die ouderdomsgroep van 9,6 tot 10,6 jaar. twee take is aan hulle gestel, om hulle begrip van die terme: hier, daar, hierdie en daardie en kom, gaan, bring en neem/vat vas te stel. in die eerste taak is van die kinders verwag om volgens instruksie een van 'n diere paar te beweeg, en in die tweede, moes hulle die "spreker" en die "aangespreekte" uitken. resultate het aangetoon dat terwyl die normale kinders die diektiese kontras tussen die paar terme wat getoets is, verstaan, die taalversteurde kinders, dit nie begryp het nie. 'n kwalitatiewe analise van die data het aangedui dat die taalversteurde kinders skynbaar dieselfde ontwikkelings-volgorde, as dii van normale kinders in die aanleer van hierdie terme volg, en dat van dieselfde strategiee as die van jonger normale kinders met 'n ooreenstemmende ontwikkelingsvlak, gebruikgemaak is. dit het geblyk dat die taalversteurde kinders die diektiese terme in 'n voorspelbare volgorde, gebaseer op die terme se relatiewe semantiese kompleksiteit, verstaan. deixis has been defined as "the term for linguistic devices that anchor the utterance to the communicative setting in which it occurs". 1 4 deictic terms are used to point out a particular object, position or direction in relation to the speaker, and can only be interpreted in the actual context of such utterances, with reference to the specific characteristics of the spatio-temporal conditions which exist at the moment of utterance. 1 1 in fact, ingram, as cited by r e e s , 1 4 states that "deictic features handle the fact that language is used to communicate between speakers and hearers". as such, it is intimately bound to the area of pragmatics which occupies the interface between linguistic, cognitive and social development. 1 4 the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) comprehension of deictic terms 93 traditionally deixis has been divided into three categories: time, person and place deixis. place deixis, the concern of the present study comprises devices for expressing the speaker's view of his position relative to the listener and other surroundings.1 4 examples of these are the locational adverbs here and there, the demonstrative adjectives this and that, and the verbs come, go, bring and take. there are three factors that contribute to the underlying complexity of deictic terms. 4 ' 6 ' 1 3 these are that: deictic terms all have a point of reference; they involve a shifting reference; and they have shifting boundaries. the normal point of reference for deictic terms is the speaker, e.g. here locates the place near the speaker as opposed to the place further away (there) and this locates an object near the speaker and that an object away from the speaker. here and this are thus proximal with respect to the point of reference, while there and that are nonproximal. from this it can be seen that the perception of deictic contrasts involves the mastery of two principles: the speaker principle which indicates that the speaker is the point of reference; and the distance principle which indicates that each pair of terms contrasts on the distance dimension.6 the fact that all deictic expressions involve a shifting reference indicates that the meaning of these terms varies depending on who is speaking at that particular time. it is because all deictic terms involve shifting reference that the speaker principle is difficult to master. 6 however, the reference of here and there not only shifts with every change of speaker, but in addition to this shifts with every change of position of each speaker. here locates the speaker's place which may or may not include the listener's place. if it does not, then the location of there also shifts with every change of listener. thus there shifts reference even more than here. the more shifting a term involves, the harder it is for the child to master. thus as the non-proximal terms (there and that) shift more than the proximal ones, they are more difficult to acquire.4' 6 ' 7 furthermore, it has been suggested that the difference in the amount of shifting between the terms predisposes children to treat both terms of a pair as if they were proximal.6 the distance principle may be considered to be difficult to acquire because of the shifting boundaries of deictic terms. this refers to the fact that the physical space located by the word here differs according to the context in which it is used. thus here may be used to indicate the precise spot on the floor where the speaker is standing (here where i am) or the room he is in (here in the study). the context of discourse thus determines the distance that will be referred to. the foregoing discussion illustrates the fact that in order for spatial deictic terms to be understood, the hearer must not only know the speaker's position in space and his point of view, but must also understand the context of the utterance. furthermore, he needs to know whether his own position and point of view differs from that of die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28,1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 94 michelle i the speaker. the differing levels of complexity for spatial deictic terms are represented in table i. table i: degree of complexity of spatial deictic terms deictic terms degree of complexity 1. here — there speaker and place 2. this — that speaker and place and object 3. come — go speaker and place and object and movement 4. bring — take speaker and place and object and movement and cause it has been suggested that the true deictic contrast between pairs of deictic terms is acquired through a process in which semantic features are added to the words until the adult meaning is attained. 1 6 this is in accord with clark's 2 , 3 · 9 semantic feature hypothesis (sfh). the acquisition of the deictic verbs come/go and take/bring has been found to be compatible with that predicted on the basis of the relative semantic complexity of the four deictic terms. 5 however, recent studies indicate that the positive, marked terms here and this are acquired earlier than their negative, unmarked counterparts there and that. 6 · 1 6 this result shows that semantic markedness is not applicable to the acquisition of polarity for these terms. this discrepancy has been explained in terms of the fact that children rely on non-linguistic strategies in interpreting the meanings of words and that for the deictic pairs herelthere and this/that, the non-linguistic strategy coincided with the negative marked member of the pair, and not, as is usually found, with the positive, unmarked member. 5 ' 6 ' 1 6 in the course of working out the contrast between deictic terms, children apply different strategies which are the outcome of their changing hypotheses about the meanings of the words. the acquisition of such contrasts has been shown to be characterized by three stages: no contrast, where the children usually use only one of the deictic pair to represent both situations; partial contrast where the other word in the deictic pair is used but only partially or incorrectly contrasted to its counterpart, and then finally the full contrast where the true deictic contrast is perceived.4' 5 ' 6 to the present writer's knowledge, no research has been undertaken to date on deictic comprehension in language-impaired children. since, as demonstrated above, deixis appears to be a rich area for characterizing the pragmatic capabilities of the child and for examining the different stages of acquisition, the potential contribution to the study of language impairment is felt to be great. in particular, this aspect may the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) comprehension of deictic terms 95 be sensitive to the language difficulties of the older child whose problems so often manifest at the level of pragmatics. the present study was thus undertaken to compare the comprehension of deictic expressions in normal and language-impaired children. m e t h o d o l o g y aim to examine the comprehension of deictic terms in a group of languageimpaired children and compare their interpretation of these terms with those of non-language impaired children of the same age range. for the purposes of this study the following contrasting pairs of place deixis were chosen: here — there, which differentiate between the place where the speaker is as opposed to where he is not; this — that, which differentiate between something in the same location of the speaker and something in a different location; come — go, which differentiate between the movement of a person or object towards or away from the place where the speaker is, was or expects to be; and bring — take, which are the causative counterparts of the terms come — go. hypotheses 1. whereas the non-language impaired children will comprehend the full deictic contrast between the pairs of terms, the language impaired children will not. 2. although the language impaired children will be delayed in their comprehension of these terms, they will employ the same series of strategies in dealing with the tasks as the non-language impaired children. 3. the language impaired children will comprehend these terms in a predictable order based on the semantic complexity of the terms and according to acquisition in non-language impaired children.5' ' subjects two groups of subjects (ss) comprising an experimental (e) group of ten language impaired children and a control (c) group of ten non-language impaired children were selected. on the basis of a pilot study, the age range was between 9, 6 and 10, 6 years. all ss came from white, english-speaking, middle class south african homes. they were required to be of average intelligence and to have hearing within normal limits. due to the visual nature of the task, ss were also required to have no visual spatial problems as assessed by the occupational therapists attached to the remedial schools. tasks taskl to assess the comprehension of the deictic terms here/there and this/that. (based on a study designed by clark and sengul6). testing die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) michelle mentis was carried out under two conditions: (a) with the tester and child seated at a table beside each other (same perspective) and (b) with the tester and child seated at a table opposite each other (different perspective). child tester figure la: testing situation used for task 1: condition a tester * — 62cm 15cm j — η ο o 15cm 62cm child figure lb: testing situation used for task 1: condition b one pair of identical toy animals was placed on the table for each instruction. the task was introduced as a game in which the s had to decide which of two toy animals moved. on each trial the tester placed a pair of animals on the table, named them alternately and asked the child to look at them both. instructions such as "make the dog over there turn around" or "make this chicken hop" were then given and the s was required to respond by making one of the animals move. there were eight practice trials, one for each combination of word and condition followed by thirty-two test trials. ' task 2 to assess the comprehension of the deictic terms come/go and bring/take. (based on a study designed by clark and garnica5). each the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) comprehension of deictic terms 97 child was seated next to the tester at the table with a display board on which was placed a model house, pool, barn and garden. (these models will be referred to as goals.) for each instruction, one set of three animals was arranged on the board as if at the points of a roughly equilateral triangle with one point inside one of the goals and the other two outside as shown in figure 2. the three animals on the points all faced each other. with bring and take the appropriate animal carried a small object. the task was introduced as a game in which various animals lived on a farm and in which all the animals could speak to each other. each child had to tell the tester which animal was talking or to whom a particular animal was talking — i.e. identify either the speaker or addressee. each of the four deictic verbs come, go, bring and take were used in each of four situations. in two of the situations the child had to identify the speaker (sp. 1 and sp. 2) and in the other two, had to identify the addressee (ad. 1 and ad. 2). on each trial the tester placed the three animals in their appropriate position, named them and the goal and then gave the child instructions such as 'which animal can say to the lion: "come into the h o u s e ? ' " or 'the pig says: "can i come into the b a r n ? ' " which animal is he talking to? the child was then required to identify either the speaker or the addressee. there were four practice trials, one for each verb in each of the four situations followed by forty-eight instructions, twenty-four with come and go and twenty-four with bring and take. a n a l y s i s o f r e s u l t s for task 1 each s's responses were scored as correct or incorrect according to which animal they moved. for task 2 each s's responses were scored as correct or incorrect according to the choice of animal as speaker or addressee. results of both tasks were analysed on an overall basis as well as on an individual task basis. the data were subjected to both statistical and qualitative analysis. results a n d discussion t a s k 1 a summary of mean scores and percentages of semantically correct responses produced by each group can be seen in table ii. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 98 michelle i table ii mean scores and percentages of semantically correct responses produced by each group on task 1. ' deictic term speaker beside speaker opposite c ε c ε x % x % x % x % here 4 100 3,8 95 4 100 1,4 35 there 4 100 2,2 55 4 100 2,5 62,5 here there 8 100 6 75 8 100 3,9 48,75 this 4 100 3,9 97,5 3,7 92,5 1,1 27,5 that 4 100 1,8 45 4 100 2,8 70 this that 8 100 5,7 71,25 7,7 96,25 3,9 48,75 table iii mean scores of semantically correct responses to proximal and distal terms in each of the two situations (task 1) deictic term speaker beside speaker opposite here — this 7,7 2,5 there — that 3,3 5,3 table iv: number of ss that fell into each category for each pair of terms (task 1) here — there this — that no contrast partial contrast full contrast no contrast partial contrast full contrast ε 4 4 1 4 4 1 c 0 0 10 0 0 / 10 all ss in group c perceived the full deictic contrast between both pairs of terms in both situations, and were thus considered to have mastered both the speaker and the distance principles. these results support the first aspect of h j . ss in group ε did not perceive the full deictic contrast between the pairs of terms tested in either situation. these results fully supported the second aspect of h j . the percentage of correct responses varied according to the specific term used and the situation in which it was the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) comprehension of deictic terms 99 used. this was in accord with the prediction ( h 3 ) that the ss woul comprehend the full meaning of each term in a predictable order based on the semantic complexity of the terms and the order of acquisition in non-language impaired children. thus in the "speaker beside" situation group ε ss obtained a higher mean score for the linguistically simpler deictic pair here—there than for the pair this—that (t = 8; η = 10; ρ < 0,025) and for the linguistically simpler proximal terms (there & that) (τ = 0; ν = 10; ρ < 0,005). however, in the "speaker opposite" situation ss obtained similar scores for both pairs of deictic terms (t = 10; ν = 10; not significant) and as can be seen in table ii were more often correct for the non-proximal terms (t = 6; ν = 10; ρ < 0,025). a reason for the ss obtaining similar scores for both pairs of deictic terms may be that the task in this situation was a more complex one as it required full perception of the deictic contrast. correct responses to both pairs of terms was dependent on the ss' ability to take the speaker's perspective and was thus dependent on mastery of the speaker principle. with respect to the ss being more often correct on the non-proximal terms, it was felt that this was not a result of their comprehending the true meaning of the terms there and that but rather a result of their overextended use of the proximal terms. thus if the ss responded to both terms as if they meant closer to the child, then in the speaker opposite situation, the ss would respond incorrectly to the proximal terms but correctly to the non-proximal ones. this is then in accord with the hypothesis ( h 3 ) that the semantically simpler terms are acquired before their more complex counterparts. this phenomenon of overextension occurs when the meaning of one member of a pair of terms is extended to cover both words, and has been frequently cited as occurring during the initial stages of semantic development of relational terms and adjective pairs. 1 , 1 5 in the present study the phenomenon of overextension was evident in the responses of all ss in group ε at the most primitive level of comprehension of deictic terms i.e. the no contrast stage. this provides support for h 3 as the language impaired ss were responding in a similar way to that reported in younger non-language impaired children at an equivalent stage of semantic development. in order to analyse what strategies the ss were using in responding, the data for each child was studied qualitatively. it was felt that an analysis of the strategies the ss used in interpreting the words would provide the writer with insight into what hypotheses they had formed about the meaning of the words. the ss were calssified into groups on the basis of their individual response patterns in the manner adopted by clark and sengul.6 they divided the response patterns they obtained into three distinct categories: no contrast, partial contrast and full contrast. their results indicated that these categories were a function of the ages of their ss and that they thus represented three ordered stages of acquisition in die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 100 michelle i normal children. the ss in this study were grouped according to these stages. all group c subjects were at the full contrast stage whereas only one s in group ε perceived the full deictic contrast. four of the ss in group ε were at the no contrast stage, and the other four ss were at the partial contrast stage. these results support h j (see table iv). a consideration of these patterns and strategies indicated that the ss followed two basic routes in comprehending the full deictic contrast. those ss taking the child-centered route relied on the strategy of choosing the animal nearest themselves and those ss taking the speaker centered route relied on the strategy of choosing the animal nearest the speaker. ss in group ε who appeared to be functioning at the no contrast , and partial contrast stages appeared to use the strategies younger nonlanguage impaired children use in their acquisition of deictic terms.6· 1 6 this supports h 2 and is consistent with what has been previously reported on the language development of language-impaired children. it has been shown that the behaviour of language-impaired children is rule governed and that although delayed, follows the same development sequence of normal children. 1 0 ' 1 2 in further support of this prediction, it appeared that nine ss in group ε were developing comprehension of the full deictic contrast through stages in which semantic features were added in a hierarchical order in accord with clark's s m h . 3 this is consistent with what has been reported on the semantic development in non-language impaired children.2' 8 task 2 a summary of mean scores and percentages of correct responses produced by each group can be seen in table v. table v : mean scores and percentages of correct responses produced by each group (task 2) come go come go bring take bring take x % x % x % x % x % x % c 12 100 11,2 93,3 23,2 96,6 11,5 95,8 11,9 99,2 23,4 97,5 ε 10,5 87,5 3,2 26,6 13,7 57,1 10,1 84,1 4 33,314,1 58,75 whereas all ss in group c perceived the full deictic contrast between both pairs of terms, ss in group ε did not. these results support hi. the percentage of correct responses in group ε varied according to the specific term used. although it was postulated that the semantically simpler verb pair come—go would be acquired before its more complex causative counterpart bring—take ( h 3 ) , this view was not supported (t = 21; ν = 10; not significant). this result may be the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) comprehension of deictic terms t a b l e vi: number of ss that fell into each category for each pair of terms (task 2) come — go bring — tak 0 no contrast partial contrast full contrast no contrast partial contrast full contrast ε 7 2 0 5 4 0 c 0 1 9 0 0 10 explained in terms of the relative frequencies of use of the deictic verbs in the south african english dialect with the assumption that the more frequent terms are easier to learn because the child will have greater exposure to them. this would be in accordance with the view that external environmental factors influence language acquisition.1' 7 ss in group ε made significantly fewer errors on the semantically simpler positive pair come—bring than they did on the semantically more complex negative pair go—take (t = 4; ν = 10; ρ < 0,01). these results provide support for h 3 and are consistent with the claim that positive unmarked members of word pairs are acquired first.9 however, this is in contrast to the fact that the proximal pair here and this have been discussed as being linguistically simpler and acquired earlier than the non-proximal pair there and that even although the non-proximal pair represent the positive unmarked terms while the proximal pair represent their negative marked counterparts.6' 1 this may be explained in terms of the fact that the ss were responding on the basis of non-linguistic strategies (for example the proximity and egocentric bias) and these were compatible with the negative marked terms rather than with the positive unmarked ones. in the above instances however, it can be argued that the non-linguistic response biases corresponded with the positive unmarked terms. the data for each child was classified into the following groups on the basis of their correct responses: no contrast; partial contrast and full contrast these categories were based on the results obtained by clark and garnica5 who statistically revealed that the categories were age based and hypothesized that they represented the normal stages of acquisition of these terms. all group c ss fell into the full contrast category for the verbs come and go, while nine of the ten group c ss fell into the full contrast category for the verbs bring and take. the other s fell into the partial contrast category for these verbs. group ε ss fell into the no contrast and partial contrast categories. for the verbs come and go, seven ss fell into the no contrast category while two ss fell into the partial contrast category. for the verbs bring and take, five ss fell into the no contrast category while four ss fell into the partial contrast category. these results support h, (see table vi). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 102 michelle i as with task 1, ss in group ε who appeared to be functioning at the no contrast and partial contrast stages appeared to use the strategies younger non-language impaired children use in their acquisition of deictic verbs.5 this supports h 2 . conclusion results from the statistical and qualitative analysis of the data indicated that the language impaired ss were delayed in their comprehension of deictic terms in comparison with the non-language impaired ss. these results fully supported the first hypothesis. group c contained a higher overall mean score for the comprehension of all deictic terms tested (9,8) than did group ε (5,82). (u = 0; n j = n 2 = 10; ρ < 0,001). a qualitative analysis of the data revealed that although the language impaired ss were delayed in their use of these terms, they appeared to follow the same developmental sequence as normal children, passing through the stages of no contrast and partial contrast before perceiving the full deictic contrast. in support of the second hypothesis it was found that the language impaired ss primarily used the same strategies in responding that non-language impaired children use, and exhibited the developmental errors previously observed in younger normal children. 5 · 61 6 the third hypothesis predicted that the language impaired ss would comprehend the deictic terms in a predictable order based on the semantic complexity of the terms and according to acquisition in non-language impaired children. in support of this hypothesis it was found that ss in group ε obtained significantly fewer errors on a predictable member in each pair of terms. however, there was no significant difference between the comprehension of each pair of deictic terms. h 3 was thus only partially supported. the findings of the present study indicated that the language impaired children tested were having problems on a semantic level. this suggests that the current academic interest in semantics should be extended to diagnostic testing and the planning of therapy. furthermore, in view of the dearth of tests for the assessment of older language impaired children, tests involving the comprehension of deictic terms would be a useful part of diagnostic assessment. references / 1. campbell, p. and wales, p. 1(1977): the study of language acquisition, chap. 13 in new horizons in linguistics, lyons, j., (ed.), penguin books ltd., harmondsworth, england. 2. clark, ε. v. (1971): on the acquisition of the meaning of before and after. / . verb. learn. verb. beh., 10, 266-275. 3. clark, ε. v. (1973a): what's in a word? on the child's acquisition of semantics in his. first language in cognitive the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) comprehension of deictic terms 103 development and the acquisition of language, moore, τ. e . , (ed.), academic press, new york. 4. clark, ε. v. (1978): from gesture to word: on the natural history of deixis in language acquisition, chap. 4 in human growth and development. wolfson college lectures 1976 bruner, j. s. and garton, a. (eds.), oxford university press, oxford. 5. clark, ε. v. and garnica, ο. k. (1974): is he coming or going? on the acquisition of deictic verbs. j. verb. learn. verb. beh., 13, 556-572. 6. clark, e. and sengul, j. (1978): strategies in the acquisition of deixis. / . child. lang., 5, 457-575. 7. de villiers, p. a. and de villiers, j. g. (1974): on this, that, and the other. nonegocentricsm in very young children. j. exp. ch. psych., 18, 438-447. 8. de villiers, p. a . and de villiers, j. g. (1978): the development of word meaning. chap. 5 in language acquisition, harvard university press, cambridge. 9. donaldson, m. and balfour, g. (1968): less is more. a study of language comprehension in children. brit. j. psychol., 59, 461-471. 10. lackner, j. r. (1976): a development study of language behaviour in retarded children. in normal and deficient child language. morehead, d. m. and morehead, a. e. (eds.), university park press. 11. macrae, a . j. (1976): movement and location in the acquisition of deictic verbs. j. child lang., 3, 191-204. 12. morehead, d . m. (1976): the development of base syntax in normal and linguistically deviant children. in normal and deficient child language. morehead, d. m. and morehead, a. e. (eds.), university park press, baltimore. 13. olson, d. r. (1977): the contexts of language acquisition. chap. 13 in language learning and thoughts. macnamara, j. (ed.), academic press, new york. 14. rees, n. s. (1978): pragmatics of language. applications to normal and disordered language development. chap. 5 in bases of language intervention. schiefelbusch, r. l. (ed.), university park press. baltimore. 15. townsend, d. j. (1976): do children interpret "marked" comparative adjectives as their opposites? / . child lang., 3, 385-396. 16. webb, p. a. and abrahamson, a. a. (1976): stages of egocentricsm in children's use of "this and that". a different point of view. / . child lang., 3, 349-367. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a i d s for • t h e d e v e l o p m e n t of p e r c e p t i o n • t h e a c q u i s i t i o n of s p e e c h a n d l a n g u a g e skills • t h e i m p r o v e m e n t of m o t o r c o o r d i n a t i o n plus • helpful t e x t s for t h e r a p i s t s • e d u c a t i o n a l toys, b o o k s a n d e q u i p m e n t • r e c o r d s for a u d i t o r y t r a i n i n g • c a t a l o g u e s o n r e q u e s t • l a r g e v a r i e t y of tests a v a i l a b l e s t o c k i s t s o f • learning to listen • t w o sound lottos • full lda range play and schoolroom 8 t y r w h i t t a v e n u e , r o s e b a n k ( a d j o i n i n g t h e c o n s t a n t i a c i n e m a ) t e l e p h o n e s : 7 8 8 1 3 0 4 p . o . b o x 52137^, s a x o n w o l d , 2 1 3 2 ο m the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language intervention at schools: changing orientations w i t h i n the s.a. context 9 language intervention at schools: changing orientations within the south african context erna alant, d phil (pretoria) department of speech pathology and audiology, university of pretoria abstract the role of the speech therapist in the school has changed drastically over the last decade. the reasons for these changes originate from a growing realisation of the importance of contextualising intervention within a particular community. this article aims at providing an analysis of the present school population in south africa with specific reference to the black schools as a basis for discussion on the role of the speech and language therapist within this context. the problems of second language learning and teaching are highlighted and the role of the language therapist as a consultant within the black school system is emphasized. opsomming die rol van die spraak en taalterapeut binne die skoolkonteks het die afgelope dekade drastiese veranderinge ondergaan. die redes vir hierdie veranderinge spruit uit 'n groeiende bewuswording van die belangrikheid van die kontekstualisering van intervensie binne 'n bepaalde gemeenskap. hierdie artikel poogom 'n analisetemaakvan diehuidigeskoolbevolkingvan suid-afrika met spesifiekeverwysingna die swart skole as basis vir bespreking van die rol van die spraak en taalterapeut binne hierdie konteks. die probleme van tweedetaalonderrig en -leer asook die rol van die taalterapeut as konsultant binne die swart skoolsisteem word beklemtoon. the role of the speech and language therapist in language remediation has changed drastically over the last decade. these changes are evident in diagnostic and therapeutic intervention and can be seen as,an outcome of the paradigm shift from a traditional medical model of service where the therapist was mainly involved in individual therapy, to a functional or consultative model where the therapist is more involved in the facilitation of the individual's communication within specific functional contexts (marvin, 1987). the n e w pragmatic approach (gallagher et al. 1983) with the strong emphasis on the functionality of language and interaction has forced the therapist to move out of the therapy room and into the classroom or every day environment, as the following quotation illustrates: "we cannot expect to be employed by a school if we only provide limited services within a medical model." (simon, 1987:41.) apart from a n e w theoretical or philosophical orientation, focus on the functionality of language brought with it many more issues that confront the language pathologist. for example, if the aim of language intervention is to improve general communicative competence by alleviating language pathology, what exactly is meant by communicative competence and language pathology? firstly, the therapist has to consider the dynamic nature of the concept of'communicative competence'. a functional orientation towards therapy implies that the therapist has to consider the social context within which individuals interact. she has to be aware of the use of language in different contexts in order to plan relevant intervention goals. being aware of the norms of the broader society (or ruling class) as well as the immediate environment of the individual therefore forms the basis of intervention. the therapist can work in a variety of contexts (daily living, the home and work environment, or the academic context), which pressupposes a thorough understanding of communication skills required within these contexts. effective intervention thus necessitates a sound understanding of the interrelationship between the individual and the society, and the specific contexts within which he functions. only by acknowledging the dynamic nature of society can the concept of communication competence be operationalized. secondly, much emphasis has been placed on sensitising therapists to the difference between language pathology (deviance) and language difference within varied linguistic contexts in order to prevent misdiagnosis of language pathology. once again, this implies an active understanding of the linguistic contexts within which nonstandard language variations are used, the cultural implications as well as the problems involved in communicating within the broader societal context. therapists have to be sensitized to work with both bidialectical and bilingual language situations in an attempt not only to diagnose, but also to plan effective and relevant intervention. although basic to the work of the language pathologist, the issue of what constitutes communicative competence and pathology remains complex and difficult to deal with, especially within the south african context. this article aims to describe some of the broader communication needs within the educational system in south africa in order to facilitate the restrucdie suid-afikaanse tydskrif vir kmmunikasiafykins, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 erna alant turing and reformulation of the role of the language therapist within this context. one of the major difficulties confronting any profession is the need for continuous adaptation of training in order to ensure the creation of relevant skills in the context of a changing society (adler, 1988; uys, 1985). it is therefore difficult to describe the role of the speech and language pathologist without some reference to the context within which these professionals have to function. one of the more controversial issues in the american literature in the last decade, has been the involvement of the speech and language therapist in dealing with children who speak nonstandard languages. this problem did not only lead to much critical evaluation and discussion on the effectiveness of evaluation and therapeutic procedures (taylor, 1986; vaughncooke, 1986), but also highlighted the language needs of these children. in this regard, asha (1983) stated that "speechlanguage pathologists may also be available to provide elective clinical service to nonstandard language speakers who do not present a disorder." sol adler (1985), however, describes the approach taken by asha as a "do nothing" or laissez-faire strategy that is totally unacceptable as he believes that the therapist should be involved in the facilitation of bidialectism within the school context. the urgency of this appeal stems from the many research studies (edwards, 1979; taylor, 1986) which confirm the disadvantaged position of these children when entering the school context. this disadvantage also extends to the employment situation when the children are not able to familiarize themselves adequately with the standard language used within a particular society (edwards, 1979; terrell et al. 1983). an equally important assertion by adler (1985) in answer to the position paper of asha (1983) is that the focus on the linguistic aspects of bidialectism and bilingualism detracts from the importance of a sound cultural understanding when working within any communication context. many authors stress the interrelationship between communicative competence in language and understanding of the social context within which that language functions, which supports the issues raised by adler in this regard (e.g. chick, 1987; trudgill, 1987). to become a bidialectical or bilingual speaker involves much more than learning the rules of a particular language. various authors (taylor, 1986; westby and rouse, 1985) in the field of bilingual education have stressed the importance of cultural education in an attempt to enhance bilingualism. for example, the importance of the cultural context in evaluation and remediation is highlighted by taylor (1986:1 1) in the following statement "... the study of normal and pathological communication must be couched ifi cultural terms. to do otherwise is to run the risk of making claims and judgements about the communicative behaviours of a given group of speakers from an inappropriate or, even worse, an ethnocentric set of assumptions and norms." t h e role of the school therapist within an american context it may be useful in attempting to find our bearings in the south african situation to examine the role of the school therapist in the united states. sensitivity to the social context within which the child functions demands that the role of the therapist has to be dynamic in order to comply with the orientations and pressures experienced within a particular school context (marvin, 1987). simon (1987:41) elaborates on this point by stating that "... most change is the result of economic factors. when school districts find they are using 26% of the budget to service 10% of the school population, current practices are scrutinized." it is therefore important that the therapist critically evaluates her own role in the school context and improves her accountability by identifying the most pressing needs of the children in the school and developing the most effective methods for reaching the largest number of children. recent awareness of the therapist's role in nonstandard language as well as the learning disabled contexts stems from a growing realisation of the important role of language within the learning process. the realisation that many students are not successful learners and that there are obvious differences in how children from different social, ethnic and linguistic backgrounds experience the educational set-up contributed to the "rediscovery" of the role language proficiency plays in the educational process (damico, 1987:17). at the same time, the unease many educators displayed when the topic of languageacross-the curriculum was discussed highlighted the fact that "few teachers have the academic background, practical experience and professional freedom to address language-related issues by themselves. consequently language issues are overlooked and children with language differences suffer a variety of abuses within the educational system." (damico, 1987:17.) according to damico (1987) the most likely professional to confront the concerns, abuses and other language related issues in the school is the speech and language pathologist. he emphasizes that the role of the language therapist should be that of a "language specialist" and she should have the flexibility to interact with students and teachers without being tied to a caseload or schedule. this role would involve that the therapist be available to the rest of the school as a consultant on problems relating to language and its impact on classroom activities, testing procedures, culturally diverse populations and other issues. this consultancy would not only involve discussing individual children with the class teacher, but helping to facilitate the student's mastering of the demands made by the school, particularly with regard to the medium of instruct tion or standard language. "no matter what activities are targetted, language is the delivery medium of instruction. u n | less students understand the language, they will not benefit from the instruction." (comkowycz et al. 1987.) ' j ι to facilitate the interaction of the child in the classroom there-1 fore necessitates a closer look at the cultural context and' mother-tongue of the children involved, to ensure that intervention is relevant. it is against this background that the educational context within which the speech and language therapist has to work within south africa will be discussed. the emphasis in the article is on mainstream education although the same issues apply to the special education context. ' t h e educational context in south africa in order to provide some basis from which the speech and language therapist's role in the educational process in south africa can be evaluated,a description of the school context is the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language intervention at schools: changing orientations w i t h i n the s.a. context 11 essential. this will be done by looking at three different aspects: a description of all the children at school in south africa during 1988 according to their race in order to get an overall view of the school population. a description of the different languages used by staff and students in the black schools in 1987. a description of the language used most frequently as the medium of instruction in black schools in 1987. figure 1: pupils to population group for 1 9 8 8 including self-governing states *data obtained from dept of national education (nated 02-214) table 1: mother-tongue language used by students and staff in primary schools in det for 1 9 8 7 * language ! students staff zulu 1 395 090 27 675 / n sotho 649 263 16 633 s sotho 386 547 9 503 xhosa 365 644 9 459 tsongo 286 604 6 485 tswana 215 869 6 576 swazi 183 992 4 444 s ndebele ι 102 683 374 ν ndebele | 33 531 2 091 venda \ 14 316 328 english/afrikaans & other · 124 * data obtained from det annual report (1987) from figure 1 it is clear that the majority of the school-going population in south africa (70,00%) is black, with white children accounting for only 14,41% of the overall population. this paper will therefore concentrate only on this majority group in order to highlight specific issues. one of the major issues in the black school context relates to the different languages used as mother-tongues within this population. table 1 gives some indication of the number of students speaking a particular mother-tongue. it is clear from this table that the diversity of languages poses a problem in terms of which language should be used as the medium of instruction within black schools. the major arguments for and against mother-tongue education will not be discussed here, but the reader can consult reagari (1986) for a summary of the debate. for the purpose of this article it will suffice to quote from the department of education and training's annual report for 1987 in relation to their policy as regards the medium of instruction (det annual report 1987:51.) "from substandard a up to the end of standard 2, the medium of instruction is the pupil's mother-tongue. in substandard β the teaching of one of the official languages is introduced: that is afrikaans or english, according to the parent's choice. the teaching of whichever official language was not chosen in substandard β commences in standard 1. as from standard 3 the medium of instruction is the mother-tongue or one of the two official languages, as decided by the governing body of the school. special attention is given to the official language which serves as medium of instruction. increasingly, the teaching of this language will "cut across the complete curriculum", so that the language becomes an effective medium of instruction. irrespective of the language being used as the medium of instruction, the mother-tongue and the second official language are offered as subjects." from this passage, it becomes clear that firstly the second language that will become the medium for instruction of the school is introduced after one year of schooling (sub b) and is used across the curriculum after three years of exposure to this language. secondly, the mother-tongue is continued in the form of a subject in the school curriculum. apart from an acknowledgement and acceptance of the child's home language, this could reflect a sensitivity in the system towards the "interdependency principle" (kessler, 1984; mcdonald, 1988) which stresses the importance of the development of the first language for the acquisition of the second language. from table 1 it is also clear that a very small percentage of teachers in the det are mother-tongue speakers of english with the majority speaking zulu as their home language. figure 2 provides a clear picture of the languages used as medium of instruction in primary schools. figure 2: enrolment according to medium of instruction in primary schools in det for 1 9 8 7 * * data obtained from det annual report (1987) die suid-afrikaanse tydskrif vir kommunikasicafivykinys, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 erna alant it is clear that english is the language most commonly used as the medium of instruction, followed by relatively small percentages of a range of other languages. in addition all secondary schools (with only few exceptions) also use english as the medium of instruction. in this regard, johanson (1988) states from observation of students at the university of bophuthatswana that english was widely used, and that only 27% of student communication recorded took place in the mother-tongue. the mother-tongue was mainly used in communication with parents and elderly people, and in community gatherings, churches and courts. in its pure form, the mother-tongue is very seldom used. instead mainly a mixture of languages is used in daily interaction. she concludes that english plays an important, but essentially academic role, and is a lingua franca among the educated and sophisticated. "its importance cannot be questioned, but it is by no means a language of the masses:" (johanson, 1988:2.) obviously, any generalization is problematic, but it seems reasonable to conclude that the urban areas would be less mother-tongue orientated than the rural areas. the implication of these observations is that one can assume a great difference in linguistic background between home and school environments, a factor which contributes to a restricted use of english outside of the academic context. the medium of instruction therefore is (for most of the children) learned and acquired within the school environment, with very little support for the use of english in the actual community (alant, 1988; mawasha 1986). t h e role of t h e speech and language therapist in south african schools a number of important points flow from the above analysis: at least 70% of the total school population (excluding coloured, asian and white children speaking a nonstandard language) come from cultural and linguistic contexts which are different from the standard language or prevailing standard english used in south africa. due to various considerations (reagan, 1986) it is important for these students to obtain entrance into the standard english or ruling-class cultural context to facilitate the acquisition of communicative competence within the content. teachers at black schools are mostly teaching in their second language and have limited communicative competency in standard english which not only inhibits and limits teaching, but also causes a high level of frustration. various authors have also suggested a strong relationship between the above issues and the generally poor performance of students at school (odendaal, 1985; hsrc report 1986). when looking at the overall educational set-up in south africa it is clear that therapists should be involved within this context of second language teaching particularly as regards the prevention of learning problems at schools. the mere fact that far more than half of the children in schools have to study through a second or third language with only limited support from their own environments accentuates the problems that arise from the language issue within the school context (lewis, 1988). under the circumstances, what should the involvement of the language therapist be? traditionally the therapist's primary involvement is with the identification and remediation of communication pathology particularly as this pertains to mother-tongue interaction problems. the underlying philosophy of intervention centers around the individual's basic ability to make contact with people in his immediate environment. obviously the importance of mother-tongue proficiency cannot be underestimated, particularly also in view of its importance for second dialect or second language learning. at the same time, the emphasis on functional communication and the acknowledgement that different situations or contexts require different communication skills necessitates that the therapist has a better understanding of the communication demands in specific contexts. the issue centers around the relevance of facilitating communication skills (e.g. mothertongue) in limited contexts only, thus ignoring interactional difficulties and learning problems the individual might encounter in the broader community. this involvement does not, however, imply that the therapist should become a language teacher. various writers have expressed the opinion that the therapist is not a teacher and that she can therefore not be held responsible for the actual teaching of a second language (taylor, 1986; yoder 1970). as therapists have no background in teaching, this argument is valid. of critical importance to the therapist, however, is the student's competency in the language used as medium of instruction in schools, as this is a prime factor in the development of learning problems. in order to prevent as well as remediate language learning problems at school, the therapist has to be involved in the design and planning of language programmes within the school context. to expect the teacher to take full responsibility for the planning of language programmes and the execution of such programmes seems unrealistic, not only because of the complexity of the phenomenon of second language learning, but also because of the teachers' own lack of proficiency in english, the medium of instruction in the majority of schools (mawasha, 1986). damico's assertion that the language pathologist seems to be the most appropriate person to confront the concerns, abuses and other language related issues in the school seems relevant in that the language pathologist has the linguistic background and the sensitivity towards communication contexts to support arid advise the teacher on strategies and methods that might facilitate language performance (damico, 1987.) j the therapist's role as languag^ consultant within the school context should therefore be emphasized. she has to aid in the planning and execution of in-service training programmes for teachers and although not responsible for the teaching of a second language, should participate extensively in helping teachers to facilitate interaction in the classroom by demonstrating certain communication skills and strategies. the therapist should therefore be available to teachers as a language specialist as damico (1987) suggests. the implication of the above for the training of speech and language therapists within south africa is self-explanatory. firstly, students need a firm grounding not only in the development of the mother-tongues, but also in the development of second language skills. obviously, the emphasis oh the development and remediation of the mother-tongue is of prime importance in providing an adequate basis for general interaction skills. the fact that over 70 per cent of children in south the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language intervention at schools: changing orientations w i t h i n the s.a. context 13 africa s t u d y by m e a n s of a s e c o n d l a n g u a g e n e g a t e s t h e possibility t h a t t h e r a p i s t s c a n r e g a r d t r a i n i n g in s e c o n d l a n g u a g e a c q u i s i t i o n a n d skills as a n 'elective' ( a s h a 1983). t h e t r a i n i n g of s p e e c h a n d l a n g u a g e t h e r a p i s t s i n s o u t h africa h a s b e e n closely l i n k e d t o t h e a m e r i c a n m o d e l . h o w e v e r , in t h e l a s t decade, p a r t i c u l a r l y w i t h t h e s t r e s s o n c o m m u n i t y w o r k ( a r o n , 1 9 8 7 ) a n d c o n s u l t a t i o n (uys, 1 9 8 5 ) t h e r e h a v e b e e n definite a t t e m p t s at c o n t e x t u a l i z i n g t h e profession in o r d e r t o i n c r e a s e its r e l e v a n c e t o d e v e l o p i n g c o u n t r i e s . t h e s e a t t e m p t s c a n o n l y be w e l c o m e d , as t h e y reflect a d y n a m i c m o v e m e n t w h i c h is vital in t h e g r o w t h p r o c e s s of a n y profession. o n l y by o n g o i n g self-evaluation a n d d i s c u s s i o n c a n t h e " e l i t i s m " w h i c h often c h a r a c t e r i z e s p r o f e s s i o n s in d e v e l o p i n g c o u n t r i e s be r e d u c e d i n o r d e r to b e c o m e m o r e r e l e v a n t to t h e p e o p l e m o s t in n e e d of i n t e r v e n t i o n . r e f e r e n c e s adler, s. comment on social dialects. asha, 27, 4, 46-47, 1985. adler, s. a new job description and a new task for the public school clinician. lshss, 19, 1, 28-33, 1988. alant, e. the strengths and weaknesses of written english of black high school pupils. per linguam, 4, 1, 16-23, 1988. aron, m.l. community-based rehabilitation for communication disorders. in w. smith and s. meyer (eds.) sasha national conference proceedings,"wits: johannesburg, 1987. asha social dialects: a position paper. asha, 25, 9, 23-24, 1983. chick, k. interactional perspectives on communication needs of zulu work seekers .journal of multilingual and multicultu ral development, 7, 6, 479-492, 1987. comkowycz, s.m. ehren, b.j. & hayes, ν.,η. meeting classroom needs of language disordered students in middle and junior high school: a program model.journal of childhood communication disorders, 11, 1, 119-208, 1987. damico, j.s. addressing language concerns in the schools: the slp as consultant. journal of childhood commu nication disorders, 11,1, 17-40, 1987. department of education and training (det): det annual report for 1987, rp 65/1988, pretoria: government printer, 1988. department of national education: preliminary education statistics for 1988. nated 02-214 (88/07), pretoria. edwards, j.r. language and disadvantage. london: edward arnold, 1979. gallagher, t.m. and prutting, c.a. pragmatic assessment and intervention issues in langu age.cayifornia: college-hill press, 1983. hsrc-report. the role of language in black education. pretoria: hsrc, 1986. johanson, l. in search for the common tonguenecessity or dream? mathlasedi, 7, 1/2, 7-8, 1988. kessler, c. language acquisition in bilingual children. in n. miller (ed.) bilinguatism and language disability. san diego: collegehill, 1984. lewis, r. memorandum on language-learning deficit in katlehong township. communiphon, sept/oct, 285, 20-21, 1988. marvin, c. a. consultation services: changing roles for the slp's. journal of childhood communication disorders, 11, 1, 1-15, 1987 mawasha, a. l. medium of instruction in black education in southern africa. hsrc-report: the role of language in black education. pretoria: hsrc, 1986. mcdonald, c.a. primary english school curriculumon the threshold of radical change. mathlasedi, 7, 1/2, 18-19,1988. odendaal, m.s. needs analysis of higher primary teachers in kwazulu. per linguam, special issue, 1985. reagan, t. the role of language policy in south african education. language problems and language planning, 10, 1, 1-13, 1986. simon, c.s. out of the broom closet and into the classroom: the emerging slp .journal of childhood communication disorders, 11, 1, 41-66, 1987. taylor, o. treatment of communication disorders in culturally and linguistically diverse populations. san diego: college hill press, 1986. terrell, s.l. and terrell, f. effects of speaking black english upon employment opportunities. asha, 25, 6, 27, 1983. trudgill, ρ accent, dialect and the school. london: edward arnold, 1987. vaughn-cooke, f.b. the challenge of assessing the language of nonmainstream speakers. in o. taylor (ed.) treatment of communication disorders in culturally and linguistically diverse populations. san diego: college hill, 1986. uys, i.c. 'n mede-konsultasie model vir spraaken gehoorterapie in die rsa. in i.s. hay en i.c. uys (eds.) taalverskeidenheid en taalpatologie. pretoria: universiteit van pretoria, 1985. westby, c.e. and rouse, r. culture in education and the instruction of language learning-disabled students. topics in language disorders, 5, 4, 15-28, 1985. yoder, d. some viewpoints of the speech, hearing and language clinician. in f. williams (ed.) language and poverty. chicago: markham, 1970. i 1 v x e d i f i x h e a r i n g s y s t e m c o . cape p . o . b o x 5 2 l y n e d o c h natal p.o. box 4 7 4 4 3 g r e y v i l l e 7 6 0 3 4 0 2 3 p h o n e : ( 0 2 4 ) 5 1 2 4 9 5 p h o n e : ( 0 3 1 ) 2 9 4 0 5 0 surgical & medical p.o. box 19 bedfordview 2008 south africa phone: (011) 53-4188/9 1 r i c h a r d s 2008 south africa phone: (011) 53-4188/9 ir i hearing systems j tomorrow s technology tor today's hearing problem die suid-afrikaanse tydskrif vir kommunikasiaykins, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h i s p a g e i s s p o n s o r e d b y t h e l i t e r a r y g r o u p ( p t y ) l t d academic & medical booksellers johannesburg: campus bookshop phone: 34 bertha street (011) 339-1711 2017 braamfontein westdene services 4 ameshoff street 2017 braamfontein phone: (011) 339-3026 durban: logans westdene 660 umbilo road 1400 durban phone: (031) 253221 ext 22 gape town: westdene rondebosch phone: 18 main road (021) 689-4112 7700 rondebosch r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'ν o n d e r s o e k ν α t a a l p r o b l e m e by l e e r g e s t r e m d e kinders. elize d e koker, m . ( l o g . ) ( p r e t . ) department speech pathology and audiology, university of the witwatersrand, johannesburg opsomm1ng hierdie studie ondersoek met behulp van die toets vir mondelinge taalproduksie (tmt) (vorster 1980), die taalvermoens van 'n groep van 30 leergestremde kinders. resultate het getoon dat, wat betref mondelinge taalproduksie, die eksperimentele leergestremde groep betekenisvol swakker as die normgroep presteer. die voorkoms en aard van betrokke taalprobleme, asook die nut van die tmt vir gebruik by leergestremde kinders, word bespreek. summary the. study examined the language abilities of a group of 30 learning-disabled children using the "toets vir mondelingse taalproduksie" (tmt) (vorster, 1980). results revealed a significant difference between the scores of the experimental group and the norms of the test. the evidence and nature of proven oral language difficulties were discussed as well as the use of the tmt with learning disabled children. die wetenskaplike vakgebied van "leergestremdheid" het met die verskyning van die murray-verslag in 1969 sy amptelike beslag in suid-afrika gekry. hierdie vakgebied het sy ontstaan oor 'n lang tydperk gehad vanaf 1800 tot 1940 (myers en hammill 1 3 ). hierdie periode word veral gekenmerk deur min of geen empiriese navorsing waar observasies van breinbeseerdes die grondslag van die teoretiese kennis gevorm het. met die verloop van tyd het navorsers daarin geslaag om tussen verskillende soorte leerprobleme te onderskei. u y s 1 7 byvoorbeeld, noem dat verstandelike vertraging, emosionele versteuring en sintuiglike gebreke reeds in die middel van die twintigste eeu as oorsake van leerprobleme bekend was. daar het geleidelik egter 'n nuwe soort leergestremde kind onder die aandag van navorsers gekom, naamlik 'n kind wat nie: verstandelik vertraag sintuiglik gestremd primer emosioneel versteurd of motories gestremd was nie, maar wat wel skolastiese probleme ondervind het en byvoorbeeld nie leer lees, skryf, praat en reken het nie (johnson en myklebust,9). soos byna sonder uitsondering die geval in die "gedragswetenskappe" is, het daar letterlik tientalle definisies, diagnostiese en remedieringsmetodes en benaderings tot hierdie kinders ontstaan. b a r e n 2 noem dat die verskeidenheid van terme wat vir die probleem ontstaan het tot the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) taalprobleme by leergestremde kinders 17 geweldige verwarring aanleiding gegee het. dit is egter nie slegs die terminologie wat kontroversieel geword het nie, maar die hele studiegebied van leergestremdheid. die redes vir die verwarring en kontroversie wat daar heers, le hoofsaaklik in die volgende faktore opgesluit: die leergestremde kind het eerstens 'n baie gevarieerde en wye simptoombeeld. kirk en k i r k 1 0 noem byvoorbeeld dat gestremde kinders nie altyd in sulke goed gedefinieerde kategoriee met homogene eienskappe tuishoort nie._navorsers het dus probleme ondervind om die studiegebied logies en goedgedefinieerd af te baken. tweedens is die leemtes in die kennis ten opsigte van die sentrale senuweestelsel en sy funksionering 'n baie beperkende faktcfr in die studiegebied. derdens, en seker die belangrikste faktor wat ongetwyfeld tot die verwarring moes bydra, was daardie baie denkrigtinge en dissiplines wat hulle met die kinders bemoei, bydraes gelewer, gediagnoseer en behandel het. die spektrum van gei'nteresseerde persone sluit onder andere die volgende in: sielkundiges, onderwysers, sosiale werkers, medici, spraakterapeute, opvoedkundiges, arbeidsterapeute, neuroloe, pediaters, — mense met verskillende teoretiese agtergronde en uitgangspunte. die genoemde verwarring wat daar heers, is ongetwyfeld slegs tot nadeel van die leergestremde kind en daarom moet die oplossing van die verwarring en kontroversie 'n primere doelstelling word. die doelstelling kan onder andere verwesenlik word deur meer en verbeterde empiriese navorsing. daar moet dus gepoog word om die leemtes in die huidige korpus van kennis en navorsing in die studiegebied te identifiseer en nader te bestudeer. probleemstelling slegs een leemte sal vervolgens genoem en bestudeer word naamlik die feit dat die leergestremde kind se taalproblematiek, en dan veral gesproke taal, grootliks in die diagnose en remediering van die kinders oor die hoof gesien is. (wiig en s e m e l , 2 3 hallahan en kauffman,7) 'n bewys vir hierdie stelling is die feit dat hallahan7 drie keer meer artikels in die literatuur vir leergestremdheid ten opsigte van perseptueel — motoriese probleme gevind het, in vergelyking met artikels oor die kinders se moontlike taalprobleme. die perseptueel-motoriese benadering wat tot leerprobleme gevolg word, kan ongetwyfeld weens die pionierswerk van mense soos strauss en cruickshank verantwoord word (myers en hammill, 1 3 ) wallach en goldsmith 2 0 is egter verder van mening dat hierdie benadering nie slegs weens die bydraes van die pioniers op die gebied gevolg word nie, maar ook omdat professionele persone reeds jare die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 elize de koker lank van mening is dat die kern van die leergestremde kind se probleem die perseptueel-motoriese aantasting is. 'n rede hiervoor kan wees dat lees-problematiek met 'n baie hoe frekwensie onder leergestremde kinders voorkom en lees as 'n uitsluitlike visuele taak gesien word. alhoewel dit nie weg te redeneer is dat perseptuele defekte in samehang met leergestremdhede voorkom nie, is hierdie benadering nie 'n bevredigende oplossing nie. baren 2 se byvoorbeeld in die verband dat daar geen bewyse is dat perseptuele vermoens so belangrik vir die leerproses is as wat veronderstel word nie. wallach en goldsmith 2 0 haal "ook ter ondersteuning van bogenoemde stelling vyf outeurs aan wat die volgende mening toegedaan is: . . . question the validity of available visual perceptual testing materials and most importantly question the educational usefulness of the concept of perceptual deficit in treating learning disabilities kritiek kan ook uitgespreek word teen die engheid van 'n perseptuele benadering. daar moet onthou word dat daar verskillende vlakke in die leerproses bestaan. dit is verkeerd om slegs op die hierargies laer vlakke van die leerproses nl. motoriek en persepsie te konsentreer en prosesse soos simbolisering en konseptualisering op die hoere vlakke van die leerproses (myers en hammill, 1 3 johnson en myklebust,9) oor die hoof te sien. ter motivering van 'n taalbenadering tot leergestremde kinders kan daar geen eenvoudiger motivering wees as die feit dat taalprobleme wel 'n deel van die kinders se simptoombeeld vorm nie. daar word spesifiek van 'n leergestremde kind gepraat as gevolg van die opvoedkundige of skolastiese probleme wat hulle ondervind — skolastiese take wat vermoens soos lees, spel, skryf en reken insluit. die genoemde vermoens is almal sekondere taalvermoens. alhoewel monroe (wiig en s e m e l , 2 3 ) reeds in 1932 gevind het dat taalen leerprobleme dieselfde etiologiese faktore toon, kan daar selfs nog aan die begin van die tagtigerjare gese word dat navorsing na die aard en voorkoms van die taalprobleme nog byna afwesig is. die spraakterapeut, onderwyser of opvoedkundige staan dus in die praktyk dikwels magteloos in hulle hantering van taalprobleme wat opgemerk word, veral omdat daar nie diagnostiese toetse bestaan nie en omdat daar oor die algemeen so min kennis en gevolglik min literatuur in die verband beskikbaar is. / dit is dus verstaanbaar dat sommige outoriteite wat by leergestremde kinders betrokke is, orale taalprobleme oor die hoof sal sien en op perseptueel-motoriese probleme sal konsentreer. deur middel van hierdie projek is daar dus gepoog om die genoemde leemte te vul wat veral by die afrikaanse leergestremde kind soveel groter is. daar word ook gehoop dat dit verdere navorsing sal stimuleer en die gebrekkige belangstelling waarvan wiig en s e m e l 2 3 ) praat, sal ophef. the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) taalprobleme by leergestremde kinders 19 e k s p e r i m e n t e l e o n t w e r p spesifieke doelstellings en hipotese bewys van orale taalproblematiek deur middel van die eksperimentele metode wat vervolgens bespreek sal word, is daar gepoog om te bewys dat leergestremde kinders taalprobleme het. daar word spesifiek na orale taal gekyk omdat dit die mees waarneembare asook die basiese medium is. die motivering hiervoor is as volg: moran en b y r n e 1 1 noem dat daar tans steeds beperkte bewyse is dat die leergestremde kind se taal van die van die normale kind verskil. vogel1 8 noem die "moontlikheid" dat dislektiese kinders afwykings in orale sintaksis het. uit bogenoemde drie outeurs se bydraes is dit duidelik dat daar nog min wetenskaplike bewyse bestaan, alhoewel outoriteite* spekuleer dat daar wel taalprobleme voorkom. bogenoemde beperkte bewyse en min navorsing word ook deur outeurs soos wiig en semel 2 2 ' 2 3 wiig en r o a c h 2 1 en hallahan7 onderskryf. hallahan en kauffman7 is van mening dat die studies so beperk in getal is en dat daar soveel teenstrydighede bestaan, dat verdere navorsing noodsaaklik is. daar word spesifiek die hipotese gestel dat leergestremde kinders wel gesproke taalprobleme het. voorkoms van taalproblematiek daar is ook gepoog om die vookoms van taalprobleme onder die leergestremde bevolking te bepaal. die motivering vir bogenoemde is as volg: as daar bewys kon word dat leergestremde kinders wel taalprobleme het en dat daar 'n relatiewe hoe insidensie is, gee dit soveel meer rede vir 'n betoog dat die kinders se taal meer aandag moet geniet. daar is spesifiek ouer kinders, m.a.w. sewetot tienjariges in die studie ingesluit. hierdeur is daar gepoog om uitsluitsel te verkry oor die kontroversie wat daar bestaan met betrekking tot die aanwesigheid, al dan nie van simptome van leergestremdheid by ouer kinders. die aard van die taalproblematiek daar is derdens deur hierdie eksperiment gepoog om die aard van die taalprobleme te bestudeer. die volgende vrae kan byvoorbeeld gevra word: — verskil die leergestremde kind se orale taal kwalitatief of kwantitatief van die normale kind s'n? — is daar 'n aparte diagnostiese kategorie waarin die leergestremde bevolking ten opsigte van taalvermoens pas? — wat is die verhouding of onderlinge verband tussen die taal en leerprobleme? die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 elize de koker evaluering van die toets vir mondelinge taalproduksie (tmt) aangesien die toets tans die enigste normatiewe data ten opsigte van sekere aspekte van die ouer afrikaanse kind se taalvermoe verskaf is dit belangrik dat die waarde van die toets se gebruik by leergestremde kinders bepaal sou word. seleksie van proefpersone kriteria vir seleksie in 'n poging om die orale taal van leergestremde kinders met die van normales te vergelyk, is daar van 'n eksperimentele, sowel as kontrole groep (eg en kg) gebruik gemaak. kontrole groep die kg is die verteenwoordigende steekproef waarop die norms van die tmt gestandardiseer is. eksperimentele groep die volgende kriteria is aan die groep gestel: (i) kinders met 'n leergestremdheid moes geselekteer word. omdat daar soveel moontlike interpretasies van die term bestaan, word die volgende definisie as kriterium gebruik: die kinders mag nie — opvallende fisiese of sintuiglike gebreke gehad het nie — ernstig emosioneel versteur gewees het nie — gemanifesteerde epilepsie of serebrale verlamming ondervind het nie — daar moes wel sagte neurologiese tekens teenwoordig gewees het (ii) omdat 'n ondergemiddelde intelligensie taaltoetse nadelig bei'nvloed, is daar vereis dat proefpersone (pp) 'n gemiddelde intelligensie sou he (m.a.w. 100+) (iii) skoolgaande kinders is geselekteer omdat intelligensie .syfers by hulle meer betroubaar is. leergestremdheid is by hulle ook reeds gei'dentifiseer en daar kon so ook afleidings gemaak word t.o.v. die aanwesigheid van taalproblematiek tydens stadia waar dit nie meer verwag word nie (schain1 6) .(iv) dertig proefpersone is geselekteer om statisties betekenisvolle resultate te kon verkry 7 (v) emosionele onstabiliteit, sosio-'ekonomiese status, sowel as geslag is as moontlike bei'nvloedende faktore in ag geneem. eersgenoemde twee faktore is deur ewekansige steekproeftrekking geassimileer. omdat leergestremdheid baie meer by seuns as dogters aanwesig is, is daar besluit op 'n ewekansige steekproef. daar sal dus noodwendig meer' seuns as dogters in die steekproef wees wat 'n getroue weergawe van die verskynsel is. the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) taalprobleme by leergestremde kinders 21 verkryging van die proefpersone die kinders is uit hulpklasse van die t . o . d . verkry. die proefpersone is spesifiek uit die totale bevolking van hulpklaskinders in pretoria gekies omdat die brandstofkrisis 'n groter area onmoontlik gemaak het. daar bestaan in pretoria vyftien hulpklasse, elk met 8 leerlinge, met ander woorde, 'n totale bevolking van ± 120 leerlinge. 'n verteenwoordigende en ewekansige steekproef van 30 leerlinge tussen die ouderdomme 7-4 tot 9-10 is uit bg. bevolking getrek. eksperimentele materiaal die tmt is gebruik asook — 'n bandmasjien (draagbare sony) — lae-geruis/kasette (hitachi) — die ,,samevattende verslag oor 'n leerling met leergestremdhede" (t.o.d. omsendminuut 73 van 1979 — bylaag a ) 1 5 die verslag is deur die betrokke ortodidaktikus wat die hulpklaskinders geselekteer het, voltooi. daaruit is agtergrond-historiese gegewens vir elke pp ingewin. prosedure die toets is volgens spesifikasies, bv. met betrekking tot omgewing, aanwysings en prosedure afgele. statist1ese verwerking die proefpersone se roupunt vir elkeen van die 16 sub-toetse van die toets is met behulp van die normtabelle na persentielrange omgesit. laasgenoemde kon egter nie vir statistiese verwerking gebruik word nie en is daarom na staneges verwerk. ten einde te bepaal of die pp se prestasie as groep betekenisvol van die normgroep verskil het, is die t-toets vir statisties betekenisvolle verskille op die 5% en 2\% vlak van betekenisvolheid uitgevoer. resultate. (sien tabelle i i i i ) die resultate word kortliks aan die hand van die spesifieke doelstellings bespreek. vir 'n meer gedetaileerde bespreking word u verwys na de koker. 5 bewys van orale problematiek bewyse het wel deeglik uit die eksperimentele navorsing na vore getree. die eerste bewys is reeds uit die leerlinge se agtergrond-gegewens verkry. daar -is gevind dat 'n minimum van 73,3% van die pp 'n geskiedenis van spraaken taalverwante probleme gehad het. daar was bv. by 40% van die eg spesifiek genoem dat hulle laat begin praat het. hierdie verskynsel is ook deur m u r r a y 1 2 genoem. uit tabel ii — blyk dit dat die eg in die tmt op 12 uit die 16 subtoetse betekenisvol swakker as die normale kind presteer het die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) elize de koker η s η .53 •6 c a > u "m μ (λ c *{λ a c e υ <υ "ο ο. ο c ο ιλ <υ ο. μ ι υ ο c α > <υ μ c α c <υ <υ cl, -ι μ (0 < η | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 ο en no s no ts ο en ο on on ĉ ο no en en •st ts no ĉ •st d oo ο | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 on cn £ no ο ο ο ο no no cn no in m oo m 00 oo no •st ο | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 oo cn ο en tf no no •st iri en no cn no no ο 3 on oo no on •st no | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 cn no ο 00 on •st ts •st ο) cn no ts ο •st •st no no •st ts ts •st 00 no •st | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 no cn no no ο oo ron en on no no t̂ 00 00 00 no on o) | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 cn on ο en ο on •st ο in on ĉ ο no no r-ts oo rno no oo no ο cn •st in | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 •st ts ο no no no •st cn cn oo on no on en no •st •st no on ts •st no no ts 00 no no •st •st | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 ο ts ο ts ο no on ĉ ο cn no rno •st 00 00 00 no en | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 cs cn) oo •st in ο on en no ο rο cn 00 ο cn ĉ r•st -h oo no en in r| 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 ts en •st on no in t— cn on en ο cn no •st m ĉ ĉ oo on t— en ts | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 ο ts oo •st ts in oo •st on 00 ο en on ο •st cn 00 oo no t— 00 no rts | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 on •st (n o) wi 00 on ro) ts on m ο oo r-•st 00 t— 00 r00 no on <n | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 oo •si-rs on 00 00 •st en ts •st in on en •st no ο ο 00 t— ts in oo no | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 •st ο •st 00 •st oo on en no 00 00 •st 00 t— no cn oo no ^ | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 no o •st en no en on •st •st ο no 00 m 00 rts in t— •st ο | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 no •st ts en in ο ο no on en •st ο ο ο •st on ts ĉ no •st no oo no •st ts ο | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 •st cn ts ts ο •st ο tt no on ο ο cn 00 no no ο | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 en ts ts ο ο en oo no ο •st ο ts on •st en 00 r00 ts oo no oo ts cn •st | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 ts in cn ο ο ο no on •st ts ĉ no on ο •st m ο en no ο | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 £ on en •st ts •si-ts ο ο in ο on ο ο ο on ts ο ο no •st •st 00 no •st on | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 ο en •si-rs on ο ο •st cn ts cn ts ts 00 on on •st on •st 00 no en •st en | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 on no •st •st •si-rs •st en no •st 00 on en ο oo on ts •st no 00 no no en cn | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 oo in o cn on no no 00 00 oo on ο ο no on 00 ο ο no oo no no no ̂ | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 00 en •t oo on a\ <n oo no •st ts cn ο •st on •st no tf oo ο oo no 00 1/ί no | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 no £ cn ol cn m on en on no ο ĉ •st no cn oo no s ο | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 on 00 00 m on 00 ιη no ο en on en en en no ο cn o) in 00 •st 00 no r(ν no | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 •st •st on ο ο ο on ο in oo rο ο cn on en •st •st ο cn en •st no •st ο 00 no oo ο ο | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 en on ο on ' ο en •st •st on en en en no no ts ts 00 •st 00 no ο ro | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 ts oo t— in <3no oo ts ĉ ο •st ts ο no cn r-ĉ ο rο en 00 no m rο | 74 75 76 78 78 79 79 7-1 0 8-0 0 8-0 0 8-0 0 8-0 0 800 8 -1 8 -2 8 -4 8 -4 8 -6 8 -7 8 -8 8 -9 8 -9 8 -10 9 -0 9 -00 9 -0 9 -2 9 -2 9 -3 9 -10 1 oo in in on ο on no cn no cn ts rο in cn ts •st ο •st 00 no on cn in ω -a ο ο is "cu ο η ο ^ c <u j* u ύ a i••—' u t-l o.i2 •§1 § 8 μ ο. 1-8 •s § <u > a (λ "u ιλ ω ιλ ο ο > d. a> •o kh ο ο ι d3 a 1λ 00 c 'w c8 "a <υ > q. ml c3 "ob ω a (λ 0d c 'eb c5 ca & > u ό ο ο-ο ο ϋ οχ. ο c (λ an a •c <u w u a •s's" u c £ .s u & on μ 00 c „ 'π a ω ^ a> ω ·£ ή ω ο έ | u w-ιζι a 1λ 00 x; t-l u κ a [λ 00 c ε-υ ο c a> m •a .'δ / ί a> a> ξ j2 » ο ί · 8 ιλ j) ca αϊ a υ c 'ξ ce o ud er do m m e <u c ο (λ ο cl <+-< 0) ο fch ph ι the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) taalprobleme by leergestremde kinders t a b e l ii: uitslag van die t-toets vir statistiese betekenisvolheid sub-toets skaal t-waarde betekenisvolheid 5% 2i% 1% vlak vlak vlak totale woorde tipe-teken ratio woorde per t-eenheid produktiwiteit 5,222 3,4166 0,324 * * * * * * medewerkwoorde per t-eenheid voorsetsels per t-eenheid bywoorde per t-eenheid kompleksiteit 0,6425 0,473 6,934 * * * verplasings weglatings vervangings onvoltooide uitinge korrektheid -12,173 -11,163 0,1662 -19,631 * * * * * * * * * selfverbeterings (sinne) selfverbeterings (woorde) herhalings vlotheid 5,949 1,795 3,907 * * * * * * * benoemings abstrak-konkrete skaal waninterpretasies inhoud 2,332 4,854 8,489 * * * * * * * * alhoewel hulle gemiddelde en bo-gemiddelde verstandelike vermoens gehad het. die feit dat hierdie kinders, as 'n geweldige heterogene groep tog van die norm-groep afgewyk het, is miskien die grootste bewys van hulle taalprobleme. verder het die kinders steeds taalprobleme ondervind ondanks die feit dat hulle reeds vir 'n minimum van nege maande in 'n hulpklas was. hierdie wetenskaplike bewyse wat gevind is, dui daarop dat elke persoon wat homself met leergestremde kinders bemoei, van die kinders se orale taalproblematiek kennis moet dra. dit is duidelik dat hulp aan die kinders se sekondere taalprobleme soos lees en skryf van weinig waarde sal wees indien die bousteen nl. orale taal ignoreer word. voorkoms van orale taalproblematiek leergestremde kinders beskik oor 'n wye variasie van simptome (wiig en semel, 2 3 ) wat daartoe lei dat hulle moeilik in homogene kategoriee tuishoort. heterogeniteit by die pp het egter nie tot gevolg gehad dat hulle nie betekenisvol, wat taal betref, van normale kinders verskil het nie. daar het 'n geweldig hoe voorkomssyfer van taalprobleme gepresenteer. indien daar na elke pp se prestasie gekyk word, (tabel i) is dit opvallend dat elke proefpersoon onder gemiddeld presteer het. slegs 2 pp het in minder as 50% van die subtoetse onder-gemiddeld presteer. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 elize de koker daar was dus 'n 100% voorkomssyfer van orale taalproblematiek. dit is sorgwekkend as daar in ag geneem word dat van die pp amper 10 jaar oud was. die moontlikheid van taalprobleme tot in die adolessente fase (wiig en semel, 2 3 ) is met ander woorde nie uitgesluit nie. indien daar verder na individuele kinders se prestasie gekyk word (tabel i) is dit duidelik dat oneweredige prestasie in toetse, soos deur murray 1 2 en kirk en k i r k 1 0 genoem, ook hier voorkom. ten opsigte van die een subtoets sal een proefpersoon gemiddeld presteer en ten opsigte van die volgende weer onder-gemiddeld. die geweldige variasie blyk uit die volgende voorbeeld: tabel iii persentielrange van proefpersoon 2 op die t m t subtoets persentielrang 1 78 2 55 3 64 4 81 5 32 6 10 7 24 8 0 9 61 10 21 11 37 12 70 13 30 14 68 15 73 16 3 die aard van die orale taalproblematiek uit die individuele prestasies en groepprestasie volgens die verskillende subtoetse, blyk dit dat daar 'n redelike wye en algemene taalprobleem by die kinders voorgekom het wat nie aan 'n enkele subtoets of taalmodaliteit gebonde was nie. onderprestasie het by alle subtoetse nl. produktiwiteit, kompleksiteit, korrektheid, vlotheid en inhoud voorgekom. wiig en semel 2 3 se hipotese dat leergestremde kinders te taalprobleme multi-dimensioneel is, is dus hier onderskryf. 'n kort opsomming van enkele verdere bevindinge is as volg:— op grond van die e g se prestasie op die produktiwiteitskaal, kan daar afgelei word dat die leergestremde kind se taalgebruik besonder onproduktief is — verbale perseverasie deur onder andere g r e e n 6 vermeld het nie by die eg voorgekom nie. — die e g het 'n minder diverse leksikon vertoon — die leergestremde groep se gemiddelde uitingslengte het nie van the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) taalprobleme by leergestremde kinders 25 die normale verskil nie. die lengte van uitinge sou dus nie as 'n waardevolle diagnostiese hulpmiddel by leergestremde kinders aanbeveel word nie. — die e g se sinne is deur baie funksielose woorde gekenmerk. — wat die prestasie op die kompleksiteitskaal aanbetref, het die eg nie betekenisvol minder medewerkwoorde en voorsetsels as normale kinders gebruik nie. dit was egter opvallend dat die eg 'n baie hoe frekwensie lokatiewe voorsetsels gebruik het wat volgens wiig en semel 2 3 baie maklike voorsetsels is — ondergemiddelde bywoord gebruik het op sintaktiese probleme gedui — dit was opvallend dat nie een van die pp besondere komplekse sinne gebruik het nie — die e g het meer verplasings, weglatings en onvoltooide uitinge as die normale kind gebruik. dit skyn dus of die kontrolerende funksie oor hulle spraak nie voldoende is nie — 'n verdere bewys vir die foutiewe kontrole oor die taalfunksie is die hoe voorkoms van selfverbeteringe en woordherhalings by die kinders — die leergestremde kind se geweldig baie woordherhalings het die kinders se taal ongetwyfeld in 'n "afasie"-konteks geplaas. vorster 1 9 noem dat die funksielose herhalings van woorde eintlik in die plek van pouses gebruik word waar woordvindingsprobleme ondervind word. — uit die eg se uitinge het dit geblyk dat funksielose pouses, tussenwerpsels en herhalings van lettergrepe ook grootliks tot die onvlotheid en onsamehangende taalgebruik bygedra het — die e g se taal was besonder konkreet en stimulusgebonde — met ander woorde, verbeeldingloos — die kinders het ook betekenisvol meer waninterpretasies in hulle stories gehad. dit het dikwels 'n aanduiding gegee van die kinders se gebrekkige logika en onvermoe om 'n storie in die regte perspektief te plaas. — oor die algemeen kommunikeer die leergestremde groep swak weens onvlothede, waninterpretasies, konkreet gebondenheid, onlogiese vertellings, tussenwerpsels, foutiewe woordorde en woordherhalings indien daar wel vir 'n patroon van taalprobleme by die kinders gesoek word, skyn dit dat dit e g se grootste probleme in die vlotheid en inhoudsaspekte van orale taal voorgekom het (tabel iii) wiig en semel 2 3 het die leergestremde kind se onvlotheid ook as een van die belangrikste probleme beskou. uit die resultate is dit ook duidelik dat die eg se taalprobleme nie so subtiel is soos vorige navorsers beweer het nie en ook nie so kompleks nie. alhoewel die probleme wel kompleks mag wees is daar sprake van redelike eenvoudige en basiese probleme soos bv. onderbeklemtoning van die gebruik van bywoorde. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 elize de koker daar is ten slotte in hierdie navorsing slegs op ekspressiewe orale taal gekonsentreer. omdat resepsie ekspressiewe voorafgaan, is dit dus nie onrealisties om te vermoed dat leergestremde kinders ook reseptiewe orale taalprobleme ondervind nie. nut van die tmt uit hierdie navorsing het dit geblyk dat die tmt 'n nuttige instrument is, en wel in die volgende opsig: — hierdie toets meet kinders se taakvermoe oor 'n wye verskeidenheid van afdelings en nie net op die sintaktiese gebied nie. crystal et al4 laat bv. aspekte soos vlotheid en inhoud (juis hierdie kinders se grootste probleem) agterwee — die afneem van die toets geskied oor 'n baie kort tydsbestek wat dit baie bruikbaar by veral hiperaktiewe kinders maak. — die tmt verskaf normatiewe data aan die hand waarvan afrikaanse kinders se taal evalueer kan word. (ook vir die ouer kind) as gevolg van die aard van die toets is daar egter ook nadele aan verbonde: — die toets is op grond van die kwantitatiewe aard daarvan onderhewig aan kritiek aldus bloom en lahey. 3 menslike gedrag is aldus die outeurs nie tot syfers reduseerbaar nie. die toets gee verder nie omvattende riglyne vir terapie nie. dit is wel die geval wanneer taalmonsters kwalitatief ontleed word. — die e g , en dan veral ouer kinders, se sintaktiese ontwikkeling word te oppervlakkig beoordeel. — die morfologiese aspek van taal word nie geevalueer nie, net so ook nie die funksies van taalen kommunikasievermoens nie. — die toets word visueel aangebied, 'n faktor wat by leergestremde kinders, weens hulle perseptuele defekte, moontlik die kwaliteit van die taalmonster verlaag. — die insluiting van pouses, tussenwerpsels en herhalings van klanke sou die vlotheidskaal meer bruikbaar gemaak het. (dit het wel deeglik tot die e g se onvlotheid bygedra). konklusie uit die voorafgaande bespreking het dit duidelik geword dat die leergestremde kind probleme met gesproke taal ondervind wat, ondanks remediering en normale verstandelike vermoens, selfs op nege-jarige ouderdom nog voorkom. dit is egter nie duidelik wat die oorsaak van die leeren taalprobleem is nie en ook welke verband daar tussen hierdie twee probleemsituasies heers nie. daar bestaan ook nog onduidelikheid oor die wyse waarop die kinders se taalsimptome verklaar kan word. 'n verdere twispunt is die vraag of die kinders se taal kwalitatief of kwantitatief van die normale verskil! wiig en semel 2 3 het gevind dat leergestremde kinders se sintaksis afwykend maar ook vertraag is. the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) taalprobleme by leergestremde kinders 27 uit die eksperimentele navorsing is daar beperkte bewyse ter ondersteuning van beide gevind. ten opsigte van kwalitatiewe verskille kan gese word dat die kinders se taal in 'n "afasie-konteks" geplaas is met die bewyse van hulle woordvindingsprobleme en waninterpretasies. dit blyk egter nie moontlik te wees om leergestremde kinders se simptome met volwasse afate se simp tome te korreleer nie, aangesien eersgenoemde se simptome nie so ekstensief is nie en daar ook nie van verworwe breinletsels by die kinders sprake is nie. tog wil dit voorkom of daar 'n merkbare ooreenkoms tussen leergestremde kinders en kinderafate kan wees. resente definisies van kinderafasie deur onder andere jakobson,8 waar afasie na probleme in begrip en gebruik van linguistiese simbole verwys, kan direk op leergestremde kinders van toepassing gemaak word. verskeie navorsers het al hierdie noue ooreenkoms tussen afatiese en leergestremde kinders ingesien. abrahams 1 noem die volgende: it seems that the language disordered child could be said to fall into the wider syndrome of the so-called mbd children hallahan en kauffman7 se dat eisenson van mening is dat die leergestremde en afatiese kind een en dieselfde persoon is. pelzer 1 4 verklaar die skynbare verband as volg: "afasie is voor disleksie sigbaar" met ander woorde, die een verskynsel gaan die ander slegs vooraf. die vraag wat dus in die toekoms beantwoord moet word, is die volgende: in welke mate ontstaan leerprobleme uit 'n basiese taalonvermoe? verwysings 1. abrahams, ε. α., (1972): follow-up study of children with a history of language disorders. ongepubliseerde tesis, universiteit van witwatersrand. 2. baren, m., et al, (1978): overcoming learning disabilities. a team approach. reston publishing company, virginia. 3. bloom, l. en lahey, m., (1978): language development and language disorders. john wiley and sons, new york. 4. crystal, d. et al, (1976): the grammatical analysis of language disability. edward arnold publishers, london. 5. de koker, e., (1980): 'n ondersoek na taalprobleme by leergestremde kinders. ongepubliseerde magister tesis, universiteit van pretoria. 6. green, g., (1974): kommunikasieprobleme by psigoneurologiese disfunksie. ongepubliseerde tesis, universiteit van pretoria. 7. hallahan, d. p. en kauffman, j. m. (1976): introduction to learning disabilities. a psycho-behavioral approach. prentice hall, inc., englewood cliffs, new jersey. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 elize de koker 8. jakobson, r., (1971): studies on child language and aphasia. mouton, the hague. 9. johnson, d. j. en myklebust, h. r., (1967): learning disabilities. educational principles and practices. grune and stratton, new york. 10. kirk, s. α . . e n kirk, w. d . , (1976): psycholinguistic learning disabilities. diagnosis and remediation. university of illinois press, illinios. 11. moran, m. r. en byrne, m. c., (1977): mastery of verb tense markers by normal and learning disabled children, j.s.h.r., 20, (3) p. 529. 12. murray, c. h. de c., (1969): verslag van die komitee van ondersoek na die opvoeding van kinders met minimale breindisfunksie. (r/p. 72/1969) staatsdrukker, pretoria. 13. myers, p. i. en hammill, d . d . , (1976): methods for learning disorders. john wiley and sons, inc. new york. 14. pelzer, w., (1965): spraakterapeutiese benadering tot kinderafasie. universiteit van pretoria. ongepubliseerde tesis. 15. samevattende verslag oor 'n leerling met leergeremdhede. t . o . d . omsendminuut 73 van 1979. bylaag a. 16. schain, r. j., (1972): neurology of childhood learning disorders. williams & wilkins, baltimore. 17. uys, i. c., (1974): psigoneurologiese disfunksie: 'n tipering volgens sekere spraakpatologiese verskynsels. ongepubliseerde tesis, universiteit van pretoria. 18. vogel, s. α., (1977): morphological ability in normal and dyslexic children. journal of learning disabilities, 10, (1), p. 41 19. vorster, j., (1980): handleiding vir die toets vir mondelingse taalproduksie. raad vir geesteswetenskaplike navorsing, pretoria. 20. wallach, g. p. en goldsmith, s. c., (1977): language based learning disabilities: reading is language too! journal of learning disabilities, vol. 10, p. 178. 21. wiig, ε. h. en roach, μ. α., (1975): immediate recall of semantically varied sentences by learning disabled adolescents. perceptual + motor skills. vol. 40, p. 119. 22. wiig, ε. h. en semel, ε. m., (1973): comprehension of linguistic concepts requiring logical operations. j.s.h.r. vol. 16, p. 627. / 23. wiig, ε. h. en semel, ε. m., (1976): language disabilities in children and adolescents. charles e. merrill, ohio. the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) in-situ measurement of hearing aid gain 1. acoustimed has developed a measuring system for testing the insertion gain (etymotic response) of hearing aids in real ears with the earmould in position. 2. to the best of our knowledge there are only three similar systems in use in the world and the acoustimed instrument is the only one which prevents artifacts from standing w a v e s and noise generated in the room, e.g. the subject's own voice. 3. t h e system is presently in use for routine fitting of hearing aids and to improve understanding of the problems encountered in the fitting of hearing aids. 4. audiologists and universities are invited to m a k e use of the system to assist patients at no charge. acoustimed hearing services 3 1 5 b o s m a n b u i l d i n g s c o r . e l o f f a n d b r e e s t r e e t s j o h a n n e s b u r g t e l : 3 7 2 9 7 7 agents for danavox h e a r i n g a i d s die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a fluency-based programme with a clutterer: a case study benita cohn ba (sp & η th) (witwatersrand) joan girson ba(log) (witwatersrand) margaret marks wahlhaus ma (log)(witwatersrand) department of speech pathology and audiology, university of the witwatersrand, johannesburg abstract a fluency-based programme developed for stutterers was used with a clutterer, and its effects were assessed. pre-and post-intervention measures included dysfluencies, articulation errors, paralinguistic features, intelligibility, rate and attitude. results indicated an overall improvement in most of the speech parameters, with particularly interesting changes in attitude. the implications of these results are discussed. opsomming 'n vlotheidsprogram ontwerp vir hakkelaars is met η stamelaar uitgevoer, en die uitwerking daarvan is bepaal. metings voor en na afloop van die behandeling het die volgende ingesluit: vlotheidsafwykings, artikulasiefoute, paralinguistiese eienskappe, verstaanbaarheid, tempo en houding. die resultate het op 'n algemene verbetering t.o.v. die meeste spraakparameters gedui met veral interessante veranderings t.o.v. houding. die implikasies van hierdie resultate word bespreek. for many years research on pathological states of non-fluency has focused almost exclusively on the disorder of stuttering. recently, increased attention has been paid to cluttering which is a contentious issue. it is variously considered a disorder of fluency, of language, and/or of conceptualisation (luchsinger and arnold, 1965). non-communicative concomitants, such as learning and motoric problems have been associated with it (weiss 1967). the etiology is equally confusing. some have attributed it to a central language imbalance (weiss 1964), others to a type of psychoneurological dysfunction (uys 1974). additional confusion is caused by the fact that the term itself is applied by some to describe the symptomatology (dalton and hardcastle 1977), and by others to imply an etiological entity (weiss 1960). cluttering is characterized by some symptoms which are considered to constitute the core behaviours of the condition. these are described by weiss (1960, 1964, 1967) as obligatory symptoms, assumed to be present in all clutterers, as opposed to the facultative symptoms which are sometimes present. the obligatory symptoms include short attention span and poor concentration, lack of 'complete' awareness of the disorder, and an excessive number of repetitions in speech. the facultative behaviours are slurring, elisions, iterations and transpositions of phonemes, syllables and words. additional facultative problems are alexia, agraphia, amusia and voice problems (weiss 1964, grewel 1970, de fusco and menken 1979) as well as those associated with minimal brain dysfunction (langova and moravek 1970). according to freund (cited in weiss 1960), stuttering may frequently be confused with the disorder, as both present with symptoms of dysfluency. dysfluency in cluttering is manifested on various levels (dalton and hardcastle 1977). at the phonetic level there may be repetitions of initial sounds, syllables or words, or prolongations of sound segments. at the grammatical level, co-ordinating conjunctions for example ' may be omitted. at the prosodic level there may be a succession of similar stereotyped intonation patterns, and at the lexical/semantic level, abnormal development of logical sequences of ideas in a discourse may occur. with regard to pausing, dysfluency may be manifested by drawlings and interjections (grewel 1970, weiss 1964, 1967, de fusco and menken 1979, becker and grundman 1970, bradford 1970). © sasha 1985 cluttering was for a long time considered virtually unbeatable. the first documented treatment for clutterers was by froeschels in 1931 (as cited by wolk 1980). the focus of cluttering treatment has been to compensate for specific areas of difficulty, such as tachylalia, insufficiency of articulation, vocabulary and language formulation (weiss 1960), lack of verbal attention (langovd and moravek 1970) as well as monotony of the voice of the clutterer (weiss 1960). weiss (1960) is of the opinion that prognosis is poor for many clutterers. however, dalton and hardcastle (1977) view the key factor to prognosis as lying in the determination and hard work of the particular clutterer. the fact that the element of dysfluency is so basic to cluttering, directed the present researchers' consideration of the application to cluttering of a technique designed for the remediation of stutterers' dysfluencies. a number of speech-fluency procedures applied to the problem of stuttering have been reported during the past decade. having considered a number of these fluency-based techniques, it was decided to utilise the stutter-free speech procedure as outlined by shames and florance in 1980. besides; being directed to the attainment of fluency, this technique seems particularly appropriate for clutterers as it incorporates so many , other aspects of their problem. weiss (1967) has stated that heightened attention to the speech act improves the clutterers speech problem. shames and florance (1980) emphasize the development of selfmonitoring skills in their clients, thus demanding attention to their speech act. excessive speed of delivery is often a feature of cluttered speech and modification to a slower rate seems necessary. both speech and reading rates are modified using this fluency based technique (shames and florance 1980). the articulation of the clutterer is often slurred, unintelligible and "drunken" sounding. the shames and florance (1980) technique aims to teach the speaker a way of articulating sounds using little pressure. it was postulated that this technique might improve the clutterer's articulation. andrews and ingham (1972) have proposed evaluation standards with regard to the improvement of fluency. these standards have been met by the shames and florance (1980) technique in that there is continued measurement of fluency, speaking rate and normal prosody, transfer of fluency to extraclinical settings, and measurement of the permanence of fluency. the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) fluency-based programme with a clutterer a case study 39 for these reasons, and in view of the paucity of the literature on the treatment of cluttering, the major aim of the present study was designed to assess the therapeutic effectiveness of a fluency-based programme, namely the shames and florance (1980) 'stutter-free' s p e e c h technique, on the speech of an adult clutterer. method subject the subject was a 20 year old male technicon student who was diagnosed as a clutterer by three graduate speech pathologists. this diagnosis was made according to a checklist devised by one of the table 1 a checklist of the diagnostic criteria for the classification of the subject as a 'clutterer' absent present slightly present a short attention span and poor concentration 1 general disorderliness 1 2 3 7 general restlessness 1 2 3 0 1 hyperactivity (quick movements) 1 2 3 4 inpatient listener 2 3 1 β lack of awareness of disorder 1 2 3 c excessive number of repetitions 1 2 3 η pro!ongations/drawlings and interjections i drawlings 1 2 3 7 interjections 1 2 3 addition of phonemes 1 2 3 4 addition of syllables 1 2 3 5 addition of words 1 2 3 f. tachylalia 1 excessive speed in speech 1 2 3 2 excessive speed in reading 1 2 3 1 festinating 1 2 3 f poor articulation 1 lack of precision 1 2 3 7 slurring 1 2 3 non-systematic articulatory breakdowns 1 2 3 4 variable occurrence of imprecise consonants 1 2 3 « ellipsis, i.e. omission of sounds, syllables and words 1 2 3 6 spoonerisms, i.e. transpositions of sounds, syllables and words 1 2 3 7 heterotopy, i.e. displacement of sounds 1 2 3 l· s metathesis, i.e. inversion of the order of sounds 3 1 2 9 telescoping, i.e. omission of one element of a blend 1 2 3 g intelligibility 1 reading 1 2 3 2 spontaneous speech i 1 2 3 η inflection ί / 1 monotonous | 1 2 3 2 lack of rhythm j 1 2 3 peculiarities in repetition of melody 1 3 2 1 voice j 1 lacking in intonation 1 1 2 3 7 low pitched ; 1 2 3 1 nasal quality 1 3 1 2 j writing i 1 repetition 1 2 3 7 revisions 1 2 3 transpositions 1 2 3 4 omissions 1 2 3 corrections 1 2 3 6 spelling difficulties 1 2 3 7 irregular sprawling 1 2 3 κ expressive language 1 disorganized sentence structure ' 1 2 3 2 groping for words 1 3 2 1 reduced vocabulary 1 2 3 4 inversions of word order 1 2 3 f 1. variability 1 speech improves when speaking to a stranger 1 2 3 • 2 speech improves when speaking slowly 1 2 3 ο = obligatory symptoms f = facultative symptoms 1, 2, 3 = judges 1, 2, 3 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 , ι η t h e s y m p t o m s w h i c h h a v e b e e n a s s o c i a t ratings is p r e s e n t e d in t a b l e 1. on the basis of the large proportion of symptoms being noted as present, the authors decided that the subject could be considered as a clutterer. the subject's hearing, intelligence and neurological integrity were within normal limits. there was no history of previous therapy. the subject's laterality was mixed. this shift of handedness is commonly described in clutterers (arnold 1970). a family history of cluttering on the subject's paternal side was reported. this accords with findings of an hereditary factor in the family of the clutterer (weiss 1967, dalton and hardcastle 1977, uys 1974). benita cohn, joan girson and margaret marks-wahlhaus a. ratings by three speech pathologists in order to assess the presence or absence of specific cluttering symptoms in the subject's speech, both preand postintervention the experimenter devised a speech profile. this profile consisted of selected items in the original diagnostic checklist. more specifically, these were those items concerned with dysfluency, poor articulation and paralinguistic features. this profile was rated by three graduate speech pathologists who had had no previous contact with the subject nor knowledge of the aims of the study. in accordance with rosenthal's view, that an observer's outcome expectations can bias the measurements he makes (silverman 1977), symptoms were scored in terms of general frequency analysis always, most of the time, sometimes, seldom and never. procedure intervention intensive intervention therapy was carried out by the experimenter over a three-week period. the programme employed was the 'stutter-free speech technique' of shames and florance (1980). there were 15 intervention sessions, of one hour each. therapy involved the carrying out of the first four stages of the shames and florance programme i.e. volitional control, self reinforcement, transfer and training in unmonitored speech. intervention commenced at a prolonged speech rate of 30 words per minute and increased to a rate of 85 words per minute. to evaluate the effectiveness of this technique on the subject's speech, preand post-intervention measurements were taken and evaluated by a number of raters. rating measures will be discussed in detail below. collection of data preand post-intervention recordings were made in a sound proof recording room at the speech and hearing clinic, university of the witwatersrand. videofilming was done through a one-way mirror using a national vhs video camera. for both sets of recordings a spontaneous speech sample was obtained where the subject was required to talk about his job, his hobbies and his favourite country. to lessen the possible effects of adaptation, he was required to talk about a different country and different hobbies during the second recording. to obtain a reading sample, he was required to read "the rainbow passage" and "arthur the young rat" (johnson, darley and spriestersbach 1963). the pre-assessment recordings were made one day prior to the commencement of therapy and the post-assessment recordings, one day after termination of the intensive period of three weeks. for postassessment measures, the subject was not instructed to talk using monitored or unmonitored speech, as it was felt this most closely resembled a normal speaking situation. it is obvious that more definite conclusions concerning the effectiveness of the programme could have been drawn if several further assessments had been carried out at various time periods after -the termination of the programme. this is particularly relevant in terms of the carry-over problems shown in stuttering therapy. data were analysed by two different groups of raters. both groups were unaware whether the material they were rating was recorded preor post-therapeutically in order to reduce any rater expectation and bias (rosenthal and rosnow as cited in silverman 1977). b. ratings by three lay listeners to reflect the approach of the average listener who has minimal insight into the symptoms of cluttering, three lay listeners were asked to rate the data in terms of intelligibility, defined by le mesurier and mcintosh (1966), as speech that can be understood and is comprehensible to the listener. they were also asked to mark rate of speech, presence of stuttering, and monotony. symptoms were scored in terms of general frequency analysis always, most of the time, sometimes, seldom and never. c. objective rate of speech this was determined by counting the number of words used per minute in conversation and reading, both preand post-intervention. this was carried out by the experimenter and confirmed by an independent rater. d. attitude to speech the subject's attitude to his speech was assessed on the "s-scale of communication attitudes" (erickson 1969), which was administered by the experimenter both preand post-intervention. despite the fact that this scale was specifically designed for stutterers, it was felt by the authors that the areas covered could be considered applicable to clutterers as well. results and discussion a. speech profile as rated by speech pathologists i 1. dysfluencies as is evident in table 2, there is a difference in the number of dysfluencies observed in the preand post-intervention situation. all three raters noted a decrease in repetitions, prolongations/drawlings and interjections, with ratings moving from always present (i) to seldom present (iv) (see table 2). the marked decrease in the frequency of the dysfluent characteristics supports accumulated information that the use of fluency procedures may prove to be of therapeutic value with dysfluent speech (ingham and andrews 1971). results are also in accordance with ryan and van kirk's (1973) description of fluency-based therapy with stutterers. the decrease provides evidence that the initial fluency was reinforced and modified until there was approximation of normal conversational speech in the clinical setting. / 2. poor articulation table 3 shows that there has been a notable reduction of poor articulation from the preto the post-intervention situations; this lessening of poor articulation post-therapeutically fulfills the demands, made by weiss (1960) and langova and moravek (1970), that an the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a fluency-based programme with a clutterer a case study aim of cluttering treatment should be to attend to the insufficiency of articulation. intelligible speech can thus be enhanced. table 2 analysis of changes of rating of dysfluencies in the preto post-intervention recording pre-intervention prolongations/drawlings and interjections i drawlings 2 interjections 3 addition of phonemes 4 addition of syllables addition of words post-intervention repetitions an excessive number in speech an excessive number in reading prolongations/drawlings a n d interjections drawlings interjections addition of phonemes addition of syllables addition of words rater one i rater two 2 rater three 3 i always ii most of (he time iii sometimes iv seldom v never 1 2 3 i 2 3 table 3 analysis of changes of rating of poor articulation in the preto post-intervention recording pre-intervention telescoping i.e. omission of one element of a blend rater one 1 rater two 2 rater three 3 i always ii most of the time πι sometimes iv seldom v never die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 table 4 benita cohn, joan girson and margaret marks-wahlhaus analysis of changes of rating of paralinguistic features in the preto post-intervention recording' pre-intervention i 11 iii iv v a inflection 1 monotonous 1 2 3 2 lack of rhythm 1 2 3 3 peculiarities in repetition of melody 3 1 2 β voice 1 lacking in intonation 1 2 3 2 low pitched 1 2 3 3 nasal quality 2 3 1 c tachylalia 1 excessive speed in speech 1 2 3 2 excessive speed in reading 1 2 3 3 festinating 1 2 3 post-intervention i π iii iv v a inflection 1 monotonous 1 2 3 2 lack of rhythm 1 2 3 3 peculiarities in repetition of melody 1 2 3 β voice 1 lacking in intonation 1 2 3 2 low pitched 1 2 3 3 nasal quality 2 3 1 c tachylalia 1 excessive speed in speech 1 2 3 2 excessive speed in reading 1 2 3 3 festinating 1 2 3 rater one 1 i always rater two 2 it most of the time rater three 3 in sometimes iv seldom v never 3. paralinguistic features as can be seen in table 4, the ratings remained the same in inflection and voice post-therapeutically. this was unexpected, as the stutter-free speech technique is designed to focus on improving the prosodic elements of speech. however, shames and florance (1980) report that difficulties in prosody have often been observed when using this technique. these findings imply strongly, that to make the programme maximally effective for a clutterer, special attention should be paid to inflection and stress exercises, as clutterers are very poor in this area. table 5(i) analysis of changes in laymen's judgements of intelligibility of the speech sample from the preto the posttherapeutic recording rater one i i always rater two 2 i] most of the time rater three 3 iii sometimes iv seldom v never the south african journal of communication disorders, vol. 32, 1985 with regard to the tachylalic symptom of the subject, there was a marked reduction of excessive speed in spontaneous speech and reading from preto post-intervention. modification to a slower rate appears necessary for a clutterer to establish a more intelligible pattern of speech. b. ratings by lay listeners it is interesting to note that there was perfect concurrence in the ratings of all three lay listeners for both the preand post-intervention periods over all four parameters. all parameters were rated identically for both speech and reading tasks. j i. intelligibility i r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) fluency-based programme with a clutterer a case study table 5(10 analysis of changes in laymen's judgements of stuttering rate and monotony in the speech sample from the preto the post-therapeutic recording conversation fast speech evidence of stuttering monotonous reading fast speech evidence of stuttering monotonous rater one i rater two 2 raier three 3 123 123 123 123 123 123 123 123 123 i always [1 most of [he time iii sometimes iv seldom v never as is evident in table 5(i) the lay listeners rated the subject's speech as seldom clear (iv) pre-interventionally, and always clear (i) postinterventionally, thus indicating a marked improvement in an important feature of communication. 2. evidence of stuttering table 5(ii) shows a marked reduction in dysfluency. the preintervention rating of (i) indicates much evidence of what was described as stuttering, whereas post-intervention ratings noted that stuttering was seldom present. the lay listeners were as aware of the non-fluent speech phenomena as were the graduate speech pathologists. their perception of improvement substantiates the findings of the trained listener, that this program was effective in reducing non-fluencies. 3. rate some slight reduction in rate was noted (see table 5(ii)) by the listeners from preto post-intervention recordings. this parameter can'be considered as corresponding to tachylalia, one of the symptoms usually associated with cluttering. whereas the lay raters perceived only a slight change in the dimension described to them as 'fast speech', the trained listeners had noted a marked reduction in tachylalia. 4. monotony i the lay listeners felt that the monotony of the subject's speech had increased slightly during therapy. this finding was not unexpected as an increase in monotony is often a feature of the technique used, particularly in the early phases. (the final recording was done when the subject was still on phase 3 of the shames and florance programme.) as monotony is one of the symptoms often associated with cluttering, the findings of the lay listeners provide further support that work in the area of building up prosodic elements is specifically needed in a therapy programme for a clutterer. c. objective rate there was a significant reduction in the amount of words per minute for both spontaneous speech and reading and it is evident that this method has shown carryover into the spontaneous speech of the subject. the implications for therapy are clear. modification to a slower rate is beneficial in a programme aiming to alleviate symptoms of cluttered speech. table 6 objective measures of the rate of speaking (words per minute) for spontaneous speech and reading from the preto the post-therapeutic recording total amount of words pre-intervention post-intervention conversation 179 108 reading 153 119 d. attitude table 7 shows that there has been a meaningful change in attitude from preto post-intervention, as assessed by a reduction in the score. pre-intervention scores, which showed that the subject was aware of his problem, contradicts reports that the clutterer is relatively unaware of the problem and should thus score low on erickson's (1969) s-scale (hahlow in dalton 1983). some authorities have observed however, that clutterers often acknowledge that they are not satisfied with their speaking and reading abilities (weiss 1964). the post-intervention score, which shows a marked change in the subject's attitude, supports the hypothesis of andrews and cutler (1974), that attitude change occurred after the achievement of fluent speech in the clinic, and when the subject had completed a series of speaking assignments outside the clinic. the acquisition of a better selfconcept and a more positive attitude towards speech is in keeping ibble 7 analysis of changes in therapeutic assessment of attitude from the preto the post-therapeutic recording test. score interpretation s-scale of communication attitudes (erickson 1969). pre-intervention 31/39 (i) experiences great discomfort in social conversation situations. (ii) severe speech problems. (iii) no improvement in speech. s-scale of communication attitudes (erickson 1969). post-intervention 16/39 (i) experiences little discomfort in social conversation situations. (ii) mild speech problems. (iii) improvement in speech. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 with the therapeutic goals of shames and florance (1980). it must be kept in mind however that attitude change could be due to the fact that he received therapy, and not necessarily as a result of this particular programme. furthermore, the findings of testing immediately after completion of therapy could have influenced these results in that the change in attitude may reflect the subject's desire to please his therapist by showing improvement. these hazards are often inherent in subjective attitude testing. conclusions a therapy programme which differs from previous approaches towards cluttering was used with one clutterer and was found to be clinically effective. while there are obvious limitations in using only one subject, a single case study design does enable the experimenter to make a preliminary investigation into the possible efficacy of certain procedures. a study such as this can be considered as a first step in the investigation of the application of a specific therapy procedure to a population for whom, up to now, few treatment procedures have been evolved. although the subject did not make meaningful changes with regard to prosodic elements, there was a meaningful post-therapeutic improvement in all the other parameters tested. the fact that at the end of the period of intensive therapy, the subject was able to correct himself spontaneously, is evidence that his self-monitoring ability had developed. these findings support the contention of weiss (1967) and arnold (in de fusco and menken 1979) that a clutterer's speech will improve when attention is called to it. it is possible that the improvements noted in the patient's speech post-therapeutically arose out of his desire to please the therapist, and as such was an artifact of the patient-therapist relationship. however his ability to modify his speech seems, to some extent, to be a testament to the effectiveness of the therapeutic programme. while it would have been desirable to have had additional postintervention assessments some months after therapy, this was not feasible. therapy did however continue on a less intensive basis after the conclusion of this study. an informal assessment of the subject's speech, eight months after completion of intensive therapy, showed that he had maintained the improvements noted in his speech and is still motivated to continue working on the programme. according to weiss (1964, 1967), however, clutterers are generally unmotivated to receive therapy. this study indicated the value of an intensive therapy programme for a clutterer. the motivation and success can be attributed in part to the fact that improvement was established quickly, and thus the effort demanded from the subject was justified by the fluent results achieved. in order to ascertain whether it was this particular fluencybased programme, or the intensive nature of its implementation, research must be carried out utilising this technique on a nonintensive basis. it may be short-sighted to rely only on clinical performance as an indication of outcome from fluency-based therapy. measures from . clutterers regarding their attitudes toward communication may provide a firm foundation for the amount of treatment required by an individual clutterer in the normalization of attitude or self-concept. finally, findings imply that additional emphasis should be given to the maintenance of normal prosody in the treatment of a clutterer. inflection and stress exercises, to facilitate normal pitch and decrease the monotony of speech, could be used. benita cohn, joan girson and margaret marks-wahlhaus in conclusion, if the improvement of these dysfluencies, articul ry errors and a slowing down of the rate of speech enables the cut terer to enhance his intelligibility, as has been shown in this stud'" then the value of this approach, even if presently unquantified ^ demonstrated. there is an urgent need for further research and ^ seems appropriate to utilize this approach in order to benefit those clients with cluttering symptoms. reference list andrews, g. and cutler, j. stuttering therapy: the relation between changes in symptom level and attitudes, j. speech hear. dis ord., 39, 312-319, 1974. andrews, g. and ingham, r.j. an approach to the evaluation of stuttering therapy, j. speech hear. res., 15, 296-302, 1972 arnold, g.e. an attempt to explain the causes of cluttering with the llmm theory, folia phoniatrica, 22 , 247-260, 1970. becker, k.p. and grundmann, k. investigations on incidence and symptomatology of cluttering, folia phoniatrica, 22, 261-271 1970. bradford, d. cluttering, folia phoniatrica, 22, 249-272, 1970. dalton, p. maintenance of change: towards the integration of behavioural and psychological problems. in approaches to the treatment of stuttering, dalton, p.(ed.) croomhelm, kent, 1983. dalton, p. and hardcastle, w.j. disorders of fluency and their effects on communication, edward arnold, guildford, 1977. de fusco, e.m. and menken, m. symptomatic cluttering in adults, brain lang., 8, 25-33, 1979. erickson, r.l. assessing communication attitudes among stutterers, j. speech hear. res., 12, 711-724, 1969. grewell, f. cluttering and its problems, folia phoniatrica, 22, 301-310, 1970. ingham, r.j. and andrews, g. stuttering: the quality of fluency after treatment, j. commun. disord., 4, 279-288, 1971. johnson, w., darley, e. and spriestersbach, d.c. diagnostic methods in speech pathology, harper and row publishers, inc., new york, 1963. langova, j. and moravek, m. some results of experimental examinations among stutterers and clutterers, folia phoniatrica, 16, 290-296, 1970. le mesurier, h.g. and mcintosh, e. the pocket oxford dictionary, fourth edition, oxford university press, clarendon, london, 1966. luchsinger, r. and arnold, g.e. voice speech language, chapter 6, belmont, california, wadsworth, 1965. ryan, b.p. and van kirk, b. the establishment, transfer and maintenance of fluent speech in 50 stutterers using delayed auditory feedback and operant procedures, j. speech hear. disord., 39, 3-10, 1973. j shames, g.h. and florance, c.l. stutter-free speech, a goal for therapy, charles, e., merrill publishing company, toronto, 1980. silverman, f.h. research design in speech pathology and audiology, prentice-hall, englewood cliffs, new jersey, 1977. uys, i.c. psigoneurologiese disfiinksie: 'n tipering volgens sekere spraakpatologiese verskynsels, doctoral dissertation in speech pathology, university of pretoria, pretoria, 1974. weiss, d.a. therapy for cluttering, folia phoniatrica, 12, 216-223, 1960. weiss, d.a. cluttering, prentice-hall foundations of speech pathology series, 1964. weiss, d.a. cluttering, folia phoniatrica, 19, 233-263, 1967. wolk, l. diagnostic evaluations of ah adult clutterer: a case report. unpublished m.a.(speech pathology) dissertation. department of speech pathology and audiology, university of the witwatersrand, johannesburg, 1980. the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the current pratices, training and concerns of a group of hospital-based speech therapists working in the area of dysphagia naina modi and eleanor ross department of speech pathology and audiology university of the witwatersrand abstract the aim of the study was to investigate the current practices, training, and concerns of a group of hospital-based speech therapists regarding the area of dysphagia practice. questionnaires were posted to 75 speech therapists working in the major hospitals around gauteng, kwa-zulu natal and the cape province and responses were obtained from 50 therapists within the stipulated time. closed-ended questions were analysed quantitatively using descriptive statistics, while openended items were subjected to content analysis of themes articulated by respondents. results indicated that the overwhelming majority of the respondents were involved in assessing and treating dysphagia patients. specific problems faced by respondents included limited staff to share their workloads, large caseloads, restricted access to supervision / mentor systems and poor knowledge by other health personnel of their role in dysphagia. almost half of the respondents also reported that they were involved in student training which included the area of dysphagia. investigation of respondents' undergraduate and postgraduate training in dysphagia suggested that there were gaps in the theoretical content of these courses as well as a limited focus on practical training. another finding was that respondents showed an awareness of the specific roles of the speech therapist in dysphagia intervention as well as the roles of the professionals constituting a multidisciplinary dysphagia team. most of the respondents reported that they had access to dysphagia team members as well as to diet modification services. however, many of the respondents showed decreased knowledge of and awareness regarding accessibility of diagnostic procedures and suctioning methods used in dysphagia. the majority of the respondents rated their knowledge about specific theoretical areas as well as their counselling abilities to be better than their actual skills and confidence in assessing and treating dysphagia patients. implications of the study included the need for clinicians, universities and professional organizations to work together to improve the existing situation. / key words: dysphagia; practices; training; hospital-based speech therapists introduction of all the areas of work of a speech-language pathologist (slp), dysphagia constitutes the most prominent single area where improper management places patients at risk for physical impairment or even death (cannito, 1995). dysphagia is a disorder of swallowing and refers to the difficulty in moving food efficiently through the oral, pharyngeal or oesophageal areas. dysphagia symptoms may include aspiration, slowed or laboured eating, weight loss, coughing during eating, frequent throat clearing or expectoration, a sensation of swallowed material being retained in the throat, and pneumonia. the patient may also exhibit an inability to keep food in the oesophagus or stomach resulting in reflux (logemann, 1998). while no figures are currently available for the south african population, it is estimated that 6-10 million americans suffer from some degree of dysphagia. speech language pathologists (slps) have been evaluating and managing patients with oropharyngeal dysphagia since the 1930s when clinicians began to work with patients whose oral motor control for speech and swallowing was compromised as a result of cerebral palsy. since then, the involvement of slps in dysphagia has grown steadily, particularly in the united states (logemann, 1998). the 1993 asha omnibus survey (cited in martin, 1995) revealed that approximately 60% of practising slps in health care settings throughout the united states were involved in dysphagia intervention. the role of the slp has also expanded beyond providing assessment and treatment to the overall management of the patient's nutrition and pulmonary health, thereby dealing with severe and complicated problems (langmore, 1991). from the possible complications that can occur as a result of dysphagia, aspiration is most significant clinically. when the airway is unprotected and foreign material is aspirated into the lungs, the patient is at risk of developing pulmonary infection and aspiration pneumonia, a disease that has been identified as the fifth leading overall cause of mortality in the united states (cannito, 1995). the life-threatening nature of dysphagia intervention thus highlights the need for a high standard of service provision. in recognition of this need, asha has revised many of its policy documents defining the scope of practice; die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 naina modi & eleanor ross the preferred practice patterns; position statements; and practice guidelines specifically related to dysphagia (asha, 1993). detailed proficiencies, knowledge and skills have been outlined not only by asha (1989), but also by the college of speech therapists (cst, 1990) as well as the australian association of speech and hearing (aash, 1994). these competencies relate to ensuring effectiveness in the various aspects of dysphagia intervention including: identifying individuals at risk for dysphagia; conducting clinical oropharyngeal and respiratory examinations with detailed case history information; undertaking instrumental structural physiologic examinations with related professionals; determining management decisions regarding methods of oral intake, risk precautions and treatment strategies with other professionals; providing education, counselling and training for patients, their families and other members of the dysphagia team; participating in an interdisciplinary dysphagia team which requires knowledge of the roles of different team members and facilitating team communication, and teaching and supervising supportive personnel and students in training which requires the ability to identify education and clinical training needs and to provide effective supervision and training. essential resources for quality care have also been identified by asha (1989), cst (1990) and aash (1994). these include the availability of allied health professionals who play a critical role in establishing and sustaining a successful dysphagia programme; adequate communication channels amongst the health professionals in the dysphagia team; access to basic appropriate equipment such as gloves, spatulas and torches; availability of suction equipment during oral intake trials; access to specific programmes for non-oral feeding intervention, and facilities for diet modification (aash, 1994). this delineation of the competencies required for high quality dysphagia treatment has served to highlight the main obstacles faced by practising slps. there has been a general finding in the united states, united kingdom and australia that most undergraduate speech pathology courses have not adequately equipped graduates with sufficient knowledge and skills in the area of dysphagia (aash, 1994; martin, 1995). dysphagia has typically been integrated into existing courses resulting in an overwhelming body of information and a decreased amount of hands-on experience and observations (cannito, 1995). slps have been found to be lacking in knowledge of concepts relating to human physiology and seem to have only a vague appreciation of surgical techniques, laboratory data, radiological protocols, medical procedures as well as the roles of various members of the dysphagia team (miller, 1995). much difficulty has been experienced in working with patients in critical care units where continuous cardiopulmonary monitoring occurs. lack of training in this area thus leads to feelings of intimidation and incompetence in treating the critical care patient (martin, 1995). the amount of closely supervised hands-on experience under qualified professionals with demonstrated expertise in dysphagia has also been found to be lacking (miller, 1995) due to the shortage of, or under-utilisation of suitable medically-based practicum sites (groher, 1995). with the high demand for services for both paediatric and adult dysphagia in medical settings, clinicians have been forced to improve their knowledge and skills through alternate sources such as conferences and workshops run by colleagues with self-acquired clinical expertise, through journals and books, and through observing dysphagia clinicians in medical settings (martin, 1995). however, the availability of such resources is limited and most conferences and workshops tend to be short 1-2 day courses which offer limited opportunities to develop practical skills (cst, 1990). these limitations lend themselves to questioning the efficacy of slps' intervention with dysphagia. logemann (1998) suggests that the ultimate test of efficacy relates to the number of patients who are managed effectively and the percentage of hospitals that exhibit multidisciplinary dysphagia programmes. several steps have been taken to identify possible solutions for the gaps in dysphagia training and intervention. martin (1995) emphasises the important role of position statements and guidelines which clearly outline the proficiencies, knowledge bases and competencies required for the effective provision of services in specific areas. she also describes the benefits of creating special interest groups where slps with similar clinical and research interests are able to interact and exchange information on a regular, structured basis. specific plans should also be developed in order to recognise individuals demonstrating a particular expertise in an area of clinical practice. this goal could, for example, be achieved by developing a dysphagia speciality certification programme which recognises such professionals and utilises their services as clinical competency instructors for novice clinicians in the field (martin, 1995). the development of a comprehensive graduate core curriculum for speech -pathology programmes in universities around the country is likely to ensure that all slps are able to demonstrate basic clinical competencies in dysphagia management before actually treating medical patients (martin, 1995). it is evident from the literature that asha, aash as well as the cst are all actively involved in trying to implement the above recommendations. a position paper of the cst drafted in 1990 outlines the recommended levels of training required for undergraduate and postgraduate studies in dysphagia. detailed information is provided on specific objectives, aims, course content and clinical experience to be achieved at the undergraduate and postgraduate levels. similarly, the aash position paper (1994) clearly describes the knowledge and skills needed for effective assessment and treatment as well as for exercising necessary safety precautions related to cross-infection and emergency situations. the ad hoc committee on dysphagia (asha, 1987) outlined the guidelines for adequate clinical preparation needed to conduct competent evaluation and management of dysphagia. specific attention was also paid to the slps scope of practice in relation to instrumental diagnostic procedures for swallowing, including videofluroscopy, pharyngeal manometry, manoflurography, ultrasonography, scintigraphy and electromyography (asha, 1991). in summary, countries such as the united states, united kingdom and australia, have identified the following key components that comprise an acceptable standard of service in dysphagia: a) adequate training in dysphagia at an undergraduate and postgraduate level including·, (i) a separate detailed module on dysphagia; (ii) supervised hands-on practical training at medically-based practicum sites; and (iii) the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the current practices, training and concerns of a group of hospital-based speech therapists working in the area of dysphagia 5 experience with working on an interdisciplinary level b) adequate knowledge of slps regarding: (i) human anatomy related to dysphagia; (ii) risk factors in dysphagia; (iii) instrumental procedures used in dysphagia assessment and intervention; (iv) the roles of the key members in a dysphagia team; and (v) medical terminology and conditions associated with dysphagia c) access to essential resources in the work setting including: (i) appropriate equipment; (ii) diet modification services; (iii) and key members of the dysphagia team in view of the nature of the problems identified in these developed countries, it was postulated that similar problems were probably being experienced by slps working in south africa. training for a career in speech pathology is limited to selective larger universities throughout south africa and the typical size of such departments is relatively small in contrast to other medical and paramedical professions. a separate course in dysphagia may thus not be common in these departments due to financial constraints. furthermore, not all of these departments may be comprehensively linked to a medically-based practicum site. the knowledge and experience gained by slps may thus be inadequate in a number of areas including instrumental evaluations, teamwork, medical conditions as well as oropharyngeal anatomy. in spite of the fact that therapists may feel inexperienced and incompetent in dealing with dysphagia patients, they may be unable to retract their services due to a lack of manpower and also due to the fact that they still appear to know more about dysphagia than many other health professionals. furthermore, in view of the general economic crisis currently confronting the south african health sector, slps are also being faced with limited resources in terms of support services and equipment (white paper for the transformation of the health system in south africa, 1997). while the role of the slp in the treatment of dysphagia is recognised in many countries, it was envisaged that the same might not be occurring in the south african situation. according to the preliminary draft of the policy document for communication professionals (1993) in south africa, 'individuals with dysphagia were not included as a separate client group, suggesting that at the time in south africa, the role of the slp in dysphagia treatment was not well recognised both within and outside the profession. the neglect of dysphagia may also be partly related to current health care policy as articulated in the white paper for the transformation of the health system in south africa (1997), which emphasises a primary health care approach. dysphagia treatment, on the other hand, utilises expensive high technology equipment and requires high levels of expertise, thus falling within the ambit of tertiary health care. nevertheless, the risks for pulmonary infections and aspiration pneumonia coupled with high mortality rates, make dysphagia intervention of critical importance. educational standards, access to services and standards of facilities all contribute to the process of quality assurance, yet research into dysphagia training and practice among slps in the south african context has been extremely limited with few studies focusing specifically on dysphagia training and practice. information about the extent of involvement of south african slps in dysphagia intervention is important, but even more crucial than this aspect is the standard and quality of current dysphagia practices. by investigating clinicians' knowledge and concerns regarding dysphagia intervention and linking this information to their training and practical experience, it was anticipated that major gaps might be identified in present undergraduate and postgraduate training curricula. it was further envisaged that insight into the types of obstacles faced by practising clinicians might highlight factors preventing comprehensive dysphagia intervention. this type of information is vital for therapists motivating for equipment and staff. in view of the fact that the south african speechlanguage hearing association (saslha) was involved with drawing up a position paper on dysphagia at the time the present study was undertaken (saslha, 1996), it was considered useful to gain insight into the training, current practices, knowledge and fears of slps working in dysphagia. the present study thus aimed to investigate these areas amongst hospital-based slps in south africa so that the information could be fed back to the professional body and relevant academic institutions. methodology aim main aim the overall purpose of the research project was to explore the current practices, training, knowledge and concerns of a sample of slps working in hospitals regarding dysphagia intervention. sub-aims: 1. to explore current practices of a group of hospital-based slps with regard to dysphagia management. 2. to investigate the undergraduate and postgraduate training of respondents with respect to dysphagia. 3. to elicit respondents' views regarding the role of the speech therapist in the dysphagia management team. 4. to investigate respondents' knowledge and perceptions of multidisciplinary teamwork in dysphagia management. 5. to obtain information on respondents' access to essential resources 6. to explore their self-perceived levels of professional competence and emotional comfort with regard to the area of dysphagia. 7. to explore respondents' general views and concerns regarding the management of dysphagia. research design the research project was undertaken in the form of a cross-sectional survey employing a postal questionnaire. subjects a convenience sample was surveyed which comprised 75 speech-language pathologists (slps) working at 24 provincial hospitals in gauteng, kwa-zulu natal and the cape province. it was assumed that these therapists would probably have more contact with dysphagia patients than therapists working in other settings, and that the complexities involved in managing dysphagia patients might be more die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 obvious in an acute care setting where life-threatening medical problems often co-exist with dysphagia. procedure research instrumentation in view of the cost implications related to the large sample size and wide geographical distribution of the respondents, a postal survey was chosen as the most appropriate research method for the purposes of this study. a copy of the questionnaire is available from the authors on request. the questionnaire comprised seven sections: section a: biographical data the aim of this section of the questionnaire was to obtain data on factors such as year and university of graduation as well as amount of work experience in a hospital setting. section β : current practices in dysphagia management the aim of this section was to obtain information about the number of speech therapists working in respondents' departments; respondents' involvement in the area of dysphagia management; respondents' involvement in student training; involvement of students in dysphagia intervention, and sources of referral of dysphagia patients. section c: training in dysphagia this section was divided into two sub-sections. questions in the first section related to respondents' undergraduate training in dysphagia intervention. perceptions of the adequacy of their training were assessed via a five-point rating scale. the second part of this section focused on respondents' postgraduate training. section d: speech therapists' role in dysphagia management the first part of this section aimed to investigate table 1: description of the subjects (n=50) naina modi & eleanor ross respondents-perceptions of the specific roles of the speech therapist in dysphagia intervention. an additional aim of this section was to investigate respondents' perceptions about whether this role was recognised by their medical and paramedical colleagues. the second part focused on respondents' perceptions and knowledge about teamwork as it relates to dysphagia intervention as multidisciplinary teamwork is strongly advocated in the literature as being the most appropriate model of care in dysphagia (logemann, 1990). section e: access to resources access to resources has been identified as one of the key elements of an effective service. the questions in this section thus aimed to obtain information about respondents' access to various diagnostic procedures, diet modification services, suction equipment, other health professionals and a system of supervision and mentoring. section f: knowledge and competence therapists' selfperceived knowledge and competence in the area of dysphagia are likely to affect their comfort and confidence levels in handling dysphagia patients and counselling their families. respondents' were thus asked to rate their knowledge, skills and feelings in relation to specific areas of dysphagia on a five-point rating scale. section g: general views on management of dysphagia this section consisted of further open-ended questions to elicit information regarding respondents' general concerns and comments about the area of dysphagia as well as their suggestions for overcoming these concerns. pilot study the questionnaire was pre-tested on three slps who had previously worked in hospital settings, but were excluded demographic number of factor respondents percentage witwatersrand 17 34% university pretoria 1 28% of durban-westville 15 30% graduation cape town 2 4% stellenbosch 1 2% reading (england) 1 2% total 50 100% before 1980 1 2% year 1980-1984 2 4% of 1985-1990 8 16% graduation 1991-1994 14 28% 1995-1998 25 50% to tal 50 100% <1 year 12 24% number of years 1 to < 3 years 18 ' 36% working in 3 to <6 years 10 20% a hospital 6 to <10 years 8 ζ 16% >10 years 2 4% total 50 100% the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the current practices, training and concerns of a group of hospital-based speech therapists working in the area of dysphagia 7 from participation in the field study. based on the results of the pilot study, various changes were made to the questionnaire. field study the heads of the speech therapy departments at the 24 hospitals involved were thus contacted telephonically. information about the purpose of the study was provided and the number of therapists working in each department was confirmed. questionnaires were then posted to the various departments and due dates for their return was stipulated in the cover letters. a follow-up telephone call was then made approximately one week later to ascertain whether the departments had received the questionnaires. data analysis descriptive statistics were employed to analyse the responses obtained from the closed-ended items in the questionnaire, while content analysis was used to analyse open-ended questions qualitatively according to themes expressed by respondents. results and discussion to the years of working experience of these therapists, it emerged that almost one-fifth (18%) of the respondents were working in departments where all the therapists had less than three years' working experience i.e. they were all junior therapists. even more disconcerting was the finding that 8% of these respondents were working alone in their departments with no support from other junior or more senior experienced staff. these results suggested that many of the respondents might have been experiencing difficulty in obtaining the necessary support and guidance from more experienced or senior colleagues. it was therefore recommended that efforts be made to organise such supervision/mentor systems in conjunction with other hospitals and with university staff members. the need for supervision has been highlighted as an ethical responsibility for clinicians with limited experience (aash, 1994: sashla, 1998) a further finding in this section was that respondents received most referrals of dysphagia patients from doctors (82%) and considerably fewer referrals from allied health disciplines. this finding suggested poor knowledge of the role of slps in dysphagia by other health professionals. the need for slps to advocate their role and services in dysphagia as well as to educate health professionals was thus highlighted. self-administered questionnaires were sent out to 75 slps working in the major provincial hospitals around gauteng, kwa-zulu natal and the cape province, from which a 67% response rate was obtained. results are discussed in accordance with the sub-aims of the study. current practices investigation of respondents' current practices in dysphagia revealed that the overwhelming majority of respondents (90%) were involved in assessing and treating dysphagia patients. a minimum of 1-5 patients were seen by most respondents (62%) on a monthly basis. almost half (46%) of the respondents also reported that they were involved in student training and this training included the area of dysphagia management. these findings highlighted ythe need for respondents to be adequately trained in dysphagia practice at an undergraduate level. this need was further emphasised by the fact that many respondents were working in small departments that had a limited number of more experienced senior staff. opportunities for supervision and mentoring were thus thought to be limited. the results indicated that the majority of the respondents (56%) were working in small departments consisting of only 1-4 therapists. when this fact was related the training of respondents in dysphagia undergraduate training results displayed in table 2 indicate that dysphagia was covered in the vast majority (96%) of the respondents' undergraduate courses. amost disconcerting finding related to two respondents who reported that they were actively involved in assessing and treating dysphagia patients despite not having received any basic training in dysphagia at an undergraduate level. although both respondents did report attendance at continuing education courses and workshops, the exact level of this input could not be ascertained. this finding has serious implications as the code of ethics (saslha, 1997) clearly stipulates that slps should provide only those services for which they hold the appropriate qualification and for which they are competent by training. a lack of adherence to this principle is potentially harmful to the client, particularly in the area of dysphagia practice where improper management may have life-threatening consequences (cannito, 1995). within the group of 48 respondents who received dysphagia training in their undergraduate studies, more than two-thirds (73%) reported that dysphagia was not table 2: dysphagia courses in undergraduate training dysphagia included in undergraduate courses n=50 no yes no. 2 48 percent 4% 96% whether dysphagia was included as a separate or integrated course n=48 number percent separate module 13 27% integrated course 35 73% die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 naina modi & eleanor ross taught as a separate module, but rather integrated into other speech pathology courses. toner (1995) suggests that this integration of the dysphagia module is typical in small speech therapy departments where the teaching load already exceeds university recommendations and therefore precludes the addition of new courses. he further states that this situation frequently results in a focus on theory with limited time for observation and hands-on experience, and therefore recommends that a separate course in dysphagia is a necessity. approximately half (48%) of the respondents reported that their undergraduate speech therapy departments had not been linked to medically-based practicum sites. however, students are generally required to complete a clinical block at a hospital setting, thus it can be assumed that dysphagia practice is incorporated into the student training by such hospital-based clinicians. with regard to the theoretical areas in the undergraduate courses as suggested by asha (1989), cst(1990) andaash (1994), most of the respondents were apparently taught about the anatomy and physiology of swallowing (86%), medical conditions and disorders related to swallowing (73%), assessment methods in dysphagia (79%) and management procedures in dysphagia (75%). however, the areas of legal and ethical issues (52%), the roles of team members (50%) and safety and emergency procedures (65%) and did not appear to be covered in the majority of the respondents' undergraduate. these results are summarised in table 3. findings in respect of safety and emergency procedures are particularly disturbing if one considers that hospitalbased slps are frequently faced with complex, medically unstable dysphagia patients. consequences such as choking, aspiration and malnutrition are therefore a daily reality for dysphagia clinicians in acute care settings (mirro and patey, 1991). it is thus essential for clinicians to have adequate knowledge of emergency and safety techniques in order to prevent or intervene in the event of medical complications (asha, 1987; cst, 1990). although clinicians may often not be personally trained in emergency procedures, they still need to ensure that appropriate safety equipment and trained personnel are available during potentially dangerous situations (aash, 1994). clinicians should also be aware of local policy and guidelines in the area of crossinfection (aash, 1994; saslha, 1998). the limited number of respondents who reported receiving this input during their undergraduate training is very disconcerting. saslha (1998) lists routine precautions for infection control in a hospital setting but no specific attention is paid to the area of dysphagia. an added concern is the lack of attention in the document on the precaution against hiv transmission, especially in view of current health policy stressing that health care workers are in high risk situations for hiv transmission (college of medicine of south africa, 1991). it is therefore recommended that saslha use kulpa's (1990) guidelines for slps with regard to safety precautions against hiv transmission and management of patients. practical clinical training at an undergraduate level was investigated according to the guidelines provided by cst (1990), asha (1991) and aash (1994). according to table 4, the vast majority of the respondents reported that they did not receive any level of the recommended practical training at the undergraduate level. this is a disconcerting finding as these guidelines serve to ensure that students receive comprehensive clinical training. while it may be understandable that independent assessment and treatment of dysphagia patients may not be allowed due to the high risk nature of the area, this factor does not account for students not practicing techniques on normal subjects or even observing and assisting qualified professionals. based on these findings, it is not surprising that the overwhelming majority (92%) of the respondents rated their undergraduate training as poor. the most common reason given by respondents was the lack of practical training included in their undergraduate courses. similar findings were obtained in an asha standards validation study which aimed to validate the professional domains, tasks, knowledge and skills in the general practice of speechlanguage pathology (cited in bernthal and bankson, 1992). respondents recommended an increase in practical training hours in order to ensure that students have a variety of experience with individuals with various disorders of differing severity. other reasons provided by respondents for rating their undergraduate training as poor, included the lack of a specific dysphagia module, the limited number of lectures on dysphagia, an insufficient amount of information covered theoretically, poor structuring of the course and a lack of exposure to teamwork. postgraduate training almost two-thirds of the respondents (64%) in the study indicated that they had attended conferences, lectures or areas covered in courses not covered in courses no responses anatomy / physiology 86% 6% 8% medical conditions 73% 21% 6% assessment 79% 13% 8% management 75% 17% 8% ethical issues 35% 52% 13% safety issues 25% 65% 10% roles of team members 50% 40 10% table 3. theoretical areas in dysphagia covered at an undergraduate level (n = 48) the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the current practices, training and concerns of a group of hospital-based speech therapists working in the area of dysphagia 9 workshops after graduation. respondents' attendance at postgraduate courses indicates their awareness of their responsibility to continue their education after qualification in order to maintain a high standard of professional competence (saslha, 1997; saslha, 1998). technological advances and everincreasing knowledge bases demand that clinicians acquire current levels of expertise through various forms of continuing education. almost half (47%) of the postgraduate courses attended by respondents were one day in length. more importantly, none of the courses extended for as long as a week and therefore did not comply with recommendations by logemann (1995) in terms of length of course, namely 5-6 workshops, each of 2-3 days in length. such courses are probably inappropriate in the south african situation where staff and financial resources for rehabilitation services are poor (white paper for the transformation of the health system in south africa, 1997). clinicians therefore have to maximise existing resources by considering their access to the major providers of continuing professional education in speech-language pathology. rassi and mcelroy (1992a) identify these providers as being: a) college and universities; b) state and national professional associations and public agencies; c) hospitals and clinics, and d) independent providers such as publishers and equipment manufacturers. the content included in the courses attended by the respondents was investigated according to the theoretical areas recommended by asha(1989), cst (1990) and aash (1994). these results are summarised in table 3.3. the vast majority of respondents (94%) reported the inclusion of anatomy and physiology related to dysphagia. all the respondents (100%) also reported that the procedures and techniques of dysphagia assessment and management were covered in their postgraduate courses. in contrast, only about half of the respondents reported the inclusion of interdisciplinary teaching and clinical practice on normal subjects and dysphagia patients. this finding is disconcerting as a lack of multidisciplinary management in dysphagia has been shown to lead to fragmented patient care (lefton-grief and arvedson, 1997). the limited inclusion of clinical practice with both normal subjects and with dysphagia patients in respondents' postgraduate courses is also of great concern in view of the restricted hands-on training received by most respondents during their undergraduate courses. this finding is not unique to the south african situation. inherent in this finding is the lack of recognition that practical training plays a vital and integral role in the educational preparation of slps (rassi and mcelroy, 1992b). respondents in the study thus apparently had limited opportunities for application of theoretical knowledge in the clinical setting during both undergraduate and postgraduate training. once again, the table 4: practical training in dysphagia at an undergraduate level (n=47)* / / practical areas covered in training not covered in training practising dysphagia assessment and treatment with normal subjects 4% 96% observing dysphagia assessment and treatment with dysphagia patients 34% 66% assisting with dysphagia assessment and treatment of dysphagia patients under supervision 15% 85% ' independent dysphagia assessment and treatment of dysphagia patients 4% 96% interdisciplinary dysphagia assessment and treatment of dysphagia patients 4% 96% * not applicable to 2 respondents; 1 respondent failed to respond table 5. content of postgraduate courses in dysphagia (n=38) areas covered in courses not covered in courses no responses anatomy/physiology 94% 3% 3% assessment procedures & techniques 100% 0% 0% management procedures and techniques 100% 0% 0% interdisciplinary teaching 56% 38% 6% clinical practice on normal subjects 50% 47% 3% clinical practice on dysphagia patients 53% 44% 3% die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 naina modi & eleanor ross findings highlight the need for the professional organisation for slps to develop a position paper on dysphagia so that appropriate standards of postgraduate courses can be established and maintained. only half of the respondents (50%) who attended postgraduate training rated it as good. a further 44% of the respondents rated their training as average, while a limited number of respondents (6%) felt that the training was poor. various positive aspects of the postgraduate courses were described by respondents. the most common aspect related to the opportunity for practical training and the fact that the trainers were adequately qualified experts working in the field. other positive factors included the adequacy of the course content in terms of material not covered at an undergraduate level, information on new advances in the field, input from various professionals and the relevance of material to the hospital environment. a focus on multidisciplinary work and counselling skills as well as specific training on interpreting normal and abnormal videofluroscopic studies was also described as being particularly beneficial. as with the undergraduate training, limitations of postgraduate courses described by respondents related most frequently to the lack of practical training included in the courses. role of the speech therapist with regard to the role of the slp in dysphagia, the vast majority of the respondents showed an awareness that the slp should be involved in all areas including identification of dysphagia patients (90%), assessing and treating dysphagia patients (100%), establishing and co-ordinating a multidisciplinary team (78%), providing information to patients and caregivers (100%),educating other health professionals about dysphagia (100%) and conducting research on normal and abnormal swallowing (98%). this finding was encouraging as these roles of the slp are emphasized in the literature and by the various professional organizations. the overwhelming majority of the respondents (90%) felt that the role of the slp in dysphagia management was only partially recognised by their medical colleagues. the most common reason cited by respondents for the lack of full recognition by medical colleagues related to the lack of knowledge not only of their role in dysphagia but also the general areas of work of a speech therapist. respondents claimed that this lack of knowledge was evident in the limited number of referrals generally and the number of inappropriate referrals received. respondents reported that referrals were made by a restricted number of doctors usually older doctors who had been educated by speech therapists over the years or newly trained doctors who had a rehabilitation week included in their undergraduate training. underlying reasons suggested by respondents for this poor knowledge included the lack of information on rehabilitation provided to doctors at an undergraduate level and the fact that most speech therapy departments were not situated at medical schools where doctors are trained. respondents also felt that the limited numbers of speech therapists in the hospital setting as well as general time constraints severely restricted attendance at ward rounds and participation in teamwork as well as opportunities for initiating contact with doctors. the majority of the respondents (71%) felt that their role in dysphagia was only partially recognised by their paramedical colleagues. as with medical staff, the main reason offered by respondents for the lack of full recognition, related to the limited knowledge about the specific role of the speech therapist in dysphagia. respondents felt that this lack of knowledge was reflected in the small number of paramedical staff who referred patients, the restricted number of referrals received, the fact that most dysphagia patients were initially referred only as speech/language patients, and the fact that only patients with severe dysphagia symptoms were referred. these findings serve to highlight the importance of interdisciplinary teaching at an undergraduate level so that there is carryover into the work setting after qualification. respondents also highlighted the critical need for clinicians to actively market their role in dysphagia practice. knowledge and perceptions of multidisciplinary teamwork in dysphagia all the respondents (100%) felt that teamwork was role of the slp yes no ; identification of dysphagia patients 90% 10% i assessment of dysphagia patients 100% 0% treatment of dysphagia patients 100% 0% establishing a multidisciplinary team 92% 8% co-ordinating a multidisciplinary team 78% 22% providing information to patients and caregivers 100% 0% education of other health professionals 100% 0% conducting research on normal and abnormal swallowing 98%* 0% *1 respondent did not respond table 6: role of the speech-language pathologist in dysphagia (n=50) the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the current practices, training and concerns of a group of hospital-based speech therapists working in the area of dysphagia 11 necessary for assessing and managing dysphagia patients. several investigators have in fact reported that comprehensive treatment by an interdisciplinary team has led to improved management of patients' nutritional status, reduced likelihood of complications, greater cost-effectiveness of treatment and earlier discharge of patients (young and durant-jones, 1990). furthermore, the majority of respondents showed an awareness of which professionals comprise a multidisciplinary dysphagia team. the overwhelming majority of the respondents included all the professionals listed as part of the dysphagia team, namely dieticians, physiotherapists, occupational therapists, neurologists, doctors, nurses, radiologists and ear, nose and throat specialists. access to essential resources respondents' access to essential resources for dysphagia practice was investigated. these sources included various diagnostic procedures, suctioning equipment, diet modification services, dysphagia team members and supervision / mentor systems. with regard to diagnostic procedures, the overwhelming majority of the respondents (98%) indicated that they had access to x-rays as a diagnostic procedure. only approximately half of the respondents (54%) indicated that they had access to videofluoroscopy. almost one-third (32%) did not have access, while a further 14% failed to respond to the question. this relatively high rate of a lack of response could be related to respondents being unaware of whether the diagnostic procedure was available or not, which could imply limited use of the procedure in dysphagia management. this finding is disconcerting as videofluoroscopy, specifically the modified barium swallow has been described as the 'gold standard' in the evaluation and treatment of dysphagia (mchorney and rosenbek, 1998). a number of implications arise from the responses furnished by clinicians in the study. firstly, there is a need for respondents to be aware of the specific uses of videofluoroscopy in dysphagia assessment and treatment. efforts also need to be made by respondents to find out about access to this diagnostic procedure. lastly, if there is a lack of access to video/fluoroscopy, respondents need to be aware of alternative diagnostic procedures as well as the need for more conservative management as suggested by groher (1995). comprehensive knowledge of assessment procedures and techniques thus needs to be provided at an undergraduate level. | many of the respondents (32%) failed to respond to the question about access to ultrasound and a further 6% indicated that they were unsure of availability of this procedure in their work settings. hence, it can be postulated from these results that limited use was made of this procedure as a diagnostic tool even if it was available. the results also suggest poor knowledge of instrumental procedures by many respondents. a very limited number of respondents (38%) indicated that they had access to ultrasound. the unique characteristics of ultrasound make the procedure an important part of the comprehensive diagnosis of dysphagia. limited access and possibly poor knowledge of the procedure thus places respondents and patients at a distinct disadvantage for more comprehensive holistic care. increased understanding of instrumentation in dysphagia therefore needs to be facilitated at an undergraduate level. almost half of the respondents (46%) failed to respond to the question about scintigraphy and a further 8% indicated that they were unsure of access to this procedure in their work settings. once again, it can be postulated that this finding reflected limited knowledge of the procedure and limited use of it as a diagnostic tool even if it was available. only 10% of the respondents indicated access to scintigraphy while 36% were sure about not having access to the procedure. this finding is not surprising particularly in the south african situation considering that scintigraphy is both costly and requires specialised nuclear medicine expertise (sonies, 1991). the present focus of the south african health department is to shift expenditures and commission equipment for the delivery of primary health care services (white paper for the transformation of the health system in south africa, 1997). in line with this focus, national policy and guidelines have been developed for essential technology. similar findings in relation to previous diagnostic procedures were obtained with respect to fibreoptic endoscopic examination of swallowing (fees). almost half (46%) of the respondents failed to respond while a further 10% indicated that they were unsure of access to fees. an extremely limited number of respondents (8%) indicated that they had access to fees, while 36% did not have access to this procedure. the accuracy of this finding is questionable if one considers that this procedure is routinely used by ents for assessing the integrity of the laryngeal and pharyngeal structures (logemann, 1998). it is therefore disconcerting that many of the respondents appeared to be unaware of access to this procedure and were therefore presumably making limited use of it as an effective tool for dysphagia management. with regard to electromyography (emg), almost half of the respondents (46%) failed to respond and a further 6% indicated that they were unsure of whether emg was available in their work settings. a mere 10% of the respondents indicated access to emg while more than onethird (38%) were sure about inaccessibility. it is important for clinicians to be aware of the specific use of this diagnostic procedure as an assessment and therapeutic tool in dysphagia, especially in the presence of neuromuscular disorders. the procedure may also prove to be useful in the absence of other procedures, especially in the south african situation where resources are limited. there are therefore serious concerns regarding the large number of respondents who appeared to be unaware of the availability of emg as well as the large number who did not have access to this resource. appropriate referrals for specific patients are therefore compromised and this situation, in turn, may impact on early diagnosis and comprehensive care. the results of access to manometry followed a very similar pattern to those for the other diagnostic procedures. the largest proportion of the respondents (46%) did not respond to the question, while 8% indicated their uncertainty about access to manometry. only 8% of the respondents indicated definite access to the procedure, while 38% clearly had no access to this resource. almost one-third of the respondents (31%) indicated that they did not have access to suctioning equipment in their work settings. this result was surprising as one would have expected the standard availability of suction equipment in a hospital setting where it is regularly used by nurses and physiotherapists in patients with chest conditions. it can therefore be postulated that respondents had limited die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 naina modi & eleanor ross knowledge about suction equipment and were therefore unaware of available access to it. this finding is extremely worrying as suctioning can play a critical role during management of dysphagia patients. limited knowledge of access to suction equipment suggests that respondents were not familiar with safety and emergency procedures in the event of choking or aspiration. this finding is not surprising in view of earlier findings that almost two-thirds (65%) of the respondents reported that safety and emergency procedures were not covered in their undergraduate courses. poor knowledge of these procedures has potentially lifethreatening implications for patients, especially those with chronic pulmonary disease. there is therefore an urgent need for undergraduate curricula in dysphagia to incorporate the area of safety and emergency procedures. furthermore, a dysphagia position paper by saslha could serve to highlight potential risk factors in dysphagia and the necessary precautions that need to be undertaken. the overwhelming majority of respondents (94%) indicated that they had access to diet modification facilities. this finding is important for dysphagia management as diet modification is a specific strategy in the assessment and treatment of swallowing disorders. standard hospital diets often pose problems for dysphagia patients. the overwhelming majority of the respondents indicated that they had access to all the team members mentioned i.e. dietician, physiotherapist, occupational therapist, neurologist, doctor, nurse, radiologist and ent. the results indicate that more than half (54%) of the respondents did not have any system of supervision/ mentoring operating in their departments. cst (1990) and aash (1994) state that it is the medico-legal and ethical responsibility of slps who are aware that they lack the desired level of skill to seek guidance from more senior or experienced staff before intervening in management of the patient. the principle of ethics ii (asha, 1994) clearly stipulates that clinicians should engage in only those aspects of the profession that are within the scope of their competence considering the level of their education, training and experience. saslha (1998) also states that negligence can be proved in instances where it is clear that intervention should have been undertaken by a more experienced clinician or the inexperienced therapist should have requested supervision. the lack of respondents' access to a system of supervision or mentoring in dysphagia management has serious implications. without the institution of an organised system of supervision or mentoring, many of the respondents might not have been getting the necessary support and assistance from more experienced staff and the level of clinical service might not have been optimal for the patient. this possibility, in turn, raises questions about quality assurance at the work settings in the study. just under half of the respondents (46%) indicated that there were systems of supervision or mentoring operating in their departments. there was a combination of both formal and informal systems being implemented at the time of the study, and this situation depended largely on the presence and level of experience of more senior staff. there appeared to be a specific focus in many departments on new graduates. these clinicians were either specifically assigned to senior supervisors or were simply made aware of available assistance whenever needed. some of the respondents also reported that their heads of department and senior staff took responsibility for organising regular case discussions and continuing education and also encouraged new graduates to attend outside courses and conferences. rassi and mcelroy (1992a) found that this responsibility of senior staff for more junior personnel was important as most professionals cannot easily identify their learning needs and therefore require guidance and assistance in structuring their continuing professional education. an overwhelming majority (98%) of the respondents felt that a system of supervision or mentoring for dysphagia treatment was important. they linked the need for supervision to the life-threatening nature of the work and many expressed concern about the safety of the patients. a number of the respondents also remarked on the challenging, stressful and frightening nature of dysphagia management. the lack of confidence and feeling of incompetence in new graduates and junior therapists was a frequently cited concern and these feelings were linked by many respondents to limited undergraduate training in dysphagia, especially with respect to the practical component. it was felt that supervision and mentoring would allow for the development of experience and confidence, as well as for accountability to the patient and the profession as a whole. respondents felt that supervision would give therapists the opportunity to recognise their own limitations and thereby not compromise optimal care of the patient. the large caseload of dysphagia patients within hospitals was also of concern to respondents and the need for quality assurance measures was highlighted. in addition, respondents recognised that dysphagia management is a growing field with new advancements occurring all the time. therefore the need for sharing information, knowledge and skills was vital. respondents' concerns in this area highlight the need for a position paper in south africa which could specify the need for supervision as formulated by cst (1990) and aash (1994). knowledge and competence knowledge almost half of the respondent (46%) rated their knowledge on human anatomy related to dysphagia as being average while a further 42% rated their knowledge as being good. this finding was not surprising as the majority of the respondents indicated that they had covered this aspect theoretically in their undergraduate training. in addition, the theory on anatomy was covered in 94% of the postgraduate courses attended by respondents. j the majority of the respondents (58%) rated their knowledge of the risk factors in dysphagia as being good. this finding was not unexpected as the majority of the respondents (70%) were exposed to the various medical conditions and disorders resulting in dysphagia at an undergraduate level. the majority of the respondents rated their knowledge about instrumental procedures as poor (36%) or average (38%). earlier results had indicated that assessment procedures and techniques had been covered in the majority of respondents' undergraduate and postgraduate courses. however, respondents' knowledge and awareness of access to specific instrumental procedures was found to be limited when access to resources was probed. this finding suggests that respondents' knowledge might have been restricted to commonly used procedures such as x-rays and videofluoroscopy and their limited knowledge about other procedures the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the current practices, training and concerns of a group of hospital-based speech therapists working in the area of dysphagia 13 may have been highlighted by the question on access to resources. the largest proportion of the respondents (48%) rated their knowledge of alternate feeding methods as good. this finding could be anticipated in view of the fact that procedures and techniques of dysphagia management were reported to have been covered theoretically in the majority of the respondents' undergraduate training. the majority of the respondents (65%) rated their knowledge of the roles of key dysphagia team members as good. this finding can only be partially attributed to respondents' training as the roles of team members were reportedly covered in only approximately half of the respondents' undergraduate and postgraduate courses. it can be postulated that respondents' self-perceived 'good' knowledge of the roles was also related to their access and exposure to various team members in their work settings. the majority of the respondents rated their knowledge about medical terminology and conditions associated with dysphagia as being either average (40%) or good (42%), i.e. only 18% rated their knowledge as poor. this finding is not surprising if one considers that this area was covered in the majority (70%) of the respondents' undergraduate training. skills just under half of the respondents (47%) rated their skills in assessing dysphagia patients as average i.e. a limited number of respondents (29%) rated their skills as good. this finding was not surprising considering the fact that the vast majority of respondents reported limited opportunities for practical training in both undergraduate and postgraduate courses attended. these results suggest that the provision of theoretical knowledge without the accompanying practical experience was perceived by respondents as inadequate in terms of preparation of their skills for use in the workplace. this finding of a lack of practical training in dysphagia courses is well documented in the literature (toner, 1995). , inadequate skills with regard to assessing patients has serious implications for the safety of patients as clinicians /need to make accurate diagnoses in order to implement appropriate treatment. the life-threatening risks of choking and aspirating demand ajhigh level of skill in assessment of dysphagia patients and highlights, once again, the need for position statements which guide effective training of students at an undergraduate level and clinicians at a postgraduate level. i as with the assessment of dysphagia patients, the largest proportion of the respondents (49%) rated their skills in treating dysphagia patients as being average. similar reasons can be postulated for this finding i.e. the limited practical hands-on training gained by the respondents during their undergraduate and postgraduate courses. feelings of emotional comfort or confidence the largest proportion of the respondents (41%) rated their feelings of emotional comfort or confidence in handling dysphagia patients as average. inadequate theoretical and practical training provided at courses attended, large case loads, limited knowledge of safety and emergency procedures and limited access to support systems from more experienced professionals were probably all factors contributing to decreased emotional comfort and confidence levels in handling dysphagia patients. a possible implication of such feelings is that clinicians may then not be willing to engage in active advocacy regarding the professionals' role in dysphagia and may also project a poor image of the profession by not being assertive in their knowledge, skills and decision-making. probably one of the best ways of improving respondents' emotional comfort and confidence levels in handling patients is to ensure effective training at an undergraduate level. the majority of the respondents rated their feelings of emotional comfort or confidence in counselling the families of dysphagia patients as being average (37%) or good (39%). a possible explanation for respondents being more comfortable or confident with counselling the families as compared to actual handling of patients is that respondents might have been experienced with counselling in general as it is incorporated regularly into all areas of work in speech and language pathology. furthermore, respondents had generally rated their knowledge about dysphagia better than their skills in handling dysphagia patients. a large component of counselling families includes the sharing of information and therefore requires a good theoretical knowledge base. general views and concerns at the end of the questionnaire, respondents were given the opportunity to express their general views and concerns about the area of dysphagia. the types of concerns cited by respondents included inadequate training in dysphagia at an undergraduate level (particularly limited hands-on practical training and lack of knowledge of safety and emergency procedures); poor knowledge of the role of the slp in dysphagia by other health professionals; limited resources available (including objective diagnostic instrumentation, suction equipment, postgraduate courses and continuing education, experienced contact people in the field, monthly support groups with more experienced clinicians, and guidance and supervision within the work setting); and the need for quality assurance measures. respondents' suggestions for overcoming these concerns related to improving undergraduate and postgraduate training, maximising limited resources and the need for policy documents.considering dysphagia as only a postgraduate specialisation area was described by respondents as being impractical since all hospital speech therapists were faced with the ethical responsibility of treating dysphagia patients on a daily basis. in addition, it is recommended that supervision/mentoring systems be implemented using existing resources and expertise from both academic institutions and hospital departments. more than half (59%) of the respondents proposed strategies for dealing with the inadequacies of undergraduate training. it was felt that the course should be taught as a separate module which was structured to provide students with a firm theoretical grounding. significantly more emphasis on the practical hands-on training in dysphagia assessment and treatment was suggested with both normal subjects and dysphagia patients. respondents also felt that students should be involved in more clinical practicals at hospitals in order to gain experience in multidisciplinary dysphagia management. it was felt that students should also be taught about legal and ethical issues and be exposed to advances in instrumentation at an die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 n a i n a m o d i & e l e a n o r ross undergraduate level. in addition, respondents recommended a need for the university lecturers involved in teaching the area of dysphagia to be adequately experienced in the area, particularly o n a practical level. there was a strong consensus among respondents that all postgraduate courses include a practical component in a d d i t i o n to t h e theory. a s y s t e m of o b s e r v i n g s p e e c h t h e r a p i s t s at o t h e r h o s p i t a l s w a s also r e c o m m e n d e d . h o w e v e r , r e s p o n d e n t s d i d n o t d i s t i n g u i s h b e t w e e n postgraduate training for degree or non-degree purposes. in order to improve access to resources it was felt that support g r o u p s c o n s i s t i n g o f therapists from different hospitals would allow for case discussions and guidance. developing a specialist list would also allow for easy contact with more experienced therapists whenever the need arose. c o n c l u s i o n in conclusion, the results of this study suggest that many slps in s o u t h africa m a y b e i n v o l v e d in the area o f dysphagia intervention. findings have also indicated that there are possible gaps in clinicians' knowledge and skills in this area, which may be linked to inadequate training r e c e i v e d at u n d e r g r a d u a t e a n d p o s t g r a d u a t e l e v e l s , particularly with regard to practical hands-on training as well as theory o n advances in instrumentation; ethical issues; safety and emergency procedures; and multidisciplinary management of dysphagia. furthermore, clinicians are probably also faced with limited access to supervision systems as well as limited resources in general. these difficulties would appear to be further confounded by limited k n o w l e d g e o f t h e i r role in d y s p h a g i a b y o t h e r health professionals and the subsequent need to actively market their services in their work settings. these problems faced by clinicians, in addition to the life-threatening nature of the w o r k , h i g h l i g h t s the need for clinicians, t r a i n i n g institutions and the professional organisation for slps to make a concerted effort to improve the existing situation. however, possibly the most important reason to undertake such efforts is for the basic rights of dysphagia patients themselves. as health care workers, "the concept of quality care is fundamental to the values, ethics and traditions of our profession at the very least to do no harm; usually to do some good; and ideally to realise the greatest good possible in any given situation" [frattali, 1990, p.39]. note the first author is a senior speech and hearing therapist employed at the chris hani baragwanath hospital and conducted this research project as a partial requirement for the degree m.a. speech pathology at the university of the witwatersrand. references american speech-language-hearing association. 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(1993). s.a.: bonaledi nursing college. rassi, j.a. and mcelroy, m.d. (1992a). curriculum development. in j.a. rassi and m.d. mcelroy (eds.) the education of audiologists and speech-language pathologists. maryland: york press. rassi, j.a. and mcelroy, m.d. (1992b). education in the clinic', in j.a. rassi and m.d. mcelroy (eds.) the education of audiologists and speech-language pathologists. maryland: york press. sonies, b.c. (1991). instrumental procedures for dysphagia diagnosis. seminars in speech and language, 13 (3), 185-198. south african speech-language hearing association. (1996). newsletter. south africa: saslha. | south african speech-language hearingassociation. (1997). code of ethics. south africa: saslha. south african speech-language hearing association. (1998). guidelines on service provision in hospitals. south africa: saslha. ibner, m.a. (1995). obstacles to providing dysphagia training in a small academic program. asha special interest divisions, 4 (2), 8-9. white paper for the transformation of the health system in south africa. 16 april 1997. government gazette notice no. 667 of 1997. pretoria: government printers. young, e.c. and durant-jones, l. (1990). developing a dysphagia program in an acute care hospital: a needs assessment. dysphagia, 5, 159-165. the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 27 place pitch discrimination and speech recognition in cochlear implant users johan j hanekom department of electrical and electronic engineering university of pretoria robert v shannon head: department of auditory implant and perception house ear institute los angeles, california, united states of america abstract the considerable variability in speech perception performance among cochlear implant patients makes it difficult to compare the effectiveness of different speech processing strategies. one result is that optimal individualized processor parameter setting is not always achieved. this paper investigates the relationship between place pitch discrimination ability and speech perception to establish whether pitch ranking could be used as an aid in better patient-specific fitting of processors. three subjects participated in this study. place pitch discrimination ability was measured and this information was used to design new channel to electrode allocations for each subject. several allocations were evaluated with speech tests with consonant, vowel and sentence material. it is shown that there is correlation between the perceptual pitch distance between electrodes and speech perception performance. the results indicate that pitch ranking ability might be used both as an indicator of the speech perception potential of an implant user and in the choice of better electrode configurations. opsomming die beduidende verskille in spraakherkenningsvermoe van kogleere-inplantpasiente bemoeilik die vergelyking van die effektiwiteit van verskillende spraakverwerkingsstrategiee. 'n gevolg is dat die individuele instelhng van spraakverwerkerparameters 'vir pasiente nie altyd optimaal gedoen word nie. hierdie artikel ondersoek die verband tussen plek-toonhoogtediskriminasie en spraakherkenning om te bepaal of toonhoogte-rangskikking nuttig is as hulpmiddel vir beter gebruiker-spesifieke passing van spraakverwerkers. drie proefpersone het aan hierdie ondersoek deelgeneem. plektoonhoogtediskriminasie is gemeet en die inligting meruit is gebruik vir die ontwerp van nuwe afbeeldings van elektrodes op kanale. verskeie afbeeldings is evalueer met spraaktoetse met vokaal-, konsonanten sinsmateriaal. daar word aangetoon dat daar korrelasie bestaan tussen toonhoogtediskriminasie en spraakherkenningsvermoe. die resultate wys dat toonhoogterangskikkingsvermoe gebruik kan word as beide 'n indikator vir die spraakherkenningspotensiaal van 'n kogleereinplantgebruiker en vir die beter keuse van elektrodekonfigurasies. key words: cochlear implants, multi-electrode stimulation, pitch discrimination, speech recognition, neural selectivity, perceptual distance. introduction two parameters, which influence the speech perception abilities of cochlear implant users, are the quality of spectral information and the quality of temporal information received by their electrically activated auditory systems. this paper focuses on the importance of spectral information. multiple-electrode stimulation is preferred in cochlear implants, because it is generally accepted that the tonotopic organization found along the length of the cochlea in the healthy auditory system is retained to some degree for electrical hearing. many research studies, including earlier work by eddington (1980) and a recent study by nelson, van tasell, schroder & soli (1995), have shown that electrodes stimulating the more basal areas of the cochlea result in higher perceived pitches (or sharper tonal quality) and stimulation closer to the apex results in lower perceived pitches. it would be natural to assume that tonotopic organization in electrical hearing is retained by multiple electrodes selectively stimulating discrete neural populations. however, the assumption that discrete neural populations can be activated is not always true. when electrodes are closely spaced, considerable overlap occurs in the neural populations excited by the stimulation current, a problem which was addressed by tbwnshend & white (1987). this die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 is the result of spread of electrical current in the biological medium of the cochlea. the implication is that if two electrodes stimulate the same neural population or overlapping neural populations, sound sensations elicited by the two stimuli might be confused or might even be indistinguishable. this reduces the number of independent channels of information that can be conveyed to the cochlear implant user's auditory system. it is important to realize that the number of independent channels of information is not equal to the number of electrodes. the question which presents itself then, is how much overlap in stimulation of auditory neurons does occur in the cochlea, and how important is this in the patient's ability to understand speech? although it is generally assumed to be true, is it really beneficial to have excitation of distinct neural populations? in other words, on the one hand it is assumed that multi-electrode implants perform well because they utilize the tonotopical organization of the cochlea, but on the other hand current spread inside the cochlea might defeat this purpose by having different electrodes stimulating identical neural populations. if many electrodes stimulate the same neural population, why do some patients perform so well on open set speech recognition tasks? a secondary question which follows is whether using simpler implants with a smaller number of electrodes (which in turn could potentially be cheaper and more reliable) would not perform as well as implants with many electrodes. the questions formulated above and related questions have been investigated by a number of researchers. the effect of the number of electrodes on speech perception performance has been addressed in lawson, wilson, zerbi & finley (1996). they found that by increasing the number of electrodes, speech perception performance is improved, but for as few as four to seven electrodes, speech performance levels are close to what can be achieved by using ten or twenty electrodes. busby, whitford, blarney, richardson & clark (1994) studied patients' abilities to rank electrode pitch as a function of stimulation mode of the nucleus1 implant device. (clark, tong & patrick (1990) give detailed descriptions of this device). as will be explained in the text to follow, the nucleus device can utilize different stimulation modes, which produce differences in the amount of current spread from the electrodes. busby et al. (1994) found that the ability to rank pitch for stimulation on a specific electrode (in other words, place pitch) was related to the mode of stimulation used (and thus the amount of current spread). nelson et al. (1995) studied the relationship between pitch ranking ability (or electrode ranking ability) and consonant perception in ten subjects using the nucleus cochlear implant. they found correlation between the consonant perception and pitch discrimination, but they found little correlation between recognition of consonants based on recognition of place cues and place pitch perception. however, they concluded that this might be related to the speech processing strategy not taking full advantage of the user's ability to do place pitch ranking. this paper addresses some of the questions mentioned above. specifically, we investigate the question of the reone of the most widely used cochlear implant devices is the nucleus, manufactured by cochlear pty limited in australia and by their united states subsidiary, cochlear corporation. johan j hanekom en robert v shannon lationship between speech perception performance and the stimulation of overlapping neural populations in the cochlea. the approach used is to find a measure of the amount of overlap among stimulated neural populations. this is accomplished by determining the amount of electrode confusion with a pitch discrimination experiment. an additional question, which we also address, is whether it is possible to improve speech discrimination with the correct design of electrode configuration. experimental approach one way to quantify the amount of overlap among neural populations stimulated by different electrodes, is to measure the amount of confusion between electrodes. we measure the pitch discrimination between electrodes as a measure of the amount of electrode confusion, which is then also a measure of the amount of overlap in the neural populations stimulated. this is in turn a measure of the amount of current spread resulting from electrical stimulation. the procedure we use is to compile a place pitch ranking matrix (or electrode discrimination matrix) which is transformed to perceptual distance values, as explained below. based on the pitch discrimination information, we then design various maps and evaluate the speech perception performance for these. we focus primarily on the relationship between pitch discrimination data and speech perception performance for various different maps in a single subject, while repeating only some of the tests in other subjects. in this respect our approach differs from that used by nelson et al. (1995). they compared speech perception abilities in ten subjects using their everyday maps2, and related this to the subjects' place pitch ranking abilities. however, they did not study the effect of using different maps in the same patient. the rationale for this would be to investigate to which dimensions of place pitch discrimination speech perception is related. the term dimensions refers to the fact that place pitch discrimination ability might be related to various physical electrode parameters, for example electrode spatial separation and current spread from the electrodes, but also to perceptual distance between electrodes. our study evaluates nine different maps in the same subject, to establish whether speech recognition performance is related to the perceptual distance between electrodes or to other dimensions of pitch discrimination ability. it will become clear in the description of the properties of the pitch discrimination abilities of each of the subjects why more maps were evaluated in one specific subject. the three subjects who participated included a good user, the term map used in this context, usually refers to the patient-specific settings that are made to the nucleus processor. a map is a table of values with the threshold and uncomfortable loudness stimulation current values for each electrode. the map also holds information on the specific frequency allocation table used. the frequency allocation table is a table specifying the filter cutoff frequencies used in the twenty channels of the nucleus speech processor. different frequency allocation tables are available. the software used in this study to program the nucleus device allows the user an extra option, namely to allocate multiple filter channels to the same electrode. when we refer to map in this article, we are actually referring to this filter-to-electrode allocation. the other parameters we used for the maps were from the subjects' everyday maps and remained unchanged throughout the experiments, unless noted otherwise. everyday map refers to the regular maps that the subjects used daily. the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) place pitch discrimination and speech recognition fair user and a relatively poor user. we relate our findines to this observation. perceptual distance between stimuli is quantified by d', a asure often used in psychophysical studies to express perm ® a l distances in forced choice experiments. this measw a s u s e d in the context of pitch discrimination studies b^townshend e t a i (1987) and more recently by nelson et al (1995)· smaller values of d' indicate more confusion between stimuli. negative values of d' in the pitch discrimination experiment indicate pitch reversal. for no confusion between stimuli, the largest value of d' (3.29) is achieved. the d's can be calculated from signal detection theory as described in green & swets (1966). hacker & ratcliff (1979) tabulated the values of d' for a two alternative forced choice experiment such as is described here. we used a vowel test, a consonant test and a sentence test in the evaluation of speech perception ability with each map. in previous studies (for example nelson et al., 1995) consonant perception was used to assess speech perception ability. we included a vowel test, because vowels are recognized primarily by their formant structure (dubno & dorman, 1987) and as such their recognition should be dependent on the ability to activate discrete neural populations selectively. sentence material was included in the speech perception tests to evaluate open set speech understanding for the various different maps. the number of electrodes used in the maps in our experiments was six or seven throughout. the reason for this choice was that it was found that seven-electrode maps gave speech perception performance levels that allowed some play for the speech perception scores to improve or deteriorate. a study by lawson et al. (1996) showed that speech recognition demonstrated a rapid decline when the number of electrodes was lowered from seven to four to two and to one, and that with a seven-electrode map it is possible to get speech discrimination close to what can be achieved by ten or twenty-electrode maps. an advantage of using a reduced number of electrodes is that the stimulation rate of the nucleus processor increases. higher stimulation rates have proved to result in better speech recognition performance (wilson et al., 1991). a corollary of this study is to establish a procedure which could optimize an electrode map when only a small number of electrodes are used. fewer electrodes than the twenty available in the nucleus might be used for several reasons. other implants that use fewer electrodes are in cochlear implant users 29 available. it is also possible that only a small number of stimulation sites are available as a result of poor neural survival, or that a reduced number of electrodes are available because of electrode damage. another possible application for fewer electrodes would be a future lower cost device. the rest of this paper is discussed in two sections. in the first section, the pitch discrimination experiment is described and in the second section the results are used in the design of maps which are evaluated with speech perception experiments. pitch discrimination experiment methodology subjects three users of the nucleus cochlear implant participated in this study. all of them were users of the nucleus spectra speech processor. this processor implements the speak speech processing strategy, which is described in skinner et al. (1994). table 1 contains detailed information on the three subjects. electrode parameters all three subjects used the nucleus 22 electrode array (described in clark et al., 1990, p. 114), implanted into the scala tympani. the electrode bands in this array are separated by 0.75 mm. we refer to the two electrodes of a stimulation pair as the stimulation electrode and the return electrode. stimulation was always with current-balanced biphasic pulsatile waveforms, with the positive pulse preceding the negative pulse. the stimulation electrode was the electrode on which a positive first biphasic pulse could be measured if the other electrode was used as reference. the return electrode was always the more apical of a stimulation pair. the electrode numbering convention used in this paper is as follows: an electrode pair is referred to by the stimulation electrode number, and with the stimulation mode known (explained below), the return electrode is implicitly known. electrode 1 was the most basal electrode and electrode 20 was the most apical electrode used as stimulation electrode. the nucleus speech processor allows different stimulation modes. in bp mode3, the stimulation electrode and table 1. subject information for the three subjects who participated in this study. insertion depth refers to the number of electrode bands inside the cochlea. the first twenty-two electrodes are active. subject age gender age of onset of profound hearing loss time of implant use processor type insertion depth cause of deafness ewb 55 male 45 6 years spectra 27 trauma jem 39 male 35 4 years spectra 26 trauma rek 54 male 47 6 months spectra 22 progressive hearing loss 3 the abbreviation bp, for bipolar, is used throughout this paper. this is the standard abbreviation used in texts by cochlear pty limited to indicate the nucleus device's stimulation modes. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 the return electrode are adjoining. in b p + 1 mode one electrode separates the stimulation electrode and the return electrode: in b p + 2 mode two electrodes separate the ξ γ ™ t r ° d e a n d ; e t u r n e l e c t r ° d e simulation modeus up to bp+3 were used in this study. the symbol δε is used for electrode spatial separation. stimulus parameters mode of stimulation. for subject jem w t ^^ ^ e d a bp+1 everyday map, we used stimulation in bp, b p ^ and ms i z z 1 " a ? d l t l ° n 1° b p + 1 m o d e · t h e reasons for this will become clear in the discussions to follow aij^stimuli were current-balanced biphasic pulses posi ζ p γ / 1 1 " 8 ' ; s t l m u l a t l 0 n r a * e was 1000 puisespersecthe l e n e t h ^ ) f u e d u r a t i o n 200 microsecond . was 500 ms flnhsmg p r e s e n t a t i o n ° n a « ο electrode was 500 ms and no ramping was used. stimuli were pre ut below ι ο : ' z t t t l e v e l ° f s t l m u l a t above 50%, but below 80% of the dynamic range of the subject. acorn c o r d e d t h t , t n n e r a t e d ^ a p p r ° p r i a t e stimuli and " s cor l t f ^ / r " 0 " ! ? ' t h e s t i m u l i w e r e — d e d in me correct format to enable presentation directly to the internal receiver of the nucleus device. the coded sttmuli were p r e s e n t e d directly to the internal receiver οο γ ο the subjects (the subjects' processors were not used) ^ a a custom m t e r f a c e (described in shannon, adams fe^rel pal umbo & grandgenett, 1990). ' psychophysical procedure eact of t h 7 h d l s t m m a t l 0 n m a t r i x was measured for u s s f o r all th b p + 1 s t l m u l a t i o n o d e was u i p i n> κ i s u b j e c t s ' a n d i n a d d i t i ° n we also measured pitch discrimination matrices for bp, b p + 2 and β ρ λ mode for subject jem. + 3 the pitch discrimination matrix was compiled by usstirmiltof 500 p s y c h ° p h ^ p-cedure. consecutive stimuli of 500 ms, separated by a brief quiet interval of the s = e n w 0 n , t w ° ° f ^ s ^ c t ' s e l e s e piched r t t " t 0 j u d g e w h i c h s t i m u l u * was higher s a m tbl « w 3 s c ° n t r 0 l l e d ^ a computer p r o s z r ί ! γ h a d t 0 i n d i c a t e h i s c h o i c e by depressing th^firqt w o buttons, with one button c o r r e s p o n d to the first s o u n d and the other button to the second sound d e l ^ t s o m t t ° f l t l m u l 1 w a s p-sented x r a delay of 200 ms after the patient had made his choice ζ γ : ζ τ 0 η ΐ ο τ repetiti°n °f t h e p a i r o f < p n u 7 t p a i r c o n s i s t e d of stimuli on two different electrodes. the stimuli were balanced for loudness to minimize confusions between loudness and pitch thts was done b y l o u d b a l a n d n g o c e pteh.̂ ihiswas z z f p l t c t d l s c n m i n a t l 0 n experiments. a reference midd e ofth: c i t ' , 1 l s u a l l y e l e c t r ° d e 1 0 ' w h i c h » the middle of the electrode array. the subject was asked to potcatheeastir 0ttabl! " ΐ " ^ l 6 v e 1 ' a n d ^ ts pdur! pose tne stimulation levels were varî h , tween 50% and 80% of the d y z ^ t s ^ ot thereference stimulus being presented, followed by a w " r peated3 a ? " 1 1 6 e l e c t r ° d e s ^ ^mjns^ x e s e s f t t y 3 8 n e c e s s a ^ i n to find level setting for the second stimulus which had the same johan j hanekom en robert v shan apparent loudness as the first stimulus, l b be more a, ' rate in pinpointing the stimulation level which was " in loudness to the reference, subjects were also a s k ^ 1 find a level that was just noticeably softer than the r r 1 0 ence and also to find a level just not.eab y loude/th^' the reference^ in this way three datapoints z e l t hshed for each electrode's simulation level and we j ' able to make a good estimation of the stimulus m r ! ' 6 necessary to have al, the electrode s t i m u ^ ^ * the electrodes used for the stimulation pairs duri the pitch discrimination experiment were complem8 randomized for each run. one run consisted οί γ ρ ^ tation of all possible combinations of electrodes fn l "' p w r , o . e s " \ o r m o d e · this amounted to twentv sion between electrodes, a considerable n t m b e r of c l pansons were needed. twenty runs were completed tn b p + 1 mode for each of the subjects, which gave a t o s of forty comparisons of each electrode with evfry other elel to ϊ ί ΐ r e a c t i ° n ' i n d i c a t i n g which stimulus was judged mmssszt electrode of a stimulation pair was iudwh f„ ι· , pitched than the « o r e a p i c a u w h r x t u k tte e m order based o „ the tonotopic organization rftie s f a ) a p , « l eieetade to be higher pitched c x l ™ ' ^ re s d ° i f a t " " 1 ; ρ * γ · w m ™ d e s o n d very aistinct pitch difference, resulting in a l a m a' without the pitch difference being very w e a large d , probably an indication of w h e t h e / o v e l p p f g or ^ neural populations are stimulated n u m h ^ f p i d t y w a s p r e s e n t > electrodes with lower numbers (located more basally) would be expected t 7 z consistently judged higher in /u expected to be higher m i m w ! 7 f ! p t c h t h a n electrodes with companson i u n t ^ ^ ^ e l e c t r o d e s ) in a paired tfonst™ , ' l f c o m p l e t e l y separate neural populations (non-overlapping) were stimulated by each electrode i e t t r t c l ° s e e l e c t r ° d e s p a d n ^ ' n ° c o ^ u s t n b e t e s electrodes was expected. on the other hanh 7 s m f a s s k w f t i f f l a f e s . s a n ^ c a t , o n of the amount of current the south africa journal of communication disorders, vol. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) lace tc discrimination and speech recognitionin cochlear implant users 31 results t i m u l u s r e s p o n s e matrices for the three subjects t h e s in fi srures 1 to 4 after they have been converted a r e shown i " " 6 1 0.36 0.62 2 -0.07 3 1 0.36 0.62 2 -0.07 1 0.36 0.62 2 -0.07 0.18 0.36 0,51 .0.36 0.25 0.62 0.00 -0.62 -0.18 0.43 0.18 0.36 0,51 .0.36 0.25 0.62 0.00 -0.62 -0.18 0.43 0.07 •0.18 0.18 0.36 0,51 .0.36 0.25 0.62 0.00 -0.62 -0.18 0.43 0.07 •0.18 0.00 0.07 1.53 1.66 .0.25 0.62 1 53 0.00 -0.62 -0.18 0.43 0.07 •0.18 0.00 0.07 1.53 1.66 .0.25 0.62 1 53 0.00 -0.62 -0.18 0.43 0.62 1.00 0.51 0.07 1.53 1.66 1.81 2.09 7 33 1 53 1.53 1.35 1.14 0.25 0.07 1.53 1.66 1.81 2.09 7 33 2.33 2.33 2.33 1.24 1.66 0.36 1 81 3.29 3.29 1.81 1.66 2.09 1.66 1.24 0.91 2.90 3.29 3.29 2.90 2.90 3.29 2.33 1.81 1.53 0.51 3?9 2.90 3.29 3.29 3.29 3.29 2.90 2.90 2.09 3.29 1.81 1.66 1.14 190 2.90 3.29 3.29 2.33 2.90 3.29 3.29 1.81 1.66 1.81 1.24 0.91 3.29 3.29 3->9 3 29 3.29 2.90 3.29 3.29 2.90 2.90 2.33 1.66 2.33 1.66 1.14 3.29 3.29 3->9 3.29 3.29 3.29 3.29 3.29 2.90 2.90 3.29 2.90 2.09 1.53 1.35 1.14 3 79 3 29 3.29 3.29 3.29 3.29 3.29 2.90 3.29 2.90 1.53 2.33 2.33 1.81 1.81 0.18 3.29 1.29 3.29 3.29 3.29 2.90 2.90 3.29 2.90 2.09 2.90 3.29 1.66 1.53 1.66 1.00 0.91 3.29 3.29 3.29 1.29 3.29 3.29 3.29 2.33 3.29 2.33 3.29 2.90 3.29 3.29 2.09 2.90 1.66 1.24 1.14 0.62 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 2.90 2.90 2.33 2.33 2.09 2.09 2.09 1.14 0.78 0.70 0.36 figure 1. pitch discrimination matrix for subject jem for bp+1 mode of stimulation. positive values of d' in the table indicate that the electrode numbered at the top was judged to have a higher pitch than the electrode numbered at the left, d' values of 3.29 indicate 100% consistency in pitch judgement and values higher than 1.5 indicate an 85% consistency. jem had a large area of good pitch discrimination. 10 11 12 13 14 15 16 17 0.18 1.19 0.74 0.00 0.18 -0.74 0.18 0.74 -0.55 0.54 0.54 0.18 -0.74 0.18 0.18 > 1.19 0.18 0.18 0.74 0.95 0.36 [ 1.81 1.47 1.47 2.33 1.81 1.47 0.95 1 2.33 3.29 1.81 2.33 3.29 1.81 2.33 1.47 1 3.29 2.33 2.33 3.29 3.29 2.33 2.33 2.33 0.74 3.29 3.29 3.29 3.29 3.29 2.33 3.29 1.81 1.81 0.95 2.33 3.29 3.29 3.29 3.29 3.29 3.29 3.29 2.33 3.29 1.81 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 1.19 1.47 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 1.47 0.18 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 2.33 2.33 1.81 1.47 0.18 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 1.81 0.74 0.36 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 1.19 1.19 0.18 0.36 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 3.29 2.33 1.47 3.29 2.33 0.95 0.95 0.54 0.18 figure 2. pitch discrimination matrix for subject jem for bp+3 stimulation mode. note that the number of available electrodes was only 18 instead of 20. that is because the return electrode, for electrode 18 as stimulation electrode in bp+3 mode, is electrode band 22, which is the most basal electrode band. also, note that the pitch discrimination pattern differs from that in figure 1. some electrodes which did not exhibit good discrimination in bp+1 mode, had good discrimination in bp+3 mode. compare the d' between electrodes 11 and 12 in these stimulation modes. the inverse was also true for some electrodes. ' to d' values. two aspects are immediately evident from these matrices. first, the distribution of areas where electrode discrimination was better, varied considerably for the three subjects. this might have been dependent on electrode placement, with areas of good electrode discrimination being where the electrodes were situated closer to the (surviving) nerves. this result underlines the fact that there are two important but uncontrollable factors in perception of sound in cochlear implants: (1) placement of electrode and (2) nerve survival. if a d' of 1.5 was (arbitrarily) taken as a criterion for largely independent neural populations (this corresponds 13 14 15 16 17 18 19 0.36 0.36 0.36 1.47 0.95 0.54 0.74 0.74 -0.36 0.00 1.19 1.19 1.81 0.18 0.18 0.95 1.47 1.81 0.74 0.36 0.18 1.19 0.95 0.74 0.00 0.55 0.74 0.18 0.54 0.18 0.36 0.00 1.47 0.95 1.19 0.74 1.47 1.19 1.47 0.54 0.00 0.74 0.00 0.54 1.47 1.81 2.33 2.33 1.19 1.47 0.95 0.18 0.54 1.47 0.54 2.33 1.81 1.19 1.81 0.74 0.54 1.19 1.19 1.19 0.74 0.36 3.29 3.29 1.81 1.19 1.47 1.19 0.95 0.74 3.29 0.74 0.18 0.18 2.33 3.29 2.33 3.29 0.54 1.19 0.74 0.54 1.47 0.18 0.18 0.54 0.00 2.33 3.29 1.81 1.81 0.95 1.19 1.19 1.47 1.81 0.54 0.36 0.54 0.36 •0.36 3.29 2.33 1.81 1.81 1.81 0.54 0.18 1.81 1.47 0.74 0.36 0.36 0.00 0.18 0.00 3.29 0.95 1.81 2.33 0.36 0.36 0.54 0.74 1.47 1.19 0.36 0.18 0.36 0.18 •0.36 0.36 1.47 0.00 0.36 0.36 •0.36 •0.18 •0-18 0.00 0.74 •0.55 0.95 1.47 -0.74 •0.18 -0.74 •1.19 0.95 0.18 •0.74 «.36 0.55 •0.18 •1.47 •1.47 •1.47 0.95 •2.33 •1.81 1.47 •1.19 1.81 •1.47 -1.81 0.00 0.55 1.19 0.55 0.36 •0.18 •0.18 1.19 0.74 •0.36 0.55 0.95 •1.19 •1.47 1.19 1.81 1.19 •1.47 •1.81 •0.36 1.47 figure 3. pitch discrimination matrix for subject rek. the values in the table are the calculated d' values. positive values of d' indicate that the electrode numbered at the top was judged higher in pitch than the electrode numbered at the left more than half of the time. for normal tonotopic organization, the d' values are expected to be positive, as electrode 1 is the most basal electrode and electrode 20 the most apical. rek had a region of good pitch discrimination toward the left side of the matrix. ι 2 3 4 5 6 7 8 9 10 ii 12 13 14 15 16 17 18 19 -0.07 -0.70 0.00 0.14 -0.14 0.00 0.54 -0.07 0.62 0.54 -0.21 0.07 -0.21 0.21 0.14 -0.43 -0.14 -0.07 -0.07 -0.43 0.36 0.29 -0.07 -0.21 -0.21 -0.21 -0.21 -0.14 0.14 -0.29 0.62 0.21 -0.07 0.00 0.07 -0.14 0.87 -0.14 0.36 •0.07 0.43 0.62 0.07 0.29 0.36 0.54 0.21 0.87 0.07 0.14 0.00 0.21 0.43 0.43 -0.14 0.78 0.29 0.70 0.14 -0.14 0.70 0.14 0.21 0.29 0.36 -0.07 0.36 0.00 0.54 0.07 0.21 0.54 0.36 0.54 0.54 -0.14 -0.36 0.00 0.29 -0.21 0.21 -0.21 0.00 0.07 0.21 0.21 0.14 -0.43 0.00 -0.62 -0.29 0.43 -0.07 0.07 0.14 -0.36 0.14 0.07 0.00 0.14 0.07 -0.78 -0.43 0.14 0.21 0.54 -0.21 0.00 -0.36 0.00 -0.43 -0.14 0.07 -0.70 -0.70 -0.36 -0.87 -0.95 -0.36 0.07 0.95 0.54 1.14 0.62 0.70 0.70 0.87 0.87 0.54 0.21 0.70 0.07 0.29 1.05 0.78 1.05 1.05 0.78 0.87 1.24 0.87 0.87 0.62 1.35 0.95 0.70 0.70 0.70 0.29 0.78 1.14 1.24 0.43 1.66 0.78 1.14 1.14 1.14 1.35 0.95 1.99 1.35 0.70 1.05 0.95 0.78 1.24 1.05 1.81 1.05 -0.07 1.14 1.47 1.05 1.05 1.05 1.66 1.35 1.47 0.95 1.24 1.24 0.87 1.05 1.66 1.24 1.47 1.14 1.14 0.78 figure 4. pitch discrimination matrix for subject ewb. this subject exhibited poor pitch discrimination throughout the electrode array, although he did a little bit better toward the apical side. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 to 85% consistency in pitch ranking), then subject ewb had almost no discrimination between any of his electrodes, although he did a little better toward the apical side. subject rek had a region of good pitch discrimination, but primarily for large electrode separations. subject jem had very good electrode discrimination throughout his electrode array when the electrode spatial separation was two or more. his best region was near to the middle of his electrode array. more details concerning the analysis of the properties of the subjects' pitch discrimination matrices are discussed when the maps used in the speech perception experiment are described below. speech perception experiment methodology objective the speech perception experiment was used to investigate whether there was correlation between subjects' ability to discriminate among electrodes based on place pitch (as reflected by the information in the pitch discrimination matrices), and speech perception performance. two parameters (which could be deduced from the pitch discrimination matrices) were identified as being important in speech perception: the perceptual distance between pitch sensations elicited by electrodes as reflected by the d' values and δε, the electrode spatial separation. the maps used where chosen to reflect the effect on speech perception of varying these two parameters. speech materials we used vowel, consonant and sentence material to evaluate speech perception performance. all the speech material was available on laser disk. the vowel test used a set of eight vowels in a /hvdi context uttered by a male talker. each vowel syllable was repeated three times in randomized order. the consonant test used sixteen consonants in a /aca/ context. the consonant syllables were repeated five times in randomized order during a single consonant test. the sentence test consisted of a set of thirty-six sentences uttered by a female speaker. no repetitions of the same sentences were used and a new set of sentences was used for the evaluation of every map. none of the subjects had been tested with the specific sentence material before. procedure the software used for the creation of the subject maps allowed the programmer to allocate the output of any of the nucleus processor's filters to any electrode. multiple filter outputs could be allocated to the same electrodes. this enabled us to use maps utilizing a reduced set of electrodes, while still presenting all the spectral information from the twenty filters to the electrodes. the operation of the nucleus implant is such that reducing the number of electrodes increased the stimulation rate on the electrodes that were used (shannon et al., 1990). subjects were tested with their regular bp+1 maps and frequency allocation tables which they had been using daily johan j hanekom en robert v shannon for several months. the only changes to these maps were that the regular filter-to-electrode allocations were replaced by maps with a reduced number of electrodes of which multiple filter channels were allocated to each electrode. the specific choices of electrodes which were used in the various different maps are explained below. the subjects wore these experimental maps for a period of two full days before evaluation with the speech material. tests were conducted in a sound-isolated booth. speech stimuli were presented at 60 db spl. speech stimuli were played from a laser disc player through high quality audio loudspeakers. a computer program controlled the presentation of the speech material to the subjects. the subjects responded by indicating their choice on a computer keyboard. the computer program recorded the subject reaction for the vowel and consonant tests, and compiled stimulus-response matrices for these. the computer program also controlled the laser disc player for presentation of the sentences. the subject had to repeat as many words as he could understand from the sentence material, which was then recorded by the experimenter. map parameters details of the maps that were used for each patient are explained below. as explained earlier, all maps were sevenelectrode maps, except two of jem's maps, which were six-electrode bp+3 maps. maps were chosen to give either large or small cumulative values of d', and maps with similar cumulative d' were evaluated using different electrode spatial separations. both orderly and disorderly electrode spatial separations were used. table 2 summarizes the maps used. the motivation for the choice of each of the maps is given in the descriptions below. we evaluated more maps for jem than for the other two subjects. this was primarily dictated by the fact that subject jem's pitch discrimination matrix provided more degrees of freedom in the choice of various maps. this statement will become clear in the explanation of the procedure used to choose electrodes to be used in the maps. this procedure was very simple and was as follows: a list of all possible combinations forming seven-electrode maps was compiled (for example electrodes 1, 2, 3, 4, 5 6 7 or electrodes 1, 3, 5, 7, 9, 11, 13 and so on): then, 'for each subject, the cumulative d' was calculated for all these electrode sets by simply adding the corresponding six d' values. for example for subject rek, for the electrode set consisting of electrodes 1, 2, 3, 4, 5, 6 and 7, the six d' values to be added were 0.36 (d' between electrode 1 and 2), 0.36 (the d' between electrode 2 and 3), -0.36, 0, 0.18 and 0.18. the cumulative d' was thus calculated as 0.36. it was assumed that electrodes were distinguishable if d' was larger than 1.5. from subject rek's pitch discrimination matrix in figure 2, it can be seen that only a small region in the lower left corner of this matrix produced d' values in the region of 1.5 or larger, and then for an electrode spacing of four or larger. for smaller a criterion level of d'>l, a larger area in the d' matrix was identified. between electrodes 9 and 10 a d' of 1.47 was produced but for all other electrodes the electrode spatial separation had to be at least three to find a d'larger than 1. it can also be seen that electrodes could not be discriminated at the apical end of the electrode array. in this area all electrodes were confused and d' values were generally very low this means that to find a seven-electrode set with a large value the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) lace pitch discrimination and speech recognitionin cochlear implant users 33 of cumulative d', the electrodes had to be chosen more toward the basal side of the array. even then we would not be able to choose an electrode set with all d' values greater than 1. for example, if we started with electrode 1, the next electrode had to be electrode 5 for d' greater than 1. then, the third electrode had to be electrode 11 to have a d' greater than 1 between electrode 5 and the third electrode to be used. from electrode 11 toward the apical side of the electrode array, all electrodes were confused. comparing this to jem's pitch discrimination matrix, it becomes clear that for jem there was much more flexibility in possible choices of electrodes for good cumulative d'. a d' of greater than one was found for all electrodes if electrode spatial separation was eight, and for most electrodes if the spatial separation was only two or larger, excluding electrodes to the more basal side of the array. this gave us many different possibilities of choice of seven-electrode maps with good cumulative d'. confusion between electrodes occurred primarily on the basal electrodes. there seemed to be total confusion of electrode pitch for all electrodes in subject ewb's case, except for a few electrodes near the basal end of the array, l b find a d' of larger than 1, electrode spatial separation had to be at least 14 in the more apical half of the electrode array, and no d's of 2 or larger were found. this gave very little flexsubject: jem map no electrodes used stim mode d' c δε a d no of sites vowel test cons test sent test 1 3,4,9,13,15,17,19 bp+1 10.3 2.7 2.2 5 92 88 95 2 6,7,8,9,10,11,12 bp+1 2.54 1 1 1 54 76 20 3 2,4,6,9,11,17,2 bp+1 4.98 3 2 2 88 88 88 4 4,5,10,11,16,17,19 bp+1 7.46 2.5 4 3 79 83 85 5 3,4,9,13,15,17 bp+3 6.53 2.8 3 3 83 89 92 6 2,4,6,9,11,17 bp+3 7.27 3 2.3 4 79 85 82 7 12,13,14,15,16,17,18 bp+1 5.42 1 1 1 62 81 66 8 2,5,8,11,14,17,20 (bp,bp,bp2,bp2,bp2, bp2,bp1) j mixed 13+ 3 1 5 92 90 97 9 2,4,7,10,13,16,jl9 bp+1 6.64 2.8 1.1 3 88 85 98 subject: rek map no electrodes used i 1 stim mode d' c δε a d no of sites vowel test cons test sent test 1 1,3,6,10,12,14,116 . bp+1 4.37 2.5 1.8 2 46 56 38 2,-, 1,2,5,12,13,14,19 bp+1 0.60 3 5 1 58 65 74 3 2,4,6,8,10,12,14 bp+1 2.00 2 1 1 50 55 38 4 2,5,8,11,14,17,20 bp+1 -0.87 3 1 1 46 88 94 5 1,4,7,10,13,16,19 bp+1 0.41 3 1 1 67 74 87 subject: ewb map no electrodes used stim mode d' c δε a d no of sites vowel test cons test sent test 1 3,5,8,16,17,18,20 bp+1 3.72 2.8 3.25 1 38 49 30 2 1,4,7,9,12,14,16 bp+1 -0.55 2.5 1.5 1 62 53 33 3 1,4,7,10,13,16119 bp+1 0.86 3 1 1 67 49 57 table 2. results for the speech perception experiment. the number/) is a simple measure for the disorder in electrode spacing as calculated by equation 1. δελ is the average spacing between electrodes. d'c is the cumulative d'. no of sites refer to the number of discrete stimulation sites when d ' > 1.5 is used as criterion. cons and sent are abbreviations of consonant and sentence, respectively. the table lists the stimulation modes used for each electrode for the mixed stimulation mode map for jem (map 8). the abbreviations bp1 and bp2 are used for bp+1 and bp+2 stimulation modes, respectively. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 johan j hanekom en robert v shannon ibility in choice of electrodes if a seven-electrode map was to be constructed, because although a range of different cumulative values for d' could be found, the electrode pitch sensations could not be discriminated for many of the possible electrode pairs. the hypothesis we wanted to test was whether electrodes that were clearly distinguishable were better choices to achieve good speech perception performance. at least we wanted to be able to compare good and poor electrode discrimination. consequently, only three different maps were tested for subject ewb. two choices of cumulative d' were contrasted: a map with ewb's best possible cumulative d' (3.72), and a map with a very poor cumulative d' of -0.55 were used. map 2 (with the poorer cumulative d') had the electrodes spaced more orderly than map 1, with δε at least 2. δε was 2 toward the apex and 3 toward the base. map 1 had a very disorderly electrode spacing with a big gap between electrodes 8 and 16 and some electrodes having spatial separation of only 1. the third map had an intermediate value of cumulative d' and all δε were 3 throughout. five maps were tested for subject rek. map 1 utilized both a good cumulative d' and a reasonably good electrode spacing. although the electrode spacing was irregular, δε was equal to or larger than 2. the cumulative d' of 4.37 was close to the best cumulative d' of 5.12 achievable for rek. the second map had a small cumulative d' of only 0.6, but with the interesting property that the d' values between every second electrode were relatively large. this map possibly stimulated only four distinct sites in the cochlea. map 3 had a cumulative d' of 2, which was near 50 % of the maximum achievable d', with a very orderly electrode spacing of 2. the electrodes used were situated in the middle of the electrode array. maps 4 and 5 also used very orderly electrode spacings, but this time the spatial separations used were 3. the cumulative d's were the small value of-0.87 and 0.41 respectively. nine maps were tested for subject jem. these maps tested speech perception performance for a spectrum of cumulative d's, from very low to the highest achievable values for this subject. some of these maps had very orderly electrode spacing, and some of them had very irregular electrode spacing. six of the maps used bp+1 mode (which was the stimulation mode used in jem's everyday map). two of the maps used bp+3 mode and one used different stimulation modes on different electrodes. map 1 was chosen for maximum d' (10.34) in bp+1 mode. the electrode spacing was irregular with the largest electrode spatial separation of 5 between electrodes 4 and 9. map 2 was chosen for low d' (2.54) and had an electrode spacing of 1. map 3 had an irregular spacing with a large separation gap between electrodes 11 and 17. the map was chosen for its cumulative d' of 4.98, in the middle of the d' value of maps 1 and 2. map 4 was chosen to be similar to map 2'of subject rek. although this map had a large cumulative d' of 7.46, electrodes were grouped into pairs, with the spacing between the pairs being only 1, and these electrodes were essentially stimulating the same areas within the cochlea. map 5 en map 6 used exactly the same electrodes as maps 1 and 2 respectively, but bp+3 stimulation mode was used. these maps were chosen to test whether the wider spread of stimulation current in bp+3 mode would influence the speech results negatively. thus, if d' was a good indication of current spread, then larger current spread would result in smaller d' values and poorer speech perception performance. map 7, a bp+1 map, tested another δε = 1 map, this time closer to the base, where jem had better electrode discrimination. map 8 was an attempt to create a map with the maximum achievable d', with the best possible electrode spacing. different stimulation modes were used on different electrodes. the stimulation modes were chosen to give the best achievable d's. to obtain the d's for the other stimulation modes, pitch discrimination matrices were compiled for these. the cumulative d' for this multi-stimulation mode map was larger than 13. the exact value is not known, because the d's between electrodes 5 and 8, and also between electrodes 17 and 20, were unknown because the electrodes in these pairs used different stimulation modes for each electrode. map 9 was a δε = 3 map with an intermediate value of d'. results although it was clear that electrode spatial separation was a parameter in determining speech perception performance, we had to find a way to quantify this parameter. various simple measures of how well the electrodes were spaced, were used. we calculated a value for the average δε, δεβ, by simply adding all the inter-electrode separations and dividing by the number of inter-electrode separations (six for a seven-electrode map). we also calculated a number, d, for the amount of electrode disorder caused by using irregular electrode spacing. the rationale for using this measure of disorder was that when we used these seven-electrode maps, we always added the same filter outputs, but for each choice of map these filter outputs were relayed to a different electrode. in some map we connected two neighbouring filters to electrodes that were spaced far apart. thus, we were actually introducing spectral distortion, and the number d calculated for electrode disorder gave some indication of how much this distortion was. a third measure of the quality of our choice of electrode spacing was to find a measure for the number of discrete stimulation sites activated. this could be found from the d's under the assumption that the perceptual distance between two electrodes was an indication of how much overlap there was in neural excitation. we assumed that a d' of 1.5 reflected reasonably little overlap, because this value of d' translated to an 85% consistency in pitch judgements. | table 2 summarizes the results for all the maps tested for the three subjects. the electrodes used in each map, the cumulative d's and the three measures reflecting the electrode spatial separations are included in the table. the results are given as percentage correct scores for tlie vowel, consonant and sentence tests. several interesting observations can be made from these results when we investigate the relative contribution of the two parameters (d' and electrode spacing) to speech perception performance. simple linear regression analysis was used to relate various map parameters to the results of the speech perception tests. regression lines and correlation coefficients are given in the figures. significance o f correlation was tested by the t-test and a 5% level of significance was used. speech perception as a function of cumulative d' as explained earlier, perceptual pitch distance as measured by d' was used as measure of the amount of overlap the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) place pitch discrimination and speech recognitionin cochlear implant users 35 in neural population stimulated by electrodes. for a specific seven-electrode map, cumulative d' is also simply a measure of a subject's ability to pitch rank this set of electrodes. figures 5 to 7 relate speech perception results to this measure for each of the subjects. the three figures for each subject give results for vowels, consonants and sentences, respectively. as was also demonstrated by nelson et al. (1995), significant correlation between pitch ranking ability and speech perception performance was evident. there was, however, considerable variation in how pitch ranking ability was correlated with speech perception. the regression lines and correlation coefficients for linear regression are given in the figures. in general, for subject jem, for whom the most data were available, higher cumulative values of d' were correlated to better performance on the three speech perception measures. there was a correlation of around 70% for all three speech perception measures to cumulative d'. there was a significant increase in vowel perception with larger values of d', the total range being nearly 40%. consonant perception increased over a smaller range of 14%. far too few data points were available for subject ewb to be conclusive. no correlation between vowel perception and cumulative d' was evident (r=0.03), but there was correlation with consonant perception (r=0.95) and sentence perception (r=0.68). the vowel test did not have significant correlation to the cumulative d ' for subject rek. the weakest vowel performance was achieved for the smallest and the largest values of d'. this subject showed an inverse relationship between cumulative d' and consonant scores. the best consonant recognition scores were achieved for small values of d'; increasing the cumulative d' decreased consonant perception. the correlation coefficient of 0.84 is significant. the range of consonant performance scores was υ <u u u ο υ 4> cd « β <u <j u <u 0» vowels r = 0.72 consonants r = 0.71 sentences r = 0.69 10 12 4 6 8 10 12 cumulative d' 8 10 12 figure 5. speech perception as a function of cumulative d ' for subject jem. regression lines for linear regression are fitted through the data. the jcorrelation coefficients are shown above each panel. although the correlation coefficients are significant for all three speech perception performance measures, the slope was shallow for the consonant test. 100 υ <u u u ο ο 4> cd eg e <u ο u <u cl, 20 vowels r = 0.34 ί γ consonants r = 0.84 1 1 1 1 1 γ sentences r = 0.89 γ — ι 1 1 1 r i 0 1 0 1 2 3 cumulative d' -1 0 1 figure 6. speech perception as a function of cumulative d ' for subject rek. regression lines for linear regression are fitted through the data. the correlation coefficients are shown above each panel. this subject demonstrated a decline in performance levels for increasing cumulative d ' . die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 johan j hanekom en robert v shannon more than 30%. there was even stronger correlation with the perception scores for sentence material, the relationship also being inverse. the general tendency in all three subjects was that increase from very small cumulative d's to intermediate values influenced speech perception scores more than increases from intermediate d' values to large d' values. the variability among subjects and also the strong inverse relationship between d' and speech perception scores for rek, prompted us to investigate which other parameters also influenced speech perception. speech perception as a function of average electrode spacing as described earlier, three measures were used to quantify the influence of electrode spacing on speech perception. figures 8 to 10 show speech perception performance as function of the average electrode spacing. the number ε is an indication of the general spacing of the electrodes used in a specific map. the larger the number, the more widely spaced the electrodes are. in general, there was significant correlation between electrode spacing and speech perception for the three subjects. the correlation coefficients are given in figures 8 to 10. although riot enough data were available for subject ewb, the tendencies shown were that consonant and sentence perception was correlated to electrode spacing, but that vowel perception had little correlation with electrode spacing. rek also showed little correlation between electrode spacing and vowel perception, but jem showed significant correlation between electrode spacing and vowel perception. his worst vowel perception performance was for the two maps with δε = 1. good vowel performance was achieved for all maps when δε was larger than 2 for most electrodes. jem also showed strong correlation between consonant performance and δε, but as mentioned previously, the range of consonant scores was small and improvement with larger δε was minimal. rek achieved his best consonant scores for δε = 3. also, rek had his w fi u ο w v ox) « s 41 u u 41 a* 100 80 60 40 20 0 vowels r = 0.03 " γ consonants r = 0.95 sentences r = 0.68 1 1 1 γ ί γ j l j l 0 1 2 3 cumulative d' 0 1 u ν u u ο υ οι ml « β 41 w u 41 a. 20 vowels r = 0.92 τ ύ consonants r = 0.86 sentences r = 0.84 ~t τ _l τ 1.0 1.5 2.0 2.5 3.0 1.0 1.5 2.0 2.5 3.0 1.0 1.5 2.0, 2.5 3.0 average electrode spatial separation figure 8. speech perception as a function of average electrode spatial separation for subject jem. linear regression lines fitted through the data indicate correlation between electrode separation and speech perception performance. the correlation coefficients are given above each panel. figure 7. speech perception as a function of cumulative d ' for subject ewb. the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) lace pitch discrimination and speech recognitionin cochlear implant users 37 best sentence scores with δε = 3. jem achieved good sentence scores for all δε above 2.5, and his worst sentence scores were for δε = 1. s p e e c h perception as a function of disorder of electrode spacing the second measure used to quantify electrode spacing was the amount of disorder in the electrode choice. looking at the results for average electrode spacing, one gets the impression that these might somehow be correlated to how regular (or how disordered) the chosen electrode spacing was. a simple measure of the amount of disorder of electrode spacing (a number to which we assign the symbol d) was calculated with this equation: d=(sum of the three largest electrode spacings)/ (sum of the three smallest electrode spacings) (1) for the bp+3 maps with only six electrodes, we used only the two largest and two smallest electrode spacings in this equation. the values obtained for d are reflected in table 2. if the spatial separations among all electrodes are equal (1, 2.or 3), the number d equals 1. larger numbers correspond to more disorder in electrode spacing. for jem, map 3 had one large gap, map 1 had two large gaps and map 4 had three groups of electrodes with spacing of 1, separated by two large gaps. the increasing numbers calculated with the above equation correspond to this increasing amount of disorder in electrode spacing. interestingly, disorder in spacing was either unimportant, in the speech perception tests, or inverse relationships were found between the amount of disorder and speech perception performance. jem showed very little correlation between amount of disorder and any of the speech perception tests (correlation coefficients of 0.25, 0.23 and 0.32 for the vowels, consonants and sentences respectively). ewb had significant correlation between disorder and vowel performance (r=0.99), the two being 100 80 60 40 20 vowels r = 0.44 consonants r = 0.75 sentences r = 0.88 pe rc en ta ge co rr ec t 100 80 60 40 20 i 1 1 • • · 1 1 1 • ^ ^ ^ · i 1 • ·\ · · 1 1 1 1 0 1 1 1 1 1 1 i 1 0 2.0 2.5 3.0 2.0 2.5 3.0 2.0 2.5 3.0 i average electrode spatial separation figure 9. speech perception as a function of average electrode spatial separation for subject rek. linear regression lines are fitted through the data and correlation coefficients are given above each panel. vowels r = 0.27 consonants r = 0.8 sentences r = 0.87 3.00 2.50 2.75 3.00 2.50 average electrode spatial separation figure 10. speech perception as a function of average electrode spatial separation for subject ewb. linear regression lines are fitted through the data and correlation coefficients are given above each panel. de suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 johan j hanekom en robert v shannon inversely related, and he also had correlation between sentence performance and electrode disorder (r=0.75). rek had no correlation between d and speech perception, except for vowels, where he also demonstrated an inverse relationship (r=0.77 for vowels, r=0.17 for consonants and r=0.33 for sentences). speech perception as a function of the number of discrete stimulation sites as explained earlier, a measure for the number of discrete stimulation sites was the number of electrodes in a specific map with d' > 1.5. based on this criterion, both rek and ewb had no or very little discrimination between different electrodes in the maps used. figure 11 shows the speech perception performance as a function of the number of electrode sites for jem. all the measures of speech performance showed significant correlation (r=0.7 or larger) with the number of discrete stimulation sites. speech perception as a function of position of electrodes most of the maps for subject jem were spread over the entire range of electrodes, except his map 2 and map 7. map 2 was in the middle of the electrode array, and map 7 was on the apical end of the electrode array. vowel and consonant scores improved slightly with the electrodes in the more apical position, but the sentence score improved dramatically from 20% to 66%. no similar data were measured for the other two subjects. speech perception as a function of the stimulation mode subject jem was the only subject for whom speech perception tests were conducted as a function of stimulation mode. maps 1 and 3 in bp+1 mode were repeated in bp+3 mode. the goal was to evaluate the effect of larger current distribution on speech perception. current spread is larger in bp+3 mode than in bp+1 mode (busby et al., 1994), therefore it was assumed that neural selectivity decreased and it was expected that speech perception performance would decrease. the bp+3 maps utilized the same electrodes as the corresponding bp+1 maps, except that the.most basal electrode iri each map was omitted. this decreased the number of discrete stimulation sites for map 5 (a bp+3 map) in comparison to map 1 (a bp+1 map), but, contrary to expectation, the number of discrete stimulation sites increased for map 6, the bp+3 counterpart for map 3 (a bp+1 map). for both maps significant (10%) decreases in vowel perception scores were observed. this might be explained by the bp+3 maps using only six instead of seven electrodes. an alternative explanation might be the fact that vowels are primarily recognized by their formant structure, and for the bp+3 mode the formant structure was less pronounced. however, there is no significant decrease in performance for the consonant and sentence tests. discussion the relationship between speech perception and pitch discrimination ability of subjects the experiments clearly identified both physical electrode spacing and perceptual electrode distance (as reflected by the cumulative d') as parameters determining speech perception performance. (note that pitch ranking ability as measured by cumulative d' is dependent on the specific set of electrodes used in a map.) these two parameters are related: the physical electrode spacing influences the amount of current distribution from electrodes. this in turn determines the neural selectivity that can be achieved. the actual number of discrete neural sites that are activated is also a function of other factors, including electrode distance from neurons, neural survival (zimmermann, burgess & nadol, 1995) and the conductive properties of the biological medium. thus, electrode spacing is vowels r =0.79 consonants r = 0.70 sentences r = 0.72 number of discrete stimulation sites figure 11. speech perception as a function of the number of discrete stimulation sites for subject jem. linear regression lines are fitted through the data and correlation coefficients are given above each panel. the number of discrete sites were calculated for each map by taking a d ' value of larger than 1.5 as criterion for two electrodes stimulating discrete neural populations. the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) place pitch discrimination and speech recognitionin cochlear implant users 39 nhysical parameter determining electrical current 3 read. on the other hand, perceptual distance is a psychophysical parameter, meaning that this is a derived ° rameter, dependent on neural selectivity as well as experimenta'l and subject-dependent variables. thus, although there is correlation between current distribution and neural selectivity, the relationship is subject-dependent this is demonstrated by comparing the neural selectivity for bp+3 and bp+1 modes for jem, as reflected by the d' matrices in figures 1 and 2. the results also indicate that better overall pitch discrimination ability (measured over the set of all twenty electrodes) is related to better speech perception ability. this is demonstrated by comparing overall pitch discrimination ability to speech perception abilities. one measure of overall place pitch discrimination ability of a subject is the maximum cumulative d ' achievable for a specific number of electrodes. in this study, jem achieved a maximum seven-electrode cumulative d' of 10.34 in bp+1 mode. this can be compared to a maximum achievable cumulative d' of just more than 5 for rek and 3.72 for ewb. relating this to speech perception abilities as reflected by this study, jem was the best implant user in the group and ewb derived the least benefit from his implant. the relationship between the amount of benefit that the user derives from the implant and the pitch discrimination ability can also be quantified with two other measures of overall pitch discrimination ability. these are (1) the area of the d' matrix with large d' values (say d'>1.5) and (2) the minimum δε required for electrode discrimination. if d'>1.5 is used as the criterion for electrode discriminability, it is seen that jem generally required a δε of 2, while rek required a δε of 4 or more and ewb required large δε values to have d'>1.5. speech perception and spectral distortion disorder in the choice of electrode spacing did not seem to be an important parameter determining speech perception performance. however, the results obtained by shannon et al. (1995) suggested that spectral distortion might be an important factor determining cochlear implant users' speech perception abilities. an explanation for this apparent anomaly might be that different current distributions from each electrode, overlap in neural excitation and neural survival patterns might already introduce so much spectral distortion that the effect of poor electrode allocation is simply swamped. ' speech perception and the number of discrete neural sites although the number of discrete neural excitation sites in the cochlea (therefore, the number of discrete spectral locations) is correlated to speech perception performance, other information in the speech signal may also be utilized to understand electrical speech. this was evident from results achieved by ewb and rek. although being poorer users than jem, both demonstrated significant speech perception even with the excitation of so few discrete neural sites. these subjects might rely on temporal information for speech recognition. this paper emphasised the importance of cochlear place information (spectral information), but other studies have demonstrated the importance of temporal information in speech recognition (see, for example, shannon, zeng, kama'th, wygonski & ekelid (1990) or dorman et al. (1990)). using pitch ranking data to determine better subject-specific maps it is possible to make better choices of electrodes to be used in a reduced electrode map by basing the electrode choices on pitch discrimination data. the choice of a smaller number of electrodes leads to improved stimulation rates in the nucleus processor (shannon et al., 1990). it has been shown that higher stimulation rates lead to better speech perception performance (wilson et al., 1991). also, the careful choice of electrodes can be used to choose the set of electrodes with the best neural selectivity. the best neural selectivity is achieved by paying attention to two parameters: the physical electrode spacing, which determines current spread, and perceptual distance as measured with the d's, which is related to neural selectivity. furthermore, current distribution can be controlled by choice of stimulation mode. different stimulation modes result in different pitch ranking ability, as demonstrated in subject jem and also by busby et al. (1994). stimulation modes with larger current spread do not necessarily lead to decreased neural selectivity, as was demonstrated by map 6 of subject jem, where more discrete neural channels were achieved than in the bp+1 equivalent of this map. it might be possible to achieve better neural selectivity by. using multi-stimulation mode maps. by varying both electrode spacing and stimulation mode, current distribution patterns might be obtained which give larger perceptual distances between electrodes. this was accomplished in map 8 for subject jem. this technique for individualized fitting is more useful when subjects have good pitch discrimination abilities. for subjects in which pitch discrimination ability is not very good in a specific stimulation mode, other stimulation modes might be used. for subjects with poor pitch discrimination ability it might be advantageous to use fewer electrodes in order to increase the stimulation rate. the rationale is that if discrete excitation sites are few, place pitch abilities will be poor regardless of the number of electrodes used, and place pitch resolution may be substituted with better temporal resolution by increasing the stimulation rate. conclusions (1) the ability to discriminate electrodes based on place pitch, varies considerably among subjects. also, if it is assumed that perceptual distance between electrodes is related to current spread in the cochlea, the patterns of current spread vary considerably among subjects. (2) the variability in performance among subjects makes it difficult to compare the effectiveness of different speech processing strategies. also, there is a need for alternative procedures for better individualized fitting of processors. our results indicate that pitch ranking ability might be used both to assess implant user potential and to choose better electrode configurations. (3) two parameters that can be related to subjects' ability to rank pitch according to place of stimulation influence speech perception performance: electrode spatial ie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 j o h a n j h a n e k o m e n r o b e r t v shannon separation and perceptual distance between electrodes. (4) it is possible to make better choices of electrodes to be used in a reduced electrode m a p b y basing the electrode choices on pitch discrimination data. (5) it might be possible to achieve better neural selectivity b y using multi-stimulation mode maps. a c k n o w l e d g e m e n t s this research was done in the department of auditory implant and perception at the house ear institute in los angeles, u s a . we especially wish to thank kim fishman for m a k i n g available unpublished results of a previous study w i t h the same subjects. r e s e a r c h w a s partially funded by the national institutes of health, united states. r e f e r e n c e s busby, p.α., whitford, l.a., blarney, p.j., richardson, l.m. & clark, g.m. (1994). pitch perception for different modes of . stimulation using the cochlear multiple-electrode prosthesis. journal of the acoustical society of america, 95,5,2658-2669. clark, g.m., tbng, y.c. & patrick, j.f. (1990). cochlear prostheses. melbourne: churchill livingstone incorporated. dorman, m.f., soli, s., dankowski, k., smith,l.m., mccandless, g. & parkin, j. (1990). acoustic cues for consonant identification by patients who use the ineraid cochlear implant. journal of the acoustical society of america, 88,5, 2074-2079. dubno, j.r. & dorman, m.f. (1987). effects of spectral flattening on vowel identification. journal of the acoustical society of america, 82, 5, 1503-1511 eddington, d. (1980). speech discrimination in deaf subjects with cochlear implants. journal of the acoustical society of america, 68, 885-891. green, d.m. & swets, j.a. (1966). signal detection theory and psychophysics. new york: john wiley and sons incorporated. hacker, m.j. & ratcliff, r. (1979). a revised table of d' for malternative forced choice. perception and psychophysics, 26, 2, 168-170. lawson, d.t., wilson, b.s., zerbi, m. & finley, c.c. (1996). speech processors for auditory prostheses. third quarterly progress report, february through april 1996, nih contract n01-dc5-2103. nelson, d.a., van tasell, d.j., schroder, a.c. & soli, s. (1995). electrode ranking of "place pitch" and speech recognition in electrical hearing. journal of the acoustical society of america, 98, 4, 1987-1999. shannon, r.v., zeng, f-g., kamath, v., wygonski, j. & ekelid, m. (1995). speech recognition with primarily temporal cues. science, 270, 303-304. shannon, r.v., adams, d.d., ferrel, r.l., palumbo, r.l. & grandgenett, m. (1990). a computer interface for psychophysical and speech research with the nucleus cochlear implant. journal of the acoustical society of america, 87, 2, 905-907. skinner, m.w., clark, g.m., whitford, l.a., seligman, p.m., staller, s.j., shipp, d.b., shallop, j.k., everingham, c., menapace, c.m., arndt, p.l., antogenelli, t., brimacombe, j.a., pijl, s., daniels, p., george, c.r., mcdermott, h.j. & beiter, a.l. (1994). evaluation of a new spectral peak coding strategy for the nucleus 22 channel cochlear implant system. the american journal of otology, 15, supplement 2, 15-27. townshend, b. & white, r.l. (1987). reduction of electrical interaction in auditory prostheses. ieee transactions on biomedical engineering, 34, 11, 891-897. wilson, b.s., finley, c.c., lawson, d.t., wolford, r.d., eddington, d.k. & rabinowitz, w.m. (1991). new levels of speech recognition with cochlear implants. nature, 352, 236-238. zimmermann, c.e., burgess, b.j. & nadol, j.b. (1995). patterns of degeneration in the human cochlear nerve. hearing research, 90, 192-201. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 78 an e v a l u a t i o n of the speech perception in noise test lucille p. dickens, ba(log) (pretoria) callum m. delaney, ba (sp. and h. therapy) (witwatersrand) department of logopaedics, university of cape town, cape town abstract the effects of presentation level and signal-to-babble ratio (s/b) on spin performance were investigated for eighty normal hearing listeners. both intensity and s/b had a significant effect on scores. performance improved at the more favourable s/b regardless of presentation level, and scores were better at the lower presentation level regardless of s/b. possible clinical applications of the spin test are discussed. opsomming die uitwerking van aanbiedingsvlak en sein-tot-babbel-verhouding (s/b) op spin-toets-diskriminasietellings is ondersoek by tagtig normaalhorende luisteraars. beide aanbiedingsvlak en s/b het 'n beduidende uitwerking op diskriminasietellings. 'n hoer persentasie korrekte diskriminasie is by die meer gunstige s/b verkry, ongeag die aanbiedingsvlak, en beter diskriminasietellings is by die laer aanbiedingsvlak verkry, ongeag die s/b. kliniese toepassings van die spin-toets is bespreek. the routine procedure in clinical speech audiometry over the past few decades has been to obtain a speech reception threshold for spondaic words and an estimation of monosyllabic discrimination ability. these measures art generally obtained in quiet conditions. in spite of the seeming popularity of this approach, much criticism has been directed against it (dirks, morgan and dubno, 1982). discrimination tests using monosyllabic words have been criticized for a number of reasons, but most frequently because test stimuli and conditions do not represent typical listening environments, and because test forms are not equivalent (dirks and dubno, 1984). with this in mind kalikow, stevens and elliott (1977) developed the speech perception in noise (spin) test in order to assess the understanding of speech in noise. they recognised that in speech communication adults utilize acousticphonetic and linguistic-contextual information for perception. consequently the spin test comprises eight lists of 50 sentences each, where the predictability of the final target or key word of each sentence is controlled. in each list 25 items are designed to be primarily identified by the acoustic-phonetic information (low predictability (lp)) and the other 25 sentences include linguisticcontextual information which could aid identification (high predictability (hp)). the following are examples of each, "i had not thought about the growl" (lp) and "the watchdog gave a warning growl" (hp). since everyday speech communication commonly occurs in the presence of noise, the sentences are presented in a 12-voice background babble. the sentences and babble are recorded ori separate channels of audio tape, thus permitting variation of the signal-to-babble (s/b) ratio. in constructing the test kalikow et al. (1977) chose 250 target words from an original pool of words, with each test word presented in both an h p and an lp context in complementary lists. form equivalence for these ten lists was investigated for a group of normal listeners at 80 db spl and at a 0 db s/b. two lists were discarded, and on the basis of an analysis of variance the remaining eight were considered to be equivalent for the difference score (i.e. h p lp). while the analysis did not show similar equivalence for hp and lp scores, kalikow et al. (1977) did no feel that this was a serious problem. morgan, kamm and velde (1981) and bilger, nuetzel, rabinowitz and rzeczkowski (1984) who also examined list equivalence did not agree with the results of kalikow et al. (1977) and concluded that only seven of the original ten lists were © sasha 1986 equivalent. however, the experimental design of all three studies differed with respect to presentation level and s/b, subjects (normal hearing or hearing impaired) and statistical method of analysis. thus the results of these later studies do not necessarily contradict those of kalikow et al. (1977). the effects of variations in presentation level, s/b, age and hearing impairment on spin performance have also been investigated. a consistent finding is the expected separation between the hp and lp scores, both of which improve with improved s/b ratios (kalikow et al., 1977; hutcherson, dirks and morgan, 1979; elliott, 1979; owen, 1981). kalikow et al. (1977) found a slightly smaller difference score for an elderly group as compared to young subjects and elliott (1979) found poorer hp sentence scores for 11 and 13 year old children compared to 15 and 17 year olds, which was not apparent when the sentences were presented in quiet. this finding may lend support to owen's (1981) conclusion that differences found in difference scores are related to the audibility of the sentences rather than to the listener's use of context. from these studies no clear pattern of results or administrative protocol emerges that might make the spin test clinically useful. with these issues in mind the present study was designed to examine the performance of a group of audiologically normal subjects using a locally produced recording of the test material. the object was to collect data that might provide a basis for comparison with the spin results of hearing impaired individuals and to identify aspects of the test that might most usefully and reliably be used in a clinical context. methodology aim to investigate the performance of a group of normal hearing subjects on the spin test, and to examine the effect on performance of presentation level and signal-to-babble ratio. subjects eighty young adults aged between 18 and 29 years with normal hearing sensitivity (<15 db re: ansi 1979) at octave frequencies from 250 to 8000 hz bilaterally, served as subjects. english was the native language of all subjects, and no subject had had any previous test experience with the spin materials. the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) an evaluation of the speech perception in noise test 79 instrumentation the eight lists of the spin test were recorded by an englishspeaking south african male. the babble was generated by recording each of six adults (3 males and 3 females) reading the same passage from a children's story book in an anechoic chamber, mixing these six recordings and combining two repetitions of the six-voice babble to produce the final 12-voice babble. both the sentence and babble tracks were preceded by 1000 hz calibration signals. during the test sessions the lists were played on a two-channel (pioneer stereo cassette tape deck ct-f650) tape recorder. the signal and babble outputs from the tape recorder were routed to a speech audiometer (grason-stadler, gsi 10) where the intensity of each was determined separately before being mixed. the mixed output was delivered to the subject via a tdh-39 earphone mounted in a supra-aural cushion (mx 41/ar). the audiometers were calibrated according to ansi 1979 standards, and prior to each test session the vu meters of each channel were adjusted according to the 1000 hz calibration signal. all testing was conducted in dual chamber sound treated test suites. procedure lists were presented at two intensity levels (60 and 40 db η l) and two s/b ratios (0 and + 5 db). the 60 db hl 0 s/b condition was chosen to allow comparison to the kalikow et al. (1977) study. the 40 db hl level was chosen because normal to loud conversational speech falls within the 40 to 60 db hl range, and because at a 40 db sensation level (re: srt) testing would be possible for a larger percentage of hearing impaired individuals than at higher levels. the + 5 db s/b ratio was chosen because it is a more favourable condition as research (pearsons, bennett and fidell, 1976 as cited by dirks et al. 1982) has shown that this ratio is usually maintained for conversations in background noise. subjects were divided into two groups. forty subjects were tested with the odd numbered lists, and forty subjects with the four even numbered lists, thus ensuring that complementary lists were not heard by the same person. the stimuli (signal and babble) were presented to the subject's preferred ear under four listening conditions: 60 db hl with a s/b of + 5 db, 60 db hl with a s/b of 0 db;, 40 db hl with a s/b of + 5 db, and 40 db hl with a s/b of 0 db: the order of presentation remained constant, but the order of presenting the lists was varied so that each list was presented under each listening condition the same number of times. subjects were instructed to write down the last word of each sentence. analysis o f results a strict scoring protocol was adopted. (singular/plural conversions were not acceptable). total, hp, lp and difference scores were converted into percentages. summary statistics (means and standard deviations) were used to describe central tendencies for each of the listening conditions. data were subjected to a two factor analysis of variance with repeated measures of both factors (treatments-by-treatments-by-subjects aov) to assess the effects of presentation level and s/b ratio. results and discussion table 1 summarizes the mean scores and standard deviations found for all the lists under the different listening conditions. table 1: means and standard deviations of scores obtained under four listening conditions. listening conditions 60 db 40 db total score x 80,34 52,53 85,48 59,73 (hp+lp) sd 8,89 11,77 6,42 13,04 hp score x 96,15 73,00 98,10 78,50 sd 5,30 13,07 3,49 13,94 lp score x 64,30 32,05 72,20 40,95 sd 14,66 13,51 11,04 14,86 difference score x 31,90 40,95 25,90 37,50 (hp-lp) sd 13,44 12,36 10,83 11.99 the results obtained at 60 db 0 s/b in the present study are slightly lower than those reported by kalikow et al. (1977), who reported the following mean values: hp = 87,8 lp = 40,3, and difference = 47,4. means for the other conditions have not been reported in the literature. there is a difference for scores obtained at the two s/b ratios for each intensity as well as at the two presentation levels for each s/b ratio. four 2-way analyses of variance with repeated measures on both factors were performed to determine whether scores (total, hp, lp and difference) obtained under four listening conditions (60 db, + 5 s/b, 60 db, 0 s/b, 40 db, + 5 s/b and 40 db, 0 s/b) differed significantly. the results of these anova's showed no significant interaction between intensity level and s/b ratio. both main effects (intensity level and s/b ratio) were significant (p<0.01), mean scores being better at the more favourable s/b ratio regardless of s/b ratio. the f values obtained are summarised in table 2. (in each case the degrees of freedom were 1,79.) table 2: f-values obtained in four anova's to test the difference between four scores (total hp, lp and difference) obtained under four listening conditions. total hp lp difference source intensity 74,69* 14,43* 78,69* 13,40* s/b 888,17* 435,08* 689,27* 54,07* intensity χ χ 0,94 2,86 0,13 1,06 s/b * ρ 0 . 0 1 the finding that all scores improve at the more favourable s/b ratio regardless of presentation level was to be expected and confirms results from previous studies (hutcherson et al., 1979; owen, 1981). an unexpected finding was that scores were better at the lower presentation level for both s/b conditions. this finding is contradictory to that of hutcherson et al. (1979) who found little difference in scores at 50 db and 80 db spl, and a definite improvement from 30 to 50 db spl. since the order of testing under the four listening conditions was held constant it may be postulated that a learning effect produced this result. however, in such a case less of a difference would be expected between the 60/40 db 0 s/b conditions than the +5 s/b conditions, but examination of the results indicates that the difference is of equal magnitude. a similar intensity effect appears to be present in data reported for thee normal hearing subjects for words from nu # 6 lists presented in spin background babble (dirks et al., 1982). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 80 l.p. dickens and c.m. delaney taken together these results may suggest that there is an optimal presentation level for discrimination of speech in noise, and that an increase or decrease in this level will result in a deterioration of performance. this level may correspond to that of conversational speech (40 db hl). the eftect should be more thoroughly explored — for both the normal hearing population and those with sensorineural hearing losses. it would be interesting to determine how, for example, individuals with cochlear losses and concomitant intolerance for loud sounds would perform. the immediate clinical implication of these results is that the spin test should not be administered under listening conditions for which normative data is unavailable. regardless of the measure used, both intensity and s/b affect performance. consequently no generalizations about scores can be made. the present findings provide a means for comparing the performance of hearing impaired individuals with that of normal listeners. for such a purpose it is suggested that the 40 db +5 s/b protocol is adopted. at the 40 db sl re srt presentation level testing is likely to be possible for the majority of hearing impaired listeners, and the +5 db s/b provides the most well defined normal performance. the good hp scores and the relatively high lp scores would allow measurement of the poorer performance by the hearing-impaired individual over a wider range than would be possible under the other three conditions. the hp and lp scores provide two sources of information. they provide an indication of performance that can be compared with normal performance. in addition the relationship between the hp and lp scores for an individual provide an indication of the extent to which he is taking advantage of sentence context, and this has important therapeutic implications. however, this relationship is only meaningful in the context of the normal hp andlp scores. considering that noise has a differential effect on individuals even with similar audiometric configurations and degree of loss (plomp and mimpen, 1979), determination of performance functions for various s/b ratios and intensity levels would give the best estimate of ability to understand speech at suprathreshold levels. however, in its present form the spin test would not be a cost effective or practical method for this purpose, being too time-consuming and fatiguing. in conclusion it is suggested that the spin test be administered at the 40 db + 5 s/b level in order to obtain comparative and rehabilitative information. any diagnostic application of the spin test among hearing-impaired individuals requires further research. references bilger, r.c., nuetzel, j.m., rabinowitz, w.m., and rzeczkowski, c. standardization of a test of speech perception in noise. j. speech hear. res., 27, 32-48. 1984. dirks, d.d., morgan, d.e., and dubno, j.r. a procedure for quantifying the effects of noise on speech recognition. j. speech hear. disord., 47, 114-123, 1982. dirks, d.d., and dubno, j.r. speech audiometry. in j. jerger (ed.) hearing disorders in adults: current trends, san diego: college-hill press, 1984. elliott, l.l. performance of children aged 9 to 17 years on a test of speech intelligibility in noise using sentence material with controlled word predictability. j. acous. soc., am., 66, 651-653, 1979. hutcherson, r.w., dirks, d.d.,and morgan, d.e. evaluation of the speech perception in noise (spin) test. otolaryngol. head neck surg., 87, 239-245, 1979. kalikow, d.n., stevens, k.n., and elliott, l.l. development of a test of speech intelligibility in noise using sentence materials with controlled word predictability. j. acoust. soc., am., 61, 1337-1351, 1977. morgan, d.e., kamm, c.a., and velde, t.m. form equivalence of the speech perception in noise (spin) test. j.acoust.soc., am., 69, 1791-1798, 1981. owen, j.h. influence of acoustical and linguistic factors on the spin test difference score. j. acoust. soc. am., 70,678-682, 1982. plomp, r., and mimpen, a.r. speech reception threshold for sentences as a function of age and noise level. j. acoust. soc. am., 66, 1333-1342, 1979. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 81 information for contributors the south african journal of communication disorders publishes reports and papers concerned with research, or critically evaluative theoretical, or therapeutic issues dealing with disorders of speech, voice, hearing or language, or on aspects of the processes underlying these. the south african journal of communication disorders will not accept material which has been published elsewhere or that is currently under review by other publications. all contributions are reviewed by at least two consultants who are not provided with author identification. form of manuscript. authors should submit four neatly typewritten manuscripts in triple spacing with wide margins which should not exceed much more than 25 pages. each page should be numbered. the first page of two copies should contain the title of the article, name of 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psychology: the explanation and treatment of speech sound disorders. j. speech hear. disord., 48, 339-341, 1983. penrod, j.p. speech discrimination testing. in j. katz (ed^handbook of clinical audiology, 3rd ed., baltimore: williams & wilkins, 1985. van riper, c. the nature of stuttering. englewood cliffs, new jersey: prentice-hall, 1971. proofs. galley proofs will be sent to the author wherever possible. corrections other than typographical errors will be charged to the author. reprints. 10 reprints without covers will be provided free of charge. all manuscripts and correspondence should be addressed to: the editor, south african journal of communication disorders, south african speech and hearing association, p.o. box 31782, braamfontein 2017, south africa. inligting vir bydraers die suid-afrikaanse tydskrif vir kommunikasieafwykings publiseer verslae en artikels oor navorsing, of krities evaluerende artikels oor die teoretiese of terapeutiese aspekte van spraak-, stem-, gehoorof 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buitelandse bydraers voorsien word. alle paragrawe moet teenaan die linkerkantlyn begin word en moet nie ingekeep word nie. hoofopskrifte moet, waar dit van toepassing is, in die volgende volgorde wees: metode, resultate, bespreking, gevolgtrekking, erkennings en verwysings. tabelle en figure moet op afsonderlike bladsye verskyn (een bladsy per tabel/illustrasie). figure, grafieke en lyntekeninge moet oorspronklike weergawes wees en moet in swart ink op wit papier van 'n hoe gehalte gedoen word. letterwerk wat hierop verskyn moet eenvormig wees, professioneel gedoen word en daar moet in gedagte gehou word dat dit leesbaar moet wees na 'n 50%-verkleining in drukwerk. letterwerk by die illustrasie moet onder geen omstandighede getik word nie. verkladie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 rings of omskry wings moet nie in die illustrasie nie, maar daaronder verskyn. die byskrifte van tabelle moet bo-aan verskyn en die van figure onderaan. tabelle en figure moet in die volgorde waarin hulle verskyn, genommer word (met arabiese syfers). die hoeveelheid materiaal in die vorm van tabelle en illustrasies wat toegelaat word, word deur die redakteur bepaal (gewoonlik nie meer as 6 nie). verwysings. verwysings in die teks moet voorsien word van die skrywer se van en die datum, bv. van riper (1971). waar daar meer as twee skrywers is, sal et al. na die eerste skrywer voldoende wees. die name van alle skrywers moet in die verwysingslys verskyn. verwysings moet alfabeties in 3-spasiering aan die einde van die artikel gerangskik, word. vir die aanvaarde afkortings van tydskrifte se titels, raadpleeg die vierde uitgawe (oktober) van dsh abstracts of the world list of scientific periodicals. die getal verwysings wat gebruik is, moet nie veel meer as 20 wees nie. let op die volgende voorbeelde: locke, j.l. clinical phonology: the explanation and treatment of speech sound disorders. j. speech hear. disord, 48 339-341 1983. penrod, j.p. speech discrimination testing. in j. katz (ed^handbook of clinical audiology, 3de ed., baltimore: williams & wilkins, 1985. van riper, c. the nature of stuttering. englewood cliffs, new jersey: prentice hall, 1971. proewe. galeiproewe sal waar moontlik aan die skrywer gestuur word. die onkoste van veranderings, behalwe tipografiese foute, sal deur die skrywer self gedra moet word. herdrukke. 10 herdrukke sonder omslae sal gratis verskaf word. alle manuskripte en korrespondensie moet gerig word aan: die redakteur, die suid-afrikaanse tydskrif vir kommunikasieafwykings. die suid-afrikaanse vereniging vir spraaken gehoorheelkunde, posbus 31782, braamfontein 2017, suid-afrka. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 59 speech discrimination in the elderly l.p. dickens, ba(log) (pretoria) department of logopaedics, university of cape town. abstract the performance of 39 elderly subjects on three speech discrimination tasks, viz, cid yj-22 word lists, the spin test and compressed spin sentence lists, was investigated. the effects of age and audiometric configuration on discrimination ability were examined, and age was found to significantly differentiate between subjects while audiometric configuration did not prove to be significantly variable. with the exception of the hp sentences for the spin and compressed speech tests, scores for all other measures differ significantly and thus would seem to assess different aspects of discrimination. the implications of these results are discussed. opsomming die prestasie van 39 bejaarde proefpersone op drie spraakdiskriminasietoetse, naamlik cid w-22 woordlyste, die spin-toets en saamgeperste spin-sinlyste, is ondersoek. die invloed van ouderom en oudiometriese konfigurasie op diskriminasievermoe is bestudeer en daar is gevind dat ouderdom beduidend differensieer tussen proefpersone, terwyl oudiometriese konfigurasie nie 'n beduidende variant blyk te wees nie. met die uitsondering van die hp-sinne van die spin en saamgeperste spraaktoetse, het resultate vir alle ander metings beduidend verskil en dit wil dus voorkom asof die toetse verskillende aspekte van diskriminasie ondersoek. die implikasies van hierdie resultate word bespreek. introduction the fact that hearing sensitivity deteriorates with age has been known for many years. the characteristic high-frequency nature of the loss was identified by zwaardemaker as early as 1899 (cited by arnst, 1985). the initial studies were mainly concerned with documenting the amount of hearing loss occurring at various frequencies (bunch, 1929, 1931 cited by willeford, 1978), but following the reports by gaeth (1948, cited by willeford, 1978) of discrimination problems experienced by the elderly, which he called ' 'phonemic regression", interest has been focused on speech discrimination ability. the descriptive term used to denote this deterioration of auditory function that accompanies the aging process is presbycusis (krnst, 1985, garstecki, 1981). the more recent descriptions (miller, 1983; marshall, 1981; osterhammel and osterhammel, 1979; and willeford 1978) of it being a slowly progressive, bilaterally symmetrical, mildly sloping sensorineural loss. with speech discrimination skills that are poorer than would be expected for the amount of hearing loss concur with the earlier ones. anatomical changes due to aging have been found throughout the auditory system, and these have been extensively and unequivocally documented, e.g., valenstein, 1981; nadol 1981; schuknecht, 1974, and consequently will not be dealt with in this paper. however, there is less conformity amongst the reports concerning the effect of age on auditory function, and more especially speech discrimination ability. many studies have compared word discrimination with sensitivity loss, and have attributed the disproportionate problems with speech perception to central auditory nervous system (cans) degeneration (e.g., bergman, 1971; pestalozza and shore, 1955). a number of practical issues have complicated these investigations; thus our knowledge about the normal deterioration of hearing with age is limited (miller, 1983) and further evaluation of the behavioural effects of presbycusis are needed (marshall, 1981; hayes, 1984). in investigating speech discrimination the majority of studies only measured performance at one sensation level, usually 30-40 db sl re srt (marshall, 1981). however, it has been shown that maximum discrimination in the elderly may only occur at much higher levels (kasden, 1970), thus it may be reasonable to expect that performance may have been underestimated. generally, the early studies were concerned with monosyllabic word discrimination in ideal conditions, yet plomp and mimpen (1979) have established that the problems experienced by the elderly primarily manifest themselves in noisy environments. while some investigators examined the effects of noise on word and sentence identification (e.g., jerger and hayes, 1977; arnst, 1985) results are conflicting and the stimuli used were not representative of everyday listening conditions. in order to define the problems experienced by the elderly, more realistic speech discrimination measures need to be used (marshall, 1981). a measure which seems to be more appropriate for this task is the spin test. kalikow, stevens and elliott (1977) developed this test taking into account the fact that normal adults utilise both acoustic-phonetic and linguistic-contextual cues for speech recognition, and that everyday communication occurs in a background of noise. the test examines discrimination as a function of both context and competing noise, and research has established that, as would be expected, the performance of normal hearing young adults improves when contextual cues are present and the noise level is decreased (kalikow et al. 1977; dickens & delaney, 1986). however, besides a brief preliminary report on the performance of ten elderly subjects whose scores were slightly die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 © sasha 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 l.p. dickens depressed relative to those of younger listeners (kalikow et al. 1977), no research (to the writer's knowledge) has concerned itself with investigating this aspect in the elderly population. central auditory processing can be seen as a kind of speech discrimination (willeford, 1978), and research has suggested that reduced cans function becomes evident when the speech is degraded in some manner. speech can be degraded in many ways, e.g., by filtering, by time compression, by the introduction of competing messages, etc. compressed speech provides a quick and simple means of assessing cans function, and was first used by calearo and lazzaroni in 1957. these authors documented the problems that the elderly, in comparison to young listeners, experience with fast speech. since this report much interest has been shown in this area, but subsequent studies have not all been in agreement. while konkle, beasley and bess (1977) for example, confirmed the findings of calearo and lazzaroni, others such as miller (1983) and luterman, welsh and melrose (1966) found no difference between young and elderly listeners, and schmitt (1983) and schmitt and mccroskey (1981) reported improved performance for compressed speech in a group of the elderly. a variety of procedures and materials were used in these studies. according to beasley and maki (1976) one needs to consider whether data from a specific study reflects upon intelligibility or comprehension. monosyllabic stimuli would provide information pertaining to intelligibility, but may be inadequate for assessing the linguistic integrity of the central processing system, especially in cases where there is concomitant peripheral involvement (beasley, bratt and rintelmann, 1980). since this is likely to be the situation with the elderly, it would seem appropriate to use sentential stimuli for this purpose, and material such as the spin lists appear to be ideal, combining as they do monosyllabic and sentential features. finally, the effects of hearings loss, as opposed to age per se, do not appear to have been examined in much detail. marshall (1981) suggests that peripheral problems other than sensitivity loss may underlie those problems experienced by the elderly. dubno and dirks (1982, 1984) have reported a strong relationship between audiogram shape and speech discrimination, and this needs to be investigated in relation to the elderly. it is evident that the effects of aging on speech discrimination are not clearly understood and that the previous use of the term "phonemic regression" to explain the poor speech discrimination observed in some elderly individuals needs to be reassessed. methodology aims to investigate the performance of a group of elderly subjects on "three speech discrimination tasks viz. cid w-22 word lists, the spin test, and time-compressed speech, and to examine the differential effect on performance of age as opposed to audiogram configuration. subjects subjects (ss) were selected from five old age homes located in the cape town area. at each of these volunteers were requested from a group of residents that had been preselected by the matron or sister-in-charge. potential ss were required to be over 60 years of age, english speaking, show no signs of senile dementia, and be normally active, i.e., not confined to a wheelchair or bed. while sex was not a criterion, it was hoped that a reasonable proportion of males to females would be obtained. however, there were very few male residents, and only a small percentage of these conformed to all the criteria and were willing to act as ss. 39 ss (78 ears) participated in the study, 36 females and 3 males. the age range was 60 to 87 years, with a mean age of 74.2. no ss were excluded from the study on the basis of previous history of hearing problems or noise exposure, because the aim was to examine speech discrimination abilities in the aged population as it presents itself, as was suggested by miller (1983). furthermore it has been suggested that it is unrealistic to expect accurate recall of any confounding factors over a 60 year life-span or longer (osterhammel and osterhammel, 1979; hayes, 1984). materials and instrumentation all speech materials were prerecorded by the same englishspeaking south african male. the cid w-22 lists were recorded in quiet, while the spin lists were presented in a 12-voice background-babble, with sentences and babble recorded on separate channels allowing for variations of the signal-to-babble (s/n) ratio. lists 1 and 3 were used in the present study. the compressed speech was obtained by processing the recorded spin lists (6, 7 and 8) without the background babble through a lexicon varispeech model ii. the speed factor dial was set at 2, which corresponds to a 100% compression rate. the procedure for selecting this speed factor dial setting and the collection of normative data has been described elsewhere (dickens, 1987). list 7 was used for practice. spin lists were used for compressed tasks because, as previously discussed, they combine monosyllabic and sentential ίεβΐμγββ, and in addition would allow for direct comparison of the effects of noise and compression on discrimination. all audiometric testing was conducted on a madsen micro-5 digital audiometer, with tdh-39 earphones mounted in mx/ar supra-aural aircushions, to which a two-channel (pioneer stereo tape deck — ct-f650) tape recorder was connected. the audiometer was calibrated according to ansi 1979 standards, and prior to each test session the vu-meters of each channel were adjusted according to the 1000 hz calibration signal. testing was conducted in a dual chamber sound-treated test suite. procedure prior to assessing performance on the speech discrimination tasks, pure tone (air and bone conduction) and speech thresholds were obtained for each subject. these were necessary in order to group ss according to audiogram configuration, and to determine presentation levels for the speech tasks. all speech measures were obtained separately for each ear under earphones. cid w-22 lists were presented at 20̂ 40 and 60 db sl (re srt) unless the 60 db level exceeded the threshold of discomfort, in which case a lower sl was used when necessary. the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) speech discrimination in the elderly spin lists were presented at 40 db sl (re srt) at a s/n ratio of +5 db, as was suggested by dickens and delaney (1986). compressed speech (cspin) lists were also presented at 40 db sl (re srt), to allow for comparison between the various measures. 61 do not differ much for mean age or pta, and that the standard deviations for these measures are similar for all three groups. table 1: mean age and pta values for ss grouped according to age ss were instructed to respond verbally. analysis of results all scores were converted into percentages. the total high predictability (hp) and low predictability (lp) scores for both the spin and cspin tests and the maximum discrimination scores (regardless of sl) were used in the analysis. summary statistics were calculated to describe the central tendencies. data were subjected to two factor analyses of variance (anova) with repeated measures on one factor (treatments-by-groups) to examine the difference between scores obtained for grouping according to age as opposed to audiogram configuration. multivariate analyses and the scheffe test were used to determine the specific comparison which accounted for the significant f-ratios within the interactions. grouping was as follows: by age in decade: group i — 60 to 69 years group ii — 70 to 79 years group iii — 80 years and older by audiometric configuration: the system described by dubno and dirks (1982) was used. group a group β / group c — flat; < or = 20 db difference in threshold from 250 to 4000 hz. — gradually sloping; 25 to 40 db difference in threshold from 250 to 4000 hz, and < 30 db difference in! threshold between adjacent octave frequencies. — steeply sloping; > 40 db difference in threshold from 250 to 4000 hz, or > 30 db difference between adjacent octave frequencies. results and discussion pta age group i x 25.77 64.91 sd 15.33 3.93 group ii x 33.44 74.72 sd 11.81 3.04 group iii x 39.90 83.30 sd 17.66 2.20 table 2: mean age and pta values for ss grouped according to audiogram configuration age pta group a x 74.40 33.19 sd 8.10 13.26 group β x 73.70 30.94 sd 6.65 13.86 group c x 74,75 32.00 sd 7.98 13.61 table i illustrates the mean pure tone average (pta) for each of the three age groups. as can be seen, there is a slight increase in pta with an increase in age. the mean age and pta for ss grouped according to audiometric configuration can be seen in table 2. it is interesting to note that the groups table 3: means and standard deviations of scores obtained on the speech measures the means and standard deviations obtained for the speech measures can be seen in table 3. the results of the anovas to examine the difference between the speech scores for the ss grouped according to age and audiogram configuration are summarised in table 4 and 5. these show that when ss were grouped according to age there was a significant variance for both main effects, i.e., age and speech score, while for ss grouped according to audiogram configuration there was a significant difference for speechscore, but not for audiogram configuration. from these results, it can be concluded that ss scored differently on the different speech tasks, and that age rather than audiogram configuration is the critical factor which differentiates between ss. the lack of differentiation between the audiometric groups could possibly be explained by the fact that, for some of the speech tasks, sentence stimuli were used, i.e., the spin and cspin hp items, and dubno and dirks (1982) report that the relationship between discrimination and audiometric configuration is weakened when sentences are used as stimuli. however, this does not explain the lack of variance between the ss for the other speech measures, viz. the cid w-22 maximum and the lp items of the spin and cspin tests. a more likely explanation may be that the difference between the groups is qualitative rather than quantitative. another confounding variable may be related to sample size. group cid w-22 spin spin spin cspin cspin cspin group max hp , lp total hp lp total group i x 91.46 88.38 45.90 67.14 86.29 69.71 78.00 (60-69) sd 13.14 8.76 12.50 8.75 20.30 23.41 20.00 group ii x 88.89 79.54 37.83 58.69 80.12 58.91 70.06 (70-79) sd 9.47 14.32 20.20 14.91 14.91 17.67 12.61 group iii x 72.84 62.35 18.82 40.59 60.00 37.18 48.59 (80 + ) sd 19.67 25.65 13.91 18.79 27.13 24.36 24.35 all subjects x 85:66 78.08 35.73 56.90 77.13 56.90 67.27 all subjects sd 15.37 18.83 19.46 17.31 22.10 24.10 21.10 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 l.p. dickens table 4: a n o v a summary table showing interaction between age (a) and speech score (s) cid w-22 χ spin η χ cspin η source df f ρ cid w-22 χ spin η χ cspin η a 2 12.30 .0000 cid w-22 χ spin η χ cspin η s 2 26.28 .0000 cid w-22 χ spin η χ cspin η sxa 4 1.81 .1299 cid w-22 χ spin l χ cspin l a 2 14.84 .0000 cid w-22 χ spin l χ cspin l s 2 359.38 .0000 cid w-22 χ spin l χ cspin l sxa 4 2.43 .0509 cid w-22 χ spin τ χ cspin τ a 2 15.65 .0000 cid w-22 χ spin τ χ cspin τ s 2 235.15 .0000 cid w-22 χ spin τ χ cspin τ sxa 4 3.19 .0154 table 5: a n o v a summary table showing interaction between audiogram configuration (g) and speech score (r). cid w-22 χ spin η χ cspin η source df f ρ cid w-22 χ spin η χ cspin η g 2 1.48 .2346 cid w-22 χ spin η χ cspin η r 2 22.76 .0000 cid w-22 χ spin η χ cspin η rxg 4 1.98 .1004 cid w-22 χ spin l χ cspin l g 2 1.95 .1502 cid w-22 χ spin l χ cspin l r 2 253.86 .0000 cid w-22 χ spin l χ cspin l rxg 4 1.46 .2188 cid w-22 χ spin τ χ cspin τ g 2 1.82 .1703 cid w-22 χ spin τ χ cspin τ r 2 170.26 .0000 cid w-22 χ spin τ χ cspin τ rxg 4 2.29 .0632 the variance in age was further investigated by means of multi-variate analysis and scheffe post hoc comparisons. the scheffe test results are summarised in table 6. these indicate that the scores obtained by group iii differed significantly from those obtained by the other two groups. this difference was apparent for all the speech measures. while the mean values for the speech tasks seen in table 3 show a tendency for performance to deteriorate with increasing age for all the tests, the difference between groups i and ii was not found to be statistically significant. this performance difference could reflect a loss effect, since mean pta scores also reflect an increase with corresponding increase in age. however, t-test computations (summarised in table 7) show that the pta values for group i differ significantly from groups ii and iii, with no significant difference between the latter two groups. this is in contrast to the speech score differences, where groups i and ii were not statistically differentiated. the data therefore suggests a complex interaction between age and degree of loss. this is in agreement with a study by bess and townsend (1977) which showed that discrimination ability is dependent on both age and degree of loss, i.e., discrimination as a function of age only decreased for individuals whose pta scores exceeded 49 db, while there was no age effect for ss with pta scores below 49 db. the mean pta values for the three groups in the present study are all below 49 db, and a general trend for an agerelated reduction in discrimination was evident. the fact that bess and townsend (1977) did not see much of an age effect for ss with smaller pta scores could be due to their age grouping, i.e., by twenty year spans rather than by decade. table 6: summary of scheffe values showing significant age group variation for specific speech tasks. speech score αι—a2 a i a 3 a2—a3 a j = 60-69 max. cid w-22 1.2 4.215 + + + 3.487 + + a2 = 70-79 spin η 1.6741 4.8738+++ 3.7609** a3 = 80 + cspin η 1.1064 4.0337+" 3.3736++ spin l 1.7360 4.8347+++ 3.6602" cspin l 1.8283 4.7118+++ 3.4397" spin τ 1.952 5.675 + + + 4.448 cspin τ 1.5613 4.948 + + + 3.9365+++ f crit 2,68: 2.501 : ρ <0.05 + 3.138 : p<0.01 + + 3.908 : ρ <0.001 + + + table 7: summary of t-test values showing significant pta difference comparison t-value groups i χ ii 2.085 + groups ii x iii 1.822 groups i x i i i 2.776 + + + ρ 0.05 + + ρ 0.01 the present results indicate that a significant age x degree', of loss interaction occurs when the loss exceeds 33 db (meanj pta value for group ii), and that the trend for scores to1 deteriorate with increasing age is also apparent for smaller' pta values. , the distribution of the cid w-22 maximum scores for each group and the entire sample can be seen in figure 1. this shows that the majority of ss (56%) had discrimination scores which were better than 91%, which can be seen to refute the statement that disproportionately poor speech discrimination scores are a general feature of age-related hearing loss. this supports miller's (1981, cited by miller, 1983) finding, although the present proportion is slightly lower than miller's. the reason for this may be twofold; miller only used 70 year old ss (reassessed at 75), and their average loss was less severe. in addition to the quantitative difference betweengroups iii, and i and ii, figure 1 also illustrates the qualitative differences (in terms of general distribution). groups i and ii folthe south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) speech discrimination in the elderly 63 examination of the spin scores shows that there is the expected hp and lp separation, and that the scores are reduced in relation to those reported for normal hearing young ss (dickens and delaney, 1986). while both hp and lp scores are reduced, the reduction is much larger for the lp items, and this becomes more pronounced with increasing age. this was also seen for the compressed speech. scores collected from 30 normal hearing ss were: total equals 90.00 (3.58), hp = 97.09 (3.14), and lp = 82.91 (6.95) (dickens, 1987). an interesting finding is that the standard deviations for all groups tend to be larger for compressed speech. this would seem to support miller's contention that in a "non-clinical" group of elderly, there are those individuals with well-preserved central auditory function as well as those with presumable central auditory problems. the results of the scheffe computations to investigate significant speech score variation within the different age groups can be seen in table 8. for group i there was no significant difference between scores obtained for the cid w-22, the spin hp and the cspin hp procedures, and for both groups ii and iii there was no difference between the spin hp and cspin hp scores. for all the other measures the speech score variation was found to be significant within all three age groups, indicating that the tests assess different aspects of auditory discrimination. the lack of significant difference for the hp measures for all ss, regardless of age or audiometric configuration, is interestable 8: summary table of scheffe values showing significant speech score variation within age groups. groups sj — s2 s, s , s2 — s3 si = cis w-22 max. a, (60-69) 1.6829 2.4219 .0738 52 = spin η 53 = cspin η a2 (70-79) 3.701 + + 3.9755+++ .2703 / / a3 (79 +) 4.4917 +~ 5.2393*" .7476 groups si — s2 s i s , s2 — s3 s, = cis w-22 max. a! (60 69) 13.643 6.7667 +++ 6.8764+++ 52 = spin l 1 53 = cspin l j a2 (70 79) 18.647 10.925 7.7215+++ a, (79 +) 14.9788+" 10.2084"+ 4.7703+++ groups si — s2 s i s , s2 — s3 s, cis w-22 max. a, (60 69) 10.198 5.938 + + + 4.2596+++ 52 = spin τ 53 = cspin τ a2 • (70 79) 14.721 * ++ 9.3587"* 5.364 a3 (79 +) 13.368 9.839 + + + 2.823 + f crit 2,68: 2.501 : ρ<0.05 + 3.138 : p<0.01 + + 3.908 : p<0.001 + + + 100% i [ all s u b j e c t s θ g r o u p i [jj[j] g r o u p ii q g r o u p iii figure 1. cid w-22 maximum discrimination scores low a similar trend (which is the trend shown by the entire sample), i.e., the majority of ss show good discrimination, with only 9% and 14% respectively, obtaining scores below 76%. the pattern for group iii differs, showing a flatter distribution curve with the majority (37%) having scores below 76%. this further illustrates the complex interactive effects of age and degree of loss on discrimination. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 l.p. dickens ting. introduction of noise and compression did not have a differential effect on hp performance, while for the lp sentences the two conditions were differentiated. thus, the important feature seems to be context, which apparently helps to overcome the distortion, regardless of the nature of the distortion. this has important implications for rehabilitation with the elderly hearing impaired client, in that more emphasis should be placed on teaching him to utilise contextual information in order to overcome problems which he experiences in the less than ideal type of communicative situation. it would also be interesting to investigate the performance of different groups of ss, including those with cans disorders, to determine whether any demonstrate an hp discrepancy for the spin and cspin tests, and thus whether this could be used diagnostically. for all ss the scores obtained for the cid w-22 lists were the highest, with cspin and spin following in that order. very often the elderly specifically complain of problems in understanding speech in noise, yet this aspect is not routinely investigated. the present results indicate that the ss perform differently in noise and quiet, supporting the research by plomp and mimpen (1979), which showed that ss with the same hearing loss for speech in quiet may differ in their performance in noise, and that this could not really be predicted from the performance in quiet. the fact that the scores for the speech measures in quiet and noise differ significantly suggests that different aspects of auditory function are being measured. a study by festen and plomp (1983) provides support for this. they investigated the relationship between various auditory functions in hearing impaired individuals, and concluded that hearing loss for speech in quiet is determined by audiometric loss, while hearing loss for speech in noise is governed by frequency resolution abilities. if different aspects of auditory function are being measured, as this and previous research suggests, it is necessary to include, in the routine audiologic battery, a test which evaluates discrimination in noise. all the ss performed more poorly in the spin than on the cspin test. the reduction in performance on both the cspin and the spin tests could be seen as evidence of central processing problems (i.e., compressed speech is generally considered to be sensitive to disorders in the central auditory nervous system, and all ss performed more poorly on the spin). it could be argued that the noise element in the spin test reduces the redundancy of the speech signal to a greater degree than the compression in the cspin test and, that it it is therefore tapping more subtle cans disorders. however, the more likely explanation is that reduced performance on the spin is the result of peripheral processing problems, and that the reduction in performance on the cspin may also be due to the peripheral involvement rather than central problems. the study of plomp and mimpen (1979) which investigated srt for sentences as function of age and noise appears to support this, i.e., they found that for ss up until about 90 years of age, the critical variable in hearing loss for speech is deterioration in auditory processing rather than in central processing. in conclusion, it is evident that, except for the hp sections of the spin and cspin tests, all other measures appear to be assessing different aspects of auditory discrimination, and that age rather than audiometric configuration is the distinguishing factor. as a group the elderly perform fairly well on conventional speech discrimination tasks (i.e., cid w-22 lists in quiet) but this does not reflect the problem that they may have in different situations. since the most common complaint of the elderly patient in a clinic is the difficulty that he experiences with speech in noisy situations it is recommended that a speech in noise test be administered routinely. it may be advisable to administer both the spin and cspin tests, since this may provide potentially important diagnostic and rehabilitative information concerning the differential effect of distortion. at this stage it is not clear whether the problems that the elderly experience with compressed speech and especially with speech in noise is a reflection of cans disorder or breakdown in peripheral auditory processing. before any final comment can be made concerning the question of central processing problems in the elderly, further research needs to be conducted, firstly, to determine the sensitivity of the spin and cspin in detecting cans disorders in patients with documented lesions and, secondly, to establish the influence of peripheral sensitivity loss on young listeners' performance on these tests. references arnst, d.j. presbycusis. in j. katz (ed.) handbook of clinical audiology, 3rd edition baltimore: williams & wilkins, 1985. beasley, d.s. & maki, j.e. time and frequency altered speech. in n.j. lass (ed.) contemporary issues in experimental phonetics. new york: academic press, 1976. beasley d.s., bratt, g. & rintelmann, w. intelligibility of timecompressed sentential stimuli./. speech hear. res., 23, 722739, 1980. bergman, m. hearing and aging, audiology 10, 164-171, 1971. bergman, m. central auditory disorders. in r. hinchcliffe (ed.) hearing and balance in the elderly. new york: churchill livingstone, 1983. bess, f.h. & townsend, t.h. word discrimination for listeners with flat sensorineural hearing losses. j. speech hear. disord., 42, 232-237, 1977. calearo, c. & lazzaroni, a. speech intelligibility in relation to the speed of the message, laryngoscope, 67, 410-419, 1957. dickens, l.p. & delaney, c.m. an evaluation of the speech percep-j tion in noise test. s.a. j. comm. dis., 33, 78-80, 1986. j dickens, l.p. audiological correlates of aging. unpublishedl master's dissertation, university of the witwatersrand, 1987. 1 dubno, j. & dirks, d. evaluation of hearing impaired listeners us-1 ing a nonsense-syllable test. i. test reliability./. speech j hear. res., 25, 135-141, 1982. dirks, d.d. & dubno, j.r. speech audiometry. in j. jerger (ed. j hearing disorders in adults: current trends. san diego: college-hill press, 1984. 1 festen, j.m. & plomp, r. relations between auditory functions in impaired hearing./. acous. soc. am., till, 652-662, 1983 garstecki, d.c. aural rehabilitation for the aging adult. in d. beasley & g. davis (eds.) aging: communication processes and disorders. new york: grune & stratton, 1981. hayes, d. hearing problems in aging. in j. jerger (ed.) hearing, disorders in adults: current trends. san diego: college-hill press, 1984. jerger, j. & hayes, d. diagnostic speech audiometry. arch. otolaryngol, 102, 216-222, 1977. / kalikow, d.n., stevens, k.n. & elliot, l.l. development^ a test of speech intelligibility in noise using sentence materials with controlled word predictability./. acousfsoc. am., 61,5 1337-1351, 1977 ^ kasden, s.d. speech discrimination in two'age groups matched for hearing loss./. aud. res., 10, 210-212, 1970. konkle, d.f., beasley, d.s. & bess, f.h. intelligibility of timealtered speech in relation to chronological aging. j. speech hear. res., 20, 108-115, 1977. the south african journal of communication disorders, vol. 34,1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) speech discrimination in the elderly 65 luterman, d.m. welsh, c.l. & melrose, j. responses of aged males to time-altered speech stimuli./. speech. res., 9, 226230, 1966. marshall, l. auditory processing in aging listeners./. speech hear. disord, 46, 226-240, 1981. m011er, m.b. changes in hearing measures with increasing age. in r. hinchcliffe (ed.) hearing and balance in the elderly. new york: churchill livingstone, 1983. nadol. j.b. the aging peripheral hearing mechanism. in d.s. beasley & g.a. davis (eds.] aging: communication processes and disorders. new york: grune & stratton, 1981. osterhammel, d. & osterhammel, p. high frequency and audiometry: age and sex variation. scand. audiol. 8, 73-81, 1979. pestalozza, g. & shore, i. clinical evaluation of presbycusis on the basis of different tests of auditory function. laryngoscope, 65, 1136-1163, 1955. plomp, r. & mimpen, a.r. speech-reception threshold for sentences as a function of age and noise level./. acous. soc. am., 66, 1333-1343, 1979. schmitt, j.f. & mccroskey, r.l. sentence comprehension in elderly listeners: the factor of rate./. gerontology, 36, 441-445, 1981. schmitt, j.f. the effects of time compression and time expansion on passage comprehension by the elderly. /. speech hear. res., 26,373-377, 1983. schuknecht, h.f. pathology of the ear. campbride mass: harvard university press, 1974. valenstein, e. age-related changes in the human central nervous system. in d.s. beasley & g.a. davis (eds.) aging: communication processes and disorders. new york: grune & stratton, 1981. willeford, j.a. the geriatric patient. in d. rose (ed.) audiological assessment, 2nd ed., new yersey: prentice-hall, 1978. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) c the stanoaflo of silence industrial acoustics company '™ ketton road, wadeville ext. 5 (011) 902-4492/3 14337, wadeville 1422 we set the standards for your audiologic equipment throughout south africa industrial acoustics professional hearing test booths and suites grason-stadler gsi 10 and gsi 16 microprocessor audiometer systems grason-stadler auto tympanometers gsi 27a and 28a grason-stadler middle ear analyzers model 33 versions 1 and 2 bio-logic evoked potential systems aep vep sep enn erg rep biocoustics simulators for audiometric and evoked potential training ics medical electronystagmographic systems industrial acoustics c o m p a n y (pty) limited p.o. box 14337 wadeville 1422 tel: (011) 902-4492 your contacts: hillary j reichenberg j a a p seymore we are only a phone call a w a y for further information on our products, maintenance and calibration service the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 5 3 single case experimental designs: an essential service in communicatively disabled care isabel c uys d phil (pretoria) department of speech pathology and audiology university of pretoria abstract a situation analysis of communication disabilities ofand services to this population in the rsa reveals a lack ofknowledge about the field and a paucity of research, probably due to therapists' extreme involvement in clinical practice. in this article the advantages of single case experimentation are putforward and specific designs are discussed in an attempt to motivate and enable clinicians to be producers of research. it is pointed out that this type of research will not only add valuable scientific information to the field of speech pathology and audiology, but it will also increase accountability in clinical practice. opsomming 'n situasie-ontleding van kommunikasie-afivykings van en dienste aan hierdie populasie in die rsa dui op 'ngebrek aan kennis op diegebied, sowel as 'n beperkte navorsingsuitset. lht kan waarskynlik toegeskryf word aan die terapeute se ekstreme betrokkenheid by die kliniese praktyk. in hierdie artikel word die voordele van enkelgeval eksperimentering uiteengesit. spesifieke ontwerpe word voorgehou in 'n poging om terapeute te inspireer om navorsingsbeoefenaars te word. hierdie tipe navorsing lewer nie slegs waardevolle inligting vir spraakheelkunde en oudiologie nie, maar help ook om die toerekenbaarheid van die kliniese praktyk te verhoog. introduction the report of the inquiry into the circumstances of disabled people in the republic of south africa reveals inter alia that about 12,5% of the total population is disabled and it includes the recommendations that the quality of services should be improved and that research with a view to the improvement of services should be conducted (department of national health and population development, 1987). unfortunately, due to the paucity of services, trained personnel are swamped with medical and rehabilitative services mostly diagnosing and treating patients on an individual basis. in a situation such as this, research is limited to a minimum, and research involving large groups of subjects, a near impossibility. a solution to this problem can, however, be found in the utilisation of the potential of clinicians, not only as consumers of research, but as producers of single case research. during their daily routine these professionals come into contact with potential subjects for research, but as has been pointed out, on an individual basis. these circumstances should be exploited for single case experimentation. single case experimental designs: advantages and limitations the results of single case study approaches have been used and quoted for many years usually with questionable credibility due to subjectivity and lack of experimental control. mcreynolds and thompson (1986:195) suggest that "a better role for case studies is description and identification of potential variables to be evaluated in experimental studies". this is especially applicable to the rsa context. because of the diversity of handicapped people, particularly from different language and cultural backgrounds, many unusual problems are encountered. the study of unique cases,will under these circumstances be of particular benefit to the science of communication pathology. single cases can be used in a number of different research designs. in the field of speech pathology and audiology single cases are often studied implementing a descriptive or even analytic survey design. these are, however, not experimental designs. a single case design can also be an experimental design, the socalled cause and effect method, the pretest-posttest control group design, or the laboratory method. "in its simplest form, the experimental method attempts to control the entire research situation, except for certain input variables which then become suspect as the cause of whatever change has taken place within the investigative design" (leedy, 1980:211). such data obtained from these studies are functual, objective and reliable. the question at this stage is: how can single case experimentation be utilised as a research input and as a service to the disabled? theoretically these studies are valuable in measuring the effectiveness of treatment variables, of describing disorders, or identifiable components of disorders over long periods of time, of evaluating the effects of disorders on the resulting disability, and of ultimately describing subgroups of disorders. single case experimentation can also be implemented in the identification of all the different variables related to or responsible for human development be it normal or pathological. die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 isabel c uys one of the greatest practical advantages of single subject experimentation is the fact that the clinician can do research without sacrificing clinical intervention. in diagnosis the clinician identifies the behaviours to be modified (the dependent variables) and then selects specific procedures for treatment (the independent variables). this automatically forms the basis of a single case experimental design. the experiment can also be conducted during ordinary therapy sessions without the expense of sophisticated apparatus. this is often impossible when large groups of subjects are involved. "individuals differ in every physical and psychological attribute ever studied" (lindgren, byrne & petrinovich, 1961:219). it is recognised that patients with a specific disorder are not necessarily homogeneous. they differ qualitatively, in degree of impairment, and with regard to responsiveness to a particular treatment variable. in group experimental research this variability is managed through statistical analysis, usually referring to averages which in the end conceals rather than clarifies individual variability. single subject experimentation must never be confused with the unscientific, unplanned observation of behaviour. the single subject experimental approach is a scientific method which requires meticulous planning in advance and strict control during the execution of the experimental phases. selection of a single case experimental design "research is not aimless, undirected activity... (it) demands a definite aggressive plan" (leedy, 1980:5). planning is the most important prerequisite for successful research. the planning and execution of the research is done within the framework of the scientific method, which is a means whereby insight into undiscovered truth is sought (leedy, 1980:82); a set of rules that can be used for describing events, explaining events, and predicting events (silverman, 1977:29); and which involves certain decision taking steps (mouton & marais, 1985:16, 22). planning a single case study involves the following decisiontaking steps: the selection of a research theme, or problem or question. the topic or theme should always be rephrased in terms of an answerable question. not all questions are equally answerable, and "one cannot get a clear answer to a vague question" (johnson, 1946:52). silverman (1977:62) quotes the following example: "is hypnosis effective in treating stuttering? (versus) is the post-hypnotic suggestion, 'you will not stutter anymore', effective in reducing stuttering frequency?" ferent kinds of single case experimental designs and the researcher must be sure that the appropriate design is selected for a specific study. this depends first of all on the research question and secondly on the nature of the data required. this will be dealt with in detail later on. the collection, organization and classification of the data. data is collected within a closed system of controlled conditions "an area sealed off by given parametric limitations" (leedy, 1980:85). factors which are critical to the research can be isolated and the nature of the variables can actually be determined by control. without control the data will be worthless. the analysis and interpretation of the data. accumulated data are only potentially meaningful. "the significance of the data depends upon the way in which the facts are regarded" (leedy, 1980:6). in analyzing and interpreting the data, n e w insights are discovered and new meanings are revealed. this would then give rise to further unexplored questions for future research. only after this planning has been done systematically, can the researcher select the design. in disabled care experimental designs are frequently used to explore the full range of intervention questions including the acquisition, generalization, and maintenance of behaviours for impaired individuals. a heuristic method of selecting an appropriate design to answer a given question, is, however, necessary. kevin kearns (1986:205) devised such a method,, providing a variety of design options which depend on factors such as the nature of the target behaviours, the setting in which a study is conducted, the availability of additional subjects, and other practical exigencies. the sequential arrangement of steps in this design selection process is given in table i and this taxonomy could be viewed as a general, organizational tool that is intended to facilitate an understanding of factors to consider in the selection and use of single case designs. although the columns are presented in the order of evaluation strategy, clinical research questions, selected design options; and basic considerations, it is suggested that in using this method, the researcher deals with them in the order of clinical research question, evaluation strategy, basic considerations,, and lastly selected design options. j the research question refers to the outcome of intervention | and the way in which intervention strategies influence behai viour modification, e.g.: is there a difference in behaviour with ι or without treatment? to what degree do separate com-' ponents of the treatment contribute to behaviour modification? the drafting of a research programme, including the conceptualization of theoretical issues and the operationalization of these concepts i n terms of measurable parameters. in the humanities, measurement poses a bigger problem than in the physical sciences. the above example does, however, illustrate how behaviour can be measured in this case by counting the frequency of the occurrence of stuttering. without a clear operationalization of the central concepts included in the research question, it is impossible to select a design, or collect and interpret data. the selection of an appropriate design. there are many dif\ after the research question has been asked, the researcher can state the nature of the strategy to be followed, e.g.: can the behaviour during treatment be compared with the same type of behaviour without treatment? ^ ^ at this stage the researcher should pay attention to some basic considerations, or factors which would influence the selection of the appropriate design, e.g.: if there is uncertainty about the reversibility of behaviour, an abab design should rather be replaced by a multiple baseline design. only after all these factors have been dealt with, can the researcher select the design most appropriate for a particular study. the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 55 single case experimental designs: an essential service in communicatively disabled care t h e following figures i l l u s t r a t e t h e u s e of different d e s i g n o p t i o n s : 1. treatment no treatment strategies. t h e i n i t i a l p h a s e is a p e r i o d d u r i n g w h i c h b a s e l i n e m e a s u r e m e n t s a r e t a k e n . it is i m p o r t a n t t h a t b a s e l i n e m e a s u r e m e n t s c o n t i n u e u n t i l a c e r t a i n a m o u n t of s t a b i l i t y i n b e h a v i o u r is r e a c h e d . d u r i n g t h e s e c o n d p h a s e t h e t r e a t m e n t is i n s t a t e d a n d table 1. evaluation strategies, research questions, design options, and considerations for single-subject experimental designs. evaluation strategy treatment no treatment comparison clinical research question does treatment, with all of its components, result in improved performance relative to no treatment? selected design options withdrawal and reversal designs abab bab aba multiple baseline designs (m,b) across behaviours across settings across subjects basic considerations is the therapeutic effect likely to reverse following the withdrawal of treatment? are functional independent behaviours or settings available? component assessment treatment — pari son treatment comsuccessive level analysis relative to a treatment package, to what degree do separate components of treatment contribute to improvement? does the addition of a component to a treatment package facilitate treatment effectiveness? what is the relative effectivenss of two or more treatments? multiple probe technique (variation of mb) (horner & baer, 1978) interaction (reduction) bc-b-bc-b bc-b-bc-a-bc-b-bc does treatment result in acquisition of successive steps in a chaining sequence? does treatment effectively modify a single, gradually acquired behaviour? interaction (additive) b-bc-b-bc b-bc-b-a-b-bc-b alternating treatments design replicated crossover design (barlow, hayes, & nelson, 1984) multiple probe technique changing criterion design are functionally independent behaviours available? are long or continuous baselines impractical? can the components be examined alone and in combination with the treatment package? can replication be obtained across subjects? can the components be examined alone and in combination with the treatment package? can replication be obtained across subjects? can treatments be rapidly alternated for each subject? are multiple subjects or target behaviours available? can treatment be "crossed over"? are nearly equal phase lengths possible? are steps in the treatment sequence independent? are earlier steps prerequisite to acquiring later steps? will changes in the dependent variable correspond to changes in the criterion level? will the dependent variable stabilize at successively more stringent criterion levels? φ ca oc a ( b a s e l i n e ) β ( t r e a t m e n t ) / a (withdrawal) β (treatment) a t i m e fkearns, 1986 a series of m e a s u r e m e n t s a r e t a k e n i n o r d e r t o i n d i c a t e t h e m o d i f i c a t i o n of t h e b e h a v i o u r . t h i s is followed b y a p e r i o d of w i t h d r a w a l of t r e a t m e n t , w i t h t h e p r e s u m p t i o n t h a t a r e l a p s e i n b e h a v i o u r w i l l b e d e m o n s t r a t e d . m u l t i p l e m e a s u r e m e n t s w i l l i n d i c a t e t h i s c h a n g e . t h e n t r e a t m e n t is a g a i n i n s t a t e d , etc. i n t h i s d e s i g n m u l t i p l e m e a s u r e m e n t s a r e m a d e o n m o r e t h a n o n e s i m i l a r , b u t i n d e p e n d e n t b e h a v i o u r , d u r i n g t h e a p h a s e . t r e a t m e n t is t h e n a p p l i e d for o n l y o n e b e h a v i o u r , w h i l e t h e a p h a s e c o n t i n u e s for t h e s e c o n d b e h a v i o u r . o n c e a s t a b l e c h a n g e is o b t a i n e d i n t h e first b e h a v i o u r , t h e β p h a s e is i n s t a ted for t h e s e c o n d b e h a v i o u r . f i g u r e 1 : a b a s i c a b a b w i t h d r a w a l d e s i g n w i t h t h e a l t e r n a t i o n o f n o t r e a t m e n t a n d t r e a t m e n t p h a s e s . (mcrleynolds & t h o m p s o n , 1 9 8 6 : 1 9 9 ) t h i s ab a r r a n g e m e n t r e m o v e s t h e n e c e s s i t y of w i t h d r a w a l of t r e a t m e n t a n d c a n b e u s e d w h e n w i t h d r a w a l o r r e v e r s i n g is i m p o s s i b l e o r e v e n u n e t h i c a l . die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 isabel c uys 2. component assessment strategies behavior 1 ! i a | β / * * » a. . . behavior 2 a β j^r v ^ s m m h j time figure 2: a multiple baseline across behaviours design with an extended baseline phase for behaviour 2. (mcreynolds & thompson, 1986:199) bc bc follow-up 1 0 0 80 ο α h— 5 60 υ <υ σι c 4 0 « u <ΰ c. a r r' 1 1 , . 1 . , — 1 ... .1..... j._ p / u i x l._l_ i _1 1 1 \ i 1 . 1 1 _ 1 l_ v 1 1 1 1 1—1 • f » 1 1 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 s e s s i o n s / figure 3: an interaction (additive) design including the phases a-b-bc-b-bc and a follow-up period. (kearns, 1986:210) the south african journal of communication disorders, vol 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) single case experimental designs: an essential service i n communicatively disabled care 57 this design is selected when the researcher wants to establish whether the addition of another component to a specific treatment package would facilitate progress or enhance the effectiveness of the treatment. once again baseline measurements are taken. during the first phase only one type of treatment is given, followed by a combination of that treatment and the additional treatment. the additional treatment is withdrawn, and again added. during these consecutive phases multiple measurements of the behaviour change should indicate when optimal change takes place. s u h i e c ! 2 baseline treatment these are only a few examples of how single case experimental designs can be employed in disabled care research. unfortunately, especially when dealing with people, murphy's law will come into operation. to counteract this contingency, the researcher can employ certain alternatives, which is a product of the flexibility inherent in the application of single subject experimental designs. building in insurance through flexibility every researcher should be creative in designing experiments. while it is true that specific designs are appropriate for ans» p i c t u r e s qo b i e c t s figure 4: an alternating treatments design i (kearns, 1986:211) 3. treatment treatment comparison strategies as the effectiveness of one type of treatment is compared to that of another, an initial baseline phase is not required. the incorporation of a baseline phase does, however, give additio; nal information on a no-treatment-treatment comparison. in this design the treatments to be compared are administered and alternated rapidly, e.g.', half of each session. unfortunately this design does not permit unequivocal conclusions about the effectiveness of each method of treatment, but it does provide a means of evaluating the relative effectiveness of different treatment methods for specific patients. 4. successive level analysis this is a most successful method to employ in developmental studies. it answers the question about whether treatment would effectively modify a single, gradually acquired behaviour. after the baseline phase, a specific criterion is set according to which the success of the behaviour is measured. once the patient succeeds, another criterion is again set. it is, however, necessary that the researcher is familiar with the successive steps in the acquisition of this specific behaviour pattern as each criterion would serve as a goal in the developmental pattern. zoo 2 1 6 0 so 8.0 • β.ο ε ± 4 . 0 s u b l e c t s.c. b a t a t a ! · i t r e a t m e n t | e x t i n c t i o n i 2 . 0 t — -ι —1 16 —r20 f i v e m i n u t e i n t e r v a l · —ι— 2 5 figure 5: the changing criterion design (kearns, 1986:212) die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 isabel c uy wering specific questions and that research must be planned in such a way that control can be exercised throughout the project, there still is a certain amount of flexibility that can be utilized to provide for the unexpected to provide additional sources of control. compared to research involving large groups of subjects (where similar control strategies must be maintained across the group), single subject designs lend themselves to flexible application (connell & thompson, 1986:214-215). flexibility should never weaken the scientific nature of single subject research; it should be utilized as an insurance against lack of control while examining the relationship between independent and dependent variables. "controls for an independent variable (treatment) applied in single-subject designs can be created to fit the particular characteristics of the treatment. the controls, if properly arranged, can be changed in response to changes in treatment once an experiment is underway." (connell & thompson, 1986:215.) t w o general forms of flexibility can be utilized in single subject research, viz. a priori and ad hoc flexibility. a priori flexibility comes into operation during the selection-ofdesign stage, i.e., before the experiment is carried out. the maintenance of experimental control can be assured when more than one design is incorporated in a single study. "even if all planned sources of control are preserved throughout the study, the extra control is not wasted because it is a form of replication that would increase confidence in the results." (connell & thompson, 1986:220.) as aba and multiple baseline designs are particularly compatible, the researcher can for instance decide on this combination when there is uncertae reversibility of behaviours. this combination will also reveal a possible dependency of behaviours which were previously regarded as independent of one another, as baselines might change even before treatment is introduced for a specific behaviour. connell & thompson (1986:221) suggest the general principle that additional controls be built into all studies except those that examine highly predictable behaviours. ad hoc flexibility comes into operation while the experiment is being conducted. a study should be planned in such a way that the design can, be modified during one of the experimental phases. these modifications are made in response to developments that arise during the course of the experiment in an attempt to maintain control. "the within-subject nature of experimental control allows for a certain amount of freedom in the selection of control strategies ... the controls, if properly arranged, can be changed in response to changes in treatment once an experiment is underway ... it is this freedom in how independent variables and control can be implemented and changed ... that distinguishes single-subject from group designs." (connell & thompson, 1986:215.) this "response-guided" experimentation (edgington, 1983: 64-65) comes into operation when unexpected patterns occur in the data. without an extension of the original design, treatments cannot be studied in greater depth. when investigating the effectiveness of a treatment package, the researcher might decide to select a multiple baseline across subjects design implementing a reversal design as control. during the course of treatment it becomes clear that the independent variable proves to be effective for two of the three subjects only. the experimenter can then systematically change the treatment implementing an interaction design while maintaining the reversal design control that was originally implemented. this modification will allow the experimenter to determine which modifications of procedures are effective for an individual subject. connell & thompson (1986:223) summarize the benefits of flexibility in single case research as follows: "by using flexible designs, it would be possible to obtain detailed information about factors in existing treatments that have a variable effect, a weak effect, or even no effect on learning. by contrasting variable and ineffective factors with consistent, effective factors across treatments, individuals and behaviours, it may be possible to identify common attributes of factors that are related to effectiveness within a particular disorder area and possibly across areas." revealing new meaning as accumulated data are only potentially meaningful, the researcher needs to process the data in order to obtain greater insight into the nature and meaning of the data. one of the available tools for processing and interpretation is statistics. in disabled care research wants to evaluate and draw conclusions about behaviour change, and experimental, as well as therapeutic criteria, and invoked to evaluate data (risley, 1970:103-127). the experimental criterion refers to reliability. this criterion is met when the subject's behaviour changes reliably under specific experimental conditions. on the other hand, the therapeutic criterion is met when the level of behaviour change is such that the subject presents with adequate functioning in society, complying with the norm. evaluation and interpretation of data in terms of the experimental criterion include visual inspection and statistical analysis. visual inspection may seem completely subjective, but special data requirements, in terms of specific criteria (e.gj, trends in change during certain experimental phases) need to be met. statistical methods again present the researcher with replicable computational methods and rules for making deci] sions about the reliability of a particular experimental crite-j rion. 1 ι ι the applied or clinical significance, i.e., the therapeutic criterion, can be addressed by comparing the subject's post-experimental behaviour with the norm, o r by having various raters evaluate the magnitude of the behavioural change. interrater reliability then becomes an issue. although there are still sources of controversy, "statistical analyses in single case research may provide a valuable sup-. plement rather than an alternative to visual inspection" (kazdin, 1984:291) and a number of statistical tests can be applied to data obtained from a single case. / ' in a a-b-a-b design comparisons can be made of behaviour during the baseline and intervention phases (t-test), or analysis of variance (f test) can be made to compare the four phases. / the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) single case experimental designs: an essential service in communicatively disabled care 59 if, however, the data are serially dependent, these tests may not be appropriate w h i c h w o u l d necessitate variations of these tests in order to reduce the effect of serial dependency. time series analyses can be used to compare behaviour change over time for a small group of subjects or e v e n a single subject. in single case research the time series analysis is advantageous in that a t-test is provided and important information o n the change i n level and slope is given during the different phases. randomization tests are used when treatments are assigned randomly to different occasions and as such are useful for evaluating data obtained from alternative treatment designs. if the design complies with the criterion of randomization and rapid alteration of experimental conditions, these tests provide a useful set of statistical techniques for single case research. the test of ranks (r) is used for evaluating data obtained in multiple baseline designs and requires that data be collected across several baselines, e.g., different behaviours, subjects, or settings the minimum requirement for detecting a statistically significant effect at the .05 level of confidence being four baselines. in the case of slow and gradual, or even fluctuating performance, the intervention can still be evaluated on the basis of mean performance, which is an advantage of this statistical procedure. a description of the rate of behaviour change over time is supplied by the split-middle technique. it reveals a linear trend in the data, characterizes present performance, and predicts future performance. "rate of behaviour" (frequency/time) has been advocated as the most useful measure for this method (kazdin, 1984:313). problems do exist in drawing inferences when using this method, but as a descriptive tool the splitmiddle technique provides valuable information about level and slope changes, that is otherwise seldom reported. on the issue of whether statistical tests should be used to draw inferences from single case research, kazdin (1984:321) concludes that statistical analyses does not necessarily conflict with single case designs or their purposes; that when applied research attempts to developja technology of behaviour change and to achieve clinically impjortant effects, statistical analyses will have limited value, but that there are several uses of statistics that may contribute to the goals of applied research. i conclusion i / the world health organization and the report of the inquiry into disability in south africa define rehabilitation as an effective, goal-oriented and time-limited process (department of national health and population development, 1987). with this implied emphasis on accountability in disabled care, personnel will find it increasingly advantageous to demonstrate scientifically the impacts of their clinical programmes on their patients/clients (silverman, 1977:xiii). the subcommittee on speech impairment stresses the importance of a research methodology applicable to the wide variety of multilingual, multicultural disabilities in the republic of south africa. a situation analysis of the state of disability care reveals inter alia that there are insufficient services and insufficient knowledge about the communicatively disabled in this complex society. while these facts stress the need for basic and applied research, the employment of typical subject designs (group designs) for the evaluation of applied behavioural interventions is rendered impossible the primary task of speechlanguage-hearing therapists being the assessment and rehabilitation of the communicatively disordered, usually on an individual basis. the value of research with large populations should not be underestimated, especially because of the advantage of generalization. but, as a solution to a variety of practical problems, viz. the one-to-one relationship in therapy, and individual differences, single case experimentation should be utilized more extensively. single case experimental designs are presented as a methodology particularly applicable to the needs of disabled care. it provides data concerning the "typical" behaviour of an individual subject under experimental conditions, allows for the evaluation of intervention strategies applied to a specific individual, and creates the possibility to generalize to the population from which the subject was selected, while not on a statistical, then on a logical basis (silverman, 1977:67). the research potential of health care personnel should be tapped by bringing the advantages of single case experimental research to their attention. ultimately this will be to the benefit of the disabled. bibliography connell, p.j. & thompson, c.k. flexibility of single-subject experimental designs. part iii: using flexibility to design or modify experiments, journal of speech and hearing disorders, 51, 214-225, 1986. department of national health and population development. disability in the republic of south africa, vol 1 & 10, 1987. edgington, e.s. response-guided exx>eximentati(m.contemporary psychology, 28, 64-65, 1983. johnson, w. people in quandaries, ny: harper & row, p. 52-53 1946. kazdin, a.e. statistical analyses for single-case experimental designs. in: barlow, d.h. & hersen, m. single case experimental designs. new york: pergamon press, 1984. kearns, k.p. flexibility of single-subject experimental designs. part ii: design selection and arrangement of experimental phases, journal of speech and hearing^disorders, 51, 204-213, 1986. leedy, p.d. practical research, 3rd ed., new york: macmillan publishing company, 1980. lindgren, h.c., byrne, d., petrinovich, l. psychology: an introduction to a behavioural science, 2nd ed., new york, john wiley & sons, inc., 1961. mcreynolds, l.v. & thompson, c.k. flexibility of single-subject experimental designs. part i: review of the basics of singlesubject designs, journal of speech and hearing disorders, 51, _ 194-203, 1986. mouton, j. & marais, h.c. metodologie van die geesteswetenskappe. pretoria: raad vir geesteswetenskaplike navorsing, 1985. risley, t.r. behaviour modification: an experimental-thera-peutic endeavour. in hamerlynck, l.a., davidson, p.o., & acker, l.e. (eds.), behaviour modification and ideal health services, canada, university of calgary press, 1970. silverman, f.h. research design in speech pathology and audiology. new jersey: prentice-hall, inc., 1977. diesuid-afrikaanse tydskrif vir kommunikasieafykings, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 0 information for contributors the south african journal of communication disorders publishes reports and papers concerned with research, or critically evaluative theoretical, or therapeutic issues dealing with disorders of speech, voice, hearing or language, or on aspects of the processes underlying these. the south african journal of communication disorders will not accept material, which has been published elsewhere or that is currently under review by other publications. all contributions are reviewed by at least two consultants who are not provided with author identification. form of manuscript. authors should submit four neatly typewritten manuscripts in triple spacing with wide margins which should not exceed much more than 25 pages. each page should be numbered. the first page of two copies should contain the title of the article, name of author/s, highest degree and address or institutional affiliation. the first page of the remaining two copies should contain only the title of the article. the second page of all copies should contain only an abstract'^ 100 words) which should be provided in both english and afrikaans. afrikaans abstracts will be provided —for overseas contributors. all paragraphs should start at the left margin and not be indented. -major headings, where applicable, should be in the order of method, results, discussion, conclusion, acknowledgements and references. tables and figures should be prepared on separate sheets (one per table/figure). figures, graphs and line drawings must be originals, in black ink on good quality white paper. lettering appearing on tl êe should be uniform and professionally done, bearing in mind » that such lettering should be legible after a 50% reduction in printing. on no account should lettering be typewritten on the illustration. any explanation or legend should not be included in the illustration but should appear below it. the titles of tables and figures should be concise but explanatory. the title of tables appears above, and of figures below. tables and figures should be numbered in order of appearance (with arabic numerals). the amount of tabular and illustrative material allowed will be at the discretion of the editor (usually not more than 6). references. references should be cited in the text by surname of the author and date, e.g. van riper (1971). where there are more than two authors, et al. after the first author will suffice. the names of all authors should appear in the reference list. references should be listed alphabetically in triple-spacing at the end of the article. for acceptable abbreviations of names of journals, consult the fourth issue (october) of dsh abstracts or the world list of scientific periodicals. the number of references used should not exceed much more than 20. note the following examples: locke, j.l. clinical psychology: the explanation and treatment of speech sound disorders. j. speech hear. disord, 48, 339-341, 1983. penrod, j.p. speech discrimination testing. in j. katz (ed.) handbook of clinical audiology, 3rd ed., baltimore: williams & wilkins, 1985. van riper, c. the nature of stuttering. englewood cliffs, new jersey: prentice-hall, 1971. proofs. galley proofs will be sent to the author wherever possible. corrections other than typographical errors will be charged to'the author. reprints. 10 reprints without covers will be provided free of charge.' all manuscripts and correspondence should be addressed to: the editor, south african journal of communication disorders, south african speech and hearing association, p.o. box 31782, braamfontein 2017, south africa. inligting vir bydraers die siiid-afrikaanse tydskrif vir kommunikasieafwykings publiseer verslae en artikels oor navorsing, of krities evaluerende artikels oor die teoretiese of terapeutiese aspekte van spraak-, stem-, gehoorof taalafwykings, of oor aspekte van die prosesse onderliggend aan hierdie afwykings. die suid-afrikaanse tydskrif vir kommunikasieafwy kings sal nie materiaal aanvaar wat reeds elders gepubliseer is, of wat tans deur ander publikasies oorweeg word nie. alle bydraes word deur minstens twee konsultante nagegaan wat nie ingelig is oor die identiteit van die skrywer nie. formaat van die manuskrip. skrywers moet vier netjies getikte manuskripte in 3-spasi'ering en met bree kantlyn indien, en dit moet nie veel langer as 25 bladsye wees nie. elke bladsy moet genommer wees. op die eerste bladsy van 2 afskrifte moet die titel van die artikel, die naam van die skrywer/s, die hoogste graad behaal en die adres of naam van hulle betrokke instansie verskyn. op die eerste bladsy van die oorblywende twee afskrifte moet slegs die titel van die artikel verskyn. die tweede bladsy van alle afskrifte moet slegs 'n opsomming (100 woorde) in beide engels en afrikaans bevat. afrikaanse opsommings sal vir buitelandse bydraers voorsien word. alle paragrawe moet teenaan die linkerkantlyn begin word en moet nie ingekeep word nie. hoofopskrifte moet, waar dit van toepassing is, in die volgende volgorde wees: metode, resultate, bespreking, gevolgtrekking, erkennings en verwysings. tabelle en figure moet op afsonderlike bladsye verskyn (een bladsy per tabel/illustrasie). figure, grafieke en lyntekeninge moet oorspronklike weergawes wees en moet in swart ink op wit papier van 'n hoe gehalte gedoen word. letterwerk wat hierop verskyn moet eenvormig wees, professioneel gedoen word en daar moet in gedagte gehou word dat dit leesbaar moet wees na 'n 50%-verkleining in drukwerk. letterwerk by die illustrasie moet onder geen omstandighede getik word nie. verklarings of omskrywings moet nie in die illustrasie nie, maardaaronder verskyn. die byskrifte van tabelle moet bo-aan verskyn en die van figure onderaan. tabelle en figure moet in die volgorde waarin hulle verskyn, genommer word (met arabiese syfers). die hoeveelheid materiaal in die vorm van tabelle en illustrasies wat toegelaat word, word deur die redakteur bepaal (gewoonlik nie meer as 6 nie). verwysings. verwysings in die teks moet voorsien word van die skrywer se van en die datum, bv. van riper (1971). waar daar meer as twee skrywers is, sal et al. na die eerste skrywer voldoende wees'. die name van alle skrywers moet in die verwysingslys verskyn. verwysings moet alfabeties in 3-spasi'ering aan die einde van die artikel gerangskik word. vir die aanvaarde afkortings van tydskrifte se. titels, raadpleeg die vierde uitgawe (oktober) van dsh abstracts of the world list of scientific periodicals. die getall verwysings wat gebruik is, moet nie veel meer as 20 wees nie. ' let op die volgende voorbeelde: ι locke, j.l. clinical phonology: the explanation and treatment of speech sound disorders. j. speech hear. disord, 48, 339-341, 1983. penrod, j.p. speech discrimination testing. in j. katz (ed.) handbook of clinical audiology, 3de ed., baltimore: williams & wilkins, 1985. van riper, c. the nature of stuttering. englewood cliffs, new jersey: prentice hall, 1971. proewe. galeiproewe sal waar moontlik aan die skrywer gestuur word. die onkoste van veranderings, behalwe tipografiese foute, sal deur die skrywer self gedra moet word. herdrukke. 10 herdrukke sonder omslae sal gratis'verskaf word. alle manuskripte en korrespondensie moet gerig word aan: die redakteur, / die suid-afrikaanse tydskrif vir kommunikasieafivykings. die suid-afrikaanse vereniging vir spraaken gehoorheelkunde, posbus 31782, braamfontein 2017, suid-afrika. the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die keuring van eerstejaarstudente in die departement spraakheelkunde en oudiologie (universiteit van pretoria) isabel c uys dphil (pret) erna alant ma(log) (pret) departement spraakheelkunde en oudiologie universiteit van pretoria opsomming die artikel handel oor die keuring van logopedika-studente aan die universiteit van pretoria en beskryf die kompleksiteit van hierdieprosedure. die huidige benaderingpoog om studente te selekteer wat die kursus suksesvol kan voltooi, met die aanname dat 'n toegewyde student wel deur die regte supervisie gelei kan word tot 'n volwaardige terapeut. gerekenariseerde data illustreer sekere verbande tussen studenteprestasies in die finale jaar en inisiele keuringtellings. hierdie inligting word gei'nterpreteer in terme van die tekortkominge sowel as sterk punte van so η benadering. abstract this article deals with the selection of speech therapy students at the university of pretoria and describes the complexity of this process. the present approach attempts to select students that have potential to successfully complete the course, with the assumption that with appropriate supervision, these students can be guided to become competent speech therapists. computerized data illustrates certain correlations between students' achievements in the final year and initial selection scores. this information is interpreted in terms of the short-comings as well as strengths of this approach. meeste van die gevestigde professionele kursusse word op die een of die ander tyd gekonfronteer met 'n probleemtoestand wat keuring van voornemende studente noodsaak. by^die universiteit van pretoria, soos seker ook by ander universiteite die geval is, is die uitsoek van die beste studente vir een bepaalde kursus ten koste van ander kursusse 'n vreemde gedagte. in die geval van die β log-kursus het verskeie faktore daartoe aanleiding gegee dat keuring oorweeg moes word, nl. — studentetalle het vanaf 1971-1976 aansienlik toegeneem, te wete 'n toename van 109,1%! by eerstejaarstudente en 92,2 % by alle jaargroepe tesame in die departement. — die fisiese opleidingsfasiliteite kon nie in der mate uitgebrei en aangepas word om al die studente, veral met betrekking tot praktiese opleidingsgeriewe, sinvol te akkommodeer nie. — 'n bykomende faktor waarvan kennis geneem moes word, is die wyse waarop natuurlike seleksie wel gemanifesteer het. in die periode vanaf 1971-1975 het gemiddeld slegs 50% van die studente gekwalifiseer. met die toename in studentetalle is daar ook 'n beduidende afname in die slaagsyfer bemerk. in 'n poging om die vereiste akademiese en praktiese standaarde te handhaaf, is dus besluit om 'n ondersoek te loods na die wenslikheid van keuring. 'n vasgestelde inname sou kwaliteitskontrole verseker en die natuurlike seleksie (staking, druipdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 syfer, ens.) laat afneem. kandidate met die grootste potensiele kans op akademiese sukses sou toegelaat word tot die kursus. hierdie oorwegings geld dan ook by verskeie kursusse ter plaatse en oorsee. (hilson en mckendrick 1978; furler-kools 1981) beskrywing van die keuringsprosedures die afdeling universiteitsonderwysbeplanning van die studentediensburo in samewerking met die departement spraakheelkunde en oudiologie het 'n deeglike veldverkenning gedoen met die oog op die samestelling van 'n bevredigende keuringsmeganisme. daar bestaan werklik min navorsingsgegewens oor keuring. uit alle beskikbare studies blyk dit egter dat keurders met een grondliggende probleem te doen kry, nl. word studente gekeur met die oog op die suksesvolle voltooiing van hulle opleiding, of met die oog op sukses in die toekomstige praktyk? (furlerkools 1981; hilson en mckendrich 1978). anders gestel: moet goeie studente of goeie terapeute geselekteer word? hierdie dilemma word gekompliseer deur die gebrek aan wetenskaplike bewyse oor die verband tussen opleidingsondervinding en praktykvereistes (malan 1979). dit lyk asof opvoedkundige en praktykdoelwitte selfs in sekere opsigsasha 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 isabel c uys and erna alant te van mekaar kan verskil. hilson en mckendrick (1978) brei op hierdie verskille uit waar dit betrekking het op die maatskaplike werk. indien die potensieel-suksesvolle student gesoek word sal daar bewyse van akademiese vermoens en intellektuele kapasiteit moet wees. daarteenoor, sal die potensieelsuksesvolle maatskaplike werker sekere persoonlikheidseienskappe moet openbaar, bv. volwassenheid en emosionele stabiliteit. hierdie bevindings is eweneens van toepassing op die spraakterapeut-oudioloog. matriekresultate (akademiese en intellektuele vermoens) blyk nog steeds die beste indikator van sukses op die tersiere onderwysvlak te wees. dit is 'n sterk motivering vir keuring op grand van akademiese prestasie. ongelukkig is dit so dat die mens nie voorspelbaar is nie. geen keuringstelsel kan ooit waterdig wees nie. soos in die geval van maatskaplike werk (hilson en mckendrick 1978) kan mens alleenlik hoop dat die student na 'n versigtig-beplande opleiding, ook in die praktyk sukses sal bereik. dit is juis hierdie aanname wat die keuring van verskeie kursusse (malan 1979; hilson en mckendrick 1978 en staf van die opleiding logopedie, hoensbroek 1981) rig. uit die voorafgaande blyk dit dat verskeie vrae moes beantwoord word voordat 'n sinvolle keuringsprosedure opgestel kon word: — watter eienskappe word gesoek in die voornemende β logstudent? — watter prosedure sal hierdie eienskappe uitlig? — wanneer moet keuring plaasvind? — deur wie moet die keuring hanteer word? aan die hand van beginselbesluite in die beantwoording van die bogenoemde vrae, het die belang van die volgende na vore gekom, nl. akademiese en intellektuele vermoens, spesifieke persoonlikheidseienskappe (aanleg, menslike dienslewering, motivering, ens.) asook normale spraak, stem en gehoor. met die oog hierop is op die volgende keuringsprosedures besluit: aantal studente met inagneming van beskikbare opleidingsfasiliteite is besluit op 'n maksimum van 25 studente per jaar. eerste keuring die eerste keuring vind teen die einde van die jaar plaas en word gegrond op die kandidaat se prestasie in die rekordeksamen, omdat die eindeksamenpunt nog nie beskikbaar is nie. hiervolgens word 50 kandidate tot die finale keuring toegelaat. finale keuring die finale keuring vind gedurende januarie plaas en in hierdie geval word gebruik gemaak van akademiese prestasie, groeptoetse, 'n persoonlike onderhoud, sowel as 'n evaluasie van die kandidaat se spraaken gehoorvermoens. akademiese prestasie daar is in beginsel besluit om die studente wat die grootste kans op sukses in die kursus het, te selekteer. die finale keursyfer vir akademiese prestasie (met 'n gewig van 50%) word bereken van die gemiddelde matrikulasie-eindeksamenpunt plus kredietpunte (vir vakke op die hoer graad geslaag, asook enige toepaslike universiteitsen ander kursusse), minus strafpunte (vir universiteitsen ander kursusse wat gedruip is). aanleg en ander toetse omdat daar besluit is dat sekere eienskappe 'n voorvereiste is van suksesvolle voltooiing van die β log-kursus, is besluit om die volgende groeptoetse af te neem. al die toetse saam dra 'n gewig van 30% by tot die totale keursyfer. nuwe suid-afrikaanse groeptoets (rgn 1965) die voile skaal van 6 subtoetse (3 verbaal en 3 nie-verbaal) word toegepas om 'n beeld van die kandidaat se algemene intellektuele vermoens te verkry. die totale roupunt word met die oog op 'n keurpunt uit 10 verwerk volgens riglyne soos neergele deur die studentediensburo (u p). senior aanlegtoets (rgn 1975) die noodsaaklikheid om sekere eienskappe by voornemende studente te identifiseer word deur verskillende opleidingsinstansies beklemtoon. (furler-kools 1981; staf van die opleiding logopedie, hoensbroek 1981). aanleg verwys in hierdie toets na spesifieke verstandelike vermoens wat die persoon in staat stel om sekere vaardighede en bekwaamhede te ontwikkel. hierdie toets dek 'n baie wye veld en alleenlik drie items is toepaslik gereken by die keuring van β log-studente, nl. verbale begrip, woordbou en geheue (paragraaf). hierdie items is aanduidend van die kandidaat se algemene peil van kognitiewe funksionering, redeneringsvermoe, assosiasievlotheid en geheue. ook hierdie roupunte word volgens 'n tabel tot 'n keurpunt verwerk. sestienfaktor-persoonlikheidsvraelys (cattel, eber en tatsoeka 1970) hierdie baie omvattende toets meet sestien afsonderlike persoonlikheidsdimensies waarvolgens uitsprake in verband met verwagte prestasie, beroepsgerigtheid, leierskapeienskappe en selfs moontlike neurotiese neigings gemaak kan word. vir die doel van die keuring is slegs vyf van die faktore as toepaslik beskou, nl. intelligensie, emosionele rypheid, pligsgetrouheid, skuldgeneigdheid en gespannendheid (d.i. faktore b, d, g,jo en q4). ook hierdie roupunte word tot 'n keurpunt verwerk. die resultate van hierdie drie toetse gesamentlik stel die keurkomitee in staat om te verseker dat die kandidaat die regte kursus kies, omdat spesifieke vermoens, algemene kognitiewe vermoens en persoonlikheidseienskappe ondersoek word. hierdie gesamentlike punt dra dan die gewig van 30% by tot die finale keursyfer. persoonlike onderhoud / die persoonlike onderhoud dra alleenlik 'n gewig van 20% by tot die finale keursyfer. die feit dat die onderhoudsvoerthe south african journal of communication disorders, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die keuring van eerstejaarstudente in die departement spraakheelkunde en oudiologie (universiteit van pretoria) 31 ders opgeleide personeel met ervaring is, lei nie noodwendig tot intraen interbeoordelaar betroubaarheid nie. daarby duur elke onderhoud ongeveer 10-15 minute, wat 'n baie kort tyd is om aspekte soos gemotiveerdheid en belangstelling, kommunikasieen taaluitdrukkingsvermoe, tweetaligheid en mensgerigte dienslewering te evalueer. 'n ander aspek wat egter in 'n persoonlike kontaksituasie hanteer word, is die ondersoek van spraaken gehoorvermoens. indien enige sodanige belemmerings die kandidaat se prestasie tydens die opleiding nadelig sal be'invloed, word die kandidaat afgekeur, afgesien van enige ander keursyfers. hierdie keuringsprosedure word vanaf 1977 gevolg. die eerste gekeurde studente het dus in 1980 gekwalifiseer en daar is besluit dat opvolgingsnavorsing 'n aanvang kan neem, hoewel die steekproef nog relatief klein is. die belang van langtermynnavorsing, asook korrelasies tussen prestasie op keuring en sukses in die praktyk word besef. huidiglik is dit egter alleenlik moontlik om navorsing en evaluasie van die keuringsprosedures te rig op finalejaarstudente se prestasie. tabel 1 steekproefbeskrywing jaar herhalers nil we gekwalifiseerde jaar herhalers kandidate terapeute 1977 25 18 1978 2 23 15 1979 2 23 18 totaal 4 71 51 'n totaal van 51 studente is dus by die studie betrek. dataverwerking die data is gerekenariseer waarna beskrywende statistiek sowel as verskeie korrelasies tussen veranderlikes bereken is. 'n inferensie insake die korrelasiekoeffisient het verskeie liniere verbande tussen sekere veranderlikes bevestig. volgens hierdie metode word 'n p-waarde kleiner as 0,05 gei'nterpreteer as betekenisvol (steyn, smit, du toit 1984). evaluasie metode van evaluasie die keuringsprosedure is geevalueer aan die hand van twee aspekte: i vergelyking van die slaagsyfer by kwalifikasie van spraakterapeute vyf jaar voor keuring ingestel is, en drie jaar nadat keuring ingestel is. hoewel keuring nie hoofsaaklik ingestel word om die slaagsyfer by kwalifikasie te verhoog nie, kan die gegewens moontlik ook 'n aanduiding gee van die algemene toewyding van die studente aan hul studies, ii assosiasies van keuringsyfers en prestasiesyfers (akademies sowel as prakties) van finalejaar-(kwalifiserende) spraakterapiestudente. ideaal gesproke sou die evaluasie van 'n keuringsprosedure slegs kon geskied deur middel van die vergelyking van gekeurde en ongekeurde studente in dieselfx d e beroep. aangesien laasgenoemde nie in die situasie prakties uitvoerbaar is nie, sou 'n mens die gekeurde studente se vordering in die spraakterapiekursus noukeurig kon dophou en telkens prestasie van die studente vergelyk met die aanvanklike keuringstellings. hilson et al (1978) het by voorbeeld keuringstellings vergelyk met die prestasietellings van maatskaplike werkstudente aan die einde van hul eerste jaar. aangesien die eerste jaar in die spraakterapiekursus egter baie inleidend van aard is (bv. baie beperkte prakties word gedoen), is gevoel dat die waarde van keuring by spraakterapie meer sigbaar kan word wanneer die keuringstellings vergelyk word met die kwalifiserende prestasies. dit is dan ook teen hierdie agtergrond dat daar besluit is om gebruik te maak van die finalejaar-prestasietellings en die te vergelyk met keuringstellings. 1 resultate vergelyking van slaagsyfer (aan die einde van die finale jaar) gedurende vyf jaar voor keuring (sien tabel 2) en die slaagsyfer gedurende drie jaar na keuring ingestel is (sien tabel 3) tabel 2 ongekeurde finalejaarstudentesyfers jaar aantal eerste jaars aantal gekwalifiseer fersentasie gekwalifiseer 1971 33 11 33 1972 31 27 87 1973 39 21 54 1974 55 22 40 1975 53 19 36 totaal 211 100 50 tabel 3 gekeurde finalejaarstudentesyfers jaar aantal eerste jaars aantal gekwalifiseer ptrsentasie gekwalifiseer 1977 25 18 72 1978 25 15 60 1979 25 18 72 totaal 75 51 68 steekproef alle gekeurde studente (tussen 1977 er. 1979) wat gekwalifiseer het (tussen 1981 en 1983) is by die studie ingesluit (sien tabel 1). ' uit bogenoemde tabelle blyk dit dat die gemiddelde slaagsyfer by kwalifikasie toegeneem het met 18% sedert keuring ingestel is. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 isabel c uys and erna alant assosiasies vir keuringsyfers en die prestasie by f1nalejaarstudente korrelasiematriks vir assosiasies van keuringsyfers en die prestasie by finalejaarstudente spraak heelkunde oudiologie kombineer spraakheelkunde en oudiologie aanlegtoetse onderhoud matriekprestasie finale keuringspunt praktiese jaarpunt -0.20881 0.25940 0.25077 0.09699 0.1414 0.0660 0.0759 0.4984 teoriejaarpunt 0.01871 0.15535 0.57103 0.42570 0.8963 0.2763 0.0001 0.0018 totale jaarpunt -0.11859 0.25191 0.48316 0.30761 0.4112 0.0745 0.0003 0.0281 eksamenpunt 0.02520 0.23497 0.34233 0.30932 0.8607 0.0970 0.0139 0.0272 finale punt -0.02649 0.25633 0.42208 0.32976 0.8536 0.0694 0.0020 0.0181 praktiese jaarpunt -0.35374 0.09118 0.19728 -0.07846 0.0109 0.5246 0.1652 0.5842 teoriejaarpunt -0.20149 0.06024 0.37900 0.15814 0.1562 0.6745 0.0061 0.2677 totale jaarpunt -0.31969 0.09862 0.34480 0.05938 0.0222 0.4911 0.0132 0.6790 eksamenpunt -0.04961 0.20213 0.48404 0.35022 0.7296 0.1549 0.0003 0.0118 finale punt -0.16401 0.16847 0.50310 0.28122 0.2501 0.2373 0.0002 0.0456 praktiese jaarpunt -0.31179 0.20067 0.25249 0.01471 0.0259 0.1580 0.0739 0.9184 teoriejaarpunt -0.10269 0.12145 0.53497 0.22890 0.4733 0.3959 0.0001 0.0184 totale jaarpunt -0.23606 0.18977 0.44786 0.19883 0.0954 0.1823 0.0010 0.1619 eksamenpunt -0.01191 0.24445 0.45753 0.36681 0.9339 0.0838 0.0007 0.0081 finale punt -0.09709 0.22793 0.48850 0.32556 0.4979 0.1077 0.0003 0.0197 die volgende gegewens (sien tabel 5 en 6) kan uit tabel 4 onttrek word ter verduideliking van betrokke assosiasies. tabel 5 betekenisvolle assosiasies tussen teoretiese en keuringsyfers tabel 6 betekenisvolle assosiasies tussen praktiese jaarpunt en keuringsyfers j keuringsprosedure spraakheelkunde oudiologie gekombineerd aanlegtoetse _ onderhoud matriekprestasie 0,0001* 0,0160* 0,0001* finale keuringspunt 0,0042* 0,0559* keuringsprosedure spraakheelkunde oudiologie i gekombineerd aanlegtoetse -0.0308* -0,0830* onderhoud matriekprestasie finale keuringspunt dit blyk duidelik uit voorafgaande dat matriekresultate die enigste veranderlike is wat 'n betekenisvolle verband vertoon met die teoretiese punte gedurende die jaar. dieselfde neiging is ook waarneembaar wanneer die eksamenpunte inaggeneem word in tabel 4. uit die bogenoemde blyk dit dat 'n negatiewe betekenisvolle verband bestaan tussen resultate van die aanlegtoetse en oudiologie prakties, asook die gekombineerde praktiese punt. geen verdere betekenisvolle assosiasies is duidelik nie. the south african journal of communication disorders, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die keuring van eerstejaarstudente in die departement spraakheelkunde en oudiologie (universiteit van pretoria) 33 beskrywende stat1stiek met betrekking tot die onderskeie keur1ngsaspekte tabel 7 gemiddelde telling en standaard afwyking van keuringsaspekte gemiddeld standaard afwyking aanlegtoetse onderhoud matriekprestasie • finale keuringspunt 20.54901961 14.78235294 37.12941176 72.29019608 3.39596069 1.79105621 3.88197342 6.12929165 uit voorafgaande tabel blyk dit dat die 'onderhoud' in die prosedure die kleinste standaard afwyking toon, met ander woorde, die kleinste variasie random die gemiddelde. laasgenoemde is interessant aangesien dit impliseer dat hierdie groep meer homogeen was wat betref hulle tellings op hierdie keuringsaspek. bespreking matriekprestasie was die mees konstante indikator van teoretiese prestasie van die studente in oudiologie sowel as spraakheelkunde. hierdie bevinding is ook gestaaf in hilson et al. (1978) se studie op maatskaplike werkstudente. wat egter effe verontrustend is, is die neiging wat betref die korrelasie tussen die praktiese punte en keuringspunte. die enigste betekenisvolle verband gevind in hierdie korrelasie is tussen aanlegtoetse en oudiologie-prakties, en hierdie verband is 'n negatiewe verband. hoewel so 'n bevinding oenskynlik verbasend kon wees, kan dit moontlik verklaar word aan die hand van die betrokke toetse wat ingesluit is onder die kategorie 'aanlegtoetse'. die aanlegtoetspunt word verkry deur die som van gegewens op drie toetse wat elk op 'n tienpuntskaal beoordeel word. hierdiedrie toetse gekombineer dra by tot 30% van die keuringstelling. die toetse is die volgende: senior aanlegtoets (sat), nuwe suid-afrikaanse groepstoets (nsag), persoonlikheidsvraelys (16-pf slegs vyf van die sestien faktore word inaggeneem by keuring: intelligensie, pligsgetrouheid, skuldgeneigdheid, gespannendheid en emosionele rypheid). wanneer hierdie toetse van nader beskou word blyk dit dat daar 'n baie groot klem is op die meting van intellektuele vermoens van kandidate. die sat sowel as die nsagt meet kognitiewe funksionering, spesifiek en algemeen, met ander woorde, ten minste 20 % van die aanlegtoetspunt word verteenwoordig deur 'n kognitiewe metingspunt. in hierdie lig gesien, sou 'n mens nie noodwendig 'n positiewe korrelasie verwag tussen praktiese werk en aanlegtoetse nie aangesien daar nie noodwendig 'n noue verband bestaan tussen praktiese vaardigheid en intellektuele of akademiese vermoens nie (hilson et al 1978). terselfdertyd kan die voorafgaande argument nie gesien word as 'n verklaring van 'n betekenisvolle negatiewe verband tussen intellektuele vermoens (soos hier getoets) en praktiese punte nie. die grootte van die huidige steekproef kon inderdaad 'n faktor gewees het by hierdie bevinding. dit sou dus onvanpas wees om hierdie resultate as allesomvattend te beskryf. nog 'n interessante waarneming wat gemaak kan word, is die afwesigheid van enige verband tussen die 'onderhoud' tydens keuring en die teoretiese en praktiese punte. wanneer die standaard afwyking vir die groep se onderhoudtellings beskou word, word dit duidelik dat die gekeurde studente baie dieselfde punte behaal het in die onderhoud. hieruit kan moontlik die volgende afleidings gemaak word: dat alle kandidate dieselfde eienskappe gehad het met betrekking tot die aspekte gedek in die onderhoud (motivering en belangstelling kommunikasie en taaluitdrukking, mensgerigte dienslewering en algemene ingesteldheid en voorkoms); dat die vier aspekte gedek in die onderhoud te wyd gedefinieer is en derhalwe nie individuele verskille reflekteer nie. hilson et al (1978) het wel 'n betekenisvolle verband tussen die onderhoud in seleksie en finale eerstejaarspunte gevind. mens sou moontlik hierdie verband kon verklaar in terme van die relatiewe kort tyd wat verloop het tussen die keuringstyd (met ander woorde, die begin van die jaar) en die eksamen aan die einde van die jaar. blootstelling aan die kursus tydens die eerste jaar is inleidend van aard en kan dus nie in werklikheid gesien word as 'n betroubare maatstaf vir die evaluasie van die keuringsprosedure nie. dit is nie noodwendig te se dat alle studente wat die eerste jaar slaag die kursus gaan voltooi nie. die huidige studie het dus eerder die finalejaarprestasie geneem as maatstaf. dit impliseer egter dat daar 'n vier jaar verloop is tussen die 'onderhoud' (of enige ander keuringstelling) en die prestasiepunt. gedurende hierdie tyd word die studente nie alleenlik blootgestel aan die terapeutiese situasie nie, maar vereis die kursus dat studente emosionele groei toon om steeds meer veeleisende pasiente in die terapiesituasie te kan hanteer. dit is dus nie heeltemal verrassend wanneer die huidige bevindings toon dat daar geen betekenisvolle verband bestaan tussen die aanvanklike onderhoudspunte en finalejaarprestasie nie. laasgenoemde kan gemotiveer word deurdat die onderhoud soos gedefinieer in 'n vorige paragraaf nie potensiele emosionele groei uitlig nie, maar wel klem le op die student se belangstelling en ingesteldheid tydens die onderhoud. die fokus in keuring is dus op die seleksie van studente wat die opleiding suksesvol kan voltooi, eerder as die keuring van studente in terme van hul potensiaal vir toekomstige praktyk (hilson et al 1978). dit is veral duidelik wanneer gekyk word na die keuringsprosedure in terme van kognitiewe funksionering, matriekprestasie, ingesteldheid en belangstelling tydens aansoek. die aanname wat hier gemaak word, is dat die gekeurde student gelei kan word om 'n goeie terapeut te word onder bevoegde leiding. dit impliseer dat die proses van kliniese supervisie tydens opleiding baie sterk benadruk word (oratio 1977; lewis 1983). soos blyk uit die bespreking, is die konsep van 'keuring' voorwaar kompleks. dit spruit nie net uit die probleme by die seleksie van faktore wat ingesluit moet word in die keuring nie, maar ook uit die dilemma van wanneer die beste tyd sou wees om die effektiwiteit van die keuringsprosedure te toets, asook die keuse van maatstawwe waaraan keuringseffektiwiteit gemeet kan word bo en behalwe akademiese prestasie. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 isabel c uys and erna alant hoewel daar baie praktiese probleme met die keuring van studente bestaan, is dit egter belangrik dat hierdie aspekte gesien moet word binne die raamwerk van die persentasie van studente wat uiteindelik kwalifiseer. soos voorheen genoem is daar 'n-duidelike styging in die persentasie van spraakterapeute wat kwalifiseer sedert keuring ingestel is. hoewel keuring nie gerig is op die verhoging van die slaagsyfer in 'n kursus nie, maar eerder die selektering van studente wat die beste bydrae tot die beroep sou kon maak, kan 'n verhoging in slaagsyfer wel 'n maatstaf wees in die meting van betrokkenheid van die student by die kursus. binne hierdie bree raamwerk sou die proses van keuring wel baie nuttig en relevant wees, hoewel daar noodwendig altyd krities gekyk sal word na die inhoud en wyse van die keuringsproses. dit is teen hierdie agtergrond dat sekere veranderinge in die bestaande keurings-prosedure gemaak kan word. hoewel keuring gerig is op die seleksie van studente wat die spraakterapiekursus suksesvol sal voltooi, is dit nodig vir die keurders om sensitief te wees vir indikatore wat groeipotensiaal by studente kan aandui. voorbeelde van sulke indikatore is die volgende: — aanlegtoetse soos hier gedefinieer, sou moontlik aangepas kan word om minder klem te plaas op die kognitiewe vermoens van die individue, ten einde meer inligting oor die persoonlikheid en belangstellings van die individu te kan insluit. — die onderhoudsprosedure kan moontlik gerig word ten einde potensiele groei van die individu te probeer meet. laasgenoemde sal impliseer dat onderhoudsvoerders moet opgelei word in die kuns van onderhoudsvoering vir hierdie bepaalde doel dit is ook aan te beveel dat die prestasie op keuringsprosedure gekorreleer word met praktiese vaardighede van terapeute. aangesien keuring gerig is om studente te selekteer vir die kursus moet daar gewaak word teen die opskuif van standaarde ten einde 'n 'normale verspreidingskurwe' met betrekking tot punte te verkry, wat noodwendig dui op 'n groepie onsuksesvolle kandidate. laastens is die opleiding van personeel in die toesighoudende situasie van kardinale belang om te verseker dat die student die nodige leiding kry om te kan groei tot 'n volwaardige terapeut. bedankings graag word erkenning gegee aan die volgende: afdeling universiteitsonderwysbeplanning (studentediensburo, universiteit van pretoria) vir waardevolle inligting. mev f woodrow (kliniese sielkundige, department spraakheelkunde en oudiologie, up) vir inligting oor en evaluasie van sielkundige toetse. mev e.m louw (departement statistiek, up) vir hulp met statistiese verwerkings. verwysings cattell r.b., eber h.w. en tatsoeka m.m. handbook for the 16 personality factor questionnaire. illinois, institute for personality and ability testing, 1970. furler-kools s. de toelatingsprocedure. logopedie en foniatrie, 1981, 53, 11-13. hilson f. en mckendrick b. selecting students for admission to undergraduate courses of social work education and training. maatskaplike werk/social work, 1978, 14, 3, 108-114. lewis c. supervision in the training of speech therapists. unpublished dissertation submitted to the department of speech pathology and the witwatersrand, johannesburg, south africa, 1983. malan s.p.t. evaluering van die keuringstelsel waarvolgens voornemende kandidate vir die diploma in mondhigiene vanaf 1974-1978 gekeur is. ongepubliseerde stuk: studentediensburo, universiteit van pretoria, 1979. nuwe suid-afrikaanse groeptoets. raad vir geesteswetenskaplike navorsing, instituut vir psigometriese navorsing, 1965. oratio a.r. supervision in speech pathology. baltimore, university park press, 1977. senior aanlegtoets. raad vir geesteswetenskaplike navorsing, instituut vir psigometriese navorsing, 1975. j staf van de opleiding hoensbroek. opleiding logopedie, hoensbroek, 1981, 53, 24-38. ! steyn a.g.w., smit c.f. en du toit s.h.c. moderne statistiek vir die praktyk. pretoria, van schaik, 1984. | the south african journal of communication disorders, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustiμ ε d hearing services a c o u s t i m e d (pty) l t d . , p.o. box 9 9 8 8 j o h a n n e s b u r g 2000 s o u t h a f r i c a t e l : ( 0 1 1 ) 3 3 7 2 9 7 7 p a n a v o x l ^ ^ danac rastronics hearing aids audiometers test equipment computer systems head office : 327 bosman buildings hoofkantoor : bosman gebou 327 cor. eloff and bree streets h/v eloff en bree strate • johannesburg ' 2001 johannesburg " 2001 june 1984 dear audiologist, one day soon you will sit behind the panel with the usual row of buttons and dials. of a new audiometer however, on this occasion you will press just one button and sit back while the audiometer runs through the tests. you will listen to a verbal report on the progress of the test while the audiogram is plotted on a video monitor (the patient will not realise that the test is being controlled by a machine). any inconsistencies in the patients responses will be checked and if things get really rough the audiometer will invite you to take over. thisis no gimmick or science fiction toy it is one of a /powerful new breed of instruments which use computer technology ' to provide consistent test procedures, data evaluation, statistical analysis, graphic storage etc. programmed entirely to your own .specifications by enhance · your procedures. j we provide full software backup and complete custom-designed computer systems.x please phone me for more details acoustimed these instruments •facilities for research, educational and clinical sincerely, d.a. smith managing director ' d i r e c t o r s / d i r e k t e u r e : d . a . s m i t h ( m a n a g i n g / b e s t u r e n d e ) , l . m . s m i t h die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 15 comorbidity of stuttering and disordered phonology in young children lesley wolk, ph.d (syracuse university) edward g. conture, ph.d (university of iowa) mary louise edwards, ph.d (stanford university) department of communication sciences and disorders syracuse university syracuse, new york, usa abstract young stutterers frequently exhibit concomitant speech and/or language disorders. the co-occurrence of these disorders is, however, not get well understood. the purpose of this paper is to introduce the notion of "comorbidity" as it relates to the field of speech-language pathology: specifically, to discuss comorbidity (coexistence) of stuttering and disordered phonology in young children. literature on concomitant speech and language disorders in young stutterers is reviewed, with special reference to the prevalence of articulatory/phonological disorders in young stutterers. future research on the coexistence of two speech and language disorders is encouraged, as well as the consideration of diagnostic treatment and prognostic implications for children who,exhibit both stuttering and disordered phonology as opposed to children who exhibit each disorder in isolation. opsomming jong hakkelaars vertoon dikwelssamegaandespraak en/of taalafivykings. diegelyktydige voorkoms van hierdie afivykings word tans egter nie ten voile bcgryp nie. die doel van hierdie artikel is om die begrip van "ko-morbiditeit" bekend te stel soos wat dit toegepas word op die vakgebied van spraakheelkunde en ook spesifiek om die gelyktydige voorkoms van hakkel en fonologiese afivykings in jong kinders te bespreek. 'n liter atuuroorsig van die gelyktydige voorkoms van spraak-en taalafivykings injong hakkelaars word verskaf met spesiale verwysing na die voorkoms van artikulasic/fonologiese afivykings injong hakkelaars. verdere navorsing oor die gelyktydige voorkoms van twee spraaken taalafivykings word aangemoedig. die oorweging van diagnostiese, behandelings en prognostiese implikasies vir kinders wat beide hakkel en afivykende fonologiese ontwikkeling vertoon. in teenstelling met kinders wat elke afwyking afionderlik vertoon. word aangebied. comorbidity refers to "... any distinct additional clinical entity that-has existed or that may occur during the clinical course of inpatient who has the index disease under study" (feinstein, 1970, p. 456). comorbidity has been discussed in some detail in the medical literature, particularly in relation to psychiatric disorders (boyd, burke, gruenberg, holzer, rae, george, karno, stoltzman, mcevoy &|nestadt, 1984; feinstein, 1970). yet it has received little attention in the field of speechlanguage pathology. although children with more than one speech disorder (e.g., stuttering and disordered phonology) are encountered frequently in clinical practice, there has been a paucity of research dedicated to understanding the coexistence and inter-relationships between two speech disorders. indeed, stuttering (s) and disordered phonology (dp) have traditionally been investigated and treated as two distinct disorders. little attempt has been made to merge the two disorders in terms of the following: (1) investigation of their cooccurrence in some children; (2) therapy regimens when both disorders are exhibited in the same child; and (3) conceptual explanations for their co-existence, and in some cases, persistence. the general purpose of this paper is to introduce the notion of "comorbidity" as it relates to the field of speech-language pathology. the more specific aim is to discuss the comorbidity (co-existence) of stuttering and disordered phonology exhibited in young children. literature on concomitant speech and die suid-afrikaanse tydskrif ir kommunikasieafwykins vol. 37 1990 language disorders in young stutterers is reviewed, with special reference to the prevalence of articulatory/phonological disorders in young stutterers. understanding the coexistence of two speech disorders in particular, stuttering (s) and disordered phonology (dp), has clinical implications, for example, differential diagnosis, such as the possibility of behavioral subgroups of young stutterers. further, diagnostic treatment and prognostic features may be different for children who exhibit the co-occurrence of two speech disorders as opposed to each disorder in isolation. feinstein (1970, p. 456) states: "with comorbidity omitted from consideration, two clinicians arguing about the merits of a mode of treatment for a particular disease may fail to recognize that their contradictory results arise not from the actions of treatment, but from the different associated diseases in the patients subjected to treatment." regarding the co-occurrence of stuttering and disordered phonology in young children, several studies have investigated the prevalence of their coexistence (e.g., blood & seider, 1981; daly, 1981). these studies are presented and discussed in detail below. in general, findings from previous studies have shown that 30-40% of young stutterers also exhibit articulation/phonological concerns (see table 1 below). however, only a few studies have attempted to explore the nature of this co-occurrence in more depth (e.g., st. louis & sasha 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 lesley wolk, edward g. conture and mary louise edwards hinzman, 1988; louko, conture & edwards, 1990). thus, little objective information is available regarding the nature and relation of these two disorders in young children. because it appears that approximately one third of children who stutter at one time or another exhibit articulation difficulties (e.g., cantwell & baker, 1985), it would seem important to increase our understanding of the nature and relation between stuttering and articulatory/phonological disorders in young children. to further highlight the existence and clinical importance of the co-occurrence of these two disorders, it is noted that clinicians frequently report that young children who are being treated for articulation difficulties may subsequently begin to stutter. comas (19 74, cited in bloodstein, 198 7, p. 221) reported that out of 1,050 cases of young children, in some, stuttering was observed to appear while they were being treated for articulation difficulties. in addition, with reference to childtable 1: published studies on the co-occurrence of stuttering and articulation/phonological difficulties in young children author date stut. ν nonstut. source of information % stut. with artie. diff. % nonstut. with artie. diff. summary of findings 1. mcdowell (1928) 33 33 speech exam. (articulation test) 19% 16% articulation difficulties with significant difference between groups 2. schindler (1955) 126 252 speech exam. 49% 15% "other speech disorders" 3. darley (1955) 50 50 parental reports 26% 4% associated articulation difficulties 4. morley (1957) 37 113 speech exam. 50% 31% "other speech disorders" 5. andrews and harris (1964) 77 78 parental reports 30% 10% associated articulation difficulties 6. williams and silverman (1968) 115 115 speech exam. 24% 9% .associated articulation difficulties 7. van riper (1971) 250-300 clinical records 14-25% delayed speech and language, articulation difficulties or evidence of organic involvement (track ii stutterers) 8. riley and riley (1979) 100 — speech exam. 33% associated articulation difficuties ! 9. preus (1981) 100 clinical records 18% van riper's track ii stutterers [ 10. daly (1981) 138 speech exam. 58% articulation j disorders ^ 11. blood and seider (1981) 1060 clinical reports 16% articulation difficulties 12. seider, gladstein and kidd (1982) 201 201 (siblings) parental reports — — no significant difference between groups 13. thompson (1983) 48 speech exam. 35-45% "suspected articulation difficulties" 14. cantwell and baker (1985) 40 speech exam 30% 15. st. louis and hinzman (1988) 48 24 speech exam. 67-96% / 16. louko, edwards and conture (1990) 30 30 speech exam. 40% 7% associated articulation difficulties the south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) comorbidity of stuttering and disordered phonology in young children 17 ren treated for language disorders, merits-patterson & reed (1981) recently showed that speech disfluencies can increase for some children who receive speech/language therapy. they investigated 27 preschool children classified into 3 groups of 9 each: language delayed children who had received language therapy, language delayed children.who had not received therapy, and those children with normal language development. none of the 27 children had ever been diagnosed as stutterers. they found that the group of language delayed children who received therapy produced significantly more whole-word and part-word repetitions (after therapy) than the other two groups. although there have been few published reports on the influence of therapy on other aspects of young stutterers' speech and language apart from the studies by comas (1974; cited in bloodstein, 1987), and merits-patterson & reed (1981), clinical reports suggest that stuttering often occurs secondary to the treatment of phonological and language disorders in young children; but, to our knowledge, the reverse has never been reported. c o n c o m i t a n t s p e e c h a n d l a n g u a g e d i s o r d e r s i n y o u n g s t u t t e r e r s p r e v a l e n c e o f a r t i c u l a t o r y / p h o n o l o g i c a l d i s o r d e r s in y o u n g s t u t t e r e r s a review of studies from 1928-1990 is presented in table 1. for each study, the author(s), date, sample size, source of information, percent stutterers and nonstutterers with articulation disorders, and major findings are summarized. "major findings" refers to the major characteristics pertaining to the stutterers for that study. the first of these studies was conducted by mcdowell (1928). he matched 33 stutterers and 33 nonstutterers according to age, sex, intelligence, native language and racial background. for both groups, the mean age was 10 years (range = 7-12 years). a nonstandardized articulation test was used, in which each child was required to repeat a series of sentences after an examiner, who recorded errors in the production of vowels, diphthongs, consonants and consonant clusters. findings indicated that the mean error rates for the stutterers and nonstutterers were 19% and 16%,'respectively. this represented a small but statistically significant difference between the two groups. mcdowell questioned the validity of these findings, however, because subjective scoring procedures were employed. moreover, it could be argued that repetition of sounds in sentences is a different form of speech elicitation than a naming task or conversational speech, since an imitation task may overestimate the child's performance. subsequent studies in the 1950's made reference to the presence of "other speech disorders" in young stutterers, with only vague suggestion that these "other disorders" were most likely to be articulation difficulties (morley, 1957; schindler, 1955). for example, schindler (1955) found that 49% of 126 stuttering children had "other" speech disorders, whilst this was evident in only 15% of 252 nonstutterers. similarly, morley (1957) reported that 50% of 37young stutterers and 31 % of 113 nonstutterers had "other speech disorders". it is difficult to determine from these early studies exactly what was implied by "other speech disorders". however, it is assumed that many of these were difficulties with speech sound production. die huui-ajrikuunse 'lytlskril vir kornmumkasicafwtikiiifp, vol. 37. i!).')!) more recent studies have reported specifically on the prevalence of articulation difficulties in young stutterers. williams & silverman (1968) found 24% of 115 school-aged stutterers had associated articulation difficulties. riley & riley (1979) showed this to be the case in 33% of 100 young stutterers. daly (1981) reported that 58% of a subgroup of 25 young stutterers (η = 25), out of a larger sample (n = 138), exhibited articulation disorders. thompson (1983) observed a 35-45% prevalence of suspected articulation difficulties in two samples (n = 3 1 & n = 1 7 ) o f young stutterers. recently, cantwell & baker (1985) reported a prevalence of approximately 30% in a sample of 40 young stutterers out of a larger sample of 600 children with speech and/or language disorders. st. louis & hinzman (1988) found that 67-96% of their school-aged stutterers (n = 48) had articulation difficulties. in general, they found that young stutterers are likely to manifest other communicative impairments, especially in articulation and voice. further, several studies have indicated a prevalence of 15-30% articulation difficulties in young stutterers based on clinical and/or parental reports (e.g., andrews & harris, 1964; darley, 1955). van riper (1971), using clinical records and related observations, reported that 14-25% of young stutterers had "de-layed speech and language, articulation difficulties or evidence of organic involvement". he categorized these as "track ii" stutterers. preus (1981) studied the clinical records of 100 young norwegian stutterers, and reported that 18% had similar difficulties and could be classified as van riper's "track ii" stutterers. blood & seider (1981) found that, among caseload reports of 1,060 young stutterers, 16% exhibited articulation difficulties. however, it is difficult to interpret this result meaningfully because blood & seider did not employ a control group of nonstutterers. furthermore, the criteria used in diagnosing articulation difficulties varied among clinicians (cf. nippold, 1990). most recently, louko. edwards & conture (1990) found that among 30 stutterers and 30 age-matched nonstutterers, 40% of the stutterers exhibited articulation difficulties as opposed to 7% of the nonstutterers. one study that did not support the view that stutterers have a higher incidence of articulation disorders than nonstutterers is that by seider, gladstein & kidd (1982). in their study, informants were questioned about the presence of articulation disorders in stutterers and same-sex nonstuttering siblings. results showed that stutterers and nonstutterer siblings did not differ significantly in the frequency of associated articulation difficulties. instead, articulation difficulties occurred most frequently in late talking subjects compared to early (or average) speakers regardless of the presence or absence of stuttering. findings of this study suggested that language and articulation onset and development may be more a function of familial patterns and gender than of stuttering. in general, more studies support than refute the finding that articulation disorders frequently co-exist with stuttering in young children. however, an important consideration in reviewing these studies is the variation in assessment methodology. that is, some studies have used direct examination/observation of children's speech production, whereas others have relied on questionnaire data and/or parental reports. this one in addition to other methodological considerations has been highlighted in a recent critique of the literature on concomitant speech and language disorders in stuttering children (nippold, 1990). these are: r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 lesley wolk, edward g. conture and mary louise edwards (a) the use of parental interview or informal observation in place of direct testing of children (e.g., andrews & harris, 1964; darley, 1955; seider et al. 1982). (b) the absence of data establishing test-retest and interscorer reliability of articulation assessment (e.g., blood & seider, 1981; mcdowell, 1928; williams & silverman, 1968). (c) the difficulty in distinguishing true articulation errors from manifestations of stuttering (e.g., schindler, 1955). (d) the absence of ethnic and linguistic background matching criteria. a recent study (wolk, 1990) was designed to overcome some of these methodological concerns, in an attempt to further explore the co-occurrence of s+dp in young children. wolk compared the behaviours of children who exhibited both s+dp with those of children who exhibited each disorder in isolation. the methods employed were (a) use of the 162-item picture naming task for direct testing of children's speech articulation, (b) intraand inter-rater reliability measures and (c) clearly developed criteria for distinguishing between true articulation errors and stutterings. findings from this study suggest that stutterers with phonological concerns exhibit some unique disfluency characteristics (e.g., significantly more sound prolongations) which distinguish them from stutterers without phonological difficulties. there are also reports of "language delay" in young children who stutter, although this does not appear to be nearly as prevalent in young stutterers as articulation difficulties (bloodstein, 1987). furthermore, it is often difficult to determine from these studies whether language delay refers exclusively to syntactic, semantic and/or cognitive factors, or whether it is a more global term including phonological difficulties. the following section provides and overview of studies on language delay in young stutterers. l a n g u a g e d e l a y s i n c h i l d r e n w h o s t u t t e r some investigators have reported that stutterers tend to be slow in developing language (berry, 1938; morley, 1957), although the iowa studies (of nearly 200 stutterers and their matched controls) showed slight or no differences (bloodstein, 1987). andrews & harris (1946, p. 35) speculated that the population groups used as subjects in the iowa studies tended to be representative of higher socio-economic levels which could possibly explain the difference between their findings and those of other studies. more recently, accordi et al. (1983, cited in bloodstein, 1987, p. 215) found "...retarded language development" in 28 percent of stutterers as opposed to 8.7 percent of a control group. conversely, bernstein ratner & costa sih's (1987) results do not support subtle language differences between normal and stuttering children. however, their findings suggest that disfluency breakdown is significantly correlated with gradual increases in syntactic complexity for both stuttering and normalchildren. some studies have investigated the co-occurrence of disfluency with specific syntactic structures in 2-4 year old normally developing children (colburn & mysak, 1988a, 1982b; helmreich & bloodstein, 1973). helmreich & bloodstein found that pronouns and conjunctions appeared in significantly greater proportion among the disfluent words, than did nouns and verbs. colburn & mysak concluded that "developmental disfluency was more strongly attached to the syntax of utterances than to the production of particular words" (1982b, p. 421). further, they concluded that"... the cognitive effort exerted in learning syntactic structures is reflected in systematic changes in speech disfluency in the early languagelearning period" (p. 425).' murray & reed (1977j reported that preschool stutterers scored significantly lower than their controls on the peabody picture vocabulary test (ppvt), the northwestern syntax screening test (nsst), and the verbal abilities scale of the zimmerman preschool language scale. kline & starkweather (1979) found that stutterers (aged 3:0 to 6:0 years) had a significantly lower mean length of utterance (m.l.u.) than did nonstutterers, as well as lower scores on the carrow test for auditory comprehension of language. in further support for a language delay, westby (1979) showed that her stutterers scored significantly poorer than normal speaking children in regard to frequency of grammatical errors, in receptive vocabulary on the ppvt, and in responses on semantic tasks selected from the torrance test of creative thinking. in a syntactic analysis of the speech of four stutterers (aged 5:0 to 6:0 years) and four age-matched controls, wall (1980) found that the stutterers tended to use simpler, less mature language. conversely, meyers & freeman (1985) reported no significant differences in m.l.u. between 4:0 to 5:0 year old stutterers and their nonstuttering peers during communicative interaction with their mothers. most recently, enger, hood & shulman (1988) examined both language and fluency characteristics of 20 linguistically advanced preschool and school-aged children (aged 3:2 to 7:0 years). they found that, although these linguistically-advanced children exhibited slightly more frequent disfluencies than would be expected, their disfluency patterns paralleled those characteristics of normal speakers (i.e., interjections and revisions). the majority of their disfluencies were "semantically more filled than empty," occurred internal (rather than external) to the constituent clause, and appeared to be neither physically tense nor highly fragmented. i thus to date, only limited data are available to support language differences in stutterers, with research results being equivocal regarding the prevalence and specific nature of language abilities between stutterers and nonstutterers. ! some possible explanations for young stutterers' concomitant speech and ' language problems i i there have been very few speculations about the meaning of young stutterers' concomitant speech and language problems. furthermore, few of these speculations have been supported with empirical research. one view, which takes a psychosocial perspective, is that held by bloodstein (1975, cited in bloodstein, 1987). he suggested that children with communication disorders are more likely to acquire a sense of failure as speakers and thus learn to struggle with their speech attempts. a second view is that there is a common predisposition underlying the twoproblems (stuttering and other speech and/or language problems); that is, they are caused by some ex tent.-by the same thing (bloodstein, 1987, p. 221). for example, west, kennedy & carr (1947, p. 93) suggested that "stuttering" and "speech retardath south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) comorbidity of stuttering and disordered phonology in young children 19 tion" often tend to appear in the same individuals because they have inherited a common predisposition to both conditions. a third view is perhaps a subcategory of the second view, in that both stuttering and associated speech/language problems are speculated to be caused by the same phenomenon; specifically a "central neurological processing deficit" (byrd & cooper, 1988). there is some preliminary support for this speculation via empirical research, which is discussed below. byrd & cooper (1988) administered the blakeley screening test for developmental apraxia of speech (stdas) to 16 young stutterers, 15 d e v e l o p m e n t a l ^ apraxic children, and 15 normal speaking children aged.4:0 to 9:0 years. results indicated that although significant differences were observed among the three groups on the overall test score (8 subtests), the apraxic and stuttering groups performed similarly on all stdas subtests except for the articulation subtest. specifically, they interpreted their findings to provide support for a possible "central neurological processing deficit" in some young stutterers. also, observations by yoss & darley (1974) suggest that in some children, articulatory problems and stuttering might both be manifestations of "developmental apraxia". among 30 children with articulation problems, sixteen performed poorly on a test of oral apraxia. in addition, these children had more repetitions and prolongations in their speech than did the others. there is still some controversy, however, as to the precise definition of the term "developmental apraxia", and, in fact, as to the existence of this disorder as a clinical entity. concluding remarks in conclusion, bloodstein (1987) recently stated: "there is hardly a finding more thoroughly confirmed in the whole range of comparative studies of stutterers and nonstutterers than the tendency of stutterers to have functional difficulties of articulation, 'immature' speech and the like" (p. 219-220). it seems, then, that the approximately 30-40% prevalence of articulation difficulties in young stutterers is greater than the approximate 2-6.4% prevalence that would be expected in a typical population (beitchman, nair.clegg & patel, 1986; hull, mielke, timmons & williford, 1971). thus, articulation disorders appear to be one of the speech-language disorders most commonly associated path stuttering. although much literature isjavailable regarding the nature of speech disfluencies in young stutterers and the nature of phonological difficulties in young children, there is still limited information regarding the co-occurrence of the two disorders in young children. investigation of this co-occurrence is encouraged since it would appear to have intrinsic value for a deeper understanding of each disorder separately, as well as for the relationship between the two disorders. in addition, we believe such research may have important clinical implications for treating these two coexisting speech disorders. it is hoped that this review will stimulate research and interest in comorbidity in speech-language pathology, in particular, in the interrelations between stuttering and disordered phonology and/or language delay in young children. finally, clinicians are urged to give specialized consideration to the diagnostic, treatment and prognostic implications for children who exhibit both stuttering and disordered phonology as opposed to those who exhibit each disorder in isolation. acknowledgements supports in part by osep grants (6000850252 & h023c8008) to syracuse university, syracuse, new york. thanks to the human sciences research council (hsrc), pretoria, south africa, for financial assistance to the first author. references andrews, g„ & harris, m. the syndrome ofstutteriny, chapters 4 , 5 , 6 . london: the spastics society medical education and information unit in association with williams heineman medical books, 1964. beitchman, j.h., nair, r„ clegg, m. &, patel, p.c. prevalence of speech and language disorders in 5-year-old kindergarten children in the ottawa-carleton region journal of speech and heariny disorders, 51, 98-110, 1986. bernstein ratner, n. & costa sin, c. effects of gradual increases m sentence length and complexity in children's disfluency.jowrnal of speech and heariny disorders, 52, 278-287, 1987. berry, m.f. development history of stuttering children. journal of pediatrics, 12, 209-217,1938. blood, g.w. & seider, r. the concomitant problems of young stutterers. journal of speech and heariny disorders, 46, 31-33, 1981. bloodstein, o. a handbook on stutteriny (4th ed.). chicago, 1l.: national easter seal society, 1987. boyd, j.h., burkej.d., gruenberg, e„ holzer, c.e., rae, d.s., george, l.k., karno, m., stoltzman, r., mcevoy, l. & nestadt, g. exclusion criteria of dsm-i11: a study of co-occurrence of hierarchyfree syndromes. archives of general psychiatry, 41, 983-990, 1984. byrd, k. & cooper, e.b. apraxic speech characteristics in stutteriny, developmentally apraxic and normally speaking children. paper presented at the annual convention of the american speech-language-hearing association (asha), boston, ma., 1988 (november). cantwell, d. & baker, l. psychiatric and learning disorders in children with speech and language disorders: a descriptive analysis. advances in learning and behavioral disabilities, 2, 29-47,1985. colburn, n. & mysak, e.d. developmental disfluency and emerging grammar 1. disfluency characteristics in early syntactic utterances. journal of speech and heariny research, 25, 414-420, 1982a. colburn, n. & mysak, e.d. developmental disfluency and emerging grammer ii. co-occurrence of disfluency with specified semantic-syntactic structures. jo»r«fli of speech and heariny research, 25, 421-427, 1982b. daly, d. differentiation of stuttering subgroups with van riper's developmental tracks: a preliminary study .journal of the national student speech lanyuaye heariny association, 9, 89-101, 1981. darley, f. the relationship of parental attitudes and adjustments to the development of stuttering. in w.johnson and r. leutenegger (eds.), stutteriny in children and adults. minneapolis. mn: university of minnesota press, 1955. enger, n.c., hood, s.b., & shulman, b.b. language and fluency variables in the conversational speech of linguistically advanced preschool and school-aged children. journal of fluency disorders, 13, 173-198, 1988. feinstein, a.r. the pre-therapeutic classification of co-morbidity in chronic disease journal of chronic diseases, 23, 455-468, 1970. helmreich, h.g. & bloodstein, o. the grammatical factor in childhood disfluency in relation to the continuity hypothesis. jou rnal of speech and heariny research. 16, 731-738, 1973. hull, f.m., mielke, p.w., timmons, r.j. & willeford, j.a. the national speech and hearing survey: preliminary results. asha, 13, 501-509, 1971. kline, m.l. & starkweather, c.w. perceptive and expressive language performance in young stutterers. asha, 21, 797, abstract, 1979. louko, l.j., edwards, m.l. & conture, e.g. phonological characteristics of ifouny stutterers. manuscript submitted for publication, 1990. mcdowell e.d. educational and emotional adjustment ofstutteriny children. new york: columbia university teachers college, 1928. merits-patterson, r. & reed, c.g. disfluencies in the speech oflanguage-delayed children .journal ofspeech and heariny research, 46. 55-58, 1981. die suid-afrikaanse tydskrif vir kommunikasieafivykinys, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 lesley wolk, edward g. conture and mary louise edwards meyers, s.c. & freeman, f.j. are mothers of stutterers different? an investigation of social-communicative interaction. journal of fluency disorders, 10, 193-209, 1985. marley, m.e. the development of disorders of speech in childhood. edinburgh, scotland: livingstone, 1957. murray, h.l. & reed, c.c. language abilities of preschool stuttering children. journal of fluency disorders, 2, 171-176, 1977. nippold, m.a. concomitant speech and language disorders in stuttering children: a critique of the literature. journal of speech and hearing disorders, 55,51-60, 1990. preus, a. attempts at identifying subgroups of stutterers. oslo, norway: university of oslo press, 1981. riley, g.d. & riley, j. a component model for diagnosing and treating children who stutter .journal of fluency disorders, 4 279-293 1979. st. louis, k.o. & 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kennedy, l. & carr, a. the rehalnlitation of speech (rev. ed.). new york: harper bros, 1947. westby, c.e. language performance of stuttering and nonstuttering children. j«/<r«a/ of communication disorders, 12, 133-145, 1979. williams, d.e. & silverman, f.h. note concerning articulation of school-age stutterers. perceptual motor skills, 27, 713-714,1968. wolk, l. an investigation of stuttering and phonological difficulties in young children. unpublished doctoral dissertation, syracuse university, syracuse, ny, 1990. yoss, k. & darley, f. developmental apraxia of speech in children with defective articulation. journal of speech and hearinq research, 17, 399-416, 1974. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) its not just the learner.html ‘it’s not just the learner, it’s the system!’ teachers’ perspectives on written language difficulties: implications for speech-language therapy indira navsaria michelle pascoe harsha kathard department of health and rehabilitation sciences, university of cape town correspondence to: i navsaria (indira.navsaria@gmail.com) abstract the failure to achieve academic outcomes in linguistically diverse classrooms in poor areas of the western cape, south africa, is well documented. a major contributing factor is the written language communication difficulties experienced in these classrooms. this paper describes the views of intermediate-phase teachers on why written language difficulties are experienced by learners and ways in which these difficulties might be overcome. a series of interviews were conducted with two class teachers in one urban school from which there had been a high number of referrals for speech-language therapy. the teachers were individually interviewed using an in-depth, semi-structured format. teachers reported that 50 70% of learners in their classes were not meeting grade level academic outcomes. they were asked to explain the difficulties experienced with regard to written language, and the challenges and solutions linked to these. the findings suggest that there are barriers and opportunities at the school system, individual learner and home/social community levels. major challenges identified at the school system level included limited training and lack of support for teachers, poor foundation skills in learners and difficulties with language. the current opportunities for the development of written language were insufficient and teachers identified further opportunities to promote the learners’ written language development. these included training and support for teachers, clear and consistent assessment guidelines, remedial assistance for learners and safe, nurturing home environments. there is a need to look beyond the learner as the site of the problem; a systemic approach is essential. in the light of these findings, suggestions are made for the role of the speech-language therapist. keywords: classrooms, linguistic diversity, speech-language therapists, teachers, western cape, written language the impetus for this study was the high number of referrals that speech-language therapists (slts) based at a newly established university clinic in the cape flats area of the western cape had received. there were no slt services in this poor community prior to the establishment of the university clinic in 2004. when teachers were informed of the service available to assist learners with communication difficulties, they referred learners in large numbers. the majority of learners were from intermediate-phase classrooms, and reported to be experiencing problems with written language. the situation warranted further investigation, and a project was therefore initiated to understand the challenges and to explore possible intervention strategies. this paper focuses specifically on teachers’ perspectives on written language expression in intermediate-phase learners in an urban ordinary school in the cape flats area of the western cape, south africa. the term ‘ordinary’ is used to refer to classrooms in mainstream government schools and not to classrooms in ‘special schools’ (doe, 2001, p.15). intermediate phase refers to grades 4 6 in these ordinary schools. written language may be defined as a set of phonological (sounds), syntactical (form) and semantic (content/meaning) rules represented by orthographic features (nicolosi, harryman & krescheck, 1989, p. 142). it also refers to reading, writing and related processes (asha, 2001, p. 355). written language expression refers to the written language texts that are generated through the writing processes as a form of communicating meaning to the reader (asha, 2001, p. 169). while the problem was highlighted at a localised site, the reading and writing difficulties of children throughout south africa are well documented (centre for evaluation and assessment, 2006; doe, 2008). in 2003, the south african department of education (doe) investigated literacy levels among grade 3 learners and found that 61% of children did not have age-appropriate reading and writing skills (centre for evaluation and assessment, 2006). the progress in international reading literacy study (pirls) reported results from south africa which showed the lowest reading literacy levels of all 40 countries investigated (mullis, martin, kennedy & foy, 2007) despite the fact that the south african grade 5 learners were compared to grade 4 learners internationally (scherman, van staden, venter & howie, 2008). south african learners were found to be more than two grades behind their international peers as regards reading. as reading and written language are closely related, it is likely that their written language skills would also be compromised. reading and writing are important tools in other learning areas in later grades, so it is vital that effective interventions take place to help these children (centre for evaluation and assessment, 2006). current research by the western cape education department (wced) confirms the concern about written language and reading, which has been described as a national crisis (doe, 2008). the south african context: a historical perspective the current education crisis must be understood in the context of south africa’s history. in its second decade of democracy, south africa’s transformation of basic education is still underway and the vestiges of apartheid still hamper children’s ability to learn (nelson mandela foundation, 2004). relevant to this study is that apartheid effectively divided education, had a language policy built for separate development, unequal resources and a cognitively impoverished curriculum that resulted in the majority of the population being under-educated (heugh, 2000). post apartheid, one of the most dramatic changes that occurred as a consequence of the schools act in south africa was racial desegregation, which resulted in the migration of learners. the flow of learners mimicked the apartheid racial hierarchy: african learners migrated to schools that had previously been open only to indian, white or coloured children, while coloured learners migrated to indian and white schools, and indian learners moved to white schools (pluddemann, xola & mahlahela-thusi, 2000). classrooms became linguistically diverse – a cause for celebration – yet with no redeployment of appropriately qualified african-language speaking teachers to the relevant schools, communication difficulties between teachers and learners have arisen (pluddemann et al., 2000). in the community in which this study was conducted, african learners had migrated to previously coloured schools. as a consequence, learners as well as teachers frequently came from different language backgrounds, resulting in diverse languages in the classroom (walton, 2002). however, the language of learning and teaching (lolt) remained english, resulting in many learners learning in a foreign language, i.e. a language that is not their home language and which is often unknown to them as they had little exposure to english outside of school. this situation has created numerous teaching and learning challenges contributing to low achievement. added to the communication challenges is that many of these previously black and coloured schools continue to be overcrowded and under-resourced. basic amenities and infrastructures have still not been put in place, while previous white-only schools continue to be relatively well resourced (soudien, 2008). in impoverished communities, such as the community in this study, teachers continue to encounter a large number of learners with many socio-economic problems that contribute to their learning difficulties. in both rural and poor urban schools there is a shortage of classrooms, teachers, and basic educational tools like stationery and textbooks, combined with poor basic needs like water and electricity (nelson mandela foundation, 2004). written language the overall purpose of writing is to communicate ideas. spoken language provides a critical foundation for the development of reading and written language, and this relationship is reciprocal (bishop & clarkson, 2003; locke, ginsborg & peers, 2002). written language, together with spoken language and reading, contributes to the process of literacy (asha, 2002). written language expression (production) is comprised of two stages, viz. the process and the product (asha, 2001). writing processes include the cognitive-linguistic and motor acts that are involved in producing written language texts. these include planning (prewriting), organising, drafting, reflecting, revising and editing, as well as forming letters and sequences of letters into words. written language is an important tool for learning as well as assessing learners in the classroom. with regard to the pass/fail criterion for learners in south african schools, oral communication accounts for approximately one-third of the total mark for english language (kapp, 2004). in contrast, written language accounts for two-thirds of the total, signalling the high value placed on written language. learners must have adequate written language skills in order to pass a grade, complete school and ultimately obtain employment. teachers’ perspectives o’connor and geiger (2009) described the challenges facing primary school educators of english second (or other) language (esol) learners in both advantaged as well as disadvantaged schools in the western cape. their study used a self-administered questionnaire as well as focus groups to explore the attitudes and perceptions of grade 1, 2 and 3 teachers working with esol learners in schools in the region. these teachers described a shortage of educators able to speak isixhosa, the most frequently occurring first (or home) language of the region’s english second-language learners. challenges faced by educators when teaching these learners included learners’ academic and socio-emotional difficulties and a lack of parent involvement. participant educators indicated a need for departmental, professional and parental support, and additional training and resources. wium, louw and eloff (2010) also turned their attention to educators in the south african context, developing a continued professional development (cpd) programme for foundation-phase educators in a rural and township context. these authors describe the challenges facing these educators that have been documented in the literature, e.g. implementing a ‘new’ curriculum (gouws & dicker, 2006), coping with the legacy of apartheid and managing a linguistically diverse classroom. the studies of o’connor and geiger (2009), and wium et al. (2010) focused on educators in the foundation phase. in contrast, limited research has been carried out with educators in the intermediate phase, i.e. grades 4 6. one such study is that by botes and mji (2010), which focused on linguistically diverse grade 4, 5 and 6 classrooms and specifically looked at the teaching of mathematics. the authors investigated whether a multilingual visual aid (similar to a mathematical ‘dictionary’) was able to enhance the performance of learners. they were able to demonstrate the effectiveness of this tool in their quasi-experimental study, and the comments of educators also supported the use of that strategy. the present study focused on written language in the intermediate phase since it was in this phase that teachers were reporting significant concern about learners’ literacy skills which are critical in the assessment of all learning areas, including mathematics (as described by botes and mji, 2010). academic language learning problems frequently become visible as basic literacy skills are applied and the day-to-day demands of the classroom intensify. the long-term result of poor reading and writing skills among young learners is that they leave primary school with low literacy levels, and face ongoing problems in secondary school, as evidenced by the poor matric results (unesco, 2010). negative long-term outcomes have been linked to limited support received in schools (doe, 2001). education white paper 6, the policy document on inclusive education and training system in south africa, states that 70% of learners in mainstream education who experience barriers to learning receive little or no educational support (doe, 2001). slts have the expertise and knowledge to assist with communication difficulties of all kinds. it has been argued that they should be involved in supporting teachers and learners in linguistically diverse classrooms to enhance communication and promote literacy learning among the learners (du plessis & louw, 2008; wium, 2010). however, in order to propose intervention relevant to the context, an in-depth understanding of teachers’ perspectives is required. this study therefore focused on two intermediate-phase educators in one school, asking: ‘what are teachers’ concerns about written language? what are the challenges and what are some of the ways in which these might be addressed?’ method aims the study aimed to describe: 1. teachers’ perceptions of the learners’ written language expression. 2. teachers’ perceptions of the challenges affecting the development of written language. 3. teachers’ perceptions of the opportunities to develop the written language of the learners. research design an exploratory, inductive case study research design was used to: (i) satisfy the researchers’ desire to gain a better understanding of the issues surrounding written language; (ii) generate ideas for a more extensive study and establish priorities for future research; and (iii) develop new interpretations or theories of certain areas of interest (sofaer, 2002). the study was an in-depth investigation of teacher, learner and parent perspectives on why learners were not achieving grade-level outcomes for written language. however, this paper focuses specifically on teachers’ perspectives of written language expression in intermediate-phase learners in an urban ordinary school in the cape flats area in the western cape, south africa. this study investigated written language through the eyes of classroom teachers using individual semi-structured interviews. this study was conducted in accordance with the declaration of helsinki (world medical association, 2008). confidentiality was maintained and each participant had to be legally competent and informed before they were invited to voluntarily sign a consent form. no incentives were given for participating in this study. the privacy accorded to the participants gave them freedom to speak openly about their views, and by opting for individual interviews, a polarisation effect was avoided (maxwell & satake, 2006). participants two teachers from the same school participated in the study. their accounts provided rich data allowing for in-depth analysis. typical case sampling, a form of purposive sampling, illustrates what is typical in a specific context (patton, 2002). the school is situated in the socio-economically disadvantaged cape flats area in cape town, south africa, where violence and crime are prevalent. politically, it was classified as a coloured area in apartheid south africa where people of mixed race resided. inclusion criteria for teacher participants were: • currently teaching in the intermediate phase in a linguistically diverse classroom • teaching language and one other learning area that included written language (e.g. history/geography/science) • a minimum of 3 years’ teaching experience in linguistically diverse classrooms • willingness to participate and the ability to reflect on language-related issues • to have previously reported written language as a challenge. the two form teachers of the grade 5 and 6 classrooms were selected as they were involved in teaching all learning areas except art. the investigation was limited to two participants because of the in-depth, qualitative nature of the study. table i summarises the biographical information about the teachers. materials and procedure permission was requested from the wced to conduct the study at the relevant school. the study was approved by the university of cape town faculty of health sciences human research ethics committee (rec ref: 460/2007). the school principal and the chairperson of the school governing body (sgb) were contacted for permission to conduct the research with teachers. the teachers were interviewed individually at the school during their free period, a time in which they were not teaching. the interviews took place in the school staff room and also in the classrooms. the rooms were quiet and private with minimal interruptions. the teachers were interviewed formally in a semi-structured interview format which ranged from 90 to 120 minutes. follow-up discussions then took place over a period of 6 months following the main interview. these follow-up discussions ranged from 30 to 60 minutes and typically took place in the classrooms, again on an individual and private basis. the formal interviews were audio-recorded while field notes were made during the ongoing discussions. the main question was about the difficulties experienced by the learners in the classes with regard to written language, and the challenges and solutions linked to these. the topic areas used in the semi-structured interviews are listed in appendix a. however, the interviewer and teachers had the freedom to deviate from the planned structure of the interview in order to explore a particular subject of interest in more depth using elaboration, clarification and continuation probes (rubin & rubin, 2005). a number of steps were taken to ensure trustworthiness and rigour of the research. dependability was accomplished through careful documentation of procedures for generating and interpreting data. peer debriefing was done with the supervisors of this study. in order to ensure credible/valid data, main interviews were audio-recorded. participants were asked to select a language they were comfortable with. predefined questions and procedures were used with both participants. there had to be a degree to which interpretations and theories were shared by the participants and the researcher (rubin & rubin, 2005). therefore, the researcher attempted to clarify any misunderstandings during the interviews to ensure that the participants’ responses were correctly interpreted by the interviewer. the researcher transcribed the interviews. the transcriptions were typed verbatim according to the audio tapes using a computer and microsoft office word. the researcher then cross-checked all the transcriptions with the audio recordings to verify accuracy of the transcriptions. finally, the transcripts were checked by an experienced slt who had no vested interest in the study. there was 99% agreement between the researcher’s and the proofreader’s transcriptions. analysis the researcher read the transcripts several times to become totally familiar with the data. data collection and ongoing analysis took place over the next 5 months before the final analysis took place (rubin & rubin, 2005). the next stage of analysis was recognition, in which concepts, themes, events and topical markers in the interviews were found (rubin & rubin, 2005). the researcher read the transcriptions to note core ideas and concepts, recognise emotive stories and find themes (rubin & rubin, 2005). the themes obtained from the data were then sorted to determine which ones were related in order to answer the research questions. peer review took place throughout the analysis process to discuss and verify results. saturation was reached when the researcher had become fully immersed in the phenomenon being studied in order to achieve complete understanding (maxwell & satake, 2006). saturation implies that a researcher has performed a deep or dense description in an effort to extract as much meaning from the data as possible and further information becomes redundant and repetitive (maxwell & satake, 2006). results teachers’ perceptions of the learners’ written language expression the teachers had many concerns regarding the learners’ written language performance. teacher 1 estimated that 70% of the learners in her grade 5 class were not meeting the written language outcomes for the grade, while only 30% of the learners were able to write coherently. t1: ‘very, very bad, i’m very concerned. i’m doing what i can do but i’m very concerned.’ learners need to be able to write a cohesive story with good punctuation and paragraphs in both grades 5 and 6. however, the teachers need to focus on the content of the story and not on the spelling of words, which it is assumed that they can do already. teacher 1 stated that the learners struggled with all aspects of written work: spelling, punctuation, and reading and written comprehension. t1: ‘they should have good punctuation, good cohesion and paragraphs, but they don’t. i’m supposed to be introduced to average punctuation and good cohesion. because in grade 4 they are taught how to link sentences and how sentences are supposed to run into each other, you know like a story that kind of thing, but they have a story lacking.’ teacher 2 reported that 50% of the learners in his grade 6 class were not meeting the written language outcomes for the grade and were not able to write coherently. he also reported that sentence construction was poor. t2: ‘fifty per cent (50%) of the class are not up to standard with their written language, creative writing or any kind of writing for that matter. it seems to me that it’s difficult for them to put pen to paper when it comes to their own thoughts and ideas. they just can’t write cohesively.’ a concern is that if learners continue to fail to meet the writing outcomes, they may not be able to catch up, and the gap between the learners and the required outcomes will persist. these learners will enter high school not having met the writing outcomes for primary school. learners may not be able to cope with the national matriculation examination. matriculation failure rates mean poor employment prospects as learners are not able to pursue further tertiary education. in this study, both teachers identified large number of learners as experiencing written language difficulties. all learners were affected, i.e. esol learners as well as english first-language learners. written language development is a general concern and not specific to esol learners. teachers’ perceptions of the challenges affecting the development of written language the teachers identified major challenges that were hampering written language development in learners. these were grouped into three main levels: (a) a school system level; (b) an individual learner level; and (c) a social/home community level. a. barriers at the school system level the majority of the challenges identified were at the school system level. both teachers emphasised the systemic barriers that affect the written language of the learners: t1: ‘because of systemic problems 70% ... bad, only 30% of my children can write coherently. i can prove it.’ t2: ‘i came through the system, the old system and i’m in the new system. i think we’ve thrown out the good of the old system. writing, reading, doing your basic 1, 2, 3’s, your reading, your writing.’ specific barriers relating to the school system are discussed below. lack of inclusive education practice teacher 1 tried to apply the principles of inclusive education in her classroom as she understood that many learners came into her classroom with language, visual or emotional barriers. she tried to accommodate these barriers when carrying out her assessments. for example, as she was aware that many learners struggled with written language and reading, but were good oral language communicators, she allowed learners to do oral presentations and posters when assessing them in the different learning areas. however, not all teachers in the school do this and therefore inclusive education as a practice was not being applied consistently at the school. t1: ‘we have a very big problem, the policy from the wced is that the learner should be assessed alternatively. there is a big thing about inclusion where deaf children and children with down syndrome … are supposed to be included within a classroom. for example a xhosa-speaking child is supposed to be taught and assessed in her mother tongue and that is not happening in our school, that child is disadvantaged. it is not supposed to be happening. i have children who have a visual acuity problem and if a child can’t read, we supposed to be reading questions to them and they are supposed to be answering and that is not happening. so as far as assessment is concerned that is why i let them do posters and i let them do oral assessments. i’m trying to … so lots of children fail because they couldn’t read the questions and not all the teachers are patient to read to them.’ limited training and lack of support for teachers t2: ‘no remedial support. the onus falls on the teacher. there’s lots more that need to be done, i only have, let’s say ten months, counting all the holidays. so i have ten months in which to work on the efficacy of their writing. they obviously come from grade 5 with these problems, so basically i’m doing a little bit and sending them off to the next teacher with these problems. i think remedial. i think we should take those children aside and … have somebody in there to support them.’ t1: ‘the teachers have not been trained to do intervention with struggling learners, yet it is expected of them and that is why teachers are upset.’ the teachers reported that there were two levels of challenge. firstly they do not have access to a remedial teacher, and secondly they do not have the skills to reinforce or develop foundation skills in intermediate-phase learners. as there is no remedial teacher at the school, the doe expects the teachers to provide remedial and additional intervention. many of the learners who are struggling with reading lack the skills that are taught in the foundation phase. the teachers in this study are intermediate-phase teachers who are not equipped, and do not have the time, to teach the early basic phonics that is the focus in the foundation phase. limited reading and writing opportunities although reading and written language is very important for assessment purposes and in determining promotion to the next grade, the learners are not being given sufficient reading and writing opportunities in the classroom. learners are often given worksheets where they are required to fill in single words; the writing of paragraphs, creative writing stories and compositions are limited. learners do not have enough opportunity to develop academic literacy through practice. t2: ‘i would agree with that because we’ve come to this whole conclusion that we must give worksheets. so they are so inundated with worksheets from grade 1 right through to grade 2, 3, 4 (which is single-word answers) and that i think is where we’re losing it. now you will always see my hands are filthy with chalk, because i try to get them to write a lot. there are lots of times where i can just type it out, hand it to them, makes life easy for me they can just fill in one-word answers, but i need them to write more. the syllabus actually does require [it] but because of the loads that we carry these days … the syllabus is so huge and there are always time constraints and all those things so we sort of try to shorten their writing, rather than to increase it. ja, because it’s easier. so instead of having to mark a long piece you can just tick, it makes things easier for you. ten years ago i would say children at this school in the grades that i have taught, grade 6 and 7, would write beautiful long pieces. these days i think the children can just about write half a page of cohesive.’ it is a challenge for the teachers to create adequate opportunities to develop writing skills, as the curriculum does not facilitate this. disrupted and incompetent teaching another barrier is the disruption of teaching because of lack of teachers or poor teaching skills. teacher 1 reported that her class was disadvantaged, having had a disrupted year in grade 4 because of poor teaching from two different teachers. she described how she aimed to redress this through the use of various activities, such as drama, oral discussions and debates, when approaching written language tasks. teacher 2 reported that when approaching a written language task, e.g. creative writing, he spends up to 4 days engaging the class in oral discussions, providing examples, relating the topic to the learners’ lives and using the computer to locate and show areas discussed. t1: ‘this is a very difficult class. they had two teachers last year, a very old lady and a gentleman who did very little teaching. so this class is disadvantaged, seriously disadvantaged … by using drama, they are using their bodies a lot in my class, everything gets dramatised in my class. by enticing them, by using oral work.’ t2: ‘they need concrete ... ja. they need to see. and we’re fortunate at the moment, we have computers now, up and running for a few months. so if i am going to do something with them and we discuss, even if it’s a comprehension, i will always make it so that its geographically located somewhere and it has a issue somewhere so that i will then take them afterwards into the computer room and then, this is only now just for the last couple of weeks because we only got the computers recently.’ teacher 2 also asks them to prepare a draft copy of the written work and discusses this with them to give them feedback on their content and grammar. he goes around the class assisting individual learners with written language difficulties (e.g. vocabulary, spelling and grammar problems). the teachers spend much time on redressing the difficulties of previous grades instead of focusing on moving forward with the curriculum. the teacher participants in this study were insightful and concerned – hence their participation in the study and the creative solutions they described to cope with the challenges – but this is not the case for all teachers. poor foundation skills early reading and writing skills should be learnt in the foundation phase, i.e. grades 1 3. teachers in the foundation phase are trained to teach phonics and early writing conventions. these skills are part of phonological awareness skills (bus & van ijzendoorn, 1999). teacher 1 reported that if the foundation-phase skills are not acquired, then difficulties arise later in the intermediate phase. t1: ‘in grade 1 there is supposed to be … a certain set of phonics the child is supposed to know, able to read, able to write and able to recognise. so what happens, children are being shoved over without having satisfied … that level of proficiency of phonics, reading, writing.’ it is very important that learners leave the foundation phase and enter the intermediate phase with solid foundation skills that have initiated the development of reading and written language – but this is often not the case. learners are passed into the next grade without having achieved the necessary outcomes of that grade. the end result is an accumulation of difficulties over time, as is evident in the large failure rate of learners in the matric examinations. interventions to boost phonological awareness skills need to be integrated with teaching to improve reading and written language skills (hatcher, hulme & ellis, 1994). large teacher-learner ratios t2: ‘we need smaller classes to be able to give children individual attention.’ another barrier that prevents teachers from providing individual instruction to learners is large teacher-learner ratios and overcrowded classrooms. in the present study, there were 48 learners in the grade 5 and 38 learners in the grade 6 classrooms. teacher 1 reported that she found it very difficult to give the learners individual attention, as there were too many learners in her classroom. studies have shown that individual assistance or tutoring by teachers to learners who are struggling with reading can improve reading (wasik & slavin, 1993). as reading and written language are closely linked, this would suggest that individual assistance for written language work would also help support written language skills. furthermore, a study by jooste (2003) in the western cape found that grade 5 learners who came from classes with a lower teacher-learner ratio performed better in reading comprehension tasks than the learners who came from classes with higher teacher-learner ratios. language barriers t2: ‘the township children. so now they come here … the language barriers were something terrible. so we try to push the parents to rather bring them here in grade 1 so they come right through the system.’ t1: ‘the xhosa-speaking, i can’t blame them it’s their second language but there are children who have been in our school since preschool that speak beautiful english. but a xhosa-speaking child that started at our school 2 years ago struggles tremendously with english: when the xhosa children go back to their homes … they have restricted contact with english because their parents can’t speak english. i think that what needs to happen is that our teachers need to go on a course to learn to speak xhosa. paid for by the school or the department. and an intensive one where we can at least converse, so conversational xhosa, so we can teach in their mother tongue, ’cos that is a problem.’ both teachers reported that where learners were exposed to english from a young age, e.g. from preschool or grade 1, they are able to cope in the intermediate phase as their english language skills have had time to develop. however, if learners only enter the school in grade 3 or 4 and have not been exposed to english prior to that, there is a language barrier. not only do these learners need to acquire basic interpersonal communication skills (bics), they also need to develop cognitive academic language proficiency (calp) (cummins, 2008). teaching and learning is a challenge for all concerned. according to the education white paper 6 (doe, 2001), all learners have different learning needs and the education system is required to meet them. the language in education policy (liep) gives learners the choice of the lolt (doe, 1997). learners in ordinary schools in south africa have the right to choose any of the eleven official languages as the lolt and as a learning area from grade 3 onwards (doe, 1997). hence, learners may be taught in their mother tongue up to grade 3, and then have the option of extending the use of their home language into the intermediate phase (doe, 1997). however, to make it practical, the liep makes provision for the consideration of learner numbers when making the choice of the lolt. in practice, the sgb decides on the lolt. although there have been changes in learner profiles and schools are now linguistically diverse, many schools still choose to have english as the lolt, as is the case in the school in this study. the teachers in both classrooms speak english and afrikaans, but cannot speak isixhosa or any of the other african languages and are therefore not able to communicate with esol learners in their mother tongue. inclusive education is not taking place as the school is not able to support the learners and teachers who are faced with language barriers. there is a need for support for learners to improve their oral english language skills, as this would also assist in promoting their written language development. no library at school the school does not have a library, so learners cannot borrow books. the learners do not go to public libraries either, and many come from homes with few or no books. many learners therefore do not do any reading at home. the teachers felt that a library at the school would encourage the learners to borrow books and read more, which would enhance their written language skills. according to harrison (2001), an effective primary school library can have a significant impact on standards of literacy and levels of achievement across the whole curriculum. the absence of a library at the school sends an important and inaccurate message to the learners, that books and reading are not important. t1: ‘our school doesn’t have a library. our children don’t really make use of libraries …’ b. barriers at the individual learner level aversion to writing and reading the main barrier at the individual learner level is an aversion to writing and reading. teacher 2 reported that learners do not like to write or to read outside of school because they have many other interests outside of school (e.g. sport), and also as a result of some of the other barriers described (e.g. no library, weak foundation-phase literacy skills). he also stated that learners have an aversion to writing and find it difficult to engage in creative writing tasks even in school: t2: ‘i would say it’s not as good as their spoken language. because children by nature are very lazy to write. aversion to writing, they don’t want to write.’ a vicious cycle was described, with learners not wanting to write (and read) because they find it a challenge, and then because of fewer opportunities finding it even more challenging, and wanting to do so even less. t2: ‘our children don’t really make use of libraries because they’re not interested in reading really.’ c. barriers at the social/home community level lack of parental support t1: ‘so if you don’t have parents’ participation, there is nothing you can do … so unfortunately the parents’ participation is not very good within the school in general.’ the teachers reported that many parents do not provide academic support to their children at home and do not attend parent-teacher meetings. reasons cited for non-attendance of meetings included not having money for transport, not being able to get time off work or not being interested/not understanding the value of meetings. parents are often not aware of what is happening with their child’s learning. they feel that it is the teacher’s job to educate their child and do not have an understanding of their role in the education process. socio-economic difficulties t1: ‘lots of socio-economic barriers. there are many children that i referred to the school psychologist this morning. seven people are living in a wendy house, it’s overcrowding. some children have single parents and they are frustrated so it carries over to the child and the child brings it to school. it just affects them psychologically.’ linked to the lack of support described, many of the learners come from extreme poverty and are disadvantaged in terms of their socio-economic background. many of the learners come from homes with single parents, and there is often alcohol and drug abuse, violence and crime in and around the homes. teacher 2 reported that many learners are left in the care of their grandparents while their parents move out to live in areas closer to their employment. the learners and their families often lead lives where basic needs for survival are the main priority. teachers’ perceptions of the opportunities to develop the written language of the learners both teachers described a range of opportunities that could help learners to develop their written language. some of these are opportunities that already exist and might be taken further by the learners, families of learners, teachers and schools. immediately available opportunities include a feeding scheme, reading books and writing opportunities in the classrooms, peer intervention, various teaching strategies and individual assistance to learners experiencing written language difficulties. these current opportunities are however insufficient and further opportunities are necessary. opportunities are now presented in turn as they relate to the challenges and to the three different levels identified in the previous section. a. opportunities at the school system level clearer, consistent assessment guidelines it would be helpful for teachers if assessment guidelines and pass/fail criteria were made more explicit and specific training was given in the implementation of these guidelines. the teachers emphasised the need for clear and consistent guidelines to aid in making these decisions. t1: ‘my problem is there is no continuation, it doesn’t continue to next grade. whatever we do in primary school doesn’t get even carried on to high school, and that is a problem with our entire education system. things we do in primary school, we are still very maturing, doesn’t get continued. it stops in high school, a child introduced to a whole new system. and a child gets matriculated and goes to university and it’s like a total adjustment. there is no consistency with regard to assessment.’ training for teachers training workshops for teachers would enable them to update and improve teaching strategies and feel more empowered in their delivery of the curriculum in the present context. teachers could also learn more about how to provide support to learners who are experiencing difficulties. workshops might focus on written language and the development and facilitation of literacy, as well as all other subject areas. wium et al. (2010) developed a support programme for foundation-phase teachers to assist them with facilitating listening and language in learners. enhanced listening and language skills would help learners to cope with numeracy and literacy development in the foundation phase. a support programme for intermediate-phase teachers to assist with the facilitation of foundation skills for reading and writing is needed. the teachers in this study were emphatic in their request for support for helping learners struggling with written language. t1: ‘never mind the intervention. mr s, what does he know about the phonics? he is a grade 6 teacher, he has not been trained, he doesn’t know how, and nobody from the department is coming and saying, look guys we running this course, we will give you bursaries, do the course and we will pay for you to do the course so that you are equipped.’ increased reading and writing opportunities at school studies by semke (2008), hafiz and tudor (1989) and tsang (1996) support the importance of reading and writing opportunities in schools. however the learners in this study do not receive sufficient opportunities to practise reading and writing at school. learners need to be given more reading and writing opportunities at school, to break the cycle of having poor literacy skills, thus finding literacy hard, thus reading/writing even less. this may be achieved by arranging class visits to a public library, and through the use of technology, e.g. cell phones and computers, to stimulate interest in reading and writing. this suggestion is linked to teacher training above, since training might help teachers to create more reading and writing opportunities in the classroom. t1: ‘so i try to play all these games to engage them with the language … writing games. so i give them lots of opportunities that may not be in the curriculum to write. people think writing is compositions and paragraphs but you can start small. i’m there but i do my own thing. in my class where there are a lot of barriers and problems even if i get the child to write two words or eight words its writing. i go down to the level they are at.’ teaching strategies improved teaching strategies would help to support all learners with their written work, and in particular those with difficulties. again, this suggestion is linked to teacher training above since training might help improve teaching and may go some way towards overcoming the disrupted and incompetent teaching described. t1: ‘so i try to teach them clues to help them succeed. strategies to learn and to succeed and you will be surprised how empowered that child is because he couldn’t read and i started him small with small words, little strategies and he is so excited to read now, and he wants his book first so that he can read, ask teacher what … and praise him again this morning and i’m noticing he is starting to spell words correct. i help them with flash cards, the buddy system …’ another example of a creative strategy is the buddy system or peer intervention, which was used frequently in the grade 5 classroom where a stronger learner is seated next to a weaker learner to assist the latter with reading and written language. the teacher felt that this was a beneficial opportunity for learners with difficulties. a study by simmons, fuchs, fuchs, mathes and hodge (1995) found that reading comprehension and fluency was significantly higher in learning-disabled and low-performing learners in regular classrooms who received both explicit teaching as well as peer tutoring, than in those who received explicit teaching alone. this suggests that learners who are struggling with reading may benefit from additional peer intervention. remedial assistance there is currently a remedial teacher at the school who provides assistance only to the foundation-phase learners. a remedial teacher for the intermediate phase would be a strategy to assist with written language difficulties and enable the learners to achieve the foundation skills in reading and writing that they did not achieve in the foundation phase. remedial education has been shown to increase levels of school performance and achievement (sharif al-shureify, 2004). children who struggle to learn in the class environment may attend remedial lessons individually or in small groups with other learners who have similar difficulties. the remedial teacher often adapts the teaching materials and tasks to the learners’ needs so that the learners may overcome their difficulties and progress at school (sharif al-shureify, 2004). t2: ‘i think remedial. i think we should take those children aside and work with those who are … in the meanwhile have somebody there to support them. i think they need support. they don’t get very much support at home in terms of their writing also.’ smaller classes t2: ‘i think we should take those children aside and work with those who need support. extra teachers, smaller classes would help. i have 38 in my class. i have to pitch everything at an average kind of learner so that the stronger learner will pick it up, the weaker learner hopefully does pick it up. i’ll most times spend a few extra minutes with the weaker writer. then i’ll call them up. some of them don’t want to come up, some i’ll go to them, i obviously know who they are and i’ll spend more time but i can’t spend enough time with the weaker ones. we need extra teachers, smaller classes.’ in order to promote effective teaching and learning, a further opportunity would be to build more classrooms and expand the school. the teachers felt that extra teachers and smaller classes would be beneficial in providing more individual assistance to the learners. early english exposure t2: ‘the township children, if they come here from grade 1, or if they come to our school even from preschool … we have a preschool here, then they are in the system from the beginning. so we try to push the parents to rather bring them here in grade 1 so they come right through the system.’ teachers felt that if learners were exposed to english from an early age, they would be competent with english by the intermediate phase and the language barriers would be less problematic. working with teachers to facilitate english language development in the early grades would also be a useful topic to include in teaching training courses and workshops. library at school t2: ‘a library period. that could help, yes.’ the teachers reported that a further opportunity would be setting up a library at the school to promote reading among the learners. a library at the school would encourage the learners to borrow books and participate in more reading, which would ultimately enhance their written language. b. opportunities at the individual learner level reading and writing outside school learners have an aversion to reading and writing. if they were to engage in more reading and writing outside school, their written language skills would improve in the classroom. ways of encouraging this would be to have parents more involved with reading, co-reading and supervision of reading at home. in the absence of a school library parents should take learners to public libraries to borrow books, thus increasing the opportunities to practise reading skills. t1: ‘i believe strong, i told my learners and parents, and i’m not a magician either, i don’t make things happen. we need to work together in order to succeed.’ t2: ‘up till about ten years ago, i had grade 6s and i encourage reading all the time, who would bring in the books, they come with their library books and for the first half-an-hour of the day they would read. in my class now, there are only two children who are coming with their library books to school. so the rest of them are not really interested in reading.’ interesting and relevant books teacher 2 reported a need for books that interest the learners and are related to their life and culture. the learners need to be encouraged to see the relevance of reading in their lives. t2: ‘but also the books should be entertaining enough and new enough with new ideas. not your older books. it must be within their life, world, rather than something that is far removed.’ this should be applicable to both school reading materials and books that the learners read outside of school. c. opportunities at the social/home community level increased parental support and safe, nurturing home environments the teachers felt that learners need to have a safe, nurturing home environment in order to support them and enable them to do well at school. both teachers believed that the learners need support from home, particularly from their parents. parental support with homework is linked to increased academic achievement at school (steinberg, lamborn, dornbusch & darling, 1992), and conversely a lack of support from home has a negative effect on learners’ written language skills and overall academic performance. t2: ‘… first of all a loving environment. a warm nurturing environment. parents who are interested, actually interested in what their children are doing. any child who has the interest and support of the parent does better than the child who doesn’t have any interest.’ feeding scheme at school t1: ‘75% of my class is depending on the school feeding scheme.’ teacher 1 ensures that 75% of the learners in her class receive a meal from the school feeding scheme. they need adequate nutrition to be able to learn. the school has put in place basic support in addition to academic support, as learners who do not bring lunch from home are provided with a full meal at lunchtime. this is an example of a way in which the school has begun to address a barrier at the social/home community level. table ii provides a summary of the challenges and opportunities at the school system level, individual learner level and social/home community level as identified by the participants in this study. many of the opportunities suggested may help in addressing more than one barrier, e.g. further training for teachers may be one way of addressing the current issues regarding lack of support and training for teachers, but it would also help to develop teachers’ knowledge of how to create more opportunities for literacy development, increase weak foundation skills and help teachers to cope better with language barriers. discussion in-depth semi-structured interviews with two intermediate-phase educators revealed their concerns about the written language of the learners in their classrooms. in both grade 5 and 6 classrooms it was found that the learners were experiencing difficulties with written language expression. according to the teachers, 70% of the learners in the grade 5 classroom were not able to meet the writing outcomes for their grade, while in the grade 6 classroom 50% of the learners were struggling to achieve the writing outcomes. the extent of the difficulties described fits with other studies, both local (e.g. o’connor & geiger, 2009; doe, 2008) and international (e.g. mullis et al., 2007). written language difficulties are not the only area of concern. language and communication lie at the heart of the difficulties described. written language is a very tangible way of evaluating language, a window into the child’s stored knowledge of his/her languages (bishop & clarkson, 2003). both teachers emphasised that the difficulties experienced by the learners are directly related to problems in the school system. the learners were described as products of a defective system rather than being the problems themselves. the doe in south africa has put forth the policy of inclusive education for all learners in ordinary schools. it has been acknowledged that learners come into classrooms with a range of barriers, and schools need to accommodate these barriers and support learners. however with a variety of challenges in the school system itself, schools and teachers are often ineffective in supporting learners with barriers, and this results in a failed school system. eight main barriers that impinge on learners at the school system level were identified. these included aspects such as teachers having received insufficient training and therefore not being able to support the learners effectively, a lack of resources at the school, and disrupted and incompetent teaching. while most of the barriers identified centred at the school level, another barrier was at the social/home community level where difficulties like lack of parental support and socio-economic hardships were seen to impact on the learners. it is interesting that only one barrier was identified at the level of individual learners: their aversion to reading and writing. while this problem may be sited within the learners themselves, it is clear that the aversion is the end result of the other barriers described. if the school system were improved, children would have more opportunities to develop their reading and writing, and ultimately be better at it and possibly enjoy it more. figure 1 provides a graphical representation of the factors promoting written language: a model that integrates the school systems, home/social community, and learners as well as any additional other support that will promote the written language development in ordinary linguistically diverse classrooms. for written language to develop successfully, the school system, home/social community and individual learners need to work together to promote written language development. the school system has to be an effective, inclusive system. it needs to provide effective opportunities to promote written language development among learners, as well as taking into account and breaking down barriers that may arise. the home/social community needs to be involved in education. parents need to create a safe home environment, as well as support written language and learning activities at home. since literacy is not established in the community, caregivers and others in the community require support in how to embed such practice. learners also need to be motivated towards learning and developing their written language. teachers in this study frequently mentioned the need for remedial support, and having a remedial teacher in the school (albeit for the foundation phase) has made them familiar with the role of such a professional. slts also have an important contribution to make in such contexts. the teachers in this study did not directly mention the role of the slt – and may in fact have had little experience of their role – but in many places they did describe a potential role that slts would be able to fill, e.g. offering small-group support, developing phonological awareness skills, and developing a solid basis of spoken language. the barriers described by the teachers and presented in this paper are more complex than a series of isolated problems since they interact with each other in multiple, complex ways. this complexity is shown, for example, in table ii, where opportunities to overcome barriers do not necessarily map from one to the other in a neat way. rather, it has been found that there will be several ways of addressing a barrier, and one opportunity for change may in turn impact on several of the identified barriers. the need for teacher training was frequently emphasised in the interviews, and supports the work carried out by wium et al. (2010) where slts provided support to teachers focusing on language and literacy development. internationally, slts have an established role in the development of literacy – of which writing is a part – due to the strong connection between oral and written language (asha, 2001; ehren & whitmire, 2009; justice, invernizzi & meier, 2002). conclusion the results of this study indicated that teachers were very concerned about the written language development of the learners in their classrooms. multiple barriers impede written language development. these range from limited reading and writing opportunities, limited training of teachers, language barriers, lack of resources in the school, unsafe home environments and lack of parental support to poor foundation skills in reading and writing and limited reading and writing outside of school. while the teachers spoke about the problems of the individuals in their classrooms, they presented a broader view of the learners’ difficulties contextualised against a backdrop of historical inequalities and social inadequacies. they suggested that to understand the difficulties you have to look beyond the learners as the site of the problem, and understand the system in which they are being educated and the context more generally. immediately available opportunities include a feeding scheme, reading books and writing opportunities in the classrooms, and various teaching strategies to assist learners who are experiencing written language difficulties. these opportunities are insufficient, however, and further opportunities are necessary. further opportunities include training for teachers (e.g. around assessment), remedial assistance, a school library, a lower teacher/learner ratio, providing interesting and culturally related reading books, greater parental support and involvement, and safe, nurturing home environments. the school, home/social community and learners collectively play a role in the development of written language and the overall education of the learners. a joint partnership between the school and home is needed to assist and support learners to achieve the writing outcomes of their grade and ensure future success in their academic careers. furthermore, there is a need for slts in ordinary schools in south africa to support the crisis of written language. currently, however, there are no posts, so even though slts may have the expertise, they are unable to provide the necessary support required in ordinary linguistically diverse classrooms in south africa. implications for slts in ordinary schools in south africa in south africa, there are no doe posts for slts in ordinary schools. slts are employed in government hospitals and special schools where they assess and treat learners with verbal and written language difficulties (overett & kathard, 2006). however, it is acknowledged that there is a need for slts in south africa to expand their services to learners in ordinary schools who are not developing age-appropriate literacy and numeracy skills (du plessis & louw, 2008; wium, 2010). there is a critical need for slts as there is a large at-risk population of learners. the slt’s role may extend beyond this in linguistically diverse classrooms, where there is a need to differentiate between children who are struggling to learn because of second-language difficulties and those who have learning problems as a result of delayed language development and phonological awareness skills. slts are challenged to find ways to work in the ordinary classroom in south africa as there is a need to assist learners who may present with slow development rather than disorders (kathard & pillay, 2006). lewis (2004) emphasised the need for slts to expand their support to learners in ordinary schools who are not developing grade-appropriate literacy and numeracy skills. slts are uniquely qualified to help individual learners achieve literacy, and also be part of the team associated with enhancing literacy among all the learners in schools (gottfred, 2008). in the usa, schools have teams consisting of slts, reading specialists, teachers and remedial teachers who assist learners with reading difficulties, from preschool level, by providing intensive reading programmes (ciampaglio, 2008). these programmes have been found to enhance literacy (tsang, 1996). in south africa, it is imperative that slts be part of the team in ordinary schools to promote and enhance literacy, and that an slt’s role in this context be defined. asha (2001, p. 356) described the role of slts with regard to literacy development across the school curriculum in all grades at primary schools in the usa: • preventing written language problems by fostering language acquisition and emergent literacy support • identifying children ‘at risk’ for reading and writing problems and providing early intervention to these children • assessing reading and writing in learners • providing intervention and documenting outcomes for reading and writing • assuming other roles such as providing assistance to teachers, parents and learners • advocating for effective literacy practices and advancing the knowledge base • providing support to teachers and learners in the classrooms and across the school system. slts in the south african context may have additional contributions to make. for example: • slts together with other professionals should be involved in policy-making decisions regarding language across the school systems, e.g. bilingual education, learning in esol, as well as motivating for slt posts in ordinary schools in south africa. • slts should collaborate with teachers in identifying children who require speech and language intervention, and then in providing early language support to all learners to prevent speech and language difficulties. • slts should assist teachers in ordinary classrooms in the planning and teaching of language lessons. this collaboration with teachers should strive to promote an understanding of the total communication resource that learners bring to the classroom rather than only focusing on whether a learner can speak and write english. figure 2 summarises the proposed role of slts in ordinary linguistically diverse south african classrooms. the teachers interviewed in this study described the systemic failure that has led to the failure of the learners in their classrooms. in south africa, slts may have an important role not only in supporting individual learners, their families and educators in their language and literacy learning, but also through working as change agents who strive to improve the system and create a more optimal environment in which all learners can develop their literacy. acknowledgements. the authors sincerely thank the teachers and the school principal for their assistance throughout this project. we would like to acknowledge the national research fund for their financial assistance (thuthuka project: enhancing communication in classrooms – kathard 2006 2011). references american speech-language-hearing association (2001). role and responsibilities of speech-language therapists with respect to reading and writing in children and adolescents. asha, 21(suppl.), 17-28, rockville, md. american speech-language-hearing association (2002). designing and implementing an early literacy screening protocol: suggestions for the speech-language pathologist. language, speech and hearing services in schools, 33, 84-101. bishop, d.v.m., & clarkson, b. 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(1993). preventing early reading failure with one-to-one tutoring: a review of five programs. reading research quarterly, 28(2), 178-200. wium, a.m. (2010). the development of a support programme for foundation phase teachers to facilitate listening and language for numeracy. postgraduate doctoral thesis. university of pretoria: electronic theses and dissertations. retrieved on 25 june 2010 from www.upetd.up.ac.za/thesis/available/etd-05152010-233034/ wium, a.m., louw, b., & eloff, i. (2010). speech-language therapists supporting foundation-phase teachers with literacy and numeracy in a rural and township context. south african journal of communication disorders, 57(1), 14-21. world medical association (2008). declaration of helsinki – ethical principles for medical research involving human subjects. retrieved on 8 march 2010 from http://www.wma.net. table i. biographical details of teacher participants initials grade taught years of experience qualifications race sex age language spoken t1 5 21 honours degree in education coloured f 45 english and afrikaans t2 6 10 honours degree in education coloured m 46 english and afrikaans table ii. barriers to and opportunities for written language development school system level barriers lack of inclusive education limited training and lack of support for teachers limited reading and writing opportunities disrupted and incompetent teaching poor foundation skills large teacher-learner ratio language barriers no library at school opportunities clearer consistent assessment guidelines training for teachers increased reading and writing opportunities at school teaching strategies remedial assistance extra teachers/smaller classes early exposure to english library at school individual learner level barriers aversion to writing and reading opportunities reading and writing outside school interesting and relevant books social/home community level barriers lack of parental support socio-economic difficulties opportunities increased parental support and safe, nurturing home environments feeding scheme at school promotion of written language development effective inclusive school systems with further support or services from other sources supportive home/community environments motivated, interested, disciplined learners fig. 1. summary of factors promoting written language development in ordinary linguistically diverse classrooms. speech language therapists advocacy influencing policy curriculum driven interventions collaborating with teachers in identification and language support assisting teachers in language lessons and understanding total communication fig. 2. proposed role of slts in ordinary linguistically diverse south african classrooms appendix a. interview schedule: teachers exploratory question tell me about the expectations of written language for grade 5/6. probes and possible follow-up questions what kinds of difficulty or challenges were encountered? how do you approach written language tasks in your class? how important is the oral versus written language in the class? what are the pass/fail criteria in the grade? how important is written language in the assessments of the learners in the different learning areas? tell me about the oral and written communication of the learners. what are the quality and style of the written language of the learners, e.g. vocabulary, grammar, spelling, punctuation, narration? what were the consequences? how do you try to support the learner with written language difficulties? what was the outcome? what are the continuing barriers? what are some support strategies that may assist the learners at school? what are the support strategies at home that may assist the learners? 3 k o m m u n i k a s i e p a t o l o g i e : onderrig vir die toekoms" isabel c. uys hoof: departement spraakheelkunde en oudiologie universiteit van pretoria inleiding a i h ° r 1 r o s s s t t departement s p r a a k h e e m u n . wat het d o e n ? „ „ „ „ flaardie woorde met 'n ε κ ϊ wetroses tussen twee of meer mense waann gemeenskaplike betekenis'deur die oordrag en interpretasie van 'n boodskap verkry word. mense leef in sosiale groepe leer en ^ gedragspatrone van 'n spesifieke ge-eenskap en sy kultuur die gedragspatrone bestaan uit die mteraks e van mense met mekaar en met die omgew.n . h ^ interaksie word grotendeels tot stand gebrmg cie r kommunikasie, die stuur en ontvangs van boodskappe die mededeling van inligting vanaf die e e n n a d e a d e j . die medium van hierdie kommumkasieproses ι. taal dit is 'n uniek menslike besit omdat ^ enigste lewende wese is wat sy uitinge sistematiseer in 'n stelsel van arbitrere kommunikasiesimbole die mens het die vermoe om die taal v a r s gemeenskap aan te leer en om dit oor te dra aan andere en hierdie vermoe om kennis oor te dra, vorm d̂ e grondslag vir die ontwikkeling van a l l e g e d r a g s p a t r o n e wat as kultuur beskryf kan word. dit is die hoofkenmerk van menswees. maar , om te hoor is nie noodwendig om te luister nie om te praat is nie noodwendig om te kommunikeer 1116 moses het dit besef toe hy gese het "ek praat swaar, die farao sal nie na my luister nie." historiese perspektiewe dit is die besef dat ongeveer 10% van die bevolking se dat die spreker wanaangepas is, wat mense o ^ s suid-afrika, p u j j . £ s y t.ekomsv.s,o. » ^ f i f ^ t n , en beroep in i ^ r ^ r r ^ u s " danke^an sy fand.rnentee s s s s a a i s s f w e p " » l . p u k . g e f u n d . e r d e dis.ipline ger.spekteer j. ; „ ,9371» d.ar op 'n klein sk.al begin met die eers is slegs η tweejarige v > n k u ; f , 9 e r s t " l d r pienaar .e,f dat hy horn ge,oepe g e v t , \ . t — ^ j ^ t a l s universiteit van pretoria te vestig hy het reeds.η i ho.;'g.word v a , = departement s p r . a ^ w e t e n s k a p e n s p r a a k h e e i k u i n a , a f e e s t u d e e r by uuste^spraakwetenskaplike, ^ ^ ^ k g g k h f d stelling en uitgebreide kennis oor die, toule vakgeb het gedurig tot vernuwing gelei. geen wonder , η 27 aoril 1993 in d i e senaateaal, u n i v e r s i t e i t v a n p r e t o r i a . * hierdie artikel is as professorale intreerede gelewer op 27 april die suid-afrikaanse tydskf vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 isabel c. uys met die kennis-ontploffing gedurende die 1960's gesorg het dat die naam van die departement verander na die departement spraakwetenskap, spraakheelkunde en oudiologie nie. dit is egter so dat ontwikkeling van 'n vakgebied r a s i o n a l i s a s i e n o o d s a a k u i t b r e i d i n g , sowel as inperking. in 1983, met die afskaffing van die vak spraakwetenskap vir graaddoeleindes, is die naam van die d e p a r t e m e n t v e r a n d e r na d i e d e p a r t e m e n t spraakheelkunde en oudiologie. vooruitgang op die gebied van taalteorie-ontwikkeling en die implikasies daarvan op taalafwykings het egter weer toevoeging noodsaaklik gemaak. spraak-taalpatologie en oudiologie, en spraak-taal-gehoorterapie het reeds wereldwyd algemene en aanvaarde vakterme geword. ongelukkig is dit so dat, as gevolg van die konseptuele verskille, geen een van hierdie begrippe uitgelaat kan word sonder om afbreuk te doen aan die omvang van menslike kommunikasie en dus ook die naam van die departement nie. dit laat ons met 'n dilemma van lompheid en fragmentasie in die benaming wat aangespreek moet word. deur al die j a r e is prof p i e n a a r se filosofiese uitgangspunt weerspieel in die missie van die departement om 'n holistiese en organismiese benadering tot kommunikasiepatologie te bevorder en om beroepsbeoefening as 'n idealisties-gei'nspireerde roeping te beskou. maar, die uitbreiding van die veld en die toevoeging van kennis het noodwendig tot spesialisasie en f r a g m e n t a s i e g e l e i . steeds is dit die e n i g s t e omskrewe b e r o e p wat dienslewering aan kommunikasiegestremdes ten doel het die beroep wat die diagnose, habilitasie en rehabilitasie van diegene met kommunikasieafwykings (spraak-, taalen gehoorafwykings) omvat. selfevaluasies die weegskaal vir onderrig en beroep uit die voorafgaande blyk dit duidelik dat daar aan die een kant volgehoue vordering op die vakgebied en in die beroep voorkom, maar aan die ander kant moet die toepaslikheid en effektiwiteit van onderrig en dienslewering in andersoortige en veranderende omstandighede g e d u r i g b e v r a a g t e k e n w o r d . n o o i t moet verandering gelykgestel word aan onstabiliteit nie. die afwesigheid van verandering lei nie tot stabiliteit nie, maar tot stagnasie. mens moet dus altyd ingestel wees op daardie tekens wat 'n behoefte aan verandering en 'n geleentheid vir vordering aandui (feldman, 1981, p.942). 'n behoefte aan kritiese evaluasie reflekteer dus nie noodwendig onsekerheid en ontevredenheid nie, maar eerder 'n bewustelike, sensitiewe ingesteldheid om te weeg en nooit onverhoeds te lig bevind te word nie. in 1966 het prof pienaar gese: "...one does feel that a substantial part of the idealistic program which was planned in 1936 has already been realized. a young country, with a comparatively small percentage of wage earners, keen on expansion in every sphere of life, with no endowments and handicapped by a lack of funds, has had to march foreward on faith, hope and charity and its youthful idealism. we are jealous of our standards of training, of research and therapeutics. we are eager to learn from those who can spare more manpower for research. we realize the vastness of the field still lying fallow; the great task still ahead of us to cater to the needs of the whole population of south africa and through south africa for the whole of the awakening southern africa." (rieber & brubaker, 1966, p. 600-601). as the development of the profession was initially based on models from europe (especially germany with its strong physiologic orientation) and america (the founders of behaviourism in our field), the training and service delivery in this country is still geared towards the western model. i am not saying "...that a foreign model modified on the basis of limited information is necessarily inadequate, but rather that it is important that we be aware that this is the situation." (delaney & malan, 1984, p. 75). and where has this adherence to the western model led us? i quote from the main report on disability in the republic of south africa (1987, p. 14): "...it is clear that the existing services are distributed unevenly in the development regions. there are in fact development regions which completely lack certain basic services for the disabled. it is further noticed that in many respects there is an unequal distribution of services among the various population groups... the complete view that is obtained at the macrolevel is that services are mainly limited to the metropolitan areas and that a significant percentage of disabled people have little or no access to the existing services. it is, therefore, selfevident that in a programme for the upgrading of services, the horisontal distribution of services must be examined before generally vertical extension of services can be considered." even before the investigation into disability in south africa, the south african speech-language-hearing association took steps based on the realisation that three issues should be addressed: " the multifaceted nature of the linguistic and socio-cultural make-up of various communities in south africa; the consequences of this on the effective implementation of tasks performed by speech and hearing therapists, and the extreme manpower shortage of speech and hearing therapists in the country." (aron, 1984, p. 1). x these service delivery issues reflect on training within the southern african context. we realise that "we can either shape our own future, or we can live with a profession someone else shapes" (cole, 1986, p. 41). external evaluation had already been initiated by t h e u n i n i t i a t e d in t h e f i e l d , and u n f o r t u n a t e l y the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kommunikasiepatologie: onderrig vir die toekoms misconstruction of the facts can harm, not only the profession, but also the clients we serve. it was time for the profession to shape its own future. extensive and in-depth self-evaluation was indeed called for, taking cognizance of the stated scope of our profession, weighing it in terms of the needs of the population of disabled, the needs of the professionals, the existing resources, the infrastructure and the demands made by the system. it was reasonably easy to identify the scope of the profession as it is internationally acknowledged that a speech-language pathologist specialises in the diagnosis and treatment of speech and language problems, and engages in the scientific study of human communication. diagnoses are made of speech and language competencies of individuals, including the assessment of speech and language skills as related to educational, medical, social and psychological factors. human communicative efficiency of individuals with communication problems of organic or nonorganic origin is restored through planning, directing or conducting habilitative or rehabilitative treatment programmes. counselling and guidance to speech and language handicapped individuals, as well as consultation with educational, medical and other professionals, are provided. the scientific principles of human communication are taught. projects investigating epidemiological and biosocial phenomena, associated with speech, voice and language are directed and research is conducted to develop, design and evaluate diagnostic and remedial techniques and apparatus. but, as in south africa professionals have a double qualification, the scope of the audiologist had to be included, which states that the audiologist specialises in the diagnostic evaluation of hearing, prevention of hearing problems, habilitative and rehabilitative services for individuals with auditory problems. electroacoustic instrumentation is used to determine the range, nature and degree of hearing function related to the patient's auditory efficiency (his communication needs). audiometric results are coordinated with other diagnostic data, such as educational, medical, social and behavioural information. conservation, habilitative and rehabilitative programmes are planned, directed and conducted. teaching and research in the physiology, pathology, biophysics and psychophysics of the auditory system are carried out. consultation with educational, medical and other professional groups is provided (flower, 1984, p. 5). in considering these definitions of the scope of the profession, we realised that due to the complex nature of human communication and its disorders, it is essential that information of an academic, research and scientific nature is continually developed and evaluated. a university provides the optimal environment for constant academic validation of current professional training as teaching in the field of speech-language pathology and audiology is directed towards the accumulation and integration of theoretical knowledge rather than technical skills. it was, however, more difficult to identify the demands, threats and opportunities that we are faced with in the present south african context. during 1989-1990 our department undertook an investigation (uys & hugo, 1989) aimed at a situational 5 and needs analysis. information, based on questionnaire responses and personal interviews, gathered from a sample of nearly 1000 people throughout south africa, was utilised in the formulation of a vision of the future in clem sunter's words the story of our profession and training. as the story unfolded, we realised that our profession, and indeed our training, had reached the proverbial crossroads. first of all we had to sell our story to all those involved in training and service delivery and, as is the case with all salesmen in economically straitened circumstances, this was, and to a certain extent still is, an unenviable and painful task. it is never easy to venture into the unknown, but as in goal-directed and purposeful selling one has to teach the buyer to take off his own shoes before he can step into another person's (johnson & wilson, 1987). the difficulty did not lie in the new ideas, but in the ability and willingness to escape from the old ones. in this case to renounce the often impractical and irrelevant, for models and strategies which promise to be appropriate and applicable within the southern african context (crossley, 1986). we then had to develop strategies for the implementation of action plans to test the validity and viability of our new story. this i would like to share with you. kruispaaie in onderrig en dienslewering opleiding is die een enkel grondslag waarop effektiewe, kwaliteit dienslewering gebaseer word. maar omdat hierdie opleiding afstuur op sowel 'n akademiese as 'n professionele kwalifikasie is dit nodig om te voldoen aan akademies-wetenskaplike eise, navorsingseise en beroepseise. die tyd het aangebreek om die opleiding te weeg teen hierdie eise. is hierdie vakgebied noodwendig 'n wetenskaplikgefundeerde dissipline? is universiteitsopleiding werklik nodig? is spraak-taalterapeute en oudioloe nie maar net resepopmakers, waarvoor 'n laervlak tegniese opleiding voldoende en heelwat goedkoper sal wees nie? wat is die minimum vereistes wat aan onderrig en dienslewering in suid-afrika gestel moet word? voldoen die bestaande opleiding aan al die gestelde eise? wat is die realiteit? die rsa is hoofsaaklik 'n derdewereldland, met eiesoortige probleme, beperkings, behoeftes en uitdagings, waarin die beroep oorwegend as 'n luuksheid gesien word. in 'n ontwikkelende land word die spraak-taalterapeut en oudioloog met e i e s o o r t i g e probleme gekonfronteer en dienslewering (en gevolglik ook opleiding) moet daarby aangepas word. die relevansie van die tradisionele opleiding is dus bevraagteken. die rsa beleef 'n gevaarlike bevolkingsontploffing. in 1984 was daar na raming reeds 'n tekort van 4 4y4 spraak-taalterapeute en oudioloe in die rsa. in 1986 het die tekort gestyg tot oor die 5 000 en volgens die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 isabel c. uys projeksie sal daar in die jaar 2000 'n tekort van minstens 10 000 wees. die rsa het 'n unieke multikulturele, veeltalige bevolkingsamestelling. dit het aan die lig gekom dat bykans alle dienste u i t s l u i t l i k gerig is op bevoorregte, stedelike blankes. dienste aan die ontwikkelende plattelandse bevolkingsgroepe is totaal ontoereikend en voorkomingsdienste is feitlik nerens beskikbaar nie. by verreweg die meeste terapeute is slegs afrikaans of engels magtig, terwyl die grootste behoefte by anderstaliges gevind word. in die geval van spraak-, taalen gehoorterapie is taal en kommunikasie so uiters belangrik, omdat dit beide die middel en die doel van intervensie is. die opleiding en dienslewering van spraak-taalterapeute en oudioloe geskied steeds binne die raamwerk van eerstewereldse, westerse modelle. gesofistikeerde hoe-tegnologie word in die meeste gevalle in gei'nstitusionaliseerde praktyke aangewend. diens in die gemeenskap aan die gemeenskap bestaan omtrent nie. die standaard van opleiding en diens wat gelewer word, word internasionaal as uitnemend beskou. spraak-taalterapeute en oudioloe wat hier kwalifiseer bereik groot sukses met nagraadse studies en navorsing oorsee. hulle voldoen aan die eise van kliniese vaardigheidsprofiele oorsee. hulle word met ope arms in die internasionale arbeidsmag ontvang. namate al hierdie feite aan die lig gekom het, het daar nog 'n paar vraagtekens ontstaan. indien die opleiding en dienslewering dan van so 'n hoe gehalte is, waarom verkies van ons beste graduandi om oorsee te gaan werk? kan dit dalk toegeskryf word aan 'n onvermoe om beroepsbevrediging te verkry, juis omdat terapeute nie opgelei word vir die tipe praktyk wat hulle plaaslik beoefen nie? waarom is daar steeds so 'n tekort aan beskikbare, bereikbare, gelykwaardige diens aan alle taalen k u l t u u r g r o e p e in die land? die enigste gevolgtrekking wat gemaak kan word, is dat daar erens 'n wanpassing is tussen die aard van die opvoeding en dienslewering aan die een kant, en die aard van die behoeftes en eise van die gestremde bevolking aan die ander kant. hierdie hipotese is bewys deur antwoorde op die vraelyste wat van b e r o e p s l u i , die professionele vereniging, die beroepsraad, universiteitspersoneel en werkgewers ontvang is: die algemene indruk is dat daar in die opleiding 'n hoe standaard gehandhaaf word. die studie van menslike kommunikasie behels 'n sterk filosofiese en universeel-wetenskaplike onderbou basiese wetenskaplike en universeel-teoretiese vakinhoud, omdat die hantering van die kommunikasieafwykende afhanklik is van 'n grondige kennis van al die prosesse o n d e r l i g g e n d aan n o r m a l e menslike kommunikasie. juis as gevolg hiervan is dit die tipe opvoeding wat steeds op universiteitsvlak aangebied behoort te word. daar is orals 'n mannekragtekort, sodat terapeute met onhanteerbare waglyste gekonfronteer word. meer spraak-taalterapeute en oudioloe is nodig; 'n herorientasie in die benadering tot beroepsfunksies is nodig; andersoortige beroepsbeoefenaars is nodig. in die bestaande kurrikulums word egter 'n gefragmenteerde, afwykinggerigte benadering beklemtoon. dit kan waarskynlik as toepaslik in 'n ryk eerstewereldse land beskou word, maar in die rsa-konteks sal fragmentasie en spesialisasie tot oneffektiewe d i e n s l e w e r i n g lei. 'n h o l i s t i e s e , funksionele benadering moet gevolg word, waar elke afwyking as 'n verbreking in die totale menslike kommunikasieproses, in perspektief geplaas moet word. spraak, taal en gehoor is slegs die waarneembare elemente van 'n omvattende kommunikasieafwyking, waarin die geheel belangriker as die som van die dele is. die beroepsomstandighede waarvoor opgelei word, is geleidelik besig om te verskuif vanaf die normale skoolsituasie na spesiale onderwys, die hospitaal en veral die privaat praktyk. deregulering in gesondheidsdienste is 'n werklikheid en ook terapeute neig al hoe meer om werkgewers te word en nie werknemers te bly nie. opvoeding moet dus voorsiening maak vir inskerping in andersoortige en meer omvattende beroepsfunksies, wat sal aanpas by die eise wat aan 'n werkvoorsiener gestel word. die bestaande westerse klem moet afrikagerig word. afrikakultuur en taal moet 'n integrate deel van die opleiding vorm. daar is 'n groot behoefte aan voortgesette onderrig, juis om die brug te slaan tussen westerse, hoe-tegnologieopleiding en afrikakonteks behoeftes, maar ook om volgehoue kwaliteit dienslewering in die toekoms te verseker. hierdie onderrig moet as gevolg van die mannekragtekort en geografiese verspreiding van beroepsbeoefenaars, deur afstandsonderrig aangebied word. wat die eise van professionele opleiding betref, was dit duidelik dat die volgende beginsels moet geld: die doelwitte van opvoeding moet gespesifiseer word in terme van die hele omvang van toepaslike bevoegdhede: kennis, vaardigheid en gesindheid. die leerproses wat tot hierdie bevoegdhede lei, vereis 'n kombinasie van akademiese en praktiese opleiding (cunnington, 1985, p. 76). wat die standaarde betref, moet die opleiding voldoen aan die eise van die universiteitswese, sowel as die minimum vereistes wat deur die beroepsraad vir spraak-taalterapie en oudiologie gestel word. dit was duidelik dat daar 'n nuwe, toepaslike model vir opleiding en dienslewering geskep moes word. hierdie model (uys & hugo, 1990) hou 'n veelvlak diensleweringshierargie voor, waarin verskillende soorte insette in 'n verskeidenheid van omstandighede aan die behoeftes van die kommunikasiegestremde in sy gemeenskap kan voldoen. kommunikasiegestremdheid moet aangespreek word vanaf die vlak van/primere gesondheidsorg, reg deur die spektrum van gesondheidsen rehabilitasiedienste, tot by die hoogste vlak van spesialisasie en tegnologiese ontwikkeling. uit die aard van die saak hou hierdie model dus ook implikasies vir opleiding in. tans is die universiteite die enigste opleidingsinstansies waar kursusse in kommunikasiepatologie aangebied word. voorgestelde the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kommunikasiepatologie: onderrig vir die toekoms aanpassings en byvoeging van opleidingsprogramme moet dus aanvanklik die verantwoordelikheid van die universiteite se deskundiges wees. onderrig vir die toekoms: die verantwoordelikheid van die departement die departement spraakheelkunde en oudiologie wil homself verbind tot verantwoordbare opleiding van studente vir die toekoms. met hierdie diensleweringsmodel as uitgangspunt, glo ek, is dit moontlik. op die makrovlak is die belangrikste faktor waaraan aandag geskenk word die voorsiening van spraak-, taalen gehoordienste, waarin op die regieplek, die regie diens deur en aan die regie mense gelewer sal word. hierdie stelling impliseer dat 1. genoeg persone verskillende soorte opleiding moet ontvang om 'n veelvlakdiens te lewer; 2. dienste in 'n groot mate gede'institusionaliseer moet word; 3. effektiewe diens op elke vlak gelewer moet word, veral met die oog op bestuur, supervisie en medekonsultasie; 4. persone kennis moet dra van die taal en kultuur van die gemeenskap van die gestremdes; 5. personeel in staat moet wees om deur opvoeding en verryking gemeenskappe te bekragtig om self te besluit oor hulle eie behoeftes ten opsigte van gestremdheid en intervensie. dit is vandag algemeen bekend dat gesondheidsberoepe gekritiseer word omdat hulle te hooggekwalifiseer is. is 'n minimum van 'n duur, vierjarige universiteitsgraad werklik nodig vir 'n persoon om basiese hulp te verleen aan duisende kommunikasiegestremdes wat tans geen hulp ontvang nie? daarteenoor, is dit eties verdedigbaar om komplekse menslike dienslewering te onderneem, sonder dat jy daarvoor opgelei is? kan die onopgeleide p|ersoon skade doen, of is 'n halwe eier beter as 'n lee dop? omdat daar baie bewyse is dat persone wat voorgee dat hulle opgelei is, wel meer kwaad as goed aan die kommunikasiegestremde !doen, kan minderwaardige; vinnige, goedkoop opleiding, net om gou meer werkers in die veld te kry, nie toegelaat word nie. maar 'n middeweg is tog moontlik deur werksverspreiding oor verskillende vlakke van dienslewering en samewerking. ek is geen voorstander van laer standaarde in opvoeding en dienslewering nie. daarom wil ek pleit vir die behoud van die hoogste standaarde op verskillende vlakke van opvoeding en dienslewering, waar persone in verskillende beroepskategoriee die beste opleiding ontvang om uitnemende diens op spesifieke vlakke te lewer. ι spraak-taalterapie en oudiologie is in 'ri groot mate gedragwetenskappe en 'n verskeidenheid van insette kan suksesvol aangewend word in die verandering van menslike gedrag. sertifikaatprogramme: op grondvlak is daar tans 'n noodoproep om direkte gemeenskapsopvoeding' en -verryking vir die voorkoming van kommunikasiegestremdheid, vir sifting, 7 verwysing en ook basiese verligting van lyding te voorsien. die opleiding van gemeenskapsgesondheidswerkers/gemeenskapsrehabilitasiewerkers kan deur gedesentraliseerde diensleweringsorganisasies soos hospitale sonder noemenswaardige finansiele implikasies behartig word, met die aanbieding van sertifikaatprogramme en indiensopleiding. gemeenskapsleiers en gemeenskapsverpleegkundiges kan hierdie verantwoordelikheid aanvaar sonder dat daar werklik tot hulle werksbelading toegevoeg word. alhoewel hierdie opleiding noodwendig baie beperk sal wees, het ons universiteit 'n verpligting om hierdie soort gemeenskapsopvoeding te steun. dit is ons plig om vir die gemeenskappe waarby ons betrokke is die visstok in die hand te gee, om binne die raamwerk van die "doctrine of informed consent" die gemeenskap te bekragtig om self behoeftes te identifiseer en besluite te neem op grond van oorwoe kennis, wat ons vir hulle behoort te verskaf. in ons sentrum vir aanvullende en alternatiewe kommunikasie word gemeenskapsopvoeding reeds met groot sukses aangewend tot voordeel van die erggestremde. ons word oorval met noodoproepe om hulp, en in die kort bestaan van die sentrum is honderde mense, selfs tot in namibie, se lewenskwaliteit al deur die bemiddeling van persone wat in die gemeenskappe o p g e l e i is, verbeter. d e u r e w o r d o o p g e m a a k vir m o e d e r t a a l o n d e r r i g , t w e e d e t a a l o n d e r r i g en selfs geletterdheid. diplomaprogramme: die volgende vlak van dienslewering behoort egter dieper kennis te dra van kommunikasiegestremdhede, omdat habilitasieen rehabilitasieprosedures 'n groter mate van tegniese kennis en vaardigheid vereis. die technikons kan, in samewerking met die universiteit diplomakursusse daarstel om spraaken gehoorgemeenskapswerkers en spraak-taal-gehoorterapieassistente op te lei om in konsultasie met, of onder die toesig van gekwalifiseerde terapeute tegnieke vir kommunikasieherstel aan te wend. hierdie diens kan ook tyden geldbesparend wees en 'n verhoging in toerekenbare en doeltreffende mensekrag teweegbring. weer eens het ons universiteit die verantwoordelikheid om te sorg dat die opleiding toepaslik is, sodat 'n verantwoordbare diens, wat veilig vir die publiek is, gelewer kan word. daar is ook reeds bewyse dat hierdie samewerking suksesvol kan wees, omdat van ons personeel reeds betrokke is by die opleiding van spraaken gehoorgemeenskapswerkers en gehoorapparaatakoestici, wat 'n baie spesifieke diens aan die gemeenskap bied. universiteitsgrade: maar die universiteit se primere taak bly die opvoeding van spraak-taalterapeute en oudioloe persone wat al die komplekse fasette van menslike kommunikasie en kommunikasiepatologie ken en kan hanteer. hierdie persone moet 'n bree basies-wetenskaplike en 'n dieptevakwetenskaplike kennis he om probleme te kan identifiseer en te kan oplos. hulle moet bereid en in staat wees om die uiteindelike verantwoordelikheid vir die lewering van effektiewe diens aan alle kommunikasiegestremdes en hulppersoneel op hulle skouers te neem. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 isabel c. uys indien ons kursus dan, soos ek beweer het, van hoogstaande gehalte was, waarom het ons oor die afgelope paar j a a r so drasties geherkurrikuleer? waarom het ons die magistergraad geherstruktureer? kursusse is opgestel binne die raamwerk van nuutgeformuleerde modelle vir opleiding en dienslewering. dit is proaktiewe optrede om te verseker dat hierdie kursusse voorsiening maak vir dienslewering vir die toekoms. baccalaureusgrade: alhoewel ons nie met die beskikbare fasiliteite en bestaande personeelkorps onmiddellik meer voorgraadse studente kon keur nie, word verskeie van die dilemmas reeds aangespreek: sekere teoretiese kursusse word oopgestel, sodat studehte uit ander verwante vakgebiede kennis kan verwerf oor menslike kommunikasie en kommunikasiepatologie. die doel hiervan is gemeenskapsverryking en -opvoeding, waardeur die kommunikasiegestremde indirek sal baat vind. studente uit al die verskillende taalen kultuurgroepe, wat aan die vereistes vir keuring voldoen, word gewerf om die tekort aan terapeute in sekere sektore aan te vul. 'n vakgerigte akademiese ontwikkelingsprogram word in die departement aangebied om studente, wie se moedertaal nie afrikaans is nie, te ondersteun. daar word van alle studente verwag om op die 200vlak 'n afrikataal aan te bied, sodat hulle beter voorberei kan word om in verskillende taalen kultuurgemeenskappe met ander te kan saamwerk om'n effektiewe diens te lewer. gemeenskapsdiens, wat die basis vorm vir onderrig en navorsing, vind plaas in 'n verskeidenheid van taalen kultuuromgewings. studente word dus reeds op voorgraadse vlak toegerus met vaardighede om gedei'nstitusionaliseerd intervensieprogramme te implementeer. alhoewel die kursus besonder swaar gelaai is, word spraak-taalpatologie en oudiologie steeds gesamentlik as hoofvakke aangebied. hierdie kombinasie word nie by alle universiteite oorsee aangebied nie, en tog pleit beroepsverenigings oorsee al vir die afgelope twee dekades dat spraak-taalterapie en oudiologie as 'n enkel-professie beoefen moet word (feldman, 1981). tesame hiermee, is weggedoen met die afwykinggerigte fragmentasie in h i e r d i e professionele opleiding. die menslike kommunikasieproses word deurgaans as uitgangspunt in die onderrig gesien. spraak-, taalen gehoorafwykings word gesien as aspekte van menslike kommunikasie en intervensie word gerig op kommunikasie-patologie. dit is die rede waarom die lomp benaming van die departement ontoepaslik en verwarrend is en waarom 'n naams·' verandering na die departement kommunikasiepatologie oorsee deur meeste universiteite, en plaaslik deur betrokkenes op verskillende vlakke, ook in die vakvereniging en beroepsraad gesteun word. hierdie opleiding van generaliste hou die voordeel in, dat gegradueerdes toegerus word om alle soorte kommunikasiegestremdhede onder alle verskillende omstandighede effektief te hanteer. met in agneming van die uitdagings en bedreigings in die toekoms, is die beroepsfunksies van die gegradueerde ondersoek. dit het duidelik geword dat samewerking met verwante dissiplines en betrokkenes in die gemeenskap onontbeerlik is. daarom word daar in die opleiding nie slegs aandag gegee aan diagnose en terapie nie, maar ook aan gemeenskapsopvoeding (veral met die oog op voorkoming); beraad; konsultasie; supervisie; navorsing; onderrig; bestuur. graduandi word dus voorberei om ook as besluitnemers, konsultante, bestuurders en werkgewers op te tree. maar die uitdagings van beroepsbeoefening in die toekoms, moes ook op ander vlakke aangespreek word. daar moes voorsiening gemaak word vir spesialisdienste in die geval van baie komplekse en moeilik hanteerbare gestremdhede. magister en doktorale grade: die departement bied reeds die afgelope drie jaar 'n gestruktureerde magisterprogram aan met die oog op die a k a d e m i e s e o n d e r r i g van s p e s i a l i s t e in die wetenskappe van kommunikasiepatologie en navorsingsmetodologie. ten spyte van die feit dat dit nie 'n professionele, kliniese graad is nie, kan die sukses van die magisterprogram reeds gemeet word aan die hoogstaande gehalte studente, ook van ander taalen kultuurgroepe wat inskryf en kwalifiseer (ook graduandi en personeel van ander universiteite); oudstudente wat op professionele vlak in uitvoerende poste bevorder word; wat hulle navorsingsvaardighede inspan om die effektiwiteit van dienslewering te verhoog; wat internasionaal aanvaarbare navorsingsen publikasie-uitsette lewer. 'n volgende toekomsideaal is om gespesialiseerde, professionele magisterprogramme in te stel vir persone met 'n algemene, maar toepaslike baccalaureusgraad. so, byvoorbeeld, kan gegradueerde onderwysers op nagraadse vlak 'n magister verwerf, kwalifiseer as spraak-taalterapeut of oudioloog, beperkte registrasie toegelaat word en ook 'n spraak-taalterapeutiese diens aan die skoolgaande kind lewer. die onderwyser by 'n skool vir gehoorgestremdes sal met hierdie kwalifikasie weer 'n belangrike bydrae tot die gehoorgestremde gemeenskap kan lewer. j hierdie soort opleiding is dan ook algemene praktyk by verskeie amerikaanse universiteite. 1 een van die implikasies van uitbreiding van opleiding is fasiliteite en personeel. deur akkreditering van diensleweringsinstansies, kan die universiteit gebruik maak van daardie personeel om die universiteitspersoneel op 'n tydelik-deeltydse basis by te staan in die kliniese opleiding van studente. die voordeel hieraan verbonde is dat die universiteit al hoe meer gebruik sal kan maak van afstandsonderrig. nagraadse studente sal steeds hulle beroepe kan beoefen terwyl hulle deur middel van afstandsonderrig die teoretiese onderrig ontvang. die praktiese, kliniese opleiding kan by geakkrediteerde praktyke, onder die supervisie van gekwalifiseerde spraak-taalterapeute en oudioloe plaasvind in hulle woongebiede.' inspeksie van opleiding deur die beroepsraad en e k s a m i n e r i n g deur die universiteit sal steeds die versekering bied dat die standaard van onderrig bevredig. the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kommunikasiepatologie: onderrig vir die toekoms 9 voortgesette onderrig: waar die westerse model die afgelope drie dekades vir die opleiding van spraak-taalterapeute en oudioloe aan die universiteit van pretoria gebruik is, is 'n herorientasie tot die afrikakonteks gebiedend noodsaaklik. ons oudstudente het, met 'n ingeskerpte etiese bewustheid, deur selfstudie en selfverryking hulle basiese opleiding aangevul om te voldoen aan die eise wat die beroep in suid-afrika aan hulle stel. maar nou, meer as ooit tevore, het die universiteit die verantwoordelikheid teenoor hierdie oudstudente om die nuwe raamwerke bekend te stel. voortgesette onderrig in die vorm van konferensies, werkswinkels en simposiums is, soos in die verlede noodsaaklik, maar oudstudente behoort ook aangemoedig te word om vir nie-graaddoeleindes modules van die nuwe voorgraadse kursus by te woon. die personeel en studente het die verdere verantwoordelikheid om opleiding en dienslewering gedurig te weeg deur navorsing, en hierdie bevindings bekend te stel ter bevordering van die wetenskap en die beroep en die verryking van die gemeenskap. ook op hierdie gebied pleit ek vir hoe standaarde, maar bevraagteken die kriteria wat gestel word vir e r k e n n i n g van publikasies oor navorsingsbevindings. navorsingsbevindings wat geplaas word in ongesubsidieerde publikasies, kan gemeet word aan ander, ook streng wetenskaplike en kommunikasiekundige kriteria en juis as gevolg daarvan van groter waarde wees. geen wonder dat davies (1993, p. 14) die volgende se nie: "too often scientists publish only in highly technical journals and the message does not reach the people that count." die personeel in die departement is voorberei daarop om hierdie verantwoordelikhede te aanvaar, omdat hulle met behoud van die eiesoortige aard en met uitnemendheid kommunikasiepatologie as wetenskap deur onderrig, navorsing en gemeenskapsdiens wil beoefen en 'n studentekorps wil ontwikkel en vorm deur die oordrag van dissiplinegerigte kennis en k u n d i g h e i d ten einde 'n verantwoordelike en betekenisvolle beroepsgerigte bydrae tot die samelewing te lewer. is dit die moeite werd? ek laat dit in u midde met die woorde van beukelman en garrett (1988, p. 104): "speechlessness is not a loss of life, but a loss of access to life." verwysings aron, m.l. (1984). introduction. proceedings of conference on community work in speech and hearing therapy, 1-5. beukelman, d.r. & garrett, k.l. (1988). augmentative and alternative communication for adults with acquired severe communication disorders. augmentative and alternative communication, 4, 104-121. cole, p.r. (1986). i want to shape my own future. how about you? asha, 28(9), 41-42. crossley, s. (1986). how to train clinicians to work with culturally different clients. communiphoh, 280, 2-11. cunnington, b. (1985). the process of educating and developing managers for the year 2000. journal of management development, 4, 66-79. davies,r. (1993). on their way to the top. scientech, 14. delaney, c. & malan, k. (1984). community speech and hearing therapy:some questions before answers. proceedings of conference on community work in speech and hearing therapy, 73-84. (1987). disability in the republic of south africa. main report. 1. pretoria: department of national health and population development. feldman, a.s. (1981). the challenge of autonomy. asha, 941945. flower, r.m. (1984). delivery of speech-language pathology and audiology services. baltimore: williams & wilkins. johnson, s. & wilson, l. (1987). the one minute sales person. glasgow: william collins. rieber, r.w. & brubaker, r.s. (1966). speech pathology. amsterdam: north-holland publ. co. uys, i.c. & hugo, s. r. (1989). 'n veelvlakevaluasie as grondslag vir die herkurrikulering van 'n professionele universiteitskursus. evaluering in tersiere onderwys. stellenbosch: buvo & savnoho. 259-274. uys, i.c. & hugo, s.r. (1990). kurrikulering vir spraakheelkunde en oudiologie. pretoria: universiteit van pretoria. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 boeke is wen met kennis! van schaik boekhandel is jou voorste boekhandelaar met 'n reuse verskeidenheid akademiese boeke, lekker-leesboeke, rekenaargidse, skryfware en geskenke! besoek ons vandag en deel in die magdom kennis. virdaardie spesiale geleentheid of kopkrap is ons daar! want ons en boeke is een! one lever dienskeer op keer! van schaik boekhandel nedbank forum h/v burnetten festivalstraat hatfield 0083 β (012) 43-3717 f (012) 43-6536 the south african journal of communication disorders, vol. 40, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a markedness analysis of initial consonant clusters in aphasic phonological impairment: a case study. lesley wolk, b.a. (sp. & η. th.) (witwatersrand) dept. speech therapy and audiology, baragwanath hospital, johannesburg. summary the purpose of this study was to assess both the theoretical and clinical value of markedness theory in phonological impairment in aphasia. a markedness analysis was carried out on initial consonant clusters in a single aphasic adult, at two points during the spontaneous recovery phase. results revealed systematic, rule-governed behaviour, reflecting similar linguistic trends, in terms of natural segments and natural processes, on both testing occasions. some inadequacies of the distinctive feature approach are discussed. the findings of this study suggest that a markedness analysis may be extremely useful for the analysis and treatment of phonological disorders in aphasia. opsomming die doel van hierdie studie was om beide die teoretiese en kliniese waarde van die merkbaarheids teorie ('markedness theory') in fonologiese gebrek in afasie te evalueer. 'n merkbaarheids analise is uitgevoer op inisiele konsonant groepe in 'n enkele volwassene met afasie op twee tydstippe tydens die spontane herstel periode. resultate het sistematiese reel-gebonde gedrag tydens albei toetsgeleenthede getoon, wat 'n soortgelyke taalpatroon weerspieel het in terme van beide natuurlike segmente en prosesse. sommige tekortkominge van die benadering van die onderskeidings kenmerke word bespreek. die bevindings van hierdie studie toon aan dat 'n merkbaarheids analise baie nuttig mag wees in die analise en behandeling van fonologiese abnormaliteite in afasie. ' central to the analysis and treatment of aphasic phonological impairment is the application of linguistics. luria assumes the phoneme to be the basic unit of all spoken language.21 this statement encompasses two fundamental justifications for the study of phonology as discussed by spreen,30 firstly for its own intrinsic value, and secondly as the presence of articulatory substitutions may interrupt the investigation and treatment of higher order linguistic events. there are two major characteristics of aphasic phonological impairment; the substitution process in which the selection and substitution are two faces of the same operation,'6 and the disruption of phonemic sequencing. studies of articulatory difficulties in aphasia have dealt mainly with substitution phenomena, and have placed little emphasis on the combination process. in view of the fact that patients with articulation problems show particular difficulty in the production of consonant clusters, 1 ' 2 0 ' 2 9 an in-depth investigation of this was felt to be an interesting medium through which these dimensions (selection and sequencing) could be explored. die suid-afrikaanse tydskrif vir kommunikasieafwykings vol.25, 978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 82 lesley wolk 'apraxia of speech' is a term commonly used to describe articulation difficulties in aphasia. it is clearly differentiated in this study from oral apraxia, which is defined by derenzi and vignolo8 as: the inability to perform voluntary movements with the muscles of the larynx, pharynx, tongue, lips and cheeks; although automatic movements of the same muscles are preserved. a basic controversy seems to emerge from the literature, reflecting two opposing views about articulation disorders in 'apraxia of speech.' several s t u d i e s 5 ' 7 ' 2 9 reveal that articulation errors in 'apraxia of speech' are primarily inconsistent, reflecting a lack of systematic relationships between error and target sounds; while other w r i t e r s 1 ' 9 ' 1 3 ' 1 6 ' 3 3 have emphasized the systematic nature of articulation errors. specific attention has been drawn to the possibility of applying distinctive — feature theory to phonemic errors in an aphasic adult.19 it seems that the distinctive — feature (d.f.) approach may have certain inadequacies. while most researches in speech pathology have found a feature framework valuable as both a descriptive and therapeutic tool, 2 5 ' 3 1 it has come under attack by walsh,34 hyman1 4 and others, who feel that a d.f. approach has as its principle object an abstract, idealized level of language. it is primarily concerned with the system and structures of phonological oppositions rather than with concrete manifestations of human speech. recently, another linguistic theory has received attention in the exploration of children's phonological systems. this theory is called 'markedness theory' (m.t.) based on the underlying theoretical assumptions of natural phonology proposed by david stampe. 6 ' 1 4 while it has been claimed that the notion of markedness is highly relevant to the analysis of aphasic speech, in agreement with kagan,1 9 the writer felt that it had not been placed in perspective linguistically. the 'naturalness' of certain segments in phonological systems can be captured through the notion of 'markedness.' two phonemes or phoneme sequences (segments) are differentiated by considering one of them unmarked (u) for a particular feature and the other marked (m) for that feature. the basic assumption is that the (u) member represents the more natural state, whereas the sum of the (m) features represents the complexity of that phoneme. 2 ' 4 relative complexity is derived from perceptual distinctiveness, frequency of occurrence of certain phonemes among languages of the world, and physiological considerations such as deviations of the vocal apparatus from a phonetically neutral position.2'2 4 within the framework of natural ι phonology, it is assumed that the process of acquisition of the phonetic pattern of language, is therefore a process of inhibiting natural processes.6 i the underlying rationale for this study was to investigate whether an application of m.t. would firstly bje of theoretical value in yielding a better understanding into speech processes resulting from neurological disruption, and secondly to assess its clinical use. the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) markedness analysis of phonology in aphasia 83 method s u b j e c t (s) the s used in this study was a white, south african, english-speaking adult male, aged 56 years. severe expressive aphasia resulted from an intracerebral haemorrhage in the distribution of the middle cerebral artery, which was further confirmed by an emi scan. the s selected fulfilled the following criteria: 1) he was diagnosed as aphasic by a neurologist and a speech therapist, and was assessed as having 'apraxia of speech' (as defined by deal and darley7). this was further confirmed by a formal rating on the boston diagnostic test of aphasia.'2 2) the s demonstrated articulation difficulties, particularly on consonant clusters. 3) dysarthria was ruled out as being etiologically related to the articulation difficulties. 4) oro-facial apraxia was ruled out as being causally related to the articulatory errors. 5) peripheral hearing and vision were within normal limits. 6) the s's mother tongue was english. 7) the s had an adequate premorbid acquisition of speech and language. a i m s 1) to determine whether articulation errors on initial-stem consonant clusters in a single case of aphasia, can be characterized by systematic, rule-governed behaviour. 2) to assess the applicability of markedness theory to phonological impairment in an aphasic in terms of the following:a) are unmarked (u) phonemes and phoneme sequences substituted for marked (m) ones more than the reverse? b) do successive attempts at self-correction reveal a progression towards the target segment in terms of complexity values (u · m), or are they random? c) are predictable patterns set up in one testing confirmed by another? d) can articulation errors be characterized by natural phonological processes? 3) to discuss the appropriateness of the term 'apraxia of speech' used to describe phonological impairment in aphasia, with reference to the general findings and two further issues:i) whether 'apraxia of speech' is purely a motor disorder, or whether there is a sensory component. ii) whether 'apraxia of speech' is purely an articulatory disorder or whether there is an inter-action with other levels of language function. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 84 markedness analysis of phonology in aphasia t e s t s a n d p r o c e d u r e pre-tests 1) the boston diagnostic aphasia examination.12 this test was used in order to obtain a profile of scores on various linguistic dimensions. administration followed the procedures laid down in the test manual. 2) a screening pure-tone audiometric test. this test was administered at a reference threshold level of 15 db (iso 1964). the s responded adequately at all frequencies, indicating that hearing was within normal limits. 3) a neurological examination. a detailed battery of neurological tests were carried out by a neurologist, which served to satisfy those criteria not assessed on the boston examination and to further confirm others. 4) auditory discrimination tests. a) the goldman-fristoe test of auditory discrimination." this test was administered in order to assess the s's competence for discriminating between single consonants. administration procedures followed those laid down in the test manual. b) in order to evaluate the s's ability to recognize cluster versus noncluster segments, an informal test of 50 minimal pair words was devised (eg. tea/tree). 5) auditory memory span. an informal test of auditory memory span was administered using (a) a series of digits, (b) a series of related words and (c) a series of unrelated words. this was felt to be a crucial aspect in the consideration of consonant cluster production. 6) the goldman-fristoe test of articulation.10 part of this test was administered in order to assess basic trends occurring on single consonants within the context of meaningful words. this was felt to provide a basis for the analysis of consonant clusters. tests two approaches were used for elicitation of speech for linguistic analysis: a) controlled elicitation through naming (naming t a s k . y b) uncontrolled elicitation through the collection of spontaneous speech (spontaneous tasks.) a) naming task while many articulation tests are available, none have been designed for in-depth phonological analysis of consonant clusters. a task was thus devised, comprising 106 stimulus cards representing words with initial-stem consonant cluster sequences. stimulus cards consisted of large coloured pictures mounted on white cards. the words the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) markedness analysis of phonology in aphasia 85 to be elicited were written on the back of each card for the purpose of the tester. criteria for selection of words: 28 initial-stem consonant clusters in english are listed.18 each one was elicited in more than one stimulus word, ranging between two and six different phonemic environments. the environment was varied with respect to both vowels and consonants in the immediate phonemic vicinity. an attempt was made to take into account word length and syllable structure in devising the test items. experimental manipulation of words: stimulus pictures were restricted by the following constraints i) phonological rules governing the combination and sequencing of phonemes in english, and ii) those words which could be pictorially represented, for the reason that the use of imitation was deliberately avoided so as to prevent contamination of results by providing a model. in addition, an informal test of 20 words comprising final-stem consonant clusters was devised. they were divided into two groups of 10 each. in the first group, the consonant clusters were purely phonological constructions (pc) such as / s p / in "lisp". in the second group, the final consonant clusters were morphological combinations such as /st/ in "crossed" or /ts/ in "pots". cvcc words were restricted to combinations of / s / + voiceless plosive (sp, st, sk) or (ps, ts, ks), as these are the only two elements comprising a final-stem cluster which occur in both (pc) and (mc). each word was tested in two to three different phonemic environments. this test was included so as to assess superficially whether any other subtle linguistic deficits were operating apart from a phonological impairment. rationale for use of meaningful words: meaningful words were used as opposed to nonsense syllables, for the reasons that firstly in all speaking situations, sound and meaning are inseparable and phonological errors are thus necessarily interactive with both semantic and syntactic levels of speech. secondly, by observing errors in meaningful words, interesting phenomena such as assimilations and reversals within words and over word boundaries become obvious, and act as potential cues.for both diagnosis and treatment. furthermore, the idea which permeates throughout this study, is that of naturalness, and nonsense syllables are in themselves an artificial form of speech. b) spontaneous tasks i) thirty minutes of an open-ended conversation was elicited, concerning the patient's illness, work and general issues. ii) three thematic apperception test (tat) cards were used (numbers 1, 2, 13b) in order to elicit a spontaneous story. iii) six large coloured picture cards were carefully chosen in order to elicit several words with initial consonant clusters, within the context of connected speech. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 86 lesley wolk in addition, much of the spontaneous samples resulted from the s's misnaming of test items and interjected spontaneous speech. it was felt, that many previous studies in 'apraxia of speech' could be criticized for their use of nonsense syllable repetition tasks and specific naming tasks, thus failing to stimulate communicative language. a d m i n i s t r a t i o n o f t e s t p r o c e d u r e s : two testing sessions took place with a six week interval between them. testing a was carried out six weeks post-stroke, and testing β was carried out three months post-stroke, which was considered to have taken place at a point of neurological stability.28 the second testing served (a) to assess improvement of articulatory performance during the period of spontaneous recovery; (b) to confirm phonological patterns set up in the first testing; and (c) to control for chance factors. for the naming tasks, the s was instructed to name the pictures on presentation of each card. they were presented in a random order, but attempts were made not to present two words with the same consonant cluster successively. stimulus words with final-stem consonant clusters were elicited in a similar manner. for the spontaneous tasks, the s was instructed to tell a story with a beginning, a middle and an end in response to each individual tat test card, and to describe each of the six test picture cards discussed above. testings took place at different times of the day, so as to obtain a representative sample of performance. they were carried out for short periods of time (30 — 40 minutes per session) which enabled the tester to control as far as possible for variables such as fatigue, anxiety, motivation, mood and other external factors. in testing b, the following pre-tests were re-administered: the goldman-fristoe test of auditory discrimination" and production,10 and the boston diagnostic aphasia examination.12 analysis procedure and scoring: all responses were recorded on a revox tape recorder (model 1132 dolby version). responses were transcribed in broad phonetic transcriptions at the time of testing where possible, and later by several transcribers, thus providing maximum objectivity and accuracy of recorded data. the analysis procedure was carried out along the following dimensions:1. a) a frequency count of correct versus incorrect responses. one point was assigned for the correct production of the cluster on initial attempt. half a point was assigned for the correct production on one of the subsequent attempts, and 0 for the incorrect production ie. where the target was never reached. all points were totalled for each cluster in proportion to the total number (n) of test words for that cluster (which varied according to the number of self-corrections). a percentage was calculated for the total number of correct responses out of the total number of stimulus test words. the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) markedness analysis of phonology in aphasia 87 (note: both testing a and β comprised 106 test items each on naming tasks; whereas the criterion for spontaneous tasks, was to extract from the total spontaneous speech sample, between 100106 initial-stem consonant cluster words in order to confirm the findings on the more structured tasks). b) a distribution of errors according to omissions (o), substitutions (s), additions (a) and distortions (d). in c1c2vc syllable structures, it is obvious that one or more of the 4 error categories may occur concurrently in one word. c) a subphonemic feature analysis of substitution errors according to the features of place (p), manner (m), voice (v). overlapping categories were developed so as to accommodate substitutions which were defective in two or more features. (p-m, p-v, m-v, pm-v). this method is suggested by la pointe and johns.20 2. a markedness analysis a) articulation errors on initial consonant clusters were subjected to a markedness analysis by applying marked (m) and unmarked (u) values to every consonant and total complexity values to every consonant cluster sequence. b) the m/u table, devised by the writer, was based on those values suggested by cairns,2 chomsky and halle4 with various modifications. (see table i). c) a 9-distinctive feature (d.f.) matrix was used with values available for the following features: consonantal, sonorant, anterior, coronal, continuant, strident, voice, lateral and nasal. a complexity score was computed by adding the (rti) features in each consonant. feature ρ b f v θ δ t d j 3 t j d 3 m η q 1 r w y h k g s ζ x consonantal u u u u u u u u u u u u u u u u u u u u u u u u u sonorant m m m m m m m m m m m m u u u u m u u u m m m m m anterior u u u u u u u u m m m m u u m u u u m m m m u u m coronal u u u u u . u u u u u u u u u u u u u continuant u u m m m m u u m m u u m m m m m m m m u u m m m strident u u u u u u u u m m m m u u u u u u u u u u m m u voiced u m u m u m u m u m u m u u u u u u u u u m u m u lateral + nasal u u u u u u u u u u u u m m m u u u u u u u u u u 6u 5u 5u 4u 6u 5u 7u 6u 4u 3u 5u 4u5u 6u 5u 7u 6u 6u 6u 5u 6u 5u 5u 4u 5u complexity 1 2 2 3 2 3 1 2 4 5 3 4 2 2 3 1 2 1 2 2 2 3 3 4 3 note: although / x / is not an english phoneme, it is included in the table as the s used this sound in his speech. table i: m/u values for all consonants in english, using a 9 distinctivefeature matrix. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 88 lesley wolk d) the analysis of individual feature change can, therefore, assume one of the following possible patterns m u, m · m, u -> u, u * m. e) the symbols (m), (u) and (mm) were used to refer to the direction of change in terms of complexity values: (m) — the target cluster, or a substitution of equal complexity value to that of the target, (u) — a substituted phoneme or phoneme sequence which has a lower complexity value than that of the target, (mm) — a substituted phoneme or phoneme sequence which has a greater complexity value than that of the target, which is always (m); it reflects a change from less complex to more complex. (note: the reason for assigning (m) values to all target segments is that the ccvc words are already complex in terms of syllable structure.) f) phonological processes of simplification include a more detailed analysis of errors in the following categories: i syllable structure, ii environment, iii substitutions. (see table vi). scoring: model for assigning complexity values. 1) paradigmatic values refer to a discrete value for each phoneme, depending on the sum total of (m) features for each consonant. in this model, v = 0 , c=range between 1 and 5, where p = l , 3 = 5; thus reflecting the 'naturalness' of phonemes relative to articulatory and perceptual complexity. 2) syntagmatic values refer to complexity values assigned according to the syllable structure of a word (or phonemic sequencing) such that cv = (+0) c1c2v = ( + 1) c1c2c3v = (+2) these values are justified in terms of the 'naturalness' of syllable structure. syntagmatic values were applied to all consonant sequences, with the following implications — one of the most common neutralization rules governing consonant sequences in english, is that involving the / s/ phoneme. a feature is said to be 'neutralized' in an environment if the value of the feature in this environment is determined by a sequential restraint,32 a neutralization rule (n-rule) thus specifies that a particular feature or set of features may not have a (m) value in a given environment; ie the complexity value is reduced. in this model, a value of ( 2 ) is thus subtracted from the total complexity value, if / s / occurs in the following environments: i a) in a c1c2 cluster, where c2'varies with a voiceless plosive, b) in c1c2c3 cluster, where / s / is the only phoneme which may occur in position ci, according to the rules of phonemic sequencing in english. the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) markedness analysis of phonology in aphasia (the value ~2 was fairly arbitrarily chosen. often an n-rule would require a subtraction of the entire value; however, in this case / s / has a value of 3 so that it would result in a value of 0 which is equal to a vowel in this model. for this reason, only a value of 2 was subtracted). 3) complexity of cluster segments refer to values assigned according to the acquisition of consonant clusters. a definite sequence of acquisition for each cluster has not been given in the literature, as has been done for singletons. however values were based on the broad order of acquisition described by ingram.15 these were divided into 3 groups:i) those acquired by age 4 years (+0) ii) those acquired between ages 4 — 6 years (+1) iii) those acquired by age 7 years (+2) justification: one of the criteria used for assigning (m) values to single consonants, is according to acquisition o r d e r . 2 ' 1 4 it was thus felt necessary to .extend this to consonant clusters. all utterances were thus analyzed by applying all three rules. no. 1 describes complexity of single consonants or singletons; no. 2 refers to the complexity of syllable structure; and no. 3 describes complexity of consonant clusters. note: consonant sequences produced by the s, which were 'nonenglish' sequences, followed rules (1) and (2) but not (3). the identical analysis procedures were applied to the data obtained in testing a and testing b. cluster r-b lends 1-blends s-b lends 2-element blends 3-element blends cluster pr br tr dr kr gr fr θ γ j r pi bl kl gl fl sm sn sp st sk si sw tw kw spl spr str skr skw complexity value 4 5 4 5 5 7 6 7 9 3 4 4 5 5 4 4 3 3 4 7 7 3 4 7 8 7 9 7 t a b l e 11: a list of complexity values for each initial-stem consonant cluster in english. results and discussion (i) the boston diagnostic aphasia examination:the s obtained overall scores of (2) and (3) on testing a and testing β respectively, according to goodglass and kaplan's categories.12 the profile of scores thus served to reflect the interactions of various deficits at a given time, and the improvement from one point in recovery to another. (ii) the s made no errors on traditional tests of auditory discrimination. 1. a) frequency count: analysis of correct versus incorrect responses, revealed an improvement on consonant cluster production during the period of spontaneous recovery. for example, a score of 51,42% was the south african journal of communication disorders, vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 90 lesley wolk obtained on the naming task in testing a, and 65,56 % on the naming task on testing b. 1. b) analysis of omissions (o), substitutions, (s), additions (a) and distortions (d): results clearly illustrated the predominance of (s) errors, followed.^ by (o). (a) and (d) comprised the smaller part of the contribution'* to the total number of errors. the frequency of errors followed the sequence s > ο > d > a which was consistent on all tasks. the fact that patients with 'apraxia of speech' make more errors in substitutions is well supported in the literature.1'3 3 1.c) subphonemic feature analysis: on all tasks, results revealed that errors of place (p) comprised the largest percentage (%), followed by errors of manner (m) and a combination of these (p-m). errors of voice (v) either alone or in combination with others comprised the smaller parts. these results were consistent with the literature. 2 0 ' 3 3 it is interesting that the frequency of errors in children is also seen as ρ > μ > v. 2. a) markedness analysis: a separate 9-d.f. matrix was drawn up for each target consonant cluster and its various substitutions; for the naming and spontaneous tasks on both testing a and testing b. marked (m) and unmarked (u) values were assigned to each consonant in the matrix (transposed from table i). the total number of m's were added so as to reveal the complexity value of each consonant on the paradigmatic axis. by applying the 'rules' discussed in analysis procedure, total complexity values were assigned to each cluster sequence, thus incorporating both paradigmatic and syntagmatic levels. a markedness analysis of all errors revealed that many of the utterances consisted of phonemes and phoneme sequences in which the value of the features in the target segments were retained (m). when a change occurred, most of the target segments were replaced by (u) segments and only a few were replaced by (mm) segments. for example, in naming a, out of a total of 285 utterances, 128 (44,92%) were replaced by (u) segments, and only 49 (17,19%) were replaced by (mm) segments. the remainder revealed no change (m). clearly the data did not support a statement that the s's articulation errors always reflect a change from more to less complex. however, they did suggest that when a change occurs, it is more likely that the direction will be from more to less complex (m -j> u). a number of suggestions were made to explain those occasions where (mm) segments replaced (m) segments, such as assimilations, slips of the tongue, or complexity over the entire word. the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) markedness analysis of phonology in aphasia 91 sm (3—2)+2 + l = (4) total complexity feature s m s ρ m cons u u u u u son m u m m u ant u u u u u cor u u cont m m m u m stri m u m u u voice u u u u u lat nas u m u u m complexity 3 2 3 1 2 word cluster total c m/u 1 smell m 2 u 4 u—>m sm 4 m 2 smarm 2 u ties u—>m ties sp 3 u u—>m 3 smiling sp 3 u sp 3 u 4 smoke sm 4 m total c m/u : total complexity : marked or unmarked segments. table iii: example of a 9 d.f. matrix computed for the initial consonant cluster /sm/, and its various substitutions. from table iii it can be seen that there is a tendency for (u) segments to replace (m) ones, which is consistent with blumstein' and kagan's19 findings. it should be noted that kagan dealt primarily with singletons, blumstein with consonant clusters on syllable structure only, and neither provided a detailed account of relative complexity values. it thus makes it difficult to incorporate their findings in the discussion of the present data. cairns3 found that the child's substitutions may be characterized by a shift towards the (u) value for a particular feature. she felt that the m/u values of features are of more value in accounting for substitutions, than only the +/— dimension. 2. b) analysis of self-correction: results indicate that there was a stronger tendency for a progression to occur, rather than a nonprogression. ie. as the s approximated the target segment, he substituted phonemes or phoneme sequences of increasing complexity. not only do results on spontaneous tasks confirm those on naming tasks, but also results on testing β revealed that the tendency for a pr.ogression in terms of complexity values to occur, becomes more firmly established towards the end of spontaneous recovery. the example 'scratch' in table iv clearly demonstrates the process of self-correction for the cluster /skr/. the initial attempt is a single consonant / l / with a low complexity value equal to 1, reflecting the most natural syllable structure cvc. the second and third attempts are consonant clusters / k l / and /si/ respectively with complexity values of 4 and 7 respectively. on the fourth attempt, the target segment is reached, namely the most complex syllable structure c1c2c3vc where /skr/ has a total complexity value equal to 9. johns and darley17 characterize the 'variability' of phonemic production in 'apraxia of speech,' as unrelated, additive, substitutions, repetitions and blocks, groping through repeated efforts towards the correct production. this finding contradicts that of the present study, which provides evidence for a pattern of successive attempts at self-correction die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 92 lesley wolk skr ( 3 2 ) + ( 2 + 2 ) + 2 + 2 = (9) feature s k r 1 k 1 s 1 cons u u u u u u u u son m m m u m u m u ant u m u u m u u u cor u u u u u u u u cont m u m m u m m m stri m u u u u u m u voice u u u u u u u u lat + + + nas u u u u u u u u compl. 3 2 2 1 2 1 3 1 total complexity wordcluster total m/u scratch 1 1 u" kl 4 u si u—> m si 7 u u—> m skr 9 m table iv: example of a 9 d.f. matrix computed for the initial-stem consonant cluster /skr/, to show the process of self-correction. with a definite link or 'relatedness' between error production and desired production. these results were felt to be extremely significant for two reasons: firstly it provided an opportunity to observe dynamic linguistic processing, and secondly it provided further information about perception. the fact that the s was able to monitor his own productions showed that to some extent the perceptual mechanism is functioning. however, that this process of selfcorrection was somewhat less than perfect, resulting in further substitution errors seemed to point to a subtle deficit in the sensori-motor feedback loop. the interesting phenomenon which seems to arise is that there is a discrepancy between performance on a purely perceptual task and performance on a task involving an interaction between perception and production. the implications of this were felt to go beyond the scope of this study. however, it may be a worthwhile point for future investigation, which might provide further insight into theories of speech perception and production. pr (1 + 2) + 1 (4) total complexity word testing a testing β cluster total c m/u cluster total c m/u 1 prize ρ 1 u pi 3 u f 2 u pr 4 / m pl 3 u / / pr 4 m 2 pram pi . 3 u pi 3 u pr 4 m 3 present pr 4 m pr 4 m table v: an example of cluster / p r / from naming task a and naming task b, to show the predictable course of recovery. the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) markedness analysis of phonology in aphasia 93 table v provides an illustration of the predictable patterns set up in testing a which are confirmed in testing b. the same progression occurred on both testings ie. u-> m, and fewer attempts were required in testing b, before reaching the target segments. for example, in the word 'prize', there were four attempts towards the target segment in testing a ranging from / ρ / — (1) to / p r / — (4). assuming the pattern to be a range from 1 — 4 in terms of complexity, one could predict a substitution of a phoneme or phoneme sequence comprising these phonemes, of values 2 — 4, as approximations before reaching the target segment. in testing β the first approximation was / p i / with a complexity value of 3, after which •the target cluster / p r / was reached. this finding seems to have relevance for assessment and as a therapeutic aid. the ability to predict the outcome of each phonetic process is pointed out as another important difference between jakobson and stampe's theories. jakobson's16 account of d.f. theory has a universal hierarchy of features arranged in a strict pattern of successive branchings, which are viewed as relative properties of a phoneme, defined within a network of oppositions. by contrast, stampe 6 ' 1 4 sees a dynamic system consisting of these innate rules of natural processes, rather than a static hierarchy. from an informal analysis, similar trends were noted on singletons, in initial, medial and final positions, which provided further confirmation for results above. an observation of the data showed that similar error trends tended to occur on different clusters comprising the same elements. for example, in the clusters sp, pr, spr, the following substitutions were noted to occur in testings a and b: b/sp, br/spr, f/sp, f/pr, pl/pr, spl/spr. these results thus served to validate and confirm the findings on initial-stem consonant clusters and further suggested that some underlying system of internalized rules might be governing articulation errors. ' some general points: i) the s was seen to correctly produce more of those clusters acquired earlier in normal child development than those of later acquisition. results also corresponded with children's progress from u ^ m in their learning process. ii) it is interesting to note than when the s was struggling to produce a particular cluster, he frequently used several self-devices to aid the production. for example, to spell the word out aloud which was seen to facilitate correct production immediately, or to spontaneously incorporate the stimulus word in a sentence ie. an attempt to produce it in natural running speech. iii) several error productions could be interpreted as having semantic confusions, yet are fully explicable on a phonological level, eg. 'kribs' for twins, 'god' for dog, 'grub' for mug and 'breast' for dressed. 2. c) analysis of errors according to natural phonological processes the major processes were subdivided into fourteen categories, thus extending those used by blumstein' and hatfield.13 table vi die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) lesley wolk represents a summary of all natural phonological processes, with a few examples from the raw data, to illustrate the type of errors produced on cvc and ccvc words. the findings indicate that certain processes seemed to occur more frequently than others in naming and spontaneous tasks on both testings a and b. i) syllable structure: cluster reduction occurred most frequently, representing a form of simplification = ccvc-> cvc. ii) environment: there was a general tendency for regressive assimilations (r.a.) to occur more frequently than progressive assimilations (p.a.) on all tasks. metatheses were less common, but when they did occur, reversals of syllables occurred more often than reversals of phonemes. this finding may be interpreted in terms of m.t, in that such rules of consonant harmony increase the redundancy of the articulatory instruction of the word so that 'gog' would be easier than 'dog'·.6'32 iii) substitutions: the processes of fronting (f) and stopping (s) were clearly the most frequent where f > s. many utterances were seen to include an overlap of stopping (plosivization) and fronting within the same segment. it would appear that while (f) is more common, there is a marked tendency to substitute velar sounds, particularly the voiceless plosive / k / . this is consistent with hatfield13 who reports some interchangeability between / t / and / k / in both singletons and clusters. generally, the above findings are well supported in the literature on aphasic phonological impairment.1'1 3 from a brief comparison with phonological acquisition in the child, similar linguistic trends were seen to occur. apart from the consistent findings of cluster reduction, 1 5 ' 2 6 other processes of syllable simplification have been found to occur in the child ie. syllable closure (cv-> cvc), and the insertion of an epenthetic schwa thus splitting the cluster (clc2-> cvc).15 environmental errors, such as metatheses and assimilations, where regressive assimilation was greater than progressive assimilation were found to occur in the child. 1 5 ' 2 6 the various substitution processes found to operate in the s, are also reported to occur in the child, such as: fronting^ stopping, denasalization, gliding, frication, nasal and velar substitutions.15 overall results of 2a, b, c, d indicate that the general trends occurred on both natural segments and natural processes. stampe discusses the repeated use of strategies or natural phonological processes in the child. its importance would seem to be the fact that it is the fiijst theory to account for both the learning of the phonetic repertoire and of phonological relations.14 the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) markedness analysis of phonology in aphasia 95 ir> νΐ s b (n 1, 06 po s. sb m co coo'· (n po s. sb cn i 1 ,0 6 tfi w x i§ ο α. σ σ n b cn 1, 85 i ο ' ζ po s. n b cn m <> ζ ο po s. n b it) | 4, 63 tfi w x i§ •ό of) .ξ 5 s a co 1, 59 i η ζ ο •ό c μ κ « sa 18 ,5 1 < υ 5 u^ •ό π υ ω sa co i 1, 39 w οο ο (λ cfl n a ο ο ο" os uσ* μ £ ν α m 21 ,7 4 < υ 5 u^ ϊ = n a r| 4, 35 in e rr or | e rr or br /g r t/ k e rr or f/ sw f/ kw /m ai n / /s ad a 1 ' sb <n ω ei υ > \ λ ir ε sb τ (ν /m ai n / /s ad a 1 ' sb in in \ο po s. sb .rco d c; e g / m ai n / /s ad a 1 ' sb po s. —• n b ^ ο e g ζ ο jj £ nb (n oo ο ζ n b t co' υ fi 1 ,5 9 33 n b ^ α 3 ο < in co υ fi < co 1, 59 ω sa cn oo α 3 ο •ό ε re -ο α a < in go •«t co η £ n a pj χ η < sa u 1 α 3 ο ε re -ο α a oo < j vc η £ n a ο ο pj χ η < c t i2 2 w < ζ cn t <n r") ζ t cn >> vc pj χ η < < ζ in ^ η ω s ω μ 03 uo ο » | ο, ο e rr or pw /p r w /r υ υ ζ ο ο ζ 1, 60 ε ω c ο ω ζ ο sb ιη ρ s b co 1, 60 ε ω c ο υ v) sa ^ co \λ s b — υ ο α . n b i n α . υ v) sa t -cr. cc n b fn < θ! ο α . n b ( ν go (λ n a ο ο ο t -cr. cc n b i. n a ο ο cr. sa go (n ο ελ τ os e sa go o* c; ελ (ν < ο sa o* os ω η ί tr ou ta x < ζ ιτ) co • < s b 7, 45 pj > re ο 2 £ < ζ go 11 ,1 8 d j υ ο • crt £3 ^ χ ν > £ ο α . χ ) < \ α . υ 3 n b 2, 77 δ ω ίλ [λ υ £ ο α . χ ) < \ α . υ 3 s a r") (n 12 ,1 6 ω ο η < _ι | 00 υ οέ s 3 sa r") (n 12 ,1 6 ο ζ s b i 0, 53 ο η < _ι | 00 υ οέ n a <n 7, 45 ζ ο po s. i s b t 2, 13 η η 3 α. u0 β: ο α. 03 ζ ο ο ο ο η < _ι | sb r") η < ν po s. n b tt 3, 7 η η 3 α. u0 β: •d so ng s sa r-> 1, 59 < ρ < n b r") 2, 77 < ελ w or d ε ο χ. 2 sa r3, 71 ω η ελ d ϊ so ng s ν α i 0, 63 > '(λ λ ιυ ο -σ sa 2, 65 < ζ ω α w or d ε € d re π χ) n a t 2, 48 j υ ο ν ο 00 00 ο £ n a ττ 2, 48 < ζ ω α δ π i ω ο \ ω ζ ο m co 20 ,7 5 po s. ξ ι sb co [1 6, 49 ζ ο po s. sb go 4, 25 ι υ d q ω os • os ω η d j υ ο α. / n b i ιπ (ν 23 ,1 5 ο • ζ po s. ξ ι n b i r.6 ,4 9 η d η po s. n b tt 12 ,9 7 ι υ d q ω os • os ω η d j υ w or d gr in ni ng br ok en sa r(ν 14 ,2 9 α. α. ο w or d sa y de ci de < ελ τ co 17 ,1 8 ελ m d w or d <λ ο τ ι < in tt 2, 12 ι υ d q ω os • os ω η d j υ w or d gr in ni ng br ok en ν α i co co 20 ,5 π ύο w or d sa y de ci de < ζ fo <n 14 ,2 9 < w or d ό 0c ,ν α co 8, 07 ι υ d q ω os • os ω η d j υ e rr or o t . ^ 0 0 ^ b h z ii e rr or t ot al = n o < ζ ο e rr or m /d r n/ d t ot al = n o 2 c o'i die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 96 lesley wolk in an attempt to assess the appropriateness of the term 'apraxia of speech', the following 2 sub-tasks were carried out. 3. i) a test of oral stereognosis an abbreviated test of oral stereognosis comprising ten test items was carried out on the aphasic s and 3 normal control subjects (c) matched for age, sex and educationail level. each test item (a threedimensional shape attached to a wand) was presented orally to the subjects, who were then required to match the shapes with a corresponding visual diagram. one point was awarded for each correct identification. the maximum score was thus ten points, which was then converted to a percentage. results revealed that the aphasic s scored considerably lower than did the c subjects. (c1c2c3 all scored 100%, while s scored 60%). this finding seems to suggest a subtle deficit in oro-sensory abilities in this aphasic adult; which is consistent with previous literature.27 it serves to revise the previous concept of a strictly motor disorder in 'apraxia of speech' and further suggests the incorporation of the kinesthetic modality in therapy. 3. ii) naming task of final consonant cluster words of phonological (pc) and morphological construction (mc) findings revealed that the s produced more words with (pc) clusters correctly than those with (mc) clusters. this would seem to indicate that more difficulty was experienced on final stem consonant clusters (cvcc) when there is a morphological (inflectional) ending superimposed on a phonological construction. these results are supported by martin, wasserman, gildman, gerstmenn and west2 3 who found that more errors occur on (mc) rather than (pc) final consonant clusters. martin et al 2 3 make the point that if 'apraxia of speech' was confined to a purely articulatory disorder, words involving an (mc) cluster, should have no effect on production. martin2 2 states conclusively t h a t : . . . the concept of an apraxia of speech is a reflection of an outdated dichotomous model of language functioning that obscures the complex interactions involved in normal and aphasic language. no conclusive remarks, however, can be drawn from the small sample of words tested. it may only serve as an example indicating that this might be the case. further research into the overlapping phonological and morphological constructions of final consonant clusters, might provide useful information about the interdependence of language functions in the adult aphasic. ! general discussion and conclusion an integration of all results revealed that 1) (u) segments tended to replace (m) segments. 2) successive attempts at self-correction showed approximations towards the target segment (u-> m). the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) markedness analysis of phonology in aphasia 97 3) articulation errors could be characterized by natural phonological processes. 4) trends observed in testing a were confirmed in testing b, and those occurring on naming tasks were confirmed on spontaneous tasks, ie. predictable patterns set up in one testing were confirmed by another. slight variability, which was seen to occur within strict linguistic classes, was noted. evidence thus seems to point to an organized 'system', less variable than a random set of articulation disorders. the appropriateness of the term 'apraxia of speech' was questioned in view of the following three conclusions: a) that errors could be characterized linguistically. b) that rather than a purely motor disorder, there might be a mild orosensory perceptual component c) the possibility of subtle levels of language breakdown on a morphological level, operating together with the phonological impairment. it would thus appear to be a condition inseparable from the general aphasic disorder, and should be both assessed and treated in the light of the total syndrome. overall results seem to demonstrate the applicability of natural phonology (np) to phonological impairment in aphasia. the apparent bias of n.p. is clearly that of 'production'. the perceptual data in the present study are not adequately dealt with in the conceptual framework of n.p., which places certain limitations on its general use. however, it is felt that in conjunction with other approaches, m.t. may be highly applicable to aphasia, particularly for analysis and treatment of production errors. theoretically, an attempt has been made to extrapolate from m.t for the aphasic s as it was originally developed to explain acquisition of phonology in the child. from the conclusions, possibly one may view the phonological breakdown in the following way: where the child learns to inhibit natural segments and processes in the acquisition of his system, the aphasic adult fails to suppress the more natural processes as a result of neurological disruption. this may be viewed as 'disinhibition' or 'release phenomenon'. in a sense, this may be associated with the regression hypothesis proposed by jakobson,16 and spreen.30 however, it must be stressed that this is only seen in terms of broad phonological processes and general trends, rather than specific phoneme production. the applicability of natural phonology to aphasia incidentally bears some relation to an early theorist, pick, who explained various speech disturbances on the basis of a 'disinhibition principle'.5 the writer suggested an alternative term to describe the phonological impairment in this adult aphasic s, namely: "phonological disinhibition". the word 'disinhibition' was used as it relates to the theory of natural phonology, but is quite distinct from that used by luria.21 an m/u analysis may be a useful tool for an in-depth phonological analysis, and may indeed supplement existing standardized tests. the implications extend outside clusters into all aspects of phonological impairment. it die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol.25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 98 lesley wolk may facilitate an analysis in terms of (m) and (u) segments, graded on a continuum of relative complexity values. phonological errors are assessed within a contextual framework, thus encouraging a certain amount of flexibility in relation to different phonemic environments. the relative complexity values facilitate the hierarchical arrangement of speech sounds and clusters, on which therapy can be based. it is essential to teach phonemes within a contrastive framework, yet defined within a scale of complexity as postulated in m.t. 2 1 an assessment of natural phonological processes as outlined in table vi, may provide an understanding of the 'system' and rules governing the error patterns of an individual patient. central to the concept of 'naturalness' is the discoverable "path" from input to output, within complex sound changes.6 for example, in cluster reduction, d.f. theory would require a direct 'jump' from pr p, whereas m.t provides an explanation for the entire process, possibly from pr-^ pl-^ ρ in terms of complexity values. markedness theory thus seems to provide the intermediate steps necessary for prediction of error patterns or vulnerability of a particular phoneme to change; direction of change, evaluation of progress and accurate planning of steps towards rehabilitation. with validation from further research, this approach might prove to be useful in the analysis and treatment of other phonological impairments. references 1. blumstein, s.e. (1973): a phonological investigation of aphasic speech. brown university and aphasia research centre, boston. mouton, the hague. 2. cairns, c.e. (1969): markedness, neutralization, and universal redundancy rules. language., 45, 863-885. 3. cairns, h.s. (1975): phonetic feature theory: the linguist, the speech scientist and the speech pathologist. j.comm. dis., 8, 157170. 4. chomsky, n., and halle, m. (1968): the sound pattern of english. new york, harper and row. 5. critchley, m. (1952): articulatory defects in aphasia. j. laryngoi. ο to i., 66, 1-17. 6. darden, b.j. (1974): introduction, in natural phonology — papers from the parasession on natural phonology, chicago linguistic society. april 18th. 7. deal, j.l., and darley, f.l. (1972): the influence of linguistic and situational variables on phonemic accuracy in apraxia of speech. j. speech hear. res., 15(3), 639-653. ; 8. de renzi, e., and vignolo, l.a. (1966): oral apraxia and aphasia. cortex, 2, 50-73. 9. fry, d.b. (1959): phonemic substitutions in an aphasic patient. lang speech, 2, 52-61. \ 10. goldman, r„ and fristoe, m.s. (1969): goldman-fristoe test of' articulation. american guidance service, inc., minnesota. the south african journal of communication disorders vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) markedness analysis of phonology in aphasia 99 11. goldman, r., fristoe, m.s., and woodcock, r.w. (1970): goldmanfristoe test of auditory discrimination. american guidance service, inc., minnesota. 12. goodglass, h., and kaplan, e. (1972): the assessment of aphasia and related disorders. boston veterans administration hospital and aphasia research centre, department of neurology, boston university. 13. hatfield, f.m., and walton, k. (1975): phonological patterns in a case of aphasia. lang, and speech., 18, 341-357. 14. hyman, l.m. (1975): phonology: theory and analysis. holt, rinehart and winston, new work u.s.a. 15. ingram, d. (1976): phonological disability in children. studies in language rehabilitation and remediation 2. department of linguistics, university of british columbia. 16. jacobson, r. (1968): child language, aphasia and phonological universals. mouton, n.v. the hague. 17. johns, d.f., and darley, f.l. (1970): phonemic variability in apraxia of speech. j. speech. hear. res., 13, 556-583. 18. johnson, w„ darley, f.l., and sprietersbach, d.c. (1963): diagnostic methods in speech pathology. new york: harper and row. 19. kagan, a. (1976): a linguistic analysis of expressive and receptive phonological difficulties in apraxia, and its relevance to therapy: a case study. unpublished research report, department of speech pathology and audiology, university of the witwatersrand, johannesburg. 20. la pointe, l.l. and johns, d.f. (1975): some phonemic characteristics in apraxia of speech. j.comm. dis., 8, 259-269. 21. luria, a.r. (1970): traumatic aphasia, its syndromes, psychology and treatment. mouton, the hague. 22. martin, a.d. (1974): some objections to the term apraxia of speech. j. speech hear. dis., 39(1), 53-64. 23. martin, a.d., wasserman, n.h., gilden, l„ gerstman, l. and west, j. a. (1975): a process model of repetition in aphasia: an investigation of phonological and morphological interactions in aphasic error performance. brain and lang., 2, 434-450. 24. mc reynold, l.v., engmann, d., and dimmitt, k., (1974): markedness theory and articulation errors. j. speech, hear. dis., 39(1), 93-103. 25. menyuk, p. (1968): the role of distinctive features in children's acquisition of phonology. j. speech, hear. res., 11, 138-146. 26. olmsted, d.l. (1971): out of the mouth of babes. earliest stages in language learning. mouton and co. n.v., the hague. 27. rosenbek, j.c., wertz, r.t., and darley, f.l. (1973): oral sensation and perception in apraxia of speech. j. speech. hear. res., 16, 2235. 28. sarno, m.t., and levita, e. (1971): natural course of recovery in severe aphasia. arch. ofphys. med. and rehab., 52, 175-178. die suid-afrikaanse tydskrif vir kommunikasieafwykings vol.25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 100 lesley wolk 29. shankweiler, d., and harris, k.s. (1966): an experimental approach to the problem of articulation in aphasia. cortex., 11, 277-292. 30. spreen, o. (1968): psycholinguistic aspects of aphasia. j. speech hear. res., 11(3), 467-480. 31. standel, j., gardner, j., and hannah, e.p. (1974): distinctive feature analysis. chap. 7 in applied linguistic analysis hannah, e.p. (ed.), joyce publications, california. 32. stanley, r. (1967): redundancy rules in phonology. language., 43 393-436. 33. trost, j., and canter c.j. (1974): apraxia of speech in patients with broca's aphasia: a study of phonemic production accuracy and error pattern. brain and lang., 1, 63-79. 34. walsh, h. (1974): on certain practical inadequacies of distinctive feature systems. j. speech hear. dis., 39(1), 32-43. ch rom a/son y/cctv do you use video equipment in therapy? chroma provides a service of hire and sales, of the total range of sony video and audio equipment. chroma p.o. box 31483 braamfontein 2017 johannesburg tel. 46-1750 the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) less disturbance from noise improved speech discrimination more natural sound wider frequency range the lineariser is a tiny acoustic device which eliminates the worst effects of resonance caused by the sound tube of behindthe-ear hearing aids. the lineariser is fitted on the top of the earhook and can be attached to almost any hearing aid in a few seconds approximately 90% of hearing aid users report an immediate i m p r o v e m e n t with the lineariser fitted to the hearing aid. in many cases successful results are achieved with the lineariser where people have not previously been able to use a hearing aid. available from: acoustimed (pty) ltd 515 louis pasteur building schoeman st. pretoria tel: 23202 (pretoria) hearing services 315 bosman buildings cor. eloff and bree streets johannesburg tel: 372978 manufactured by: acoustimed (pty) ltd 302 sandown centre maud street, sandown tell 784-0152 agents throughout south africa die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) speech discrimination abilities of hearing impaired children using conventional hearing aids and radio neckloop at different signal-to-noise ratios asoka moodley m.ed (audio)(manchester) hearing impaired service, humberside county council, england abstract speech discrimination scores of 20 hearing impaired children with a mean age of 14 years were examined when using their own conventional hearing aids on the microphone setting and the radio neck loop with and without the use of the environment microphone of the radio receiver. testing of speech discrimination was administered in noise where s/n of +20db, +10db and odb were used. electroacoustic measurements of the hearing aids used were carried out to ascertain the extent to which the frequency response was altered when the aid was coupled to the neck loop used on the telecoil setting. results highlighted the excellent performance of individual hearing aids when the favourable s/n +20db was used. the use of the environment microphone on the radio receiver did not significantly affect speech discrimination scores, implications regarding the radio neck loop and the use of amplification in the classroom situation are discussed. opsomming die spraakdiskriminasietellings van 20 gehoorgestremde kinders met 'n gemiddelde ouderdom van 14 jaar is vergelyk tydens gebruik van hulle eie konvensionele gehoorapparate op die mikrofooninstelling en die radio neklussisteem met en sender gebruik van die radio ontvangsmikrofoon. spraakdiskriminasietoetsing in geraas met 'n sein tot ruisverhouding van +20db, +10db en odb is uitgevoer. ten einde die frekwensieresponsveranderinge te bepaal wanneer die gehoorapparaat, gekoppel aan die neklussisteem op die induksielusinstelling geplaas word, is elektroakoestiese metings van die gehoorapparate wat gebruik is, uitgevoer. resultate het die uitstekende werkvermoe van individuele gehoorapparate in 'n gunstige sein tot ruisverhouding van +20db beklemtoon. spraakdiskriminasietellings is nie betekenisvol geaffekteer deur die gebruik van die omgewingsmikrofoon wat aan die radio ontvanger gekoppel was. die implikasies rakende die radio neklussisteem en die gebruik van amplifikasie in die klaskamersituasie word bespreek. the importance of auditory stimulation for hearing impaired children cannot be over-emphasised. such children, particularly those with severe or profound hearing losses, need to derive maximum benefit from amplification if they are to undergo auditory training with the ultimate aim of communication. in the past, hearing losses of more than 85 db or 90 db have been considered virtually unaidable injso far as they could be expected to contribute to the recognition of speech. during the last decade, in educational situations, the writer has seen a total change in expectations. whereas children with a hearing loss of 90 db or more would have been classified as severely/profoundly deaf, and referred to schools for the deaf, nowadays, a child with a 90 db loss would be expected to function as partially hearing and often would be integrated into ordinary schools. ! one of the main problems facing any hearing aid user, and especially children who integrate into ordinary classrooms, is the varying acoustic conditions throughout the school. hearing aids amplify and possibly distort both the desired speech signals and any environmental noises having components between the effective high and low frequency cut-offs. hearing aid users have to adjust to the fact that whatever signal-to-noise ratios exist from moment to moment at the face of the microphone will also exist in their ear canals except at higher levels for both speech and noise. one of the major acoustic problems facing hearing impaired children in educational settings is noisy reverberent classrooms. (john 1957; sanders 1965; finitzo-hieber 1978; ross & giolas 1972). several studies have shown that hearing impaired listeners require a higher signal-to-noise ratio thlan normal listeners in order to achieve their maximum speech discrimination score. gengel (1971) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 reported that hearing impaired subjects rated as relatively effortless, listening conditions of -i-17 db s/n ratio for fluctuating noise and +20 db s/n ratio for constant noise. in contrast ratios less than +10 db required so much effort that the subjects indicated that under these conditions "they would prefer not to use their hearing aids but to rely on speech reading and manual communication'', (gengel 1971). nabelek and pickett (1974) report that a signal-tonoise ratio of +10 db "is the lowest ratio that should be considered for hearing impaired listeners wearing hearing aids in reverberent rooms". radio aids one of the ways of reducing the damaging effect of noise and reverberation is to ensure that the child receives the teacher's speech in the most favourable signal-to-noise ratio relationship possible. it seems reasonable to assume that if the distance between the teacher and the microphone of the child's amplifying system could be reduced, his ability to understand the teacher's speech should substantially increase. hearing aids not entirely worn on the person — more commonly referred to as radio aids, seem to meet this requirement and have been used increasingly in the united kingdom over the last 10-12 years. much of the earlier research on radio aids had been concerned with design, construction, batteries, acoustic gain, dynamic range and compression (n.c.t.d. 1976, bates and holsgrove 1979). markides, huntingdon and kettlety (1980) compared a range of hearing aids including infra red systems, radio aids and speech training units. markides et al. reported disappointment with radio aids as they "did not fulfil their theoretical potential". however, the authors did note that in poor listening conditions, radio aids have much to © sasha 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 78 asoka moodley be said for them. in recent years there has been a sharp increase in the use of personal f.m. systems. the "radio received" signal picked up by the child's radio receiver is passed on to his hearing aid for amplification in one of two ways: (i) by direct connection (audio input), (ii) by loop induction which involves the child wearing the loop of cord around his neck and under his clothes (neck loop). it is mainly to neck loops that this study is directed. in the neck loop system the child sets his hearing aids to the telecoil at "mt" position. the electrical signal from the f.m. receiver is routed to the small loop of cord worn around the neck. this neck loop emits an electromagnetic field that is picked up by the telecoil of the child's hearing aid, amplified by the aid, transduced by its receiver and delivered via the earmould to the child's ear. if the child's hearing aid does not have the "mt" facility, it is possible for him to use a receiver which has an inbuilt environmental microphone. both the radio neck loop and direct audio input systems are very attractive to schools and students in further education and there is now widespread use of these systems throughout the united kingdom. however, very little is known about the ways in which incorporation of the personal hearing aid into the direct audio input or neck loop fm system alters the characteristics of the sound delivered to the child's ear and what effect these systems have on the discrimination of speech in various listening conditions. hawkins and van tasell (1982) reported that the frequency response of the hearing aid altered when used with the neck loop and they went on to suggest that "the altered frequency response due to the fm neck loop configuration can be expected to affect speech perception differently for each hearing impaired child". they found that the frequency response curves for post-aural aids in the microphone and direct audio input modes are virtually identical being ±2 db from 250-6300 hz. most investigators agree that the frequency response of a hearing aid inductance loop system is frequently different from that of the hearing aid operating on the microphone input. however there is some conflicting data on the nature of this difference. hodgson and sung (1971) report relatively greater gain in frequencies below lkhz when the hearing aid is operating via the telecoil mode. nolan (1982), on the other hand, looked at various hearing aids and was very critical of the low frequency amplification that most aids afforded on the telecoil setting. his findings are supported by barr-hamilton (1978), matkin and oslen (1970) and huntingdon (1976) whose studies show that the low frequency gain dropped sharply when the hearing aid was switched from the microphone to the telecoil position. sung, sung and hodgson (1973) noted fluctuations of between 8 db to 30 db when a hearing aid was switched from microphone to telecoil setting. kortschot (cited by b0rrild (1968)) reported that hearing impaired children showed significantly better speech discrimination scores when using the inductance loop than with conventional hearing aids. on the contrary, vargo et al (1970), found that speech signals were significantly less intelligible when the hearing aid operated on the telecoil setting than on the microphone setting. one factor that is common to all the studies, and something about which there is little disagreement, is that changes do take place in the frequency characteristics of hearing aids when they are switched from the microphone setting to the telecoil setting. method aims of the study the present study was undertaken with four aims in mind: 1. to examine the speech discrimination abilities of hearing impaired children using their conventional hearing aids and radio neck loop in conditions where signal-to-noise ratios of +20db, +10db and odb were used. 2. to find out whether there was any significant difference in the speech discrimination scores of children when use was made of the environmental microphone on the radio receiver. 3. to examine and compare the electroacoustic characteristics of the aid set on the telecoil position coupled to the radio neck loop and the microphone setting of the aid. 4. to ascertain the noise levels generated in the hearing aid on the telecoil setting compared to the microphone setting. subjects twenty hearing impaired children of average age 14 years 0 months, with an age range of 10 years 10 months 16 years 6 months, took part in this study. the average hearing loss in the better ear averaged across the frequencies 250hz-4khz, was in the range 47 db to 88 db. all the children had sensori-neural hearing losses and the onset of deafness was at birth or in the first eighteen months of life. all the children were regular hearing aid users. eighteen of the children wore binaural post-aural aids and two of the children were monaural users of post-aural aids. relevant particulars of the children who took part in the study are shown in tables 1 and 2. table 1 number, age, sex and hearing levels of children taking part sex no. mean age in years range hearing levels in db average 250-4khz in the better ear. mean range boys 12 13.5 10.10-14.10 72.0 49 -87 girls 8 14.5 13.11-16. 6 67.7 44.5-87 boys & girls 20 14.0 10.10-16. 6 69.35 47 -88 i table 2 hearing aids used by the children all children wore post-aural aids 18 were binaural users 2 were monaural users types of hearing aid used n.h.s. b.e.51 = 6 n.h.s. b.e.ll = 4 philips hp8276 = 4 siemens pp.agc = 2 widex = 1 oticon e22p = 1 philips hp8273 = 1 phonak pp-c = 1 20 / physical arrangement of the room and equipment the tests were carried out in an acoustically treated room measuring 18 feet by 14 feet. the floors were fully carpeted, the windows were curtained, and the walls and ceilings were covered with acoustically treated tiles. the conditions were as ideal as could be expect/ the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) speech discrimination abilities of hearing-impaired children using conventional hearing aids 7 9 ed. the reverberation time was within acceptable limits (approx. 0,5 sec.). 5' radio transmitter mic. 6 " speech 14' figure 1 physical arrangement of the free-field speech discrimination test. figure 1 shows the physical arrangements of the free-field speech discrimination test. the child was seated 5 feet from the speaker delivering the speech. the transmitter/microphone was supported by a chemical stand 6" from the spjeaker in order to simulate classroom-listening conditions. two speakers delivering the wide-band noise were positioned at a 45° angle to each ear of the child and placed five feet away, on a level plane with the ear. 1 the a.b. word lists were recorded on tape and played through a tandberg 6000x tape recorder via a jessops speech audiometer attachment (s. a. a.) number 420 terminating in a chartweil ls3/5a speaker. competing noise, which was white noise shaped as cocktail party noise, was also recorded on tape and played through a uher type 4000l tape recorder via a jessop speech audiometer attachment (saa) number 420 terminating in two chartweil ls3/5a speakers. both speech audiometer attachments were calibrated at 5 db intervals. the speech signal was always presented at the same intensity level of 130 db (saa) dial reading. the intensity of the competing noise (using the saa reading) was varied accordingly to obtain signal-to-noise ratios of +20db, +10db and odb. at the beginning of both the speech and the noise tapes a 1 000 hz pure tone was recorded for calibration purposes (0 db vu meter deflection on the saa). the 130 db dial reading for speech was equivalent to speech peaking at 70 dba, and the 125 db dial reading for noise was equivalent to 70 dba. the measurement was carried out with a β. & k. sound level meter type 2203 (linear mode) at 5 feet distance from the speakers at the position where the child was seated. procedure speech discrimination testing each subject was tested separately using his own hearing aid on the microphone setting, using the radio neck loop with the environmental microphone, and using the radio neck loop without the environmental microphone. subjects were tested in three signal-to-noise ratios for each mode of listening: s/n +20db; s/n +10db; s/n odb. each subject was asked to listen carefully to speech prior to each listening condition (a few a.b. words were given) and to adjust the volume control of his hearing aid to his/her most comfortable listening level. the subject was asked to select at random a card on to which the three modes of listening, the three signal-to-noise ratios, and the word list for each listening condition were indicated in randomized order. each child was then instructed as follows: you are going to hear some words. you will also hear some hissing noise from the speakers behind you. listen carefiilly to the words and repeat each word whatever you think you heard. even if you hear part of a word or a word that does not make sense, or even a single sound like 'p' or y please repeat it. children were asked to switch from using their hearing aid microphone, to using the neck loop with their hearing aids set to the telecoil position, according to the cards they selected. the environmental microphone of the radio receiver was switched on and off according to the card they had chosen. a careful note was made of the volume setting of the hearing aids and the radio receiver as these were to be used in electroacoustic measurements after the speech discrimination test. the responses of each child for each listening condition and at each signal-to-noise ratio were recorded on specially designed forms and later on, scored, based on the number of phonemes correctly repeated. electroacoustic measurements electroacoustic measurements were carried out on the child's hearing aid using the phonic ear hc1000 acoustic test computer. (i) the hearing aid was tested as an ordinary aid on the microphone setting at the child's usual volume setting. the internal noise of the hearing aid in this mode was measured by pressing the test push button on the test box. this cuts out the signal going to the hearing aid microphone and thus a measure of the noise being generated by the hearing aid is obtained, (ii) measurements were then carried out with the child's hearing aid set to the telecoil position and linked to the radio receiver. the hearing aid was coupled to the 2 cm3 coupler of the test box and placed on a tailor's dummy at a position closely approximating the way the hearing aid would normally be worn by the child. the neck loop was placed around the neck of the dummy. the internal noise of the hearing aid at the telecoil setting was then measured in the manner described above. a record of all the electroacoustic measurements was made on specially designed forms and graphs were plotted. as a final measure, the hearing aid set on the telecoil position was moved around gradually within the neckloop and observations were noted of any fluctuations in output of the aid as it was positioned in different parts, within the magnetic field created by the neck loop. after the whole sample had been tested, one third of the sample was chosen at random and· re-tested on all the measures. t die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 80 asoka moodley results speech discrimination scores a comparison of the mean speech discrimination scores achieved with the conventional hearing aid on microphone setting and the radio neck loop at three signal-to-noise ratios is shown in table 3. all this information is shown graphically in fig. 2. the results were analysed using "t" tests of significance to find out how the different hearing aids performed under conditions of noise. table 3 comparison of mean speech discrimination scores (% phonemes) of hearing aid microphone and radio neck loop at 3 different s/n ratios. faired t test values and levels of significance are given s/n ratios hearing aid microphone radio neck loop plus env. mic. radio neck loop minus env. mic. s/n +20db 74,8% 72,3% t = 0,62 n/s at 0,05 or 0,01 level 66,5% t = 2,08 significant at 0,05 level s/n +10db 57,6% 74,3% t = 3,8 significant at 0,05 and 0,01 level 68,1% t = 2,62 significant at 0,05 and 0,01 level s/n odb 36,1% 63,5% t = 4,85 significant at 0,05 and 0,01 level 63,5% t = 4,82 significant at 0,05 and 0,01 level s/n +20db the most favourable signal-to-noise ratio was +20db when the conventional hearing aid was on its microphone setting producing a mean speech discrimination score of 74,8% and 72,3% when the radio neck loop was used with or without the environmental microphone of the radio receiver. 1 50 ) — ) / / x = he arint x k ll ck u aid oop v >op u mil. (itii ithol in vir jt en dnme yirols ntal m e n ! mic. al μ 1c. c ο = ni = ne arint x k ll ck u aid oop v >op u mil. (itii ithol in vir jt en dnme yirols ntal m e n ! mic. al μ 1c. τ 1 , +20 figure 2 mean speech discrimination scores for individual hearing aids and radio neckloop. s/n +10db at a signal-to-noise ratio of +10db, the performance of the hearing aid falls 17,2% while the performance of the neck loop remained much the same. at this signal-to-noise ratio there is a significant difference between the performance of the conventional hearing aid when compared to the performance of the neck loop, with and without the environmental microphone (p>0.01). s/n odb the most unfavourable signal-to-noise ratio was odb, when a marked deterioration in the performance of the conventional hearing aid on its microphone setting was noted. this represents a fall of 38,7% when considering the performance at s/n +20db. there is a significant difference between the performance of the conventional hearing aid and the radio neck loop (p>0.01). these results show that background noise affects both types of hearing aids but that the conventional hearing aid on its microphone setting is more adversely affected by noisy conditions. as the noise level increases the performance of the conventional hearing aid rapidly deteriorates (see figure 2). use of the environmental microphone on radio receiver paired "t" tests of significance were undertaken to find out what effect, if any, the environmental microphone had on the performance of the radio neck loop at the three signal-to-noise ratios used in the study. table 4 illustrates the results and shows levels of significance. i table 4 comparison of mean speech discrimination scores (% phonemes) of radio neck loop with and without use of the environmental microphone at 3 different s/n ratios. paired t test values and levels of significance are given. | s/n ratios radio neck loop with env. microphone radio neck loop without 1 env. microphone s/n +20db 72,3% 66,5% t = 1,3 n/s s/n +10db 74,3% 68,1% t = 1,85 ' n/s s/n odb 63,5% 63,5% x = 0 . ' ' ' n/s when the performance of the neck loop with environmental microphone was compared to its performance without the environmental microphone at similar signal-to-noise ratios no significant differences were found. in other words, at similar signal-to-noise ratios, / the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) s p e e c h discrimination abilities of hearing-impaired children using conventional hearing aids table 5 test-retest-reliability of speech discrimination scores mean phoneme discrimination in % 81 hearing aid mic. radio neckloop + env. mic. radio neckloop — env. mic. test s.d. retest s.d. r test s.d. retest s.d. r test s.d. retest s.d. r signal-to-noise ratio in db. +20db 75.5 14.0 74.9 11.9 .94 74.9 15.1 77.1 13.8 .96 74.9 9.5 74.4 6.57 .85 +10db 60.5 20.1 66.6 17.7 .82 79.3 10.4 77.2 10.4 .95 71.65 9.7 72.1 9.48 .84 odb 38.85 26.2 47.15 20.1 .75 61.5 16.9 61.0 16.0 .92 66.1 21.8 66.5 15.6 .97 the use of the environmental microphone did not significantly affect discrimination for speech. on the other hand, the use of the environmental microphone at s/n +20db compared to the use of the environmental microphone at s/n odb produced a significant difference at the 0.05 level of confidence. this appears to indicate that while the environmental microphone has no adverse effect on speech discrimination in reasonable levels of background noise, it should not be used in extremely noisy conditions, especially when the source of the noise is close to the environmental microphone. test — retest reliability of speech discrimination scores the test retest reliability of the speech discrimination scores was ascertained by retesting a third of the sample chosen at random: the mean speech discrimination scores of the children in both the test and retest reliability sessions are shown in table 5. the values of the pearson coefficient of correlation (r) between the original and retest scores of the children are also shown. the mean scores of the children in both the test and retest sessions were very similar indicating a high degree of reliability. electroacoustic measurements large differences were noted between the performance of the hearing aid on its microphone setting as compared to the performance of the hearing aid when used in the "t" position, in conjunction with the heck loop. in nearly all cases the performance of the aid with the neck loop was inferior to its performance on the microphone setting. similar hearing aids at identical volume settings produced frequency response curves on the telecoil setting which were^ sometimes vastly different. i internal noise generated by the| hearing aids noise levels generated in all the hearing aids used in conjunction with the neck loop were much higher than noise levels generated in the hearing aids when used on the microphone setting. it is clear from the results that the transduction of the signal by the loop causes an increase in the internal noise that reaches the users eardrum. table 6 shows the noise levels generated by hearing aids when used as an ordinary aid and when the aid is used with the neck loop. , 2 , ^ • _ ^ k \ ν 3 , ' ιικλκγ = telec 1g aid ογ oil sett • ιικλκγ = telec 1g aid ογ oil sett ing 0 250 500 ik 2k 3k 4k 5k frequencies in hz figure 3 b.e. volume 3 rec. vol. 4.5 hearing aid set on "t" position and coupled with neckloop held at three different positions in relation to the neckloop. the effect of distance of the hearing aid from the neck loop it was found that by moving the hearing aid arbitrarily at different positions within the neck loop there was a great fluctuation in the output of the hearing aid. the effect of distance of a hearing aid from the neck loop is shown in fig. 3 where aid b.e.11 is given as an example. numbers 1, 2 and 3 show the three different positions the hearing aid was held at in relation to the neck loop. these large differences in the output of the hearing aid could well result when children tilt their heads, or bend forwards or backwards in the course of the day. in addition, average gain will vary from child to child depending on neck lengths (hawkins and van tasell 1982). constantly fluctuating gain due to the child's head movements could be very distracting to a child and could well affect his ability to perceive speech adequately. discussion most workers in the field of audiology agree that the use of speech discrimination tests both in quiet and noise is the most adequate approach to the evaluation of hearing aids. in the present study there was no statistically significant difference between conventional hearing aids normally worn by the children, and the radio neck loop at a signal-to-noise ratio +20db, that is, under good acoustic conditions. the differences only became apparent under conditions of noise. there is no doubt that individual post-aural hearing aids, when they have been correctly prescribed, are working at maximum efficientable 6 internal noise levels (shown in db) generated in the various types of hearing aids used in the study. type of noise noise difference hearing aid generated generated ' in noise on telecoil on mic. levels setting setting b.e.51 108 88 20 b.e.i 1 88 68 20 widex ao pp 78 68 10 otikon e22p 98 78 20 phonak super front 88 78 10 philips hp8273 92 85 7 siemans 24pp-agc 88 | 78 10 philips hp8276 76 56 20 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 82 asoka moodley cy, and are used in good acoustic conditions have much to offer. their most positive advantage is that they are small and hence more cosmetically acceptable. they can be worn throughout the day both in school and after school. they are more readily acceptable particularly to teenagers because they can easily be concealed. the results of this study highlighted their excellent performance under favourable acoustic conditions. at a s/n of +20db, their performance surpassed that of the radio neck loop, though the difference in mean discrimination scores did not approach statistical significance. however.under poor acoustic conditions such as noisy classrooms and at a distance from the speaker, individual hearing aids rapidly lose their effectiveness. this study has shown that at a signal-to-noise ratio of +10db the performance of the individual aids falls from 74,8% to 57,6% and at a signal-to-noise ratio of odb the performance of the individual aids falls a further 21,5%. thus there is an overall deterioration of over 38 % in poor acoustic conditions. in many classroom conditions, the distance between the nearest desk and the blackboard (where the teacher would normally stand) is rarely less than six feet. at such distances a pupil using an individual hearing aid would lose much of the information which would be constantly buried in background noise. most ordinary classrooms have high levels of background noise. this combined with distance from the teacher make individual hearing aids almost useless in such classrooms. in recent years with accumulating evidence on the detrimental effects of noise and reverberation on speech perception, there has been widespread use of radio aids. this study confirms the need for some, type of radio system in the education of hearing impaired children. the more recent radio aids which incorporate the use of the child's individual hearing aid have become increasingly popular and at the moment seem to provide the answer to noise and reverberation problems. an examination of the results of this study shows that the radio neck loop certainly has advantages over the individual hearing aid in conditions of noise. at a signal-to-noise ratio of odb (the most unfavourable signal-to-noise ratio in this study) the performance of the individual aids falls by 38,7%, while the performance of the radio neck loop falls to under 10%. furthermore the use of the environmental microphone does not adversely affect speech discrimination scores at any of the signal-to-noise ratios in this investigation. this is an important consideration as it is vital for children to be able to hear their own voices and environmental sounds. it is important to bear in mind that the scores achieved with the use of the neck loop in this study relate to a group of children who normally make extensive use of the inductance loop at school and have been doing so for several years now. the children use the telecoil facility of their hearing aids to watch television. they use it in the hall and chapel almost daily and most of the classrooms are looped. these children then,,have extensive experience of perceiving speech through the telecoil facility of their hearing aids. young, inexperienced hearing aid users who have not been exposed to similar experience of using the telecoil facility of their hearing aids might 'not be in a similar position and may suffer a loss in speech discrimination resulting from the changes in the frequency response of the hearing aid which take place. secondly, during the test situation, children sat upright with the neck loop carefully positioned around their necks and there was little likelihood of fluctuation in the strength of the speech signal. this is not the case in the day-to-day use of the radio neck loop in a classroom where children are moving around and moving their heads from side to side. the teacher cannot assume that the child using the radio neck loop is receiving the same signal as when the individual hearing aid is worn in the microphone mode. all the hearing aids used in the study showed that when the hearing aid was used in conjunction with the neck loop, there was a change in the frequency response of the hearing aid. in most cases the greatest change occurred in the lower region of the frequency range. this would therefore have serious limitations for profoundly hearing impaired children who depend almost entirely on lower frequencies for their information. the study also showed that the location of the hearing aid in relation to the neck loop is a critical variable and a matter of great concern to users of the neck loop. the great fluctuation in the output of the hearing aid as it is moved around within the neck loop can cause the child to lose audibility of the signal as he moves his head about. older children who are experienced hearing aid users, and those who have less severe hearing impairments, may be sensitive to this and make the necessary adjustments. young, inexperienced hearing aid users are less discriminating in their use of hearing aids and will suffer a loss in perception of the speech signal. the general implication resulting from this study is that more attention should be given to the performance characteristics of hearing aids used in conjunction with the radio neckloop. not only do different hearing aids show different sensitivity for loop induction, but when hearing aids are chosen for their performance on the microphone setting, these advantages are lost when the hearing aid is coupled to the radio neck loop and has to be used on the telecoil setting of the aid. in view of the number of limitations that the radio neck loop has, it should not be the radio system of choice when considering the provision of radio systems for children. what is required is a system that offers all the advantages of reducing noise and reverberation and yet preserves the frequency response of the hearing aid that has been prescribed for the child. the performance of a radio microphone hearing aid system should be equivalent on both audio and radio channels. this means that a child does not suffer from the change that takes place in the frequency response of the aid when it is switched from the microphone to the telecoil setting. direct audio-input seems to be the answer to this problem. in the study by hawkins and van tasell (1982) it was shown that hearing aids showed a remarkable similarity in frequency response when used with the direct audio input facility, in contrast to the, variable and often unpredictable, microphone-telecoil differences. there is a wide range of hearing aids on the market today and there is more flexibility in the way they can be adjusted to cater for a variety of different hearing losses. individual aids can therefore be chosen and set as far as possible to cater for the special needs of each child's hearing loss. as hearing aids are prescribed largely on the basis of their microphone performance it would make sense to preserve this frequency response while at the same time offering the child the benefits of reduced noise and reverberation that audio input would provide. in addition, the direct audio input system is not susceptible to the effects of distance and hearing aid orientation that has been noticed with the aid coupled to the radio neck loop. thus a child whose hearing aid was specifically prescribed because of the low frequency emphasis which it afforded him would not be at a disadvantage in this respect when the aid was used in conjunction with the audio input facility. acknowledgements the author wishes to express his thanks to: the children at ovingdean hall school in brighton where much of this study was underthe south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) speech discrimination abilities of hearing-impaired children using conventional hearing aids 83 taken; dr michael nolan of the department of audiology, manchester university for his advice and assistance with this study; and mr r. bennett, county hall, beverley for his assistance with the illustrations. references barr hamilton, r.m.a. a theoretical approach to the loop induction system. brit. j. audio., 12, 135-139, 1978. bates, a. and holsgrove, g. the phonic ear. teacher of the deaf, (3), 5, 154-170, 1979. b6rrild, k. the induction loop and its possibilities. in g. liden (ed.) geriatric audiology, almquist and wiksell, stockholm, 1968. finitzo-hieber, τ., and tillman, t.w. room acoustics effect on monosyllabic word discrimination ability for normal and hearing impaired children. j. speech hear. res., 21, 440-458, 1978. gengel, r.w. acceptable speech-to-noise ratios for aided speech discrimination by the hearing impaired. j. audio. res., 11, 219-222, 1971. hawkins, d.b., and van tasell, d.j. electroacoustic characteristics of personal f.m. systems. j. speech hear. disord., 47, 355-362, 1982. hodgson, w.r., and sung, r.j. performance of individual hearing aids utilizing microphone and induction coil input. j. speech hear. res., 14, 365-371, 1971. huntingdon, a. tests on induction loops in current use in schools for the deaf. teacher of the deaf, 74, 7-18, 1976. john, j.e.j. acoustics in the use of hearing aids: educational guidance and the deaf child. manchester university press, 1957. markides a. huntingdon, α., and kettlety, a. comparison of speech discrimination abilities through infra red radio and conventional hearing aids. teacher of the deaf, (4), 5-14, 1980. matkin, n. and oslen, w. response of hearing aids with induction loop amplification systems, amer. annals deaf, 115, 73-78, 1970. nabelek, a.k., and pickett, j.m. monaural and binaural speech perception through hearing aids under noise and reverberation with normal and hearing impaired listeners. j. speech hear. res., 17, 724-739, 1974. national council for teachers of the deaf. the phonic earhc421 fm stereo hearing aid. northern branch hearing aid subcommittee report. national council for teachers of the deaf. u.k., 1976. nolan, m. hearing aids for children. teacher of the deaf, (6) 5, 122, 1982. ross, m., and giolas, t.g. audiology management of hearing lmpaird children: principles and prerequisites for intervention, university park press, baltimore, 1980. sanders, d. noise conditions in normal school classrooms excep. children, 31, 344-551, 1965. sung, r.j. sung, g.s., and hodgson, w.r. telecoil versus microphone perforrrgnce in hearing aids. volta review, 19, 15, 417-424, 1973. vargo, s.w., taylor g., and tannahill, j.c. the intelligibility of speech by hearing aids on induction loop and microphone modes of signal reception. j. speech hear. res., 13, 87-91,1970. address for reprints: t.a. moodley, hearing impaired service, lowfield lane, melton, n. ferriby, n. humberside, hu14 3ht, england. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aids for plus the development of perception the acquisition of speech and language skills the improvement of motor co-ordination helpful texts for therapists educational toys, books and equipment records for auditory training catalogues on request large variety of tests available stockists of learning to listen two sound lottos full lda range ο play and schoolroom 44 president place, 148 jan smuts ave., rosebank. telephone 788-1304 p.o. box 47288, parklands 2121. x the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) information for contributors the south african journal of communication disorders publishes reports and papers concerned with research, or critically evaluative theoretical, or therapeutic issues dealing with disorders of speech, voice hearing or language, or on aspects of the processes underlying these. the south african journal of communication disorders will not accept material which has been published elsewhere or that is currently under review by other publications. all contributions are reviewed by at least two consultants who are not provided with author identification. form of manuscript. authors should submit four neatly typewritten manuscripts in triple spacing with wide margins which should not exceed much more than 25 pages. each page should be numbered. the first page of two copies should contain the title of the article, name of author/s, highest degree and address or institutional affiliation. the first page of the remaining two copies should contain only the title of the article. the second page of all copies should contain only an abstract (100 words) which should be provided in both english and afrikaans. afrikaans abstracts will be provided for overseas contributors. all paragraphs should start at the left margin and not be indented. major headings, where applicable, should be in the order of method, results, discussion, conclusion, acknowledgements and references. tables and figures should be prepared on separate sheets (one per table/figure). figures, graphs and line drawings must be originals, in black ink on good quality white paper. lettering "appearing on these should be uniform and professionally done, bearing in mind that such lettering should be legible after a 50% reduction in printing. on no account should lettering be typewritten on the illustration. any explanation or legend should not be included in the illustration but should appear below it. the titles of tables and figures should be concise but explanatory. the title of tables appears above, and of figures below. tables and figures should be numbered in order of appearance (with arabic numerals). the amount of tabular and illustrative material allowed will be at the discretion of the editor (usually not more than 6). references. references should be cited in the text by surname of the author and date, e.g. van riper (1971). where there are more than two authors, et al. after the first author will suffice. the names of all authors should appear in the reference list. references should be listed alphabetically in triple-spacing at the end of the article. for acceptable abbreviations of names of journals, consult the fourth issue (october) of dsh abstracts or the world list of scientific periodicals. the number of references used should not exceed much more than 20. note the following examples: locke, j.l. clinical phonology: the explanation and treatment of speech sound disorders. j. speech hear. disord., 48, 339-341, 1983. penrod, j.p. speech discrimination testing. in j. katz (ed.) handbook of clinical audiology, 3rd ed., baltimore: williams & wilkins, 1985. van riper, c. the nature of stuttering. englewood cliffs, new jersey: prentice-hall, 1971. proofs. galley proofs will be sent to the author wherever possible. corrections other than typographical errors will be charged to the author. reprints. 10 reprints without covers will be provided free of charge. all manuscripts and correspondence should be addressed to: the editor, south african journal of communication disorders, south african speech and hearing association, p.o. box 31782, braamfontein 2017, south africa. inligting vir bydraers die suid-afrikaanse tydskrif vir kommunikasieafwykings publiseer verslae en artikels oor navorsing, of krities evaluerende artikels oor die teoretiese of terapeutiese aspekte van spraak-, stem-, gehoorof taalafwykings, of oor aspekte van die prosesse onderliggend aan hierdie afwy kings. die suid-afrikaanse tydskrif vir kommunikasieafwykings sal nie materiaal aanvaar wat reeds elders gepubliseer is, of wat tans deur ander publikasies oorweeg word nie. alle bydraes word deur minstens twee konsultante nagegaan wat nie ingelig is oor die identiteit van die skrywer nie. formaat van die manuskrip. skrywers moet vier netjies getikte manuskripte in 3-spasiering en met bree kantlyn indien, en dit moet nie veel langer as 25 bladsye wees nie. elke bladsy moet genommer wees. | op die eerste bladsy van 2 afskrifte moet die titel van die artikel, die naam van die skrywer/s, die hoogste graad behaal en die adres of naam van hulle betrokke instansie verskyn. op die eerste bladsy van die oorblywende twee afskrifte moet slegs die titel van die artikel verskyn. die tweede bladsy van alle afskrifte moet slegs 'n opsomming (100 woorde) in beide engels en afrikaans bevat. afrikaanse opsommings sal vir buitelandse bydraers voorsien word. alle paragrawe moet teenaan die linkerkantlyn begin word en moet nie ingekeep word nie. hoofopskrifte moet, waar dit van toepassing is, in die volgende volgorde wees: metode, resultate, bespreking, gevolgtrekking, erkennings en verwysings. tabelle en figure moet op afsonderlike bladsye verskyn (een bladsy per tabel/illustrasie). figure, grafieke en lyntekeninge moet oorspronklike weergawes wees en moet in swart ink op wit papier van 'n hoe gehalte gedoen word. letterwerk wat hierop verskyn moet eenvormig wees, professioneel gedoen word en daar moet in gedagte gehou word dat dit leesbaar moet wees na 'n 50%-verkleining in drukwerk. letterwerk by die illustrasie moet onder geen omstandighede getik word nie. de suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 verklarings of omskrywings moet nie in die illustrasie nie, maar daaronder verskyn. die byskrifte van tabelle moet bo-aan verskyn en die van figure onderaan. tabelle en figure moet in die volgorde waarin hulle verskyn genommer word (met arabiese syfers). die hoeveelheid materiaal in die vorm van tabelle en illustrasies wat toegelaat word, word deur die redakteur bepaal (gewoonlik nie meer as 6 nie). verwysings. verwysings in die teks moet voorsien word van die skrywer se van en die datum bv. van riper (1979). waar daar meer as twee skrywers is, sal et al. na die eerste skrywer voldoende wees. die name van alle skrywers moet in die \ferwysingslys verskyn. verwysings moet alfabeties in 3-spasiering aan die einde van die artikel gerangskik word. vir die aanvaarde afkortings van tydskrifte se titels, raadpleeg die vierde uitgawe (oktober) van dsh abstracts of the hbrld list of scientific periodicals. die getal verwysings wat gebruik is, moet nie veel meer as 20 wees nie. let op die volgende voorbeelde: locke, j.l. clinical phonology: the explanation and treatment of speech sound disoiders. j. speech hear. disord., 48, 339-341, 1983. penrod, j.p. speech discrimination testing. in j. katz (ed.) handbook of clinical audiology, 3de ed., baltimore: williams & wilkins, 1985. van riper, c. the nature of stuttering. englewood cliffs, new jersey: prentice-hall, 1971. proewe. galeiproewe sal waar moontlik aan die skrywer gestuur word. die onkoste van veranderinge, behalwe tipografiese foute, sal deur die skrywer self gedra moet word. herdrukke. 10 herdrukke sonder omslae sal gratis verskaf word. alle manuskripte en korrespondensie moet gerig word aan: die redakteur, die suid-afrikaanse tydskrif vir kommunikasieafwykings. die suid-afrikaanse vereniging vir spraaken gehoorheelkunde, posbus 31782, braamfontein 2017, suid-afrika. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pg6-12.html the translation of the vertigo symptom scale into afrikaans: a pilot study christine rogers jacques de wet ayanda gina ladine louw musa makhoba lee tacon division of communication sciences and disorders, department of health and rehabilitation sciences, university of cape town correspondence to: c rogers (christine.rogers@uct.ac.za) abstract dizziness is a common clinical problem that is challenging to diagnose and treat. one of a subset of symptoms that fall under the encompassing term of dizziness is vertigo, which is the subjective experience of hallucination of movement, often associated with vestibular disorders. while dizziness has a broad range of causes, the association between vestibular disturbance, and its attendant vertigo, and anxiety is well established. the vertigo symptom scale (vss) is a questionnaire that assesses aspects of vertigo and vertigo-related anxiety. the aim of this study was twofold. in phase 1, a translation of the vss into afrikaans was evaluated using the delphi consensus technique and two panels of participants. panel 1 comprised first-language afrikaans speakers who commented on the language, grammar and vocabulary of the items. panel 2 were bilingual health care practitioners with either a psychology background or a special interest in vertigo. after two rounds of consultation, consensus was achieved and the final translation of the afrikaans vertigo symptom scale (avss) was agreed upon, as well as a list of afrikaans words descriptive of vertigo. phase 2 used a descriptive, correlational design. the aim was to pilot the avss with a sample of vertiginous and control participants to establish its ability to differentiate between the two groups and to explore experiences of vertigo and anxiety within the two embedded subscales. the results of the pilot study yielded significant statistical differences (p<0.001) between the groups on both subscales of the tool. preliminary results suggest that the avss is able to identify patients with vertiginous disturbance and anxiety. the avss presents with good sensitivity and specificity as measured by the receiver-operating characteristic (roc) curve. afrikaans is the home language of almost 6 million people in south africa. the translation of the vss into afrikaans presents health care professionals with a tool with which to assess vertigo and vertigo-related anxiety in this population. keywords: afrikaans, anxiety, delphi, dizziness, vertigo, vertigo symptom scale, vestibular disorders diagnosis and management of dizziness is challenging and often a source of frustration for the clinician (kerr, 2005). reasons for this difficulty include the subjective nature of the complaints, issues that patients have when trying to describe symptoms, and the broad range of causes, ranging from vestibular to psychological, which could be responsible for the presence of symptoms. dizziness is a general term often used by patients to describe a variety of sensations, which include light-headedness, presyncope and other experiences including vertigo. vertigo is a perception of motion when there is no external source for that sensation (yardley, luxon & haacke, 1994), and is classically associated with vestibular disorders. vertigo may be viewed as a distinct clinical entity along a continuum of symptoms that are broadly described as dizziness. the identification of the presence of vertigo, and its association with vestibular dysfunction, may direct professionals such as otologists and audiologists in their choice of investigations, management and subsequent referrals. for example, it would be mandatory to conduct an audiological assessment in cases of vertigo, while dizziness related to presyncope or cardiac causes would not necessitate such tests. although an appreciation of the difference between dizziness and vertigo is critical for effective diagnosis and treatment, the two terms are often used interchangeably and are confused by both patients and clinicians (mcpherson & whitaker, 2001). attacks of vertigo may be distressing because of the associated autonomic and vegetative symptoms (mégnigbêto, sauvage & launois, 2001). in addition, vertiginous episodes have been associated with anxiety, panic and social phobia (aslan, ceylan, kemaloglu & goksu, 2003; tschan et al., 2008; wiltink et al., 2009). there is increasing evidence of an association between vestibular disorders and activation of areas of the brain concerned with emotion, and in turn with the autonomic nervous system (best et al., 2006; meli, zimatore, badaracco, de angelis & tufarelli, 2007; wiltink et al., 2009). an additional concern regarding the psychological sequelae of vestibular syndromes is that negative or maladaptive coping mechanisms, which include avoidance of stimulation, may reduce compliance with vestibular rehabilitation therapy and ultimately delay recovery (aslan et al., 2003; cohen & kimball, 2003; luxon, 2004; meli et al., 2007). it is therefore suggested that the dual elements of vestibular symptoms and potential psychological involvement are investigated in all patients who present with vertigo. a detailed, systematic and holistic case history, conducted with insight and an empathic manner, is crucial in every case and most likely to result in a diagnosis of the cause of vertigo (bennett, 2008). reliance on sophisticated clinical or laboratory testing in place of, or as an adjunct to, the case history will seldom return a useful diagnosis; indeed, it is the exception that results of formal vestibular tests would influence, or change, management decisions (shepard, 2007). while an accurate case history is essential for effective treatment, anamnesis may be more problematic when there are linguistic and cultural differences between the health care professional and patient, a scenario common in a diverse country such as south africa. a variety of questionnaires have been used in clinical practice in order to identify or assess vertigo symptoms or handicap, as well as related issues such as anxiety. one advantage of questionnaires is to focus patients’ thoughts on their complaints prior to the consultation, allowing the clinician to highlight relevant issues. questionnaires may be used as an entrée to explore areas that may otherwise be difficult to address, for example, probing symptoms of panic or anxiety may elicit a guarded or defensive response. skilfully selected questionnaires add to the completeness of the case history, and results may signal the need for further investigations or referrals. one such questionnaire, the vertigo symptom scale (vss) (yardley, masson, verschuur, haacke, & luxon, 1992), has two embedded subscales; one evaluates vertigo severity and the explores symptoms of somatic anxiety. it was developed after extensive interviews which explored the experience of patients living with vertigo. results from the vss were correlated with independent scales of anxiety and vertigo handicap, as well as diagnostic classification systems and objective testing. the resulting vss has been researched extensively and good reliability and concurrent validity have been established (yardley et al., 1992). the vss is the self-assessment scale targeting vestibular symptoms most used in clinical practice (faag, bergenius, forsberg & langius-eklöf, 2007). it has been translated into a number of languages without losing validity (tschan et al., 2008). the south african context in south africa, almost 6 million people use afrikaans as their home language, making it the third most common language spoken. a further 15 million people are proficient in afrikaans (south africa info, 2001). in the western cape, where this study was conducted, the majority (55.3%) of the population speak afrikaans (statistics south africa, 2004). english language questionnaires exploring health-related quality of life, functional assessments of chronic illness therapy and measures of mental health have been translated into afrikaans using a variety of methods (jelsma & ferguson, 2004; harpham et al., 2003; webster, cella & yost, 2003). efforts have been made to translate audiological materials, such as stimuli for speech recognition, into zulu (panday, kathard, pillay & govender, 2007). while many english language questionnaires are available for exploring aspects of dizziness and vertigo, to the authors’ knowledge none has been translated into other languages spoken in south africa. at present there are no questionnaires available in afrikaans with which to explore the experience of symptoms of vertiginous patients presenting to health care services. given the large numbers of afrikaans speakers nationally and their predominance in the western cape, a self-assessment scale was selected for translation and validation. the vss was selected for this research because of its ability to explore vertiginous symptoms and those of anxiety and panic simultaneously. delphi consensus procedure the delphi consensus procedure is a method often used in health-related research and involves obtaining consensus of opinion from knowledgeable participants through the use of structured questioning in a series of rounds (hasson, keeney, & mckenna, 2000). results from the first round of questions are relayed back to participants in subsequent rounds (de villiers, de villiers & kent, 2005) and in this study suggestions of afrikaans words that would capture the essence of the word vertigo were also sought. delphi procedures are cost-effective methods of gathering information, and in contrast to focus groups, participants are not in contact with each other, or aware of the identities of other panel members (hardy et al., 2004; powell, 2002). use of delphi consensus procedures in audiology is ongoing, with panels currently employing this method to aid the development of international classification of functioning (icf) health core sets for hearing loss (danermark et al., 2010) and vertigo (podlipny, personal communication, 10 october 2010). the aims of this study were to validate a translation of the vss (yardley et al., 1992) into afrikaans, and to conduct a pilot study of the translation’s ability to differentiate between participants with and without complaints of vertigo. the study was conducted in two phases, which will be presented in the ‘method’ section. method study design in phase 1, a delphi consensus procedure was used first, to gain agreement on the translation of the vss from two panels of participants. panel 1 comprised first-language afrikaans speakers, who commented on grammar and vocabulary used. panel 2 were bilingual health care professionals who had experience in treating patients with vestibular disorders. in addition both panels were asked to contribute afrikaans words that captured the essence of the experience of vertigo. in phase 2, a descriptive, correlational design was used and the afrikaans vertigo symptom scale (avss) was piloted among a sample of participants with and without vertigo. phase 1: translation of the vss and delphi consensus procedure the vss was translated from english into afrikaans using the steps depicted in the flow chart (figure 1). the delphi procedure was used to obtain consensus on the translation. conventional delphi designs have four rounds, but this was modified to two rounds as consensus was only sought on the translation of a pre-exisiting, validated scale. phase 1 participants two panels were selected through purposive sampling. panel 1 consisted of 5 first-language afrikaans-speaking lay participants, and panel 2 comprised 5 bilingual health care practitioners from a variety of disciplines, including otolaryngology, audiology, psychology and aviation medicine, who regularly treated patients with vertigo. all except the psychologist had received specialised training in vestibular disorders and were familiar with the vss. phase 1 materials and procedures – delphi consensus rounds 1 and 2 panel 1 answered a list of questions on the language, grammar and vocabulary of items in the translated vss. as the scale was to be directed at patients, the translation needed to be comprehensible to lay individuals. questions for panel 2 centred on the applicability of items to the afrikaans patient population to which practitioners were exposed, as well as to verify the use of vocabulary chosen to explain terms such as ‘giddy’. panel 2 was also polled with regard to words commonly used by their patients to describe the experience of vertigo. both panels were consulted regarding the afrikaans translation and equivalence with the english original. panelists selected answers from a 5-point likert scale ranging from ‘strongly agree’ to ‘strongly disagree’; in addition qualitative comments were invited. examples of questions asked of the panels are indicated in box 1 below. • a patient who reads ‘swewing’ will make the association with a feeling of ‘swimming, floating or soaring’ (item 7). • do you think that ‘dofheid’ encompasses the essence of visual ‘blurring’ (item 13)? box 1. example of questions posed to the panellists participating in the delphi consensus procedure, round 1. there is a lack of agreement in the literature as to what percentage is acceptable as consensus, with values ranging from 55% to 100% (powell, 2002). an 80% majority was chosen as it represented a robust majority leaving less room for errors (hardy et al., 2004). when 80% consensus was achieved no changes were made to the initial translation. round 2 of the delphi consensus addressed items from round 1 upon which consensus had not been achieved. panel members were able to re-evaluate their opinion based on the responses and suggestions from both panels that were presented verbatim (greatorex & dexter, 2000). respondents had to ‘agree’ or ‘disagree’ with each item. for round 2 a majority consensus of ≥51% finalised the changes. an example of one of the questions from round 2 appears in box 2. the results of the delphi consensus are the avss (appendix 1), and a list of afrikaans words used to describe the subjective experience of vertigo (see box 3 in the ‘results’ section). for item 4, both panel 1 and panel 2 agreed by majority that ‘ neerval ’ is an appropriate translation for ‘fall’. however, other suggestions were made. choose the item that you most agree with. do you agree with a) ‘ neerval ’ agree/ disagree or the suggestion b) ‘ omval ’ agree/ disagree box 2. example of questions posed to the panellists participating in the delphi consensus procedure, round 2. phase 2: pilot study of the avss phase 2 piloted the avss and used descriptive correlational statistics to analyse the results. there were two aims for phase 2: first, to assess and describe the relationship between the participants’ presenting symptoms and their scores on the avss for the anxiety and vertigo subscales; and second, to demonstrate whether the avss could discriminate between vertiginious and control participants. phase 2 participants as both a non-vertiginous group and group of participants with vertigo were sought, all adult patients attending ent outpatient services were asked if they were interested in enrolling in the research study. phase 2 participants who reported that their first language was afrikaans and who were capable of completing the avss unassisted were selected using a purposive non-randomised sampling method. the delphi consensus procedure generated key terms used to describe vertigo (see box 3), and symptoms reported by participants within the last 3 months had to match one or more of these terms for participant inclusion in the vertiginous group; control subjects reported no vertigo within the same period. eighty-five patients gave consent; subsequently 13 were excluded because the questionnaire was returned incomplete. the sample consisted of 72 participants, of whom 50 were female. vertigo was present in 41 participants and 31 were controls. the age of participants with vertigo ranged from 20 to 82 years (mean 49 years), and that of the controls from 27 to 81 years (mean 45 years). the median schooling level was grade 10, mode of grade 12 (n=72). ethical clearance the research protocol was designed in accordance with the declaration of helsinki (world medical association, 2008). ethical clearance was obtained from the institution’s human research ethics committee as well as from the two hospitals at which data were collected. informed consent was obtained from all participants for both phases of the study. professor lucy yardley granted permission for the use of the vss, its translation and naming as the afrikaans vertigo symptom scale (yardley, personal communication, january 2009). phase 2 materials and procedures once informed consent was obtained, participants completed the screening questionnaire assessing the main reason for the visit: presence of previous and current symptoms of vertigo, panic, anxiety, depression and medication use. the avss was completed and participants were divided into vertiginous and control groups based on the results of the screening questionnaire. statistical analysis the diagnosis was recorded from the hospital folder. data were initially entered into microsoft office excel 2007 (v. 12.0.6300.5000). data from 10% of the sample were re-analysed at random to check for reliability of data capturing. the statistica (v. 8) package and statistical package for social sciences (spss) (v. 15) were used for statistical analysis. cronbach’s alpha assessed internal consistency. the mcnemar test determined the classification congruence between the participants’ presenting complaint of vertigo, or the lack thereof, and their diagnosis. the adjusted t-test and mann-whitney u were conducted. the receiver-operating characteristic (roc) curve was used as a visual index of the accuracy of the avss and analysed sensitivity and specificity. results phase 1 the researchers who performed the initial translations found that the two independent preliminary translations were very similar. furthermore, no substantial differences were found when the initial forward and back translations were compared. in round 1, the first-language afrikaans panel reached consensus on 22 of 31 items. the health care professional panel agreed on 22 of 32 questions. round 2 consisted of 21 questions, 19 of which had suggestions included. consensus was achieved for all of the 21 questions in round 2 and the avss was finalised. participants mentioned that the layout of the avss made it challenging to complete, so the format (but not the content) was reworked to make it more accessible. for example, response options were arranged in boxes for participants to tick or circle. the terms suggested by the panellists for afrikaans synonyms for vertigo appear in box 3. • rondomtalie, tuimel, bollemakiesie, mallemeule, tol • ‘draai’ (patient or the environment) • draaiduiseligheid • dronk/kop-dronkheid • ‘ek beweeg hierdie kant toe, die wêreld anderkant toe.’ box 3. words and terms that were obtained from qualitative feedback in round 1 of the delphi technique describing the symptom of vertigo. phase 2 the vss evaluates two areas – the experience of vertigo, dizziness and imbalance (ver subscale) and symptoms of anxiety and related psychological problems, the anxiety and autonomic symptom scale (aa subscale). cronbach’s alpha indicated good internal consistency on the ver subscale (α=0.8822) and the aa subscale (α=0.9248), i.e. the results obtained on the two subscales indicated that the scale will elicit consistent results, rather than results obtained by subject or item variance. the mcnemar test was used to analyse the classification congruence between complaints of vertigo and the expectation of the symptom based on the diagnosis recorded in the hospital notes. four of the 72 participants included in the final analysis (those with complete avss scores) were incorrectly categorised as having vertigo when in fact they did not. the mcnemar test (0.98; p=0.3211) found no significant difference between the participants’ complaint of vertigo and the expectation of the symptom based on diagnosis. this minimal difference in classification indicated good categorisation of vertiginous participants and controls, based on participants’ presenting complaints. for the vertiginous participants the score of symptoms of dizziness, vertigo or imbalance was relatively high, with the ver subscale showing mean 19.902, standard deviation (sd) 12.047, n=41, where the highest possible score obtainable on the ver is 76. most of the vertiginous sample (54%) scored on all three features of dizziness: a feeling of spinning or moving around, being light-headed, swimmy or giddy, and a feeling of unsteadiness (items 1, 7 and 18 on the avss). in contrast, no participant from the control group reported all three classic features of dizziness with increased occurrence (scores of 3 or 4 on the avss). the control sample yielded a significantly lower mean score overall, with the ver subscale showing mean 3.742, sd 3.838, n=31. this would suggest that the ver is able to differentiate reliably between those with and without vertigo. figure 2 shows histograms of the ver data for both samples. in addition to the presence of symptoms of dizziness, over one-third of the vertiginous sample complained of symptoms of autonomic nervous system arousal and/or anxiety; checking items such as the presence of hot or cold spells, heart palpitations, and presyncope (items 3, 10 and 22). a relatively high mean score overall for the aa subscale was obtained (mean 26.829, sd 16.269, n=41), where the highest possible score on this subscale is 60. the control group reflected a lower overall mean score, with the following obtained: mean 13.065, sd 9.284, n=31. interestingly, none of the participants in the control group reported presyncope. figure 3 shows histograms of the scores obtained on the aa for both samples. successful differentiation between the participant groups was therefore obtained on both subscales of the avss. further statistical analysis was conducted, and both the parametric and non-parametric measures used indicated significant statistical differences on both subscales between the samples with t-test and mann-whitney u values less than p=0.05. between both samples, the following results were obtained on the adjusted t-test and mann-whitney u non-parametric analysis: ver [t (50.25)=-8.065, p<0.001; mann-whitney u (49)=0.000, p<0.001] and aa: [t (65.64)=4.529, p<0.001; mann-whitney u (316.5)=0.000, p<0.001]. the p-scores obtained for the t-test and mann-whitney u are substantially less than 0.001, which is less than the set criteria for statistical significance, increasing the significance of the results obtained. an roc curve (figure 4) was constructed in an attempt to establish cut-off scores that would distinguish between cases of vertigo and non-cases. the avss shows good sensitivity and specificity for both subscales and as a whole. the ver has better sensitivity in identifying vertiginous versus control participants than the aa’s ability to identify those with anxiety from those without. the ver has an optimal cut-off suggested at 7.5, which yields a sensitivity of 0.902 and specificity of 0.097. the aa did not indicate an optimal cut-off and 17.5 was suggested, as the best balance for sensitivity is 0.683 and specificity is 0.258 at this level. to conclude, the entire avss presents with relatively good sensitivity and specificity (demonstrated by the second line from the reference line on the roc). discussion there are various methods of evaluating the translation of an instrument, ranging from simple forwardand back-translations to subjecting the translation to a process of review using a technique such as the delphi. in this study a delphi consensus procedure, using panels of first-language afrikaans speakers and bilingual health care professionals, yielded the avss which was piloted with vertiginous and control participants. although the focus of the discussion is on the results of the pilot study, the delphi is discussed briefly. delphi consensus procedures have a number of features that may either enrich or weaken a study. they are cost-effective, and panel members are usually selected for their strengths and are not unduly influenced by each other. however, a lack of standardisation in the method, including decisions about when consensus has been reached, lack of test-retest reliability and possible selection bias (hasson et al., 2000), all warrant concern. although there is no agreement on what to accept as consensus in the literature (hasson et al., 2000), a conservative figure was chosen for consensus in the first round, favouring caution. in the second round, consensus was achieved for all items. there were limitations in terms of the small number of participants on each panel. it is possible that the panels’ opinions were not representative of a wider first-language or expert population, raising the possibility of selection bias. in addition, the use of a first-language lay panel could be queried with regard to their value; however, it was felt that the final translation should be accessible in terms of vocabulary to a projected patient population, and that the lay panel would bring a different perspective to that of the health care professionals. furthermore, no formal tests to establish language competence of any of the participants were conducted. although the limitations of the delphi consensus procedure require acknowledgement, they are somewhat ameliorated by its use only to confirm a translation of an already validated questionnaire. the researchers believe that concurrent validity has been established as a result of the avss’s ability to discriminate between individuals presenting with and without vertigo. furthermore, cronbach’s alpha suggested internal consistency within the scale. clinical utility of the avss because of the array of symptoms and aetiologies with which a vertiginous patient may present, the underpinning of a competent assessment is a thorough case history (mégnigbêto et al., 2001; yardley et al., 1992). however, in south africa clinicians may encounter challenges in obtaining a case history as a result of linguistic issues. a questionnaire such as the avss explores symptoms of dizziness and vertigo, associated autonomic nervous system symptoms and anxiety-related factors. the avss has proven reliable and could be useful for clinicians to categorise patients’ subtypes of dizziness. it bears reiteration that precise symptom definition, plus identification of associated symptoms such as anxiety, is essential for effective diagnosis. further, self-assessment scales require patients to be reflective about their complaint. as the avss covers a wide range of symptoms, the patient is asked to consider several aspects of his/her condition. the avss may create an opportunity for the clinician to explore specific areas, which may assist in keeping the consultation focused and time-efficient. for example, identification of anxiety is essential for successful management (luxon, 2004), and high scores on the aa subscale would alert the clinician to explore this during the clinical encounter and refer the patient if necessary. even when physical symptoms cannot be controlled optimally, such as in the case of ménière’s disease, recognition and management of psychological distress can result in improvements in the quality of life (kirby & yardley, 2008). significant statistical differences were found between the samples for both subscales embedded in the avss. the roc curve suggested that the avss is sensitive and specific in correctly identifying true cases of participants complaining of vertigo. however, a clinical tool may have considerable power in identifying those patients whom it aims to identify, yet be of little value when it comes to patient care (zwieg & campbell, 1993). as one of the primary concerns in management of vertigo is delineating its true nature, which in turn will dictate subsequent treatment and referral options, instruments with a high hit rate are desirable. the avss could be used at various levels of care and ensure that patients are referred to the appropriate health care professional – in this case vertiginous patients to audiologists and otologists. in spite of the avss being statistically robust, it is apparent that not all tools are suitable for all patients. in this study, 13 participants were excluded because the avss had not been completed in full. qualitative feedback from these individuals suggested that some had difficulty with the format, which followed the published english version. this resulted in a new layout for the scale, with boxes for participants to enter their responses, which had a clearer appearance. however, when the challenges of a self-assessment scale in cases where literacy may be an issue are considered, the avss in its present format may still be too daunting for some patients. for individuals with low general literacy levels faced with material presented in a different language, written documents used in health care may give rise to frustration. interestingly, clinicians are thought to overestimate their patients’ literacy skills, leading to more difficulties (schmidt von wühlisch & pascoe, 2010). it is possible that the avss may not be of practical use in some clinical settings, depending on the functional and health literacy of the patient population. the study did not explore the threat to validity should the scale be administered by a health care professional rather than self-administered, but this could be investigated at a later stage. the generalisability of the study is limited by the size and centralised nature of the sample. study data cannot account for the range of dizzy patients who could potentially consult a clinician. the state hospitals were both located in an urban centre and it is possible that rural participants may have yielded substantially different results. in addition participants did not undergo objective testing, thus limiting the correlation between the participants’ diagnosis and their presenting complaint of vertigo, or lack thereof. however, a counter-argument to this is that objective testing often does not prove a diagnosis or even the presence of a patient’s symptoms (kerr, 2005; mendel, bergenius & langius, 1999). it is possible that a hawthorne effect exists. participants may have reported more symptoms, or more severe symptoms, on the avss in the hope that they might receive preferential treatment or have their medical needs given more priority. however, it was pointed out to each potential participant that the researchers would neither assess nor manage patients’ conditions and that this would be attended to by the regular staff. as this was a pilot study, future research should include a larger sample of participants, from a variety of settings. furthermore, as there is no other suitable afrikaans questionnaire with which to compare the avss, construct validity was not evaluated. it is therefore recommended that another scale such as the dizziness handicap inventory (dhi) (jacobson & newman, 1990) be translated and piloted. the results of the two scales could be compared for information regarding the validity of the avss. furthermore, the results of the self-assessment scales could be correlated with findings on clinical or objective examination. in south africa, a range of clinicians may be involved in the management of patients with vestibular involvement, including otolaryngologists, neurologists, audiologists with vestibular training, physiotherapists and psychologists. all of these professionals will approach the vertiginous patient from a different perspective relative to their training. the study revealed that there does not appear to be an afrikaans word that appropriately implies the symptom of vertigo, so ‘draaiduiseligheid’ is suggested as suitable for use within clinical settings. the term adequately conveys a sense of dizziness or of being light-headed, while incorporating the vital aspect of a hallucination of movement. consistent use of terminology within and between disciplines, as well as use of the avss, may offer something to bridge professional differences and aid the clinician who is not specialised in the area of vestibular disorders. clinical reasoning regarding both the definition of the presenting symptoms and the results from the subscales of the avss may in turn make referrals more rational and appropriate. conclusion the avss is able to detect classic symptoms of vertiginous distress, which often include associated symptoms of autonomic nervous system arousal. the roc measure indicated that the avss presents with good sensitivity and specificity, and therefore demonstrates good discriminative ability in identifying patients with vertigo. hence it is an ideal first option in patient self-assessment and can appropriately confirm the presence of symptoms, explore facets of anxiety and direct appropriate management and future referrals. the avss will complement the case history, which in turn will support more accurate diagnosis. it should be noted that the english and translated vss were designed as self-assessment scales, and this could render them inaccessible for a sizeable proportion of the population who do not have functional literacy. the word ‘draaiduiseligheid’ is a useful addition to the clinical armamentarium as it captures a description of movement and disorientation to the environment. as symptom definition is a fundamental first step in discriminating between dizziness and vertigo, and thus directing assessment and management decisions, it is hoped that this will prove to be a useful contribution. considering the wide use of the vss around the world in specialist clinics, the avss has the potential to enhance the assessment of vertigo and attendant vertigo-related anxiety in the afrikaans-speaking population. acknowledgements. the researchers would like to extend their gratitude to professor lucy yardley for permission to use and translate the vss, and ms anneli hardy for her statistical analysis. we also wish to acknowledge the contribution of the panellists and the participants at the two institutions at which the study was conducted, and the two anonymous reviewers for their constructive comments. references aslan, s., ceylan, a., kemaloglu, y.k., & goksu, n. 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(2007). dizziness and balance disorders: the role of the history and laboratory studies in diagnosis and management. the asha leader. retrieved on 23 august 2011 from http://www.asha.org/publications/leader/2007/070529/f070529a.html south africa info. afrikaans. retrieved on 23 august 2011 from http://www.southafrica.info/about/people/language/html statistics south africa (2004). provincial profile 2004, western cape. retrieved on 4 january 2009 from http://www.statssa.gov.za tschan, r., wiltink, j., best, c., bense, s., dieterich, m., beutel, m.e., et al. (2008). validation of the german version of the vertigo symptom scale (vss) in patients with organic or somatoform dizziness and healthy controls. journal of neurology, 255, 1168-1175. webster, k., cella, d., & yost, k. (2003). the functional assessment of chronic illness therapy (facit) measurement system; properties, applications and interpretation. health and quality of life outcomes. retrieved on 23 august 2011 from www.hqlo.com/content/pdf/1477-7525-1-79.pdf wiltink, j., tschan, r., michal, m., subic-wrana, c., eckhardt-henn, a., dieterich, m., et al. (2009). dizziness: anxiety, health care utilisation and health behaviour – results from a representative german community survey. journal of psychosomatic research, 66, 417-424. world medical association (2008). declaration of helsinki. retrieved on 17 may 2010 from www.wma.net/en/30publications/10policies/p3/17c.pdf yardley, l., luxon, l.m., & haacke, n.p. (1994). a longitudinal study of symptoms, anxiety and subjective well-being in patients with vertigo. clinical otolaryngology & allied sciences, 19, 109-116. yardley, l., masson, e., verschuur, c., haacke, n., & luxon, l. (1992). symptoms, anxiety and handicap in dizzy patients: development of the vertigo symptom scale. journal of psychosomatic research, 36, 731-741. zwieg, m.h., & campbell, g. (1993). receiver-operating characteristic (roc) plots: a fundamental evaluation tool in clinical medicine. clinical chemistry, 39, 561-577. fig. 1. flow chart depicting the translation of the vertigo symptom scale into afrikaans. fig. 2. histograms depicting the spread of scores obtained on the ver subscale. the control results are in the left diagram. scores on the ver are found on the x-axis with the number of participants found on the y-axis. note that the control sample’s scores are substantially lower than those obtained by the vertiginous sample. fig. 3. histograms depicting the spread of scores obtained on the aa subscale. scores for the control group are displayed in the left diagram. scores obtained on the aa are found on the x-axis. overall, the vertiginous sample scored higher on the aa. fig. 4. the roc curve obtained for the avss, including both the ver and aa subscales. appendix 1. afrikaanse vertigo simptome skaal instruksies: omkring asseblief die gepaste nommer om aan te toon ongeveer hoeveel keer jy die volgende simptome, op die lys, ervaar het gedurende die laaste 12 maande (of sedert die duiseligheid begin het, indien jou duiseligheid minder as ’n jaar gelede begin het). die verskeidenheid van keuses is: 0 1 2 3 4 nooit enkele kere (1 3 maal ’n jaar) verskeie kere (4 12 maal ’n jaar) redelik gereeld (gemiddeld, meer as 1 maal per maand) baie gereeld (gemiddeld, meer as 1 maal per week) hoe gereeld gedurende die afgelope 12 maande het jy die volgende simptome gehad: nooit enkele kere (1 3 maal ń jaar verskeie kere (4 12 maal ń jaar redelik gereeld (gemiddeld, meer as 1 maal per maand) baie gereeld (gemiddeld, meer as 1 maal per week) 1. ’n gevoel dat alles draai of in die rondte beweeg, vir ’n tydperk van: [beantwoord asseblief a) tot e)] a) minder as 2 minute b) tot en met 20 minute c) 20 minute tot 1 uur d) ’n aantal ure e) meer as 12 ure 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 2. pyn in die hart of bors area 0 1 2 3 4 3. warm of koue gloede 0 1 2 3 4 4. onvas op jou voete, so erg dat jy omval 0 1 2 3 4 5. naarheid (siek voel), ’n draai gevoel in die maag 0 1 2 3 4 6. spanning/seerheid in jou spiere 0 1 2 3 4 7. ’n gevoel van lighoofdigheid, ’n gevoel van ‘swewing’ of duiseligheid, vir ’n tydperk van: [beantwoord asseblief a) tot e)] a) minder as 2 minute b) tot en met 20 minute c) 20 minute tot 1 uur d) ’n aantal ure e) meer as 12 ure 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 8. bewerigheid, rillings 0 1 2 3 4 9. ’n gevoel van drukking in die oor/ore 0 1 2 3 4 10. hartkloppings of -versnellings 0 1 2 3 4 11. braking 0 1 2 3 4 12. ’n swaar gevoel in die arms of bene 0 1 2 3 4 13. visuele versteurings (bv. dofheid, flikkering, kolle voor die oë) 0 1 2 3 4 14. hoofpyn of ’n gevoel van drukking in die kop 0 1 2 3 4 15. onvermoeë om behoorlik, sonder ondersteuning, te staan of te stap 0 1 2 3 4 16. moeilike asemhaling, kortasem 0 1 2 3 4 17. verlies van konsentrasie of geheue 0 1 2 3 4 18. onvas op jou voete, besig om balans te verloor, vir ’n tydperk van: [beantwoord asseblief a) tot e)] a) minder as 2 minute b) tot en met 20 minute c) 20 minute tot 1 uur d) ’n aantal ure e) meer as 12 ure 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 19. tinteling, prikkeling of lamheid in dele van die liggaam 0 1 2 3 4 20. pyne in jou laerug area 0 1 2 3 4 21. oormatige sweet 0 1 2 3 4 22. voel flou, besig om bewussyn te verloor 0 1 2 3 4 13 attitudes of a group of south african speech-language pathologists towards stutterers and stuttering therapy belinda baker, eleanor ross and joan girson department of speech pathology and audiology university of the witwatersrand abstract the present study aimed to examine the attitudes of a group of south african speech-language pathologists towards stuttering and stuttering therapy. further aims were to investigate whether a stereotype of stutterers was found among these speech-language pathologists, and to determine whether there was any relationship between the attitudes held about stutterers, and the therapists' training and experience. a random probability sample of respondents was selected from the population of speech therapists registered with the interim medical and dental council of south africa (i.m.d.c.s.a.). a self-administered mailed questionnaire was employed to realise the aims of the study. the main result of this investigation indicated that almost 50% of the sample of qualified clinicians surveyed, viewed stutterers as a group characterised by specific personality traits and psychological problems. this belief held true irrespective of the number of years of experience working in the field, the time of graduation, the frequency of treating stutterers, or the training emphasis. implications of these results are considered with respect to student training, continuing education of qualified practitioners and future research. opsomming die huidige navorsing is gemik om die houding van 'n groep suid-afrikaanse spraak-taalpatoloe te ondersoek. verdere doelstellings was om ondersoek in te stel na 'n moontlike verwantskap tussen die opleiding en ondervinding van terapeute en hulle houding teenoor hakkelaars, asook of hulle hakkelaars stereotipeer. 'n waarskynlikheids-toevalssteekproef van respondente is uit die suid-afrikaanse tussentydse mediese en tandheelkundige raad (s.a.t.m.t.r.) se geregistreerde terapeute geselekteer. 'n selfopgestelde posvraelys is gebruik vir die doeleindes van hierdie studie. die hoofresultaat het aangedui dat amper 50% van respondente hakkelaars as 'n groep met spesifieke persoonlikheidseienskappe, asook sielkundige probleme beskou, ongeag van die aantal jare van werksondervinding, die datum van graduering, die aantal hakkelaars behandel en die opleidingsklem. die implikasies vir studente-opleiding, voortgesette onderrig aan gekwalifiseerde terapeute en toekomstige navorsing word bespreek. keywords: attitudes, speech-language pathologists, stutterers, stuttering therapy the relationship between attitudes and stuttering has long been highlighted in the literature (peters & guitar 1991). in fact, various authorities have found that the attitudes of speech therapists towards their stuttering patients is a crucial factor in therapy (cooper & cooper, 1985b; watson, 1995). these findings highlight the need for speech therapists to approach stuttering therapy with a positive attitude (daly, simon & burnett-stolnack, 1995). in contrast with this viewpoint, other research has suggested the presence of a negative stereotype of stutterers, lb stereotype a group is to think and refer to all members of that group as though they were the same (jones, 1977). according to ham (1990a), it is the perception of the general public that stutterers are less adequate people than non-stutterers, and non-stutterers often describe stutterers with mainly negative characteristics (kalinowski, lerman & watt, 1987). negative stereotypes may serve as self-fulfilling prophecies, influencing the stutterers' selfimage and behaviour (turnbaugh, guitar & hoffman, 1979). the expectations that people have, influence the behaviour of the person holding the expectation and the person about whom the expectation is held, as in most instances the latter party is aware of the stereotype (jones, 1977). it is not only the general public which has negative views of stutterers. speech therapy students have been found to be prejudiced against stutterers (barbosa, schiefer & chiari, 1995). several studies have found that speech therapists use predominantly negative personality traits to describe stutterers (yairi & williams, 1970; woods & williams, 1971). negative stereotypes of stutterers as people with psychological problems appeared to persist irrespective of the severity of the disorder (turnbaugh et al., 1979); the age of the patient (woods & williams, 1971) or the clinicians' degree of exposure to stuttering clients (woods & williams, 1976). in 1975 cooper devised the clinicians' attitudes towards stuttering (cats) inventory as he felt that existing attitude scales did not adequately assess clinicians' attitudes (cooper, 1996). in 1983 and 1991 cooper and cooper administered the cats inventory to a sample of american clinicians and found that 50% and 58% respecdie suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 tively of their respondents believed that stutterers possess characteristic personality traits (cooper & cooper, 1985b & cooper 1996). the negative attitude held by clinicians could impede the stutterer in therapy (cooper & cooper, 1985a), and hinder the therapeutic relationship (starkweather, 1982). clinicians' negative attitudes may also add to the stutterers' need to hide their speech disorder, and may impede any therapy which requires patients to advertise their stutter (woods & williams, 1976). in addition, the therapist's reaction may add to the client's sense of guilt associated with belonging to such a negatively perceived group (leahy, 1994). young stutterers may also learn a negative stereotype of stutterers from the important adults in their lives (rustin & cook, 1995), including the therapist. stereotypes of stutterers contradict research which has repeatedly shown that stutterers are not a homogeneous population and that a "stuttering personality" does not exist (andrews et al., 1983; lass et al., 1992). stutterers themselves have opposed the idea that they are a homogeneous group which can be stereotyped (fransella, 1968 as cited by ham, 1990a) and there has been no significant difference in the self-descriptions of stutterers and nonstutterers (kalinowski et al., 1987). in view of the reported negative attitudes of speech therapists towards stutterers, it is not surprising that stuttering has been described as one of the least favoured speech disorders to treat (st louis & durrenberger 1993). this finding may reflect the fact that therapists often report feeling inadequately prepared for treating stutterers (st louis & durrenberger, 1993); and incompetent in managing stutterers (mallard, gardner & downey, 1988; cooper & cooper, 1985b). therapists also mention feeling pessimistic about the outcome of stuttering therapy (andrews et al., 1983). andrews et al. (1983) claim that the persistence of a negative stereotype of stutterers held by qualified clinicians may reflect the lack of assimilation of new knowledge about stuttering in training procedures, coupled with the continued use of approaches that are more than 30 years old. they state that in the past 10 20 years studies have shown that stutterers as people are no different to anyone else and that stuttering therapy can be highly effective (andrews et al., 1983). training may be a significant contributing factor in the development of attitudes towards stutterers, as attitudes are learnt (triandis, 1971). contradictory findings have been documented in the literature regarding the effects of practical experience and training on students' attitudes towards stuttering. on the one hand, st. louis and durrenberger (1993) found that increased practical experience in stuttering therapy may result in clinicians adopting a more positive attitude. on the other hand, increased academic training may lead to students becoming more pessimistic about their competence (st louis & lass, 1981). st louis and lass (1981) concluded that the fear of stuttering is embedded in training programmes. there may be a fundamental problem with the basic preparation students receive. hence, a change in the type or direction of programmes may be required if additional academic courses are unsuccessful in enhancing clinicians' confidence. the nature of peoples' attitudes towards stuttering should be amenable to change if they are exposed to the belinda baker, eleanor ross & joan girson appropriate knowledge and experience regarding stuttering (emerick, 1960). unfortunately, leith (1971) found that students often have limited practical experiences with stutterers in their training. using current knowledge about the existing stereotype of stutterers, leahy (1994) was able to modify student clinicians' attitudes as a direct result of her training procedures. she found that experience in treating stutterers at an undergraduate level, as well as group therapy experiences, were significant contributing factors in changing negative stereotypes of stutterers. st louis and lass (1981: 68) recommended that "one potentially fruitful avenue of future research would be to determine the extent to which various types of information or clinical experience influence attitudes towards stuttering. .. .such information would assist training programs and instructors in designing programs and courses better able to shape student attitudes in healthy, productive ways". this knowledge would appear to be especially relevant to the south african context where there is a limited supply of speech therapy services and resources available to the stuttering population. in 1987 van der merwe used a survey questionnaire to investigate the attitudes of south african speech therapists towards stuttering, stutterers and stuttering therapy. she found that afrikaans clinicians, as well as clinicians with more practical experience in treating stutterers, tended to have a more positive approach to therapy and were optimistic about the efficacy of therapy. the present study aimed to look more closely at the possible relationship between training and experience, and the personality attributes that clinicians believe stutterers to possess. methodology aims 1. to examine the attitudes of a group of south african speech-language pathologists towards stutterers and stuttering therapy. 2. to investigate whether a stereotype of stutterers was held by these speech-language pathologists. 3. to determine whether there was any relationship between the attitudes clinicians held about the personalities of stutterers and these clinicians' training and experience. research design in order to investigate the aims of the study a cross sectional survey research design was adopted which utilised a mailed questionnaire. subjects subject selection criteria three hundred names were randomly selected from the 1024 speech-language pathologists registered -with the interim medical and dental council of south africa as at june 1995. a total of 123 subjects returned useable questionnaires, representing a response rate of 41%. according to de vaus (1991), for purposes of analysis, a 10% response represents an adequate proportion of the total population. the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) attitudes of a group of south african speech-language pathologists towards stutterers and stuttering therapy description of questionnaire 1 a five-page questionnaire was designed by the researcher, based on questionnaires devised by cooper (1996), van der merwe (1987) and mallard, gardner and downey (1988). the questionnaire comprised the following sections:1. the "clinicians' attitudes towards stuttering (cats) inventory" 2. biographical information 3. experience with stuttering therapy. each of these sections is described separately as follows: clinicians'attitudes towards stuttering (cats) inventory the cats inventory consists of 50 attitudinal statements regarding eight areas of stuttering. respondents indicate their reactions to the statements via a five point strength of agreement scale ranging from "strongly agree" through "undecided" to "strongly disagree" (cooper & cooper, 1996). in the analysis these responses were collapsed to form a three point strength of agreement scale, as the differences between the "strongly agree or disagree" and "agree or disagree" categories are highly subjective. van der merwe's modified version of the cats inventory and her afrikaans translation were used by the researcher where appropriate. based on pre-test procedures further modifications were made. the questionnaire aimed to determine the attitudes of south african speech-language therapists towards: a) the etiology of stuttering. b) early intervention. c) efficacy of stuttering therapy. d) the personality of stutterers. e) clinicians who treat stutterers. f) teachers' and others' reactions to stuttering. g)/various therapy techniques. h) parents of stutterers. biographical information a biographical section devised by the researcher was used to obtain background!information on the subjects regarding their age, sex, year of qualification, training, years of professional experience and where that experience was received. this section was based largely on areas targeted by mallard, gardner and downey (1988) and van der merwe (1987). experience with stuttering therapy this section consisted of eight questions probing undergraduate and professional experience with stutterers. two open-ended questions were included to obtain qualitatively rich information. data analysis descriptive statistics were used as there were insufficient data in each cell of the cross tabulation table to warrant the use of inferential statistical procedures such as 15 chi square. frequency distributions were utilised to determine the percentage of speech-language pathologists who fell within each of the strength of agreement categories for each statement. the biographical information was summarized using these statistics. content analysis was utilised to analyse open-ended questions. the possibility of a relationship between clinicians' attitudes towards stutterers as people and the clinicians' training and professional experience was investigated by means of cross tabulation. results and discussion attitudes towards stutterers and stuttering therapy "etiology" the overwhelming majority of respondents, i.e., 86.2% disagreed with the statement that stuttering is a relatively simple disorder of dyssynchrony of the speech musculature, table 1 biographical profile of respondents (n = 123) no. % gender male 1 0.8 female 122 99.2 age under 26 yrs 30 24.4 2 6 3 5 59 48.0 3 6 4 5 25 20.3 4 6 5 5 6 04.9 55 + 3 02.4 date of 1990 1995 52 42.3 graduation 1986 1990 17 13.8 1981 1985 24 19.6 1976 1980 11 08.95 1971 1975 11 08.95 1966 1970 2 01.6 1961 1965 3 02.4 1955 1960 3 02.4 years of 1 5 50 40.7 experience 6 10 26 21.1 11 15 24 19.6 1 6 2 0 12 09.8 21 25 5 04.0 2 6 3 0 4 03.2 31 35 1 00.8 36 + 1 00.8 language of english 75 61.0 instruction afrikaans 48 39,0 majority of hospital 30 14.4 professional school 51 24.4 experience special school 37 17.7 (n = 209) * private practice 71 34.0 university 12 05.7 other 8 03.8 * numbers do not total 123 as respondents had worked in more than one setting. percentages are given in terms of the percentage of responses in this category. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 belinda baker, eleanor ross & joan girson while 89.4% agreed that stuttering results from multiple co-existing factors. as many as 83% disagreed with the view that parents are the primary cause of stuttering in their children, suggesting a decline in support for johnson's diagnosogenic model of etiology which states that a child's normal speech pattern becomes abnormal through the anxious reaction of parents (peters & guitar, 1991). although there is a dearth of literature to support johnson's theory (andrews et al., 1983), 8.9% of the south african sample of clinicians still held parents primarily responsible for stuttering in their children. this belief is maintained despite the literature over the past 20 years which suggests that the parent-child relationship of a stutterer is no different from that of a non-stutterer (andrews et al, 1983). in fact, onslow (1996) advocates counselling parents and providing them with literature on the physiological nature of stuttering, in an attempt to alleviate the guilt which has plagued the parents of stutterers for years. despite the small proportion of clinicians in the present study holding the view regarding parents' responsibility for their childrens' stuttering, it would appear to have important implications for the continuing education of speech therapists. "early intervention" the results suggest that when it came to helping preschool stutterers, 96% of respondents felt that counselling parents was the critical factor, and 76.4% felt that therapy should focus on the parents. according to onslow (1996), while counselling may not be the primary means to eliminate stuttering, counselling techniques which teach parents the correct behavioural response to stuttering represent an indispensable component in managing this disorder. according to cooper and cooper (1985a) it is an almost universally held belief of clinicians that parent counselling is the critical factor in therapy with pre-school stutterers. most clinicians (86.2%) disagreed with the statement that no matter what the age of the child, clinicians should make him/her aware of his/her stuttering behaviours. respondents agreed that clinicians should avoid using words like "stutterer" and "stuttering" when working with patients in grade one or two (62.6%). this kind of finding may represent the impact of johnson's diagnosogenic theory and does not reflect the current literature (cooper & cooper, 1985a). the majority of the sample of clinicians disagreed with the notion that children between 4-7 years of age should not be enrolled in therapy (82.1%) while 73.2% of respondents did not agree that most young stutterers will outgrow the problem without intervention. this finding supports literature which claims that as soon as a child shows signs of abnormal, persistent disfluencies, he or she should be enrolled in therapy (prins & ingham, 1983 as cited by cooper & cooper, 1985a; onslow, 1996). despite the previous findings, over 50% of respondents appeared reluctant to initiate therapy with young children as soon as their disfluent behaviour became apparent. prins and ingham (1983) suggest that this viewpoint may be the result of clinicians not wanting to draw the child's attention to his/her speech behaviours, for fear of "causing" stuttering (as cited by cooper & cooper, 1996). this fear may reduce the efficacy of therapy. although therapists felt strongly that young stutterers needed speech therapy, there was a prevailing attitude of fear about handling a young stutterer. in theory, therapists appeared to agree that young stutterers should have therapy, but they felt apprehensive about accepting this type of patient for fear of causing further harm. there was a definite contradiction between what therapists reportedly believed and how they reportedly acted. "therapy techniques" one of the strongest responses came from 96.8% of therapists who disagreed that speech therapists should avoid counselling parents of stutterers. a further 75.6% agreed with the statement that parent counselling is still a critical factor in treating adolescent stutterers. however, clinicians seemed divided as to whether or not psychotherapy for stutterers should be left to the psychologist. this finding may indicate that although clinicians are aware of the crucial role of counselling parents of stutterers, as discussed in the previous section, they do not feel adequately skilled to assume the role of psychotherapist. no specific handling techniques were probed by the questionnaire, but approaches to therapy were discussed. just over half, i.e., 51,2% of respondents disagreed with the method of getting stutterers to force themselves to speak in situations where they find fluency difficult. seventy nine (79.7) per cent of clinicians also disagreed that it was in stutterers' own interests to be called to recite in front of a class. "parents of stutterers" the majority (80.5%) of clinicians agreed that parents' misperceptions of stuttering frequently impede the child's progress. a further 58.6% of respondents believed that parents resent the speech behaviour of their stuttering child. almost 50% of the respondents did not believe that parents of stutterers tend to possess identifiably similar personality patterns. this finding is in agreement with research that has shown that the parents of stutterers are no more, nor less neurotic than parents of non-stutterers (andrews et al., 1983). "clinicians who treat stutterers" the majority (87.8%) of clinicians, reported disagreeing with the statement that clinicians are more comfortable with stutterers than with articulation disordered children. this finding is hardly surprising, as stuttering has been described as one of the least popular disorders to treat (st. louis & durrenberger, 1993). of concern, yet not unexpected, is the fact that 62.6% of respondents disagreed with the notion that most speech therapists are adept in treating stuttering. clinicians generally reported being effective in modifying the self-concept of stutterers (60.2%) while 99.2% were opposed to the idea of counselling of schoolaged stutterers not being the domain of the speech therapist. in fact, 44.7% of respondents disagreed that psychotherapy for stutterers should be left to the psychologist. in support of these findings, 98.4% of clinicians felt that counselling techniques are important skills in treating stutterers. this notion is reinforced by the results found in a previous section, namely, that counselling of parents is a very important therapy technique. this result has important implications for the training of speech therapists, as students in some training institutions often receive no formal instruction in counselling (watson, 1995). the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) attitudes of a group of south african speech-language and stuttering therapy "teachers'and others'reactions to stuttering" the results suggest that the majority of clinicians surveyed believe that while teachers are generally accurate in identifying stutterers in the classroom (69.9%), they are usually unaware of the psychological ramifications of stuttering (74%), and are not knowledgeable about handling stutterers (87%). if teachers are handling stutterers inappropriately, this behaviour may result in the child's educational performance deteriorating (gottwald & starkweather, 1995). the majority of respondents (69.1%) also believed that the general public reacts more negatively to stuttering than to other speech abnormalities. "efficacy of stuttering therapy" in view of the current emphasis on intensive therapy programmes such as the successful stuttering management program (breitenfeldt and lorenz 1989) at certain academic institutions, it is of interest to note that 69.1% of respondents believed that this type of programme is the most effective way to treat stutterers. when it came to therapy, 64.2% of respondents disagreed with the statement that stuttering behaviour is relatively easy to modify. almost half (49.6%) of the respondents agreed that the type of programme followed in therapy was a significant factor in the success of therapy, and 67.5% believed that self-evaluative type therapies, or a combination of self-evaluative type therapy and operant therapy was most effective. this approach to therapy is endorsed by onslow (1996) who advocates the behavioural management of stuttering. "therapists'feelings about working with stutterers" the open-ended questions were analysed into two broad categories, according to whether respondents disliked or liked stuttering therapy, and each of these categories was further subdivided according to the themes which emerged. these themes were based on the reasons which therapists provided to explain why they liked or disliked stuttering therapy. the majority of responses fell into one of the following categories. j 1. long-term success with stutterers (or the lack thereof). 2. training (adequate or inadequate). 3. practical experience with stutterers (adequate or inadequate). ι 4. therapy programmes (unstructured or challenging). 5. stutterers' personalities (psychologically unstable or not). 6. other (no specific reason stated). it is of interest that an almost equal number of therapists fell within the "dislikes stuttering therapy" (62) category as within the "likes stuttering therapy " (61) category. of those who fell within the "dislikes stuttering therapy" category, 32.3% attributed their aversion to a lack of longterm success with stutterers. this finding is not surprising as 85.4% of the sample disagreed that stuttering is the speech disorder most amenable to therapy. this lack of success maybe attributable to what cooper and cooper (1996) referred to as the "frequency fallacy", i.e., the erroneous assumption that the number of disfluencies is the only measure of success of therapy. they claim that therapy should aim at a feeling of fluency control rather than actual fluency. however, this is only one approach and many programmes are based on attaining actual fluency. within the "dislikes stuttering therapy" group, 24.2% of respondents pathologists towards stutterers ^ expressed the view that their training was inadequate; 17.7% felt that their lack of experience with stutterers at both an undergraduate and professional level was responsible for their negative attitude towards stuttering therapy. a further 17.7% felt that the type of therapy was to blame. they maintained that stuttering therapy is often unstructured and therefore frustrating and stressful. these results suggest that an improvement in training programmes might result in a more positive outlook among clinicians on stuttering therapy. only 8.1% of the sample of therapists attributed their dislike of therapy to the individual stutterer, claiming that stutterers have severe psychological problems which speech therapy cannot address, or that they disliked stutterers. it is of interest that while 48.8% of respondents believed that stutterers have psychological problems, only 8.1% attributed their dislike of stuttering therapy to this factor. this finding may indicate that although therapists may not enjoy working with stutterers, their reasons may have little to do with their reaction to stutterers as people. on the other hand, therapists may also be reluctant to admit that their dislike of stuttering therapy stems from their view of a stutterer's personality. of the 61 respondents who claimed to "enjoy stuttering therapy", 29.5% reported feeling comfortable with stutterers for no apparent reason; others reported adequate success in therapy (19.7%) or feeling challenged and rewarded by stuttering therapy (18%). only 9.8% said that their training had adequately prepared them for treating stutterers, which highlights the need for improved training methods, while 11.5% claimed that their positive attitudes were the result of their practical experiences with stutterers. this result supports van der merwe's (1987) and leahy's (1994) findings that experience with stutterers yields more positive attitudes. a further 11.5% of therapists claimed that they only enjoyed stuttering therapy because of the counselling aspect. this finding highlights the need to incorporate counselling skills into the training of speech therapists at an undergraduate level. stereotypes of stutterers almost half of the sample (48.8%) agreed that most stutterers are likely to have psychological problems. the same percentage of respondents agreed that there are personality traits attributable to stutterers. an even greater percentage of respondents (56.1%) believed that stutterers have feelings of inferiority. these self-reported beliefs of clinicians contradict findings reported in the literature which show that stutterers are generally not psychologically abnormal, nor do they have characteristic personality traits (andrews et al., 1983). the majority of respondents (66.7%) believed that stutterers have a distorted perception of their stuttering behaviour, and 43.1% agreed that they have a distorted perception of their social relationships. over 70% of clinicians felt that stuttering was the most psychologically devastating of all speech disorders. the relationship between clinicians' attitudes regarding the personality of stutterers and their training and experience an aim of the study was to investigate whether there was any relationship between the attitudes clinicians hold about the personalities of stutterers and their training and experience. in order to investigate this aim, the results of die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 questions concerning the personality attributes of stutterers were cross-tabulated with the year of graduation, years of professional experience, training approaches emphasised, and frequency of therapy with stutterers. the first area investigated was year of graduation and years of professional experience. distribution of personality stereotypes by year of graduation the majority of respondents graduated during the time span extending from 1991-1995; the minority of respondents between 1955 and 1980. due to the small number of respondents graduating during the latter period, this was treated as one category. findings represented in table 3 suggest that the time of graduation did not affect clinicians' attitudes towards stutterers. this result was supported by cross-tabulating years of professional experience with personality attributes of stutterers. the findings shown in table 2 suggest that young, newly graduated clinicians did not belinda baker, eleanor ross & joan girson differ noticeably in their attitudes towards stutterers from those who had years of professional experience. this is a surprising result as previous research (van der merwe 1987) has shown that clinicians with more experience were more optimistic about the efficacy of stuttering therapy. one might have expected younger graduates to be more progressive and liberal in their approach as they should have been exposed to more current literature on stuttering and stutterers. a possible explanation for this finding is that the greater the degree to which a group has previously been stereotyped, the less likely it is that any new information or knowledge will change the stereotype (triandis 1971). thus, stereotypes tend to persist over time (triandis 1971). white and collins (1984) provide another explanation by suggesting that the stereotype people have of stutterers is justified to some extent. they claim that when fluent speakers experience moments of disfluency, they feel shy, embarrassed and anxious. fluent speakers then logically conclude that stutterers experience these same feelings when they are disfluent, and they translate these feelings into negatable 2 distribution of personality attributes by years of experience (n = 123) personality attributes years of experience question 1 5 6 10 11 15 16 + 3. chances are that most stutterers have psychological problems agree 27 10 10 13 3. chances are that most stutterers have psychological problems undecided 3 4 4 5 3. chances are that most stutterers have psychological problems disagree 21 11 . 11 4 7. most stutters have distorted perception of their own stuttering behaviour agree 32 19 15 16 7. most stutters have distorted perception of their own stuttering behaviour undecided 9 3 2 2 7. most stutters have distorted perception of their own stuttering behaviour disagree 10 3 8 4 22. most stutterers could be described as possessing a feeling of inferiority agree 32 15 12 10 22. most stutterers could be described as possessing a feeling of inferiority undecided 9 8 7 5 22. most stutterers could be described as possessing a feeling of inferiority disagree 10 2 6 7 26. there are some personality traits characteristic of stutterers agree 25 8 14 13 26. there are some personality traits characteristic of stutterers undecided 15 8 4 6 26. there are some personality traits characteristic of stutterers disagree 11 9 7 3 30. most stutterers display a distorted perception of their own social relationships agree 21 11 11 10 30. most stutterers display a distorted perception of their own social relationships undecided 17 9 9 7 30. most stutterers display a distorted perception of their own social relationships disagree 13 5 5 5 47. stutterers are generally more intelligent than those with other kinds of speech • handicaps agree 6 0 4 2 47. stutterers are generally more intelligent than those with other kinds of speech • handicaps undecided 19 8 7 11 47. stutterers are generally more intelligent than those with other kinds of speech • handicaps disagree 26 17 14 9 / 49. clinicians must be more understanding of the feelings agree 15 9 9 7 49. clinicians must be more understanding of the feelings undecided 3 1 0 2 of stuttering clients than nonstuttering clients disagree 33 15 "16 13 the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) attitudes of a group of south african speech-language pathologists towards stutterers and stuttering therapy tive personality attributes about stutterers. this explanation would account for the finding that the year of graduation or years of professional experience did not appear to influence clinicians' attitudes towards stutterers to any great extent. distribution of personality attributes by frequency of therapy with stutterers the results indicated in table 4 suggest that the frequency with which clinicians treated stutterers did not appear to shape their attitudes in general. the exception to this finding was in relation to question 3, namely clinicians who treated stutterers some of the time, most of the time, or all of the time, were more inclined to agree that stutterers have psychological problems. while most clinicians agreed that stutterers possess feelings of inferiority and have certain personality traits which characterise them, clinicians who treated stutterers all of the time were more likely to disagree with these statements. while these findings may appear to be contradictory, they reveal an interesting trend. clinicians who treat stutterers all of the time may be inclined to disagree that there are personality traits characteristic of stutterers because they have been exposed to a variety of different stutterers each of whom was unique. this finding is supported by literature which shows that clinicians who work more with stutterers have a more positive attitude towards them (st. louis & durrenberger 1993; leahy 1994) as well as by the respondents who reported a positive attitude towards stuttering therapy as a result of numerous years of experience with stutterers. conversely, clinicians who hold more positive attitudes towards stutterers might be more willing to work with them all of the time. the fact that clinicians who work with stutterers are more likely to agree that stutterers have psychological problems supports the "kernel-of-truth" hypothesis. proponents of this theory would claim that the stereotype that stutterers have psychological problems contains an element of truth. according to triandis (1971), many stereotypes origitable 3 distribution of personality stereotypes by year of graduation (n = 123) personality attributes year of graduation question 1991 1995 1986 1990 1981 1985 1955 1980 3. chances are that most stutterers have psychological problems agree 26 8 10 16 3. chances are that most stutterers have psychological problems undecided 3 3 5 5 3. chances are that most stutterers have psychological problems disagree 19 11 8 9 7. most stutters have distorted perception of their own stuttering behaviour agree 30 17 15 20 7. most stutters have distorted perception of their own stuttering behaviour undecided 8 3 2 3 7. most stutters have distorted perception of their own stuttering behaviour disagree 10 2 6 7 22. most stutterers could be agree 30 14 11 14 described as possessing feeling of inferiority a undecided 7 8 6 8 described as possessing feeling of inferiority a disagree 11 0 6 8 26. there are some personality traits chara :teristic agree 21 10 12 17 26. there are some personality traits chara :teristic undecided 15 6 5 7 of stutterers | disagree 12 6 6 6 30. most stutterers display/ a distorted perception of their own social relationships agree 18 12 9 14 30. most stutterers display/ a distorted perception of their own social relationships undecided 15 7 10 10 30. most stutterers display/ a distorted perception of their own social relationships disagree 15 3 4 6 47. stutterers are generally more intelligent than those with other kinds of speech handicaps agree 5 1 4 2 47. stutterers are generally more intelligent than those with other kinds of speech handicaps undecided 17 7 7 14 47. stutterers are generally more intelligent than those with other kinds of speech handicaps , disagree 26 14 12 14 49. clinicians must be more understanding of the feelings of stuttering clients than non1 stuttering clients agree 14 8 8 10 49. clinicians must be more understanding of the feelings of stuttering clients than non1 stuttering clients undecided 3 1 0 2 49. clinicians must be more understanding of the feelings of stuttering clients than non1 stuttering clients disagree 31 13 15 18 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 nate in this way. so, while certain stutterers may display psychological problems, these are not an integral part of the stuttering syndrome (andrews et al., 1983). the finding that clinicians who never treat stutterers or who only treat them occasionally, tend to agree with stereotypical phrases to describe stutterers, suggests that these stereotypes may result directly from clinical training, as opposed to emanating from direct contact with stutterers. distribution of personality attributes by training approach emphasised when training emphasis (theory; therapy approaches or both) was cross-tabulated with questions relating to personality attributes of stutterers, the majority of respondents fell within the "both" category. from the respondents whose training emphasised either theory or therapy, it would appear that the training emphasis did not influence attitudes to a large extent. these results must, however, be interpreted with caution as the number of respondents in belinda baker, eleanor ross & joan girson the "theory" and "therapy" cells was very small, as can be seen in table 5. distribution of personality attributes by training approach emphasised when data were cross-tabulated to compare which method of stuttering therapy was emphasised in training there appeared to be no difference in the attitudes of clinicians who were taught the "stutter-fluently" approach versus the "speak-fluently" approach, as demonstrated in table 6. again, clinicians who were taught a combined approach versus choosing a therapy depending on the patient showed no great differences in attitudes. this finding, when coupled with the results from table 5, lends credence to researchers who propose that a change in the type of training is required for student clinicians, as teaching different approaches does little to ameliorate the stereotype clinicians have of stutterers. table 4 distribution of personality attributes by frequency of therapy with stutterers (n =123) personality attributes frequency of therapy with stutterers question never once in a while some of the time most of the time all of the time 3. chances are that most stutterers have psychological problems agree 3 19 29 5 4 3. chances are that most stutterers have psychological problems undecided 1 5 8 2 0 3. chances are that most stutterers have psychological problems disagree 5 22 16 1 3 7. most stutterers have a distorted perception of their own stuttering behaviour agree 5 27 38 5 7 7. most stutterers have a distorted perception of their own stuttering behaviour undecided 3 8 5 0 0 7. most stutterers have a distorted perception of their own stuttering behaviour disagree 1 11 10 3 0 22. most stutterers could be described as possessing a feeling of inferiority agree 4 28 30 5 2 22. most stutterers could be described as possessing a feeling of inferiority undecided 3 10 14 1 1 22. most stutterers could be described as possessing a feeling of inferiority disagree 2 8 9 2 4 26. there are some personality traits characteristic of stutterers agree 3 19 31 5 2 26. there are some personality traits characteristic of stutterers undecided 4 16 9 2 2 26. there are some personality traits characteristic of stutterers disagree 2 11 13 1 3 30. most stutterers display a distorted perception of their own social relationships agree 3 20 24 4 2 30. most stutterers display a distorted perception of their own social relationships undecided 4 19 18 0 1 30. most stutterers display a distorted perception of their own social relationships disagree 2 7 11 4 4 47. stutterers generally are more intelligent than those with other kinds of speech handicaps agree 0 6 5 0 1 47. stutterers generally are more intelligent than those with other kinds of speech handicaps undecided 3 16 21 3 2 47. stutterers generally are more intelligent than those with other kinds of speech handicaps disagree 6 24 27 5 4 49. clinicians must be more agree 1 14 21 3 1 understanding of the feelings of undecided 1 1 3 1 0 stuttering clients than nonstuttering clients disagree 7 31 29 ya 6 the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a t t i t u d e s of a group of south african speech-language and stuttering therapy conclusions in summary, many strongly held beliefs emerged among the therapists surveyed. some of these beliefs were reflected in the responses pertaining to the etiology of stuttering. most clinicians appeared to be in agreement that stuttering is caused by multiple co-existing factors. therapists also felt strongly about the positive role of counselling in stuttering therapy as well as about the benefits of early intervention. in direct contrast to the latter belief, therapists also mentioned experiencing extreme trepidation when approaching young stutterers and expressed the view that they might unwittingly harm the stutterer. there still appeared to be a widespread belief among clinicians that stutterers have a different psychological profile from other young children who need speech therapy, and that stutterers are more susceptible to being harmed by intervention. therapists did, however, see themselves as having a very important role in the counselling of parents of stutterers, as they believed that parents' misperceptions of stuttering frepathologists towards stutterers ^ quently impedes the child's progress. one of the most disconcerting results was that over 60% of therapists did not think that speech therapists were adept at treating stutterers and almost 50% of the sample of qualified clinicians surveyed, viewed the term "stutterer" as denoting a certain personality type as opposed to a description of a speech symptom. this belief held true irrespective of the number of years working in the field, the time of graduation, the frequency of treating stutterers, or the training emphasis. very similar results have been found in great britain and the united kingdom by cooper and rustin (1985). the results are therefore not uniquely south african. nevertheless, the findings have important implications for training and future research. implications for student training and continuing education • negative attitudes may reduce the effectiveness of stuttering therapy (lass et al., 1989). it is therefore necespersonality attributes training approach emphasised question theory therapy approaches both 3. chances are that most stutterers have psychological problems agree 7 . 0 53 3. chances are that most stutterers have psychological problems undecided 0 1 15 3. chances are that most stutterers have psychological problems disagree 8 1 38 7. most stutterers have a distorted perception of their own stuttering behaviour agree 11 1 70 7. most stutterers have a distorted perception of their own stuttering behaviour undecided 3 0 13 7. most stutterers have a distorted perception of their own stuttering behaviour disagree 1 1 23 22. most stutterers could be described as possessing a agree 11 1 57 22. most stutterers could be described as possessing a undecided 1 1 27 feeling of inferiority , disagree 3 0 22 26. there are some personality traits char icteristic agree 8 0 52 26. there are some personality traits char icteristic undecided 6 1 26 of stutterers | disagree 1 1 28 30. most stutterers display s distorted perception of their own social relationships agree 5 1 47 30. most stutterers display s distorted perception of their own social relationships undecided 4 1 37 30. most stutterers display s distorted perception of their own social relationships disagree 6 0 22 47. stutterers generally are more intelligent than those with other kinds of speech handicaps agree 0 0 12 47. stutterers generally are more intelligent than those with other kinds of speech handicaps undecided 10 0 35 47. stutterers generally are more intelligent than those with other kinds of speech handicaps disagree 5 2 59 49. clinicians must be more understanding of the feelings of stuttering clients than non1 stuttering clients agree 3 0 37 49. clinicians must be more understanding of the feelings of stuttering clients than non1 stuttering clients undecided 1 0 5 49. clinicians must be more understanding of the feelings of stuttering clients than non1 stuttering clients disagree 11 2 64 table 5 distribution of personality attributes by training approach emphasised (n = 123) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 belinda baker, eleanor ross & joan girson sary for educators to increase the clinician's awareness of areas in which they feel secure as well as the areas of insecurity as "the more realistic clinicians are about themselves, the more able they are to respond positively and constructively to their clients" (gregory, 1982: 17). • open discussions should be held during the training of speech therapists on the issue of stereotypes. lass et al., (1989) believe that this approach may reduce the negative impact of holding stereotypes. • van riper (1977) advocated the training of specialists in the field of stuttering in an attempt to improve speech therapists' attitudes towards stuttering. the fact that 98.4% of respondents agreed that clinicians working with stutterers need to be skilled in counselling techniques may strengthen the case for training fluency specialists (cooper & cooper, 1996). these specialists could receive special training, not only in fluency disorders, but in counselling techniques (cooper & cooper, 1985a). • specialized training beyond initial qualifications may also overcome the problem of a lack of practical experience with stutterers at an undergraduate level. this area which needs to be addressed as 17.7% of the present sample of south african speech therapists who disliked stuttering therapy claimed that the reason for their attitudes stemmed from a lack of practical experience. • competency-based educational strategies may overcome the negative attitudes of speech therapists working with stutterers. if a list of specific competencies was incorporated into clinical training, clinicians could graduate with a basic foundation to which additional skills and qualifications could be added (culatta & harris, 1976). this system is advantageous for tutors as well, as it is likely to be easier to provide specific feedback and suggestions for improvements when one is working from a specific list of competencies (culatta & harris, 1976). • within a south african context where resources are limited, group therapy experiences in treating stutterers during training may be a realistic solution. these expetable 6 distribution of personality attributes by training approach emphasised (n = 123) personality attributes approach emphasised question stutter fluently speak fluently combined depends on patient 3. chances are that most agree 10 7 26 17 stutterers have psychological undecided 3 3 6 4 problems disagree 10 10 18 9 7. most stutters have distorted agree 14 15 35 18 perception of their own undecided 3 2 7 4 stuttering behaviour disagree 6 3 8 8 22. most stutterers could be agree 8 10 31 20 described as possessing a undecided 6 6 14 3 feeling of inferiority disagree 9 4 5 7 26. there are some agree 9 10 29 12 1 personality traits characteristic undecided 8 5 11 9 : of stutterers disagree 6 5 10 9 1 30. most stutterers display agree 12 7 23 11 ! a distorted perception of their undecided 7 8 15 12 1 own social relationships disagree 4 5 12 7 47. stutterers are generally agree 1 1 10 0 more intelligent than those undecided 11 7 15 12 with other kinds of speech • handicaps disagree 11 12 25 18 / 49. clinicians must be more agree 5 5 21 9 understanding of the feelings undecided 1 3 1 1 of stuttering clients than nonstuttering clients disagree 17 12 2̂8 20 the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) attitudes of a g r o u p of south african speech-language and stuttering therapy riences have been found to effectively reduce the negative stereotypes that clinicians hold in respect of stutterers (leahy, 1994). this strategy may also enable more student clinicians to treat stutterers at an undergraduate level (mallard et al., 1988). • the need for continuing education in stuttering is evidenced by the response of over half the sample who disagreed with the view that they currently have at their disposal, adequate therapy techniques with which to treat stutterers. implications for further research • due to time constraints, it was beyond the scope of the present study to consider more of the possible contributing factors in training which may influence clinicians' attitudes. o f particular interest may be to ascertain whether there is a difference in attitudes between speechlanguage therapists who were exposed to intensive group training at an undergraduate level with those who were not. it would be of interest to see if results supported leahy's (1994) findings that group therapy yielded more positive attitudes. • an interesting area of research would be to attempt to consciously ameliorate the stereotype which undergraduate students may have of stutterers. in conclusion, it is hoped that this study m a y raise the awareness of clinicians and educators regarding the prevailing attitudes which exist with regard to stutterers. holding on to certain attitudes may cause clinicians to neglect their clients' individual attitudinal and behavioural responses, and may impede therapy. if clinicians feel that they are not competent in handling stutterers, they may look for convenient ways to circumvent their lack of confidence. onslow (1996) believes that australian therapists may have adopted this strategy by referring stutterers to intensive treatment centres and/or programmes, instead of handling them themselves. the same may hold true in south africa, as many of the respondents in this survey specifically mentioned referring patients to breitenfeldt and lorenz's (1989) successful stuttering management program. this tendency may, as onslow (1996) believes, perpetuate a cycle of ignorance as therapists deprive themselves of personal experience in treating stutterers. a way to break this cycle may be through workshops for therapists who wish to learn the latest therapy techniques for stutterers, j r e f e r e n c e s andrews, g., hoddinott, s., craig, α., howie, p., feyer, α., & neilson, m. (1983). stuttering: a review of research findings and theories circa 1982. journal of speech and hearing disorders, 48, 226 246. barbosa, l., schiefer, α., & chiari, b. (1995). how students of speech therapy perceive stuttering: a matter of prejudice. proceedings: first world congress on fluency disorders, munich, 1994. breitenfeldt, d.h. and lorenz, d.r. (1989). successful stuttering management program, eastern washington university, cheney, washington. cooper, e. (1996): personal communication. cooper, e.b. & cooper, c.s. (1985a). cooper personalised fluency control therapy revised. allen, tx: dlm. cooper, e.b. & cooper, c.s. (1985b). clinicians'attitudes towards stuttering: a decade of change (1973 -1983). journal of fluency disorders, 10, 19 33. 1 cooper, e.b. & cooper, c.s. (1996 in press). clinicians' attitudes pathologists towards stutterers z o towards stuttering: two decades of change. journal of fluency disorders. cooper, e.b. & rustin, l. (1985). clinicians' attitudes towards stuttering in the united states and great britain: a cross cultural study. journal of fluency disorders, 10, 1 17. culatta, r. & harris, a. (1976). a competency-based system for the initial training of speech pathologists. asha, 18, 10, 733 738. daly, d.a., simon, c.a. & burnett-stolnack, m. (1995). helping adolescents who stutter focus on fluency. language, speech, and hearing services in schools, 26, 2, 162 168. de vaus, d.a. (1991). surveys in social research, london, allen & unwin. emerick, l.l. (1960). extensional definition and attitude toward stuttering. journal of speech and hearing research, 3 , 2 , 181 185. gottwald & starkweather c.w. (1995). fluency intervention for preschoolers, and their families in the public school language, speech and hearing services in schools, 26, 117 127. gregory, h.h. (1982). the clinician's attitudes. in gruss, j. (ed) counselling stutterers. memphis, t.n.: speech foundation of america. ham, r.e. (1990a). what is stuttering: variations and stereotypes. journal of fluency disorders, 15, 259 273^ jones, r.a. (1977). self-fulfilling prophecies social, psychological, and physiological effects of expectancies. new jersey: lawrence erlbaum associates publishers. kalinowski, j.s., lerman, j.w., & watt, j. (1987). a preliminary examination of the perceptions of self and others in stutterers and non-stutterers. journal of fluency disorders, 12, 317 331. lass, n.j., ruscello, d.m., schmitt, j.f. , pannbacker, m.d., orlando, m.b. , dean, k.a., ruziska, j.c. & bradshaw, k.h. (1992). teachers' perceptions of stutterers. language, speech and hearing services in schools, 23, 78 -81. leahy, m. (1994). attempting to ameliorate student therapists' negative stereotype of the stutterers. european journal of disorders of communication, 29, 39 49. leith, (1971) clinical training in stuttering therapy : a survey asha, 13, 1, 6 8. mallard, α., gardner, l. & downey, c. (1988). clinical training in stuttering for school clinicians. journal of fluency disorders, 13, 253 259. onslow, μ (1996). behavioural management of stuttering, san diego: singular publishing group. peters, t. & guitar, b. (1991). stuttering :an integrated approach to its nature and treatment, baltimore, md: williams and wilkins. rustin, l. & cook, f. (1995). parental involvement in the treatment of stuttering. language, speech, and hearing services in schools, 26, 2, 127 137. starkweather, c.w. (1982). talking with parents of young stutterers. in gruss, j (ed) counselling stutterers. memphis, t.n.: speech foundation of america. st. louis, k.o. & durrenberger, c.h. (1993). what communication disorders do experienced clinicians prefer to manage? asha, 35, 12, 23 31. st. louis, k. & lass, n. (1981). a survey of communicative disorders students' attitudes toward stuttering. journal of fluency disorders, 6, 49 79. triandis, h.c. (1971). attitude and attitude change. u.s.a.: john wiley and sons inc. turnbaugh, k., guitar, b. & hoffman, p. (1979). speech clinicians' attribution of personality traits as a function of stuttering severity. journal of speech and hearing research, 22, 37 45. van der merwe, k. (1987). the attitudes of south african speech clinicians towards stuttering. university of cape town: unpublished research report. van riper, c. (1977). the public school specialist in stuttering. asha, 19, 7, 467 469. watson, j.b. (1995). exploring the attitudes of adults who stutter. journal of communication disorders, 28, 143 164. woods, c.l. & williams, d.e. (1971). speech clinician's conceptions of boys and men who stutter. journal of speech and hearing disorders, 36, 225 235. woods, c.l. & williams, d.e. (1976). traits attributed to stuttering and normally fluent males. journal of speech and hearing research, 19, 267 278. yairi, e. & williams, d. (1970). speech clinician's stereotypes of elementary schoolboys who stutter. journal of communication disorders, 3, 161 170. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) municatioi at telkom, we believe that everyone has the right to better communication. that's why we've developed the teldem a portable terminal designed for the deaf. thanks to teldem, your business is your own you no longer need to rely on a third party for telephone messages. face to face communication is easier too, since teldem replaces a paper and pen. at only r1 1 .40 (including vat) a month, teldem is much cheaper than imported communication terminals. and of course, you get all the benefits of telkom's service and maintenance facility. for more information, ask a friend to call this toll-free number: 0 8 0 0 11 95 96 w telkom teldem r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 die invloed van sekere kontekstuele faktore op die ouditief waarneembare foute by verbale apraksie a. van der merwe, d.phil (pretoria) departement spraakheelkunde en oudiologie, universiteit von pretoria. i.c. uys, d. phil (pretoria) departement spraakheelkunde en oudiologie, universiteit van pretoria. j.m. loots, dsc (fisiologie) (pretoria) departement menslike bewegingskunde, universiteit van pretoria. r.j. grimbeek, bsc (hons.) (pretoria) departement statistiek universiteit van pretoria. opsomming die rol van kontekstuele faktore by verbale apraksie is belangrik omdat dit implikasies inhou vir die interpretasie van simptome, die aard van die afwyking en vir verdere navorsing. die invloed van die kontekstuele faktore, klankstruktuur en artikulasie-eienskappe op die ouditief waarneembare simptome van vier persone met verworwe verbale apraksie en een persoon met verbale.ontwikkelingsapraksie is nagegaan. die effek van sistematiese variasie in die klankstruktuur en artikulasie-eienskappe van onsineenhede op die tipe en aantal foute in die spraak van die verbaal apraktiese sprekers is bepaal. daar is bevind dat afwykings in temporale vloei, klankdistorsie en afwykings in prosodie in hierdie volgorde die hoogste frekwensie van voorkoms vertoon ongeag die klankstruktuur of artikulasieeienskappe van die uiting. daar is wel 'n toename in klankvervangings, weglatings en byvoegings namate die moeilikheidsgraad van 'n uiting toeneem. dit wil voorkom asof die simptome van verbale apraksie op grond van konteks-sensitiwiteit verdeel kan word in kernsimptome en geassosieerde simptome. abstract the role of contextual factors in verbal apraxia is important as it has implications for the interpretation of behaviour, the nature of the disorder as well as for further research. the influence of the contextual factors, sound structure and articulatory features on the auditorily perceived symptoms of four patients with acquired verbal apraxia and one patient with developmental verbal apraxia, was investigated. the effect of systematic variation in the sound structure and articulatory features of nonsense units on the type and number of mistakes in the speech of the apraxic speakers, was determined. findings indicate that abnormalities in temporal flow, sound distortion and abnormalities in prosody exhibited in this order the highest frequency of occurrence, independent of the sound structure or articulatory features of the utterance. there is, however, an escalation of sound substitutions, ofnissions and additions with increasing complexity of the utterance. the symptoms of apraxia have been classified in core symptoms and associated symptoms based on their context sensitivity. verbale apraksie is vir meer as 120 jaar reeds 'n omstrede onderwerp. oor die kenmerkende eienskappe, die onderliggende aard van die afwyking en ook die naam van die afwyking het sterk meningsverskil ontstaan (rosenbek, kent & la pointe, 1984). broca het in 1861 die afwyking as "aphemia" benoem en sedertdien is talle ander name daaraan.gegee (johns & la pointe, 1976; darley, aronson & brown, 1975). groot verwarring het ontstaan en die term verbale apraksie is gebruik om verskillende tipes gedrag by verskillende tipes pasiente te beskryf (buckingham, 1981). dit is opvallend dat weinig van die vroee navorsers die afwyking wat hul bestudeer het, gedefinieer het. darley (1967) was die eerste resente navorser wat verbale apraksie gedefinieer en as 'n afwyking in spraakprogrammering beskryf het. darley het sodoende rigting gegee aan 'n groep navorsers wat vandag steeds hierdie afwyking bestudeer. 'n groot mate van eenstemmigheid is die afgelope paar jaar bereik. verbale apraksie word tans algemeen as 'n afwyking in spraakprogrammering beskryf en dit word onderskei van broca-afasie, fonemiese parafasie en disartrie wat ook afwykings in spraakproduksie weens breinskade is (mohr, pessin, finkelstein, funkenstein, duncan & davis', 1978;' buckingham, 1981; itoh & sasanuma, 1984; mackenzie, 1982). die kenmerkende eienskappe van suiwer verbale apraksie word deur kent & rosenbek (1983) beskryf as onvlot spraakproduksie met probeer-en-tref-artikulasiebewegings, pogings tot selfkorreksie, onkonstantheid in die foute by herhaalde produksie van dieselfde woord en disprosodie. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 © sasha 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die invloed van sekere kontekstuele faktore op die ouditief waarneembare foute by verbale apraksie 11 ten spyte van die eenstemmigheid wat bereik is, bestaan daar nog talle onbeantwoorde vrae oor verbale apraksie. rosenbek et al. (1984) verwys na "questions in search of answers" en noem onder meer die volgende: is die huidige definisie voldoende? is dit 'n afwyking op die fonologiese vlak of slegs versteurde artikulasie? is dit 'n dipe disartrie? wat is willekeurige beweging? wat is foutonkonstantheid? daar is 'n groeiende bewustheid dat navorsing oor verbale apraksie gerig moet word deur 'n volledige teoretiese model (itoh & sasanuma, 1984; rosenbek et al. 1984; kelso & tuller, 1981; marquardt & sussman, 1984). slegs enkele teoretiese modelle is reeds toegepas op liggaamsen verbale apraksie (roy, 1978; russell & whitaker, 1979; itoh & sasanuma, 1984; kelso & tuller, 1981; van der merwe, 1986). 'n model met groot moontlikhede vir verdere toepassing op verbale apraksie is waarskynlik die koalisiemodel (kelso & tuller, 1981; kelso, tuller & harris, 1983; tuller, fitch & turvey, 1982). die koalisiemodel is 'n teoretiese model wat gebaseer is op die idee dat gedrag ontstaan uit die funksionele koalisie van strukture ("coordinative structures"). tydelike koalisie of samewerking tussen neurale strukture en ook anatomiese strukture soos die spiere, ontstaan afhangende van die beweging wat uitgevoer moet word. die beweging of gedrag wat uitgevoer word, word in hierdie teorie omskryf as die konteks waarbinne funksionering plaasvind. hierdie teorie verklaar volgens die aanhangers daarvan die wyse waarop die individu die vryhede van die stelsel hanteer. kelso & tuller (1981) noem dit 'n "theory of context and constraints rather than a theory of commands". die konteks-sensitiwiteit van gedrag is dus die belangrikste eienskap van die koalisiemodel en afwykings in gedrag word beskou as die gevolg van 'n afwyking of onvermoe tot 'n koalisie van sekere strukture. kelso en tuller (1981) pas die koalisiemodel toe op apraksie. die toepassing op liggaamsapraksie is meer volledig as die op^verbale apraksie. die toepassing sentreer hoofsaaklik om die invloed van konteks, wat benut behoort te word in die ' i verklaring van apraksie. geen verduideliking van konteks in spraakproduksie word egter verskaf nie. slegs die bekende voorbeeld van 'n diskrepansie tussen proposisionele en outomatiese spraakproduksie word genoem. ten einde die koalisiemodel op verbale apraksie toe te pas, is dit dus nodig om kontekstuele faktore by spraakproduksie te identifiseer. i die huidige studie is uitgevoer binne die raamwerk van 'n omvattende spraakproduksiemodel wat spraakproduksie hierargies voorstel, maar ook die konsep van die kontekssensitiwiteit van spraak inkorporeer (van der merwe, 1986). die koalisiemodel word gewoonlik direk in teenstelling met die hierargiese model van kontrole gestel (kelso & tuller, 1981). die konsep van konteks-sensitiwiteit'kan egter wel bevredigend met die hierargiese model versoen word. sekere neurale dele verrig waarskynlik "hoer" funksies as ander dele, maar tree in 'n funksionele koalisie wat kan verander na gelang van die konteks waarin gedrag plaasvind. enkele kontekstuele faktore in spraakproduksie is hipoteties ge'identifiseer in hierdie model (van der merwe, 1986) en sluit die volgende in: willekeurigheid van inisiering, klankstruktuur, motoriese kompleksiteit, lengte van die uiting, bekendheid en spoed van produksie. twee van die belangrikste van hierdie kontekstuele faktore, wat ook sistematies gevarieer kan word, is klankstruktuur en artikulasie-eienskappe. die identifikasie van hierdie twee eienskappe van spraak as kontekstuele faktore kan teoreties gemotiveer word. daar is aanduidings in die literatuur dat sekere spraakklanke en kombinasies van klanke in woorde, groter vaardigheid vereis en moeiliker is om te bemeester as ander (calvert, 1980; oiler & macneilage, 1983). die feit dat sekere spraakklanke vroeer aangeleer word deur die kind en dat die eerste uitings wat geproduseer word, bestaan uit 'n konsonant (k) en 'n vokaal (v) dus kv of 'n reduplikasie daarvan (kvkv) (ingram, 1976), kan daarop dui dat die eerste klanke wat aangeleer word en die kvkv-struktuur makliker is om te produseer as ander klanke en strukture. dit is egter moeilik om die moeilikheidsgraad van 'n uiting toe te skryf aan 'n spesifieke faktor. 'n sekere kombinasie van klanke kan op 'n fonologiese enkoderingsvlak moeiliker wees, dit kan hoer eise stel aan die geheue van die persoon en dit kan motories moeiliker wees om te produseer. daar is faktore wat motoriese kompleksiteit kan verhoog sonder dat die klankstruktuur verander. hierdie faktore sluit koartikulasiemoontlikhede en groter variasie in artikulasie-eienskappe soos die opeenvolgende strekking en ronding van die lippe in. daar is weinig gegewens oor motoriese kompleksiteit in die literatuur en bogenoemde voorbeelde is slegs hipoteties. die totale konsep van konteks-sensitiwiteit soos hier uiteengesit, is nuut, hipoteties en onontwikkeld. die moontlikheid bestaan egter wel dat sekere uitings vanwee hul besondere klankstruktuur en artikulasie-eienskappe verskillende eise stel aan 'n spreker en dus as verskille in konteks gereken kan word. daar is aanduidings in die literatuur dat variasie in sekere van hierdie faktore 'n effek het op verbale apraksiesimptome (kent & rosenbek, 1983; collins, rosenbek & wertz, 1983; wertz, la pointe & rosenbek, 1984), maar in geen vorige ondersoek is faktore soos klankstruktuur, artikulasie-eienskappe en koartikulasiemoontlikhede sistematies gevarieer nie. indien variasie in hierdie faktore 'n effek het op die waargenome simptome van verbale apraksie, hou die feit belangrike implikasies in vir die interpretasie van simptome, die aard van die afwyking en vir verdere navorsing. dit sal ook deels 'n verklaring bied vir die bekende veranderlikheid van verbale apraksie (wertz, la pointe & rosenbek, 1984; kent & rosenbek, 1983; collins, rosenbek & wertz, 1983). dit is moontlik dat sekere aspekte van veranderlikheid deur kontekstuele invloede veroorsaak word. die invloed van sistematiese variasie in die kontekstuele faktore, klankstruktuur en artikulasie-eienskappe, op die spraakproduksie van die verbaal apraktiese spreker word dus in hierdie ondersoek nagegaan. daar sal bepaal word of daar enige verband bestaan tussen die eienskappe van 'n uiting en die ouditief waarneembare foute. hierdie ondersoek is deel van 'n groter ondersoek waarin ook akoestiese analises uitgevoer is ten einde die invloed van kontekstuele faktore te bepaal (van der merwe, 1986). metode: doel: die hoofdoel van die ondersoek is om te bepaal of sekere kontekstuele faktore in spraakproduksie, naamlik die klankstruktuur (foneemstruktuur) en die artikulasie-eienskappe die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 a. van der merwe, i.c. uys, j.m. loots, r.j. grimbeek (motoriese kompleksiteit) van 'n uiting 'n effek het op die frekwensie en tipe ouditief waarneembare simptome of foute in die spraak van persone met verbale apraksie. proefpersone: -* die proefpersone het bestaan uit vier persone met verworwe verbale apraksie en een persoon met 'n verbale ontwikkelingsapraksie. die kriterium is gestel dat 'n suiwer verbale apraksie vertoon moet word. vir die vier persone met verworwe verbale apraksie is die kriteria van kent en rosenbek (1983) gestel. hierdie persone het onvlot spraakproduksie met probeer-en-tref-artikulasiebewegings, pogings tot selfkorreksie, onkonstantheid in die foute by herhaalde produksie van dieselfde woord en disprosodie vertoon. ten einde 'n gepaardgaande afasie te beperk moes die proefpersone in staat wees om: — verbaal te kommunikeer met geen uitgesproke agrammatisme nie; — sinne te kan formuleer met 'n stel gegewe woorde; — 'n stel gegewe sinne te kan lees; en — normale taalbegrip te vertoon soos bepaal met 'n bekende afasietoets. die teenwoordigheid van 'n gepaardgaande disartrie is ook uitgeskakel. die proefpersone moes: — geen waarneembare boonste motorneurongesigof -tongparese vertoon nie; — geen ander neuromotoriese simptome in die liggaam vertoon as 'n hemiparese van die arm en been nie; en — geen disartriesimptome soos vegetatiewe probleme of 'n konstante distorsie vertoon nie. die lokalisasie van die letsel is nie gekontroleer in hierdie ondersoek nie omdat daar sterk aanduidings in die literatuur is dat daar nie 'n direkte verband tussen die lokalisasie van die letsel en die simptome van verbale apraksie bestaan nie (marquardt & sussman, 1984). die jongste beskikbare proefpersone is geselekteer. drie van die proefpersone is egter ouer as 65 jaar. ten einde die moontlike effek van ouderdom na te gaan, is daar ook afgepaarde kontrolepersone by die studie ingesluit. die resultate van die kontrolepersone word egter nie vir hierdie aspek van die studie gebruik nie omdat geen van die ouditief waarneembare foute by die kontrolepersone voorkom nie. daar kan dus aanvaar word dat die ouderdom van die proefpersone nie 'n effek gehad het op die resultate nie. die vyfde proefpersoon is op die ouderdom van vier as 'n geval met verbale ontwikkelingsapraksie gediagnoseer op grond van die voorkoms van die volgende simptome: — 'n diskrepansie tussen ekspressiewe vermoe en reseptiewe taalvermoe wat nie meer as ses maande agter sy chronologiese ouderdom is nie. — 'n on vermoe om willekeurig spraakbewegings uit te voer met gevolglike nie-verbaliteit. — kommunikasie het deur middel van gebare geskied. ten tye van die ondersoek het hy reeds ses jaar lank verbale apraksieterapie (van der merwe, 1976; 1985) ontvang en gebruik vyf tot seswoordsinne. gegewens omtrent die proefpersone word aangegee in tabel 1. luisteraars: twee luisteraars is geselekteer om deel te neem aan die ouditiewe analise. die een het opgetree as hoofluisteraar tesame met die ondersoeker en die ander as kontroleur-luisteraar. die hoofluisteraar is 'n spraakterapeut met 'n meestersgraad en met 'n paar jaar ondervinding in sprekerherkenning vir forensiese doeleindes. die kontroleur-luisteraar is 'n fonetikus verbonde aan 'n universiteit. beide is dus hoogs gesofistikeerde luisteraars. materiaal: ten einde die invloed van variasie in die klankstruktuur en artikulasie-eienskappe van 'n uiting op die ouditief waarneembare simptome na te gaan, is eenhede ontwikkel waarvan die klankstruktuur en artikulasie-eienskappe volkome gekontroleerd is. onsineenhede is saamgestel omdat die eienskappe van betekenisvolle woorde nie volkome kontroleerbaar en dus vergelykbaar is nie. die eenhede is in afrikaans en engels saamgestel en op so 'n wyse dat presies dieselfde klankstruktuur en artikulasie-eienskappe daarin voorkom (kyk tabelle 2 en 3). die samestelling van die materiaal word omvattend bespreek in van der merwe (1986) en slegs die belangrikste kriteria word hier genoem. wat die klankstruktuur van die eenhede betref, is vyf struktuurgroepe geselekteer. die klankstruktuurgroepe (s) sluit dupliserings van die kv-sillabe (wat vroeg voorkom in kinderspraak, moontlik die eenheid van spraakproduksie is en moontlik maklik is om te produseer) met meer en minder variasie in die aantal klanke wat gebruik word, (si en s2) en ook klankstruktuurgroepe wat die kvken kv-sillabes en uitbreidings daarvan (s3, 4 en 5) bevat, in. baie ander strukture kan gebruik word, maar daar is hiermee volstaan vanwee die groot hoeveelheid data wat dit reeds verskaf. die vyf klankstruktuurgroepe wat ingesluit is, is die volgende: 1 struktuurgroep 1: κι vi k1 v2 struktuurgroep 2: κι vi k2 v2 struktuurgroep 3: κι vi k2 v2 k3 struktuurgroep 4: κι vi k2 struktuurgroep 5: κι vi k2 v2 k3 v3 k4 en κι vi k2 v2 k3 v2 k4 die syfers wat hier aangegee word, verwys na die getal verskillende konsonante of vokale wat in 'n spesifieke eenheid voorkom. die eenhede bevat bekende foneme en voldoen aan die fonotaktiese reels van afrikaans en engels. hierdie proses van produksie is dus verwant aan spraakproduksie van betekenisvolle woorde. die artikulasie-eienskappe van die foneme in die eenhede is the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a. van der merwe, i.c. uys, j.m. loots, r.j. grimbeek 13 tabel 1: gegewens omtrent die proefpersone kriteria proefpersone kriteria 1 2 3 4 5 oorsake svi* svi svi svi verbale ontwikkelingsapraksie tydperk sedert aanvang van toestand 6 maande + 6 maande + 1 jaar + 1 jaar + geboorte ouderdom 30 jaar 70 jaar 66 jaar 70 jaar 10 jaar geslag vroulik vroulik vroulik manlik manlik spreektaal engels engels engels afrikaans afrikaans gepaardgaande afasie geen minimaal minimaal minimaal geen behandeling verbale-apraksie-terapie verbale-apraksie-terapie verbale-apraksie-terapie verbale-apraksie-terapie verbale-apraksie-terapie taalbegrip normaal gering ingekort normaal normaal normaal volgens chronologiese ouderdom op reynell-skaal ander probleme geen geen geen matige hoe frekwensie gehoorverlies gering verstandelik vertraag (i.k. 81 + ) lokalisasie van die letsel links frontotemporaal onbekend onbekend links parietaal perifeer en strek tot by posterior been van kapsula interna onbekend * svi serebrovaskulere insident gekontroleer met betrekking tot die plek en wyse van artikulasie. die eise wat die produksie van die eenhede aan die spreker stel ten opsigte van adaptasie by die klankomgewing en koartikulasiemoontlikhede (borden & harris, 1984) is in aanmerking geneem by die keuse van klanke wat in die eenhede voorkom. die moontlikheid bestaan dat eenhede wat oor verskillende artikulasie-eienskappe beskik, verskil in motoriese kompleksiteit en dus as verskille in konteks gereken kan word. j ι vier artikulasie-eienskapgr0epe (a) is onderskei (kyk tabelle 2 en 3). al die uitings in a1 en a2 begin met ibl wat 'n mate van adaptasie by die klankomgewing toelaat, maar antisiperende koartikulasie verhoed (borden & harris, 1984). die ibl staan by al voor 'n vokaal wat min lipbeweging vereis en by a2 voor 'n vokaal wat lipronding vereis. die tweede vokaal is by al en a2 afwisselend gestrek en gerond. die tweede konsonant by al en a2 is die itl wat antisiperende koartikulasie toelaat (borden en harris, 1984) vir die tweede vokaal. by s3, s4 en s5 is die lil die derde konsonant en hierdie konsonant vereis spesifieke aanpassing in lipbeweging. wat die artikulasie-eienskappe van a3 en a4 betref, is dieselfde tipe kontrole toegepas. al die uitings in a3 en a4 begin met idl wat die lippe en in 'n mate die mandibula vrylaat vir antisiperende koartikulasie (borden & harris, 1984). die antisiperende koartikulasie-moontlikhede in hierdie twee groepe is dus hoer as by al en a2. die eerste en tweede vokale is soos by al en a2 gekontroleer met betrekking tot gerondheid en strekking. die tweede konsonant ikl laat ook soos itl 'n mate van antisiperende koartikulasie van die lippe toe. die lil word ook om dieselfde redes as by a1 en a2, by a3 en a4 gebruik. die feit dat die eienskappe van die eenhede sistematies gevarieer is, maak dit moontlik om die invloed van hierdie eienskappe op spraakfoute goed gekontroleerd na te gaan. die proefpersone het elke eenheid vier keer geproduseer. 'n totaal van 160 uitings per persoon is dus versamel. herhaalde uitings van dieselfde eenheid is verkry ten einde te kontroleer vir die veranderlikheid van verbale apraksie. die spraakopnames is in 'n taallaboratorium gedoen en sluit die volgende apparaat in: — 'n nakamichi 550-bandopnemer; — 'n beyer dynamic m201-mikrofoon. die apparate wat gebruik is vir die ouditiewe analise was ook van die taallaboratorium van die universiteit van pretoria en het bestaan uit: — die tandberg tcr 5600 kassetspeler; — die tandberg learning laboratory met 'n is 9-luidspreker. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34,1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 a. van der merwe, i.c. uys, j.m. loots, r.j. grimbeek tabel 2: eenhede waarvan die klankstruktuur en artikulasie-eienskappe gekontroleer is (afrikaans) klankstruk= tuurgroepe (s) artikulasie-eienskapgroepe (a) klankstruk= tuurgroepe (s) 1 2 3 4 ] 1.1 babe 1.2 bobs 1.3 dade 1.4 dode 1.5 babu 1.6 bobu 1.7 dadu 1.8 dodu 2 2.1 b a t s 2.2 bote 2.3 daks 2.4 doks 2.5 batu 2.6 botu 2.7 daku 2.8 doku 3 3.1 b a t s f 3.2 b o t s f 3.3 d a k e f 3.4 d o k s f 3.5 b a t u f 3.6 b o t u f 3.7 dakuf 3.8 dokuf 4 4.1 b a t 4.2 b o t 4.3 dak 4.4 dok 4.5 b e t 4.6 but 4.7 dek 4.8 du:k 5 5 . ] b a t e f u p 5.2 b o t e f u p 5.3 dakefup 5.4 doksfup 5 . 5 b a t u f u p 5.6 botufup 5.7 dakufup 5.8 dokufup tabel 3: eenhede waarvan die klankstruktuur en artikulasie-eienskappe gekontroleer is (engels) klankstruk= tuurgroepe (s) artikulasie-eienskapgroepe (a) klankstruk= tuurgroepe (s) 1 2 3 4 1 1.1 ba : b a i 1.2 bob® l . 3 d q : d a e 1.4 dcd® 1.5 b a : b u 1.6 t d b u 1.7 da:du 1.8 dcdu 2 2.1 ba:iffi 2.2 bd"i® 2.3 da:ka? 2.4 duka; 2.5 batu 2.6 b o i u 2.7 d a : k u 2.8 dcku 3 3.1 ba lisef 3.2 boiarf 3.3da:ka>f 3.4 ddkaif h h 3.5 b a : t u f 3.6 b c t u f 3 . 7 d a : k u f 3.8ddkuf 4 4.1 b a : t h 4 . 2 b o i 4 . 3 d a : k 4.4 dck h h 4.5 bffit 4.6 but 4.7 dsek 4.8 du:k 5 5 . 1 b a : i a ; f u p 5 . 2 bdtha?fup 5 . 3 da:k£efup 5.4 ddkffifup 5.5 b a : i u f u p 5 . 6 bdtilifup 5 . 7 d a : k u f u p 5 . 8 dnkufup the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die invloed van sekere kontekstuele faktore op die ouditief waarneembare foute by verbale apraksie 15 prosedure: — die materiaal is in geskrewe vorm (elke eenheid afsonderlik op 'n kaartjie in groot drukskrif) voorgehou en die ondersoeker het die uiting twee tot drie keer herhaal sodat die spreker 'n duidelike beeld van die eenheid kon verkry. sodoende is probleme as gevolg van 'n onvermoe om die eenheid te onthou, sover as moontlik uitgeskakel. — die prosedure van kent en rosenbek (1983) is gevolg, naamlik om aan die proefpersoon die geleentheid te gee om die eenheid 'n paar keer te oefen met die hulp van die ondersoeker. sonder die oefengeleentheid sou die proefpersone soms nie in staat gewees het om die eenheid te produseer nie. sodra die proefpersoon dit eenkeer "korrek" geproduseer het, is hy/sy gestop, die instruksie is herhaal en die opname het plaasgevind. die proefpersoon het die uiting dan vier keer herhaal sonder enige verdere hulp. die prosedure het dus meegebring dat die uitings selfge'inisieerd was. — geen instruksies omtrent spraakspoed is aan die proefpersone gegee nie. sodoende is nie ingemeng met spontane aanpassings in spoed nie. die normale sprekers is wel aangese om net 'n normale spraakspoed te handhaaf. — die volgorde waarin die eenhede aangebied is, was dieselfde by alle persone. dit is gekontroleer ten einde te verhoed dat eenhede met soortgelyke eienskappe na mekaar geproduseer word en adaptasie intree. data-analise: in die eerste stadium van die analise is 'n lys saamgestel van alle spraakfoute wat voorgekom het by die vyf proefpersone. foutkategoriee is dus bepaal. die twee luisteraars en die ondersoeker het deelgeneem'hieraan. in die tweede stadium het,die hoofluisteraar en ondersoeker gesamentlik na die spraakopnames geluister en idie foute in elke uiting aangeteken. daar is gemiddeld tienjkeer na elke uiting geluister en vyftien tot twintig uur is aan die analise van elke spreker se opnames bestee. die kontroleur-luisteraar het op 'n later stadium steekproewe gedoen en ook na alle uitings geluister waar ooreenstemming nie bereik is nie. die beoordelings van die kontroleur-luisteraar het honderd persent met beoordelings van die twee luisteraars ooreengekom. sy beslissings in probleemgevalle is aanvaar. sewe tipes foute het voorgekom by die verbaal apraktiese sprekers. elk van hieidie foutkategoriee (a-g) het bestaan uit 'n aantal subkategoriee wat volledig aangegee word in die bylae. die foutkategoriee is die volgende: a. vervangings b. verandering van die struktuur van die eenheid c. klankdistorsie d. afwykings in temporale vloei e. afwykings in vlotheid f. spraakfoute gevolg deur selfkorreksie g. afwykings in prosodie daar is gepoog om die groeperings beskrywend te maak en om nie oorsaaklike aanduidings te gee nie. dit is onmoontlik om in hierdie stadium oorsake te identifiseer. die gebruik van oorsaaklike terme sal interpretasie van die data waarskynlik ook be'invloed en objektiwiteit benadeel. enkele probleme het wel voorgekom in die groepering van foute. veranderinge in die plek van lettergreepafbreking en afbreking binne 'n geslote lettergreep is as veranderinge in die struktuur van die eenheid geklassifiseer. die enigste ander moontlike klassifikasie is by die probleme in temporale vloei. dit was egter nie bloot 'n probleem in hierdie opsig nie, omdat onsensitiwiteit vir lettergreepgrense geopenbaar is. afwykings in temporale vloei is onderskei as 'n groep omdat al die foute in hierdie kategorie verband lou met die spoed van bewegings. dit is weer onderskei van afwykings in vlotheid omdat die foute wat in hierdie groep beskryf word, aandui dat die spreker probleme ondervind om die volgende uiting of deel daarvan te inisieer. die vasstekings en worstelgedrag is ouditief duidelik identifiseerbaar. versteurings in die stemhebbendheid van klanke is as klankdistorie geklassifiseer omdat dit ouditief so waargeneem word. dit is waarskynlik die gevolg van temporale wansinchronisasie maar klassifikasie by 'n groep wat dui op temporale versteurings sal impliseer dat die luisteraar 'n oorsaak aan die verskynsel koppel. dit is soms as vervangings geklassifiseer wanneer die luisteraars oortuig was dat dit nie bloot die stemaanvangstyd is wat versteur is nie. selfs in hierdie gevalle kan die oorsaak ook temporale wansinchronisasie wees. dataverwerking: die somtotaal van elke verskillende tipe fout oor vier herhalings van 'n spesifieke eenheid is bepaal vir elke proefpersoon. hierdie data is gebruik om te bepaal wat die frekwensie en tipe foute is wat voorkom by die verskillende klankstruktuurgroepe en artikulasie-eienskapgroepe vir elke proefpersoon. die totale van die proefpersone is egter ook saamgevoeg (dus die resultate van 20 produksies van elke eenheid en in elke klankstruktuurgroep en artikulasie-eienskapgroep is daar 8 eenhede wat 'n totaal van 160 uitings per klankstruktuurgroep en artikulasie-eienskapgroep lewer) ten einde te bepaal wat die frekwensie en tipe fout is wat voorkom by die verskillende klankstruktuurgroepe en artikulasie-eienskapgroepe. verder is die verdelingsvrye variansie-analiseprosedure van friedman in 'n horisontale en vertikale rigting toegepas op die data (tabelle 5 en 9) ten einde die betekenisvolheid van verskille in frekwensie en tipe foute te bepaal. die foutkategoriee is ook in dalende volgorde van foutvoorkoms gerangskik by al die klankstruktuurgroepe, artikulasie-eienskapgroepe en proefpersone. verder is 'n ooreenstemmingsanaliseprosedure toegepas om die assosiasiesterkte tussen verskillende foutkategoriee en klankstruktuurgroepe en tussen foutkategoriee en eenhede vas te stel. resultate: die frekwensie van foute by die verskillende klankstruktuurgroepe: die gegewens in tabel 4 toon aan dat die grootste getal foute die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 a. van der merwe, i.c. uys, j.m. loots, r.j. grimbeek by klankstrukture 3 en 5 (s3 en s5) voorgekom het. klankstrukture 1 en 2 vorm 'n tweede groep wat minder foute veroorsaak en die minste foute kom voor by s4. dit wil dus voorkom asof die getal foute die moeilikheidsgraad van 'n uiting reflekteer. die totaalwaardes in tabel 4 dui dus daarop dat die langste strukture die meeste foute veroorsaak. dit is in 'n sekere sin vanselfsprekend, maar 'n interessante verskynsel is dat daar nie 'n proporsionele toename in getal foute is nie. klankstruktuur 3 is slegs een klank langer as s2, maar vertoon baie meer foute. daar is dus ook ander faktore as bloot die lengte van 'n uiting wat 'n effek het op moeilikheidsgraad. 'n moontlike faktor is die ritme van 'n uiting en ook die spesifieke struktuur wat moontlik moeiliker is om te beplan. by sekere foutkategoriee soos byvoorbeeld distorsie en afwykings in temporale vloei, vertoon s3 meer foute as s5. die spreker was geneig om die kvkv-gedeelte van s3 as 'n eenheid te produseer en die finale konsonant as 'n ge'isoleerde klank wat moontlik afsonderlik beplan word. die besondere struktuur van s3 het dus waarskynlik die moeilikheidsgraad daarvan verhoog. ten einde te bepaal of die klankstruktuur van 'n uiting 'n effek het op die frekwensie van foute binne elke foutkategorie is 'n tweerigting-variansie-analise uitgevoer op die data wat aangegee word in tabel 4. die p-waardes toon aan dat geen betekenisvolle verskille voorkom tussen die getal foute by die verskillende klankstrukture nie. die numeriese waardes in tabel 4 toon egter aan dat daar wel verskille is tussen die getal fcrnte by die verskillende klankstrukture binne elke foutkategorie. klankstruktuur 5 lei byvoorbeeld tot 126 vervangings terwyl s4 net tot 4 lei. hierdie gegewens word ook weerspieel deur die analise waarin die tipe foute wat by die verskillende klankstrukture voorkom, nagegaan word. die tipe foute by die verskillende klankstruktuurgroepe: die aantal foute in elke foutkategorie by die verskillende klankstruktuurgroepe word ook vervat in tabel 4. die tipe foute wat by elke klankstruktuurgroep voorkom, kan deur verwerking van hierdie data bepaal word. die foutkategoriee wat die hoogste voorkoms vertoon, is afwykings in temporale vloei (35,6%) en dan distorsie (30,7%). al die ander foutkategoriee vertoon 'n veel kleiner voorkomspersentasie. afwykings in prosodie en veranderinge van struktuur neem die derde plek in beide met 'n persentasie van 9,6%. klankvervangings neem die vierde plek in (8,5%) en daarna volg afwykings in vlotheid (4,7%). foute gevolg deur selfkorreksie (1,3%) het die heel minste voorgekom (kyk tabel 4). ten einde te bepaal of daar betekenisvolle verskille is tussen die voorkoms van die verskillende foutkategoriee by elke klankstruktuurgroep is 'n tweerigting-variansie-analise uitgevoer op die data in tabel 4. die p-waarde van die globale analise toon aan dat daar 'n betekenisvolle verskil (op die 5% peil van betekenis) is tussen die frekwensie van voorkoms van die verskillende foutkategoriee. die verskillende tipe foute kom dus nie in dieselfde mate by hierdie groep verbaal apraktiese sprekers voor nie. betekenisvolle verskille tussen die frekwensie van voorkoms is ook by si, s4 en s5 verkry. die verskille wat verkry is, is tussen die foutkategoriee met die hoogste en laagste voorkoms. in die geval van byvoorbeeld si verskil die voorkoms van foutkategoriee c en d betekenisvol van β en f. die verskille by s2 en s3 is nie so groot dat dit statisties betekenisvol is nie, maar dieselfde verskille kom voor by hierdie klankstruktuurgroepe. tabel 4: die frekwensie (en persentasie) van voorkoms van die foutkategoriee by die verskillende klankstruktuurgroepe klankstrukfoutkategoriee | klankstruka β c d ε f g 1 tuurgroepe vervangings verandering van struktuur distorsie afwykings in temporale vloei afwykings in vlotheid selfkorreksie afwykings in prosodie j , totale aantal foute si 25 (4,8%) 12 (2,3%) 205 (39,1%) 213 (40,6%) 12 (2,3%) 4 (0,8%) 53 (10,1%) 524 ι (100%); s2 22 (4,7%) 28 (6,0%) 128 (27,3%) 206 (43,9%) 23 (4,9%) 5 (1,1%) 57 (12,1%) 469 (100%) s3 37 (6,1%) 92 (15,2%) 169 (28,0%) 223 (36,9%) 27 (4,5%) 8 (1,3%) 48 (8,0%) 604 (100%) . s4 4 (1,5%) 17 (6,5%) 110 (42,2%) 64 (24,5%) 19 (7,3%) 1 (0,4%) 46 (17,6%) 261 ^ /(100%)' s5 126 (19,4%) 92 (14,2%) 157 (24,2%) 186 (28,6%) 37 (5,7%) 14 (2,2%) 38 (5,7%) 650 (100%) totaal 214 (8,5%) 241 (9,6%) 769 (30,7%) 892 (35,6%) 118 (4,7%) 32 (1,3%) . 242 (9,6%) 2508 (100%) the south african journal of communication disorders, vol 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die invloed van sekere kontekstuele faktore op die ouditief waarneembare foute by verbale apraksie 17 die feit dat alle foutkategoriee nie dieselfde frekwensie van voorkoms vertoon nie, laat die moontlikheid dat sekere foutkategoriee 'n hoer voorkoms by sekere klankstruktuurgroepe het. om te bepaal of die klankstruktuur van 'n uiting 'n effek het op die tipe foute wat voorkom, is die data verder verwerk. 'n rangskikking van die verskillende foutkategoriee in dalende volgorde van foutvoorkoms by die verskillende klankstruktuurgroepe is gedoen en word weergegee in tabel 5. meer fonologies gebaseerde probleme gereken word. hierdie foute neem by die ander strukture slegs die vyfde of sesde plek in. klankvervangings is dus op grond van hierdie resultate nie die mees kenmerkende simptoom van verbale apraksie nie. dit is interessant dat afwykings in vlotheid of inisiering wat as kenmerkend van verbale apraksie beskryf word (kent en rosenbek, 1983) slegs by s4 die derde plek inneem en by die ander strukture die vyfde of sesde plek. die lae voorkoms van afwykings in vlotheid in hierdie studie tabel 5: rangskikking van foutkategoriee in dalende volgorde van foutvoorkoms by die verskillende klankstruktuurgroepe klankstruktuurgroepe rangskikking van foutkategoriee si d (40,6%) c (39,1%) g (10,1%) a (4,8%) β (2,3%) ε (2,3%) f (0,8%) s2 d (43,9%) c (27,3%) g (12,1%) β (6,0%) ε (4,9%) α (4,7%) f (1,1%) s3 d (36,9%) c (28,0%) β (15,2%) g (8,0%) a (6,1%) ε (4,5%) f (1,3%) s4 c (42,2%) d (24,5%) g (17,6%) ε (7,3%) β (6,5%) α (1,5%) f (0,4%) s5 d (28,6%) c (24,2%) a (19,4%) β (14,2%) ε (5,7%) g (5,7%) f (2,2%) die rangskikking van foutkategoriee (tabel 5) toon aan dat die klankstruktuur van 'n uiting slegs deels 'n invloed het op die tipe foute wat voorkom. afwykings in temporale vloei toon die hoogste voorkoms by al die klankstrukture behalwe by s4 waar distorsie die hoogste frekwensie vertoon. distorsie neem die tweede plek in by al die strukture behalwe by s4. by s4 neem afwykings in temporale vloei die tweede plek in. hierdie studie bevestig dus die mees resente mening van navorsers (itoh en sasanuma, 1984; wertz et al. 1984; kent en rosenbek, 1983) dat distorsie tesame met afwykings in temporale beheer die mees kenmerkende simptome van verbale apraksie is. die derde plek by si, s2 en s4 word ingeneem deur afwykings in prosodie, maar by s3 en s5 wat die meeste probleme tot gevolg gehad het en die langste eenhede is, word die derde plek ingeneem deur vervangings en veranderinge van struktuur. laasgenoemde kan moontlik as kan moontlik die gevolg wees van die besondere omstandighede waaronder spraak geproduseer is. 'n voorbeeld van produksie is verskaf voordat die persoon dieselfde uiting moes herhaal. selfinisiering was dus in 'n mate beperk. die resultate van die ooreenstemmingsanalise wat uitgevoer is op die ouditief waarneembare foute wat by die verskillende klankstrukture voorkom, word grafies voorgestel in figure 1 en 2. die afleidings wat op grond van die frekwensie-analise gemaak is, word deur die ooreenstemmingsanalise bevestig. laasgenoemde werp egter ook 'n ander lig op die data. die sterkte van assosiasie of ooreenstemming tussen foute a tot g en die verskillende klankstrukture (kyk figuur 1) en die verskillende eenhede (kyk figuur 2) word afgelei van die afstand tussen die twee punte op die grafiese voorstelling. s3 s5 a s4 s2 d si figuur 1: resultate van die ooreenstemmingsanalise om die sterkte van assosiasie tussen die klankstrukture (s1-s5) en foutkategoriee (a-g) te illustreer die suid-afrikaanse tydskrif vir kommunikasieafwykgs, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 a. van der merwe, i.c. uys, j.m. loots, r.j. grimbeek 3.8 4.3 4.4 4.1 4 · 5 3.5 4.2 c 4.7 3.3 4.8 5.8 β 3.2 1-2 3.6 ε 2.4 5.7 3.4 3.1 2.2 2.6 g 1-8 1.3 2.1 2.3 d 4.6 1.7 1.1 2.5 1.5 2.7 1.6 1.4 5.4 3.7 2.8 f 5.2 5 3 * 5.1 5.6 a 5.5 figuur 2: resultate van die ooreenstemmingsanalise om die sterkte van assosiasie tussen die eenhede (1.1-5.8) die foutkategoriee (a-g) te illustreer enkele belangrike assosiasies kan afgelei word uit figuur 1. foutkategoriee a en β assosieer die sterkste met s5 en s3. meer klankvervangings en byvoegings en weglatings van klanke wat die klankstruktuur verander, kom dus voor by die langste eenhede. afwykings in inisiering (e) en foute gevolg deur selfkorreksie (f) assosieer ook die sterkste met s3 en s5. dit is werklik insiggewend dat s3 en s5 by alle analises 'n groep vorm. dit is waarskynlik onder meer 'n aanduiding dat die data wat verkry is, betroubaar is. foutkategoriee c (distorsie) en d (afwykings in temporale vloei) assosieer die sterkste met s2 en si. dit is belangrik om daarop te let dat c en d sterker met si, s2 en s3 assosieer as wat a en β met s3 en s5 assosieer. dit impliseer waarskynlik dat distorsie en afwykings in temporale vloei meer kenmerkende probleme van verbale apraksie is en dat indien klankvervangings en struktuurveranderinge by verbale apraksie voorkom, dit meer waarskynlik by langer eenhede sal wees. dieselfde afleidings word ook gemaak op grond van figuur 2. dit is baie duidelik in hierdie visuele voorstelling (kyk figuur 2) dat foutkategoriee a en β en ook in 'n mate ε en f nie nabv aan die verskillende eenhede geplaas is nie. dit toon aan dat dit nie algemene tipe probleme is'riie want dit assosieer slegs sterk met enkele van die eenhede. hierdie eenhede is almal in klankstruktuurgroep 5. foutkategorie β vertoon 'n minder duidelike assosiasie met 'n besondere klankstruktuurgroep, maar dit is veral s3 en s5 eenhede wat die sterkste daarmee assosieer. die enigste uitsondering is eenheid 4.8 wat baie sterk met β assosieer. dit impliseer waarskynlik dat die simptome van verbale apraksie nie volkome voorspelbaar is nie. foutkategoriee c, d en g is naby aan die meeste eenhede gelee en assosieer dus sterk met die meeste (kyk figuur 2). dit bevestig die afleiding wat reeds gemaak is dat distorsie, afwykings in temporale vloei en afwykings in prosodie die mees kenmerkende probleme is. 'n interessante verskynsel wat ook gefllustreer word in figuur 2 is dat distorsie (c) die swakste assosieer met s5. die lengte van die struktuur het dus nie meegebring dat die hoeveelheid distorsie toeneem nie. die getal vervangings (a) het egter wel toegeneem. ι opsommend kom die resultate daarop neer dat die mees kenmerkende simptome van verbale apraksie (soos dit deur hierdie studie aangetoon is) afwykings in temporale vloei, distorsie en afwykings in prosodie is. hierdie simptome vertoon die hoogste voorkoms ongeag die klankstruktuur van die uiting. die frekwensie van voorkoms van ander simptome wat as minder kenmerkend gereken kan word, soos klankvervangings, byvoeging en weglating van klanke wat die klankstruktuur verander, word egter wel be'fnvloed deur die klankstruktuur van die uiting. hierdie foute word die sterkste geassosieer met s5. dit assosieer ook sterk met s3, maar s3 en s5 assosieer sterker met klankdistorsie en afwykings in temporale vloei. laasgenoemde twee probleme is dus die prominentste afwykings ook by s3 en s5. die frekwensie en tipe foute by die verskillende artikulasie • eienskapgroepe: die frekwensie van voorkoms van die verskillende ouditief waarneembare foute by die agt artikulasie-eienskapgroepe is bereken en word weergegee in tabel 6. the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die invloed van sekere kontekstuele faktore op die ouditief waarneembare foute by verbale apraksie 19 tabel 6: die frekwensie (en persentasie) van voorkoms van die verskillende artikulasie-eienskapgroepe artikulasie_ eienskapgroepe a vervangings β verandering van struktuur c distorsie d afwykings in temporale vloei ε f afwykings selfkorrekin vlotheid sie g afwykings in prosodie totale aantal foute a l 41 ( 12,3%) 32 (9,6%) 90 (27,1%) 120 (36,2%) 10 (3,0%) 4 (1,2%) 35 (10,6%) 332 (100%) a2 32 (9,5%) 48 (14,2%) 124 (36,7%) 89 (26,3%) 14 (4,1%) 6 (1,8%) 25 (7,4%) 338 (100%) a3 20 (7,1%) 13 (4,6%) 92 (32,6%) 108 (38,3%) 18 (6,4%) 2 (0,7%) 29 (10,3%) 282 (100%) a4 24 (7,8%) 22 (7,1%) 102 (33,1%) 111 (36,0%) 22 (7,2%) 5 (1,6%) 22 (7,2%) 308 (100%) a5 30 (9,4%) 21 (6,6%) 85 (26,6%) 127 (39,9%) 11 (3,4%) 0 (0%) 45 (14,1%) 319 (100%) a6 30 (9,6%) 28 (9,0%) 88 (28,2%) 116 (37,2%) 10 (3,2%) 10 (3,2%) 30 (9,6%) 312 (100%) a7 20 (7,1%) 22 (7,8%) 78 (27,8%) 115 (41,0%) 14 (5%) 3 (1,0%) 29 (10,3%) 281 (100%) a8 17 (5,1%) 55 (16,4%) 110 (32,7%) 106 (31,5%) 19 (5,7%) 2 (0,6%) 27 (8,0%) 336 (100%) totaal 214 (8,5%) 241 (9,6%) 769 (30,7%) 892 (35,6%) 118 (4,7%) 32 (1,3%) 242 (9,6%) 2508 (100%) dit blyk uit die totale aantal foute by elke artikulasie-eienskapgroep dat die verskillende groepe tot ongeveer dieselfde getal foute aanleiding gegee het. die variasiewydte strek vanaf 281 tot 338 foute terwyl dit by die klankstruktuurgroepe vanaf 261 tot 650 (kyk table 4) strek. die verskillende artikulasie-eienskapgroepe stel dus ongeveer dieselfde eise aan die verbaal apraktiese sprekers. die artikulasie-eienskappe wat vervat is in die materiaal het dus nie 'n effek op die frekwensie van die ouditief waarneembare foute nie. 'n tweerigtingvariansie-analise wat uitgevoer is om bogenoemde afleiding te staaf, nisvolle verskille bestaan toon ook aan dat daar nie beteketussen die frekwensie van foute by die verskillende artikulasie-eienskapgroepe binne elke foutkategorie nie. j tabel 7: rangskikking van foutkategoriee in dalende volgorde van foutvoorkoms by die verskillende artikulasieeienskapgroepe die afleiding kan egter nie gemaak word dat artikulasieeienskappe geen effek het nie. eenhede met dieselfde klankstruktuur maar verskillende artikulasie-eienskappe byvoorbeeld /b"dth ®fup/ en /b-dthufup/ het nie tot dieselfde hoeveelheid en tipe foute gelei nie. eersgenoemde eenheid wat meer variasie in artikulasiebewegings vereis en meer koartikulasie-moontlikhede bied, het tot 'n groter getal foute gelei. om 'n beeld te verkry van die tipe foute wat meer voorkom by spesifieke artikulasie-eienskapgroepe, is die foutkategoriee in dalende volgorde van foutvoorkoms gerangskik (kyk tabel 7). die rangskikking van foutkategoriee toon aan dat of distorsie of afwykings in temporale vloei die eerste en tweede plekke inneem. vervangings, verandering van artikulasieeienskapgroepe rangskikking van foutkategoriee a l d (36,2%) c (27,1%) a (12,3%) g (10,6%) β (9,6%) ε (3,0%) f (1,2%) a2 c (36,7%) d (26,3%) β (14,2%) a (9,5%) g (7,4%) ε (4,1%) f (1,8%) a3 d (38,3%) c (36,6%) g (10,3%) a (7,1%) g (6,4%) β (4,6%) f (0,7%) a4 d (36,0%) c (33,1%) a (7,8%) ε (7,2%) = g (7,2%) β (7,1%) f (1,6%) a5 d (39,9%) c (26,6%) g (14,1%) a (9,4%) ε (6,6%) ε (3,4%) f (0%) a6 d (37,2%) c (28,2%) g (9,6%) = a (9,6%) β (9,0%) ε (3,2%) = f (3,2%) a7 d (41,0%) c (27,8%) g (10,3%) β (7,8%) a (7,1%) ε (5,0%) f (1,0%) a8 c (32,7%) d (31,5%) β (16,4%) g (8,0%) ε (5,7%) α (5,1%) f (0,6%) rw„ afrlhnnnco tuj<ihrif vir knrrimijmhnsip.nfwvhi'nps. vnl. 34. 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 a. van der merwe, i.c. uys, j.m. loots, r.j. grimbeek struktuur of afwykings in prosodie neem die derde plek in. selfkorreksie het deurgaans die laagste frekwensie. hierdie resultate bevestig dus dat distorsie en afwykings in temporale vloei die kenmerkende simptome van verbale apraksie is en die hoogste voorkoms vertoon ongeag die artikulasie-eienskappe of klankstruktuur van die uiting. die tweerigting-variansieanalise wat uitgevoer is om te bepaal of daar betekenisvolle verskille is tussen die frekwensie van voorkoms van die verskillende foutkategoriee in die verskillende artikulasie-eienskapgroepe toon aan dat die verskille betekenisvol is op die 10% peil van betekenis. die verskille was soos by die klankstruktuurgroepe tussen foutkategoriee c of d en f. resultate van die individuele proefpersone: dat daar baie individuele verskille tussen verbaal apraktiese sprekers is, is goed bekend (wertz et al. 1984). die proefpersone in hierdie studie is egter as 'n groep hanteer en die vraag ontstaan dus of die resultate van die groep ook die individuele verbaal apraktiese sprekers se resultate weerspieel. met die oog op kontrole hiervan, is die totale aantal foute in elke foutkategorie van elke proefpersoon, in tabel 8 gerangskik in dalende volgorde van voorkoms. proefpersoon se spontane spraak is steeds beperk tot vyf of seswoordsinne en dit is moontlik dat die groot hoeveelheid vervangings sy algemeen vertraagde spraakontwikkeling weerspieel. die slotsom is dat individuele verskille voorkom, maar dat die proefpersone die meeste foute gemeen het en in die meeste gevalle ooreenstemmend gereageer het op die manipulasie van die struktuur en artikulasie-eienskappe van eenhede. die groep se resultate weerspieel dus ook in 'n groot mate die individuele resultate. volgens wertz et al. (1984) sal individuele verbaal apraktiese proefpersone in groepstudies nie alle eienskappe met die groep gemeen he nie, maar soos hulle dit stel: "failure to do so does not necessarily cast a patient out of his ilk". groepstudies by verbale apraksie is dus voordelig omdat dit individuele verskille deels neutraliseer en 'n meer algemene beeld verskaf. bespreking en gevolgtrekkings: die ondersoek na die invloed van sistematiese variasie van sekere kontekstuele faktore het aangetoon dat die klankstruktuur en artikulasie-eienskappe van 'n uiting geen rol speel by die voorkoms van die mees kenmerkende simptome nie, maar wel 'n effek het op die voorkoms van minder tabel 8: rangskikking van foutkategoriee in dalende volgorde van voorkoms by elke proefpersoon proefpersone rangskikking van foutkategoriee 1 c (52,0%) d (38,8%) β (6,2%) α (1,6% ') ε (1,2%) g (0,2%) f (0%o) 2 d (42,2%) c (23,6%) β (14,6%) g (14,0% ) a (2,8%) ε (2,0%) f (0,8%) 3 c (33,5%) d (25,3%) ε (14,0%) β (11,9%) a (8,5%) g (4,6%) f (2,2%) 4 d (58,0%) g (24,5%) c (9,2%) a (4,0% ) ε (2,4%,) f (1,9%) β (0%) 5 c (42,4%) a (27,4%) β (19,1%) d (8,8% ) g (0,9%) ε (0,7%) f (0,7%) uit die gegewens in tabel 8 blyk dit dat die proefpersone alle foute gemeen het, behalwe dat proefpersoon 1 geen foute gevolg deur selfkorreksie getoon het nie en proefpersoon 4 het geen veranderinge van struktuur getoon nie. afwykings in temporale vloei en distorsie, wat by die vorige ontledings as die mees kenmerkende simptome uitgelig is, toon die hoogste frekwensie van voorkoms by al die pasiente. slegs by proefpersone 4 en 5 neem een van hierdie foute nie ook die tweede plek in nie. proefpersoon 4 vertoon in vergelyking met die ander proefpersone baie meer afwykings in temporale vloei. dit was veral die temporale organisasie van die duur van klanke wat die grootste afwyking getoon het. artikulasieverlenging het 'n groot effek op prosodie gehad. dit is moontlik dat die letsel wat ook deels subkortikaal was, tot die besondere simptoomkompleks van hierdie persoon aanleiding gee. proefpersoon 5 wat as 'n geval met verbale ontwikkelingsapraksie gediagnoseer is, vertoon verbasende ooreenstemming met die ander vier proefpersone. nie alleen vertoon hy dieselfde tipe foute nie, maar ook die frekwensie van foute by die verskillende klankstrukture stem in groot mate ooreen. 'n groot hoeveelheid vervangings kom by hierdie proefpersone voor en dit was soos by die ander proefpersone hoofsaaklik beperk tot klankstruktuur 5. hierdie kenmerkende simptome. ι die kenmerkendste simptome van verbale apraksie (soos dit deur hierdie studie aangetoon is) naamlik afwykings in temporale vloei, distorsie en afwykings in prosodie vertoon die hoogste frekwensie van voorkoms, ongeag die klankstruktuur van die uiting. die voorkoms van ander simptome ,wat as minder kenmerkend gereken kan word, soos klankvervangings en byvoegings en weglatings van klanke wat i die klankstruktuur verander, word wel bei'nvloed deur idie klankstruktuur van die uiting. 'n toename in die lengte van 'n klankstruktuur en ook die besondere sillabestruktuur soos die van s3 (kvkvk) bring mee dat die minder kenmerkende simptome toeneem. dit impliseer ook dat daar meer foute gemaak word tydens produksie van hierdie eenhede. die artikulasie-eienskappe wat in die materiaal verteenwoordig is, het geen statisties beduidende effek.op die frekwensie en tipe ouditief waarneembare foute in die spraak van die groep verbaal apraktiese sprekers riie. die kenmerkende simptome van verbale apraksievertoon die hoogste frekwensie van voorkoms ongeag die artikulasie-eienskappe van die uiting. daar is wel aanduidings waargeneem dat eenhede met groter koartikulasiemoontlikhede en meer variasie in artikulasie-eienskappe 'n toename in die minder the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die invloed van sekere kontekstuele faktore op die ouditief waarneembare foute by verbale a p r a k s i e 2 1 kenmerkende simptome tot gevolg gehad het. daar moet in gedagte gehou word dat die artikulasie-eienskappe van eenhede slegs minimaal verskil het en dat selfs hierdie klein verskille 'n effek gehad het op die prestasie van al die proefpersone. die toename in motoriese kompleksiteit van 'n uiting bring dus mee dat die verbaal apraktiese spreker meer foute maak. dit is dus 'n aanduiding dat die probleem van 'n verbaal apraktiese spreker gesetel is in die motoriese beplanning van spraak. die resultate van die ondersoek waarin die invloed van kontekstuele faktore nagegaan is, stel die simptome van verbale apraksie dus in 'n nuwe en insiggewende perspektief. dit wil voorkom asof die simptome op grond van konteks-sensitiwiteit in twee groepe verdeel kan word. die eerste groep is nie konteks-sensitief nie en kom voor ongeag die klankstruktuur, lengte of artikulasie-eienskappe van 'n uiting. dit weerspieel waarskynlik die kernprobleem in verbale apraksie. hierdie simptome is klankdistorsie wat moontlik ontstaan weens oorskryding van temporale en ruimtelike ekwivalensiegrense en afwykings in temporale vloei, in die besonder lettergreepafbakening, wat moontlik aandui dat die vermoe tot vooruitbeplanning ingeperk is. in die verlede is aanvaar dat klankvervangings die mees kenmerkende simptoom van verbale apraksie is (wertz et al. 1984; johns & la pointe, 1976; rosenbek, et al. 1984). daar is egter 'n groeiende bewussyn dat 'n foutiewe analisemetode, naamlik bree fonetiese transkripsies, daartoe aanleiding gegee het dat klankdistorsies as klankvervangings aangeteken is (itoh & sasanuma, 1984; wertz et al. 1984). hierdie navorsers wys ook daarop dat klankdistorsie waarskynlik die kernsimptoom van verbale apraksie is en die resultate van hierdie studie waarin eng fonetiese transkripsie gedoen is, bevestig dus dat dit waarskynlik wel die geval is. afwykende tydreeling is ook deur talle ander navorsers beskryf as die mees kenmerkende probleem van verbaal apraktiese sprekers (kent & rosenbek, 1983; collins, et al. 1983; itoh & sasanuma, 1984; buckingham, 1981). die aanduidings in hierdie studie dat afwykings in temporale vloei en klankdistorsie die mees kenmerkende simptome van verbale apraksie is, en ook die kernprobleem reflekteer, is dus nie strydig met vorige bevindirige nie. dit is wel insiggewend dat die afwesigheid van konteks-sensitiwiteit hierdie simptome aanwys as die kernsimptome van verbale apraksie. die tweede groep simptome wat geassosieerde simptome genoem kan word, is wel konteks-sensitief en is waarskynlik nie 'n primere komponent van die probleem nie. hierdie simptome sluit vervangings, byvoegings en weglatings van klanke en lettergrepe in. oppervlakkig geoordeel dui hierdie simptome op 'n afwyking in fonologiese beplanning en dus in linguistiese vermoe by die verbaal apraktiese sprekers. tydens die ondersoek is aanduidings verkry wat op die teendeel wys. daar is onder andere waargeneem dat tydens herhaalde produksie van 'n eenheid die foneemstruktuur soms korrek was en soms nie. dit is onwaarskynlik dat 'n afwyking in kennis van die fonotaktiese reels van 'n taal en 'n onvermoe om die foneme korrek te selekteer en kombineer so labiel sal wees. selfkorreksie was in alle gevalle verbeterings van klankvervangings en in gevalle waar die struktuur van 'n eenheid verander is, het die nuwe uiting steeds voldoen aan die fonotaktiese reels van die taal. hierdie feite weerspieel dus die vermoe tot fonologiese herbeplanning by hierdie sprekers. die waarnemings dat vervangings gewoonlik met 'n eenheidskonsonant was wat meebring dat daar minder variasie in die eenheid voorkom en ook die verkorting van eenhede dui daarop dat hierdie geassosieerde simptome moontlik kompensatoriese strategiee of manifestasies van pogings is om te kompenseer wanneer die kompleksiteit van 'n uiting toeneem. 'n ander moontlike verklaring vir die toename in geassosieerde simptome is dat die produksie van moeiliker eenhede verhoogde koalisie-eise stel aan die betrokke neurale dele en dat 'n belemmering van fonologiese beplanning sodoende ontstaan. indien dit wel die geval is, weerspieel die geassosieerde simptome ook nie afwykings in linguistiese vermoe nie, en dui dit meer waarskynlik op probleme wat ontstaan tydens die beplanning van 'n uiting. hierdie ondersoek wat uitgevoer is binne die raamwerk van 'n spraakproduksiemodel wat die konsep van konteks-sensitiwiteit, soos ontleen van die koalisiemodel, akkomodeer, het nuwe lig gewerp op die problematiek van verbale apraksie. die resultate dui daarop dat motories gebonde foute waarskynlik die kernsimptome van verbale apraksie is terwyl fonologies gebonde simptome waarskynlik geassosieerde simptome is. die effek van variasie in die ander kontekstuele faktore kan ook in toekomstige navorsing nagegaan word. die invloed van kontekstuele faktore moet wel in alle navorsing oor verbale apraksie in aanmerking geneem word. erkennings geldelike bystand van die raad vir geesteswetenskaplike navorsing vir hierdie navorsing word hiermee erken. verwysings ( borden, g.j. en harris, k.s. speech science primer: physiology, acoustics and perception of speech, 2de uitgawe, baltimore: williams en wilkens, 1984. buckingham, h.w. explanations for the concept of apraxia of speech. in m.t. sarno (red.) acquired aphasia. new york: academic press, 1981. calvert, d.r. descriptive phonetics. new york: thieme-stratton, inc., 1980. collins, m., rosenbek, j.c. en wertz, r.t. spectrographs analysis of vowel and word duration. journal of speech and hearing research, 26, 224-230, 1983. darley, f.l. lacunae and research approaches to them: iv. in c.h. millikan en f.l. darley (reds.) brain mechanisms underlying speech and language. new york: grune & stratton, 1967. darley, f.l., aronson, a.e. en brown j. motor speech disorders. philadelphia: saunders, 1975. ingram, d. phonological disability in children. london: edward arnold, 1976. itoh, m. en sasanuma, s. articulatory movements in apraxia of "speech. in j.c. rosenbek, m.r. mcneil en a.e. aronson (reds.) apraxia of speech: physiology, acoustics, linguistics, management. california: college-hill press, 1984. johns, d.f. en la pointe, l.l. neurogenic disorders of output processing: apraxia of speech. in h. whitaker en h.a. whitaker (reds.) studies in neurolinguistics, 1. new york: academic press, 1976. kelso, j.a.s. en tuller, b. toward a theory of apractic syndromes. brain and language, 12, 224-245, 1981. kelso, j.a.s., tuller, b. en harris, k.s. a 'dynamic pattern' perspective on the control and coordination of movement. in p.f. macneilage (red.) the production of speech. new york: springer-verlag, 1983. kent, r.d. en rosenbek, j.c. acoustic patterns of apraxia of speech. journal of speech and hearing research, 26, 231-249, 1983. mackenzie, c. aphasic articulatory defect and aphasic phonological defect. british journal of disorders of communication, 17, 27-46, 1982'. die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 a. van der merwe, i.c. uys, j.m. loots, r.j. grimbeek marquardt, t.p. en sussman, h. the elusive lesion — apraxia of speech link in broca's aphasia. in j.c. rosenbek, m.r. mcneil en a.e. aronson (reds.) apraxia of speech: physiology, acoustics, linguistics, management. san diego: college-hill press, 1984. mohr, j.p., pessin, m.s., finkelstein, s., funkenstein, h.h., duncan, g.w. en davis, k.r. broca aphasia: pathological and clinical. neurology, 28, 311-324, 1978. oiler, d.k. en macneilage, p.f. development of speech produc, tion: perspectives from natural and perturbed speech. in p.f. macneilage (red) the production of speech. new york: springer-verlag, 1983. rosenbek, j.c., kent, r.d. en la pointe, l.l. apraxia of speech: an overview of some perspectives. in j.c. rosenbek, m.r. mcneil en a.e. aronson (reds.) apraxia of speech: physiology, acoustics, linguistics, management. san diego: collegehill press, 1984. roy, e.a. apraxia: a new look at an old syndrome. journal of human movement studies, 4, 191-210, 1978. russell, d. en whitaker, h. apraxia as a dysfunction of motor planning. cognition and brain theory, 3, 26-32, 1979. tuller, b., fitch, h.l. en turvey, m.t. the bernstein perspective: ii the concept of muscle linkage or coordinative structure. in j.a.s. kelso (red.) human motor behaviour: an introduction. london: lawrence erlbaum associates, 1982. van der merwe, a. artikulatoriese ontwikkelingsapraksie. nuusbriefvan die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, 198, 4-11, 1976. van der merwe, a. terapieprogram vir verbale ontwikkelingsapraksie met toepassingsmoontlikhede vir ander spraakafwykings. publikasie van die universiteit van pretoria, pretoria, v & r 1985. van der merwe, a. die motoriese beplanning van spraak by verbale apraksie. ongepubliseerde d.phil-verhandeling. universiteit van pretoria, 1986. wertz, r.t., la pointe, l.l. en rosenbek, j.c. apraxia of speech in adults: the disorder and its management. orlando: grune & stratton, inc., 1984. bylae 'n lys van die spraakfoute wat voorgekom het by die verbaal apraktiese sprekers — die afkortings κ (konsonant) en v (vokaal) word gebruik. — die term eenheidsklank verwys na 'n klank wat in die eenheid wat geproduseer moet word, voorkom. 'n nie-eenheidsklank verwys na 'n klank wat nie daarin voorkom nie. a. klankvervangings 1. κ met 'n eenheidsklank 2. κ met 'n nie-eenheidsklank 3. v met 'n eenheidsklank 4. v met 'n nie-eenheidsklank 5. vervanging van 'n lettergreep b. verandering van die struktuur van eenhede 1. byvoeging van 'η κ in die mediale posisie (eenheidsklank) 2..· byvoeging van 'η κ in die mediale posisie (nie-eenheidsklank) 3. byvoeging van 'η κ in die finale posisie (eenheidsklank) 4. byvoeging van 'η κ in die finale posisie (nie-eenheidsklank) 5. byvoeging van 'η v (eenheidsklank) 6. byvoeging van 'η v (nie-eenheidsklank) (hierdie byvoegings was nooit in die finale posisie nie) 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 1. 2. 3. 4. 5. e. 1. 2. 3. 4. f. 1. 3. 4. weglating van 'η κ weglating van 'η v byvoeging van 'n lettergreep weglating van 'n lettergreep weglating van alle konsonante en slegs vokaalproduksie struktuur verander na kv struktuur verander na kvkv struktuur verander na kvk struktuur verander na kvkvk struktuur verander na kvkvkv struktuur verander na kvkvkvk ander struktuurveranderings (slegs die mees algemene is by 12-17 ingesluit maar daar was ook ander uitsonderings) plek van lettergreepafbreking verander afbreking binne 'n geslote lettergreep byvoorbeeld da...k klankdistorsie versteuring in die stemhebbendheid van konsonante ander konsonantdistorsies vokaaldistorsie verandering van die vokaaleienskappe tydens produksie van die vokaal ('n tipe diftong) distorsie van 'n hele lettergreep of eenheid d. afwykings in temporale vloei verlenging van v verlenging van κ (dit is 'n buitengewone verskynsel maar duidelik identifiseerbaar in die verbaal apraktiese spreker se spraak. die afsluitingsgedeelte van ploffers is veral verleng). artikulasieverlenging (alle artikulasiebewegings was stadig. dit was 'n deurlopende verskynsel by proefpersoon 4). stadige doelbewuste artikulasie (dit het onkonstant voorgekom en verskil van 3). lettergrepe kom afgebakend voor (dit verwys na die lettergreepspraak wat as kenmerkend van verbale "apraksie beskryf word in die literatuur). afwykings in vlotheid onvlot herhaling van 'n klank of lettergreep vassteking fn glottale afsluiting was dikwels hoorbaar tydens die vassteking) vassteking met hoorbare worstelgedrag (hierdie vassteking was ernstiger as die vorige by 2. beskryf) stadige worstelende artikulasie fn hele eenheid is stadig worstelend geproduseer) spraakfoute gevolg deur selfkorreksie klankverandering (k of v) wat suksesvol was (die tweede of volgende poging was dus korrek) klankverandering: onsuksesvol (foute het dus steeds voorgekom) lettergreepverandering: suksesvol / lettergreepverandering: onsuksesvol g. afwykings in prosodie ' enige afwyking in prosodie, byvoorbeeld monotone spraak, oormatige klem, buitengewone intonasie en stemkwaliteitsverandering wat momenteel is (onkonstant voorkom). the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) vol 58 • october 2011 • sajcd 13 comprehensive management in the neonatal nursery includes not only medical treatment of the infant but also developmental care and the provision of guidance, counselling and information to the family who are part of the decision-making process regarding the infant’s care (asha, 2005). a programme that has shown positive results for premature infants is the newborn individual developmental care and assessment programme (nidcap) (als et al., 2004). this programme requires specialised training based in the usa, which makes it inaccessible to most south african professionals. kangaroo mother care (kmc) has been shown to be a safe alternative for thirdworld countries, where 96% of the world’s premature infants are born (bergman, linley & fawcus, 2004). the effectiveness and safety of kmc is well established (bergman, malan & hann, 2003) and it is regarded as an important developmental care practice for developing, as well as developed, contexts (bergman et al., 2004). in south africa’s public health sector, early communication intervention (eci) services to neonates are less developed and less comprehensive in comparison with those of a developed country such as the usa (kritzinger, louw & hugo, 1995). while the role of the speech-language therapist (slt) in the neonatal intensive care unit (nicu) is clearly described in international literature (asha, 2005; rossetti, 2001; ziev, 1999), currently no guidelines for service delivery in the nicu in the south african context exist (de beer, 2003). slts who are employed in south african provincial hospitals are often faced with difficult working conditions, such as lack of community awareness of services, inadequate instrumentation and tools, insufficient services of trained interpreters and limited literacy of caregivers (fair & louw, 1999). the diversity of language and culture in south africa poses a challenge for slts in providing family-centred early intervention services (louw & avenant, 2002). current health care policies in south africa prioritise care of mothers and young children, as can be seen in legislation that emphasises the provision of free primary health care to children under the age of 6 years (national health act, 2003). although eci may be regarded as a component of services to women and young children, it is still not a health care priority in south africa. the undervalued perception of eci is not only due to the hiv/aids pandemic, but also to the limited knowledge about the benefits of eci, a shortage of eci facilities and early communication interventionists, an insufficient referral system and poor teamwork (kritzinger, 2000). in a study conducted by h. louw (2007) regarding eci service delivery in public hospitals in four provinces in south africa, it was concluded that some of the high-risk infants and families were still not receiving linguistically appropriate services. a shortage of qualified and trained interpreters was also identified (h. louw, 2007), which presents an obstacle to effective eci service delivery in public hospitals. south africa has 11 official languages, of which isizulu is the most commonly spoken (24%) with english in 5th place (8%) (population census key results, 2001); english is the language most commonly spoken by slts. language differences may pose a considerable barrier to effective understanding between professionals and families (madding, 2000). h. louw (2007) found that only 11% of the respondents in her study worked with trained interpreters at their hospitals. since the multilingual nature of the south african population creates barriers to service delivery, it necessitates different approaches to intervention. the shortage of slts who can provide eci and initiate prevention campaigns (fair & louw, 1999) and the insufficient number of therapists in the public hospital context result in large caseloads. another challenge to eci in south africa is a dearth of apparatus and materials for the assessment and treatment of high-risk and at-risk infants. h. louw’s findings (2007) indicated that 93% of community service slts employed in mpumalanga, western cape, kwazulu-natal and gauteng in the public health sector expressed the need for more culturally and language-appropriate materials specifically designed to address the unique needs of the south african community. the results the development of a neonatal communication intervention tool esedra strasheim alta kritzinger department of communication pathology, university of pretoria brenda louw department of audiology and speech-language pathology, east tennessee state university correspondence to: e strasheim (esedra1@gmail.com) abstract neonatal communication intervention is important in south africa, which has an increased prevalence of infants born with risks for disabilities and where the majority of infants live in poverty. local literature showed a dearth of information on the current service delivery and roles of speech-language therapists (slts) and audiologists in neonatal nurseries in the south african context. slts have the opportunity to provide the earliest intervention, provided that intervention is well-timed in the neonatal nursery context. the aim of the research was to compile a locally relevant neonatal communication intervention instrument/tool for use by slts in neonatal nurseries of public hospitals. the study entailed descriptive, exploratory research. during phase 1, a survey was received from 39 slts and 2 audiologists in six provinces. the data revealed that participants performed different roles in neonatal nurseries, which depended on the environment, tools, materials and instrumentation available to them. many participants were inexperienced, but resourceful in their attempts to adapt tools/materials. participants expressed needs for culturally appropriate and user-friendly instruments for parent guidance and staff/team training on the topic of developmental care. during phase 2, a tool for parent guidance titled neonatal communication intervention programme for parents was compiled in english and isizulu. the programme was piloted by three participants. suggestions for enhancements of the programme were made, such as providing a glossary of terms, adapting the programme’s language and terminology, and providing more illustrations. slts and audiologists must contribute to neonatal care of high-risk infants to facilitate development and to support families. keywords: developmental care, early communication intervention, neonatal communication intervention, neonatal nursery, public health context 14 sajcd • vol 58 • october 2011 development of a neonatal intervention tool confirm the earlier findings of kritzinger et al. (1995) that there are limited diagnostic tools developed from a speech-language pathology and audiology perspective for neonatal assessment and management. in south africa, poverty is a characteristic of the majority of the neonatal population requiring eci. poverty in itself may not be the direct cause of developmental problems in young children, but family conditions such as malnutrition, inadequate prenatal care, exposure to infectious diseases and toxicants in utero, unsafe living conditions, living with parents who are addicted to alcohol or drugs and inadequate educational opportunities are all common in circumstances of poverty (thompson, 1992). certain risk conditions associated with communication disorders, such as low birth weight, cerebral palsy, fetal alcohol spectrum disorder and hiv/aids, also have a higher prevalence in south africa than in developed countries (kritzinger, 2000; swanepoel, 2004). the high prevalence of conditions affecting young children is of significance to slts, as these conditions can be related to many developmental disorders but more specifically to communication delays and disorders (kritzinger, 2000; rossetti, 2001). asha (2004) states that slts have the responsibility to fulfil eci roles using practices that are based on research, family-centred, culturally and linguistically appropriate, developmentally appropriate and collaborative. the execution of these responsibilities and functions is dependent upon a well-developed theoretical and clinical foundation. evidence-based practice is a framework for clinical decision making that entails the integration of best research evidence with clinical expertise and patient values (johnson, 2006). according to louw (2007), basing clinical decisions on scientific research is fundamental to ethical practice in eci. in order to fulfil the roles and responsibilities in neonatal communication intervention effectively, the slt requires certain tools. local research already provides guidelines to useful training strategies. gani (2004) found materials based on the hanen programme (pepper & weitzman, 2004) to be useful in training a group of caregivers in communication stimulation in a care centre, and a positive effect on caregiver-child interaction patterns was determined. best practice in developmental care in neonatal nurseries needs to be encouraged and facilitated, which necessitates the development of appropriate tools for the local context. asha (2005) urges speechlanguage pathologists to develop culturally appropriate programmes that meet the needs of ethnically and linguistically diverse families. culturally and contextually appropriate tools and programmes for neonatal communication intervention therefore need to be developed for the south african context, in order to serve the unique high-risk population in south africa in an effective and ethical manner. the unique contextual reality of south africa should be taken into account. to be contextually relevant, tools should be based upon an expressed need within a given context. if based on western models of communication stimulation, these tools should be adapted appropriately for the south african context. because of the diversity of cultural groups in south africa, overseas tools and programmes cannot merely be translated (visser, 2005). the interdependent relationship between culture and language must be carefully considered during cross-cultural service delivery, otherwise the tool will still not be suitable even once translated (pakendorf, 1998). it may also be beneficial to consider other adaptations in order to bridge additional challenges such as limited literacy among caregivers. according to louw, shibambu and roemer (2006), literacy issues may be overcome by using visual sources such as pictorial illustrations and demonstrations, as written materials are not necessarily viewed as important, especially by individuals with low literacy levels. to propose a solution to address the dearth of tools in the public health context, a survey was conducted to determine the perceptions of slts and audiologists providing services in provincial hospitals in south africa. the aim of the survey was to investigate the role of slts in the neonatal nurseries and to identify participants’ needs in terms of neonatal communication intervention instruments/tools. this information was utilised to compile a preliminary instrument/tool based on the selection of one of the perceived needs of the participants. method aim the overall aim of this study was to compile a locally relevant neonatal communication intervention instrument/tool for use by slts in the neonatal nurseries of public hospitals. the following objectives were formulated in order to reach the main aim: • to describe the perceptions of slts and audiologists providing eci services in provincial hospitals in south africa regarding their role in the neonatal nurseries • to identify participants’ needs in terms of neonatal communication intervention instruments/tools • to select and justify a specific need of the participants in terms of neonatal communication intervention instruments/tools in the public hospital context • to compile a preliminary instrument/tool based on the selection of one of the perceived needs of the participants • to pre-test the completed instrument/tool and make changes, if necessary. research design for the purpose of this study a descriptive, exploratory study within the quantitative and qualitative frameworks of research design was selected. ethical considerations ethical clearance to conduct the study was obtained from the research ethics committee of the faculty of humanities, university of pretoria. all participants gave written informed consent. data were treated with confidentiality and no identifying information of the participants or their hospitals was reported. participants all the participants in this study had to provide eci to infants in a neonatal nursery such as an nicu, a neonatal high-care ward or a kmc ward, as this study specifically focused on the participants’ needs regarding neonatal communication intervention. permission was obtained in writing from 6 of the 9 provinces contacted, namely gauteng, kwazulu-natal, eastern cape, north west, northern cape and mpumalanga. the departments of health of the free state, western cape and limpopo provinces did not respond within the time constraints of this study, which further reduced the population available for the research. the provincial health departments were requested to provide statistics regarding the number of slts and audiologists employed at the hospitals in their province, as well as to provide each hospital’s contact details. the potential participants targeted for the study were contacted telephonically at the hospitals to explain the aim of the study and discuss participation. all participants who responded were included in the study. questionnaires were sent to 175 slts and audiologists in public hospitals in the six provinces. a total of 41 slts and audiologists returned a completed questionnaire, a return rate of 23%. the responses obtained are therefore not representative of speech-language therapy and audiology services in the public health sector in south africa. the majority of participants worked mostly at district or regional hospitals, as well as at community outreach clinics. they mostly provided eci in neonatal high-care units and kmc units of their hospitals. most participants appeared to be inexperienced in providing neonatal communication intervention services. they may have been without supervision, as most participants were the only slts/audiologists employed at their hospital and had limited access to interpreters and assistants. the participants’ characteristics are displayed in table i. research process the research was conducted in two sequential phases. vol 58 • october 2011 • sajcd 15 development of a neonatal intervention tool data collection: phase 1 a self-designed questionnaire was selected as the data collection tool to conduct the survey. a pilot study was conducted to pre-test the questionnaire which provided recommendations to enhance its efficacy and practicality. the questionnaire was e-mailed or faxed to the potential participants during phase 1 of the study. the first section gathered biographical data, which was used to describe the participants and to interpret the data from other sections of the questionnaire. the following section enquired about the service delivery regarding eci in the hospital, task allocations, contexts for eci (nicu, neonatal high care, kmc) and the participants’ functions and roles in terms of assessment and intervention with the infant, parents or staff. the questionnaire enquired about the participants’ needs in terms of service delivery, their perceptions of culturally appropriate and user-friendly tools, and their needs in terms of tools regarding assessment, intervention directed at the parents/caregivers and intervention directed at the staff/team. data analysis: phase 1 frequency distribution was set up from the raw data to obtain an overall view of the data (maxwell & satake, 2006). descriptive statistics were used to examine the data and to graphically display the data (maxwell & satake, 2006). the qualitative data were presented as detailed textual descriptions, and phase 1 included direct quotations from participants (fossey, harvey, mcdermott & davidson, 2002). method: phase 2 the needs analysis in phase 1 informed the type and the format of the tool, which was compiled during phase 2. the tool could therefore only be compiled after the results of phase 1 were obtained. for this reason, the instrument/tool was pre-tested in a pilot study as part of phase 2 and presented in the results. the evaluation of the training tool entailed descriptive data, which were analysed according to recurring themes. validity in this study slts’ and audiologists’ perceptions of their roles, their competence, work satisfaction and their needs were constructs that could not be measured directly. the construct validity could therefore be influenced by the participants’ subjective opinions and by the wording of questions in the questionnaire. the content of the questionnaire was reviewed by a statistician to determine whether the questions were relevant and appropriate for statistical purposes. the construct and content validity of the questionnaire were determined by making use of a pilot study, and certain changes were implemented according to the recommendations made. because of the small sample size, the results of this survey were not representative of the perceptions of all slts and audiologists employed in government hospitals. therefore no attempt will be made to generalise the findings. reliability the questionnaire was piloted to determine whether any items were misleading or unclear, which could result in participants misinterpreting some items. the pilot study therefore also contributed to the reliability of the questionnaire. the data collection procedures were described in detail, contributing to the repeatability of the study and thereby increasing its reliability. results and discussion: phase 1 participants’ roles in the neonatal nursery figure 1 illustrates that some participants performed roles in the nicu that require specialised equipment, such as hearing evaluation and video-fluoroscopy. video-fluoroscopic instrumentation is not readily available at all hospitals and is usually only found in tertiary or academic hospitals because of the costs involved, which explains why few participants performed this role. this finding can be explained by the fact that most of the participants were employed at district or regional hospitals that would not have specialised equipment such as videofluoroscopy. participants appeared to be performing multidimensional professional roles relating to screening and assessment, which is attributed to their awareness of the risks of development problems in the areas of attachment and communication development in infants with low birth weight and preterm birth. the majority of the participants reported that they fulfil a number of roles in direct intervention with infants and parents, as seen in figure 2. most slts were the only slt/audiologist employed in their department and had large caseloads, which possibly did not leave time to engage in discharge planning and planning of follow-up services. because patients come from a wide geographical area and have limited finances and transport to return to the hospital or clinic, regular followup services are a problem area in the south african public health sector (fair & louw, 1999). given the nature of the south african context, the roles performed by the participants need to be expanded and adapted to meet local needs to improve neonatal communication intervention service delivery. according to figure 3, most participants appeared to be aware of the impact they might have in this context through teamwork, as this is preferred practice because of the benefits for the infant, the family and the slt. early intervention in the nicu should follow a transdisciplinary team approach (rossetti, 2001). however, in-service training of staff members was not yet performed by all facilities, and their service delivery was limited by poor attendance of ward rounds. ziev (1999) describes this function as an opportunity to learn from others and to become a familiar face among team table i. characteristics of the participants professional qualifications slt – 49% slt & audiologist – 46% audiologist – 5% provinces where employed eastern cape – 5% gauteng – 8% kwazulu-natal – 25% mpumalanga – 29% northern cape – 28% north west – 5% years of experience in government sector 1 year or less – 25 participants 2 years – 6 participants 3 years – 3 participants 5 years or more – 6 participants contexts of service provision clinics/community health centres – 26 participants (participants indicated more than one working context) district/regional hospital – 30 participants tertiary/academic hospital – 12 participants other – 1 participant wards where ei was provided nicu – 14 participants neonatal high-care unit – 23 participants kangaroo mother care ward – 20 participants number of slps and/or audiologists in the department 1 – 15 participants 2 – 10 participants 3 5 participants 4 or more – 11 participants trained interpreters or assistants at their disposal yes – 10% no – 90% 16 sajcd • vol 58 • october 2011 development of a neonatal intervention tool members, as well as to request referrals based on infants’ symptoms or histories. as mentioned earlier, many participants were the only slt/ audiologist employed in their department, which may have limited the time available for them to attend neonatal ward rounds as they may have been involved in other paediatric or adult ward rounds, clinics or consultations. this is problematic as many participants had limited experience, which resulted in missed opportunities in the neonatal nursery. two of the participants in this study were qualified as audiologists only. only one of the two audiologists performed hearing screenings, which is ascribed to the fact that hearing screening equipment is not readily available in government hospitals (theunissen & swanepoel, 2008). both audiologists worked as part of a team and consulted with other team members in accordance with asha’s guidelines for audiologists (2008b). current literature emphasises the importance of ongoing audiological and medical monitoring of any child who demonstrates risk indicators for delayed onset or progressive hearing loss for at least 3 years (northern & downs, 2002). interestingly, both audiologists also assisted in discharge planning and planning of follow-up treatment/ management after discharge, while only half of the larger group of 39 slt participants performed this role. this may be due to a lack of infant follow-up clinics at many district or regional hospitals. families need information, consistent encouragement, reassurance, and positive feedback regarding their competency and ability to cope with the birth and hospitalisation of their critically ill newborn (northern & downs, 2002). participants’ needs in the neonatal nursery an overview of the needs of the slts as determined in phase 1 was compiled in table ii. the 5 most frequently indicated needs are highlighted, namely tools for parent guidance (4 topics), a tool for staff and team training (1 topic) and an assessment tool (1 topic) (2 needs in 4th place). eci services are required to be family-centred, as well as culturally linguistically responsive (asha, 2008a). neonatal communication intervention services therefore cannot be effective without culturally appropriate tools. an urgent need for culturally appropriate materials for use in the neonatal nurseries of provincial hospitals was identified. participants were aware of the importance of providing culturally sensitive services, but were hampered by the dearth of tools and materials that could be utilised in clinical practice. phase 1 demonstrated that participants performed different roles in neonatal nurseries, which were determined by the environment, tools, materials and instrumentation available to them. although many participants were relatively inexperienced, they were resourceful in their attempts to develop and adapt tools and materials. the fact that these self-developed and adapted tools are not research-based compromises the quality of services and precludes best practice. the participants expressed a need for culturally appropriate and user-friendly instruments specifically for parent guidance and staff/team training. these descriptive findings justified the compilation and development of a locally relevant instrument/tool for use in public hospitals’ neonatal nurseries. results and discussion: phase 2 the compilation of a neonatal communication intervention tool a tool regarding parent guidance with the topic of developmental care was selected as the tool to be compiled, as this was a need fig. 2. speech-language therapists’ roles in intervention specifically directed at the infant and parents/caregivers (n=39). fig. 3. speech-language therapists’ roles in intervention specifically directed at staff and team members (n=39). fig. 1. speech-language therapists’ indication of their roles regarding screening and assessment of the high-risk infant (n=39). vol 58 • october 2011 • sajcd 17 development of a neonatal intervention tool indicated by the majority of the slt participants. most participants were also involved in services directed at parents/caregivers in the neonatal nursery. the ‘neonatal communication intervention programme for parents’ aimed to provide slts in local public hospitals with a programme to educate and guide parents/caregivers of infants in the neonatal nursery regarding developmental care, early reciprocal interaction and appropriate stimulation of their infants. adult-learning principles were utilised in the compilation of the programme. guidelines to teach adult learners consider mature learners as independent and self-directed (kaufman, 2003). the researcher formulated an aim as well as outcomes for the programme (popich, 2003). the structure and sequence of the programme as conceptualised is illustrated in figure 4. the programme is divided into four sections, which include an introduction with ‘warm-up time’ and definitions, information on the behaviours of the neonate, information on how parents may respond to these behaviours, and a conclusion that informs parents of options for follow-up services and provides time for reflection and questions. informal terminology was used to make the language more accessible to the parents/caregivers. the term ‘baby’ is used in the programme instead of ‘infant’ as this is the term most commonly used by south african parents in conversation (popich, 2003). it was decided that the programme should consist of a microsoft powerpoint presentation and a handout for parents. the powerpoint presentation was provided in two different formats as it allows each clinician to select a method that is conducive to his/her working environment. some slts and audiologists in public hospitals have limited technical resources, and the powerpoint presentation was therefore provided on a compact disc as well as transparencies. handouts were provided to parents during the programme to generalise and reinforce the newly learnt information as well as to actively involve each parent during the presentation. the handout included photos and images to manage literacy barriers. the content of the handout was translated into isizulu by a private translation service to address language barriers. isizulu was selected as it is the home language of almost a quarter of south africans and is the language most spoken in south africa (population census key results, 2001). the programme was pre-tested in a pilot study, which concluded that the programme was enjoyed by the parents who received the training. it was further determined that the content was appropriate but that the programme should be more concise and shorter so as to be more user-friendly. the parent handout was deemed suitable for the training. certain suggestions for enhancements of the programme were made during the pilot study, such as providing a glossary of terms with definitions for therapists to use and adapting the programme’s language and terminology. table ii. speech-language therapists’ needs (n=39) need no. of responses (n=39) no. who indicated need % hierarchy 1 14 assessment tools neonate’s communication development 36 15 41.6 9 feeding 34 15 44.1 8 mother-child communication-interaction 33 16 48.4 7 neonatal nursery environment 33 19 57.5 3 parent guidance tools neonatal nursery environment and staff 36 24 66.6 1 paediatric dysphagia and feeding therapy 34 18 52.9 5 over-stimulation, identifying infant’s stress cues 35 19 54.2 4 developmental care 35 19 54.2 4 kangaroo mother care (kmc) 35 8 22.8 14 communication interaction with infant 35 12 34.2 11 developmental milestones and follow-up after discharge 34 9 26.4 12 normal communication development 36 9 25.0 13 staff/team training tools developmental care 36 23 63.8 2 kmc & eci 35 13 37.1 10 role of the slt in the neonatal nursery 36 19 52.7 6 highlighted sections indicate the most frequently mentioned needs. fig. 4. structure and content of the programme. 18 sajcd • vol 58 • october 2011 development of a neonatal intervention tool clinical and theoretical implications the current research identified and attempted to fulfil a need expressed by slts and audiologists. the study managed to achieve the aim of compiling a programme for slts for use with parents and caregivers in the neonatal nurseries in south african provincial hospitals. this study highlighted the role of the slt and audiologist in terms of prevention of communication delays and disorders. this research is an example for slts and audiologists in the public health sector on how to use adult education principles in parent training to prevent communication delays and disorders in infants. the programme could also be used for raising awareness of eci services within a certain community. south africa has an increased prevalence of infants at risk for communication disorders (kritzinger, 2000), and marketing of eci among the general public, as well as health care workers, should therefore be a priority of local slts working in the public health sector. according to asha (2008a) eci services must promote children’s participation in natural environments, which include community settings outside the home environment, where children without disabilities participate. community work increases the existing professional knowledge on diverse communities within south africa, which presents therapists with the opportunity to implement prevention programmes such as adult training (popich, 2003). this study emphasised involvement in community work and not only in the lives of individual families. the research could be used as an example of caregiver training within a specific community in order to reach more infants and toddlers in need of eci services and to improve the current services in communities. this study highlighted information on the roles of slts and audiologists in the neonatal care of high-risk infants in the public health sector. this research gathered valuable information regarding the roles and responsibilities of slts and audiologists in local nicu, neonatal high-care and kmc nurseries. it can therefore be used to guide future attempts to compile local guidelines for slts in the nicu. conclusion the study complied with the guiding principles for best practice in eci (asha, 2008a) as it aims to be family-centred, culturally and linguistically responsive and developmentally supportive, to promote children’s participation in their natural environments, to be comprehensive, co-ordinated and team-based, and is based on evidence. this research therefore contributed to neonatal care of highrisk infants in south africa. the increased prevalence of infants at risk for communication disorders in south africa (kritzinger, 2000) necessitates early interventionists to become involved in clinical and research efforts to develop eci services for provincial hospitals. slts and audiologists not only have an essential role to fulfil in the neonatal nursery, but also have an ethical responsibility to develop creative solutions for challenges arising from service delivery in the south african public health context. slts and audiologists must contribute to neonatal care of high-risk infants to facilitate their optimal development. acknowledgements. the authors would like to thank the professionals who participated in this study and who are committed to early communication intervention. the corresponding author (esedra1@gmail.com) may be contacted for more information about obtaining the ‘neonatal communication intervention programme for parents’. authors’ note. since the article was accepted for publication, saslha has adopted revised guidelines for early communication intervention, which include specific guidelines on neonatal communication intervention. the document may be obtained from the ethics and standards committee (2011). guidelines: early communication intervention. www.saslha.co.za references als, h., duffy, f.h., mcanulty, g., rivkin, m.j., vajapeyam, s., mulkern, r.v., warfield, s.k., huppi, p.s., butler, s.c., conneman, n., fischer, c., & eichenwald, e.c. 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(2004). randomized controlled trial of skin-to-skin contact from birth versus conventional incubator for physiological stabilization in 1200 2199 gram newborns. acta paediatrica, 93, 779-785. bergman, n.j., malan, a., & hann, m. (2003). news from the regions – south africa. fourth international workshop on kangaroo mother care. journal of tropical pediatrics, 49(5), 311-312. de beer, m. (2003). die rol van ’n groep spraak-taalterapeute in neonatale hoësorgeenhede, unpublished b. communication pathology research project, university of pretoria. fair, l., & louw, b. (1999). early communication intervention within a community-based intervention model in south africa. the south african journal of communication disorders, 46, 13-23. fossey, e., harvey, c., mcdermott, f., & davidson, l. (2002). understanding and evaluating qualitative research. australian and new zealand journal of psychiatry, 36, 717-732. gani, a. 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(2000). maintaining focus on cultural competence in early intervention services to linguistically and culturally diverse families. infant-toddler intervention. the transdisciplinary journal, 10(1), 9-18. maxwell, d.l., & satake, e. (2006). research and statistical methods in communication disorders. london: williams & wilkins. national health act (2003). retrieved on 8 june 2007 from http://www.info.gov.za/ speeches/2005/05042013451004.htm northern, j.l., & downs, m. (2002). hearing in children (5th ed.). baltimore: lippincott, williams & wilkins. pakendorf, c. (1998). 10 punt plan vir die vertaling en kulturele aanpassing van toetsmateriaal vir die suidafrikaanse konteks. clinica: applications in clinical practice in communication pathology, monograph 3, 1-10. pepper, j., & weitzman, e. (2004). it takes two to talk. toronto: hanen centre. popich, e. (2003). the development of a tool for communication stimulation for infants (0 12 months). unpublished d.phil. thesis, faculty of humanities, university of pretoria. statistics south africa (2003). population census key results. retrieved on 8 june 2007 from http://www. statssa.gov.za/census01/html/key%20results_key%20results.pdf rossetti, l.m. (2001). communication intervention: birth to three (2nd ed). albany: singular thomson learning. swanepoel, d. (2004). a review of the south african context: information for community-based speech-language and hearing services. clinica: applications in clinical practice of communication pathology, monograph 9, 11-16. theunissen, m., & swanepoel, d. (2008). early hearing detection and intervention services in the public health sector in south africa. international journal of audiology, 47(1), 23-29. thompson, t. (1992). developmental risk factors and poverty. in t. thompson & s.c. hupp (eds.). saving children at risk: poverty and disabilities. newbury park: sage publications. visser, c. (2005). die toepaslikheid van ’n afrikaanse vertaling van die ‘scan-c: test for auditory processing disorders in children – revised’ vir voorskoolse leerders. unpublished m. communication pathology dissertation, university of pretoria. ziev, m.s.r. (1999). earliest intervention: speech-language pathology services in the neonatal intensive care unit. asha, may/june, 32-36. phonologically based assessment a n d intervention in spastic c e r e b r a l palsy: a case analysis michael a. crary (phd) speech pathology and audiology southern illinois university, carbondale il 62901 and suzanne comeau central michigan university mt. pleasant, michigan summary the articulation errors of one adult subject demonstrating a spastic variety of congenital cerebral palsy were evaluated via a phonological process analysis. this analysis indicated that a stopping process (replacement of fricatives with homorganic stops) was the most detrimental to the subject's, intelligibility. subsequent to this analysis a phonemic contrasting programme was initiated toward the goal of minimizing the influence of the stopping process. results of spontaneous speech sample analyses indicated that this approach was successful in increasing the percentage of correctly produced fricative patterns. success in this case suggests the applicability of a linguistically based intervention approach in structural/functional disturbances of speech articulation. opsomming die artikulasiefoute van 'n volwassene proefpersoon met 'n verskeidenheid spastiese simptome van kongenitale serebrale verlamming, is met behulp van 'n fohologiese proses-analise geevalueer. die analise het aangetoon dat 'n afsluitingsproses (vervanging van frikatiewe met homorganiese afsluitingsklanke) die proefpersoon se spraakverstaanbaarheid, hoofsaaklik bei'nvloed het. 'n fonemiese kontrasprogram is hieropvolgend gei'nisieer met die doel om die invloed van die afsluitingsproses te verminder. die resultate van 'n spontane spraakmonsteranalise het aangedui dat hierdie benadering suksesvol was wat betref die verhoging van korrek geproduseerde frikatidfpatrone. die sukses behaal suggereer die toepasbaarheid van 'n linguisties gebaseerde benadering by strukturele funksionele artikulasieafwykings. assessment and intervention of articulatory disorders has traditionally focused on individual sound errors that detract from a client's intelligibility. this approach has been employed commonly for both functional and organic disorders of speech articulation.' though this approach has been successful to some degree, it often fails to bring about clinically significant improvement in those individuals demonstrating multiple articulation errors.' the past decade has yielded an emphasis on the identification of "patterns of errors" in those cases; where multiple sound errors are observed. a recent development related to this pattern approach of assessment is the identification of general phonological processes in the the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) phonology and cerebral palsy 31 defective speech pattern. a phonological process is considered to be a type of "mental operation" which simplifies a production by removing certain difficult properties from that production (oiler6; stampe8). in his dissertation on natural phonology, david stampe 8 points out that although a phonological substitution is a mental operation, it is clearly motivated by the physical character of speech — its neurophysiological, morphological, mechanical, temporal, and acoustic properties (p. 6). given this description, it is surprising that relatively little attention has been focused on the identification and elimination of phonological processes in organically based articulation disorders. ingram5 reviews literature which identified error patterns in the speech of hard-ofhearing, cleft palate, and mentally retarded subjects. paskowitz and bond 7 have also used the phonological process approach to identify error patterns in the speech of hearing impaired children. crary and h u n t 3 (in preparation) have demonstrated the clinical effectiveness of a pattern approach in the identification and subsequent elimination of phonological processes in the speech of one child with a repaired palatal cleft. in a recent didactic article, crary and fokes2 have argued that this approach may be clinically efficient in the identification and elimination of defective articulatory patterns in the speech of neurologically impaired adults. the present study reflects an attempt to: (1) identify phonological processes in the speech of a neurologically impaired adult, (2) quantify the influence of those processes on intelligibility, and (3) reduce the influence of the processes determined to be the most detrimental to perceived intelligibility. m e t h o d o l o g y subject: the subject was a twenty-five-year-old female with congenital cerebral palsy of the spastic variety. she was enrolled in a public school special class and received one hour of speech therapy per week. her therapist judged her to be "fairly intelligible" with multiple sound errors evident in her speech pattern. therapy for the preceding eight months had focused on facilitating correct fricative production at the sound level. although the subject could produce some fricatives in isolation, there was no reported or observed carryover to the syllable or word level. assessment: process identification in an attempt to identify phonological processes in the speech pattern of our subject two procedures were employed: (1) the phonological process analysis (weiner9), and (2) analysis of a spontaneous speech sample using procedures outlined by crary.1 table i presents the results of weiner's analysis procedure. it can be seen that cluster reduction and stopping were the "strongest" (i.e., most frequent) processes, occurring in 100% and 88% of the test items die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 μ. crary & s. comeau respectively. cluster reduction was also observed in 75% of the applicable non-test items, while stopping was observed in 89% of the applicable non-test items. in addition, the stopping process was observed in 92% of those clusters involving fricatives. other processes noted include deletion of final consonants and prevocalic voicing. table i: results of phonological process analysis (weiner9) process % occurrence in test items % occurrence in non-test items deletion final consonants 25% (4/16) 39% cluster reduction 100% (28/28) 75% prevocalic voicing 38% (6/16) 27% stopping 88% (14/16) 89% table ii presents the results of the spontaneous speech analysis. to comprehend these data a brief discussion of the analysis procedures is required. the columm marked " r s " indicates the "relative strength" of each process. this is determined by dividing the number of actual occurrences of a process by the number of potential occurrences. " r a " indicates "relative appearance" of those phonological patterns simplified by processes. this is determined by dividing the potential occurrence of each process by the total number of words in the sample. " r i u " indicates the "relative influence on unintelligibility". this is calculated by multiplying rs and ra. the higher the riu value, the greater the detrimental influence on intelligibility. table ii: spontaneous speech analysis: pre-therapy process rs ra riu deletion final con. .24 .85 .20 cluster reduction 1.00 .25 .25 prevocalic voicing .47 .25 .12 stopping .92 .37 .34 as shown in this table, the stopping process had the greatest influence on our subject's speech (highest riu value) followed' by cluster reduction, deletion of final consonants, and prevocalic voicing. in considering the rank orderings of processes in each assessment procedure it can be seen that there is excellent agreement between the two procedures. they both suggest that our subject was simplifying her productive patterns by reducing cluster complexity, replacing fricatives with homorganic stops, deleting final consonants, and voicing prevocalic voiceless stops. because of the high riu values for stopping in the speech sample analysis and the frequent occurrence of this process in the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) honology and cerebral palsy 33 both test and non-test items in the weiner procedure, the stopping process was chosen as our intervention target. therapy programme in an attempt to reduce the influence of the stopping process on our subject's speech, a phonemic contrasting programme was developed which focused on the feature contrast ± continuant. following the general outline for phonemic contrasting prepared by fokes a six-step programme was developed (two carryover steps were added to the basic programme to facilitate correct production beyond the word level) briefly, the steps consisted of presenting words individually or in a minimal pair and emphasizing: (1) the perceptual qualities of the target features, (2) the differences in physical production patterns for the contrasted feature, and (3) imitation of the word pairs combined with perceptual identification of the feature contrast. the final training step involves spontaneous production attempts by the client. a copy of this programme is provided in table v. results of t h e r a p y figure 1 presents the charted results of the therapy programme. the subject attended twenty half-hour sessions. data presented in this figure indicate that the subject acquired improved continuant production from a pretest performance of 50% to a post-test performance of 80%. note that step 5 appears to be the "critical step" in the programme for our subject. in this step the subject had to first correctly identify the feature contrast and then imitate a target word. it is apparent from the data on step 5 that our subject was more successful on the imitative task than the perception task (imitation scores noted by ( )). even over repeated trials and sessions no improvement was noted in the ability to correctly identify the presented feature. this was confusing to us since our subject had performed the same perceptual task at the 80% level or above for three sessions prior to step 5. the final comment to be made on these data regards the abrupt termination of the programme. this was not a planned feature. rather, it was necessitated by the end of our subject's academic semester. note that the post-test did reach the preset criteria even though criteria was not demonstrated in step 6. post-therapy speech analysis at the end of the therapy programme a second speech sample was collected and analysed to assess changes in the spontaneous production of fricative patterns. the analysis performed on this sample was identical''to that performed on the pre-therapy sample. the results of this analysis are presented in table iii. several changes die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28,1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) phonology and cerebral palsy 35 in the rs and riu values can be seen. the relative strength of the stopping process decreased from 92% in the pre-therapy sample to 48% in this sample. in -the post-therapy sample decreases were also noted in rs for deletion of final consonants and for cluster reduction. the final table (table iv) summarizes riu changes from the pre-therapy sample to the post-therapy sample. improvement is noted for the stopping process (riu .34 to .21), deletion of final consonants (riu .20 to .13), and cluster reduction (riu .25 to .14). t a b l e iii: spontaneous speech analysis: post-therapy process rs ra riu deletion final con. .18 .74 .13 cluster reduction .80 .17 .14 prevocalic voicing .52 .28 .14 stopping .48 .44 .21 t a b l e iv: spontaneous speech analysis: riu comparisons process pre-therapy post-therapy deletion final con. .20 .13 cluster reduction .25 .14 prevocalic voicing .12 .14 stopping .34 .21 conclusion the present case study attempted to demonstrate that patterns of articulatory errors could be identified in the speech of a neurologically impaired adult via a phonological process analysis. a second consideration of this study was to attempt to reduce the influence of observed patterns via a phonemic contrasting approach to therapy. pretherapy speech samples revealed a strong and influential stopping process indicating a systematic replacement of fricatives with homorganic stops. the results of a therapy programme aimed at reduction of the stopping process indicated an increase in correct fricative production at the word level. results of a post-therapy speech sample analysis indicated a reduction in the frequency and influence of the stopping process which reflects an increase in correct fricative production in spontaneous speech. the results of this case study indicate the clinical effectiveness of using a pattern approach in the assessment and intervention of organically based articulatory disorders. future clinical research in this area should die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 μ. crary & s. comeau address the issue of improved clinical efficiency and should attempt to define the potential use and limitations of this type of approach with clients presenting structural and/or functional impairments of the speech mechanism. a cknowledgement the authors would like to thank susan patra-mcpherson for her assistance in the data analysis portion of this report. t a b l e v : phonemic contrasting programme for ± continuancy problem: quadraplegic spastic cerebral palsy pretraining activities la. select words which emphasize ± continuancy (try to maintain one feature difference). lb. be sure the client knows what the words mean. *2. explain client's present pattern (e.g., stopping) in terms of: (a) air stream dynamics (b) oral cavity postures *3. explain the "normal" pattern for the feature contrast to be taught. (see 2 ± continuancy). note:* for steps 2 and 3, it is recommended you use 2 balloons — one tied without air being released (for continuant) and one with air being released (for + continuant). training programme (critieria = 8/10 on each step) note: make 2 boxes to hold cards. make a picture (balloons letting out air or tied) for each contrast box. la. present words one at a time. b. discuss key feature. c. client places word in appropriate contrast box. 2a. present 2 words (contrast pair). b. say one word. c. client puts the word in the appropriate box. 3a. present one word. b. present a physical activity depicting the key feature (e.g., blowing vs closed lips). c. client imitates and puts card in correct box. 4a. word pair is presented. say one word. / b. client performs airstream feature and, y' c. puts it in the correct box. 5. word pair is presented. say one word. client imitates and puts it in the appropriate box. ι 6a. client becomes the teacher. word pair is presented. b. client produces one. c. therapist picks up correct word and puts it in the box. ****if step 6 fails, repeat steps 1 5 with client as teacher. 7. put each word in a 3-word imitative phrase. word at the end of the phrase. 8. present word pair. client says it in a sentence. client: female age: 25 the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) honology and cerebral palsy 37 references 1 crary, m. a. (1979), procedures for sampling prominent phonological processes. unpublished manuscript. 2 crary, m. a. and fokes, j. (1980), phonological processes in apraxia of speech: a systematic simplification of articulatory performance. aphasia, apraxia, agnosia. 11: 1 1 3 . 3. crary, m. a . and hunt, t. l. (in preparation), phonological intervention with a cleft palate child. 4. fokes, j. (1976), working with sound systems of children with multiple articulation problems: phonemic contrasting. unpublished manuscript; ohio university, athens. 5. ingram, d . (1976), phonological disability in children. new york: elsevier, north-holland. 6. oiler, d . k. (1974), simplification as the goal of phonological processes in child speech. language learning, 24, 229-303. 7. paskowitz, p. and bond, z. s. (1980), phonological structure of the speech of hearing impaired children. ohio speech and hearing journal (in press). 8. stampe, d . (1973), a dissertation on natural phonology. unpublished p h . d . dissertation, university of chicago. 9. weiner, f. (1979), phonological process analysis. baltimore: university park press. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a comparison of the sisi and the stapedius reflex test in the differential diagnosis of cochlear pathology linda block, b.a. (sp. & h. therapy) (witwatersrand) forest town school for cerebral palsied children, johannesburg. summary previous research has cast doubt on the reliability and validity ofthe sisi in the differential diagnosis of cochlear pathology. this study further evaluates this test by comparing it to the stapedius reflex test, a test of recruitment and cochlear pathology. two groups of 10 subjects each were selected (36 ears). the first had cochlear pathology as detected by the reflex test, and the second, the control group, had normal ears. the results revealed that the sisi was significantly inferior to the reflex test in the detection of cochlear pathology. possible modifications of the sisi are suggested. opsomming vroeere navorsing betwyfel die betroubaarheid en geldigheid van die sisl-toets in die differensiele diagnose vir cochlieere patologie. hierdie studie evalueer verder die sisl-toets deur dit met die srt, 'n toets vir herstel en cochlieere patologie, te vergelyk. twee groepe van tien pasiente elk is ondersoek, die eerste groep met cochlieere patologie soos deur die reflekstoets uitgewys en 'n kontrole groep met normale gehoor. die resultate toon aan dat die sisl-toets minder waardig is teenoor die reflekstoets, vir die diagnosering van cochlieere patologie. moontlike wysigings aan die sisl-toets word voorgestel. the short increment sensitivity index (sisi) is a test commonly used in the differential diagnosis of cochlear pathology. it measures the ability to detect remarkably small changes in sound intensity, assumed to be related to the presence of a suprathreshold phenomenon known as loudness recruitment.12 recruitment is defined by hirsh et al. 1 1 as ' . . . a more-rapid-than-normal increase in subjective loudness for a given increase in physical intensity'. the presence of recruitment has been proved to be indicative of cochlear pathology?' 3 1 the tests measuring the phenomenon therefore play an important role in the diagnosis of site of lesion in sensori-neural hearing impairment. the sisi has been regarded as an indirect test of recruitment, because of the assumption that the ability it measures is due to the presence of recruitment. the basic rationale for this assumption is t h a t ' . . . if the loudness is increasing more rapidly than normal as the stimulus intensity is increased, a smaller than normal amount of intensity change is necessary for a jnd (just noticeable difference) in loudness!10 this rationale was later found to be invalid, on the basis that a linear relationship between loudness and intensity does not exist.11 consequently, workers in the field appear to have abandoned sisi as an indirect test of recruitment. jerger13, however, believed that the test did have some value. this belief was tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 100 linda block based on the observation that certain patients (generally those with recruitment) are often able to detect smaller changes in intensity, at comparable levels above threshold,13 and these patients were found to have cochlear pathology. whether these patients had recruitment or not, was not felt to be of importance. jerger believed that the primary issue in determining the value of this test was whether it was a true test of site of lesion, and not whether it correlated with direct tests of recruitment. it is felt by some writers, however, that since recruitment is generally accepted as evidence of cochlear pathology, there should be a close relationship between a high sisi score and the presence of recruitment.24' 3 1 the validity of the sisi has been queried in the literature. high sisi scores have been found in patients with acoustic neuromas,13' 2 3 ' 3 1 as well as in subjects with normal ears.14' 2 3 ' 2 6 ' 2 7 ' 3 2 some investigators have shown the sisi score to be related to the sound pressure level (spl) of the tone.3 2 given the same spl as pathological ears, normal ears also achieve high sisi scores. the reliability of the sisi is also questionable since the test relies on the subjective decision of the individual and has been found to be susceptible to factors such as boredom and fatigue.7 thus doubt has been cast on both the validity and reliability of the sisi as a differential diagnostic test of cochlear pathology. the stapedius reflex test (reflex test) involves the objective measurement of the recruitment phenomenon, and as such is regarded as a site-of-lesion test. the test is one of three tests of an impedance audiometric battery. basically, it involves the measurement, by an impedance audiometer, of the alteration in the impedance of the middle-ear system caused by the reflex contraction of the stapedius muscle:20 the reflex is elicited bilaterally and consensually via the cochlea and brain stem in response to an acoustic stimulus.28 it is believed to be related to the subjective loudness experience of the stimulus rather than the absolute intensity. 5 ' 1 4 ' 2 0 ' 2 8 as such, the reflex threshold, measured as the lowest sound intensity capable of eliciting a detectable contraction of the stapedial muscle,16 yields objective evidence of the loudness growth pattern of the ear.1 9 in a patient with an abnormally rapid growth of loudness (recruitment), it has been found that the reflex will be elicited at the same sound intensity as in normal ears (i.e. 70-90 db), but producing an abnormally small sensation level (sl) due to the elevated pure-tone thresho l d s . 4 ' 5 ' 1 5 ' 1 6 ' 2 0 ' 2 1 liden in 1970 1 8 concluded from his experimental and clinical studies, that ' . . . loudness recruitment established by means of the stapedial reflex test is equivalent to the presence of a lesion in the cochlea'. his findings confirmed those of metz.21 the reflex test has the advantages of not being restricted in applicability; of being objective; and of being quick and simple to administer.15 it does not require any voluntary response from the subject and is thus more reliable than the sisi. its only major disadvantage is that a number of factors, other than the absence of recruitment, can prevent the reflex from being elicited. if no recruitment is present, the limits of the audiometer (usually 110 db, iso 1964) will not allow for the production of a stimulus of sufficient intensity journal of the south african speech and hearing association. vol. 23 december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the sisi and the stapedius reflex test 101 to elicit the reflex. 6 ' 1 6 however, pathological conditions of the middle-ear or tympanic membrane, as well as a reflex arc which is not intact (as in bell's palsy, for example), will also prevent the reflex's elicitation.15' 3 0 furthermore, the reflex has been found to be absent in a certain percentage of normal ears.3' 2 8 these findings led thompsen30 to state that: 'while thus a positive result (demonstrative of recruitment) is altogether conclusive evidence, the same significance cannot quite be attached to a negative result'. the reflex test has therefore been widely accepted as a valid and reliable test of the recruitment phenomenon and as such, as a test of cochlear pathology. this study was designed to re-evaluate the reliability and validity of the sisi by comparing it to the reflex test in its ability to differentially diagnose cochlear pathology. method subjects two groups of subjects (ss) were selected; one group with cochlear pathology (designated group p), and the other with normal ears (designated group n). group p: this comprised ten ss with bilateral mild to moderate sensori-neural hearing loss, selected from the files of the speech and hearing clinic at the university of the witwatersrand, johannesburg. the thresholds of these ss were from 20 to 65 db at a minimum of two of the frequencies 500, 1000, 2000 and 4000 hz. the mean auditory threshold was 34 db. four ss were female and six male, ranging in age from 20-50 years with a mean age of 35.5 years. ss with hearing loss of less than 65 db3 were selected to prevent, as far as possible, the elicitation of the reflex being precluded by the limits of the audiometer. for the purpose of this study, the etiology of the hearing loss was not ascertained. group n: ten ss with bilaterally normal auditory thresholds were randomly selected from the residence population of the university of the witwatersrand, as a control. the criterion of normality was bilateral auditory threshold sensitivity of 15 db or less over the entire frequency spectrum. no ss had any previous history of ear problems, and recordable stapedius reflexes were required in at least one ear. six ss were female and four male, ranging in age from 20-24 years'with a mean age of 22 years. all ss, in both groups, were untrained listeners with little or no knowledge of the audiological test procedures. no s had any prior knowledge of the study. equipment all tests were administered in an acoustically treated booth (iac series 1604 act.). the maico model ma-24 dual channel research and diagnostic audiometer was used for the administration of pure-tone audiometry and the sisi. for the reflex test, the madsen z0-70 electro-acoustic impedance bridge, with a type tdh 39 earphone attached to the headset, was connected to an amplivox 103 audiometer (maximum intensity output 110 db). all machines had been recently calibrated according to the iso (1964) reference zero level. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23 desember1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 102 linda block tests a d m i n i s t e r e d three tests were administered in the study: pure-tone audiometry; followed by the two tests to be compared, the sisi and the stapedius reflex test. pure-tone audiometry: conventional pure-tone audiometry was administered to order to establish present auditory thresholds. pure-tone thresholds were established first, as these formed a basis for the selection of ss. also, the hearing levels (hl's) at which further tests were to be administered were determined with reference to these thresholds. in group p, bone-conduction in addition to air-conduction thresholds were established, in order to ascertain the absence of any conductive component in the hearing impairment. in group n, bone-conduction thresholds were assumed normal if hearing was normal as tested by air-conduction.22 pure-tone thresholds were established using the "method of limits".22 a descending method of threshold determination was employed. hood's shadow or masking technique was employed in the determination of bone conduction thresholds.22 threshold curves were charted on a conventional audiogram. the sisi: as recommended by harford,9 the sisi was administered immediately after the establishment of pure-tone thresholds. furthermore, early administration of this test minimised, as far as possible, subjective factors such as loss of attention and boredom to which the sisi is believed to be susceptible.7 after giving the s the necessary instructions,9 the test was administered according to the conventional procedure as described by jerger.17 he utilised a 1 db increment superimposed on a continuous tone presented at 20 db sl, at each frequency. the test run, consisting of twenty 1 db increments, was commenced after the presentation of five 5 db practice increments. after every five increments a "check" increment of either 0 db or 5 db, depending on the s's responses was inserted. the sisi score was calculated by determining the number of 1 db increments out of twenty responded to, and multiplying the total by five to yield a percentage at each frequency. the stapedius reflex test: this test was administered last as it does not require any voluntary response from the s and is therefore not susceptible to the aforementioned subjective factors. stapedius reflex thresholds were determined according to the procedure outlined in the madsen z0-70 handbook.20 the reflex threshold was taken as the lowest level capable of eliciting an observable deflection of the balance meter needle.15 the sensation level of the reflex threshold was then calculated relative to the pure tone threshold. f r e q u e n c y selection the most central frequencies were selected for this study. additional frequencies were not utilized as it was felt that this would tire the ss, and make the sisi therefore more susceptible to subjective factors. frequencies were tested in the order 1000, 2000, 4000 and 500 hz. journal of the south african speech and hearing association, vol. 23, december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the sisi and the stapedius reflex test 103 classification of scores scores obtained on the sisi and the reflex test were classified as shown in table i. the sisi is traditionally classified into three categories, positive, questionable and negative.24 the reflex test is classified only into positive and negative.20 a positive score on both tests indicates the presence of cochlear pathology, and a negative score the absence of cochlear pathology. sisi score reflex threshold categories jerger modified jerger reflex threshold positive (cochlear pathology) 60-100% 60-100% 60 db sl and below questionable 20-60% 20-59% negative (no cochlear pathology) 0-20% 0-19% above 60 db sl table i: method of test score classification in classifying the sisi scores, the categories of jerger14 were modified slightly so as not to overlap, thereby facilitating statistical analysis. both the original and modified categories are represented in table i. the criterion of 60 db as a critical level of recruitment was used in the reflex test (see table i). this was found by the majority of investigators to be the most valid c r i t e r i o n . 5 ' 1 5 ' 2 0 statistical methods results for group ρ and group ν were computed separately. of the total of twenty ss (i.e. forty ears), two in each group had no recordable reflex in one ear. these ears were excluded from the computation, leaving thirty-six remaining ears, eighteen in each group. there were four scores per ear on each test, one at each of the four frequencies tested, making the total number of scores seventy-two per test. the difference between the number of positive scores obtained on the two tests in each group was then calculated and the significance of this difference determined. results the results of group ρ are depicted in table ii. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23. desember**1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 104 linda block g r o u p ρ t e s t 5 0 0 hz ( 1 8 ) 1 0 0 0 hz ( 1 8 ) 2 0 0 0 hz ( 1 8 ) 4 0 0 0 hz ( 1 8 ) t o t a l ( 7 2 ) reflex 8 12 15 14 4 9 sisi 0 1 5 5 11 g r o u p ν reflex 0 0 0 0 0 sisi 0 1 0 1 2 t a b l e i i : n u m b e r of positive s c o r e s in g r o u p ρ a n d g r o u p ν ( f i g u r e s in b r a c k e t s reflect t o t a l n u m b e r of scores) forty-nine of the 72 scores were positive on the reflex test; 11 of the 72 scores were positive on the sisi. there were thus 38 more positive scores on the reflex test than on the sisi. this is a large difference, and the probability of it occurring by chance alone is is extremely small: ζ 7,6 ρ < 0.001 hence this difference is highly significant. the same applies to the results found at the individual frequencies, where the difference between the findings on the two tests was also significant. in group ν (table ii) none of the 72 scores were positive on the reflex test. on the sisi two were positive. discussion jerger13 believed that the primary issue in evaluating the sisi was whether it was a true test of site-of-lesion (cochlear or retrocochlear). the reflex test in the present study indicated the presence of cochlear pathology in group p. this pathology, however, was not detected by the sisi on a significant number of occasions. the scores thus indicated a normal condition when in fact cochlear pathology was present. the sisi is therefore not an adequate site-oflesion test on the basis of the present findings. / as expected, no cochlear pathology was'detected by the reflex test in group n, thus confirming the reliability of this test. in the case of the sisi, however, the two positive scores in this group, although a very small proportion of the total number of scores, do cast doubt on the reliability of this test. this is especially true in view of the fact that positive scores in normals on the sisi have been r e p o r t e d . 1 4 ' 2 3 the number of scores falling into the "questionable" category on the sisi should also be considered. in group p, 14 of the 72 scores were "questionable". if these scores are taken as being positive, the difference between the journal of the south african speech and hearing association vol. 23. december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the sisi and the stapedius reflex test 105 number of positive scores on the two tests is still significant. in group n, however, 23 of the 72 scores were "questionable". if these are included as positive scores, even further doubt is cast on the validity.and reliability of the sisi, since there would then be a greater number of false positives. it was noted that 49 of the 72 scores in group ρ were positive. the remaining 23 negative scores can be accounted for by the following: 1) the presence of a normal threshold at the frequency at which the negative score was obtained. 2) the presence of a retrocochlear lesion. although recruitment was present at at least two frequencies in each ear, indicating the presence of cochlear pathology, it has been reported that dual loci of lesions can exist.1 4' 3 1 the amount of recruitment present has been found to increase with increas' ing hearing loss.25 this was borne out in the present study by the finding that decreasing size of reflex sl corresponded with ascending size of auditory threshold. the measurement of the reflex sl consequently has additional value in that it yields quantitative as well as qualitative evidence of recruitment. this trend was not evident in the sisi results where no systematic relationship was found between the sisi score and the degree of loss. this also implies, contrary to the findings of some previous investigators,32 but in support of yantis and decker,31 that the sisi score is not a function of the spl of the tone. as mentioned earlier, it is generally accepted that the stapedius reflex is elicited at a sound intensity of 70-90 db in both normal and recruiting ears. by combining the reflex sl's with the threshold values, the hl's of the reflexes are obtained. sixty-six of the 72 scores in group p, and 68 of the 72 scores in group ν fell within these limits. as mentioned initially, the reflexes could not be recorded in two ears in each group. the possible reasons for this are manifold, and cannot necessarily be attributed to the absence of recruitment. 3 0 this illustrates the notion discussed earlier that a limitation of the reflex test as a test of recruitment is that a negative result cannot be taken as demonstrative of the absence of recruitment. generally agreement was found between the present results in the reflex test and those reported in the literature. this seems to emphasize that results obtained on this test are consistent, and highlights the reliability and validity of the test. the sisi, on the other hand, was found to be unreliable and/or invalid. it was felt that the test could perhaps be improved by the introduction of various modifications to the standard form of the test. these modifications are considered below. suggested modifications of the sisi the size of the practice increments. the conventional procedure of changing from the 5 db increments used for practice to the 1 db increments of the test itself may be too abrupt.2 3' 3 1 many ss may find it difficult to make the subjective decision that the initial test increments are the ones to which they should respond.23 this could cause ss to miss the first few increments, resulting in generally lower sisi scores, and this appeared to occur in the present tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23 desemer1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 106 linda block study. harford9 suggested that the practice run should consist of gradually reduced increments from 4 or 5 db to 2 db. in the present study it was also observed that ss often missed the first few increments after the inserted 5 db "check" increments. it is therefore suggested that in addition to harford's modification, the "check" increments be reduced in intensity to a level dependent on the smallest increment the patient is able to hear, as determined during the practice run. the instructions. the recommended instructions are to respond only when the s is sure that the increment was heard. this has been reported to result in a general tendency of reduction in positive sisi scores.26 it is suggested, therefore, that instructions should not include the phrase "if you think you heard the jump, but you're not sure, don't do anything",9 unless the patient is thought to be guessing. in such a case, the additional instructions (as above) should be given and the test run restarted. the intensity of the carrier tone. the mean auditory threshold in the present study was 34 db. the sisi has been found to be a poor predictor of cochlear pathology in mild hearing loss9' 2 3 ' 3 2 and owens23 therefore suggested that the presentation of the carrier tone at 25 or 30 db sl may improve the reliability of the test. thompson,29 however, showed that sisi scores improved with increasing sound intensity in normal ears. additional false positives in normal groups could thus occur if the intensity of the carrier tone was increased. thompson also showed that the scores remained low in patients with retrocochlear pathology. he thus suggested that a modified sisi carried out at high sl's would differentially diagnose retrocochlear pathology by the inability to detect these small changes in intensity. high sisi scores have, however, been found in patients with retrocochlear l e s i o n s , 9 ' 1 3 ' 3 1 and this modification cannot yet be assumed valid. further research as to the effect of increased sound intensity on the different clinical pathologies, as well as on normal ears, is indicated. the number of test increments. the sisi has been found to be susceptible to factors such as fatigue, inattention, and inability to concentrate.7'1 9 many ss in the present study reported the operation of such factors. loeb1 9 found performance on the sisi generally to decline with time. a number of investigators have suggested presenting only ten increments rather than twenty, where all responses to the first ten are either positive or negative.2 3'3 1 the split-half reliability of the test has been found to be good at all frequencies except 250 hz 8 , and this modification would have the further clinical advantage of considerably reducing the testing time. a test of a different type of cochlear pathology. as discussed earlier, the sisi is not a test of recruitment13 and is not related to subjective loudness.5 it is possible that the ability measured by the sisi is one less frequently associated with cochlear pathology than is recruitment. if this is so, good recruitment tests are obviously more likely to reveal cochlear pathology than are tests of the ability to detect abnormally small sound intensity increments. the phenomenon measured by the sisi, however, may be characteristic of a journal of the south african speech and hearing association.. vol. 23. december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the sisi and the stapedius reflex test 107 different type of cochlear pathology from that characteristically revealed by recruitment.14 it is possible that this type also occurs subclinically, which would account for the high scores in individuals with normal hearing. if this is so, the sisi would yield additional information concerning the nature of the cochlear pathology, and as such be a very valuable clinical and research tool. conclusion the results of the present study cast doubt on the ability of the sisi, in its present form, to diagnose cochlear pathology differentially and, as such, its value as a site-of-lesion test. it is possible that a modified version of the test may still prove to be reliable and valid. furthermore, the test may have hitherto undiscovered value, such as in the determination of retrocochlear pathology or in the differentiation of type of cochlear pathology. further research would therefore seem necessary before this test is discarded as a site-of-lesion test. it is strongly recommended that the test, even with modification, be used only as part of a battery of site-of-lesion tests, and it is worthwhile to recall the words of jerger:14 the key to successful use of hearing tests in otologic diagnosis seems to be in the employment of multiple test batteries rather than single tests alone. references 1. beedle, r.k. and harford, e.r. (1973): a comparison of acoustic reflex and loudness growth in normal and pathological ears. j. speech hear. res., 16, 271-281. 2. bell, a. (1966): noise. an occupational hazard and public nuisance. public health paper, no. 30, world health organization, geneva, ch. 8. 3. brooks, d.n. (1969): the use of the electro-acoustic impedance bridge in the assessment of middle ear function. int. audiol., 8, 563-569. 4. chiveralls, k., and fitzsimons, r. (1973): stapedial reflex action in normal subjects. brit. j. audiol., 7, 105-110. 5. colletti, v. (1974): some stapedius reflex parameters in normal and pathological conditions./. laryngol. otol, 88, 127-137. 6. feldman, a.s. (1971): impedance measurement and the middle ear. maico audiological library series, 9, report 8. 7. fowler, e.p. (1950): the recruitment of loudness phenomenon. laryngoscope, 60, 680-685. 8. griffing, t.s. and tuck, g.a. (1963): split-half reliability of the sisi. /. aud. res., 3, 159-164. 9. harford, e.r. (1967): the sisi test. maico audio. lib. series, 4, report 9. 10. hirsh, i.j. (1952): the measurement of hearing. mcgraw-hill book company, inc., u.s.a. chs. 7 and 8. 11. hirsh, i.j., pavla, t., and goodman, a. (1954): difference limen and recruitment. arch. oto-laryngol, 60, 525-540. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23. desember1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 108 linda block 12. jepsen, j., (1953): dl difference test. arch. oto-laryngol, 57, 490500. 13. jerger, j.f. (1960-61): recruitment and allied phenomena in differential diagnosis./. aud. res., 1, 145-151. 14. (1962): hearing tests in otologic diagnosis. asha, 4, 139-145. 15. (1970): clinical experience with impedance audiometry. reprint, from the dept. of oto-laryngol., baylor college of medicine and the audio-vestibular laboratory, methodist hospital, texas medical centre, houston, texas. 1-25. 16. jerger, j., jerger, s., and maudlin, l. (1972): studies in impedance audiometry. arch. oto-laryngol, 96, 513-523. 17. jerger, j., shedd, j.l., and harford, e. (1959): on the detection of extremely small changes in sound intensity. arch. oto-laryngol, 69, 2 0 0 2 1 1 . 18. liden, g. (1970): the stapedius muscle reflex used as an objective recruitment test: a clinical and experimental study. sensorineural hearing loss, westholme, g.e.w. and knight, j., eds., a ciba foundation symposium, longman group ltd. 19. loeb, m. (1963): some factors influencing the effective auditory intensive difference limen./. accoust. soc. amer., 35, 884-891. 20. madsen model z0-70 electro-acoustic impedance bridge. application and instruction for use. 21. metz, o. (1952): threshold of reflex contractions of muscles of middle ear and recruitment of loudness. arch. oto-laryngol, 55, 536-543. 22. newby, h.a. (1972): audiology. merideth corporation, u.s.a., 3rd ed. 23. owens, e. (1965): the sisi test and viii th nerve versus cochlear involvement. j. speech hear. dis. 30, 263-268. 24. peterson, j.l., and liden, g. (1972): some static characteristics of the 25. reger, s.n. (1936): differences in loudness response of the normal and slightly hard-of-hearing ear at intensity levels slightly above threshold. ann. otol. rhinol. laryngol, 45, 1029-1036. 26. rubenstein, m., lipman, b., yundef, h. and luz, h. (1970): sisi findings in normal subjects. acta oto-laryngol, 69, 112-116. 27. silberberg, g. (1972): recruitment of loudness in the normal young adult. unpublished research report, department of speech pathology and audiology, university of the witwatersrand, johannesburg. 28. terkildsen, k. (1962): intra-aural muscle reflex testing. int. audiol, 1, 228-230. 29. thompson, g. (1964): a modified sisi technique for selectetlcases with suspected acoustic neurinoma. /. speech hear. dis., 29', 231-246. 30. thomsen, k.a. (1955): employment of impedance measurements in otologic and otoneurologic diagnostics. a eta oto-laryngol, 45, 159-167. 31. yantis, p.α., and decker, r.l. (1964): on the short increment sensitivity index (sisi test). j. speech hear. dis., 29, 231-246. 32. young, i.m. and harbert, f. (1967): significance of the sisi test. /. audit. res., 7, 303-311. i journal of the south african speech and hearing association. vol. 23. december 976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) brciel & kjaer manufacturers of electro-acoustical instrumentation for audiologists * audiometer calibration * hearing aid test sets * sound level meters * noise dose meters * artificial ears * artificial voice * artificial mastoid * frequency analysers for more information write or phone: sole s.a. agents:— telkor electronics (pty.) ltd. p.o. box 50856 randburg 2125 telephone jhbg.: 48-9740/8 a l s o : dowson & dobson ltd. + durban — cape town — port elizabeth member of the african oxygen limited group. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 67 the masking property of the auditory system: the masking of speech signals johan j hanekom department of electrical and electronic engineering university of pretoria abstract [ the masking property of the auditory system is well known in the context of two-tone masking. for complex (speech) signals, the effects of masking are less well known. this paper explores the masking of speech signals, by calculating which parts of the speech signal is inaudible because of masking. the theory for the masking of one tone by another is expanded, to establish an equation for the masking threshold. this masking threshold takes into account the masking of each frequency component on all other frequency components. speech is then synthesized in which the supposedly inaudible parts of the speech signal are discarded, and the effects are evaluated in a very simple psychoacoustic experiment. it is shown that the information below the masking threshold is indeed redundant. opsomming die maskeringseienskap van diegehoorstelsel is welbekend in die konteks van twee-toon-maskering. die effek wat maskering het op komplekse (spraak) seine, is minder bekend. hierdie artikel verken die maskering van spraakseine deur te bereken waiter gedeeltes van die spraaksein is onhoorbaar. die teorie van die maskering van een toon deur 'n ander word uitgebrei om 'n vergelyking vir die maskerdrempel te bepaal. hierdie maskerdrempel neem die maskeringseffek van elke frekwensiekomponent op elke ander frekwensiekomponent in ag. spraak word dan gesintetiseer, met die dele wat as onhoorbaar geag word, verwyder. die effek hiervan word in 'n eenvoudige eksperiment evalueer. dit word aangetoon dat inligting onder die maskerdrempel wel oortollig is. key words: auditory processing, masking functions, masking threshold, speech spectrum, spectrum synthesis, twotone masking introduction many questions concerning masking1 in the auditory system remain unanswered.; on the one hand, the phenomenon of two-tone masking is well known (javel, 1981), (kanis & de boer, 1994), as is the masking of a noise band by a tone, or vice versa. on the other hand, little information is available on masking and its effects in complex sounds (speech sounds). we might ask whether the masking mechanism does in fact function for complex sounds. if masking does function for complex sounds, what is the mechanism and why does the auditory system suppress some information? what are the effects of the masking? the purpose of this paper is to explore some of these questions about masking. ι the approach used in this paper regards masking from a different perspective than that normally found in the literature on the subject. instead of setting up a psychoacoustic experiment, and using various tones or complex signals to determine the masking of one signal by another, a speech synthesis approach is used. a speech signal, in which all the parts of the signal which are supposedly inaudible owing to masking, are discarded, is synthesized. if one tone can mask a second tone, then this second tone might also have a masking effect on a third tone (as well as on the first). the hypothesis is that each component in the speech frequency spectrum has a masking effect, however limited, on every other component of the speech spectrum. this statement implies that some parts of the speech spectrum are never heard or are redundant·, but which parts? can we discard these parts of the spectrum without loss of fidelity? to attempt to answer these questions, we have to develop a model which describes how each component of the spectrum masks every other component of the spectrum, almost as if each spectral component was in a two-tone contest with each other spectral component. we will use the well-known data on masking to determine mathematical expressions for masking functions for each spectral component of a complex signal. 1 the auditory system has|the characteristic that weaker spectral components are masked by stronger spectral components. this simply means that the weaker component is inaudible in the presence of the stronger component (allen, 1985). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 68 johan j hanek φ t3 q. ε < φ τ3 q. ε < frequency (a) φ τ3 q. ε < figure 1. masking explained conceptually. the frequency spectrum for two pure tones is shown in (a), (b) shows the activation area of each tone, (c) shows the resulting activation area: the activation area of the softer tone is swamped by the louder tone. the louder tone masks the smaller tone, and only the larger frequency component (the louder tone) is audible. the amplitude axis might represent the displacement of the basilar membrane or, alternatively, the neural firing rate. the origin of masking before we start the mathematical analysis to describe masking in the auditory system, a brief explanation of the possible origins of masking will shed light on the above statement that each spectral component masks every other spectral component. the pathway that the auditory signal follows through the auditory system is conceptually summarised in the statements to follow. this description ignores some of the complexities of the auditory system. a pressure wave (the sound wave) is transmitted in the air. the pressure wave is received by the antenna (the pinna) and transmitted through the outer ear canal. tympanic membrane to cochlea transmission takes place via the middle ear structures. the pressure wave travels from the cochlear oval window down the basilar membrane. a frequency to position transformation takes place on the basilar membrane (the cochlear partition acts as a dispersive filter) (allen, 1985). hair cells sense the basilar membrane displacement, and in turn displacement of hair cells stimulates the generation of action potentials on the nerve endings synapsing with the hair cells (or, in other phraseology, the neurons fire). the cochlear nerve carries information in the form of action potentials, via various auditory centres, to the auditory cortex of the brain (keidel, kallert & korth, 1983). masking is observed at several locations in the auditory system: at the hair cell level, in the coding of the neural firing patterns, as well as on the basilar membrane (javel, 1981). the origin of masking is explained below. the description is conceptual, and for the greater part an unconfirmed hypotheses; see also zwicker & zwicker (1991). the coding of frequency information in the auditory system adheres, according to most of the currently accepted models (neely & kim, 1986, and allen, 1985), to the place theory, i.e., frequency is coded mainly by the place of maximum activity on the basilar membrane (a frequency to position transformation transpires). temporal mechanisms for frequency coding also exist, e.g., phaselocking (allen, 1985). the so the coding of intensity information for a single tone is done according to a principle sometimes known as the volley principle (keidel, 1980): the louder the sound, the wider the area of nerve activity in the vicinity of the specific frequency component's characteristic basilar membrane position; and the louder the sound, the higher the frequency of firing of the nerves that emanate from that specific position of maximum basilar membrane displacement. if the activation area (the area of basilar membrane displacement as well as the nerve activation area) in the vicinity of a loud tone becomes wider, and a softer tone has a frequency near to the louder tone, then overlap might occur between the activation areas of the two tones (figures 1 and 2). the brain's auditory processor might interpret basilar activation at the softer tone's characteristic position on the basilar membrane, as if the louder tone had activated a wider area, which extends to the softer tone's basilar position. if the auditory processor ignores the softer tone, it is said to fall below the maskirig threshold of the louder tone. j if the description above is indeed a true account of the mechanism of masking, it is expected that an inaudibly soft tone (below the masking threshold) in the frequency vicinity of a louder tone, would make the louder tone sound even louder. this has been observed in c o c h l e a r implant experiments (hanekom, 1990 and eddington et al., 1978), and the mechanism is called sensitizing. in summary, this explanation simply means that a softer tone is swamped by a louder tone, and that in this swamped condition the specific neural channel normally used by the softer tone is unavailable. two further explanations for the masking phenomenon exist. in addition to the foregoing explanation, masking is also explained by the inability of the hair cells to have a displacement much greater than the displacement already caused by the louder tone, so that the softer tone has little additional effect on hair cell displacement. lateral inhibition between adjacent neural pathways is an additional potential contributing factor in masking. african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) masking property of the auditory system: the masking of speech signals φ σ φ t3 3 φ t3 3 ο. c ω. ε q. r\ e < < j \ < -ν \ frequency frequency frequency (a) (b) (c) f eure 2. masking in the case of two strong frequency components (a), (b) shows the activation area for each tonetln this case, the weaker component still influences the resulting activation, and thus both tones are audible (c). no masking takes place. this simply means that a high frequency of neural activity on a specific neuron can suppress activity on adjacent neurons. from the explanation above, it is clear that the further the softer tone is away from the louder tone on the spectral plane, the less the masking influence of the louder tone on the softer tone. many examples of studies of twotone suppression can be found in the literature (see for example tterhardt, 1979, javel, 1981 and kanis & de boer, 1994), and also of the suppression of a tone by bandlimited noise, or vice versa. tterhardt (1979) made an analysis of the processes involved in masking, and fitted models to available data from the literature, in order to design mathematical equations for the characterization of masking. the experiments on which this paper reports, apply the theory developed by terhardt (1979). the theory, which is briefly elucidated below, refers to these equations as the masking functions, because they define a masking threshold in the frequency domain. the sections of the sound signal below this threshold are supposedly inaudible! mathematical analysis: the masking functions ! in the explanation to follow, the data from two-tone experiments are extended to an equation that gives the sum of the masking effects of all the frequency components in the speech spectrum, on a specific tone somewhere in the spectrum. thus, for each spectral position, a masking threshold is calculated. if this masking threshold is known for each spectral position, the masking threshold function for the spectrum in its entirety is known. this masking threshold function can be found as an explicit equation, as will be shown below. according to the hypothesis, all spectral components with amplitudes: below this masking threshold are inaudible and are regarded as redundant. we should be able to discard this information from the spectrum with no loss in fidelity. we will test the truth of this statement in an exploratory psychoacoustic experiment, which is described following the mathematical analysis. as the first step in finding the masking function of a specific single tone, the frequency of the tone (in hz) is transformed to the bark scale. the symbol for frequency on the bark scale is ζ and on this scale, frequency is known as the critical band rate. the motivation for the use of the bark scale will be clarified below. the equation for the translation of frequency to bark is given in terms of the arctan function (terhardt, 1979): ζ = 13.3 arctan(0.75 f) bark (1) (where f is the frequency in khz) or alternatively, in terms of hyperbolic sine (schroeder, atal & hall, 1979): f= 650 sinh(z/7) " (2) these equations have been determined empirically by the authors, to fit measured (psychoacoustic) data. as an example, the transformation equation (either equation (1) or equation (2)), when applied, translates 0 hz to 0 bark and 4 khz to 16.6 bark. the frequency interval from 0-1 bark (0-100 hz) is known as the first critical band, with the second critical band from 1 to 2 bark (100 hz to 310 hz). these critical bands increase in width with higher frequency, which means that the masking functions, which are functions of the critical band rate z, become wider for higher frequency tones. this in turn means that the frequency resolution of hearing decreases at higher frequencies. the bark scale is convenient, in that the masking functions are linear on this scale, and all masking functions throughout the spectrum have the same shape and width, whereas on a linear frequency scale, the masking functions become wider at high frequencies. this explains why the bark scale is sometimes preferred in descriptions of auditory function. the masking functions can now be calculated. the amount of masking by a tone of frequencies lower than itself, is found to be = 27 decibel(db) i bark (terhardt, 1979) and masking of frequencies higher than the masker tone is dependent on the specific sound pressure level (spl) value of the masker tone, as well as the frequency of the masker tone, and is given by s 2 = [24 + 0.23 (f ) _ 1 0.2 lj (3) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 johan j hanekom in db/bark. this is the equation for a straight line: the slope of the masking functions are linear on the bark scale. s 2 is the slope towards the higher frequencies, s t is the slope towards the lower frequencies, f is the frequency in khz of the masker tone, and lv is the level (in db spl) of the masker tone. next, we determine how much of the softer tone, which is being masked (the maskee), protrudes above the masking threshold. the value for the masker threshold at f is simply the equation for a straight line:. l ( 1 ) = l s„(z -z ) for f < f uy y 2 v μ υ' ν μ l® = l s,(z -z ) for f > f (4) (ΐϋ ι) 1 l· μ l· μ v / is the frequency of the maskee. ζ μ and zv are the frequencies of the maskee and the masker on the bark scale, respectively. l'11^ and l'21^ are the amounts by which the maskee values exceed the masking thresholds, for a maskee to the right and to the left of the masker tone, respectively. if the masking threshold is not exceeded by the maskee, the maskee is inaudible. thus, theoretically, the inaudible parts of the spectrum can be removed without a listener being able to perceive the difference. the masking function as depicted above, describes how one tone masks another tone. it seems intuitively obvious that to find the masking thresholds that operate on a specific frequency component, as a result of all the other frequency components, the preceding theory could be expanded to establish the sum of the effects of all the masking tones. if we want to determine the masking effect of each frequency component in the spectrum on every other frequency component, this sum can be derived from equation (4): l = 20 log a„, with au = jv» + 1 0 ^ » (5) this equation calculates a value for the masking threshold. note that the sound pressure amplitudes in pascal/ m 2 are summed, and not the db spl values. this sum is then converted back to db spl. the two summations are used to calculate the contributions to the masking of respectively all the components lower, and all the components higher than the specific maskee frequency under consideration (f). for frequency components higher than the maskee frequency f , masker contributions are calculated by taking into account their masking threshold slopes on their lower frequency sides (sj = -27 db/bark). for frequencies lower than f , s 2 from equation (3) is used. this analysis is adequate for exploratory experiments on the effects of masking in speech. method for a two-tone experiment, masking is easily established in a psychoacoustic experiment (javel, 1981). in order to investigate in a psychoacoustic experiment whether masking does occur in the auditory processing of the complex speech spectrum in the way predicted by equation (5), the test will be whether or not the information theorized to be redundant (the information below the masking threshold calculated from equation (5)), is audible or i n a u d i b l e . as a first e x p l o r a t i o n , a simple psychoacoustic experiment was devised. the equations above (1-5) were implemented in a computer program. the program takes normal speech as input, and outputs a "distorted" version of this speech signal (all information below the masking threshold is regarded as redundant and is discarded). the operation of the program is briefly described. the input signal is a file of prerecorded speech data. the data comes from a calibrated microphone, and as such each value of the data is a digital representation of a voltage. data samples were taken at a frequency of 8 khz. the voltage values can be converted to spl values if the characteristics of the microphone are known. for the conversion the equation used is ν(μν)=100 < μ 7 5 s p u i b > ο·' which was established empirically for the specific microphone used. after the conversion to spl values, the time domain signal is transformed to the frequency domain using the fast fourier transform. the masking threshold in the frequency domain is then calculated according to the equations given earlier (5). the masking threshold is then compared to the spectrum of the original signal, and where the spectrum does not exceed the threshold, the spectral information is discarded. discarding of sections of the spectrum does not mean that we can merely make those values zero, because zeros in the spectrum cause echoes in the resultant sound. a discarding function was therefore implemented, as explained later. a minimum of 10 db was chosen as the minimum value that any spectral component can assume. 10 db was chosen as a minimum, because it is far below the normal 30-40 db ambient noise. after thresholding, the thresholded spectrum is transformed to the time domain by the inverse fourier transform. this data is then output through a digital to analog converter, amplifier and loudspeaker. the quality of speech after masking could only be determined qualitatively because of a lack of quantitative measures of speech quality. mathematical measures, e.g., mean square error, is inadequate for the measurement of speech quality. a reasonable objective measure is described in schroeder (1979), where the masking functions are used to calculate a single value as a measure for quality. for reliable qualitative determination of sound quality, a reference is needed, and this reference is used in paired comparison tests. two references were used. the original signal was used as the one reference, and the other reference was the speech signal thresholded by a level threshold, which was initially set at 25 db spl. 25 db was used as threshold, as with this choice about 50 % of the signal spectrum was below the threshold, which was more or less the same amount of data below the calculated masking threshold for the specific input speech signal. the speech signal, distorted by applying the calculated masking threshold and discarding redundant information, was then compared to these two reference signals. in further experiments the threshold was translated-linearly upward, resulting in more of the original spectrum falling below the threshold and therefore being discarded. the purpose is explained in the discussion. the same linear translation was done with the level threshold, always ensuring that the percentage of discarded data remained similar for the level threshold and the threshold calculated from the masking functions. the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) masking property of the auditory system: the masking of speech signals 71 the purpose of this experiment was to establish whether the discarding of supposedly redundant information w a s p e r c e p t i b l e . uninformed listeners were asked to grade the quality of three different speech signals: the original, the signal distorted b y a level threshold, and distortion by a threshold calculated from the masking functions. two implementations of the discarding function were used: (1) the discarded values were set equal to 10 db, (2) the discarded values were taken as value (n) = value (n-1) χ 0.9. this simply gives a gentle decay to 10 db, instead of an abrupt transition. deep holes in the spectrum have the perceptual effect of sounding like echoes. also, normally abrupt transitions carry speech information (e.g., the sharp transitions found in start and stop consonants). thus, the way in which the redundant data are discarded, influences the perceptual quality of the thresholded speech signal, while not having any relation to the effects of masking. ib establish the occurrence of masking in the way predicted by equation (5), we simply need to demonstrate that random alterations can be made to the part of the signal below threshold, without any perceptible difference in the signal. any alteration is fine, on two conditions: (1) no deep holes in the spectrum are allowed and (2) the changed section of the signal must still be below threshold. results examples of the thresholding process and the resultant signal are given in figures 3 and 4. the results of the grading experiments are given in table 1 below. method 1 refers to the method in which discarded values are set equal to 10 db. method 2 refers to the method in which the gentle decay function was implemented. the percentages refer to the amount of data that has been discarded. the discarding of approximately 50 % of the original spectral data occurs for the specific input speech (phonetically balanced sentences) when equation (5) is applied. thus, the 50 % case in the table is without any upward translation of the threshold curve. the numbers in the table refer to the grading given by the listeners, where 1 is the best and 4 the worst. where the same grading is given in two columns, the differences between these two sounds were imperceptible. with 50 % of the signal below threshold, no difference between any of the signals is'discernible. although this might seem amazing, most of the data that were discarded, were at the higher frequencies (figure 4), where the frequency sensitivity is not as high. this means that the periodic time structure of the time domain signal is wellpreserved, and no audible pitch distortion is observed. at 75 % discarded information, the difference between the threshold signals and the original becomes audible, although not considerably. interestingly, the quality of sound from the level threshold was rated the same as the masking threshold. at 90 %, method 2 gave the best thresholded sound quality. the level threshold gave the worst sound quality by far. in both the 75 % and the 90 % case, the method 2 sounded better than method 1. figure 3. the original spectrum before thresholding, plotted from 0 hz to 4000 hz (x-axis). the y-axis gives the spectral amplitude in db spl. the scaling is not shown and is not important. figure 4. the spectrum after thresholding, plotted from 0 hz to 4000 hz (x-axis). the y-axis is the amplitude in db spl. the threshold is the smooth line. the jagged line is the spectrum after thresholding. the part of the spectrum above the threshold is retained. the part below the threshold is the spectrum after application of the discarding function. the effect of the gentle decay discarding function can be seen clearly at the high frequency side of the spectrum. discussion as is evident from the results, masking does seem to occur in the auditory processing of complex (speech) signals in the way predicted by equation (5). for the specific speech signal used in this simple experiment, alterations in the supposedly redundant sections of the spectrum were table 1. results of the grading of the speech signal quality, before and after masking threshold set at: original 1 method 2 method 1 method 2 original level threshold masking threshold masking threshold 50% 1 1 1 1 75% 1 2 3 2 90 % 1 1 4 3 2 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 johan j hanekom inaudible. although it is not the only information-reduction process in the auditory system, masking does play an important information-reduction role. with masking function based distortion, even with 90 % of the original signal discarded, the speech is still easily comprehensible, although the speech quality has decreased. masking eliminates some of the redundancy in the signal. using the original calculated masking threshold (without translation), the information rate is cut by about 50 %, without any audible reduction in sound quality. the purpose of the linear translation of the masking threshold was to explore the possibilities of using the calculated masking threshold for engineering applications. this shifted threshold is artificial and does not have any direct significance in a description of the functioning of masking in the auditory system. the information being discarded is not redundant and audible distortion is expected. distortion is, however, applied in a controlled way, and we are not discarding more important information from some sections of the spectrum than from other sections, as we are doing when a level threshold is applied. engineering applications of the masking thresholds as they are described here, are among others in speech coding. with a preprocessor based on the masking thresholds of the normal ear, one can apply controlled distortion onto a speech signal to reduce the information rate. as explained earlier, the fact that approximately 50 % of the spectrum was discarded with the calculated masking threshold, was used to determine the level for the level threshold. although the difference between the level threshold and the threshold determined by the masking functions is not directly evident in the 50 % experiment, from the sound quality observed in the 75 % and 90 % experiments it is conceivable that the calculated masking functions approximate the masking process in the auditory system. improvements could be made to the model used for masking in this paper, e.g., by basing the model not on psychoacoustic experimental data, but on physiological data. as has been explained, results from two-tone masking experiments have been used to determine the masking functions which were used in these experiments. the two-tone masking functions were expanded in equation (5) for application to more complex spectra. possibly, this expansion is not the most applicable masking model to implement on complex speech spectra, as was done here. however, no measured data on the masking observed in complex spectra are available (although data for tone/ bandlimited noise masking are available). this might account for the somewhat strange result, that the signal distorted by the level threshold sounded almost the same as the signal distorted by masking threshold (in the 75 % case). the discarding function is not based on any measured data. it is not possible to determine from psychoacoustic experiments how the data reduction in masking is implemented into neural firing patterns. from the description in the introduction, it can be guessed that the information is not suppressed, as in the implementation, but simply swamped. that masking operates like a swamping (or saturation) function and not an attenuation function, is motivated by kanis & de boer (1994) and javel (1981). the discarding function was implemented here in order to demonstrate that the frequency components below the threshold are inaudible, and not to try to simulate the normal auditory functioning. actually, we might just as well have distorted the sections of the signal below threshold in any other way to prove that these distortions would be inaudible. when we do this, we have to comply with at least the two rules stated earlier, and a third rule may be implemented with flexibility: the amplitude in the sections of the signal that are to be distorted must stay within the same bounds as the amplitude of the original signal in these regions. conclusion masking plays an important role in the data-reduction mechanism of the peripheral parts of the auditory system. although the experiment described here was meant to be exploratory rather than conclusive, the result indicates that the understanding of the mechanism of masking that led to equation (5), seems to be reasonable. in orderto gain a better understanding of the complexities of auditory processing, it is important that the masking property of the auditory system is not studied in isolation from the other characteristics of auditory processing. on the one hand, the psychoacoustic study of the masking of complex signals should be expanded. on the other hand, more cohesive cochlear models, based on the physiology rather than being heuristic, should be created to assimilate the available data. references allen, j.b. (1985). cochlear modelling. ieee acoustics, speech and signal processing magazine, 2, 1, 3-29. eddington, d.k., dobelle w.h., brackmann, d.e., mladejovsky, m.g. & parkin, j.l. (1978). auditory prostheses research with multiple channel intracochlear stimulation in man. the annals of otology, rhinology & laryngology, s53, 87, 6,1-39. hanekom, j.j. (1990). die ontwikkeling van 'n suid-afrikaanse bioniese-oor. master's dissertation. department of electrical and electronic engineering: university of pretoria. javel, e. (1981). suppression of auditory nerve responses i: temporal analysis, intensity effects and suppression contours. journal of the acoustical society of america, 69, 6, 1735 -1745. | kanis, l-j. & de boer, e. (1994). two-tone suppression in a locally active nonlinear model of the cochlea. journal 'o/the acoustical society of america, 96,4, 2156-2165. i keidel, w.d. (1980). neurophysiological requirements for implanted cochlear prosthesis. audiology, 19, 105-127|. keidel, w.d., kallert, s. & korth, m. (1983). the physiological basis of hearing: a review. new york: thieme-stratton incorporated. neely, s.t. & kim, d.o. (1986). a model for active elements in cochlear biomechanics. journal of the acoustical society of america, 79, 5, 1472-1480. schroeder, m., atal, b.s. & hall, j. l. (1979). optimizing digital speech coders by exploiting masking properties of the human έατ. journal of the acoustical society ofamerica, 66,12,16471652. terhardt, e. (1979). calculatingvirtual pitchfhearing research, 1, 155-182. zwicker, e. & zwicker, u.t. (1991). audio engineering and the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 13 bilingualism: theoretical perspectives of language diversity carlin l. stobbart department of speech and hearing therapy university of durban-westville abstract bilingualism and second language acquisition are discussed with reference to different theoretical perspectives. an integrated definition of bilingualism is provided and concepts underlying second language acquisition are presented. theoretical perspectives according to dodson (1985), skinner (1985) and krashen (1982) are explored. it is concluded that due to the diverse nature ofbilingualism, a single universal theory of second language acquisition does not seem feasible. the need for an increased awareness of the complexity ofbilingualism and second language acquisition, particularly within the multicultural and multilingual south african context, is highlighted. opsomming tweetaligheid en tweede taalverwerwing word met verwysing na verskillende teoretiese benaderings, bespreek. 'n gemtegreerde definisie van tweetaligheid word verskaf en onderliggende konsepte tot tweede taalverwerwing word uitgelig. die teoretiese benaderings van dodson (1985), skinner (1985) en krashen (1982) word bespreek. daar word tot diegevolgtrekkinggekom dat 'n enkele universele teorie vir tweede taalverwerwing nie moontlik is nie. die behoefte aan groter bewustheid van die kompleksiteit van tweetaligheid en tweede taalverwerwing, veral binne die multi-kulturele en multi-talige suid afrikaanse konteks, word beklemtoon. throughout history, humans have learned to use languages other than their native tongue to communicate with members of other language groups and other cultures. all humans can acquire additional languages, but must have the opportunity to use the language for real communicative purposes. the literature on bilingualism is extensive and comes from many diverse disciplines. this results in many different, and often fragmented conceptualisations ofbilingualism. mccollum (1981) has pointed out that the early study ofbilingualism did not consider the bilingual's use of language within the speech community: neither the sociological factors that determine usage, nor the speaker's motivation for using one language over another in a particular social situation. the important relationship between language use and language structure was therefore mostly ignored. recent literature does, however, focus on bilingualism in both linguistic and sociological terms. miller (1984a), for example, views bilingualism as the complex consequence of the interaction of social and individual variables. the study of bilingualism should therefore include an understanding of the cognitive, linguistic and social development of the individual within the community context in which it occurs. this has important implications for the study of bilingualism within the multilingual and multicultural south african context. the present climate of change in south africa has an impact, not only on political find economic levels, but also on a cultural level. part of this change process is an increasing acceptance and recognition of the diversity of populations and ethnic groups within our society. this seems to follow a global trend where there appears to be a significant increase in the awareness of cultural diversity within bilingual and multilingual communities (miller, 1988). the fact that language is an inextricable part of the cultural life of a social group, and interdependent with the habits and values of behaving and sharing among members of a particular group, must be recognised. it can thus be said that a change in attitude toward different cultures, and greater tolerance between individuals of different cultures is likely to become more important in the years to come. consequently, the importance of a sensitivity towards the linguistic and communication differences between cultures is implied. it is contended that within the present south african context, a greater awareness ofbilingualism and second language development is needed amongst speech therapy and audiology professionals. bilingualism and second language learning must, therefore, be understood within the context of both linguistic and communication differences between cultures. terrel and hale (1992) have stated that an understanding of learning styles is also relevant within such a context, as learning styles are mostly culturally determined. speech therapists and audiologists must, therefore, gain insight into the normal processes of second language acquisition within particular cultural contexts. it is against this background that diagnostic and therapeutic implications regarding language acquisition and language delay must be considered. the purpose of the present paper therefore is to investigate the complexities of bilingualism and second language development. different theoretical perspectives will be explored and facilitating factors in bilingualism and second language development will be presented. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 39, 1992 sasha r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 carlin l. stobbart a. bilingualism defined the simultaneous acquisition of two or more languages in language learning environments associated with biand multilingual circumstances can be viewed as an exceptional and complex process. a single definition of the nature of bilingualism can, therefore, not adequately describe the nature of second language acquisition within a particular sociolinguistic context. the complexity of bilingualism lies in the function and purpose it has within a particular bilingual community. for too long there has been an incorrect conceptualisation of bilingualism, which focused on the rules and abstract aspects of the languages rather than on their use in conversation and communication (miller, 1984a). this was also emphasised by mackey (1962, in mccollum, 1981) when he asserted that bilingualism is not a phenomenon of language, but of the message. such a definition of bilingualism clearly suggests the recognition of the relationship between language structure and language use, as well as the complex interaction between social and historical factors surrounding bilingualism within a particular community. bilingual communities and individuals within these communities can not be described in terms of discrete or absolute characteristics. the language usage within a particular community is, furthermore, relative rather than absolute as it is determined not only by an individual's needs, motives, attributions and perceptions (miller, 1984a), but also by a speech community's norms for language use in various domains (mccollum, 1981). the significance of such a conceptualisation of bilingualism is that it describes bilingual behaviour at the level of the individual as well as at the sociocultural level. it is thus clear that the language choice within a particular community is a product of the interaction between individual factors (age, sex, ethnic group and the individual's willingness to comply with the language laws of the community), the setting of communication (the physical and symbolic setting) and the topic of conversation (miller, 1984a). according to dodson (1985), a discussion of bilingualism must also reflect the relationship between the two languages, and the language environment in which learning and communication take place. the relationship between languages is related to broad social circumstances rather than to any formal qualities of the languages involved. within these social circumstances a language has a certain power within the community and a command of that language will be a prerequisite in gaining access to particular resources (miller, 1984a). it must, however, be noted that the relationship between any two languages is not static and may change depending on the frequency and intensity of contacts in either language, and as a result of changes in the environment. miller (1988, p.241) has described the relationship between the languages as "fluid and dynamic, varying from one aspect of the language system to another in accordance with a complex of socio-linguistic determiners". this implies that bilingualism cannot be understood in terms of two separate language entities without considering the effects of the one language upon the other. utterances will therefore carry features of both languages. the sporadic alternation that occurs between the two languages is referred to as code-switching, while constant intermingling of the two languages is referred to as code-mixing. both of these features are typical of all bilingual situations. bilingualism can further be defined with reference to language proficiency and communicative competence. according to williams and snipper (1990), language proficiency refers to an individual's ability to process two languages in each of the following four skills: the ability to understand a message in each of the spoken languages the ability to respond in each language in a manner appropriate to the situation the ability to read and understand a written message in each of the languages the ability to write in each language. kessler (1984) has-defined bilingualism as a social process that develops along a continuum ranging from full proficiency in two languages to a minimal degree of competency in one of the languages. bilingualism thus results from "efforts to communicate, to take part in that interpersonal interactive process defined by the social situation in which it occurs" (kessler, 1984, p.27). this definition highlights the relevance of a communicative perspective in bilingualism. acquiring a second language is, therefore, a complex process of developing communicative competence, and of using two language systems to communicate with individuals of differing languages and cultures. it is proposed therefore that a holistic perspective of bilingualism is needed to accommodate the complex yet dynamic nature of bilingualism. a holistic view will acknowledge the complementary and interdependent nature of the languages spoken. a holistic perspective of bilingualism will, furthermore, recognise the interaction between individual and sociolinguistic factors within a particular community. bilingualism can be understood therefore within a communicative framework by focusing on both language structure and language use. b. concepts underlying second language acquisition prior to a discussion of theoretical perspectives in second language acquisition and the development of bilingualism in children and adults, certain underlying concepts must be clarified, because these concepts are central to the acquisition of a second language. bilingualism must, therefore, be understood with reference to the notions of communicative competence, language proficiency and language environment. according to kessler (1984), this allows the various dimensions of bilingual language development to be placed into perspective. figure 1 presents concepts relevant to second language acquisition. the various dimensions of communicative competence, as well as other factors that may influence communicative competence in second language acquisition are also indicated. 1. communicative competence ' canale and swain (1980, in kessler, 1984) have stated that communicative competence is an essential part of communication, as it includes knowledge about the language as jwell as skills in language use which underlie the actual communication. according to miller (1988), communicative competence refers to the individual's ability to have basic language structures available, and the ability to use, maintain and structure these towards the desired conversation exchanges. it must be noted however, that the various dimensions of communicative competence are not acquired in a universal order. as miller (1988) has indicated, an individual may have good grammatical competence (due to formal instruction), but poor sociolinguistic competence (inability to use linguistic knowledge), while another individual may have good strategic and sociolinguistic competencies but poor grammatical competence. it is, thus, implied that relative dominance in one competence (grammatical, sociolinguistic) will fluctuate over time in one indi-vidual and between individuals of the same speech community. similarly, an individual need not be equally dominant in all competencies. it is thus clear that the various dimensions the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) u a i : theoretical perspective of language diversity 15 figure 1: a schematic presentation of the concepts underlying second language acquisition and factors that affect the development of a second language (adapted from kessler, 1984). of communicative competence together have an impact on second language acquisition. the dimensions identified by kessler (1984) will be discussed separately. 1.1 grammatical competence. thisisalsocalledlinguistic competence and refers to mastery of the linguistic code, that is, to mastery of the formal features of the language. the phonological, syntactic and lexical features of the language must be recognised and the ability to combine these features in pronunciation, word and sentence formation must be acquired. i 1.2 sociolinguistic competence. previously, the role of sociolinguistic competence in second language acquisition has received little recognition. this component refers to the sociocultural rules of language use, and defines the appropriate use of the language according to the social context in which communication occurs. sociolinguistic competence is crucial in the interpretation of utterances for their social meaning. kessler (1984, p.29) has stated that "this is an intricate developmental process for children1 that takes place over time and reflects aspects of normal maturational processes". 1.3 discourse competence. according to kessler (1984) conversation is a form of interaction governed by rules for the introduction and maintenance of topics, opening and closing of utterances and turn-taking conventions. discourse competence, therefore, refers to the ability to successfully communicate messages during conversation. the discourse component utilises grammatical components (the knowledge and use of language structures), sociolinguistic components (the constraints imposed by particular socio-cultural contexts), as well as the rules which govern ongoing conversation. 1.4 strategic competence. this refers to strategies used to overcome breakdown in communication due to imperfect knowledge of rules in one or more dimension of communicative competence (kessler, 1984). two types of strategies can be identified. firstly, communication strategies, which are devices implemented to communicate effectively, and secondly, learning strategies, which are mental processes used to construct the rules of the language. some strategies used in second language (l2) acquisition are similar to those used for first language (li) acquisition. corder (1981, in kessler, 1984) has said that in the early stages of l2 development children may implement specific strategies but these may change as the child grows older and the degree of l2 proficiency increases. summary the above discussion reflects the complexity of communicative competence. moreover, the acquisition of communicative competence must be understood in terms of the interdependence of the above mentioned dimensions. furthermore, the interaction between the two language systems in the acquisition of second language must be acknowledged (kessler, 1984). the complex nature of this interaction is not yet fully understood. communicative competence can however not merely be expressed as interaction between various components. the synergistic nature of the various interacting dimensions of communicative competence must at all times be recognised. a further crucial aspect, not to be overlooked, is the context in which second language acquisition takes place. 2. language environment a discussion of the language environment necessitates a distinction between language acquisition and language learning (krashen, 1982). language acquisition, according to kessler (1984), is a natural, subconscious process that occurs in informal environments. the focus of this process, through which both first and second languages are acquired, is on communication or meaning. language learning, on the other hand, is a conscious process, with a focus on grammatical competence (language form), that occurs in formal learning environments. this is a process available to older children and die suid-afrikaase tydskrif vir kommunikasieafykins, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 carlin l. stobbart adults in developing a second language. according to kessler (1984) language acquisition is central, and through language learning a system to edit language output is developed. the distinction between language acquisition and language learning must, however, be seen in a larger context. skinner (1985a) has indicated that language is a function of learning, but that learning is also a function of language. second language acquisition must, therefore, be viewed as a learning process. this has important implications for the language environment in which a second language is acquired. a further factor related to language environment that has an impact on second language acquisition is the nature of language input. optimal comprehensible input of language is an important characteristic of the language environment. this must, however, be seen with reference to individual factors in the language learning environment, for example, the levels of cognitive development and life experiences (krashen, 1982). an individual factor that has a significant impact on second language acquisition is what krashen (1982) has termed the affective filter. this refers to the relationship between the affective variables (motivation, self confidence and anxiety) and the process of second language acquisition. kessler (1984, p.32) has concluded that "input is the primary causative variable in l2 acquisition and that affective variables either impede or facilitate delivery of input to the brain where language processing occurs". the degree to which the individual is open to input from the environment is dependent upon the amount of comprehensible input that is received and understood, as well as the strength of the individual's affective filter (how the environment is perceived affectively). the acquisition and use of a second language within a particular language environment cannot be fully understood without reference to the mutual influence of the languages upon each other. we can, therefore, not assume that one language is dominant, either because it was acquired first or because it was the language of instruction. such a view would neglect the impact of the different patterns and contexts of bilingual acquisition. each language performs a particular communicative function and thus serves a different purpose in communication. the individual's competence in either language will be closely related to the nature and frequency of access to the situations in which the particular language is used (miller, 1988). bilingual language proficiency can thus not be understood in terms of separate language entities. language proficiency as part of second language acquisition thus needs further clarification. 3. language proficiency a discussion of language proficiency must emphasise the connection between learning and language acquisition. according to skinner (1985a), language proficiency relates directly to learning, and thus to the acquisition of knowledge. an integrated conceptualisation of language proficiency, language acquisition and learning is thus proposed. in this way, various language/learning issues and variables can be examined within a single framework. this has important implications for understanding the successful acquisition of a second language. the connection between language and learning can be explained by referring to the work of piaget, chomsky and vygotsky on language acquisition. chomsky and piaget (in skinner, 1985a), agree that interaction with the environment facilitates the acquisition of knowledge and language. there is, however, a difference in emphasis, as piaget has suggested that learning and language develop from successive experiences with the environment, whereas chomsky has indicated that interaction with the environment activates what the learner brings to the interaction. the essential nature of language and thought as prerequisites to communication thus become an important issue to consider. vygotsky (1962, in skinner, 1985a) has stated that the union of thought and word produces meaning: meaning is thus a continual interaction between these two components. according to vygotsky, the acquisition of grammar and vocabulary is the beginning in the development of meaning, while changes in meanings and the acquisition of new meanings represent learning. it can thus be concluded that knowledge is a function of language and that the acquisition of knowledge, although related to language, will be limited by the language proficiency of the learner (skinner 1985a). language proficiency is, therefore, an integral part of the learning process. this means that an individual's academic performance may be directly related to language proficiency. cummins (1981, in skinner, 1985a) became interested in the academic difficulties experienced by apparently fluent second language speakers. based on the notion that different languages have different functions in different contexts, cummins has identified two kinds of language proficiency: basic communication proficiency and cognitive academic proficiency. basic communication skills entail the use of surface features of the language, and thus basic knowledge and understanding of language structures. academic proficiency, however, includes higher language abilities. this refers to the ability to "think" by using the language, thus manipulating meanings inherent to the language itself. according to skinner (1985a), this conceptualisation can best be explained with reference to bloom's taxonomy of cognitive learning (table 1). table 1: the relationship between cummins' constructs and bloom's taxonomy of cognitive learning (from skinner, 1985, p. 104). cummins' constructs bloom's taxonomy of cognitive learning basic interpersonal communicative skills knowledge comprehension cognitive academic language proficiency application analysis synthesis evaluation i from table 1 it can be seen that academic proficiency in a language can not be separated from critical thinking skills. skinner (1985a) has thus concluded that language can be related directly to learning. cummins (1981, in skinner, 1985a) has suggested that language proficiency be seen as a developmental progression rather than in terms of distinct and separate realms. he thus portrayed language proficiency in terms of two vectors: the ability to identify and communicate meaning in the absence of contextual clues, and the ability to think (determine/communicate meaning) in cognitively demanding situations. table 2 presents the dynamic developmental progression in language proficiency (from quadrant a to quadrant d) as indicated by cummins. quadrant a refers to basic communication proficiency (context-embedded and cognitively undemanding communication), whereas quadrant d refers to cognitive academic proficiency (context-reduced and cognitively demanding communication). a language learner therethe south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) b i l i u a i : theretical perspective of language diversity 17 table 2: the developmental progression of language proficiency (adapted from cummins, 1981, in skinner, 1985a). cognitively undemanding cognitively demanding context embedded a β context reduced c d fore progresses from a to d as more meanings become available. this view clearly supports the connection between language and learning. cummins' conceptualisation of language proficiency (1981, in skinner, 1985a) can further be understood with reference to vygotsky's notions on childhood grammar and adult grammar, represented by basic communication skill and cognitive academic language proficiency respectively. the development of language proficiency along a continuum once again becomes apparent. basic communication skill thus refers to the initial command of grammar whereby the child has a broad use of the phonics and syntax of the language. the child is able to converse fluently at seemingly adult level, but lacks abstract, deliberate thinking skills. as the child progresses in concept development, word meanings change which represents development in language proficiency (toward cognitive academic proficiency). a child and an adult may use exactly the same words, although the meanings may be very different for each. meanings of words change as the thoughts embodied in those words change. adult grammar is thus nearer to cognitive academic proficiency as it involves the ability to deal with meanings and relationships at an abstract level (skinner, 1985a). summary the preceding discussion highlights the various dimensions underlying second language acquisition as well as factors that may contribute to second language acquisition. this has important implications for the understanding of bilingual development within a particular context. furthermore, the relevance of analyzing an individual's language system as a whole becomes clear. manyj of the issues regarding language learning addressed by different theories are dependent upon which competencies are examined and under which circumstances. this leads to different views on which factors will facilitate bilingualism. the complexity of second language acquisition thus becomes apparent which clearly prompts a more holistic perspective on second language acquisition. c. second language acquisition: a theoretical perspective kessler (1984) has stated that to become bilingual is a uniquely human phenomenon, yet an extraordinarily complex process. many different theoretical perspectives have therefore been proposed to explain the acquisition of a second language. it must also be stressed that "theory" and "theoretical research" have for too long been the only input in decisions on methodologies and materials for second language teaching. for this reason krashen (1982) has proposed interaction between the various approaches that influence language teaching methodology. theories of second language acquisition and bilingual development are concerned with the same basic issues as theories of first language acquisition, i.e. rate, pattern and processes of language development (genessee, 1988). an additional interest in second language acquisition, however, in contrast to first language acquisition theories, is whether the patterns and processes of language learning are influenced in some way by learning two or more languages simultaneously; or by learning a second language after a first language has been acquired. we can therefore ask whether there are interactions between the two language systems that result in a pattern of language acquisition that is different in comparison with monolingual development. this is further complicated by the possibility that different processes might be involved in successive acquisition of more than one language than those involved in simultaneous acquisition of two languages. a number of different theoretical approaches are evident in the literature, all with differing views regarding the relationship between li and l2. there is, furthermore, no consensus regarding the process and sequence of l2 acquisition, or whether or not a second language is acquired in the same way as the first language. early theories, for example grammar-based approaches, focused on codifying the second language into rules of morphology and syntax to be explained and memorised. oral work was consequently reduced to a minimum. the real experience of the language in natural communication situations was largely ignored (krashen & terrell, 1983). current theories are, however, more tuned to the communicative importance of second language learning. this means that to acquire communicative competence, the key component is the use of language for real communication and that exercises and drills are not necessary. krashen (1982) has pointed out that communicative ability develops rapidly, and that grammatical accuracy increases at a slower rate and after much experience with the language. the following discussion on current theories will reflect three different perspectives on second language acquisition. 1. dodson (1985) dodson (1985) has emphasised that bilinguals, irrespective of age and environment, have a preferred (li) and a second language (l2). the terms "preferred" and "second" language must, according to dodson (1985), always refer to the languages of individuals as the term "dominant language" refers to the language of groups. a distinction can thus be made between an individual's mother tongue (or first language of acquisition) and his/her preferred language. the mother tongue for many people, is not their preferred language. dodson's (1985) theory explains increasing language competence in terms of medium-orientated communication and messageorientated communication. according to dodson (1985), the process whereby the language learner focuses on language or the language learning process, can be called medium-orientated communication. other utterances, in which the message is more important than the medium, have been classified as message-orientated communication. these two forms of communication which can be seen as extremes of a spectrum within which all utterances can occur, are presented in figure 2. a and β (in figure 2) represent all possible utterances that can be made. these two levels of activity are not restricted to speaking and listening and can also be applied to the development of reading and writing. most utterances are predominantly a or β although a mixture of a and β can occur depending on the speech intentions of the speaker. dodson (1985) has suggested that the acquisition of a second language initially die suid-afrika arise tydskrif vir kommunikasieafivykinys, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) increasing second language proficiency — figure 2: medium-orientated and message-orientated communication in second language acquisition (dodson, 1985, p. 337). depends largely on medium-orientated communication. as language proficiency increases, the amount of necessary medium-orientated communication decreases. a developmental trend is thus implied. medium-orientated communication is consciously focused on the "mechanics" of communication, while at the message level, communication is more spontaneous, not consciously dealing with the grammatical correctness of a message. at the medium level, the aim is to communicate to the self something about language and the languagelearning activity. the direction of such communication is thus inward. dodson (1985, p.36) has stated that communication at this level is important as it "helps developing bilinguals to separate their two languages, to reduce or eliminate cross language interference and to develop their facility to codeswitch effectively". at the message level the direction of communication is outward. medium-orientated communication thus refers to the sharing of messages with others on different occasions. language acquisition can, therefore, be described as a fluctuating process between language learning and application of what has been learnt. the fluctuation takes place between bilingual preferred/second language medium-orientated communication and monolingual second language messageorientated communication (see figure 2). as second language proficiency increases, the individual relies less on prior medium-orientated confirmation of any message-orientated utterance. it is thus proposed that second language acquisition can be encouraged by allowing the developing bilingual to experience the fluctuation and interdependence of monolingual and bilingual activities in "varying proportions according to the area of experience and the degree of proficiency" (dodson, 1985, p.339). a positive feature of this theory is that dodson (1985) has emphasised the environment in which communication occurs. * he has indicated that unfavourable linguistic treatment may have a handicapping effect on second language acquisition, thus causing a large number of second language utterances not to be made fully at message-orientated level. this aspect may be related to krashen's (1982) proposal of an affective filter. this means that the individual perceives an unfavourable language environment which then has a negative impact on the acquisition of the second language. it is clear that this theory has valuable features that can be implemented in the explanation of sequential acquisition of a second language. fluctuation between these two levels of communication as part of second language acquisition, is an important aspect of this theory. it is, however, possible that the distinction between the preferred and second language status as explained by dodson (1985), is overemphasised. 2. skinner (1985) according to skinner (1985a, p. 106) the ideas of piaget, chomsky, vygotsky and cummins can be merged into "a unified conceptual construct" as a means of directly correlating primary language acquisition, language proficiency and learning. furthermore, this composite construct can be successfully applied to the explanation of second language acquisition. figure 3 demonstrates how skinner (1985a) has proposed that the ideas of piaget, chomsky and vygotsky be merged. skinner (1985a) has noted that the word/age axis (representing grammar and vocabulary) indicates growth in knowledge and language facility. the presentation of growth against "thoughts" and "meanings" indicates vygotsky's proposals on the unity of "word" and "thought" in order to produce "meaning"'. this can further be interpreted by adding cummins' ideas on language proficiency to vygotsky's notions of thought and word unity. it thus becomes clear that as meanings become available, freedom from contextual cues increases. this provides the opportunity to use language for cognitively more demanding purposes. this unified theory represents skinner's (1985a) idea of a single construct that unifies language proficiency, language acquisition and learning. the dynamic growth in language acquisition, and its link to the learning process, can be seen in relation to knowledge. the value of this integrated approach to language acquisition is that it can be applied successfully to the acquisition of a second language. not only is this model based on sound theoretical principles, but it has clear methodological guidelines for the language learning process. as indicated by skinner (1985b) in this model, the language learner is assisted by connecting thoughts with words. it is thus implied that li will be the language of instruction for l2 acquisition, particularly in the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) b i l i u a i : theoretical perspectives of language diversity 19 language proficiency (cummins) meanings a language/learning (vygotsky) contextual freedom thoughts language proficiency gap level of cognitive functioning 4 6 word/age (piaget and chomsky) figure 3: a unified model for language acquisition, language proficiency and learning (skinner, 1985a and 1985b) the early stages. this may also be related to dodson's (1985) view of the fluctuation between medium-(bilingual activity: l2) and message-(monolingual activity: li) orientated communication. the use of contextual clues as a means of conveying meaning thus contributes significantly to the acquisition of meaning in the early stages of l2 learning. furthermore, the value of this approach lies in the fact that it considers cognitive competency as a key factor in determining the level of language proficiency and the ability to think in the language. as stated by skinner (1985b, p.385), "a programme that attends to the transfer of concepts from li to l2 should result in more rapid development of language proficiency". through this model, concept development can thus be maintained at age-appropriate levels. this means that an effective methodology will ensure instructional content and sequence of explanation on the level of li conceptual development (skinner, 1985b). the particular significance of this model is, however, that it pays careful attention to what skinner (1985b, p.386) calls "the language equivalency assumption", i.e. that l2 is acquired in the same way as li. there is thus an awareness of the methodological problems involved vyhen a language learner is forced to function at a conceptual level below his actual equilibrium in li (see figure 3). this results in a cognitive gap, as the learner is unable to unify adult (more advanced) thoughts with l2 words. skinner (1985b, p.5) has argued that "the gap can also be expressed as a language proficiency gap, because of the connections between language proficiency and learning". he has proposed that the cognitive gap and language proficiency gap are related to the learner's anxiety and frustrations in acquiring the second language. such affective learning difficulties are therefore the result of a disorientation imposed by the methodology of language teaching (skinner, 1985b). this has important implications particularly for adults in the process of acquiring a second language. it must, however, be pointed out that this model places almost exclusive emphasis on language proficiency. as discussed previously, this is only one of the significant issues underlying second language acquisition. it is suggested that the use of language (i.e. communicative competence) should be acknowledged more explicitly. in addition, more emphasis is needed ori issues related to factors in the language environment conducive to successful acquisition of a second language. 3. krashen (1982) according to krashen (1982) the best methods for second language teaching are those that supply comprehensible input in low anxiety situations, containing messages that students really want to hear. it is suggested by krashen and terrell (1983) that language acquisition occurs mainly through comprehensible input, viz. by understandable auditory and written input. they have described the following four principles in their theory of second language acquisition: comprehension precedes production, thus emphasising that acquisition is the basis for production ability and that for acquisition to take place, the message must be understood production takes place in stages, meaning that an individual is not forced to speak unless he/she is ready to do so the syllabus should consist of communicative goals where the focus of language activities is organised by topic not by grammatical structure all language acquisition activities must foster a lowering of the affective filter of the acquirer. based on these principles, five hypotheses have been formulated as part of this second language acquisition theory. these hypotheses are not absolute, but subject to change. 3.1 the acquisition-learning hypothesis. according to this hypothesis, there are two distinct ways in which an adult can acquire a second language. firstly through language acquisition, which means that language is used for communicative purposes, and secondly through language learning, thus implying conscious knowledge about the language. this is an important distinction because it determines the nature of language input from the language environment. it is thus implied that language teaching is too often aimed at learning, and not acquisition of the second language. 3.2 the natural order hypothesis. according to this hypothesis, grammatical structures are acquired (not necessarily learned) in a predictable order: certain structures are acquired early and others late, allowing for the possibility die suid-afrikaase tydskrif vir kommunikasieafykins, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 carlin l. stobbart figure 4: average order of acquisition of grammatical morphemes for english as a second language: children and adults (from krashen & terrell, 1983, p. 29). that structures may be acquired in groups. regarding second language acquisition in adults, krashen and terrell (1983) have indicated that a natural order for the acquisition of morphemes exists. this is shown in figure 4. the fact that the natural order for adults acquiring a second language appears under certain conditions, forms the basis of the following hypothesis. 3.3 the monitor hypothesis. this hypothesis emphasises the limited function of conscious learning as a language monitor (editor) in adult second language performance. fluency in production is thus the result of what is acquired in natural communication situations, whereas formal language knowledge has the function of checking and correcting the output of the acquired system. the monitor hypothesis claims that conscious learning has value as a "language monitor" only and that it is not used to initiate production in a second language (krashen, 1982). 3.4 the input hypothesis. input has become a central issue in many theories of second language acquisition. krashen (1982) has emphasised the importance of input over other aspects of second language learning in his argument that output, or opportunities to use the language productively, are not necessary to develop production skills. in the hypothesis, therefore, it is claimed that language acquisition occurs through the understanding of messages, that is, through receiving comprehensible input. efficient input is described as a message that involves general language difficulty not exceeding the learner's ability (dornyei, 1991). krashen and terrell (1983) have argued that when input is enough, the equation of i + 1 will be satisfied, where stage i refers to the acquirer's level of competence and 1 refers to the stage immediately following i along some natural order. this has important implications for the language material the learner is exposed to as part of the acquisition process. the practical significance of this hypothesis is, however, questioned by dornyei (1991) as he has contended that it does not serve as a satisfactory guide for language teachers. furthermore, genessee (1988) has argued that more attention should be given to the role of output. swain (1985, in dornyei, 1991) has argued that comprehensible input is not the most important ingredient in language teaching. an output hypothesis was thus proposed by swain (1985, in dornyei, 1991) to fulfil functions in communication not met by the input hypothesis. efficient output thus involves more than uncontrolled learner talk. the language learner should, according to the output hypothesis, be prompted to express messages more appropriately and more precisely. it thus appears that fluctuation between these hypotheses may result in optimal language learning conditions. 3.5 the affective filter hypothesis. according to this hypothesis that attitudinal and affective variables relate to second language achievement, language learners with optimal attitudes have a lower affective filter, meaning that they are more open to input. according to krashen and terrell (1983) the right attitude will encourage the learner to obtain more input and to interact with speakers of the target language, while at the same time, being receptive to the input they receive. a review of the literature indicates that this hypothesis has the most important impact on second language acquisition theory as many other theories have been altered to accommodate the role of affective variables. it has implications not only for the language environment, which should present favourable language conditions to foster positive attitudes, but also for the individual language learner, to be aware of environmental factors and his/her own response to these. although krashen's (1982) theory of language learning has been the source of much controversy and academic discussion, it can be viewed as a comprehensive theory of second language acquisition, mostly applicable to older language learners. dornyei (1991, p.33) has pointed out that "this theory has undoubtedly succeeded in bridging the gap between linguistic theory and actual language teaching". an advantage of this theory is that it focuses on the acquisition of communicative competence in natural communication settings. in addition, the emphasis in this theory on affective and attitudinal variables makes a valuable contribution to the theoretical perspectives on second language acquisition. from the above discussion on three theoretical approaches, it can be seen that in spite of some overlap in concepts, each theory's main focus is on a different aspect of second language acquisition. the theories discussed are aimed at accommodating the complexity of bilingualism, as well as the various factors that influence second language acquisition. as pointed out by genessee (1988), individual differences im second language acquisition are important issues to consider. factors associated with age, cognitive style, personality, type and amount of exposure, attitudes and motivation have an impact on language learning and language acquisition. the social, cognitive and linguistic consequences of being bilingual must also be considered in a theoretical approach to bilingualism. due to the diverse nature of bilingualism, an integrated perspective on second language acquisition is proposed. this implies a holistic view of the development of bilingualism, based on the interdependence of communicative competence, language proficiency and factors in the language environment! furthermore, such an approach to bilingualism can be based on a composite of the strengths of the various theoretical perspectives, leading to an integrative theoretical view which can be applied to each unique bilingual situation according to the needs of language learners and the features of the language environment. d. second language acquisition in the discussion on second language acquisition which relates to both children and adults an attempt will be made to highlight those factors that will facilitate language acquisition the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) b i l i » i u a u e i n : 'theoretical perspectives of language diversity 21 • children. kessler (1984) has indicated that for an understanding of bilingualism in children one must consider the developmental perspectives of communicative competence for very young children, older pre-school children and schoolaged children. furthermore, the relationships between the bilingual child's two languages, as well as aspects of communicative competence related to school contexts, must all be taken into account. the following two points are important to consider when discussing second language acquisition. simultaneous versus sequential acquisition. kessler (1984) has pointed out that bilingualism in children is related to the timing of acquisition of the two languages. the process of acquiring two languages simultaneously is referred to by swain (1972, in kessler, 1984) as first language bilingualism. according to schiff-myers (1992) this can also be called infant bilingualism. the child develops both languages simultaneously in naturalistic situations. ben-zeev (1984) has stated that bilingualism can also develop in a situation where the child experiences language-switching in the environment from a very young age, as in the case of a caretaker switching from one language to the other whilst talking to the child. this type of developmental bilingualism begins at the onset of language in infancy and refers to the acquisition of two languages prior to age three. the acquisition of another language after this point is referred to as sequential or successive bilingualism. this occurs when one language follows or is second to the first in acquisition order. schiff-myers (1992) has referred to this as childhood bilingualism. the child hears only one language in the home and is only later exposed to a second language. second language acquisition in children must, however, be separated into l2 acquisition in the pre-school years and l2 acquisition in the school years. this is an important distinction as the older child is at a higher maturational level and, during the school years literacy, reading and writing tasks become an integral part of the total process of becoming bilingual. schiff-myers (1992, p.29) has referred to these children as "sequential or consecutive language learners with the first language designated as li and the second language as l2". psycholinguistic similarities and differences between li and l2 acquisition. authors seem to differ regarding the linguistic faculties or linguistic principles involved in first (li) and second language acquisition (l2). schachter (1986, in genessee, 1988) has identified certain basic differences in first and second language acquisition. schachter has cited evidence that older second language learners, in contrast to first language learners, often fail to acquire basic linguistic structures or acquire incorrect or incomplete language forms, thus they do not always acquire complete competence in the target language. the first language, furthermore, has a considerable influence on the acquisition of the second language. this may be due to the nature of the learning environments in which a second language is acquired. according to schachter (1986, in genessee, 1988), these differences do not occur with acquisition of two languages simultaneously during the period of primary language development. the role of cognitive factors in li and l2 acquisition must also be acknowledged. according to genessee (1988) cognitive factors of a non-linguistic nature (i.e. memory capacity and perceptual-motor abilities) influence the child's ability to perceive and to produce particular linguistic structures in first language acquisition. "the determining factors in primary language development are largely cognitive or conceptual in nature because the language acquisition device is a given, while the determining factors in subsequent language learning are largely linguistic in nature since cognitive/perceptual | maturity is a given" (genessee, 1988, p.67). a further factor to consider in li and l2 acquisition is the relationship between the two languages. research has shown that the conditions under which, and the extent to which, a second language learner uses the first language when processing the second language are important factors to consider. genessee (1988) has stated that the older language learner's knowledge base includes specific contextual knowledge regarding social relations within a particular social group. such established conversation knowledge may, therefore, have an effect on the acquisition of a second language. in contrast to the older second language learner, the pre-schooler acquires language in parallel with social knowledge and thus the influence of established social knowledge on language acquisition is not profound. the conclusion that can be drawn from these theoretical arguments is that bilingual development is psycholinguistically distinct from monolingual or first language acquisition. genessee (1988) has summarised such research by stating that children acquiring two languages simultaneously initially go through a stage of extensive linguistic interaction when the two language systems are mixed. this can easily be seen as a stage of linguistic confusion or as a unitary, undifferentiated language system. these points will be discussed further in the following section. 1. simultaneous acquisition of languages in young children two patterns of simultaneous acquisition can be identified. firstly, where the child is presented with different languages in a one-person, one-language association and secondly, where the languages are not person specific and are alternated in the same discourse situation. extensive code-switching may thus, for some children, be the primary type of input rather than one which clearly distinguishes two language systems (kessler, 1984). evidence of uneven development during the simultaneous acquisition of languages must be acknowledged. children often develop faster in the language to which they are most often exposed. the quantity of language input within a particular language environment may, therefore, provide balanced exposure to both languages or greater quantity for one of the languages. these factors interact in complex ways and can, according to kessler (1984), affect the degree of bilingualism, the rate of realisation of two distinct language systems and the degree of negative language transfer (li and l2 interference) between the two languages. according to kessler (1984), such interference, or code-mixing seems to occur when the adult input is characterised by extensive codeswitching. code-mixing refers to "a sophisticated, rule governed communicative device used by linguistically competent bilinguals to achieve a variety of communicative goals" (genessee, 1988, p.69). mixing the linguistic elements from one language into another is constrained so that the syntactic rules of both languages are respected. switching between languages occurs as a function of certain sociolinguistic factors, such as the setting, and tone and purpose of the communication situation. fatini (1976, in kessler, 1984, p.36) has stated that "the more separate the environments in which each language is used and the more consistent the language use within each of these environments, the more rapidly and the more easily bilingual children learn to differentiate their linguistic systems". it can thus be seen that the nature of linguistic input is an important aspect of the language environment as a facilitating factor ofbilingualism in young children. kessler (1984) has highlighted two stages in simultaneous language acquisition. 1.1 undifferentiated single-language system. input taken from both languages is acted upon by cognitive processes die suid-afrikaase tydskrif vir kommunikasieafykins, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 carlin l. stobbart to form a unique language system consisting of elements of both languages. the two languages are, therefore, not encoded separately but as a common core of rules. code-mixing is a typical and natural feature of simultaneous acquisition. there are at least two sources of code-mixing at this level. firstly, the language input may be a mixed code. secondly, during the simultaneous acquisition of two languages, a period of insufficient metalinguistic skill prevents the child from separating the two languages. as a consequence, a mixed language develops along similar lines to a single language. a functional and acquisitional differentiation emerges around the age of two years and six months (miller, 1988). it is then, that codeswitching as opposed to habitual code-mixing gradually becomes predominant. another phenomenon evident in sequential acquisition is a silent period during which the child has limited l2 expressive language, despite good comprehension of the language. this may be a period of consolidating knowledge of l2 to enable the child to use l2 without having to resort to li. pressure on children to communicate during this phase forces them to use li-based strategies to succeed (miller, 1988). 1.2 differentiated language systems. as bilingual children develop they gradually begin to differentiate between the two language systems. according to kessler (1984) the precise age at which this may occur varies as input conditions, language balance and other linguistic and sociolinguistic variables interact. differentiation occurs when the child starts to communicate with different people in different languages. code-switching becomes evident depending on the conditions of the communication situation. bilingual children learn to identify a specific language with a particular person and with particular situations. in order to create conditions favourable to second language acquisition, kessler (1984) has stressed the importance of understanding the complex and fragile nature of bilingualism. should a child be removed from bilingual language input, one language may soon be lost to the child. continued input! however, can stabilise bilingualism, allowing for distinct and separate language use. kessler (1984) has emphasised that for bilingualism to be maintained, the continued use of both languages in communicative, naturalistic settings is required. 2. sequential acquisition of languages this implies that the acquisition of li has taken place before l2 acquisition. it therefore tends to be related to older children and adults. 2.1 sequential acquisition in pre-school children. by the age of three years, children usually have basic communicative competence in their first language. acquisition of a second language at this age thus implies adding a second language to one already in place. in informal settings, pre-school children will direct their attention to the meaning of utterances rather than to linguistic forms. according to krashen (1982) this is an important process used by children for developing a second language. kessler (1984, p.43) has indicated that this process can be greatly impaired "when input is deficient in quality or quantity or when children, because of the complex set of personality characteristics each brings to the task, have negative attitudes or do not have access to the cognitive and social strategies that facilitate language acquisition". this has important implications for the facilitation of a second language at pre-school level. it is recommended that the language environment must be natural, with emphasis on communication. krashen's (1982) emphasis on affective and attitudinal variables in relation to language achievement, provides valuable guidelines in this regard. the aim is therefore, to foster a positive attitude toward l2 in a favourable language environment. corder (1981, in kessler, 1984) has referred to l2 acquisition at the pre-school level as acquisition of an inter-language. this is a unique language system constructed by the child and can be described as "a dynamic, fluid system shifting and changing as the child reorganises it to accommodate new rules" (kessler, 1984, p.43). the inter-language can be seen as a developmental continuum characterised by so-called errors which mark divergence from the native-speaker norms for the target language (language acquired). making of errors thus plays a vital and necessary role for the successful outcome of l2 processes, as they provide evidence of the learner's acquisition strategies. it is possible that dodson's (1985) view on fluctuation between bilingual medium-orientated communication and monolingual message-orientated communication (see figure 2) is applicable in this regard. this would mean that during the early stages of sequential bilingualism, the child relies heavily on the li system, as it is drawn upon for l2 development. as language proficiency increases, li has less influence and the errors observed in the inter-language increasingly resemble the normal, developmental errors which are part of the child's acquisition of the li. interaction between li and l2 does, however, continue, and it must be acknowledged that l2 acquisition is not a linear process. 2.2 sequential acquisition in older school-aged children. increased age, cognitive maturity and extensive language experience are variables which can enhance the language acquisition in older children. according to kessler (1984), other variables such as increased awareness of the separateness of the two language systems, differences in the language environment, differences in language input, as well as awareness of the affective environment in combination with the more highly developed affective filters also influence language acquisition at this level. here, literacy, learning and writing become crucial aspects of l2 acquisition. cummins' conceptualisation of communication proficiency (1981, in skinner, 1985a) has relevance for understanding language acquisition in older children (see table 2). the developmental nature of language acquisition from context-embedded basic interpersonal communication to cognitively demanding tasks in context-reduced settings must be acknowledged. according to cummins (1981, in kessler, 1984), cognitively-academic language is crosslingual and thus applicable to any language context, li or l2. this means that language proficiency on this level, although mastered in li, will carry-over to l2, when sufficient l2 code is available. learning a second language for school use is a task that imposes its own specific demands. the child must become aware of language as a separate structure and learn how to use it in context-reduced forms. this has important implications for l2 reading and writing ability as the child must write or understand a message correctly without recourse to contexts available through face-to-face encounters of spoken language. kessler (1984) has emphasised that differentiation between context-embedded and context-reduced and cognitively demanding and cognitively undemanding tasks outlines a critical distinction between l2 development in the pre-school years and l2 development at school. 2.3 sequential acquisition in adults. second language acquisition in adults can be understood with reference to sequential bilingualism. krashen's (1982) approach to second language acquisition is most suitable for the adult language learner. adults often appear to be more efficient language learners, possibly due to greater cognitive maturity and better metalinguistic skills. affective variables are also crucial in the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) b i l i u a i n : theoretical perspectives of language diversity language acquisition at this level. the language learner must have a positive attitude toward the language and feel confident within the language environment. biological factors, cognitive factors and social factors thus interact in providing optimal conditions for adult language learning. code-mixing and codeswitching have also been observed in adult second language learners. summary the above discussion of second language development indicates that complex interactions of various factors related to the individual language learner, the language environment and the nature of language input determine optimal conditions for language learning. it is proposed that these conditions must be understood within a particular theoretical framework, suitable to unique conditions of a particular bilingual situation. all these factors emphasise that second language acquisition is not a predictable, even process. the process is, according to miller (1988), open to influences from external (environmental, nature of language input, role of first language) and internal (affective, personality, cognitive-linguistic maturity at onset of acquisition) factors. conclusion the aim of this paper was to describe bilingualism and second language development in children and adults. different theoretical perspectives were explored and facilitating factors in the acquisition of a second language were discussed. the discussion highlighted the complexity ofbilingualism and emphasised that an understanding of second language acquisition should focus on the relation between language structures and language use within a particular bilingual community. communicative competence, language proficiency and aspects related to the language environment were emphasised as important underlying concepts to second language acquisition. a holistic approach to bilingualism was proposed. it is clear that speech therapy and audiology professionals in south africa must become(more aware of the implications of working in multilingual and multicultural settings. a great deal of diversity is presentjin the languages used in south africa. bebout and arthur (1992, p.45) have emphasised that "professionals need to become cross-cultural communicators in order to provide adequate services when working with a culturally and linguistically diverse population". this has important implications for the evaluation of a child's language abilities. professionals working within multicultural, multilingual contexts must therefore become knowledgeable concerning the interaction of li and'l2 within bilingual communities. furthermore, the cultural factors relevant to any specific bilingual situation, for example english/afrikaans as opposed to english/zulu, must be recognised. greater understanding of the complexity ofbilingualism within a particular cultural context, and knowledge of the theoretical issues involved in second language acquisition will enable speech therapy and audiology professionals to meet the needs of each unique bilingual situation within the south african context. as indicated by miller (1984a, p. 7), favourable contexts for the acquisition and use of languages will be societies where "pluralism is tolerated, preserved or even encouraged". acknowledgements this paper evolved from an assignment submitted to the university of pretoria as part of a post-graduate study programme. the valuable comments from prof. erna alant (university of pretoria) and mrs glen jager (university of durban-westville) are noted with appreciation. references bebout, l. & arthur, b. (1992). cross-cultural attitudes toward speech disorders. journal of speech and hearing research, 35, 45-52. ben-zeev, s. (1984). bilingualism and cognitive development. in n. miller (ed.), bilingualism and language disability: assessment and remediation. london: chapman and hall. dodson, c.j. (1985). second language acquisition and bilingual development: a theoretical framework. journal of multilingual and multicultural development, 6 (5), 325-345. dornyei, z. (1991, january). krashen's input hypothesis and swain's output hypothesis in practice: designing "i+1" teaching techniques. usis pretoria english teaching office newsletter: english teaching forum, 33-35. genessee, f. (1988). bilingual language development in pre-school children. in d. bishop & k. mogford (eds.), language development in exceptional circumstances. edinburgh: churchill livingston. kessler, c. (1984). language acquisition in bilingual children. in n. miller (ed.), bilingualism and language disability: assessment and remediation. london: chapman and hall. krashen, s.d. (1982). principles and practice in second language acquisition. oxford: pergamon press. krashen, s.d. & terrell, t.d. (1983). the natural approach: language acquisition in the classroom. california: alemay press. mccollum, p.a. (1981). concepts in bilingualism and their relationship to language assessment. in j.e. erickson & d.r. omark (eds.), communication assessment of the bilingual bicultural child. baltimore: university park press. miller, n. (1984a). language use in bilingual communities. in n. miller (ed.), bilingualism and language disability: assessment and remediation. london: chapman and hall. miller, n. (1984b). language problems and bilingual children. in n. miller (ed.), bilingualism and language disability: assessment and remediation. london: chapman and hall. miller, n. (1988). language dominance in bilingual children. in m.j. ball (ed.), theoretical linguistics and disordered language. london: croom helm. schiff-myers, n.b. (1992). considering arrested language development and language loss in the assessment of second language learners. language, speech and hearing services in schools, 23, 28-33. skinner, d. (1985). access to meaning: the anatomy of the language/ learning connection. part i. journal of multilingual and multicultural development, 6 (2), 97-116. skinner, d. (1985). access to meaning: the anatomy of the language/ learning connection. part ii. journal of multilingual and multicultural development, 6 (2), 369-388. terrell, b.y. & hale, j.e. (1992, january). serving a multi-cultural population: different learning styles. american journal of speech language pathology, 5-8. williams, j.d. & snipper, g.c. (1990). literacy and bilingualism. new york: longman. die suid-afrikaase tydskrif vir kommunikasieafykins, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) f" «ν^τ"'5 talking to professionals the needier westdcntr organisation p.o. box 28975 sandringham 2131 telephone (011) 485-1302/3/4/5 mm p l a y m a n d • j s c h o o l r o o m shop 6l the rosebank mews 173 oxford road rosebank jhb. play & s c h o o l r o o m , specialists in the field of child education have been offering assistance to both professionals and parents for nearly thirty years. their expertise and advice range through preschool education, perceptual training, primary and remedial education and adult education. play and schoolroom are sole agents for learning development aids which include an excellent selection of materials of interest to the speech therapist. they also offer an interesting range of aids and books to foster and develop language and communicative skills. their stock of educational books and toys is exceptionally wide. you are invited to view their superb range in their new beautifully laid out showroom phone 788-1304 fax: 880-1341 po box 52137 saxonwold 2132 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 elsie μ. schoeman and david p. fourie being all ears: a systemic perspective on the role of the psychologist in cochlear implantation elsie m. schoeman and david p. fourie university of south africa abstract for those hearing-impaired individuals who do not derive any benefit from hearing amplification, cochlear implantation sometimes provides a useful alternative. recently cochlear implant teams started to incorporate psychological services, mainly as a means to evaluate candidates as to their suitability to receive implants. this paper shows that cochlear implants can have serious and wideranging repercussions for the implantee and/or for the family, sometimes necessitating psychotherapeutic services. a case study is provided to illustrate the need for a much wider role for psychotherapeutic services and to also demonstrate how the adoption of a systems perspective can be of value to the therapeutic process. key words: cochlear implants, hearing loss, systemic perspective, case study, role of the psychologist/psychotherapist. introduction hearing loss is arguably one of the most devastating forms of sensory deprivation (wagenfeld, 1987). not only does hearing loss interfere with the ability to perceive sounds in the environment but, if present from birth to a significant degree, it also prevents the acquisition of speech and more importantly, language, unless treated actively and continuously. while huge strides have been made in the treatment of various forms of hearing loss, there is an unfortunate group of patients who have a profound hearing loss and who derive minimal or no benefit from amplification. research involving cochlear implants originated in an attempt to provide these patients with an alternative sensory device (millar, tong & clark, 1984). cochlear implants have been used to treat both adults and children with profound bilateral sensorineural hearing loss by hearing health professionals for more than a decade. the effectiveness of these devices varies and is dependent on a number of factors. although the implant enables the hearing-impaired person to hear better, it does not cure the hearing impairment. the process of cochlear implantation is a complex one. human qualities like emotions and expectations influence the process and can determine the success of the implant. hence hearing and hearing impairment play a major role in the intrasystemic as well as the intersystemic functioning of a person. advanced technology will no doubt lead to more and more cochlear implants, with younger and younger children as recipients. promotion of optimum development of such children requires that cochlear implants be seen not as a single event but as an intervention that has developmental implications that unfolds over time. the field of cochlear implants is relatively new and research has been conducted mainly in the areas of audiology, speech therapy and surgery. very little work has been done on the psychology of cochlear implantation. cochlear implant teams traditionally incorporated psychological services, but mainly to evaluate prospective implantees for the surgical procedure. it is the aim of this paper to show that cochlear implants can have wide ranging psychological and systemic implications necessitating psychotherapeutic interventions going far beyond such prior evaluation of implant candidates. in doing so, the paper will adopt a systemic perspective to illustrate the role of the psychologist/psychotherapist within the cochlear implant team. the systemic perspective the systemic perspective refers to the cybernetic theory of systems that provides an abstract framework for the observation of human behaviour (simon, stierlin & wynne, 1985). it holds that natural systems or groups or persons, such as an individual, family, or a larger social network, are always part of still larger systems. systems also consist, of smaller systems called subsystems. thus, any system containing an individual or group of individuals is simultaneously a whole unto itself and a part of a larger whole. harvey (1989) illustrates this with the following example: depending on our frame of reference, an individual can be viewed as a complete entity, as the sole object in our perceptual field, or as one part of a family; a family can be viewed as a complete entity, as part of a neighbourhood, or as part of an informal network system. there are thus many levels of organisation in human experience, from the subatomic particle and living cell, to complex organs and organ systems, to whole persons, to families, to communities, to cultures,jand to larger societies. we speak of a hierarchy of biopsychosocial systems to refer to systems that are both a "whole" and a "part". according to bronfenbrenner (1979) these differing system levels appear to be arranged hierarchically, with each level more complex than the one before and encompassing all those that come before it. he has depicted this hierarchy as a set of nested structures, like a set of russian matrioschka dolls, each encompassing the other. from the systemic perspective, an individual and his/her family are viewed as systems within a biopsychosocial hierarchy and the behaviour of these systems is described by tracking the changes that occur within that system and its subsystems, and the system as a larger whole. stated more technically, an individual and family, or family and informal network, are seen as systems of differing logical types within the biopsychosocial hierarchy (keeney, 1983). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) being all ears: a systemic perspective on the role of the psychologist in coclear implantation 17 consequently behaviour of any given system can only be properly understood by tracking changes that occur within that system and its subsystems and by tracking changes between that system and the larger whole. thus, there is a need to "step back" and perceive all systems interacting with each other. the functioning of the larger system cannot be inferred by simply observing each of its members (subsystems) separately (atomism); the whole (gestalt) is qualitatively and "behaviourally" different from the sum of the system's individual elements (harvey, 1989). this wider framework views behaviour as inherently part of reciprocal, circular interplays between environmental conditions and intrapsychic processes. this circular causality (hoffman, 1981) implies that environmental change leads to intrapsychic change that in turn, leads to environmental change. circular causality is in contrast to a linear idea of causation, which focuses on one direction of linear causation event a —• event β —• event c —• circular causation event a f \ event d event β \ y event c figure 1: linear causation and circular causation change; either the environment causing individual change, or individual change causing .environmental change (harvey, 1989). see figure 1 for an illustration of the difference between linear and circular causality, j organisms relate on interand intrasystemic levels and the hearing-impaired are no exception. if a person is diagnosed with a profound hearing loss] or if a person received a cochlear implant, it will not only affect the diagnosed person, but also the family and friends who! form part of the systems of the hearing-impaired person. ; the following is a brief discussion of those intersystemic levels, or nested structures, which are most relevant to the study of hearing-impaired people (harvey, 1989). family the family is the main environment for the developing child, particularly the young child. the family's behavioural patterns, conceptions of hearing loss, emotional responses to the loss, interactions with the child and so on, all exert powerful influences on development. in a reciprocal manner, family development is powerfully influenced by the child and by the demands of raising a deaf child. in this sense, the child influences everything from the use of time and space to financial arrangements, travel patterns, patterns of communication among all family members, and even the family's image of itself— as well or not well, competent or incompetent, and nurturing or not nurturing. in this circular view of causation the hearing-impaired child is seen to influence, and simultaneously and reciprocally be influenced by parents, hearing siblings, grandpareiits, and extended family members. professional as with disabled or chronically ill people, many hearingimpaired clients have extensive and often intense relationships with a number of professional systems, including educational, medical, audiological and other service agencies. for each ramification of hearing loss, there is often a corresponding professional system that can be more or less relevant at the different stages of the deaf client's life. for example, physicians tend to be important early on, with school systems later becoming more influential forces. harvey (1989) pointed out that professional systems and their relationships with family members may become patterned and rigid over time and thereby exert an ongoing influence on the family. for example if parents differ in their attitudes toward plans for their hearing-impaired child, a particular professional's advice can tip the scales. continued support for one parent's position over that of the other can exacerbate a split between the parents. alternately, continued support and guidance toward the child can undermine parental authority, as when a professional exclusively meets with the child, while covertly assuming that he or she does a better job at parenting than the child's actual parents. the undermining of parental authority may also emerge in the relationship between schools, parents, and children when the school and parents compete about being in charge of the child (bodner-johnson, 1986). the interpersonal patterns that emerge between parents and professionals may become so powerful that the boundary between these two systems virtually disappears. therapeutic efforts to help the hearing-impaired child and his or her family are frequently impossible unless the way that professional systems reinforce family patterns, and vice versa, are also addressed. informal informal networks made up of friends and acquaintances of both the child and parents can exert strong influences on family development and thereby on the development of the individual child. the support parents receive may play a role in how well they cope informal networks made up of friends and acquaintances of both the child and parents can exert strong influences on family development and thereby on the development of the individual child. the support parents receive may play a role ni how well they cope with the extra demands a hearing-impaired child may place on them. these networks reinforce functional and family patterns and play an increasingly important role in the development of such individuals, particularly during adolescence, since this is the time the developing child associates with those who demonstrate the identity traits the child longs to emulate. cultural the way a particular culture or subculture views being deaf through its political processes and the manner in which that the south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 elsie μ. schoeman and david p. fourie culture provides for such persons, exerts a major influence on the development of each child (higgins, 1980; lane, 1984; sussman, 1976). with reference to deafness, moores (1982) reported "most of deaf people's problems are caused by the dominant society. deaf people have survived and endured in the face of an indifferent world that must be dealt with daily" (p. 141). people who have received cochlear implants, and parents who have children with implants can provide a vital support network for diverse human needs, such as exchange of information and social/emotional support. biological biological factors are important, including the etiology of the hearing loss, the age of onset, the degree of hearing loss, the rate of loss, prognosis for continued hearing loss or gain, the configuration of the audiogram across the speech range, and the amount of residual hearing. there may be related medical conditions in addition to hearing loss, depending on etiologic factors. psychological the particular characteristics of an individual have a great influence on how he or she adapts to being hearing-impaired and on how the hearing loss is treated by his/her family, school and greater society. although such children may well pass through some common and identifiable stages of development, each will do so in a unique manner coherent with his or her personality (palmer, 1970). interaction of the systemic levels all of these system levels comprise the context in which symptomatic behaviour is embedded. it is not enough to say that "it is a problem" or "it is an individual problem" for as was described earlier, a "whole" is simultaneously a "part". consequently, it is necessary to thoroughly understand the interactional patterns within and between each system level in order to provide effective treatment. as bateson (1971) stated, "if you want to understand some phenomenon or appearance, you must consider that phenomenon within the context of all completed circuits which are relevant to it" (p. 244). the systemic perspective or cybernetic theory offers the clinician a more precise map of the interrelationship of symptoms and context. the qualities of systems stability and change cybernetics is based on the complementary relationship between stability and change (keeney, 1983). change is necessary for stability; stability is necessary for change. the theory posits that living systems maintain their form throughout processes of change. this ability of a system to remain stable in the context of change and to change in the context of stability is defined by the concepts known as morphostasis and morphogenesis. morphostasis describes a system's tendency towards stability, a state of dynamic equilibrium. morphogenesis refers to the system-enhancing behaviour that allows for growth, creativity, innovation, and change, all of which are characteristic of functional systems (becvar & becvar, 1996). keeney (1983) illustrated this process by describing a tightrope walker who makes frequent adjustments to achieve balance on the high wire. without these constant yet almost imperceptible changes, the acrobat could not maintain stability on the wire; without this stability, the acrobat could not perform the pattern of changes. the complementary nature of change and stability is also central to evolutionary processes and to the development of new structures in systems. for example, in order to maintain stability, a family must constantly adjust to internal and external changes, such as the developmental changes of its members, diagnosed disabilities of a member, a change of jobs and other environmental changes. a family must constantly adjust to changes within and between the systems' levels of the biopsychosocial field in order to remain stable (harvey, 1989). changes at any level influence the other levels as a partial function of temporal factors. this process is described by the concept of co-evolution. according to bateson (1972), coevolution begins when one system level adapts in reaction to disequilibrium at the same level or at another level. internal and/or external forces may impose the disequilibrium. when a change at one system level affects, and is affected by changes at other levels, the systems are then said to co-evolve with each other. for example, a change in a child's physical symptoms (the biological level) is related to a change in how a child feels (the psychological level), which is related to a change in how the parents relate to each other (the family level), which is related to a change in how the professional helpers relate to the family and to each other (the professional level), and so forth. all of these levels are said to co-evolve with each other (harvey, 1989). recursive cycle within cybernetic theory, the concept of the recursive cycle helps us to track the co-evolutionary relationships occurring among the multiple levels of a complex ecological field (dym, 1987; harvey & dym, 1987, 1988). a recursive cycle is a sequence of interactions that, like keeney's tightrope walker, constantly adjusts to new conditions by processing new information in order to maintain stability. at any given time, the clinician may focus on a specific system level to the temporary exclusion of other levels. for example, at one particular time, the clinician may perceive psychological and communication factors of the hearing loss as more important and thereby perceive other variables as less important, or vice versa (harvey, 1989). the clinician not only continually shifts his or her perception within the ecological field, but also generates hypotheses about the relationships among several variables and system levels, which include the presenting problem. these relationships are conceptualised by the recursive cycle. the systemic model posits that the behavioural and emotional characteristics that may be presented by many hearingimpaired clients have come about, are supported, and are reified as a function of the interaction within and between system levels across time. furthermore, they are context based. the systemic perspective offers the clinician several choices about how, when, and where to intervene in the context of the biopsychosocial field. phenomena at different levels of the die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) being all ears: a systemic perspective on the. role of the psychologist in coclear implantation 19 ecology involve biological, psychological, familial, informal network, professional, and cultural influences that co-evolve with each other. therefore, modification at one level will influence, and be influenced by, all other levels to varying degrees. intervention at one particular level may well exert a "ripple effect" across several other levels, and therefore may be the optimal point of intervention. alternately, all the system levels may reinforce each other like glue to preclude effective intervention at any one level, and therefore may require simultaneous or sequential interventions at several levels. the role of the psychologist until recently, not many cochlear implant teams incorporated psychologists/psychotherapists as part of the team. if a psychologist was involved, it was mainly to evaluate and to determine if the cochlear implant candidate was psychologically balanced enough to be able to adjust to the implant and also to exclude any other potential psychopathology. this role is a restricted one. the following case study is presented to illustrate that the role of the psychologist can be more comprehensive. in the case description, pseudonyms are used to protect the family's anonymity. case study: a hearing impaired family the therapist first saw the b. family to evaluate 2-year-old mary for a possible cochlear implant. the mother (lui'sa), father (gregory), brother (sam, 6yrs) and maternal grandmother accompanied mary. the following information was presented: lui'sa contracted rubella while she was pregnant with mary. it was a difficult pregnancy and mary was bom by means of a caesarean section. mary had a weak immune system and easily contracted illnesses. at the age of one month, the family suspected that mary was hearing-impaired. they took her to a paediatrician and at the age of six months a serious sensorineural hearing loss was diagnosed. she received hearing aids at eight months. because of financial reasons, lui'sa had to work full-time. the maternal grandparents decided to move in with the family so that the grandmother could assist with mary's rearing. at this stage mary's brother, sam, was six years of age. the cochlear implant team approved the family and mary, and she subsequently received an implant. prior to the implant there was an article about maiy in'the local newspaper and the family put a lot of energy and time into fundraising to be able to afford the cochlear implant. a year later, lui'sa contacted the therapist and an appointment was scheduled. this time, it was not mary who was seen as the person with a problem, but her brother, sam. lui'sa, gregory, mary, sam and the maternal grandmother were present at this interview. nobody mentioned the grandfather. on inquiry from the therapist, the grandfather was described as a quiet person and not very involved with the rest of the family. lui'sa voiced most of the complaints while the grandmother contributed some of the time. gregory sam's father was, as in the previous interview, quiet and did not contribute much. the family situation was as previously the grandparents were living with the family, lui'sa was in full-time occupation and gregory had begun to work after hours to supplement the family's income. complaints relating to sam included the following: sam experienced problems at school which was in contrast to the previous year, when he seemed to have fared quite well. according to his mother, sam showed signs of disobedience and often cried when he felt that the adults did not want to help him or attend to him. he was willful and told lies. he often verbalised that his parents did not love him. his sister did extremely well with her implant and the grandmother referred to her as "brilliant" and a "star". during the session the two children were playing with toys that the therapist provided in the room. on several occasions mary would take a specific toy from sam. if he complained or tried to retrieve it, his mother or grandmother would scold him and tell him to be good to his sister because of her hearing impairment and therefore her lack of understanding at times. five monthly sessions of family therapy were scheduled. during the first two sessions, the therapist and the family tried to explore and describe the complexity of the problem. sam was the identified patient and there were definite behaviour problems on his side. mary, the cochlear implantee, was the obvious favourite within the family and ignored any efforts to discipline her. there was more than one mother figure as well as an absent father figure. a consistent daily-routine seemed absent in the household. the boundaries within this family were diffuse. involvement of the grandparents, and specifically the grandmother, seemed to complicate the boundaries between the mother and father, as well as between the parents and siblings. the way lui'sa and her mother spoke to one another and talked about gregory instead of with him, suggested a coalition between them. such a coalition might have undermined gregory's authority, which could explain his reserved manner. although the grandfather was absent, the therapist suspected that a similar communication pattern existed between lui'sa, and her mother and father. of further interest, was the particular order in which the members took their seats during the initial sessions. the grandmother and lui'sa sat next to each other. between them and gregory was an open space. the children moved in and out as they were playing on the side of the grandmother and lui'sa. the metaphor of a hearing-impaired family gradually took shape. all the attention and energy were focused on mary, but sam was not "heard". in a symbolic way, sam was shouting for attention by creating all kinds of behaviour problems but nobody in the family seemed to "hear" him. his behaviour gave him some form of attention from the adults in his family and this supplied him with a certain identity. furthermore, the voices of the male authority figures in the family seemed not to be heard either, while the voices of the mother, grandmother and most of all that of mary, could be heard loudly and clearly. mary received constant attention, she received speech therapy, went for "mapping" (the programming of the speech processor) sessions at the cochlear implant clinic, all the friends asked about her well-being and people could even read about her in the local newspaper. in addition, sam possibly sensed that his father's authority was being undermined, which could perhaps account for his challenging behaviour towards authority evident in his disobedience and wilfulness at home and at school. in a picture sam was asked to draw of his family, the father figure was shown as big and prominent with an open the south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 elsie μ. schoeman and david p. fourie grandmother i / father mother 1 children figure 2: this map shows the coalition between the grandmother and mother against the father as well as the diffuse boundaries in the family. mouth shouting swear words. this depiction was opposite to the impression the therapist had formed about the father during the sessions. sam could have been expressing the father's underlying aggression or he could have been expressing his own aggression towards the absent father figure. the therapist reframed the problem by composing a structural map of the family. the map is depicted in figure 2. this is a three-generational family and the key issues were: who were the children's parents? was the mother the grandmother's "child", and thus more of a peer and less of a parent to her own children? were they competing for the role of primary parent to the children? was there a parental coalition between grandmother and child to the detriment of the role of the father? by the end of the second session, the therapist decided to intervene in a manner that would perturb the current family structure, to initiate change in the coalitions as described. this interaction involved asking gregory to bring his wife, son and daughter to the next session and to leave the grandmother at home, seeing that she was already working so hard during the week. the therapist reframed it as allowing the grandmother time-out from the family and thereby opening the possibility that she could spend more time with her husband. in doing this, the message implied by the therapist was that gregory was the head of the family and that a change in the definition of his role in the family was required. the assumption made by the therapist was that, should the father's "voice" again be "heard", it could contribute to a realignment of boundaries within the family. in a non-threatening way it also sent a message to the grandmother that her children were able to care for themselves. lui'sa needed support to care for the children and the grandmother it seemed, bestowed the necessary love and warmth. this kind of necessary energy spent by the grandmother in support of the mother was not defined as negative for it did serve a purpose. sam's presenting problems indicated that the time had come for the family to redefine their roles. in the third session, lui'sa reported that there was an improvement in sam's schoolwork but that he still told lies. he also wanted to sleep between his mother and father and he did not want his sister, mary, to attend the family therapy sessions. this was a good example where the change in the family's functioning was followed by stability, in the sense that, although sam's behaviour changed, there were still "hearing" problems in the family. it also showed the symptoms as expressions of ambivalence (fourie, 2003). sam "shouted" but in such a way that he was still not "heard". the therapist requested from the parents their explanation for the behaviour of their son. this enquiry was a way of recognising the parents as the experts in the upbringing of their children. it also relieved the therapist of the expectation to "heal" the family. this process was also congruent with the structural viewpoint (minuchin, 1974) of the need for the parents to form a strong subsystem. in response to the therapist's question, gregory realized that he might not have spent enough time with sam. the opportunity for the therapist to discuss the "hearing impairment" in the family had opened up. it also presented an opportunity to gain clarity on how the parents perceived their different roles. lui'sa responded by expressing the need to be more of a mother figure to the children, not only to nurture, but also to spend more fun time with them. she also said that she knew it would be better if her parents could live in their own place, instead of living with them in the same house and she was aware of the fact that she, her husband and two children did not spend enough time together as a family. she also mentioned that gregory might sometimes feel overwhelmed by the presence of his mother-in-law, and she knew that sometimes she and her mother tended to make decisions without consulting him. thus she indicated an awareness of the need for change concerning their situation, as well as a readiness to realign the boundaries within the family. in responding to this, it was clear that gregory was cautious not to hurt his wife's feelings. he realised that his mother-in-law was a big help to them in their situation but that he also had a need for them to spend time on their own. according to lui'sa they had considered building a separate apartment on their premises for the grandparents. the grandparents could still take care of the children till five o'clock in the afternoon. when lui'sa arrived home from work, the family could then spend time together without the grandparents. lui'sa and gregory continued to discuss the possibilities of being involved in more family activities without1 the grandparents. gregory suggested activities where he could involve sam, for example sam could spend time with him somej of the evenings while he was working. his evening job was 1 fixing cars in his garage at home. the therapist continued to ask j him about his own activities and interests and also about his | perception of sam and of sam's interests. the intent was, once ι again, to confirm gregory's important role as a father figure in ι sam's life and as the person who had the knowledge to give his son what he needed. the parents and the therapist then went on to explore other possibilities of spending time with sam. lui'sa suggested that she sit with sam in the evenings while he took his bath. thereafter she could also read him a bedtime story while gregory spent time with mary. during the conversation, sam stopped playing and came to sit on his father's lap. he expressed his love for cars and motorbikes, just like his father. sam's non-verbal and verbal behaviour seemed to express a need to be closer to his father. the therapist ended the session by commenting in a positive way on the parents' need to be more involved with their children and on the ways they already cared for the family. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) being all ears: a systemic perspective on the role of the psychologist in coclear implantation 21 only sam and gregory attended the fourth session. lui'sa had to work and was unable to attend. gregory said he felt it was an opportunity for him and his son to be together and that had they left mary at home with the grandmother. they were also planning to attend an air show after the session. the change in gregory was remarkable. he talked much more than in any of the other sessions. sam. too, was different. he seemed excited and energetic. he would alternate between playing with the toys and sitting on his father's lap. the therapist asked him to draw a picture of the family (the same task she gave him during the first session). he drew a picture of the family but with his grandmother and grandfather separate in the top part of the house. gregory told the therapist that they had started building an apartment for the in-laws and that they were all very excited about that. he also mentioned that he and sam managed to spend more time together. sam did not display the earlier wilful and disobedient behaviour. he still liked to tell fantasy stories in which he played the main character as if it were the truth. the task of the therapist during this fourth session was mainly to confirm and reinforce the new behaviour patterns between father and son. this confirmation and reinforcement is part of structural family therapy, where praise is given for performing an action in order to help the family members feel confident in themselves and for them to realize that they are capable of doing what needs to be done. the therapist also gave sam and gregory an assignment to work on together in the therapy session. in the follow-up session two months later a strong bond between sam and gregory was evident. gregory was more outspoken than earlier. the family was still in the process of building an apartment for the grandparents. lui'sa, gregory, sam and mary attended this session. gregory announced that the grandparents went to visit their other children in another city. sam seemed to be happy and relaxed and his parents mentioned that they did not experience any of the earlier behaviour problems with him. the boundaries and the communication in the family, as illustrated in figure 3, seemed to be clear and an effective hierarchical structure seemed to be in place. figure 3: a structural map of the family after therapy. mother (m), father (f), grandmother (gm), grandfather (gf) and grandchildren (gchildren). all individuals are equally respected and clear boundaries exist in the family. discussion of the therapy during the first two sessions it was clear that the diagnosis of deafness in the daughter affected the whole family. the parents went to extremes to try to restore her hearing through a cochlear implant. possible guilt feelings manifested in the way they handled the other sibling, sam. he had to accommodate the hearing impairment in his sister at the cost of his own needs. the grandmother involved mary in all kinds of therapies in order for her to be "normal". lui'sa left more and more of her responsibilities to the grandmother. the family showed a tendency to over-protect the hearingimpaired child at the cost of the other sibling. the other members of the cochlear implant team perceived the implant as a huge success, as mary was doing so well with the implant. they focused on the hearing and the performance of the little girl according to measurable standards. this improved hearing was the positive side on the other hand, the cochlear implant and all the aspects surrounding it, contributed to changes in the family's overall situation. the presence of the grandparents and the nature of communication in the family complemented the specific situation in the family where the voice of mary was heard but not the voice of sam. the above is an example of how the change in one member of the family, through a hearing impairment or a cochlear implant, had an effect on the rest of the family system. in this case, the behaviour of sam could only be fully understood when the therapist "stepped back" and perceived all the subsystems interacting with each other. the circular interplay was clear: the diagnosis of hearing impairment and the cochlear implant in the one sibling affected the family, which impacted the behaviour of sam, which in turn altered the family's behaviour. the intervention of other professionals, such as the speech therapists and audiologists, affected the family system and contributed to sam's feelings of being ostracised. even the informal networks, such as the friends and acquaintances, reinforced the focus of attention on the implanted child, thus in a way excluding the other sibling. conclusion it is clear from this case description that cochlear implants can have a much wider impact than merely improving the hearing and the quality of life of the implantee. occasionally, unforeseen and sometimes negative intraand/or intersystemic effects can and do come to the fore. a successful surgical implant and subsequent audiological adaptation do not necessarily constitute the end of the involvement of the cochlear implant team. confining the role of the psychologist/ psychotherapist, as part of this team, to the prior evaluation of prospective implantees is therefore short sighted. assessment and intervention can and should proceed throughout the period of post-implant rehabilitation. while we do not suggest a fixed way of working with cochlear implantees and their families, it is increasingly clear that such assessment and intervention should encompass as wide a perspective as possible. a systemic approach was followed and proved favourable. μ f gm gf children gchildren the south african journal of communication disorders, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 elsie μ. schoeman and david p. fourie 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(1971). a systems approach. family therapy: critical evaluation. international journal of psychiatry, 9, 242-244. bateson, g. (1972). steps to an ecology of mind. new york: ballantine. becvar, d.s., & becvar, rj. (1996). family therapy: a systemic integration. massachusetts: allyn and bacon. bodner-johnsen, b. (1986). the family in perspective. in d. m. luterman (ed.), deafness in perspective (pp. 225239). san diego, ca: college-hill press. bronfenbrenner, u. (1979). the ecology of human development. cambridge, ma: harvard university press. dym, b. (1987). the cybernetics of physical illness. family process, 26, 9-21. fourie, d.p. (2003). limited options: symptoms as expressions of ambivalence. american journal of family therapy, 31, 51-59. harvey, m.a. (1989). psychotherapy with deaf and hard-ofhearing persons: a systemic model. new jersey: lawrence erlbaum associates, inc. harvey, ma., & dym, b. (1987). an ecological view of deafness. family systems medicine, 5, 52-64. harvey, m.a., & dym, b. (1988). an ecological perspective on deafness. journal of rehabilitation of the deaf, 21(3), 12-20. higgins, p.c. (1980). outsiders in a hearing world: a sociology of deafness. beverly hills, ca: sage publications. hoffman, l. (1981). foundations of family therapy. new york: basic books. keeney, b.p. (1983). aesthetics of change. new york: guilford. lane, h. (1984). is there a "psychology of the deaf'? paper presented at the office of special education programs. conference of research project directors, boston, ma. millar, j.b., tong, y.c., & clark, g.m. (1984). speech processing for cochlear implant prosthesis. journal of speech and hearing research, 27, 280296. minuchin, s. (1974). families and family therapy. cambridge, ma: harvard university press. moores, d.f. (1982). educating the deaf: psychology, principles and practices (2nd ed.). boston, ma: houghton mifflin co. palmer, j.o. (1970). the psychological assessment of children. new york: wiley. simon, t.b., stierlin, h., & wynne, l.c. (1985). the language of family therapy: a systemic vocabulary and sourcebook new york: family process press. sussman, a.e. (1976). attitudes towards deafness: psychology's role past, present and potential. in f.b. crammette & a.b. crammette (eds.), vii world congress of the world federation of the deaf (pp. 154168). washington, dc: national association of the deaf. wagenfeld, d.j. (1987). cochlear implants. south african medical journal, 72, 452-454. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 51, 2004 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) biofeedback a n d stuttering dr. e. gordon ( m b b c h . bsc. h o n s ) baragwanath hospital johannesburg dr. a. gordon, ( m b b c h . ) l. gordon, b . a . ( s p & η τ η ) witwatersrand μ. shapiro, b . a . ( s p & η τ η ) witwatersrand μ. mentis, b . a . ( s p & η τ η ) witwatersrand μ. suchet, bsc ( h o n s . ) witwatersrand summary electromyographic biofeedback was used to reduce tension and enhance control of the speech associated muscles, resulting in a reduction of the frequency of stuttering. five sessions were conducted over a course of three weeks. a mild, moderate and severe stutterer were assessed. a decrease in stuttering frequency was seen in each subject from pre to post biofeedback sessions on both a descriptive and an inferential level. opsomming elektromiografiese bioterugvoering is gebruik om spanning te verminder en kontrole van die spraakspiere te bevorder. drie proefpersone met verskillende grade van hakkelsimptome is geevalueer. 'n vermindering van hakkelfrekwensie is in elke proefpersoon, van pretot post-bioterugvoeringsessies op twee verskillende vlakke waargeneem. biofeedback therapy is the technique of monitoring, feeding back and thereby learning control of involuntary physiological responses, or learning more sophisticated control over voluntary responses. a simple diagramatic representation of a biofeedback loop is delineated below. any physiological parameter e.g. the tone of the speech related muscles, are monitored via the biofeedback machine. the response is amplified and converted into a visual and/or audial display, which is easily interpreted by the subject. the subject gains an impression, from the display, of e.g. the tone of speech muscles. it is via this feedback that the subject may learn to re-educate these muscles. the new physiological response is learnt through operant conditioning. a u d i t o r y o r v i s u a l d i s p l a y s u b j e c t e . g . m u s c l e t e n s i o n m a c h i n e die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 106 ε. gordon et al the reward is the sense of success which is able to be interpreted via the biofeedback machine.6' 7 biofeedback therapy has a wide range of applications including e e g , cardiovascular, neuromuscular and gastro-intestinal behaviour modifications. stuttering is considered by numerous researchers to be accompanied by spasm of the laryngeal muscles (van r i p e r , 1 2 ) . a pilot study by richmond et al (1975) reported that auditory biofeedback of laryngeal muscle tension reduced stuttering in a single subject. the study demonstrated that there was an intimate relationship between laryngeal tension arid stuttering. electromyographic investigations by freeman and ushijima (1975) lend support to the hypothesis that the laryngeal behaviour associated with certain of the stutterings, is related to simultaneous contraction of antagonistic laryngeal muscles. since speech is but part of the total mechanism of communication it is evident that the central co-ordination of speech movements will be involved with a variety of additional muscular activities associated with expression (e.g. facial, head, arm, hand movements) and that these may consequently be affected by factors causing disharmony in speech itself (dewar et al 3 ). using electromyographic recorders on the masseter muscles it has been demonstrated that there is an increase in muscle tension in stutterers as opposed to non-stutterers (williams,1 1; shrum, 9 , 1 0 ) . s h r u m 1 0 measured surface electrical activity of facial neck and chest muscles in stutterers. he observed a relationship between increases in electromyographic signal amplitude prior to speech and stuttering. stuttering was apparently preceded by an early and sustained rise in signal amplitude in almost all muscles studied. elimination of covert pre-utterance activity was achieved by employing an audible analog of electromyographic activity to train stutterers to begin speaking with nearly resting levels of muscle action potentials. if feedback is progressively reduced in learning situations, control may become a "proprioceptive" skill permitting unobtrusive and perhaps automatic maintenance of fluency (hefferline,5). the technical aspects of muscular action and of electromyography in speech research have been comprehensively dealt with in the literature (fromkin and ladefoged,4 ohrian et a l ., 8 buchthal2). / / m e t h o d o l o g y a i m to demonstrate that using electromyographic (emg) biofeedback, subjects can control the muscles related to speech and reduce the frequency of stuttering. the south african journal of communication disorders, vol. 28,1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) biofeedback and stuttering 107 s u b j e c t s the subjects were volunteers in response to an advert in the university newspaper. the subjects were adults ranging in age from 27 to 37 years and had a long history of stuttering with onset in early childhood. all subjects had previously received therapy at various stages in their lives. no subject had a prior knowledge of biofeedback. there was one female and two male subjects. subject a's stuttering pattern was characterized by infrequent cessation of vocal activity on the initial sound of the word. he was classified both by frequency and severity as a mild stutterer. subject b's stuttering pattern was characterized by sound and word repetitions and prolongations with a rise in pitch. she was classified as a moderate stutterer in both frequency and severity. subject c's stuttering pattern was predominantly characterized by deep inhalation associated with facial contortion, before initiating words. other stuttering symptoms were facial tremor, grimacing, flaring of nostrils and peripheral tension. subject c was classified as a severe stutterer in terms of frequency and severity. m a t e r i a l s a n d m e t h o d two model atlas 251a six function physiological data monitoring and feedback systems were used. for the purpose of this study the emg biofeedback was utilized. signals from two electrodes were collected, averaged and then converted into two types of feedback, a visual meter reading (an amp. meter) and a variable frequency audio tone. a reduction in the subject's tension produced lower meter readings and lower auditory frequencies. auditory feedback was received by the subject through an earphone. the muscle groups selected were: (a) peri-oral muscle groups. on these mimetic muscles the electrodes were placed onto the angle of the mouth. (b) the laryngeal muscle group. two surface emg electrodes were attached one on either side of the neck midline, approximately one cm superior to the thyroid cartilage, hereby assessing the laryngeal muscle group. a ground electrode was attached five cm below the elbow on the ulna bone. all three subjects read the same passage from a child's reading book. they were then asked to speak spontaneously. it is customary when estimating the frequency of stuttering moments to use the above two methods (aron 1 ). in addition the subjects described thematic apperception tests (tat). this was included in an attempt to measure the effect of biofeedback on stuttering while the subject was pre-occupied with creative thinking. all speech was tape recorded so that it could be transcribed and the die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 108 ε. gordon et al moments marked and studied by four testers. ratings of all items were based on frequency and not severity of stuttering. the counting of the stuttering moments constituted the basic measurements of the disorder. this was in accordance with sherman et al (1958), who compared three measures of stuttering severity, namely reading time, frequency moments of stuttering and scale values from listeners ratings. interrelationships were found to be statistically significant and the strength of the relationship was highest between the frequency counts and the rated severity. five sessions were conducted over a course of three weeks with equal intervals inbetween. the same clinical therapy rooms were utilized throughout. each biofeedback session consisted of one hour, subdivided in the following way: (i) a baseline stuttering frequency was assessed at the start and end of each session. the biofeedback equipment was disconnected during the baseline assessments in order to minimize the effect of distraction. (ii) in the initial 10 minutes of the first session the subject received a succinct explanation of the anatomy and physiology of the speech mechanism. the potential role of biofeedback in these muscle groups associated with stuttering was explained in an appropriate fashion. (iii) the aim of the first half of the biofeedback session was for the subject to master and reinforce the relaxation of the specific muscle group selected. (iv) the second half of the biofeedback session was to extend this relaxation training to the speaking situation. two therapists conducted each training session, alternating on a rotatory basis to minimize the effect of subject familiarity. results figures 1, 2 and 3 delineate the results obtained. the mean combined stuttering frequencies of reading, tat, and free speech, before and after biofeedback training, are seen in figure one. on a descriptive level a reduced stuttering frequency can be seen for each subject, from pre to post biofeedback training. subject a showed a decrease of 38,5%, subject β 35,6%, and subject c 26;2%. the mean decrease in stuttering frequency for the total samplcwas 33,4%. on an inferential level these decreases are statistically significant. in both the one way and two way analysis of variance a significant difference was found between pre and post biofeedback. this was significant at the 6,1% level. no significant difference was found at the 10% level between the different methods of analysis, nor between the sessions. ; figure 2 illustrates the cumulative mean results of each subject's stuttering frequency, measured at the beginning and end of each the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) biofeedback and stuttering 109 25 η 20 10 5 • before biofeedback after biofeedback β subject figure 1: the mean combined reading, tat, and free speech stuttering frequencies before and after biofeedback. a = b e f o r e b i o f e e d b a c k b = a f t e r b i o f e e d b a c k i l i a i l l b s e s s i o n n u m b e r figure 2: the cumulative mean frequency of stuttering/100 words, measured at the beginning and end of each session, over five sessions. session. on a descriptive level, the stuttering frequency carry over from the end of one session to the beginning of the next is intermittently reduced. however, on an inferential level, this carry over is not statistically significant. figure 3 illustrates the differences in the three methods of analysis of stuttering frequency (free speech, tat and reading). in all cases reading showed a marked decrease in relation to tat and free speech. this is especially noticeable in subjects β and c in which decreases were 73% and 78% respectively. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 110 ε. gordon et al pre post a β c 36 i f 4 > change ii iii a β c 40 73 78 a β c 46 3 2 ι 1 6 . 8 % 0 '7.0,2 t ii β subjects 21.c i (i) thematic apperception test (tat) (ii) reading (iii) free speech (figure 3 demonstrates the numerical and percentage change in mean frequency of stuttering/100 words from pre biofeedback programme to post biofeedback programme;) figure 3: a comparison of the three different methods of analysing stuttering frequency (free speech, tat, and reading). discussion pertinent to this report as a pilot study are additional subjective (patient and therapist) perceptions. most evident was subject c, in whom quantitative analysis yielded the least decrease in stuttering but in whom the stuttering pattern was markedly changed. the subject spoke in a more controlled manner and demonstrated a reduction of head shaking, deep inhalation and facial contortion. this would concur with the findings of dewar et al 3 . he noted that abnormal activity of the orbicularis oculi muscles concomitant with stammering was abolished at the same time as the speech disfluency, by larynx triggered auditory feedback masking. subject a, although demonstrating mild symptomatology, stated that he had benefitted from the programme and that his family had noticed an improvement in his speech. / subject b, felt that he had benefitted in that the relationship between tension and stuttering had been highlighted for him. he felt he was able to gain control of both general and focal tension areas. a positive influence was the encouragement he had received from his family, who expressed having noticed improvement in his speech. all three subjects strongly felt that maximum benefit would be derived from a more intensive programme. stuttering has been reported to be the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) biofeedback and stuttering 111 under stimulus control. when trying to alter a well learned habit pattern numerous opportunities may be required in the re-education, reinforcement and internalization of the new task. regardless of severity, all 3 subjects benefitted from biofeedback training. much criticism has been levelled at current trends in stuttering therapy and it has been expressed that the success achieved in some instances is often short lived and may be attributed to distraction. dewar et al 3 used an apparatus providing an auditory feedback masking noise triggered by means of a throat microphone switch. evaluation tests of this device made on 53 stammerers demonstrated its effectiveness in reducing stammering and abolishing gross concomitant movements. an attempt was made to eliminate the influence of distraction and no biofeedback machinery was used during the evaluation of the pre or post experimental baselines. it was felt that the age of the subjects was a limitation of the study. the subjects had been exposed to many forms of stuttering therapy which have determined their present attitudes with regard to the success of stuttering treatment. an intense training period with a group of adolescent stutterers is being investigated by the authors. with conservative modalities of therapy adolescents have proved to be difficult to work with and often resistant to becoming involved in a therapeutic relationship. the use of sophisticated machinery may stimulate an interest and motivation in the adolescent stutterer. conclusions 1. biofeedback was found to significantly decrease stuttering within sessions in all of the subjects tested. 2. on a descriptive level an intermittent carry-over of reduced stuttering between sessions was evident. on an inferential level however this trend was not statistically significant. 3. a mild, moderate and severe stutterer achieved significant reductions in stuttering frequency with biofeedback training. 4. biofeedback re-education may have a place in the management of stuttering. ackno wledgements the authors wish to express their thanks to prof. m. l. aron, head, department of speech pathology and audiology, university of the witwatersrand, for granting permission for the subjects to be used in this study. references 1. aron m. l. (1967) the relationships between measurements of stuttering behaviour. journal of the south african logopedic society, vol. 14, no. 1. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 112 ε. gordon et al 2. buchthal, f. (1960) the general concept of the motor unit. res. publ. ass. nerv. ment. dis. 38, 1. 3. dewar, α . , dewar, a . d . , anthony, j. f. k. (1976) the effect of auditory feedback masking on concomitant movements of stammering. british journal of disorders of communication. 4. fromkin, victoria and ladefoged, p. (1966) electromyography in speech research. phonetica, 15, 219. 5. hefferline, r. (1958) the role of proprioception in the control of behaviour. trans. n:y. acad. sci., 20, 739. 6. kinsman, r. a. g. staudenmayer, h. (1978) baseline levels in muscle relaxation training. biofeedback and self-regulation 3 87-194. 7. lanyon, r. i. et al (1976) modification of stuttering through emg biofeedback, a preliminary study. behaviour therapy 7, 96-103 academic press new york. 8. ohrian, s. et al (1965) electromyographic studies of facial muscles during speech. stl-qpsr-3/1965. speech transmission laboratory, royal institute of technology, stockholm. 9. shrum, w. f. (1967-1968). the study of the study of the speaking behaviour of stutterers and non-stutterers by means of multichannel electromygraphy. dissertation abstracts a. cushing-malloy, inc., ann arbor michigan, u.s.a. 10. shrum, w. (1969) a study of speaking behaviour of stutterers and non-stutterers by means of multichannel electromyography. doctoral dissertation, univ. of iowa. 11. williams, d. e. (1955) masseter muscle action potentials in stuttered and non-stuttered speech. journal of speech and hearing disorders 20, 242-261. 12. van riper, c. (1971) the nature of stuttering. englewood cliffs n.j. prentice hall. i the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) does the child hear? in many cases, only the abr can tell infants, y o u n g c h i l d r e n , retarded individuals, a n d other n o n c o m m u n i c a t i v e patients can't accurately describe t h e i r h e a r i n g , t h e auditory b r a i n s t e m r e s p o n s e (abr) is a sensitive tool for objectively identifying and d i a g n o s i n g h e a r i n g disorders in such p e r s o n s . it provides exact information a b o u t t h e functional status of t h e cochlea a n d b r a i n s t e m pathways that c a n n o t b e obtained by o t h e r tests, behavioral o r physiologic. it is a reliable m e t h o d for m e a s u r i n g h e a r i n g threshold. further; t h e t e c h n i q u e d i s t i n g u i s h e s recruiting from non-recruiting losses, and r e t r o c h o c h l e a r from peripheral d i s o r d e r s . p e d i a t r i c e v a l u a t i o n the abr is especially valuable in s c r e e n i n g high-risk infants, testing infants with c o n g e n i t a l malformations, a n d in t h e abr c a n b e r a p i d l y a n d c o n v e n i e n d y m e a s u r e d i n t h e c l i n i c -or at t h e b e d s i d e . c l i c k s t i m u l i d e l i v e r e d t h r o u g h e a r p h o n e s e l i c i t t h e abr, w h i c h is m e a s u r e d f r o m e l e c t r o d e s p l a c e d o n t h e p a t i e n t ' s h e a d . assessing o t h e r hard-to-test c h i l d r e n . such early d e t e r m i n a t i o n s allow p r o p e r m a n a g e m e n t , e n s u r i n g n o r m a l linguistic skill d e v e l o p m e n t . a t y p i c a l s e r i e s o f abrs m e a s u r e d at v a r y i n g c l i c k i n t e n s i t i e s . each abr is t h e s u m m a t i o n o f r e s p o n s e s f r o m 2 0 0 0 c l i c k s t i m u l i . t h e i n d i v i d u a l w a v e s r e p r e s e n t t h e s o u n d i n d u c e d n e u r a l a c t i v i t y a s it a s c e n d s t h e a u d i t o r y p a t h w a y . t h e w e a k e s t c l i c k that p r o d u c e s a w a v e v r e s p o n s e e s t a b l i s h e s t h e h e a r i n g t h r e s h o l d . a c o u s t i c t u m o r d e t e c t i o n with p r o p e r i n t e r p r e t a t i o n , t h e abr is an efficient test in t h e early d i a g n o s i s of acoustic t u m o r s . in short, t h e abr t e c h n i q u e can s e r v e as a significant and v a l u a b l e tool for t h e otologist a n d audiologist. a c o m p l e t e s y s t e m from n i c o l e t , t h e e s t a b l i s h e d l e a d e r i n a b r i n s t r u m e n t a t i o n . the nicolet ca-1000 is a complete, clinically-proven system for recording eiokedpotentials. its e a s e of o p e r a t i o n a n d portability m a k e it ideal for clinical use. nicolet's 14 years of l e a d e r s h i p in e v o k e d potential t e c h n o l o g y p r o v i d e t h e ca-1000 u s e r with an u n e q u a l l e d s u p p o r t system, including r e g i o n a l sales and service, o n s i t e training, a n d w o r k s h o p s o n r e c o r d i n g t e c h n i q u e s a n d diagnostic applications. please phone or write for further details or to arrange for a demonstration. -8 conductive sensorineural ο y v hearing . recruiting = / \ ioss λ loss high 2 v a frequency / n v v. λ, loss υ,1 normal range n y / ^ > > stimulus intensity (decibels) c u r v e s o f w a v e v l a t e n c i e s a s a f u n c t i o n o f i n t e n s i t y . c u r v e s o b t a i n e d f r o m h e a r i n g i m p a i r e d p a t i e n t s differ f r o m t h e n o r m a l c u r v e . t h e s e d i f f e r e n c e s d e t e r m i n e b o t h m a g n i t u d e a n d t y p e o f h e a r i n g l o s s . galambos r, hero* kj clinical applications of the auditory brainstem response. otolaryngol. clin. north am. 11:709-722,1978. d e f e r e n c e · plcton τ w, et. al: evoked potential audiometry. j. otolaryng. 6:90-119.1977. clemisj d, mcgeet: brain stem electric response audiometry in the differential diagnosis of acoustic rumors. laryngoscope, lxxxjx; 31-42,1979. nicolet biomedical a division (4nicolet instrument corporation p.o. box 6 2 7 0 • j o h a n n e s b u r g , south a f r i c a 2 0 0 0 . 6 t h floor, s p e s c o m h o u s e , c o m e r p i o n e e r a n d c e n t r a l r o a d s f o r d s b u r g , j o h a n n e s b u r g 2092. t e l e x : 8 6 2 7 3 . t e l e p h o n e : (011) 834-7551 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28,1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) l a r y n g e a l behaviour and fluency-inducing therapy marlene behrmann ma (speech path.) (witwatersrand) department of speech pathology and audiology, university of the witwatersrand, johannesburg itemed behaviour of an adult stutterer was assessed preand post-therapy intervention. i n t e r v e n t i o n comprised a fluency based ram^directedto the modification ofphonatory behaviour and rate reduction. electrolaryngographic tracings, as well as seventy and t ^ l ratzs vere obtained preail post-intervention. results revealed a marked change in all measurements post-intervention, m^cating the effectiveness of therapy. the 'efficacy of the electrolaryngograph as a measurement tool was illustrated and the results are considered in the light of the current literature on phonatory disturbance in stuttering. teltzfegedrag van >n volwasse hakkelaar is preen post-terapeutiese ingryping ondersoek. ingryping het uit'n vlotheidsgebaseerde ^roe^am ger'g °p d'e ^ s m van fonatoriese gedrag en vermindering van spoed, bestaan. eiektrolaringeografiese op ekeninge asook zoliin o ' die graad en.frelensie van die hakkelgedrag, is voor en na terapeutiese ingryping verkry. die doeltreffendheid van terapfe isbewys deurdat η opvallende verskil t.o.v. alle post-ingrypingsmetings gemerk is. die effektiwiteit van die elektrol^og aaf as meetinstnment is aangetoon en die resultate is teen die agtergrond van die huidige literatuur i. v. m. fonatoriese asking in hakkel bespreek. program is to establish rate control and this dimension together with the emphasis on phonatory adjustments, has currently proved to be the most effective variable handled in treatment (andrews et al. 1982). the stutter free therapy program falls within the 'speak more fluently' school of stuttering therapy, as discussed by gregory (1979). these approaches, also known as the fluency-inducing therapies, advocate the establishment, maintenance and transfer of an entirely new speech pattern. the call for clearer delineation and identification of the factors which contribute to the success or failure of stuttering therapy has been made by boberg, howie and woods (1979) and continued research into the outcome of therapy is necessary both to predict the amount of change and to enhance and modify existing treatment regimes. the concept of an organic etiology of stuttering is not a novel one, stuttering having been ascribed to, among others, neurological causes, auditory perception problems and biochemical factors (van riper 1978). recently, numerous allusions to abnormal laryngeal functioning of stutterers have been made, but whether this abnormal functioning is due to etiological or symptomatological factors is as yet undetermined and may indeed prove unanswerable. several writers have stated that the problem resides in the larynx itself whilst others have suggested that an overriding neural component is responsible for the disturbed phonatory behaviour (conture, mccall and brewer 1977). the stutterer's inability to initiate phonation and to make vocalization adjustments has been examined (adams and reis 1971), as hasjvoice onset time problems (cross and luper 1979) and unusuajl abductory laryngeal behaviour (schwartz 1974). perkins (1981) has concluded that there exists a "mistiming and excessive contraction of laryngeal and supraglottal muscles". one of the difficulties in examining the laryngeal behaviour of stutterers arises from the lack of testing equipment. the development of the electrolaryngograph affords the researcher the opportunity of investigating the phonatory pattern of a speaker in a non-invasive manner (fourcin and abberton 1971). this technique which provides a dynamic, instantaneous and simple method for assessing vocal fold contact and for examining the laryngeal behaviour of stutterers, has not been extensively applied to stuttering nor has it been used to evaluate the laryngeal behaviour preand postintervention. the laryngographic tracings are obtained by placing two electrodes on either side of the thyroid cartilage. the output is derived from the voltage variations which result in the changing conductance of the vocal fold configurations. a potential application of the electrolaryngograph is as a means of examining laryngeal functioning following therapy which has been instituted specifically to modify vocal fold movement. one such therapy program, "stutter free speech" (shames and florance 1980) is designed to modify the phonatory behaviour of the speaker through continuous phonation. a further purpose of this die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 methodology the aim of the current study is to evaluate the change in a stutterer's laryngeal behaviour following a therapy program designed to intervene at the level of phonation. the applicability of the electrolaryngograph as a measurement tool of laryngeal behaviour will also be considered. a single case study design was selected in accordance with perkins (1983) proposal that studies "with an ν of 1" support the tendency away from hypothetical speculation and provide much needed empirical evidence. subject description the subject, s, was a 31 year old male who had stuttered since early childhood. no family history of stuttering had been reported. s had received therapy previously but there had been no observable change in his speech pattern. no previous history of laryngeal pathology had been noted. s presented as aphase lv advanced stutterer, according to luper and m u l d e r s ( 1964) classification system. his speech pattern was charactered by severe blocks and hard contacts, tense repetitions and interjections of phonemic a i d non-phonemic utterances. tension loci were identified as the hps, tongue, laryngeal area and abdomen. secondary behavtours © sasha 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 marlene behrmann included eye blinking, head jerks, lip tremor and flaring of the nostrils. respiratory disturbances were evident in frequent pausing, gasping and speaking on residual air. fluency facilitating techniques (utilised prior to the implementation of a therapy program) such as whispering, choral speaking and slowed speech produced a decrease in the frequency and severity of stuttering. s obtained a score of 12.9 on the erikson s24 (1969) scale which suggests that he viewed himself in a positive light prior to intervention. pre-intervention speech assessment the need for comprehensive assessment pre-intervention has been highlighted by andrews, guitar and howie (1981). a preintervention percentage of syllables stuttered (%ss) and a mean syllable per minute (spm) were computed in order to describe the frequency and severity of the stutter pattern. a sample of s's speech was collected including a spontaneous speech sample, a reading sample and a telephone call interchange. these varying conditions were included since bloodstein (1975) contended that the stutter pattern varies under different circumstances. for the purposes of , this study, stuttering was defined as "any sound or syllable repetition, block, prolongation or effortful emission of a word or syllable" (ingham, andrews and winkler 1972). the pre-intervention %ss were 26,5%, 18,2% and31,4% for the three samples outlined above. these figures are suggestive of a severe stutter pattern in comparison with previous studies (goldsmith and anderson 1984) and support the classification of s as a phase iv advanced stutterer. the mean spm counts were 139,5, 132 and 123 for the three samples and are all slow compared with the norm of 196 spm for normal speaking adult males (andrews and ingham 1971), thus confirming the diagnosis of a severe stutter pattern. the electrolaryngographic examination was conducted using a uher 4200 report stereo i.c. tape recorder with a m816 directional microphone to record the subject's spoken output while the mingograf inkjet recorder traced the laryngeal information. the subject was seated in a comfortable position with the microphone at a distance of 30mm from the lips. tracings were made on both a spontaneous speech sample and a reading sample. owing to practical difficulties the tracings could not be carried out during a telephone conversation. the dimensions for analysing the laryngographic tracings were selected to yield a comprehensive picture of laryngeal functioning. examples of the pre-intervention tracings are presented in figures la and lb which reflect the spontaneous speech and reading samples respectively. a. regularity of the wave this dimension refers to the maintenance of a stable vibratory pattern which is achieved through the laryngeal musculature and through air pressure control. much variabil^ ^ ^ ^ — r ^ m i m ^ ^ v w s / w v w · — ivvv-</vvuwnnfl/i/|l» vuuuuia^^ immrnwrnmnmh /v»/ figure la examples of pre-intervention spontaneous speech laryngographic tracings figure lb examples of pre-intervention laryngographic tracings during reading ity and erratic movement may be observed in figures la and lb and these tracings reflect a disturbance in laryngeal functioning and co-ordination as described by conture et al. (1977). an alternative explanation is that the laryngeal inco-ordination results from an uneven interplay between the agonist and non-agonist laryngeal muscles. these results are supported by studies which have demonstrated abnormal laryngeal functioning in stutterers (adams and reis 1971; schwartz 1974). b. shape the shape of the waveform (lx) provides a basis for determining the nature of the vocal fold contact and its timing (anthony 1978). a normal vibratory cycle consists of a rapid closing phase (adduction), represented by a vertical rise, a slower opening phase (abduction) shown as a downward tracing and a period of no contact when the glottis is opening. the pre-intervention spontaneous speech tracing (fig. la) reflects an erratic pattern of vocal fold movement as noted in the poorly proportioned rise and fall times and the exaggerated gradual decline owing to the failure of the folds to meet along their entire length. the double peak at base provides further evidence for asynchronous vibration. c. ease of achieving steady amplitude — this dimension, measured from the first excitation until steady amplitude is achieved, reflects the ease with which a stable vibratory pattern is instituted. an impressionistic overview reveals that steady amplitude is achieved relatively quickly in the pre-intervention tracings, although amplitude variations are noted on the fluent and stuttered phonatory stretches. this pattern is indicative of a difficulty in regulating the vibratory pattern even during the fluent phases of speech. d. fx: refers to the fundamental frequency of voicing (anthony 1978) and the term 'jitter' has been coined to describe the fx pitch variations. the relative degrees of rise and fall provide crucial information about normal and deviant vibration patterns. sporadic jitter, especially at the onset of phonation, was evident across all conditions. almost the entire pre-intervention utterance was characterized by jitter, suggestive of an uneven mode of vocal fold vibration. the increases in fx reflect the tension of the laryngeal muscles and increased subglottic air pressure. e. gx: refers to the observation of gross laryngeal adjustments. this dimension is superimposed on the lx waveform. rapid laryngeal adjustments are noted pre-intervention especially on the spontaneous speech sample. this finding, however, must be viewed with caution since the excess gx activity may have resulted from the subject's secondary symptoms such as head jerks (although the subject was requested to remain still during the recordings) and not necessarily from laryngeal activity. in view of this, any judgements on pre-intervention gx must be reserved. the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) laryngeal behaviour and fluency-inducing therapy 47 in sum, the pre-intervention laryngographic tracings reflect disturbed phonatory patterns as evidenced by, for example, the variable waveform, amplitude variations and irregular shape. these findings suggest a dysfunction at the laryngeal level both during spontaneous speech and during reading. the laryngeal abnormalities noted on the reading tracings are not as marked as those on the spontaneous speech tracings. therapy process an intensive schedule of therapy was undertaken since the subject lived out of town and a limited time period was available. in many instances intensive therapy has been regarded as the ideal form, especially in a fluency based program as the 'new' speech pattern may be acquired in a short period of time. twenty three hours of therapy were completed in ten days. the first three stages of the stutter free program were completed. this involved the establishment of a fluent speech pattern under volitional control as well as self-reinforcement and transfer. it was hoped that an alternative form of laryngeal behaviour would be achieved by this stage and that the remaining two phases of the program (unmonitored speech and follow-up) would be monitored over a long period of time. a number of modifications were made to the program, devised by shames and florance (1980). delayed auditory feedback was excluded since the subject achieved continuous phonation of his own accord. syllables per minute were calculated instead of words per minute as words differ in their syllable count and do not facilitate cross-language comparison (hayhow 1983). pre-planned contract activities were arranged in a hierarchical manner in accordance with van riper's (1978) suggestions. post-intervention measurements were taken following the termination of the therapy and compared to the pre-intervention baselines. post-intervention speech assessment the post-intervention tracings were taken following the identical procedure of the pre-intervention recording. figures 2a and 2b depict examples of the post-intervention tracings. / h e i p i ^ t t e v ^ · * figure 2a example of post-intervention spontaneous speech laryngographic tracing a. regularity of the wave — the post-intervention tracings reflect a moreregular and stable waveform post-intervention than the preintervention tracings. figures 2a and 2b suggest a controlled vibratory pattern of the vocal folds. b. shape — a synchronous, symmetrical mode of vibration is evident from the spontaneous speech and reading post-intervention tracdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 mmmmmwmmummm^m figure 2b example of post-intervention laryngographic tracing during reading ings. a distinguishing feature of these tracings is the relatively flat base which suggests a long open phase of the vocal folds. figures 2a and 2b resemble each other closely although the spontaneous speech tracing (figure 2a) contains more evidence of abnormality than the reading tracing. the reading tracing (figure 2b) demonstrates a sharp vertical rise (closure) associated with maximum excitation of the folds followed by a sharp peak or short period of maximum contact. the decline is vertical and the rise and fall times are well proportioned. these results approximate normal laryngeal functioning. c. ease of achieving steady amplitude a change in amplitude control following intervention is observed since no amplitude variations are noted on the post-intervention tracings. the absolute amplitude cycle could not be compared across the preand post-intervention tracings since the gain on the laryngograph was turned up on the post-intervention recording and hence any differences may be a result of artifact. d. fx: the post-intervention tracings depict a stable fx and thus suggest the elimination of the tension of the laryngeal muscles. e. gx: post-intervention tracings reveal no gx activity thus providing further evidence for a change in laryngeal behaviour. table 1 summarises the overall trends of the laryngographic tracings and allows for comparisons across the preand post-intervention conditions. table 1 summary of overall trends of laryngographic analysis preand post-intervention pre-intervention speech reading post-intervention speech reading a. regularity of lx wave + + + + b. normal vibratory cycle + + + c. steady amplitude obtained + + + d. fx jitter + e. gx + key: + = present + — = variable = absent change across all dimensions is observed except for the fx jitter and gx which remained the same for the pre-intervention spontaneous speech and reading and the post-intervention conditions. despite this, an alteration of phonation mode is seen in both reading and in spontaneous speech following intervention. the post-intervention tracings approximate normal patterns along all dimensions, apart from the lengthened wave base. this additional feature on the postr ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 marlene behrmann intervention tracings is not unusual since metz, onufrak and ogbum (1979) observed that post-therapy speech may be fluent despite the addition of certain temporal characteristics. it must be borne in mind that the therapy program was not entirely complete at this stage and thus the timing element was not yet habituated. it was also interesting to note that the results of the erickson attitude scale taken after the therapy program showed change as a score of 9.2 was obtained. hayhow (1983) has proposed that therapy continue until an s24 score of ten or less (for males) is achieved as was done in the present study. of interest, too, is the comparison of the post-intervention frequency and severity ratings with the pre-intervention scores. the postintervention %ss and spm are presented in figure 3 for comparison with the pre-intervention assessment. a post-intervention reduction in %ss is evident across all conditions and the post-intervention %ss count falls within the normal limit of 6,5%ss as specified by andrews and ingham (1971). the telephone condition produced the highest %ss both preand post-intervention, a finding which supports the observation of leith and timmons (1983) that the telephone is the most difficult situation for stutterers. spontaneous reading speech sampling conditions key: ξ pre • post figure 3 mean percentage syllables stuttered across all conditions preand post-intervention a minimal increase in spm was noted from preto post-intervention speech sampling (see figure 4). the post-intervention rate of approximately 140 spm is slow compared to normals but may be accounted for in terms of the stage of therapy attained i.e. 140 spm stutter free speech under volitional control. | loo cc p. 7 5 to iu m so s p o n t a n e o u s s p e e c h e a d i n g key: η pre • post s a m p l i n g c o n d i t i o n s figure 4 mean syllables per minute across all conditions preand post-intervention. it is evident from these results that not only did a change in laryngeal patterns occur but a definite alteration of the frequency and severity of stuttering was also noted. the present findings support the contention that laryngeal disturbances are associated with stuttering (conture et al. 1977; wingate 1977) and that modifications in laryngeal behaviours are possible through the implementation of a continuous phonation therapy program. although it is impossible to determine whether the laryngeal abnormalities are the cause or effect of stuttering, it is interesting to note the relative ease with which the laryngeal dysfunction could be remediated. it may be postulated that in accordance with schmitt and cooper (1978), the irregular phonatory behaviour reflects habituated compensatory strategies in response to the dysfluencies and thus the pathology, whether neurological or physiological, does not 'reside' in the vocal folds themselves. this suggestion, however, is speculative and further evidence is indicated. this case study has highlighted the benefits of a fluency inducing therapy program and has revealed the alteration in the laryngeal behaviour and the change in frequency, severity and rate of the stutter pattern. furthermore, it illustrates the necessity for in-depth baseline evaluation of the stutter pattern in order to estimate the efficacy of a therapy program. in addition, the applicability of the electrolaryngograph as a measurement tool for assessing and monitoring change in the vocal fold vibration of a stutterer is illustrated. whereas traditionally, phonatory behaviours of stutterers were measured through the use of rating scales and other subjective means, the electrolaryngograph has been shown to be a useful and objective assessment tool for evaluating vocal fold behaviours. conclusions and implications this study was directed to the objective evaluation of laryngeal behaviour preand post-intervention in an adult stutterer, the intervention being in the form of a fluency-based program designed to modify phonatory pattern and to reduce rate. the results revealed a marked difference between the laryngographic tracings in the two conditions. this difference was evident along several dimensions such as regularity, shape of the waveform, and ease with which steady amplitude is achieved, gx and fx. in addition to this, the results demonstrated a decrease in the frequency and severity of stuttering during reading, spontaneous speech and the telephone situation. a positive change in the subject's attitude was also noted. several clinical and theoretical implications are evident. these pertain not only to this particular subject or to stutterers in general, but also to the measurement techniques employed in this study! with regard to the subject of the present study, long-term follow! up to assess the therapeutic gains is indicated and, indeed, the use of the electrolaryngograph to evaluate long-term outcome should prove informative. the utilization of the electrolaryngograph with other stutterers in an attempt to identify and describe the deviant phonatory pattern should prove interesting. furthermore, the electrolaryngograph may be utilized in conjunction with techniques for the assessment of the respiratory and articulatory mechanism of the stutterer. interactions between these systems have been reported (adams 1974) and the evaluation of these should provide interesting information. future research in these areas should contribute to the increasing amount of information in this field and consequently, therapeutic intervention should improve. acknowledgement the writer wishes to thank professor a. traill, department of linguistics, university of the witwatersrand, johannesburg, for his the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) laryngeal behaviour and fluency-inducing therapy assistance in the administration and interpretation of the electrolaryngographic tracings. references adams, m.r. vocal tracts dynamics in fluency and stuttering. in m. webster and l. furst (eds.) vocal tract dynamics and dysfluency. speech and hearing institute, new york, 1974. adams, m.r. and reis, r. the influence of the onset of phonation on the frequency of stuttering. j. speech hear. res. , 1 4 , 639-644, 1971. andrews, g., guitar, b., and howie, p. meta-analysis of the effects of stuttering treatment. j. speech hear. disord., 45, 287-307, 1981. andrews, g., howie, p., dosza, m. and guitar, b. stuttering: speech pattern characteristics under fluency inducing conditions. j. speech. hear. res., 25, 208-216, 1982. andrews, g. and ingham, r.j. stuttering: considerations in the evaluation of treatment. brit. j. commun. disord., 6, 129-138, 1971. anthony, j. the chief scientist reports . . . the voiscope. national health bulletin, london, 321-328, 1978. bloodstein, o. stuttering as tension and fragmentation. in j. eisenson (ed.) stuttering: a second symposium. harper and row, new york, 1975. boberg, e., howie, p. and woods, l. maintenance of fluency: a review. j. fluency disord., 4, 93-116, 1979. conture, e.g., mccall, g.n. and brewer, d.w. laryngeal behaviour during stuttering. j. speech hear. res., 20, 661-668, 1977. cross, d. and luper, h. voice reaction times of stuttering and non-stuttering children and adults. j. fluency disord., 4, 59-78, 1979. 49 erickson, r.l. assessing communication attitudes among stutterers. j. speech hear. res., 12, 711-724, 1969. fourcin, a.j. and abberton, e. first applications of a new laryngograph. medical biological illustrations, 21, 172-182, 1971. goldsmith, t. and anderson, d. the enigma of fluency: a single case study. s.a. j. commun. disord., 31, 47-52, 1984. gregory, h.h. controversial issues: statement and review of the literature. in h.h. gregory (ed.) controversies about stuttering therapy. university park press, baltimore, 1979. hayhow, r. the assessment of stuttering and the evaluation of treatment. in p. dalton (ed.) approaches to the treatment of stuttering. croom-helm, london, 1983. ingham, r.j., andrews, g. and winkler, r. stuttering: a comparative evaluation of the shortterm effectiveness of four treatment techniques. j. commun. disord., 5, 91-117, 1972. leith, w.r. and timmons, j.l. the stutterer's reaction to the telephone as a speaking situation. j. fluency disord., 8, 233-243, 1983. luper, h.l. and mulder, r.l. stuttering therapy for children prentice hall, englewood cliffs, 1964. metz, d.e., onufrak, j.a. and ogburn, r.s. an acoustical analysis of stutterer's speech prior to and at termination of speech therapy. j. fluency disord., 4, 249-254, 1979. perkins, w.h. implicationsof scientific research for treatment of stuttering a lecture. 7. fluency disord., 6, 155-162, 1981. schmitt, l.s. and cooper, e.b. fundamental frequencies in oral reading behaviour of stuttering and non-stuttering male children. j. commun. disord., 11, 17-23, 1978. schwartz, m.f. the core of the stuttering block. j. speech hear. disord., 39, 169-177, 1974. shames, g. and florance, c.l. stutter-free speech: a goal for therapy. ohio: charles e. merrill, 1980. van riper, c. speech correction: principles and methods. prentice hall, new jersey, 1978. wingate, m.e. the immediate source of stuttering: an integration of evidence. j. commun. disord., 10, 45-51, 1977. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) hearing aid centre s.a. (pty) ltd established in 1949 offers • • • • • comprehensive wide range of modern hearing aids complete service facilities modern range of audiometric and allied equipment own earmould laboratories in fact everything that the audiologist may require country-wide service and fully equipped offices at j o h a n n e s b u r g (head office) hearing aid centre s.a. (pty) ltd 212 harley chambers 187 jeppe street johannesburg 2001 telephones: 337-2643/4/5 pretoria hearing aid centre s.a. (pty) ltd 633 kerkade centre 267 church street pretoria 0002 cape t o w n hearing aid centre s.a. (pty) ltd 104 cartwright's corner c/o adderley & darling streets cape town 8001 telephones: 21-7245/6 telephone: 46-5816 the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mass generalised learning applied to the problem of carry-over in articulation therapy avril klaff, b.a. (sp. & h. therapy) (witwatersrand) department speech pathology and audiology, university of the witwatersrand, johannesburg. summary this study was designed to investigate morehead and johnson's hypothesis that mass generalised learning experience in therapy will eliminate carryover problems. four subjects who consistently misarticulated the /s/ phoneme participated in an intensive six week therapy programme. two experimental subjects were trained in the production of the entire category of sounds of which the target phoneme is a member. two matched control subjects received traditional articulation therapy. preand post-therapy measures included an articulation test, competence tests and spectrographic analysis. sound production tasks and carry-over tasks were administered at regular intervals during therapy to assess generalisation to untrained contexts. complete carry-over was evidenced by one experimental subject at the end of the sentence phase of therapy. the remaining three subjects demonstrated inconsistent carry-over at the conclusion of the therapy programme. it is suggested that a mass generalised learning procedure may offer an efficient approach to articulation therapy. opsomming hierdie studie ondersoek morehead en johnson se hipotese dat 'n veralgemeende leerproses in terapie oordrag vergemaklik. vier proefpersone wat die /s/-foneem konsekwent foutief geartikuleer het, is in 'n intensiewe terapieprogram van ses weke betrek. twee eksperimentele proefpersone is opgelei om die volledige groep foneme in die kategorie van klanke waarvan die foutiewe foneem 'n deel is, te produseer. twee proefpersone het as kontrole tradisionele artikulasieterapie ontvang. artikulasieen bevoegdheidstoetse sowel as spektrografiese analises is deur die proefpersone voor en na terapie ondergaan. klankproduksieen oordragtake is met gereelde tussenposes gedurende terapie onderneem om oordrag in 'n onopgeleide verband te beoordeel volledige oordrag is deur een eksperimentele proefpersoon aan die einde van die sinsfase van terapie behaal. die ander drie proefpersone het wisselvallige oordrag aan die einde van die terapieprogram getoon. daar word voorgestel dat 'n veralgemeende leerproses moontlik 'n doeltreffende benadering tot artikulasie terapie bied. articulatory disorders have long been recognised as the most prevalent of all speech disorders.2'1 2'3 0 thus the need to devise efficient and effective procedures for the remediation of these problems is strongly indicated. the ultimate goal of an articulation therapy programme is to bring the individual to a point where he can communicate normally regardless of the speech context and the environment in which he finds himself.1 >2'!'35 however, the problems involved in accomplishing this goal require no introduction to the speech therapist. the terms generalisation, transfer of training and carry-over have been used interchangeably in the literature to refer to this aspect of therapy. the approachjournal of the south african speech and hearing association. vol. 23. december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mass generalized learning and articulation therapy 31 es that have traditionally been advocated for facilitating this phase of.therapy suggest that most speech therapists have viewed carry-over as the extension,of correct articulation from the clinical setting to other situational settings. inherent in these procedures is the assumption that carry-over is an event,which occurs only in the final stages of therapy. their ineffectiveness is reflected in a statement made by mowrer.21 'carry-over remains one of the most perplexing problems speech clinicians have to face in attempting to modify articulation.' since the problems of carry-over continue to plague speech therapists it is fitting that research be directed towards scrutinising the efficacy of traditional therapy procedures and to designing alternative procedures with the sole purpose of eliminating carry-over difficulties.4 it is to this aim that the present study was directed. recently morehead and johnson20 made observations that have shed a new light on the carry-over controversy. they attribute the unstable changes that ; occur in therapy to the learning theory framework in which most speech therapy programmes take place. raymore25 notes that most speech therapists use the basic "stimulus method" of therapy t a teach correct production. this technique has its origin in the early work of travis (1931) but the procedure formulated by van riper in 1939 is frequently referred to as the "traditional approach" to articulation therapy. in most cases the therapist presents a model of the correct sound and the child is asked to repeat it. reinforcement is provided for each successful attempt on approximation to success. morehead and johnson20 note that this pairing of a stimulus and response constitutes a specific training experience, the consequences of which are unstable changes in the newly learned behaviour. . in contrast piagetian-based programmes.'.. assume that mass generalised experience is crucial to learning and these should provide more stable changes in behaviour. many enthusiasts in different fields have adapted piaget's viewpoint to suit their specific needs. since no further references to this method of teaching could be found which is specifically applied to speech therapy, the writer interpreted this principle in a way that was thought best suited to articulation learning. impetus for change in the nature of articulation therapy has also resulted from the application of linguistic theory to normal and defective articulation. recent research has resulted in the proposal that articulation problems be considered in the framework of the phonological s y s t e m . 3 ' 4 ' 1 4 ' 1 9 ' 2 2 ' 2 3 ' 3 1 as a number of phonemes share features in common it has been thought that it is the omission or misuse of a feature that accounts for the misarticulation errors of the child. the implication is that correction of articulation must be directed at locating and correcting the feature which is common to a number of misarticulations.18'19'23 thus traditional therapy procedures of teaching sounds in isolation are being substituted for by procedures in which an entire category of sounds is worked o n . 1 3 ' 3 1 it is proposed that these recent developments in the remediation of multiple articulation defects can be utilised to translate the principle of mass generalised tydskrif van die suid-afrikaanse vereniging vir sprak en gehoorheelkunde vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 avril klaff learning experience into a practical therapy procedure for dealing with a group of children having difficulty with only one phoneme. it was hypothesized that emphasis on the entire category of sounds of which the target phoneme is a member will provide the child with more generalised learning experience than the teaching of a single, isolated sound. this in turn will result in more stable changes in articulatory ability, hence eliminating carry-over difficulties. method aim it was the aim of the present study to employ the principle of mass generalised learning experience in articulation therapy and to observe its effects on the entire therapeutic process. subjects: four subjects (ss) were divided into two groups of two ss each. the experimental ss were trained according to the principle of mass generalised learning. the control ss received traditional articulation therapy. all ss were selected according to the following criteria: 1. chronological age of 8 years or more in order to eliminate developmental articulation errors. 2. presence of an interdental lisp. 3. hearing within normal limits. since great difficulty was experienced in obtaining ss who conformed to these criteria, those available had to be matched as closely as possible according to the following variables: subject c.a. sex articulation error etiological factors previous therapy el 7,6 yrs. f θ is biz l/r none observable none ci ' 9,6 yrs. μ 0/s b/z m φ none observable none e2 8,0 yrs. μ 0/s &/z tongue thrust emotional problems. learning problems. none / c2 9,6 yrs. f 0/s &/z tongue thrust emotional problems. learning problems. a few sessions at 4 yrs. table 1. criteria according to which subjects were matched. journal of the south african speech and hearing association, vol. 23. december 976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mass generalized learning and articulation therapy 33 age since the ages of ss ranged from 7,6 years to 9,6 years, the experimenter (e) felt that group therapy would be enhanced by placing children of the same age in the same group. therefore, experimental and control ss were not matched according to this variable. sex one male and one female was placed in each group although this variable is not considered crucial.34 articulation error el (experimental s 1) and ci (control s 1) had additional errors. (see table 1) etiological factors e2 (experimental s 2) and c2 (control s2) were matched for the presence of a tongue thrust swallow pattern and suspected emotional difficulties both of which may be related to articulation disorders.16'34 intelligence ss were not matched according to l.q. since this is not felt to be causally related to articulation disorders.34 however ss were matched according to an informal assessment of learning ability. procedure tests for the effects of therapy: , figure 1 shows the sequence of therapy with the relative position of the testing sequence indicated. the tests were administrated on a before and after therapy basis as well as at specific intervals during therapy. pre-therapy test: > a. goldman ftistoe b. competence tests c. baseline probes * intra-therapy probes final position training post-therapy test: goldman fristoe b. spectrographic analysis c. 24 hi. retention probe d. 3 week retention probe figure i. the sequence of therapy with the relative position of the testing sequence indicated. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 avril klaff pre-therapy tests these were administrated to determine the level of performance for each s prior to the commencement of therapy. these included the goldman fristoe test of articulation8 arid two competence tests devised by the ε to determine if ss were able to make the phonological and phonetic distinctions between the target and error sound. thus ss were required to discriminate between minimal pairs containing [ + strident] sounds and [ strident] sounds as well as minimal pairs containing slit and grooved phonemes. in addition the acoustic spectrograph was used to analyse the ss renditions of the /s/ phoneme in an attempt to characterise more accurately the acoustic properties of the pretherapy and post-therapy articulations. intra-therapy probe tests l the probe tests used in the present study were based on those used by elbert, she it on and arndt,5 shelton, elbert and arndt2 7 and wright, shelton and arndt.35 the tests can be divided into two categories. a. sound production tasks (spts) a 40 item spt was divided into 20 items for the /s/ phoneme and 20 items for the /z/ phoneme. both phonemes were sampled in initial, medial final positions and in clusters. b. carry-over tasks generalisation of correct production to spontaneous speech was measured in four ways: 1. subjects were asked to read aloud until 20 instances of the /s/ and /z/ phonemes had been sampled. 2. spontaneous speech was tape recorded in the therapy setting. 3. spontaneous speech was recorded in an extra-therapy setting, namely the grounds of the university. 4. parents were given some understanding of how to observe the child's speech in different situations and were asked to report carry-over progress to the e. all the intra-therapy probes were administered prior to therapy in order to establish baseline performance levels for each s. the sequence of administration of these probes during therapy was not uniform for all ss since they all progressed at difference rates. probe tests were administered when a s obtained a score of 18/20 at the end of each phase of therapy.,if scores indicated that generalisation had taken place to the next level of production then that phase of therapy was omitted. post-therapy tests 1. the goldman-fristoe test of articulation8 was re-administered 24 hours after the termination of therapy. 2. both spts and carry-over tasks were re-administered 24 hours and again 3 weeks following the termination of therapy. 3. spectrographic analyses were made of each ss pre-therapy and posttherapy renditions of 7 /s/ and /z/ words from the goldman-fristoe test of articulation.8 journal of the south african speech and hearing association, vol. 23 december 976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mass generalized learning and articulation therapy 35 reliability random samples of recordings of probe tests were played to two experienced speech therapists. the ε rated the probes at the time of recording and on playback. therapy procedures each group was seen for approximately 30 minutes, five days a week. therapy was terminated when complete carry-over had been achieved or when the maximum number of 20 sessions had been reached. discrimination training the initial stages of the experimental therapy procedure were aimed at establishing the distinction between the two groups of contrasting sounds. thus all the [ + strident] or grooved sounds (/s/, /z/, /s/, /z/, /ts / and /dz/ according to halle10 were said to belong to "the man with the tall hat". the [ strident] or slit sounds (/f/, /v/, /0/ and (/£/) according to halle10 were identified with the "man with the short hat". discrimination exercises were carried out in which the children were required to associate minimal pair words with the relevant "men". in contrast, control therapy was concerned with identifying the error and the target sound (/0/"and /s/) and training the children to discriminate between these two sounds.30 the acquisition phase the experimental ss were taught production of all the [ + strident] sounds. production of /s/ and /z/ was taught by emphasizing the auditory and visual similarities between these sounds and other f + strident] sounds. the ss were asked to consciously contrast [ + strident] and [ strident] sounds in their own speech so that the differences could be emphasized. the correct production of all [ + strident] sounds was stressed at all levels of the acquisition phase. this differs markedly from the traditional procedures in which the child's attention is focused solely on correct production of the phoneme /s/. the carry-over phase this phase was provided for ss who failed to demonstrate carry-over following the acquisition phase of therapy. figure 1 indicates that this phase was divided into two stages. experimental and control procedures differed in that experimental ss were encouraged to use all [ + strident] sounds while the attention of the control ss was focused only on the consistent use of /s/. results and discussion the small number of ss used in the study did not justify a statistical analysis of the results and data are therefore presented in terms of individual performances. comparison of pre-therapy and post-therapy test results a. competence tests results indicated that all ss were able to discriminate on both a phonetic and phonological level, therefore all had competence for correct production. b. the goldman fristoe test of articulation — all ss were found to consistently misarticulate the /s/ and /z/ phonemes prior to therapy. all were consistent in correct production of these two phonemes on the tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23, desember 1976. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 avril klaff post-therapy test seemingly indicative of the fact that all ss had achieved the same level of performance. however, results of the carry-over tasks administered at the conclusion of therapy showed that only one s (el) had attained consistent use of /s/ and /z/ in all spontaneous speech situations while the remaining three ss demonstrated inconsistent carry-over. c. spectrograph^ analysis the spectrograms were analysed with the aid of a phonetician. a systematic variation between pre-therapy and posttherapy renditions was observed. 1. the lowest frequency at which peaks of energy occur shifted from 2000hz to 3500hz. 2. weighting of energy shifted from the mid-frequencies to the higher frequencies. 3. peaks of energy extended to 16 000hz. the accoustic patterns of the pre-therapy articulations do not conform to those reported to be characteristic of any other english fricatives. thus the misarticulation does not appear to be one of substitution of/#/ for /s/ but could be more adequately described as an "articulatory displacement".9 however, the post-therapy patterns correspond closely to the patterns apparent in the e's spectrogram confirming that the ss had achieved acceptable production as a result of therapy. intra-therapy probe test r e s u l t s the results presented in this section document the changes that occurred in articulation generalisation as each s progressed through the programme. a. sound production tasks table ii shows the total number of correct responses on the word and sentence task for each s. the following trends can be extracted from table ii. 1. discrimination training minimally improved production. a number of researchers have questioned the excessive reliance of therapy programmes on discrimination training.6'1 5;1 7' ' ' 2. the scores on the /s/spt exceeded scores obtained on the /z/spt for all ss during word training. thus the benefits of training the experimental ss in correct production of /s/ and /z/ simultaneously was not evident. however, while all four ss obtained maximum scores on the /s/spt, only the experimental ss scored maximally on the /z/spt. (see table ii). the ε postulates that the effects of mass generalised learning experience may have begun to manifest itself in the ease with which the experimental ss generalised correct production from words to sentences. it was observed that the control ss produced the stimulus word correctly but had difficulty generalising correct production to other target phonemes in the sentence. the control ss were oriented towards a one-to-one relationship between response and reinforcement whereas the experimental ss were rewarded for a diversity of responses. the latter journal of the south african speech and hearing association, vol. 23 december 976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mass generalized learning and articulation therapy 37 appears to reduce the child's focus on specific stimuli. rather, the child is made aware of the generality of correct production. subject probe phase of therapy baseline discrim. i f μ sent. sp.sp. pi p2 ei is/ spt 0 1 17 18 / 20 / 20 20 ei /z/spt 0 0 11 14 / 20 / 20 20 ci isi spt 0 0 18 / 20 20 20 ci /z/spt 0 0 19 / 15 20 20' e2 is/ spt 0 0 6 16 / 20 20 19 e2 /z/ spt 0 0 0 13 / 20 20 20 c2 isl spt 0 3 18 / 20 20 20 c2 /z/spt 0 0 10 / 16 20 18 discrim. = discrimination training 1 / 1 = no therapy indicated sp.sp. = spontaneous speech — = probe not administered pi = 24 hour retention test | = termination of therapy p2 = 3 week retention test table ii. total number of correct articulations for all subjects on sound production tasks. b. carry-over tasks in order to afford a comparative analysis the graphs of matched experimental and control ss will be compared. comparison between el and ci (see figure 2) el and ci obtained similar results on the reading tasks and intra-therapy talking task. however, scores on the extra-therapy talking tasks differed for these two ss. el showed spontaneous generalisation to extra-therapy situations following the sentence phase of therapy. ci failed to demonstrate generalisation to these contexts until correct production had been reinforced in extra-therapy settings. parental reports confirmed that el had attained complete carry-over to all speaking situations and consequently she was dismissed at the end of the sentence phase of therapy. ci retained 100% scores on the retention tests. after having been subjected to carry-over therapy ci remained inconsistent jn his generalisation of correct production to the extratherapy talking task. further, the results of the three week retention test suggested that ci had regressed rather than improved in his carry-over ability. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23, desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 avril klaff 18' 17in « uj 0) 15-ζ ο μtη subject e1 / s / r t r t -itt -ett = baseline = discrimination = i n i t i a l position = f i n a l position = m e d i a l position = s e n t e n c e s = c a r r y o v e r in t h e clinic coc = c a r r y over o u t s i d e t h e clinic pi = 24 hour r e t e n t i o n t e s t p2 = 3 week r e t e n t i o n t e s t r t = r e a d i n g t a s k itt = i n t r a t h e r a p y t a l k i n g task ett = e x t r a t h e r a p y t a l k i n g task 10 11 ,12 13, 14 15 16 17 1θ 19 20 ~~' s cic p1 i f μ therapy phase f & m s cic t h e r a p y phase figure 2: performance of el and ci on reading tasks and talking tasks at each phase of therapy. comparison between e2 and c2 (see figure 3) e2 did not attain the 50% criteria at the end of the initial position phase of therapy for the administration of carry-over tasks. c2 attained this criteria but failed to demonstrate any carry-over at all. e2's carry-over to spontaneous speech was investigated at the end of initial position training and the data indicates a greater degree of generalisation than c2 had shown to the initial carry-over tasks. journal of the south african speech and hearing association vol. 23 december 976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mass generalized learning and articulation therapy 39 e2's generalisation to the reading tasks and the intra-therapy talking task was similar to that of c2. however, e2 showed some spontaneous generalisation to the extra-therapy talking task at the end of the sentence phase of therapy while c2, like ci, failed to show generalisation to these contexts until correct production had been reinforced in spontaneous speech. e2's scores on the extra-therapy talking task exceeded those of c2 at all levels of therapy. neither of these ss attained complete carry-over before termination and both showed regression following the three week break. f μ s therapy phase coc pi p2 = baseline = discrimination = i n i t i a l position = f i n a l position = m e d i a l position = s e n t e n c e s = c a r r y o v e r in t h e clinic coc = c a r r y o v e r outside the clinic = 24 hour r e t e n t i o n test = 3 week r e t e n t i o n test = r e a d i n g task = i n t r a t h e r a p y talking task e t t = e x t r a t h e r a p y talking task i t 2 3 4. .5 6 7. θ .9 10 ii 12 .13 14 15. .16 17 18 19. 20 β d i fsm s cic coc p1 p2 therapy phase figure 3: performance ofe2 and c2 on reading tasks and talking tasks at each phase of therapy. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde vol. 23, desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 avril klaff a general trend emerges from the close comparison of the intra-therapy probe test results of matched experimental and control ss. in the initial acquisition stages of therapy the scores of the control ss exceeded that of their matched experimental counterparts. however, this situation reversed itself starting at the sentence phase of therapy. of significance are the greater scores obtained by the experimental ss on the extra-therapy talking task. although a limitation of the present study is a lack of accurate assessment of carry-over to nonclinic environments, these scores appeared to demonstrate that both experimental ss were readily able to generalise correct production to situations unrelated to speech therapy. reliability of data (see table iii) phase of rating r1 and r2 rl, r2 and e2 el and e2 discrimination 59,4% 46,9% 91,2% initial pos. 90,6% 69,4% 80,0% 24 hr. retention 90,0% 87,8% 96,0% r1 and r2 rating between 2 independent judges rl, r2 and e2 agreement between raters and the experimenter el and e2 — agreement between 2 sets of measurements made by the experimenter table iii. mean percentage of inter-judge and intra-judge reliability. the poor reliability scores found in this study seem to-indicate that listener judgement alone is inadequate due to the acoustic similarity between /0/ and /s/. the use of visual cues as in videotaping and a more objective measure such as spectrographic analysis could eradicate some of the uncertainty. general discussion a number of factors have been said to be important in determining "an individual's ability to modify his behaviour.29 the unique characteristics of each ss progress suggests that these factors must be taken into account when examining the efficacy of a therapeutic technique. a limitation of this study was the number of inter-subject variables that had to be controlled for. the results of this study suggest that the presence of a tongue thrust did not impede e2 and c2'slability to acquire correct production these results support mason and proffit's16 contention that the speech defect can be corrected without prior correction of the tongue thrust. tongue thrust does not appear to be related to carry-over problems since.ci experienced the journal of the south african speech and hearing association, vol. 23. december 976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mass generalized learning and articulation therapy 41 same difficulty. however, the influence of motivational factors, differences in chronological age and variations in learning ability may have contributed to the differing rates of progress observed. the effect of certain therapeutic variables was controlled for since all ss were seen for intensive group therapy. since the ε was the therapist for both groups, the role of therapist variables and experimenter bias cannot be excluded. despite these confounding variables, it is important to ask what factors inherent in the principle of mass generalised learning may have accounted for the finding that el showed spontaneous carry-over of correct production. the following tentative explanation is offered on the basis of certain concepts taken from piagetian and phonological literature. the writer postulates that 'grouping' based on distinctive feature similarity may serve to provide the child with a permanent system of articulatory monitoring. the grouping together of sounds closely related to one another provides the child with the opportunity of discerning the relationship between sounds already in his repertoire namely /s/, /z/, /ts/ and /dz/ and the target phonemes is/ and /z/. studies have shown that the child improves his articulation of phonemes that share distinctive features with the phoneme being taught. 1 8 ' 3 3 similarly, it is possible that the child will generalise the properties of the sounds he is already able to produce to those sounds that are in error. distinctive feature classes are reported to have corresponding clusters of sensory and motor feedback networks.28 thus, when the child attempts production of /s/ and /z/ correspondence to the feedback patterns associated with /s/, /z/, /ts/ and /dz/ would be a signal to the child that his attempts were successful. it is hypothesized that if this internal referent system is established for the child in the early stages of therapy, carry-over of correct production to speech contexts unrelated to the speech therapy situation will be facilitated. the efficiency of this procedure may reside in its ability to provide the child with an independent system of articulatory monitoring. herein lies the major downfall of traditional procedures. the result of their focus on the stimulusresponse reinforcement paradigm is that the child is dependent on the therapist to monitor and reinforce his attempts at correct production. mass generalised learning experience, however, seems to provide the child with a strategy for coping with correct production regardless of the presence or absence of stimuli related to correct production in the clinic. conclusion despite the limitations and difficulties inherent in this type of study, the results do provide some support for morehead and johnson's20 hypothesis and also seem to suggest that the application of this principle in the field of articulation therapy may offer the speech therapist the advantage of naturally and effectively attaining successful carry-over. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde vol. 23 desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 avril klaff references 1. backus, 0 . and dunn, h.m. (1947): intensive group therapy in speech rehabilitation./. speech dis., 12, 2, 135-142. 2. carrell, j.a. (1968): disorders of articulation. prentice-hall inc., englewood cliffs, n.j. 3. compton, a.j. (1970): generative studies of children's phonological disorders. 7. speech hear. dis., 35, 4, 315-399. 4. crocker, j.r. (1969): a phonological model of children's articulation competence. / speech hear. dis., 34, 3, 203-213. 5., elbert, m. shelton r.l. and arndt, w.b. (1967): a task for the evaluation of articulation change: i. the development of methodology./. speech hear. res. 10,2,281-288. 6. ' fry, d.b. (1968): the phonemic system of children's speech. british j. disorders communication. 3, 1, 13-19. 7. goda, s. (1970): articulation therapy and consonant drill book: grune and stratton, n.y. 8. goldman, r. and fristoe, m. (1969): goldman-fristoe test of ariculation. american guidance service inc., minnesota. 9. guile, t.c. (1975): personal communication.oept. of phonetics and linguistics, univ. of witwatersrand. 10. halle, m. (1964): on the bases of phonology. in fodor, j.a. and katz, j.j. (eds.) the structure of language: readings in the philosophy of language. prentice-hall inc., englewood cliffs, n.y. 11. hall-powers, m. (1971): functional disorders of articulation: symptomatology and etiology. chapter 33 in handbook of speech pathology and audiology. travis, l.e. (ed.) appleton-century crofts, n.y. 12. hall-powers, m. (1971): clinical and educational procedures in functional disorders of articulation. chapter 34 in handbook of speech pathology and audiology. travis, l.e. (ed.) appleton-century crofts, n.y. 13. hannah, e.p. standel, j. and gardner, j. (1974): distinctive feature analysis. chapter 7 in applied linguistic analysis, hannah, e.p. (ed.) joyce publications, california. 14. leonard, l.b. (1973): the nature of deviant articulation./. speech hear. dis., 38,2, 156-161. 15. lewis, f.c. (1974): distinctive feature confusions in production and discrimination of selected consonants. language and speech, 17,1, 60-67. 16. mason, r.n. and proffit, w.r.: the tongue thrust controversy: background and recommendations. /. speech hear. dis., 39, 2,' 115-132. 17. mcclean, j.e. (1970): extending stimulus control of phoneme articulation by operant techniques. a.s.h.a. monographs, 14, 4, 2447. 18. mcreynolds, l.v. and bennet, s. (1972): distinctive feature generalisation and articulation training. /. speech hear. dis., 37, 4, 462470. 19. mcreynolds, l.v.' and huston, k. (1971): a distinctive feature analysis of children's misarticulations./. speech hear. dis., 36, 155-166. 20. morehead, d.m. and johnson, m. (1972): piaget's theory of intelligence applied to the assessment and treatment of linguistically deviant journal of the south african speech and hearing association, vol. 23. december / 976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mass generalized learning and articulation therapy 43 children. papers and reports on child language development, 4, 143-161. 21. mowrer, d.e. (1971): the transfer of training in articulation therapy. /. speech hear. dis., 36, 4, 427446. 22. oiler, d.k. (1970): regularities in abnormal child phonology. j. speech hear. dis., 38, 3647. 23. pollack, e. and rees, n.s. (1972): disorders of articulation: some clinical application of a distinctive feature approach./. speech hear. dis., 37,4,451461. 24. prins, d. (1963): relations among specific articulatory deviations and responses to a clinical measure of sound discrimination./. speech hear. dis., 28, 4, 382-388. 25. raymore, s. (1970): the effects of systematic training programs on the generalisation of new phoneme responses across different positions in words. unpublished master's thesis, kansas state university. 26. shafer, g. (1974): a spectrographs investigation of acoustic cues in reduced consonant clusters in normal and abnormal child speech. unpublished research report, dept. of speech pathology and audiology, university of the witwatersrand. 27. shelton, r.l. elbert, m. and arndt, w.b. (1967): a task for the evaluation of articulation change. ii. comparison of task scores during baseline and lesson series testing. /. speech hear. res., 10, 3, 578-585. 28. sommers, r.k. and kane, a.r. (1974): nature and remediation of functional articulation disorders. chapter 3 in communication disorders: remedial principles and practices. dickson, s.e. (ed.) scott, foresman and co., illinois. 29. van demark, d.r. (1971): articulatory changes in the therapeutic process. cleft pal. j., 8, 159-165. 30. van riper, c. (1972): speech correction: principles and methods. (5th edition). prentice-hall, inc., englewood cliffs, ν j : 31. weber, j.l. (1970): patterning of deviant articulation behaviour. /. speech hear. dis., 35,2, 135-141. 32. weiner, p.s. (1967): auditory discrimination and articulation. /. speech hear. dis., 32, 1, 19-28. 33. winitz, h. and priesler, l. (1967): the effect of distinctive feature pretraining in phoneme discrimination learning./. speech hear. res., 10,3,515-530. 34. winitz, h. (1969): articulatory acquisition and behaviour. appletoncentury crofts, n.y. 35. wright, v. shelton, r.l. and arndt, w.b. (1969): a task for the evaluation of articulation change: iii, imitative task scores compared with scores for more spontaneous tasks. /. speech hear. res., 12, 4, 875-884. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde vol. 23, desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustics and signal analysis noise problems? general radio has the solution: a complete family of noise measuring instruments for community and industrial noise: n gr1933 — 9 precision sound-level meter gr1944 noise-exposure indicator and monitor gr1565-b for more information please contact: associated electronics (pty.) ltd. p.o. box 31094, braamfontein, phone 839-1824 150 caroline street, b r i x t o n , johannesburg. journal of the south african speech and hearing association. vol. 23 december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 73 the teaching of blissymbols as a bridge into literacy for children with cognitive impairments: a comparison of two training approaches enid moolman and erna alant centre for augmentative and alternative communication, department of communication pathology, university of pretoria summary this study compares the learning of blissymbols by six mildly cognitively impaired children by means of a global and an analytic approach. training consisted of two stages. the first was the training of eight compound symbols and the second the training of seven single configuration symbols. the study concludes that blissymbols as an entrance into literacy can be taught successfully to cognitively impaired individuals by means of either an analytic or a global approach. the analytic approach seems to have greater long-term benefits, as the subjects instructed by the analytic approach consistently performed better in the generalization and re-evaluation procedures. the analytic approach, however, was much more time consuming than the global approach in terms of the length of training required. the implications for literacy development and augmentative and alternative communication systems are discussed. opsomming hierdie studie vergelyk, deur middel van 'n globale en 'n analitiese benadering, die aanleer van blissimbole deur ses kinders elk met geringe kognitiewe gestremdheid. opleiding het uit twee fases bestaan, waarvan die eerste die opleiding van agt saamgestelde simbole behels het en die tweede die opleiding van sewe enkel-element simbole. die bevindinge dui daarop dat bliss-simbole suksesvol deur individue met geringe kognitiewe gestremdheid aangeleer kan word deur middel van of 'n globale of'n analitiese benadering, alhoewel die verskille tussen resultate nie statistics betekenisvol is nie. dit het egter geblyk dat die analitiese opleidingsmetode sekere langtermynvoordele ingehou het, aangesien daar 'n konstante tendens vir die analitiese groep was om beter te vaar met die veralgemeningsen die herevaluasie-prosedures. wat betref die lengte van opleiding was die analitiese opleidingsmetode egter baie meer tydrowend as die globale metode. die implikasies vir die ontwikkeling van geletterdheid en aanvullende en alternatiewe kommunikasie is bespreek. key words: blissymbols, literacy, global approach, analytic approach j introduction j i for many years it was believed that cognitively impaired individuals cannot acquire any literacy skills as they seem to be unable to learn to read and write. studies by researchers such as sterick (1979), folk and campbell (1978), and raver and dwyer (1986), however, demonstrate that the cognitively impaired child can, in fact, learn to read and write. nevertheless, it is worth noting that cognitively impaired individuals tend to achieve reading levels that are below their cognitive levels (buttery & creekmore, 1985). the latter fact has led to a re-evaluation of instructional approaches for teaching literacy skills to the cognitively impaired population as well as our definition of literacy. as a result, the use of augmentative and alternative communication strategies as a bridge to literacy has come under scrutiny. many view literacy in a restricted sense, namely as the ability to read and write. in contrast with this limited view, miller (1990:2) states that "... becoming literate involves learning how to manipulate various bodies of knowledge ... and because being literate involves a way of thinking, literacy becomes entwined with how and what people know. one who is literate is conversant with what is going on in the world." two models of teaching literacy skills can therefore be distinguished. we can either teach the child the technical skill of reading and writing (model 1), or social skills, in other words, equip the child to become a literate participant in society (model 2). the problem with teaching the child only the technical skills of reading/writing is that this is neither meaningful nor functional and the child is unable to identify with it. literacy can be viewed as a systematic progression from recognizing pictures to the use of an abstract symbol system such as normal orthography. to become literate, an individual must be visually directed, able to extract meaning, and able to interpret symbols on different levels of abstractness. initially, blissymbols were used primarily to augment speech in individuals with severe speech and communication problems. it was soon realized, however, that blissymbols could play an important role in bridging the die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 74 enid moolman & erna alant gap between pictures and print, as blissymbols are concept-based and thus easier to learn than normal orthography (luftig & bersani, 1985). in addition, the child can be prepared for the processing of print through the use of blissymbols, as their use includes many of the skills needed for normal orthography. the ability to synthesize elements to make a word, and the ability to integrate and process a number of symbols that communicate an idea are important elements in preparing a child for reading (archer, 1977). these skills can be facilitated by the use of blissymbols, depending on the nature of the instructional approach. as in the teaching of reading, two main approaches for the teaching of blissymbols can be identified, namely a global and an analytic approach. a global approach entails training of the entire symbol without any reference to the symbol elements. an analytic approach, on the other hand, requires an explanation of the meaning of each of the elements within a compound symbol. if a child is therefore taught blissymbols by means of an analytic approach, he/she might be able to transfer this analytic skill to normal orthography (alant, 1994; mcnaughton, 1993). shepherd and haaf(1992) compared the global and analytic training approaches by training individuals who were not disabled, and they found that an analytic training approach could have several advantages over a global approach. results obtained on cognitively normal individuals, however, cannot simply be transferred to the cognitively impaired population. the research discussed in this article therefore serves as a preliminary study to investigate the effects of the global and analytic approaches to blissymbol training for cognitively impaired individuals. it is important for us to determine the effect of these two training approaches as it might be significant in our clinical application. method aims the primary aim of this study was to compare two training approaches in the teaching of blissymbols to cognitively impaired children. the objectives of this study were: to teach specific symbols to group 1 by means of a global approach to teach the same symbols to group 2 by means of an analytic approach to compare the results obtained by these two groups with reference to: * the number of presentations required to reach the criterion * the number of minutes required to reach the criterion * the % of symbols correctly analysed and synthesized during a generalization procedure * the % of symbols correctly identified after a set period without any exposure (re-evaluation procedure) to do a qualitative analysis of individual subject's performances in symbol acquisition with regard to: * ease of acquisition * nature and complexity of symbols subjects pupils enrolled at a school for cognitively impaired children were selected according to specified selection criteria. a total of eight subjects was initially selected, but due to numerous absences and poor co-operation (which, it was felt, could contribute to invalid test results), subjects 1 and 8 were dropped from the study. six subjects (4 male, 2 female) were thus used in this study. all subjects presented with mild cognitive impairment, with an iq score of between 50 and 65, and their chronological ages ranged from 7 to 10 years. to check that, subjects were unable to read the blissymbols, subjects who had a functional reading vocabulary of less than 40 words were selected and subjects had to have had no prior familiarity with blissymbols. all subjects' speech was intelligible most of the time in a context unknown to the listener. none of the subjects suffered from visual, speech, hearing or obvious emotional problems that would have interfered with their performance in the tasks required in this study. all subjects were native afrikaans speakers and came from families who enjoyed middle to high socio-economic status (moolman, 1994). subject characteristics are outlined in table 1. subject selection procedures all subjects had to comply with the criteria previously discussed. for the initial selection of the eight subjects, a pre-evaluation of certain skills was administered (see table 2 and appendix d for a detailed outline). subjects were then paired with one another according to the results obtained during the pre-evaluation. general level of functioning (which included iq score) as judged by the teacher and the local occupational therapist, was considered to be an important aspect for the pairing process. subjects were further paired according to their receptive language, visual perception and reading skills. subject 4 was paired with subject 2, subject 3 with 7 and subject 5 with 6. after subjects had been paired, they were randomly divided into two groups, with each group having the same number of subjects, with more or less the same level of skills. subjects in group 1 (subjects 3, 4, 5) were trained by means of a global training approach and subjects from group 2 (subjects 7, 6, 2) by means of an analytic training approach. table 2 provides a description of the paired subjects' performances on the different aspects used for pairing. research design . a quasi-experimental design was selected for this study as a tightly controlled experimental design in which two groups would be totally comparable would be impossible due to the diversity of children with cognitive impairments. for the purpose of this study six children were identified (three in a group). each child in group 1 was paired with another in group 2. although pairing was a difficult process within this context, the teachers and therapists at the school agreed that on a functional level these two groups were comparable. material and apparatus used during the pre-eval uation phase the tests and material used to assess the subjects' reading, visual perception, level of functioning and receptive language during the pre-evaluation, are outlined in table 3. all the tests and material used during the pre-evaluation are, however, not discussed here due to restricted the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the teaching of blissymbols as a bridge into literacy for children with cognitive impairments 75 t a b l e 1. subject characteristics characteristics subject 2 (group 2) subject 3 (group 1) subject 4 (group 1) subject 5 (group 1) subject 6 (group 2) subject 7 (group 2) chronological age (years and months) 8,5 8,6 9,3 7,3 7,6 8,11 socio-economic status middle-high middle-high high middle high middle hearing normal normal normal normal normal normal vision: general description adequate glasses, adequate adequate short-sighted, adequate adequate glasses, adequate gender male female male female male male home language afrikaans afrikaans afrikaans afrikaans afrikaans afrikaans intelligence quotient* 59 (1991) 50 (1991) 64 (1990) 63 (1992) 64 (1992) 55 (1991) diagnosis cognitive impairment down syndrome microcephaly diffuse brain damage cognitive impairment cognitive impairment medical problems no epilepsy no epilepsy no epilepsy no epilepsy no epilepsy no epilepsy prior exposure to bliss none none none none none none emotional state no obvious problems no obvious problems no obvious problems no obvious problems no obvious problems minimal autistic key to table 1: group 1: subjects taught by global training approach group 2: subjects taught by analytic training approach chronological age: the age recorded in years and months at the commencement of the pre-evaluation phase * intelligence quotient: the year in which the iq test was administered is included in brackets. table 2. criteria used for pairing subjects criteria used for pairing pair 1 1 pair 2 pair 3 subjects s2 (group 2) ί s4 (group 1) s7 (group 2) s3 (group 1) s6 (group 2) s5 (group 1) visual perception good averagegood good good average good average reading (average %) 86 75 76 78 18 17 level of functioning mild cognitive impairment mild cognitive impairment mild cognitive impairment mild cognitive impairment mild cognitive impairment mild cognitive impairment level of functioning: iq score 59 64 50 52 64 63 receptive language (months) 54 1 52 50 60 61 48 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 76 enid moolman & erna alant space. results obtained during thhe pre-evaluation are provided in appendix d. training material and procedure blissymbols were selected from hehner's (1980) "blissymbols for use" as well as from mcdonald's (1989) "teaching and using blissymbolics". a total of twenty eight symbols that represent everyday concepts were selected. eight compound symbols were selected for training during stage 1 and seven single configuration symbols for training during stage 2. a total of fifteen symbols plus three practise items (ball, flower and chair) were thus included for training. symbols for the training phase were selected to include elements of the compound symbols included in the generalization procedure. ten symbols were carefully selected for the generalization procedure (refer to appendix c). the aim of this procedure was to determine whether subjects were able to analyze, synthesize and interpret new symbols based on knowledge gained during training. the symbol elements of the stimuli used in the generalization procedure were all introduced during training, but in combination with different elements: single configuration as well as compound symbols were selected from different word categories (nouns, verbs, adjectives). single configuration symbols can be defined as symbols that contain only one semantic unit or element, e.g., "house", "wheel" and "cloth". compound symbols refer to combinations of more than one semantic element to form new meaning. the symbols that were used during training as well as for the generalization procedure are listed in the appendix. pictures and/or objects representing the eighteen symbols (fifteen training plus three practise items) selected for training were used to explain the concepts and to facilitate training. games and apparatus which included a bliss-man, bliss-electro, a contextual storyboard, matching symbol-to-picture worksheets, picture-your-bliss table 3. tests and material used during the pre-evaluation phase areas tested person responsible for administering the tests tests/material used processing of data reading researcher in co-operation with classroom teacher flashcards containing words which had been taught during the year, were used. areas of evaluation: class mates' names (recognition and labelling) functional reading (recognition and labelling) sight words (recognition and labelling) an average score was determined which was derived from the results obtained for recognition as well as labelling. the percentage referred to in table 2 is thus the mean percentage recognized and labelled correctly in the three areas of evaluation visual local developmental test of visual perception (frostig, 1963) draw-a-man test (goodenough, 1926) developmental test for visualmotor integration (beery, 1967) subjective evaluation: * visual memory * sequencing skills an average score which included all of the subtests, was obtained. visual perceptual skills were categorized as good or average-good i level of functioning iq score school psychologist of that particular district unknown most of the children were tested in the year that they turned six. the year in which the iq test was administered is provided in table 1. iq scores were felt to be current, as the experiment was conducted in 1993 and most of the iq tests performed in 1991 and 1992 / receptive language researcher afrikaans translation of tacl-r (kritzinger, 1985) subtests: word classes grammatical morphemes elaborated sentences a mean score was derived from the results obtained on the three subtests the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the teaching of blissymbols as a bridge into literacy for children with cognitive impairments 77 (blissymbolics communication institute, 1984), dice, puzzles and snap cards were used during the training stage. colour-coded flash cards of all the symbols were made according to the guidelines provided by mcdonald (1989). a weekly outline of the data collection procedures is provided in table 4. prior to training, a pre-evaluation of various skills (language, speech, visual perception, vision, hearing and reading) was performed (see appendix d for results). a pilot study was performed prior to the main study in order to test the effectiveness of the procedure and materials. recommendations were made on the basis of the results of the pilot study. please refer to moolman (1994) for a detailed discussion of the results. the concepts were evaluated on the day before training started. concepts that were unknown were explained, until the subject(s) reached 100%. a baseline evaluation was also performed on this day in order to determine the subjects' ability to guess the meaning of the symbols. training consisted of two stages. stage 1 concentrated on the training of compound symbols and stage 2 on the training of single configuration symbols. compound symbols were trained first, as the researcher wanted to start with two distinct approaches. if single configuration symbols were trained first, the subjects of group 2's actual orientation towards the compound symbols might have been influenced negatively. the presentation of the seven single configuration symbols was the same for both the analytic and global groups. presentation of the compound symbols, however, differed. training was performed by the researcher on a daily basis for approximately 30 minutes per group. this procedure was continued until the 100% criterion for each stage was met by all the subjects. subjects who met this criterion were still included in the training, in order to keep the time without exposure to symbols the same for all subjects. this was an important factor in the re-evaluation procedure. games and activities were used during each training session. picturejyour-bliss was used on days 1, 2 and 3 of stage 1, and only on day 1 of stage 2 of the training. j experimental group 1 (subjects 3,4,5) was trained by means of a global approach. the global training approach implied visual recognition of the symbol as a whole. no elements or components or the composition of the symbols were explained to the subjects. experimental group 2 (subjects 2,6,7) was trained by means of an analytic approach. all the symbols were thus discussed in terms of their composition, elements and components. training of the symbols for both groups included three steps (identification, association and labelling) which can also be referred to as one presentation. the association and labelling steps were exactly the same for both groups. during step 2 (association) subjects had to match the symbol to the storyboard picture and/or to the bliss-man (association within a context). step 3, labelling, was done once within the group and then individually, as each individual subject in the group was asked to label the symbol once. the identification process, however, differed for the analytic and the global groups. the identification process for the global group entailed an outline of the visual agreement between the object/picture and the symbol. the symbol together with the picture/object was held up, the visual agreement was pointed out (only for single configuration symbols) and the symbol labelled. during the identification step for group 2, the symbol was shown to the subjects and labelled. the visual agreement between the real object/picture was pointed out and the different symbol elements were analysed. the meaning of each element was explained and visual agreement of elements was pointed out, for example, "to spit", contains three elements (mouth, arrow, action indicator), and all three had to be discussed individually. elements were then synthesized to form a unit again. subjects of this group were thus guided in their analysis and synthesis of symbols during training and the rationale behind each symbol was explained. individual evaluations of each subject's performance on the eight (compound) or seven (single configuration) symbols were performed daily throughout the training period. the aim of this evaluation was to determine progress and to determine when the criterion (100% correct identification of symbols) was met. directly after the training (in other words, as soon as all the candidates in the group had met the criterion of 100% correct identification of symbols), the generalization procedure was administered. the objective of this evaluation was to determine whether the subjects were able to generalize information they had already been taught to new symbols. a non-verbal response (pointing) was thus required for this section of the evaluation. a choice of one out of three unfamiliar symbols that have visual correspondence (a similar semantic element) had to be made (one stimulus item and two distractors). (please refer to appendix c for symbols.) one month after the generalization procedure, subjects' ability to recall the fifteen symbols taught during training was assessed. a one month time period was selected to coincide with the school holidays. during the four week holiday, subjects had no exposure to blissymbols. the same procedure as that used during daily evaluations was followed in this re-evaluation. table 4. weekly outline of the data collection procedures weeks 1 and 2 week 3 week 4, day 1 rest of week 4, week 5 and 6 (12 days of training) day 13 one month following the generalization procedure pre-evaluation pilot study 1 concept and baseline evaluations training of compound symbols: 10 days training of single configuration symbols: 2 days administering of generalization procedure administering of re-evaluation procedure die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 78 enid moolman & erna alant response definitions a verbal response was expected during the daily evaluations and the re-evaluation procedure in order to eliminate guessing, but a non-verbal response (pointing) during the generalization procedure. responses were scored as correct ( · ) or incorrect (/), and the subject's incorrect responses were also recorded during training, the re-evaluation and generalization procedures. a response was regarded to be incorrect if the subject did not know the answer or gave the wrong answer. symbols that were identified incorrectly were repeated once at the end of the evaluation session to provide the subjects with another opportunity to respond (in both daily evaluations and the reevaluation procedure). data analysis at the beginning of each training session, the exact time was recorded in order to ensure that sessions did not exceed 30 minutes. directly after the training session, the researcher recorded the length of time that the session had lasted (in minutes) as well as the number of presentations for that particular session. "number of presentations" refers to the number of times that the individual symbols were identified, associated with the pictures and labelled by the researcher and/or subjects. "minutes of training" refers to the total number of minutes that were required in order to reach the criterion of 100% correct identification of all the symbols. subjects were then evaluated individually. responses were recorded verbatim and responses were scored as either correct or incorrect. a raw score was therefore obtained. a percentage was calculated in order to determine whether the criterion had been met. this procedure was followed for each training session until the criterion was met. after training, the number of presentations and number of minutes that each subject required to fulfil the criterion for each stage (first the compound symbols and then the single configuration symbols) were calculated. a mean percentage for the global and analytic groups was then calculated for each stage. for the generalization and re-evaluation procedures, responses were once again scored as either correct or incorrect and the subject's responses were written down. following the calculation of a raw score, a percentage for each individual subject was once again calculated, as was a mean percentage for the global and analytic groups. results obtained were firstly analysed in terms of a comparison between the global and analytic groups. a qualitative error analysis was then performed in order to determine the nature of the subjects' errors and difficulties. results a comparison of the results of the global training method group and the analytic training method group the results obtained by group 1 and 2 during training are presented graphically in figures 1 and 2. the results shown in figures 1 and 2 clearly indicate that group 1 required fewer minutes of training to fulfil the criterion for both the single configuration and compound symbols. group 1 required 95 minutes to learn all 15 symbols, whereas group 2 required 155 minutes. thus there is a difference of 60 minutes. although group 2 resingle configuration compound total i global group 3 analytic group total: minutes (mining for compound and single configuration symbols single configuration compound i global group i analytic g r o u p ' total: number of presentations for compound and single configuration symbols figure 1: results obtained during training: length of figure 2: results obtained during the generalization training procedure table 5. results obtained during the generalization procedure group 1 (subjects trained through global training approach) group 2 (subjects trained through analytic training approach) raw scores percentages raw scores percentages individual raw scores 6,6,6 7,6,7 mean scores and percentages 18/30 60% 20/30 66,7% the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) teaching of blissymbols as a bridge into literacy for children with cognitive impairments 79 uired more minutes to fulfil the criterion, the number of q r e s e n t a t i o n s for both groups to learn the compound symbols was the same (9 presentations). group 1, on the other hand, required fewer presentations for the single configuration symbols than group 2 (2 vs 4 presentations). results obtained during the generalization procedure are presented in table 5. in ikble 5 it is interesting to note that group 2 performed slightly better in the generalization procedure, with a mean of 66,7% (20/30), compared to group l's 60% (18/ 30). all the subjects in group 1 obtained a raw score of 6/ 10 whereas two subjects from group 2 scored 7/10 and the third subject scored 6/10. results obtained during the re-evaluation procedure are presented in table 6. as table 6 indicates, group 2 also performed slightly better than group 1 on the re-evaluation procedure. group 2 obtained a mean of 97,8% (44/45), whereas group 1 remembered 91,1% (41/45) of the symbols correctly. three subjects, two from group 2 and one from group 1, remembered all the symbols and scored 100%. error analysis a qualitative error analysis has been performed in order to determine the nature of the subjects' substitutions and difficulties in the three phases (training, re-evaluation and generalization procedures). ease of acquisition was one of the areas of interest. it was scored in terms of number of presentations. during the training phase some symbols were acquired with greater ease than other symbols and differences in the performances of the two groups in terms of ease of acquisition were noted. the results are outlined in table 7. table 6. results obtained during the re-evaluation procedure group 1 (subjects trained through global training approach) group 2 (subjects trained through analytic training approach) raw scores percentages raw scores percentages individual raw scores 13,15,13 15,14,15 mean scores and percentages 41/45 91.1% 44/45 97,8% table 7. an error analysis of the results obtained during the training phase group 2 (analytic training method) group 1 (global training method) symbol mean number of presentations symbol mean number of presentations compound symbols symbols most ' difficult to acquire to smell 5 to fly 6 symbols most ' difficult to acquire rain 5 symbols easiest to | acquire ] i 1 to dance 1.6 to dance 2 symbols easiest to | acquire ] i 1 bath 1.6 bath 2.6 symbols easiest to | acquire ] i 1 to fly 1.6 / single configuration symbols symbols easiest to acquire house 2 house 2 symbols easiest to acquire ear 2 ear 2 symbols easiest to acquire wheel 2 wheel 2 symbols easiest to acquire cloth 2 cloth 2 symbols easiest to acquire table 2 table 2 symbols easiest to acquire eye 2 eye 2 symbols easiest to acquire 2 room 2 symbols most j difficult to acquire room 2.7 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 80 enid moolman & erna alant group 2 experienced most difficulty with the symbols "to smell" and "rain". a mean of 5 presentations was required to fulfil the criterion. group 2 acquired the symbol "to fly" with great ease, requiring a mean of 1.6 presentations, whereas group 1, by contrast, experienced the greatest difficulty with this symbol, requiring a mean of 6 presentations. similarities were, however, also noted. the symbols "bath", "to dance" and "to fly" were acquired first by group 2 with a mean of 1.6 presentations. group 1 also acquired the symbol "to dance" first, with a mean of 2 presentations, followed by "bath" (mean of 2.6 presentations). the symbols "happy", "to smell" and "rain" were acquired only in the later stages of training in both groups. all the single configuration symbols were acquired with the same degree of ease by group 1, requiring a mean of 2 presentations. one subject from group 2, however, experienced difficulty with the acquisition of the symbol "room" and therefore a mean of 2.7 presentations were required by group 2 to fulfil the criterion. a qualitative analysis of subjects' responses during the generalization procedure revealed a number of interesting points. the results are outlined in table 8. group 2 scored the lowest (0%) for the symbols "to cry" and "sad" and scored 100 % for the symbols "to hear", "bathroom", "garage", "aeroplane" and "low". 66,7% of the group was able to recognise "table cloth" and "legs" and 33,3% recognised "to jump". group 1 scored the lowest for the symbol "sad" (0%) and the highest for the symbol "to hear" (100%). only 33,3% were able to identify "to jump" and "legs", and 66,7% were able to identify the rest of the symbols ["garage", "bathroom", "low", "to cry", "aeroplane", "to dance"]. similarities and differences were once again noted in the performances of the two groups during the generalization procedure. both groups scored 100% for the symbol "to hear" and scored 0% for the symbol "sad". the symbols "bathroom", "garage" and "aeroplane" were identified correctly by most of the subjects of both groups, as group 2 scored 100% and group 1 66,7% correct identification. table 9 provides the results of the re-evaluation procedure for the different word classes as well as the different symbols. during the re-evaluation procedure, group 2 scored a mean of 96,3% for nouns, as opposed to 100% for verbs and adjectives. group 1 remembered 88,9% of the nouns, 100% of the adjectives and 91,7% of the verbs. group 2 thus performed better than group 1 for nouns as well as for verbs. group 2 thus remembered 100% of the compound symbols and 85,7% (6/7) of the single configuration symbols. during the re-evaluation of group 2, only subject 6 responded incorrectly once, as he did not remember the noun "cloth" (single configuration symbol). subjects from group 1 responded incorrectly to the symbols representing the following nouns: "room", "wheel" (single configuration symbols), "rain" (compound symbol) and also to the verb "to spit" (compound symbol). group 1 remembered 71,4% (5/7) of the single configuration and 75% (6/8) of the compound symbols. the qualitative error analysis furthermore revealed that the subjects of both groups remembered more compound than single configuration symbols after a period without any exposure to the symbols. symbol reduction table 8. an error analysis of the results obtained during the generalization procedure % correct (from lowest to highest score) score) group 2 (analytic training method) group 1 (global training method) lowest score: 0% sad sad lowest score: 0% to cry 33,3% to jump to jump 33,3% legs 66,7% table cloth garage 66,7% legs bathroom ! 66,7% low 1 66,7% to cry 66,7% aeroplane 66,7% to dance highest score: 100% to hear to hear highest score: 100% bathroom / highest score: 100% garage highest score: 100% aeroplane highest score: 100% low the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) teaching of blissymbols as a bridge into literacy for children with cognitive impairments table 9. an error analysis of the results obtained during the re-evaluation procedure: word classes and symbols % correct group 2 (analytic training method) group 1 (global training method) word classes nouns 96,3 88,9 word classes verbs 100 91,7 word classes adjectives 100 100 symbols single configuration symbols 85,7 71,4 symbols compound symbols 100 75 was noted within group 2 during training, as subjects often only remembered one element and responded accordingly. indicators were also often ignored by this group. during the generalization procedure, the subjects of both groups scored 100% correct identification for the symbol "to hear", and 0% correct identification for the symbol "sad". group 2 also scored 0% for the symbol "to cry". discussion from the above results it is clear that group 2 required much more time (in minutes) during the training-phase to reach the criterion of 100%. the main reason for this is most probably the nature of the teaching strategy. the teaching strategy used involves three steps, namely identification, association and labelling. these three steps can also be referred to as "one presentation". only the identification process differs for ithe two groups and led to the longer training period for group 2. the length of training obviously has important implications, particularly for educators and clinicians. time is a very important factor in the lives of the handicapped. alot of time goes into therapy and very little time is left [over for educational programs (light & kelford smith, 1993; smith, 1992). the implication is therefore that clinicians/educators often choose the approach which takes leastjtime, as opposed to an approach which takes much longer,! but gives the same initial results. this is supported by literature on the teaching of reading (greyling & joubert, 1989). colheart (in blau, 1988) suggested that the two routes to reading operate parallel to each other, but that the direct visual route (global approach) is a faster method for lexical access than the indirect visual route (analytic approach). many teachers therefore prefer a global approach to an analytic approach due to the shorter teaching time. however, the hypothesis can be argued that the time required for training (teaching strategy) is reduced the longer the subjects are exposed to blissymbols. the reason for this is that more symbols and elements are already known and therefore require less/no explanation, as well as the fact that subjects might be more familiar with the processes of analysis and synthesis. light and lindsay (1991) refer to this as "automaticity". according to these researchers the cognitive operations become fully automatized with repeated practise, and as a result they no longer require attentional resources and hence do not use up any of the limited space in working memory. what is clear, however, is that a criterion of 100% correct identification of symbols does not necessarily imply that the skills of analysis and synthesis are established. educators need to help cognitively impaired children more (and in other ways) with the transfer of these skills. one possibility could be to combine symbol elements with a variety of other symbol elements in as many contexts as possible, for example, "house" + "wheel"; "house" + "animal"; "house" + "envelope", etc. in other words, the number of different recurrent elements should be increased in a variety of contexts. the finding that group 2 required more time to reach the criterion does not necessarily imply that these subjects experienced more difficulty in acquiring the symbols. the ease of acquisition (scored in terms of number of presentations) for compound symbols was the same for both groups. in terms of ease of acquisition of compound symbols, the one method therefore did not seem to be more effective than the other. in fact, shepherd and haaf (1992) found that their non-disabled subjects trained using the composite meaning method (the analytic approach) required fewer trials for learning than those subjects trained via whole symbol memorization (the global approach). it therefore appeared to be easier for subjects to learn blissymbols when trained to their component elements. one must bear in mind, however, that results obtained by non-disabled individuals cannot be applied uncritically to cognitively impaired individuals. it is worth noting that group 1 in this study required a smaller number of presentations to reach the criterion for the single configuration symbols (2 vs 4 presentations), but this observation alone was not the main reason for the noticeable difference in the length of training required by the two groups. one has to conclude that the methodology or teaching strategy of the analytic approach is the main factor/cause for the longer training period required. it is important to note that the subjects of group 2 initially (day 1 of training) seemed overwhelmed by the different components/elements and therefore scored less well than group 1. on day 2, however, they scored much better and the difference between the two groups' performances was much smaller. this might be explained by the complexity of die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 82 enid moolman & erna alant blissymbols. according to luftig and bersani (1985), it appears that component complexity may initially confuse a naive learner as he/she struggles to learn a new list of unfamiliar symbols. these researchers, however, mentioned that the effects of component complexity are reduced as the learner becomes more familiar and has to link the symbols with a new set of responses. according to luftig and bersani (1985), clinicians should introduce the less complex symbols first, until the learner is familiar with the nature of the system. in this study, however, compound symbols were introduced first in order to differentiate clearly between the two stages and the two distinct training strategies. it was felt that training single configuration symbols first would influence the subjects of group 2's orientation to an analytic approach. at this stage it is uncertain whether this aspect has influenced the results of the study or not, as the study had no control group. it is, however, clear that all the subjects, particularly those of group 1, acquired the single configuration symbols with real ease, requiring only 2 presentations to fulfil the criterion (4 presentations for group 2). an important difference was noted in the performance of the two groups during the re-evaluation and generalization procedures. the results of this study, as well as of that of shepherd and haaf (1992), suggest that subjects trained by means of an analytic approach benefitted more in the long term than those trained by means of a global approach. the results of this study indicate that there are no major differences between the two groups' performances, but that group 2 consistently tended to perform better on the re-evaluation and generalization procedures. consequently, this phenomenon suggests that the analytic approach has long-term benefits. in the selection of a teaching approach for the teaching of blissymbols, the long-term effects must definitely be considered. group 2 performed slightly better than group 1 on the re-evaluation procedure. whatever advantages were gained in the analytic training approach were maintained over the one month period without training. this confirms shepherd and haaf's (1992) research, as they also found that their nondisabled subjects trained by composite meaning (analytically) out-performed subjects trained via whole symbol memorization (global approach) in the re-evaluation phase. this raises the question as to why group 2 remembered the symbols better, but did not necessarily learn them faster than group 1. schlosser and lloyd (1992) postulated that it is possible that acquisition and retention require different skills. "hypothetically speaking, acquisition testing may have been mastered primarily through immediate recall, while retention testing may have required more reliance on an analysis of the cues provided (compound blissymbols) on the testboards" (schlosser & lloyd, 1992:25). an analytic training approach may have facilitated the analysis of these cues as well as aided recognition memory. if a child only remembers the element" bread" in the compound "toast", for example, he might be able to extrapolate the other elements and the combined meaning or make a good guess (schlosser & lloyd, 1992). an alternative explanation for group 2's better performance on the re-evaluation procedure might be that the subjects understood the logic behind the symbols, and because they knew the different elements, it was easier for them to remember the symbols. for group 1, it was merely a visual symbol that they had to memorize, with no logic behind the symbols. that could also explain why subjects of group 1 substituted symbols such as "rain", with "to fly" and "to smell", and the symbol "to spit", with "to dance" and "flower". there was no correlation between the actual symbol and the substitute symbols (in terms of elements) it seemed as if they rather relied on guessing and thus showed limited coping skills. results also indicate that the subjects from group 2 did slightly better on the generalization procedure. this also confirms shepherd and haaf's (1992) study. they found that subjects who were trained via the composite meaning method (analytic approach) were able to generalize symbol knowledge more effectively than subjects trained via whole symbol memorization (global approach). johnsen and jennische (in mcnaughton, 1993) suggested that the processing skills of segmenting and sequencing that a child develops by using type 2 symbols (such as sequenced ideographic blissymbols) can help prepare the child for the processing of print. an analytic training approach therefore equips the child with the potential to transfer these skills to novel symbols. the difference between the two groups' performances was small, and thus statistically insignificant, and this raises the question of why the differences were not more marked. one factor could be that the skills of analysis and synthesis were not totally established and carried over. although some of the subjects knew all the different components of each of the training symbols, they were not ready to transfer these skills to novel symbols. they were, however, able to do so in most of the cases and were well on their way to achieving these skills. a longer training period would probably have helped the individuals with the transfer of these skills. a qualitative error analysis led to a few interesting observations with regard to the acquisition, retention and generalization of specific symbols. these are discussed briefly. according to many researchers (bloomberg, karlan & lloyd, 1990; blackstone, 1990), translucency seems to have a positive effect on learning when individuals are learning to pair an already familiar spoken word with a symbol. iconic symbols are easier to learn because most iconic symbols represent concrete objects/entities (blackstone, 1990). it is therefore not surprising that the single, configuration symbols were learned by both groups after a smaller number of presentations than the compound symbols. however, single configuration symbols were not retained better than the compound symbols by either group. with the re-evaluation procedure, group 2 only had one symbol wrong, namely "cloth" (doek). group 1 also remembered more compound symbols than single configurations. although a number of reasons are possible, the two main reasons that contributed to this phenomenon would appear to be the level of possible visual discrimination and component complexity. "visual discriminability" (in other words, when a group of related symbols appear very similar with only minor differences) could have played a role in the results that were obtained. musselwhite and ruscello (1984) reported that the "discriminability" of the symbols can pose a possible identification (and, it seems in this case, retention) problem. in an informal analysis, schlosser and lloyd (1992) found that the number of elements in compounds does not correlate with the degree of acquisition when elements are pretaught (analytic approach). however, the number of the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) teaching of blissymbols as a bridge into literacy for children with cognitive impairments elements in compounds seems to correlate negatively with the degree of acquisition when compounds are taught directly (global approach). in other words, the fewer elements in a compound, the better the degree of acquisition if a global training approach is used (schlosser & lloyd, 1992). this could explain why group 1 required only 2 presentations in the acquisition of single configuration symbols, versus group 2's 4 presentations. l b summarize: no major differences between the two training groups' performances were noted, but there was a definite tendency for group 2 to perform better on the re-evaluation and generalization procedures. conclusions the purpose of the study was to compare two training approaches (global vs analytic) in the learning of blissymbols by mildly cognitively impaired subjects. the following results were obtained: a slight difference between the two groups' performances in all the areas was noted. group 2 consistently tended to perform better in the reevaluation and generalization procedures. one could hypothesize that if the training period were to be continued, even stronger gains could have been made by group 2. the analytic training approach, however, was much more time-consuming than the global approach. the two groups required almost the same number of presentations to fulfil the criterion (with group 1 requiring two presentations less than group 2) and therefore one can conclude that the ease of acquisition was similar for both groups. a qualitative analysis reveals that compound symbols are retained better over a one month period without any exposure than single configuration symbols are. individual variations were noted throughout training. subjects experienced specific problems with the generalization of some of the symbols, such as "to cry" and "sad", but then again acquired other symbols such as "bath" / "to dance" with relative ease. one can thus conclude that mildly cognitively impaired subjects are able to learn blissymbols by means of either an analytic approach or a global approach, but that individuals seemed to benefit more from an analytic approach. more emphasis should, however, be placed on the teaching of indicators land abstract elements. whether or not these conclusions extend to individuals with more severe levels of cognitive impairment is subject to further inquiry. ; this study confirmed .that blissymbols can be taught successfully to the mildly cognitively impaired child through either a global and/or an analytic approach. although there was only a slight difference between the two groups' performances during training, there was a consistent tendency for group 2 to perform better than group 1 in the re-evaluation and generalization procedures. this study thus provides initial data to suggest that the training of blissymbols through an analytic approach provides advantages in the retention of symbols as well as with regard to the generalization to new symbols. as cognitively impaired individuals may experience problems with analysis and synthesis, the use of an analytic approach to help such children to cope with these skills in relation to normal orthography is important. also, if one considers the benefits that an analytic approach offers, in that it prepares the child to cope with the processes of analysis and synthesis which are required to learn normal orthography by means of a phonetic approach, the analytic approach seems to be preferable. one should, however, not see blissymbol teaching as an either/or approach, but one should rather try to balance longand short-term goals and teach whatever is needed (whether this is pictographic/single configuration or compound symbols) (schlosser & lloyd, 1992). this recommendation is also in line with the suggestion made by ehri (in gough, ehri & treiman, 1992) to use a combined approach rather than an either/or approach in teaching reading. references alant, e. 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(1990). facilitating literacy learning in children with speech and physical impairments. paper presented at isaac conference, stockholm, sweden. koppenhaver, d.a., coleman, p.p., kalman, s.l. & yoder, d.e. (1991). the implications of emergent literacy research for children with developmental disabilities. american journal of speech-language pathology, 1, 38-44. kritzinger, a. 1985. afrikaans translation of the "test of auditory comprehension of language ii (tacl): original compiler: carrow-woolfolk. texas: dlm teaching resources. light, j. & lindsay, p. (1991). cognitive science and augmentative and alternative communication. augmentative and alternative communication, 7, 186-203. light, j. & kelford smith, a. (1993). home literacy experiences of preschoolers who use aac systems and of their nondisabled peers. augmentative and alternative communication, 9, 1025. luftig, r.l. & bersani, h.a. (jr). (1985). an investigation of two variables influencing blissymbol learnability with nonhandicapped adults. augmentative alternative communication, 1, 32-37. mcdonald, e.t. (1989). teaching and using blissymbolics. toronto: blissymbolics communication institute. mcnaughton, s. (1993). graphic representational systems and literacy learning. topics in language disorders, 13, 58-75. miller, l. (1990). the roles of language and learning in the die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 84 development of literacy. topics in language disorders, 10, 124. moolman, e. (1994). a comparison of two training approaches in the learning of blissymbols by cognitively handicapped children. unpublished m-logopaedics thesis, university of pretoria. musselwhite, c.r. & ruscello, d.m. (1984). transparency of three communication symbol systems. journal of speech and hearing disorders, 27, 436-443. raver, s.a. & dwyer, r.c. (1986). teaching handicapped preschoolers to sight read using language training procedures. the reading teacher, 40, 314-321. romski, m.a., sevcik, r., pate, j. & rumbaugh, d. (1985). discrimination of lexigrams and traditional orthography by nonspeaking severely mentally retarded persons. american journal of mental deficiency, 90, 185-189. e n i d m o o l m a n & e r n a alant schlosser, r.w. & lloyd, l.l. (1992). effects of initial element teaching in a story-telling context on blissymbol acquisition and generalization. purdue university, west lafayette, in. shepherd, t.a. & haaf, r. (1992). a comparison of two training methods of blis-symbols. paper presented at isaac conference, philadelphia. singh, n.n. & singh, j. (1986). reading acquisition and remediation in the mentally retarded. international review of research in mental retardation, 14, 165-199. smith, m.m. (1992). literacy and aac: methodological issues and research priorities. paper presented at isaac conference, philadelphia. sterick, g. (1979). a follow-up study often children who learned to read in a class for trainable students. education and training of the mentally retarded, 14, 170-176. a p p e n d i x a a p p e n d i x β graphic r e p r e s e n t a t i o n of s y m b o l s u s e d d u r i n g t r a i n i n g a n d g e n e r a l i z a t i o n proc e d u r e s c o m p o u n d s y m b o l s u s e d d u r i n g training (stage 1) single c o n f i g u r a t i o n s y m b o l s u s e d d u r ing training (stage 2) s y m b o l g r a p h i c r e p r e s e n t a t i o n b a d (bath) r e e n (rain) ψ spoeg (to spit) έν vlieg (to fly) dans (to d a n c e ) ruik (to s m e l l ) 1 bly / g e l u k k i g (happy) c n h o o g ( h i g h ) s y m b o l g r a p h i c r e p r e s e n t a t i o n tafel (table) 1—. d o e k (cloth) η huis (house) ώ w i e l (wheel) β o o g (eye) ο k a m e r (room) η o o r (ear) ! ι the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t b t e a c h i n g of blissymbols as a bridge into literacy for children with cognitive impairments 85 appendix c symbols used during the generalization procedure g^lmulus item additional symbol additional symbol tafeldoek (table cloth) # 1 — 1 mat (carpet) ή ι ζ ] servet (napkin) # 2 motorhuis (garage) poskantoor (post office) 0 0 skuur (barn) huil (to cry) j\ ο φ slaap (to sleep) a m reenjas (raincoat) badkamer (bathroom) klaskamer (classroom) z l v l / o eetkamer (diningroom) ί ο hoor (to hear) a ο asem (breath) a. z o bril (classes) e n o a spring (to jump) λ. swaai (to swing) λ meng (to mix) vliegtuig (aeroplane) ύ wa (wagon) rolskaatse (roller skates) a ^ si bene/voete (legs/feet) klim (to climb) z l t kom (to come) λ ongelukkig (sad) 0 j , troos (to comfort) φ ώ vrede (peace) ώ laag (low) i ! < dun (thin) v ί κ groot (big) v i appendix d results of the pre-evaluation test subjects j 2 3 4 5 6 7 area assessed: } ae ae ae ae ae ae a. receptive language: (months) 45-48 word classes and relations: 48-51 47-50 51-54 42-44 59-65 45-48 grammatical morphemes: 49-53 58-63 58-63 54-58 46-50 59-65 elaborated sentences: 61-64 71-75 42-45 42-45 71-75 40-43 b. auditory perception: <6,0 auditory memory 6,8-6,11 <6,0 8,0-8,3 <6,0 7,4-7,7 <6,0 auditory sequencing 6,0-6,3 6,0-6,3 6,0-6,3 6,8-6,11 6,4-6,7 <6,0 auditory analysis <6,0 <6,0 <6,0 <6,0 <6,0 <6,0 (pendulum score) subjective evaluation: 5/5 *2 syllable words: 5/5 5/5 5/5 5/5 5/5 5/5 *3 syllable words: 3/5 3/5 0/5 3/5 5/5 5/5 *4 syllable words: 1/5 0/5 0/5 1/5 0/5 0/5 auditory closure <6,0 <6,0 <6,0 <6,8<6,0 <6,0 suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 86 enid moolman & erna alant auditory synthesis <6,0 <6,0 <6,0 <6,0 <6,0 <6,0 sound blending 7,7 5,3 7,1 6,2 6,8 5,3 c. reading: names of classmates: % recognized % labelled 100 71 100 71 93 79 46 18 27 18 100 100 functional words: % recognized % labelled 100 100 67 44 100 75 38 0 38 25 78 56 sight words: % recognized % labelled 67 75 100 83 67 33 0 0 0 0 67 50 average score: % word recognition 89 89 87 28 22 2 average score: % word labelling 82 66 63 6 14 69 d. expressive language: mean length of utterance 6,6 2,3 5,9 5,30 6,1 4,1 predicted chronological age (months) >58,3 29,3 57,5 52,8 >58,3 43,4 speech intelligibility (see scale) 5 3 5 5 3 5 e. visual perception rating: average score (the average score includes all the subtests provided below) good 4,8 good 4,4 average good 4,4 average 4,5 average 4,3 good 4,9 *key: ae: age equivalent ps: although the test of oral language production was administered, the results are not provided here, as it was thought to be unreliable. subjects experienced extreme difficulty with story formulation, and were unable to provide a meaningful story most of the time. ( results of the visual perception testing subtests s 2 s4 s7 s3 s s 5 , draw-a-man test 3,6 3,9 4,6 4,3 3,6 4,0 j visual-motor integration 3,9 3,6 4,9 4,4 4,9 4,9 ; hand-eye co-ordination 4,0 3,9 4,9 4,9 4,6 4,6 ' foreground-background 3,3 3,6 3,6 3,9 4 3,9 form consistency 5,6 6,0 5,6 4,6 4 4,6 position in space 5,0 5,0 5,0 4,9 4,9 5,6 ' spatial relationships 4,9 3,0 4,9 5 4,9 4,9 . memory (subjective evaluation) 8 6,0 6,0 4 4 ' 5 sequencing (subjective evaluation) 5 4,6 4,6 4 4 4 total score 43,3 39,6 44,1 40 38,9 40,7 average score 4,8 4,4 4,9 4,4 4,3 4,5 the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 49 the knowledge and attitudes of occupational therapy, physiotherapy and speech-language therapy students, regarding the speech-language therapist's role in the hospital stroke rehabilitation team. lisa felsher and eleanor ross department of speech pathology and audiology university of the 'witwatersrand abstract the purpose of the present study was to survey and compare the knowledge and attitudes of final year occupational therapy, physiotherapy and speech-language therapy students, concerning the role of the speech-language therapist as a member of the stroke rehabilitation team in the hospital setting. in order to achieve this aim, a questionnaire was administered to final year students in these three disciplines, and included questions on most areas of stroke rehabilitation with which the speech-language therapist might be involved, as well as the concepts of rehabilitation and teamwork in relation to stroke rehabilitation. results suggested a fairly good understanding of the concepts of rehabilitation and teamwork. students appeared to have a greater understanding of those disorders following a stroke, with which the speech-language therapist is commonly involved, such as aphasia, dysarthria, verbal apraxia and dysphagia. however, students appeared to show less understanding of those disorders post-stroke, for which the speechlanguage therapist's role is less well defined, such as agraphia, alexia and amnesia. in addition, a high percentage of role duplication / overlapping in several aspects of stroke rehabilitation, such as family and social support, was found. several implications for facilitating communication, collaboration and understanding between paramedical professions, as well as for further research are also provided. opsomming die doel van die huidige studie was om die kennis en houdings van finalejaarstudente in arbeids-, fisio en spraaktaalterapie ten opsigte vdn die rol van die spraak-taalterapeut as lid van die beroerterehabilitasiespan in die hospitaalopset te ondersoek en te vergelyk. om die doel te bereik, is 'n vraelys deur die finalejaarstudente in die drie dissiplines voltooi en is vrae in die meeste areas van beroerterehabilitasie waarby die spraak-taalterapeut betrokke mag wees, sowel as konsepte van rehabilitasie en spanwerk in verband met beroerterehabilitasie, ingesluit. die resultate^ dui op 'n redelike goeie begrip van die konsepte van spanwerk en rehabilitasie. die studente blyk 'n beter begrip te he vir die afwykings na 'n beroerte waarby die spraak-taalterapeut dikwels betrokke is, soos afasie, disartrie, verbale apraksie en disfagie. die studente toon egter minder begrip van die afwykings na beroerte waar die spraak-taalterapeut se rol minder duidelik gedefinieer is soos agrafie, aleksie en amnesie. verder is 'n hoe persentasie van die funksies dupliserend of oorvleuelend bevind in 'n aantal aspekte van beroerterehabilitasie soos familiale en sosiale ondersteuning. verskeie implikasies vir die fasilitering van kommunikasie en begrip tussen paramediese professionele personeel, sowel as vir verdere navorsing is ook verskaf. stroke is r e g a r d e d as o n e of the l e a d i n g c a u s e s of d e a t h and disability in all races in south africa (fritz & penn, 1992). t h e t e r m " s t r o k e " is s y n o n y m o u s w i t h c e r e b r o v a s c u l a r accident (cva), which a c c o r d i n g to the world h e a l t h o r g a n i s a t i o n ( w h o ) , can be defined as "a sudden ( a c u t e ) d i s t u r b a n c e ) of b r a i n (cerebral) function of v a s c u l a r origin, c a u s i n g disability lasting m o r e t h a n , or d e a t h w i t h i n , 24 h o u r s " ( c l i f f o r d r o s e & c a p i l d e o , 1981). t h e c o n s e q u e n c e s of s t r o k e are far r a n g i n g and i n c l u d e p h y s i c a l , c o m m u n i c a t i o n , social, p e r s o n a l and e c o n o m i c d i s t u r b a n c e s . a p a r t from the m e d i c a l attention stroke patients m a y need, they m a y also require n u r s i n g s u p p o r t , and will usually need help in r e c o v e r i n g their physical, e m o t i o n a l and social functioning (wade, langton-hewer, skilbeck & david, 1985). thus, m o r e often the major thrust of t h e r a p y is in t e a c h i n g the patient to live in a n o r m a l e n v i r o n m e n t , providing family support, social welfare a s s i s t a n c e , p s y c h o logical care, and rehabilitation of speech, m o v e m e n t and co-ordination (fritz & penn, 1992). c h a m b e r l a i n (1989, p.311) defined r e h a b i l i t a t i o n as "a process designed to m a x i m i s e a patient's physical, m e n t a l , social and v o c a t i o n a l p o t e n t i a l . " a s no single health professional can be expert in all t h e s e areas, a t e a m of professionals is necessary for a r e h a b i l i t a t i v e p r o g r a m m e to b e effective ( s t o n n i n g t o n & b r o w n e , die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 lisa felsher & eleanor ross 1987). dean & geiringer (1990, p.275) add that the ideal rehabilitation team uses an interdisciplinary approach, whereby "individual professionals from different disciplines evaluate patients according to their own speciality and contribute to a team conference for the patient." through the synchronous endeavours of multiple specialists, rehabilitation thus attempts to identify all disturbances and their causes, attempting to reduce them, while s i m u l t a n e o u s l y identifying c o m p e n s a t i n g strengths (bluestone, 1976). the concept of team management is rapidly becoming accepted as one of the most holistic, economic and efficient means of providing a patient with the best possible care (haller & sheldon, 1976; boone, 1987). while many advantages of teamwork have been listed in the literature, such as the experience in participatory learning for team members and the provision of a comprehensive but integrated range of services for the patient (kane, 1975; germain, 1984; stonnington & browne, 1987), several disadvantages to team practice also exist. these include a lack of knowledge abovit the education and expertise of other disciplines, the problem of role definition that exists among team members, and the fostering of undesirable competition or professional jealousy. according to penn (1992), a large proportion of people who have had a stroke, suffer from a communication disability. hence, the speech-language therapist who specializes in communication disorders, is an integral member of the professional partnership that exists between rehabilitation specialists. "communication is a basic function, taken for granted until it fails" (wade et al., 1985, p. 135). the three most common disorders of communication resulting from a stroke which affect speech and language are aphasia, dysarthria and apraxia. aphasia refers to "the loss or impairment of the ability to use and understand language" (fritz & penn, 1992, p.203), while dysarthria is defined as an "impairment in articulation of sounds caused by muscle weaknesses and incoordination of muscles responsible for speech and breathing" (fritz & penn, 1992, p.205). in contrast, apraxia, which is "a disorder of learned movement distinct from paralysis, weakness and incoordination, that results in a disturbance in motor-planning" (love & webb, 1986, p. 275). in addition, dysphagia which is a disorder of swallowing, occurs in approximately one third of stroke patients (penn, 1992). communication disorders "often impinge upon social, emotional and financial well-being" (simmons, 1985, p.7). as a result, "speech pathology and audiology have a closer affinity to rehabilitation medicine than any other department in a hospital" (bluestone, 1976, p. 12). moreover, simmons (1981) states that the speech-language therapist, who is experienced in the diagnosis and management of neuropathologies of communication, can be a major contributor to the care of the neurologically impaired patient. according to softley (1987), the aims of treating speech and language disorders in the stroke patient, are the restoration of an effective communication system and the readjustment of the patient and his/her family, to changes in the way they communicate. in addition penn (1992, p.55) states that "a speech and language therapist teaches patients to communicate as fully as possible, assessing and treating problems of speech, hearing, understanding, verbal and gestural expression, and reading and writing disorders." according to simmons (1981), the management of the patient with a neurogenic communication disorder ideally involves a co-operative interaction between medical specialists and speech-language therapists. in addition, a variety of other professionals are extremely i m p o r t a n t in the m a n a g e m e n t of p a t i e n t s with neurogenic communication disorders. while physiotherapists and occupational therapists improve the physical foundations for successful communication and contribute information on the integrity of sensori-motor systems, the neuropsychologist where appropriate, administers comprehensive test batteries to provide data on various aspects of intelligence and mental status (simmons, 1981). from the previous discussion, it would appear that the speech-language therapist has a crucial role to play in the stroke rehabilitation team. however, it would seem that there is often a lack of understanding among medical and paramedical personnel regarding the role and functions of speech and language therapy, with the result that the patients requiring such services may not always be referred to a speech-language therapist (clifford-rose & capildeo, 1981). this fact is illustrated by milner (1989), who investigated the knowledge and attitudes of senior medical students concerning the role of the speech-language and hearing therapist in the treatment of communication disorders. she concluded that most members of the medical profession remain unaware of the critical importance of speech and hearing therapy services for individuals whose communication abilities are impaired. findings in this study suggested that the medical students required education concerning the profession of speech and hearing therapy, and "the assistance that speech and hearing therapists can offer as members of the health team" (p.30). furthermore, motona and nowitz (1991) attempted to establish qualified physiotherapists' appropriate definitions of rehabilitation, and their views regarding what it encompasses. included in a questionnaire, were questions pertaining to the composition and leadership of the rehabilitation team. the speech-language therapist was seen to be an essential member of the team, however, the extent to which he/ she is involved in the stroke rehabilitation team was not established. in a study by waller and murphy (1985), speech-language therapists who work in a medical setting, were requested to indicate how well other rehabilitation workers understood the role of the speech-language therapist. approximately sixty percent of the occupational therapists, and approximately fifty percent of the physiotherapists indicated that they had a good understanding of the speech-language therapist's role, while the remaining percentage of each profession had only some or no understanding. as a result of these research findings, it appeared to be both relevant and timely to investigate the knowledge and attitudes of final year occupational therapy and physiotherapy students towards the role of the speech-language therapist as a member, of the stroke rehabilitation team in a hospital setting, and to compare their views with those of final year speech and hearing therapy students. since final year students represent future allied health professionals in the new south africa, it was envisaged that a survey-type rethe south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the knowledge and attitudes of occupational therapy, physiotherapy & speech-language therapy students, regarding the speech-language therapist's role in the hospital stroke rehabilitation team 51 s e a r c h project targeted, at final year students, would provide some indication of the preparation they receive during their formal undergraduate training, in terms of stroke rehabilitation and the various professions inv o l v e d in an inter-disciplinary team. furthermore, it was felt that participation in the research study might serve an educational purpose by enhancing respondents' i n s i g h t into, and awareness of, the profession of speechl a n g u a g e pathology in relation to stroke rehabilitation. methodology i. aim of the study 1. to investigate the knowledge and attitudes of final year occupational therapy, physiotherapy and speechlanguage therapy students, regarding the role of the speech-language therapist as a member of the stroke rehabilitation team in a hospital setting. 2. to descriptively compare the views of occupational therapy and physiotherapy students with those of speech-language therapy students. ii. subjects and criteria for selection final year (fourth year) occupational therapy, physiotherapy and speech-language therapy students, registered at the university of the witwatersrand were used as subjects in the study. iii. research design in order to achieve the aims of the study, a crosssectional survey research design was implemented which involved the administration of a questionnaire within a group setting. questionnaire content the questionnaire consisted of 30 questions or items and was divided into four sections. a copy of the questionnaire is set out in appendix a. section a consisted of twojclosed-ended questions that elicited biographical information. section β consisted of open-ended and closed-ended questions that focused on rehabilitation and teamwork. ι section c ' 7 this section consisted of questions that required the subjects to indicate which professional(s) would be responsible for various aspects of the stroke patient's rehabilitation. these aspects included :motor recovery of limbs; the treatment of communication problems; emotional adjustment of the patient; family and social support; cognitive rehabilitation; and the management of long-term occupation. these questions were included to ascertain whether the respondents felt that more than one discipline would be responsible for each aspect of the stroke patient's rehabilitation, i.e., role duplication/ overlapping, and whether each group of students tended to assign most aspects of stroke rehabilitation to their own profession. in addition, the researcher attempted to establish each student group's perception regarding the speech-language therapist's role or responsibility in the above-mentioned aspects of stroke rehabilitation. section d this section consisted of 15 statements encompassing the diversity of disorders which may present post stroke, and with which the speech-language therapist might be involved, such as aphasia, dysarthria, apraxia and dysphagia. iv. procedure a) piloting the questionnaire questionnaires were distributed to a recently qualified speech therapist, an occupational therapist and a physiotherapist, all of whom work with stroke patients in a hospital setting. following the pilot study, certain questions were modified and rephrased. b) administration of the questionnaire sixty-seven questionnaires were distributed to students and collected during the same afternoon by the researcher. v. treatment of data descriptive statistics comprising pie-charts "and tables, with frequencies and percentages were employed. those questionnaire items that were presented in the form of a likert scale, were analyzed according to a three-category system. the five-category system was reduced to a three-category system. therefore, "strongly agree" and "agree" categories were combined, as well as the "strongly disagree" and "disagree" categories. the "undecided" category remained unchanged. open-ended questionnaire items were described both quantitatively and qualitatively. results and discussion (limitation of space precludes the inclusion of figures or tables to illustrate all the questions.) section a question 1a the pie-charts in figure 1 represent the percentage of respondents who indicated that they either had or had not, worked with stroke patients respectively. it is interesting to note that 42,9 % of the speech-language therapy students had not worked with stroke patients. the reason for this may possibly be attributed to the fact that only in their fourth year of study, are speechlanguage therapy students provided with the opportunity to work with stroke patients. this opportunity arises either during a six week hospital block, or at the speech and hearing clinic at the university of the witwatersrand. in comparison, only 23,1 percent of physiotherapy students had no experience working with stroke patients, while all occupational therapy students had worked with the latter. question ib ninety percent of the occupational therapy students, and 57,7% of the physiotherapy students reported that they had worked with stroke patients who had communication problems. this may have influenced the occupational students' understanding of communication disorders post-stroke, as well as the speech-language therapist's role in the stroke patient's rehabilitation. die suid-afrikaanse rif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 lisa felsher & eleanor ross question 2a the physiotherapy and occupational therapy students were requested to indicate whether they had contact with speech-language therapists during their clinical blocks, while the speech-language therapy students were requested to indicate whether they had contact with occupational therapists and/or physiotherapists. findings reflected similar percentages of contact suggesting that all three student groups may have been equally exposed to other rehabilitation specialities. question 2b this question required occupational therapy and physiotherapy students to specify where they had made contact with speech-language therapists, and speech-language therapy students were requested to specify where they had made contact with occupational therapists and/or physiotherapists. twenty physiotherapy students (76,9%) and 15 occupational therapy students (75%) had made contact with speech-language therapists, while 15 speech-language therapy students (71,4%) had made contact with occupational therapists and/or physiotherapists. most contact appeared to occur within the hospital setting, while all three student groups indicated that they had been exposed to other therapists at schools for cerebral palsied children such as forest town school. section β question 1 definition of rehabilitation nichols (1976), suggests that all clinicians should be concerned with the rehabilitation of their patients, but there are many who will not have had the opportunity as students to develop an understanding of the wider aspects of patient care called "rehabilitation." in analyzing the definitions of rehabilitation put forward by the physiotherapy, occupational therapy and speech-language therapy students, the salient points (displayed in table 1 below) of current definitions of rehabilitation by gloag (1985), gresham (1986), galley & forster (1987), purtilo (1988), walker (1988) and chamberlain (1989), were taken into account. table 1 below highlights the percentage of respondents for each group, which included these prominent features in their definitions of rehabilitation. the emphasis of point one in table 1 is that rehabilitation aims at helping the individual reach his/her maximal potential. a relatively lower percentage of speech-language therapy students mentioned this point in their definitions of rehabilitation, while its prominent occurrence in the majority of current definitions in the literature is evident. point two of table 1 highlighted the various aspects with which rehabilitation is concerned. a relatively higher percentage of physiotherapy students included this point in their definitions, which is also found in most definitions in the literature. while some of the physiotherapy and occupational therapy students mentioned the goal of working toward patient independence (point three), none of the speechlanguage therapy students mentioned this factor. it is interesting to note that a very low percentage of respondents across all student groups, mentioned the holistic nature of rehabilitation (point five). this finding may possibly be attributed to the fact that students are not provided with the opportunity to work within an interdisciplinary, holistic environment. this implies that students might not see themselves as members of a larger stroke rehabilitation team, but rather perceive themselves as being the exclusive providers of occupational, speech and physiotherapy respectively. on the whole, the speech-language therapy students provided the narrowest definitions of rehabilitation, suggesting a possible under-emphasis of this concept during their theoretical and clinical training. o t s p t s 100.0% 7 6 . 9 % l h i e x p e r i e n c e w i t h s t r o k e p a t i e n t s n o e x p e r i e n c e o t s = o c c u p a t i o n a l t h e r a p y s t u d e n t s (n-20) p t s = p h y s i o t h e r a p y s t u d e n t s (n-26) s t s = s p e e c h l a n g u a g e t h e r a p y s t u d e n t s (n-21) figure 1. experience with stroke patients s t s 5 7 . 1 % 2 3 . 1 % 4 2 . 9 % the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the knowledge and attitudes of occupational therapy, physiotherapy & speech-language therapy students, regarding the speech-language therapist's role in the hospital stroke rehabilitation team 53 question 2: definition of teamwork brill (1976) states that teamwork has a variety of m e a n i n g s , but valid generalizations can be made about it. in his definition of teamwork, brill (1976, p.22) highlights four essential points. 1) a team is a group of individuals, each of whom is responsible for making decisions. 2) each particular member possesses particular expertise. 3) team members hold a common purpose. 4) team members communicate, collaborate and consolidate knowledge together from which plans are made, actions are determined and future decisions influenced. in analyzing the respondents' definitions of teamwork, many points consistent with those made by brill (1976) were evident. represented in table 2 below, are the pertable 1. definition of rehabilitation centages of respondents who included these points in their definitions. question 3a +3b : advantages of teamwork kane (1975, p.12) and brill (1976, p.26) delineate the following advantages of teamwork for professionals: 1) simplified access to and communication with other professionals. 2) promotion of learning. 3) awareness that the work of others can facilitate one's own work. 4) co-ordination of skilled services for the patient. 5) avoidance of duplication. 6) teamwork provides a more comprehensive but integrated range of services. 7) teamwork provides a forum for examination and evaluation of ideas in the light of the differing frames of reference of the various members. pt ot st 1. rehabilitation involves the treatment and the training of the patient so that he/she may obtain his/her maximal potential for normal living, given the constraints imposed by illness or injury. 61,5 % 70,0 % 23,8 % 2. rehabilitation embraces the physical, social, vocational and mental aspects of the patient's life. 73,1 % 30,0 % 19,0 % 3. the emphasis is on improving the patient's capability to function independently. 11,5 % 25,0 % 0,0 % 4. a habit of identifying potential compensating strengths in a person's functioning, as it is not what the patient has lost but what he has left that is important. 7,7 % 25,0 % 19,0 % 5. rehabilitation is undertaken by doctors in co-operation with physiotherapists, occupational therapists, social workers, speech-language therapists, psychologists and nurses in an attempt to treat a patient holistically. 7,7 % 10,0 % 4,8 % 6. returning the patient to a premorbid state of living as far as possible. 23,1 % 20,0 % 33,3 % percentages do not add up to 100 as respondents could include more than one feature in their definitions. table 2. definition of teamwork i pt ot st 1. teamwork involves a group of individuals. 42,3 % 65,0 % 71,4 % 2. teamwork involves co-operation, communication and collaboration of ideas and information. 42,3 % 20,0 % 28,6 % 3. each member has particular expertise in his/her field. 3,8 % 40,0 % 14,3 % 4. there are common goals, aims or plans of action. 30,8 % 10,0 % 28,6 % 5. teamwork is an approach that achieves optimal benefit for the patient. 3,8 % 20,0 % 28,6 % 6. there is complementation of different treatments, and reinforcement of behaviours taught in other therapies. 11,5 % 5,0 % 4,8 % 7. teamwork is a holistic approach to patient care. 0,0 % 5,0 % 0,0 % 8. teamwork includes the patient, his/her family, and other lay people. 7,7 % 35,0 % 23,8 % percentages do not add up to 100 as respondents could include more than one feature in their definitions. die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 the responses to question 3a showed that the majority of respondents in each student group, were in agreement regarding the possible advantages of teamwork. the majority of respondents agreed that teamwork is an experience in participatory learning (3a.1), that teamwork provides for an exchange of ideas (3a.3) and that teamwork focuses on goals for mutual effort (3a.4). there was one hundred percent agreement across student groups that the holistic approach to teamwork (3a.2) is advantageous. finally, responses to statement 3a.5 (teamwork provides an overlap of services) showed greater variability. less than ten percent of respondents in each group were in disagreement with this statement. the majority of respondents (over eighty percent in all groups) however, were in agreement that the overlap of services in teamwork is beneficial. item 3b, an open-ended question, requested the respondents to add any further possible advantages of teamwork. forty-eight percent of the speech-language therapy students, 54 % of the physiotherapy students and 55 % of the occupational therapy students, all contributed further advantages, namely, there is a support system for professionals. goals are prioritised in terms of the whole patient. teamwork breaks down professional barriers. question 4a + 4b disadvantages of teamwork "it is naive to bring together a highly diverse group of people and expect that, by calling them a team they will in fact behave as a team" (wise, beckard, rubin & kyte, 1974, p.56). in the light of the above quote, it is important to acknowledge the possible problems that may arise when professionals work within a team. brill (1976), schlesinger (1985), and germain (1984) point out the major downfalls of teamwork, namely, 1) the team situation fosters undesirable competition. 2) problems of role definition and frequent overlap. 3) there are major problems of communication in teams. 4) team meetings are often time-consuming. 5) health professionals often have insufficient knowlisa felsher & eleanor ross ledge about the education and expertise of other disciplines. 6) health professionals tend to assign most tasks to their own profession rather than to others. 7) disagreement with the goals of treatment. the responses to question 4a, that consists of seven statements concerning the possible disadvantages of teamwork, showed greater variability relative to the responses to question 3a. approximately 70 % of respondents in each group were in agreement that a lack of knowledge of what other team members do (question 4a.5) is a disadvantage of teamwork. furthermore, the majority of respondents in each student group, were also in agreement that problems of role definition (question 4a.4) may be a possible downfall of teamwork. these findings highlight the need to educate students of all three professional disciplines, regarding the roles and functions of other rehabilitation specialities. the second part of question 4, required respondents to add any other possible disadvantages of teamwork. ten percent of both speech-language therapy and occupational therapy students, and four percent of physiotherapy students, contributed further disadvantages, namely, personality clashes between team members. professionals, for example doctors, may doubt the efficacy of the other professionals' therapies. there may be too many opinions. professionals may give contradictory suggestions for therapeutic intervention. question 5a and 5b according to galley & forster (1987), wade et al., (1985), and dean & geiringer (1990), the doctor or physician tends to be the leader of the team. bonner (1969) states that all members of the team look to the doctor for guidance, direction and enlightenment, while dean & geiringer (1990) propose that the physician is skilled in integrating a complex patient-care system. in contrast with the above view, wade et al., (1985) state that doctors take a less-than-active role, leaving the decio t s p t s s t s 8 5 % 88% 1 5 % 8 1 % 1 2 % ^ s h a r e d l e a d e r s h i p of the t e a m b y m o r e t h a n o n e m e m b e r . s o l e l e a d e r s h i p o n e m e m b e r of the t e a m a s s u m e s t h e l e a d e r s h i p role. figure 2. leadership of the rehabilitation team. / the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the knowledge and attitudes of occupational therapy, physiotherapy & speech-language therapy students, regarding the speech-language therapist's role in the hospital stroke rehabilitation team 55 sions to the other team members. in a research study c o n d u c t e d by motona & nowitz ( 1 9 9 1 ) , qualified physiotherapists were asked to give their opinion regarding who should be primarily in charge of a rehabilitation team. the majority of respondents indicated that the physiotherapist should be in charge of the team, while approximately one third of the respondents believed that leadership should be shared. this finding suggests that there is a movement away from the doctor-led team. figure 2. depicts in the form of pie-charts, the percentages of respondents, who indicated that leadership should be shared by more than one professional of the team, and those who expressed that only one professional of the team should be in charge. the respondents who indicated that one professional should lead the team, mentioned the doctor, the social worker and the occupational therapist as being sole leaders. it is interesting to note that not one of the physiotherapy respondents indicated that the doctor should lead the rehabilitation team. this may possibly be due to the fact that physiotherapists do not require patient referrals from doctors (beenhakker, 1991), while under the current legislation, occupational therapists and speech-language therapists have to have their patients referred to them by a registered medical practitioner (south african medical and dental council, act 56). of the respondents who indicated that leadership should be shared among professionals, four main combinations of leaders emerged, namely 1) all members should share leadership. 2) the speech-language therapist, the occupational therapist, and the physiotherapist. 3) the speech-language therapist, the occupational therapist, the physiotherapist and the social worker. 4) the speech-language therapist, the occupational therapist, the physiotherapist and the psychologist. question 6a and 6b beenhakker (1991, p.8) suggests that "for professionals to be able to work together as a team, they need to study together as students." she believes that this encourages a greater understanding of health professionals' mutual problems, and will establish co-operative behaviour patterns. beenhakker (1991) further adds that to date, this is not being achieved at the university of the witwatersrand, medical school, and probably at very few other training institutions. beenhakker (1991, p.8) emphasises the need for students to campaign for a "multidisciplinary approach to teaching from their first year of study". only then may students learn from an early stage the "mechanics of multidisciplinary activities and the particular expertise of the individual professions." in a research study conducted by waller & murphy (1985, p. 19-22) qualified speech-language therapists who worked in hospital settings, were questioned as to whether they felt a need for more knowledge of rehabilitation specialities such as occupational therapy, physiotherapy and social work. approximately 50 % of the respondents indicated that iri "some cases", they could use more information on all rehabilitation specialists. in addition, when asked about course lectures received in their undergraduate training, regarding other rehabilitation specialists, 80,6 % of the respondents stated that no courses on occupational therapy were covered, while 77,6 % of the respondents indicated that courses on physiotherapy had not been given. question 6a requested respondents to indicate their attitudes to the statement read as follows: "for professionals to be able to work together as a team, they need to work together as students." the pie-charts in figure 3 indicate the percentage of respondents who were in agreement, disagreement and who were undecided about the above statement. o t s p t s s t s 95% 77% 1 5 % 100% figure 3. working together as students die suid-afrikaanse rif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 lisa felsher & eleanor ross speech-language therapy students unanimously agreed with the above statement. this may be attributed to the fact that speech-language therapy students at the university of the witwatersrand are not part of the medical campus and have no contact with occupational therapy and physiotherapy students. occupational therapy and physiotherapy students are both situated on the medical school campus, and have formal lectures together for the first two years of their four year course. occupational therapy and physiotherapy hospital departments are located in close physical proximity and thus more interaction occurs between these two professional disciplines. some of the comments made in agreement with the statement were as follows: it is important to build rapport and understanding of each other's professions at a student level. there is little communication between students of different disciplines. a basic foundation of mutual co-operation must be instilled in students. we must learn to respect and appreciate other disciplines. this is not being done at present, largely due to the lack of communication between members of staff of the various disciplines. i have never in my three and a half years worked with another student, nor received formal information on the roles of other professionals. some comments made by those respondents who were undecided about the statement were as follows :although professions overlap, there is no need for specific interaction. when qualified, it should be just as easy to move into a team approach. the following comments were made by those respondents who were in disagreement to question 6a. students are still trying to prove themselves to their peers. as professionals, people feel on a more equal footing. professionals can quickly learn to work together once qualified. section c bluestone (1976, p. 14) aptly sums up both the advantages and disadvantages of role duplication. she states that "because of the overlapping interests of the various professions, a definition of roles is needed to avoid both gaps and duplication". on the other hand, "cross-fertilisation of skills permits valuable reinforcement" of each professional's treatment by the other health professionals on the team, for example the social'worker and the speech-language therapist both may be counselling the patients about their reduced but active role in the family. wade et al., (1985, p.322) made the following suggestions regarding which team professionals would be responsible for different aspects of stroke rehabilitation, most of which were included in the research questionnaire. they saw the physiotherapist and the occupational therapist as being involved in the motor recovery of limbs. the occupational therapist, the physiotherapist and the nurse were the three team members seen to be responsible for rehabilitation of activities of daily living such as feeding, grooming and bathing. wade et al., (1985) further stated that the speech-language therapist, the psychologist and the social worker were responsible for emotional adjustment of the patient, while they suggested that the social worker, the psychologist, friends, religious advisors and the speechlanguage therapist were responsible for family and social support. the rehabilitation of communication problems was seen to be in the professional realm of both the speech-language therapist and the psychologist. finally, the social worker and the occupational therapist were the two members who were perceived to be involved in the patient's long-term occupation. ylvisaker and urbanczyk (1990) comment on cognitive rehabilitation, and view it as being an inter-disciplinary attempt to overcome cognitive obstacles which may result from a stroke, such as impairment of memory. while the role of the neuropsychologist in cognitive rehabilitation has been primarily diagnostic (turnbull, 1992), it is felt that the speech-language therapist and the occupational therapist fulfil a more therapeutic role in the rehabilitative efforts of impaired cognitive abilities. each of the seven aspects of stroke rehabilitation are discussed separately as follows. of those respondents who indicated that more than one professional is involved in motor recovery of limbs (question one), 60% of the occupational therapy students, 26,9% of the physiotherapy students and 14,3% of the speech-language therapy students, indicated that the occupational therapist and the physiotherapist would be jointly involved in this aspect of rehabilitation. in question two, 45% of the occupational therapy students, 27% of the physiotherapy students, and 14,3% of the speech-language therapy students, indicated that the occupational therapist is exclusively responsible for the rehabilitation of activities of daily living. twenty percent of the occupational therapy students and 11,5% of the physiotherapy students indicated that the speechlanguage therapist would have a role to play in this aspect of stroke rehabilitation, while almost half (47,6%) of the speech-language therapy students felt that they had a role to play in the rehabilitation of activities of daily living. this important finding may -possibly be attributed to the fact that the speech-language therapist is frequently involved in the diagnosis and treatment of dysphagia, which can be viewed as an essential function of daily living. in question three, a substantially large percentage of students across all three groups indicated that more than one professional would be responsible for the emotional adjustment of the patient. this finding may possibly be attributed to the fact that all members of the team receive some form of training in counselling skills, in their student education. ^ it is interesting to note that for the rehabilitation of communication problems (in question 4), substantially higher percentages of occupational therapy and physiotherapy respondents indicated that only one professional, i.e., the speech-language therapist, should be involved in this aspect. in comparison to these findings, 71,4% of the speech-language therapy students indithe south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the knowledge and attitudes of occupational therapy, physiotherapy & speech-language therapy students, regarding the speech-language therapist's role in the hospital stroke rehabilitation team 57 cated that rehabilitation of communication problems involved more than one team member. this finding suggests that speech-language therapy students do not see themselves as exclusively responsible for the rehabilitation of communication disorders, but rather see other team members as also being valuable contributors to communication rehabilitation. question 5 dealt with the aspect of family and social support. while 25% of the occupational therapy students, 19% of the physiotherapy students and 9,5% of the speech-language therapy students, indicated that the social worker is exclusively responsible for this aspect, there was a substantially high percentage of respondents in each group who felt that family and social support is given by more than one professional. it is interesting to note that more than half (54,4%) of the speech-language therapy respondents felt that they had a role to play in family and social support, while only 30% of the occupational therapy students and 34,6% of the physiotherapy students mentioned the speech therapist's role in this aspect. of those respondents who indicated that more than one professional is responsible for cognitive rehabilitation (question 6), 30% of the occupational therapy students and 23% of the physiotherapy students indicated that the occupational therapist and the speech-language therapist are jointly responsible. nineteen percent of the speech-language therapy students mentioned that in addition to the occupational and speech-language therapists, the family and the psychologist are also responsible for rehabilitation of impaired cognitive abilities. it is interesting that an extremely high percentage (95,2) of speech-language therapy students felt that they had a role to play in cognitive rehabilitation, compared with 61,5% of the physiotherapy students and only 35% of the occupational therapy students who indicated the involvement of the speech-language therapist. the reason for only 35% of occupational therapy students mentioning the speech-language therapist's role in cognitive rehabilitation, may possibly be attributed to the fact that occupational therapy students view cognitive rehabilitation as falling within their own professional realm. j the final aspect of stroke rehabilitation is that of long-term occupation (question 7). haydock (1992) states that the patient's ability to return to his or her previous employment mayj have to be assessed by the occupational therapist. thirty-five percent of the occupational therapy students, and 31% of the physiotherapy students mentioned that both the occupational therapist and the social worker need to be involved in longterm occupation of the patient, while 14,3% of the speech-language therapy students indicated that the family should be involved together with the occupational therapist and the social worker. it is important to note that 35% of the occupational therapy students saw their profession as being exclusively involved in long-term occupation. it is also interesting to note that 33,3% of the speech-language therapy students mentioned their involvement, together with other team members, in the aspect of long-term occupation . this finding may possibly be attributed to the fact that communication disabilities often impinge upon vocational aspects of the patient's life. section d the role of the speechlanguage therapist as mentioned previously, four of the most common disorders resulting from a stroke, in which the speechlanguage therapist plays an active role are aphasia, dysarthria, apraxia and dysphagia. logemann (1990, p.157) states that the role of the speech-language therapist in dysphagia encompasses evaluation and treatment of dysphagic patients. in question 3, there was one hundred percent agreement from both occupational and speech-language therapy students, and 96,2% agreement from the physiotherapy students, regarding the active role of the speech-language therapist in the treatment of dysphagia. penn (1992), simmons (1981), clifford-rose & capildeo (1981) and softley (1987), all stress the active role of the speech-language therapist in the treatment of aphasia. similarly, respondents in each student group were all in total agreement regarding the role of the speech-language therapist in the treatment of aphasia. as with the treatment of aphasia, penn (1992), simmons (1981), clifford-rose & capildeo (1981) and softley (1987) all emphasise the role that the speechlanguage therapist plays in the diagnosis and treatment of verbal apraxia or apraxia of speech. one hundred percent of both occupational therapy and speech-language therapy students agreed that the speech-language therapist is actively involved in the treatment of verbal apraxia, while only 84% of the physiotherapy students were in agreement. one hundred percent agreement of occupational therapy students in comparison with 84,6% agreement of the physiotherapy students, may possibly be attributed to the fact that occupational therapy students diagnose and treat other types of apraxia such as dressing apraxia, limb apraxia, and constructional apraxia (thompson & morgan 1990). the role of the speech-language therapist in the treatment of dysarthria, has also been highlighted by various authors including penn (1992) and softley (1987). in question 12, there is unanimous agreement on the part of both occupational and speech-language therapy students, while 96,2% of the physiotherapy students agreed that the speech-language therapist plays a role in the treatment of dysarthria. thus, it appears that both occupational therapy and physiotherapy students are well informed, with regard to the four main disorders post-stroke, with which a speech-language therapist would be actively involved. in addition, these four most common disorders are intensively covered in the latter two years of the fourth year speech-language therapy course. it is interesting to note that, while both occupational and physiotherapy students were in one hundred percent agreement regarding the role of the speech-language therapist in the treatment of auditory agnosia (question 14), only 80,9% of the speech-language therapy students agreed with question 14's statement. auditory agnosia, together with visual object agnosia, visual spatial agnosia and tactile agnosia, is a disorder of perception that may be present following a stroke (thompson & morgan, 1990). the lower percentage of agreement within the speech-language therapy group, may possibly be attributed to the fact that auditory die suid-afrikaanse rif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 lisa felsher & eleanor ross agnosia and the clinical treatment thereof, is less intensively covered in their academic curriculum. in addition there appears to be a paucity of literature, covering the role of the speech-language therapist in the treatment of auditory agnosia. to date, there appears to be lack of clarity regarding the role of the speech-language therapist in the treatment of agraphia as well as alexia. while both disorders imply a loss or impairment of some mode of communication, the speech-language therapist's role in such disorders is unclear. penn (1992) differentiates between difficulties of reading and writing that arise from different problems. reading and writing difficulties that arise from sensori-motor deficits such as hemianopsia and hemiplegia, must not be confused with reading and writing problems that are a result of difficulty in comprehending or producing the written word respectively. this suggests that both the speech-language therapist and the occupational therapist should have a role to play in the treatment of alexia and agraphia. furthermore, reading and writing difficulties that arise from sensorimotor deficits should fall within the professional realm of the occupational therapist, whereas reading and writing difficulties that are a function of a greater language impairment should fall within the ambit of speech-language therapy. in questions four and five, occupational therapy students in comparison with physiotherapy and speech-language therapy students were in the least agreement, and were the most undecided about the speech-language therapist's role in the treatment of agraphia and alexia respectively. it is interesting to note that 76,2% of the speech-language therapy students agreed that they had a role to play in the treatment of agraphia, while 85,7% of the speech-language therapy students were of the opinion that they could contribute to the treatment of alexia. question 11 dealt with the role of the speech-language therapist in the treatment of amnesia. the view that cognitive rehabilitation, which includes the treatment of amnesia, should be a broad-based, functional and inter-disciplinary effort (ylvisaker & urbanczyk 1990) suggests that more than one professional discipline has a role to play in cognitive rehabilitation. it is interesting to note that, while 100% of the speech-language therapy students felt that their profession had a part to play in the treatment of amnesia, only 30% of the occupational therapy students were in agreement with this. this finding is consistent with that of question 6 in section c, which suggests that occupational therapy students may view the treatment of amnesia (an aspect of cognitive rehabilitation), within their own professional field. similarly, speech-language therapy students may see the treatment of amnesia, as exclusively belonging to their discipline. conclusion in summary, results of this study suggested a fairly good understanding of the concepts of rehabilitation and teamwork. however, speech-language therapy students provided the narrowest definition of rehabilitation suggesting a possible under-emphasis of this concept in their clinical and theoretical training. students appeared to have a greater understanding of those disorders post-stroke, with which a speech-language therapist is commonly involved. however, students showed less understanding of those disorders following a stroke, for which the speech-language therapist's role is less clearly defined. in addition, a high percentage of role duplication/overlapping in the several aspects of stroke rehabilitation was found. these results hold important implications for the profession of speech-language pathology in the 1990's in terms of undergraduate and postgraduate inter-disciplinary education, clarification of the speech-language therapist's clinical role, public relations, and for further research. inter-disciplinary education inter-disciplinary education at both undergraduate and postgraduate levels should be a joint and reciprocal way in which health care professionals can learn from and about each other. this could be achieved in a number of possible ways, namely, i) inter-departmental case presentations on a regular basis whereby cases would be presented from different frames of reference. ii) collaborative research involving students from vari\ \ ous disciplines. iii) joint rural/community blocks at present, only final year occupational therapy and physiotherapy students attend a three-week rural block. iv) seminars or a series of lectures covering other paramedical professionals' roles in stroke and other rehabilitation. v) improving inter-departmental links between both staff members and students alike. vi) setting up student rehabilitation clinics, allowing students to work in a holistic environment. speech-language therapist's clinical role the results of this study suggested that occupational therapy, physiotherapy and speech-language therapy students acknowledged the role of the speech-language therapist in the treatment of such disorders as aphasia, dysarthria, verbal apraxia and dysphagia] with which the speech-language therapist is commonly associated. however, students showed less understanding of such disorders as amnesia, alexia and agraphia, for which the speech-language therapist's role is not as well defined. this finding implies the need to clarify the speech-language therapist's clinical role, as well as other paramedical therapist's roles in such disorders. / public relations there appears to be the need for speech-language and hearing therapists to market their profession. van hattum (1980) maintains that it is ironic that a profession devoted to the treatment of communication disor' der has had so much difficulty communicating this information. thus, the profession of speech-language and hearing therapy needs to perform an,educative role, which could be achieved in a number of ways: 1) through academic contributions to medical and paramedical journals of south africa.. 2) through explanatory pamphlets or audio-visual media outlining the role of the speech-language and hearing therapist in the treatment of different comthe south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the knowledge a n d attitudes of occupational therapy, physiotherapy & speech-language t h e r a p y students, regarding the speech-language therapist's role in the hospital stroke rehabilitation t e a m 59 munication disorders. 3) through workshops, orientation programmes or professional forums for medical and paramedical students and professionals throughout their programs. suggestions for further research 1. replication of the present study, using a similar or the same questionnaire, on qualified occupational, speech and physiotherapists, to establish the extent to which their attitudes and knowledge are related to increased experience. 2. evaluation of an existing inter-disciplinary stroke rehabilitation team, to assess the effectiveness of such an approach for future teamwork practise. 3. investigation of the knowledge and attitudes of final year social work and/or nursing students, as well as medical doctors specialising in neurology, regarding the role of the speech-language therapist in the hospital stroke rehabilitation team. 4. investigation of the attitudes and knowledge of medical doctors specialising in ear, nose and throat surgery, towards the speech-language and hearing therapist's role in the cleft-palate or laryngectomy team. 5. investigation of t h e attitudes and k n o w l e d g e o f occupational t h e r a p y and p h y s i o t h e r a p y students, reg a r d i n g the s p e e c h l a n g u a g e therapist's role in the i n t e r d i s c i p l i n a r y m a n a g e m e n t o f c e r e b r a l p a l s i e d children. brill ( 1 9 7 6 , p. 143) m a i n t a i n s that " t h e great need o f the student in intraand intergroup relations is not only for k n o w l e d g e o f the g r o u p s i n v o l v e d but also for the ability to r e a c h a c r o s s t h e s e b o u n d a r i e s w h i l e at the s a m e time r e s p e c t i n g t h e m " . it is hoped t h a t this study will p r o m o t e a g e n e r a l a w a r e n e s s of the need to gain k n o w l e d g e a n d u n d e r s t a n d i n g of the roles that v a r i o u s p a r a m e d i c a l professionals p l a y in stroke rehabilitation and u l t i m a t e l y lead to m o r e effective and holistic p a tient m a n a g e m e n t . j i r e f e r e n c e s beenhakker, j.c. (1991). role of the physiotherapist in the health team. the leech 60,2,8 -9. bluestone, s.s. (1976). rehabilitation medicine. in haller, r.m. & sheldon, n. (eds.) speech pathology and audiology in medical settings. new york: stratton intercontinental medical book corporation! bonner, d. (ed.) (1969). the\team approach to hemiplegia. illinois: charles thomas publisher. boone, p.r. (1987). human communication and its disorders. new jersey: prentice hall incorporated. brill, n.i. (1976). teamwork working together in the human services. philadelphia: j.b. lippincott company. chamberlain, m.a. (1989). what is rehabilitation ?br. j. hosp. med., 41,311. clifford-rose, c. & capildeo, r. (1981) stroke: the facts. oxford university: new york press. dean, b.z. & geiringer, s.r. (1990). psychiatric therapeutics. 6. the rehabilitation team/ behavioural management. arch. phys. med. rehabil., 71, 4, s-275 s-276. fritz, v. (1992). the medical perspective. in fritz, v. & penn.c. (eds). stroke: caring and coping. j o h a n n e s b u r g : witwatersrand medical press. fritz, v. & penn,c. (eds) (1992). stroke: caring and coping. johannesburg: witwatersrand medical press. galley, p.m. & forster, a.l. (1987). human movement: an introductory text for physiotherapy students. second edition, new york: churchill livingstone. germain, c.b. (1984). social work practise in health care: an ecological perspective. new york: the free press. gloag, d. (1985). severe disability: tasks of rehabilitation. br. med. j., 290, 1333-1336. gresham, g.e. (1986). the rehabilitation of the stroke survivor. in barnett, h.j.m. (ed). stroke: pathophysiology, diagnosis and management. new york: churchill livingstone. haller, r.m. & sheldon, n. (1976). speech pathology and audiology in medical settings. new york: stratton intercontinental medical book corporation. haydock, s. (1992). occupational therapy. in fritz, v. & penn, c. (eds) stroke caring and coping. j o h a n n e s b u r g : witwatersrand university press. kane,r.a. (1975) interprofessional teamwork. syracuse: new york syracuse university press. logemann, j. (1990). dysphagia. sem. speech lang. 11,3,157163. love, r.j. & webb, w.g. (1986). neurology for the speechlanguage pathologist. boston: butterworth publishers. milner, m.(1989). knowledge and attitudes of fifth year medical students concerning the profession of speech therapy and audiology. unpublished honours research project. department of speech pathology and audiology: university of the witwatersrand. motona, b.s. & nowitz, l.m. (1991). physiotherapists' perceptions of rehabilitation. unpublished honours r e s e a r c h project. d e p a r t m e n t of p h y s i o t h e r a p y : university of the witwatersrand. n i c h o l s , p.j.r. (1976). rehabilitation medicine: the management of physical disabilities. london: butterworth publishers. penn, c.(1992). management of communication problems. in fritz, v. & penn, c. (eds). stroke: caring and coping. johannesburg: witwatersrand university press. purtilo, r. (1988). ethical issues in teamwork: the context of rehabilitation. arch. phys. med. rehabil. 69, 5, 318-322. schlesinger,e.g.(1985).hea/<a care social work: concepts and strategies. st. louis:mosby college publishing. simmons, n.n. (1981). the i n t e r a c t i o n between communication disorders and neurogenic disorders. in darby, j.k. (ed) speech evaluation in medicine. new york: grune and stratton. softley, l. (1987). speech therapy. in kamal, a. (ed) the colour atlas of stroke: cerebrovascular disease and its management. england: wolf medical publishers. south african medical and dental council (act 56) government gazette. 1986. stonnington, h.h. & browne, j.a. (1987). team approach to management. in brandstater, m.e. and basmajian, j.v. (eds) stroke rehabilitation. baltimore: williams and wilkins. thompson, s.b.n. & morgan, m. (1990). occupational therapy for stroke rehabilitation. new york: chapman & hall. turnbull, o. (1992). the neuropsychology of stroke. in fritz, v. & penn, c. (eds). stroke: caring and coping. johannesburg: witwatersrand university press. van hattum, r.j. (ed.) (1980). an introduction to communication disorders. new york: m a c m i l l a n publishing company. wade, d.t., langton-hewer, r., skilbeck, c.e. & david, r.m. (1985). stroke: a critical approach to diagnosis, treatment, and management. london: chapman & hall. waller, m.r. & murphy, w.p. (1985). the speech-language pathologist in a medical setting. asha, 25,19-22. walker, a. (1988). rehabilitation: micro-market or major partner in healthcare's future. j. rehabil. 54,1,19-22. wise, h., beckard, r., rubin, j., & kyte, a.l., (eds) (1974). making health teams work. cambridge: ballinger. ylvisaker, m.s. & urbanczyk, m.s. (1990). the efficacy of speech-language pathology intervention: traumatic brain injury. semin. speech lang. 11,4,215-224. die suid-afrikaanse rif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 lisa felsher & eleanor ross apppendix a views of occupational therapy, physiotherapy and speech-language therapy students regarding the role of the speech language therapist in the stroke rehabilitation team. dear final year students i am a final year speech-language therapy student at the university of the witwatersrand. i am conducting an undergraduate research project regarding the role of the speech language therapist as a member of the stroke rehabilitation team. the study involves a questionnaire that seeks your opinions and attitudes. i would sincerely appreciate your help in completing the questionnaire. all information given will be treated confidentially and results will be presented in aggregate, thus assuring your anonymity. sincerely thanks l. felsher questionnaire section a biographical data (occupational and physiotherapy students) l.a. have you worked with stroke patients during your student training ? yes q no | | 1.b. if yes, did any of the stroke patients have communication problems ? yes q no | | 2.a. have you ever had any contact with occupational therapists and/or physiotherapists during your clinical training blocks ? yes q no | | 2.b. if yes, please specify where questionnaire section a biographical data (speech-language therapy students) l.a. have you worked with stroke patients during your student training ? l.b. if yes, did any of the stroke patients have problems other than communication problems, e.g., hemiplegia |? 2.a. have you ever had any contact with speech-language therapists during your clinical training blocks ? yes | | no | | 2.b. if yes, please specify where • section β teamwork and rehabilitation this section considers teamwork in relation to rehabilitation. 1.define 'rehabilitation' in your own words. 2. define 'teamwork' in your own words. the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the knowledge and attitudes of occupational therapy, physiotherapy & speech-language therapy students, regarding the speech-language therapist's role in the hospital stroke rehabilitation team 61 3.a. please indicate your answers to the following statements by placing a tick in one of the following blocks. possible advantages of teamwork are : strongly agree agree undecided disagree strongly disagree 1. teamwork is an experience in participatory learning. 2. teamwork is a holistic approach to patient management. 3. teamwork provides an opportunity for an exchange of ideas from different frames of reference. 4. there is a focus on goals that provide necessary direction for mutual efforts. 5. there is an overlap of services performed by more than one team member. 3.b. in your opinion, are there any other advantages of teamwork ? if so, please specify 4.a. please indicate your answers to the following statements by placing a tick in one of the following blocks. possible disadvantages of teamwork are: strongly agree agree undecided disagree strongly disagree 1. communication problems. 2. time consuming meetings. 3. professional jealousy/competition. ] 4. problems of role definition, i.e., there i is an overlap of therapeutic services. j 5. lack of knowledge of what other team members do. j 6. dispute for leadership of the team. 7. lack of co-operation between team members. 4.b. in your opinion, are there any other disadvantages of teamwork ? if so, please specify die suid-afrikaanse ±j^,onrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 lisa felsher & eleanor ross impairment of t h e a b i , i l y to , e a d ) , a . a p h i a < t l f o r p a t i m t x ' » — (please tick one box that corresponds to your answer.) i i occupational therapist | | psychologist | | speech-language therapist i leadership shared by 1 1 more than one professional if so, please specify which professionals | | social worker | | physiotherapist | j family | | doctor 5.b. please give reasons for your choice of answer in question 5.a. 6.a. please indicate to the following statement by placing a tick in one of the following blocks . strongly agree agree undecided disagree strongly disagree for professionals to be able to work together as a team, they need to work together as students. 6.b. please comment on your answer to question 6.a ι section c stroke rehabilitation this section looks at the various aspects of stroke rehabilitation. please note the following abbreviations used in this section : dr. doctor ot occupational therapist n. nurse st speech-language therapist fm family sw social worker pt physiotherapist psy psychologist please tick one or more of the following blocks that correspond(s) to your answer(s). in your opinion, which professional(s) would be responsible for :the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the knowledge and attitudes of occupational therapy, physiotherapy & speech-language therapy students, regarding the speech-language therapist's role in the hospital stroke rehabilitation team 63 dr. n. fm pt ot st sw ps y other (please specify) 1. motor recovery o f l i m b s . 2. rehabilitation of activities of daily living e.g., eating, dressing. 3. emotional adjustment of the patient. 4. treatment of communication problems. 5. family and social support. 6. cognitive rehabilitation e.g., memory problems. 7. management of long-term occupation. section d role of the speech-language therapist this section seeks your opinion regarding the role of the speech-language therapist in the following conditions that occur post-stroke/cva. please indicate your answer to the following statements by placing a tick in one of the following blocks the speech-language therapist has a role to play in the treatment of: strongly agree agree undecided disagree strongly disagree 1. hemiplegia the loss of movement on one side of the body. 2. hemianopsia visual field defect on one half of the eye field. 3. dysphagia a neuromotor disorder of swallowing. 4. agraphia loss or impairment of the ability to read. 5. alexia loss or impairment of the ability to write. 6. aphasia loss or impairment of the ability to use and/or understand language. 7. depression sadness, despair, and discouragement. 8. hemispatial neglectjtendency to ignore things on one side of the body.] 9. apraxia of speech a disorder of motor programming of speech. 1 10. dressing apraxia loss of ability to put on or take off clothes in an orderly manner. 11. amnesia impairment of memory. 12. dysarthria impairment in the articulation of sounds due to muscle weakness and incoordination of muscles for speech and breathing. 13. visual agnosia inability to recognise objects, colours, and pictures. . 14. auditory agnosia inability to comprehend speech and/or non-speech sounds in the face of normal hearing. 15. disorder of proprioception lack of awareness of a part of the body in relation to its position in space. thank-you for your co-operation !!! die suid-afrikaanse rif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 philips international hearing i n s t r u m e n t s (pty) ltd (edms) bpk technology to enrich your life philips cares for you for all your h e a r i n g i n s t r u m e n t requirements ind: a g e n t s f o r : amplaid audiometers earmark. em. systems rexton evaluation equipment head office: g r o u n d f l o o r . b l o c k b, g i l l o o l y s v i e w , o f f i c e p a r k . 5 o s b o r n e l a n e , b e d f o r d v i e w . tel: 622-3628 fax 616-2838 p h i l i p s the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 7 communication skills of biologically at-risk neonates alta kritzinger, brenda louw and rene hugo department of communication pathology university of pretoria abstract early communication intervention has advanced to include neonatal assessment and management. currently, however, there are limited diagnostic tools developed from a speech-language pathology and audiology perspective. the purpose of the study was to design a comprehensive neonatal communication assessment protocol and use it to describe the communication skills of 50 biologically at-risk neonates (852g-3060g birthweight). the results indicated that the subjects' general development was within normal limits, but their communication abilities displayed a serious delay. a high risk register consisting of 13 factors predicting the subjects'communication abilities was compiled. the length of time before the subjects could successfully take bottle feeds was found to be the strongest predictor of their communication development. the study is of particular relevance to the present south african context which has an increased incidence of low birth weight, thus rendering an enlarged population of biologically at-risk neonates. opsomming vroee kommunikasie-intervensie het ontwikkel om neonatale evaluering en intervensie in te sluit. daar is egter beperkte evalueringshulpbronne beskikbaar wat ontwikkel is vanuit 'n spraak-taalpatologieen oudiologie-perspektief. die doel van die studie was om 'n omvattende neonatale kommunikasie-evalueringsprotokol te ontwerp en toe te pas om die kommunikasievaardighede van 50 biologiese-risikoneonate (852g-3060g geboortegewig) te beskryf. die resultate het aangedui dat die proefpersone se algemene ontwikkeling bihne normale perke was, maar dat hulle kommunikasievermoens 'n ernstige agterstand vertoon het. 'n hoerisikoregister bestaande uit 13 risikofaktore wat die proefpersone se kommunikasievermoens voorspel het, is opgestel. die duur van die tydperk voordat die proefpersone suksesvol met 'n bottel kon voed, is as die beste voorspeller vir hulle kommunikasieontwikkeling bevind. die studie is van besondere relevansie vir die huidige suid-afrikaanse konteks wat 'n verhoogde insidensie van lae geboortegewig vertoon en daarom 'n vergrote populasie van biologiese-risikoneonate oplewer. key words: neonatal communication assessment, biologically at-risk neonates, high risk register for communication development introduction ι early communication intervention for handicapped and at-risk infants and toddlers and their families is a new speciality of speech-language pathology and audiology, but is already accepted as the preferred form of intervention for this population (rossetti, 1990). as the emphasis of health care shifted towards prevention and primary health care, and the need to treat infants from birth onwards became apparent, early communication intervention has advanced to include neonatal assessment and intervention. as a result of this development speech-language therapists and audiologists have become members of the multi-disciplinary team providing services in the neonatal intensive care unit (nicu). but there are still shortcomings regarding knowledge and assessment instruments. for example, in a survey of early communication intervention services in nicu's in the usa, dunn, van kleeck and rossetti (1993) found that 91% of the speech-language pathologists involved in such services made use of informal assessment procedures. this indicates that early communication interventionists use a variety of resources available for neonatal assessments that may not be specifically designed for a comprehensive evaluation of these infants' communication skills and may not sufficiently address the specific needs of neonatal communication intervention. in south africa, however, neonatal intervention services are far less developed than in the usa. the provision of these services in the nicu is primarily devoted to hearing screening programmes (malan, 1993). the lack of comprehensive speech-language pathology services in nicu's in south africa is of particular concern as an increased incidence of infants born at biological risk occurs. according to wainer (in smith, 1992) the incidence of lowbirthweight infants is as high as 16% in baragwanath hospital, in soweto, which serves a large underprivileged community. the accepted incidence of premature and lowbirthweight infants in technologically developed countries is much lower, and estimated between 6% and 8% (gordon, 1987). the nicu population in south africa also differs from that in developed countries as the majority of these die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 infants are environmentally, as well as biologically at risk due to unfavourable socio-economic circumstances. research on the communication skills of the nicu population in south africa is necessary to provide guidelines for the improvement of nicu services provided by speechlanguage therapists and audiologists. although research from different disciplines has contributed to a body of knowledge about the communication skills of biologically at-risk neonates, it is fragmented and lacks a speech-language pathology perspective. the assessment of neonatal behaviour and developmental status has long been dominated by medical and developmental psychology studies that focus on the fullterm neonate (brazelton, 1973; rosenblith, 1992) and the biologically at-risk neonate. the research on biologically at-risk neonates provide knowledge about their behaviour (brazelton, 1984) and neurological functioning (majnemer, brownstein, kadanoff & shevell, 1992). the knowledge base about the communication skills of these neonates has also been expanded by studies on early interaction patterns between parents and their at-risk neonates (klein & briggs, 1987), feeding patterns (bu'lock, woolridge & baum, 1990) and hearing abilities (brown & taxman, 1993; pearce, saunders, creighton & sauve, 1988). the importance of understanding the neonatal communication abilities of biologically at-risk infants is that it provides the speech-language therapist and audiologist with a prospective view of the first stages of their communication disorders and the conditions that interfere with the earliest parent-child communication interactions. neonatal assessments, however, do not yet provide us with sufficient information to predict the course of further development (brazelton, 1990; rossetti, 1990). the neonate's behaviour is a powerful language, providing us with insight into prenatal and perinatal events. it is also an intricate language of interactions between various systems within the neonate as well as externally. according to brazelton (1990) a simple linear model of assessment and prediction is not viable and ignores the synergy of developmental systems. the aim of assessing neonatal communication skills of biologically at-risk neonates is to provide baseline data for early communication intervention and serial assessments. such an assessment should consider at least four factors, namely: the nicu environment which provides ongoing nonsocial auditory, visual, kinaesthetic and tactile stimulation (noise, uninterrupted light, physical handling for routine care, and pain caused by necessary medical procedures) and limited and inconsistent social stimulation directed at the neonate when he/she displays readiness; the levels of consciousness that the neonate is able to maintain and control in response to his/her physical condition and inappropriate nicu environment stimulation; the different biological risk conditions that a specific neonate has been exposed to; the neonate's genetic endowment and prenatal events which may account for established risk factors, such as down syndrome (who are at-risk for low birthweight). (als, 1986; brazelton, 1987; dunn et al., 1993) based on these factors the aim of the current study was to develop a comprehensive communication assessment alta kritzinger, brenda louw and βηέ hugo protocol to describe the communication skills of biologically at-risk neonates. method aims l b design a communication assessment protocol for biologically at-risk neonates. l b apply the neonatal communication assessment protocol to a group of biologically at-risk neonates. l b determine correlations between the communication skills and other developmental areas of the group of biologically at-risk neonates. to identify risk factors relating to the communication skills of the group of biologically at-risk neonates in order to compile a high risk register of their communication development. subjects a descriptive survey was conducted. fifty subjects were randomly selected from the population of biologically atrisk neonates and were required to present with prematurity (37 weeks or less gestation) and/or low-birthweight (2 500g or lower birthweight). the subjects had to be discharged from the incubator less than two days, but had to be still in the nicu, and in a medically stable condition as judged by their doctors. subject selection was limited to four hospitals in the urban area of pretoria. biological and established risk factors the subjects were assessed at an average corrected age of 38 weeks, ranging from 34 to 43 weeks. their average chronological age at assessment was, however, 26 days, ranging from 1 to 75 days (see table 1 no 1). table 1 provides information regarding the general characteristics (no 1 to 4), biological risk conditions (no 5 to 19) and established risk conditions for development (no 20) of the subjects. according to table 1 the sample displayed large differences in birthweight (from extremely low birthweight to normal birthweight) and gestational age (from extremely premature to fullterm). it may appear as if some of the subjects did not meet the selection criteria, but one subject displayed mild prematurity and normal birthweight (3060g), while four subjects were fullterm, but small-for-gestational age. 30% of subjects who were small-for-gestational age (see table 1 no 16), may be associated with biological risk factors coupled with environmental risk factors. the sample did not, however, reflect a high percentage of environmentally at-risk infants as can be expected elsewhere in south africa as the subjects were mostly from middle-income families living in an urban area. non-social environmental risk factors apart from the biological and established risk factors provided in table 1 the nicu environment was investigated for possible non-social environmental risk factors. the noise levels in one of the nicu's that were utilised for subject recruitment were measured with a rion na24 soundlevel meter. these measurements are provided in table 2 in order to give an account of the noise levels that the subjects were exposed to during their stay on the warm table and in the incubator. as consistent high inthe south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication skills of biologically at-risk neonates tensity noise levels hold the greatest potential for hearing damage, the noise caused by oxygen supplied through corrugated tubing can be singled out as a high risk condition for cochlear damage in the subjects of this study. boettcher, h e n d e r s o n , gratton, danielson and byrne (1987) found a potential interaction between high intensity noise levels in the nicu and the use of aminoglycoside therapy. it is s u g g e s t e d that the developing cochlea of premature 9 neonates is more vulnerable for the joint effects of high intensity noise and the use of ototoxic drugs. the noise levels of the nicu reflected in table 2 may also have a non-auditory effect on the subjects, as they contribute to sensory overstimulation and interfere with communication interaction by masking the human voice. it also appeared that the seriously ill subjects were exposed to more treatment procedures involving the highest table 1: description of subjects feature or risk factor qualitative description 1. chronological age at assessment mean: 26 days range: 1-75 days 2. gender 28 girls; 22 boys 3. number of subjects visited daily by parents 42 subjects (84%) 4. number of subjects receiving breast milk 26 subjects (52%) 5. gestational age mean: 34 weeks range: 26-40 weeks 6. birthweight mean: 1906g range: 852-3060g 7. number of days in incubator mean: 24 days range: 1-75 days 8. number of days before bottle-fed mean: 17 days range: 0-74 days 9. multiple pregnancy 14 subjects (28%) 7 pairs of twins 10. respiratory distress syndrome 22 subjects (44%) 11. perinatal infection j 38 subjects (76%) 12. intra-cranial haemorrhage 5 subjects (10%) i 13. aminoglycoside therapy 27 subjects (54%) 14. duration of aminoglycoside therapy t i mean: 11 days range: 7-63 days 15. 5 minute apgar score mean: 8 range: 2-10 16. small-for-gestational-age 15 (30%) 17. jaundice 42 subjects (84%) 18. phototherapy for jaundice 38 subjects (76%) 19. recurrent apnoea attacks 12 subjects (24%) 20. family history of hearing loss 2 subjects (4%) 21. other non-infective conditions* 6 subjects (12%) *key:other non-infective conditions included hydrocephalus, craniostenosis, blindness and congenital abnormality of limb. i die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 alta kritzinger, brenda louw and hugo intensity noise levels. the noise caused by life-supporting systems can therefore be considered as a risk factor for the subjects' hearing abilities and the development of communication interaction skills. communication assessment protocol various sources from the literature were used to design a neonatal communication assessment protocol which would serve to collect a case history (rossetti, 1990), assess hearing abilities (proctor & kennedy, 1990), precursors of cognitive abilities (brazelton 1987), motor development (clarke-stewart & friedman, 1987), oral-motor functioning (morris & klein, 1987) and communication skills. these include precursors of language use (klein & briggs, 1987; sparks, 1989), precursors of language form (louw, 1986; proctor, 1989) and precursors of language content (lahey, 1988) (see kritzinger, 1994 appendix b,c & d). the zoom lens model as suggested by van kleeck and richardson (1988) was used as a theoretical framework for designing the protocol and conducting the research project. figure i provides a summary of the neonatal communication assessment model. procedure data collection as a first step to determine the exact sequencing of all the components of the assessment protocol and to gain clinical skills in the unknown field of neonatal communication assessment, a pilot study was carried out on ten fullterm neonates. as a result of the practical experience and insight gained from the pilot study, specific procedures were established for the collecting of data on the 50 subjects of the main study, namely: data collection was done in the afternoons to ensure less disruption of the busy routines of the nicu during mornings. table 2: noise levels in a nicu the subjects were assessed half an hour before feeding to avoid deep sleeping and difficulties of waking the subjects. data collection began by measuring the middle-ear functioning while the subject was still sleeping and less likely to move. this was followed by behaviour observation audiometry while the subject was sleeping or in a quiet state. after audiometric measurements were completed the subject was usually awake and interactive behaviour could be elicited for the evaluation of communication and cognitive skills. motor and oral-motor skills were evaluated before feeding, as oral reflexes are depressed after feeding. observation of feeding skills concluded the assessment protocol. relevant data from the case history was collected last, in order to avoid biased observations (kritzinger, 1994). all measurements, responses and observations were immediately recorded on the scoresheets of the case history: biological and established risk factors and communication assessment scales for infants at biological risk: neonatal period (kritzinger, 1994 appendix b, & d). after experience in assessment were gained from the ten subjects of the pilot study, data collection was done by only one examiner. as recommended by brazelton (1973) no more than two subjects were assessed on one day, a3 fatigue may interfere with the examiner's accuracy. analysis of data data was analyzed and statistically processed in order to present qualitative and quantitative results of the survey. by following the different assessment levels of the zoom lens model (van kleeck & richardson, 1988), the results were compared to normal development and interpreted by indicating intrasystem interactions and finally presenting a broad perspective by indicating intersystem interactions of the communication skills of the subjects. general sources of noise persistent intermittent noise level at subject in head box yes no noise level at subject on warm table yes no ! additional sources of noise heart monitor: high frequency impulse noise yes no heart monitor: low frequency impulse noise yes no heart monitor alarm no yes ventilator monitor no yes warm table monitor no yes voices and trolley no yes oxygen fed through corrugated tubing yes no the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication skills of biologically at-risk neonates 11 step 1 intersystem analysis variables assessment areas biological variables case history environmental variables noise levels in nicu behavioural variables: hearing system motor system . cognitive system hearing and middle-ear functioning* gross motor and oral motor skills precursors of cognition i step 2 intrasystem analysis variables assessment areas communication system precursors of language use precursors of language form precursors of language content i s t v p 3 comparison to normal developmental information i step 4 intrasystem interactions interpretation of results i slop r> intersystem interactions implications of results * key: equipment used for tile hearing assessment included the weiss neometer providing calibrated high and low frequency narrowband noise for behaviour observation audiometry and the gsi 28aauto tymp (grason-stadler, inc) for the evaluation of middle-ear functioning. figure i: neonatal communication assessment model for biologically at-risk infants results and discussion figure ii presents an overall view of the average functioning of the 50 subjects for the eight areas of assessment. according to figure ii the subjects presented with normal levels of functioning (values of 7 to 10 according to the rating scale as suggested by allen & alexander, 1992) for hearing abilities, middle-ear functioning, motor and oral-motor skills, whereas precursors for cognition and language use, form and content displayed a delay in development. precursors for language use can be singled out as the developmental area displaying the greatest delay. the subjects' normal developmental levels are comparable to results of research done by aylward, gustafson, verhulst & colliver (1987) and gorga, stern, nass & nagler (1988) for subjects | ranging from minimal to extreme prematurity. these studies found that most subjects displayed no neurological or motor disorders in the neonatal period. studies on extremely premature neonates (majnemer et al., 1992; piper, kunos, willis & mazer, 1985; tbuwen, 1990) however, found large differences in general development in comparison with fullterm neonates. it therefore appears that the more premature the neonates are, the greater the delay in their general development. the delays in cognitive and communication development displayed by the subjects indicate limited interaction with their environment and caregivers. these findings are recognized by various researchers as typical neonatal behaviour of biologically at-risk infants (als, 1986; brazelton, 1984; stjernqvist & svenningsen, 1990). it is suggested that these disordered interaction patterns are related to sensory overstimulation, absence of contingent interaction with caregivers and a lack of rhythmicity and routines in the nicu (als, 1986). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 alta kritzinger, brenda louw and ιιβηέ hugo figure iii presents the results of the spearman correlation coefficients conducted to determine significant correlations (<0,5) between the subjects' developmental levels across the different developmental areas. all significant correlations that occurred were positive, indicating the subjects' improvement or delay in one developmental area displayed an improvement or delay in the correlated developmental area as well. according to figure iii significant positive correlations occurred between the assessment areas of the communication protocol representing different aspects of behaviour (motor and oral-motor skills and precursors of cognition, language use, form and content). those assessment areas measuring physiological d e v e l o p m e n t a l level 10 9 1 8 -76 i i i i 5 4 3 2 1 1 1 1 i i 1 1 1 1 m 1 it 1 fa • it 1 η mel μ om c lc li lu 9.64 7.46 7.56 6.92 5.01 4.98 5.21 3.52 . a s s e s s m e n t a r e a s figure ii: average developmental levels of subjects, n=50 key: h= hearing abilities; mef= middle ear functioning; m= motor skills; om= oral-motor skills; c= precursors of cognition; lc= precursors of language content; lf= precursors of language form; lu= precursors of language use θ λ (me) v j i l l figure iii: significant correlations between the results of the different developmental areas, n=50 key: h= hearing abilities; me= middle ear functioning; m= motor skills; om= oral-motor skills; c= precursors of cognition; lc= precursors of language content; lf= precursors of language form; lu= precursors of language use functioning (the subjects' hearing abilities and middle-ear functioning) did not indicate any intersystem interactions as they require different parameters of assessment compared to behaviour. a detailed analysis of the results based on figure ii and figure iii is supplied by discussing each developmental area separately. general developmental systems: intersystem analysis and interactions hearing abilities the subjects' response levels were indicative of normal hearing abilities in a non-soundproof room. no sensoryneural hearing loss was detected among the subjects and risk factors such as the noise levels in the nicu, the use of ototoxic drugs (see table 2) and all other risk conditions described in the high risk criteria for the identification of hearing loss in children (asha, 1989) did not seem to have affected their hearing abilities. it was found that doctors in the hospitals studied, carefully monitored the ototoxic levels in the blood when such drugs were used and often avoided using these drugs. it could therefore be that reported incidence of sensory-neural hearing loss between 2% and 10% among the nicu graduates (salamy & eldridge, 1991), served to focus the attention on preventative measures of which we see the results now already. middle-ear functioning three different aspects of the results on the middle-ear functioning of the subjects are discussed, namely abnormal middle-ear measurements, acoustic reflexes and tympanograms. the measurement of 7,48 (see figure ii) indicates normal middle-ear functioning for the group as a whole. 20% of the subjects, however, displayed abnormal middle-ear measurements for static compliance, middle-ear pressure and the shape of the tympanogram. these findings seem to indicate an increased incidence of abnormal middle-ear functioning among the subjects when compared with studies on middle-ear functioning of fullterm neonates, which found the incidence of middle-ear pathology between 0% (zarnoch & balkany, 1977) and 4,1% (mann, 1986) in that population. it has been suggested that abnormal middleear functioning is related to the prolonged use of nasogastric tube feeding resulting in decreased ventilation of the middle-ear as no swallowing is required for this kind of feeding. there is, however, no clarity about the nature of the abnormal middle-ear measurements displayed by the subjects as these neonates have just completed courses of antibiotics that would have cleared up otitis media with effusion as well. clinical experience indicates the difficulty of diagnosing abnormal middle-ear functioning as the premature external meatus is very narrow and limits the visual inspection of the tympanic membrane. it is therefore suggested that increased fluid in the middle-ear as measured in 20% of the subjects may be sterile, but can still cause a conductive hearing loss. although this hearing loss will only influence communication development when it recurs frequently, early detection of abnormal middle-ear functioning in biologically at-risk neonates may lead to the early identification of those who are otitis media-prone. further research is necessary to establish if this the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication skills of biologically at-risk neonates 13 is indeed the way to identify otitis media-prone infants at biological risk. early identification of otitis media in biologically at-risk neonates can ensure early treatment resulting in decreasing the negative effects on their communication development as various studies have already found a high incidence of otitis media among biologically at-risk infants (pearce et al., 1988). the subjects' acoustical reflexes displayed normal values but could only be elicited after an average of four attempts. these findings are in agreement with other studies finding neonatal acoustical reflexes difficult to elicit (mann, 1986; walters & shimizu, 1990). finally, 94% of the subjects displayed type d and type ε tympanograms indicating highly mobile middle-ear systems. research done by keith (1975) and mann (1986) on fullterm neonates and zarnoch and balkany (1977) on biologically at-risk neonates indicates a high incidence of mobile middle-ear systems that can be related to the incomplete ossification of the middle-ear system in fullterm neonates as well as in premature neonates. the incidence of mobile middle-ear systems in these three studies, however, are not as high as in the present study. the findings of the present study on the mobility of the subjects' middle-ear systems are therefore only partly in agreement with previous studies. motor akilla the subjects' average motor skills were within normal limits and are comparable to the studies of aylward et al. (1987) and gorga et al. (1988). uncontrolled body movements and lack of an overall extension pattern can be singled out as the subjects' typical motor behaviour. according to morris and klein (1987) the lack of a physiological flexion pattern of the body is characteristic of premature neonates as they are born too soon to be forced into flexion due to decreased intra-uterine space. oral-motor skills the subjects' oral-motor skills displayed values just below the average (6,92). the| subjects were assessed at a stage when they had already overcome most of their feeding problems and shortly before discharge from the nicu. table 1 no 8 indicates that the| subjects did experience feeding problems prior to assessment, some to the extent that it took them 75 days to bottle-feed satisfactorily. a qualitative analysis of the results revealed depressed rooting reflexes, prolonged dependence on nasogastric tube-feeding (44% of subjects) and prolonged duration of feeding (only 28% of the subjects couldcomplete their feeding within 20 minutes) as the remainder of their feeding difficulties. the feeding difficulties experienced by the subjects are similar to those described by bu'lock et al. (1990), jaffe (1989) and morris and klein (1987). it is suggested the feeding difficulties of biologically at-risk neonates are related to neurological disorganization and the predominant extension pattern of the body. these results, supported by the spearman correlation coefficients (see figure iii) indicated that relationships exist between the subjects' motor and oral-motor skills, therefore demonstrating interactions within the motor system. precursors of cognitive skills the results indicate that the subjects evidenced a delay in the development of precursors of cognitive development. on average the subjects displayed difficulties with actively attending to environmental stimuli. according to brazelton (1984) the neonates' characteristic ability to control stimuli by changing their levels of consciousness (from sleep to alertness) may be the most predictive aspect of their behaviour. the subjects' passive state can therefore be ascribed to their limited.ability for organization and intergration of stimuli within and from the environment. these findings are also supported by majnemer et al. (1992) and stjernqvist and svenningsen (1990). communication system: intrasystem analysis and interactions precursors of language use the results of the development of the precursors of language use revealed the subjects' lowest level of development of all areas assessed. characteristic neonatal communication interaction behaviour such as eye contact, imitation of facial expressions and synchronized interactions occurred rarely. these results display clear intersystem interactions between the cognitive and communicative systems (see figure iii as well) of the subjects and can be explained in the same way as the subjects' passive responses to non-social stimuli (development of precursors of cognition). the development of the precursors of language use indicates that the subjects' social interaction with the environment was poor. this can be related to the inconsistent and limited social interaction provided by the nicu environment. comparison of the subjects' severe delay in developing precursors for language use to the other results, appear to support the opinion of rosenblith (1992) namely, that infants at biological risk exhibit a specific vulnerability for communication disorders. when taken into consideration that precursors of language use are the first forms of communication to develop (lahey, 1988), the results of this study may point to some of the underpinnings of the communication disorders of biologically at-risk infants. precursors of language form as indicated in figure ii the subjects displayed a delay in the development of precursors of language form. it seemed that their typical vocal behaviour was still undifferentiated and reflexive in nature, again indicating limited interaction with the environment. these results are supported by morris and klein (1987) by their description of the limited vocal behaviour of biologically at-risk neonates as they do not cry to signal for hunger. the subjects' results regarding the development of precursors for language form displayed significant positive correlations with their oral-motor skills (see figure iii). these findings indicate that interactions between the motor and communication systems occurred, which is also recognized in the literature (morris & klein, 1987). precursors of language content although the subjects displayed normal hearing abilities, their development of listening skills as precursors of language content demonstrated delay. listening behaviour, distinguished by sustained attention, arrest of activity and alertness (brazelton, 1973) was seldomly observed. the lack of these responses also demonstrates the subjects' limited interaction with the social and non-social environment, thus possibly explaining the existence of the correlations displayed between the development of predie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 alta kritzinger, brenda louw and hugo cursors of language use and cognition (see figure iii). the results of the subjects' general and communication development indicated interactions across developmental systems as well as intrasystem interactions. this serves as a means to provide a wide angle perspective on the subjects' communication development. the results also indicate the synergy of the different developmental systems and demonstrates the difficulties that the subjects experienced to gain control over their developmental systems by means of regulation and organization of their behaviour. in summary, the subjects gave the impression of a neonate with normal hearing abilities, but a high risk for otitis media. s(he) mainly lies quietly in an extension pattern and has not fully mastered independent feeding skills. this neonate is mostly in a semi-alert state, pays attention to auditory and visual stimuli momentarily, cries or vocalizes seldom and attends only fleetingly to human contact and voices. this neonate is tiny, vulnerable, passive and has insufficient skills for communication interaction when compared to his / her fullterm counterpart who has been "prewired" (owens, 1984, p21) for communication. identification of risk factors relating to the subjects' communication development according to rossetti (1993) the early identification of communication disorders of biologically at-risk neonates is one of the most important factors contributing to the success of early communication intervention. the use of a high risk register for communication disorders implies that biologically at-risk neonates who are at special risk for communication disorders, can be identified before being discharged from the nicu and early communication intervention can continue without any interruption between neonatal ̂ nd postnatal intervention. a stepwise regression analysis was done in order to identify significant independent variables (on a 5% level of significance) correlating with the subjects' delayed communication development. thirteen significant independent variables were identified as significant risk factors that predicted the subjects' delayed communication development. this implies that the presence of a risk factor had a negative influence on the subjects' communication functioning. table 3 provides these risk factors in order of predictability as well as the different aspects of communication development that they were related to. according to table 3 ten risk factors were directly related to the subjects' biological conditions. birthweight and prematurity are among these risk factors, but they were not the strongest predictors of the subjects' commutable 3: significant risk factors of communication development in order of predictability, n=50 risk factor type of risk communication behaviour 1. success with bottle feeding biological risk precursors of language use precursors of cognition oral motor skills motor skills 2. receive breast milk environmental risk precursors of language content precursors of language form motor skills 3. frequency of parental visits in nicu environmental risk oral motor skills motor skills 4. gestation age (prematurity) biological risk precursors of language use ' precursors of language form 1 5. small-for-gestational-age biological risk precursors of language form [ middle-ear functioning j 6. gender (masculine) biological risk middle-ear functioning precursors of language form 7. birthweight biological risk oral motor skills 8. multiple births (twins) biological risk middle-ear functioning 9. perinatal infection biological risk precursors of language content 10. intracranial haemorrhage biological risk precursors of language f o r m / 11. apnoea attacks biological risk precursors of cognition 12. respiratory distress syndrome biological risk precursors of language content 13. non-infective conditions established risk middle-ear functioning the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication skills of biologically at-risk neonates 15 nication functioning as regarded in the literature (rossetti, 1993). the strongest predictor of the subjects' communication development was their success with bottle-feeding, as measured by the number of days taken to achieve successful bottle-feeding. the quicker the subjects could feed independently, the better their communication development was. the subjects' success with bottle-feeding predicted their functioning on a wide range of developmental areas, namely social and non-social interaction skills as well as motor and oral motor development, representing the communication, cognitive and motor systems. this indicates that feeding skills could be singled out as a basic prerequisite for the subjects' communication development. these findings are in agreement with alexander (1990) who considers impaired vegetative functioning as one of the earliest signs of developmental disorders. in considering all the different risk factors indicated in table 3, lack of success with bottle-feeding was the only parameter that provided information about the subjects' developmental status. some of the other biological risk factors (no 9 to 12) merely indicated the subjects' recovery from perinatal conditions, whereas birthweight, prematurity, gender and multiple births indicate well-known risks, but did not indicate how individual neonates react to these conditions. table 3 also indicates that environmental risk factors, as measured by parental involvement, negatively influenced the subjects' communication development. the parents' involvement was measured by providing breast milk for feeding and the frequency of their visits to the nicu. those subjects who received breast milk (mostly expressed breast milk received via tube feeding or bottlefeeding) benefitted from the interaction with mothers as these mothers had to bring the milk to the nicu daily and often fed the subjects themselves. the parents' regular involvement with the subjects in the nicu had a positive effect on aspects of their communication development as well as their motor and oral motor skills. the importance of parental involvement in the nicu is also stressed by various authors (als, 1986; jacobson & shubat, 1991; sparks, 1989). the last parameter indicated in table 3 were conditions that represent established risks (also see table 1 no 20) and indicates the close relationship existing between biological risks and established risks. established risk conditions can have their origin in prenatal stress conditions and are usually associated with retarded intrauterine growth. this implies that the risk status of an infant at biological risk can already begin during prenatal development. the established risk conditions as identified in this study, however, had a limited influence on the subjects' communication development, namely on their middle-ear functioning. the thirteen risk conditions as indicated in table 3 can therefore be considered as high risk factors for the subjects' neonatal communication development and are presented in table 4. the predictability of these risk factors for later communication development must still be established by further research in the form of longitudinal studies. in conclusion, the results of the study highlighted certable 4: high risk register for the prediction of the subjects' communication development, n=50 parameter risk factor 1. feeding the greater the number of days before successful bottle feeding, the greater the risk 2. receiving breastmilk in >nicu j ί mother not supplying breast milk implies less communication interaction with one caregiver and a risk for communication delay 3. parental visits in nicuj the lower the frequency of parental visits, the greater the risk 4. gestation age j the lower the gestation age, the greater the risk 5. small-for-gestational age | the presence of intra-uterine growth retardation implies a risk for communication delay / 6. gender boys displayed as greater risk for communication delays 7. birthweight the lower the birthweight, the greater the risk 8. multiple births twins displayed a greater risk for communication delay 9. perinatal infection the presence of an infection implies a risk for communication delay 10. intracranial haemorrhage the presence implies a risk for communication delay 11. apnoea attacks the presence implies a risk for communication delay 12. respiratory distress syndrome the presence implies a risk for communication delay 13. non-infectious conditions 1 the presence of established risk factors implies a risk for communication delay die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 tain aspects of neonatal communication abilities of biologically at-risk infants such as: the incidence of sensory neural hearing loss. the results of the study add to the unsolved question in the literature about the incidence of sensory-neural hearing loss among the nicu population; neonatal middle-ear functioning of infants at biological risk and the fact that the literature provides very limited guidelines for neonatal tympanometry. further research into the early identification of otitis prone infants at biological risk is necessary; the serious delay in communication interaction skills compared to other aspects of language development and general development. the effects of biological as well as environmental risk factors on neonatal communication abilities as evidenced in the proposed high risk register. it therefore appears that the results of the study, as obtained from the proposed assessment protocol, provided comprehensive information about the communication abilities of a group of biologically at-risk neonates, both from a speech-language pathology perspective as well as from an audiological viewpoint. conclusions neonatal communication intervention is the first link in the chain of continuous service delivery from birth to schoolgoing age to biologically at-risk infants and their families. this study focused attention on the earliest communication abilities of biologically at-risk infants. such an approach contributes to a perspective that retrospective studies, which have dominated this field of study in the past, cannot provide. the neonatal perspective underscores the detrimental influence of the nicu environment on the communication development of biologically at-risk neonates. the results of the study suggest that the noise levels in the nicu may pose a risk for hearing loss as well as interference with communication interaction. the results of the study also indicate that appropriate parental involvement in the nicu can make a difference to these neonates' early communication skills. a neonatal perspective further provides first-hand knowledge of the different biological and established risk conditions as well as neonatal communication behaviour and the interactions of these two aspects with one another. these aspects need to be explained to parents to ensure bonding and effective parent-infant communication interaction when the neonate displays readiness. it is therefore clear that a neonatal perspective on the communication abilities of biologically at-risk infants can contribute to the effectiveness of early intervention and adds a new dimension to the role of the early communication interventionist. the involvement of the speech-language therapist and audiologist in the multidisciplinary neonatal intervention team implies an extension of the field of communication pathology demanding specialized knowledge and clinical skills. this has implications for undergraduate training as well for continuing education of qualified professionals. another implication of the speech-language therapist's and audiologist's involvement in neonatal intervention is alta kritzinger, brenda louw and hugo the opportunity to provide services on the level of secondary prevention of communication disorders and in this way responding to the objectives of early communication intervention, i.e., preventing minor problems from becoming serious and new problems from developing (asha, 1991). the current study provides a tool for screening by means of the proposed high risk register (see table 4) as well as a neonatal communication assessment protocol for comprehensive evaluation purposes. the proposed high risk register for identification of those biologically at-risk neonates who are also at risk for communication disorders is a first attempt at such a strategy of early detection of communication pathology. the validity and reliability of the high risk register must, however, still be established as in the case of the well-known high risk criteria for the identification of hearing loss in children (asha, 1989). although a high risk register will always have limitations as there are still many immeasurable causes of communication pathology, it can be of much clinical value. the specific items of the proposed high risk register, especially the neonate's success with bottle feeding (see table 4), requires information that is readily available from the neonate's case history file or from the parents. the high risk register can therefore be a cost effective screening instrument to be used in primary health care in south africa. in a trans disciplinary context, community nurses may be trained to identify those neonates exhibiting risk factors for follow-up by early communication intervention specialists. this study provides a clinical assessment tool for the evaluation of neonatal communication abilities of biologically at-risk infants. the neonatal communication assessment protocol is as far as is known, unique in south africa. it is also a first attempt to objectify neonatal intervention by means of assessment. neonatal intervention in the south african context, however, still poses many challenges. this research project focused only on biologically at-risk neonates and did not study those who are also environmentally at-risk. further research needs to be conducted regarding the concerns of the most needy of the south african biologically at-risk population. additional research will enhance the development of early communication intervention in south africa, thereby giving priority to a strategy for the secondary prevention of communication disorders. early communication intervention is a key strategy that needs to be employed to cope with the large numbers of clients and the limited number of speech-language therapists and audiologists. correspondence should be addressed to: ι alta kritzinger, department of communication pathology, university of pretoria, pretoria 0002 references alexander, r. 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(eds.) impedance screening for middle ear disease in children. new york: grune & stratton. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) two s e p a r a t e a n d i d e n t i c a l c h a n n e l s t h r e s h o l d s p l o t t e d o n screen f r e q u e n c i e s 125 t o 20 000 hz w o r d l i s t s s t o r e d i n m e m o r y s o f t w a r e p a c k a g e 2 y e a r g u a r a n t e e i c u s t o m i z e d protocol's ι in p r i n t e r = p t y l t d t h e h e a r i n g h e a l t h c a r e s p e c i a l i s t s sovereign hous sovereign strei bedfordview 2008south africa p.o. box 630 bedfordview 2008 south africa tel: (011) 622-174 fax: (011) 622-130 reg. no. 77/01577/07 the south african journal of communication disorders, vol. 42, 1995 a m i w o o m [bir@alkodiig ftlh® s o u n d b a r r i e r ® r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) evalutaion of a programme.html evaluation of a programme to support foundation-phase teachers to facilitate literacy anna-marie wium department communication pathology , university of pretoria brenda louw professor emeritus: department communication pathology, university of pretoria irma eloff faculty of education, university of pretoria correspondence to: a wium (anna-marie1.wium@ul.ac.za) abstract learners who do not develop adequate listening and language skills during their early years are at risk of academic failure and early drop-out. future learning problems may be prevented by supporting these children in the foundation phase to overcome their developmental delays. a continued professional development (cpd) programme was developed to support foundation-phase teachers to facilitate literacy. the theoretical basis for the workshop material was the articulation between an auditory processing model, a language processing model, and literacy. the focus of this article is on the qualitative findings obtained from the literacy component of a more comprehensive cpd programme that covered several topics. the research was conducted as action research cycles across two contexts (a semi-rural and an urban-township context) and included 96 participants. this article explores how the teachers implemented the strategies to facilitate literacy in their classrooms and the benefits obtained from it. data were collected by means of questionnaires, self-reflections and focus groups, as well as a research diary and field notes. the results revealed that the strategies trained were implemented in the classrooms and were valued by the participants. those who participated in critical reflection felt that they had developed competence and professional growth. challenges identified included the language used in the support provided, which had an impact on phonological awareness training, and the use of terminology. the importance of collaboration was emphasised. the participants gained in the sense that they learnt how to implement the assessment standards in the curriculum, and learners benefited from the new strategies as they could all participate in the activities. the research confirmed the value of teacher support in the facilitation of literacy, which highlights the role of speech-language therapists working in school contexts. keywords: teacher support, listening, auditory processing, phonological awareness, qualitative research, speech-language pathologists background this study developed a continued professional development (cpd) programme for foundation-phase teachers to facilitate and promote emergent literacy skills. the first author acted as programme facilitator, and will be referred to as such throughout the article. the cpd programme was based on the principles of adult learning (knowles, holgotn, & swanson, 1998) and whole-brain learning (herrmann, 1996), to accommodate all learning preferences. the relationship between auditory processing and language processing information processing is a complex process (hamman & squire, 1996, 1997 in owens, 2004) that involves sensory input on many levels, which in turn is integrated and regulated by meta-cognition. it requires selective attention, inhibition, and the co-ordination of stimuli and concepts. the facilitation of literacy skills in this study is based on a three-level model that aligns a model for central auditory processing (bellis, 2003) with a language processing model (richards, 2004), which is then articulated with literacy. figure 1 was created to illustrate the link between bellis’s model for central auditory processing and how richards described the language processing model, and the learning outcomes for literacy (revised national curriculum statement (rncs)) (department of education, 2002). in figure 1, the first level of the central auditory processing model refers to how the sound signal is being received through the ear (bellis, 2002), which corresponds with the first level in the language processing model, described by richards (2004) as ‘listening skills’. listening is an active process that involves an awareness and localisation of sounds, as well as the behaviour (characteristics) of a good listener (bellis, 2003). the acquisition of such skills is an important first step in the processing of auditory input and also the first step in acquiring phonological awareness. learners need to learn the art of listening actively, attentively and analytically in order to learn (adams, foorman, lundberg, & beeler, 1998). the second level in the auditory processing model refers to the ‘signal manipulation’ level, which in turn corresponds with the ‘perception of speech’ (gillon, 2002) in the language processing model. this level includes both phonological awareness and phonemic processing. phonological awareness is critical to the ability to analyse (segment) speech units and to synthesise (blend) speech sounds into words, which makes it a strong predictor of success in reading and writing (goldsworthy, 1998; muter & diethelm, 2001). poor phonological awareness in turn negatively affects the acquisition of reading and spelling, so phonological awareness is viewed as the strongest predictor for academic success (ehri, nunes, willows, schuster, & yaghoub-z., 2001). learners need to develop phonological awareness skills to an age-appropriate level at school entry. many learners from low socio-economic schools (ses) have not developed adequate phonological awareness skills on entering school (nancollis, lawrie, & dodd, 2005). this may be attributed to limited or no prior literacy experiences at home. it is often found that such learners have limited access to structured preschool education. learners who are unable to read by the end of grade 1 tend to lag behind and may develop learning problems. on the third level of the auditory processing model (figure 1), the auditory signal is interpreted through higher cognitive functions, and relates to how meaning is extracted from the auditory input. richards (2004) considers the focus on this level to be more on linguistic skills than on auditory skills. such a view supports the notion that these two processes are closely related. bellis (2003: 95) is of the opinion that, ‘… it is not easy to separate acoustic and phonemic processing from one another or from higher-order linguistic influences’. to facilitate literacy development in the classroom, each of the three levels of language processing (richards, 2004) has a different effect on literacy learning (figure 1). the relationship between the three-level model and the national curriculum the national curriculum (nc) specifies ‘listening’ as the first learning outcome (lo1) for ‘literacy’ in the foundation phase (grades r 3). lo1 is a stepping stone for acquiring phonological awareness skills, which is integral to the development of emergent literacy skills. because the development of oral language is a prerequisite for the development of reading and writing (justice, meier, & walpole, 2005), this aspect is addressed in learning outcome 2 (lo2) of the rncs, (referred to as ‘speaking’) (figure 1). language skills include the visual modality (johnson & roseman, 2003), which is addressed in learning outcome 3 (lo3) (referred to as ‘reading and viewing’), as well as learning outcome 4 (lo4) (referred to as ‘writing’), where the focus turns towards acquiring more formal literacy skills. foundation-phase learners are also introduced to ‘thinking and reasoning’ in learning outcome (lo5) and ‘language structure and use’ in learning outcome 6 (lo6). the last four los correspond with the third level of the three-level language model, which is described as ‘linguistic skills’. the workshops provided in this cpd programme addressed each of the learning outcomes for literacy in the rncs, which again corresponds with the three levels of the model for language processing shown in figure 1. a cpd programme for foundation phase for the facilitation of literacy the content of this specific cpd programme was developed in collaboration with the gauteng department of education (provincial and district levels), and had to correlate with the rncs. the programme was considered a joint effort between the programme facilitator and the district facilitators. the other learning outcomes were addressed in the cpd programme as a whole, but this article focuses on the section that targeted the facilitation of ‘listening’ as a stepping stone for the development of phonological awareness and phonic awareness (refer to levels 1 and 2 in figure 1), as such skills are required for literacy. the cpd programme consisted of three components: a training component, supported by practical and mentoring components (wium, louw, & eloff, 2010). the training component in turn consisted of a series of workshops that were repeated in two contexts over a period of 2 years. the workshops (refer to appendix a) provided the participants with strategies and activities to facilitate literacy. the approach followed in the cpd programme was based on adult learning theories and made use of facilitative strategies for learning, e.g. action learning strategies (kemmis & mctaggart, 2005), co-operative learning (department of education, 2002; killen, 2007) and peer learning. experiential learning (kolb, 1984) opportunities allowed participants to practise the strategies through role play in the workshops and thereafter to implement it in their classrooms. such support allowed the participants to first observe the strategies before they were required to apply them, and then allowed them the opportunity to reflect on the process by completing self-reflection sheets for their portfolios. method aim of the research the aims of the article are to explore how the participants implemented the strategies to facilitate literacy in their classrooms, and to describe the benefits of the support provided. study design this study was part of a more comprehensive study using programme evaluation as research design (creswell & plano clark, 2007). the research made use of two action research cycles across two contexts (semi-rural and urban townships), and made use of qualitative methods of inquiry. participants the data collected for this article were obtained from the main study. in its effort to redress past inequalities, the gauteng department of education (gde) identified 24 low socio-economic schools (ses) in the tshwane region to participate in this project; 12 schools were from a semi-rural area, and 12 from an urban/densely populated area (including township schools and schools in informal settlements). stratified sampling was used to select the sample (mcmillan & schumacher, 2006), as each school that accepted the invitation to participate in the programme identified 1 teacher in each grade level of the foundation phase (e.g. grades r, 1, 2 and 3), so 4 teachers from each school enrolled for the programme, provided their participation was voluntary. there were 12 teachers representing each grade level in the foundation phase (grades r 3) included in the programme, totalling 96. at the time of the research it was estimated that there are about 3 4 classes in each grade level of each school, and therefore the selection of one participant from each grade level in each school represented approximately 25% of the total number of foundation-phase teachers in these selected schools. as only one primary trainer was available to conduct the workshops, groups of 48 participants per context were regarded as manageable, and were sufficient to allow for possible attrition later in the programme. in the larger study each group of four teachers in each school was encouraged to select a representative to attend the focus group meeting, which implies that these participants have already met the selection criteria for the original sample (nested design) (leech & onwuegbuzie, 2005). the focus groups consisted of 12 participants in each context (1 from each school), considered an adequate size for a focus group and a representative sample (25%) of the entire group that was trained. it also allowed for attrition (leedy & ormrod, 2010). focus groups were voluntary; in some instances more than one participant from each school attended the meeting, and in other cases none attended. the programme facilitator also acted as moderator in the focus groups, whereas the district facilitators acted as assistant moderators in both the contexts of the research. the district facilitators were required by the gde to assist the programme facilitator, and were partners in the project. both district facilitators were northern sotho speaking and familiar with research methods as they were both enrolled for master’s degrees at that time. with the exception of two participants, all were female. the sample was fairly homogeneous in terms of contexts, grade levels represented and the teachers’ experience in teaching, but not in terms of qualification, and therefore is considered as a realistic cross-section of the population (leedy & ormrod, 2005). the participants’ qualifications and prior learning may have been an advantage for some and a disadvantage for others, as the pace of training could have been too fast for some while adequate for others. questionnaire and self-reflection data were collected from 96 participants, whereas focus group data were contributed by 24 participants across the two contexts. in these specific contexts the most prominent language used as language of learning and teaching (lolt) was northern sotho (62%), followed by english (24%), setswana (8%) and isizulu (6%). all participants were part of the larger study and therefore were required to be appointed in full-time teaching positions in the foundation phase at schools in the targeted contexts. they also had to be willing to use english during the contact sessions, as it is the language used by the gde in all communication with and support of teachers. english is also the language used as medium of instruction at all institutions of higher education. this aspect was explained in the initial invitation letter to the schools, and also in the briefing meeting, so that participants could make informed decisions on whether they wanted to participate in the programme. participants who declined were not included. it was also emphasised that the teachers had to participate of their own free will and not as a result of coercion by their superiors. data collection qualitative data were collected from a variety of sources. all the participants from the main study attended the specific workshop to facilitate emergent literacy, and each of the 96 participants was expected to complete questionnaires after the workshops and to engage in self-reflection following a period of implementation of the strategies learnt in their classrooms. the original purpose of the questionnaires was mainly to collect quantitative data and therefore included only a limited number of open-ended questions, as they take longer to complete and therefore could be a cause of non-response (mcmillan & schumacher, 2010). such open-ended questions provided the opportunity for additional comments or recommendations, which was explanatory. all participants (n=96) were required to implement the strategies to facilitate literacy in their classroom following the workshops and to complete portfolio assignments for assessment. as part of the portfolio assignment they were required to engage in self-reflection (using reflection sheets) at the conclusion of the implementation period. such self-reflection is an inherent part of outcomes-based education (obe) (killen, 2007), and is known to facilitate deep learning. it was also a useful tool to monitor the implementation of the strategies. the two focus groups (each with 12 participants) were conducted 4 6 weeks after the workshops and were used to evaluate the workshop in terms of the participants’ perceived benefits, and to obtain feedback on their experiences in implementing the strategies. a focus-group schedule was used to guide the discussions. diary entries were made by the programme facilitator throughout the entire programme, without following any particular pattern. entries were made whenever the programme took a specific turn, or after a specific event took place, or when the researcher felt the need to reflect on specific issues. the aim of the research diary was to document the research process and to reflect on issues arising. it also provided insight regarding the system, and factors that could affect the outcomes of the programme. these entries were used to share ideas with experts and colleagues, and therefore elicited meta-reflection. all the workshop material and measuring instruments/procedures were developed in english, although particular examples were prepared in northern sotho for the facilitation of phonological awareness. it was acknowledged from the start that not all participants would be equally proficient in english, and because the programme facilitator had limited proficiency in the indigenous languages, arrangements were made with the district facilitators (each of whom was proficient in at least two african languages) to translate or interpret should the need arise. participants were encouraged to participate in their language of preference throughout the programme. credibility the credibility of the questionnaires was increased when a language editor reviewed and edited the questions. these questions were also scrutinised by two experts in the professional field, as well as a statistical advisor, to identify any potentially imprecise or ambiguous terms. pre-testing determined the clarity of instructions as well as questions, and the time for completion. focus group schedules were scrutinised by two experts prior to use to determine whether they would elicit the required responses. such measures increased the likelihood of trustworthiness. the programme facilitator acted as the moderator of the focus groups, and the district facilitators as assistant moderators, and as interpreters and translators when necessary. the district facilitators documented significant quotes and summarised each question discussed on the summary sheet specifically designed for this purpose. at the conclusion of the session, the district facilitators as assistant moderators verbally summarised the responses to questions. member-checking was done when these summaries were presented to the groups for approval, thereby increasing the trustworthiness of the data (bloor, frankland, thomas, & robson, 2001). the programme facilitator took field notes to supplement the summary and transcription of the audio recording. after the participants had departed, the programme facilitator (moderator) and the district facilitator (assistant moderator) met to reflect on the procedures, the participation, and outcomes of the session. they compared notes and confirmed the key ideas. shortly after the session the programme facilitator further reflected on the focus group by keeping a research diary. however, the fact that the assistant moderators were involved in the study may have biased the results to some extent. the audio recordings from the focus groups were transcribed verbatim by the course facilitator according to guidelines obtained from the literature (bloor, et al., 2001). coding was confirmed by 80% interand intra-rater agreement. for reasons of anonymity, speakers were referred to as ‘participant 1’, ‘participant 2’, etc. thick descriptions within the context were created and rich data from several data sources (diary entries, focus groups and open-ended questions) were obtained. it is acknowledged that the close proximity of the programme facilitator and the participants over time could have impacted on the results as the programme facilitator personally conducted the focus groups and transcribed, coded and analysed the data, and may have become subjective. data analyses the responses obtained from open-ended questions in questionnaires, as well as the self-reflections, were listed in word documents. the focus group sessions were transcribed verbatim and these, together with the self-reflections, diary entries and open-ended questions from questionnaires, were placed in a single hermeneutic unit and qualitatively analysed using content analyses. units were identified to answer the research questions (ryan & bernard, 2000) and were coded with the atlas-ti software suite (thomas muir scientific software development, 2003-2004), and categorised. the strength of atlas-ti is its ability to manage and organise large quantities of textual data. all text (apart from opening statements) was coded, and in turn categorised and grouped as major themes. the software used to analyse the qualitative data enabled the counting of specific codes (enumeration) to indicate the prominence of the various categories and themes. all items coded were categorised as either positive (confirming the research question) or negative (refute the research question) to provide a judgement in the evaluation of the programme, and were calculated as a percentage. results and discussion the findings were grouped as topics to answer the two research questions which relate to the implementation of strategies in the classroom, and the benefits obtained from the support provided. implementation of strategies in the classroom in response to the question: ‘how were the strategies implemented in the classroom?’ the following topics emerged. confirmation that strategies were applied in classrooms following the training the data firstly confirmed the implementation of strategies in the classrooms. the results showed that from the 125 items coded, 70% confirmed the implementation of strategies in classrooms. evidence of strategies being implemented in classrooms was obtained from portfolio assignments. strategies were implemented in the classrooms by using the lolt, which was in accordance with the language policy specified for the foundation phase (department of education, 2002). such results show a shift from what was the situation a decade ago, when the majority of teachers in gauteng were teaching in english (setati, adler, reed, & bapoo, 2003). mother-tongue or home-language instruction is considered most effective for learning in the foundation phase (motshekga, 2010). however, some participants acknowledged that the portfolio assignment was not a true reflection of their teaching as it was submitted without implementing the strategies. t: ‘there is no use to writing. you know writing, for the sake of a due date.’ (line 130, focus group 2(b)) a: ‘so some of you did the assignment without implementing it in the class. so you feel the assignment is not a true reflection of what is going on in the class? oh, ok.’ t: ‘but you … you don’t implement that what you have written on the assignment, you just write it to submit it to the lecturer. it is like studying for a degree.’ (line 200, focus group 2) such revelations indicated negative feelings (n=35), and because these individuals were from two specific schools, their attitudes could be school-related. a negative school culture has been identified as one of the reasons for dysfunctional schools (metcalfe, 2008). the participation in the cpd programme (e.g. implementation of strategies in the classroom as part of a portfolio assignment) depended on the participants’ motivation and attitudes, which emphasises the importance of including motivational strategies in future programmes. participants’ appreciation of the strategies the information included in the cpd programme for literacy was viewed positively as 73% (n=20) of the items coded as such indicated that the participants appreciated the information and the strategies taught. ‘i have learnt good ways of improving listening and be able to draw the attention of learners to listen attentively.’ (focus group 3(b)) ‘those strategies … we can now go on all day and forget about the time.’ (line 50, diary entry 29) the facilitation of listening requires teachers to firstly make learners aware of sound and to provide them with positive reinforcement for active attention to sound (bellis, 2003). such facilitation of strategies may imply a shift from the didactic approach where learners are instructed to listen, to a whole-body listening approach that focuses on active attending in class (bellis, 2002). critical reflection on practices/professional development currently reflective thinking in teacher support is emphasised as it facilitates quality teaching and professional development (cunningham, 2005). the participants reported that the implementation of strategies in their classrooms made them ‘think and reflect’ on their practices. as a result of the cpd programme several participants reported a change in their teaching practices. such reflection on practices is in keeping with the reflective competence required by the ‘norms and standards for teachers’ (department of education, 2000). reflection on their practices also put teachers in control of their own learning (bowles, 2004), which is in accordance with adult learning practices and therefore could be related to behaviour changes. ‘… improve my teaching, help me to reflect back’ (line 97, un-tabled open questions) ‘it makes you think.’ (line 217, focus group 1) ‘the workshop made a big difference to me because i could see that i was doing many wrong teaching in my teaching.’ (line 123, un-tabled open questions) however, the review of the portfolio assignments revealed that the personal reflection and self-assessments were often omitted. the fact that participants were required to complete the reflections by themselves in written format in the portfolios could have contributed to such omissions. it is also possible that the participants (and district facilitators) had little prior experience of reflective practices (killen, 2007) and did not know how to apply this technique. because of the recent introduction of these practices with the implementation of the obe approach (killen, 2007), the majority of the participants in this study may not have been trained in reflection and self-assessment. reflection is the basis for the successful implementation of obe (schwahn & spady, 1998). the participants’ inability to reflect on their own practices indicates that they had not yet mastered the basic skills required by an obe approach. reflection (from a technical or moral perspective) is an acquired skill that needs to be developed by practice and guidance (killen, 2007), and therefore this practice needs to be addressed in future programmes. challenges in the support provided language of delivery in the cpd programme a limitation of the workshop was that there were insufficient examples of phonological awareness in the different languages. despite preparing several examples in northern sotho, the participants required more impromptu examples in the workshops, and also in the other official african languages. some of the participants found it difficult to transfer the knowledge learnt in the workshop (in english) to the lolt used in their classrooms. despite having the district facilitators supporting the training, it proved challenging as the programme facilitator was not proficient in an african language and the district facilitators were not familiar with the concepts related to phonological awareness as they had not been pre-trained, and were also not proficient in other african languages. direct translation of english to the lolt is often not possible as it does not provide the required results (in many african languages a combination of words would be required to fully translate the meaning of a single english word). the multilingual south african context poses a challenge to speech-language therapists (slts) supporting teachers in training phonological awareness as currently less than 3% of slts have an african language as l1 (health professions council of south africa, 2005). a solution would be to have a teacher who is proficient in the lolt and who has a sound understanding of the underlying phonetic structure of the language as co-presenter of such workshops. concept of rhyming in african languages rhyming, as it appears in english, is a repetition of the final vowel-consonant cluster (johnson & roseman, 2003), (e.g. ‘the cat sat on the mat’), and is the first level in the development of phonological awareness (gillon, 2007). several comments (n=43) obtained from the data described the facilitation thereof as ‘difficult’, which implies that it is an unfamiliar concept in african languages (vermaak, 2006). ‘it was difficult for me, the rhyming. like, we don’t have so many rhymes like they have in english. so it was difficult with the lolt, to get like rhymes, to find rhymes. like we associate to do that. to get songs and rhymes. that was difficult for me.’ (line 205, focus group 1). these preliminary data call for critical consideration of facilitating rhyming as the first step in phonological awareness training in certain african languages, e.g. northern sotho, setswana and isizulu. if rhyming does not occur commonly in these african languages, then there is no point in training it as the concept cannot be explained to learners. further research is needed to determine the nature of rhyming in such languages. the question also arises whether this aspect should be facilitated in english additional language (eal) classrooms. examples obtained from portfolio assignments showed that the participants were more familiar with the concept of alliteration, which is repetition of a word beginning or ending with the same sound (e.g. ‘tloka, tlela’), with onset being the initial phoneme (johnson & roseman, 2003). the purpose of facilitating alliteration is similar to that of rhyming, in that it familiarises the ear to repetitive patterns of sound (at the beginning of words). would it then not be more suitable to focus on onset-rime in these african languages, as it is possible that the same benefits can be derived as for rhyming? this matter should be further researched. teachers’ unfamiliarity with new terminology the use of new terminology was, however, not generalised during the training as became evident when 64% (n=14) of the items were coded as ‘inability to recall the information’. p: ‘yeah, i think i benefited from it, because when i was trying this clapping method … so that the learners were enjoying it. they clapped two times, and then they clapped three times.’ a.m: yes – that was segmentation. yes … you will learn the terminology for these things soon … but i understand what you are saying. it was one of the strategies we did.’ (line 96, focus group 2). the above example indicates an awareness of specific concepts, which is the lowest level of acquiring new knowledge and thus regarded as ‘shallow learning’. such participants did not necessarily understand the information provided in the workshops, or know how to apply it. in several instances confusion in terminology was noted in the self-reflection in the portfolios, e.g. the term ‘auditory discrimination’ was used interchangeably with the term ‘rhyming’, as were ‘identification’ and ‘auditory memory’. this lack of understanding of these concepts became apparent early in the programme presented in the rural context. when the programme was repeated in an urban context the term ‘auditory discrimination’ was specifically emphasised and explained as: ‘... the difference between the sounds ...’ which appeared to be more effective, as no such confusion was noted again. sufficient repetition and explanation of new vocabulary is required in workshops, as discipline-specific terminology used by slts is unfamiliar to teachers. in a collaborative approach to providing teacher support it is necessary for slts and teachers to share their knowledge in order to come to a new understanding of such vocabulary in relation to the rncs. multidisciplinary collaboration should therefore be addressed in teacher preparation. benefits of the programme participants learnt to address assessment standards the results showed that the participants had previously omitted assessment standards in the curriculum because they did not know how to apply these. the participants believed that they had benefited from the training because they had learnt to address assessment standards in the rncs which they were unable to do before. ‘you know you helped us a lot. we used to skip most of the things.’ (line 284, focus group 1) strategies specified by the rncs to facilitate literacy, such as ‘riddles’ (used to facilitate auditory memory) and segmentation and blending activities, were particularly popular and were singled out by some participants as being successful and useful. ‘yes, in mother tongue i like the riddles, we also have the songs.’ (line 214, focus group 1) certain elements of phonological awareness were reportedly easy to teach in the lolt, specifically the segmentation of words as syllables and sounds, as well as the identification of the initial and final sounds of words. ‘… they specifically singled out “riddles” and “segmentation and blending activities” as being very effective and it seemed as if they have all implemented these strategies.’ (diary entry 14) many of the participants reported that they had previously omitted phonological awareness training from their curriculum because they did not understand the rationale thereof and did not know how to address it (even though it is specified in the rncs). adult learners learn more effectively when information is relevant to their needs and can be applied to their contexts (bowles, 2004). the participants were therefore more receptive to learn the new strategies, because as adult learners they were motivated to learn when they could understand the relevance of the learning objectives and activities for their own work (bowles, 2004). phonological awareness (in particular phonemic awareness) is facilitated in the context of literacy activities (lo2, lo3 and lo4). phonological awareness training in english (bernthal, bankson, & flipsen, 2009) follows a developmental sequence, of which rhyming is the first step in the english language (e.g. in nursery rhymes and songs, discrimination and production, e.g. ‘the cat sat on the mat’). this is followed by onset-rime, when the initial consonant changes the meaning and phonograms, e.g. ‘h-and’, ‘s-and’, ‘l-and’, ‘st-and’, etc. alliteration is repetition of a word beginning or ending with the same sound (e.g. ‘bana ba sekholo’). the next step is segmentation (auditory analyses), which is the ability to separate sentences as words; compound words, syllables, and also phonemes (e.g. b-u-s). segmentation of sounds consists of isolating initial, final, medial sounds (e.g. which sound is at the beginning/end or in the middle of ‘hat’?). it also comprises deletion of parts (e.g. say dustbin, say again without the ‘dust’ part). the most advanced levels are sound substitution (e.g. say ‘hat’, say it again but change the ‘h’ to ‘m’ = mat), and sound blending where sounds/components are connected in one meaningful utterance (e.g. ae-ro-plane = aeroplane, or sun + flower = sunflower). as mentioned previously, such skills require advanced knowledge of the sound system of the language, and therefore should ideally be facilitated by a teacher/facilitator who is proficient in the lolt. the facilitation of phonological awareness skills in the foundation-phase curriculum is a preventative strategy that enhances literacy development. it is of particular importance to learners from low ses, as they are at risk of experiencing difficulties in developing literacy skills (nancollis, et al., 2005). poor development of phonological awareness may lead to difficulty in reading and spelling (rvachew, chiang, & evans, 2007). reading and spelling problems can be prevented if phonological awareness is facilitated in the foundation phase, which justifies the inclusion of such information in teacher support programmes. benefits for learners participants in both contexts were exposed to information regarding phonological awareness and its role in facilitating literacy for the first time, and were excited about the effect the strategies had on their learners. t1: ‘... you know, we teachers have never done stories, songs and rhymes in class. we thought all of that in the rncs – it was for nothing. i feel our children ... their minds were caged in. we have since opened the screws, and the children came flying out like ... birds!’ (line 45, diary entry 16, focus group 1). the current study reported perceived gains made by learners, but these findings were subjective. research to determine the impact of programmes on learners’ performance is limited (khoza, 2007). recommendations for teacher support programmes phonological awareness should be presented by facilitators who are proficient in the lolt as the concepts cannot be translated directly as, for example, vocabulary. the support of teachers in the facilitation of phonological awareness in workshops firstly requires in-depth knowledge of the sound system of the lolt in order to generate language-specific examples. a clear understanding of the sound system of a language will allow programme facilitators to determine whether rhyming features in that language, and to plan an alternative means of facilitating where necessary. district facilitators who are proficient in african languages should be included in such workshops as co-presenters to facilitate phonological awareness skills. alternatively teachers who are proficient in the various african languages should be pre-trained as co-presenters of such skills. from the results obtained in this study it is proposed that research be conducted to determine whether alliteration rather than rhyming should be facilitated in schools where the lolt is an indigenous language. should research confirm this notion, it will infer a slight adaptation of the assessment criteria in the rncs. it is important for slts working in education contexts to acknowledge the uniqueness of the local language and culture (sowden, 2007). such sensitivity contributes to a better understanding of the specific dynamics embedded in the context, which may be attributed, at least in part, to the fact that south africa is a country characterised by considerable linguistic and cultural diversity. support programmes for teachers therefore cannot be generic in nature, but should be designed with consideration of the specific language and culture of the context. although such considerations may be time-consuming, they will be worthwhile to improve the performance of learners. slts have specific roles to play in education contexts. firstly, they have a preventive role, to provide preschool and foundation-phase teachers with support in the acquisition of literacy skills. secondly, they have to play a consultative and collaborative role in both district and school-based support teams to facilitate literacy and numeracy by providing training, mentoring, monitoring and consultation. it is recommended that district facilitators/teachers who are proficient in the lolt be included in the preparation of the workshop material, and also be pre-trained by the slt as co-presenters in such workshops. such measures build capacity and contribute to more effective collaboration. finally, it is important that such collaborative programmes be carefully documented as knowledge about their impact on learners’ performances is limited (khoza, 2007). the effect of cpd programmes for teachers on learners’ performance needs further investigation. conclusion the finding that the strategies trained through this specific cpd programme were mostly implemented in the lolt is in accordance with the language policy (department of education, 2002) for foundation-phase teaching and learning. such results show a shift from the situation a decade ago, despite the guidelines provided by the language policy at that time. the fact that the language policy is currently adhered to implies that progress has been made in the implementation of education policies, and that it is possible to change how teachers implement policy. the department of education has been effective in breaking down stereotyping and prejudices that existed with regard to english being considered by teachers and parents as superior to the local languages. in accordance with the language policy it is currently accepted throughout all levels (ranging through national, provincial, district and school levels) that mother-tongue or home-language instruction is considered as most effective for learning in the foundation phase (motshekga, 2010). it is disturbing to note that participants previously omitted phonological awareness because they did not understand this concept and did not have skills and strategies to teach it. this could have impacted on their learners’ development of literacy (justice & kaderavek, 2004). the support provided to the teachers in this study was considered effective as they felt that they could implement the strategies in their classrooms. such results also confirm that collaboration with district officials is important to achieve success, but that pre-training is required for optimal assistance in workshops. within a collaborative approach to teacher support, it is essential to establish positive and constructive relationships among slts, teachers and district facilitators, as this contributes to the success of adult learning experiences (galusha, 1998). it is therefore also essential that the education system supports slts in the execution of their tasks (law, 2002: 2, in o’toole & kirkpatrick, 2007). with regard to the slt’s role in supporting learners in the acquisition of literacy (department of education, 2001), it is imperative that teachers and slts work as a team, because as a team they can achieve so much more than when attempting anything on their own. acknowledgements . the authors wish to acknowledge the support of the shuttleworth foundation for supporting the fieldwork. references adams, m.j., foorman, b.r., lundberg, i., & beeler, t. 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(2007). culture and the good teacher in the english language classroom. elt journal, 61 (4), 304-310. thomas muir scientific software development (2003 2004). atlas-ti: the knowledge workbench v5.0. berlin, germany: thomas muir scientific software development. vella, j. (1994). learning to listen, learning to teach: the power of dialogue in educating adults. san francisco, ca: jossey-bass. vermaak, c. (2006). phonological awareness skills of a group of grade 4 learners, in a multi-cultural, multi-lingual education context with english as language of learning and teaching unpublished masters thesis, university of pretoria, pretoria. wium, a.m., louw, b., & eloff, i. (2010). speech-language therapists supporting foundation phase teachers with literacy and numeracy in a rural and township context. south african journal of communication disorders, 57(1), 14-22. fig. 1. the relationship between the three-levels of central auditory processing (bellis, 2003) with language processing (richards, 2004) and literacy outcomes (department of education, 2002). appendix a. content of the workshops to facilitate emergent literacy facilitating listening skills the participants in this study were provided with sufficient information to understand the rationale for facilitating listening skills, but also received strategies and opportunities to develop hands-on skills which allowed them to effectively facilitate listening skills. the participants were made to understand that in order for them to create an optimal listening environment in their classroom, may require of them to make some acoustic and teacher-based environmental modifications (bellis, 2003). the programme made participants aware of how to minimise interfering factors (goldsworthy, 1998) and how to facilitate listening behaviour that facilitates auditory attention (e.g. whole-body listening strategies) (bellis, 2003). furthermore, the workshops included strategies and activities to facilitate auditory tasks, e.g. auditory discrimination, memory, sequencing, figure-ground and perception of speech, which are required for language development, but also for phonological processing skills. facilitating phonological processing several teachers in the current education system feel unsure about the facilitation of phonological awareness and have a need for support. less than 5% of the teachers in lessing and de wit’s (2008) study in mpumalanga and limpopo provinces reported that they had confidence in teaching the sub-skills for literacy acquisition. this may be attributed to the fact that the role of phonological awareness in the development of literacy only became fully known in the early 1990s and therefore was not included in the professional training of teachers until much later. the facilitation of emergent literacy skills have been included in this cpd programme because of its relevance to literacy learning, but also to address a need of teachers who had not been trained in this aspect before. the cpd programme addressed the skills required to develop phonological awareness, e.g. rhyming, alliteration, segmentation, sound blending, and sound manipulation (gillon, 2002, 2007; goldsworthy, 1998). facilitation of phonological awareness starts with rhyming songs and nursery rhymes, and then proceeds to make the learners aware of words in a sentence (e.g. i-sit-on-a-chair), followed by awareness of syllables (e.g. but-ter-fly). lastly, the focus is on the awareness of sounds (phonemes) which ultimately results in blending and segmenting individual phonemes (e.g. j-u-m-p; c-a-t, rhi-no-ce-ros) (bernthal, et al., 2009). in addition, skills such as auditory closure, auditory association, and phonemic analysis linked to phoneme identification, grapheme-phoneme identification, and grapheme-phoneme correspondence were also included (richards, 2004). the workshop activities included demonstrations and practice of the identification of initial sounds, end-sounds, the segmentation of sentences into words, words into syllables, and individual sounds. blending of syllables and sounds, as well as sound manipulation was also addressed. although the inclusion of songs and rhymes in the facilitation of literacy is a good start towards the development of phonological awareness, the traditional actions that accompany these activities are intended to facilitate the meanings of words and not necessarily to focus on the sound structure of the language. participants were made aware that it is necessary to import different strategies into their classroom practices, e.g. waving hands when rhymes are heard, clapping hands/stomping feet when alliteration patterns are recognised, clapping the syllables in peers’ names, and slowly stretching of arms when syllables are blended to form words. 67 early detection of ototoxicity by high-frequency audiometry — a case study gustav r. voogt, ba(log) (pretoria) department of otorhinolaryngology, medical university of southern africa. abstract the effect of an ototoxic aminoglycoside antibiotic jtobramycinj on the hearing acuity of an adult black female cardiac patient was evaluated with a new type of high-frequency audiometer. results indicated the effectivity of this audiometer for the early detection of ototoxicity. the possibility of higher susceptibility to ototoxic damage in blacks due to a higher concentration of melanin in the inner ear is discussed. opsomming die effek van 'n ototoksiese aminoglikosied antibiotikum (tobramycin) op die gehoorsensiwiteit van 'n volwasse swart vroulike hartpasient is geevalueer met behulp van 'n nuwe tipe hoefrekwensieoudiometer. resultate dui op die effektiwiteit van hierdie oudiometer vir die vroee opsporing van ototoksisiteit. die moontlikheid van 'n hoer vatbaarheid vir otoksiese skade by swartes as gevolg van 'n hoer konsentrasie van melamien in die binneoor word bespreek. conventional diagnostic audiometry generally deals with assessment of auditory sensitivity for frequencies of 8 khz and below, even though humans can hear tones as high as 16 to 20 khz. it has also been proven that ototoxic substances first cause a decline in the high-frequency hearing, i.e., above 10 khz (schuknecht, 1974). various drugs are known to be ototoxic. of these, tobramycin is rated a?highly ototoxic (lane and routledge, 1983). in these reports the ototoxic effects were determined by histologic examinations of the hair cell damage occurring in the cochlea and by measuring thfe resultant decline in hearing sensitivity as measured by conventional pure tone audiometry (fee, 1980; smith, lipsky, laskin, hellmann, mellits, longstreth and lietman, 1980; matz, 1986). ototoxic agents cause hair cells to begin to degenerate first at the very basal end of the organ of corti, that part of the cochlea which is used to detect the highest frequencies the living animal can hear. this is a process that gradually and systematically progresses farther into the cochlea (schuknecht, 1974). by the time this damaging effect becomes visible on a conventional pure tone audiogram valuable time for prevention has passed and permanent damage has been done to the high frequency region in the cochlea. thus, by measuring high-frequency hearing, drug-induced ototoxic damage can be detected at a much earlier stage (tonndorf and kurman, 1984). this preoccupation with testing may be explained by various mechanoacoustic problems encountered when trying to test for the higher frequency auditory thresholds. the biggest problem appears to be in calibration as the quarter and half wavelengths of the higher frequency sound approach ear canal width and length, causing transversal resonances and standing waves to occur. this means that the sound front impinging on the tympanic membrane no longer resembles the sound being fed into the external ear canal (stinson, 1984; tonndorf and kurman, 1984). logicaldie suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 34,1987 ly this also leads to immense problems when trying to mask the contralateral ear. a further problem seems to be to find audiometers and transducers capable of producing these high-frequency stimuli at the necessary amplitude and fidelity but still maintaining a reasonably flat response curve. then there are also a vast number of smaller aspects which still need clarification, e.g., high-frequency interaural attenuation, inter subject variability in responding to highfrequency sounds, etc. quite a number of large-scale studies of high-frequency hearing can be found in the literature (rosen, plester, el-mofty, and rosen, 1964; zislis and fletcher, 1966; harris and myers, 1971; northern, downs, rudmose, glorig and fletcher, 1971). it is, however, practically impossible to compare results due to differences in audiometer, transducer, ear coupling, calibration methods and equipment, testing method and environment, population characteristics, selection criteria and very high interand intra-individual variability. as such, no normative audiometric threshold values exist for high-frequency audiometry (fausti, frey, erickson and rappaport, 1979; fletcher, 1965; de seta, bertoli and filipo, 1985; gauz and smith, 1985; henry, east, nguyen, paolinelli and ayors, 1985). furthermore it has been found that certain drugs like the polycyclic amines, especially the aminoglycocide antibiotic tobramycin, has a very high melanin affinity (potts, 1962a; 1962b; 1964a; 1964b; potts and au, 1971; 1976; lindquist, 1973). add to this the fact that melanin is present in quite large quantities in the cochlea, as first reported by the italian anatomist alfonso corti as far back as 1851. this may be an important factor in the etiology of drug induced ototoxicity (dencker and lindquist, 1975; dencker, lindquist and ullberg, 1975; wasterstrom, 1984; wasterstrom, brendberg, lindquist, lyttkens and rask-anderson, 1986). due to the earlier-mentioned problems encountered when trying to measure high-frequency thresholds, a new type of © sasha 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) early detection of ototoxicity by high-frequency audiometry — a case study 68 high-frequency audiometer, the tonndorf audimax model 500, has recently been developed which could possibly bypass most of these problems (tonndorf and kurman, 1984). this audiometer works on the principle of electrostimulation. the test signal is superimposed on a modulated carrier frequency and is delivered via mylar-coated electrodes into the skin over each mastoid (fig. 1.). as the subject is then capacitatively coupled to the electrodes, no real current flows between the electrodes and the subject. numerous studies have identified electrostimulation as a order to guard against possible renal failure. any renal failure during this period would have resulted in very high serum levels due to the accumulation of tobramycin in the bloodstream. the hearing test battery as mentioned above was repeated postoperatively on day 3, day 6, day 13 and day 20. on postoperation (po) day 21 she was discharged from hospital. three months later when she came to hospital for a followup examination her hearing was tested again according to r f carrier (60 khz) audiofrequency (0.2-20khz) modulator 7 att / l τ mylarcoated electrodes •s^mpl fig 1: schematic of high-frequency audiometer (from: tonndorf and kurman, 1984) means of audio-transmission of electromechanical vibration in the bone and tissue structures surrounding the inner ear and the cochlea. thus it would appear that the subject's bone-conduction hearing is being tested (sommers and von gierke, 1964). this audiometer tests frequencies from 200 hz right up to 20 khz in 200 hz steps. the stimulus intensities can be adjusted from 0 to 120 electrostimulation hearing threshold levels (eshtl) in 1 eshtl step sizes. zero to 120 eshtl corresponds with zero to 60 db spl. it was therefore decided to use this new audiometer to monitor the very early ototoxic effect of tobramycin on the high-frequency hearing of a black cardiac surgery patient in ga-rankuwa hospital, near pretoria. methodology the subject for this case report is a 25 year old black woman who required open-heart surgery. she had to use tobramycin prophylactically for a period starting immediately after the operation. before the operation her hearing was tested on two consecutive days by impedance audiometry, conventional pure tone audiometry and high-frequency audiometry. seeing that both ears tested almost identically the test results for left and right ears were combined. as no standardized norms for high-frequency thresholds exist, it was decided to use the first two high-frequency test results as the biological baseline. on the day of the operation she received 40 mg tobramycin and thereafter the consecutive doses were altered so that the "tobramycin serum levels were maintained between a trough of not less than 2 fig/ml and a peak not exceeding 10 mg/ml. this range is considered ototoxically safe (matz, 1986). the tobramycin regimen was continued for 72 hours. throughout this period, the tobramycin blood serum levels were carefully monitored, as well as the renal functioning, in the above test battery. the initial two tests before the operation served to check on test-retest reliability and also served as the control test against which all further test results were to be compared. results on impedance audiometry no differences could be detected for consecutive tests except for very small variations in middle-ear pressure. all the other impedance test results (maximum compliance, acoustic reflex thresholds) remained essentially the same throughout the test period. ! conventional pure tone audiometry test results also remained essentially unchanged, with only about 5 db total differences in thresholds between tests. j high-frequency audiometry, on the other hand, showed marked changes (fig. 2). the first two pre-operation test' results were decidedly identical, indicating very good test-1 retest reliability. on p.o day 3 there was a very clear' decrease in high-frequency sensitivity, especially at the high end of the hearing range. this decrease continued as is shown on the po day 6 test. on po day 13 there was a marked recovery, but not back to the original pre-operation hearing levels. the last test before the patient was discharged on po day 20 indicated that the recovery process had ceased and the test results were similar to those of po day 13. the follow-up test done 3 months after discharge from hospital matched that of po days 13 and 20, thus indicating that there was no further recovery whatsoever. it is to be noted that this patient did not suffer from any renal dysfunction during the entire period. thus there was no possibility of tobramycin accumulation due to renal failure which could have led to the tobramycin exceeding the ototoxically safe upper serum level of 10 fig/ml. the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gustav r. voogt 69 0 5 10 15 20 25 30 35 4 0 45 5 0 5 5 60 65 70 75 80 85 90 95 100 105 110 115 120 pre-op test 1 • pre-op test 2 3 d a y po 6 -day po 1 3 d a y po 20-day po 9 0 d a y po 10 11 12 13 14 15 16 17 18 19 20 frequency (khz) fig 2: high-frequency threshold changes over time discussion it would appear that high-frequency audiometry by electrostimulation shows very good test-retest reliability, seeing that the average difference in thresholds between the first two tests was no larger than 5 eshtl units, corresponding to about 2,0 to 2,5 db spl. high-frequency audiometry could detect ototoxicity at a very early stage, as well as the severity of damage and recovery from damage, whilst standard audiometry and impedance tests were still showing no effects whatsoever of ototoxicity on hearing sensitivity. ί it is clear from fig. 2 that the otoxic effect continued long after cessation of drug administration and long after the serum levels indicated no drug residue in the bloodstream. this might be further proof of the possible accumulation of this drug on the melanin ofj the inner ear. this accumulation could, however, not be proved in this case study as no biopsies could be taken from or histological examinations done on the patient's inner!ear. on the other hand, if the drug really accumulates in |the inner ear, the monitoring of drug/serum levels would be of no use, since it would not represent the actual level of tobramycin in the inner ears. it may also be possible that blacks have more melanin in the inner ear than whites (dencker and lindquist, 1975; dencker et al. 1975) and are thus more susceptible to ototoxic damage, but this is only speculative as no human experimental data on this aspect could be found in the literature. this possibility has, however, been proven in a study done on albino and pigmented guinea pigs (wasterstrom, 1984; wasterstrom et al. 1986). thus it would appear that the "safe" serum levels for ototoxic drugs were based on hearing tests for frequencies up to 8 khz only and may really not be safe at all. it would appear that the monitoring of patients for drug-induced ototoxicity should rather be done by high-frequency audiometry or a combination of measuring blood/serum levels and high-frequency audiometry. conclusion high-frequency electrostimulation audiometry seems to show good test-retest reliability. it is also very effective in the early detection of ototoxicity, compared to standard audiometry. ototoxic drug accumulation, possibly on the melanin in the inner ear will have to be investigated further. also the possibility of blacks having more melanin in the inner ear and thus a higher susceptibility to drug-induced ototoxicity needs further research. lastly, a thorough investigation of present ototoxically "safe" serum levels is required. acknowledgements the loan of the tonndorf audimax 500 high-frequency audiometer by the needier westdene organization pty ltd, johannesburg is acknowledged with thanks. references dencker, l. and lindquist, n.g. distribution of labelled chloroquinine in the inner ear. arch. otolaryngol, 101, 185-188, 1975. dencker, l., lindquist, g.g. and ullberg, s. distribution of 125i-labelled chloroquinine analogue in a pregnant macaca monkey. toxicology, 5, 255-265, 1975. de seta, e., bertoli, g.a. and filipo, r. high frequency audiometry above 8 khz. audiology, 24, 254-259, 1985. fausti, s.a., frey, r.h., erickson, d.a. and rappaport, b.z. 2afc versus standard clinical measurement of high frequency auditory sensitivity (8-20 kc/s)./. aud. res., 19, 151-157, 1979. fee, w.e. aminoglycoside ototixicity in the human. laryngoscope, 90, (suppl 24), 1-18, 1980. fletcher, j.l. reliability of high frequency thresholds. j. aud. res., 5, 133-137, 1965. gauz, m.t. and smith, m.m. the simplified hf e-800 audiometer : calibration and normative aspects. j. aud. res., 25, 101-122, 1985. harris, j.d. and myers, c.k. tentative audiometric hearing threshold level standards from 8 through 18 kilohertz./. acoust. soc. am., 49, 600-601, 1971. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 early detection of ototoxicity by high-frequency audiometry — a case study henry, k.r., east, g.a., nguyen, h.h., paolinelli, m.c. and ayors, n.m. extra-high-frequency auditory thresholds : fine structure, reliability, temporal integration and relation to ear canal resonance. audio!., 24, 92-103, 1985. lane, r.j.m. and routledge, p.a. drug-induced ototoxicity. drugs, 26, 124-147, 1983 lindquist, n.g. accumulation of drugs on melanin. acta radiol (stockhj suppl. 325, 1-92, 1973. matz, g.j. aminoglycoside ototoxicity, am. j. otolaryngol., 7, 117-119, 1986. northern, j.l., downs, m.p. rudmose, w., glorig, a. and fletcher, j.l. recommended high-frequency audiometric threshold levels (8000-18000 hz], j. acoust. soc. am., 52, 585-597, 1971. potts, a.m. the concentration of phenothiazines in the eye of experimental animals. invest. opthalmol, 1, 522-530, 1962a. potts, a.m. uveal pigments and phenothiazine compounds, tr. am. opthalmol soc., 60, 517-552, 1962b. potts, a.m. further studies concerning the accumulation of polycyclic compounds on uveal melanin. invest. opthalmol, 3, 399-404, 1964a. potts, a.m. the reaction of uveal pigment in vitro with polycyclic compounds. invest. opthalmol, 3, 405-416, 1964b. potts, a.m. and au, p.c. thallous ion and the eye. invest. opthalmol, 10, 925-931, 1971. potts, a.m. and au, p.c. the affinity of melanin for inorganic ions. exp. eye res., 22, 487-491, 1976. rosen, s., plester, d., el-mofty, a. and rosen, h. high frequency audiometry in presbycusis. arch. otolaryngol, 79, 25-35, 1964. schuknecht, h.f. pathology of the ear. cambridge, massachusets: harvard university press, 1974. smith, c.r., lipsky, j.j., laskin, o.l., hellman, d.b., mellits, e.d., longstreth, j. and lietman, p.s. double blind comparison of the nephrotoxicity and auditory toxicity of gentamycin and tobramycin. n. engl j. med., 302, 1106-1108, 1980. sommers, h.c. and von gierke, h.e. hearing sensations in electric fields. aerospace med., 35, 834-839, 1964. stinson, m.r. audiometry and the geometry of the human ear canal caa symposium, quebec city, 1984. tonndorf, j. and kurman, b. high frequency audiometry. ann. otol rhinol. laryngol., 93, 576-582, 1984 wasterstrom, s. accumulation of drugs on inner ear melanin: therapeutic and ototoxic mechanisms. scand. audiol. suppl. 23, 1-40, 1984. wasterstrom, s., bredberg, g., lindquist, n.g., lyttkens, l. and rask-andersen, h. ototoxicity of kanamycin in albino and pigmented guinea pigs i: a morphologic and electrophysiologic study. am. j. otol, 7, 11-18, 1986. zislis, t. and fletcher, j.l. relation of high-frequency thresholds to age and sex./ aud. res., 6, 189-198, 1966. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) •ί*· ί y new automatic hearing aid a truly advanced and innovative sound amplifier the automatic sound processor (asp) was developed especially for those people who have difficulty in hearing speech in noisy environments. for years, hearing aid wearers have avoided restaurants, theatres, church and parties because of the inability of an ordinary hearing aid to control background noises. the a.s.p. is simply and uniquely designed to normalize background noise so that speech is more easily understood. to be able to restore sound to even one human being makes your life especially important. 4l 7, , , ^ τ l. to restore hearing... what a blessed talent to have medifix "earing system co. surgical & medical p.o. box 19 bedfordview 2008 south africa phone: (011)53-4188/9 cape p.o. box 52 lynedoch 7603 phone: (02234) 442 or (02231) 93442 natal p.o. box 47443 greyville 4023 phone: (031)236164 m r i c h a r d s hearing systems tomorrow's technology for today's hearing problem r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 information for contributors the south african journal of communication disorders publishes reports and papers concerned with research, or critically evaluative theoretical, or therapeutic issues dealing with disorders of speech, voice, hearing or language, or on aspects of the processes underlying these. the south african journal of communication disorders will not accept material which has been published elsewhere or that is currently under review by other publications. all contributions are reviewed by at least two consultants who are not provided with author identification. form of manuscript. authors should submit four neatly typewritten manuscripts in triple spacing with wide margins which should not exceed much more than 25 pages. each page should be numbered. the first page of two copies should contain the title of the article, name of author/s, highest degree and address or institutional affiliation. the first page of the remaining two copies should contain only the title of the article. the second page of all copies should contain only an abstract (100 words) which should be provided in both english and afrikaans. afrikaans abstracts will be provided for overseas contributors. all paragraphs should start at the left margin and not be indented. major headings, where applicable, should be in the order of method, results, discussion, conclusion, acknowledgements and references. tables and figures should be prepared on separate sheets (one per table/figure). figures, graphs and line drawings must be originals, in black ink on good quality white paper. lettering appearing on these should be uniform and professionally done, bearing in mind that such lettering should be legible after a 50% reduction in printing. on no account should lettering be typewritten on the illustration. any explanation or legend should not be included in the illustration but should appear below it. the titles of tables and figures should be concise but explanatory. the title of tables appears above, and of figures below. tables and figures should be numbered in order of appearance (with arabic numerals). the amount of tabular and illustrative material allowed will be at the discretion of the editor (usually not more than 6). references. references should be cited in the text by surname of the author and date, e.g. van riper (1971). where there are more than two authors, et al. after the first author will suffice. the names of all authors should appear in the reference list. references should be listed alphabetically in triple-spacing at the end of the article. for acceptable abbreviations of names of journals, consult the fourth issue (october) of dsh abstra cts or the world list of scientific periodicals. the number of references used should not exceed much more than 20. note the following examples: locke, j.l. clinical psychology: the explanation and treatment of speech sound disorders. j. speech hear. disord., 48, 339-341, 1983. penrod, j.p. speech discrimination testing. in j. katz (ed̂ handbook of clinical audiology, 3rd ed., baltimore: williams & wilkins, 1985. van riper, c. the nature of stuttering. englewood cliffs, new jersey: prentice-hall, 1971. proofs. galley proofs will be sent to the author wherever possible. corrections other than typographical errors will be charged to the author. reprints. 10 reprints without covers will be provided free of charge. all manuscripts and correspondence should be addressed to: the editor, south african journal of communication disorders, south african speech and hearing association, p.o. box 31782, braamfontein 2017, south africa. inligting vir bydraers die suid-afrikaanse tydskrif vir kommunikasieafwykings publiseer verslae en artikels oor navorsing, of krities evaluerende artikels oor die teoretiese of terapeutiese aspekte van spraak-, stem-, gehoorof taalafwykings, of oor aspekte van die prosesse onderliggend aan hierdie afwykings. die suid-afrikaanse tydskrif vir kommunikasieafwykings sal nie materiaal aanvaar wat reeds elders gepubliseer is, of wat tans deur ander publikasies oorweeg word nie. alle bydraes word deur minstens twee konsultante nagegaan wat nie ingelig is oor die identiteit van die skrywer nie. formaat van die manuskrip. skrywers moet vier netjies getikte manuskripte in 3-spasi'ering en met bree kantlyn indien, en dit moet nie veel langer as 25 bladsye wees nie. elke bladsy moet genommer wees. op die eerste bladsy van 2 afskrifte moet die titel van die artikel, die naam van die skrywer/s, die hoogste graad behaal en die adres of naam van hulle betrokke instansie verskyn. op die eerste bladsy van die oorblywende twee afskrifte moet slegs die titel van die artikel verskyn. die tweede bladsy van alle afskrifte moet slegs 'n opsomming (100 woorde) in beide engels en afrikaans bevat. afrikaanse opsommings sal vir buitelandse bydraers voorsien word. alle paragrawe moet teenaan die linkerkantlyn begin word en moet nie ingekeep word nie. hoofopskrifte moet, waar dit van toepassing is, in die volgende volgorde wees: metode, resultate, bespreking, gevolgtrekking, erkennings en verwysings. tabelle en figure moet op afsonderlike bladsye verskyn (een bladsy per tabel/illustrasie). figure, grafieke en lyntekeninge moet oorspronklike weergawes wees en moet in swart ink op wit papier van 'n hoe gehalte gedoen word. letterwerk wat hierop verskyn moet eenvormig wees, professioneel gedoen word en daar moet in gedagte gehou word dat dit leesbaar moet wees na 'n 50%-verkleining in drukwerk. letterwerk by die illustrasie moet onder geen omstandighede getik word nie. verklarings of omskrywings moet nie in die illustrasie nie, maar daaronder verskyn. die byskrifte van tabelle moet bo-aan verskyn en die van figure onderaan. tabelle en figure moet in die volgorde waarin hulle verskyn, genommer word (met arabiese syfers). die hoeveelheid materiaal in die vorm van tabelle en illustrasies wat toegelaat word, word deur die redakteur bepaal (gewoonlik nie meer as 6 nie). , verwysings. verwysings in die teks moet voorsien word van die skrywer se van en die datum, bv. van riper(1971). waar daar meer as twee skrywers is, sal et al. na die eerste skrywer voldoende wees. die name van alle skrywers moet in die verwysingslys verskyn. verwysings moet alfabeties in 3-spasi'ering aan die einde van die artikel gerangskik word. vir die aanvaarde afkortings van tydskrifte se titels, raadpleeg die vierde uitgawe (oktober.) van dsh abstracts of the world list of scientific periodicals. die getal verwysings wat gebruik is, moet nie veel meer as 20 wees nie. ' let op die volgende voorbeelde: ' locke, j.l. clinical phonology: the explanation and treatment of speech sound disorders. j. speech hear. disord., 48, 339-341 1983. penrod, j.p. speech discrimination testing. in j. katz (ed.)handbook of clinical audiology, 3de ed., baltimore: williams & wilkins, 1985. van riper, c. the nature of stuttering. eng|ewood cliffs, new jersey: prentice hall, 1971. proewe. galeiproewe sal waar moontlik aan die skrywec-gestuur' word. die onkoste van veranderings, behalwe tipografiese foute, sal deur die skrywer self gedra moet word. herdrukke. 10 herdrukke sonder omslae sal gratis verskaf word. alle manuskripte en korrespondensie moet gerig word aan: die redakteur, die suid-afrikaanse tydskrif vir kommunikasieafwykings. die suid-afrikaanse vereniging vir spraaken gehoorheelkunde, posbus 31782, braamfontein 2017, suid-afrika. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the pragmatics of language: theoretical and applied issues carol a prutting phd university of california santa barbara, california abstract the paper reviews the contributions made by the paradigm shift which has occurred in our discipline. comments arc also made from the broader perspective of the philosophy of science. opsomming die artikel beskou die bydrae wat gemaak is deur die paradigmatiese verskuiwing watplaasgevind het in ons dissipline. opmerkings word ook gemaak vanuit 'n breer perspektief van die filosofie van die wetenskap. "i cannot give any scientist of any age better advice than this: the intensity of the conviction that a hypothesis is true has no bearing on whether it is true or not" (medawar, 1979, p. 39). once a hypothesis is made the scientist is in business. it guides the observation and suggests empirical tests which might otherwise not have been performed. in the past few years a shift in out theoretical models has taken place. we, as a discipline, have moved from a linguistic paradigm (chomsky, 1957; 1965) to a philosophical one (austin, 1962; searle, 1969). the,changes we have experienced and what this shift represents for the field of speech and language pathology will be discussed. under the linguistic generative grammar paradigm the innate predisposition to learn language was of primary import for learning an abstract set of rules to account for one's knowledge of language. in the philosophical speech act paradigm an account of what speakers and listeners do in various communicative interactions is of paramount interest. within this framework much attention is given to the contextual influences in the environment which account for one's ability to perform in a competent manner. in the case of the former model the focus is on the speaker. in the latter model, the unit of analysis is the dyad. proponents of the linguistic paradigm define language as a set of sentences. the philosophical paradigm defines, language as an instrument for social interaction. generative grammarians view the function of language as the expression of thought, whereas for the speech act enthusiasts, the function is to communicate. competence is viewed differently as well for both camps. from a linguistic framework competence is discussed as the ability to produce, comprehend and judge grammaticalness. in contrast, from a philosophical viewpoint competence is rooted in social competence, i.e. the ability to initiate, maintain, and terminate relationships. humboldt (1836), writing over a century ago, inspired chomsky (1957, 1965) with his notion of the generative aspects of language. humboldt maintained that language makes infinite use of finite means. austin (1967) and searle (1969) were influenced by the early pragmatist peirce (1878) as well as james (1907) and wittgenstein (1958) all of whom believed that language meaning was in its use. peirce, in turn, was very much affected by the early philosophy of kant (1781). it is true that rival theories such as the linguistic and speech act seldom address the exact same set of problems. some issues are lost and others gained whenever different theories evolve. kuhn (1962) suggested that no paradigm solves all problems. however, paradigm debates do revolve around the question: which particular problems are more significant to have solved? there is a certain discomfort which takes place when theories shift within a discipline. the discomfort can be replaced by the quest for solutions, a respect for time, and an understanding that in science there are more disproofs than there are proofs. lewis thomas (1983), recent author of the youngest science, suggests a healthy state is that of "informed bewilderment" with our feet firmly planted in mid-air. this is a difficult state to maintain especially among the younger members of a profession. theories are invaluable in that they can be likened to road maps for problem solving. they lead us to ask certain questions and select one methodological solution over another. our empiricism does not always keep pace with our theoretical constructs. however, methodology can sometimes outstrip theory. for instance, both the babylonians and egyptians employed * this paper is a written version of the ρ de v pienaar memorial lecture delivered on september 21, 1983 at the university of pretoria. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 'v sash a 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 carol a prutting mythology to explain astronomical phenomena. for the babylonians the earth was a hollow mountain and the universe was an oyster with water underneath and overhead. similarly, the egyptians conceived of the universe as a more rectangularly shaped oyster or box; the earth was its floor, while the sky was a cow whose feet rested on the four corners of the earth. during this time chaldean priests observed the stars and made maps and timetables of positions and movements. the timetables became calendars used to regulate agricultural activities and religious ceremonies. these observations and calculations were precise and deviated less than .001 % from our modern calculations. in this example we have an exact science, in terms of accurate predictions, outstripping a theoretical construct. gould (1981), in an excellent book entitled the mismeasure of man, writes about science as a social act which has subjectivity at its core. science is that exploratory activity whose purpose is to understand the world for the betterment of society. the actual exploratory activity is termed research. there are many theories generated and many ways of going about understanding and bringing order to the phenomena under study. medawar (1979) has discussed the various ways toward understanding: baconian — truth is all around us and one needs only to observe things as they really are. aristotelian — one has preconceived notions of the world and one needs to act on these ideas. galilean — one discriminates between different ways of doing something and this either gives one confidence in one's view or alters one's view in some way. kantian — one's view of the world is based on a prior knowledge. all of these approaches are justifiable and each, in somewhat different ways, adds to and contributes to our understanding of the world. once our theoretical underpinnings are tightened they give way to methodological considerations. some of our choices in design are descriptive, experimental, longitudinal, and cross-sectional. the choice one makes generally has to do with ones theoretical orientation, the research question asked, and the background of literature in which the study will be embedded. the theoretical shift which has taken place in our discipline is enumerated elsewhere (prutting, 1982). for the purposes of this paper only the sediments which remain after shifting through the speech act theory will be presented. the implications of these changes are far reaching for the communicatively disordered client. what follows is an outline of the changes as a result of our theoretical shift: assessment principles areas of assessment: analysis across linguistic, cognitive, and social domains. bates (1979) slightly tongue and cheek concludes there are some 30 000 possible models for intervention principles competence: goals should be toward relevant and functional communicative interaction. the demonstration of understanding this threeway relationship. as fuller (1975) suggests with his idea of "synergy" — the behavior of whole systems is unpredicted by their parts taken separately. it is therefore important to view the three areas in relationship to the entire communicative system of any given client. unit of measurement: the dyad should be the unit of analysis since competence lies in the relational system and as such should be assessed with relational parameters intact. societal as priority over clinical judgements: societal judgements are concerned with appropriate or inappropriate appraisals rather than correct/incorrect. a behavior may indeed be incorrect but appropriate. appropriate is defined as positive or neutral effects on the interaction while inappropriate behaviours detract or penalize the communicator. as johnson said some time ago — for a behavior to be different it must make a difference. social conventions, cognitive knowledge of the world, and linguistic rulegoverned behavior is competence. considerations for intervention: behavior goals i communicative acts (i.e. speakers intentions and effects on listeners requests, responses, statements). social roles (formal/informal, egalitarian/unequal, work/social). discourse rules (obligations and options of speakers and listeners, i.e. turn-taking, topic maintenance and shift, cohesion strategies). compensatory strategies: permit and encourage the use of alternative methods to carry out the goals and obligations of appropriate, effective, and successful discourse. some strategies. already identified are: repetition, grammatical and phonological simplifica : tion, reliance on nonverbal behavior to revise | utterances. one can easily see the important changes which have taken place with our shift in paradigms. one last contribution has to do with criteria for dismissal from remediation. prior to our shift we most often enrolled and dismissed clients with reference to their scores on standardized tests. in america, many guidelines set up by various states utilized a 1 or 2 standard deviation from the mean on a standardized test in the areas of phonology, syntax, and/or semantics. today, we are considering dismissal when we can document that a client has improved some aspect of the communicative system and is thus better able to manage relationships with others, through communication, with more ease and comfort. it is quite evident that theoretical changes have filtered down to the clinical treatment of clients. there is no doubt that the focus in the mid-eighties is on the social dimensions of communication. as johnson (1946) stated decades ago: "leaving any consideration of language behavior the south african journal of communication disorders, vol. 31 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the pragmatics of language 5 out of a discussion of personality would be somewhat like leaving the cheese out of a cheese souffle. as a matter of fact, most of the key terms that we customarily use in talking about personality are seen, on close scrutiny, to refer somehow to reactions that are made to and with words and other symbols" (p. 243). why deal with the social aspects of communication alongside of linguistic and cognitive aspects? argyle (1983) has some startling evidence to support the fact that with a rich network of social relationships one lives longer and is happier. can we then think of any better reason for dealing with communicative behaviors from a social perspective? the communicative system is an individual's most powerful tool for getting along in this world. in steiner's, the portage to san cristobal of a. h. (1981) he describes words as able to heal, bless, cripple, and kill. there seems to be nothing which cannot be done with the power of words. for example one can see how hitler with his verbal and paralinguistic communicative abilities committed hideous crimes against all humanity. gandhi, on the other hand, communicated through silence and enriched the lives of millions. we are in an exciting and challenging era and those of us who call ourselves speech, language clinicians are in the business of social change. i do not imagine our clients will turn out to be any more homogeneous in the area of pragmatics than they are in the areas of phonology, syntax, and semantics. the shift is exhilarating. as is often the case this paradigm shift appears to be a revisit from the earlier days when our field was just developing — "we shall not cease from exploration and in the end of our exploring will be to arrive when we started and know the place for the first time." t.s. eliot references argyle, μ .visiting scholar, university of cape town, cape town, south africa, august 1983. austin, j. how to do things with words. cambridge: harvard university press, 1962. bates, e., benigni, l., bretherton, i., camaioni, l., and volterra, v. the emergence of symbols. new york: academic press, 1979. chomsky, n. syntactic structures. the hague: mouton, 1957. chomsky, n. aspects of a theory of syntax. cambridge: mit press, 1965. fuller, r.b. synergetics. new york: macmillan, 1975. gould, s. the mismeasure of man. new york: w.w. norton and co., 1981. humboldt, w. von. uberdie verschiedenheit des menschlichen sprachbaues. berlin, 1836. james. w. what pragmatism means pragmatism; a new name for some old ways of thinking. new york: longmans, green, & co., 1907. johnson, w. people in quandaries. new york: harper and brothers, 1946. kant, i. critique of pure reason. (first edition, 1781). new york: e.p. dutton & co., inc., 1978. kuhn, t. the structure of scientific revolution: chicago: university of chicago press, 1962. lewis, t. the youngest science. new york: the viking press, 1983. medawar, pb. advice to a young scientist. new york: harper and row, publishers, 1979. peirce, w. how to make ideas clear. popular science monthly, 1878, 12, 286-302. prutting, c.a. pragmatics as social competence. j. speech hear. dis., 1982, 47, 123-134. searle, j. speech acts: an essay in the philosophy of language. cambridge: university press, 1969. steiner, g. the portage to san cristobal ofa.h. new york: simon and schuster, 1981. wittgenstein, l. philosophical investigations. new york: macmillan publishing co., 1958. die suid-afrikaan.se tydskrif virkommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 55 word-finding strategies in closed head injured adults juleen kleiman, ba (speech and hearing therapy) (witwatersrand) lesley bucke, ba (speech and hearing therapy) (witwatersrand) department of speech pathology and audiology, university of witwatersrand, johannesburg abstract word-finding difficulties are a common and prominent language deficit following closed head injury. the word-finding difficulties of three closed head injured patients were investigated within the framework of compensatory strategies using teicher's taxonomy of wordfinding strategies (teicher, 1986). the word-finding difficulties were evaluated during procedural discourse and two confrontation naming conditions. each subject's communicative competence and language ability was determined. results indicated that all subjects employed a wide range of strategies, particularly during confrontation naming, but with differential effectiveness. a relationship was noted between the strategy's effectiveness and the subject's pragmatic ability. the results are discussed in the light of the existing literature on head injury. the theoretical and clinical implications are considered. opsomming woordvindprobleme is 'n algemene en prominente taalverskynsel na geslote hoofbeserings. woordvindprobleme van proefpersone met geslote hoofbeserings is geevalueer binne 'n raamwerk van kompensasiestrategiee deur gebruik te maak van teicher se "taxonomy of word-finding strategies" (teicher, 1986). die woordvindprobleme is geevalueer tydens proseduregesprekke en twee konfrontasiebenoemingstake. elke proefpersoon se kommunikasieen taalvaardigheid is bepaal. die resultate dui daarop dat al die proefpersone gebruik gemaak het van 'n wye reeks stategiee, veral tydens konfrontasiebenoeming, maar met variasie in effektiwiteit. 'n ooreenkoms is opgemerk tussen die strategies wat gebruik is en die proefpersone se pragmatiese vermoens. die resultate is bespreek in die lig van reeds bestaande literatuur in verband met geslote hoofbeserings en daar is verwys na teoretiese en kliniese implikasies. closed head injury (chi) has been termed "the invisible epidemic" (holland, 1982) in view of the marked increase in the incidence of the disorder during this decade (annegers, grabouw, kurland and laws, 1980). the primary source of pathophysiology in chi is that of blunt trauma to the skull which results in multiple diffuse damage to the brain, discontinuation of neural substance and shearing and straining of the axons in j the white brain matter occurs (hagen, 1984). this results 'in a diversity of cognitive, memory and language deficits, based on the combination of pathophysiologic mechanisms and severity of the injury (ylivisaker and szekeres, 1986). the chi patient therefore presents the speech-language pathologist with a "unique and complex diagnostic, prognostic and treatment challenge" (hagen, 1984:245). the neurobehavioural and linguistic sequelae following chi constitutes an area of much controversy. different labels including "aphasia" (luria, 1970), "subclinical aphasia" (sarno, 1980) and "confused" language (hagen, 1984) have been adopted to describe the linguistic symptoms following chi. the heterogeneity of this population is being increasingly well recognised. despite this heterogeneity, researchers are in agreement that anomia is a common and prominent language deficit following chi (hagen, 1984; heilman, safron and geschwind, 1971; levin, benton and grossman, 1981). anomia has been defined as poor access to lexical items (word retrieval) and as a failure to name on confrontation and during discourse (goodglass, kaplan, weintraub and ackerman, 1976). the primary cortical areas identified as being responsible for naming abilities include the parietotemporo-occipital areas of the left dominant hemisphere (luria, 1975; benson, 1979). the chi patient frequently presents with circumlocutions, paraphasias and reduced fluency which are typical of aphasia (holland, 1982). in addition, chi patients reportedly exhibit "non-aphasic" naming errors resulting from their impulsivity, perceptual disinhibition and lack of language boundness (holland, 1982; teicher, 1986). within the past few years there has been a renewed focus on the importance of observing and assessing language and behaviour of the chi within a compensatory strategy framework? (kirchner and skarakis-doyle, 1983; penn, 1985; penn and cleary, 1987; teicher, 1986). when compensation follows a head injury we are observing the patient's direct attempt to compensate for his primary deficits. this is in accord with piaget's (1952) belief that the human organism constantly strives to maintain a balance and adapt to environmental demands. this process of equilibrium is determined in part by neurological and subject variables, and in part by ecologic variables (penn and cleary, 1987). compensatory strategies, which may develop spontaneously or which may be trained, have been defined as alternate methods of controlling and manipulating information (kirchner and skarakis-doyle, 1983). the individual adopts these strategies to meet the communicative demands of the situation when he is unable to bring together all the necessary resources, as a result of brain damage (penn, die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 © sasha 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 j u l e e n kleiman and lesley bucke 1985). the degree to which a brain damaged patient will develop and utilise compensatory strategies will play a major role in determining the eventual outcome for the patient (penn, 1985). teicher (1986) examined the word-finding strategies employed by a group of chi individuals during an instance of word-finding difficulty. the results revealed that by utilising a behavioural taxonomy to assess word-finding strategies, many of the strategies employed by the subjects could be identified, described and compared within and across subjects. profiles of successful and unsuccessful strategies and their pragmatic effectiveness were identified. furthermore, the importance of evaluating naming ability during discourse, as well as confrontation naming was stressed. this study highlighted the potential value of the chi population's word-finding difficulties within a compensatory framework. according to ylvisaker and szekeres (1986:474) "impaired social interaction is often the residual deficit most troubling for the patient's family and for the patient himself." assessment tools which therefore have as their basis a social interaction model of communication which incorporates linguistic, pragmatic, social and cognitive variables are invaluable (penn and cleary, 1987). the purpose of this study therefore is to examine the wordfinding compensatory strategies being employed by three chi subjects during discourse and confrontation naming and to determine the effectiveness of these strategies in communicative interaction. by evaluating chi wordfinding difficulties in terms of compensatory strategies a pattern of behaviour may emerge which may offer insight into the central nervous sytem (marshall, 1976) as well as provide us with useful prognostic and diagnostic information. this will then assist us in designing more effective therapeutic strategies as the ultimate therapeutic goal, according to penn (1985), is to teach positive strategies which will increase pragmatic competence and flexibility of style. method aims the aim of the present study was to identify, describe and compare the word-finding strategies employed by three chi subjects during procedural discourse and confrontation naming tasks in an effort to adapt to their word-finding difficulties. the study was further designed to determine whether a relationship exists between the nature and the effectiveness of such strategies, and the individual's overall communicative effectiveness and language ability. subjects (ss) three english speaking subjects who had sustained closed head injuries as a result of motor vehicle accidents (ss 1 and 2) and assault (s3) were selected as subjects for this study. ss 1 and 3 were males, s2 female and their age range was 27.1 years to 44.4 years (mean 33.3 years). mean coma duration of the subjects was 4 weeks (range 2 — 6 weeks), thus indicating a severe head injury according to the criteria suggested by russell (1971). all subjects were neurologically stable at the time of testing with a mean post-injury time of 21 months (range 8 — 48 months). subjects were all pretraumatically right-handed and had completed at least 11 years of schooling. family reports indicated that subjects were of average intellectual capacity prior to the accident. no previous history of sensory or motor deficit was reported nor was any history of drug or alcohol abuse noted. hearing was within normal limits for all three subjects at the time of testing. further relevant clinical and biographical details are included in table 1 below. testing material as there are presently no language tests designed specifically for the chi population it was necessary to employ and table 1: relevant clinical and biographical detail for all subjects subject 1 subject 2 subject 3 age 27.1 years 28.3 years 44.4 years , sex male female male j educational standard 9 apprentice matric diploma greenoaks secretarial college standard 8 j • 1 premorbid laterality right right right <' | coma (weeks) 3 6 2 ! time since injury to testing (months) 48 8 8 history of speech therapy yes, until 1984 presently receiving theraphy yes, until 1987 present motor problems l-arm hemiplegia l-hemiplegia. previous l-side neglect resolved l-hemiplegia occupation supervising packing of medical supplies unemployed unemployed ** / immediate post-trauma cat scan results diffuse cerebral oedema with small parieto-temporal haemorrhage on left diffuse cerebral oedema with parieto-occipital haemorrhage on right intracerebral haemorrhage occupying most of right temporal lobe with right and left lateral ventricle involvement. craniotomy to drain sub-dural haemotoma the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) word-finding strategies in closed head injured adults 57 modify tests designed for other neurogenic groups such as aphasia. the following tests were administered: a. western aphasia battery (wab) (kertesz, 1980) the aphasia quotient (aq) was only administered as it serves as a functional measure of spoken language impairment. it thus provided an overall language severity score in subjects and a basis for comparison between subjects. b. prutting's pragmatic protocol (prutting, 1982) — a strong relationship seems to exist between the chi ss' effective use of compensatory strategies and their overall communicative competence (cleary, 1985; teicher, 1986). the general pragmatic communication abilities of the ss were therefore assessed using prutting's pragmatic protocol (prutting, 1982). this provides a global measure of communicative competence and places language in the context of socialisation. the data for the analysis consisted of a 10 minute interactional language sample which was simultaneously videoand audiotaped. topics discussed in this sequence were: family structure, the subject's accident, daily activities and interests. c. discourse tasks — this is a procedure for sampling and quantifying connective speech for chi ss who display social and vocational communicative deficits yet have difficulty on standardised aphasia tests (milton, prutting and binder, 1984). procedural discourse was employed as the mode of elicitation and it provides the tester with a moderate level of context control and has temporal constraints (ulatowska, north and macaluso-haynes, 1981). the task involved a complete discussion of three daily activities noted for their familiarity and relatively high frequency of occurrence for an adult (ulatowska et al. 1981). instructions given were: "i'd like you to tell me as completely as possible, how to make a sandwich; change / a bed; wash laundry." d. confrontation naming tests — chosen to evaluate different aspects of confrontation naming. the boston naming test (bnt) (kaplan, goodglass and weintraub, 1976) was employed to evaluate object (noun) naming on confrontation, while the action naming test (ant) (obler and albert, 1986) was employed to evaluate action (verb) naming on confrontation. repetition and cueing were provided if the subject did not respond after a 20 second delay. behaviours associated with word-finding difficulties on the procedural discourse tasks, the bnt and the ant, were described using teicher's behavioural taxonomy of word-finding strategies (teicher, 1986), based on penn's taxonomy of compensatory strategies (1985). this qualitative analysis yields pertinent information about language use difficulties in chi. five broad strategy categories were derived and are displayed in table 2. an additional category for analysis "repetition" was included in the taxonomy as penn (1985) makes use of this strategy in her taxonomy of compensatory strategies. repetition facilitates processing and captures the listener's attention. a 'detailed description and example of each word-finding strategy is displayed in appendix i. table 2: teicher's taxonomy of word-finding strategies (teicher, 1985) elaboration fluency description circumlocution silent pause filled pause non-verbal/paralinguistic social symbolic noise meaningless gesture iconic/pantomime facial expression deictic comment clause self-correction requests help other any behaviour not included in the preceding categories testing procedure testing was carried out individually and extended over a number of morning sessions in an attempt to eliminate fatigue as a confounding variable. in order to reduce anxiety, rapport was established with each subject prior to his being tested. analysis of data standardised tests administered were scored according to the procedure laid down in the test manual. non-standardised test results were analysed according to the methods described previously. the examiner and two reliability judges completed prutting's pragmatic protocol (prutting, 1982) independently in order to measure reliability. point-to-point inter-rater reliability was calculated separately for the three categories of the protocol. reliability was 82%, with a range extending from 75,5% to 85,5%. rating was thus reliable, based on silverman's (1977:157) minimal acceptable inter-rater reliability of 0,75. three raters rated each ss' word-finding strategies using teicher's taxonomy of word-finding strategies (teicher, 1986). the raters involved one of the authors and two third year speech therapy students blind to the aims of the study. all raters had been trained in the use of the profile. training sessions included familiarisation, discussion and explanation of each strategy listed on the taxonomy. clinical videotapes of chi ss engaged in conversation were chosen to illustrate and clarify certain strategies. judges rated each interaction separately and independently on all three viewings and completed the ratings according to their observation of relevant dimensions. during the first viewing, raters were required to underline when a word-finding difficulty had occurred. during the second viewing, the raters were required to comment if the word search was successful or unsuccessful. a successful word search was any attempt at word-finding which resulted in the production of a specific lexical item. in an unsuccessful word search, the listener may not have known the desired word, but knew when the speaker had not reached the target word or when the search strategy was ineffective die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 j u l e e n kleiman and lesley bucke (teicher, 1986). finally, the raters were required to categorise the behaviours accompanying the word-finding instances into teicher's behavioural taxonomy (teicher, 1986). point to point inter-rater reliability was determined. reliability values ranged from 83.2% for s2 to 77.4% for si. it can therefore be concluded that rating was reliable according to silverman's (1977; 157) minimal acceptable interrater reliability value of 0.75. duration of each word search for all ss was analysed quantitatively by' computing the overall ratings of successful and unsuccessful searches. it was calculated from the moment of onset of the search to the moment of successful or unsuccessful achievement and then rounded to the nearest half second. finally, the percentage of time each initial word-finding strategy and strategy sequence was employed successfully and unsuccessfully was computed for each subject. results and discussion a. western aphasia battery (kertesz, 1980) subject 1 obtained a wab aphasia quotient of 74.8 while ss 2 and 3 scored 92.6 and 64.0 respectively. none of the ss therefore scored above 93.8 which is the suggested cut-off point for aphasia (kertesz, 1980). this indicates an element of language form disturbance for all ss, the nature of which was diffuse. this contradicts milton, prutting and binder's (1984) opinion that chi ss do not present with a degree of aphasia. word-finding difficulties were observed in all ss in addition to problems in the areas of comprehension and repetition which correlates with cleary's (1985) findings. brooks (1984), cleary (1985) and groher (1977) have suggested that an underlying memory problem together with reduced attention and concentration span are contributory factors towards overall difficulties in these areas. naming ability and verbal associative fluency have been shown to be the most effective predictors of injury (levin et al. 1981) which corresponds with the findings. s3 presented with the most severe generalised cerebral dysfunction in addition to the most severe linguistic deficit. b. prutting's pragmatic protocol (prutting, 1982) all 3 ss presented with a greater or lesser degree of pragmatic difficulty. s2 experienced the least overall difficulty (15% inappropriate responses), si presented with 22% inappropriate responses while s3 experienced the most overall difficulty (66%). similar findings were found on the wab (kertesz, 1980). this observation contributes towards irvine and behrmann's (1986) finding of a balance existing between language form and language use skills in chi individuals. results indicate that overall appropriateness of subjects' responses occurred mainly in the utterance act and the propositional act categories while the least appropriate response occurred in the ilocutionary/perlocutionary act. this is in agreement with cleary (1985), milton et al. (1984), and teicher (1986) and it seems to imply that chi individuals function inadequately in their roles as discourse partners. the south african journal of communication disorders, vol. 35, 1988 table 3: subjects' performance on the procedural discourse tasks si s2 s3 number of word-finding difficulties 32 7 19 percentage: successful 69% 86% 74% percentage: unsuccessful 31% 14% 26% , duration: successful mean range 2.0 sec 0.5 — 5.0 sec 1.0 sec 0.5 — 1.0 sec 2.0 sec | 1.0 — 5.0 sec ' duration: unsuccessful mean range 3.5 sec 0.5 — 7.0 sec 2.0 sec 4.0 sec ; 2.0 5.0 sec j number of different strategies used: ' successful 7 2 ! number of different strategies used: ' unsuccessful 7 2 4 number of different strategy sequences: successful 5 0 3 number of different strategy sequences: unsuccessful 6 1 2 most frequently used initial strategy: successful filled pause 37% silent delay 86% filled pause 58% most frequently used initial strategy: unsuccessful filled pause 30% repetition 30% silent delay 100% filled pause 100% most frequently used stategy sequence: successful filled pause/ repetition 23% / filled pause/ silent delay ' 2 1 % most frequently used stategy sequence: unsuccessful filled pause/ repetition 20% filled pause/ description 60% r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) word-finding strategies in closed head injured adults 59 c. procedural discourse tasks while all 3 subjects presented with word-finding difficulties they all experienced relatively high levels of success for production of the desired lexical item following this difficulty. table 3 describes the subjects' performance during the procedural discourse tasks. both the duration mean and range of word searches were calculated. all ss presented with a longer duration when strategies were unsuccessful. for example s3's mean duration of a successful word search was 2 seconds while that of an unsuccessful word search was 4 seconds, a difference of 2 seconds. a wide range of successful and unsuccessful initial word-finding strategies were employed, namely filled pause, silent delay and repetition, though a greater number and variation of strategies were used when success was not attained. this may relate to the ss' attempts to compensate for increased instances of word-finding difficulty. certain strategies occurred more frequently than others, particularly fluency strategies. silent delay and filled pause were employed 69% of the time during a successful word search and 75% during an unsuccessful word search. repetition was the most facilitative initial strategy and was employed by ss to maintain listener attention (penn, 1985). ss 1 and 3 employed word-finding strategy sequences, successfully and unsuccessfully, in an attempt to produce desired lexical items. filled pause was the most frequently used initial strategy in all sequences. filled pause may be potentially distracting if used too often (cleary, 1985). this was particularly evident in si's speech where it was the most frequently table 4: subjects' performance on the bnt used initial strategy and part of the most frequently used strategy sequence, both successfully and unsuccessfully. this may relate to the increased number of word-finding difficulties experienced by si. d. confrontation naming tests — boston naming test (bnt) (kaplan et al. 1976) all ss experienced word-finding difficulties and, as a result, employed word-finding strategies to overcome this difficulty. table 4 illustrates the ss' performance on the bnt (kaplan et al. 1976). the level of success for production of the desired lexical item was relatively low for all ss — 16%, 20% and 42% for ss 1, 2 and 3 respectively. the duration mean and range of word searches indicates that all ss presented with a longer duration when strategies were unsuccessful, for example 8 seconds versus 2 seconds for s3. the ss' results differed from each other for successful and unsuccessful initial word-finding strategies. however, for all ss, an increase in the number and variation of different initial strategies and word-finding strategy sequences was evident when success was unattainable. all ss employed word-finding strategy sequences, but the most frequently used successful and unsuccessful strategy sequences varied across and within ss. s2, however, employed the same successful and unsuccessful strategy sequences, silent delay/description. this is hypothesised to relate to s2's careful self-monitoring. elaboration strategies (description and elimination), fluency si s2 s3 number of word-finding difficulties 49 30 19 percentage: successful 16% 20% 42% percentage: unsuccessful 84% 80% 58% / / / percentage: successful with cueing phonemic cues 34% 56% 57% / / / percentage: stimulus cues 0% 44% 0% duration: successful mean range 6.0 sec 1.0 20.5 sec 6.5 sec 2.0 10.0 sec 2.0 sec 0.5 3.5 sec duration: unsuccessful mean range 10.0 sec 2.5 19.0 sec 8.5 sec 2.5 14.5 sec 8.0 sec 2.5 11.5 sec . / , successful 5 3 5 t inumder o r u m e r e n t s t r a t e g i e s u s e u . unsuccessful 11 6 5 successful 4 2 1 inumder o i u m e r e n t s t r a t e g y s e q u e n c e s . unsuccessful 14 11 5 most frequently used initial strategy: successful repetition 50% silent delay 50% repetition 63% most frequently used initial strategy: unsuccessful description 50% description 45% description 73% successful repetition/ description 25% silent delay/ description 33% comment/ filled pause 13% iviost irequentiy useu stategy sequence: 1 unsuccessful description/ comment clause 13% silent delay/ description 30% description/ filled pause 28% die suid-afrikaanse tydskrif vir kommunikasieawykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 j u l e e n kleiman and lesley bucke strategies (silent delay and filled pause) and social strategies (comment clause, self-correction and requests help) were the most frequently used initial strategies. all the ss required cues following the failure to name the desired lexical item. phonemic cues were the most successful in facilitating retrieval of the specific lexical item for all ss. — action naming tests (ant) (obler and albert, 1986) all 3 ss experienced instances of word-finding difficulty on the ant. they employed word-finding strategies to overcome their difficulty. table 5 illustrates the ss' performance on the ant (obler and albert, 1986). level of success for production of the desired lexical item was low for all ss — 27%, 22% and 30% for ss 1, 2 and 3 respectively. results obtained correlate closely with those obtained on the β nt (kaplan et al. 1976). ss presented with longer duration when strategies were unsuccessful in facilitating production of the specific lexical item. for all ss an increase in the number of different initial strategies and strategy sequences was evident when success was not attained. s3, however, deviated from the trend. the number of different initial strategies employed during the bnt (kaplan et al. 1976) and the ant (obler and albert, 1986) for successful and unsuccessful word searches was equivalent. si and s2 employed word-finding strategy sequences while s3 failed to successfully employ strategy sequences. this is hypothesised to relate to s3's inappropriate pragmatic behaviour and lack of self-monitoring. the most frequently used successful and unsuccessful strategy sequences varied across and within ss except s2 who employed the same strategy sequence (silent delay — description) successfully and unsuccessfully.' this was also evident on the bnt (kaplan et al. 1976). fluency and elaboration strategies were the most frequently employed initial word-finding strategies. all ss required cues following the failure to name the desired word, and phonemic cues were the most successful in facilitating retrieval of the specific lexical item. the superiority of phonemic cues over stimulus and verbal contextual cues is confirmed by the results on both confrontation naming tests and by the studies performed by pease and goodglass (1978) and williams (1983). e. summary of results and discussion the results indicate that three different patterns of performance were identified with some commonality of wordfinding strategies employed across ss. the study indicates that a relationship exists between ss' effective use of wordfinding strategies during procedural discourse tasks and their overall communicative competence, as shown on prutting's pragmatic protocol (prutting, 1982) and the wab. viewed within a compensatory strategy framework, it is advocated that the chi ss are self-monitoring more carefully in an attempt to compensate for their deficits; hence the use of word-finding strategies. this is in accord with cleary table 5: subjects' performance on the ant si s2 s3 number of word-finding difficulties 22 18 17 percentage: successful 27% 22% 30% percentage: unsuccessful 73% 78% 70% successful with percentage: cueing phonemic cues 61% 83% 53% percentage: verbal contextual cues 45% 56% 29% successful mean 5.0 sec 9.5 sec 3.0 sec duration: range 2.0 8.0 sec 4.5 13.0 sec 1.5 5.0 sec duration: unsuccessful mean 11.0 sec 10.0 sec 6.5 sec range 5.5 18.5 sec 4.5 18.0 sec 0.5 16.5 sec number of different strategies used: successful 4 3 3 number of different strategies used: unsuccessful 7 4 3 number of different strategy sequences: successful 3 2 0 number of different strategy sequences: unsuccessful 7 8 1 successful filled pause 38% description 50% self-correct 40% filled pause most frequently used initial strategy: 40% most frequently used initial strategy: unsuccessful silent delay 38% description 57% description 50% most frequently used stategy sequence: successful repetition/ pantomime 33% silent delay/ description 40% most frequently used stategy sequence: unsuccessful filled pause/ description 32% silent delay/ description 35% description/ filled pause 16% the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) word-finding strategies in closed head injured adults 61 (1985) and teicher (1986). in terms of word-finding difficulty, a confrontation naming task was found to be more difficult for chi ss than a procedural discourse task. while procedural discourse maximally challenges the chi individual's communicative ability, it may facilitate naming as found in non-brain damaged individuals (clark and clark, 1977). the semantic, syntactic and temporal constraints characteristic of procedural discourse (ulatowska et al. 1981) seemed to assist ss 2 and 3 in the recall and production of the desired lexical items as the "lost" word seemed to be closer to the "tip of the tongue". within the confrontation naming task, naming of objects (nouns) appeared to be more difficult than the naming of actions (verbs). this finding is consistent with the findings of goodglass et al.'s (1966) study and irvine and behrmann's (1986) study. mean length of response time for successful and unsuccessful searches during the procedural discourse tasks was less than during the confrontation naming condition for all 3 ss. this is hypothesised to relate to the nature of the discourse task which may have facilitated naming. this finding is confirmed by newcombe et al. (1965, cited by berko-gleason, goodglass, obler, greene, hyde and weintraub, 1980) and teicher (1986). si presented with a longer successful mean latency for object naming versus action naming whereas the converse was found for ss2 and 3. furthermore individual patterns exist for unsuccessful mean latencies for object and action naming. it is evident from the data that no one pattern of performance is generated, confirming the notion of heterogeneity within the chi population (hagen, 1984; irvine and behrmann, 1986). in contrast to this diverse picture, all ss presented with a longer duration for unsuccessful word-finding strategies during procedural discourse and confrontation naming. pausing to reconsider and reattempt when not experiencing success is speculated to contribute to this longer duration as chi ss experience significant difficulty processing complex information (hagen, 1984). i i alkss displayed an increase in the number of different initial strategies and different strategy sequences when success was not attained. it appears that in an attempt to overcome the unsuccessful attempt, additional and varied strategies are employed. this appears to confirm a breakdown in luria's (1975) 'rule of forcej theory where strong and weak stimuli evoke similar responses so that no selective organisation of the relevant associational process is possible. an analysis of the entire sequence of strategies employed reveals much variability across and within ss. the same initial strategies were used successfully and unsuccessfully by all the ss during the procedural discourse tasks and occasionally during the confrontation naming tasks, namely fluency strategies. this finding correlates with cleary's (1985) and teicher's (1986) results. ulatowska et al. (1981) state that in discourse, message transmission in any form is the goal. therefore the chi ss, in an attempt to maintain the conversational flow and transmit the message, predominantly adopted fluency strategies. other strategies employed which were not accounted for by teicher's behavioural taxonomy of word-finding strategies (1986) were the use of unfinished words, okay', and humour. these strategies have implications in the development of assessment tools for chi and in their treatment. in summary, word-finding strategies were employed by all the subjects in an attempt to overcome their word-finding difficulty, but to differential effect. there are several possible explanations for the performance variation noted. coma duration and neurological dynamics may account for the differences. other variables which may play a role are age range, the time-since-injury and non-medical variables such as personality and motivation since affective disorders are a well-recognised by-product of chi (hagen, 1984). in addition, the increasingly well accepted fact that the chi group is a heterogeneous group is a further important consideration. individual patterns, rather than a single group pattern, characterise this population (irvine and behrmann, 1986), a finding supported by this data. conclusion it is clear from this study that chi ss are generally using word-finding strategies frequently and effectively to overcome their word-finding difficulties. this is in agreement with the results of teicher's (1986) study. this may indicate that chi ss are, in fact, effective communicators who learn useful compensatory strategies if given the opportunity to do so (cleary, 1985; teicher, 1986). the implications of this finding for remediation are many. in view of the heterogeneity of the chi population, it is essential that the clinician assesses each closed head injured patient individually without relying on the predicted findings from the literature. the need for sensitive assessment measures aimed at evaluating communicative efficiency in chi is stressed. measures such as teicher's taxonomy (1986) may be employed to present a profile of compensatory strategies. the speech-language pathologist may then structure an effective treatment programme as "... treatment serves to challenge and channel spontaneous recovery, maximise residual function, and compensate for lost abilities." (hagen, 1984:275.) references annegers, j.f., grabouw, j.d., kurland, l.t. and laws, e.r. the incidence, causes and secural trends of head trauma in olmsted country, minnesota. neurology, 30, 912—919, 1980. benson, d.f. neurological correlates of anomia. in h. whitaker and h. whitaker (eds.) studies in neurolinguistics. new york: academic press, 1979. berko-gleason, k., goodglass, h., obler, l., greene, e., hyde, m.r., and weintraub, s. narrative strategies of aphasic and normal speaking subjects. journal of speech and hearing research, 23, 3 7 0 3 8 2 , 1980. brooks, n. cognitive deficits after head injury. in n. brooks (ed.) closed head injury — psychological, social and family consequences. new york: oxford university press, 1984. clark, h. and clark, e. psychology and language: an introduction to psycholinguistics. new york: harcourt brace jovanovich, 1977. cleary, j. compensatory strategies in closed head injury. undergraduate research report, department of speech pathology and audiology, university of the witwatersrand, 1985. goodglass, h., kaplan, e., weintraub, s. and ackerman, n. the "tip-of-the-tongue" phenomenon in aphasia. cortex, 12, 1 4 5 1 5 3 , 1976. groher, m. language and memory disorders following closed head trauma. journal of speech and hearing research, 20, 2 1 2 2 2 3 , 1977. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 juleen kleiman and lesley bucke hagen, c. language disorders in head trauma. in a. holland (ed.) language disorders in adults. san diego: college-hill press, 1984. heilman, k., safron, a. and geschwind, n. closed head trauma and aphasia. journal of neurology, neurosurgery and psychiatry, 34, 2 6 5 2 6 9 , 1971. holland, a. when is aphasia aphasia? the problem of closed head injury. paper presented at the clinical aphasiology conference, oshkosh, wisconsin, 1982. irvine, l. and behrmann, m. the communicative and cognitive deficits following closed head injury. south african journal of communication disorders, 33, 49—54, 1986. kaplan, e., goodglass, h. and weintraub, s. the boston naming test. unpublished test, boston, m.a. : veterans hospital, 1976. kertesz, a. western aphasia battery. london, ontario, canada: university of western ontario, 1980. kirchner, d. and skarakis-doyle, e. developmental language disorders: a theoretical perspective. in t. gallagher and c. prutting (eds.) pragmatic assessment and intervention issues in language. san diego: college-hill press, 1983 levin, h.s., benton, a.l. and grossman, r.g. neurobehavioural consequences of closed head injury. new york: oxford university press, 1981. luria, a.r. traumatic aphasia: its syndromes, psychology and treatment. the hague: mouton, 1970. luria, a.r. basic problems of language in the light of psychology and neurolinguistics. in e. lennenberg and e. lennenberg (eds.) foundations of language development. new york: academic press, 1975. marshall, r.c. word retrieval of aphasic adults. journal of speech and hearing disorders, 61, 444—451, 1976. milton, s.b., prutting, c.a. and binder, g.m. appraisal of communicative competence in head injured adults. paper presented at the clinical aphasiology conference, seabrook island, california, 1984. obler, l.k. and albert, m.l. the action naming test, 1986. pease, d. and goodglass, h. the effects of cueing on picture naming in aphasia. cortex, 14, 178—189, 1978. penn, c. compensatory strategies in aphasia: behavioural and neurological correlates. in k.m. grieve and d. griesel (eds.) neuropsychology. university of south africa press, muckleneuk, pretoria, 1985. penn, c. and cleary, j. compensatory strategies in the language of closed head injured patients. unpublished paper, university of the witwatersrand, johannesburg, 1987. piaget, j. the origin of intelligence in children. new york: basic books, 1952. prutting, c.a. pragmatics as social competence. journal of speech and hearing disorders. 47, 123—134, 1982. russell, w.r. the traumatic amnesias. london: oxford university press, 1971. sarno, m.t. the nature of verbal impairment after closed head injury. journal of nervous and mental disorders, 1968, 6 8 5 6 9 2 , 1980. silverman, s. research design in speech pathology and audiology, engelwood cliffs, new jersey : prentice hall inc., 1977. teicher, s.h. word-finding strategies in closed head injured adults. masters dissertation, university of california, santa barbara, 1986. ulatowska, h., north, α., macaluso-haynes, s. production of narrative and procedural discourse in aphasia. brain and langauge, 13, 3 4 5 3 7 1 , 1981. williams, s. factors influencing naming performance in aphasia: a review of the literature. journal of communication disorders, 16, 357—372, 1983. ylivisaker, m. and szekeres, s.f. management of the patient with closed head injury. in r. chapey (ed.) language intervention strategy in adult aphasia (2nd ed). williams and wilkins, baltimore: 1986. the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) word-finding strategies in closed head injured adults 6 3 appendix 1 description of teicher's (1986) taxonomy of word-finding strategies strategy type definition examples elaboration — description — circumlocution — elimination fluency — silent delay — filled pause social — comment clause — self-correction — requests help non-verbal/ paralinguistic — symbolic noise meaningless gesture iconic gesture/ pantomime — facial expression — deictic other — incorrect lexical choice expansion or elaboration of the message to ensure effective transmission. description of the appearance or function of what is being spoken about. production of general words or "empty words" (heilman et al. 1971) in place of the desired word. elimination of a series of words which may be semantically related to the desired word. used to hold the place in conversation. an unfilled pause. pause filled with some sound indicating ongoing lexical search. devices reflecting sensitivity to the needs of the interlocuter. any metalanguage about the desired word search used to maintain a speaking turn. correction of phonetic or semantic errors without cues from the listener. direct request or a non-verbal cue for help. vocal and/or gestural behaviours which supplement or substitute for the verbal message. ί sound effects made in conjunction with or in place of the intended word to ensure effective transmission. meaningless, natural gesture, lacking structure. clearly, discernible gesture representing a particular word, object or its use. facial configuration in conjunction with or in place of the intended lexical item. pointing to an object or in a general direction. any behaviour unclassifiable in the preceding taxonomy synonym or any acceptable alternative for the desired lexical item. ' ί have one at home — it's white and you dry yourself with it." (towel) "you get a free whatschimacallit." "it's not january, it's february." "we use the uh, uhm the book." "you know" or "oh, what are those things?" "he hit the bat, i mean the ball." "i'll know if you give me the first sound", or use of gesture. the use of a high pitched, glottalised screech made to represent a car's brakes. an upward and outward hand movement. left hand in a cupped position as if holding a jar and the right hand moving in a circular motion above the left as if opening a jar. widening of eyes and opening of mouth to indicate surprise. "over there" or "that one". "digging" for "pushing". die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) furnquip manufacturing and wholesale suppliers (pty) limited registration no. 61/02456/07 t / a furnqup medical group your yellow pages of medical equipment head office correspondence only to: p.o. box 84416 greenside 2034 south africa tel. a d d . furnquip tel: (011) 787-5733/4, 787-5768/9 head office: "greenbriars" 75 conrad drive, blairgowrie 2194, south africa telex 4-28072 sa. fax (2711) 787-5716 associated companies deliveries store only furnquip medical natal (pty) ltd furnquip medical transkei medical industries c / o dolphins transport p.o. box 1999, bophuthatswana (pty) ltd (pty) ltd joe arnison str., durban 4000 p.o. box 84416, p.o. box 9030 madeira str., labore tel. 031-309-2313/4 greenside 2034 umtata 5100 brakpan telex 6-22133 tel. (011) 787-5717 tel. 0471-24221 electronic artificial larynx a n d complete speech therapy aids fq/jm001 — barts artificial larynx mark ii this has been improved and although an old design, is still very useful as a back-up larynx or as a teaching aid. fq/jm005, 006, 007, 008 these are the different microphones that are available for use with the de luxe speech amplifier (010) and continue in production unchanged. fq/jm010 de luxe speech amplifier m k ii this has been completely redesigned. output has been increased by approximately one third and a new loudspeaker used which gives a much clearer and more crisp tone. fq/jm011 — m a r k ii electronic artificial larynx this unit has been improved and now has a separate on/off isolator switch to prevent accidental use in one's pocket etc. the output is increased and if the optional high power battery is used very great volume can be achieved. this unit is supplied with one battery and charger. fq/jm015 pausaid this is supplied complete with a microphone and battery. pausaid has a throat microphone which will detect when phonation is continuous and will therefore prompt the patient auditorially to make regular stops in speech. fq/jm016 — vocal loudness indicator the vli is a compact battery operated device intended to display relative levels of vocal loudness. the vli consists of a series of eight numbered lights, each lighting up at a different loudness level. fq/jm017 — companion intra oral larynx 1 introduced early 1987, this has proved extremely suej cessful as an intra-oral larynx for post operative use and for further information please fill in the following in some cases for permanent use by laryngectomies and return: where a throat larynx is not liked or acceptable. ! surname: fq/jm018 s u m m i t amplifier ' this is an amplifier in the same housing as the mark ii first names: 010 amplifier. address: fq/jm019 headset or throat microphone for the new type amplifier 018. fq/jm020 pocket audiometer ^ this unit is designed as a front line free field screening telephone no: audiometer capable of quickly and easily checking whether or not a patient has a hearing problem. v ^ s ^ f k directors: g.l.l. harding (group managing) j.l. m c f a r l a n d (rn. dip. nurs. sci) consultant national (british) m everything for hospitals and institutions under one roof ^f^s^ "the original turnkey project specialists" r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 15 videofluorografiese ondersoek van die slukproses by serebraal gestremde kinders videofluorografiese ondersoek van die slukproses by serebraal gestremde kinders karin le roux, β log (pretoria) anita van der merwe, d phil (pretoria) brenda louw, d phil (pretoria) departement spraakheelkunde en oudiologie, universiteit van pretoria, pretoria opsomming die slukprobleme van serebraal gestremde kinders word klinies aan die hand van subjektiewe kriteria omskryf weinig navorsing is nog uitgevoer om die aard van hierdie probleme objektief en wetenskaplik te beskryf. die doel van hierdie studie was om die slukpatrone van twee ouderdomsgroepe serebraal gestremde kinders deur middel van videofluorografie te ondersoek. tien serebraal gestremde kinders tussen die ouderdomme van vier en dertienjaar het as proefpersonegedien. tydens die videofluorografiese evaluasie waar daar van die proefpersone vereis is om 'n vloeistof te sluk, is sekere aspekte van die oraal-voorbereidende, or ale en faringale fases van die slukproses geevalueer. die resultate van die studie toon aan dat slukprobleme wel voorkom by serebraal gestremde kinders. probleme kom hoofeaaklik voor tydens die oralefase en neem die vorm aan van byvoorbeeld onvoldoende tongpalatumkontak en swak beheer van die bolus. diejongergroep kinders vertoon meer slukprobleme as die ouer groep. by diejongergroep speel die tipeserebralegestremdheid skynbaargeen rol by die aard van die slukprobleme nie, terwyl daar by die ouer groep aanduidings is dat die tipe serebrale gestremdheid wel 'n rol speel. die resultate van die studie toon aan dat videofluorografie effektief geimplimenteer kan word om slukprobleme by serebraal gestremdes wetenskaplik te evalueer. abstract the swallowing problems of cerebral palsied children are clinically evaluated by means of subjective criteria. little research has been done to analyse these problems objectively and scientifically. the aim ofthis study was to analyse the swallowing patterns of cerebral palsied children in two age groups by means of videofluorography. ten cerebral palsied children between the ages of four and thirteen years were selected as subjects. during the investigation they were asked to swallow a liquid and certain aspects of the oral preparatory, oral and pharyngeal phases of swallowing were analysed. the results of the study indicated that swallowing problems do occur in cerebral palsied children, mainly during the oral phase, and in some cases take on the form ofinadequate contact between the tongue and palate and poor control of the bolus. the group ofyounger children had more swallowing problems than the older group. in theformer group the type of cerebral palsy did not seem to play any role in the swallowing problems which occurred while in the older group there were indications that the type of cerebral palsy could p6ssibly play a role. the results of the study indicate that videofluorography can be implemented effectively to scientifically evaluate the / swallowing problems of cerebral palsied children. voedingsprobleme asook swak speekselbeheer is van die grootste probleme wat die serebraal gestremde persoon ervaar. afwykings in die slukproses vorm deel van en dra by tot die voedingsprobleme van hierdie populasie. voedingsprobleme word hoofsaaklik as 'n geheel beskryf en min literatuur bestaan oor afwykings in die slukproses in besonder. uit 'n oorsig van die literatuur blyk dit dat die serebraal gestremde kind wel soms probleme ondervind met sluk (love, hagerman & tiami, 1980; hardy, 1983; logemann, 1983). die aard van die slukprobleme is nog grootliks onbekend en moontlike verskille ten opsigte van slukpatrone soos dit voorkom in die hoofgroepe serebraal gestremdes word nie in die literatuur omskryf nie. kliniese ondervindingtoon datevaluasiemetodes van die slukprobleme by hierdie kinders, oor die algemeen, op subjektiewe beoordeling tydens orofasiale ondersoeke berus (steenkamp, 1988). 'n leemte bestaan dus in die kliniese uitvoering van wetenskaplike, objektiewe en betroubare evaluering van slukprobleme by serebraal gestremdes (hardy, 1983). 'n videofluorografiese ondersoek bied die geleentheid om die totale slukproses objektief waar te neem en die spesifieke probleme in die oraal-voorbereidende, orale en faringale fases te identifiseer. die moontlike verband wat tussen voedingsprobleme en veral slukprobleme by babas kan bestaan, en die ontwikkeling van abnormale spraakpatrone in latere jare word tans algemeen aanvaar. identifisering en remediering van die abnormale bewegingspatrone in voeding en veral sluk van serebraal gestremde kinders, is dus noodsaaklik om 'n meer normale basis vir spraak daar te stel (mueller, 1976; morris, 1985). voedingsprobleme, onder andere slukprobleme en swak speekselbeheer is die gevolg van abnormale orale reflekspatrone en posturale afwykings van die hele liggaam. abnormale spiertonus, tongretraksie of stoot, retraksie van die lippe met gevolglike swak/geen lipsluiting, tongimmobiliteit, onstabiliteit van die mandibula, swak gradering van mandibulabewegings, verhoogde orale sensitiwiteit en kopen nekhiperekstensie bei'nvloed die slukproses onder andere en gee aanleiding tot voedingsprobleme (mueller, 1976; alexander, 1987; van der walt, 1988; steenkamp, 1989). die neuromotoriese probleme verhoed onder meer vorming en effektiewe hantering van die bolus tydens die slukproses. die gedisorganiseerde linguale bewegings verhinder weer gladde peristaltiese bewegings van die tong wat nodig is vir sluk. minder is bekend die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 karin le roux, anita van der merwe e n brenda louw oor slukafwykings in die faringale en esofagale fases. 'n ondersoek van 40 serebraal gestremde kinders by die northwestern university medical school het aangetoon dat 'n vertraagde slukrefleks en beperkte faringale peristalsis die probleme met die hoogste voorkoms in die faringale fase was (logeman 1983 : 216). die rol wat die lokalisasie van die neuromotoriese patologie speel by die aard van die slukprobleme is onbekend. die drie hoofgroepe van serebrale gestremdheid, naamlik spastiese, atetotiese en ataktiese tipes het die moontlikheid van differensiele aantasting van die slukproses. differensiele aantasting kan te wyte wees aan die verskillende vorms van neuromotoriese aantasting veroorsaak deur letsels in die verskillende dele van die neuromotoriese stelsel (hardy, 1983). slukprobleme word deur middel van verskeie evaluasiemetodes bestudeer (love et al. 1980; lear, flanagan & moorrees, 1965; logemann, 1983). videofluorografie verskaf egter die eerste maal die geleentheid om die slukproses akkuraat en objektief te kan bestudeer (logemann, 1983; brogan, foulner & turner, 1987). aangesien sluk 'n vinnige en dinamiese proses is, waar normale orale en faringale deurgangstye elk slegs 'n maksimum van 1 sekonde duur, sal die stadige raam-virraam opnames van videofluorografie, bydra tot 'n objektiewe beoordeling en herhaalde ondersoek van sluk (bzoch, 1979; logemann, 1983; brogan et al. 1987). inligting verkry met behulp van videofluorografie kan deur die terapeut gebruik word om neuromotoriese afwykings teenwoordig in die pasient se slukproses, aan te dui. sodanige inligting maak dit moontlik om te bepaal watter konsistensie voedsel geskik sal wees vir voeding, en identifiseer ook direkte sowel as indirekte behandelingsprosedures ten opsigte van die spesifieke probleem. mueller (1976:113) het die belangrike stelling gemaak dat 'n serebraal gestremde kind gehelp kan word slegs deur noukeurige waarneming en analise van sy vermoens en onvermoens. : dit blyk dus dat talle faktore kan bydra, of aanleiding gee, tot slukprobleme by serebraal gestremdes en dat die aard van die slukprobleme moontlik by die verskillende tipes serebrale gestremdheid kan verskil. objektiewe beoordeling van die slukproses met behulp van tegnieke soos videofluorografie kan inligting verskaf wat die aard van die probleme kan toelig. tot op hede is die voedingsprobleme van serebraal gestremdes egter slegs in die algemeen beskryf en 'n behoefte bestaan aan die beskrywing van 'n prakties jiiitvoerbare evaluasietegniek wat objektiewe data van veral die slukproses kan verskaf. sodanige data kan vir beide navorsing en terapeutiese intervensie aangewend word. die doel;van hierdie studie is dus om die leemtes in die kliniese praktyk aan te vul deur die slukpatrone van serebraal gestremdes wetenskaplik te beskryf en die verskillende tipes serebraal gestfemdes met mekaar te vergelyk. metode doelstelljngs: die hoofdoel van die studie is om die slukpatrone van serebraal gestremde kinders te ondersoek. die spesifieke doelstellings is: om te bepaal wat die aard van moontlike slukprobleme by serebraal gestremdes in die oraal-voorbereidende, orale en faringale fases, is; om te bepaal of, en in watter opsigte die slukpatrone van die drie hooftipes serebraal gestremdes, naamlik die spastiese, atetotiese en ataktiese tipes, verskil; om te bepaal wat die invloed van behandeling van oraal motoriese probleme en maturasie van orale funksionering op serebraal gestremde kinders se slukpatrone is deur twee verskillende ouderdomsgroepe serebraal gestremdes te vergelyk. ν a vorsjngsontwerp die ondersoek het die vorm aangeneem van 'n beskrywende opnamestudie waarin tussengroepvergelykings getref is (smit, 1983). proefpersone: daar is drie groepe proefpersone geselekteer, naamlik twee eksperimentele groepe, elk bestaande uit 5 serebraal gestremde proefpersone en een kontrolegroep bestaande uit 2 normale proefpersone. groepe 1 en 2 is leerlinge aan 'n skool vir serebraal gestremdes in pretoria. atetotiese, ataktiese en spastiese kinders is in die groepe opgeneem. die 5 proefpersone in groep 1 het reeds minstens twee jaar terapie ontvang vir voedingsprobleme ten einde die invloed van behandeling op die slukproses te kon bepaal. die proefpersone was tussen die ouderdomme van 11 jaar en 12 jaar ses maande wat verseker het dat anatomiese ontwikkeling van die larinks (wat 'n effek het op sluk) reeds voorgekom het (kennedy & kent, 1985). j die 5 proefpersone in groep 2 was tussen die ouderdomme drie en ses jaar en het nie langer as ses maandebehandeliiig ontvang vir hul slukprobleme nie. sodoende kon die invloed van behandeling van oraal motoriese probleme e h , maturasie van die orale strukture op die slukproses van die proefpersone bepaal word. die proefpersone word in tabelle 1 tot 3 beskryf. τ abel 1. beskrywing van die relevante eienskappe van eksperimentele groep1ά kenmerke ' proefpersone 1 2 3 4 5 geslag van kind manlik manlik manlik vroulik vroulik ouderdom van kind · 12,6 11 12,9 12,2 12,10 tipe serebrale gestremdheid atakties atakties atetoties spasties spasties graad van aantasting ' gemiddeld gemiddeld gemiddeld gemiddeld gemiddeld tydperk van terapie ontvang 2 j r 2,1 jr 2,6 jr 2,3 jr 2 j r · ' intelligensie ondergemiddeld gemiddeld the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 17 videofluorografiese ondersoek van die slukproses by serebraal gestremde kinders tabel 2 beskrywing van die relevante eienskappe van eksperimentele groep2 kenmerke proefpersone 6 7 8 9 10 geslag van kind ouderdom van kind tipe serebrale gestremdheid graa3 van aantasting typerk terapie ontvang manlik 5,5 atakties gemiddeld 7 mnde vroulik 6,1 atetoties gemiddeld 6 mnde vroulik 5,11 spasties gemiddeld 5 mnde vroulik 4,6 spasties gemiddeld 4 mnde vroulik 4,0 atakties gemiddeld 3 mnde intelligensie gemiddeld tabel 3. beskrywing van die relevante eienskappe van die kontrolegroep kenmerke 1 2 geslag van kind vroulik manlik ouderdom van kind 11,4 5,3 intelligensie bo-gemiddeld gemiddeld apparaat en materiaal die volgende apparaat en materiaal is tydens die uitvoering van die eksperiment gebruik: % siemens siregraph ii vir die videofluorografiese opnames. die bestralingsdosis was 141 ma per minuut. die totale blootstellingstyd aan bestraling vir elke kind was ongeveer 45 sekondes; 'n sony u-matic video-opnemer, en 'n sony u-matic kcs 20-videoband, vir die video-opnames van die slukproses; ezhb bariumsulfaatvloeistof vir die proefpersone om te sluk, om sodoende die evaluasie van die slukproses moontlik te maak; evaluasievorm waarvolgens die slukproses by elke proefpersoon geevalueer word (sien aspekte genoem by dataanalise). / prosedure elke proefpersoon is individueel geevalueer. die kinders is geposisioneer in 'n sittende posisie terwyl hulle na vore kyk. 'n laterale beeld van die slukproses is gefotografeer. die deiirligting is volgens die standaardprosedure uitgevoer, terwyl die video-opnemer die beeld aanhoudend opgeneem het (logemann, 1983). geen kopstut is gebruik in die eksperiment nie, aangesien al die proefpersone voldoende kopkontrole gehad het. ezhb bariumsulfaat is gebruik om die beeld wat waargeneem is te verhelder. die farinks is met materiaal gevul. sodoende het die strukture duideliker sigbaar geword en kon die slukproses makliker geevalueer word (haubrich, 1977). elke proefpersoon moes 'n sluk van die bariumsulfaat neem en dit in hul mond hou en dan op bevel sluk. die ondersoeker kon sodoende bepaal of die proefpersone willekeurig 'n slukrefleks kon ontlok. elke proefpersoon het twee keer bariumsulfaat gesluk, wat die blootstellings aan bestraling minder as 1 minuut gemaak het (brogan, et al. 1987). elke sluk is op videoband opgeneem en later aan die hand van kriteria geevalueer deur die ondersoeker en 'n medeondersoeker met gesofistikeerde kennis van die slukproses asook van videofluorografie. data-analise: data-optekening die videoband is vir opleidingsdoeleindes drie maal deurgegaan sodat die posisie van orale strukture asook die fases in die slukproses gei'dentifiseer kon word. dit is gedoen met behulp van 'n sony u-matic redigeerstel. die ondersoeker en die mede-ondersoeker het daarna saam na die videoband gekyk, en met behulp van raam-vir-raam metings, is elke proefpersoon se slukproses geevalueer. moontlike probleme is gei'dentifiseer en daar is weer na die hele slukproses van elke proefpersoon gekyk om die slukprobleme finaal te identifiseer en te klassifiseer. nadat die ondersoeker en mede-ondersoeker ooreenstemming bereik het ten opsigte van klassifisering van die probleme, is daar op 'n optekeningsvorm aangeteken wat normaal en afwykend in die waargenome slukproses voorgekom het, asook die tyd wat dit vir elke persoon geneem het om te sluk. aspekte geevalueer die eerste drie fases van die slukproses is geevalueer, naamlik die oraal-voorbereidende fase, orale fase en die faringale fase. logemann (1983) se beskrywings van elke fase van die slukproses is gebruik om die waargenome slukbewegings van die proefpersone mee te vergelyk, te beskryf en te kategoriseer (le roux, 1988). resultate die resultate van die videofluorografiese analise van die oraal voorbereidende, orale en faringale fases in die slukproses van die drie groepe proefpersone word vervolgens kortliks beskryf en in tabel 4 samevattend weergegee. die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 • . , κ a r m le roux, anita van der merwe en brenda louw tabel 4. resultate van eksperimentele groepe 1 en 2. kriteria proefpersone kriteria groep1 groep 2 kriteria 1 2 3 4 5 atakatakatespasspasties ties toties ties ties 1 2 3 4 5 atakatespasspasatakties toties ties ties ties a. oraal voorbereidende fase i. bolus-formasie: kan vloeistof in mond hou kan 'n bolus behou b. orale fase voldoende tong-palatumkontak normale linguale peristalsis geen vasklewing aan harde verhemeltevoldoende anterior-posterior tongbewegings beheerde bolus voldoende velere elevasie voldoende slukrefleks c. faringale fase geen vallekula stasis voeldoende tiroi'ed-elevasie voldoende laringale elevasie voldoende laringale sluiting krikofaringale koordinasie geen statis in piriforme sinusse (links en regs) totale tyd geneem om sluki proses te voltooi (sek.) * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * _ * * * * * * * _ _ * * * * * * * * * * * * * * * * * * * * * * * * * * 2 3 2 . 2 3 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 3 3 4 3 3 sleutel: * = aanwesig afwesig kontrolegroep by hierdie groep proefpersone het geen afwykings in die slukproses voorgekom nie. die kontrolepersone kon die vloeistof in hul mond hou en so ook die bolusvorm behou. voldoende tongpalatumkontak het voorgekom wat normale linguale peristalsis tot gevolg gehad het. geen vasklewing aan die harde verhemelte, voldoende anterior-posterior tongbeweging en beheerde bolus wat normale sluk veronderstel, het voorgekom. voorts was daar voldoende velere elevasie en 'n normaal ontlokte slukrefleks. met betrekking tot die faringale fase was daar geen vallekula stasis nie en voldoende tiro'ieden-laringale elevasie, sowel as voldoende laringale sluiting en krikofaringale koordinasie is deur hierdie kinders vertoon. laastens het geen stasis, in die piriforme sinusse voorgekom nie.." die totale tyd wat dit geneem het pm die bolus te sluk, was binne die perke van ongeveer twee sekondes wat in die literatuur as normale sluk geklassifiseer word (logemann, 1983; lear, et al. 1965). eksperimentele groep 1 eksperimentele groep 1 wat bestaan uit serebraal gestremde kinders tussen nege en dertien jaar wat reeds vir 'n paar jaar terapie ontvang het, het tvdens die oraal voorbereidende fase geen probleme vertoon nie. elkeen kon die vloeistof in hul monde hou en ook die bolusvorm behou. dit impliseer dat hierdie kinders voldoende mandibulabeweging en mobiliteit van die lippe het om lipsluiting te bewerkstellig. in die orale fase is elke probleem waargeneem. twee proefpersone (4 en 5), albei spastiese kwadruplee, het onvoldoende tongpalatumkontak vertoon. dit het tot gevolg gehad dat daar residu van die vloeistof op hul harde verhemelte agtergebly het. hierdie onvoldoende tongpalatumkontak kan moontlik wees as gevolg van onvoldoende tongelevasie. van riper en emerick (1984) noem dat die spastiese serebraal gestremde as gevolg van hipertonus dit moeilik vind om gelykmatige en gegradeerde bewegings uit te voer. die onvermoe om die bewegings gelykmatig en gegradeerd uit te voer, het ook betrekking op die spraakmeganisme. hierdie onvermoe kan moontlik ook van toepassing gemaak word op die beweging van die tong. die hipertonus be'invloed die kind se vermoe om die tong voldoende op te lig en dus tongpalatumkontak te bewerkstellig. verder het al die proefpersone normale linguale peristalsis en voldoende anterior-posterior tongbeweging getoon en geen vasklewing aan die harde verhemelte het voorgekom nie. 'n voldoende slukrefleks was ook teenwoordig. proefpersoon 4 het onvoldoende vel£re elevasie vertoon. vertraagde velere elevasie kan soms !n onvoldoende velofaringale sluiting tot gevolg he. alhoewel voedsel soms in die nasale holtes kan kom, was dit nie hier die geval nie. al die ander the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) videofluorografiese ondersoek van die slukproses by serebraal gestremde kinders 19 proefpersone het egter voldoende velere elevasie vertoon. in die faringale fase het proefpersone 2 en 3, ataktiese en atetotiese serebraal gestremde kinders onderskeidelik, stasis in die vallekula vertoon. alhoewel die slukrefleks betyds ontlok word en die bolus nie in die vallekula vassteek nie, kan daar residuele vloeistof agterbly in die vallekula nadat die sluk reeds afgehandel is. hierdie residu dui gewoonlik op 'n vermindering in krag van die faringale peristalsis. indien daar slegs in die een kant van die vallekula residu voorkom, dui dit 'n swakheid aan daardie kant aan (logemann, 1983). geen ander proefpersoon het vallekula stasis vertoon nie. voldoende tiro'ieden laringale elevasie asook voldoende laringale sluiting het voorgekom by al die proefpersone in eksperimentele groep 1. die totale tyd wat die proefpersone geneem het om die slukproses, vanaf die oraal voorbereidende na die orale en laastens die faringale fase te voltooi, was ook normaal, naamlik gemiddeld 2,4 sekondes (logemann, 1983). eksperimentele groep 2 hierdie groep hetoor die algemeen meer probleme vertoon as die proefpersone in eksperimentele groep 1. tydens die oraal voorbereidende fase het al die proefpersone daarin geslaag om die vloeistof in hul mond te hou. proefpersone 6, 7, 8 en 9, 'n ataktiese, atetotiese en twee spastiese serebraal gestremdes onderskeidelik, het egter 'n onvermoe vertoon om die bolus te behou. die vloeistof het deur die orale holte versprei en is nie in 'n klein massa bymekaar gehou nie. hierdie onvermoe kan moontlik aan verminderde en beperkte tongbewegings toegeskryf word. in die orale fase het proefpersone 6, 7, 8 en 10 onvoldoende tong-palatumkontak vertoon. soos beskryf by die resultate van groep 1, het daar gevolglik residu van die materiaal aan die proefpersone se harde verhemelte vasgekleef. onvoldoende tongpalatumkontak kan moontlik aan verminderde tongelevasievermoens toegeskryf word (logemann, 1983). ί proefpersone 6, 7 en 8 het abnormale linguale peristalsis vertoon. die versteurde linguale peristalsis is moontlik te wyte aan gedisorganiseerde anterior-posterior beweging van die tong. die onvermoe om die fjjner spraakstruktuurbewegings te bemeester, kan gedisorganiseerde tongbewegings tydens sluk teweegbring (macdonald 8ί chance, 1964). abnormale vasklewing van) die vloeistof aan die harde verhemelte is by proefpersone 6 , 7 , 8 en 10 opgemerk. residu van die vloeistof het aan die verhemelte vasgekleef nadat die sluk reeds afgehandel was. die bolus het verdeel en slegs 'n deel het beweeg na die farinks en die faringale fase van sluk. voldoende anterior-posterior tongbeweging bet die bolus na agter gevoer by al die proefpersone in hierdie groep. proefpersone 6, 7 , 8 en 9 het egter almal 'n onbeheerde bolus vertoon, deurdat 'n deel van die bolus verlore gegaan het as gevolg van onvoldoende tongkontrole. al die proefpersone het in die orale fase voldoende velere elevasie vertoon en die slukrefleks is normaal ontlok. in die faringale fase het proefpersoon 9, 'n spastiese kwadrupleeg, stasis in die vallekula vertoon. hierdie vallekula stasis het by geen ander proefpersoon voorgekom *nie. geen verdere probleem is in die faringale fase gevind by enige van die proefpersone nie. die totale tyd wat dit die proefpersone geneem het om die slukproses te voltooi, was gemiddeld 3,2 sekondes, 0,8 sekondes stadiger as die tyd geneem vir eksperimentele groep 1. hierdie tyd word egter nog nie as abnormaal beskou nie (logemann, 1983). bespreking van resultate die bespreking van die resultate sal gedoen word aan die hand van die doelwitte van die studie. die aard van die slukprobleem by die serebraal gestremde kinders \ uit die beskrywing van die resultate is dit duidelik dat daar wel slukprobleme by serebraal gestremde kinders voorkom. slegs eksperimentele groep 2 het probleme ondervind in die oraal-voorbereidende fase. sommige van die proefpersone het 'n onvermoe vertoon om die bolus te behou. hierdie onvermoe is gekenmerk deur die verspreidirfg van die bolus deur die orale holte. robbins (1985) noem dat afwykende lipfunksies en tongbewegings as gevolg van neuromotoriese aantasting kan resulteer in 'n onvermoe om die bolusvorm te behou in die willekeurige fase van sluk. die versteurde anterior, posterior, laterale en basale linguale bewegings kan ook lei tot spesifieke probleme. verminderde tongpuntsterkte of beperkte beweging van die tong, manifesteer in 'n stadige of oneffektiewe bolusformasie. logemann (1983) noem ook dat serebraal gestremdes wel 'n onvermoe kan vertoon om die bolusvorm te behou. die huidige studie bevestig dus hierdie standpunt. in die orale fase het onvoldoende tongpalatumkontak by ses van die proefpersone voorgekom en kan moontlik aan onvoldoende tongelevasie toegeskryf word (logemann, 1983). die onvoldoende tongbewegings kan ook voorkom as gevolg van die versteurde spiertonus (hiper-, hipoen fluktuerende tonus) wat kenmerkend van hierdie serebraal gestremde kinders is (van riper & emerick, 1984). die abnormale linguale peristalsis wat by drie van die proefpersone voorkom, kan moontlik verband hou met onvoldoende tongpalatumkontak as gevolg van die versteurde spiertonus. die gevolg van die afwykende linguale peristalsis is dan gedisorganiseerde tongbewegings. vasklewing van die vloeistof aan die harde verhemelte hou ook verband met onvoldoende tongbewegings. die tong se onvermoe orti die vloeistof posterior te beweeg, vind plaas as gevolg van hiper-en hipotonus (logemann, 1983). vier proefpersone, almal van eksperimentele groep 2, het 'n onbeheerde bolus gehad. die bolus het deur die mond versprei nadat die persone die vloeistof gesluk het. dit word toegeskryf aan hul onvermoe om tongbewegings te beheer en te koordineer. al die bogenoemde probleme wat in die orale fase voorgekom het, hou verband met mekaar. verminderde tongbewegings, afwykende krag van beweging of'n afwyking in die tydsberekening van die posterior tongelevasie sal resulteer in onbeheerde bewegings van dip bolus deur die orale holte na die farinks voordat die faringale respons gei'nisieer word. die verminderde omvang van posterior linguale beweging sal resulteer in vasklewing aan die harde verhemelte nadat die orale fase reeds afgehandel is (robbins, 1985). dit is egter belangrik om in gedagte te hou dat die orale strukture betrokke by die slukproses, onder andere die mandibula, lippe en tong, nie die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 karin le roux, anita van der merwe e n brenda louw onafhanklik van mekaar funksioneer nie. die slukproses is inderdaad die produk van interaksie tussen strukture. by spesifieke neurologiese afwykings kan unieke oromotoriese patrone resulteer, wat dan die slukproses en spraakproduksie aantas (robbins, 1985). ekedahl, mansson en sandberg (1974) noem dat serebraal gestremde kinders veral probleme ondervind in die orale fase. een van die proefpersone van eksperimentele groep 1 het probleme ondervind met velere elevasie. die vertraagde velere elevasie kan tot gevolg he dat daar onvoldoende velofaringale sluiting plaasvind en vloeistof na die nasale holtes toe kan beweeg. die spastisiteit wat deur van riper en emerick (1984) beskryf word as die gevolg van gelyktydige sametrekking van antagonistiese spiergroepe, kan moontlik die oorsaak wees van onvoldoende velere elevasie. in die faringale fase het drie proefpersone stasis in die vallekula vertoon. vallekula stasis kan moontlik die gevolg van onvoldoende beheer van die bolus wees. die vallekula stasis van hierdie kinders kan te wyte wees aan die konsistensie van die barium wat hul vir die eksperiment moes s l u k dit is 'n dik, stroopagtige vloeistof, wat hul poging om te sluk verder bemoeilik. kennedy en kent (1985) merk ook op dat sommige neurologies aangetaste persone meer probleme ondervind met die sluk van vloeistowwe as vaste stowwe. proefpersoon 1, 'n ataktiese serebraal gestremde kind, het in hierdie fase krikofaringale inkoordinasie getoon. die groep serebraal gestremdes vertoon hoofsaaklik 'n onvermoe om bewegings van die onderskeie spiergroepe te koordineer (hardy, 1983). hierdie bevinding bevestig die resultate van logemann (1983). die tydsduur van die genoemde fases was vir elke individu gemiddeld 2,4 sekondes wat binne die perke van die duur van normale sluk geklassifiseer word (logemann, 1983;-lear et al. 1965). die slukpatrone van die ataktiese, atetotiese en spastiese serebraal gestremdes geen duidelik identifiseerbare slukpatrone kom by die drie tipes serebraal gestremde proefpersone in groep 2 voor nie. tydens die oraal voorbereidende fase vertoon al drie tipes serebraal gestremde proefpersone 'n onvermoe om die bolus te behou. tydens die orale fase vertoon die verskillende tipes serebraal gestremde proefpersone ook ooreenstemmende foutpatrone. onvoldoende tongpalatumkontak, afwykings in linguale peristalsis, vasklewing van die bolus aan die harde verhemelte en 'n swak beheerde bolus kom gesamentlik by die meeste proefpersone voor. proefpersoon 4, wat spasties is, vertoon die minste probleme, naamlik slegs beperkte beheer van die bolus. die aftder spastiese proefpersoon het egter al die genoemde probleme gemeen met die ander tipes serebraal gestremdes. op grond van die beskikbare data wil dit dus voorkom asof individuele faktore soos waarskynlik die graad van aantasting, die slukpatrone van die jonger groep proefpersone bepaal eerder as die tipe serebrale gestremdheid. by groep 2, wat uit die ouer groep proefpersone bestaan, is daar twee interessante verskynsels wat na vore kom. slegs die spastiese groep vertoon residuele probleme in die orale fase en wel met betrekking tot tongpalatumkontak en velere elevasie. verhoogde spiertonus is waarskynlik die oorsaak vir die beperkte omvang van bewegings (darley, aronson & brown, 1975 : 80). die tweede verskynsel wat die data aan die lig bring, is dat slegs ataktiese en atetotiese proefpersone residuele probleme in die faringale fase vertoon. vallekula stasis of krikofaringale wankoordinasie word by drie van die proefpersone waargeneem. geen proefpersoon in die jonger groep het egter sodanige probleme vertoon nie. hierdie tipe probleme kan dus nie as kenmerkend van hierdie twee tipes serebrale gestremdheid beskryf word nie. dit is egter wel betekenisvol dat die ataktiese en atetotiese serebraal gestremdes as 'n groep na vore tree teenoor die spastiese groep aangesien die aard van die letsel by die eerste twee tipes geheel andersoortig en ook meer ooreenstemmend is as die letsel van die spastiese tipe. die serebellum en basale ganglia speel 'n rol by onder andere die koordinasie van beweging, terwyl die motorkorteks geen sodanige rol het nie (darley et al. 1975; eccles, 1977). dit wil dus voorkom asof die tipe serebrale gestremdheid wel 'n rol kan speel by die aard van residuele slukprobleme by ouer serebraal gestremde persone. 'n groter steekproef is egter nodig voordat enige gevolgtrekking in hierdie verband gemaak kan word. die invloed van behandeling en maturasie op slukpatrone uit die resultate is dit duidelik dat daar minder probleme in die slukproses van die groep ouer serebraal gestremde kinders voorkom as in die van die groep jonger kinders. dit kan waarskynlik toegeskryf word aan maturasie van die orale strukture en/of behandeling van die voedingsprobleme. dit is belangrik om te onthou dat as daar met normale ontwikkeling ingemeng word, daardie abnormale komponente distorsie en agterstande in die normale ontwikkelingsproses sal veroorsaak (morris, 1985). die abnormale posturale tonus, abnormale sensoriese integrasie en kompensatoriese bewegingspatrone wat serebraal gestremde kinders ervaar, het ook 'n negatiewe uitwerking op die ontwikkeling van oraal motoriese vaardighede. die ouer serebraal gestremde kinders het egter oor 'η 1 anger tydperk spraakterapie, fisioterapie en arbeidsterapie ontvang vir hul probleme. hierdie behandeling dra by tot stabiliteit en mobiliteit van die hele liggaam maar ook tot die beheer van die orale strukture. ( i die behandeling wat die kinders vir voedingsprobleme by (lie betrokke skool ontvang, is gebaseer op die bobath benadering. die spesifieke tegnieke wkt die terapeute toepas, blyk baie siiksesvol te wees as daar gelet word op die beperkte hoeveelheid probleme wat die groep ouer kinders in hul slukproses vertoon teenoor die van die groep jonger kinders. ^ die groep drietot sesjarige serebraal gestremdes het beduidend meer slukprobleme vertoon as die groep ouer proefpersone. die probleme wat hierdie kinders in die slukproses ondervind, het hoofsaaklik in die oraal voorbereidende en orale fase voorgekom. kenmerkend was dat die beperkte en verminderde tongbewegings vertoon deur hierdie proefpersone, die meeste van die probleme in die betrokke fases veroorsaak. robbins (1985) beskryf die tong as die prim6re bewegingsorgaan tydens die eerste twee fases van die slukproses, asook in spraakproduksie. die tong neem 'n verskeidenheid van posisies tydens spraak en ook die slukproses in. tydens die slukproses (hoofsaaklik die oraal-voorbereidende en orale fase) word daar 'n komplekse patroon van gegradeerde veranderinge in spieraktiwiteit uitgevoer, waartydens fyn kontrole en voldoende krag van die intrinsieke sowel as ekstrinsieke / the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) videofluorografiese ondersoek van die slukproses by serebraal gestremde kinders 21 spiere nodig is vir die volvoering van 'n normale slukproses (robbins, 1985). kennedy en kent (1985) verduidelik dat die daling van die larinks tot op die vlak van die vierde tot sewende servikale werwels ook 'n verlenging van die faringale holte veroorsaak. die volwassene se slukproses, vokalisering en asemhaling verskil dus baie van die van 'n baba. daar kan nie presies bepaal word of die verandering oor ouderdom, die gevolg van behandeling of maturasie is nie. beide hierdie faktore is aanwesig by al die proefpersone en verbetering is dus waarskynlik die gevolg van beide maturasie en behandeling. gevolgtrekkings op grond van die resultate van hierdie ondersoek kan die volgende gevolgtrekkings omtrent die proefpersone se slukprobleme gemaak word: dit is duidelik dat daar wel slukprobleme by serebraal gestremde kinders voorkom. die probleme het hoofsaaklik in die orale fase van die slukproses voorgekom. logemann (1983) se bevinding dat meer probleme in die orale fase opgemerk word, ondersteun die resultate van hierdie studie. die aantasting van die orale spiergroepe by die serebraal gestremdes verskil drasties van kind tot kind. hul kan byvoorbeeld 'n onvermoe vertoon om die bolus te behou; die bolus versprei dan deur die orale holte en gedisorganiseerde tongbewegings verhoed dat die kind op 'n normale wyse kan sluk. die totale tyd wat elk van die proefpersone geneem het om die oraal voorbereidende, orale en faringale fases van die slukproses te voltooi, was ongeveer 2,5 sekondes wat logemann (1983) nog as voldoende beskryf. die motoriese koordinasie probleme het dus nie 'n invloed op die duur van die sluk by enige van die twee eksperimentele groepe tot gevolg gehad nie. die jonger groep proefpersone vertoon ooreenstemmende , slukprobleme ongeag die tipe serebrale gestremdheid. by / die ouer groep was daar wel aanduidings dat die tipe serebrale gestremdheid 'n jrol kan speel by residuele slukprobleme. slegs spastiese -proefpersone vertoon probleme in die orale fase en sle'gs ataktiese en atetotiese proefpersone vertoon probleme in die faringale fase. die steekproefgrootte is egter te beperk om enige gevolgtrekkings in hierdie verband te maak. ι i die feit dat die jonger groep soveel meer probleme vertoon het, dui daarop dat die behandeling wat die groep ouer kinders ontvang het vir enige voedingsprobleme 'n invloed op die slukproses uitgeoefen het. moontlik speel maturasie ook 'n rol deurdat dit meer stabiliteit en mobiliteit aan hierdie proefpersone verskaf het in hul orale strukture om dan sonder enige probleme te kan sluk. ι die inligting wat tydens hierdie studie verkry is, het belangrike implikasies vir die evaluering en behandeling van die serebraal gestremde kind se voedingsprobleme. videofluorografie as 'n objektiewe meetinstrument is effektief gei'mplementeer om die aard van hierdie probleme bloot te 16. navorsing op hierdie gebied in suid-afrika 16 egter nog braak alhoewel waardevolle riglyne vir die toepassing verkry is. hierdie studie kan dus as vertrekpunt dien vir verdere navorsing. verwysings alexander, r. prespeech and feeding development. in ε. t. mcdonald (red. ) treating cerebral palsy. austin : pro-ed, 1987. brogan, w. f. , foulner, d. m. en turner, r. a videofluorographic investigation of the position of the tongue prior to palatal repair in babies with cleft lip and palate. cleft palate journal, 24, 336338, 1987. bzoch, k. r. communicative disorders related to cleft lip and palate. boston:little, brown & company, 1979. darley, f. l., aronson, a. e. en brown, j. r. motor speech disorders. philadelphia: w. b. saunders company, 1975. eccles,j.c. the understanding of the brain. new york: mcgraw-hill, 1977. ekedahl, c., mansson, i. en sandberg, n. swaljpwing dysfunction in the brain damaged with drooling. acta otolaryngology, 78, 141149, 1974. hardy, j. cerebral palsy. englewood cliffs: prentice-hall inc. , 1983. haubrich, w. in defense of the radiographic diagnosis of dysphagia. gastrointestinal endoscopy, 23, 214, 1977. kennedy, j. g. en kent, r. d. anatomy and physiology of deglutition and related functions. seminars in speech and language, 6, 257273, 1985. lear, c. s. c., flanagan, j. b. en moorrees, c. f. a. the frequency of deglutition in man. archives of oral biology, 10, 83-99, 1965. le roux, k. 'n ondersoek van die slukproses by serebraal gestremde kinders. ongepubliseerde b. log-verhandeling. universiteit van pretoria, 1988. logemann, j. evaluation and treatment of swallowing disorders. san diego: college-hill press, 1983. love, r. j. , hagerman, e. l. en tiami, e. g. speech performance, dysphagia and oral reflexes in cerebral palsy. journal of speech and hearing disorders, 45, 59-75, 1980. macdonald, ε. t. en chance, b. cerebral palsy. new jersey: prenticehall, 1964. morris, s. e. development implications for the management of feeding problems in neurologically impaired infants. seminars in speech and language, 6, 293-315, 1985. mueller, h. feeding. in n. r. finnie, handling the young cerebral palsied child at home, 2de uitgawe. london: william heinemann medical books, 1976. robbins, j. swallowing and speech production in the neurologically impaired adult. seminars in speech and language, 6, 337-359, 1985. smit, g. l. navorsingsmetodes in die gedragwetenskappe. pretoria: haum, 1983. steenkamp. m. persoonlike onderhoud. pretoria skool vir serebraal gestremdes, pretoria, 1988. steenkamp, m. nuwe ontwikkelings in die behandeling van serebrale gestremdheid. lesing gelewer by die universiteit van pretoria, 1989. van der walt, r. voedingsprobleme. kort kursus, pretoria, 1988. van riper, c. en emerick, l. speech correction: an introduction to speech pathology and audiology. new jersey: prentice hall, 1984. die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) do it yourself insertion gain instrument if you have a suitable ibm compatible computer and if you are familiar with it acoustimed can now offer you a "do it yourself' insertion gain instrument. we sell you a kit which you asemble yourself without any special tools. the equipment has all the features of the ha-2000 ii system but is in a less expensive housing and we save on installation costs. any support which you may need is given over the telephone or in our offices saving you thousands of rands on the world's most versatile hearing aid analyzer. features: complex test signals fast pure tone sweep speech weighted signals transients, bursts, continuous signals built in signal synthesizer real time analysis time delay spectometry "prescription" calculations are programmable auto-correlation for noise reduction signal averaging and spectrum averaging rms, peak and crest factor displayed linear response probe microphone data management with sophisticated data base program easy to use acodat programming language word processor with graphics facility mailing list programs invoicing programs calendar/scheduling program no other system offers all these features. write or call for a descriptive booklet. n b . this is a marketing experiment for which we have prepared two instruments. we reserve the right to request that you bring your computer to us for assembly, demonstration and instruction. acoustimed (ρτύ) ltd 3 2 7 bosman building cor. eloff and bree streets johannesburg tel: ( o i l ) 3 3 7 2 9 7 7 / the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) o u d i t i e w e a a n d a g by d i e voorskoolse kind elmarie niemand m . a . ( l o g . ) ( p r e t . ) departement spraakwetenskap, spraakheelkunde en oudiologie, universiteit van pretoria. opsomming daar is met hierdie navorsingsprojek gepoog om 'n duidelike beeld te vorm van ouditiewe aandagsprosessering by die voorskoolse kind. aangesien ouditiewe aandagsprosessering van groot belang is vir die kind wat skool toe gaan is daar op die groep wat in die daaropvolgende jaar skool toe gaan besluit. 'n groep van 64 kinders is geselekteer. daar is gebruik gemaak van 'n gegradeerde ouditiefgerigte ondersoekprogram wat s<5 saamgestel is dat dit wetenskaplik verantwoordbaar is. in sy geheel gesien dui die navorsingsresultate daarop dat die basiese ontwikkelingsproses van ouditiewe aandagsprosessering op hierdie ouderdom (5;2 tot 5;8) voltooi is. 'n verdere evaluering van dieresultate in terme van die uiteengesette doelstellings van die navorsingsprojek dui daarop dat kinders in hierdie ouderdomsgroep nog soms moeite ondervind om aan 'n ouditiewe sei binne omgewingslawaai aandag te skenk. bekende seine verhoog die vermoe om aandag te skenk. daar kon egter nie vir alle aannames wat in die literatuur gemaak word, bewys gevind word nie. summary the object of this research project is to establish a clear picture of the process of auditory attention of the pre-school child. the immense importance of the process of auditory attention for the school-age child guided the decision to use a group of children qualifying for school in the following year. a group of 64 children was selected. a scientifically acceptable graded auditory research programme was used. in general, the research results indicate that the basic development of the process of auditory attention has been completed at the age of 5;2 to 5;8. a further evaluation indicates that some children, however, still have difficulty in attending to an auditory stimulus in the presence of background noise. known stimuli tend to improve the ability to pay attention. all claims in the literature could not be accounted for. aandag is die aspek van ouditiewe persepsie wat waarskynlik met die totale proses van ouditiewe persepsie verband h o u . 1 3 'n studie in die , veld sal dus van waarde wees wanneer daar na oplossings gesoek word vir vraagstukke wat direk met ouditiewe persepsie en dus ook ouditiewe aandag in verband staan. die belang van aandag word ook deur lewis 1 9 beklemtoon deur sy beskouing dat aandag nie slegs verband hou met ouditiewe persepsie nie, maar dat die toetsing van aandagsvermoens ook van waarde kan wees by die identifikasie van kortikale betrokkenheid en patologie. wanneer daar gepoog word om ouditiewe aandag te definieer is dit moontlik om hedendaagse beskouings in een omvattende definisie te vervat vanwee die groot mate van oorvleueling wat voorkom. so 'n definisie kan soos volg lui: die funksie van aandag is om instelling van die organisme ten opsigte van die sein te verbeter aangesien dit lei tot die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 elmarie niemand aktiewe gemoeidheid met die sein. deur die proses van aandag word inligting verkry deur die inkomende stimuli te filtreer en dan te bepaal watter gedeelte van die inkomende stimuli die sentrale prosesseerder in beslag sal neem op 'n gegewe oomblik. relevante inligting word dus uit die omgewing geselekteer en geprosesseer. in die literatuur word ook begrippe gevind wat baie nou verwant is aan aandag en ook in baie gevalle aandag impliseer. hierdie begrippe is konsentrasie, waaksaamheid, seleksie, soektog, aktivering en instelling.9 dit is dus duidelik dat aandag nie stereotiep van aard is nie, maar dat dit 'n integrale deel van die persepsieproses is. dit lei tot die verwagting dat daar verskillende vorms van aandag sal wees. die verskillende vorms van aandag sluit primere aandag; sekondere aandag; tersiere aandag; aktiewe aandag; passiewe aandag; eksterne, interne, sensoriese en begripsvormende aandag; vernoude aandag; 1 2 selektiewe a a n d a g ; 2 0 fokusaandag5 en ewewigtige aandag in. wat veral hier van belang is, is dat die verskillende vorms van aandag, behalwe vir tersiere, passiewe en ewewigtige aandag, ook tot 'n mindere of meerdere mate oor 'n selektiewe eienskap beskik. hierdie verwantskap wat onderling bestaan, dui ook daarop dat daar waarskynlik spesifieke eienskappe gevind word wanneer die proses van aandag ontleed word. die eienskappe van aandag betrek kontrole, 1 4 die leerproses, 1 8 die inkomende sein, 2 1 die wakkertoestand,1 6 verskillende modaliteite,2 konsentrasie, persoonlikheid,1 2 die sekondere stimulus,2 2 persepsie en integrasie. hieruit kan die belang van aandag as deel van die totale persepsieproses afgelei word, 'n ander aspek wat van belang is, maar tot nog toe baie min aandag geniet het, is die ontwikkeling van aandag. die waarde van die beperkte inligting tot die leser se beskikking le daarin dat dit aandui dat die kind op 'n skoolgaande ouderdom oor 'n goed ontwikkelde ouditiewe prosesseringsisteem beskik. daar is verskillende benaderings tot die aspek van aandag waarvan die mees aanvaarbare waarskynlik die neuro-psigologiese benadering 2 3 is aangesien die rol van die sentrale sisteem ook in berekening gebring word. die doel van hierdie studie is om 'n beeld te vorm van ouditiewe aandagsprosessering soos gepresenteer deur die normale voorskoolse kind. eksperiment doelstellings 1. doelstellings met betrekking tot maskeringsvariante die eerste doel van die eksperiment is om te bepaal of kinders, net voordat hulle skool toe gaan, wel aandag kan skenk aan 'n ouditiewe sein in die teenwoordigheid van omgewingslawaai. 'n tweede doel is om te bepaal of maskering by die normale kind tot gevolg sal he dat daar 'n verskerping in aandag sal wees. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ouditiewe aandag 21 'η derde doel is daarop gemik om vas te stel of daar 'n betekenisvolle verskil tussen maskering deur middel van wyebandgeraas (pienkruis) en maskering deur middel van 'n roesemoes van stemme bestaan. dit sal dus van akademiese waarde wees om hierdie aspek by die navorsing in te sluit. 2. doelstellings met betrekking tot die sein die eerste doel is om vas te stel of 'n meer betekenisvolle sein, byvoorbeeld 'n klokkie of 'n trom, makliker aandag ontlok en behou as 'n nie-betekenisvolle sein, byvoorbeeld 'n suiwertoon (500 hz of 4 000 hz). 'n tweede doel is om te bepaal of daar 'n verskil gemaak word tussen klankseine en spraakseine wat betref die mate waarin daar aandag daaraan geskenk word. 'n derde doel het te doen met 'n belangrike aspek, naamlik bekendheid wat deur yusson et a l 2 4 beklemtoon word. binne dieselfde subtoets word gebruik gemaak van 'n bekende sein (trom) teenoor 'n onbekende sein (suiwertoon: 500 hz). 3. doelstellings met betrekking tot intensiteit die doel hier is om te bepaal of dit wel so is dat harder klanke of te wel seine met 'n hoer intensiteit makliker aandag trek as klanke wat net op die gehoordrempel val. 4. doelstellings met betrekking tot die intensiteitsverhouding tussen die maskering en die sein die doel van die eksperiment sal ook wees om te bepaal of daar beduidende verskille voorkom by die vermoe om aandag te skenk indien die maskeringslawaai harder as die sein is, gelyk aan die sein is, of sagter as die sein is. 5. doelstellings met betrekking tot die kompleksiteit van die toetsmateriaal die doel hier sal wees om te bepaal of kompleksiteit van die toetsmateriaal 'n invloed uitoefen op die ouditiewe aandagsvermoe van die jong kind. volgens johnson en toppino8 en jordaan et al 9 bestaan daar by die jong kind die neiging om voorkeur te gee aan minder komplekse seine. die eksperiment sal dus gegradeer word. daar sal aanvanklik slegs van die proefpersoon verwag word om aandag te skenk aan 'n klanksein en 'n spraaksein te midde van maskering. daarna word die opdrag meer kompleks deurdat visuele komponente (voorwerpe en prente) ook gei'nkorporeer word en die ouditiewe sein by die visuele sein gepas moet word. hierna word die opdrag verder gekompliseer deurdat van die proefpersoon verwag word om die spraaksein te identifiseer en te reproduseer. die laaste opdrag vereis prosessering van die boodskap asook 'n motoriese handeling na aanleiding van die geprosesseerde boodskap. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 elmarie niemand ή. d o e l s t e l l i n g s met betrekking t o t geslag 'n verdere doel van die eksperiment sal wees om te bepaal of daar enige verskille bestaan tussen seuns en dogters van die ouderdom 5;2 tot 5;8 wat betref ouditiewe aandagsvermoe. 7. doelstellings met betrekking tot gedragspatrone die doel hier is om gedragspatrone waar te neem wat kan dien om die resultate verder toe te lig. aspekte wat hier in ag geneem word is verveling, 'n algemene onvermoe om sekere toetsitems te bemeester, die nodigheid om bo en behalwe die aanvanklike opdrag ook tussenin met die proefpersoon te kommunikeer om motivering te versterk en reaksietyd. proefpersone kriteria vir die seleksie van proefpersone seleksie het volgens die volgende kriteria geskied: om 'n verteenwoordigende beeld van die ouditiewe aandagsvermoens van die proefpersone te verkry, was dit nodig dat seleksie so sal geskied, dat elke area van die stadsgebied van pretoria verteenwoordiging sal geniet. daar is in oorleg met 'n statistikus besluit om 100 proefpersone te selekteer. die ondersoek word so gerig dat die vermoe om aandag te skenk direk gekoppel word aan die klaskamersituasie. die proefpersone is dus so geselekteer dat dit die groep wat die daaropvolgende jaar toegelaat word tot graad i, betrek. hierdie groep is ook verder geskik vir seleksie aangesien daar aangeneem kan word dat die proses van ouditiewe aandagsprosessering reeds op hierdie ouderdom (5;2 tot 5; 8) ten voile ontwikkel i s . 1 7 die moontlikheid van 'n psigo-neurologiese disfunksie moes uitgegeskakel word aangesien ondervinding in die praktyk geleer het dat kinders wat as sodanig geklassifiseer word, meesal leerprobleme presenteer en ook aandagsprobleme ondervind. so 'n proefpersoon sal dus nie geskik wees vir die studie nie. die proefpersone moet ook oor 'n normale intelligensie beskik aangesien dit nie bekend is in hoe 'n mate 'n subnormale intelligensie die aandagsvermoe van die kind sal bei'nvloed nie. die selfhandhawing van die proefpersoon is ook van belang aangesien 'n infantiele emosionele toestand die eksperimentele prosedure nadelig sal bei'nvloed. , ζ 7 die mediese geskiedenis van die proefpersoon moet ook in ag geneem word aangesien aspekte soos epilepsie,6 medikasie,1 gedurige oorinfeksies en mangelinfeksies 'n belangrike rol speel in die afname van die aandagsvermoe. dit is ook belangrik dat die proefpersone oor 'n normale gehoorvermoe beskik aangesien die eksperiment ouditief aangebied word. aangesien die verskille, indien enige, tussen seuns en dogters met betrekking tot ouditiewe aandag bepaal moet word, moet die seleksie the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ouditiewe aandag 23 van proefpersone sodanig wees dat albei geslagte verteenwoordig word. aangesien die literatuur nie besliste onderskeid maak met betrekking tot geslag nie, is seuns en dogters op 'n toevallige basis geselekteer. die seleksie van proefpersone die proefpersone is geselekteer uit verskeie kleuterskole binne die stadsarea van pretoria. daar is op kleuterskole besluit vir die volgende redes: — proefpersone is makliker bekombaar; — 'n meer betroubare beeld met betrekking tot, byvoorbeeld, intelligensie, sosiale aanpasbaarheid, ensovoorts, kan verkry word deur middel van vraelyste wat onderskeidelik deur die ouers en die onderwyseres voltooi moes word; — 'n verteenwoordigende monster van die populasie van pretoria word so verseker. om te verseker dat die hele stadsgebied van pretoria ingesluit word, is die stad in 5 blokke verdeel waaruit 2 kleuterskole elk geselekteer is. daar is bepaal dat die groep wat in die daaropvolgende jaar (1980, in die geval van die navorsing) skool toe sou gaan tussen die ouderdomme 5;2 tot 5;8 val. alle kinders by die 10 kleuterskole in hierdie ouderdomsgroep is aanvanklik in die navorsing ingesluit as potensiele proefpersone. om 'n oorsigtelike beeld van die kind se algemene ontwikkeling, intelligensie, emosionele ryping, gedrag, aandagsvermoe en mediese geskiedenis te verkry, is afsonderlike vraelyste aan beide die kleuterskoolonderwyseres en ouers vir voltooiing gegee. hierdie vraelyste moes dien om proefpersone wat nie vir hierdie studie geskik is nie, te identifiseer, byvoorbeeld 'n geskiedenis van leerprobleme in die familie. die vraelyste is ook so opgestel dat belangrike aspekte, soos byvoorbeeld intelligensie op beide vraelyste voorkom sodat daar ook 'n mate van kontrole tussen die twee vraelyste is. nadat die gegewens verkry uit die vraelyste gekontroleer is, is moontlike proefpersone geselekteer. hierdie proefpersone is onderwerp aan identifikasie-oudiometrie11 om te bepaal of hulle oor normale gehoor beskik. hierdie siftingstoetse is by die kleuterskole uitgevoer waar die lokaal so gekies is dat omgewingslawaai sodanig beperk is dat 'n normaalhorende persoon die toetstoon wel by 20 db hoor. 7 alle kinders wat ook oor 'n normale gehoor beskik is hierna ingesluit as proefpersone in die eksperiment. daar is uiteindelik van 64 proefpersone gebruik gemaak; 32 seuns en 32 dogters. materiaal en apparaat hier kan 'n tweeledige verdeling gemaak word, naamlik eerstens, die apparaat en materiaal wat van toepassing was by die seleksie van die die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 elmarie niemand proefpersone en tweedens, apparaat en materiaal wat betrekking het op die eksperiment self. 1. materiaal en apparaat vir die seleksie van proefpersone vraelyste twee vraelyste is saamgestel: een vir voltooiing deur die ouers en 'n tweede vir voltooiing deur die onderwyseresse. gehoorsifting hier is gebruik gemaak van 'n draagbare madsen-oudiometer, model ob 40 (iso, 1964). 2. materiaal en apparaat vir die uitvoer van die eksperiment maskering by die keuse van maskering is dit nodig om die aspek van integrasie in gedagte te hou. dit word as belangrik beskou aangesien die parameters van die sein bei'nvloed kan word en dus 'n verkeerdelike of onewe beeld kan gee. daar is besluit op pienkruis omdat dit 'n bree spektrum het en op 'n roesemoes van stemme aangesien dit baie nou verband hou met die omgewingslawaai wat in die klaskamersituasie gevind word. toetsmateriaal die toets is in 5 subtoetse verdeel. in die eerste 4 subtoetse is gebruik gemaak van klank of spraakseine wat kontrasteer deurdat dit hoofsaaklik hoe of lae frekwensies betrek. die 5e subtoets behels verbale opdragte. • * samestelling van die toetsmateriaal en maskering dit is met die hulp van die wetenskaplike navorsing en nywerheidse raad (wnnr) (departement akoestiek) saamgestel. die maskering en die stimulussein is so vermeng dat die sein en die maskering eerstens gelyk is aan mekaar, daarna is die sein 10 db sagter as die maskering en in die laaste instansie, 10 db hoer as die maskering. elke subtoets is 12 keer herhaal. tabel i: 'n voorstelling van die vermenging van die stimulussein en die maskering / 40 db bo die gehoordrempel op die gehoordrempel pienkruis stemme pienkruis stemme sein in db 1 0 2 0 0 i o 2 0 ;o 1 0 2 0 0 1 0 2 0 0 maskering in klankdrukpeil 1 0 1 0 1 0 1 1 0 1 0 1 0 1 1 0 1 0 1 0 1 0 1 0 1 0 the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ouditiewe aandag 25 die rede vir die herhaling van die pienkruis en die stemme is dat die eksperiment eers 40 db bo die gehoordrempel (60 db) uitgevoer word, en daarna op die gehoordrempel (20 db — na aanleiding van die gehoorsifting) om te bepaal of 'n verhoogde intensiteit aandagsvermoe verbeter. die tydsintervalle tussen elke toetsitem is vooraf ewekansig geselekteer en tydens die opname by die wnnr met behulp van 'n stophorlosie gekontroleer. daar is ook 'n kalibrasiesein op die band aangebring sodat dit gekoppel kan word aan 'n oudiometer en die nodige verstellings (van 60 db na 20 db) met behulp van die oudiometer gedoen kan word. apparaat die apparaat wat uiteindelik in die eksperiment gebruik is, is 'n nagra iv-bandmasjien, 'n oopspoelband waarop die toetsmateriaal is, 'n maico ma 24-oudiometer (iso, 1964), oorfone en twee aangrensende klankdigte lokale. die bandmasjien is aan die oudiometer gekoppel en sodoende kon die toets binouraal en streng gekontroleerd aangebied word. addisionele apparaat is gebruik tydens subtoets 3 waar die proefpersoon die voorwerp of prent moes uitwys. vir die doel is 'n trom, 'n klokkie en prente van 'n wiel en 'n bad op 'n tafeltjie voor die proefpersoon geplaas. die volgorde waarin die items geplaas is, was sodanig dat dit nie dieselfde volgorde is waarin die sein aangebied word nie. daar is deurgaans gepoog om in soverre dif moontlik was die eksperiment so saam te stel dat dit verantwoordbaar was in terme van wetenskaplike akkuraatheid. eksperimentele prosedure die nagra-bandmasjien is aan die oudiometer gekoppel. die oudiometer is met behulp van die kalibrasiesein op die band gekalibreer (vu-meterlesing = 0) sodat lesings op die oudiometer werklike lesings sou wees. elke subtoets is deur die opdrag, wat deur die toetsafnemer direk gegee is, voorafgegaan. daarna is die subkategorie as 'n geheel eers teen 60 db en dan teen 20 db aangebied. daar is besluit dat die eksperiment binouraal aangebied gaan word aangesien dit die alledaagse situasie beter verteenwoordig as 'n monourale sein. dit sluit ook die aspek van lateraliteit uit, met ander woorde, dat in die geval van 'n digotiese luistertaak, die boodskap in die regteroor meer akkuraat weergegee w o r d . 1 5 proefpersone is indiwidueel gesien. die toets is aaneenlopend aangebied en geen pouse is gemaak tussen subtoetse nie. uitputting is voorkom deurdat opdragte voor elke subtoets gegee is en sodoende word die toets onderbreek. tydsintervalle tussen die items van die subtoetse word gevarieer om te verseker dat daar nie 'n reaksiepatroon vasgele word nie, byvoorbeeld sein (3 sek.) sein (3 sek.) sein. 'n aspek die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 elmarie niemand o p ge ho or dr em pe l | st em m e (2 0 db ) | ca •a ο 27 24 24 29 26 26 25 30 31 31 30 32 29 31 29 32 26 27 29 27 31 30 30 29 26 30 29 31 31 31 30 32 32 32 32 32 32 32 30 31 o p ge ho or dr em pe l | st em m e (2 0 db ) | 10 d b 3 * 8 oo oo in cn 25 26 26 31 16 20 23 24 20 25 19 24 9 13 19 24 ι s ι | 00 (s | 5 3 16 18 21 25 23 21 o p ge ho or dr em pe l | st em m e (2 0 db ) | 20 d b 22 20 27 28 18 22 22 29 f) f) f) ο ο on 00 m m (ν (ν 24 27 24 28 32 31 30 28 7 16 20 21 20 22 26 30 30 31 32 32 32 31 31 30 o p ge ho or dr em pe l | pi en kr ui s (2 0 db ) 30 d b 00 9\ © ο rs η λ η σ\ oo ο\ md cs cs cs (ν 30 32 30 32 31 31 29 32 24 26 32 30 32 30 30 30 28 30 27 28 32 31 26 30 32 32 32 32 32 32 31 31 o p ge ho or dr em pe l | pi en kr ui s (2 0 db ) 10 d b η η « η — η η ο in ν cs ( ν 27 30 22 23 28 29 22 27 . 19 24 11 13 20 20 21 23 w 00 ό τ2 | ^ 19 21 21 21 14 20 23 28 o p ge ho or dr em pe l | pi en kr ui s (2 0 db ) 20 d b 22 20 28 29 26 27 28 29 31 31 30 32 30 32 32 32 ί 1 0 10 25 27 31 32 29 32 17 21 22 20 27 26 17 21 31 31 32 31 27 31 31 32 40 d b b o ge ho or dr em pe l st em m e (6 0 db ) 7 0 db 22 27 28 28 24 30 27 27 29 32 31 32 31 32 29 32 21 24 29 31 31 32 29 31 17 19 27 27 30 30 27 29 31 32 32 32 31 31 31 32 40 d b b o ge ho or dr em pe l st em m e (6 0 db ) 50 d b a ' λ r ο φ η ο cn (ν 29 28 28 30 16 24 27 30 24 28 21 22 15 16 23 24 π ι i ι ν β ι ι r 40 d b b o ge ho or dr em pe l st em m e (6 0 db ) 60 d b * ΐ ττ γ ts η η μ γ4 ν «) γι μ ν ν 28 32 30 32 30 32 31 32 22 26 25 29 24 30 26 28 5 7 27 26 30 28 11 16 20 25 32 32 27 20 30 32 40 d b b o ge ho or dr em pe l pi en kr ui s (6 0 db ) 70 d b 30 29 26 30 27 29 29 28 31 32 31 32 31 31 30 32 tβ on 00 γ ι ν μ «η ο γ-υ-ι cs ĉ cs (ν 20 25 27 25 30 30 26 28 31 32 32 32 25 18 29 32 40 d b b o ge ho or dr em pe l pi en kr ui s (6 0 db ) 50 d b 18 15 14 9 18 15 21 21 so ο ψ* 00 η η η *ν α ο co ο ν η μ μ 17 16 7 10 14 12 18 19 η β m η » β | v) v) νο tĉ 00 ·<3· 40 d b b o ge ho or dr em pe l pi en kr ui s (6 0 db ) 60 d b 19 21 26 23 18 19 26 24 32 32 30 32 29 30 30 31 17 24 28 28 25 27 20 21 13 18 19 21 19 14 8 9 13 17 11 15 6 7 28 31 40 d b b o ge ho or dr em pe l m as k. se in η η η ^ η ν m ^ η ν ρί ^ οι π ^ / / η μ rt ^ se un s = 32 d og te rs = 3 2 t ot aa l = 64 su bt oe ts 1 su bt oe ts 2 su bt oe ts 3 su bt oe ts 4 su bt oe ts 5 the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ouditiewe aandag 27 wat nie gekontroleer is nie, is die feit dat toetsiterns altyd in dieselfde volgorde aangebied is en die moontlikheid van leer nie uitgeskakel word nie. daar is in 'n klankdigte kamer gewerk en aangesien dit vir 'n kind bedreigend kan wees, is 'n ouer toegelaat om by die proefpersoon te sit tydens die eksperiment. die ouers is so geplaas dat hy/sy buite die gesigsveld van die proefpersoon was om te voorkom dat die proefpersoon se aandag afgetrek word. alvorens die toetsafnemer na die aangrensende klankdigte kamer gegaan het, is die prosedure van die eksperiment aan die proefpersoon verduidelik. daar is ook aan die proefpersoon gevra om die voorwerpe en prente op die tafel te identifiseer om te verseker dat die proefpersoon daarmee vertroud is. hierdie voorbereidende prosedure is as belangrik beskou aangesien daar goeie rapport met die kind opgebou moes word. daar moes ook verseker word dat die proefpersoon die prosedure van die eksperiment goed verstaan. soos reeds genoem is die opdragte vir die verskillende subtoetse direk gegee en is dit nie op die band geplaas nie. dit was om die toetsafnemer die geleentheid te gee om kontak met die proefpersoon te behou. dit is belangrik aangesien daar van voorskoolse kinders gebruik gemaak is. 'n toetsvorm is opgestel en die reaksies van die proefpersone is as korrek ( v ) of foutief (x) aangedui. hierdie gegewens is in tabel ii weergegee. .resultate die ontleding van die resultate is gedoen met behulp van die tegniek van regressie-analise met skynveranderlikes. 'n samevattende beeld van die resultate word in tabel iii weergegee. uit hierdie resultate kan die volgende afgelei word: aspekte wat ouditiewe aandagsprosessering nie beinvloed nie daar is slegs 3 aspekte wat deurgaans geen verandering in die respons van die proefpersone meebring nie. hierdie aspekte is: — die aanbieding van die toetsmateriaal op die gehoordrempel; — die wisselwerking tussen die sein en maskering waar die sein en die maskering gelyk is aan mekaar; — geslag. aspekte wat die vermoe om aandag te skenk laat afneem hier is 6 aspekte betrokke. die afleiding kan dus gemaak word dat daar tog op hierdie ouderdom (5;2 tot 5;8) aspekte is wat ouditiewe aandagsprosessering bemoeilik. hierdie aspekte is: — die seine wat hoofsaaklik lae frekwensies betrek; — 'n hoe frekwensiesein, asook die opdrag "vryf jou neus"; die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 elmarie niemand i > ο .a u •ό μ u 2 3 i/i u un υ ή c λ > λ u εβ β c λ > ω ω χι υ τ3 c ω 13 > υ ε λ <*> -j ω α •c « •ό cq ό ο co ό co ό co ό 8 α ο ο. ο η χ s)30)qn$ « γ7γ μ 23 ζ sjsojqns υ a ° g s f £ sjaojqns §• g a 1 3 .1 § ζ ·° i * 8 a s >. ω p ο j< s3 > > ρ s)30)qns ς sjaojqns the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ouditiewe aandag 29 — wanneer die toetsitems en maskering 40 db bo die gehoordrempel (wat vir die studie as 20 db aangeneem is) aangebied word en die proefpersoon die toetsitem moet herhaal of 'n motoriese opdrag moet uitvoer na aanleiding van die sein; — pienkruis as maskering wanneer klankseine sowel as spraakseine gebruik word; hierdie invloed word verder vergroot indien dit in wisselwerking met 'n sein teen +10 db ten opsigte van die maskering is; — stemme as maskering waar slegs van klankseine gebruik gemaak word; — 'n wisselwerking tussen stemme as maskering en die sein teen 1 0 db ten opsigte van die maskering by klankseine sowel as verbale opdragte; — die aanbieding van die sein teen 1 0 db ten opsigte van die maskering. aspekte wat die vermoe om aandag te skenk laat toeneem die aspekte wat hier aangedui word, is soos volg: — die aanbieding van die sein teen +10 db ten opsigte van maskering in die subtoetse waar die sein herhaal moes word en waar 'n motoriese handeling uitgevoer moes word na aanleiding van die sein; joj as sein by die verbale herhaling waarskynlik omdat dit die enigste betekenisvolle klank is. met hierdie resultate beskikbaar kan die oorspronklike doelstellings in oenskou geneem word en die resultate kan daarop van toepassing gemaak word. bespreking van die resultate aan die hand van die doelstellings die invloed van maskering dit wil uit die resultate voorkom asof maskering wel aandag be'invloed en dit skyn asof kinders van die ouderdom 5;2 tot 5;8 nog nie in alle gevalle kan aandag skenk in die teenwoordigheid van omgewingslawaai nie. wanneer van klankseine as stimulus gebruik gemaak word be'invloed stemme as maskering die response sodanig dat 'n betekenisvolle afname in korrekte response waargeneem is. sodra daar ook 'n visuele sein bygevoeg word en die stimulussein beide uit klanke en spraak bestaan, verlaag pienkruis die aantal korrekte response betekenisvol. hier is ook gevind dat maskering in wisselwerking met die aanbieding van die sein teen 1 0 db en +10 db ten opsigte van die maskering die aantal korrekte response betekenisvol laat afneem. hier is dus heelwat teenstrydighede. die afleiding wat gemaak kan word, is dat omgewingslawaai wel op hierdie ouderdom (5;2 tot 5;8) nog 'n invloed uitoefen. daar is egter heelwat gevalle waar dit nie betekenisvolle invloed uitoefen nie. indien northern en d o w n s 1 7 se aanname dat die ouditiewe sisteem se ontwikkeling op 4;0 voltooi is, die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) elmarie niemand 30 l ria 1 0 simon 2 1 en andere, se aannames dat daar 'n verdere'verfymng'van die ontwikkeling plaasvind ook aanvaar kan d sou eese kon word dat die vermoe om aandag te skenk binne η omeewingslawaai waarskynlik deel van die verfyningsproses is, aangesien die groep kinders wat gebruik is in die ouderdomsgroep 5;2 tot 5;8 val. daar kon nie enige bewys gevind word in die geval van hierdie o u d e r d o m s g r o e p (5;2 tot 5; 8), vir die bewering van jordaan et al 9 dat maskering aandag verskerp nie. geen verskil kon gevind word tussen die gebruik van pienkruis en stemme as maskering nie. die invloed van die sein daar kon geen bewys gevind word dat meer betekenisvolle seine, byvoorbeeld 'n klokkie of 'n trom teenoor suiwertone, 'n beter respons tot gevolg het nie. dit wil dus voorkom asof betekenis nie meer op hierdie ouderdom (5;2 tot 5;8) vir die herkenning van seine belangrik is nie. dit blyk ook dat daar nie onderskeid gemaak word tussen klank en spraakseine nie. frekwensie speel wel in 'n mate 'n rol aangesien daar swakker respons verkry is op lae frekwensieseine as in die geval van hoe frekwensieseine. die bekendheid met die stimulus is 'n aspek wat wel die vermoe om aandag te skenk be'invloed. die feit dat subtoets 2 so min inligting verskaf, word toegeskryf aan die aspek van bekendheid. daar word slegs van die proefpersone verwag om 'n vrouestem ten opsigte van maskering te herken, en daarop te reageer. hulle word daagliks aan 'n vrouestem (kleuterskoolonderwyseres) blootgestel en dit is dus baie bekend aan hulle. in subtoets 3 vaar die proefpersone betekenisvol swakker waar die woord ml/ as stimulus gebruik word teenoor die woord /bat/. in die alledaagse lewe is die proefpersone waarskynlik meer blootgestel aan die woord /bat/ as die woord /vil/, aangesien die woord /bat/ 'n huishoudelike woord is. in subtoets 4 is daar 'n betekenisvolle verbetering in die aantal korrekte response by die aanbieding van die spraakklank /o/. daar word in die kleuterskole gebruik gemaak van die geluide wat diere maak en av is die klank wat aan 'n vark verbind word. dit is waarskynlik waarom die proefpersone so goed daarop reageer. 'n verdere aspek wat daarop dui dat bekendheid met die stimulus belangrik is, is die feit dat alle opdragte in subtoets 5 behalwe die opdrag "vryf jou neus" waarskynlik' bekend is aan die proefpersone. hulle vaar daii ook betekenisvol swakker wanneer die opdrag "vryf jou neus" aangebied word. die invloed van die intensiteit van die aanbieding daar word gevind dat daar 'n betekenisvolle afname in respons voorkom by subtoetse 4 en 5, waar net van spraakseine gebruik gemaak is, wanneer hierdie seine teen 60 db aangebied word. dit is belangrik om in gedagte te hou dat die maskering ook teen 60 db the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ouditiewe aandag 31 aangebied is, en dus die reaksie van die proefpersone mag be'invloed. daar is egter geen bewys gevind vir die stelling van jordaan et al9 dat seine met 'n hoer intensiteit makliker aandag trek as seine wat op die gehoordrempel val nie. die invloed van die intensiteitsverhouding tussen die maskering en die sein hier blyk dit deurgaans dat indien die stimulussein 10 db swakker as die maskering is, daar 'n betekenisvolle afname in die aantal korrekte response van die proefpersone is. 'n verdere aspek wat 'n afname teweegbring is die wisselwerking tussen die aanbieding van die sein teen 1 0 db ten opsigte van die maskering en die gebruik van 'n roesemoes van stemme as maskering. sodra die sein 10 db bo die maskering aangebied word, is daar 'n betekenisvolle verbetering in die aantal korrekte response van die proefpersone en wel met betrekking tot spraakseine. hierdie resultate moet in ag geneem word wanneer kinders wat in hierdie ouderdomsgroep (5;2 tot 5;8) val, blootgestel word aan konvensionele sein-tot-ruistoetse. dit behoort interessant te wees om die resultate van sulke toetse te vergelyk met die resultate van hierdie studie. die invloed van die kompleksiteit van die toetsmateriaal daar kon geen bewys gevind word vir die feit dat meer komplekse seine aandagsvermoens be'invloed nie. by die bespreking van die opstel van die eksperimentele materiaal is genoem dat daar gegradeer is wat betref die moeilikheidswaarde van die toetsmateriaal. indien kompleksiteit wel 'n rol speel sou die verwagting dus wees dat die aantal korrekte response moet afneem namate die toets vorder. dit het egter nie gebeur nie en vandaar die afleiding dat dit geen invloed uitoefen nie. die moontlikheid dat die moeilikheidswaarde nie genoegsaam gegradeer is nie, kan nie uitgeskakel word nie. die rol van geslag hier kon deurgaans geen verskille gevind word nie en dit blyk dus dat dit geen invloed uitoefen op aandagsvermoens van die kind op die ouderdom 5;2 tot 5;8 nie. die waarneming van gedragspatrone wat die resultate mag be'invloed hierdie waarnemings is tydens toetsing gedoen en 'n aantekening is gemaak wanneer enige gedragspatroon voorgekom het wat die toetsresultate mag be'invloed. daar is slegs in twee gevalle verveling opgemerk. die proefpersone het verder deurgaans stil gesit en aandagtig geluister na die opdrag en daarna na die stimuli. daar is gepoog om die duur van die toets te beperk om verveling uit te skakel. dit blyk geslaagd te wees. geeneen van die gekose toetsitems was te gekompliseerd nie en die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 elmarie niemand opdragte is ook dadelik begryp. die moeilikheidswaarde blyk dus ook nie 'n faktor te wees wat die resultate kon bei'nvloed nie. dit was met die jonger groep (5;2) soms nodig om met die oorskakeling van die aanbieding teen 60 db na 20 db 'n bietjie aanmoediging te gee in die vorm van verbale beloning. dit was veral tussen die aanbiedings van toetse 4 en 5 nodig. dit was egter nie deurgaans gedoen nie en slegs wanneer dit wou voorkom asof daar 'n algemene afname in motivering was. geeneen van die proefpersone het moeite ondervind om te reageer binne die tydperke wat daargestel was nie. die tydperk gelaat tussen die verskillende items van die subtoetse was dus heeltemal voldoende. gevolgtrekkings uit die literatuur het dit geblyk dat die aspek van ouditiewe aandagsvermoens op die ouderdom van 4;0 sodanig ontwikkel is, dat daar slegs verdere verfyning van die bestaande prosesse voorkom tussen die ouderdomme 5;0 tot 1 4 ; 0 . 1 7 ' 1 9 wanneer die resultate verkry uit die eksperiment van hierdie studie aan die stelling gemeet word kan die stelling aanvaar word, mits die invloed wat maskering op aandag uitoefen beskou word as 'n verdere verfyning van die proses. daar is egter nie deurgaans gevind dat maskering in alle gevalle die vermoe om aandag te skenk nadelig be'invloed nie aangesien sommige proefpersone wel goed gereageer het ten spyte van die maskering. daarom word 'n verdere afleiding gemaak dat, indien dit 'n verfyningsproses is, nie alle kinders op skoolgaande ouderdom hierdeur be'invloed sal word nie. hierdie is dan ook waarskynlik 'n aspek wat aandag moet geniet wanneer besluite aangaande skoolrypheid geneem moet word. daar sal bepaal moet word of die kind wel kan aandag skenk binne 'n omgewingslawaai aangesien dit 'n belangrike element is vanwee die hoe peil van omgewingslawaai in die klaskamer van veral die jonger groepe (gr i en gr i i ) . 1 9 op die ouderdom 5;2 tot 5;8 is die kind ook nog baie aangewys op die bekendheid van die materiaal waarna geluister word. hierdie vermoe om aandag te skenk aan relatief minder bekende seine is dus waarskynlik ook deel van die verfyningsproses. dit is weer eens 'n aspek waarna opgelet moet word wanneer besin word oor die feit dat die kind skoolgereed is, al dan nie, aangesien daar 'n groot blootstelling aan onbekende stimuli binne die klaskamersituasie is. 'n aspek wat deurgaans aandagsvermoens nadelig be'invloed het, was wanneer die sein 10 db swakker as die maskering was. dit is 'n belangrike waarneming met betrekking tot voorligting aan die onderwyser(es) van die jonger groep in die1, skool (gr i). daar sal beslis deurgaans probleme ondervind word deur die kinders om aandag te skenk aan 'n stimulus te midde van omgewingslawaai en dit moet in gedagte gehou word tydens onderrig of aanbieding van veral onbekende of nuwe materiaal. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ouditiewe aandag 33 hierdie gegewens is ook belangrik vir die oudioloog aangesien dit die response op sein-tot-ruistoetse definitief sal be'invloed. response op so 'n toets kan dus nie as betroubaar beskou word nie. opsommend kan dus gese word dat die ontwikkelingsproses van ouditiewe aandag by die groep 5;2 tot 5;8 voldoende is om aan die eise wat binne die formele onderrigsituasie gestel word, te voldoen. wanneer daar dus 'n leerprobleem opgemerk word, sal dit ook belangrik wees om ondersoek in te stel na die ontwikkeling van ouditiewe aandagsvermoens. ouditiewe aandagsprosessering verdien 'n regmatige plek in navorsingstudies en behoort ook as 'n belangrike aspek gereken te word wanneer die jong kind 'n probleem, byvoorbeeld 'n vertraagde taalontwikkeling, presenteer: in childhood the delay in language acquisition, poverty, or inarticulate oral expression, difficulty in responding to oral instructions, apparent difficulty in appreciating the sequence of oral instruction, and difficulty in sound localization would suggest central dysfunction. if these manifestations represent an absence of function when they should be present, a developmental origin should be suspected and when there is a decline in these functions which are described to have been previously present, acquired central nervous system disorder should be suspected.4 as ouditiewe aandag beskou word as 'n integrale deel van ouditiewe persepsie is dit ook dus 'n sentrale proses en kan kennis daaromtrent van groot diagnostiese waarde wees. dankbetuigings mev s r hugo en mnr η ε c tesner, departement spraakwetenskap, spraakheelkunde en oudiologie, universiteit van pretoria, vir hulle hulp gedurende die studie. prof d j stoker, hoof van die departement statistiek, universiteit van pretoria, vir die statistiese ontledings van die resultate. mnr ρ meffert, departement akoestiek, wnnr, vir die tegniese samestelling van die toetsmateriaal. verwysings 1. botha, d. (red) (76/77): summarized outlines on the pharmacology of important drug groups. mims desk reference, 12, 26-31. 2. caplan, l. r. (1978): variability of perceptual functioning: the sensory cortex as a "categorizer" and "deducer". brain and language, 6, 1 1 3 . 3. carhart, r. (1967): binaural reception of meaningful material. in: a. b. graham sensorineural hearing processes and disorders. little, brown and company, massachusetts. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) elmarie niemand 34 4 duane, d. d. 1977: central auditory dysfunction in: keith, r. a neurologic perspective of central auditory dysfunction. grune & stratton n.y. 5 fox, j· (1974): recognition and attention. quarterly journal of experimental psychology, 26, 144-157. 6. guyton, a. c. (1966): function of the human body. w. b. saunders company, philadelphia. 7. johnson, d. j. & myklebust, h. r. (1967): learning disabilities: educational principles and practices. grune and stratton, n.y. 8. johnson, p. j. et al (1974): effects of category attention, relative frequency of relevant values and practice on attribute identification performance. journal of experimental psychology, 103, 160-166. 9. jordaan, w. j. et al (1975): algemene sielkunde: 'n psigobiologiese benadering. mcgraw-hill, johannesburg. 10. luria, a . r. (1973): the working brain: an introduction to neuropsychology. the penguin press, allen lane. 11. martin, m. (1978): retention of attended and unattended auditorily and visually presented material. quarterly journal of experimental psychology, 30, 187-200. 12. meldman, m. j. (1970): diseases of attention and perception. pergamon press, n.y. 13. moray, n. (1969): attention: selective processes in vision and hearing. hutchinson educational, london. 14. moray, n. et al (1976): attention to pure tone. quarterly journal of experimental psychology, 28, 271-283. 15. myers, t. f. (1970): asymmetry and attention in phonic decoding. in: sanders, a. f. (red). attenion and performance iii: proceedings of a symposium on attention and performance. north-holland publishing company, amsterdam. 16. neisser, u . (1967): cognitive psychology. meridith publishing company, n.y. 17. northern, j. l. & downs, m. p. (1974): hearing in children. the williams and wilkins company, maryland. 18. rydberg, s. & arnberg, p. w. (1976): attending and processing broadened within children's concept learning. journal of experimental child psychology, 22, 161-177. 19. saunders, d. a. (1977): auditory perception of speech: an introduction to principles and problems. prentice hall, n-y20. shiffrin, r. m. et al (1976): attending to fourty-nine spatial positions at once. journal of experimental psychology: human perception and performance, 2, 14-22. 21. simon, h . a . (1972): on the development of the processor: in: farnham-diggory, s. (red). information processing in children. academic press, n.y. j 22. underwood, g. (1977): attention, awareness and hemispheric differences in word recognition. neuropsychologia, 15, 61-67. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ouditiewe aandag 35 23. walley, r. e. & weiden, t. d. (1973): lateral inhibition and cognitive masking: a neuropsychological theory of attention. psychological review, 80, 284-302. 24. yusson, s. r. & levy, v. m. (jnr.) (1975): effects of warm and neutral models on the attention of observational learners. journal of experimental child psychology, 20, 66-72. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aids for • the development of perception • the acquisition of speech and language skills • the improvement of motor co-ordination plus • helpful texts for therapists • educational toys, books and equipment • records for auditory training • catalogues on request • large variety of tests available stockists of • learning to listen • two sound lottos • "listen what is that?" play and schoolroom 8 tyrwhitt avenue, rosebank (adjoining the constantia cinema) telephones: 788-1304 i p.o. box 52137, saxonwold, 2132 ο m the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 21 the development of a framework for assessing developing conversational skills susan rumble, b.sc. (log) (cape town) hearing and speech clinic, tygerberg hospital karen malan, m.a. (appl. linguistics) (reading, u.k.) department of logopaedics, university of cape town abstract a framework for investigating the development of conversational skills in children, comprising the areas of topic control, repair ofcomlinguistic cohesion, was devised. this was undertaken bya process f . ^ ^ ^ ^ t j s i oraamatic profiles and the developmental literature. the framework was then modified inductively to accommodate features of the data ^iha^ed&om 12 normally developing english-speaking children in the aye groups three, four and five years. a number of aye-related trends assessment procedures which will aid the collection of normative data presently lacking. opsomming vi raamwerk om die ontwikkeling van gesprekvaardighede, bestaande uit instandhouding en gespreksonderwerp, herstel van komnozaat^ss^sspr^dekindcrs, in die ouderdomsgroepe drie, vier en vyfjaar te akkommodeer verskeie ontwikkehngss olelstem met bevindinge in die ontwikkelingsliteratuur. hierdie studie beklemtoon lebehoefte aan meer verfynde evaluasieprosedures wat sodoende die versameling van normatiewe data, wat tans ontoereikend is, sal bevorder. the development of pragmatic language skills has been perhaps the most rapidly expanding area of child language research over the last decade. much of the work in this area has focused on either communicative intentions (the functions -that speech acts serve for the speaker) or the skills involved in conversational competence (including presupposition and the social organization of discourse). however, while the acquisition of communicative intentions has been quite extensively researched (klecan-aker & swank, 1988), the available information on developing conversational skills, particularly in the pre-school population, is as yet fragmented and sparse. the absence of adequate baseline data on conversational development in normal communicators has hampered attempts to construct clinically applicable frameworks for assessing the conversational skills of language disordered children. compounding the difficulty are disagreements over definitions of conversation and the scope of conversational analysis, with a consequent lack of coherent models for studying its development and for developing assessment instruments. of the commonly available clinical protocols (eg. prutting & kirchner, 1987; penn, 1985; roth & spekman, 1984; wollner & geller, 1982), most comprise categories designed to provide a measure of overall communicative ability and hence lack the specificity required for in-depth analysis of conversation. further, some were developed explicitly for use with older age groups penn's (1985j profile of communicative appropriateness for adult populations and prutting & kirchner's (1987) pragmatic die suid-afrikaans tydskrif vir kommunikasiawykings, vol. 37 1990 protocol for subjects older than 5 years. wollner & geller's (1982) communication profile and roth & spekman's (1984) organizational framework for assessing pragmatic skills, although derived from the developmental literature, are plagued by problems of significant gaps in developmental information and have been criticized for their lack of discrete, well-motivated categories of description (mctear & contiramsden, 1989). a need exists, therefore, for assessment frameworks that focus specifically on conversational competence and that are sensi: tive to developmental trends in skills in this area in pre-school children. paired with the need for detailed normative data is the requirement for adequate models of the skills involved in conversation. mctear (1985) observes that models of conversational competence should account for increasing sophistication in three basic areas: (i) topic control (involving turn-taking and the structuring of conversational turns), (ii) repair of conversational breakdown· and (hi) the use of linguistic cohesive devices and presuppositions. he argues that in addition to the acquisition of detailed normative data, more attention should be paid to the validity of descriptive analyses and to providing reliable criteria for the recognition of analytic categories. bearing these requirements in mind, the present study was designed as a preliminary attempt to develop a framework for evaluating conversational skills that would reflect developmental trends in the pre-school age group. " sasha 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 susan rumble and karen malan methodology aims 1. the development of a framework for the assessment of developing conversational skills in the areas of topic control, repair of communication breakdown and linguistic cohesion. 2. use of the assessment framework to investigate developmental trends in conversational skills in normally-developing children aged 3 to 5 years. procedure procedures for fulfilling the two aims overlapped, in that the assessment framework was further modified to accommodate specific features of the data obtained from normally developing children, in order to ensure its sensitivity to the developmental changes that emerged. stage 1: a preliminary assessment framework was devised, by combining selected portions of two existing pragmatic profiles. penn's (1985) profile of communicative appropriateness (pca), although developed for use with adult clinical populations, includes three sections (response to interlocutor, control of semantic content and cohesion) which fall within the scope of conversational analysis defined here; these were therefore included in the preliminary framework. since the pca does not specifically examine repair of conversational breakdown, section iii ofwollner & geller's (1982) communication profile, (communication breakdown, dealing with repair strategies), was added. section ii (conversational acts, dealing with ability to initiate, extend and terminate topics) was also included, with the intention of comparing its usefulness with the corresponding section of the pca (control of semantic content). stage 2: samples of conversation were collected from 12 normally-developing, english-speaking children in three agegroups (see table 1) attending a creche for coloured children of groote schuur hospital employees. both sexes were equally represented. audiometric and language screening measures were undertaken to ensure normal hearing and language development in all subjects. table is subject characteristics age-group no. of s's mean age age range 3 years 4 3.6 years 3.4 3.9 4 years 4 4.5 years 4.3 4.7 5 years 4 5.3 years 5.1 5.5 each subject was audioand video-taped while conversing individually with the investigator in a familiar room at the creche. following the suggestion of brinton et al. (1986) and mctear (1985), a naturalistic setting was used. tasks used were those which had been established in a prior pilot study (outlined in rumble, 1988) to be most successful in generating spontaneous conversation: doll play; free conversation on topics initiated by the investigator relevant to the subjects' environment and a story re-tell task, following the suggestion of griffiths et al. (1986) and liles (1987) who advocate narrative tasks to investigate use of linguistic cohesion devices. roth & spekman's (1984) strategies for creating communication breakdown (mumbling intentionally, responding with a noncontingent reply, providing inadequate or ambiguous instructions for performing a task) were utilized, a consistent number of times in each subject interaction, at regular points during f the conversation. data from each subject was orthographically transcribed from the video tapes, including contextual, non-verbal and prosodic information. stage 3: the preliminary assessment framework was modified by coding the data obtained from one subject in each age group according to the categories of the preliminary framework. modifications were necessitated by difficulties related to the use of different scorin'g and coding systems for sections of the framework obtained from different sources. furthermore, expansion, re-ordering and omission of certain categories was necessary to reflect subtle developmental trends. information from the developmental literature was consulted for this purpose and included in the final framework. thus, an inductive process was employed whereby descriptive categories evolved out of information reported in the literature and were subsequently modified to accommodate features that emerged from the data. the information was organized into a single framework comprising the superordinate categories of topic control, repair of communication breakdown and linguistic cohesion. stage 4: data from all 12 subjects was coded and analyzed to the final assessment framework. all utterances were coded for the linguistic cohesion and repair of breakdown sections, whereas only those produced during the free conversation task were coded for the topic control section. for the latter section, the investigator's utterances were also coded. coding of data was undertaken independently by two trained speech and language pathologists from observation of the videotapes. both raters were familiar with the defining criteria for recognition of categories. point to point inter-rater reliability was calculated at 80%, above silverman's (1977) criterion of 75%. frequencies of occurrence of each category were calculated for eaeh-subject. these frequency scores were then subjected to one-way analysis of variance tests to determine if differences between these frequencies were statistically significant. | results and discussion 1 the categories of conversational skills that emerged in the process of developing a final assessment framework are shown in tables 2 , 3 and 4. discussion of the specific modifications and expansions of categories undertaken in developing and refining the original descriptive categories to accommodate the developmental data is not within the scope of this paper. a description of these processes, together with full definitions and examples of all categories in the final framework is provided in rumble (1988). the discussion here will focus on the developmental data gathered from the normally developing subjects. tables 2,3 and 4 also provide, for each age group, the mean frequencies of occurrence of the categories of conversational skills in each section of the framework. few o f t h e comparisons of frequencies across age groups yielded statistically significant results, presumably due, at least in part, to the small sample size which magnifies the-effects of individual variation on overall comparisons. despite this, a number of developmental trends were evident; these are discussed below for each section of the framework. the south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the development of a framework for assessing developing conversational skills 2 3 topic control 1 initiatory acts (ia): table 2 shows that 3 and 4 year olds initiated a greater number of topics overall than did the 5 year olds, a trend also reported by wanska & bedrosian (1985). however, at least half the ias produced by all subjects were inappropriate, as they occurred where responses to previous turns were expected. both prutting (1979) and mctear (1985) note that children from 2 to 3 years exhibit problems maintaining and extending the topic of conversation, resulting in inappropriate and rapid changes of topic throughout their discourse. the drop in number of topic initiatory acts after 4 years may thus reflect an increasing ability to use more appropriate strategies for topic maintenance, with a corresponding decreasing dependency on initiatory acts to serve this function. table 2: mean frequency scores per age group for the categories of topic control category initiatory act investigator subjects topic relevant response investigator subjects: verbal acknowledgement verbal response to interrogative nonverbal acknowledgement nonverbal response ; to interrogative topic relevant act investigator subjects off topic act inappropriate response no response age group 3 years 4 years 5 years 5.0 4.5 32.75 0.5 15.25 3.5 19.75 37.5 9.0' 2.5 6.5 6.5 4.5 38.0 1.0 19.0 3.5 8.5 33.5 26.75* 1.0 4.25 6.25 2.5 30.0 0.25 22.25 1.5 6.5 32.75 14.75* 4.0 3.5 * 4 year group produced significantly more than 3 year group (p=0.05) 2. topic relevant responses (trr): these occur in response to an utterance of the previous speaker. table 2 shows that for subjects in all three age groups, a far greater proportion (90%) of trrs were responses to interrogatives, rather than acknowledgements of previous turns, a finding supported by bloom et al. (1976) and mctear (1985). the tendency for adults to rely heavily on interrogatives in dialogue with young children is well documented (corsaro, 1979) and may serve to facilitate conversational development by providing the child with opportunities to provide linguistically contingent replies, thus keeping the conversational ball in play. table 2 also shows that subjects' use of verbal trrs increased from 3 to 5 years, while the frequency of non-verbal trrs declined, reflecting an expanding linguistic competence and a corresponding diminishing reliance on non-linguistic modes of response to maintain discourse topics. 3. topic relevant acts (tra): these are spontaneous utterances that go beyond the previous turn by adding new information of relevance to the topic. table 2 shows a higher occurrence of tras in the 4 and 5 year old groups, with the increase from 3 to 4 years being statistically significant. many more tras were produced by the investigator in all age groups, a trend also noted by corsaro (1979) who observed that adults generally respond to children's utterances with tras, while children tend to respond to adults' tras with trrs. the number of investigator-tras diminished with oldel subjects who provided greater numbers of tras themselves. 4. off topic acts either inappropriate responses to questions or failure to respond where a response was expected showed a general tendency to diminish with age, corresponding to the increase in appropriate verbal responses to interrogatives. 5. mean number of utterances per turn: in interactions with all age groups, the investigator produced a greater number of utterances per turn than subjects. the data on topic control generally confirmed mctear's (1985) observation that from 3 to 5 years the major development is from relatively closed exchanges with an initiaterespond structure to more extended sequences of dialogue. by 5 years of age the children here showed increased ability to maintain and extend a topic of conversation in the form of topic relevant acts and responses. yet, even at this age, the adult remained the dominant member of the communicative dyad, taking responsibility for topic control in the form of a high number of interrogatives and extensions of the child's utterances (tras) to ensure shared meaning, as well as producing an overall greater quantity of utterances at each turn. repair of conversational breakdown 1. clarification requests: some clear patterns emerged here with regard to a sequence of development. as table 3 shows, requests for clarification were just beginning to emerge in the 3 year old group, supporting both gallagher (1977) and garvey's (1979) observation that children do not produce contingent queries until 3 years of age. clarification requests were produced incrementally by one 3 year old, two 4 year olds and all five year olds. first to emerge, at 3 years, were specific requests for confirmation, where the child requests confirmation of some element of the previous utterance about which he is uncertain, as in the following example. i : 'pass me another chair s: tets (s holds up chair) i : yes non-specific requests for repetition emerged at 4 years; like specific requests for confirmation, these do not specify which part of the previous utterance needs to be clarified: i : 'give me another one s: hmm i : 'pass me another chair die suid-afrikaanse tydskrif ir kommuniksieafikinis, vol. 37. 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 2 4 table 3: mean frequency scores per age group for the categories of repair of conversational breakdown age group category 3 years 4 years 5 years clarification requests non-specific request for repetition 0. 0.25 1.25 specific request for repetition 0. 0. 0.25 specific request for confirmation 0.5 0.5 1.0 specific request for specification 0. 0.75 1.25 repair strategies revision 0. 0.5 0. addition 4.25** 1.75** 1.5** cue 0. 0. 0. whole repetition 2.25 2.5 1.25 part repetition 0. 1.0 1.25 no response 1.75 1.0 1.25 * * 3 year group produced s 5 year group (p=0.01) ignificantly more than 4 and more demanding linguistically are requests that require identification of specific ambiguous or missing information, as in specific requests for specification and specific requests for repetition. the former emerged at 4 years and is illustrated in the following example. 1 : those 'people who came to your creche that were 'telling you stories s : what people the latter was produced only once, by a 5 year old subject: 1 : put the 'cat in the box s : the (pause 2 seconds) (s looks questioningly at i) * i : cat 2. repair strategies: as is evident from table 3, the developmental picture with regard to use of repair strategies in response to requests for clarification was less clear, as subjects showed a fairly high degree of variability and inconsistency in their use of these strategies. nevertheless, certain strong tendencies emerged. 3 year olds produced a significantly greater number of addition repairs (involving addition of information not provided in the original utterance) than 4 or 5 year olds. the relative linguistic immaturity of this age group may account for this : 3 susan rumble and karen malan year olds frequently produced utterances containing either insufficient information or inappropriate anaphoric and demonstrative reference (discussed below), necessitating a large number of clarification requests for additional information, as the following example shows. i : 'what was the mommy saying here s : birthday i wlibse birthday s : the girl's birthday whilst the frequency of addition repairs declined in the older age groups, 4 and 5 year olds most frequently used repetition repairs, involving repetition of the whole or part of a previous utterance. the trend here, shown in table 3, was for a decrease in whole repetitions and an increase in part repetitions with increasing age, reflecting a growing ability to distinguish which specific linguistic elements require repeating. adults may play a facilitative role in this process: the majority of part repetitions in the data were produced in response to specific requests for specification which assist the child in determining which elements need clarification. revision repair is a more complex linguistic strategy than repetition or addition, involving recoding of the message in the form of alterations to syntactic structure; these were used by only one child, a 4 year old. no examples of cues (involving definition of terms from the original utterance or providing relevant background information for its interpretation) occurred, suggesting that these require a level of metalinguistic abstraction that is beyond the 5 year old level. to summarize, the findings suggest that the development of effective strategies for dealing with conversational breakdown depends at least in part on the ability to identify specific information bearing elements of a message. this ability did not begin to manifest in either clarification requests or repair strategies before 4years of age, although repair strategies were certainly in evidence in younger children of 3 years. further, it seems the ability to recode surface syntactic or lexical aspects of the message in formulating repairs is a skill developed only from 5 years and beyond. | linguistic cohesion ; ι 1. anaphoric reference: this category comprises pronouns that refer to previously identified referents. they were coded as appropriate when interpretable either with the aid of contextual cues or due to the referent having been previously identified. table 4 shows that many more instances of anaphoric reference used by subjects were appropriate than inappropriate and that appropriate use increased with age. however, many of the appropriate instances may have been considered inappropriate in the absence of contextual cues to aid the investigator's interpretation. appropriate use of pronouns is closely linked to the ability to make correct assumptions regarding given versus new infor: mation. bates & macwhinney (1979) point out that inappropriate use of pronouns (ie. without prior identification of the referent) does not necessarily imply lack'of awareness that pronouns specify given information, but rather that the child makes incorrect assumptions about the 'givenness' of information. in the data reported here, such incorrect assumptions were found in all age groups. further, the use of rising intonathe south african journal of communication disorders, vol. 37,1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the development of a framework for assessing developing conversational skills 2 5 table 4: mean frequency scores per age group for the categories of linguistic cohesion category age group 3 years 4 years 5 years anaphoric reference appropriate inappropriate 16.25 5.5 27.5 21.25 28.75 9.25 demonstrative reference appropriate inappropriate 22.5 2.0 18.5 2.0 23.25 1.0 substitution appropriate inappropriate 6.25 11.75 6.5 2.75 8.25 0.25 ellipsis appropriate inappropriate 15.25* 6.75 23.0* 3.0 27.5* 3.75 additive conjunction 7.25 15.75 6.0 causal conjunction 1.0 3.0 1.25 temporal conjunction 1.0 4.75 6.5 antithesis conjunction 0.25 0.25 1.75 * 5 year group produced significantly more than 3 year group (p=0.05) tion accompanying information that the child assumed was shared was a feature used consistently by all subjects. this is illustrated in the following example from a 5 year old who incorrectly assumed that the investigator knew who the members of her household were. i : so 'who lives in your, house then s : v ^ i : who's we s : 0 (s looks puzzled) • 2. demonstrative reference: this refers to the use of deictic terms such as 'this', 'that', 'here', 'there', which refer to referents by specifying their location on the dimension of distance. table 4 indicates that subjects in all age groups had attained the ability to encode these deictic relations linguistically. the vast majority of instances of demonstrative reference were apropriate, with inappropriate use (where the referent was not clear from the context) decreasing slightly at 5 years. these findings are consistent with the observations of both bloom et al. (1976) and bates & macwhinney (1979) that children as young as 3 years show awareness of deictic shift by correct use of demonstrative pronouns. 3. ellipsis: use of elliptical utterances allows the speaker to reduce redundancy in a message by encoding only the essential elements; it therefore relies on the ability to identify given information in prior messages which can then be deleted in the elliptical utterance. table 4 shows that appropriate ellipsis was present from 3 years, its use increasing significantly with age while inappropriate use declined. these trends were closely associated with type of ellipsis. clausal ellipsis (involving ellision of both noun and verb phrase) results in encoding of minimal information; this occurred with greater frequency in all age groups than either nominal or verbal ellipsis. a large amount of inappropriate clausal ellipsis occurred in the data from 3 year olds, who were unaware that further specification was necessary. the use of appropriate nominal and verbal ellipsis increased with age, often prompted by specific requests for specification from the investigator. their use appears to coincide with the development of increasing ability to take the listener's needs into account and consequently to select the appropriate elements of a message to encode. 4. substitution: this category refers to items other than personal pronouns which replace previously identified elements. as is evident from table 4, the data here suggests that correct use of substitution is possibly a later acquired form of alternative coding then ellipsis. only two 3 year olds used substitution appropriately whereas all of them used appropriate ellipsis and far fewer appropriate instances of substitution than ellipsis occurred overall for the whole subject group. all instances of substitution in the data were nominal (one word substituting for a noun phrase), except for one example of verbal substitution (one word substituting for a verb phrase), produced by a 5 year old. thus verbal and clausal substitution may be more complex forms acquired only after 5 years. 5. conjunction: conjunctions serve a cohesive function in discourse when they relate successive utterances to each other across speaking turns. ervin-tripp (1978) described a tentative sequence of development of conjunction use across turns: additive (and, too, also) followed by temporal (then), causal (so, because), and then antithesis (but). the frequencies shown in table 4 for conjunction use replicate this sequence exactly. additive conjunctions were used more frequently than any other type by all age groups; this is in accordance with mctear's (1985) observation that a 5 year old's 'and' is still the main cohesive conjunction used. an interesting feature of these subjects' conjunction usage which is not reported elsewhere in the literature, however, was the use of 'now' (as well as 'and') to express additive relations and 'so' to express temporal relations, as shown in the following examples. i : that's the shower s : now 'where's the tap (additive) i : now 'what happens next s : so the 'pram ride by itself (temporal) these features are assumed to be a feature of the dialect of english spoken by the subjects,since they were used by all the children in this study. to summarize, the data on cohesion indicated that correct use of all types of cohesive devices investigated was present to some degree from 3 years of age, with a general trend for die suid-afrikaanse tydskrif rir kommunikasieafiviikiniis, vol. 37. 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 susan rumble and karen malan increasing apropriate use and a decrease in inappropriate use up to 5 years. developing competence in the use of cohesive devices seemingly involved the ability to scan prior messages, make correct assumptions regarding the need for new as opposed to given information and to take the listener's perspective into account. conclusion this study has emphasized the need for the development of more refined procedures for assessing conversational skills in children, as well as for the collection of normative data. the procedure employed here, of collating descriptive categories from previous research and modifying these inductively to accommodate features of the data collected from normally developing children, proved useful in ensuring that the resultant categories were adequately motivated in terms of their relevance to developing language. further, the use of small subject samples in successive age levels, while raising problems of generalizability, allowed for detailed descriptive analysis of relatively subtle developmental trends. given the paucity of present knowledge about the development of conversation, this approach may be preferably to a more superficial analysis of larger samples. it would certainly be premature at this stage to consider the framework provided here as a clinically applicable tool. mctear (1985) rightly cautions that we are a long way off from being able to produce profiles of conversational development on analogy with similar existing profiles for areas such as syntax and phonology. we would suggest that a great deal more groundwork is required in the form of careful refinement of descriptive categories on the basis of developmental information. additionally, several problematical theoretical and methodological issues require attention if the goal of an effective clinical tool is to be realized. for one thing, findings from naturalistic methods of data collection, such as that used in this study, are invariably limited by the fact that conclusions are drawn regarding subjects' linguistic competence on the basis of their performance in a limited and particular sample of interaction. thus, further research efforts to validate the descriptive categories derived here should include systematic exploration of the effects on performance of contextual factors such as variations in communicative partner and physical setting. it seems likely, for instance, that important differences may exist between adult-child and child-child discourse. future research will also need to address the issue of how best to 'score' categories of conversational behaviour in clinical assessment; as mctear & conti-ramsden(1989) point out, both frequency counts and judgements of appropriacy are problematical as indices of conversational analysis. finally, it is possible that descriptive categories based on normal development may not be sensitive to specific problems that arise in language disorder, suggesting the need for testing the assessment framework with language impaired children. references bates, e. & macwhinney, b.a. a functionalist approach to the acquisition of grammar. in e. ochs and b.b. schieffelin (eds.) developmental pragmatics. new york: academic press, 1979. bloom, l., rocissano, l. & hood, l. adult-child discourse: developmental interaction between information processing and linguistic knowledge. cognitive psychology, 8, 521-522, 1976. brinton, b., fujiki, m., winkler, e. & loeb, d.f. development of conversational repair strategies in response to request for clarification./ speech hear. res., 29, 75-81, 1986. corsaro, w.a. sociolinguistic patterns in adult-child discourse. in e. ochs & b.b. schieffelin (eds) developmental pragmatics. new york: academic press, 1979. ervin-tripp, s. some features of early child-adult dialogues. language in society, 7, 357-73, 1978. gallagher, t.m. revision behaviours in the speech of normal children developing language./ speech hear. res., 20, 303-318, 1977. garvey, c. contingent queries and their relations in discourse. in e. ochs & b.b. schieffelin (eds) developmental pragmatics. new york: academic press, 1979. griffith, p.i., ripich, p.n. & dastoli, s.l. story structure, cohesion and propositions in story recalls by learning disabled and nondisabled children. journal of psycholinguistic research, 15(6), 539-555, 1986. klecan-aker, j.s. & swank, p.r. the use of a pragmatic protocol with normal preschool children./ comm. dis., 21, 85-102, 1988. liles, b.z. episode organization and cohesive conjunctives in narratives of children with and without language disorder./ speech hear. res., 30(2), 185-196, 1987. mctear, m.f. children's conversation. oxford: basil blackwell 1985. mctear, m.f. & conti-ramsden, g. assessment of pragmatics. in k. grundy (ed.) linguistics in clinical practice. taylor and francis, 1989. penn, c. the profile of communicative appropriateness: a clinical tool for the assessment of pragmatics. south african journal of communication disorders, 32, 18-25, 1985. prutting, c.a. process: the action of moving forward progressively from one point to another on the way to completion./ speech hear. dis., 44(1), 3-30, 1979. prutting, c.a. & kirchner, d.a. a clinical appraisal of the pragmatic aspects of language./ speech hear. dis., 52, 105-119, 1987. roth, f.p. & spekman, n.j. assessing the pragmatic abilities of children. part i: organization framework and assessment parameters./ speech hear. dis., 49, 2-11, 1984. rumble, s. the development of a framework for assessing children's conversational skills and its use in a preliminary investigation into developmental trends in normal three, four and five year olds. unpublished research report, department of logopaedics; university of cape town, 1988. silverman, s. research design in speech pathology and audiology. new, jersey: prentice-hall, 1977. / j wanska, s.k. & bedrosian, j.l. conversational structure and topic) performance in mother-child interaction./ speech hear res 28,579-584,1985. '' wollner, s. & geller, e. methods of assessing pragmatic abilities. in 1 j.v. irwin (ed) pragmatics: the role in language development.! university of laverne: fox point publishing, 1982. the south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the relationship between phonology and inflectional morphology in an agrammatic aphasic meryl kobrin ba (sp. & h. therapy) (witwatersrand) lesley wolk ma (speech pathology) (witwatersrand) department of speech pathology and audiology, university of the witwatersrand, johannesburg abstract the interaction between phonological and morphological breakdown in an agrammatic aphasic was investigated. three linguistic tasks were constructed which were presented via two modes, reading and repetition. results revealed that purely phonological consonant clusters were easier than clusters which contain a morphological component, and that these categories could be differentiated in terms of phonological error type. inflectional omission was conditioned by phonological characteristics of the preceding segment. there was an interaction between the phonological and morphological hierarchies of difficulty in inflections which are homonyms phonologically. findings suggest an interdependence between phonological and morphological breakdown in the agrammatic aphasic examined. results were discussed with reference to clinical implications. opsomming die interaksie tussen fonologiese en morfologiese uitvalle in 'n agrammatiese afasia pasient is ondersoek. drie linguistiese take is opgestel. die pasient moes die take ouditief (deur middel van herhaling) en visueel (deur middel van lees) uitvoer. resultate dui daarop dat suiwer fonologiese konsonant groepe makliker was om uit te voer, as groepe wat 'n morfologiese komponent bevat het en dat hierdie kategoriee gedifferensieer kon word in terme van tipe fonologiese foute. die voorafgaande segment se fonologiese karakteristieke het inflektiewe weglatings bepaal. daar was interaksie tussen die fonologiese en morfologiese hierargiese moeilikheidswaarde van infleksies wat fonologiese homonieme is. bevindings dui op 'n interafhanklikheid tussen fonologiese en morfologiese uitvalle in die pasient. resultate is bespreek met verwysing na kliniese implikasies. to date, the trend within the psycholinguistic aphasia research has been to focus on the components of language (syntax, semantics and phonology) in isolation, rather than to investigate interrelationships between these levels of linguistic breakdown. the symptomatology of agrammatic aphasics, particularly their tendency to delete inflectional morphemes and their high proportion of phonemic errors, provides a unique opportunity to examine the mutual influence of phonologically i and morphologically impaired systems. independent research into phonology and inflectional morphology has been well documented. articulatory investigations have resulted in conflicting opinions as regards the nature of aphasic error performance. johns and darley (19j70) and shankweiler and harris (1973), for example, support the notion that phonemic substitutions are primarily random, variable and unrelated to the target sound. other investigators suggest that aphasic articulatory errors reflect systematic, rule-governed variations from the target phonemes (blumstein, 1973; marquardt, reinhart and peterson, 1979). studies exploring the performance of agrammatic aphasics on inflectional endings reflect a consistent hierarchy of difficulty for the various morphemes (goodglass and berko, 1960; goodglass, 1976). de villiers (1974) contends that explanations such as transformational complexity, semantic complexity, stress, redundancy and frequency of occurrence of each morpheme in normal adult speech are insufficient to explain the hierarchical morphemic impairment. this suggests that alternative explanations should be sought. a number of theories have been proposed to account for the underlying deficits in agrammatism. kean (1977) contends that agrammatism is an " . . . interaction between an impaired phonological capacity and otherwise intact linguistic capacities" (p. 10). this condie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 troversial phonological explanation has subsequently been criticized. garman (1981) suggests that a number of kean's arguments are based on misinterpretations of the existing literature. kolk (1978) argues that although a phonological approach may have value with respect to the 'articulation' impairment in agrammatism, it does not provide a convincing argument to explain the syntactic omissions characteristic of these patients. goodglass and berko (1960) take an opposing view to kean (1977) and suggest that grammatical function is more important than phonological structure in determining the difficulty of an inflectional ending. this theory is based on their finding that the plural, possessive and third person singular inflectional morphemes (all of which are homonyms phonologically) are omitted with differential frequency in agrammatic aphasics (goodglass and berko, 1960). martin, wasserman, gilden, gerstman and west (1975) suggest that neither a purely phonological nor a purely morphological breakdown is sufficient to explain aphasic error performance. they propose that " . . . it is the interaction of processes which is affected in aphasia rather than a specific impairment of a particular process or component" (p. 449). this interactional model between phonological and morphological impairment has not been confirmed in the aphasia literature. however, several studies in child language have shown an interaction between syntax and phonology (menyuk and looney, 1972; paul and shriberg, 1982). the paucity of research into the relationship between linguistic components in aphasia, provided a strong motivation for this study. the broad goal was thus to investigate the inter-relationship between phonological and morphological impairment in the expressive language of an agrammatic aphasic. the specific aims were: 1. to compare the subject's error performance on consonant clusters which are purely phonological constructions (pc); clusters which © sasha 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 meryl kobrin and lesley wolk are phonological constructions but with morphological poss talities (pcm); and clusters which are morphological combinations (mc) 2 to establish whether the subject's omission of inflectional morphemes is conditioned by the sonorance hierarchy of the preceding segment, as suggested by kean (1977). 3. to examine the subject's production of three grammatical morphemes which are homonyms phonologically, namely the plural marker, the possessive marker and the third person singular, all of which are realized morphophonemically by the allophones /s,z,az/. method subject the subject used in this study was r.p., a white, south african, english speaking female, aged thirty-eight years. in december 1978, she presented with a sudden onset of expressive aphasia. computerized tomography revealed a left middle cerebral artery infarct, the etiology of which was unknown. no further neurological details were available. pre-morbidly, she was right handed. r.p. fulfilled the following criteria: 1. she was a moderately impaired agrammatic aphasic as assessed on the boston diagnostic aphasia examination (bdae) (goodglass and kaplan, 1972). 2. r.p. demonstrated phonemic errors, particularly on consonant clusters. 3. her expressive language was characterized by omission of inflectional morphemes. 4. dysarthria and oro-facial apraxia were excluded as being causally related to the phonemic errors. 5. phonemic discrimination abilities were excluded as being etiologically related to phonemic errors. 6. r.p. demonstrated a competence for the tasks on which she would be expected to perform. more specifically, reading and auditory comprehension abilities, as assessed on the bdae were sufficiently intact to enable these modalities to be utilized in testing. 7. r.p.'s mother tongue was english. 8. peripheral hearing and vision were within normal limits. 9. r.p. was neurologically stable during the test period. tasks and procedure a. preliminary investigations on the bdae, r.p. obtained a profile representing broca's (agrammatic) aphasia. results served to satisfy some of the criteria for subject selection, specifically her relatively intact receptive language and reading abilities and the presence of phonemic and morphological errors. on the goldman fristoe test of articulation (goldman and fristoe, 1969) r.p. showed several articulation errors on both single phonemes and phonemic sequences, verifying the presence of phonemic errors in meaningful words as elicited on a naming task. on a test of ten english inflectional morphemes, designed by the authors, r.p. demonstrated inflectional omission. in accordance with the format proposed by goodglass and berko (1960) a sentence completion test was constructed to assess the following morphenes: plural /s,z/; plural /sz/; past /t,d/; past /ad/; present singular /s,z/; present singular /sz/; possessive /s,z/; possessive /sz/; comparative /a/; superlative /sst/. the test included six opportunities for the use of each morpheme selected. the following is an example of an item (plural) "i bought a large pot, a medium-sized pot and a small pot. altogether i bought three ? " . on the goldman fristoe test of auditory discrimination (goldman, fristoe and woodcock, 1970), administered in order to verify the subject's competence for discriminating between single consonants, r.p. scored 100%, indicating no errors on this standardized test of auditory discrimination. r.p. responded adequately at all frequencies on a screening pure tone audiometric test, indicating that hearing was within normal limits. b. tasks all tasks designed for the purpose of this study were evaluated by means of a pilot study on three normal adults. 1. ccvcc word list a list of 150 ccvcc words (appendix i) was devised in accordance with the format proposed by martin et al,. (1975). the stimuli were divided into three groups of fifty words each. in the first group, the final cluster was a purely phonological construction (pc) such as /mp/ in 'cramp'. in the second group, the final consonant cluster was a phonological construction, but the final segment belonged to the group /s,z,t,d/ and therefore suggested the possibility of a morpheme (martin et al., 1975). an example of a phonological construction with the morphological possibilities (pcm) is /st/ in 'breast'. the third group contained final consonant clusters which were morphological combinations (mc), such as /st/ in 'dressed'. the inflections included in the (mc) list in the present study were limited to the plural /s,z/ and past /t,d/, and in order to maintain uniformity, words in the pcm group were limited to the phonemes (s,z,t,d/ in final consonant position. 2. sonorance-inflection word list a list of 150 words was composed (appendix ii). each word was a combination of a stem morpheme (cv or cvc) and an inflectional morpheme (past /d/ or plural (z(), for example (bees, called). the stem morphemes were divided into five groups of thirty words each, according to the sonorance hierarchy of the final segment of the stem. sonorance was used to refer to the extent to which the airflow is impeded during the articulation of a segment (kean, 1977). the five categories of final stem segments arranged hierarchically from the most sonorant (least impeded airflow) to the least sonorant (most impeded airflow) were: vowels and diphthongs, liquids, nasals, fricatives and stops respectively. within each group fifteen words were combined with the plural inflectional allophone /z/ and fifteen words with the past inflectional allophone /d/. i rationale for selecting the allophones /z/ and /d/ i i since stems ending in a vowel are constrained by morphophonemic rules to take a voice allophone, voiced allophones were used throughout. several studies in the aphasic literature have shown that' the plural is a relatively well retained morpheme whereas the past regular is a frequently omitted morpheme (goodglass and berko, 1960; de villiers, 1974). these two morphemes were assessed in an attempt to control for the possibility of obtaining too few omissions (exclusive use of plural) or too many omissions (exclusive use of past), for between group com parison. martin et al., (1975) contend that the number of phonemes within a syllable is not significant in aphasic error performance on a given phoneme. johns & darley (1970) suggest that the number of syllables is an important factor in error performance. for these reasons all stem and morpheme combinations were restricted to monosyllabic words of the structure cvc or cvcc. no initial clusters were included an an attempt was made to randomly vary the consonants utilized in initial position. the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the relationship between phonology and infectional morphology in an agrammatic aphasic 5 3. phrase/sentence list of plural, possessive and third person singular in order to compare r.p.'s production of the plural marker, the possessive marker and the third person singular morpheme, a list of 135 sentences/phrases was compiled (appendix iii). the stimuli were divided into nine groups, so that each allophone /s,z,az/ of each morpheme was tested fifteen times. phrases were constructed since the possessive nature of a stimulus cannot be inferred from a single word. for example horse's in a repetition task would be interpreted as a plural. it was felt that a minimum of four syllables was necessary to convey the possessive nature of a stimulus, for example, 'the horse's mouth'. all stimuli therefore comprised four syllables. c. administration of tasks each list was administered using two modes of presentation. 1. an auditory mode — repetition 2. a visual mode reading two modes of presentation were selected because the stringent criteria adopted in test construction limited the number of stimuli available in certain groups. due to the specific nature of the areas being investigated, a spontaneous sample, which may be considered as an ideal medium for linguistic investigation, would not have enabled sufficient sampling of all aspects under study. for repetition tasks, r.p. was instructed to repeat each item after the experimenter. if no response was given the item was repeated. for reading tasks each item was printed clearly and individually in 10mm capital letters. word items were printed on 7cm by 9cm cards and phrase/sentence items on 14cm by 9cm cards. each card was presented singly to r.p. and she was instructed to read it aloud. testing was carried out on two different days for approximately forty-five minute periods in order to control for fatigue. d. analysis procedure and scoring all responses were recorded on a revox tape recorder (model 375 dolby version) and subsequently transcribed in broad phonetic script by three independent transcribers. a two out of three consensus was accepted for each word. analysis procedure specific to particular tasks j i. ccvcc word list j a) a frequency count of correct versus incorrect initial and final clusters in the three categories was carried out. b) phonological errors occurring in final clusters were differentiated according to type, on the basis of two broad categories, namely sequencing and substitution errors. sequencing errors for the purposes of this study included additions, omissions and metatheses. in instances where a number of phonological errors occurred in one cluster, each was tabulated separately. for example, /st/ —» /tz/ was scored as both a sequencing and a substitution error. 2. sonorance-inflection word list a frequency count of morphemes omitted, retained and incorrectly produced was carried out. the incorrect category included instances where r.p. retained a morpheme, but not the particular morpheme under stimulation; for example the allophone /z/ instead of /d/. results were expressed as percentages. 3. phrase/sentence list of plural, possessive and third person singular a frequency count of retained morphemes was carried out. a morpheme was considered as retained even if r.p.'s allophonic realization was not entirely accurate. for example, 'wishes' (third person singular) was realized by r.p. as /wijs/ and this was scored as a retained inflection. results and discussion results of r.p.'s performance on each task will be presented individually and overall trends will be discussed in relation to the stated aims of this study. 1. a comparison of r.p. 's error performance on pc, pcm and mc consonant clusters a) frequency count of correct versus incorrect consonant clusters table 1 frequency count of correct versus incorrect initial and final consonant clusters pc pcm mc initial cluster final cluster initial cluster final cluster initial cluster final cluster no. no. no. no. no. no. correct 39 36 41 22 53 28 incorrect 61 64 59 78 47 72 total (n) 100 100 100 100 100 100 table 2 breakdown of correct initial and final clusters category correct clusters category initial cluster final cluster category no. no. pc 39 36 pcm 41 22 mc 53 28 total 133 86 table 1 illustrates that r.p.'s incorrect final clusters increased in the progression pc —» mc —» pcm. table 2 provides a more specific breakdown of correct clusters. it indicates that within each category, more initial clusters were correctly produced than final clusters. for the purposes of this study, 'difficulty' was conceptualized as the number of incorrect clusters in a category. martin et al., (1975), in a similar study, conceptualized difficulty as the number of phonemic errors in a particular category. for example 'drink' / 'glink' contains two phonemic errors, whereas 'drink' / 'grink' contains one phonemic error. martin et al. contend that the former production reflects greater difficulty than the latter. in this study, any two incorrect clusters were considered as being equally 'difficult', die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 meryl kobrfn and lesley wolk irrespective of the number of phonemic errors occurring in each. results of the present study were not entirely consistent with martin et al.'s, (1975) prediction of increased difficulty in the progression pc pcm — mc. however, the fact that incorrect final clusters increased in the direction pc mc, supports the contention that due to the added cognitive decision component, a ccvcc word with two morphemes (e.g. dressed) would be more difficult for an aphasic to process than a ccvcc word which has one morpheme (e.g. trump) (martin et al., 1975). the feet that the pcm category reflected the highest frequency of incorrect clusters is difficult to explain. it is felt that the pcm category as proposed by martin et al, (1975) needs careful consideration. whether in feet the /st/ cluster in a word such as 'breast', for example, is interpreted as a possible morphological combination by the aphasic, is open to speculation. however, results of the present study, suggest that further research into whether the pcm category is conceptualized as a phonological or morphological construction, and whether such a category is in fact valid, could be of value in providing insight into the interaction between these two linguistic components. the finding that initial clusters are more likely to be correctly produced than final clusters is consistent with that of martin et al., (1975) who contend that the final cluster position may suggest the possibility of a morphological component which would thus pose a more difficult processing task to the aphasic. b) frequency count of sequencing versus substitution error types in final clusters table 3 distribution of phonological errors in final cluster position according to sequencing and substitution error types category of error pc pcm mc category of error no. no. no. sequencing 34 54 54 substitution 58 59 36 total number of errors 92 113 90 table 3 clearly illustrates that the three categories are distinguishable on the basis of error type. the pc category reflects a greater proportion of substitution versus sequencing errors; mc a greater proportion of sequencing versus substitution errors; and pcm an approximately equal distribution of both. the distribution of error types supports the contention that " . . . the substitution error is more indicative of a basic phonological impairment, while sequencing errors are more indicative of interactions between the phonological and morphological components" (martin et al., 1975, p. 446). the approximately equal error distribution in the pcm category, seems to suggest the need for further research into the aphasics' conceptualization of this group as discussed above. 2. frequency count of omitted inflections as a function of the sonorance hierarchy of the preceding segment table 4 represents a summary of morphemes retained, omitted and incorrectly produced, expressed in relation to n. omission of the morpheme increased in the order v (least omitted) s l ν ^ f (most omitted), where (v), (s), (l), (n) and (f), represent the sonorance category of the final segment of the stem! more inflections were retained following vowels than consonants. within the consonantal group, the morpheme was most likely to be omitted when preceded by a fricative and least likely to be omitted when preceded by a stop. kean (1977) hypothesized that omission of the morpheme would increase as the airflow in the articulation of a segment became more impeded, that is in the order v (least omitted) ^ l — » n — » f — » s (most omitted). this contention was not supported by the present results. a possible explanation for the finding that the morpheme is more likely to be retained following a vowel than a consonant may be related to the syllable structure of words included in this task. stem morphemes ending in vowels were of the construction cv (e.g. bee): while those ending in consonants were of the construction cvc (e.g. dog). addition of the morpheme resulted in cvc stimuli for the vowel category (e.g. bees) and cvcc stimuli for the consonant category (e.g. dogs). therefore retention of the inflection when the stem ends in a vowel, and omission when it ends in a consonant, may reflect a strategy to maintain the cvc syllable structure form.' there is thus clear evidence to suggest that this subject has a tendency to employ simplification processes. j i shankweiler and harris (1973) suggest that vowels are easier for aphasics to produce than consonants and that within the consonantable 4 distribution of morphemes retained, omitted or incorrectly produced, expressed as a function of the sonorance hierarchy of the stem final segment sonorance hierarchy of final segment of stem morpheme 1 (v) vowel diphthong ν = 49a (l) liquids ν = 12a (n) nasals ν = 52" (f) fricatives ν = 34a (s) stops ν = 46" retained % 81,63 33,40 36,50 32,30 45,60 omitted % 16,37 41,60 50,00 64,70 32^60 incorrect % 2,00 25,00 13,50 3,00 21,80 total % 100,00 100,00 100,00 100,00 ' 100,00 the number of words in which the final segment produced by r.p. corresponded to the category under investigation. the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the relationship between phonology and infectional morphology in an agrammatic aphasic 7 tal group, fricatives and affricates are more susceptible to error than other phonemes. the present findings suggest that the omission of inflections may be conditioned by the susceptibility to error or 'complexity of articulation' of the preceding segment. it appears that although r.p.'s inflectional omission was not conditioned strictly by the sonorance hierarchy of the preceding segment, omission and retention were influenced by certain phonological characteristics of this segment as well as the overall syllable structure of the word. if her inflectional deletions were solely attributable to a syntactic impairment, an equal percentage of omissions would have been expected across all groups. verification of the present trends on a large group of agrammatic aphasics, assessing a variety of inflectional morphemes, may provide strong evidence for an interaction between phonological and morphological breakdown. 3. frequency count of retained plural, possessive and third person singular morphemes as a function of their stimulus allophonic realization correct. however, the fact that r.p. retained the syllabic allophone /az/ with greater frequency than the non-syllabic form /s,z/ is consistent with the findings of goodglass (1976) and in opposition to those of de villiers (1974). goodglass (1976, p. 250) ascribes the greater retention of the syllabic form /az/ to the added 'saliency' of the extra syllable. he states that "there is no basis at present for anything but a first order intuitive definition of saliency as the resultant of information, load, affective tone, increased amplitude and intonational stress" (goodglass, 1976, p. 253). it is clear that this definition of saliency, includes both receptive and expressive components. therefore, if saliency, as delineated above by goodglass (1976), were the sole explanation for the present findings, greater retention of the voiced /z/ as opposed to the unvoiced /s/ would have been expected, particularly on repetition tasks. however, the fact that r.p. showed greater retention of /s/ as opposed to /z/, suggests that alternative explanations, possibly with phonological implications should be sought. wolk (1978) reported that voiced fricatives may be more susceptible to error in aphasics than their voiceless cognates, which may explain r.p.'s greater retention of the stimulus allophone /s/ as opposed to /z/. liable 5 distribution of retained plural, possessive and third person singular morphemes as a function of their stimulus allophonic realization stimulus allophonic realization plural no. possessive no. third person singular no. total no. /s/ 24 13 14 51 / z / 24 7 8 39 /3z/ 30 17 28 75 total 78 37 50 165 table 5 clearly illustrates that the frequency of morpheme retention increases in the progression: possessive (least retained) —> third person singular —> plural (most j retained). the frequency of allophonic retention increases in the progression /z/ (least retained) —> /s/ —> /az/ (most retained). this pattern is maintained for each individual inflection, with the exception of plurals where /s/ = /z/. an interactional analysis reveals that: — third person singular /az/ is better retained than plurals /s/ and / z / . — possessive /az/ is better retained than third person singular /s/ and /z/. — possessive /s/ is better retained than third person singular /z/. morphological complexity the hierarchy of grammatical difficulty exhibited by r.p. is consistent with reports in the literature (de villiers, 1974;' goodglass, 1976). phonological complexity for the. purposes of the present study, any realization of the allophone was tabulated as a retention of the stimulus allophone. this phonological scoring procedure precluded strict comparison with other writers, who considered the allophone as either correct or inwhilst some explanations have been provided, a more complete account of the above findings would involve detailed consideration of receptive language and perceptual factors, which is felt to go beyond the scope of this study. however, r.p.'s differential retention of the stimulus allophones /s/ and /z/, suggests that further research into receptive language and phonemic perception in agrammatic aphasics, may provide valuable information. interactional analysis the finding that syllabic forms of more complex morphemes are more likely to be retained than non-syllabic forms of less complex morphemes, provides strong evidence for an interaction between apparent phonological and morphological hierarchies of difficulty. major trends overall, the following trends exhibited by r.p. in this study, suggest an interdependence between the phonological and morphological levels of breakdown for this case: la. consonant clusters of purely phonological construction were more likely to be correctly produced than clusters containing a morphological component or suggesting the possibility thereof. b. the cluster categories pc, pcm and mc were clearly differentiated in terms of the proportion of sequencing versus substitution errors. pc reflected a greater proportion of substitution errors, mc a greater proportion of sequencing errors and pcm an approximately equal distribution of both. 2. inflectional deletion appeared to be conditioned by phonological characteristics of the preceding segment as well as the syllabic structure of the word. 3. there was an apparent interaction between the grammatical and phonological hierarchies of difficulty in three morphemes which are homonyms phonologically. conclusions results of this study reflect a mutual interdependence between the phonologically and morphologically impaired systems of this agrammatic aphasic patient. such findings contradict the notions that agrammatism is a uniquely phonological deficit (kean, 1977) or that it is a disruption of the syntactic component of language co-occurring with an independent disorder of articulation (berndt and caramazza, 1981, p. 171). an interactional model between phonology and morphology, suggesting a unitary linguistic representation is strongly die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 meryl kobrin and lesley wolk indicated. verification of the present trends on a large group of agrammatic aphasics may support the contention that there is no single impairment at a specific level in agrammatism. rather, a complex interaction of linguistic processes, all of which are operating at a reduced level of efficiency would be indicated (martin et al., 1975). such a model highlights the inherent limitations of fragmenting the linguistic components in the treatment of agrammatism and suggests a number of clinical implications for the aphasiologist. firstly, diagnostic procedures could possibly include a description of morphological breakdown in the context of phonological breakdown, rather than two detailed but separate analyses. secondly, phonological environments conditioning the omission of inflectional morphemes should be evaluated for each patient and therapy could proceed from phonologically simpler to more complex contexts. further research into the relationship between linguistic components in both aphasia and child language disorders is indicated. this would not only facilitate a more holistic approach to the management of these patients, but would provide greater insight into the organization of language components in a linguistically intact system. references berndt, r.s., & caramazza, a. syntactic aspects of aphasia. in acquired aphasia, m.t. sarno (ed.) new york, academic press, 1981. blumstein, s.e. some phonological implications of aphasic speech. in psycholinguistics and aphasia, h. goodglass & s.e. blumstein (eds.) baltimore, johns hopkins university press, 1973. de villiers, j. quantitative aspects of agrammatism in aphasia. cortex, 10, 36-54, 1974. garman, m. is broca's aphasia a phonological deficit? in linguistic controversies, d. crystal (ed.) london, edward arnold, 1981. goldman, r., & fristoe, m.s. goldman-fristoe test of articulation, minnesota, american guidance service, inc., 1969. goldman, r., fristoe, m.s., & woodcock, r.w. goldman-fristoe test of auditory discrimination. minnesota, american guidance service, inc., 1970. goodglass, h. agrammatism. in studies in neurolinguistics, h. whitaker& h.a. whitaker (eds.) vol. 1, new york: academic press, 1976. goodglass, h., & berko, j. agrammatism and inflectional morphology in english. j. speech hear. res., 3, 257-267, 1960. goodglass, η., & kaplan, e. the assessment of aphasia and related disorders. boston veterans administration hospital and aphasia research centre, department of neurology, boston university, 1972. johns, d.f., & darley, f.l. phonemic variability in apraxia of speech. j. speech hear. res., 13, 556-583, 1970. kean, m.l. the linguistic interpretation of aphasic syndromes: agrammatism in broca's aphasia; an example. cognition, 5 9-46, 1977. kolk, h.h.j. the linguistic interpretation of broca's aphasia. a reply to m.l. kean. cognition, 6, 349-362, 1978. marquardt, t.p., reinhart, j.b., & peterson, h.a. markedness analysis of phonemic substitution errors in apraxia of speech. j. commun. dis., 12, 481-494, 1979. martin, a.d., wasserman, n.h., gilden, l., gerstman, l., & west, j. a. a process model of repetition in aphasia: an investigation of phonological and morphological interactions in aphasic error performance. brain and language, 2 434-450 1975. menyuk, o., looney, p.l. relationships among components of the grammar in language disorders. j. speech hear. res. ,15, 395-406, 1972. paul, r., & shriberg, l. associations between phonology and syntax in speech-delayed children. j. speech hear. res., 25, 536-553, 1982. shankweiler, d., & harris, k.s. an experimental approach to the problem of articulation in aphasia. in psycholinguistics and aphasia, h. goodglass and s.e. blumstein (eds.) baltimore: johns hopkins university press, 1973. wolk, l. a markedness analysis of initial consonant clusters in aphasic phonological impairment: a case study. s.a.j. commun. disord., 25, 81-100, 1978. appendix i ccvcc word list purely phonological construction (pc) blank blanch blink branch breadth frank brink brisk clamp clank clasp clench clinch blimp clump cramp crank crunch brunch crisp phonological construction with morphological possibility (pcm) blind blitz blond blunt brand breast bronze bland brunt cleanse cleft craft crest grant crust crux draft drift flex flux drench drink drunk flank flask shrink french fringe frisk frump grange grasp plank scalp slump stump stink stamp plump prank trump clamp tramp shrimp trunk spunk spank stench trench stomp possibility (pcm) friend front frost grunt gland glance glint craft grand grind ground plant prance prince print scant slant scald spend spoilt stand stance stilt stunt " thrift trance trend trust blast flint phonological construction with morphological combination (mc) frogs tricks spots flossed planes plans slides planned spoons flags sticks groaned steps stoves closed flocks frills spades stocks grabbed stabbed flipped gripped blessed dressed crates braced bricks . smacked crossed brats plaits pricked slapped pressed crabs clocks drapes groped placed cribs clogs ' pricks gripped plates priced clicks grapes clips x the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the relationship between phonology and infectional morphology in an agrammatic aphasic a p p e n d i x ii sonorance inflection word list vowels and dipthongs liquids nasals izl idl izl idl izl bees lied bills bowled farms fees weighed bulls rolled palms knees cared bells called psalms keys died wills pulled charms peas sighed walls wailed rams bears tied wells sailed lambs pears paid pools piled worms firs toyed pills filed bins ways feared pals ruled buns boys reared shells fooled fins toys wired sales cooled pans goes hired goals peeled sons cows shared girls sealed sins fears dared mills mailed vines shears sheared tills railed signs fricatives stops idl izl idl izl idl bombed caves paved jobs dubbed combed coves saved bibs robbed dimmed hives sieved ribs rubbed roamed wives dived cobs fibbed named dives lived cubs rigged tamed waves raved kegs wagged timed thieves loved pigs sagged shunned revs revved pegs begged pinned fives shaved tags tugged sinned calves shoved figs mugged dined hooves seethed buds bugged moaned leaves heaved dogs jogged fined sieves soothed beds jabbed signed doves . moved rugs pegged shamed lives waved pods jigged a p p e n d i x iii phrase/sentence list of plural, possessive and third person singular plural i si i have big cats give me red mats take the pips out turn the lights off i will buy pots i wear white socks i like my shirts they are white rats i like pet shops he took big sips we both hate bats we have red gates i have two kites i buy eight books give me the sacks possessive isl the cat's big paw pat's little boy kate's big red hat the hat's ribbon the pet shop's door the cup's handle the white rat's tail the pet's delight the cake's icing the lake's water the'rake's handle the book's cover rick's baby girl the pope's red robe the pot's handle third person singular isl the young boy laughs the big dog barks the big boy fights that young man jokes the good boy writes he likes to run he wants to eat she puts it in he takes it out she sips the coke he eats the cake he pats the dog the young man talks the good boy waits the white dog bites plural izl i have big dogs she has two bags i bought the pigs he ate two figs i hurt both legs he made the beds i found the logs i like the jugs i have two jobs i bought two wigs he took two rods pass me the rags here are two rugs • i saw lion cubs i bought two nibs possessive izl the dog's collar the jug's handle bob's little girl dad's new red car the boy's handle the big pig's hoof the bird's one wing the bed's one leg the pub's doorway the lad's new toy the lab's doorway the mob's loud noise rob's new baby the bud's petal the rug's colour third person singular izl he begs for food she rubs her leg he rides the bike he robs the bank pat jogs to work he wags his tail she hugs the boy he lugs the chair she digs a hole she leads the way he reads the book she feeds the dog tim guides the man he bides his time he fibs often plural bz/ two big horses they are nurses two red purses take two buses i like sauces run the races take two paces tie your laces two sad faces two big cases take two wishes two big bushes wash the dishes two long sashes two hard courses possessive hzl the nurse's hat the jones's car the horse's mouth james's big hat liz's red shoe the fish's mouth the witch's nose the boss's car the case's key gus's new car roz's new hat the bus's door dez's new cat bess's red hat madge's new car third person singular hzl he washes it he rushes home he dashes home he wishes once she cashes it he misses her she kisses him it gushes out she bashes him he watches her it mashes food he fishes there she pushes him he lashes out she dishes up die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h i s page is s p o n s o r e d by l i t e r a r y s e r v i c e s ( p t y ) ltd academic & medical booksellers johannesburg: pretoria: durban: cape town: campus bookshop 34 bertha street 2017 braamfontein westdene services 76 king george street 2001 hillbrow westdene medio 36 nedbank plaza 175 beatrix street arcadia pretoria phone: (011) 339-1711 phone: (011) 339-1711 phone: (012) 266366 (012) 3233487 phone: i (031) 253221 ext 22 logans westdene 660 umbilo road 1400 durban westdene rondebosch 18 main road 7700 rondebosch phone: (021) 654830 (021) 692407 the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 15 strangers in the house? communication between mothers and their hearing impaired children who sign lavanithum joseph and erna alant centre for augmentative and alternative communication university of pretoria abstract many hearing impaired children rely on signing as a method of communication and are educated through this medium at school. while there is a paucity of information on the use of signing in the home, the impression in the literature is that these children are often unable to communicate through this medium in their homes. this has serious implications for family relationships as well as the personal well being, educational success and social integration of the child. the present study explored the signing experience of 45 mothers of children in the junior primary phase at schools for the deaf in the durban region of kwa-zulu natal as a reflection of the use of signing within the home. a descriptive survey design, using two researcher administered questionnaires, was used to obtain information on the signing practice of mothers, exploring aspects related to the extent to which signing is used, the type of signing used and signing proficiency. the findings revealed mothers' signing skill to be inadequate in terms of their own assessment on rating scales and descriptions of their signing. they signed less frequently than their children did, using speech more often, and with the vast majority using simultaneous communication when they did sign. signing ability was judged to be below that of their children, with sign vocabularies of between 0-50 words for 85% of the participants. it appears that sign learning by hearing parents of deaf children in this region needs to be actively promoted. the implications of these findings are discussed to address the communication needs of signing deaf children and their families within the south african context. key words: sign language, sign systems, signing proficiency, deafness, mothers of deaf children. introduction . ' the professions of 'speech language therapy and / audiology in south africa have concerned themselves with issues of signing for some time. studies have been undertaken to assess the signing abilities of teachers (aron et al., 1986) and resource development for sign learning (cohen, 1996). deaf education and deaf culture in south africa have been raised as pertinent issues (penn and reagan, 1991; penn, 1993). more recently there have been • discussions around the issue of sign bilingualism in deaf education with reference to the profession (joseph, 1998; joseph, 2000; noorbaai, 2000). professional interest in the young deaf child begins during the period of diagnosis and early habilitation and interfaces with deaf education. the greatest task facing both parents and professionals working with deaf children in the early years is that of breaking the communication barrier that exists between a mother and her deaf child (gregory, 1995). parents need to establish communication, as any withdrawal from interaction would later be played out in a complex way by society's withdrawal of communication from the deaf child (hull, 1997). the decisions now facing parents, however, tends to be more complex because of the choice to sign or not to sign, and whether or not to stress signing with speech or sign language (gregory, 1995). parents are given options with regard to communication methods that are available, viz. oralism, total communication or bilingualism (lynas, 1994), yet they often have to enter an education system that focuses on signing. for example, all eight public schools for the deaf in kwa-zulu natal use signing as a medium of instruction. thus parents have to sign out of necessity if they want to communicate with, and be part of their deaf child's world. the complexity· of this situation cannot be underestimated. more than 90% of deaf children are born to hearing parents who do not know how to sign (kyle and woll, 1988). acceptance of signing, learning to sign, and interacting meaningfully and easily with the child through signing is what is required. the signing skills of parents, their attitude towards signing and the opportunities they have to learn to sign are strongly related to each other and have a direct bearing on their use of signing (bornstein, 1990). in this respect there is a paucity of information on the experiences of mothers who sign. there are indications however, that signing is generally not exploited in the home environment. it appears that the communication methods used at school do not commonly match those used in the home, as speech rather than signing seems to dominate interaction among hearing parents and their signing deaf children (bess and humes, 1995). according to bornstein (1990) half the children exposed to signing at school may not see it at home. the majority of deaf children learn to sign without input from their parents and 90% of parents are learning to sign at the die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 lavanithum joseph & erna alant same time as their child (gregory and hartley, 1991). luterman (1987) states that most hearing parents do not develop sufficient signing skills to communicate fully with their children. it therefore appears that while there are parents who do learn and use signing to communicate with their deaf signing children, many do not. learning to sign requires an investment in time and effort that many parents are often unwilling and/or unable to make (bornstein, 1990). inadequate signing proficiency of parents of children who are in signing programmes in the education system can be attributed to barriers that parents encounter in their attempts to learn to sign. these can be broadly classified as distance from the learning centre, transport difficulties, time constraints due to employment and family responsibilities, language difficulties with regard to lack of proficiency in the spoken language of the school, lack of immersion in a signing environment, and the lack of resources (swisher and thompson, 1985; cohen, 1996; lynas, 1994). impoverished communication between signing children and their parents is evident in the numerous accounts of the difficulties, isolation and bewilderment that deaf children experience in situations that are considered normal in everyday life. these reports tell of children's inability to access information vital to their understanding of events around them, and of sharing their thoughts, joys and fears with those closest to them (lane et al., 1996; mindel and vernon, 1987). in most instances, these are their parents and siblings. these children and their parents are described as being "strangers" in their own home (mindel and vernon, 1987:xix). the terms being used to describe the failure to address the language needs of deaf children are "oppression" and "abuse" (preston, 1994:127; deafsa, 1997:10). on the other hand, mothers of young deaf children have been reported as feeling "cutoff' from their children, often wondering what their children were thinking or feeling (gregory, 1995:194). mindel and vernon (1987) show concern for the emotional frustrations that deaf children and their parents undergo and call for enhanced sympathy toward these families. information relating to parents' use of signing appears to be particularly relevant at this stage in deaf education. there have been significant changes in the status of sign language all over the world with important implications for deaf education and service provision. sign language has been acknowledged as a legitimate language, equivalent to any spoken language (kyle and woll, 1988). many researchers consider sign language as the first and natural language of deaf people (sacks, 1989; stokoe, 1990). in keeping with these developments, sign language has been accepted by the south african constitution as a language that needs to be promoted, and the new south african schools act recognizes sign language as an official language for educational purposes (deafsa, 1997). bilingualism as an approach in deaf education is being promoted by academics and the world federation for the deaf. this educational philosophy has implications for the professions of speech-language therapy and audiology. these relate particularly to the issues of counselling at diagnosis, prescriptive practice, information dispensing following diagnosis, the role of the audiologist in parentinfant programmes and the role of speech training for the deaf child. it has been stated that parents have not been served well by the professionals involved in the area of deafness (mindel and vernon, 1987) due to a lack of awareness of the communication needs of parents and their deaf children as well as a failure to provide them with realistic solutions. related to this is the critical issue of lack of consensus among professionals in the field with regard to signing being a method of choice with the deaf child. therefore, eliciting information from parents themselves about their signing experience, would appear to contribute to a better understanding of the unique needs of parents who need to sign. the extent to which signing is used within the home context by signing children and their parents would be explored in terms of meaningful communication that is perceived as mainly inadequate by most writers. methodology aim the aim of the study was to describe the signing practice of mothers of junior primary school children in signing programmes at schools for the deaf in the durban metropolitan area. objective: to describe mothers' perceptions of: • their use of signing in comparison to other methods of communication used • the type of signing used • their signing proficiency research design a descriptive survey design was employed with the use of a structured interview format. this method was considered suited to the data which were the perceptions of mothers (leedy, 1993). the design, through the descriptive record allows scrutiny of the data as well as relations within the data, including the use of statistical techniques. subjects subject selection criteria the subjects needed to be mothers of children attending schools for the deaf where signing was used as a medium of instruction. mothers were chosen as they are considered the main language stimulators in the home and the caregivers most likely to be involved in the intervention programme. in addition, mothers were considered to be more easily accessible and, by restricting the sample to mothers alone, the homogeneity of the sample would be increased. legal guardians and primary care-givers such as grandmothers were included in keeping with the definition of parent used in the public discussion document of the national commission on special needs in education and training and the national committee for education support services (1997). only schools in durban registered with the kwa-zulu natal education department were included. children needed to be in the junior primary phase of education as the first level of formal schooling was seen as beneficial in terms of addressing the issue of parent-child communication in the early years of school life. only children in grade one (entry the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) strangers in the house? communication between mothers and their earing impaired children who sign 17 level) and grade three (exit level) were selected as this was considered an adequate range of this phase. thus the sampling method can be described as purposeful sampling. description of schools all four public schools for the deaf in the durban area were included in the study. these schools were based at amanzimtoti, gillits, newlands west and umlazi. two schools were residential schools. all schools were english medium schools. the sign dialect varied amongst the schools, although all four schools embraced the concept of sign bilingualism. description of mothers forty five mothers participated in the study. mothers came from a diversity of backgrounds. age: most mothers (62%) fell in the 30-39 year age group. marital status and employment: a large number of mothers (39%) were single mothers with 52% of mothers working. educational status: most mothers (55%) had not completed high school. language background: more than a third of mothers (36%) spoke zulu in the home, while many of them (28%) were not proficient in the language medium of the school, viz. english. residential background: the majority of mothers (91%) lived in and around durban. home visits revealed that many mothers lived in poor conditions in both informal and formal dwellings, while some came from wealthy suburban homes. description of children there were 42% males and 58% females in the study. age and grade: children were between 5 and 13 years of age, with most of them (33%) in the 8year category. / approximately half the children were in grade one (51%) / and half in grade two (49%). hearing status: according to school records, hearing losses (based on the pure-tone average of the better ear unaided), fell within the range of moderate to profound. most of the children (58%) had profound losses, while 27% ' had severe losses. thus the majority of children (85%) in the study could be classified as having severe and profound hearing impairment,'with onset prelingually (89%). hearing aids were worn consistently (daily at home and at school) by a small percentage of these children (24%), although 91% of them did wear hearing aids. signing background: all children were able to sign. most children (64%) had begun signing between the ages of 3 and 6 years with the majority signing for 3 years or more (78%). the average number of years of signing was 4 years. spoken language: with reference to spoken language ability, 18% were described by their mothers as not using spoken language at all, while a further 58% were only able to communicate using a small vocabulary, speaking on a few topics. thus 76% of the children were considered by their mothers to have inadequate spoken language ability. approximately a third of the children lived in the school residential facility. description of the instrument two questionnaires, questionnaire i-mothers' experience with sign communication: background information, and questionnaire ii-mothers' experience with sign communication: methods of communication were developed based on relevant literature and consultation with experts in the field with regard to the suitability of the questions in terms of structure and content. closedended questions using mainly multiple choice responses were used as it was felt to be an easier format because of the difficulties with terminology and concepts, and their implications for the analysis of responses and reliability of the instrument. care was taken with the wording of questions so as to avoid ambiguity, maintain a logical sequence and provide an exhaustive range of possibilities with the category of "other" available to allow respondents freedom to express themselves. the first questionnaire sought background information of both the mother and the child. the second questionnaire focussed specifically on issues relating to signing practice. questionnaire i consisted of 20 questions that sought demographic information of mothers, mothers' communication background with regard to home language, language proficiency, and hearing status as well as identifying information of the children with regard to gender, age, grade and hearing status. questionnaire ii comprised of 19 questions that pertained to mothers' perceptions of their children's spoken language abilities, methods of communi.cation (speech, natural gestures, signing, writing and 'other') used in parent-child communication in terms of frequency of use and the success of these modes in conveying information, mothers' rating of their own and their children's signing ability, and mothers' description of their signing with regard to range of topics, syntactical complexity and type of signing used. rating scales were used to describe the use of signing in comparison to other methods of communication and to describe signing proficiency. the assessment of signing proficiency was based on the 5point scale used by metz et al. (1997) in the language background questionnaire. according to the authors, the rating of signing skills on a scale of one to five, with one being equivalent to no skills and five being equivalent to excellent skills, was found to have reasonable criterion validity for self-assessment of sign language skills of adults as there was a high degree of congruence between self-assessed communication skills and formal measures of communication skills. the authors further cite the advantages of self -assessment instruments as including ease of administration, low expense, non-threatening and non-invasive nature, as well as validity of the tool in terms of face validity as self reports reflect personal experience. mothers rated their signing proficiency both globally and specifically on a receptive level. their global skill was taken as the main indicator of their signing skill. information was also sought on the communication modes and signing proficiency of the children for purposes of comparison as parents have been observed to adjust their level of communication to suit that of their children (gallaway and richards, 1994). multiplechoice and multiple response questions were used to allow parents to describe the type of signing they used. a cross check was used to assess the validity of the response by probing with the use of the centre for assessment and demographic studies (cads) measure die suid-afrikaanse tdskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 to assess the type of signing used by teachers, based on the way teachers described how they would sign two english sentences (woodward, 1990). both a pre-pilot and a pilot study were undertaken to test the instrument and assess the conditions under which the study would be carried out. following these procedures adjustments were made to the wording of certain questions to improve clarity. the questionnaires were translated into zulu as many children at the schools came from a zuluspeaking background. the back-translation method was used. note: this article is based on an aspect of a study (joseph, 1998) which may be consulted for a sample of the questions described above. procedure mothers were accessed via the school. school principals granted permission for letters requesting parent participation to be sent home via the children selected for the study, viz. all children in grades one and grades three at the selected schools. interviews were set up with all parents who indicated their willingness to participate in the study via return slips. interviews were confirmed telephonically. the site of the interview was determined by parent preference such as the home, place of employment or school to encourage parent participation. interviews were scheduled over a twoweek period and were of approximately 20 minutes duration. questionnaires were administered via a structured interview by the researcher or a fieldworker who was fluent in zulu and english. fieldworkers were chosen for their familiarity with the interview process. two fieldworkers were used. one fieldworker was a nurse at one of the schools and who had frequent contact with parents and often acted as an interpreter at the school. the other fieldworker was a student in her third year of study in speech and hearing therapy and who had experience in interviewing parents and issues of communication. both field workers received training in terms of administering the particular questionnaires via role-play and during the pilot study so as to ensure reliability and consistency across interviews. the interview was particularly important in obtaining data from those who were illiterate or who had low literacy levels and whose participation would be restricted by the use of a selfadministered questionnaire. data analysis lavanithum joseph & erna alant results and discussion the signing practice of mothers is described in terms of three aspects, viz. their use of signing in comparison to other modes of communication used, the type of signing used, and their signing proficiency. use of signing in comparison to other modes of communication the frequency of signing is presented both in terms of a comparison between its use with other modes of communication, and a comparison between its use by mothers and their children. an overview of communication modes used is presented in table 1. figure 1-3 describes the findings for specific modes. use of signing children tended to sign more frequently than their mothers did as more than half the sample (53%) always used signing as a method of communication, compared to 40% of mothers who always used signing as a method, as is reflected in figure 1. this is further exemplified by the mean responses on table 1 which shows children as bordering on the category of "usually" using signing table 1: frequency of use of the various modes of communication used by mothers and their children (note: the 5 point rating scale used translated as 1 = never, 2 = rarely, 3 = sometimes, 4 = usually and 5 = always). communication mode mother child communication mode x sd x sd signing 3.60 1.44 3.89 1.35 speech 3.69 1.51 3.42 1.57 gestures 3.49 1.38 3.51 1.29 ; writing 1.40 0.72 1.40 0.78 . other 1.46 0.87 1.36 0.81 , the data was analysed using both descriptive and inferential statistics. measures of central tendency (mean, median and mode) and measures of variability (standard deviation and range) were calculated for all variables in questionnaire i and questionnaire ii. correlation coefficients were calculated to determine the strength of the relationship between variables. a series of non-parametric tests including chisquare, spearman's correlation coefficient and mann-whitney tests were used in accordance with the nature of the data for which relationships were sought (leedy, 1993). 60 50 40 30 20 10 0 53 13 22 18 _ 1 7 i n 16 n e v e r r a r e l y s o m e t i m e s u s u a l l y a l w a y s i m o t h e r s ® c h i l d r e n figure 1: comparison of mothers' and children's use of signing the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) strangers in the house? communication between mothers and their earing impaired children who sign 19 compared to mothers who were closer to the description of "sometimes" using signing. there was, however, a positive correlation (r = .7020, ρ < .01) between mothers' and children's use of signing. thus, as the child's tendency to sign increased so did their mother's signing. this tendency to match the child's mode of communication is reported by gregory et al. (1995) in their study of deaf young people and their families. parents whose children had been educated in the oral tradition had subsequently learned to sign or accompanied gesture with their speech if their children were using sign language in their later years. use of speech there was a positive and significant relationship between mothers' use of speech and the child's use of speech (r = .6613, p< .01). once again parents and children tended to match the communication mode used. however, a comparison between mothers' use of signing and speech indicated a negative correlation (r = -.4584, ρ < .01). it therefore appears that parents who were speaking tended not to sign or vice versa. in addition, for those mothers who used speech to communicate, only about a third (31%) found it always successful in conveying information to their child (results not presented). on the other hand, 22% of children who used speech were considered to be always successful in conveying information to their mothers. it therefore appears that speech was used by the majority of mothers despite it not always being successful. the use of speech by mothers of deaf children has been encouraged in both the oral and total communication approaches. gregory (1995) reports that while many mothers in the oral tradition (33% in her study) spoke constantly to their child whether they were listening or not, none reported not speaking at all. preston (1994) confirms this by stating that even those deaf persons who were oral were no more likely to have good communication with hearing parents. only 13% (37 of 288) of his sample of deaf adults could communicate well with at least one parent. use of writing and other methods of communication writing as a method of communication, was generally not exploited by both parents and children. the majority of parents and children (71%) did not use writing at all as a method of communication. those who did use it as a method tended to do so rarely. this could be considered a low result given that children were in the formal phase of schooling, with approximately half the children (49%) in grade three where writing was being used in the educational programme. this is especially so given the difficulties that children, who used speech, were generally having in conveying and receiving information. studies have shown that reading as a receptive mode is highly successful in communicating with deaf children (grove, et al., 1984). the failure to explore writing has implications for the bilingual approach which promotes the use of writing as a primary method of communication to be used in interaction. gregory et al. (1995) also report parents' failure to use writing to communicate with young deaf people. only 1% (1 in 82) of parents reported using writing to communicate. similarly a large number of parents (76%) did not use any other method to communicate. those mothers who did use other methods, did so infrequently and used drawings (11%), pictures (7%), objects (4%) and the "sign language" dictionary (2%) to communicate. over one third of the children (38%) used other methods to communicate and these included the use of drawings (40%), pictures (4%) and the "sign language" dictionary (2%). it appears therefore that there was a group of parents and children who felt the need to explore alternate means of communication as they could not communicate effectively with signing, gestures or speech. the fact that 40% of children 60 « 5 0 1 j? 40 | 30£ 20 ί ο η 0 13 18 11 13 m l 18 20 9 7 never rarely sometimes usually always i mothers id children use of gestures figure 2: comparison of mothers' and children's use of speech in terms of the relationship between mothers' use of gestures and signing, there was a positive correlation (r = .5728, ρ < .01). this is unlike the relationship with mothers' use of speech and signing. it therefore appears that mothers who used formal signing more also tended to use gestures more. however, only 39% of mothers who used gestures found it always successful in conveying information. the need to use gestures seems to indicate a possible inadequacy of their formal signing skill as well as an inability to communicate through speech. , ν cn η c a υ l. a q. 40 35 30 25 2 0 15 1 0 5 0 31 31 11 11 11 ε 18 u l n e v e r rarely s o m e t i m e s u s u a l l y a l w a y s i m o t h e r s h c h i l d r e n figure 3: comparison of mothers' and children's use of gestures die suid-afrikaanse tdskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 lavanithum joseph & erna alant were using drawing to communicate indicates their need to establish effective communication with their mothers. this finding seems to support the reports of many deaf children of the poor communication between themselves and family members. lane et al. (1996) cites a survey at a school for the deaf which found that only one in ten parents could communicate with his/her deaf child. in summary it is clear that the three most common methods of communication used in parent-child interaction were speech, signing and gestures. however, the extent to which each was used varied much between both mothers and children as is evident in the means recorded in table 1. however, children tended to sign more than their mothers. on the other hand, mothers tended to speak more than their children did. this finding has been reported by bess and humes (1995) as a general trend with children in signing programmes. the reliance on spoken language as the sole means of communication with a deaf child is said to severely restrict parent-child interaction and interfere with the bonding process and communication with far reaching implications for the child's cognitive, linguistic, emotional and educational progress (lane et al., 1996). mothers'description of their signing mothers' signing is described in terms of their stated vocabulary, their communication at discourse level, use of sentences and the type of signing used. sign vocabulary if signing vocabulary by itself was to be used as a yardstick for measuring parents signing skill, the overall results are very low. the majority of mothers (65 %) had a vocabulary ranging from 0 to 20 words. a further 20% had a vocabulary of between 21 to 50 words. in effect, 85% of the sample had a vocabulary size below 51 words. it appears that the majority of mothers had a signing vocabulary that was inadequate for fluent communication table 2: mothers' estimation of their signing vocabulary through the medium of signing. the 50-word vocabulary is regarded as an indication of normal developmental level for a speaking child of 18 months, while the average preschool child, according to yoshinaga-itano as cited in jones (1995), is said to have a vocabulary of between 3000 and 6000 words. in addition sign language lexicons have been described as ranging from 1000 to 4000 words, which, even so, is considered a gross underestimation of american sign language which is considered to be a fully expressive language (bellugi, 1980). the signed english sign system has a lexicon of over 3100 words. the inadequacy of the stated vocabulary of most parents is indicated by the fact that the majority (74%) of those parents who did sign described their signing vocabulary as allowing them to communicate on only a few topics, while none were able to sign on any topic as reflected in figure 4. communication at discourse level the ability to construct sentences is required to communicate efficiently at discourse level. however, only 42% (16) of the 38 mothers who signed could sign sentences. results are similar to those obtained by bornstein (1990) who reported low signing skill at sentence level in a study conducted at maryland school for the deaf in the usa. approximately half the parents could sign sentences after six months of lessons. however, if the entire sample of this study were considered it can be said that only 29%, less than a third, of the sample could sign sentences. of those who could sign sentences, the majority (81%) only felt competent to interpret for their own child. none felt competent to communicate with deaf adults. figure 5 reflects parents' rating of their communication at discourse level. the ability to communicate with deaf adults is considered to be an indication of a high level of skill and is used as a measure of proficiency in sign learning programmes. as none of the parents could communicate freely with a deaf adult, it can be assumed that mastery of signing as a mode of communication had not occurred for any of the parents in the sample. it is acknowledged though, that the level of skill is not the only factor influencing proficiency. sign dialect could also influence whether or not parents feel competent in communicating with deaf adults. however, this factor was not considered significant in the study as parents were expected to be at least in contact with those who shared a similar dialect because of association with the particular school. j size of vocabulary number (n=45) percentage 0 7 16% 1-10 13 29% 11-20 9 20% 21-50 9 20% 51-100 1 2% 101-200 4 9% 201-300 0 0% 301-500 1 2% 501-999 0 0% 1000+ 1 2% total 45 100% most topics 1 0 % \ any topic y g 0 % m a n y topics__ / λ 1 1 6 % ^ ^ • , f e w topics 7 4 % figure 4: mothers' ability to sign on a range of topics the south african journal of communication disorders vol. 47 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) strangers in the house? communication between mothers and their searing impaired children who sign 21 type of signing used home signs constituted the most common type of signing used, with 58% of signing mothers reporting its use. two zuluspeaking mothers who used home signs exclusively were included in this category. one of the mothers reported an elaborate signing system that included a vocabulary of more than 100 signs that allowed her to converse with and interpret for her child. lane et al. (1996) make reference to this type of communication which develops when a child is unable to communicate with family members through an oral medium and does not have access to a formal signing system. home signs are said to quickly disappear when children are exposed to formal signing (stokoe, 1990). it therefore appears that this mother did not have access to the system her child was using at school. the fact that many mothers were using home signs together with formal systems seems to indicate inadequate proficiency in formal signing. fingerspelling was the second most common type of signing used, even though it was used by a relatively small percentage of parents, i.e. 38 %, who were able to sign the manual alphabet. as fingerspelling supplements signing, it appears that the majority of parents would have difficulty in providing novel information to their children as is accommodated with fingerspelling for those who sign. as fingerspelling is a component of both sign languages and sign systems, parents' lack of this skill could be used to estimate their general signing ability. on the probe of the description of how they would sign two english sentences which could be taken as a more accurate representation of the type of signing that mothers were using, 44% (7) of those mothers who could sign at sentence level were using manually coded english (mce). this closely matched the number of mothers who actually stated using this method as reflected in table 3. however, only 19% (3) used key word signing. thus the other 9 mothers who described themselves as using key word signing (table 3) could not be classified in this category, confirming their lack of knowledge in describing their signing or possibly their poor signing skill. gregory et al. (1995) also record the tendency of parents to describe themselves as signing despite poor skills, which their rating 4 rating 3 0 % rating 1 19% v rating 2 81% rating 1 can hold a simple conversation rating 2 can interpret a simple conversation for their deaf child rating 3 can hold a good conversation with a deaf adult rating 4 can interpret for deaf adults without difficulties young deaf children chose to rather not consider as signing at all when describing their parents' ability to sign. it appears that deaf children used stricter criteria for what constituted signing ability. only 1 mother (6%) appeared „ to be using sign language. there were 5 mothers (31%) who could not be classified into a particular system as a result of inconsistencies in their signing. it therefore appears that only 8 of the mothers signed fluently within a prescribed system, that is, 18% of the sample and 50% of those mothers who signed at sentence level. whatever the type of signing used though, it became evident that signing was largely based on english as the vast majority of the 40 mothers who did sign, i.e. 36 (90%), reported speaking and signing at the same time. according to lane et al. (1996:269), 90% of teachers surveyed in a 1990 study in the usa reported using simultaneous speech and signing, with over 85% of teachers using or trying to use mce. it would therefore appear that parents' responses in this study are similar to those of teachers of the deaf. it must be noted though, that the use of simultaneous communication has been associated with poor signing skill (erting, 1980). furthermore, it has been a contention that simultaneous communication does not serve the purpose of communicative interaction (sacks, 1989; lane et al., 1996). mothers'perception of their signing proficiency a comparison was made between mothers' and children's signing skill to ascertain if mothers' level of signing was in any way influenced by their children's level of skill. it is clear from their description of their signing proficiency that mothers' signing skill is inadequate in the main. a large percentage of mothers (29%) stated that they had no signing skill as such while a further third (33%) described themselves as having poor skills. only 5 mothers (11%) considered themselves better than average. these results are in keeping with the previous description of generally low vocabulary levels and inability to converse at discourse level. on the probe of their receptive signing ability, mothers rated their receptive signing higher than expressive signing (as depicted in table 4). this therefore indicates that although mothers described low levels of signing competence, they were able to understand their child's table 3. mothers' report of the type of signing used figure 5: mothers' rating of their communication at discourse level (n=16) type of number percentage signing used (n-40) not sure/unknown 19 48% home-signs 23 58% fingerspelling 15 38% key word signing 14 35% . manual code of english 6 15% south african sign language 3 8% other 14 35% die suid-afrikaanse tvdskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 lavanithum joseph & erna alant signing better than they were able to sign themselves. this seems to indicate that they were realistic in their assessment of their own skills as receptive language is generally judged to be better than expressive language for competent speakers of a language (bornstein, 1990). their responses do differ, however, from findings for hearing teachers of the deaf in non-residential, nonintegrated school settings who in the 1985 cads study (bornstein, 1990) rated their receptive signing poorer than their expressive signing. it therefore appears that these hearing parents were closer in their responses to teachers of the deaf in residential schools who tended to rate their receptive signing higher, perhaps reflecting a better proficiency and maybe perception of their abilities due to increased contact with signers and exposure to signing. it would appear also that children were signing despite their parents' poor proficiency. when a comparison of mothers' and children's signing is made, it is evident that mothers considered their children's signing to be superior to their own, as evidenced by the mean score of 3.7 for children, a rating of almost good and 2.2 for mothers, a rating close to poor. it therefore appears that these mothers are generally unable to communicate on an equal level with their children through signing, which is of serious consequence, if signing is the main medium of communication for the child. this could very well be the case as the majority of children in the study (76%) were described as either not using spoken language or able to speak on only a few topics. this seems to confirm the impression in the literature that signing children are generally unable to communicate within the family. the study by gregory et al. (1995) of young deaf people and their families records only half the number of young people whose preferred language was british sign language as having parents who used any type of signing. to explore possible factors influencing mothers'signing proficiency, relationships with certain demographic details was sought. results are reflected in table 5. it appears that home language was a significant factor. given the fact that the majority of zulu-speakers, 27% of the entire sample, described themselves as not being proficient in english which was the medium of instruction at these schools, it appears that this is impacting on their signing skill. christensen (1986) highlights the difficulty that monolingual spanish speaking parents of children attending english medium schools in the usa have in learning to sign. christensen therefore suggested a trilingual approach as an alternative to bridging the communication gap between english speaking teachers, spanish speaking parents and signing children. the trilingual approach which consisted of using both the oral languages and conceptual signing was subsequently tried in a two year programme using television as a medium. results mdicated that those parents who viewed the programme regularly improved their signing competence (christensen, 1986). in addition, positive attitudinal change was noted both towards hearing loss generally as well as toward com60 -, 50 40 i 30 η 1) m> « 1) ph 2 0 10 0 munication with the child. thus mothers' signing skill was judged to be inadequate in terms of their own assessment on the rating scale and descriptions of their signing. only 11% (5) considered their signing to be good or excellent. the majority of parents had a vocabulary of 50 words or less. as these children are in the first phase of formal schooling and are very much dependent on parent input, the role of parents as the primary educators of their children comes into question. it is evident that the majority of parents in the study are not in a position to support the academic programme as their children are ahead of them in relation to signing skill. as the majority of children were described as having low spoken language ability, it appears that communicative interaction for the majority of mothers and children is inadequate. there is reference in the literature to the signing child growing apart from his family. gregory et al. (1995) describe mothers who began learning to sign in order to be part of their growing child's social world. when language barriers between parents and their young child exist, communication is said to become frustrating and stressful as well as superficial (schoenwald-oberbeck, 1984). it appears therefore that the subjects in this study are at risk for such a situation. there have been other indications that the signing skills of parents of deaf children in other regions in south africa is low, e.g. lenasia (cohen, 1996). it therefore appears that sign learning by parents of deaf children is a serious issue especially within this region if not nationally. while schools for the deaf have traditionally carried the responsibility of teaching parents to sign, it appears that a broader response to the issue is needed, involving close co-operation table 4: mother's rating of their own and their children's signing skill (scores on the rating scale were interpreted as: 1 = no skills, 2 = poor skills, 3 = fair, 4 = good, 5 = excellent) variable x sd mothers' global singing ability 2.22 1.04 mother's receptive singing ability 2.60 1.01 children's signing ability 3.73 0.92 53 33 29 i i no skills poor 16 fangood excellent mothers' global signing ability • children's global signing ability figure 6: comparison of mothers' and children's signing skill the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) strangers in the house? communication between mothers and their hearing impaired children who sign between the health and education sectors as well as welfare and non-governmental organisations. sign learning by hearing parents of deaf children has to be actively promoted at all levels by all professionals working with children who are dependent on a visual mode of communication. policies and strategies need to be put in place to ensure that opportunities are available, together with the necessary support for families to learn to communicate through sign language with young deaf members of the family. conclusion the low levels of signing proficiency among hearing mothers of deaf children in signing programmes has implications for both service provision and future research. fundamental to this would be the stance that parents need to sign and should receive the necessary support when their child is committed to a signing educational programme. as the children in this study were already committed to a methodology, viz. signing, the debates around methodology become less significant in comparison to the issue of parents' communicating meaningfully with their children and supporting the educational programme by becoming competent signers. luterman (1987) stresses that professionals recognize that they are working with functional families that could be made more optimal by their intervention. according to mcconkey (1985), the implication for all professionals working with helping children is that parental help is necessary if they are to do their jobs efficiently and effectively. he does feel however, that this is "more often preached than practiced" (mcconkey, 1985:13). according to jones (1995) family-professional relationships need to be based on fundamental beliefs that make them workable, such as the belief that families have the capacity to be competent and do have resources. the professional role becomes one of mobilizing and assisting families to draw on their resources. outcomes are then based on the professional's capacity and desire to promote the family and utilize their resources. the role of the professional 7 therefore is expanded beyond the technical skills of their discipline, in that professionals drive policies and procedures that result in the empowerment of the family. these principles appear applicable to the audiologist and speech -language therapist who especially in the initial stages, work closely with deaf children and their parents in order to break the communication barrier and prevent isolation of these children within the family. references aron, m. l., louis, r. e. & willemse, j. l. (1986). the issue of signs and the coding of prefix markers by teachers at a school for the deaf. south african journal of communication disorders, 33, 64-72. bellugi, u. (1980). how signs express complex meanings. in c. baker & r. batterson. sign language and the deaf community. usa: national association for the deaf. bess, f. h. & humes, l. e. (1995). audiology: the fundamentals. (2nd ed.) baltimore: williams & wilkins. bornstein, h. (ed.). (1990). manual communication: implications for education. washington: gallaudet university press. christensen, κ. m. (1986). conceptual sign language acquisition by spanish-speaking parents of hearing impaired children. american annals of the deaf, 131, 4, 285-287. cohen, b. (1996). the development of a sign language resource for parents of deaf children in lenasia. unpublished undergraduate research report. johannesburg: university of the witwatersrand. deafsa. (1997). higher education and the needs of the deaf community: discussions with the university of south africa (unisa). unpublished paper, johannesburg. erting, c. (1980). sign language and communication between adults and children. in baker, c. and batterson, r. sign language and the deaf community: essays in honour of william stokoe. silverspring: national association for the deaf gallaway, c. & richards, b. j. (1994). input and interaction in language acquisition. new york: cambridge university press. gregory, s. (1995). deaf children and their families (2nd ed). cambridge: cambridge university press. gregory, s., bishop, j. & sheldon, l. (1995). deaf young people and their families: developing understanding. cambridge: university press. gregory. s. & hartley, g.m. (eds.). (1991). constructing deafness. london: pinter publishers limited. grove, c. & rodda, m. (1984). receptive communication skills of hearing impaired students: a comparison of four methods of communication. american annals of the deaf, 129,4, 378-385. hull, r. h. (1997). aural rehabilitation: serving children and adults (3rd ed). san diego: singular publishing group. jones, a. (1995). joining the family. seminars in hearing, 16, 2, 196-205. joseph, l. (1998). perceptions of mothers of children in schools for the deaf in durban with reference to the use of sign language. unpublished master's dissertation. pretoria: variable mean rank ρ value significance grade grade 1 -21.20 grade 3 -24.89 .3258 not significant day versus residential scholar day scholar -23.17 residential -21.07 .5996 not significant home language english -26.57 zulu -16.03 .0057 significant at <.05 level gender male -20.95 female -24.64 .3288 not significant table 5: exploration of selected variables associated with signing proficiency die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 lavanithum joseph & erna alant university of pretoria. joseph, l. (2000). bilingual education for deaf children: the challenge to the professions of speech-language pathology and audiology. paper delivered at the 2nd international symposium on communication disorders in multilingual populations. 1821 july. pilanesberg national park. south africa. kyle, j. g. & woll, b. (1988). sign languagethe study of deaf people and their language. new york: cambridge university press. lane, h., hoffmeister, r. & bahan, b. (1996). a journey into the deaf-world. california: dawnsignpress. leedy, p. d. (1993). practical research: planning and design. (5th ed.). new york: mcmillan publishing company. luterman, d. (1987). deafness in the family. boston: college-hill press. lynas, w. (1994). communication options in the education of deaf children. london: whurr publishers ltd. mcconkey, r. (1985). working with parents: a practical guide for teachers and therapists. london: croomhelm. metz, d. e, caccamise, f. & gustafson, m. s. (1997). criterion validity of the language background questionnaire : a selfassessment instrument. journal of communication disorders, 30, 1, 23 -32. mindel, e. d & vernon, c. (eds.). (1987). they grow in silence: understanding deaf children and adults. boston: collegehill press national commission on special needs in education and training (ncsnet) &'national committee for education support services (ncess). (1997). education for all. from 'special needs and support' to developing quality education for all learners. summary of publication document. noorbaai, k. (2000). the role of the speech therapist in a school for the deaf. paper delivered at the 2nd international symposium on communication disorders in multilingual populations. 18-21 july. pilanesberg national park. south africa. penn, c. (1993). signs of the times: deaf language and culture in south africa. south african journal of communication disorders, 40, 11-23. penn, c. & reagan, t. g. (1991). towards a national policy for deaf education in the 'new' south africa. south african journal of communication disorders, 38, 19-25. preston, p. (1994). mother father deaf: living between sound and silence. cambridge: harvard university press. sacks, o. w. (1989). seeing voices. a journey into the world of the deaf. texas: pro-ed. inc. schoenwald-oberbeck, b. (1984). a communication programme , for enhancing interaction in families with a hearing impaired child. american annals of the deaf, 129, 4, 362-369. stokoe, w. c (1990). language, prelanguage and sign language. seminars in speech and language, 11, 2, 92-99 swisher, μ. v. & thompson, m. (1985). mothers learning simultaneous communication: the dimensions of the task. american annals of the deaf, 130, 3, 212-217. woodward, j. (1990). sign english in education of deaf students. in bornstein, h. (ed.). manual communication: implications for education. washington: gallaudet university press. the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 71 burnout: a smouldering problem amongst south african speechlanguage pathologists and audiologists? marilyn swidler & eleanor ross department of speech pathology & audiology university of the witwatersrand abstract the present study aimed to investigate the frequency of burnout occurring within the profession of speech-language pathology and audiology and to examine possible work situation factors unique to the profession, that may be correlated with burnout. a cross-sectional postal survey research design was used, including a standardised measure of burnout as well as a questionnaire inquiring about demographic and work situation variables. subjects were randomly drawn from names obtained from the south african medical and dental council. results were analysed statistically using pearsons correlations, multivariate analysis as well as bonferroni t-tests. the main finding that emerged was that, as a group speech-language pathologists (splp's) and audiologists in south africa are experiencing moderate levels of emotional exhaustion, low levels of depersonalisation as well as high levels of personal accomplishment. therapists working in hospitals, mainly treating peripheral hearing disorders, working either as audiologists only or speechlanguage therapists and audiologists, with heavy caseloads and extensive paperwork, and perceiving themselves to be under large amounts of work pressure, appear to be the most susceptible to burnout. opsomming die huidige studie het ten doel om die frekwensie van uitbrand ("burnout") binne die beroep van spraak-taalpatologie en oudiologie te ondersoek en om moontlike werksituasiefaktore wat uniek is aan die beroep en met uitbrand gekorreleer kan word, uit te lig. 'n veldopname navorsingstegniek is gebruik tesame met 'n gestandaardiseerde uitbrandmeting asook 'n vraelys aangaande demografiese en werksituasie veranderlikes. proefpersone is toevallig geselekteer uit name van beroepslede wat van die suid-afrikaanse mediese en tandheelkundige raad verkry is. resultate is statistics geanaliseer. die belangrikste bevinding was dat spraak-taalterapeute en oudioloe in suid-afrika as 'n groep redelike vlakke van emosionele uitputting, lae vlakke van persoonlikheidsaftakeling, asook hoe vlakke van persoonlike bekwaamheid ervaar. terapeute wat in hospitale werksaam is en veral die wat perifere gehoorafwykings behandel, wat as oudioloe of as spraak-taalterapeute en oudioloe werksaam is, wat swaar pasient-ladings en uitgebreide administratiewe skryfwerk hanteer, en wat hulself ag as om onder groot werksdruk te wees, blyk die mees vatbaar vir uitbrand te wees. j the term " b u r n o u t " was originally coined by freudenberger in 1974 and was subsequently defined by maslach (1982) as a syndrome which results in a state of emotional exhaustion, depersonalisation, and reduced personal accomplishment among individuals who work with people. although burnout has seldom, if ever, been documented in the research literature on south african speech-language pathologists (splp's) and audiologists, it seemed unlikely that these professionals would be immune from this phenomenon— particularly given the stressful nature of their work with communicatively-impaired persons, and the unique socio-economic and politico-cultural context in which they are expected to practise their profession. cherniss (1980), summarises burnout as a process beginning with excessive and lengthy levels of job stress, leading to strain in the worker, i.e. feelings of tension, irritability, fatigue and emotional exhaustion. the second stage of the process occurs when workers defensively cope with the job stress by detaching themselves from the job psychologically, developing depersonalised attitudes and becoming apathetic, cynical and rigid towards their clients. the final stage occurs when caregivers develop a sense of failure and inadequacy regarding their inability to relate to clients and experience a sense of reduced personal accomplishment. the symptoms or effects of burnout can be classified into three dimensions: physical effects (e.g. headaches, insomnia, gastro-intestinal disturbances and susceptibility to illnesses); psychological effects (e.g. emotional exhaustion, negative attitude changes and apathy); and behavioural effects(e.g. lower work productivity, absenteeism, drug and alcohol abuse and an assumed deterioration of patient care (maslach & jackson, 1981; van der ploeg, van leeuwen & kwee, 1990). in addition to the effects on the individual person, the burnout sufferer's family may be affected in terms of increased friction and tension in the home (barling, 1986). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 marilyn swidler & eleanor ross finally, burnout may affect employing organisations which receive poor work performance and low productivity from their employees and have to deal with high rates of absenteeism and staff turnover. it can thus be seen that burnout has individual, institutional and familial repercussions thereby affecting the whole of society. furthermore, from an ecological perspective, burnout is viewed as an imbalance between environmental demands and people's stress-coping resources, and causes or correlates of burnout may occur anywhere within the ecological system including the individual person, the organisation or work environment, and the broader socio-cultural milieu. the person individual factors and personality characteristics play a role in the burnout process. for example, age, gender, marital status and the number of years working experience have been correlated with burnout (bernstein, 1992). burnout among human service workers has been found to be significantly correlated with neurotic anxiety, unrealistic goals and low self-esteem (ratcliff, 1988). furthermore research has correlated burnout with personality factors such as locus of control, hardiness, and type a personality. for example, cherniss (1980) suggested that persons with an external locus of control, i.e. people who believe that their lives are influenced by external forces, were more likely to experience burnout; while kobasa (1979) maintained that persons with high levels of hardiness tended to be resistant to stress because their personalities were characterised by a commitment to personal values, a sense of control over their lives, and a view of change as a challenge. type a behaviour is the term used to describe people who are intensely ambitious, hard-driving, impatient and aggressive with a keen sense of time urgency. although people of this type tend to be highachievers, they tend to experience more heart attacks and be more susceptible to stress than the placid, relaxed type β person (cooper and davidson, 1991). in addition to personal attributes, factors within the work environment can also potentially contribute to burnout. the work environment cherniss (1980), believes that differences in jobs and organisations are stronger etiological factors of burnout than are differences in individual characteristics or personality. he is supported by maslach (1982), who believes that although personality plays a part in burnout, the phenomenon is best understood and modified in terms of situational sources of job related, inter-personal stress. maslach (1982) believes that burnout is a unique form of stress, in that it is a response to the chronic emotional strain of working extensively with other human beings, particularly when they are experiencing problems. splp 's and audiologists do not only deal with communication and hearing problems, they deal with people who also exhibit emotional and physical problems which need to be dealt with in therapy and which can be accompanied by possible negative attitudes on the part of patient and therapist. moreover therapeutic work is usually demanding and emotionally draining. it is difficult to assess the degree of therapeutic success in the helping professions and how much time is required to see progress in therapy. most human service work, compared with other types of work, offers very little feedback, thus the therapist must work in the dark, not knowing the success of his or her efforts. a lack of therapeutic success has been cited as one of the most stressful aspects of therapeutic work (maslach, 1982). miller and potter (1982), investigated stress among a sample of 123 members of the american speech-language-hearing association. they found that 43% of their respondents reported themselves to be moderately burned out. a survey conducted by van der gaag (1988), as cited by kersner and stone (1991), found that 99% of district speech therapy managers in the united kingdom felt that stress levels in the profession had increased in the last few years. moreover, this problem was cited as a major factor affecting the performance of the speech therapists. according to fimian, lieberman and fastenau (1991), who formulated a burnout scale specifically for speech-language pathologists working in schools found that increasing demands for accountability, together with large caseloads, excessive paperwork, and feelings of isolation, would appear to make splp 's and audiologists especially prone to stress and burnout. these researchers point out that splp's cannot be expected to function effectively if suffering from excessive fatigue, headaches and other reported symptoms of stress. it is of interest that fimian et al., (1991, p.444), found stress scores in their sample, to be highly correlated with "bureaucratic restrictions, time and workload management and lack of professional supports". kersner and stone (1991), found that speech therapists as compared to occupational and physical therapists in the united kingdom experienced the size of their caseload and feelings of isolation as stressful. in fact a very high proportion of their respondents, namely 82%, reported being stressed at work. the findings from these three overseas studies of stress and burnout within the profession of speech-language pathology highlight the need for splp's and audiologists' stress symptoms to be taken seriously and for the underlying etiologies to be addressed. these findings also lend support to cherniss's contention that factors within the work environment play a crucial role in the development of burnout. j among the work setting variables that have been implicated in previous research as possible correlates or moderators of the burnout syndrome are social support, workload and clientele. 1 cobb (1976) defines social support as information leading the individual to believe that: 1) he or she is cared for and loved (emotional support), 2) he or she is esteemed or valued (esteem support), and 3) he or she belongs to a network of communication and mutual obligation (network support). according to the buffering hypothesis, as cited by ross, altmaier and russell (1989) , persons involved in supportive relationships are able to rely on others to help them when dealing with stress, a resource likely to lessen the adverse effect of stress on physical and mental health. several researchers cited by macfarlane (1990)^ emphasised that social support from co-workers and supervisors is one of the most effective ways to alleviate negative effects of organisational stress.-the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) burnout: a smouldering problem 73 a further important work variable is that of workload. according to maslach (1982), a large case load means that less time can be spent on each case, fewer services may be provided and there may be little or no follow-up. the helper may develop a quick and emotionally withdrawn method of dealing with her clients to try and avoid the emotional strain of dealing with so many people. this inadequate care provided may in turn induce feelings of inefficiency, failure and a lack of personal accomplishment and thus a large case load may represent a major source of burnout. fimian et al. (1991, p.433), found that "time and workload management" questions, consisting of items dealing with splp's perceptions of time at work, accounted for 32% of the stress variance. high scorers on this factor reported having "too much work to do, no time to get things done, little time to prepare, little time for personal priorities, and too much paperwork." one also needs to look at the effect of the type of clientele on the frequency of burnout. cherniss (1980), cites the example of helpers who have low functioning clientele. he argues that such persons are likely to believe that there is little they can do to improve their functioning leading to feelings of a poor sense of impact and efficacy. furthermore such professional caregivers are unlikely to be able to use their clinical skills to the fullest extent and may experience their roles as less consistent with their professional identities. tuomi (1993, p. 11), explains how quality care for the severely retarded person may just involve "doing something and maybe teaching the patient to cope with simple tasks..." these factors can have an effect on the experience of job stress and the coping reaction. these stressors within the work environment are likely to be further exacerbated by stressors emanating from broader societal factors. the broader sociocultiiral milieu according to handy (1988, p.354), "... the root causes of both stress and burnout are often far removed from the individual person or job and may be more appropriately conceptualised in jsocietal and organisational terms". an ecological perspective, where stress can be viewed as a result of an ι imbalance between environmental demands and resources, is possibly applicable to south african splp's and audiologists. becker and isaacs (1993, p.15), believe that "south africa is a country in transition. there are changes in the structure of society, in terms of social change and the elimination of apartheid, and in terms of massive moves from rural to urban settlement. concomitant with the promising aspects of societal change, there are, however, other aspects which place strain on the available health care services". a major source of strain is poverty which has a serious impact on individuals, families, and society in general. according to phiyega (1992), in south africa, poverty presents itself in political unrest due to stress and conflict, violence in families and communities, unemployment, lack of provisions and lack of facilities. hence, there are economic, political and social stressors operating in this country at the present time. an aspect of the inadequate provision of resources cited by beecham (1990), concerns the small number of speech and hearing therapy graduates trained in south africa which results, from aron's (1991) estimation of 1984 figures, in therapeutic services reaching only 138,000 persons from a possible client population of 3.5 million. in 1986, a survey conducted by the department of national health and population development found the following: in respect of so called "coloured" people, there was a shortage of 520 therapists. for asians the shortage was 139 while the shortage for the black population group was 3396. aron (1991), provided the following statistics: 223,200 persons with communication disorders receive attention in a period of a year, however, there are approximately three million who have communication disorders. clearly the ratio of therapists to patients requiring therapy is not improving with time. these figures lend support to becker and isaacs's (1993, p.24), contention that "in south africa the need to cater to increasing numbers of clients needing assessment and treatment is juxtaposed with the scarcity of trained professionals in the helping professions". from the above statistics it would seem likely that practising splp's and audiologists are being required to work with excessively large caseloads. secondly, therapists have to adapt their first world training to meet the need of particular social, educational and communicative problems within south africa's culturally diverse population. speech therapy and audiology can no longer safely slot into a tertiary level of intervention. splp's and audiologists now have to shift to intervention at a primary or secondary level, in communities where these needs are not being met. this may be placing an extra burden on the therapists who no longer confine themselves to giving therapy, but also have to tackle education of communities on relevant issues. steenekamp (1993, p.5), states that in the light of the economic situation "there is an increasing demand for the therapist's clinical skills, with a decreasing amount of time available for other demands, eg., research, tutoring, training of students, observation and so forth. increasing demands from other institutions are only adding to an increasing amount of stress." aron (1991), commented on the frustration endured, defending and interpreting the profession of speech pathology and audiology to official sources, university administrators and medical personnel. she states that this in fact may be a contributing factor in the burnout syndrome. clearly, south african splp's and audiologists appear to be subject to stresses at all levels of the social system, and to factors unique to the context of this country. it therefore appeared to be both relevant and timely to investigate the occurrence of burnout within members of this profession and to endeavour to relate frequency of burnout with factors occurring at the individual or personal level, within the work environment as well as the broader sociocultural milieu. although miller and potter (1982), conducted a national survey of burnout among splp's, criticism can be levelled against them because of their failure to use a standardised measure of burnout, such as the maslach burnout inventory (mbi). instead they merely asked respondents "how burned out they felt". in order to obtain more valid and reliable data on stress symptom levels in the profession, fimian et al., die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 74 marilyn swidler & eleanor ross (1991), developed the speech-language pathologist stress inventory (slpsi). more specifically, they constructed "... an instrument designed to measure job related sources and manifestations of stress experienced by speech-language pathologists in the schools..". these researchers attempted to adapt the mbi to speech pathologists. a possible weakness with the slpsi is that the authors averaged scores from individual subscales to yield a total burnout scale. koeske and koeske (1989, p. 142), advise against the use of this procedure for the following reason: "given the differential associations of the three subscales with one another and with other measures, researchers probably should avoid computing a composite "burnout" score and instead preserve the three subscale scores and relate them separately to other measures whenever appropriate". furthermore, this inventory was standardised on school speech-language pathologists only and may not necessarily tap possible stressors affecting speech-language pathologists in other job settings. the present study endeavoured to improve on the methodology utilised in these three overseas studies, and to extend their scope by incorporating standardised measures of burnout, co-worker support and supervisory support and by eliciting information on the broader sociocultural factors unique to south african splp's and audiologists. furthermore, it was hoped that the study would add to the theoretical knowledge of burnout and possibly provide practical suggestions for reducing the potentially deleterious effects on splp's and audiologists, their employing organisations and their clients. methodology aims the aims of the study were: (1) to investigate the frequency of burnout occurring among speech-language pathologists (splp's) and audiologists. (2) to determine the relationship between frequency of burnout and certain personal characteristics and work situation variables specific to splp's and audiologists. independent variables personal factors: gender work experience dependent variables burnout: emotional exhaustion depersonalization reduced personal accomplishment organisational factors: caseload place of work type of impairment treated severity of impairment treated adult/child working as splp/audiologist paperwork and administration language of client broader sociocultural factors perceived to contribute to the experience of stress, were analysed descriptively and were not included in the statistical analysis as no standardised scale is available to measure the phenomenon. subjects subject selection criteria a random probability sample of 500 names was drawn from the register of splps and audiologists in the republic of south africa registered with the s.a. medical and dental council as at june 1992. krejcie and morgan as cited by christenson (1980, p.299), suggest a sample size of 270 people to be an adequate representation of the total population of 852 people. description of subjects the sample comprised 500 therapists, 98% of whom were female and 2% were male. extent of work experience ranged from 1 year to 40 years with a mode of 11 years. with regard to place of work, 35% of respondents were employed in schools; 32% in private practice; 10% in hospitals; 7% in universities; and 16% in other settings. type of impairment treated was broken down as follows: language-learning disabilities 27%; language 20%; peripheral hearing loss 10.5%; central hearing loss 2%; articulation 8%; fluency 5.5%; traumatic brain injury 2%; mental retardation 3%; aphasia 1.5%; and other 2%. the vast majority of respondents, namely 73.5% worked with children only, while 4.5% worked solely with adults, and 22% provided services for both children and adults. in terms of the focus of intervention, only 7% of the sample were employed solely as audiologists; 44% worked only as speech pathologists; while 49% fulfilled the dual role of splp and audiologist. research procedure research design in order to investigate the aims of the study, a crosssectional, survey research design was employed which involved the use of a postal questionnaire. | description of the questionnaire a 9-page questionnaire (set out in appendix i) was constructed which could be completed in approximately 10-15 minutes. the research instrument was made available in both english and afrikaans translations as all respondents supposedly received their tertiary level education in either of these languages. a covering letter explained the purpose of the questionnaire, provided assurance of confidentiality, and clarified how and when to return the questionnaire. the questionnaire \ comprised the following sections: demographic information; open-ended questions on the respondent's perceptions of the influence of certain factors on stress and stress-coping strategies used by the respondents; subscales from moos and insel's work environment scale; and the maslach burnout inventory. these sections were included in order to provide information on the relationship between the frequency bf burnout being experienced, and biographical as well as work environment variables of the splp's and audiologists. each section is described separately as follows: the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) burnout: a smouldering problem 75 demographic information the aim of this section of the questionnaire was to s o l i c i t biographical information, namely respondent gender as well as data on factors such as job setting, caseload size, type of impairment, respondents subjective perceptions of severity of client's communication impairment and the amount of time spent on administration of paperwork. open ended questions this section of the questionnaire included items aimed to elicit respondents' perceptions of the possible influence of socio-economic and politico-cultural factors on the experience of work stress. also included were questions soliciting information on strategies used by respondents to cope with stress. finally, the respondents were asked whether they felt stress-management techniques should be taught to students as well as graduates. the work environment scale(wes) the wes is a 90-item, paper and pencil measure developed by moos and insel (1974), to assess the social climate of many types of work units, and focuses on relationships among employees, between employees and supervisors, and on the unit's basic organisational structure and functioning. the wes is composed of ten subscales that tap three underlying dimensions: relationship, personal growth, and system maintenance and change. from the relationship dimension two sub-scales were utilised in this research, namely: peer cohesion, and supervisor support. these sub-scales assess the extent to which employees are friendly to and supportive of one another, and the extent to which management is supportive of employees and encourages employees to be supportive of one another· (moos, 1986, p.l). from the personal growth or goal orientation dimension, one sub-scale was utilised, namely: work pressure. this sub-scale assesses the degree to which the press of work and time urgency dominates the work milieu (moos, 1986). j internal consistency calculated for each of the ten wes sub-scales using a sample of 1,045 employees, has been found to be within an acceptable range, i.e. 0.690.86 (moos, 1986, p.4). ! importantly, sub-scale inter-correlations indicate that the sub-scales measure distinct though somewhat related aspects of work environments. test-retest reliability has also been found to be acceptable. scales have also been reported to have satisfactory content and face validity as well as construct and criterion validity (moos, 1987). the maslach burnout inventory (mbi) the mbi, is a 22-item self-report scale developed by maslach and jackson (1981). responses involve the frequency of feelings towards each question, ranging from never (0) to "every day" (6). the instrument is composed of three sub-scales measuring the three areas that maslach and jackson believe best define the experience of burnout, namely: emotional exhaustion, depersonalisation, and lack of personal accomplishment. the instrument is labelled "human services survey" rather than "burnout" in order to avoid biasing respondents. the developers recommend that the inventory be presented as a survey of job-related attitudes without being connected to burnout and that anonymous responses be requested. in view of the fact that burnout is a multi-dimensional construct, the test does not yield an overall diagnosis of "burned-out" versus "non-burned out" but instead provides three separate, non-additive scores of emotional exhaustion, depersonalisation, and reduced personal accomplishment. maslach and jackson (1986) report that studies using the mbi have obtained high scores for internal consistency reliability, test-retest reliability, and convergent validity, and that the scale is free of social desirability bias. offerman (1985) states that the main limitations of the mbi is that it does not indicate the meaning of the score levels. the researcher needs to question what a "moderate" level of burnout means in terms of behaviour (offerman, 1985, p.421). nevertheless, the mbi has been in use for nearly twenty years and has been part of the methodology of hundreds of studies. research protocol pilot study the questionnaire was pre-tested on a small group of english and afrikaans speaking therapists not included in the final sample. distribution i) the target population comprised 500 registered splp's and audiologists. ii) in an attempt to increase the rate of returned completed questionnaires the researcher included stamped, addressed return envelopes and sent reminder cards requesting respondents to return questionnaires if they had not done so already. analysis of data initially the data was summarised using a univariate analysis procedure, which provided means where appropriate, standard deviations, modes, and ranges. following this, results were analysed to establish relationships between the independent and dependent variables using inferential statistics such as pearson productmoment correlations. this analysis was followed by a multivariate analysis of variance, using a general linear models procedure. finally bonferroni t-tests were used to further analyse the data, and establish differences between sub-groups. the open-ended questions were analysed descriptively by summarising and describing common themes expressed in the responses. results and discussion although 230 questionnaires were returned only 202 were used as the remainder arrived too late to be incorporated into the statistical analysis. the response rate was therefore 40.4% which moser and kalton (1971), die suid-afrikaanse tydskrif vir kommunikasieafuiykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 76 marilyn swidler & eleanor ross regard as acceptable for mail surveys. missing data on certain measures being correlated reduced the sample size below 202. hence sample sizes ranged from 197202, depending on the measure being correlated. the question on the language spoken by the respondents' patients was not included in the statistical analysis, due to the ambiguity of the responses obtained. the first step in the data analysis involved obtaining the mean, mode, range and standard deviations of the variables. from the results it appeared that as a group splp's and audiologists were suffering from a moderate level of emotional exhaustion (i.e obtained a score between 17-26 on the mbi) although the range extended from a mild to high level of emotional exhaustion. the mean for depersonalisation was 3.8 indicating that as a group the respondents had a low tendency to depersonalise their patients (i.e. obtained a score between 0-6). these findings indicate that respondents have not, as a whole, developed a cynical opinion of their patients, expecting the worst from them and even disliking them. scores did, however, range from 0-22 with any score above 13 being considered as a high level of depersonalisation. the group indicated a low level of feelings of r e d u c e d personal a c c o m p l i s h m e n t (i.e.obtained a score between 0-31) with a mean of 10.23 and scores ranging from 0-28. these results suggest that splps were feeling competent and adequate in their jobs and their ability to relate to and treat their patients. these findings also underscore the fact that despite feeling emotionally exhausted, therapists can still derive a sense of accomplishment from the work and do not necessarily experience negative attitudes towards clients. these results are also consistent with oktay's (1992) findings that despite relatively high levels of emotional exhaustion experienced by hospital social workers who work with aids patients, they felt a substantially high level of personal accomplishment because of the meaningfulness of their work. table 1. burnout scores mean range std. dev mode low high emotional exhaustion 22.2 0 52 23 10.8 deperson. 3.8 0 22 0 4.3 personal accomplish 10.2 0 28 9 5.7 the relationships between the independent and dependent variables are discussed as follows: gender a negative relationship significant at the 0.05 level (f=6.41, p<.05) was found between depersonalisation and gender and no significant relationship was found between gender and the other two dependent variables of emotional exhaustion and reduced personal accomplishment. the research on gender and burnout is controversial with some researchers finding huge differences in the experiences of burnout between males and females and some finding very little difference. men are reportedly more susceptible to develop callous feelings about the people they work with and hence more likely to experience depersonalisation (maslach 1982;). the reasons offered by maslach (1982) are that men tend less towards close contact with people. however, there is no empirical data to support this reasoning. in addition, the present sample included only four males therefore making the generalisability of gender results more difficult. length of working experience a very significant negative relationship at the 0.01 level was found between the number of years the clinician has been working and depersonalisation, although this was not supported by the multivariate analysis (f=0.92, p>.05) or the bonferroni t-test. research has shown that burnout is lower among older and more experienced workers (maslach 1982; van der ploeg et al.,1990; ross & altmaier, 1989). it seems that it is not just a case of work experience but also the maturity and stability that accompanies increasing age. edelwich and brodsky (1980) suggested that newly qualified professionals are prone to experience burnout when their initial energy and ideals are eroded by the real difficulties and limitations of their profession. this could be especially true for south african trained speech therapists who are taught western techniques during their training which may no longer be appropriate in a multi-cultural society such as south africa and when the ideal clinic situation during their university training is no longer applicable in the real job context. of related interest is that a highly significant relationship at the 0.01 level of confidence was found between the number of years worked and the amount of paperwork completed. pines and maslach (1978) as cited by savicki and cooley (1987) offer an explanation for the above, suggesting that as workers remain in the field longer, they tend to become less involved in direct therapy work and more involved in administration and administrative duties which may be impacting on burnout in a unique way. • ι place of work ι ι a significant negative relationship was found at the 0.05 level (f=5.43, p<.005) between place of work and emotional exhaustion, and a very significant relationship at the 0.01 level (f=2.85, p<.05) existed between place of work and depersonalisation. t-tests revealed that therapists working in a hospital setting tended to experience more emotional exhaustion than therapists working in private practice, and therapists working in institutions experienced more emotional exhaustion than those working in private practise. these findings suggest that the clinical setting and the work environment play a role in the type and severity of stress experienced by professionals. / caseload also of interest is the significant correlations at the 0.005 level between place of work and caseload and at the 0.05 level between place of work and the severity of the client treated..these relationships possibly offer an the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) burnout: a smouldering problem 77 explanation for the relationship between place of work and emotional exhaustion. furthermore a significant r e l a t i o n s h i p existed b e t w e e n place of work and depersonalisation (f=2.85, p<.05). hospital therapists tended to experience more depersonalisation than either school therapists or private practitioners. a very significant relationship at the 0.01 level ( f=5.43, p<.001) was found between case load and emotional exhaustion. according to maslach (1982, p.38), a large case load may lead to a situation of "too many people and too little time to adequately serve their needs— a situation ripe for burnout." furthermore larger caseloads mean that more energy is depleted in order to perform satisfactorily. type of impairment a significant relationship at the 0.05 level ( f=2.50, p<.05) exists between the type of defect treated and depersonalisation. t-tests revealed that treating peripheral hearing disorders tended to be associated with greater depersonalisation of patients than treating both a language and a language/ learning disability. this could possibly be attributed to the fact that treating a peripheral hearing disability usually involves three or four sessions or perhaps even one diagnostic session, therefore the therapist is not afforded the opportunity to establish a relationship with her patients. paperwork a very significant relationship was found at the 0.001 level ( f=2.67, p<.05) between the amount of paperwork completed in a week and emotional exhaustion. according to maslach (1982), administrative tasks and paperwork can interfere with the therapists' direct work with the patient as it could take up therapy time. in fact many of the therapists reported in'the open-ended questions, that paperwork often needed to be done after hours as there was usually not enough time during the workday to complete all the necessary {administration. hence long work hours may be leading to feelings of emotional exhaustion. ι co-worker support j a very significant relationship exists at the 0.001 level between emotional exhaustion and co-worker support. this relationship was, however, not in the expected direction. statistical analysis of the data, revealed the presence of a few outlying values which could have grossly distorted the data, resulting in a spurious rather than a meaningful or substantive correlation. work pressure work pressure and emotional exhaustion were highly correlated with each other and a very significant relationship at the 0.001 level (f=5.76, p<.001) existed between them. cherniss (1980, p.44) maintains that "stress occurs when there is a perceived imbalance between resources and demands. demands can be external (for instance formal job requirements) or internal (for example, personal goals, needs, and moral values)." since it appears that external demands such as caseload, impairment treated, and lack of social support did not seem to be correlated significantly or were minimally correlated with the burnout phenomenon, it would seem that these demands are possibly internal as reported by some of the private practitioners in their open-ended questions. it is possible that practitioners were not perceiving their work demands realistically and were constantly plagued by a sense of urgency and lack of time to complete their worki descriptive analysis of open-ended responses question 1 work stressors common themes emerged in the responses of private practitioners and those working at schools and hospitals. rules, regulations and bureaucracy, writing of detailed reports as well as inspections were considered as stressful factors at work. those working in schools needed to use groupwork as a therapeutic technique due to time constraints and a situation of too many pupils and too few therapists and they tended to find groupwork stressful and emotionally draining. they claimed that this method was associated with poor progress of pupils due to insufficient treatment time. poor cooperation between teachers, parents and therapists was a problem cited by many respondents. private therapists complained of poor cooperation of parents with home programmes. they were pressurised to obtain results in a certain period of time and often parents and teachers had unrealistic expectations of therapy results. a few therapists found it stressful that patients who travel from far expect results within periods as short as in three sessions. furthermore, private therapists were expected to make an immediate diagnosis, leaving them no time to test thoroughly and arrive at a carefully considered diagnosis. working in isolation was found to be extremely difficult as one cannot confirm results and diagnosis with another therapist. financial handling of a private practice and collection of fees was reported to be highly stressful. lack of training in certain areas of treatment was also found to be stressful for some therapists. inadequate test materials and inappropriate standardised tests due to cultural and language biases increased the stresses of therapy. many therapists felt that the profession has not seemed to have established itself. some respondents highlighted the fact that one continually needed to promote the profession as there was insufficient knowledge about speech-language pathology and audiology and the contribution it can make. time restraints and time pressure were found to be stressful by the majority of therapists irrespective of their job context. time management was not confined to therapy but included school visits, speaking to parents, writing reports and programmes. there appeared to be little time for research and reading to keep pace with the unending amount of new information. therapists often needed to work after hours to keep up to date with administration and paperwork. therapists reported sometimes feeling ill-equipped to deal with emotional support and counselling during the session and the emotional difficulties involved in working with severely impaired patients who show little improvement. die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 78 marilyn swidler & eleanor ross question 2 -societal stressors handy (1988) cautions that societal and organisational causes of stress cannot be ignored simply because there are no easy solutions to solving these problems. figure 1 indicates that 30% of the respondents felt that broader societal factors did not contribute to their experience of stress. however, among the 70% of respondents who perceived themselves to be affected by socioeconomic and politico-cultural factors, common themes were expressed. figure 1. affected by sociocultural factors. therapists found it stressful that children from poor economic backgrounds seem to show little progress in therapy. one of the most important demands confronting human service staff is the expectation of competence and many caregivers are motivated to achieve a sense of efficacy or psychological success in their work (cherniss, 1980). lack of progress in therapy might therefore be stressful for therapists. the respondents attributed this occurrence to poor parental education levels, the fact that patients often do not attend therapy, follow home programmes or advice given and do not understand the implications of the disorder. in addition to this, caregivers often have to work and there is little stimulation in the home. another related issue was that many patients cannot afford to come regularly to therapy. furthermore, new medical aid cutbacks have frequently required reducing the number of therapy sessions and thus therapists feel that because of rising costs they are more accountable to achieve rapid results. many therapists were also distressed at the prospect of not being able to treat patients who could not afford clinic fees. several respondents reported that for those therapists not in private practise, the number of posts available has been reduced resulting in large workloads and little job satisfaction. salaries have been cut or are not being increased making it difficult to meet the rising cost of living. political unrest results in therapists fearing for their safety and the security of their families. a few therapists found that travelling to work was stressful as they feared rioting or being attacked. the above are examples of physical work stressors which can potentially influence workers' perception of job comfort. there appeared to be uncertainty as to the future of the profession in a third world country where primary needs are not being met. there is often a lack of reliable transport to and from the townships and violence and stayaways seriously disrupt provision of services. the poor economy and uncertain politics— including political differences among co-workers, impacts on enthusiasm and ease of working conditions. from a sociocultural point of view therapists remarked on the difficulty of working with patients from different cultures and different languages. person-role conflict can contribute to burnout (cherniss, 1980). many therapists indicated that they felt unprepared to work with other communities because they lack the necessary knowledge and skills. the implications of these findings are that if the splp's and audiologists are not adequately trained for new role demands, the consequences are likely to be high levels of person-role conflict, j o b stress, dissatisfaction and b u r n o u t (cherniss, 1980). some therapists commented on the language barrier between teachers and therapists and the difficulty in advising teachers on how to handle second language learners. on the other hand those therapists serving only white south africans were concerned that they were not addressing the needs of the larger community. furthermore, many of the children treated live with their grandparents and subsequently it was difficult to obtain medical and genetic histories. finally, parents may not bring their children for an assessment until they are older and the problem has become compounded and multifaceted and in some cases resulting in poor prognoses. question 3 -stress-coping strategies "coping refers to changing cognitive and behavioral efforts used to manage internal or external demands perceived as exceeding the resources of the individual" ( folkman, lazarus, gruen & de longis, 1986, p.23). strategies used to cope with stress varied and appear to be highly individualistic. common techniques utilised involved regular exercise, time away from jwork, religious beliefs as well as careful planning ancl organisation of work schedules and demands. some negative strategies such as smoking, overeating and drinking coffee were also reported. i question 4 stress-management course during training the majority of respondents, namely, 62% of the respondents felt that a stress management course should be incorporated into the training curricula of speechlanguage and hearing pathologists. others felt that the course was too full and that to include another subject would only serve to increase the stress experienced by students. furthermore, it was felt that if time was available it should rather be utilised for areas that were not taught in detail. others felt that such a course would be useless without specific job experience, and that different work contexts cause different forms of stress. the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) burnout: a smouldering problem 79 wilder and plutchik cited in paine (1982, p.115) agree, believing that " just giving knowledge to professional trainees about stress and the phenomenon of burnout during training will probably have few long term effects". figure 2. stress management course for students. question 5 -stress-management course for qualified therapists ί a high proportion of respondents, namely 80%, felt that a stress-managementjcourse should be made available for qualified speech-language and hearing pathologists. it was, however, specified by many respondents that this course should not be run by fellow speech-language therapists and audiologists as the subject matter was regarded as too personal. among those who felt the course was unnecessary, reasons given were that percentage figure 3. stress management for qualified therapists stress management is a personal choice and is too varied to apply to everyone. conclusions the data suggest that although moderate levels of burnout characterised the sample on average, certain job characteristics tended to make splp's more susceptible to this experience. furthermore, despite the fact that many respondents were subject to difficult work conditions which tended to give rise to feelings of emotional exhaustion, the majority of therapists reported deriving a sense of accomplishment from their work and relatively low levels of depersonalisation. it is important to note that this study provided correlational data and thus no conclusions about causal relations among socio-demographic factors, work setting variables and burnout can be drawn. nevertheless, the findings from the study do have implications for clinical practice and job design; research; and the training and continuing education of speech-language pathologists and audiologists. clinical practice and job design in view of the fact that certain job settings such as hospitals, appear to contain more potential for job stress than other contexts, it is recommended that employers of splps and audiologists pay attention to the structure and design of the job. for example, support meetings, informal case discussions, supervision and buddy or mentorship systems are alternate strategies that could possibly be built into work structures. these support mechanisms would appear to have particular relevance to newly qualified therapists with limited work experience who were shown to be particularly prone to experience high rates of depersonalisation. it is also suggested that care be taken to control the number of difficult cases allocated to therapists and the supervision of those cases. moreover, in view of the significantly high correlation between depersonalisation and treatment of peripheral hearing disorders, it is recommended that— where practically feasible— supervisors endeavour to allocate a wide range of patients with different types and degrees of communication impairment to the therapists in their employment. in addition, the complaint expressed by a large number of respondents regarding excessive paperwork, suggests the need for employers and clinicians to brainstorm ways of possibly streamlining routine administrative tasks, particularly in large bureaucratic organisations. research it is recommended that future studies incorporate personality variables into the research design and analysis as these factors may predispose some splps and audiologists to be susceptible to burnout. it is possible that certain personality characteristics are looked for in the selection procedures for training in the profession orto quote one respondent"perhaps the feeling of work pressure instilled in us during our training, is an image that we carry with us into the "real' world, thus affecting our perceptions of work demands." die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 80 m a r i l y n s w i d l e r & e l e a n o r r o s s a n o t h e r i m p o r t a n t a s p e c t w h i c h w a s o m i t t e d from the s t a t i s t i c a l a n a l y s i s i n the p r e s e n t s t u d y a n d w h i c h n e e d s to b e r e s e a r c h e d , w a s the effect o f l a n g u a g e s spok e n b y the c l i e n t s o f s p l p s a n d a u d i o l o g i s t s on b u r n out. f u r t h e r m o r e a s u b j e c t i v e m e a s u r e of client c o m m u n i c a t i o n i m p a i r m e n t w a s u t i l i s e d i n this study. it is s u g g e s t e d t h a t future r e s e a r c h e n d e a v o u r s to i n c o r p o rate m o r e o b j e c t i v e m e a s u r e s o f t h i s v a r i a b l e . a further fruitfu-l area for future r e s e a r c h is the different c o p i n g styles adopted b y speech-language pathologists a n d a u d i o l o g i s t s as t h e y c a n influence h o w indiv i d u a l s r e s p o n d to stress. t h e p r e s e n t s t u d y focused o n g e n e r a l w o r k s t r e s s e s e x p e r i e n c e d b y a n a t i o n a l s a m p l e of t h e r a p i s t s w o r k i n g i n v a r i o u s j o b s e t t i n g s . f u t u r e r e s e a r c h n e e d s to focus on specific s t r e s s e s a s s o c i a t e d w i t h specific j o b contexts s u c h as a i d s p a t i e n t s , n e u r o l o g i c a l disorders and so forth. a further l i m i t a t i o n of t h e s t u d y c e n t r e d on the use o f t h e w o r k e n v i r o n m e n t scale w h i c h m e a s u r e s perc e p t i o n s o f r e s p o n d e n t s r e g a r d i n g their w o r k milieu. p e r c e p t i o n s m a y h a v e b e e n u n i n t e n t i o n a l l y distorted or subjects m i g h t h a v e provided socially desirable answers. for t h i s r e a s o n future r e s e a r c h c o u l d p r o b a b l y i n c o r p o rate m o r e o b j e c t i v e i n d i c e s o f the j o b b y focussing on the a c t u a l n u m b e r o f c a s e s s e e n e a c h w e e k , a n d the actual t i m e d e v o t e d to p a p e r w o r k . t r a i n i n g a n d c o n t i n u i n g e d u c a t i o n t h e fact t h a t 6 2 % of the r e s p o n d e n t s w e r e in favour of a s t r e s s m a n a g e m e n t c o u r s e b e i n g i n c o r p o r a t e d into the u n d e r g r a d u a t e t r a i n i n g c u r r i c u l u m and 8 0 % felt t h a t a c o u r s e s h o u l d b e m a d e a v a i l a b l e to qualified s p l p s a n d a u d i o l o g i s t s , u n d e r l i n e s t h e n e e d to a d d r e s s this g a p i n professional e d u c a t i o n . in c o n c l u s i o n , it is h o p e d t h a t t h i s s t u d y offers i m p o r t a n t g u i d e l i n e s for future r e s e a r c h a n d the d e v e l o p m e n t o f i n t e r v e n t i o n p r o g r a m m e s a n d for future r e s e a r c h a n d e d u c a t i o n . if s p e e c h p a t h o l o g i s t s and audiologists are to s u r v i v e the d e m a n d s o f the 1990's, a n d are to c o n t i n u e to b e influential a n d effective profess i o n a l s , t h e y w i l l n e e d to identify a n d m a n a g e stressr e l a t e d p r o b l e m s before the i m p a c t o f t h e s e p r o b l e m s b e c o m e s e x c e s s i v e a n d t h e i r s o l u t i o n difficult. a c k n o w l e d g e m e n t s financial a s s i s t a n c e received from the s.a. speech-lang u a g e a n d h e a r i n g a s s o c i a t i o n t o w a r d s the costs of the study, is a c k n o w l e d g e d w i t h a p p r e c i a t i o n . r e f e r e n c e s aron, m.l. perspectives. 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(1990). burnout among dutch psychotherapists. psychological reports, 67, 107-112 appendix i dear speech pathologist/ audiologist as a requirement for my degree, i am conducting a study of occupational stress among south african speechlanguage pathologists and audiologists, and the specific work situations which clinicians are currently experiencing. i believe that therapists working in this country are having to deal not only with the day-to -day stresses of all helping professionals but also with the unique economic and socio-political conditions prevalent in our society. your participation in this study will add to our knowledge and understanding of work stress within our profession. furthermore, depending on the level of stress found to be experienced, intervention strategies may need to be recommended both at a training and occupational level. it would therefore be highly appreciated if each one of you could take the time to fill out the enclosed questionnaire thereby helping to ensure that the findings of the study are representative of the profession of speech-language pathology and audiology. please would you assist by answering each item as openly and honestly as possible, and when completed, sealing the questionnaire in the envelope provided, and posting it back to me by the 24th of april at the latest. there are no wrong or right answers. rather, what i am looking for, is the response that is most accurate for you. please note that your responses will be kept strictly confidential and you will remain anonymous as your name is not required anywhere on this questionnaire. supplied with this questionnaire is a postcard with your name written on it. kindly return the postcard separately, informing me that the questionnaire has been returned and no follow-up questionnaires will be sent to you. if you are interested in the results or have any questions, i will be only too willing to give you feedback at a mutually acceptable time. i can be contacted at telephone number: 453-7025. thank you again for your time and cooperation. yours sincerely marilyn swidler demographic data 1. your sex: 1) female 1 2) male 2. how many years have you worked in the profession since graduation? 3. please check the main work setting in which you are currently employed. ι a) hospital-clinic b) private clinic c) school d) insitution e) university f) private practise g) other 4. as of this time, my client caseload per week is: a) 1-15 b) 16-30 c) 31-45 d) 46-60 e) 60 or more 5. most of my clients have defects of: (select only one). a) articulation b) language c) language/learning difficulties d) aphasia e) traumatic brain injury f) degenerative neurological disorders g) dysphagia h) fluency i) peripheral hearing disorders j) central hearing disorders k) mental retardation 1) other (specify) die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 82 marilyn swidler & eleanor ross 6. are the majority of your caseload: a) mildly impaired b) moderately impaired c) severely impaired 3. what strategies do you use to cope with stress? open-ended questions the following statements are about the place in which you work. the statements are intended to apply to all work environments. however, some words may not be quite suitable for your work environment, for example the term "supervisor" can also refer to a manager, department head, or the person or persons to whom an employee reports. you are to decide which statements are true of your work environment and which are false. if you think the statement is true or mostly true of your work environment, make an x in the corresponding box in| the column labelled true. if you think the statement |is false or mostly false of your work environment, make an x in the corresponding box in the column labelled false. if,a statement is not applicable to your work environment please mark the n/a column. please be sure to answer every statement. section a 1. people go out of their way ' to help a new employee feel comfortable. 2. the atmosphere is somewhat impersonal. 3. people take a personal interest in each other. true false n/a the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) burnout: a smouldering problem 83 4. employees rarely do things together after work. 5. people are generally frank about how they feel. 6. employees often eat lunch together. 7. employees who differ greatly from the others in the organisation don't get on well. 8. employees often talk to each other about their personal problems. section β 1. supervisors really stand up for their people. 2. employees discuss their personal problems with supervisors. 3. supervisors expect far too much from their employees. 4. employees generally feel free to ask for a raise. 5. supervisors often criticise employees over, minor things. 6. supervisors usually give full credit to ideas contributed employees. [ j 7. supervisors tend to ! discourage criticisms j from employees. j 8. supervisors tend to talk down to employees. 9. supervisors usually compliment an employee when he does something well. section c 1. people often have to work overtime to get their work done. 2. people cannot afford to relax. 3. you can take it easy i and still get your work done. true false n/a true false n/a 4. there is no time pressure. 5. it is very hard to keep up with your workload. 6. nobody works too hard. 7. there are always deadlines to be met. 8. there is a constant pressure to keep working. 9. there always seems to be an urgency about everything. human services survey the purpose of this section is to discover how speechlanguage pathologists and audiologists as human service or helping professionals, view their jobs and the people with whom they work closely. the term "client" refers to the people for whom you provide service, care, treatment or instruction — even though you may use another term in your work, eg., patient, student, employee, etc. there are 22 statements of job-related feelings. please read each statement carefully and decide if you ever feel this way about your job. if you have never had this feeling, write a "0" (zero) before the statement. if you have had this feeling, indicate how often you feel it by writing the number (from 1 to 6) that best describes how frequently you feel this way. how often true false n/a 0 1 2 3 4 5 6 never a few once a a few once a a few every times month times week times day a year or less a a or less month week how often 0 6 statements 1. i feel emotionally drained from my work. 2. i feel used up at the end of the workday. 3. i feel fatigued when i get up in the morning and have to face another day on the job. 4. i can easily understand how my clients feel about things. 5. i feel i treat some clients as if they were impersonal objects 6. working with people all day is really a strain for me. 7. i deal very effectively with problems of my clients. 8. i feel burned out from my work. 9. i feel i'm positively influencing other people's lives through my work. 10. i've become more callous toward people since i took this job. die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 84 11. i worry that this job is hardening me emotionally. 12. i feel very energetic. 13. i feel frustrated by my job. 14. i feel i'm working too hard on my job. 15. i don't really care what happens to some clients. 16. working with people directly puts too much stress on me. 17. i can easily create a relaxed atmosphere with my clients. marilyn swidler & eleanor ross 18. i feel exhilarated after working closely with my clients. 19. i have accomplished many worthwhile things in this job. 20. i feel like i'm at the end of my rope. 21. in my work, i deal with emotional problems very calmly. 22. i feel clients blame me for some of their problems. a new australian phonological profile for complex phonological disorders developed and trialled in western australia initially designed for use with profoundly deaf children, this profile can deal with the analysis of the most complex phonological cases, including those in hearing children. unique profile format that provides information about • vowels .consonants .clusters ' • • " s s s s s & s ^ • processes tfte kit contains •profile sheets , r * stimulus picttjrfs •recording sheets -manual * c a s e l ^ s u g g e s l l o n s f o r remediation) iris vardi tel/fax 6 1 9 3 6 7 1 5 7 8 marie kormendy tel 6 1 9 3 2 8 9 4 0 6 6 1 9 3 8 3 8 3 4 0 fax 6 1 9 3 8 7 7 0 9 5 the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language teaching.html language teaching is no panacea: a theoretical perspective and critical evaluation of language in education within the south african context heila jordaan department of speech pathology and audiology, school of human and community development, university of the witwatersrand, johannesburg correspondence to: h jordaan (heila.jordaan@wits.ac.za) abstract language competence is both the means and the end to educational achievement, and multilingualism in particular has important cognitive, academic and societal advantages. the linguistic diversity in south africa creates an ideal context to provide learners with the educational opportunities that promote high levels of linguistic proficiency in their home and additional languages. unfortunately, the education system has not delivered on the constitutional imperatives of promoting multilingualism. english continues to dominate as the preferred language of teaching and learning, at the expense and marginalisation of the african languages. this is regarded by many researchers as the primary reason for the disturbingly low numeracy and literacy achievement levels of the majority of south african schoolchildren. however, the effects of language-in-education practices on academic achievement are not straightforward. this paper analyses recent research pertaining to the effects of language-in-education practices and argues that the critical role of educational linguistics is neglected in the south african education system. this affects the quality of teaching irrespective of the language of instruction and has a significant impact on the achievement of our children. the purpose of this paper is to present a critical theoretical perspective on language in education in order to influence policy and practice. an additional aim is to promote the role of speech-language therapists (slts) in education, since these professionals are well positioned to work in collaboration with educators to enhance language learning in mainstream/ordinary classrooms. however, slts also need to be well informed about the challenges in education and the theory underlying language-in-education practices. keywords: language-in-education; the role of the slt the current south african education system is in crisis and confronted with serious challenges (fleisch, 2008; webb, lafon & pare, 2010). a number of recent large-scale national and international research projects have unequivocally shown that the majority of south african children have very low literacy and numeracy levels (department of education, 2005; reddy, 2005; moloi & strauss, 2005; taylor & yu, 2008; mtshali & smillie, 2011). although the problems in education are exacerbated by conditions of poverty and poor teaching quality (fleisch, 2008; reddy, kanjee, diedericks & winnaar, 2006), many educational researchers propose that the main reason for the poor performance of south african schoolchildren is that the majority are learning in english as an additional language (heugh, 2009; brock-utne & skattum, 2009; alexander, 2005). the term ‘additional language’ as opposed to ‘second language’ is used, since many south african children are exposed to more than one language in the home and community in addition to and often before learning english. while it is true that english is dominant in south africa, both in the public domain and in education, the effects of language-in-education practices are not straightforward. there is a complex interaction of factors causing poor achievement, and research on language-in-education practices has yielded inconsistent results. the central argument of this paper is that one of the most important reasons for the poor achievement of south african learners is that the pivotal role of language in education is neglected in the curriculum and in teacher-training programmes, resulting in limited language awareness, and consequently inadequate teaching methods that lead to language difficulties across all curriculum areas. this is a problem irrespective of whether english or one of the african languages serves as the medium of instruction, or is the subject of study. this argument is based on a number of theoretical constructs. the first is the distinction between social and academic language (cummins, 2008), which is not acknowledged in the outcomes-based education (obe) assessment standards. the development of the academic language register is one of the primary goals of education, since it underlies literacy, mathematics, and meaningful engagement with the subject matter at all stages of education (scarcella, 2011). it is not acquired as naturally as the social-communicative functions of language and develops through formal instruction at all stages of the education process (cummins, 2008; scarcella, 2011). the second is social constructivism as a theory of language learning. although obe claims to be constructivist (heugh, 2009), it is essentially positivist in that it focuses on performance and outcomes, and not on the processes essential for language learning (balfour, 2007; reagan, 2009). the third is content and language integrated learning (clil) (coyle, 2008; sherris, 2008), which is highly effective in contexts where learners are required to master both the subject matter and language of learning, as is the case for the majority of south african children. research on children instructed in english as an additional language in contrast to the generally positive findings on the achievement of african children educated in their home language and/or in bilingual programmes (heugh, 2009; obondo, 2008), the language problems experienced by children who are instructed in a second or additional language have been extensively researched both internationally and in south africa, and a growing number of educational researchers attribute underachievement to learning in a second or additional language (alexander, 2005; brock-utne & skattum, 2009; pluddeman, vuyokazi & ncedo, 2010, in webb et al., 2010). these authors suggest that the choice of english by a large proportion of african-language-speaking parents is undermining the academic achievement of the children they are seeking to empower through education. in most research studies there is almost complete agreement that underachievement is linked to instruction and assessment in english. these studies, which all suggest an achievement gap between english first-language (efl) and additional-language learners (eal), are discussed below. referring to the third international mathematics and science study (timss) on 900 grade 8 learners, in which south africa obtained an average score of 264 for mathematics compared with the international average of 467, howie (2005a) states that fluency in english was the most significant determinant in learning science and mathematics. reddy et al. (2006) report that in the 2003 timms test, children who ‘always’ spoke the language of the test at home scored an average of 349, while those who ‘never’ spoke the language of the test at home scored only 192. the western cape grade 6 assessment study (wced, 2004) showed that children who spoke english as a first language (l1) had a mean score of 70% on the literacy test, while isixhosa l1 speakers obtained only 37%. only 1.6% of isixhosa speakers performed at official grade level. broom (2004) investigated the reading achievement of grade 3 learners in 20 urban primary schools in gauteng, and found that the average score on the reading test for eal learners in township schools was 31.8%, as opposed to the 87.8% achieved by efl learners. the performance of efl learners was consistently higher than that of eal learners, even in the same urban schools, but the performance of eal learners in the urban schools was better than that of their peers in the township schools. a number of studies have also investigated the language proficiency, as opposed to educational outcomes, of children learning in english. a study by jooste (2003) on grade 5 children in a number of upper and lower socio-economic status (ses) schools in cape town, showed that by grade 5, eal learners were still performing significantly below their efl peers on measures of reading comprehension. van rooyen and jordaan (2009) assessed 464 grade 8 12 learners in an ex-model-c high school on a measure of complex sentence comprehension. although the results of the study indicated that the majority of learners achieved within the average range, and there were no statistically significant differences between efl and eal learners, the eal participants tended to score, on average, one scaled score below the efl participants, suggesting that they had not quite reached the proficiency levels of the first-language participants. this means that despite a substantial period of educational exposure to english throughout the primary and high school grades, parity with monolingual peers is not always achieved, even on oral tasks. one would therefore expect greater differences on reading or written tasks, which demand higher levels of language processing. in addition, the language comprehension scores were positively correlated with the most recent school report mark and the most recent english mark, confirming that oral language proficiency underlies academic achievement (cummins, 2008). webb et al. (2010, p. 279) claim that the choice of english as the medium of instruction by learners in the ex-model-c schools is not as problematic as in rural and township schools, because in the former context the learners have ‘reasonably adequate’ english proficiency. however, this may be an assumption based on the research evidence showing that middle-class children of all races in this system perform as well as those in international contexts on measures of numeracy and literacy and go on to obtain a university entrance exemption and education (fleisch, 2008). it should be noted that the research referred to by fleisch (2008) does not consider the differences between efl and eal learners in these schools and some of the reported difficulties, particularly related to language, experienced by teachers and learners in ex-model-c contexts (du plessis & naude, 2003; du plessis & louw, 2008; o’connor & geiger, 2009). for example, meier (2005, p. 171) found that teachers in this context experienced increased workloads in accommodating learners from diverse backgrounds since they had to adapt their teaching methods by teaching at different levels, sometimes ‘lowering standards’, and they had not been prepared to deal with multilingualism in the classroom. from the eal learners’ perspective, the complexity of the english used by efl teachers demands high levels of auditory processing and short-term memory and can lead to attention problems (brice & brice, 2000). if these children experience academic problems as a result of learning in english, this leads to lowered self-esteem and a lack of confidence (o’connor & geiger, 2009). in a study on 80 foundation-phase teachers in ex-model-c schools in the cape town metropolitan area, o’connor and geiger (2009) found that teachers expressed difficulties with discipline as a result of comprehension problems in eal learners, and had limited success in collaborating with parents, because of social circumstances such as extended working hours, transport problems and financial difficulties. parents’ limited english proficiency and low literacy levels were also identified as problems since they could not assist with homework. teachers found it difficult to teach at different linguistic levels when they had both eal and efl children in their classes, and experienced time pressures when they had to pre-teach the vocabulary and concepts required in a particular lesson. efl teachers were frustrated by not being able to speak the home languages of the children in their classes and did not always understand the influence of the home language on the learning of english. teachers expressed a need for support such as assistants who speak african languages, language-enrichment teachers, and language-teaching resources. they also felt that their training was not adequate in either multilingualism or teaching practice to equip them for the task of educating learners from diverse linguistic backgrounds. it is therefore apparent that one cannot assume that eal learners in ex-model-c schools are necessarily achieving the english proficiency they need to perform to their full potential academically. furthermore it has become evident in studies of university students (pienaar, 2009) that language problems are perpetuated at this level, and there is growing concern among academics that many students, regardless of educational background and whether they are l1 or second-language (l2) speakers of the language of instruction at the university, enter the tertiary level with weak language and literacy skills and are ill-equipped to deal with the demands of academic language in the various disciplines. this is particularly reflected in their writing skills. questions can therefore be raised regarding the language-learning processes in all schools and whether children attain the language proficiency and consequent literacy skills required for the increasing conceptual demands of the curriculum in the higher grades and beyond. fleisch (2008, p. 98) points out that although the research shows a relationship between achievement and instruction in english, the studies often do not provide insights into the ‘generative mechanisms, the underlying reasons or causes that link children’s experiences with language at school and their failure to become proficient in reading and mathematics’, i.e. exactly how language proficiency is linked to academic achievement. particularly in rural and township schools that adopt a transitional or ‘english from grade 1’ model, the generative mechanisms are considered to be as follows: a lack of sufficient academic language development in the l1, making the leap from learning the language in the first 3 grades to using it for learning in grade 4 too steep (heugh, 2009); teachers’ inevitable use of code switching, which arguably builds neither the l1 nor l2 (holmarscottir, 2003); and the focus on lower-order cognitive tasks as a way of compensating for lack of mastery of the medium of instruction (fleisch, 2008). another proposed mechanism involves the emotions of l2 teaching and learning. probyn (2001) showed that teachers in township schools found teaching in english to be stressful and felt that the learners were equally affected by the demands of learning in english, in that they often understood what they were learning but could not express themselves, leading to embarrassment and a loss of self-esteem. however, although these factors are important, they are not necessarily the real ‘generative mechanisms’, as fleisch (2008, p. 98) suggests. an analysis of the actual language teaching and learning mechanisms on a psycholinguistic level is more likely to reveal what it is that teachers are teaching and learners are learning about language that may or may not support their academic development. a recent study by meirim, jordaan, kallenbach and rijhumal (2010), for example, examined the development of semantic processing skills such as fast mapping and lexical organisation in a longitudinal study of grade 1 3 eal learners, and suggest that these skills need to be developed at this stage of the education process in order to enhance the learners’ vocabulary acquisition. alternative interpretations of the research on language effects in academic achievement fleisch (2008) points out that although the evidence for language as a major factor contributing to the poor performance of south african children is convincing, the interpretation of these findings needs to be carefully evaluated. he bases this argument on a study by braam (2004), howie’s (2005b) detailed analysis of the timms studies, and a re-appraisal of heugh’s (2000; 2006; 2009) arguments, which are based on earlier research by malherbe (1977). braam (2004) found that in a dual-medium english-afrikaans school on the cape flats, serving a mixed community of lower-middle-class and working-class coloured families, 55% of the children registered in the english stream despite reporting that afrikaans was their home language. across the curriculum, these children were more successful academically than the afrikaans-speaking children enrolled in the afrikaans stream. braam (2004) explains this as reflecting a complex set of class dynamics. in this specific community, afrikaans is stigmatised as the language of the lower class and the teaching practices are aligned to this stigmatisation, with the afrikaans classes subjected to more direct, transmission teaching while the teachers in the english stream, who are also efl speakers, associate english with academic achievement and encourage higher-order thinking. the implication is therefore that home language instruction ‘does not exist in a social and political vacuum’, and teaching in the home language does not necessarily lead to better outcomes (fleisch, 2008, p. 112). howie’s (2005b) analysis of the timms results showed that there are other countries where a large proportion of children (more than 70%) did not speak the language of the test at home (e.g. indonesia, malaysia, morocco, philippines and singapore). in both indonesia and malaysia, a significant proportion of these children did better than children who ‘always’ or ‘sometimes’ spoke the language of the test at home. in singapore, ‘seldom’ or ‘never’ speaking the language of the test at home did not preclude academic excellence. these findings apply not only to east asia but also to countries in north africa, and while the difference on the average mathematics score between children who ‘always’ and ‘never’ spoke the language of the test at home was 157 points in south africa, it was only 46 points in botswana. taken together, these results suggest that language factors are not the only contributors to educational achievement. fleisch (2008) argues that heugh and co-workers, who are advocates of home language instruction in the context of an additive bilingual approach, frequently cite the work of malherbe (1977) on afrikaans-english bilingual schools, showing that children who had afrikaans home language instruction up to grade 7, followed by dual-medium instruction in afrikaans-english from grades 8 12, performed better in both languages than children in monolingual afrikaans or english schools. they also showed higher levels of tolerance for linguistic diversity, and even learning-disabled children performed better. in addition, the dual-medium schools were mostly in rural and less well-resourced areas. heugh (2000) interprets this research as indicating that the african languages should be used as media of instruction for as long as possible, while english is taught as a subject. however, according to fleisch (2008), these findings offer evidence against the ‘home language is best’ position. he cites malherbe’s conclusion that although learning in the l2 results in an initial disadvantage in content subjects, the medium of instruction is less significant as the child progresses to higher grades and eventually has no impact on achievement. malherbe (1977) actually found that the language performance of afrikaans-speaking children in english-medium schools was better than for afrikaans-speaking children in afrikaans schools in the higher grades. it is ironic that fleisch (1995) himself criticised malherbe’s groundbreaking work for its link to a particular political agenda, when in fact it showed the importance and advantage of maintaining both languages, either through using them as the medium of instruction or teaching them as subjects, since the majority of schools in malherbe’s (1977) research were either parallelor dual-medium. this meant that even if the children were being educated in the l2 (english), they still received input in the l1 (afrikaans) at an academic level through subject teaching, and there was continued use of afrikaans in the home environment. of course, comparisons between afrikaans and the african languages as media of instruction should be treated with caution, since the apartheid government invested significant amounts of money in the development of afrikaans, and textbooks, dictionaries, fiction, etc. were readily available. afrikaans also enjoyed high status and was used extensively in the public domain. the support for the home language under these learning conditions makes a difference. the results of a study by morrow, jordaan and fridjhon (2005) contribute some insight into the perceived advantages of bilingual and home language instruction. in this study 181 grade 7 learners from three different contexts (rural, urban and township), where the language-of-instruction practices varied, were tested on an assessment tool constructed in english and translated into isizulu. the assessment tasks were based on the frequency of occurrence of key concepts in a published curriculum package. the learners showed specific patterns of performance dependent on context. the learners in urban ex-model-c schools (taught only in english) performed significantly better in english (89.5%) than in isizulu (58.1%), demonstrating the highest level of competence in english but the lowest in isizulu. learners in townships schools (taught in both english and isizulu) showed similar proficiency in both languages, demonstrating the same level of competence in isizulu (71.43%) and english (73.5%) but significantly higher english scores than the learners in rural schools (taught in both english and isizulu), who did much better in isizulu (75.1%) than in english (53.4%). the study showed that children in the urban schools who were instructed only in english did very well and better than the children in township and rural schools in either english or isizulu, thus contradicting the claim that bilingual education is preferable to monolingual education, and that performance in the l2 is dependent on l1 proficiency, especially since the urban learners obtained a relatively low average score on the isizulu test (58.1%). the children in the township schools demonstrated a balanced profile, but did not do as well in english as their urban counterparts, although they may have caught up at a later stage and would have the advantage of being proficient in both english and isizulu on an academic level. despite receiving instruction in english from grade 4 onwards, the children in the rural schools showed that they were not coping with this medium of instruction and would be far better off if isizulu were used as the language of teaching and learning. the findings of this study thus confirm the strong contextual influences on language in education, and reinforce the conclusion that the role of language in poor school performance is not clear-cut. fleisch (2008) therefore poses the question: do children fail because they do not understand the language of learning and assessment, because of poverty-related issues or because they attend inadequate schools? in all likelihood the answer is an interaction and combination of all these factors, but it is nevertheless important to address the issue of quality, since it is highly variable in different contexts and is considered to be ‘the fundamental problem in south african education …’ (fleisch, 2008, p.121). quality of education and language teaching practices in rural and township schools, the quality of education is affected by five main factors: many teachers are not literate and have poor subject knowledge; the children receive less instructional time because of poor punctuality, absenteeism and preoccupation with other tasks; teachers have low expectations of children; there is poor utilisation of existing materials; and inadequate methods of instruction are used (fleisch, 2008). once again, the extent to which these factors affect urban schools has not been widely researched, but there is some evidence to suggest that there are problems in this system as well. for example, van der sandt and niewoudt (2003) found that grade 7 and prospective student teachers in ex-model-c schools had weak knowledge of geometry. also, in contrast to other countries where teacher expectations are low for certain children, south african teachers are said to have low expectations for all children because of misinterpretation of the grade level requirements of the official curriculum standards and misunderstanding of child-centred pedagogy (vinjefold, 2004, in fleisch, 2008). this results in lower teaching standards and in children becoming complacent about what they know. in particular, and of relevance to this paper, is south african teachers’ knowledge of language and knowledge about language, collectively referred to as ‘teacher language awareness’ (andrews, 2003, p. 81), which directly affects their teaching practices. andrews (2003, p. 84) defines language-teaching practices as the ‘creation of opportunities for language learning in the classroom.’ language-teaching goals and methods may be planned in advance, but the teacher also needs to be flexible and adapt to the discourse demands created by the classroom interaction (wright & bolitho, 1997). according to andrews (2003, p. 86) teachers’ language awareness is ‘metacognitive’, involving the ability to reflect on knowledge of and about language, and this distinguishes the teacher from the learner. this metacognitive dimension of language teaching is central to educational linguistics (brumfit, 1997; reagan, 2009). however, in the international literature as well as in south african research there is evidence to suggest that language in education is a ‘tricky business’ (reagan, 2009, p. vii). educational linguistics is a specialised area that has unfortunately been neglected in teacher-training programmes, and consequently few teachers have sufficient knowledge of the complex, multidimensional nature of language and the implications for language-learning and language-teaching processes in either l1 or l2 contexts (uys, van der walt, van den berg & botha, 2007; o’connor & geiger, 2009; mroz, 2006; wong-fillmore & snow, 2000; andrews, 2003). one of the central issues in educational linguistics is the notion of academic language (wong-fillmore & snow, 2000; cummins, 2008). academic language a recurring theme in the literature on school-age language is the distinction between social and academic uses of language (bailey, 2006; cazden, 2001; chamot, 2005). saville-troike (1984, p. 216) introduced the term ‘academic competence’ to refer to the ‘qualitative difference between the communicative tactics and skills that children find effective for meeting their social needs and goals and those that are necessary for academic achievement in the classroom’. a number of theorists have proposed that the language used in the academic context is qualitatively different from that used in everyday conversational contexts (e.g. bruner’s (1975) communicative and analytic competence, donaldson’s (1978) embedded and disembedded language, olson’s (1977) utterance and text, gibbons’ (1991) playground and classroom language and gee’s (1990) primary and secondary discourses), but a precise description of academic language is elusive (wong-fillmore & snow, 2000) and is dependent on the particular focus of different professional or research communities (valdes, 2004). although the concept of a distinct academic language register can be applied to any language used for teaching and learning, which is an important consideration in the south african context, most of the work in this area has focused on english. for those working with individuals whose l1 is english, academic language refers to literature, writing, language arts, and proficiency in oral and written text, also known as ‘academic discourse’ (valdes, 2004, p. 108). for those working with individuals for whom english is an l2 or additional language, the definition of academic language varies depending on the perspective of the community of practice. the ‘teaching english as a second language’ (tesol) profession views academic language as the language used to carry out academic work at university level as well as the language used by particular disciplines for communication in the field. within this profession, research has focused on english for specific purposes (esp) and english for academic purposes (eap) (bhatia, 1997; johns, 1997; swales, 1990). in contrast, the esl profession working with school-age children defines academic language as language needed to succeed academically in all content areas, including the english used to interact in the classroom and the english used to obtain, process, construct and provide subject matter information in spoken and written form using appropriate learning strategies (valdes, 2004). two approaches are adopted in this community: the teaching of english as a preliminary to instruction in subject matter and clil (coyle, 2008). the bilingual education profession is concerned with the development of academic language in both english and the l1 of students, focusing almost exclusively on cognitive academic language proficiency (calp) in contrast to basic interpersonal communication skills (bics) (cummins, 1984). this distinction was introduced by cummins to explain research findings on bilingual children who appeared to be fluent conversationalists but were still below grade expectations on verbal academic performance in both languages (cummins, 2008). the bics/calp distinction formalised the difference between conversational fluency and academic language as two of, but not the only, conceptual components of the language proficiency construct (cummins, 2008). cummins and yee-fun (2007) distinguish three dimensions of language proficiency: conversational fluency, discrete skills and academic language proficiency. each follows a different developmental trajectory among l1 and l2 children and each responds differently to particular types of instructional practices. conversational fluency is acquired within 1 2 years in face-to-face conversations and uses high-frequency vocabulary and simple grammatical constructions. discrete language skills (listening, speaking, reading and writing) involve learning the rule-governed aspects of language (phonology, grammar and spelling), and are developed by direct instruction and/or immersion in a language-rich home or school environment. these skills can develop concurrently with conversational fluency (weber & longhi-chirlin, 2001) within 2 years (geva, 2000; lesaux & siegel, 2003), but there is little transference to academic language proficiency (kwan & willows, 1998; verhoeven, 2000), which requires more focused teaching. cummins uses calp and academic language proficiency interchangeably to refer to ‘the extent to which an individual has access to and command of the oral and written academic registers of schooling’ (cummins, 2000, p. 67). according to cummins (2008), the distinction should caution educators against conflating the conversational and academic dimensions of proficiency, which may create academic difficulties for children because of the difference in the timelines for the acquisition of conversational and academic language, which depends on language-teaching practices and can take between 5 and 7 years to reach levels commensurate with grade norms. the implications are that students need support in the acquisition of academic language, and in fact scarcella (2009; 2011) claims that with adequate teaching and support, academic language can be acquired more rapidly. the bics/calp distinction was elaborated (cummins, 1984) to show how instructional practices could assist learners to catch up academically. essentially, bics and calp could vary along two dimensions: cognitive demand and contextual support, with the best instructional methods involving context-embedded, cognitively demanding tasks (cummins, 2008). this has implications for teaching quality, which in south africa is often influenced by low teacher expectations and consequently low cognitive demand in the classroom (reddy et al., 2006). cummins (2008), guthrie (2004) and wong-fillmore and snow (2000) suggest that written texts are a reliable source of academic english but need to be presented with instructional support to aid in language development. hence teachers need to help children acquire the academic language register by discussing not only the content but also the language used in texts. teachers can transform text into usable input by helping children to make sense of what they read and drawing attention to how language is used in the materials they are reading (wong-fillmore, 1997). cummins’ model has been criticised (scarcella, 2003; valdes, 2004; edelsky 1990; martin-jones & romaine, 1986; macswan, 2000) as an oversimplification of what constitutes contextual support and cognitive demand and for reflecting a ‘deficit’ perspective (aukerman, 2007) that attributes academic difficulties to low calp. however, the bics/calp distinction can be related to other theoretical distinctions (see bruner, 1975; donaldson, 1978; olson, 1977; gibbons, 1991; gee 1990) and although the terms vary, the basic distinction relates to the extent to which meaning is supported by contextual cues or is primarily linguistic in nature. westby (1994) shows how both the rhetorical (who is talked to) and referential (what is talked about) dimensions of communication become less context-embedded in school. along the rhetorical dimension, children are expected to learn to talk not only to individuals as they did in the preschool period, but also to groups of people, and to both familiar and unfamiliar listeners. this requires more specificity in vocabulary and syntax, since the child cannot depend on shared knowledge and must learn to take the listener’s perspective. along the referential dimension, children no longer talk only to meet their social needs, but must learn to talk about past and future experiences, and to generalise and theorise about these experiences, which involves increasing distance from contextual cues. according to westby (1994), narrative language is particularly important for the development of this decontextualised communication and should be used extensively in the early school years. furthermore wong-fillmore and snow (2000) and cummins and yee-fun (2007) maintain that academic language is challenging for both l2 and l1 learners, since few children start school with the ability to interpret text and do not necessarily have the discourse skills required in education. language-in-education practices in south african classrooms in south africa, the lack of attention to educational linguistics is exacerbated by ill-informed and misunderstood concepts and teaching practices such as ‘whole language’, ‘communicative language teaching’ (heugh, 2009, p. 168) and ‘natural language’, which have become almost ‘orthodoxies’ in the education system (balfour, 2007, p. 6). the communicative approach assumes that language learning only occurs in real-life contexts, where the communicative functions of language drive the acquisition process. teachers do not act as instructors but as facilitators of the process through natural communication and interaction, using comprehensible input of a sufficiently high quality and complexity to ensure that learners will acquire the semantic and syntactic systems of the language of instruction in a subconscious, implicit way (balfour, 2007). this approach is based on krashen’s (1988) distinction between acquisition and learning, which are in fact not ‘distinct and separate’ processes (baker, 2001, in reagan, 2009, p. 59), and are both adequately aligned with a constructivist approach to language learning (reagan, 2009). this approach is discussed in more detail below. furthermore, one of the most disabling effects of obe has been that teachers were encouraged not to teach language and literacy skills explicitly (heugh, 2009), which meant that learners did not receive the necessary scaffolding to develop these skills. teacher-training programmes have similarly de-emphasised explicit teaching because they have had to work within the obe framework because of the substantial financial investment in its introduction and implementation (heugh, 2009). although there have been various attempts to remedy the situation from time to time, e.g. the foundations for learning campaign (tyobeka, 2008), and the minister of basic education’s recent announcement of changes to the obe system (motshekga, 2010), teachers’ language awareness and consequently the power of language in education remains limited. the practice of contentand language-integrated instruction is virtually non-existent, because subject teachers regard language teaching as the responsibility of the language teachers and do not know that they can also teach the language of the subject (uys et al., 2007). the recent introduction of a training module at north-west university, in which student teachers were shown how to implement this approach, is an encouraging development and proves that it can be done within an outcomes-based framework (uys, van der walt, botha & van den berg, 2006). the above discussion leads to the conclusion that perhaps the fundamental problem in education is that language learning should be approached within a ‘constructivist epistemology’ (reagan, 2009, p. 54) that focuses on generative mechanisms and processes, while obe, although claimed to be constructivist (heugh, 2009), has been misunderstood and thus misdirected. it essentially reflects a positivist epistemology (balfour, 2007). social constructivism reagan (2009), in his book language matters, maintains that theories of learning in general and of language learning in particular are examples of metaphors which are culturally determined cognitive tools that shape our thoughts. it is therefore understandable that there would be different philosophies of learning within a multicultural society such as south africa, and that what are essentially western concepts would be misconstrued. to understand what learning is about, and how learning theories have evolved over time, reagan (2009) argues that one should examine some of the philosophies of learning. plato, for example, theorised that learning is basically accessing what one already knows, and according to reagan the socratic teaching method, involving active engagement with learners, is grounded in this idea. in contrast, the philosopher locke posited that the child’s mind is a ‘tabula rasa’ and the ‘teacher pours knowledge into the child’ (reagan, 2009, p. 57). this philosophy was adopted by 19th-century psychologists, who emphasised scientific, observable facts in understanding learning, and the philosophy developed into the behaviourist school of psychology, which was influential in education throughout the 20th century. transmission teaching methods and the audiolingual method in l2 teaching are applications of behaviourist psychology. it is interesting that these teaching methods are still evident in many south african classrooms (fleisch, 2008), despite the introduction of the new curriculum. reagan (2009, p. 59) claims that although cognitive science has changed our understanding of how the human brain learns, there is still a gap between this knowledge and application to classroom practice, and ‘the science of learning has not yet emerged ... we are still reliant on metaphors to understand the nature of learning’. according to this author, constructivism is one of the more powerful metaphors, but has not been investigated extensively in the context of language learning. furthermore, there is no general consensus on the meaning of the concept and whether it is an epistemology, educational philosophy, teaching approach or theory of teaching or learning (reagan, 2009). because metaphors often inform us about what things are not, we do know that constructivism is not a theory of teaching; it is a theory for defining knowledge and learning (fosnat, 1993, in reagan, 2009, p. 62) and it rejects traditional, transmission approaches. constructivism defines knowledge as temporary, developed socially, and mediated culturally. it emphasises the individual learner’s construction of knowledge and the personal nature of learning. one of the principles of learning in constructivism is that the classroom is a discourse community, engaged in reflection, conversation and activity (reagan, 2009). according to reagan (2009), there are two competing types of constructivism: radical constructivism, which is piagetian in orientation and takes a cognitive view of learning, and social constructivism, which is vygotskian and emphasises the sociocultural context of learning as a socially constructed, mediated process. the two types can, however, be reconciled. social constructivism is also entirely compatible with direct instruction, and although it is learner-centred, the content and skills of the learning process are the teacher’s responsibility (reagan, 2009). social constructivism can be applied to language acquisition and learning, if it is correctly interpreted. furthermore, it is compatible with clil (coyle, 2008; gibbons, 2002). broadly defined, clil is instruction in the academic language necessary to accomplish content-area tasks (sherris, 2008), and it has been shown in research to have a positive impact on learning (coyle, 2008). historically, clil stems from the position that l2 proficiency is facilitated by using the language as a medium for learning (mohan, 1986) and it has four key principles of practice: planning content and language goals for each lesson; construction of specific language and content knowledge and skills through interaction; opportunities to develop reading, writing and listening skills within content areas; and assessment of outcomes during lessons (sherris, 2008). social constructivism also informs the practice of speech-language therapists (slts) who work with children who do not acquire their l1 naturally. these professionals have learned that to facilitate language learning it is necessary to create authentic, pragmatically appropriate contexts for communication, as in communicative language teaching, but within this it is essential to set explicit language targets and to use selected elicitation techniques and interaction methods that advance the acquisition of language through scaffolding (owens, 2004). for this reason, slts are well positioned to work in collaboration with teachers to enhance language learning in south african classrooms. two recent studies (wium, louw, & eloff, 2010; olivier, anthonissen & southwood, 2010) confirm that this is not only possible but highly effective. conclusion in the final analysis, and if we acknowledge that one of the primary goals of education is to develop academic language, so that learners may engage meaningfully with the content and subject matter across the curriculum at all stages of the process, it is irrelevant whether the language of learning is the l1 or an additional language, and whether the language is taught as a subject or is the medium of instruction. to achieve academic language proficiency, language-teaching practices that construct the process of learning must be addressed as a matter of urgency. as taylor, vinjevold and muller (2003, p. 65) have stated, the most significant issue for quality in education is: ‘the all pervasive and extremely powerful influence of language which is unambiguously implicated in learning … and the need for pupils to have as good a grasp of the language of teaching and learning as possible.’ well-informed, experienced slts may well be able to assist in achieving this goal, by providing input to teacher-training programmes, collaborating with teachers on setting and developing language-learning goals, and developing academic language through clil within a 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(1990). genre analysis: english in academic and research settings. cambridge: cambridge university press. taylor, n., vinjevold, p., & muller, j. (2003). getting schools working: research and systemic school reform in south africa. cape town: pearson education south africa. taylor, s., & yu, d. (2008). the importance of socio-economic status in determining educational achievement in south africa. development policy research unit. stellenbosch university, department of economics, working papers. tyobeka, p. (2008). foundations for learning assessment framework foundation phase. south africa: department of education. uys, m., van der walt, j., botha, s., & van den berg, r. (2006). an integrated course for english-medium of instruction teacher trainees in south africa. journal for language teaching, 40(2), 68-86. uys, m., van der walt, j., van den berg, r., & botha, s. (2007). english medium of instruction: a situation analysis. south african journal of education, 27(1), 69-82. valdes, g. (2004). between support and marginalization: the development of academic language in linguistic minority children. international journal of bilingual education and bilingualism, 7, 102-132. van der sandt, s., & niewoudt, h. (2003). grade 7 teachers’ and prospective teachers’ content knowledge of geometry. south african journal of education, 23(3), 199-205. van rooyen, d., & jordaan, h. (2009). an aspect of language for academic purposes in secondary education: complex sentence comprehension by learners in an integrated gauteng school. south african journal of education, 29(2), 271-287. verhoeven, l. (2000). components in early second language reading and spelling. scientific studies of reading, 4, 313-330. webb, v.a., lafon, m., & pare, p. (2010). bantu languages in education in south africa – ongekho akekho! the absentee owner. language learning journal, 37(3), 273-292. weber, r., & longhi-chirlin, t. (2001). beginning in english: the growth of linguistic and literate abilities in spanish-speaking first graders. reading research and instruction, 41, 19-50. westby, c. (1994). communication refinement in school age and adolescence. in o. haynes & b. shulman (eds.). communication development: foundations, processes and clinical applications (pp. 341-383). englewood cliffs, nj: prentice-hall. western cape education department (2004). grade six learner assessment study 2003: final report. cape town: western cape education department. wium, a.m., louw, b., & eloff, i. (2010). speech-language therapists supporting foundation phase teachers with literacy and numeracy in a rural and township context. south african journal of communication disorders, 57, 14-21. wong-fillmore, l. (1997). authentic literature in esl instruction. glenview, il: scott foresman. wong-fillmore, l.w., & snow, c.e. (2000). what teachers need to know about language. usa: clearing house on language and linguistics. wright, t., & bolitho, r. (1997). towards awareness of english as a professional language. language awareness, 6(2&3), 162-170. probing comprehension of h7/questions in an echolalic child john m . panagos, ph.d. (ohio) dept. speech pathology and audiology, kent state university, kent, ohio. summary comprehension of what, where and when wh questions was evaluated in a four-and-one-half year old echolalic boy who displayed in therapy and at home equivocal response to various question forms. deficits of comprehension were traced to an inadequately developed deep structure (particularly adverbials) rather than to limited knowledge of wh transformations. delayed development of semantic rules, as in the case of time distinctions, may block acquisition of those syntactic rules dependent upon them. opsomming begrip van wat, waar en wanneer is by 'n 41/2-jarige eggolaliese seuntjie geevalueer wat tuis en tydens terapie woordelikse nabootsing van vraagvorme gebruik het. 'n gebrek aan begrip ontspring waarskynlik nie soseer uit 'n beperkte kennis van vraagtransformasies nie, as uit 'n dieptestruktuur wat nie toereikend ontwikkel het nie (veral met betrekking tot bywoorde). die aanleer van sintaktiese reels wat van die semantiese ontwikkeling afhanklik is, kan verhinder word deur 'n vertraagde ontwikkeling van semantiese reels (soos in die geval van onderskeiding van werkwoordtye). in the course of evaluating comprehension of wh questions in an echolalic boy named evan we made some interesting clinical observations. when evan first enrolled in our child language program at kent state university at age four years he was hyperactive, inattentive and language delayed. sentences and phrases spoken to him were typically repeated verbatim. a clinician would ask him, "what are these?" and evan would reply with clear pronunciation, "what are these?" spontaneous utterances were fragmented and telegraphic. they suggested a pre-base level of oral syntax development.7 there were also signs of delayed motor development. toilet training had been later than might be expected, preference was shown for the left hand, vocal quality was husky and low-pitched, and gait was at times noticeably irregular. otherwise evan was regarded by all who knew him as a bright and healthy child with normal developmental potential. in addition he had the benefit of warm and caring parents, both with college degrees and considerable understanding of child development. the mother was a teacher of the deaf. tydskrif van die suid-afrikaansc vereniging vir spraak en gehoorheelkunde, vol. 22, dese/nber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 john μ. panagos after seven months of group and individual language therapy, focusing on expansion of the base grammar and particularly the auxiliary system within it evan had made considerable progress with us. at 4,8 his spontaneous sentences showed a good variety of expanded base strings with several properly applied elementary transformations. here is a sample of evan's sentences drawn from a corpus of spontaneous utterances collected at home and in free play sessions at the clinic5: ( 1 ) 1 already ask jon. (2) we're having those cookies up there. (3) i want to use blue on my caterpillar. (4) albert doesn't talk (elephant puppet). (5) move your chair, i can't. (6) he waiting for me, for evan. (7) there are legs. (8) the head is upside down. (9) want to play with us? (10) is tarah coming? (11) was that john panagos? (12) what did you study? (13) what's on top of that house? (14) what you making? (15) what's that under there? (16) what did you at school, trina? (17) hey you guys, what you doing here? (18) what happen to theresa's nose? (19) where's this go? (20) where's her flu? (21) where's a telephone pole? (22) where's mother goose (a book)? (23) where's shurdon's blue dune buggy? (24) where jeff get those cookies? (25) my mom bought this shirt where? (26) who brought those? (27) who drew on the wall? (28) who draw that? (29) whose draw that truck? . (30) whose papers are these? furthermore, hyperactivity had diminished along with the echolalic behavior. evan could now sit at a table with his clinician for 40 minutes or more, and work through his lessons attentively without simply repeating everything said to him. comprehension of wh questions, however, remained a problem. depending on the type of interrogative involved (what, how, why . ..), responses were either inconsistently correct, or occurred not at all. occasionally a given question (e.g. "what are you doing?") would cause evan to revert to echolalia. although, as mentioned, spoken sentences were now meaningful and syntactically well-formed, inconsistency in answering questions puzzled and journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) wh questions in an echolalic child 25 frustrated evan's parents, and presented a challenge to the clinician on the case. apparently the problem we faced is not an uncommon one in clinical circles. echolic children are found to be particularly sensitive to various question types4 as are younger normal children around the age of three years.2 we thought it was time to probe evan's comprehension of wh questions more carefully. why and //ow.interrogatives were ruled out from the beginning for the reasons that they were structurally and semantically complex, and that evan to the best of our knowledge had never responded to them or used them in spontaneous speech. however, there was sojne evidence from speech samples that he could process what and where questions. although little was known about the when question, it was also of interest to us. the probe was begun with the what question because it seemed to be the most fundamental of the three. with the help of evan's clinician, the evaluation was carried out over a three week period during individual therapy sessions. the probe at the outset certain operating assumptions (ignoring some detail) were made about the what question. first, an intact noun phrase (np) in the base is required for the application of the rule. second, an np can be marked as either human (someone) or nonhuman (something). third, the what morpheme is a kind of synonym for np-nonhuman. fourth, what can replace np-nonhuman in an underlying string. finally, when np substitution occurs in the predicate, the what morpheme is positioned at the beginning of the sentence. assuming the application of auxiliary transposition and do support transformations, the steps from underlying to surface structure can be shown this way: john kicked the ball. ->• john kicked np-nonhuman (something) john kicked what? what did john kick? a similar analysis can be given for the who question which differs from the what form only in that it applies to nphuman rather than to np-nonhuman. furthermore, the transformational principles of the what question are the same for all wh questions in english, hence the much advertised power and generality of transformational rules.2 with the foregoing structural analysis in mind it was hypothesized that failure to comprehend the what question could be caused by: (1) absence of an intact or lexically differentiated underlying np. (2) failure to distinguish nphuman (someone) from np-nonhuman (something), (3) failure to associate what with. np-nonhuman, (4) failure to grasp the what for np substitution, or (5) failure to track the relocation of the what morpheme when moved from the predicate to the beginning of the sentence. to probe these components of comprehension of the what question was the task at hand. it was found that evan could comprehend all aspects of the what question. his clinician placed a group of small objects (car, ball, comb, penny . . ,),on the table in front of him and asked him to name each one in turn. he could do so without difficulty. next the clinician asked, "what?", and simultaneously pointed to one of the objects. accordingly, evan named all of the items flawlessly. then the clinician pointed again to the objects, one at a time, and said, "this is what?", making the what substitution in the predicate. still tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 22, desember 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 john μ. panagos evan's naming responses were correct and unhesitating. finally, the inverted form of the what question was asked, "what is this?", and the same pattern of correct response obtained. thus knowledge of the what question within the limits of the tasks used was assumed. evan's parents agreed. they reported his ability to name was exceptional, and that he always answered what questions as well as who questions whenever they were asked of him. inspection of our corpus of spontaneous utterances revealed a number of well-formed what questions involving both subject and predicate contexts (cf. sentences 12-18 above). who questions (sentences 26-28) were also present. next a similar analysis of the where question was performed. the where question relies on the same transformational principles used in the what question, except that the phrase structure context of the replacement process is the place adverbial (somewhere) instead of the noun phrase. from deep to surface structure, then, the progression takes this form: the ball is there (somewhere) the ball is where? where is the ball? a variant form is one in which the place adverbial is a prepositional phrase: the ball is in the box (somewhere) the box is where? where is the ball? in this case the where morpheme replaces an entire phrase with its own internal structure (prep + np). furthermore, the relations between the prepositions and noun phrases designate spatial relations within the conceptual system. the objects used to evaluate comprehension of the what question were used to evaluate the where question. they were divided into two groups and separated spatially. half were placed on the therapy table at which evan was seated, and the other half were positioned on a second table across the room. in a sense evan was asked to name the location of the objects with the adverbials here and there. upon hearing the word "ball", for example, he was required to say "there" because it was located on the distant table. evan could perform this locative task easily, making no errors in the process. the same held true for the sentence forms, "the ball is where?" and "where is the ball?" he responded quickly and accurately to all questions asked. the results here were consonant with those found for the what question. in both cases evan showed the ability to process separately and collectively all phases of wh question derivation. however, when the testing'paradigm required a response with a locative prepositional phrase, the picture changed somewhat. ability to respond correctly depended directly on knowledge of prepositions. with all of the objects placed on the table in front of evan, along with a cardboard box, the clinician selected an object and held or placed it in a position relative to the box. asked "where is the ball?", evan could reply appropriately with "on the box'^and "in the box", but not with "behind the box" or "near the box". many prepositions like near, behind, and between, as well as the phrases in front of, and close-to, were simply unknown to evan, and this was the reason why some where questions were incomprehensible to him. ; examination of the corpus of spontaneous utterances showed a good number of well-formed where questions (cf. sentences 19425 above) to support the findings of our comprehension testing. there was!, interestingly enough, one sentence in which when replacement occurred in the predicate without prejournal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) wh questions in an echolalic child 27 posing (my mom bought this shirt where?). the base included a sufficient number of place adverbials to define the category, but lexical differentiation was limited. prepositional phrases included only six locative prep + np sequences (at-, from-, to-, on-, in-, under-). the when interrogative next evaluated is structurally similar to the what and where questions, except that it elicits from the base information concerning time adverbials. time adverbials can be single words (now, later, today) or phrases (in the evening, last night, in june). transformationally we have, late the cake yesterday (sometime) late the cake when? when did i eat the cake? adverbials of time of course do not make reference to tangible objects, but to abstractions about the time continuum (weber and weber, 1973). this fact makes when questions difficult to evaluate, since, unlike what and where forms, objects cannot be displayed as the context of testing. our only alternative was to query evan about obvious time distinctions (yesterday-today, last-night, this-morning. ..) perhaps known to him from everyday experience. our efforts to probe the when question were short lived. questions like, "when did you watch hockey, evan?", or, "you ate dinner when?" went unheeded. evan would just mumble to himself and look down at the therapy table in front of him. his mother confirmed our observations: "time concepts are really a problem for him. he doesn't seem to remember when he's done something" (like going to his grandfather's). review of the corpus items quickly revealed the problem. it was that evan.did not have a sufficiently developed system of time adverbials with which to understand when questions. there were only two occurrences of time adverbials, both single words and quite likely memorized items (no, i already did (write to santa). he still lives in mansfield?). nor could there be found a single when question. in fact, there was in general little evidence of grammatical productivity of time features. a few strong verbs of past-tense form were located (who drew on the wall? who was that on the phone? my mom bought this shirt where?), as well as one instance of an inflected verb (i burped). in several instances do carried past-tense meaning appropriately (what did you study? what did you at school? . . .). however, many of these utterances had an immediacy to them (i burped now) or reflected only the grossest differentiation of time categorization. temporal adverbials serving as sentence conjunctions (before s, when s) were totally absent from the corpus. all available evidence indicated that evan possessed a highly restricted system of temporal concepts whose contributions to syntactic development were minimal. discussion the findings of our inquiry into evan's comprehension of wh questions can be summarized as follows. adult native speakers around him (parents, clinicians) indicated difficulty in understanding wh questions, but for the most part this judgment proved erroneous. evan had receptive and expressive control over the operations of the wvj/constituent association, wh for constituent replacement, and wh preposing, both as separate steps in the derivation of interrogatives, and combined processes.2 rather what determined and predicted his comprehension performance was the availability or nonavailability of underlying phrasal categories to which particular wh questions referred. tydskrif van die sid-arikaanse vereniging vir spraak en gehoorheelkunde, vol. 22, desember 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 john μ. panagos noun phrases were well developed lexically and therefore what questions presented no difficulty. adverbials of place were reasonably established in the base, so where questions were not problematic, unless specific prepositions mapping spatial relations were involved. finally, when questions could not be answered, for they were referenced to nonexistent time adverbials or temporal concepts. in short, evan's comprehension difficulty lay less with comprehending questions than it did in understanding particular aspects of the deep structure of the language. in 1965, chomsky3 revised his theory of generative grammar to include a semantic component having the purpose of interpreting the meaning of syntactic strings. then and since then, there has been considerable debate about the nature and scope of the semantic component and its influence on syntactic rules. that the two components have reciprocal influences on one another in early language acquisition was insightfully demonstrated by bloom1 and further clarified by macnamara.6 some recent evidence dealing with the acquisition of time designations demonstrates the independence and uniqueness of semantic systems.8 these advances in semantic theory are applicable here. our hyperactive and echolalic friend evan, with his perceptual inclination to be bound to the here-and-now, seemed to lack adequate semantic acquisition to support aspects of his syntax development. most striking was his inadequate knowledge of temporal concepts relating to time adverbials in the base of his syntax grammar. it could be hypothesized that the absence of a semantic system of time concepts was blocking growth at several levels of syntactic development. with figure 1 the ways in which this influence might w h e n evan past eat dinner yesterday semantic distinction time = present/past syntactic coding: a,b,c,d.. adv-time past go figure 1. hypothetical phrase marker representation showing various syntactic contexts (a-d) in which the present/past semantic distinction is coded. journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) wh questions in an echolalic child 29 be manifested are illustrated. it can be seen that the nonacquisition of the semantic distinction of present/past could simultaneously affect development of the when question (a), tense marking of the main verb (b), time adverbials within the basefc), and embedded strings derived from time adverbials (d). we have therefore a semantic deficit affecting the distinctly different syntactic processes of morpheme inflection, phrase structure categorization, simple transformations, and generalized transformations. certainly semantic rules about which little is known can have subtle and far-reaching effects on the syntax development of normal children, and on language-impaired children like evan. acknowledgments my thanks to roberta bronahan, sheila higgins, judy badovinac, sue williams, and patricia dukes for sharing sentence data with me, and to candice wice who was the clinician on the case and helped with the evaluation reported here. special thanks go to my friends tom and jane, evan's parents, and to evan himself, who continues to be a delightful fellow to know. references 1. bloom, l. (1970): language development. cambridge, mass.: m.i.t. press. 2. brown, r. (1968): the development of wh questions in child speech. j. verb. learn. verb. behav., 7, 279-290. 3. chomsky, n. (1965): aspects of the theory of syntax. cambridge, mass.: m.i.t. press. 4. fay, w.h. (1973): occurrence of children's echoic responses according to interlocutory question types. unpublished manuscript, university of oregon medical school. 5.. higgins, s.m. (1973): normal and disordered child language: grammatical analysis and comparison. unpublished seminar paper, kent state university. 6. macnamara, j. (1972): cognitive basis of language learning in infants. psychol. rev., 79, 1-13. 7. menyuk, p. (1969): sentences children use. cambridge, mass.: m.i.t. press. 8. weber, j., and weber, s. (1973): early acquisition of linguistic designations for time. unpublished paper delivered at american speech and hearing association convention, detroit, michigan. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 22, desember 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustics and signal analysis noise problems? general radio has the solution: a complete family of noise measuring gri565-b i i instruments for community and industrial noise: for more information please contact: associated electronics (pty.) ud. ro.box 3 1 0 9 4 , phone 7 2 4 5 3 9 5 braamfontein, johannesburg general radio journal of the south african speech and hearing association, vol. , december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 vocal t r a c t dynamics in an a d u l t stutterer lesley wolk, b . a . ( s p & η therapy) ( w i t w a t e r s r a n d ) , department of speech pathology and audiology, university of the witwatersrand, johannesburg. summary the present study was motivated by the clinical observation of "laryngeal spasms" during dysfluency in an adult female stutterer. the flexible fiberoptic nasolaryngoscope was employed in an attempt to assess this phenomenon objectively. findings from fiberscopic and spectrograph^ investigations provided evidence for a disturbance in laryngeal behaviour, and in turn served to determine the nature of the treatment programme. asymmetry of the vocal folds and partial abductory laryngeal behaviour, reflecting a conflict between adductory and abductory forces, characterized the dysfluency in this patient. a subjective evaluation after treatment revealed a reduction in both severity and frequency of stuttering behaviour. furthermore, fiberscopic examination carried out after treatment revealed an absence of the laryngeal disturbances noted previously. results are considered in terms of vocal tract dynamics in stuttering and its clinical applicability. opsomming die kliniese waarneming van "laringeale spasmas" gedurende onvlotheid in 'n volwasse vroulike hakkelaar het die navorser beweeg tot verdere ondersoek van hierdie verskynsel. 'n buigbare fiberskopiese nasolaringoskoop is gebruik in 'n poging om die verskynsel objektief te evalueer. bevindings van fiberskopiese en spektografiese ondersoeke het bewys gelewer van 'n versteuring in laringeale gedrag, en het terselfdertyd ook die aard van die terapieprogram bepaal. asimmetrie en gedeeltelike abduksie van die stemlippe wat 'n konflik tussen adduktor en abduktor kragte reflekteer, was 'n kenmerk van die pasient se onvlotheid. 'n subjektiewe evaluasie na behandeling het 'n vermindering in beide die graad en frekwensie van hakkelgedrag getoon. 'n fiberskopiese ondersoek, wat na die behandeling uitgevoer is, het verder 'n afwesigheid van laringeale versteuring getoon. resultate is gei'nterpreteer teen die agtergrond van vokale kanaal dinamiek in hakkel en die kliniese toepassing daarvan. many years ago it was theorized that the larynx plays a significant role in stuttering (kenyon9). recently, investigations have provided some evidence for a relationship between phonatory behaviour and stuttering; the nature of which however, is still unclear (adams and hayden, 1 conture, mccall and brewer, 2 freeman and ushijima3, inter alia). modern technological advances have facilitated the use of several physiological measurement strategies in research with stutterers (hutchinson8). to date, none of these techniques has received more than isolated research interest. furthermore, only little significant effort has been made to extend these experimental results to their practical clinical utility.. this study was motivated by the clinical observation of "laryngeal spasms" ι associated with dysfluency, during the course of therapy with an adult female stutterer. the flexible fiberoptic nasolaryngoscope (fiberscope) was thus employed to investigate the phonatory gestures in this patient. the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 39 vocal tract dynamics in stuttering m this paper, the author's intention i s : (a) to discuss the fiberscopic ^ n a t i o n in the ongoing assessment of this adult stutterer; (b) to s describe the treatment programme employed and (c) to discuss the overall findings in terms of vocal tract dynamics in stuttering and to c o n s i d e r some practical implications. background to subject history of speech disorder: mrs. a, aged 40 years, was aft seen at the university speech and hearing clinic, university of the witw a t e r s r a n d , johannesburg, on the 21st march 1979 mrs a reported that she had stuttered since childhood, which her mother associated with the bombing during the war. she was born in eneland and lived there for many years until recently when her husband was transferred to south africa on a contract with a diamond mining company. about 18 months prior to the initial assessment mr. a suffered a traumatic head injury which resulted in bilateral deafness. mrs a stated that her stutter deteriorated noticeably since her husband's accident. at three stages of her life, mrs. a received short periods of speech therapy, although on all these occasions she felt that she had not benefited. medical history: she suffered from common childhood illnesses and underwent surgery for an eye defect. no other significant illnesses were reported. psychological a n d family history: mrs. a reported that she experiences much social discomfort since the onset of her husband s hearing impairment and the deterioration of her speech she is said to share a warm relationship with her husband and three daughters. two of her children are reported to stutter mildly. assessment of communication b e h a v i o u r the following areas were assessed by the author before the onset of treatment. results are summarized in table i. description of stuttering behaviour mrs a was classified as an advanced stutterer. her speech was characterized by frequent prolongations on fricatives, and several hard contacts on plosives, nasals and affricates in all positions hard contacts seemed to occur most frequently on voiceless plosives /p, t, k/ appearing as tense, forceful attacks combined with a severe remor. the tension loci were in the lips, tongue, cheeks and laryngeal areas. this nonfluent speech pattern appeared to be habituated and consistent — some adaptation was noted. there was evidence of severe facial tension, characterized by eye closure, eye rolling, frowning, jaw jerks, tremor of lips and flaring of nostrils upward movement of the head was noted to occur, as well as die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) lesley wolk t a b l e i: summary of findings from an assessment of communication behaviour hearing — within normal limits oral peripheral examination — structural competence — functional adequacy for speech language — normal receptive and expressive language skills voice — soft, high-pitched voice articulation — normal rhythm, stress, phrasing — interrupted laterality — established right (r) dominance motor co-ordination — adequate clinical observations — reserved personality — anxious and tense, pleasant disposition — insightful awareness and attentativeness some movement of the extremities. there was associated disturbance of the respiratory mechanism such as pauses, gasping and frequent inhalations. she was often seen to cease a speech attempt and try again, and to employ starters with a sudden increase in tension and force. after a severe block, there was evidence of humiliation and intense anxiety. eye contact was extremely poor. choral speaking, singing, whispering and diminished auditory sensitivity were found to induce fluent speech. she was able to isolate several word and situation fears; the telephone being the most anxiety-provoking situation for her. diagnostic investigations o f l a r y n g e a l beh a v i o u r fiberscopic assessment the fiberscope was employed to . observe laryngeal behaviour directly during connected speech for the purpose of providing objective data that would assist in evaluating the role of the larynx in the dysfluency of this adult stutterer. ! procedure ; the patient's nasal passages and ι posterior aspects of the pharyngeal wall were topically anaesthetized! to prepare for the insertion of the fiberscope. it was connected by a c-mount adapter to a camera. a the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) vocal tract dynamics in stuttering 41 diagnostic fiberoptic light source provided necessary illumination. the fiberscope was inserted into one nostril until the tip of the scope reached a level slightly rostral to the superior margin of the epiglottis. a tape recorder, uher 4200 report stereo i.c. with an m816 directional microphone, was prepared to run concurrently with this examination so as to record all utterances. a transcription of the tape recordings was carried out as each utterance was correlated with its corresponding slide. there was a total of 38 slides. broad-band spectrographic analyses with amplitude displays were carried out on each of these utterances in order to segment the duration of exposure, thus confirming whether the photograph was taken at the moment of the stuttered block. it was always entirely clear, both from broad-band spectrograms and the amplitude displays when the shutter had opened and closed. for the purpose of this paper, only a few of these utterances were selected in order to highlight the major findings. results figures 1(a) and (b) show that the vocal cords are normal at rest and during deep inhalation respectively. figure 2(a) shows a stuttering block on /k/ in the word "cancellations". from observation during fiberscopic examination, it appeared that there was asymmetry of the vocal folds relative to each other. posteriorly at the" vocal processes, the left (l) cord is more adducted than the right (r) cord. there is also clear asymmetry of the arytenoid cartilages. it can be seen that there is a conflict between adductory and abductory forces, which may be referred to as "partial abductory" laryngeal behaviour. the same asymmetry appears as the standard picture of a characteristic block on other plosive sounds (voiced and voiceless) in initial and medial positions. the broad-band spectrogram in figure 2(b) confirms the fact that this photograph was taken at the moment of the stuttered block. the first noise burst, marked s(o) on the spectrogram, refers to when the shutter opened and the second noise burst, marked s(c), refers to when the shutter closed. in figure 3(a) similar partial abductory laryngeal behaviour can be seen during a sound prolongation on /s/ in the word "sweater". the broad-band spectrogram in figure 3(b) provides confirmation as in figure 2(b) above. during observation of the vocal cords, there was evidence of epiglottic movement and shuddering of the entire larynx during dysfluency. this figure clearly illustrates the standard picture of asymmetry where the (r) fold appears more prominently than the (l) one. the distances between the vocal cords were measured. results revealed that the distance posteriorly was 5 units of measurement, medially 3 units and anteriorly 4 units*. the anterior measurement was taken at the point where the folds seem to shade off, i.e. •it is not claimed that these are absolute glottal widths, as the degree of magnification has not been computed, but the proportions are correct. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 lesley wolk anterior m e a s u r e m e n t w h e r e cords lose definition notice that there is medial adduction which is abnormal. thus the narrowest portion of the glottis is medial, while the posterior and anterior portions are both wider, reflecting a disturbance in normal largyngeal behaviour. the striking feature was this recurring picture of arching, which will be referred to as the "arched effect". in summary, a review of the tape recordings and corresponding slides, together with measurements of the glottis calculated for each utterance, revealed the following: 1. the vocal folds were normal at rest and during deep inhalation. they were parallel and symmetrical during all fluent utterances and during singing. 2. there was a general picture of shuddering of the larynx during dysfluency. a figure 1(a) subject mrs. a's laryngeal behaviour during quiet breathing, showing that the vocal cords are normal at rest. the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) vocal tract dynamics in stuttering 43 3. there was evidence of asymmetry of the arytenoids and vocal cords during all dysfluent utterances, where the (r) fold appeared more prominently than the (l) one. 4. partial abductory laryngeal behaviour referred to as the "arched effect", characterized all dysfluency, stuttering blocks and prolongation in all positions. the identical picture was observed with voiced and voiceless fricatives, affricates and plosives. β figure 1(b) subject mrs. a's laryngeal behaviour during deep inhalation, showing that the vocal cords are normal during deep breathing. a β figure 2(a) laryngeal behaviour during a stuttering block on /k/ in "cancellations". the line-tracing which overlays b, outlines the laryngeal structures shown during this production. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 lesley wolk 5(o> sco i 4 κ < 9'ψ fna* «̂ί» is mte..ti «rati figure broad-band spectrogram showing a block on dysfluent production of /k/ in "cancellations" before treatment. a β figure 3(a) laryngeal behaviour during prolongation on /s/ in "sweater". the line-tracing which overlays β outlines the laryngeal structures shown during this production. 5co) sco . ji i f'j.». riit^e-jii >1 .-sri-1 til , i ι it·:11 itm ι· λ λ ι μ ι ma λμλβλ» η. a -·; • ' • % si ί μ t αΐκ • ·•· figure 3(b) broad-band spectrogram showing a prolongation on dysfluent production of /s/ in "sweater" before treatment. the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) vocal tract dynamics in stuttering 45 discussion abductory laryngeal behaviour during stuttering is reported in several recent studies (conture et a l 2 ) . however, the specific picture of a s y m m e t r y ("arched effect") reflecting a conflict between adductory and abductory forces, characteristic of the dysfluency in this subject, has not been reported in the literature. in contrast to the present data, conture et al 2 found differences in laryngeal behaviour among the various types of stutterings. they found a separation of the posterior aspects of the vocal folds during part-word repetitions, but normal laryngeal behaviour in sound prolongations. literature on normal vocal cord function in man shows that:— adduction of the vocal cords for phonation is due to the contraction of the vocalis (voc), lateral cricoarytenoid (lca) and interarytenoid (int) muscles; whilst abduction is due to the contraction of the posterior cricoarytenoid (pca) muscle (hiroto, hirano, toyozumi and shin 7 ). the v o c muscle and to a lesser degree the lca muscle regulate the style of phonation. they are active in the medial compression of the vocal cords to produce inner tension of the cords. three "styles of phonation" are generally considered: hypertense, hypotense and optimum styles (freeman et a l 3 ) . with regard to complexity of laryngeal movements preparatory to vocalization, three types of vocal attack are commonly described (a) soft attack (simultaneous) where pca activity is suppressed throughout the pre-phonatory period; lca and v o c activity increase gradually until it reaches a constant level shortly before or after the vocal onset, (b) hard attack (glottal) where pca activity decreases well before the onset of voicing, shows a transient increase in activity just before the onset of voicing and is then suppressed for the period of voicing; there is a high level of lca and v o c activity, presenting forceful action potentials before phonation, and (c) breathy attack (aspirate) where pca remains active throughout the pre-phonatory period up to the point immediately before the onset of voicing. lca and v o c activity is often decreased temporarily before phonation. therefore, the type of vocal attack depends on vocal cord placement at the initiation of voicing, which is determined by the precise co-ordination between sub-glottic pressure, glottal resistance and supraglottic pressure. (gay, strome, hirose and sawashima5). it thus seems reasonable to postulate that in this adult stutterer, there may be higher levels of v o c and/or lca muscle activity (adductors) and inappropriate functioning of the pca muscle (abductor), resulting in a disturbance of the interplay between agonist and antagonist intrinsic laryngeal muscles during stuttering. the fact that the cords are abducted posteriorly would indicate that there is adequate functioning of the interarytenoid muscles. the v o c and lca muscles are thus considered responsible for the relative hypertonicity of the adductors. these findings are in accordance with current research (conture et a l , 2 freeman and ushijima3). it appears that the difficulty may lie in the die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 lesley wolk pre-phonatory and/or re-phonatory phase, whereby voicing is initiatied with hard vocal attacks resulting in a hypertense style of phonation. there is evidence in the literature to support the belief that some stutterers fail to produce adequate voluntary pre-setting of the phonatory musculature, and that there is a lack of co-ordination between respiration, articulation and phonation in stuttering (gautheron, liorzou, even and vallancien, perkins, rudas, johnson and bell 1 1 ). w y k e 1 7 and others would explain findings such as these in terms of the reflex arc, whereby higher centres control laryngeal reflex activity. according to this model, psychological stresses affect the supramedullary centres which fail to inhibit pca muscle activity, producing abductive responses to the larynx during stuttering. treatment: a treatment programme incorporating the psychological aspects as well as modification of the faulty laryngeal adjustments developed from the diagnostic findings discussed above. only a brief discussion of this programme will be included in this paper. set within a van r i p e r 1 5 framework, various techniques were employed within the modification phase of therapy. these included van r i p e r ' s 1 5 shaping processes, "prolonged speech" (perkins1 0), "passive-airflow technique" (schwartz1 3), "precision fluency shaping" as discussed by w e b s t e r 1 6 and "modification of vocal attack" developed by the author. modification of vocal attack considering hard attack to be the error pattern with high levels of voc and lca muscle activity and significantly earlier voice onset time, one may view soft attack as the target behaviour representing optimal muscular activity. in view of the fact that breathy attack reduces voc and lca muscle activity temporarily before phonation, thus facilitating gradual voice onset, it was employed as a therapeutic strategy (gautheron et al 4 ). furthermore, there is continuous pca muscle activity during the pre-phonatory period in breathy attack, thus preventing jerky "on-off" vocal adjustments. breathy phonation was combined with a low pitch in order to further reduce electrical activity during phonation (gay et al 5 ). a marked reduction in dysfluency was noted to occur when this method was employed in a variety of speech tasks. / a further technique, biofeedback, was applied. the underlying principle of biofeedback training is that a subject can learn to exert some control over a physiological process if he receives immediate, accurate (auditory or visual) information about the process (hanna, wilfling and mcneill6). briefly, emg activity was recorded from the laryngeal and facial areas where there was excessive tension. a pair of surface electrodes were placed on the skin over the levator labii superioris. the action potentials from this muscle were amplified and the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) vocal tract dynamics in stuttering 47 i n t e g r a t e d into a voltage-to-frequency converter. as the electrical activity of the muscles increased, so did the frequency of the emg analog tone. mrs. a was provided with a baseline or reference frequency. she was then presented with a tone whose frequency was analogous to the voltages recorded from the electrodes and her task was to concentrate on lowering this tone, hence lowering the muscular hypertonicity. a second electrode pair was placed over the orbicularis oris and a third electrode pair over the cricothyroid region below the thyroid notch. each time the same procedure was carried out. an informal assessment during the sessions and a subsequent replay of the tape recordings demonstrated that there was a significant reduction in laryngeal e m g activity with a concomitant increase in fluency. no conclusions can be drawn from this preliminary investigation. however, it is conceivable that after sufficient training, a stutterer could learn to attend to somesthetic cues of laryngeal tension in the absence of biofeedback equipment. it is of interest to note that in the study of gautheron et al 4 , their stutterers were encouraged to start phonating breathily while attempting to obtain auto-correction with the aid of visual feedback. in summary, gaining conscious control of speech production by reconstructing articulatory details, enhancing proprioceptive awareness, encouraging smooth transition of laryngeal adjustments and altering the tension of the vocal cord musculature, seems to be the features common to the modification techniques employed in this treatment programme. results of treatment a subjective evaluation after treatment revealed a significant reduction in both severity and frequency of stuttering behaviour. there appeared to be very little facial, neck and laryngeal tension or associated movements. furthermore, there was evidence of improved self-concept and personal adjustment. towards the end of treatment, a further fiberscopic examination was carried out in order to compare mrs. a's laryngeal behaviour before and after treatment. the entire procedure followed that described above. there was a total of 141 utterances (from spontaneous speech) with corresponding slides. figure 4(a)-a shows a stuttering block on /k/ in "cancellations" before treatment, reflecting the asymmetrical "arched effect" with partial abductory laryngeal behaviour. figure 4(a)-b shows a stuttering block on ikj in " k e e n " after treatment. here it can be seen that the glottis is wide open for the voiceless plosive /k/ and there is an absence of the asymmetrical "arched effect" seen in (a). similarly in figure 5(a)-β it can be seen that there is an absence of the arching in the sound prolongation /s/ in "this sea" after treatment. the apparent asymmetry is not due to the original "arched effect", but is due to the asymmetry of the false cords. die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) figure 4(a) laryngeal behaviour on (a), a stuttering block on fkj in "cancellations" before treatment, and (b), a stuttering block on /k/ in "keen" after treatment. 5(0) sco figure 4(b) broad-band spectrogram showing a block on dysfluent production of /k/ in " k e e n " after treatment. in each case, broad-band spectrograms confirmed that the.photographs were taken at the instance of the stuttered block (see figures 2(b), 3(b), 4(b) and 5(b)). the fibrescopic representations described here were chosen at random for the purpose of this discussion. however, these representations are characteristic of the standard dysfluencies (stuttering blocks and prolongations) throughout all utterances analysed after treatment. an obvious limitation should be considered in the interpretation of these results. increased tension may have been created by the initial the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) vocal tract dynamics in stuttering 49 figure 5(a) laryngeal behaviour on (a), a sound prolongation /s/ in "sweater" before treatment, and (b), a sound prolongation /s/ in "this sea" after treatment. s(o) $co figure 5(b) broad-band spectrogram showing prolongation on dysfluent production of /s/ in "this sea" after treatment. note: the peak value of pca laryngeal muscular activity is the same for /s/ sounds in different positions, initially and medially (hirose and ushijima, 1974). die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 lesley wolk fiberscopic procedure resulting in increased stuttering, and conversely the familiarity of the procedure after'treatment may have reduced stuttering. however, qualitative assessments of the tape recordings during both procedures were found to be representative when compared with tape recordings of her speech outside of the fiberscopic investigations. conclusions a n d implications the present findings support the contention that laryngeal disturbances are associated with many moments of stuttering (conture et al2). while this may explain the proximal cause of stuttering, we are still faced with the question of "primary causation". in a recent study, schmitt and c o o p e r 1 2 found no laryngeal abnormalities in a group of young stutterers. this leads one to question whether the differences observed in the phonatory behaviour of adult stutterers might be more a reflection of habituated compensatory phonatory adjustments in response to dysfluencies than they are indicators of an etiological key to stuttering. while reference has been made to some underlying neurologic fault in some stutterers, (for example, faulty laryngeal innervation, flaws in temporal lobe sequencing, a deficit in auditory feedback systems or aberrant inter-hemispheric relationships (wyke, 1 7 travis 1 4 ), there is also convincing information that psychological factors must be considered. thus a multidimensional etiology of the manifestations of stuttering behaviour as suggested by van r i p e r 1 5 still seems plausible. the unresolved etiology of stuttering should not, however, restrict the continued search for treatment methods. the benefits of intensive stuttering therapy in this case are clearly indicated. these findings pertain to a single case of stuttering. they are thus tentative and should be regarded as an indication for further research. future investigations in biofeedback as a treatment for stuttering is strongly indicated. thus, an attempt to integrate research on laryngeal dysfunction in stuttering with learning-theory and servo-theory might well be of clinical value. acknowledgements the author wishes to thank mrs. m. wahlhaus, senior lectiirer of the department of speech pathology and audiology, and ms. c. penn, lecturer of the department of speech pathology and'audiology, of the university of the witwatersrand, johannesburg, for their guidance and support; dr. a. traill, senior lecturer of the department of phonetics and general linguistics for his valuable assistance in the spectrographic and fiberscopic testing of this patient; dr. e. gordon and dr. a. gordon for their assistance with the biofeedback procedure. the author also acknowledges the human sciences research council for its financial assistance. ι the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) vocal tract dynamics in stuttering 51 references 1. adams, m. r. and hayden, p. (1976): the ability of stutterers and non-stutterers to initiate and terminate phonation during production of an isolated vowel. j. speech, hear. res. 19, 290-296. 2. conture, e. g., mccall, g. n. and brewer, d. w. (1977): laryngeal behaviour during stuttering. j. speech. hear. res. 20, 6 6 1 6 6 8 . 3. freeman, f. j. and ushijima, t. (1978): laryngeal muscle activity during stuttering. j. speech. hear. res. 21(3), 538-562. 4. gautheron, b., liorzou, α., even, c. and vallacien, b. (1973): the role of the larynx in stuttering. in: neurolinguistic approaches to stuttering: proceedings of the international symposium on stuttering. le β run, y. and hoops, r. (eds) mouton, the hague. 5. gay, t., strome, h., hirose, h. and sawashima, m. (1972): electromyography of the intrinsic laryngeal muscles during phonation. ann. otol. rhinol. laryngol. 81, 401-408. 6. hanna, r., wilfling, f. and mcneill, b. (1975): a biofeedback treatment for stuttering. j. speech. hear. dis. 40, 270-273. 7. hiroto, i., hirano, m., toyozumi, y. and shin, t. (1967): electromyographic investigation of the instrinsic laryngeal muscles related to speech sounds. ann. otol. rhinol. laryngol. 76, 861-872. 8. hutchinson, j. m. (1974): aerodyamic patterns of stuttered speech. in: vocal tract dynamics and dysfluency. webster, l. m. and furst, l. (eds). speech and hearing institute, n.y., 71-88. 9. kenyon, e. l. (1943): the etiology of stammering: the psychophysiologic facts which concern the production of speech sounds and stammering. j. speech. dis. 8, 337-348. 10. perkins, w. h. (1979): from psychoanalysis to disco-ordination. in: controversies about stuttering therapy. gregory, η. h. (ed). university park press, baltimore. 11. perkins, w. h., rudas, j., johnson, l. and bell, j. (1976): stuttering: disco-ordination of phonation with articulation and respiration. / . speech. hear. res. 19, 509-521. 12. schmitt, l. s. and cooper, ε. b. (1978): fundamental frequencies in oral reading behaviour of stuttering and non-stuttering male children. j. of comm. dis. 11, 17-23. 13. schwartz, m. f. (1976): stuttering solved. (part ii) the treatment. lippincott. j. b. co., redwood, burn. ltd. trowbridge and escher. 14. travis, l. e. (1978): the cerebral dominance theory of stuttering 1931-1978. j. speech. hear. dis. 43, 278-281. 15. van riper, c. (1973): the treatment of stuttering. prentice-hall inc., englewood cliffs, n.j. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 lesley wolk 16. webster, r. l. (1977): a few observations on the manipulation of speech response characteristics in stutterers. in the problems of stuttering — theory and therapy. reiber, r. w. (ed). elsevier north-holland, inc. n.y., 73-76. 17. wyke, b. (1974): phonatory reflex mechanisms and stammering folio phoniat. 26, 321-338. books books campus bookshop westdene services 34 bertha st, braamfontein 76a king george st, hillbrow j h b 3 9 1 7 1 1 j h b 3 9 1 7 1 1 / university medical the south african journal of communication disorders, vol. 28, 1981 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 25 teacher accuracy in the identification of pre-school pupils with hearing loss nicole chambers and ilona anderson department of speech pathology and audiology university of the witwatersrand abstract teachers of 110 pre-school pupils used a questionnaire to identify which children they thought would fail a hearing screening. following screening, the data was compared to both audiometric only, and combined audiometric and tymponometric screening results. teachers identified one out of six pupils who failed audiometric screening, and one out of seven who failed combined screening. we concluded that teachers could not accurately identify pupils with hearing problems and should not be used to detect hearing losses in pupils without prior education and training. opsomming onderwyseresse van 110 voorskoolse hinders is gevra om 'n vraelys te voltooi en aan te dui watter kinders hulle sou identifiseer as die wat nie 'n gehoorsifting sou slaag nie. hierdie resultate is vergelyk met die siftingsresultate ten opsigte van slegs oudiometrie sowel as 'n kombinasie van oudiometrie en timpanometrie. een uit ses hinders, wat nie die oudiometriese siftinggeslaag het nie, en een uit sewe kinders wat nie die gekombineerde siftinggeslaag het nie is deur die onderwyseresse geidentifiseer. die gevolgtrekking was dat onderwyseresse nie kinders met gehoorprobleme kon identifiseer nie en dus nie sonder verdere inligting en opleiding as betroubare identifiseerders gebruik kon word nie. keywords: teachers, pre-school children, hearing loss, identification introduction undetected hearing loss in children can be of detrimental consequence. hearing-impaired children may not receive adequate auditory, linguistic or social stimulation necessary for speech and language learning, social development and emotional development (nih consensus statement, 1993). even a mild loss can place a child at risk for language and learning problems; place an unbearable strain on their coping abilities; and put them at a disadvantage in the classroom (roeser & downs, 1988; davis, elfenbein, schum & bentler, 1986; menchor & mcculloch, 1970). furthermore, entire family functioning may be affected by a child's hearing loss (nih consensus statement, 1993). hearing loss is a problem of significant magnitude and ranks as the commonest form of sensory deprivation (swart, 1995; 1996a). considering the magnitude of the problem of hearing-impairment and its detrimental consequences it becomes clear that early intervention is of critical importance. in developed countries universal screening is usually implemented (swart, 1996b). unfortunately the adoption of such an approach in south africa is unlikely due to problems of inadequate resources, lack of services, lack of facilities, inadequate technology for the underprivileged majority, and lack of personnel (swart, 1995). hearing impairment and deafness affect at least 3 million individuals in south africa (swart, 1995); yet there are only 1094 registered speech and hearing therapists and 5 registered audiologists to provide services for these individuals (samdc, 1997). there are also a number of primary health care workers, nurses and speech and hearing diplomats who are trained to administer hearing screening testing (roeser & downs, 1988) but they are also too few in number to service the entire population. primary health care professionals have little training in the early identification and management of hearing-impairment and ear disease (swart, 1995), and nurses already have a high work-load with which they need to cope. thus the implementation of hearing screening programmes in south africa is problematic. in spite of these problems we need to extend hearing screening services to the whole community. a screening method needs to be developed that is easy to teach, learn and administer. it should be cost-effective, be developed with consideration of the context in south africa, be linguistically and culturally appropriate (child health policy group, 1996), and not require expensive training or high level salaries (northern & downs, 1991). one such approach which is user friendly and fits these criteria is the questionnaire approach (swart, 1996a). questionnaires incorporating at-risk registers have been used quite extensively with neonates, however, they have been used less frequently for the screening of the pre-school population. there have been reports of a slight incidence peak of otitis media within the two to seven year age range, possibly due to increased infection at entry to pre-school or school. furthermore, the two to five year age range gives us problems in identification because the children are ofdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 nicole chambers & ilona anderson ten not seen by doctors or clinics (northern & downs, 1991). the use of a questionnaire as a screening method for this age group could therefore, be especially valuable. at-risk registers would incorporate risk factors that are different from those used for neonates. unlike neonates, pre-school children have begun to use speech and language. delay, deviance or regression in their use of speech and language could serve as new at-risk behaviours for preschoolers. many authors emphasize that the first signs of hearing loss in children are changes in behaviour, learning and language (savary & ferron, 1982). the recognition of these changes as at-risk behaviours could serve as an important screening test. those individuals who have frequent contact with children should be utilized as key personnel for the screening of disabilities (child health policy group, 1996). this would include parents or other caregivers, pre-school teachers, community health workers, traditional healers, nurses and doctors. unfortunately, there is a significant gap of time between the age of eighteen months and five years, where children are often not seen by health professionals (child health policy group, 1996), thus utilizing community health workers, traditional healers, nurses or doctors in the screening process may not be very efficient for children in this age range. parents or caregivers, and pre-school teachers usually do have frequent contact with children in this age group and as a result, could prove useful in administering questionnaires and at-risk registers as part of the hearing screening process during this period. teachers were found to be able to identify one out of four (curry, 1950) or one out of six (kodman, 1956) children who had a hearing loss. nodar (1978) found similar results when the teachers' data was compared with the results of audiometric screening test results, as was done in the above two studies. when the teachers' data was compared with the results of rescreening and tympanometry followed by otoscopy, agreement doubled and teachers were found to be able to identify 47% of the children who had a hearing loss (haggard & hughes, 1991). savary and ferron (1982) found that out of 265 children who were identified by teachers as having 'school pathology', 35% had audiographic abnormalities and 45% had ear conditions requiring otolaryngologic management. in south africa it is becoming increasingly common for young children to be placed in pre-schools while both parents or single parents attend work. pre-school teachers see the children in their classes on a regular, daily basis and often spend more time with them than any other individual. this study suggests utilizing teachers in the hearing screening process for a number of reasons: they are already available; no additional salaries need to be paid; they have some knowledge about speech and language in children; they are easier to educate than parents as there are fewer of them, and they may be easier to reach; they can educate parents about hearing problems; they see the children on a regular basis; and they can. administer the questionnaire a number of times throughout the year. in addition to this, they may be able to pick up subtle changes in children's behaviour because they see them so frequently. this study aims to determine teacher accuracy in the identification of pre-school pupils with hearing loss by means of a questionnaire. teacher identification will be compared firstly to audiometric only and then to combined audiometric and tympanometric screening results. method subjects subject selection criteria teachers , the teachers selected as subjects for the study had to be those who were the class teachers of the pupils involved in a hearing screening practical carried out by second year speech and hearing therapy students from the university of the witwatersrand. this practical took place from september 1996 to april 1997. pupils the pupils selected had to fall into the three year to six year eleven month age range and had to be involved in the second year hearing screening practical. description of subjects teachers thirteen teachers from three nursery schools and two childcare centres were involved in the study. table 1 gives a description of the teachers' qualifications and their number of years of teaching experience. there was much diversity in the qualifications, but the most common qualification was a diploma in pre-primary education. the years of teaching experience ranged from one year to nineteen years with the mean being ten years experience. pupils in total, questionnaires were completed for 210 children. of these, 100 pupils were not used. this was due to the following: many did not have their hearing screened as they were either absent or did not return their consent forms; the birth dates for some of the children were not filled in and thus their ages were not known; two of the pupils had joined the nursery school two weeks before the screening and the teacher did not feel that she had enough knowledge to complete the questionnaire for them; and one of the children for whom the questionnaire was completed was younger than three years. the mean age of the final sample was 4 years 7 months and the ages ranged from 3 years to 6 years 8 months with the most common age range being 3 years 6 months to 3 years 11 months. refer to figure 1 for the pupil-age distribution. table 2 gives a description of the teacher-pupil distribution across the pre-schools according to the 110 pupils in the sample. the average ratio of teachers to pupils involved in the study is 1:8.5. equipment and materials equipment portable audiometers these included two ιηίβ^οομβίίοβ as7 screening audiometers with peltor "type a earphones, two eckstein brothers 390mb audiometers with maico 78711 earphones, the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) teacher accuracy in the identification of pre-school pupils with hearing loss materials 27 one maico ma20 audiometer with tdh 39p earphones, and one maico ma 40 audiometer with tdh 39 earphones. all of the audiometers were calibrated in june 1996. immittance machines three interacoustics at22 impedance audiometers were used. these were calibrated in june 1996. otoscopes welch allyn klinic otoscopes with detachable speculae were used. table 1: teacher qualifications and teaching experience teacher qualifications years experience 1 n3; presently studying n4 to n6 through the johannesburg college of education 1 2 national higher certificate in child care 8 3 degree in education from the university of liverpool 12 4 diploma in pre-primary education 14 5 diploma in pre-primary education; diploma in child care 5 6 1 year child care qualification 4 7 senior primary higher education diploma 7 8 . ' / / higher education diploma in pre-primary and primary; degree in pre-primary education 15 9 diploma in junior primary education | 14 10 bachelor of arts degree 4 11 diploma in nursing psychology 13 12 lmc training in london 14 13 ami training in france 19 a questionnaire was used to gain information from the teachers about the school performance, speech, language and hearing of each of their pupils (see appendix a). the questionnaire was especially brief because the teachers were required to complete the questions for all of their pupils. it was kept as simple as possible requiring only a cross or tick or one word response for each question. an example was given of how the questionnaire should be completed so that the teachers knew what responses were expected and where they were meant to respond to each question. the questions in the questionnaire were divided into seven main groups. i. identifying information: i.e., 'name' and 'date of birth' ii. school performance: e.g., 'concentration and attention' (roeser & downs, 1988) iii. hearing information: e.g., 'hears and answers when first called' (roeser & downs, 1988; american speech and language foundation pamphlet, 1986; masland, 1970) and 'turns head to where sound came from' (swart, 1996b) speech and language information: e.g., 'says all sounds other than r, 1, th, s' (roeser & downs, 1988; american speech and language foundation pamphlet, 1986) medical information: e.g., 'has had ear infections' (roeser & downs, 1988) and 'child has allergies' (swart, 1996; haggard & hughes, 1991) iv. v. 35 3-3.5 3.6-3.11 4-4.5 4.6-4.11 5-5.5 5.6-5.11 6-6.5 6.6-6.11 age groups figure 1: pupil age distribution in years and months. table 2: teacher pupil distribution across pre-schools according to the specific sample used in this study school aletta sutton educare centre greenhouse child care centre hansel and gretel nursery school hug-a-bug nursery school melville montessori nursery school total no. teachers 4 2 2 3 2 13 no. pupils 1 17 15 14 38 26 110 die suid-afrikaanse tydskrif ir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 nicole chambers & on anderson vi. other problems or any other important information vii. main question: i.e., 'do you think the child would pass/fail a hearing test?' the questions in groups ii. v. were included in the questionnaire as the information obtained from them could alert one to the possible presence of a hearing loss and might prove useful to teachers in identifying potential hearing loss. procedure teachers were given questionnaires which they were required to complete to the best of their ability. no form of intervention or training was given in the use of the questionnaire or on speech, language and hearing. the questionnaires were collected on the day of the hearing screening. the second year speech and hearing therapy screened the hearing of each pupil; provided they had parental permission. the students were supervised by staff members from the university of the witwatersrand department of speech pathology and audiology. the hearing screening included otoscopy, tympanometry, and pure tone audiometry via air conduction at 1000 hz, 2000 hz and 4000 hz at 20 db calculated using biological calibration (katz, 1994). otoscopy was used to check for perforated tympanic membranes, impacted wax or foreign bodies in the external ear canal to ensure appropriate testing and ent management. criteria for failure were a type β or type c tympanometry result (northern & downs, 1991) and / or failure to respond to any two frequencies during pure tone testing (irrespective of whether they occurred in one or two ears). pure tone testing was performed in the quietest available room at each of the pre-schools. the windows and doors of the rooms were closed in order to reduce background noise. however, some background noise still existed. biological calibration was used in an attempt to account for the effects of the noise but it must be noted that the lack of a soundproof environment may have had an affect on the accuracy of the pure tone results. results pupils were classified into two groups: those who passed the screening and those who failed the screening. they were first classified on the basis of audiometric screening results and then on the basis of combined audiometric and tympanometric screening results. figure 2 is a comparison of the teacher identification results and the audiometaudiometric identification no. pupils fail no. pupils pass * a ο th 'j3 ϊ ee ss ο y is no. pupils fail 1 8 ce -s s fi φ ό i—h no. pupils pass 5 96 figure 2: error matrix comparing teacher identification with audiometric identification ric screening results. the teachers identified 8.2% of the total sample as having a hearing problem, whereas only 5.5% of the pupils tested failed the audiometric screening. furthermore, there was agreement between teacher ' identification and audiometric identification on only 1% of the total sample. the mcnemar chi square was computed and found to be 0,31 for 1 degree of freedom, and indicated that no significant difference existed between teacher identification and audiometric identification (mccall & kagan, 1994). the confidence interval for proportion was calculated and indicated that the probability is 0.95 that the proportion of pupils who were classified differently by teacher identification and audiometric identification, lies between 5.78% and 17.84% of total cases with the best estimate being at 11.81% (mccall & kagan, 1994). figure 3 compares teacher identifications with combined audiometric and tympanometric screening results. the agreement between the two procedures has increased to 3.7%; it has tripled with regard to hearing loss. the mcnemar chi square was computed and found to be 12.03, which is significant beyond 0.01 for 1 degree of freedom (moall & kagan, 1994). this indicates that there was a significant difference between teacher identification and combined audiometric and tympanometric identification. the confidence interval for proportion was calculated and indicated that the probability is 0.95 that the proportion of pupils who were classified differently by teacher identification and combined identification, lies between 18.97% and 35.57% of total cases (m'call & kagan, 1994). descriptive analysis of the teacher responses on the questionnaire was carried out. in the cases where the teachers correctly identified the pupils who failed the hearing screening, the following responses were noted (from most to least common): poor grammar, vocabulary and syntax; poor concentration and attention; lack of understanding of most speech; inability to pronounce 'r', ί', 'th' or's'; presence of allergies; below average class performance; loud speaking voice; and second language english. perhaps these factors alerted the teachers to the presence of hearing problems. 1 in the cases where the teachers failed to identify the pupils who failed the hearing screening, two factors were noted by the teachers but did not seem to alert them to the presence of a hearing problem: poor classroom interaction, and an inability to hear and answer when first called. it is somewhat surprising that the latter factor did not alert the teachers to a hearing problem, as it woul'd audiometric and tympanometric identification no. pupils fail no. pupils pass a ο th φ ce rc ο y ίΰ no. pupils fail 4 > ce -13 φ pi a a> x) l—h no. pupils pass 25 76 figure 3: error matrix comparing teacher identification with combined audiometric and tympanometric screening results the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) teacher accuracy in the identification of pre-school pupils with hearing loss 29 appear to be an obvious indicator of a hearing problem. for the teachers who correctly identified one or more pupils who failed the hearing screening, years of teaching experience ranged from thirteen to nineteen years with a mean of fifteen years, and qualifications included a diploma in nursing psychology, lmc training in london, and ami training in france. for those teachers who did not correctly identify any pupils, years of teaching experience ranged from one to fifteen years with a mean of eight years. these results would suggest that successful teacher identification is associated with greater years in teaching experience. this did not hold true for all cases, however, as four of the teachers who did not identify any pupils, had between twelve and fifteen years teaching experience. discussion the results of this study suggest that without prior education or training in the use of a questionnaire, preschool teachers are not accurate in identifying pupils with hearing problems, and should not be used to detect hearing losses in the pre-school population. findings tend to support those of kodman (1956) who found that teachers could correctly identify one out of six pupils with hearing losses, as determined by audiometric testing. results are also similar to those obtained by curry (1950) who found that in comparison to audiometric testing, teachers could identify one out of four hearing loss cases. results obtained by nodar (1978) were more favourable than the results obtained in this study. he found that in comparison to audiometric testing teachers identified one out of three hearing loss cases, while in comparison to combined audiometric and tympanometric testing they identified one out of two. perhaps these differences in results are due to the fact that the pupils in nodar's study were in the 5-12 year age range, while the pupils involved in this study were between 3 years and 6 years 11 months of age. results found, both in this study and in nodar's study, support the view that there is a decrease in hearing problems with an increase in age, so one would expect a much higher incidence of jhearing problems in this study xthan in nodar's. findings in fact do support this as 4% of the total sample were found to have hearing problems in nodar's study, while 26% were identified with hearing problems in this study. one would expect to find a higher incidence of otitis media iii this study than in nodar's study because of the younger age range of the sample. otitis media often leads to mild hearing losses, which may be more difficult for teachers to identify. this could account for their poorer performance in identification which was noted in this study. perhaps teachers find it easier to identify hearing problems in older pupils due to differences in the behaviour of older children as compared to younger children. the teachers reported having difficulty determining whether some of their pupils had hearing problems, or were simply having difficulties due to the fact that they were second language english .speakers. for example, they were unsure whether some of their pupils with poor language, poor concentration, and inappropriate responses were hearing-impaired or simply experiencing these problems due to a poor understanding of the english language. the majority of the children in this study were second or third language english speakers and this could have had a negative effect on teacher identification. there were also methodological differences that might have accounted for the difference in results obtained between nodar's study and this study. nodar (1978) used a 25 dbhl audiometric screening level, while this study used a 20 dbhl level. nodar (1978) also included the 250 hz, 500 hz and 6000 hz frequencies in his audiometric screening, while these frequencies were excluded from the audiometric screening in this study. perhaps these variations also contributed to the differences in results. the results of this study also differed from those of savary and ferron (1982). they found 35% of pupils identified by teachers had audiographic abnormalities while 45% had otolaryngologic disease processes. once again methodological differences existed between the two studies. savary and ferron (1982) instructed teachers to identify any pupils who experienced a drop in grades; or who developed behavioural, language or learning problems. perhaps this extra instruction led to better teacher performance. because savary and ferron (1982) believe that hearing impairment is a hearing disorder at any level of severity, their criteria for failure included any air-bone gap of 10 db or more on three conversational frequencies. this does not follow the screening criteria recommended by katz (1994). it is generally considered that hearing threshold levels of above 25 db constitute hearing loss; that an air-bone gap of 10 db or less is not clinically significant (hodgson, 1985); and that bone conduction testing is not included as part of hearing screening procedures. because savary and ferron (1982) used stricter criteria than these, perhaps it is possible that their audiological testing identified some false positive cases. if this is the case then it is possible that some of the teacher identifications were also false positives, and that teacher identification was not actually as good as reported. if the screening criteria recommended by katz (1994) were used in the savary and ferron (1982) study, the results may have been similar to those obtained in this study. the teachers from the pre-schools involved in this study demonstrated a willingness and eagerness to learn more about speech, language and hearing in their pupils. they responded favourably to offers of a workshop to their preschool staff, covering these areas. in addition to this, the many other advantages of utilizing teachers in the screening process still remain: they are already available and see their pupils on a regular basis;.no additional salaries need to be paid; and they have some knowledge about speech and language in children. perhaps future research could repeat this study with the inclusion of teacher education and training in the use of a questionnaire in identifying hearing problems in pupils. teachers coiild be given guidelines on when to fail pupils. for example, if the child displays one or more of a given list of behaviours and physical symptoms that may indicate a hearing problem (roeser & downs, 1988). the educational background of audiologists equips them to assume the role of'educators' and to be responsible for the effective training of teachers. this brings us back to the problem of having too few audiologists in south africa to deal with all the demands of the population. to oveicome this problem perhaps a course on hearing education and training in the use of a questionnaire, could be included in the final year syllabus of teaching students. this would ensure that all teaching students are reached and that they are educated and trained in the identification of hearing problems. it would be cost-effective, time-effective, and would require fewer audiologists to act as 'edudie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 n i c o l e c h a m b e r s & i l o n a a n d e r s o n cators'. it could also serve to h e i g h t e n g e n e r a l a w a r e n e s s of hearing-impairment. b e a r i n g the r e s u l t s o f this study in m i n d it m i g h t be useful to i n c r e a s e the training a n d education p e r i o d for those teachers w i t h fewer years teachi n g e x p e r i e n c e . c o n c l u s i o n this s t u d y l o o k e d at teacher a c c u r a c y in the identification of p u p i l s w i t h h e a r i n g loss c o m p a r e d to audiometric s c r e e n i n g r e s u l t s , a n d c o m b i n e d a u d i o m e t r i c a n d t y m p a n o m e t r i c s c r e e n i n g results. f i n d i n g s from the study r e v e a l e d t h a t t e a c h e r s identified only one o u t o f six pupils w h o failed a u d i o m e t r i c screening, a n d one o u t of seven p u p i l s w h o f a i l e d c o m b i n e d a u d i o m e t r i c a n d t y m p a n o m e t r i c s c r e e n i n g . a g r e e m e n t b e t w e e n t e a c h e r identification a n d a u d i o m e t r i c identification w a s only o n 1% o f the total s a m p l e while there w a s a g r e e m e n t b e t w e e n teacher identification a n d c o m b i n e d identification o n 3.7% of the total s a m p l e . it w a s c o n c l u d e d t h a t teachers w e r e n o t a c c u r a t e i n identifying pupils w i t h h e a r i n g loss a n d thus should n o t b e u s e d to detect hearing p r o b l e m s in their pupils, u n l e s s t h e y are g i v e n prior e d u c a t i o n , a n d training in the u s e o f a questionnaire. t h u s it a p p e a r s i m p e r a tive t h a t i n o r d e r to o v e r c o m e v a r i o u s s c r e e n i n g p r o b l e m s b y utilizing t e a c h e r s i n the s c r e e n i n g process, a period o f teacher e d u c a t i o n a n d training i n the use of a screening q u e s t i o n n a i r e is essential. a c k n o w l e d g e m e n t s w e w o u l d l i k e to t h a n k p e t e r f r i d j h o n a n d m i k e greyling for their assistance w i t h the statistical analysis of this study. r e f e r e n c e s american speech and hearing foundation and psi iota xi sorority. (1986). find your child's speech and hearing age. maryland : nahsa. child health policy group. (1996). workshop on screening for developmental disability in the pre-school population university of cape town, child health unit. curry, e.t. (1950). the efficiency of teacher referrals in a school hearing testing program. j. speech hear. disord., 15 211-214 davis, j.m., elfenbein, j., schum, r. & bentler, r.a. (1986)! effects of mild and moderate hearing impairments on language, educational, and psychosocial behaviour of children j. speech hear. disord., 51 53-62. haggard, m. & hughes, e. (1991). screening children's hearing: a review of the literature and the implications of otitis media london : hmso. hodgson, w.r. (1985). basic audiologic evaluation. florida : robert e. krieger publishing company. katz, j. (1994). handbook of clinical audiology (4th ed.). baltimore : williams and wilkins. kodman, f. (1956). identification of hearing loss by the classroom teacher. laryngoscope, 66 1346-1349. masland, m.w. (1970). speech and hearing checklist. volta review. washington : alexander graham bell association for the deaf. mccall, r.b. & kagan, j. (1994). fundamental statistics for behavioural sciences (6th ed.). usa : harcourt brace college publishers. menchor, g.t. & m'culloch, b.f. (1970). auditory screening of kindergarten children vasc. j. speech hear. disord., 35 241247. nih consensus statement on early. identification of hearing impairment in infants and young children. (1993). 11(1) 3nodar, r.h. (1978). teacher identification of elementary school children with hearing loss. language, speech and hearing services in schools, 9 24-28. northern, j.l. & downs, m.p. (1991). hearing in children (3rd ed.). baltimore : williams and wilkins. roeser, r.j. & downs, m.p. (1988j. screening for hearing loss and middle ear disorders: auditory disorders in school children (2nd ed.). new york : thieme medical publishers inc. savary, p. & ferron, p. (1982). screening of hearing disorders in schoolchildren. american journal of otolaryngology., 3 388391. south african medical and dental council. (1997). telephonic information. swart, s. (1995λ deafsa: policy document on early identification and ear care. unpublished. swart, s. (1996a;. hearing loss in infancy and childhood: early identification and intervention. unpublished. swart, s. (1996b). hearing loss in infancy and childhood: early identification and intervention. health and hygiene, (supplement) september / october. the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 25 departmental evaluation: speech therapy and audiology, an academic department aimed at teaching a profession s r hugo department of communication pathology university of pretoria w μ j hugo director: graduate school of business leadership, unisa abstract in a recently established policy guideline of the department of national education it was clearly indicated that programmes and departments at tertiary education institutions should institute evaluation procedures as a matter of urgency. this has become necessary to provide a basis for decision making and policy formation, to accredit programmes, to monitor expenditure of public funds and to improve educational material. it is the aim of this paper to develop an evaluation model, based on accepted education principles, for evaluating the actual performance of a department of speech therapy and audiology. a basic management model is used and specific functional indications are given of the steps that should be taken in evaluating a department. the model is a comprehensive one which can easily be adapted for use in other departments. opsomming in 'n belangwekkende publikasie van die departement van nasionale opvoeding is aangedui dat dit tans gebiedend noodsaaklik geword het dat departemente verbonde aan tersiire opleidingsinrigtings dringend moet beplan om evalueringsprogramme te loots. die redes hiervoor is dat evaluering basisinligting verskafvir beleidsbesluite, akkreditering van programme moontlik maak, besteding van fondse monitor en akademiese opleidingsmateriaal en -stelsels verbeter. dit is die doel van hierdie artikel om 'n evalueringsmodel, gegrond op erkende opvoedkundige beginsels, te ontwikkel virgebruik in die bepaling van waarde van 'n departement vir spraakheelkunde en oudiologie. 'n bestuursmodel is geselekteer en spesifieke aanduidings is verskafvan die strategies, stappe en norms wat gebruik kan word in departementele evaluering. die model is 'n omvattende een wat suksesvol aangepas kan word vir gebruik deur ander departemente. "due to the complex nature of human communication and its disorders, it is essential that information of an academic, research and scientific nature is continually developed and evaluated. a university provides the optimal environment for constant academic validation of current professional training." feldman 1981, ρ 942 1 introduction evaluation, or the need to determine the worth and merit of whatever is being evaluated, is a well-known concept. there is ample evidence that evaluation in education was an accepted practice even prior to 1920. from the literature, it is equally clear that the debate is still raging on how evaluation should be conducted and what role it should fulfil in different spheres. the emergence of educational evaluation in terms of student outcomes and institutional effectiveness has been a significant trend in higher education in the past few years (nichols, 1989, ρ vii). in the united states of america, for example, standards are established and enforced to ensure institutional quality. to maintain accredited status, institutions must be evaluated periodically to demonstrate achievement of standards and to document ongoing efforts for institutional improvement (middleton et al., 1989, ρ 15). in europe too, there is growing emphasis on the philosophy of value for money, and funding for higher education is therefore being linked directly to performance (goedebuure et al., 1990, ρ 15). institutions for higher education throughout the world increasingly accept the fact that they are accountable to political authorities and to the communities they serve. establishing evaluation programmes at institutional, departmental and programme levels in higher education serves the dual purpose of proving quality of performance to stakeholders, while at the same time protecting the traditional autonomy of tertiary education institutions. in south africa, education authorities clearly indicated in a policy statement that academic departments are expected to institute evaluation procedures aimed at internal evaluation and to plan for external evaluation according to prescribed guidelines (nasop 02-129 87/10). in spite of the contemporary urgency of evaluation at tertiary level, no formal and generally acceptable evaluae suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 s.r. hugo & w.m.j. hugo tion model has been developed that could be used to provide quantitative information on the actual performance of departments in general. wolf (1990, ρ 19) reports that there are no less than fourteen different evaluation models and five different approaches. there is also little agreement or data to support the efficacy of one model or approach over another. evidently the fundamental problem is that the various models are built on differing and often conflicting conceptions and definitions of evaluation (worthen & sanders 1987, ρ 44). in view of the above, the following problem statement can be formulated: what are the principles involved in structuring an evaluation model for an academic department engaged in a professional programme aimed at developing speech therapists and audiologists? 2 research objectives and design the objective of the study is to develop an evaluation model, based on accepted educational principles, for evaluating the actual performance of a department of speech therapy and audiology in south africa, in order to address the specific needs of this unique and divers context. to attain this objective, a research plan comprising of two consecutive stages was devised: • establishing the underlying principles of evaluating programmes and departments in tertiary education institutions by means of a comprehensive literature study • developing a proposed model for the evaluation of a department of speech therapy and audiology. 3 conceptual and contextual issues of evaluation 3.1 terminology and concepts as previously indicated, various approaches and definitions of evaluation may lead to fundamental differences in educational evaluation. the term evaluation for example, may be interpreted to mean measurement, appraisal, assessment, professional judgment, scientific enquiry, a political activity or an act of collecting and providing information (worthen & sanders 1987, ρ 22). in this study, evaluation will be interpreted as the act of rendering judgment to determine worth or merit that is: ... the making of judgments about the worth and effectiveness of educational intentions, processes and outcomes; about the relationships between these; and about the resource, planning and implementation frameworks for such ventures. (adelman & alexander, 1982, ρ 5.) because of differences in interpretation and the divergent μββ of evaluation processes in various institutions and also in different countries, the meaning attached to evaluation concepts and procedures may be utterly confusing. nisbet (1988, ρ 4) suggests a cognitive map to assist in establishing a common understanding of concepts and their role in evaluation. this is represented in figure 1. only the most important (and perhaps most controversial) concepts referred to in this figure will be dealt with here. the controversy about the formative or summative nature of evaluation has raged for many decades. in essence, the question is whether evaluation should provide immediate feedback of information useful to programme developers who would use the information for revision during the development process (formative evaluation). contrary to this point of view, summative evaluation is conducted at the end of the programme and is aimed at providing judgment about the value of a programme. since the evaluation of an academic department is the subject of this study and because academic departments, like academic programmes are forever changing and in a state of development, formative evaluation is of crucial importance. however, it is equally important to provide feedback to authorities about the actual performance of an academic department at particular times (at the end of an academic or financial year or review cycle, for example). hence evaluation in the context of this study must also perform a summative role. linked to the issue of formative and summative evaluation is the question of internal or external evaluation. because of the immediateness of formative evaluation, information provided by this type of evaluation is valuable to departmental managers and often used to effect improvements. this type of evaluation is therefore frequently undertaken internally with internal evaluation objectives in mind. summative evaluation, however, can be used for accountability and is often undertaken by external evaluators commissioned by some external audience or decision maker. as an extension of the argument that formative as well as summative evaluation play an essential role in departmental evaluation, it is evident that in evaluating the academic department, both internal and external evaluation are essential. the quantitative or qualitative base of evaluation is another conceptual issue referred to in the cognitive map depicted in figure 1. qualitative inquiry focuses on processes rather than outcomes and uses an inductive approach to data analysis while quantitative inquiry focuses on numbers by emphasizing standardization, precision, and objectivity (worthen & sanders, 1987, ρ 51). j however, in departmental evaluation quantitative and qualitative methods can be regarded as compatible and complementary approaches. worthen and sanders (1987, ρ 53) support this premise and point out that the trend in evaluation today is towards methodological pluralism. the concepts of accountability and professionalism are of particular importance in the context of evaluation (see figure 1). educational accountability is the responsibility for identifying and measuring educational outcomes and using the information about these outcomes for decision making (kogan, 1986, ρ 75). accountability has three major dimensions in education. moral accountability is related to the fact that academic institutions are answerable to their clients. this implies that if resources are spent on educational programmes, it is necessary to determine whether the programmes (or departments) achieve what they are designed to achieve (lee & sampson, 1990, ρ 157). evaluation of performance outcomes provides proof of academic quality and it is important to note that funding for higher education is increasingly linked to the quality of this performance (goedegebuure et al., 1990: 15). professional accountability refers to the fact that academicians are answerable to themselves and to their colleagues in the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) departmental evaluation: speech therapy and audiology 27 η top-down hard data appraisal external evaluation outward-looking accountability teacher as trained practitioner assessment testing control performance indicators product summative judgement evaluation η % % % formative flexibility process understanding insights growth management objectives planning rational x teacher as reflective professional % teacher involvement commitment consensus building internal evaluation self-evaluation grass-roots professionalism inwnrd-iooking figure 1: evaluation a cognitive map. academy. professional accountability is therefore fundamental to self-evaluation and peer evaluation. peer evaluation is indeed the oldest and most fundamental of all evaluation principles in higher education (kogan, 1989, ρ 118). finally, educational accountability also encompasses contractual accountability. academic departments are therefore answerable to management in higher education as well as to political authorities. 3.2 purpose and objectives of departmental evaluation evidently the first step in any evaluation procedure is to determine the purpose and objectives of the evaluation process (worthen & slanders, 1987, ρ 147). this is not only dictated by logic but is vitally important because educational evaluation is always undertaken within a particular context. important contextual parameters can be determined by clarifying beforehand issues such as why evaluation is being undertaken, who the main audiences are, to what use evaluation findings may be put, what method of enquiry should be used and who should do the evaluation (house, 1986, ρ 16). an analysis indicates that the purposes and objectives of departmental evaluation can be subdivided into three major categories. • improvement (organisational learning) a major objective of departmental evaluation is to generate useful information for the improvement of departmental activities: information to management of the department for decision making and to do planning. seldin (1988, ρ 24) points out that there is no better reason to evaluate than to improve performance. evaluation data assist the faltering, motivate the tired and encourage the indecisive. supplementary (but related) to this, is the evaluation objective of incorporating into the operation of the academic department an ongoing concern for self-study and self-improvement (kells, 1989 ρ 100). • accreditation in this category, the objective of evaluation is to assess the extent to which accreditation standards are being met. it also provides useful written material for the evaluation team and formal reports for the accreditation authorities. • accountability as previously indicated, a major objective of evaluation is to provide proof that resources are used optimally (contractual and moral accountability). an additional objective is to ascertain the quality of higher education provided by the academic department (professional accountability). finally, the objective of the evaluation process should be to provide a clear statement of the relationships between the goal and objectives of the academic department and the mission statement of the institution (contractual accountability). the importance of the conceptual and contextual issues discussed in the above paragraphs gains additional perspective for departmental evaluation when viewed against the background of specific concerns relevant for academic training for professional programmes. 3.3 specific concerns relevant to evaluating education programmes for the professions the central feature that distinguishes a professional academic programme from general university courses can die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 s.r. hugo & w.m.j. hugo be found in the definition of a profession. according to hughes (1963, in goodlad, 1985, ρ 7) the central feature of all professions is the motto "credat emptor" (let the buyer trust). thus is the professional relation distinguished from markets in which the rule is "caveat emptor" (let the buyer beware). to develop an individual that embodies this code of conduct implies the incorporation of very specific academic aims, strategies and procedures in the education programme. the one unchanging feature of professional training (and perhaps the main factor that distinguishes professional academic training from other university programmes) is unceasing movement towards new levels of performance. in this energizing process some of the following characteristics are observable: • concern with mission / function clarification • mastery of theoretical knowledge • capacity to solve problems • credentially • public acceptance • ethical practices (nowlen, 1988). this feature is usually utilized in the evaluation done by professional training bodies. these bodies play an important role in establishing minimum standards for education and training, in controlling professional ethics and even in structuring university programmes. this may, on the one hand, be negative because it can function in direct opposition to the autonomy of academic institutions. on the other hand the professional bodies can contribute to the objective determination of worth of a specific department because of their role as independent external observer of actual performance. there are moreover specific considerations appropriate to the evaluation of an academic department concerned with programmes for speech therapy and audiology. firstly, academic departments for speech therapy and audiology in the rsa have the general characteristics of all academic departments in a developing country. their main characteristic is the fact that up to now the departments have failed to establish sustainable capacity for monitoring and evaluation. in consequence there is a lack of information on educational outcomes and costs. in an era of constrained resources for education development this implies that the effects of investments are difficult to gauge and lessons of experience difficult to accumulate (middleton, et al., 1989, ρ 1). secondly, on a ground roots level, evaluation of departments for speech therapy and audiology must take certain practical characteristics into consideration. these include: π a low student-lecturer ratio and in conjunction with this a low student enrolment figure attributed to the policy of individual training and practical limitations; high grades of students and a low failure rate because of student selection practised by most universities; π the difficulty in evaluating practical training of students where qualitative rather than quantitative measures are employed; • the fact that practical training is dependent on the availability and cooperation of outside agencies like hospitals, schools and clinics; • the influence on programmes by systems independent of the academic institutions, such as the national health policy, the professional board for speech therapy and audiology and the south african medical en dental council. 4 a model for the departmental evaluation process 4.1 conceptual basis a classification by worthen and sanders (1987, ρ 60) of different approaches to evaluation identifies six categories: π objective oriented approaches π management oriented approaches • consumer oriented approaches • expertise oriented approaches • adversary oriented approaches • naturalisticand participant-oriented approaches in analysing each of the above categories it became immediately obvious that the management approach would be a valuable basis for evaluation of a professional academic department for speech therapy and audiology. there are three compelling reasons for this preference. the management approach to education which regards education as essentially an instrumental activity designed to bring about the achievement of specifiable and uncontroversial educational goals is becoming increasingly dominant (mortimore & stone, 1990, ρ 69). this is especially true of tertiary institutions in general and universities in particular. the choice of the management approach for departmental evaluation is therefore congruent with a general trend. the second reason is that any department of speech therapy and audiology is today, with the general movement at universities towards accreditation, reduced funding and unavailability of qualified academic staff (strydom et al., 1991), involved in a struggle for survival. a management approach towards evaluation will provide valuable information for decision making (and decision makers) in this endeavour. lastly the management approach, if correctly understood and used in context, includes many of the characteristics and principles of the other six approaches towards evaluation in education. it is therefore a comprehensive basis for departmental evaluation. i the questions now are: what is the management approach to evaluation and how.can it be utilized by a department of speech therapy and audiology? in their analysis, worthen and sanders (1987, ρ 77) state that the management approach to evaluation is meant to serve decision makers. they continue to emphasise that, by highlighting different levels of decision makers (levels of management), this approach clarifies who will use evaluation results, how they will use them and what aspects of the system they will be making decisions about. in the normal management control procedure in an organisation information about actual performance is channelled to operational management, middle management and top management in accordance with the nature of the information and the control process. this is conceptually identical to the principal characteristics of educathe south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) departmental evaluation: speech therapy and audiology 29 1. internal departmental self-study 2. external review or site visit by experts 3. review of reports • audience operational management • audience middle management • audience top management • formative evaluation • formative / summative evaluation • summative evaluation • aimed at improvement • improvement and reporting • review reports generated by selfstudy and peer group • departmental management • peer group of professionals • faculty / institutional management / political authorities • professionally | accountable • professionally / contractually accountable • contractual accountable figure 2: management approach to departmental evaluation. tional evaluation referred to in paragraph 3.1.and can be illustrated in figure 2. firstly, according to the improvement purpose of evaluation, information is provided to departmental management to continually effect improvement. this is clearly formative evaluation aimed at enabling departmental management to be professionally accountable. secondly, in accordance with the accreditation purpose, information about the department and the actual performance of it's activities is forwarded to some higher authority (faculty management level or even (institutional management level). this evaluation is clearly of a summative nature although it may contain some formative elements. evaluation information at this level enables departmental management to be contractuallyj accountable. thirdly, in order to answer to moral accountability, evaluation information is provided to the highest management levels in tertiary education, the political authority that controls funding and also to other stakeholders such as professional boards and statutory controlling bodies. the control hierarchy typical of ordinary management control procedures is therefore also embedded in the basic principles of educational evaluation. the implications of the preceding arguments for evaluating a department of speech therapy and audiology using the management approach, are in essence that a threetier evaluation hierarchy with the following characteristics should be constructed (adapted from kells, 1989, ρ 99): π an internal departmental self study prepared by the professionals concerned, using an evaluation model with a management approach; π an external review or site visit by experts in speech therapy and audiology (peer evaluation) using the evaluation data generated by the internal study and other suitable evaluation procedures. this can be used in conjunction with a report from the professional board for speech therapy and audiology, but should not be based on such an evaluation alone; • a review of the internal departmental report(s) and the reports of the external peer evaluation by a professional group in the institution (faculty management or institutional management) and by the controlling board of the profession. 4.2 proposed model the evaluation model proposed in this section is a conceptual model based on the general principles of educational evaluation and on guidelines for departmental evaluation discussed in previous paragraphs. the model is illustrated in figure 3, and in broad terms follows six logical steps. 4.2.1 preplanning for evaluation the first step for departmental management is to identify clearly the need for evaluation why the department should be evaluated. this decision can only be finalised once the persons and organisations who are likely to be interested in the evaluation results have been identified. information generated by evaluating the department of speech therapy and audiology is aimed at a three-tier audience departmental management; an external review board of experts; and at top management, at institutional and political levels. in general the reasons for evaluating an academic department can include any of the following (worthen & sanders, 1987, ρ 8): • improving student development and performance • enhancing educator qualifications and performance • improving the departmental organisational structure • upgrading textbooks and other curriculum materials and products π determining whether to continue, modify, expand or terminate an existing programme • reviewing and improving curriculum design and processes. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 s.r. hugo & w.m.j. hugo pre-planning • need' . • audience • objectives" * / ν <'«*<%; , processloesignf activity areas scheduling p e r s o n n e l ϊ designing performance indicators admin • financing • workload • user satisfaction process γ "-"-^.outcomes ί management • planning • organising •control . r if (fj »,„<•, >> !j i ; r ii -may f & proficiency • teaching • research •community service efficiency • manpower •finances •facilities comparison objective information gathering assessment o f actual performance reporting figure 3: evaluation model. this step also involves demarcating exactly what should be evaluated (for example, administration, programmes, organisational structures or research outputs) and identifying the purposes and objectives of the evaluation. finally, the pre-planning phase should also include a survey of the resources available for evaluation. 4.2.2 evaluation process design drafting a plan of action for departmental evaluation is the main objective of this step. based on the demarcation exercise in the first step and on the purpose and objectives of the evaluation, major departmental activity areas to be evaluated must be identified. , ^ figure 3 indicates that departmental evaluation for speech therapy and audiology can be subdivided into two major but interrelated entities: process evaluation and outcomes evaluation (adapted from worthen & sanders, 1987, ρ 77 and house 1986, ρ 17). on the process side, administrative evaluation is aimed at how well the administrative support activities of the the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) departmental evaluation: speech therapy and audiology 31 department function. in addition, the evaluation is also aimed at determining how well the department is being managed. process evaluation provides an overview of the ability of the department to function dynamically and flexibly and of its capacity to survive. in the outcomes section there are two major subdivisions or components. evaluation procedures aimed at establishing how well the department is doing what it is supposed to do, i.e. success in attaining its objectives (proficiency also referred to as effectiveness) is one component. the second is the efficiency component, and it refers to how well the department is utilising the resources at its disposal. figure 3 also shows that the major objectives of the department that must be realised are in the activity areas of education, research and community service. the most important resources at the disposal of the department are manpower, finances and facilities. 4.2.3 planning and designing performance indicators for evaluation establishing performance measures and the concomitant norms, involves, in effect, designing yardsticks for the practical evaluation of departmental performance. a performance measure represents an integrated group or category of related departmental characteristics or activities that jointly provide a picture of a specific departmental outcome or result. evaluation norms are a series of measurement techniques whereby quantitative values and/or relationships can be determined for specific departmental activities, several of which jointly depict departmental performance in terms of a performance measure (hugo & van rooyen, 1990, ρ 295). it is essential that a large number of measures and norms be determined for each major activity area identified in step 2. here follow some measures and norms that may serve as examples. it isjhowever necessary that every department should develop jits own specific measures and norms based on internal characteristics and in conjunction with the aims of the department. 4.2.3.1 measures and norms for process evaluation • administration j measures and norms for administrative activities must be based on a comprehensiye description of the administrative task. measures and norms evaluating both proficiency and efficiency are essential. the following are examples (adapted from wirgin & braskamp, 1987, ρ 29). 1. financial consideration: 3. user satisfaction: administrative services: total cost ratio annual administrative budget cost of typing = total departmental budget annual cost of typing staff number of pages of study material produced 2. administrative workload: spread number of assignments processed a month average number of assignments processed per month lead times = average waiting time (hours or days) for typing, photocopying any month travel arrangements average waiting time for same tasks previous month number of errors in travel arrangements total number of requests for travel arrangements per time period • management evaluation of management attempts to obtain a picture of how thoroughly the management elements of planning, organising, coordinating and controlling are implemented. at managerial level the management-elements are therefore used as performance measures. bearing in mind that the managerial process is an interactive process between the different elements of management, it is obviously not possible (nor desirable) to isolate the contribution to performance outputs of any particular element of management in the evaluation process. the evaluation of management performance is therefore largely conducted on a subjective basis with the aid of an evaluation sheet or questionnaire. 4.2.3.2 measures and norms for outcomes 4.2.3.2.1 proficiency proficiency measures and norms are aimed at determining how successful a department of speech therapy and audiology is in attaining its goals. the most important of these goals are in the three areas, teaching, research and community services as indicated in figure 3. here follow examples of measures and norms to determine proficiency on the attainment of goals on these three areas: • teaching 1. staff teaching performance: student feedback = external examiners = average assessment of students for a particular course average assessment of students all courses in the department number of appointments of μ + d examiners for individual staff members 2. staff quality: qualification ratio •• total number of appointments of m + d number of staff members with doctorates total number of academic staff in department 3. student performance: completion ratio = students: completion of course in four years students completion of course in more than four years die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 s.r. hugo & w.m.j. hugo average pass mark: students in 1st, 2nd, 3rd and 4th year in ^ _ speech ther/aud average pass ma average pass mark: students in the faculty man-hours) and a outputs of the department of speech therapy and audiology (hugo & van rooyen, 1990, ρ 298). most academic departments have only three major resources available: manpower, finances and facilities (see figure 3). • research 1. output: publications = n u m h e r of accredited papers this year average number of accredited papers in last 3 years productivity =_ total number of research publications this year man-years allocated to research this year student activity j^umi>er of active doctoral students /year number of registered doctoral students /year 2. quality: international ratio = composition of research = number of internationally published articles this year total number of articles published by the department number of research papers: basic /applied / dissertation / monographs /accredited/ proceedings / reports 3. impact: citations = total number of papers / publications published number of citations in research publications in past 3 years number of citations in this field: science citations index • community service 1. involvement: number of staff on boards of representation associations/institutes this year membership fees paid by department 2. continued education: number of students registered certificate programmes = year number of students the previous year 4.2.3.2.2 efficiency evaluation of efficiency is aimed at determining how well the department is utilising the scarce resources at its disposal. the measures applied for efficiency essentially depict the ratio between the inputs (for example, • manpower 1. workload: input ratio = distribution =. number of postgraduate students qualified / year number of professors in department / year number of assignments marked by individual lecturer average number of assignments for all lecturers 2. development: number of conferences attended conference attendance = fry all staff total number of academic staff study leave = n u m b e r of staff on sabbatical /year total number of academic staff 3. growth of academic staff: growth rate = growth rate of academic staff / 5 years growth rate of students registered/ 5 years number of staff who acquired qualification ratio ^doctoral degrees in the past 2 years average number of staff in the department ι • finances | i 1. budget objectives: i total budget allocation for conference conferences = attendance | number of conferences attended by staff/year i i total budgeted cost for photocopying = photocopying / year actual budgeted cost for photocopying / year 2. availability of finances: increase in student subsidy units ratio of financing = in past 3 years increase iryactual departmental budget in past 3 years total budget allocated to total budget = department/year total academic staff complement /year the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) departmental evaluation: speech therapy and audiology 33 • facilities 1. utilisation: computertime library = actual number of hours utilised on research mainframe computer budgeted number of hours on research mainframe available /year total number of loan requests for department /year total number of academic staff in department 2. availability: computerisation = number of pc's available in department total number of academic staff in department area of office space available to accommodation = department number of students registered in 4.2.4 information gathering and quantifying deparmental outcomes (results) in this step basic data are collected and analysed using the measures and norms identified. in step 3 it may be necessary to review some of the measures and norms during this exercise because the process of gathering information sometimes reveals relevant aspects of performance that were ignored in the planning phase, or alternatively, the data required for specific measures and norms may not be available. 4.2.5 evaluating actual departmental performance this step involves the actual evaluation, judgment or assessment of the evaluation data generated in step 4 in order to draw a conclusion about the worth or value of departmental performance, j four major approaches can be used in judging or assessing actual departmental! performance (adapted from worthen & sanders, 1987 ρ 302 and hugo & van rooyen, 1990, ρ 302): j • comparison referenced assessment performance is judged against other academic departments • criterion referenced assessment performance is compared to absolute standards • objective-referenced assessment actual performance compared to planned performance or specified performance objectives • historically referenced assessment actual performance is compared to own previous performance or performance trends based on historical data. 4.6 reporting the evaluation report aims at providing evaluation information (based on quantitative and qualitative elements of the evaluation procedure) to relevant authorities. as in the case of an academic department, these authorities may be departmental management, faculty management or political authorities. it is essential that the report should be drafted with reference to the purpose and objectives of the evaluation plan. based on evaluation information, it should also indicate areas or activities where improvement is recommended and should reflect possible future developments. 5 conclusion the evaluation model proposed above is a conceptual model designed to be used for and by the a department of speech therapy and audiology. it is essential to realise that in the implementation of the model, contextual influences unique to each department will have to be considered in structuring appropriate measures and norms. the principles on which the model is based are not new, and its only merit may perhaps be found in a logical structure for the measurement of departmental performance. measuring outcomes of educational practices is a modern phenomenon. valuing their worth is as old as philosophy itself. house, 1986 ρ 1 references departement van nasionale opvoeding. 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(1987). evaluating administrative services and programs. san francisco: jossey-bass. wolf, r.m. (1990). evaluation in education: foundations of competency assessment and programme review. 3rd.ed. new york: preager. worthen, b.r. & sanders, j.r. (1987). educational evaluation: alternative approaches and guidelines. new york: longman. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 zodiac 901, another star in the madsen constellation zodiac 901 offers the best of both worlds 1. fast automatic performance of tympanometry and acoustic reflex testing for routine screening. 2. complete impedance testing capabilities, preprogrammable automatic test sequences, coupled with the refinement of sensitive manual testing. children's headset clinical tests screening tests zodiac 901 lets you get the most out of middle-ear analysis = pty ltd the hearing health care specialists swf house sovereign street bedfordview 2008 south africa p.o. box 630 . bedfordview 2008 south africa tel: (011)622-1743 fax: (011) 622-1306 reg. no. 77/01577/07 amtronix breaking the sound barrier the south african journal of communication disorders, vol. 40, 199 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 41 stemprobleme by enkele groepe professionele stemgebruikers: implikasies vir voorkoming anita van der merwe, marita van tonder, estelle pretorius en helga crous departement kommunikasiepatologie universiteit van pretoria opsomming primere voorkoming van kommunikasieafwykings word toenemend 'n belangrike beroepsfunksie van die spraak-taalterapeut. funksionele stemhiperfunksie wat dikwels voorkom by professionele stemgebruikers kan voorkom word. in hierdie artikel word gesamentlik verslag gedoen oor drie onafhanklike ondersoeke na stemprobleme by drie groepe professionele stemgebruikers. daar het 183 persone in onderwysprofessies, 50predikante en 20 sangers aan die studie deelgeneem en die inligting is versamel met vraelyste. die resultate toon aan dat stemprobleme en simptome van stemprobleme by aldrie groepe voorkom, dat hulle weinig kennis oor die onderwerp het, hulselfblootstel aan risikofaktore en nie hul stemme konserveer nie. riglyne vir voorkomingsonderrig word verskaf. abstract the primary prevention of communication problems is a growing part of the professional responsibility of the speechlanguage therapist. functional voice hyperfunction, which often occurs in professional users of voice, can be prevented. in this article three separate studies on voice problems of people in three different professions are reported. the subjects included 183 educators, 50 ministers and 20 singers. the data were obtained using questionnaires. the results indicate that voice problems and symptoms of voice problems occur in all three groups, that these speakers have little knowledge of the subject, that they expose themselves to high risk factors, and that they do not conserve their voices. guidelines for instruction in prevention are provided. sleutelwoorde: stemprobleme, professionele stemgebruikers, stemhiperfunksie, voorkoming. histories gesproke is die primere beroepsfunksie van die spraak-taalterapeut die habilitasie of rehabilitasie van kommunikasie-afwykings. 'njbelangrike klemverskuiwing het egter die afgelope paar jaar voorgekom in die beroepbeskrywing. die kons'epte van primere, sekondere en tersiere voorkoming is bekendgestel met gevolglike uitbouing van die beroep. tersiere voorkoming verwys na wat tradisioneel beskou is as habilitasie of rehabilitasie van 'n reeds bestaande kommunikasieafwyking. sekondere voorkoming verwys na die vroee identifikasie van 'n probleem met die doel om die effek daarvan te verhoed of te beperk. primere voorkoming daarenteen verwys na die voorkoming van 'n probleem wat nog nie ontstaan het nie (gerber, 1990; marge, 1991). die behandeling van 'n reeds bestaande probleem is arbeidintensief en duur en in 'n gemeenskap soos in suid-afrika met beperkte fondse en mannekrag spreek dit vanself dat voorkoming meer voordelig sal wees. nie alle kommunikasie-afwykings kan primer voorkom word nie, maar die stemprobleme van professionele stemgebruikers, wat 'n groot persentasie van stemprobleme uitmaak (brodnitz, 1988), kart wel voorkom word. hierdie persone wat bestaan uit politici, dosente, onderwysers, predikante en enige-ander persone wat hul stemme professioneel gebruik, beoefen dikwels foutiewe stemgewoontes en kom soms op' 'n punt waar hulle nie verder die beroep kan beoefen nie of lang periodes siekverlof moet neem as gevolg van die • stemprobleem. verlies van hierdie hoogopgeleide persone is 'n onnodige ekonomiese verlies vir 'n land. vir die persoon self hou die verswakking of verlies van die stem nie alleen ernstige implikasies vir die beoefening van sy beroep in nie, maar ook sosiale en emosioneel-persoonlike implikasies. funksionele stemhiperfunksie kom nie alleen by professionele stemgebruikers voor nie. enige volwassene of kind kan sy stem misbruik en dan 'n stemprobleem ontwikkel. ook in hierdie gevalle sal voorkoming meer effektief wees as genesing (child & johnson, 1991). primere voorkoming vereis begrip van die onderliggende etiologie van 'n toestand (gerber, 1990). funksionele stemhiperfunksie, maar ook bydraende organiese en emosionele faktore gee aanleiding tot die stemprobleme van professionele stemgebruikers (van der merwe, 1982). "tesame hiermee is daar ook die eis van stemgebruik vir baie ure per dag. die foutiewe stemgewoontes wat kan voorkom by hierdie persone word deur boone (boone, 1983; die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 4, 199 • re pr od uc ed b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 anita van der merwe, marita van tonder, estelle pretorius en helga crous boone & mcfarlane, 1988) beskryf as funksionele stemhiperfunksie en verdeel in hiperfunksie in fonasie, respirasie en resonansie. die foutiewe gebruik word ook soms verdeel in stemwangebruik en stemmisbruik (child & johnson, 1991). eersgenoemde verwys na die foute in fonasie, respirasie en resonansie terwyl laasgenoemde verwys na gewoontes soos gil, hoes en keelskoonmaak. in essensie is beide egter vorms van stemhiperfunksie waar oormatige spierspanning gebruik word. psigogene faktore kan bydra tot hiperfunksionele gedrag (aronson, 1985), maar spanning en angs kan ook as gevolg van die stemuitputting ontstaan en aanleiding gee tot 'n bose kringloop (brodnitz, 1988). omgewingsfaktore soos stof en gasse lei ook dikwels tot irritasie van die stemstrukture (child & johnson, 1991) terwyl lawaai veroorsaak dat die persoon onnodig hard moet praat. professionele stemgebruikers stel hulself dikwels bloot aan hierdie en ander risikofaktore wat voorkombaar is. voorbeelde van professionele stemgebruikers wat hulle stemme vir lang periodes per keer moet gebruik, wat dikwels in ongunstige omgewingsomstandighede moet optree en wat spanningsvolle situasies moet hanteer, is predikante, persone in onderwysprofessies en sangers. hierdie groepe ontvang wel tot 'n mate onderrig in stemgebruik, maar dit is ook persone uit hierdie groepe wat dikwels na spraaktaalterapeute verwys word as gevolg van stemprobleme wat hulle ondervind. dit wil dus voorkom asof hierdie groepe teikenpopulasies is vir voorkomende optrede deur die spraak-taalterapeut. ten einde te bepaal of stemprobleme by hierdie groepe professionele stemgebruikers in suid-afrika voorkom en of hulle kennis het omtrent die voorkoming van stemprobleme, is drie onafhanklike studies uitgevoer by persone in onderwysprofessies, by predikante en by sangers. in hierdie artikel word gesamentlik verslag gedoen oor die inligting wat bekom is en riglyne word gegee vir voorkomende optrede deur die spraak-taalterapeut. metode doelstellings die doel van die drie studies was om te bepaal: of stemprobleme en simptome wat dui op stemprobleme voorkom by enige van die professionele stemgebruikers wat by die studie betrek is en of hierdie persone kennis dra omtrent stemprobleme, hulself blootstel aan risikofaktore en of hul enige voorkomende stappe neem. navorsingsmetode as metode van data-insameling is selfbeoordelingsvraelyste gebruik. drie verskillende vraelyste is opgestel ten einde relevante data vir elke groep te bekom. proefpersone die enigste kriterium vir seleksie van proefpersone is dat hul steeds hul beroep aktief beoefen. ouderdom verwante invloed op die stem word sodoende sover as moontlik beperk. afrikaanssprekende persone is betrek β aangesien die vraelyste slegs in afrikaans opgestel is. die proefpersone is almal werksaam in die stedelike gebiede van gauteng. drie verskillende groepe stemgebruikers is in die drie studies gebruik: studie 1 (crous, 1991): persone uit verskillende onderwysprofessies, naamlik 61 hoerskoolonderwysers, 57 laerskoolonderwysers, 42 tegnikondosente «.en 23 universiteitdosente het deelgeneem aan die studie. die responspersentasies was onderskeidelik: 96%, 100%, 93% en 46%. studie 2 (van tonder, 1995): predikante uit die drie sogenaamde afrikaanse susterkerke is geselekteer aangesien die preekstyl baie ooreenkom. vyftig persone het deelgeneem aan die studie. die responspersentasie was ongeveer 90%. studie 3 (pretorius, 1994): sangers wat hoofsaaklik in afrikaans sing, populere liedere sing en nie noodwendig formele sarigonderrig gehad het nie, is genader om aan die studie deel te neem. die sangstyl van die sangers is sodoende gekontroleer ten einde heterogeniteit te beperk. twintig sangers tussen die ouderdornme van 20 en 55 jaar is betrek. materiaal drie vraelyste met relevante vrae vir elke spesifieke groep is opgestel. die vrae is in verskillende afdelings verdeel ten einde die verlangde inligting te bekom soos aangedui in die doelstellings. die vrae het dus gehandel oor die voorkoms van stemprobleme by die respondente, die blootstelling aan risikofaktore wat uniek is by elke groep, die hoeveelheid stemgebruik, voorkomende optredes en hul kennis omtrent stemgewing is ook indirek nagegaan. by elke vraag is alternatiewe antwoorde verskaf en die respondent moes aandui of die antwoord op hom van toepassing is deur ja of nee te antwoord. byvoorbeeld, die aard van stemprobleme wat reeds ervaar is, is gelys en die respondent moes dan 'n keuse maak tussen die alternatiewe antwoorde. die vraelyste aan die drie groepe is nie identies nie. die omstandighede van elke groep verskil en nie alle vrae is relevant vir elke groep nie. verder is die data bekom uit drie studies wat oor 'n aantal jare uitgevoer is en insig in die belang van sekere aspekte (soos blootstelling aan risikofaktore) is eers mettertyd besef op grond van die vorige studies. die vraelyste is in samewerking met statistici ontwikkel ten einde effektiewe kodering te verseker tydens die analise van die data en ook om te verseker dat 'die vraelyste voldoen aan die algemene vereistes gestel aan vraelyste. die vraelyste bestaan uit kort ondubbelsinnige vrae waarop die persoon slegs ja of nee moes antwoord. die voltooing moes nie langer as 15 minute in beslag neem nie en dit is ook anoniem ingevul. die drie vraelyste gaan nie volledig weergegee word nie aangesien dit te omvattend sal wees en aangesien die vrae blyk uit die tabelle waarop die resultate aangeteken is. die volledige vraelyste is wel beskikbaar in die genoemde drie studies. die vrae en beoordeling van die vrae berus op erkende feite aangaande stem en stemafwykings soos in die literatuur aangegee. analise van die data die frekwensie van voorkoms van elke alternatiewe antwoord in die drie verskillende vraelyste, is bepaal. die the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) stemprobleme by enkele groepe professionele stemgebruikers: implikasies vir voorkoming data van die verskillende afdelings van die vraelyste en die vrae wat daaronder resorteer word in afsonderlike frekwensietabelle weergegee. die data van die drie erskillende studies is onafhanklik verwerk en word a f s o n d e r l i k aangebied. hierdie frekwensietabelle word subjektief beskryf en bespreek. beskrywing van resultate die resultate van elke onderskeie studie word afsonderlik beskryf: studie 1: vraelyste aan persone in onderwysprofessies die resultate van die ondersoek na die stemgebruik van persone in verskillende onderwysprofessies word weergegee in tabelle 1 tot 3. 43 in tabel 1 is die resultate van onderwysers en dosente geskei aangesien die aantal ure van onderrig oor die algemeen verskil en dus 'n invloed sal he op die voorkoms van probleme. in tabelle 2 en 3 was hierdie onderskeid nie nodig nie. die syfers in tabel 1 dui aan dat groot getalle van die |persone in onderwysprofessies wel reeds stemprobleme ondervind het. heesheid sonder rede en dus waarskynlik as gevolg van stemmisbruik, het by 23% van onderwysers en 23% van dosente voorgekom. ernstiger probleme soos verlies van stem het by tussen 51% en 7% van respondente gepresenteer. die duur van hierdie probleme was oor die algemeen nie lank nie, maar daar was wel 9 persone by wie dit vir weke of maande voortgeduur het. die grootste persentasie persone ondervind nie ten tyde van die ondersoek probleme nie, maar daar is tog baie persone (7%, 8%, 19% en 6%) wat wel probleme ondervind. simptome wat kan dui op probleme kom in hoe persentasies voor by die twee groepe. tabel 1: stemprobleme en simptome van stemprobleme by die persone in onderwysprofessies vraag moontlike aantal aantal vraag antwoord onderwysers dosente (n=118) (n=65) probleme heesheid met verkoue 88 (75%) 45 (69%) ondervind heesheid sonder rede 27 (23%) 15 (23%) verlies van stem 23 (19%) 15 (23%) geringe stemverlies 51 (43%) 33 (51%) ernstige stemverlies 7 (6%) 7 (11%) duur van kortstondig 59 (50%) 33 (51%) probleem dae 51 (43%) 23 (35%) weke 4 (3%) 3 (5%) maande 0 (0%) 2 (3%) tans 'n probleem ja 8 (7%) 5 (8%) nee 83 (70%) 54 (83%) ; soms 22 (19%) 4 ( 6 % ) kenmerke van asemrig 8 (7%) 2 ( 3 % ) stem gereeld hees 28 (24%) 20 (31%) ofvoortdurend stemverlies 4 (3%) 3 ( 5 % ) hoes 10 (8%) , 5 ( 8 % ) pyn 11 (9%) 8 (12%) i keelskoonmaak 43 (36%) 21 (32%) 1 1 te hard 4 (3%) 6 (9%) te sag 15 (13%) 6 (9%) word gou moeg 20 (17%) 14 (22%) monotoon 1 (1%) 1 (2%) luisteraarja 2 (2%) 5 (8%) klagtes te sag 0 (0%) 3 ( 5 % ) te vinnige spraak 0 (0%) 2 ( 3 % ) stem het ja 14 (12%) 5 (8%) verander harder 9 (8%) 2 (3%) sedert aanvang meer hees 4 (3%) 0 ( 0 % ) van beroep verswak 4 (3%) 2 ( 3 % ) pyn as praat 5 (4%) 1 (2%) krapperig 3 (3%) 3 (5%) gouer moeg 2 (2%) 3 (5%) toonhoogte verander 4 (3%) 3 ( 5 % ) 1 stemverlies 0 (0%) 1 (2%) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 anita van der merwe, marita van tonder, estelle pretorius en helga crou gereelde keelskoonmaak wat gewoonlik 'n teken is van stemongemak (boone & mcfarlane, 1988), kom by 36% en 32% van die groepe voor. daar is by 12% en 8% van die persone 'n bewussyn dat hulle stemme verander het sedert die aanvang van hul beroepe. brodnitz (1988) noem dat 'n spreker gewoonlik die laaste persoon is wat daarvanbewus tabel 2: kennis van stemprobleme by die persone in onderwysprofessies word dat sy stem verander en in die lig hiervan is die genoemde persentasies wel veelseggend. die gegeweris in tabel 2 wat handel oor die kennis van stemprobleme toon aan dat die meeste van die moontlike veroorsakende faktore genoem word, maar dit is oor die algemeen slegs klein getalle van die respondente wat daarvan bewus is. die persentasies van 19% en 12% wat daarvan bewus is dat oormatige gebruik en 'n harde stem probleme kan veroorsaak, is besonder laag en dui op swak kennis van die oorsake van stemprobleme. die feit dat slegs 31% voorheen ingelig is aangaande goeie stemgebruik, bevestig hierdie afleiding. soveel as 81% is bewus daarvan dat stemprobleme wel kan ontstaan, maar vraag moontlike antwoord aantal (n= =183) redes vir die oormatige gebruik 35 (19%) ontstaan van te hard praat 22 (12%) stemprobleme soos foutiewe stemaangegee deur gebruik 9 (5%) respondente rook 8 (4%) (oop vraag) spanning van stembande 3 (2%) praat sonder luidspreker 3 (2%) praat as verkoue'het 14 (7%) skree 9 (5%) mediese redes 7 (4%) langdurige gebruik 13 (7%) allergiee/sinusitis 2 ( 1%) omgewingsfaktore 3 (2%) emosioneel 2 ( 1%) sportafrigting 8 (4%) werkomstandighede 2 (1%) blameer vir foutiewe ontstaan van 'n stemgewoontes · 54 (30%) stemprobleem beroepseise 100 (55%) omgewing 23 (13%) rook/besoedeling 52 (28%) mediese redes 24 (13%) spanning 37 (20%) voorheen ingelig goeie stemgebruik 57 (31%) omtrent die risikofaktore vir volgende ontstaan van 'n stemprobleem 14 (7%) hoe werksituasie aangepas kan word 12 (7%) hoe om 'n stemprobleem te hanteer 15 (8%) instansies waar hulp verkry kan word 6 (3%) was voorheen nooit daaraan bewus van gedink nie 30 (16%) moontlikheid van was bewus stemprobleme daarvan ervaar angs oor moontlike ontstaan 148 (81%) van 'n probleem 9 (5%) die vraelys het ja 108 (59%) bewussyn geskep nee 71 (39%) van stemprobleme tabel 3: optrede en houding teenoor stemprobleme by die persone in onderwysprofessies vraag moontlike aantal antwoord (n= 183) neem stappe om ja 115 (63%) stem op te pas nee 28 (15%) tipe stappe stemrus tydens geneem volgens siekte 2 ( 1%) respondente waak teen (oop vraag) ooreising 3 (2%) nie te hard praat nie 15 (8%) laer "stemtoon" 19 (10%) praat minder 0 (0%) beperk allergiee 7 (4%) voorkom siekte 2 ( 1%) elimineer irritasie 7 (4%) rook nie 1 ( 1%) kry mediese hulp 1 (1%) reaksie op 'n skuldig voel 7 (4%) moontlike dit aanvaar 6 (3%) stemprobleem wegsteek 2 (1%) ignoreer 4 (2%) werk bedank 4 (2%) staak rook 12 ( 7%) stilbly 3 (2%) hulp soek \ 122 (67%) stemeienskappe verander 20 (11%) ontsteld wees 56 (31%) optrede indien 'n na huisdokter stemprobleem gaan 123 (67%) sou ontstaan na spraakterapeut gaan 38 (21%) na onk-arts gaan 42 (23%) verlof neem 5 (3%) stemgebruik beperk 23 (13%) werk volhou / ongeag probleem 27 (15%) bewus dat ja 26 (14%) spraakterapeut nee 138 (75%) met stemprobleme werk the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) tmprobleme by enkele groepe professionele stemgebruikers: implikasies vir voorkoming 45 . w i l voorkom asof kennis van en insig in die probleem k is die vraelys het by 59% 'n bewussyn geskep van mprobleme en was dus waardevol in hierdie opsig. die b e w u s s y n van 'n probleem moet egter aangevul word met ^ uittabel 3 blyk dit dat'slegs 63% van die respondente . stappe neem om hul stemme te konserveer. die tipe f p e wat aangegee is in 'n oop vraag dui ook op beperkte snsig in veroorsakende faktore. relevante stappe word wel 1 noem, deur klein persentasies van die persone, maar daar is'belangriker voorkomende maatreels waarvan hierdie persone bewus behoort te wees. die meeste van die persone sal wel hulp soek as hul probleme ondervind, m a a r 'n onaanvaarbare persentasie (15%) sal hul werk volhou. slegs 'n baie klein persentasie (14%) was bewus daarvan dat die spraakterapeut van hulp kan wees by die bantering van stemprobleme. studie 2: vraelyste aan predikante die resultate van die ondersoek na stemprobleme by 'n groep predikante word saamgevat in tabelle 4 tot 7. uit tabel 4 blyk dit dat 54% van die respondente wel reeds stemprobleme ervaar het. in die meeste gevalle (46%) was die probleme kortstondig, maar daar is 4 persone wat langdurige probleme het. die meeste van die predikante het probleme ondervind as gevolg van laringitis, maar daar is 20 (11 + 9) wat heesheid ervaar het sonder laringitis of verkoue. die oorsaak van laasgenoemde is waarskynlik stemmisbruik. ander aanduidings van stemmisbruik kom ook voor. stemuitputting en pyn in die keelarea kom by 56% voor en 38% se dat hulle gereeld moet keelskoonmaak. die volgende twee vrae oor die ervaring van sekere simptome tydens en na afloop van 'n optrede dui op 'n baie hoe voorkoms van stemmisbruik by hierdie groep. geringe stemuitputting, forseer van stem, heesheid en ander simptome kom by die meeste persone voor. slegs 7 (14%) het aangedui dat hul wel pyn ervaar (wat ook kan dui op uitputting), maar geen hoorbare stemverandering het nie. die inligting in tabel 5 toon aan dat die predikante ook blootgestel word aan ander risikofaktore as bloot baie stemgebruik. agtergrondslawaai (by 72%), rook en gasse (by 34%) en swak akoestiek met onvoldoende luidsprekerstelsels (by 74% en 70%) kom voor waar hulle optree. verder stel hulle hulself ook bloot deur lang stukke voor te lees (50%) en doelbewus hul stemeienskappe te tabel 4: stemprobleme en simptome van stemprobleme by predikante vraag moontlike antwoord aantal n=50 stemprobleme ervaar het al stemprobleme ervaar kortstondige probleme langdurige probleme beide kortstondige en langdurige probleme 27 (54%) 23 (46%) 2 ( 4 % ) 2 ( 4 % ) simptome ervaar 1 i ! 1 kortstondige stemheesheid tydens verkoue of laringitis kortstondige stemheesheid sonder verkoue of laringitis stemheesheid vir 'n paar ure tydens verkoue of laringitis stemheesheid vir 'n paar ure sonder verkoue of laringitis stemheesheid vir 'n dag of langer tydens verkoue of laringitis stemheesheid vir 'n dag of langer sonder verkoue of laringitis stemverlies tydens verkoue of laringitis stemverlies sonder verkoue of laringitis stemuitputting pyn in keelarea gewoonte om gereeld keel skoon te maak ander stemprobleme organies dui waarskynlik op stemmisbruik 43 (86%) 15 (30%) 36 (72%) 11 (22%) 35 (70%) 9 (18%) 6 (12%) 2 ( 4 % ) 28 (56%) 28 (56%) 19 (38%) 5 (10%) 3 ( 6 % ) 2 ( 4 % ) negatiewe kommentaar negatiewe kommentaar aangaande stemkwaliteit 2 ( 4 % ) ervaar tydens optrede geringe stemuitputting voel asof ek my stem forseer heesheid tree in behoefte om gereeld keel skoon te maak pyn in keel, maar geen verandering in stemkwaliteit 19 (38%) 10 (20%) 11 (22%) 14 (28%) 7 (14%) ervaar na optrede geringe stemuitputting heesheid behoefte om gereeld keel skoon te maak pyn in keel, maar geen verandering in stemkwaliteit 27 (54%) 12 (24%) 15 (30%) 7 (14%) stem verander sedert aanvang van beroep 1 geringe veranderinge groot veranderinge 9 (18%) 1 ( 2 % ) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 anita van der merwe, marita van tonder, estelle pretorius en helga cro verander, soos die verhoging van luidheid (52%). wat kennis omtrent stemprobleme betref (sien tabel 6), blyk dit dat die predikante beperkte kennis het. dit blyk onder meer uit 'n beskrywing van wat 'n stemprobleem is en wat subjektief deur die ondersoeker beoordeel is op grond van erkende literatuur. in antwoord op die vraag of daar enige gevolge is indien stem misbruik word, dui 88% aan dat daar geen gevolge is nie en 12% is onseker. die helfte van die groep besef wel dat fisiese veranderinge kan voorkom, maar hulle verstaan dus nie wat die implikasies sal wees nie. hul kennis oor die meganisme van luidheidverhoging is ook beperk. slegs 40% gee die korrekte antwoord, naamlik dat dit nie moontlik is om luidheid te verhoog deur verhoogde nekspierspanning nie (boone & mcfarlane, 1988). net 30 (60%) van die respondente besef dat emosionele faktore 'n tabel 5 die blootstelling aan risikofaktore by predikante vraag moontlike antwoord aantal (n= =50) omstandighede agtergrondslawaai waar optree teenwoordig rook en gasse 36 (72%) teenwoordig 17 (34%) swak akoestiek 37 . (74%) luidsprekerstelsel afwesig of onvoldoende 35 (70%) doen die volgende lees lang stukke hardop voor 25 (50%) gebruik doelbewus 'n ander stem 3 (6%) gebruik 'n preekstem wat hoer of laer in toonhoogte ' i s as my normale praatstem 2 (4%) gebruik 'n preekstem wat harder in luidheid is as my normale praatstem 26 (52%) rookgewoontes rook 10 of minder sigarette per dag 2 (4%) rook meer as 10 sigarette per dag 5 (10%) rook glad nie 43 (86%) stemgebruik in as ek op reis is in 'n voertuig voertuig gesels ek die heeltyd met die passasiers 6 (12%) as ek op reis is in 'n voertuig gesels ek soms met die passasiers 43 (8%) as ek op reis is in 'n voertuig gesels ek glad nie 1 (2%) invloed het op stem (aronson, 1985). riglyne oor g 0 e i e stemgebruik is wel ontvang (76%), maar slegs 12 (24%) het dit van 'n spraakterapeut ontvang. die moontlikheid bestaan dat dit nie werklik 'n spraakterapeut was nje aangesien die kennis van die publiek oor die algemeen nie baie goed is in hierdie verband nie. in tabel 7 word die optrede en houding teenoor stemprobleme saamgevat. die grootste persentasie (98%) besef wel dat stemprobleme kan voorkom by predikante en soveel as 34% is altyd bekommerd oor die moontlikheid en 62% is nou en dan bekommerd. hierdie hoe persentasies dui aan dat hulle onseker is oor die wyse waarop 'n probleem voorkom kan word. die stappe wat hulle neem is by klein persentasies van die groep wel relevant tabel 6: kennis van stemprobleme by predikante vraag moontlike antwoord aantal vraag (n=50) eie beskrywing geen kennis 6 (12%) van stemprobleem beperkte kennis 28 (56%) goeie kennis 8 (16%) geen antwoord 8 (16%) kennis van tydelike stemprogevolge van stembleme kom voor: 41 (82%) misbruik ja 1 (2%) nee 8 (16%) onseker fisiese veranderinge aan stembande kom voor: ja 25 (50%) nee 24 (48%) onseker 1 (2%) daar is geen gevolge nie: ja 0 (0%) nee 44 (88%) onseker 6 (12%) verhoogde luidi ja, dit is moontlik heid verkry deur slegs in sommige 14 (28%) spanning in gevalle 7 (14%) nekspiere glad nie j 20 (40%) weet nie 1 9 (18%) het emosionele ja, beslis 30 (60%) faktore 'n nee, glad nie 11 (22%) invloed? onseker 9 (18%) riglyne oor geen riglyne 12 (24%) stemgebruik beperkte riglyne 31 (62%) tydens opleiding volledige riglyne 7 (14%) riglyne ontvang spraakonderwyser 11 (22%) van spraakterapeut 12 (24%) dosent in spraakleer en drama 8 (16%) dosent by teologie departement 5 (10%) sangonderwyser 2 (4%) onseker 2 (4%) the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mprobleme by enkele groepe professionele stemgebruikers: implikasies vir voorkoming 47 tabel rj. optrede en houding teenoor stemprobleme "j vraag moontlike antwoord aantal (n=50) pas stemrus toe wend pogings aan om doelbewuste stemrus toe te pas 6 (12%) stemprobleme by predikante ja, dit is. moontlik onseker nee, dit kom selde voor 49 (98%) 1 (2%) 0 (0%) bekommerd oor stem ek is altyd bekommerd daaroor ek is nou en dan bekommerd daaroor ek is glad nie bekommerd daaroor nie 17 (34%) 31 (62%) 2 (4%) stappe tot konservering neem stappe om stem op te pas 31 (62%) tipe stappe geneem medikasie gereelde stemrus beperkte luidheid beperkte hoeveelheid stemgebruik 20 (40%) 10 (20%) 19 (38%) 17 (34%) reaksie op moontlike stemprobleem ophou werk vir 'n tydperk en gaan hulp soek ophou werk vir 'n kort tydperk aanhou werk, maar gaan hulp soek aanhou werk, sonder, om hulp te soek j 13 (26%) 3 (6%) 43 (86%) 0 (0%) vorige hulp ontvang huisdokter homeppaat oorn;eusen keelarts kollegas spraakterapeut elokusie-onderwyser geen hulp gesoek nie 36 (72%) 3 (6%) 10 (20%) 3 (6%) 3 (6%) 2 (4%) 12 (24%) wie in toekoms raadpleeg huisdokter homeopaat oor-, neusen keelarts kollegas spraakterapeut elokusie-onderwyser 40 (80%) 2 (4%) 31 (62%) 2 (4%) 23 (46%) 3 (6%) spraakterapeut kan help ja nee onseker 46 (92%) 1 (2%) 3 (6%) (byvoorbeeld 10 pas gereelde stemrus toe), maar 'n groot groep (20) is van mening dat medikasie van waarde sal wees. in reaksie op 'n moontlike stemprobleem dui al die predikante aan dat hulle hulp sal gaan soek en selfs sal ophou werk vir 'n periode. die grootste persentasie (72% en 80%) het in die verlede en sal weer in die toekoms na hul huisdokter gaan vir hulp. dit wil ook voorkom asof groter persentasies (20% teenoor 62% en 6% teenoor 46%) die hulp van 'n oor-, neus-, en keelarts en spraakterapeut sal inroep vir moontlike toekomstige probleme. groter bewussyn is moontlik geskep met die vraelys of die persone het uit ervaring geleer dat hierdie twee professies in samewerking die beste bystand kan bied. studie 3: vraelyste aan sangers die resultate van die ondersoek na stemprobleme by 'n groep sangers word weergegee in tabelle 8 tot 12. in tabel 8 word die voorkoms en simptome van stemprobleme by hierdie groep saamgevat. kortstondige probleme na 'n vertoning kom by 5 (25%) van die groep tabel 8: stemprobleme en simptome van stemprobleme by sangers vraag voorkoms van stemprobleme agteruitgang van stem probleme tydens optredes moontlike antwoord geen stemprobleem ervaar kortstondig, na vertoning probleme na. verkoue/laringitis 1/meer episodes vir weke/maande geen verandering sedert aanvang geringe veranderinge in stem groot veranderinge in stem geringe uitputting • herstel gou forseer stem heesheid tree in keelskoonmaak ligte pyn, geen veranderinge asemrigheid geeneen van bogenoemde probleme na afloop van optrede geringe uitputting • herstel gou heesheid ook in spraakstem ligte pyn, geen veranderinge keelskoonmaak geeneen van die bogenoemde aantal (n=20) (25%) (25%) 10 (50%) 4 (20%) 13 (65%) 5 (25%) 2 (10%) 10 2 13 5 2 2 (50%) (10%) (65%) (25%) (10%) (10%) (20%) 14 (70%) 12 (60%) 2 (10%) 3 (15%) 2 (10%) die suid -afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) anita van der merwe, marita van tonder, estelle pretorius en helga crou 48 voor en soveel as 4 (20%) het een of meer episodes van probleme ervaar wat vir weke of maande voortgeduur het. daar was ook agteruitgang in stemkwaliteit by 7 (35%) van die groep. slegs 4 (20%) sangers het geen stemprobleme tydens optredes nie terwyl slegs 2 geen stemprobleme het na afloop van optredes nie. dit is dus duidelik dat stemuitputting weens stemmisbruik by die meeste van die sangers voorkom. die inligting in tabel 9 toon aan dat die sangers hulself wel blootstel aan risikofaktore. slegs 3 (15%) berei voor vir optredes. die luidheid van begeleiding word net deur 7 (35%) sangers beperk en 14 van die groep gebruik nie gereeld monitor-luidsprekers wat terugvoer van die stem verbeter nie. die gevolg sal dus wees dat hulle stemluidheid uitermate moet verhoog ten einde voldoende terugvoer te kry. daar is selfs 2 sangers wat nie altyd klankversterking gebruik nie en 8 (40%) gesels baie in vervoermiddels waar lawaai ook stemterugvoer beperk. addisionele omgewingsfaktore soos geraas en rook word slegs deur 11 (55%) van die sangers beperk. die enigste positiewe saak is dat geen een van die sangers meer as 10 sigarette per dag rook nie. die meeste (18) rook gladnie. wat kennis omtrent stem en stemprobleme betref, is daar persone wat weinig kennis het. vyf (25%) het geen sangopleiding ontvang nie en daar is ook 5 wat van mening is dat die stemomvang met meer as een register verhoog kan word. dit is nie die geval nie aangesien die bou van die stembande die register en toonhoogte van die stem bepaal (colton & casper, 1990). 'n verdere aanduiding van swak kennis van stemgewing blyk uit die feit dat 5 (20%) nie besef dat verhoogde nekspierspanning nie nodig is vir verhoogde luidheid nie (colton & casper, 1990; stemple,1984). soveel as 13 het geen of weinig riglyne oor stemkonservering ontvang tydens opleiding. die meeste sangers is wel bewus van waiter gewoontes potensieel skadelik is vir die stem, maar dit is verrassend dat almal nie skadelike gewoontes kan identifiseer nie. byvoorbeeld, slegs 7 besef dat dit skadelik is om sonder versterking te sing en slegs 12 (60%) besef dat keelskoonmaak potensieel skadelik is (boone & mcfarlane, 1988). tabel 10: kennis van stemprobleme by sangers tabel 9: die blootstelling aan risikofaktore by sangers vraag moontlike antwoord aantal (n=20) voorbereiding oefen toonlere en vir optrede doen ander voorbereidende oefeninge 3 (15%) oefen slegs paar toonlere 9 (45%) geen voorbereiding 8 (40%) luidheid van beperk luidheid 7 (35%) begeleiding beperk luidheid in 'n mate 10 (50%) beperk luidheid glad nie 2 (10%) monitorgebruik altyd luidspreker monitor-luidspreker 5 (25%) gebruik soms monitor-luidspreker 11 (55%) gebruik nie monitorluidsprieker 3 (15%) klankgebruik altyd versterking versterking 18 (90%) buite met en binne sonder versterking 1 (5%) geen klankversterking 1 (5%) toestande tydens geen geraas en rook 11 (55%) optrede tydens optredes min geraas en rook 8 (40%) gedurige geraas en rook 1 ( 5%) rook rook gladnie 18 (90%) rook minder as 10 sigarette per dag 2 (10%) rook meer as 10 sigarette per dag · 0 (0%) stemgebruik in gesels die minimum 12 (60%) vervoermiddel gesels voortdurend 8 (40%) vraag moontlike antwoord aantal (n=20) sangopleiding green sangopleiding individuele sangopleiding kooropleiding 5 (25%) 11 (55%) 4 (20%) opleiding in voorkoming volledige riglyne ontvang beperkte riglyne ontvang geen riglyne oor stemkonservering 7 (35%) 11 (55%) 2 (10%) meganisme vir luidheid-verhoging nekspanning nie nodig vir luidheid nekspanning somtyds nodig nekspanning nodig vir luidheid 14 (70%) ί (5%) 4 (20%) potensieel skadelik vir stem keelskoonmaak skadelik vir stem hard sing sonder versterking sing buite natuurlike omvang geen opwarming van die stem 12 (60%) 7 (35%) 13 (65%) 16 (80%) stemomvangvergroting stemomvang binne perke vergroot verhoog met 1 register deur oefen verhoog met meer as 1 register 15 (75%) 1 (5%) 5 (25%) the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) me by enkele groepe professionele stemgebruikers: implikasies vir voorkoming 49 tabel 11· stemkonservering deur sangers vraag moontlike antwoord aantal (n=20) stappe in stemkonservering pas stemrus toe gebruik medikasie neem geen stappe om stem op te pas nie 16 (80%) 9 (45%) 3 (15%) stemrus tydens pouses totale stemrus tydens pouses gesels wel, maar min gee nie aandag aan stemrus nie 1 (5%) 9 (45%) 6 (30%) duur van optredes minder as 1 uur tussen 1 en 2 ure langer as 2 ure 6 (30%) 13 (65%) 1 (5%) frekwensie van optredes tree 1 of 2 kere per week op tree 3 of 4 kere per week op tree meer as 4 keer per week op 12 (60%) 7 (35%) 1 (5%) opeenvolging van optredes tree nooit op opeenvolgende dae op nie slegs sekere weke op opeenvolgende dae dikwels op opeenvolgende dae 2 (10%) 13 (65%) 4 (20%) duur van sangoefening geen formele sangoefening ongeveer 20 minute per dag ongereelde oefening langer'as 1 uur per dag | 8 (40%) i (5%) ii (55%) 0 (0%) rusperiodes tydens optredes altyd rjusperiodes soms rjusperiodes geen rusperiodes nie 3 (15%) 9 (45%) 8 (40%) ander beroep geen addisionele beroep | beoefen addisionele beroep 8 (40%) 12 (60%) gebruik in ander beroep gebruik stem nooit te veel gebruik stem met tye gebruik stem baie in ander beroep 1 (5%) 3 (15%) 8 (40%) hoeveelheid spraakstem gebruik beperk stemgebruik gee nie aandag aan hoeveelheid nie 9 (45%) 11 (55%) luidheid van spraakstem beperk altyd stemluidheid beperk luidheid as stem uitgeput is gee geen aandag aan luidheid nie 1 (5%) 10 (50%) 10 (50%) die suid-afrikaanse tydskrif vir kommunikasieafwykings, op grond van die voorafgaande inligting is dit te wagte dat baie min van die sangers wel hul stemme konserveer (sien tabel 11). nege (45%) van die proefpersone reken dat medikasie kan bydra tot stemkonservering. slegs 1 pas totale stemrus toe tydens pouses en 8 (40%) tree drie of meer kere per week op. soveel as 17 (85%) tree soms op agtereenvolgende dae op wat weinig geleentheid vir die stembande bied om te herstel na uitputting. slegs, 3 (15%) neem altyd rusperiodes tydens optredes. sangoefening word deur al die sangers afgeskeep en 12 beoefen addisionele beroepe waar 8 hulle stemme baie gebruik in die uitoefening van die beroep. ook die spraakstem word nie gekonserveer nie. elf (55%) gee geen aandag aan die hoeveelheid gebruik nie en 10 gee geen aandag aan die luidheid van die spraakstem nie. die optrede en houding teenoor stemprobleme by sangers word in tabel 12 weergegee. veertien (70%) sal wel ophou sing indien hulle probleme ondervind en 19 sal tabel 12: optrede en houding teenoor stemprobleme by sangers vraag moontlike antwoord aantal (n=20) reaksie op stemprobleem verwelkom nuwe stemkwaliteit ophou sing en gaan hulp soek ophou sing vir 'n kort tydperk aanhou sing en gaan hulp soek 1 (5%) 9 (45%) 5 (25%) 5 (25%) wie raadpleeg huisdokter homeopaat oorneusen keelarts kollegas of agente sangonderwyser spraakterapeut 8 (40%) 11 (55%) 1 (5%) 5 (25%) 5 (25%) bewussyn van probleem stemprobleme kan by sangers voorkom onseker nie bewus van stemprobleme nie 20 (100%) bekommernis oor stem altyd bekommerd oor stemprobleme nou en dan bekommerd glad nie bekommerd nie 6 (30%) 8 (40%) 6 (30%) kennis van gevolge gevolge: ligte pyn en stemuitputting fisiese veranderinge in die stembande onseker oor gevolge van stemprobleme 4 (20%) 12 (60%) 6 (30%) invloed van spraakstem spraakstemprobleem bei'nvloed sangstem bei'nvloed moontlik die sangstem 13 (65%) 7 (35%) vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 anita van der merwe, marita van tonder, estelle pretorius en helga crous mediese hulp verkry. al die sangers is bewus daarvan dat stemprobleme by sangers kan voorkom, maar 14 (70%) bekommer hulle nie baie oor die moontlikheid nie. ses (30%) is onseker oor die gevolge van stemprobleme en slegs 12 (60%) besef dat fisiese veranderinge kan intree in die stembande indien die stem misbruik word.,slegs 13 (65%) besef dat 'n probleem met die spraakstem beslis ook die sangstem sal bei'nvloed (colton & casper, 1990). bespreking van resultate dieselfde tendense is waargeneem by die drie groepe. stemprobleme' en simptome van stemprobleme kom in wisselende grade voor by al drie die groepe professionele stemgebruikers wat betrek is by die studie. kennis oor stemgewing en stemprobleme is beperk en die persone stel hulself bloot aan allerlei risikofaktore sonder om aandag te gee aan stemkonservering. hulle is wel bewus van die moontlikheid van 'n stemprobleem en sommige is selfs angstig dat hulle so 'n probleem sal ontwikkel, maar beskik nie oor die nodige kennis om stemgebruik te monitor nie. hoewel hierdie studies slegs onderneem is by enkele professionele groepe, is dit wel moontlik dat dieselfde resultate verkry sal word by ander professionele en taalgroepe. die enigste ander studie (sover bekend) oor stemmisbruik by professionele sprekers in suid-afrika is die van reynolds (1994) wat die bewussyn van stemmisbruik by finalejaar studentonderwysers van twee universiteite in kwa-zulu natal ondersoek het. meer as die helfte van die 209 studente wat deelgeneem het aan die studie het aangedui dat hul bewus is van stemuitputting en stemprobleme en soveel as, 19 het tydens hul eerste blootstelling aan die praktyk hul stemme verloor. die resultate van hierdie studie bevestig dus die bevindinge van die huidige studie, naamlik dat stemprobleme wel voorkom by professionele stemgebruikers. stemprobleme kan voorkom word deur riglyne vir optimale stemgebruik in te sluit by die kurrikula vir opleiding van persone wat hul stemme professioneel gaan gebruik, deur publieke opleiding deur middel van die openbare media en deur inligting aan professionele persone deur die spraak-taalterapeut. dit is nie alleen professionele sprekers wat by voorkomingsaksies baat sal vind nie, maar ook die bree publiek wat ander groepe stemgebruikers ook insluit (heidel & torgerson, 1993; nilson & schneiderman, 1983; aaron & madison, 1991). die essensie van voorkoming van stemmisbruik en 'n gevolglike stemprobleem-, is volgens johnson (1991) die self-monitering van gedrag. die persoon moet dus opgelei word om self sy stem te konserveer. ten einde 'n persoon daartoe in staat te stel is daar egter sekere sake wat aangespreek moet word in 'n opleidingsprogram en sekere vereistes waaraan dit moet voldoen: die relevansie van die onderwerp vir die gehoor moet gemotiveer word. die persoon moet dus die noodsaaklikheid van stemkonservering insien en verstaan dat voorkoming 'n eie verantwoordelikheid is. navorsingsresultate omtrent stemprobleme by soortgelyke groepe kan kortliks genoem word asook enkele gevallestudies. basiese feite oor stemgewing moet kernagtig, maar wetenskaplik oorgedra word ten einde insig en begrip te vestig vir normale en abnormale stem. die verskillende oorsake van stemprobleme, naamlik primer-organiese, psigogene en funksionele oorsake met en sonder sekondere organiese gevolge kan net genoem word. die noodsaaklikheid van 'n ondersoek deur 'n oor-, neusen keelarts indien enige stemprobleem voorkom, moet te alle tye beklemtoon word. die persoon moet die aard van stemhiperfunksie verstaan. die vorms van stemmisbruik in fonasie, respirasie en resonansie moet verduidelik word sodat die persoon verstaan wat swak stemgewoontes behels en dus instaat sal wees tot identifisering daarvan in eie stemgebruik. die persoon moet die oorsake van stemhiperfunksie verstaan ten einde risikofaktore te kan identifiseer en uitskakel. die rol van oorsake soos foutiewe stemgewoontes en oormatige gebruik, omgewingsen fisiese faktore soos lawaai, gasse en allergiee en emosionele faktore moet verduidelik word. die simptome of "waarskuwingstekens" van stemmisbruik moet genoem word: stemuitputting met ongemak of selfs pyn wanneer stem geproduseer word; heesheid en selfs stemverlies vir 'n periode nadat stem gebruik is; die behoefte om gedurig keel skoon te maak wanneer die stem gebruik word; 'n beter stem soggens en na naweke en swakker stem later in die dag en later in die week. die risikofaktore vir die spesifieke groep kan uitgelig word. in die geval van dosente of onderwysers is daar onder andere swak luidsprekerstelsels, swak akoestiek, praat in die teenwoordigheid van studentelawaai en die uitdrogende effek van bordkryt. die stappe vir voorkoming wat geneem kan word behoort ook prakties uitgelig te word teen die agtergrond van die inligting wat verskaf is. die stappe kan die volgende behels: beheer, verander of vermy omgewingsfaktore wat aanleiding gee tot stemmisbruik; gee aandag aan emosionele faktore wat spanning veroorsaak en soek hulp indien die probleem ernstig word; verminder die hoeveelheid stemgebruik deur onder andere rusperiodes; beheer fisiese faktore soos rook, sooibrand en die oormatige inname van stowwe soos kafeien en koladranke (aronson, 1985; child & johnson, 1991); skakel stemmisbruik en wangebruik uit. dra belangrike algemene reels vir optrede'indien 'n probleem reeds voorkom, oor: die spesifieke faktore wat aanleiding gee tot 'n stemprobleem, moet by elke persoon individueel gei'dentifiseer word en dan sistematies uitgeskakel word; daar moet opgetree word voordat die probleem sover gevorder het dat 'n stemband-operasie nodig is; soek hulp by 'n oor-, neusen keelarts en dan ook by 'n spraak-taalpatoloog indien 'n stemprobleem wel ontwikkel. hierdie is algemene riglyne vir voorkomingsonderrig vir stemprobleme. enkele meer spesifieke programme vir spesifieke groepe is in die literatuur beskikbaar (aaron & madison, 1991; kaufman & johnson, 1991; nilson & schneiderman, 1983). gevolgtrekking die resultate van hierdie ondersoek toon aan dat die groepe wat ondersoek is, almal hoerisikogroepe is vir die ontwikkeling van stemprobleme. binne die konteks van 'n land met beperkte hulpbronne, is dit dus belangrik dat die plaaslike spraak-taalterapeut voorkomingsonderrig vir the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) s t e m p r o b l e m e b y e n k e l e g r o e p e professionele s t e m g e b r u i k e r s : i m p l i k a s i e s v i r v o o r k o m i n g 51 stemprobleme sal inisieer as deel van die beroepsfunksies w a t vervul moet word. verwysings aaron, v.l. & madison, c.l. (1991). a vocal hygiene program for high-school cheerleaders. language, speech, and hearing services in schools, 22, 287-290. a r o n s o n , a.e. (1985). clinical voice disorders. new york: thieme. boone, d.r· (1983). the voice and voice therapy (3rd ed.). new jersey:-prentice-hall. boone, d.r. & mcfarlane, s.c. (1988). the voice and voice therapy (4th ed.). new jersey: prentice-hall. brodnitz, f.s. (1988). keep your voice healthy (2nd ed.). boston: college-hill. child, d.r. & j o h n s o n , t.s. (1991). preventable and nonpreventable causes of voice disorders. seminars in speech and language: prevention of voice disorders, 12, 1-13. colton, r.h. & casper, j.k. (1990). understanding voice disorders. baltimore: williams & wilkins. crous, h. (1991). 'n ondersoek na stemprobleme by die professionele stemgebruiker in sekere onderwysprofessies. ongepubliseerde b.log-verhandeling, universiteit van pretoria. gerber, s.e. (1990). prevention: the etiology of communicative disorders in children. new jersey: prentice hall. heidel, s.e. & torgerson, j.k. (1993). vocal problems among aerobics instructors and aerobic participants. journal of communication disorders, 26, 179-191. johnson, t.s. (1991). principles and practices of prevention as applied to voice disorders. seminars in speech and language: prevention of voice disorders, 12, 14-22. kaufman, t.j. & johnson, t.s. (1991). an exemplary preventative voice program for educators. seminars in speech and language: prevention of voice disorders, 12, 40-48. marge, m. (1991). introduction to the prevention and epidemiology of voice disorders. seminars in speech and language: prevention of voice disorders, 12, 49-72. nilson, h. & schneiderman, c.r. (1983). classroom program for the prevention of vocal abuse and hoarseness in elementary school children. language, speech, and hearing services in schools, 14, 121-127. pretorius, e. (1994). stemkonservering by 'n groep professionele sangers. ongepubliseerde b.log-verhandeling, universiteit van pretoria. reynolds, m.a. (1994). an investigation into self-awareness of vocal abuse with special reference to final year student-teachers. ongepubliseerde m.a.-verhandeling, universiteit van natal. stemple, j.c. (1984). clinical voice pathology: theory and management. columbus: charles e. merrill. van der merwe, a. (1982). a hierarchical analysis of voice pathology: a guide to diagnosis and treatment. the south african journal of communication disorders, 29, 16-22. van tonder, m. (1995). stemgebruik by 'n groep predikante. ongepubliseerde b.kommunikasiepatologie-verhandeling, universiteit van pretoria. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a neuropsychological approach to the study of gesture and pantomime in aphasia jocelyn kadish, b.a. (sp. & h. th.) (witwatersrand) dept. logopaedics. university of cape town. summary t h e impairment of gesture and pantomime in aphasia was examined from a neuropsychological perspective. the boston diagnostic test of aphasia, luria's neuropsychological investigation, pickett's tests for gesture and pantomime and the performance scale of the wechsler adult intelligence scale were administered to six aphasic subjects with varying etiology and severity. results indicated that severity of aphasia was positively related to severity of gestural disturbance; gestural ability was associated with verbal and non-linguistic aspects of ability, within receptive and expressive levels respectively; performance on gestural tasks was superior to that on verbal tasks irrespective of severity of aphasia; damage to luria's second and third functional brain units were positively related to deficits in receptive and expressive gesture respectively; no relationship was found between seventy of general intellectual impairment and gestural deficit. it was concluded that the gestural impairment may best be understood as a breakdown in complex sequential manual motor activity. theoretical and therapeutic implications were discussed. opsomminc die versteuring van gebare is vanuit 'n neuropsigologiese oogpunt ondersoek in ses proefpersone met afasie. verskillende oorsake en grade van aantasting het voorgekom navorsing is deur middel van die "boston diagnostic test of aphasia", luria se "neuropsychological investigation", pickett se "test for gesture and pantomime" en die "wechsler adult intelligence scale" gedoen. resultate dui op 'n positiewe verband tussen graad van afasie en die graad van gebareversteuring. die vermoe om gebare te gebruik hou verband met die verbale en nie-iinguistiese vermoens op beide die reseptiewe en ekspressiewe vlakke. desnieteenstaande die graad van afasie, is in die ondersoek gevind dat die vaardigheid om gebare te gebruik beter was as die vaardigheid op η verbale vlak. beskadiging van luria se tweede en derde funksionele breineenhede hou positief verband met η gebrek in reseptiewe en ekspressiewe gebare onderskeidelik. geen verband is gevind tussen die graad van algemene intellektuele versteuring en gebareversteuring nie. dus kan die versteuring in die gebruik van gebare beskou word as η belemmering in die komplekse opeenvolgende motoriese aktiwiteit van die hande. implikasies vir die teorie en terapie is bespreek. the role of gestures in communication has been demonstrated'by several a u t h o r i t i e s 2 ' 4 ' 7 ' " · 2 0 · 4 8 and has been crystallised by vetter5'1· when he stated that "gestures are language". however, speech pathologists have, for a long time, recognised speech as the only "true form" of language in the aphasic population. in the desire to elicit verbal communication, the clinician frequently overlooks the aphasic patient's need to communicate in some fashion.19·48 the present study was concerned with an aspect of non-verbal communication, namely, gesture and piantomime, which will be used the south african journal of communication disorders vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 1 at gesture and pantomime in aphasia svnonomously to refer to a condition in which a person uses a series of s e q u e n t i a l manual movements, in the absence of speech, in an apparent attempt to communicate.43 a number of experimental studies on non-clinical populations17'222 3 ' 2 5 ' 2 6 ' 2 8 have suggested that a strong relationship exists between speech and manual motor activity. for example, kimura22' 23>24' 5<26 has attributed he relationship to the neural overlapping of cerebral areas which control speech and gesture and has further suggested that both gestural and speech activity are sub-classes of a more general mechanism for the control of sequentially organised motor activity. within this theoret.ca framework, kimura2 5 has derived and validated the proposition that aphasia and gestural disturbance are related. a considerable body of literature dealing with a p h a s i c 1 ' 1 0 ' 1 2 ' a n d deaf aphasic p o p u l a t i o n s 5 ' 9 ' 2 5 ' 4 5 ' 4 9 has further supported the idea of a relationship between speech and manual communicative behaviour for example, goodglass and kaplan1 5 have suggested that gestural deficit s e essentially ipraxic disturbances. however liepman's concept of ideamotor apraxia suggests the existence of an ideat.ona component in addition to an essentially apraxic component. there are also a^number of fairly extreme ideational theories which have viewed gesture and pantomime as part of a general asymbolia25 or in terms of a generalised non-specific intellectual deficit.15 the close relationship between gesture and speech has also been conceptualised within an evolutionary and ontogenetic framework. the work of hewes19 has lent considerable credence to the hypothesis that a manual communicative system developed prior to the vocal communicative system in a phylogenetic sense. from an ontogent.c point ol view mcniell37 has stated that gestures appear during piaget s sensory m o t o r operational stage. mcniell cites as evidence the fact that during the holophrastic stage utterances are typically produced together with an ongoing action. the nature of the present study required that a formal distinction be made between the recognition of gesture (receptive gesture) and performance of gesture (expressive gesture). receptive gesture is regarded as distinct from the afferent control of gestural praxis at a k i n e s t h e t i c level and "receptive gesture" is here regarded as a visuoperceptive phenomenon. in· more exact terms, receptive gesture involves the perceptual recognition of sequentially occunng manual postures within a visuospatial system of coordinants, and the translation of this perception into a symbolic system. within the theoretical system of luria,31 receptive gesture involves the translation of sequential recognition processes into instantaneous recognition and their incorporation into a simultaneously perceived logical scheme to he extent that this holds true, receptive gesture is subserved by the secondary occipital cortex, parietal cortex and temporo-paneto-occ.p.tal functions, the structures representing luna s second functional unit. die suid-afrikaanse tydskrif vir kommunikasieafwykings. vol. 25. 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 104 jocelyn kadish because receptive gesture involves both analytic and synthetic perceptual processes it would appear to depend on both left and right cerebral hemispheres. expressive gesture may be defined as the encoding of information transmitted via the use of sequential motor movements which are superimposed on manual postures and are unaccompanied by speech therefore, expressive gesture may be conceptualised as a phenomenon which is subordinated to the demands of goal directedness and symbolic processes.3' it is therefore essentially dependant on the integrity of luna's third functional unit which is comprised of the frontal and prefrontal motor systems.31 to the extent that gestural praxis is brought into correspondence with symbolic or prepositional constraints, it is also dependant on the integrity of the parietal tertiary corteses. the prepositional and temporal nature of expressive gesture suggests its dependance upon the left hemisphere. this conceptualisation of receptive and expressive gesture within luria's neuropsychological framework forms the basis for the present research and contains several implications for a clinical approach to aphasia. the major aims of the present study were to examine the relationship between gestural deficit and integrity of neuropsychological systems as determined by means of luria's neuropsychological investigation3 and to examine the relationship between gestural deficit and severity of aphasic disturbance. a subsidiary aim was to explore possible relationships between residual intellectual efficiency and gestural competence. method subjects (ss) six aphasic patients of varying etiology and severity were selected on the basis of the following criteria:ss were to 1. have been diagnosed as aphasic by a neurologist and speech therapist this was to be further confirmed by a formal rating on the boston diagnostic test of aphasia.16 2. have suffered their cerebral insults at least six months prior to testing and were thus regarded as neuropsychological^ s t a b l e . 8 ' 4 5 ' 5 2 3. be native speakers of the english language. 4. show no evidence of sensory deficits in the auditory, visual and tactile modality. / 5. come from similar cultural backgrounds and have 'a minimal educational level (std. 8). 6. have passed two preliminary screening tests adapted from pickett4 3 which determine abilities in recognition and naming of objects and tactile-visual matching tasks prerequisites for the gesture tests to be used in the present study. description of subjects see table i for relevant clinical and biographical the south african journal of communication disorders, vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gesture and pantomime in aphasia 105 ss age mean age age range sex education level home language premorbid occupation occupation changed due to illness laterality hemiplegia pathology si s2 48,1 46,4 57,83 46 years 4 months to 70 s3 6,3 s4 59,11 f std. f μ university degree ε civil maniengineer curist years 2 months f f std. 8 std.i r ν (recovered) trauma followed by removal of tissue due to infection r r vascular arteriosclerosis in carotid artery. hypercholesterolmic saleslady r r i) loss of sensation ii) oral apraxia months post onset therapy at ambulant recovered r side y 37 sp. & h. clinic y 36 sp. & h. clinic r side s5 70,2 μ matric cerebro vascular accident varied. saleslady collector ν collector r ν (recovered) aphasia cerebral thrombosis followed by absces in left inferior carotid artery. surgery resulted in right hemiparesis r side ν 168 company director l r vascular arteriosclerosis etiology: hypertension j.g. stryd sp. & h. hospital clinic s6 59,6 f matric typist bookkeeper r r cerebrovascular accident r side y 7 bramley old age home ν r side y 99 sp. & h. clinic key: μ = male l = left f = female y = yes ε = english ν = no r = right table l. relevant biographical and clinical information pertaining to the subjects (ss). testing the following tests were administered :1. gesture and pantomime tests, adapted from pickett. this test was selected from currently available t e s t s 1 0 ' 1 2 ' 1 5 ' 4 3 ' 4 4 as it die suid-afrikaanse t y d s k r i f vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 106 jocelyn kadish tests both comprehension and expression of gesture; makes use of homogeneous items between tests; capitalises on all sensory modalities to elicit performance and hence eliminates the contamination of an impaired sensory modality on performance potential; and, allows for verbal as well as non-verbal means of communication in giving the instructions and hence facilitates optimal comprehension about the nature of the task. description of gesture tests: each test was centred around 10 commonly used homogeneous objects, contained in the porch index of communicative ability.43 two test items were modified so as to render them suitable for the south african population. the tests were graded in order of extent of information given about the test. ss were cautioned not to talk during the administration of the tests. gestural test 1 (gl) — expressive: ss were presented with a picture of an object and were required to pantomime the function. gestural test 2 (g2) expressive: ss were given the actual object to use in pantomime. gestural test 3 (g3) — receptive: ss were presented with pictures of persons in postures associated with the function of the test objects and were required to point to the appropriate object. gestural test 4 (g4) — expressive: ss were given auditory instructions to pantomime. gestural test 5 (g5) — receptive: the ε pantomimed the functions of each object, and the ss were required to point to the appropriate object. gestural test 6 (g6) — imitative: the ε pantomimed the functions of an object, and subsequently, the ss were required to imitate the e. 2. luria's neuropsychological investigation.3 this was administered so as to yield a measure of functioning at various neuropsychological levels; to localise the lesions of each subject; and, to gain an understanding of the basic factors upon which gesture depends and the critical structures involved. the following subtests were selected on the basis of their relevance to this study:z 7 (i) motor functions , (ii) acoustico-motor organisation (iii) higher cutaneous and kinaesthetic functions (iv) higher visual functions (v) impressive speech (vi) expressive speech ' (vii) mnestic processes 1 the south a frican journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gesture and pantomime in aphasia 107 in addition, two total scores were obtained for visuo-spatial functions and dynamic organisation since it was hypothesized that these functions are involved in receptive and expressive gesture, respectively. the totals of the following subtests were used to yield the two measures. (viii) visuo-spatial functions: kinaesthetic basis of movement optico-spatial organisation of the motor act stereognosis objects and picture recognition spatial orientation intellectual operations in space form recognition size contrast effects immediate reproduction of visual, acoustic, kinaesthetic and verbal traces (ix) dynamic organisation: dynamic organisation of the motor act oral praxis speech regulation of the motor act scoring a set of optimal criteria (optimality range) was drawn up for each of the 44 subtests. a score of 1 was assigned to each optimal criterion which corresponded to the s's performance e.g. for the subtest entitled opticospatial organisation, 4 optimal criteria were drawn up:(i) muscle power and tone (ii) accuracy of movements (iii) symmetry (iv) immediacy of response thus, a s who performed within this range would get a score of 4. the optimality ranges were compiled on the basis of christenson3 and luria.30 3. boston diagnostic test of aphasia.16 to obtain an unequivocal diagnosis of aphasia and an objective severity.rating of the ss' linguistic abilities. 4. the performance scale of the "wechsler adult intelligence scale.52 to yield a measure of performance i.q., the latter defined as a deviation score on the wechsler adult intelligence scale. results and discussion the principle statistical analysis applied to the present data was the spearman rank order correlation coefficient and the associated tests of significance.35 because of the small number of subjects involved in the present study, apparently high correlations may be non-significant and further, the non-significant correlations cannot be interpreted in a totally die suid-afrikaanse t y d s k r i f vir kommunikasieafwykings, vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 108 jocelyn kadish unambiguous fashion. hence, only those correlations which were significant were interpreted as reflecting a systematic relationship and the non-significant correlations, no matter how high the r value, were interpreted as being no different from zero. gesture the scores obtained on the gesture tests are represented in table ii. table iii represents the matrix of intercorrelations between the gesture tests. the findings presented in table iii suggest that a gestural impairment encompasses a deficit which incorporates the manipulation of real and pretended objects. the deficit clearly extends from the level of the formulation of a motor sequence to the execution of that sequence, and additionally involves imitation. the significant correlation coefficients obtained between receptive (g3; g5) and expressive (gl) gesture tests suggests the existence of a general underlying process which represents gestural competence, i.e. reception and expression seem to be part of a continuum as opposed to being dichotomous alternatives. receptive expressive gesture gesture st 20 463 52 20 453 53 17 404 54 20 476 55 7 118 56 20 417 ν maximum score 20 480 table ii. scores obtained on receptive and expressive gesture tests for all ss. g1(e) g2(e) g3(r) g4(e) g5(r) g6(l) (e)g1 0,81426» 0,857143* 0,942857» 0,857143» 0,942857* (e)g2 0,58714 0,9* 0,585714 0,671429 (r)g3 0,714286 1» 0,914286* (e)g4 0,714286 0,885714* (r)g5 0,914286* (1)g6 key: ε = expressive gesture ' r = receptive gesture * = significant correlation ( r s 0,829: ν — 6; ρ 0,05). spearman correlation coefficient of at least 0,829 is required for significance (p = 0,05) when ν = 6. 1. — imitation j table iii. spearman rank-order intercorrelation coefficients between the six gesture tests. the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gesture and pantomime in aphasia a ε s o cx υ χ cx ω ι λ cx υ s ο. « cλ • g o < 2 _ ο g s ' l .a μ 5 c q..7 3 ** [λ ui ' s e 5 ο ο qo 3 00 o" o" 00 o" 00 ο ο β 1) u u1 q. <λ (u u u os ο ω ο cn cn rrt o t o 00 00 cn cn s s ο ο to — vo ο ω υ υ υ ' π ora qu a υ > g cx * cx u •s " >. > 8q < die suid-afrikaanse t y d s k r i f vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 110 jocelyn kadish neuropsychological functions and gesture. although a general gestural competence has been postulated, it is nevertheless true in terms of the model proposed that they are dependant on separate neurological subsystems and therefore the question of whether they are dependant on different neuropsychological functions becomes relevant. spearman rank-order correlations were obtained between gesture (receptive and expressive respectively) and several neuropsychological functions as tested on luria's neuropsychological investigation.3 (see table iv). the findings suggest that receptive gestural ability is closely and differentially related to visuo-spatial functioning and mnestic ability. there is therefore an association between receptive gesture and the various perceptual processes which are dependant upon luria's unit 2 i.e. the posterior secondary and tertiary corteses.30 this finding then suggests that receptive gesture, in common with other perceptual processes, is similarly dependant on unit 2. in terms of the present framework, the absence of a correlation between expressive gesture and dynamic organisation and acousticomotor organisation, respectively, is surprising since gesture is often regarded as a form of praxis.3 0'3 1 however, it is clear that future research is required to elucidate this problem. case studies detailed results obtained from tests administered for each subject are summarised in table v. although detailed case studies formed a large part of the present study, it is not within the scope of this paper to discuss them in depth. for the purposes of this article, only one case will be presented in terms of what is directly relevant to the stated aims. subject 2 (s2) (a) s2 showed symptoms indicative of a lesion of the posterior frontal or fronto-temporal areas of the left hemisphere, manifesting as symptoms typical of "transcortical aphasia"3 3 i.e. difficulty in connected motor speech, breakdown occurring when extent of repetition is broadened to several words, difficulty in the smooth transition between words, and symptoms of pathological inertia.3 furthermore, there was evidence of a breakdown in "kinetic melodies"32 of motor skills, writing difficulties and confusion between articulemes, all of which were suggestive of a lesion of the lower portion of the premotor zone.32 while simple motor functions of the hands seemed unimpaired, the latter lesion seemed to manifest in apparent difficulties in the dynamic organisation of movement functions. s2 performed well on acoustico-motor functions, cutaneous and kinaesthetic functions and mnestic processing tests, (the latter corresponding to an "average" performance iq of 100) which suggests intact functioning of the posterior regions of the brain. the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gesture and pantomime in aphasia 111 receptive tests gesture language neuropsychological functions visuomnestic acouscutaneous spatial processticoand organiing motor kinestic sation percepperception tion si 20 23 26 27 6 17 s2 20 35 29 27 10 19 s3 17 21 18 4 2 12 s4 20 23 31 20 7 18 s5 7 2 15 4 4 7 s6 20 24 31 14 8 18 maximum 10 19 score 20 42 45 31 10 19 x = 17,3 expressive tests gesture language neuropsychological functions motor dynamic acoustico functions organimotor of hand sation performance si 463 37 16 26 12 s2 453 48 18 29 13 s3 404 3 17 18 3 s4 476 36 17 31 10 s5 118 13 6 15 3 s6 417 45 13 31 13 maximum 13 score 480 58 22 44 13 x = 338,5 tests subjects performance scale of the wechsler adult intelligence scale si s2 s3 s4 s5 s6 110 100 28 96 32 89 boston diagnostic aphasia test severity rating 3 3 0 3 1 2 t a b l e v. scores obtained for gestural, linguistic and neuropsychological tests, on receptive and expressive levels respectively, in addition to performance iq, and severity rating. die suid-afrikaanse t y d s k r i f vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 112 jocelyn kadish (b) the areas implicated above seemed to overlap with those presumed to subserve expressive gesture, while the posterior cerebral areas concerned with receptive gesture appeared intact. hence, it may be predicted that some difficulty on expressive gesture would be evident, associated with no apparent receptive gesture difficulties. (c) as demonstrated in table iv, scores yielded by the gesture tests confirmed the above i.e. a score of 453 out of a maximum score of 480 obtained for expressive gesture, while a score of 20 out of a maximum of 20 obtained for receptive gesture. summary of case studies 1. dynamic localisation of a lesion affords one the opportunity to predict a s's receptive and expressive ability on gestural tasks. (a) lesions of the posterior divisions of the cerebral cortex invariably manifest as an impairment on receptive gesture tasks. this was clearly evident in si, s3 and s5. (b) lesions of the anterior divisions of the brain result in expressive gestural impairments as was the case in all ss. 2. the relation between verbal language and gesture was demonstrated in that all ss manifested concomitant deficits on both receptive and expressive levels. 3. for all subjects, performance on verbal language tests was superior to that on gestural tests. gesture and speech a significant correlation coefficient was obtained for impressive speech and receptive gesture (r s = 0,8714286; ν = 6; ρ 0,05). this has been supported by several authorities all of whom attributed the relationship to an underlying communication breakdown. 1 0 ' 4 3 however, within a neuropsychological framework the results assume another ' dimension. according to luria,30 the areas of the brain subserving impressive speech include posterior-superior and middle zones of the left temporal region, temporo-occipital and temporo-parieto-occipital zones of the left hemisphere. the latter two areas were found, in the present study, to be a part.of the mechanism responsible for the comprehension of gesture. thus speech and gesture, on a receptive level, appear to have a similar neurological basis. κ at an expressive level, the absence of a relationship between gesture and speech is not consistent with the framework proposed here and again must be a subject of future research. an important finding of the present study was that gestural language suffers considerably less than does verbal language, on both receptive and expressive levels, irrespective qf the severity of the aphasia. this contrasts with those of duffy et al1 0 who found inferior performance on pantomime recognition tests irre'spective of whether they were pathological or not. the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gesture and pantomime in aphasia 113 the sparing of gestural communication relative to the verbal counterpart may be viewed in a number of ways: firstly, in terms of the ontogenetic framework proposed by mcnielf and hacean1 8 aphasia may be viewed as a regression to piaget's sensori-motor stage. this theory would lend support to "ribot's rule" which states that in the dissolution of aphasia the last acquired functions are first to be involved, while the first acquired, offer the greatest resistance to extinction.42 a second interpretation, although somewhat less plausible than the first one, may be derived from the socio-cultural evolutionary framework proposed by hewes19 which hypothesises that gesture occurs earlier in the evolutionary sequence than speech or independently of speech. in this context, aphasia may be viewed as a regression to an earlier phylogenetic stage. finally, one may view this finding in terms of minkowski's principle38 that stressed the "affectional, psychological and emotional" background of language and suggested that language supporting emotional content will recover best. this seems particularly relevant to the language of gesture which has been reported to be an important vehicle for the transmission of emotionally charged information.2 residual intellectual capacity and gestural ability intellectual efficiency can no longer be ignored as a factor which contributes to the capacity to perform gesture and pantomime,15 spearman rank-order correlation coefficients obtained between scores yielded by the performance scale of the wechsler adult intelligence scale53 and receptive and expressive gesture respectively failed to reach the 0,05 level of significance. (r = 0,8; ν = 6; ρ 0,05) and (r s = 0,7714286; ν = 6; ρ 0,05). this suggests that performance on the intelligence test did not predict gestural ability, either receptively or expressively. however, these results must be viewed with caution since it is important to bear in mind the criticisms levelled against the reliability of non-verbal intelligence tests when applied to the brain damaged p o p u l a t i o n . 3 6 ' 4 3 ' 5 0 aphasia and gesture defining a gestural deficit as part of an aphasic communication disorder requires that it be correlated with the severity of aphasia.spearman rank-order correlation coefficients computed between severity of aphasia and receptive and expressive gesture respectively were significant: (r = 0,8571429; ν = 6; ρ 0,05) (r s = 0,8857143; ν = 6; ρ 0,05). this finding suggests that a gestural impairment is a component of the aphasic syndrome and concurs with findings by duffy et al1 0 and pickett.43 however, the latter authors regarded gesture and aphasia to be related on a linguistic or cognitive level, through symbolism or representation. on the basis of criteria enumerated by goodglass and kaplan1 5 and within the present framework, the findings seem to lend credence to the following suggestions:die suid-afrikaanse t y d s k r i f vir kommunikasieafwykings, vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 114 jocelyn kadish 1. the notion of a complex sequential motor movement disorder was not supported by results of the present study, and the tentative nature of the present finding does hot allow a definitive interpretation with respect to this relationship. however, this conclusion receives some support from the fact that (a) there was a strong relationship between formulation of gestures and expression of gestures which was not accounted for by the verbal impairment and (b) there was a relationship between manipulation of real objects in addition to pretended ones which, according to goodglass and kaplan1 5 conforms to the definition of a movement disorder. in the light of these findings, the notion of asymbolia seems unlikely but can not be entirely discounted. 2. the close associations found between impressive speech and receptive gesture, from statistical analysis as well as from case study data, suggests that these two functions are dependant on common underlying neurological substrate. however, this interpretation cannot as yet, in terms of the present findings, be extended to expressive gesture and expressive speech. at an expressive level, no association was found between speech and gesture on statistical analysis, even though a positive relationship was found in the case studies. the finding of a strong relationship between verbal language and gesture in general, supports the idea of a common underlying neurological substrate. moreover, the evidence relating to overlapping areas of brain function involved in visuo-spatial functioning, mnestic processes, impressive speech and receptive gesture and the evidence that a lesion of the left cerebral cortex manifested in concomitant expressive verbal language and expressive gestural language impairments, further served to render this hypothesis compelling. finally, the relationship between severity of aphasia and gestural ability, may also serve as evidence for this conclusion. conclusion the neuropsychological approach adopted served to highlight the reliance of receptive and expressive gesture on certain areas of the brain. 1. receptive gesture subserved by the posterior regions of the brain encompassing the secondary occipital cortex, occipitoparietal cortex, parieto-temporal and temporo-parieto-occipital area. hence receptive gesture appears to be linked with luria's second functional unit.31 2. expressive gesture subserved by the anterior regions of the brain, incorporating the basal areas of the cerebral cortex, postcentral regions, premotor divisions and frontal systems. hence this seems to involve luria's third functional unit of the cerebral cortex.31 the conclusion that a gestural impairment is a part of the aphasic syndrome would necessitate a broader view of aphasia than many the south african journal of communication disorders, vol.25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gesture and pantomime in aphasia 115 authorities present.1 0 in addition, the need for a revised conception of the neurological basis of language was indicated. in conclusion however, the present results must be regarded as tentative and further research employing larger samples is indicated. if the hypotheses suggested here are supported by future research, intervention strategies involving gesture may become a valuable part of the therapy regime. references 1. alajouanine, t. and lhermitte, f. (1963): non-verbal communication in aphasia. in disorders of language. de reuch, a. and o'conner, m. (eds.), boston: little, brown. 2. bates, j.a.v. (1975): the communicative hand. in the body as a medium of expression: essays in social studies. benthall, j. and polhemus, t. (eds.), penguin books ltd. london. 3. christenson, a. (1974): luria's neuropsychological investigation. (text and manual) munksgraad. 4. cicourel, a.v. (1975): gestural-sign language and the study of nonverbal communication. in the body as a medium of expression: essays in social studies. benthall, j. and polhemus, t. (eds.), penguin books ltd. london. 5. critchley, m. (1938): aphasia in a partial deafmute. brain, 61, 163169. 6. critchley, m. (1939): the language of gesture. arnold, london. 7. crystal, d. (1975). paralanguage. in the body as a medium of expression: essays in social studies. benthall, j. and polhemus, t. (eds.), penguin books ltd. london. 8. culton, g.l. (1969): spontaneous recovery from aphasia. j. speech hear. res., 12, 825-32. 9. douglass, e. and richardson, j.c. (1959): 'aphasia' in a congenital deaf-mute. brain, 82, 68-80. 10. duffy, r.j., duffy, j.r. and pearson, l.k. (1975): pantomime recognition in aphasics. j. speech hear. res., 18, 105-114. 11. egolf, b.d. and chester, s.l. (1973): non-verbal communication and the disorders of speech and language. asha 15, 511-518. 12. gainotti, g. and lemmo, m.a. (1976): comprehension of symbolic gestures in aphasia. brain and language 3, 451-460. 13. gainotti, g. and tiacci, c. (1971): the relationship between disorders of visual perception and unilateral spatial neglect. neuropsychologia, 9, 451-459. 14. gardner, r.a. and gardner, b.t. (1969): teaching sign language to a chimpanzee. science, 165, 664-672. 15. goodglass, h. and kaplan, e. (1963): disturbance of gesture and pantomime in aphasia. brain, 86, 703-720. 16. goodglass, h. and kaplan, e. (1972): the assessment of aphasia and related disorders. lea and febiger, philadelphia. 17. goodglass, h. and quadfasel, f.a. (1954): language laterality in left-handed aphasics. brain, 77, 521-548'. die suid-afrikaanse t y d s k r i f vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 116 jocelyn kadish 18. hacean, h., de ajouriaguerra, j. and angelergues, r. (1963): apraxia and its various aspects. in problems of dynamic neurology: studies of the higher functions of the human nervous system. halpern, l. (ed.). department of nervous diseases, rothschild hadassah university hospital and the hebrew university hadassah medical school, jerusalem. israel, pp 217-230. 19. hewes, g.w. (1973): primate communication and the gestural origin of language. current anthropology, 14, 5-24. 20. hinde, r.a. (1975): t h e comparative study of non-verbal communication. in the body as a medium of expression: essays in social studies. benthall, j. and polhemus, t. (eds.), penguin books ltd. london. 21. kellog, w.n. (1968): communication and language in the homeraised chimpanzee. science, 162, 423-427. 22. kimura, d. (1973 a): manual activity during speaking — i. righthanders. neuropsychologia 11, 45-50. 23. kimura, d. (1973 b): manual activity during speaking — ii. lefthanders. neuropsychologia 11, 51-55. 24." kimura, d. (1973 c): the assymetry of the human brain. scientific american, 228, 70-78. 25. kimura, d. (1976): the neural basis of language qua gesture. in studies in neurolinguistics. whitaker, h.a. and whitaker, h.a., (eds.). vol ii. academic press, new york. , 26. kimura, d. and archibald, y. (1974): motor functions of the left hemispheres. brain, 97, 337-350. 27. kimura, d. battison, r. and lubert, b. (1976): impairment of nonlinguistic hand movements in deaf aphasics. brain and language, 3, 566-571. 28. kimura, d. and vanderwolf, c.h. (1970): the relation between hand preference and the performance of individual finger movements by left and right hands. brain, 93, 769-774. 29. kortlandt, a. (1973): discussion of paper by hewes, g.w. primate communication and the gestural origin of language. current anthropology. 14, 13-14. 30. luria, a.r. (1970): traumatic aphasia — its syndromes, psychology and treatment. mouton press. the hague. 31. luria, a.r. (1973): the working brain. allen lane, the penguin press books. 32. luria, a.r. (1974): language and brain: towards the basic problems of neurolinguistics. brain and language, 1, 1-14. / 33. luria, a.r. and hutton, j.t. (1977): a modern assessment of the basic forms of aphasia. brain and language, 4, 129-151. 34. mateer, c. and kimura, d. (1977): impairment of nonverbial oral movements in aphasia. brain and language, 4, 262-276. 35. mccall, r.b. (1970): fundamental statistics for psychology. harcourt, brace and world, international edition. 36. mcfie, j. and piercy, m. (1952): intellectual impairment with localised cerebral lesions. brain, 75, 292-311. the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gesture and pantomime in aphasia 117 37. mcneill, d. (1976): semiotic extension. in information processing and cognition. solso, r.l. (ed.) chap. 11. the loyola symposium, usa. 38. minkowski, m. (1963): on aphasia in polyglots. in problems of dynamic neurology: studies on the higher functions of the human nervous system. halpern, l. (ed.). department of nervous diseases rothschild hadassah university hospital and the hebrew university hadassah medical school, jerusalem, israel, pp 119-161. 39. moscovitch, m. (1976): on the representation of language in the right hemisphere of right-handed people. brain and language, 3, 47-71. 40. olson, d.r. (1970): cognitive development: the child's acquisition of diagonality. academic press, london. 41. piaget, j. (1962): play, dreams and imitation in childhood. norton, new york. 42. pick, a. (1973): aphasia. translated and edited by brown, j.w., charles c. thomas publisher, usa. 43. pickett, l.w. (1974): an assessment of gestural and pantomimic deficit in aphasic patients. acta symbolica, 5(3), 69-86. 44. porch, b.e. (1967): porch index of communicative ability (volumes i and ii). consulting psychologists press. palo alto, california. 45. sands, e., sarno, m.t. and shankweiler, d. (1967): long-term assessment of language function in aphasia due to stroke. arch. phys, med, rehab., 50, 202-206. 46. sarno, j.e., swisher, l.p. and sarno, m.t. (1969): aphasia in a congenitally deaf man. cortex, 5, 398-414. 47. sarno, m.t., silverman, m.g. and sands, e.s. (1970): speech therapy and language recovery in severe aphasia. j. speech hear. res., 13, 607-23. 48. schlanger, p.h. and schlanger, b.b. (1970): adapting role-playing activities with aphasic patients. j. speech hear. dis., 35, 229-235. 49. tureen, l.l., smolik, e.a. and tritt, j.h. (1951): aphasia in a deaf mute. neurology, 1, 237-244. 50. vega, a. jr. and parsons, o.a. (1963): relationship between sensory-motor deficits and w.a.i.s. verbal and performance scores in unilateral brain damage. cortex, 5, 238-240. 51. vetter, j.h. (1969): language behaviour and communication. f.e. peacock publishers inc., illinois. ch. 14. 52. vignolo, l.a. (1967): evolution of aphasia and language rehabilitation; a retrospective exploratory study. cortex, 1, 344-67. 53. wechsler, d. (1955): the wechsler adult intelligence scale. the psychological corporation, new york. 54. wiener, m„ devoer, s., rubinow, s. and geller, j. (1972): nonverbal behaviour and non-verbal communication. psychological review, 79(3), 185-214. 55. wepman, j.m. (1976): language without thought or thought without language. asha 18(3), 131-136. die suid-afrikaanse t y d s k r i f vir kommunikasieafwykings vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) selected acoustic characteristics of emerging esophageal speech: case study glenn binder, b.a. (sp. & η. th.) (witwatersrand) dept. speech pathology and audiology, university of the witwatersrand, johannesburg. summary the development of esophageal speech was examined in a laryngectomee subject to observe the emergence of selected acoustic characteristics, and their relation to listener intelligibility ratings. over a two-and-a-half month period, the data from five recording sessions was used for spectrographic and perceptual (listener) analysis. there was evidence to suggest a fairly reliable correlation between emerging acoustic characteristics and increasing perceptual ratings. acoustic factors coincident with increased intelligibility ratings appeared related to two dimensions: firstly, the increasing pseudoglottic control over esophageal air release; secondly the presence of a mechanism of pharyngeal compression. increased pseudoglottic control manifested in a reduction of tracheoesophageal turbulence, and a more efficient burping mode of vibration with clearer formant structure. spectrographic evidence of a fundamental frequency did not emerge. these dimensions appeared to have potential diagnostic and therapeutic value, rendering an analysis of the patient's developing vocal performance more explicit for both clinician and patient. opsomming die ontwikkeling van esofagale spraak is ondersoek in 'n gelaringektomeerde geval om die voorkoms van geselekteerde akoestiese eienskappe waar te neem, en hulle verhouding tot luisteraar-verstaanbaarheids-beoordelings. gedurende 'n twee-en-'n-half-maand periode, is data van vyf opname sessies gebruik vir spektrografiese en luisteraar-analise. daar is bewyse vir die daarstelling van 'n redelik betroubare korrelasie tussen die akoestiese eienskappe wat te voorskyn kom en die verhoogde perseptuele beoordelings. akoestiese faktore wat saam val met verhoogde verstaanbaarheids beoordelings blyk verbind te wees ten opsigte van twee aspekte: eerstens, die verhoogde pseudoglottiese beheer oor esofagale lugvrylating; tweedens die teenwoordigheid van 'n meganisme van faringale samepersing. verhoogde pseudoglottiese beheer het 'n afname van trageo-esofagale turbulensie tot gevolg, en 'n meer doeltreffende wind-opbreek metode van vibrasie met 'n duidelike formantstruktuur. spektrografiese bewyse van 'n grondtoon het nie te voorskyn gekom nie. dit blyk dat hierdie aspekte 'n potensiele diagnostiese en terapeutiese waarde het, met die moontlikheid van 'n duideliker analise van die pasient se ontwikkelende vokale prestasie vir die terapeut en pasient. esophageal speech is one of two alternative methods of functional postlaryngectomy rehabilitation. investigators over the past few decades have realised the importance of testing its efficacy both subjectively and objectively — one of the more recent objective methods being the use of spectrographic a n a l y s i s . 2 ' 5 ' 6 ' 7 ' 1 0 ' " ' 13>j17>28>29 the purpose of this article is a) to discuss how spectrographic analysis may be used as a diagnostic and therapeutic tool, and also b) to examine the relationship between subjective and objective data obtained. the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) emerging esophageal speech 25 it would be interesting to follow the development of speech from a mechanism that at first is halting, and seemingly acquires a great deal of effort to produce faltering sounds, to the effortless smooth production of sustained speech,4 despite brooks hunt and va's4 valid comment, more than a decade has passed with a dearth of information available on the developmental aspects of esophageal speech acquisition. the importance of measuring a laryngectomized patient's progress in treatment has likewise been stressed by very few writers.3'3 1 however, in the general field of vocal pathology, more recent impetus has been provided by rontal, rontal and rolnick20 who have advocated the use of serially-made spectrograms. these would provide the referring ear nose and throat specialist, clinician and patient with a visual display reflecting the nature of the vocal rehabilitation process. the value of assessing rontal et al's20 finding specifically in the progression of esophageal speech development, was strongly indicated. the paucity of literature with regard to the acoustic and perceptual developmental aspects of esophageal speech acquisition is apparent. the establishment of a description of emerging acoustic characteristics correlated with subjective listener ratings, would be of diagnostic, prognostic, and therapeutic value. it would provide the speech therapist with objective, quantitative criteria against which each laryngectomee's esophageal speech development could be assessed. furthermore, the understanding of the relationship between the emerging dimensions would facilitate a more explicit approach to therapy for both clinician and client. the term 'esophageal speech' refers to speech production resulting from an air supply from the vicarious air chamber located within the esophageal lumen. the cricopharyngeus has been localized as the pseudoglottic site. t h e outflowing air is interrupted by crude pseudoglottic vibrations which alternatively open and close the esophageal lumen. the kay sonograph has been used to provide spectrograms which permit an objective, reliable analysis of the phonetic — acoustic elements of esophageal speech. the sonograph provides: a) narrow-band displays in which harmonic structure is highlighted, and b) broad-band displays which highlight formant structure (represented as dark, thick vertical bands). formants are resonances of the supraglottal vocal tract, 'upon which the distinctive quality of vowels and resonant consonants depend.' 9 (see figure 5, 5-9, and 11-14, a and c, along the horizontal and vertical axes respectively). kerr and lanham9 have used broad-band spectrograms to analyze esophageal speech, and have described the following phenomena which have been corroborated by other investigators:10' " ' l 3 ' 2 9 parameter i: vibratory cycles resulting from the manner of esophageal sphincter control over air release. a. rapping: a term used by kerr and lanham9 to refer to the slow, irregular, rap and tap-like pulses received by the vocal tract functioning die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol.25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 glenn binder as a resonating system. (see figure 6, 1,8,9,10,11,17,18,19 along the horizontal axis). b. esophageal burping: the raps smooth out into a succession of air puffs more rapid and regular, and lower in amplitude . . . still lacking in harmonic structure.9 these more rapid cricopharyngeal vibrations facilitate the emergence of a clearer formant structure (see figure 3, 611, a and b, along the horizontal and vertical axes respectively). c. friction noise: this random, aperiodic ill-defined turbulence emanates from the more or less open esophageal sphincter. friction noise has been found to play a major role in producing quality changes 9 ' 1 0 (see figure 6, 20-22 along the horizontal axis). d. possible absence of fundamental frequency: fundamental frequency is the physical correlate of pitch perception,1 0 and is a measure of the frequency of components of periodic waves. despite reference made to the low pitch of esophageal s p e e c h , 2 ' 5 ' 6 · 2 5 ' 2 < " 2 8 ' 2 9 confusions are prevalent in spectrographic findings related to fundamental frequency characteristics of esophageal speakers. lanham and kerr1 3 have suggested that these confusions have arisen from a failure to recognize that a measurable fundamental frequency is often lacking13 in esophageal speech. hence, the need to examine approximate vibratory rates, as opposed to fundamental frequency is apparent. e. other less obvious vibratory features: (i) vibration of the tone is more rapid at the onset of phonation, and slows down as the amount of air in the . esophagus decrease; (ii) the opposite phenomenon to (i) (occuring more rarely10), where subglottic vibrations increase; and (iii) pseudoglottic vibrations may cease for a moment, and then continue at a slower rate than before, thus splitting the word or vowel into two parts.1 0 parameter ii: variables dependent upon degree of neuromuscular control, and affecting periodicity of vibrations: a. sound caused by air intake into the esophagus (swallowing noise): spectrographically the energy in swallowing is fairly evenly distributed over the entire frequency scale. its presence represents what the writer referred to as an 'esophageal click' i.e. one considerably intense pulse (rap) followed by a gap of relative silence prior to the onset of phonation. (see figure 1, 9 and l l i along the horizontal axis). b. leakage of air from the mouth of the esophagus: this may occur prior to and in anticipation of the onset of voicing, and is indicative of an inadequate neuromuscular mechanism (see figure 1, t-5 along the horizontal axis). c. tracheostomal (stomal) noise: this refers to the powerful expulsion of air accompanied by an undesirable murmur from the patient's tracheostoma. strong amplification may occur of those frequencies falling within the bandwidths of the resonators, resulting in horizontal, formant-like bands (see figure 1, a, along the horizontal axis). d. gurgling: this occurs auditorily before, during, a n d / o r after the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) emerging esophageal speech 27 phonation, and is commonly represented spectrographically by highly irregular wide-spaced raps (see figure 2, 22-38 along the horizontal axis). parameter iii: formant structure. a case study was therefore undertaken with the following aims: i. to identify the emergence over time of selected acoustic characteristics which might contribute to a description of the emerging features of esopheal phonation. ii. a further aim was to relate intelligibility ratings of developing esophageal speech to the emergence of these acoustic characteristics. s u b j e c t (s) the s was a 37 year old white portuguese-speaking male. he underwent a total laryngectomy in february 1977 after laryngoscopy biopsy had revealed the presence of widely infiltrating, poorly differentiated squamous cell carcinoma on both his vocal folds. total laryngectomy involved removal of the larynx from above, leaving the esophagus and cricopharyngeal muscles essentially intact. it was not necessary to perform a radical neck dissection. prior to the operation he was a healthy man, with no reported speech or hearing problems. criteria for selection: (a) the s was required to have undergone a laryngectomy operation and to have commenced speech therapy for the first time postoperatively. (b) he was to be capable of producing an esophageal sound involuntarily. this indicates the intactness of his mechanism for esophageal sound production, making an evaluation of his progress from this most basic level possible.3' (c) potential anatomical and physiological variables that could interfere with the s's development of esophageal speech had to be considered. thus, before testing commenced, the ear nose and throat surgeon who performed the laryngectomy was asked questions pertaining to medical information from the questionnaire for biographical, medical, social communication and speech training variables.22 (d) hearing was bilaterally within normal limits. therapy: therapy was administered by a fourth year undergraduate speech and hearing therapy student at the speech and hearing clinic, university of the witwatersrand. over a seventy-five day testing period, the s had received approximately 54 sessions of speech therapy. therapy was directed towards the development of esophageal speech as based primarily upon the work of berlin,3 and snidecor.27 methodology i t a p e r e c o r d i n g p r o c e d u r e s . a. a revox tape recorder was used to produce high quality recordings at random time intervals over a 2xk month testing period. during each recording session the s would read the following data: die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 glenn binder (i) a list of exercises which were constructed by the e. these were based upon snidecor's27 principles of a nine-stage plan of esophageal speech development. (ii) a further group of test words based upon the six groups of consonants found in the portuguese language. (iii) the s used only one overt inflation in repeating plosive syllables (da) as many times as possible. this was based upon berlin's3 measure of mean number of syllables per air charge. (iv) the s used only one inflation in repeating the following two sentences. a. the first sentence contained many liquids: («luisoc iu liunej^nccjeram ocm bcxriocnum o j p i t a j ) b. the second sentence contained an equal number of voiceless plosives: (paula i pejxuj.au muituf kocuj ikocj ojjuj emkasoc) the construction of these two sentences (by the' e), was based upon moolenaar-bijl's16'17 observation that some form of air conservation, or esophageal reinflation is accomplished by plosive consonants. (v) on the final recording session, the s read twenty unseen minimal pair words. b. on one occasion, a normal (laryngeal) portuguese-speaking s read and recorded the same set of stimuli (i) — (v), under the same testing conditions as the s. ii spectrographic/objective assessment: a kay sonagraph model 6061-b (kay elemetrics 6, pine brook, n.j.) was used to produce type b/65 broad-band spectrograms from the tape recordings. selection of speech samples and methods of spectrographic recording: note: several narrow band spectrograms were made of utterances produced by the s on the final session. however, these failed to show harmonic components of the complex speech signals, so that the data in the present study was derived from broad band spectrograms only. for practical reasons it was not possible to spectrographically analyze all the data recorded over the 75 day testing period. thus: (i) ninety-five broad band spectrograms were produced from a list of 19 words recorded by the s at 15 day intervals. these words were selected, as they constituted a representative sample of consonants in the portuguese language (eg. ( p e j ) , (bo'd°c), (lpik«), (doiz), (soblimu)). (ii) 20 broad band spectrograms were also obtained from the s's production of minimal pair utterances on the final recording session. (iii) 39 broad band spectrograms were likewise made of the normal s's recordings of the 19 words, and 20 minimal pair word list. the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) emerging esophageal speech 29 iii subjective perceptual assessment: perceptual ratings were made in the following manner: (i) a portuguese-speaking listener who did not know the s, and who was unaware of the nature of the experiment was asked to subjectively rate the intelligibility of all the data recorded by the s at each of the five recording periods selected for analysis. intelligibility of single utterances was determined by the number of correct responses made by the listener to the recorded speech stimuli. intelligibility of sentence material was rated on a five-point equal appearing interval scale. (ii) the ε was assisted by a phonetician in perceptually calculating the following data on each of the five recording sessions: (a) the mean number of plosive syllables (da) per overt inflation in five trials,3 and (b) t h e number of words per breath charge in the sentences constructed."" 17 although these measures were made, together with an evaluation of the relationship between the s's quantified performance over time on skills (a) and (b) above, the findings will not be discussed in the present article. iv phonetic analysis: a phonetician aided the ε in phonetically transcribing the 115 broadband spectrograms. this permitted a direct comparison of unusual auditory qualities perceived by the listener with the spectrographic correlates. results and discussion a. objective data. the analysis of spectrographic data was descriptive in nature. based on the work of several a u t h o r i t i e s 9 ' 1 0 ' " ' 1 3 ' 2 9 the development of the acoustic parameters i — iii and their related variables (described above), were examined in the data obtained in five recording sessions. however, for the purpose of this article, it will be sufficient to document the major changes that occurred in the utterance (bo'd°<) on sessions i and v, thereby highlighting the emergence of these parameters. spectrographic representations of utterances produced by the s on the first recording session (session ϊ) revealed the inadequacy of his neuromuscular mechanism in the following manner: figure i: spectrogram showing utterance (bo d <*): session i. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 glenn binder there was a prominence of random respiratory and tracheostomy turbulence over the whole of the visible frequency scale. resonance amplification created wide horizontal formants with ill-defined edges (see formant 2, figure j, 21-31 along the horizontal axis). the overriding turbulence made clear definition of most utterances virtually impossible. this turbulence appeared to be due to the s's attempts to produce louder, more intelligible speech. this resulted in a burst of outrushing stomal noise frequently louder than the concomitant esophageal voice. most utterances were characterized by several random pulses (raps) before, and immediately after, indicative of swallowing noise caused by air intake into the esophagus. gurgling noises were spebtrographically and auditorily prominent in several utterances (see figure 2 below, 2238, (til)). figure 2: spectrogram showing utterance (til) — gmvling snitnd. in contrast to the inconsistency that was a noticeable feature of the spectrographic displays of the s's utterances on the first recording session, spectrograms of utterances produced on the final recording session (session v) revealed the greatest consistency. this seemed to be due to the s's high morale, in conjunction with increased muscular control and co-ordination over his esophageal air release. figure 3. below reveals the presence of the burping mode of vibration, with considerable energy located in aperiodic components outside the pulses. according to kerr and lanham,1' and kytta,1" this turbulence is due to the probably incompletely interrupted airflow, characteristic of the burping vibratory mode. figure 3: spectrogram showing utterance (bo 'd°<): (session v). the south african journal of communication disorders, vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) emerging esophageal speech 31 the s's neuromuscular control still appeared insufficiently adequate and this in relation to an inadequate esophageal airflow, manifested spectrographically as follows: (i) widening of pulses were still evident at the end of utterances, disturbing the continuity of the generally clearly defined formant structure. (see figure 3, 13-14, where the rate of vibration is ~£ 36,99 per second, as compared with around 86,31 per second at 8-9). (ii) apparent air leakage from the esophageal mouth prior to (eg. figure 3, 1-3), and during certain of s's utterances. narrow band spectrograms (eg. see figure 4, below) made of several utterances revealed an absence of harmonic structure and measureable fundamental frequency. this appeared a characteristic feature of the s's low pitched esophageal phonation, which lanham and kerr1 3 have referred to as 'pitchless'. ι yigf figure 4: spectrogram (narrow) showing utterance (pe"). general developmental trends viewed spectrographically several interesting and significant developmental trends appeared to have emerged. the most marked feature throughout was one of inconsistency, postulated to be related partly to the s's neuromuscular, and psychological status at various points in time. a noticeable progression occurred from a rapping to a burping mode of esophageal sphincter vibration in which pulses became significantly more rapid and lower in amplitude. vibrations, however, were conspicuously lacking in the rapidity and periodicity reportedly found in superior esophageal, and laryngeal s p e a k e r s . 1 0 ' 2 0 ' 2 3 ' 2 9 compare the vibratory pattern in figure 3, above, with that in figure 5 below. figure 5: spectrogram showing utterance (bo'd ) of a laryngeal speaker. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 glenn binder generally, spectrographic evidence refuted the concept of fundamental frequency in esophageal phonatitfn. it revealed a vibratory pattern lacking in periodicity, and devoid of a harmonic structure. these measureable rates of irregular vibration appeared to be comparable to what investigators have measured in assessing the fundamental frequency of esophageal speech, «ίο, 11,23,24,» if this is indeed the case, then tato's finding29 that fundamental frequency increases with training, was supported. continuous and more clearly defined formant structure appeared dependent upon a reduction of tracheo-esophageal turbulence, as well as an increasingly regular and rapid vibratory pattern. b. subjective data. listener ratings of intelligibility. table i below reveals an increase in the portuguese-speaking listener's mean intelligibility ratings over the twoand-a-half month recording period. i ii iii iv v carry-over task mean intelligibility rating 1 =20 % 1,5=30% 1,5=30% 3 = 6 0 % 3,5=70% 3,75=75% table i: mean intelligibility ratings as a function of stage of esophageal speech development these findings would appear to indicate the s's progression over the observed period of speech acquisition towards becoming a more proficiently-rated esophageal speaker. the listener experienced the greatest ease in understanding the carry-over task items, corroborating the spectrographically-observed evidence of generalized cricopharyngeal control. comparison of listener intelligibility ratings with spectrographic displays. this revealed the following: i. evidence to suggest a fairly reliable correlation between emerging acoustic characteristics and increasing intelligibility ratings. the latter appeared related to the following acoustic variables: (i) a more rapid and regular burping mode of vibration; (ii) clearer, more continuous formant structure; and (iii) a reduction of tracheo-esophageal noise. the variable (iii) appeared to be the most important independent factor in speech intelligibility ratings, and supported findings reported in the literature. 1 0 ' 1 5 ' 2 3 ii. the s's attempts to produce effective voice-voiceless plosive and fricative distinctions manifested in interesting inconsistent discrepancies between perceptual and spectrographic data. the presence of these the south african journal of communication disorders vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) emerging esophageal speech 33 discrepancies supported nichol's18 contention that voicing is a vulnerable feature in esophageal speech intelligibility. only two of the numerous discrepancies noted, shall be described in the present article, so as to illustrate the presence of certain phenomena: (i) target: voiceless unreleased plosive (p,t,k) (note: in portuguese, as opposed to english, voiceless plosives are unreleased). word initial position: (n=48) fifteen discrepancies occurred between spectrographic and subjective ratings. the listener heard the powerful voiced cognate predominantly, which was spectrographically represented in the following decreasing order of prominence as a: a. voiceless released plosive. (n= 11) example: (pe j ) — recording session ii (see figure 6, 7) listener's response: (be γ/ p e l ) figure 6: spectrogram showing utterance (pel): (session 11) b. voiced released plosive. (n=4) example: (pipa) — recording session iv (see figure 7, 1-4) listener's response: (bipa/pipa). figure 7: spectrogram showing utterance (pipa): (session iv) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol.25. 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 glenn binder (ii) target: voiceless fricative (s, j) word final position: (n= 10) the listener heard an affricated (j), which was likewise represented spectrographically as a voiceless released affricate. example: (doi j) — recording session iv (see figure 8, 14-17) listener's response: (doit j/doi j) figure 8: spectrogram showing utterance (doij): (session iv) general conclusion from the results, the writer has postulated that the above-described discrepancies, revealing the s's ability to produce perceptually powerful, apparently ejected plosive and fricative consonants, may have been due to a mechanism of pharyngeal compression or 'squeezing'. it is apparent, that the intensity and power with which the s produced these consonants could not have been achieved by the small and variable amount of air reported to be present in the upper esophagus. 1 2 ' 2 7 ' 2 8 rather, the presence of an eggressive glottalic-type of air mechanism, in which a substantial amount of pharyngeal air compression occurred, would appear to facilitate this powerful auditory impression. to produce fricatives, it seemed necessary for the s to block his vocal tract first with a tight labial closure, in order to build up sufficient pressure. affrication resulted both auditorily and spectrographically. this appeared due to the s's inadequate control and consequent inability to produce this articulatory movement of closure lightly. similarly, when the s produced a voiceless plosive, a powerful auditory impression was heard. this was caused by a strong intra-oral pressure bursting through a very tight closure made by the s in an attempt to produce a sufficiently audible voiceless stop. spectrographic evidence likewise supported these above-described findings. for example, when producing medial voicedreleased stops, the 'voice' bar would frequently disappear, and spectrographically a gap would appear prior to the release burst. this gap likewise, may have been indicative; of pressure build-up by the s, to produce an effective auditory impression.12 (see figure 9, 20-22, for an illustrative example). the south african journal of communication disorders vol. 25 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) emerging esophageal speech 35 ' ' h i : · figure 9: spectrogram illustrating mechanism of pharyngeal compression in word-medial position. the only reference to this squeezing-type mechanism appears to have been made by kerr and lanham,9 and pellegrini and raaglini, cited by brooks hunt and va.4 the latter investigators concluded that a squeezing mechanism forces air through a narrow channel, thus producing effective sound. esophageal speech has been described as being a compensation of high d e g r e e . 1 ' 1 0 ' 2 1 this pharyngeal eggressive air mechanism, postulated to be operating, would appear to constitute a compensatory mechanism, rendering support for tikofsky's comment that intelligibility results from modifications 'other than those introduced by the use of a different sound-producing mechanism'.30 i m p l i c a t i o n s observations made in this study suggested the use of a developmental framework to more effectively quantify and assess the patient's process of esophageal speech acquisition. by using serially-made spectrograms, diagnosis and therapy would indeed be interrelated parts of a continuous process of trying to understand an individual and to help him learn.14 the regular clinical use of these objective measures would: (i) provide the ear nose and throat specialist, patient and clinician a meaningful mutual evaluation of the changes in the emergence of esophageal speech. the patient would then be reinforced for intermediary successes, with a concomitant reduction of frustration of having to work towards a remote, sometimes obscure goal of intelligible esophageal speech; and (ii) offer a motivating device which recognizes the need of every patient to gauge his own rehabilitation. in addition, spectrographic data would provide interested family members and friends the opportunity to visualize the patient's progress, and support his effort more realistically. these objective acoustic measures should constantly be compared with subjective perceptual evaluations. therapy goals and tasks would then remain more realistically orientated towards the goal of communicative effectiveness in the patient's linquistic environment, as opposed to an unobtainable level of intelligibility. for example, with regard to the 'vulnerable feature of voicing in esophageal speech', 1 8 constant comparison of objective and subjective data would enable the clinician to assess whether: (i) the patient attempted to produce the voiceless die suid-afrikaanse tydskrif vir kommunikasieafwykings vol.25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 glenn binder consonant and failed to do so audibly, or (ii) whether he omitted it completely. finally, spectrograms should never be used as a substitute for good clinical acumen. judgements in the initial assessment and during the therapy process must be based upon an evaluation of all the parameters available to the clinician, and not on the basis of a single test. however, within these limitations, the use of an analytical, developmental framework would make intelligibility a somewhat more attainable goal for the laryngectomized patient. references 1. bentzen, n., guld, α., and rasmussen, h. (1976): x-ray video-tape studies of laryngectomized patients. j. laryngol. otol., 90(2), 655666. 2. berg, j.w. van den, and moolenaar-bijl, a.j. (1959): cricopharyngeal sphincter, pitch, intensity, and fluency in esophageal speech. pract. orl basel, 21, 298-315. 3. berlin, c.i. (1963): clinical measurement of esophageal speech: (l)methodology and curves of skill acquisition. j. sp. hear. dis., 28(1), 42-51. 4. brooks hunt, r., and va, r. (1964): rehabilitation of the laryngectomee. laryngoscope, 74(1), 382-395. 5. curry, e.t., (1962): frequency measurement and pitch perception in esophageal speech. chapter 5 in speech rehabilitation of the laryngectomized, snidecor, j.c., (ed.), springfield, il.: charles c. thomas. 6. curry, e.t., and snidecor, j.c. (1961): physical measurement and pitch perception in esophageal speech. laryngoscope, 71,415-424. 7. diedrich, w.m., and youngstrom, k.a. (1960): a cineradiographic study of the pseudoglottis in laryngectomized patients. paper read at the ash a convention. 8. hoops, h.r., and noll, j.d. (1969): relationship of selected acoustic variables to judgements of esophageal speech. j. commun. disord., 2, 1-13. 9. kerr, w.a., and lanham, l.w. (1973): anatomical and spectrographic analysis of the voice in disease: a report of five cases. j.s. african speech hear. assoc., 20, 81-107. 10. kytta, j. (1964): finnish esophageal speech after laryngectomy. sound spectrographic and cineradiographic studies'. acta otolaryngol., stockholm, supp. 195, 1-102. 11. kytta, j. (1964): spectrographic studies of the sound quality of esophageal speech. acta oto-laryngol., supp. 188, 371-378. 12. lanham, l.w. (1977): professor, department of phonetics and linguistics, university of the witwatersrand, johannesburg. personal communication. june. 13. lanham, l.w., and kerr, w.a. (1975): pitch in esophageal speech. j.s. african speech hear. assoc., 22, 31-41. the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) emerging esophageal speech 37 14. lerner, j.w. (1971): children with learning disabilities. boston. houghton mifflin company. 15 martin, h. (1963): rehabilitation of the laryngectomized. cancer, ' 16(7), 823-841. 16. moolenaar-bijl, a.j. (1951): some data on speech without larynx. folia phoniat., 3, 20-24. 17. moolenaar-bijl. a.j. (1953): the importance of certain consonants in esophageal voice after laryngectomy. ann. orl, 62(4), 979-988. 18. nichols, a.c. (1962): loudness and quality in esophageal speech and the artificial larynx. chapter 6 in speech rehabilitation of the laryngectomized. snidecor, j.c., (ed.) springfield, il.: charles c. thomas. 19. perkins, w.h. (1971): vocal function: assessment and therapy. chapter 20 in handbook of speech pathology and audiology. travis, l.e. (ed.) n.y.: appleton-century crofts. 20. rontal, e„ rontal, m., and rolnick, m. (1975): objective evaluation of vocal pathology using voice spectrography. ann. orl, 84(5), part 1, 662-671. 21. safran, α., and szende, t. (1973): die osophagusprache als sprachlicher kampensations vorgang. folia phoniat., 25, 347-364. 22. shames, g.h., font, j., and mathews, j. (1963): factors related to speech proficiency of the laryngectomized.' j. speech hear. disord., 28(3), 273-287. 23. shipp, t. (1967): frequency, duration, and perceptual measures in relation to judgements of alaryngeal speech acceptability. j. speech hear res., 10, 417-427. 24. sisty, n.l., and weinberg, b. (1972): formant frequency characteristics of esophageal speech. j. speech hear. res., 15, 439-448. 25. snidecor, j.c., and curry, e.t. (1959): temporal and pitch aspects of superior esophageal speech. ann. orl, 68, 623-636. 26. snidecor, j.c., and curry, e.t. (1960): how effectively can the laryngectomee expect to speak? laryngoscope, 70, 62-67. 27. snidecor, j.c. (1962): speech therapy for those with total laryngectomy. chapter 9 in speech rehabilitation of the laryngectomized. snidecor, j.c., (ed.), springfield, il.: charles c. thomas. 28. snidecor, j.c., and isshiki, n. (1965): vocal and air-use characteristics of a superior male esophageal speaker. folia phoniat., 17(3), 217-232. 29. tato, j.m. (1954): a study of sonospectrographic characteristics of the voice in laryngectomized patients. acta oto-laryngol., 44, 431438. 30. tikofsky, r.s. (1965): a comparison of the intelligibility of esophageal and normal speakers. folia phoniat., 17, 19-32. 31. wepman, j.m., macgahan, j.α., rickard, j.c., and shelton, n.w. (1953): the objective measurement of progressive esophageal speech development. j. speech hear. dis., 18(3), 257-251. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) if you don't give them a chance to try the 775 pp what will you say when they find out the facts? hearing aid centre s.a. (pty.) ltd. announces the new dana vox 775pp behind-the-ear model. * 0 c d a t a i n a c c o r d a n c e w i t h u s a s s 3 , 8 1 9 6 7 a n d d i n 4 5 6 0 5 ( p r e v i o u s h a i c d a t a ) : g a i n : o u t p u t : o u t p u t : p 3 o u t p u t : p 2 o u t p u t : p 1 5 8 d b 1 2 9 d b r e 2 0 μ ρ α 1 2 0 d b r e 2 0 μ ρ β 1 1 1 d b r e 2 0 μ ρ β f r e q u e n c y r a n g e : 2 5 0 5 5 0 0 h z a technical novelty is the electric input terminal called the audio-input socket. this audio-input socket facilitates a direct connection to an educational system, fm receiver, television, infra-red receiver or tape recorder employed for teaching or listening purposes. this adaptor which is easily plugged to the lower part of the aid is an optional extra. / available only from: hearing aid centre 212 harley chambers 187 jeppe street johannesburg 2001 tel: 37-2643/4/5 hearing aid centre 633 kerkade centre 267 church street pretoria 0002 tel: 2-6379 & 2-7777 hearing aid centre 104 cartwrights corner cor adderley & darling sts cape town 8001 tel: 22-3665 hearing a i d centre: s u p p l i e r s of h e a r i n g a i d s & allied e q u i p m e n t ; a u d i o m e t e r s ; silent c a b i n s ; e a r p r o t e c t i o n . the south african journal of communication disorders, vol. 25, 1978 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a c o m p a r i s o n o f t h e p e r f o r m a n c e o f f i v e a p h a s i c p a t i e n t s o n d i f f e r e n t t e s t s o f l a n g u a g e a b i l i t y b a r b a r a solarsh b.a. (sp. & h. therapy) (witwatersrand) summary the performance of five aphasic patients was rated o n three tests of language ability: the minnesota test for differential diagnosis; luria's t e s t s of aphasia; and a test of expressive language based on graded stimuli from the peabody picture vocabulary test. in order to assess communicative-ability of the subjects, each expressive language sample was administered to four judges and a score of c o m m u n i c a t i v e success was c o m p u t e d . t h e study aimed at comparing each subject's performance on these tests of aphasia and its relationship t o the degree of c o m m u n i c a t i v e success, in an attempt t o ascertain which test is the m o s t accurate predictor of " a m o u n t " of aphasic impairment. it also aimed at extracting those variables m o s t useful and appropriate in the diagnosis of the impairment found in aphasic patients. inter-test correlations revealed that tests of aphasia appear to b e accurate predictors of " a m o u n t " of c o m m u n i c a t i v e success. inter-item comparison revealed fourteen sub-tests w h i c h indicated greatest difference in the performance of all the subjects. opsomming i die prestasie van vyf afasie pasiente is met drie t o e t s e van taalvermoe vergelyk. die minnesota t o e t s vir differensiele diagnose, luria se t o e t s e vir afasie en 'n t o e t s vir ekspressiewe taal is gebruik. laasgenoemde t o e t s is o p gegradeerde stimuli van die peabody prent taal t o e t s gebaseer. ten einde die kommunikasie vermoe van die pasiente te bepaal, is elke ekspressiewe taalmonster aan vier beoordelaars oorhandig en 'n telling van kommu'nikasie sukses is bepaal. die d o e l van die ondersoek was o m 'n verband tussen hierdie t o e t s e van afasie en die graad van kommunikasie sukses te verkry in 'n poging o m vas te stel watter t o e t s die mees akkurate voorspelling vir afatiese b e l e m m e r i n g sal bied. dit stel o o k ten doel o m daardie veranderlikes wat nuttig en bruikbaar is in die diagnose van die belemmering in d i e afasie pasient, uit te lig. inter-toetskorrelasies dui aan dat t o e t s e van afasie akkurate voorspellings van die mate van kommunikasie sukses weergee. inter-itemvergelyking dui aan dat daar veertien sub-toetse nodig is o m die grootste verskille tussen pasiente aan te dui. w h e n c o n f r o n t i n g t h e p r o b l e m o f t h e language b r e a k d o w n in a p h a s i a , it falls t o t h e s p e e c h p a t h o l o g i s t t o d e t e r m i n e t h e n a t u r e of t h e p r o b l e m a n d t h e m o s t s u i t a b l e t e c h n i q u e s for r e h a b i l i t a t i o n . it is h e r r e s p o n s i b i l i t y t o select t h e m o s t a c c u r a t e a n d a p p r o p r i a t e m e t h o d of d i a g n o s i s , a n d in o r d e r t o m a k e t h e t h e r a p e u t i c p r o c e s s m a x i m a l l y successful, she m u s t b e fully a w a r e of t h e e x t e n t t o w h i c h t h e s u d d e n l y a c q u i r e d i m p e d i m e n t affects t h e p a t i e n t as a t o t a l a n d c o m m u n i c a t i n g p e r s o n . a n a s s u m p t i o n u n d e r l y i n g "all a p p r o a c h e s t o t h e s t u d y of a p h a s i a , is t h a t it is a d i s t u r b a n c e of language, a n d all i n v e s t i g a t o r s a i m t o study, t h i s a s p e c t . h o w ever, this h a s a f u r t h e r i m p l i c a t i o n . v e r b a l l a n g u a g e h a s b e c o m e m a n ' s p r i m e tdskrif van i suid-afrikanse vereniging virsprak n oorhlknde, vol. , dsmber 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) barbara solarsh means of communication, so that loss of·ability to use language effectively infers loss of ability to communicate effectively. aphasia is therefore primarily a disturbance in the communicative process. this study was prompted by questioning the extent to which the people who treat aphasics, the speech pathologists, are aware not only of the best tests of aphasia, but the degree to which the patient's communication is limited. this implies that it is not only the language impairment that must be studied, but also the communication impairment. consequently both these aspects must be considered in treatment. currently, there are three popular approaches to the study of aphasia: schuell's8 approach, luria's2 approach, and that of the psycholinguists.3 schuell emphasizes the perceptual processes involved in language: luriastresses the highly organized interaction of functional units in the cortical centres of the brain; and the psycholinguists emphasize acquisition of the , rules of language — these approaches are not mutually exclusive, each approach incorporating something of the others. uriel weinreich5 has defined communication as the intentional induction by means of symbols of a certain state in the receiver which corresponds to that, in the sender. thus, successful communication may be regarded as the listener's comprehension of the message as intended by the speaker. even though the language of the aphasic may not be faultless in terms of skills underlying language or in terms of the rules of the language, he may still be able to convey a message. the listener, by having his own intact competence, may still infer and comprehend the intended communication. thus tests of aphasia directed towards the examination of the functions related to language, and to language itself, are in essence evaluating the patient's ability to communicate. the question is to what extent are tests of aphasia reliable as indicators of communicative abilityor " a m o u n t " of aphasic impairment? this study aims at investigating: (i) the relationship between performance on the three tests of aphasia; (ii) the relationship between performance on the tests of aphasia and the patient's ability to communicate his ideas; (iii) it also aims at extracting those items from all the tests which reveal the greatest difference between the subjects on the basis of an inter-item correlation, in an attempt to use them as most accurate predictors of communicative success. method criteria for selection ok subjects: criteria for selection were very broad. (1) each subject had to be diagnosed as aphasic by a neurologist and a speech therapist, i.e. as having suffered damage to that part of the c.n.s. necessary for language, and displaying'evidence of loss of linguistic skills. 1 0 | (2) each subject had to be neurologically stable (the minimum time being six months after onset of the aphasic symptoms). journal of the south african speech (aid hearing association. vol. 21. december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a comparison of five aphasic patients on tests of language ability 23 (3) each subject had to be regarded as physically healthy and able to cope with the large test battery. subjects five aphasic adults served as subjects. four were males and one was a female; three were right handed and two were left handed.'their age range was,27-70 years, with the mean of 56 years. two of the subjects were university graduates, two had matriculated and one had a standard eight qualification. at present two of the! subjects are working, the other three have no fixed occupation. in four subjects, aphasia was caused by cerebrovascular accidents, and in one subject it was caused by trauma. date of onset ranged from one to ten years, the mean time being four years. diagnosis at the time of onset revealed global aphasia with no peripheral involvement in two subjects, global aphasia with right h'emiparesis in two subjects, and expressive aphasia with right hemiplegia in one subject. amount of therapy received ranged from two months to four-and-a-half years. recent diagnosis by speech therapists indicated predominantly expressive aphasia.in two subjects, predominantly nominative aphasia in one subject, jargon aphasia in one subject, and predominantly expressive aphasia with hemi-paresis and apraxia in one subject. procedure each patient was tested for approximately ten hours over a period of three to four weeks. with two subjects the order of administration was the minnesota test for differential diagnosis (m.t.d.d.a.), the test of expressive language, and luria's tests of aphasia. with three subjects, luria's tests were administered first, and the m.t.d.d.a. was administered last. the order was changed to control for the variable of attitude towards tests affecting test performance in the last tests. it was felt that it would be more suitable to administer the test of expressive language second, to change the nature of testing which was similar for the other two tests. each test session was terminated when the subject began to show signs of fatigue. tests the m.t.d.d.a. the standardised test was administered in accordance with the stipulated test procedure. luria's tests. the principles described by luria2 formed the basis in the construction of the test items. his full battery of tests was administered. where possible exact items were extracted e.g. tests of visual perception, but in most cases the items were devised by the experimenter. test of expressive language. the method described below was selected in accordance with the requirements stipulated by margo e. w i l s o n 1 1 for collecting a language sample. (1) all subjects must be given standard instructions. (2) a standard set of stimulus material must be used that is easily available and convenient to use. picture stimuli from the peabody picture votvdskrif van die suid-afriknanse vereniging vir spraak en gelworheelkunde, vol. 2!, december 1914 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 barbara solarsh cabulary test were used. fifty pictures of graded difficulty along the whole range of the test were shown to each subject. the standardised instruction was: "tell me as much as you can about each picture". each response was transcribed and analysed. a collection of fifty to eighty linguistic responses formed the language sample for each subject. this method was chosen because: (a) it assured the experimenter that a minimum of fifty responses would be emitted. (b) the experimenter would know the nucleus of the target sentence. e v a l u a t i o n οι· communicative success four judges were used to rate communicative success. all the judges were non-aphasic adults with an age range of 25 to 55 years. all judges had matriculation qualifications. all sentences that were to be rated by the experimenter as having one or more errors were read by the experimenter to the four judges in one session. the instructions given were: "if you think you understand the sentence, write what you think that particular sentence is. if you do not understand at all, place a cross next to the number of that sentence". the experimenter made every attempt to reproduce the sentences as the subjects had spoken, considering pause, intonation and gesture in order to convey the full communication as given by the subjects, to the judges. the method was chosen to evaluate the degree to which these aphasic patients could communicate their thoughts about the picture to the judges who were unaware of the original stimuli. scoring m.t.d.d.a. performance was scored according to the criteria as stated in the test manual. luria's tests. criteria for passing or failing were established for each subtest, and performance of each subject was scored according to these criteria. expressive language. each sample was transcribed and total number of sentences was counted. following psycholinguistic principles, each sample was scoredin terms of phonemic, semantic and syntactic errors. phonemic errors were regarded as breakdowns in the use of sounds to d i f f e r e n t i a t e , ^ meanings of w o r d s . 3 these included omissions, distortions, substitutions and additions. a word may contain more than one phonemic error. semantic errors were regarded as the inability to find a word, or inappropriate use of a word. one word may be substituted for another, or a jargon word may be substituted. inappropriate addition of words or jargon was considered as a semantic error. a syntactic error was regarded as any error in the sentence structure caused by incorrect application of rules or omission to apply a rule where indicated. syntactic errors covered the range of transformational rules found within normal language. journal of the south african speech ad hearing association vol. 21 december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a comparison of five aphasic patients on tests of language ability 25 within each linguistic category scores of one to five were given in accordance with the number of errors in that particular category occurring within the sentence. 5 _ no errors present in the surface structure >> >> >> >> " 4 one error ,, >> " >> 3 _ two errors 2 three errors 1 more than three errors present in the surface structure, but the sentence still conveys meaning. 0 unacceptable sentence. each subject was given a score for phonemic performance, semantic performance and syntactic performance, as well as a total score for expressive language ability. rommunicative success. each sentence proposed by the judges that indicated understanding of the target sentence was given a score of one, and each sentence that was incorrectly understood or not understood at all, was given a score of zero. if the experimenter was unsure of the target sentence, and there was no uniformity in the understanding as portrayed by the judges, the sentence was automatically scored zero. generally, the experimenter was aware of the target sentence owing to prior knowledge of the stimulus, and questioning of the subject at the time the response was emitted. a score of total number of sentences conveying the correct meaning t o the listener was computed as the score of communicative success. inter-item comparison of performance. as the number of subjects in the study was small, statistical inter-correlation was not possible. thus a more subjective method was adopted whereby each sub-test score of one subject was compared to that of every other subject. subjects were compared in pairs, resulting in ten sets of comparisons. the difference between each pair of scores was calculated and the first fifteen scores indicating greatest degree of difference were ranked. each item was then scored according to the number of times it was ranked. the fourteen items selected were those that revealed the greatest differences in more than half of the comparisons made. in all computations scores were computed as percentages in order to provide a standard basis for comparison. results: general comparison of the three test scores: 1. is there any difference between the scores obtained on each of the three tests? a two-factor analysis of variance for repeated measures showed that there was no significant difference between the three sets of scores. (f= 0,3569, df = 2/8, ns). tyskrif van die suid-afrikaanse vereniging vir spraak en geoorheelkunde, vol. 21, desember 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 barbara solarsh test item sub j. 4 sub j. 5 diff. rank luria τ preliminary conversation 41,67 100,00 58,33 14 2. motor functions 58,67 74,67 15,00 3. phonetic anal. & synth. 0,00 92,00 92,00 3 4. writing 64,00 100,00 36,00 5. reading 39,06 90,63 51,57 6. automatic speech 15,52 100,00 84,48 8 7. imitative speech 20,00 89,33 69,33 12 8. nom. function of speech 13,89 100,00 86,11 6 9. predicative function 26,67 86,67 60,00 13 10. grammatic function 0,00 90,00 90,00 5 11. comp. of no. structure 31,43 100,00 68,57 13 12. arith. operations 0,00 100,00 100,00 1 13. phonemic hearing 20,00 94,29 74,29 9 14. word comprehension 30,00 100,00 70,00 11 15. sentence comprehension 45,00 100,00 55,00 16. logical gram. system 26,00 80,00 54,00 17. acoustic motor co-ord. 60,00 86,67 26,67 18. visual perception 63,33 91,67 28,34 19. mnestic processes 25,00 80,00 55,00 20. intellect. processes 0,00 95,71 95,71 2 exp. lang. 1. phonemic performance 7,80 92,80 85,80 7 2. semantic performance . 7,80 98,00 90,20 4 3. syntactic performance 10,60 • 66,00 55,40 15 schuell 1. auditory discrim. 52,14 88,89 36,75 2. vis. & read. disturbances 45,00 93,75 48,75 3. disturb, of numerical rel. & arith. processes 27,27 100,00 72,73 4. sp. & lan. disturbances 27,27 100,00 72,73 10 5. visuo-motor & writing disturbances 51,75 91,23 39,48 / / table i. example of inter-item comparison subjects 4 and 5. 2. is there a general similarity or concordance between the three tests of scores, i.e. are the rankings of subjects fairly similar on all three tests? the kendall coefficient of concordance (\v) showed that there was a significant concordance between the three sets of scores. (w = 0 , 8 5 3 3 , s = 80, ρ 0,01). journal of the south african speech ad hearing association vol. 21 december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a comparison of five aphasic patients on tests of language ability 3. is there direct correlation between: (a) luria's and schuell's test scores? the spearman rank correlation coefficient ( r s ) showed a perfect correlation of one between the two tests. ( r s = 1,00, n = p 0,01). (b) luria's and expressive language test scores? the same statistical test showed a correlation of 0.825, not significant. ( r s = 0,825, ν = 5, ns). (c) schuell's and expressive language test scores? the same statistical test showed a correlation of 0.825, not significant. ( r s = 0,825, ν = 5, ns). · comparison of r e s u l t s of the t h r e e tests with communication score 1. is there a general similarity or concordance between the three sets of scores as well as those on communication, i.e. between the four sets of scores? the kendall coefficient of concordance (w) showed that there was a significant concordance between the four sets of scores. (w = 0 , 8 6 2 5 , s = 138, ρ 0,01). 1. is there direct correlation between the group's communication scores and their mean scores for the other three tests combined? the spearman rank correlation coefficient r s showed a significant correlation of 0.90 between the communication scores and the combined tests scores. ( r s = 0,90, ν = 5, ρ 0,05). 3. is there direct correlation between the group's communication scores and their scores on: (a) luria test? the spearman rank correlation coefficient ( r s ) showed a correlation of 0,25 which proved not to be significant with only five subjects ( r s = 0,825, ν = 5, ns). (b) schuell's test? the same statistical test showed a correlation of 0,825 not significant. ( r s = 0,825, ν = 5, ns). (c) expressive language test? the same statistical test showed a correlation of 0,800 not significant. ( r s = 0,800, ν = 5, ns). analysis of the three tests for the most reliable items: inter-item comparison revealed the following items as indicators of the greatest degree of difference amongst subjects. tests ranked in nine out of ten comparisons: (1) test of the grammatic system indicated greatest difference amongst subjects l u r i a ' s t e s t tyskrif van die suid-afrikaanse vereniging vir spraak en geoorheelkunde, vol. 21, desember 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 barbara solarsh ss m . t . d . d . a . l u r i a ' s t e s t s e x p r e s s i v e l a n g . c o m m u n i c a t i o n s c o r e 1. 70% 65% 65% 78% 2. 70% 65% 85% 90% 3. 68% 55% 76% 72% 4. 38% 30% 8% 8% 5. 89% 92% 86% 84% table ii. summary of results of performance of subjects on each of the tests. tests ranked in eight out often comparisons: (2) the preliminary conversation — luria's test (3) phonetic analysis and synthesis — luria's test (4) phonemic hearing — luria's test (5) automatic speech — luria's test (6) predicative function of speech — luria's test (7) comprehension of number structure — luria's test (8) arithmetic operations — luria's test tests ranked in seven out of ten comparisons: • (9) imitative speech — luria's test (10) nominative function of speech — luria's test (id. intellectual functions — luria's test (12) disturbance in numerical relations — schuell's test tests ranked in six out often comparisons: (13) word comprehension luria's test (14) syntactic ability — psycholinguistic test discussion comparison of the t h r e e t e s t s of a p h a s i a : results indicate that whereas the tests administered in this study measured different aspects of language breakdown, there was no significant difference in the 'amount' of aphasia as revealed by each test. journal of the south african speech ad hearing associaion vol. 21 december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a comparison of five aphasic patients on tests of language a b i l i t y 2 9 the significant concordance score verified this by indicating that if a subject performed well on one test, he also performed well on the other tests. inter-test correlations revealed that in spite of different theoretical standpoints, the m.t.d.d.a. and luria's'tests showed a perfect correlation. they were equally reliable in predicting 'amount' of aphasic impairment. correlations between expressive language and each of the other two tests, were both high, although not significant for the small sample. however, the experimenter still feels that it is valid to infer that expressive language ability is reflected in the performance of the other two tests. these correlations may indicate that the contents of the m.t.d.d.a. and luria's tests are more similar. thus the difference in correlation could be explained in terms of 'what' is being tested. this study indicates the importance of both reauditorisation and higher mental functions in the re-acquisition of language, as well as the importance of retrieval and application of the rules of the language. the findings imply that there is a certain element which causes language breakdown in aphasia.it may be regarded as a particular function or a link in a system of functions. however, this element can be quantitatively measured in different ways by the different tests of aphasia. the manifestations as revealed by the various test items may differ, but the central disturbance is consistent. comparison of the t h r e e t e s t s a n d communicative success: 'amount' of aphasia as measured on the tests was shown to concur with 'amount' of communicative impairment, when subjects attempted to convey a message.concerning a particular stimulus picture. assuming that this is reflective of general communicative ability, the speech pathologist may refer to the score obtained by the patient on a test of aphasia as a reliable indication of the degree to which communication is impaired. the experimenter feels that while significant scores may be obtained for communications expressing simple needs or ideas, as the degree of abstraction and complexity is increased, communicative ability of the aphasic would decrease. thus communication at a high level of abstraction would not reflect this high correlation between test performance and communicative ability. however, considering the qualitative continuum of communication, the patient's communicative status may be indicated by the type of sentence he uses. the form of communication he is attempting may be regarded as the aphasic impairment and his ability to convey the message at his own level, as the communication impairment. as previously discussed one may be considered as a product of intellectual ability and the other a product of linguistic ability, although it is always difficult to clearly differentiate between them. a n a l y s i s of the t h r e e t e s t s for the most reliable items: the majority of items from the entire battery were those derived from luria's test items directly related to language and, to auditorisation of sounds, e.g. analysis and synthesis of words and sounds, and phonemic hearing — differentiation amongst sounds and words. auditorisation is implicit in schuell's approach. this supports previous statements validating both theoretical tyskrif van die suid-afrikaanse vereniging vir spraak en geoorheelkunde, vol. 21, desember 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 barbara solarsh i approaches in diagnosis and treatment of aphasia, and emphasises that the approaches are not mutually exclusive. luria's test of the grammatical system, from his tests of expressive language, was revealed to be most indicative of aphasic difference, i.e. it is the best diagnostic tool. this gives support to the psycholinguistic approach to the study of aphasia, of which syntactic performance was ranked as being the most significant of the three psycholinguistic aspects of language. thus ability to apply the rules of the language in both expression and reception, play an important part in a qualitative description of aphasic impairment. intera n d intrasubject comparison of p e r f o r m a n c e : analysis of the performance of each subject on the tests on a subjective basis, has lead to some interesting findings: a comparison of subjects 1 and 2 shows that their performance on the m.t.d:d.a. and luria's tests was similar, but differed considerably in language performance and communicative ability. their levels of higher mental functioning were similar, auditorisation and superimposed perceptual functioning were similar, yet expressive language ability differed considerably. this may be explained in terms of the differing ability to retrieve the rules of the language which supports the psycholinguistic approach to the study of aphasia. it may also be explained in terms of different neurological impairment in the two subjects. a comparison of the performance of subjects 3 and 5 gives rise to different implications about higher mental functioning. for subject 3 the score obtained on luria's tests was the lowest, whereas for subject 5 the score was highest. the influences of premorbid status must be considered as a factor here. although subject 5's communication score was better than t h a i of subject 3, both scores indicated adequate communication on the level that was tested in this study. this indicates that higher mental functionings may not in fact be of such great importance, but with a sample of two subjects, no real conclusions can be drawn. once again, localisation of the lesion may be the crucial factor here. this may be explained in terms of luria's theory by postulating that different systems within the brain were disturbed. although subject 4 could perform certain tasks underlying language as tested on luria's tests and the m.t.d.d.a., his expressive language was extremely poor. his performance was similar to that of subject 5, in that they both scored lower on the language test and higher.on the traditional tests-of aphasia. this supports the idea that there are, in fact, certain skills underlying language, or certain mental activities basic to language which create the foundations of language expression and reception. subjective analysis of the results has indicated that scores obtained on the tests of expressive language were most similar, to scores of communicative success in four out of five subjects. this stresses the importance of a psycholinguistic test in evaluating aphasia. journal o the south african spe n hearing association vol. 21, december 974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a comparison of five aphasic patients on tests of language ability 31 implications for d i a g n o s i s a n d t h e r a p y : it is a well accepted fact that accurate diagnosis provides the basis to successful therapy. test results reveal a perfect correlation between m.t.d.d.a., and luria's tests. the tests rate equally in their measurement of aphasic impairment with regard to language. the experimenter thus feels that in order to make a full diagnosis of aphasia, the speech pathologist should select either the m.t.d.d.a., or luria's tests and combine this with a psycholinguistic analysis of expression and comprehension. whereas a previous s t u d y 6 has shown that clinical tests are less sensitive than linguistic tests, the results of this study seem to contradict this. the critical element lies in the fact that the subject on which the study was based had minimal language problems. the subjects in this study all had obvious difficulty in language performance. this indicates the relevance of psycholinguistic tests in the final stages of re-acquisition of language. aphasic therapy may be approached from all three different standpoints. the experimenter postulates an eclectic approach to therapy, in which principles of all three approaches are combined. for example, rules of the language may be taught through auditory repetition of examples involving that rule, which includes the basic principle of reauditorisation. in the same way the speech pathologist can help the patient reacquire higher mental functions. mental functions such as memory, can be considered in terms of teaching linguistic units within the limits of the patient's memory span. conclusion the experimenter agrees with goldstein's9 conclusion that "aphasia is no disease, no isolated complex, but it is a functional disturbance of the complex structure of language within the totality of man's capacities and behaviour." in spite of the small sample of subjects, the lack of standardised items for luria's tests, and the subjective analysis of the test items, the study did serve to highlight certain aspects of aphasia. there appears to be a certain element in aphasia which can be measured successfully by the three tests used in the study. aphasia has been considered as causing a defect in communication thus the urgent need to relearn language is directly related to the need to communicate. therefore an efficient mode of diagnosis is essential. basic to a true understanding of the problem of aphasia is an awareness on the part of the speech pathologist as to how great a problem the language impairment really is to the aphasic patient. references 1. critchley, m. (1970): aphasiology and other aspects of language. edward arnold, london. 2. luria, a.r. (1966): higher cortical functions inman. tavistock publications, london. tyilskrif van die suid-afrikaanse vereniging vir spraak en geiioorheelkunde, vol. 21, desember 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 barbara solarsh 3. macmahon, m.k.c. (1972): modern linguistics and aphasia. british journal of disorders of communic., 7, 1, 54-63. 4. mcneill, d. (1966): developmental psycholinguistics. in the genesis of language, smith, f., and miller, g.a. (eds.). m.i.t. press. 5. osgood, c.e. and miron, m.s. (1966): approaches to the study of aphasia. university of minnesota press. 6. penn, c. (1972): a linguistic approach to the detection of minimal language dysfunction. unpublished research report, university of the witwatersrand, johannesburg. (published in this issue of the j.s.a. speech hearing assoc.) 7. scliuell, h. (1953): auditory impairment in aphasia: significance and retraining techniques. j.s.h.d., 18, 1, 14-21. 8. scliuell. h., jenkins, j.j,, jimenez-pabon, e. (1964)\aphasia in adults. harper & row, new york. . 9. taylor, o.l. (1965): a measurement of functional communication in aphasia. archives of physical med. and rehabilitation. 46j 101-107. 10. tikofsky, r.s. (1966): language problems in adults. in speech pathology. lids. richer. r.w. and brubaker, r.s. chap 11 . northern holland company, amsterdam. 1 i. wilson. m.e. (1969): a standardized method of obtaining a spoken language sample. 7.5\h.r. 12.95-102. journal of the south african speech ai hearing association vol. 21 december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) drooling in cerebral palsy audrey shavell, b.a. logopaedics (witwatersrand) senior speech therapist, forest town cerebral palsy school, forest town, johannesburg summary a review of methods of treatment used over t h e past twelve years in the alleviation of drooling in cerebral palsy is considered. a small group of patients remain persistent droolers in spite of intensive conservative treatment. information was obtained on patients who had been referred for oral surgery between october 1973 december 1976 t o determine whether any common factors would be found among t h e m which might assist in t h e selection of future cases for oral surgery; predict t h e outcome of future surgery more accurately; assess the improvement achieved in t h e t w e n t y cases of this series; and indicate post-operative complications. data was obtained from an analysis of the results of a questionnaire completed by speech therapists o n patients who had all undergone bilateral submaxillary gland excision combined with parotid duct elongation and posterior relocation. the oral surgery was carried out by the late dr. isidore kaplan formerly honorary plastic surgeon, forest town cerebral palsy school. opsomming die kwylprobleem by die serebraalverlamde, en die behandeling daarvan gedurende die afgelope 12 jaar word in hierdie studie in oorsig geneem. 'n klein aantal pasiente hou aan met kwyl tenspyte van intensiewe konserwatiewe behandeling. dit sou dus t o t die terapeut se voordeel strek om meer inligting te he van die pasiente wat gedurende die tydperk oktober 1973 t o t desember 1976 vir mondchirurgie verwys is, om vas te stel of daar enige faktore was wat die pasiente in gemeen gehad het en om dus voortaan keuring vir mondchirurgie te vergemaklik deur 'n meer objektiewe standaard daar te stel en 'n prognose te kan maak. die algemene vordering van die 20 pasiente wat mondchirurgie ontvang het, en enige komplikasies wat ingetree het na die operasie word ondersoek. die inligting vir die studie is verkry deur die analise van 'n vraelys wat voltooi is deur die spraakterapeute wat bogenoemde pasiente behandel het. die chirurgie is uitgevoer deur wyle dr. isidore kaplan, voormalige ereplastiese chirurg, forest town skool vir serebraalverlamde kinders. the problem of drooling in cerebral palsy has troubled therapists working in this field for many years. severe drooling is usually found in those patients who are unable to communicate orally or in those with serious dysarthric bulbar involvements. over the years various approaches have been tried. examples of these are:— 1. constant reminders to patients to close their mouths, suck up and swallow their saliva. 2. mirror work to draw their attention to the escape of saliva and wet chins as-many have, or seem to have, a sensory loss. 3. conscious use of a 'head back' posture, mouth closure and conscious swallowing for increasing lengths of time. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 76 audrey shavell 4. carefully graded feeding programmes to improve co-ordinated activity of lips, tongue, jaws and cheek musculature on a vegetative level emphasizing posterior placement of food on insertion and insistence on a swallow between each mouthful of food.14 5. hard food programmes.11 6. an adaptation of a device to control extensor thrust of the mandible suggested by westlake and rutherford.16 perspex chin cups were individually fitted and moulded to the shape and size of each child's chin. holes were carefully drilled into the chin cups to allow air to enter and circulate. the chin cups were attached to a headband and when correctly worn facilitated mouth closure and hopefully swallowing. most patients found the appliance very difficult to tolerate. in thefew who were able to tolerate the appliance, it was found that it kept their mouths closed (opposite to their habitual open mouth posture) but did not in any way facilitate swallowing or reduce the pooling of saliva. saliva escaped from the corners of the lips, accumulated in the perspex chin cups and excoriation on the chin usually increased so this was soon abandoned. 7. regular inclusion of sour liquids in the child's daily diet to actually increase salivation and voluntary swallowing. a dessertspoon of lemon juice was given four times a day. the sour taste causes an involuntary sucking in of cheek and lip muscles and a swallow. one patient showed a definite improvement in control of drooling for 15-30 minutes after drinking the lemon juice but then complained of stomach pains. control of drooling regressed to the pre-treatment state after the initial state of improvement. 8. encouraging the child to have all liquids and semi-liquid foods (like soups, porridge, custard) through a plastic tube or straw to improve functioning of lip musculature and better co-ordinate sucking and swallowing movements. 9. teaching the child to chew chewing or bubble gum, under supervision, to increase awareness of oral muscle functioning and develop mouth' closure. 10. operant procedures to eliminate drooling in one cerebral palsied adolescent were successfully used by garber.5 11. mueller's application of neuro-developmental principles to speech therapy, and specifically her approach of trying to achieve saliva control through feeding and drinking therapy, has been extensively used since early 1974 λ her approach is based on normalizing muscle tone throughout the body. particular attention is paid to head, neck and trunk position while muscle tone is reduced in oral areas (in the case of the spastic) and more normal swallowing patterns are facilitated. normalizing the response to intra-oral, digital stimulation and facilitating mouth closure forms part of helen mueller's pre-speech therapy programme. in all phases of her 'mouth' therapy she frequently interrupts the particular activity to facilitate swallowing. she suggests south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) drooling in cerebral palsy 77 various specific methods to overcome drooling by developing mouth closure and eliciting a swallow which all staff members should include in their handling of the patient. the child's attention is never drawn to the drooling as mueller believes it overburdens the child to expect him to consciously think of swallowing. 12. sensory stimulation techniques icing, brushing and resistance techniques applied in and around the mouth to increase sensory awareness, improve mouth closure and swallowing in carefully selected patients.13 the latter two methods (oral stimulation and sensory stimulation) have been most successful when combined with graded feeding programmes in those patients treated from a very young age on neuro-developmental lines. however, even in some of-these cases, when they begin walking or the amount of walking increases, a deterioration in control of drooling occurs,10 and one has to reintroduce drooling therapy. control of drooling may also break down when the child is involved in fine motor activities/classwork etc. 13.' medical treatment used has been atropine type drugs to actually reduce the flow of saliva to try and 'dry up' these patients. these proved to be unsuitable because of the relatively large doses required and the side effects. other medical and surgical approaches reported in the literature include division of the auriculotemporal nerve and submandibular ganglion of the tympanic plexus this works temporarily but drooling recurs. sectioning of the chorda tympani nerve may result in loss of taste sensation, though it is claimed that this eventually does return.4 diamant and kumlein3 excised the sub-mandibular gland on one side and the chorda tympani on the contralateral side within the middle ear. the results of surgery on 12 mentally retarded cerebral palsied patients aged 3 1 7 years over a two-year period, revealed that five patients were free of symptoms, three patients showed considerable improvement and four patients showed slight improvement. parotid duct ligation works, but has a high incidence of refistulization and parotitis.1 worster drought19 described various medical and surgical procedures used with patients suffering from suprabulbar paresis who were severe droolers. these are illustrated in his description of the treatment of case vii, 'j' an eight year old child diagnosed as a case of congenital suprabulbar paresis who was a severe drooler with extremely dysarthric speech. an attempt was made to relieve the persistent dribbling by prescribing atrophine sulphate (1/100 grain three times daily) but the result was only a slight and temporary reduction in the degree of dribbling. tincture of stramonium (up to 30 minims every four hours) produced a similar result. it was then decided to try the effect of x-ray irradiation to the parotid glands on both sides. j. was given daily treatment in hospital for one week, and for about six weeks afterwards there was slight improvement in the die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 78 audrey shavell degree of dribbling, probably because less saliva was produced. however, several weeks later dribbling was as profuse as before. the following year bilateral ligation of stensen's duct from inside the cheek was performed, but again the result was not satisfactory and there was only slight improvement of the dribbling. one year later an examination of the parotid ducts was carried out by probing. on the left side the ligature was found to be adequate, but on the right side stensen's duct was found to be patent throughout its length. the left submaxillary gland was then removed. the operation resulted in considerable improvement in dribbling. by the end of each morning there were only a few stains on his shirt-front, compared with the previous wet 'dickie' area. dribbling occurred only when close mental concentration made him forget to swallow excess saliva. by the beginning of the following year there had been a further improvement in dribbling and he now had to change his shirt during the day only twice a week, compared with twice a day prior to operation. towards the end of the year there was some relapse in the degree of dribbling, and the right submaxillary gland was removed. after this last operation dribbling became negligible. our experience has been that if the child has not acquired control of drooling by the time he reaches the age of formal schooling (between the age of six and eight years), he is usually very distressed by the constant soiling of school books, papers, equipment and table-top activities and usually resents having to wear bibs. in desperation we have suggested the use of cotton towelling wristbands to dab wet chins as this may be more socially acceptable for the older child. many of the children have wet chins and sodden top clothes and require several changes of clothing a day. depending on how fastidious the parents are, we have known children who have had 2 8 3 0 bib changes a day in an attempt to keep them dry. the social stigma of drooling increases as the child gets older and parents and siblings find it increasingly difficult to be 'loving' and 'patient' with the drooling member of the family although the patient may be unaware of his drooling on a physical level he is made aware of it by the looks and stares of strangers and the remonstrations of those in the immediate family circle. the social and economic problems faced by the older adolescent and young adult drooler were vividly brought to our attention early in 1973 when we were asked to assist an intelligent, 21 year old, self-conscious, spastic hemiplegic female who had very severe involvement of oral musculature and who had no control of drooling. habitual mouth position was open and isolated movements of lips, tongue and jaw were virtually impossible. any attempt to move parts of the speech mechanism (e.g. prptrude or elevate her tongue) or to vocalize or communicate orally, caused a marked increase of tension in face, jaw, cheek and neck muscles, accompanied by a strong tempero-mandibular joint slip. she used a spelling board toispell out individual letters in communicating. basic functions of chewing, sucking and swallowing were very poor and there was much loss of liquid in drinking. she drooled continuously; on effort, amount of drooling was increased. she was living in a south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) drooling in cerebral palsy 79 centre for adult cerebral palsied patients in natal where her occupation was to assist in the kitchen. the inability to control her drooling was both a threat to her job and a serious embarrassment to her. there appeared to be no automatic swallowing pattern and pooling of saliva was so excessive, and oral musculature so severely impaired that prognosis for acquiring control of drooling using conventional methods was considered to be hopeless. the possibility of oral surgery was considered and fortunately, at the time, a paper by brody became available. in his paper, brody1 acknowledged that the pathophysiology of drooling and the principles of its surgical correction were first described by theodore wilkie,1 7' 1 8 a canadian plastic surgeon. wilkie noted the significance of tongue function in the control of saliva while observing cineradiographs taken to analyse the palatal movement of cleft palate patients. he concluded that swallowing was divided into oral and pharyngeal phases. in the normal person in the oral phase of swallowing, the co-ordinated tongue first manipulates the food and/or saliva onto it and then forms a cup which seals against the hard palate sweeping the bolus posteriorly and depositing it into the pharynx. this initiates the second phase, the pharyngeal phase which is automatic. when one considers that twenty-one muscles are used in a split second during a swallowing movement and that the average person swallows approximately two thousand times a day, one appreciates how difficult it is for the cerebral palsied child to manipulate the saliva and/or food back into position for swallowing. the cerebral palsied child's tongue discoordinately slaps against the palate, sending the oral contents in all directions with only a portion reaching the pharynx. brody1 assumes that the pharyngeal phase of swallowing in cerebral palsy is relatively normal, if the child has had no respiratory or nutritional difficulties, and that the main cause of drooling is the ineffective tongue co-ordinating mechanism. approximately 1,000 to 1,500 cc of saliva are produced daily. 90 to 95% of saliva is produced by the submaxillary and parotid glands while the remainder is derived from buccal and sublingual glands. the submaxillary glands empty into the mouth through ducts located under the tongue anteriorly in the floor of the mouth and the parotid ducts emerge in the upper cheeks at the level of the second maxillary motor. two or more salivary glands can be removed with relative ease, but parotid resection is more complicated with considerable risk to the facial nerve.7 in 1967, wilkie17 postulated that if the saliva could enter directly into the pharynx, the need for tongue manipulation would be by-passed, sufficient saliva would remain for mastication, pooling of saliva in the front of the mouth would cease and drooling should be controlled. working on the basis that a strip of mucosa could be buried submucosally and would spontaneously tube itself, he lengthened the parotid duct and rerouted it into the tonsillar fossa. in this way the saliva from the parotid secretions by-passed the tongue and were deposited far enough posteriorly for the pharyngeal phase of swallowing. this substantially decreased the amount of saliva in the anterior portion of the mouth. wilkie first described two patients who were successfully treated for drooling by the above described surgical procedure,17 and later reported die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 0 audrey shavell a series of eight patients treated in a five year period including his two original cases.18 seven of the eight cases required a second surgical procedure viz. submandibular gland resection. significant improvement in control of drooling was recorded in all eight patients. brody1 reported on a large series of over sixty patients, aged between 6—65 years, who had the combined procedure of bilateral submaxillary gland resection and posterior transplantation of the parotid duct. approximately onehalf of these patients had a primary diagnosis of severe mental retardation (iq range 15 — 60) with or without cerebral palsy. the other half of his series were primarily cerebral palsied with lesser degrees of intellectual impairment. of brody's first 60 patients, 55 had sufficient improvement in their drooling to consider the surgery successful. of this group, approximately two-thirds had no residual drooling and minimal or no side effects. stenosis of the orifice of the new duct occurred in 13 patients representing 16 of 120 ducts. brody1 stated that recent refinement of the operation has lowered the incidence of stenosis. the surgical procedure described by wilkie17 was employed by dr. isidore kaplan to successfully alleviate our young adult's drooling problem. subsequently nineteen other patients, ranging in age from 4 years 9 months to 21 years, had the bilateral procedure of submaxillary gland excision with parotid duct elongation and relocation. fourteen patients were males and six were females, and all had been diagnosed as uncontrollable droolers who had not responded to conservative measures.7 the remainder of this paper consists of a follow-up report on dr. kaplan's' series of cases based on the results of a preand post-operative oral surgery questionnaire completed by speech therapists working at cerebral palsy schools in the republic of south africa. it was hoped that analysis of the results of the questionaires would provide us with additional information on the problem of drooling in cerebral palsy. information was obtained on nineteen of the twenty patients who underwent oral surgery between october 1973 and december 1976. as this is a relatively small sample, detailed statistical analysis of the results was not undertaken. the writer has attempted to determine response trends in possible relationships between severity of drooling and the following factors:(a) type of cerebral palsy. (b) degree of involvement. (c) intelligence. (d) presence of a complicating oral sensory loss and/or apraxia. . (e) habitual mouth position and swallowing pattern. (f) oral communicative ability. (g) length of period of pre-operative speech therapy. on the post-operative side we were interested in comparing: (a) the surgeon's evaluation of results in each case with the; speech therapists' rating of the success of oral surgery and whether these assessments agreed with the parsnts' opinions of the results of surgery, (b) the incidence and types of post-operative complications, (c) the incidence and types of post-operative behavioural south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) drooling in cerebral palsy 81 disturbances. many of these children are subjected to several orthopedic surgical procedures during their formative years and the psychological effects of additional surgery should not be overlooked.12 patients attended the following cerebral palsy schools or adult cerebral palsy centre. name of school no. of patients case no. as in table i forest town cerebral palsy school 5 4 , 5 , 1 0 , 1 1 , 1 2 . nuwe hoop cerebral palsy school 1 1 muriel brand cerebral palsy school 2 8,15. pretoria cerebral palsy school 2 9,14. west rand cerebral palsy school 6 2 , 6 , 7 , 1 3 , 1 6 , 1 7 . pevensy place adult cerebral palsy centre 1 19 two patients were not attending cerebral palsy schools and no questionaires were completed on them. information on these two patients was obtained from the surgeon's files (case numbers 3 and 8 as listed on table i). case no. age at surgery yrs mths type of cerebral palsy degree of involvement most recent iq assessment 1 4 9 athetoid and spastic quadriplegia c a . 4,7; m a . 7 , 1 l-reynell verbal comprehension μα. 2,2. pp.v.t. (peabody) 2 7 aphasia {dysarthria no phys. inv. 1q 69-snijders-oomen non verbal intelligence scale. 3 6 not known not known not known 4 7 6 spastic quadriplegia 1q 61-old sa.1.s. iq 48-new s.a.i.s. 5 7 9 spastic, pseudo bulbar palsy, apraxia bilateral \ hemiplegia/ 1q 52-stanford binet; iq 56-columbia 6 11 spastic and athetoid quadriplegia iq 77-snijders-oomen non verbal intelligence scale. 7 11 athetoid quadriplegia iq 60-columbia mental maturity scale. 8 11 8 athetoid not known iq 107-new s.a.i.s. 9 11 8 spastic and athetoid quadriplegia iq 85-columbia mental maturity scale. 10 12 7 spastic bilateral \ hemiplegia/ iq 83-new s.a.i.s. 11 12 11 spastic bilateral \ hemiplegia / iq 62-new s.a.i.s. 12 13 3 spastic athetoid quadriplegia iq 55-pj.v.t. (peabody) 13 14 3 spastic quadriplegia iq 64-columbia. 14 is spastic quadriplegia iq 50-ravens progressive matrices. 15 16 7 spastic quadriplegia iq 73-new s.a.i.s. 16 17 spastic quadriplegia iq 73-ravens progressive matrices. 17 17 2 spastic hemiplegia iq 86-old s.a.i.s. 18 18 spastic quadriplegia not known. 19 21 spastic hemiplegia not known. table i summary of selected features from the case histories of the droolers. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 2 audrey shavell s έ = 8 2s » 9 ο oo j s s o α u ο g * " £ < ο μ μ st o o c l o o v o o o o o o o o o o o ^ l o z 2 z 2 z > z z z z z ? z z z z z z z o o ^ o o w o o « o o o o o o o o ¥ . o zzzzz>*zz>*zzzzzzzzzz v) m m α>α><̂ 00α> oovoouvc.ovoc.a» ο « ϋ α> ο a) α>4>4>4> ο ο α> α> α>^.α> z>-z>->-z>->->->->-zz>-z>->-z>· « 3 3 ο 4> ·—. β : ζ >• ζ £ . μ ϊ έ . η μ . μ η μ μ η μ 10 ^ μ ου'— ο υ υ ο υ υ υ υ ο υ υ υ ο^,υ ζ>·ζ.ζ.>>·ζ.>>·>>ζ.>>·>·*. ζ ζ >• ζ + + ζ + + + + 1+ + + ζ μ ζ u + + + + + ζ + ^ ι ϊ ^ ϊ , ϊ . ι * s* * s s« ζ ο ζ ζ-3 ο ζ ζ ζ ζ ο ζ ο ζ ζ ο ο ζ ζ 6 : 3 j ο "53 α 2β ο χ α. c c c c c c c c c c ' z o o o o o o o o o o o o o o o u o o c c c « c c « c c c c c c c c c c c c α α α ο α α ο ααααα.αο.ο.αο.αα ο ο ο υ ο ο υ ο ο ο ο ο ο ο ο ο ο ο ο ututut g * * α> ω-—.-—.-—. ω . ο . ω ο ω —. ζζζζζ>>·ζζζ>·ζζζζ>ζ>·ζ t i s ο 9> s ι -a a + + + + + + + + + + + + + + + + ε ί i ι ι h " .s s-s e.s "•s ii 3 c is i i . s f § s f l o 2 >· •3 1 i f o, λ ut <u j= •s <u <u o, c/3 μ e ε •a * 3 (o •9* δ »" c c λ 1 e >» « ό α> i, .. χ ο = * h i j s ω ο -ο 75 c c· .ο ο « ο ji ut a. -s -· &. 00 ; » σ* ! i s s g e ι2 — α> ·η e = η *o ' s u. ω ζ ; ί ι , · = χι ο·«! » u 2 3 i § 1 ? ϊ κ u 8 » ϋ λ -ο i s 2 . i 3 3: «β α> ο 1 | | : ° ο ο όι α> ο 1 ί ϊ ! i f δ 8 i s • — <λ ι-, ^ ω ,j? ι 8 (μ f « ο i i 1« c « . ε gju a •3 oil=· μ >, υ •a 3 1 = jj • i f . e l s 5-36 «ρ ό 5 c α \ j « or o, i u o · · ϊ » : « c j < ο : ο ο ut t3 <υ ο ό <υ u <υ ut . 3 τ3 <υ ο & λ 3 c/i ω j η c η 77if south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) drooling in cerebral palsy 83 table i indicates that the majority of severe droolers are spastic or mixed spastics and athetoids. only two patients were diagnosed as athetoids and one as predominantly athetoid with some spasticity. when one considers degree of involvement, the majority of patients who are severe droolers are the physically more severely affected ones, i.e. quadriplegics or double hemiplegics (involvement of all four limbs, arms more than legs and involvement of bulbar musculature.) there was only one patient in the series who had no physical involvement, two were hemiplegics and two whose degree of involvement was not known. it is difficult to make firm statements about intelligence because of the variety of intelligence tests used. in the sixteen patients where some formal assessment was available iq scores ranged from 50 — 107. twelve of the sixteen patients had intelligence quotients below 80. table ii shows that fourteen of the nineteen patients were rated by the speech therapists as continuous droolers, requiring several changes of clothing or bibs each day. three were rated as severe droolers not necessarily requiring change of clothes or bibs. two were rated as moderately severe droolers i.e. drooling could be controlled while concentrating on it but control broke down when the child engaged in other activities. the answer to the fourth question, whether the child drooled while sleeping, was in most cases not known. habitual mouth position at rest and on effort was open in the majority of cases as was to be expected. mouth position while sleeping was not known in twelve of the nineteen patients. as far as pre-operative awareness of drooling was concerned, nine patients were classified as being acutely aware of their drooling, five had some awareness and three were totally unaware of their drooling. the speech therapists felt that eleven of the patients had a possible oral sensory loss, five had no oral sensory loss, no information was available on two cases and a therapist was not sure whether there was an oral sensory loss in one case. when swallowing ability is considered, we see that eleven of the nineteen patients had problems projecting food from the front to the back of the mouth. once the bolus of food reached the pharynx twleve of the nineteen subjects could swallow normally, four had problems in the pharyngeal phase of swallowing as well. no information was available on swallowing on the remaining three patients. ten of the nineteen patients had some or much loss of food while eating. two patients frequently regurgitated their food and one patient had problems of liquids and semi-liquids being expelled through the nose. table iii does not contain information on years of pre-operative speech therapy and frequency of treatments per week is not set out in detail as the number of years of pre-operative therapy varied between one and ten years and number of weekly sessions between one and five. a wide variety of methods and techniques was used so meaningful comparisons cannot be made. results of table iii indicate a complicating apraxic component in seven out of the sixteen cases on whom questionaires were completed, i.e. an incidence of 43% — a higher incidence of apraxia in a cerebral palsied group than one normally expects to find. fifty per cent of the patients were unable to communicate orally and among the remaining 50%, half had very distorted speech with poor speech intelligibility and the other half were patients with articuladie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 84 audrey shavell rating scale of case severity of no. apraxia dysarthria/apraxia method of communication. 1 2 3 1 no + points. vocalizes. simple gesture. 2 yes + + ++ distorted oral communication. 3 n/k + + + ++ not known. 4 no communicates orally. good intelligibility. 5 yes + eye pointing. communication board. 6 yes + gesture & typing. 7 yes + communication board. 8 no + distorted oral communication. 9 no + gesture. communication board and typing. 10 no . + very distorted oral communication. 11 no communicates orally. reasonable intelligibility. 12 yes + gesture. vocalisation. communication board. 13 yes + gesture. communication board. 14 no + isolated vocalisations. types. 15 n/k + very distorted oral communication. 16 yes + gesture and typing. 17 no + communicates orally but distorted. 18 n/k not known. 19 no + joints. simple spelling board. legend: + + = excluded in totals. 0 = communicates orally. reasonably-good intelligibility. n/k = not known. rating scale of severity of dysarthria/apraxia. 1) totally unable to communicate orally. / 2) attempts to communicate orally, but severely distorted. 3) communicates orally but has articulatory + phonatory errors. table iii summary of selected features related to the speech of the patients. tory and phonatory errors. one child (case no. 4) had speech completely within normal limits although she was a severe drooler and another child (case no. 11) has intelligible speech after several years of speech therapy. south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) drooling in cerebral palsy 85 table iv consists of a comparison between the surgeon's evaluation of results achieved and the various speech therapists' ratings of the success of the surgical intervention. details of post operative complications and the parents' evaluation of surgery are also included. case no. surgeon's evaluation of results post operative comnegative psychological speech therapists' evaluation of parents' opinions plications reactions results a b c d a b c d 1 + none none + very pleased. 2 + none none + not satisfied. 3 + +++ none n/k very pleased. . 4 + + +++ none none + satisfied. 5 + none none + satisfied. 6 + none n/k + n/k. 7 8 + + none none none y e s + + + very happy. happy. 9 + stenosis of none + happy. 10 + +++ left duct none y e s + + + + happy. 11 + stenosis of none + very happy. 12 + right duct none y e s + + + + + very satisfied. 13 + none n/k + satisfied. 14 + none none + expected more. 15 + none none + n/k. 16 + +++ none none + n/k. 17 + none none + satisfied. 18 + n/k n/k + very pleased. 19 + none none + satisfied. l e g e n d : n / k — n o t k n o w n . + + 3 cases w e r e e v a l u a t e d b y t h e s u r g e o n as b e t w e e n g o o d a n d e x c e l l e n t a n d h a v e b e e n t a b u l a t e d a c c o r d i n g l y . t h e y w e r e n o t h o w e v e r c o u n t e d t w i c e i n final t o t a l s . + s o m e b e h a v i o r a l d i s t u r b a n c e s w e r e n o t e d p o s t o p e r a t i v e l y , t h e s p e e c h t h e r a p i s t felt p r o b a b l y m o r e d u e t o m a r i t a l strife in t h e h o m e . + + + w e e p y a n d i n s e c u r e for o n e w e e k after d i s c h a r g e f r o m h o s p i t a l , h a d b e e n fine w h i l e in h o s p i t a l . + + + + v e r y u p s e t for a b o u t o n e m o n t h p o s t o p e r a t i v e l y t h e n s e t t l e d d o w n . table iv summary of the evaluation of selected features of surgery. examination of table iv shows exact agreement between the surgeon's evaluation of results and the various speech therapists' ratings in ten of the eighteen cases i.e. 55%. the surgeon did not rate any case as representing no improvement, i.e. drooling problem unchanged, but the speech therapist and parents gave one case this rating. (the surgeon evaluated this case as fair). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 6 audrey shavell four more cases were rated as being fair by the speech therapists than by the surgeon. twelve of the nineteen patients achieved an excellent result according to the surgeon and four a good result. the speech therapists' figures for these two categories were five and five respectively. stenosis occurred in only two of the thirty-eight ducts operated on i.e. 5,2% of cases. no instances of bilateral stenosis occurred. occurrence of stenosis was not related to whether the parotid ducts were tubed or not.7 this is a lower incidence of stenosis than that reported by brody1 where stenosis occurred in 13,3% of cases. three of the fifteen patients on whom information was available had negative psychological reactions to the oral surgery. none of these lasted longer than one month. fourteen of the sixteen parents were satisfied or highly delighted with the results of oral surgery, one set of parents were dissatisfied, one expected more and information was not available on three cases. additional positive results were mentioned on two of the cases. in case i, the speech therapist commented on the fact that the child had an immediate increase in appetite and a gradual disappearance of halitosis which had been a problem pre-operatively. one other case was reported as being very thirsty pre-operatively but not post-operatively. results and conclusions the majority of droolers in this study were spastics or spasticity was the dominant disability when more than one disability was present. as was to be expected, most of these patients were severely involved in terms of degree of disability. seventy-five percent of them had intelligence quotients below eighty as assessed on various scales. habitual mouth position was open in seventeen of the nineteen patients on whom questionnaires had been completed. an oral sensory loss was suspected in eleven of eighteen patients and seven out of sixteen or 43% were considered to be apraxic in addition to their severe dysarthria. fifty percent of the group were totally unable to communicate orally, twenty-two percent could communicate verbally but with very poor intelligibility and the speech of the rest of the group ranged from reasonable intelligibility to normal speech. there was a fifty-five percent agreement in rating improvement between the speech therapists and the surgeon. agreement in rating improvement between the therapists and the parents was higher. only one child was considered by the speech therapist and his parents as totally unchanged post-operatively and as a fair result by the surgeon. in all the other patients, improvement in control of drooling ranged from fair to excellent. there has been a very low incidence of stenosis and fistula formation which kaplan attributed to the method of creating a vshaped, rather than a circular, orifice of sufficient width in the tonsillar fossa.7 study of the four cases where the pharyngeal phase of swallowing was considered abnormal by the speech therapists reveals that three out of the four had a poorer surgical result than the rest of the group. conclusions cannot be south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) drooling in cerebral palsy 87 drawn from such limited data but more detailed pre-operative assessments of swallowing including cineradiography will be done on future patients. this may enable us to predict more accurately the kind of results to expect from oral surgery and be able to advise parents accordingly. it is also incumbent upon the speech therapist to inform both the patient and parents about the post operative hospital treatment which includes administration of fluids and antibiotics intravenously for the first forty-eight hours, intra-oral suction and routine oral hygiene and the restriction of intake to only clear fluids. on the third day a soft diet is permitted with mouth washes and continuous oral hygiene. frequent encouragement to swallow by the nursing staff is important and regular visits by the speech therapist help to maintain the morale of patients and family. most patients are discharged on the seventh or eighth day. all patients have fairly marked facial oedema for a while post-operatively. adequate pre-operative preparation for hospitalization reduces the likelihood of psychological trauma occurring post-operatively. oral surgery is not suggested as a panacea for all cerebral palsied droolers. the twenty cases who underwent the surgical procedure described in this paper represent a very small percentage of patients in cerebral palsy schools in the republic. it is suggested as a form of treatment which should be offered to persistent droolers who have not shown improvement with other methods. the positive psychological effects observed post-operatively in nineteen of the twenty patients and their families were quite dramatic. many of the older patients actually verbalized that the drooling was the most distressing and unpleasant feature of all their disabilities. persistence of drooling into late adolescence and early adulthood is accompanied by self-consciousness and feelings of inferiority and inadequacy which increase problems in job placement, even in sheltered workshop situations. acknowledgements the writer gratefully acknowledges the interested assistance of dr. g. brody, rancho los amigos hospital, california for introducing us to the field of oral surgery and to the late dr. i. kaplan who carried out the oral surgery. his patience and kindness towards both patients and paramedical colleagues will always be remembered. sincere thanks to the speech therapists who completed the questionnaires from which the data was drawn. references 1. brody, g. s. (1972): the surgical control of drooling in cerebral palsy. paper presented to the american academy for cerebral palsy 2. brody, g. s. (1973): the surgical control of drooling in cerebral palsy. abstract of paper presented to american academy for cerebral palsy. devel. med. and child neurol, 15, no. 2. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gg audrey shavell 3. diamant, m. (1974): a treatment for drooling in children with cerebral palsy./. laryngology otology. vlxxxviii, no. 1. 4. enfors, b. and lundberg, a. (1969): diebehandlungder hyper salivation bei kinder in mit zerebral paresen. paper presented at a meeting, dusseldorf. 5. garber, ν. b. (1971): operant procedures to eliminate drooling behaviour in a cerebral palsied adolescent. devel. med. child neurol., 13,641. 6. kaplan, i., and shavell, a. (1974): the surgical control of drooling. film/slide demonstration and presentation to cerebral palsy division of the national council for the care of cripples in south africa. june 25th, president hotel, johannesburg. 7. kaplan, i. (1977): results of the wilkie operation to stop drooling in cerebral palsy. plastic and reconstructive surgery. 59, 5, ρ. 646. 8. mueller, h. (1972): facilitating feeding and pre-speech. in physical therapy services in the developmental disabilities. pearson, p. et al. (eds), c. c. thomas. springfield, 111. 9. mueller, η. (1974): handling the young cerebral palsied child at home, w. heinemann. med. books 2nd. ed. 10. mueller, h. (1976): notes from speech therapy workshop. forest town cerebral palsy school, july 1976. 11. palmer, m. (1947): normalization of chewing, sucking and swallowing reflexes in cerebral palsy: a home programme. j. speech dis., 12, no. 4. 12. reynell, j. (1965): post operative disturbances observed in children with cerebral palsy. devel. med. child neurol. 7,360-376. 13. rood, m. (1969): sensory stimulation techniques. notes from the rood course. s.a. physiotherapy soc. 14. shavell, a. (1973): home speech therapy programme for the young cerebral palsied child. forest town cerebral palsy school. 15. shavell. a. (1977): changing attitudes and approaches to speech therapy with cerebral palsied patients. s.a cerebral palsy j. 21. 16. westlake, h. and rutherford, d, (1961): speech therapy for the cerebral palsied. national soc. for crippled children and adults, inc. 17. wilkie, t". f. (1967): the problem of drooling in cerebral palsy a surgical approach. canadian j. surg., 10:60. 18. wilkie, t. f. (1970): the surgical treatment of drooling: a follow up report of five years experience. plastic and reconstruction surgery. v, 45. no. 6. 19. worster drought, c. (1974): suprabulbar paresis. devel/med. child neurol, 16,1. supplement no. 30. south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) phonological and neuroanatomical findings in three cases with apraxia of speech* lesley wolk ma (speech pathology) (witwatersrand) department of speech pathology and audiology, university of the witwatersrand, johannesburg abstract this study investigated whether or not the articulatory errors on single consonants and initial consonant clusters in three adult aphasic patients with apraxia of speech could be characterized by underlying phonological processes. naming tasks and spontaneous narrative tasks were used for elicitation of speech samples. computerized tomography was carried out in order to determine possible neuroanatomical correlates of the linguistic findings in these cases. results revealed that in each case, it was possible to trace underlying phonological processes which fit into strategy groups operationalizing particular phonetic preferences. similar trends occurred on all tasks. self-employed strategies to aid phonological production were used by all cases during their struggle with successive attempts towards the target utterance. neuroanatomical findings demonstrated brain lesions which were more extensive than would be expected in the traditional concept of a focal lesion in broca's area. in each case the left parietal region was involved. theoretical and clinical implications are discussed. opsomming hierdie studie ondersoek die moontlikheid dat onderliggende fonologiese prosesse die artikulasie foute (enkel konsonante en inisiele konsonant kombinasie) van drie afasiepasiente met verbale apraksie kan karakteriseer word. benoemingstake en spontane verhalende spraak is gebruik om spraakmonsters te ontlok. gerekenariseerde tomografisie is onderneem om moontlik neuroanatomiese korrelate van linguistiese bevindings in hierdie gevalle te bepaal. resultate dui daarop dat dit in elke geval moontlik was om onderliggende fonologiese prosesse uit te wys. hierdie prosesse kon ingedeel word in groepe wat spesifieke fonetiese voorkeur verleen t.o.v. strategic soortgelyke neigings het in al die take voorgekom. selftoegepaste strategies om fonologiese produksie te bevorder, is deur alle pasiente gebruik tydens hulle worsteling met opeenvolgende pogings tot die teiken uiting. neumanatomise bevindings het getoon dat brein letsels groter was as wat verwag word van die tradisionele konsep van 'nfokaleletsel van broca se area. in elkepasient was die linkse parietale area betrokke by die letsel. teoretiese en kliniese implikasies is bespreek. ι controversy has further ensued regarding the nature of articulatory impairment. some investigators have argued that articulation errors are random and unrelated to the target sound (critchley, 1952; deal and darley, 1972) while others have concluded that errors are systematic and rule-governed (blumstein, 1973; martin and rigrodsky, 1974a; 1974b; klich, ireland and weidner, 1979). the development of apparent incompatible conceptions of the disorder is due, at least in part, to the phenomenon itself. in addition, guidelines for treatment have been somewhat fragmentary and meagre. numerous workers in the field of adult apraxic disorders have extrapolated from child language in an attempt to unravel some of the conceptual controversies discussed and to design effective treatment programmes. there may be several! imitations of this procedure, for example that of over-simplifying the adult aphasic breakdown. yet, the knowledge acquired through extrapolating from child language has contributed in some way * this study formed part of the author's ma dissertation entitled "phonological impairment in aphasia" submitted to the department of speech pathology and audiology, university of the witwatersrand, johannesburg. the south african journal of communication disorders, vol. 31 1984 @ sasha 1984 recent research into the area of aphasia has witnessed a surge of interest in articulatory disturbances, particularly in broca's aphasic patients. multiple terms have been employed to describe the articulatory impairment; for consistency in this paper, the term 'apraxia of speech' will be used. the investigation of apraxia of speech in this study extracts from linguistic approaches and neurological methods of investigation. apraxia of speech is both controversial and complex despite many years of research. several investigators have described the disorder as a motor programming disturbance not primarily due to neuromuscular or higher language functioning deficits, and have suggested that the programming of phonemes can be selectively impaired without impairment of language (deal and darley, 1972). martin (1974), however, objected to the term 'apraxia of speech' and argued that motor programming disturbances are inextricably tied to language deficits and cannot be defined except within the framework of aphasia. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) phonological and neuroanatomical findings in three cases with apraxia of speech 37 to the understanding of these cases and to the overall clinical management. research on distinctive feature analyses in patients with apraxia of speech suggests that error productions are systematically related to their target sounds in terms of a feature breakdown (martin and rigrodsky, 1974a; 1974b). there has been limited application of phonological process analyses (bowman, 1982). phonological processes, as they are described in child language, refer to general simplifying processes that affect entire classes of sounds (ingram, 1976). they do not reflect random errors, rather they are said to result from a set of systematic strategies operationalizing a child's phonetic preferences (ingram, 1976; 1981). it has been argued that the phonological processes may provide the general patterns that need to be eliminated in therapy, and that if trained on key sounds, generalization is likely to occur (weiner, 1979). cohen, gelfer and sweet (1980) feel that it is essential for the clinician to evaluate the aphasic patient's speech performance and to compare this with the anatomical localization afforded by computerized tomography (ct). buckingham (1979) further argues that it is difficult to determine what constitutes an apraxia of speech without further specifying the location of the lesion and the stimulus conditions which evoked the behaviour said to be apraxic. thus the primary goal of this study was to investigate whether the articulatory errors on single consonants and initial consonant clusters in three adult aphasic patients with apraxia of speech could be characterized by underlying phonological processes, considering which ones operate most commonly; a secondary goal was to describe ct scan findings in these cases. these findings are discussed briefly in a recent report (wolk, 1982a). method subjects three adult male aphasic patients were used as subjects for this study. all cases were chosen from johannesburg hospitals and were diagnosed as aphasic by neurologists and speech pathologists. they ranged from age 58 to 73 years with a mean age of 63,3 years. all cases presented a history of left (l) hemisphere cerebrovascular accident (cva). they demonstrated various degree of concomitant broca's aphasia. in each case, however, phonological deficit predominated. they ranged in months post onset (mpo) from 9 to 24, with a mean of 15,7 months. all cases were native speakers of english and had no previous history of speech or hearing problems, premorbid psychological problems, senility or mental retardation. years of education ranged from 8 to 11 with a mean of 9,7 years. case 1 had the most severe form of apraxia of speech, and case 3 the least severe disorder. subjects had to have suffered a left (l) cerebral infarct, and were required to have reached a point table 1 description of cases age sex aetiology months post onset mpo type of aphasia home language educational level premorbid occupation handedness speech therapy received case 1 (a.m.) 58 male cva 24 broca english std. 6 plumber (r) 18 months case 2 (ft:) 73 male cva θ broca english std. 8 despatch manager (r) 4 months / /case 3 (e.j.) 59 ma e cva 14 broca english std. 9 salesman (r) 12 months table 2 results of preliminary tests ! / preliminary test case 1 (a.m.) case 2 (f.t.) case 3 (e.j.) boston diagnostic aphasia examination (bdae) goodglass and kaplan (1972) score on severity rating scale = 2 score on severity rating scale = 2 score on severity rating scale = 2 token test de renzi and faglioni (1978) 34/36 = 940/0 34/36 = 94o/0 3 6 / 3 6 = 100% oral non-verbal gesture battery moore, rosenbek & la pointe (1976) 56/56 = 100% 56/56 = 100% 56/56 = 100% screening pure-tone audiometric test normal normal except 45db at 4000 hz bilaterally normal goldman-fristoe test of auditory discrimination (goldman, fristoe and woodcock, 1970) 100% 100% 100% discrimination of cvc and ccvc words (designed by the writer) 100% 100% 100% die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 lesley wolk of neurological stability considered as six months after the neurological insult (sarno and levita, 1971). the description of cases is summarized in table 1. procedure preliminary tests were carried out to determine whether the subjects satisfied the selection criteria. these are summarized in table 2. two approaches were used for elicitation of speech for linguistic analysis: — (1) naming tasks and (2) spontaneous narrative tasks. 1. naming tasks a test comprising two parts was developed by the writer for use in this study. part i was designed to test single consonants in initial (i) and final (f) word position, and part π was designed to test initial consonant cluster sequences. criteria for selection of words part i of the articulatory test was composed of 89 items, carefully selected to elicit all the consonants (c) in english in (i) and (f) word positions. an attempt was made to select items in which the desired consonant in (i) and (f) word position could be elicited simultaneously, thus maximally conserving the total number of picture stimuli required (for example, initial id/ is elicited by the picture words 'dog' and 'duck' at the same time that final igl and /k/ are being elicited). each consonant was elicited at least twice in (i) and (f) word position, ranging between two and four different phonemic contexts. the phonemic environment was varied with respect to both vowels and consonants in the immediate phonemic vicinity. thus 81 words represented consonants in (i) position, and 70 words represented consonants in (f) position, while the total number of test items was equal to 89. part π of the articulatory test was composed of 99 items. each (i) cluster of english was elicited in at least two stimulus words, ranging between two and four different phonemic contexts. experimental manipulation of words stimulus items were constrained by the following:' i) phonological rules governing the combination and sequencing of phonemes in english; ii) words which could be pictorially represented, for the reason that imitation was to be deliberately avoided; iii) word length and syllable structure were considered mono syllabic and disyllabic words were included, while multisyllabic words were excluded; iv) morphological endings were excluded when devising the list of single consonants in (f) position so as to elicit 'pure phonological constructions'. the entire articulatory test thus comprised 188 stimulus items (part i = 89; part ii = 99). each response was elicited twice, to provide an estimate of the subjects' consistency of production of the same sounds in identical environments. thus both parts of the naming task, naming singletons (ns) and naming clusters (nc) were administered twice to all subjects. 2. spontaneous narrative tasks these included an open-ended conversation, description of fifty pictures and constructing a story from six pictures depicting real-life scenes. administration of phonological assessment procedure all testing took place in a sound-treated room and was carried out by the writer during several 45-minute sessions. subjects were tested individually. for the naming tasks, pictures were presented in a random order, but attempts were made not to present two words with the same consonant or consonant cluster successively. part i (ns) and part ii (nc) were administered twice over four sessions, following the same procedure. for the spontaneous tasks, each subject had to describe the fifty picture cards selected and to tell a story for each of the six picture cards chosen. spontaneous narrative tasks were administered once over three or four sessions. response transcription all responses were recorded on a high quality revox tape recorder (model 1132 dolby version). wherever possible onsite transcriptions were carried out by the writer, utilizing both visual cues and contextual information. tape recordings were transcribed by the tester in broad phonetic transcriptions, and were used as a comparison with on-site transcriptions. a second transcription of all data was carried out using three transcribers who served as judges. judges worked independently and then met jointly to resolve any discrepancies, discarding any instances in which no consensus could be reached, providing maximum objectivity and accuracy of recorded data. phonological process analysis the goal was to discover whether articulation errors of these subjects could be characterized by general processes, and if so, which phonological processes were operating for each case. all cvc and ccvc words with error productions were analyzed in terms of one or more of the following broad categories as described by weiner (1979): a) syllable structure processes, b) harmony processes and c) feature contrast processes. within these categories, several specific phonological processes were selected from those described in child language (ingram, 1976; 1981; weiner, 1979). i it was possible that multiple processes could occur at the same time for a particular error utterance, in which case credit jwas given to as many processes as were operating for that utterance. in this way it was possible to determine the frequency of occurrence of each process and its probable resulting effect on intelligibility. the same procedure was carried out for both naming and spontaneous tasks for each case. assessment procedure for neurological investigation neuroanatomical investigations of the cases in this study included general neurological examinations carried out by the same neurologist, and computerized tomography (ct) scans for each case. ct scans were performed with contrast enhancement on the elscint 905 system. ct scan pictures obtained from the assessment procedure for the cases of this study were interpreted by a radiologist and two independent neurologists in order to provide a measure of objectivity and reliability. the south african journal of communication disorders, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) phonological and neuroanatomical findings in three cases with apraxia of speech 39 results and discussion phonological findings tkble 3 represents a summary of the phonological processes operating for all cases. the findings indicate that in each case certain phonological processes occurred more frequently than others, and that these occurred in similar proportions on both naming and spontaneous tasks. the findings will be discussed below in terms of three broad categories, i.e. syllable structure processes, harmony processes and feature contrast processes. syllabi" structure processes the three most commonly used syllable structure processes for all cases, were deletion of final consonant, weak syllable deletion and cluster reduction. cluster reduction was the most commonly operating phonological process on naming tasks for all cases. it was necessary to develop a subcategory of the cluster reduction process to indicate that it was possible for an error substitution to reflect an extraction of select features of one or more elements of the target segment which merge together to form a new segment. this was referred to as 'feature merging'. feature merging comprised a substantial number of errors, for example in the case of a.m., 27,64% and 34,48% of cluster reduction errors were seen to occur on naming and spontaneous tasks respectively. an example of feature merging is clearly illustrated in the error substitution /sp/ for the target segment /skw/ which occurred in cases 1 and 3. here it can be noted that isl remains the same, /p/ retains the plosive quality of c2 but acquires the labial quality of c3 in the target segment. a review of the data indicated that there was a frequent collapse of 2-element and 3-element cluster segments into one element in all cases. in a.m.'s system, the sound preference or neutralization process (weiner, 1979) was /(/ as in j/sl, |/sk, ]/spl, (r/skw. in f.t.'s system, there were two sound preferences, /]/ and if i as in j/skw, j/str, f/skw, f/spl, f/bl, f/gr, fr/skw, fl/spr. in e.j.'s system there were three sound preferences /(/, if i and isl as in j/str, j/skw, f/)r, f/kw, s/0r, s/fr s/tw. therefore the blade-palatal fricative / / was a favourite sound strategy in all cases, the labiodental fricative if i was common to f.t. and e.j., and the tip-alveolar fricative isl was an additional favourite sound strategy in e.j.'s system. the processes of reduplication, cluster contraction and epenthesis were operating in all cases, although less commonly table 3 a distribution of errors on cvc and ccvc words according to phonological processes no. and % of errors naming spontaneous phonological process a.m. f.t. e.j. a.m. f.t. e.j. no % no % no % no % no % no % syllable 1. deletion of final consonant structure 2. weak syllable deletion processes 3. cluster reduction feature merging 4. reduplication 5. cluster contraction 6. epenthesis / vowel / consonant 49 5,94 32 3,88 123 14,93 (34)* (27,64) 1 0,12 6 0,73 24 2,39 (11) (45,83) (13) (54,17) 51 12,17 35 8,35 89 21,24 (14) (15,73) 7 1,67 0 , 0 10 2,39 (2) (20,00) (8) (80,00) 13 5,78 4 1,78 39 17,34 (8) (20,51) 1 0,44 1 0,44 6 2,67 (4) (66,66) (2) (33,33) 40 6,23 66 10,28 58 9,04 (20) (34,48) 4 0,62 2 0,31 24 3,74 (7) (29,17) (17) (70,83) 46 9,74 71 14,61 40 8,23 (7) (17,50) 4 0,82 3 0,62 7 1,44 (2) (28,57) (5) (71,43) 14 4,64 30 9,93 48 15,89 (3) (6,25) 1 0,33 5 1,66 9 2,98 (3) (33,33) (6) (66,66) i harmony 7. assimilations processes a) progressive (p.a.) b) regressive (r.a.) initial consonant devoicing final consonant devoicing prevocalic voicing labial assimilation alveolar assimilation velar assimilation nasal assimilation 8. metathesis feature metathesis 29 3,52 62 7,52 15 1,82 16 1,94 9 1,09 21 2,55 41 4,98 13 1,58 10 1,21 30 3,64 (13) (43,33) 18 4,30 28 6,68 4 0,96 13 3,10 13 3,10 6 1,43 30 7,16 2 0,47 2 0,47 11 2,63 (7) (63,64) 11 4,89 27 12,00 3 1,33 7 3,11 4 1,78 14 6,22 13 5,78 2 0,89 2 0,89 1 0,44 (0) (0) 22 3,43 50 7,79 10 1,56 4 0,62 7 1,09 21 3,27 36 5,61 3 0,46 9 1,40 16 2,49 (8) (50,80) 26 5,35 33 6,79 12 2,47 6 1,23 11 2,26 14 2,88 30 6,17 2 0,41 6 1,23 12 2,47 (9) (75,00) 13 4,31 29 9,60 8 2,65 2 0,66 3 0,99 4 1,33 31 10,27 2 0,66 2 0,66 6 1,99 (1) (16,67) feature 9. stopping : contrast 10. fronting , processes 11. denasalization 12. nasal substitutions 13. gliding ' 14. velar substitutions 15. liquidation 16. interchange of /i/ and iii 17. frication 18. affricatian 19. vocalization (weakening) 66 8,01 93 11,29 12 1,46 27 3,28 16 1,94 23 2,79 27 3,28 49 5,94 4 4,9 26 3,16 0 0 9 2,15 29 6,92 2 0,47 7 1,67 4 0,96 5 1,19 11 2,63 12 2,86 4 0,96 8 1,91 9 2,15 14 6,22 28 12,45 2 0,89 5 2,22 5 2,22 4 1,78 6 2,67 1 0,44 5 2,22 5 2,22 2 0,89 47 7,32 103 16,04 17 2,65 13 2,03 9 1,40 7 1,09 29 4;52 36 5,61 4 0,62 4 0,62 1 0,16 22 4,53 80 16,46 9 1,85 10 2,06 4 0,82 8 1,65 10 2,06 6 1,23 5 1,03 0 0 9 1,86 19 6,29 44 14,57 5 1,66 3 0,99 3 0,99 2 0,66 8 2,65 5 1,66 2 0,66 1 0,33 3 0,99 total i 824 100 419 100 225 100 642 100 486 100 302 100 * those, numberscenclosedibetween brackets are sub-divisions of major categories and are therefore not included in the totals of each column. die-suid-afrikaanse jyuikrifvir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 lesley wolk than those processes discussed above. reduplication reflects the patients' awareness of the number of syllables in a given word, though he may not have the ability to produce the variety of syllables in sequence. for epenthesis in all cases, the insertion of a consonant was usually slightly more common than the insertion of a vowel for both tasks. an observation of the data showed that in vowel epenthesis, the vowel most commonly used in all cases was the mid schwa /a/, whilst in consonant epenthesis, a.m. used nasals, stops and liquids, f.t. and e.j. used nasals, stops, liquids and fricatives. cluster contraction was used less commonly. an observation of the data showed that when it was employed however, it was more likely to result in a voiceless rather than a voiced affricate. the common use of cluster reduction in aphasic patients with apraxia of speech is well documented in the literature (blumstein, 1973). the interesting observation in the present study was the finding that when clusters were reduced the error segment could reflect an extraction of select features of one or more of the target elements, a phenomenon referred to in this study as 'feature merging'. feature merging occurred in each case, but was found to be most common in case 1 (the most severe case), and least common in case 3 (the least severe case). this would seem to imply a simultaneous processing (decoding and encoding) of features comprising different phonemes. further evidence is provided by the observation noted during testing that in each case occasional error utterances seemed to reflect the simultaneous production of two elements of a cluster. the intrusive schwa comprised the major part of vowel epenthesis, a process commonly reported in previous reports (klich et al., 1979). blumstein (1973) observed epenthesis of schwa and stop consonants, and she feels that these errors are often motivated by the particular environment in which they occur. harmony processes harmony processes were generally common in the system of these cases. assimilations occurred more commonly than metatheses and in each case regressive assimilations (anticipatory errors) outnumbered progressive assimilations (post-positioning errors) on both naming and spontaneous tasks. for a.m. and e.j. regressive assimilation occurred twice as frequently as progressive assimilation, while the difference was slightly narrower for f.t. it may be observed in table 3 that there was a striking predominance of alveolar assimilation on both tasks for all cases. there was a prevalence of alveolar and labial assimilation for a.m. and e.j. velar and nasal assimilation occurred less commonly. other assimilatory processes such as prevocalic voicing, initial and final consonant devoicing occurred, though less commonly in all cases. assimilations took place not only with respect to syllables, phonemes or distinctive features within the boundary of a word, but also to those across word boundaries. most errors occurred within a word. metathesis occurred commonly in a.m.'s system, less commonly in f.t.'s system and was uncommon in e.j.'s system. a subcategory of metathesis was developed to indicate a reversal of individual features as opposed to reversal of an entire phoneme, which will be referred to as 'feature metathesis'. feature metathesis comprised a major part of the total number of errors reflecting metathesis in the cases of a.m. and f.t., while only one instance of feature metathesis was noted on spontaneous tasks in the case of e.j. in f.t., for example, 63,64% and 75,00% of metathesis errors were seen to occur on naming and spontaneous tasks respectively. the general trend that regressive assimilation occurred more commonly than progressive assimilation and that metathesis was less predominant, is consistent with previous findings (blumstein, 1973; itoh, sasanuma and ushijima, 1979). by contrast sasanuma (1971) found metathesis to be more common than assimilation, but it is of interest to note that he found a similar occurrence of feature metathesis in his patients. the findings of feature metathesis contributes to the viewpoint discussed above that these patients may have simultaneous processing (decoding and encoding) of features comprising different phonemes. according to itoh et al. (1979), the coarticulatory phenomenon in aphasic patients, especially anticipatory coarticulation, can be regarded as some manifestation of cortically generated motor programming. the analysis of data from a coarticulatory point of view thus seems to indicate that some 'future scanning' appears to be operating in these patients with apraxia of speech, so that for example, the articulatory gestures for the following segments are brought into the preceding segments. anticipations, perseverations and transpositions of speech sounds occur in normal speakers and have been referred to as 'slips of the tongue' (fromkin, 1971). feature contrast processes several processes governing the substitution of one sound for another were operating in each case. it may be observed in table 3 that fronting and stopping were clearly the two feature contrast processes most commonly used, where fronting was more common than stopping. fronting and stopping were predominant for a.m. and e.j., yet fronting alone was most common for f.t. other processes operating for all cases were denasalization, nasal substitutions, velar substitutions, liquidation, interchange of /]/ and /r/, frication, affrication, vocalization and gliding. a review of the data showed that in the process of gliding, the substitution of /w/ was generally more common than /j/ in all cases. i these findings are consistent with previous research (critchley, 1952; blumstein, 1973). specifically, the prevalence of stopping, in patients with apraxia of speech, has beein highlighted (klich et al., 1979). in support of the universality of language dissolution, peuser and fittschen (1977) found some similar phonological processes, such as stopping and denasalization, to be operating in a case of a turkish aphasic, and thus feel that "phenomic disorders due to aphasia seem to have a regular and universal character" (peuser and fittschen, 1977, p. 202). thus in common with blumstein (1973), it can be concluded that many of the error types found in these aphasic adults with apraxia of speech, do in fact reflect the natural phonological processes which operate in all languages. in this study the same phonological processes were seen to be operating for both singletons (cvc) and clusters (ccvc), providing evidence for the systematic jgovernment of articulation errors. blumstein (1973) showed that phonological error patterns were systematic within groups and were similar across groups of aphasic adults. it might be valuable to investigate further whether phonological errors in other aphasic types (with varied lesions) y the south african journal of communication disorders, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) phonological and neuroanatomical findings in three cases with apraxia of speech 41 could be characterized by similar natural phonological processes as found for the broca's aphasic cases of this study. the data in this study refer to the speech samples of three adult cases. they therefore clearly cannot form the basis for any extensive comparison with the development of speech in children. however, the findings suggest that there are some differences between the phonological dissolution in these apraxic cases and phonological acquisition in the child, but that the general patterns in these adult cases resemble those used by children. the reader is referred to wolk (1982b) for a further discussion. during the course of eliciting phonological data it became clear that all cases tended to employ a number of different strategies to aid phonological production. self-employed strategies were used on naming and spontaneous narrative tasks in their struggle with successive attempts towards the target utterance. the following strategies will be discussed below: 1. revisualization of the written word. 2. use of semantic associations. 3. silent articulations. 4. reduced speech rate. 1. revisualization of the written word case 1 (a.m.) and case 2 (f.t.) were frequently able to evoke clear-cut mental images of the written words and could operate with these mental images, while they were completely unable to articulate them. a.m. could spell the appropriate letter(s) of a target word out aloud, although he could not produce them phonically, for example "y" for "yacht", "g" for "frog" and "c,q" for "squirrel". it may be noted that he arbitrarily selected a letter from the initial or final word position. furthermore, he spelled out aloud the letters "s", "k", "y" for the word "sky", but could not articulate the word as a whole. he was often noted to recall the number of letters comprising a target word, such as "three letters" for "zoo". on one occasion a.m. was seen to perform the mechanical movements of writing with his j fingers in an attempt to spell the word, i.e. "x, y, ζ . . . zed" for "zoo". it thus appeared that he was mechanically converting sound sequences into graphic symbols. j f.t. was also noted to spell the words put aloud in order to facilitate articulatory production. the interesting feature noted in this case was that the articulatory error production often reflected a revisualization of the visual representation of the word (the graphic symbols) rather than the phonic representation (the acoustic image). for example /i d t j . . . j dtj/ and /i dtj . . . t| d:/ were successive attempts at the target word "yacht". it can be observed here that the error utterances show possible signs of interference from f.t.'s visual associations with spelling pronunciation variants. the finding that these cases recall printed letters in order to aid articulatory production is consistent with previous literature (nebes, 1975). 2. use of semantic associations all cases were seen to employ a carrier phrase with semantic relevance in order to aid articulatory production. this tendency was the most prominant in f.t. table 4 provides an example from the data for f.t., illustrating how he uses several semantic associations in order to recall the target item 'zebra'. here it can be seen that some basic features of the object to be named are distinguished. buckingham and rekart (1979) state that this necessitates a clear image of the object on the one hand, and a well-organized acoustic-phonologic structure of the appropriate name on the other. for further discussion, refer to wolk (1982b). table 4 an example of the use of semantic associations to recall the target item 'zebra' by f.t. target word error utterances in the sequence as produced by c2 zebra /z zlfva zfba blfva taijki hd:s r . . . . straips/ 3. silent articulations it was observed during elicitation procedures that all cases used subvocal activity to aid articulatory production. this was in the form of continually moving articulatory structures groping to find correct postures. on presentation of a stimulus item a.m. and e.j. were sometimes noted to monitor themselves silently using covert articulations prior to producing the word aloud. similar behaviour was seen for f.t., although his covert articulations seemed to be combined with an audible whisper, and it was noted that for f.t. the labiodental fricative /f/ was commonly used during repeated trials of subvocal activity. an interesting observation was that f.t. often achieved correct articulation during whispering but not with voicing. this would suggest that one of the manifestations of the difficulty in this case with apraxia of speech, might be the co-ordination between articulatory and phono-respiratory mechanisms. these findings are consistent with studies reported in the literature pertaining to both normal subjects and cases with apraxia of speech (mcguigan, 1970; warren, 1977). mcguigan (1970) demonstrated that in normal adults internal verbal processes (rehearsal) are usually accompanied by small, covert movements of the lips, tongue and larynx which may be referred to as 'implicit speech'. mcguigan (1970) further states that as the performance of a task becomes more automatized, both the amplitude and the frequency of occurrence of these movements tend to decrease, which led to the suggestion that covert oral activity plays an important role in language. nebes (1975) in common with warren (1977) contends that patients with apraxia of speech have relatively intact implicit speech patterns. for the cases in this study, it is interesting to note that the amplitude and frequency of covert articulatory movements were significantly less in e.j. than in a.m. and f.t., suggesting that in the more severe cases of this study, automaticity of the articulatory movements was more impaired. in an attempt to extrapolate from various proposals put forward by nebes (1975), the following theoretical possibilities can be considered: (a) whether covert oral activity in these cases may in feet fecilitate processing of articulatory images in the presence of possible auditory feedback disturbance, and die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 lesley wolk (b) it may be that proprioceptive/kinaesthetic feedback from the muscles of articulation, which in these cases was felt to be disrupted (noted on oral stereognostic findings, which are not discussed in this paper), is an important factor in formulating an internal representation of the articulatory form. 4. reduced speech rate finally a most significant observation was that all cases, particularly a.m., tended to reduce speech rate during their struggle with successive attempts towards the target utterance. this together with their deliberate syllabification of words was seen to aid correct production. this finding seems to highlight the importance of temporal sequencing in articulatory production and has obvious clinical implications. neuroanatomical findings the ct scans for each case are presented below (see figures 1, 2 and 3). figure 1 case 1: a.m.'s ct scan showing cerebral infarction involving mainly the (l) parieto-occipital region and extending towards the island of reil (insula) on the (l) side. figure 2 case 2: f.t. 's ct scan showing cerebral infarcts in the (l) parieto-frontal region involving broca's area and in the (r) parieto-occipital region. figure 3 case 3: e.j.'s ct scan showing cerebral infarction involving the (l) parietal region extending towards the'vertex and interiorly to the (l) island of reil (insula) and upper temporal lobe. table 5 summary of ct scan results for all cases case 1 a.m. case 2 f.t. case 3 e.j. | (l) parieto-occipital region, extending towards the island of reil (insula) on the (l) side a) (l) parieto-frontal region including broca's area b) (r) parieto-occipital region c i (l) parietal region, extending towards the vertex, interiorly to the island of | reil (insula) and upper temporal region on the (l) side moderate degree of cerebral atrophy generalized cerebral atrophy ct scan asymmetry of lateral ventricles (left larger than right) asymmetry of lateral ventricles, where (l) lateral ventricle is more dilated than (r) ventricle widening of sylvian fissure on (l) side generalized dilation of ventricular system, and widening of sulci over the vertex widening of sylvian fissures bilate, rally (left more than right) / no displacement of midline structures no displacement of midline structures no displacement of midline structures .. ^ no abnormal enhancement occurred after contrast some peripheral enhancement of lesion in (l) broca's area occurred after contrast no abnormal enhancement occurred after contrast / the south african journal of communication disorders, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) phonological and neuroanatomical findings in three cases with apraxia of speech 43 the results will be discussed in relation to current research in the neuroanatomical correlates of language. each case discussed presents with the major neurological insult in the dominant (l) hemisphere. in the cases of a.m. and e.j., the major lesion is in the (l) hemisphere. in the case of f.t., the major lesion is in the (l) hemisphere with a minor lesion in the (r) hemisphere, which is said to have resulted from a mild transient (r) hemispheric cerebral embolus suffered previously. . . . a major function of the left hemisphere is the control of changes in limb or articulatory posture, and its complex verbal and praxic functions are derived from such control. (kimura, 1977, p. 540) here kimura (1977) suggests that the (l) hemisphere contains a system specialized particularly for producing the correct articulatory posture, and consequently also for controlling the transition from one position to another. halsey, blauenstein, wilson and wills (1980) studied regional cerebral blood flow measurements in normal speakers and speakers with brain lesions. they found that in normal speakers during verbal activation, there were significant increases above rest level in the inferior frontal region, roughly corresponding to broca's area. there were no significant differences between (l) and (r) hemisphere regions. according to halsey et al. (1980), this relative symmetry of response suggests that probably relatively little intellectual effort is involved in ordinary speaking, and that the bilateral inferior frontal principle activation mainly reflects bilateral cortical control of the muscles of articulation. further measurements were made during attempted speaking in patients with (l) and (r) hemisphere lesions. in the (l) hemisphere lesion group, the largest flow changes were in the inferior frontal and temporal regions bilaterally. the only interhemispheric significant difference was in the parietal region in the (l) hemisphere lesion group. these findings are of particular interest in relation to the neurological findings of the cases in the present study. it may be observed that ct scans for ea£h case revealed involvement of the parietal region. x i many years ago liepman forecast that lesions permitting the appearance of apraxia ('facial apraxia' and 'apraxic dysarthria' now referred to as 'apraxia of speech') would be found in the parietal lobes, in the preand post-central gyri and the foot of the first two frontal gyri, with the subjacent part of the centrum semi-ovale, and the corpus callosum (nathan, 1947). according to buckingham (1979), the supramarginal gyrus is a crucial zone for the discussion of apraxia in general and of apraxia of speech. he states that: although it is a cortical area of the parietal lobe strategically located for the language zones, it is also anatomically quite near the arcuate fasciculus fibers traveling through opercular regions. (buckingham, 1979, p. 212.) lebrun, buyssens and henneaux (1973) describe a' single case with 'pure anarthria' who suffered a vascular accident in the (l) parietal lobe. the patient presented clinically with apraxia of speech, an absence of bucco-facial apraxia and no paralysis. in a more recent case study, investigations of an apraxic patient showed a lesion in the (l) parietal region (di simoni and darley, 1977). itoh, sasanuma, hirose, yoshioka and ushijima (1978) reported on ct scan findings in a patient with apraxia of speech, indicating an infarct involving the cortical surface near the anterior tip of the sylvian fissure of the (l) hemisphere and the immediately subjacent white matter. f.t.'s ct scan revealed a well marked lesion in broca's area on the (l) side. evidence in the literature suggests that a lesion in broca's area will result in disintegration of skilled coordinated movements of the articulatory organs, referred to as motor apraxia of speech (whitaker and seines, 1975; mohr, pessin, finkelstein, funkenstein, duncan and davis, 1978). it is probably not possible to identify a unitary aspect of speech with a delimited cortical area in the narrow sense, given the present state of our knowledge and methodology. while broca's area is not felt to have a unitary function, there is recent evidence to support the general hypothesis that broca's area is specialized for certain expressive (motor) components of language, particularly speech or articulatory parameters (whitaker and seines, 1975). goodglass and geschwind (cited in whitaker and seines, 1975, p. 92) have stated that: . . . injuries in this area (broca's area) appear to implicate most directly but not exclusively the phonological and graphic aspects of language. in a recent study, ruff and arbit (1981) describe a single case with 'aphemia' (apraxia of speech), whose ct scan reflects injury extending from broca's area to the inferior left precentral gyrus. these writers suggest that the articulatory disturbance which they refer to as 'aphemia' may have resulted from disruption of the connection between broca's area and the portion of the motor cortex that controls oral and pharyngeal muscles. mohr et al. (1978) have found that when a lesion lies outside broca's area and focally affects other adjacent sites in the operculum or insula, and even in a few instances apparently affects the deeper structures alone, the resulting syndromes are remarkably uniform, including dyspraxia and faint evidence of language disturbance. this provides some support for the findings in the present study, where a clearly identified lesion in broca's area was observed on the ct scan for f.t., but not for a.m. and e.j. the neuroanatomical findings in each case under study reflect lesions in the areas similar to those described in broca's original patient. broca, in describing the brain of his original aphasic patient, noted a large lesion encompassing the (l) insula, frontal, central and parietal operculum, and even extending into the adjacent inferior parietal region posterior to the sylvian fissure (mohr et al., 1978). he attributed this patient's aphasia to involvement of the frontal operculum, but not to the overall lesion. thus we see his readiness to emphasize only a small, focal portion of the overall lesion. mohr et al. (1978) feel that by modern standards, the initial physiologic basis for broca's clinico-pathological correlations seems dubious, and yet, the concept of an aphasia produced by infarction of the broca area has persisted. recent literature thus highlights the constraints produced by dogmatic adherence to the traditional formulation of the syndrome referred to as broca's aphasia, resulting from infarction of the broca's area. it is currently felt that the syndrome arises from a considerably larger brain injury in the sylvian region, that encompasses most of the operculum, insula and subjacent white matter in the territory of the middle cerebral artery serving the dominant cerebral hemisphere; thus far exceeding broca's area. this in fact conforms more to the die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 lesley wolk large zone of damaged brain actually present in broca's original cases (roch-lecours and lhermitte, 1976). mohr et al. (1978) together with whitaker and seines (1975) contend that broca's aphasia emerges as a residuum of a larger infarct which initially produces global aphasia. they suggest that there is a gradual emergence of stereotypes, agrammatism and protracted apraxia of speech which evolve slowly towards the long-standing deficit profile of broca's aphasia. conclusion from the discussion above, it is concluded that there is a certain lawfulness to the apraxic impairment in these adult aphasic patients. articulation errors on single consonants and consonant clusters were characterized by systematic rule-governed behaviour. in each case, it was possible to trace underlying phonological processes which fit into strategy groups operationalizing particular phonetic preferences. the major process groups included a tendency for less complex syllable structures to replace more complex ones, a tendency towards phonetic symmetry and a tendency for errors to result from a lack of feature contrasts. in syllable structure processes, cluster reduction, deletion of final consonants and weak syllable deletion were most common. harmony processes were generally common, where assimilations occurred more frequently than metatheses and regressive assimilations outnumbered progressive assimilations. in feature contrast processes, fronting and stopping were clearly most common. similar error trends occurred on both singletons and clusters for all cases. analysis from a coarticulatory point of view indicated that some 'future scanning' appeared to be operating in these patients with apraxia of speech, resulting in assimilatory processes, feature merging and feature metathesis. it is thus argued that the impairment in these cases may not be confined to the motor aspects of speech, but probably extends into the linguistic spheres as well. this suggests that descriptions of apraxia of speech and clinical treatment regimes should perhaps consider both linguistic and articulatory variables. all cases employed a number of strategies to aid phonological production. this has several theoretical implications. in particular, revisualization of the written word and the use of silent articulations may indicate the preservation of relatively intact implicit speech patterns in these cases. all cases made several errors which were semantically related to the target word, yet fully explicable phonologically. this, combined with the fact that a carrier phrase with semantic relevance was often employed to aid phonological production, would suggest simultaneous semantic and phonological processing in these cases. this highlights direction for further research into the simultaneous processing or overlap between the levels of language in the aphasic patient. reduced speech rate was seen to facilitate improved phonological production, which may suggest a disruption in timing for these cases. the neuroanatomical findings suggest that apraxia of speech in these cases may result from some synergistic interaction between several areas of the brain rather than a specific localized area. this is in agreement with the view proposed by roch-lecours and lhermitte (1976) who suggest that particular language functions may be the result of an interaction of the entire opercular and insula regions. the findings indicate that apraxia of speech for these subjects does not appear to exist as a separate entity, but rather as a part of the total aphasic breakdown. parietal involvement suggests that enhanced kinaesthetic awareness and tactile discrimination of speech sounds should perhaps be more emphasized in therapy than has previously been considered. the fact that the brain lesion in each case was more extensive than would be expected in the traditional concept of a focal lesion in broca's area, would seem to suggest an orientation away from rigid diagnosic differentiation between broca and wernicke aphasic types. in this way, the speech pathologist might take cognisance of symptoms which could otherwise be overlooked. a phonological process analysis may form the basis for therapy by providing a way of describing the adult aphasic's phonological system as an entity, and allowing the clinician to isolate individual phonological processes contributing to unintelligibility. entire processes may thus be the focus of therapy rather than isolated sounds. clinically, it may be useful to explore the value of graphic symbols, covert articulatory movements and enhanced kinaesthetic awareness in the management of patients with apraxia of speech. in addition, treatment procedures involving rhythm, rate and syllable timing might be fruitful for future research. it is hoped that these findings will stimulate future investigations to improve both diagnostic and therapeutic efficacy and contribute to the endless search in understanding one of the most complex disorders of the human brain. acknowledgements the writer wishes to offer her sincere thanks to professor m. l. aron, head of the department of speech pathology and audiology and dr. c. penn, senior lecturer in the department of speech pathology and audiology, university of the witwatersrand, for their guidance and support in carrying out this research. for financial assistance, the writer is grateful to the human sciences research council and the witwatersrand university senior bursary fund. ι references blumstein, s. e. a phonological investigation of aphasic speech. brown university and aphasia research centre, boston, the hague: mouton and co., 1973. | bowman, c. a. a process analysis of verbal apraxia. paper presented at the annual american speech-languagehearing association (asha) convention, toronto, canada, november, 1982. buckingham, h.w. explanation in apraxia with consequences for the concept of apraxia of speech. brain lang., 1979, 8, 202-226. buckingham, h. w. & rekart, d. m. semantic paraphasia.,/ commun. disord., 1979, 12(3), 197-209. cohen, j.α., gelfer, c.e. and sweet, r.d. 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patient with apraxia of speech. brain lang., 1979, 7, 227-239. kimura, d. acquisition of a motor skill after left hemisphere damage. brain, 1977, 100, 527-542. klich, r. j., ireland, j. v. and weidner, w. e. articulatory and phonological aspects of consonant substitutions in apraxia of speech. cortex, 1979, 15,(3) 341-470. lebrun, y., buyssens, e. & henneaux, j. phonetic aspects ofanarthria. cortex, 1973,19, 126-135. / i martin, a. d. some objections to the term apraxia of speech'. j. speech hear. dis., 1974] 39(1), 53-64. martin, a. d. and rigrodsky, s. an investigation of phonological impairment in aphasia, part 1: cortex, 1974(a), 10(4) 317-328. i ι martin, a. d. and rigrodsky, s. an investigation of phonological impairment in aphasia, part 2: distinctive feature analysis of phonemic commutation errors in aphasia. cortex, 1974(b), 1064), 329-346. mcguigan, f. j. covert oral behaviour during the silent performance of language tasks. psychol. bull., 1970, 74, ' 309-326. mohr, j.p., pessin, m.s., finkelstein, s., funkenstein, η.η., duncan, g. w. and davis, k. r. broca aphasia: pathologic and clinical. neurology, 1978, 28, 311-324. moore, w.m., rosenbek, j.c. and la pointe, l. l. ayiessment of oral apraxia in brain-injured adults. proceedings of clinical aphasiology conference, portland, oregon, may, 1976. nathan, p. w. facial apraxia and apraxic dysarthria. brain, 19487, 70, 449-478. nebes, r. d. the nature of internal speech in a patient with aphemia. brain. lang., 1975, 2, 489-497. peuser, g. and fittschen, m. on the universality of language dissolution: the case of a turkish aphasic. brain, lang., 1977, 4, 196-207. roch-lecours, h. and lhermitte, f. the pure form of the phonetic disintegration syndrome (pure anarthria). brain. lang., 1976, 3, 88-113. ruff, r. l. and arbit, e. aphemia resulting from a left frontal hematoma. neurology, 1981, 31, 353-356. sarno, μ. t. and levita, e. natural course of recovery in severe aphasia. arch. phys. rehabil., 1971, 52, 175-178. sasanuma, s. speech characteristics of a patient with apraxia of speech. section of communication research, department of rehabilitation medicine. tokyo metropolitan institute of gerontology, tokyo, japan. 1971. warren, r.l. rehearsal of naming in 'apraxia of speech'. proceedings of clinical aphasiology conference, 1977. 80-90. weiner, f. f. phonological process analysis. baltimore: university park press, 1979. whitaker, h. a. and seines, o. a. broca's area: a problem in language-brain relationships. linguistics an international review, 154/155, june 15, 1975, 91-101. wolk, l. phonological impairment in aphasia. paper presented at the annual american speech-language-hearing association (asha) convention, toronto, canada, november, 1982(a). wolk, l. phonological impairment in aphasia. unpublished dissertation submitted to the department of speech pathology and audiology, university of the witwatersrand, johannesburg, south africa, 1982(b). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 31, 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gsi 28 auto tymp the gsi 28 auto tymp provides testing capability for tympanometry, ipsilateral and contralateral acoustic reflex testing and screening audiometry. selection of test sequence is as simple as pressing a button! the" auto tymp is lightweight and compact so it can be easily moved from one location to another. an optional carrying case is available if more portability is required. the needier westdene organisation (pty) limited in association with / in medewerking met hearing and acoustic instruments (pty) ltd lewis's hearing centre (pty) ltd engineered acoustic products noise control needier westdene house, 33 durham st., raedene, p.o. box 28975, sandringham 2131, south africa. johannesburg 2192, south africa. telex: 4-25028. tel: (011) 640-5017. cables: needlerog. the south african journal of communication disorders, vol. 31 1984 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 23 'η ondersoek na die ekspressiewe kommunikasievermoens van premature hoerisikokinders helene j.e. smit, b.log (pretoria) brenda louw, d.phil (pretoria) isabel c. uys, d.phil (pretoria) departement spraakheelkunde en oudiologie, universiteit van pretoria. opsomming . die ekspressiewe kommunikasievermoens van ses afrikaanssprekende hoerisikokinders tussen die ouderdom dertig tot sewe-en-dertig maande is geevalueer aan die hand van die drie taaldimensies, naamlik taalvorm, taalinhoud en taalgebruik, aangesien kliniese bewyse daarop dui dat vertraagde taalontwikkeling meer algemeen onder premature hoerisikokinders voorkom. 'n beeld van die ekspressiewe kommunikasievermoens van die kinders is verkry, en daar is gevind dat die proefpersone 'n beperkte ekspressiewe woordeskat sowel as 'n ontwikkelingsagterstand van ekspressiewe kommunikasievermoens vertoon. die belang van die rol van die spraakterapeut m die vroee identifisering, evaluasie, behandeling en opvolg van die kommunikasievermoens van premature jong kinders, word deur die bevmdings van hierdie studie beklemtoon. abstract the expressive communicative ability of six afrikaans speaking high-risk children between the ages of thirty to thirty seven months was evaluated on the basis of the three dimensions of language form, language content, and language use, as clinical evidence points to the fact that retarded language development more often occurs amongst premature high-risk children. a picture of the communicative ability of the children was obtained and it was found that the subjects tested manifested a limited expressive vocabulary as well as a developmental retardation of expressive communicative ability. the importance of the role of the speech therapist with regard to the early identification, evaluation, treatment and follow-up of the communicative ability of premature young children is emphasised by the findings of this study. vroee diensleweringsprogramme vir jong hoerisikokinders word tans deur verskeie ontwikkelingspesialisasiegebiede gepropageer in 'n poging om die invloed van hoerisikofaktore op die kind se ontwikk'eling te modifiseer of selfs te oorkom (liebergott, bashir enlschultz, 1984). belangstelling in die unieke behoeftes van hoerisikokinders het in die afgelope twee dekades toegeneem, en het gelei tot die ontwikkeling van die relatief nuwe vakgebied van vroee intervensie by hoerisikokinders deur 'n multi-dissiplinere span. die hoerisikobaba is 'n baba by'wie daar as gevolg van verskeie faktore wat tydens die prenatale, perinatale en neonatale geskiedenis voorkom, 'n groter as normale risiko bestaan dat hy 'n ontwikkelingsagterstand en later potensiele ontwikkelingsprobleme sal vertoon. geboortegewig en gestasie-ouderdom word as die primere bepalers van hoerisikostatus beskou (rosetti, 1986). prematuriteit word deur liebergott et al. (1984) omskryf as 'n biologiese risikofaktor wat inmeng met die ontwikkelende sentrale senuweestelsel wat die moontlikheid van latere afwykende ontwikkeling verhoog. usher (in rossetti, 1986) kategoriseer prematuriteit op grond van die graad daarvan en hy onderskei tussen drie kategoriee, naamlik grensprematuriteit (37-38 weke); matige prematuriteit (31-36 weke) en ekstreme prematuriteit (24-30 weke). kliniese bewyse dui daarop dat vertraagde taalontwikkeling meer algemeen onder premature hoerisikobabas voorkom, maar daar is min empiriese bewyse ter stawing van hierdie verskynsel (hubatch, johnson, kristler, burns en moneka, 1985). die belang van deeglike ondersoek van die taalen kommunikasieontwikkeling van jong hoerisikokinders, met die oog op die vroee identifisering en behandeling blyk duidelik uit die literatuur (marge, 1984; louw, 1986). aram en nation (1980) en strominger en bashir (1977) is van mening dat vroee versteurings van taalen spraakontwikkeling die voorlopers van latere leerprobleme is. vertraagde en afwykende spraak-, taalen gehoorontwikkeling word dikwels eers ge'identifiseer wanneer die kind skoolgaande ouderdom bereik. op daardie stadium het die kritiese taalaanleerperiode reeds verstryk, en taalopleidingsprogramme kompenseer nie altyd voldoende vir die verlies aan tyd tydens die normale ontwikkelingsperiode nie (ehrlich, shapiro, kimball en huttner, 1973; cole, 1982). afwykende taalvermoens kan ook 'n nadelige invloed uitoefen op die kind se interpersoonlike groei, verwerwing van kennis en vaslegging van 'n eie identiteit (cole, 1982). dit blyk dus dat die voorkoms van hoerisikotoestande in die kind se ontwikkelingsgeskiedenis daarop dui dat die kind onder 'n groter risiko vir die ontwikkeling van kommunikasieprobleme verkeer (liebergott et al. 1984). liebergott et al. (1986) is egter van mening dat slegs longitudinale studies van jong hoerisikokinders se taalontwikkeling, die vroee identifisering van die jong hoerisikokinders wat latere taalprobleme kan ontwikkel moontlik sal maak. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 © sasha 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 van wee die huidige gebrekkige navorsing oor die kommunikasievermoens van hoerisikokinders, en die negatiewe gevolge wat vroee kommunikasieafwykings op latere ontwikkeling kan he, word die volgende vrae gestel: hoe vertoon vroee kommunikasieontwikkeling van premature hoerisikokinders en is hulle kommunikasieontwikkeling van so aard dat dit later ontwikkeling wel kan benadeel? 'n algemene kenmerk van prematuur gebore jong kinders is 'n vertraagde taalontwikkeling (kastein en fowler, 1959 en field, dempsey en shuman, 1979). 'n beduidende vertraging in die ekspressiewe en reseptiewe taalvermoens van premature jong kinders is deur verskeie navorsers gei'dentifiseer (hubatch et al. 1985, en wright, thistlewaite, elton, wilkinson en forfor, 1983). hierdie kinders vertoon ook dikwels 'n beperkte aantal uitinge as gevolg van 'n beperkte ekspressiewe woordeskat, asook woordvindingsprobleme, probleme met sinsuitbreiding, die verskaffing van definisies van begrippe, 'n vertraging in die produksie van sinne en die weergee van gegewe getikte ritmepatrone (hubatch et al. 1985 en de hirsch, jansky en langford, 1964). volgens hubatch et al. (1981) is hierdie kinders ook onderhewig aan die ontwikkeling van latere kommunikasieprobleme. 'n hoe voorkoms van leesprobleme is onder prematuur gebore kinders gei'dentifiseer, wat nie net in geskrewe taal nie, maar ook in gesproke taal manifesteer (douglas, 1960; pasamanick en knobloch, 1960; benton, 1962). vertraagde spraakontwikkeling, wat dikwels nog tot op skoolgaande ouderdom voorkom, kom ook algemeen onder hoerisikokinders voor (fitzhardinge, 1980). jong hoerisikokinders presenteer dikwels met konduktiewe gehoorverliese, wat ook tot vertraagde spraaken taalontwikkeling kan lei (northern en downs, 1984; hubatch et al. 1985). aangesien vroee kommunikasieprobleme in 'n latere globale kommunikasievertraging kan presenteer, is die vroee identifikasie en gereelde opvolg van hierdie kinders van kardinale belang (hubatch et al. 1985). die toepassingswaarde van bogenoemde studies in terme van die vroee identifisering en die behandeling van hoerisikokinders is egter beperk as gevolg van metodologiese verskille tussen die studies (liebergott et al. 1984). ten spyte van die beperkte navorsing en die uiteenlopende aard van die beskikbare navorsing oor die kommunikasieontwikkeling van jong hoerisikokinders, dui bevindinge op die voorkoms van vroee kommunikasieprobleme en die belang van vroee ingryping om hierdie probleme te identifiseer en op te hef (marge, 1984; louw, 1986). daar bestaan egter 'n gebrek aan skakeling tussen eksperimentele navorsing en die kliniese praktyk. slegs enkele hoerisikokinders word in die kliniese praktyk na die spraakterapeut verwys vir ondersoek en behandeling. op grond van die belang van vroee ingryping wat in die literatuur uitgewys is, is die aandag wat aan jong hoerisikokinders in die praktyk geskenk word dus onvoldoende. vanwee die dringende behoefte wat bestaan aan verdere empiriese navorsing oor jong hoerisikokinders se kommunikasieontwikkeling, is die doel van hierdie studie die bestudering van die ekspressiewe kommunikasievermoens van afrikaanssprekende hoerisikokinders. metodologie doelstellings die hoofdoel van hierdie studie is om die ekspressiewe komh e l e n e j . . smit, brenda louw en isabel c. uys munikasieontwikkelingsvlak van 'n groep premature hoerisikokinders te ondersoek. bogenoemde doelstelling word bereik deur die evaluering en omskrywing van die proefpersone se taalinhoud, taalvorm en taalgebruik. proefpersoonseleksie die volgende kriteria van seleksie van proefpersone is gestel, naamlik: — prematuriteit al die proefpersone moes drie of meer weke prematuur gebore wees, dit wil se as grenslyn premature gevalle gediagnoseer wees. prematuriteit word as 'n biologiese risiko vir die ontwikkeling van kommunikasievermoens beskou (liebergott et al. 1984; rosetti, 1986). — ouderdom alle proefpersone moes tussen die ouderdom van 30 tot 36 maande wees aangesien die doel van die studie die bepaling is van die vroee ekspressiewe kommunikasieontwikkelingsvlak by jong kinders wat prematuur gebore is. — huistaal die kinders moes almal afrikaanssprekend wees, aangesien die doel van die studie die bestudering van die ekspressiewe kommunikasieontwikkelingsvlak van afrikaanssprekende hoerisikokinders is. — geassosieerde afwykings die proefpersone moes geen geassosieerde afwykings wat noodwendige kommunikasieprobleme tot gevolg het, byvoorbeeld breinskade, vertoon nie. (sien tabel 1.) voorlopig is 30 proefpersone uit die geboorte-rekords van die kraamafdeling van 'n provinsiale hospitaal, asook die geboorte-rekords van twee pediaters in privaat praktyke, deur middel van toevallige steekproeftrekking geselekteer. vanuit die 30 voorlopige proefpersone wat geselekteer is, jis ses kinders as proefpersone vir die studie geneem. 1 apparaat | i speelgoed is op grond van die kinders se belangstelling geselekteer vir ontlokking van 'n spontane taalmonster. 'n bandopnemer (sanyo model μ 4200) en oudio-kasette (emi sp 90) is benut vir die beoordeling van die proefpersone se ekspressiewe kommunikasikevermoens. die proefpersone se middeloorfunksionering is met behulp van 'n outomatiese siftingsimpedansmeter (tympanometer model 85 ar) bepaal. / materiaal die proefpersone se ekspressiewe kommunikasievermoens is geevalueer volgens hulle taalinhoud, taalvorm en taalgebruik (bloom en lahey, 1978) en word vervolgens in tabelvorm verskaf, na aanleiding van die drie dimensies van taal wat geevalueer is. (sien tabel 2.) the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η ondersoek na die ekspressiewe kommunikasievermoens van premature hoerisikokinders tabel 1: beskrywing van die proefpersone 25 kenmerke geslag van kind ouderdom van kind massa van kind by geboorte aantal weke prematuur probleme met gesondheid waar kind gedurende dag bly aantal kinders in gesin: seuns dogters hoeveelste kind in gesin is proefpersoon probleme met swangerskap en behandeling tipe geboorte posisie van kind by geboorte hulpmiddels gebruik by geboorte toestand van kind na geboorte beroep van ouers: moeder vader hoogste standerd geslaag: moeder vader naskoolse kwalifikasies: moeder vader ouderdom van: moeder [ vader i bj md jf jl cw rb vroulik vroulik vroulik manlik manlik manlik ': -naande 35 maande 34 maande 33 maande 30 maande 37 maande 1,5 kg 1,99 kg 2,73 kg 3,18 kg 2,9 kg 2,19 kg 7 weke 6 weke 3 weke 7 weke 3,5 weke 6 weke geen geen diken duru geen geen gereelde mangelderm probleme ontsteking en en blindederm swak tande is verwyder op 6e dag moeder moeder moeder ouma moeder & 2 dae by bediende en moeder by vriendin twee oggende in speelgroepie 0 0 1 1 2 1 1 1 1 0 1 1 eerste eerste tweede eerste derde eerste kalmeermiddels geen inspuiting, drup verwydering dreigende misplasentale vir emosionele en hospitalisasie van nierstene kraam afwyking skok op 7 mnde vir epilepsie op (dood van suster) 7 maande natuurlik natuurlik natuurlik natuurlik natuurlik keisersnee kop eerste kop eerste kop eerste kop eerste kop eerste kop eerste instrumente/ geen geen geen medikasie vir geen induksie moeder in broeikas kalsiumoortapblindedermopein broeikas geelsug. drup ping. in broeikas. rasie op 6e dag. vir 1 week. in geelsug bloedoortapping broeikas. op 8e dag. huisvrou huisvrou huisvrou kredietklerk maatskaplike asst. rekenmeeswerker ter landdros admin. bestuurambagsman — wetenskaplike regs adm. beder ampte st 10 st 10 st 9 st 8 st 10 st 10 st 10 st 10 st8 — st 10 st 10 radiografiesekretariele geen geen ba maatskapb. juris diploma diploma like werk b. juris llb b. juris ba-graad ambag (passer/ — bsc rek.wetenb. juris llb b. juris draaier) skap. 35 jr 25 jr 25 jr 22 jr 30 jr 26 jr 34 jr 28 jr 30 jr — 32 jr 28 jr tabel 2: opsomming van evaluasiewyses vir ondersoek van ekspressiewe kommunikasievermoens i taaldimensie wat ondersoek is evaluasiewyses vir ondersoek van ekspressiewe kommunikasievermoens taalinhoud dore (1979) se metode vir die analise van gesprekskategoriee. taalvorm atrikaanse artikulasie-ondersoek (lotter, 1979) eerste ondersoek van die orofasiale meganisme (louw en van der merwe, 1981) afrikaanse vorm van ''language assessment, remediation and screening procedure" (crystal, fletcher & garman, 1976) taalgebruik moeder-kind-kommunikasie-interaksie-skaal (clezy, 1979) bates (1977) se metode vir die analise van (die kategoriee van kommunikatiewe gebare. eksperimentele prosedure — naturalistiese observasie is in die tuissituasie gemaak, om sodoende so 'n natuurlik moontlike omgewing te skep, sodat die proefpersone op hul gemak is vir die verkryging van 'n verteenwoordigende spraakmonster (bloom en lahey, 1978; lund en duchan, 1983). — proefpersone is in 'n spelsituasie waartydens natuurlike wyse van kommunikasie ontlok is, waargeneem. 'n dertigminuut-bandopname asook aantekeninge is deur die ondersoeker gemaak oor die aktiwiteite van die kind en moeder. — eers het die moeder van die proefpersoon, en daarna die ondersoeker met die kind vir 'n periode van 15 minute elk, tydens spel, in interaksie getree. daar is besluit op 'n interaksieperiode van 30 minute om uitputting van die proefpersoon te voorkom en aangesien die tyd genoegsaam is om verskeie analiseringsprosedures te implementeer (miller, 1981). — spel het tydens die interaksie plaasgevind in 'n vertrek die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 helene j.ε. smit, brenda louw en isabel c. uys deur die ouers geselekteer, om sodoende die toetssituasie minder formeel te maak. — kontak is eers deur die ondersoeker met die kind opgebou alvorens met die toetsing begin is. — die volgende instruksies is aan die moeder verskaf sodat sy geweet het wat van haar verlang word tydens toetsing: — sy moet op so 'n natuurlik moontlike wyse met die kind tydens spel in interaksie optree soos wat sy gewoonlik doen. — 'n vertrek van haar keuse moet geselekteer word om 'n natuurlike omgewing te verseker. — spel moet op die vloer plaasvind. — die kind moet toegelaat word om self te kies waarmee hy wil speel, om sodoende die ontlokking van spraak te verseker. — die duur van die kommunikasie-interaksie moet 15 minute wees. die ondersoeker sal die moeder in ken* nis stel wanneer die ondersoeker by haar oorneem. — 'n bandopname, asook aantekeninge sal deur die ondersoeker gemaak word, om sodoende die optekening van resultate te vergemaklik. — die afrikaanse artikulasie-ondersoek (lotter, 1979) is na spelinteraksie met elke proefpersoon uitgevoer. — die orofasiale ondersoek van elke kind is laastens uitgevoer aangesien beter samewerking so verkry kan word. optekening en analise van data die optekening en analise van data is vergemaklik deur middel van die gebruik van 'n bandopname, asook aantekeninge oor aktiwiteite en beskrywing van die nie-verbale konteks, gedurende die kommunikasiesituasie (miller, 1981). die optekening van data geskied aan die hand van riglyne wat in die literatuur verskaf word, en word opsommend in tabel 3 weergegee. in die tabelle word die prestasies van die verskillende proefpersone, vir die verskillende toetse, individueel en indien toepaslik, gesamentlik aangetoon. vir vergelykingsdoeleindes is daar van persentasies en rekeningkundige gemiddeldes gebruik gemaak (ferguson, 1981). die wyse waarop die data opgeteken en geanaliseer is, word in tabelvorm beskryf. (sien tabel 3.) resultate en bespreking dit blyk dat die proefpersone as groep 'n ontwikkelingsagterstand vertoon wat hulle ekspressiewe kommunikasievermoens aanbetref, aangesien hulle ekspressiewe kommunikasievaardighede ooreenstem met die van jonger kinders (bloom en lahey, 1978). die resultate word aan die hand van die evaluasiekategoriee van taalinhoud, taalvorm en taalgebruik bespreek. taalinhoud die taalinhoud van die proefpersone is geevalueer deur die toepassing van dore (1978) se metode vir die analise van gesprekskategoriee. die resultate van die ses proefpersone se taalinhoud word in tabel 4 verskaf. die gesprekskategoriee is in tabel 4 gerangskik in volgorde van afname van die gemiddelde persentasie van voorkoms van die proefpersone. die voorkoms van gesprekskategoriee vir elke proefpersoon is ook in terme van persentasies uitgedruk. uit die resultate blyk dit dat die kategorie van response die meeste voorgekom het, naamlik met 'n gemiddelde persentasie van 63,2% terwyl die kategorie van performatiewe totaal afwesig was. die hoe voorkoms van die responsekategorie kan verklaar word aan die hand van rodgon (1979) se bevindings dat kinders tussen een en 'n half tot twee jaar, reeds kan diskrimineer tussen "ja/nee-vrae" en "w-vrae" — vrae met vreemde voornaamwoorde, soos byvoorbeeld wat, wie, waar — en toepaslik op die vrae kan antwoord. al die proefpersone het toepaslik op alle "ja/neevrae" en "w-vrae" geantwoord. die kategorie van organisasie met 'n gemiddelde voorkomsfrekwensie van 11,4% het die tweede hoogste voorkoms getoon en die resultate stem ooreen met bevindings van bloom et al. (1976) en keenan (1974), wat van mening is dat organisasiemiddele reeds in die dialoog van tweetot driejarige kinders behoort voor te kom. die resultate van die proefpersone stem dus ooreen met die beskrywing van normale ontwikkeling van engelssprekende kinders, wat in die literatuur verskaf word. die kategorie van versoeke het die derde hoogste voorkomsfrekwensie vertoon (10,1%) wat korreleer met resultate van studies van die normale ontwikkeling van engelssprekende kinders van tyack et al. (1979) en wood (1981). hulle het bevind dat kinders vanaf tweetot vierjarige ouderdom "ja/nee-vrae" en "w-vrae" gebruik. versoeke het minder voorgekom as response, waarskynlik omdat response op "ja/nee-vrae" en "w-vrae" reeds begin ontwikkel voordat normaal ontwikkelende kinders die vrae kan vra (rodgon, 1979). slegs 8,8% van die kategoriebeskrywings het voorgekom, moontlik aangesien voorskoolse kinders dikwels hiermee probleme ondervind, en die ontwikkeling van beskrywings tot in die skooljare voortduur (wood, 1981). slegs 4,4% van die kategorie van erkennings het voorgekom. kinders van tweetot driejarige ouderdom verwag reeds erkennings op hulle uitinge en gebruik erkennings om aan die spreker te kenne te gee dat hulle die informasie wat hy wil oordra, ontvang het — moontlik om die vloei van kommunikasie aan die gang te hou (rodgon, 1979; cole, 1982). die' lae voorkoms van die gebruik van stellings, naamlik (2,1%) korreleer met opvattings van bloom en lahey (1978) dat normale tweetot driejariges nie altyd oor hulle gevoelens, houdings en oortuigings praat nie, moontlik omdat hulle nie weet hoe om daaroor te praat nie. attribusies word egter reeds vanaf een jaar tien maande deur engelssprekende kinders gebruik (ainsfeld, 1984). j uit bogenoemde bespreking skyn die proefpersone se taalinhoud ooreen te stem met die literatuurbeskrywing van normale engelssprekende kinders se ontwikkeling van taalinhoud, behalwe vir die gesprekskategorie van performatiewe wat vertraagde ontwikkeling vertoon, moontlik omdat die moeders tydens waarneming glad nie van die gesprekskategorie in hulle interaksie met die proefpersone gebruik gemaak het nie. moontlik beskik die proefpersone oor die gebruik daarvan, maar het dit nie tydens die taalopname spontaan gebruik nie. 'n voorstel kan egter gemaak word dat 'n ondersoeker sodanige kategoriee wat nie spontaan voorkom nie, moet ontlok (miller, 1981), taalvorm die evaluasie van taalvorm het die evaluasie van die artikulasievermoens, orofasiale meganisme en ekspressiewe taalthe south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) η ondersoek na die ekspressiewe kommunikasievermoens van premature hoerisikokinders tabel 3: optekening en analise van data taaldimensie evaluasiewyses optekening van data analise van data taalinhoud dore (1978) se metode vir die analise van gesprekskategoriee transkripsie van bandopname van interaksie tussen moeder en kind, en ondersoeker en kind. analise van data aan die hand van verskeie gesprekskategoriee: versoeke beskrywings erkennings performatiewe-response stellings organisasie ander, in terme van aantal kere van voorkoms, toepaslikheid en ontoepaslike gebruik (dore, 1978). taalvorm afrikaanse artikulasie ondersoek (lotter, 1979) optekening van data op toepaslike vorm. analise van data aan die hand van vermoe en onvermoe tot produksie van enkelklanke en konsonantkombinasies in inisiele, mediale en finale woordposisies in terme van: klankomruilings klankweglatings klankdistorsies klankvervangings (van riper) eerste ondersoek van die orofasiale meganisme (louw & v.d. merwe, 1981) optekening van data op die voorgeskrewe vorm. analise van data op grond van normale of afwykende vorm in funksie van al die spraakorgane, soos voorgeskrewe vorm bepaal (louw en v.d. merwe, 1981). afrikaanse vorm van "language assessment, remediation and screening procedure" (crystal, fletcher en garman, 1976) transkripsie van bandopname van die interaksie tussen die moeder en kind, en die ondersoeker en kind se optekening van resultate van analise op die vertaalde larsp-profiel, soos voorgeskryf analise van data vind plaas aan die hand van 4 vlakke van strukturele organisasie, naamlik: frasevlak sinsvlak woordtipes bysinne (crystal et al. 1976) taalgebruik / / moeder-k teraksie (( ind-kommunikasie-in:iyzy, 1979) transkripsie van 15-minuutbandopname van interaksie tussen moeder en kind en optekening van resultate op vertaalde vorm van die versterkingsprofiel. analise van data aan die hand van 5 kategoriee deur clezy (1978) bepaal: positiewe kommentaar van moeder. korrekte leer van kind. onderrig van moeder aan kind. foutiewe leer van kind. negatiewe kommentaar van moeder. die totaal van elke kategorie word verdeel deur die tydsduur van die spraakmonster om die snelheid per minuut te verkry. bates (19 analise v. kommun: 77) se metode vir die in die kategoriee van katiewe gebare. / data word opgeteken op opgestelde vorm, op grond van aantekeninge gemaak van die nie-verbale kommunikasiekonteks tydens die interaksie. data word geanaliseer op grond van die aanwesigheid of afwesigheid asook die toepaslikheid of ontoepaslikheid van die volgende kategoriee van kommunikatiewe gebare, nl: wys na voorwerpe vertoon van voorwerpe gee voorwerpe aan 'n volwassene uitreik weiering afwys ( bates, 1977) vermoens van die proefpersone gedek en word volgens hierdie indeling bespreek. artikulasievermoens die foutklanke en frekwensie foute van elke proefpersoon, sowel as die persentasie proefpersone wat elke foutklank foutief geproduseer het, soos verkry deur die toepassing van die afrikaanse artikulasie-ondersoek (lotter, 1974), is bereken (smit, 1986). verskeie artikulasiefoute met onderlinge variasie het tussen die proefpersone voorgekom. die artikulasiefoute het slegs uit klankvervangings en klankweglatings bestaan, waarvan klankweglatings die meeste voorgekom het. klankkombinasies is die meeste aangetas, veral die produksie van /r/die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34,1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 h e l e n e j . . smit, brenda louw en isabel c. uys tabel 4: opsommende tabel van dore (1978) se metode vir die analise van gesprekskategoriee kategorie % voorkoms van kategoriee per proefpersoon kategorie bj md jf jl cw rb gemid. response 59,3 67,0 65,2 66,3 61,8 59,5 63,2 organisasie 12,0 10,0 10,6 8,1 16,0 11,8 11,4 versoeke 17,6 7,3 12,1 9,3 6,2 8,1 10,1 beskrywings 8,3 8,3 5,0 11,6 13,6 5,9 8,8 erkennings 0,0 2,8 5,0 3,5 1,2 14,0 4,4 stellings 2,8 4,6 2,1 1,2 1,2 0,7 2,1 performatiewe 0,0 0,0 0,0 0,0 0,0 0,0 0,0 totaal 100,0 100,0 100,0 100,0 100,0 100,0 100,0 kombinasies in die aanvangsso wel as die eindposisie. hierdie resultate stem ooreen met die van lotter (1974), wat bevind dat afrikaanssprekende kinders eers vanaf 9,25 tot 9,45 jaar 100% korrekte produksie van klankkombinasies van /r/, korrek kan produseer. foutiewe produksie van /j/ het by 100% van die proefpersone voorgekom. afrikaanssprekende kinders bemeester egter eers 100% korrekte produksie van /j/ op ongeveer 7,5 tot 8,42 jaar (lotter, 1974). volgens die norme van spraakontwikkeling van afrikaanse kinders, blyk hierdie proefpersone se spraakontwikkeling egter binne normale perke vir hulle chronologiese ouderdom te wees (lotter, 1974) en hulle artikulasiefoute kan as normale ontwikkelingsfoute beskou word (weiss, lillywhite en gordon, 1980). aangesien fonetiese vermoens be'invloed word deur die ryping van die artikulators, mag die normale ontwikkelingsfoute wat die proefpersone vertoon, moontlik toegeskryf word aan die feit dat die artikulators van die jong kinders eers met toename in ouderdom tot voile ryping sal kom (weiss et al. 1980). eerste ondersoek van die orofasiale meganisme met die ondersoek van die orofasiale meganisme van die proefpersone is daar geen afwykings in die vorm of funksie van die spraakorgane, soos deur die voorgeskrewe vorm bepaal, ge'identifiseer nie. die vorm en funksie van die spraakorgane behoort dus nie hulle artikulasievermoens negatief te be'invloed nie (weiss et al. 1980) en daar is dan ook bevind dat die proefpersone wel net artikulatoriese ontwikkelingsfoute vertoon het. die ekspressiewe kommunikasievermoens van die proefpersone in tabel 5 word die resultate van elke proefpersoon soos tabel 5: opsommende weergawe van die proefpersone se ekspressiewe taalvorm na aanleiding van die larsp-prosedure verkry met die toepassing van die afrikaanse weergawe van die larsp-tegniek (crystal, fletcher en garman, 1976) opsommend weergegee. in tabel 5 word die totale frekwensie van voorkoms van sinen frasestrukture van elke proefpersoon op stadia een tot vyf van sintaktiese ontwikkeling weergegee. die stadium van sintaktiese ontwikkeling waarop elke proefpersoon gefunksioneer het, word beskou as die stadium waar elke proefpersoon die grootste totale frekwensie sinstrukture en frasestrukture vertoon het. uit die resultate blyk dat al die proefpersone wat sintaktiese ontwikkeling betref, ongeveer ses maande onder hulle toepaslike oudersomsvlakke gefunksioneer het (pieterse, 1969 en crystal et al. 1976). vyftig persent van die proefpersone het 'n groot aantal onverstaanbare sinne getoon. daar was 'n hoe voorkoms van die gebruik van voornaamwoorde en koppelwerkwoorde onder vier van die proefpersone naamlik bj, md en rb, wat op stadium 3 van sintaktiese ontwikkeling funksioneer. die bevindings stem ooreen met resultate deur pieterse (1969) verkry ten opsigte van normaalontwikkelende afrikaanse kinders wat op stadium 3 gefunksioneer het. verkleinwoorde is geredelik deur alle proefpersone gebruik. dit kan toegeskryf word aan die hoe voorkoms daarvan soos waargeneem is in die moeders se kommunikasie met die kinders (clezy, 1979; cole, 1982). 'n groot aantal herhalings het ook in die sintaktiese strukture van die proefpersone voorgekom, wat ooreenstem met resultate van hubatch et al. (1985), wat die verskynsel toeskryf aan 'n beperkte ekspressiewe woordeskat van die kinders. die gemiddelde sinlengtes van die proefpersone bestaan uit 1,67 tot 2,76 woorde, maar volgens die ontwikkelingsnorme behoort hulle egter reeds drietot vierwoordsinne te kan gebruik (pieterse, 1969; crystal et al. 1976). 'n beperkte aantal uitinge asook probleme met die uitbreiding van sinne kom by die proefpersone voor, soos ook bevind is in navorsing deur hubatch et al. (1985) en de hirsch et al. (1984) uitgevoer. (sien tabel 6.) tabel 6: opsommende weergawe van die sinsproduksie van die proefpersone na aanleiding van die larsp-prosedure veranderlike proefpersoon 1 veranderlike bj md jf jl cw rb totale aantal woorde 200 237 212 143 127 239 totale aantal sinne 87 86 95 73 76 96 gemiddelde sinlengte 2,30 2,76 2,23 1,96 1,67 2,49 onvolledige sinne 10 5 1 0 1 2 onverstaanbare sinne 0 1 24 28 48 2 'n aantal onvolledige sinne het,ook voorgekom, moontlik as gevolg van probleme wat die kinders ondervind het; om verskillende eenhede in 'n enkele sin te kombineer (ainsfield, 1984), en wanneer die kinders se aandag na 'n nuwe fokus verskuif het. die kinders se spraakverstaanbaarheid is hierdeur negatief be'invloed. uit bogenoemde bespreking wil dit dus voorkom of die proefpersone as 'n groep 'n beperkte ekspressiewe woordeskat vertoon het en 'n ekspressiewe ontwikkelingsagterstand van ongeveer ses maande onder hulle chronologiese ouderdomsvlak vertoon het. die resul•kategorie proefpersone en frekwensie sin& frasestrukture •kategorie bj md jf jl cw rb 1. 9-18 maande 37 32 34 32 37 10 2. 18-24 maande 45 59 73 51 62 75 3. 24-30 maande 117 101 127 28 24 164 4. 30-36 maande 3 23 20 16 0 34 5. 36-42 maande 0 3 3 0 0 1 the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) -η ondersoek na die ekspressiewe kommunikasievermoens van premature hoerisikokinders 29 tate stem ooreen met die resultate van premature kinders wat reeds in die literatuur bestudeer is (de hirsch et al. 1964). taalgebruik die evaluasie van taalgebruik het die aspekte van moederkind-kommunikasie-interaksie en kommunikatiewe gebare deur die proefpersone gebruik, gedek en word in die volgorde bespreek. die moeder-kind-kommunikasie-interaksie tabel 7 verskaf 'n visuele voorstelling van die resultate van die moeder-kind-kommunikasie-interaksie. die voorkoms van die vyf kategoriee van moeder-kind-kommunikasieinteraksie volgens clezy (1979), naamlik positiewe kommentaar van die moeder, negatiewe kommentaar van die moeder, korrekte en foutiewe leer van die kind en die onderrig van die kind deur die moeder, word in tabel 7 as 'n persentasie van die totale interaksies tussen elke moeder en kind weergegee. tabel 7: resultate van die moeder-kind-kommunisie-interaksie kategoriee volgens clezy (1979) proefpersoon kategoriee volgens clezy (1979) bj md jf jl cw rb positiewe kommentaar van moeder 9,1 9,3 5,0 5,0 7,4 10,4 kind leer korrek 30,3 29,1 38,3 27,5 26,5 31,2 moeder onderrig 42,8 kind 50,0 47,4 46,7 37,3 42, b 42,8 kind leer foutief 9,1 10,6 8,3 13,9 13,2 7,8 negatiewe kommentaar van moeder 1,5 3,6 1,7 16,3 10,3 7,8 totaal (persentasie) 100,0 100,0 100,0 100,0 100,0 100,0 oor die algemeen het daar meer positiewe kommentaar van die moeders (7,7%) as negatiewe kommentaar (6,8%) voorgekom. proefpersone cw en jl het egter meer negatiewe as positiewe kommentaar van hulle moeders ontvang, en het ook die minste korrekte leer en die meeste foutiewe leer vertoon in verglyking met die persentasie vir hierdie kategoriee by die ander proefpersone. hierdie verskynsel kan moontlik toegeskryf word aan 'n wedersydse negatiewe versterking tussen moeder en kind (clezy, 1979). die moeders van die proefpersone, as 'n groep het heelwat uitbreidings, herhalings, retoriese vrae en selfbeantwoording van eie vrae as taalonderrigmiddele gebruik. hierdie waarneming stem ooreen met literatuurbevindings ten opsigte van moeders met normaal ontwikkelende kinders (bloom en lahey, 1978). bogenoemde gebruik van taalonderrigmiddele deur die moeders mag ook aanleiding gegee het tot die hoer persentasie korrekte leer van die proefpersone, naamlik van 26,5 tot 38,3% teenoor die laer persentasie van foutiewe leer deur die proefpersone vertoon, naamlik van 7,8 tot 13,9% (clezy, 1979). die feit dat cw en jl se sintaktiese vermoens en spraakverstaanbaarheid ook die swakste van al die proefpersone was, mag ook moontlik toegeskryf word aan die beperkende invloed wat te veel negatiewe kommentaar van 'n moeder op 'n kind se spraak mag he (clezy, 1979). oor die algemeen proefpersone cw en jl uitgesonder blyk dit dat die moederkind-kommunikasie-interaksie van die proefpersone oorwegend 'n positiewe, fassiliterende invloed op die kinders se taalontwikkeling uitgeoefen het, moontlik omdat die ouers besorgd was oor hulle kinders se prematuriteit en daarom gepoog het om goeie modelle te wees. kommunikatiewe gebare deur die proefpersone gebruik tabel 8 verskaf die resultate van elke proefpersoon in terme van die teenwoordigheid en toepaslike gebruik van die kategoriee van kommunikatiewe gebare volgens bates (1977). uit tabel 8: analise van die kategoriee van kommunikatiewe gebare (bates, 1977) proefpersoon kategorie 1. wys na voorwerpe:| (a) nie-kommunikatief (b) kommunikatief ' 2. vertoon van voorwerpe 3. gee van voorwerpe 4. uitreik: (a) nie-uitgebreid (b) uitgebreid 5. weiering: (a) nie-uitgebreid (b) uitgebreid 6. afwys: (a) nie-uitgebreid (b) uitgebreid bj tw tw tw tw md % voorkoms van kategoriee per proefpersoon 40 tw tw tw tw tw tw tw tw jf tw tw tw tw tw tw 80 jl tw tw tw 60 tw tw cw tw tw tw tw rb tw tw tw tw tw 50 40 50 vo voorkoms van kategoriee by proefpersone 83 83 50 67 50 33 50 50 50 17 tw = teenwoordig en toepaslike gebruik . die blanko spasie dui op die afwesigheid van 'n spesifieke kategorie van kommunikatiewe gebare by elke proefpersoon. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34,1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 die resultate blyk die kategoriee wat die meeste voorgekom het die kategoriee van kommunikatiewe "wys na voorwerpe" (83%) en nie-kommunikatiewe "wys na voorwerpe" (83%) te wees. volgens bates (1979) is dit een van die eerste kategoriee wat in die -vroee ontwikkelingstadia van normaal ontwikkelende kinders voorkom. die kategorie wat die minste voorgekom het is "uitgebreide afwys". slegs 17% van die proefpersone, het hierdie kategorie gebruik. hierdie kategorie vertoon ook die laagste frekwensie van voorkoms in studies wat op normaal ontwikkelende kinders deur bates (1979) uitgevoer is. die kombinasie van verbalisasies en nie-verbale kommunikatiewe gebare deur die proefpersone het minder voorgekom as wat die toepaslike voorkomsfrekwensies van die spesifieke chronologiese ouderdomsvlakke is (bates et al. 1979). hierdie vertraagde ontwikkeling van die kombinasie van nie-verbale kommunikatiewe gebare en spraakuitings mag ook die proefpersone se latere kommunikasieontwikkeling be'invloed (bates et al. 1979; long en dalston, 1982). geen ontoepaslike gebruik van enige van die kategoriee het voorgekom nie, alhoewel die gebruik van die gebare op 'n laer vlak as hulle chronologiese ouderdomme was. uit bogenoemde bespreking blyk dit dat die proefpersone vertraagde ontwikkeling van die koppeling van nie-verbale kommunikatiewe gebare met spraakuitings vertoon het. volgens long en dalston (1982) en bates (1979) kan 'n agterstand in die koppeling van nie-verbale kommunikatiewe gebare met spesifieke spraakuitings moontlik die voorloper van 'n latere ekspressiewe taalagterstand wees. hierdie konsep is deur bates (1979) en long en dalston (1982) as 'n belangrike stadium in normale taalontwikkeling gehipotetiseer maar is tot dusver beperk by ontwikkelende kinders nagevors. verkree resultate dui daarop dat dit 'n aspek van taalverwerwing is wat indringend by hoerisikokinders bestudeer behoort te word. gevolgtrekkings uit die bespreking van die resultate van die taalvorm, taalinhoud en taalgebruik van die proefpersone blyk hulle dus as 'n groep 'n ontwikkelingsagterstand te vertoon wat hulle 'ekspressiewe kommunikasievermoens aanbetref, aangesien hulle ekspressiewe kommunikasievaardighede ooreenstem met die van jonger kinders (bloom en lahey, 1978; crystal et al. 1976). die grootste agterstand blyk in hierdie kinders se taalvorm voor te kom, en wel wat hulle morfologiese en sintaktiese vermoens aanbetref, aangesien hulle 'n vertraging van ongeveer ses maande vertoon. die kinders se taalinhoud vertoon die geringste ontwikkelingsagterstand deurdat slegs die gebruik van die kategorie van performatiewe 'n agterstand vertoon. die agterstand in die ontwikkeling van die proefpersone se taalgebruik blyk 'n negatiewe invloed te he op die taalvorm wat die agterstand in die ontwikkeling van die kombinasie van nie-verbale kommunikatiewe gebare en spraak van al die proefpersone aanbetref, en ook wat die teenwoordigheid van 'n negatiewe element in proefpersone cw en jl se moeder-kind-kommunikasie-interaksie betref. hierdie verskynsel kan toegeskryf word aan die wedersydse interaksie wat daar tussen taalinhoud, taalvorm en taalgebruik bestaan, soos wat deur bloom en lahey (1978) beskryf word. as gevolg van die beperkte aantal proefpersone wat vir hierdie studie gebruik is, is dit moeilik om die invloed van die h e l e n e j . . smit, brenda louw en isabel c. uys sosio-ekonomiese faktore op elke proefpersoon se taalontwikkelingsvlak te bepaal, alhoewel daar tog probeer is om verskille tussen proefpersone op te klaar. dit blyk dus dan dat die premature hoerisikokinders wat as proefpersone gedien het, se ekspressiewe kommunikasieontwikkeling van die normale afwyk deurdat dit 'n ontwikkelingsagterstand vertoon. 'n ontwikkelingsagterstand van die ekspressiewe kommunikasievermoens word deur verskeie outeurs in die literatuur erken. as gevolg van onvoldoende navorsing hieroor, kan daar nog nie tot 'n gevolgtrekking gekom word wat 'n voldoende verklaring vir die agterstand bied nie. 'n moontlike tentatiewe rede is dat die ontwikkelingsagterstand moontlik toegeskryf kan word aan die feit dat premature kinders probleme met integrasie ondervind as gevolg van '"n vertraging van neurologiese rypheid" wat deur die prematuriteit veroorsaak word (douglas, 1960; pasamanick en knobloch, 1960; de hirsch, jansky en langford, 1964). die beperkte aantal proefpersone van hierdie studie dien as voorloper vir verdere navorsing. aangesien slegs die ekspressiewe kommunikasievermoens van premature hoerisikokinders in hierdie studie ondersoek is, word aanbeveel dat die reseptiewe kommunikasievermoens van premature hoerisikokinders wat afrikaanssprekend is, ook ondersoek word, ten einde 'n volledige beeld van die kinders se kommunikasievermoens te verkry. verdere studies wat die verband en onderskeid tussen die linguistiese, kognitiewe en affektiewe vermoens van hoerisikokinders ondersoek, word benodig (liebergott, et al. 1984), asook opvolgstudies om vas te stel of die agterstand in die taalontwikkeling van jong hoerisikokinders aanhou presenteer met toenemende ouderdom, asook die verhouding daarvan tot latere opvoedkundige en sosiale ontwikkeling (wright et al. 1983). die taalontwikkeling van hoerisikokinders wat jonger is as die proefpersone van hierdie studie behoort ook ondersoek te word, vir vroee identifikasie (de hirsch et al. 1964). 'n groter aantal deeglike evaluasieprosedures vir baie jong hoerisikokinders word ook benodig (liebergott et al. 1984), en ander hoerisikokinders wat kommunikasieprobleme mag ontwikkel, soos byvoorbeeld die met anoksie by geboorte, behoort ook ondersoek te word (liebergott et al. 1984; hubatch et al. 1984). i die resultate van die huidige studie beklemtoon die belangrike rol van die spraakterapeut in die vroee identifiseririg, evaluasie, behandeling en opvolg van die kommunikasievermoens van jong premature hoerisikokinders, om sodoende probleme wat mag ontstaan te minimaliseer of selfs te voorkom. aangesien voorkoming 'n belangrike rol van die spraakterapeut is, kan hoerisikokinders in hierdie opsig dus as ideale gevalle beskou word. verwysings ainsfield, m., 1984. language development from birth to three. new jersey: lawrence erlbaum associates; inc. / aram, d. & nation, j. 1980. preschool language disorders and subsequent language and academic difficulties. journal of communication disorders, 13, pp. 159—170. bates, e., 1977. language and context; the acquisition of pragmatics. new york: academic press, inc. / ' bates, e., 1979. the emergence of symbols: cognition and communication in infancy. new york: academic press, inc. benton, a.l., 1962. behavioural indices of brain injury in school children. child development, 33, pp. 199—208. the south african journal fcmmunitin disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) η ondersoek na die ekspressiewe kommunikasievermoens van premature hoerisikokinders 31 bloom, l. & lahey, m. 1979. language development and language disorders. new york: john wiley & sons, inc. bloom, l., rocissano, l. & hood, l. 1976. adult-child discourse: developmental interaction between information processing and linguistic knowledge. congenitive psychology, 8, pp. 521-552. clezy, g., 1979. modification of the mother-child interchange in language, speech and hearing. baltimore: university park press. cole, p.r., 1982. language disorders in preschool children. new jersey: prentice-hall inc. crystal, d., fletcher, p. & garman, m. 1976. the grammatical analysis of language disability: a procedure of assessment and remediation. londen: edward arnold ltd. de hirsch, k., jansky j.j. & langford w.s., 1964. the oral language performance of premature children and controls journal of speech and hearing disorders, 29 (1, pp. 60—69). dore, j., 1978. conditions for the acquisition of speech acts, in markova, i. 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'n ondersoek na die ontwikkeling van artikulasie by die afrikaanssprekende kind met die oog op die opstel van 'n geskikte artikulasie toets. ongepubliseerde m. logverhandeling, universiteit van pretoria. lotter, e.c., 1979. afrikaanse artikulasie-ondersoek. universiteit van pretoria. louw, b., 1986. kommunikasie-evaluasie van jong kinders 0-3 jaar. communiphon, nr. 270, in druk. louw, b., & van der merwe, α., 1981. eerste ondersoek van die orofasiale meganisme. universiteit van pretoria. lund, n.j. & duchan, j.f., 1983. assessing children's language in naturalistic contexts. n.j.: prentice-hall. marge, m. 1984. the prevention of communication disorders. american speech-language-hearing association, 26 (8), pp. 29-33. miller, j.f., 1981. assessing language production in children: experimental procedures. baltimore: university park press. northern, j.l. & downs, m.p., 1984. hearing in children. baltimore, williams & williams. pasamanick, b. & knobloch h., 1960. brain and behaviour. symposium 2. brain damage and reproductive casualty. amer. j. orthopsychiat, 30, pp. 298—305. rodgon, m., 1979. knowing what to say and wanting to say it: some communicative and structural aspects of single-word responses to questions. journal of child language, 6, pp. 81-90. rosetti, l. 1986. high-risk infants; identification, assessment and intervention. san diego: little, brown & co. smit, h.j.e., 1986. 'n ondersoek na die ontwikkeling van die ekspressiewe kommunikasievermoens van premature hoerisikokinders. ongepubliseerde b.log-verhandeling, universiteit van pretoria. strominger, a. & bashir α., 1977. a nine-year follow-up of language disordered children. paper presented at the annual convention of the american speech-language-and-hearing association. chicago, november. tyack, d. & ingram, d., 1977. children's production and comprehension of questions. journal of child language, 4, pp. 211-224. van riper, c., 1978. speech correction. principles and methods. prentice-hall, inc. weiss, c.e., lillywhite h.s. & gordon, m.e., 1980. clinical management of articulation disorders. st. louis: the c.g. mosby company. wood, b.s., 1981. children and communication. new york: prentice hall, inc. wright, n.e., thistlewaite, d., elton, r.a., wilkinson, e.m. &forfor, j.o., 1983. the speech and language development of low birth-weight infants. british journal of disorders in communication, 18 (3), pp. 187—196. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34,1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) n e w from amtronix — computerized impedance system features analog meters for compliance and pressure permit easy visualising of test. digital displays for ear canal volume and static compliance. tympanometric pressure may be read digitally. tympanometric gradient is calculated and digitally displayed. digital displays for frequency and intensity for stimuli. expanded reflex mode reveals latency, amplitude, growth and morphology. evoked potential testing with cadwell instrumentation ea sa ca e » e s \ ea ο ω s9 «a « (u μ s3 frl objective detection of a u d i o l o g i c and vestibular dysfunction the simple solution for complex audiologic cases auditory evoked response to evaluate middleand late-latency responses from the higher centers of the cortex eng to evaluate central and peripheral vestibular dysfunction bsep to objectively localize deficits to the cochlea, the auditory nerve, or the brainstem auditory pathways 40-hertz evoked response audiometry to objectively measure hearing thresholds electroneurography to obtain objective measurements of facial nerve function ί audiometry rooms i ; • \ i i ί . l μ amtronix (pty) ltd., p.o. box 630, bedfordview 2008 phone (011) 6221743 teletex 4-50033 amtron fax 6221306 i i n r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 29 the acoustic reflex at a 1000 hz probe frequency: phasor and vector analysis judy ferguson and louise reynolds department of logopaedics, university of cape town. abstract phasor plots of reflex growth functions have been inconclusive concerning the effect of the reflex for mass dominated ears. the present study aimed to establish whether vector plots clarified the effects of the reflex for phasors not showing a clear circular shape. measured admittance data (ipsilateral reflexes across a wide intensity range) was represented as both phasor diagrams and converted to impedance quantities, represented as vectors. the results analysed for 34 ears showed few unclassifiable phasor diagrams. in addition, all growth functions showed increased stiffness on vector analysis. resistance changes appeared to be variable. the results suggest that vector diagrams may be a useful way of representing data that is not clearly represented via phasor diagrams. the current study, however, does not clarify the pattern for mass dominated ears. opsomming fasor-uitstippeling van refleksiewe groeifunksies was tot nog toe onafdoende ten opsigte van die refleks se uitwerking by massa-gedomineerde ore. die onderhawige studie het as mikpuntgehad om vas te stel of vektor-uitstippeling die uitwerking van die refleks opgeklaar het ten aansien van fasore wat nie 'n duidelik sirkulere vorm vertoon het nie. gemete toegangsdata (ipsi-laterale reflekse oor 'n wye intensiteits-spektrum) is weergegee sowel as fasor-diagramme as omgesit in skynweerstandsyfers, aangebied in vektore-vorm. die uitslae ten aansien van 34 ore wat ontleed is, het weining onklassifiseerbare fasordiagramme opgelewer. bowendien, alle groeifunksies het verhoogde styfheid vertoon by vektor-ontleding. weerstandsveranderinge was skynbaar wisselend. die resultate wys in die rigtingdat vektor-diagramme moontlik 'n nuttige manier mag wees om data weer te gee wat nie duidelik deur fasor-diagramme weergegee word nie. die huidige studie klaar egter nie die patroon vir massa-gedomineerde ore op nie. key words: immittance,! reflex measures, high probe frequency, phasors, vectors introduction the middle ear acts as a transducer of sound from the external environment to the cochlea (berlin & cullen, 1980). the effects of the acoustic reflex on the transmission of sound through the middle ear can be observed indirectly through immittance measures (wiley & block, 1985). this technique has been used extensively in the literature to describe the effects of the reflex on transmission properties of the middle ear at low probe frequencies (226 and 678 hz). however, the effects of the reflex recorded at higher probe frequencies using immittance measures, have not been fully investigated in the literature. this is of particular interest given that baseline transmission properties differ across the frequency range in human ears (berlin & cullen, 1980). there are several ways of representing the quantities of the relationship between admittance and impedance components (van camp & creten, 1976). rectangular notation represents the magnitudes of both components of admittance (susceptance (b) and conductance (g)) or impedance (reactance (x) and resistance (r)) as co-ordinates (b;g) or (x;r). polar notation represents the components of admittance or impedance as having both mag/ nitude and phase angle (degree) (magnitude ; <0). dynamic aspects of middle ear function, such as reflex growth functions, may be represented as phasor diagrams, using rectangular notation (joining up the coordinates). this method has been used by lutman (1984) and reynolds and morton (1995) to investigate the effect of the acoustic reflex. vector diagrams, as used by bennett and weatherby (1979) show the dynamic aspects of the reflex by selecting points along the dynamic process and representing aspects of the reflex in both polar and rectangular notation. immittance recordings of the acoustic reflex are usually made in admittance rather than impedance components, because there is a linear relationship between the admittance components at the probe tip and the plane of the tympanic membrane (margolis, 1981). however, impedance quantities are usually used to explain immittance patterns (van camp & creten, 1976). it is possible to correct measurements made at the probe tip to the level of the tympanic membrane, and to convert these components from admittance to impedance, using the formulae shown in table 1. researchers agree that the major effect of the reflex at low probe frequencies (220 and 660 hz) is an increase in stiffness or negative reactance (feldman & williams, 1976; die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 judy ferguson and louise reynolds bennett & weatherby, 1979, lutman, mckenzie & swan, 1984; reynolds and morton, 1994). this is made clear in phasor diagrams, which show circular, anticlockwise movement. this same effect is shown as an increase in negative phase angle on vector diagrams. table 1: formulae to convert admittance (y) components to components to impedance (z) components (margolis, 1981). jx = -jb/(b2 + g2) r = g/(b2 + g2) x = reactance β = susceptance r = resistance g = conductance reynolds and morton (1995) examined whether phasor plots at 1000 hz, where normal ears may not be stiffness dominated, followed the circular, anti-clockwise phasor diagram, indicating the constant resistance, stiffness change model proposed by lutman (1984). while the majority of their phasor diagrams matched lutman's (1984) model, some of their plots were difficult to interpret, particularly those derived from ears that were mass dominated at the probe frequency used (1000 hz). the reasons for some phasor plots deviating from the standard model proposed by lutman (1984) could have been due to procedural variables, such as the nonsimultaneous recording of susceptance and conductance, or could be due to the effect of the reflex on systems where transmission properties are at or above resonance. previous researchers have found variable effects of the reflex on resistance. this variability influences the overall effect at higher probe frequencies due to smaller reactance effects which cannot so easily mask the resistance changes that are occurring, as happens for low probe frequencies (sprague, wiley & block, 1981; bennett & weatherby, 1979; and feldman & williams, 1976). it is possible that phasor diagrams are unclassifiable when significant resistance changes occur, and as they interact with reactance changes, cause irregularities in the shape of the phasor. if this were the case, then phasor diagrams may not be the clearest means to show the effect of the reflex, for high probe frequencies or mass dominated ears, but the true effect of the reflex may be clarified through representing the effect of the reflex through plotting the resistance and reactance changes as vectors. this study aimed to explore whether unclassifiable phasor representations of admittance measures could be explained by means of vector representations of impedance values derived from the same reflex measures. of further interest was whether mass dominated systems were always responsible for unclassifiable phasor plots as suggested by reynolds and morton (1995) and the present study therefore also investigated the relationship between baseline transmission and the phasor plots obtained. clarification as to whether deviations from the constant resistance, stiffness change model were related to the means of representation was therefore the focus of the study. methodology subjects thirty four normal hearing young adults served as subjects. data was collected from one ear per subject to prevent duplication of results due to the very small inter-aural differences reported in subjects by hall (1979) and creten, van der heyning and van camp (1985). subjects were required to be within 18 and 30 years of age, and to have no known history of ear pathology. normal hearing was determined as pure tone air and bone conduction thresholds within normal limits (-10 and 25 db hl), as defined by goodman (1965, cited by yantis, 1985). air and bone conduction thresholds were required to be within 10 db of each other to exclude any middle ear pathology not known to the subject. in addition, normal middle ear functioning was required, and this was established on the basis of tympanometry and acoustic reflex measurements. subjects were required to have a single peaked admittance tympanogram at 226 hz probe frequency, and ipsilateral acoustic reflex thresholds within normal limits (70 1 0 0 db hl), as defined by northern, gabbard and kinder (1985), for 500, 1000 and 2000 hz stimulus frequencies, measured at a 226 hz probe frequency. apparatus hearing thresholds for all subjects were established using either a gsi10 clinical audiometer, with tdh-50p headphones and b71 bone vibrator, or a beltone 2000 audiometer, with tdh-50p headphones and b71 bone vibrator. both audiometers are calibrated in hearing level and meet the ansi s.26-1981 standard for clinical audiometers. immittance measurements were carried out using a gsi-33 (version 2) middle ear analyser, which meets the ansi s.3.39-1987 standard for acoustic-immittance instruments. the instrument was calibrated for the specific altitude of the test environment (98 m above sea level). calibration checks, following the manufacturer's instructions, were carried out on each day of the data collection. all hearing threshold measurements were carried out in acoustically treated audiometric suites (lac 109), meeting the sabs 0182 (1982) code of practice. procedure baseline information for each subject was established first in order to relate phasor and vector classifications to transmission at 1000 hz. baseline transmission at 1000 hz for both susceptance (b) and conductance (g), recorded simultaneously, was established for each ear according to the vanhuyse, creten and van camp (1975) classification. tympanometric values were recorded at pressure' values of-350 dapa, and tympanometric peak, in order to (correct the values to the plane of the tympanic membrane (shanks, wilson and cambron, 1993). a positive-to-negative (+200 dapa to -400 dapa) pressure sweep procedure was used. pressure was varied at a rate of 50 dapa per second (grason-stadler, 1987). shanks and lilly (1981) and margolis, van camp, wilson, and creten (1985) found that positive to negative pressure sweeps result in less complex tympanometric patterns than negative to positive pressure sweeps. acoustic reflexes were recorded at stimulus frequencies of 500 hz and 1000 hz at a 1000 hz probe frequency, for susceptance, followed by conductance, as these measures could not be displayed simultaneously. the intensity range used was 66-106 db hl. a 4 db increment size was used. this increment size has been used in other studies (for example, reynolds and morton, 1995). the the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the acoustic reflex at a 1000 hz probe frequency: phasor and vector analysis 31 m i l l i m h o change (magnitude of the reflex growth) at each intensity level was recorded as well as the direction of the reflex growth (i.e., whether it was positive or negative). the stimulus duration was kept constant at 1.5 seconds, as time related aspects were not being investigated in this study. susceptance recording always preceded conductance recordings, and measurements at 500 hz preceded measu r e m e n t s at 1000 hz. each subject's testing was completed within one day. data organisation and data analysis: data was corrected to the plane of the tympanic membrane by subtracting the susceptance and conductance values at -350 dapa from those values at tympanometric peak, as suggested by shanks et al. (1993). observed reflex values (x) were added to the corrected baseline values (bc;gc) for each intensity level: (be + x; gc + x). frequency counts of the number of phasor plots classified as above were recorded in table form. vector diagrams: all corrected susceptance and conductance values were converted to reactance and resistance values by means of the formulae presented in table 1 (margolis, 1981). these corrected and converted reactance and resistance values were plotted on vector diagrams, which allowed for examination of the impedance data. vectors were classified as showing an increase in stiffness (+s), a decrease in stiffness (-s), or no change in stiffness (os), and an increase in resistance (+r), a decrease in resistance (-r), no change in resistance (or) or variable resistance (vr) at threshold and suprathreshold levels. from this, the effects of the reflex on reactance (increase or decrease in stiffness) and changes in resistance could be extracted and presented in table form. phasor representation: corrected susceptance and conductance values were represented in the form of phasor diagrams for each reflex growth function recorded. in such diagrams, conductance values are represented on the x-axis and susceptance values on the y-axis. a phasor trajectory was obtained by joining up the coordinates at each point and the shape of the trajectory was then classified. the axes used for each graph were standard for all graphs, but the scaling for each graph was different. this was done in order to maximize the visual representation of each phasor plot. the resulting phasors were classified as either: 1. fitting with the lutman (1984) model of an anti-clockwise circular movement, indicating constant resistance, and an increase in stiffness. these were termed classifiable. 2. phasor plots not fitting the lutman (1984) model. these were termed unclassifiable. results and discussion the distribution of ears used in the study across types of baseline characteristics is shown in table 2. as expected, the majority of ears were at resonance at this frequency, with only a small number of ears being stiffness dominated. the ten mass dominated ears at the 1000 hz probe frequency were of particular interest, given the focus of the study. as normal ears are expected to be close to resonance at 1000 hz (colletti, 1977), it would be necessary to use a higher probe frequency to measure the reflex for many mass dominated ears, and the ten were considered to be a sufficient number to clarify the research question. table 3 shows, that similarly to reynolds and morton (1995), the majority of phasor plots obtained were matched to the constant resistance, stiffness change model explained by lutman (1984). an example of this is provided in figure 1. table 2: summary of | baseline transmission characteristics of subjects in this study. (n=34). ! number of subjects van huyse classification stiffness dominated eairs ! 4 1b1g ears at resonance \© 3b1g mass dominated ears 10 3b3g table 3: results of the phasor analysis of growth functions obtained for 500 and 1000 hz stimuli (n = 68). classified phasors unclassified phasors stifness dominated ears 6 2 ears at resonance 34 6 mass dominated ears 1 1 8 2 co ο jc ε ε ω «μ* ω ο c « α ω ο <λ co 1.62 1.53 1.44 1.35 1.26 1.17. 1.08 0.99 0.90 0.81 4.99 5.04 5.09 5.14 5.19 5.24 5.29 5 3 4 5.39 conductance (g) m m h o s figure 1: example of classifiable phasors demonstrating anticlockwise, circular movement form baseline to suprathreshold levels. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 judy ferguson and louise reynolds however, an unexpected result was the distribution of unclassifiable phasors across ears, regardless of baseline transmission properties. unlike reynolds and morton (1995), who found that those phasors that deviated from the model were from mass dominated ears, the results of the present study indicated that unclassifiable phasors were obtained from stiffness dominated ears, ears at resonance, and mass dominated ears. both the present study and the reynolds and morton (1995) study did not differentiate between degrees of mass domination within subjects. it is possible that the ears in the present study behaved similarly to ears at resonance or stiffness domination with the added stiffness effect of the reflex, which, as shown below, was demonstrated for the reflex patterns obtained. given that normal ears are expected to be close to resonance at 1000 hz, it may be necessary to use a higher probe frequency to demonstrate the effect of the reflex for mass dominated ears, although problems will be encountered in the measurement of such small immittance changes in mass dominated ears (lutman, 1995). of particular interest in the results of this study, is the nature of the deviation from the model. clearly, as shown in the examples in figure 2, the deviations from the constant resistance, stiffness change model are not marked in the present study, and all showed overall patterns that could be broadly described as circular, anticlockwise movement, at least for some portion of the phasor plot. these results are shown in table 4, where a brief description of the phasors obtained is provided. it is evident from this table that the patterns which were not strictly showing anticlockwise movement with the activation of the reflex typically showed clockwise movement close to threshold, and then at suprathreshold levels the typical pattern of anticlockwise movement was seen. examples of this are provided in figure 2a. one contributing factor to this pattern may relate to the determination of reflex threshold, as it is possible that the threshold values obtained were not the actual thresholds of the subjects, and that true threshold was reached at higher intensity levels, where the pattern was consistent with.the model. the criteria used to determine threshold on the gsi 33, derived from bennett and weatherby (1979), may not be absolute threshold values. lutman (1984) argues that there is some question regarding the accurateness of the criterion values given by grason-stadler (1987). it is therefore possible that absolute thresholds were not obtained at the level at which they were recorded. this would mean that only two phasors did not actually match the model (see table 4). these two demonstrated deviations from the model at suprathreshold intensity levels. an example is shown in figure 2b. it is well documented that the reflex reaches saturation (wilson and mcbride, 1978), and it may be that the complex interaction of immittance components, coupled with saturation of the reflex contributed to the patterns obtained. in analyzing the results of the study using vector analysis, an attempt was made to clarify the effect of the reflex, particularly for phasors which were not classifiable. in spite of the few unclassifiable phasors obtained, the vector analysis did provide some useful information, shown in tables 5,6 and 7, particularly as regards the unresolved table 4: description and frequency count of unclassifiable phasors (n=10) classifiable at threshold, & unclassifiable at suprathreshold levels 2 unclassifiable at threshold, & classifiable at suprathreshold levels 8 conductance (g) mmhos 4.85 5.02 520 5.38 5 56 5.74 5.92 6.10 6.28 6.46 0.55ο 0 β5 jc. i 0.75 m 0 . 8 5 w φ ο 0.95 ια <0 q. 105 φ § 1 1 5 " u5 h 1.351.62 co 1.59 ο -c ε ε m a> ο c ra a. a> υ co 3 co 1.56 1.53 1.50 1.47 1.44 1.41 1.38 1.35 a 244 2 5 0 2 5 6 2 6 2 2 6 8 274 2 8 0 2 8 6 2.92 conductance (g) mmhos figure 2: examples of unclassifiable phasors. a) represents clockwise movement at threshold, followed by anticlockwise circular movement. b) represents anticlockwise movement at threshold, followed by deviations from the model at suprathreshold levels. / the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the acoustic reflex at a 1000 hz probe frequency: phasor and vector analysis 33 question of the effect of the reflex on resistance. c o n s i s t e n t with all previous studies , for example l u t m a n et al. (1984) and reynolds and morton (1995), is that the effect of the reflex on reactance is an increase in stiffness. during the course of some of the reflex growth f u n c t i o n s obtained in the present study , there was some d e v i a t i o n from this pattern at threshold, but as mentioned above, this may have related to the definition of threshold i n t e r e s t i n g l y , two growth functions, both obtained from mass dominated ears showed decreased stiffness at s u p r a t h r e s h o l d levels, as shown in table 5. however, these growth functions were classifiable within the model, as this pattern did not emerge for the unclassifiable phasors, as shown in the detailed analysis in table 7. thus, there did not appear to be any relationship between the reactance change and the classifiability of phasors. a variety of effects on resistance were observed, consistent with previous findings (for example sprague et al., 1981). as shown in table 6, the most common effects were decreased resistance at threshold, with most demonstrating increased resistance at higher intensity levels. several of these typical patterns were also obtained from u n c l a s s i f i a b l e phasors (see table 7), thus indicating that there was no clear relationship between the resistance pattern and the classifiability of phasors. conclusions while the reactance and resistance changes from classifiable and unclassifiable phasors across ears with differing baseline properties were not differentiated in the results of this study, some interesting observations relating to phasor and vector analysis of reflex growth functions were nonetheless evident. as the complex interaction of reactance and resistance change was demonstrated in unclassifiable phasors, isolating the effects of the reflex on impedance quantities does allow for the identification of increased stiffness, in spite of fairly obscure phasor patterns, possibly making this a useful tool for clinical interpretation of obscure reflex patterns. however, identifying expected patterns for mass dominated ears appears to require either a more sophisticated form of recording reflex phenomena, or more sophisticated form of analysis. factors contributing to the lack of clarity of the effect may i table 5: vector analysis: ̂ effect of the reflex on stiffness reactance. j +s = increase in stiffness -s = decrease in stiffness ^ os = no change in stiffness ; = shows the difference between baseline, threshold and suprathreshold levels. stiffness dominated ears ears at resonance mass dominated ears +s 8 24 7 -s;+s 0 10 11 os;+s 0 6 0 +s;-s 0 1 0 2 relate to the nonsimultaneous recording of the reflex, but probably the most overriding factor is the use of a probe frequency where normal ears are typically at resonance. thus in order to clarify the effect of the reflex for mass dominated ears, a higher probe frequency should be incorporated for studies of normal ears, but this is not currently possible using commercially available equipment, due to the increasing complexity of immittance recordings as ears deviate from simple stiff systems. one further table 6: vector analysis: effect of the reflex on resistance. +r = increase in resistance -r = decrease in resistance or = no change in resistance vr = variable resistance changes ; = shows the difference between baseline, threshold and suprathreshold levels. stiffness dominated ears ears at resonance mass dominated ears or;+r 3 2 0 -r;+r 2 21 11 +r 0 0 4 or;-r 0 2 0 -r 2 7 2 vr 0 4 1 or 1 0 0 -r;or 0 4 2 table 7: detailed vectorial description of the ten unclassifiable phasors. +s = increase in stiffness -s = decrease in stiffness os = no change in stiffness +r = increase in resistance -r = decrease in resistance or = no change in resistance vr = variable resistance changes ; = shows the difference between baseline, threshold and suprathreshold levels. stiffness dominated ears ears at resonance mass dominated ears +s, or;+r os;+s, -r;+r -s;+s -r;+r +s, -r;+r +s, -r -s;+s -r;+r os;+s, vr +s, -r;or -s;+s, -r +s, -r;+r die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 judy ferguson and louise reynolds possibility may be to investigate the pattern of reflex growth functions in pathological ears, or in ears selected because of their marked mass domination at the probe frequency, rather than in terms of simply a normal phenomenon, as was the case in the present investigation. references american national standards institute. 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(1987). gsi33 middle ear analyser: preliminary instruction manual. grason-stadler international, inc. hall, j.w. (1979). effects of age and sex on static compliance. archives of otolaryngology. 105 153-156. lutman, m.e. (1984). phasor admittance measurements of the middle ear 1: theoretical approach. scandinavian. audiology. 13 253-264. lutman, m.e, mckenzie, η & swan, i.r.c. (1984). phasor admittance measurements of the middle ear 2: normal phasor tympanograms and acoustic reflexes. scandinavian audiology. 13 265-274. lutman, m.e. (1995). personal communication. margolis, r.h. (1981). fundamentals of acoustic immittance. in popelka, g.r. (ed). hearing assessment with the acoustic reflex. grune and stratton. margolis, r.h, van camp, k.j, wilson, r.h, & creten, w.l. (1985). multifrequency tympanometry in normal ears. audiology. 24 43-54. northern, j.l, gabbard, s.a, & kinder, d.l. (1985). the acoustic reflex. in katz, j (ed.) handbook of clinical audiology. (3rd ed.) williams & wilkins. reynolds, l. & morton, l.p. (1994). direction of susceptance and conductance reflexes at high probefrequencies. the south african journal of communication disorders. 41 85 92. reynolds, l. & morton, l.p. (1995). acoustic reflex measures at a high probe frequency: a phasor diagram approach. british journal of audiology 29 144 152: shanks, j.e, & lilly, d.j. (1981). an evaluation of tympanometric estimates of ear canal volume. journal of speech and hearing research 24 557-566. shanks, j.e, wilson, r.h, & cambron, n.k. (1993). multiple frequency tympanometry: effects of ear canal volume on static acoustic admittance and estimates of middle ear resonance. journal of speech and hearing research 36 178-185. south african bureau of standards. (1982). code of practice for obtaining an acoustic environment suitable for audiometric testing. sabs 0182. sprague, b.h, wiley, t.l, & block, m.g. (1981). dynamics of acoustic reflex growth. audiology. 20 15-40. van camp, k.j, & creten, w.l. (1976). principles of acoustic impedance and admittance. in feldman, a.s, & wilbur, l.a. (eds.) acoustic impedance and admittance the measurement of middle ear function. williams & wilkins. vanhuyse, v.j., creten, w.l. & van camp, k.j. (1975). on the w-notching of tympanograms. scandinavian audiology. 4 45 5 0 . wiley, t.l., & block, m.g. (1985). overview and basic principles of acoustic immittance measurements. in katz, j. (ed.) handbook of clinical audiology. (3rd ed.) williams & wilkins. wilson, r.h. & mcbride, l.m. (1978). threshold and growth of the acoustic reflex. journal of the acoustical society of america. 63 (1) 147 164. yantis, p.a. (1985). pure tone air conduction testing. in katz, j (ed.) handbook of clinical audiology. (3rd ed.) williams & wilkins. ι the south african journal of communication disorders, vol. 42, 1995 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 3 the problem of stuttering: where are we in 1986?* hugo h. gregory, ph.d (northwestern university, usa) department of communication disorders, northwestern university, illinois, usa ttaler regies the author's experience as a person with a stuttering problem, as a student and as a professional clinician, teacher and researcher. an overview of the state of the art in 1986 is presented z7rl7v7skaf-noorsigvandieouteurseondervindingas-nhakkela^ van hakkel. die stand van die teorie en die kliniese praktyk in 1986 word beskryf my review and analysis, leading to statements about the current status of our knowledge of stuttering, begins over 40 years ago when a blond, fourteen year old boy from the state of arkansas in the usa journeyed 1500 miles to the state of rhode island to get help with his stuttering problem. that summer at an institution known as martin hall, i learned that stuttering was due to a faulty reaudiorization and revisualization of words and developed fears of speaking. therapy consisted of being on silence (no conversation) for periods of time in which we practised syllables, words and sentences from a drill manual. we learned a rule for the production of each consonant, and as we said a syllable or word, we thought of the rule for each consonant and called up strong auditory and visual images. this first step was known as word analysis. i analyzed words all over that beautiful landscape on mount hope bay in rhode island. in word analysis, transitions between sounds were very smooth, but words were spoken one at a time. at the end of two weeks, we came off a silence for the weekend and were allowed to speak, using careful word analysis. to a girl, to whom i had been writing notes while on silence, i was now able to say, "p-a-t, w-o-u-l-d y-o-u l-i-k-e t-o g-o t 0 t-h-e m-o-v-i-e s-a-t-tj-r-d-a-y n-i-g-h-t?" after that weekend we went back on silence to practise phrasing in which we analyzed only the first word of the phrase. at the end of two more weeks, i was able to say, "pat / would you like to go / to the biltmore hotel / in providence / for dinner / saturday night?". in addition to the improvement in speech, the jump up in two weeks from a movie in bristol to dinner at the biltmore in providence was pretty exciting. not bad for a 14 year old! this was my first introduction to what we now designate as the speak-more-fluently approach to therapy. i viewed word analysis and phrasing as the way to break the habit of stuttering and to learn to speak fluently. i hoped to substitute word analysis and phrasing for stuttering. although i was conscientious in practising words and sentences every day, utilizing my rules, a few months after i returned home i began to slip, to have increasingly more trouble. however, i never had as much difficulty again as before that first summer of therapy. today, we would say that i did not have an adequate transfer and maintenance experience. during this period, i gained "this paper is a written version of the ρ dev pienaar memorial lecture die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 a greater appreciation of the fear component of stuttering, as i perceived the way in which my apprehension about speaking reappeared. when i returned to the program the followingsummer, i began to realize that i had concentrated on the speech aspect of therapy and was missing a great deal of the part having to do with attitude. i recalled that the clinicians had talked about the way in which stutterers, in fact all people, tend to overemphasize what they perceive as a problem. for example, stutterers tend to become very sensitive about the fluency of their speech. in examining my attitude, i began to see that if i stuttered in a situation, i was very hard on myself. i considered myself pretty much of a failure. later on, after i was in college, wendell johnson's ideal helped me to understand that i should not attempt to evaluate myself as "either or", i.e. either i am a stutterer or i am not a stutterer. therefore i began to view myself more and more as a person who stuttered sometimes as he talked, and i realized that i was going through a process of changing. in 1949, i went to northwestern to study "speech correction". i learned about many theories of stuttering with the most focus on the ideas of charles van riper and wendell johnson. van riper spoke of predisposing factors, precipitating factors, and maintaining factors. predisposing factors could be physiological. johnson emphasized that the misevaluation of children's disfluency by parents and others led to an apprehensive, anticipatory, hypertensive, avoidance reaction. this led to the learning of stuttering. i had some great experiences. i met and talked with wendell johnson and lee edward travis at the 1950 convention of the american speech and hearing association attended by only 400 people. i had some not-so-great experiences too. i met a gentleman at that convention who asked me what i had learned about stuttering at northwestern, and so i told about bryngelson, johnson, sheehan, travis, van riper, etc. he asked if i had heard of isaac karlin's delayed mylinization theory; and after i said i had not, he told me, "i am isaac karlin." of course, i reviewed van riper's text and found out about dr. karlin and wrote to tell him i now knew about his theory. well, you live and learn! delivered on 16 july 1986 at the university of the witwatersrand. © sasha 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) at that 1950 convention of asha, john black from ohio state and grant fairbanks of the university of illinois demonstrated delayed auditory feedback (daf) equipment and the effect of daf on speech. one of my professors introduced me to them and i spoke under daf. apparently i did better than most people, i.e. daf did not distrub my speech flow as much as black and fairbanks expected. they concluded that this was due to my concentrating on tactile-kinesthetic monitoring as i spoke, one thing i had learned to do in therapy. as the 1950s moved along, several studies including my own doctoral dissertation, looked at auditory processes in stutterers, research that has continued until the present time. findings of a problem in the auditory system have not been conclusive. in the decade and one-half from 1960 to 1975, there was a great emphasis on studying stuttering as learned behaviour. actually, the foundation for this work was laid by wischner's reasoning, relating learning theory concepts to johnson's diagnosogenic explanation of the development of stuttering, and by sheehan's writing about stuttering as an approach avoidance conflict. from sheehan and wischner, i learned that the momentary reduction of anxiety and tension that follows the occurrence of stuttering probably reinforces unadaptive stuttering behaviour (sheehan, 1953; wischner, 1950). since we were so focused upon the punishing nature of stuttering, it was difficult to comprehend how the occurrence of stuttering could be rewarding or reinforcing in this way. in my first university teaching position at southern illinois university, from 1958-1962,1 had two colleagues, israel goldiamond and eugene brutten, both of whom were to become well known for their research relating learning concepts to stuttering. flanagan, goldiamond, and azrin (1958) investigated the possibility that stuttering was an operant behaviour by presenting bursts of a loud noise contingent upon moments of stuttering. this contingency resulted in decreases of stuttering in 3 subjects. later they presented five seconds of daf contingent upon stuttering with the same results. they began to conclude that stuttering responded like an operant behaviour as defined by skinner (1953). flanagan related to me that one day while he went to get coffee, he left the daf on continuously, and on his return, he found a stutterer speaking without stuttering in a prolonged speech pattern. thus, the use of daf in therapy was born. after many more studies showing that the effects of assumed positive, negative and neutral verbal response contingencies ("right", "wrong", "tree") and time-out were all equally as effective in reducing stuttering, it was assumed that the best explanation was that all of these contingencies highlighted stuttering. highlighting, it was said (siegel, 1970) may result in an increase of the aversive properties of cognitive and response produced stimuli; thus, these responses could serve to punish the behaviour. maybe in this way, stuttering did follow the rules of operant behaviour. meanwhile, returning to my sequential story, my other colleague at southern illinois university, gene brutten, had teamed up with don shoemaker to offer us a two-factor theory of stuttering (brutten and shoemaker, 1967). their concept was that fluency, the predominant characteristic of normal speech, is disrupted by learned classically conditioned negative emotionality that increases fluency failures (repetitions and prolongations). unadaptive instrumental behaviours or operant responses, known commonly as secondary reactions, that reduce emotional' responses are reinforced, adding to the complexity of fluency failure. a very important observation to be made of conditioning studies hugo h. gregory was that not all subjects responded in the same way. again saw that stuttering could not be simplified. in a d d i t i o n ^ emotional variables and overt behavioural variables, c o m p i ° cognitive variables probably also influence stuttering behaviou * designing research to deal with all of these influences is conmr cated and requires much more work. l~ as for the application of learning concepts, hobart mowrer the great american psychologist, assured me that we speech-languat^ pathologists had always been the quintessence of behaviourists'1 during the period i am now discussing, we clinicians, influenced by the behaviourists of our times, gave more specific attention to target responses, instructions, modelling, reinforcement, and the programming of change. we became more definitive in measurino behaviour and recording quantity of change in our reports i never thought we could measure objectively all of the dimensions of change with which we deal, but we measured what we could and our goal has been to strive for better approaches to assessment. meanwhile, kidd and his associates (kidd, 1980), and even sheehan (sheehan and costley, 1977), were becoming more convinced that there is a genetic factor in stuttering, a postulation that has been around for a long time. at the same time, all of us were recognizing the higher incidence of other speech and language problems in children who stutter (an observation first made by mildred berry [1938]). perhaps, it is the motolinguistic developmental factors that are inherited. finally, a book clarifying the present status of our knowledge about the genetic aspects of speech and language disorders has been written (ludiow and cooper, 1983). more recently, the findings of brain hemispheric functioning differences with reference to alpha suppression when anticipating expressive speech has brought forth considerable discussion. stutterers show more alpha suppression (representing greater activity) in the right hemisphere on verbal tasks; whereas nonstutterers show more in the left hemisphere (moore, 1984). this difference reminds us of the differences in auditory dichotic listening (using meaningful words) in which stutterers show more reversals and smaller between ear difference scores (gregory and mangan, 1982). remember, these are group results and do not mean that all stutterers respond in one way or another. finally, the recent findings that a group of adult stutterers who showed more right hemisphere alpha suppression before therapy, shifted to more left hemisphere suppression following therapy is intriguing. the therapy program emphasized the temporalsegmental aspects of speech, and possibly this treatment is mirrored by brain functioning (boberg, yendall, schopflocher and bolassen, 1983). that is the way it should be. although findings are somewhat mixed, the motor speech reaction time differences in which stutterers show slower voice initiation times implies a slower reacting motor system in stutterers. one study of this in children (cullinan and springer, 1980) showed that stuttering children with other language and learning problems showed the motor reaction time differences, others did not. but, there is still debate about the influence of emotional conditioning on the small differences found. / here we are in 1986. the blond boy of earlier years turned grey early as he grappled with the problem of stuttering. up to this point in this paper i have traced my experience as a person with a stuttering problem, as a student, and as a professional clinician, teacher, and researcher. at this point in my development, where do i think we are? the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) problem of stuttering: where are we in about the disfluency of children's speech and , we know mor , q u t a c h i l d s disfluency with reference to when to be c o n c e r n _ ^ d i s f l u e n c y _ including such charact h e q u a n t i t y and qua > fons p e r i n s t a n c e g f part-word, or teristics as the nurnoe ^ n £ w i n f o r m a t i o n from 0 n e s y ' l a b l % u c h a f electro-g.ottography (conture, .984) will p r o c e d u r e s sucn ^ t h e d e c i s i o n making process. if provide a d j l t l ° " ^ e r e i i v i n g today, we would see that we have s ^ s ' g n s t ' y to our understanding of the complexities of children's disfluencies. , w s in the future we may be precise in stating the cause 2 . sometimes in the ^ ^ ^ ^ , e a m i n g m o r e e a c h y e a r o r causes of s utter, g a i ^ ^ ^ a p p e a r t q b e a b 0 u c i a t ^ with smttering and about how the manipulation of a s s o c i a t e d witn t t e r i n g . w e must constantly question zszzjx** ~ w e h a v e a s f e c t i v e l y a s w l mv colleagues and i are continuing to refine our pro^ fotd.ff ent.al evaluation differential theory. we are focustng our attention on adults as we.1 as children. at present, here is more specificity in this regard about children, who are nearer to the age of onset, than there is for adults. 3 we have gained a better understanding of motor and linguistic factors associated with stuttering and about how to manage those factors as an integral part of therapy. many stuttering children appear to have marginal capacities for speech production. the demand for communication has to be controlled carefully. with references to research findings that there are minimal motoric differences of the speech mechanism (slowness of vocal reaction time and longer voice onset times [vot] or measurably longer glottal adduction per glottal cycle in some children who stutter) it would seem appropriate to utilize procedures that provide' a vivid model for the child and that usually involve the slowing of speech production and a smoother blending of speech sound transitions. on the other hand, if we are only dealing with maladaptive learning, these modifications of speech production are still appropriate. possibly, we should consider giving stutterers practice in the rapid initiation and termination of vowels and consonant-vowel combinations. assuming that the fluency of speech is related to these basic skills, particularly when children are experiencing linguistic or environmental stress, it could be important to improve these skills, j 4. progress has been made in assessing parent-child interaction factors more objectively using standardized observation procedures. recent work by meyers and freeman (1985a,b) on parental interruptions of disfluent children is important in this regard. parallel to this we are counselling parents more effectively by employing not only verbal counselling, but by modelling changes for them. i first wrote about this in 1973, and we have continued to refine procedures over the years for changing parental behaviour, as well as the child's behaviour. 5. in the past 15 years, research and clinical experience in behaviour-analysis behaviour-modification has enabled us to be more effective and efficient in changing the behaviour of children who are beginning to stutter, their parents, and more confirmed stutterers. we are more systematic in the manipulation of stimulus variables including consequences for unadaptive and adaptive behaviour. but the planned use of modelling, clinicians seeing the importance of their role as a model, has been one of the most significant developments in behaviour change procedures. behaviour modification is viewed to include making up for deficit behaviours such as sound sequencing and word finding, assertive behaviour, and social skills. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 6 the controversy between the advocates of stutter-more-fluently and speak-more-fluently models has been clarified and many clinicians are now integrating the two. for example, we begin with adult stutterers by monitoring unadaptive stuttering behaviour, stuttering with less tension; and then, through relaxed speech onsets, phrasing, etc. stutterers learn behaviour that is counter to stuttering. a major advantage of combining the two models is that stutterers learn to cope with moments of stuttering, resulting in reduced sensitivity about stuttering and diminished fear of regression or relapse, but they also learn improved speech skills and flexibility in speaking. 7. during the last ten years we have faced up to the definite need for planned transfer and maintenance activities that include making speech production spontaneous and natural. in this connection, in building fluency i always attempt to distort natural prosody as little as possible. i now say that the person, child or adult has to continue therapy on a less intensive basis, with less and less self-monitoring, for 12-18 months following the core period of therapy (whether it is one month, six months, or whatever), until speech is more spontaneous and normally fluent, and self-confidence to handle variations in fluency and disfluency is sufficient. 8. attitude change remains a controversial area. valid measurement is a paramount issue. possibly a new scale being standardized by jenifer barber watson that taps behavioural, cognitive, and affective factors and that stresses a comparison of these components will be useful. all clinicians influence attitudes. some see direct work on cognitive and affective components as important others see behaviour change as the most effective approach to attitude change. although subjective, i believe we need to explore beliefs and feelings as verbalized, or demonstrated in behaviour, to help clients clarify their attitudes and see the relation between their attitude and their behaviour. 9 increased measurement of stuttering behaviour, and here we still have a problem of definition, has resulted in more efficient and effective therapy. criteria for stuttering differ somewhat, but one syllable word repetition, part-word sound and syllable repetition, prolongations, combinations of these behaviours, and unique vocal tract disruptions characteristic of individual stutterers are counted as stuttering. extratherapy measurements involve problems. overt and covert measures, according to howie woods and andrews (1982), appear to differ the most immediately following treatment. ingham (1984) has provided a model for a time-series of assessments before, during, and following therapy. 10 clinicians are becoming more able to adapt procedures, generate their own approaches, and treat stutterers as the individuals they are. 11 finally, we must improve the training of clinicians. more clinicians are specializing in stuttering therapy. in the summer of 1985 we had a two-week workshop for specialists who already had from one to twenty years of experience. i would be pleased to see the certification of specialists so that the public could identify those who are more competent in the evaluation and treatment of stutterers. (continued on page 7) r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aids for • the development of perception • the acquisition of speech and language skills • the improvement of motor co-ordination plus • helpful texts for therapists • educational toys, books and equipment • records for auditory training • catalogues on request • large variety of tests available stockists of • learning to listen • two sound lottos • full lda range play and schoolroom 44 president place, 148 jan smuts ave., rosebank. telephone 788-1304 p.o. box 47288, parklands 2121. ο the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 7 the problem of stuttering (continued from page 5) references berry, m. developmental history of stuttering children. j. ped., 12: 209-217 1938. brutten, e. and shoemaker, d. the modification of stuttering. new jersey, prentice-hall, 1967. boberg, e., yendall, l., schopflocher, d., bo-lassen, p. the effects of an intensive behavioural program on the distribution of eeg alpha power in stutterers during the processing of verbal and visuospatial information. j. fluency dis., 8, 245263, 1983. conture, e. observing laryngeal movements of stutterers. in curlee, w. and perkins, w.h. (eds). nature and treatment of stuttering. san diego: college-hill, 1984. cullinan, w. and springer, m. voice initiation and termination times in stuttering and nonstuttering children. / speech hear. res., 23, 344-361, 1980. flannagan, b., goldiamond, i. and azrin, n. operant stutterin the control of stuttering behaviour through response contingent consequences. j. experimental analysis ofbehav., 1, 173-177, 1958. gregory, h. and mangan, j. auditory processes in stutterers. in lass, n. (ed) speech and language advances in basic research and practice, volume 7. new york: academic press, 1982. howie, p., woods, c. and andrews, j. relationship between covert and overt speech measures immediately before and immediately after stuttering treatment. j. speech hear. disorders, 47, 419-422, 1982. ingham, r. toward a therapy assessment procedure for treating stuttering in children. in gregory, h.h. (ed). stuttering therapy: prevention and intervention with children. memphis: speech foundation of america, 1984. kidd, k. genetic models of stuttering. j. fluency dis., 5,187-201, 1980. ludlow, c. and cooper, j. genetic aspects of speech and language. new york: academic press, 1983. meyer, s. and freeman, f. interruptions as a variable in stuttering and disfluency. j. speech hear. res., 28, 428-435, 1985a. meyers, s. and freeman, f. mother and child speech rates as a variable in stuttering and disfluency. j. speech hear. res., 2.8, 436-444, 1985b. moore, w.h. central nervous system characteristics of stutterers. in curlee, w. and perkins, w.h. (eds). the nature and treatment of stuttering. san diego: college-hill press. sheehan, j.g. theory and treatment of stuttering as an approachavoidance conflict. journal of psychology, 36, 27-49, 1953. sheehan, j.g. and costle, m. a reexamination of the role of heredity in stuttering. j. speech hear. dis., 42, 47-59, 1977. siegel, g.m. punishment, stuttering and disfluency. j. speech hear. res., 13, 677-714, 1970. skinner, b. the sciences of human behaviour. new york: appleton-century-crofts, 1953. wischner, g.j. stuttering behaviour and learning: a preliminary theoretical formulation. j. speech hear. dis., 15, 324-335, 1950. the application of the peabody picture vocabulary test — revised (ppvt-r) to non-mainstream children erna alant, d.phil (pretoria) s.m. beukes, ma (pretoria) department of speech pathology and audiology, university of pretoria. abstract this article focuses on the difficulties involved in diagnosing the communication of non-mainstream speakers within a south african context. various alternatives are discussed whereby tests can be made more relevant to this population. the revised version of the peabody picture vocabulary test is applied to a group of afrikaans-dialect speaking coloured children in order to determine the merits of standardizing the jest for this population. the test results are correlated with the accuracy scores on a story. the findings indicate the feasibility of the standardization of the ppvt-r for this population. opsomming die problematiek verbonde aan die diagnosering van nie-standaarsprekers se kommunikasie in 'n suider-afrikaanse konteks word onder die loep geneem verskeie alternatiewe benaderings waardeur die relevansie van toetse verhoog kan word, word bespreek. die hersiene weergawe van die peabody picture vocabulary test is op 'n groep nie-standaard afrikaanssprekende kleurling kinders toegepas ten eindediemerietevan toetsstandaardisasie vir hierdie teikengroep te bepaal. die toetsresultate word met die akkuraatheidstellings van 'n storie gekorreleer. die bevindings dui daarop dat standaardisasie van die ppvt-r vir hierdie populasie uitvoerbaar is. © sasha 1986 die suid-afrikaanse tydskrif vir kommunikasieafwykmgs, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sajcd 256 are we there yet? on a journey towards more contextually relevant resources in speech-language therapy and audiology audiologists and speech-language therapists working in developing contexts like south africa have the opportunity to address a range of needs through their research. one of these needs is the development of assessments and therapy materials that are appropriate for their clients’ particular language needs and cultural background. this editorial paper aims to introduce original research in speech-language therapy and audiology, which has been carried out in south africa and other developing contexts and is presented in this volume of the journal. in addition we suggest that while the focus of much research is on the destination or end product that is developed, there is a need to share the methodologies that are used to reach that goal so that more research can be carried out by a wider pool of students, researchers and clinicians. we describe some of the methods that we have used in our research – often in small scale projects with budgetary constraints, which would be feasible for clinicians in their routine clinical contexts. our hope is that others can build on these approaches, critique and share their own strategies for the ultimate advancement of the professions in southern africa. keywords: cross-cultural adaptation, methodology, resources, delphi, isixhosa, afrikaans s afr j cd 2013;60:2-9. doi:10.7196/sajcd.256 appendices a c are available in the pdf version of this article online at http://dx.doi.org/10.7196/sajcd.256 speech-language therapy and audiology are relatively new and relatively small professions in south africa and are beset with a host of challenges. some of these challenges include perceived low priority and low relevance against the backdrop of a quadruple burden of disease, lack of awareness about the profession and its scope, and the fact that language and communication lie at the heart of our work; yet in many cases the mismatch between therapists and audiologists and their clients in terms of language creates almost insurmountable barriers in providing equitable service delivery. many papers that have been published in this journal (barrat, khoza-shangase & msimang, 2012; kathard, naude, pillay & ross, 2007; pascoe & norman, 2011; penn, 2007) and in others (penn, 1998; southwood & van dulm, 2013; swanepoel, 2006; maphalala, pascoe & smouse, 2013) detail this context and the challenges of providing a population-based service delivery. authors such as kathard et al. (2007) and penn (2007) focused on the need for more research, as well as research that has greater relevance in our context. barrat et al. (2012) looked primarily at clinical encounters and the use of untrained personnel as translators and interpreters. southwood and van dulm (2013) focused on development of multilingual therapy materials, and maphalala et al. (2013) on isixhosa speech assessment. one of the more tangible aspects of the challenges faced is that of a lack of contextually relevant assessment and therapy materials. in 2011 our editorial introduction (pascoe & norman, 2011) explored this in detail, while that entire volume (sajcd, volume 58) showcased original south african research that was carried out with a view to furthering the development agenda of speech-language therapy and audiology. in this volume of sajcd, gonasillan, bornman and harty (2013) describe their work with toddlers from a range of different language and cultural backgrounds in south africa and the way in which the language development survey (lds) (rescorla, 1989), a widely used checklist with demonstrated validity and reliability, was adapted and found suitable for use within the south african context. detailed and systematic studies of established assessments, such as this one, provide much-needed support for clinicians who may be unsure about which assessments are appropriate for adaptation, and where it may be preferable to devise an assessment ‘from scratch’. another excellent example of contextually relevant intervention material comes from southwood and van dulm and (2012) who have devised a language therapy tool kit specifically for use with older children in the south african context who speak english and/or afrikaans. they presented this at the recent saslha conference held in bloemfontein in september 2013. of course, materials development or adaptation is not the only priority for the professions in south africa. however, the focus on materials development is appealing because it provides a very tangible and practical focus for speech-language therapists (slts) and audiologists (as) who want to make a change to their practice with clients and who may wish to become involved in research that will have a direct bearing on their own clinical practice. in this volume, the papers by wium and louw (2013) and erasmus, schutte, van der merwe and geertsema (2013), speak to the need for the professions to respond to the changing contexts in which we work. other priorities for the professions include finding and documenting the research designs and methodologies employed. ‘pragmatic approaches’ have been described in the literature as research which has relevance to stakeholders and is feasible to be conducted in and used in real-world settings (glasgow & riley, 2013). there is a growing literature base describing pragmatic study designs and the development of pragmatic measures. pragmatic measures are clearly much needed in our fields. single case studies are another potentially useful research design relevant to developing contexts. in the editorial introduction to child language teaching and therapy, vance and clegg (2012) suggested that the single case study can make an important contribution to the evidence base of the profession of speech-language therapy. one of the main messages here was that case studies are achievable for practitioners in their everyday working contexts ‘of nurseries, schools and other health and educational services’ (p. 257). vance and clegg’s editorial inspired our current editorial paper; we believe that practitioners have an important role to play in the adaptation and development of materials for use with all our clients in south africa. the pragmatic approaches and methodologies such as single case studies are achievable for practitioners in their everyday work settings. the challenges that we face in south africa are not unique to our context. mcleod, verdon and bowen (2013) recently published a paper detailing the development of a position paper to guide slts in managing children’s speech in multilingual contexts. in this paper, the five phases that were followed in order to develop the position paper are detailed: a face-to-face workshop, creation of the initial draft, online panel discussion, thematic analysis, moderation and finalisation. the paper was developed by 57 members of the international expert panel on multilingual children’s speech who represented 33 different countries. of course, the final product will be of great interest to slts and as working in southern africa (http://www.csu.edu.au/research/multilingual-speech/position-paper) and has close relevance to the topic under discussion here. what is also interesting and inspiring about mcleod et al.’s (2013) paper is the careful detailing and description of the way in which the expert panel was formed and the journey that was undertaken to reach the ultimate destination of the position paper. it is a journey that could be undertaken by different groupings in different contexts to address different issues. we aim to describe some of the research methods that can be used by clinicians to add to the body of contextual knowledge. the work we describe is not necessarily an example of best practice, but rather modest examples aimed to inspire and empower practitioners. replications of small-scale studies across different settings and different individuals will increase the external validity of these projects. ultimately publication should occur to ensure that the work is shared and read by practitioners. all too often development projects have fallen by the wayside because the ultimate destination was not reached, and valuable methodological lessons are lost. the methodologies described here could all be used in a variety of different projects and adapted for the particular aim of a study. they all require few resources and are simple to execute. they are ‘pragmatic’ in the sense of being important and relevant for stakeholders as well as being timeand cost-effective. the delphi technique is a research approach that has been widely used in social sciences, and increasingly in health sciences (keeney, hasson & mckenna, 2011). it involves the formation of an expert panel or panels whose members have specific knowledge of a particular topic. the panel is tasked with reaching consensus on a particular topic or set of questions. multiple rounds are often needed in order for the panel to carry out a problem-solving or decision-making remit. originally developed for military settings in which the demands of a task exceeded a single person, the delphi technique has been widely adapted for a range of very different purposes. in our research we have used this approach in two different ways: (i) to reach consensus regarding the selection of stimuli (words and pictures) which were needed for use in a pilot version of an isixhosa speech assessment for children, and (ii) to reach agreement about the translation of items for an audiology assessment. maphalala (2012) convened a delphi panel as part of a larger study which aimed to develop a single-word-picture naming assessment in order to collect preliminary data about the typical development of isixhosa speech (see maphalala et al., 2013). the objectives of the panel were to arrive at consensus regarding the stimuli (single words and pictures) chosen for the assessment. the panel was presented with a draft list of words. the process was undertaken to ensure that all words included were (i) culturally appropriate, (ii) age-appropriate for the children in question, and (iii) that the assumed pronunciation and meaning were also correct. there were five participants on the panel chaired by the researcher. two participants (females) were first-language isixhosa speakers. they were preschool educators who are familiar with young children. two participants (one male, one female) were academics at the university working in african languages. these participants were not first-language isixhosa speakers but were fluent in that language and had studied it. both of them are parents of young children. finally, the fifth participant was an undergraduate student of speech therapy who had isixhosa as her first language. the panel was chosen because of their innate and learnt knowledge of isixhosa and because of their interest and knowledge of young children’s speech and language development. a checklist was devised for the purpose of the panel (table 1). it contained words that had been selected by the researcher and were thought to include all the speech sounds (consonants and vowels) and word shapes that appear in the isixhosa phonetic inventory. the words were judged to be age-appropriate for preschool children as well as able to be represented by a picture. however, these judgments of the researcher required further validation from the panel. the purpose of the study was explained and checklists were distributed. an explanation of the word-checking process was given. terms were defined (e.g. what is meant by culturally appropriate) and participants were given the opportunity to ask questions about the checklist. participants were given time to fill out the checklist, a process that took approximately 20 minutes. they were urged to refrain from any discussions until the checklists were completed. during this time, no audio recordings were taken. recording began when the discussion was started. in order to analyse the wordlist, each word was read out aloud by one of the first-language speakers. participants were given the opportunity to comment on words they found inappropriate, i.e. if a word received any ‘no’s’, it was considered problematic and was discussed. participants who raised issues with words were asked to comment on what the exact problems were. this was discussed among the group and if there was agreement, a new word was suggested by the panel. this was checked in terms of the three criteria and if it passed, it was then used as part of the wordlist. of the 65 words initially in the list, 54 were found appropriate in all three categories. the main reason for inappropriate words was that they were not age-appropriate vocabulary. table 1 provides examples of some of the problematic items. the development of a preliminary isixhosa speech assessment was a challenging process that required ongoing validation and development. using the expert panel at this early stage of the research was helpful in validating some of the decisions that had been made, and also in flagging potentially problematic items. another example of the use of a delphi panel comes from audiological literature and illustrates how this type of approach can be used in translation work in our field. rogers et al. (2011) focused on dizziness, a common occurrence in the general and medical population. frequently patients and clinicians are at odds regarding symptom definition, e.g. there are 26 different english language words for ‘dizziness’, not all of which suggest the quality of the complaint and especially not a possible vestibular origin. lack of understanding becomes compounded when managing symptom description across a range of languages. the original english language vertigo symptom scale ((vss), yardley, masson, verschuur, haacke & luxon, 1992) is a validated self-assessment scale, which explores aspects of vertigo and associated symptoms of anxiety, and has been widely used in research and clinical settings. translated measures should be validated; however, there is evidence in the literature that both the quality and validation of translated instruments are variable (sousa & rojjanasrirat, 2011). delphi panels offer a time-efficient, low-cost and effective way to reach consensus and refine translations of instruments. panels may be facilitated electronically which may offer an additional advantage in that members do not influence one another in the way that may occur in focus groups – as in maphalala’s (2012) project, for example; but instead can be used to build on the work of all members and reach consensus (mokkink et al., 2010). rogers et al. (2011) used a modified (two-round) delphi consensus procedure to refine translation of the vss, as well as to seek opinion regarding afrikaans words which would capture the essence of the word ‘vertigo’. two first-language afrikaans-speaking audiology students independently translated the vss into the target language. thereafter two panels were selected in preparation for the delphi consensus procedure. panel 1 comprised five lay individuals who were first-language afrikaans speakers. levels of education ranged from having completed high school (grade 12) to university graduates. five bilingual healthcare professionals who regularly treated patients with vertigo contributed to panel 2. disciplines included audiology, otolaryngology, aviation medicine and psychology. with the exception of the psychologist, all practitioners had received specialised post-graduate training in vestibular disorders and were familiar with the vss. the initial two translations into afrikaans were merged into one as there were no differences between the versions. translation back into english helped highlight areas of ambivalence, e.g. items in which a choice of words could be used, which in turn formed the basis for discussion with both expert panels. questionnaires with five-point likert-scale responses and space for qualitative comments regarding the translation of the vss were prepared for each panel. participants in panel 1 responded to questions regarding the language, grammar and vocabulary of translated items. examples of questions are shown in table 2 and specifically probe if the meaning of translated items is clear. questionnaires were constructed with both positively and negatively phrased constructs in order to cross-check consistency of opinion. the purpose of round one of the delphi was to: • identify items on which there were high levels of agreement regarding the translation. these could be adopted immediately without need for further exploration. • give and elicit examples of different words and terminology for the translation from english to seek vocabulary equivalence in afrikaans. vocabulary equivalence (suleiman & yates, 2011) involves the selection of words, which capture the essence, and the nuances of the word used in the original. • identify which items were problematic. these items and the suggestions that emanated from them were fed back to both panels in round two. panel 2’s focus was on the applicability of the translated items to the afrikaans-speaking patient population. in addition, panel 2 was invited to contribute words commonly used by their patients to describe their symptoms of dizziness. the questionnaire used for panel 2 is shown in appendix a. the forward-backward method of translation proved effective with the proposed afrikaans version submitted for round one of the delphi, reaching high levels of consensus with both panels. items which required further refinement were identified by both panels and the combined input from lay and professional groups fed back in round two allowed a tight focus and an abbreviated version of the delphi to achieve reliable results when the afrikaans vss was presented to a patient population (rogers et al., 2011). input from a variety of disciplines allowed development of a vocabulary which would be recognised by first-language afrikaans speakers, patient populations and clinicians. the panels described by maphalala (2012) and rogers et al. (2011) were relatively simple to organise and manage; participants brought a variety of different types of expertise to the groups (different professional backgrounds, parental, tertiary education/academic and preschool education) so that a wealth of information was obtained, and in the case of maphalala’s group (2012) lively debate occurred. the checklists and questionnaires were helpful in structuring and focusing the experts. weaknesses include the relatively small number of participants in the groups, the fact that not all participants were first-language speakers of the language in question and that the dialects and origins of speakers were not explicitly considered. authors such as keeney et al. (2011) and cialkowska, adamowski, piotrowski and kiejna (2008) caution that delphi approaches have been revised and adapted so many times that they can end up being very different watered-down forms of the rigorous approach originally intended. for example, cialkowska et al. (2008) note that the original delphi was characterised by features which include anonymity of responses from panel experts, controlled feedback and a statistical description of responses. the size of the panel used in the research by maphalala (2012) and rogers et al. (2011) is also small, compared to the recommended number which literature suggests may range from 10 to over 1 000 participants. however, it should be noted that the literature is clear that increased panel size does not necessarily improve the decision-making process or guarantee a more valid outcome (powell, 2003). the size of the panel may well be dependent on the expertise that is available on a given topic at a given time. clearly maphalala’s (2012) panel may not meet all the characteristics of a true delphi – she referred to it as an ‘expert panel’. the boundaries between a true delphi panel and an expert panel convened for pragmatic purposes may be blurred in this type of research. this should not matter if the panel serves its purpose. in contrast to the delphi panels described, the process of protocol development involves documenting the methods used in research as the primary aim in order to enable replication in further projects or clinical settings. fish et al. (2012) devised a protocol for the development of speech processing and production tasks with young children. working with isixhosa-speaking children, they found that there were few assessment resources available in this language, and in order to answer their research questions, they needed to develop some isixhosa assessment tools suitable for their participants. since the process of devising these assessment materials proved complex, they documented the steps taken and the practical requirements so that others in a similar situation looking to develop stimuli for a specific language, would be able to build on the steps they had taken. the protocol follows the principles of the stackhouse and wells (1997, 2001) psycholinguistic framework, and the stimuli selection and design principles detailed as part of this framework. in glasgow and riley’s (2013) paper describing pragmatic measures, they suggest that it is desirable for pragmatic approaches and measures to be related to a theoretical model, which can help in understanding and interpreting findings and ultimately advance scientific understanding. the protocol details three tasks: naming, repetition and auditory discrimination. the children who participated in this study were three 2-year-old children who were acquiring isixhosa as their first language and attended a crèche in nyanga, cape town. the results of the tasks carried out are described by fish et al. (2012). the protocol is presented in figure 1. fig. 1. a protocol for assessing speech processing and production in young children (from fish et al., 2012). the single-word naming list (from maphalala, 2012) was used as the starting point for the development of the tasks. children were asked to name simple pictures of everyday items such as ball (ibhola), head (intloko), cat (ikati) and money (imali). where children could not name words because of vocabulary limitations, they automatically defaulted on the naming task and responses were elicited using a repetition format. items that were spontaneously named were analysed in terms of speech accuracy and how closely they resembled adult target productions. additional words were then selected for the repetition task, and these included a mix of words that were accurately and inaccurately produced. children may struggle with repetition tasks for a variety of reasons and having different stimuli to repeat (unknown words which are effectively non-words, words which a child knows but cannot yet produce, and words which a child knows and can produce in an adult-like way) may help a clinician to determine the nature of the underlying difficulties. the auditory discrimination task used an abx protocol, a simplified auditory discrimination task appropriate for 2-yearolds. this type of task does not require the participants to understand the concepts of ‘same’ and ‘different’ as many tests of auditory discrimination require. in the abx task, children were confronted with their own error and the correct target production, and asked to discriminate between the two using a visual format. for example, if the child produced ‘imati’ for ‘ikati’, the abx task may have involved these two words. one toy would ‘say’ the word ‘imati’ (stimulus a) and another toy the word ‘ikati’ (stimulus b). the child would then be asked to show which toy had said one of the words, e.g. ‘imati’ (stimulus x). appendix b is a form that could be used to administer the assessment tasks; it provides a framework to record the data from the three tasks in a manner that allows for ready administration and analysis. items that are not named immediately default to the repetition task, and auditory discrimination items are only based on errors in the naming and repetition tasks. data can then be transferred to appendix c, which provides a structure for analysis based on what was done in this study. the protocol presented here could be used to assist with clinical assessment of children with speech difficulties – when working in any language. additional resources may be needed to complete the protocol, e.g. a phonetic inventory of the language in question. using three tasks allows for more in-depth investigation of children’s speech processing, stored representations and speech production skills than typical ‘output only’ tasks allow. children may present with similar speech sound difficulties that reflect different underlying causes, e.g. one child may have articulation or motor programming difficulties, and another child whose speech errors appear similar may have difficulties with auditory discrimination which means that words are inappropriately stored and produced as a result of the input problems. having detailed information about a child’s speech processing, production and phonological representations may mean that if intervention is needed the slt can make sure it is specific to the child’s needs. some children will require therapy focusing on input skills and others may need help in updating old/inaccurately stored motor programmes. it is not suggested that this is the only or even best way to undertake this work, but fish et al. (2012) aimed to share what was done as a documented starting point. authors such as these contribute to the development agenda of slts in south africa by documenting their journey undertaken and making it available to others who may find it useful for their own research or clinical purposes. conclusions in this editorial we aimed to share some of the methods that we used in research projects that have aimed to adapt or develop contextually relevant resources for the use of slts and as in the western cape region of south africa. delphi panels can be used in a variety of ways to meet a variety of goals. here we gave two examples of how they could be used to assist with stimuli selection when compiling assessment or therapy tasks, and the process of translation. these panels can enhance the validity of the work undertaken in studies of cross-cultural adaptation and are well documented in the literature (beaton, bombardier, guillemin & ferraz, 2000; du plessis & human, 2007; keeney et al., 2011; vernon, 2009; world health organization, 2012). we aimed to describe them specifically as they were used in studies focusing on slt/a materials development in south africa. the results of some small-scale or single-subject research may be limited in generalisability to the wider population, but we have argued that there may be much to be learned about the journey taken – even if the ultimate destination is not yet reached. the answer to the question posed in our title is probably ‘no’ – we have some way to go in our development of culturally and linguistically appropriate materials for use with all of the people with communication difficulties in our country. however, the journal shows that we are moving forward towards this goal. small projects, undertaken by clinicians in response to their day-to-day needs, and the work of undergraduate students in their clinics, assignments and research projects, need to be ‘out there’ for all to see, share and learn from. documenting the steps taken, such as the protocol of fish et al. (2012), is one way in which a small-scale study can make a potentially bigger impact. acknowledgements. thanks to anita edwards for managing the peer review of this paper, and to the peer reviewers for their helpful comments. thanks to our undergraduate student groups who contributed to some of the work we describe; zinhle maphalala and mantoa smouse for their key roles in much of the isixhosa work described here, and shajila singh who was involved in discussions which led to this paper. m pascoe, phd; c rogers, msc audiology; v norman, m communication pathology department of health and rehabilitation sciences, university of cape town barrat, j., khoza-shangase, k. & msimang, k. (2012). speech-language assessment in a linguistically diverse setting: preliminary exploration of the possible impact of informal ‘solutions’ within the south african context. south african journal of communication disorders, 59, 34-44. doi:10.7196/sajcd.57 beaton, d. e., bombardier, c., guillemin, f., & ferraz, m. b. (2000). guidelines for the process of cross-cultural adaptation of self-report measures. spine, 25 (24), 3186–3191. cialkowska, m., adamowski, t., piotrowski, p. & kiejna, a. (2008). what is the delphi method? strengths and shortcomings. psychiatr pol, 42 (1), 5-15. du plessis, e. & human, s. p. (2007). the art of the delphi technique: highlighting its scientific merit. health gesondheid, 12, 13-24. fish, l., jansen, c., manley, n., powell, m., pratt, k. & rosen, l. (2012). speech processing and production in two-year old children acquiring isixhosa: a description of three cases. unpublished undergraduate thesis. university of cape town. glasgow, r. & riley, w. (2013). pragmatic measures: what they are and why we need them? am j prev med, 45(2), 237-243. kathard, h., naude, e., pillay, m. & ross, e. (2007). improving the relevance of speech-language pathology and audiology research and practice. south african journal of communication disorders, 54, 5-7. keeney, s., hasson, f. & mckenna, h. (2011). the delphi technique in nursing and health research. chichester: wiley-blackwell. doi:10.1002/978144439 maphalala, z. (2012). phonological development of first language xhosa-speaking children aged 3;0 5;11 years: a descriptive cross-sectional study. unpublished undergraduate thesis. university of cape town. maphalala, z., pascoe, m. & smouse, m. (2013). phonological development of first language isixhosa-speaking children aged 3;0 6;0 years: a descriptive cross-sectional study. clinical linguistics and phonetics, early online: 1-19. doi: 10.3109/02699206.2013.840860. mcleod, s., verdon, s., bowen, c. & the international expert panel on multilingual children’s speech. (2013). international aspirations for speech-language pathologists’ practice with multilingual children with speech sound disorders: development of a position paper. journal of communication disorders, 46: 375-387. mokkink, l. b., terwee, c. b., patrick, d. l., alonso, j., stratford, p. n., et al. (2010). the cosmin study reached international consensus on taxonomy, terminology and definition of measurement properties for health-related patient reported outcomes. j clin epidemiol, 63, 737-745. pascoe, m. & norman, v. 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(1989). the language development survey: a screening tool for delayed language in toddlers. journal of speech and hearing disorders, 54, 587-599. sousa, v. & rojjanasrirat, w. (2011). translation, adaption and validation of instruments or scales for use in cross-cultural health care research: a clear and user-friendly guideline. journal of evaluation in clinical practice, 17, 268 – 274. southwood, f. & van dulm, o. (2012). receptive and expressive activities in language therapy (realt). johannesburg: jvr psychometrics. southwood, f. & van dulm, o. (2013). child language assessment and intervention in a multilingual context: the state of the art in the rainbow nation. paper presented at saslha conference, bloemfontein, september 2013. http://www.entcongress.co.za/images/2013presentations/venue3/30th/14h30southwoodvandulmvenue3monday.pdf stackhouse, j. & wells, b. 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(2012). process of translation and adaptation of instruments. retrieved on 22 november 2012 from http://www.who.int/substance_abuse/research_tools/translation/en/ yardley, l., masson, e., verschuur, l., haacke, n. & luxon, l. (1992). symptoms, anxiety and handicap in dizzy patients: development of the vertigo symptom scale. j psychosom res, 36, 731-741. 'ν neuro-evolusionere εν neurofisiologiese benadering tot die ondersoek en behandeling van verworwe disartrie anita van der merwe m.a.log. (pretoria) departement spraakheelkunde, universiteit van pretoria opsomming die konvensionele benadering tot verworwe disartrie soos dit gevind word in die literatuur word kortliks bespreek. die noodsaaklikheid vir 'n gewysigde benadering wat praktiese leidrade aan die spraakterapeut sal verskaf, word beklemtoon. die opkoms van die neuroevolusioner-gefundeerde benadering tot serebrale verlamming, met ander woorde, tot kongenitale disartrie, word genoem. sover bekend, is daar geen georganiseerde gegewens in die literatuur wat die neuro-evolusie van spraakmotoriek blootle vanaf die mees outomatiese, mees georganiseerde en mees eenvoudige vlak tot die meer willekeurige, meer komplekse, en minder georganiseerde vlak van funksionering nie. bekende gegewens in verband met spraak is hipoteties georden en 'n hierargiese spraakskema is opgestel wat die neuro-evolusie van spraak blootle. op grond van die skema en met inagneming van neuro-fisiologiese disfunksies, is 'n ondersoek program opgestel wat die spraakprobleem van die verworwe disartriegeval in sy geheel ondersoek. behandeling geskied aan die hand van die riglyne wat die skema aandui. deur die gebruik van toepaslike spraakterapeutiese metodes word beoog om 'n herevolusie te bewerkstellig waar moontlik. summary the conventional approach to acquired dysarthria as found in the literature, is briefly discussed. the necessity for an altered approach, which will provide practical guidelines for speech therapists, is emphasized. the approach to cerebral palsy (in other words to congenital dysarthria) based on neuro-evolutional theory, is mentioned. as far as is known, there are no organised data in the literature that describe the neuro-evolution of s p e e c h motor-co-ordination from the most automatic, most organized and simplest level to the more voluntary, more complex and less organized level of functioning. known data concerning speech have been hypo the tically ordered and a hierarchical speech scheme describing the neuro-evolution of speech was constructed. based on this scheme and taking the neurophysiological dysfunction into account, an examination procedure which examines acquired dysarthria as a whole, has been compiled. therapy follows the guidelines indicated by the scheme. disartrie is 'n griekse woord wat letterlik beteken 'n versteuring van artikulasie as gevolg van 'ri letsel van die perifere of sentrale senuweestelsel.18 die term behels egter meer as dit en verwys na defektiewe motoriese beheer van die totale spraakmeganisme uitgesonderd die simboliese. dit verwys na spraakprobleme as gevolg van paralise, swakheid, of swak koordinasie van spraakspiere en dit sluit in artikulasie, fonasie, respirasie en resonansie.5'10 die term "verworwe" dui aan dat die toestand nie aangebore is nie, maar dat gestabiliseerde spraak reeds bestaan het voor die toestand ingetree het. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23. desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 anita van der merwe aanduidings van belangstelling in verworwe disartrie word in die literatuur gevind vanaf die begin van hierdie eeu. navorsing op die gebied volg veral twee benaderingswyses. enersyds word een of meer van die spraaksimptome wat kenmerkend is van verworwe disartrie, ondersoek. enkele simptome soos byvoorbeeld hipernasaliteit,19 verstaanbaarheid,15 wanartikulasie, disdiadokokinese,14 en verminderde beweeglikheid van artikulators,7 word in isolasie bestudeer. die verband met ander simptome en die onderliggende neuro-fisiologiese disfunksie word dus nie duidelik toegelig nie. andersyds is die simptome wat in 'n spesifieke toestand voorkom, nagegaan. baie aandag is geskenk aan parkinsonisme, veelvuldige sklerose en myasthenia gravis. verskeie nie-spesifieke terminologie is gebruik om die spraaksimptome te beskryf, byvoorbeeld "stadig", "geforseerd", "eksplosief" en "staccato". beskrywing van 'n sekere toestand se simptome verskil van outeur tot outeur en die gevolg is 'n algemene verwarrende beeld. dieselfde neiging om die probleem oppervlakkig te benader, word gevind met betrekking tot die behandeling van verworwe disartrie. metodes wat wissel vanaf die koumetode,17 tot die gebruik van eksterne hulpmiddels byvoorbeeld 'n prostese vir nasale spraak,16 en chirurgiese kleefband,4 word beskryf. elk van die metodes kan wel nuttig wees deurdat sekere simptome sodoende verlig word. geen algemene beginsels word egter in die literatuur verskaf op grand waarvan al die simptome van alle gevalle van verworwe disartrie ondersoek en behandel kan word nie. darley en sy medewerkers,5'6 doen in 1969 die mees omvattende studies tot op datum. spraaksimptome van al die verskillende tipes verworwe disartrie word bestudeer met as doel die samestelling van differensiaal-diagnostiese simptoomgroepe. die simptome word verklaar en in verband gebring met die onderliggende neurofisiologiese disfunksie. die praktiese implikasies van die studies is egter steeds beperk vir die spraakterapeut. gedurende die vyftigerjare is 'n groot deurbraak gemaak op die gebied van serebrale verlamming toe bobath en bobath neuro-evolusioner georienteerde terapiemetodes in fisioterapie begin toepas het. mysak11 het die waarde van die benadering besef en dit ook toegepas op die behandeling van spraakprobleme van die serebraalverlamde kind. mysak12 verklaar egter dat die enkele groot struikelblok in die weg van die praktiese toepassing van 'n neuro-evolusionere benadering in spraakterapie, die gebrek aan georganiseerde materiaal op die gebied van oro-neuro-motoriese ryping van spraak, is. kennis van die gebied is noodsaaklik aangesien die motoriese probleme van die serebraalverlamde vanuit 'n neuro-evolusionere oogpunt gesien word as 'n arrestasie of wanontwikkeling op die evolusieleer van motoriek. die simptome van verworwe disartrie kan daarenteen gesien word as 'n devolusie van motoriek. die herverskyning van infantiele orale reflekse by die volwasse brein-beseerde persoon soos beskryf deur, o.a. brain,2 en mysak,13 bevestig die aanname. ten einde die rasionaal van 'n neuro-evolusioner-gefundeerde benadering te verstaan, is dit nodig om die konsep van evolusie en devolusie van die funksionering van die sentrale senuweestelsel en die duplekse simptomatologie van neuropatologie kortliks te beskryf. die welbekende neuroloog, john hughlings jackson, het in die vorige eeu hierdie beginsels gepostuleer, en dit bied steeds journal of the south african speech and hearing association, vol. 23. december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η benadering tot verworwe disartrie 47 'n handige basis vir die bestudering van die simptome van neuropatologie. jackson9 onderskei 'n hierargie in die sentrale senuweestelselareas en ook in die funksies van die areas. onderskeid word hoofsaaklik gemaak tussen hoogste en laagste vlakke. die funksies van die laagste vlak is minder kompleks of meer eenvoudig, meer georganiseerd en dus minder veranderbaar, en ook meer outomaties. bewegings wat op die vlak beheer word, toon min kompleksiteit en min spesialisasie. dit is kenmerkend van gedrag net na geboorte. die funksies van die hoogste vlak en gedrag wat beheer word op die vlak, is minder georganiseerd, meer kompleks en meer willekeurig. mysak13 definieer die term "evolusie" as: ' . . . an ascending development in a particular order'. die genoemde onderskeid in funksies dui dus ook die orde van motoriese ontwikkeling aan. ontwikkeling vind plaas vanaf die mees outomatiese funksies na die meer willekeurige, vanaf die mees eenvoudige na die meer komplekse en vanaf die mees georganiseerde, tot die funksies wat steeds verder georganiseer word.1 3 daar is dus 'n ordelike verloop in motoriese ontwikkeling. elke vlak van ontwikkeling is die resultaat van die vorige vlak en die voorloper van die daaropvolgende vlak.3 primitiewe motoriese response word geleidelik gei'nhibeer namate hoer vlakke van ontwikkeling bereik word.1 neuropatologie veroorsaak daarenteen 'n devolusie of afbraak van funksionering en gee aanleiding tot 'n duplekse simptomatologie volgens jackson.9 negatiewe simptome is die verlies van funksies as gevolg van 'n letsel terwyl positiewe simptome die resultaat is van aktiwiteit of ooraktiwiteit van die intakte dele van die sentrale senuweestelsel wat vrygestel is van beheer deur hoer dele, 'n voorbeeld van 'n negatiewe simptoom is 'n parese of paralise wat die gevolg is van 'n verlies van willekeurige beheer en 'n voorbeeld van 'n positiewe simptoom is die verskyning van infantiele reflekse.13 in terme van die leer van devolusie is die negatiewe element dus die verlies van die minder georganiseerde, meer komplekse en meer willekeurige funksies, terwyl die positiewe element die vrylating is van meer georganiseerde, meer eenvoudige en meer outomatiese funksies. die verskynsel van duplekse simptomatologie bevestig dus die konsep van devolusie van motoriek as gevolg van neuropatologie. indien die neuro-evolusionere beginsels van sentrale senuweestelselfunksies toegepas word op spraakmotoriek, impliseer dit 'n rangorde van kompleksiteit van spraakgedrag wat geleidelik tot stand kom en ook afgebreek kan word as gevolg van breinskade van die motoriese areas. indien sodanige rangorde of evolusieleer saamgestel kan word, kan dit dus 'n raamwerk bied waarbinne verworwe disartrie ondersoek en behandel kan word. die mate van devolusie kan nagegaan word en die heropbou van spraakfunksies kan geskied aan die hand van die riglyne wat die evolusieleer, of soos dit later genoem word, die hierargiese skema, aandui. alvorens daartoe oorgegaan word om die neuro-evolusionere beginsels toe te pas op spraak, moet genoem word dat die meer neurofisiologiese aspekte van verworwe disartrie nie geignoreer mag word nie aangesien dit van groot belang is in die behandeling. motoriek en dus ook spraakmotoriek word beheer deur die gesamentlike werking van 'n aantal dele van die sentrale senuweestelsel. in tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23, desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 anita van der merwe die verskillende etiologiese groepe of ook genoem motoriese siridroomgroepe, word motoriek op 'n kenmerkende wyse aangetas. 'n letsel van enige deel van die sentrale senuweestelsel wat motoriek bei'nvloed, sal waarskynlik 'n devolusie van spraakgedrag tot gevolg he aangesien komplekse spraakfunksies afhanklik is van die gesamentlike werking van die verskillende dele van die sentrale senuweestelsel. sover moontlik word die neurofisiologiese disfunksie, byvoorbeeld 'n parese wat die uitvoer van meer of minder komplekse funksies verhoed, dus behandel ten einde 'n herevolusie te bewerkstellig. waar beide die neuro-evolusionere en neurofisiologiese komponente in ag geneem word, bied dit 'n verantwoordbare rasionaal vir die ondersoek en behandeling van verworwe disartrie. die toepassing van neuro-evolusionere beginsels op spraak sover bekend bestaan daar geen georganiseerde gegewens wat die neuro-evolusie van spraak blootle nie. in terme van die genoemde beginsels kan afgelei word dat ook spraakmotoriek vanaf'n mees outomatiese, mees georganiseerde en mees eenvoudige vlak na 'n meer willekeurige, minder georganiseerde en meer komplekse vlak van funksionering ontwikkel. die infantiele orale reflekse kan gesien word as die laagste vlak van orale funksionering en as die beginpunt van vegetatiewe gedrag en spraakontwikkeling. ingram8 se dat die reflekse plaasvind via die medulla en op latere stadiums in willekeurige motoriese aktiwiteite gei'ntegreer word. oor die verband wat daar bestaan tussen spesifieke orale reflekse en artikulasie-beweging kan slegs gespekuleer word. gestabiliseerde spraak is direk geinisieerde en willekeurige bewegings, maar die presiese funksionering is afhanklik van die onderliggende onbewuste integrasie van die aktiwiteite van 'n komplekse reeks reflekse. hierdie reflekssisteme verskaf die onbewuste substratum vir spraakproduksie.20 die reflekssisteme word gekodrdineer met die willekeurige meganismes deur die dalende projeksiebane vanaf die serebrale korteks, nl. die kortikobulbere en kortikospinale bane.21 enkele reflekse kan waarneembaar uitgelok word in die spraakorgane, nl. die faringale, palatale en mandibulere reflekse. die reflekssisteme kan beskou word as die meer outomatiese, meer georganiseerde en meer eenvoudige aspekte van orale funksies tydens spraakontwikkeling en gestabiliseerde spraak, en word dus onderskei van die infantiele reflekse wat as mees outomaties geklassifiseer is. die vegetatiewe funksies, die velofaringale sfinkter, respirasie en fonasie word op grond van hul funksionering op 'n laer bewussynsvlak deur die skryfster gegradeer as meer outomatiese, meer georganiseerde "en meer eenvoudige funksies. as 'n derde vlak, word die ontwikkeling van artikulasie en artikulasie tydens gestabiliseerde spraak, as die meer willekeurige, minder georganiseerde en meer komplekse aspek van: orale funksionering, onderskei. daar kan dus tot die slotsom gekom word dat gestabiliseerde spraak gegradeerde komponente bevat, met ander woorde, outomatiese en willekeurige aspekte. genoemde gradering dui dus nie slegs die orde van ontwikkeling aan nie, maar gee 'n aanduiding van die neuro-evolusionere organisasie en funksionering op enige stadium. journal of the south african speech and hearing association vol. 23. december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η benadering tot verworwe disartrie 49 met die oog op die praktiese toepassing van die teoretiese besinning, is daar as volg te werk gegaan: 1. daar is 'n hierargiese spraakskema opgestel wat die neuro-evolusionere organisasie van spraakfisiologie aandui en wat as basis sal dien vir die opstel van 'n ondersoekprogram en riglyne sal verskaf vir die behandeling van verworwe disartrie. 2. 'n ondersoekprogram is saamgestel wat die spraakprobleem van die verworwe disartriegeval in sy totaliteit ondersoek en die neuro-evolusionere en neurofisiologiese simptome uitlig. bespreking van die hierargiese skema bekende feite in verband met spraak word hipoteties georden deur die skryfster en weergegee in die hierargiese skema. enkele vereistes is gestel aan die skema: 1. in ooreenstemming met neuro-evolusionere beginsels moet die skema spraakmotoriek voorstel vanaf die mees eenvoudige tot die meer komplekse, die mees outomatiese tot die meer willekeurige, en vanaf die mees georganiseerde tot die minder georganiseerde vlakke van funksionering. 2. die subsisteme van spraakfisiologie, nl. respirasie, fonasie, artikulasie, resonansie en vegetatiewe gedrag, word alles in ag geneem en ook die interskakeling moet na vore kom aangesien geeneen van die subsisteme onafhanklik bestaan nie. 3. die skakeling met sensoriese terugvoering word ook op die skema aangegee aangesien spraak sensories-motoriese gedrag is. 4. vir praktiese doeleindes moet die skema van waarde wees in die diagnose van motoriese spraakprobleme en ook riglyne verskaf vir die behandeling van die probleme. die skema word dan ook in vlakke verdeel wat stadia in die ontwikkeling van spraak en organisasie in die gestabiliseerde stadium aandui ten einde die teorie meer konkreet voor te stel. dit gee noodwendig aanleiding tot 'n mate van oorvereenvoudiging aangesien spraak in sy totaliteit uiters kompleks is en moeilik grafies voorgestel kan word. die voorstelling van die hierargiese spraakskema is soos reeds gese, bloot hipoteties en kan slegs deur verdere uitgebreide navorsing bevestig word. in 'n voorlopige ondersoek gedoen deur die skryfster, is bevind dat dit reeds in die huidige vorm tot 'n groot mate ooreenstem met die orde van devolusie en herevolusie in die verworwe disartriegeval en van groot praktiese waarde is. enkele aspekte van die skema word vervolgens bespreek: respirasie respirasie is die mees basiese funksie van alle lewende wesens en dit word slegs sekonder aangepas vir spraakdoeleindes deur geleidelike dieper respirasie met vinnige inspirasie en gekontroleerde verlengde ekspirasie. die uitvloei van lug word ook gevarieer om verhoogde subglottale druk te verkry wat aangepas word vir die klempatrone van 'n taal. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23, desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 anita van der merwe • 1> bfi.j. ̂ έ ΐ ϊ β β λ ό > — 4) <u « ο > μ +c bfi «• <υ.; £ έ 8 8 g > £ c cw 5·° ο g ο λ ό b w ο α> ^ τ3 c 60— ο c ο α> ή u. ο ο (λ c si'5 £ c ω « > α ω (λ — « ο ; « ο ® c " ζ sjs 3 •ξϋ-s a> 3 "i c t. 4> ̂ a) 4> ω — 4> tm c c tui 0 ο b co a. η <υ ο ε μ g.e ο ω •ο ο 5 ο α § ι ^ « j5 c c 3 « • he _ π ο c < 'e?s° ο ji" u sti· c π™ 5 ξ ο £ ο.» g " 3 ο"?-ξ 2.5 ο _ (λ 5 2 c ji ο ®·" 2 -a-src '•3 "ξ·!·* _ u π α μ >.2 ο c 2 u o n · ; i s i i ε » <u ji 5.ε u ji •a 3 •a 3 £ ° ooa w ε «ά c .2-r-ii ; ϊ · . 5 •s π·°·α ι· c i " i u m j*(λ (λ ι *»-[/) l. q 5 s « u 0> £ •.spas c > 52·α c w ω ρ ωΐ bo α> λ _ ~ « > 2 3 xj c d c _ «•"«•st .2 β c u « ο β> > vi .5 bo'w s 0) ι. ό a ι, μ · • c ; s-ji» « κ > i •5 ε c <υ a> a> q. t. "o •5os5 s = 3 1 3 t ζ ι c r " a ® ό c-^·0 c β ° >. π > c « μ <i> c ε •ξ »c <d τ r .ο ο "•π 3.21 a s 0-2·-2 t 4· i ' i e i s ? a> α» β> λ e v) ~ — c 5 sjc ta <λ·c 2 υ w m mm η —s u ο = 2 > μ 6 0 mt 5 si ο ̂ ·γ· * * 5 > : £ c _ w ω 3 a> <u <u w > 'vj </j bfitd x) <υ a> "s 03 _ a> a> c ^ 3 « υ ο di a> a> (λ 2 o.c & λ 2 2 ^ π j2 s? o-: ο : c c oi ο /fcu " <u (u a» — μ q. > 2 journal of the south african speech and hearing association, vol. 23. december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η benadering tot verworwe disartrie t 51 fonasie glottale adduksie is aanvanklik suiwer refleksief en so ook die aanvanklike skakeling tussen ekspirasie en glottale sluiting tydens huil. vanwee die versterking deur sensoriese terugvoering, word die skakeling meer willekeurig en word glottale sluiting gebruik vir fonasie. die vaardigheid waarmee die fonasiemeganisme gebruik word en die diadokokinese van glottale abduksie en adduksie neem geleidelik toe, asook die vermoe om variasie in intonasie te produseer. die stippellyne dui op die begin van interskakeling wat op 'n latere stadium meer vasgele is, soos aangedui deur die vaste lyn. klempatrone en intonasievariasie in die bree konteks van spontane kommunikasie in enige taal word beskou as die mees komplekse vlak van interskakeling tussen fonasie en respirasie. vanuit 'n bewussynsvlak gesien kan die aspek nie op dieselfde vlak gestel word as artikulasie nie, want daar is beperkings op die willekeurige beheer van die aspekte vanwee die beperkte hoeveelheid proprioseptiewe inligting vanaf die fonasie en respirasie-meganisme. artikulasie die soekrefieks word gesien as die basis van artikulasiebeweging aangesien massabewegings van al die artikulasie organe en die kop hierin voorkom. dit is die beginpunt van latere onafhanklike bewegings. die liprefleks word ook hier geplaas hoewel dit ook by die meer suiwer vegetatiewe reflekse geplaas kan word. gei'soleerde lipronding is egter op latere stadiums waarskynlik meer verwant aan artikulasie as aan die basiese funksies. vanuit die soekrefieks ontwikkel kopkontrole en onafhanklike spraakorgaanbewegings. die mondrefleks wat 'n gekondisioneerde refleks is, ontstaan op 'n latere stadium en kan moontlik ook by die vegetatiewe funksies geplaas word, aangesien mondopening 'n voorvereiste is vir eet. dit kan egter ook gesien word as die basis vir latere willekeurige mondopening tydens artikulasie. terugvoering speel weer eens 'n belangrike rol in die verdere motoriese ontwikkeling en word op die skema aangedui. vaardigheid en diadokokinese neem geleidelik toe en artikulasie vereis akkurate plasing in steeds groter wordende kontekse namate die kind vorder vanaf woorde na sinne in sy taalontwikkeling. resonansie die velum dien aanvanklik as deflektor vir voedsel en hieruit kan afgelei word dat daar aanvanklik nie velere bewegings voorkom nie. namate die meer volwasse slukpatroon aangeneem word, is dit nodig dat 'n velere sluiting gevorm word. die beweging ontstaan waarskynlik dan op 'n latere stadium en word om die rede op vlak 2 aangedui. die sluiting word geleidelik gekoordineer met fonasie, die vaardigheid en diadokokinese neem toe, en nasalering vind plaas volgens die vereistes van die taal. vegetatiewe gedrag die aanvanklike infantiele orale reflekse word aangedui as die beginpunt van vegetatiewe gedrag. refieksiewe suig is die beginpunt van die volwasse slukrefieks. die slukrefleks soos byvoorbeeld vir speekselbeheer, word weer beskou as onderliggend aan die slukpatroon tydens eet in die volwasse stadium. retydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde. vol. 23. desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 anita van der merwe fleksiewe kou en byt vorm die basis vir latere gekoordineerde byt en kou. die suigfunksie word ook op vlak 3 aangedui aangesien dit 'n hoe mate van ko5rdinasie vereis tussen verskillende organe soos die velum, lippe en tong en slegs op 'n latere stadium moontlik is. vegetatiewe gedrag is die gebruik van die orale organe vir laer funksies wat nie-simbolies is nie. dit word egter nie streng gesproke gesien as die basis van artikulasie nie. die neurofisiologiese organisasie is waarskynlik totaal verskillend aangesien die vegetatiewe funksies onafhanklike kortikale verteenwoordiging het en dus nie net 'n laer orde organisasie van spraakbewegings is nie. om die rede word vegetatiewe gedrag as 'n onafhanklike subsisteem aangegee wat ook soos die ander subsisteme nou skakel met artikulasie aangesien dit steeds bewegings van dieselfde organe vereis. vereistes gestel aan die ondersoekprogram 1. afleidings in verband met neuro-evolusionere en neurofisiologiese aspekte van die probleem moet gemaak kan word met die oog op diagnose, behandeling en verdere navorsing. 2. die inligting verkry uit die program moet 'n indikasie gee van die algemene toestand en aard van die probleem aangesien die spraakprobleem as deel of simptoom van die totale probleem gesien moet word. 3. daar word nie gepoog om die probleem te klassifiseer nie, maar wel om die simptome van die toestand soos dit presenteer in elke individuele pasient, na te gaan. die literatuur dui aan dat die huidige klassifikasie van die motoriese sindroomgroepe nie onomwonde bewys en aanvaar word nie, en die neiging om elke persoon se individuele simptome na te gaan, word bespeur. 'n individuele benadering is aanvaarbaar en noodsaaklik as in ag geneem word dat die lokalisasie en dus ook die effek van 'n letsel verskil van persoon tot persoon. dit is egter so dat algemene beginsels met betrekking tot fisiologie ooreenstem in alle persone en aan die hand .van die beginsels kan alle persone wel ondersoek en behandel word. 4. elke subsisteem van spraak word nagegaan vanaf die mees eenvoudige tot die meer komplekse funksies ten einde 'n beeld van die totale spraakprobleem te verkry. 5. die aandeel van organiese bou in die funksionele probleem moet nie geignoreer word nie. die wyse waarop die probleem organies presenteer; byvoorbeeld in 'n verlamming, word ook aangeteken vanwee die belangrike rol in die spraakprobleem en die diagnostiese waarde daarvan. '' 6. ten einde vaste norms daar te stel, word die moontlike vorme wat 'n toestand kan aanneem aangegee, en die ondersoeke dui slegs met 'n kruisie die aard van 'n toestand aan. die metode is bok tydsbesparend. 7. die implikasies van die bevindings moet'ook aan die terapeut wat nie oor 'n diepgaande kennis van die neuro-evolusie beskik nie, riglyne verskaf vir die doelstellings van terapie. ; i 8. ruimte word egter ook gelaat vir kwalitatiewe beskrywings aangesien elke journal of the south a frican speech and hearing association, vol. 23. december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η benadering tot verworwe disartrie 53 individuele probleem in sy totaliteit nie deur keusemoontlikhede aangedui kan word nie. 9. die program moet met gemak en vinnig prakties toegepas kan word. 10. ruimte word gelaat vir die optekening van resultate op 'n latere stadium, byvoorbeeld na 'n periode van terapie aangesien die verloop van die toestand daaruit afgelei kan word, asook die effek van behandeling, medies sowel as terapeuties. vir navorsingsdoeleindes kan afleidings ook in verband met her-evolusie gemaak word. die ondersoekprogram vir verworwe disartrie algemene fisiese ondersoek 1. spiertonus: normaal; parese; paralise; verlaag; verhoog; links; regs; bilateraal. 2. reflekse: normaal; verhoog; verswak. 3. abnormale reflekse: afwesig; teenwoordig. 4. balans: kopkontrole: goed, swak, geen; kan sit; kan staan;kan loop. 5. onwillekeurige bewegings: afwesig; teenwoordig. 6. sensasie: normaal; verlies. 7. kraniaalsenuweeuitvalle: i-xii; geen. 8. diagnose: 9. prognose: opmerkings: die algemene fisiese ondersoek moet verkieslik deur die geneesheer voltooi word. perifere orale ondersoek die lippe en gesig, mandibula, tong en velum word aan die hand van die volgende aspekte ondersoek waar toepaslik. 1. bou: normaal; gebreke anatomies; atrofie. 2. spiertonus: normaal; verhoog; verlaag; links; regs; bilateraal. 3. simmetrie: normaal; asimmetries: trek na links; regs. 4. refleksiewe beweging: normaal; verhoog; verswak. 5. willekeurige beweging: normaal; swak; immobiel; feitlik immobiel. spraakmotoriek-ondersoek a. infantiele orale reflekse. 1. soekrefieks: teenwoordig; gedeeltelik; afwesig. 2. hand-mandibulere refleks: ditto. 3. liprefleks: ditto. 4. suigrefleks: ditto. 5. kourefleks: ditto. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23 desemer 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 anita van der merwe 6. bytrefleks: ditto. 7. mondoopmaakrefleks: ditto. 8. mandibulere strekrefleks. b. behoue reflekse. 1. slukrefleks: teenwoordig; verswak; verhoog; afwesig; vertraag. 2. speekselbeheer: ditto. 3. faringale refleks: ditto. 4. palatale refleks: ditto. 5. mandibulere refleks: ditto. 6. gaap: ditto. c. vegetatiewe funksies. 1. byt: normaal; verswak; afwesig; geassosieerde bewegings. 2. kou: ditto. 3. gesinkroniseerde byt, kou en sluk: ditto. 4. sluk: ditto. d. respirasie. 1. dominante tipe: abdominaal; torakaal; gemeng. 2. diepte van respirasie: normaal; vlak. 3. gebruik tydens rus: ekonomies; onekonomies. 4. reelmatigheid: egalig; onwillekeurige bewegings. 5. as aktivator vir refleksiewe glottale sluiting: voldoende; onvoldoende. 6. as aktivator vir fonasie: voldoende; onvoldoende. 7. duur van lang ekspirasie sonder stem: . . . sekondes. 8. inspirasiespoed vir spraak: normaal; stadig. 9. gebruik tydens spraak: ekonomies; onekonomies. 10. spraakluidheid: normaal; verswak; verhoog. 11. konstantheid van toonluidheid: normaal; neem geleidelik af; onwillekeurige bewegings. 12. ekspirasie vir klempatrone in woorde: voldoende; onvoldoende. 13. ekspirasie vir klem in groter konteks: voldoende; onvoldoende. e. fonasie. 1. glottale sluitrefleks, byvoorbeeld in hoes: teenwoordig; verswak; afwesig. 2. willekeurige koordinering met ekspirasie: voldoende; onmoontlik. 3. duur van verlengde fonasie: . . . sekondes. 4. konstantheid van verlengde fonasie: aanhoudend; wissel; neem vinnig af; onwillekeurige bewegings. journalof the south african speech and hearing association vol. 23. december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η benadering tot verworwe disartrie 55 5. inisieringspoed van stem: normaal; vertraag; gering vertraag. 6. diadokokinese van glottale sluiting: . . . keer in 5 sek., aaneenlopend. 7. ritme van glottale diadokokinese: ritmies normaal; stadig ritmies; a-ritmies 8. beweging tydens diadokokinese: afsonderlik; word aaneenlopend. 9. algemene toonhoogte: normaal; laag; hoog; wissel. 10. stemkwaliteit: normaal; swak. 11. toonhoogtevariasie in sinne: normaal; gering; monotoon. 12. toonhoogtevariasie in groter konteks: normaal; gering; monotoon. f. resonansie 1. palatale refleks: teenwoordig; afwesig; verswak; ontoetsbaar weens verhoogde faringale refleks. 2. koordinering met fonasie: teenwoordig, afwesig. 3. verlengde sametrekking met fonasie: normaal; vinnige uitputting; afwesig; onwillekeurige bewegings. 4. diadokokinese van velere sluiting: . . . keer in 5 sekondes. 5. kwaliteit tydens diadokokinese: goed; onvoldoende bewegings; bewegings worcl aaneenlopend. 6. nasale resonansie in spraak: normaal; hipernasaal; hiponasaal. 7. graad van nasaliteit: gering; erg; totaal. g. artikulasie. spraaksisteemdifferensiasie: goed; gedeeltelik; geen. 1. kop van toraks. 2. artikulators van kop en nek. 3. lippe van kaak en tong. 4. tong van kaak en lippe. 5. kaak van tong en lippe. 6. intra-orgaandifferensiasie. diadokokinese: . . . keer in 5 sek.; ontoetsbaar. 1. enkelartikulasie. i) nie-spraakbewegings: tong in en uit; tong heen en weer; lippe; kaak. ii) spraakbewegings: tong; lippe; kaak; velum (bv. la; pa; ka; pm) 2. twee-plekartikulasie. i) voor na agter in mond. ii) voor na mid del. iii) agter na voor. iv) agter na middel. 3. drie-plekartikulasie i) voor, middel en agter van mond. ii) agter, middel en voor. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23, desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 anita van der merwe iii) middel, voor en agter. artikulasie 1. aard van artikulasie: akkuraat; goed; swak; baie swak; uiters swak; weggelaat. i) bilabiaal. ii) labiodentaal. iii) palataal. iv) alveoler. v) veler. vi) vokale. vii) klankverbindings. 2. algemene indruk van artikulasie: goeie artikulasie; verswakte artikulasie; uiters verswak; erg verswak; weinig artikulasiebewegings. 3. gelykvormigheid van artikulasie in spontane spraak: konstant dieselfde geartikuleer; varieer; breuke in artikulasie; verswak met uitputting. artikulasie tydens diadokokinese: 1. kontinui'teit van bewegings: bly behoue; neem vinnig af; geleidelik; onwillekeurige bewegings; feitlik immobiel. 2. ritme tydens diadokokinese toetsing: ritmies; stadig ritmies; a-ritmies. 3. akkuraatheid van plasing: goed; swak; baie swak. 4. geassosieerde bewegings van: ander artikulators; ander liggaamsbewegings. 5. spoed van spontane spraak: normaal; stadig; baie stadig; onreelmatig. h. vlotheid van spraak: 1. vlotheid van spraak: normaal; onvlot. 2. ritmespoed van spraak: normaal; stadig; wissel. i. kompensasie. kompenseer deur: geen; spoed van spraak; addisionele bewegings. j. verstaanbaarheid. 1. verstaanbaarheid van spontane spraak: goed; swak; baie swak. 2. verstaanbaarheid tydens: woorde; sinne; spontane spraak. k. indruk van algemene erns van toestand: uiters swak; baie.swak; swak; gemiddeld; gering; weinig. /* behandeling van verworwe disartrie nadat die vlak van funksionering van elke subsisteem van spraak bepaal is met behulp van die ondersoekprogram, is die doel van terapie om waar moontlik, 'n herevolusie te bewerkstellig. in 'h degeneratiewe of statiese toestand word ondersteuningsterapie gedoen om devolusie tee te werk. binne die raamwerk wat die skema bied kan verskeie tegnieke toegepas word ten einde die neurofisiologiese disfunksie, byvoorbeeld 'n parese, te verbeter. keuse van tegnieke journal of the south african speech and hearing association, vol. 23 december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η benadering tot verworwe disartrie 57 word aan die diskresie van die terapeut oorgelaat ten einde aan te pas by die behoeftes van die pasient. die metode wat gevolg moet word kom neer op: 1. lnhibisie van positiewe simptome indien dit voorkom. 2. fasilitasie van negatiewe simptome. die metode word hoofsaaklik gevolg in spraakterapie aangesien spraak as 'n hoer funksie hoofsaaklik uit negatiewe simptome bestaan. tegnieke wat gebruik kan word, is die volgende: 1. mysak11' 1 2 ' 1 3 ,beskryf tegnieke wat veral waardevol op die refleksvlakke gebruik kan word. 2. proprioseptiewe neuromuskulere fasilitasietegnieke wat gerig is op die verbetering van onderliggende bewegingspatrone, is uiters geslaagd. die tegnieke is veral van waarde by fasilitering van die middelvlakke, byvoorbeeld verlengde ekspirasie en onafhanklike orgaanbewegings. 3. willekeurige pogings, byvoorbeeld by diadokokinese verbetering. 4. tradisionele spraakterapeutiese grondbeginsels, byvoorbeeld multisensoriese stimulasie en motivering van pasient. hippocrates het gese dat genesing nie slegs afhanklik is van tyd nie, maar ook van geleentheid, en dit is die verantwoordelikheid van die spraakterapeut om aan elke pasient wat in haar sorg geplaas word, die maksimum geleentheid tot herstel te bied. verwysings 1. bobath, k. (1969): the motor deficit in patients with cerebral palsy. clinics in developmental medicine no. 23. william heineman medical books. 2. brain, r. (1956): diseases of the nervous system. university press, london. 3. crickmay, m.c. (1972): speech therapy and the bobath approach to cerebral palsy. charles c. thomas, illinois. 4. crouch, z.b. (1971): lip taping for buccal-labial insufficiency. /. speech hear. dis., 36, 543-545. 5. darley, f.l., aronson, a.e. & brown, j.r. (1969): differential diagnostic patterns in dysarthria. / speech hear. res., 12, 246-270. 6. darley, f.l., aronson, a.e. & brown, j.r. (1969): clusters of deviant speech dimensions in the dysarthrias. /. speech hear. res., 12, 462-297. 7. hixon, t.j. & hardy, j.c. (1964): restricted motility of the speech articulators in cerebral palsy. /. speech hear. dis., 29, 293-306. 8. ingram, t.t.s. (1973): developmental disorders of speech. handbook of clinical neurology, vol. 4, disorders of speech, perception and symbolic behaviour. american elsevier publishing co., new york. 9. jackson, j.h. (1925): neurological fragments. oxford medical publications. tydskrif van die suid-afrikaanse, vereniging vir spraak en gehoorheelkunde, vol. 23, desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 anita van der merwe 10. morley, d.e. (1955): the rehabilitation of adults with dysarthric speech. j. speech hear. dis., 20, 58-64. 11. mysak, e.d. (1959): significance of neuro-physiological orientation to cerebral palsy habilitation. j. speech hear. dis., 24, 221-230. 12. mysak, e.d. (1963): dysarthria and oropharyngeal reflexology: a review. j. speech hear. dis., 28, 252-260. 13. mysak, e.d. (1968): ν euro-evolutional approach to cerebral palsy and speech. teachers college press, new york. 14. peacher, w.c. (1950): the etiology and differential diagnosis of dysarthria./. speech hear. dis., 15, 252-265. 15. tikofsky, r.s. & tikofsky, r.p. (1964): intelligibility measures of dysarthric speech. / speech hear. res., 7, 325-333. 16. wedin, s. (1972): rehabilitation of speech in cases of palato-pharyngeal paresis with the aid of an obturator prosthesis. british j. dis., comm., 7, 117-129. 17. weiss, d.a. & beebe, h.h. (1951): the chewing approach in speech and voice therapy. s. karger, new york. 18. west, r.w., ansberry, m. & carr, c. (1957): the rehabilitation of speech. harper & brothers, new york. 19. wolski, w. (1967): hypernasality as the presenting symptom of myasthenia gravis. /. speech hear. dis., 32, 36-38. 20. wyke, b. (1966): recent advances in the neurology of phonation: phonatory reflex mechanisms in the larynx. speech pathology diagnosis: theory and practice, report of the national conference of the college of speech therapists in glasgow. e. & s. livingstone, london. 21. wyke, b. (1970): neurological mechanisms in stammering: an hypothesis. british j. dis., comm., 5, 6-15. journal of the south african speech and hearing association vol. 23. december 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) tonal purity is our speaaiite de la maison . . . and it has been since 1948, when we began. they tell us that today's state-of-the-art of audioelectronics owes much to studer research and specialisation in this field. . . . we're human. so we blush. but we must agree that we design and manufacture audio equipment of superb quality. in a product range unequalled in its bracket . . . which is the highest. we supply this equipment to professionals and discerning amateurs throughout the world. they buy it for its tonal purity. . . . and that, as we said, is the speciality of our house. studer · revox · akg · thorens professional recording and audio mixing equipment for radio. television, motion-picture and disc-recording studios studer-revox south africa (pty)ltd microphones. amplifiers, turntables, fm-tuners, loudspeaker systems, language laboratory installations, audiovisual teaching equipment toiai^-h^ubx s t u d e r r e v o x s o u t h a f r i c a (ptyl ltd., audward house. 3 0 ameshoff street, braamfontein. 2001. tel. 724-9680/88 .p.o. box 3 1 2 8 2 , braamfontein. 2017. telex 8-6683 tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 23. desember 1976 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a speech production changes with the use of a multichannel cochlear implant in a postlingually hearing impaired adult sandy cummings emily groenewald rene hugo department of communication pathology university of pretoria lida miiller department of speech pathology and audiology university of stellenbosch mike van der linde department of information technology division of academic computing university of pretoria abstract profoundly deaf cochlear implant users provide an interesting population in which to assess the role of distorted auditory feedback in speech, since their electrically stimulated hearing is significantly different from normal hearing. the aim of the study was to evaluate, by means of spectrograph^ and listener analyses, the speech production changes in a postlingually deafened adult with the use of a multichannel cochlear implant over time, compared to that of hearing aids as well as no-amplification. the results indicated significant improvements in the use of suprasegmental speech features as well in the production of specific segmental features of speech. opsomming uitermatige dowe pasiente met kogleere inplantings vorm 'n interessante populasie waarby die invloed van versteurde ouditiewe terugvoer op spraak ondersoek kan word, aangesien elektries-gestimuleerde gehoor betekenisvol verskil van normale gehoor. die doel van die studie was 'n ondersoek na die invloed van 'n multikanaal kogleere inplanting oor 'n verloop van tyd, in vergelyking met geen ouditiewe versterking en versterking dmv gehoorapparate op spraakproduksie van 'n postlinguale dowe volwassene. 'n vergelykende spektrografiese en luisteraaranalise is uitgevoer. die resultate het betekenisvolle verbeteringe getoon in die suprasegmentele, sowel as spesifieke segmentele eienskappe van spraak. introduction research on the benefits of cochlear implants have in the past focused primarily on the speech perception of the postlingually deafened implant user (dowell, brown, seligman & clark, 1985; dowell, seligman, blarney & clark, 1987; eddington, 1983; cohen, waltzman & shapiro, 1985 and schindler, kessler, rebscher, yanda & jackler, 1986). improvements in environmental sound recognition as well as improvements in auditory sensitivity (thielemeir, eisenberg & brimacombe, 1982; tyler, gantz, mccabe, lowder, otto & preece, 1985) have also been widely documented. an increasing number of researchers have begun to place emphasis on the speech production characteristics of postlingually deafened implant wearers, (iler-kirk & edgerton, 1983; leder, spitzer, milner, flevarisphillips, richardson & kirchner, 1986; tartter, chute & hellman, 1989; waldstein, 1990; lane & webster, 1991; economou, tartter, chute & hellman, 1992; perkell, lane, svirsky & webster, 1992; svirsky, lane, perkell & wosniak, 1992). the lack of research directed at the speech production changes could be due to the fact that a postlingually acquired deafness does not necessarily lead to problems of speech degeneration (ling, 1976). studies designed to investigate the speech die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 sandy cummings, emily groenewald, rene hugo, lida miiller, mike van der linde characteristics of postlingually deaf subjects have, however, found that longterm total auditory deprivation in hearing adults resulted in eventual deterioration into flat, unmodulated and dysprosodic voice, (cowie, douglas-cowie & kerr, 1982). waldstein (1990) investigated some effects of postlingual deafness on speech by exploring selected properties of consonants, vowels and s u p r a s e g m e n t a l s in the speech of seven totally, postlingually deafened individuals. their results demonstrated that postlingual deafness affects the production of all the classes of speech sounds. re-introduction of "auditory input" with the electrical stimulation of the auditory nerve should result in changes in speech production. these changes in speech production are primarily reliant on the type of information derived from stimulation and finally the implant listener's articulatory adaptation to prolonged profound deafness, (perkell et al., 1992). the most common changes in speech production with the use of multichannel cochlear implants can be described in terms of suprasegmental and segmental changes, although previous studies have indicated that the suprasegmental features are affected the most due to the presence of a profound hearing loss, (leder et al., 1986). waldstein, (1990) indicated that the results of his study do not support the hypothesis that the suprasegmental properties of speech show the greatest effects of a loss of auditory feedback, while the segmental properties remain relatively unaffected. "rather, auditory feedback appears to be implicated in monitoring and maintaining phonetic precision in all classes of speech sounds." waldstein, (1990:211). various s t u d i e s i n v e s t i g a t i n g the effects of multichannel cochlear implants on speech production have indicated that significant changes in speech production can occur with the use of a multichannel implant. lane & webster, (1991) have reviewed some of the studies investigating the speech of postlingually deafened speakers including several studies on the effects of cochlear implants. they conclude that the majority of studies implicate a role for audition in regulating, directly or indirectly, several speech properties including voice quality, voice aspiration, vocal duration, pitch, intonation, stress, tempo, nasality and frication and plosive articulation, (iler-kirk & edgerton 1983; leder et al., 1986; tartter et al., 1989; economou et al., 1992; perkell et al., 1992). method aims the aim of the present study was to evaluate the speech production changes brought about by the use of a multichannel cochlear implant over time, in an adult with a profound postlingual sensorineural hearing loss. the subject's speech production skills were evaluated preand post-operatively by means of spectrographic and listener analyses. these evaluations included: the spectrographic evaluation of the suprasegmental features of speech, in terms of sentence duration, fundamental frequency variations and word stress (amplification). the spectrographic evaluation of the segmental features of speech, namely vowels and consonants. the vowels were evaluated in terms of vowel length and the formant relationships between f1 and f2. the consonants were evaluated in terms of the spectral noise band frequencies for fricatives, the spectral frequency ranges for the plosive sections of the stop sounds and the relative amplitude peaks of both the fricatives and plosives. the listener's analysis of speech production was evaluated in terms of pitch variation, and vocal and pausal duration. the results of the speech production changes with the multichannel cochlear implant over time were compared to the subject's speech production without any amplification and with binaural hearing aids. research methodology a single-case research study using a time series experimental design was used in order to evaluate the speech p r o d u c t i o n changes with the use of a multichannel cochlear implant in an adult with a postlingual sensorineural hearing loss. the data was obtained by performing evaluations in the following phases: pre-implant: no-amplification (na); hearing aid (ha) post-implant: 0-months (ci-0), 3-months (ci.3) and 6-months (ci-6) cochlear implant subject the subject (mc) lost his hearing due to meningitis at 19 years of age. he was implanted five years later. his pre-implant audiograms indicated a bilaterally total sensorineural hearing loss with minimal benefit from binaural hearing aids as well as a vibrotactile device. his right ear was implanted on 31 october 1991 with the cochlear 22-channel implant. all electrodes were easily inserted. the electrodes were programmed in the bipolar + 1 mode using the mpeak coding strategy. the subject (mc) was an afrikaans speaker using a nonstandard dialect. implant and speech processor t the cochlear implant used in the present ^tudy is known as the mini-system 22 comprising 22 pure platinum bands supported on a flexible silicone rubber carrier. the speech processor utilized is referred to as the msp (mini speech processor). the mpeak coding strategy extracts and codes f1 and f2, where the f1 is represented by the dominant spectral peak in the range from approximately 300-1000hz and f2 between 8004000hz. the estimate of f1 from the acoustic signal controls the selection of an apical electrode pair, while the estimate of f2 controls the selection of a basal electrode pair. the spectral energy in the regions of 20002800hz, 2800-4000hz and above 4000hz are presented to three basally located electrodes. the fundamental or voicing frequency determines the pulse rate of the stimulation and the amplitude of the acoustic signal determines the stimulus intensity, (cochlear, 1989). the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) speech production changes with the use of a multichannel cochlear implant in a postlingually hearing impaired adult hearing aids the two phonak ppc-l-4 hearing aids were utilized in the pre-implant evaluation condition. the maximum output of the hearing aids is 142 db sspl with a frequency range of 140 4900 hz. the subject used the hearing aid on volume 2,5 with the following settings: lc 1 , hc 5, g 6 and sspl 6. the subject also wore new standard acrylic ear moulds. stimuli and equipment the data for the evaluation of the subject's speech production skills were determined objectively and subjectively by means of spectrographic and listener analyses respectively. for the spectrographic analysis of the suprasegmental features of speech, seven sentences varying in length and including the various typical prosodic features of statements, questions and commands, were selected to be spectrographically analyzed. for the spectrographic analysis of the segmental features, eight isolated single vowels; / i /, / a /, = / y /, / oe /, / u /, / a /, / ο / & / ε / in cvc combinations were selected to be analyzed. the vowels selected were the most common vowels utilized in afrikaans where the transition to diphtongs does not take place. the consonants selected were those consonants which are either ommitted or distorted in the presence of a profound hearing loss (nickerson, 1975). the plosives, / t / f / k / , / p / and the fricatives / s / and / χ / were used in the final position and / s / and / f / were used in the initial position of the word. these consonants were analyzed within the context of two different words and preceded or followed by different vowels. for the listener analysis, the subject was required to read a paragraph in which the length, language, content and complexity was appropriate for the purpose of the evaluation as well as the subject's reading skills. the specified material wfas read into a dynamic m 0 2 ncc microphone (15cm from the microphone) in an i ac soundproof and sound reverberation free unit. the recordings were made on a direct head casette deck. nachamitchi, model 682 2x the speaker's distance from the microphone as well as the input attenuation were kept c o n s t a n t t h r o u g h o u t all the r e c o r d i n g s . spectrographic analyses wrere conducted using the kay dsp sonagraph, model 5500. the analysed data was graphically displayed on ainec/multisync colour monitor. procedure recording of data recordings of all the stimulus words and sentences were made without any amplification of the signal in the pre-implant condition, with binaural hearing aids in the pre-implant condition, the following day after switch-on i.e., 0months; 3-months and 6-months postimplant. spectrographic analysis for the analysis of the suprasegmental features, a combination analysis setup of the sonagraph, whereby the waveform, amplitude and pitch trace of the sentences were displayed, was used for the measurements. the sentence duration was measured by applying time cursors on the speech wave display. pitch variation was determined by using the frequency cursor readings on the computed pitch curves at the highest and lowest peaks in the pitch trace. word stress or amplification was measured by the time cursors at the highest peak of computed amplitude curves. the analysis of segmental features of specific speech sounds focused on the duration and formant frequencies of vowels and the spectral characteristics of the fricatives and the plosive energy of stop consonants. the vowels were analyzed up to 4000hz and the consonants up to 8000hz. a combination display of a wideband spectrogram in conjunction with a narrowband amplitude spectrum of the computed spectral energy between two time cursors was used. time cursors were used in order to determine the length of the vowel. for the measurements of the formant frequencies, a stable middle portion of each vowel was selected in order to exclude the transitions to the consonants. frequency cursors, in conjunction with the time cursors were utilized in order to determine the formant frequencies. the consonants were analyzed in terms of the spectral noise band frequencies for the fricatives (i.e., minimum and maximum frequencies of the fricatives), the spectral frequency range for the plosive sections of the stop sound (i.e., minimum and maximum frequencies of the plosive sections of the stop sounds) and the relative amplitude peaks of the fricatives and plosives. time and frequency cursors were used to determine the frequency boundaries as well as the relative amplitude peaks. listener analysis for the listener's evaluation of the subject's speech production, a rating scale for listener's evaluation of pitch variation and vocal and pausal duration was used, (coles, 1990). the recordings were presented to four trained listeners via tandberg educational headphones in a language laboratory by means of a tandberg educational is 10 cassette player. the listeners were asked to evaluate pitch variation, vocal duration and pausal duration by means of a five point rating scale (appendix a). results results of the speech production evaluation using spectrographic analysis. it is important to note that there were no marked abnormal characteristics pertaining to the subject's suprasegmental and segmental features as found in some postlingually deafened adults. spectrographic analyses were executed in order to detect any degeneration of speech features which had possibly occurred during the period of profound deafness as well as any changes in speech production brought about by the use of the cochlear implant. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 sandy cummings, emily groenewald, rene hugo, lida m l l e r , mike van der linde suprasegmental features the results of sentence duration across various auditory input situations are presented in table 1. when analyzed, the majority of the sentences showed an increase in sentence duration at the six month cochlear implant level, as opposed to the no-amplification and hearing aid conditions. the increases in sentence duration occurred at either the cochlear implant 0-month or 3-month situation, with a highest mean duration for the seven sentences at 0-months. a qualitative analysis of the individual sentences does, however, give logical explanations for these results. the interpretation and explanation of the above findings will be given in the discussion of results. as can be seen in table 2, the highest relative amplitude peaks for stressed words showed a small, however, consistent increase in the amplitude range with the use of the cochlear implant, with the values ranging from 33,ldb, 37,4db and 37db during the 0-, 3and 6-month cochlear implant intervals, compared to 31,7db and 34db obtained during the no-amplification and hearing aid conditions respectively. the values for all.sentences obtained during the 3-month interval showed an increase in amplitude peaks when compared to the 0month interval. during the 6-month interval, however, there was a slight decrease in amplitude peaks for sentences two, four and six when compared to the 3-month cochlear implant interval. these values compared to the 0-month interval did, however, show an increase in amplitude range. the results of the fundamental frequency (f0) variations, including the minimum and maximum f0 values as well as the differences in f0 across the various auditory input situations, are presented in table 3. as can be seen in table 3, the mean difference in fundamental frequency variations for the no-amplification (49,7hz) and hearing aid (48,7hz) situations did not differ significantly from one another. surprisingly, the results for the 0-month cochlear implant interval showed a decrease in f0 variation (44,4hz). a significant increase in the mean f0 variation occurred at the 3-month interval (110,7hz), indicating a possible over compensation in the use of varying f0. the results obtained at the 6-month interval (86,5hz) also showed an increase in f0 variation when compared to the no-amplification and hearing aid situations, however, the variation was less and possibly more normalized, than observed during the 3-month interval. segmental features vowels due to variations in vowel duration for each of the vowels within the three cochlear implant evaluation intervals, a mean vowel duration for each of the eight vowels during the cochlear implant intervals was calculated. the results of the evaluation of vowel duration presented in table 4, did not indicate significant table 1. sentence duration (seconds) for sentences across various auditory input situations. sentence number n.a. h.a. ci-0 ci-3 ci-6 mean values ci 0, 3, 6 1 0,8719 0,9750 0,9937 0,9031 0,8844 0,927 2 1,153 1,272 1,438 1,472 1,387 1,432 3 1,700 1,727 2,425 1,993 1,878 2,098 4 1,537 1,691 1,628 1,600 1,547 1,591 5 1,237 1,575 1,456 1,359 1,322 1,379 6 0,9469 0,9688 0,9562 1,031 0,9312 0,972 7 0,8031 0,9600 1,006 0,9750 0,9125 0,964 table 2. highest amplitude peaks (db) for stressed words in sentences across various auditory input sentence number n.a h.a ci-0 ci-3 ci-6 1 25 35 33 37 37 2 24 32 30 37 35 3 37 34 31 36 37 4 34 30 33 36 35 5 34 34 37 40 41 6 33 35 32 39 37 7 35 38 36 37 37 mean amplitude peaks (db) 31,7 34 33,1 37,4 37,0 the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) e e c h production changes with the use of a multichannel cochlear implant in a postlingually hearing impaired adult differences between the various auditory input situations. for all the vowels examined except for the vowel /y/, however, when a mean value for the 0-, 3and 6m o n t h evaluations was calculated, the latter did show a decrease in vowel duration when compared to either the no-amplification or hearing aid condition. the formant frequencies of the vowels analyzed, i.e., f1 and f2, presented in table 5, did not differ from one another significantly across the various auditory input situations. compared to the normal values of f1 and f2 in the vowels of male afrikaans speakers, (van der merwe, groenewald, van aardt, tesner & grimbeek, 1993), the formant frequencies of four of the vowels i.e. / i /, / a /, = / u / and / ε / fell within the normal limits. in the four remaining vowels i.e. / oe /, / ο / and /oe/ examined except for / y /, the f2 values fell within the normal limits for these vowels. the f1 values, however, 7 were measured at higher frequencies than the normal limits for f l . the results in the present study did, however, indicate that the f l and f2 values did remain relatively consistent across the various auditory input situations as was observed with the other four vowels examined. consonants as can be seen in table 6 for the majority of the consonants examined in the present study, the use of the cochlear implant did show an increase in the relative amplitude peaks measured for consonant production i.e., plosives and fricatives. the relative amplitude peaks for the consonants in the various auditory input situations ranged from 0-46db in the no-amplification situation, 0-50db in the hearing aid situation, 19-5ldb in table 3. minimum and maximum fundamental frequency values (fo-hz) and difference in fundamental frequency (δ fo) for sentences across various auditory input situations. sentence number max fo min fo n.a n.a δ fo h.a h.a δ fo ci-0 ci-0 δ fo ci-3 ci-3 δ fo ci-6 ci-6 δ fo 1 max 162 45 157 70 134 34 243 137 222 103 1 min 117 45 87 70 100 34 106 137 119 103 2 max 132 43 129 45 124 38 204 113 182 80 2 min 89 43 84 45 86 38 91 113 102 80 3 max 170 ' 89 150 62 129 48 213 115 213 89 3 min 81 ' 89 88 62 81 48 98 115 124 89 4 max 144 28 128 30 138 35 182 56 186 69 4 min 116 28 98 30 103 35 126 56 117 69 5 max 179 73 165 72 186 89 262 176 256 149 5 min 106 73 93 72 97 89 86 176 107 149 6 max t 144 27 142 42 124 23 196 79 165 54 6 min 1 117 27 100 42 101 23 117 79 111 54 7 max 162 43 167 60 144 44 222 99 204 62 7 min 119 43 107 60 100 44 123 99 142 62 mean difference in fo ! 49,7 54,4 44,4 110,7 86,5 table 4. vowel duration (seconds) for vowels across various auditory input situations word vowel n.a. h.a. ci-0 ci-3 ci-6 mean mier /i / 0,4812 0,4016 0,4187 0,2469 0,3125 0,3260 waak /a/ 0,2187 0,3719 0,2813 0,3875 0,3562 0,3416 duur /y/ 0,3375 0,3156 0,4812 0,3312 0,4590 0,4238 dop /d/ 0,1469 0,1344 0,1500 0,1312 0,1094 0,1302 toer /u/ 0,5875 0,5594 0,4906 0,4094 0,4031 0,4343 pen /ε/ 0,1656 0,1563 0,1781 0,1187 0,1156 0,1374 rug /oe/ 0,1219 0,1656 0,1594 0,1281 0,1563 0,1479 mis /a/ 0,0781 0,1312 0,1344 0,0962 0,0734 0,1013 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 sandy cummings, emily groenewald, rene hugo, lida muller, mike van der linde table 5. formant frequencies hz (f/fj) for vowels across various auditory input situations word vowel f / f 2 n.a h.a ci-0 ci-3 ci-6 mean ci 0, 3, 6 normal f'/f '•• ·.. mier /i / f. 300 260 300 300 280 293 245 2180 2190 2160 2320 2380 2287 2186 waak (a) fi 760 620 770 640 600 670 679 f 2 1180 1160 1180 1220 1060 1153 1113 duur /y/ 260 240 220 390 290 300 * f 2 2180 2160 2080 2310 2470 2287 * dop ν fi 580 280 540 540 590 557 373 f 2 1020 1080 1180 1040 1040 1087 805 toer /u/ f , 260 250 260 390 360 337 266 f 2 780 920 780 800 1010 863 961 pen /ε/ f , 500 480 500 560 530 530 353 f 2 1960 2040 2060 2100 2000 2053 2055 rug /ce/ f, 640 540 560 580 580 573 429 f 2 1280 1200 1240 1160 1040 1147 1314 mis /a/ f, 580 540 540 540 600 560 507 f 2 1400 1520 1480 1470 1330 1427 1514 table 6: relative amplitude peaks (db) for consonants in cvc word combinations tory input situations word consonant position no amplification hearing aid ci 0 months ci 3 months ci 6 months lied /t/ final 0 38 23 35 48 pit /t/ final 29 18 31 47 j 48 loop /p/ final 0 19 22 23 ! 21 druip /p/ final 0 0 19 31 j 29 bek /k/ final 26 0 20 37 1 39 rok pej final 0 20 21 33 ' 36 kous /s/ final 31 43 48 44 48 mos /s/ final 44 43 48 44 49 rug /x/ final 33 43 27 38 36 saag /x/ final 29 35 34 33 31 sag /s/ initial 43 50 51 29 54 saag /s/ initial 46 48 48 54 52 vaak m initial 19 34 22 34 28 vuur m initial 33 34 26 29 32 the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) e e c h production changes with the use of a multichannel cochlear implant in a postlingually hearing impaired adult the 0-month cochlear implant interval, 23-54db in the 3 m o n t h interval and 21-54db in the 6-month interval. three of the consonant productions in the final position j e / 1 /, / k / and / ρ / were not produced with any audible'plosive release in the no-amplification and hearing aid situations therefore having no measurable amplitude peaks i.e., odb. the results of the mean spectral frequency ranges for the plosive energy of the plosives i.e., / 1 /, / ρ /, and / k / and the spectral noise band frequencies for the fricatives i.e., / s /, i x l and / f /, presented in table 7, did show a narrowing of these frequency ranges for the majority of consonants evaluated in the three cochlear implant intervals when compared to the hearing aid conditions. once again there were no measurable spectral frequency ranges (0hz) for three of the consonants i.e., / ρ /, / t / and / k /, as there was no audible plosive release in the final position during the no-amplification and hearing aid conditions. 9 results of the speech production evaluation using listener analysis. the results of the listener's evaluation of the subject's speech production are presented in table 8. the trained listeners rated the subject's spontaneous speech at the various auditory input situations, according to the rating scale used. these ratings occurred in a language laboratory. as can be seen in table 8 the listeners rated the subject's use of pitch variation as being monotone in the no-amplification, hearing aid and 0-month cochlear implant conditions. at the 3-month cochlear implant interval, the listeners rated the subject's speech as having little variation and the 6-month cochlear implant interval the listeners rated the subject's use of pitch variation as being normal. with regard to vocal duration, the listeners evaluated the subject's vocal duration in the no-amplification, hearing aid and cochlear implant 0-month interval as being longer than normal. table 7. minimum and maximum frequencies for consonants in cvc word combinations across various auditory input situations. word consonant position minimum no amp ha ci-0 ci-3 ci-6 maximum lied /t/ final min 0 1760 2460 1680 2880 max 0 8000* 4900 8000* 6040 pit 111 final min 3440 1760 2480 2720 3400 max 6800 3160 8000* 8000* 8000* loop /p/ final min 0 3560 1080 1160 3680 max 0 4720 8000* 7960 6440 druip /p/ final min 0 0 1040 1240 980 max 0 0 8000* 8000* 8000* bek pej final min 880 0 1060 960 880 max 8000* 0 5000 5600 6240 rok pej final min 0 960 880 680 640 max 0 4280 5020 8000* 3680 kous isl | final min 2420 2240 2500 2720 3200 max 8000* 8000* 8000* 8000* 8000* mos isl ! final min 2220 2360 2480 2560 3160 max 8000* 8000* 8000* 8000* 8000* rug ixl final min 800 760 2480 2640 2320 max 8000* 8000* 8000* 8000* 6960 saag ixl final min 2460 880 2060 2760 2280 max 8000* 8000* 8000* 8000* 7440 sag isl initial min 2180 3200 1080 2800 3320 1 max 8000* 8000* 8000* 8000* 8000* saag isl initial min 1000 3320 1060 2960 3000 max 8000* 8000* 8000* 8000* 8000* vaak ifl initial min 2100 3440 3480 1360 3680 max 8000* 8000* 8000* 8000* 8000* vuur ifl initial min 1360 3520 1620 2880 3600 max 8000* 8000* 8000* 8000* 7360 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 sandy cummings, emily groenewald, ren hugo, lida m l l e r , mike van der linde at the 3-month and 6-month cochlear implant intervals, the subject's vocal duration was evaluated as being normal. as far as pausal duration is concerned, the listeners evaluated the use of pausal duration as being primarily longer than normal in the no-amplification and hearing aid conditions. at the cochlear implant 0-month interval, two of the listeners rated the pausal duration as being normal, with the remaining listeners describing it as being either abnormally long or longer than normal. the pausal duration at the 3-month interval was evaluated by the majority of the listeners as being longer than normal. one listener judged it to be normal. at the 6-month cochlear implant interval, however, the subject's use of pausal duration was evaluated as being normal. as can be seen in table 8, listener two was the only listener who differed from the other listeners. the pearson correlation co-efficient and t-test was used in order to determine whether or not listener two differed significantly from the other listeners, i.e., one, three and four. these results indicated that there were no significant differences between the listeners ratings and that all the listeners ratings correlated significantly with one another. discussion spectrographic analysis suprasegmental features prior to having the cochlear implant, it was noticed subjectively that the subject was inclined to increase his utterance length. the latter being a characteristic of profoundly deaf individuals, as noted by nickerson, (1975). taking this into account, it was expected that when utterance length was spectrographically analyzed, the results obtained with the cochlear implant would show a decrease in duration, when compared to the noamplification and hearing aid condition. results obtained from the evaluation of sentence duration (table 1), however, did not at first yield any significant data. in fact, the mean values calculated for the cochlear implant condition were in all instances longer than the values obtained in the no-amplification situation, as well as the majority of values obtained during the hearing aid condition. these results are in direct contrast to the sentence duration characteristics of profoundly deaf individuals. these individuals tend to speak at a slower rate than what is considered normal speed, (waldstein, 1990). the values measured were consequently compared with the spectrograms obtained for each of the sentences in the various auditory input situations. these comparisons indicated that the reason for the lower sentence duration values in the no-amplification situation and the higher sentence duration values in the cochlear implant situations was that in many instances the plosive release of final consonants of the last words spoken in the sentences were often omitted due to the absence of auditory feedback. the utterance length measured did therefore not include these omitted plosive portions of the consonants. this resulted in shorter sentence duration measurements. during the three cochlear implant intervals the subject was aware of these final consonants due to the improved speech information being provided by the cochlear implant as well as improved auditory feedback, and the subsequent production of these final consonants productions resulted in a measured increase in the utterance length. as far as word stress (amplification) within the sentences is concerned, the use of the cochlear implant resulted in an increase in the highest relative amplitude peaks for stressed words when compared to the no-amplification and hearing aid situations (table 2). the specific words within the sentences which were stressed remained consistent throughout all the auditory input situations. the relative amplitude peaks of these words increased as the subject was receiving increasing evaluation parameters listeners no-amplification: listeners ratings hearing aid: listener ratings cochlear implant 0-months: listener ratings cochlear implant 3-months: listener ratings cochlear implant 6 months: listener ratings pitch l.l 1 1 1 2 3 variation l.2 1 2 2 3 3 l.3 1 1 1 2 3 l.4 1 1 1 2 3 vocal l.l 2 2 2 3 "3 duration l.2 2 2 2 3 4 l.3 2 2 2 3 3 l.4 2 2 2 3 / 3 pausal l.l 2 3 3 2 3 duration l.2 1 2 2 2 3 l.3 2 2 1 2 3 l.4 2 2 3 '3 3 tabel 8. rating scale for listeners' evaluation of pitch variation, vocal duration and pausal durationresults . the south african journal of communication disorders, vol 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) e e c h production changes with the use of a multichannel cochlear implant in a postlingually hearing impaired adult 11 a m o u n t s of intensity information via the cochlear imnlant. these alterations in loudness are coded by the multichannel cochlear implant as changes in current level, (tobey & hasenstab, 1991). an individual's ability to make use of intensity variations within utterances p r e v e n t s the tendency to become monotone and reinforces the normal patterns of intonation in speech, (ilerkirk & edgerton, 1983). in terms of the pitch variations in fo, there appeared to be an over compensation in the use of varying fundamental frequency at the 3-month interval, with a slight decrease in variation at the 6-month interval, resulting in a more normalized version of fundamental frequency v a r i a t i o n s . the subject was, therefore, at the 3-month interval beginning to perceive the increased spectral information being provided by the implant as well as the variations in fo as coded by the stimulation rate delivered to a given channel, (tobey & hasenstab, 1991). these variations in fo were in turn providing increased suprasegmental information required in the use of questions, as was emphasizing certain words within a sentence in order to either alter the meaning of the sentence or emphasize a specific word within the sentence, (iler-kirk & edgerton, 1983). it is also interesting to note that the words in the sentences which were produced with the highest fo pitch remained consistent throughout all the auditory input situations. these words produced with the highest fo pitch were also the words produced with the highest amplitude peaks. these results indicate that the subject is utilizing the suprasegmental features of speech accurately with the aim of emphasizing a specific word in an utterance. segmental features vowels the overall decrease in vowel duration with the use of the cochlear implant is 'confirmed by the results obtained by tartter et al., (1989) who also found a decrease in vowel length in a postlingually deafened individual during the first year of usejwith a multichannel cochlear implant. the decrease in vowel length can be attributed to the improved temporal coding mechanisms provided by the cochlear implant, which in turn, improve and enhance auditory feedback monitoring, implicated in regulating the phonetic precision of segmental and suprasegmental characteristics of speech, (waldstein, 1990; svirsky et al., 1992). as far as the relationship between the vowel formant frequencies is concerned, the results of the f1 and f2 values across the various auditory input situations did not show any significant differences (table 5). the relationship between the f1 and f2 values for the eight different vowels indicated that the vowel,productions across the various auditory input situations occupy well defined loci as expected. these results verify the minimal changes in the relationship between f1 and f2 across the various auditory input situations, indicating relatively stable vowel productions. to further enhance the interpretation of these results, the mean f1 and f2 cochlear implant values were compared with the mean values obtained from normal hearing afrikaans speaking male subjects, (van der merwe et al., 1993). the mean f1 values obtained in the cochlear implant condition for each vowel were consistently higher than the normal f1 values. tartter et al., (1989) in their study indicated that their subjects exhibited lower values after a period of use with the cochlear implant. a possible explanation for the higher f1 values obtained in the present study, could be attributed to the fact that the subject was not a standard afrikaans speaker. variations from the norm are often found when a dialect of a language is spoken, (sommerstein, 1977). by taking the overall results into account, it can therefore be assumed that the subject's profound hearing loss did not result in deviant vowel productions. consonants with regard to the relative amplitude peaks for consonants in cvc word combinations across the various auditory input situations, the most significant increases in amplitude peaks were for the plosive sections of the stop consonants (table 6). these significant increases in amplitude peaks can be interpreted in terms of the absence, in the first instance, of the plosive releases in the no-amplification situations for the consonants / ρ /, / 1 / and / k / as well as the consonants / ρ / and / k / in the hearing aid situation, to the presence in the second instance of plosive releases for these consonants during the cochlear implant intervals. for the fricatives in the initial and final positions, the majority of amplitude peaks in either the 3or 6-month cochlear implant conditions are higher than the amplitude peaks observed in the no-amplification or hearing aid conditions, indicating improved accuracy in consonant production. this can be attributed to two factors. in the first instance, the cochlear implant is providing increased spectral information which in turn allows the subject to perceive these consonants auditorily, thereby improving the auditory feedback mechanism of the subject's own productions, (dorman, soli, dankowski, smith, mccandless & parkin, 1990). in the second place, the cochlear implant is resulting in increased accuracy in the articulation of consonants, which consequently results in an increase in the intensity of the production. the spectral frequency ranges of the plosive sections of the stop consonants during the 6-month cochlear implant interval did show a decrease in the frequency regions occupied for the majority of the productions when compared with the no-amplification condition. a decrease in frequency range is a direct result of a more concentrated release of the plosive section of the stop consonant, thereby improving the accuracy of productions. minifie (1973), mentions that the noise bursts of the stop consonants are dependent upon the volumes within the vocal tract, which participate in resonance of the source energies. these volumes are primarily determined by the vocal tract occlusion. it can therefore be assumed that the more concentrated production of the plosive sections of the stop sounds, can be attributed to the correct placing of vocal tract occlusion. the latter is a result of the improved auditory feedback mechanisms provided by the cochlear implant itself. as far as the fricatives are concerned, the spectral noise bands with the cochlear implant at the 6-month interval also showed a decrease in the frequency ranges measured for each fricative when compared to the nodie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 sandy cummings, emily groenewald, rene hugo, lida miiller, mike van der linde amplification situation. these spectral noise band limits measured for the fricatives fell within the noise band limits of normal speakers, (baken, 1987). the majority of the fricatives showed an increase in the minimum frequency with the use of the cochlear implant. these findings resulted in a narrowing of the spectral noise band frequencies which once again indicated the concentration of energy as a result of marked vocal tract constriction, resulting in increased accuracy of fricative production (minifie, 1973). listener analysis the results of the listener's rating of pitch variation indicated that the subject was beginning to use pitch and intensity information being provided by the cochlear implant. these results are supported by iler-kirk & edgerton, (1983); dowell et al., (1985); leder et al., (1986); and tyler & kelsay, (1990), who also reported improvements in voice control with the use of a multichannel cochlear implant. these improvements can be attributed to the pitch information being provided by the cochlear implant resulting in improved auditory feedback of the subject's utterances. as far as vocal duration and pausal duration are concerned, the improvements which were made could once again be attributed to the improvements in auditory feedback resulting in improved voice control and temporal resolution, (leder et al., 1986; tyler & kelsay, 1990; tartter et al., 1989). the latter improvements correlate well with the results obtained during the suprasegmental analysis. conclusion in conclusion, the results of the spectrographic analyses indicated that the information provided by the cochlear implant resulted in the improved use of suprasegmental features by the subject. there was an overall decrease in sentence length resulting in less drawn out speech. for the sentences where there was an increase in sentence length, the presence of consonants in the final position during the cochlear implant intervals as opposed to the absence thereof during the no-amplification and hearing aid situations, provided a logical explanation for this occurrence. the use of increased word stress measured in terms of relative amplitude as well as an increase in the variation of fundamental frequency, typically resulted in less monotone and more variable speech production. as far as the segmental features are concerned, the results of the vowel analysis indicated that the cochlear implant was providing improved auditory feedback which subsequently resulted in a decrease in vowel length over time. the relationship between the first and second formants for the various vowels did not show any significant differences across the various auditory input situations. these results were expected as the subject's vowel productions were not perceived as being deviant when subjectively compared to the same vowel productions by normal hearing individuals. the overall increase in relative amplitude peaks for the consonants investigated as well as the narrowing of the spectral frequency ranges and the spectral noise band frequencies indicated that the use of the cochlear implant was resulting in far more accurate consonant productions. the results of the listener's analysis of speech production indicated that the multichannel cochlear implant confirmed a significant improvement in the use of suprasegmental features in the subject's speech production as perceived by the listeners. the overall improvement in the use of suprasegmental speech features can be attributed to the normalization in the use of pitch variation as well as vocal and pausal duration with the cochlear implant over time. finally, the "hearing" provided by the cochlear implant is considered to have two major roles in maintaining the communicative effectiveness of the production mechanisms in adults. in the first instance, self hearing helps to calibrate production mechanisms by monitoring relations between the implant user's own articulations and his/her acoustic output. in the second instance, the speaker can validate his/her acoustic output by observing the behaviour of the listeners and by detecting discrepancies between his own speech and that of the listeners, (perkell et al., 1992). references baken, r.j. (1987). clinical measurement of speech and voice. massachusetts: collegehill press, inc. cochlear pty limited. (1989). mini system 22: audiologists handbook. sydney, australia. cohen, n.l., waltzman, s.b. & shapiro, w.h. (1985) clinical trials with a 2 2 c h a n n e l c o c h l e a r p r o s t h e s i s : in laryngoscope, 95: 1448-1454. coles, l.d. (1990). the effect of certain suprasegmental features of the hearing impaired child's speech intelligibility. unpublished master's thesis, university of pretoria. cowie, r., douglas-cowie, e. & kerr, a.g. (1982). a study of speech deterioration in post-lingually deafened adults. in journal of laryngology and otology, 96: 101-112. dorman, m.f., soli, s., dankowski, k., smith, l., mccandless, g. & parkin, j. (1990). acoustic cues for consonant identification by patients who use the ineraid cochlear implant. in journal of the acoustical society of america, 88: 2074-2079. dowell, r.c., brown, a.m., seligman, p.m. & clark, g.m. (1985). patient results for a multiple-channel cochlear prosthesis. in schindler, r.a. & merzenich, m.m. (eds.): cochlear implants. new york: raven press, ι dowell, r.c., seligman, p.m., blarney, p.j. & clark, g.m. (1987). speech perception using a two formant 22-electrode cochlear prosthesis in quiet and in noise|. in acta otolaryngology (stockholm), 104: 439-446. > economou, α., tartter, v.c., chute, p.m. & hellman, s.a. (1992). speech changes following reimplantation from a single-channel to a multichannel cochlear implant. in journal of the acoustical society of america, 92: 1310-1323. eddington, d.k. (1983). speech recognition in deaf subjects with multi-channel intracochlear electrodes. in parkins, c.w. & anderson, s.w. (eds.): cochlear prosthesis: an international symposium, annals of the new york academy of sciences, 405: 48-63. iler-kirk, k. & edgerton, b.j. (1983). the effects if cochlear implant use on voice parameters. in otolaryngologic clinics of north america, 16: 281-292. lane, h. & webster, j. (1991). speech deterioration in postlingually deafened adults. in journal of the acoustical society of america, 89: 859-866. leder, s.b., spitzer, j.b., milner, p., flevaris-phillips, c., richardson, f. & kirchner, j.c. (1986). reacquisition of contrastive stress in an adventitiously deaf speaker using a single-channel cochlear implant. in journal of the acoustical society of america, 79: 1967-1974. ling d. (1976). speech and the hearing-impaired child: theory and practice, washington, d.c.: the alexander the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) c o e e c h p r o d u c t i o n c h a n g e s with the u s e of a m u l t i c h a n n e l cochlear i m p l a n t in a p o s t l i n g u a l l y h e a r i n g i m p a i r e d a d u l t 13 graham bell association for the deaf. minifie. f.d. (1973). speech acoustics. in minifie, f.d., hixon, j j. & williams, f. (eds.): normal aspects of speech, hearing and language. englewood cliffs, new jersey: prentice-hall, inc. n i c k e r s o n , r.b. (1975). characteristics of the speech of deaf p e r s o n s . in the volta review, 77: 342-362. perkell, j., lane, h., svirsky, m. & webster, j. (1992). speech of c o c h l e a r implant patients: a longitudinal study of vowel production. in journal of the acoustical society of america, 91: 2961-2978. schindler, r.a., kessler, d.k., rebscher, s.j., yanda, j.l. & jackler, r.k. (1986). the ucsf/storz multichannel cochlear implant: patient results. in laryngoscope, 96: 597603. s o m m e r s t e i n , a.h. (1977). modern phonology. edward arnold publishers. svirsky, m.a., lane, h., perkell, j.s. & wozniak, j. (1992) effects of short-term auditory deprivation on speech production in adult cochlear implant users. in journal of the acoustical society of america, 92: 1284-1300. tartter, v.c., chute, p.m. & hellman, s.a. (1989). the speech of a postlingually deafened teenager during the first year of use of a multichannel cochlear implant. in journal of the acoustical society of america, 86: 2113-2121. thielemeir, m.a., eisenberg, c.s. & brimacombe, j.a. (1982) audiological results with the cochlear implant. in annals of otology, rhinology and laryngology, 91, (suppl. 91): 6266. tobey, e.a. & hasenstab, m.s. (1991). effects of a nucleus multichannel cochlear implant upon speech production in children. in ear and hearing, 12: 48-54. tyler, r.s., gantz., b.j., mccabe, b.f., lowder, m.w., otto. s.r. & preece, j.p. (1985). audiological results with two single-channel cochlear implants. in annals of otology, rhinology and laryngology, 94: 133-139. tyler, r.s. & kelsay, d. (1990). advantages and disadvantages reported by some of the better cochlear implant patients. in the american journal of otology, 11: 282-288. van der merwe, α., groenewald, e., van aardt, d., tesner, h.e.c. & grimbeek, r,j. (1993). die formant-patrone van afrikaanse vokale soos geproduseer deur manlike sprekers. in south african journal of linguistics, 11(2): 71-79. waldstein, r.s. (1990). effects of postlingual deafness on speech production: implications for the role of auditory feedback. in journal of the acoustical society of america, 88: 2099-2114. a p p e n d i x a. r a t i n g s c a l e for the l i s t e n e r ' s e v a l u a t i o n of p i t c h v a r i a t i o n a n d v o c a l a n d p a u s a l d u r a t i o n description o f feature as perceived by listener 1 2 3 4 5 ω l-c pitch v a r i a t i o n m o n o t o n e little v a r i a t i o n normal too m u c h v a r i a t i o n a b n o r m a l v a r i a t i o n cd <u vocal d u r a t i o n a b n o r m a l l y l o n g longer than normal normal shorter than normal a b n o r m a l l y short pausal d u r a t i o n a b n o r m a l l y l o n g longer than normal normal shorter than n o r m a l a b n o r m a l l y short die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustimed medical instrument division d a n p l e x i s a d a n i s h company which manufactures a wide range of audiometers a n d a c o u s t i c i m p e d a n c e meters. ail the instruments presently o n offer u s e m o d e r n digital technology, resulting in high stability and reliability. s c r e e n i n g a u d i o m e t e r s as42 simple portable screener as52 full frequency range plotting pad as53 automatic with computer interface as54 automatic printer computer interface d i a g n o s t i c a u d i o m e t e r s da63 air and bone conduction da64 air bone speech c l i n i c a l a u d i o m e t e r da74 2 channel free field sisi etc. with computer interface t y m p a n o m e t e r s t83 ipsi and contra reflex decay printer t87 full diagnostic printer l c d display h a n d t y m p e a s y c o n v e n i e n t t y m p s a n d reflex with data transfer to remote printer jedmed video otoscope d i s p l a y s a v e r y h i g h q u a l i t y v i d e o i m a g e of the ear e x a m i n a t i o n for y o u r p a t i e n t s a n d t h e i r family. c o l o u r prints for your r e c o r d s a n d r e f e r r i n g doctors. t h e medical instrument division of acoustimed specializes in equipment for the e n t and audiology professions. it is our policy to obtain the most modern instrumentation available and some of the equipment is described here. p l e a s e enquire about other items in our large range of diagnostic and surgical products. s.r. electronics acoustic rhinometers acoustic rhinometry provides a c c u r a t e a n d o b j e c t i v e m e a s u r e m e n t of t h e n a s a l c a v i t i e s . a r e a , v o l u m e , m i n i m u m c r o s s s e c t i o n a l area, variance and mean are analysed by the computer. m u l t i p l e d i s p l a y s c a n b e p r i n t e d a n d s a v e d in a database with patient data. t h e r h i n 2000 instruments provide objective indication of an oblique nasal septum, swollen mucosa or blocking polyps. snoring, pulseoxymeter and allergen packages (including olfactometry) are optional. jedmed infra-red video eng ultra small video cameras with computer imaging technology provide continuous observation a n d v i d e o r e c o r d i n g of e y e movement for 4-channel, direct coupled vestibular analysis. c o m p l e t e e n g without electrodes electrode free n o i s e f r e e e n g ' s n o calibration faster t e s t i n g e y e s o p e n more r e p r o d u c i b l e t e s t s s p o n t a n e o u s t e s t s positional t e s t s hallpikes caloric t e s t s rotational t e s t s n y s t a g m u s monitor hor. a n d vert. tracking g a z e s a c c a d e s acoustimed (pty) ltd. 74 t h i r d a v e . melville, j o h a n n e s b u r g p . o . box 909, a u c k l a n d park; 2006 t e l e p h o n e : (011) 482-3085 f a x : (011) 726-2430 the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) how can speech-language.html how can speech-language therapists and audiologists enhance language and literacy outcomes in south africa? (and why we urgently need to) harsha kathard lebogang ramma michelle pascoe department of health and rehabilitation sciences, university of cape town heila jordaan sharon moonsamy department of speech pathology and audiology, university of the witwatersrand anna-marie wium sandra du plessis department of speech-language pathology and audiology, university of limpopo (medunsa campus) lidia pottas department of communication pathology, university of pretoria nasim banu khan department of health, kwazulu-natal corresponding author: h kathard (harsha.kathard@uct.ac.za) abstract basic education in south africa faces a crisis as learners fail to achieve the necessary outcomes in the related areas of language and literacy. the aims of this paper are twofold. firstly, we aim to describe and discuss the education crisis by outlining the educational landscape, relevant policy imperatives and implementation challenges in post-apartheid education. the systemic factors contributing to the literacy crisis are emphasised. secondly, we argue that speech language therapists and audiologists (sltas) have a role to play in supporting basic education in south africa through developing language and literacy. it is suggested that the professions of speech-language pathology and audiology must be socially responsive and population-focused in order to make meaningful contributions to development in south africa. the potential roles of sltas are discussed with suggestions for further actions required by the professions to enable a contextually relevant practice in a resource-constrained environment. barbara ehren (department of communication sciences and disorders, university of central florida) responds to the paper by raising the issues that sltas should be cognisant of, and making suggestions for the way forward. keywords: language, literacy, basic education, speech language therapist and audiologist roles, south africa ‘creating literate environments and societies is essential for achieving goals of eradicating poverty, reducing child mortality, curbing population growth, achieving gender equality and ensuring sustainable development, peace and democracy.’ koichiro masuura (2005, p. 5) ‘in today’s era of globalisation, economic growth depends increasingly on an educated workforce that is poised to take advantage of opportunities.’ usaid (2004, p. 2) development as an ethos of practice for speech-language therapists and audiologists (sltas) in post-apartheid south africa, all sectors have an obligation to contribute to the building of a democratic nation. to sustain this democracy, education as a basic human right for all people is fundamental (unesco, 2005); not having essential literacy skills is morally indefensible and an appalling loss of untapped human potential and economic capacity. as language is the medium used in the classroom for teaching and learning, it has major implications for a collaborative role between teachers and sltas. the professions of speech-language pathology and audiology are key roleplayers in this process. in this paper, we consider how the professions of speech-language therapy and audiology can advance development in south africa through their contributions to basic education. the notion of development in this paper is underpinned by sen’s (2001) conceptualisation of development as expansion of freedoms allowing choice. many countries in the world, including south africa, face serious challenges such as oppression, poverty, illiteracy, hunger, disease and threats to civil liberties. according to sen (2001), development is about how we overcome these difficulties. the way to achieve development is to expand freedoms, allowing people to make choices. as human beings we aspire to having the right to elect our governments (political freedom), make choices about how we earn and spend (economic freedom), have opportunities to be educated and maintain good health (social freedom), engage with each other in a trusting way and benefit from protective social security. the different types of freedoms are interlinked; freedoms of one kind promote other kinds of freedoms. in south africa, we achieved political freedom in 1994 but have a long way to go in achieving social freedoms, as health and education remain key areas of challenge. in the domain of basic education the professions can make key contributions through advancing education by supporting literacy development. literacy has been defined as ‘an individual’s ability to read, write, speak and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one’s goals, and to develop one’s knowledge and potential’ (asha, 2002, p. 168). literacy development in south african basic education is in a serious crisis. in 2003, the department of education investigated literacy in grade 3 learners and found that 61% were not achieving grade level outcomes (centre for evaluation and assessment, 2006). the poor performance of learners was also evident in the progress in international reading literacy study (pirls), which included south africa in a comparison of literacy across 40 countries (mullis, martin, kennedy & foy, 2007). of significant concern was that south african grade 5 learners obtained the lowest scores despite being compared with grade 4 learners internationally (scherman, van staden, venter & howie, 2008). it is even more distressing to learn that south african learners were reported to perform worse than those in neighbouring countries such as mozambique, swaziland and botswana, even though a larger educational budget is allocated in south africa (barry, 2006). the situation has not improved over time. the recent report on the annual national assessment of 2011 (department of basic education, 2011b) indicated that 6 million learners (grades 2 7) were assessed in language and mathematics as part of its quality improvement strategy. the findings revealed that only 12 31% of learners had reached an ‘achieved level of performance’. the lowest results were evident in poor and rural communities. learner failure is symptomatic of a systemic problem. clearly, the quality of education is a problem and therefore all stakeholders are obliged to participate in improving schooling. given that literacy, as part of communication, is key to learning, the potential role of sltas is invaluable. in proposing development as an ethos of practice we advance an equity-driven approach that forces engagement with the challenges experienced by the majority of south africans. in the past, the professions served a privileged minority and as we plan for the future the emphasis must be on how the population as a whole can benefit from slta services. the lens of the professions must expand from a traditional impairment-driven frame to a broader and more inclusive framework which considers not only those who have language and literacy learning impairments, but those who are at risk for literacy development and hence educational failure as a result of disabling systemic conditions. in this paper, we share current thinking and relevant research regarding the contributions of sltas in promoting social freedom through our work in supporting literacy development. the emphasis is on our potential contribution to enhancing basic education since it is well established that a good foundation in education promotes long-term access to employment and health, but more fundamentally is a basic human right. education in south africa: the period prior to 1994 the literacy crisis in south africa cannot be understood without considering the history that shaped the current reality. the present education system with its systemic weaknesses was created by the combined influences of colonialism and racism. three hundred years of colonialism resulted in a curriculum that denigrated and devalued local knowledge and identities, and reinforced the false notion that some people were superior to others. the curriculum was a vehicle to entrench the superiority of europeans over native african inhabitants (kumar, 2010). from 1961 to shortly before 1994, south africa was under apartheid rule, a period characterised by an ideology of racial segregation and racial inequality (cross & chrissholm, 1990, in ratshitanga, 2007; welch, 2003). the segregated education system provided a different quality of education to african, coloured, indian and white learners. ‘white education’1 benefited far more than that for other races in terms of fiscal allocation, which resulted in disparities in all aspects of education (department of education, 1995a). in stark contrast, the bantu education act of 1953 was intended to provide an inferior education system for africans (75% of the sa population) designed to maintain their status as labourers. poor infrastructure, dilapidated and overcrowded classrooms, inadequate teacher training, lack of textbooks and learning materials characterised bantu education (hartshorne, 1992). apart from a racially segregated education system, there were two separate components for mainstream and special education, also characterised by racial disparity. this resulted in a fragmented education system with large numbers of learners being excluded from mainstream education (naicker, 2000). the fragmented and inequitable education system adversely affected the professional training of teachers, especially in the bantu education system. of significance is that the teachers trained for apartheid education continue to teach in post-apartheid education without effective support and training (wium, louw & eloff, 2010). the democratic elections in 1994 aimed to open the doors of learning to all south africans (african national congress, 1995). south africa emerged as a democracy with a new constitution, which in turn became the bridge between the apartheid past and political reform (department of education, 1995b). the chapter on human rights in the constitution of south africa (1996) spelled out the values of equality, dignity and freedom. simultaneously there was an international call to eliminate illiteracy throughout the world, and to facilitate scientific and technical knowledge and modern teaching methods (charter of the united nations, 1990). educational aspirations and challenges post-apartheid with the birth of democracy and the progressive south african constitution in 1994, a key priority has been the strengthening of basic education. in 2009, the schooling system in south africa had over 12 million learners with approximately 400 000 teachers in 25 000 schools. as in other countries, the schooling system comprises public and independent sectors. more than 11 million learners were enrolled in 24 699 public schools and were taught by 3 872 837 teachers in 2009 (department of basic education, south african country report, 2011c), while 393 447 learners attended 1 207 independent schools, and were taught by 25 230 teachers. these figures are based on learners attending ‘ordinary’ or mainstream schools, and do not include figures for learners attending ‘special’ schools. the challenge set forth by the constitution was to create a just and equitable system that provides a good-quality education to all learners (constitution of south africa, 1996). numerous reforms brought about fundamental changes in the process of redressing and enhancing equity: the south african schools act (department of education, 1996b) mandated children to attend school from the age of 5 to 15. the national education policy act (department of education, 1996c) and national norms and standards for school funding (department of education, 1998) resulted in fundamental changes in schooling. two types of schools are recognised – independent and public schools – with major resourcing inequities between them and within public schooling. funding for schools is currently aimed at equity and redress. therefore, schools are now categorised on the basis of their resources and revised funding norms are meant to advantage the poorest schools. a system of participative governance was implemented which devolved decision making, allowing school governing bodies to make decisions about many issues including fees and language policy. hofmeyer (2000) argues that south africa, as a middle-income developing country, demonstrates its commitment to education by spending 23% of its national budget and 7% of its gross domestic product (gdp) on education. however, even this investment has not been sufficient to address historical inequities and provide quality education. one of the immediate consequences of the schools act was learner migration (chisholm, 2008). within the public schooling system there has been migration of african learners to indian, coloured and white schools; while indian and coloured learners migrated to white schools. the flow of learners from white, coloured and indian schools to african schools is almost non-existent. as a consequence of learner migration, classrooms, especially in urban areas, have become racially and linguistically diverse with the schooling system being unprepared for such change. nevertheless the majority of african learners, particularly those who cannot afford to enrol in fee-paying schools, remain in under-resourced schools benefiting little in education post-apartheid. in addition to the changes discussed so far, the inclusive education policy and the language in education policy (liep) are of relevance to this paper. to raise education standards for all children, a more inclusive system was required. such an inclusive approach is based on the classroom becoming a supportive environment for all members, including learners and teachers. inclusive education is shaped by two major policy developments, namely white paper 6 on special needs education (department of education, 2001b) and the revised national curriculum statement (rncs) grades r 9 (department of education, 2002). while the rncs focuses on the curriculum and outcomes, education white paper 6 is focused on inclusion and creating learning environments which benefit all learners. inclusion, viewed broadly, is intended to create opportunities for all learners – regardless of race, gender, language, culture, class and disability – to participate optimally in education. the policy emphasises a shift from learners’ weaknesses to emphasising and building on their strengths. it also highlights the importance of collaborative learning and curriculum-based intervention. learners with special needs, as well as those at risk, are in regular education or ordinary classrooms. to make it possible for all learners to access the curriculum, schools need to respond to learner diversity by transforming the curriculum and to minimise, remove, and prevent barriers to learning and development. the system, not only the learners, is required to change. the rncs is a curriculum guideline that describes the learning areas, learning outcomes and pace and sequence of learning expected in an academic year, as well as assessment standards (department of education, 2002). although the department of education provided policy guidelines for each learning area, the onus rests on the nine provinces to customise these for their diverse populations. the rncs specifically refers to the successful development of language and literacy as a basic foundation for successful learning in all phases for all learners throughout schooling. it emphasises the importance of quality of education during the foundation phase of schooling (grades r 3), as well as the continued development of cognitive and linguistic skills through experiential learning. although the policy emphasised the importance of language as a key part of learning during the school years, it is also well known that language learning is a lifelong process and one of the most reliable predictors of scholastic success is learners’ language and literacy development prior to grade 1. the rncs for the foundation phase outlines three learning areas: literacy (including listening and language), numeracy and life skills. each of these main learning areas has specific learning outcomes and assessment standards linked to the concepts, skills and values to be taught at each grade level (department of education, 2002). the implementation of this curriculum relies on strong communication/language skills of teachers and learners. unfortunately, the implementation and success of the revised curriculum has been negatively influenced by a variety of factors, e.g. resources and teacher preparedness. among these, communication as a key factor has been overlooked and hence has become a barrier to learning. when south africa became a democracy in 1994, exemplary and progressive language policies were formulated to protect linguistic diversity (we have 11 official languages), promote language equity and develop the historically marginalised african languages. the liep (department of education, 1997) stipulates the right to education in the language of choice and promotes multilingualism within a framework of additive bilingualism, in which the home language (l1) is maintained while providing access to and the effective acquisition of additional languages (bengu, 1997). despite these enlightened policies, there is agreement that they have not been implemented either in the broader public domain or in education. english continues to be the dominant language in south africa (balfour, 2010; beukes, 2009; jankie, 2009; lafon, 2009; singh, 2009; sookrajh & joshua, 2009; webb, lafon & pare, 2010), at the expense and marginalisation of the other official languages (alexander, 1997; kamwangamalu, 2000; mbatha and pluddemann, 2004). beukes (2009) attributes the incongruence between policy and practice to three main factors: the hegemonic position of english, the government’s lack of political will, and negative attitudes to the african languages. however, there is a strong sense that african languages should be developed as instructional media, while access to english should not be denied (alexander, 2010; webb et al., 2010). a central question is how this should be accomplished, and decisions on language in education practices may need to be informed by the context of education. table i reflects the language of learning across grades. it is evident that in grades 1 3 the majority of learners are schooled in african/home languages. between 1998 and 2007 there has been an increase in the number of foundation-phase learners (grades 1 3) who learned in their l1. while the data indicate that there is a greater percentage of african l1 learners, it is also evident that approximately 25% have english and afrikaans as lolt. however, a major transition to english is evident at grade 4 as a consequence of the liep. in effect, the majority of learners do not learn in their l1 from grade 4. of significance is that the majority of learners are not exposed to english or afrikaans as a subject in grades 1 3 but are expected to learn and be assessed in these languages from grade 4 onwards. uneven performance studies assessing the literacy and numeracy of primary school learners reflect significant inequality in achievement across different educational contexts, resulting in a bimodal frequency distribution, where the majority of learners perform in the lower range and a smaller number of children perform in the upper range (fleisch, 2008; taylor & yu, 2008). the learners who do well attend former model c schools (higher-fee-paying public schools) and independent schools (fleisch, 2008). according to webb et al. (2010, p. 276), two types of schools have evolved from the former model c system. the first type, referred to as ‘upper ex-model c schools’, are attended by elite and middle-class children of all races, who attain literacy and numeracy outcomes comparable to those of middle-class children anywhere else in the world (fleisch, 2008). these schools are generally well resourced because the fees are determined by governing bodies. in these schools english or afrikaans is typically used as the medium of instruction (lolt) throughout, and the majority of teachers are first-language speakers of the lolt. the second type, referred to as ‘lower ex-model c schools’ (webb et al., 2010, p. 276) have fewer facilities and resources because the fees are lower, and many parents reportedly do not pay fees at all. as a result of urbanisation and migration within the urban population (chisholm, 2008), these schools are also demographically different from the upper ex-model c schools in that they are attended by predominantly african learners. white and indian parents have either moved away from the area or have enrolled their children elsewhere (chisholm, 2008; webb et al., 2010). the teachers at these schools are predominantly english first-language teachers but are also increasingly english second-language speakers. the medium of instruction at these schools is english from the first grade. the use of english in these contexts is often determined by pragmatic reasons and is indicative of the heterogeneity in home language backgrounds of the learners in certain provinces. in this context, english as the lolt may appear to be the only practical choice, since the complex multilingual composition of schools makes it difficult to select a particular african language as the lolt. rural and township schools, which are typically former african department of education and training (det) schools, are still attended predominantly by african learners. these schools continue to have very little funding and are poorly resourced in terms of libraries, electricity, water, etc. furthermore, teachers at these schools were trained by the bantu education system and therefore require significant reskilling to improve educational quality. as indicated previously, in these schools the official policy is to use the l1 as the lolt up to grade 3, frequently with little or no exposure to english as a subject in the foundation phase. from grade 4, learners then make the transition to english as the lolt. however, this transition is not fully implemented in practice (webb et al., 2010). it seems that in these schools, the l1 may be used (brock-utne & holmarsdottir, 2003), code switching is common, and urban vernaculars are increasingly used to facilitate understanding and classroom interaction, mainly because the english proficiency of learners and teachers is not adequate (webb et al., 2010). despite this, learners are officially assessed only in english and the fact that they have to demonstrate their knowledge and understanding in a language which is at best their second (l2) or even third language (l3) is simply not acceptable (lafon, 2008; webb, 2004; webb et al., 2010). furthermore, while they have not developed adequate english language competencies for school, they are also not advancing the development of the l1 for academic purposes resulting in underdeveloped linguistic competencies across languages. poor/underdeveloped linguistic competence in lolt is considered to be a contributing factor to poor performance of children in this context (alexander, 2005; brock-utne & skattum, 2009; heugh, 2009). unsupported language transitions the transitional system was also implemented during the apartheid era, and was largely discredited in the threshold project by macdonald (1990), who showed that learners had not acquired a sufficient vocabulary to use english as the lolt after 4 years of learning english as an l2. this policy has also been severely criticised by heugh (2002, 2009), who argues that l1 instruction should be implemented for at least 8 years. drawing on educational outcomes research in africa commissioned by the unesco institute for education and the association for the development of education in africa (adea) in 2004, heugh (2006) maintains that if early l1 instruction is to be beneficial, it must continue at least to the end of grade 6 but preferably longer, because the academic language and literacy needed for the whole curriculum cannot be developed in the first 3 years. in line with an additive bilingual approach, she recommends that the l2 is developed through subject teaching so that it can become a complementary medium of instruction during the second half of secondary school. a sudden and unsupported switch from l1 to l2 as lolt is not necessarily the best way to ensure high levels of proficiency in the l2. in addition, the literature on optimal age of l2 acquisition (e.g. marinova-todd, marshall & snow, 2000) suggests that in these contexts english need not be taught from the first grade, but can be introduced later when academic proficiency in the l1 has been established and developed. older children who have consolidated the l1 and have access to a number of additional cognitive resources, such as explicit learning strategies, learn l2s more rapidly than younger children (macwhinney, 2005; paradis, 2004; ullman, 2001). in contrast, younger children develop languages gradually, and teachers need to be aware of how long it takes for children to become proficient in the additional language if it is to be used as a medium of instruction. heugh (2006) argues that although issues of poverty and ill health (e.g. hiv/aids) compound the language problem and result in the generally low educational outcomes throughout africa, the inadequacy of early-exit transitional programmes has also been demonstrated in developed countries such as the usa and canada, which are not as affected by such problems (e.g. thomas & collier, 2002 cited in heugh, 2006). heugh (2002; 2006) and ramani, kekana, modiba, and joseph (2007) believe that african languages can be used as the lolt beyond the third grade. this claim is based on research by heugh and mahlalela-thusi (2002), showing that considerable work was done on the development of african languages before, during and even after bantu education. heugh (2002) therefore urges stakeholders to consult these resources in african language departments across the country. on the use of l1 instruction beyond grade 3, heugh (2009) adds a very important caveat. she maintains that research findings on first to third-grade children often show no achievement differences between l1 children and children in either l2 instruction from grade 1, early exit from l1 instruction, or dual-medium instruction programmes. however, she points out that gaps in performance start to emerge late in the third year and reach significant levels by grade 6, and the only learners who perform at similar levels to their monolingual peers are those who have had instruction in their l1 as well as the l2 throughout. the implication of this is that even if l2 learners perform similarly to monolingual peers in the first 3 grades, they will fall behind if they do not receive support in both their l1 and english. her findings explain the reasons for the large-scale referral of grade 4 6 intermediate-phase learners by teachers for literacy intervention in the western cape (kathard & pillay, 2006). the teachers in linguistically diverse classrooms in poor communities were concerned that the majority of learners who made the sudden unsupported transition to english were not meeting grade level outcomes for literacy. the teachers reported that learners had not developed foundation-phase language and literacy skills and they were not skilled to support these learners (navsaria, 2010). heugh (2006) claims that the language problems of children learning in their l2 have the most significant impact on their achievement in mathematics, since they achieve on average 10% less for mathematics than for language. in addition, heugh (2009) cites recent evidence from ethiopia, a much poorer country than south africa, where children are instructed in their l1 (e.g. amharic) for 4, 6 or 8 years. children with 8 years of l1 instruction have higher scores across the curriculum (in mathematics, science and biology) than children with 4 or 6 years of instruction in the l1. one of the widely used arguments against bilingual instruction and therefore the use of the l1, concerns the perception that such programmes do not provide sufficient exposure to the l2, as instruction time between l1 and l2 is divided (obondo, 2008). this is known as the ‘time on task argument’ (genesee, paradis & crago, 2004, p. 168). however, although exposure is necessary for acquisition it is not sufficient (obondo, 2008). this has been repeatedly demonstrated in research showing either no significant differences in the l2 proficiency of children in l2 monolingual programmes and bilingual programmes or an advantage to those in bilingual programmes (chisholm, 2001). there is therefore overwhelming evidence that an additive bilingual approach in which the l1 is used for as long as possible while the child acquires other languages is the best for african children (obondo, 2008), and yet there is resistance to this across africa. importance of african languages in education ‘being able to use the language(s) one has the best command of in any situation is an empowering factor and conversely, not being able to do so is necessarily disempowering. the self-esteem, self-confidence, potential creativity and spontaneity that come with being able to use the language(s) that have shaped one from early childhood ... is the foundation of all democratic policies and institutions. to be denied the use of this language is the very meaning of oppression.’ alexander (2005, p. 3), in no uncertain terms, places a high priority on the use of african languages in education from the learners’ perspective. while he acknowledges the value of empowering learners with english, he argues against the hegemonic use of english, i.e. english is privileged over all other languages and results in loss or decline of indigenous languages. the use of african languages is also considered to be important for economic development and sustainability (kamwendo, 2009). the period 2005 2014 has been declared the united nations decade of education for sustainable development. this refers to the use of current resources in ways that will ensure their continued availability for future generations. education systems are the avenue through which individuals can be developed to create a sustainable future in terms of environmental resources, economic prosperity, and social justice (unesco, 2005). the use of former colonial languages (english, french and portuguese) as media of instruction in african schools impacts negatively on educational achievement when these languages are not well known by the learners (kamwendo, 2009). dlodlo (1999) and bunyi (1999) elaborate on this point by proposing that these languages, which contain words and concepts that bear little relationship to the learners’ daily experiences, deprive them of the opportunity to apply what they are learning to what they already know, which is a fundamental philosophy of learning (reagan, 2009). finally, the use of african languages as media of instruction in african schools can help to minimise the impact of noisy classrooms on speech understanding of most learners. anderson (1999) reported that an average first-grader misses 1 in every 6 words when learning in a class with too much background noise. further, learners who learn in classrooms with high background noise levels such as schools near the airport or railway tracks, often exhibit poorer reading skills than learners who learn in less noisy classrooms (anderson, 1999). the negative effect of poor learning environment (i.e. classrooms with too much background noise) on speech understanding has been shown to be much greater in children who learn in an l2 in comparison with those who learn in their native language (crandell, smaldino & kreisman, 2004; tabri, chacra & pring, 2010). therefore, in south african schools where there are often less than optimal learning environments (e.g. overcrowded classrooms, too much background noise, etc.), using a language other than the language in which most learners are competent will severely limit their access to the information being communicated in class. reasons for limited implementation of liep the main reasons for the dominance of english in education are the stigma attached to african languages as a result of ‘bantu education’ during apartheid (nyika, 2009; webb et al., 2010) and the view that english provides access to social and economic advancement. african parents associate poor-quality bantu education with being educated in an african language. heugh (2000) argues that in the drafting of the outcomes-based curriculum, there was always a covert agenda that all children would ultimately learn in english, evidenced by the fact that language issues were reduced to the language and literacy learning area, as if they were not connected to the other learning areas. development of terminology and materials in all the official languages, and teacher training for multilingual education and the new curriculum, were therefore not discussed (heugh, 2000). the liep was announced 4 months after curriculum 2005 was finalised, and heugh (2000) maintains that the centrality of language in education was disregarded at a critical point in south africa’s history. webb et al. (2010) suggest the following additional explanations for the limited support for and non-use of african languages in education. first, learners have been found to have underdeveloped literacy in their l1, and are also aware of this (barkhuizen, 2001; pretorius, 2008; webb et al., 2010). according to webb et al. (2010), there is a general tendency for african language learners and teachers to overestimate their proficiency in english, and underestimate their l1 proficiency. second, the african languages have not been adequately developed and standardised, and although there has been work in this area by the national languages bodies under the pan south african language board (pansalb), the standardised varieties have not been widely accepted, are not familiar to l1 speakers and are not used in formal contexts such as classrooms. in the development of the standard varieties there has been insufficient attention to status, acquisition and planning, and they are not seen to have economic or social power (webb et al., 2010). the development of technical terms in african languages is also challenging in that there is considerable difficulty in finding terms for concepts (singh, 2009). for example, southern sotho has only one term, ‘lebelo’, for ‘speed, velocity and acceleration’ (moji, 1998, p. 258), and in isizulu there is only one word, ‘amandla’, for ‘power, force and energy’ (wildsmith-cromarty & gordon, 2009, p. 368). dlodlo (1999, p. 321) attributes this conceptual void to the fact that african languages have not been used in education and consequently a modern scientific vocabulary has not developed. he argues for ‘giving scientific meaning to generally accessible words that are explanatory of the context, rather than borrowing from european languages ...’. this approach implies that acquisition planning (the actual use of languages) drives corpus planning (the development of terminology by language bodies) so that teachers do not need to wait for terms to be developed before they can be used in the classroom (wildsmith-cromarty & gordon, 2009). translation of english terminology is problematic in that english and the african languages are non-cognate languages, and there may be a lack of semantic and structural equivalence (catford, 1965; nida, 1975), lexical gaps (fawcett, 1997) and translation shifts (catford, 1965). the third reason for not using african languages in education is the increasing use of urban, code-mixed vernaculars such as tsotsitaal, iscamtho and pretoria sotho, in gauteng schools in particular (cook, 2008; lafon, 2005). webb et al. (2010) attribute this practice to the absence of well-developed standard languages, and the rejection of standard varieties particularly by the urban youth. this is because new terms, developed by experts on language boards, are experienced as contrived (wildsmith-cromarty & gordon, 2009) and more aligned to rural dialects, which are slower to change than urban dialects, as a result of less contact with and influence from other languages (anthonissen & gough, 1998). an example of this dichotomy is the tension between urban and rural isizulu. the rural variety is considered to be the standard, but is virtually a foreign language to urban schoolchildren who do not learn successfully using this form (webb et al., 2010). while the post-apartheid schooling policies offer an ideology of improved education, implementation has been of serious concern. the key issues of language and learning have not been given sufficient consideration and, as a consequence, the majority of learners are being systemically disadvantaged and hence cannot meet grade level outcomes. although school governing bodies (sgbs) have authority to make lolt policy decisions, pluddemann, mati and mahlalela-thusi (2000) anticipated that in the absence of a comprehensive plan to educate and support sgbs on the language learning policies, it is likely that they will take the path of least resistance and adopt policies which are easier to implement. in effect, the evidence in table i confirms their concern, i.e. there has been little innovation or development of multilingualism in schools as english remains the lolt beyond grade 4. furthermore, those who have specific language learning and other communication disabilities remain masked in the system as the majority of learners are at risk for not meeting educational outcomes. clearly, the discussion so far has demonstrated the impact of a systemic problem on learner outcomes. while some learners might have specific impairments, the majority of learners are disadvantaged because of systemic problems at school and in their communities. the pressing question that needs to be addressed, therefore, is: how can sltas support the education system to enhance language and literacy? speech language therapists and audiologists in education: where are they? in the current system, sltas do not play a visible role in the public sector education for a variety of reasons. firstly, as a consequence of apartheid-era policy, sltas were employed by the provincial departments of education at district level under the auspices of the ‘school psychological services’, benefiting a privileged minority. they also worked within a ‘special school’ model which offered services to learners based on their impairment/condition, e.g. schools for intellectually impaired/hearing-impaired/physically impaired children. in these historical educational contexts their traditional role was to identify learners who presented with ‘speech and hearing deficiencies’ and to provide the relevant therapy to treat them. their interventions were guided by a medical model/deficit model which resulted in a pull-out approach where the child rather than the system was the focus of intervention. as a consequence, a small number of learners received individual support which was not cost-effective. with the dawn of the new democracy, several of the sltas previously employed in the education system remained as district facilitators for learning without rendering direct professional services. while their roles are emerging, their impact has yet to be felt by the majority of learners and teachers in the public sector in ordinary/mainstream classes who receive minimal direct support. secondly, therapy to school-age populations has been offered mainly by private practitioners who are parent-employed and work in a pull-out model benefiting mainly individual learners who can afford help. thirdly, although sltas are part of the education system, their roles in supporting general education in public sector schools are only emerging. they have not had opportunity to articulate their roles or the types of interventions which could potentially benefit education. therapists are therefore still faced with the challenge, articulated by lewis (2004), of making visible the links between language, literacy and learning, and demonstrating their role in supporting general education. a conceptual separation still exists between what is considered the domain of the teacher and the domain of the therapist. in moving forward, therapists must align interventions to engage with curriculum support and assist teachers and learners to meet learning outcomes. the current human resource capacity of sltas is severely limited. the authors were unable to gain official documentary information on the number of sltas employed in the basic education sector and their role. however, available human resource data indicated that there are 186 speech-language therapists (slts) across the country appointed at ‘special’ schools. in addition, there are 73 ‘office-based’ therapists (general category which includes occupational therapists and physiotherapists) whose job functions are unknown (schoeman, personal communication, july 2011). given school populations and current challenges in the education system, it is clear that sltas are grossly under-represented. within a resource-constrained environment, sltas must therefore creatively craft service delivery models and types of interventions that would serve population needs. furthermore, sltas must be able to demonstrate that their interventions are beneficial, particularly in parts of the system that experience disadvantage. in the discussion that follows, the links between language, literacy and learning are explained and the potential role of sltas is discussed. while the evidence base for slta intervention in south africa is minimal, developments in the usa and uk offer possibilities. the paper concludes with suggestions for further actions. language, literacy and learning language as a key part of communication is central to learning (bohlmann & pretorius, 2002; owens, 2002), as it is required for the development of reading and writing, and therefore becomes a prerequisite for all other learning areas. linked to learning, language is not only an important part of a person’s identity but also contributes to the understanding of other cultures and world views. it stimulates imagination and creativity, which link with arts and culture. it is also used to communicate information and to promote science, technology and environmental education. language develops the critical tools required to become responsible citizens. the language learning area is crucial as it is central to people’s lives (department of education, 2002). language is used as the medium for learning in all learning areas, and underdeveloped language skills impact negatively on academic performance (bohlmann & pretorius, 2002). while spoken, and not written, language is the domain most often associated with sltas, a large body of research (bishop & snowling, 2004; stackhouse & wells, 1997) suggests that spoken and written language should be viewed on a continuum, with written language being developed on a foundation of spoken language, and phonological awareness acting as the mediating bridge between the two domains. thus, sltas working in classrooms may be focused on any or all of a combination of these areas. there are others who suggest that written and spoken language develop simultaneously and influence each other (scott, 2005). supportive of a simultaneous development stance, the department of education (2002) in south africa recognises that language learning outcomes for the foundation phase are collectively those of listening, speaking, reading and viewing, writing, thinking and reasoning, and language structure and use (department of education, 2002). they maintain that these outcomes should be integrated when taught and assessed, even though they are presented as separate outcomes. sltas in other contexts while south african sltas work towards the development of contextually relevant intervention practices, they can draw on the experiences of sltas in other contexts around the world. american therapists in particular have shifted from a traditional pull-out model to a classroom-focused approach. here the slta’s role in the classroom is to support the development of a robust oral and written linguistic base, which includes a learner’s l1 and any additional languages (ehren & ehren, 2001). ehren (2009) describes the role of slts in a ‘content literacy continuum’, a five-level framework that addresses the speaking, listening, reading and writing needs of learners. level 5 (therapeutic intervention) is the most intensive level where learners with language difficulties receive therapy from an slt, either within the classroom setting or outside it. this is perhaps the model of working that many slts will be most familiar with. however, slts should also be involved at the other four levels, with levels 1 and 2 involving close collaboration with classroom teachers, e.g. guiding the teacher’s use of language, identifying learners in need of further interventions, and determining the language underpinnings of the curriculum. for levels 3 and 4, the more intensive and specific role of the slt, again in collaboration with teachers, is outlined. the royal college of speech language therapists (rcslt, 2011) describes a similar system of working which emphasises the slt’s role at various levels within the school setting, ranging from highly specialised work with individual children to preventive work with all children or particularly vulnerable groups of children. the preventive focus should include working with parents and other community support structures to facilitate literacy development in the home context (navsaria, 2010). because of the central role of language in learning (slabbert, de kock & hanttingh, 2009), a system responsive to the needs of all learners must first and foremost consider how language and communication for learning can be maximised. given the link between audition, language and literacy, sltas should provide supportive structures, which promote and enhance spoken and written language (owens, 2010). learners and teachers need language support that is functionally related to the academic and social tasks of school. the classroom’s cognitive activities are the best context, presenting the most significant and interactive opportunities for the learners, to enhance learning (ehren, 2000). having a close understanding of the relationship between curricular demands and the role that language and communication play in learning, teachers and sltas can address the academic and social challenges as a team within the classroom (ritzman, sanger & coufal, 2006). the role of the slta is to use classroom activities as the basis for intervention and implement a format of team-teaching where both the teacher and the slta teach small groups simultaneously, or where the teacher works with the larger class, and the slta works with a smaller group needing support. one-on-one classroom-based intervention that centres on language strategies for classroom use with selected students is not excluded. the slta also acts as a consultant who advises teachers and primary caregivers on intervention strategies, and sets joint goals and objectives with the classroom teacher. this model requires in-service training of all teachers as well as primary caregivers with regard to the language curriculum, including metalinguistic and metacognitive processes, syntax and morphology, and listening and literacy skills. sltas can work with teachers to identify and ameliorate acoustic barriers in the classroom to promote accessibility of the teacher’s speech to the learners. further, they are better placed to advise teachers on the implications of hearing difficulties for individual learners, as well as devise effective management of their listening needs within a range of settings (british association of education audiologists (baea), 2003). for these reasons sltas’ contributions would be valuable when collaborating with teachers, in planning relevant and meaningful learning programmes for all learners. a developmental approach within the policy of inclusion and collaboration is essential in preventing later scholastic difficulties (owens, 2010). finally, because of their scopes of practice, sltas are also essential in serving as the ‘key link’ professionals between the education and health systems to ensure seamless service provision to learners and teachers. in south africa, the current policy in its intention provides a firm grounding for developing a collaborative approach. in the education white paper 6, support is described as the provision of training, mentoring, monitoring, consultation and collaboration. clearly, all stakeholders must work towards the practical implementation. sltas in classrooms: can we make a difference? evidence from the international literature demonstrates that learners and teachers who have received support from slt services have experienced positive outcomes supporting the goals of successful schooling (ehren & ehren, 2001; mccartney, ellis & boyle, 2009; wilson, nash & earl, 2010; wren, roulstone, parkhouse & hall, 2001). a systematic review (cirrin et al., 2010) of the evidence base regarding slt intervention for primary school learners over the past 30 years suggests that: slt intervention has positive outcomes; direct classroom-based intervention is at least as effective as traditional pull-out models; and trained assistants can be as effective as slts when working with this population, but there are very few studies and an expanded research agenda is urgently required. this latter observation is particularly pertinent in our context. there are few south african studies that demonstrate the effectiveness of slta involvement in mainstream schools. moodley, chetty and pahl (2005) argue that sltas are well positioned to support language, literacy and learning given their skills base. therefore they must craft their roles in relation to the rncs and inclusion. they focused on the role of sltas in developing learning and teaching support material relevant for a multicultural population through use of folktales. they make a strong case for the collaboration between teachers and therapists, suggesting that success will depend on a conscious change of attitude regarding their roles and responsibilities. wium et al. (2010) reported on the benefits of teacher support in facilitating literacy and numeracy with foundation-phase learners in previously disadvantaged schools. they found that teachers benefited from a support programme provided by sltas, as they were better prepared to implement those learning outcomes for literacy and numeracy. another local study by du plessis (1998) investigated whether a model of teamwork could lead to improved goal-setting and intervention at preschools where learners and teachers required support with language development. the results indicated that the most adequate goals and successful language intervention were achieved in the transdisciplinary model of team functioning between sltas and preschool teachers. it is speculated that role transfer, a specific characteristic of this model, led to the improvement. the sharing of knowledge, expertise and skills by professionals involved in education is notably the best way in which a learner’s potential can be realised (du plessis, hugo & soer, 2000). a further investigation was done into the support needs of preschool teachers regarding language acquisition by preschool learners acquiring the lolt. preschool teachers acknowledged the need for knowledge regarding language acquisition and the need for support. they were willing to consult and collaborate with other professionals, including slts in support of preschool learners (du plessis, 2005). while these studies are encouraging, it is vital that sltas develop a strategy to enhance their presence in the education system. opportunities, issues and actions becoming partners: action plan to 2014 this paper has explained the current crisis in education, and its links to language and literacy development. given the large-scale challenge facing south african education, it is imperative that sltas seek opportunities to support the national imperative for quality education. the department of basic education, in recognising the enormity of the challenge, has formulated a longer-term vision reflected in ‘schooling 2025’. the immediate steps are documented in a 5-year plan, ‘action plan to 2014’ (department of basic education; notice 752 of 2010), which outlines 27 goals to improve the quality of education. slta input is particularly relevant to several goals, the first of which is to increase the number of learners in grade 3 who by the end of the year have mastered the minimum language and numeracy competencies for that grade. the second goal highlights the importance of sustaining literacy and numeracy competencies to grade 6 learners. sltas would have to consider how they could support the realisation of these goals in partnerships to support current strategies. for example, the ministry has initiated the workbook project in all 11 official languages. the aim of the workbooks is to support more effective teaching, which is recognised as a significant constraint. the workbooks are intended to assist teachers with teaching content knowledge, as well as to monitor how learners do tasks. sltas could assist with developing materials to ensure that both language and content goals are met. furthermore, therapists could make an important contribution to the review of the rncs, and specifically to the national curriculum and assessment policy statements (caps) which have been developed for each subject for all grades. the provision of quality early childhood development has also been prioritised. the department of basic education has indicated that all learners would have access to grade r by 2014. sltas could make critical inputs into this process to ensure that language development and emergent literacy skills are prioritised in the curriculum and teacher training. the teacher development programme has been launched through the participation of all stakeholders, creating a further opportunity for collaboration between teachers and therapists. therapists could support pre-service and in-service teachers in a range of areas to improve literacy outcomes. clearly, sltas must intervene politically and raise awareness of their roles and their potential contribution. this process has been initiated by the education task team in october 2010 under the auspices of the south african speech-language hearing association. the task team have made submissions to the national department of education on the potential contribution of sltas, summarised below. while this is a first step, it is imperative that further strategic action is taken to ensure that the professions participate meaningfully in supporting basic education. expand employment of sltas in basic education the further employment of sltas in the department of basic education will provide systemic support in language and literacy development to support improved learning outcomes. in the current service delivery model, the department of health employs the majority of sltas who provide services for children under 6 years of age. school-aged learners are not given priority if they do not have an accompanying medical condition, leaving a major gap in support in the education sector. while the education sector has employed sltas, they service mainly schools catering for learners with special needs and are beginning to form part of district-based service delivery teams. however, the number of sltas is far from optimal and must be increased if teachers and learners are to obtain tangible support. the further employment of sltas will also affirm that the department of education is accepting responsibility for the support of learners and teachers, particularly in contexts where language and literacy problems are prevalent. the following employment options may be pursued: • community service posts. each year, approximately 200 sltas graduate from university. graduates could be integrated into the education system by using a strategy of compulsory community service in education. this strategy was put in place by the department of health in 2003, and has been successful in establishing services in under-resourced areas. in the future, the graduates could be placed in either health or education settings during their community service year as their roles straddle these sectors. • improving post provisioning in the basic education sector for qualified practitioners with emphasis on strengthening interventions to support language and literacy development in ordinary classrooms. at a minimum, sltas should be employed at every full-service school and collaborate on all district-based teams. slta competencies sltas will have to be (re)skilled to become effective participants in supporting basic education. while universities are aware of how sltas should be working to support basic education, the professions do not have guidelines for the specific competencies required to address the crisis. the majority of sltas trained in south africa would require reskilling to develop competencies to address national priorities. key issues that sltas must consider include the following: • what kind of service delivery models would be relevant for the south african context? what would intervention priorities be? what type of service delivery model would be effective and cost-effective? • how would sltas support the development of all languages, especially african languages, particularly as the majority of clinicians are mainly english or afrikaans first-language speakers? • how can sltas respond to the numerous calls to assist with developing english as an additional language? would sltas need additional esl competencies? • how can sltas lead or participate in social innovation needed to respond to this magnitude of crisis? • what human resource base would be required, given the large-scale challenge? conclusion this paper has outlined the challenging landscape of basic education in south africa. difficulties with the past and current system have impacted on learners and teachers to create a crisis situation. there are no easy solutions, but there are choices facing the professions of speech-language therapy and audiology, which if judiciously made, may lead to important and significant contributions to the basic education sector in this country. sltas must pursue a development agenda to be socially relevant. usaid (2004, p.2) suggests that the economic growth of a country depends on an educated workforce that is poised to take advantage of opportunities. there is a dual meaning here for sltas. we must strive to contribute to the development of that workforce through the enhancement of language, learning and literacy in basic education. secondly, as professionals ourselves we constitute a small but highly educated workforce and if we wish to ensure the future relevance and value of our work in south africa, we should take advantage of the great opportunities that currently await us in the education system. the professions must be strategic in their engagement with education. but we should also do what is right: educated and literate individuals have better long-term access to employment and health – they have freedom. what bigger contribution can speech-language therapists and audiologists make than this? response the respondent, barbara ehren, offers commentary on the issues raised and makes further suggestions for the way forward. we asked her: ‘as a speech-language pathologist, how would you respond to this contextual challenge?’ i appreciate the opportunity to respond to this paper not only as a speech language pathologist (slp) but also as an educator with a longstanding interest in systems change. what the authors call for is a major shift in the roles and responsibilities of slps in south africa, which will require changes in the way slps view themselves and their work scope, as well as how other educators view them and their contributions to student achievement in general and literacy specifically. these changes in perceptions must be accompanied by new or revised implementation mechanisms, including substantive alterations in processes and infrastructures within the education system at many levels. i wholeheartedly support this call for more substantive contributions of slps to literacy. it is in keeping with my own work, along with that of many colleagues in language/literacy and school practice who share this vision. it is inspiring to encounter kindred spirits working toward this end in another part of the globe. it is encouraging that mutual goals may provide an opportunity to collaborate on enhancing the impact of slps around the world, striving to make a difference in the lives of all human beings. at the outset, i would recommend a clarification with regard to the inclusion of audiologists in this mix. i would not want to minimise their contributions in supporting access to instruction by addressing acoustic considerations, especially in noisy environments, and in working with children and adolescents who are hearing-impaired to promote literacy acquisition. however, i do not see their potential contributions to the overall literacy agenda to be on a par with slps, because slps have many more roles to play in a wider variety of areas affecting literacy. i think that including both professions in a single package of ‘slta’ convolutes the issue and fails to send a clear message about what respective roles should be. rather, i would define a suggested role set in education for each profession separately. therefore, in the rest of my commentary, i shall address only slps. the rationale for the summons this call for slps to participate more broadly in language and literacy instruction is crucial to nations that recognise literacy as central to the development and maintenance of a democracy and that appreciate the corresponding urgency of addressing poor literacy rates. a literate citizenry is essential to promoting full participation in the way of life of a democratic society. further, in our technologically advanced world, workforce readiness requires high levels of literacy, way beyond what previously has been considered ‘basic’ (ehren & murza, 2010). therefore, a cogent argument is that with a matter of such urgency it behoves all segments of a society to be engaged in the effort, and slps should be no different. however, additional weight should be given to the case for slp involvement, because they bring to the literacy table unique contributions, given their knowledge of language. in fact, the american speech-language-hearing association (asha) recently promulgated as official policy a position statement and professional issues statement on the roles and responsibilities of slps in schools that embrace many critical roles, including those highlighting literacy within the context of slps’ unique contributions and within a broad range of responsibilities (asha, 2010, p. 1): ‘slps provide a distinct set of roles based on their focused expertise in language. they offer assistance in addressing the linguistic and metalinguistic foundations of curriculum learning for students with disabilities, as well as other learners who are at risk for school failure, or those who struggle in school settings’. other companion roles articulated in the asha documents are in the areas of collaboration and leadership. the former arena lends credence to slps forging partnerships with other educators in support of literacy and the latter points to the advocacy needed from slps to assume new and expanded roles. in supporting slps’ contributions to the national imperative for quality education, i would endorse framing the conversation in terms of ‘backward design’ (wiggins & mctighe, 2005) (which is basically what the authors have done); that is, to advocate that all stakeholders start with the end in mind in defining roles for slps (or anyone else, for that matter). in such a construct, the larger picture of the social and economic goals for south africa provides the target for educational goals. where south africa wants to be as a nation then becomes the starting point for discussing roles of slps. working backward from that point, the next question is ‘what has to happen in education to create the kind of society south africans want?’ and from there, ‘what do slps have to do within educational systems to contribute to this grand plan?’ this is a different approach from looking first at slps’ roles based on their professional preparation and expertise. my own experience in working with slps in many different states within the usa is that this approach provides a convincing rationale for them to consider doing things differently. they see their potential contributions as serving a larger purpose, a key factor in motivating them to make the necessary changes. a titillating challenge for slps is to expand their sphere of influence in areas of major consequence to their country so that role definition is no longer just a matter of ‘this is what we do as slps’ but ‘this is what south africa needs for us to do.’ of course, in the final analysis, professional preparation and expertise are considered in defining roles, but they are not the starting point. implementation considerations even if taking larger roles with literacy makes sense to slps and other stakeholders, the practical aspects of implementation is where the ‘rubber hits the road’. for one thing, with the pull-out model having been the mainstay of service delivery, slps will need to expand their repertoire to accommodate refocused priorities. first, it is important to note that including more students and activities within the work scope of slps should in no way imply abandonment of students with communication disorders. even with that population, slps would do well to consider alternatives to pull-out. for more effective and efficient services, a variety of delivery models, including in-classroom direct services and indirect services to teachers and caregivers (ehren, 2000), should be considered. for example, when students with speech and language disorders are at a generalisation stage of therapy, pulling them out may not well serve the goal of transferring new behaviours to the classroom. however, within a broader scope of concern for literacy status with more students, it is of even greater import to consider a variety of options. especially in light of limited resource capacity, contributions of slps may in many instances be to assist teachers, other professionals and caregivers who might be the primary deliverers of intervention. therefore ‘indirect services’ are important to include in a menu of service delivery options. thus, slps’ roles in intervention may expand beyond direct work with students who struggle with literacy. in this regard, i think it is helpful to think in terms of four types of activities with which slps may be involved: 1. triaging students 2. looking at students individually 3. deciphering patterns of strengths and challenges in learning with an eye on language underpinnings (foundations) that may be involved 4. helping to decide who needs what service from whom 5. guiding language-sensitive assessment/instruction/intervention delivered by others, including accommodations for students with disabilities. (this may be accomplished by consultation/problem-solving, demonstration teaching and provision of professional development to others.) 6. providing direct intervention to students on language underpinnings in collaboration with others. 7. providing speech and language therapy to students with communication disorders. given a broad array of service delivery options, slps will still need to make judicious selection of students to serve, directly and indirectly, deciding how best to use their expertise; otherwise, they will become overwhelmed with too much to do. a key component in effective and efficient deployment of personnel is collaboration among professionals to parlay resources and avoid redundancy or conflicting directions. ehren and laster (2010) and goetze, laster & ehren (2010) have recommended a partnership among specialists who share an interest and expertise in language; in the usa that would include the slp, reading specialists and teachers of english language learners. with whom might slps join forces in south africa? as slps jump into the mainstream of education, they should avoid becoming just another pair of hands to do the work in schools that needs to be accomplished. that is, the tasks they are assigned should make use of their unique skill set in language and offer added value to the education of children and adolescents. intervention activities need to be relevant to social and academic goals with the following caution: slps should not become responsible directly for mastery of subjects such as maths, social studies and science; instead they should facilitate access to these curricula through work on foundational language elements. thus, curriculum provides the context, not the content of intervention, unless the curriculum under consideration is language arts. this approach does not require slps to be as expert as teachers in curriculum. what they need is enough knowledge about curriculum to select specific content as the raw material to teach language underpinnings. content foci it is important to discuss language not just as prerequisite to learning but also as corequisite. figure 1 is a graphic used by deshler and ehren (2008) to convey the ongoing contribution of language to all aspects of learning; it is helpful to explain how language is both foundational to learning at all stages, not just the basic foundation that precedes academic learning. rather than thinking of language as developing linearly along a continuum, it might be more productive to think of it as reciprocal along all points on the continuum of learning, as the above figure would imply. research has consistently demonstrated reciprocal relationships with listening, speaking, reading, and writing (e.g. bradley & bryant, 1983; catts & kamhi, 2005; englert & thomas, 1987; gillon & dodd, 1995; hiebert, 1980; kroll, 1981; ruddell & ruddell, 1994), all of which share linguistic, cognitive, metalinguistic and metacognitive underpinnings (ehren, 2006). highlighting the reciprocity of language processes and framing literacy as including listening, speaking, reading and writing, in my experience, helps slps to understand the relationship between oral and written language. also, i would suggest that a focus on literacy should include more than phonology as a ‘mediating bridge’ and include differences in oral and literate styles with complexities in syntax, semantics and discourse structures. systems change even if there should be a resounding affirmation of the logic of this summons from many sources, change occurs slowly. carefully consider the mountain you have to climb; don’t underestimate the time and energy required to reach the summit! attending specifically to the requirements of educational reform and change will help manage and sustain the process. consult notable authors like elmore (2004), fullan (2005), guskey (2005) and hall & hord (2010), among others. hall and hord’s concerns-based adoption model (2010) is one that will be of particular assistance in implementing and managing change. the authors’ observation that the traditional roles of slps are rooted in a deficit model implies that broader roles with literacy will require not only a different mind-set but also a different skill-set to serve in these capacities. to prompt and then sustain this change, both pre-service and in-service professional development will be needed. in the case of pre-service education, two issues are germane: (i) preparing a sufficient number of slps to serve in expanded roles; and (ii) refining the university curriculum to include specific instruction in language and literacy issues, as well as methods in school practice and collaboration, among other important areas. however, it is difficult to imagine that universities could address all aspects of implementing literacy-related roles in schools in sufficient depth. therefore, an important companion piece is in-service education. this preparation will also be needed to retool practising slps. in this regard, the evidence base on high-quality professional development should be heeded in the development of slps’ willingness and competency to engage in these roles (desimone, porter, garet, suk yoon & birman, 2002; penuel, fishman, yamaguchi & gallagher, 2007). ongoing professional development, including experiences with initial learning, supported by follow-up activities will be essential. a major consideration is that if sufficient funding is not allocated to high-quality professional development for all involved, slps and their collaborators’ efforts to move ahead will be in vain. (see standards for high-quality professional development from learning forward, formerly known as the national staff development council at www.nsdc.org). slps who embrace these roles conceptually should be prepared to encounter challenges along the way. for example, articulation of roles with literacy is a reiterative process. just because slps explain to school district or school building administrators what they have to offer to address literacy needs, does not mean these administrators will internalise this message immediately, if their schema for slp work is rooted in traditional roles. another consideration, however, is that to obtain buy-in from stakeholders, the latter must understand and appreciate what slps have to offer, starting with an appreciation for the role of language in all aspects of learning. i would not assume that most teachers have such understanding. one of the biggest obstacles we encounter in the usa is that teachers, especially of older students, do not understand the continued importance of language to the achievement of academic goals. another systems issue is measuring the impact of slps’ contributions. this is easier said than done. the impact of slps on literacy will be difficult to measure, especially if we extend roles to more than direct service to students. as we advocate for a collaborative approach, the whole may not equal the sum of the parts; i.e. the benefit to students may not be additive when collaborators are involved. the interchange among professionals may create a synergy and produce results that reflect a ‘shared creation’, as schrage (1995) describes. how can we tease out the contributions of individual professionals if we view the result of collaboration to be a shared creation and not merely a completion of delegated tasks by a ‘team’? this is a matter of ongoing discussion in the usa. conclusion in their closing section, the authors noted: ‘if we wish to ensure the future relevance and value of our work in south africa we should take advantage of the great opportunities that currently await us in the education system’. i would suggest that relevance and value are the cornerstones that should mark the work of slps in all corners of the globe. i would further say that indeed the education system affords slps wonderful opportunities to use their knowledge and skills for substantive outcomes. we need to make a difference! although that goal can be accomplished in a variety of ways, it makes sense that the impact of slps should be as broad as possible, given the needs of society and that literacy proficiency is surely one of those exigent needs. a mantra for me that may resonate with slps in south africa is this quote from hynds (1994, p. 162): ‘i teach so that the world will be a better place. it’s really that simple. i teach in the hope that some day, there might be a few more people who can use the gift of language in authentic ways: to respond to others, to learn new things, and ultimately, to positively influence the world in which we all must live.’ dr barbara j ehren, ccc-slp, asha fellow board recognised specialist in child language professor director of the doctoral program interim associate chair department of communication sciences and disorders university of central florida orlando, florida, usa references african national congress (1995). a policy framework for education, training and development. johannesburg: anc. alexander, n. 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(2001). a model for a mainstream school-based speech and language therapy service. child language teaching and therapy, 17(2),107-126. glossary of terms annual national assessments (anas) annual national assessment (ana) in literacy and numeracy is performed for grades 3, 6 and 9 to continually measure the performance of individual learners and that of classes, schools, districts, provinces and the country as a whole. it provides information on individual learner performance, but also informs the department how the sector as a whole is functioning. going forward, ana results will enable the department of education to measure the impact of specific programmes and interventions to improve literacy and numeracy (motshekga, 2011). basic education ‘basic education’ includes both primary and secondary education and is guaranteed to everyone without any discrimination or exclusion based notably on gender, ethnicity, nationality or origin, social, economic or physical condition, language, religion, political or other opinion, or belonging to a minority. beyond preschool education, the duration of which can be fixed by the state, basic education consists of at least 9 years and progressively extends to 12 years (unesco, 2007). community service in south africa community service differs from that in other countries, where it is related to volunteerism. in an effort to redress previous inequalities in the south african health system, the department of health launched the national human resource plan in 2006. newly qualified graduates (e.g. medical and allied health professions) are employed by the government for a period of 1 year to provide professional services to communities (ranging from urban to rural) where a need exists to make up for the shortfall in such skills (department of health, 2006). curriculum and assessment policy (caps) the national curriculum and assessment policy statement is a single, comprehensive, and concise policy document, which will replace the current subject and learning area statements, learning programme guidelines and subject assessment guidelines for all the subjects listed in the national curriculum statement grades r 12. it is important to note that the development of national curriculum and assessment statements must not be seen as a new curriculum but only as a refined and repackaged national curriculum statement grades r 12 (department of education, 2008). district level each provincial department of education is known as the ‘provincial level’ of management. each provincial level has several ‘district offices’ known as the ‘district level’ of governance. each school district is a geographical unit as determined by the relevant provincial legislation, or prevailing provincial practice, and manages a number of schools within a specific geographical district. district-based support teams are a group of professionals whose responsibility it is to promote inclusive education through training, curriculum delivery, distribution of resources, identifying and addressing barriers to learning, leadership and general management (department of education, 1996a, 1996b). early childhood development (ecd) early childhood development (ecd) covers the education of a child from the period from birth to 9 years of age which is a critical time of change in his/her social, physical, cognitive, and emotional development (department of education, 2001a). in the south african context ecd refers to the policies and an approach where parents and caregivers participate actively in their child’s programme (family-centred approach) (republic of south africa, 2005). ex-model c school model c schools existed in the period just prior to democracy in south africa. this categorisation no longer exists and the schools are therefore referred to as former/ex-model c schools. these former model c schools were permitted to top up their funding with fees payable by the parents of the schools. thus, former model c schools varied in relation to their fees, budgets, teacher-to-student ratios, and quality of facilities (department of education, 1996a). foundation phase the foundation phase includes grades r, 1, 2, and 3. it provides the learning that forms the grounding or basis for literacy, numeracy and life skills (department of education, 2002). full-service school full-service schools are ordinary schools which are specially equipped to address a full range of barriers to learning in an inclusive education setting (department of education, 2008). further education and training (fet) refers to levels of education which are above ‘general education’ but below ‘higher education’. fet consists of grades 10 – 12, which are offered in high schools (department of basic education) or fet colleges (previous technical colleges) (republic of south africa, 1998). general education ‘general education’ refers to the compulsory school attendance phase as referred to in section 3 of the south african schools act (republic of south africa, 1998). independent school private or independent schools receive no funding from the government and are funded entirely by fees paid by the parents. the general perception is that the teacher: student ratio is lower than in government schools and that the standard of education is high (department of education, 1996b). intermediate grades the intermediate grades of primary education comprise grades 4 6 (department of education, 2002). language in education policy (liep) the language in education policy (liep) in south africa provides for schools (depending on their needs) to adopt either one language as a medium for learning (home language) or use two languages: a home language in the early grades and a second one later as language of learning. according to the liep, whichever route is followed, the underlying principle is to maintain home language(s) while providing access to and the effective acquisition of additional language(s) (department of education, 1997). language of learning and teaching (lolt) the revised national curriculum statement (rncs) stipulates that the learner's home language should be used for learning and teaching wherever possible. this is particularly important in the foundation phase where children learn to read and write. the lolt is the language of the majority of learners in the school/class, which is used for teaching in the classroom (department of education, 2002). ordinary schools an ordinary school is a school that is not a special school (department of basic education, 2011a). pan south african language board (pansalb) pansalb was established in 1995 to promote multilingualism in south africa by fostering the development of all 11 official languages, while encouraging the use of the many other languages spoken in the country (pansalb, 2011). provincial departments of education the provincial departments of education reside in each province of south africa, under the national department of education. glossary of terms public school public schools are under the jurisdiction of the government and learners are subsidised by the provincial legislature. at public schools, parents vote on the level of school fees. poor parents are given exemption or reductions. a public school may be either an ordinary public school or a public school for learners with special education needs. the latter should receive relevant educational support services for these learners (department of education, 1996b). public schools are governed by elected school governing bodies, which have a significant say in the running of their schools. revised national curriculum statement the rncs stipulates the specific outcomes and the assessment standards to be achieved for a specific grade. it provides the framework for what learners should know in order to become ‘… citizens that are multi-skilled, knowledgeable, sensitive to environmental issues and able to respond to the many challenges that confront south africa in the 21st century’ (department of education, 2002). school psychological services the school psychological services were multidisciplinary units consisting of psychologists, remedial educationists, speech therapists/audiologists, and career counsellors. they provided services (assessment, management and intervention programmes) to learners who experienced barriers to learning, and in career counselling. under the previous dispensation such services were available only to children in former white schools (mashau, steyn, van der walt & wolhuter, 2008). senior phase the senior phase of education comprises grades 7 9 with the child promoted to high/secondary school at the beginning of grade 8 (department of education, 2002). south african department of education: basic education and higher education the former department of education was the south african government department responsible for education and training until 2009. since then it has been split into the department of basic education (schools) and the department of higher education and training (universities, technikons). special education special education in south africa consists of special schools that offer segregated education for learners with specific education needs. a special school is one that is resourced to deliver education to learners requiring high-intensity support (department of basic education, 2011a). special education needs are based on specific disabilities: e.g. physical/mobility impairments, blindness, deafness, autism spectrum disorders, epilepsy, learning disability and cognitive impairments. 1 it is acknowledged that reference in terms of 'black education' and 'white education' is highly contested in the current context. these terms are used to explain the racial divide that was created by the apartheid system. table i. percentage of learners by language of learning and teaching across grades in 2007 lolt gr 1 gr 2 gr 3 gr 4 gr 5 gr 6 gr 7 gr 8 gr 9 gr 10 gr 11 gr 12 sa afrikaans 9.5 9.6 9.9 12.3 12.2 12.2 13.2 13.1 14.0 12.7 12.1 12.8 11.9 english 21.8 23.8 27.7 79.1 81.1 81.6 80.6 80.9 80.0 81.2 82.0 81.4 65.3 isindebele 0.7 0.8 0.8 0.3 0.3 0.3 0.3 0.1 0.1 0.1 0.1 0.1 0.4 isixhosa 16.5 15.0 14.0 3.1 2.5 2.0 1.9 1.6 1.4 1.3 1.2 1.5 5.5 isizulu 23.4 21.7 20.1 1.5 1.0 1.0 1.0 1.1 1.1 1.1 1.1 1.1 6.8 sepedi 8.3 9.1 9.2 1.1 0.9 0.9 0.9 0.9 0.9 1.0 1.0 1.0 3.1 sesotho 4.7 4.8 4.4 0.5 0.4 0.3 0.4 0.4 0.5 0.5 0.4 0.3 1.6 setswana 7.5 7.4 6.8 0.6 0.5 0.5 0.6 0.6 0.7 0.6 0.5 0.3 2.4 siswati 2.1 2.1 1.7 0.4 0.3 0.3 0.3 0.1 0.1 0.1 0.1 0.1 0.7 tshivenda 2.2 2.4 2.4 0.3 0.2 0.2 0.2 0.4 0.5 0.5 0.6 0.5 0.9 xitsonga 3.1 3.3 3.1 0.7 0.6 0.6 0.6 0.7 0.7 0.8 0.8 0.8 1.4 total 100 100 100 100 100 100 100 100 100 100 100 100 100 source: department of basic education (2010). lolt = language of teaching and learning. fig. 1. the ongoing contribution of language to academic learning (from deshler & ehren, 2008, used with permission). functional dysacusis: the utilization of eeg activity in the determination of hearing threshold level, a case report i. h a y , b.sc. (ing.) (stell.), m.a. (washington u.) head, department of speech science, logopedics and audiology, university of pretoria, pretoria summary a case of functional dysacusis was subjected t o routine as well as electric response testing. test results were unreliable and electrical cortical responses to stimuli delivered t o the right ear were so poor that the results c o u l d n o t be utilized. a marked difference b e t w e e n t h e raw eeg tracings was observed w h e n stimuli were s w i t c h e d b e t w e e n left t o right ears. this fact was eventually used t o determine the hearing threshold level of t h e right ear. opsomming 'n geval van funksionele disakusie is onderwerp aan roetine en elektriese respons-toetse. die toetsresultate was onbetroubaar en elektriese kortikale response o p stimuli aan die regteroor gelewer, was so swak dat die resultate nie gebruik kon w o r d nie. 'n duidelike verskil tussen onverwerkte eeg-opnames is waargeneem b y die skakeling van stimuli na die linkeren regterore. hierdie feit is uiteindelik gebruik o m die gehoorpeil van die regteroor te bepaal. the designing of objective methods for testing the hearing ability of individuals who are unable to respond and those that are unwilling to respond to auditory stimuli, have occupied the minds of many clinicians for many years. the results can be seen in any audiology clinic in the form of test methods as well as test equipment. these methods and the equipment are in almost daily use all over the world. few, however, can be regarded as successful in providing the clinician with an accurate indication of the true threshold level since most methods are designed to differentiate between.an elevated hearing level and a level that is closer to the real threshold hearing level. this short paper reports the testing of a case of functional dysacusis who persistently reported that he perceived no sounds when acoustic stimuli were presented to the right ear even at levels of 1 lodb i.s.o. case history: a normal, healthy male aged 20 years. no history of ear infection, exposure to excessive noise or deafness in the family. hearing acuity in both ears deteriorated suddenly towards the end of 1972 with no known cause. he was journal of the south african speech and hearing association, vol. 20 december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) functional dysacusis 77 happy in his work at the military dog school and there seemed no reason why he could be regarded as a malingerer. a udiological assessment: in response to requests by the military hospital, audiological tests were performed by the hearing clinic, of the department of speech pathology and audiology of the university of pretoria. the following test results were obtained: pure tone audiometry: left: inconsistent htl of approximately 50 60db i.s.o. right: no response (even at 1 lodb i.s.o.) bekesy audiometry: left: type v right: no response. intra-aural reflex threshold: left: 95db i.s.o. (technically good) right: 105db i.s.o. (technically poor since a severe beat persisted on the balance meter) speech audiometry: left: srt 35db i.s.o. right: no response. evoked response audiometry: since the subject reported that no sounds were perceived in the right ear (not even a shadow curve was obtained!) it was decided to refrain from performing further subjective tests. also the results of the intra-aural reflex threshold test gave an indication of a functional problem. as a last resort it was decided to perform an era test using the par equipment available at the clinic, in a quiet room but not sound proofed. electrode placement: vertex, right mastoid and forehead. beckman wafer electrodes were used. equipment settings: sensitivity: 50yv/div. pulse duration: 200 ms. pulse interval: 1 sec. responses summated: 60 filter passband: 1-15 hz. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 78 i. hay testing the left ear. positive cortical responses (n90, p160) were identified when 250,1000 and 3000 hz tones of 40db hl were presented to the left ear. the raw eeg trace (see fig. 1) gave a steady, relatively low voltage recording. figure 1. summated evoked response and raw eeg tracings indicating the difference in the eeg tracings when auditory stimuli are perceived in the right and left ears. sensitivity: 50yv/division. threshold estimation: odb hl i.s.o. testing the right ear: with the first presentation of high level tones to the right ear (from which no responses could be elicited up to this stage) it was noticed that the raw eeg trace changed drastically to a very high voltage trace. the background eeg was so unfavourable that no evoked response could be identified (see fig'. 1). using the changing eeg tracings for threshold measurement: when it became evident that the era method could not be used to determine the threshold of the right ear, it was decided to use the changing eeg by switching between left and right ears at different levels. the results can be seen on figs. 2, 3 and 4. in order to retain the same presentation method previously employed, responses were summated although the results could not be utilized. only the changes in eeg were noted. journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) figures 2, 3 and 4. summated evoked responses and raw eeg tracings showing the effect that switching from left to right ear has on the eeg tracings. sensitivity 50yv/division. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 80 i. hay to make absolutely sure that the eeg changes were not caused by the red earphone touching the electrode on the right mastoid, the phones were reversed. the reversal made no difference. also, to make sure that the change in the eeg was related to actually hearing the stimuli, tests were performed at odb hl in which case presentation of stimuli to left and right ears alternatively, made no difference to the eeg (see fig. 2). results: since the change in the eeg when presenting tones to the left and right ears alternatively, could be observed at lodb hl i.s.o. at 1000 and 3000 hz in a room that was not sound proofed, it was concluded that the patient had normal hearing in the right ear. the markings l and r on the figures indicate the moments of switching to the left and right ears respectively. at low levels (fig. 2) a delay was observed between the moment of switching to the right ear and the moment of eeg change. this was probably caused by an amount of uncertainty (at low levels) as to whether a sound was perceived or not. discussion: the case reported here might be an isolated one in that not all cases of functional dysacusis present this clear difference between eeg tracings when acoustic stimuli are switched between the left and right ears. it might be speculated that the increased eeg activity has an emotional basis which is understandable in the case of a malingerer who becomes aware of the fact that sounds are perceived in the ear which has the elevated threshold. subsequent tests performed two weeks later using only the changing eeg confirmed the results given above. at this time, however, the changes were identified at 15-20db hl i.s.o. the patient reported that the hearing to his right ear seemed to return to normal. it might be advantageous to subject all malingerers and individuals with functional overlays to the eeg method of testing, to determine whether this phenomenon can be observed more often. journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 23 communicative competence in a group of visually impaired children michelle simpson, ba (speech and hearing therapy) (witwatersrand) glenda shapiro, ba (log) (witwatersrand) department of speech pathology and audiology, university of the witwatersrand, johannesburg abstract aspects ofverbal and non-verbal communicative competence offive visually-impaired six and seven year old children were investigated. the profile of communicative appropriateness (penn, 1983) was used to assess communicative competence in one discourse interaction with a known interlocutor (mother). the results indicated that the subjects were predominantly appropriate in terms ofverbal communication, and predominantly inappropriate in terms ofnon-verbal communication. severity ofvisual impairment influenced performance in terms of nonverbal communication. research and therapeutic implications are discussed. opsomming aspekte van die verbale en nie-verbale "kommunikasievermoens van vyf visueelgestremde kinders tussen die ouderdomme ses en sewejaar is ondersoek. die "profile of communicative appropriateness "(penn, 1983) is gebruik om kommunikasievermoens in een interaksiesituasie met 'n bekende persoon (die moeder) te evalueer. die proefpersone se verbale kommunikasie is as hoofiaaklik toepaslik beoordeel terwyl nieverbale kommunikasie as hoofiaaklik nie toepaslik beoordeel is nie. diegraad van gesigsgestremdheid het nie-verbale kommunikasie betnvloed. implikasies vir navorsing en behandeling word bespreek. at birth, humans are the most helpless of living creatures, whereas, as adults, they are social and communicative individuals at high levels of creativity. this transformation occurs through acquisition, learning and development, which evolves as a result of continuous interaction between the environment and the individual (affolter & sticker, 1980). full sensory integrity is essential for establishing fundamental cognitive and emotional stability (affolter & strieker, 1980; wills 1965). early sensory deficits interfere with perceptual infor/ mation processing, and a child lacking a major sense such as vision understands and structures his world differently to a child with vision. j fraiberg (1977) describes the blind child's world as one in which objects, persons and things emerge from a void as transient tactile auditory experiences, and disappear to become meanihgless experiences.'it is a conceptual problem for the blind infant, who must infer the identity and substantiality of an object. as language development is closely linked to stages of cognitive development, and vision plays an important role in theories of cognitive development, the significance of visual impairment in relation to language acquisition needs to be examined. vision is the "synthesizer" of sense experience, and a visual deficit therefore imposes significant cognitive constraints on the visually-impaired baby, particularly during the sensori-motor period (fraiberg, 1977). ' mcgurk (1983) reviewed some of the more recent literature on the language acquisition of visually-impaired children, and felt that visual impairment, rather than having specific determinate effects, seems to have general moderating, or modulating influences upon the development of communicative competence. fraiberg (1977), although noting that without vision the child faces an arduous task in acquiring language, concludes that ultimately the blind child has equivalent language to the sighted child. other researchers (anderson et al. 1984; mcginnis, 1981), show that visually-impaired children's use of action words is self-directed, rather than directed to external objects, and suggest that blind children's language reflects the experience-specific conceptualisations of objects that they are able to obtain via non-visual senses. overall, it seems that the word meaning and usage of visually-impaired children may reflect specific, experiential deficits. interactive experience and exchange of messages in all communicative modalities are at the basis of language development (bullowa, 1979; bloom, 1973), and communicative behaviours develop in early infancy arising from the matrix of adult-infant interaction (rogow, 1982). the sighted child literature predicts significant constraints on the visually-impaired child's learning to communicate. bateson (1975) called the first mother-infant interchanges "protoconversations", i.e., constant or nearly constant communication in one modality (visual) and intermittent alternating communication in another, and emphasizes the importance of preverbal conversational skills in relation to later communicative development. bullowa (1979) states that she has observed mother-infant pairs engaging in face-to-face conversations from as early as a few hours old. overall, therefore, the path to communicative competency begins in early infancy, where babies first converse with their eyes, then their bodies (mainly hands), and finally add spoken language (bullowa, 1979). rowland (1983) examined the pragmatic perspective of preverbal blind infant development and found that many schemes associated with competent language development (e.g., symbolic play) were absent. a delay in symbolic play may be die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 attributed to the "self/other" confusion typical of visuallyimpaired children (fraiberg & adelson, 1976). giving and showing, which normally form the basis of the early games and turn-taking rituals that bruner (1983) considers precursors to the joint regulation of verbal exchanges, were virtually absent. pointing, an especially good predictor of language development (bates et al. 1977), and reaching-as-a-request, both of which are visually-guided behaviours, were also absent. the absence of these, visually-mediated deictic behaviours from tjie blind child's repertoire, severely constrains the opportunities for contingent interaction over shared referents, and to. that extent the child's competence-enhancing experiences are restricted (mulford, 1983). various researchers (urwin, 1978; anderson et al. 1984; mcginnis, 1981), have examined the nature of the interactive language patterns between a blind child and an adult speaker, and have discovered usage problems in relation to the effectiveness of the children's contributions to the conversations. these include sudden topic shifts and minimal use of communicative gesture. controversy exists regarding blind children's use of expressive bodily action (apple, 1972; brieland, 1950). many studies in the language acquisition of visuallyimpaired children may be criticised methodologically. anderson et al. (1984) attempted to overcome some of the methodological shortcomings of previous studies, and found that at a purely structural level, the language of blind children resembles that of their sighted peers, whereas, when examined in its discourse context, there are consistent discrepancies. this, together with the fact that mcginnis (1981) feels that more research is needed on the communication of blind children, particularly in the area of gestural communication, compelled the writer to examine more specifically the communicative competence of a group of visually-impaired children. communicative competence is: "... the mastery of an underlying set of appropriateness rules which are determined by culture and situation that affect the verbal and non-verbal choices in communication events." (wood, 1981, p. 238.) furthermore, since mcginnis (1981), states that the inclusion of both blind and partially-sighted subjects in a study would assist a fuller understanding of whether partial vision results in the development and use of communicative gestures, both blind and partially-sighted subjects were included in this study, which examined the communicative competence of five visually-impaired six and seven year old children in one discourse interaction each with their mothers. methodology the study aimed to examine the communicative competence of five visually-impaired six to seven year old children, with the ultimate purpose of examining trends regarding the relationship between visual impairment"' early preverbal development, and the cumulative implications for later communcative competence. subject selection five subjects were used in a descriptive research design. all children had a visual impairment which precluded normal educational mainstreaming, and attended prinshof school for the partially sighted as day scholars. the subjects were engmichelle simpson and glenda shapiro lish-speaking with a normal iq, and a preverbal onset of visual impairment. two subjects were bilaterally blind, and three subjects were visually-impaired. description of the subjects subjects were chosen according to the above-mentioned criteria. -relevant biographical and clinical data are provided in table 1. table 1: description of the five subjects ( 1 5 ) age sex aetiology age of onset degree of 1 impairment 1 6 μ hereditary absent corneas bilaterally congenital bilateral blindness (minimal light perception) 2 : ' 6 f ' bilateral cataracts congenital unilateral· blindness (left) adequate vision in right* 3 % μ •birth*· anoxia congenital unilateral blindness (right). 30% vision in left* 4 6 f unknown congenital bilateral blindness minimal light perception 5 t f albinism (with nystagmus) congenital 30% vision bilaterally procedure test environment only one discourse interaction (subject 1) was conducted in the one-way observation room at the university speech and hearing clinic. the other four discourse interactions-.were conducted in the.subjects' homes using a portable video camera. according to umiker-sebqpk (1979), conversations in more intimate surroundings, such as the child's own home, where he is more familiar and at ease, are significatitiy more developed, ι i interaction time a time-based sampling of free conversational interaction ; (crystal, garmen &.fletcher, 1976) was employed. as perin (1983) recommends, the interaction lasted for 15 minutes'. i method ' ι a free-play interactive situation was utilised in the testing procedure. prior to initiating recording, all participants were provided with the same instructions. the mothers were instructed to interact in a natural manner with their children, and the children were told that they were allowed to play freely in the room. / y recording of the data video and audio recordings were made of the conversational interactions, to allow for a detailed verbal and non-verbal analysis of the data obtained. according to muma (1978), videotaping is the best recording method, as it not only allows the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communicative competence i n a group of visually impaired children 25 a way of rechecking what was said, but it also provides a way of noting reference and communicative intent. additionally, one of the scales of the pca required analysis of non-verbal behaviour, and therefore, necessitated video-recording. analysis firmation that the data reflect a true change in subject behaviour rather than variability in observer recording (mcreynolds & kearns, 1983). the formula advocated by them w a s employed to analyse inter-rater reliability. results and discussion materials profile of communicative appropriateness the conversational sample was analysed according to the profile of communicative appropriateness, (pca; penn, 1983). the pca was selected as it evaluates the appropriateness of language usage along various parameters which were relevant for the study. furthermore, the pca includes a verbal and a non-verbal analysis, and the importance of assessing both verbal and non-verbal behaviours in visually-impaired children has been stressed (mcginnis, 1981; apple, 1972). transcription the data was transcribed using traditional english orthography. the unit of analysis employed was one-minute "chunks" of data known as the conversational unit (penn, 1983). ten minutes of each interaction served as the basis for analysis. two judges, both experienced in language pathology, were employed. conversational partner according to penn (1983) the degree of familiarity with the interlocutor determines, to some extent, both the style and topic of a subject's output. fielding and fraser (1978) define familiarity behaviourally, in terms of the extent of previous, interaction, and cognitively, in terms of the participants' knowledge of each other, and state that it is an important aspect of the speaker-listener relationship. therefore, the writer acknowledges the limitations of the use of only one familiar conversational partner, i.e., the child's mother. method of analysis the judges were given a blank pca sheet which was completed for each interaction, a written instruction sheet and a 'table exemplifying and defining each component of the profile. judges were additionally provided with a typed transcription of the interaction (as described above). this is in accordance with penn (1983). the judges were required to indicate the position on a five point rating scale which they felt best described the appropriateness of the communicative behaviour of each subject on the dimension under consideration during each c.u. of one minute. the five-point rating scale delineated on the pca was employed: mostly inappropriate; mostly appropriate and appropriate. inappropriate; some appropriate; penn (1983) also includes a category for 'could not evaluate' which she requests her judges to use as little as possible. included in the pca analysis were the dimensions of response to interlocutor; control of semantic content; cohesion; fluency; sociolinguistic sensitivity and non-verbal communication. the specific quantitative data obtained for each subject were tabulated on the pca. inter-rater reliability measures of inter-rater reliability provide independent coninter-rater reliability of discourse interaction inter-rater reliability was calculated by employing the formula provided by mcreynolds and kearns (1983). for the conversation involving subject 1 inter-rater reliability fell between 88% and 100% on all scales of the pca, for subject 2 86% to 100%, for subject 3 88% to 98%, for subject 4 86% to 100%, and for subject 5 85% to 95%. according to the criteria provided by kazdin (1977; cited by mcreynolds & kearns, 1983), these findings may be considered as acceptable levels of inter-rater agreement. this degree of interrater reliability implies that the observations were reliable, as well as accurate (dollagham & miller, 1986). results of the pca appropriate mostly appropriate some appropriate mostly inappropriate inappropriate β d f i f j scales of the pca (penn, 1983) figure 1: performance of the five subjects on all scales of the pca scales of the pca : key a = response to interlocutor β = control of semantic content c = cohesion d — fluency ε = sociolinguistic sensitivity fi = non-verbal communication: vocal aspects fj = non-verbal communication: non-verbal aspects subjects: key 51 52 = x 53 = δ 54 = α 55 = all subjects scale a. response to interlocutor as can be seen in figure 1, all five subjects attained predominantly appropriate ratings for their responses to the interlocutor. some minor inappropriate responses were observed in subject 4, but were felt to be a function of the child's age rather than the visual impairment specifically. scale b. control of semantic content all of the subjects were rated as appropriate on all of the six die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 behaviours reflecting control of semantic content. however, two subjects (4 and 5) showed some difficulty with topic initiation and adopted passive positions in the discourse interaction. these results were felt to possibly be an artifact of the testing situation wherein the mothers used the question form of interaction, thereby reducing the opportunity for spontaneous interaction. scale c. grammatical discourse features all subjects were rated as predominantly appropriate in terms of grammatical cohesion. scale d. fluency all subjects were judged to be highly appropriate in terms of fluency control. scale e. sociolinguistic sensitivity all subjects were rated as being appropriately sensitive to the demands of the communicative situations. scale f. non-verbal communication this parameter of the pca is divided into vocal aspects (intensity, pitch, rate, intonation and quality) and non-verbal aspects (facial expression, head movement, body posture, breathing, social distance and pantomime). as can be seen in figure 1, all the subjects exhibited predominantly appropriate vocal aspects but were judged to be inappropriate as regards head movement, facial expression and gesture. subjects 2 , 3 and 4 made more use of gesture and facial expression but even then it was felt that more utilisation of these components of non-verbal behaviour would have improved communication. the two subjects who were severely visually-impaired (1 and 4) exhibited inappropriate non-verbal behaviour, as seen in recurrent head movements, repetitive inutile hand movements, no head-turning to localise interlocutors' verbal input / and reduced facial expression. t,he least visually impaired subjects (2 and 3) exhibited mainly reduced facial expression whilst they were able to employ the previously mentioned non-verbal behaviours. the remaining subject (5) who was moderately visually impaired, exhibited predominantly inapproriate facial expression, head movement and gesture. as seen in table 2, the subjects' abilities to respond to the interlocutor were seen to be predominantly appropriate. this summary of t h e results . tahle 2: percentage of appropriateness obtained by all subjects on all scales of the pca pca scales !. subjects pca scales 1, 2 3 4 5 , response to interlocutor 90 90 100 80 100 control of semantic content 90 80 80 80 80 cohesion 90 100 100 80 100 fluency 100 100 100 100 100 socio-linguistic sensitivity 90 100 100 100 100 non-verbal communication 30 40 40 30 40 michelle simpson and glenda shapiro is in accordance with evidence provided by mulford (1983), who concludes that the communicative competence of visuallyimpaired children, with a familiar interlocutor (e.g., mother), is adequate, as the familiar listener is able to assess the child's focus of attention. some inappropriate turn-taking skills were seen, but their occurrence was minimal. a further interesting finding of this study was that the mothers of visually-impaired children tended to ask questions requiring a direct answer, or that the children carry out a request. anderson et al. (1984) also noted this. the mothers in this study also provided fewer descriptions of the surrounding environment, rather providing labels for immediate objects or actions. topics tended to be centred on the child, rather than the environment. overall, it is important to note that the severe constraints predicted for visually-impaired children in terms of the early precursor'' development of turn-taking skills (urwin, 1983), were not observed, i.e., the few inappropriate turn-taking skills observed did not interfere significantly with the communicative competence of the children. in terms of control of semantic content, it was seen that most subjects displayed much reliance on the interlocutor for context, particularly topic initiation. subjects were able to maintain the flow of conversation, and to convey adequate information and vocabulary. this conflicts with the findings reported by anderson et al. (1984), wherein they reported many instances in which the child strayed form the general conversation, and made unrelated topic shifts. some inappropriate topic shifts were observed in subject 2, but it was felt by both judges to be related to the child's age, rather than a function of poor semantic cohesive abilities. all the subjects were judged to have predominantly appropriate grammatical cohesion features. two subjects (1 and 4) were noted to have instances of incorrect pronoun usage wherein they replaced "i" (when referring to themselves), with "you". incorrect pronoun usage has been discussed extensively by various researchers (fraiberg & adelson, 1976; mcginnis, 1981), who noted that blind children make significantly more personal reference errors than their sighted peers. this has been linked to poor development of body image and selfconcept (fraiberg, 1977; burlingham, 1965). it is interesting that the incorrect pronoun usage observed in this study occurred in the blind as opposed to the partially sighted subjects (see table 2), indicating that the more severe the visual impairment, the more likely the specific experiential deficits will have cumulative implications for later language development. mulford (1983) found that the use of situational deictic terms by these children was worse than that of their sighted peers, indicating that blind children are unable to take the relative viewpoint of the listener. in this study, however,; it was noted that the visually-impaired children were able to functionally utilise all deictic terminology correctly. as can be seen in table 2, all subjects were judged to have appropriate fluency control, which suggests that apart from the occurrence of normal non-fluencies, tbe visually-impaired child does not seem to exhibit non-fluencies which interfere with the coherence or sequence of the intended message. all subjects were judged to be predominantly appropriate in those behaviours which reflected a sensitivity to the demands of the communicative situation. as has already been mentioned, some instances of lack of sensitivity to the interlocutor were noted, and although this is in accordance with the literature (mcginnis, 1981), it is felt to be not particularly significant, having only occurred minimally. / the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communicative competence in a group of visually impaired children 27 the most significant findings were in the area of non-verbal behaviour. this can most clearly be seen in table 2 and figure 1. in terms of the vocal aspects, all of the subjects demonstrated approriate pitch and intonation, with some instances of inappropriate intensity being reported. this was observed in both the blind and visually-impaired subjects and may be linked to the conversational reticence noted. various non-verbal behaviours deemed to be inapproriate were observed in all of the subjects. controversy exists regarding the presence or absence of facial expression in visually-impaired subjects (brieland, 1950; apple, 1972). in this study facial expression was judged to be minimal,and not consistent with the verbal message in subjects 1, 4 and 3. this seems to be predicted in much of the literature on the preverbal development of the blind and visually-impaired child (fraiberg, 1977; urwin, 1983). four of the five subjects showed inappropriate head movements. the severity was increased in the two blind subjects as opposed to the two visually-impaired subjects. this seems to indicate that the more severe the visual impairment, the worse the degree of aberrant head movement is. inappropriate gesture (inutile hand waving), was also noted in subject 1, although in none of the other subjects. it was felt by the raters that the gestural systems of the other four subjects, although not inappropriate, were reduced and inexpressive. this supports the findings of mcginnis (1981), who found that blind subjects used minimal expressive hand gestures to accompany their speech, relying on sometimes ambiguous verbal communication. a further finding, also described by mcginnis (1981), was that the subjects did not use head-nodding as a substitute for words. it appears, therefore, that visually-impaired children exhibit predominantly appropriate communicative competence in terms of some of the parameters, measured by the pca (penn, 1983). however, various inappropriate behaviours are observed in terms of non-verbal behaviours, specifically facial expression gesture and head movement. conclusion the results of this study revealed that the visually-impaired subjects were on average, appropriate in terms of verbal communicative competence, and on average, inappropriate in terms of non-verbal communicative competence. non-verbal skills which appeared to be predominantly inappropriate were head movement, facial expression and gesture. the inappropriateness of the non-verbal skills tended to increase with the severity of the visual impairment, i.e., the blind subjects demonstrated aberrant head movement, whereas the partially sighted subjects showed ineffective communicative head movement. gesture was found to be minimal, and in some cases aberrant. instances of incorrect pronoun usage were noted in the blind subjects, and not seen in the partially sighted subjects. the small size of the sample, and the lack of randomness in the selection of subjects, necessitates caution in generalising the results. a further limitation of the study was the use of a single familiar interlocutor, and this may have implications for future research, as mulford (1983) states that the introduction of an unfamiliar interlocutor will provide further information pertaining to how referentially successful blind speakers are,and whether or not an "unskilled" interpreter would be able to establish the visually-impaired individual's foci of attention. however, it is felt that the significant findings in terms of nonverbal communicative skills have important implications. firstly, it increases the understanding of the specifically visual processes which contribute to the development of communicative skills (bruner, 1983; bates et al. 1977). secondly, it provides practical and clinical guidelines for the development of necessary intervention procedures directed toward maximising the early communicative environment of the blind and visually-impaired child. according to prutting: "the communicative system is the individual's most powerful tool for getting along in this world." (1984), and it is on the basis of this that the authors believe that communication therapy with young blind, and visuallyimpaired children, will facilitate the blind child in building a model of their world (urwin, 1983). references affolter, f. and strieker, e. (ed). perceptual processes as prerequisites for complex human behaviour: a theoretical model and its application to therapy. vienna: hans huber, 1980. anderson, dunlea and kekelin. blind children's language: resolving some differences. journal of child language. 11, 645-666, 1984. apple, m.m. kinesic training for blind persons: a vital means of communication. new outlook for the blind. 66, 201-208. 1972. bates, e; benigni, l; bretherton, 1; camaioni, l; volterra, v. from gesture to the first word: on cognitive and social prerequisites. in lewis, m. and rosenblum, l (eds.) interaction, conversation and the development of language. canada: john wiley and sons inc, 1977. bateson, m.c. mother-infant exchanges: the epi-genesis of conversational interaction. in aaronson and rieber (eds.) developmental psycholoinguistics and communication disorders. new york: new york academy of sciences, 1975. bloom, l. one word at a time: the use of single-word utterances before syntax. the hague: mouton, 1973. brieland, m.d. acomparative study of the speech of blind and sighted children. speech monographs. 17, 99-103, 1950. bruner, j. the acquisition of pragmatic commitments. in golinkoff, r. (ed.) the transition from prelinguistic to linguistic communication. new jersey: lawrence erlbaum associates inc. new jersey, 1983. bullowa, m. infants as conversational partners. in myers (ed.) development of conversation and discourse. edinburgh: edinburgh university press, 1979. burlingham, d. some problems of ego development in blind children. psychoanalytic study of the child. 20, 194-208, 1965. crystal, d; garmen, m. and fletcher, p. the grammatical analysis of language disability. london: edward arnold, 1976. dollagham, c. and miller, j. observational methods in the study of communicative competence. in schiefelbusch, r.l. (ed.) language competence: assessment and intervention, college-hill, 1986. fielding, c. and fraser, c. language and interpersonal relations. in, markova, j. (ed.): the social context of language. toronto: john wiley and sons, 1978. fraiberg, s. insights from the blind. norwich: fletcher and son ltd, 1977. fraiberg, s. and adelson, e. self representation in young blind children. american foundation for the blind. 1976. mcginnis, a.r. functional linguistic strategies of young blind children. journal ofvisual impairment and blindness. 210-214,1981. mcgurk, h. effectance motivation and the development of communicative competence in blind and sighted children. in mills (ed.) language acquisition in the blind child: normal and deficient. san diego: college-hill press, 1983. mcreynolds and kearns. single-subject experimental designs in communicative disorders. baltimore: university park press, 1983. mulford, r. referential development in blind children. in mills (ed.) language acquisition in the blind child: normal and deficient. san diego: college-hill press, 1983. muma, j.r. language handbook: concepts, assessment and intervention. prentice-hall inc, englewood cliffs, 1978. penn, m.a.c. syntactic and pragmatic aspects of aphasic language. unpublished doctoral thesis, university of the witwatersrand, johannesburg, 1983. die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 michelle simpson and glenda shapiro prutting, c.a. the pragmatics of language. the south african journal of communication disorders. 31, 3-5, 1984. rowland, c. patterns of interaction between three blind infants and their mothers. in mills (ed.) language acquisition in the blind child: normal and deficient. san diego: college-hill press, 1983. rogow, s. rhythms and rhymes: developing communication in very young blind and multi-handicapped children. child care, health and development. 8, 249-260, 1982. umiker-sebeok, d. pre-school children's intraconversational narratives. journal of child language, 1979. urwin, c. early language development in blind children. br. psychol. soc. occasional papers, 1978. urwin, c. dialogue and cognitive functioning in the language development of three blind children. in mills (ed.) language acquisition in the blind child: normal and deficient. san diego: college-hill press, 1983. wills, d. some observations on blind nursery-school children's understanding of their world. psychoanalytic study of the child. 20, 344-364, 1965. wood, b.s. children and communication. englewood-cliffs: prenticehall, 1981. 4 < > r n e ' talking to professionals the needler westdene organisation beg. no.ck87/02503/23 223 d.f. malan drive northcliff 2196 p.o. box 2739 northcliff 2195 ®(011) 888-1009/1087 fax: (011) 888-1186 telex: 4-2e068 the south african journal of communication disorders, vol. 36, 1989 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) semantic acquisition in language impaired and normal speaking four year old children marlene green b.a. (sp. & h. t h e r a p y ) ( w i t w a t e r s r a n d ) summar y for the purpose of assessing a semantic feature theory of semantic acquisition in language impaired and normal pre-schoolers, semantic feature manipulation tests were administered to two language-impaired and two matched normal speaking four-year olds. results support clark's hypothesis that lexical acquisition proceeds from over-extended quasi-superordinate terms with few semantic features to more differentiated subordinate terms with a greater number of features. language impaired and normal children did not seem to be differentiated on these results. opsomming die volgorde van die aanleer van semantiese eienskappe is by taalgestremde en normale voorskoolse kinders nagegaan. 'n toets vir die manipulering van semantiese eienskappe is op twee taalgestremde en twee afgepaarde normale 4 jaar oue kinders toegepas. die resultate bevestig clark se hipotese dat leksikale aanleer geskied vanaf 'n baie bree algemene term met 'n paar semantiese eienskappe na 'n fyner gedifferensieerde onderverdeling van terme met 'n groter aantal kenmerke. daar is nie 'n verskil gevind tussen normale kinders en kinders met taalprobleme nie. up to the present time research in linguistic development has concentrated mainly on syntactic growth, β · 1 0 · 1 6 · 1 7 little emphasis has been placed on the acquisition of semantics (which is the system of meaning underlying language in the deep structure) although this system is gaining recognition as an important part of native-speaker competence. 3 · 4 · 1 4 · 1 7 while semantic acquistion plays an essential role in language growth, it also seems important in cognitive structure and growth. as bierwisch3 postulates, semantic universal might indeed form the basis for human perceptual and cognitive development. in semantic theory it is generally accepted that the units of meaning are lexical items. these are verbal concepts and comprise combinations of semantic markers which represent features abstracted from reality. 3 · 1 0 · 1 4 for example, "dog" is a lexical item comprising the features <+ animate > < human > < + 4 legs> <+ canine > etc. having defined lexical items as verbal concepts, it is necessary to examine the notion of concepts. from the literature the following four main generalizations can be d r a w n : 5 . 7 . 8 . 9 . i i . i 2 , 1 9 . 2 0 . 2 3 , 2 6 tydskrif van die suid-afrikaans verniging vir spraak en ehoorheelkunde, vol22, deseber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 marlene green 1. concepts are the symbolic means whereby events which are discriminably different are rendered equivalent, due to their common incorporation of critical features, in order to form a class or category. the exemplars or members of the class formed in this way become differentiated from all other objects or events due to the presence (versus the absence) of the relevant critical features. therefore, "bananas", "meat" and "milk" which all contain the feature <+ edible> are classed together as exemplifying "food" in contrast to "paint" and "hat", which exclude this feature. 2. the extraction or isolation of features from a stimulus configuration, usually for the purposes of forming a concept, is termed abstraction. when abstracted features are used as the criteria of a category, generalization is said to occur. 3. the greater the number of criterial features, the more specific or concrete is the defined class. therefore, where there is a single criterial feature the defined class is broader and more abstract than any subordinate class (lexical item) with more features and hence greater definition. the class defined with a single criterial feature thus includes more exemplars. therefore, the concept "food", which has only the feature <+ edible>, is a broad superordinate concept. in contrast "fruit" also includes the features <+ tree-grown> < + natural> and lies subordinate to "food", although "fruit" in turn is broader than, and superordinate to "apple" which includes extra features ( <+ edible> <+ fruit> <+ apple tree> etc.) 4. concepts, because they focus on critical features, and ignore those which are irrelevant, are economic in terms of storage and retrieval in an efficient model of cognition. thus, in verbal concepts, the features which have been abstracted are termed semantic markers or features. it is the method whereby these are abstracted and generalized which concerns us in the study of semantic acquisition. until recently no satisfactory theory had been proposed on semantic acquisition. eve v. clark 1 0 , has however, attempted to integrate diarized observations and experimental evidence on word^meaning acquisition in young children into a conceptually feasible theory of semantic development. clark1 0 emphasizes that the number of extracted features determine the breadth of the defined category. she hypothesizes that verbal classes are first defined in early language acquisition by the presence of one semantic feature these pseudo superordinate classes are thus broad and poorly differentiated, and termed "overextended" by clark. 1 0 with the addition of differentiating , criterial semantic features during the development of the semantic system, the classes achieve greater definition and better symbolize reality. only when all differentiating features are incorporated into the meaning of the lexical entry, can further feature abstraction be achieved. at this later stage, when common features within a category can be abstracted, true superordinate concepts will develop. these true superordinates will have the fewest semantic features. thus the direction of semantic growth as hypothesized by clark,1 0 is vertical, from the overextended pseudo-superordinate (and often fictitious) class, downwards to the concrete, where the class is clearly defined by a great number of features abstracted from the environment. it is only when all the journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) semantic acquisition in four-yr. olds 5 features are present in the lexicon of the concrete items that it is possible for the child to abstract what features are common to the items, and he is able to construct the valid vertical semantic hierarchy with correct and highly abstract superordinates, and progressively more concrete subordinates, stract superordinates, and progressively more concrete subordinates. in this way, clark 1 0 has clarified the central controversy of semantic acquisition theory, namely the direction of growth in semantic development. ! · 1 6 . 2 6 in addition her theory allows understanding of difference between adult and child word-meaning. these differences are thus seen as qualitative. further her theory lies in close agreement with vygotsky, 2 6 as both emphasize that the strategy used for abstracting semantic features from the environment closely affects the meaning of the word thus evolved. in accounting for this, vygotsky 2 6 postulates three phases in the acquisition of word-meaning: 1. syncretism: heaps of objects with arbitrary and unstable relationships are categorized together, and the words labelling these reflect the nature of the categorization. 2. complexes: concrete abstractions are made from the environment, often reflecting functional similarities. the words used reflect the concrete nature of the abstractions, though referring to the same referents as the adult words. this allows communication between adult and child. this strategy occurs in adults too, to some degree. 3. conceptual thought occurs when the child is no longer bound by concrete interrelationships. word meanings symbolize only the abstracted features as in adult thought. therefore, early in semantic development, words represent classes formed according to synthetic or complexive strategies. at this stage, the labels of focal items can be projected onto items associated with them perceptually. for example, "bow-wow", though originally representative of "dog" and "toy-dog", becomes attached to "buttons", "cufflinks" and small long objects. the features abstracted from the original, i.e. oblong shape or shiny surface, have caused generalization of the original label (vygotsky p. 70). later in development abstraction strategies approximate those used by adults, and the resultant word meanings approximate those of adult thought. thus, as the strategy affects word-meaning, it seems important to determine what strategies of abstraction the child used for attaching meaning to words. another dimension of cognitive mechanisms in semantic growth is emphasized by bloom4. she feels that language learning is semantically based. her con-itention is that syntactic relationships and the existence of the form-classes (e.g. noun, verb, adjective) result form the child's observations that certain words and their referents constantly appear in fixed relationships. the abstraction of these fixed relationships, allows words of the same form-class to be used interchangeably. language acquisition is achieved by the child correlating his experiential observations of relationship between agent, action and object, with the adult verbal input symbolizing these relationships. for example "the boy pats the dog" and "the girl eats the cake" symbolize the same tydskrif van die su-afrikaae veriin vir spraak en gehoorheelkde, vol. 22, decmber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 marlene green relationship (agent, action, object), and adult verbal input confirms this relationship. if, as bloom4 suggests, language learning is semantically based, then, in the field of speech pathology, it is necessary to assess this aspect in children who have not learned language correctly. diagnosis for the individual child seems important, as areas of breakdown of linguistic learning seem to be individual· i z e d 2 · 2 1 . perhaps then for some language impaired children there is difficulty in abstracting relationships from the environment. the literature further suggests the presence of cognitive deficiency in children who learn language in a deviant manner. however, this deficiency has been inadequately defined 2 1 and requires further attention. from the preceding discussion it can be seen that there is a need for research into semantic theory and cognition for the following reasons: 1. a semantic feature acquisition hypothesis is as yet tentative and requires substantiation. 2. it is necessary to understand conceptual strategies of abstracting features from the environment as these seem to affect word-meaning acquisition. 3. as children with language impairment seem to have conceptual disorders, it is necessary to investigate whether this occurs in the area of abstracting meaning from the environment. method aims in view of the preceding rationale, the present study had as its aim the following: 1. to devise an adequate semantic test based on semantic feature abstraction and generalization in order to: (a) assess the reality of the feature acquisition theory of semantics and to (b) assess whether language impaired and normal children can be differentiated on this level. 2. to investigate cognitive strategies used in the abstraction of meaning in order to ascertain whether these differentiate language impaired and normal children. 3. to ascertain whether verbal concepts actively emphasized in the child's' environment are acquired in a manner different from those used less consciously or actively. further, it aimed to see whether differential experience with the words caused differences between the language impaired and normal children. subjects: two four year old boys with language impairment and two normal matched controls were used for the purpose of this study. in order to ensure maximum homegeneity within the sample for purposes of valid comparison, all subjects journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) semantic acquisition in four-yr. olds 7 were selected according to the following criteria: 1. all subjects were four years old, as at this stage the language of children with normally developing language is contrasted markedly with that of children with language impairment. this differentiation is apparent because normal four-year-olds have correctly developed complex syntax and several transformations while language impaired children have developed few or deviant rules. diagnosis of language impairment is thus fairly certain at this age. while investigations into vocabulary development have utilized either very young children,10 or children older than six y e a r s , 1 , 1 6 none have attended to the age group between those — the four-year-olds. another factor motivating choice of four-year-olds is that rate of vocabulary acquisition is reported to peak at about four years, thereafter progressively decreasing with a g e . 1 7 2. male subjects were selected to control for certain differences in language acquisition found between males and females. males, as a group, seem to acquire language later and more slowly than females, during the first few y e a r s . 1 3 3. all subjects had older siblings. this was controlled for, as first-born children are reported to acquire language at a greater rate than their siblings.18 4. further all children were judged subjectively by the experimenter and the subjects' nursery school teachers to be of normal intelligence and to have no behavioural problems. these criteria were used in an attempt to control for factors other than linguistic ability which might influence performance on verbal, perceptual or conceptual tasks. 2 5 experimental subjects (li j a n d l i 2 ) : the essential criteria for selection of the experimental subjects were that they had been previously diagnosed as language impaired, and that they were presently attending speech therapy. experienced language pathologists at the university of the witwatersrand's speech and hearing clinic diagnosed the errors in the subjects' language as reflecting a deviation rather than a delay in linguistic acquisition. maturation would thus not remedy the errors, as would occur with language d e l a y . 1 8 control subjects (njand n 2 ) : each language impaired subject was matched with a male control subject from the same nursery school, who was closest in age to him. and who was regarded by the teacher to have normal language and intelligence. the linguistic ablity of all subjects was assessed in terms of its deviation or sophistication and an attempt was made to rank the linguistic ability of the subjects in relation to each other by the experimenter and an experienced language pathologist. lij was judged to have a greater degree of impairment than l i 2 , while njwas assessed as having less mature language than n 2 . table 1 summarises all variables where differences were found between the subjects. it is concerned with age, sibling position and linguistic ranking and description. tydskrif van die su-afrikaanse verenigin vir spraak en gehoorheelkunde, vol. 22, desmber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) marlene green su bj ec t ω oc < po si ti on in f am il y n um be r in f am il y r an ki ng o f l in gu is ti c a bi li ty description of linguistic output li j 4;3 3 3 4 multiple phonologic and syntactic deviations. vocabulary fair. n1 4 -2 2 2 2 normal syntax and phonology with developmental errors. vocabulary fair. li2 4;7 2 .3 3 syntactic and mild phonological deviations. vocabulary fair. n 2 4;7 4 4 1 sophisticated mature syntax and phonology. /s/ articulation error. vocabulary good. table 1: lntersubject differences tests used in the study a selection pretest was first administered (for purposes of subject selection) followed by the semantic feature manipulation tests. for purposes of clarification the tests administered will be discussed in terms of the rationale for their use, and a description of the test materials. pretest for selection purposes'a pretest was conducted to ensure that all subjects could categorize conceptually and to establish to which commands they responded best, in order to select the command most effective for subsequent testing. use was made of several three-dimensional objects exemplifying the conceptual categories of "dolls", "animals" and "fruit and vegetables". semantic feature manipulation tests two sets of material manipulating semantic markers, were constructed in / order to assess what features constitute the child's verbal concept, what ·' referent types he has present in his vocabulary, what contrasts he draws between referents, and how the semantic features selected relate to his experience. two superordinate concepts.were utilized for the purposes of this test — "furniture" and "containers". these superordinates were selected as the child has variable contact with these in his environment.through discussion with the parents of subjects, it seems that "furniture" is subject to active teaching by parents, whereas "containers" seem to be more passively taught. it was journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) semantic acquisition in four-yr. olds 9 felt that there might consequently be a difference in the manner in which the child would form the concepts underlying these two superordinates. it was also felt that the less familiar class might yield interesting results which could possibly differentiate between language impaired and normal children in the way they learn passively defined concepts. in the adult lexicon both superordinates fall under the following hierarehic feature matrix. < + noun > < + entity > < + object > < + concrete > < + inanimate > < + common > we may not, however, assume that this is so in the child's lexicon. rather, word association studies with children have led to confusion about what features might be present. word-association studies cited by anglin1 show that young children tend to associate stimulus words with words of other form-classes, e.g. "ball" elicits the response "throw". however, the present writer feels that this heterogeneity probably results from the functional use of the words being grouped together in frequently used contexts. it is consequently felt that the conclusion drawn by anglin, 1namely that children do not have distinct form classes, is an invalid one. rather, in observing normal four-year-olds, we can assume that, as they make use of nouns interchangeably in similar semantic relations, nouns are functionally and syntactically equivalent for them. for example, because "cat" and "dog" are interchangeable in the same relations they can be assumed to belong to the same forrji-class (as drawn from bloom's 4 conclusions). thus it is felt that investigation into one form-class is appropriate for this age group, and removes confounding variables introduced byword-association tasks. the form-class of nouns has been selected in this study, as nouns' referents are easily represented in a manner which cannot be easily misinterpreted by the child — by models or pictures. models, then, are amenable to the manipulation of those physical features which are regarded as representative of possible semantic markers, and it is through the use of such models that it is proposed one can come to understand the concepts of referents which the child has labelled.15 tydskrif van die sukl-afrikaan.se verenigini! vir spraak en gehoorheelkunde, vol. 22, descmber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 marlene green as categorization into subordinate classes requires the abstraction of common criterial features, a categorization task can be used for investigating classmembership criteria — that is, what features constitute the concept..for the purposes of deducing the criterial semantic markers, a set of semantic markers was manipulated in terms of all possible interrelationships. the features common to all objects categorized similarly, are then the criterial features for that class. rosch 2 2 shows that each concept has focal and peripheral exemplars, due to its internal structure. focal items are those which most accurately incorporate the ideal features of the concept. these items are not ambiguous and can be interpreted only as exemplars of the original concept. peripheral items do not incorporate all the critical features of the concept and because of their insufficient definition can be incorporated into other concepts (being on the periphery between them). they are in this sense ambiguous. it was decided to determine these as it was felt that focal items would demonstrate those semantic features most typical of the class. the semantic features manipulated were perceptually present, three-dimensional physical features of the objects, e.g. back and seat. the use of visual stimuli and primarily nonverbal responses was motivated by findings that children demonstrated improved performance on such tasks, in contrast to those where stimuli and responses were verbal.1 , 5 description of semantic feature manipulation test materials: the features of eight types of furniture items present in the adult vocabulary were systematically manipulated in 127 wooden models. the furniture items selected for feature manipulation were: bed, table, desk, dressing-table, stool, chair, bench and couch. containers representing eight items focal in adult language were selected: cup, mug, glass, jug, jar, bowl, bottle and vase. only certain features which ran almost throughout all the types were manipulated e.g. lid. in all 47 real-size objects were used, because, in contrast to the furniture, models are difficult to construct, and items of real size are portable. procedure on all tests subjects were tested individually by the experimenter in quiet, familiar surroundings. the pretest was administered in their homes in order for experimenter to establish rapport with the subject and to eliminate unnecessary tension which affects test responses.7 the remaining tests were carried out in an isolated room at the children's nursery schools, except in the case of li j , who was tested at home due to unavoidable circumstances. in all test enviroments an attempt was made to decrease extraneous distracting stimuli to ensure maximal attention being directed to test materials. each testing session was broken by frequent short rest intervals (about three minutes) whenever subjects showed evidence of restlessness or fatigue, due to the limited concentration span of the four-year-old. journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) semantic acquisition in four-yr. olds 11 figure 1 systematic manipulation of semantic features shown on examples of the "bed" series fig. la. <+ 4 legs . > <+ top > <+ headboard > <+ bedding > <+ mattress > fig. lb. <+ 4 legs > <+ top > <+ headboard > c bedding > <+ mattress > fig. 1c. <+ 4 legs > <+ top > <+ headboard> <— bedding > <— mattress > fig. id. <+ 4.1egs > <+ top > < headboard > <+ bedding > <+ mattress > fig. le. <+ 4 legs . > <+ top > < headboard > < bedding > <+ mattress > _ fig. if. <+ 4 legs > <+ top > < headboard > <— bedding > <— mattress > tydskrif van die su-afrikaanse verenigin vir spraak en ehoorheelkunde, vol. 22, desmber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 marlene green feature manipulation tests before the feature manipulation tests could be administered, it was necessary to ensure that subjects could categorize in terms of the superordinates. four, two-dimensional photographs of each superordinate were required to be sorted into two groups (i.e. containers and furniture). the following tests were then performed: 1. free categorization: subjects spontaneously sorted firstly the furniture and then the containers, into classes. it was felt that such sorting would tap the superordinates relevant to the child. 2. forced categorization: subjects were required to categorize objects into classes labelled by the experimenter, to ascertain whether these concepts were present in the child's lexicon. 3. subjects were then required to select focal versus peripheral members of the forced categories. method of recording and analysing responses all responses were recorded by the experimenter in written form. the results were then analysed by examining the feature matrices of each item in the subject's grouping, and abstracting out the features common to the exemplars of the category. results and discussion in dealing with the results an attempt will be made to analyse and discuss the responses of the subjects qualitatively on each test. this will be followed by a general discussion of the important trends emerging from this study. i'retkst all subjects were able to supersede perceptual categorization and categorized according to named superordinates, although each subject used different methods of categorization. llj immediately attempted categorical sorting, grouping dolls together. he then sorted more primitively according to the common feature of colour/' (i.e. perceptually). although behaving inappropriately, he was unable to alter his mode of response until the experimenter prompted this by suggesting an alternative. he then sorted entirely conceptually, ignoring perceptual features. both subordinates and superordinates~were labelled, although the category "fruit and vegetables" was namely functionally — 'we eat them' ll2 demonstrated a categorical attitude, sorting according to superordinates. he seemed also to use complexive thought, as, after two yellow fruit items were grouped together, he began sorting perceptually, according to colour. when prompted, he again commenced conceptual categorization, including journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) semantic acquisition in four-yr. olds 13 colour-categorization within classes. subordinates and superoidinates were labelled. n j sorted concretely (i.e. perceptually) according to colour at first, but when requested to change his mode of response, categorized conceptually. he was then able to name subordinates and labelled superordinates "dolls", "fruits" and "animals". n 2 first evidenced concrete sorting, grouping into sets of identical objects. however, responses immediately became conceptual when instructions were modified from sorting "things that are the same to things that are a little bit the same". superordinates were termed "dolls", "fruit we eat" and "animals." all subjects were selected for participation in feature manipulation tests on the basis of their ability to sort conceptually, especially with appropriate commands. feature manipulation tests as the results on these tests are too lengthy to present in full in a report of this nature, pertinent examples of typical responses will be presented in the frame-work of an analysis and discussion of the results. relationship between parent word-referent model and child's responses an examination of the data reveals that there is a close correlation between the child's knowledge of word-referent relationships and the amount of contact he has had with the word-referent relationship from his mother's speech. therefore, in those word-referent relationships very frequently encountered by the child, the feature specification was identical to that of the mother. less known relationships were seen to be less-adequately defined by the child (see figure 2). more actively taught relationships (i.e. "furniture") were apparently better known. free categorization in examining the results it is evident that free categorization generally led to the abstraction of objects into broad, ill-defined categories. these categories were labelled and their feature-specification incorporated few semantic markers. for example, the category "chair" (incorporating the features <+ back> <+ seat>) was seen to contrast with "table" (which incorporated <+ top> <+ legs>). in terms of the evidence that these categories were able to be subdivided into more specific categories, it seems that subjects spontaneously categorized into their superordinates. forced categorization, therefore, led to subjects sub-dividing the superordinates. the superordinate categories thus evidenced were more specific and incorporated a greater number of semantic markers including those general markers specifying the superordinate. for example, lij was able to sub-divide the superordinate "table" in the following manner — tydskrif van die su-afrikaanse verenigin vir spraak en gehoorheelkunde, vol. 22, desmber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 marlene green -tabletable ""<+ top > <+ legs > <— enclosed > <— mirror > <— drawers > desk <+ top > <+ legs > <+ enclosed > < i mirror > <— drawers > forced categorization the following generalizations may be drawn from the results: the child's method of categorization correlated strongly with his contact with word-referent relationships. thus the subjects showed greater ease in naming and categorizing conceptually with familliar word-referent relationships. this was seen in contrasting between "furniture and "containers" as well as within these general categories. from the forced categorization of objects, the following types of word-referent relationships emerged. ( see figure 2). figure 2. word-referent relationships found in the study known referent-label relationships superordinate (overextended) known subpartially known ordinates subordinates unknown referent label relationships categorized referents attached randomly to meaningless labels (li 2 , l i 2 ) ( n 1 ( n 2 ) categorized referents unattached to meaningless label (all (all subjects) subjects) the strategies of abstraction were closely affected by the type of word-ref-' erent relationship applicable. as can be seen from the above figure, all subjects had the ability to categorize conceptually with the meaningful stimuli. when they were familiar with the label applicable to the stimuli they sorted according to the correct superordinate. they were also able to show exemplars of familiar superordinates when asked to do so. however, with less familiar or less meaningful word-referent relationships (i.e. unknown referent-label relationships) the subjects were faced with the task of ascribing meaning to the unfamiliar objects, and this was achieved by the use of certain general strategies: journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) semantic acquisition in four-yr. olds .15 the unfamiliar objecis were perceptually sorted or else sorted together into undifferentiated heaps. sometimes the language-impaired subjects labelled perceptually grouped items irt terms of an arbitrary unfamiliar label for example "stool" was randomly used to name a class of unfamiliar objects. normal children would not do so if the name was unfamiliar. where the label was familiar to the subjects but only partially meaningful in terms of its attachment to referents it was apparent that all the subjects were uncertain of the referents, as in the cases of "dressing table" and "desk" (see figure 3). in this event it seemed that an attempt was made by subjects to hypothesize sets of abstracted features for the labels, and all subjects became perceputally bound to the present stimuli. they-seemed to attempt to abstract out two sets of features, one set applicable to each label, each set of features being mutually exclusive. thus each subject reached a different feature specification, although all were seen to work from concrete comparisons see figure 3. n 2 , however, was the only subject to achieve totally exclusive feature specifications for these two classes even though his deductions led to categorizations different from those made by the adult. figure 3. feature specification deduced from subjects' differentiation of the partially known labels "dressing table" and "desk". li, li, table table "dressing "desk'" "dressing "desk" table" table" <+ top> <+top> <+ top> <+ top> <+ legs> <+ legs> <+ legs> <+ legs> <+ enclosed > <+ enclosed > <+ enclosed > <+ enclosed> <— mirror > < mirror> <— mirror> <— mirror> <+ drawers >_ <— drawers >_ <+ drawers>_ <— drawersx νχ table "dressing table" <+ top> <+ legs> <+ enclosed > <— mirror> <— drawers> "desk" <+ top> <+ legs> <+ enclosed > <— mirror> <— drawers > "dressing table" <+ top> <-+ legs> <+ enclosed > <+ mirror> <+ drawers> "desk" <+ top> <+ legs> <+ enclosed: <— mirror> <— drawers> tydskrif van die su-afrikaanse verenigin vir spraak en eoorheekunde, vol. 22 desmber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 marlene green conversely, where a referent seemed appropriate to two sets of objects, subjects lij li 2 , and n j grouped these items perceptually. these items were, therefore, evaluated in terms of which item they closest resembled, and were named similarly. for example, in being presented with the object with four legs, and a padded top surface, these subjects compared this to certain items previously categorized as beds, because of their headboards. in a manner typical of complex thought, the feature of padding (or <+ mattress>) was abstracted, and the unlabelled item termed "bed". however, n 2 did not depend on perceptual stimulus-bound comparisons. rather he labelled this item a "table" drawing on his past experience, where the features of the present item conformed with the features of the schema for "table". while no conclusion about semantic acquisition may be drawn from the data on familiar subordinates, unfamiliar subordinates furnish interesting information. it is these subordinates which are in the process of developing and thus it is possible to discuss whether the process of development in the child with already established language, is in agreement with a semantic feature acquisition hypothesis. in order to assess this, it is necessary to examine the validity of the principle of overextension, as well as the direction of semantic growth on those developing word-referent relationships. for the purposes of this discussion, a developing word-referent relationship will be defined as a label whose semantic feature specification is incomplete in terms of the adult model, although approximating this e.g. with "desk" and "dressing table". from examination of the data two types of developing relationships are found: (a) where the adult model implies an incomplete feature specification (e.g. with li 2 the model word "cup" used by the mother implies incomplete specification as it refers to all drinking utensils see table iib); and (b) where the adult model incorporates all differentiating features (e.g. the parents of all subjects adequately contrast "desk" with "dressing table" and thus these model labels can be assumed to incorporate all semantic features). the several examples of such relationships seen in the data seem to demonstrate that all subjects follow a common trend. as an instance of type (a) it is seen that in all subjects "bench" and "couch" were not contrasted either in the adult model or the child's vocabulary item. the feature specification of these was uniform amongst all children, but the label attached conformed to the relevant adult's model. the feature specification was <+ back >] <+ seat > <+ 2 people> <+ legs > which excluded the feature differentiating between the two labels ("bench" and "couch") (i.e. <+ upholstery> or < upholstery>). thus both adult model and child word can be termed overextended, and not superordinate, journal of the south african speech a hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) semantic acquisition in four-yr. olds . 17 ελ λ ό ελ λ 2 •g v •ΐί λ 5 ε +1 ν « ca ^ β.f j c ό "2 s " 8 | 5··° f £ ν ν 0} >ϊ •c ελ ελ 3 3 £ 1 c >. ϋ · » •s sp ο ζ υ rt c α ο ελ ο s c * § 2 = ^ s (ν •!a + λ •α £ s •ΐί ο * s 2 ·α c λ +1 ο &0 w υ e ν c ·3 λ σ · 2 2 5+1 £ t£3 v ™ >1 μ ε s ·δ+ι > λ v c α ) ελ (u ω >>~ι 4) ν ο >. .η -•8 >? 3-s s s §•§ g· s £ .s λ υ <υ rt ed ο •5 ο λ ο t-h c <u 3 i ο t-h .ta σ (u — . ε + 1 c v v ελ λ ό ελ λ s λ £ s ε «+ι ϊ λ ϊ 8 t f | c 3 "2 <υ ^ rt 3 <d <d ffi fi <u +1 +1 £ ν ν σ* υ <u α. γ τ * > 3 σ λ λ ο ο 2 -s ο i o + " ν " v s a s a s2 ~ oj s2 ~ ω <s % —' ό •3 + h ν h ν λ a •g v ζζ λ 5 ε ~ +1 μ ν λ i λ s 8 £?§ 1= ώ c 2 a> ~ ed 3 <d <d 5" λ ·= a> +1 +1 £ ν ν c ό 2 c 3 μ σ„ λ ο ό ^ 8 s 3 5 σ" <u <υ ο. £ £ j= ο λ c ε s ω >. ο β λ ο .8 s > . £ ιττ v ο > ε λ ε ο i 2 v c ο λ ο ελ ^ e <u <u ό •s + £ ν η 3 ο u ο) χ) τ3 c ο -«-» j3 3 α. 'ξ α ε 3 c3 τ3 % 3 <υ υ c ρ £ 8 ω. α. χ <υ u <u ω ε j => « t 1 " fs< r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) marlene green cvj 2 fr eq ue nt c on ta ct < + dr in k> < + o pa qu e> fr eq ue nt c on ta ct < +d ri nk > < + tr an sp ar en t > n o co nt ac t fr eq ue nt c on ta ct < + po ur > ' fr eq ue nt c on ta ct < +f lo w er s > fr eq ue nt c on ta ct < + po ur in g > v er y in fr eq ue nt c on ta ct in fr eq ue nt c on ta ct o nl y us ed in t er m s of " m ix in g bo w l" ih ζ fr eq ue nt c on ta ct < + dr in k> <+ op aq ue > n o co nt ac t n o co nt ac t fr eq ue nt w it h on ly o ne ex em pl ar < + po ur > v as e sy no ny m ou s w it h "b ow l" u se " bo w l" m or e fr eq ue nt ly fr eq ue nt c on ta ct < + po ur in g> n o co nt ac t in fr eq ue nt c on ta ct . in t er m s of " su ga r bo w l" o r "b ow l o f flo w er s" cvj 3 fr eq ue nt c on ta ct < +d ri nk > <+ op aq ue > fr eq ue nt c on ta ct < + dr in k > <+ tr an sp ar en t > n o co nt ac t fr eq ue nt < + po ur > fr eq ue nt c on ta ct fr eq ue nt c on ta ct < +p ou ri ng > n o co nt ac t in fr eq ue nt c on ta ct ih 3 fr eq ue nt c on ta ct < + op aq ue > < +d ri nk > fr eq ue nt c on ta ct < + dr in k > < +t ra ns pa re nt > in fr eq ue nt c on ta ct w it h co ffe e m ug s < sa uc er s> fa ir ly f re qu en t co nt ac t f < + p ou r> in fr eq ue nt c on ta ct fr eq ue nt ly u se d < +p ou ri ng > = ja r in fr eq ue nt c on ta ct w ith "t in " n o co nt ac t cu p g la ss m ug ju g v as e ο « ja r/ ti n/ c an b ow l journal ofthe south african speech and hearing association vol. 22 december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) semantic acquisition in four-yr. olds 19 because the real superordinate would make use of a different label (e.g. perhaps "double chairs" as used by n 2 , or "furniture.") in terms of type (b) the explanations of the evolution of the terms "desk" and "dressing table" already proposed, seems also to support the semantic feature acquisition theory, as in all subjects an attempt was made to elaborate a detailed feature specification. in both types of evolving word-referent relationships the growth, seems, therefore, to proceed hierarchially in a downward direction — i.e. from generalized overextended terms to more differentiated, specific word-referent relationships, with nevertheless incomplete feature matrices. language-impaired and normal subjects were not able to be differentiated on these tests, except in terms of the unknown referent-label relationships as seen in figure 2. focal versus peripheral categorization known word referent-relationships: in all subjects it was seen that focal and peripheral exemplars included certain features which seemed to be essential to the exemplar being included in the class. these features were deduced by the experimenter to be the critical features of the class. these features, present in the focal exemplar but absent in the peripheral, were necessary for the object to be a realistic examplar of a class. however, even if these features were absent the item was categorized as a peripheral exemplar of the class if the critical features were present. for example all subjects contrasted focal and peripheral chairs in the following way: .chair focal chairs peripheral chairs <+ back > <+ seat > <+ 1 person > <+ legs >_ <+ back > <+ seat > <+ 1 person> <— legs > unknown word-referent relationships: all subjects were unable to differentiate focal and peripheral exemplars on any of these. general discussion the general discussion will be concerned with the implications and limitations of the present study. investigation is indicated into later semantic feature acquisition, in order to determine whether all subordinate terms (with completed feature specifications) must be acquired, before the child becomes able to abstract out supertydskrif van die su-afrikaanse verenigin vir spraak en gehoorheelkunde, vol. 22, desmber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 marlene green ordinate features and concept like <+ animate> and < animate> which are established later in semantic development.2 4 language-impaired subjects were seen to cope well when the word-referent relationships were familiar through frequent usage in their environments. therapeutically, this implies that vocabulary can be best learned when the lexical item is frequently paired with varying exemplars of the same category, and that attention should be drawn to the constant elements present in all the examples — i.e. the critical semantic markers. the limitations of this study lie mainly in its use of a small sample, which prevents the generalization of conclusions. furthermore, only a small aspect of semantic theory was investigated. such limitations imply the necessity for further research. the subjectivity of a qualitative analysis of responses, as well as the tediousness of detailed semantic marker manipulation testing, provide major criticisms of this study conclusion in conclusion, tasks of semantic feature manipulation reveal that there is reality for a semantic feature acquistion model, where the child draws firstly on predefined concepts from experience, and then from present perceptual data to attribute word-meanings to stimuli. words receiving conscious and active teaching are acquired with more definition than those learned less actively, though no differences seemed to exist between language-impaired and normal children on this level. references 1. anglin, j.m. (1970): the growth of word meaning. cambridge, massachusetts: m.i.t. press. 2. berry, m.f. (1969): language disorders of children: the bases and diagnoses. new york: appleton-century-crofts. 3. bierwisch, m. (1970): semantics. ch.l in j. lyons (ed.), new horizons in linguistics. penguin books. 4. bloom, l. (1973): one word at a time. the hague: mouton. 5. brown, r. (1956): language and categories. appendix in bruner, j.s., goodnow, j.j., and austin, g.a. a study of thinking. new york: john wiley and sons, inc. 6. brown, r. (1970): the child's grammar from i to iii. ch. 6 in r. brown. psycholinguistics: selected papers. new york: the free press. 7. bruner, j.s. goodnow, j.j., and austin, g.a. (1956): a study of thinking. new york: john wiley and sons inc. 8. bruner, j.s., olver, r.r., and greenfield, p.m. (1966): studies in cognitive growth. new york: john wiley and sons inc. 9. carrol, j.b. (1964): language and 77z0hgft?.englewood cliffs, new jersey: prentice-hall inc. journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) semantic acquisition in four-yr. olds 21 10. clark, e.v. (1973): what's in a word? on the child's acquisition of semantics in his first language. in t.e. moore (ed.) cognitive development and the acquisition of language. new york and london: academic press, inc. 11. hoffman,.h.n. (1955): a study in an aspect of concept formation with subnormal, average and superior adolescents. genetic psychology monographs, 52,193-239. 12. johnson, d.m. (1972): a systematic introduction to the psychology of thinking. new york: harper and row. 13. johnson, w., darley, f.l., and spriestersbach, d.c. (1963): diagnostic methods in speech pathology. new york: harper and row. 14. katz, j.j. (1972): semantic theory. new york: harper and row. 15. lanham, l.w. (1974): personal communication. 16. mcneil, d. (1970): the acquisition of language: the study of developmental psycholinguistics. new york: harper and row. 17. menyuk, p. (1971): the acquisition and development of language. englewood cliffs, new jersey: prentice-hall, inc. 18. narun, l. (1973): speech pathology iii, lecture notes, university of the witwatersrand, johannesburg. 19. olson, d.r. (1970): language and thought: aspects of a cognitive view of semantics. psychological review, 77, (4) 257-273. 20. olson, d.r. (1970): cognitive development: the child's acquisitional diagonality. new york and london: academic press. 21. rees, n.s. (1973): auditory processing factors in language disorders: the view from procrustes' bed./. speech hearing disorders, 38(3), 304315. 22. rosch, e.h. (1973): on the internal structure of perceptual and semantic categories. in t.e. moore (ed.) cognitive development and the acquisition of language. new york and london! academic press, inc. 23. rosenstein, j. (1963): concept development and language instruction. exceptional children, 30, 337-343. 24. schaeffer, b., lewis a.e., and van decar, a. (1971): the growth of children's semantic memory: semantic elements. j. experimental child psychology, 11,296-309. 25. strauss, a.a.; and lentinen, l.e. (1950): psychopathology and education of the brain injured child. new york: grune and stratton. 26. vygotsky, l.s. (1962): thought and language. new york and london: m.i.t. press. tydskrif van die su-afrikaanse vereniginvir spraak en ehoorheelkunde, vol. 22, decmber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) b e l l & h o w e l l l a n g u a g e m a s t e r s y s t e m teacher records the master track on a mams-powered language master. on a classroom .1727, pupil listens to the teacher's recorded voice. pupil makes his own recording, in pupil listens to his own recording, response to what the teacher has then compares it with the teacher's, said. if he is not satisfied, he can rerecord (re-recording automatically erases the previous pupil recording, but leaves the teacher's recording unimpaired). the inhnitely patient language master reading: in learning to read, listening is a key factor. by its unique combination of sight and sound, the language master system enables the child to look at a whole word or a phonic element within a word and at the same time hear the correct pronunciation on the teacher's track. speech t h e r a p y : because of the infinitely patient, individual attention it provides, the language master/' system is particularly useful in teaching both reading and speech to children or adults who are handicapped in some way (e.g. by aphasia, speech impediments, partial deafness). for f u r t h e r i n f o r m a t i o n c o n t a c t t h e language m a s t e r c o n s u l t a n t at g a l l o f o x in johannesburg. p.o. box 31884, braamfontein 2017. tel.: 28-6152. journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustic reflex measurements a n d the loudness function in sensorineural h e a r i n g loss sheila uliel, m . a . ( a u d i o l o g y ) ( w i t w a t e r s r a n d ) unit for hearing-impaired children, university of the witwatersrand, johannesburg. summary the suprathreshold acoustic reflex responses of forty two ears affected by sensorineural hearing loss of cochlear origin and fifty-eight ears demonstrating normal hearing, were recorded by means of an electro-acoustic impedance meter and attached x-y recorder. the recordings were done in ascending and descending fashion, at successively increasing and decreasing 5 db intensity levels from 90-120-90 db hl respectively, for the individual pure-tone frequencies of 500, 1 000, 2 000 and 4 000 hz. the contralateral mode of measurement was employed. analysis of these recordings indicated that the acoustic reflex responses could be differentiated into five characteristic patterns of growth, which could be depicted upon a continuum of peaked, peaked-rounded, rounded, rounded-flat, and flat shapes. the peaked and peaked-rounded patterns were found to predominate at all four pure-tone frequencies in the normal ears, while the rounded-fiat and flat patterns were found to predominate only at the higher pure-tone frequencies of 2 000 and 4 000 hz in the ears affected by sensorineural hearing loss. this latter relationship was also able to be applied to two disorders of the loudness function — loudness recruitment and hyperacusis. it was concluded that the flattened acoustic reflex patterns at the higher pure-tone frequencies constituted a potential diagnostic cue related to the differential diagnosis of sensori-neural hearing loss, and to disorders of the loudness function. opsomm1ng die bo-drumpel akoestiese refleks responsies van twee-en-veertig ore wat aangetas is deur sensori-nervale hoorverlies van cochlear oorsprong, en agt-en-vyftig ore met normale gehoor, is deur 'n elektro-akoestiese impedansmeter en aangehegte x-y opnemer vasgele. die opnemings is in stygende en dalende wyse, teen opeenvolgende toenemende en afnemende 5 db intensiteitvlakke van 90-120-90 db elk, vir die afsonderlike suiwerklank frekwensies van 500, 1 000, 2 000 en 4 000 hz gemaak. ontleding van hierdie opmetings bewys dat die akoestiese refleks responsies in vyf karakteristieke groeipatrone gedeel kan word. die groeipatrone kan weergegee word op 'n kontinuiim van puntig, puntig-gerond, gerond, gerond-plat en plat vorms. die puntig en puntig-geronde patrone is oorheersend gevind teen alle vier van die suiwerklank frekwensies in die normale ore, terwyl die gerond-plat en plat patrone slegs teen die hoer frekwensies van 2 000 en 4 000 hz in die ore aangetas deur sensori-nervale gehoorverlies oorheersend was. hierdie laasgenoemde verwantskap kan ook toegepas word op twee afwykings van die geluidskrag funksie — geluidheidsopbou en hiperakusie. die gevolgtrekking is afgelei dat die plat akoestiese reflekspatrone teen die hoer suiwerklank frekwensies as 'n potensiele leidraad kan dien, verwant aan die differensiele diagnose van sensori-nervale hoorverlies en afwykings van die geluidskrag funksie. /' / in recent years, there has been considerable discussion of a variety of suprathreshold auditory measures which have been used for both diagnostic and rehabilitative evaluations of patients with sensorineural hearing losses. j according to stephens et a l 1 9 a limited dynamic range of hearing, is in fact, the demonstration of 'loudness recruitment', which is traditionally die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustic reflex threshold 59 used to indicate . . . a more-rapid-than-normal increase in subjective loudness for a given increase in physical intensity, (hirsch et al, ρ 213) 9 loudness recruitment has been conventionally accepted as being of great clinical value in pinpointing the locus of the sensorineural impairment. dix et al 8 were the first investigators to claim that the presence or absence of loudness recruitment would differentiate cochlear from retrocochlear pathologies, respectively. following on from their work, various procedures, both direct and indirect, were developed to determine the presence of loudness recruitment in the clinical situation. serious limitations have been noted with all the loudness recruitment procedures, with the exception of the metz recruitment test, developed in 1952. this test, which is considered to be both a direct and objective procedure, employs, as its basis, the fundamental principle of measuring changes in acoustic impedance at the eardrum, caused by the contraction of the acoustic (stapedius) reflex in response to sound. the acoustic reflex threshold is considered to be the most basic, static characteristic of the acoustic reflex (petersen and liden), and it describes the sensitivity of the fundamental acoustic reflex stimulusresponse function. it has been thoroughly investigated, and is currently well understood and extensively applied to clinical audiological diagnosis. for example, cochlear diagnosis utilises the narrowed relationship between the acoustic reflex threshold and the lowered audiometric threshold in the establishment of inner ear dysfunction and disordered loudness growth (or loudness recruitment) (metz). the dynamic properties of the acoustic reflex, which incorporate aspects of its response beyond threshold, have been the concern of investigators such as borg 4 and m 0 l l e r . 1 3 · 1 4 it is their contention that the suprathreshold growth of the acoustic reflex response amplitude in the auditory frequency — and temporal — domains and the interrelationship between this behaviour and different sound intensities, represents an important aspect of the dynamic behaviour of he acoustic reflex, which has not as yet been systematically applied to the clinical field. , _ retrocochlear diagnosis utilises the dynamic temporal response characteristics of the acoustic reflex, in that an abnormally rapid decay of the acoustic reflex to prolonged suprathreshold stimulation is indicative of auditory nerve dysfunction (anderson et al 1 · 2 ; sheehy and inzer ) cochlear diagnosis, however, does not utilise any of the knowledge gained from an understanding of the dynamic properties of the acoustic reflex, and relies exclusively upon examination of its static characteristics. _ it would appear that the amplitude regulation of the acoustic reflex, within the auditory frequency-domain, can offer much to the establishment of cochlear sensori-neural hearing loss diagnosis. ' ' ' ' i n e cochlear is involved with the analysis of the frequency and intensity characteristics of sound (resulting in the perception of pitch and die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 sheila uliel loudness), and disorders of the cochlear function interfere both with the hearing of certain frequencies (hearing loss), and with the loudness function (loudness recruitment). the acoustic reflex threshold has been shown to be related to the perception of l o u d n e s s , 3 ' 5 ' 6 ' 1 1 ' 1 7 but the relationship of its supra-threshold response characteristics to loudness perception requires detailed investigation. considerable variations in the growth of the acoustic reflex resp<dnse amplitude to intensity have been noted, both with normal hearing, and with sensori-neural hearing loss, but as the precise significance of these variations has not yet been established, they appear to be generally attributable to individual differences (mccandless1 5). furthermore, the influence of different sound frequencies upon the acoustic reflex amplitude growth has not been investigated, either in normal or pathological ears. no detailed description or classification of the types of acoustic reflex amplitude growth patterns exists, although a 'flattening' effect has been shown to occur with sensorineural hearing loss, which is exaggerated by the concomitant presence of loudness recruitment (beedle and harford3). the present investigation aims at establishing if any variations in the acoustic reflex amplitude response, other than the 'flattening' effect, exist, which may be able to be differentiated and classified. furthermore, this investigation attempts to examine the relationship between the acoustic reflex growth and several variables such as the frequency and intensity of the stimulus; the presence of absence of hearing loss; the presence or absence of cochlear pathology; and the presence or absence of loudness function disorders. it is hoped that if differential acoustic reflex growth patterns are forthcoming, and that if these are significantly related to different pure-tones in normal hearing and cochlear sensori-neural hearing loss, and influenced by disorders of the loudness function, then an additional diagnostic cue regarding such disorders will be apparent. the writer anticipates that more sophisticated and accurate measurements of the dynamic response characteristics of the acoustic reflex will not only add to the body of knowledge about the acoustic reflex, but will also add to the diagnostic and rehabilitative acumen of the clinical audiologist. m e t h o d o l o g y / / ' aims to investigate the variations in the suprathreshold amplitude growth of the acoustic reflex, for different pure-tones, in normal hearing and in sensori-neural hearing loss, for the purposes of: 1. specifically characterising any differential acoustic reflex amplitude growth patterns or trends; 2. examining whether any such trends are related to different pure-tone frequencies; the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustic reflex threshold 61 3. analysing whether the acoustic reflex amplitude growth is differentially related to normal hearing and sensori-neural hearing loss; 4. analysing whether the acoustic reflex amplitude growth is in any way influenced by disorders of the loudness function. subjects fifty subjects were selected to participate in the experiment, their ages ranging from 15 to 53 years, with a mean age of 32,8 years. these age limits were imposed in order both to ensure sufficient maturity for co-operation throughout the testing, and to avoid any contaminating effects of the ageing process upon hearing and the behaviour of the acoustic reflex. both sexes were represented in that 24 males and 26 females were selected. from the 50 subjects selected, an experimental group (eg) and a control group (cg) were derived, the former comprising 42 ears with cochlear sensori-neural hearing loss; the latter comprising 52 ears with normal hearing. the hearing, in each case, was assessed according to specific predetermined criteria, which were established from an extensive assessment including a battery of audiological tests as follows: (1) case history details each patient was carefully questioned with regard to any present or past difficulties with hearing; ear pathology; ear surgery; tinnitus, vertigo, headaches, problems with balance. (2) otoscopic examination this was carried out by an ear, nose and throat specialist prior to the administration of the audiological test battery. (3) audiological test battery: the following procedures were employed: a. testing of the bilateral hearing function, by establishing: (i) pure-tone air and bone conduction thresholds. (ii) speech reception thresholds. (iii) speech discrimination scores. b. assessment of the bilateral middle ear function, by means of: (i) tympanometry. (ii) calculation of the absolute acoustic impedance value at the plane of the eardrum. (iii) establishment of the acoustic reflex thresholds. c. differential diagnostic assessment of the site-of-lesion, incorporating an evaluation of the loudness function, including: (i) ablb test die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 sheila uliel (ii) sisi test (iii) metz recruitment test (iv) carhart tone decay test (v) acoustic reflex decay test. table i summarises the criteria differentiating the subjects selected into the e g and the cg. table 1: summary of the criteria for subject selection, differentiating them into eg and cg procedure eg-sensorineural (cochlear) hearing loss cg-normal hearing case history positive re: hearing difficulties, vertigo, tinnitus, negative re: me pathology or surgery negative otoscopic examination negative negative hearing thresholds between 25 and 75 db no air/bone gap no poorer than 25 db no air/bone gap audiogram flat, low or high frequency loss flat srt between 25 and 75 db srt and pta agreement no poorer than 25 db srt and pta agreement sd score 60-90% 90-100% tympanometry ά ' t y p e tympanograms ά ' t y p e tympanograms middle ear pressure ommavs ommavs acoustic impedance value 1 000-30001 000-3 0 0 0 acoustic reflex threshold up to 120 db hl at all pt's but 4khz between 70 and 90 db sl at all pt's but 4 khz ablb lr either positive or negative in the unilaterally affected ear not applicable sisi positive (70-100%) at the relevant pt frequencies negative (0-70%) at all the pt frequencies acoustic reflex threshold/puretone threshold difference 60 db sl or less with loudness recruitment: <60 db with no loudness recruitment <60 db sl only / / tone decay negative negative 7 acoustic reflex decay negative ' negative equipment all the tests were conducted with the subject seated in a single-suite sound-attenuating booth, where the ambient noise-level measured was not more than 36,7 db spl, recorded on the 'c' scale of the bruel and the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustic reflex threshold 63 kjaer (type 2203) precision sound level meter, with condensor microphone (model 4131). the maico 24 dual-channel diagnostic audiometer, with attached t d h 39-102 earphones and mx/ar cushions was used. immediately, prior to the commencement of the testing, the equipment was calibrated re: iso 1964 standards, using the bruel and kjaer sound-level meter, with filter 1613 and artificial ear 4152/4145. the danplex electro-acoustic impedance meter (model za20) with attached t d h 39 earphone and standard (madsen) clinical rubber tips on the probe-unit was used. this was calibrated re: ansi 1971 standards, and the calibration was checked prior to each testing session by means of the 1 c.c. coupler provided. the. minigor x-y recorder, supplied with strip-chart cards and blue pen-marker, was connected to the impedance meter. the equipment was modified in terms of the insertion of an automatic timer, which was activated simultaneously with the pure-tone stimulus generator. the timer was set to produce a pure-tone stimulus of approximately 2 sees., (recorded as exactly 1,90 sees, within 5% — refer to fig. 1), with intervals of 8 sees, between each stimulus-pulse. this 10 sees, timing interval was accordingly translated on to the demarcated strip-chart card in terms of 10 sees, per 1 cm., along the abscissa (refer to fig. 2). also along the abscissa, the ascending and descending intensity levels, in db, were marked, with each intensity step corresponding to each 10 sec. timing interval. figure 1. example of an acoustic reflex response to a two second stimulus pulse die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 sheila uliel j_ stimulus interval time—in secs j l _l figure 2. representation of the time base in seconds (10 sec/cm). along the ordinate, the magnitudes of the acoustic reflex responses were scaled according to 20 mv = 1,0 cc with the impedance meter set at sensitivity 2, and the x-y recorder set to mv/cm., (refer to fig. 3). in this manner, a bar diagram was obtained representing the recording of: (i) each 2 sec. stimulus-pulse across 1/5 cm. on the x-axis; (ii) each 8 sec. interval between stimulus-pulses across 4/5 cm. on the x-axis; (iii) the systematically ascending and descending 5 db intensity levels (90-120-90 db), along the x-axis; (iv) the maximum amplitude of each acoustic reflex response, represented according to the given scale of l m v = 0,05 cm, along the y-axis. figure 3 provides an example of one such recording for 1 000 hz tone pulses, indicating the acoustic reflex amplitudes at each intensity level. experimental procedure each ear was individually tested via the contralateral mode crf'stimulus presentation. the acoustic reflex response elicited was automatically recorded. the ear-order of testing was noted, as the ear-tested-first was randomised from subject to subject.. this was done in order to eliminate any artefacts which might be introduced into the experiment by temporary threshold shifts (tts) due to fatigue of the contralateral ear-tested-second, after having previously been exposed to prolonged stimulation. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustic reflex threshold 65 intensity in db figure 3. example of the acoustic reflex amplitudes at different intensity levels for 100hz pure-tone stimulus pulses. the subject was instructed to sit comfortably, and as motionlessly as possible, during the recording of each set of stimulus presentations, the duration of which involved a maximum period of 120 sees. the pure-tone frequencies tested were 500, 1 000, 2 000, and 4 000 hz, in that order, for each ear. each pure-tone frequency tested represented a single strip-chart card. the minimum stimulus intensity level of presentation (starting and ending point) for each pure-tone frequency tested, was arbitrarily selected as 90 db; the maximum intensity level, beyond which point the descending presentation mode began, was 120 db. (this represented the maximum output level of the impedance meter). the test was begun by the investigator manually depressing the interruptor switch, which automatically put into operation the first 2 sec. stimulus-pulse (ie. 500 hz at 90 db), followed by an 8 sec. interval. during the interval, the investigator manually raised the intensity level by 5 db (ie. the dial was then set at 95 db), and again depressed the interruptor switch. in this way, 90-120 db stimuluspulses were presented in ascending fashion, followed by 115-90 db stimulus-pulses in descending fashion, for each pure-tone frequency, for each ear. in this manner, 8 bar-diagrams per subject were obtained, representing the behaviour of the acoustic reflex amplitude response to systematically increasing and decreasing intensity levels, for four pure-tone frequencies, per ear, with a constantly maintained time interval. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 66 sheila uliel these bar-diagrams represented the raw data. at each pure-tone frequency, a pattern of acoustic reflex amplitude growth was able to be established by connecting the points of maximum amplitude for each individual acoustic reflex response recording over the ascending and descending 90-120-90 db intensity levels. examination of the acoustic reflex growth patterns (argp's), thus established, was done by the examiner, who subjectively and arbitrarily assigned a label to each pattern aimed at succinctly describing its shape. objective verification of the subjectively labelled patterns was then carried out. this was considered necessary, so that the individual results could be pooled, into a composite diagram reflecting the average pattern for each a r g p , which was done in the following manner: firstly, each individual acoustic reflex response, at each intensity level, was measured (in mm) and recorded on to computer coding sheets. thirteen measures, per strip-chart card, were recorded, and a total of 104 such measures for each person was recorded. examinations of these measurements revealed that the scale of the argp's was highly variable between subjects, and a standardisation procedure, in order to arrive at a comparable scale between the numerous measurements was therefore, applied to each individual acoustic reflex response measure recorded. thereafter, the standardised data was coded, and punched onto computer cards. the ibm 360 computer at the university of the witwatersrand was used, and the statistical package for the social sciences computer programme (nie et al, 1975 . . . spssh version 6.00 for the university of the witwatersrand, johannesburg), was employed. the statistical means of all the standardised measures, at each individual intensity, both for the ascending and for the descending presentations, for each pure-tone frequency, were computed. these averages were then processed, enabling them to be represented as computerised graphs. in this way, twenty different computerised average graphs were obtained, each representing a different a r g p , at each of the four pure-tone frequencies. following the establishment of the different argp's they were then analysed in detail with regard to their occurrences in normal hearing and sensorineural hearing loss, and with regard to their relationships to disorders of the loudness function. relative percentage frequency distributions were used for intraand inter-group comparisons,, and the chi-square test was used to test''the significance of relationships between the groups. results a n d discussion i ( 1 ) analysis of the acoustic reflex response five different argp's were able to be distinguished, both by subjective and objective means. the argp's appeared to lie upon a continuum as follows: the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustic reflex threshold 67 figure 4. diagrammatic representation of five different a r g p ' s where no acoustic reflex response was triggered, despite maximumstimulation, (which occurred most frequently at 4 000 hz), the label 'no growth' was assigned. table ii illustrates the distribution of the argp's in the cg and e g while table iii compares the relative distributions of the argp,s in the cg and e g . table ii: frequency distribution of argp's in the cg and eg ears cg eg % total argp cg peaked 29,5% 8,5% 38% rounded 10,5% 9,5% 20% peaked-rounded 12,5% 3,75% 16,25% flat 2,75% 10,75% 13,5% rounded-flat 0% 7,25% 7,25% no growth 2,75% 2,25% 5% total 58% 42% 100% table iii: relative % frequency distribution of argp's in the cg and eg ears argp cg eg peaked 51% 20% rounded 17,5% 23,5% peaked-rounded 22% 8% flat 5% 26,5% rounded-flat 0% 17% no growth 4,5% 5% total 100% 100% in the cg, peaked patterns are seen to dominate (51% of the time), while flat and rounded-flat patterns are minimally represented (5% and 0%, respectively). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 68 sheila uliel in the e g , although all but the peaked-rounded patterns have relatively similar statistical representation (ranging from 17 to 26,5%), when comparing these percentages to the same pattern categories in the cg, a distinct differentiation is observed. flat and rounded-flat patterns occur with much greater frequency in the e g than in the cg; while peaked and peaked-rounded patterns occur with much greater frequency in the cg than in the e g . the rounded patterns and cases of 'no growth' are very similarly distributed, respectively, within the e g and cg. the dichotomy of the two extremes on the a r g p continuum is clear, with the peaked and peaked-rounded extreme occurring most frequently in the cg, and the flat and rounded-flat extreme occurring most frequently in the e g . the rounded patterns, form an intermediate link between the two extremes, in both groups, which are not significantly distinguishable as a single entity. table iv compares the relative distributions of the argp's with each pure-tone frequency between the e g and the cg. table iv: relative % frequency distribution of argp's at each pure-tone frequency for eg and cg i % frequency of occurrence at 500 hz 1 000 hz 2 000 hz 4 000 hz cg eg cg eg cg eg cg eg peaked 0 3 % ) 1 % 13% 11% rounded 16% 26% 15% 0 i % ) 21% 15% 23% 23% p/rounded 26% 19% 24% 12% 16% 1% 15% 2% flat 2% 0% 8% 29% 5% (^8 %) 5% r/flat 0% 9% 0% 15% 0% 0% 17% no growth 0% 0% 0% 0% 12% 5% 16% 5% total 100% 100% 100% 100% 100% 100% 100% 100% from observations of the ringed figures in each pure-tone frequency column it is clear that: y at 500 hz peaked patterns dominate in both grou^s'of ss. at 1 000 hz peaked patterns dominate in the cg, while rounded do so in the e g . at 2 000 hz peaked patterns dominate in the cg, while flat and rounded-flat occur most frequently in the e g . at 4 000 hz peaked patterns dominate in the cg, while flat do so in the e g . from the above tables, it would appear that peaked patterns dominate in normal ears at all four pure-tone frequencies. with sensorineural the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustic reflex threshold 69 hearing loss, the a r g p ' s are difficult to be 'typed' with the lower pure-tone frequencies of 500 hz and 1 000 hz, but the flat and rounded-flat patterns occur most frequently in this group at the higher pure-tone frequencies of 2 000 and 4 000 hz. the fact that a 'flattening' of the a r g p ' s occurs in the presence of sensorineural hearing loss is in agreement with the findings of beedle and harford3 who demonstrated an overall flattening of the acoustic reflex response in such cases. the results of the present investigation, however, appear to indicate that the 'flattening' effect is pure-tone frequency specific, occurring predominantly with the higher pure-tone frequencies. no growth occurs most frequently at 4 000 hz and not at all at the lower pure-tone frequencies. this is an expected result as acoustic reflexes are almost always readily demonstrable at the lower pure-tone frequencies, but often do not occur at all at the higher pure-tone frequencies, especially 4 000 hz. out of the total sample, the 'no growth' was shown 5% of the time, and this is in agreement with a previous study of jerger et a l 1 0 who found that no acoustic reflex could be recorded at 4 000 hz 4 1 0 % of the time, both in normal and abnormal hearing. the conclusions derived from the results of the jerger et a l 1 0 study and from the present study, therefore, appear to indicate that 4 000 hz is at least qualitatively different from the other pure-tone frequencies with respect to its incidence of inexplicable absence of the acoustic reflex, both in normal hearing, and in sensorineural hearing loss. jerger et al, however, do not accord the absence of acoustic reflex responses at 4 000 hz with any pathological significance. with regard to the frequency range of 500 to 4 000 hz, (including the 4 khz tone in the instances where an acoustic reflex is able to be demonstrated), however, the results of the present investigation show a significant frequency effect upon the argp's, which occur beyond threshold, in both normal and senorineural hearing loss, whereas the jerger et al study showed no such frequency effect upon the acoustic reflex responses at threshold. the writer takes cognisance of the fact that although both studies were concerned with measurement of the acoustic reflex response, the jerger et a l 1 0 study was concerned with its response at threshold, while the present investigation is concerned with its response beyond threshold, and as such, a different phenomenon might well be implicated. according to jerger et a l , 1 0 the lack of a frequency effect upon the acoustic reflex at threshold provides one of the most important norms of impedance audiometry for the practising clinician — ie. the maximum audiometric loss that a patient with sensorineural hearing loss can sustain before the acoustic reflex disappears at any or all of the pure-tone frequencies tested. this parameter has greatest value in lending support to audiometric thresholds established, especially in such cases where this is informally done by means of die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 sheila uliel behavioural observations. the fact that there is a significant frequency effect upon the acoustic reflex response beyond threshold, may just as well provide an important future diagnostic sign for the practising clinician with regard to the differential diagnosis of the sensorineural hearing loss from normal hearing, in the acoustic reflex suprathreshold realm. ( 2 ) analysis of the argp's in disorders of the loudness function (i) analysis of the a r g p ' s in sensorineural hearing loss with concomitant loudness recruitment (refer table v) the differential diagnostic assessment of site-of-lesion, and the evaluation of the loudness function incorporated three procedures considered capable of demonstrating the presence or absence of loudness recruitment. loudness recruitment was considered to be present in any ear if, at any single pure-tone frequency, the results of the ablb, metz recruitment and sisi tests were positive — (with the ablb results included where applicable). table v: the frequency of occurrence of loudness recruitment in the eg and c g . lr group present absent total eg 37 (88%) 5 (12%) 42 (100%) cg 0 58 (100%) 58 (100%) total 37 63 100 loudness recruitment was not demonstrated in any of the 58 normal ears, forming the cg. loudness recruitment was demonstrated in 37 out of the 42 ears having sensorineural hearing loss, constituting 88% of the e g . only 5 ears which were affected by sensorineural hearing loss did not demonstrate loudness recruitment, constituting 12% of the eg. as such, nearly all of the results pertaining to the e g , with the exception of the 5 ears which did not demonstrate loudness recruitment, can be considered to be representative of the characteristic/ a r g p in sensorineural hearing loss with loudness recruitment. due to the extremely small sample size of the subgroup representing sensorineural hearing loss without loudness recruitment (ie. 5 ears), individual examination of the characteristics of these ears was carried out in order to see if they were consistently similar to or different from the results of the major eg. depending upon the observations that were forthcoming, inferences regarding the e g , with the exclusion of these 5 ears (ie. sensorineural hearing loss with loudness recruitment the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustic reflex threshold 71 only), were then able to be made, upon qualitative, if not upon quantitative grounds. (ii) the analysis of the a r g p ' s in sensorineural hearing loss, without concomitant loudness recruitment this is illustrated as follows: table vi: frequency distribution of the argp's at each pure-tone frequency in eg, without loudness recruitment (5 ears) argp frequency of occurrence at: argp 500 hz 1 000 hz 2 000 hz 4 000 hz total peaked rounded p/rounded flat r/flat no growth 5 0 0 0 0 0 3 2 0 0 0 0 4 0 1 0 0 0 ο ο ο ο 4 *· 16 2 1 0 0 1 total • 5 5 5 5 20 it is clearly obvious that this small group of ears functions essentially like the cg, and not like the e g , in terms of the frequency distribution of the argp's. peaked patterns are observed to dominate at all four pure-tone frequencies, while the rounded-flat and flat patterns have no representation whatsoever. this implies that the results of the e g , therefore, can be taken to be representative of the sensorineural hearing loss with loudness recruitment sub-group, as the small sub-group of sensorineural hearing loss without loudness recruitment is shown to function in a consistently different manner, with regard to the argp's. the a r g p responses in sensorineural hearing loss, in the presence of loudness recruitment, therefore, were shown to be predominantly rounded-flat and flat at the higher pure-tone frequencies of 2 000 and 4 000 hz. f the a r g p responses in sensorineural hearing loss, in the absence ot loudness recruitment, on the other hand, were shown to be predominantly peaked at all pure-tone frequencies, which was the identical a r g p response obtained in normal hearing. (in) analysis of the a r g p ' s in normal hearing with hyperacus 'hyperacusis' is the term used by the investigator to describe increased sensitivity to very loud sounds occurring with normal hearing. as such, it is distinct from loudness recruitment, which describes an abnormal sensitivity to loudness because of cochlear pathology, resulting in sensorineural hearing loss. although hyperacusis occurs in the presence of normal hearing, it is nevertheless a disorder of the loudness die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 sheila uliel function, and has been reported to be a characteristic symptom of bell's palsy, which also provides an example of disordered loudness function in the absence of a hearing loss (zakrisson and b o r g 2 0 ) . the demonstration of hyperacusis was not anticipated prior to the actual recording of the acoustic reflex amplitude responses, and its specific investigation, therefore, was not included within the original scope of this study. however, the presence of hyperacusis was reported several times during the recordings of the acoustic reflex amplitude response, by several normally hearing subjects, who found the extremely loud pure-tone stimuli (115 and 120 db) most discomforting, and almost painful, despite the fact that no evidence of loudness recruitment as tested by the metz recruitment test was demonstrated, and where the sisi scores of the same subjects were negative. furthermore, observation of the recordings of the acoustic reflex amplitude response in the specific cases where increased loudness sensitivity was reported, indicated that the growth of these acoustic reflex amplitude responses was dramatically larger when compared to the other cases who did not report increased loudness sensitivity. figures 5 and 6 illustrate the differences in acoustic reflex amplitude response growth between one subject who reported an increased sensitivity to loudness with normal hearing, and another subject, also with normal hearing, who did not experience this. figure 5. example of acoustic reflex amplitude response growth in a case of normal hearing where hyperacusis was reported the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustic reflex threshold 73 1 000 hz threshold ar l ,00 105 ho π5 120 π5 " 0 105 100 95 90 intensity in db hl figure 6. example of acoustic reflex amplitude response growth in a case of normal hearing where hyperacusis was not reported the fact that the phenomenon of hyperacusis was demonstrated so vividly led the investigator to consider its analysis warranted however superficial. table vii: the frequency of occurrence of hyperacusis in the eg and cg hyperacusis present absent total eg 0 42 (100%) 42 (100%) cg 15 (8,5%) 43 (91,5%) 58 (100%) total 15 85 100 hyperacusis was not demonstrated in any of the 42 sensorineural ears forming the e g . hyperacusis was demonstrated in 15 out of the 58 normal ears, constituting 8,5% of the cg. table viii: the distribution of the argp's at each pure-tone frequency for hyperacusis in normally hearing ears frequency of occurrence at: argp's 500 hz 1 000 hz 2 000 hz 4 000 hz total peaked rounded p/rounded flat r/flat 0 3 0 1 0 0 4 0 2 0 0 6 0 8 8 0 6 0 12 10 0 19 0 23 18 total 4 6 22 28 60* •note: the total is equal to 60, as any a r g p could occur in 15 ears at four pure-' frequencies. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 74 sheila uliel the most significant finding here is that no peaked or peaked-rounded patterns occurred at all with hyperacusis, while rounded, rounded-flat and flat patterns occurred with relatively similar total frequency of occurrence, but noticeably more so at the higher than lower pure-tone frequencies. as such the a r g p ' s in the hyperacusis group appear to be able to be 'typed' in an identical manner to those of the subjects with sensorineural hearing loss with loudness recruitment, despite the fact that none of the normal hearing group demonstrated loudness recruitment on testing, by means of the traditionally accepted tests. as such, the results of the analysis of the argp's in hyperacusis tend to imply that acoustic reflex response growth is more an indicator of disordered loudness function, than of sensorineural hearing loss, per se. this in turn implies that an assessment of disordered loudness function may be carried out, irrespective of the audiometric threshold, by assessing the acoustic reflex amplitude response in its suprathreshold realm. conclusions of the five acoustic reflex growth patterns which were established, two were able to be differentially related, by pure-tone frequency, to normal hearing and sensorineural hearing loss, as well as to disorders of the loudness function as follows: peaked patterns were observed predominantly at all four pure-tone frequencies in normal hearing or in sensorineural hearing loss w i t h o u t concomitant loudness recruitment, while flat patterns were observed predominantly at the higher pure-tone frequencies of 2 000 and 4 000 hz in sensorineural hearing loss with concomitant loudness recruitment, or in normal hearing with hyperacusis. in other words, the acoustic reflex response growth demonstrated a linear relationship to systematically increasing and decreasing intensity levels with normal loudness function, whereas it demonstrated an asymptotic (flattened) relationship to the same intensity levels with abnormal loudness function. the writer concludes that the linear and asymptotic growth patterns of the suprathreshold acoustic reflex response, which respectively demonstrate the absence or presence of loudness dysfunction, are analogous to the well established linear and asymptotic loudness balance curves. the differential acoustic reflex growth patterns, therefore, appear to be able to be accorded with the same diagnostic significance as the differential loudness balance curves, and may be considered as complementary to the ablb and mlb procedures, having the additional advantages of being quick and easy to administer, and relying upon objective and quantifiable responses. in cases where loudness balancing procedures are either not possible, or unsuccessful, as with very young children or with elderly people, the measurement of the suprathreshold acoustic reflex growth patterns is highly recommended. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustic reflex threshold 75 the dynamic properties of the acoustic reflex with regard to its amplitude regulation within the frequency-domain, therefore, appear to offer significant cues to the establishment of cochlear diagnosis, in the same way as its dynamic properties in the temporal-domain have been demonstrated to offer significant cues to the establishment of retrocochlear diagnosis. however, the writer wishes to emphasise that the measurement of the acoustic reflex response characteristics does not constitute a 'new' test of cochlear impairment and disordered loudness function. rather, it represents another procedure in a series of tests which are based upon the same theoretical principles, and which appear to be illustrating the same basic pathological entity, ie. a selective destruction of the low-intensity elements in the organ of corti (the outer hair cells) with the high-intensity elements (the inner hair cells) left intact to subserve the loudness function at high intensities. the phenomenon of hyperacusis in normal hearing, might appear to confound the pathological entity described above, as there is no concomitant loss of hearing (which is the manifestation of the selective destruction of the low-intensity elements). however, the phenomenon of hyperacusis may be due, like some incipient retrocochlear disorders which do not manifest themselves in a hearing loss, to some type of malfunction beyond the level of the organ of corti itself — ie. within the neural fibres or along the neural pathways, where no selective sparing of the lowor high-intensity elements occurs. apart from this intriguing theoretical speculation regarding the source of hyperacusis, the differential relationship of the acoustic reflex growth patterns to it, appears to be of considerable practical value in the clinical situation. not only can the acoustic reflex growth patterns provide objective evidence of reported hyperacusis in some cases of facial nerve damage, but the same can be applied to the numerous reported incidences of hyperacusis among people with 'otherwise normal' hearing, who seek otological specialist opinion. instead of the usual somewhat curt dismissal of the problem, or its appraisal as a manifestation of 'neuroticism' or an idiosyncratic personality trait, the objective demonstration of this reported subjective sensation might help to alleviate the frequent associated anxieties of hyperacusis, whereby it is interpreted (by the person who suffers from it) as being indicative of either impending 'deafness' or 'mental instability'. the writer is well aware of the fact that these suggestions are proffered on the basis of the results found with only 15 ears, and recommends that further investigation of the phenomenon of hyperacusis be carried out, on larger sample sizes, before adopting the suggestions with any degree of confidence. continuing in the same vein, the writer feels that hearing-aid users can also benefit from the objective evidence of their 'intolerance' to amplification, which might otherwise be construed by others as being 'obstinacy' as regards the use of a hearing-aid. finally, in conclusion, the writer takes cognisance of the fact that the flattened acoustic reflex growth patterns were restricted to the higher die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 76 sheila uliel pure-tone frequencies. this may be entirely due to experimental design and the subject-selection procedures, which resulted in a sample of sensorineural hearing loss which was mainly restricted to these frequencies, with the exception of meniere's disease, where the hearing loss occurred mainly in the lower pure-tone frequencies. the number of cases of meniere's disease in this experiment, however, was not sufficiently large to be able to be subjected to any statistical analysis. future research aimed at investigating the effects of predominantly low-frequency and predominantly high-frequency hearing losses upon the acoustic reflex growth patterns, therefore, is required. this would enable the determination of whether the specifically highfrequency flattened response of the acoustic reflex growth patterns is merely an artefact of the experimental design in this study, or whether it represents another theoretical issue, or characteristic aspect of the acoustic reflex response in the suprathreshold realm. r e f e r e n c e s 1. anderson, h . , barr, b., and wedenberg, e. (1969): intra-aural reflexes in retrocochlear lesions. in: disorders of the skull base region, p. 49, hamberger, c., and wersall, j. (eds.), almquist and wiksell, stockholm. 2. anderson, h . , barr, b. and wedenberg, e. (1970): early diagnosis of eighth nerve disorders. acta otolaryngol., suppl. 263: 232. 3. beedle, r. k. and harford, e. r. (1973): a comparison of acoustic reflex and loudness growth in normal and pathological ears. j. speech hear. disord., 16: 271. 4. borg, e. (1976): dynamic characteristics of the intra-aural muscle reflex. in: acoustic impedance and admittance: the measurement of middle ear function. ch. 11, pp. 236-299. wilber, l. and feldman, a . (eds.) the williams & wilkins co., baltimore, usa 5. chiveralls, k. and fitzsimons, r. (1973): stapedial reflex action in normal subjects. br. j. audiol., 7: 105. 6. colletti, v. (1974): some stapedius reflex parameters in normal and pathological conditions. j. laryngol. otol., 88: 127'. / 7. dallos, p. (1964): dynamics of the acoustic reflex: phenomenological aspects. j. acoust. soc. amer., 36, 2175. 8. dix, m., hallpike, c., and hood, j. (1948): observations upon the loudness recruitment phenomenon with special reference to the differential diagnosis of disorders of the internal ear and the vllth nerve. j. laryngol. otol., 62: 671. 9. hirsh, i., palva, t., and goodman, a . (1954): difference limen and recruitment. arch. otolaryngol., 60: 525. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acoustic reflex threshold 77 10. jerger, j . , jerger, s., maulding, l. (1972): studies in impedance audiometry: i. normal and sensorineural ears. arch. otolaryngol., 96, 513. 11 jerger, s., jerger, j . , mauldin, l. (1974): studies in impedance audiometry: ii. children less than six years old. arch. otolaryngol., 96: 513. 12. metz, o. (1952): threshold of reflex contractions of muscles of the middle ear and recruitment of loudness. arch. otolaryngol., 55: 536. . 13. m0ller, a . (1977): function of the middle ear. reprint from handbook of sensory physiology, keidel, w., and neff, w. (eds.) springer-verlag, pp. 492-516, berlin, 1974. presented at 1st amplaid international impedance meeting, milan. 14. m0ller, a . (1977): the acoustic middle e a r muscle reflex. reprint from handbook of sensory physiology. keidel, w. and neff, w. (eds.) pp. 520-544, springer-verlag, berlin, 1974. presented at 1st aplaid international impedance meeting, milan. 15. mccandless, g. (1975): future directions. in: handbook of clinical impedance audiometry, jerger, j., (ed.) ch. 8., american electromedics corporation. morgan press, ny. 16. peterson, j. and liden, g . (1972): some static characteristics of the stapedius muscle reflex. audiology, 11: 97. 17. ross, s. (1968): on the relation between the acoustic reflex and loudness. j. acoust. soc. amer., 43: 768. 18. sheehy, j. and inzer, b. (1976): reflex decay in brainstem lesions: acoustic reflex test in neuro-otologic diagnosis. arch. otolaryngol., 102: 647. 19. stephens, s., blegvad, b. and krogh, h . (1977): the value of some suprathreshold auditory measures. scand. audiol., 6, (4): 213. 20. zakrisson, j. e. and borg, e . (1974): stapedius reflex and auditory fatigue. audiology., 13: 231. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) advertisement binaural hearing mr. d. a. smith today we can provide miniature hearing aids individually made to fit entirely into the ear with each hearing aid tailored to suit the individual hearing loss. there are hearing aids with automatic volume control, television attachments, telephone devices, acoustic filters and a host of technical innovations to improve performance. with all these facilities available it is sad to think that most hearing aid users cannot enjoy truly relaxed hearing because of one simple fact — we are trying to make one ear do the job of two ears. nature has provided us with two ears for a very good reason. anyone with normal hearing can experience the problems of a hearing aid user by simply blocking one ear in a group conversation — suddenly it becomes impossible to separate the voices. the time has come to face some common s e n s e facts. no-one with deficient eyesight wears a monocle anymore — or buys a spectacle with only one lens. yet we allow people to wear one hearing aid and pretend the other ear doesn't exist. binaural (two ear) hearing aid fittings are not new. when they have been used they are extremely successful and people who have worn two hearing aids enjoy a quality of hearing comparable to normal hearing. why should this be s o ? well, in the first place, with two hearing aids only half the sound power is needed for each ear. this means that loud sounds cause much less discomfort. ' secondly, because of the "phase relations" of sounds arriving at the two ears at slightly different time intervals the brain is able to "focus" subconsciously on desired sounds while ignoring unwanted background sounds.' this makes hearing possible in group conversation where everyone is talking at once. think also of the effect when crossing a busy street and not being able to tell where sounds are coming from. people with two normal ears react automatically to a noise from behind because two ears tell not only the direction of a sound but also the distance to the source of the sound. with a hearing aid on one ear it is a bit like crossing the road with one eye closed. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) advertisement of course hearing aids can be expensive and it is not everyone who can pay for two hearing aids without some hardship. in order to encourage binaural fittings wherever appropriate we make special price arrangements where two hearing aids are required. for the adult hearing aid user best results can be obtained with two custom-made all-in-the-ear hearing aids. the picture shows the danavox model 771 hearing aid with the microphone positioned where it should be — in the ear. with an in the ear hearing aid the user does not have the feeling of wearing a hearing aid. the user can move around without thinking of the hearing aid falling off or being damaged by sudden shocks. acoustimed hearing services 315 bosman buildings cor. eloff and bree streets johannesburg telephone (head-office) 37-2977 agents for world renowned danavox hearing aids die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 65 the efficacy of the prescription of gain/output (pogo) in fitting hearing aids to mild and moderate sensorineural hearing losses sandra thorpe and carol jardine department of speech pathology and audiology university of the witwatersrand abstract this study investigated the effectiveness of the application of the prescription of gain i output (pogo) in hearing aid fittings. six subjects were tested. each presented with binaural mild to moderate sensorineural hearing losses and were previously fitted monaurally with behind-the-ear aids using modifications of the traditional carhart (1946) approach. functional gain requirements stipulated by pogo were calculated from unaided thresholds and compared to actual functional gain measurements. five subjects, whose functional gain measures were not within prescribed limits, were referred for modification of the gain and frequency responses of their hearing aids and earmoulds. postmodified functional gain measurements were analysed. the extent to which the required functional gain measurements were met, was investigated statistically in relation to word recognition scores and subjective ratings of perceived benefit. the conclusion reached was that the application of pogo results in improved word recognition scores and self-reported user satisfaction. opsomming hierdie studie het die doeltreffendheid van die aanwending van voorskrif van vordering / uitset (vvu) in gehoorapparaatpassing ondersoek. ses proefpersone is gebruik. elk het met 'n geringe tot matige binaurale sensories -neurale gehoorverlies gepresenteer en was voorheen met monaurale, agter-die-oor tipe gehoorapparate gepas deur modifikasies van die tradisionele carhart-benadering (1946) te gebruik. funksionele wins vereistes wat deur wu gestipuleer is, is berekenl vanaf nie-versterkte drempels en is vergelyk met werklike funksionele vordering. vyf proefpersone, wie se winsmetings nie binne die voorgeskrewe perke was nie, is verwys vir modifikasie van die wins en frekwensie responskurwes van hulle gehoorapparate en oorstukke. post-modifiseerde funksionele winsmetings is geanaliseer. die mate waarin-die vereiste funksionele wins-metings nagekom is, is statistics bereken in verhoudmg tot woordherkenningstellingslen subjektiewe beoordeling van waargenome voordeel. die gevolgtrekking is gemaak dat die aanwending van wu gelei het tot verbeterde woordherkenningstellings en verbruikerstevredenheid tot gevolg gehad het. introduction "although electronic hearing aids have existed for over forty years, there still is no consensus of opinion today regarding the most appropriate method for hearing aid selection and adjustment to an individual" (mccandless & lyregaard, 1983, p. 16). unfortunately, this comment has held its validity even though it was made more than a decade ago. while the principles of selective amplification (the supply of gain according to different frequency requirements based on pure-tone audiogram results) are now generally accepted, the most prevalent technique of hearing aid fitting in south africa is still based on carhart's (1946) comparative procedure and its modifications. this approach attends to the relationship between hearing aid frequency response and the unaided audiogram in a general way and relies on aided speech thresholds and word recognition scores to differentiate hearing aid performance when selecting the best hearing aid for the individual patient (hodgson, 1986). limitations of this procedure and its modifications are highlighted as the following : 1. due to the large statistical spread in speech intelligibility scores, only large differences between hearing aids can be reliably interpreted due to the poor test-retest reliability of these procedures (northern, 1993). 2. speech tests are time consuming and therefore expensive. moreover, northern (1993) comments that the reliability of speech scores is not good enough to warrant the investment of extensive clinical time. 3. speech-based tests have a severely limited application in a multilingual country such as south africa. 4. speech intelligibility is not the only relevant property to be considered in hearing aid selection as poor sound quality can result in the rejection of the heardie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 66 sandra thorpe & carol jardine ing aid (mccandless & lyregaard, 1983). in 1946, davis et al., (cited in rose, 1977) maintained that the hearing impaired patient is usually primarily interested in obtaining a hearing aid with a pleasing or natural quality, however, the quality preferred by the patient is not always compatible with the greatest intelligibility. 5. although speech tests may demonstrate that a particular hearing aid is not adequate, they fail to identify which electroacoustic characteristics may contribute to better word recognition (angelo & miller, 1988). speech tests in isolation are unable to prescribe modifications required to improve performance. indeed berger (1991, p.40) comments that these methods "often consisted of no more than a guess at the gain-frequency response needed for a given hearing loss". contemporary alternatives of hearing aid selection based on a variety of mathematical formulae were thus devised. these utilise audiogram-based prescriptions of appropriate amplification and the measurement of unaided and aided sound field thresholds (hawkins, montgomery, prosek & walden, 1987). "the basis of a prescriptive method is to select the hearing aid's characteristics of frequency and gain, by relating the aid's electroacoustic characteristics to relevant characteristics of the individual's hearing loss, based on a theory about this relationship" (angelo & miller, 1988, p.184). although prescriptive methods differ somewhat in their underlying principles they are all based on the belief that different electroacoustic features are needed for different individuals and that a rationale exists, linking audiological and electroacoustic characteristics (buerkli-halevy, 1988). they tend to share the following basic tenents : 1. the amount of hearing aid gain is determined as a function of frequency and is related to the degree of hearing loss (buerkli-halevy, 1988). 2.. the frequency response is related to the audiometric configuration and the input signal. the goal of any method is to provide the hearing aid user with an aid that reproduces speech that is highly intelligible while also being comfortable to listen to (angelo & miller, 1988). 3. reduced gain at the lower frequencies to avoid the upward spread of masking and thus improve speech intelligibility in noise (berger, 1991). 4. the selection of maximum output such that it exceeds the threshold of hearing without exceeding the uncomfortable loudness level (buerkli-halevy, 1988). berger (1991) highlights the advantages of using prescriptive methods of hearing aid selection. he comments that since its use is based on hearing threshold levels its test-retest reliability is considerably better than word recognition testing. they are also applicable to a larger "sector of the population since they do not require any particular linguistic competence or intellectual abilities. by providing a method of evaluating the hearing aid's performance, it is also more objective than traditionally used methods based on speech audiometry. one such method, prescription of gain/output (pogo) proposed by mccandless & lyregaard in 1983, attempts to combine simplicity and practicality in hearing aid fitting procedures. the authors of pogo conclude that this prescription method represents a consensus amongst existing proposed prescriptive methods following comparative research in the area. they claim that their procedure is a close approximation of the required characteristics which constitute the best fitting procedure and thus it essentially provides a starting point for any subsequent fine adjustment (angelo & miller, 1988). pogo is based on the premise that the hearing aid should ensure that sound levels which are important in daily life, are audible without being excessively loud. pogo is based on the half gain principle proposed by lybarger in 1963 (mccandless & lyregaard, 1983; berger, 1991) where the optimum functional gain is equal to one half of the magnitude of the hearing loss. however, this half gain rule has been modified in pogo in order to reduce the effects of the upward spread of masking by reducing the gain in the low frequencies. to ensure hearing aid acceptability, the method includes the selection of maximum output such that intense sound levels will approach the uncomfortable loudness level without exceeding it. the use of the pogo has been advocated by various researchers (angelo & miller, 1988; chasin, 1988). smirga (1984) cited in hodgson (1986), reported an improvement in the sound quality and user satisfaction when aids were adjusted according to the pogo criteria. mccandless & lyregaard(1983) report that a study of several existing selection methods such as those suggested by berger and national acoustics laboratory, revealed results closely approximating those predicted by pogo and therefore argue that pogo represents a consensus of expert opinion but that this method is exceptional in that it is a simple procedure capable of administration within a short time. a high level of hearing aid acceptance and benefit for the user involves a compromise between good speech intelligibility and comfortable sound according to mccandless & lyregaard (1983). in this study, we have attempted to answer questions regarding whether the application of the pogo method results in good speech intelligibility and sound quality, and thus subject satisfaction, as a high level of hearing aid acceptance and benefit for the user involves a compromise between good speech i n t e l l i g i b i l i t y and comfortable sound (mccandless & lyregaard, 1983). ' | the term "functional gain" has been used in this text to refer to the effective gain of the aid i.e., the difference in sound pressure level with and without the hear, ing aid, measured behaviourally on a sound-field audiogram. although the use of real-ear insertion gain measurements have also been advocated, the expense of such equipment places it beyond the reach of most practising audiologists and its cheaper alternative using sound-field measurements was therefore chosen, y furthermore, the term "required gain" refers to the gain specified by the prescription formula as calculated in table 1. • / / methodology / aims x the main aim of the study was to investigate the efthe south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the efficacy of the prescription of gain/output (pogo) in fitting hearing aids to mild and moderate sensorineural hearing losses ficacy of pogo in hearing aid fittings of mild and moderate sensorineural hearing losses. this involved : 67 1 determining the extent to which the required gain a c c o r d i n g to p o g o and the functional gain differ; 2 (a) determining the correlation between the difference between functional and required gains, and word recognition scores; (b) determining changes in word recognition when the aid was modified to meet the prescription more closely; (a) determining the correlation between the difference between functional and required gains, and subject satisfaction. (b) determining changes in subject satisfaction when the aid was modified to meet the prescription more closely. tbjects six subjects with b i l a t e r a l l y s y m m e t r i c a l isorineural hearing losses ranging from mild to moditely severe levels (pure tone averages (pta) better in 65dbhl) were tested. subjects with severe and jfound hearing losses have different amplification [uirements, requiring hearing aids to assist in speechiding and to increase awareness of environmental inds. all subjects were experienced hearing aid usi. the audiometric configuration was not considered be an important selection criteria for this study, al>ugh all subjects had either a rising or flat audiometslope. details regarding the method of initial hearζ aid fitting were unavailable although all hearing is were fitted using general principles from the traional carhart approach. these subjects were fitted monaurally with behind-the-ear aids and although it is well established that a binaural fitting would have been more beneficial, many could only afford a single hearing aid due to financial constraints. the ages of the subjects ranged from 52 to 83 years with a mean of 72,3 years. none of the subjects showed evidence of central auditory processing deficits as suggested by a poor correlation between pure-tone findings and word recognition tasks, not by a significant deterioration in word recognition abilities in the presence of noise. pure tone and word recognition testing were conducted in an inter-acoustics company (iac) two-roomed sound-proof booth, using a grason stadler gsi-10 audiometer. sound-field frequency-modulated pure tones at 250 4000hz were generated and routed through the audiometer and amplified to a loudspeaker located in the sound booth. this speaker was also used for the word recognition testing. the audiometer, earphones, speakers and sound field had been calibrated to iso (1964) specifications four months previously. word recognition testing was conducted using the cid w22 phonetically balanced word lists developed by hirsch (1952). due to the unresolved controversy retable 1. calculation of gain and maximum power output a c c o r d i n g to pogo ( m c c a n d l e s s and lyregaard, 1983) the required insertion gain is calculated as follows: frequency (hz) insertion gain (db) 250 500 1000 2 0 0 0 3000 4000 0,5 htl 10 0,5 htl 5 0,5 htl 0,5 htl 0,5 htl 0,5 htl (where htl refers to hearing threshold level) the maximum power output (mpo) is calculated as follows : mpo (ucl 5 0 0 + u c l 1 0 0 0 + ucl2 0 0 0)/3 (where ucl refers to the uncomfortable loudness level) obtain frequency-modulated pure-tone thresholds for aided ear. calculate the require'd gain and output characteristics based on pogo. administer hearing aid questionnaire. determine aided sound-field thresholds. 4.1 calculate functional insertion gain. compare functional gain with required insertion gain. 5.1 functional gain within specified limits 5.2 functional gain not within specified limits check aided ucl 6 check aided ucl speech discrimination in quiet and noise. 7 speech discrimination testing in quiet and noise. 8 refer subject to hearing aid acoustician for modification if necessary. 8.1 subject returns to clinic after two weeks adjustment period. 8.2 return to step 3 above and proceed. figure 1. flow diagram of the administrated test procedure die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol: 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 68 sandra thorpe & carol jardine garding 25 or 50 word testing, the entire list of 50 words was administered (schmitz, 1980). a hearing aid questionnaire developed by maclean (1988) was administered to assess the effectiveness of hearing aid performance in the reduction of the hearing handicap (refer appendix a). the subjects were not permitted to peruse the questions before answering, in order to avoid premeditated responses. test procedures figure 1 provides a diagrammatic representation of the procedure followed. 1. pure tone audiometry a pure tone audiogram was established for each subject's aided ear at 250, 500, 1000, 2000, 3000 and 4000hz. 2. calculate gain and maximum power output requirements the required gain and maximum power output (mpo) according to pogo was determined as indicated in the table below (mccandless & lyregaard, 1983). 3. hearing aid questionnaire subjects evaluated their aids subjectively by means of a hearing aid assessment questionnaire (maclean, 1988) (appendix 1). due to statistical reasons related to the small population size it was not feasible to devise a rating scale. 4. aided sound-field audiogram an aided sound-field audiogram was obtained using frequency-modulated pure tones as recommended by mccandless & lyregaard (1983). the subject was seated at 0 degrees azimuth at a distance of one metre from the speaker. the non test ear was muffed with an earphone to prevent its influence on test results. 4.1 calculate required functional gain functional gain was determined by calculating the difference between unaided and aided thresholds at each frequency. 5. comparison of actual functional gain with required gain the criteria for acceptance of the hearing aid fittings were adapted from mccandless & lyregaard (1983). deviations between the measurements in the region 500 2000hz should not exceed 5dbs to constitute an acceptable hearing aid fitting. occasionally a lodb deviation is felt to be unavoidable and larger deviations are acceptable if they occur at all frequencies and in the same direction as this may be adjusted by the volume control. 5.1 functional gain within specified limits if the subject's functional gain met those specified by pogo, the hearing aid fitting was considered appropriate. 5.2 functional gain not within specified limits if functional gain was not within specified limits, the fitting was not considered appropriate and the subject was referred for further modification and testing. 6. checking uncomfortable loudness levels (ucl) to determine whether the maximum power output (mpo) of the hearing aid is appropriately set, mccandless & lyregaard (1983) recommend that the procedure incorporate testing to ensure that the ucl is not exceeded. this involved turning the hearing aid control full on and gradually increasing the level of narrow band noise at 1000hz. the mpo adjustment is considered satisfactory if the level of narrow band noise can be turned up beyond 80dbhl without reaching the subject's ucl. 7. word recognition testing "the purpose of a hearing aid is to enable hard of hearing subject to hear sounds that he cannot otherwise hear but desires to hear particularly the human voice ... (it) must make speech intelligible ..." (davis et al., 1946 as cited in pascoe, 1985). as difficulty in understanding speech is often the primary complaint in hearing impaired persons (martin, 1975 as cited in downs, 1982), a comparison of unaided and aided performance is an integral part of the hearing aid evaluation procedure. although not included in the prescriptive approach, the importance of word recognition testing cannot be easily dismissed because of its intuitively high face validity. unaided and aided word recognition testing was administered in a sound field situation. the subject was seated at 0 degrees azimuth at a distance of one metre from the speaker . both the primary message (speech) and the c o m p e t i n g message (speechweighted noise) were routed through the same speaker. monitored live voice was selected as the presentation mode to allow for the variations in response time required by the individual subject and to facilitate reinstruction or reinforcement where necessary (hodgson, 1987). word recognition testing was administered in both quiet and noisy situations. the use of background noise represents an approach that allows some realistic prediction about a person's functioning in real life noisy c o m m u n i c a t i v e settings (schmitz, 1980). a signal-to-noise ratio of odbhl, utilising speech-weighted noise was selected asjrepresentative of the most difficult listening condition encountered (lawrence et.al., 1976 cited in bress and bratt, 1977). , a level of 65dbhl was selected to conduct word recognition testing. whilst this level overcame! the stressful effects of having speech presented at a level too soft for the subject to respond to, as reported by most of the subjects, it nevertheless served as an appropriate level at which the subjects experienced substantial difficulty unaided (hodgson, 1986). 8. referral to the hearing aid acoustician the stipulated conditions for modification were that only earmould, tone control, gain settings and mpo changes be implemented to adjust the response of.the aid and that a new hearing aid would not be recommended. ^ subjects were required to wear their hearing aids for at least two weeks following modifications. this time period allowed the subjects the opportunity to use the modified aid extensively within their everyday routine, thereby enabling them to comment on / the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the efficacy of the prescription of gain/output (pogo) in fitting hearing aids to mild and moderate sensorineural hearing losses 69 the new set of electroacoustic characteristics. subjects were then required to re-evaluate their aids subjectively using the hearing aid questionnaire. finally, a new sound field audiogram was obtained to determine whether gain requirements had been met. word recognition testing was then readministered. results and discussion all results should be considered in the light of the small sample size which had a direct bearing on the statistical procedures which could be applied. although trends have been established, all results should be seen as largely qualitative and not quantitative. in those circumstances where statistics cannot be applied at all, a descriptive analysis will be provided. 1. comparison between actual and required functional gain as shown in table 2, the extent to which the ideal and actual functional gain differ ranges from 0,4dbs at 500hz to 17,ldbs at 4000hz. according to mccandless & lyregaard's (1983) criteria for acceptance, only the gain at 250 and 1000hz represents acceptable fittings i.e., deviations between the actual and ideal do not exceed 5dbs at these frequencies. all these patients were originally fitted for amplification using the general principles of the modified comparative approach suggested by carhart (1946), although exact details were unavailable. there is much controversy about the importance of the high frequencies in speech intelligibility abilities. mccandless & lyregaard (1983) state that the hearing aids' frequency response should predominantly fit the table 2. the aided mean of ideal and actual functional gain at each frequency, and differences between them before modifications. hz 250 500 1000 2000 3000 4000 required gain (db) 5,4 13,3 21,7 25,4 27,1 25,4 actual gain (db) 5,0 6,7 17,5 14,2 15,0 8,3 delta fg (db) 0,4 6,6 ' 14,2 11,2 12,1 17,1 table 3. the aided mean of ideal and actual functional gain at each frequency, and the difference between them after modification. hz 250 500 1000 2000 3000 4000 required gain (db) 4,5 13,0 21 26 i 27 25 actual gain (db) 9,0 14,0 22 21 22 17 delta fg (db) 4,5 1 1 5 5 8 region of 250 to 2000hz. for frequencies above 2000hz, the requirements should be met as far as possible but are not as important as the lower and middle frequencies. a large discrepancy between ideal and actual gain means at 3000 and 4000hz is evident. however, pascoe (1985) comments that the critical range of frequencies which have a significant effect on word recognition scores, particulary those in noise, are those between 2500 and 6300hz. the relevance of this statement will be discussed later, however, it is important to note that this region is critical for speech intelligibility. as the difference between the ideal and actual functional gain is the basis for which an aid is accepted as a good or poor fitting, none of these aids would be accepted as appropriate and thus modifications were recommended for all subjects. subject dissatisfaction is often related to unsatisfactory mpo settings, therefore these were evaluated. according to mccandless & lyregaard's (1983) mpo specifications, all subjects' mpo levels were appropriate and thus did not require any adjustments. only five of the six subjects were prepared to have their hearing aid response altered by means of modifications to their earmoulds and/or tone control/gain settings. the results following modification of the hearing aids of these five subjects are presented in table 3 below. all subjects were using standard earmoulds and bores. although minor variations in earmoulds will not significantly alter the acoustical properties in the region 250 to 3000hz (mccandless & lyregaard, 1983), improvement of high frequency amplification from an increase in the inner diameter of the sound canal from the hook of the hearing aid to the tip of the earmould has been reported in the literature (ringdahl, leijon, liden & backelin, 1984). the use of a horn also provides an increase in functional gain at 3000 and 4000hz (hodgson, 1986). as these are the frequencies where the most modification was necessary, their implementation was discussed with the hearing aid acoustician. table 4. unaided word recognition scores in quiet and noise conditions subjects a β c d ε f quiet 20% 6% 16% 26% 32% 30% noise 24% 6% 10% 24% 10% 24% table 5. aided speech discrimination scores in quiet and noise before and after modification to the hearing aid. subject a β c d ε f before quiet 56% 46% 54% 54% 46% 36% noise 36% 18% 34% 42% 34% 24% after quiet 68% 64% 66% 80% 48% noise 42% 30% 52% 40% 34% die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 sandra thorpe & carol jardine however, strategies to improve the hearing aid response were left to the acoustician's discretion. as it was stipulated that a new hearing aid could not be recommended, it is important to bear in mind the limitations on the extent to which the hearing aid's response can be modified. table 3 indicates that a great improvement in functional gain was obtained across all frequencies. accordingly, all fittings except at 4000hz would be considered acceptable by mccandless & lyregaards' (1983) standards. shapiro (1976) stated that the predicted gain at 4000hz is the most difficult to attain. the significance of the negative numbers in the table is that too much gain was provided at those frequencies, i.e., over-amplification occurred, but these values are still within the acceptable range. 2. word recognition testing results of the word recognition testing are presented below (table 4) : the relevance of unaided word recognition scores and the benefits from aiding are particularly significant. hodgson (1986) states that poor discrimination ability is indicative of poor hearing aid candidacy and substantiates this statement by adding that individuals with unaided discrimination scores below 50% cannot expect to follow c o n v e r s a t i o n even with amplification (williamson & webber, 1985). hence, none of these subjects are candidates for successful amplification. a comparison of word recognition scores in quiet and noise, before and after modifications is illustrated in table 5. the criteria for a good hearing aid fitting in terms of word recognition scores is 80% or above according to ewerston (1966) and niemeyer (1969), thus only subject e's response in quiet conditions can be considered a good fitting. a scatterplot of word recognition scores in both quiet and noisy situations versus delta functional gain (delta fg), where delta fg refers to the modulus of the difference between actual and ideal fg generated and a definite trend noted. linear regression lines are as indicated in figure 2 below. (δ) delta insertion gain (db) • quiet • noise quiet noisy figure 2. linear regression of word recognition scores versus delta functional gain. (a) quiet conditions there appears to be a general trend towards improved word recognition scores as delta fg decreases. this suggests that pogo could provide some acceptable criteria for hearing aid use in quiet situations. a correlation coefficient of 0,79 confirms an acceptable correlation between word recognition scores and delta fg and is statistically significant. the regression line for the quiet condition is more reliable than that generated in noise. an r-square value of 63,39 implies that the regression curves account for 63% of the variation in the data. the correlation coefficient of 0,79 confirms an acceptable correlation between word recognition scores and delta fg. the f-ratio of 15,6 also describes the significance of the curve as a whole. (b) noisy conditions there is a far weaker trend towards improvement of word recognition in noise, and decreases in delta fg. indeed with regard to the regression line obtained for noisy conditions, only 29% of the variation is explained by the regression line i.e., r-square value of 29,49. this slope cannot be regarded as statistically significant. the curve could, however, still intuitively be considered significant and shows the kind of trend expected. however, these results are not convincing and may be due to the fact that required gain was not always successfully met at 4000hz as illustrated in table 3. alternatively, pogo may not be providing sufficient high frequency amplification as considered essential by pascoe (1985), or does not limit low frequency amplification to prevent the upward spread of low frequency masking in the presence of background noise. in summary, the regression line for quiet conditions supports the argument that as the delta fg decreases so word recognition scores improve. in addition, it acknowledges that a relationship does exist. on the other hand, the regression line for noisy conditions does not support this argument convincingly although a slight trend can be seen. intuitively some relationship does seem to exist since statistically the slope of this line cannot be construed as being zero. the correlation coefficient and r-square values support the latter statement. | it is evident from the above analysis that a closer approximation to ideal functional gain measurements as prescribed by pogo results in an improvement in word recognition scores, especially in quiet conditions. a disappointing correlation was found in noisy situations but it is anticipated that a closer approximation of ideal gain at 4000hz could improve results. welzl-muller & sattler (1984) note that patients whose hearing defects already cause a marked deterioration of word recognition in noise without a hearing aid, are considerably impaired even with a hearing aid. this may account for the poor relationship between word recognition scores in noise and delta fg. moreover, the central processing deficits in the geriatric ^population have been well documented and the difficulties encountered in noise is particularly noteworthy (staab, 1993). the results should, however, be viewed critically because of the poor test-retest reliability of word recognition testing and the high probability that differences in performance, could be due to chance and not changes in electroacoustic characteristics of the hearing aid the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the efficacy of the prescription of gain/output (pogo) in fitting hearing aids to mild and moderate sensorineural hearing losses 71 (schwartz & walden, 1983). hence, it is difficult to distinguish whether changes in word recognition scores are due to a closer approximation of functional gain values with pogo or the unreliability of word recognition measures. 3. subject satisfaction subject satisfaction was determined from responses to question 1 of the hearing aid questionnaire (refer appendix 1), taking into account questions 7 to 10. the former gave an indication of the subject's fundamental feeling about the hearing aid, whilst the latter determined specific circumstances of communication difficulty, benefits derived from the hearing aid and the necessity for further changes to the aid. satisfaction was ranked as 0 for happy and 1 for unhappy. in order to determine the relationship between satisfaction and delta fg, the following procedure was administered. delta fg was ranked as 0 for small differences and 1 for large differences. a grand mean of means of the differences in fg and satisfaction was taken for 11 data sets i.e., six subjects before and five subjects after modification. delta fg was compared to this grand mean. two of these differences were excluded from the analysis as their closeness to the grand mean implies that they were indeterminate differences i.e., neither small nor large. with the remaining nine data sets, a correlation matrix was drawn up showing an apparent correlation between satisfaction and delta fg. a ranking of 0 represents small delta fgs or good satisfaction with the hearing aid whilst a ranking of 1 shows that large differences exist between required and functional gain or that the patient was dissatisfied with the hearing aids. table 6 reflects that in 4 cases where the difference between actual and required gain is small, the subject is happy with his hearing aid. conversely, 3 cases show that large differences are associated with dissatisfaction. a spearman's correlation coefficient of 0,55 was recorded for correlation within this matrix. these results show a· general correlation between improved user satisfaction and smaller delta fgs but j [satisfaction 0 1 row total delta (δ) insertion gain 0 4 80 1 25 5 55.8 1 1 20 3 75 4 44.4 column 5 3 9 total 55.6 44.4 100 table 6. a correlation matrix depicting the relationship between satisfaction and delta functional gain they are disappointing. hearing aid fitting using the pogo solely does not appear to be sufficient to ensure user satisfaction and supplementary methods of hearing aid evaluation are therefore indicated. according to mccandless & lyregaard (1983) in the final analysis it is the patient who has the last word in hearing aid fitting as it is he/she who must live with the hearing aid in daily life. thus, from the above analysis we can tentatively suggest that a close approximation of hearing aid reponses to pogo results in a more satisfactory fitting. conclusions although the sample size was too small to allow any meaningful interpretation, there appears to be some correlation between the magnitude of difference in delta fg, scores obtained on word recognition tests and the user's satisfaction with the hearing device. it appears that as differences between functional and required fg decreases, so speech intelligibility and satisfaction improves. in the light of the afore-mentioned statements, we can tentatively suggest that the application of pogo appears to result in more acceptable hearing aid fittings and that it is fulfilling a very necessary requirement. it seems to be best suited to providing the basis for further modifications, i.e., it is a starting point at which to prescribe frequency and gain characteristics of the hearing aid as one can intuitively assess that improvements in gain will result in better speech intelligibility and greater satisfaction. the weak trends, however, suggest that pogo cannot be used solely but should be used with supplementary methods of hearing aid evaluation. this is particularly true if the hearing aid is to be used in noisy situations for large periods of time. in conclusion, "there is no single standard of hearing aid selection" (pascoe, 1986). however, the prescription of gain/output appears to be a valid predictor of the electroacoustic characteristics of a hearing aid, necessary for improved speech intelligibility and satisfaction. there are therefore direct implications for the introduction of this hearing aid fitting procedure to replace the modified carhart comparative approach as a gross hearing aid selection procedure, at least in patients presenting with mild and moderate sensorineural hearing impairments. these results also suggest that pogo may be used on other h e a r i n g i m p a i r e d populations other than the one researched. acknowledgements the authors wish to express their sincere thanks to mr d. smith of acoustimed hearing services for his time, willingness and assistance in earmould and instrument modifications. references angelo, r. & miller, g. 1988. selecting hearing aid gain and frequency response characteristics based on a comparison of loudness judgments and pogo, seminars in hearing, 9, 3, p.183-195. berger, k.w. 1991. introduction to three current hearing aid fitting methods, the american journal of otology, 12, 1, 40-44. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 s a n d r a t h o r p e & c a r o l j a r d i n e berger, k.w., hagberg, e.n. & rane, r.l. (1984). prescription of hearing aids : rationale, procedures and results, 4th edition, ohio : herald publishing house. bress, f. & bratt, g. (1977). special alterations of hearing aids and their effects on speech intelligibility. in larson, v., egolt, d., kirlin, r. & stile, s., auditory and hearing prosthetics research, new york : grune and stratton. buerkli-halevy, o. (1988). a guide to practical application of preselection formulae, phonak focus, 6, p.1-17. carhart, r. 1946. tests for the selection of hearing aids. laryngoscope. 56, 510-526. chasin, m.n. 1988. a clinically adaptive hearing aid fitting procedure, seminars in hearing, 9, 3, p.207-215. downs, d. (1982). effects of hearing aid use on speech discrimination and listening effort. journal of speech and hearing disorders, 47, 189-193. ewerston, h. 1966. the fitting of hearing aids in the danish hearing rehabilitation centres. audiology, 5, 2, p.384-391. hawkins, d., montgomery, α., prosek, r. & walden, b. 1987. examination of two issues concerning functional gain measurements. journal of speech and hearing disorders 52, 58-63. hirsch, i.j. 1952. the measurement of hearing. new york : mcgraw-hill book company. hodgson w. 1986. hearing aid evaluation : chapter 7. in hodgson w., hearing aid assessment and use in audiologic habilitation, 3rd ed., baltimore : williams and wilkins co. hodgson, w. 1987. basic audiologic evaluation. malabar : robert ε krigler publishing company. maclean, m. 1988. application of the national acoustics laboratories' hearing aid selection procedure and a new hearing aid assessment questionnaire. seminars in hearing, 9, 3, 173-181. mccandless, g. & lyregaard, p. 1983. prescription of gain/ output (pogo) for hearing aids. hearing instruments, 34, 1, 16-21. niemeyer, w. 1969. difficulties and effectivity of hearing aid equipment in presbyacusis. audiology. 8, 4, 535-538. northern, j. 1993. hearing aids, university of stellenbosch and south african speech-language-hearing association conference, somerset west, october. pascoe, d. 1985. hearing aid evaluation : chapter 46. in katz, j. (ed.), handbook of clinical audiology, 3rd edition, baltimore : williams & wilkins. ringdahl, α., leijon, α., liden, g., & backelin, l. 1984. hearing aid prescription rules using insertion gain measurements. scandinavian audiology, 13, 211-218. rose, d. 1977. hearing aid evaluation historical and present day perspectives. in larson, v., egolt, d, kirlin, r. & stile, s., auditory and prosthetic research, new york : grune and stratton. schmitz, h.d. 1980. hearing aid selection for adults : chapter 5. in pollack m.c. (ed.). amplification for the hearingimpaired, 2nd edition, new york : grune and stratton. schwartz, d. & walden, b. 1983. speech audiometry and hearing aid assessment: a reappraisal of an old philosophy. in konkle, j. and rintelmann, j.,perspectives in audiology series : principles of speech audiometry. baltimore : university park press. shapiro, i. 1976. hearing aid fitting by prescription. audiology, 15, 163-173. staab, w. 1993. hearing aid fittings in the geriatric population, society of hearing aid acousticians symposium, johannesburg, august. welzl-muller, k. & sattler, k. 1984. signal-to-noise threshold with and without hearing aid. scandinavian audiology, 13, 283-286. williamson, d.g. & webber p.j. 1985. hearing aid selection for adults : a review, audiological acoustics, 24, 1-16. a p p e n d i x 1 : h e a r i n g a i d a s s e s s m e n t q u e s t i o n n a i r e (maclean, 1988, p. 179) patient's n a m e : y e s n 0 1. a r e y o u h a p p y w i t h your h e a r i n g aid? 2. is it p h y s i c a l l y comfortable? 3. do y o u h a v e difficulties : a. i n s t a l l i n g it? b. o p e r a t i n g it? c. c l e a n i n g it? d. w i t h feedback (squealing or w h i s t l i n g ) ? 4. do other people's voices s o u n d p l e a s a n t ? 5. is the s o u n d of your o w n voice o k a y ? 6. do y o u h a v e difficulty w i t h the p h o n e ? 7. before y o u r e c e i v e d the aid w h a t w a s your m o s t t r o u b l e s o m e listening situation? 8. in that s i t u a t i o n , has the aid h e l p e d ? 9. has the aid h e l p e d in other s i t u a t i o n s ? 10. w h i c h l i s t e n i n g situations still pose p r o b l e m s ? 11. a r e you satisfied w i t h b a t t e r y life? 12. how m a n y h o u r s per day do y o u w e a r the aid? 13. in general are y o u getting g o o d v a l u e for the m o n e y spent on the aid? 14. would y o u r e c o m m e n d that a h e a r i n g h a n d i c a p p e d friend or relative try one? 15. a d d i t i o n a l c o m m e n t s . / the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 51 methodological considerations in employing the continuous discourse tracking procedure with hearing-impaired adults l. le roux, ba (pretoria) department of speech pathology and audiology, university of the witwatersrand, johannesburg r.w. turton, ma (witwatersrand) department of psychology, university of the witwatersrand, johannesburg abstract this article addresses the various methodological issues involved in the use of the continuous discourse tracking (cdt) procedure as a test instrument for evaluating communication efficiency in hearing-impaired adults. an overview of the potentially confounding variables associated with the cdt technique is provided and consideration isgiven to the reliability of this procedure with reference to areas requiring systematic investigation. it is proposed that the adoption of an alternative paradigm as well as interdisciplinary approach to test construction may facilitate a multi-dimensional perspective to the assessment of speechreading and communicative ability in the hearing-impaired population. opsomming hierdie artikel bespreek die verskillende metodologiese aspekte inherent aan die gebruik van die "continuous discourse tracking" prosedure as 'n meetinstrument by die evaluering van kommunikasie-effektiwiteit by gehoorgestremde volwassenes. 'n teoretiese oorsig van die moontlike kontaminerende veranderlikes wat met hierdie tegniek gepaardgaan, word verskaf. vervolgens word die betroubaarheid van hierdie instrument indringend beskou met verwysing na navorsingsareas wat sistematiese ondersoek verg. daar word voorgestel dat die aanvaarding van 'n alternatiewe paradigma sowel as interdissiplinere pogings wat betref toetskonstruksie, 'n multidimensionele benadering tot die evaluasie van spraaklees en kommunikasievermoens by gehoorgestremdes kan bevorder. introduction recent advanced technology has introduced a new era in intervention strategies with profoundly hearing-impaired individuals, particularly for those postlingually deafened. south africa has recently inaugurated a multi-disciplinary approach to the assessment and rehabilitation of these individuals (miiller, 1988) which has sparked joff general interest in the potential benefits of cochlear implants in particular. for the audiologist, whose role is crucial, these developments present exciting challenges. t h e profession is increasingly called upon not only to assess candidates for cochlear prostheses, but also to recommend suitable alternatives, document the effectiveness of sensory devices and to provide for essential after-care services. these considerations, coupled with the current focus on quality assurance in clinical practice, emphasize the importance of accurate measurement of speech communication in the profoundly hearing-impaired. in addition, there is an urgent need to adapt currently available test instruments and to construct test stimuli to meet local demands for culturally appropriate diagnostic tools. the objective of this paper is to consider critically one of the speechreading assessment techniques, namely the continuous discourse tracking procedure, which has been widely applied to the assessment and treatment of postlingually, die suid-afrikaanse tydskrif vir kommunikasieafwykiniis, vol. 37. 1990 profoundly hearing-impaired persons. an appreciation of this technique is essential in order to avoid mechanical application of this procedure and to encourage clinicians to become discerning test users. the assessment of speechreading ability in reviewing the literature on speechreading assessment it is notable that, despite the absence of a conclusive theoretical framework for speech information processing, many innovative and radically different approaches have appeared during the last decade (e.g. boothroyd, 1987 (cited in montgomery & demorest, 1988); cronin, 1979; middelweerd & plomp, 1987). the absence of a viable model of speech perception has, nevertheless, exerted a noticeable influence on the standard of speechreading instruments developed so far; montgomery & demorest (1988) view most of these as being of inferior quality and describe them as not meeting current psychometric requirements. this statement needs some qualification however; it pertains specifically to the insufficient availability of psychometric data on existing measures, rather than to the inadequacy of the instruments per se. fortunately, as a result of several developments, most researchers are positive about improvements in the standard of speechreading instruments. they base their optimism on the following: θ sash a 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a legacy of sound advice and equipment philips hearing aids audiometers fm systems head office: 1005 cavendish chambers, 183 jeppe street p.o. box 3069, johannesburg 2000. tel: (011) 337-7537. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) methodological considerations in continuous discourse tracking procedure w i t h hearing-impaired adults 53 1) the recent strides which have been made in terms of model development (massaro, 1987); 2) the advent of interactive videodisc technology which has opened up avenues for exploring new methods of testing and 3) the availability of test construction and evaluation techniques which hopefully will be increasingly used by experimenters in this field during the stages of test development. at present, however, it is generally agreed that the researcherclinician who strives to evaluate an individual's speechreading performance in a reliable manner, is confronted with an extremely complex task. the connected discourse tracking (cdt) procedure one unique and highly versatile procedure which represents an alternative aproach to the measurement of speechreading skills in the hearing-impaired, is the cdt procedure, originally described by de filippo and scott (1978). tracking is a timed technique in which the talker (sender.) reads from a prepared text presented in a phrase-by-phrase manner. the receiver "listens" to each successive group of words as an entity, before repeating verbatim what the sender has said. if the receiver is correct, the talker proceeds to the next segment; if an error occurs in the repetition of the material, the talker and receiver employ various strategies to elicit a verbatim response. the goal of the procedure is to obtain a repetition that matches the text verbatim without the use of non-speechrelated cues such as gestures (de filippo & scott, 1978). tracking performance is quantified and scored in terms of the number of words transmitted per minute (wpm). this procedure can be differentiated from traditional approaches to speechreading testing on the following grounds: 1) it comprises a discourse task and therefore ongoing "meaningful speech" (and not isolated, single-word stimuli-) is employed. j 2 ) / l t can be described as interactive in nature. since the procedure utilises a dyad and the talker's behaviour depends on the speechreader's performance, the interactive dynamics of a real conversation are allowed to play an important role in the evaluation. 3) the scoring deviates drastically from conventional procedures in that the typically "all or nothing" approach to sentence scoring is not employed; rather, scoring results is a rate measure (although as a prerequisite a 100% accuracy is implied.) 4) the final wpm score relates to communication efficiency and, as such, represents a composite measure of communication rate. therefore, in contrast with traditional measures, the wpm score reflects all the components within the communication interaction, namely the transmission, processing and correction as well as response time. in fact, de filippo and scott (1978) have suggested that this task not only taps perceptual skills (and the accuracy thereof), but a combination of an individual's perceptual and communicative abilities. since the tracking technique's inception, it has been used with individuals of all ages and with a number of modifications for multiple purposes (owens &iraggio, 1987; osberger, johnson & miller, 1987). as mentioned previously, its most extensive use has been in studies documenting changes in communication efficiency as a result of sensory devices (cowan, alcanta, blarney & clark, 1988; de filippo & scott, 1978; sparks et al. 1979; muller, 1988). in addition, a number of studies [e.g. danz & binnie, 1983; lesner & kricos, 1987) have demonstrated its feasibility for intervention and training purposes. for the purpose of this article, discussions will be limited to the use of speech tracking with adults. appeal of t h e speech tracking procedure since tracking is a live-voice procedure, it can be easily administered without the use of any equipment. in addition, it allows for quantification of the efficacy of the communication process. the procedure requires a different passage to be used at each session and therefore any learning of the test material is prevented. in view of the fact that ongoing speech is used in an interactive manner, "real-life" conditions are more closely approximated with use of the cdt technique; the task is therefore known for its high face validity (levitt, waltzman, shapiro & cohen, 1986). as with many of the tracking method's predecessors, the development of this procedure seems to have arisen from clinical necessity. in retrospect, it is speculated that perhaps one of the major motivations for its development revolved around the aspect of repeated presentations. it seemed that the typical practice effects associated with perceptual tasks could be bypassed by means of this new technique. although difficulties associated with traditional speechreading tests have to some extent been overcome by the speech tracking procedure and while other problematic issues are shared by conventional methods of speech recognition testing, it has now become apparent that this new procedure has introduced different sources of variability, which have often been disregarded by the clinical and research communities (for example, hopkinson et al. 1986). these methodological issues appear to contra-indicate the use of tracking for purposes of evaluation and in research investigations employing an across-subject design(lesner, lynn & brainard, 1988). a recent position paper by tye-murray and tyler (1988) has been the first to review and identify formally the confounding variables specific to this technique. in addition, in order to minimize the shortcomings associated with the use of this test instrument, these authors have proposed stringent guidelines for within-subject testing. criticisms directed at continuous discourse tracking as a test procedure the overall concern regarding the use of tracking as a test instrument pertains to one major aspect, namely that the ultimate score achieved by a receiver will vary as a function of several extraneous variables. tye-murray & tyler (1988) maintain that these variables are almost impossible to control. as mentioned before, many of the problems associated with tracking as a test procedure are also relevant to the use of sentence-list speechreading tests. in their opinion, however, there are unique shortcomings specific to the use of the tracking task. this has led these authors to conclude that the speech tracking procedure "does not reliably measure a receiver's ability to recognize speech" (tye-murray & tyler, 1988, p. 227). in contrast de filippo (1988) has argued that "for evaluating speechreading performance tracking requires careful attention to the (very) same issues of assessment as any other die suid-afrikaanse tydskrif vir kommunikasieafi<njl:in/is, vol. :17. 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 l. le roux & r.w. turton (speechreading) technique" (emphases added) (p. 230). hence, the purpose of the following discussion is firstly, to summarise the main variables and issues of concern faced by the clinician-researcher when employing the cdt procedure for evaluative purposes. particular emphasis is given to textrelated variables, since a review of the literature reveals an urgent need to give priority attention to issues underlying this aspect. secondly, in response to tye-murray and tyler's (1988) critique, this article endeavours to address some fundamental theoretical issues arising from their comments and to delineate areas awaiting further exploration. such investigations are deemed essential, before the cdt technique is either prematurely discarded or restricted in terms of its potential usefulness as an assessment tool. table 1: summary of sources of error associated w ith the cdt task sender (s) variables: rapport and familiarity with receiver (r) ss' different testing/interaction styles ss' personal attributes: visual intelligibility, clarity of speech production etc. sender bias change of s characteristics over time variations in s presentation across conditions receiver (r) variables: degree of familiarity with s speech intelligibility and language proficiency ability to utilise contextual cues interactions between rs and text material cognitive abilities (e.g. memory) age variables learning and adaptation effects differences in nonsensory factors: motivation, r bias team variables: strategy used across conditions efficiency in probing/use of repair strategies text variables: text complexity literary style (dialogue vs descriptive vs narrative) ease of segmenting text level of familiarity/difficulty throughout text socio-cultural relevance resemblance to the spoken idiom source of material booklength material: r's ability to exploit story plot, r's familiarity with characters passage equivalence: across conditions, devices and r's; method whereby determined scoring variables: type of scoiing system method used in interpretation of scores manner whereby missed words are accounted for the application of the cdt procedure to the test situation gives rise to the issues of uncontrolled sender and receiver characteristics as well as confounding text characteristics. in addition, a variety of scoring schemes have been proposed some with the precise aim of statistically controlling the sources of variability. table 1 provides an overview of confounding variables associated with the use of tracking as a test procedure as identified and described in some of the most recent publications (tye-murray & tyler, 1988; de filippo, 1988; lesner, lynn et al. 1988; montgomery & demorest, 1988). proposed solutions for minimizing these effects are summarized in table 2. table 2: summary of strategies which may reduce error on the cdt task for sender (s) variables: use a variety of senders (ss) probe the effects of different senders train ss before data collection define the ss' rules provide sources of external validation computerise the speech tracking task keep s blind to the test condition monitor s externally use same s across conditions for receiver (r) variables: provide orientation to the tracking task provide pre-training practice specify the repair strategies ensure that r (s) follow precise pattern of responding insist on verbatim responses include a last-resort repair strategy "normalise" the tracking scores probe suspect nonsensory effects for team variables: provide both partners with orientation and practice for text variables: use of different text source each session? use of controlled materials average performance over a large sample of text/time predetermine passage equivalence determine text equivalence by: subjective ratings of passages by a panel ranking of texts based on scores of good speechreaders grading of selected texts for scoring variables: ' y use wpm scores only for within-subject comparison reduce some sources of error by use^of scoring systems / account for missed words by. adopting a penalty scheme or limiting the correction time the south african journal of coiuwnuicarioii disorders. vol. .17. 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) methodological considerations in continuous discourse tracking procedure w i t h hearing-impaired adults 5 5 sender variables as reflected in table 1, the sources of talker variability constitute one of the major obstacles to the collection of reliable and valid assessments. although recent developments in computer-assisted tracking such as casper (boothroyd, 1987 citedbyde filippo, 1988) and cast (fuller &cicchelli, 1986 cited by sims, 1988) offer a potential solution in terms of controlling talker variables; it will be at the cost of restricting interactions with the receiver and limiting tracking as a test procedure to well-equipped centres. however, in the light of mounting criticisms of the use of tracking as a test, computerisation of the cdt technique for evaluative purposes may eventually become universal. it follows that until such time and until further more specific information regarding the differential effects of the various sender variables becomes available, clinicians and researchers will need to take the necessary steps to ensure adequate talker training. in fact, the implementation of the suggestions provided in the literature can be viewed as a pre-requisite for generating data of at least minimal accuracy and borderline reliability. in addition, as highlighted by the study of sparks et al. (1979), it remains the obligation of the experimenter/ clinician to explore particular sender effects, for instance talker bias, whenever this becomes suspect. receiver variables many receiver-related confounding variables do not appear to be unique to tracking. nonsensory factors such as reluctance to guess, motivation, level of attention and alertness also operate when other speech recognition tests are employed, although it is apparent that some speechreader characteristics (day-to-day variability over time, the receiver's learning curve of the tracking task per se) specifically pertain to tracking. as suggested by montgomery and demorest (1988) nonsensory effects are an important area for research, requiring specialised research designs and; new methods of testing speech recognition. in the meantime,1 the diagnostician who strives to increase her/his accountability in clinical practice will stand to benefit from allocating sufficient time to incorporate de filippo's (1988) proposed sets of activities which are aimed at reducing the effects associated with receiver task learning. furthermore, by ensuring optimal test conditions and replicating conditions, one can minimise the influence of short term maturational effects. j i text variables ^ the most neglected area in terms of speechreading assessment in general concerns the issues of test construction and evaluation. these inadequacies are also apparent when it comes to the tracking method. it is clear that no standardised or extensively researched text materials are available for use with cdt and investigators employ a variety of connected discourse materials selected from a wide range of sources. furthermore, there are variations in the degree to which such materials have been adapted and subjected to preliminary investigations. an unfortunate trend which has been noted is that investigators seem to prefer the selection of new "untested" materials, rather than subjecting existing text material to further refinements before administration to their subjects. in terms of material selection and text composition, it is evident that only arbitrary guidelines and loosely defined criteria appear to be available in the audiology literature. the urgent need for rigorous studies in order to find the optimum length, type, and linguistic difficulty of tracking materials has been echoed by researchers such as lesner & kricos (1987) and matthies & carney (1988). perhaps by borrowing from recent interdisciplinary research in the study of connected discourse (e.g. ulatowska et al. 1983; van dijk & kintsch, 1978) audiologists could establish more objective methods for indexing the complexity and structure of the various types of discourse materials. this would be a promising first step in generating more specific and academically sound criteria for the construction of text materials. another factor often ignored by therapists using the cdt technique, but of considerable importance in terms of the south african context, is the selection of culturally appropriate test stimuli. a practice which appears to characterise existing "try-out" procedures during the test development and evaluation stage of the tracking task involves the reliance on subjective and rather superficial methods of determining the suitability of the material. as borne out by the studies of lesner and kricos (1987) and lesner et al. (1988), the piloting of text material on a few normal hearing college students does not guarantee suitability of the text stimuli particularly when tracking is performed with the geriatric population. nor does rating by a panel of judges alone ensure enterpassage equivalence. it follows that the application of more large-scale and thorough methods to determine the suitability of text materials is indicated and this area should become a research priority. the provision of psychometric data for any newly constructed test is a recurrent theme in the research literature on speech pathology and audiology. ventry & schiavetti (1980) make the point that many researchers fail to realise that the concept of reliability and its assessment also applies to measurements made by those who develop their own measuring material. it is generally agreed that extra time should be spent by such researchers (as well as test users) in examining the instruments' reliability before reporting on their use. in terms of the tracking task itself (and the material employed), test evaluation is urgently required in order to examine systematically the various facets of reliability, inter-passage equivalence, susceptibility to practice, talker influences, etc. by calibrating the cdt procedure on a large representative sample and analysing the data psychometrically utilising the present statistical theories applicable to speechreading instruments (montgomery & demorest, 1988), more concrete documentation regarding the performance of hearing-impaired individuals on the tracking task could be obtained. in accordance with the main focus of this paper, namely, the need for systematic research into the suitability of text materials, the authors propose that a small sample of passages is initially selected for investigation and that this sample is: 1) rated for similarity by expert judges; 2) assessed for equivalence in the reading speed (wpm) of senders using a repeated measures design with control of order effects; 3) assessed for equivalence of comprehensibility by normal hearing agegraded receivers; 4) assessed for equivalence in cdt wpm rates using normal hearing receivers and the same type of design advocated in (2); die suid-afrikaanse tydskrif vir kommunikasicahvjikings. vol. 37. 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 l. le roux & r.w. turton 5) used to establish norms in terms of the average wpm rates of agegraded normal hearing receivers; and 6) assessed for text equivalence by using number of errors as the criterion measure. in terms of this requirement the same person should make the same number of errors on each text. in addition, test-retest reliability in the form of correlations (per text) of the wpm performance data can be computed. in this case test-retest intervals must be large enough to counter the effects of memory and text learning but short enough to avoid maturational influences. methods of scoring one of the major issues faced by test developers interested in speechreading performance concerns the important and rather arbitrary decision-making required in the selection of a final scoring system. in tracking, no universal scoring procedure exists and this further complicates the interpretation of tracking performance across studies. it is uniformly agreed that absolute wpm scores have little meaning on their own, except perhaps in within-subject comparisons. as discussed in the literature, expressing performance in terms of relative gain, although meaningful, can be quite misleading if reported only in terms of gain. chemal (1989) and de filippo( 1988) point out the differences in functional communication skills between the following two individuals: a) speechreader a who has changed tracking rate from 10-20 wpm and β who has increased from 45-90 wpm. although both individuals claim a 100% gain (by doubling their scores), the difference in functional communication between individual a and β are considerable. b) speechreader a who demonstrates a 10 wpm gain in tracking rate (improvement from 20-30 wpm) and β who also demonstrates a relative gain of 10 wpm by increasing his/ her scores from 90-100 wpm. again, the differences in functional skills between the two receivers are clear, despite the uniform increments in tracking rates. a number of modifications to the calculation of the wpm scores which minimise the influence of some sources of variability have been suggested in the literature. until a uniformscheme has been adopted, however, it would appear essential for the clinician-researcher to heed the following statement (de filippo, 1988, p. 299): "scoring should be accomplished by strict adherence to whatever rule system is constructed for both talker and speechreader, with consistency in its application, adjustment of the final wpm score to account for missed words and inclusion of sufficient data in each score reported." discussion despite the apparent simplicity of the procedure, clinical experience with tracking and preliminary investigations of this method have established that speech tracking is not straightforward. in fact, a number of issues need to be fully appreciated in order to avoid the many pitfalls inherent in its application. in the experience of the first author, the implementation of the multitude of precautions cited in the literature (in order to reduce possible contamination of tracking data) has certain negative effects. the clinician in order to adhere to all the "rules" (in an attempt to approximate laboratory conditions), tends to become a "testing robot" and some of the original appeal of the tracking method is thereby lost. in such circumstances, the clinician who assesses client performance may well be tempted to hand over the task of evaluation to high technology instruments. this problem which reflects the fine balance which exists between internal validity (control) and external validity(generalisability) is well recognized in experimental methodology (kerlinger, 1983) and explains why any effort to increase control is likely to coincide with a decrease in external validity. in view of the above, future research which differentiates between "critical" and "negligible" extraneous variables affecting tracking performance would seem to be of paramount importance. it is evident that although previous research has suggested many potentially important factors influencing tracking performance, formal studies exploring their relative effects are seriously lacking. by examining the magnitude of potentially confounding variables (and not only the presence or absence thereof), the clinician-researcher is likely to be in a better position to identify and control the essential sources of variability. in addition, the problems associated with "over-control" will probably be greatly reduced. future studies employing single-subject designs may offer a suitable evaluation technique for exploring experimentally the extent of sender effects (i.e. sender maturation) and for manipulating sender characteristic such as talker bias. of equal importance is the reduplication of studies in order to systematically accumulate a substantial body of data which will assist in differentiating between "significant" and "insignificant" variables. however, any research applications of the tracking technique are likely to be severely restricted, until further studies into the establishment of equivalent passages and appropriate methods for determining passage equivalence are undertaken. it is felt that speech therapists/audiologists have much to contribute to the area of test development and evaluation. inter·; disciplinary efforts such as those evident in the development of sophisticated hearing handicap scales (demorest & erdman, 1987) have increased our professional confidence in both1 diagnosis and the specification of treatment strategies and! have enhanced our credibility as members of an essential! profession. j i in an attempt to address the need for more suitable local track-1 ing materials for assessment purposes, the first author com-; piled twenty sets of controlled text passages. a detailed account of the methodology used in the development of the material is beyond the scope of this article. it suffices to report that the available literature guidelines were employed in the construction of the material and modifications to the test passages were performed as a result of subjective ratings on a number of criteria by two independent speech therapists/ audiologists. evaluation of a small sample of selected texts has been initiated and is continuing. conclusion / x , / the foregoing discussion highlighted the need to establish research priorities in terms of future investigations pertaining the south african journal of communication disorders, vol. 37, 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) m e t h o d o l o g i c a l c o n s i d e r a t i o n s i n c o n t i n u o u s d i s c o u r s e t r a c k i n g p r o c e d u r e w i t h h e a r i n g i m p a i r e d a d u l t s 5 7 to t h e t r a c k i n g p r o c e d u r e . f u r t h e r m o r e , specific r e c o m m e n d a t i o n s in t h i s r e g a r d w e r e p r o p o s e d . at t h e s a m e time, it s e e m s r a t h e r u n r e a l i s t i c to r e q u i r e t h a t o n e p a r t i c u l a r m e a s u r e m e n t tool s h o u l d be e n t i r e l y a d e q u a t e to a c c o u n t for t h e m u l t i p l e d i m e n s i o n s u n d e r l y i n g t h e s t u d y of s p e e c h informat i o n p r o c e s s i n g d u r i n g face-to-face c o m m u n i c a t i o n . t r a c k i n g is a f u n c t i o n of a specified m e s s a g e a n d c h a n n e l a n d t a k e s place i n a specific e n v i r o n m e n t . t h e r e s u l t a n t t r a c k i n g score globally, if i m p r e c i s e , reflects t h e c o m b i n a t i o n a n d i n t e r a c t i o n of all t h e s e c o m p o n e n t s a s t h e y r e l a t e to a single c o n t e x t . in fact, t h e a d v a n t a g e of for i n s t a n c e , g a r s t e c k i ' s ( 1 9 8 1 ) assessm e n t s c h e m e is t h a t it p e r m i t s s y s t e m a t i c s a m p l i n g of a u d i t o r y v i s u a l s p e e c h p e r c e p t i o n p e r f o r m a n c e over a m u c h b r o a d e r c o n t i n u u m . f i n a l l y , it m u s t be r e m e m b e r e d t h a t t h e p r e s e n t c r i t i c i s m s d i r e c t e d at t h e c d t p r o c e d u r e reflect m u c h of a cause-effect t h e o r e t i c a l f r a m e w o r k in t e r m s of r e s e a r c h m e t h o d o l o g y . n e w p a r a d i g m s p a r t i c u l a r l y i n t h e field of p s y c h o l o g y (e.g. b u s s & c a n t o r , 1 9 8 9 ) a r e e m e r g i n g w i t h t h e e m p h a s i s o n i n t e r a c t i v e a s s e s s m e n t a n d e v a l u a t i o n of t h e a d a p t i v e f u n c t i o n i n g of t h e i n d i v i d u a l i n t e r m s of real-life d e m a n d s . r o s s ( 1 9 8 8 ) for e x a m ple, refers to t h e e c o p s y c h o l o g i c a l a p p r o a c h i n t h e a s s e s s m e n t of the b e h a v i o u r of d e a f i n d i v i d u a l s w h i c h h a s e m e r g e d i n resp o n s e to g r o w i n g d i s e n c h a n t m e n t w i t h t r a d i t i o n a l p e r s o n a l i t y tests. in t h e a r e a of e v a l u a t i n g s p e e c h r e a d i n g a n d c o m m u n i c a tive f u n c t i o n i n g of t h e h e a r i n g i m p a i r e d a d u l t , t h e a d o p t i o n of s u c h a p a r a d i g m w o u l d a p p e a r to h a v e t h e p o t e n t i a l of p r o v i d ing t h e c l i n i c i a n w i t h f u n c t i o n a l m e a s u r e s of a p p r a i s a l w h i c h , in c o n j u n c t i o n w i t h t h e u s e of formalized m e t h o d s , c o u l d u l t i m a t e l y c o n t r i b u t e to a m o r e i n t e g r a t e d d i a g n o s i s a n d b a l a n c e d t h e o r e t i c a l p e r s p e c t i v e . a c k n o w l e d g e m e n t s t h i s p a p e r is d e d i c a t e d t o t h e late m r s e v e l y n v e r m a a k w h o s e active p a r t i c i p a t i o n in t h e r a p y g r e a t l y e n h a n c e d t h e clinical p e r s p e c t i v e of t h i s a r t i c l e . t h e w r i t e r s gratefully a c k n o w l e d g e t h e s u p p o r t of t h e following p e r s o n s d u r i n g t h e p r e p a r a t i o n of t h i s m a n u s c r i p t : professor jc p e n n ( h e a d , d e p a r t m e n t of s p e e c h p a t h o l o g y a n d a u d i o l o g y , u n i v e r s i t y of t h e w i t w a t e r s r a n d ) , alida miiller, e l e a n o r ross, d e n i s e a n d e r s o n , sue s h e r r a t a n d h e i l a j o r d a a n . r e f e r e n c e s bliss, d.m. and cantor-, n. personality psychology: recent trends and emerging directions. springer-verlag, new york, 1989. chemal, c. personal communication. (ex) senior research specialist, nipr, johannesburg, 1989. cowan, r.s.c., alcanta, j.i., blarney, p.j. and clark, g.m. preliminary evaluation of a multichannel electrotactile speech processor. journal of the acoustical society of america, 83, 2328-2338, 1988. cronin, b. the david system: the development of an interactive video system at the national technical institute for the deaf. american annals of the deaf, 124, 616-618,1979. danz, a.d. and binnie, c.a. quantification of the effects of training the auditory-visual reception of connected speech. ear and hearing, 4, 146-151, 1983. de filippo, c.l. tracking for speechreading training. in de filippo, c.l. & sims, d.g. (eds.) new reflections on speechreading. the volta review, 90, 215-236, 1988. de filippo, c.l. & scott, b.l. a method for training and evaluating the reception of ongoing speech. journal of the acoustical societg of america, 63, 1186-1192, 1978. demorest, m.e. and erdman, s.a. development of the communication profile for the hearing-impaired. journal of speech and hearing disorders, 52, 129:143, 1987.' garstecki, d.c. auditory-visual training paradigm for hearingimpaired adults. journal of the academy of rehabilitative audiology, 14, 223-238, 1981. hopkinson, n.t., mcfarland, w.h., owens, e., reed, c., shallop, j., tillman, t„ tyler, r.s. and williams, p.s. report of the ad hoc committee on cochlear implants, asha, 28, 29-52, 1986. kerlinger, f.n. foundations of behavioural research. holt-saunders, new york, 1983. lesner,s.a. and kricos, p.b. tracking as a communication enhancement strategy with nursing home residents. journal of the academy of rehabilitative audiology, 20, 39-48, 1987. lesner, s.a., lynn, j.m. and brainard, j. feasibility of using a singlesubject design for continuous discourse tracking measurement. journal of the academy of rehabilitative audiology, 21, 83-89, 1988. levitt, h. waltzman, s.b., shapiro, w.h. and cohen,l. evaluation of a cochlear prosthesis using connected discourse tracking. journal of rehabilitation research and development, 23, 147-154, 1985. massaro, d.w. speech perception hy ear and eye: a paradigm for psgchological inquiry. erlbaum, hillsdale, new jersey, 1987. matthies, m.l. and carney, a.e. a modified speech tracking procedure as a communicative performance measure. journal of speech and hearing research, 31, 394-404, 1988. middelweerd, m.j. and plomp, r. the effect of speechreading on the speech reception threshold of sentences in nois e.journal of the acoustical society of america, 82, 2145-2147, 1987. montgomery, a.a. and demorest, m.e. issues and developments in the evaluation of speechreading. in de filippo, c.l. and sims, d.g. (eds.) new reflections on speechreading. the volta review, 90, 1988. miiller, a.m.u. multichannel cochlear implant program at tygerberg hospital. proceedings of the audiology congress, south african speech and hearing association, cape town, 1988. osberger, m.j., johnson, d.l. and miller, j.d. use of connected discourse tracking to train functional speech skills. ear and hearing, 8, 31-36, 1987. owens, e. and raggio, m. the ucsf tracking procedure for evaluation and training of speech reception by hearing-impaired adults. journal of speech and hearing disorders, 52, 120-128, 1987. ross, e. the implications of applying empirical research with deaf communities. welfare focus, 23(2), 8-12, dec. 1988. sims, d.g. video methods for speechreading instruction. in de filippo, c.l. & sims, d.g. (eds.) new reflections on speechreading. the volta review. 90, 1988. sparks, d.w., ardell, l.a., bourgeois, m., wiedmer, b. and kuhl, p.k. investigating the mesa: the transmission of connected discourse. journal of the acoustical society of america, 65, 810815, 1979. tye-murray, n. and tyler, r.s. a critique of continuous discourse tracking as a test procedure. journal of speech and hearing disorders, 53, 226-231, 1988. ulatowska, h.k., freedman-stern, r., doyel, a.w., macalusohaynes, s. and north, a.j. production of narrative discourse in aphasia. brain and language, 19, 317-334, 1983. van dijk, t. a. and kintsch, w. cognitive psychology and discourse in recalling and summarizing stories. in dressier, w.u. (ed.) current trends in text linquistics. de gruyter, new york, 1978. ventry, i.m. and schiavetti, n. evaluating research in speech pathology and audiology. addison-wesley, menlo park, california, 1980. die suid-afrikaanse tdskrif r kommunikasiaikings. vol. 37 1990 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 in-the-canal hearing aids with acoustimed's exclusive "anti-feedback" technology aids the acoustic a d v a n t a g e s of i n t h e c a n a l h e a r i n g aids are well known. however, u n t i l now t h e i r use h a s been l i m i t e d by acoustic feedback which causes oscillation (whistling). acoustimed h a s developed a t e c h n i q u e for controlling t h e phase response of h e a r i n g aids t o prevent oscillation. full details are a t r a d e secret b u t r e s u l t s are s p e c t a c u l a r . we can now m a k e i n t h e c a n a l h e a r i n g aids t h a t have m o r e usable gain t h a n b e h i n d t h e e a r models a n d they do n o t oscillate regardless of how large we m a k e t h e v e n t . with t h e p h a n t o m model afp (power) version it is possible to correct nerve deafness with high frequency loss as g r e a t as 90db. the p h a n t o m models af a n d afp have a simple b u t effective noise control. when t h e volume is t u r n e d down low frequency noise is reduced more t h a n t h e essential high frequencies. this u n i q u e feature h a s t h e effect of improving t h e s i g n a l t o n o i s e r a t i o in noisy c o n d i t i o n s . because of t h e microphone position p h a n t o m h e a r i n g aids have b e t t e r high frequency performance t h a n b e h i n d t h e e a r models a n d since t h e r e is no t u b i n g they are more efficient a n d have a s m o o t h e r frequency response. previously l n t h e c a n a l h e a r i n g aids could be used only for mild h e a r i n g loss due to feedback problems. with t h e new p h a n t o m h e a r i n g aids t h e r e are less feedback problems t h a n with b e h i n d t h e e a r models. this allows us to m a k e p h a n t o m aids which work b e t t e r t h a n m a n y b e h i n d t h e e a r pp h e a r i n g aids. p h a n t o m h e a r i n g aids are m a d e in 3 basic models. the a p p r o x i m a t e fitting r a n g e is i l l u s t r a t e d in t h i s d i a g r a m . performance is controlled by t r a n s d u c e r selection. m unlimited venting without whistling more usable gain than behind-the-ear user-controlled noise reduction easily handled battery drawer frequency 125 250 500 ik 2κ 4khz acoustimed hearing services 327 bosman building cor. eloff and bree streets, johannesburg tel: fd11) 337-2977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 (continued from page 26) word intelligibility measures. journal f speech and hearing research 27, 623-626, 1984. schmidt s intelligibility and the child with multiple articulation deviations. in h.a. winitz (ed.), treating articulation disorders: for clinicians by clinicians. baltimore: university park press, 1984. schultz, m.c. world familiarity influences in speech discrimination. journal of speech and hearing research, 7, 395-400. shriberg, l.d. and kwiatkowski, j. phonological disorders iii: a procedure for assessing severity of involvement. journal of speech and hearing disorders. 47, 242-256, 1982. skelly, m. (ed.) glossectomee speech rehabilitation. springfield, illinois, charles c. thomas, 1973. south africa 1985: official yearbook of the republic of south africa. eleventh edition. johannesburg: chris van rensburg, 1985. tikofsky, r.s. a revised list for the estimation of dysarthric single word intelligibiliy. journal of speech and hearing research, 13, 59-64, 1970. tobias, j.v. on phonemic analysis of speech discrimination tests. journal of speech and hearing research, 7, 98-100, 1964. van wyk, e.b. language contact and bilingualism. in l.w. lanham and k.p. prinsloo (eds.), language and communication studies in south africa. cape town: oxford university press, 1978. westphal, e.o.j. syllable and sound change in southern bantu languages. journal of the south african speech and hearing association, 20, 22-41, 1973. marlene carno jacobson and anthony traill wilkes, a. bantu language studies. in l.w. lanham and k.p. prinsloo (eds.), language and communication in south africa, cape town: oxford university press, 1978. yorkston, k.m. and beukelman, d.r. a comparison of techniques for measuring intelligibility of dysarthric speech. journal of communication disorders, 499-512, 1978. yorkston, k.m. and beukelman, d.r. a. a clinician-judged technique for quantifying dysarthric speech based on single word intelligibility. journal of communication disorders, 13, 15-31 1980. yorkston, k.m. and beukelman, d.r. communication efficiency of dysarthric speakers as measured by sentence intelligibility and speaking rate. journal of speech and hearing disorders, 46, 296-301, 1981. young, m.a. and downs. t.d. testing the significance of the agreement among observers. journal of speech and hearing research, 11, 5-17, 1968. ziervogel, d., louw, j.α., ferreira, j.α., baumbach, e.j.m. and lombard, d.p. handbook of the speech sounds and sound changes of the bantu languages of south africa, unisa handbook series no. 3e. university of south africa, pretoria, 1967. ziervogel, d., louw, j.a. and taljaard, p.c. a handbook of the zulu language. third edition. pretoria: j.l. van schaik, 1981. ziervogel, d. and mokgokong, p.c. groot noord-sotho woordeboek. pretoria: j.l. van schaik, 1975. kritiese beoordeling van evaluasietegnieke van toepassing op gesplete-lip-en-verhemeltebabas brenda louw, d.phil (pretoria) isabel c. uys, d.phil (pretoria) departement spraakheelkunde en oudiologie, universiteit van pretoria, pretoria. opsomming die verkryging van 'n klinies geldige en 'n voorskrywende proflel van 'n baba se kommunikasiefunksionering verg noukeurige seleksie van ondersoekmetodes en meetinstrumente wat aangewend word. voorgestelde evaluasietegnieke wat van toepassing is op swart gesplete-lip-enverhemeite-babas word teen die agtergrond van 'n kritiese oorsig van die evaluasieproses beoordeel in terme van navorsingsen kliniese toepassingswaarde. vyf-en-twintig swart babas met gesplete verhemelte onder die ouderdom van twaalf maande het asproefpersone gedien. riglyne vir toepassing van die voorgestelde evaluasiemodel deur middel van direkte dienslewering deur die spraakterapeut en deur middel van konsultasie-as-voorkoming in 'n multi-kulturele gemeenskap word verskaf. / abstract the obtaining of a clinically valid and prescriptive profile of the communication function of infants calls for an accurate selection of the research methods and measuring instruments to be used. suggested evaluation techniques applicable to black cleft lip and palate infants are judged and evaluated within the framework of a critical review of the evaluation process in terms of research and clinical applicability. twenty-five black cleft lip and palate infants under the age of twelve months served as subjects. guidelines are supplied for use of these techniques through direct services provided by the speech pathologist and through consultation -asprevention in a multi-cultural society. © sasha 1986 the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) beoordeling van evaluasietegnieke van toepassing op gesplete-lip-en-verhemelte-babas 29 die term 'diagnose' verwys na 'n deeglike begrip van 'n probleem en dit word verkry deur evaluering. die evalueringsproses sluit w a a r n e m i n g , meting, beskrywing en differensiasie in (emerick & haynes, 1986) en dit dien as 'n basis vir behandeling. gevolglik bepaal die kwaliteit van die evaluering in 'n groot mate die effektiwiteit van behandeling. in die evalueringsproses word gebruik gemaak van objektiewe, g e s t a n d a a r d i s e e r d e metingstegnieke of toetse, sowel as sensitiewe, doelgerigte subjektiewe waarneming waarvolgens diagnostiese data ingesamel word. formele toetse is hoofsaaklik gerig op die identifikasie van 'n probleem, maar verskaf dikwels nie genoeg inligting oor die aard van die probleem en doelwitte vir behandeling nie. toetse verskerp die diagnostikus se waarnemingsvaardighede en verskaf leidrade vir verdere verkenning en intervensie. hoe meer bewus die diagnostikus word van die kompleksiteit van menslike kommunikasie, hoe meer verloordie toetse wat gebruik word geloofwaardigheid. die vaardige diagnostikus beskou nie toetstellings as 'n doel op sigself nie, maar eerder as aspekte van die mens se kommunikasievaardigheid (emerick & haynes, 1986). daar is dus plek vir beide objektiewe en subjektiewe evaluat e s in 'n omvattende, maar ook intensiewe diagnostiese program. verder moet diagnostiese programme voldoen aan sekere kriteria. evaluering berus op sekere basiese teoretiese veronderstellings of modelle. dit moet die ouderdom, kultuur en sosioekonomiese status van die populasie in ag neem omdat betroubaarheid en geldigheid nie slegs 'n funksie van die toets self is nie, maar ook van die groep waarop dit toegepas word (schepers, 1972). die kwantiteit van inligting wat in verband met behandeling verskaf word en die verskillende aspekte wat ondersoek word, is ook faktore waaraan die effektiwiteit van diagnose gemeet kan word. hierdie faktore moet dus ook in ag geneem word by evaluering van babas wat 'n risiko vertoon om 'n kommunikasie-afwyking te ontwikkel. swart gesplete-lip-en-verhemelte-babas vorm so 'n groep, maar omdat die gebied nog nie werklik die aandag van navorsers geniet het nie, bestaan daar geen beproefde diagnostiese battery vir evaluering van hierdie groep se kommunikasie nie (louw, ,1986). 1 metxdie bogenoemde kriteria as juitgangspunt is daar gepoog om 'n werkbare diagnostiese battery] bestaande uit verskeie evaluasietegnieke, van toepassing op swart gesplete-lip-en-verhemeltebabas, saam te stel. 'n holistiese evaluasiemodel, met in agneming van die sinergistiese aard van ontwikkelingsareas, is as teoretiese grondslag ontwikkel (louw, 1986). hierdie model berus dus op die beginsel dat die geheel meer as die som van die dele is. soos uit figuur 1 blyk, verkry die diagnostikus reeds uit hierdie teoretiese orientasie 'n aanduiding van die omvang van evaluasieareas. hierdie teoretiese veronderstelling laat ook ruimte vir inagneming van die ander kriteria waarvolgens die effektiwiteit van evaluasietegnieke beoordeel word, oa die eiesoortige aard van die toetspopulasie, die verskaffing van inligting vir intervensie en 'n bre'e omvang van aspekte wat ondersoek behoort te word. so byvoorbeeld word die evaluering van beide die orofasiale morfologie en vroee gedragsontwikkeling vereis indien daar 'n verteenwoordigende beeld van die manifestasie van die afwyking in die baba voorgehou moet word. tydens evaluering moet die interaksie wat tussen die baba se orofasiale morfologie en kommunikasievermo'ens voorkom dus tesame met 'n beskouing van vroee kommunikasiegedrag binne die raamwerk van algemene ontwikkeling bepaal word. vroee ontwikkeling word gekenmerk deur 'n simbiotiese interaksie wat tussen verfiguur 1: skematiese voorstelling van die sinergistiese aard van ontwikkelingsareas waarop die holistiese evaluasiemodel berus skillende ontwikkelingsareas bestaan en hierdie sinergistiese aard van ontwikkeling moet geevalueer word om 'n verteenwoordigende beeld van die baba se algemene funksionering te verkry. die doel van hierdie artikel is om die geselekteerde evaluasietegnieke, van toepassing op swart gesplete-lip-en-verhemeltebabas, krities te beoordeel in terme van navorsingsen kliniese effektiwiteit. m e t o d o l o g i e die verkryging van 'n klinies geldige en voorskrywende profiel van 'n baba se kommunikasiefunksionering verg noukeurige seleksie van ondersoekmetodes en meetinstrumente wat aangewend word. volgens mclean & mclean (1978) moet die doel van evaluering, die aard van die meetinstrument en die metodes van gebruik van die meetinstrument tydens seleksie daarvan oorweeg word. vanwee die leemtes en beperkinge van beskikbare meetinstrumente en die individuele kenmerke en behoeftes van babas, is die toepassing van slegs gestandaardiseerde toetse nie voldoende vir 'n omvattende evaluasie nie. nie-gestandaardiseerde evaluasieprosedures kan met groot vrug aangewend word om addisionele data oor vroee kommunikasiefunksionering te verskaf. riglyne vir uitvoering wat in die literatuur verskaf word, verhef nie-gestandaardiseerde evaluasieprosedures bo toevallige en informele waarnemings (mclean & mclean, 1978). in die lig van die voorafgaande teoretiese agtergrond is 'n evaluasiemodel wat op swart babas met gesplete lip en verhemelte van toepassing is, ontwikkel en empiries ondersoek. materiaal en apparaat die holistiese evaluasiemodel van toepassing op swart babas met gesplete lip en verhemelte is aangewend en word in tabel 1 omskryf in terme van evaluasieareas, materiaal en apparaat en die evaluasiewyses wat benut word. die motivering vir die seleksie van die evaluasiewyses gegrond op die evaluasiemodel word vervolgens bespreek. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) brenda louw and isabel g. uvs 30 y j van die bolistiese evaluasiemodel vir babas met gesplete lip en verhemelte tabel 1: opsommende weergawe van urc » fvaluasiearea materiaal en apparaat evaluasiewyse orofasiale morfologie siemens somatom 2 heelliggaamskandeerder uitvoering van: gerekenariseerde tomografie kognitiewe ontwikkeling cognitive-social communication assessment (dunst, 1978) developmental assessment schema: iperceptuo-cognitive skills subscale (anderson, nelson & fowler, 1978) birth to three developmental scale: problem solving subscale (bangs & dodson, 1979) toepassing van evaluasieskale gehoorvermoens amplaid reactometer (amplied usa inc). grayson-stadler, 1723 middle ear analyzer (gsi 27). uitvoering van: elektro-akoestiese impedansoudiometrie (hodgson, 1980) vryeveld pedo-oudiometriese toetsing (martin, 1978) kommuhikaisevermoens — voedingsproses vorm vir die optekening van data versamel en waarnemings gemaak. data-insameling deur middel van: — raadpleging van bedkaarte in hospitaalleer, — konsultasies met saalsuster/moeder/ oppasser, — direkte waarneming van voedingsessie. optekening van bogenoemde inligting op 'n opgestelde vorm. huilgedrag elastiese rekkie vir indusering van pynstimulus (michelsson et al., 1982) nakamichi 550-bandopnemer met tdk sa-x90-klankkassette. voice identification 700 series — spektrograaf. ontlokking en spektrografiese ontleding van pyngei'nduseerde huilpatrone michelsson et al., 1982). — vokaliseringsgedrag babaspeelgoed nakamichi 550-bandopnemer met tdk sa-90-klankkassette ontlokking en fonetiese en frekwensieontledings van vokaliseringsgedrag (smith & oiler, 1981). — reseptiewe en ekspressiewe taalvermoens receptive expressive emergent language scale (bzoch & league, 1971). developmental assessment schema: speech-language receptive/expressive subscales (anderson, nelson & fowler, 1978) birth co three developmental scale language comprehension and expression subscales (bangs & dodson, 1979) toepassing van evaluasieskale — kommunikasieinteraksievermoens cognitive-social communication assessment (dunst, 1978) nonverbal indicators of communication exchange (du bose-fewell, 1982) vorm vir optekeninge van data versamel nakamichi 550 bandopnemer en tdk sa-x90-klankkassette toepassing van evaluasieskale subjektiewe waarneming van moeder-kind^ interaksie (bower, 1977; trevarthen, 1979; | kaye, 1980; owens, 1984; strydom, 1985)., 1 — motoriese ontwikkeling birth to three developmental scale: motor subscale (bangs & dodson, 1979). developmental assessment schema; gross and fine motor subscales (anderson, nelson & fowler, 1978). toepassing van evaluasieskale — gerekenariseerde lomografie. hierdie tegniek is geselekteer om die orofasiale morfologie van babas te bestudeer vanwee die feit dat die pasient aan minimale bestraling blootgestel word; waarneming van beide hardeen sagteweefseldetail moontlik is; morfologiese verhoudings sonder versteurings deur die ondersoekprosedure bestudeer kan word; en 'n driedimensionele beeld van strukture verkry word wat morfologiese detail visualiseer en deur the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kritiese beoordeling van evaluasietegnieke van toepassing op gesplete-lip-en-verhemelte-babas 31 seen ander radiologiese tegnieke ge'ewenaar word nie (dickson en maue-dickson, 1983; banna, 1976). hierdie tegniek is sover slegs vir navorsing met gesplete-lip-enverhemelte-babas aangewend en die praktiese uitvoerbaarheid as roetinemeetinstrument by hierdie babas is tot dusver nie bepaal nie. ten spyte hiervan hou die tegniek talle voordele bo ander radiologiese tegnieke in en is dit geselekteer spesifiek met die doel om omvattende driedimensionele data van die orofasiale morfologie te verskaf. __ vryeveldtoetsing en elektro-akoestiese impedansloetsing. hierdie twee tegnieke is geselekteer as geskikte metodes om die gehoordrempels en middeloorfunksionering van babas te bepaal. v r y e v e l d t o e t s i n g is 'n standaardprosedure in pedo-oudiom e t r i e s e toetsing en word suksesvol aangewend om babas se r e a k s i e op klank te evalueer (hodgson, 1980). hierdie tegniek is ook bewys om lae vals-positiewe resultate in grootskaalse o n d e r s o e k e te vertoon en word as 'n effektiewe wyse van gehoorsifting aanvaar (katz, 1978). impedansoudiometrie beskik oor sekere kenmerke en voordele wat hierdie tegniek vir toepassing op kinders geskik maak, naamlik: dit is 'n objektiewe kwantitatiewe metode wsl vinnig en effektief uitgevoer kan word; dit is akkuraat en verg geen aktiewe deelname of konsentrasie van die kind nie, en word nie beinvloed deur 'n hoe peil van omgewingsgeraas nie (hodgson, 1980). — ontwikkelingskale. kognitiewe en motoriese ontwikkeling word dikwels tesame met taalvermo'ens en kommunikasieinteraksievermo'ens deur middel van vroee ontwikkelingskale geevalueer. gevolglik word die evaluering van hierdie vier gedragsareas saam in terme van die geselekteerde meetinstrumente bespreek. meetinstrumente is geselekteer uit die beskikbare ondersoekmetodes wat op vroee kommunikasiegedrag fokus (louw, 1986). die meeste van hierdie meetinstrumente is normgerig, globaal en verskaf oppervlakkige eerder , as diepte-inligting oor ontwikkeling. gevolglik word daar; nie aan al die teoretiese kriteria vir 'n toepaslike meetinstrument j/oldoen nie. 'ntweede probleem wat ondervind is, is dat slegs fn beperkte verskeidenheid van hierdie meetinstrumente in suid'-afrika beskikbaar is. dit word toegeskryf aan die feit dat |evaluering van prelinguistiese vaardighede 'n relatief resente konsep is en dat meeste van die meetinstrumente in die vsa saamgestel en gepubliseer is. die receptive expressive emergent language scale (reel) (bzoch & league, 1971); birth to three developmental scale (bangs & dodson, 1979) en die non-verbal indicators of communicative exchange (nice) (du bose-fewell, 1982) is geselekteer omdat hulle gestandaardiseerde meetinstrumente vir die evaluering van vroee ontwikkeling en kommunikasieontwikkeling van babas is. prosedures, materiaal, apparaat en die bepuntingsprosedure word gespesifiseer om betroubare, geldige en objektiewe data te verskaf (mclean & mclean, 1978). die developmental assessment schema (das) (anderson, nelson & fowler, 1978); die cognitive-social communication assessment (csca) (dunst, 1978) en die subjektiewe waarneming van moeder-kind-interaksie (trevarthen, 1979; kaye, 1980; strydom, 1985) is ook geselekteer as betroubare meetinstrumente vir die evaluering van vroee ontwikkeling en kommunikasie-ontwikkeling. laasgenoemde is nie-gestandaardiseerde evaluasieprosedures met sistematiese voorskrifte vir toepassing om 'n redelike mate van objektiwiteit te die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 verseker. kombinering van hierdie twee tipes evaluasiewyses laat toe vir die bepaling van die chronologiese ouderdomsvlak waarop die baba funksioneer sowel as vir die inherente implikasie dat genoegsame data verskaf word vir gedetailleerde beplanning van behandeling (liebergott et al. 1984). vanwee die ooreenstemmende wyses van data-insameling, naamlik direkte waarneming van gedrag en onderhoudsvoering met ouers, vul hierdie ontwikkelingskale mekaar goed aan (mclean & mclean, 1978; mcclowry, 1982). sodoende word daar ook toegelaat vir die evaluering van 'n wye omvang van gedrag wat akkurate bepaling van die vlak van funksionering moontlik maak. toepassing van hierdie toetsbattery laat toe vir die kategorisering van kommunikasie en aanverwante gedrag. gevolglik kan verbande tussen die verskillende ontwikkelingsareas bepaal word tesame met die beskrywing van die baba se individuele patroon van ontwikkeling. — evaluasieprotokol: voedingsproses. 'n prosedure vir datainsameling oor die voedingsproses is deur louw (1986) opgestel vanwee die gebrek aan so 'n evaluasieprotokol in die literatuur. die doel van die evaluering van die voedingsproses is slegs om te bepaal hoe funksie daar uitsien en dus is data deur middel van die raadpleging van leerinligting, konsultasie met sorggewendes en direkte waarneming van voedingsessies ingesamel (louw, 1986). objektiewe meetinstrumente soos videoen kineradiografiese opnames is nie uitgevoer nie aangesien 'n diepteversameling van fisiologiese data nie binne die grens van hierdie evaluasiemodel val nie. — spektrografiese analise van huilgedrag. vir die. bestudering van huilgedrag is die toediening van 'n pynstimulus om gedrag te ontlok en die spektrografiese analise van bandopnames as evaluasiemetodes geselekteer (michelsson et al. 1982). ontlokking van huilgedrag deur die toediening van 'n pynstimulus is bo die bestudering van spontane huilgedrag geselekteer om gedifferensieerde huilpatrone uit te skakel (michelsson et al. 1982). die toediening van 'n pynstimulus laat toe vir die maak van objektiewe en gekontroleerde vergelykings op 'n interen intrapersoonlike vlak. hierdie metode word deur verskeie navorsers gekritiseer maar is steeds die mees algemene ontlokkingswyse vir die bestudering van huilpatrone wat in die literatuur aangetref word (crystal, 1973; prescott, 1980). — foneliese ontleding van vokaliseringsgedrag. die evaluasiewyse wat vir die bestudering van vokaliseringsgedrag geselekteer is, is ook volgens literatuuraanbevelings bepaal. vokaliseringsgedrag is in 'n natuurlike konteks ontlok en met behulp van oudio-bandopnames volgens die prosedures wat in die literatuur beskryf word, foneties ontleed (smith & oiler, 1981; o'gara & logemann, 1983). uit voorafgaande bespreking blyk dit dus dat 'n verskeidenheid evaluasiemetodes en meetinstrumente voorgestel is. die navorsingsen kliniese effektiwiteit en bruikbaarheid van die geselekteerde evaluasietegnieke kan egter slegs deur empiriese toepassing op 'n omskrewe populasie beoordeel word. proefpersone vyf-en twintig swart babas met onherstelde gesplete lip en verhemelte is tydens hulle hospitalisering in die ga-rankuwa hospitaal as proefpersone geselekteer. die proefpersone se ouderdomme strek van 0,7 maande tot 11,2 maande met gemiddelde ouderdom van 5,95 maande. die groep vertoon 'n byna gelyke verspreiding wat hul geslag betref, daar is naamlik 13 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 „ „ h o e t e r s die 25 proefpersone is afkomstig uit huise 9 l e as huistale het, naamlik venda, noord-sotho, suid-sotho, zulu, swazi, shangane, xhosa, tswana en ndebele. vyf tipes gesplete lip en verhemelte is deur die proefpersone gemanifesteer. numeriese waardes is aan die verskillende tipe splete toegeken om die graad van die afwyking aan te dui. die klassifikasiesisteem wat deur die american cleft palate association (acpa) voorgehou word, is gevolg (berlin, 1979; mcwilliams et al. 1984). die verspreiding van die proefpersone na aanleiding van die graad van die afwyking word in tabel 2 verskaf. die belangrikste eienskappe van die proefpersone word opsommend in tabel 3 weergegee. tabel 2: graad van gesplete lip en verhemelte van proefpersone kategorie van tipe spleet (acpa-klassifikasie) spleet van die lip en alveolus spleet van die velum spleet van die palatum en velum unilaterale spleet van die lip, alveolus, palatum en velum bilaterale spleet van die lip, alveolus, palatum en velum waarde toegeken getal proefpersone tabel 3: opsommende weergawe van die belangrikse kenmerke van die proefpersone pr oe fp er so on no m m er g es la g ti pe s pl ee t c hr on ol og ies e ou de rd om ta al v an m oe de rs m oe de rs ge ho sp ita lis ee r 1 v 5 .70 venda ja 2 v 4 .93 noord-sotho — 3 v 1 .93 noord-sotho ja 4 μ 4 .93 zulu — 5 v 2 1.16 shangane — 6 v 1 1.16 xhosa ja 7 μ 5 1.16 venda — 8 μ 5 1.40 shangane ja 9 μ 4 1.40 noord-sotho — 10 μ 1 1.40 xhosa — 11 v 5 1.63 tswana ja 12 μ 5 1.63 ndebele — 13 v 3 1.86 suid-sotho — 14 μ 4 2.80 tswana ja 15 v 4 2.80 xhosa — 16 v 4 2.80 noord-sotho ja 17 v 4 3.73 suid-sotho — 18 μ 2 3.73 shangane — 19 μ 1 3.73 noord-sotho ja 20 μ 3 3.73 suid-sotho ja 21 μ 1 4.66 swazi — 22 v 4 5.60 tswana ja 23 μ 4 6.53 noord-sotho — 24 μ 1 7.46 noord-sotho — 25 v 2 11.20 venda ja prosedure elk van die 25 proefpersone is binne een week na opname in die ga-rankuwa hospitaal individueel geevalueer. vyf datainsamelingsessies is vir elke proefpersoon geskeduleer. een sessie is aan die uitvoering van gerekenariseerde tomografie gewy. brenda louw and isabel c. uys hierna is een sessie vir gehoortoetsing, insameling van data oor die voedingsproses en die ontlokking van huilgedrag benut. in die twee daaropvolgende sessies is kognitiewe, motoriese, sosioemosionele en taalontwikkeling geevalueer. 'n sessie is hierna afgestaan aan die ontlokking van vokaliseringsgedrag en die evaluering van moeder-kind-kommunikasie-interaksie by die proefpersone waar moeders wel beskikbaar was vir die waarneming van interaksie met hulle babas. die evaluasieprosedures wat tydens die ontwerp van die evaluasiemodel ontwikkel is, is vir die insameling, optekening en analisering van data in elk van die evaluasieareas aangewend (louw, 1986). die data wat ingesamel is, berus op twee verwerkingsprosedures, naamlik 'n telling (gehoorvermoens, motoriese, kognitiewe en kommunikasie-ontwikkeling) en 'n meting (afmeting van die orofasiale strukture en metings van huilkenmerke). gegewens wat op tellings berus, is deur middel van statistiese metodes verwerk (louw, 1986). eerstens is korrelasies bereken om te bepaal watter verwantskappe daar tussen die evaluasieareas bestaan. tweedens is die voorspellingswaarde van die verskillende ontwikkelingsaspekte wat ten opsigte van mekaar geevalueer is, statisties bepaal (louw, 1986). resultate en bespreking in samehang met die doel van die artikel, naamlik die kritiese beoordeling van die evaluasiemetodes en meetinstrumente wat aangewend is, word die resultate soos volg aangebied: — resultate wat deur die toepassing van die verskillende evaluasiemetodes en meetinstrumente verkry is. — resultate van statistiese berekeninge wat lig werp op die bruikbaarheid van die evaluasiemetodes en meetinstrumente. die resultate en bespreking van die evaluasiemetodes word in dieselfde volgorde aangebied as in die seleksie van die evaluasiewyses. (sien materiaal en apparaat.) — gerekenariseerde tomografie die orofasiale morfologiese inligting wat verkry;is, is op tweeledige wyse beskryf. anatomiese landmerke is op die skanderingsfoto's geidentifiseer en kwalitatiewe beskrywings van die proefpersone se orofasiale morfologie is gemaak. vanwe'e verskeie probleme wat met die uitvoering van 'n kwantitatiewe analiseprosedure ondervind is,. is absolute metings met bogenoemde kwalitatiewe beskrywings van waargenome strukture vervang. tabel 4 verskaf die anatomiese landmerke wat op die skanderingsfoto's van vyf proefpersone voorkom. hierdie proefpersone is geselekteer as voorbeelde ter illustrasie van die orofasiale morfologiese inligting wat deur middel van gerekenariseerde tomografie verkry is. dit blyk dus volgens tabel 4 dat 'n verskeidenheid morfologiese strukture op die skanderingsfoto's geidentifiseer kan word. relatief min inligting is egter beskikbaar oor die sagte weefsel van die orofasiale strukture wat daarop dui dat die kwaliteit van die skanderingsfoto's steeds nie genoegsaam is om werklik 'n omvattende beskrywing van die orofasiale morfologie van die proefpersone te verskaf nie. die interpretasie van die skanderingsfoto's volgens die literatuurriglyne wat aangewend is, is bemoeilik deur die feit dat die anatomiese beskrywings in die literatuur gegrond is op die strukture van normale kinders en the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kritiesebeoordeling van evaluasietegnieke van toepassing op gesplete-lip-verhemelte-babas 33 v o l w a s s e n e s wat verskil van die ontwikkelende morfologie van babas. t bei 4; orofasiale morfologiese struktuur wat geidentifiseer is 3 op die skanderingsfoto's van die proefpersone (n = 5) ctmkture geidentifiseer nasale septum vomerbeen nasale holtes nasale konga sigomatiese boog koronoi'edproses van die mandibula mandibulere kondiele mandibulere ramus premaksilla maksillere alveolere prosesse tuberositas van die maksilla tong nasofarinks hamulus pterigoi'edbeen eksterne oorkanaal mastoi'edproses petrusbeen oksipitale kondiele ordontoi'edproses van die aksis p p l + + + + + + + + + + + + + + + + pp4 + + + + + + + + + + + + + + + + pp9 + + + + + + + + + + + + + + + + p p l 7 + + + + + + + + + + + + + + pp23 + + + + + + + + + + + + + + + die babas se orofasiale morfologie. alternatiewe objektiewe evaluasietegnieke soos byvoorbeeld ortodontiese orale afdrukke en die tegniek van kernmagnetiese resonansie moet ook ondersoek word (berkowitz, 1982). ortodontiese orale afdrukke verskaf driedimensionele inligting oor die maksillere boogvorm en oppervlakte van die palatum (berkowitz, 1982). die voordeel van hierdie tegniek is dat dit meer koste-effektief is as gerekenariseerde tomografie en dat alginaatafdrukke van gesplete-lip-en-verhemelte-babas as roetineprosedure by opleidingshospitale gemaak word, wat die toeganklikheid van die tegniek vir die spraakterapeut verhoog (gavron, 1986). die tegniek van kernmagnetiese resonansie moet ook as evaluasietegniek ondersoek word aangesien daar in die vooruitsig gestel word dat hierdie tegniek gerekenariseerde tomografie gaan vervang vanwee die voordele bo die van tomografie veral ten opsigte van die gebrek aan die gevaar van bestraling (dickson en maue-dickson, 1983). ten slotte blyk dit dat die bestudering van die orofasiale morfologie van gesplete-lip-en-verhemelte-babas slegs kan slaag indien interdissiplinere samewerking voorkom. — pedo-oudiometrie die response van die proefpersone op die pedooudiometriese toetsing wat uitgevoer is en die tipe timpanogramme wat deur die proefpersone vertoon is, word in tabel 5 en 6 verskaf. sleutel: + = waarneembaar sleutel: — = nie sigbaar nie die kwalitatiewe beskrywing van die skanderingsfoto's is gerig op 'n beskrywing van die invloed wat die tipe spleet op die orofasiale struktuur van die proefpersone uitoefen. op grond van die beskrywing van die individuele skanderingsfoto's van die proefpersone (louw, 1986) blyk dit dat die invloed van 'n gesplete lip en verhemelte op die neusstrukture duidelik waarneembaar is. verskille tussen ciie spleeten nie-spleetkante van unilaterale splete is ook duidelik geillustreer. die deviasie van die nasale septum en vomerbjeen is deurgaans duidelik waarneembaar. die gebruik van 'n1 snitdikte van 4 mm blyk relatief min strukturele detail te verskjaf ten opsigte van die palatum en velum, maar is geselekteer om|die mate van bestraling te beperk (banna, 1976). die tegniek van gerekenariseerde tomografie dui egter wel op fyn morfologiese detail van die proefpersone wat nie anders sigbaar is nie, byvoorbeeld detail oor die benige en kraakbeengedeeltes van die 'vomer en die hamulus van die mediale pterigoi'edplate wat waarneembaar is. die gebruik van die tegniek van gerekenariseerde tomografie om inligting aangaande die orofasiale morfologie van gespletelip-en-verhemelte-babas aan die spraakterapeut te verskaf, met die doel om die morfo-funksionele verhouding in hierdie babas te bepaal, blyk egter nie geslaagd te wees nie. op grond van die resultate wat van die proefpersone verkry is, blyk dit nie dat hierdie morfologiese data meer lig op die verhouding met die funksionele aspekte van die baba werp as wat die klassifikasiesisteem wat aangewend is, doen nie. hierdie tegniek kan egter vir die chirurg tydens beplanning en evaluering van chirurgiese metodes van waarde wees (marsh & gado, 1982). die gevolgtrekking word gemaak dat die spraakterapeut wat by die evaluering en behandeling van hierdie babas betrokke is van klassifikasiesisteme gebruik moet maak in die beskrywing van tabel 5: response van die proefpersone op pedo-oudiometriese toetsing toetsmetode tipe respons persentasie response vryeveldtoetsing elektro-akoestiese impedanstoetsing (akoestiese refleksdrempel) positief negatief 72% 28% vryeveldtoetsing elektro-akoestiese impedanstoetsing (akoestiese refleksdrempel) teenwoordig afwesig 76% 24% tabel 6: timpanometriese resultate wat deur die proefpersone vertoon is tipe timpanogram voorkoms in persentasie van getal ore interpretasie a 38% normaal β 30% vog in middeloor c 32% negatiewe druk in middeloor d 0% littekenweefsel op timpanum ε 0% breuk in ossikulere ketting die kriteria wat deur hodgson (1980) vir die bepaling van middeloorprobleme op grond van pedo-oudiometriese toetsresultate voorgestel is, is aangewend om die voorkoms van middeloorprobleme by die proefpersone te bepaal. daar is bevind dat 76% van die proefpersone ten tye van toetsing middeloorprobleme ondervind het. tabel 5 dui aan dat 28% van die proefpersone se reaksie op vryeveldtoetsing (50-70-db-klankdrukpeil) as negatief geklassifiseer is die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 en dat daar by 24% van die ore wat getoets is geen akoestiese refleksdrempel ontlok kon word nie. uitvoering van die twee pedo-oudiometriese toetsmetodes in die e^sperimentde prosedure maak 'n vergelyking van die resultate watto verkry is, moontlik. proefpersone wie se reaks.es op vryeveldtoetsing as negatief gekategoriseer is, het almal op grond van elektro-akoestiese impedanstoetsing m i d d e l o o r p r o b l e m e vertoon. dit het egter verder geblyk dat 26% van die proefpersone wie se reaksies op vryeveldtoetsing as positief geklassifiseer is, op grond van resultate wat deur elektro-akoestiese impedanstoetsing verkry is, middeloorprobleme vertoon het. hierdie bevinding steun literatuurmenings dat elektro-akoestiese impedansoudiometrie middeloorprobleme uitlig selfs al word normale reaksies op vryeveldtoetsing ontlok, en dat dit as 'n sensitiewe meettegniek brenda louw and isabel c. uys toegepas kan word in die opsporing van middeloorpatologie by jong kinders (katz, 1978; millard, 1980). die afleiding word gemaak dat vryeveldtoetsing op sigself nie 'n voldoende siftingsprosedure is vir die uitlig van middeloorprobleme by gesplete-lipen-verhemelte-babas nie, ten spyte van die feit dat daar bewys is dat hierdie tegniek lae vals-positiewe resultate in omwattende ondersoeke vertoon het (katz, 1978). vryeveldtoetsing in kombinasie met elektro-akoestiese impedanstoetsing blyk volgens die huidige resultate 'n betroubare pedo-oudiometriese siftingsbattery vir babas met gesplete lip en verhemelte te vorm. — ontwikkelingskale die resultate wat van die proefpersone (n + 25) verkry is deur toepassing van die ontwikkelingskale wat in tabel 3 verskaf is, word kortliks in tabelvorm opgesom. (sien tabel 7.) tabel 7: opsommende weergawe van die proefpersone (n = 25) se funksionering soos bepaal deur die verskeie ontwikkelingskale evaluasiemetode evaluasieareas % beoordeling van funksionering toepassing van ontwikkelingskale kognitiewe ontwikkeling normaal agterstand toepassing van ontwikkelingskale kognitiewe ontwikkeling bogemiddeld normaal gering gemiddeld erg toepassing van ontwikkelingskale kognitiewe ontwikkeling 4% 16% 64% 12% 4% toepassing van ontwikkelingskale reseptiewe taalontwikkeling 12% 12% 64% 8% 4% toepassing van ontwikkelingskale ekspressiewe taalontwikkeling 4% 16% 60% 8% 12% toepassing van ontwikkelingskale kommunikasie-interaksievermoens 16% 32% 36% 16% 0% toepassing van ontwikkelingskale motoriese ontwikkeling 24% 32% 24% 16% 4% sleutel: interpretasie van funksionering: normale ontwikkeling: telling op en bokant chronologiese ouderdom geringe agterstand: telling -0,5 maande onderkant chronologiese ouderdom gemiddelde agterstand: telling -1,0 maande onderkant chronologiese ouderdom erge agterstand: telling -2,0 maande onderkant chronologiese ouderdom dit blyk volgens tabel 7 dat 80% van die proefpersone 'n agterstand in kognitiewe ontwikkeling toon; 76% 'n agterstand in taalontwikkeling toon; 62% 'n kommunikasie-interaksie-agterstand toon en slegs 44% 'n motoriese ontwikkelingsagterstand toon. die relatief hoe insidensie van 'n kognitiewe ontwikkelingsagterstand van die proefpersone bevestig fox et al. (1978) en mcwilliams et al. (1984) se mening dat babas met 'n gesplete lip en verhemelte 'n risiko vertoon om 'n kognitiewe agterstand te ontwikkel. opsommend blyk dit dat die swart gesplete-lip-en-verhemelteproefpersone se kognitiewe agterstand aan verskeie faktore toegeskryf kan word. die orofasiale afwyking wat normale ontwikkeling negatief kan bei'nvloed, kulturele gebruike en sosiale omgewings mag as verklaring vir bogenoemde bevindings voorgehou word (nyiti, 1982; kolobe, 1984). die taalagterstand wat deur die proefpersone vertoon is, word gedeeltelik deur navorsing ondersteun maar 'n presiese verklaring vir die voorkoms van 'n taalagterstand by gesplete-lip-enverhemelte-babas ontbreek tans en verg verdere navorsing (fox et al. 1978; long & dalston, 1983; nation & wetherbee, 1985). die kommunikasie-interaksie-ontwikkelingsagterstand wat deur die proefpersone vertoon is, blyk nie kenmerkend van die! steekproef as geheel en ook nie van 'n ernstige aard te wees nie (louw, 1986). dit blyk asof swart gesplete-lip-en-verhemelte-babas dieselfde ontwikkelingsverloop as normale swart babas ten opsigte van kommunikasie-interaksievermo'ens vertoon (strydom, 1985). tweedens blyk dit asof die gesplete lip en verhemelte nie 'n nadelige invloed op hierdie proefpersone se toetrede tot die kommunikasie-interaksie-situasie uitoefen nie. die bevinding dat die swart babas met gesplete lip en verhemelte wat in hierdie steekproef ondersoek is, se motoriese ontwikkeling skynbaar in 'n mindere mate deur hulle orofasiale afwyking bei'nvloed is as die motoriese ontwikkeling van blanke gespletelip-en-verhemelte-babas wat in die literatuurbeskryf is (starr etal. 1977; fox et al. 1978; louw & van den bergh, 1985) kan aan.die hand van 'n tweeledige verklaring geekspliseer worcl. dit blyk eerstens dat die voedingsprobleme wat deur die proefpersone ondervind is, nie van so ernstige graad is dat al die proefpersone se motoriese ontwikkeling negatief bei'nvloed is nie. tweedens het verskeie outeurs bewys dat swart babas se vroee motoriese ontwikkeling in vergelyking met die van blanke the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kritiese beoordeling van evaluasietegnieke van toepassing op gesplete-lip-en-verhemelte-babas 35 e u r o p e s e en amerikaanse babas versnel is (super, 1976; lester & brazelton, 1982; richter-strydom & griesel, 1984). hierdie versneuing in motoriese ontwikkeling word toegeskryf aan kulturele gewoontes ten opsigte van die fisiese hantering van jong swart babas. dit blyk dus dat die negatiewe invloed wat 'n gesplete lip en v e r h e m e l t e op 'n baba se motoriese ontwikkeling kan uitoefen, m o o n t l i k by die proefpersone teegewerk is deur eiesoortige kulturele gebruike en waardes wat vroee ontwikkeling fasiliteer. die evaluering van 'n wye omvang van gedrag wat deur die ontwikkelingskale toegelaat is, het die akkurate bepaling van die vlak van die proefpersone se funksionering moontlik gemaak. dit blyk dus op grond van die verkree resultate dat die vlak van ontwikkeling in grade van normaliteit en agterstand uitgelig kan word wat onder andere toegeskryf word aan die feit dat die proefpersone se relatiewe ontwikkelingsouderdom gebruik is. dit laat toe vir 'n meer gedetailleerde interpretasie van funksionering. relatiewe ontwikkelingsouderdom verwys na die ouderdomsvlak wat op die evaluasieskaal behaal is, minus die baba se chronologiese ouderdom. dit wil se, die vlak van funksionering relatief tot die individu self word bepaal (fox et al. 1978). die evaluering van funksionering deur middel van die toepassing van ontwikkelingskale blyk dus 'n efiektiewe evaluasiemetode te wees en talle riglyne vir behandeling word verskaf. moeder-kind-kommunikasie-interaksie direkte observasie is van moeder-kind-interaksies gemaak en kwalitatiewe waarnemings gee aanleiding tot die gevolgtrekking dat geen bewyse bestaan dat die proefpersone se orofasiale afwyking kommunikasie-interaksie met hulle moeders negatief beinvloed het nie. hierdie waarneming word toegeskryf aan die feit dat moeders nie die voile implikasie van die afwyking en die behandeling daarvan besef nie. hulle blyk met die onmiddellike situasie gemoeid te wees eerder as om toekomsgerig te wees (kolobe 1984). die riglyne wat in die ontlokking en waarneming van hierdie interaksies gevolg is, verskaf genoegsame data om 'n verteenwoordigende beeld van individuele moeder-kind-kommunikasie-interaksie daar te stel. hierdie tipe kwalitatiewe analise pas egter nie voldoende aan by die kwantitatiewe en kwalitatiewe analises wat deur die evaluasiemodel aanbeveel word nie. verskeie evaluasieskale van moeder-kind-kommunikasie-interaksie wat voorgeskrewe ontlokkingsprosedures aangee en in relatief kort periodes kwantitatiewe en kwalitatiewe data sowel as behandelingsriglyne verskaf, word in die literatuur beskryf (clezy 1979). daar word verder aanbeveel dat video-opnames wel tydens moeder-baba-interaksies aangewend word, aangesien dit tot meer objektiewe optekening van data kan lei. gebruikmaking van rekenaartegnologie verhoog die objektiwiteit van data-optekening verder en brei die moontlikhede van 'n moeder-kindkommunikasie-interaksie-analise uit (strydom, 1985). dit kom dus voor dat meer tegnologies geori'enteerde analises van moeder-kind-kommunikasie-interaksies meer waardevolle inligting verskaf as die subjektiewe waarnemingstegnieke wat benut is. voedingsproses die resultate van die beoordeling van die voedingsproses met behulp van die evaluasieprotokol word in tabel 8 verskaf. tabel 8: resultate van die beoordeling van die voedingsproses kategoriee beoordeel getalwaardes toegeken sleutel kenmerke van proefpersone (n = 25) in persentasiewaardes suigrefleks 1 2 3 sterk suigrefleks (geen suigprobleem) aanvanklike sterk suigrefleks word egter nie volgehou nie (gemiddelde suigprobleem) swak suigrefleks (erge suigprobleem) 32% 30% 38% tipe voedingswyse i! i 4i 5 borsvoeding bottelvoeding voeding met voedingsbeker voeding van vloeistowwe met lepel buisvoeding 28% 80% 26% 22% 4% tipe voedingsprobleme 1 2 uitermatige las van winde oormatige braking 22% 34% 84% 3.1 3.2 3.3 soms dikwels meestal 29% 33% 38% graad van voedingsprobleme 1 2 3 geringe voedingsprobleme gemiddelde voedingsprobleme ernstige voedingsprobleme 30% 43% 27% daar moet gelet word dat dit vir elke proefpersoon moontlik was om in die kategoriee van tipes voedingsprobleme en tipes voedingswyses meer as een telling te behaal. dit bring mee dat die persentasiewaardes van die kenmerke van die proefpersone in hierdie twee kolomme dus nie op 'n totaal van 100% te staan kom nie. die persentasie verwys telkens na die getal proefpersone uit 25 wat 'n sekere kenmerk vertoon. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 brenda louw and isabel c. uys die drie aspekte van die voedingsproses wat geevalueer .s, toon η noue verwantskap en kan dus nie onafhankl.k geevalueer word indien "n ware beeld van die gesplete-lip^n-verhemelte-babas se voedingsprobleme verkry moet word nie. die graad van die voedingsprobleem wat op hierdie resultate bereken is, word gevolglik as 'n akkurate beoordeling van die probleem beskou. volgens tabel 8 het 30% van die proefpersone geringe en 70% gemiddelde (43%) tot erge (27%) voedingsprobleme ondervind. die feit dat 30% van die proefpersone slegs 'n geringe voedingsprobleem getoon het, word bevestig deur die resultate dat 32% van die proefpersone 'n sterk suigrefleks vertoon het en dat bottelen borsvoeding die voedingswyse was wat die algemeenste toegepas is. die feit dat slegs 38% van die proefpersone suigprobleme gehad het, dui daarop dat aanpassingsgedrag tydens die voedingsproses moontlik vir hierdie verskynsel verantwoordelik gehou kan word. kliniese waarnemings tydens die empiriese ondersoek dui daarop dat aanpassingsgedrag in die vorm van aanpassings in die plasing en bewegings van die orale strukture, veral van die tong, tydens vloeistofinname voorgekom het. hierdie aanpassingsgedrag kan egter nie sonder die aanwending van objektiewe meettegnieke, soos byvoorbeeld kineradiografie, akkuraat beskryf word nie. kennis van aanpassing en kompensatoriese bewegings word as belangrik beskou aangesien dit 'n invloed op die individu se orale sensories-motoriese ondervinding uitoefen wat 'n rol in latere spraakproduksiepatrone kan speel (fletcher, 1978). die gebrek aan toepassing van objektiewe meettegnieke impliseer dat moontlike belangrike aspekte van die suigaksie oor die hoof gesien kan word. evaluering van die voedingsproses dek nie wanvoeding nie en aangesien swart onwikkelende gemeenskappe se babas dikwels wangevoed is (morley, 1979) word aanbeveel dat inligting aangaande voedingstatus van die mediese personeel verkry word. spektrografiese analise van huilbuie sewe huilkenmerke is deur middel van huilbuie van die proefpersone bestudeer. aangesien geen metings van die huilkenmerke van melodietipe en nasaliteit gemaak kon word nie, is hierdie kenmerke slegs kwalitatief bespreek. die data van die vyf oorblywende huilkenmerke is statisties verwerk en word in tabel 9 verskaf. tabel 9: data wat van spektrografiese huilanalises van die proefpersone verkry is (n = 25) huilkenmerke statiestiese berekeninge huilkenmerke rekenkundige gemiddeld standaardafwyking mediaan variasiewydte latente periode (sekondes) 1,69 sek 0,95 sek 1,60 sek 3,40 sek duur van huilbuie (sekondes) 2,38 sek 1,63 sek 2,00 sek 5,60 sek amplitude van huilsein (db) 75,17 db 2,89 db 74,52 db 10,30 db minimum toonhoogte van fundamentele frekwensie (hz) 449,2 hz 120,8 hz 410,0 hz 550,0 hz maksimum toonhoogte van fundamentele frekwensie (hz) 813,4 hz 293,9 hz 670,0 hz 1060,0 hz opsommend blyk dit dat die proefpersone as groep nie beduidend verskil het van die literatuurbeskrywings van die sewe huilkenmerke van normale babas nie (golub & corwin, 1982; lester, 1984). op grond van hierdie resultate is die gevolgtrekking gemaak dat 'n anatomiese afwyking van die orofasiale strukture nie 'n beduidende invloed op die huilpatrone van babas uitoefen nie. hierdie resultate bevestig die bevinding van michelsson et al. (1975) wat die enigste bekende huilanalise op gesplete-lip-enverhemelte-babas uitgevoer het. bogenoemde afleidings is egter in direkte teenstelling met die mening van golub & corwin (1982) naamlik dat enige afwyking van die anatomiese strukture wat by die produksie van huilgedrag betrokke is, in die akoestiese eienskappe van die huilbuie gereflekteer sal word. indien 'n gesplete lip en verhemelte 'n invloed op 'n baba se huilpatroon uitoefen, is dit van so 'n geringe aard dat dit nie deur 'n spektrografiese analise bewys kan word nie. ten slotte blyk dit dat die evaluasietegniek van huilanalise 'n definitiewe rol te vervul het in die evaluering van die funksionering van die sentrale senuweestelsel in jong babas, maar weinig inligting verskaf oor die invloed wat 'n gesplete lip en verhemelte op huilgedrag as voorloper van latere spraakproduksie uitoefen. | verdere ontwikkeling van die tegniek van huilanalise kan leiltot 'n beter begrip van huilgedrag as 'n weerspie'eling van die fisiologiese meganismes en anatomiese strukture van die baba se klankproduksiesisteem. sulke inligting sal insig gee in die wyse waarop babas die betrokke spierstelsels koordineer en kontroleer en sal sodoende nuwe lig op prelinguistiese gedrag werp. fonetiese analise van vokaliseringsgedrag op grond van die fonetiese analise wat van die proefpersone se vokaliseringsgedrag gemaak is, is bevind dat glottale artikulasie die meeste gebruik is tydens konsonantproduksies. (sien tabel 10.) tydens die normale ontwikkelingsverloop is daar egter 'n afname in glottale konsonante na die ouderdom van twee maande en dit kom dus voor dat die gesplete-lip-en-verhemelte-proefpersone kwalitatief van die normale ontwikkelingsverloop verskil. die palatale plek van artikulasie is in 18,7% van die konsonantproduksies gebruik volgens tabel 10. dit kom voor asof die proefpersone se gesplete verhemelte nie 'n beduidende the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kritiese b e o o r d e l i n g van evaluasietegnieke van toepassing op gesplete-lip-en-verhemelte-babas 37 , nalatale artikulasie uitgeoefen het nie. verder is die normale ontwikkeling en die afleiding word gemaak dat dieproefi n v l o e d op palatale art.kuias.e u j j , ^ ^ ^ ^ p e r s o n e n geringe ontwikkelingsagterstand vertoon (mowrer, (1980). eksplosiewe klanke is gekenmerk deur glottale klanke ' nvicfnprsone~se vokaliseringsgedrag gekenmerk deur die relatief ρ γ n o r k o m s van frikatiewe (38,3%) en nasale (32,3%) klanke. (1980). eksplos.ewe kiamce is s , , , , , , s i h s voorkoms van frikatiewe is <n kenmerk van vroee veral die glottale afslu.t.ngsklank / 7 / . % produksies bilabiaal labiobiaal plek interdentaal van artiku alveoler lasie palataal veler glottaal 30 8% 15,2% 2,2% 7,5% wysi 13,2% van artikl 18,7% (lasie eksplosiewe frikatiewe nasale wrywinglose kontinuante late' rale klanke glyklanke trillers 20,5% 38,3% 32,3% 7,3% 0% 0% 1,6% tabel 11 verskaf 'n oorsig van die proefpersone se vokaalproduksies en hiervolgens blyk dit dat die plek van vokaalproduksie ooreenstem met die van normale ontwikkeling. verder toon tabel 11 dat 73,42% van die vokale in 'n middellaag-toonhoogteposisie geproduseer is, wat dui op vertraagde ontwikkeling en ooreenstem met die bevindinge van o'gara en logemann, 1983. tabel 11: voorkoms van die vokale wat geproduseer is volgens plek van artikulasie en tonghoogte tydens produksie tonghoogte tydens produksie % vokale geproduseer plek van artikulasie % vokale geproduseer hoog 8,63% voor 40,85% middel 73,42% middel 41,88% laag 17,95% agter 17,27 % i die gevolgtrekking is bereik dat beide die konsonanten vokaalproduksies van die gesplete-lip-en-verhemelte-proefpersone kwalitatief verskil van die literatuurbeskrywings van die vokaliseringsgedrag van normale babas (mowrer, 1980; o'gara & logemann, 1983). j fonetiese analise laat slegs jtoe vir 'n kwantitatiewe en kwalitatiewe beskrywing van konsonanten vokaalproduksies en daar word aanbeveel dat vokalisering ook uit 'n sosialiseringsp e r s p e k t i e f bestudeer moet word (smith & oiler, 1981). die verwantskap tussen die motoriese komponente van prelinguistiese vokaliseringsen spraakgedrag moet bepaal word om meer spesifieke riglyne vir vroee behandelingsprogramme te verskaf (sheppard, 1980). die invloed van tydsberekening van chirurgie, en die dra'van 'n maksillere prostese moet ook bestudeer word. dit blyk dus dat om 'n meer verteenwoordigende beeld van vokaliseringsgedrag as deel van prelinguistiese kommunikasiegedrag te verkry, die evaluering van vokaliseringsgedrag vanuit 'n breer perspektief beskou moet word as wat deur die evaluasiemodel voorgestel is. op grond van die voorafgaande resultate is statistiese berekeninge uitgevoer om te bepaal watter verwantskappe tussen die vroee morfologiese en funksionele ontwikkeling van die proefpersone bestaan. die doel van hierdie bewerking is om op grond van verkre'e resultate die holistiese evaluasiemodel te evalueer. eerstens is sewe-en-twintig korrelasies wat tussen die evaluasieareas bestaan, bereken (louw, 1986). daar is bevind dat 52% van die korrelasies 'n statistics beduidende verwantskap toon wat bevestig dat die vroee ontwikkeling van die proefpersone wel sinergisties van aard is en 'n simbiotiese interaksie, vertoon. die afleiding word gemaak dat die holistiese evaluasiemodel voorsiening maak vir die noue interaksie van vroee ontwikkeling en dat die geselekteerde evaluasietegniek mekaar aanvul eerder as oorvleuel. die holistiese evaluasiemodel maak dus voorsiening vir 'n diepte-evaluasie van die verreikende negatiewe invloed wat 'n gesplete lip en verhemelte op die baba kan uitoefen. tweedens is die statistiese ontledingstegniek van stapsgewyse meervoudige lineere regressie (draper & smith, 1981) toegepas om te bepaal watter ontwikkelingsaspekte van die holistiese evaluasiemodel as voorspellers vir funksionering in sekere evaluasieareas dien. resultate dui daarop dat dit statistics bewys is dat taalontwikkeling, kommunikasie-interaksievermoens, voedingsprobleme, kognitiewe ontwikkeling en graad van die tipe spleet belangrike voorspellers van die verskillende evaluasieareas is (louw, 1986). die ontwikkelingsaspekte wat deur die holistiese evaluasiemodel gedek word, blyk oor die algemeen 'n goeie seleksie te wees aangesien daar bewys is dat 'n noue verwantskap tussen die ontwikkelingsaspekte bestaan en dat sekere van hierdie aspekte van ontwikkeling as voorspellers van ander ontwikkelingsaspekte kan funksioneer. die voorspellende aard van die verskillende ontwikkelingsaspekte moet egter met omsigtigheid geinterpreteer word. hierdie bevinding impliseer slegs dat die ontwikkelingsaspekte sinergisties van aard is, en nie dat daar byvoorbeeld in die kliniese praktyk slegs een ontwikkelingsaspek geevalueer hoef te word nie met die veronderstelling dat afleidings oor ander ontwikkelingsaspekte op grond van die geevalueerde area se voorspellingswaarde gemaak kan word nie. die voorspellers dien eerder as 'n verklaring van funksionering in 'n betrokke evaluasiearea. op grond van die bogenoemde bevindings dat toepaslike evaluasieareas deur die holistiese evaluasiemodel gedek word, kan die afleiding gemaak word dat die evaluasietegnieke wat aangewend 'is, toepaslike inligting aangaande die proefpersone se funksionering verskaf het wat hulle geskiktheid as effektiewe tegnieke onderskraag. die kliniese toepassing van die holistiese evaluasiemodel het dus genoegsame inligting verskaf cim beide evaluasieareas en die die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 brenda louw and isabel c. uys evaluasietegnieke van die model krities te evalueer en aanbevelings oor die aanwending van die tegnieke te maak. gevolgtrekkings na aanleiding van die voorafgaande bespreking van die resultate wat deur toepassing van die holistiese evaluasiemodel verkry is, blyk dit dat noukeurige teoretiese seleksie van evaluasiemetodes en meetinstrumente alleen nie voldoende is om die kliniese uitvoerbaarheid en bruikbaarheid te bepaal nie. dit het duidelik uit die resultate geblyk dat kliniese toepassing ook krities geevalueer moet word alvorens evaluasiemetodes en meetinstrumente sinvol beoordeel kan word. daar word aanbeveel dat evaluasiemetodes en meetinstrumente beide op grond van teoretiese en kliniese oordeel geselekteer word. verskeie leidrade ten opsigte van die seleksie van gepubliseerde meetinstrumente wat van toepassing is op babas (mclean & mclean, 1978; lund & duchan, 1983) en wat met vrug benut kan word, is in die literatuur beskikbaar. indien die spraakterapeut egter 'n nuwe evaluasiemetode of meettegniek wil aanwend wat nog nie van te vore in die literatuur beskryf of geevalueer is nie, word onderwerping aan 'n praktiese toets aanbeveel. op grond van verkree resultate van so 'n praktiese toets moet 'n beoordeling van die volgende aspekte uitgevoer word: betroubaarheid; geldigheid; koste; tyd wat nodig is vir die uitvoering sowel as vir die verwerking van resultate; gemak van uitvoering; beskikbaarheid van evaluasiemetodes en aanpasbaarheid daarvan by 'n gegewe populasie. 'n krities evaluerende benadering tot die beplanning en uitvoering van die vroee evaluasie van babas behoort tot verantwoordbare en praktiese optrede deur die spraakterapeut te lei. in die bespreking van die resultate is daar gewys op die moontlike toepassingsmoontlikhede van die evaluasiemetodes en meetinstrumente in terme van navorsing. aangesien die evaluasiemodel primer vir navorsingsdoeleindes ontwikkel is en baie tydrowend is, word aanbeveel dat die evaluasieproses tydens kliniese dienslewering sinvol verkort word. evaluering van swart babas met gesplete lip en verhemelte word weer eens as praktiese voorbeeld voorgehou. hiervolgens word voorstelle ten opsigte van elke evaluasiearea van die evaluasiemodel aan die hand gedoen om te illustreer hoe die uitgangspunt van die navorsingsgerigte evaluasiemodel behou is terwyl die kliniese uitvoering verkort en vergemaklik word. — orofasiale morfologie: verkryging van inligting oor die klassifikasie van die tipe gesplete lip en verhemelte en bykomstige belangrike morfologiese inligting van die chirurg. — gehoorvermoens: siftingstoetsing soos in die evaluasiemodel voorgestel is. — kognitiewe ontwikkeling: toepassing van die bayley scales of infant development — mental scale (bayley), 1969) en gebruikmaking van die voorlopige norme van swart babas opgestel deur richter en griesel (1985). die verandering word voorgestel op grond van richter-strydom en griesel (1984) se suksesvolle toepassing van hierdie ontwikkelingskaal op normale swart babas en die feit dat hulle voorlopige norme vir kognitiewe ontwikkeling van swart babas opgestel het. — huilanalise: toepassing slegs indien daar vermoed word dat die baba 'n afwyking van die sentrale senuweestelsel vertoon. — voedingsproses: evaluering deur objektiewe waarneming soos in die holistiese evaluasiemodel voorgeskryf is. — vokaliseringsgedrag: ontlok tydens moeder-kind-kommunikasie-interaksie en slegs tipe klanke wat geproduseer word, word genoteer. — reseptiewe en ekspressiewe taalontwikkeling: toepassing van die denver developmental screening test (frankenburg & dodds, 1969) en gebruikmaking van voorlopige norme opgestel deur richter en griesel (1985). — kommunikasie-interaksie-ontwikkeling: evalueer tydens moeder-kind-kommunikasie-interaksie. — moeder-kind-interaksie: ontlok tien minute interaksie tussen moeder en baba en beskryf breedweg moeder-kindinteraksie-patrone, die baba se interaksionele en vokaliseringsgedrag. gebruik riglyne wat in holistiese evaluasiemodel verskaf word (louw, 1986). — motoriese ontwikkeling: toepassing van denver developmental screening test (frankenburg & dodds, 1969) en gebruik voorlopige norme wat deur richter en griesel (1985) vir swart babas opgestel is. — interpretasie van data moet egter steeds volgens die riglyne wat in die evaluasiemodel verskaf word, geskied (louw, 1986). 'n ernstige probleem wat egter in die kliniese praktyk voorkom, is naamlik dat beskikbare hulpbronne nie voldoen aan die vereistes wat gestel word om die behoeftes van die gemeenskap aan mediese en paramediese dienste te bevredig nie. die konsep van mede-konsultasie wat deur uys (1985) voorgestel is, kan met groot vrug in die evaluering van swart babas met gesplete lip en verhemelte aangewend word. volgens die uitgangspunt van die medekonsultasiemodel kan die verpleegkundige as sorgpersoon benut word aangesien die rol van die verpleegster toenemend uitbrei (foster & anderson, 1978; morley, 1979; uys, 1985). die verpleegkundige se rol as sorgpersoon kan die volgende omsluit: — uitvoering van gehooren ontwikkelingsiftingsprogramme by swart gesplete-lip-en-verhemelte-babas in roetine babaklinieke, tydens hospitalisering van die babas en by creches; — verskaffing van individuele vroee stimulasieprogramme en lesings oor die belang van vroee stimulasie aan groepe ouers van gesplete-lip-en-verhemelte-kinders. ten slotte blyk dit dat die kritiese evaluering van evaluasietegnieke op grond van empiriese bewyse wat deur kliniese toepassing verkry is, die geskiktheid, waarde en bruikbaarheid ι van die evaluasietegnieke verhoog en verskillende toepassingsmoontlikhede daarstel. ; ι bedanking j die skrywers erken met dank die finansiele ondersteuning van die raad van geesteswetenskaplike navorsing. ι verwysings anderson, d., nelson j. en fowler s. 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(reds.): infant communication development, assessment, and intervention. new york: grune & stratton, 1983. sheppard, j.j. "motor components of social vocalizations in infants" pp. 126-130 in the proceedings of the 18th congress of the international association oflogopedics andphoniatrics. washington, d.c., 1980. smith, b.l. & oiler, d.k. "a comparative study of pr e_ meaningful vocalizations produced by normally developing and downs syndrome infants" in journal of speech and hearing disorders, 46, pp. 46-51, 1981. starr, p., chinsky, r., canter, h. en meier, j. "mental, motor and social behaviour of infants with cleft lip and/or palate" in cleft palate journal, 14, pp. 140-147, 1977. strydom, l.m. development of communication between african mothers and their infants in the first year of life. referaat: biennial meeting of the society for research and child development, toronto, april 1985. super, c.m. "environmental effects on motor development: the case of african infant precocity" in developmental medicine and child neurology, 18, pp. 561-567, 1976. trevarthen, c. "communication and cooperation in early infancy: a description of primary intersubjectivity" in bullowa, m. (red.): before speech: the beginning of interpersonal communication. cambridge: cambridge university press, 1979. uys, i.c. "'n medekonsultasiemodel vir spraak--en gehoorterapie in die rsa" in hay, i.s. & uys, i.c. (reds.): taalverskeidenheid en taalpatologie. pretoria: universiteit van pretoria, 1985. aspekte van tydre'eling in normale en verbaal-apraktiese spraak matilda de jager, b(log) (pretoria) departement spraak.heelk.unde en oudiologie, universiteit van pretoria opsomming die doel van hierdie ondersoek is om inligting te verkry in verband met 'n aspek van tydreeling van spraakproduksie, naamlik segmentele tydsduur in afrikaans. vier normale sprekers en 'n apraktiese spreker is as proefpersone gebruik. uit die resultate blyk dit dat daar wel temporale reels in afrikaans voorkom. deur segmentele tydsduur by die apraktiese spreker te bestudeer, kan verdere insig in die afwyking asook terapieleidrade verkry word. abstract the aim of this research report is to obtain information concerning an aspect of timing of speech production, namely, the duration of speech segments in afrikaans. four normal speakers and an apraxic speaker were used as subjects. from the results obtained it is evident thai timing rules do exist in afrikaans. by analyzing the productions of the apraxic speaker in terms ofsegmental duration, more insight into this disorder, as well as therapeutic guidelines can be obtained. huidige kennis oor temporale organisasie of tydreeling van spraak is hoofsaaklik gegrond op studies wat uitgevoer is in engels. omdat daar nog geen studies in die verband in afrikaans gedoen is nie, bestaan daar 'n groot behoefte aan inligting omtrent die toepassing van tydreeling deur normale afrikaanssprekende persone. tydreeling is een van die twee belangrikste komponentevandie beplanning erf programmering van spraak. motoriese kontrole vir spraakaksies vereis dus akkommodasie en koordinasie in tyd en ruimte van die artikulatoriese gebeure vir die produksie van opeenvolgende segmente in die spraakketting (lofqvist & yoshioka, 1981). verskeie navorsers het die belang van temporale inligting as deel van die gestoorde motorprogram vir spraakaksies gedemonstreer (cooper & allen, 1977). volgens bell-berti en harris (1981) het vroe'ere modelle van spraakproduksie nie daarin geslaag om wel spraakproduksie te verklaar nie, juis omdat dit tydreeling beskou het as 'n byproduk © sasha 1986 van artikulatoriese gebeure in plaas van as 'n integrate organiserende parameter van motoriese spraakbeplanning. die aspek van tydre'eling wat in hierdie studie ondersoek word, is segmentele tydsduur. navorsing in verband met segmentele tydsduur le veral klem op 3 aspekte. die eerste aspek is kontekstuele invloed op segmentele tydsduur. volgens disimoni (1974 a) is die kontekstuele invloed op segmentele tydsduur deel van die tydre'elingsisteem van elke taal en word dit aangeleer deur die sprekers van die taal. die tweede aspek is temporale kompensasie, met ander woorde die effek wat inwerk om die duur van die interne segmente van artikulatoriese eenhede te modifieer in herhaalde produksies. temporale kompensasie is ook nie 'n eienskap van alle tale nie (disimoni 1974 b) en die feit dat dit eers na 9 jaar ten voile aangeleer is, dui daarop dat ontwikkeling plaasvind tot 'n volwasse gesofisitikeerde, akkurate tydreelingsmeganisme. die derde aspek is die invloed van die konsonantkombinasie (kk) op segmentele tydsduur binne eenlettergrepige woorde. uit navorsing gedoen, blyk dit the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 65 dementia and communication pathology: two case examples claire penn, ph.d. (witwatersrand) beulah sonnenberg, (speech and hearing therapy) (witwatersrand) yael schnaier, (speech and hearing therapy) (witwatersrand) department of speech pathology and audiology university of the witwatersrand, johannesburg abstract the discourse characteristics of two female patients with dementia are described — one patient with a cortical dementia of alzheimer's type and one patient with a classical subcortical dementia of progressive supranuclear palsy. distinct patterns of breakdown were observed and related to an explanatory model. implications of the findings for differential diagnosis are discussed and the neurological representation of the pragmatic level of language is considered. opsomming die gesprekvoeringseienskappe van twee vroulike pasiente met demensie word beskryf. een pasient ly aan 'n kortikale demensie van die alzheimer tipe en die ander een aan 'n kenmerkende demensie, nl. progressiewe supranukleere verlamming. bepaalde simptoomgroepe is waargeneem en in verband gebring met 'n verduidelikende model. die implikasies van die resultate ten opsigte van 'n differensiaal-diagnose word bespreek en die neurologiese verteenwoordiging van die pragmatiese taalvlak word oorweeg. introduction the role of the language pathologist in the area of dementia has been increasingly acknowledged during the past few years particularly in the field of differential diagnosis. language and communication testing thus forms an important part of the diagnostic battery for dementia. dementia may be broadly defined as a "condition of chronic progressive deterioration of intellect, memory, personality and communicative function resulting from organic brain disease" (bayles 1984). j various types of dementia have been identified. among the most common classification schemes is the subdivision of dementia into cortical and (subcortical types depending on the anatomic site of lesion (albert 1978; cummings & benson 1984). this classification has been a division of some controversy and will be the focus of the present paper. essentially cortical dementia refers to the cluster of symptoms arising from damage to cortical areas and resulting in symptoms such as apraxia, memory impairment and aphasia (cummings & benson 1984). as such, this type of dementia is traditionally measured by standard cortical, neuropsychological and language tests. the most classic example of a cortical dementia is dementia of alzheimer's type (dat) which is characterized by cortical atrophy particularly in the frontal, parietal and temporal lobes as well as ventricular dilatation. microscopically the presence of neuritic plaques, neurofibrillary tangles and areas of granulovacuolar degeneration in the temporal lobe and hippocampus are indicative of dat (schneck, reisberg & ferris 1982). resulting symptoms as formally specified in dsm iii of the american psychiatric association (1980) include intellectual dysfunctions sufficient to interfere with social behaviour, memory impairment and at least one of the following: personality change, impairment in abstract thinking, poor judgment and aphasia, apraxia or agnosia. subcortical dementia results form involvement of the thalamus, basal ganglia and the rostral brain stem nuclei (albert, feldman & willis 1974; cummings & benson 1984) with relative sparing of the cerebral cortex. the pattern of dementia involves a slowness of mental processing, forgetfulness, impaired cognition, apathy and depression and an impaired ability to manipulate acquired knowledge. language symptoms have been documented as being mild or indistinct (obler & albert 1981; cummings & benson 1984). traditional neuropsychological measures are less sensitive to subcortical dysfunction. cited examples of subcortical dementias include parkinson's disease, huntington's disease and progressive supranuclear palsy (psp). the latter condition is considered to be the best example of a subcortical degenerative process in which dementia is a consistent finding (kristensen 1985; cummings 1986). this disease entity is characterized by supranuclear opthalmoplegia, pseudobulbar palsy, axial rigidity and dystonia, dysarthria, dysphagia and a mild, slow progressive dementia (albert 1974; kirstensen 1985;maher & lees 1986). anatomically the lesion in psp is fairly widespread and involves neuronal loss, granulovacuolar degeneration, gliosis and neurofibrillary tangles (jonati & appell 1984). cortical hypometabolism is also evident in psp through the loss of subcortical afferents to the prefrontal cortex (albert 1987; d'antona, baron, samson, serdara, vidder, agid & cambier 1985; huber & paulson 1985; cummings 1986; maher & lees 1986). while certain writers (eg. bayles 1984) argue that the dividie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 © sasha 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 66 claire penn, beulah sonnenberg and yael schnaier sion of dementias into cortical and subcortical appears "perplexing and premature", because of the overlap of symptoms and the anatomical connection between cortical and subcortical areas, (mayeux, stern, rosen & benson 1983; maher, smith & lees 1985; pillon, dubois, lhermitte & agid 1986) recent writers continue to explore the possibility of discrete clinical profiles (freedman 1984; cummings 1986; huber, shuttleworth, paulson, bellchambers & clapp 1986). table i illustrates the similarities and differences between the two types of dementia investigated in the present study and highlights the basis of this debate. cummings (1986) in an excellent review article on subcortical dementia, suggests that cortical and subcortical abilities can be categorized as instrumental and fundamental functions respectively. instrumental functions are the most highly developed of human abilities and depend on phylogenetically recent and ontogenetically late developing structures. instrumental abilities include language praxis, perceptual recognition, memory and calculation and depend on the integrity of discrete cortical regions. abnormalities of these functions produce deficits associated with cortical dementias including aphasia, apraxia, agnosia, amnesia and acalculia. fundamental functions are essential for survival and emerge early in ontogenetic and phylogenetic development. these functions which include arousal, activation, attention, sequencing, motivation and mood are less discretely neurologically organized and involve subcortical structures (basal ganglia and thalamus) that interconnect widely with the cerebral cortex. abnormalities of fundamental functions produce the cardinal features of subcortical dementia including deficits in information processing, mood, cognition and motivation. inter-etiologic comparison of subcortical and cortical dementia allows one to observe the effect of such fundamental functions versus instrumental functions on communication skills. bayles and kaszniak (1987) feel that further inter-etiologic comparison is needed especially within the realm of language and communication. this becomes particularly important when considering possible differential treatment options. systematic attempts to describe language disturbance in dementias have been rare and results are often contradictory, probably because the traditional aphasia measures which have been utilized are insensitive to pertinent discourse features of dementia (appell, kertesz & fishman 1982). other aspects studied include: confrontation naming, receptive vocabulary, word association, reading comprehension, sentence judgment and correction, pantomime recognition, and verbal fluency (bayles & kaszniak 1987). such studies, most often conducted on parties with cortical dementias, generally conclude that while syntactic and phonologic levels of language remain relatively unaffected particularly in early stages, the semantic and pragmatic levels of language are most often affected. this has been particularly noticeable in the studies undertaken on discourse dimensions (eg. bayles & tomoeda 1983; horner & royall, 1985). discourse is a particularly sensitive indicator of social and cognitive competence and seems to be implicated in all types and phases of dementia. little research on the discourse level exists particularly in subcortical dementia. clinical investigation patients two female patients with dementia of moderate severity were used in the study: patient with dat (patient a) a was seen at the university speech and hearing clinic at the age of 56 years. she first noticed difficulties in certain cognitive functions three years previously. she reported a lack of concentration, memory and a degree of disorientation. she had a series of neurological and neuropsychological assessments both locally and overseas which revealed generalized brain atrophy with no significant focal abnormalities, but large ventricles with enlargement of the sulci. there was no evidence of endocrine or metabolic disease. the condition was diagnosed as presenile dementia of the alzheimer's type. no family history of any neurological disease was reported and there was no history of alcohol or drug abuse. premorbidly, a was an intelligent lively person, educated at a tertiary level and running her own business. initial diagnostic testing on an aphasia battery revealed a mild slurring pattern of articulation especially on more complex words or words containing blends or fricatives; on receptive language tasks she showed difficulties with complex material; severe word finding difficulties in expressive language affecting flow, severe dyslexia, dysgraphia and acalculia. self-correction behaviour was evident during test performance. details 0f the neuropsychological assessment are not available, but the neurological report revealed a typical pattern of memory, visuospatial and cognitive deficits. patient with psp (patient b) β was 64 years old when referred for a speech and language assessment. her disease onset was six years previously and presented with slight personality changes, frequent falls, and reduction in rate and volume of speech. at this time, alzheimer's disease was posited, but four years later after further deterioration in physical, psychological'and speech status, together with dysphagia, psp was diagnosed. a medical examination revealed /marked akinesia of trunkal movements, axial rigidity and dystonia in extension. supra; nuclear opthalmoplegia, palsy of vertical eye movement and restricted lateral gaze were present. facial features were stiff and immobile with lack of facial expression. these features are in accordance with characteristics of psp as described by a number of authors, (jonati & appell 1984; kristensen 1985, izzo, dilotenzo & roth 1986). cat scans with contrast revealed a moderate widening of the corticosubarachnoid channels, specifically in the posterior fossa, together with some atrophy in cortical and cerebellar areas. compression of the lateral ventricles and dilation of the quadrigeminal cistern were present. this-is in accordance with findings by ruberg et al. (1985). extensive neuropsychological testing showed a mild level of dementia, involving an early intellectual concretism, impaired concentration, intact immediate memory and an impairment of recent the south african journal of communication disorders, vol 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) dementia and communication pathology: two case examples 67 table i: contrasting features of cortical (dat) and subcortical (psp) dementias after albert et al. (1974); appel et al. (1982); bayles & kaszniak (1987); cummings (1986); cummings & benson (1984); cummcharacteristics cortical dementia (dat) subcortical dementia (psp) initial — memory impairment — progressive impairment of memory symptomatology — personality/mood changes — personality changes — intellectual dysfunction — slowing of mental operations — gait normal — disturbances of gait gait normal — postural instability — altered vision — no dysarthria — dysarthria — dysphagia progression of — progress more rapidly than subcortical forms — steady progressive deterioration of all signs disorder — as cortical degeneration progresses, loss of arid symptoms higher order associative functions neuropathology macroscopica lly macroscopically — cortical atrophy in parietal, temporal, frontal — fairly widespread lesion throughout sublobes cortex involving basal ganglia, thalamus and — ventricular dilation of mild-moderate degree structures — cerebral cortex involved — cerebral cortex largely spared — basal ganglia, thalamus, mesencephalon — frontal lobe involvement via subcortical prolargely spared jections to prefrontal cortex microscopica lly microscopically — senile or neuritic plaques, neurofibrillary — neuronal loss, granulovacuolar degeneration tangles — granulovacuolar degeneration in temporal — gliosis, neurofibrillary tangles lobe and hippocampus neuropsychological — more severe deficits earlier in disease course — mild to moderate deficits throughout most of features course — progressive dementia with aphasia, amnesia — mild, slow, progressive dementia with poor and early cognitive impairment abstraction and categorization — normal speed of cognition — slowed speed of cognition and response latency — memory disturbed early in the course — memory disturbances are a cardinal feature — impaired visuospatial skills — impaired visuospatial skills neuropsychiatric — indifferent; unconcerned — marked personality changes: apathy; irritabi-neuropsychiatric lity; brief outbursts of rage / — depression uncommon — depression common / / — absent mania — infrequent mania physical features — normal psychomotor speed — psychomotor retardation — motor functions normal until final stages of dat — normal posture and co-ordination — axial rigidity and dystonia — normal gait . — slow, broad-based giat — supranuclear opthalmoplegia speech and language features aphasia (transcortical sensory; wernickes); agnosia and apraxia no dysarthria syntax relatively spared most prominent early defect is marked semantic loss (verbal paraphasias) phonology preserved normal, fluent speech output personalized, irrelevant and repetitious speech with frequent circumlocutions and semantic jargon anomia — benefits little from clues comprehension skills more impaired particularly of more complex material i breakdown of language as a tool for communicating with others no aphasia; agnosia; apraxia dysarthria syntax intact semantic paraphasias altered speech output — little spontaneous speech; fragmented sentences; dysfluencies stereotypical speech • normal or mild anomia — profit from clues frontal lobe signs, eg. abnormal verbal fluency intact receptive language or mild deficit die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 68 verbal and nonverbal memory. certain features of a cortical dementia were also present via involvement of the frontal lobe. this was evident in signs-of perseveration, reduced word fluency and the dissociation between thought and action. on an aphasia battery she revealed unintelligible speech due to a severe dysarthria. receptive language was primarily intact. she used telegrammatic expressive language with claire penn, beulah sonnenberg and yael schnaier limited use of complex sentences. perseveration of words and phrases was evident. there was a breakdown in word fluency, flexibility and speed of word retrieval. very little awareness of test performance seemed evident (no selfmonitoring). severe dysgraphia was present. details of subject characteristics and performance on standard tasks are presented in table ii. table ii: subject characteristics and performance on standardized tasks characteristics subject a (dat) subject β (psp) sex female female age at onset and at time of testing 52 (1981) and 55 (1984) 58 (1981) and 65 (1987) final diagnosis 1984 dat 1985 psp educational level tertiary education tertiary education environmental support strong family support from husband, sister, friends strong support from husband, friends initial symptomatology — difficulties in certain cognitive functions — lack of concentration, memory — degree of disorientation — dysgraphia — slurring speech — difficulty with polysyllabic words — slight personality changes — frequent falls — reduction in rate and volume of speech neurological involvement — degree of generalized cerebral atrophy with slight dilation of lateral ventricles and enlargement of sulci — moderate widening of cortico-subarachnoid channels, specifically in posterior fossa — general atrophy in cortical and cerebellar areas — compression of lateral ventricles and dilation of quadrigeminal cistern neuropsychological features — moderate generalised cerebral dysfunction involving all cognitive, perceptual and motoric abilities compatible with dementia — mild dementia — early intellectual concretism — impaired concentration — intact immediate memory — impaired recent verbal and non-verbal memory neuropsychiatric features — buoyant, cheerful, friendly personality — alert — high level of awareness — depressed — apathetic 1 physical features — youthful appearance — exercises daily with good co-ordination, normal gait and station — marked akinesia of trunkal movements j — axial rigidity j — dystonia in extension | — gait — small steps with tendency towards | retropulsion 1 — supranuclear opthalmoplegia ' — stiff facial features — lack of expression speech and language features mild slurring articulation pattern difficulty articulating complex words and sounds particularly blends and fricatives excessive output with much digression and tangential communication problems with specificity and conciseness severe anomia affecting fluency and flow difficulties comprehending more complex material severe reading and writing difficulties heavy reliance op interlocutor for topic choice and direction of conversation many compensatory strategies willingfless to communicate effectively pseudobulbar palsy severe mixed dysarthria — speech highly unintelligible apathy of spontaneous output telegrammatic output with perseveration of words and phrases reduced speed of word retrieval / receptive language primarily intact. severe dysgraphia little self-initiated output ' heavy reliance on interlocutor lack of compensatory strategies no apparent willingness to communicate effectively the south african journal of communication disorders, vol. 35, 1988 ι r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) dementia and communication pathology: two case examples 69 assessment in addition to the standard battery of language and neuropsychological tests, an analysis of both patients within a conversational framework was undertaken. the results on standard measures are summarized in table ii and will not be described in detail here. the focus of this paper will be on communicative testing. the method of analysis was the pca originally devised by penn (1985) to characterize the communicative performance of adult aphasics and is described in detail elsewhere (penn, 1988). the 6 communicative components identified by the pca are as follows: a response to interlocutor β control of semantic content c cohesion d fluency ε sociolinguistic sensitivity f nonverbal communication penn (1988) found that aphasic patients could be differentiated with regard to the relative retention of each of these components and such a profile is useful in characterizing communicative impairments of other neurological populations, eg. chi (irvine & behrmann 1986) and right hemisphere patients (friedman 1986). appropriate -r mostly appropriate some appropriate / / mostly inappropriate inappropriate returning to the instrumental-fundamental distinction proposed by cummings (1986), it would appear that this scale may be sensitive to both these functions in that global aspects such as sociolinguistic sensitivity, non-verbal communication and overall fluency seem more closely linked to fundamental functions, while specific features of the linguistic message in scales a (response to interlocutor); β (control of semantic content); c (cohesion) seem more sensitive to instrumental functions such as language and memory. the communication of both patients was examined in an interactive framework with familiar conversational partners, the topic of conversation being on everyday events. global ratings on a 5-point rating scale of appropriateness were made by two trained graduate language pathologists in terms of each of the categories using 15 minute videotaped samples. results are presented in figure 1 and profiles appear in appendices a and b. resitt.ts it was clear that there were marked differences on the pca with respect to the profile and communicative characteristics between patients a and b. on the whole, patient a was construed to be more pragmatically appropriate in that, despite linguistic problems such as word finding difficulties and comprehension defects, she seemed an easy communicative partner, aware and compensating with excellent strategies for communicative interchange. on the other hand, patient β seemed an unwilling an unmotivated partner whose interactions were largely elicited and restricted, with poor conversational flow. detailed communicative profiles of each patient will now follow. key: o — a (dat) x β (psp) patient a (dat) patient a's response to the interlocutor was felt to be mostly appropriate. she showed a willingness to respond to input and while often reliant on the interlocutor for the initiation of the topic, was able to proceed in the conversation. on ocι ι ι ι ί i a β c d ε f scales of pca figure 1: relative position of the subjects on a 5-point rating scale of appropriateness in relation to each scale of the pca. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 claire penn, beulah sonnenberg and yael schnaier casion, her specific comprehension defect accounted for inappropriate responses but self correction took place. scale β (control of semantic content), was frequently judged inappropriate. topic initiation and shift and completion of ideas was often judged inappropriate. a number of incomplete phrases appearing in her transcript related strongly to her word fining difficulties resulting in a lack of accuracy and specificity, eg. "what's his name? he's got all the hotels. i know so well... he goes around with the blonde girl." such problems reflect also in scale c (cohesion), where little sentence embedding was observed. however, linking devices, eg. pronouns were present. no agrammatism was observed. patient a's fluency behaviours were judged to be mostly appropriate and seemed linked to the word-finding difficulties which manifested in filled pauses and incomplete phrases. sociolinguistic sensitivity was judged to be mostly appropriate. she proved to be an extremely entertaining interlocutor with evidence of humour, reference to her conversational partner and self correction. she demonstrated good control of direct speech as well as a number of comment clauses, eg. "i know the name so well. now you see, it shouldn't have gone out of my mind." non-verbal communication strategies such as gesture were used to support verbal behaviour and in fact served as a compensation yielding additional information. she had animated facial expression; used gesture and tone of voice. occasional slowing of rate was noticed — possibly related to the mild dysarthria which manifested particularly in the production of blends. patient β (psp) on scale a (response to \interlocutor), patient β also performed at a level of mostly^ appropriate. it should be noticed, however, that she was heavily reliant on the interlocutor for topic initiation and maintenance and her response^ were restricted to short replies for, pg. t: did he send in his dig team? ρ: i don't know. yes. t: jean and robbie were the main diggers. p: yes. t: did rev go with you? p: no. this aspect was reflected particularly in scale β (control of semantic content) where topics such as topic initiation and shift were judged inappropriate. in contrast, however, to patient a, lexical choice and idea completion were appropriate. little opportunity to judge cohesion (scale c) was available due to lack of spontaneity. however, | it seemed to be relatively unimpaired in that there was appropriate use of aspects such as tense and ellipsis. a number of nonfluencies were present in her conversational speech and were judged on occasion to interfere with communicative flow. in particular, pauses were felt to be lengthy, possibly related to the dysarthric element. very few examples of aspects linked to social sensitivity were evident. not observed were polite forms, reference to interlocutor, place holders, comment clauses, humour and control of direct speech. generally the patient showed a general lack of interest and motivation in conversation, linking closely to the picture of adynamia described by luria (botez, lucours & berube 1983). non-verbal communication was extremely impaired and judged consistently inappropriate, particularly vocal aspects relating to intensity, pitch, rate, intonation and quality. these are a direct reflection of her severe mixed dysarthria. non-verbal aspects were also related to the physical components of the disease, for example difficulties in lateral gaze. discussion the results indicated that both patients, with dementia of different etiologies, show a range of linguistic and communicative deficits. the pragmatic sequelae of the different disease processes and their outcomes (eg. dysarthria in patient b) are different and allow one to hypothesize as to the relationship between fundamental and instrumental processes on the one hand and components of pragmatics on the other. despite specific linguistic deficits, patient a was more communicatively appropriate than patient β and the severity of deficits appears more marked for β than a. this appears to be related primarily to a disruption of the fundamental aspects of motivation, mood, timing and arousal. hence, while patient a is motivated and alert in the communicative situation and focuses on maximizing communication flow and compensating for her deficits, patient β has a basic deficit at the level of arousal which in turn influences more instrumental (linguistic) components of the interaction. albert et al. (1974) have hypothesized that the basic disorder in subcortical cases is one of arousal, timing and activation and this seems to be the essential feature differentiating it from the cortical pattern in patient a. the results of this study suggest that the area of language use is a complex and multidimensional one involving the operations of many different systems. ι figure 2 represents schematically the hypothesized relationship between fundamental and instrumental processes and their possible pragmatic counterparts. ι in the area of topic control, for example, certain elements may be viewed as reflecting competence on a fundamental level while other aspects seem to be linked to an instrumental level. topic initiation and shift seem more closely linked to fundamental processes in that arousal and initiative are prerequisites for such skills. lexical specificity and sequencing seem more closely associated with instrumental processes, because they depend on linguistic competence. at the level of communication therefore it appears that the cortical-subcortical differentiation seems to hold some validity. whereas results from other research (eg. bayles and tomoeda 1983) suggest that the cortical patient-is more impaired in certain pragmatic tasks (eg. judgment of a literal sentence) than some subcortical dementias such as parkinson's and huntington's cases, the present study confirms the suggestion that psp is a type of subcortical dementia with a consistent intellectual deficit and which gravely affects the pragmatic level of language. the relatively widespread nature of the lesion in contrast to other subcortical r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) dementia and communication pathology: two case examples 71 recognition subcortical hypothetical pragmatic counterparts comprehension; control of semantic content; topic maintenance; lexical choice and cortical specificity; grammatical cohesion; fluency; gesture; sociolinguistic sensitivity; self-correction behaviours topic initiation, maintenance and shift; vocal and non-verbal aspects (facial expression, eye contact and posture); awareness and response to interlocutor, rate, flow, coherence, contingency figure 2: schematic view of the brain showing-basic localization of processes relevant to communication and their hypothesized pragmatic counterparts. dementias seems to provide an explanation for this (cummings 1986). a clear connection to frontal lobe symptomatology is seen in this case as in all documented cases of psp which has important implications for the language pathologist in terms of differential diagnosis. many of patient b's symptoms and neurologic manifestations seem similar to traditional descriptions of dynamic aphasia as described by luria and tsvetkova (1970). they viewed the fundamental disturbance in dynamic aphasia as one affecting inner language and the predicative function. the initial idea of the action is present but the patient is unable to programme the action. the patient remains lacking/in spontaneity and there is a major, usually global, decrease in physical and intellectual activity. authors such as botez et al. (1983) suggest that these symptoms are similar to those resulting from a lesion of the convexity of the frontal lobe. such patients demonstrate a lack of initiative and drive. it is clear that the differences between dynamic aphasia and subcortical problems are not easy to observe and, given the rich anatomical connections (through the reticular activating system) between the frontal lobe and the subcortical areas (albert, 1978) it is possible that in some patients traditionally labelled as "dynamic aphasia" particularly in the presence of dysarthria and motor signs, the lesion may be more subcoritcal. the writers are in agreement with cummings (1986) who suggests, that terms such as "frontalsubcortical systems disorder" might more accurately reflect the realm of anatomic, metabolic and neurochemical dysfunction found in this group of conditions. aside from the role in differential diagnosis, the language pathologist plays a critical role in the management of cortical and subcortical dementias (bayles, 1986). despite very poor ultimate prognosis, the role of the environment in dementia is felt to be particularly important. both subjects in the present study were in a most supportive and understanding environment which in patient a's case (like that of the patient with pick's disease described by holland, mcburney & reinmuth 1985) would seem to contribute to the surprisingly spared pragmatic skills despite severe semantic and intellectual deterioration. patient b, however, because of the severe physical concomitants of the disease and its effects on the fundamental processes, seemed unresponsive to environmental manipulation and therapy. the role of the speech and language pathologist is that of information and support and from a communication framework, facilitating, maximising and adapting compensation behaviour both in the patient and in the family (bayles 1986). clearly the type and intervention is determined by etiology and stage of dementia and will differ if fundamental as well as instrumental processes are involved. for example, patient a responded well to a compensatory strategy paradigm which encouraged maximizing communicative performance. patient b, however, was unresponsive to such efforts and environmental intervention was seen to be the most appropriate strategy. the fundamental-instrumental dichotomy might perhaps have useful application to the treatment of other communicative disorders. as with other neurogenic language disorders, the pattern of impairment in different diagnostic groups of dementia provides important implications for language organization in the brain. unlike other levels of language, eg. phonology, syntax and semantics, pragmatics seems to have much more generalized representation and depends on both cortical and subcortical integrity: "pragmatic processing, like semantic, depends on conscious processing and results from the operation of other mental systems, among them perception, attention and abstraction" (bayles, 1985). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 the results of this study suggest that one needs to analyze the components of such language use in an attempt to explain the symptoms. it is clearly not enough to say that a language problem exists in dementia, but we need to describe how that pattern manifests and what its implications are for overall communicative functioning. the results of this study confirm that "communicative impairment is an integral feature of the dementia syndrome" (bayles, 1986) and that a pragmatic analysis may be useful in differentiating dementias of differing etiologies. references albert, m.l., feldman, r.g. and willis, a.l. the "subcortical dementia" of progressive supranuclear palsy, journal of neurology, neurosurgery and psychiatry, 37, 121 — 130, 1974. albert, m.l. subcortical dementia. in: r. katzman, 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"subcortical dementia" a recognizable clinical entity? annals of neurology, 14, 7 8 2 8 3 , 1983. obler l.k. and albert, m.l. language in the elderly aphasic and in the dementing patient. in: m.t. sarno (ed.) acquired aphasia. new york: academic press, 1981. penn, c. the profile of communicative appropriateness. south african journal of communication disorders, 32, 18—32, 1985. penn, c. the profiling of syntax and pragmatics in aphasia. clinical linguistics and phonetics, 2 (3), 179-207, 1988. pillon, b., dubois, b., lhermitte, f. & agid, y. heterogeneity of cognitive impairment in progressive supranuclear palsy, parkinson's disease and alzheimer's disease. neurology, 36, 1179-1185, 1986. ruberg, m., javoy-agid, f., hirsch, e., scatton, b. lheureux, r., hauw, j.j., duyckaerts, c., gray, f. morel-maroger, α., rascol, α., serdara, m. and agid, y. dopaminergic and cholinergic lesions in progressive supranuclear palsy. annals of neurology, 18, 523—529, 1985. ; schneck, m.k., reisberg, b. and ferris, s.h. an overview of current concepts of alzheimer's disease. american journal of psychiatry, 139, 1982. j steele, j.c. progressive supranuclear palsy. brain, 95, 693—704, 1972. the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) dementia and communication pathology: two case examples 73 appendix a profile of communicativc appropriateness name patient a features of sampling date unit of analysis person eliciting sample inapprop mostly inapprop some approp mostly approp approp ω ζ u comments request s ο reply v s s clarification request • §-'a acknowledgement υ e 05 5 teaching probe others topic initiation • 1 topic adherence ε v υ g (λ ω ο i topic shift • ε v υ g (λ ω ο i lexical choice v / τ a ιμ idea completion c ο υ idea sequencing c ο υ others ellipsis l / tense use reference \/ ο '35 lcxical substitution forms / -c ο υ relative clauses v / -c ο υ prcnominal adjcctivcs • conjunctions v / others interjections v ' repetitions v revisions v / >· υ incomplete phrases v ^ α> false starts u. pauses v word-finding difficulties ^ others' polite forms i / ' reference to interlocutor v ' placeholders, fillers, stereotypes v / υ acknowledgements v <ο >-< h i self correction • c ,ts comment clauses hj κ sarcasm/humour hj κ control of direct speech indirect speech acts others vocal aspects: intensity v / pitch v / rate intonation v quality nonverbal aspects: facial expression head movement l / body posture breathing v/ social distance v gesture and pantomime • others i totals 1 5 8 16 13 , 2 the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 74 claire penn, beulah sonnenberg and yael schnaier appendix β profile of communicative appropriateness name patient β features of sampling date unit of analysis person eliciting sample inapprop mostly inapprop some approp mostly j approp approp comments request 2 s reply • 5 * clarification request acknowledgement t / «85 teaching probe others topic initiation •β i topic adherence • ε ji g ο g topic shift 1 / ε -ji g ο g lexical choice •a a ^ idea completion c 3 idea sequencing others ellipsis tense use 1/ reference 1 / ο lexical substitution forms js δ relative clauses js δ prenominal adjectives conjunctions others interjections repetitions revisions t / _> c incomplete phrases s u. false starts 1/ pauses word-finding difficulties others polite torms reference to interlocutor 1/ placeholders, fillers, stereotypes υ to acknowledgements self correction l / 12 '35 o c comment clauses r sarcasm/humour control of direct speech / indirect speech acts / others / ' vocal aspects: intensity pitch rate a intonation 1 1 quality ο a c ? nonverbal aspects: facial expression v/ § i ζ ε head movement a body posture l/" breathing social distance • y gesture and pantomime others totals 15 2 11 7 0 1 0 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 25 language abilities of 18-month-old zulu speakers melissa a. bortz department of speech pathology and audiology university of the witwatersrand abstract the receptive, expressive and pragmatic language abilities of 18-month-old zulu speakers were assessed in order to obtain preliminary norms. twenty-five participants of the birth to ten cohort study were investigated using parent reports, mother-child and tester-child interactions. data was transcribed and analysed using nonparametric statistics. results demonstrated that receptively subjects understood two-part instructions. expressively, the mean lexicon was 4.12 words and mean length of utterance 0.65. pragmatically, subjects were functioning on a nonverbal level and exhibited culture-specific items. the results provided information which could enable speech, language and hearing therapists to engage in primary and secondary prevention. an appropriate test battery for these children is discussed. opsomming die respetiewe, ekspresiewe en pragmatiese taalvermoens van 18 maande oue zulusprekers isgeevalueer om voorlopige norms op te stel. vyf en twintig deelnemers aan die geboorte tot tien longtudinale studie is deur middel van oueronderhoude, moeder-kind en toetserkindinteraksies ondersoek. data isgetranskribeer engeanaliseer deur middel van nonparametiese statestiek. die resultate dui aan dat die proefpersone op reseptiewe vlak instruksies bestaande uit twee komponente, begryp het. op ekspressiewe vlak was diegemiddelde leksikon 4.12 woorde en die gemiddelde lengte van 'n uiting 0.65. op pragmatiese vlak het die proefpersone op 'n nie-verbale vlak funksioneer en kultuurspesifike gedrag vertoon. die resultate het inligting verskafwat spraak-taal-en-gehoorterapeute in staat kan stel om betrokke te raak in primere en sekondere voorkoming van taalprobleme. 'n geskikte toetsbattery vir hierdie kinders is bespreek. epidemiology is the professional discipline concerned with "searching put and understanding the factors relating to the occurrence of disease in the population" (peterson & thomas, 1978, p. xv). mausner and bahn (1985) cited by m. marge*1 (personal communication, april 20, 1992), have defined epidemiology as the study of the distribution and determinants of disorders in human populations. a cohort study is based upon one of the methods used by epidemiologists to study disease occurrence and has been described as "a systematic follow up of a group of people for a defined period of time" (the oxford reference concise medical dictionary, 1990 p. 142). cohen and manion (1991) have described cohort studies as prospective longitudinal methods which "are particularly appropriate in research on human growth and development" (p. 73). cohorts usually refer to a birth cohort which contain persons born in a specified period of time (miller & keane, 1983). although cohort studies belong to the realm of epidemiology, they are also a powerful tool that can be used for descriptive research, which is concerned with "acquisition of skills in young children" (cohen & manion, 1991, p. 70). this methodology has been adopted by speech, language and hearing therapists who have made use of cohorts for developmental research, such as the connecticut longitudinal study in which mother-infant communication was examined (thoman, 1981, m. marge (1992) professor communication sciences and disorders, division of special education and rehabilitation, syracuse university. p. 194). epidemiology, from a speech, language and hearing therapists' perspective, is concerned with the prevention of communicative disorders, where prevention usually occurs at three levels: primary, secondary and tertiary (gerber, 1990). primary prevention refers to the elimination of the occurrence of a communicative disorder, for example, by mass public education and the promotion of better health in general; secondary prevention focuses on early detection and treatment of a communication problem and tertiary prevention relates to rehabilitation, the traditional focus of attention for speech, language and hearing therapists (gerber, 1990; marge, 1991). marge (1984, cited in gerber, 1990, p. 319) has contended that "preventing communicative disorders should be the added new dimension to the professional responsibility of speech-language pathologists and audiologists". according to van haatum (1980, cited in gerber, 1990) this "will ultimately prove to be more productive than curing" (p. xiii). this has been reiterated by segal who quoted critical health, (1982,pp. 12-13) when motivating for a re-allocation of priorities: to direct more effort to prevention than cure. furthermore child and johnson (1992, p. 1) have declared "an ounce of prevention" may truly be worth "a pound of cure". the committee on prevention of speech-language and hearing problems of asha (1983) referred to in gerber (p. 311) strongly recommended that increased development, and implementation of primary prevention strategies should be undertaken, particularly for low-income populations, who are at the greatest suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 39, 1992 sasha 1 2 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 melissa a bortz risk for conditions that can lead to communication disorders. once early identification and screening for communication problems have taken place, it is possible to determine the incidence and prevalence of speech problems. in south africa, speech, language and hearing therapists have not concentrated their efforts on prevention of communication disorders, particularly for the "vast sections of the population who do not receive even the most basic speech therapy" (drew, 1982). a possible explanation for this is that we have limited tools available to perform the identification of speech and language problems, and those that do exist are inadequate (ballantine, ballantine & morgan, 1982), the writer, a speech, language and hearing therapist, was given the opportunity, to enter the field of epidemiology and prevention by participating in a cohort study entitled birth to ten: children of the nineties, which is currently in operation on the witwatersrand. this is a ten year longitudinal study, combining over thirty different disciplines studying the growth and child health development of children born between april and june 1990, in johannesburg and soweto. the speech and language project of birth to ten, is aimed at collecting information on the acquisition of speech and language in the targeted children, of various language groups prevalent in this area, with a view to establishing normative data. an additional aim of the study is to develop, modify and standardise measurement tools and procedures for assessing speech and language development. the purpose of this particular substudy was twofold: 1) to investigate the language abilities of 18-month-old zulu speakers with a view to establishing preliminary norms, and 2) to evaluate the effectiveness of the assessment materials utilised in the study. the establishment of such preliminary norms has "definite implications for secondary prevention, that is mass screening and early identification once the norms have been established" (m. marge, personal communication, april 20, 1992). it is necessary to study early language development so that timeous identification of language problems can be performed. this can prevent the broad and long term effects of language disorders in children, such as the "extreme emotional side effects of being learning disabled" (vorster, 1980, p. 2). the definitions of language and its components used in this study are as follows: language "is a code whereby ideas about the world are represented through a conventional system of arbitrary signals for communication" (lahey, 1988, p. 2). the components of language are receptive language, which is defined by nicolosi, harryman & kresheck (1989, p. 142) as "spoken messages received by the individual"; expressive language or the "use of conventional symbols to communicate one's perceptions, ideas, feelings or intentions to others" (nicolosi et al., 1989, p. 141); and pragmatics or use which is defined by bernstein & tiegerman (1989) as the rules relating to the use of language in social contexts. both the verbal and nonverbal aspects of pragmatics were considered and morphology, syntax and semantics were regarded both receptively and expressively. all these components are interrelated and interact dynamically in communication. bernstein & tiegerman (1989) have contended that from a developmental perspective, communication precedes and facilitates speech and language behaviour while both semantics ' the term toddler is used as an equivalent form of 18-month-old in this study. 2 zulu was spoken by 6,5 million people in 1980 according to the central statistical service. this is the most recent figure available. a new figure will only be available in late 1992 when the results of the 1991 census are published. and syntactic functions are derived from pragmatic experiences. from birth to 24 months children use different forms of behaviour such as vocal, gestural and lexical, to signal interaction or to produce speech acts, all of which occur in the social context. between 12 and 24 months children first acquire phonemes followed by lexical items based upon the emerging phonological and semantic systems (bernstein & tiegerman, 1989). 18-month-old children or toddlers1 can either be at the illocutionary stage of communication development, in that they use symbolic means to convey intentions, or at the locutionary phase in which they use language to express meaning (bates, camioni & volterra, 1979; ochs & schieffelin, 1979). gesell' (1954) maintained that 18-month-old children communicate by both gesture and words and, that in fact, words can be accompanied by gestures or even begin replacing these. the child may have a vocabulary of ten words and may be egocentric at this stage but it can be seen that she/he is beginning to communicate more than younger children. the 18-month-old plays independently but will react to companions. nicolosi & collins (1989) have claimed that 18-month-olds understand simple commands and prohibitions, recognise familiar objects and persons and identify one body part. expressively, they have an average sentence length of 1.5 words and say two or three word combinations. it was mentioned previously that the purpose of this study was to examine the language abilities of zulu speakers. the reason for this is that zulu is the most commonly spoken african language in south africa2. although it is the language primarily of natal and kwazulu, suzman (1990) has maintained that it is also the lingua franca of cities in the transvaal. linguistic features of zulu structurally, zulu is an agglutinating language in that various morphemes are combined to form a single word, in which simultaneously, each element maintains a distinct and fixed meaning (fromkin & rodman, 1978). it can also be described as a synthetic language in which grammatical relations depend mostly on affixes (bhatnager & whitaker, 1984); and a tonal language where tone has a grammatical function, a lexical function and serves to maintain syllable prominence (suzman, 1990). furthermore, zulu is a svo language with a reasonably flexible word order (suzman, 1990). the actual structure of zulu is characterised by three features: 'the noun class system, extensive concord and a full suffix system of verbal derivatives (doke, 1945). i taking the above mentioned information into account the present study was designed to determine the language abilities of 18-month-old zulu speakers by investigating the communication development from which language develops. a further goal was to devise a suitable repertoire of assessment procedures for this sample group. method subjects twenty-five first language zulu speakers from the birth to ten cohort study were selected. being participants in birth to ten implied that all subjects met the following criteria: subjects were residents in either johannesburg or soweto subjects had been enroled in the birth to ten from its inception, that is, they had antenatal, six month and one year questionnaires completed. the different disciplines participating in the birth to ten had asked pertinent questions at all of these stages which had been compiled into questhe south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abilities of 18 month-old zulu speakers 27 tiormaires which were administered by specially trained fieldworkers. speech and language questions asked, included details about case history factors and biographical information such as languages spoken in the home. in addition for the purposes of this study all subjects met the criteria described below: all subjects resided in soweto, to ensure homogeneity of environment subjects were in the age range 18-20 months so that they could be expected to be both understanding simple commands and producing a small number of words and possibly joining these together in two word phrases (hopper & naremore, 1978; nicolosi&collins, 1989), thus providing sufficient communication behaviour to evaluate subjects were first language zulu speakers as reported by their parents in the birth to ten questionnaires 13 male and 12 female subjects were selected in an attempt to eliminate the effects of the sex variable all subjects were accompanied to the evaluation by the person who usually took care of the child, either the mother or the caregiver as "bonding with a caregiver... fosters speech development" (van riper & emerick, 1990, p. 92).3 procedures pretest preparation. all appointments for the assessment were made by research assistants who personally visited each subject and the caregiver, in soweto, in order to explain the purpose of the project and to give explicit directions on how to reach the test venue. these personal contacts proved successful as the response rate for attendance at the test situation was high. communication sampling procedures 1. parent report measure. according to dale (1991) parent report can provide valuable information on early child language development particularly in the age range 8-30 months. prior to the formal assessment research assistants asked mothers specific questions about the communication behaviours that their children were using. the parent report was devised by the writer based on information on development of child language from sources such as nicolosi & collins (1989); gesell (1954) and hopper & naremore (1978). (see 3 the term mother and caregiver will be used interchangeably. table 1: communication sampling procedures appendix a). 2. language sampling. a 40 minute sample of each subject's communicative behaviour was obtained, consisting of a 20 minute mother-child interaction, in which the mother and the child interacted freely, and a 20 minute tester-child interaction in which the clinician gave a variety of questions and commands in order to "analyse children's comprehension and expression through answers to questions and responses to commands" (miller, 1981, p. 13). this sampling procedure was loosely based on that described by miller (1981), when he suggested that 30 minutes should be used to obtain a language sample, as this is an appropriate length of time for the concentration span of 18-month-old children and that 30 60 utterances should be elicited in this period. all samples were recorded on a national vhs ms2 video camera and audio taped on a sanyo trc 2500 tape recorder, for back up. the testing situation took place in a one-way mirror room at the university of the witwatersrand speech and hearing clinic (ushc). 2.1 mother-child interaction. the objective of this interaction was to observe the communication between the mother and child. in order to stimulate communication, subjects and their mothers were given objects appropriate to age and culture, from two of the categories identified by reynolds (1989). stimuli therefore were either specific play objects eg. dolls and balls or items borrowed from the adult world such as eating utensils and towels. the stimuli were placed in accessible parts of the testing room and the caregivers were instructed to interact with their children as they would at home "in a natural manner" (wetherby, yonclas & bryan, 1989, p. 151). it is however, acknowledged that mothers may not play with, or speak to children in this way at home. 2.2 tester-child interaction. receptive and expressive language was elicited in the tester-child interaction by the child either having to choose or name an item from three familiar objects that is inkomishi 'cup', ibhola 'ball' and indishi 'plate' as for the reynell developmental language scales (1978): furthermore, pragmatic behaviour was elicited according to a "standard series of communicative situations" devised by wetherby and prutting (1984, p. 151) "to induce child-initiated communicative behaviour". the tester waited and looked expectantly at the child and responded naturally to the child's communicative behaviour. an example was to blow up a balloon, deflate it and then give it to the child and observe the reaction and to react appropriately to it. see table 1. ι receptive language abilities expressive language abilities pragmatic language abilities parent report questions 2, 4, 9 and 10 on appendix a, to elicit knowledge about receptive language questions 1, 3, 5 and 8 on appendix a to elicit knowledge about expressive language questions 6 and 7 to elicit knowledge about pragmatics mother-child interaction not tested mlu. mean number of utterances per turn. topic shifts qualitative assessment of communicative behaviours tester-child interaction child to identify inkomishi 'cup', ibhola 'ball' and indishi 'plate' and body parts child to name inkomishi 'cup', ibhola 'ball' and indishi 'plate' and body parts eliciting pragmatics from wetherby and prutting (1984) standard series of communication situations die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 melissa a bortz research assistants the study was conducted by four research assistants, diplomates in speech and hearing (community work) and who were fluent in both zulu and english. they established contact with the mothers, performed the testing and transcribed and scored the data. pilot study the aim of the pilot study was to determine the suitability of the procedures and stimuli described above and the length of time it would take to administer such a procedure. the pilot study was performed on seven subjects who met the criteria for the research, previously mentioned. a preliminary version of the research was devised, based on principles of language testing and materials devised for children of this age such as the reynell developmental language scales (1978). care was taken to make the procedures relevant and appropriate to the south african population so i consulted with researchers who had previously conducted investigations into zulu language acquisition such as s. m. suzman*2 (personal communication, october, 1991). in addition, preliminary scoring procedures were devised. results of the pilot study demonstrated that the proposed testing and scoring procedures were appropriate and provided useful information for analysis. furthermore, the pilot study indicated that the optimal length of time for the mother-child interaction was 20 minutes as children did not provide additional information for language sampling, thereafter. certain stimuli such as a teddy bear were eliminated as this frightened the subjects. analysis of the communication sample transcription. in pairs, the research assistants transcribed the mother-child interactions and the contexts in which these occurred, using standard orthography (miller, 1981; conti-ramsden & dykins, 1991). thereafter, pairs ofresearch assistants viewed segments of the video tape, repeatedly, until they established agreement on the interaction. in addition, the transcription was translated from zulu into english for me to understand what had been said. scoring. the following structural analysis was performed on the mother-child interaction. 1. mean length of utterance (mlu). the mlu for both child and mother was counted in morphemes because zulu has an "extremely rich morphology" (suzman, 1990 abstract) mlu was calculated according to miller's (1981) counting rules. paralinguistic features were not included and mlu was only counted for fully intelligible utterances. the mean number of morphemes and the mean number of utterances, used to calculate mlu, were judged individually, as these figures provide valuable information. percentage of clear and unintelligible utterances was also considered individually. 2. mean number of utterances per turn. the number of utterances for both child and mother were calculated in order to measure the density of each speaker's turn. this was determined by taking the number of utterances for each speaker, and the number of turns for that speaker and dividing them (g.conti-ramsden*3, personal communication, april 14 1992). *j s.m. suzman (1991) phd, department of linguistics, university of the witwatersrand. * 3 g. conti-ramsden (1992), phd, centre for educational guidance and special needs, school of special education, university of manchester. 3. topic shifts. topic shifts occur when one of the conversational partners disengages her/himself from the previous set of concerns at either the verbal or nonverbal level (contiramsden & dykins, 1991). these were counted as having occurred when either the mother or the child changed both the focus and the theme of the conversation or the toys they were playing with as suggested by g. conti-ramsden (personal communication, april 14, 1992). 4. parent report and tester child interaction. the parent report and tester-child interaction samples were scored by a pair ofresearch assistants according to a format devised by the writer where responses were analysed as being correct or appropriate, incorrect or inappropriate, or, not tested. the 'not tested' category included any item not examined by the research assistants either due to a lack of response by the subjects or the subjects not responding to the previous stimulus eg. on the tester-child interaction if the subject could not point to indishi 'plate' because of loss of attention, then the next item, inkomishi 'cup', was not tested. the pragmatic interaction was scored as a communication act when "the child initiated interaction with the adult or focused attention on an object" (wetherbyetal., 1989, p. 151). wetherby etal. (1989) have described intentional communicative acts that occur as a result of the interaction in detail, but because the subjects only focused attention on objects, and there was little interaction with adults, this was not investigated further. all scores obtained were converted to percentages and analysed by means of nonparametric statistics. results will be discussed in terms of these values. interrater reliability research assistants worked in pairs in order to transcribe and score the full data sets. the, 30% of the data were randomly selected and independently recoded as suggested by contiramsden & dykins (1991). interrater reliability was calculated according to the following formula proposed by mcreynolds & kearns, (1983): percentage agreement agreements x i 0 0 agreements & disagreements attempts were made to achieve a minimum of 80% agreement with this formula but only 66% agreement was obtained. poor interrater reliability is not uncommon with children this age. bates, bretherton and snyder (1988) attempted to obtain similar agreement with 20 month olds and could not, as subjects of this age have "a relatively high proportion of unintelligible utterances" (p. 84). i results and discussion the results from the analyses of communication samples are presented below. they are divided into receptive, expressive and pragmatic language abilities, insofar as it was possible to separate these related skills. parent report, mother-child interaction and tester-child interaction will be discussed for each section. a discussion of a suitable repertoire of assessment tasks, based on these findings, follows. receptive language abilities parent report. from parents reports it appears that 95,5% of the subjects listened, when communication was addressed to them and responded appropriately to this communication for example, by either looking at or approaching the mother when called, while 4,5% of the subjects did not respond to communication. responding to communication is regarded as the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language abilities of 18 month-old zulu speakers onriate according to nicolosi & collins, (1989). all of age a pp™ p n w e r e reported to understand what was being said thechil r e ^ ^ ^ fouow two-part instructions such as hlalapant®1 «die 'sit down and eat' and hamba uyalale 'go ^ n i s o s i and collins (1989) have stated that 18-month-old h'ldren should be able to identify one body part. in this sam1 63 6% of children were reported to be able to do so while l ^ ' c o u l d not. children were able to identify ten different rts of their bodies and most often able to point to their izindlebe 'ears' (9 subjects), and least often to their ubuso 'face', iminwe 'finger' or isisu 'stomach' (see figure 1 for exact information). body part 29 0 2 4 6 8 frequency figure 1: frequency of correct identification of body parts children's ability to identify their body parts was also assessed in the tester-child interaction, in which it was found that ten of the subjects (40%) did not respond to this task while nine subjects (36%) could identify body parts such as izindlebe 'ears' and umlomo 'mouth' and six subjects (24%) could not identify parts of their bodies. the subjects' ability to identify body parts appears to be more advanced than their english speaking counterparts. hedrick, prather & tobin (1984), in their standardisation sample for the sequenced inventory of communication development, (sicd), found that children were able to point to their eyes, hair, mouth and nose at two years and only at 28 months to their ears, although certain subjects of this study could identify all the above, including ears, at 18 months. the results obtained in the parent-child report and the tester-child interaction were correlated using a spearman correlation coefficient resulting in a poor correlation (r=. 149). thus, parents maintained that children knew more parts of the body than the testing situation indicated. tester-child interaction. the majority of the subjects were able to point to the objects in the tester-child interaction: specifically 72% (18 subjects) were able to identify inkomishi 'cup', 80% (20 subjects) could recognise ibhola 'ball' and 60% (15 subjects) identified indishi 'plate' (see figure 2). it is interesting to note that fewer subjects were able to identify the objects as the procedure continued, while the percentage of children who could not be tested increased from 16% for the identification of inkomishi 'cup' to 40% at the end of the procedure, possibly signifying that the subjects were losing concentration towards the end of this task. to summarise the findings about receptive language abilifrequencles cup ball plate i yes sub no i i not t e s t e d figure 2: frequency for tester-child receptive abilities ties, it was found that 54% of children understood the questions, while 26% could not be tested in this way and 18% did not understand the instructions. therefore, the majority of children in the study were understanding symbolic representation and as such, relating words to toys (reynell, 1977). as regards the most suitable repertoire of assessment procedures to use for reception, the parent report appeared to yield more information than when the tester assessed the child, as it was difficult to obtain cooperation from children this young4. this confirms the findings of dale (1991) who maintained that parent report "is more representative of toddler language than laboratory samples" (p. 566). expressive language abilities parent report. nicolosi & collins (1989) have contended that jargon is at its peak at 18 months and gesell (1954) has reported that children of this age conduct expressive inflected "conversation" (p. 32). all subjects (100%) were reported to babble and use jargon. parents reported believing this to be appropriate in 74% of cases and inappropriate in 26% of instances. twenty-four subjects were reported as using imitation and all of the subjects were reported as able to sing, which is common in the expressive abilities of children this age. all mothers reported that their children were saying words. the subjects' words reported by the mothers are presented in figure 3. according to clark (1979, p. 160) the first words children say "show considerable agreement... across children and across languages". these first words refer to "here and now" topics and fall into the following categories: people, particularly "adult caretakers familiar to the child" food, houseword mama tata dipnltie matume " t i p let ha inla lbft?jg family names pnuza g o m β inkonilsi^ kudla dad a h a m o a 10 15 frequency 20 25 it should be noted that the reliability of parent report was not formally assessed. this is seen as a limitation of this study. figure 3: words children are saying according to caregivers die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 hold items like cup, toys like ball, body parts and actions. it can be seen that the words the subjects were saying concur with these categories for example inkomishi 'cup', for household items. the mean lexicon of each child was 4,12 words, with a standard deviation of 2,2 words, and a pool of 25 words. dale (1990, p. 566) has asserted that parent report is "potentially an excellent measure of vocabulary development" and therefore these results could be regarded as providing information concerning a preliminary lexicon for these children, although it is acknowledged that for a truly representative lexicon a larger sample of children would have to be tested. the literature describes a broad range in the number of words that children are expected to produce at 18 months. this mostly depends on the source and particular discipline that is being referred to, as paediatricians tend to expect children to produce small numbers of words, for example illingworth (1983), has reported that children can name a single word at 18 months and holt (1977, p. 218) suggested that paediatricians should only be alerted to further investigation for an expressive language problem if "a child of 18 months" is not "producing at least one or two words". linguists and language therapists expect toddlers to be saying many more words at this stage, for example nicolosi & collins (1989) have noted that 18-month-olds produce 10 20 words while clark (1979) has stated that toddlers should have lexicons of approximately 50 words. it is interesting to note that, of the words the children were saying, several are not pure zulu forms but adoptives from other languages such asbhuti 'brother' and dankie 'thankyou' from afrikaans or no, from english. this is a common feature of the zulu that people on the witwatersrand speak. (m. mngadi*4, personal communication, july 20, 1992). in this sample, morphology was not formally assessed, but it was noted that some children used marked forms of the word and correctly denoted which noun classes the words belonged to, such as ibhola 'ball', noun class 5 and amanzi 'water', noun class 6 and others used the unmarked form manzi. (m. mngadi, personal communication, july 20,1992). this use of the prefix in zulu could be compared to english speakers' beginning to put two or three words together which is a normal development at this stage (hopper & naremore, 1978· nicolosi & collins, 1989). a more detailed investigation of morphology and syntax will be undertaken in a separate study in the birth to ten cohort programme. mother-child interaction. complexify measures of syntax revealed that the subjects had an mlu of 0,38 which is below the mean of 1,14 and 1,31, that english speaking children are reported as having at this stage (miller, 1981 ρ 27· bates et al., 1988, p.85). miller (1981, p. 25) has cautioned that "mlu can only be interpreted when the criteria for representativeness of the speech sample, such as sample size, have been satisfied". bates et al., (1988) have contended that to calculate mlu "a traditional minimum of fifty intelligible utterances" is required (p. 85). in the study of bates et al., (1988) investigating the mlu of 20 month olds, a mlu score of 1,00 was assigned to the children who produced only single-word utterances when "the number of intelligible utterances fell well below this criterion" (p. 85). even when using the same adjustments instituted by bates et al., (1988) for the ten subjects of this study whose number of utterances was below 50, the mlu for this sample remained below that of english speaking subjects, at 0,65. this mlu, however, indicates that the submelissa a bortz jects were functioning at the "early one-word stage" or " s e sorimotor stage v" which is acceptable in the age range 10 -ι"» months (miller, 1981, p. 55). bates et al. (1988) also found their subjects to have a rang of mlus of from 1,00 to 2,11. similar fluctuations were found in this study, with one subject not saying anything and another having a mlu of 1 word. it was found, however, that the children were using an average of 2,78 different morphemes i„ this interaction. the mean number of utterances produced was 72,4 with a large discrepancy between three in one child and 202 in another. the mean number of clear utterances for the sample was 1,17, while the mean number of unintelligible utterances was 0,74, indicating that although subjects was saying few utterances, most of those that were produced, were intelligible. it must be remembered, that, according to the rules for counting morphemes in each utterance, fillers such as 'aaaa' were not counted (miller, 1981, p. 24). these constituted a large portion of what the children were saying, as they were at the jargon stage of production (gesell, 1954). chapman, (1981, p. 206) has noted that "mothers speech averages about 2,4 morphemes longer than her child's during the 12-27 month period". results of the current study are not consistent with this finding, as mothers' mlu was approximately one morpheme longer than their childrens' (mothers mlu 1,4 and children's 0,65). a possible explanation for this is that mothers' mlu varies with conversational context and is shortest in free play situations, from which this sample was elicited (snow, 1972, cited in chapman, 1981, p. 206). the mlu for both mothers and children was more restricted in this sample, than the mlu reported in the literature for english speaking subjects. a pearson correlation coefficient indicated a poor correlation (r= 21) suggesting that the mothers' speech did not affect the childrens' speech (see figure 4). the mean number of utterances per turn for the children was 1,519 and for mothers, was 3,32, showing that mothers were saying more in each turn, than their children, which is to be expected given the superior language skills that adults have. there was a poor correlation between the mothers' speech and that of their children (r=.33). furthermore the subjects changed the topic more often than the caregivers with a mean number of 22 times and the caregivers with a mean of 18 times. this could suggest that subjects were concentrating on the conversation or toys that they were playing with, for short periods of tinie, which is to be expected at this age. 1200 1000 mother *4 m. mngadi (1992), senior tutor, department of african languages, university of the witwatersrand. figure 4: correlation between number of morphemes of mother and child tester-child interaction. the majority of subjects were not able to name items that they had identified in the receptive tasks, providing no response to items, so earning a "not tested" the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language abilities of 18 m o n t h d zulu speakers . q n t h e item indishi 'plate' three of the subjects classificatio_ ^ ^ ( 1 2 % ) ; one subject was able to name produced t a n ( j o n ] y four s u b j e c t s ( 1 6 % ) w e r e a b l e t q inkomism ^ f . a n d o n ] y four s u b j e c t s ( 1 6 0 / 6 ) w e r e a b l e t q inkofflis > o f the children was able to name name lbnoia u«ui • body parts. (see figure 5.) cup ball p l a t e i y e s i no w not t e s t e d figure 5: frequencies for tester-child expressive abilities from these results, it can be seen that the tester-child assessment of expression yielded very few examples of childrens' ability to name objects. these data indicating poor naming capabilities support the findings of the limited expressive abilities of these subjects on the mother-child interaction sampling. although the subjects exhibited restricted mlus in the mother-child test situation, their mlus (0,65) however, did indicate an ability to express themselves. these poor results therefore do not reflect an inability to verbalise, but, suggest the unsuitability of the task, for these children. the fact that the subjects' expression seems to be more limited than their reception is not unexpected, as it is well documented that the development of receptive language precedes expression. results of the tests of expression for these subjects did, however, indicate, that their expressive language abilities were more limited than those reported in studies performed on certain of their english speaking peers, as can be seen from the few words they are producing and their restricted mlu. pragmatic language abilities parent report. all the subjects were able to communicate their needs and 95,5% were able to do so appropriately. appropriate responses included saying mama or papa while pointing to the required object. inappropriate responses were those in which the parents did not understand the child's communication eg. in non specific crying. all children were also reported to be using gesture to communicate intention. mother-child interaction. an ethnographic approach as defined by mctear and conti-ramsden (1992) was taken for this analysis, where the emphasis was on qualitative, rather than on quantitative analysis eg. a description of all communicative behaviours was therefore recorded. the absence of evidence of a communicative behaviour however can not be construed as implying absence from a child's repertoire (roth & spekman, 1984). forty-four percent of the children attempted to sweep with a broom while 56% of subjects did not exhibit this behaviour. according to illingsworth (1983) who has commented that toddlers "copy mother in her domestic work for example sweeping the floor" (p. 145), this activity is typical. thirteen of the subjects were observed to carry dolls tied to 31 their backs, after the mothers had put them there. this is strongly related to how mothers traditionally carry their children (read, 1959). the above two activities are indicative of halliday's account of pretend play which is part of the imaginative act of phase i language functions and which occurred in her child at 18 months showing that these children are functioning in a similar way to their english speaking peers (halliday, 1975, cited in miller, 1981). in addition, subjects were observed engaging in autosymbolic play such as brushing their teeth with a toothbrush. they also used common objects and toys appropriately, such as playing with a car or ball. due to the qualitative nature of the analysis utilised for the spontaneous emergence of communicative behaviour, exact scores were not obtained but their presence demonstrates that the subjects were functioning at stage iii of westby's symbolic play scale check list, which occurs between 17 and 19 months (westby, 1980). it must be stressed however that non emergence of a behaviour was in no way interpreted as absence from the child's repertoire. researcher-child interaction. the results of the analysis of subjects' responses to the standard series of communication situations (wetherby & prutting 1984) are presented in figure 6. it can be seen that subjects responded positively to communication acts by focusing attention on them. communication a c t s w i n d u p toy s t a c k b l o c k s r e a d m a g a z i n e w r i t e w i t h p e n o p e n b u b b l e s inflate b a l l o o n blow windmill play x y l o p h o n e s p e a k o n p h o n e e a y t h a n k you indicate t h a n k s t a k e a w a y o b j e c t s53 a 10 16 2 0 26 i yes i no i i not t e s t e d figure 6: frequencies for tester-child pragmatic abilities saying thank you had more responses of not tested than positive responses: 52% of subjects were not tested on this item while 32% were able to thank. these results could be attributed to the fact that these targets could not be elicited in this way, as the subjects did not appear to be able to understand the verbal command to thank the tester. however, subjects were able to indicate thanks when they imitated their mothers doing so. the subjects' improved ability to indicate thanks could be culture specific as the thanking ritual is indicative of zulu culture where the subject is instructed papate 'thank' and then claps her/his hands before receiving something (gowlett, 1975, p. 14). the responses to the communicative acts were more often manifest by the child's focusing of attention on the object than by his/her interacting with the adult. according to wetherby et al., (1989), this is appropriate albeit on a nonverbal level. some vocalisation did occur and accompany gesture, for example during telephone play. the fact that children primarily responded to communication acts nonverbally corresponds with the limited level of the childrens expressive repertoire, previously discussed. this further demonstrates the related and integrated nature of the acquisition of language abilities. another possible reason for responses being mainly nonverbal could be attributed to the highly structured nature of the die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 melisa a bortz task which did not, in fact, pragmatically, require a verbal response from the children: for example, there was no need to request or acknowledge others as described by coggins and carpenter (1978, in miller, 1981, p. 118). a further justification for responding to the communication act by focusing attention on the object, rather than initiating interaction with the parent, could be that children may not be used to playing with their parents, either because their parents are not at home due to work commitments, or because adults tend not to play with their children as play is regarded as being undignified. (reynolds, 1989). furthermore, few adults involve themselves in the play of children. play is not seen as sacrosanct and sometimes it is regarded with suspicion and as a waste of time. adults do not seek to direct play (reynolds, 1989, p. 87). it is also interesting to note that most of the objects used in this sample were not familiar to the children, except possibly the telephone, yet children responded appropriately to them. this is particularly relevant with obj ects that are not common in the homes, such as pens and paper as this has implications for school. general discussion in this study, some attempt was made to relate the subjects language to research performed on english speaking peers in order to investigate the possibility of common trends. attempts were also made to observe parallel trends in subjects whose language more closely resembles zulu, such as hebrew. there has been no report of these in the study as berman (1985, p. 267) has claimed that most of the developmental data obtained for hebrew "are biased in favour of the language of 2 3 year olds" and thus no trends could be observed. repertoire of assessment procedures. a comprehensive test battery, including parent report, mother-child and testerchild interaction was utilised in order to obtain these results. all measures were useful and complemented each other, for example, tester-child interaction was not found to be effective for eliciting expressive language, eg., naming body parts, yet this interaction provided worthwhile results for pragmatic, eg., trying to weigh up a toy, and receptive, eg., identifying body parts, language abilities. however, when correlating these interactions statistically, poor results were obtained indicating the need {jor such a comprehensive assessment at this stage of language development. nonetheless, although this test battery is believed to be extensive, it does not appear to be practical, as administration is time consuming and restricting in terms of requiring specialised and sophisticated equipment such as video cameras and specialist knowledge of language assessment and analysis. the results of this study, although indicating that all measures are useful, also indicate that parent report provides a general evaluation of all parameters of child language. thus, it is recommended that parent report beusedasa screening tool for children of this age, as this is cost effective; a valuable basis for a rapid evaluation of child language and a useful measurement over a wide range of social class (dale, bates, resnick & morriset, 1989; dale, 1991). parent reports are effectively used in appraisal at this stage of language development, for example, the receptive-expressive emergent language scale (bzochleague, 1979). in addition, parent reports are particularly suitable for the south african situation and for zulu-speakers specifically, because they have limited access to formal intervention facilities for speech, language and hearing disorders. parent reports can easily be utilised in the community by primary health care workers. the results of this study provide information about relevant content to include in such screening assessments. (see appendix b). the findings of this study have epidemiological implications on both a primary and secondary level of prevention. on a primary level, it is now possible to begin to educate people, particularly mothers and caregivers, about how to stimulate language at this level in order to prevent language problems from occurring. on a secondary level, this study has established preliminary norms for 18-month-old zulu speakers which were previously nonexistent. further research is required for validation and to establish more norms than these early findings so that speech, language and hearing therapists will be able to compare other children to these subjects in order to identify delayed or disordered language. once these norms have been established, mass screening of all zulu speaking children, of this age, can be undertaken in order to determine the prevalence and incidence of communication disorders. (m. marge, personal communication, april 20, 1992). such early identification would prevent the serious and long term consequences of language disorders that affect the psychological, educational and vocational dimensions of the child (bernstein & tiegerman, 1989; penn & segal, 1982, and aram & nation, 1980). conclusion the language abilities of these 18-month-old zulu speakers indicated that the development of the content, form and use of language are all integrated and that communication precedes and facilitates speech and language behaviour (lahey, 1988; bernstein & tiegerman, 1989). on a receptive level, subjects were able to understand two-part instructions, identify body parts and three objects. expressively, subjects were at the early one word linguistic stage, having a lexicon of 4,12 words and an mlu of 0,65, with a mean number of morphemes of 2,78 and a mean number of utterances per turn of 1,519. tester-child interaction provided few results as 85% of subjects could not name simple objects or body parts. pragmatically, the subjects responded mostly nonverbally, by focusing attention on an object rather than communicating verbally with the adult to ifems presented in communicative acts. this demonstrates the link between pragmatic and expressive language abilities and is to be expected in view of the limited expressive abilities. this analysis also contributed examples of pragmatic behaviour that were specific to zulu,culture, such as mothers tying a doll to their childrens' backs and the thanking ritual. as regards the second aim of this study, to evaluate the effectiveness of assessment materials, the previous discussion indicated that parent report provided a comprehensive method of assessing young children's language. in addition, this method is thought to be particularly suitable and useful for the south african situation, both in terms of the broad range of information it provides and in terms of being accessible to administration by a wide range of health personnel. this study has also established preliminary norms for 18-monthold zulu speakers which should be used to establish comprehensive norms to determine the prevalence and incidence of communication disorders in the zulu speaking population. as the year 2000 rapidly approaches, it is necessary that speech, language and hearing therapists make a concerted effort to undertake research of this nature such as incidence and prevalence studies, in order to provide an effective service to all people with communication problems in south africa. acknowledgements the author acknowledges with appreciation a grant from the hsrc, which funded this research. ursula booysen of the the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language abilities of 18 month-old zulu speakers 33 institute of biostatistics of the medical reseach council is sincerely thanked for her assistance and patience with the statistical data. furthermore, the immense contribution of bennedicta tlhomola, sylvia jongidiza, sydwell khene, bernice mdongoana and tebogo rankoane is acknowledged for their invaluable contribution in data collection and analysis. references aram, d.m., & nation, j.e. (1980). preschool language disorders and subsequent language and academic difficulties. journal of communication disorders, 13, 159-170. ballantine, j., ballantine, p.r. & morgan, r. (1982, july). auditory perceptual skills in zulu school children a preliminary normative investigation. sasha newsletter, 196, 5 20. bates, e., bretherton, i., & snyder, l. (1988). from first words to grammar: individual differences and dissociable mechanisms. cambridge: cambridge university press. bates, e., camaioni, l., & volterra, v. (1979). the acquisition of performatives prior to speech. in e. ochs, & β. b. schieffelin (eds.), developmental pragmatic, (pp.111-130). new york: academic press. berman, r.a. (1985). the acquisition of hebrew. in d. i. slobin (ed.), the crosdinguistic study of language acquisition vol. 1: the data (pp.255-371). hillsdale, new jersey: lawrence erlbaum associates. bernstein, d.k., & tiegerman, e. (1989). language and communication disorders in children (2nd ed.). columbus, oh: charles e. merrill. bhatnager, s., & whitaker, h.a. (1984). agrammatism on inflectional bound morphemes: a case history of a hindi speaking aphasic patient. cortex, 20, 295 301. bzoch, k.r., & league, r. (1979). receptive-expressive emergent language scale for the measurement of language skills in infancy. chapman, r.s. (1981). exploring children's communicative intents. in j.f. miller (ed.), assessing language production in children: experimental procedures, (pp. i l l 138). baltimore: university park press. child, d.r., & johnson, m.s. (1991). preventable and nonpreventable causes of voice disorders. seminars in speech and language, 12(1), 1-13. clark, e.v. (1979). building a vocabulary: words for objects, actions and relations. in p. fletcher & m. garman (eds.), language acquisition: studies in first language development (pp. 149-160). cambridge: cambridge university press. cohen, l., & manion, l. (1991). research methods in education (3rd ed.). london: routledge. ( conti-ramsden, g., & dykins, j.j(1991). mother-child interactions with language-impaired children and their siblings. britishjournal of disorders of communication! 26, 337-354. dale, p.s. (1991). the validity of a parent report measure of vocabulary and syntax at 24 months. journal of speech and hearing research, 34, 565-571. i dale, p.s., bates, e., reznick, j.s.,|& morisset, c. (1989). the validity of a parent report instrument of child language at 20 months. journal of child language, 16, 239-249. drew, m. (1982, september/october). editorial. sasha newsletter, 250, 1-6. i doke, c.m. (1945). textbook ofzulu grammar (4th ed.). london: longmans, green and co. fromkin, v. & rodman, r. (1978). an introduction to language (2nd ed.). new york: holt, reinehart and winston. gerber, s. (1990). prevention: the etiology of communicative disorders in children. englewood cliffs nj: prentice hall. gesell, a. (ed.). (1954). the first five years of life. a guide to the study of the preschool child. london: metheun. gowlett, d.f. (1975, november). toward black-white understanding in south africa. lecture delivered to the institute for the study of man in africa. johannesburg. , hedrick, d.l., prather, ε. m., & tobin, a. r. (1984). sequenced inventory of communication development. test manual, (rev. ed.). seattle: university of washington press. holt, k.s. (1977). developmental paediatrics: perspectives and practice. london: butterworths. hopper, r., & naremore, r.j. (1978). children's speech: a practical introduction to communication development (2nd ed.). new york: harper and row. illingworth, r. s. (1983). the normal child. some problems of the early years and their treatment (8th ed.). edinburgh: churchill livingstone. lahey, μ. (1988). language disorders and language development. new york: macmillan. marge, μ. (1991). introduction to the prevention and epidemiology of voice disorders. seminars in speech and language, 12(1), 49-73. mcreynolds, l.r., & kearns, k. p. (1983). single subject experimental designs in communicative disorders. baltimore: university park press. mctear, m.f. & conti-ramsden, g. (1992). pragmatic disability in children. london: whurr. miller, b. j., & keane, c.b. (1983). encyclopedia and dictionary of medicine, nursing and allied health. (3rd ed.). philadelphia: w.b. saunders. miller, j.f. (1981). assessing language production in children: experimental procedures. baltimore: university park press. nicolosi, l., & collins. (1989). developmental sequences of language behaviour: overview. in l. nicolosi, e. harryman, & j. kresheck (1989). terminology of communication disorders, speech-languagehearing. (3rd ed.). baltimore: williams & wilkins. nicolosi, l., harryman, e. & kresheck, j· (1989). terminology of communication disorders, speech-language hearing. (3rd ed.). baltimore: williams & wilkins. ochs, e., & schieffelin, b.b. (eds.). (1979). developmental pragmatics. (p. 110). new york: academic press. oxford reference concise medical dictionary. (1990).(3rded.). oxford: oxford university press. penn, c. & segal, d. (1982). case history factors in a group of languageimpaired children. the south afiicanjournal of communication disorders, 29, 3-14. peterson, d.r., & thomas, d.b. (1978). fundamentals of epidemiology. lexington, ma: d.c. heath and company. read, m. (1959). children and their fathers: growing up among the ngoni of nyasaland. fackenham: metheun. reynell, j. (1978). reynell developmental language scales, (rev. ed). london: national foundation for educational research. reynolds, p. (1989). childhood in crossroads: cognition and society in south africa. claremont: david phillip. roth, f. p., & spekman, n.j. (1984). assessing the pragmatic abilities of children: part 2. guidelines, considerations, and specific evaluation procedures. journal of speech and hearing disorders, 49, 12-17. segal, d. (1982, november/december). community-based therapy: some preliminary suggestions. sasha newsletter, 251, 15-18. suzman, s.m. (1990). language acquisition in zulu. unpublished doctoral dissertation. university of the witwatersrand, johannesburg. thoman, e.b. (1981). affective communication as the prelude and context for language learning. in r.l. schiefelbusch, & d.d. bricker (eds.), early language: acquisition and intervention (pp. 181200). baltimore: university park press. van riper, c., & emerick, l. (1990). speech correction: an introduction to speech pathology and audiology (8th ed.). englewood cliffs, nj: prentice hall. vorster, j. (1980). manual for the test for oral language production. pretoria: s.a. institute for psychological and psychometric research, h.s.r.c. westby, c. e. (1980). assessment of cognitive and language abilites through play. language, speech and hearing services in schools, xi, 151-168. wetherby, a.m., & prutting, c. (1984). profiles of communicative abilities. journal of speech and hearing research, 27, 364-377. wetherby, a.m., yonclas, d.g., & bryan, a.a. (1989). communicative profiles of preschool children with handicaps: implications for early identification. journal of speech and hearing disorders, 54, 148 -158. address correspondence to ms m. bortz, department of speech pathology and audiology, university of the witwatersrand, private bag 3, wits 2050. 1 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 melisa a bortz appendix a questions used in the parent report [instruction: ask the mother or caregiver these questions the first time they come to wits.] 1) can your child say any words? yes/no. if yes, elaborate on the words. 2) does your child understand what you say to her/him? yes/ no. if yes: a) provide examples of what your child understands. b) provide examples of words you say that your child understands. 3) does it sound as if your child speaks to her/himself? yes/ no. if yes, what does your child say? [it should sound like they are speaking to themselves, but there may be no real speech, just the rhythm and intonation of speech. this is a clue or prompt that you can give to the mother if she doesn't understand the question.] 4) does your child listen to you when you call her/him or speak to her/ him? yes/no. if yes, how do you know this? 5) does your child copy what you say? yes/no. 6) does the child communicate when she/he wants something? yes/no. if yes, how does your child communicate? 7) does your child use her/his hands to communicate or point to what she/he wants? yes/no. 8) does the child sing? yes/no. 9) can your child understand and do simple instructions? yes/no eg. close the door, get the rag. if yes, what does your child understand, provide examples. 10) can your child point to or show parts of her/his body? yes/ no. if yes, which parts does your child know? based on nicolosi & collins, (1989); gesell (1954) and hopper & naremore (1978). appendix β receptive, expressive and pragmatic language abilities of 18-month-old zulu speakers receptive language listens and responds to communication addressed to him/ her understands two-part instructions, for example hlalapantsi udle 'sit down and eat' identifies a range of body parts identifies three objects expressive language babbles and uses jargon imitates and sings four word vocabulary inconsistent use of marked forms of noun classes mlu 0,65 words difficulty naming objects in a formal test situation pragmatic language demonstrates autosymbolic play such as drinking from a cup, washing with a face cloth uses common objects and toys appropriately for example pencil, paper, car and ball imitates parents in domestic tasks, for instance sweeping with a broom exhibits culture specific behaviours papate 'thanking ritual', carries doll tied to back vocalises, to gain adult's attention j gestures to get adult's attention ! simultaneously vocalises and gestures to achieve adult's attention , focuses attention on object, for example, attempts to blow up a balloon ! the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 87 an exploratory study of an undefined acquired neuromotor speech disorder within the context of the four level framework for speech sensorimotor control dunay schmulian, anita van der merwe and emily groenewald department of communication pathology university of pretoria abstract in this study, the speech of a 28-year-old male with acquired brain injury and who presents with an undefined neuromotor speech disorder which cannot be categorised as either apraxia of speech or dysarthria, is described. voice onset time, vowel duration, utterance duration and vowel formant analyses were done acoustically. a perceptual analysis and intelligibility rating were also executed. the subject was found to present with unique perceptual symptoms, intelligible speech, prolonged sound duration and distorted vowel quality. the results are interpreted within the context of the four level framework of speech sensorimotor control (van der merwe, 1997). opsomming in hierdie studie word die spraak van 'n 28-jarige manlike persoon met 'n verworwe hoofbesering, en met 'n ongedefmieerde neuromotoriese spraakafwyking wat nie as verbale apraksie of disartrie geklassifiseer kan word nie, beskryf. stemaanvangstyd, vokaalduur en uitingduur, sowel as vokaalformant-analises is akoesties uitgevoer. 'n perseptuele analise en verstaanbaarheidstoets is ook toegepas. die proefpersoon het gepresenteer met unieke perseptuele simptome, verstaanbare spraak, verlengde klankduur en distorsie in vokaalkwaliteit. die resultate word binne die konteks van die viervlak raamwerk van sensoriesmotoriese spraakkontrole geinterpreteer (van der merwe, 1997). key words: neuromotor speech disorders, four level framework. l b appreciate the speech production process and its overwhelming complexity, one only has to study the vast amount of literature attempting to capture the essence of this process and its concomitant pathologies. the identification of phases involved in this process remains problematic and yet a clear differentiation is necessary to comprehensively define sensorimotor speech disorders. mcneil and kent (1987) state that the assumptions underlying neurogenic pathologic populations need to be reconsidered. the reason being that there are existing pathologies that cannot be satisfactorily explained by the traditional conception of the speech production process. the origin of the traditional speech production model can be traced to the three stages involved in motor skill namely the encoding, programming and execution of body movements. this model was projected onto the speech production process and traditionally three stages have been distinguished: linguistic encoding, articulatory programming and execution of movements (darley, aronson & brown, 1975). aphasia is seen as a deficit on the highest level of the model namely linguistic encoding, apraxia of speech (aos) as an impairment on an articulatory programming level and dysarthria as a deficit on the level of execution of movement. reconsideration of our traditional conception, would question and evaluate the validity of the three level model. according to van der merwe (1997) a four level framework should be adopted on the grounds of differential neurophysiological involvement of the various brain structures involved in neuromotor function and that, therefore, a distinction should be drawn between motor planning and motor programming based on these neurophysiological grounds. the so-called association areas are believed to be responsible for motor planning (allen & tsukahara, 1974; brooks, 1986; marsden, 1984). the motor association areas, namely the premotor cortex (lateral area 6), the supplementary motor area (medial area 6) as well as the prefrontal and parietal association areas, are indicated in motor planning. brooks (1986) posits that the caudate circuit of the basal ganglia is part of the "higher" hierarchical level in the sense that it enables the high level plans to be translated into motor action. the neural areas involved in motor programming comprises the basal ganglia, the lateral cerebellum, the sma, the motor cortex and the fronto-limbic system. it is generally accepted that the basal ganglia and the lateral cerebellum in particular are involved in programming and these parts perform complementary functions. the exact role of each, however, is not known. there are indications that the basal ganglia has a more "sophisticated" role to play than the cerebellum. the motor cortex, the lower motor neurons, peripheral nerves and motor units are the neural structures involved in the execution phase of the hierarchy (van der merwe, 1997). thus differentiation between the functions of the neuromotor areas indicate involvement die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 88 dunay schmulian, anita van der merwe & emily groenewald on three motor levels, namely planning, programming and execution. speech production is also a motor act and it is probable that the same three motor phases can be distinguished. language planning is, however, also essential in speech. this implies an addition to the traditional three stage model of linguistic encoding, programming and execution of speech movements, resulting in a four level model / framework consisting of one pre-motor stage namely linguistic-symbolic planning and three motor stages namely motor planning, motor programming and the execution of movement (van der merwe, 1997). where the terms motor planning and motor programming were used interchangeably in the traditional speech production models (lapointe, 1982; itoh & sasanuma, 1984), van der merwe (1997) draws a clear distinction. motor planning is described as the recall of a core motor plan for each phoneme in the planned unit, sequential organization of the motor goals identified for each phoneme, adaptation of the core motor plans within the context of the planned unit and specification of motor plan subroutines. motor programming on the other hand, entails the selection and sequencing of motor programs for movements of the muscles of articulatory structures. specifications of muscle tone, movement direction, force, range, rate and the mechanical stiffness of joints required by the planned movement, are specified by the motor program (van der merwe, 1997). needless to say, a four stage model such as van der merwe's framework, holds vast implications for the classification of the different neuromotor speech disorders. it advocates a fourth grouping of disorders not yet identified or described clearly in the literature, namely a pure motor programming disorder. aos seems to fit the definition of a motor planning disorder, dysarthria due to basal ganglia, cerebellar and motor cortex lesions would represent coexisting problems in both motor programming and execution and lower motor neuron dysarthria indicates a disorder in the execution of movement (van der merwe, 1986; 1997; van der merwe, groenewald, brittz & grimbeek, 1995). the questions arise whether a pure motor programming speech disorder exists, and also what the symptomatology of such a disorder will entail. the above-mentioned definition of programming predicts that symptoms resulting from such a disorder would probably be sound distortions, defects in speech rate, or problems in the initiation of movement. these would occur in the absence of muscle tone disorders or involuntary movements which induce dysarthria (van der merwe, 1997). the differentiation between different speech disorders is not always clear cut. symptomatology may differ and yet if symptoms correspond, it does not necessarily imply or indicate a homologous problem. one way of addressing the essence of motor speech disorders is by manipulating certain contextual factors such as sound structure and the articulatory characteristics of the utterance and thereby placing differential demands on the motor system. by determining and comparing reactions to variation in speech context, more insight could be gained into the nature of motor speech disorders and it can contribute towards differentiating disorders in the different stages of the motor process (van der merwe, 1986). this same method is applied in the present study. if context sensitivity is displayed, the pattern of sensitivity can be compared to that of other subjects with neuromotor speech disorders who were studied in previous research (van der merwe, 1986; brittz, 1994; van der merwe, et al., 1995). the aim of this study is to describe the acoustic and perceptual symptoms and also the effect of variation of certain contextual factors on the speech of a person with an undefined acquired neuromotor speech disorder. based on the symptomatology, his speech disorder cannot be classified as either apraxia of speech, dysarthria or a combination of the two. we aim to describe the symptoms within the theoretical context of the four level framework (van der merwe, 1997), where it might be representative of an impairment on the level of motor programming in the speech production process. method goals and subgoals the main goal is to describe the perceptual and acoustic speech symptoms of a speaker with an acquired neurogenic speech disorder which does not fit the traditional classification of dysarthria or aos or a combination of both. the symptomatology will be explained within the theoretical context of the four level framework. subgoals • to identify symptoms occurring and to determine similarity with symptoms that are categorised under dysarthria or aos in world literature, through a perceptual analysis (perceptual analysis 1). • to describe certain temporal characteristics of the subject's speech through acoustic analysis of nonsense units that are systematically varied in sound structure and articulatory characteristics and to determine the possible reaction to manipulation of context (acoustic analysis 1). • to rate the intelligibility of words on a closed set format (perceptual analysis 2). • to analyze deviant vowel production as identified by the intelligibility test (acoustic analysis 2). research subject and listener panels research subject. the criteria for the research subject were: • the subject must display an acquired neuromotor speech disorder which does not fit the classification of either apraxia of speech or dysarthria or a combination of both, as diagnosed by an experienced speech pathologist specialising in the field of neuromotor speech disorders. the subject should not display the core symptoms of these disorders namely, effortful speech with self-initiated trials to correct errors, islands of error-free speech or sound substitutions and distorted sound substitutions as can be expected from aos or muscle tone abnormalities and involuntary movements which cause consistent distortion in dysarthria (mcneil, robin & schmidt, 1997: darley, et al., 1975; yorkston, beukelman & bell, 1988). • normal auditory comprehension and memory should be present to ensure comprehension of instructions. • reading skill must be adequate to read a passage orally. the selected research subject is a 28-year-old afrikaans speaking male. he has a head injury resulting from a motorcycle accident in 1989. he exhibited an indriven fracthe south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) an exploratory study of an undefined acquired neuromotor speech disorder within the context g 9 of the four level framework for speech sensorimotor control the literature on aos and the different dysarthrias (kent ture (3cm by 3cm occipital). scan information further showed bleeding in the left motor cortex. he remained in a coma and on a respirator 7 weeks post-trauma. he presented with right hemiplegia and spasticity after regaining consciousness. he received intensive physiotherapy which helped to reduce the hemiplegia to near normal. he received intensive speech and language therapy at the speech-, language and hearing clinic at the university of pretoria for seven years post accident. the western aphasia battery (kertesz, 1982) was performed yearly and overall scores stabilised and formed a plateau from 1991 onwards. he obtained an aphasic quotient of 94.2 classifying him as a mild anomic aphasic. the pragmatic protocol (prutting & kirschner, 1983) also showed fewer inappropriate behaviours since 1992. speech intelligibility was assessed with the "afrikaanse toets vir spraakverstaanbaarheid" (klopper, 1983) and scores prior to dismissal were respectively 83% and 91% for intelligibility on single words and sentences. other assessments include screening for closed head injury as well as tests identifying and rating severity of dysarthria (van der merwe, 1985) and aos (van der merwe, 1986). his speech could not be classified as either purely apraxic or dysarthric or a combination of the two. listener panels two listener panels were utilized in the study. the first was a sophisticated panel which did the perceptual analysis of characteristic symptoms as this required specialised skills and a semi-sophisticated panel which did the intelligibility scoring as these scores would be representative of intelligibility for the general population. the criteria for the sophisticated listener panel stipulated that members should be experienced speech language pathologists specialising in the field of neuromotor speech disorders and the perceptual analysis of neuromotor speech disorders. the selected panel consisted of two speech pathologists as the analyses were done by consensus. the criteria for the semi-sophisticated listener panel stipulated that the members should be afrikaans-speaking and have knowledge of normal and abnormal speech production. the selected panel consisted of six final year communication pathology students at material the university of pretoria. perceptual analysis: the symptom profile a list of possible symptoms indicative of neuromotor speech disorders was compiled, using symptoms listed in & rosenbek, 1983; yorkston, et al., 1988; mcneil, et al., 1997, darley, et al., 1975). the sophisticated listener panel indicated presence or absence of the symptom in the subject's tape recorded speech. the subject was recorded while reading a phonetically balanced passage ("in die wildtuin") which was developed for research purposes. acoustic analysis 1: voice-onset-time, vouiel duration and utterance duration the material for this analysis was duplicated from a similar, but more comprehensive study by van der merwe (1986) in which the influence of certain contextual factors on temporal features were studied. the material consists of groups of nonsense syllables that differ in sound structure and articulation characteristics. five sound structure groups and four articulation characteristic groups can be distinguished. the sound structure groups differ in length, sequence of consonants (c) and vowels (v), as well as the number of phonemes in every utterance. the articulation groups differ in place and manner of articulation. nonsense syllables make the strict control of sound structure and articulation characteristics possible. the material consisted of 20 nonsense units. each unit was repeated six times and the five most constant repetitions were analysed. table 1 contains the nonsense units in their respective articulation characteristics and sound structure groups. perceptual analysis 2: intelligibility test in order to ascertain intelligibility on a single word level, a list of twenty words from the "afrikaanse verstaanbaarheidstoets vir disartriese sprekers" (klopper, 1983) were applied. listeners had to select and circle the appropriate word out of a closed set of nine similar sounding words. acoustic analysis 2: formant values in order to ascertain differences from normal formant values of vowels, as obtained from a previous study (van der merwe, groenewald, van aardt, tesner & grimbeek, 1993), the two most deviant vowels (as determined during perceptual analysis 2), namely [a] and [a], were analysed. the vowels were taken from the phonetically balanced passage which the subject read. the contexts in which these vowels occurred, were controlled by analyzing identical words or vowels with similar phonetic contexts. table 1: nonsense units slotted into sound structure and articulation characteristics sound structure articulation characteristics 1 1.1 babe 1.2 bobs 1.3 dade 1.4 dode 2 2.1 bats 2.2 bats 2.3 dake 2.4 doks 3 3.1 batef 3.2 botsf 3.3 dakef 3.4 doksf 4 4.1 bat 4.2 bat 4.3 dak 4.4 dak 5 i 5.1 batefup 5.2 botefup 5.3 daksfup 5.4 daksfup die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 90 dunay schmulian, anita van der merwe & emily groenewald apparatus recording equipment for acoustic analysis 1 and 2: akg d1200 ε short distance, directional microphone, a nakamichi versatile cassette system and a tdk 90 minute magnetic cassette. analysis equipment for acoustic analysis 1: a nakamichi 550 cassette was used to send the speech signal to the kay dsp sona-graph model 5500 where the speech signal was analysed by a digital signal processor. the speech was monitored with two jbl pro 3 loudspeakers. the speech signal was displayed on a nec multisync 2 display screen, where the time cursors and a time axis were used to obtain all required measurements, l b permit comparison to controls used by brittz (1994), it was decided to use the identical analysis set-up and recording equipment. analysis equipment for acoustic analysis 2: the computer speech laboratory (csl) model 4300 β of kay elemetrics corporation was used because of its automatic formant tracing facility. procedure as it was an exploratory study, it was decided to commence the study by allowing the sophisticated listener panel to listen to a tape recorded speech sample of the subject to determine the diagnostic, neurogenic speech disorder category of the subject (perceptual analysis 1) by identifying the symptoms in his speech. it was then decided to study the influence of variation in contextual factors, on the three temporal features previously mentioned, and to determine whether context sensitivity occurred (acoustic analysis 1). the data of normal control speakers studied by van der merwe, et al. (1993) and brittz (1994) were used for comparative purposes. a semi-sophisticated listener panel's intelligibility rating and subjective diagnostic interpretation of the subject's speech was obtained. it was also required of this panel to identify sounds perceived as deviant from normal production (perceptual analysis 2). the analysis of the formants of the subject's vowels [a] and [d], was executed as a result of the semi-sophisticated listener panel's perception that vowels were more deviant from normal production than consonants, particularly [a] and [o] (perceptual analysis 2). data analysis perceptual analysis 1: symptom profile symptoms of neuromotor speech disorders, as taken from the literature, were tabulated to form the starting point from where to examine all other results. the presenting symptoms were identified by applying the method of analysis through consensus of two sophisticated listeners. acoustic analyses training in the use of the analysis equipment, and the technique involved in acoustic measurements, was received from a researcher who had obtained a masters degree in the field and who is an experienced user of the equipment. the analysis was done by the first author and problematic analyses received consultation from the above-mentioned researcher. acoustic analysis 1: voice-onset-time, vowel duration and utterance duration three temporal speech parameters, namely voice-onsettime (vot), vowel duration (vd) and utterance duration (ud) were measured. identical analysis set-ups were used for all three speech parameters. a twofold analysis of the speech signal was displayed simultaneously on the screen, with the sound wave on the upper half of the screen and a broadband spectrogram of the speech sound energy between 0 and 8000 hz on the lower screen. with vot, vd and ud, the two representations were constantly compared to increase reliability of the measures. vot of the initial voiced plosives was measured. the initial consonant was selected for analysis as it indicates more sensitivity towards contextual factors (ingrisano & weismer, 1979). the vot is measured from the plosive to the commencement of the first vertical striate on the spectrogram that represents glottal pulsing (lisker & abrahamson, 1964). the commencement of the plosive was regarded as the graphic nil point and the voice onset after the plosive obtained a positive notation, while the voice onset preceding the plosive was noted as negative. the range of vot was calculated for each category, in other words, the biggest negative, or the smallest positive value was recorded as borders of the range. the criteria for normal vot, namely -180 msec to +15 msec (van der merwe, 1986; brittz, 1994) was applied to the range of vot. the speech parameter vd was measured during the production of a short vowel after the initial plosive. the transition between a consonant and the following vowel provides a context for the greatest variance in acoustic parameters (gay, 1979). the speech parameter ud was measured as the first cvcv unit of each utterance and cvc in the case of structure 4 units. measurement started from the commencement of the first vowel, i.e., the plosive where a positive value was obtained, or voice onset in cases of negative vot values. the processing of vd and ud were both conducted as follows: * the median values of the five repetitions of the nonsense syllables were calculated using non-'parametric statistical analysis in order to make comparison with the, control data possible. the control data was taken from a study by brittz (1994) who used the same material and did the study in the same laboratory. the control subject used in that study was a normal male speaker in the same age group as the subject used in the current study. * the influence of variation of the contextual factors was examined to determine if the subject showed context sensitivity. acoustic analysis 2: vowel formants the speech signal was received from the cassette tape and captured at a sampling rate of 10 000 hz (i.e. 0-4062 hz) for analysis. the steady state of the vowel was marked with time cursors. a wideband spectrogram, as well as a linear prediction coding (lpc) formant history was obtained of the captured steady states of the respective productions of [a] and [o]. the mean value of formant 1, 2 and 3 was obtained by means of the formant history statistics provided by the csl. the absolute formant values (mean value) of formant 1, 2 and 3 of the respective productions of [a] and [o] were the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) exploratory study of an undefined acquired neuromotor speech disorder within the context g i of the four level framework for speech sensorimotor control and delineate this unusual speech disorder, the speech c o m p a r e d to the control data of van der merwe, et al. (1993) using non-parametric statistical analysis. in the study of van der merwe, et al., (1993) the formant patterns of the vowels of afrikaans were studied. ten males aged between 18 and 45 years, with no speech deficits and mother tongue speakers of afrikaans, were selected. formant frequency values of the same order were obtained from the ten subjects for all vowels. the overall conclusion was that reliable data was obtained. the relative formant relationships of f1/2, f2/3 and fl/ 3 were also calculated and compared to the formant relationships found in normal speakers (van der merwe et al., 1993) using non-parametric statistical analysis to determine whether the current subject's formant relationships fall within normal intervals. perceptual analysis 2: intelligibility test each panel member's score of the number of words correctly identified was individually calculated out of 20 and converted to a percentage. the type of error was also noted. results findings of the sophisticated listener panel regarding symptom profile in order to determine if the subject belongs to either the diagnostic category of aos or dysarthria, a sophisticated listener panel listened to a tape recorded sample of continuous speech. the finding was that, although highly intelligible, the subject could not be classified on the basis of salient perceptual features as either verbally apraxic or dysarthria the subject displays symptoms from both diagnostic categories (see table 2), but in a unique combination. variable, often normal rate with inconsistent prolongations of phonemes occurred, together with inconsistent distortion in the spatial and temporal dimensions of utterances, particularly vowels, which appeared to be due to articulatory telescoping. the subject's speech cannot be categorised as the slow, struggling speech of an apraxic speaker, yet does not exhibit the constant distorted quality of dysarthric speech. the conclusion was thatjthe subject belongs to a unique category of neurogenic speech disorders. in order to describe symptoms were further analyzed. acoustic analysis 1 voice-onset-time (vot) vot was examined by categorising the articulation groups into the five sound structure groups hereby determining whether context sensitivity was present in such a controlled sound structure environment and if such a controlled environment had any influence on the presence and possible type of error presented by the subject. the range of vot scores are given in table 3. the subject's vot ranges (smallest and biggest vot measure of each unit) are compared to the normal range of-180 msec to +15 msec. in the category si, three of the four articulation characteristic groups' vot scores deviated from the normal range: a l by 45 msec, and a3 and a4 both by 2 msec. in the category s2, two articulation characteristic groups' vot deviated from the norm (a2 and a3), both with 2 msec. in sound structure categories s3, s4 and s5, all vot scores of the articulation groups fell within normal limits. fifteen of the twenty vot scores ranged from -180 to + 15 msec, which is within normal limits. this represents-normal vot scores in 65% of all nonsense unit utterances. four of the five errors are so marginal that they cannot be depicted as true vot errors which leaves one error. it can be explained by the fact that it was the first utterance produced by the subject and he could possibly have been rather anxious to articulate to the best of his ability. the data seem to indicate that the subject rarely produces vot's outside the normal range and also that those errors that did occur are to a certain extent context sensitive for variation in sound structure. due to the low frequency of errors, it is not possible to make any final conclusions in this regard. vowel duration (vd) the vd of the subject is displayed with articulation characteristics and sound structure groups in table 4. the general tendency seems to be longer than normal vd, with occasional normal vd and only one occurrence of shorter than normal vd. because of only one shorter vd table 2: salient features of aos and dysarthria with the presence and absence of feature in speech of the apraxia of speech subject dysarthria subject slow struggling speech absent slow speaking rate absent slow speaking rate absent variable rate present inconsistent distortion present consistent distortion absent spatial and temporal distortion present short rushes of speech absent normal respiration and phonation present respiration and phonation problems absent trial and error articulation absent phonemes prolonged present false starts and restarts absent inappropriate silences absent prolongations present monoloudness absent syllabic speech absent articulatory telescoping present die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 92 dunay schmulian, anita van der merwe & emily groenewald and inconsistent normal durations, no conclusions can be drawn regarding context sensitivity. the longer vd scores do not show any tendencies regarding either sound structure nor articulation characteristics. longer vd occurred in all sound structure groups across all articulatory groups with the exception of sl/al, s2/a4, s5/a1 and s5/a4 which showed shorter, longer, normal and normal vd respectively. the frequent longer vd that occurred does not seem to be context sensitive as no clear pattern emerged from the results. statistical analysis indicated that vd exceeded normal duration significantly. utterance duration (ud) the ud of the subject is displayed with sound structure and articulation characteristics in table 5. the general tendency seemed to be toward longer than normal ud, with normal and shorter than normal ud occurring occasionally. longer ud was represented in all sound structure groups across all articulation characteristable 3: vot results with ranges indicated sound structure articul. group unit range of vot (msec) normal/ deviant si a l babe -184,4 +56,25 deviant with 45 msec a2 bobe +7,81 +10.94 normal a3 dads -37,5 +17,19 deviant with 2 msec a4 dode +10,94-+17,14 deviant with 2 msec s2 a l bate +6,25 +14,06 normal a2 bote +9,37 +17,19 deviant with 2 msec a3 dake +10,94 +17,19 deviant with 2 msec a4 doke +4,68 +10,94 normal s3 a l batef +3,25 +10,94 normal a2 botef +10,94 +12,50 normal a3 dakef +10,94 +15,63 normal a4 dokef +9,37 +15,63 normal 1 s4 a l bat +7,81 +10,94 normal a2 bot +4,68 +7,81 normal a3 dak +12,50 +14,06 normal a4 dok +10,94 +15,63 normal s5 a l batefup 0 +15,63 normal a2 botefup +7,81 +12,50 normal a3 dakefup +10,94 +14,06 normal a4 dokefup +10,94 +15,63 normal the south african journal of communication disorders, vol. 44, 1997 tic groups except with s3/a1 and a2 (shorter than normal ud) and s4/a1, a2, a3 (normal ud was recorded). this observation was confirmed by statistical analysis. shorter than normal and normal ud did occur, but it occurred inconsistently. due to the small sample of analysis material of temporal speech characteristics, such as ud, it is not possible to make final conclusions in this regard. findings of the intelligibility ratings intelligibility scores are displayed in table 6. the average intelligibility was calculated at 92,5% with scores of 80%, 85%, 95%, 100% and 100%. only nine words were perceived incorrectly out of 100 evaluations overall (20 words produced and evaluated by 5 panel members). interrater comparisons revealed little differences between the intelligibility scores. it was therefore ascertained that the subject was highly intelligible. the phonetic nature of the material aided description of errors. two types of errors occurred: r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) exploratory study of an undefined acquired neuromotor speech disorder within the context g 3 a " t h e p o u r level framework for speech sensorimotor control table 4: vowel duration results with contextual factors sound structure and articulation characteristics ίππι^ι·"-" sound structure articul. group unit vd of control vd of subject (in msec) comparison using non-parametric statistical analysis si ' a l babe 136 148 153 153 118.7 114.1 85.9 171.9 35.9 shorter a2 bobe 116 111 117 117 135.9 125 132.8 135.9 129.7 longer a3 dade 140 144 144 159 159.4 184.4 190.6 198.4 190.6 longer — a4 dode 123 121 119 120 148.4 159.4 159.4 148.4 178.1 longer s2 a l bate 116 123 123 123 139.1 129.7 120.3 123.4 134.4 longer a2 bote 109 112 121 116 126.6 115.6 139.1 134.4 107.8 normal a3 dake 106 112 119 120 139.1 132.8 132.8 121.9 123.4 longer a4 doke 100 112 119 92 151.6 135.9 134.4 132.8 134.4 longer s3 a l batef 114 107 112 116 117.2 121.9 125 109.4 131.2 longer a2 botef 116 112 102 98 135.9 153.1 173.1 151.6 162.5 longer a3 dakef 111 111 111 114 134.4 123.4 117.2 126.6 121.9 longer a4 dokef 98 112 112 101 140.6 140.6 140.6 153.1 135.9 longer s4 a l bat 144 150 150 139 150 168.7 156.3 153.1 157.8 longer a2 bot 136 133 140 125 168.7 173.4 160.9 164.1 168.7 longer a3 dak 112 109 128 128 190.6 185.9 170.3 168.7 182.8 longer a4 dok 125 127 123 128 181.2 190.6 182.8 181.2 178.1 longer s5 a l batefup 122 122 117 127 118.7 128.1 109.4 109.4 106.2 normal a2 botefup 106 89 92 100 134.4 134.4 148.4 170.3 139.1 longer a3 dakefup 103 120 107 103 132.8 137.5 132.8 115.6 123.4 longer a4 dokef up 108 109 97 105 106.2 129.7 110.9 101.6 121.9 normal table 5: utterance duration results with contextual factors sound structure and articulation characteristics indicated . sound structure articul. group unit vd of control vd of subject (in msec) comparison using non-parametric statistical analysis si a l babe 512.5 523 589 564 764.1 754.7 564.1 643.7 700 longer a2 ! bobe 562 717 728 525 639.1 723.4 498.4 701.6 687.5 longer a3 i dade 344 397 428 464 681.2 670.9 821.9 771.9 798.4 longer a4 1 dode 428 448 455 433 712.5 764.1 754.7 754.7 750 longer s2 a l j bate 447 472 575 584 698.4 704.7 687.5 689.1 701.6 longer a2 bote 412.5 414 527 528 662.5 695.3 701.6 712.5 570.3 longer a3 dake 317 420 409 450 623.4 632.8 659.4 645.3 682.8 longer a4 doke 395 589 553 592 612.5 598.4 614.1 626.6 631.2 longer s3 a l batef 534 547 561 616 482.8 484.4 498.4 498.4 451.6 shorter a2 botef 527 561 570 494 504.7 512.5 493.7 523.4 510.9 shorter a3 dakef 350 417 402 422 528.1 548.4 546.9 529.7 506.2 longer a4 dokef 409 408 489 425 495.3 520.3 523.4 537.5 526.6 longer s4 a l bat 312:5 320 484 325 379.7 410.9 379.7 351.6 398.4 normal a2 bot 327 502 494 325 404.7 403.1 390.6 406.3 406.3 normal a3 dak 272 411 319 406 404.7 398.4 367.2 387.5 392.2 normal a4 dok 320 366 306 319 418.7 421.9 403.1 375 365.6 normal s5 a l batefup 464 494 436 478 381.2 364.1 331.2 364.1 373.4 shorter a2 botefup 333 451 417 350 456.2 493.7 476.6 475 484.4 longer a3 ' dakefup 452 334 334 353 426.6 437.5 454.7 443.7 434.4 longer a4 dokefup 353 353 344 314 403.1 421.9 404.7 415.6 418.7 longer die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 94 dunay schmulian, anita van der merwe & emily groenewald * continuants were perceived as plosives in 55% of all errors. * initial devoiced consonants were perceived as voiced in 44% of the occurring errors. although the errors give some insight into the phonetic nature of the problem, the error scores are marginally small. the semi-sophisticated listener panel members, who had no background information on the case, perceived the subject as a second language speaker or a clutterer when they were asked for a subjective diagnostic interpretation of his speech. they perceived his vowels to be more deviant from normal production than his consonants and the [a] and [a] as particularly deviant. formant analysis of distorted vowels the decision to analyze vowels was based on both the sophisticated and the semi-sophisticated listener panels' observation that the subject's production is deviant from table 6: scores obtained by the semi-sophisticated listener panel in the intelligibility rating listener panel panel member (lpm) score out of 20 percentage lpm 1 16 80% lpm 2 17 85% lpm 3 19 95% lpm 4 19 95% lpm 5 20 100% lpm 6 20 100% normal afrikaans mother tongue speakers' vowel production and more so than his consonant production. the vowels identified as being most deviant were the [a] and [a]. the first three formant frequencies of [a] were analyzed on six productions and [a] on five productions of the sound in similar contexts. the average formant frequency values of the current subject's production of [a] and [a] are displayed in table 7 and 8 respectively. the data obtained is characteristic of the subject's [a] and [a] production in continuous speech. a comparison of the average formant frequency values of van der merwe et al. (1993) (the control group) and the current subject is displayed in table 9 for [a] and in table 10 for [a]. in the selected productions of [a] by the subject (see table 7 and 9), the following was observed:• the formant frequency values of formant 1 (fl) lie between 515.4 hz and 760.3 hz with an average value of 638.4 hz. the control group's values for formant 1 of [a] range from 521.7 hz to 778.7 hz with the average value for formant frequency 1 calculated at 697.2 hz. using non-parametric analysis, no significant difference between the subject and the control data could be found. although the subject's fl falls within normal limits with non-parametric statistical analysis, there is some variability in the respective values obtained. for productions of aan, the values varied between 744.2 hz and 760.3 hz (a difference of 16 hz). in aandete, the value lowered to 515.4 hz which is more than 200 hz lower. • the formant frequency values of formant 2 (f2) of the subject lie between 1260.1 hz and 1571.6 hz with the average frequency value for f2 of [a] calculated at 1421.2 hz. the frequency values for formant 2 of the control group range from 924.1 hz and 1295.6 hz with the average calculated at 1113.7 hz. according to non-parametric statistical analysis, the subject's mean for f2 was significantly higher than the median of the control group. the variability in formant values continued in f2 with aan land aan 2 obtaining values of 1571.6 and 1443.2 table 7: the formant frequencies of six productions of [a] in similar phonetic contexts formant frequency in hz for six productions ; formants aandete aan 1 aan 2 gaan daar 1 1 daar 2 | 1 formant 1 515.4 744.2 760.3 539.6 655.9 615.1 1 1 formant 2 1260.1 1571.6 1443.2 1559.6 1377.1 1315.7 ' formant 3 2564.0 2872.4 2680.9 2840.0 2575.0 2479.8 formant frequency in hz for five productions formants samekoms kom word rok ongemaklik formant 1 480.7 478.8 503.9 662.6 585.8 formant 2 1982.9 1738.9 1006.7 1557.6 1975.2 formant 3 3314.3 3027.3 2472.0 2662.7 2825.0 the south african journal of communication disorders, vol. 44, 1997 table 8: the formant frequencies of five productions of [ ] in similar phonetic contexts r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) an exploratory study of an undefined acquired neuromotor speech disorder within the context of the four level framework for speech sensorimotor control 95 hz respectively a difference of 128 hz. there is a difference of 61 hz between values obtained for daar. • the formant frequency values of formant 3 (f3) of the subject's production of [a] lie between 2564.0 hz and 2872.5 hz with the average calculated at 2668.2 hz. in the control group, formant 3 values of [a] range from 2213.6 hz and 2798.1 hz with the average calculated at 2479.8 hz. non-parametric statistical analysis showed that the median of the subject was significantly higher. f3 showed more variability in values obtained for aan 1 and aan 2 : 2872.4 hz and 2680.0 hz respectively. the difference between those two calculate to almost 200 hz. the value of daar 1 (2575 hz) and daar 2 (2479.8 hz) differed by 95 hz. in the selected productions of [a], (see table 8 and 10) the following were observed:• the formant frequency values obtained for formant 1 (fl) of the subject, lie between 478.9 hz and 662.6 hz with the average calculated at 542.3 hz. in the control group, formant frequency values for fl range from 298.8 hz to 433.6 hz with the average calculated at 373.8 hz. no identical words could be used for formant analysis of [aj. three of the five productions contained [a] followed by a nasal sound : samekoms, kom, ongemaklik with their fl values of [a] respectively 480.7, 478.8 and 585.8 hz. even though samekoms and kom differed in number of syllables, their formant values of [a] differ with just more than 2 hz. however, f l of [a] in ongemaklik differ from them both by almost 100 hz. • formant 2 (f2) values of the subject lie between 1006.8 hz and 1982.9 hz with the average calculated at 1652.3 hz. in the control group, values of f2 of [a] range from 708.2 hz to 942.8 hz with the average calculated at 805.6 hz. f2 of [a] followed by a nasal sound were 1982.9 hz (samekoms), 1738.9 hz (kom) and 1975.2 hz (ongemaklik). the f2 values for production of samekoms and ongemaklik, the three syllabic words, were closer and both of them differed considerably from the value of [a]1 in kom at 1738.9 hz, 200 hz below their value. j • the formant frequency values of formant 3 of [a] of the subject lie between 2472.0 hz and 3314.3 hz with the average calculated at 2860.2 hz. in the control group, formant frequency valuesjrange from 1991.2 hz to 2754.4 hz with the average calculated at 2333.3 hz. the values of f3 in the productions'of [a] followed by a nasal sound, the values obtained were respectively 3314.3 (samekoms), 3027.3 (kom) and 2825.0,(ongemaklik) hz. the first two values of [a] differ with 300 hz and the first and the latter with 500 hz. the values obtained for [a] in rok (2662.7 hz) and word (2472.0 hz) also vary considerably. with fl, 2 and 3, the median of the formant values of the subject was significantly higher than the median and formant values of the control group in production of [aj. discussion the study aimed to collect exploratory data on the speech of a subject with an undefined acquired neuromotor speech disorder. the initial findings indicate that the subject displays a unique combination of symptoms, different from both aos and dysarthria, namely inconsistent distortion of temporal and spatial dimensions, prolongations, variable rate and articulatory telescoping. these are all symptoms of neuromotor speech disorders which also occur in aos and dysarthria. however, they occurred in the absence of the core or salient features of these two disorders, namely slow effortfull speech with self-initiated attempts to correct errors, false starts and restarts, substitutions and distorted substitutions which is characteristic of aos according to most current authors and muscle tone disorders and involuntary movements which affects articulation, respiration, phonation, resonance and sometimes vegetative functions as well. despite the above characteristics, the subject was perceived as highly intelligible. there were no clear tendencies that could be identified in the speech of the subject on examination of the temporal features. the duration measurements (vowel and utterance) revealed longer than normal duration, however, the utterances were not perceived by the listeners as abnormally long. one can possibly attribute the longer durations to the nature of the material used. the nonsense syllables could facilitate careful productions. no conclusions can be drawn with regard to vot due to the rare occurrence of errors. the temporal features also showed no clear tendencies with regard to context sensitivity. this is contrary to the findings for aos, cerebellar dysarthria and lower motor neuron dysarthria which displayed diverse patterns of context sensitivity (van der merwe, 1986; brittz, 1994; van der merwe, et al., 1995). however, the lack of context sensitivity, might be characteristic of this particular disorder. this particular issue needs further research before any conclusions can be reached. the distorted quality in the subject's speech could not be explained by vot errors as they rarely occurred. the extended vd and ud might have contributed to the pertable 9: average formant frequencies (in hz) of the control data and the subject of [a] calculated average formant frequency (hz) formants control data subject formant 1 679.2 638.4 formant 2 1113.7( 1421.2 formant 3 2479.8 2668.2 table 10: average formant frequencies (in hz) of the control data and the subject of [ ] calculated average formant frequency (hz) formants control group subject formant 1 373.8 542.3 formant 2 805.6 1652.3 formant 3 2333.2 2860.2 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 96 dunay schmulian, anita van der merwe & emily groenewald ception of distortion in speech production. the formant analysis, however, revealed more about the subject's particular speech pattern. despite the high intelligibility, there was a combination of acoustic features in the vowels that were not characteristic of normally produced afrikaans vowels in a similar phonetic context. inconsistent distortions occurred due to inaccurate direction and range of movement. firstly, absolute formant values of fl, f2 and f3 varied considerably between productions. the first formant is most responsive to changes in mouth opening. speech sounds requiring small mouth openings have low frequency first formants. conversely, open mouth sounds are characterised by relatively high first frequency formants (borden, harris & raphael, 1994). while the subject's first formants are quite low in comparison to the controls, it can be proposed that the subject has a relatively small opening of the mouth for [a] and [o] which are back vowels and that possibly require relatively greater mouth opening. the second formant is most responsive to changes in the oral cavity. tongue backing or lip activity might lower the frequency of this formant, as these conditions occur in areas of high velocity, but any tongue or jaw movement which would narrow the region in the oral cavity, where the pressure is relatively high, would result in raising the frequency of the second formant (borden et al., 1994). as the subject's second formant values are higher than those of the control group, a possible explanation can be a too narrow region in the oral cavity due to excessive jaw and/or lip activity while producing [a] and [a]. the third formant is responsive to front versus back constriction of the articulators (borden et al., 1994), with the subject showing consequent difficulty in this area. this confirms the subject's difficulty with the relative mouth opening, oral cavity space and front versus back constriction of the articulators. this limited range of movement could contribute to the articulatory telescoping present in the subject's speech. vowels are perceptually differentiated according to the ratio of relationships between formant frequencies fl, f2 and f3 and not their absolute values (minifie, hixon & williams, 1973). the f1/f2 relationship is the most important for the perception of vowels (minifie et al., 1973). this does not imply that the interpersonal differences in formant relationships do not occur, but these differences should vary within the degrees of freedom or equivalence barriers (sharkey & folkins, 1985). with regard to formant relationships for [a], statistical analysis indicated deviant fl/2 and f2/3 relationships with only fl/3 falling within normal criteria. the typical coarticulatory patterns found in afrikaans, provide a possible explanation for the [a] sounding better than acoustic analysis indicated. with [a], fl/2 and fl/3 fall within normal intervals, even though the absolute formant frequencies showed deviation from the norm. the f2/3 deviated from the norm. it can therefore be assumed that the deviant formant relationships that did occur, led to the perception of distorted vowel quality and not . misperception of the vowel as being another vowel. but dominating the subject's symptom profile, and possibly underlying it, is the distortion of spatial and temporal dimensions in his speech. the distortion in vowel quality, the variable segmental duration and occasional errors in interarticulator synchronisation, could possibly be attributed to a disorder in motor programming of tone, rate, direction and range of movement (van der merwe, 1997). the finding that these symptoms occurred inconsistently might confirm this hypothesis. the unique combination of symptoms as found in this subject, might constitute one form of a pure motor programming speech disorder. the observation made by the listener panels that the subject sounded like a second language speaker, which he is not, is perhaps significant. in the literature, mention is made of a foreign accent syndrome which is an acquired neurogenic disorder (blumstein, alexander, ryalls, katz & dworetzky, 1987; takayama, sugishita, kido, ogawa, & akiguchi, 1993). it is possible that this case is an example of this syndrome. similar abnormalities in vowel production was identified in these cases. the basis of this syndrome, however, needs careful further research. the true nature of disorders in motor programming as postulated by the four level framework (van der merwe, 1997) needs to be clarified by future research. all possible cases should be studied with regard to site of lesion and symptomatology (acoustic and perceptual). the four level framework (van der merwe, 1997) should be considered as a basis for the comparison of the symptoms in these cases with that of other neuromotor disorders as a guide to a better understanding of the complex nature of acquired neurogenic communication disorders. the four level framework developed by van der merwe (1997), offers a novel view on neurogenic communication disorders, generating new questions to be answered by future research in the hope that "our gained insight will consequently assist in optimising clinical assessment and intervention" (van der merwe, 1997 : 19). references allen, g.i. & tsukahara, n. (1974). cerebrocerebellar communication systems. physiological reviews, 54, 957-997. blumstein, s.e., alexander, m.p., ryalls, j.h., katz, w. & dworetzky, b. (1987). on the nature of the foreign accent syndrome: a case study. brain and language, 31, 215-244. borden, g.j., harris, k.s. & raphael, l.j. (1994). speech science primer (3rd ed). baltimore: williams & wilkins. brittz, h.c. (1994). die invloed van kontekstuele faktore op sekere temporale parameters in disartriese spraak: 'n vergelyking tussen serebellere en onderste motor neuron disartrie. unpublished b. communication pathology research report. university of pretoria. ' brooks, v.b. (1986). the neural basis of motor control. new york: oxford university press. darley, f.l., aronson, a.e., & brown, j.r. (1975). motor speech disorders. philadelphia: w.b. saunders company. gay, t. (1979). coarticulation in some consonant-vowel and consonant cluster vowel syllables. in b. lindblom & s. ohman (eds). frontiers of speech communication research. london: academic press. ingrisano, d. & weismer, g. (1979). [s] duration: methodological influences and linguistic variables. phonetica, 36, 32-43. itoh, m. & sasanuma, s. (1984). articulatory movements in apraxia of speech. in j.c. rosenbek, m.r. mcneil & a.e. aronson (eds.). apraxia of speech: physiology, acoustics, linguistics and management. san diego: college-hill press. / kent, r.d. & rosenbek, j.c. (1983). acoustic patterns in apraxia of speech. journal of speech and hearing research, 26, 231249. kertesz, a. (1982). western aphasia battery. grune & stratton: new york. klopper, k. (1983). spraakverstaanbaarheid by afrikaanse disartriese sprekers: 'n voorgestelde toets. unpublished b.communithe south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) exploratory study of an undefined acquired neuromotor speech disorder within the context ^ t h e four level framework for speech sensorimotor control 97 cation pathology research report. university, of pretoria, ointe, l.l. (1982). neurogenic disorders of speech. in g.h. shames & d.h. wigg (eds.). human communication disorders: an introduction. columbus: charles e. merril publishing company. lisker, l. & abrahamson, a.a. (1964). a cross-language study of voicing in initial stops: acoustic measurements. word, 20, 384422. marsden, c.d. (1984). which motor disorder in parkinson's disease indicates the true motor function of the basal ganglia? in: ciba foundation symposium 107. functions of the basal ganglia. london: pitman. mcneil, m.r. & kent, r.d. (1987). relative timing of sentence repetition in apraxia of speech and conduction aphasia. in: j.h. ryalls (ed.). phonetic approaches to speech production in aphasia and related disorders. boston: collage-hill, little brown and company. mcneil, m.r., robin, d.a. & schmidt, r.a. (1997). apraxia of speech: definition, differentiation, and treatment. in m.r. mcneil (ed) clinical management of sensorimotor speech disorders. new york: thieme medical publishers. minifie, f.d., hixon, t.j. & williams, f. (1973). normal aspects of speech, hearing and language. new jersey: prentice-hall. prutting, c.a. & kirschner, d.m., in t.m. gallagher & c.a. prutting (1983). pragmatic assessment and intervention issues in language. college-hill press, inc.: san diego. sharkey, s.g. & folkins, j.w. (1985). variability of lip and jaw movements in children and adults: implications for the development of speech motor control. journal of speech and hearing research, 28, 8-15. takayama, y., sugishita, m., kido, t., ogawa, m. & akiguchi, i. (1993). a case of foreign accent syndrome without aphasia caused by a lesion of the left precentral gyrus. neurology, 43, 1361-2. van der merwe, a. (1985). disartrie-ondersoekvorm. universiteit van pretoria. van der merwe, a. (1986). die motoriese beplanning van spraak by verbale apraksie. unpublished d.phil dissertation. university of pretoria. van der merwe, α., groenewald, e., van aardt, d., tesner, h.e.c. & grimbeek, r.j. (1993). die formantpatrone van afrikaanse vokale soos geproduseer deur manlike sprekers. south african journal of linguistics, 11(2), 71-79. van der merwe, α., groenewald, e., brittz, h.c. & grimbeek, r.j. (1995). differentiating the levels of dysfunction in acquired neuromotor speech disorders: the context sensitivity of temporal features in apraxia of speech, cerebellar dysarthria and lower motor neuron dysarthria. proceedings of the british aphasiology society biennial international conference 12th 14th september 1995, p.16. van der merwe, a. (1997). a theoretical framework for the characterization of pathological speech sensorimotor control. in m.r. mcneil (ed.). clinical management of sensorimotor speech disorders. new york: thieme medical publishers. yorkston, km., beukelman, d.r. & bell, k.r. (1988). clinical management of dysarthric speakers. texas: pro-ed. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) our real problem is in t h e hearts and minds of men. our real problem is in the hearts and minds of men. it is not a problem of physics but of ethics man's skills has outstripped his morals. his engineering has leaped ahead of his wisdom. we cannot cancel or call back his scientific advances, but we can, and we must, if the world is to survive, help man to catch up. in god's name, if you still believe in god, take him seriously, and somehow get control of what science has given the world, or else we shall likewise perish!" albert einstein. do you face advancing technology with apprehension and a little fear? this need not be! if you have a supplier who will help you all the way! for more than 20 years teknimed have brought the latest and most advanced solutions out of an enormous range of hearing health care products to dispensers, schools, ent specialists and hospitals all over south africa. we do everything to make your task as painless as possible by providing our very best product, service, price, training and after-sales service. from anything like a simple earlight, to custom acoustic enclosures, you can rely on us to give you an efficient and honest service! if you would like to find our more about what our team of specialists can do for you, write phone fax or email us at: teknimed enterprises cc ρ 0 box 662, somerset west, 7129 tel 0 2 1 8 5 2 1619. fax 0 2 1 8 5 1 3 8 3 3 . e-mail: teknimed@ilink.nis.za the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mailto:teknimed@ilink.nis.za pitch in esophageal speech l.w. l a n h a m , ph.d. (witwatersrand) head, department of phonetics & general linguistics, university of the witwatersrand, johannesburg and w . a . kerr, m . r . c . s . , d . l . o . ( l o n d o n ) department of otorhinolaryngology, johannesburg hospital. (head: d.r. haynes) summary most reports on pitch in esophageal speech emphasize that it is low-pitched with a measured fundamental frequency rarely higher than 100 cps. our investigations show, however, that much esophageal 'phonation' lacks periodicity and,' therefore, a fundamental frequency (i.e. pitch in the accepted sense). an auditory impression of pitch modulation can, nevertheless, be created by physical properties other than a varying harmonic structure. our sample includes a rare case of truly high-pitched esophageal phonation with a fundamental frequency in the upper limit of the voice an octave higher than the highest reported in the literature. high-pitched phonation apparently requires a vibratory source in a 'mode' different from that of low-pitched phonation and should therefore be distinguished from it in discussing pitch in esophageal voice. opsomming meeste verslae oor esofageale spraak beklemtoon dat dit 'n lae toonhoogte het met 'n gemete grondtoon frekwens wat selde hoer is as 100 c.p.s. ons ondersoeke toon egter aan dat in baie gevalle die esofageale fonasie nie periodies varieer nie, en dat daar dus nie sprake kan wees van 'n grondtoon (d.i. toonhoogte in die aanvaarde sin) nie. die gehoorlike indruk van toonhoogte modulasie kan nietemin ook veroorsaak word deur fisiese eienskappe ander as harmoniese veranderende struktuur. die toonhoogte in een van die ondersoekte gevalle was uitsonderlik hoog, met 'n grondtoon in die boonste grensgebied van die stem, 'n oktaaf hoer as die hoogste tot dusver vermeld in literatuur. hoe toonhoogte fonasie vereis blykbaar 'n vibrerende bron in 'n vibrasietoestand wat verskil van die van 'n lae toonhoogte fonasie, en moet dus onderskei word van 'n lae toonhoogte in die verhandeling van toonhoogte in esofageale spraak. while the current literature provides a fair consensus as to the limitations of pitch in esophageal speech, certain anomalies and contradictions are nevertheless apparent. our evidence suggests that this arises from a failure to recognize that a measurable fundamental frequency (the physical correlate of pitch perception in normal voice) is often lacking, or only intermittently present, tydskrif van die suid-afrikaans vereniging vir spraak en gehoorheelkunde, vol. 22, deseber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 l.w. lanham and w.a. kerr in the typical 'low-pitched' esophageal 'voice'. it is nevertheless necessary to account for the weak auditory impression of pitch variation in esophageal voice even without a measurable fundamental frequency. in distinguishing between pitchless 'phonation' and the esophageal voice with sustained, true pitch, we find in the data offered in the literature (in particular, kytta 7 ) and in our own sample, evidence of an upper limit to the pitch range in esophageal voice at least an octave higher than the highest frequency previously reported (see below). such high pitch is only achievable by a small number of laryngectomees who have both a high-pitch and low-pitch 'mode'. the suggestion that there are two apparently disjoint modes in esophageal phonation leads us ton investigate the possibility of two correspondingly different states of the cricopharyngeus muscle in vibration. methodology the kay sonagraph (model 6061 -b) was used to analyse the physical properties of esophageal voices in the manner described in kerr and lanham6. as indicated there, narrow-band spectrograms show harmonic structure in narrow lines on the horizontal axis (see, for example, spectrogram c2, narrow, 12-18 in this paper); wide-band spectrograms show each release burst in a sequence of vibratory cycles by vertical lines whose regularity and timing can be measured on the horizontal axis (± 12.33 cm = 1 second). fundamental frequency is measured as the interval between successive lower harmonics using frequency-scale magnification for greater accuracy (possible error is in the region of ± 5 hz). all of our spectrograms are cuts from the flow of speech in normal conversation or, in one case, from an attempt at singing. three of our cases are presented spectrographically here. one of them (case c) provided still radiographs drawn from extensive still and cineradiographic investigation of the site and mechanism of this case's two voices 'low' and 'highpitched' phonation. these will be found in kerr and lanham6, (p. 100.) case a (female, aged 61) underwent laryngectomy in 1953 when more than the usual segment of trachea was removed. she received speech therapy over a period of 6 months, but no great improvement was recorded. case β (female, aged 61) underwent laryngectomy in 1950; the infrahyoid muscles were preserved and overlapped to strengthen pharyngeal repair. she received speech therapy shortly after the operation and was greatly helped by it. case c (female, aged 62) underwent laryngectomy in 1951 with surgery similar to that of case b. she received speech therapy after the operation, but believes that it was largely due to her own efforts that she 'found her voice'. . / a comparison of findings in studies dealing with pitch in esophageal speech 1. fundamental frequencies and pitch ranges. reports on pitch in esophageal speech give measured fundamental frequencies and pitch ranges which are low in comparison with normal laryngeal speech (a full octave lower according to snidecor and curry1 0), but the extent of the pitch range may actually be greater than that of normal speakers a differjournul of the south african spccch ami hearing association, vol. 22, dcccmber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pitch in esophageal speech 33 ence of 13.21 tones against 10.5 tones according to these authors. obvious anomalies do, however, arise in reports of this kind. after reporting the abnormally wide frequency range of superior esophageal speakers in their sample, curry and snidecor1 continue: '. . . the esophageal speakers were nonetheless considered to have a restricted pitch range . . .' and 'the frequency measured indicated a considerably greater movement than was apparent in pitch to the listener.' in citing a statement by van den berg: 'the speech of a clever patient sometimes gives the illusion of agreeable changes of pitch which objectively are not present' these authors do not fully explore the obvious contradiction. kytta7 states: 'the auditory observation group did not in fact notice any appreciable frequency variation . . . however, measurement of the fundamental frequency showed an unexpectedly large variation, 3-4 tones. ..'. anomaly and contradiction is, however, partly explained by the conclusions to which our studies have led us: (a) much 'low-pitched' esophageal phonation is actually pitchless, but does have measurable rates of vibration without periodicity (i.e. repeated cycles) and it is these aperiodic vibrations which are often measured, (b) the voices of many speakers have pitchless stretches interspersed with stretches in which periodicity is achieved and lower harmonics are discernible, (c) an auditory impression of pitch modulation can be achieved by varying prosodic properties other than a harmonic pattern, (d) the most effective pitch modulation is achieved by a small number of laryngectomees who can produce 'highpitched' phonation with pitch ranges considerably higher than those reported in the literature. in this article the main focus is on high-pitched phonation which has properties sufficiently distinct to warrant separation from the common lowpitched esophageal phonation. these properties apparently correspond to a different state or mode of the vibratory source. the major differences are found in pitch range and in a sustained harmonic structure with most of the energy concentrated in harmonics rather than in concomitant aperiodic components. spectrographic evidence of high-pitched phonation is found in the spectrograms below: c2 (narrow) and, less distinctly, ci (narrow). these demonstrate a clear harmonic structure up to 2 khz, a measurable fundamental varying between 215 and 317 and, therefore, pitch in the accepted sense of the term. (to our knowledge, the highest reported frequencies in esophageal speech are an estimate of 185 cps by damste3 and a measured 135.5 cps by curry and snidecor1.) our data on low-pitched esophageal voices show that the majority, including some highly intelligible ones, either totally lack a measurable fundamental frequency, or intermittently, even spasmodically, present short stretches of a syllable or less with a few lower harmonics and considerable aperiodic energy between discrete harmonic energies. a minority are capable of sustaining a discernible harmonic structure over several syllables and all these vibrations occur at rates which are within the 'pitch ranges' reported for esophageal speech, e.g.: 32 to 72 in kytta7, 17 to 135 in curry and snidecor1, 50 to 100 in van den berg and moolenaar-bijl13. the output of these slow rates of vibration of the pseudoglottis is, therefore, aperiodic more often than tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheekde, vol. 22, deseber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 l.w. lanham and w.a. kerr journl of the south african spch a hearing association, vol. 22, dcmber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pitch in esophageal speech 35 ckb7. b1 (miiwi p oh make her a home (sung > * tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheekde, vol. 22, deseber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 l.w. lanham and w. a. kerr journl of the south african spch a hearing association, vol. 22, dcmber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pitch in esophageal speech 37 periodic, but auditory impressions of pitch variation in esophageal speech are not necessarily dependent on periodicity; our evidence suggests that differ-, ences in intensity, duration, etc., can compensate in a limited way in giving an impression of pitch modulation (see our discussion below on case b's attempt at singing). plomp8 reports that in normal laryngeal speech, pitch is determined by the lower harmonics; fry5 states that it is the fundamental frequency which determines pitch, but the ear interprets the interval between lower harmonics as the pitch if there is no energy present in the first harmonic. as true pitch is a potential property of esophageal speech (particularly when it is 'high-pitched') we propose that esophageal phonation be recognized as pitchless where there is no evidence of lower harmonics and a fundamental frequency, or these are only spasmodically present over very short stretches. 2. characteristics of low-pitched esophageal speech in attempting to characterise low-pitched esophageal phonation we use kytta's data and our own. kytta's discussion reveals the basis for discrepancies between his interpretation of pitch properties and ours: in the spectrogram in fig. 3, p. 31, labelled 'spectrographs analysis of the fundamental frequency of the fundamental' we see a vibratory pattern producing releases which are bursts of noise irregular in time and amplitude, and varying in complexity. our spectrogram b1 (narrow) shows a very similar pattern which we recognize as common in low-pitched esophageal speech (all kytta's spectrograms on pp. 57-63 are of the same type). but fig. 3, and our spectrogram b1 (narrow) above, both show a vibratory pattern lacking periodicity and devoid of harmonic structure, and a measurable fundamental; they do, however, show measurable rates of vibration and it is apparently this which kytta measures in stating the limits of the pitch range of his subjects. vibratory rates in this mode can be considerably faster (varying around 92 at β1 1-2), but do not necessarily acquire periodicity, nor a higher pitch because of this. fast vibration in this mode (up to roughly 110 in our data) tends to lose release bursts in continuous turbulence (see b2, wide and narrow, 1-3 and kytta's hiipi 0-0.25 on p. 63). in some, possibly a minority of esophageal speakers phonating in this mode, discrete lower harmonics (usually below 1 khz) do indeed emerge intermittently over short stretches often shorter than a syllable, but a good deal of energy in random aperiodic components partly obscures them. (in our data these intermittent harmonics occur in the range of 60 to 130 cps.) in respect of the quantity of periodicity in low-pitched esophageal phonation, yielding a measurable first harmonic, we find it difficult to accept curry and snidecor's2 finding that 59.5% out of 61.4% total phonation is periodic. 3· characteristics of high-pitched esophageal phonation. high-pitched esophageal phonation is characterized by sustained harmonic structure over more than one syllable; high concentration of energy in the lower harmonics as distinct from accompanying noise; and the pitch range, the lowest limit of which is probably in the region of 150 cps and the highest tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheekde, vol. 22, deseber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 l.w. lanham and w.a. kerr close to 400 cps (the latter frequency is seen in spectrogram dvi in kerr and lanham6, p. 92). in addition to our case c, kytta provides spectrographs evidence of high-pitched esophageal phonation similar to case c (but lacking the vibrato in the voice of the latter) on p. 50 (the utterance vaara) and p. 54 (tlodco). fundamental frequency in the former is roughly 170 cps at 0.25 and 162 cps at the peak of the first syllable in the latter. kytta, however, fails to interpret his data correctly and gives the highest recorded fundamental frequency in his sample as 72 cps. case c has a pitch range between 210 cps and nearly 400 cps; the fundamental frequency in spectrogram c2 is 270 cps at 1.3 and 317 cps at 16.4. (notice, however, the break into low-pitched phonation at c2 3-8). another possible feature of high-pitched phonation is the significantly longer 'duration of air charge'. snidecor and curry 1 0 , reporting on mean duration of air charge in their sample, give a maximum of 2.25 sees. case c can repeat 'all my arms are sore'1 for approximately 4.5 sees. in tape-recorded conversation her longest stretch without obviously recharging her esophagus is 3.7 sees. an analysis of the three voices in briefly reviewing our three cases presented here we note that radiography locates the vibratory source at the cricopharyngeus for all. (the postulation of an upper pharyngeal vibrator for case c's high-pitched phonation made in kerr and lanham6, has been refuted by recent cineradiography.) the voices of cases a and β are confined to low-pitched phonation with no evidence of discernible harmonics in the voice of the former and virtually none in the latter. case a's voice is croaky, low in power and intelligibility and gives no auditory impression of pitch modulation. there is believed to be some loss of muscular function in the inferior pharyngeal constrictor. spectrogram a1 shows very slow, highly irregular rates of vibration; at a1 1-3 there are 9 vibrations over some 17 csecs at rates ranging between 30 and 61. case β on the other hand has a highly efficient voice of considerable power and high intelligibility although unpleasantly harsh. vibrations are faster and more regular; a variation of ± 11 around a mean rate of 92 at β1 1-2 and ±2 around a mean rate of 45 at b1 11-12. case b's voice is capable of weak impressions of pitch modulation and the sung and spoken versions of the same utterance are shown in spectrograms b1 and b2 respectively as evidence of the physical properties of 'pitch' in aperiodic low-pitched esophageal speech. the sung version differs in the ' following respects: (a) where the highest pitch is attempted (make at b2 5-8) the syllable duration is more than doubled, (b) the rate of vibration increases by nearly 40% at b2 5-8 and approximately 30% at b2 11 (the vowel nucleus of her), (c) the intensity of the prominent syllables is greater by 3.3 db for the vowel nucleus of make and 1.3 for the nucleus of home, (d) more energy 1 this utterance was chosen because it lacks stop (plosive) consonants. the articulation of these consonants has been shown by van den berg, et a l . 1 2 to present opportunities for filling the esophagus. 1 journl of the south african spch a hearing association, vol. 22, dcmber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pitch in esophageal speech 39 is located in higher frequencies (above 3 khz); an impression of this difference can be gained at b2 1-3. apart from (b), which does not create discernible harmonics to any extent, the other differences, probably collectively, contribute to the auditory impression of higher pitch. case c has two 'voices' (low and high-pitched esophageal phonation) and spectrograms c2 are produced in order to show how they alternate in the continuum of speech and reveal the basis of the strong impression of pitch modulation which, over the telephone, can deceive even the most experienced ear as to the true nature of the voice. as seen at c2 3-8, where the second, high-pitched voice breaks and the first voice takes over, case c's first voice gives no evidence of a harmonic structure. the first voice is heard as lowpitched and it is the alternation between the two voices which contributes to the strong impression of wide pitch variation. case c reports that her second voice is the product of strenuous, sustained effort in the months after laryngectomy and obviously requires a much higher degree of neuromuscular control; the vibrato effect best seen in ci (narrow), is evidence of this. with declining morale in recent years case c tends to lapse into her first voice for longer and longer stretches. the general impression of case c's voice is that it is a high-pitched woman's voice (spectrographically at c2 13-17 it is strikingly similar to female laryngeal phonation), but extreme, often abrupt, variation in power is a feature. pitch change is often sharp, sudden and somewhat unpredictable. the abrupt changes usually correspond to a change from one voice to another; spectrogram c2 shows this with c2 at 1 and 12-21 being the second voice with a onesyllable break into the first voice at 3-8. state and function of the esophageal sphincter in vibration the site and mechanism of the two modes of phonation in case c's voice may be examined by reference to radiographs on p. 100 in ken and lanham6. in that article they are numbered d1 d4. d2 and d3 represent phonation in the first (low-pitched) and second (high-pitched) modes respectively, d4 outlines the cricopharyngeus immediately after phonation has ceased. in d3 the shadow over the lower three-fourths of a club-shaped head of the cricopharyngeus outlines a channel of air which rises and tapers abruptly to a point of occlusion in the upper quarter of the clubhead. the constriction ring within the esophageal sphincter is apparently located here. in d2 the constriction ring is less easily identifiable, but an air channel is seen above the protruding fold (marked a) and forward of the lower third of the inferior anterior edge of the clubhead. blurring at the upper half of this anterior edge suggests a comparatively large mass of the inner margin of the sphincter involved in vibration, which is not the case in d3. this latter state is consistent with highfrequency vibration in which only a short stretch of a tightly constricted inner margin is involved. in an attempt at simulating the second mode of vibration in the form of a labial trill, l.w.l. produced, in the manner described below, a spectrogram tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheekde, vol. 22, deseber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 l.w. lanham and w.a. kerr fairly similar to ci (narrow) 6-10, which showed a fundamental around a mean of 400 cps with undulating harmonics. it was necessary to make a very tight labial closure with strong intra-oral pressure bursting through a very short stretch (about .5 cm) which produced a high-frequency labial trill. essential requirements are that each lip present a stiff, tense, edge which is relatively thin. with more flaccid, thicker edges labial trilling becomes slower and less regular, a longer stretch is involved in vibration and periodicity is easily lost. for high-frequency trilling the level of effort required to achieve the balance between air pressure, muscle tension and the configuration of the vibrating edge appears to match that required for case c's second voice and is as difficult to maintain at an even level. in comparison with radiograph d4 (kerr and lanham6) in which there is no vibration, phonation in d2 and d3 is seen to involve a shortening of the 'neck' behind the clubhead of the cricopharyngeus and a lifting and flattening of the head (contrast the drooping head in d4). the head is flattened in the vertical plane more in d3 than in d2 suggesting tighter constriction. taking account of the differences shown in the radiographs referred to above, we suggest that first-mode and second-mode vibrations differ in mechanism in the following ways: in the former a relatively thick, fairly relaxed inner margin of the sphincter is drawn into closure or close approximation in a muscular movement not much different from that required for esophageal burping in a normal speaker; consequent vibrations involve a comparatively large mass of the cricopharyngeus. second-mode vibration, however, requires a much more highly controlled movement which produces greater tension along the inner margin and presents a stiffer, firmer edge at the point where vibration takes place. much less of the margin is involved in high-frequency, low amplitude vibration with only small quantities of esophageal air released in the process. this could account for the significantly longer 'duration of air charge' in this type of phonation. the distended upper end of the esophagus suggests high intra-esophageal pressure. conclusion in the discussion above it has not been our intention to present a case for two mutually exclusive categories of esophageal phonation, but to highlight a type of esophageal phonation of which only a limited number of laryngectomees is capable. this 'second mode' of pseudoglottal vibration is the product of a relatively intact musculature and considerable effort both in acquiring and maintaining it. we.suggest, however, that in one or more of the parameters of esophageal phonation the two modes are discontinuous states and not merely different points on the same scales. there is, for example, no evidence that over any voiced' stretch in esophageal speech a gradational move from one to the other mode is possible (by progressively increasing muscle tension along the margin of the esophageal sphincter). spectrogram c2 (wide) shows how case c moves from one mode to another by a discrete abrupt change; in fact, 2 v a n den berg's 'high pitch' is not equatable to our second mode in esophageal phonation. his upper limit of the fundamental frequency is 85 cps and is said to coincide with high intensity and stronger air flow. journl of the south african spch a hearing association, vol. 22, dcmber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pitch in esophageal speech 41 we have no evidence at all of harmonic energies in case c's first, low-pitched voice and, therefore, no evidence of an ability to shift gradually from low to high pitch. other investigators have suggested that one 'setting' of the pseudoglottis in phonation cannot be phased gradually into another. van den berg et a l . 1 2 , state: '. . . he always separated the section with a high pitch2 from that with a low pitch by a new breath and a new injection of a i r . . .'. there is evidence, therefore, that for stretches of, possibly, the duration of an air charge, the esophageal speaker is locked into a particular mode of phonation and, if a harmonic structure is present, into maintaining more or less the same pitch. references 1. curry, e.t. and snidecor, j.c. (1961): physical measurement and pitch perception in esophageal speech. the laryngoscope. lxxi: 415-424. 2. curry, e.t. and snidecor, j.c. (1973): fundamental frequency characteristics of japanese asai speakers. the laryngoscope. lxx1ii: 17591763. 3. damste, p.h. (1958): oesophageal speech after laryngectomy. thesis, print. gebr. hoitsema. groningen. 4. damste, p.h. (1959): the glotto-pharyngeal press. speech pathology and therapy. 2:70-76. 5. fry, d.b. (1970): prosodic phenomena. in malmberg, b. ed., manual of phonetics. amsterdam. 6. kerr, w.a. and lanham, l.w. (1973): anatomical and spectrographic analysis of the voice in disease: a report on five cases. j. sa speech & hear, association. 20:81-107. 7. kytta, j. (1964): finnish oesophageal speech after laryngectomy. acta oto-laryngologica, supplementum 195.vammala. stockholm. 8. plomp, r. (1966): experiments on tone perception. van gorcum and comp. netherlands. 9. robe, e.y., moore, g.p., andrews, a.h., holinger, p.h. (1956): a study of the role of certain factors in the development of speech after laryngectomy. the laryngoscope. lxvi: 382-401. 10. snidecor, j.c. and curry, e.t. (1959): temporal and pitch aspects of superior esophageal speech. the annals of otology, rhinology and laryngology. lxviii: 623-636. 11. tato, j.m. (1954): study of the sonospectrographic characteristics of the voice in laryngectomized patients. acta oto-laryngologica. 44: fasc. 5-6. 12. van den berg, j.w., moolenaar-bijl, a.j., damste, p.h. (1958): oesophageal speech. folia phoniatrica. 10:65-81. 13. van den berg, j.w. and moolenaar-bijl, a.j. (1959): cricopharyngeal sphincter, pitch, intensity and fluency in oesophageal speech. prac. oto-rhino-laryngol. 21:4. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheeikimde, vol. 22, deseniber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) modern hearing aids (pty.) limited 305 rand central 305 22-4855 165 jeppe street/straat 165 johannesburg 2001 box/bus 83, johannesburg 2000 the latest from telex the tw2/tdr2 fm auditory training system: featuring: teachers microphone and transmitter all in the size of a hearing aid. student direct receiver for the following modes of operation: — 1) fm and hearing aid with a control for adusting fm relative to hearing aid sound pick-up. 2) telephone or loop pick-up alone. 3) hearing aid alone. peak output, compression and tone controls are also provided. uses a dry battery or rechargeable cell. automatic built in squelch provided. operating frequency changed by plug in module allowing free movement from one classroom to another. no extra wires required — no cross talk between classrooms — 32 channels available. our services also include: 1) the supplying of the latest directional discrimina ting hearing aids for mid-medium-severe hearing losses. 2) making the most comfortable instant earmoulds for our patients — while they wait. 3) first service facilities covered by a 3 month guarantee. other products include: 1) screening and diagnostic audiometers. 2) sound measuring instruments. journal of the south african speech and hearing association, vol. , december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) relationship between v e r b a l l a n g u a g e and symbolic play — a case study denise segal, m . a . ( s p e e c h pathology) ( w i t w a t e r s r a n d ) department speech pathology and audiology, university of the witwatersrand, johannesburg. summary the linguistic ability and play of a language-impaired child were analysed to determine whether a breakdown in symbolic play occurs together with a language deficit. observation of play was conducted at the child's nursery school (unstructured situation) and in a situation designed to elicit specific play behaviours (structured situation). imaginative play and its concomitants — affect, mood variability, concentration, aggression and interaction — were rated along descriptive scales, while each individual play unit was scored for organization of behaviour. syntactic, semantic and phonological aspects of language were recorded during free play and analyzed within a syntactic framework. the normal developmental sequence provided the baseline of comparison for both language and play. results indicated a developmental lag in play and a linguistic deviation from the normal pattern, which supported the possibility of a general representational deficit. a method for incorporating symbolic play into a language programme was suggested and the necessity for normative studies in this area was stressed. opsomming die linguistiese vermoe en spel van 'n taalgestremde kind is ontleed om vas te stel of 'n versteuring in simboliese spel gelyk met 'n taaltekort plaasvind, al dan nie. waarneming van spel het by die kind se kleuterskool plaasgevind (ongestruktuurde situasie) en ook in 'n situasie beraam om spesifieke speelgedrag te ontlok (gestruktueerde situasie) verbeeldingsryke spel en die konkomitante verskynsels — gevoelsinhoud, wisselvalligheid van stemming, konsentrasie, aggressie, en aksie en reaksie — is volgens beskrywende maatstawe beordeel, terwyl elke adsonderlike speleenheid vir organisasie van gedrag opgeteken is. sintaktiese, semantiese en fonologiese aspekte van taal is gedurende vry spel aangeteken en binne 'n sintaktiese raamwerk geanaliseer. die normale ontwikkelingsvolgorde is gebruik as die basis van vergelyking vir sowel taal as spel. 'n ontwikkelingsvertraging in spel en 'n linguistiese afwyking van die normale is deur die resultate aangedui, wat die moontlikheid ondersteun van 'n algemene weergewende tekort. 'n metode om simboliese spel in 'n taalprogram te integreer is voorgestel en die noodsaaklikheid vir normatiewe studies in die gebied beklemtoon. it is generally agreed upon by researchers that language and cognition are correlated although the nature of the relationship is controversial. recent investigations2· 3 ' 4 ' 2 1 · 3 1 ' 3 2 have tended to support piaget's hypothesis2 4 that language is based in prior cognitive growth. this suggests that a linguistic breakdown may be a reflection of an underlying cognitive disturbance thereby providing a conceptual framework within which to view diagnosis of, and therapy for, the language-impaired child.1' 2 1 definitions and classifications of play are numerous and variable according to theoretical orientation but the viewpoint adopted in the present investigation is that of piaget. 2 5 he theorized 2 4 that children die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 denise segal aged two to four years develop a general representational ability which manifests in all symbolic systems, namely, deferred imitation, imagery, drawing, dreaming, symbolic play and language. he defined symbolic play as ". . . the deformation and subordination of reality to the desires of the self".2 5 l u n z e r 1 7 considered it to be the natural medium of behaviour and of intellectual growth at that period which coincides with speech development. although the cause-effect relationship is undetermined, 1 2 , 1 5 ' 1 7 language and symbolic play are believed to share a common cognitive base and to function similarly as 'signifiers' to an absent content. while language enables man . . . ίο represent objects and situations in their absence . . . (p. 207) 1 7 symbolic play allows the child to use one object, action or event, to represent another object, action or e v e n t . 1 0 ' 1 9 ' 2 8 it is thought that language at first accompanies play until the child's naming of an object emancipates word from object. 7 with increased play complexity and the substitution of play names for real names at about three years of age, the child is able to plan an activity verbally.7' 1 8 since the actions involved in play resemble the significant content, they are believed to be more easily acquired than wordmeanings which are arbitrary.1' 2 4 this suggests that in some children a linguistic deficit may also present with a breakdown in symbolic play. piaget (p. 338) 2 5 described play as . . . an exercise of action schemes . . . in which assimilation predominates over accommodation. thus the child utilizes and incorporates an aspect of the environment into himself rather than imitating and adapting his own body to the social milieu. in 1951 piaget drew up a classification scheme comprising practice play, symbolic play and games with rules, each class characteristic of a particular developmental stage — sensori-motor, representational and concrete operational respectively. during the sensori-motor stages ii-v (from 2 to 28 months), the child's actions are exercised for pleasure alone. the genesis of the symbolic function occurs at about 18 months of age (sub-stage iv), with a subsequent developmental progression both in the organization of symbolic play behaviours, and in the degree of representational ability that they reflect.17· 2 4 · 3 1 piaget's scales, although theoretical and not intended for clinical usage, have been adapted by researchers such as l u n z e r 1 7 and bass et al1 for use in both clinical and natural settings. bass et al stressed that in truly symbolic behaviour, the child is aware of the distortion of reality whereby the action occurs out of context. initially, the action rather than the object is the symbol anil can be performed with objects inadequate to fulfil the goal (e.g. using a stick in a representation of eating), or in the absence of any objects (e.g. simulating eating with no external aids). at this stage, the child is able to perform these actions only upon himself, and is not able to attribute them to others until the representational stage has been reached. the representational stage comprises three substages, each including the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) verbal language and symbolic play 39 different types of behaviour, according to their symbolic structure. during substage i, the child is able to project his own actions (type ia), and then his imitated action patterns (type ib) onto new objects. substage ii, involves representation by simply identifying one object with another, eg. picking up a stick and saying, "this can be a broom" ( t v p e 2a) and subsequently, by using bodily actions to assume another identity (type 2b). the child's ability to utilize individual objects symbolically within an integrated framework (type 3a) is apparent from three to four years of age. the value of symbolism in play subsequently diminishes in that it becomes differentiated into games with rules. thus while these substages and classes constitute an evolutionary continuum with no clear delineations1 5' they do allow for the study of the child's cognition through the observable mode of symbolic play. this is felt to be particularly appropriate for the language-impaired child where cognitive investigation through the linguistic medium would inevitably be unrepresentative of his true performance. . comparatively few studies have investigated the relationship between language and symbolic play, but the symbolic function has been shown to be impaired in linguistically deviant children.1' 1 5 ' 2 1 ' in addition, luria and yudovich, 1 8 and vygotskaia7 found progress in symbolic play as a result of speech improvement. however, further research is necessitated. the investigation by lovell, hoyle and siddall considered only duration of play behaviour which lunzer found to be an unreliable measure, whereas bass et al1 utilized a structured play situation only, thereby ignoring crucial aspects which have been found to be related to play. these comprise affect during play, concentration and aggression, as well as interaction and co-operation with both peers and adults. . it is controversial which aspects of play actually involve symbolic or abstract thought. el'konin 7 considered only dramatic play, the substitution of an imaginary situation to satisfy the child's needs. other investigators17' 3 0 have added constructive play whereby objects are manipulated in order to create. it was this latter viewpoint that was adopted by the present investigator. play like language, is learnt in relation to ongoing meaningful activities.13 the writer thus set out to study play . . . in the overall context of the individual and social actions of the child, (p. 339) the child's continuous interaction with his environment as an essential aspect of play has been emphasized since his spontaneous . . . direct collision . . . with reality (p. 228)7 enables him to assimilate reality to his limited cognitive schema. in accordance with singer, it is believed that certain defensive or conflict-reducing behaviours may also participate in this process. interaction with, and observation of adults, has been similarly emphasized in the development of play. this is believed to facilitate separation of an activity from an object, its generalization to new objects, and progressive abstraction of usage. die suid-afrikaanse t y d s k r i f vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 denise segal f r e y b e r g 8 also argued that the adult model serves as the catalyst for the development of latent skills which are basically within the child's capabilities, despite lacks in experience or cognition. whereas the parent initially directs the child's behaviour by verbal instruction, this is later internalized by the child. on the basis of foregoing findings, the aim of the present study was to analyse and to describe qualitatively the symbolic play and linguistic ability of a language-impaired child. more specifically, this study was designed to determine whether a linguistic breakdown would manifest with a corresponding breakdown in symbolic play. m e t h o d o l o g y aims 1. to describe qualitatively and to analyze the symbolic play and linguistic ability of a language-impaired child. 2. on the basis of the above, to determine whether a symbolic breakdown will co-occur with a language impairment. 3. if (2) above is supported, to determine whether the nature of the breakdown, that is, delay versus impairment, at the level of play corresponds with that at the language level (namely, impairment). 4. to determine whether play performance of this particular child differs in a structured versus an unstructured situation. 5. on the basis of the above findings, to devise a therapy programme for this child incorporating symbolic play within a linguistic framework. subject one male child (s) aged 3 years 8 months was selected as subject. he was the youngest of three children and had been diagnosed by a qualified speech therapist from the speech and hearing clinic at the university of the witwatersrand, johannesubrg, as presenting with an expressive language-impairment. s fulfilled the following criteria: 1. chronological age — s's chronological age fell within the range of that reported in normal development for a fully established linguistic system (3v2-4 years) and heightened symbolism in play (2-4 years). 1 7 · 2 4 2. mental age — due to s's inattention and lack of co-operation, a traditional iq measure could not be established however, s was assessed by his speech therapist to be of average intelligence according to his performance on non-verbal tasks. 3. s had no physical or primary emotional disability. 4. s had hearing within normal limits. 5. at the commencement of observation, s had been attending a nursery school (mornings only) for five months, thereby ensuring that he had adjusted to, and had become familiar with, the physical and social environment. 1 6. previous speech therapy could not be controlled for. for a year the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) verbal language and symbolic play 41 prior to this study, s had attended a play group for languageimpaired children three times a week, while simultaneously receiving individual speech therapy twice a week at the speech and hearing clinic of the university of the witwatersrand. however, while the added stimulation with regard to language and play as well as experience with play materials would influence the child's performance, it would work against the proposed hypothesis of a deficit in play occurring together with a language deficit. general procedure 1. language: (a) syntax and semantics — a sample of the child's spontaneous oral language was elicited during his regular speech therapy period. play materials included toys and action pictures which have been found to facilitate speech in three and four-year olds. the entire session was tape recorded using a reel-to-reel tape recorder. s's regular therapist conducted the session with the experimenter (e) observing behind a one-way mirror. the therapist and ε together transcribed the utterances. (b) phonology — this was included only to ensure differentiation between a syntactic error and one which was phonologically based, for example, omission of copula versus omission of phoneme [s]. the phonetic inventory test was administered by both the therapist and e. 2. play: (a) unstructured play situation — ε visited the nursery school to familiarize herself with the environment and routine. play materials included all the indoor and out-door equipment present. children were not encouraged into conversation with her, and any questions were answered 'tersely but pleasantly'. this allowed her to become part of the situation as an 'object' offering nothing in return for a child's advances as would an assistant. this ensured that ε would exert minimal influence on the child's activity.1 5 ε observed the child during free play for twenty ten-minute periods which were randomly scattered over ten days. the number of ratings was sufficient to eliminate such variables as the individual's feelings at the time and fluctuations in performance,1 7 while brief periods minimized the influence of fatigue. an interval of at least five minutes was allowed between each observation period. ε transcribed the child's overt expressions, play behaviours, interactions and verbalizations. a random sample of one in every five of the play sessions was simultaneously observed but independently transcribed and rated by a second, similarly experienced observer, (b) structured play situation — this was carried out during one of the child's speech therapy periods after completion of observadie suid-afrikaanse t y d s k r i f vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 denise segal tions in the unstructured situation. this prevented experience with play materials and examples of their symbolic usage from influencing the child's performance in the unstructured situation. the entire session which lasted 20 minutes was recorded on a reel-to-reel videotape. instructions were conveyed with the aid of linguistic and gestural cues and by means of example, in order to minimize the possible influence of receptive difficulties. rating scales a n d analysis of data: 1. language: (a) syntax and semantics — the child's language was analyzed in relation to the context and his ongoing activities. while a semantic analysis would appear to be more applicable in relation to cognitive assessment, a syntactic analysis was preferred on the basis of the view of crystal et al 6 that no semantic theory has been worked out sufficiently for descriptive studies of any general validity to have taken place. a standardized syntactic analysis allowed for the establishment of a quantitative language level as well as affording qualitative analysis. this was necessary in order to confirm the diagnosis of language-impairment and to ascertain whether delay occurred together with impairment. it is felt that if the interaction between language and symbolic play was being considered at a 'microscopic' (rather than a 'macroscopic') level, a semantic and pragmatic analysis would be more appropriate. this would involve analysing the functional language that occurs together with a particular type of play activity, for example, language that serves to extend the play activity as opposed to language that describes the ongoing activity. contrarily, the present study aimed to determine a language level, a play level, and only subsequently to establish whether similarities exist between these two behaviours in this particular child, this constitutes a 'macroscopic' or 'surface level' analysis. thus, semantics and pragmatics were included only to differentiate a semantically-based from a syntacticallybased error, as well as to exemplify unintelligible utterances by considering their intent within the play context. analysis included development sentence scoring (dss) and development sentence types (dst) comprising ^^developmental sentence analysis (dsa) devised by l e e . 1 3 from the corpus, the final fifty intelligible and consecutive complete sentences (with noun and verb in subject-predicate relationship) were selected for dss analysis. repeated, stereotyped and imitated utterances were excluded. it was agreed by the therapist (who was 'blind' to the aims of the study) and ε that s had acclimitized to the situation, and that his optimal performance was thereby included in the sample. the 68 pre-sentence the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) verbal language and symbolic play 43 formulations from the corpus were included in a dst analysis. in addition, all s's utterances in which the target was a complete sentence (179) were analysed qualitatively in terms of linguistic trends as well as use and diversity of base structure and transformational rules. (b) phonology — the phonetic inventory test was analysed by ε together with a member of the phonetics and linguistics department at the university of the witwatersrand. 2. play: (a) unstructured play situation — play behaviour was rated along the dimension of imaginativeness, affect, mood variability, concentration, aggression and interaction with peers and adults, devised by singer. 3 3 in accordance with lunzer's 1 7 view that constructive play is a pretence or abstraction from reality, this type of play was included in the rating for imaginativeness. this dimension and those for affect and concentration each received one overall score for the most frequent behaviour within each ten-minute period. a score was assigned for each and every interactive and co-operative behaviour displayed since it was often impossible to assign only one descriptive term which would do justice to the diversity of these behaviours within any ten-minute period. the scale for aggression measured direct overt aggression as opposed to that manifest in make-believe play. here, intensity rather than frequency of behaviour was considered. it was felt that an intense aggressive attack against a peer, even if momentary, could hinder future interactions and therefore, social play. the rating from 1 4 on the aggression scale was altered to 1 5 to comply with scoring on the other scales. a low score of 1 was positive, indicating no aggression, while a high score of 5 was negative, describing a great deal of aggression. for all other scales the reverse occurred in that a score of 1 was the negative side of the scale, for example, indicating low imaginativeness in play. in addition to the above, each separate play unit was rated on a 9-point index for the organization of play behaviours devised by l u n z e r . 1 7 this comprises two subscales — adaptiveness in the use of play materials which measures the child's treatment of the play materials, and integration of behaviour which concerns the complexity of the play behaviour itself. this scale yielded validity and reliability scores of 0,73 and 0,75 respectively. significant iriterscorer correlations of 0,92; 0,97; 0,85 and 0,90 (p 0,05) were obtained by means of the pearson productmoment correlation coefficient, (b) structured play situation — play was rated on a modification of lunzer's scale devised, in an unpublished masters dissertation, by bass, brown and redmond. 1 this measured symbolic play die suid-afrikaanse t y d s k r i f vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 denise segal behaviours at the substages, and of the type described by p i a g e t . 2 4 results the dearth of normative studies yielding quantitative data necessitated a largely qualitative analysis. for both language and play the normal developmental sequence served as the baseline for comparison. chronology, as well as the child's present developmental stage allowed any delay in, or deviation from the norm to be noted. 1. language: s obtained a dss score of 5,44 which falls below the tenth percentile for his chronological a g e . 1 3 ' 1 4 his language usage was comparable to that of a child aged 3 years 1 month, indicating a delay of seven months. dst analysis demonstrated that s used the earlier acquired verb phrase (vp) more frequently than the noun phrase (np). although s did combine noun and modifier to constitute two-word np's, his vp constructions were more advanced, being three, four or five words in length. this indicated that s was in a transition stage between pre-sentence formulation and consistent sentence stage. qualitative analysis revealed a delay in language development as well as a deviation from the normal sequence (impairment). the base structure rule (s—>np+vp) was not fully established, diversity of structural type and frequency of usage were limited, while application of transformational rules was not consistently correct. 2.1 play behaviour: (a) imaginative play as rated on the scale devised by singer.33 from figure 1 it is evident that s's most frequently occurring play behaviour was either extremely unimaginative and stimulus-bound (a score of 1) or it included a few pretend elements with little originality or organization (a score of 2). (b) organization of play behaviours as rated on the scale devised by lunzer.17 figure 2 reveals that s most frequently used play materials '. . . in a manner recalling the play of infants' (57% of the time). cognizance was not taken of their physical or representational properties, and the integration of play behaviours was minimal with little achieved (a composite score of 2). s's play behaviour fell predominantly (89,9% of the time) within scores 2 6 which has been equated with·-'piaget's 'practice play'. he obtained a score of 7, comparable to the rudimentary stages of piaget's 'symbolic play' (scores 7-10) only 10,1% of the time. thus, on the basis of his performance, it appears as though s is functioning slightly below the range for his age level although still conforming with the normal developmental pattern. the peak of symbolic play at two-to-four years of a g e 1 7 ' 2 4 was not apparent from his performance in the unstructured situation. thesouth african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) verbal language and symbolic play 45 20 18 16 14 12 key: 1 = extremely unimaginative. 2 = slightly imaginative. 3 = moderate amount of pretending. 4 = substantial pretend elements. 5 = high originality. 2 • ' • ' • l 0 1 2 3 4 5 6 imaginative play figure 1. frequency of occurrence of imaginative elements in play. (c) performance in structured play situation — this was included to determine whether s would be able to perform these activities when presented with appropriate stimuli for their elicitation. a qualitative analysis of s's performance demonstrated his ability to carry out activities equivalent to all stages except stage iiib. at all stages, the highest score attained (i 3 ), described integration of a number of separate behaviours within the framework of a fairly complex task. for example, in representational substage i, type ia, he put his hand into the box and lifted 'food' from the 'bowl' to the doll's mouth. the highest score achieved for adaptiveness in the use of play materials was a3, that is, the material was used with regard to its properties but in an obvious way. for example, in representational substage ii, type 2a, he built a tower and a train by placing blocks along a vertical and horizontal plane respectively. in one example only, he received higher scores of a5 for highly die suid-afrikaanse t y d s k r i f vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 denise segal 7 9 a 50 45 40 key: 2 = infant play; no integration. 3 = some regard for properties; no integration. 4 = some regard for properties; routine integration. 5 = obvious regard for properties; routine integration. 6 = obvious regard for properties; integrated framework. 7 = use transcends properties; integrated framework. 8 = use transcends properties; central theme. 9 = insightful use; central theme. 10 = insightful use; coherent sequence. 35 30 25 20 15 1 0 5 ' ' ' ' ' ' * j ι ο 2 3 4 5 6 7 8 9 10 organization of play behaviour figure 2. frequency ratings of categories of play organization. insightful usage of material and i 4 for the elaboration of a single theme, when he displayed types 2a and 2b concurrently (not included in scale by bass et al). here he represented an 'alarm clock' by combining two objects, a bubble-blower and a hair roller, while simultaneously producing a ringing sound. thus, s's performance at all stages, though inconsistent, was more advanced than that displayed in the nursery school. 2.2 associated play concomitants: (refer fig. 3) (a) affect — from figure 3a it can be seen that s scored 2 predominantly for affect, descriptive of only mild pleasure and interest accompanying 'desultory manipulation' of play mathe south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) verbal language and symbolic play 2 0 a 1 2 1 0 >< ο ζ ω d σ ω f* ο α. 20α 1 2 1 0 κευ: 1 = no interest or pleasure in play. 2 = mild pleasure and interest. 3 = moderate pleasure and interest. 4 = pleasure frequently expressed. 5 = extreme delight in play. 2 3 affect key: 1 = little attention to activities. 2 = superficial play — frequent change of activities. 3 = moderate interest activities changed once. 4 = good absorption in play — no change in activity. 5 = intense absorption in play. 0 1 2 3 4 b. concentration 2 0 a 1 2 1 0 6 key: 1 non-aggressive activity. 2 = play with aggressive toy. 3 = aggression directed at inanimate object. 4 = aggression directed at another child's toy. 5 = aggression directed at another child. aggression figure 3. frequency ratings of categories of affect, concentration and aggression. die suid-afrikaanse t y d s k r i f vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 denise segal terials. he did enjoy himself in the play situation (scores 3, 4 and 5) although this occurred infrequently. a pearson productmoment correlation coefficient demonstrated a significant relationship (r = 0,48; ρ 0,05) between play and affect. it has been argued that the child should display positive affect if the play in which he is engaged is inherently rewarding.8' 3 3 (b) concentration: — from figure 3b it is evident that s engaged predominantly (50% of the time) in 'superficial play', altering toys and activities frequently while looking around the room, staring passively, talking to the teacher, or wandering aimlessly. a further 35% of the time he displayed 'hyperactivity with no real interaction with play material'. a significant correlation (r = 0,46; ρ 0,05) was found between imaginative play and concentration. the child's generation of complex, interesting games, should create sufficient satisfaction for prolonged involvement. (c) aggression — it is apparent from figure 3c that s engaged predominantly in non-aggressive activities (a score of 1 occurred 45% of the time). however, an additional 45% was involved with directing a threat or physical attack against another child (scores 4 and 5 combined). no significant correlation was found between play and aggression. figure 4 demonstrates that s sought adult company more often than that of his peers. interaction with his peers varied from an apparent lack of trust to interact, resulting in avoidance of contact (a score of 1) to actively seeking their company (a score of 4). 20 1 4 1 2 1062il l 1 2 3 4 interaction j l — = interaction with peers = interaction with adults key: interaction with peers 1 = avoids contact. 2 = reluctant interaction. 3 = ready participation with peers. 4 = at ease with peers. 5 = initiates and maintains peer relationships. interaction with adults 1 = avoids contact. 2 = reluctant interaction. 3 = ready participation with peers. 4 = at ease with peers. / 5 = initiates and maintains peer relationship. figure 4. frequency ratings of categories of interactive behaviour. thesouth african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) verbal language and symbolic play 49 (d) interaction — a correlation coefficient between interaction (with peers and adults) and imaginative play could not be determined due to the differing number of scores rated along the two dimensions. however, imaginative play has been viewed as a vehicle to enhance social development. g e n e r a l discussion the results demonstrated a linguistic deviation from the norm and a developmental delay in symbolic play, with sensori-motor activity predominating. thus, in relation to the aims of this study, s manifested with a breakdown in both representational functions but the nature of the deficit differed. the contention that the sensori-motor child is 'egocentric' in his overt actions while the pre-operational child is 'egocentric' in his representations,2 3 lends support to the finding that s is in a transition period from sensori-motor to symbolic activity. the symbolic function, rather than appearing in its final form, can be seen to build gradually upon sensori-motor achievements.3' 1 7 ' 2 6 ' the play protocols affirm that this child's, use of language was 'amorphous', similar to that of a two-year o l d . 1 8 it was almost exclusively an adjunct to direct ongoing activity, for example, ί riding bike!'. in addition, s made use of verbalizations to indicate his needs and as a tool to gain another person's attention. on the few occasions that s played symbolically in the unstructured situation it was the accompanying language, rather than the behavioural organization per se, that demonstrated its symbolism. this is contrary to the finding of lovell, hoyle and siddall1 5 that normal three and four-year olds gain so much satisfaction out of their self-created symbols in play that language is secondarily important. it is possible that s's inability to organize his play behaviours necessitated the use of language to explain its symbolism. only once, when he used a block of wood as a 'gun' to 'shoot' the gardener, did s demonstrate a substantial amount of pretending (a score of 4). his total involvement in this play activity was demonstrated by his frowning (suggesting anxiety) when the gardener fell down feigning injury, and by his 'seeking protection' behind an observer when the gardener 'aimed' the 'gun' at him. this seems to suggest that s has the 'competence' with regard to using play materials to transcend their immediate properties. however, performance would reflect this competence under ideal conditions only.5 in addition, variables such as the influence of television, suggest that this might be an imitative rather than a creative activity. s engaged predominantly in 'sensori-motor activity characterized by the mere pleasure of mastering reality'. his coincident verbalizations such as ί riding bike!' were bound to his overt activity. if he had referred to the bicycle as a space-ship, for example, clear transcendence of the immediate situation would have been demonstrated. die suid-afrikaanse t y d s k r i f vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 denise segal s's awareness of the 'double function' of objects and actions, (p. 191)9 and the ability to ascribe these actions to others as opposed to performing them only on himself, was apparent in his few symbolic activities. he rolled a 'snake' from dough and used it symbolically, warning the teacher that it is 'gonna bite you!' (representational stage — types 1a and ib). s also utilized language to symbolically identify one object with another, as when he picked up sand, threw it into the air and called it 'fire'. however, this cannot be considered as evidence of substage ii since s interposed physical action between himself and the represented object. as occurs in substage i, the 'psychological distance' (p. 328) 3 6 between the symbolizer and the symbolized was minimal. s's performance was found to be more advanced in the structured situation as compared with the unstructured setting. this is felt to be important in devising a therapy programme since both the child's potential and his performance should be taken into consideration. it is possible that restricting stimulus materials enhances awareness of novel symbolic applications to the play materials.1 7 however, according to piaget 2 4 who placed representational substage iii as occurring from age three, s is still functioning below his age level. in addition, only delay from the normal developmental sequence was evident contrary to impairment found for language development. the consideration of play within a cognitive-affective framework3 3 would account for s's maximal positive affect accompanying sensorimotor as opposed to symbolic behaviour. this model dictates that novel material, within the child's capacity for mastery, will yield interest, alertness and positive emotional reaction. as was evident from s's scores for organization of behaviour (fig. 2), he engaged most frequently in sensori-motor activity. since no cause-effect relationship has been determined, it is possible that improved concentration might result in improved imaginative play. in accordance with freyberg's8 suggestion, the present investigator feels that the two correlates may be a unitary dimension, the very nature of imaginative play implying the ability to concentrate. the present findings for .aggression accord with those of singer.3 3 freyberg8 did find however, that increased role-play behaviour results in decreased fighting. socialization with peers was often imitative and s seemed unable to initiate his own plan of action. he would play alone in their vicinity and subsequently emulate their behaviours particularly if these had been approved by an adult. the development of the symbolic function within the context of imitation as well as the apparent satisfaction s found in activities with adults, are both pertinent issues. hyperactivity, distractibility and perseveration, all evident in s's performance, have been found in association with languageimpairment. 3 4 ' 3 5 while the exact relationship between these behavioural manifestations, language and play is as yet undetermined, the thesouth african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) verbal language and symbolic play 51 present findings demonstrated a positive correlation between concentration and imaginative play. thus, a therapy programme including symbolic play within a linguistic framework would necessarily be incorporating concentration whether directly or indirectly. clinical implications while a subjective, case study analysis does not allow for generalization of findings to other language-impaired children, it does exemplify aspects of diagnosis and therapy for these children. it is suggested that diagnosis of the child with a language difficulty should include an analysis of his level of play. this affords a non-verbal assessment of his cognitive abilities and general level of symbolic functioning as well as providing for therapeutic direction. for the child whose receptive language appears to be intact, the structured play situation can be utilized. this allows for a rapid assessment (about 20 minutes per child) involving clinical presentation of tasks graded developmental^. however, since verbal instructions are inherent in its design, it is unsuitable for the child with severe receptive language impairment or for the profoundly deaf child. it is suggested that these latter children be observed in an unstructured setting, either at home or at nursery school and rated along a scale such as that devised by lunzer. this is time-consuming but it will facilitate differential diagnosis with regard to the child's general level of symbolic functioning. it is felt that language therapy should be carried out in relation to the child's total cognitive functioning. whether cognition can be taught is controversial, but materials and activities which are high relative to the child's present level of mastery should be provided in order to challenge his intellectual growth. 1 1 thus, as with regard to his language, so his play must be adapted to the child's unique stage of symbolic usage. the present writer proposed two ways in which symbolic play can be useful in language therapy: 1. for the child who is using only one-three word utterances — since the child learns language in relation to his ongoing activities as he interacts with the environment, parents should be encouraged to verbalize their own and the child's actions to allow for word-action association. from the naming of real objects, the child should progress to reproducing the same action using realistic toys and then 'junk' material, following the developmental sequence. daily activities can be re-enacted in 'pretend' play, for example, acting out a situation of 'going shopping' after the child's return from such an outing. at a later stage, the outing can be played out prior to its occurrence in real life. increased play complexity involves progressive 'deceleration' of the action from the child's own body, and complexity both in the use of the play material and in the behaviour (or behavioural die suid-afrikaanse t y d s k r i f vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 denise segal sequence) itself. with increased complexity so the time spent in the activity will be increased, thereby encouraging longer periods of concentration. in addition, involvement in the play activity will lead to positive affect during play, which in turn, will motivate further play. aggression can also be expressed within the play situation rather than being directed outward. 2. for the child who has acquired sufficient syntax — it is proposed that symbolic play should be embodied within the linguistic approach of interactive language development teaching devised by lee et a l . 1 4 to replace the use of a flannel board, objects such as boxes, sticks etc. can be used. these should be kept out of sight and brought into the child's focus only when mentioned in the story, to prevent excessive hyperactivity. abstract uses for these objects in relation to the ongoing narrative should be suggested and the child should be encouraged to discover additional symbolic applications. as the story is related and the child asked to respond to the clinician's utterances, so he must simultaneously utilize the objects to create the scene. for example, if the theme is a fishing trip, a cup could be a container for worms, pieces of paper could be worms, and so on. in this approach, the child can actively interact with is environment, an important consideration in intellectual growth. 4 , n ' 2 7 , 2 9 he is encouraged to explore his surroundings and to discover things for himself. the child who is hyperactive can draw the scene as it is related rather than acting it out or reproducing it in miniature. the flexibility of this method allows for other approaches to be incorporated within it. an example is the 'forced alternative' questioning put forward in the remediation technique of crystal et a l . 6 this can be used together with a story devised by lee et a l ; 1 4 a story made up by either the clinician or the child; as well as a symbolic sequence enacted or drawn. particular emphasis can be placed on that area (syntactic, semantic, categorical, etc.) most delayed for the child. in addition, most of these play activities can be carried out in groups which allows for socialization, interaction and co-operation, parallel play and imitation, all of importance for both linguistic and cognitive development. in conclusion, future research should be geared towards normative studies in this field which may highlight theoretical controversies, and towards evaluating therapy programmes which have a representational basis comprising'both language and symbolic play. references 1. bass, k., brown, j. b. & redmond, a. p. (1975): symbolic play in normal and language-impaired children. unpublished master of science dissertation, department of speech pathology and audiology, emerson college, canada. thesouth african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) verbal language and symbolic play 53 2. bloom, l. (1970): language development: form and function in emerging grammars. m.i.t. press, massachusetts. 3 bowerman, m. f. (1974): discussion summary — development of concepts underlying language. chap. 7 in language perspectives — acquisition, retardation and intervention, schieffelbusch, r. l. and lloyd, l. l. (eds.), university park press, u.s.a. , . 4. bricker, w. a . & bricker, d. .s. (1974): an early language training strategy. chap. 17 in language perspectives — acquisition, retardation and interaction, schieffelbusch, r. l. and lloyd, l l. (eds.), university park press, u.s.a. 5. chomsky, n. (1975): aspects of the theory of syntax. m.i.t. press, massachusetts. 6 crystal, d . , fletcher, p. & garman, m. (1976): the grammatical analysis of language disability. edward arnold publishers, london. d 1 f 7 el'konin d (1971): symbolics and its functions in the flay ot children.' chap. 14 in child's play, herron, w. e. and sutton-smith, b., (eds.), john wiley and sons, inc., new york. 8 freyberg, j. (1973): increasing the imaginative play of urban disadvantaged kindergarten children through systematic training. chap. 6 in the child's world of make-believe — experimental studies of imaginative play, singer, j. l., (ed.), academic press, inc., new york. 9. furth, h. g. (1966): thinking without language: psychological implications of deafness. the free press, new york. 10 furth h. g. (1975): on the nature of language from the perspective of research with profoundly deaf children. annals of the new york academy of science, 263, 70-75. 11 furth, h. g. & wachs, h. (1974): thinking goes to school: piaget's theory in practice. oxford university press, inc., u.s.a. 12. hulme, j. & lunzer, e. a. (1966): play, language and reasoning in subnormal children. / . child psychol. psychiat., 7, 107-123. 13. lee, l. l. (1974): developmental sentence analysis. northwestern university press. evanston, illinois. 14. lee, l. l., koenigsknecht, r. a. & mulhern, s. (1975): interactive language development teaching: the clinical presentation of grammatical structure. northwestern university press, evanston, illinois. 15. lovell, k., hoyle, h. w. & siddall, m. q. a study of some aspects of the play and language of young children with delayed speech. / . child psychol. psychiat., 9, 41-50. 16. lowenfeld, m. (1939): the world pictures of children. british journal of medical psychology, 18, 65-101. 17. lunzer, e. a . (1959): intellectual development in the play of young children. educational review, 11, 205-217. die suid-afrikaanse t y d s k r i f vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 denise segal 18. luria, a. r. & yudovich, f. la."(1959): speech and development of mental processes in the child. penguin books, ltd., england. 19. moerk, e. l. (1977): pragmatic and semantic aspects of early language development. university park press, u.s.a. 20. moore, τ. e. & harris, a. e. (1978): learing and thought in piagetian theory. chap. 6 in alternatives to piaget: critical essays on the theory, siegal, l. s. and brainard, c. j., (eds.), academic press, new york. 21. morehead, d. m. (1972): early grammatical and semantic relations: some implications for a general representational deficit in linguistically deviant children. in papers and reports on child language development, ingram, d., (ed.), stanford university, stanford. 22. morehead, d. m. & ingram, d. (1973): the development of base syntax in normal and linguistically-deviant children. j. speech hearing res., 16, 330-344. 23. phillips, j. l. (1969): the origins of intellect: piaget's theory. w. h. freeman and co., san francisco. 24. piaget, j. (1951): play, dreams and imitation in childhood. heinemann, london. 25i piaget, j. (1966): response to brian sutton-smith. chap. 22 in child's play, herron, r. and sutton-smith, b. (eds.), john wiley and sons, inc., new york, 1971. 26. piaget, j. (1967): six psychological studies. university of london press, london. 27. piaget, j. (1971): the construction of reality in the child. ballantine books, inc., new york. 28. piaget, j. & inhelder, b. (1969): the psychology of the child. routledge and kegan paul, london. 29. riley, s. s. (1973): some reflections on the value of children's play. young children, 146-153. 30. rubin, κ. h. & maioni, t. l. (1975): play preference and its relationship to egocentrism, popularity and classification skills in pre-schoolers. merrill-palmer quarterly, 21, 3, 171-179. 31. sinclair, h . (1970): the transition from sensori-motor behaviour to symbolic activity. interchange, 1, 3, 119-126. 32. sinclair-de-zwart, h. (1972): a possible theory of .language acquisition within the general framework of piaget's developmental theory. chap. 19 in language in thinking, adams, p., (ed.), penguin books, ltd., england. 33. singer, j. l. (1973): the child's world of make-believe experimental studies of imaginative play. academic press, inc., new york. 1 34. strauss, a. a. & kephart, n. c: (1955): psychopathology and education of the brain-injured child. vol. ii. grune and stratton, new york. the-south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) verbal language and symbolic play 5 5 35 strauss, a. a. & lehtinen, l. (1950): psychopathology and ' education of the brain-injured child. grune and stratton, n.y 36 werner, h. & kaplan, b. (1963): symbol formation: an organismic-developmental approach to language and the expansion of thought. john wiley and sons, inc., n.y. die suid-afrikaanse t y d s k r i f vir kommunikasieafwykings, vol. 27, r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) photographic teaching materials visual aids for use in language development catalogue and price list available from: p . t . m . , 23, horn steet, winslow, buckingham. mk18 3ap. england. tel: winslow (029 671) 3776. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) society of hearing aid consultants (s.a.) the society of hearing aid consultants (sa.) is a group of concerned hearing aid suppliers dedicated to improving and maintaining standards of hearing aid dispensing. our members have freely committed themselves to abide by the rules and disciplines of the society in the interests of promoting the highest standards of conduct and competence. special membership is available to interested persons in allied fields. enquiries: the secretary, society of hearing aid consultants (sa), po box 4581 johannesburg 2000 tel: 23-5791 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) operation of the auditory feedback monitoring loop in children with articulatory defects sandra o s s i p , b . a . l o g . ( r a n d ) introduction audition serves as the principle controlling unit in the speech servosystem, the motor aspect being subject in a large part, to the command of audition. from studies carried out on the deaf and hard-of-hearing population, such as that of carr,1 it is apparent that although normal hearing and auditory defective infants have many similarities in their early vocalizations, they develop aberrant speech patterns. chase3 quoted othei types of clinical cases, such as those with somesthetic sensory deficits, and concluded that both acoustic information about speech and intact feedback are relevant in the normal acquisition of speech, and lead, according to chases' hypothesis, to neurophysiological organization which underlies the ability to speak. the motor and sensory systems, and the interaction between the two, are necessary for the development of verbal behaviour. a closed-loop control system exists when the system can operate to control the machine of which it is a part, and is error-sensitive, error-measuring, self-adjusting and goal directed. in contrast, an openloop system would not be able to measure the output and make adjustments, if the results are not those desired. mysak8 was one of the first to hypothesize the development of closed internal and external audiovocal and audioverbal loops as the components of the speech system. in this study project the writer is concerned with the internal monitoring feedback loop, but information about the development of this, particularly the auditory feedback monitoring system for speech, is rather scant. the studies carried out to date have assumed, as fairbanks4 did, that the closed-loop auditory feedback monitory system can be inferred from the disturbances in speech produced by an experimental technique which delays the air conducted feedback to the speaker's ears, i.e. delayed auditory feedback (da'f). studies done by yeni-komshian,12 chase,3 mackay7 and chase et al.2 suggest that older children show greater daf effects than younger children, indicating that in younger children, the monitoring loop is still in the process of being closed and the motor organization of speech incomplete or still under practice. ; when considering the importance of sensation in this loop system and in the consequent acquisition of speech, disregarding the motor mechajournal of the south african speech and hearing association, vol. 18, december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a u d i t o y feedback monitoring l o o p in articulatory defects 49 nisms which may be inadequate, defective speech could arise from a defective model which guides the output, or, from a failure of this mechanism which compares the output with the intended or desired production. within the cybernetic framework adopted here, aspects such as auditory memory span and phonetic discrimination defects can be considered as "substandard functioning of some component of the speech servo-mechanism" which may be possible because of many functional articulatory disorders.5 here it is assumed that the defect arises from a failure of the comparative mechanism from which the original auditory image or model had to be derived. because of the significance of maturation of the ability to articulate, another aspect must be considered. this is the possibility that the loop control system in children with articulation disorders, has not been closed and does not have the properties of "monitoring" the output. experimental methodology aim the purpose of this experiment is to determine whether the auditory feedback monitoring system for speech is operative in children with multiple articulatory errors. this assessment was done by mechanically inducing an interference in the air conducted loop and studying the effects on a sample of the above-mentioned population as compared to the effects on a normal population-sample. the hypothesis thus being that the children with articulatory disorders will show less severe breakdown under delayed auditory feedback than children with no articulatory defects. method i. subjects the ages of the subjects ranged from four years seven months to nine years five months; six of the children were males and four females. the experimental group consisted of three males and two females who were known to have two or more articulatory errors. the control group consisted of five subjects who were pair matched with the experimental group on the following variables: (a) sex. (b) age.—the subjects were matched to have equal ages within approximately three months. (c) educational level.—the controls were taken from the same classes as the experimental subjects. the subjects taken from a nursery school were in the same group. (d) intelligence.—subjects were not formally tested and matched, but were judged to be "above average" or "average" by the individual class teachers. (e) level of maturity.—assessed and judged by the class teachers. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. is, desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50, sandra ossip (f) personality.—no formal tests were administered but children were matched according to teachers' recommendations. (g) socio-economic status.—the children all attended schools which were situated in similar types of areas. they could be assessed to be of middle socio-economic level. (h) aircfiildren had histories of normal speech and hearing development, and apparently normal central nervous systems. 2. instrumentation (a) an amplivox audiometer (model 82) was used to establish the air-conduction threshold for each subject. (b) a national tape recorder (model rq7065) was used to record all responses made while the subjects were in the experimental situation, and these samples were used for later analysis. the speed for recording was kept constant at i.p.s. and recording volume level also remained fixed. (c) the madsen (model bs63) delay speech unit was used to induce the experimental conditions of normal auditory feedback (naf) and delayed auditory feedback (daf). the recorder and playback heads were combined, enabling adjustment of delay intervals. the critical interval of 0,2 seconds was used throughout the experiment. the output intensity level was also kept constant. maico soft cushion headphones were used. 3. materials (a) the templin darley picture articulation test was used and the spontaneous method of eliciting responses was followed. validity and reliability of the examiner's judgements of articulation were found to be adequate, following appropriate statistical and subjective analysis. two other therapists independently recorded the same responses. (b) the material used for two of the three tasks in the experiment consisted of two sets of five cards each (set a and set b). the cards .contained clear pictures of common every-day objects together with a clearly written representation of them. (c) recitation of a nursery rhyme. 4. procedure the experimentation took place in an iac (series 1600 act) soundproof testing booth where the experimenter established' an air conduction threshold for each ear. the articulation screening test was then administered to assess the subjects' articulatory abilities. after a rest interval, the subject was taken to another soundproof room where the child was settled with the experimenter e. the microphone of the tape recorder was placed on the table so that it was able to pick up all the responses elicited from the child. the earphones, which were connected to the delayed speech 'unit, were placed over the child's ears. ε presented the first set of cards (set a) within the child's visual journal of the south african speech and hearing association, vol. is, december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a u d i t o y feedback monitoring l o o p in articulatory defects 51 field and the subject was asked to name the pictures on the cards. when this was completed to the satisfaction of the e, the child was asked to repeat the naming procedure from the beginning. before the following repetition was commenced, the child was rold of the possibility that his voice "may sound funny". the daf condition was then commenced. as soon as the child completed the task of naming all five cards, the daf condition was discontinued. the same procedure was repeated with the second set of cards (set b) first under the condition of naf and then daf. the final experimental task was then begun, where the subject was required to repeat a nursery rhyme under the two conditions of naf and daf. results analysis after a short pilot study conducted on ten adult subjects under naf and daf conditions, and critical evaluation of the information gained on these subjects, the writer felt that the measures which would yield empirical data that could be subjected to analysis would be: 1. time: the mean rate reduction score was obtained by subtracting the time taken for a task under naf from the time taken under daf. three such scores were obtained for each subject, one for each task. 2. the second score was a more qualitative measure of the number of words prolonged under daf. the experimenter judged these, after finding that two judges' (speech therapists) evaluations agreed with her's. a percentage score was obtained for each subject on the two sets of cards. percentage of words prolonged = number of words prolonged x 100. 3. observation of the subjects during the experimental situation. their reactions and verbal responses were recorded by the experimenter. method of analysis 1. the time scores (in seconds) were recorded and summaries were compiled allowing for comparison between the experimental and control groups. 2. the time scores obtained for task three (the nursery rhyme) were subjected to a test of significance. the student "t" test was applied to see if the differences between the two groups were significant. 3. the mean percentage prolongation scores obtained for each group were subjected to a similar "t" test analysis. 4. a graph was drawn to represent the age-link hypothesis. the percentage prolongation of the subjects in the experimental group was used, where each subject represented a different age level. discussion under conditions of daf, all the "normal" subjects or those having no articulatory errors, broke down considerably in comparison to their tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. , desember r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 sandra ossip performance under naf. in contrast, under similar conditions, the experimental group showed less impairment of their natural speech and voice. the most marked change in speech, was the increase in time taken to produce the same speech sample under daf than under naf. these scores, together with the mean prolongation scores (tables 1 and 2) revealed that there were significant differences between the two samples of the population at the 15% level of confidence. subjects reduction score control group i reduction score experimental group ii difference between reduction score ( / / / ) pair 1: (ca = 4.6 years) ci 38 el 4 34 pair 2: (ca = 6.3 years) c2 22 e2 19 3 pair 3: (ca = 6.7 years) c3 28 e3 13 15 pair 4: (ca = 7.5 years) c4 5 e4 11 6 pair 5: (ca = 9 . 5 years) c5 14 e5 10 4 significant at the .001 % level. table 1: summary of the mean reduction scores of task three subjects number of prolongations control group i number of prolongations experimental group ii difference between prolongations ( / / / ) pair 1: (ca = 4.6 years) ci 7 el 0 7 pair 2: (ca = 6.3 years) c2 4 e2 2 2 pair 3: (ca = 6.7 years) c3 2 e3 2 0 pair 4: (ca = 7.5 years) c4 3 e4 3 0 pair 5: (ca = 9.5 years) c5 6 e5 3 3 significant at the 10% level. table ii: summary of the mean prolongation scores on tasks one and two the results indicate that the auditory feedback monitoring loop system is not operating at the same level or is still in the process of being "closed" in the child with functional articulatory defects compared to the child with normal speech. it appears that chase's2 hypothesis, which states that the auditory feedback monitoring system for speech develops as a function of age, journal of the south african speech and hearing association, vol. is, december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a u d i t o y feedback monitoring l o o p in articulatory defects 53 is borne out in these results (see figure 1). it was noted that a subject of four years shows less marked behavioural disturbance under daf figure: the percentage of breakdown in the experimental group, measured by prolongations as a function of age. it can thus be assumed that the speech system develops from an open 'external audio-vocal loop to form a closed audio-verbal loop. this is the most complex form of behaviour as it is the ability to monitor, to check the output and to change it if necessary. under daf, the sensory information and the motor output are out of phase, and this results in a disruption of speech, as there is an interruption in the temporal pattern of motion. if a person regulates his behaviour continuously, there will be a marked effect on his speech under daf. if, however, the temporal patterning is not as organized or practiced, the disruption will not be as severe, as the loop is not a closed monitoring circuit thus the child with articulatory disorders appears to be immature in the development and acquisition of speech. it appears from this project that sensory information is as relevant to speech development as is the motor aspect. auditory feedback consequently appears to play an important role in the process of speech acquisition. the writer has in this study continually stressed the importance of sensory feedback for adequate motor function, but it would be an oversimplification to say that the organism functions as a computer, and treat him as a simple control system. she has assumed the basic hypothesis that the individual possesses the control properties of a cybernetic system, but as a living system, exhibits flexibility and change in pattern of control. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. is, desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 sandra ossip one of the most complex forms of behaviour is verbal communication, which emerges in the context of active exchange of acoustic information that ultimately results in the development of a system of speech motor gestures that conforms to the system utilized by the adult culture. some therapeutic procedures have been devised by therapists such as mysak8 and van riper and irwin11, but the writer feels that not enough emphasis is placed on audition as being the major source of sensory feedback information. she advocates use of increased auditory stimulation, auditory training techniques, and the use of the auditory training aid (train-ear) in order to develop the auditory feedback monitoring system for speech. the therapist, at first, is the monitor, and eventually the child can exercise automatic control. in a similar manner other speech disorders can be attributed to breaks in the cybernetic feedback systems and therapy programmes be devised. an implication of the above theorising that has not been fully discussed is the classification of function in the structure of the nervous system. one assumption that is important is that the stream of speech is activated and controlled by a multiple determined plan and intention of communication, by antecedent and simultaneous internal and external events, by intention and organization of the message and by further sets of instructions that activate and control the movements that convert the message into sound. this assumption leads to an auxiliary statement that disorganization of the motor aspects of speech behaviour results from a variety of lesions. aphasia results from interference that disrupts both analysis and integration of verbal messages as the analysis and integration of language requires continuous and dynamic discriminatory and feedback activity. schuell et al.10 advocated her aphasic therapy on the above assumptions. her principles stress the need to provide the patient with adequate feedback by giving him adequate and increased stimulation. the patient depends on the therapist or a machine for feedback until he is able to regulate his behaviour in terms of his own feedback. mecham6 considered apraxia with this framework. apraxia refers to a disorder in the motor functioning in which "the individual has a basic motor capability to perform a motor act, but is unable to plan the act at an identical level, or transpose a visual impression into an appropriate motor counterpart or sequence". he viewed apraxia as a "distorted or unstable or nonvaried reafferent feedback''and the disruption of visual perceptual function in terms of failures or retardation of central organization". the training of these children and other braininjured children is orientated towards facilitating basic processes of general neurological organization, establishing or enhancing intermodal sensory integration, and to help clarify or define the child's sensory motor interaction. the child with: "functional articulatory errors" can be seen to have a similar defect though there is no known central nervous system involvement. journal of the south african speech and hearing association, vol. , december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) auditoi-y feedback monitoring l o o p in articulatory defects 55 implications from this can be extended to problems encountered in teaching speech to the deaf child. here there is definite auditory sensory deprivation. the writer feels that it" is necessary not only to provide the child with a complete representation of the adult speech models to allow them to be reproduced, but it is also necessary to provide this information in a form that allows the child to match his speech with the adult speech, and compute the degree of approximation necessary to make systematic alterations directed at minimizing the mismatch between the two. the cybernetic interpretation of the developmental literature, taking into account the closed-loop nature of the behaviour and its selfregulating characteristics, suggests some ideas about teaching and training in general. the two main principles developing are: that the individual at all ages should be aided in gaining control over his own actions, and that teaching of specific skills must be adjusted to the phase of development of the feedback-control mechanism. teaching and training design should be adjusted to the level of control already achieved and also should be sensitive to the potential changes in response organization that may come in time through maturation. summary this study constitutes a preliminary evaluation of the utilization of auditory feedback for the acquisition of normal speech in normal speaking children and children having functional articulatory errors. the degree to which this is utilized for the organization and control of motor activity was inferred by delaying auditory feedback in time and quantitating the resulting disturbances in the speech behaviour. evidence was found to support the following hypotheses: i. there is a breakdown of speech under daf. ϊ : children with multiple articulatory disorders exhibit less severe breakdown effects under daf than their normal peers. 3. there appears to be a strong relationship between increasing age and articulatory ability. 4. there tends to be a relationship between increasing age and the breakdown of speech under daf. 5. monitoring of speech is a highly skilled control system which tends to develop with age and experience, and is not operating as strongly in the child with articulation-defects. from the results of the study, it seems that the auditory feedback monitoring loop for speech is not operating as successfully in the child with multiple articulatory errors as it operates in the normal child, and that the development of a closed loop system appears to be retarded in some way. opsomming hierdie studie vorm 'n voorbereidende evaluasie van die beniitting van ouditiewe terugvoering vir die verwerwing van spraak in normaaltydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. , desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sandra ossip sprekende kinders en kinders met funksionele artikulasiefoute. bewyse is verkry om die volgende hipoteses te o n d e r s t e u n : 1. d a a r is 'n afbraak van spraak tydens vertraagde ouditiewe terugvoering. 2. kinders met veelvoudige artikulasieafwykings vertoon minder ernstige afbraakeffekte tydens vertraagde ouditiewe terugvoering as hul normale maats. 3. d a a r blyk 'n sterk verhouding te wees tussen ouderdomsverhoging en artikulatoriese vermoe. 4. d a a r is ' n neiging tot 'n verhouding tussen ouderdomsverhoging en die afbraak van spraak tydens vertraagde ouditiewe terugvoering. 5. aktiewe kontrolering van spraak is 'n hoogs ontwikkelde sisteem wat neig om te ontwikkel met o u d e r d o m en ondervinding. dit blyk ook nie so aktief te wees in die kind met artikulasieafwykings nie. uit die resultate verkry van hierdie studie wil dit voorkom asof die kontrolebaan van die ouditiewe terugvoering van spraak nie so effektief werkende is in die kind m e t veelvoudige artikulasie foute as in die n o r m a l e kind van dieselfde o u d e r d o m nie. die ontwikkeling van 'n geslote baansisteem blyk o p een of ander wyse vertraag te wees. r e f e r e n c e s 1 carr j (1953): an investigation of the spontaneous speech sounds of the five-year-old deaf born child. journal of speech and hearing disorders, 18, 22-29 2 chase, r. α., sutton, s., first, b. and zubin, j. a. (1961): a developmental study of changes in behaviour under delayed auditory feedback. journal of genetic psychology, 99, 101-112. 3 chase, r. a. (1967): motor organization of speech. annual report. johns hopkins university school of medicine, baltimore, maryland, 103-145. 4. fairbanks, g. (1955): selective effects of delayed auditory feedback. journal of speech and hearing disorders, 20, 333-345. 5 mange, c. n. (1960): relationship between selected auditory perceptual factors' and articulation ability. journal of speech and hearing research, 6 mecham, m. j. (1966): introduction—nature and scope of the problem in communication training in childhood brain injury. charles c. thomas. 7. mackay, d. g. (1968): metamorphosis of a critical interval: age-linked changes in the delay in auditory feedback that produces maximal disruption of speech. journal of the acoustic society of america, 43, 811-821. 8. mysak, e. d. (1966): speech pathology and feedback theory. charles c. thomas. springfield, illinois. . 9. reef, h. (1968): lecture notes in "neurology given to speech and hearing therapy students. , 10. schuell, h., jenkins, j. j. and jimenez-pabon, e. (1967): aphasia in adults. harper and row, inc., new york.. ' 11. van riper, c. and irwin, j. n. (1959): voice and articulation. pitman medical publishing co., london. 12. yeni-komshian, g. (1968): the development of auditory feedback monitoring : no. 2. delayed auditory feedback studies on the speech of children between 2 and 3 years of age. journal of speech and hearing research, 11, 307-315. journal of the south african speech and hearing association, vol. , december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aphasia: a societal and clinical appraisal of pragmatic and linguistic behaviours glenn m. goldblum, ma (sp. & h.sc.) (uc, santa barbara) department of speech pathology & audiology, university of the witwatersrand, johannesburg abstract pragmatic abilities of eleven aphasics classified into fluent and nonfluent groups were examined, and compared with global ratings of communicative adequacy. further, subjects 'pragmatic performance was compared with performance on two standardised linguistic measures. all subjects demonstrated high levels of appropriate pragmatic behaviours and were apparently resourceful in using the context, frequently facilitated by use of compensatory communicative strategies. similar and different pragmatic deficits were noted for both groups. regardless of classification and linguistic severity, subjects were less impaired on pragmatic compared to standardised linguistic measures. implications were highlighted, emphasising the importance of pragmatics relative to other aspects of language function. opsomming die pragmatiese vermoens van elf afasie-pasiente, wat ingedeel is in 'n vlot — en 'n onvlotgroep, is ondersoek en hul kommunikatiewe vaardighede is onderling vergelyk. die proefpersone se pragmatiese prestasie is ook vergelyk met hul prestasie op twee gestandaardiseerde linguistiese toetse. al die proefpersone het bewys gelewer van hoe vlakke van toepaslike pragmatiese gedrag en was oenskynlik vindingryk om die konteks te gebruik vir kompensatoriese kommunikatiewe strategiee. tekortkominge in die twee groepe was soms dieselfde en soms verskillend van aard. ongeag die klassifikasie van die groepe en die graad van linguistiese onvermoe, was die proefpersone deurgaans pragmaties minder belemmer as op die linguistiese vlak. gevolgtrekkings is beklemtoon, wat die relatiewe belang van die pragmatiek tot ander aspekte van taalfunksionering onderstreep. as speech-language pathologists, one of our primary concerns has always been to improve communicative effectiveness of the individuals we serve. in attempting to meet this goal, the intervention strategies we have used have been continually refined and revised-molded by the changing theoretical views of language over the past several decades. earlier in our history many investigators including johnson (1946) and van riper (1939 cited by prutting, 1982a) stressed the need for our goals to be mutually acceptable to both the client and society. much of this societalj perspective was lost over the past few decades, perhaps in the name of objectivity and accountability. more recently, researchers in applied behavioural research and in the field of child and adult language disorders, (e.g. kazdin (1977); mueller (1983); prutting (1982a); prutting and kirchner (1983); and prutting, kirchner, hassan and buen (1984)) have pointed out the need to move back clinically to viewing communication disorders from a social perspective, taking context into account, rather than attempting to control it. despite this proposed change in perspective, clinical aphasiologists still need to concern themselves with identifying behaviours and effecting changes that make socially relevant differences in the client's life. as in the discipline of science, the field of acquired adult aphasia has undergone many paradigmatic shifts which have resulted in conceptual and methodological reorganisation. at present there is a contemporary and ongoing shift towards a functionalist paradigm which appears to provide promise of a different theoretical framework for examining and attempting to understand the aphasic communication problem. holland's observation (1977) that "aphasics probably communicate better than they talk" (p. 173), which views aphasia as a communication (rather than a language) problem, reflects this broadened functional perspective. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 a perusal of the more recent literature reveals that despite the growing interest towards pragmatics in aphasia, a diverse and large list of behaviours are included under the general rubric of pragmatics, in the absence of a comprehensive theoretical framework of natural aphasic communication. such a framework remains to be developed to help clinicians incorporate pragmatics more effectively into the treatment process. _ while most traditional and current assessments of aphasic language focus on the structural aspects of their verbal output, a few researchers have begun to be challenged by, and address the assessment of diverse communicative functions in aphasia. using a variety of communication assessment protocols and observational measures a few investigators including guilford and o'connor (1982); holland (1980, 1982); and penn (1983) have demonstrated generally superior pragmatic abilities with little correlation between traditional syntactic profiles and communicative performance. while their data has furthermore resulted in support for holland's belief (1982, 1983) in the preservation of communicative competence in aphasia, penn (1983) has warned that since the social context of communication is so redundant, we may be overestimating the aphasic's ability. communicative competence compared to linguistic competence may thus best be viewed as less impaired in aphasia rather than intact. the most comprehensively linguistic study evident in this regard appears to be that by penn (1983), who developed a profile of communicative appropriateness (pca) based upon a relatively comprehensive taxonomy derived from child language literature. penn used her pca (penn, 1983) and the language assessment remediation and screening procedure (larsp) (crystal, garman and fletcher, 1976 cited by penn, 1983) to obtain and compare com© sasha 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 municative and linguistic profiles of hem.sphere aphasic subject, termined by the boston d j ^ ; ^ 1 9 8 3 ) . t h e r e s u l t s e t • c i t e d b y p e n n ' 1 9 8 3 ) of the larsr syntactic j ^ ] e s s e r e x t e n t s e v e n . correlated c.osely ^ . ^ ^ " f ^ o n s t r a t e d essentially idiosynskills by indivtdua. subjects, whtah were not n e c e s s a r i l y related to subjects' capacities on a syntactic level severity and type distinctions did not always account for subject clusters on the pca (penn, 1983), particularly when individual scales were considered, although severity was postulated to relate more closely to appropriate communicative performance than site of lesion or type of aphasia as predicted by traditional tests of aphasia. though exploratory in nature, penn's data (1983) suggesting the relative independence of syntactic and pragmatic aspects of aphasia are extremely provocative, raising concern with two important issues. firstly they cast some doubt on the validity of traditional classification schemes and their ability to reflect functional communicative competence. alternatively, penn's data highlights the need to consider structural and functional data together to facilitate a more comprehensive evaluation of an aphasic's communicative competence. in contrast to these data, in the area of child language disorders, prutting et al, (1984) have recently demonstrated clearly different pragmatic profiles across normal, language and articulation disordered groups of children using a societally-based pragmatic protocol (prutting 1982b) inclusive of the behaviours discussed in the literature. their documentation of a relationship between pragmatic function and linguistic performance, (which contrasts with the limited data reported in the adult aphasic literature) may reflect prutting et al's (1984) use of societal criteria to evaluate the childrens' language use, using a protocol based upon a sound theoretical frameglen goldblum work (austin, 1962; searle, 1969 cited by prutting et al, 1984) to evaluate a range of pragmatic behaviours. furthermore, mueller's data (1983) revealing a strong relationship between this protocol and measures of societal judgements, highlighted the apparent value of this tool as a means of approaching the assessment of social competence. while prutting and kirchner (1983), have emphasised the necessity to gather and analyse data utilising methods which reflect advances in our theoretical knowledge, to date there appears to be no study in the field of aphasia utilising societal criteria to analyse the individual's pragmatic strengths and deficits across a range of pragmatic behaviours. as of yet we have no clear understanding of how pragmatic abilities and deficits stratify across different types of aphasic clients. furthermore, despite the increasing number of studies examining discrete pragmatic behaviours in aphasic adults, a marked paucity is nevertheless apparent of investigations evaluating pragmatic function in relationship to linguistic performance. the theoretical, clinical and research consequences of using a societal pragmatic protocol (prutting, 1982b) in conjunction with traditional clinical measures are apparently far-reaching. not only would the effects of communicative behaviour in relation to societal values be considered, but attempts would be made to merge clinical and societal goals into our intervention programmes, enhancing the overall communicative competence of the aphasic individual. in view of these issues, this study examined the pragmatic abilities of eleven aphasic adults classified into fluent and non-fluent groups using the western aphasia battery (wab) (kertesz, 1980) taxonomy, and compared them with global ratings of communicative adequacy. furthermore, subjects' performance on a societal pragmatic protocol (prutting, 1982b) was compared with performance on two clinical linguistic measures the wab (kertesz, 1980) and the communicative abilities in daily living (cadl) (holland, 1980). table 1 descriptive data for subjects used in the study subject sex age months post onset educational level premorbid occupation premorbid communicativeness rating on scale from 1-7* apraxia rating on scale from 0-7** dysarthria rating on scale from 0-7** classification of type of aphasia on western aphasia battery behavioural classification severity rating on western alphasia battery 1 μ 70 7 high school retired auto service manager 3 0 0 wernicke's fluent moderate i 2 μ 58 27 college retired navy test pilot 3 2 0 conduction fluent mildmoderate 3 f 51 8 10th grade laundromat assistant, bartender 4 0 0 conduction fluent mild i 4 μ 69 5 8th grade retired security guard 5 0 2 anomic fluent mild 5 f 51 7 high school retired legal secretary 3 0 0 anomic fluent mild 6 f 69 3 ma (art) retired general manager 1 0 0 anomic fluent mild 7 μ 67 9 incompleted ma retired military colonel 4 5 0 broca's non-fluent moderate . · 8 μ 68 300 8th grade retired carpet & tile salesman 2 2 0 broca's non-fluent mild ' 9 μ 65 40 high school retired plumber 2 3 0 broca's non-fluent mild 10 μ 54 16 college retired licensed land surveyor 2 3 0 broca's non-fluent mild 11 f 60 120 high school retired meter maid 2 0 0 broca's ·' non-fluent mild *key: 1 = superior communicativeness 7 = uncommunicative " k e y : 0 = absent 7 = severe the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aphasia : a societal and clinical appraisal of pragmatic and linguistic behaviours 1 3 sonal clinical experience and the literature (e.g. holland, 1980; 1983; penn, 1983) seemed to highlight their importance in aphasia. method subjects eleven english speaking aphasic adults were selected for this study a c c o r d i n g to certain criteria. these included confirmed presence of aphasia due to a completed, single, left hemisphere cerebrovascular accident, neurological stability and the absence of gross conc o m i t a n t problems. all aphasics were required to have absent to moderate symptoms of apraxia and/or dysarthria ranging from 0-5 onaseverity scaleof7(wertz, 1984). portions of the motor speech evaluation (wertz, weiss, kurtzke et al., 1978) and the spontaneous section of the wab (kertesz, 1980) were used to determine this. a representation of both fluent and non-fluent aphasics was required as determined by the classification on the fluency subtest of the wab (kertesz, 1980). since fluency appears to be one of the most important factors differentiating the aphasia types, and is a dimension that has been emphasised in more recent behavioural classifications of aphasia, the fluent : non-fluent dichotomy was selected in this study to facilitate comparison of pragmatic abilities in fluent : non-fluent aphasic subjects. global aphasics were excluded to control for severity of the sample examined (wertz, 1984). table 1 illustrates relevant case history information pertaining to the aphasics. pragmatic protocol (prutting, 1982b) is a societal protocol which reflects the theoretical shift to place language within the context of socialisation (prutting, 1982a). in contrast to traditional measures, the pragmatic protocol (prutting, 1982b) examines the individual's pragmatic strengths and deficits within the conversational discourse, and across a variety of contexts. "the resulting configuration allows the clinician to evaluate pragmatic function in relation to linguistic performance" (prutting, et al., 1984, p.24). the pragmatic protocol (prutting, 1982b) has been developed over a four year period and pilot tested at the university of california, santa barbara speech and hearing centre (prutting, et al., 1984). it comprises a pool of 32 behaviours all known to be developed and used appropriately by children entering school, adolescents and adults. this tool was designed to be used while observing individuals engaged in spontaneous conversation during unstructured communicative interactions (prutting, et al., 1984). the pragmatic protocol^prutting, 1982b) was developed using the following criteria: theoretical framework, representative range of behaviours found in normal development, and inter et al., 1984). •investigator reliability (prutting, theoretical framework: the speech act theory proposed by austin (1962) and searle (1969)|(cited by prutting et al., 1984), constitutes the framework underlying this pragmatic protocol (prutting, 1982b). • " the 32 behaviours were organised within the following speech act categories. the utterance act includes 13 behaviours which form the verbal, non-verbal and paralinguistic aspects of production, characterising the "raw material" of the communicative act (prutting and kirchner, 1983). the prepositional act is comprised of 4 behaviours which define the linguistic dimensions of meaning. the 15 items comprising the illocutionary and perlocutionary acts constitute the reciprocal behaviours that regulate discourse between speakers. the illocutionary act represents the speaker's intention, while the perlocutionary act represents the speaker or listeners' effects. modification to the pragmatic protocol in addition, the investigator added two behaviours namely personal appearance and affect (under the utterance act), since perdie suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 32, 1985 scoring since the pragmatic protocol (prutting, 1982b) is a societal appraisal rather than a clinical appraisal, the judgement made is not whether the behaviour is correct or incorrect in a clinical sense, but rather if the behaviour is penalising or not. the investigator must decide whether society will penalise an individual for exhibiting a particular behaviour. thus, a behaviour may be incorrect but not necessarily judged as inappropriate (prutting, et al, 1984). the following guidelines were used to judge each of the behaviours listed on the pragmatic protocol (prutting, 1982b): appropriate: behaviours are marked appropriate if they facilitate the communicative interaction, or are neutral. inappropriate: behaviours are judged inappropriate if they detract from the communicative exchange and penalise the individual. no opportunity to observe: when the evaluator has insufficient information to judge the behaviour as appropriate or inappropriate (prutting and kirchner, 1983). scale of overall communicative adequacy a 5 point subjective rating scale (derived from holland's protocol for adult aphasia (1982)) was used to obtain an estimate of the aphasics' and their partners' overall communicative adequacy. each rating would be converted into a percentage out of a total of 5 for comparison purposes. testing procedure and schedule preselection tests and standardised procedures were administered over two sessions. aphasic clients were seen individually in various facilities, or in their home environments. a constant task presentation order was maintained. firstly, portions of the motor speech evaluation (wertz, et al., 1978) and the oral portion of the wab (kertesz, 1980) were administered. during the second session the cadl (holland, 1980) was administered, and each aphasic was videotaped while conversing with a familiar comfortable partner of his/her choice with whom they had some shared history. while c o n v e r s a t i o n a l partner and topic were not specified, the affiliative nature of the relationship, and topic familiarity were held constant across all aphasics to facilitate and maximise conversational flow. results pragmatic protocol data while fluent aphasics demonstrated significantly superior pragmatic skills compared with non-fluent aphasics (see table 2), all individuals demonstrated a high level of appropriate pragmatic behaviours which manifested as retained social competence (see figure 1). table 2 between group comparison of percent appropriate pragmatic behaviours on pragmatic protocol in fluent and non-fluent groups fluent group (n = 6) non-fluent group (n=5) x range s.d. 86.27%* 79.41-94.11% 2.07 x range s.d. 75.88%* 61.76-85.29% 2.95 *t-test significance at ρ <0.05 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 τ — i — i — i — i — i 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 n u m b e r of inappropriate pragmatic behaviors figure 1 number of inappropriate pragmatic behaviours on pragmatic protocol for individual subjects within each group table 3 percentage of inappropriate pragmatic behaviours for fluent and non-fluent aphasics in each speech act category group utterance act propositional act elocutionary perlocutionary act fluent 11.1% 33.3% 11.1% non-fluent 10.6% 55% 29.3% glen goldblum aphasics were apparently resourceful in using the context, frequently facilitated via the use of compensatory communicative strategies. these included word finding strategies, appropriate repair and revision strategies, and a range of largely effective idiosyncratic strategies such as non-talking, to avoid communicative failure. the highest proportion of inappropriate pragmatic behaviour displayed by both groups was in the propositional act category. the non-fluent group demonstrated significantly greater difficulty on the perlocutionary/illocutionary act level, reflecting greater problems in managing the dyad (see table 3 and figure 2). examination of profiles of pragmatic deficits across fluent and nonfluent groups revealed interesting similarities and differences. firstly, the nearly comparable presence of the following four inappropriate pragmatic behaviours across fluent and non-fluent groups: specificity/accuracy (100%) in both groups, fluency (50%) and (60%); pause time (50%) and (80%); quantity/conciseness (60%) and (100%) across fluent and non-fluent groups respectively. it is noteworthy that while fluency was rank ordered third as compared to sixth for fluent and non-fluent groups respectively, more nonfluent aphasics (60%) were penalised for this behaviour than fluents (50%). generally, the prevalence of these four deficits across both fluent and non-fluent aphasics would seem to appropriately reflect the inherent problem of aphasia, irrespective of classification. in contrast to these similarities, two inappropriate pragmatic behaviours were very prominent in the non-fluent group, and either relatively rare or absent in the fluent group. these were word order (16%) and (100%); variety of speech acts (0%) and (100%) in the fluent and non-fluent groups respectively. these data clearly seem to differentiate the fluent from the non-fluent aphasics suggesting that rules of dyadic interaction are most difficult for the non-fluent aphasics in this investigation. in view of the presence of similar and different inappropriate pragmatic behaviours within the fluent and non-fluent groups used in this study, it is apparent that the pragmatic protocol (prutting, 1982b) both does and does not differentiate between these aphasic groups. ro ο •·-» ο <υ ω in ro . c a . ® < σ> τ * s aphasic type 1 wernicke's fluent 2 conduction fluent 3 conduction fluent 4 anomic fluent 5 anomic fluent 6 anomic fluent 7 broca's nonfluent 8 broca's nonfluent 9 broca's nonfluent 10 broca's nonfluent 11 broca's nonfluent group utterance act figure 2 inappropriate pragmatic behaviours within each speech act category on pragmatic protocol for individual subjects in fluent and non-fluent groups the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) societal and clinical appraisal of pragmatic and linguistic behaviours 15 comparison of performance on the pragmatic protocol and the scale of overall communicative adequacy performance on the scale of overall communicative adequacy (holland, 1982) revealed the same trend evidenced in the fluent aphasic groups' overall superior performance on the pragmatic protocol (prutting, 1982b) thereby substantiating the pragmatic protocol (prutting, 1982b) as a measure reflecting communicative competences (see table 4). despite the aphasic individuals' use of largely effective compensatory strategies to enhance communicative success, communicative burden on their respective partners was nevertheless high, resulting in their use of a variety of frequently facilitative strategies (e.g. probing, and encouraging the aphasics' use of strategies). these data highlighted the inherently interactive nature of the communicative process. table 4 mean communicative adequacy ratings for fluent and non-fluent groups and their partners on the scale of overall communicative adequacy the relatively small range of mean percentage scores on the pragmatic protocol (prutting, 1982b) for the fluent and non-fluent groups (79.41-94.11% and 61.76-85.29% respectively) as compared with the greater ranges of scores for these groups on the wab (kertesz, 1980) and the cadl (holland, 1980) (see figure 3) was interesting, yielding several implications. this reflected an overall higher group mean of appropriate pragmatic behaviours (social competence scores) across fluent and non-fluent groups irrespective of severity. further, since the pragmatic protocol (prutting, 1982b) is based on societal rather than clinical criteria (used by the wab (kertesz, 1980) and the cadl (holland, 1980), these overall higher scores may also reflect the discrepancies reported in the literature, i.e. related to societal and clinical ratings of aphasic communicative competence. computational correlation coefficients were performed in order to determine and compare the relationship between societal and clinical performance of (a) fluent and non-fluent aphasic individuals fluent group* non-fluent group* x = 3.5 (70%) range = 3-4 s.d. = 0.55 χ = 2.4 (48%) range = 1-3 s.d. = 0.89 partner** partner** x = 4.6 (92%) range = 4-5 s.d. = 0.52 x = 4 (80%) range = 2-5 s.d. = 1.22 key: 'rating of 1 = minimal communicative ability rating of 5 = normal communicative ability ••rating of 1 = nominal skill in communicating with aphasic rating of 5 = competence in communicating with aphasic correlation between pragmatic protocol scores and performance on the western aphasia battery and the communicative abilities in daily living in fluent and non-fluent aphasic individuals the relationship between societal'and clinical profiles was examined and'revealed some interesting trends. while significant differences were obtained between social competence scores of fluent and nonfluent aphasics on the pragmatic protocol (prutting, 1982b) (p<0.05), differences between these two groups on the clinical measures (namely the wab (kertesz, 1980) and the cadl (holland, 1980)) were found to be nonsignificant (p>0.05). (see table 5) 100 90 80 70 60 50 40 30 2 0 10 f nf pragmatic protocol aphasic group and measure f nf wab f nf cadl key: f = fluent group nf = non-fluent group figure 3 percentage group means and ranges of appropriate pragmatic behaviour on the pragmatic protocol, and correct responses on the western aphasia battery and communicative abilities in daily living. table 5 percentage group means, ranges and standard deviations «η the pragmatic protocol, the western aphasia battery and the communicative abilities in daily living *t-test significance at ρ <0.05 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 fluent group non-fluent group measure x range s.d. x range s.d. pragmatic protocol 86.26%* 79.41 %-94.11% 2.07 75.88%* 61.76-85.29% 2.95 wab 74.92% 46.48%-96.26% 18.99 64.56% 42.96%-78.57 % 13.64 cadl 81.25% 52.94%-97.79% 22.95 86.32% 72.79%-94.85% 11.72 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 glen goldblum separately and (b) combined (see table 6). the nonignificant correlation (for both fluent and non-fluent groups) between the pragmatic protocol (prutting, 1982b) and the wab (kertesz, 1980), t d the pragmatic protocol (prutting, 1982b) and the cadl (holland 1980) suggested that these tests are measuring different aspects of an individual's communicative competence, and would not necessarily predict his/her performance on one or other test. table 6 computational correlation coefficient among three measures of fluent and non-fluent aphasics' communicative abilities group pragmatic protocol + wab pragmatic protocol + cadl wab + cadl fluent 0.20 0.34 0.97* non-fluent 0.83 0.13 0.57 non-fluent minus subject 7 0.32 0.28 0.99* fluent + non-fluent combined 0.53 0.05 0.75 fluent + non-fluent combined minus subject 7 0.26 0.15 0.91* *t-test significance at ρ <0.05 in the fluent group, the cadl (holland, 1980) correlated significantly with the wab (kertesz, 1980) (s = 0.97) (p<0.05) reflecting the cadl's (holland, 1980) almost perfect ability to predict a client's communicative abilities in daily living (holland, 1980). while the non-fluent group revealed a non-significant correlation between the wab (kertesz, 1980) and cadl (holland, 1980) (s = 0.57) (p>0.05), removal of subject seven's extremely variable data reduced the disproportion and resulted in comparable correlational trends between the fluent and non-fluent groups (see table 6). it is apparent from these data, that the highest correlation exists between the wab (kertesz, 1980) and the cadl (holland, 1980) while performance on the pragmatic protocol (prutting, 1982b) would not necessarily predict performance on the cadl (holland, 1980) and the wab (kertesz, 1980). similar correlational trends occur when the three measures of communicative abilities are compared for the fluent and non-fluent groups combined, and when the 'outsider' subject seven is removed (see table 6). the overall consistent pattern of generally low non-significant correlation of the pragmatic protocol (prutting, 1982b) with the cadl (holland, 1980), and even more so with the wab (kertesz, 1980) (p>0.05) when fluent and non-fluent groups are examined separately, and combined (excluding subject seven's data) yield some interesting implications — most notably the apparent trustworthiness of the data based on the stability of data. thus it is evident that fluent and non-fluent aphasics perform consistently superiorily on societal as compared to clinical measures. while these data are based upon a small and heterogeneous sample, which may have tended to inflate the obtained correlation coefficients, their implications are provocative. 'discussion a pragmatic perspective of aphasia in accordance with several investigators (e.g., davis and wilcox, 1981, foldi, cicone and gardner, 1983; guilford and o'connor, 1982; holland, 1977, 1982, 1983; penn, 1983; wilcox, 1983) the results of this study revealed a high level of appropriate pragmatic behaviours manifesting as retained social competence across all aphasic subjects. generally despite their linguistic impairments, aphasics are apparently resourceful in using the context effectively in conversational interactions, frequently facilitated via the use of compensatory communicative strategies (including for example, simplification, humour, circumlocutions and interjections to maintain turns). these strategies reflecting the aphasics' attempts to readapt communicatively to their cerebral insult were found by penn (1983) to constitute retained communicative competence. while the pragmatic protocol (prutting, 1982b) was able to differentiate between the fluent and non-fluent group of aphasics on the basis of the almost exclusive presence of two inappropriate pragmatic behaviours in the non-fluent group, namely, word order and variety of speech acts, in view of the following factors, caution needs to be observed in concluding that this tool clearly differentiates between fluent and non-fluent aphasics: the combined presence of four inappropriate pragmatic behaviours across fluent and nonfluent groups (i.e., specificity/accuracy, fluency, pause time, and quantity/conciseness); as well as the scattered presence of pragmatic deficits across individual aphasics, irrespective of classification. these latter idiosyncratic deficits attest to the perplexing feature of variability that is so characteristic of aphasia (holland, 1983). furthermore, the small sample of fluent aphasics manifesting mild linguistic deficits combined with a relative absence of pragmatic deficits may well have inflated the data. further research using larger samples of equivalent types of aphasic subjects is clearly needed to clarify these issues. to the present writer's knowledge, penn's investigation comparing syntactic and pragmatic abilities of aphasics appears to be the one most closely related to the research questions addressed in this study. it is therefore interesting to speculate why penn's profile of communicative appropriateness (pca) (penn, 1983), unlike the pragmatic protocol (prutting, 1982b) did not reveal any clearly differentiating pragmatic deficits across aphasic types. features of the pragmatic protocol (prutting, 1982b) that may account for these differential findings appear to include the following: firstly, it encompasses a broad range of pragmatic behaviours which are examined in a more global or molar rather than a molecular manner. secondly, the pragmatic protocol (prutting, 1982b) employs societal criteria of appropriateness. furthermore the data base used in this study was spontaneous conversation as compared with penn's study (1983), where topic content was controlled. pragmatic protocol profiles and overall communicative adequacy ratings ; the contemporary revival of the awareness of the importance of subjectivity in science (gould, 1981), resulted in holland's ;scale of overall communicative adequacy being used in the present study in an effort to provide a global subjective rating of the aphasic individual's communicative adequacy with their partner. since all communicative partners used in this study were familiar and affiliative, the latter being an acknowledged factor contributing to communicative efficiency (linebaugh, kryzer, oden and myers 1982), it was apparent that overall, the manner and ease with which these partners communicated with the aphasic, and helped share the communicative burden, facilitated greater communicative success with less frustration in the dyad. more effective partners tended to use strategies such as slowing down, stress, cueing, and encouraging the aphasic's use of strategies (e.g. writing, repetition, and a variety of cues such as requesting help from the listener). this use of a range of compensatory strategies by the aphasic was likewise seen to be related to their overall superior performance on the pragmatic protocol (prutting, 1982b). the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a societal and clinical appraisal of pragmatic and linguistic behaviours 17 aphasia the clinical implications of these data are apparently far reaching, yielding support for linebaugh, et al's suggestion (1982) that it would be valuable to help aphasics (within their limitations) and their partners maximise their share of the communicative burden, and increase the effective use of demonstrated compensatory strategies, thereby enhancing the efficiency of the communication in the dyad. social and clinical profiles while the fluent and non-fluent groups demonstrated significantly different pragmatic competencies, these inter group differences were not observed when comparing performance on the clinical profiles (namely the wab (kertesz, 1980) and the cadl (holland, 1980)). possible reasons accounting for the stable pattern of discrepant performance apparent across these pragmatic and linguistic tasks include differential task requirements and criteria used in the evaluation of each aphasic's performance. these data imply firstly that in the sample investigated, overall high pragmatic competence was apparently independent of linguistic severity, and secondly that these tools are therefore measuring different aspects of an individual's communicative competence. it is therefore apparent that severity can no longer be measured by linguistic competence alone, but that measures of pragmatic competence need to be considered in relation to these other aspects of language function. this latter interpretation was supported by the overall insignificant correlation between the pragmatic protocol (prutting, 1982b) and the wab (kertesz, 1980), and the pragmatic protocol (prutting, 1982b) and the cadl (holland, 1980) in fluent and non-fluent groups separately and combined. while level of linguistic severity was insignificant in the present study, closer examination of the data reveals some apparent contribution to communicative competence by severity. for example, examination of the data showing fluent and non-fluent group performance on the four subtests of the wab (kertesz, 1980) indicates overall superior linguistic performance for the fluent group as compared with the non-fluent group. since these aphasics are generally the least impaired (holland, 1980), the data again points toward a role played by linguistic severity in overall communicative competence. future research is needed to clarify these issues. / theoretical implications the findings of this study clearly demonstrated the aphasic individuals' retained pragmatic abilitiesinecessary for social competence. support was thereby rendered for holland's observation that "aphasics probably communicate better than they talk" (1977, p. 173). all aphasics' social competence scores were above the level predicted by their linguistic impairments. these data therefore indicate that despite linguistic limitations, relatively intact pragmatic abilities permit effective communication and management with others within the reality of the client's limitations. despite this, interpretation of pragmatic deficits independent of linguistic structure was problematic. as with the language disordered child (prutting, et al, 1984), it is evident that some 'spill over' exists between these different areas of communicative competence, and that the processes underlying appropriate use of pragmatic skills are not easily explained apart from the aphasic individual's linguistic limitations. however, overall superior pragmatic competence in relation to other linguistic skills may well account for the differential progress made by aphasic clients of apparently equal severity. while critical evaluation of traditional theories and methodologies through the telescope of time is crucial to sharpen our focus and reduce distortion, it is equally important to incorporate, rather than exclude the wisdom of our predecessors. it would thus appear valudie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 32, 1985 able to view language within the context of socialisation (prutting, 1982a) where pragmatics, which is "a pervasive aspect of language which affects the entire communication system" (prutting and kirchner, 1983, p.60) is the core. clinical implications since the measures used in the present study served to highlight different communicative competencies and deficits, clearly one needs to consider the range of pragmatic aspects of language in relation to other aspects of language (foldi et al, 1983; penn, 1983; prutting and kirchner, 1983; prutting et al., 1984; prutting, 1984; wilcox, 1983). more all-encompassing, and dynamic intervention goals could thereby emerge, aimed to enhance structural and functional aspects of communication in relationship to one another. the value of a societal measure such as the pragmatic protocol (prutting, 1982b) as a means of approaching the assessment of social competence and a context for interpreting a variety of communicative measures likewise yields several clinical implications. since competence lies in the relational system, the dyad is necessarily the unit of analysis, whose behaviours are judged in terms of societal criteria of appropriateness rather than clinical criteria of correctness. since these criteria take cognisance of the societal values surrounding the client, facilitating a 'real world prognosis' (marshall, 1982 cited by penn, 1983), our criteria for dismissal from remediation will need to shift so that dismissal occurs when the client can manage his/her relationships in a personally appropriate and effective manner within the limitations imposed by his/her stroke. furthermore, intervention goals can emerge directly from the areas assessed by the pragmatic protocol (prutting, 1982b) in which targets are always embedded within this framework (prutting, 1984). such a framework presupposes interactional, contextually based exchanges related to ongoing communicative situations at the level at which the client can meaningfully participate. since the use of this tool serves to highlight the residual compensatory strengths of each individual, rather than simply faulting them for their inaccuracies and linguistic limitations, emerging intervention goals would be based inherently upon a strength, rather than a deficit model. these data and emerging issues constitute a changing paradigm. while the results of the present study have provided some prelimi nary answers, they have raised many more questions. the 1980's will undoubtedly continue to add further in-depth understanding of aphasic pragmatic abilities in relation to other aspects of their communicative competence. in attempting to merge these changing views of theory with practice, aphasiologists need to heed prutting and kirchners' apt comment that "new advances always require a respect for time in order to fit them into our existing schemas (1983, p.48). acknowledgements the writer expresses her sincere gratitude to carol prutting, department of speech and hearing sciences, university of california, santa barbara, for her invaluable guidance as the supervisor of the masters' dissertation on which this paper is based. references davis, g., & wilcox, m.j. incorporating parameters of natural conversation in aphasia treatment. in r. chapey (ed.), language intervention strategies in adult aphasia. baltimore, williams & wilkins, 1981. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 . . „ γ α r h n p r η pragmatic aspects of comfoldi, n.s., cicone μ · > & « . f a g s . l s e g a l o w i t z (ed.), munication in bram-damaged pat ents. ^ y o r ^ l a n g u a g e junctions and brain organisa g o u t s . treasure of ma. new york, w.w. norton and _ £ ° τ 7 μ 1 9 & o'connor, j . k . pragmatic functions in aphasia j. comma, disord., 15, 337-346, 1982. holland, a.l. some practical considerations in aphasia rehabilitation.in m. sullivan and m.s. kommers (eds.), rationale for adult aphasia therapy. nebraska, university of nebraska medical center, 1977. holland, a.l. communicative abilities in daily living. baltimore, university park press, 1980. holland, a.l. observing functional communication of aphasic adults. j. speech hear. disord., 47, 50-56, 1982. holland, a.l. spontaneous recovery from stroke: an investigation of its earliest phases. paper presented at the academy of aphasia, minneapolis, minnesota, 1983. kazdin, a.e. assessing the clinical or applied importance of behaviour change through social validation. behaviour modification, 1, 427-452, 1977. kertesz, a. western aphasia battery. london, ontario canada, university of western ontario, 1980. linebaugh, c.w., kryzer, k.m., oden, s.e. & myers, p.s. reapportionment of communicative burden in aphasia: a study of narrative interactions. in r.h. brookshire (ed.), clinical claire penn aphasiology conference proceedings. minneapolis, mn, brk publishers, 1982. mueller, s.l. an investigation in social competence using clinical and societal profiles. ma thesis, university of california, santa barbara, 1983. penn, m.c. syntactic and pragmatic aspects of aphasic language. doctoral dissertation, university of the witwatersrand, johannesburg, south africa, 1983. prutting, c.a. pragmatics as social competence. j. speech hear. disord., al, 123-134, 1982a. prutting, c.a. observational protocol for pragmatic behaviours. developed for the university of california, santa barbara speech and hearing clinic, clinic manual, 1982b. prutting, c.a., & kirchner, d. applied pragmatics. in t. gallagher and c. prutting (eds.), pragmatic assessment and intervention issues in language. san diego, college-hill press, 1983. prutting, c.a., kirchner, d., hassan, p., & buen, p. a societal appraisal of pragmatic behaviours. unpublished manuscript, university of california, santa barbara, 1984. wertz, r.t., weiss, d., kurtzke, j.f., et al., a comparison of clinic, home and deferred treatment of aphasia. veterans administration cooperative study protocol, v.a. hospital, martinez, california, 1978. wertz, r.t. personal communication, v.a. hospital, martinez, california, 1984. wilcox, m.j. aphasia: pragmatic considerations. topics in language disorders, 3, 35-48, 1983. the profile of communicative appropriateness: a clinical tool for the assessment of pragmatics claire penn ph.d (witwatersrand) department of speech pathology & audiology, , university of the witwatersrand, johannesburg abstract i the profile of communicative appropriateness — a newly developed profile for the characterisation of pragmatics is described. the theoretical background to this profile is covered as well as its main components. its application to a group of eighteen aphasic patients is outlined, results suggesting that patient groupings on the profile could be predicted in terms of severity but not in terms of type of aphasia. explanations for this finding are discussed and the potential utility of this profile is suggested. 1 opsomming die profile of communicative appropriateness — 'n nuutontwikkelde profiel vir die karakterisering van pragmatiek word beskryf. die teoretiese rasionaal hieragter en die hoofkomponente van die profiel word behandel. die toepassing hiervan op 'n groep van agtien afatiese pasiente word omskryf resultate dui daarop dat die pasientgroeperings aanduidend kan wees van die erns van afasie maar nie van die tipe afasie nie. verduidelikings hiervoor en die potensiele bruikbaarheid van die profiel word bespreek. the clinical profile is a method of characterising language which has become increasingly popular in recent years. essentially " . . . a linguistic profile is a principled description of . . . those features of a person's . . . use of language which will enable him to be identified for a specific purpose." (crystal, 1982). the format of such a profile is the presentation of a wide range of variables simultaneously so that the clinician is able to see at a glance the communicative assets and deficits of a patient. the main purpose of such a profile according to crystal (1982) is to provide not only a comprehensive description of a patient's data but also an adequate basis for remedial intervention. it is not a standardized measure; nor is it an exhaustive linguistic description. the profile is, however, a compromise to the clinician faced with the realisation that language disability requires comprehensive and individual description. the amount of information contained on a profile is determined by the behaviours being measured © sasha 1985 the south african journal of communication disorders, vol. 32, 1985 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'ν evaluasie van gedragsterapie by die behandeling van funksioneel disfonie by kinders w. g. nel hoofterapeut by die transvaalse onderwysdepartement, pretoria in hierdie studie is daar gepoog om 'n evaluasie te doen van die gebruik van 'n gedragsterapeutiese benadering by die behandeling van funksionele disfonie by kinders; 'n nuwe benaderingswyse van die probleem is voorgestel ten einde meer permanente resultate te verseker. neurotiese gedrag word deur die gedragsterapeute as aangeleerde gedrag beskou en derhalwe interesseer enige terapie wat gebaseer is op die beginsels van die leerproses, hulle veral.7 die term ,gedragsterapie' is vir die eerste keer deur prof. h. j. eysenck gebruik in 1958 tydens een van sy lesings. die leerbeginsels is alreeds so vroeg as 1927 deur pavlov bestudeer en veral die begrip klassieke kondisionering is deur horn omskryf. tipes kondisionering. vandag is daar twee belangrike tipes kondisionering naamlik: (a) klassieke kondisionering (kortliks, wanneer 'n respons van die proefpersoon onvermydelik is). (b) operant kondisionering (wanneer die eksperimenteerder wag totdat die respons op natuurlike wyse ontstaan). laasgenoemde proses het sy ontstaan van die eksperimentele bevindings van bechterev en thorndike. hulle belangrikste opvolger was b. f. skinner wat dan 00k die term ,operant kondisionering' vir die eerste keer in 1938 gebruik het. kenmerkend van hierdie prosedure, is dat die gedrag van die proefpersoon op sigself instrumenteel is vir die aanbieding of weglating van versterking (beloning) of straf. ν daar is verskeie operante kondisioneringsprosedures wat gebruik kan word, byvoorbeeld gedrag wat 'n aangename verloop vir die individu tot gevolg het sal meer geredelik voorkom as gedrag wat 'n onaangename gevolg vir die individu inhou. indien die terapeut 'n spesifieke responspatroon van die individu wil versterk, behoort opleiding d.m.v. beloning (d.i. wanneer die produksie van 'n spesifieke respons lei tot 'n doelwit waartoe die individu gemotiveer is) die doeltreffendste te wees. opleiding d.m.v. beloning is veral effektief wanneer die gedrag wat die terapeut wil versterk, glad nie aanwesig is nie en ,daar dus weinig is om te beloon. in sulke gevalle begin die terapeut om gedrag wat min of meer lyk op die gewenste gedrag te beloon. wanneer sodanige gedragspatroon voldoende versterk is, kan hoer verwagtinge daargestel word voordat 'n respons beloon word, sodat slegs die gewenste gedrag uiteindelik beloon word, 'n soortgelyke aaneenlopende prosedure word genoem ,shaping' of ,successive approximation'. uit die werk van verskeie navorsers word dit duidelik dat strafopleiding journal of the south african logopedic society, vol. is, no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η evaluasie van gedragsterapie—funksionele disfonie by kinders 15 'n uiters ontoereikende prosedure is om 'n gedragspatroon deurgaans uit te skakel. 'n meer efeektiewe prosedure vir die uitskakeling van 'n sekere gedragspatroon blyk die volgende te wees: nl. om die weglating van ongewenste gedrag aan te moedig deur 'n tydelike uitsluiting van beloning in plaas van spesifieke straf. lg. prosedure is veral van waarde wanneer die mate waarin die ongewenste gedrag voorkom, minder opvallend is. die ongewenste gedrag lei dan tot 'n vermindering van enige positiewe versterking. die pasient kan 00k beloon word in 'n situasie vir die weglating van tot nog toe ongewenste gedrag (weglatingsopleiding), veral wanneer sodanige ongewenste gedrag dikwels voorkom. verskeie skedules vir versterking kan gebruik word. wanneer 'n terapeut 'n sekere gedragspatroon, telkens wanneer dit na vore kom, versterk, toon dit spoedig 'n toename in frekwensie en die terapie bereik sy doelwit. operant kondisionering bied groot geleenthede vir individuele verskille en kan sodoende aangepas word by die pasient sowel as by die terapeut (wat verskillende prosedures kan gebruik). wat die tipe van beloning aanbetref wat die terapeut wil gebruik, is daar verskeie moontlikhede. dit is nodig dat die terapeut die kardinale belang van gekontroleerde versterking aan die pasient besef en derhalwe die verskillende faktore, wat 'n rol mag speel by beloning, voor die aanvang van 'n terapieprogram bepaal. die ondersoek na enige sodanige faktore moet so noukeurig moontlik beplan word, omdat daar nie slegs vasgestel moet word of die gekontroleerde beloning in sy doel slaag nie, maar 00k of daar nie enige ander faktore ongemerk tydens terapie in werking was en verkeerdelik versterk is nie, bv. 'n glimlag van die terapeut kan net soveel beloningswaarde he as 'n ander vorm van beloning. wanneer die terapeut sou glimlag wanneer sy dit nie spesifiek as 'n beloning op 'n sekere'moment wil gebruik nie, sou die operante kondisioneringsprosedure nie konsekwent deurgevoer word nie. hieruit blyk dit duidelik dat die rol van die terapeut tydens 'n operante kondisioneringsprosedure nie maklik is nie. dit is verder noodsaaklik dat die terapiesessies noukeurig geadministreer word: dit is van die uiterste belang by die evaluasie van die terapie en kan dien as 'n waardevolle hulpmiddel vir die terapeut om haar eie doelstellings te hersien en om haar eie gedrag, waar moontlik, reg te stel. operante kondisioneringsterapie. wanneer operante kondisioneringsterapie begin word, is dit veral van belang dat die onmiddellike omgewing van die pasient deeglik op hoogte is van die terapieprogram en 'n goeie insig daarin het. die nodige instruksies moet dus vooraf gegee word aan die ouers, onderwysers, verpleegsters ens. of wie 00k al tydens die terapie met die kind gemoeid is, sodat die pasient nie buite die terapiesessies met heeltemal 'n verskillende beloningsisteem gekonfronteer word nie.1 by die behandeling van die disfoniese kind moet die ouers veral saamwerk; van die uiterste belang is om toe te sien dat die ouers nie die gebruik van die verkeerde stemgewoonte versterk deur aandag daaraan te gee juis wanneer dit voorkom nie. straf het skynbaar geen motiverende waarde vir die kind om die goeie stemtoon te gebruik nie (soos wat tydskrif van die suid-afrikaanse logopediese vereniging, vol. is, nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) w. g. nel j6 negatiewe oefening het vir die vaslegging van 'n sekere klank in spontane spraak nie): dit plaas alleen groter druk op die kind. die ouer kan die terapiesessies bywoon ten einde te leer om die goeie stemkwaliteit onmiddellik te herken (sodat dit tuis ook beloon kan word). die moeder kan van die uiterste hulp wees om situasies waar die stem tuis minder goed was, aan die terapeut te rapporteer. vol gens rachman6 kan die toepassing van die operante kondisioneringstegnieke, sowel as meer bekende metodes'van gedragsterapie, verder van onskatbare waarde wees, veral in die gebied van die kindersielkunde. die algemene oorsaak van kinderdisfoniee, is stembandknobbeltjies, wat te wyte kan wees aan oorsake soos 'n verkeerde spreekstemtoonhoogte, ooreising van die stem deur oormatige geskreeu of 'n te harde insit van die aanvangsklanke ens.8 volgens greene is die heropleiding van kinderstemme moeilik, omdat permanente resultate a.g.v. hulle ouderdomme, nie rnaklik verkry word deur stemoefeninge, of deur hulle te belet om hulle stemme te ooreis nie. spraakterapie behoort dus eers op elfjange leeftyd in aanvang te neem indien die disfonie dan nog bestaan. sy is van mening dat die herstel van die toestand op hierdie ouderdom ook spontaan kan geskied. in alle gevalle van stemmisbruik het die toestand van die pasient se vokale patroon heelwat te doen met sy aangebore konstitusie, sy algemene gesondheid, sy vatbaarheid vir verkoues en sy reaksie op spanning. babas wat hees word na baie huil, mag later in hulle lewens as volwassenes disfoniee ontwikkel.4 damste noem ook die probleem van hoe 'n permanente verandering in 'n foutiewe stemgewoonte verkry kan word.2 heelwat van die kinders met stemprobleme wat onlangs by die afdeling spraakpatologie van die universiteitskliniek te utrecht ondersoek is, toon duidelike tekens van gespannenheid en kom senuweeagtig van geaardheid voor. indien hierdie senuweeagtigheid uitgeskakel kon word (afgeleer kon word volgens die gedragsterapeute deur die proses van wederkerige remming van angs) sou die verkryging van meer permanente resultate makliker wees. die belangrikste aanduiding vir die noodsaaklikheid van verdere navorsing in die moontlike toepassing van tegnieke soos hierbo beskryf in die gebied van kinderdisfoniee, is 'n verslag deur gray, england en mahoney3 oor die suksesvolle behandeling van 'n volwassene met stembandknobbeltjies, deur middel van gedragsterapie volgens die metode van wederkerige remming soos beskryf deur wolpe.9 die tegniek van ,sistematiese ongevoeligmaak' wat gebruik'word by die proses van wederkerige remming, blyk uiters bruikbaar te wees vir die stemterapeut ten einde meer permanente resultate te verkry by die behandeling van funksionele disfoniee. dit kan veral van hulp wees by die oordrag van die nuwe stem na situasies wat nog vir die pasient angs mag inhou. volgens wolpe is dit nie noojdsaaklik om die gevreesde voorwerp of situasie werklik aan te bied nie, aangesien daar slegs van 'n angshierargie gebruik gemaak kan word. sodoende.kan hierdie metode van werk veral tydbesparend wees. journal of the'south'african logopedic society, vol. 15, no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η evaluasie van gedragsterapie—funksionele disfonie by kinders opsomming van bevindings 17 stemoefeninge < ten einde goeie stemtoon te verkry. beginsels soos o.k. kan gebruik word om kind te motiveer. effektiewe beloning dan noodsaaklik. w.r. vir oordrag van „nuwe" stem na situasies waarin kind nog nie bereid is om sy „goeie" te gebruik nie. heesheid < senuwee-agtigheidgeen direkte gedragsterapie vir vermindering van angs nie; geen kind het 'n fobie gehad nie; sou van waarde wees vir die psigotiese kind. o.k. = operant kondisionering. w.r. = wederkerige remming. >verander omgewing behandel ouers volgens gedragsterapeutiese tegnieke alleen as kind enige spesifieke gedragsprobleme openbaar het; geen een van die ouers het die kind vir sodanige probleem gebring operante kondisioneringsprosedures—met die gebruik van effektiewe versterking—kan dus van nut wees ten einde meer permanente resultate te verkry en om die kind sover te kry om die goeie stem so gou moontlik te gebruik (stemoefeninge kan van nut wees om 'n beter stemtoon o.l.v. die stemterapeut te verkry; die kind moet leer om die goeie en die minder goeie stemtoon te onderskei). daar kon slegs 'n begin gemaak word met die behandeling van kinders en derhalwe is die deel van die ondersoek as 'n voorstudie beskou. alhoewel hierdie werkmetode veel van die terapeut verg en oenskynlik tydrowend is, is dit 'n intensiewer werkswyse, gegrond op 'n meer wetenskaplike beskouing van die verskillende beloningsisteme as sodanig. afgesien van die waarde van effektiewe beloning waarop dit wys, dui dit 00k op die noodsaaklikheid van verdere gekontroleerde eksperimentele toepassing van gedragsterapie op die gebied van funksionele stemstoornisse. hierdie studie is gedoen onder leiding van dr. p. h. damste, hoof van die afdeling foniatrie, aan die universiteitskliniek te utrecht. opsomming terapie gebaseer op beginsels van die leerteorie word bespreek, en die behavioristiese benadering tot terapie vir kinders met knobbels op die stemplooie word ge-evalueer. summary therapy based on learning principles is discussed, and a behaviourist approach to the difficulties of therapy for children with nodular laryngitis is evaluated. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 75, nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 w: g. net bibliografie i bakker, b. (1967): operante konditionering—ongepubliseerde lesing in kinderpsigiatrie gehou te utrecht op 9 november 1967 by die• ,snchting academisch ziekenhuis utrecht.' . „ 2. damste, p. h. (1967): stembandknobbeltjies. logopedie en foniatrie, 39, 95-9». j. b. wolters, groningen. , t 7 3. gray, β. b., england, g., and mahoney, j. l. (1965): treatment of vocal nodules by reciprocal inhibition. journal of behaviour research and therapy, 3, 187-193, london. , , _ . · , 4. greene, m. c. l. (1957): the voice and its disorders. pitman medical publishing co., ltd. τ τ 5. mednick, s. a. (1964): psychologie van het leren. prentice hall, inc., englewood cliffs, n.j. 6. rachman, s. (1962): child psychology and learning theory. journal ot child psychology and psychiatry, 2, 149-163. 7. santer-weststrate, h. c. (1964): gedragsterapie. van gorcum and co. 8. wilson, d. k. (1961): children with vocal nodules. journal of speech and hearing disorders, 26, 19-26. . 9. wolpe, j. (1958): psychotherapy by reciprocal inhibition. stanford university press, stanford, california, and witwatersrand university press, johannesburg. journal of the south african logopedic society, vol. 15, no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'ν kommunikatiefgefundeerde ondersoek να bepaalde waarnemingsverskynsels by disfemie r e n e h u g o m.a. (log.) (pretoria) spraak-, stem en gehoorkliniek, universiteit van pretoria ops om μ ing hierdie studieprojek stel h o m t e n d o e l die bestudering van bepaalde o u d i t i e w e waarnemingsvermoens b y disfemie, s o o s gesien vanuit 'n k o m m u m k a t i e w e o o g p u n t . eksperiment 1: stel h o m ten doel die bepaling van suiwertoonsensitiwiteit en spraakdiskriminasievermoens van 'n groep van 10 hakkelaars, en die vergelyking van hierdie gegewens met 'n kontrole groep nie-hakkelaars. die resultaat dui o p 'n betekenisvolle verskil,tussen die suiwertoondrempelwaardes van die regterore van die hakkelaars en nie-hakkelaars en kan m o o n t l i k in verband gebring word met s o w e l terugvoeringsafwykings as gehoordominansieteoriee. eksperiment 2: b e o o g die bepaling van waarnemingsdrempels van neutrale en negatiewe w o o r d e (woorde waarop gewoonlik gehakkel word) b y 'n groep hakkelaars, en die vergelyking hiervan met 'n aantal nie-hakkelaars. die resultate t o o n 'n betekenisvolle verskil tussen hierdie 2 lyste vir die hakkelaars, maar nie vir die vlotsprekers nie. ter verklaring kan aangevoer word dat die hakkelaars, o p grond van e m o s i o n e l e kwaliteite verbonde aan die negatiewe w o o r d e , hierdie w o o r d e makliker waarneem as die vlotspreker, waarskynlik deur gebruik te maak van perseptuele verdedigingsmeganismes soos perseptuele ingestemdheid. eksperiment 3 : is gerig op die bepaling van die bestaan van onwaarneembaarheid van betekenisvolle stimuli b y die hakkelaar t y d e n s die h a k k e l p e n o d e . geen sodanige verskynsel kan betekenisvol a a n g e t o o n word nie, h o e w e l daar in die bespreking daarop g e w y s is dat 'n verandering in die eksperimentele prosedures nogtans so 'n f e n o m e e n kan u i t w y s . in sy geheel gesien, is daar dus in hierdie studieprojek bepaalde waarnemingsabnormaliteite b y die disfemie a a n g e t o o n wat nie b y die vlotspreker gevind kan w o r d nie. hierdie abnormaliteite dui essensieel op 'n wyer siemng van disfemie nl., as 'n komplekse, k o m m u n i k a t i e w e probleem. summary in this s t u d y certain aspects of auditory perception in cases of dysphemia are studied, emphasis being o n c o m m u n i c a t i o n aspects. experiment 1: has as its object the determination of pure-tone sensitivity and speech discrimination abilities of a group of 1 0 stutterers, and t h e comparison of these data with a control group of non-stutterers. the results point to a sienificant difference b e t w e e n the pure-tone threshold values of the right ears of the stutterers and the non-stutterers, and may b e linked with feedback deficiences and with theories on auditory d o m i n a n c e . tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 19. desember 197 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 0 rene hugo experiment 2: sets o u t to determine perceptual thresholds of neutral and negative words (words which are usually stuttered on) in the case of a group of stutterers, and to compare these threshold values with t h o s e of non-stutterers. the results s h o w a significant difference b e t w e e n these t w o lists for the stutterers, b u t not for fluent speakers. a suggested explanation is that the stutterers perceive negative words more readily than fluent speakers d o , because of the e m o t i o n a l qualities c o n n e c t e d with these words, probably b y putting up perceptual defence mechanisms such as the perceptual set. experiment 3 : aims, at the determination of the e x i s t e n c e of imperceptivity with regard t o meaningful stimuli in the case of the stutterer during the stuttering b l o c k . n o such p h e n o m e n o n can b e proven, although in the discussion it is indicated that a variation of the experimental procedure m a y point to such a p h e n o m e n o n . in general this s t u d y thus presents certain perceptual abnormalities evidenced in dysphemia cases, which are n o t found in fluent speakers. these abnormalities clearly p o i n t t o the need for a broader c o n c e p t of dysphemia. it must b e seen as a c o m p l e x problem. edward sapir9 het te kenne gegee: „human beings do not live in the objective world alone, nor alone in the world of social activity as ordinarily understood, but are very much at the mercy of the particular language which has become the medium of expression for their society". hierdie afhanklikheid word groter en verkry 'n definitiewe negatiewe kleur, sodra die taalvermoe bepaalde nie-normale verskynsels vertoon. die verskynsel van disfemie kan waarskynlik as een van die grootste en mees omvattende abnormaliteite beskou word, omdat dit die kommunikasievermoe as geheel betrek.3 daarom is dit aanvaarbaar om te verwag dat die motoriese herhalingsen verlengingsabnormaliteite ook 'n sensoriese (perseptuele?) komponent moet he. selfs al word disfemie in die lig van 'n leerproses, eerder as 'n fisiese of neurale afwyking gesien, moet dit nogtans 'n sensoriese komponent besit as in ag geneem word dat mowrer verklaar het: „ all learning takes place on the sensory side".3 daar bestaan dan op die huidige stadium heelwat teoriee en bespiegelings wat hierdie gebied betrek. in 'n poging om al die uiteenlopende benaderings tot persepsieafwykings en disfemie as 'n eenheid te sien, kan die benadering van freund as verteenwoordigend dien: / persepsie-afwykings by die hakkelaar as spreker. in die verhouding tussen innerlike spraak en uiterlike hakkel, kan gevind word dat die bespeuring van 'n ,moeilike' woord op 'n baie vroee stadium van sinsamestelling plaasvind. op 'n stadium wat die woord self onhoorbaar en onsigbaar is vir die innerlike oor, d.w.s., op 'n preverbale, preperseptuele stadium, kan die moontlike aanwesigheid van die woord alreeds deur leidrade van ongemak ervaar word. op hierdie wyse kan modifikasie, in 'n poging tot vermyding, alreeds op 'n onbewuste vlak plaasvind. dus: „even in this 'deep' perceptual layer of inner speech, the complex of disturbances exerts its influence". journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ' kommunikatiefgefundeerde ondersoek 41 persepsie-afwykings by die hakkelaar as waarnemer. die oomblik van hakkel gaan gepaard met 'n groot aantal perseptuele distorsies, nl.: i. verkleining van die bewussynsveld; ii. werklike perseptuele distorsies. ondersoekers soos johnson en william het hierdie abnormaliteite as die natuurlike gevolg van die hakkelaar se foutiewe self-evaluasie verklaar. freund beweer egter dat die foutiewe evaluasies sekonder, en nie aanleidend is, tot die perseptuele distorsies nie. gedurende die hoogtepuiit van hakkel is daar 'n gerigte affektief-outosuggestiewe aandagkonsentrering op die struikelblok. hierdie konsentrasie is van so 'n intensiewe aard dat die gepaardgaande nodige perseptuele aksies verlore gaan. freund noem hierdie verskynsel „kinesthetic illusion" en verklaar dit as die gevolg van 'n hoogs emosionele toestand waartydens 'n persoon sy hulpeloosheid ervaar in die aanwesigheid van onoorkomelike probleme. hierdie terme is soortgelyk aan die deur hans w. meur gebruik en deur froeschels oorgeneem nl., „catathymia" wat die invloed van sterk affektief-belaaide kompleksiteite op bewustheid en persepsie impliseer.4 metode dit word gehipoteseer dat die hakkelaar bepaalde ouditiewe waarnemingsabnormaliteite vertoon wat: a) voorkom tydens die hakkelperiode; b) die waarnemingsdrempel sal beinvloed. hierdie verskynsels sal waarskynlik nie aanwesig wees by die nie-hakkelaar nie. daar sal gepoog word om aan te toon dat hierdie waarnemingsabnormaliteite, indien dit wel voorkom, nie so afwykend is as wat aanvanklik gemeen is nie. dit hou eerder verband met „normale" verdedigingsmeganisme — in soverre as wat verdedigingsmeganisme as normaal beskryf kan word — teen dreigende stimuli. probleemstelling dit is van 'n drievoudige aard nl.: 1. is die suiwertoonkurwe en spraakdiskriminasievermoens van die hakkelaar vergelykbaar met die van die nie-hakkelaar? indien nie, op waiter gebiede sal hierdie verskille voorkom? 2. is daar 'n verskil tussen die waarnemingsdrempel van neutrale en emosioneeldreigende woorde by die hakkelaar? kom hierdie verskil, indien dieselfde woorde gebruik word, ook by die nie-hakkelaar voor? 3. toon die hakkelaar bepaalde onwaarneembaarheidskenmerke tydens die hakkelperiode? indien wel, kan dit in.verband gebring word met die aard van die stimuli? tydskrif van die suid-afrikaanse vereniging vir spraak en cehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 2 rene hugo apparaat die maico m.a. 24 dubbelkanaal-oudiometer (standaard i.s.o.) gelee in 'n klankdigte tweekamer-kompleks kamer, is gebruik. proefpersone 1. eksperimentele groep bestaan uit 'n groep van 10 hakkelaars tussen die ouderdomme 16-31 jaar. die groep is verkry uit verwysings van die spraak-, stemen gehoorkliniek, universiteit van pretoria. omdat die eksperimente 'n redelike mate van insig in die probleem vereis, is slegs die hakkelaars geselekteer wat 'n deelname in terapie het en wat deur hul terapeut as volwasse eedefinieer is. 2. kontrolegroep — bestaan uit 10 nie-hakkelaars, ook tussen die ouderdom van 16-31 jaar. hierdie groep is geselekteer met die doel om te verseker dat hulle homogeen in alle opsigte is, in vergelyking met die eksperimentele groep, behalwe vir die element van vlotheidsversteuring. om dit te verseker, is gebruik gemaak van die metode van afgepaarde vergelykings waar die volgende faktore konstant gehou is: ouderdom, geslag, intellektuele peil, sosio-ekonomiese klas en swangerskappe. eksperimente drie verskillende eksperimente word uitgevoer, en in hierdie verslag sal die eksperimente apart behandel word. eksperiment i doel: die bepaling van suiwertoonsensitiwiteit en spraakdiskriminasievermoens. materiaal: i. vir die suiwertoontoets is gebruik: 'n suiwertoonoudiogram wat frekwensies 125, 250, 1 000, 2 000,4 000, 8 000 hz asook die intensiteitsvlak 0-110 db-gehoorpeil (iso. 1964) aandui. hierdie oudiogram is vir elke oor afsonderlik gemeet en laat toe vir optekening van luggeleidings-, beengeleidingsen smalbandmaskeringswaarde. ii. vir die spraakdiskriminasietelling: 6 fonetiesgebalanseerde woordelyste van 25 woorde elk opgestel deur die wnnr (1962) is gebruik. daar is gepoog om hoofsaaklik een waarde te bepaal nl., 100% korr.ekte spraakdiskriminasie. 1 / metode: i. soos gebruik vir die suiwertoontoets. die aanbieding is by 1 000 hz begin, gevolg deur die lae frekwensies, weer 1 000hz om die eerste bepaling te bevestig en laastens die hoe frekwensies. die intensiteitsvermeerdering het in diskrete stappe van 5 db plaasgevind. die drempel (def: die intensiteitsvlak waar die proefpersoon 50% reageer op die stimulusaanbiedinge) is bepaal deur 'n kombinasie van die stygende en dalende metode. journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ',n kommunikatiefgefundeerde ondersoek 4 3 ii. soos gebruik vir die spraakdiskriminasietelling. die aanbieding is begin by 'n intensiteitswaarde ongeveer 20-30 db bokant die gemiddelde suiwertoonkurwe. verdere verhogings/verlaging het berus op die reaksie van die proefpersoon totdat die persentasiewaardes 50-100% gedek is. resultaat (ij die resultate word in tabel i uitgele. proef persone • geslag regteroor linheroor ε 1 μ 6 , 6 7 5 , 0 0 §· ε 2 μ 1 1 , 6 7 1 1 , 6 7 fe e 3 v 8 , 3 3 1 0 , 0 0 n> ε 4 μ 1 3 , 3 3 7 3 , 3 3 i ε 5 μ 2 3 , 3 3 1 0 , 0 0 ε e 6 "ε ε 7 μ 0 , 0 0 1,67 ε e 6 "ε ε 7 μ 6 , 6 7 5 , 0 0 i · ε 8 v 1 1 , 6 7 1 0 , 0 0 3 ε 9 v 6 , 6 7 5 , 0 0 ε 1 0 μ 1 3 , 3 3 1 5 , 0 0 κ 1 1 0 , 0 0 11,67 κ 2 6,67 8,33 •α κ 3 6,67 5,00 ο κ 4 3,33 5,00 » κ 5 8,33 5,00 ε κ β 5,00 11,67 i κ 7 3,33 1,67 ϋ< κ 8 3,33 1,67 κ 9 5,00 5,00 κ10 8,33 5,00 tab el i gemiddelde suiwertoon luggeleidingsdrempel in ab van frekwensies 512, 1024, 2048 hz. ter verklaring van hierdie gegewens is dan gepoog om aandag aan die volgende resultaatverwerkings te gee: 1. 'n vergelyking tussen die gemiddelde suiwertoondrempelwaardes van die linkeren regterore van die eksperimentele groep, waartydens die nulhipotese, dat daar geen verskil tussen hierdie ore bestaan nie, gestel is. geen betekenisvolle verskil kan, wat betref die suiwertoondrempelwaardes, tussen die linkeren regterore van die eksperimentele groep aangetoon word deur toepassing van die tekentoets nie. tydskrif van die suid-afrikaanse vereniging vir spraak en cehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 4 rene hugo 2. 'η vergelyking tussen die gemiddelde suiwertoondrempelwaardes van die regterore van die eksperimentele en kontrolegroepe. met behulp van die mann-whitney-wilcoxon-toets kan aangetoon word dat die suiwertoondrempelwaardes van die regterore van die eksperimentele groep verskil, op die 2%-peil van betekenis, van die van die kontrolegroep. 3. 'n vergelyking tussen die gemiddelde suiwertoondrempelwaardes van die linkerore van die eksperimeritele en kontrolegroepe. in hierdie geval egter kan geen beduidende verskil d.m.v. die mann-whitney-wilcoxon-toets aangetoon word nie. 4. 'n vergelyking tussen die gemiddelde suiwertoondrempelwaardes van mans en vrouens van die eksperimentele groep. die gebruik van statistiese verwerkings is in hierdie geval nie wenslik nie, hoofsaaklik as gevolg van die te klein aantal proefpersone wat tot ongemagtigde gevolgtrekkings kan lei. wat hierdie aspek betref kan daar dus volstaan word met verwysing na die feit dat daar korresponderende drempelwaardes vir die vroulike lede van die eksperimentele groep, die mans van die eksperimentele groep en ook die .kontrolerende groep, bestaan. a f l e i d i n g s (i) samevattend wil dit dus voorkom asof daar wel 'n verskil tussen die suiwertoonsensitiwiteit van die hakkelaar en die nie-hakkelaar bestaan. uit hierdie eksperiment word die verskil slegs vir die regterore aangetoon 'n feit wat moontlik betekenisvol kan saamhang met ander toepaslike faktore soos liggaamsvoorkeur en hemisfeerdominansie. voordat dit egter volkome aanvaar kan word, moet in aanmerking geneem word dat die eerste verwerking nl., 'n vergelyking tussen die regteren linkerore van die eksperimentele groep, geen betekenisvolle verskille aangetoon het nie. r e s u l t a a t (ii) met betrekking tot die tweede deel van eksperiment 1 nl., die bepaling van spraakdiskriminasievermoens, is veral op twee waardes, 100% en 50% gelet. dit is aangevul met 'n verskil tussen die twee persentasiewaardes in 'n poging om die verloop van die spraakkurwe numeries voor te stel. die resultate word in tabel ii uitgele. a f l e i d i n g s (ii) ; y hoewel statistiese verwerkings in hierdie geval moeilik gedoen kon word a:g.v. die voorkoms van 'n groot aantal gelyke waardes, wil dit tog oor die algemeen voorkom asof daar nie 'n betekenisvolle verskil tussen die verskillende gegewens aangetoon kan word nie. i eksperiment ii 1 doel: die bepaling van die waarnemingsdrempel van bepaalde neutrale en journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ' kommunikatiefgefundeerde ondersoek 45 proeffa c ύί 0 intensiteitspeil in desibel proeffa c ύί 0 geslag regteroor linkeroor jsttrsu ftc verskil jsttrsu ftc 100% 50% verskil 100% 50% verskil ε 1 μ 3 0 15 15 3 0 15 15 •ci. s ε 2 μ 4 0 20 2 0 3 0 15 15 sj ε 3 v 3 0 15 15 3 0 15 15 i ε 4 μ 4 0 25 15 — — | ε 5 μ 5 0 35 15 4 0 2 0 2 0 j ε 6 μ 3 0 15 15 20 15 5 ϊ ε 7 μ 3 0 2 0 10 3 0 15 15 t ε 8 v 3 0 15 15 3 0 15 15 ^ ε 9 v 3 0 10 2 0 2 0 15 5 ε 1 0 > μ 3 0 15 15 3 0 10 20 κ 1 4 0 25 15 4 0 20 2 0 κ 2 3 0 20 10 3 0 15 15 « . κ 3 2 0 25 5 3 0 15 15 i κ 4 4 0 25 15 3 0 15 15 ι" κ 5 3 0 10 2 0 3 0 15 15 ε κ 6 3 0 10 2 0 30 15 15 1 κ 7 2 0 10 10 3 0 10 2 0 ^ κ 8 3 0 10 2 0 3 0 10 2 0 κ 9 3 0 10 20 2 0 10 10 κ10 30 10 20 3 0 15 15 tabel ii spraakdiskriminasiewaardes. vermoedelike negatiewe stimuli, aangebied in die vorm van spesifieke woordelyste. materiaal: i. neutrale woorde: woorde wat as sodanig ge-evalueer is deur 'n groep proefpersone nadat dit d.m.v. 'n tachistoskoop aan hulle gebied is. ii. hakkelwoorde — woorde wat vir elke hakkelaar spesifieke ,jiakkelwaarde" besit as gevolg van die voortdurende hakkelervaring, wat met negatiewe emosies geassosieer is. bogenoemde 2 groepe het aan bepaalde vereistes voldoen, nl.: a. eenlettergrepig omdat drempelbepaling sodoende meer definitief is. b. die woorde moes onder die 1 000 mees algemene afrikaanse woorde voorkom (vereiste gestel deur broadbent). tydskrif van die suid-afrikaanse vereniging vir sprak en ehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 6 rene hugo metode 1. aan die proefpersone van die eksperimentele groep is 'n lys van 12 neutrale woorde (soos voorheen bepaal) gebied waaruit hulle alle potensiele hakkelwoorde moes elimineer. indien nodig is 'n verdere aantal woorde deur die proefleier op 'n doelbewus-toevallige wyse uitgeskakel sodat 6 woorde oorgebly het wat.as die neutrale stimulilys sou dien. 2. 'n lys van 6 hakkelwoorde is saamgestel op grond van ondervraging en observasie van die proefpersone. 3. 'n finale stimulus-lys is saamgestel, bestaande uit 6 hakkelen 6 neutrale woorde. die orderangskikking het berus op 'n toevallige metode deur die gebruik van ewekansige tabelle. 4. die binourale drempelwaarde van elke woord is vervolgens bepaal d.m.v. die stygende metode wat in deskrete 5 db-stappe aangebied is. 5. die stimulus-lys van die neutrale woorde asook 'n saamgestelde lys van die totale aantal hakkelwoorde soos verkry van al 10 die proefpersone van die eksperimentele groep, is ook aan die kontrolegroep gebied en hulle drempelwaardes bepaal. r e s u l t a a t die resultate word in tabel iii uitgele. +proefpersone g. eksperimentelecroep kontrolegroep proefpersone +proefpersone g. neutrale woorde hakkelwoorde hakkelwoorde neutrale woorde proefpersone ε 1 μ 18,00 17,50 24,46 11,25 κ 1 ε 2 μ 20,00 17,00 17,77 13,64 κ 2 ε 3 v 20,00 15,00 11,40 14,09 κ 3 ε 4 μ 33,00 29,00 18,86 21,50 κ 4 ε 5 μ 23,00 21,25 14,00 20,45 κ 5 ε 6 μ 17,00 14,17 18,46 22,14 κ 6 ε 7 μ 21,67 22,00 17,75 21,00 κ 7 ε 8 v 21,67 17,00 13,82 14,58 κ 8 ε 9 v 15,83 15,00 8,94 10,00 κ 9 ε10 μ 15,00 12,00 14,00 14,09 κ10 tabel ιπ drempelwaardes in db verwerking van hierdie gegewens is hoofsaaklik op twee vlakke gedoen nl.; 1. 'n vergelyking tussen die eksperimentele groep se waarnemingsdrempels vir neutrale en hakkelwoorde waartydens die nulhipotese verklaar dat daar geen verskil bestaan nie. die resultate van die wilcoxon-simmetrietoets toon journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ' kommunikatiefgefundeerde ondersoek 4 7 wel 'η verskil op die 1%-peil van betekenis en verwerp dus die nulhipotese. dit wil se, die eksperimentele groep vertoon 'n hoogs betekenisvolle verskil in drempelwaardes tussen die 2 lyste en wel in di6 sin dat die waarnemingsdrempels van die negatiewe (hakkel) woorde betekenisvol laer is. 2. 'n vergelyking tussen die kontrolegroep as waarnemingsdrempels vir neutrale en hakkelwoorde. weereens υρ grond van die resultate verkry deur die wilcoxon-simmetrietoets moet in hierdie geval verklaar word dat die nulhipotese nie verwerp kan word nie, d.i., daar kan nie 'n betekenisvolle verskil tussen die drempelwaardes vir negatiewe (hakkel) en neutrale woorde gevind word nie. gesien die betekenisvolle resultate van eksperiment 1 is enige verdere kruisvergelyking (bv., vergelyking tussen eksperimentele en kontrolegroep se hakkelwoorddrempelwaardes) moeilik uitvoerbaar en sal dit waarskynlik geen praktiese bydrae lewer nie. dieselfde besware vir 'n vergelyking tussen die resultate van manlike en vroulike lede wat op eksperiment 1 ingebring is, geld ook hier en is dus nie deurgevoer nie. wat die kwalitatiewe resultate betref, kan dit betekenisvol wees om op die volgende te let: a) die lede van die eksperimentele groep wat die grootste verskil in drempelwaarde vertoon nl., e3, e4, e8, is diegene wat, volgens die proefleier se mening (let wel: dit is nie statistics d.m.v. vergelykingsskale vasgestel nie) die ernstigste ritmiese versteurings vertoon. in hierdie geval word met .ernstig' die frekwensie sowel as die graad van spanning tydens die onvlothede bedoel. b) in teenstelling hiermee is die proefpersoon, e7, wat 'n negatiewe verskil tussen sy drempelwaardes vertoon, 'n hakkelaar wat deur geringe uiterlike spanning en min vlotheidsprobleme gekenmerk word. c) proefpersone e3 en e8 wat 2 uit die 3 lede is wat 'n groot verskil in drempelwaarde vertoon, is vroulike lede van die groep. a f l e i d i n g s om tot wilde bewerings in verband met 'n definitiewe etiologie te kom op grond van hierdie resultate sou buitensporig wees. nogtans wil dit voorkom asof die gegewens op 'n aantal aspekte lig kan werp: 1. die feit dat die eksperimentele groep 'n betekenisvolle verskil in drempelwaarde tussen die negatiewe en hakkelwoorde vertoon, lei tot vrae in verband met die oorsaak hiervan. aangesien in ag geneem is dat die 2 woordelyste homogeen is wat betref aspekte soos lengte (eenlettergrepig), bekendheid (1 000 mees bekende woorde), en bewustheid (albei lyste is aan die proefpersoon gebied voor die eksperiment) wil dit voorkom asof die oorsaak van die verskil by 'n ander faktor gesoek moet word. die outeur reken dat bekendheidskwaliteite moontlik nogtans 'n rol kan speel as in aanmerking geneem word dat die definiering van „hakkelwoord" soos volg daar uitsien: „woorde waarop jy gewoonlik of altyd sal hakkel". dit kan dus veroorsaak dat hierdie woorde, al is hul algemene gebruiksfrekwensie net. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 19 desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 8 rene hugo so hoog soos die neutrale woorde, tog vir die indiwiduele hakkelaar meer bekend sal wees. nogtans is hierdie verklaring nie voldoende nie en moet die bekendheidsfaktor ook met die emosionele kwaliteit saamhang. dit is dus meer waarskynlik dat die verskil in drempelwaardes toegeskryf moet word aan die feit dat dit woorde is waarop gewoonlik gehakkel word, wat dus altyd gepaard gaan met sterk emosionele negatiewe ervaririgs en wat dus die waarnemingsdrempel op een of ander wyse sal beinvloed. gesien in die lig van die strydvraag omtrent die bestaan, al dan nie, van drempelwaardes is dit op hierdie stadium gewaagd om die resultate van hierdie eksperiment toe te skryf aan die verskynsel van subliminale persepsie en perseptuele sensitiwiteit (def.: die waarnemer reageer diskriminerend op die emosionele aspekte van 'n stimulus wat subliminaal aangebied word en wel in die sin dat emosioneeldreigende stimuli makliker waargeneem word.1 >6) nogtans is dit moontlik en wenslik om dit vergelykbaar te stel aan 'n verdedigingsmeganisme sg., aan perseptuele ingestemdheid. dit kan dan gedefinieer word as: 'n hoogs algemene toestand van gereedheid in die waarnemer om selektief te reageer op klasse van gebeure in sy omgewing. dit sou interessant wees om te sien op waiter wyse hierdie bevindings in verband gebring kan word met faktore soos: erns van die probleem, prognose, persoonlikheid en algemene lewensaanpasbaarheid van die indiwidu. 2. bepaalde disfemie-kenmerke kan met hierdie resultate in verband gebring word bv.: a) die hakkelaar se vermoe om moeilike woorde en selfs situasies vooraf „aan te voel" op 'n stadium wat dit nog nie werklik sy bewussynsveld betrek het nie. b) aan die anderkant kan dit ook verband hou met die hakkelaar se skynbare onbewustheid van sekondere simptome, en selfs met die verskynsel van onwaarneembaarheid.5 die energiekonsentrasie en waarnemingsensitiwiteit word gerig op die gevreesde woord, aangesien dit vir hom die essensie van sy probleem is en kan lei tot 'n afname in die waarnemingsvermoens op ander vlakke. 3. hierdie resultate kan ook ten nouste in verband gebring word met terapieresultate. op hierdie stadium sal alle spraakterapeute wat in die praktyk staan onomwonde verklaar dat die grootste struikelblok vir habilitasie van die disfemie, die korrekte gebruik van voorbereidende instellings tydens sosiale situasies is. waar 'n verdedigingsmeganisme (in hierdie geval die „vooraf ingestemdheid jeens die woord") as 'n wyse van aanpassing aan die gemeenskap is, kan dit miskien as 'n onmoontlikheid beskou word om van die hakkelaar te verwag om die resultaat van hierdie aanpassing te modifiseer ten einde beheer oor sy spraak te verkry. aan die ander kant kan dit dus ook as 'n prognostiese teken met betrekking tot die mate waartoe beheertegnieke wel sal slaag, beskou word. journal of the south african speech and hearing association, vol 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ' kommunikatiefgefundeerde ondersoek 4 9 eksperiment iii doel: die vasstelling van die moontlike bestaan van onwaarneembaarheid („imperceptivity" — volgens froeschels: „shut in to such a degree that they did not perceive certain signals which they perceive normally..."5) van betekenisvolle stimuli by die hakkelaar tydens 'n hakkelperiode. materiaal: potlood en blankopapier. dieselfde woordelyste soos gebruik in eksperiment ii wat bestaan uit 6 neutrale en 6 hakkelwoorde met 'n verandering in die volgorde van aanbieding. metode 1. die proefpersone van die eksperimentele groep is gekeur op grond van aard van hulle spesifieke vlotheidsversteurings. slegs die persone is gebruik wat so 'n lang hakkelperiode as simptoom vertoon dat hulle ten tye daarvan suksesvol met 'n woord gestimuleer kan word. eventueel is 5 proefpersone gebruik. 2. gegrond op die gegewens van eksperiment i is al die proefpersone se mees gemaklike luidheid, binouraal, vir spraakwaarneming bepaal. 3. die proefpersone is opgedra om oor te gaan tot 'n spontane lang beskrywingsreaksie (bv. „beskryf die pad wat u moet ry vanaf u huis tot by die spraakkliniek"). hiertydens is dan van die proefpersone verwag om te luister vir die voorkoms van bepaalde stimuluswoorde, om indien hulle dit hoor, te reageer deur die woord neer te skryf, en om dit verder te ignoreer en aan te gaan met die „gesprek". 4. tydens die beskrywingsituasie is die stimuluswoord aangebied sodra 'n hakkelperiode voorgekom het en net nadat dit begin is. vir hierdie doel is die hakkelperiode gedefinieer as „ what the onlooker observes is the so-called stuttering block . . . repetition, prolongation or a complete cessation of sound".3 5. bogenoemde resultate is kwalitatief aangevul d.m.v. gesprekke en vraelyste waartydens gepoog is om vas te stel of waarnemingsprobleme tydens die hakkelperiode ondervind is. r e s u l t a a t die resultate word in tabel iv uitgele. gesien die klein getal proefpersone is dit in hierdie geval onwenslik gereken om die gegewens statisties te verwerk. oor die algemeen kan die volgende gevolgtrekkings gemaak word: i. uit die 5 proefpersone het al 5 tenminste een defektiewe waarneming gemaak (met defektief word sowel verkeerde as geen waarneming bedoel); tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 5 0 rene hugo proefpersone aangebode stimuli (woorde) aant. woorde korrek waargeneem aant. woorde verkeerd waargeneem aant. woorde glad nie waargeneem nie proefpersone aangebode stimuli (woorde) aant. woorde korrek waargeneem neutrale woorde hakkelwoorde neutrale woorde hakkelwoorde ε 1 12 8 2 2 ε 2 12 9 2 1 ε 3 12 11 1 ε 4 12 8 2 1 1 ε 5 12 10 1 1 tabel iv getal stimuluswoorde wat ouditief aangebied word tydens die spontane spraak van hakkelaars. 46 ii. 60 =76,7% van die stimuliwoorde is korrek waargeneem; 1 1 ' iii. 60 = 20% is foutief waargeneem; _2 iv. 60 = 3,33% is glad nie waargeneem nie; v. 7 hakkel en 7 neutrale woorde is defektief waargeneem. a f l e i d i n g s 1. as bogenoemde syfers in aanmerking geneem word wil dit voorkom asof daar nie in hierdie eksperiment bewys gelewer is van die bestaan van onwaarneembaarheid tydens die hakkelperiode nie. 2. dit skyn asof die aard van stimulus (hakkel/neutrale woord), met betrekking tot sy emosionele kwaliteit nie met onwaarneembaarheid in verband gebring kan word nie. voor die uitvoering van die eksperiment is gemeen dat hierdie gegewens beslis 'n verskil sal vertoon en wel t.o.v., 'n groter onwaarneembaarheid van hakkelwoorde. die voorlopige hipotese wat gestel is, het verklaar dat onwaarneembaarheid verband kan hou met die aspek van perseptuele weerstand — d.w.s., onwaarneembaarheid van dreigende stimuli wat bo die drempel aangebied word. / bogenoemde gegewens kan op hierdie stadium nie die hipotese verwerp of aanvaar nie, aangesien die steekproef te klein was. oor die algemeen egter wil dit voorkom asof die hakkelaar nie onwaarneembaarheid ervaar tydens die hakkelperiode vir betekenisvolle spraakstimuli nie. 3. hierdie resultate is egter nie finaal nie, veral as in aanmerking geneem word dat alle proefpersone tydens die verloop van die eksperiment verklaar het: ! a) dat dit moeilik was om die woorde te hoor; journal of the south african speech and hearing association, vol 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ' kommunikatiefgefundeerde ondersoek 51 b) dat hulle dit oor die algemeen moeilik vind om stimuli waar te neem tydens die hakkelperiode. bibliografie 1. banreti fuchs, k.m. (1964)problemen der subliminale perceptie. von gorcum en comp. nederland. 2. davids, a. (1956) past experience and present personality disposition as determinants of selective auditory memory/, of personality. 25, no. 1, 19-26. 3. eisenson, j. (ed) (1958)stuttering: a symposium. harper and row, publishers, new york. 4. freund, h. (1966) psychopathology and the problem of stuttering. charles c. thomas, illinois. 5. froeschels and rieber, r.w. (1963) the problem of auditory and visual imperceptivity in stutterers, folia phoniatrica, 15, no. 1, 13-19. 6. howie, d. (1952) perceptual defense psychological review. 59, 308-315. 7. mussen, p.h. rosenzweig, m.r. (1969) annual review of psychology. 20. 8. selected papers of emil froeschels. (1964) north-holland publishing co. amsterdam, 1964. 9. sapir, e. (1949) language, harcourt, bruce & co. tydskrif van diesuid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 19, desember r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) minimal closure in cleft lip and palate surgery d . h . walker, f . r . c . s . senior plastic surgeon, johannesburg hospital it is a frequently accepted surgical principle that one should do as much as possible for any one patient at a given operation. cutting across this is the slightly mocking injunction of the late sir harold gillies: "never do today what you can legitimately put off until tomorrow." is this an "easy o u t " for actually or potentially lazy surgeons or can the patient possibly benefit from this startling proposition? after careful thought, painstaking cephalometric measurements and long periods of follow-up and evaluation, we have an answer, at least in part, from slaughter and his associates in chicago, relating to operations and other treatment in patients with cleft lip and palate. this work is not new (papers were published in 1949, 1954 and 1958) but forgotten or disbelieved or neglected for a variety of reasons. among these reasons is probably the understandable feeling of satisfaction at the appearance of completeness in the early period after operation. historical aspects. faced with the frightening cavities of a complete bilateral cleft lip and palate, a sense of panic sometimes intrudes and the cry goes up to close it quickly and close it all in a desperate hurry. t h i s used to be attempted of course, as early as the sixteenth century and arthur barsky, a new york plastic surgeon, reports that cleft lip surgery is said to have been performed in china in the chin dynasty (a.d. 229-317) but it is apparently almost impossible to separate myth and fact in accounts of early chinese surgery. it is generally concluded that pierre franco's account of surgical closure of cleft lips published in the mid-sixteenth century is probably the first published. how much credit is due to the great ambroise pare, the dominating figure in french surgery at that time, and how much to franco, his apparently more modest contemporary, is unknown. at first the lip operation was a crude pulling together of the cleft margins and transfixion by pins, the whole being held by a figure of eight' of waxed thread wrapped around the projecting ends of the pins about eight or ten times.^ where the gap was wide franco advised relaxing incisions inside the mouth. t h e r e was little advance on this until the nineteenth century and closure of the cleft palate was almost impossible until general anaesthesia developed in the 19th century. with the patient unconscious under an anaesthetic, it is regrettable to note that surgical violence in this field 1 increased. forcible manipulation and breaking of parts of the alveolar arch with savage displacement and journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) minimal closure in cleft lip and palate surgery 45 frequent amputation of the projecting premaxilla became common. ruthless undermining of soft tissues outside and inside the mouth enabled these soft parts to be brought together, but only many years later was it recognised that some patients, who had been subjected to such surgical barbarism had, in adult life, definite patterns of deformity and disproportion in their faces. t h i s was almost certainly due to the gross interference with blood supply of the bones forming the middle third of the facial skeleton. holdsworth records that as early as 1864 simon suggested that force was not necessary and that the pressure of the united lip was sufficient to reduce the projection in the infant. his suggestion does not seem to have been taken very seriously until julius wolff in 1886 advanced the same idea. he also recommended the closure of bilateral clefts in two stages. thereafter the body of conservative opinion grew, though the subperiosteal fracture or resection of the septum remained a common feature of operation in extreme cases. growth of the facial area. t h e probable normal growth stimulus for the central area of the face starts as far back as the base of the skull (fig. 1). t h e "driving force," as it were, proceeds in a long curved line (shown dotted), directed by the vomer and transmitted, ultimately, as forward growth of the tip of the nose and upper lip. t h e structures concerned in this midline growth plane also form the bony and cartilaginous septum between the two halves of the nose. fig. i . sagittal section of the skull. s i : skull interior. f s : frontal sinus. n b : nasal bone. u t : upper teeth. d : direction of growth of mid-third of face and tip of nose. v : vomer and nasal septum. fig. 2. anterior aspect of the skull. n b : nasal bones. n c : nasal cavity. v : front view of nasal septum (vomer). in effect then, a face grows not from where it appears to grow, for example, at the tip of the nose or by an advancing upper lip, but by development far behind and above these regions. a frontal view of the region affected by this process may be seen in fig. 2. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 d. η. walker no one knows the detailed plan of the blood supply to growth centres in these regions. nor is it known how much of the soft tissue can safely be stripped off the bone and moved elsewhere in operations for the closure of cleft lip and palate. carried to a literal and over-logical conclusion, one would be afraid to operate on a cleft lip or palate as long as any growth at all is going on. in practice it is believed that sufficient activity of the growth centres has taken place by about the age of four years to make any reasonably radical operation safe from the growth point of view. apart from sheer growth, there must be a consideration of what may be described as "moulding forces." these are essentially derived from muscle action in the face, lip, tongue, soft palate and pharynx. a diagrammatic representation of a normal nose, lip, palate and pharynx (fig. 3) helps to present the concept of a band of muscle in the lip constantly acting across the bone beneath the nose and the alveolar arch bearing the teeth. t h e arrows show the direction of forward growth, which is almost certainly modified by the muscle in two planes. it is also reasonable to believe t h a t : the muscle ring of the mouth, as represented in fig 3, constantly exerts similar forces in a third plane. journal the south african logopedic society, vol. 1, no. 1: may 1966 fig. 3. diagram of palate, lip and nose from below. m u l : muscle in upper lip. h p : hard palate. s p : soft palate. ρ : pharynx. m r : muscle ring. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) minimal closure in cleft l i p and palate surgery 47 farther back the muscle of the soft palate acts in a variety of directions as does that forming the pharynx. one comes to regard the muscular moulding forces of the lip, palate and pharynx as composed largely of two rings, a "mouth muscle ring" and a "palato-pharyngeal muscle ring." apart from the normal moulding forces, it is clear that there must be a tendency to unrestrained and unmodified growth in certain directions if these rings are open, interrupted or undeveloped. this, of course, is exactly the situation which pertains in a patient who has a cleft lip and palate. we now near a possible answer to our originally quoted suggestion from sir harold gillies. principles and practice. as in many awkward problems, the answer is a compromise. in this instance, the compromise takes the form of starting a process by a surgical operation, which we hope will be advanced and even concluded by natural processes. if we refer to fig. 4, it can readily be appreciated that joining muscle in the lip across the cleft must tend to produce a backward pressure on the major alveolar segment, as well as a tendency for the major segment to move towards the side of the cleft. t h i s possible movement can be taken advantage of not only surgically, but by means of an orthodontic appliance. t h i s latter method is probably the major advance since the plan was originally put forward by slaughter and his colleagues. slaughter's original views suggested that in wide clefts where it is almost impossible to get a normal appearance at the first operation, one should be satisfied with any joining of muscle across the cleft lip and gum. t h i s region is then left to the consequences of the surgical dictum that having put normal parts in as near as possible to the normal position, natural c © fig. 4. cleft lip and palate from below. l : lip. g : g u m . c : cleft. m r o : muscle ring open. m : muscle. fig. 5. residual fistula (f) in partly repaired cleft narrows later. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 13, nr. 1: mei 1966• r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 d. η. walker growth forces should be allowed to exert themselves for a period of years. if we now apply this principle to the cleft in the soft palate, whether it is part of a complete cleft or a cleft of the soft palate alone, it will be seen that the joining of the muscle in the region of the uvula or as far forward as can be done without undue tension, must exert all the force produced by an intact palato-pharyngeal muscular ring. however, this must not be taken literally as a representation of the short term result of joining a band of muscle across the lip cleft to complete as much as possible of the muscular ring in relation to the palate and pharynx. t h e intervening unclosed cleft is deliberately left, with the possible exception of closure of the anterior portion of the hard palate cleft by a vomerine flap. we must now attempt to visualise growth in about 3 places in different directions at the same time: 1. t h e forward growth of the middle third of the face already described, which will have the effect of lengthening the overall front to back dimension of the palate. 2. at the same time muscular forces in the lip are at work. 3. soft palate and pharynx muscles are working from side to side and in a circular manner. as a result of the interplay of these forces, it is believed that a large number of the residual elliptical clefts change their shape as the years go by. in the favourable case this change of shape takes the form of a long, narrow ellipse replacing the shorter, wider oval that remained immediately after the surgical closure in front of and behind it. (fig. 5.) this approach to the whole problem based on the anatomical and physiological features outlined, is being tried at our unit in the johannesburg children's hospital, with the assistance of our orthodontic colleagues, who are keeping a close watch on the shape of the residual cleft in children, who have had muscular closure in front of and behind this cleft. they are able to achieve quite satisfactory speech results with an obturator. this appliance has, of course, to be re-made fairly frequently as the child grows and as the shape of the residual central defect alters. this may, however, be a justifiable period of inconvenience in view of the fact that we hope by this method, to avoid the sometimes severe disproportion in growth of the facial skeleton, which is likely to follow the radical operation at an early age. t h e final point is usually raised in the question of when, if at all, any operation may be needed. we believe that nearly all patients need another operation for eventual closure of the central residual cleft. this may be safely left until the age of 12 or 14 years, when one hopes that the edges of the cleft will be so closed together that the final operation will be relatively easy to perform and cause little distress for the patient. opsomming hoewel slaughter en sy kollegas reeds in 1949, 1954, 1958 'n meer konserwatiewe benadering aanbeveel het by die behandeling van lipen verhemeltesplete is hulle werk vergeet of gei'gnoreer, en in elk geval nie algemeen aanvaar nie. journal of the south african logopedic society, vol. z.1, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) minimal closure in cleft lip and palate surgery 49 die oorspronklike operasies op gesplete lip en verhemelte was baie radikaal en die katastrofiese gevolge hiervan het dikwels eers na jare tot openbaring gekom in die vorm van wanontwikkeling van die gesigskelet met gevolglike disproporsie van 'n kenmerkende aard. hierdie toestand was byna sonder twyfel die gevolg van belemmerde bloed toevoer na die ontwikkelende skelet in die middelste derde van die gesig. geleidelik het 'n konserwatiewe benadering egter begin posvat en is die belangrikheid besef van 'n gehegde lip oor 'n onderliggende spleet om die vervorming van abnormale strukture te bewerkstellig. hierdie werking is die gevolg van die kragte wat uitgeoefen word deur die palato-faringeale, en mondspierkringe in drie vlakke op omliggende benige dele. wanneer die spierkringe defek is weens 'n spleet vind ongebonde groei plaas, en die gevolge word duidelik gesien in sommige volwasse persone met 'n lipof verhemeltespleet. slaughter se benadering kom daarop neer dat die spierkring op 'n vroee stadium herstel word met minimale versteuring van groeiende weefsel. dit gee dan die spleet 'n kans om nouer te word saam met die normaalontwikkelende groeiende skelet. op 'n latere stadium word die spleet dan finaal geheg. hierdie vorm van behandeling word tans op die proef gestel in die johannesburgse kinderhospitaal in samewerking met die ortodontiese afdeling. in gevalle met erge verplasing van die premaxilla word kort na geboorte 'n prostese gemaak wat druk daarop uitoefen om dit terug te druk na die versteurde alveolere boog voordat die lipspierkring gesluit word, 'n obturator-plaat word gedra nadat die sagte verhemelte spierkring geheg .is tot op die stadium wanneer die finale operasie uitgevoer word op 'n „veilige" ouderdom van 12 tot 14 jaar of meer. i would like to thank mr. h. c. de wet for the afrikaans summary of this paper. references slaughter, w. b. and brodie, a. g. (1949): plast. reconstr. surg., 4, 311. slaughter, w. b. and pruzansky, s. (1954): plast. reconstr. surg., 13, 341. slaughter, w. b. and pruzansky, s. (1959): the rationale for velar closure as a primary procedure in the repair of cleft palate defects. plast. reconstr. surg., 23, 301. holdsworth (1957): cleft lip and palate. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) glossectomy b y diana m. whiting. b. a. log. (rand) & c.s.t. in recent years several patients who have undergone partial or total glossectomy have been referred to us for help in re-establishing adequate speech. i have been unable to find references to this type of case in available speech journals. i wish to present therefore, a case of total glossectomy followed by comments on partial glossectomy and glossectomy plus total mandibulectomy based on my own limited clinical experience. total glossectomy — a case history. h.w. was an afrikaans speaking coloured male 56 years of age. he was illiterate. medical history: in 1956 he presented to the radiotherapy department with a carcinoma of the tongue and received a course of radiotherapy. he was followed up· regularly and biopsies in june 1957 and august 1959 revealed no signs of malignancy. he remained well until november 1962 when he presented with a hard ulcerating lesion of the left tip of the tongue 2.5 x 1.5 x 1.5 cms. arrangements were made for his admission to hospital for the excision of this lesion but the patient failed to turn up. he reappeared in january, 1963, the lesion having more than doubled its size. on 5th feb. 1963 .a total glossectomy was performed and 10 days later the patient was transferred to a convalescent home. on 8th march, 1963 he was followed up in the radiotherapy department who reported "appears satisfactory but cannot swallow" and referred him for speech therapy. on examination the patient still had a nasal feeding tubes in situ. (he administered his own nasal feeds at the required intervals.) he was edentulous. hej could not swallow and had difficulty in directing his saliva into the oesophagus resulting in frequent clearing of his throat and coughing to relieve glottal irritation. his soft palate functioned normally and his lips were very mobile. his speech attempts were almost unintelligible. resonance was markedly distorted, but all vowels and diphthongs were distinguishable when imitated in isolation. consonants p, b, m were normal. he had already developed an accoustically corrent η and his t and d were distinguishable accoustically from ρ and b; f and ν were approximately correct; k and fricative g were glottal; s and ζ were absebt altogether. all other consonants were distorted, r and 1 causing perhaps the most difficulty. treatment was directed towards:1. teaching him to swallow by watching, feeling and imitating the raising and lowering of the larynx during swallowing. he was soon able to do this and was very anxious to resume oral feeding. within a week he could manage porridge and soup and the nasal tube was removed. 2. developing the flexibility of his lips and thereby assisting their adaptation as prime articulators for all consonant sound. 3. teaching him accoustically adequate compensatory articulation for all consonants previously made with the tongue. he.achieved spontaneously correct f, v, n, t and d sounds. he acquired excellent s and ζ sounds, but had more difficulty in incorporating these into spontaneous speech. he produced an adequate 1 and untrilled r. all these consonants were produced with the lips. his spontaneous compensation of the glottal stop fork and fricative g added to the glottal irritations caused by his difficulty in directing fluid and food into his oesophagus. a rasping hoarseness was resulting. it was essential to reduce laryngeal irritation, but pharyngeal substitutes were not possible being a total glossectomy. he was encouraged to compensate labially. the sound 25 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) he achieved accoustically approximated a t rather than k. this, however, reduced vocal abuse and his vocal tone improved. 4. improving vocal tone and resonance. all vowels and diphthongs were readily distinguishable but resonance remained markedly distorted. treatment was discontinued after about six weeks the patient having returned to his home. he regarded his speech as adequate saying " a s hulle vir my mooi luister kan hulle vir my verstaan" (if they listen to me carefully they can understand me). partial glossectomy. vlinical experience with 3 cases of partial glossectomy one involving half the anterior third, one the whole anterior third and one the whole anterior half of the tongue has shown how readily and with very little help such patients can adopt articulatory positions to produce normal speech. total glossectomy and mandibulectomy. i have had the opportunity to observe and assist one such patient during several stages of his rehabilitation, which is not yet complete. this patient is an afrikaans speaking illiterate coloured male in his fifties. he underwent the total removal of his tongue and mandible and associated soft tissue with the exception of the lower lip which was disected out along its lower border and attached temporarily to the hyoid bone. a pedicle was raised from his abdomen and used to reconstruct the lower half of face and the lower lip was returned to the appropriate position. the only mobile articulator for consonant sounds this patient has is his upper lip. this has become very mobile. he achieves adequate p, b, m, f, v, t, d, η sounds and a very creditable s sound, r and 1 are distorted, k and fricative g are glottal. with the help of gesture and personality he makes himself understood. summary. experience with this limited number of patients seems to indicate that we can expect the normal speaker, who has to undergo removal of part or the whole of his tongue, to re-establish normal or adequate oral communication fairly rapidly post-operatively. this readjustment may be largely spontaneous requiring help primarily in finding compensatory articulation for sibilants and velar plosives and fricatives. opsomming. ondervinding met hierdie beperkte aantal pasiente dui blykbaar aan dat ons die herbevestiging van normale of bev fedigende mondelinge kommunikasie redelik spoedig kan verwag van 'n normale spreker wat die gedeeltelike of algehale verwydering van sy tong operatief moes ondergaan. hiefdie heraanpassing mag grootliks spontaan wees, maar hulp en leiding is nodig in verband met kompensatoriese artikulasiebewegings vir sisklanke, velare plosiewe en frikatiewe klanke. 26 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'ν geval van kinderafasie ε . swiegers, b.a.log. (rand) and i . c . uys, b.a.log. (rand). pretoria hierdie artikel beskrywe 'n interessante geval van kinderafasie, wat deur 'n spraakterapeut behandel is: soos dikwels gebeur, is hierdie ook 'n geval waar diagnose bemoeilik word deur verskeie simptoomkomplekse en daar word dus ook hier staat gemaak op die bydraes van 'n span van deskundiges, o.a. 'n neuroloog, spraakterapeut, kleuterskoolonderwyseres, kliniese kindersielkundige en die ouers. om die nodige duidelikheid te verkry sal die verslae van die verskillende instansies eers kortliks gegee word, en daarna 'n opsomming van die habilitasieprogram, wat gevolg word deur die resultate en verdere aanbevelings. gevalsgeskiedenis naam: pieter fourie. ouderdom: 4 jaar. probleem: swak spraak, stadige ontwikkeling en lompheid. ontwikkelingsgeskiedenis. swangerskap: nege maande swangerskap. geen abnormaliteite is opgemerk nie. geboorte: induksie is toegedien. een dag na geboorte het die pasient swart koorsblare ontwikkel, maar dit het skynbaar nie gedui op 'n patologiese bloedtoestand nie. die pasient het ook 'n ligte graad van geelsug gehad. voeding: hy \yas slaperig en lui en het suigprobleme getoon. hy het later die suigprobleem redelik oorkom, maar probleme ondervind met die inname van harde voedsel. die slukproses het deurgaans probleme opgelewer. mylpale. sit: 5 maande; kruip: 10 maande loop: 18 maande. spraakontwikkeling: babbel: pieter was 'n baie stil baba. hy het min gebabbel en min reaksies op spraakstimuli getoon. dit het gelyk asof hy nie kan hoor nie. spraak: op een jaar het hy „ma-ma" en „pa-pa" gese, maar geen nuwe woorde gese gedurende die volgende jaar nie. op vier jarige ouderdom kon hy 'n paar woorde betekenisvol gebruik, maar nog geen sinne nie. later het hy gesprekke begin naboots d.m.v. jargon. tydskrif van die suid-afrikaanse logopediese vereniging, vol.14, nr. 1: sept. 6 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 ε. swiegers and i. c. uys. toiletgewoontes: dit is.nog nie aangeleer nie. mediese geskiedenis. hy het die volgende siektes al redelik dikwels opgedoen: kroep, bronchitis, en griep. op twee jarige ouderdom het hy 'n baie hoe koors ontwikkel en is met · penicillin behandel. die rede vir die koors kon nie vasgestel word nie. familiegeskiedenis. sover vasgestel kon word, bestaan daar nie 'n soortgelyke probleem by enige familielid nie. indruk van die ouers. die ouers is beide baie intelligente, volwasse persone, wat a.g.v. hulle insig en objektiwiteif, 'n konsekwente program tuis sal kan uitvoer!. \ spraakterapeutiese ondersoek uiterlike voorkoms. 'n aantreklike, netjies seun; normaal gebou vir sy ouderdom. ·-, spraakmeganisme. tong: alle tongbewegings na links is defektief. in en uit bewegings is bevredigend, maar bewegings van kant tot kant is swak, stadig en onbeheersd. lippe: die pasient haal deur sy mond asem en die lippe is dus altyd oop. die lippe toon 'n gebrek aan tonus en, hoewel bewegings uitgevoer kan word, is dit stadig. kakebeen: hy kan die kakebeen lig en laat sak. tande: geen abnormaliteit nie. harde verhemelte: geen abnormaliteit nie. sagte verhemelte: geen abnormaliteit kan opgemerk word nie en hoewel die bewegings normaal blyk te wees, kan hy alleenlik snork, maar nie blaas nie. basiese funksies: die pasient kan blykbaar normaal sluk,"suig en kou. as gevolg van die oop mond kwyl hy soms. hy nuttig 'n normale dieet. asemhaling: geen afwyking is te bespeur by inof uitaseming nie. artikulasie: sy spraakpatroon word gekenmerk deur veelvuldige weglatings, verdraaiings, vervoegings en misartikulasies. as gevolg van die taal tekort is dit moeilik om die artikulasiefoute presies te bepaal, maar baie foutiewe klanknabootsings kom wel voor. hy ondervind ook moeilikheid met die plasing van die artikulasieorgane. stem: die stem is monotoon en ook effens hees. gehoor: die pasient reageer goed op growwe klanke en svrye-veld toetse. gehoorwaarneming blyk normaal te wees. verbale begrip: dit is baie swak. hy voer glad nie verbale bevele uit nie. dit kan egter ook toegeskryf word aan ander faktore. motoriese koordinasie. growwe bewegings: loopbewegingsj is lomp en hy sleep sy voete. hy kan glad nie hardloop nie en sy sin vir balans is swak. fyn bewegings: fynere bewegings van die hande, vingers, voete ens. is ook lomp en onderontwikkel vir sy ouderdom. hand-oog koordinasie: ook onderontwikkel vir sy ouderdom. journal of the south african-logopedic society, vol. 14, no'. 1: september 196η r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η geval van. kinderafasie 9 liggaamsvoorkeur. hand: links. oog: links. voet: links. intelligensie. vineland social maturity scale: (gegewens verkry van moeder.) sosiale ouderdomsvlak: ι jaar 9 maande. kronologiese ouderdom: 3 jaar 5 maande. formele intelligensietoetsing: dit was, weens die pasient se ouderdom en ontwikkeling nie moontlik om hom te toets nie, maar globaal gesien lyk dit of die pasient sub-normaal kan wees. vormpersepsie. die pasient kan voorwerpe en prente, wat hy ken, herken en .dan ook aandui op 'n verbale bevel. persepsieversteurings is wel teenwoordig en veral merkbaar m.b.t. ruimtelike orientasie. figuur-grond versteurings kom ook voor. spraak en taal. die pasient maak meestal van jargon gebruik, maar soms kan woorde herken word. die jargonspraak het ook 'n afwykende intonasiepatroon en veral die klinkers het 'n eienaardige kwaliteit. hy boots graag woorde en kort sinne na en met die nabootsing is die intonasiepatroon ook dikwels korrek. hierdie nabootsings mag moontlik op 'n vorm van perseverasie dui, aangesien dit redelik gereeld,voorkom en nie sin vol gebruik word nie. hy het 'n baie beperkte aktiewe woordeskat wat hy gebruik, maar dit mag wees dat sy begrip van gesproke taal verder ontwikkel is. reaksies. pieter reageer baie onkonsekwent en is uiters hiperaktief. as gevolg hiervan is hy moeilik dissiplineerbaar en kan hy nie lank genoeg op 'n gegewe stimulus konsentreer vir die nodige leerproses om plaas te vind nie. hy is egter in staat om vir langer tye te konsentreer op stimuli waarin hy belangstel, maar dit mag ook moontlik op 'n vorm van perseverasie dui. hy word baie gou moeg en verveeld, maar wanneer hy uitgerus en ontspanne is, lyk dit asof hy leergierig is en dan kan sy samewerking tog verkry word. persoonlikheid. hy is baie liefdevol en vriendelik en kontak word maklik opgebou. soms is hy egter baie gefrustreerd en moeilik hanteerbaar. neurologiese ondersoek algemene bevindings. 'n noukeurige neurologiese ondersoek het aan die lig gebring dat daar 'n neurologiese abnormaliteit teenwoordig is aan die regterkant van die liggaam. dit neem die vorm aan van 'n geringe verswakking van die gesigspiere en ook 'n verhoging van die reflekse. die linkerbeen toon 'n algemene verswakking en wanneer die pasient loop draai die linkervoet na binne. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 14, nr. 1: sept. 196η r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 ε. swiegers and i. c. uys elektroenkefalografiese bevindings. eerste verslag die pasient is in 'n toestand van slaap getoets. resultate: 1. veelvuldige linker frontale en fronto-temporale piekontladings en ook skerp golwe kom voor. hierdie abnormaliteite kom dikwels ook bilateraal voor. 2. interhemisferiese asinkronismes en aktiwiteit van 'n baie lae frekwensie, wat maksimaal is in die linker temporale en temporo-oksipitale areas, kom voor. die bevindings dui sterk op 'n gelokaliseerde abnormaliteit in die linker frontale en fronto-temporale areas, wat moontlik geassosieer is met verdere diffuse disfunksie in die temporale en temporo-oksipitale lobbe van dieselfde hemisfeer. tweede verslag die pasient is in 'n wakker toestand getoets. resultate: 1. 'n dominante frekwensie van 7 s/sek. (gemiddeld), wat effens onder die omvang vir sy ouderdom is, kom voor. 2. 'n buitengewone regter frontale versteuring van middelmatige spanning teen 6 s/sek. is opgemerk. 3. een fokale middelmatige poolspanningsparoksisme (6 s/sek.) het gedurende fotiese stimulasie by 30 f/sek. voorgekom. die bevindings dui op 'n disfunksie van die linker parieto-temporale area, wat ook die regter frontale area tot 'n mate betrek. diagnose * die pasient se defektiewe intellektuele, en spraakontwikkeling kan toegeskryf word aan 'n organiese breinbesering. dit is moeilik om die oorsaak van die breinbesering presies vas te stel, maar dit mag wees a.g.v. bloeding net na geboorte of a.g.v. 'n te vinnige geboorte. dit is opmerklik dat die pasient linkshandig is en, alhoewel dit toegeskryf kan word aan die besering aan die linker serebrale hemisfeer, is daar ook 'n oorerwingsfaktor hier betrokke, daar die moeder en een van die ander kinders ook linkshandig is. die kliniese ondersoek dui egter op besering van die linker serebrale hemisfeer en dit lyk asof dit die dominante hemisfeer is. die eeg dui daarop dat die afwyking maksimaal in die linker frontale area voorkom en dit mag impliseer dat die pasient beserings van die spraakareas opgedoen het, wat die vertraagde spraaken intellektuele ontwikkeling tot gevolg het. indien die besering van die spraakareas geassosieer is met 'n baie meer omvattende probleem, bv. die versteuring van die basiese intellektuele funksies, soos geheue, abstrakte redenasievermoe ens., sal die prognose swak wees. indien net die spraakareas aangetas is, sal die prognose vir spraakterapie moontlik goed wees. journal of the south africanlogopedic society, vol. 14, no. 1: september 196 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η geval van kinderafasie aanbevelings 1. hertoetsing oor 6 maande. 2. ouerleiding en bekendstelling met die probleem. 3. spraakterapie. 4. chemoterapie d.m.v. die toediening van encephabol vir 'n toetstydperk. 5. kleuterskool. · kleuterskoolverslag eerste verslag emosionele staat. hy het homself goed aangepas by die kleuterskool, waar hy gewoonlik ontspanne en gelukkig is. soms raak hy ontsteld as hy geterg word, of as hy ander kinders se speelgoed wil he. sosiale ontwikkeling. hy speel eerder alleen of met een ander kind, maar vir kort periodes. hy is egter ge'interesseerd in groepspel. spelbelange. driewiele, sand en water, swaai, wendy-huis, boublokke, treintjies, klei en verf. algemene opmerkings. hy vind dit nog moeilik om te deel. hy is nog nie baie behulpsaam met roetine aktiwiteite nie, bv. om sy tas te bere en hande te was. hy neem baie goed deel aan die oggendkring en stories, maar kan nie vir lank konsentreer nie. tweede verslag emosionele staat. gelykmatig van geaardheid. raak alleenlik ontsteld as hy gedwarsboom word in sosiale spel. sosiale ontwikkeling. hy speel dikwels nog alleen, maar soms ook met een maat. dit is nog parallelle spel. spelbelange. hy speel baie graag met inpasblokke en met wiele, waarmee hy iets bou wat loop of draai. hy is baie oorspronklik en konstruktief hiermee. hy konsentreer lank hierop en hou homself besig. roetine aktiwiteite. hy wil nog nie altyd saamwerk nie. dit word egter verwag en daar word vriendelik, dog beslis opgetree. (miskien geniet hy in die stilte die aandag wat hy kry.) met oggendkring en storietyd sit hy nou stil en hy is ook dikwels gemteresseerd in prente en storieboekies. verstandelike ontwikkeling. hy hanteer die potlood, kryt en kwas nog lomp. hy herhaal nie meer so graag woorde en sinne soos in die verlede nie. algemene opmerkings. hy het op 'n stadium baie goed gevorder, maar nou het hy 'n plato bereik. dit kan moontlik aan sy liggaamlike toestand toegeskryf word, omdat hy baie afwesig was weens siekte. spraakterapeutiese program doelstellings. 1. die verbetering van dissipline om die hiperaktiwiteit teen te werk en die leerproses te bevorder. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 14, nr. 1: sept. 196 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ε. swiegers and i . c . uys 2. die verbetering van konsentrasie en aandag. 3. motivering om spraak as 'n kommunikasiemiddel te aanvaar en te gebruik. 4. die opbou van 'n basiese woordeskat.. 5. die aanleer van element ere sinsbou en taalpatrone. 6. ouerleiding vir die versterking van die terapieprogram tuis. resultate. pieter het eers baie stadig gevorder en ontwikkel, maar na 'n paar maande was sy vordering so bevredigend dat verdere doelstellings in die vooruitsig gestel is. verdere doelstellings. 1. uitbreiding van die woordeskat na saamgestelde, selfs meer abstrakte woorde. 2. taalverbetering d.m.v. rympies en stories, wat ook. liggaamsritme en koordinasie sal verbeter. 3. verbetering van persepsie op die volgende vlakke: (a) gehoorpersepsie—d.m.v. klankstimulasie; die herkenning, interpretasie en toepassing daarvan. (b) visuele persepsie—d.m.v. visuele stimulasie bv. die herkenning van kleure, figure en vorms. (c) figuur-grond waarneming—d.m.v. gesig en gehoor stimuli. (1d) waarneming van ruimte en tyd en orientasie tot ruimte en tyd, ook met die doel om liggaamsbewegings en koordinasie te verbeter; (e) klassifikasie en kategorisering met behulp van items van die nebraska en goldstein-shearer toetse. (/) verbetering van reekswaarnemings. 4. vermindering van oormatige nabootsing en perseverasie. 5. spelterapie vir emosionele ontlading, sosialisering en ontwikkeling van abstrakte vermoens. 6. ouerleiding. resultate. pieter het goeie vordering getoon, hoewel 'n tipiese plato-leerkurwe tog voorkom. verbetering het op al die gebiede plaasgevind, maar hy is nog altyd redelik konkreetgebonde. spraak en taal. hy het nou 'n redelik uitgebreide woordeskat. sy begrip van gesproke taal is nog steeds beter as sy gebruik daarvan. sinsbou het egter baie verbeter. hy maak nou baie gebruik van egosentriese spraak en veral in die oplossing van probleme. ^ liggaamsritme en koordinasie. hierdie aspek het baie' verbeter. die verswakking van die linkerbeen is byna glad nie meer merkbaar nie. fynere hand-oog koordinasie het ook verbeter en hoewel hy nou redelik goed slaag met die hantering van bv. 'n potlood, is nog verdere verbetering op hierdie gebied nodig. die prognose blyk heeltemal gunstig te wees. persepsie. abstrahering is nog 'n groot probleem—hy is nog baie konkreetgebonde. visueleen gehoorspersepsie het verbeter. vormwaarneming, kategorisering en klankwaarneming het, relatief gesproke, die grootste verjournal of the south africanlogopedic society, vol. 14, no. 1: september 196 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η geval van kinderafasie 13 betering getoon. ruimtelike orientasie lewer nog soms probleme op veral t.o.v. die liggaamsbeeld. 'n moontlike ligte vorm van disartrie mag die oorsaak hiervan wees. perseverasie. hy is glad nie meer so geneig om -die verbale spraak van 'n volwassene na te boots nie. hierdie vorm van perseverasie het dus afgeneem en tesame met hierdie verandering het die groter afhanklikheid van egosentriese spraak voorgekom. die gebruik van egosentriese spraak het weer bygedra tot die ontwikkeling van die hoer verstandsfunksies in die sin dat dit hom gehelp het met probleemoplossing en abstrakte orientasie. perseverasie kom egter nog in sy eie spraakpatroon voor, maar die jargon element het baie verminder. sosiale en emosionele ontwikkeling. pieter maak nou baie makliker kontak met ander mense, hoewel nog vir baie beperkte periodes. sekere gedragsprobleme het egter nou ontwikkel, soos woedebuie, jaloesie en in sommige opsigte, hiperinhibisie. dit mag egter 'n normale reaksie wees op die vordering wat reeds plaasgevind het. hy begryp nou beter wat om hom aangaan, maar sy beperkte insig in menseverhoudings veroorsaak nou gedragsprobleme. hy kan nog nie „deel" en „gee" nie, maar wil uitsluitlik „ontvang". aanbevelings. die volgende aanbevelings word gemaak, gegrond op die waarskynlike gunstige prognose en sy vordering tot dusver: 1. spraakterapie soos voorheen toegepas, maar gemik op die verdere ontwikkeling en verbetering van die verskillende vermoens en vaardighede. 2. arbeidsterapie met die oog op die verbetering van fisiese en verstandsaktiwiteite—veral a.g.v. die moontlike bestaan van 'n ligte graad van disartrie. 3. kleuterskool onderrig vir die versterking van terapie, sosialisering ens. 4. toetsing. hoewel dit tot dusver nog baie moeilik was om hom te toets, moet verdere toetse tog uitgevoer word om sy potensialiteite vas te stel en simptoomkomplekse uit te lig: (a) intelligensietoetsing. (b) persepsietoetsing. (c) persoonlikheidstoetsing. (waarskynlik eers op 'n latere stadium.) 5. beslissing oor plasing volgende jaar. verskillende toetse, o.a. ook skoolrypheidstoetse moet uitgevoer word om vas te stel of hy moontlik na 'n normale skool sal kan gaan en of plasing by 'n ander instansie, bv. die skool vir serebraalverlamdes, meer gewens is. opsommimg 'n interessante geval van kinderafasie word hier bespreek. volgens die neurologiese verslag blyk dit asof die breinletsel, a.g.v. serebrale bloeding net na geboorte, maksimaal voorkom in die linker frontale area, met 'n moontlike implisering van ander areas. die linker hemisfeer is blykbaar die dominante hemisfeer. volgens die spraakterapeutiese ondersoek, asook die gegewens verkry uit ander verslae, is 'n omvattende terapieprogram opgestel en uitgevoer. die resultate is baie bevredigend en die prognose blyk baie gunstig te wees. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 14, nr. 1: sept. 196 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 ε. swiegers and i. c. uys summary an interesting case of childhood aphasia has been discussed. neurological reports revealed brain injury resulting from post-natal cerebral bleeding. this appeared to be manifest in the left frontal area. the left hemisphere is apparently the dominant hemisphere. as a result of a very full investigation a comprehensive therapeutic programme was undertaken. the results have been satisfactory, indicating a favourable prognosis. journal of the south africanlogopedic society, vol. 14, no. 1: september 196 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) syllable and sound change in southern bantu languages e.o.j. westphal, m.a. (witwatersrand), ph.d. (lond.) head, department of african languages, university of cape town. summary the purpose of the paper is t o s h o w the restrictive effect of the temporal quantity [q] in s o u t h e r n bantu languages w h i c h , w i t h reference t o its c o m p o n e n t s , m a y also b e described as 'syllable'. all s o u n d changes occur w i t h i n iqj although there are harmonizing changes that e c h o the effects of [q] intersyllabically. opsomming die doel van hierdie studie is o m die b e p e r k e n d e uitwerking van die temporale kwantiteit [q] in die suidelike bantoetale aan te t o o n . met verwysing na die k o m p o n e n t e , kan [q] o o k beskryf word,as „lettergreep". alle klankveranderinge vind plaas b i n n e [q] alhoewel daar harmoniserende veranderinge is wat die effekte van [q] intersillabies weerspieel. on the occasion of this memorial publication dedicated to prof. p. de v. pienaar i wish to pay him a tribute . . . and to settle a 33 year old debt. in my undergraduate days i prepared an essay on sound change for him but i did not present it for scrutiny. instead i chose an easier alternative he had given me on another subject. what was in doubt at the time was the relationship between synchronic and diachronic linguistics, but since then the matter has arisen on frequent occasions and it is perhaps not inappropriate to present some parts of this essay on historical and contemporary sound change in southern bantu languages. on reading the important work by wallace l. chafe2 introducing his views on the nature of a 'semantic grammar' (meaning and the structure of language, 1970), i was struck by his repeated reference to a recapitulation of historical changes in the post-semantic processes he describes. he considers that certain changes, themselves being processes, should be described as processes also (chapters: 4.5,4.8, 5.4, 5.6, 20.6). in chomsky and halle's3 'syntactical grammar' such a description would not be 'explicit' in the required sense and phonological processes not yielding to 'feature phonetics' would be treated either as a phonological sub-component or would be relegated to the 'lexical component' hold-all. j my undergraduate essay was concerned with bantu consonants and consonant combinations which never occurred in given grammatical circumstances. for journal of the south african speech and hearing association, vol. 20 december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) syllable and sound change in southern bantu languages 23 example, the phonology of class 9/10 words was a severely restricted phonology in which certain 'prime' sounds never occurred. this phenomenon could be handled easily enough in terms of junctions of the prefix nof classes 9/10 of nouns with the noun root, but, on the other hand, there were derivations from such class 9/10 words — side by side with the derivations into class 9/10 that preserved the class 9/10 shapes of the roots and not the 'prime' shape: ve.: -rofhe 'mud' as in lurofhe 11 'thin mud' -tope 'mud' as in matope 6 'mud' cf. thophe 9 'heavy mud', dope 5 'very heavy clay or mud' in the secondary root -tope -r-/-fh are replaced by -t-/-pi.e. not only the root syllable is affected but also the second syllable not directly in contact with the prefix n-. in venda the processes by which r/t/th/d are associated can perhaps be derived from extant examples, but this is not always the case in other languages. in such languages the native speakers' insistence that certain words are semantically associated cannot always be verified in such a direct m a n n e r . . . especially in the absence of suitable examples of sound-shift: so.: kgiitsana 'orphan' and mofutsana 'poor, friendless person' though a comparison with other languages will demonstrate that there is a relationship of -fu with -kguand that -fu may be derived from **hy and **fy (cb*ky and cb*py), there is only one example that will support this derivation viz.: so.:-fub^du'red'with cl. 9 form kgub^du but see also: -kgutshwane 'short', kgiidu 9 'tortoise' there is therefore clearly a hiatus in the sotho relationships between -fu and -kguand there are formations and back-formations that cannot be accounted for as processes, though the spontaneous nasalisation of certain combinations is in fact a process in sotho. thus: so. -kgutshwane 'short' cf. xh. -fuphi, -futshane cb* -kvpi so. kgudu 9/10 'tortoise' cf. xh. ufudu 11/10 cb* n-kydv clearly fhe following is a back-formation and not a regular form: so. mafura 6 'fat' is derived from so. ** ma-pvta and not from cb* ma-kyta the fact that historical changes and historical derivations play a part in spoken language is a factor that would have to be built into a 'syntactical' and (generative) grammar' in the form of a 'popular etymology component'.. the basis upon which such 'popular etymologies' may be weighed is that of the processes as revealed by regular and attestable shifts. this is directly in line note: ve = venda. so = southern sotho. the double asterisk indicates 'proto-sotho' or 'common sotho'. the single asterisk or cb followed by a single asterisk indicates 'common bantu'. cedillas and bars under vowels in sotho are vowel marks. the cedilla is also used to indicate dental sounds in venda since it is more convenient than the traditional dental sign (viz. the circumflex under [t] or id]). the phonological processes are indicated by the use of capitals with double or single lines through them. thus: ν = nasalisation, ν = de-nasalisation, v= vocalisation, v = devocalisation. new symbols are * and d where the sounds [t l l and [d ] are not analysed as affricates but as single lateral plosives. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 e.o.j. westphal with chafe's2 proposal — even if, as he suggests, sounds that do not occur in the spoken language have to be hypostatized. the southern bantu consonants could thus be arranged in a paradigm capturing their essential associations with a 'prime sound' somewhat as follows: prime sound +passive +diminutive +causative prime sound c+v cw+v c(w)+v cy+v nasal + c nc+v ncw+v nc(w)+v ncy+v nc ν nc+v ncw+v nc(w)+v ncy+v there are of course other processes that will be revealed in the paradigmatic statement for each language. in this statement nhas the meaning of 'plus nasalisation' or '+nasalisation' while nhas the meaning of 'minus nasalisation (of nc)' or '-nasalisation'. the treatment of the consonants in this manner reveals the basic importance of a unit within which fusion takes place. this will lead us to a statement of the entity q. the terms at the head of each column have the following significance: +p = passive (in which -wis an essential element), +d = diminutive (in which in general palatalisations and velarisations are only effected when -q.-, -ο-, and -ufollow), +c = causative. the columns marked +w do not merit special differentiation of passive and diminutive forms. s o t h o (ipa o r t h o g r a p h y ) : . +p +d +c f f/w tshw/f/w ph p/hw tshw/ b djw di/djw p' p / ' w ts'w/ m qw m qw . +p +d r rw tsh/ th thw / t / h +c s . 1/d lw ts'/dj ts' t' t'w t / ' / t / ' w =fc +w +w prime c nc nc prime c nc nc prime c nc nc residual sounds: clicks, / , dj-j relationship. though the fricatives are derivative sounds, they are not entirely and satisfactorily derivative and, so, merit separate statement: y η nw nw η ny . +w 4+w 4-thi+w ( n y ) ijijw +w h/0,h uw x-kxh +w (i}) ny prime c nc nc prime c nc nc s tsh (ts') ts' / t a j t / ' in this statement the ip a orthography has been modified for both typographical and phonetic reasons. the lateral fricative series (shown by the symbols [4-] and [d]) and the lateral plosives (shown by the symbols [fc] and [d]) are journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) syllable and sound change in southern bantu languages 25 treated as single-movement sounds. the symbol [j] represents the voiced palatal fricative. xhosa (ipa o r t h o g r a p h y ) : +p +d +w . +w +w prime c ph t/hw t / w th +w ch 4+w kh/k' +w nc mp' nt/'w n t / ' nt' +w nc' nt' +w nk' +w nc' p' t / ' w t / ' t' +w c' k' +w prime c 6 c'w c' 1 +w j 4 +w φ, y +w nc mb ndjw n d j nd,l +w "j nd +w ng +w nc bh d j d j dh,lh +w jh dh +w gh +w prime c m nyw ny η +w (ny) +w nc m η +w ny +w nc mh nh +w nyh residual ounds: clicks, fricatives and vibrants (showr below): prime c f s / x nc mpf' nts' n t / ' x nc (k'r ) cts' ) (t / ' ) kx' (k'rh) (ts'h) ( t / ' h ) prime c (v) (r) (z) (y) (h) nc mv r nz n j h nc vh rh zh djh yh hh note: the bracketed pronunciations do not occur; only the tone-depressor pronunciations are found. no 'prime c' is a tone-depressor. though these paradigms do not reflect the ur-bantu or common-bantu soundshifts they will be seen to reflect the 'prime consonants' and the 'derived consonants' of each language, and, on comparison with other languages, of uror common-bantu. similar paradigms from some 40 or 50 other languages illustrate various degrees of complexity and various kinds of solution to the various problems posed in the sound-change situations, particularly those of the class 9/10 prefixes and of the passive. a full range of processes may be observed ranging from labialisations, alveolarisations, palatalisations, velarisations, devocalisations, vocalisations, and the like. in venda the processes of vocalisation and devocalisation and of nasalisation and denasalisation are active. in shona vocalisation is accompanied by implosion. what is not reflected in such statements is the underlying reason for the change which cannot simply be stated in these phonetic terms. this underlying reason may be hypostatised as a need for homogeneity within a particular kind of entity, the syllable. but such an entity is not provided by standard 'feature phonetics' or by any other phonology since it is assumed that whatever can be said about syllables is effectively stated in terms of their components . . . whatever these may be considered to be. in general the major elements incorporating whatever might be said about a hypothetical syllable are the vowels and consonants. yet, while two major divisions of speech tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 e.o.j. westphal sounds the vowels and the consonants are recognised there is no indication in modern theory why only 2 (perhaps 3) such major stratifications or divisions are made in the speech sounds of any given language . . . and not 4 or 5 or any number. the description of linearised speech sounds in whatever kind of grammatical segment they may occur (e.g. in-morphemes, words, phrases, sentences) lacks a fundamental coherence if it cannot be shown why vowels and consonants alternate in linearised sequences. phonologists arbitrarily and capriciouslyintroduce a major division of the speech sounds into vowels and consonants and then blandly state that they alternate in sequences such as c+v+c+v+ c+v etc. in both classical and modern (chiefly tg) grammar 'vowels' and 'consonants'.are regarded as axiomatic and there is no satisfactory explanation why they should be auditorily and functionally distinct nor is it shown how and where sound change occurs in a featureless sequence such as c+v+c+v +c+v. early attempts were made to introduce a coherence to phonological and phonetic descriptions by introducing the concept of 'a syllable', but with no marked success. the term has been used from middle english onwards, but in modern usage no reality could be given to the concept though it was felt to be a necessary concept. j.r. firth, according to f.r. palmer5 introduced the concept though he nullified its value by insisting that its behaviour could be adequately stated in terms of c+v sequences. chomsky and halle3 use the term though with a double meaning of '+vocalic' and '+syllabic consonant'. it is suggested by gillian brown1 that the terms 'syllabic' and 'consonantal' may be diversified as '+syllabic', '-syllabic', '+consonantal', and '-consonantal', though she also finds it necessary in her description to speak of 'syllables', 'syllable nuclei' and 'syllable onsets' while concluding that there is no justification for setting up a separate syllable generator. the result of this assortment is that nasal compounds are set up as the entity: +cons/+syll.. +cons/ -syll.. -cons/+syll, where the third element is the vowel. all this in a bantu language. the description emanates from chomsky and halle's3 treatment of the feature '+syllabic'. this they describe as one of their major class features: a 'sonorant' e.g. semivowels, glides, etc. b 'syllabic' e.g. vowels, syllabic consonants c 'consonantal' e.g. non-syllabic consonants etc. it is not difficult to see why the term 'syllable' is redundant in tg-grammar: it is built into the system of 'tg feature-phonology' as a synonym for what was earlier described as 'vocalic' and now carries the meaning of 'vocalic', 'syllabic consonant' and 'syllabic nucleus' or 'main syllable marker'. in the last sense it skirts the issue of syllable boundaries. this example, perhaps better than most, illustrates the opportunistic bases of tg 'feature phonology' . . . though those who have studied the 'evaluation measures' for determining 'complexity' by the 'markedness' or 'unmarkedness' of a sound, warn us not to come to a hasty conclusion on this point. | for those of us who would seek to establish auditory reality besides articujournal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) syllable and sound change in southern bantu languages 27 eality and acoustic reality it is important to know whether 'syllables' l 3 t 0 r y "ch an auditory reality. from an auditory point of view it seems that chomsky and halle3 have created a cover term for 'vowel' and 'syllabic consonant' as follows: -fsyllabic vowel syllabic consonant w h e r e jt can be shown, as it can be in the languages of the sotho group, that syllabic consonants have syllabic quality while consisting of a '+conant' and a '+latent vowel' element, the terms 'syllabic' and 'vowel' are reversible in the formula and are therefore synonyms. one of them is clearly r e d u n d a n t . if this is so then the authors could equally well acknowledge the syllable as a 'generator' and describe their major class features as follows: a 'syllabic' = sonorant (+ further features provided) b '+syllabic' = vocalic c 'syllabic' = consonant the single feature '(+-)syllabic' together with a restatement of the cavity, stricture type, and stricture degree features would then provide an absolute as against a contrived measure of complexity. whatever the result of such an application, the concept of the 'syllable' has by no means been dispensed with and the contrived 'unmarkednesses' devised to secure the smallest number of marked features will not obscure the need for it. indeed it has been built into the tg phonology as indicated, though as a synonym for vocalic. the framework provided by chafe's vastly more promising 'symbolization rules' in his semantic grammar is more capable of absorbing the syllable as a symbol and as a generator in directional speech leading (a) from a semantic structure to a phonetic structure as the articulatory output and (b) from a phonetic structure to a semantic structure as the auditory input. as chomsky and halle's3 terminology will show on examination, the auditory input is not their main concern, and other writers (e.g. fudge 19734) have commented on it. in southern bantu languages there is a temporal measure which, because of its relative and non-absolute nature, is not clearly revealed in experimental analysis. it is against this measure that we may judge one speaker to speak more rapidly than another, that we may say that some segments are longer than others in a sentence, that we may say that statements have a longer termination than questions, that some vowels are double-pulse vowels while others are merely long or short. i shall term the temporal quantity [q]. [q] contains several pre-phonetic features... by which i mean that it is not a symbolic abstract in the sense of firth's c+v successions. the essential markers of [q] are shown as its nucleus [/q/] and as its boundaries [#q q#]: (1) q->#q,/q/,q# + (q) however, [q] has certain functions that are localisable to one or other component just as the essential nature of [q] maybe stated in terms of the qnucleus and may be observed in the periodic recurrence of this nucleus. the localisable functions (which include tone, stress, duration) cannot be stated in terms of [q] itself but rather in terms of the q-nuclei and q-boundaries. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 e.o.j. westphal nevertheless they are functions of iq] and not of the components. the components in the nucleus and in the boundaries may roughly be characterised as [v] = vowels and [c] = consonants and statement (1) may then be expanded as follows: (2) q ((c(v)c), (q) where [c] is a consonant to be further specified and is a boundary, and where [v] is a vowel to be further specified and is a nucleus, while the right-hand [q] marks the recurrences. the corresponding tree diagram incorporating statements (1) and (2) cannot be stated until the localisable functions of [q] are placed. we thus invest the components [c] and [v] with these functions as follows: (3) c -> (c +stress prominence) (c -stress prominence) v-> (v +tonal prominence) (v -tonal prominence) v-> (v -hength prominence) (v -length prominence) the tree diagram then has the form: (4) 9 q *,q' / q / ^ q * i i 1 ; ! ; c v c (with features of stress, tonality, duration and : ί i others localised on one or other of these com! 1 : ι ponents) s d ' ( w h e r e s = s t r e s s > t = tonality, d = duration) where the locking c # is absent the temporal quantity may be said to be open, and where it is present it may be said to be closed. a closed q does not of necessity bring about a' change in vowel quality though it will almost certainly bring about a reduction in the duration of v. the s, τ and d features are not always confined to the components on which they are based e.g. as in the depressor-consonants of xhosa which anticipate the function of the tonal nucleus, or as the locking function of the nasal in nasal compounds of xhosa where the nasal element has a distribution in the preceding [q]. i should perhaps say explicitly that i am here concerned with the orthographic representation of auditory (not articulatory) features. the premature exclusion of these auditory features will severely restrict discovery procedures that will show some languages to be 'syllable number sensitive' and that will show that certain types of [q] permit a very restricted phonology only e.g. the bantu noun prefixes which are limited to 3 vowel sounds and 7 consonant sounds. the temporal quantity has a rhythmic nature though it clearly is not an exact measure of time as in music. at least one experiment can be set up with an journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 29 syllable and sound change in southern bantu nguages • flow meter to demonstrate the articulator basis of [q]. a l f ° mnonential statement in terms of its nucleus and its boundaries, the i t has a c ° " ^ t w e e n t h e s e d u t i e s b e i n g t r u e distinction between vowels and differenc ^ ^ w i t h c o r e d u t i e s a r e v o w e i s o r vowel-like while all c°n sh7with boundary duties are consonants or consonant-like each will therefore have its special functions according to its position in [q j. rnfhm tonal functions (usually but not only stated in terms of its [v]-coml u j i ~ a s t r e s s functions (which may be expressed by the v-component fc h very often with the introduction of boundary phenomena), duration (always stated in terms of the v-component or of the syllabic consonant c o m p o n e n t ) , loudness (stated in terms of [q]). rut fol also has features that have in the past been stated as functions of the consonants perhaps rightly in the case of some languages but which could also be stated in terms of the v-components, or, in terms of the whole unit. such features are e.g. aspiration in a series such as ph/th/kh or pfh/tsh/kxh ejection in a series such as p'/t'/k' or pf'/ts'/kx' voicing in a series such as b/d/g or bv/dz/gx or combinations of these as e.g. voiced aspiration in a series such as bh/dh/gh . . . these features can probably be multiplied endlessly as special features of consonants but they can and do also function as features of the vowels or of the whole temporal quantity. in this latter interpretation they will also be seen to interfere with tonality and can therefore also be stated as c to v transition phenomena as in the bushman languages. the following paradigmatic statement suggests the complete range of features that may be linked, according to the languages, either with [c] or with [v] or with [q]. in the statement it should be noted that voicing is an additive feature affecting [c] while aspiration [+h], ejection [+'], and, strangely, implosion [+"], (a laryngeal closure feature), are seen as vowel onset features. the frictionless continuants (such as the laterals, the nasals, etc.) and the vibrants are sounds that do not usually offer a choice in voicing: they are always voiced though they may be de-vocalised in certain combinations. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) e.oj. westphal (p) plosive (f) fricative (k) click clear +hv +'v +"v clear +hv +'v + ' v clear +hv +'v +"v ( 1 ) (2) (3) (4) (5) (6) (7) (8) (9) (10) 01) ρ ph p' φ f pfh pf' θ oh 0 ' t th t' · θ t th t' s tsh ts' / /h /' t s t§h t$' ! !h /' ch /, t / h t / ' c ch c' 9 (cph cq') f ^h φ' t th t' 4(t+h t4-') ii hh k kh k' x kxh kx' q x h +voicing b bh b' b* β v d dh d' j d 3h* d' d ζ d ? j j jh j' j ν ά dh d' 4 i gh g' g* x g g* κ / fi (n) nasal (l) lateral clear +h clear +h bvh bv' bo boh bo' (l) (2) (3) dzh dz' g/ g/h g/' ( 4 ) dtfi dz' g! g!h g!' (5) djh* dj' ( 6 ) (jyh jy') gφ gfti gf' (7) (d4h d4') g// g//h g//' (8) gxh gx' (9) (10) (11) (r) rolled (w/y) semivowel clear +h + ' m mh η 1 ή nh ϊ lh r rh <5i w wh (1) (2) (3) (4) n^ h τ yh (6) (7) n r (10) ( 1 1 ) footnote * ί = [ £ ]: 6 = [b]: d = [cf]: j = [3]: g = [g·] journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) and sound change in southern bantu anguages 31 notes ή errh mav be whispered in which case voicing is not an essential part a) a u o t h e r characters of the sound may then come to the fore and ° f «t^rehed upon for distinctiveness. h^the t r a n s i t i o n from c to v may be 'clear', 'aspirated' (+h),'ejective' (+'), aid pressed with implosion of c' (+*). these transitions may be affected by voicing. . c ) the auditory characters are the following: (p) plosion i.e. stop consonants (f) friction i.e. obstruent continuant sounds (k) click i.e. injective suction sounds (n) nasal (l) molar-lateral non-obstruent sounds (r) rolled or tapped sounds (w) semi-vowels though (n) (l), (r), and (w>sounds may be whispered their character is 'voiced' in a number of languages they may appear as'voice' in combinations with v-c transitions e.g. [nh] in olunhkumbi, an angolan language. d) the place of articulation is indicated as follows: (1) labial (lab) lip-front (2) denti-labial (del) lip-back (3) dental (den) tongue-tip (4) alveolar (alv) tongue-front (5) retroflex (ret) tongue-tip (6) prepalatal (prp) tongue-front (7) palatal (pal) ' tongue-back (8) palatal-lateral (lat) tongue-side (9) velar (vel) tongue-root (10) faucal-pharyngal (fau) (11) glottal (glo) (12) epiglottal (epi), not shown in charts. from the second column indicating the position of the moving parts (lips, tongue, uvulus, pharyngeal wall, epiglottis and. larynx) it will be seen that the fixed-position classification is incidental to control and that the moving-parts classification is much more to the point and possibly more economical to state. e) the palatal and palatal-lateral fricative sounds are bracketed in the chart since they are indistinguishable in practice from the relevant plosive sounds, cf.: [ch] and [c?h], [c'] and [c?'], etc. for 'voiced' [th] and [t-th], [t] and [t4-1, etc. for 'voiced' f) all compound sounds may be stated in terms of a double/treble involvement of the moving parts features thus e.g. [px], [tx], [tsx], [pk], [mi)j, and many more: tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 e.o.j. westphal lab. . pk +voiced ps p$ ρ / p5 px +aspirated φ s tfo qi/ ^g ^x +ejective del. fs f5 if alv. ts tx/tsx sx ppl. tf cx/t/x /x vel. kx g) since [q] is a compensatory unit (a unit limiting the extent of compensatory movements), it will follow that certain effects such as de-vocalisation, aspiration, etc. will be limited by it in the grammatical (morpho-phonemic)' processes. thus e.g. the de-vocalisation in sotho languages in class 9 may be compared with the vocalisation of voiceless plosives in herero. a specification in terms of this analysis will permit us to reduce the 'feature phonetics' of chomsky and halle3 to a mere 19 items, though, in order to do this, we must specify some selections as necessary selections and some as optional. thus e.g. 'voicing' is a necessary selection with vowels and the continuants while there is a 'voice choice' item with such distinctions as p/b, f/v, etc. with the above analysis the primary operators may be confined to (1) primary q-features (i.e. syllabic features) and (2) voice-production (glottal) features. all other features are 'modification features' and not 'production features'. in chomsky and halle3 the 'unmarked' features on which 'complexity' is determined are ambiguous in that they include both 'no entry' and 'minus' features. if full use of this convention is made then the features needed to specify any sound uniquely can be reduced from their 30 to a mere 19. the use of this convention is however contrary to their basic thinking which appears in the main to be that of 'articulatory control features'. if now we were to turn our attention from 'output' or articulatory phonetics to 'input' or auditory phonetics (leaving acoustic phonetics as a laboratory interest), and, if we were not to use the combined 'no entry/minus' unmarkedness, then the following would probably be a maximum of features required for an 'auditory control phonetics': 1.0 primary q-features 1 +syllabic nucleus +vowel -consonant 2 +syllabic diffusion +depressor c -syllabic c 3 +η (tone) prominence +h ' -l 4 +up-step +up-step -down-step 5 +duration -hong -'normal' journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) syllable and sound change in southern bantu languages 33 +stress +terminal 6 +stress prominence 7 +terminal crumble 2.0 airstream features g +clear 9 +hard 10 +voice obligatory 11 +voice choice 12 +pharyngal production 3.0 moving parts/place of articulation features 13 +-labial +bilabial 14 +-frontal +interdental 14 +apical +retroflex 16 +-radical +palatal 17 +lateral (molar) +lateral-molar 18 +faucal +pharyngeal 19 20 21 22 +clear +ejected +vocalized +voiced sounds +pressed -'normal' -non-terminal -aspirated -injected -devocalized -unvoiced sounds -scraped -dentilabial -alveolar -prepalatal -velar -laryngeal 4.0 degree operators (for 3.0 and for 1.1) -front/-back = central -high/-low = mid +front +back +high +low 5.0 release type features 23 + ρ (plosive) 24 +f (fricative and affricate) 25 +κ (clicks) 26 +ν (nasal continuants, voice obligatory) 27 +l (laterals, voice obligatory) 28 +r (rolled sounds) 29 +w/y (semivowels, voice obligatory) with the combined 'no entry/minus' convention these 29 features could be drastically reduced. clearly some of the associated features require further description e.g. the reason why 'clear/aspirated' are associated is in order to distinguish 'clear/turbulent'. similarly the '+hard','+voice obligatory', and many other features can only really be clarified from demonstrations in specific languages..this is not the right place in which to demonstrate these specifications. we are here concerned with the statement of the limitations imposed upon sound-change by [q] in the bantu languages. for this purpose it was necessary to place the 1.0 'primary q-features' within an updated framework. this has been done primarily with the thought of eliminating the ambiguity arising out of the use of the term 'syllabic' to denote vowels and consonants and to show that vowelness and consonantness are secondary to syllabicity features. a further thought was to provide the necessary auditory basis for the statement of sound change. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 e.o.j. westphal sound change this description is concerned only with telescoped syllables in bantu languages of southern africa. it is not concerned with the harmonisation processes in which grammatical and syllabic environment and not telescoping play a part. the harmonising processes may be described as inter-syllabic changes and the following is an illustrative (and therefore incomplete) list of such changes: a) accumulations of labial/rounded sounds cause change: ssotho: mmutla/mebutla 3/4 'hare' cv+ [b]v cc_+ [ m ] v / . . . mo+bv mm+mv venda: mmphasi/miphasi 3/4 'hubbly-bubbly' cf. -$asi cv+ [φ]ν cc+nφν c£+ [ p h ] v / . . . mu+^v mm+phv b) pre-harmonic vowel processes: ssotho: horekisa 'to sell' cf. horeka 'to buy' -rekr e k / . . . '+high vowel' i.e. i/e/^/u/o/q where a/e/o are '+low vowel' ssotho: -fqtse 'b. finished' cf. -fela 'come to an end' -fje -*• -fe-/... '+latent-vowel consonant' i.e. s/ts/tsh/ny/ng/some n, etc. c) post-harmonic processes (vowel and consonant): sound changes that are determined by a preceding syllable include the choice of the 'applied' extension according to the root vowel e.g. -ira/ -era/-ina/-ena, -irira/-erera/-inina/-enena, -ura/-ora/-una/-ona, -urura/ -orora/-ununa/-onona, etc.; the choice of the final vowel in languages like herero where e.g. okumuna 'to see' appears as -munu in the environment '-(-present tense action'. there are also consonantal processes where a root syllable will affect secondary root syllables in reduplications e.g. venda: phalaphala 9/10 'sable antelope' +n$ala+n$ala cf. wsotho phalafala +nfalafala and shona mharapara +nparapara. this process is also reversed in venda: kupalapala 20/8 'small sable antelope' ku-n^ala-n^ala where '-n' represents 'denasalisation' several tonal processes and the typical 'concord system' of bantu languages may also be seen in this light as anticipatory or pre-harmonic processes and as subsequent or post-harmonic processes. we may now consider any utterance in a southern bantu language as a movement across a reticle in which the interstices are temporal quantities formed by c and v alternations. the threads not selected in this movement remain as contrastive elements with a semantic significance of their own. in this model of speech consonants and vowels are selectional items together with a host of 'features' presenting some 2000 specifiable and unique q-entities for an average language of 40 consonants and 5 vowels. we have already specified q as having the following behaviour: q c+v, (q) in the reticulated model of utterance we must specify q-sequences as q-cohesions in which any q has ordinal position and in which the total number of q is always stated. the ordinal position of q states whether it is a root syllable journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) syllable and sound change in southern bantu languages 35 (with stress) and the count of the number of q states what prefix rules and what tonal rules shall be applied. in several languages monosyllabic stems require distinct prefixes and in almost all of them the number of syllables by which a word is reduced determines the tonal profile selected i.e. there is an order of deletion which is confined to the specified q-cohesions. we may thus also eliminate such rules as the following xhosa rule as an interim (inter-syllabic) rule: 2q (prefix) -*• 1 q / . . . '-(-polysyllabic stem' where the prefix contains the consonants [l], [b], [m] as in the prefixes ilicl. 5, ulucl. 11, ubu(v )̂ where v is a syllabic consonant with these marking conventions we may now describe sound-changes of a nonharmonising kind as q-reductions as follows: (a) examples of unchanged syllabic sta tus with soundchange 1q(c'+v) -*• 1q(c"+v) e.g. so. /i/-»· [ [l] ] / . . . '+e/e/e/a/o/q/o' [ [d]]/. . . '+i/u' e.g. so. / h h [ [s ]]/. . . '-h/e/e/e· [ [ h ] ] / . . . '+other vowels' [ wv . . . 'q2, q 3 . . . ' these are simply the allophonic rules in which the quality of a sound is determined by its immediate syllabic environment. these changes do not include the harmonisation processes. though there is an alternative rule which may be applied to the case where the vowels -e_and -onever occur before -s-, -ts-, -ny-, -ng-, -nng-, -tsh-, these environmental conditions are distributed over 2 syllables. they do not therefore have a place under this heading. (b) examples of unchanged syllabic status with added c 1. 2q(cv+v) remain 2q but insert a new -c-: e.g. herero oku+ -enda okuyenda, but also okuenda pattern: ol ' ' there are many patterns for dealing with juxtaposed vowels, even in herero where two vowels may be juxtaposed with no change and no insertion. cl. 14, ummcl. 3 and ummcl. 1 tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 e.o.j. westphal (c) examples of reduced syllabic status but with length compensa ή on 1. 2q(cv+v) -»• cvv e.g. ndonga oka+iga -»• okiiga oka+uli -»• okuuli okayiga okayuli oka+elo -»• okeelo oka+oko ·-»• okooko okayelo / okayoko oka+anda -*• okaanda okayandawhichever pattern of juxtaposition is employed there is either no loss of syllabic status or there is durational compensation. examples of reduced syllabic status but with tonal compensation 2. 2q(cv+v) 1 q(cv) with tonal compensation e.g. venda: **ma+ito->• mato'eyes'(note: in all other circumstances the noun prefix is l) examples of syllabic reduction but with conversion of v ^ c or with total loss of one v: 3. 2q(cv+v) -*• lq(ccv) e.g. xhosa: uku+enza -*• ukwenza uku+akha -»• ukwakha 4. 2q(cv+v) -*• 1 q(cgv)/... 'where two rounded vowels follow each other, but only in combination with c' e.g. xhosa: uku+ona -»• uk^ona ->• ukona a similar process may be observed in herero where a labial consonant is incompatible with a rounded vowel e.g. herero cl. 14 prefix: o^u-»• ou5. 2q(cv+v) 1 ( c c v ) / . . . 'where all but rounded vowels follow' e.g. xhosa possessive concord: si+a -»• saand b^+a -»• ba-, but lu+a -*• lwaexcept b^l+a ->• ba(d) examples of syllabic reduction with vowel coalescence / there are many examples of this phenomenon which also involves a latent vowel and includes the substitution of an invariable vowel. 1. xhosa" (coalescence) na+imiumu-»• neminomu\ ama-· ^nama-^ 2. shona (latent vowel, harmonic) ; na+mimu-»• neminomus n v s m a / / / ^ n a m a ^ journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) syllable and sound change in southern bantu languages 37 3. shona (vowel substitution) na+mimu-»• neminemu^ ^ m a ^ ^ ^ nena-/ 4. xhosa (syllabic vowel-harmonisation) there are numerous examples in many bantu languages of the assimilation of a suffixal element though this is done in such a way as to preserve the derivations: locative ** -(i)ni ci+ini cini cu+ini ->• cwini ce+ini -»• ceni co+ini cweni ca+ini ceni the bracketed vowel **-(i) is therefore a variable vowel which is i / . . . 'high vowel' -e-/ . . . 'low vowel' and which is preceded by the element w / . . . 'back vowel' (e) examples of reduced syllabic status but with vocalic penetration of c with these examples we now return to the consonantal paradigms for bantu languages. the most varied processes may be found in both suffixal and in prefixal positions. these processes also include consonantal modifications that are not always immediately apparent as changes resembling the allophonic rules but different from them in that they have to be established statistically and that some of them have to be described as the result of the juxtaposition of a vowel-sensitive consonant with certain vowels. though prefixal examples exist the vocalic penetration of consonants is far more frequently found in suffixal positions. nd. hamantu 'it is not a person' cf. ha+^muntu haantu 'it is not people' cf. ha+^antu haiyelo 'it is not doors' cf. ha+/iyelo hauyelo 'it is not small doors' cf. ha+^uyelo hangombe 'it is not a cow' cf. ha+^ngombe haongombe 'it is not cows' cf. ha+^ongombe xh. andinabantwana ί have no children' cf. andina+^bantwana andinasihlalo ί have no seat' cf. andina+/sihlalo andinasana ί have no baby' cf. andina+iisana andinankomo ί have no cow' cf. andina+/nkomo ί have no cows' andina+^nkomo andinamalume ί have no uncle' cf. andina+tfmalume ί have no uncles' andina+^malume nifuna bani? 'whom do you want' cf. nifuna ylbani? nifuna ^ b a n i ? nifuna ntoni? 'what do you want?' cf. nifuna /ntoni? lenkomo 'this cow' cf. le+jnkomo ' ezinkomo 'these cows' cf. ezi+j(inkomo lamadoda 'these men' cf. la+^madoda tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 e.o.j. westphal ababantu 'these people' cf. aba+^ibantu abafuni zihlalo zintathu uzithengileyo 'they don't want the three chairs you bought' cf. abafuni /zihlalo ^zintathu i^(si+u)zithengileyo. these xhosa examples have an alternative interpretation in the construction of two parallel series of prefixes, one a 'free prefix' and the other a 'junction (or bound) prefix' (f) 2q 1q with fusion (coalescence), harmonic change (coalescence), and substitution these rules are best illustrated with the prefixal element na'and, together with'. but also see possessives, nga'with' xh., etc. etc. 1. 2q(cv'+v") 1 q(cv"') + fusion of two vowels xh. nomntu 'and the person' na+i +u| -> neno-, cf. na+umntu \ +e +q nesihlalo 'and the chair' \ _ j t 2 cf. na+isihlalo nezintle 'and the good ones' cf. na+ezintle nomhle 'and the good one' cf. na+omhle 2. 1 q(cv') 1q(cv") + substitution of harmonic vowel (for -a-) sh. nomunhu 'and the person' na+ci na+cu cf. na+munhu navanhu 'and the people' cf. na+vanhu nemiti 'and the trees' cf. na+miti 3. 1 q(cv') -> 1 q(cv") + substitution of invariable vowel (for -a-) sh. nemunhu 'and the person' na+ci na+cu ne ne nevanhu 'and the people' nemiti 'and the trees' \ na+ca / \ ne. 4. 2q(cv++v") 1 q(cc.'v'") 1q(cv"') there are many other sequences of vowels than those of (a+v). these are too numerous to list from the various languages with vcv-prefixes and only one is brought here from the locative forms of nouns in xhosa loc. xh. **(i)ni (ci+ini cu+) -> icini cwinij \ceni cwenj/ ceni umthi 'tree' emthini, abantu 'people' ebaritwini, intonga 'stick' entongweni, umdlalo 'game' emdlalweni, indlebe 'ear' eridlebeni. the bracketed vowel **(i) is therefore a variable vowel which is determined as i / . . . '+high vowel' e / . . . '+low vowel' \ and which is preceded by ; w / . . . '+back vowel' journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) syllable and sound change in southern bantu languages 39 (g) 2q ->• 1q with modification of consonants and with vowel penetration. with these examples we now return to the consonantal paradigms for the bantu languages. the most varied processes may be found in both prefixal (e.g. cl. 14 utywala 'beer' in xh.) and suffixal (e.g. diminutive, passive, locative) positions. these processes of consonantal change may also include consonantal modifications that are not always immediately apparent. they resemble the allophonic rules but differ from them in that they have to be established statistically and by the absence of certain vowel sequences after given consonants. these changes all have the pattern of: 2 q ( c ' v ' + v " / c v " ) 1 q ( c " 1 v " / c v " ) in which c " is the modified c the modifications are of the following kinds: labialisation: c(t)+v) cf. ve. retroflexion alveolarisation c(a)+v) cf. so. lefifi/lefitshwana retroflexion c(ft)+v) cf. ve. ulisa/uliswa [s] palatalisation c(p)+v) cf. xh. umlambo/umlanjana velarisation c(w)+v) cf. so. molamu/molangwana the following are manner of articulation modifications: implosivisation c(=)+v) cf. sh. dombo/matombo vocalisation c(v)+v) cf. ve. dombo/matombo devocalisation c(v)+v) cf. xh. **ubu+ani -* utyani these modifications are far too numerous to describe in detail in this paper but they are processes that will generate a great many sets of new consonants. a detailed statement of one example will suffice to illustrate these modifications: xh. umlambo+ana/umlanjana dim. 'river' <^u-mm-la:-mbo + ana-»· ^u-mm-la-mbw+a-na ->• $u-mm-la-mb(p)ika-na ->• 0u-mm-la-nja:-na the intrusive element in the above examples is a semivowel. it is not necessarily the velar semivowel though the result of the modification would appear to be the same (in several languages) for both w/y. • (h) 2q(c+cv) -*• (ccv) these are perhaps the most interesting and most widespread and best-known of the sound changes in bantu languages. they include 'nasalisation' (classes 9/10) and the many interesting effects arising from the loss of the class 5 prefix though this prefix may often be reinstated together with its effects. the presence of these changes means that classes 9/10 and class 5 virtually have their own greatly restricted phonology as indicated elsewhere in this paper. nasalisation in classes 9/10 the term 'nasalisation' represents a great variety of changes in not all of which there is invariably a nasal. these changes may be found with classes 9/10, with the reflexive (in sotho), with the object concord (in sotho, pedi, etc.), and in isolated cases elsewhere. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 e.o.j. westphal the prefix is hypostatised as ν which, for the southern bantu languages certainly, is a velar nasal with a possible latent vowel element. it is the velar aspect together with the vowel that is the basis of the formations which include the reflexive with no nasal element in sotho perhaps in the following starred sb** forms: sb** n+cv 1q(ncv) for cl. 9/10 nn+cv -» 2q(nn+ncv) for the object concord in sotho g¥i+cv -» 2q(gi+¥cv) for the reflexive infix in sotho the details are too numerous to exemplify and the following is no more than a comparative survey to mark the different kinds of stages of southern bantu 'nasalisation' illustrated from the labial only: n + cv-* 1q(ncv) yei: n+p->mp 1 q(n+effect+cv) nkhumbi: n + p ^ mhp 1 q(nc+effect+v) chewa: n+p -> mph xhosa: n+p^-mp' lq(nc+effect+v) sotho: n+p tfph lq(n<2+effect+v) shona: n+tf^mtfh 1 q(nc+effect+v) herero: n+p -> mb (also n+b -> mb) lqqjc+effect+v) sotho: n+b -» rip' effects of class 5 prefixal elements the effects that require description here are of two kinds viz. (1) a glottalisation process (implosion and voicing) in shona and venda and (2) a yotization process that will differentially summarise the shifts to alveolars and to labials (where *y is involved) in venda and in sotho. the shifts of the consonants can very incompletely be summarised as follows: (1) shona ¥ + ρ b t ->d k ->-g (implosive, voice) (voice) (2) shona ¥+ p -*· b t -*• d k -»-g venda ¥+ p -*· b t -»• d k -»-g venda ί + φ r h φη^· fu ru -*• pfhu hu fu β ν 1 dz φ -*• dz 0u->vu lu dzu 0u->· sotho i + { •* tshw r -+s,f h s b -> ts 1 -*• ts φ the processes are experimentally stated as follows: qp + q' (qp) + q" where qp is the prefix syllable and q" is the modified form of q' qp(c£i) + q(cv) -> ( qp(0) + q(scv) where € is the consonantal pro, cess and where the qp or prefix ( qp(lyi) syllable shows three venda and ( qp(li) sotho forms ea -> (¥ci ' (i=ci and u c i / . . . '+labialised vowel [u]' vci -*• c¥i ici cii and cui journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) syllable and sound change in southern bantu languages 41 from these latter forms it will now become evident why the results of the consonantal modifications are so similar to those of *cyv in these two languages. examples of these shifts include such as the following: (1) venda shambo/ marambo 'bone', shubi/marubi 'ruin', fumi/mahumi 'ten', shada/mahada 'shoulder', dzuvha 'pumpkin flower' cf. maluvha 'flower', vele 'seedgrain' cf. mavhele 'grain, maize', luvhele 'millet', vudzi/mavhudzi 'hair' (2) sotho: lesapo — lerapo 'bone', lesome 'ten' letsopa 'clay' cf. ve. vumba, letsoho_ 'arm', letshwafu 'lung'. in lovhedu, dogwa, pulana, and pedi and in birwa many further changes will be found. the centralising (alveolarising, palatalising) and frontalising (labialising) effects of this prefix are ascribed to the elements and **u and for this reason the effects of the process resemble those of **y and **w (in passives occasionally, and diminutives frequently). references 1. brown, g. (1970): syllables and redundancy rules./, of linguistics, 6, no. 1. 2. chafe, wallace l. (1970): meaning and the structure of language. university of chicago press. 3. chomsky, n., and halle, m. (1968): the sourid pattern of english. harper and row, new york. 4. fudge, e.c. (1973): on the notion 'universal phonetic framework'. in phonoledsi, ed., fudge, e.c. penguin books. 5. palmer, f.r. (1973): prosodic analysis. in phono led31, ed., fudge, e.c. penguin books. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) c e r e b r a l p a l s y and t h e b o b a t h t r e a t m e n t . b y w.m. guldenpfennig. b.sc. (med.), m.b., ch.b., m.med.(neur.) 1 diagnosis, severe cases of cerebral palsy, presenting with pronounced abnormalities, are only too common. a palsy from cerebral causes can, however, be very mild presenting mainly as clumsiness or lack of full motor development, with or without mental retardation. in such cases precise diagnosis can be difficult and various conditions have to be considered. cerebellar defects present as clumsiness. some children are slow to walk and to speak and slow to learn complex motor activities due to mental deficiency. a somewhat similar condition is occasionally encountered in children of normal mentality with no signs of cerebral palsy to this is given the name "congenital maladroitness". the diagnosis of cerebral palsy is a clinical and not a pathological one. various types of cerebral palsy, e.g. diplegia, hemiplegia, choreoathetosis etc., are all clinical concepts each of which can be seen with various neuropathological conditions. accurate clinical diagnosis and assessment, together with response to treatment and the end result of such treatment, is important; not only from a purely clinical point of view, but also with a view to correlation with neuro-pathology and as a basis for further research work and development of newer therapeutic methods. from such careful clinical appraisal, the bobarth treatment for example developed. ί on the pathological side, brain biopsies are more often undertaken nowadays and gradually information is being accumulated which may later aid in morej accurate diagnosis and one hopes, in more specific treatments. an interesting newer field, is the study of abnormalities in chromosomes or chromosomal patterns. this work is also being done in pretoria and a project for the future is the study of the chromosomes in cerebral palsy. it is already well known that conditions such as mongolism and the klinefelter syndrome, are most probably due to an abnormal number of chromosomes. 2. physiology. in the second place, i wish to mention briefly some of the neuro-physiological factors involved in cerebral palsy. the accent in cerfebral palsy is apt to be on the motor abnormality, and with this in mind, we are often inclined to split up motor function into so-called component parts and even to speak of higher and lower levels of motor function, forgetting sometimes that normal motor function is one perfectly integrated whole in which no level is higher or lower in importance or effect, as every part of the motor system is necessary for normal function, each playing its part as required. furthermore no motor system can function efficiently without a sensory input and the sensory input may be regarded as the most important factor in motor function, whether this be in the spinal cord or in the physical sphere. for purposes of description, however, we must divide up the nervous system and speak of various functional systems. (a) cortical. we all know the importance of the sensorimotor area of the cortex in discreet actions or movements. the exact functions of the various cortical layers are still not known and although a great significance has been attached to the large betz cells in the fifth layer as origin of the so-called pyramidal tract, we know today that these cells alone cannot account for all pyramidal fibres and functions. many other cells in the sensori-motor area take part in the formation of the pyramidal tract, and these different types of classes of fibres from the cortex, have slightly different functions. two of these, for 11 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) example, are the alpha motor pathways and gamma motor pathways from the cortex supplying impulses to the alpha and gamma motor efferents to muscles via the anterior horn of the spinal cord. the activity of these systems depends on cortical and subcortical activity. it was found that the cortex as a whole, not only possesses a potential excitability, but that it is probably at most times in a varying state of inhibition. this cortical inhibition may be altered by various routes, one of which, e.g. is thought to function as a feed-back system from the cortex, through the basal ganglia and thalamus back to the cortex by which means .the state of cortical inhibition can be increased or diminished, depending most probably on the rate of discharge by the feed-back circuit. this feed-back circuit is in its turn influenced by other circuits from the basal ganglia, the reticular formation, the cerebellum, the vestibular apparatus, and the spinal nerves and the muscles. an example of extreme cortical inhibition is to be found in many cases of post-epileptic paralyses, where the inhibitory effect may be so strong as to cause temporary complete paralysis of a limb or limbs. the importance of the state of cortical inhibition lies in its effect on muscle tone as well as its effect on phasic contractions. (b) reticular system. one of the most important mechanisms in motor effect is the reticular system of the brainstem, which by its. wide spread afferent connections and its diffuse projections to the cortex via the thalamus, plays an extensive role in all motor functions. cerebellar effects on motor function are in part exerted through fibres from the purkinje cells which pass to the reticular substance. the frequency of impulse formation is thought to cause either facilitation or inhibition. probably slow rhythmical impulses cause inhibition. when cortical inhibition is diminished, more alpha motor neurone firing occurs, so that the balance balance between alpha and gamma effect is disturbed and increase of muscle tone then results. such conditions may occur in parkinsonism, e.g. where due to loss of function of the substantia nigra, less modulating effect is exerted on the feed-back circuit, increased speed of impulse formation passes through the thalamus, decrease in cortical inhibition and therefore, relative increase in alpha motor effect occurs with resultant increase in muscle tone. i may add here that the substantia nigra, nucleus ruber and corpus subthalamicum are regarded by some merely as specially developed parts of the reticular system. not only does this system have its effect on the basal ganglia, thalamus and cortex, but it also has a more direct effect on spinal functions and especially on muscle tone. its effect is most probably in the region of the internuncial neurone rather than on the anterior horn cell itself. the vestibular influences on spinal functions are to a large extent dependant on the close connections with the reticular system. (c) spinal cord. in the spinal cord we find the continuation ofthe reticular system, where again it plays an important part in facilitation and inhibition. in traumatic paraplegia for example, it is thought that due to the local abnormalities, artificial synapses are formed, so that afferent impulses in the region of the injury are easily transmitted causing reticular facilitation and therefore, resulting in spasticity. because of the inhibition or facilitation that can probably originate in the cord itself, a second transection of the spinal cord can increase spasticity, by increasing local facilitation. (d) muscles. we have recently read more and more about the effect of the gamma system on muscle tone. this gamma system depends on socalled muscle spindles in between and parallel to the other muscle fibres, which function as indicators of change of muscle tension. through sensory afferents from these spindles, different degrees of facilitation of the anterior horn cells and the alpha motor efferents are effected, causing change in muscle tone. these muscle spindles are in their turn supplied by special gamma efferent fibres by means of 12 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) which their own tension and therefore sensitivity, can be altered. s u m m a r y . from, this short discussion on some aspects of neuro-physiological function, one realises that the nature of normal function is still very obscure and that abnormalities are therefore very difficult to explain. it is, however, the abnormalities that necessitate treatment, and if is from clinical observation of abnormal function and the manner in which normal and abnormal function can be influenced, that the bobarth treatment was evolved. opsomming. uit hierdie kort bespreking oor 'n paar aspekte van neurofisiologiese funksies, is dit diiidelik dat die aard van normale funksies nog steeds baie onbekend is en daarom is abnormale funksies baie moeilik om te verklaar. dit is egter vir die abnormaliteite wat vehandeling nodig is en uit kliniese waarneming van die abnormale funksies en die manier waarop normale en abnormale funksies beinvloed word, het die bobathbehandelingsmetodes ontstaan. 13 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 35 the mind-mapping approach (mma): a culture and language "free" technique caroline m. leaf isobel c. uys brenda louw department of speech pathology and audiology university of pretoria abstract although the roots of the mind-mapping approach (mma) reach back into the depths of psychology, it is our growing understanding of the human brain, how it functions, what affects it, how we can assist it which has become the real foundation for the model discussed in this paper. by finding ways of creating environments that are brain compatible or rather brain enhancing, we can begin to serve the whole person in all his dimensions. in this paper the need for language and culture "free" therapeutic techniques will be discussed. reference is made to the author's research where the mma was used very successfully with a closed head injured (chi) client in order to demonstrate the effectiveness of the technique. the problem of chi is also discussed. in addition, a brief theoretical review of the brain as it pertains to the concept of the mma is offered. in the conclusion, it is suggested that global techniques such as the mma, which are based on fundamental and universal principles, are the route to finding language and culture "free" techniques. alhoewel die oorsprong van die breinkaartbenadering tot die grondbeginsels van die sielkunde teruggevoer kan word, is dit ons toenemende begrip van die menslike brein, die funksionering daarvan, waardeur dit beinvloed word en hoe breinfunksionering ondersteun kan word, wat die werklike grondslag uitmaak van die model wat in hierdie artikel bespreek word. deur wyses te vind vir die daarstelling van omgewings wat breinfunksionering versterk, kan η vertrekpunt gevind word vanwaar ons die klient as geheel in al sy dimensies kan benader. die behoefte aan "kultuurvrye" terapeutiese tegnieke word bespreek. daar word verwys na die outeur se navorsmg waar die breinkaart as terppiemodel met sukses aangewend is by 'n geslotehoofbeseerde klient. die problematiek van geslote hoofbeserings word ook bespreek. daarbenewens word 'n kort teoretiese oorsig van die brem, met betrekkmg tot die konsep van die breinkaartbenadering tot intervensie, verskaf. ten slotte word daar voorgestel dat globale tegnieke soos die breinkaartbenadering, wat gebaseer is op fundamentele en universele beginsels, die weg is waarvolgens "kultuurvrye" tegnieke gevind sal word. opsomming die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 introduction speech-language and hearing therapy can be defined as "the delivery of services to (all) individuals with speechlanguage-hearing disorders, aimed at the amelioration of communication difficulties stemming from such disorders" (uys & hay, 1985). therefore, the provision of quality services to all groups and individuals is the goal of speech and language therapists worldwide. however, socio-economic, sociopolitical and demographic shifts over time have intensified "existing inequities in service delivery to specific groups" (asha, 1991:5). in fact a great deal of disparity in service delivery exists in the profession (asha, 1991). taylor (1986, ρ 3), attributes this disparity to two factors viz: speech therapists have a poor perception of the distinction "between a legitimate linguistic difference and a speech and language disorder". secondly all communication norms are based on a middle-class euro-american model (taylor, 1986). clearly, there is a need for greater understanding of dialect and language differences and for a clinical perspective that appropriately addresses these differences. in south africa it is extremely difficult to meet the needs of all individuals and to fulfil these goals as speech therapists are faced with two unique problems, namely: the therapist-patient ratio which is approximately 1 : 6000 annually; and the widely spread, multicultural, multilingual society (uys & hay, 1985). therefore, in order to be effective, a therapist needs to learn a minimum of 30 languages and as many cultures (uys & hay, 1985). based on this argument, a therapist is not able to give effective accountable therapy cross-culturally. hence, the need arises for culture and language free techniques that deal with this problem. in this article, the mind-mapping approach (mma) developed by leaf (1990) for closed head injured (chi) patients, will be discussed as a possible language and culture "free" t e c h n i q u e for the m u l t i l i n g u a l and multicultural population group specifically of south africa. the authors view language and culture as interdependent concepts, thus the language used is a reflection of the culture. the mma is a metacognitive technique and therefore the linguistic elements are not worked on directly. thus, language is used as a tool in the mma, as the mma is a metacognitive technique (leaf, 1990). if linguistic delays are presented by the client, these can be treated within the framework of the mma. mind-mapping : a therapeutic technique for chi. chi presents speech and language therapists with a unique diagnostic, prognostic and treatment challenge as a result of the widespread diffuse damage experienced by these patients, as well as the tendency to a lengthy recovery (hagen, 1984). the general lack of understanding of the sequelae of chi has inhibited the development of assessment tools, and few treatment guidelines have been proposed in literature. thus there is a need for clinicians working with head injured patients to be able to identify and develop treatment regimes, that have functional goals caroline m. leaf, isobel c. uys, brenda louw involving behaviours that will make a difference in the way each person functions in his or her cultural environment (adamovich, 1986). due to the need for the development of accountable therapy techniques that deal with the complex problems of chi, the strategy of mind-mapping therapy was developed and tested on a chi subject (leaf, 1990). as this research yielded exciting results, the technique will be elucidated in order to demonstrate the flexibility and effectiveness of this approach. it also provides a theoretical underpinning for the proposed concept of the mma as a culture and language "free" technique. the mind-mapping approach (mma) can be defined as a technique that organises and taps information in the brain by stimulating a synergistic effect between both hemispheres (leaf, 1990). it is a way of structuring information that assists in the learning of new information (leaf, 1990). as it is a psychoneurogenic technique based on the complex functioning of the brain, a brief theoretical review on the functioning of the brain as it pertains to the concept of the mma is necessary. the relationship between the functioning of the brain and the mind-mapping approach (mma). it is an often quoted statistic that humans use only 10% of their potential brain power. however, the more researchers have learnt in the last 10 years, the less likely they are to attempt to quantify brain potential. the only apparent consistent conclusion is that the proportion of our potential brain power that is used is probably nearer 0.1% than 10% (russell, 1986). in order to more fully utilize the brain's capacity one needs to consider each of the elements that comprise the way the brain functions. once one begins to understand how the brain operates the way is opened to tap that vast unused potential. in this regard sperry (1982), the pioneer of the first 'split-brain' experiments, that is cerebral localization studies on the functions of the two hemispheres, indicates that the integration of the left (more analytical) hemisphere and right (more creative) hemisphere, leads to enhanced functioning whilst thinking and learning. ! the general opinion in the available literature is that the two hemispheres process information differently (dual brain theory). the intensity of the involvement of each depends upon the specific task (sperry, 1982). for example, the hemispheres do not recall in sentences but in key / concepts and images (ornstein, 1975). of the words heard, / spoken or seen, only 1% to 10% are essential key words (buzan, 1991). every word is multi-ordinate, i.e. it has a large number of links to other words (buzan, 1991). in addition to this multi-ordinate nature of words, each brain is unique in the way it perceives images and is by nature both creative and organising (zaidel, 1985). finally, because recall is in images and words as opposed to sentences, thought processes are multi-dimensional and nonlinear (buzan, 1991). , ornstein indicates that by cultivating both hemispheres, the brain returns to a natural holistic way of functioning which in turn unlocks potential. thus, stimulating a synergy between the two hemispheres is critical to effective accelerated learning. hagin (in van kraayenberg, 1992), has pioneered research using techniques that stimulate brain hemisphere synergy on severely learning disabled children with remarkable success. some of the techthe south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the mind-mapping approach (mma): a culture and language "free" technique 37 niques he has researched are ambidextrous writing and numerical techniques. an additional example of this important research is research in the field of cerebral functioning, that has been conducted over the last 15 20 years, namely the attempt to ascertain the biological processes involved in learning and memory (rosenzweig & bennet, 1976). it is well documented that the brain is adaptable and that the brain appears to compensate for the damaged nerve fibres by: rerouting to alternative areas, the development of innate potentials in other areas of the brain, and gradual recovery from shock caused by injury (luria, 1982). a fact that has also emerged from this research and that is very useful in terms of an evolving philosophy of remediation is that these experiments have seemingly confirmed the susceptibility of the brain to actual physical and clinical changes resulting from training or enrichment of the environment (rosenzweig & bennet, 1976). the possibility therefore exists that, under the right conditions, neurons may regenerate themselves, and be capable of growing new fibres indicating that they do have the genetic potential for reproduction. it has not yet been ascertained whether or not such a regeneration can occur in a normal nervous system, but the brain appears to make the maximum use of the possibilities open to it, and one of the most likely places to find such changes in nerve cell tissues would be in damaged tissue (russell, 1986). rosenzweig and bennet (1976) indicate that much of the research done in this area will undoubtedly lead to applications such as the alleviation of learning disability caused by neural malfunctions in perception, the prevention of senile decline in memory and learning, and better means of packaging information to aid learning and retrieval. this is the principle on which mind-mapping therapy (leaf, 1990) is based. of particular interest to the above concepts is the research by scott (1976), concerning neuron regeneration. scott (1976) found that neurons can be induced to reproduce themselves if placed in a medium enriched in potassium ions which are veryj important to axonal electrical conduction this is called the k-mitotic effect. scott (1976) argued that human adult neurons have the genetic potential to reproduce themselves. unfortunately, however, the intriguing question is still left open as to why these neurons cannot exploit this reaction so as to produce true regeneration. scott's findings, do however, make some inroads into the traditional idea that the neurons of the central nervous system are incapable of regeneration. in evaluating the results of applying the mind-mapping strategy to a chi patient (leaf, 1990), spontaneous recovery cannot be overlooked as it is a controversial issue in terms of its interaction with treatment. it is estimated, that spontaneous recovery in a chi subject extends up to 18 months post-accident (adamovich, 1986). an additional complicating factor is that uncertainty exists about how treatment interacts with spontaneous recovery (adamovich, 1986). based on the foregoing discussion on brain functioning, it is possible that mind-mapping therapy encourages spontaneous recovery to extend beyond the spontaneous capacity of the brain for physiological and structural change. therefore, the mma is a neuropsychological metacognitive-communication intervention technique that attempts to utilise to the fullest possible extent, the functional plasticity of neural tissue (leaf, 1990). the concept is based on the idea that if the brain is given suitable and varied stimulation, it will continue developing and growing through life (rosenzweig & bennet, 1976). it is hypothesized that when mind-mapping therapy is initiated, luria's (1982), process of intersystematic and intrasystematic reorganisation occurs. as the environment becomes enriched and progressively more organised as a result of this stimulation, new unused areas (previously not stimulated) take over function. as a result of this, an increase in potassium and sodium at the synapses probably occurs. these are important neurochemicals that can encourage collateral sprouting and regeneration of damaged neurons (scott, 1976; russell, 1986). the latter point has only been proved in the central nervous system (cns) of animals (scott, 1976) and, as most of our neuropsychological knowledge is based on application of animal research to humans, the above is a plausible deduction (leaf, 1990). therefore, it is hypothesized that humans have a preset template of cognitive functioning that is moulded by the environment and mediators (significant people in the environment). in the brain's functional systems, however, there are other stores, i.e. potential connections that if stimulated, can carry out the cognitive activity lost or disrupted. the rationale for this is the unlimited potential of the brain and our underuse of it, that is we limit our brain by only using certain functional systems, whilst others lie dormant. if disruption due to brain damage occurs, the brain tries to restore equilibrium via compensatory strategies, for example, the patient elaborates, circumlocutes and perseverates (penn and cleary, 1988). in the mma, the therapist acts as a mediator, and through a process of stimulating both the right and left hemispheres, the patient is assisted in searching the subconscious, unused stores to urdock this dormant potential and/or stimulate the regeneration of neurons (known as the k-mitotic effect). ylvisaker and szekeres (1986) also feel that increased spontaneous recovery can be effected by providing an enriched environment. according to leaf (1990), this concept advocates a plasticity of the brain with a reorganisation emphasis, as opposed to plasticity of the brain with a change in localisation of function emphasis. therefore, with the mma it is advocated that a new area of the brain is stimulated to learn to perform the function and, in doing this, the possibility that an enriched environment enabling regeneration and therefore restoration of the damaged functional system occurs. this new concept stimulating brain hemisphere synergy, implies learning as opposed to equipotentiality and substitution, which implies a pre-existing spread of any function over the area this underestimates the potential of the brain (powell, 1981). there are many uncharted areas in the brain, and we are only beginning to understand our abilities. for instance anokhin (1985 in russell, 1986) calculated that the brain is capable of making 1 followed by 10 million kilometres of typewritten 0's of connections. furthermore, he estimated that an area the size of a pea in the human brain could control the entire world's telephone network system. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 caroline . leaf, isobel c. uys, brenda louw development of a conceptual framework as a rationale for developing the mind-mapping approach (mma). the concepts of brain-behaviour relationships, cognition and information processing will be discussed in the following section, in order to elucidate the rationale of the mind-mapping approach (mma) developed by the first author and used with a chi subject (leaf, 1990). brain-behaviour relationships luria's emphasis on understanding brain functions as interlocking functional subsystems has been a particularly important concept in the mind-mapping approach (luria, 1982). while the diffuse and complex neuropsychological deficits that seem to accompany severe traumatic head injury make it difficult to apply lurian assessment and remediation techniques, his general approach to appreciating the interconnectedness of many cognitive functions has been vital. according to luria (1982), the destruction of cortical tissue has an effect on the entire functional system to which it contributes because a link within the functional chain has been weakened or damaged. two situations can occur, namely:intersystematic incorporating a new link from a different functional system; intrasystematic vertical shift within a functional system (luria, 1982). in the mma it is hypothesized that, initially both intersystemic and intrasystemic reorganisation occur (leaf, 1990). this could lead to the areas around the neurons becoming enriched because of this stimulation resulting in two possible occurrences, namely:new unused areas take over function; and collateral sprouting and regeneration (scott, 1976) occur resulting in restoration of function. restoration to original and possibly higher levels of original functioning may occur. l b conclude: by applying lurian concepts mind-mapping therapy can be better understood. in the next section mind-mapping therapy will be viewed from the cognitive perspective in order to further elucidate this concept. the authors feel that a paradigm shift as to how we view our mental capacities, and those of our clients, is essential if we are to be more effective in our changing south africa. cognition. from the perspective of the information processing model, cognition involves a complex process with which an individual processes information for particular purposes, within certain mental structures and environmental constraints (ylvisaker & szekeres, 1986). cognition is viewed by feuerstein (1980) as mental acts that enable a person to think and therefore act intelligently. he adds another dimension to his definition by stating that well developed cognitive functions are the product of mediated learning experiences, i.e. the way in which stimuli emitted by the environment are transformed by a "mediating" agent, usually a parent, sibling or other caregiver. through this process of mediation the cognitive structure of the child is affected. the child acquires behaviour patterns and learning sets, which in turn become important ingredients of his capacity to become modified through direct exposure to stimuli, hence cultural differences. since direct exposure to stimuli quantitatively constitutes the greatest source of the organism's exposure, the existence of sets of strategies and repertoires that permit the organism to efficiently use this exposure has considerable bearing upon cognitive development. feuerstein's objective therefore, is "to change the cognitive structure of the retarded performer and to transform him into an autonomous independent thinker capable of initiating and elaborating ideas" (hobbs in feuerstein, 1980:viii). this concept of modifiable cognition is what the first author's research aimed to investigate, thus feuerstein's orientation is considered a further critical aspect of mma theory (leaf, 1990). feuerstein (1980) is interested in how the organism learns and solves problems. in mma therapy, the thought processes of the brain are being stimulated as information is being structured according to the way the brain functions. thus, deficient thought processes and learning skills can be identified as the mind-maps are being constructed because the clients' thought processes are being evaluated. at the same time, correct patterns can be set up, which would be therapy. feuerstein's (1980) interest in the formal structure of thought as opposed to the content of the mind, has relevance in that, with the mma which, aims at improving information processing, and cognitive processes, the formal structure of thought is also being improved. l b summarise, the mma, like the feuerstein approach, becomes a teach-test-teach paradigm and the therapist tries to promote the best possible learning and motivational conditions. the mma programme progresses through simple to complex reasoning tasks. it is dynamic because the person's learning style is assessed in the act of learning which highlights the metacognitive strategies and styles that the person is using. the technique also encourages the individual to take charge thus ensuring carryover. this in turn, guides specific therapeutic intervention (leaf, 1990). in the following section the mma is further evaluated in terms of information processing. information processing. i information processing refers to the analysis and synthesis of information in sequential steps (neisser, 197,6 in ylvisaker, 1986). information processing abilities can be divided into three stages, namely:j regulation of input j encoding storage retrieval i regulation of response (ylvisaker & szekeres, 1986).1 these stages become the goals of developing information processing skills. in information processing terms, humans are seen as highly sophisticated computers with elaborate programmes. viewed from this perspective/the mma can be seen as the operating system somewhat comparable to ms dos (the operating system of a computer) of the brain allowing the programmes to work and, the more efficiently the operating system is,being used, the greater the functioning of the programme. the techniques, forms and manner of the mma. the term 'mma rehabilitation' is used in a very broad sense to indicate the treatment of the cognitive communicative deficits identified in patients, namely: cognitively the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the mind-mapping approach (mma): a culture andlanguage "free" technique 39 based communicative, behavioural and psychosocial deficits, as well as the narrowly defined deficits in component systems and processes (ylvisaker & szekeres, 1986). since the scope of the mma is broad, an attempt is made to make it more manageable by distinguishing the general principles, forms and manner of the approach that guides treatment decisions. the general principles provide the environment with therapy: the form of intervention provides the philosophy: and finally, the manner of intervention provides the way information in therapy is analysed. the mind-mapping technique described in this article was evolved into a specific treatment approach for chi by the first author based on a literature review, and research. thus the mind-mapping protocol is original research and is supported by a strong theoretical base (leaf, 1990). the techniques of the mma rehabilitation. the overall objective of the mma is to achieve the effective functioning of patients in normal situations comparable to premorbid functioning. the general techniques of the mma are comparable to those of any treatment regime. there are a few specfic techniques, however, that are unique to the mind-mapping programme. these include techniques that are not uncommon in the realm of therapy such as relaxation, breathing and music. it is the combination of techniques that the researcher has put together as part of the standard procedure of mind-mapping, that is unique. the first of these techniques is relaxation. relaxation means, "a realistic response to the environment with a minimum of needless energy expended" (boone, 1977, ρ 151). therefore, by using relaxation techniques, unnecessary tension is reduced. on a physiological level, relaxation results in an increase in secretion of the brain's natural opiates endorphin and enkephalin which are generated when one feels good or relaxed (hand, 1986). this in turn relaxes the limbic system's negative potential, enabling the neurochemicals necessary for learning and remembering to be generated (hand, 1986). thus intellectual pursuit is allowed to progress more readily than when negative feelings prevail, and! the patient is guided towards comfort management rather than stress management. according to wolpe (1958) |"as we inhibit the anxiety through relaxation, the stuttering problem recedes" (boone, 1977). j the second technique of the mma is the use of controlled breathing. boone (1977) suggests the use of breathing techniques for voice patients with poor breathing patterns. russell (1986), indicates that breathing exercises aid concentration by focusing attention on the energy interplay involved in breathing. according to hand (1986), even though our brain is only approximately 3.5 pounds, it requires 25% of the body's oxygen intake to function optimally. for these reasons, breathing exercises are incorporated within the mma approach. the third technique incorporated into the mma is the use of suggestion and visualisation. according to van riper (in boone, 1977), suggestion and visualisation permeate all forms of therapy, including those practised in medicine. no patient seeks help without some expectation that his/her problem will be alleviated. therefore, directly or indirectly, deliberately or unconsciously, some kind of suggestion and visualisation seems to be inherent in any therapeutic relationship. according to lozanov & gateva (1989), using suggestion and visualisation enables people to make more effective use of their brain potential, because suggestion has a similar effect to relaxation physiologically (discussed under the principle of relaxation), and visualisation is essential to the process of activating memory (russell, 1986). fourthly, the use of music specifically baroque music is advocated by the mma to be used throughout therapy. music is used due to the documented effect it has on the alpha and beta wave forms of the brain (lozanov & gateva, 1989). music activates neurons for purposes of relaxing muscle tension, changing pulse and producing long-range memories which are directly related to the number of neurons activated in the experience (hand, 1986). music relaxes major portions of the brain so that those which are active encounter little interference from other portions. furthermore, there are different types of music for different types of activities, that is learning, relaxation and visualisation (lozanov, & gateva, 1989). baroque music specifically is important as this type of music is characterized as being generally relaxing, with a 4/4 rhythm and 60 beats per minute. the relaxation is induced due to psychological entrainment of body rhythms (hand, 1986). therefore, the techniques of relaxation, breathing, suggestion and visualisation, and music create the environment of the mma procedure, the main objective being to create an optimal learning situation. finally, there are various other techniques derived from brain-behaviour relationships that are applied to the mma intervention. these principles are adapted from hand (1986) and luria (1982), and include the following: words are read aloud this activates broca's area, wernicke's area, left hemisphere sensory and motor cortex and the angular gyrus. ' words are read with emotion and inflection this activates right hemisphere areas for prosodic functions, right motor and sensory cortex, and the limbic system. pictorial images are developed and mind-maps are used throughout thus the patient is being stimulated to think in a visual and organised way. this involves a major portion of the primary visual cortex, left and right motor sensory cortices, central and peripheral nervous system from the brain stem through the arms, hands and fingers. key words on mind-maps allow for discrimination in the right visual cortex. testing after review this reinforces neuronal connections established during initial learning, leading to hypertrophy and/or branching of neuron dendrites, and making recall easier. the more vivid and active the impression of what is being learned, the stronger the memory trace. the spike of electrical activity in the brain increases markedly with novel, surprising or vivid stimuli. this activity signals the hippocampus and hypothalamus to produce increased levels of neurochemicals related to memory formation. the forms of the mma. rehabilitation efforts in general may take the form of facilitating spontaneous recovery, direct retraining of cognitive components, retraining functional-integrative perdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 formance and compensation training. the ylvisaker & szekeres (1986) approach indicates each of these forms of intervention as separate approaches in rehabilitation through which the patient in general progresses through, terminating in compensation training to overcome deficits not remediated directly. the mind-mapping approach is more eclectic than the traditional therapy discussed above, and holistic in that the process of therapy is seen to work on components and functional-integrative performance concurrently. therefore, there is no distinction between component and functional-integrative performance (ylvisaker & szekeres, 1986). furthermore, it is felt that the mma encourages the brain to go beyond its capacity for spontaneous recovery, because patients are being taught a strategy that stimulates the whole brain resulting in increased efficiency (leaf, 1990). in conclusion the mma is not a form of compensation. in this approach, compensation is seen as for example, using logbooks to assist memory, or wearing glasses. mindmapping therapy is more, it is a strategy to stimulate whole-brain learning. the manner of mma: textlinguistics/metaphors and the creation of the mind-map. the analysis of textlinguistics as a vehicle for examining discourse beyond the sentence level has recently received attention by various groups of researchers (liles, 1985). textlinguistics provides a logical ordered way of approaching the content (story, newspaper article, schoolwork) of therapy. therefore, the story (metaphor) or macrostructure model of analysis provides the manner in which the mma is done, that is, the manner in which the texts oral and written used in therapy are approached. textlinguistics also provides the organized steps of the ' thinking process that goes into the actual creation of the mind-map. thus, the mind map becomes the visual representation of the cognitive process. the actual creation of the mind map stimulates both the left and right hemispheres, which increases the effectiveness of functioning. therefore, a mutually beneficial cyclic process is set up (buzan, 1991). based on the conceptual framework as discussed in 2.1. and the principles, forms and manner of the mma in 2.2., a treatment model was designed by the first author. this is outlined in the form of a schematic layout in figure 1. in the treatment model, therapy is viewed as being divided into two aspects, namely the creation of an optimal learning environment, and then the actual process/steps of therapy. in the first, the brain is being prepared' or grimed' to receive information and to function optimely by ensuring the correct physiological aspects (electrical and chemical and oxygen). the process takes the client through various steps which stimulate brain hemisphere synergy. discussion of the application of the mma to a single case study of chi. a number of questions were addressed in a study by leaf (1990) regarding the effectiveness of mind-mapping as a therapeutic intervention technique on a white female subject. the results revealed a statistically significant improvement in the academic ability of the chi subject, caroline m. leaf, isobel c. uys, brenda louw which was proved to be directly attributable to the intervention program. there was also a statistically significant improvement of the subject in the indirectly treated cognitive-language skills and the untreated pragmatic skills, indicating generalization effects. it is this finding that supports the postulation that the mma is a language and culture "free" technique. the results furthermore revealed increasingly competent post-treatment performance academically. with specific regard to cognitive language abilities, it was deduced that mind-mapping improved the following skills in the subject (leaf, 1990): to interpret alternative meanings in ambiguous statements by evaluating multiple meanings, features at the surface structure and features at the deep structure level to reason analytically, synthetically and logically to interpret abstract concepts to improve retrieval so that it becomes an organised efficient memory search the processing of information to associate and identify relationships to select central concepts to identify, retrieve, sequence and produce semantic units expression to identify, recall and retrieve appropriate grammatical structures expression to make judgements about concepts to attend and perceive. music creation of optimum learning environment 'understand concepts of mind-mapping and brain potential 'key concept identification * understand mind-mapping approach, namely overview, preview, invlew, learning & memory, and review metaphor: application of mlnd*mapplng approach to stories application of mlnd*mapping approach to academic learning skills figure 1. schematic layout of mind-mapping intervention preparation breathing relaxation visualisation co ( / ) l u ο ο dc α . phase one phase two phase three phase four the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the mind-mapping approach (mma): a culture andlanguage ree" technique 41 as the above receptive and expressive skills in the subject of the study (leaf, 1990) were indirectly treated, the suggestion is that a certain amount of generalization took place. this implies that the cognitive dysfunction underlies the language function further supporting the concept of the mma being language and culture "free". the improved psychosocial and pragmatic functioning of the subject which were the untreated behaviours in the study (leaf, 1990) proved interesting as prigatano (1986) had the same results in his intensive neuropsychological rehabilitation programme, but he had used professional neuropsychologists and clinical psychologists to help the patients as a separate part of their treatment. in the study conducted by leaf (1990), the only therapy received by the subject was mind-mapping therapy conducted by a speech and language therapist, however, the same type of effects were obtained. conclusion: application of the mma cross-culturally. in order to overcome the linguistic and cultural diversity that exists the world over, the study of normal and pathological communication must be couched in cultural terms. this would avoid the risk of making judgements about the communication of a given group from an inappropriate set of assumptions and norms (taylor, 1986). furthermore, cultural factors also determine the definition of what is pathological, i.e. the definition of the quality and normalcy of the environment (taylor, 1986). likewise, "treatment should take into account the preferred learning style of the client and the rules of social and communicative interaction as defined by the client's indigeneous cultural or linguistic group" (taylor, 1986, ρ 7). therefore all clinical encounters are cultural events requiring an ethnological approach. this implies a need for greater understanding of dialectical and language differences. j "however, the adoption of a dialectical perspective need not imply dramatically different clinical methods for every dialect" (taylor, 1986). that is, the universal principles of therapy would not alter, j but the material would. the learner is a product of his environment, thus, the material should be selected from his specific culture. in this way the learning process is concentrated on, and not the material. j current diagnostic and treatment procedures emphasize middle class westernized values and are therefore not "culture free" (bogatz in taylor, 1986). the therapist working in a multicultural environment needs to expand the assessment and treatment process, to determine the client's learning potential as opposed to acquired knowledge (taylor, 1986). mind-mapping, as discussed, is a way of structuring information according to the way the brain functions, stimulating both hemispheres to function in harmony (buzan, 1984). in this way, learning potential can be assessed and improved. the mma (leaf, 1990) is the application of this concept into the realms of therapy by providing the clients with a more efficient "operating system" allowing them to use/access their potential more efficiently. it appeals directly to the multi-dimensional cognitive level and therefore reflects the cognitive processes underlying language. mind-mapping therapy incorporates a unique combination of techniques that have been shown to stimulate a more efficient process of learning new information (leaf, 1990). these include relaxation, breathing, and music which provide the environment of therapy (see figure 1), which can be adapted to suit each individual. by using the mma (leaf, 1990), the patient is not simply observing long lists of words or sentences, rather he is receiving each word in the context of the words that surround it. at the same time he is also giving the multiordinate nature of each word his own special interpretation as dictated by the structure of his personal information patterns thus "culture free" and, will be analysing, coding and criticising throughout the process. in applying the mma to a single chi subject (leaf, 1990), only multi-dimensional cognitive skills as they pertained to academic abilities were worked on directly, showing a statistically significant improvement. however, the indirectly treated receptive and expressive language skills, and untreated pragmatic and psychosocial functioning also improved significantly, allowing the subject to return to her premorbid level of functioning. this stresses the universality of the mma, strengthening the possibility of the mma being a culture and language "free" technique. from this, one could postulate that by working via a common medium such as academic material, through using the mma, one could circumvent the problem of language and culture bias, l b this end, the mma lends itself to being used within a consultative framework, such as suggested by uys (1985), where a professional service is given indirectly through the use of a "consulting care person" (uys & hay 1985, ρ 4). in other words, the mma could be used within an empowerment framework, as the mma is easy and effective to use in group situations. in this way large sectors of the population could be reached. if a client is not schoolgoing, illiterate or has severely depressed functioning due to a neurogenic disorder, the mma still has applicability due to its multidimensional and sensory nature. it is also a highly visual technique, lending itself to images and pictures instead of words, if this is required. the first author has applied the technique on a clinical basis cross-culturally with blacks, coloureds, indians, chinese and japanese. the results have been encouraging in terms of linguistic, cognitive and psychosocial functioning. various trends were also observed where certain of the mma techniques were more appealing to certain cultures. for example, the black students learned material more effectively using music by steven halpern & savary (adapted baroque), whilst learning new activities. although this music has no identifiable tune and does not have the orthodox tempo of 60 beats/minute, it has been shown to facilitate whole-brain learning (halpern & savary, 1985). clynes (in halpern, 1985) indicates that there are specific forms of emotional expression called "essentic forms" that act like keys in a lock and activate specific learning memory processes. research suggests that essentic forms have innate meanings that transcend cultural learning and conditioning, and are therefore neurologically coded. it is possible that these essentic forms are more activated using this adapted type of music with black clients. critchley and henderson (in halpern & savary, 1985) found that this adapted baroque music may be able to die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 caroline . leaf, isobel c. uys, brenda louw activate the flow of stored memory material across the corpus callosum, so that right and left hemispheres of the brain work in harmony rather than in conflict, resulting in improved functioning. the asian students, on the other hand, preferred the standard combinations of classical and baroque music to the adapted music, learning more effectively with the former. lozanov & gateva (1989), using biofeedback, researched the effect of the standard classical and baroque music, finding it to be a catalyst during the process of instruction with students. the above clinical observations strengthen the premise that the technique of using music in mind-mapping therapy is a fundamental principle, and that the material type of music has a culture preference. futher corroborating the strength of the mma as an alternative fundamental "culture-free" technique, is research conducted by van kraayenburg (1992). he applied a similar combination of techniques to that of mind-mapping therapy, within a scholastic programme to teach english to 540 black south african schoolchildren in sub b, std 1 and std 2. the result was that the programme was judged foremost by the human sciences research council, after two and a half years of evaluation against seven other suggested teaching programmes. in conclusion, not only do we experience heterogeneity cross-culturally, but within each culture group there is diversity as well. using more global techniques such as mind-mapping therapy, where the individual's perception, learning style and potential to learn and think are emphasized as opposed to a group or culture's language and thought patterns, bias can be circumvented. thus, the aim should be to develop more global approaches to therapy focusing on creating richly varied culturally appropriate instructional environments. this should be done in a climate that fosters imagination, adventure and risk taking, all vital catalysts to learning. in this way we as speechlanguage therapists can try to deliver services to all individuals. einstein once said that imagination is more important than knowledge as knowledge is limited and imagination is not (buzan, 1990). the authors believe that one of the ways to deal with the mammoth task of delivering services to all cultures in south africa is to go beyond the realms of knowledge into that of imagination. hopefully then, culture and language "free" techniques will be found. references. adamovich, b.b. (1986). speciality recognition in neurogenic speech, language and cognitive disorders: training needs of speech-language pathologists regarding the cognitive rehabilitation of closed head injured persons. in r. brookshire (ed.), clinical aphasiology conference proceedings (ac). 16, 329-337. minneapolis: brk publishers. asha. (1991). reach: a model for the service delivery and professional development within remote/rural regions of the united states and u.s. territories. asha, 33, 6, 5-14. buzan, t. (1991). use both sides of your brain. united states: first plume printing. boone, d.r. (1977). the voice and voice therapy. new jersey: prentice-hall. feuerstein, r. (1980). instrumental enrichment: an intervention programme for cognitive modifiability. baltimore: university park press. hagen, c. (1984). language disorders in head trauma. in a.l. holland (ed.), language disorders.in adults: recent advances. san diego: college-hill press. halpern, s and savary, l. (1985). sound health: the music and sounds that make us whole. san francisco: harper & row publishers. hand, j.d. (1986). the brain and accelerative learning. per linguam, 2, 2, 214. hay, i.s. & uys, i.c. (1985) taalverskeidenheid en taalpatalogie: universiteit van pretoria. leaf, c.m. (1990). mind-mapping: a therapeutic technique for closed head injury. unpublished master's dissertation, university of pretoria. liles, b. (1985). production and comprehension of narrative discourse in normal and language disordered children. journal of communication disorders, 18, 409-427. lozanov, g. & gateva, e. (1989). the foreign language teacher's suggestopedic manual. switzerland: gordon and breach science publishers. luria, a.r. (1982). language and cognition. washington: winston & sons. ornstein, r.e. (1975). the psychology of consciousness. new york: penguin books. penn, c. and cleary, j. (1988). compensatory strategies in the language of closed head injured patients. brain injury, 2, 1, 3-17. powell, g.e. (1981). brain function therapy. great britain: gower. prigatano, g.p. (1986). neuropsychological rehabilitation after brain injury. baltimore: john hopkins university press. rosenzweig, m.r. and bennet, e.l. (1976). neuronal mechanisms of learning and memory. cambridge: mit press. russell, p. (1986). the brain book. london: routledge & kegen paul. scott, b.s. (1976). the effect of elevated potassium on the time course of neuron survival in cultures of dissociated dorsal root ganglia. journal of cellular physiology, 91, 305-316. sperry, r.w. (1982). some effects of disconnecting the cerebral hemispheres. science, 217, 1223-1226. i taylor, o.l. (1986). treatment of communication disorders in culturally and linguistically diverse populations (ed.). california: college-hill press. | van kraayenberg, f. (1992). lecture series: creative accelerative learning methods: lead the field, johannesburg. ylvisaker, m.a. & szekeres, s.f. (1986). management of the patient with closed head injury. in brookshire, r. (ed.), clinical aphasiology conference proceedings. minneapolis: brk publishers. 1 zaidel, e. (1985). roger sperry: an appreciation. in benson, d.f. & zaidel, e. (eds.), the dual brain. new york: the guilford press. the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) d i e o n t w i k k e l i n g e n t o e t s i n g v a n a r t i k u l a s i e v e r m o e n s b y d i e a f r i k a a n s s p r e k e n d e k i n d elsie c. lotter,m.a. (log.) (pretoria) spraakheelkunde, universiteit van pretoria, pretoria opsomming daar bestaan tans g e e n gestandaardiseerde afrikaanse a r t i k u l a s i e t o e t s nie en o n t w i k k e l i n g s n o r m s vir die klanke van afrikaans is n o g nie t e v o r e o p g e s t e l nie. in hierdie studie is g e p o o g o m 'n stel o u d e r d o m s n o r m s vir die artikulasiev e r m o e van die afrikaanssprekende kind daar te stel en o m 'n v o o r l o p i g e vorm van 'n afrikaanse a r t i k u l a s i e t o e t s vir gebruik b y j o n g kinders o p te stel. d i e g e g e w e n s van 9 9 9 p r o e f p e r s o n e ( 4 9 9 seuns en 5 0 0 dogters) tussen die ouderd o m m e 3-9 en 9 6 jaar is verwerk vir die vasstelling van d i e o n t w i k k e l i n g s norms. d i e toetsmateriaal vir d i e a r t i k u l a s i e t o e t s is gekies na aanleiding van die r e s p o n s e van 2 3 1 5 p r o e f p e r s o n e . b e n e w e n s 'n w o o r d e l y s vir gebruik as artikulasie-inventaris, w o r d verskeie verwerkings en t o e p a s s i n g s van verkree r e s p o n s e voorgestel. daar w o r d aanbeveel dat die v o o r l o p i g e t o e t s f o r m a a t die v o l g e n d e insluit: 'n tabel vir die o p t e k e n i n g van r e s p o n s e ; g e g e w e n s vir die b e r e k e n i n g van a l g e m e n e spraakverstaanbaarheid; materiaal vir die o n t l o k k i n g van 'n m o n s t e r van a a n e e n l o p e n d e spraak; 'n m e t o d e vir die o n t l e d i n g van f o u t r e s p o n s e ; en 'n s t i m u l e e r b a a r h e i d s s u b t o e t s vir d i a g n o s t i e s e d o e l e i n d e s . summary a t present, there e x i s t s no standardized afrikaans a r t i c u l a t i o n test and dev e l o p m e n t a l n o r m s for t h e s o u n d s of afrikaans have not y e t b e e n established. this s t u d y a t t e m p t s t o provide a set of age n o r m s for t h e articulatory abilities of afrikaans-speaking children and t o formulate a preliminary afrikaans a r t i c u l a t i o n test t o b e used w i t h y o u n g children. data c o l l e c t e d from 9 9 9 subjects, ( 4 9 9 b o y s and 5 0 0 girls) b e t w e e n t h e ages 3-9 a n d 9 6 years, w e r e processed for the e s t a b l i s h m e n t of t h e d e v e l o p m e n t a l norms. t h e material used for t h e articulation test w a s s e l e c t e d a c c o r d i n g t o r e s p o n s e s o b t a i n e d from 2 3 1 5 subjects. in a d d i t i o n to a list of w o r d s t o b e used as an a r t i c u l a t i o n i n v e n t o r y , several c o m p u t a t i o n s and a p p l i c a t i o n s of r e s p o n s e s o b t a i n e d from subjects are p r o p o s e d . it is s u g g e s t e d that t h e preliminary test format i n c l u d e t h e f o l l o w i n g : an i n d e x for t h e r e c o r d i n g o f r e s p o n s e s ; data for t h e c o m p u t a t i o n of general s p e e c h intelligibility; material for eliciting a sample o f cont i n u o u s s p e e c h ; a m e t h o d for t h e analysis of error r e s p o n s e s ; a n d a stimulability s u b t e s t for d i a g n o s t i c purposes. die s t u d i e e n b e h a n d e l i n g v a n a r t i k u l a s i e p r o b l e m e w o r d d i k w e l s a s ' n b e t r e k lik e e n v o u d i g e o n d e r a f d e l i n g van d i e s p r a a k p a t o l o g i e b e s k o u . t e n s p y t e hierv a n v i n d b a i e t e r a p e u t e t o g d a t d i e m e e s t e v a n h u l l e t y d d e u r gevalle m e t a r t i k u l a s i e p r o b l e m e in beslag g e n e e m w o r d , d i k w e l s t e n k o s t e van k i n d e r s w a t b l y k b a a r e r n s t i g e r p r o b l e m e h e t e n h u l p m e e r n o d i g h e t . s t e w a r t 9 w y s e g t e r d a a r o p d a t die t y d w a t n o d i g is o m b e v r e d i g e n d e s p r a a k b y s o m m i g e v a n h i e r d i e k i n d e r s t e v e r k r y , s k y n b a a r b u i t e alle v e r h o u d i n g is m e t d i e o p g a w e s o o s h y h o r n b y d i e e e r s t e o o g o p s l a g v o o r d o e n . tdskrif van i suid-afrikanse vereniging vir sprak n goorhlknde, vol. 21, dsmber 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) •34 elsie c. lotter navorsers besef in 'n toenemende mate dat powers 7 se uitgangspunt aandag verdien: artikulasieprobleme is geensins so eenvoudig om te verklaar en te behandel as wat baie mense aanvaar nie. die instrumente waarmee die terapeut artikulasievermoens kan ondersoek en 'n sinvolle terapieprogram opstel, neem dus 'n belangrike plek in. 'n artikulasie-inventaris bied 'n stelselmatige wyse waarop die klanke wat in die betrokke taal as foneemrealiserings benodig word, nagegaan kan word, 'n gesistematiseerde oorsig van die pasient se produksie van hierdie klanke vergemaklik die beplanning van die terapieprogram. soms is dit ook nodig, veral by baie jong kinders, om na te gaan watter klankproduksies wel al bemeester moes gewees het en of daar sommige ,klankfoute' voorkom wat op daardie ouderdom nog as normaal beskou word. hierdie oorwegings dra ook by tot die opstel van realistiese terapiedoelstellings. ontwikkelingsnorms (ouderdomsnorms) le dus dikwels ten grondslag van die sinvolle interpretasie van 'n persoon se prestasie tydens -n artikulasietoets. ouderdomsnorms word benut in verskillende soorte artikulasietoetse — siftingstoetse, diagnostiese en voorspellingstoetse. 'n stelselmatige aanduiding van artikulasievermoens is egter nie net in terapie nuttig nie, maar ook vir navorsingsdoeleindes. nie 'slegs op die gebied van artikulasieafwykings as sodanig nie, maar ook by studies waar die klem op ander oorwegings val, word die artikulasietoets dikwels gebruik. voorbeelde van sulke studies word oral in die huidige vakliteratuur aangetref. in baie van hierdie gevalle word prestasie op die artikulasietoets juis in terme van ontwikkelingsnorms geinterpreteer. daar kan dus geen twyfel bestaan dat die artikulasietoets of-inventaris, met sy gegewens in verband met ontwikkelingspeile, wel 'n belangrike instrument vir die klinikus en die navorser is nie. wat die ontwikkeling en afwykings van spraak en taal betref, is daar betreklik min navorsing in afrikaans en oor afrikaans gedoen. waar dit wel aangevoer is, is meestal ongestandaardiseerde vertalings en/of aanpassings van engelse en amerikaanse toetse gebruik. die gebruik van sodanige vreemde toetse lewer egter nie werklik geldige of betroubare resultate nie, veral nie met betrekking tot artikulasie nie. elke taal het 'n verskillende foneemstelsel en selfs 'n verskillende artikulasiebasis. waar baie navorsingsprogramme tans gerig is op veral die ontwikkeling van die taalstelsel as geheel en die verband tussen die onderafdelings van taal (wat ook die foneemstelsel en die realisering daarvan insluit) is daar 'n dringende behoefte aan basiese inligting. hierdie inligting moet, vir afrikaans, nog ingesamel word. ' κ in hierdie studie word dan gepoog om: (i) sekere basiese gegewens in verband met artikulasieontwikkeling te voorsien, as grondslag vir verdere navorsing; dit wil se, om ontwikkelingsnorms vir artikulasievermoe by die jong afrikaanssprekende kind vas te stel. (ii) 'n instrument daar te stel waarmee sodanige basiese gegewens by ander individuele en groepe proefpersone ingesamel'kan word, hetsy vir terapeutiese of navorsingsdoeleindes; dit wil se, om 'n voorlopige vorm van 'n afrikaanse artikulasietoets vir gebruik by jong kinders op te stel. journal of the south african speech and hearing association, vol. 21, decenivsr 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die toetsing van artikulasievermoens by afrikaanssprekende kind 35 l die navorsing wat onderneem is, het dus ook twee sake behels. in die eerste plek, die toetsing van die klanke wat as foneemrealiserings in afrikaans voorkom, soos dit deur 'n groot groep kinders van verskillende ouderdomme geproduseer word. in die tweede plek, die versameling van 'n lys woorde wat geskik sal wees vir gebruik in 'n artikulasietoets by kinders van verskillende ouderdomme. hierdie twee aspekte is tydens die ondersoek gelyktydig gedek. metode p r o e f p e r s o n e proefpersone vir hierdie studie moes „jong afrikaanssprekende kinders" wees. kinders vanaf die ouderdom 3-9 tot 9-6 is in die ondersoek ingesluit. (navorsingsgegewens uit amerikaans, engels en duits dui daarop dat kinders teen ongeveer 8 jaar reeds al die klanke van hulle taal behoort te kan se. die hipotese kan dus gestel word dat dit ook vir afrikaans die geval sal wees). alle proefpersone is uit afrikaanse skole of kleuterskole getrek. die vereiste van afrikaans as huistaal is ook gestel. kinders met sigbare fisiese afwykings, gehoorverlies of neurologiese afwykings (waar bekend) is nie in die ondersoek opgeneem nie. die ontwikkelingsnorms sal dus geld vir kinders met normale fisiese strukture. 'n totaal van 999 proefpersone (500 dogters, 499 seuns) is gebruik om die ontwikkelingsnorms te bepaal. die gegewens van 2315 kinders is gebruik om die bekendheid van die woorde of prente wat as toetsmateriaal gebruik is, te bepaal. t o e t s m a t e r i a a l die toetsmateriaal moes 'n middel voorsien waardeur die ondersoeker 'n verteenwoordigende monster van elke proefpersoon se spraak kon ontlok. hierdie spraakmonster moes aan sekere vereistes voldoen: dit moes spontaan wees, dit moes verteenwoordigend wees en die verkryging daarvan moes nie te veel tyd in beslag neem nie. uit hierdie vereistes het geblyk dat die toetsmateriaal woorde moes behels wat deur middel van prentstimulasie by jong kinders ontlok kon word en waarin die verlangde klanke dan in die verlangde posisies in woorde (prevokalies, intervokalies, postvokalies) sou voorkom. slegs konsonantklanke (enkelklanke en klankkombinasies) is in hierdie studie gedek; • vokaalklanke is nie ondersoek nie. aangesien dit belangrik was dat kinders goed moes reageer op die prentstimulasie, moes die mees doeltreffende soort prente gebruik word. shanks, sharpe & j a c k s o n 8 vergelyk verskillende soorte prente en bevind dat kinders die beste op gekleurde foto's reageer. die onkoste hieraan verbonde sou egter onprakties wees vir 'n ondersoek van hierdie aard. groot gekleurde tekeninge is dus gebruik waarop voorwerpe so realisties as moontlik uitgebeeld is. by die aanvang van toetsing is 'n voorlopige woordelys en prente saamgestel. tydens die verloop van die ondersoek is hierdie materiaal na behoefte gewysig. as dit geblyk het dat 'n betrokke woord of prent by meer as 50% van die proefpersone wat op een dag ondersoek is, onbekend was, is dit vervang. skrif vi suid-afrikanse vereniging vir sprak n oorlinde, vol. 21, dcsmbr 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 elsie c. lotter die finale woordelys is aangedui in tabel 1. woord % woord % woord % hare 0,0 21. brood .1,2 41. piesang 6,3 broek 0,0 22. blare 1,3 42. vliegtuig 7,7 knoop 0,1 23. wiel 1,6 43. boks 7,9 drink 0,1 24. seuntjie 1,9 44. wolke 8,7 sleutels 0,1 25. stoof 2,0 45. spieel 8,8 skoene 0,1 26. mielie 2,0 46. glas 9,3 mes 0,1 27. stryk 2,7 . 47. pleister 9,7 neus 0,2 28. kar 2,8 48. kwas 10,0 lepel 0,2 29. tafel 2,8 49. vloer 11,6 huis 0,2 30. water 2,9 50. skryf 12,3 vurk 0,2 31. emmer 3,5 51. spring 15,4 druiwe 0,3 32. masjien 3,5 52. jas 15,9 boom 0,3 33. deur 3,5 53. kraan 18,8 perd 0,4 34. geld 3,7 54. lamp 20,4 olifant 0,7 35. voel 3,8 55. prop 23,6 swem 0,8 36. fiets 4,1 56. zebra 31,8 vingers 0,8 37. gras 4,6 57. skulp 32,8 rok 1,0 38. klippe 4,7 58. gholf 42,1 seep 1,0 39. berg 5,2 59. gogga 45,9 trein 1,1 40. baba 5,8 60. beker 60,9 61. sjokolade 62,1 tabel 1. finale woordelys by ondersoek na artikulasievaardighede, tesame met persentasie foutiewe response verkry. a l g e m e n e p r o s e d u r e die toetsmateriaal (woorde) is aangewend om 'n spraakvoorbeeld van elke proefpersoon te verkry. hierdie voorbeeld is dan deur die ondersoeker perseptueel ontleed om die resultate vir die ontwikkelingsnorms te verkry. die groot, gekleurde tekeninge is aangebied vir elke proefpersoon, met toepaslike vrae waar nodig ten einde die verlangde respons te ontlok. (die verlangde woord is nooit in die vraag gebruik nie). die respons van elke proefpersoon op elke prent is aangeteken, vir sowel bepaling van die bekendheid van prente, as beoordeling van artikulasievermoe. journal of the south african spccch and hearing association, vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die toetsing van artikulasievermoens by afrikaanssprekende kind 37 'n getroue fonetiese transkripsie is vir die optekening gebruik. die getranskribeerde response is dan geklassifiseer as aanvaarbaar/nie aanvaarbaar nie, volgens die volwasse standaardpatroon. resultate: ouderdomsnorms die gegewens van 999 proefpersone is verwerk en in tabelvorm uiteengesit. 'n getroue weergawe is ontwikkel deur ibm 360 model 50 komper, met die program „interest" en ook verdere programme wat deur die personeel van die rekenaarsentrum aan die universiteit van pretoria opgestel is. die tabelle word nie hier weergegee nie omdat hulle te lywig is. die volgende is 'n samevatting van die vernaamste bevindings: (a) hoewel die persentasie proefpersone wat die konsonantklanke (enkelklanke en klankkombinasies) korrek produseer, in sommige gevalle met toename in ouderdom 'n stygende neiging toon,'was daar vir geen klank 'n deurlopende styging nie. afnames in die persentasie proefpersone wat 'n korrekte produksie lewer, kom voor in die omgewing van 5-0 tot 5-8, 6-8 tot 7-6 en weer voor 8-8. indien hierdie ondersoek met ander proefpersone en ander toetsmateriaal herhaal sou word en dieselfde resultate oplewer, sal 'n verklaring moontlik gesoek moet word in die verband tussen die ontwikkeling van artikulasievermoe en ander vermoens. 'n voorlopige hipotese kan gestel word in terme van tydperke van intensiewe konseptuele ontwikkeling, waartydens dan minder aandag aan die korrekte realisering van foneme (wat tog op 'n vroeere ouderdom reeds bemeester is) geskenk word. (b) enkelklanke word oor die algemeen vroeer as klankkombinasies bemeester, met' die uitsondering van die enkelklanke [r] en [sj. op die ouderdom van 8 jaar produseer die meeste kinders (75% -90%) al die konsonantklanke van afrikaans korrek, met uitsondering van die klankkombinasie [-rs]. 'n steekproef met 50 volwasse proefpersone het getoon dat 26% van die volwassenes ook 'n foutiewe produksie van die klankkombinasie lewer. die vorms wat gewoonlik voorkom, naamlik [j sj of [ r / ] , word egter algemeen as aanvaarbare variante beskou. (c) soos weerspieel deur die persentasie fouteerders, blyk dit dat [s, r, / , z, g], in daardie volgorde, die vyf moeilikste enkelkonsonantklanke vir kinders binne die ouderdomsgroep 3-9 tot 9-6 was. as hierdie gegewens met die vir amerikaans, engels en duits vergelyk word, is daar 'n groot mate van ooreenstemming, veral ten opsigte van [s, z, / ] . dit blyk dat die sibilante klanke in al vier hierdie tale as moeilik produseerbare klanke ondervind word. (d) wat die moeilikheidswaarde van konsonantklankkombinasies betref, is [-rs] die moeilikste. al tien die moeilikste konsonantklankkombinasies bevat [r], [s] of albei as komponent. (e) dit lyk asof die enkelkonsonantklanke moeiliker produseerbaar is in die eindas in die aanvangsposisie in woorde. 'n verklaring hiervoor kan gevjnd word in die hipotese van mcdonald,5 dat die eindkonsonant van tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 21, desember 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 elsie c. lotter 'n lettergreep, as gevolg van die tydsfaktor, in aaneenlopende spraak na die begin van die volgende lettergreep verskuif. die eindkonsonante is gevolglik moontlik minder konstant en moeiliker om aan te leer. (f) wanneer konsonante ten opsigte van manier van vorming met mekaar vergelyk word, kom die grootste persentasie fouteerders op wrywingsklanke voor. die konsonantsoorte kan in volgorde van die grootste na die kleinste persentasie fouteerders so gerangskik word: wrywingsklanke, die ratelof tikklank, die wrywinglose kontinuant met laterale lugvrylating, afsluitingsklanke, wrywinglose, kontinuante met nasale lugvrylating. hierdie bevindings stem ooreen met die van t e m p l i n 1 0 vir amerikaans. die ontwikkelingsnorms wat in hierdie ondersoek vasgestel is, is nuttig vir gebruik in verdere navorsing en ook by die opstel van 'n voorlopige vorm van 'n afrikaanse artikulasietoets. besprek1ng: voorlopige vorm van 'n artikulasietoets by 'n beoordeling van die toetsformaat wat hier voorgestel word, moet die voorwaardes wat deur goldman & f r i s t o e 3 gestel is, veral in gedagte gehou word: 'n artikulasie-inventaris of -toets is slegs doeltreffend as dit akkurate en voldoende inligting oplewer, as dit binne 'n kort tyd toegepas kan word en as dit vir die kind ίι hoe interessantheidswaarde het. die toets moet dus materiaal bevat wat aan die kinders bekend is en.wat hulle aandag sal behou, maar terselfdertyd moet die ondersoeker die materiaal en die verwerking van die resultate maklik kan hanteer. t o e t s m a t e r i a a l die toetsmateriaal sal bestaan uit prente wat so gekies is, dat die kind in die benoeming van die hele stel prente, die enkelkonsonantklanke en konsonantklankkombinasies van afrikaans sal produseer. enkelklanke word in drie posisies in woorde (te wete aanvang, middel en end) ontlok, behalwe in gevalle waar die taalreels spesifiseer dat 'n klank nie in 'n bepaalde woordposisie voorkom nie. die klankkombinasies word elk net in een woordposisie ontlok, na gelang van die aard van die bepaalde klankkombinasie. om die lengte van die toets te beperk, word in sommige gevalle meer as een klank per woord beoordeel. die woordelys wat in tabel 1 aangegee is, kan gebruik word as 'n bron vir die woorde wat in die artikulasie-inventaris opgeneem word. die 54 woorde wat in tabel ii verskyn word aanbeveel. daar word aanbeveel dat verdere ondersoek ingestel word om meer doeltreffende stimuluswoorde vir die volgende gevalle te vind: [k], [x] en [d] in middelposisie van woorde. daar moet ook verder gepoog word om woorde te vind wat die klanke wat nie by hierdie toets ingesluit is nie, te ontlok. sekere klankkombinasies, bv. [spl-, -rf, -rps], rrloes weggelaat word. hierdie klankkombinasies kon moeilik deur middel van prente ontlok word omdat dit nie voorkom in woorde wat aan kinders bekend is, of wat met 'n prent voorgestel kan word en 'n bevredigende respons lewer nie. journal of the south african speech and hearing association, vol. 21, decer 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die toetsing van artikulasievermoens by afrikaanssprekende kind 39 1. |>erd 19. olifant 37. glas 2. legel 20. sgieel 38. prop 3. seep 21. rok 39. drink 4. boom 22. hare • 40. kraan 5. baba 23. piesang 41. j>ras 6. mes 24. kat . 42. swem 7. emmer 25. beker 43. kwas 8. vurk 26. geld 44. knoop 9. tafel 27. vliegtuig 45. spring 10. stoof 28. gholf 46. stryk 11. water 29. masjien 47. skryf 12. druiwe 30. vingers 48. skulp 13. brood 3 1 . j a s 49. wolke 14. deur 32. pleister 50. berg 15. sjokolade· 33. zebra 51. fiets 16. neus 34. blare 52. boks 17.skoene 35. sleutels 53. seuntjie 18. trein 36. klippe 54. lamp tabel ii. aanbevole woordlys vir artikulasieinventaris. die onderstreepte gedeeltes van die woorde in die aanbevole lys, dui op die klanke wat tydens produksie van die bepaalde woord geevalueer word. daar word egter aanbeveel dat die ondersoeker ook op elke ander realisering van die betrokke klank wat in die res van die toets mag voorkom, sal let. optekening v a n response daar word aanbeveel dat elke uiting van die toetsling so getrou as moontlik foneties getranskribeer word, met bykomstige aantekeninge en/of diakritiese tekens waar nodig. sodoende word die grootste moontlike hoeveelheid inligting vir verdere interpretasie voorsien. 'n tabel soos die wat deur goldman & fristoe 3 voorsien word, kan dien om . 'n stelselmatige oorsig van die toetsling se response op die artikulasieinventaris te gee. in hierdie tabel is die klanke volgens ontwikkelingsvolgorde (soos uit hierdie navorsing verkry is) gerangskik. die ouderdomsnorms kan by d i e , toetsformaat ingesluit word, sodat die response van die toetsling daarmee vergelyk kan word. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheekunde, vol. 21, dsember 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 elsie c. lotter bykomstige verwerking v a n gegewens na 'n noukeurige bestudering van die massa literatuur wat reeds oor die onderwerp artikulasietoetsing verskyn het, is 'n paar aanbevelings vir die bykomstige verwerking van gegewens uitgelig. die volgende het geblyk die mees belowende en nuttige moontlikhede te wees: (a) artikulasievaardigheid in aaneenlopende spraak: die belang van 'n indruk van die toetsling se artikulasievaardigheid in aaneenlopende spraak, word allerwee beklemtoon. twee maatstawwe kan hier gebruik word: (i) 'n numeriese punt as aanduiding van algemene spraakverstaanbaarheid, soos aanbeveel deur barker1 en barker & england.2 hierdie punt word gegrond op die voorkomsfrekwensie van klanke; as die kind 'n aantal klanke met hoe voorkomsfrekwensie foutief produseer, sal dit sy spraak meer onverstaanbaar maak as wanneer hy 'n aantal klanke met lae voorkomsfrekwensie foutief sou produseer. die gegewens van odendal 6 kan gebruik word om so 'n puntetoekenning vir die klanke van afrikaans te bereken. (ii) om 'n perseptuele indruk van die toetsling se aaneenlopende spraak te verkry, kan 'n verhalende toets soos die van goldman & fristoe 3 opgestel word. die enkelklanke en klankkombinasies wat vir die totale groep kinders in die huidige ondersoek die moeilikste was, kan in so 'n verhalende toets ingesluit word. 'n stel sinne, waarby toepaslike prente gebruik kan word, is ook reeds opgestel; die praktiese toepasbaarheid daarvan moet egter nog deur verdere navorsing vasgestel word. eienskappe % θ s medio-alveoler / χ / bladlinguaal / χ / medio-orale lugvrylating x / /. stemloos / / / frikatief / / / eienskappe teenwoordig 4 : 3 / 5 tabel iii. fonetiese eienskappe van [s], [θ] en [ £ ]. (b) aard van foute: die artikulatoriese kenmerke van elke klank, enkelklanke sowel as klankkombinasies, kan by die toetsvorm ingesluit word. die artikulatoriese kenmerke van die toetsling se foutklanke kan dan met die journal of the south african speech and hearing association, vol. 21, decer 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die toetsing van artikulasievermoens by afrikaanssprekende kind 41 standaardpatroon vergelyk word, soos voorgestel deur hutcheson. 4 uit so, 'n ontleding kan afleidings gemaak word in verband met besondere gebiede van uitval, byvoorbeeld verskille tussen die realisering van 'n foneem in verskillende woordposisies, patroon van gebruik van sekere artikulatoriese eienskappe, en so meer. tabel iii is 'n voorbeeld van die vergelyking van die fonetiese (artikulatoriese) eienskappe van [s] met die foutiewe realiserings [θ] en [ $ ]. (c)' stimuleerbaarheid as diagnostiese maatstaf: w i n i t z 1 1 berig dat artikulasieverbetering met die grootste mate van betroubaarheid voorspel kan word op grond van reaksie op stimulasie met die korrekte klankpatroon en die toetsling se telling op die aanvanklike artikulasietoets. 'n stimuleerbaarheidssubtoets, soortgelyk aan die wat deur goldman & fristoe 3 aangegee word, kan dus by die afrikaanse artikulasietoets ingesluit word. wanneer die afrikaanse artikulasietoets in sy finale vorm opgestel word, , sal die resultate uit die navorsing soos hierbo uiteengesit, hopelik nuttig . gebruik kan word. as hierdie studie kan dien om verdere navorsing ten opsigte van die bree taalspektrum van afrikaans te stimuleer, het dit in sy doel geslaag. erkenning hierdie navorsing is moontlik gemaak deur die geldelike steun van die raad vir geesteswetenskaplike navorsing. enige menings wat uitgespreek word, is egter uitsluitlik die van die skryfster. verwysings 1. barker, j. (1960): a numerical measure of articulation./. speech & hearingdis., 25, 79-88. 2. barker, j., & england, g. (1962): a numerical measure of articulation: further developments. / . speech & hearing dis., 27, 23-27. 3. goldman, r. & fristoe, μ. (1969): goldman-fristoe test of articulation. american guidance service, inc., minnesota. 4. hutcheson, s. (1968): some quantitative and qualitative criteria in articulation test scoring. brit. j. dis. commun., 3, 36-42. 5. mcdonald, e.t. (\969): articulation testing and treatment. a sensorymo tor approach. stanwix house inc., pittsburgh. • 6. odendal, f.f. (1962) : die struktuur van die afrikaanse wortelmorfeem. h.a.u.m., kaapstad en pretoria. 7. powers, m.h. (1957): functional disorders of articulation. chapt. 23, in handbook of speech pathology, appleton-century-crofts, new york. 8. shanks, s.j., sharpe, m.r. & jackson, b.r. (1970): spontaneous responses of first grade children to diagnostic picture articulation tests. / . commun. dis., 3, 106-117. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheekunde vol. 21, desember 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 elsie c. lotter 9. stewart, a. (1968): disorders of articulation in children. brit. j. dis. commun., 3,121-129. 10. templin, μ .c. (19 5 7): certain language skills in children. university of minnesota press, minneapolis. 11. travis, l.e. (ed.). (1957): handbook of speech pathology. appletoncentury-crofts, new york. 12. winitz, h.'(1969) : articulatory acquisition and behavior. appletoncentury-crofts, new york. for all y o u r m e d i c a l book a n d j o u r n a l r e q u i r e m e n t s consult the specialists p. b. mayer 902 n o r w i c h house heerengracht cape t o w n telephone 2-9231 journal oj' the south aj'riean speech and hearing association, vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) basf introduces the jampreof c120 cassette. basf the first people in the world to make recording tape have now patented a brilliantly simple, foolproof improvement for the innards of cassettes. it's called special mechanics and, briefly, this is how it works :in all new cassettes the neatly reeled tape fits comfortably between the top and bottom of the cassette case. the hubs turn freely. but, after it's unreeled and reeled up again a few times the tape may not wind back as neatly. so that the reel of tape gets fatter and doesn't f i t comfortabiy any more. it starts to drag. and the winding up side goes slower than the unwinding side. a n d . . . need we go on? special mechanics consists of two plastic "tusks" that guide the tape on and off the hubs. so that it stays neat, the spools keep turning freely, and the music glides smoothly on at a serene 11 i.p.s. sm also incorporated in basf chromdioxide c60, c90 and c120 cassettes. special mechanics is guaranteed to give you smoother, trou blefree recording and playback. or we'll give you a free replacement cassette. basf special mechanics sm spezial mechanik ui&kiotoxlkx*rlck&llowi·' 2983 tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheeikunde, vol. 21, desember 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) philips hearing aid services a division of s.a. philips (pty) ltd. hearing aids portable audiometers group teaching systems p h i l i p s hearing aid services head office 1005 cavendish chambers, 183 jeppe street, p.o. box 3069, johannesburg. p h i l i p s @ ) 4 4 9 2 3 journal o the south african spe and hearing association, vol. 21, december 974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 31 interaction between a teacher and the non-speaking as well as speaking children in the classroom elsa popich and erna alant centre for augmentative and alternative communication, department of communication pathology, university of pretoria abstract this study examined the verbal interactions which occurred between a teacher and two groups of children (children who were non-speaking as well as children who were speaking). descriptive data, generated by analysing ten lessons, suggested that the teacher's interaction with the children who were non-speaking differed, in terms of quantity and quality. she directed approximately 10% less interaction at each of the three non-speaking children, when compared with the number of interactions that she directed at each of the five speaking children. however, she did not spend an equal amount of time interacting with each of the non-speaking children. her interaction with the non-speaking children was dominated by questions, attention directing and requesting. verbalization types, such as answering and imitating did not occur at all in the teacher's interaction with the non-speaking children. this implies that the non-speaking children's learning experiences in the classroom differed from the speaking children's learning experiences. possible reasons for these discrepancies were proposed, namely that the teacher's attitudes, skill and knowledge played a role, but the non-speaking children's lack of access to communication was also considered to be a factor in determining the amount and type of interaction. opsomming hierdie studie het die verbale interaksie tussen 'n onderwyseres en twee groepe kinders(kinders wat nie-sprekend is sowel as kinders wat sprekend is) bestudeer. beskrywende data wat gegenereer is deur die analise van tien lesse, suggereer dat die onderwyseres se interaksie met die nie-sprekende kinders verskil het in terme van hoeveelheid en kwaliteit. sy het ongeveer 10% minder interaksie aan elkeen van die drie nie-sprekende kinders gerig in vergelyking met die aantal interaksies wat sy aan elkeen van die vyf sprekende kinders gerig het. sy het egter nie ewe veel gepraat met elkeen van die nie-sprekende kinders nie. haar interaksie met die nie-sprekende kinders het oorwegend uit vrae, aandag rig en versoeke bestaan. verbalisasies, soos antwoorde en nabootsing het nie voorgekom in die onderwyseres se interaksie met die nie-sprekende kinders nie. dit impliseer dat die nie-sprekende kinders se leerervarings in die klas verskil van die sprekende kinders se leerervarings. moontlike redes vir hierdie verskille was voorgestel, naamlik dat die onderwyseres se houdings, vermoe en kennis 'n rol speel, maar dat die nie-sprekende kinders se beperkte toegang tot kommunikasie ook 'n deurslaggewende rol in die bepaling van die hoeveelheid en tipe interaksie, gespeel het. keywords: classroom interaction; non-speaking; verbalization types. ) when a child has difficulty in actively participating in class, the problems the child experiences could be due to either the fact that the child does not have access to communication or that the child is not given the opportunity to interact (beukelman & mirenda, 1992). although one can separate factors relating to access and opportunities for communication, these aspects are interrelated. the mere provision of a means to gain access to interaction is not sufficient to increase the participation of the nonspeaking child. training of potential communication partners in the provision of interaction opportunities forms an important additional component of the intervention process (calculator & luchko, 1983). limited access to communication is related to the mode of communication the child uses (beukelman & mirenda, 1992). for the non-speaking child, who cannot meet all of his communication needs through speech, another mode should be considered in order to increase access to communication, for example the use of an alternative and augmentative communication (aac) system. providing a suitable system to facilitate interaction means that the system should aim not only to increase the intelligibility of the communication attempts but also the rate of message transmission and the child's general access to a portable communication system (beukelman & yorkston, 1982). providing the correct aac system is thus important to ensure participation in the classroom in meaningful interactions. however, only providing the child with access to communication does not ensure an increase in learning (beukelman, 1991). due to the fact that aac users in the classroom primarily occupy a respondent role it is equally important for learning that the child not only die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 elsa popich & erna alant be given access to communication but also be provided with the opportunity to interact (dalton & bedrosian, 1989). opportunity barriers are, therefore, an important aspect to be considered in the description of classroom interaction and teachers will have to assume at least some of the responsibility when aac users fail to interact (mirenda & donnellan, 1986). the extent to which a child is included in classroom interaction is affected by the teacher creating opportunities for the child to communicate (beukelman & mirenda, 1992). the less the child's speaking abilities, the more difficult for the teacher to ensure the child's participation in interaction. factors such as the teacher's attitude towards the non-speaking child, the teacher's knowledge of the importance of interaction for the increasing intelligibility of the non-speaking child and the teacher's skill in including the non-speaking child in interaction; will determine the success with which the non-speaking child is included in classroom interaction. teaching strategies that do not actively demand the participation of the aac user will result in increasing passivity in the non-speaking child (bottorf & depape, 1982). research has indicated that aac users in the classroom situation seldom initiate interaction (basil, 1992) and that this lack of social interaction often results in a decrease in language competence and in fewer learning opportunities being available to the non-speaking child (grayshon, 1977). in spite of evidence that a high level of responsiveness on the part of the teacher will have a positive influence on the child's conversational abilities (mirenda & donnellan, 1986), it was found that more than fifty percent of the initiations made by mentally handicapped pupils to teachers were not responded to (beveridge & hurrel, 1980). factors contributing to the frequency and quality of teachers responses to the non-speaking children are three-fold. firstly, the teacher's lack of responsiveness can be attributed to the teacher's expectations of the individual child (low or high achiever) with more opportunities for interaction being offered to the higher-achieving individual (light & mcnaughton, 1993). secondly, the teacher may limit the number of interactions with the child due to the fact that she cannot predict the child's capabilities in performing certain tasks in interaction (light & mcnaughton, 1993). therefore, the non-speaking child may undertable 1: the levels of verbal expression of the subj achieve, which could lead to the teacher giving him even fewer opportunities due to her lowered expectations of him. thirdly, the teacher's responses to child-initiated interaction are related to the personality of the child, for example, the presence of disruptive behaviour could lead to the child being given fewer opportunities to interact (beveridge, ramsden & leudar, 1989). although aggression is often seen in non-speaking children due to the frustration of not being understood the abscence of aggression is crucial so as not to result in exclusion from communication (baumgart, johnson & helmsetter, 1990). it would seem that a vicious circle could develop, with teachers giving fewer opportunities to non-speaking children, and the children interacting less as a consequence of the teacher's lack of responsiveness to them. not only does the teacher influence the child's participation, but there is evidence that the quantity and quality of an adult's verbal behaviour is related to the verbal output of the child with whom they are interacting (mirenda & donnellan, 1986). interaction can be seen as a pattern of mutual influence and adjustment (malamahthomas, 1988). consequently, the more verbal the child is, the more frequent the interaction with the teacher. in an evaluation of the frequency of the interaction between a teacher and the speaking, as well as non-speaking members of the class, one could therefore expect the teacher to interact more with the children who have a higher verbal output. as mentioned previously, the amount of opportunities the teacher gives to the non-speaking children, will have an important influence on their level of participation and learning. various studies have indicated that not only the quantity, but the quality of interactions between the non-speaking child and the teacher is different from the interactions between the speaking child and the teacher (cicognani & zani, 1992). the degree of impairment of verbal abilities in a child affects the adult language used in communication. teachers' interactions with children with disabilities mainly consisted of instructions, statements and questions while interaction types such as affirming and praise seldom occurred (harris, 1982; klein & harris, 1986). furthermore the questions that were directed at children with disabilities were mostly questions that only required a yes/no response (lossing, yorkston & beukelman, 1985). these findings indicate a possible trend in terms of differences in the frequency and quality of ingroup raw score on the expressive one word picture vocabulary test (gardner, 1979) average percentage: ' communication assessment 1 schedule for severely handicapped students (wium and alant, 1993) group one (non-speaking) 0 1 4 0 5 % group two ' (highly verbal) above 20 75 100% / group three (miscellaneous) 15 1 9 10 70% due to the fact that the expressive one word picture vocabulary test (gardner, 1979) was standardised on normal children, the subjects (all mentally handicapped) could only be compared by using the raw scores as stanines placed them all in the same category. the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) interaction between teacher and the non-speaking as well as speaking children in the classroom 33 teractions between teachers and the speaking as well as non-speaking children in their classes. this study focuses on the teacher's interaction with nonspeaking children in the class. the definition of non-speaking has elicited much controversy (matas, mathy-laikko, beukelman & legresley, 1985). for the purpose of this study the term refers to children with less than 15 intelligible words so as to exclude those who are beginning with functional v e r b a l c o m m u n i c a t i o n (burd, hannes, bornhoeft & fisher, 1988). the purpose of this study was to describe the opportunities for interaction, offered to the non-speaking children in a classroom setting, in order to determine whether the teacher's interaction with the nonspeaking children differed in terms of quantity or quality from the teacher's interaction with the non-speaking children. method: aim: the goal of this study was to describe the interaction between a primary school teacher and the non-speaking as well as speaking children in the class, during the presentation of various lessons. the subgoals were firstly to determine the number of interactions the teacher directed at ,the non-speaking children in comparison with the number of interactions directed at the speaking children and secondly to determine the types of verbalizations that the teacher directed at the non-speaking children. subjects: the study was conducted at a school for children with impaired cognitive abilities. the school is primarily afrikaans-speaking and has three levels, namely a beginner's phase, a junior phase and a senior phase. a class in the junior phase was selected in consultation with the principal. all the children in the class had normal vision, normal hearing and sufficient'motor abilities in order to function independently in thejclassroom. at least one parent of each subject was receiving a fixed income and all the children in group 1 (non-speaking) or group 2 (speaking) spoke afrikaans as a home language. , the speech and functional communication of each child ; was evaluated using the peabody picture vocabulary test ϋ revised (dunn & dunn, 1981), the expressive one word λ picture vocabulary test (gardner, 1979) as well as the « communication assessment schedule for severely handi g capped students (wium & alant, 1993). according to the children's results on the expressive jone word picture vocabulary test (gardner, 1979) as well % as the communication assessment schedule for severely s handicapped students (wium & alant, 1993) the class was (divided into three groups, namely a non-speaking group, ft a highly verbal group and a third group which consisted ο of children who did not fulfil the requirements for either group one or two. table 1 displays the levels of verbal exg pression of the subjects in each group and table 2 gives a g description of the children in the class. 3 from the criteria, specified in table 1, for the inclusion into group one or group two it is clear that group one and two differ significantly in terms of their levels of verbal ^ expression. ^ ^ co £> ο η co [-" 36 ( m ) ih m ar ri ed en gl is h rh m en ta lly ha nd ica pp ed n on e j j η ο co η-1 s co pl, £> ο w ο κ cd oo" 29 ( m ) ih m ar ri ed p or tu gu es e rh m en ta lly ha nd ica pp ed n on e j j η ο co η-1 s co pl, £> ο w ο ο in t>" c ou ld n ot ih d iv or ce d af ri ka an s rh m en ta lly ha nd ica pp ed e pi le ps y η 00 40 ( m ) co m ar ri ed af ri ka an s rh m en ta lly ha nd ica pp ed e pi le ps y g r o u p 2 : s p e a k in g ω <35 cd" 65 ( m i) ih m ar ri ed af ri ka an s ih m en ta lly ha nd ica pp ed n on e g r o u p 2 : s p e a k in g ο < e . [ " 51 ( m i) τ ί m ar ri ed af ri ka an s rh h yp er ac ti vi ty n on e g r o u p 2 : s p e a k in g m 00 [ " 57 ( m i) ih m ar ri ed af ri ka an s rh m en ta lly ha nd ica pp ed n on e g r o u p 2 : s p e a k in g <j 00 52 ( m i) ih m ar ri ed af ri ka an s rh h yp er ac ti vi ty n on e g r o u p 1 : n o n -s p e a k in g oo" c ou ld n ot ih m ar ri ed af ri ka an s/ e ng lis h rh h ap py pu pp et sy nd ro m e e pi le ps y g r o u p 1 : n o n -s p e a k in g cd cd" c ou ld n ot in m ar ri ed af ri ka an s rh m en ta lly ha nd ica pp ed n on e g r o u p 1 : n o n -s p e a k in g oo" c ou ld n ot m ar ri ed af ri ka an s rh d ow n sy nd ro m e n on e p a r a m e te r s 1. c hi ld 2. c hr on ol og ic al a ge 3. m en ta l ag e 4. n um be r of s ib lin gs 5. p ar en ts ' m ar it al s ta tu s 6. h om e la ng ua ge 7. r ec ep ti ve v oc ab ul ar y* 8. d is ab ili ty ** 9. a dd it io na l c om pl ic at io n >> -d a) λ ο ε s die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 elsa popich & erna alant procedure: to determine the procedure needed to evaluate classroom interaction a pilot study was conducted. the aims of the pilot study were to determine the recording equipment, as well as the recording procedures and analytical procedures to be utilised in the main study. according to the results of the pilot study the following procedures were determined for the main study. pre-recording procedures: the researcher interacted with the children during teatime and playtime to allow them to familiarise themselves with her, in order to minimize the effect of her presence in the classroom. the teacher was informed that the purpose of the study was to determine the need for aac in her classroom with the possible aim of intervention in the school. the teacher was asked to continue with her lessons as usual, while the researcher observed and audiotaped them. two types of lessons were recorded, namely, perception training and scholastic abilities training. perceptual training classes were concerned with the development of skills such as visual perception and auditory processing whereas scholastic abilities classes were concerned with academic skills such as maths and geography. recording procedures: audio-recordings were made using a cassette recorder and a condenser lapel microphone. each recording was twenty minutes long. recordings were made on tuesdays and wednesdays for five consecutive weeks. ten recordings were made for each of the two types of lessons. the researcher set up the recording equipment and attached a lapel microphone to the teacher's collar. when all the children were seated in a half circle in front of the teacher, the researcher switched on the recording equipment. the researcher sat behind the children, looking towards the teacher and observed the teacher presenting the lesson. after twenty minutes (when the lesson was over), the researcher switched off the recording equipment and removed the lapel microphone from the teacher's collar. while the teacher continued with the day's work, the researcher listened to the audio recording to determine if it was clear to whom each statement had been addressed. the researcher consulted the teacher when it was uncertain. at a later stage, the audio recordings were transcribed and analysed verbatim. the materials used during recording were an aiwa condenser lapel microphone as well as a philips d6280 cassette recorder. transcription procedures: the audio soundtrack was transcribed verbatim and checked with the teacher in order to clarify at whom each statement had been addressed. the external rater simultaneously made an independent transcription and analysis, and points of disagreement were reconsidered until 100% agreement was achieved. in order to ensure that the raw data was transcribed consistently correctly, by both transcribers, certain transcription rules were followed (stuart, vanderhoof & beukelman, 1993), namely: repetitions of words were included; vocalizations that were not actual words were represented and transcribed in a consistent form, e.g., mhmmm, uhhuh, huhuh, mmm, uh, ah aw, whoop; numbers were typed as proper nouns; contractions were typed as such that the proper form was spelled out only when it was spoken that way, e.g., don't was typed as don't and do not was typed as do not; standard abbreviations were included, e.g., dr./mrs.; during the transcription of a communication segment that was unintelligible and the entire segment was skipped even when a few intelligible words were available. a spell checker was used on all transcripts before proceeding with further analysis. analysis of data: quantitative data was established by determining at whom each interaction had been directed and calculating frequencies and proportions. the total number of interactions that the teacher directed at each of the non-speaking children, was ascertained in order to compare the amount of interaction directed at the speaking and the non-speaking children. qualitative data was obtained by defining twelve types of teacher verbalizations (adapted from romski, sevcik, reumann & pate, 1989) and categorising the teachers verbalizations accordingly. the twelve types of verbalizations are as follows: 1. questioning: a sentence adapted by order of words, punctuation or intonation to elicit information, (e.g., is it a shirt? sharon? tell me ...) 2. attention directing: to guide the child's thoughts to a specific topic, (e.g., look here.) 3. answering: a reply to a child's verbalization and not merely negating or affirming, (e.g., yes, it is a shirt.) 4. requesting·. asking for an action, object or comment, (e.g., fetch me the cow.) 5. imitating (the child)·. to mimic the child's utterance with or without expansion, (e.g., hard.) 6. naming·. to designate an object or action, (e.g., it's a shirt.) 7. negating: to imply that what the child said or did was wrong, (e.g., no, it's not a shirt., uh-uh.) 8. affirming: to imply that what the child said or did was right, (e.g., you are very clever.) 9. greeting: a salutation, (e.g., hello friends.) 10. self-repetition: to reproduce their own verbalizations in more or less the same form, (e.g., what is it? what is it?) 11. informative: to state facts or opinions about a certain topic, (e.g., they run with these pants.) 12. uncodable: the utterance does not fall into one of the above communication function categories, (e.g., huh? incomplete sentences). the types of verbalizations directed at group 1 as well as the types of verbalizations directed at group 2 were ascertained, during perceptual as well as scholastic classes. in order to increase the reliability of scoring, the researcher's transcription and analysis of the recordings were checked by an external controller. final decisions were based on 100% agreement between the raters. in order to determine the consistency of the results the change over five weeks, in the types of verbalizations that the teacher directed at group 1, as well as group 2, was determined. at-test was completed to determine if there was a sigthe south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) interaction between teacher and the non-speaking as well as speaking children in the classroom 35 nificant difference between the proportions, and finally the total proportion of time that the teacher spent in interaction with each of the non-speaking children was ascertained. in order to reveal if the results were consistent over time the change over five weeks in the proportion of time that the teacher spent in interaction with group 1 as well as group 2 was determined. results and discussion the results will be discussed with reference to the aims, namely, the number of interactions directed at each child as well as the types of verbalizations used during interaction. the proportions of interaction figure 1 displays the relative amount (%) of interaction that the teacher directed at each of the subject groups. qrp 2: speaking qrp 1: non-speaking 3% qrp 3: miscellaneous 4185 figure 1: a global view of the amount of interaction directed at the three groups within the class. the teacher directed 41% of the interactions at the whole class as well as theichildren in group three, 56% of the interactions at the speaking children and 3% of the interactions at the non-speaking children. the teacher only directed approximately 1% of her interactions towards each non-speaking child, while directing approximately 11% of her interactions towards each speaking child. this means that approximately 10% less interactions were being directed at each of the non-speaking children, in comparison with the number of interactions directed at each of the speaking children. the above-mentioned figures are only hypothetical proportions however, as they are based on the assumption that the teacher interacted equally with each child in a specific group. a t-test was completed to determine if the two groups (non-speaking children and speaking children) differed significantly. the variable being compared, in the two groups, was the number of interactions directed at the two groups of children by the teacher. the t-test result was 3,31, which is larger than 2,447, resulting in the null hypothesis (the null hypothesis supposes that there is no significant difference) being rejected. therefore it is clear that there is a significant difference between the amount of interaction directed at the two groups. the teacher interacted significantly less with the non-speaking children, than with the speaking children. these findings coincide with the findings of previous studies that the number of interactions uttered by the teacher is affected by the child's level of verbal output (mirenda & donnellan, 1986). this is noteworthy, as it has been shown that a lack of interaction with the teacher could lead to the isolation of the child in the class, a lack of participation, and consequently to the development of passivity in the non-speaking child (basil, 1992). as the non-speaking child is being given less opportunities to participate, he is therefore also being limited in terms of developing and practising new skills. literature proposes that learning in the non-speaking child is reduced, due to insufficient opportunities for interaction being offered to the child (musselwhite & st. louis, 1989). an increase in the amount of verbalizations, directed at the non-speaking child will, however, not necessarily guarantee an increase in learning. to ensure participation and learning the child needs to have a means by which to interact in the classroom and, for that reason, an alternative communication system should be made available to the child (musselwhite & st. louis, 1989). the teacher directed less interactions at the non-speaking group in comparison with the amount of interactions directed at the speaking group. in order to determine whether the teacher interacted equally seldom with all the children in the non-speaking group, her interaction with each of the non-speaking children was analysed individually figure 2 displays the relative amount (%) of interactions that the teacher directed at each of the nonspeaking children (group 1). figure 2: a global view of the amount of interaction directed at each of the non-speaking children. out of the 36 interactions directed at the three children in group 1, 83% of the interactions were directed at child f, 17% of the interactions were directed at child i and 0% of the interactions were directed at child j. this means that there is not only a discrepancy between the amount of interactions that the teacher directed at each of the two groups (non-speaking children and speaking children), but that there is also a discrepancy between the number of interactions that the teacher directed at each of the non-speaking children. this opens the door to the possibility that more issues are at stake, than merely the question of verbal abilities, and these issues could influence the teacher's interaction with each of the speaking children as well. possible reasons, for the difference in the amount of interaction directed at each of the non-speaking children are, the child's personality (beveridge, ramsden & leudar, 1989), the teacher's expectations of the child as well as the teacher's ability to predict the child's capabilities in interaction (light & mcnaughton, 1993), and finally, the die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 elsa popich & erna alant child's communicative abilities (mirenda & donnellan, 1986). the presence of aggression and disruptive behaviour in a child has been shown to have a negative influence on the teacher's interaction with that specific individual (beveridge et al., 1989). in this study two non-speaking children, at whom the teacher directed the least number of interactions, had behavioural problems (hitting and biting), whereas the third non-speaking child did not. however, one must consider that the teacher only interacted with all three of the non-speaking children for 3% of the total interaction time while she interacted with each of the speaking children for approximately 10% of the total time. this means that, although the child's personality may influence the teachers interaction, the child's verbal ability will have a far greater influence. from figure 1 it is apparent that the teacher spent only a small proportion of time in interaction with the nonspeaking children. a further analysis was done in order to determine the impact of the lesson content on the amount of interaction directed at the non-speaking as well as speaking children. figures 3 and 4 display the relative amount (%) of interaction that the teacher directed at each of the subject groups, during perceptual and scholastic classes respectively. this allows for a comparison of the teachers interaction with the two groups of children, during different class activities. during perceptual classes only 2% of the interactions were directed at the non-speaking group of children, but 5% of the interactions were directed at the non-speaking group during scholastic classes. although there is a relatively small difference, it is still significant, because the teacher interacts with the non-speaking children for such a small proportion of time. this means that the non-speaking group of children got more than twice the stimulation during scholastic classes, in comparison with perceptual classes. in order to determine whether the results were representative of the classroom interaction a further analysis was done to determine the consistency of the results over time. table 3 displays the amount of interaction directed at the non-speaking children, over a period of five weeks. from the global proportions, depicted in table 3, one can see that the values obtained for the non-speaking children do not show much variation over time, and the results obtained were a true reflection of the interaction patterns in the classroom. a trend becomes apparent, namely that the teacher consistently spent a small proportion of the total amount of time in interaction with the non-speaking children. when comparing the proportions obtained in the perceptual classes to the proportions obtained in the scholastic classes, there is consistently more interaction during the scholastic classes, with one exception. during the third week the trend was reversed, with considerably more time spent in interaction during the perceptual class, than during the scholastic class. in order to establish whether the teacher merely spent less time in interaction with the non-speaking children, or whether there were differences in terms of the quality of interaction directed at the two groups of children, the types of verbalizations directed at the non-speaking as well as speaking children were also determined. the types of verbalizations used in interaction in the analysis of the classroom interactions each of the teacher's utterances was categorised into one of twelve figure 3: the amount of interaction directed at the speaking children and the non-speaking children during perceptual classes. figure 4: the amount of interaction directed at the speaking children and the non-speaking children during scholastic classes. table 3: the amount (%) of interaction that the teacher directed at group 1 (three non-speaking children), over a period of five weeks. lessons week 1 week 2 week 3 week 4 week 5 ^average χ global view 1,93% 4,23% 2,27% 4,58% 1,08% 0.03 perceptual classes 1,92% 1,76% 3,55% 2,13% / 0 0.02 scholastic classes 1,94% 8,89% 0 8,08% 2,29% 0.05 the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) interaction between teacher and the non-speaking as well as speaking children in the classroom 37 types of verbalizations. figure 5 displays how many times each of the 12 types of verbalizations occurred in the teacher's interaction with the non-speaking group of children, as well as in the teacher's interaction with the speaking group. as displayed in figure 5, only 7 of the 12 types of verbalizations occurred in the teacher's interactions with the non-speaking group of children. type 1 (questioning) occurred the most (11 times), followed by type 2 (attention directing) which occurred 8 times and type 4 (requesting) which occurred 7 times. type 6 (naming), type 7 (negating), type 8 (affirming) and type 11 (informative) also occurred. type 3 (answering the child) and type 5 (verbally imitating the child) did not occur at all. this means that the teacher's interaction with the non-speaking children was dominated by questions, attention directing and requests. one can see that the teacher's interaction with the speaking children did not follow the same trends in terms of which types of verbalizations that occurred the most. type 1 (questioning) still occurred the most (198 times), but type 8 (affirming) and not type 2 (attention directing) occurred second most. type 4 (requesting) still occurred the third most. one can therefore determine a general trend in the class, namely, that questioning and requesting occur frequently, but that attention directing occurs much more frequently in the teacher's interaction with the non-speaking children. the fact that type 11 (informative) occurs much more frequently in the teacher's interaction with the speaking children than in the teacher's interaction with the non-speaking children is also of interest due to the implications for the non-speaking child's opportunity for learning in the class. the quality of the teacher's interaction was, therefore, also influenced by the children's verbal abilities. the teacher used a limited variety of utterances when in interaction with the non-speaking children. this is of par19 β _za_ 16 β β 10 11 12 i non-tpeaklnfl wa (peaking t y p e · of verbalization· key: types of verbalizations 1. questioning 2. attention directing 3. answering 4. requesting 5. imitating 6. naming 7. negating 8. affirming 9. greeting 10. self-repetition 11. informative 12. uncodable figure 5: a global view of the types of verbalizations directed at the speaking and non-speaking children. ticular relevance in the classroom situation, because the teacher's input strategies will greatly influence the child's subsequent communicative performance (mirenda & donnellan, 1986). the child's verbal disability should, therefore, be considered in relationship to the interaction partner's behaviour, rather than in absolute terms (mirenda & donellan, 1986). the teacher's verbalizations, directed at the non-speaking children, consisted of a large proportion of questions, attention directing and requests. this confirms the literature which states that teachers' interactions with non-speaking children are characterised by the high frequency of questions (klein & harris, 1986). this type of interaction is characteristic of a directive conversational style, and may further inhibit the interaction with the non-speaking child (mirenda & donellan, 1986). consequently, the question arises of why the teacher used so many questions with the non-speaking children. hills (1986) proposes that it is a technique used by teachers to elicit responses from children and to avoid awkward silences. it has also been hypothesised that it could be a compensatory strategy on the teachers' behalf, to compensate for the child's conversational difficulties (mirenda & donellan, 1986). the high frequency of verbalization type 4 (requesting) is not surprising, as requesting for actions or objects does not require a verbal response from the child. the fact that type 3 (answering the child) or type 5 (verbally imitating the child's verbalizations) did not occur is also to be expected, as the teacher cannot answer or imitate a child who does not speak. the frequent occurrence of affirming (type 8 verbalization) in the teacher's interaction with the speaking children could be attributed to the fact that the speaking children were more involved in the lessons, and therefore had more opportunities to give the correct response. figures 6 and 7 display the types of verbalizations that the teacher directed at the non-speaking children, as well as speaking children, during perceptual and scholastic classes respectively. from figure 5 it is apparent that the teachers' interaction with the two groups of children was characterised by certain trends. a further analysis was done to determine the impact of the lesson content on the types of verbalizations directed at the non-speaking children. " the same trends are seen in the two types of classes as were noted in general, for the non-speaking group, except for the following: type 6 (naming), type 8 (affirming) and type 11 (informative) did not occur in the perceptual classes and there was a relatively large number of type 11 (informative) verbalizations during scholastic classes. a greater proportion of the teacher's interactions with the non-speaking children, occurred during scholastic classes. perceptual skills already start to develop in sensorimotor stage one (louw, 1990) and the skills required from the children during the classes were on a very basic level (e.g., differentiate between loud and soft). however, the scholastic classes required a higher level of functioning and the teacher therefore had to instruct the children more frequently. in order to determine whether the results depicted in figures 5, 6, and 7 were consistent and representational of all five weeks, table 4 compares the results obtained for each of the five weeks. any changes over time, would then become apparent. from the results, depicted in table 4, one can see that die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 the trend discussed previously (the high frequency of questioning, attention directing and requesting in the teacher's interaction with the non-speaking children) is indicated for all five weeks. however, in week 4 there is also a relatively high frequency of informative verbalizations elsa popich & erna alant directed at the non-speaking children. this means that the trend is constant over time, but there is some variation. from the results discussed, it becomes clear that the teacher's interaction with the two groups differed in terms 180 f 100 r u s « ο y «ο 10 ο 1 8 3 4 8 8 7 8 9 1 0 1 1 1 2 bnen-apaaklno e2 wmklng typaa of verbalization· key: types of verbalizations 1. questioning 7. negating 2. attention directing 8. affirming 3. answering 9. greeting 4. requesting 10. self-repetition 5. imitating 11. informative 6. naming 12. uncodable 71 1 i 9 aa j 4 1 1 i 1 9 9 ? ι 1 1 1 8 1 j i l l · i 0> i a a 4 b a r a a i o i i i 8 non-apmklng speaking typaa of wrballatbna key: types of verbalizations 1. questioning 2. attention directing 3. answering 4. requesting 5. imitating 6. naming 7. negating 8. affirming 9. greeting 10. self-repetition 11. informative 12. uncodable figure 6: the types of verbalizations directed at the speaking and non-speaking children during perceptual classes. figure 7: the types of verbalizations directed at the speaking an non-speaking children during scholastic classes. table 4: the number of times that each type of verbalization was directed at group-1 (non-speaking children), over a period of five weeks. types of verbalizations week 1 week 2 week 3 week 4 week 5 total 1. questioning 1 3 2 4 1 11 2. attention directing 3 2 1 2 8 1 3. answering o : 4. requesting 4 2 1 7 1 5. imitating ο i 6. naming 1 1 1 2 7. negating 1 1 8. affirming 1 1 1 3 9. greeting 0 10. self-repetition / 0 11. informative 1 3 4 12. uncodable 0 y 13.total 6 11 5 11 3 36 the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) interaction between teacher and the non-speaking as well as speaking children in the classroom 39 o f q u a n t i t y and quality. one can conclude that two main trends have been identified in the teacher's interaction with the non-speaking children, namely she directed only a small amount of interaction at the non-speaking children and that she only used a limited variety of utterances when in interaction with the non-speaking children. it has, however, become apparent that the children's verbal abilities were not the only factor which influenced . the findings mentioned above, but certainly had a larger impact than the other factors. conclusion the initial hypothesis of the study, that the teacher's interaction with the non-speaking children would differ from the interaction with the speaking children in terms of quantity and quality (cicognani & zani, 1992) was proven to be correct. it has also become clear, however, that although the children's verbal ability had the greatest influence on the teacher's interaction, other factors might also have played a role. additional factors were identified as important in determining the quantity and quality of the teacher's interaction with the non-speaking children, namely, the teacher's attitude towards the nonspeaking children, the teacher's knowledge of the importance of inclusion into interaction for the non-speaking children and the teacher's skill at including the non-speaking children in interaction (beukelman & mirenda, 1992). other important factors are the teacher's expectations of the non-speaking children and the ability to accurately predict whether a non-speaking child would be capable of completing a task (light & mcnaughton, 1993). the nonspeaking child's personality also has a significant influence on the teacher's interactions (beveridge et al., 1989). a teacher's skill in involving the non-speaking child in interaction has been found to influence the child's social development and learning as well as the child's level of spontaneous participation (kelly, 1978; mirenda & donnellan, 1986). in order to change attitudes, increase knowledge and improve skills, in-service teacher training programmes could be implemented (blackstone, 1989). training should provide teachers with a way to monitor and modify classroom interactions, when dealing with the non-speaking child, to promote participation, development and learning (loeding, za'ngari & lloyd, 1990). the teachers should be involved in; the process of deciding the content of the training programme (bottorf & depape, 1982). although the teacher's interaction with the non-speaking child is an important consideration in classroom intervention, the teacher's interaction is influenced by the child's participation (mirenda & donnellan, 1986). intervention with the child is, therefore, equally as important as intervention with the teacher. research has found that the child's role as an active participant in communication is an important factor in determining whether the interaction had been meaningful (mirenda & donnellan, 1986). although verbal interaction was the primary mode for learning, and it was, therefore, a valid variable to consider in the study, a shortcoming of this study is that it ignored the possible impact of natural gestures and nonspeaking communication on the child. however, natural gestures as a communication system have been found to be a very limited system, in terms of the small vocabulary and the low level of abstraction (musselwhite & st. louis, 1989). one could hypothesise that the use of natural gestures in interaction could, at best, have had a slight positive impact on the child's communication. however, further research should be done to determine the proportion and types of non-speaking interaction between the teacher and the two groups of children to determine the nature and impact thereof on the non-speaking child. research should also investigate the teacher's interaction with nonspeaking children who have aac systems as well as with non-speaking children who do not have aac systems, in order to determine the impact of the aac system on interaction. references basil, c. (1992). social interaction and learned helplessness in severely disabled children. augmentative and alternative communication, vol. 8:3, ppl88-199. baumgart,d., johnson,j. & helmsetter.e. (1990). augmentative and alternative communication systems for persons with moderate and severe disabilities. paul h. brookes publishing co. : baltimore. beukelman, d.r. (1991). magic and cost of communication competence. augmentative and alternative communication, vol. 7:1, pp2-10. beukelman, d. & mirenda, p. (1992). augmentative and alternative communication: management of severe communication disorders in children and adults. paul h. brookes publishing co.: baltimore. beukelman, d.r. & yorkston, k.m. (1982). communication interaction of adult communication augmentation system use. topics in language disorders, vol. 2, pp39-53. beveridge, m. & hurrel, p. (1980). teachers' responses to the initiations of esn(s) children. journal of child psychology and psychiatry, vol. 21, ppl75 181. beveridge, m., ramsden, g. & leudar, i. (1989). language and communication in mentally handicapped people. chapman and hall ltd.: london. blackstone, s. (1989). augmentative communication services in the schools. asha, vol.31, pp61 63. bottorf, l. & depape, d. (1982). initiating communication systems for severely speech-impaired persons. topic in language disorders, vol.2, 55 71. burd, l., hannes, k , bornhoeft, d. & fisher, w. (1988). anorth dakota prevalence study of non-speaking school-age children. language, speech and hearing services in schools, vol. 19:1, pp371-379. calculator, s. & luchko, c. (1983). evaluating the effectiveness of a communication board training program. journal of speech and hearing disorders, vol. 48, ppl85-191. cicognani, e. & zani, b. (1992). teacher-children interactions in a nursery school: an exploratory study. language and education, vol. 6:1, ppl-12. dalton, b. & bedrosian, j. (1989). communicative performance of adolescents with severe speech impairment: influence of context. journal of speech and hearing disorders, vol. 54, pp403-418. dunn, l. & dunn, l. (1981). peabody picture vocabulary test revised. american guidance service: minnesota. gardner, m. (1979). expressive one-word picture vocabulary test. academic therapy publications: california. grayshon, m. (1977). towards a social grammar of language. mouton publishers: the hague. harris, d. (1982). communicative interaction processes involving nonvocal physically handicapped children. topics in language disorders, vol. 22, pp21-36. hills, p. (1986). teaching and communication. croom helm: sydney. kelly, a. (1978). mixed-ability grouping. harper and row: london. klein, m. & harris, k. (1986). classroom communication functions of four learning-handicapped students. language, speech, and hearing services in schools, vol. 17, pp318-320. light, j. & mcnaughton, d. (1993). literacy and augmentative and alternative communication (aac): the expectations and priorities of parents and teachers. topics in language disorders, vol. 13:2, pp33-45. loeding, l., zangari, c., & lloyd, l. (1990). a "working party" die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 elsa popich & erna alant approach to planning in-service training in manual signs for an entire public school staff. augmentative and alternative communication, vol. 6:1 pp38-47. lossing, c., yorkston, k., & beukelman, d. (1985). communication augmentation systems: quantification in a natural setting. archives of physical medicine and rehabilitation, vol. 66, pp380-383. louw, d. (1990). menslike ontwikkeling.haum-tersier: pretoria. malamah-thomas, a. (1988). classroom interaction. oxford university press: london. matas, j., mathy-laikko, p., beukelman, d. & legresley, k. (1985). identifying the nonspeaking population: a demographic study. augmentative and alternative communication, vol. 1:1, ppl7-27. mirenda, p. & donnellan, a. (1986). effects of adult interaction style on conversational behaviour in students with severe communication problems. language, speech and hearing services in schools, vol. 17:2, ppl26-139. musselwhite, c. & st. louis, k. (1989). communication programming for persons with severe handicaps: vocal and augmentative strategies. college-hill press: boston. romski, m., sevcik, r., reumann, r. & pate, j. (1989). youngsters with moderate or severe mental retardation and severe spoken language impairments 1: extant communicative patterns journal of speech and hearing disorders, vol. 54, pp366-372 stuart, s., vanderhoof, d. & beukelman, d.r. (1993). topic and vocabulary use patterns of elderly woman. augmentative and alternative communication, vol. 9:2, pp95-107. wium, a. & alant, e. (1993). communication assessment schedule for severely handicapped students. unpublished study, department of communication pathology, university of pretoria. the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) developmental aphasia j o n e i s e n s o n , ph.d.* as recently as ten years ago, a paper on developmental aphasia would probably have been introduced with arguments either for or against the existence of the syndrome. although this line of argument may still be heard, most specialists in language disorders of children are more likely to be concerned about the differential symptoms of the syndrome rather than to question its existence, in the broadest possible sense, developmental aphasia may be considered to exist when we can establish that a neurologically handicapped child has failed to establish, or has severe retardation in, the understanding and production of language. in a narrower sense, and in the sense to which we shall address ourselves to the question, we consider that developmental aphasia is relatively specific to language function (absence or severe retardation of this function) and that the impairment cannot be ascribed to one or more of the frequent causes for language impairment. these causes include deafness, mental deficiency, motor disability involving the speech mechanism, or severe personality (emotional) problems. ft is not our intention in this paper to consider the question of differential diagnosis in any detail. fortunately, articles by a. l. benton1 and j. eisenson0 cover the question of the identification and differential diagnosis of the aphasic child. in this paper, therefore, we shall emphasize the possible etiology and the perceptual characteristics and intellectual functioning of the child designated as developmentally aphasic. etiology in the article by benton,1 referred to above, the author postulated two possible types of etiology for developmental aphasia. the first was an underlying impairment for associations or connections in the cerebral system between sensed sound and other cerebral processes through which meanings may be derived. the second postulation stressed the likelihood of the presence of defective perceptual processes which underlie the failure for normal language development. it is often possible for psychologists to demonstrate the second without convincing neurologists about the existence of the first. if, however, * professor, speech and h e a r i n g sciences, school of medicine. stanford university. tydskrif van die suid-afrikaanse logopediese vereniging, vol.16, nr. , des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 1 6 jon eisenson we take the position that the psychologist, in assessing perceptual functions is really engaged in an extended neurological, then establishing perceptual impairment or dysfunctioning implies that the cerebral mechanisms are defective. this is so even though a routine neurological does not provide evidence for the other positive findings. this writer accepts the position that developmentally aphasic* children suffer from a primary impairment in those aspects of auditory perception necessary for language to be learned and produced. the impairment in auditory perception may be associated with actual brain damage incurred before birth, during birth, or during the first year to year and a half of life, or because of a delay in cerebral maturation which implicates the auditory centres. until fairly recently, clinical impression rather than the results of systematic experimental studies provided the data for our observations in regard to the auditory functioning of aphasic children. some of the more frequent clinical observations cited in the literature include difficulty in the localization of a source of sound, inconsistency of responses to sound, especially to speech sounds, marked oscillation of auditory threshold, inattention to auditory stimuli, and quick dissipation of attention (benton2). the acquisition of language by the end of the second year, most children indicate by their behaviour that they understand much of what is said to them by normal speaking adults. in addition, the children are well on their way to speaking much like the adults in their environment, but with enough variation to be speaking for themselves, as well as expressing their special selves as unique members of their environment. by the end of the third year, most children understand not only what is said to them, but are able, instantly, to comprehend an amazingly large number of verbal formulations to which they have had no previous exposure. thus, we may conclude that normal children are able to listen and understand creatively, and are innovative and creative in their own utterances. each time a child arranges (formulates) a number of words he has not before so uttered, he is demonstrating creativity in verbal behaviour. chomsky,4 in an article on language and the mind, sums up this position as follows: the fact surely is . . . that the n u m b e r of sentences in one's native language that one will immediately understand, with no feeling of difficulty or strange* hereafter, the single terms aphasic, of aphasia, will be used rather than developmental aphasic, or developmental aphasia. it should be understood that a child who has established language may, as in the case of an adult, become aphasic as a result of brain damage. t h ' s would constitute acquired aphasia in a child. we are not, however, concerned with this problem in this paper. journal of the south african logopedie society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) developmental aphasia 17 ness, is astronomical, and that the n u m b e r of patterns that underlie our normal use of language and that correspond to meaningful and easily comprehensible sentences in our language is orders of magnitude greater than the number of seconds in a lifetime, or the number of seconds in the history of the language for that matter. it is in this sense that the normal use of language is innovative, in fact, potentially infinite in variety. in the normal acquisition of language a child somehow learns to listen so as to discriminate the sounds and combinations of sounds in the linguistic system of his environment, to isolate some words, and to produce utterances consisting of combinations of words according to a set of rules (the grammar) of the language cr languages to which he is exposed. interestingly, though the normal child seems to show awareness of the basic sound units (phonemes) of a linguistic system during the first year of his life, he does not usually become completely proficient in his articulatory ability until he is seven or eight years of age. along with phonemic and articulatory proficiency, the normal child also learns the melody or intonation of his language. by age eight, perhaps somewhat earlier for girls and somewhat later for some boys, except for vocal pitch range, most normal children speak essentially the way they will as adults. individually, of course, some children will develop larger comprehension and more productive vocabularies than others, and some will be able to understand and produce more complex grammatically correct utterances than others. vocal nuances may be better appreciated and productively controlled by some children than by others, so that irony, sarcasm, and the implications of utterances that are conveyed through subtle changes of inflection become individualized acquisitions. such acquisitions, along with the development of vocabularies, may continue indefinitely through the life of the speaker. before considering the specific nature of the perceptual impairments that we consider to underlie the failure for language acquisition in the aphasic child, four brief hypotheses will be stated in positive form in regard to the normal establishment of verbal behaviour. (1) as far as we presently know, only human beings are capable of learning to use language without being stimulus-bound to the events, or replication of the events, that were initially associated with and evoked the original linguistic products. (2) no theory of learning at present adequately explains the acquisition of language beyond the utterance of single words to identify objective events. learning theorists as of now, are unable to explain how a child can understand verbal formulations never responded to before, or to produce acceptable verbal formulations never before tried by the speaker. (3) concepts of imprinting and readiness are needed to explain the critical period — between fifteen and thirty months of age — tydskrif van die suid-afrikaanse logopediese vereniging, vol.16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 jon eisenson when most normal children establish verbal behaviour. in lower animals behaviour imprinting is considered to be species specific. imprinting is presumably related to special sensitivities and response potentialities which enable a member of a species to establish new behaviour patterns with a minimum of exposure, effort and opportunity for practice. (4) the critical period for most normal children for the establishment of verbal behaviour is between fifteen and thirty months. comprehension of language as manifested by appropriate non-verbal responses is normally established between nine to twelve months.* medical and psychological findings aphasic children vary considerably from one another in regard to objective findings resulting from medical, neurological and psychological assessment. as a total population, however, they are different from other non-verbal children who assess as being primarily mentally retarded or severely hard-of-hearing. the findings that will be summarized are based on examinations of more than two hundred children, of whom seventy-three were designated as aphasic. the examinations were conducted at the institute for childhood aphasia, school of medicine, stanford university. electroencephalogram findings. thirty-six of the group were found to have positive electroencephalograms. twenty-two showed localized abnormalities, of which nineteen were in the left hemisphere. these findings are in general accord with those of goldstein, landau, and kleffner10 who report that forty percent of sixty-nine aphasic children showed abnormal electroencephalograms. although these investigators found about the same percentage of abnormalities in their comparison population of one hundred and fourteen deaf children, the aphasics had a higher incidence of focal abnormalities (14.5%) than did the deaf children (6.1%). audiological examination. the aphasic child often gives the. impression of being either hard-of-hearing or deaf. objective findings indicate that many, perhaps thirty per cent, do in fact have mild to moderate hearing losses based on results of objective audiometry. however, a typical audiological report is likely to indicate that the amount of hearing loss based on test findings is not sufficient to explain the severity of the language impairment. functionally, the i 1 * f o r a detailed consideration of the implications of these basic concepts in regard to normal language development see ε. h. lenneberg. 1 2 journal of the south african logopedi society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) developmental aphasia 19 aphasic child with a hearing loss shows impairment for listening rather than for the physical reception of sound per se. he is likely to show more impairment for listening to human speech than to animal or environmental noises. in this sense, he appears to have a selective hearing loss. the reasons for this will be considered later in our discussion of the aphasic child's perceptual dysfunctions. intellectual functioning. a basic assumption in regard to most aphasic children is that despite their normal intellectual potential they are intellectually inefficient. the implication of inefficiency is that the child's performance tends to break down under conditions of noise, stress, and awareness of error, more readily than we would expect for a normal child. performance of aphasic children on standardized tests is characterized by variability. so is performance on learning tasks. a given child's productions for the same task (test item or learning situation) may vary from complete failure at one time to a high degree of success at another. if we assume that a child's best performance is indicative of his intellectual potential, then we would conclude that most aphasic children approximate the norms and the learning capabilities of their peers, at least when the estimates are based on non-verbal situations. functionally and practically, however, most aphasic children tend to perform below the level of their best efforts. behavioural observations of aphasic children when they are involved with difficult test items or difficult learning situations include strong manifestations of perseveration, expressions of hostility directed to the examiner or to the materials at hand, and often considerable hyperactivity. some children, however, withdraw from continuing with the test or learning tasks rather than act out against the situation. a highly significant clinical observation of test and learning performance of aphasic children is their tendency to lose sight of an underlying principle needed for the solution of a test task or problem. thus, if a test item requires that the child arrange a number of figures or cards in an alternating series such as a circle and a cross, a child may arrange half the figures in the required order, and then place the remainder in a random order. a related characteristic performance error is failure to carry over a principle from one test item to another. thus, even if an aphasic child succeeds in a task — e.g. pointing to the different picture on the columbia mental maturity scale, the examiner cannot assume that the child will know what he has to do on succeeding items. often it seems that each item is a task unto itself, that the aphasic child has to work out anew, or be reminded by the clinician, that tasks b, c, etc., are but items in a series that will be solved by the application of the same principle employed for task a. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 jon eisenson impairments of auditory perception associated with developmental aphasia although some aphasic children may have related productive problems (dysarthria and oral apraxia), we believe that the underlying problem is one of defective auditory perception. as noted earlier, some aphasic children have objectively determined hearing loss, and most aphasic children are functionally considerably more impaired than the degree of hearing loss would suggest. beyond the implications of such hearing limitation, aphasic children as a total population are more severely impaired in auditory perception — in their ability to discriminate and process auditorily those events that constitute speech — and in their ability to store, retrieve, and derive meaning from oral signals and symbols. in the discussion that follows we will consider some possible bases for these impairments. defective capacity for storing οϊ speech signals. we have been able to demonstrate that aphasic children, despite many initial errors, can be trained to discriminate and match isolated speech sounds when discriminations and matchings are based on immediate recall (mcreynolds13' '"). however, we have also observed that most aphasic children make considerably more matching errors than do their peers when a period of delay is introduced before an opportunity for matching. our assumption is that the children are not able to store and retain the signals after short periods of delay. in contrast, performance involving responses to mechanical sounds is usually retained. a possible explanation for this observation is that speech signals call for different storage and control than do other kinds of auditory events. support for this assumption is provided by the results of several studies by members of the haskins laboratories. dr. liberman and his associates,1'1 based upon their investigations, state: the conclusion that there is a speech mode, and that it is characterized by processes different from those underlying the perception of other sounds, is strengthened by recent indications that speech and nonspeech sounds are processed primarily in different hemispheres of the brain. impairment of sound generalization in contextual utterance. in the immediately preceding paragraphs we considered the assumption that aphasic children have an impairment in the discrimination ,οΐ isolated speech signals because of storage-retrieval dysfunction. aysecond and related impairment is concerned with the nature of speech signals in contextual utterance. except for one-phoneme words, such as / and a, our speech tokens consist of combinations of consonants and vowels, or consonant clusters and vowels. in spoken utterance, individual sounds are modified according to their contextual environment. thus, the t of too is somewhat different from the t of pit, or those in hit it and hit that. despite these differences, normal children learn to i journal of the south african logopedi society, vol. 16, no. , dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) developmental aphasia 21 recognize all of these variants of t as essentially the same sound, or at least as having essential similarities more significant than their incidental differences. we know, of course, that phoneticians refer to the basic sound category as a phoneme, and the variants as allophones. the capacity for generalization as to speech sound (phonemic) categories we believe to be impaired in aphasic children. if this assumption is correct, then it is likely that aphasic children perceive speech sounds as discrete auditory events. because no two speakers are precisely alike in their articulatory products,* the child's storage capacity for auditory events is both overtaxed and lacking in a matching to sample system to permit him to determine what auditory event he is responding to at any given time. in brief, the child is without functional basic categories for the processing of speech events. impairments related to sequencing (rate and order of utterance). aphasic children may lack the capacity for listening as rapidly as necessary to perceive and process speech. william hardy7 refers to the positive ability of normal children to process speech input as auding which he defines as the integrative functions in the brain's management of acoustic information. auding involves such related functions as the ability to discriminate between sounds on the bases of differences in intensity, frequency, and duration as well as the rate at which the changes themselves occur. unless a listener can do this, he cannot distinguish between words such as ask and ax, fits and fist, or understand such statements as the household pets became pests, or jane bit her fists when she had fits. how rapidly must a child be able to listen to be competent in auding? in broad terms, the answer is rapidly enough to make matchings between ongoing auditory events and those events, or residuals of events, that have been stored somewhere in his nervous system. he must also be able to keep in mind the order of events and be competent in making temporal resolutions. normally, all of this can be achieved in a small fraction of a second, a matter of milliseconds. experimental evidence on both normal and brain-damaged subjects provides us with information as to the minimum interval of time necessary for discrimination (resolutions) to be made between successive signals, the interval necessary for both resolution and temporal order judgment, and the effects of experience in modifying (reducing) minimum time interval between signals for the required * actually, no speaker's articulations are precisely the same even for repeated utterances. tydskrif van die suid-afrikaanse logopediese vereniging, vol.16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 jon eisenson judgments. broadbent and ladefoged3 report that the time required for a correct time order judgment between pip — hiss and hiss — pip was reduced from one hundred and fifty milliseconds to thirty milliseconds after repeated trials on this task. hirsch and sherrick9 found that an experienced subject required an interval of twenty milliseconds to make correct judgments of the presented order of two events — a light and a sound signal — when these events are produced repeatedly in the same order. when such a judgment has to be made on the basis of a single presentation, naive subjects required about sixty milliseconds for the same percentage (75%) of accuracy of judgment (hirsch, i. j., and fraisse, p.8) the experiments cited above were performed with normal subjects. subjects with cerebral pathology required an appreciably longer interval of time for temporal order judgment tasks. efrons found that some aphasic adults required as much as a full second to make correct judgment as to the order of two ten millisecond pulses markedly different in frequency, whereas neurologically normal adults performed this task in approximately fifty-sixty milliseconds. there are, unfortunately, few investigations with children as subjects. the findings, generally, are along the same lines as for adults. generally, children with aphasic involvements require considerably more time than do normal children to make correct judgments as to the timeorder of events. lowe and campbell" found that a group of aphasoid children, ranging in age from seven to fourteen years, needed a mean time of three hundred and fifty-seven milliseconds for time-order judgments (range from fifty-five to seven hundred milliseconds) compared with a mean time of thirty-six point one milliseconds (range from fifty to eighty milliseconds) for normal control subjects. the specific task involved required the subject to indicate the correct order between two fifteen millisecond sound pulses, one at 2200 cycles per second and one at 400 cycles per second. impairments of sequencing and aphasic dysfunction. both clinical observations and psychodiagnostic test findings tend to support the impression that aphasic children are impaired in their ability to sequence speech events. for some aphasic children, the impairment may be more general and involve the processing of any series (sequence) of events in time and/or space. the impairment is, usually less severe for visual events, in part because most visual ̂ events are relatively static so that it is possible;for a child to look again at and so confirm or correct an impression. it is ordinarily not possible to listen again to a succession of auditory events. words once spoken, or noises once produced, are ephemeral. they can be reproduced only by retrieval from memory. j ι ι regardless of the manner of production, or modality intake, all linguistic events are temporal and sequential. we cannot understand journal of the south african logopedi society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) developmental aphasia 23 language of more than a single sound or a single written signal — and there is very little to be understood with such a limitation — unless we are able to process ongoing events in the light of immediately past events and with anticipation of events about to occur. each moment of linguistic experience provides the listener (speaker) with an opportunity as well as a need for confirmation or rejection of preceding perceptions and assumptions. the aphasic child is seriously impaired in this game of perceptual and conceptual probabilities. some possible reasons for this impairment were suggested earlier in our speculations about poor storage capacity for auditory events, and the difficulty related to weaknesses in phonemic and linguistic generalization. it is also likely that the aphasic child has an impairment for the processing of sequences of speech events. summary and implications if our observations are correct and our speculations tenable, we may regard the aphasic child as one who may be defective in: (a) storage and retrieval of sounds; (b) in phonemic generalization; (c) in sequencing; and (d) more generally, and more broadly psychologically, in ability to generalize and to apply principles to situations that share a critical and determining common feature. the aphasic child may be born structurally ill-equipped for the acquisition of verbal behaviour. it would be helpful if at this point, we could indicate with confidence the requisite capacities and the functional structures which enable all but a small percentage of children to begin to speak and to develop verbal behaviour according to the expectations of the concerned members of their environment. we may speculate but we are by no means certain as to how a child can understand verbal formulations he has never heard before, and to produce his own formulations with considerable confidence that what he says will be understood by others. we assume, of course, that normal hearing acuity, normal perceptual ability, normal sequencing, and a fair amount of intellect are required for the acquisition of language. in regard to intellect, it is important to appreciate that most children who are mentally subnormal, unless the subnormality is profound, nevertheless learn to speak. yet some children who indicate through non-verbal behaviour that they have adequate intelligence, that is, they perform about as expected in situations where verbal mediation is not required — fail to acquire language without direct therapeutic intervention. the aphasic and some autistic children are among those tydskrif van die suid-afrikaanse logopediese vereniging vol.16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 jon eisenson with adequate intelligence who do not learn to acquire language spontaneously. some clinicians and not a few linguists take recourse to a philosophic attitude about what the capacities and structures might be for a child to acquire speech. the position they take is that a child learns to speak because speech is a human species-specific function. so, according to lenneberg,11 the development of language, also a species-specific phenomenon, is related physiologically, structurally, and dcvelopmentally to the other two typically human characteristics, cerebral dominance and maturational history. language is not an arbitrarily adopted behaviour, facilitated by accidentally fortunate anatomical arrangements in the oral cavity and larynx, but an activity that develops harmoniously by neccssary integration of neuronal and skeletal structures and by reciprocal adaptation of various physiological processes. we do not pretend that all or even most of the evidence needed to explain the lack or severe delay of speech in aphasic children is presently available. what evidence we do have strongly suggests to us that aphasic children are lacking in the basic capacities and in the correlative abilities and integrations necessary for normal language acquisition. perhaps these children are not pre-wired neurologically as well as they should be to integrate what they need, to be proficient receivers and senders of sound signals. perhaps aphasic children have a slower central nervous system maturation than normal children or even our mentally subnormal children who acquire speech. it is likely that some aphasic children develop perceptual defences because of demands made on their systems which are beyond their capacities at critical times. these are some, but not all of the possibilities which must be considered if we are to understand the nature of the problem of developmental aphasia, and if we are to develop rational and significant therapeutic and training procedures. opsomming die afatiese kind kan beskou word as defektief in die volgende funksies: (a) opberging en herwinning van klanke; (b) fonemiese veralgemening; ^ (c) opeenvolging; 7 (d) die vermoe om te veralgemeen en beginsels toe te pas op situasies wat 'n kritieke en bepalende algemene faktor deel. hierdie swakhede bemoeilik die aanleer van taal vir so 'n kind; verder kan hy ook gebore wees met 'n strukturele onvermoe om verbale gedrag aan te leer. journal of the south african logopedie society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) developmental aphasia 25 adekwate intelligensie tenspyt, leer die afatiese kind, soos die outistiese kind, nie taal spontaan aan nie. die subnormale kind daarenteen, leer uiteindelik taal aan mits die subnormaliteit nie te groot is nie. alhoewel ons nie oor al die getuienis beskik om die vertraagde spraak in afatiese kinders te verklaar nie, blyk dit tog dat hierdie kinders nie oor die nodige korrelatiewe vermoens beskik om taal aan te leer nie. alle moontlikhede moet in gedagte gehou word by die beskouing van die aard van die probleem van ontwikkelingsafasie. references 1. benton, a. l. (1964): developmental aphasia and brain damage. cortex /, 40-52. 2. benton, a. l. (1967): problems of test construction in the field of aphasia. cortex 111, 32-58. 3. broadbent, d. e. and ladefoged, p. (1959): auditory perception of temporal order. journal of the acoustical society of america, 31, 15-49. 4. chomsky, n. (1968): language and the mind, i. columbia university f o r u m 5-10. 5. efron. r. (1963): temporal perception, aphasia, and deja vu. brain, 86, 403-424. 6. eisenson, j. (1966): developmental patterns of non-verbal children. journal of neurological science 3, 313-320. 7. hardy, w. g. (1965): on language disorders in young children. journal of speech and hearing disorders, 1, 3-16. 8. hirsh, i. j. and fraisse, p. (1965): central institute for the deaf, periodic progress reports. 9. hirsh, i. j. and sherrick (1965): perceived order in different sense modalities. journal of experimental psychology, 62, 423-432. 10. goldstein, r., landau, w. m. and kleffner, f. r. (1968): neurological assessment of deaf and aphasic children. transactions of the american otologic society, 122-136. 11. lenneberg, ε. h. (1966): the natural history of language. smith, f. and miller, g. t h e genesis of language, m.i.t. press, 219-252. 12. lenneberg, ε. h. (1967): biological foundations of language, chapter 4. wiley, new york. 13. liberman, a. m., cooper, f. s., shankweiler, d. p. and studdert-kennedy, m. (1967): perception of the speech code. psychological review, 74, 431-461. 14. lowe, d. a. and campbell, r. a. (1965): temporal discrimination in aphasoid and normal children. journal of speech and hearing research. 8, 313-314. 15. mcreynolds, l. k. (1964): operant conditioning discrimination in aphasic children. unpublished ph.d. dissertation, stanford university. 16. mcreynolds, l. k. (1966): operant conditioning for investigating speech sound discrimination in aphasic children. journal of speech and hearing disorders, 9, 519-528. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 16, nr. , des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 5 3 nonspeaking children in schools for children with severe mental disabilities in the greater pretoria area: implications for speech-language therapists juan bornman and erna alant centre for augmentative and alternative communication department of communication pathology university of pretoria abstract the aim of this study was to describe children enrolled in registered schools for children with severe mental disabilities in the greater pretoria area in order to compile a profile of nonspeaking children. emphasis was placed on the prevalence of nonspeaking children as well as on their functioning in different skill areas in order to assess the need for service delivery. two questionnaires were developed; the first for obtaining biographical data from teachers; the second for obtaining information on the communication and related abilities of children between 3 -12 years. the particular teachers completed the questionnaires in conjunction with fieldworkers. results indicated a high prevalence (38%) of nonspeaking children in schools for children with severe mental disabilities in the pretoria area and also indicated that they were a heterogeneous group regarding communication and related abilities. this survey was the first step in determining prevalence and describing nonspeaking children in schools for children with severe mental disabilities in south africa. results also indicated that these children are in great need of additional service delivery with special reference to augmentative and alternative communication (aac) strategy implementation. opsomming die doel van hierdie studie was om kinders ingeskryf by geregistreerde skole vir verstandelik erg gestremde kinders in die groter pretoria-area te beskryf om sodoende 'n profiel van nie-sprekende kinders saam te stel. klem is geplaas op die voorkoms van nie-sprekende kinders asook op hulle funksionering met betrekking tot verskillende vaardigheidsareas om sodoende die behoefte aan dienslewering te bepaal. twee vraelyste is ontwikkel; die eerste vir die verkryging van persoonlike inligting van die betrokke onderwysers en die tweede vir die verkryging van inligting rakende die kommunikasieen verwante vaardighede van kinders tussen die ouderdomme 3 -12 jaar. die betrokke onderwysers het hierdie vraelyste in samewerking met veldwerkers voltooi. resultate het 'n hoe voorkoms (38%) van nie-sprekende kinders in skole vir verstandelik erg gestremde kinders in die pretoria-area aangetoon, asook dat hulle 'n heterogene groep is met betrekking tot kommunikasieen verwante vaardighede. hierdie studie was die eerste stap in die bepaling van die voorkoms en beskrywing van niesprekende kinders in skole vir verstandelik erg gestremde kinders in suid-afrika. resultate het ook aangetoon dat hierdie kinders 'n groot behoefte het aan addisionele dienslewering, met spesifieke verwysing na aanvullende en alternatiewe kommunikasie (aak) strategie-implementasie. ι keywords: augmentative and alternative communication, nonspeaking children, service delivery, prevalence. introduction the devastating effect that the inability to speak has on an individual's daily life has been described extensively during the last two decades by nonspeaking people themselves as well as by those who interact closely with them. not only does the inability to speak make it more difficult to convey messages and to participate in interactions, it also impacts on language and the development of literacy skills. kopenhaver and yoder (1992) pointed out that as many as 80% of nonspeaking people have very poor literacy skills. furthermore, they stress that poor literacy skills in this group of people relate not only to the inabil!ty of the individual to speak, but also to a lack of exposure to literacy experiences. as being nonspeaking is often interpreted by people as an inability to think and learn, these nonspeaking children are frequently denied learning opportunities. being nonspeaking within a speaking world therefore creates a number of attitudinal barriers that have to be overcome. "speech is the most important thing we have. it makes us a person and not a thing. no one should ever have to be a "thing" " (joseph, 1986). it is against this background that two major issues can be identified in the augmentative and alternative communication (aac) literature. the first relates to the importance of identifying children who are nonspeaking or at risk not to develop speech, and the second focuses on the different ways in which people who are not able to express die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 43,1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 themselves adequately through speech can gain access to other means of communication to prevent the isolation and frustration which is associated with the inability to express oneself. various studies have been conducted internationally to establish the prevalence of nonspeaking children within the special school context. different definitions were used to define nonspeaking, e.g. "persons who have a severe speech problem due to physical, neuromuscular, cognitive or emotional deficits and not due primarily to hearing impairment" (matas, mathy-laikko, beukelman and legresley 1985). bloomberg and johnson (1990) expanded on this definition by defining the nonspeaking population as "persons who are temporarily or permanently unable to meet all their communication needs verbally". the north dakota survey, however, aimed at quantifying the term nonspeaking by defining it as "people who use 15 or less intelligible words" (burd, hammes, bornhoeft and fisher, 1988). this cut-off point was utilized in this study on the assumption that with normal development, speech becomes a functional means of communication towards the end of the single word stage, when a typical expressive vocabulary consists of 15 20 words (cantwell and baker, 1985). it was further decided to use the term "nonspeaking" as opposed to "nonverbal" as the latter is an ambiguous term which technically means "without language", and is thus not used for describing individuals, but rather for describing evaluation tools (e.g., nonverbal intelligence of individuals who have difficulty comprehending or producing spoken language) (lloyd, fuller and arvidson, 1996). the north dakota survey reported that 2,4% of children in special schools in north dakota were nonspeaking (burd, et al., 1988). it further indicated a strong decrease (almost 50%) in the prevalence of non-speech after three years of schooling. matas et al., 1985, conducted a similar survey in washington state's special schools and included urban and rural populations. results from this demographic study indicated that 3,6% children of the urban and 6% children of the rural special schools were nonspeaking. in another study, which was conducted in germany and which included the whole school population, it was reported that 0,35% of all school children were nonspeaking (coon, kremer and hildebrand, 1992). when these demographic surveys were extended to include the total population, a prevalence rate of 0,12% was found in a study conducted in australia (bloomberg etal., 1990). it is interesting to note that all these studies were conducted in western countries. no similar studies have been conducted in developing countries. as far as nonspeaking people's access to aac systems is concerned, the washington survey reported that at least 18% of children in special education used some type of aac system, whilst 23,3% were being trained to use an aac system (matas et al., 1985). the other 29,2% were using only unintelligible speech and although the rest of the children met the criteria for using an aac system, they were in need of initial or follow-up evaluations. in the german survey it was reported that the majority of children used unaided communication systems (facial expressions, followed by gestures, touching, and pointing respectively) (coon et al., 1992). these results are further supported by results from the washington survey which also reported that nonspeaking children use gestures and emotional reactions (e.g., facial expressions and gross body the so juan bomman and erna alant movements) as the predominant communication system (matas et al., 1985). this tendency also seems to be present in older children, as a survey amongst university students also found gestures to be the most frequently used system (huer, 1991). as previously mentioned no studies have as yet been conducted in africa on the prevalence of nonspeaking children. this lack of descriptive statistics provided the major impetus for this survey. in order to assist professionals in planning intervention for nonspeaking children, a profile of the nonspeaking population in south africa is needed. it is against this background that the present study aimed at describing the communication abilities of children in schools for children with severe mental disabilities. method aim the main aim of this study was to establish the prevalence of nonspeaking children enrolled in schools for children with severe mental disabilities in the greater pretoria metropolitan substructure and by compiling a profile regarding their functioning in different skill areas (cognitive, motor, sensory, communication and social). in addition, their exposure to intervention was also described. research design in order to realise the aims of the study an analytical (quantitative) survey design was used as this type of design is particularly useful in describing demographic information within a particular context (groenewald, 1986). subjects description of schools all registered schools for children with severe mental disabilities within a particular geographical area, namely the greater pretoria metropolitan substructure (including pretoria central, eersterust, laudium, atteridgeville and mamelodi) were included. criteria for inclusion in the different schools varied, although certain broad principles remained the same, i.e. an iq of between 30 60 (measured as reliable as possible), age between 3 18 years at admission, a physical ability to move about and an ability at admission to show communication potential. these schools were selected as the candidacy for the use of aac strategies and techniques is high within these schools and they consequently form one of the primary focus areas in the aac field (matas et al., 1985). these schools all had to be registered with one of the following departments prior to 1995 : department of education and training, department of education and culture or the department of health. no informal schools were included. schools for the deaf and schools for the blind were also excluded as they were traditionally not the main area of focus when using aac strategies (coon etal., 1992 and bloomberg etal., 1990). this brought the total number of schools to 10. more detailed information on these schools is presented in table 1. according to table 1 there was a broad variation in the schools. some schools had a large number of pupils (school no 6), whilst others had relatively few (school no 2). some schools also had assistance from therapists (schools no 1 and 9) whilst others had no therapists (schools no 8 and african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) n e a k i n g children in schools for children with severe mental disabilities in the greater p r e t o r i a area: implications for speech-language therapists 10) all the schools had class aids to assist the teachers. 2-page questionnaire that was completed by a fieldworker description of teachers teachers acted as the main informants for this survey, as various national (skuy, westaway, makula and perold, 1988) and international studies (matas, et al., 1985) confirmed that teachers can meaningfully describe pupils' functioning. it is thus important to provide a brief description of the teachers. information related to relevant biographical information regarding the teachers was obtained from questionnaire i (bornman, 1995). this was a short table 1 : description of schools included in the study 55 in conjunction with a teacher. the total number of teachers included in the survey was 55. this questionnaire revealed that 98% of teachers were female. table 2 indicates that the teachers were a heterogeneous group regarding qualifications, training and years of teaching experience. regarding qualifications, it was found that 82% of the teachers had post-matric training, whilst 18% had only school training varying from std 8 std 10. fifteen teachers reported that they had no special training for working with children with severe mental disabilities, whilst 40 teachers reported that they had some spe# area # o f pupils # o f teachers # o f class aids # o f speech therapists # o f ot's # o f physiotherapists τ i τ i # o f class aids # o f speech therapists # o f physiotherapists 1 pretoria central 115 53 12 6 12 2 2 3 2 pretoria central 18 11 3 3 2 0 0 1 twice a week 3 eersterust 47 23 5 4 2 1 twice a week 1 once a week 1 physio assistant 4 pretoria central 30 15 3 2 4 1 once a week 1 once a week 1 once a week 5 soshanguve 110 25 6 3 2 0 1 0 6 pretoria central 336 125 34 16 10 0 1 0 7 laudium 57 35 5 4 7 1 1 0 8 mamelodi 78 21 4 3 3 0 0 0 9 pretoria central 60 39 12 10 6 1 1 0 10 atteridgeville 120 65 11 4 4 0 0 0 total 971 412 95 55 legend: τ = total number at school; i = number included in survey i ι table 2: biographical information of teachers qualifications | less than 10 years) at school i 10 12 years at school 2 3 years after school more than 4 years after school η =6 11% η = 4 7% η = 39 71% η = 6 11% special training * in-service training: less than 2 years diploma: less than 1 year diploma: less than 2 years diploma: less than 3 years n = 15 27% η = 5 9% n = 10 18% n = 10 18% years of teaching experience at schools for children with mental disabilities less than 1 year 1 2 years 3 5 years more than 5 years η = 3 5% η = 3 5% n = 13 24% η = 36 66% * please note that 15 teachers had no special training, and thus the total η = 40. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43,1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 cial training, ranging from in-service training to special diplomas. the majority of teachers had less than 2 years of in-service training. of the 25 teachers with special diplomas, 5 had diplomas of less than 1 year and 10 had diplomas of less than 2 years and less than 3 years respectively. furthermore it was found that 36 of the teachers had more than 5 years teaching experience at schools for children with severe mental disabilities, whilst only 3 had less than 1 year experience. description of children information regarding the children was obtained from the teacher and recorded in questionnaire ii. a total number of 412 children was included as they met the set criteria, namely that their chronological ages had to be between 3,0 and 12,11 years (only children from the preprimary and primary school phase were included) and the children's names had to appear on the class list. when referring to the total number of children, it would amount to 412 children, and when referring to the nonspeaking children it would amount to 158 children. as previously mentioned, nonspeaking children were classified as children who spoke 15 words or less (burd et al., 1988). more detailed information on the children included in the survey follows in the "results" section. procedure material for the purpose of this study two questionnaires were developed, one for descriptive biographical information about the teacher; and the second for information about each individual child in the class. the contents of both questionnaires were based on those used in the international demographic surveys on the nonspeaking children (bloomberg et al, 1990; matas et al, 1985; coon et al, 1992 and burd et al, 1988). questionnaire i dealt with the biographical details of the teachers and covered aspects such as identifying data (name of school, number of children in the class, and gender), qualifications, years of experience, specialized training, and whether the teacher received any additional assistance from class aids, therapists or volunteers (bornman, 1995). questionnaire ii covered the children's background information (gender and birth date), information on the functioning in different skill areas (communication, cognition, motor, sensory and socioemotional), literacy skills (reading, writing and mathematical) as well as intervention. this information, as well as the particular 5 point rating scale that was used, is described in more detail in appendix a. data collection the data collection procedure required that both questionnaire i and questionnaire ii be tested in a pilot study, after which certain revisions were made. permission to conduct this survey was then obtained from the local school authorities and 5 fieldworkers were trained in completing both questionnaires effectively and efficiently by providing them with the necessary skills and knowledge. fieldworkers were placed individually at the 10 schools, and after the principal had introduced them to the various teachers and the aims of the survey had been exjuan bornman and erna a l a i l t plained, the fieldworkers started completing the question naires in conjunction with the teachers. as the fieldworker had face to face contact with the teachers, they clarifij additional questions that seemed confusing to individual teachers. a total number of 55 teachers and 412 children were included in the survey. all questionnaires were then encoded, and the data analyzed using a variety of statists cal procedures. analysis of data data was analyzed and statistically processed in order to provide quantitative results of the survey. statistical procedures included descriptive statistics (discrete frequency distribution counts and percentages) and logistic regression procedures (in order to determine which variable(s) were the best predictors of non-speech). these variables were selected by means of a stepwise selection procedure (proc logist of sas). loglinear correlation coefficients were also applied to the data (in order to determine the strength of the relationship(s) between variables). this procedure was conducted in the following way: firstly a chi-square test was applied to a table and if significant dependencies were found on the 5% level, the loglinear model was applied to measure the strength of the relationships between the variables. a critical value of ζ = >± 2,58 was used to judge whether a particular variable was significant. the p4f procedure of the bmpd statistical package was used for the loglinear analysis. results and discussion l b accurately describe the prevalence of nonspeaking children it is important to provide a comprehensive overview of all the children included in the survey. it is for this reason that all the figures include both the speaking (n=254) and nonspeaking (n=158) children. 1. background information from figure 1 it is clear that 38% of children between the ages 3,0 12,11 years in schools for children with severe mental disabilities in the greater pretoria area were nonspeaking. as previously mentioned, "nonspeaking" referred to children "who use 15 or less intelligible words" the south african journal of communication disorders, vol 4, 199 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 57 . children in schools for children with severe mental disabilities in the greater n o o s p ? a ^ £ , a : implications for speech-language therapists p r e t o r x a ^ ^ i m p l i e s t h a t of the total number months were excluded. the majority of nonspeaking chil( b u r j e i a h i ' l d r e n included in the survey, 158 were of 4 1 / c , * „ the high prevalence figure (38%) of n ° n s p aking children was the most significant factor in n ° n s p e a a r c h this figure is significantly higher than those c o m p a r a b l e international surveys which reported nfotner 6 % (matas et al., 1985). the lower inci-o f ° t h e r e < o f 3 5 8 ^ rfnonspeaking children (3,5%) was reported in urd e n c e c h o o l s j a n d 6% in rural/remote schools implying that * f n s r e v a l e n c e of the present study might have been higher crural schools had been included (matas etal, 1985; aieu 0 when comparing speaking and nonspeaking children der the age of 6 included in the survey, it is clear that ""ore nonspeaking children are placed in schools for chil!γ θ η with severe mental disabilities than their speaking counterparts. however, at the age of 6, the number of speaking and nonspeaking children are almost even. the majority of nonspeaking children was 9 years old. the number of 13 year olds is very low, due to the fact that children older than 12 years and 6 months were rounded off to 13 years, and children older than 12 years and 11 50 b 40 20 46|·. 40 7 • 3? 4 42 34 -22 / 16 17,/ / 11 \ ^ v ' 7 8 9 age in years • nonspeaking (n= 158) speaking (n 254) figure 2 : ages of the children table 3: gender of children variable % boys % girls total group of children 66% 34% nonspeaking children 1 68% 32% dren was 9 years old, with a greater distribution at the ages higher than 9, indicating that more children were older, rather than younger than 9. however, before age 6 (when speaking and nonspeaking children are almost even) the survey indicated that there are more nonspeaking children than speaking children in these schools. this could indicate that because the lack of verbal speech is relatively easily identified by parents, they tend to send nonspeaking children to school at a relatively young age. international prevalence data by burd et al. (1988) suggests that changes in oral communication in special schools are unlikely after the age of 7. as the highest percentage of nonspeaking children in this survey was older than 7 years, the data could suggest that the possibility of changing from nonspeaking to speaking is slight. another factor confirming this finding is that a lack of speech by school entry is predictive of a poor outcome for learning to speak (burd et al., 1988). emphasis on aac systems should therefore be a priority in special schools as such a high percentage of children within these schools are aac candidates. regarding the gender of the nonspeaking children, a binomial procedure (non-parametric test) was applied to the data, which had a value of > 226, implying that there are significantly more nonspeaking boys than girls. the ratio of 2:1 (male:female) which was found in the total group of children prevailed in the nonspeaking group were a male:female ratio of 2,1:1 was reported. in other similar surveys, the male:female ratio was not as significant as in this survey, e.g., 1,4:1 in the australian survey (bloomberg et al., 1990), 1,6:1 in the scottish survey (murphy, markova, moodie, scott & boa, 1993) and 1,6:1 in the german survey (coon et al., 1992). consequently it can be stated that in this study significantly more boys than girls were described as nonspeaking. 2. communication abilities regarding the communication abilities of nonspeaking children, a number of factors were significant predictors of non-speech. table 4 describes the results obtained where the variables related to communication were tested against non-speech by means of the loglinear model. the interaction between non-speech and receptive language is highly significant. in cases where the children displayed very poor or poor receptive language skills, they spoke significantly less than 15 words, and when they distable 4: communication abilities of the children variable nonspeaking or speaking z-values (z = _ _ 2,58) variable nonspeaking or speaking very poor poor some reasonable normal receptive language nonspeaking speaking * 7,177 -7,177 * 3,052 -3,052 -3,456 *3,456 -4,645 *4,645 -1,366 1,366 ability to speak sentences nonspeaking speaking *8,545 -8,545 0,135 -0,135 -3,047 *3,047 -3,738 *3,738 -0,706 0,706 understandability of communication attempts nonspeaking speaking *2,758 -2,758 1,885 -1,885 0,971 -0,971 -4,645 *4,645 -1,366 1,366 au variables that indicate a significant correlation with nonspeech on a 95% confidence level, are marked with an asterisk (*). 1 die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 43,1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 juan bornman and erna alant played some to reasonable function, they spoke significantly more than 15 words. the generally poor expressive ability is further highlighted by the poor ability to use sentences (i.e. putting together two words or more). results indicated that nonspeaking children (thus children who were speaking 15 words or less) had a very poor ability to use sentences (they were thus not verbally putting any words together). this would indicate that speech is so limited for school purposes that it precludes functional oral communication. children speaking more than 15 words, however, were rated as having some, or reasonable functioning in speaking sentences. regarding how understandable teachers rated the children's communication attempts, it was found that the understandability of the nonspeaking children's attempts were rated as very poor, whilst the understandability of the speaking children's communication attempts were rated as reasonable. teachers were asked to rate communication desire with the following question "does the child try to communicate with people?" from figure 3 it is clear that when looking at nonspeaking children's communication desire it became evident that 89% of them did have the desire to communicate. lack of communication desire can thus not be interpreted as a major factor contributing to the high prevalence of nonspeaking children. a significant interaction between means of communication and non-speech was found when a pearson chisquare test was performed on the data. results are shown in more detail in figure 4. aac systems (including typing, writing and/or communication boards) were used only 0,79% of the time in the nonspeaking population (this percentage was rounded off to 1%). in comparison with the other means of communication that was used at least 8% of the time, it is clear that aac systems were used significantly less (figure 4). the second lowest means of communication is that of understandable speech (8%). these two variables are significantly lower than the third lowest means of communication, touching and gestures which are both present in 17% of the cases. the nonspeaking children used vocalizations as their most frequent means of communication (20%) followed by facial expressions (19%) and head nodding to indicate yes/no (18%). when looking at the high percentage of nonspeaking children, and the fact that 89% of them indicated a desire to communicate, it is to be expected that the number of children who use some sort of aac system to compensate would also be high, but this was not the case. the use of any aac system, aided (e.g., typing, writing or communication boards) or unaided (e.g., gestural systems) occurred infrequently in nonspeaking children (0,79% of the time). none of the nonspeaking children used typing, writing or high technology systems. the german study (coon et al., 1992), reported that the majority of children used unaided aac systems, with facial expressions as the means most frequently used, followed by gestures, touching and pointing respectively. this correlates with the findings of the present survey which reported that 17-19% of children used facial expressions, head-nodding to indicate yes and no, natural gestures and touching (see figure 4). these results are further supported by results from the washington state survey, which also reported that nonspeaking children used gestures/ emotional reactions as the predominant communication system (matas et al., 1985). this could be due to the fact that in the past nonspeaking children did not receive aac system intervention, and had to rely on natural gestures to make their needs known. the lack of skills training in the past thus resulted in children mostly using natural ways of communicating, as these natural ways were demonstrated in their environments (e.g., most people use facial expressions, head-nodding and natural gestures). furthermore, these unaided systems are, of course, always readily available. however, as people begin to realize the importance of communication intervention for nonspeaking children with the consequent development of cognitive abilities by giving nonspeaking children entrance into abstract thought, the use of more formal aided and unaided systems will increase, as it gives these children access to more extensive communication systems. in the past, in south africa, much emphasis was placed on the use of speech as the only way of communicating. for a great number of people the ability to communicate is equal to the ability to speak. nonspeaking children could not express themselves verbally and were therefore less frequently understood by teachers and their communication ability was also described as significantly poorer than that of speaking children (see table 4). the most frequently used means of communication were vocalizations (unintelligible speech) for the nonspeaking group, followed by facial expressions (19%) and head nodding (18%) (see figure 4). these findings correlate with those of the german study which also reported that speech was rated as the major means of communication (coon etal., 1992). this figure 3 : communication desire figure 4 : communication means the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) peaking children in schools for children with severe mental disabilities in the greater p r e t o r i a area: implications for speech-language therapists 59 vht be a reflection of the attitudes regarding aac sysf m s w h i c h prevail where information regarding these 6 s t e m s is limited and where they are mostly unknown. c o n t r a r y to research which has proved that the use of aac stems enhances communication and facilitates speech d e v e l o p m e n t , uninformed people hesitate to use aac systems as they fear that this might inhibit or prevent speech d e v e l o p m e n t as the aac systems might reduce motivation for speech communication (silverman, 1995). thus, in c o u n t r i e s where service providers do not have knowledge and skills regarding aac systems and aac does not have a strong basis for service delivery the tendency to aim at speech development was observed. this tendency was not noted in any of the other countries in which aac had been in use for some time (murphy et al., 1993 and matas et al., 1985). the general abilities of the total group of children are displayed in figure 5 and figure 6. in both of these figures a rating scale of 1 5 was used. one is indicative of very poor to almost no functioning, 2 of poor functioning, 3 of some functioning, 4 of reasonable functioning and 5 of normal functioning for chronological age (bornman, 1995). 3. general abilities in different skill areas percentages displayed on figure 5 and figure 6 were calculated to be proportionally correct for each variable. each variable discussed thus represents the proportional percentage. results from figure 5 show that children whose cognitive ability was rated as very poor spoke significantly less than 15 words. on the other hand, children who were rated as having reasonable cognitive functioning spoke significantly more than 15 words. results from figure 5 also show that for both gross and fine motor ability there was a significant interaction between these motor abilities and non-speech. results indicated that with very poor and poor gross motor functioning children spoke significantly less than 15 words, and with reasonable to normal functioning children spoke significantly more than 15 words. children who were rated as having very poor or poor fine motor abilities spoke significantly less than 15 words whilst children with reasonable fine motor abilities spoke significantly more than 15 words. j the loglinear model also showed a meaningful interac120 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 2 3 4 5 g r o s s m o t o r 1 2 3 4 f i n e m o t o r 1 2 3 4 c o g n i t i v e μ n o n s p e a k i n g ( n = 1 5 8 ) ί β s p e a k i n g ( n = 2 5 4 ) legend: 1 = very poor; 2 = poor; 3 = s o m e ; 4 = r e a s o n a b l e ; 5 = normal for chronological a g e . tion between communication (with both adults and peers) and social ability with non-speech, as displayed in figure 6. when communication ability with adults was rated as very poor to poor, children spoke significantly less than 15 words, and when communication ability was rated'as reasonable to normal, children spoke significantly more than 15 words. exactly the same tendency was found in the case of communication with peers, but the significance was even stronger in the latter case. a highly significant interaction between non-speech and social ability was also found. children who spoke less than 15 words were regarded as having very poor to poor social ability, and children speaking more than 15 words were rated as having reasonable to normal social ability. it is clear from the results obtained in the present survey that although the children's abilities varied in the different skill areas (motor, cognitive, communication and social), certain tendencies prevailed. the data indicated that when speaking and nonspeaking children's abilities were compared, nonspeaking children were rated as having significantly poorer abilities than the speaking children. this finding suggests that the abilities of the nonspeaking children might have been underestimated due to the fact that teachers do not understand these children well. as confirmation of the above, the poor communication skills of the nonspeaking children inevitably lead to poor social skills. it was clear from the results that the nonspeaking children's social abilities were mostly rated as "poor" and "very poor" whilst the majority of speaking children's abilities were rated as "good". this could be due to the fact that communication attempts from the nonspeaking children are ignored, overlooked or misinterpreted, which results in poor understanding of their intentions, which leads to increased isolation. figure 7 differentiates between the type of therapy (speech, occupational or physio-) received by the nonspeaking children as opposed to the speaking children as well as to whether the therapy was conducted on an individual or group basis. 4. therapy apart from physiotherapy, nonspeaking children received less speech and occupational therapy than their speaking counterparts. furthermore, children received group speech and occupational therapy rather than indi1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 1 0 0 2 3 4 5 1 2 3 4 c o m m u n i c a t i o n w i t h a d u l t s w i t h p e e r s μ n o n s p e a k i n g { n = 1 5 8 ) w / δ s p e a k i n g ( n = 2 5 4 ) legend: 1 = very poor; 2 = poor; 3 = s o m e ; 4 = r e a s o n a b l e ; 5 = normal for chronological a g e . figure 5 : cognitive and motor abilities figure 6 : communication and social abilities die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43,1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 juan bornman and erna alant vidual therapy. however, regarding physiotherapy, the majority of children received individual therapy. the majority of children receiving physiotherapy was nonspeaking. the therapy provided to the nonspeaking children varied from less than half an hour per week to more than five hours per week. the majority of children receiving therapy also received group rather than individual therapy. it could be due to the fact that most schools in the survey had a limited number of therapists, resulting in high caseloads. in order to address these caseloads and to serve as many children as possible, therapists mostly provided group therapy. the effectiveness of the therapy was not measured in this study, but the high number of nonspeaking children possibly suggests that the current therapy is not as effective and meaningful as it could be. it is furthermore important to note that aac is a relatively new field in south africa, therefore a strong basis for the use of aac systems within special education has not yet been laid. until recently speech therapists received no training in the use of aac strategies and thus, although 29% of the children received some kind of speech therapy, the nature of this therapy is unclear (see figure 7). i apart from requiring special training in working with children with special needs, service providers require familiarity and experience with the range of aac systems, aids, symbols and strategies available in order to equip them with knowledge and skills related to aac j (blackstone, 1990). as aac is a relatively new field of expertise in south africa, not many therapists and/or teachers (the primary aac service providers) receive any training in aac techniques during their undergraduate training (alant and emmett, 1995). in scotland, however, where aac has been in use for some time, the scottish survey also reported that the training of slp's should be addressed, as they do not receive knowledge and skill training related to aac (murphy et al., 1993). knowledge and skill alone are not sufficient, there is also a strong need for the development of interdisciplinary aac service delivery. this can be developed by exposing slp students to work with professionals from other disciplines in order to help them develop a more holistic approach to aac (huer, 1991). in the present study it was found that nonspeaking children received considerably less therapy than speaking children (see figure 7). as previously mentioned this might be due to the fact that service providers do not have the knowledge and skills necessary for working with this specific population. it might also be due to the attitudes 160 1 4 0 " 120 1 0 0 80 6 0 4 0 20 0 1 3 9 6 5 s p e e c h o c c u p a t i o n a l p h y s i o i n d i v i d u a l μ n o n s p e a k i n g ( n = 1 5 8 ) s p e e c h o c c u p a t i o n a l p h y s i o g r o u p ^ ^ s p e a k i n g ( n = 2 5 4 ) ' figure 7 : type of therapy received of service providers that nonspeaking children have a poor prognosis of developing in the various skill areas and thug the focus of service delivery is placed on the speaking children. these attitudes are interlinked with low expectations of nonspeaking children, as service providers often do not expect any progress from them (shrewsbury, lass and joseph, 1985). finally, another factor negatively affecting the services provided to nonspeaking children is the lack of a supportive infrastructure. therapists often work in isolated contexts and resources are not readily available. some schools included in the survey did not have therapists, and service provision is the responsibility of the teachers. as teachers do not have the skills and training to implement aac strategies without a supportive infrastructure, the implementation of these strategies become a low priority. conclusions nonspeaking children in schools for children with severe mental disabilities in the greater pretoria area constitute a large population with heterogeneous characteristics and abilities, who need intensive, specialized therapy and aac services. however, for a number of reasons, the nonspeaking population is underserved. this is due to the limited number of therapists working in special education (see table 1) as well as limited specialized knowledge and skills regarding aac strategies and low expectations from nonspeaking children due to attitudinal problems (shrewsbury et al., 1985). the results of this survey indicate a strong need for additional in-service and undergraduate training for professionals who serve the nonspeaking population. further research is also necessary to help improve the quality of service delivery to the nonspeaking population. acknowledgement the financial assistance of the centre for science development (hsrc, south africa) towards this research is hereby acknowledged. opinions expressed and conclusions arrived at are those of the author and are not necessarily to be attributed to the centre for science development. references aiello, s.c. (1980). non-oral communication survey: a onecountry needs assessment and demographic study. unpublished educational study. california: plavan school. alant, e. and emmett, t. (1995). breaking the silence : communication and education for children with severe handicaps. pretoria : human sciences research council. blackstone, s.w. (ed.): (1990). how you can use demographics to provide better service delivery in aac. acn news, 3(4), pp 1-7. bloomberg, k. and johnson, h. (1990). a statewide demographic survey of people with severe communication impairments. aac augmentative and alternative communication, 6(1), pp 50-60. bornman, j. (1995). nonspeaking children in schools for children with mental handicaps in the pretoria area: a survey of communication and related problems. .m.communication pathology thesis. pretoria: university of pretoria. (unpublished). burd, l., hammes, k., bornhoeft, d.m and fisher, w. (1988). a north dakota prevalence study of nonverbal school-age children. language speech and hearing services in schools, 19(4), pp 371-383. cantwell, d.p. and baker, l. (1985). speech and language: the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ν nspeaking children in schools for children with severe mental disabilities in the greater p r e t o r i a area: implications for speech-language therapists 6 1 d e v e l o p m e n t and disorders. in calculator, s.n. and bedrosian, j (eds). communication assessment and intervention for adults with mental retardation. boston : little b r o w n and company. _ r kremer, g. and hildebrand, m. (1992). a demographic analysis of people with speech impairments in west berlin, germany. unpublished presentation at isaac biennial conference, philadelphia. g r o e n e w a l d , j.p. (1986). social research: design and analysis. stellenbosch: university publishers and booksellers. huer m.b. (1991). university students using augmentative and alternative communication in the usa: a demographic study. aac augmentative and alternative communication, 7(4), pp 231-239. joseph, d. (1986). the morning. communication outlook, 8(2), 8. kopenhaver, d.a. and yoder, d.e. (1992). literacy learning of children with severe speech and physical impairments in school settings. seminars in speech and language, 13(2), pp 143-153. lloyd, l., fuller, d. and arvidson, h. (1988). glossary. in: lloyd, l., fuller, d. and arvidson, h. (eds). augmentative and alternative communication. new york: allyn bacon. matas, j.a., mathy-laikko, p., beukelman, d.r. and legresley, k. (1985). identifying the nonspeaking population· a demographic study. aac augmentative and alternative communication, 1(1), pp 17-31. murphy, j., markova, i., moodie, e., scott, j. and boa, s. (1993). augmentative and alternative communication systems used by people with cerebral palsy in scotland: a demographic survey. final report to the scottish council for spastics. stirling: university of stirling. shrewsbury, r.g., lass, h.j. and joseph, l.s. (1985). a survey of special educators' awareness of, experiences with, and attitudes towards nonverbal communication aids in the schools. language, speech and hearing services in schools, 16(4), pp 293-298. silverman, f.h. (1995). communication for the speechless. needham heights : allyn and bacon. skuy, m., westaway, m., makula, n. and perold, c. (1988). development of a screening instrument for the identification of pupils with impairments. south african journal of education. 8(1), pp 45-49. unicef. (1993). children and women in south-africa: a situation analysis. johannesburg: unicef and ncrc. yach, d. (ed). (1991). challenging health in south africa: ibwards new perspectives in research. california: the henry j. kaiser family foundation. appendix a : description of questionnaire ii description of childrens' abilities rating scale (if any) identification data: gender, age. * explanatory notes on categories can be found in bornman (1995). areas of functioning cognitive motor sensory (visual & auditory) communication, social 1 = almost no function 2 = poor function 3 = some function 4 = reasonable function 5 = normal function communication skills receptive language expressive language communication mode j 1 1 receptive language abilities were scored on a 5 point likert scale that ranges from a child who understands very limited instructions to a child who understands everything. expressive language was scored in terms of the number of words the child was able to produce intelligibly. if the child was unable to produce more that 15 words intelligibly, he/she was labelled as nonspeaking (burd et al., 1988). communication means included verbal, gestures, facial expressions, sign language, pointing to pictures, objects and symbols, writing and or typing, yes/no indication and vocalization. a question on the frequency with which the teacher understood the communication of the student was also included. reading skills ! j 1 = no interest in books 2 = interest in books/likes handling them 3 = sight vocabulary more than 30 words 4 = reads easy sentences, but not age appropriate 5 = adequate reading for chronological age writing skills 1 = no interest in writing or scribbles 2 = makes letters and letter like shapes 3 = makes letters and tries to write words 4 = writes most things, but not age appropriate 5 = adequate writing skills for chronological age number concept 1 = cannot count, or counts without number concept 2 = number concept up to 5 3 = knows concept "more hess" up to 5 4 = able to do simple mathematics, but not age appropriate 5 = adequate mathematical skills for chronological age therapy received: speech therapy occupational therapy ( physiotherapy a filter question was used (yes, no) as not all children received therapy. in applicable cases teachers had to specify the type of therapy received, and whether it was groupor individually-based. e suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43,1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) occupational therapists •user friendly speech therapists •windows / win 95 physiotherapists •full financial summary psychologists yy. y r,6i-m0n •no training necessary nurses (7 / ()s2-4i6-~i24 • \ccounts accepted /γ* /ft) γ / /wr by all mcdical aids wikrdapark south 0057 are you tired of your accounting system looking for one? is the printing of accounts a do you know what is going on with your is the input of account details a can you see all patient particulars with the press of a can you get a financial summary of any given metlvba^e/s the answer user friendly a windows / w r in 95 ^ j ν / \ no training necessary \ /accounts accepted by all medical aids requirements 386, 486, pentium 8 mb ram windows or win95 the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) on so called 'lateral isl': some observations from palatography and spectrography a. traill m. litt. (edin.) african studies institute, university of the witwatersrand, johannesburg. summary this paper supplements certain well-known aiticulatory aspects of sigmatisms (lisps) with observations derived from spectrography. the five cases studied show widely differing articulations with a relatively invariant acoustic o u t p u t . a phonological perspective of the problem is argued to be of relevance t o therapy. opsomming hierdie artikel vul sekere bekende artikulatoriese aspekte van sigmatisme (stoot-met-dietong) aan met waamemings uit die spektrografie. die vyf gevalle wat bestudeer is, t o o n grootliks verskillende artikulasietipes met 'n akoestiese uitvoer wat relatief onveranderlik is. daar word aangevoer dat 'n fonologiese beskouing van die probleem relevant is vir terapie. in this paper an attempt is made to throw some new light on the familiar problem of lisping (or sigmatism). this will be approached in two complementary directions, firstly phonetically and secondly phonologjcally. certain familiar but possibly not sufficiently widely known facts about the articulatory aspect of a class of sigmatisms will be reviewed and data from a number of case studies will be interpreted in terms of the traditional classification. the acoustic correlates of these articulations will be presented and their phonological implications assessed. implications of the findings for therapy will be hinted at. the articulatory aspect of sigmatisms for the purposes of this paper, certain oral (i.e. non-nasal) sigmatisms will be discussed. these are conventionally classified according to the two phonetic parameters of place of articulation and direction of release of the airstream, leading to classifications varying in detail, completeness and usefulness. for various examples of different classifications the reader is referred to van riper and irwin,1 3 powers, 1 0 bloomer1 and luchsinger and arnold.s the latter present the most general and explicit classification and provide airflow and palatographs backing to their observations. the oral sigmatisms most frequently described in the literature can be summarised in table i. in addition it is often noted that the lips may be involved in some degree in sigmatism, though precise details of the type of labial articulation are not specified. regarding the gaps in table i, the writer ventures to suggest that die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 a. traill articulatory position release inter-dental 'anterior' (dental & alveolar) palatal central i.d. lisp addental lisp palatal/retracted lisp lateral i.d. lat. lisp r/l ) lateral bilateral ) lisp pseudo-lateral antero-lateral lisp table i. a classification of sigmatisms. only that of the pseudo-lateral palatal reflects an articulatory limitation; the others are apparently 'accidental' gaps. in the remainder of this paper the inter-dental sigmatisms will not be discussed. luchsinger and arnold8 (pp. 564-568) define the remaining sigmatisms of table i as follows: addental: . . . the tongue-tip . . . (is pushed) . . . against the posterior surface of the front teeth . . . formation of a medial groove along the tongue-tip becomes impossible, and the air escapes broadly between the teeth in a fan-shaped manner over the anterior portion of the tongue. lateral: . . . the tongue is elevated on one side more than the other. . . so that air is forced into one cheek pouch where it produces a slurping lisp. antero-lateral (lateroflex, pseudo-lateral): . . . the tongue-tip deviates from the midline toward the right or left side and directs the airstream mostly toward the upper canine tooth of the same side. palatal: . . . occurs when the tongue lies too far backward. in that case the fricative noise originates between tongue-tip and hard palate . . . the palatal [s] therefore sounds like a german [ς] or even a [/]· these authors' injunction to use precise visual and experimental exploration for the exact differentiation of the different types of sigmatism is worth repeating since faulty or imprecise diagnoses are inimical to adequate therapy. as an example of the subtle differences that can be revealed by palatography, for example, consider the articulatory differences between two cases of antero-lateral lisps for [s] and [ / ] given by luchsinger and arnold,8 and reproduced as figure 1 opposite. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) on so-called 'lateral [s]' 5 ['•] [f] figure 1. palatograms of fine detail distinguishing sigmatisms (luchsinger and arnold if acoustic data were available to supplement the articulatory information provided by the palatograms, a precise and objective classification of the sigmatisms could be given. i shall now examine palatographic data from five cases of sigmatisms from the speech and hearing clinic of the university of the witwatersrand. the point of the exercise will be twofold: firstly it will provide a test of the adequacy of the classification of sigmatisms above; secondly it will provide the articulatory facts with which acoustic data can be correlated below. all subjects are english speaking. the shape of the dental arch has been standardised for all cases. case 1 sigmatism affecting /s/, /z/ only. diagnosed as 'lateral s' figure 2. palatogram for case 1 [s]. the hatched area in figure 2 and subsequent palatograms represents the area of articulatory contact between tongue and palate. the anterior part of the closure is asymmetric, being slightly retracted on the left side. otherwise this woiild be the sort of wipe-off one would associate with an alveolar point of articulation. there is extensive and asymmetric condie suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 a. traill tact from the alveolar ridge posteriorly. the passageway through which the airstream is channelled is a wide groove (or narrow slit) for the greater part of its length, fanning out posteriorly in the palato-velar region. the length of this wide groove is significant, stretching from the palatal to alveolar point of articulation. the groove is situated entirely to the left of the midline of the palate so that the airstream appears to be aimed against the left upper incisor. this articulation deviates from that of a normal [s] in a number of respects: the asymmetry in the anterior point of articulation and the related deviation from the mid-line of the palate of the wider groove; the length of the wide groove; the abnormally wide area of contact between tongue and palate. for comparison, a typical palatogram for a normal [s] is given in figure 3. the auditory effect of this sigmatism is something like the blade palatal fricative [?]. on this criterion it would be luchsinger and arnold's8palatal sigmatism. however, the palatographs data clearly shows that this is not the case; the anterior point of articulation is alveolar, not palatal. this sigmatism is therefore strictly not classifiable in the above classification. case 2 sigmatism affecting /s/ /z/, / / / / $ /, and / ? / / /st,/. diagnosed as 'lateral s\ figure 3. palatogram for normal [s]. figure 4. palatogram for case 2 [s] and [/]. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) on so-called 'lateral [s]' 7 the articulatory details of this sigmatism are the mirror image of those above. the anterior point-of-articulation asymmetry is on the right side and the wide groove is displaced to the right of the midline. again, the anterior point of articulation is more alveolar than anything else, and the bulk of the airstream appears to be aimed at the (right) upper central incisor. the impressionistic effect is also that of the blade palatal [9] although, as with the first case, the point of articulation is not straightforwardly palatal. however, close visual examination as well as attempts to locate the points of exit for airflow reveal something of a fanning of the airstream which is not clear from the palatogram above. in other words air is aimed at the upper lateral incisors as well as the left upper incisor. the articulation involves the blade of the tongue. the sigmatism for [ / ] involves exactly these details but has in addition lip rounding. case 3 sigmatism affecting /s/ /z/ only. diagnosed as 'lateral s\ careful inspection of the palatogram in figure 5 suggests some lingual contortions. the articulation is in fact achieved by a considerable displacement of the lower jaw to the right, that is to the same side from which the sound is released. the anterior point of occlusion is from the alveolar ridge to the teeth on the left, with the tongue tip in contact with the posterior surface of both upper incisors. however, on the right side the anterior point of closure is alveolar. this extreme asymmetry is achieved by twisting the tip of the tongue to the right so that its left edge has a wide and long contact with both the lateral and front teeth. the right edge of the tongue is therefore brought into a shorter though not exactly narrow contact with the palate from the first primary molar to beyond the second. the point of release is onto the right canine and the first molar. the passageway for the airstream is a slit displaced to the right of the midline for the greater part of its length and lines up with the right upper incisor. however, at the alveolar ridge the passageway extends bilaterally. release centrally and to the left is blocked by the left anterior closure, but release to the right is'unhindered. the total effect of the articulation is to produce a passageway that looks like a capital t, with the stem lying to the right of the midline of the palate. the auditory effect of the articulation could only misleadingly be called that of the lateral fricative figure 5. palatogram for case 3 [s]. die suid-afrikaanse tydskrifvir kommunikasieafykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 a. traill [ £ ] ; the point of release of this sigmatism is anterior to that for conventional [£-] and this no doubt contributes to the peculiar auditory effect. the deviations from normal [s] are as follows: the left-right asymmetry in the anterior closure; the abnormally wide area of contact between tongue and palate, leading to a slit to the right of the midline of the palate, which is then diverted laterally at the alveolar ridge. in other words, if the right-left asymmetry was removed, and central release effected, the result would be a slit fricative released onto the right upper central incisor. this sigmatism is clearly a right antero-lateral (or lateroflex or pseudolateral) one in terms of the classification above. case 4 sigmatism affecting /s/. diagnosed as 'lateral s'. the left to right asymmetry of the anterior point of articulation is again achieved by twisting the tip of the tongue to the right so that complete closure is achieved between the left edge of the tongue along the lateral teeth, and then along the alveolar ridge across to the upper right (primary) lateral incisor. as with case 3, the right anterior point of articulation is slightly retracted from the alveolar ridge. the point of release is approximately the upper right canine. the passageway through which the airstream is directed is a very short, wide groove adjacent to the canine. the auditory effect is, once again distinct from [£-]. this sigmatism is also a clear case of a right anterolateral one but with significant articulatory differences from that of case 3. the deviations from [s] are: left-right asymmetry of the anterior points of articulation and a slightly widened groove. notice, however, that if-the asymmetry could be corrected by maintaining the point of articulation and groove but re-positioning the tongue-tip symmetrically round the midline of the palate, no further adjustments would be necessary for an almost perfect reproduction of the articulation for normal [s] (see figure 3 above). this is because there is a relatively small amount of contact between the edge of the tongue and the palate posterior to the alveolar articulation. in this respect the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) on so-called 'lateral [s]' 9 case 4 differs from all those above (as well as case 5 below) by having a passageway that narrows anteriorly in an abrupt fashion. the other cases, it will be recalled, had either long wide grooves or a long slit resulting from broad and long contact between the edges of the tongue and palate. case 5 sigmatism affecting /s/ /z/. diagnosed originally as 'lateral s\ but the diagnosis was uncertain at the time of examination. figure 7. palatograms for case 5 [s]. the anterior point of articulation is just behind the upper incisors for (a) and roughly alveolar for (b). the striking point about the articulations is the width of the passageway through which the airstream flows. in (a) it reaches the primary upper lateral incisors while in (b) it stretches between the canines. in (a) there is naturally more contact between tongue and palate than for (b). however, this sigmatism involves a double articulation, the oral one above and a labial one shown in figure 8 below. figure 8. the labial component of sigmatism of case 5. when the lower lip is withdrawn during a prolonged articulation as in figure 9 next page, the extremely anterior placement of-the tongue-tip relative to the upper incisors can be seen, as well as the slit articulation shown in the palatogram in figure 7 above. die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 a. traill figure 9. removal of the labial articulation during the production of a prolonged [s] by case 5. the auditory impression given by this articulation is that of the so-called whistling double fricative [d], when the labial articulation is disturbed as in figure 9 above the auditory impression is that of the slit fricative [r], although in one case the point of articulation is anterior to the conventional alveolar one for [r] and there is clearly more of the lateral part of the tongue involved. the articulation is deviant firstly in the slit rather than groove articulation and the fact that the slit, although symmetrical along the midline of the palate is unvaryingly wide along its entire length. the anterior point of articulation is too advanced for an alveolar consonant in one case. finally, the labial comt ponent is gratuitous in the normal articulation. this articulation does not have a strict counterpart in the classification above. while its anterior articulation is possibly addental in the one case it is alveolar in the other and there is no fan-shaped passage for release of the airstream. the intrusion of a labial articulation in sigmatisms is noted in traditional treatments, although in this case the contribution of this additional articulation is specifically a bilabial fricative, a possibility not explicitly discussed. with the exception of case 5, all the above sigmatisms involve a significant distortion of the articulation of the midline of the tongue relative to the midline of the palate, a fact documented clearly by mcglore and profitt9 whose conclusions were derived from strain gauge measurements. only case 5 has no such deviation, but, significantly only case 5 has a labial articulation as well as the oral one. mcglore and profitt9 point out that the normal tendency to bilateral asymmetry in tongue pressure is exaggerated and distorted in the cases of lispers. they attribute this to . . . poor co-ordination of tongue movements. another articulatory characteristic to emerge from the, above palatogramsis the general failure of the subjects to achieve the correct amount of contact between the sides of the tongue and the palate and teeth, a problem which has as its immediate effect an ill-proportioned passageway through which the airstream is channelled. in some cases it results in a wide groove incorrectly placed, in others a slit and in others an anterolateral deviation. only in case 4 is there something approaching a correctly dimensioned narrowing but this has been rotated to the right and is therefore wrongly positioned. a question of considerable interest for both traditional articulatory phonetic classification and the accurate description of the sigmatisms above, arises the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) on so-called 'lateral [s]' 11 when one attempts to describe their place of articulation. for consonants, place of articulation is generally assigned to the point or points of maximum constriction in the supraglottal vocal tract (velic closures do not count). the question is to what extent this criterion is applicable in cases 1—5. case 5 is straightforward and represents a double articulation bilabial and dental in one case and bilabial and alveolar in the other, these labels identifying the two points of maximum constriction. (that these divergent articulations represent a single phonological entity is, of course, not so straightforward.) case 4 is problematic: we have referred to the direction of release of the airstream as anterolateral. the point of maximum constriction is clearly opposite the right lateral incisor and thus in the vicinity of the alveolar ridge. the fact that there is contact between the edge of the tongue and the front teeth, that is, the presence of dental articulation, seems to be only a mechanical consequence of the distortion of the midline of the tongue towards the right. in a peculiar sense, therefore, case 4 has a tip alveolar articulation. notice therefore, how inappropriate the conventional label 'lateral' is for this articulation. whereas lateral segments like [ i i λ] are classified as dental, alveolar and palatal respectively, with the airstream passing out over the edge of the tongue, in case 4, the airstream passes along the centre of the tongue. the latter observation applies to case 3 as well, though, as noted, this case differs in other respects from case 4. the point-of-articulation problem presented by case 3 is that the slit along which the airstream passes does not have any obvious point of maximum constriction so far as its lingual articulation is concerned. however, the slit is abruptly constricted by the right lateral incisor, again in the vicinity of the alveolar ridge. this poses a dilemma: because of the tongue's deviation to the right the articulation is dental but alveolar, a situation which traditional phonetics is not able to resolve adequately. cases 2 and 1 both present the problem that although they both involve an anterior point of articulation that is alveolar, the point of maximum constriction is not confined to that point. in both cases the wide groove stretches from a palatal to an (asymmetric) alveolar point of articulation without altering its dimension significantly. thus the grooves are not only uniform, they are extremely long. to give an approximate but clearer idea of the length of these grooves compare the section profiles next page for [s] and the sigmatisms under discussion. the profile for [s] is from heinz and stevens,6 the others are constructions based on the palatograms in figures 2 and 3. from a traditional articulatory point of view, the point of articulation for the two sigmatisms is indeterminate; it is thoroughly abnormal. notice that the traditional secondary articulation of palatalisation is an inappropriate label for cases 1 and 2 because of the degree and extent of the constriction. a more revealing characterisation of this sort of articulation can be provided by examining its acoustic effect, a point to which we turn below. for the reader who is impatient to learn what the relevance is of this excursion into fine articulatory phonetic detail, it should be pointed out that it is the necessary groundwork for later conclusions of a phonological nature. die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 a. traill [s] (from x-ray) (approximate) case 1 case 2 (approximate) figure 10. section profiles for normal [s] and two sigmatisms.. when the phonological status of the sigmatisms is assessed it will have to be done against a well-founded set of articulatory and/or acoustic features. the importance of establishing this set in the precisest terms possible will become most apparent when the fundamental question of degree of deviation is raised. the acoustic aspect of sigmatisms this section will be confined to examining only certain aspects of the acoustic effect of the above articulations with a view mainly to supplement the articulatory descriptions so that later phonological conclusions will be adequately grounded. the production and acoustic effect of turbulent airflow in the vocal tract has been closely studied for example by heinz and stevens,6 stevens 1 2 and fant.4 a number of factors are considered in the analysis of articulations that result in turbulence. these are the length of the cavities posterior and anterior to the constriction, the length of the constriction, the cross-sectional area of the constriction and, in stevens' terms, the degree of acoustic coupling between the two cavities. the interaction of these factors and their acoustic output can be calculated in a precise manner from an idealised model of a constricted vocal tract, yielding results which fit well with data derived from the study of actual vocal tracts (stevens1 2). the applicability of these findings to the cases under discussion is confounded by the lack of data on cavity sizes for each case, as well as the unknown effects of the abnormal articulatory configurations, in particular the irregular constrictions and cavities/it is thus not possible even to estimate a valid correcting factor in order to accommodate stevens' predictions. therefore the few interpretations made below that draw on these predictions should be judged against the reservations expressed. it should be noted, however, that the main conclusion i wish to draw from the acoustic data is not affected. figures 11 16 are broad band spectrograms of english words recorded by cases 1 —5, illustrating the various sigmatisms. table ii presents an analysis of these and other spectrograms in terms of the upper and lower limits of the thesouth african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) on so-called 'lateral [s]' figure 13: case 3 : sand figure 14: case 3 : song r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 a. traill fricative noise in the spectrum as well as the major spectral peak(s) in this range. the latter were derived from a section taken at a point immediately prior to the release of the constriction and the onset of the vocalic segment. figures in brackets refer to a section taken at a point about 8 m. sees earlier in the segment. underlined figures represent the greatest peak. the average given under the column 'range' is the averaged lowest frequency of the range. for comparison, averaged figures for 2 normal children of comparable age to the subjects are included in table ii. the striking feature about all these sigmatisms is that their spectral energy is concentrated relatively high and there is most frequently no energy at lower frequencies. this characteristic places the sigmatisms firmly in the same category as normal [s] and [/], the very segments of which they are deviant renderings. if one considers the range of articulations that underlie this acoustic unity, this is a noteworthy feature. it shows that a number of articulatory positions and adjustments are compatible with the single acoustic feature of energy at relatively high frequencies. this property is lacking in the other english fricatives [f ν θ the property has been labelled stridency (e.g. halle5) or sibilance (laaefoged7). stevens 12proposes that the basis for the distinction between the two classes of fricative is the presence in the strident set of a . . . coincidence between a pair of resonances . . .; that for particular points of constriction . . . corresponding to two coincident resonances, a maximum is obtained in sound output and the resonant peak is relatively insensitive to small perturbations in the positions of the constriction. there exist, as it were, certain discrete or quantal constriction positions (places of articulation) for sound production. the articulatory and acoustic details of the sigmatisms may be interpreted in the light of these quotations as showing that none of them involves a transgression of the optimisation point for the production of a particular acoustic result. this has been achieved articulatorily by directing the turbulent airflow at roughly right-angles onto the upper teeth or incisors which therefore provide a sharp obstacle and greater noisiness. it is known that quite considerable differences exist between languages and within a language for acceptable amounts of tongue-palate contact in the production of normal [s] and [ / ] (dieth3), but it is clear that none of the above sigmatisms can be considered to fall within the limits of this normal variation because of the excessive amount of contact and, for some cases, grossly asymmetric contact. it is likely that peculiar features of the abnormal constrictions themselves contribute to the particular effect, but this point will not be pursued in any detail here. a few observations on each case follow. / / case 1 there is a clear concentration of energy above ~ 3,6 khz and none below it. the spectrum is however flat, without any! prominent major peak. generally the greater energy is located around 6,0 khz but it falls away only very gradually around this point. the suggestion of an upward bending where f2 is expected, in the spectrogram for song, is consistent with a palatal point of articulation, but the location in the section of a peak of energy as high as 6 khz suggests a more anterior point of articulation. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) on so-called 'lateral [s]' 15 sigmatism range (khz) to 8,1 major peaks (s) (khz) case 1 'palatal s' 4,0 5,5 to 7,0 (6,0) case 1 'palatal s' 3,6 4,5 to 7,0 (5,25) 4,0 5,25 to 6,5 (6,0) 4,1 4,75 to 6,25 (6£) (av. 3,19) (av. 5,8) case 2 'palatal s' 1,75 (5,30 and 6,25 and 8,25) case 2 'palatal s' (4,25) (5,30 and (\5 and 8,20) 2,3 4,8 and 6,4 (3,25) (5,0 and 6,25 to 7,0 and 8,25 3,50 6,25 to 8,0 3,55 4j5 and 6,5 and 8,25 (av. 3,1) (av. 5,2; 6,36; 8,19) 'palatal / ' 2,5 5,0 and 6,5 and 8,0 'palatal / ' 2,25 4,25 and 6,4 and 8,0 ,60 4,0 to 5,0 and 6,3 and 7,5 (3,50) (4,5 and 6,25 and 7,75) (av. 2,87) (av. 4,56 6 , 3 6 ; 7,81) case 3 'antero-lateral s' 3,60 4,9 and 6,25 and 7,5 (2,00) (2,6 and 4,25 and 6,0 to 7,5) 2,40 3,4 and 5,1 and 6,6 (1,75) (3,0 and 5,25 and 6,5 to 7,0) (av. 2,44) (av. 3,5; 5,21; 7,00) case 4 'antero-lateral s' 3,6 4,1 and 6,0 to 7,25 3,8 4 j and 5,1 and 7,4 (3,7) (4,25 and 5,5 and 7,1) 3,8 4,4 and 6 £ and 7,0 to 7,6 (av. 3,7) (av.4,21 5 , 8 0 ; 7 , 2 6 ) case 5 (a) 'double s' 1,0 5,0 in words 0,75 5,0 0,60 5,1 (2,4) 5j0 (av. 1,19) (av. 5,0) (b) 'double s' 3,0 4j8 in isolation 2,75 4,4 and 6,4 and 7,7 (av. 2,87) (av. 4,6; 6,4; 7,7) normal 1 averages [s] 4,0 5,27 7,22 [/] 2,5 3,26 6,15 7,81 normal.2 averages [s] 4,0 6,25 8,50 [/] 2,5 3,60 7,50 table ii. an analysis of the range and concentration of spectral noise during the production of various sigmatisms. die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 a. traill the latter observation is consistent with the palatographic evidence, the former with the possibility mooted above that a point more posterior within the constriction is contributing to the production. whatever the case may be, the flat envelope is not normal for sibilance on the one hand, but its high location is, on the other. this case's productions of [ / ] are thoroughly normal with a lower peak corresponding to the coincidence of f3 and f4, and a cut off point at 2khz. case 2 although the palatogram for this case is the mirror image of that for case 1, there are a number of differences. firstly, both [s] and [f] are affected; secondly, case 2 has much more clearly defined peaks of energy in the sigmatisms; thirdly, case 2's articulation often shifts just prior to release of the consonant, with the effect of spreading the spectrum to lower frequencies of very weak intensity. this latter point is clearly seen by examining the figures in table ii for the sections taken at a point before the shift is evident acoustically. the acoustic difference between the two sigmatisms involves firstly a generally higher intensity for the sigmatism of [s] as well as a slightly wider envelope for the sigmatism of [ / ] (2,87 khz vs. 3,1 khz for the [s] sigmatism) and a lower peak of energy situated at 4 , 5 6 khz for [ / ] (ch. 5,20 khz for fs]). these differences can be attributed solely to the effect of the lip-rounding found only in the [ / ] sigmatism. the addition of this anterior cavity serves to lower the resonances slightly. however the differences achieved in this way do not approximate normal differences between [ / ] and [s] and in fact, the auditory impression is mostly of identity. if one mechanically manipulates the lips so as to prevent the formation of a labial resonating cavity, no difference exists. so far as point of articulation is concerned, this is indeterminate for traditional categories because f2 bending and f4 and f5 amplification point to the possibility of a complex source for the turbulence. this evidence suggests that use of the label 'palatal' distorts both the articulatory and acoustic reality. this accords with the palatographic evidence. both sigmatisms qualify as sibilants with a frequency range beginning very high up. it is of interest to note that the data for case 2 were collected on separate occasions about eight months apart and considerable differences in intensity are found between intensity levels for the [ / ] sigmatism, with the later sample showing less intensity than the first one. although this will not be pursued here, this sort of comparison is highly suggestive for longitudinal assessment of treatment. , / case 3 compared with the spectrum for normal sibilants and for all the sigmatisms except that of case 5, case 3's spectrum is wide, with energy as low as 1,75 khz. there are clear peaks of energy however and generally two of these are located at ~5,2lkhz and ~7,00khz. the location of a peak of energy at ~3,30khz, however, is abnormal for [s] and is undoubtedly attributable to the peculiarities of the airway and its anterior deviation. this lower peak would be expected with normal [/], but auditorily, its effect is balanced by the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) on so-called 'lateral [s]' 17 the high-frequency peaks consistent with [s]. despite the abnormality noted, this sigmatism clearly meets all the acoustic requirements for classification as a sibilant. the balance between [s]like and [/]like acoustic features relies on the location of the energy peaks in the spectrum for the fricative. in so far as the data are clear, stevens' criteria would suggest a balance has been achieved in fig 13 but that [/]like properties predominate in fig 14. unfortunately no data is available on this case's normal [ / ] . . case 4 this sigmatism involves peaks of low intensity at ~4,21khz, 5,80khz and 7,26 khz. like the previous case, this suggests a combination of [s]like and [/]like characteristics and depending on the intensity of the lower peak v. the higher peaks, one or other will predominate. for instance in fig. 15 where the section shows no clear resolution of the higher frequencies [s]like amplifications are missing in the transition to the vowel, but the peak found at ~4,0 khz is amplified into f3 and f4 suggesting [/•]like properties; other spectrograms, however, display [s]-like properties. this may be due to inconsistent articulations, but it could also reflect peculiar effects of the orientation and shape of the constriction. once again, traditional articulatory labels fail to provide an accurate categorisation. case 5 the presence of low-frequency, noise is due to the turbulence generated at the hps. in addition, this constriction evidently serves to amplify frequencies with great intensity and consistency around 5,0 khz. removing the labial constriction removes certain low-intensity noise probably generated by the lips. emerging from 5 khz in the transition to the vowel are f4 and f5 which in stevens' terms points to post dental constriction. this is of interest because it suggests a narrowing there that is not visible either from the palatograms or the picture of the position of the tongue-tip relative to the upper incisors (figure 9). one may speculate that the deep and wide groove evident in that picture extends only a short way posteriorly, possibly to the alveolar ridge, where a shallower constriction lies. although this is a double fricative with labial and dentalalveolar points of articulation and a wide groove, it is evident from the acoustic data that traditional articulatory categories do not really help to elucidate the nature of the sigmatism. it is noteworthy that this sigmatism qualifies as a sibilant like all the cases surveyed. the strongly focused, high location of an exceptionally high peak of energy is the mark of a sibilant according to the definition used in this paper, and although there is low-frequency-lowintensity noise it is effectively neutralised from a linguistic point of view by the other feature. the acoustic properties of [ / ] for this case are normal with clear spectral peaks at 2,5 khz and 5,0 khz. a certain amount of low-intensity noise at all the lower frequencies of the spectrum points strongly to the lips being involved in this articulation, although this was not noticed during the recording session. the phonological aspect of the sigmatisms in this section an attempt will be made to assess the functional significance of die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 a. traill the sigmatisms for the phonological system which underlies them. the point to be emphasised is that all the articulatory and acoustic phonetic data examined are of little interest in their own right. their true value, strictly speaking, can only be determined by examining how they are structured phonologically. to put it differently, as linguistic sounds, these sigmatisms must be seen as expressing some phonological contrast, and they lose all significance if treated outside such a context. the only way to arrive at an accurate assessment of their severity in the sense of their disruptive effect on the phonological system, is to view them in their proper linguistic context. this in turn will lead to implications for a controlled therapy routine. the english fricative series is as follows: f θ s / v £ ζ 3 the system of oppositions that structure the series involves the presence or absence of voice and articulatory position. there is, however, the need for an additional feature in order to provide a natural explanation for the distribution of the plural and 3rd person singular allomorphs /—3z/ and /—ζ—s/: safe s path s kiss 3 ζ fish 3z latch 3z cave ζ tithe ζ fizz 3z garage 3z badge 3z /—> /"ν for this rule, english treats the class of final consonants / s ζ / 3 t / d 3 / a s a natural one; they all take the /—3z/ allomorph. in order to explain this, one searches for a single feature that they all share in common which is lacking in the complementary class of / f ν θ β /. the feature is of course 'sibilance' (or stridency) and it has its phonetic basis in articulatory and acoustic details that have been mentioned though it is actually defined in acoustic terms only (ladefoged7). to express this in current terms, each fricative represents a bundle of distinctive features, the relevant ones of which can be displayed as follows: f v θ £ s ζ / 3 voice + + + + sibilance • + + + anterior + + + + + + the boxed-in fricatives are those involved in the sigmatisms discussed above and we may now ask how these so-called articulatory defects disrupt the above system. with the exception of case 2, the answer is not at all. cases 1 , 3 , 4 , 5 , show that despite widely different articulatory details, the sigmatisms are sibilants; the voice and position features are not affected. case 2 differs in the latter respect; the bundles <+ sibilant ± anterior>have been collapsed to a single sibilant using the tongue blade. that is, there is no positional contrast the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) on so-called 'lateral [s]' 19 involving the feature<+ sibilant>for case 2. instead, labialisation is the surrogate for the pair of features γanterior"! l + labial j in other words, case 2 has restructured the physical instantiation of the sibilant fricatives. the question is whether this has been successful and, as noted above, the answer is that it has not. clearly, the difference between the normal expression of /s/ and / / / cannot be achieved through lip rounding alone; a positional shift is necessary in order to create a larger anterior cavity for the particular resonances associated with normal [j]. case 2 therefore disrupts the system of fricatives at a systemic level and must to that extent be regarded as the most serious of the cases presented. this disruption is reflected below: f v θ * c j voice + + + sibilant + + anterior + + + + coronal + + (the symbols c and j cover normal [ s / ] and [ ζ respectively) it was noted above that the feature 'sibilance' is customarily given a clearly acoustic definition and i would suggest that in a sense the correctness of this emphasis is borne out by the fact that each case has managed to preserve the acoustic feature of sibilance under quite different articulatory configurations. this points strongly to the reality of the feature as the target in the child's acquisition of english fricative contrasts, and is further confirmation of the entrenched or resistant nature of the feature in various disorders (cairns and williams2). case 2 can be seen therefore to have a truly linguistic problem as against what are probably best described as the cosmetic problems of the other cases. these cosmetic problems are attributable to deviations from the norm of fine acoustic detail which arise from various kinds of articulatory distortion. put differently it is clear that cases 1 , 3 , 4 and 5 completely satisfy the requirements of english fricatives at the phonological and phonetic level and to that extent they must be regarded as normal. it is true that the abnormalities which lead these cases to be diagnosed in the first place as having a speech defect are indeed expressed in phonetic substance, but it must be understood that these phonetic deviations are not sufficient to disrupt the linguistic system and, in a sense, are therefore most superficial. their linguistic triviality may in fact partly explain why sigmatisms are so resistant to therapy: at a certain level, there is no reason to change! however, the fact is that such cases nevertheless require therapy and one may ask whether the observations made in this paper would favour any particular programme. it seems they do. they suggest that the articulatory distortions themselves should be the explicit and direct focus for therapy, rather than die suid-afrikaanse tydskrif vir kommuniksieafivykings, vol. 24 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 a. traill auditory feedback. the basis for. this emphasis is that the cosmetic distortions derive directly from the articulatory facts of abnormal constrictions and abnormal orientations. at an auditory level the output of these articulatory configurations is fully acceptable linguistically and therefore likely to be highly resistant to change. it would be reasonable instead to aim directly at articulatory adjustments which would not only preserve the linguistically necessary acoustic output, but at the same time remove the fine but offensive acoustic deviations. by way of a practical suggestion, one may suggest that normal [s] could be 'grafted on' to the release of the voiceless alveolar stop since, firstly, the sides of the tongue would be normally orientated, secondly, release would be central, and thirdly the friction associated with an aspirated release could be transformed into a linguistically and cosmetically acceptable [s]. initial [s] could be introduced in this way by juxtaposing words with initial [s] after words with final [th]. this sort of approach could establish the correct kinaesthetic feedback, arid indeed one would expect just this in terms of the motor theory of speech perception. case 2, obviously requires an approach which takes into account the linguistic and any cosmetic deviations, but it would seem that this could also be done through an articulatory programme. references 1. bloomer, η. h. (1971): speech defects associated with dental malocclusions and related abnormalities. in handbook of speech pathology and audiology, travis l. e., (ed.). new york: appleton-century crofts. 2. cairns, h. s. and williams, f. (1972): an analysis of the substitution errors of a group of standard english-speaking children. j. speech hear. res., 15,811-820. 3. dieth, e. (1950): vademekum der phonetik. bern: a. frank. 4. fant, g. (1970): acoustic theory of speech production. the hague: mouton. 5. halle, m. (1959): the sound pattern of russian. gravenhage: mouton. 6. heinz, j. m. and stevens, κ. n. (1961): on the properties of voiceless fricative consonants. j. acoust. soc. amer. 33,589-596. 7. ladefoged, p. (1971): preliminaries to linguistic phonetics. university of chicago press. 8. luchsinger, r., and arnold, g. e. (1965): voice, speech, language: clinical communicology: its physiology and pathology. belmont: wadsworth. 9. mcglore.r.e. and profitt,w.r. (1973): patterns of tongue contact in normal and lisping speakers. j. speech hear. res. 16,456-473. 10. powers, μ. h. (1971): functional disorders of articulation symptomatology and etiology .handbook of speech pathology and audiology, travis, l. e., (ed.). new york: appleton-century crofts. 11. stevens, κ. n. (1971): airflow and turbulence noise for fricative and stop consonants: static considerations!. j. acoust. soc. amer. 50, 11801192. the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) on so-called 'lateral [s]' 21 12. stevens, κ. n. (n.d.): acoustic correlates of place of articulation for stop and fricative consonants. quarterly progress report no. 89, research laboratory of electronics, massachusetts institute of technology. 199-205. 13. van riper, c. and irwin, j. v. (1958): voice and articulation. pitman medical publishing co., london. hearing aids — widest range of world-renowned makes audiometers — wide range of screening — portable — diagnostic — clinical — automatic and research models silent cabins — singleand double-wall cabins in all sizes. ventilation — one-way glass — and many other features auditory trainers — transposing apparatus — articulation amplifiers — group training equipment — speech reproducer — delayed speech reproducer — peep show accessories — visible speech apparatus — sound-level meters — plus our comprehensive service throughout the country also manufacturers of audiometry and speech training equipment h e a d o f f i c e : 2 1 2 h a r l e y c h a m b e r s , c o r n e r j e p p e a n d k r u i s s t r e e t s , j o h a n n e s b u r g . telephones: 3 7 2 6 4 3 / 4 / 5 p.o. b o x 2 2 6 9 , j o h a n n e s b u r g 2 0 0 0 telegraphic address: b o n a v o x die suid-afrikaanse tydskrif vir kommunikasieafivykings, vol. 24, 1977 s.a. (pty) ltd for r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a division of s.a. philips (pty) ltd. hearing aids portable audiometers [roup teaching systems philips head office 1005 cavendish chambers, 183 jeppe street, p.o. box 3069, j o h a n n e s b u r g . @ ) 4 4 9 2 3 the south african journal of communication disorders, vol. 24, 1977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language development of a group of hearing impaired children alida m . u . laubscher, m . s . washington university introduction recently there has been a great surge of interest and activity in the area of developmental psycholinguistics. this discipline, exemplified by the work of brown and bellugi2, ervin (1964), mcneill11, menyuk (1963, 1964a, 1964b) and others, has largely arisen because of the theoretical expositions of chomsky (1957) who provided the formulations concerning the grammatical structures of the english language. this led researchers to apply these principles to the language acquisition of children. the psycholinguists hold that children have an innate capacity to acquire most syntactic rules in the short span of life from one and a half to three and a half years of age. it is a more accurate explanationof language acquisition than the theories of imitation. evidence that imitation alone does not account for the phenomenon of language acquisition, is the observation that a normal, hearing child at the age of three or four does not produce only sentences which he has heard, but generates his own novel set of sentences. what he acquires is the group of rules that governs the generation of the sentences. he learns a finite set of rules that enable him to produce an infinite set of sentences. this process of indirectly learning the syntactic rules has been called induction of the latent structure by brown and bellugi2. early grammatical rules the generative grammar model as formulated by chomsky has been applied in the literature to describe the language acquisition of the child. brown and fraser3, braine (1963) and miller and ervin (1964) have investigated the earliest two-word combinations of normally developing children and have identified the use of pivot words as the child's first grammatical construction. the two-word combinations' were called sentences. the word combinations were found not to be random, but to follow a pattern, and the words were categorized as belonging either to the open class or to the pivot class: membership in both pivot and open class is heterogenous from the point of view of being part of speech membership in the adult language. the words in the pivot class emerge later into grammatical classes similar to that of adult grammar. brown and bellugi2 have described the development of the nounphrase as a grammatical unit in children's grammar. building on brown journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language development of a g r o u p of hearing impaired children 19 and bellugi's data, mcneill (1965) proposed that the earliest grammatical constructions are noun phrases and predicate phrases and on occasion, full sentences. the early speech of children reflects the properties of the phrase structure of sentences. it does not reflect the operation of transformational rules; these seem to come into children's grammar at a later stage. transformational development a transformational model of structure was used by menyuk (1963, 1964a and 1964b) to describe children's grammar in the age range from two to seven years to indicate developmental trends. it was found that four-year-old children used a greater number of different transformations per child than three-year-olds. it seems that .a four-year-old is less fixated as to the number of different sentence types than a child one year younger. evidence of the four-year-olds' advanced linguistic competence was seen in their decreased use .of simple active-declarative (kernel) sentences as compared with the three-year-olds. children mature toward finely differentiated linguistic competence in stages of advancement. the first sentence rules seem to be those relating to phrase structure; these are learned by two to three years. the second stage in learning the rules governing the generation of sentences seems to be that of simple transformations. the final level of maturity would be the mastery of complex transformations. morphological development development of morphophonemic rules, governing pronunciation and relating the syntactic and phonological parts of the grammar, has been investigated; the findings have indicated certain developmental trends. berko (1966) found the children's usage of noun plurals, verb inflections and possessives indicated a clear developmental trend. the children's performance on verb inflections indicated best performance on the progressive. the past tense of the irregular verb form was never used correctly by the four and five-year-olds and only one child of the sixtyone five to seven-year-olds made use of this construction. because the division between regular and irregular verbs is an arbitrary one, rote learning is required in each case. cazden (1968) found that the irregular forms are often used correctly by the child before he starts to differentiate between the rules. the application of ons rule for all forms is often found, for example, "went" and "go-ed" or "walked" and "weared". this overgeneralization is followed eventually by the correct use of the regular and irregular verb inflections. cazden (1968), reporting on the development of three verb inflections, found that the present progressive appeared first in the utterances of all three of his subjects; complete mastery was reached between approximately twenty and forty months. the sequence of acquisition of the tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 alida μ . u . laubscher regular past and present indicative was less consistent, relative to age and rate of acquisition. the studies described above, which utilized a generative model of grammar seem to agree with the hypothesis that the child has incorporated both the generative rules of the grammar and a heuristic component that samples an input sentence, and by a series of successive approximations determines which rules are used to generate a sentence. also, there appears to be a clear developmental sequence of certain features. if this is an innate capacity that the child brings to the task of acquiring language, it must also exist in the hearing-impaired child. he should possess a source of hypotheses as rich as a hearing child's, since in both cases hypotheses result from the capacity for language acquisition rather from the language itself. the limitation placed on the hearingimpaired child, however, is the input of the sentence constructions. t language acquisition of hearing-impaired children the main trend of description of the language of deaf children in the past has been based on the rules of traditional grammar. the application of linguistic rules to describe the language of deaf children indicated that deaf children show many features in their language production that some have termed "deafisms": stereotypy, syntactical errors, limited vocabulary and wrong choice of words. fries's method of reclassifying parts of speech into four classes and function types, based on their privilege of occurrence in sample sentences, has been a useful procedure in analysing the linguistic performance of hearing-impaired children. studies utilizing this method have been completed by simmons (1962), goda (1964) and mcginitie (1964). studying a group of eight to fourteen-year-old deaf and hearing children, simmons indicated that the deaf exceeded the hearing in the use of class i words (nouns), class ii words (transitive and intransitive verbs) and determiners. the hearing children used more class iv words (adverbs, auxiliaries and conjunctions). the two groups used a similar number of class iii words (adjectives and prepositions). the deaf used prepositional groups of place and accompaniment. comparing the number of different words spoken by each group, the hearing group used a higher type-token ratio than the deaf. mcginitie (1964), using a sentence completion test, indicated that the deaf children show a nearly uniform retardation in supplying content and function words. these results; are not in complete agreement with the earlier studies by heider and heider and myklebust who indicated that deaf children omit abstract or function words which have no tangible referents. language of deaf ohildren contains many nouns and verbs which tend to be more concrete. while hearing impairment seems to create under-use of some word classes, it results in a tendency to over-use nouns and articles. hearing impairment interferes with the learning of function words more than journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language development of a g r o u p of hearing impaired children 21 with the learning of content words. among the content words, adverbs are found to be an exception. function words tend to be more redundant than lexical words. cohen (1967) found that deaf children construct messages with less redundancy than is generally found in the language of their hearing peers. these investigations indicate that 'hearing-impaired children are deficient in both specific verbal skills and in general language. when the deaf child's verbalizations are more than rote performances or memov rized strings of words, his utterances will reflect a system of formulational rules. these rules can be analysed and the developmental sequence of language can be illustrated. the studies mentioned above described specific structural features in the language of deaf children. a developmental sequence was not indicated. goal the goal of the present study was to determine whether there are developmental trends of certain language features and formulistic rules in the language of hearing-impaired children. language development of normal children indicates that certain language features are acquired before others and show improvement in correct usage as a function of age. from the language samples of this group of hearing-impaired children, indications of occurrence of certain features and language rules as well as improvement in correct usage was analysed. method the language samples of the ten hearing-impaired children in this study represent the age range from five to three years and nine to seven years. the mean hearing level of the subjects, in the better ear, was 76db i.s.o. the children were all enrolled in the school programme at the central institute for the deaf, st. louis. prior to entrance, they were participants in a parent-infant programme. language appropriate to the children's linguistic age levels was used in the school programme. language was taught through experience; stories which .were written following an actual group experience were used. the traditional approach of systematic teaching of structural forms was not followed. language was elicited from the children who were instructed to talk about a picture. this was tape-recorded. the procedure followed in analysing samples was directed toward counting the occurrence of certain language features at five age levels. the language samples of each child were analysed with reference to the following features: (a) the use of single word, two word and three word combinations. (b) kernel sentences. according to the generative grammar model, a kernel sentence is any single sentence which is generated without the application of optional transformations. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 alida μ . u . laubscher (c) verb tenses and verb inflections. the occurrence of the present tense, past tense (irregular verbs) present and past progressive aspects was counted with reference to which form occurred earliest in the language samples. a comparison of the frequency of occurrence was also made. (d) the transformations conjunction, conjunction deletion, the auxiliary "have", pronominalization, particle displacement, the comparative ' and passive voice were examined. the age at which the transformations occurred was determined. the usage of sentences, possibly indicating pre-transformational sentence structures, was analysed. results verb tenses and inflections. the occurrence of the present tense, the present progressive aspect, the past tense and the past progressive aspect indicated a clear developmental trend. the present tense occurred earliest in the children's language samples. the present progressive aspect and the past tense (irregular verbs) appeared second and third respectively. although there was not a significant difference in the time of occurrence of the present progressive aspect and the past tense (irregular verbs), there was a significant difference in the frequency of usage of the two forms. the present progressive aspect was used as the dominant form when both occurred in all the language samples. this was especially true for the age range of five to seven years. the past progressive aspect appeared in the language samples at the nine year level. this verb form never appeared before the others. the present tense was always used in all language samples when verbs were present. as age increased, the present tense was not the main verb form of discourse, and was used less frequently. other verb forms became the main verb forms of discourse. a developmental sequence of verb forms appeared to be present. table i summarizes the occurrence of verb tenses and verb inflections in the language of the subjects. all the language samples, except for two out of thirty-one, indicated the same pattern. the present tense preceded or occurred .with the present progressive aspect. the past tense occurred after the present progressive, and the past progressive was the last form to appear. this sequence is representative of the group as a whole. in the two samples in which the developmental sequence was not reflected, the present and past tenses occurred. subject iii used the past progressive aspect at the age of six years but not in the later samples. the appearance of the auxiliary "be" with the present progressive, and the inflection /-ing/ were included in the analysis because there appeared to be inconsistencies of' correct usage. omission of either the auxiliary "be" or /-ing/ occurred with the correct usage of the present progressive form. more omissions occurred at ages five, six and seven than at age levels eight and nine. the correct application of "be + ing" journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language development of a g r o u p of hearing impaired children 23 concurrently with an omission of either can be illustrated as follows: subject i i : "the boy is smiling and the girl smiling, . . . the dog is laugh . . . these results appear to be in agreement with the results of cazden (1968). the present progressive aspect and the present tense were acquired first in the language of his three normal hearing subjects. tihe auxiliary "be" plus the inflection /-ing/ occurred, with" omissions and correct usage at the same time and was not completely mastered at the age of forty-nine months. berko (1966) reported that at the age of four years the children used the present progressive correctly 90% of the t a b l e 1 : o c c u r r e n c e o f v e r b t e n s e s a n d v e r b i n f l e c t i o n years subjects 5 6 7 8 9 i ν pr τ pr pr a ii + pr τ p r t pr pr a pr τ pr pr a p a t > iii pr τ pr pr a p r t pr pr a p a t pa pr a pr τ pr pr a pr τ pr pr a iv ν ν ν v pr τ p r t vi ν p r t p r t pr pr a vii ν pr τ pr pr a p a t pr τ pr pr a p a t p r t pr pr a p a t pa pr a viii ν p r t p r t pr pr a p r t pr pr a p a t pa pr a i x ν p r t pr τ + p r τ p a t x pr τ pr pr a p a t p r t pr pr a p a t p r t pr pr a p a t pa pr a symbols: n : n o occurrence p r t : present tense pr pr a : present progressive aspect pa t : past tense (irregular verb) pa pr a : past progressive aspect tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 alida μ . u . laubscher time. the past tense verb inflection of irregular and regular verbs was used correctly by a much lower percentage. the past tense of the irregular verb form was analysed because no evidence of the regular verb past tense inflection was found. it would require the allomorph /-ed/. in the training these hearing-impaired children received, they were exposed to all the verb tenses and inflections. verb tenses or verb inflections were not taught per se, but whatever form seemed appropriate was used. in general they had more exposure to the past tense of both regular and irregular verbs than the other three forms described in this study. the children used the following irregular verbs in the past tense: took, fell, were, had and got. these verbs were always inflected. when one looks at the acoustic dimension, the allomorph /-t/ that is required for the verbs used is a voiceless plosive and unstressed, and might be inaudible for the subjects'. the irregular verb inflection requires a change in the vowel and might be available auditorily. the printed form of both regular and irregular verbs was presented to the children in their language training. cazden (1968) reported that the irregular verb inflection is acquired by children first before the application of differential inflection rules . . . irregular forms may start out as separate lexical items with no past meaning for the child. in spite of the fact that these children had been exposed to both forms of verb inflections, only one form was present in their spontaneous language utterances as transcribed by several listeners. verb plus complement construction: the verb plus complement construction was analysed because the picture stimulus seemed to elicit the use of transitive and intransitive verbs in the subject's spontaneous utterances. the structural description of a sentence with a verb plus complement is as follows: sentence: s->np + vp n p = n o u n phrase v + c + (np) v + c = v e r b + complement c = particle prepositional phrase two sentences can be formulated. (a) noun phrase + verb + particle + noun phrase. (b) noun phrase + verb + prepositional phrase. in adult grammar, sentence (b) with transitive verbs /would not be used and a transformation, particle displacement would have to apply. the structural change of the sentence representing the transformation is: (c) noun phrase + verb + noun phrase + particle. the age and percentage of occurence of 'these three sentence constructions were determined. the percentage of children using the verb + complement construction suggests an increase of occurrence over years. at the eight and nine year level, it appeared in all the language samples and was used more frequently. the sentence structure, noun phrase + journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language development of a g r o u p of hearing impaired children 25 verb + prepositional phrase occurred in all the language samples of children using the construction. omission of the preposition occurred only during the early language samples of individual children. omission of prepositions appeared concurrently with the correct use of the preposition, followed soon by a stage of no omissions. menyuk (1964) reported that the child at the age of two years omits prepositions and uses them at two to six years of age, although not always where required. this stage is soon followed by correct application of prepositions. the prepositions used by the ten children in this study were all of place and accompaniment. menyuk (1964) found that the prepositional phrase of location is used before the prepositional phrase of time. feofanov (1958), reporting on the use of prepositions in children's speech (ages three to seven), found that the earliest and most often used prepositions were those having the greatest number of meanings. the three most common prepositions were "in", "on" and "with". the earliest usages expressed primarily spatial relations. the use of prepositions expressing relations of purpose, time relations and space relations used figuratively, appeared later on. the sentence structure, noun phrase + verb + particle + noun phrase which can be considered as a pre-transformational rule, was present in five language samples in the age range of seven to nine. the presence of this sentence structure may indicate that the children are using the same rule for particles with transitive and intransitive verbs. example: v + particle + np v + prepositional phrase take with the dishes look at the dishes put on the pan sit on the floor put up the pan stand up the introduction of the transformation particle displacement would indicate an advanced stage of development in that the differentiation of treatment of particles with transitive and intransitive verbs is made. the developmental sequence could be exemplified as follows: subject x stage i stage ii omission of particle v + particle + np girl and boy put the pan boy puts on the pan stage iii transformation particle displacement he puts the pan on . . . conjunction. the occurrence of conjunctions in the spontaneous language samples of this group of children indicates the usage of various rules. different levels of complexity of the use of conjunctions were found as age increased. the acquisition of conjunctions appears at an early age. the most frequently occurring conjunction was "and". conjunctions "because" and "so" were used only by two subjects at age levels six and nine. to tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 alida μ . u . laubscher describe the development of the rules as they increase in complexity, an analysis of the rules found in the language samples was undertaken. the rules are as follows: rule 1. ν + and + ν (n: noun). adj + and + adj. (adj: adjective). rule 2. np + vp + and + np + vp (np: noun phrase) (vp: verb phrase). conditions: 1 2 3 4 5 this is the conjunction of two kernel sentences in which all conditions are different, for example: the boy is laughing and the girl is crying 1—2—3—4—5 no condition in either kernel sentence can be deleted. rule 3. n p + v p + a n d + n p + v p conditions: 1 2 3 4 5 structurally rules 2 and 3 are the same, but in rule 3 certain conditions are identical. for example: the boy is laughing and the girl is laughing 1—2—3—4—5 conditions 2 and 5 are two verb phrases that are identical and condition 2 or 5 may therefore be deleted. conjunction of the two kernel sentences in rule 3 requires a transformation. the resulting transformation is conjunction deletion and is found in adult grammar. the use of rule 3 in children's grammar may be considered as a development stage before the acquisition of the conjunction deletion transformation. because the two rules are structurally the same, the child may apply this rule to all conjunctions of two kernel sentences before he acquires the differentiation between the two different and two identical conditions in sentences. rule 4. conjunction deletion no. 1. in this transformation condition 2 as described above is deleted. rule 5. conjunction deletion no. 2. rule 5 also requires the deletion of conditions from one of two combined kernel sentences. structural description: n p + v + n p + a n d + np + v + n p 1 2 3 4 5 6 7 the boy has socks and the boy has shoes structural change: transformation conjunction deletion no. 2. np + v p + n p + a n d + n p 1 2 3 4 7 the boy has shoes and socks condition 1 5 and 2 6 are identical and 5 and 6 must therefore be deleted to form the transformation conjunction deletion no. 2. in the language development of these children there was a sharp decrease in the occurence of rule 1, i.e. noun + and + noun. it ocjournal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language development of a g r o u p of hearing impaired children 27 curred in the early language samples of the children who used it. the rule was either replaced by the conjunction kernel sentence + and + kernel sentence or used concurrently with the other rules. the use of the conjunction with two different kernel sentences increased rapidly and appeared as the dominant rule in all language samples at age levels seven, eight and nine. rule 3 suggests a pre-transformation and would not appear in adult grammar. the use of rule 3 occurred at early age levels, six and seven years. this pre-transformational rule was soon either replaced by the transformation conjunction deletion or used concurrently with the transformation. transformation conjunction deletion no. 1 occurred in the age range five to nine years. it was used by only one child at age five. there was a steady increase in the number of children using it and in the frequency of occurrence. the occurrence of the transformation was preceded by rule 3 in the language samples of nine children. transformation conjunction deletion no. 2 or rule 5 occurred in the seven to nine year range. it was always used as a transformation. two children at ages six and seven used the conjunction "and" to string many nouns together in a sentence. example: the boy has some—and —sock and shoe and shoel—and pant and shoes and socks. this never occurred at the nine year level. menyuk (1963) reported on the development of transformations conjunction and conjunction deletion by normal hearing children ranging in age from 3-0 to 6-0 years. conjunction (e.g. rule 2 in this study) was used by 87% of the children at age three; conjunction deletion was used by 62% of the children at age three. at ages five and six, conjunction occurred in the language samples of all the children. conjunction deletion, however, was used less frequently but showed a steady increase in the number of children using it in the age range 3-8 to 6-0 years. the transformation conjunction is one of the few transformations used at the,three year level. development of syntax structures. the comparison of the major sentence structures used most frequently at the various age levels indicated a developmental sequence similar to that of normal children. the use of kernel sentences increases as the children become older. the use of the kernel sentence alone as the underlying rule of all sentences in a language sample decreases rapidly. at the age of eight, it was always used with other transformations by all children. at the age of seven, only two out of eight children used the kernel sentence to formulate all their sentences. there appears to be a rapid increase in the use of transformations concurrently with the kernel sentences. the transformation auxiliary "have" occurred at age level seven with correct inflection in the language samples of all the children. it was not used frequently however. the transformation pronoun occurred with high percentage and increased with age. very few errors occurred. for each individual child, there was an increase in the different kinds of pronouns used. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 alida μ . u. laubscher on the acquisition of the transformations auxiliary "have" and pronoun, menyuk (1963) and brannon (1967) reported a further development. the transformation auxiliary "have" did not occur in the language of two and three year olds and appeared at age four or later. the transformation pronoun was never used by three year olds and it seldom occurred at age four. the transformation auxiliary "have" is based upon the use of specific word endings and seems to be a more difficult morphological form to acquire. the presence of the transformation comparative and passive was also examined in the language samples of the ten subjects. the comparative was used by three children at ages five, six and seven. it occurred only once in each language sample. the passive was never used by any of the children. the use of the passive by normal hearing children as discussed by menyuk (1964) suggested an increase in the number of children using it over the age range of 2-10 to 6-0 years. at 2-10 years it was used by one out of eight children; at ages 3-6 to 3-9 it was used by 48% of the children and by age six by 85%. at age levels eight and nine, the children were using kernel sentences as well as a greater number of different transformations, as compared with the sentences formulated at the earlier age levels. of the six transformations examined, the pronoun and conjunction were the most frequently used and occurred at an earlier age. the introduction of more transformations in their language as this group became older indicates that they became less fixated as to the number of sentence types they were using in their spontaneous language utterances. discussion the results from the analysis of the language samples suggests a developmental sequence of language acquisition by the ten hearing impaired children. the data will only allow the observation of developmental trends, since the number of children and language samples were small. the language acquisition of the ten subjects appears to be similar to that of normal hearing children. the main difference is the chronological age at which the grammatical structures emerged. the usage of verb tenses and verb forms indicated similarity with normal hearing children as described by cazden (1968) and berko (1966). the,-appearance of the kernel sentence demonstrated the children's early syntactic development. the kernel sentence appeared after single word and two or three word combinations for some children. other children were already at the stage of using kernel sentences when their language was first recorded. the major portion of syntactic acquisition for normal children after kernel sentences is the growth of transformations. the ten subjects used •transformations more frequently as they became older. the transformation conjunction was one of the earliest acquired transformations. journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language development of a g r o u p of hearing impaired children 29 similar results were reported by menyuk (1964). the appearance of conjunction deletion no. 1 was preceded by a pre-transformational construct. this appears to demonstrate a developmental stage in the formulation of rules by the children. the development of transformation particle displacement was preceded by the application of a generalized rule to combine verbs and particles. at a later age, a rule to. differentiate between transitive and intransitive verbs with particles appeared. in the school situation, the transformation particle displacement would have been incorporated. there appears to be indication of development from generalizing rules to correct application of the transformation. the transformation auxiliary "have" is acquired by normal children at age three or later. the hearing impaired children used it infrequently, and it appeared later than transformations conjunctions and pronoun. the prepositions that occurred in the hearing impaired children's spontaneous language were those of place and accompaniment. according to feofanov (1958), they are the first prepositions acquired by normal hearing children. the language acquisition of these children does reflect rote performances or memorized strings of words. these data lend support to the hypothesis that deaf children, as well as normal hearing children, have an innate capacitiy for language acquisition. lennenberg (1964) stated that: "deaf children could hardly differ in the capacity for doing this, from hearing children, provided they were given enough examples and are allowed to go through a natural order of grammatical development. this capacity to acquire language can be demonstrated by the rules and/or categorization of rules used to formulate sentences. the hearing impaired child is limited in his ability to test hypotheses against adult speech, and language exposure and instruction .is brought to the task of language acquisition. a training programme utilizing the theory of the innate capacity would necessitate the provision of many language constructs so that the deaf child would be given the opportunity of inducing the structural principles of the language in a natural way. the capacity to acquire language appears to be transitory (mcneill 1966). this suggests that concentrated language exposure and teaching should begin early, i.e. before the age of four, which is the age at which some investigators have said the child is at his peak of language acquisition. summary spoken samples of language from a group of ten hearing impaired children were analysed with respect to development of occurrence of verb tenses and verb inflections, the development of the kernel sentence and four transformations: conjunction, particle displacement, auxiliary "have" and pronoun. the language samples represented an age range of five—three to nine—seven years. the mean hearing level of the ten subjects, in the better ear was 76db i.s.o. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17,nr.: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 alida μ . u. laubscher from the results obtained, general conclusions seem to emerge. firstly, the earliest acquired verb tense is the present, followed by, or appearing concurrently with, the present progressive. secondly, the kernel sentence is correctly used at an early age by some children. as age increases, so does the percentage of children using the kernel sentence. from approximately seven years of age, more transformations are used. the transformations conjunction and particle displacement indicated a clear developmental trend towards greater complexity. the conjunction and pronoun transformations were used by a greater percentage of children. the transformation auxiliary "have" appeared much later and less frequently. · these developmental trends show strong similarities to the trends observed in normal hearing children by other investigators. there is, however, a time lag in that the hearing impaired children develop these features at a later age and over a longer period of time. opsomming spontane spraakvoorbeelde van 'n groep van tien gehoorgestremde kinders is ontleed met verwysing na die ontwikkeling van die voorkoms van werkwoordtye en verbuigings, die ontwikkeling van die kernsin en vier transformasies. die taalvoorbeelde verteenwoordig 'n ouderdoms omvang van vyf—drie tot nege—sewe jaar. die gemiddelde gehoorpeil van die tien proefpersone, in die beter oor, was 76db i.s.o. sekere ontwikkelingsneigings is gevind in die taal van die kinders wat ooreenkomste getoon het soos gevind deur ander ondersoekers by normale kinders. daar is egter 'n tydsverskil, in die dat die gehoorgestremde kinders die taalelemente op 'n later ouderdom en oor 'n langer periode van tyd ontwikkel het. bibliography 1. berko, j., t h e child's learning of english morphology. psycholinguistics ed s. saporta, 1966. 2. brown, r., bellugi, u., three processes in the child's acquisition of syntax harvard educ. rev., 1964, 34, 133-151. 3. brown, r., frazer, c., t h e acquisition of syntax. mon. soc. research in child development, 1964, 29, 43-78. 4. cazden, c. b„ t h e acquisition of noun and verb inflections. child development, 1968, 39, 433-448. / 5. chomsky, n., aspects of the theory of syntax. m.i.t. press, 1965. 6. feofanov, m. p., on the use of prepositions in child speech. genesis of language, m.i.t. press, 1966, 366-367. 7. fries, c. c., the structure of english: an introduction to the construction of english sentences, new york, 1952. 8. goda, s., spoken syntax of normal, deaf and retarded adolescents. journal of verbal learning and verbal behavior, 1964, 3, 401-405. 9. lennenberg, ε. h., biological foundations of language. wiley, new york," 1967. 10. macginitie, w., ability of deaf children to use different word classes. j.s.h.r., 1964, 7, 141-150. journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language development of a g r o u p of hearing impaired children 31 11. mcneill, d., t h e capacity of language acquisition. volta review, 1966, 39, 17-32. 12. menyuk, p., alteration of rules in children's grammar. journal of verbal learning and verbal behavior, 1964, 3, 480-488. 13. , syntactic rules used by children from preschool through first grade. j child development, 1964, 533-546. 14. , comparison of grammar of children with functionally deviant and normal speech. j.s.h.r., 1964, 7, 109-121. 15. miller, w., ervin, s., t h e development of child grammar in child language. m o n . soc. res. child development, 1964, 29. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 85 spraakklankdistorsie by neuromotoriese spraakafwykings: 'n vergelyking tussen serebellere disartrie en verbale apraksie isna erasmus anita van der merwe emily groenewald departement spraakheelkunde en oudiologie universiteit van pretoria opsomming spraakklankdistorsie word algemeen in die literatuur beskryf as 'n kenmerk van neuromotoriese spraakafwykings soos serebellere disartrie en verbale apraksie. die doel van die studie is 'n vergelykende ondersoek na die temporale en ruimtelike aspekte van spraakklankdistorsie by twee persone met verworwe serebellere disartrie en een persoon met verworwe verbale apraksie. die spraakparameters stemaanvangstyd van die [d], afsluitingsduur van die [d], konsonantduur van die [s] en [i], formante van die [i]en die omvang van akoestiese energie van die [s], is spektrografies ondersoek in 'n aantal uitinge met verskillende klankstrukture. die resultate dui daarop dat ruimtelike en temporale distorsie van artikulatoriese bewegings voorkom by die proefpersone met serebellere disartrie sowel as by die proefpersoon met verbale apraksie. daar is egter verskille opgemerk in die aard en graad van die spraakklankdistorsie by die onderskeie afwykings. die teoretiese implikasies van hierdie verskille word bespreek met verwysing na 'n model van normale spraakproduksie. abstract speech sound distortion is considered to be a salient feature of neuromotor speech disorders such as cerebellar dysarthria and apraxia of speech. the aim of this study was to compare the temporal and spatial aspects of speech of two persons with acquired cerebellar dysarthria and of one person with acquired apraxia of speech. voice onset time of[d], duration of articulatory closure of[d], duration of [s] and [i], formants of [i] and the range of acoustic energy of is] were analysed spectrographically in a number of utterances with various sound structures. the results indicated that spatial and temporal distortion of articulatory movements occurred in all three subjects. however, differences in the nature and degree of speech sound distortion in the two different disorders were observed. the theoretical implications of these differences are discussed with reference to a model of normal speech production. spraakklankdistorsie word algemeen in die literatuur beskryf as 'n kenmerk van neuromotoriese spraakafwykings soos serebellere disartrie en verbale apraksie (brown, darley & aronson,. 1970; kent, netsell & abbs, 1979; itoh & sasanuma, 1984; hardcastle 1987; odell, mcneil, rosenbek & hunter, 1990; odell, mcneil, rosenbek & hunter, 1991). serebellere disartrie en verbale apraksie is egter die resultaat van die aantasting van verskillende neurale dele, wat betrokke is by verskillende stadiums of fases van die spraakproduksieproses. verbale apraksie word tradisioneel gesien as 'n afwyking in spraakprogrammering terwyl disartrie getipeer word as 'n afwyking in die uitvoering van spraakbewegings. daar is egter aanduidings in die literatuur dat serebellere disartrie en verbale apraksie sekere ooreenstemmings toon in die aard van waargenome spraakklankdistorsies soos byvoorbeeld verlenging van woordsegmente, lettergreepspraak en temporale diskoordinasie van spraakstrukt'ure wat by albei afwykings voorkom (kent etal., 1979; kent & rosenbek, 1982). die rede hiervoor is onbekend. vorige akoestiese studies aangaande verbale apraksie en serebellere disartrie het slegs enkele aspekte soos vokaalformante en segmentele duur ondersoek en die vraag ontstaan presies watter temporale en ruimtelike aspekte van distorsie by die twee afwykings ooreenkom en verskil. 'n omvattende, objektiewe akoestiese analise van verskillende fasette van spraakklankproduksie sal distorsie by hierdie afwykings verder toelig. die presiese aard van spraakklankdistorsie kan aanduidings gee van die aard van die twee tipes neuromotoriese afwykings en ook lig werp op die bydrae van die kortikaal-motoriese dele en die serebellum tot die beheer van spraakbewegings. navorsing oor die spesifieke spraakkenmerke van serebellere disartrie en verbale apraksie word hoofsaaklik gekenmerk deur twee eksperimentele ondersoekmetodes. hierdie metodes behels subjektiewe metodes soos bree fonetiese perseptuele transkripsies en objektiewe metodes soos akoestiese analises, elektropalatografiese studies en fibroskopiese studies. vroee subjektiewe ondersoeke die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 86 isna erasmus, anita van der merwe & emily groenewald aangaande serebellere disartrie is hoofsaaklik gerig op simptoombeskrywings. op grond van subjektiewe perseptuele studies word die kenmerkende simptome van serebellere disartrie in drie verbandhoudende hoofsimptoomgroepe verdeel, nl. simptome gekenmerk deur artikulatoriese onakkuraatheid bv. "onpresiese konsonante" en vokaaldistorsies, simptome gekenmerk deur prosodiese oormaat bv. oormatige en gelyke klem, verlengde foneme en stadige spraakspoed en simptome gekenmerk deur fonatories-prosodiese onvermoe bv. monotone spraak, monoluidheid en heesheid (darley, aronson & brown, 1969b; brown et al.,1970). grunwell en huskins (1979) beklemtoon dat hierdie simptome van serebellere disartrie deurlopend teenwoordig is en kumulatief van aard is. hulle beskryf die kumulatiewe aantasting van spraakverstaanbaarheid as 'n tekort aan intonasie en normale ritme met sogenaamde "scanning speech", verlengde konsonante, periodieke foutiewe stemgewing en nasaliteit as resultaat. hierdie perseptuele simptoombeskrywings slaag egter nie altyd daarin om tussen verskillende tipes disartrie te onderskei nie (zyski & weisiger, 1987) en die aard van die afwyking kom ook nie duidelik na vore nie. enkele ondersoeke met objektiewe analisemetodes soos akoestiese en kineradiografiese studies wat die aard van spraaksimptome by serebellere disartrie beter toelig, is uitgevoer. opsommend beskou, is die volgende waarnemings deur kent en netsell (1975) en kent et al. (1979) gemaak : verlengde artikulatoriese beweging van die tong, geringe vokaaldistorsie weens swak anterior-posterior aanpassing van tongposisie, konstante onakkurate artikulasie van dorsale afsluitingsklanke, verlengde segmentduur, gelyke en oormatige klem, afwykende fundamentele frekwensiewaardes en variasie in fundamentele frekwensiewaardes. vanuit hierdie resultate blyk dit dat spraakklankdistorsie 'n kernsimptoom is van serebellere disartrie. studies oor die spraakkenmerke van persone met verbale apraksie is kontroversieel van aard, deels as gevolg van die kwessie van die ontledingsmetode. aanvanklike studies aangaande verbale apraksie het hoofsaaklik gebruik gemaak van subjektiewe, perseptuele analiseprosedures soos distinktiewe eienskapsanalises en gemerktheidsanalises (klich, ireland & weidner, 1979). op grond van hierdie resultate is die kernsimptoom van apraksie dan beskryf as vervangings. nuwe navorsing deur middel van meer objektiewe studiemetodes soos akoestiese ontledings, getroue fonetiese transkripsies, en elektropalatografiese waarnemings dui egter daarop dat alhoewel ware klankvervangings ook deel vorm van die simptoomkompleks van verbale apraksie, baie van die "vervangings" wat in vroee studies gei'dentifiseer is, in werklikheid spraakklankdistorsies was (itoh & sasanuma, 1984; kent & rosenbek, 1983; hardcastle, morgan barry & clark, 1985; van der merwe, uys, loots & grimbeek, 1988; odell et al., 1990; odell et al., 1991). tans word dit algemeen aanvaar dat spraakklankdistorsie 'n kernsimptoom van verbale apraksie is. akoestiese studies van verbale apraksie en studies wat van direkte waarnemingsmetodes van die artikulators gebruik maak, verskaf direkte en meer presiese inligting aangaande afwykende motoriek. uit hierdie studies kan 'n goeie aanduiding verkry word van spraakklankdistorsies by verbale apraksie en die motoriese prosesse daarby betrokke. kent en rosenbek (1983) gee 'n simptoombeskrywing van 'n verbaal-apraktiese spreker op grond van foute gei'dentifiseer tydens akoestiese analises, nl. stadige spraakspoed met verlenging van klankoorgange, vermindering in intensiteitsvariasies oor sillabes heen, stadige en onakkurate beweging na ruimtelike teikens vir konsonanten vokaalproduksie, probleme met tydsberekening en koordinasie van stemgewing met die beweging van ander artikulators, periodieke foute met segmentseleksie of opeenvolging eri inisieringsprobleme. ander akoestiese ondersoeke van verbale apraksie bevestig die resultate van kent en rosenbek (1983) en vind byvoorbeeld ook afwykings in interartikulator-sinchronisasie en verlengde segmentele duur (sands, freeman & harris, 1978; hardcastle, 1987; itoh, sasanuma, tatsumi, murakami, fukusaki & suzuki, 1982; collins, rosenbek & wertz, 1983; kent & mcneil, 1987; van der merwe, uys, loots, grimbeek & jansen, 1989). uit die voorafgaande literatuuroorsig is dit duidelik dat spraakklankdistorsie as kernsimptoom by sowel serebellere disartrie as by verbale apraksie gei'dentifiseer is, maar dat die aard van die spraakklankdistorsies nog nie genoegsaam uitgelig is nie. vergelykende studies tussen verbale apraksie en serebellere disartrie kan meer lig werp op die motoriese aard van moontlike ooreenkomste en verskille in die spraakklankdistorsies. daar bestaan egter weinig sulke studies. in 'n resente perseptuele vergelykende ondersoek tussen serebellere disartrie, verbale apraksie en konduksie-afasie deur middel van objektiewe, getroue fonetiese transkripsies is kortliks gevind dat die persone met verbale apraksie en serebellere disartrie as 'n groep meer ooreenkomste toon met mekaar as met konduksie-afasie (odell et al., 1991). die verbale apraksie groep het egter minder distorsies vertoon as die serebellere disartrie groep, nl. 64% teenoor 81%, asook meer sillabeklemfoute en verlengings van intersegment klankoorgange. geen aanduiding word egter verskaf van die bewegingsaspekte betrokke by die waargenome foute nie. kent en rosenbek (1982) vind in 'n vergelykende akoestiese ondersoek dat sprekers met verbale apraksie sowel as sprekers met serebellere disartrie prosodiese afwykings soos artikulatoriese verlengings en sillabesegregrasie toon en verduidelik dit as die resultaatl van kompensasie vir die neuromotoriese aantasting. gillmer en van der merwe (1983) vind dat sowel sprekers 'met serebellere disartrie as sprekers met verbale apraksie afwykende stemaanvangstydwaardes (sat) vertoon en dat sat-waardes meer gevarieer het vir die sprekers met serebellere disartrie. weens 'n tekort aan objektiewe vergelykende studies en die feit dat bestaande studies slegs enkele spraakparameters ondersoek het, is daar tans steeds 'n tekort aan omvattende inligting betreffende die aard en omvang van spraakklankdistorsie by die onderskeie afwykings asook verklarings vir moontlike ooreenkomste. spraaksimptome soos spraakklankdistorsie wat na spesifieke neurale aantasting voorkom, kan gedeeltelik verklaar word aan die hand van kennis oor/die funksie van die betrokke aangetaste neurale deel. verbale apraksie en serebellere disartrie verteenwoordig letsels in verskillende dele en op verskillende vlakke van die brein. serebellere disartrie word met aantasting van die serebellum in verband gebring (kent & netsell, 1975; kent et al., 1979, grunwell & huskins, 1979). ten spyte van uitgebreide navorsing oor die funksies van die serebellum the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) spraakklankdistorsie by neuromotoriese spraakafwykings 87 is daar egter steeds weinig bekend oor die rol daarvan in spraakmotoriek (gentil, 1990). posturale en neuromotoriese simptome geassosieer met serebellere letsels, nl. asinergie, disdiadokokinese van spraakbewegings, intensietremor gedurende beweging en hipotonus van spiere lei tot die ruimtelike en temporale distorsie van spraakbewegings tydens die uitvoerstadium van die spraakproduksieproses (darley, aronson & brown, 1969a). daar is egter aanduidings in die literatuur dat die serebellum ook betrokke is by hoevlak motoriese programmering van liggaamsbeweging deur middel van 'n oop serebro-serebellere kringbaansisteem (allen & tsukahara, 1974; brooks, 1986). vanuit so 'n teorie kan daar geredeneer word dat alhoewel die serebellum en die motoriese korteks nie dieselfde funksies in die motoriese beheer van spraak vervul nie, aantasting van albei areas moontlik kan lei tot probleme met die voorbereiding van 'n "motoriese program" vir spraakproduksie (kent & rosenbek, 1982). tradisioneel word die spraakproduksieproses beskryf as bestaande uit hoofsaaklik drie vlakke, nl. linguistiese enkodering, artikulatoriese programmering en laastens die uitvoer van bewegings (itoh & sasanuma, 1984). in die lig van die neurofisiologiese onderskeid wat gemaak word tussen motoriese beplanning en programmering, verskaf hierdie tradisionele model nie genoegsame verklarings en interpretasiemoontlikhede vir navorsing aangaande neuromotoriese spraakafwykings nie. van der merwe (1994) postuleer dat daar vier hoofvlakke van spraakproduksie bestaan, nl. linguisties-simboliese beplanning, motoriese beplanning, motoriese programmering en uitvoer van beweging. van der merwe (1994) maak dus, in teenstelling met die huidige tendens in literatuur van neuromotoriese spraakafwykings om "beplanning" en "programmering" as dieselfde begrip te hanteer, 'n duidelike onderskeid tussen hierdie terme. sy postuleer verder dat dit wel moontlik is dat die serebellum sekere progammeringsfunksies vervul in spraak soos die programmering van ruimtelik-temporale bewegingspesifikasies (byvoorbeeld spoed en tonus) voordat wcrklike bewegings plaasviiid, maar dat hierdie programmeringsfunksies verskil van' die beplanningsfunksies van die assosiasie-areas tydenjs spraakproduksie. brooks (1986) se uiteensetting van die motoriese hierargie bevestig so 'n teorie. op grond van die model van van der merwe (1994) is dit dus moontlik dat spraakklankdistorsie by serebellere disartrie die) resultaat kan wees van die aantasting van beide die uitvoeren programmeringsvlakke van die spraakproduksieproses. alhoewel daar nog nie uitsluitsel bestaan oor die funksies van kortikale en subkortikale motoriese dele geassosieer met verbale apraksie nie, postuleer van der merwe (1994) dat kortikale dele soos die area van broca, die kortikaal-motoriese assosiasie-areas en ook die posteriorparietale areas betrokke is by die motoriese beplanning van spraakproduksie. verbale apraksie reflekteer dan moontlik probleme met die beplanningsfase van spraakproduksie (van der merwe, 1994). in die geval van subkortikale skade, van veral sekere dele van die basale ganglia wat ook tot apraktiese simptome lei (kertesz, 1984), is dit egter moontlik dat daar ook afwykings in die programmering van spraakbewegings is. volgens die model van van der merwe (1994) kan spraakklankdistorsies by verbale apraksie dus die resultaat wees van probleme met die beplanning van ruimtelik-temporale spesifikasies van struktuurbewegings binne die grense van ekwivalensie asook met die programmering van bewegings. op grond van die model van van der merwe (1994) bestaan daar dus teoreties 'n moontlikheid dat sekere ruimtelike en temporale aspekte van die kernsimptoom spraakklankdistorsie soos wat dit voorkom by serebellere disartrie en verbale apraksie, moontlik kan oorvleuel op die vlak van motoriese programmering. 'n tekort aan uitgebreide, objektiewe, vergelykende navorsing van die spraakkenmerke van persone met serebellere disartrie en verbale apraksie, beperk egter die begrip van afwykende spraakproduksieprosesse betrokke by hierdie twee neuromotoriese spraakafwykings. 'n uitgebreide akoestiese ondersoek na beide die ruimtelike en temporale aspekte van spraakklankdistorsie by serebellere disartrie en verbale apraksie, binne 'n omvattende teoretiese model, kan dus meer lig werp op die aard van hierdie neuromotoriese spraakafwykings. metode doelstellings die doel van die studie is die akoestiese ontleding van sekere spraakparameters in die spraak van persone met serebellere disartrie en verbale apraksie om so vergelykende data in te samel aangaande die voorkoms en aard van akoesties identifiseerbare spraakklankdistorsie by die onderskeie groepe. om die akoestiese identifikasie van die aard van spraakklankdistorsie moontlik te maak, word die volgende betroubare en akoesties identifiseerbare spraakparameters van normale sprekers, sprekers met serebellere disartrie en sprekers met verbale apraksie telkens ondersoek en vergelyk: die spraakparameter stemaanvangstyd (sat) soos gemeet tydens die produksie van 'n stemhebbende eksplosiewe klank, aangesien stemaanvangstyd 'n aanduiding verskaf van die sinchronisasie van glottale sluiting en supraglottale artikulasie (tyler & waterson, 1991). die spraakparameter afsluitingsduur soos gemeet tydens die produksie van 'n stemhebbende eksplosiewe klank, aangesien afsluitingsduur temporale aspekte van spraakproduksie, soos die spoed van artikulatoriese beweging'en ruimtelike aspekte soos die omvang en akkuraatheid van artikulasiebewegings reflekteer. die spraakparameter konsonantduur soos gemeet tydens die produksie van 'n frikatiewe klank en 'n kontinuante klank, aangesien konsonantduur temporale aspekte van spraakproduksie soos die spoed van artikulatoriese bewegings reflekteer. die spraakparameters formantfrekwensiewaardes van die eerste, tweede en derde formante van 'n kontinuante klank, aangesien formantwaardes ruimtelike aspekte van spraakproduksie soos die omvang en akkuraatheid van artikulatoriese bewegings reflekteer. die spraakparameter aard van die energiespektrum soos gemeet tydens die produksie van 'n frikatiewe klank, aangesien frekwensie-omvang en plek van gekonsentreerde energie ruimtelike aspekte van spraakdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 88 isna erasmus, anita van der merwe & emily groenewald produksie soos die omvang en akkuraatheid van artikulasiebewegings reflekteer. proefpersone kriteria vir die seleksie van proefpersone en kontrolepersone die volgende algemene kriteria is gestel: die persone se taalbegrip, ouditiewe begripsvermoens en visuele vermoens moet van so 'n aard wees dat die persoon die instruksies verstaan en die materiaal kan lees. die proefpersone moet nie 'n binourale gehoorverlies van groter as 12% he nie aangesien 'n groot gehoorverlies 'n invloed op spraak kan he. proefpersone met serebellere disartrie: die proefpersone moet deur 'n neuroloog gediagnoseer wees as breinbeseerd met serebellere skade. die neuromotoriese aantasting moet so suiwer as moontlik tot die serebellum beperk wees. die proefpersone moet disartriese spraak vertoon. die sprekers moet gepaardgaande kenmerkende liggaamlike neuromotoriese simptome toon ter bevestiging van serebellere skade bv. ataksie, dismetrie, disdiadokokinese, intensietremor en hipotonie. proefpersone met verbale apraksie: die proefpersone moet deur 'n neuroloog gediagnoseer wees as breinbeseerd met 'n fokale letsel wat nie 'n serebellere lokalisasie het nie. die proefpersone moet verkieslik 'n suiwer verworwe verbale apraksie vertoon en indien 'n gepaardgaande afasie voorkom mag dit slegs minimaal wees. die proefpersone moet voldoen aan kriteria soos gestel deur kent en rosenbek (1983) nl: * onvlot spraakproduksie met probeer-en-tref artikulasiebe wegings. * onkonstante foutproduksie by herhaalde produksie van dieselfde woord. * disprosodie. * probleme met inisiering van uitinge. die graad van apraksie moet die herhaling van uitinge moontlik maak. geen gepaardgaande disartriesimptome mag voorkom nie. kontrolepersone: die kontrolepersone moet normaalsprekende volwassenes wees wat geen spraakafwykings of geskiedenis van spraakof neurologiese afwykings het nie. die kontrolepersone moet: van dieselfde geslag as die proefpersone wees; binne die ouderdomsgrens van die proefpersone val; moet dieselfde spreektaal as die proefpersone he. geselekteerde proefpersone en kontrolepersone proefpersone met serebellere disartrie: twee sprekers met verworwe serebellere disartrie wat voldoen aan die vasgestelde vereistes is gevind. proefpersoon 1 (pp 1) is 'n manlike spreker wat na 'n motorongeluk in 1979 algemene geringe breinskade en ernstige serebellere skade opgedoen het. hy toon tans neuromotoriese liggaamlike simptome soos ataksie, dismetrie, hipotonie, disdiadokokinese en intensietremor. proefpersoon 2 (pp 2) is 'n manlike spreker wat ongeveer in 1989 ligte tekens begin toon het van balansprobleme. die oorsaak van die aantasting is in maart 1992 gediagnoseer as serebellere degenerasie weens veelvuldige sklerose. veelvuldige sklerose neem meestal oorsprong in die serebellum (bannister, 1973). alhoewel veelvuldige sklerose geleidelik 'n gemengde neurologiese toestand tot gevolg kan he, toon pp 2 slegs kenmerkende liggaamlike neurologiese simptome van 'n serebellere aard. proefpersoon 2 se algemene graad van aantasting blyk groter te wees as die van pp 1, aangesien pp 2 'n erger graad van liggaamlike simptome vertoon as pp 2 en ook meer disartries voorkom. proefpersoon met verbale apraksie: een persoon met verworwe verbale apraksie wat voldoen aan die vasgestelde vereistes is gevind. die spreker met verbale apraksie is 'n manlike spreker, proefpersoon 3 (pp 3), wat 'n gepaardgaande minimale broca afasie vertoon (aq=64) volgens die western aphasia battery (kertesz, 1982). proefpersoon 3 het verworwe breinskade opgedoen as die resultaat van twee serebro-vaskulere insidente onderskeidelik in 1984 en 1989. infarksies het voorgekom in die anterior been van die linker interne kapsula en in die regter oksipitale gebied. die spreker toon 'n regsydige hemiplegie maar daar is geen aanduiding van 'n waarneembare boonste motorneuron gesigof tongparese nie. proefpersoon 3 toon verbale apraksie in 'n erge graad maar is in staat tot nabootsing van woorde. tydens spraak kom duidelike soekbewegings en worstelgedrag voor, asook pogings tot selfkorreksie, onkonstante distorsies en vervangings, en onkonstante prodiiksies met die herhaling van uitinge. ; ι i ι i materiaal | ι die materiaal is so gekies dat dit die omvattende ruimtelike en temporale ondersoek van spraakklank-, distorsie in 'n verskeidenheid van kontekste moontlik maak, om sodoende 'n meer verteenwoordigende beeld te verkry van spraakproduksie by die onderskeie diagnostiese groepe. die materiaal is saamgestel deur die kontinuante klank [1], die stemhebbende eksplosiewe klank [d] en die frikatiewe klank [s] te varieer in die inisiele en mediale klankposisies van onsineenhede en woorde,binne sinsverband met 'n kvkven kvkvk-struktuur onderskeidelik. die klanke is gekies omdat dit verskillende wyses van artikulasie verteenwoordig en akoesties maklik identifiseerbaar is. die vokaal [a:] is telkens met die klanke in die onsineenhede gekombineer en is soos die ander klanke in die woorde en sinne lukraak gekies. twee verskillende klankstrukture is gekies om so spraakthe south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) spraakklankdistorsie by neuromotoriese spraakafwykings 89 klankdistorsie in materiaal van verskillende uitinglengte te ondersoek. die materiaal bestaan uit 12 onsineenhede en 10 woorde binne sinsverband. die onsineenhede is telkens 5 keer herhaal en die sinne drie keer. in totaal het elke persoon dus 90 uitinge geproduseer. tabel 1 gee 'n volledige uiteensetting van die wyse van die samestelling van die teikenmateriaal en die gemete spraakparameters binne elke uiting. tabel 1. samestelling van die teikenmateriaal en die gemete spraakparameters binne elke uiting 1 . 1 klank [d] konteks klankkombinasie klankposisie parameters materiaal onsinwoorde kvkv inisieel sat data onsinwoorde kvkv mediaal ad sada onsinwoorde kvkvk inisieel sat dadaf onsinwoorde kvkvk mediaal ad sadaf sinne kvkvk inisieel sat dames sinne kvkvk mediaal ad dadel 1.2 klank [s] konteks klankkombinasie klankposisie 1 parameters materiaal / / onsinwoorde inisieel kd fo piek sasa / / onsinwoorde kvkv mediajal kd fo piek dasa / / onsinwoorde inisieel kd fo piek sasaf / / onsinwoorde kvkvk media'al 1 kd fo piek dasaf sinne inisieel kd fo piek sabel sinne ivvjvvk / 1.3 klank [i] konteks klankkombinasie klankposisie parameters materiaal onsinwoorde kvkv insieel kd f1-f3 lala onsinwoorde kvkv mediaal kd f1-f3 dala onsinwoorde kvkvk inisieel kd f1-f3 lalaf onsinwoorde kvkvk mediaal kd f1-f3 dalaf sinne kvkvk inisieel kd f1-f3 laken sinne kvkvk apparaat opname-apparaat 'n nakamichi 550 "versatile stereo casette system". 'n bever dynamic μ 201 n(c) mikrofoon. basf c h r o m e maxima 60 m i n u t e m a g n e e t bandkasette. analise-apparaat 'n nakamitchi 550 kassetspeler is gebruik om die spraaksein soos opgeneem op basf chrome maxima magneetbandkassette na die kay dsp sonagraph te stuur. die spraaksein kan met behulp van die jbl pro iii luidsprekers gemonitor word. die spraaksein word geanaliseer deur 'n digitale seinprosesseerder van kay elemetrics corp. nl. sonagraph model 5500 en vertoon op 'n nec multisync ii vertoonskerm. drie verskillende toepaslike opstellings is vir die onderskeie analises gebruik. 'n weergawe van die beeld wat op die skerm verskyn kan met behulp van 'n termiese drukker, kay dsp drukker model 5510 verkry word. prosedure vir spraakseinopname die spraakopnames is in die klankdigte opnamelokaal van die taallaboratorium van die universiteit van pretoria gedoen. die mikrofoon is op 'n afstand van 10 cm voor die persoon se mond geposisioneer om ekspirasiegeraas op die opname tot die minimum te beperk. die materiaal is vooraf aan die persone gegee om deur te lees sodat hulle bekend kon raak daarmee. die volgorde van die materiaal is konstant gehou vir al die sprekers. die proefpersone is gevra om elke woord vyf keer direk na mekaar te herhaal en elke sin drie keer. vir die verbaal-apraktiese spreker is die opname effens gewysig deurdat die proefpersoon die geleentheid gegee is om die uiting 'n paar keer te oefen (kent & rosenbek, 1983). daar is deurentyd 'n opname gemaak totdat vyf produksies van elke uiting verkry is. analise van data analise van die spraakparameter stemaanvangstyd (sat) vir die meting van sat is 'n analise-opstelling met 'n gekombineerde vertoning bestaande uit 'n golfvorm met 'n amplitudeverloop en 'n grondtoonverloop sowel as 'n spektrogram gebruik. by die bepaling van satwaardes is die twee vertonings voortdurend vergelyk om sodoende die betroubaarheid van metings te verhoog. 'n positiewe stemaanvangstyd word gedefinieer as die tyd wat verloop vanaf die aanvang van die vrylating van ploffing tot by die aanvang van die eerste die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 90 isna erasmus, anita van der merwe & emily groenewald vertikale striasie op die spektrogram wat glottale pulsering verteenwoordig (lisker en abramson, 1964). sat-waardes le op 'n kontinuum en kan positiewe en negatiewe waardes aanneem. in die geval van 'n negatiewe sat-waarde gaan glottale pulserings die ploffing vooraf en word die meting gedoen vanaf die aanvang van glottale pulserings tot by die ploffingsgedeelte. analise van die spraakparameter afsluitingsduur afsluitingsduur is gedefinieer as die periode in millisekondes wat verloop vanaf die einde van die voorafgaande vokaal tot voor die aanvang van die ploffing van die eksplosief. wanneer daar nie aanduidings van 'n volledige afsluiting waarneembaar was op die golfvorm nie, is die spektrogram gebruik ter vergelyking om so betroubaarheid van metings te verhoog. analise van die spraakparameter-konsonantduur vir die meting van konsonantduur is analise-opstellings gekies wat gelyktydig 'n spektrogram, 'n gekombineerde golfvorm en 'n gemiddelde amplitudespektrum van 'n spesifieke gedeelte van 'n uiting vertoon. die frekwensieomvang van die analise-opstellings het verskil nl. 0-4 khz vir die [1] en 0-16 khz vir die [s]. konsonantduur is gedefinieer as die periode in millisekondes (msek) wat 'n konsonant spektrografies waarneembaar is. analise van die eerste, tweede en derde formantfrekwensiewaardes van die [i] vir die meting van die formantfrekwensiewaardes is dieselfde frekwensie-omvang gekies as wat gebruik is vir die analise van konsonantduur van die [1] (nl. 0-4 khz). die tydkursors op die spektrogram is so geplaas dat dit 'n verteenwoordigende stabiele deel van die [1] afbaken en 'n gemiddelde amplitudespektrum daarvan verkry. met behulp van frekwensiekursors is die formantfrekwensiewaarde vanaf die gemiddelde spektrum bepaal deur die tweede energiepiek as f l , die derde piek as f2 en die vierde piek as f3 te noteer. die gemiddelde amplitude-spektrum en spektrogram is deurentyd vergelyk. analise van die omvang van energie en piek van gekonsentreerde energie van die [s] vir die meting van die omvang van akoestiese energie en piek van gekonsentreerde energie van die [s] is dieselfde opstelling gebruik as by konsonantduur (d.w.s. 0-16 khz). met behulp van tydkursors is 'n verteenwoordigende deel van die [s] op die spektrogram afgebaken en frekwensiekursors geplaas op die onderste en boonste grense. die piek van gekonsentreerde energie is bepaal deur die energiepiek met die hoogste waarde op die amplitudespektrum te identifiseer. waar twee ewe sterk pieke waargeneem is, is die waarde van die tweede piek van energie genoteer. verwerking van data verwerking van sat-metings vir die berekening van hierdie sat-foutwaarde is satwaardes van -180 millisekondes tot +15 millisekondes (msek) aanvaar as die normale perke (zlatin, 1974). die gemiddelde sat-foutwaarde vir elke groep uitinge van elke persoon is bereken deur die hoeveelheid millisekondes bokant 15 of onder 180 oor die drie herhalings bymekaar te tel en deur drie te deel (van der merwe et al., 1989). hierna is 'n gemiddelde sat-foutwaarde vir elke persoon bereken. 'n gemiddelde sat-foutwaarde vir die onderskeie diagnostiese groepe is vervolgens bereken uit die gemiddelde foutwaardes van die betrokke proef en konrolepersone. verwerkings van afsluitingsduurmetings van die [d] en konsonantduurmetings van die [i] en [s] die resultate van afsluitingsduurmetings van die [d] en konsonantduurmetings vir die [1] en die [s] is telkens op dieselfde wyse verwerk. eerstens is 'n gemiddelde duurwaarde vir die eerste drie herhalings van elke onsineenheid en elke woord van elke persoon bereken. uit die gemiddeldes van elke persoon is tweedens 'n gemiddelde duurwaarde vir elke onsineenheid en elke woord vir die betrokke diagnostiese groepe bereken. uit die gemiddelde duurwaardes van die verskillende onsineenhede is derdens 'n totale gemiddelde duurwaarde vir onsineenhede bereken vir elke diagnostiese groep en vierdens op dieselfde wyse 'n totale gemiddelde duurwaarde vir woorde vir elke diagnostiese groep. laastens is 'n gemiddelde duurwaarde bereken vir elke diagnostiese groep, uit die som van die onderskeie gemiddelde waardes vir onsineenhede en woorde tesame. verwerkings van die resultate van formantfrekwensiewaardes van die [i] die gemete formantfrekwensiewaardes van die eerste drie formante van die [1] is telkens op dieselfde wyse verwerk. eerstens is daar vir elke persoon gemiddelde formantfrekwensiewaardes vir formante een, twee en drie bepaal uit die som van die onderskeie gemete formantfrekwensiewaardes vir onsineenhede,en woorde tesame. tweedens is gemiddelde formantfrekwensiewaardes vir elke formant van elke diagnostiese groep bepaal uit die som van die betrokke gemiddelde formantfrekwensiewaardes van die persone. derdens is forma'ntratio's bepaal vir elke persoon en elke diagnostiese groep vir formant twee teenoor formant een (f2:f1) en vir formant drie teenoor formant een (f3:f1) volgens die metode van dalston (in baken en daniloff, 1991). verwerking van die resultate van omvang van akoestiese energie en die piek van gekonsentreerde energie van die [s] / / vir die bepaling van die omvang van akoestiese energie is die gemiddelde mininmm en maksimum frekwensiewaardes van elke persoon en elke diagnostiese groep bereken. die gemiddelde minimum en maksimum frekwensiewaardes van elke persoon is bereken uit die the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) spraakklankdistorsie by neuromotoriese spraakafwykings 91 som van die gemete onderskeie minimum en maksimum frekwensiewaardes van onsineenhede en woorde tesame. uit hierdie persoongemiddeldes is vervolgens gemiddelde minimum en maksimum frekwensiewaardes vir die onderskeie diagnostiese groepe bepaal. persoonen diagnostiese groepgemiddeldes is verder op dieselfde wyse bereken vir die piek van gekonsentreerde energie van die [s], resultate en bespreking resultate en bespreking van stemaanvangstydmetings die resultate van hierdie spraakparameter dui op verskille in die aard van die waargenome spraakklankdistorsie by die onderskeie afwykings. figuur 1 illustreer die gemiddelde sat-foutwaardes van die verskillende diagnostiese groepe. die verbaal-apraktiese spreker toon die grootste foutwaarde (nl.14.8) van die verskillende groepe. gemiddelde sat-foutwaarde 14 12 normaal czh 3fb*m9 oturu· • • v«fbat* apimksw s.o. diagnostiese groepe v.a. figuur 1. gemiddelde sat-foutwaardes van die ' onderskeie diagnostiese groepe. / i / ι ontleding van die sat-data toon dat die serebellere disartriesprekers se sat-resultate konstant afwykend negatiewe sat-waardes toon by pp 2 terwyl pp 1 se waardes rondom die normale perke sentreer. teoreties beskou impliseer 'n negatiewe sat-waarde dat fonasie 'n aanvang neem voordat die lugvrylating vir afsluitingsklankproduksie plaasvind (lisker & abramson, 1964). produksie van die [d] vereis hoofsaaklik integrasie van produksiekomponente soos stemgewing, velere en alveolere sluiting om die opbou van lugdruk moontlik te maak en verder verbreking van die alveolere afsluiting met gevolglike ploffingsproduksie. by nadere ondersoek blyk dit egter dat die gemete negatiewe sat-waardes en waarneembare stemvoorloop by pp 2 die resultaat is van η perseptueel hoorbare nasalering van die aanvangsklank asook swak afsluitings en ploffingsproduksie w;at meting bemoeilik het (sien resultate aangaande afsluitingsduurmetings vir verdere toeligting). stemgewing by pp 2 is dus wel akkuraat in tyd, maar blyk skynbaar afwykend negatief te wees weens genasaleerde aanvangsdistorsie van die [d], omdat duidelike afsluitingsproduksie nie plaasgevind het nie. dit blyk dus asof die aanvang van die ploffingsgedeelte vertraag is, moontlik weens swak velere sluiting as gevolg van'hipotonie of onwillekeurige bewegings. daar is dus sprake van swak interartikulatorsinchronisasie weens stadige velere sluiting en nie weens stadige inisiering van stemgewing nie. die resultate dui dus moontlik op intakte beplanning van die artikulatoriese bewegings maar op probleme met die uitvoer van die beplande bewegings. die feit dat pp 1 nie soortgelyke afwykende satresultate vertoon as pp 2 nie, is moontlik 'n aanduiding dat die sat-afwykings by die serebellere disartriesprekers direk verband hou met die erns van die aantasting. kent et al. (1979) vind ooreenstemmende resultate deurdat satwaardes van klanke soos die [t], [p] en [k]-klanke verleng word namate die graad van aantasting toeneem. die verbaal-apraktiese spreker in die huidige studie toon in teenstelling met die serebellere disartriesprekers 'n hoe sat-foutwaarde en ook slegs sat-waardes van 'n positiewe aard. die positiewe sat-waarde dui daarop dat glottale pulserings (d.w.s. fonasie) 'n aanvang neem nadat die ploffing van die afsluiting vir die [d] geproduseer is. die vertraging in stemgewing by pp 3 reflekteer moontlik probleme met die temporale interartikulator-sinchronisasie van tongbeweging en glottale sluiting wat 'n spektrografies waarneembare distorsie van die [d] as byna 'n [t] tot gevolg het. aangesien die sat-waardes van die spreker in hierdie studie nooit die gegewe positiewe satwaarde van +40 msek (zlatin, 1974) vir stemlose klanke bereik het nie ('n gemiddelde sat-waarde van 26.6 msek kom voor), kan die afleiding gemaak word dat die spreker nie die [d] fonologies vervang het met 'n [t] nie en dat 'n spraakklankdistorsie eerder teenwoordig is. soortgelyke afleidings is deur van der merwe et al. (1989) gemaak. die sat-resultate van die verbaal-apraktiese spreker in die huidige studie stem ooreen met bevindinge van freeman, sands en harris (1978) naamlik dat sprekers met verbale apraksie geen stemvoorlope vir stemhebbende afsluitingsklanke het nie. navorsing toon oor die algemeen dat stemhebbende klanke meer stemloos gemaak word deur verbaal-apraktiese sprekers as omgekeerd (wertz, lapointe en rosenbek, 1984). kent en rosenbek (1983) vind in teenstelling met huidige bevindinge sat-foute van 'n groot negatiewe aard by sommige van hul proefpersone en wys daarop dat probleme met koordinasie en tydsberekening akoesties verskillend manifesteer by verskillende verbaal-apraktiese sprekers. daar kan gespekuleer word dat verbaal-apraktiese sprekers moontlik ideosinkratiese aantasting van sinchronisasie van fonasie en artikulasie vertoon en dat sat-foute, alhoewel dit voorkom by verbaal-apraktiese sprekers, onvoorspelbaar is in terme van die aard van die sat-foute (freeman et al., 1978; van der merwe et al., 1989). daar moet egter in gedagte gehou word dat slegs data van een verbaal-apraktiese spreker in die huidige studie beskikbaar is, wat dus spekulasies hieromtrent aansienlik beperk. resultate van afsluitingsduurmetings figuur 2 toon dat die serebellere disartriesprekers se gemiddelde afsluitingsduurwaarde (nl. 0.09 sek) gering korter is as die van die normale sprekers (nl. 0.1 sek) terwyl die verbaal-apraktiese spreker die langste afsluitingsduurwaarde vertoon (nl. 0.49 sek). dis insiggewend dat die produksie van 'n swak alveolere afsluiting vir die [d], waarneembaar is by beide serebellere disartriesprekers. spektrografiese ontleding toon dat feitlik geen onderbreking in glottale pulserings met die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 92 isna erasmus, anita van der merwe & emily groenewald 0.θ 0.7 0.θ" 0.5 0.4 0.3 0.2 0.1 afsluitingsduur (sek.) q«m. in onelneenhede i / j gem. in woord· γπ qxnkkmcl· duui η normaal s.d. v a diagnostiese groepe figuur 2. gemiddelde afsluitingsduurwaardes van die [d] van die onderskeie diagnostiese groepe, soos bereken vir onsineenhede, woorde en vir woorde en onsineenhede tesame. aanduidings van 'n ploffing waarneembaar is op die golfvorm nie, terwyl die spektrogram ook 'n mate van aaneenlopendheid in die formante vertoon. die aaneenlopende teenwoordigheid van glottale pulserings en energie op die spektrogram bemoeilik dus die bepaling van die afsluitingsgedeelte van die [d] in die woord en het tot gevolg dat verkorte tot normale afsluitingsduur gemeet word by die serebellere disartriesprekers. hierdie tendens dra dus by tot die gemete negatiewe sat-waardes by veral pp 2. proefpersoon 2 se sat-waardes was gevolglik in twee van die totaal van nege uitinge nie meetbaar nie, weens die feit dat 'n duidelike ploffing vir die [d] nie teenwoordig was nie. die resultate en afleidings van die huidige studie aangaande swak afsluitingsklankproduksie by die serebellere disartriesprekers word ondersteun deur die resultate van vorige studies. kent en netsell (1975) vind konstante afsluitingsklankdistorsie van die [t]-, [d]en [g]-klanke deur serebellere disartriesprekers deurdat die afsluitingsgedeelte van die klank of weggelaat word, (waarskynlik waarneembaar as 'n vokaalagtige distorsie), of met 'n frikatiewe kwaliteit geproduseer word. hulle rapporteer ook 'n afwesigheid van 'n prominente ploffing van die [g]-klank en skryf dit toe aan 'n onvermoe van die tong om kontak te maak met die alveolere rif weens onvoldoende spierkrag of onwillekeurige bewegings. hierdie resultate dui moontlik op probleme op 'n uitvoervlak van spraakproduksie. dis egter ook moontlik dat die voorafgaande resultate uitvalle op 'n programmeringsvlak van spraakproduksie kan reflekteer, waartydens daar sprake is van "spier-spesifieke" programmering van omvang en rigting van spraakbewegings (van der merwe, 1994). in teenstelling met die serebellere disartriespreker in die studie (pp 2) toon die verbaal-apraktiese spreker (pp 3) spektrografies beskou 'n duidelike afsluitings of ploffingsgedeelte maar stemgewing en ploffing word "afsonderlik" geproduseer. fonasie neem dus 'n aanvang nadat die afsluiting opgehef is. hierdie resultate dui daarop dat daar nie probleme voorkom met die kwaliteit van afsluitingsproduksie by die verbaal-apraktiese spreker nie. verlengde afsluitingsduurwaardes by verbaalapraktiese sprekers word ook deur ander navorsers gerapporteer (kent & rosenbek, 1983; hardcastle et al., 1985). verlenging van afsluitingsduur by die verbaalapraktiese spreker kan moontlik verklaar word as 'n kompensatoriese reaksie om sodoende meer tyd toe te laat vir die motoriese beplanning van die daaropvolgende bewegingskomponente van die uiting (kent & rosenbek, 1982; 1983). hierdie verklaring word moontlik ondersteun deur die waarneming in die huidige studie dat die verbaalapraktiese spreker langer afsluitingsduurwaardes vir kvkvk-eenhede as vir kvkv-eenhede vertoon. navorsing aangaande die invloed van verskillende kontekste op die spraak van verbaal-apraktiese sprekers dui daarop dat die kvkvk-eenheid vir 'n verbaal-apraktiese spreker moeiliker is om te beplan as die kvkv-eenheid (van der merwe etal., 1988; 1989). langer afsluitingsduurwaardes sou dan moontlik meer tyd toelaat vir die spreker om die uiting te beplan. resultate en bespreking van konsonantduurmetings van die [1] en die [s] figure 3 en 4 illustreer die resultate van konsonantduurmetings. die serebellere disartriesprekers en die verbaal-apraktiese spreker toon volgens die resultate ongeveer dieselfde mate van temporale distorsie by die [l]-klank, deurdat die mate van verlengde kontinuantduur min of meer gelyk is (sien figuur 3). vir die [s]-klank toon die verbaal-apraktiese spreker egter 'n groter mate van temporale distorsie as die serebellere disartriesprekers. die serebellere disartriesprekers toon volgens die konsonantduur (sek.) gem. in onelneenhede i / j gem. in woord· [π gemiddelde duur 0.08 0.08 μ μ μ 01 01 01 01 υ// υ// υ// υ// υ// s.d. diagnostiese groepe figuur 3. gemiddelde konsonantduurwaardes van die [1] van die onderskeie diagnostiese groepe. konsonantduur (sek.) η gem. in onsmeenhede i / j gem. in woord· i i i gemiddelde duur ys.d. · diagnostiese groepe figuur 4. gemiddelde frikatiewe duurwaardes vir die [s] van die'onderskeie diagnostiese groepe. the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) spraakklankdistorsie by neuromotoriese spraak resultate verlengde konsonantduur vir beide die [1] en die [s]-klanke. verlengde segmentele duur by sprekers met serebellere disartrie is ook deur ander navorsers bevind (kent & netsell, 1975; kent et al., 1979; kent & rosenbek, 1982). die huidige resultate stem ooreen met die van kent et al., (1979) wat verlengde konsonantduur ooreenkomstig die graad van aantasting vind by serebellere disartriesprekers. temporale distorsie in die vorm van verlengde konsonantduur by die serebellere disartriesprekers kan eerstens verklaar word as die direkte gevolg van neuromotoriese simptome soos hipotonie, ataksie en onwillekeurige bewegings wat 'n afname in die spoed van bewegings kan veroorsaak (grunwell & huskins, 1979) en dus moontlik probleme op 'n uitvoervlak van spraakproduksie reflekteer. tweedens kan verlengde duur beskou word as die resultaat van kompensasie vir die onderliggende simptome, om sodoende meer tyd toe te laat vir die evaluasie van terugvoer aangaande die posisies en bewegings van die artikulators (kent & rosenbek, 1982). kent et al., (1979) noem in aansluiting by so 'n beskouing dat wanneer sprekers met serebellere disartrie genoeg tyd tot hulle beskikking het, hulle toepaslike artikulatoriese posisies kan bereik. in die huidige studie vertoon pp 1 duurwaardes langer as die normale vir die [1] maar by die frikatiewe [s]-klank kom distorsie voor in die vorm van duurwaardes korter as die normale. kent et al., (1979) rapporteer ook duurwaardes kleiner as die normale vir die [s]-klank vir persone met minder ernstige serebellere disartrie maar verskaf geen ander verklaring daarvoor as die graad van aantasting nie. daar kan gespekuleer word dat pp 1 moontlik as gevolg van 'n unieke kompensasiewyse spraak vinniger as die normale produseer of dat vinniger as normale [s]-produksie 'n unieke spraakkenmerk van die persoon was voordat die verworwe spraakafwyking ingetree het. formele metings van spraakspoed en uitinglengte is egter nie beskikbaar ter verdere uitbreiding van die spekulasies rondom spraakspoed nie. metings van die akoestiese omvang van energie van die [s] het egter meer lig gewerp op die artikulasie-eienskappe van die [s] (sien verdere bespreking). j die verbaal-apraktiese spreker toon ook soos die serebellere disartriesprekersjtemporale distorsie van die [s] maar verskille in die aard en graad daarvan is opgemerk. 'n groter mate van temporale spraakklankdistorsie kom voor by die [s] van die verbaalapraktiese spreker deurdat duurwaardes groter is as die waardes van die serebellere disartriesprekers en die normale waardes (sien figuur 4). hierdie resultaat stem ooreen met algemene bevindinge dat verbaal-apraktiese sprekers verlengings van woordsegmente toon (kent & rosenbek, 1983; kent & mcneil, 1987; van der merwe et al., 1989). navorsers soos kent en mcneil (1987) voer aan dat verlengde segmentele en intersegmentele duur by verbaal-apraktiese sprekers die direkte resultaat kan wees van foutiewe fonetiesmotoriese kodering van die uiting. ander outeurs beskou weer verlengde segmentele duur teoreties as 'n kompensatoriese metode (kent & rosenbek, 1982; van der merwe et al., 1989). 'n interessante spektrografiese waarneming by duurmetings van die verbaal-apraktiese spreker is die konstante voorkoms van intersillabe-pouserings, selfs waar normale duurwaardes bereik is. in teenstelling hiermee het intersillabe-pouserings nooit by die serebellere disartriesprekers voorgekom nie en is aaneenlopende i n g s 93 produksies sonder duidelike afslui tings eerder opgemerk. kent en mcneil (1987) vind in ooreenstemming met hierdie resultate intersegmentduur langer as die normale by verbaal-apraktiese sprekers. hierdie bevindinge vind dus tot 'n mate aansluiting by die teorie dat intersillabepouserings as 'n kompensatoriese metode gebruik word. 'n verdere interessante waarneming wat by die duurmetings van die [s] sowel as die [l]-klank van die verbaal-apraktiese spreker waarneembaar is en nie by die sprekers met serebellere disartrie voorkom nie, is dat die verbaal-apraktiese spreker gering groter duurwaardes vir kvkvk-eenhede vertoon as vir kvkv-eenhede. van der merwe et al., (1989) vind ooreenstemmende groter duurwaardes vir kvkvk-eenhede as vir kvkv-eenhede by verbaal-apraktiese sprekers. kontekste wat moontlik hoer eise aan die spreker stel in terme van motoriese beplanning het dus moontlik verlengde duur tot gevolg (van der merwe et al., 1989). die afleiding kan dus gemaak word dat die verbaal-apraktiese spreker in die huidige studie ook moontlik probleme vertoon met die beplanning van spraak. resultate en bespreking van die meting van die omvang van akoestiese energie van die [s]-klank figuur 5 illustreer die bevindinge van die meting van die omvang van akoestiese energie van die [s]-klank. 1 2 3 4 6 8 7 8 9 1 0 11 12 frakwenaie ( k h z ) figuur 5. gemiddelde minimum en maksimum frekwensie-waardes en piek van gekonsentreerde energie vir die [s] van die verskillende diagnostiese groepe. die moontlikheid dat unieke [s]-produksie by ppl voorkom, word verder ondersteun deur resultate van die meting van die omvang van akoestiese energie by die [s] van ppl. die serebellere disartriesprekers as groep vertoon ruimtelike distorsie van die [s] deurdat die omvang van die [s] skuif na 'n effens kleiner waarde met die minimum waarde meer afwykend as die maksimum waarde (sien figuur 5). 'n verlaging in die minimum frekwensiewaardes van die [s] kan moontlik dui op 'n verminderde konstriksie vir [s]-produksie. proefpersoon 1 toon 'n gering groter omvang van akoestiese energie as pp 2 wat daarop kan dui dat 'n groter mate van [s]-distorsie voorkom by pp 1 ten spyte van normale en korter as normale duurwaardes. proefpersoon 1 toon dus 'n groter mate van ruimtelike spraakklankdistorsie vir die [s]-klank as pp 2, terwyl pp 2 weer 'n groter mate van temporale spraakklankdistorsie vir die [s] vertoon. die omvang en akkuraatheid van die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 94 artikulatoriese bewegings is dus moontlik by die s t n n : r r i e r p r e k e r s ^ ^ ^ — e n k o l i d graad van neuromotoriese simptome daar ^ die voorkoms van spraakklankdistorsie * sen*el,ere disartriesprekers, d e ^ d i e n ^ ng van akoestiese energie heelwat wyer is as die o m z g van x normale en serebellere disartriesprekers (sien ^ u r 5 ) η afname in die algemene intensiteit van die ui c k o m ook voor, wat spektrografies waarneembaar s at ^ akoestiese energie kan die gevolg wees van 'n z ^ ^ mg ν k o n s t r i k s i e t y d j apraktiese spreker vertoon dus moontlik probleme met die fyn posisionering van die a r t i l r n l ^ p r o m e , m e m e t gekanaliseerde lugstroom te verseke^ kent ^ (1983) postuleer l p r o ^ z t t ^ z s u , ? waar min,f«n 4. , teorie van motoriese kontrole waar ruimtelik-temporale skemata "or abstract <mai= space and time" (kent & rosenbek 1983 η 24fi s s s ^ s s s 3 ^ omvang en rietintr van κ p r o b l e m e het om die ^ s i k s s ^ s k i s o a e r a s m u ' · a » " · merwe 4 e m i l y g r o e „ e „ . , „ h l ' m " * ' ' e e p r e k i n g v „ f o r „ . „ t n e t i n g i 1 v < 1 1 vanaf die „ „ r die perseptuele identifikasie v l jf ̂ ^ d e l i k vir (pickett, 1980) a n d l e k l a n k a s η π] nie tf^r 7' — sprekers deurdat f3'η v e r l l ^ ? s e r f b e l l e r e disartrieg . e m i d d e l d e f«rmantfrekwensiewaardes vir formante een, twee en drie van die f l w a n s onderskeie diagnostiese groepe * s f f i e ' s 7 ? 3 8 a l l 0 f 0 n i e s e -ariasie van die [1] (pickett s s s s s s s s n ver, (sien figuur 6). die ρ 3 ^ γ ν 3 ν " γ ξ 3 1 nop™a e e ; : ; r e n 7 a h e g t e r * * * * ^ n n e d i e n v p r u i m t e i i k e f3-waarde van dte γίτι' % ? η 3 η ι β l n gemiddelde kwaliteit van nfi'f· ° ° ° k g e a s s o s i e e r word met ssmmm formante van die γπ na aan • d l e / · ' algemene bespreking resultate dui dus^p ^ s ^ x s ^ t ~ u u , l ( i 1 1 g e i 1 the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) spraakklankdistorsie by neuromotoriese spraakafwykings 95 akkuraatheid van artikulatoriese bewegings as sulks. die ruimtelike bewegingsafwykings is moontlik die resultaat van onderliggende neuromotoriese probleme soos versteurde spiertonus en onwillekeurige bewegings en blyk ook verband te hou met die graad van serebellere aantasting. hierdie resultate kan afwykings in uitvoer en programmering van spraakbewegings reflekteer. die verbaal-apraktiese spreker daarteenoor is moontlik wel in staat tot akkurate artikulatoriese bewegings aangesien goeie kwaliteit alveolere en velere afsluitings voorkom by sat-metings. dit blyk dus asof probleme met die temporale beplanning van produksiekomponente van die [d] lei tot vertraagde stemgewing by die verbaalapraktiese spreker en nie afwykings in die bewegings self nie. hierdie afleiding word bevestig deur bevindinge van hardcastle (1987) aangaande bewegingsaspekte in die spraak van verbaal-apraktiese sprekers, naamlik: "the component gestures were thus normal spatially: what was disturbed was their temporal integration and their occurrence at inappropriate places" (hardcastle, 1987, p. 126). afwykings in konsonantduur van die [1] en die [s] is by die sprekers met serebellere disartrie sowel as by die spreker met verbale apraksie opgemerk. die serebellere disartriesprekers toon verlengde duur ooreenkomstig die graad van aantasting moontlik weens probleme met die uitvoer van spraakbewegings. die verbaal-apraktiese spreker toon 'n groter mate van temporale distorsie vir die [s] as die serebellere disartriesprekers, intersillabe pouserings en langer duurwaardes vir kvkvk-eenhede as vir kvkv-eenhede, wat alles moontlik voorkom as die direkte gevolg van of as kompensasie vir 'n onderliggende beplanningsprobleem. die moontlikheid van 'n bydraende probleem in programmering is nie uitgesluit nie, veral in die lig van die subkortikale skade van die proefpersoon. die serebellere disartriesprekers sowel as die verbaalapraktiese spreker toon ruimtelike distorsie van die [1] en [s] maar verskille in die aard en graad daarvan kom voor. die verbaal-apraktiese spreker toon 'n groter mate van ruimtelike distorsie vir die [s] en toon ook 'n wyer omvang van akoestiese energie as die 'serebellere disartriesprekers. by die [l]-klank kom 'n verhoging in f3 voor inteenstelling met 'n verlaging in f3 van die serebellere disartriesprekers. ruimtelike distorsie van die [s] en [1] kan probleme met die programmering en uitvoering van spraakbewegings by die serebellere disartriesprekers reflekteer en kan dui op uitvalle met beplanning en programmering van spraakbewegings by die verbaalapraktiese spreker. dis dus moontlik dat serebellere disartriesprekers en die verbaal-apraktiese spreker se ruimtelike spraakklankdistorsie aanduidend kan wees van 'n ooreenstemming op die vlak van motoriese programmering. vanuit die studie is dit duidelik dat daar 'n behoefte bestaan aan 'n omvattende teoretiese raamwerk of model van spraakproduksie waarbinne navorsingsdata ge'interpreteer kan word en waarbinne daar na oplossings vir bestaande vraagstukke rondom neuromotoriese spraakafwykings gesoek kan word. daar bestaan ook 'n behoefte aan verdere vergelykende navorsing binne die verskillende groepe neuromotoriese spraakafwykings om sodoende die kliniese onderskeid tussen simptome wat voorkom weens aantasting van 'n beplannings-, programmeringsen uitvoerstadium van die spraakproduksieproses moontlik te maak. verwysings allen, g.i. & tsukahara, n. 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(1987). identification of dysarthria types based on perceptual analysis. journal of communication disorders, 20, 367-378. / the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 15 the development of precursors to literacy in mentally disabled children debra marais and erna alant department of communication pathology university of pretoria abstract this study aimed to investigate metalinguistic precursors to literacy in mentally handicapped children, with a view to improve literacy training in this population. language proficiency and environmental literacy factors were explored, and an analysis was made of proficiency in several metalinguistic tasks (i.e., higher level language awareness skills). six children who are educable mentally retarted, with mental ages between five and seven years (chronological ages between six and sixteen years) were assessed. results showed that environmental factors of literacy socialisation and print awareness were adequate, with reasonable exposure to literacy artifacts and events. language abilities were also adequately developed. isolated metalinguistic skills (e.g., phonemic segmentation) had developed in those children who had received reading instruction, however, most metalinguistic precursors were not adequately developed for their mental ages and were below a five year level. opsomming hierdie studie het verskeie voorlopers tot geletterdheid ondersoek onder ses verstandelik gestremde hinders, met die oog op verbetering van leesvaardigheid van verstandelik gestremde kinders. die kinders se verstandsouderdomme was almal tussen vyf en sewe jaar, met kronologiese ouderdomme tussen ses en sestien jaar. taalvaardigheid en omgewingsgeletterdheid-faktore is ondersoek, sowel as hulle vaardigheid met die verskillende metalinguistiese take (m.a.w. ho'er kognitiewe taalbewustheid). die bevindinge het bevestig dat omgewingsfaktore van skrifbewustheid voldoende was met aanvaarbare blootstelling aan geskrewe items en leesgebeurtenisse. taalvaardigheid was ook toepaslik. die kinders wat reeds leesinstruksie ontvang het, het ontwikkeling van ge'isoleerde metalinguistiese vaardighede vertoon (bv. fonetiese analise), maar die meerderheid metalinguistiese voorlopers tot geletterdheid was nie toepaslik vir hulle verstandsouderdomme nie en was onder 'n vyfjarige vlak. literacy is not merely an academic pursuit, but has become an essential skill for many employment opportunities, for daily living activities such as shopping and cooking and also for recreation. it is particularly important for mentally disabled people if they are to attain a measure of independent functioning in everyday life (singh & singh, 1986).1 research (riese, 1956 in singh & singh, 1986) which indicated that trainable mentally handicapped people could be taught to read more than a few simple words has led to the reassessment of our expectations and the need to develop appropriate instruction techniques for teaching them to read. this re-evaluation has led us to reconsider their potential despite many difficulties mentally handicapped children have on language, cognitive and perceptual levels. this introduction will mention some shifts in reading models, explain how reading can be redefined as a metalinguistic task, and explain the implications of this in the light of cognitive psychological research in mental retardation. some questions will be posed regarding the area of metalinguistic abilities in reading acquisition and instruction, and how the speech-language pathologist in whose domain this area falls can play a role in developing more effective intervention and instruction techniques for facilitating reading acquisition in the mentally handicapped population. research into reading and reading acquisition has begun to investigate the higher cognitive functions associated with reading. reading can be redefined as primarily cognitive and linguistic, rather than visual and perceptual (reid, 1981). reading acquisition models have introduced the concept of reading evolution where reading is viewed as a gradual, spontaneous process beginning with the holistic attribution of meaning to print, and later becoming refined so that knowledge about the component elements of language is mastered (reid, 1981). this knowledge of the components of language can essentially be seen as a metalinguistic skill. tunmer, pratt & herriman (1984) have defined a metalinguistic skill as the ability to reflect upon and manipulate structural features of spoken language, treating language itself as an object of thought. reading acquisition is a complex process which requires the learner to distance himself from spoken words in order to analyse them and impose a new form and structure on l a n g u a g e . the strong c o r r e l a t i o n b e t w e e n metalinguistic ability and reading ability suggests that die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 debra marais & erna alant reading is essentially a metalinguistic task (flood & salus, 1982). researchers (cherkes-julkowski & gertner, 1989; reid, 1981; berger & reid, 1989) have shown that improved meta-cognitive strategies (e.g., meta-memory) can be elicited through training, but tend not to be invoked spontaneously by mentally handicapped children and adults, as well as by children with language disorders. this has led to the hypothesis that mental handicap is primarily a meta-cognitive disorder (cherkes-julkowski & gertner, 1989). since mentally handicapped children need assistance with the development of meta-cognitive skills such as reading, it is possible that they would benefit from specific training in metalinguistic skills, particularly those which aid to reading acquisition. there is little research dealing with these aspects of learning to read (singh & singh, 1986), so it is necessary to draw on knowledge in this field from the development of normal children. current theory in research on preliteracy development ( van kleeck & schuele, 1987) indicates that the development of the "early underpinnings of literacy" begins long before formal schooling. this " wealth of knowledge many pre-school children gain about print before they actually learn how to read" has been termed emergent literacy (van kleeck, 1990; garton & pratt, 1989). these emergent literacy skills not only form the foundation for formal reading instruction, but some skills such as phonemic segmentation skills and awareness of aural word boundaries have even been cited as predicators of reading achievement (share, jorm, mcleams & m a t t h e w s , 1984 in tunmer, pratt & herriman, 1984; evans, 1987 in van kleeck & schuele, 1987). some models have been proposed in order to describe and investigate these skills. the framework used by van kleeck and schuele (1987) will be used in the following discussion. two main areas of consideration in emergent literacy are literacy socialisation and language awareness (van kleeck & schuele, 1987). firstly, literacy socialisation is the broad social and cultural aspect of learning to read. this can be divided into three main areas: literacy artifacts; literacy events; and knowledge about print, which is acquired before learning to read. secondly, language awareness or metalinguistic skill is knowledge about the linguistic code which is needed for mastering literacy. the main aspects of language awareness are: word consciousness, knowledge that language is a system with elements and rules, and phonological awareness. the metalinguistic area of preliteracy knowledge and its relation to formal reading instruction has become a controversial topic of research which has developed into a debate of the chicken and the egg. however, despite differing theoretical viewpoints, reading acquisition at pre-school level has become a valid concern for speechl a n g u a g e p a t h o l o g i s t s , d ue to its l a n g u a g e and metalinguistic basis (van kleeck & schuele, 1987). research which has shown that metalinguistic skills are underdeveloped in learning disabled children (kamhi & koenig, 1985; van kleeck & schuele, 1987) has led to investigation into alternative strategies in reading instruction. this area of emergent literacy, and particularly those metalinguistic skills which children with learning problems have difficulty mastering, can now be assessed and remediated ( van kleeck & schuele, 1987). if mentally handicapped children also experience difficulty with metalinguistic skills related to emergent literacy, then these developments in intervention could prove to be valuable in improving the quality of reading instruction for mentally handicapped children. van kleeck (1990) stated that facilitation of the foundations of literacy plays an integral part in the process of reading acquisition as it provides a solid foundation on which to build further literacy experiences. if mentally handicapped children are to benefit from this approach, more needs to be known about their development and mastery of these emergent literacy skills. for this reason, this study aims to investigate emergent literacy skills in mentally handicapped children. method this study aimed to describe the development of metalinguistic (language awareness) precursors to literacy in six mentally handicapped children of mental ages between five and seven years (chronological ages between six and sixteen years) who had received varying amounts of formal reading instruction. since the procedure used in conducting this study is described in more detail elsewhere (marais, 1991) only a brief outline of the method and aims is given here. six subjects were selected from special schools for mentally handicapped children in consultation with their teachers according to the following criteria: cognitive developmental age comparable to ages four to seven, since this is the age level in which precursors to literacy develop in normal children (van kleeck & schuele, 1987; smith & tager-flusberg, .1982 and fox & routh, 1975). chronological age between six and sixteen years since this is the traditional school-going age, and the time in which these abilities will be developed and used during reading training in mentally handicapped children. intelligence: educable mentally handicapped children, (i.e., an iq of approximately between 50 and 70). ι socio-economic background: good socio-economic status with exposure to literacy artifacts andj events in the home to exclude factors of environment deprivation. | home language: all subjects have the same home language for the purpose of uniformity in testing. afrikaans was selected. please refer to table 1 for a description of the subjects. a test battery was compiled using material available for the sample group as well as adapted and translated . subtests drawn from research (fox & routh, 1975; smith & tager-flusberg, 1982). a pilot study was conducted before formal testing began to ensure the test battery was suitable for a five year old afrikaans speaking child: testing was done in two sessions to complete the test battery, and the data was analysed according to the results available in research and standardised tests. each candidate's parents were interviewed to obtain a case history and relevant information regarding literacy dethe south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the development of precursors to literacy in mentally disabled children 17 * segmenting sentences into words i.e., the ability to isolate a separate word from the acoustic flow of speech this is also closely linked with word consciousness in normal children and has been identified as a significant predictor of early reading achievement (evans et al., 1979; mcnick, 1974 in van kleeck & schuele, 1987). * phonological awareness i.e., the ability to analyse a spoken word into its component syllables and phonological units and also to synthesize these units to produce a word. language play such as rhyming also reflects this ability. three tasks were used on a sub-word level: segmentation of bisyllabic words, analysis of single syllables into sounds and a rhyming task. results firstly language and cognitive functioning were assessed. four subjects displayed a general cognitive level between 6-0 and 6-9 years, with subject a obtaining an age equivalent of 5-3 years and β of 4-9 years. all except subject a had above average scores for receptive vocabulary, using norms for 6-0 years ( peabody picture vocabulary test, ppvt). expressive language profiles for the tmt (afrikaans test of oral language productable 1. description of subjects chronological age sex draw-a-man age level 1q approx. (·) medical diagnosis ( * ) exposure to literacy training ( * ) 6,2 yrs μ 5,3 yrs not available down syndrome no formal training use of bliss symbols 10,6 yrs f ,4,9 yrs not available athetoid elementary graphemephoneme matching. three letter word analysis and synthesis. 12,3 yrs μ 6,0 yrs i j 56 spastic diplegic limited sight vocabulary grade 1 reader level. elementary grapheme-phoneme matching, word analysis and synthesis. 13,2 yrs f 6,3 yrs 58 head injury at at age 5y 5m limited sight vocabulary. some grapheme-phoneme matching. 14,8 yrs f 6,9 yrs 63 cerebral handicap well developed analysis and synthesis of short words, with grapheme-phoneme matching. reading comprehension good, writing functional. 15,11 yrs μ 6,3 yrs 52 cerebral handicap with epilepsy. good analysis and synthesis of short words with graphemephoneme matching. writing functional. (*) obtained from school files and teachers die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 v e l o p m e n t a n d the l i t e r a c y s o c i a l i s a t i o n b a c k g r o u n d . (checklists u s e d w e r e a d a p t e d from those listed in van kleeck, 1990.) the formal test battery covered the following areas, using the framework in van kleeck (1987) as well as language and cognitive test material: language and cognitive functioning using the drawa-man test (goodenough, 1926), the peabody picture vocabulary test (afrikaans translation) (gouws, 1975), and the afrikaans test of oral language (vorster, 1980). literacy socialisation was assessed in two ways, firstly the family background and home and school environments were analysed using checklists and a rating was given. secondly, the subject's print awareness was assessed using the book-handling and situation dependent print subtests (edmiaston, 1988 with adaptations for the south african context by sher, 1989). language awareness (metalinguistic) subtests: subtests were selected from research which had been done successfully with three to six year olds, and covered the areas of: * word consciousness (the concept that words are separate from the things they represent and that they are arbitrary in nature). r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 debra marais & erna alant table 2. language and cognitive functioning subject draw-a-man test age level ppvt scored at 6y age level norms (*) tmt scored at 6.0 6.2y age level norms:· average stanine score π a 5,3 yrs below average 4.1 β 4,9 yrs above average 4,5 c 6,0 yrs average 5,5 d 6,0 yrs above average 5,6 ε 6,9 yrs above average 5,1 f 6,3 yrs above average 4,3 (*) t-score interpretation where a score of 40-60 is average for 6 year olds. [] stanine score: 5=average, standard deviation of 1,96. table 3. rating of literacy socialisation environment subject literacy artifacts ratings* literacy events rating* a good exposure to books and magazines. parents academically orientated and interested in overseas literature. lots of education toys and books. bliss symbols books. good often looks at books and magazines. parents and older sister spend a lot of time reading with him and he often draws and writes "letters" to friends. uses and reads bliss. good β good exposure to reading and writing materials. beginner reader's books. good enjoys "reading" with much use of pictures and memory. draws and "writes letters" regularly. good c good exposure to education books and beginner reader series. he enjoys "spot" series (otto) good both parents are teachers and spend time reading with him. he is involved with compiling shopping lists, signing his name in cards and "writing letters". good i d good exposure to books, writing materials, little table and chairs, children's encyclopaedia and beginners reading book. good lost interest in reading after head injury. she makes extensive use of pictures to assist recognition of items, and "writes letters" and enjoys drawing. good i 1 1 ε good exposure to books, writing materials and sound and flash cards which her mother made to help her learn to read. good excellent exposure. mother is highly motivated and has very high expectations for her. she spends a lot of time teaching analyses and synthesis of phonemes. the subject can read a recipe and go shopping. good f adequate exposure to writing materials and books and magazines. adequate parents do not have high education level and spend little time on reading and writing with the subject. he does write letters to friends, looks up tv programmes himself and reads beginner readers occasionally. adequate the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the development of precursors to literacy in mentally disabled children 19 tion) were plotted using norms for 6-0 to 6-2 years. all s u b j e c t s attained scores which were adequate for this age level, and are therefore on a par with a six year old age level. (see table 2 for scores.) since l a n g u a g e a n d c o g n i t i v e functioning m e t the criteria, e n v i r o n m e n t a l factors n e e d e d to be considered, as these play a large role in forming preliteracy a w a r e ness of print. literacy socialization i.e., the role literacy artifacts and events play in developing literacy, was assessed according to the home and school environments and case history using checklists during the interview with the parents, and also according to the subject's print awareness in the print awareness subtest. all the parents were cooperative and enthusiastic during the interview and gave detailed information about the subject's background and exposure to print. all parents seemed motivated to assist their child in attaining his or her potential and had done all within their power to provide normal, and in most cases, exceptionally good exposure to literacy artifacts and events. according to the rating given from results of the checklists (see table 3), only subject f obtained a rating of 'adequate', with all the other subjects rated as 'good' environments for fostering literacy. the print awareness subtest (figure 1) assessed bookhandling skills and situation dependent print (which assesses knowledge of brand names and names of high personal interest) to determine the subject's familiarity with the conventions of purposes of print. all subjects obtained scores between 86% and 100% for book-handling skills and handled books correctly, showing some knowledge of what print is used for as well as how it is used. situation dependent print was well developed in three subjects, however, subject d was unsure of several items and subjects a and c scored below 50%. (see figure 1.) it would seem that all subjects have language and cognitive levels which are above a five year level, with the majority on approximately a six year level, except for subject a. their exposure to literacy artifacts and events is adequate, and in many cases exceptionally good. most subjects also displayed good knowledge of the purpose and conventions of print (print awareness), though situation dependent print was not well developed in some subjects. tne final factor to consider is that of language awareness or metalinguistic ability. a profile of age equivalent scores for the five subjects who completed the language awareness subtests is given in figure 2. the youngest subject (subject a) had little comprehension of the various tasks and gave many guessing and perseverative responses. he was unable to complete the battery and his results are excluded from the presentation of the results for the language awareness subtests. further discussion is available in marais, (1991.) from the age equivalent profile in figure 2 it is clear that more than half the scores are on a four year level and below, with some scores even below a three year level. this is in sharp contrast to the language and cognitive abilities which are all above a five year age level. let us consider the results of the subtests individually. the word consciousness test was completed successfully by all five subjects, and all met the criteria of 80%, which determined mastery of the skill. two subjects (b and f) fell between the norms for three and four year olds, while the other three obtained scores of 100% which is above a four year level. the sentence analysis.subtest (segmenting sentences into words) proved particularly difficult for the subjects, despite the opportunity this task afforded for learning. only subject ε had mastered this skill, with subject f on a three to four year level. a comparison of the scores for sentence analysis with the scores obtained with normal three to five year olds is presented in figure 3. 100 80 £ 60 40 20 ιε a β c d s u b j e c t situation d e p e n d e n t p r i n t book handling skills figure 1. scores for print awareness tests c3) ( 4 ) g) ( 6 ) ( 7 w o r d c o n s c i o u s n e s s s e n t e n c e o n o l y s i s r h y m e w o r d o n o l y s i s u s e o f c o n v e n t i o n a l s y l l a b l e b o u n d a r i e s β c d ε m e j h > a g e e q u i v a l e n t in y e a r s figure 2. profile of age equivalent functioning on the metalinguistic test battery. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 the results for the word analysis subtest (segmentation of bisyllabic words) are compared with results obtained with normal three to six year olds in figure 4. the three oldest subjects achieved scores of 100% which places them on a six year old level. subject c scored on a thrge to four year level and subject β on a level below three years. the literature from which the task was drawn (fox & routh, 1975) found that most children made use of conventional syllable boundaries to break up the wgrds, which was also the case for subjects c, d and e, who scored 100% for this task (see figure 2). subject f, however, segmented 7/8 of the stimuli by giving only the initial phoneme which reflects ability to analyse words on a sub-syllable level, but not sensitivity to syllabic boundaries. the rhyme subtest, (figure 2) which assesses phonological awareness, had a criteria of 90% to determine mastery of the skill. only subject ε met the criteria, with subjects b, c and f on a four year level and subject g below a three year level. discussion the results of this research project support the hypethesis that metalinguistic (or language awareness) abilities in mentally handicapped children do not necessarily develop spontaneously as they do with normal x ο 3 ο u j ο: ο ο cη π χ / ζ , χ c d b f — s c o r e s o b t a i n e d w i t h n o r m a l 3 t o 5 y e a r o l d s i > 4 5 6 a g e in y e a r s figure 3. comparison of scores for sentence analysis with normal 3 to 5 year olds. a x ο c ο 6 tx i ° 4 u j a: ο u η t/> 2 χ χ s c o r e s o b t a i n e d w i t h n o r m a l 3 t o 6 y e a r o l d s 4 5 6 a g e in y e a r s figure 4. comparison of scores for word analysis with normal 3 to 6 year olds. debra marais & erna alant children, which is also the case with learning disability. the fact that these language awareness skills are lacking, makes it plausible that the difficulty many mentally handicapped children experience in learning to read could be contributed, at least in part, to inadequate metalinguistic skills. many mentally handicapped people derive benefit from training in other metacognitive skills. this makes it seem possible that this p o p u l a t i o n could benefit from t r a i n i n g in metalinguistic skills. word segmentation skills were well developed in three subjects, i.e., on a six to seven year old level. these abilities contrasted sharply with poor sentence segmentation abilities in all but one of the subjects. poor performance on this task was shown despite the nature of the task which gave much opportunity for learning to take place (van kleeck et al., 1987). one subject even gave responses which broke phrases up at sub-word boundaries, and others gave perseverative responses after the sentence had been broken up into two or three phrases. three of the five subjects yielded scores which fell below scores attained by three year olds. thus the awareness of the word as the basic unit of speech was clearly not well established. the discrepancy found between word and sentence analysis abilities in mentally handicapped children contrasts sharply with results obtained for the same two tasks in normal children. the research from which the tasks were drawn (fox & routh, 1975; smith & tagerflusberg, 1982) found such close correlations between these two abilities that they postulated that the same cognitive process underlies both skills. some could argue that this difference between mentally handicapped and normal children is merely another reflection of the differences between the two populations, and that comparisons between them are of little value. however, if the factor of reading instruction is introduced into the discussion, another possibility is raised. all the children who obtained high scores of word segmentation had received formal reading instruction, much of which focusses on word and phonemic analysis. they made use of word analysis and synthesis skills throughout the testing, and seemed proud of this ability wliich they had mastered. it could be the case that these high scores were a reflection of training in isolated metalinguistic skills, rather than a reflection of development of metalinguistic abilities. since some learning hald taken place, despite the discrete nature of the skills, this again strengthens the case raised in the first sectibn that mentally handicapped children can benefit from training in metalinguistic skills. a last point to consider with regard to sentence analysis abilities is the strong correlation that has been found between the ability to segment sentence into words and reading performance. evans et al., (1979) and mcnich (1974 in van kleeck & schuele, 1987) and tunmer et al., (1984) found awareness of aural word boundaries to be a significant predictor of early reading achievement. this ability was poorly developed in all but one of the subjects. subject e, who had mastered this skill (see figure 4), was also the only subject who was functionally literate. thus it would seem that awareness of aural word boundaries had a similar correlation with reading performance in the mentally handicapped population as well. the south african journal of communication disorders, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the development of precursors to literacy in mentally disabled children 21 conclusion the mentally handicapped children used in this study displayed inadequate and incomplete development of the metalinguistic precursors to literacy which were investigated, despite these children having language abilities comparable to a six year old age level, good literacy socialisation environments and receiving formal reading instruction. trends which were noted in all subjects could be indicative that the difficulties uncovered here are difficulties that many mentally handicapped children experience. this metalinguistic deficit could be due to the difficulty that many mentally handicapped children have with meta-cognitive abilities, and could also be a contributing factor to the difficulty that this population experiences with reading acquisition. more research using larger sample groups is needed to establish this. it is also possible that reading acquisition could be enhanced by training metalinguistic skills which are valuable for reading, since splinter skills had been developed in some of the subjects. since training these skills has become part of the speech pathologist's role in intervention with language disabled children (van kleeck & schuele, 1987), speech pathologists may need to play a role in training metalinguistic skills in the mentally handicapped population as well, in order to improve literacy in this population. references berger, r.s. & reid, d.k. (1989). differences that make a difference : comparisons of metacomponential functioning and knowledge bases among groups of high and low iq learning disabled, mildly mentally handicapped and normally achieving adults. journal of learning disabilities, 22(7), 422-429. cherkes-julkowski, m. & gertner, n. (1989). spontaneous cognitive processes in handicapped children. berlin : springer report. edmiaston, r.k. (1988). preschool literacy assessment. seminars in speech and language, 9(1), 27-36. flood, j. & salus, m. (1982). metalinguistic awareness : its role in language development and its assessment. topics in language disorders, 2 (sept). fox, b. & routh, d.k. (1975). analysing spoken language into words, syllables and phonemes: a developmental study. journal of psycholinguistic research, 4(4), 331-342. garton, a. & pratt, c. (1989). learning to be literate the development of spoken and written language. cornwell : basil blackwell ltd. t.j. press, 218-221. goodenough, f.l. (1926). the measurement of intelligence by drawings. london : harrap. gouws, k.l. (1975). voorlopige vertaling van die peabody picture vocabulary test item ontleding met die oog op standaardisasie. unpublished blog paper, university of pretoria. kahmi, a. g. & koenig, l.a. (1985). metalinguistic awareness in language disordered children. language, speech and hearing services in schools, (july), 199-210. marais, d. (1991). metalinguistic precursors to literacy in mentally retarded children. unpublished b.log. paper, university of pretoria. reid, d.k. (1981). child reading : readiness or evolution. topics in language disorders. special issue on language in context : listening, reading and writing, 61-71. schuele, m.c. & van kleeck, a. (1987). precursors to literacy: assessment and intervention. topics in language disorders, 7(2), 32-44. sher, k. (1989). the relatedness of auditory receptive language and visual receptive language in preschool learning disabled children. unpublished b.a. log paper, university of the witwatersrand, johannesburg. singh, n.n. & singh, j. (1986). reading acquisition and remediation in the mentally retarded. international review of research in mental retardation, 14, 165-193. smith, c.l. & tager-flusberg, h. (1982). metalinguistic awareness and language d e v e l o p m e n t . journal of experimental child psychology, 34, 449-468. tunmer, w.e. & pratt, c. & herriman, m.l. (eds.), (1984). metalinguistic awareness in children. berlin : springel-verlag. van kleeck, a. (1990). emergent literacy : learning about print before learning to read. topics in language disorders, 10(2), 25-45. van kleeck, a. & schuele, c.m. (1987). precursors to literacy: normal development. topics in language disorders, 7(2), 13-31. vorster, j. (1980). handleiding vir die toets vir mondelinge taalproduksie (tmt). pretoria suid-afrikaanse instituut vir psigometriese navorsing. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) v ^ u m m u i m i c a i i u i m a i d s for people who cannot speak dual displays o n e for t h e user & o n e for t h e p e r s o n t h e y a r e s p e a k i n g t o single switch plug-in single s w i t c h e s for s c a n o p e r a t i o n m e m o r y store f r e q u e n t l y u s e d phrases k e y b o a r d splash-proof a n d either q w e r t y or a b c d e l a y o u t the sl35 lightwriter t h e l i g h t w r i t e r r a n g e o f a l t e r n a t i v e c o m m u n i c a t i o n a i d s a r e p o r t a b l e , l i g h t w e i g h t a n d e x t r e m e e a s y t o o p e r a t e . s i m p l y t y p e w h a t y o u w a n t t o s a y a n d t h e u ^ h f f i slh s a y i t τ ο γ τ ο ω ^ ^ b ' e ^ ° v q r i e t y ° f s i n 9 ' e s w i t c h e s " ^ ™ w ^ o a r e l l i n h ! l i ! ! r r s ? k ° v e a „ r a n g e ° f h i g h q u a l i t y s p e e c h s y n t h e s i s e r s i n c l u d i n g d e c t a l k t h i sl35 i n c . u d a a l l e s t c ™ i c a t i o n a i d t h e w o r l d w i t h d e c t a l k s p e e c h s y n ^ l s f e a t u r e s i ' m ? m ™ e d , c ! i o o n " b a s e d ° n 4 0 0 0 m o s t g e n t l y s p o k e n english w o r d s . l i 9 h — *> « a p o r t a b l e w o r d processor ϊ 1 8 ® ^ " ° f s p a c e a f t e r c o m m a e t c ' t o s a v e typing tremor c o n t r o l ant,-tremor d e l a y to p r e v e n t i n a d v e r t e n t o p e r a t i o n with p o o r h a n d c o n t r o l users sole distributor o f t o b y churchill lightwriters a tw τ γ ρ a t ) ρ ο box 8 4 6 3 5 g r e e n s i d e 2 0 3 4 l / \ h j telephone: (011) 486-09-70 m i c r o s y s t e m s f a c s i m i l e : ( o i l ) 6 4 6 1 5 8 0 specialist suppliers of lightwriters a n d a d a p t e d computer e q u i p m e n t for special needs r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) editorial for the first time we are able to include in our journal, an article in afrikaans, which was made possible by the co-operation of the staff of the department of logopedics and speech science of the university of pretoria. we sincerely hope that this will be the first of many such articles. several of the articles indicate that numerous avenues for further research do exist in south africa. the success of a journal of this nature depends upon the extent to which its members take an active part in contributing to it. the journal aims to reflect the positive growth and development of logopedics and its allied fields in south africa. we must therefore draw on the resources of south african speech therapists and the allied medical professions for our material. we hope that our readers will find this issue of the journal of the south african logopedic society of interest. 1 journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) redaksioneel vir die eerste keer is dit moontlik om 'n artikel in afrikaans in die tydskrif te plaas. ons is hiertoe instaat gestel deur die samewerking van die personeel van die departement spraakheelkunde by die universiteit van pretoria. ons hoop dat dit die eerste van nog vele sulke artikels sal wees. verskeie artikels in hierdie tydskrif beklemtoon die behoefte aan verdere navorsing in suid-arika. die sukses van 'n tydskrif van hierdie aard hang uitsluitlik af van die aktiewe belangstelling van die lede en die bydraes wat hulle lewer. die doel van hierdie tydskrif is om die positiewe groei en ontwikkeling van logopedika en die verwante gebiede in suid-afrika aan te dui.daarom. ook, is ons afhanklik van bydraes deur suid-afrikaanse spraakterapeute en die verwante professies. ons hoop dat die lesers van hierdie uitgawe van die tydskrif van die suidafrikaanse spraakheelkundige vereniging interessant sal vind. journal of the south african logopedic society august, 1963 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) editorial there are many speech therapists who are aware of the value of the bobath techniques in the handling of the cerebral palsied child, but the article by jacobs and shapiro fills that vital gap between theory and practice in that they give a detailed step by step account of the application of the method. they also discard some older techniques and point out pitfalls to avoid in therapy. in his article on the aphasic child, myklebust goes into the details of every term which he uses thus establishing a clear frame of reference in which to discuss the problem. through his warm and understanding approach we begin to see the brain-injured child as a troubled little human and not merely as a theoretical concept. we are indeed priveleged to be able to publish this contribution from one of the outstanding workers in this field. surgical procedures for the relief of deafness due to otosclerosis are appraised by d. r. haynes. we thus obtain some appreciation of the problem from the point of view of the medical man. in this issue therefore, we have presented a detailed discussion and new information on topics that are of interest and importance to all workers in speech therapy and related fields. june, 1961 journal of the south african logopedic society 3 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 25 early identification of at-risk infants and toddlers: a transdisciplinary model of service delivery legini moodley, brenda louw and rene hugo department of communication pathology university of pretoria abstract traditional models of service delivery prevent speech-language therapists and audiologists from identifying and implementing early communication intervention (eci) in south africa. this study utilized the framework of the transdisciplinary team approach to develop a collaborative partnership between community nurses and speech-language therapists and audiologists. an interdisciplinary in-service training programme was implemented with 24 community nurses employed at family health clinics in kwa-zulu natal; with the aim of enhancing their knowledge and attitudes toward the early identification and referral of at-risk children to speech-language therapists and audiologists. three questionnaires were used to evaluate the nurses' knowledge and attitudes. results indicated that the training programme significantly improved the nurses'knowledge regarding eci but not their attitudes. implications of these findings are discussed in terms of service delivery for eci, and the education and training of early interventionists in the south african context. key words: early communication intervention, infants plinary in-service training. introduction early identification of at-risk infants and toddlers is the first crucial step in early communication intervention (eci), and it has a significant impact on treatment efficacy. a factor that is consistently linked to the efficacy of early /intervention services is that of age ofidentification (rossetti, 1993; 1996). improving age of identification by implementing methods of service delivery that promote earlier detection of children!who are at-risk for developing communication disorders is important for effective management, and constitutes an important goal of speechlanguage therapists and audiologists. however, gaining earlier access to infants and toddlers and their families in need of eci appears to be an international and national challenge confronting speech-language therapists and audiologists. despite research evidence to support early intervention, specifically eci, many children with communication disorders are not referred to speech-language therapists and audiologists as the prevailing attitude of many health professionals continues to be "wait and see as the child may outgrow it" (rossetti, 1996; louw & kritzinger, 1991). this attitude reflects the need for greater consultation and collaboration between speech-language therapists and audiologists and referring health care professionals to promote greater awareness of speech, language and audiological services. delayed communication development is identified as the most common symptom of developmental disability in and toddlers, at-risk, transdisciplinary team model, interdiscichildren under three years of age, affecting approximately 5% to 10% of that population (rossetti, 1996). in south africa, it is estimated that children under the age of four years comprise 5 million of the country's 38 million population (a national health plan for south africa, 1994; central statistical services, personal communication, july 2, 1998). using rossetti's (1996) estimates, which are relevant for a developing country, south africa could expect approximately 250 000 to 500 000 children to present with delayed communication development. the prevalence of developmental delays and disabilities in children under three years of age is rapidly increasing due to advances in life-saving medical technology and new and expanding populations of infants and toddlers (rossetti, 1996). in developing countries like south africa, at-risk children and their families face additional political, social, cultural, economic, linguistic, and environmental conditions that place them at increased risk for developmental disabilities (pickering et al., 1998). the white paper on integrated national disability strategy (1997) indicates that 80% of black children with disabilities live in extreme poverty in inhospitable environments. the implication for speech-language therapists and audiologists is evident: early identification of communication disorders in infants and toddlers (0-3years), and the timely provision of early communication intervention (eci) is vital to enhance the overall developmental potential of these children. there are currently only 1750 registered speechlanguage therapists and audiologists (y. hoffman, health die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 legini moodley, brenda louw and κβηέ hugo professions council of south africa, personal communication, 21 august 2000) to cater for the country's approximately 3,8 million people who require communication treatment (pickering et al., 1998). however, a very small number of these professionals are adequately trained in eci (fair & louw, 1999). besides the shortage of qualified personnel, speechlanguage therapists and audiologists' use of traditional institution-based models of service delivery have proven to be ineffective in reaching the majority of the vulnerable and disadvantaged communities of south africa. the restructured national health system mandates a transition in service delivery from institution-based services to community-based services (white paper on integrated national disability strategy, 1997). the south african government has adopted the primary health care (phc) approach as the underlying philosophy for the restructuring of its health system (department of health, 1995). however, besides legislating free health care services for all children under six years of age, specific policies for the disabled and at-risk population are lacking (white paper on integrated national disability strategy, 1997; fair & louw, 1999). the principles underlying south africa's national health system provide strong support for the implementation of recommended eci practices. asha (1989) identified four quality indicators for effective eci services to the at-risk population, namely; services need to be family-centred, community-based, comprehensive, and co-ordinated. moreover, research has identified the team model of service delivery as being critical for the provision of comprehensive and coordinated eci services (asha, 1989; fair & louw, 1999). the transdisciplinary team model of service delivery is currently viewed as the preferred model of practice in early intervention (briggs, 1997). it is an integrative service delivery model that is characterized by three operational principles, namely; role release, role expansion, and arena evaluation as it requires professionals across disciplines to pool and exchange information, knowledge, and skills by crossing and re-crossing traditional boundaries. the latter principles provide a mechanism for the delivery of community-based, family-centered, comprehensive and coordinated eci services to at-risk infants and toddlers. the transdisciplinary model is ideal for the diverse south african context as it supports the phc and community-based models of service delivery. speech-language therapists and audiologists practice at the tertiary level of health care, whilst the at-risk population is present at the primary level. the adoption of the transdisciplinary principles will allow speechlanguage therapists and audiologists to establish partnerships with referring health professionals (based at the primary level of health care), thereby facilitating access to infants and toddlers who are at-risk for developing communication disorders (fair & louw, 1999). moreover, asha (1991) states that the transdisciplinary model is especially suited to service contexts where the demand is incongruous with the services provided because of the shortage of qualified staff, and when economic and other factors restrict service provision. in light of the current south african context and the suitability of the transdisciplinary team model for eci, this model of service delivery was selected to enable south african speech-language therapists and audiologists to gain earlier access to children at-risk for developing communication disorders. for this study, community nurses employed at community-based family health clinics were selected as the health professionals with whom speech-language therapists and audiologists could consult and collaborate. community-based primary health care nurses are the frontline health professionals in the early intervention team as they have direct contact with at-risk children, and are based at family health clinics that are accessible and affordable to the majority of the south african population. more importantly, in contrast to the current 1750 registered speech-language therapists and audiologists, there are approximately 21000 qualified community nurses (national health plan, 1994). in addition, infants receive developmental screening at family health clinics from six weeks of age, thus presenting the ideal context for the monitoring of early communication development. effective collaborative partnerships require both partners to share a common philosophy about the outcome of their services (briggs, 1997); and to possess a specialized core of knowledge and skills for working with at-risk infants, toddlers and their families (roberts, crais, layton, watson, & reinhartsen, 1995). however, current research findings indicate that many health professionals do not possess this common philosophy or specialized knowledge and skills (weitzner-lin, chambers & siepierski, 1994; delport, 1998). one of the ways to ensure that community nurses possess the necessary attitudes and knowledge to identify and appropriately refer children at-risk for communication disorders, is for the speech-language therapist and audiologist to serve as a source of information and provide relevant in-service training programmes to community nurses (rossetti, 1993; delport, 1998). although the transdisciplinary team approach provides the infrastructure to promote mutual teaching and learning, it does not facilitate the process of education and training, thus necessitating the adoption of an interdisciplinary model of education and training. interdisciplinary education refers to the collaboration of two or more disciplines in the learning process (american association of colleges of nursing, 1996), and is identified as the recommended practice for the education and training of early interventionists (briggs, 1997). l b facilitate the training process and the identification of community nurses' specialized knowledge and attitudes for eci, a model of the role of community nurses in eci was developed. this model identified the primary roles of community nurses in eci as being: screening, identification, referral and monitoring of at-risk children. based on these roles, the theoretical framework proposed by hanson and brekken (1991) was utilized to identify the nurses' specialized knowledge and attitudes for eci. this framework stipulates that early interventionists' specialized attitude and knowledge base is developed from two levels: (1) a set of professional discipline-specific knowledge and attitudes; and (2) a common early intervention knowledge and attitude base. figure 1 illustrates the development of the three levels of knowledge from discipline specific to specialized. however, will an interdisciplinary in-service training programme influence community nurses' knowledge and attitudes regarding eci, so that it promotes their ability to identify and refer children who are at-risk for communication disorders ? this is the research question that formed the basis for the present study. according to briggs (1997) training programmes provide high quality, low-cost and easily accessible opportunities for professionals to master new service delivery roles; while also ensuring that infants, toddlers, and their families have appropriate and effective the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) early identification of at-risk infants and toddlers: eci services. the provision of training programmes in eci by speech-language therapists and audiologists to community nurses, is poorly documented in the literature (delport, 1998). consequently, the aim of this study is to determine whether an in-service training programme for community nurses will influence their knowledge and attitudes with respect to the early identification of at-risk children. method aim the purpose of this study was to determine whether an inservice training programme for community nurses employed at family health clinics influenced their knowledge and attitudes with respect to the early identification of infants and toddlers (0-3 years) who were at-risk for developing communication disorders. the following objectives were formulated: • determination of community nurses' present knowledge and attitudes with regard to the early identification of infants and toddlers (0-3 years) who are at-risk for developing communication disorders. ransdisciplinary model of service delivery 27 • development and implementation of an in-service training programme to enhance community nurses' knowledge and attitudes with regard to the early identification of infants and toddlers (0-3 years) who are at-risk for developing communication disorders • determination of the effect of the in-service training programme on community nurses' knowledge and attitudes with regard to the early identification of infants and toddlers (0-3 years) who are at-risk for developing communication disorders. research design an exploratory descriptive survey quasi-experimental time series design was utilized (rosnow & rosenthal, 1996). this design involved utilizing the survey method to obtain a measure of the knowledge and attitudes of community nurses with regard to eci. this evaluation was then followed by the implementation of an in-service training programme. thereafter, the survey method was utilized again to obtain two further measures of the nurses' knowledge and attitudes following the training programme, one immediately after the training programme and the second 6 weeks later. specialized knowledge and attitude for early communication intervention level 3 knowledge: * specific risk factors for communication disorders * importance of communication domain in relation to other developmental domains * concept of continuum of risk * role of speech-language therapist and audiologist * screening assessment of infant and toddlers' communication skills * criteria for identifying the presence or absence o f a communication disability * speech-language therapy and audiology resources in the community * basic communicationbased intervention attitude: a positive attitude towards the importance of communication skills for overall development, and the need for early referral to the speech-language therapist and audiologist. t common knowledge and attitude regarding early intervention level 2 knowledge: * legislation on early intervention (international and national directives) * efficacy o f early intervention * epidemiologic overview o f the at-risk inlant and toddler population * team model of service delivery, with specific reference to the transdisaplinaiy team approach attitude: a positive attitude towards early intervention, its' effectiveness, and the benefit of the transdisciplinary team model of service delivay. discipline-specific knowledge and attitude for early communication intervention level 1 knowledge: * normal infant development * atypical infant development * family dynamics and assessment * planning, implementing and evaluating an intervention plan * community's medical, social and financial resources a ttitude: a positive attitude towards the management o f infants, toddlers and their families. t figure 1: the three levels of knowledge that community nurses require for practice in early communication intervention. (conceptualized from hanson & brekken, 1991; rossetti, 1996; brandt & magyary, 1989; and cox, 1996). i die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 subjects the target population for this study was community nurses employed at family health clinics, which are situated in the durban functional region of kwa zulu natal. the subjects were required to meet the following criteria. community nurses needed to be registered with the south african nursing council to ensure that they had a valid qualification in nursing, since the study focused on their knowledge and attitudes with regard to eci. they also needed to be currently employed at family health clinics, and involved in the practice of developmental monitoring of infants and toddlers as their knowledge and attitudes in this area was the focus of the study. selection of community nurses nonprobability convenience sampling was utilized (leedy, 1993), which entailed the researcher working with those community nurses who were selected by the nursing administrators. therefore, this method of sampling made legini moodley, brenda louw and hugo no pretence of being representative of the population; and did not attempt to control for bias (leedy, 1993). logistical constraints imposed by the need to maintain service delivery at the clinics, allowed only 30 of the total 127 community nurses to participate in the study description of the community nurses in the study on the day of data collection, only 24 community nurses participated in the training programme, representing 19% of the total population. all the nurses in the sample completed and returned the pre-training and post-training 1 survey (i.e. questionnaires 1 and 2), thereby representing a 100% response rate. however, only 21 of the 24 nurses completed and returned the post-training 2 survey (i.e, questionnaire 3). the response rate for questionnaire 3 was therefore 88%. table 1 provides the biographical characteristics of the subjects who participated in the pre-training and two posttraining surveys of the study. table 1: biographical characteristics of the community nurses who participated in the three surveys characteristics pre-training survey and post-training survey 1 n=24 pre-training survey and post-training survey 1 % post-training survey 2 n=21 post-training survey 2 % work environment family health clinic 24 100% 21 100% geographic area durban functional region 24 100% 21 100% professional qualification degree diploma 5 19 21% 79% 3 18 14% 86% community nursing qualification yes no 23 1 96% 4% 20 1 95% 5% employment status permanent full-time 24 24 100% 100% 21 21 100% 100% ! experience at family health clinics 0-5 years 6-10 years 11-15 years 16-20 years >20 years 14 6 1 2 1 58% 25% 4% 8% 4% 12 6 1 2 0 1 57% 29% 5% 10% 00% attendance at early communication intervention workshop/training • programme yes no 0 24 0% 100% 21 0 100% 0% first language english zulu 16 8 67% 33% 15 6 76% 4% the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) early identification of at-risk infants and toddlers: materials and apparatus three questionnaires and an in-service training programme were the main materials and apparatus that were utilized in the study. self-administered, questionnaires were used as they facilitated the observation of the nurses' knowledge and attitudes regarding eci, which were beyond the physical reach of the researcher (leedy, 1993). questionnaire 1 was utilized in the pre-training survey, questionnaire 2 was utilized in the post-training 1 survey, while questionnaire 3 was utilized in the post-training 2 survey, as reflected in figure 2. the design and development of the questionnaires guidelines provided by brink (1996); rosnow and rosenthal (1996) and leedy (1993) were used to develop the questionnaires. the questionnaires comprised four main sections, with an additional section included in questionnaires 2 and 3, which focused specifically on the nurses' evaluation of the training programme. the four sections were: (a) biographical information; (b) discipline specific knowledge for eci; (c) common knowledge and attitudes for early intervention; and (d) specialized knowledge and attitudes for eci. [refer to tables 1, 3, 4, 5, and 6 for information regarding questions included in each section]. all questions, except the last one, were constructed using the structured closed-ended format, in order to accommodate for the time constraints of the nurses. the questionnaires contained content that was relevant for community nurses to know, in order to implement their roles of screening, ransdisciplinary model of service delivery 29 identifying, referring and monitoring children who are atrisk for communication. [for detailed motivations regarding the questions that were included in the three questionnaires, the reader is referred to the original study by moodley, 1999], reliability and validity of the questionnaires reliability was ensured by paying careful attention to the formulation, length and complexity of questions; pilottesting the questionnaire; coding of data; and qualitatively analyzing the items in the questionnaire by providing an estimate of the internal consistency of the instrument (brink, 1996). a thorough and extensive review of the literature ensured that only relevant items were included. some of the questions were based on the questionnaire utilized by louw & weber (1997), and to ensure content validity, the questionnaires were approved by two south african experts in the field of eci. design and development of the in-service training programme the training programme was designed to accommodate the restrictions placed by durban city health department regarding minimal disruptions in service delivery. consequently, it was planned to be two hours in duration and to occur over two afternoons (1 hour per afternoon). table 2 presents a description of the development of the training programme. table 2: development of the training programme factors use in training programme aims philosophy structure j 1 i implementation process training environment evaluation strategy • to enhance community nurses' knowledge in eci • to foster community nurses' development of positive attitudes towards eci • to promote a community-based, family-centred, comprehensive and co-ordinated philosophy towards the rendering of eci services to at-risk infants and toddlers (asha, 1989). • an outcomes-based approach was utilized as hugo (1996) states that training that is based on outcomes provides a logical correlation between education and professional practice. accordingly, the guidelines of the national qualifications framework were used to develop specific outcomes; and information by bennet, watson & raab (1995) were used to develop a training plan (refer to figure 2) • the following five factors informed the implementation process: a systems approach to change was adopted in order to effect longterm practice changes (briggs, 1997). a preliminary needs analysis was conducted to ensure that training was responsive to the perceived needs of the nurses (winton, 1996). an empowerment perspective was adopted to create the necessary conditions for change (trivette, dunst, hamby & lapointe, 1996). a choice of instructional strategies were utilized that supported the principles of adult learning, for example, participant choice and responsibility for own learning (winton, 1996). follow-up support was provided to ensure application of learning (winton, 1996) • the training offices of the durban city health department. • analysis of the nurses' responses on the pre-training questionnaire (questionnaire 1) and the two post-training questionnaires (questionnaires 2 and 3). key: eci = early communication intervention ι die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 validity and reliability of the in-service training programme content validity was established by presenting the plan of the training programme to two expert early interventionists with experience in the use of training programmes, as well as the nursing administrators for their critical review (rosnow & rosenthal, 1996). since the training programme was implemented over two afternoons, every effort was made to ensure that similar conditions prevailed during the implementation process for both sessions. trainer bias was controlled for by adherence to a strict legini moodley, brenda louw and hugo training protocol (rosnow & rosenthal, 1996). in addition, a pilot study of the programme was conducted. pilot studies on the questionnaires and in-service training programme pilot studies of the three questionnaires and the training programme were conducted to increase the accuracy and reliability of the data. four community nurses, who were not part of the main study, were selected according to the criteria stipulated earlier. on the basis of the pilot studies the questionnaires and training programme were adapted. | introduction and orientation to the research process pre-training survey questionnaire 1 ph^se: implementation of training programme background to the study of eci: problems in early identification of at-risk children • definition and epidemiological overview of at-risk children • early intervention and eci • legislation on early intervention • efficacy of early intervention proposed solution : collaboration and the transdisciplinary approach • importance of the team approach to service delivery in south africaspecifically the transdisciplinary team approach • best practice for ei in south africa: community-based, lamily-centered, comprehensive and coordinated service part 1 phase 3 3 role of south african community nurses in eci • screening assessment, identification, referral and monitoring • information that will promote implementation of the above roles: risk factors for communication problems concept of continuum of risk early communication behaviours to monitor, and factors to consider during screening assessment criteria for identifying the presence of a communication disorder role of the speech-language therapist and audiologist speech-language therapy and audiology resources in the community to facilitate early referral guidelines on basic communication-based intervention to assist with education and counselling of the caregiver part 2 post-training survey 1 questionnaire 2 post-training survey 2 questionnaire 3 figure 2: an illustration of the implementation of the main study the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) early identification of at-risk infants and toddlers: a transdisciplinary model of service delivery 31 the main study the main study was conducted over three phases, namely; the pre-training survey, implementation of the inservice training programme, and the post-training surveys. figure 2 illustrates the processes of the three phases as they occurred. during the introduction the trainer did not indicate her professional background, nor was any information regarding early intervention or eci presented at this stage so as not to influence the nurses responses on the pre-training survey. the pre-training survey occurred first and the trainer was present to answer queries thereby preventing misunderstandings from biasing the data (brink, 1996). the training programme commenced immediately after questionnaire 1 was collected. part 1 of the training programme commenced on the first afternoon with a brief discussion of the background to the study of eci, and ended with the proposed solution of the transdisciplinary approach (refer to figure 2). part 2 of the training programme continued the next afternoon and focussed on the role of south african community nurses in eci. a handout on eci, prepared on the basis of the training plan, was distributed to the nurses at the start of the programme to facilitate the learning process. at the end of part 1 of the training programme, the nurses were allowed to take the handout with them and were encouraged to read it. immediately after part 2 of the training programme ended, questionnaire 2 was distributed and collected. six weeks after the training programme, questionnaire 3 was given to the nursing administrators, for distribution to the participants of the training programme, and the completed questionnaires were collected from the nursing administrators. data analysis descriptive and inferential statistical methods were employed. data were analysed using the statistics computer software called statistical package for the social sciences (spss) [leedy, 1993], descriptive statistics, which included frequency counts, percentages, and measures of central table 3: community nurses' level of confidence in th preand post-training surveys tendency and variance, were used to describe and summarise the data (rosnow & rosenthal, 1996). inferential statistics, namely; the parametric one-way analysis of variance (anova) [rosnow & rosenthal, 1996] was utilized to determine whether any differences found among the three evaluations, were real differences that may be attributed to the influence of the training programmes. when a statistically significant difference was obtained, post-hoc comparison tests utilizing the bonferroni test, were' calculated to determine which of the means differed significantly (brink, 1996). thematic analysis was utilized to analyse the open-ended questions. results and discussion the results are discussed in accordance with the main aim of the study. the findings for objectives one and three are presented concurrently to highlight any similarities and differences that may exist among the three measures. influence of the in-service training programme on community nurses' knowledge and attitudes with regard to early communication intervention the findings are presented in accordance with the framework presented in figure 1, namely; the community nurses' discipline-specific·, common and specialized knowledge and attitudes regarding eci. specialized knowledge and attitudes are presented according to the nurses' four roles in eci, namely; screening, identification, referral and monitoring. community nurses'discipline-specific knowledge for early communication intervention results indicate that the training programme did influence the community nurses'discipline-specific knowledge with respect to eci. anova analysis was significant at the 0.01 level, while post-hoc comparisons found that the means for questionnaire 1 and 2 differed significantly. table 3 reveals that before training, the majority of the nurses ir discipline-specific knowledge areas as evident in the knowledge area not confident % moderately confident % confident % ql q2 q3 ql q2 q3 ql q2 q3 1. normal infant development 4.2 0 4.8 25 8.3 23.8 70.8 91.7 71.4 2. atypical infant development 16.7 0 4.8 58 25 42.9 25 75 52.4 3. family functioning and assessment 4.2 0 9.5 54.2 29.2 38.1 41.7 70.8 52.4 4. assessment of infants and toddlers 16.7 4.2 0 41.7 33.3 33.3 41.7 62.5 66.7 5. planning, implementing and evaluating an intervention plan 20.8 4.2 0 54.2 29.1 47.6 25 66.7 52.4 6. knowledge of the community's medical, social and financial resources 25 0 9.5 j 37.5 4.2 28.6 37.5 95.8 61.9 key: ql = questionnaire 1 q2 = questionnaire 2 q3 = questionnaire 3 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 legini moodley, brenda louw and hugo expressed moderate levels of confidence in their disciplinespecific knowledge, especially in the areas relating to atypical infant development, family functioning and family assessment, and planning, implementing and evaluating an intervention plan. however, immediately after training a significantly large number of the nurses felt confident, while six weeks after the training programme, although most of the nurses still expressed confidence, a large number indicated moderate levels of confidence. it is concluded that overall, more nurses were moderately confident rather than confident in their discipline-specific knowledge base. community nurses' discipline-specific knowledge base represents the foundation from which they would develop a common early intervention knowledge base and a specialized eci knowledge base (hanson & brekken, 1991). despite the positive trends, however, it is concerning that the pre-training survey found most of the nurses to be moderately confident rather than confident in their discipline-specific knowledge base. the nature of the nurses' pre-service education and training experiences may provide an explanation as cox (1996) states that the compressed and streamlined nursing curricula and the shortage of suitably qualified teaching staff are possible factors that may impact on the quality of early intervention education at the pre-service level. informal discussions with community nurses in kwa-zulu natal revealed that their pre-service training was also compressed and streamlined to equip them with the broad-based knowledge and skills that they required as primary health care providers..it appears that the nurses possess an unsatisfactory level of discipline-specific knowledge for eci, to facilitate their competent implementation of eci at family health clinics. community nurses' common knowledge and attitudes regarding early intervention common knowledge regarding early intervention: table 4 indicates that the training programme did influence the nurses' common knowledge for early intervention, as the anovaanalysis was statistically significant at the 0.05 level, and the bonferroni test found questionnaire 3 to be significant. the nurses presented with adequate levels of common knowledge with respect to the definition, efficacy, and principles of early intervention, on all three questionnaires, although training resulted in a slight increase in knowledge levels. the nurses' knowledge of international legislation increased significantly six weeks after training. unfortunately, similar findings did not occur with respect to their knowledge of south african legislation, as inadequate knowledge levels were evident on all three evaluations. it is important for community nurses to be knowledgeable about the four areas of early intervention, as this will play a significant role in influencing their attitudes toward eci, as well as facilitate effective service delivery to at-risk children and their families (brandt & magyary, table 4: community nurses' common knowledge regarding early intervention as evident during the preand post-training phases knowledge area % true % uncertain % false knowledge area qi q2 q3 qi q2 q3 qi q2 q3 1. early intervention is a range of health care services that is available to promote the well being of families with infants and toddlers who maybe at-rick for developmental disabilities 95.8 100 100 4.2 0 0 0 0 0 2. international laws do not authorize the provision of early intervention services to at-risk infants and toddlers. 4.2 33.3 4.8 41.7 8.3 9.5 54.2 58.3 85.7 : 1 3. south african health care laws authorize the provision of early intervention services to at-risk infants and toddlers. 87.5 62.5 61.9 8.3 4.2 4.8 4.2 33.3 ί 33.3 4. early identification and initiation of intervention services for developmentally delayed children is not effective in reducing and/or preventing later delay. 0 0 0 8.3 4.2 0 91.7 95.8 100 5. community-based, family-centered, coordinated and comprehensive services will promote effective management of at-risk children 95.8 100 100 4.2 0 0 0 0 0 key: q1 = questionnaire 1. q2 = questionnaire 2. q3 = questionnaire 3. the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) early identification of at-risk infants and toddlers: a transdisciplinary model of service delivery 33 1989). the community nurses' demonstration of an adequate common knowledge base with respect to three of the four areas on the pre-training survey, strongly suggests the possibility that the information is currently being provided in their discipline-specific training. this finding has relevance for the planning of eci in-service training programmes for community nurses, as these areas may not need to be addressed in detail in future programmes (delport, 1998). however, the nurses' limited knowledge regarding international and national legislation on early intervention makes it clear that the nurses' common knowledge base for early intervention is inadequate. the nurses' response to the question regarding south african legislation on early intervention may be attributed to the government's legislation of free health care services for all children under six years of age (department of health, 1995). be this as it may, however, specific and detailed policies with respect to the provision of early intervention services for the at-risk infant and toddler population as outlined by the international legislation relating to public law 99-457 (rossetti, 1996), is lacking in south africa. the latter is currently identified as a priority issue in the white paper on integrated national disability strategy (1997). it is clear that the current assumption that the nurses possess this common knowledge is incorrect, and supports research findings that many health professionals receive poor educational preparation for their roles as early interventionists (weitzner-lin et al., 1994; delport, 1998). common attitudes regarding early intervention: the training programme did not influence the nurses' common attitudes as the anova analysis was not significant at the 0.05 level. the findings in table 5 generally indicate that the nurses expressed positive attitudes toward using a team approach to service delivery in early intervention. nonetheless, some of them appear to have reservations about the transdisciplinary concepts of role release and role expansion. community nurses' possession of a common attitude base will facilitate the development of a philosophy towards eci that is shared by speech-language therapists and audiologists (rossetti, 1996). the current finding indicates that the nurses commenced the training programme with a positive attitude toward team management. similar findings were obtained in the recent south african studies by louw and weber (1997) and delport (1998). discussions with the south african nurses during the training programme revealed that they were adequately informed of the importance of teamwork during their pre-service training. they also indicated familiarity with the workings of the multidisciplinary and interdisciplinary team models, but not the transdisciplinary model. it is important to note that the transdisciplinary approach is a relatively recent model of team functioning that is discussed in the literature (briggs, 1997), and this may account for the nurses' unfamiliarity with the model. the nurses' reservations regarding the principles of role release and role expansion may indicate their fear of the loss of professional autonomy and the blurring of professional boundaries, as discussed by briggs (1997). the need for the nurses to be informed of the benefits of transdisciplinary practice for eci is clear, as the short duration of the current training programme may not have been sufficient in this regard. table 5: community nurses' attitudes regarding teamwork in early intervention as evident during the preand post-training phases / / / attitudes toward teamwork % true % uncertain % false attitudes toward teamwork ql q2 q3 ql q2 q3 ql q2 q3 1. a team approach to service delivery is important for effective management of at-risk infants and toddlers. 100 100 100 0 0 0 0 0 0 2. health care professionals should be encouraged to share their discipline-specific knowledge and skills by training other health care professionals. 95.8 95.8 95.2 4.2 0 0 0 4.2 4.8 3. health care professionals should be encouraged to carry out the roles and responsibilities of other professionals, provided that they are trained to do so. 70.8 79.2 71.4 4.2 4.2 4.8 25 16.7 23.8 4. it is important for community nurses and speech-language therapists and audiologists to consult each other about children who are at-risk for developing communication disorders. 100 100 100 0 0 0 0 0 0 key: q l = questionnaire 1. q2 = questionnaire 2. q3 = questionnaire 3. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 legini moodley, brenda louw and hugo table 6: community nurses' specialized knowledge and attitudes regarding early communication intervention community nurses roles in eci specialized knowledge regarding eci specialized attitudes regarding eci screening results per question: dl: table 7 reveals that the nurses' pre-training knowledge regarding the importance of communication for overall development of the child was limited. increased knowledge was evident after training. d2: pre-training knowledge was adequate as > 90% of the nurses considered a communication problem to be a factor that could influence the emotional, cognitive and social development of a child d4: table 8 indicates that the nurses' pre-training knowledge regarding the 13 risk factors was inadequate, but improved after training though not in all. anova: significant at 0.01 level bonferroni test: significant differences between means for questionnaires 1 and 2, and questionnaires 1 and 3. conclusion: training programme did influence community nurses specialized knowledge for screening results per question: before and after the training programme, the nurses expressed positive attitudes towards the assessment of communication skills (d3), and the reliability and validity of the developmental screening assessment utilized at the clinics (d5&6). however, shifts in the nurses' responses across the three conditions of testing indicate some degree of confusion regarding the reliability and validity of the screening assessment. anova: not significant at 0.05 level conclusion :training programme did not influence the nurses' specialized attitudes towards screening identification d7: pre-training knowledge was adequate with respect to factors that adversely affect the results of a communication assessment. a further improvement was noted after training. d8: the nurses were not confident about their knowledge of the eligibility criteria that need to be applied when identifying a child as being at-risk for developing a communication disorder. confidence levels increased significantly after questionnaire 2 (70.8%), but decreased to 57.2% on questionnaire 3 d9: excellent pre-training knowledge of the symptoms of a communication disorder anova: not significant at 0.05 level conclusion: training programme did not influence the nurses' specialized knowledge regarding the identification of children at-risk for communication disorders. referral and monitoring d10: the nurses displayed excellent knowledge in 6 of the 7 roles of the speech-language therapist and audiologist before and after training. knowledge regarding the management of feeding problems appeared to be problematic, even after training. d13: before and after training, the majority indicated that they would refer at-risk children to the speech-language therapist and audiologist d15: pre-training knowledge about the community's speechlanguage therapy and audiology resources was poor, but increased significantly after training. d16: pre-training confidence in the nurses' knowledge regarding eci was inadequate, but improved significantly after training. anova: significant at 0.01 level bonferroni test: significant differences between the means for questionnaire 1 and 3 and questionnaires 1 and 2 conclusion: training programme did influence community nurses' specialized knowledge for referral and monitoring d l l : preand post-training responses supported their roles in eci as identified in the study however, displayed some confusion regarding the depth of the assessment required d12:displayed positive attitudes toward the early referral of at-risk children before and after training d14:preand post-training responses indicated positive attitudes, toward the beneficial effects of speech-language therapy and audiology services for at-risk children 1 d17: overwhelming support for receiving assistance from speech-language therapists and audiologists in the form of inservice training programmes anova: not significant at 0.05 level conclusion: training programme did not influence community nurses' specialized attitudes toward referral and monitoring overall conclusion : the training programme did influence community nurses' specialized knowledge for eci overall conclusion: the training programme did not influence community nurses'specialized attitudes toward eci key: eci = early communication intervention. dl-17: refer to questions in the questionnaires the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) early identification of at-risk infants and toddlers: a transdisciplinary model of service delivery 35 community nurses' specialized knowledge and attitudes regarding early communication intervention table 6 provides a summary of the main findings of the nurses' specialized knowledge and attitudes for each of the four eci roles described. overall findings signify that the community nurses in this study did not appear to possess the specialized knowledge that is required to enable them to effectively execute their tasks in eci. this finding, once again, supports current research literature which contends that many health professionals are inadequately prepared for their roles as early interventionists (weitzner-lin et al., 1994; delport, 1998). the nurses' responses to questions relating to screening are particularly concerning. the fact that a limited number of the nurses were aware of the pivotal role of communication for the early identification of at-risk children is significant. this finding implies that the nurses may not be paying sufficient attention to the communication domain during developmental screenings. research findings by rossetti (1996) clearly emphasize that despite the interdependence among the cognitive, communicative, social and motor domains of development; communication remains an extremely sensitive indicator of an infant's overall development. the nurses' positive responses to this question after the training programme illustrate the positive role that training can play in enhancing their knowledge. the fact that the majority of the nurses displayed limited knowledge about risk factors that contribute to developmental pathology and specifically communication delay, is also significant. the nurses' inadequate knowledge regarding prematurity and low birth weight is especially important as the literature identifies the two as the most important high risk factors that contribute to developmental delay in general, and communication delay in particular (rossetti, 1996). similar findings regarding the nurses' limited awareness of the potential negative effects of low birth weight and feeding problems on communication table 7 community nurses' knowledge regarding the significance of the communication domain, as reflected in the preand post-training surveys: (question dl) significance of the communication domain delayed cognitive development delayed motor development delayed communication development delayed psycho-social development a. the most common symptom of developmental disability in children under 3 years of age is ... questionnaire 1 25% 54.2% 20.8% 0% questionnaire 2 0% 0% 95.8% 4.2% questionnaire 3 9.5% 4.8% 85.7 % 0% cognitive skill motor skill communication skill psycho-social skill b. the skill that has the highest predictive correlation with a child's later intelligence attainment and school performance is ... questionnaire 1 i i 58.3% 0% 37.5 % 4.2% questionnaire 2 j· " 4.2% 0% 91.7% 4.2% questionnaire 3 4.8% 0% 95.2% 0% cognitive skill motor skill communication skill psycho-social skill c. the developmental domain that consistently separates low-risk from high-risk children is the ... questionnaire 1 25% . 4.2% 33.3% 37.5% questionnaire 2 8.3% 0% 87.5% 4.2% questionnaire 3 1 9.5% 0% 81% 9.5% die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 legini moodley, brenda louw and hugo development in infants, were found in the study by louw and weber (1997). it appears that generally, south african community nurses' knowledge with respect to the latter areas appears to be inadequate. the nurses' inadequate pre-training knowledge regarding most of the risk factors that were specific to south africa's third world, multicultural and multilingual context is also noteworthy. the nurses' generally negative responses implied that they were not supportive of the transactional model of infant development that is currently advocated in the literature (rossetti, 1996). the positive effects of training are again evident in the nurses' post-training responses. the training programme did not significantly influence the community nurses' specialized knowledge regarding the identification of infants and toddlers at-risk for communication disorders. the community nurses appeared to be well versed in identifying communication symptoms in at-risk children. this finding was also evident in the study by louw and weber (1997) and may consequently imply that information regarding the symptoms of communication disorders is currently provided by the nurses' discipline-specific training. despite the anova results indicating that the nurses' specialized knowledge for identification of at-risk children appeared satisfactory, the fact that approximately 30% of the sample were not aware of the potential adverse effects of factors that could affect the reliability of assessment results, is significant. according to iglesias and quinn (1997), social and environmental factors could influence the reliability of assessments administered in infancy and childhood. in south africa, the possibility of incorrect identification is great, as the nurses indicated during the training programme that one of the main problems experienced was that children were brought to the clinic by people who were not the primary caregiver. in addition, they stated that cultural and language differences between the children/caregivers and themselves hampered their implementation of the developmental screening assessments. approximately 67% of the sample of nurses in this study were english first language speakers who did not share the language and culture of the majority black population of south africa (pickering et al., 1998). lynch and hanson (1993) as well as iglesias and quinn (1997) assert that the ethnic, culture, and language discrepancies between service providers and families can have a significant effect on the delivery of effective eci services. the community nurses' inadequate specialized knowledge regarding the referral and monitoring of at-risk children serves to further support the need for relevant educational and training programmes. although the nurses appeared to be knowledgeable about the role of the speechlanguage therapist and audiologist, many of them were not aware of the role played by the speech-language therapist and audiologist in the management of children's feeding problems. once again, these findings concur with those of louw and weber (1997). the nurses' generally limited levels of specialized knowledge regarding referral and monitoring is significant since many of them revealed prior to and after training, that referrals would also be made to other health professionals as well as the speech-language therapist and audiologist. a possible explanation for this finding could relate to the limited table 8 community nurses' knowledge of risk factors for communication disorders : (question d4) risk factors % yes % uncertain % no risk factors ql q2 q3 ql q2 q3 ql q2 q3 1. prematurity 66.7 91.7 90.5 8.3 0 0 25 8.3 9.5 2. low birth weight 41.7 87.5 85.7 12.5 0 0 45.8 12.5 14.3 3. developmental motor delay 58.3 91.7 90.5 12.5 0 0 29.2 8.3 9.5 4. syndromes 100 95.8 100 0 0 0 0 4.2 0 5. anatomical defects 87.5 .91.7 95.2 4.2 4.2 0 8.3 4.2 4.8 . 6. feeding problems 45.8 91.7 90.5 25 4.2 4.8 29.2 4.2 4.8 i 7. poor parent-child interaction 100 100 100 0 0 0 0 0 0 ι 8. hearing problems 100 100 100 0 0 0 0 0 0 9. frequent hospitalization 58.3 95.8 95.2 25 0 4.8 16.7 4.2 0 10. the family's poor educational status 33.3 83.3 81 12.5 0 0 54.2 16.7 19 11·: the family's poor socio-economic status 37.5 87.5 81 8.3 0 0 54.2 12.5 19 12. the family's cultural background 37.5 87.5 76.2 12.5 0 0 50 12.5 23.8 13. the family's language background 45.8 87.5 71.4 20.8 0 0 33.3 y 12.5 28.6 i key: q l = questionnaire 1 q2 = questionnaire 2 q3 = questionnaires the south african journal of communication disorders, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) early identification of at-risk infants and toddlers: a transdisciplinary model of service delivery 37 utilization of community-based practice by speech-language therapists and audiologists in south africa (uys & hugo, 1997). this situation would also possibly explain why the nurses have a poor knowledge of speech-language therapy and audiology resources in the community. when interpreting the significant increase in the community nurses' specialized knowledge for eci, it is important to note that these findings could be attributed to the possible effects of testing, experimenter bias, experimental mortality, and the formulation of questions in the questionnaire. with respect to the nurses' attitudes, the fact that they already possessed positive attitudes and beliefs about the outcome of eci, even before training, is encouraging as it reflects the current strength of the nurses' positive attitudes toward eci. finally, despite the positive findings relating to the nurses' attitudes, their responses to some of the questions are disturbing and consequently warrant further analysis and discussion. the perception that an infant's communication development can only be assessed after the child has said the first word (question d3 in table 6), reflects that these nurses appear not to be aware of the concept of continuum of risk. according to this concept, the beginning point for delayed communication skills occurs much earlier than when the child fails to say the first word at approximately one year of age (rossetti, 1996). thus, the nurses' current incorrect perception could have a detrimental effect on the early identification of at-risk infants and toddlers. the nurses' positive response toward receiving assistance from speech-language therapists and audiologists in the form of in-service training programmes is encouraging. although their responses can be viewed as being socially appropriate (rosnow & rosenthal, 1996) similar findings by louw and weber (1997) and delport (1998), serve to confirm this result. in summary, the nurses' positive attitudes and limited specialized knowledge base for eci before training, augurs well for the development of collaborative partnerships with speech-language therapists and audiologists. community nurses' evaluation of the inservice training programme with respect to objective two, all the nurses stated that the training programme had a positive effect on their knowledge and attitudes regarding eci services. the nurses appeared to be satisfied with most areas of the content and structure utilized in this study, except for the presentation time. the majority preferred training programmes to be presented in the mornings rather than afternoons, and over one day, instead of two afternoons. the nurses' suggestions regarding suitable training methods is also noteworthy, as their preferences for the use of videos, case studies and onsite visits clearly demonstrate their need for methods that depict the real life context (bennet, watson & raab, 1991). in conclusion, the overall results of this study clearly reflect that the interdisciplinary in-service training programme did significantly influence the community nurses' knowledge but not their attitudes toward the early identification of at-risk infants and toddlers (0-3 years). conclusions and implications the main finding of this study supports the speech-language therapist and audiologist's use of interdisciplinary in-service training programmes to enhance the knowledge and attitudes of community nurses regarding eci. various implications arise with regard to the role of speech-language therapists and their education and training. however, the conclusions and implications are made cautiously in acknowledgement of the study's exploratory nature and the limitations thereof {leedy, 1993). in view of the importance of the research topic for eci in south africa, it seems reasonable to make some tentative recommendations based on the findings of this study. implications for the roles of speechlanguage therapists and audiologists in the delivery of early communication intervention services in south africa the following implications are identified: adoption of the transdisciplinary team approach to increase accessibility to eci it is recommended that speech-language therapists and audiologists adopt the transdisciplinary team approach as it facilitates the ability of early interventionists to collaborate, and thus provide community-based eci services, as supported by the national rehabilitation policy (1997). the current study clearly demonstrated that by adopting the principles of role expansion and role release, speechlanguage therapists and audiologists are able to utilize interdisciplinary training programmes to improve community nurses' knowledge regarding early identification and appropriate referral of children who are at-risk for developing communication disorders. by expanding their roles from that of service provider to that of educator, speech-language therapists and audiologists become brokers of information (rossetti, 1996). this role enables them to extend their services from the tertiary level of service delivery to that of the secondary and primary levels where at-risk children and families are located. uys and hugo (1997) and delport (1998) emphasize the dire need for speech-language therapists and audiologists to take their services to the clients, rather than waiting for clients to come to the service. collaboration: implications for recommended practice in eci within the constraints of the limited number of qualified speech-language therapists and audiologists currently practising in south africa, it is imperative that speechlanguage therapists and audiologists are proactive in determining appropriate ways of delivering eci services at family health clinics. the community-based model of intervention proposed by fair and louw (1999) may be utilised to guide further research regarding the nature of eci services that south african speech-language therapists and audiologists can provide at family health clinics in south africa. the significance of the concept of collaboration for the role of speech-language therapists and audiologists in eci is evident, however, the current study reflects that the nature of the collaborative relationship appears to differ according to the purpose and people involved in the collaborative partnership. it is clear that speech-language therapists and audiologists need to be competent in die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 legini moodley, brenda louw and hugo developing collaborative relationships with personnel at different levels of the health care system. for example, with key personnel at national level for advocacy purposes, with administrators at management level to gain entry into the discipline specific health service, with health providers in the community, and finally, with families with at-risk children. it is essential that further research is conducted on the nature of the collaborative process that is suitable for the different types of collaborative partnerships in eci. pickering et al. (1998) emphasize the need for identifying professional competencies that transcend those of specific disabilities, and that include those related to interdisciplinary team work in the delivery of community-based service delivery. marketing speech-language therapy and audiology services in addressing the nurses' poor awareness of speechlanguage therapy and audiology services in the community, it is recommended that south african speech-language therapists and audiologists need to increase their role relating to the marketing of eci services for at-risk children (louw, 1997). a six step cross-disciplinary marketing approach devised by fugate and fugate (1996) provides an effective and efficient method of generating professional and public awareness about eci services. training of speech-language therapists and audiologists the present insufficient numbers of qualified speechlanguage therapists and audiologists in south africa clearly highlight the need for the training of more personnel to cope with the current and projected demand for eci services (pickering et al, 1998). in addressing this need, however, it is crucial that recruitment efforts are directed towards increasing the cultural and linguistic diversity of students that is reflective of those shared by the majority population in the country (uys & hugo, 1997; pickering et al., 1998). implication for the education and training of south african speech-language therapists and audiologists in early communication intervention the provision of more indirect, consultative and collaborative services requires speech-language therapists and audiologists to be competent and skilled in areas that they may not have been adequately trained in, during their pre-service years (weitzner-lin et al., 1994). it is therefore important that these areas are identified and adequately addressed in education and training programmes. the need for further training in the development of collaborative partnerships and implementation of interdisciplinary training programmes during the implementation of this study, it became evident that in order for speech-language therapists and audiologists to be able to transform their roles and utilize an alternate model of intervention, they needed to be competent in two vital areas in which they traditionally received little training. these areas are, firstly; collaboration with other health care providers utilizing the principles of the transdisciplinary team model; and secondly, the planning and implementation of interdisciplinary in-service programmes for the education and training of other early intervention professionals. in the implementation of services to at-risk children and their families, it is evident that speech-language therapists and audiologists require specialized attitudes, knowledge and skills that are not adequately provided during their pre-service training (weitzner-lin et al., 1994; delport, 1998). therefore, besides reinforcing the recommendations of delport (1998) regarding the need for further training in the identified areas, it is also recommended that competencies and specific outcomes are clearly identified according to the guidelines of the national qualifications framework. this will serve to guide the development of an appropriate curriculum for undergraduate and continuing educational and training programmes. planning appropriate training programmes the findings of weitzner-lin et al. (1994) are important in the planning of appropriate training efforts, as they indicate that formal course work was not the method through which most speech-language therapists obtained their specialized knowledge base. this study recommended that workshops and in-service.programmes needed to be structured around learning experiences that provided therapists with more hands-on experience with at-risk children and their families. the guidelines provided by roberts et al., (1995) may be used in the development of programmes for speech-language therapists and audiologists' specialization in early intervention. in conclusion, the results of the present exploratory study clearly demonstrate the suitability and potential of collaborative team initiatives in expanding the delivery of eci services in contexts that are plagued with limited financial and human resources. what is evident is that collaborative enterprises present early interventionists, like speech-language therapists and audiologists and community nurses, with challenges that highlight the need for transformation in their respective roles and responsibilities toward the delivery of efficacious eci services to the atrisk population. future research efforts are required to assist early interventionists in this regard by ensuring that solutions proposed are theoretically grounded and practically feasible within the developing south african context. | ι acknowledgements j this article is based on a thesis submitted to the university of pretoria for the masters degree , in communication pathology. assistance is acknowledged from professors brenda louw and rene hugo, as well as colleagues at the university of durban-westville, harsha karthard and cyril govender. references a national health plan for south africa. 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(1994). what specialized knowledge is needed to provide early intervention services in children's hospitals? infant-toddler intervention. the transdisciplinary journal, 4, (2), 87-104. white paper on integrated national disability strategy. (november, 1997). office of the deputy president, t.m. mbeki. rustica press. winton, (1996). a model for supporting higher education faculty in their early intervention personnel preparation roles. infants and young children, 8, (3), 56-67. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 47, 2000 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) fwift low noise, low distortion sound easy to use quick and easy programming high reliability cellphone compatible cost effective vf \ \ , \ ergo! excellent sound quality attractive design high reliability simple programming new advanced features cellphone compatible cost effective then hearing is believing. if you're not yet convinced that oticon leads the way in programmable hearing instruments, we invite you to try the ergo, swiftordigilife.com range for yourself. ergo redefines the fundamentals of hearing care while swift and digilife.com introduce a new concept in affordable hearing care. digilifejcom /digifocusjt advanced digital technology virtually invisible interactive website benefits quick, easy hearing care options cost effective • λ c a l p h o n t c o oticon sounds good to you toll free 0800 650 750 or visit us at www.oticon.com and digilife.com ο i ro r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) http://www.oticon.com a comparative study of inferential comprehension strategies between a language-learing disabled and non language-learning disabled child yael tombak, ba (speech and hearing therapy) (witwatersrand) glenda shapiro, ba (log) (witwatersrand) department of speech pathology and audiology, university of the witwatersrand, johannesburg abstract the aim of this study was to analyse and compare the inferential comprehension strategies used by a language-learning disabled and non language-learning disabled subject, as well as to investigate their performance on areas related to inferential comprehension. for these purposes, tests were either constructed or modified in order to allow for qualitative analysis of the subjects' responses and the strategies used. the non language-learning disabled subject was found to utilize efficient inferential strategies, suggestive of cognitive-linguistic integrity, whereas the language-learning disabled subject was found to use inefficient inferential strategies and to be deficient on several areas related to inferential comprehension. these findings are interpreted as being reflective of a breakdown in the interactional dynamics between cognition and language. opsomming die doel van hierdie studie was om die afleidende-begripsstrategiee wat deur 'n taalleergestremde en 'n nie-taalleergestremde proefpersoon gebruik word, te ontleed en te vergelyk. hulle prestasie in aspekte wat aan afleidende begrip verwant is, is ook ondersoek. vir hierdie doel is toetse opgestel of aangepas om kwalitatiewe ontleding van die proefpersone se response en die strategiee wat hulle gebruik, uit te voer. die nie-taalleergestremde kind het doeltreffende afleidende strategiee gebruik wat kognitiewe linguistiese integriteit aandui. die taalleergestremde kind het ontoereikende strategiee gebruik en was ook ondoeltreffend in aspekte wat aan afleidende begrip verwant is. die bevindings word interpreteer as bewys van 'n disintegrasie van die interafhanklike dinamiek tussen kognitiewe en linguistiese funksie. inferential comprehension refers to the listener's ability to use his real world knowledge, in combination with linguistic information to go beyond the explicitly stated information. thus, a person's ability to engage in inferential comprehension depends on active participation, as well as utilization of a wide variety of stored information, pragmatics and author-reader conventions (thorndyke, 1976). inferential ability is an important component of comprehension and communication. furthermore, it is an important prerequisite for dealing with information in many academic tasks (klein-konigsberg, 1984). the principles of inferential ability are important in reading comprehension (kail et al. 1977). furthermore, language demands placed on students in the academic setting require them "to understand and follow the teacher's directions and to focus and derive main ideas from the teacher's lecture, to organize and store these facts for retrieval" (o'connor and eldredge, cited by nelson, 1986). 1 both cognitive and linguistic hypotheses have been proposed to explain inferential disability (crais and chapman, 1987; ellis weismer, 1985) but only recently has inferential comprehension become an area of interest in the field of language pathology and learning disabilities (freston and drew, cited by crais and chapman, 1987; ellis weismer, 1985; klein-konigsberg, 1984). until recently, most studies of language-disabled children have focused primarily on syntax and morphology (wiig and semel, 1981). the recent shift toward the study of this area — previously the domain of psychological research (bransford and franks, 1971; johnson, bransford and solomon, 1973; paris and carter, 1973; paris and lindauer, 1976) — holds significant theoretical and practical implications relevant to the field of language problems. these implications could have an impact on our current conceptualization of cognitive and linguistic processes that operate in various language disorders, and on the ensuing course of intervention. previous research on inferential ability has revealed some interesting trends. for example, it was noted that younger children lacked a deliberate strategic approach when engaging in inferential comprehension tasks (paris and lindauer, 1976). younger children experienced difficulty integrating premises and manipulating linguistic information in memory, and their schemata were fragmented (danner & mathews, 1980). older children were found to employ more deliberate metamemorial strategies to integrate premises (paris & lindauer, 1976). their verbal representational skills were superior and their schemata richer and more comprehensive (danner & mathews, 1980). in the light of this developmental perspective it was hypothesized that perhaps language-learning disabled children would use earlier developing strategies which are less goal-orientated and task-appropriate. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 © sasha 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 there has been little research into deficient inferential abilities. as with the research on the normal inferential process, these studies were flawed by the lack of an adequate conceptual model or systematic delineation of the abilities examined. despite the scarcity of research on inferential disability in the language-learning disabled population, some trends have emerged from the literature. for example, snyder (cited by ellis weismer, 1985) noted that languagelearning disabled children made fewer inferences as do younger children, and also that their performance is characterized by difficulties with simultaneous analysis and synthesis of information. some writers (carroll, 1986), have suggested that the language-learning disabled children have poorly integrated schemata, whilst crais and chapman (1987) attributed inferential disability to poor verbal comprehension. recent literature on the nature of learning disabilities reflects an orientation which considers strategic inefficiency to be central to academic under-achievement (reed & hresko; torgeson; cited by wiig and secord, 1985). therefore, the primary aim of this study (tombak, 1987) was to analyse and compare the inferential comprehension strategies used by a language-learning disabled and non languagelearning disabled child. a strategy-based approach was used as it was considered to be a valid method for qualitative investigation of linguistic cognitive processes. with this in mind, the writer (tombak, 1987) conceptualised a model of inferential comprehension in which the inferential comprehension process may be viewed as an interaction between the text and what the listener brings with him to the comprehension process, resulting in the product or inference (see figure 1). yael tombak and glenda shapiro the contextual basis of inferential ability was considered in terms of the 'microstructure' (carroll, 1986), and the linguistic factors which may affect comprehension. listener variables were considered in terms of macrostructure and schematic knowledge. these refer to the listener's knowledge of the standard arrangement of information and generalized experiential knowledge respectively (moates and schumacher, 1980). problem-solving strategies were also taken into account. lastly, the final inference product was analysed in terms of inferential subject matter and the role of an interceding inference. this model attempted to delineate the main factors involved in the inferential comprehension process. it also aimed to provide a method of systematic task analysis, in order to establish and interpretive basis for the subjects' inferential performance and the strategies used. aims the primary aim of this study was to analyse and compare the inferential comprehension strategies used by a languagelearning disabled and non language-learning disabled child. the specific aims of the study were to describe the different inferential strategies used by these two children in a systematic, qualitative manner and to investigate the influence of selected task factors on the strategies used. subject description si was a 13.0 year old learning-disabled male. he was a standard 5 pupil at a remedial school which he had been attending for the past 2 years. on the wechsler intelligence figure 1: model of inferential comprehension 2. 3. microstructure • text organization • contextual basis text lexical implications intersentential relations 2. linguistic factors [—vocabulary i— embedding i— passivization subject matter .— event • subjective state inference 2. interceding inference macrostructure schemata/script strategies listener i the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a comparative study of inferential comprehension strategies 5 scale for children — revised, he obtained a full sclae intelligence quotient of 101, indicating intellectual functioning within the normal range. there was no significant discrepancy between his verbal and performance intelligence quotients. si experienced difficulty in the areas of reading and spelling, scoring 2-4 years below his chronological age level on formal reading and spelling tests. narrative language sampling and formal testing of auditory memory for paragraphs and story material (see table 1, criterion tests), revealed age-appropriate performance. language comprehension was not considered a subject selection criterion because this component was evaluated as a\correlation factor to inferential ability. s2 was a 12.9 year old non learning-disabled male in standard 5 at a regular school. there was no history of academic difficulty and school progress was good. narrative language sampling and formal testing of auditory memory for paragraphs and story material (see table 1, criterion tests), revealed age-appropriate performance. description of test battery (see table 1) table 1: the test battery criterion tests 1. c.e.l.f.:— subtest 6 (semel & wiig, 1980) 2. story recall "the stork in the wheat" (berry, 1969) 3. narrative tasks:— sequence story, poster picture and perso• nal narratives (westby, 1984) the test battery administered was considered under the following three categories:j— a) criterion tests: these were. tests utilized to assess the subject's fulfilment of preselection criteria. b) correlation tests: these tasks were used to evaluate the subjects' performance in areas related to inferential comprehension.. c) main test: these constituted the primary tests of inferential comprehension. a) criterion tests tests of auditory memory clinical evaluation of language functions (c.e.l.f., semel and wiig, 1980) subtest 6 — processing spoken paragraphs. story recall (berry, 1969) a test story, "the stork in the wheat", was used to measure retention and recall of salient sequential information in a story. expressive language tasks (westby, 1984) expressive language was evaluated using three narrative language tasks: a sequence story narrative, poster picture narrative and personal narrative. responses to the stimuli were evaluated in terms of 'spontaneous inferencing', or spontaneously generated inferential elaboration. b) correlation tests adequate grammatic comprehension, receptive vocabulary and schematic knowledge are considered to be critical for linguistic comprehension. these areas were tested to examine the relationship between these factors and inferential ability. grammatic comprehension tests test of adolescent language (t.o.a.l.; hammill et al. 1980) subtest 2 — listening/grammar embedding test this test was adapted from a test constructed by penn (1972) and was designed to assess comprehension of relative, complement and multiple-embedded sentences. main tests 1. spontaneous inferencing 2. t.o.l.c:— bubtest 2 (wiig & secord, 1985) 3. inferential comprehension test 1 4. inferential comprehension test 2:— microstructure, embedding, passivization, vocabularly, interceding, inference wiig-semel test of linguistic concepts — passive concept (wiig & semel, 1976) receptive vocabulary peabody picture vocabulary test — form a (p.p.v.t.; dunn, 1965). schematic knowledge schema test this test, adapted from bower, black and turner (cited by reed, 1982), was designed to assess the comprehensiveness of the subjects' schemata for five common situations involving event and action sequences. c) main tests evaluation of spontaneous inferencing the sequence story and poster narratives were analysed in correlation tests 1. t.o.a.l.:— subtest 2 (hammill et al. 1980) 2. embedding test (adapted from penn, 1972) 3. wiig-semel test passive concept (wiig & semel, 1976) 4. p . p . v . t . : f o r m a (dunn, 1965) 5. schema test (adapted from bower, black & turner; cited by reed, 1982) die suid-afkaanse tydskrif vir kommunikasieafwykings, vol. 5, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 yael tombak and glenda shapiro terms of the spontaneous inferences generated. test of language competence (t.o.l.c.; wiig and secord, 1985) subtest 2 making inferences (see appendix 1) this subtest evaluated the ability to make causal inferences based on existing event chains in which one or more causal links were missing. where appropriate, the subjects were probed for linguistic explanation, justification and elaboration of their responses. inferential comprehension test 1 (see appendix 2) this was the first of two tasks devised by the experimenter, specifically for this study, in order to evaluate inferential strategies. items consisted of sentence pairs followed by a question, and were organized according to the conceptual model outlined earlier (see figure 1). the inferential abilities required for these tasks were primarily based on real world knowlege. the tasks were linguistically simple to minimize the influence of linguistic factors. inferential comprehension test 2 (see appendix 3) this test used a paragraph format and was more reliant on linguistic factors for comprehension. each of the factors considered was represented by a pair of thematically similiar paragraphs, one of which was systematically varied with regard to that factor. each paragraph was followed by questions and probing. methods of analysis criterion and correlation tests these were scored according to test manual instructions, or specially devised scoring systems for each test, which were constructed for the purpose of the study. main tests evaluation of spontaneous inferencing the number of spontaneous inferences generated by the subjects was calculated and the nature of the inferences qualitatively described. test'of language competence — subtest 2 (wiig and secord; 1985) i ι i four analyses were carried out on the response data obtained:^ / quantitative analysis — scoring based on point calculation was utilised. quantitative analysis of strategies — the t.o.l.c. responses were analised qualitatively by the examiner. the responses were organized by the examiner into 12 major categories of deficient strategies (see results section). divergent shift analysis — this analysis considered the subjects' ability to make divergent conceptual shifts. congruency analysis — this analysis considered the subjects' attention to semantic congruency between response alternatives. test of inferential comprehension 1 the responses were qualitatively analysed in terms of strategies. test of inferential comprehension 2 the paragraph pairs were analysed in terms of strategy patterns, divergence, and the effect of factor variation on performance. results and discussion the subjects' performance on the criterion, correlation and main tests were analyzed quantitatively and qualitatively, and compared. their responses on the main tests were considered to reflect the inferential strategies utilized. a) criterion tests both subjects scored above the revised pass-fail criterion of 14 on the c.e.l.f. subtest 6 (semel & wiig, 1980) indicating the presence of adequate auditory memory for paragraph material. on the story memory task (berry, 1969), both subjects scored above 70%, calculated using a scoring system devised by the examiner (tombak, 1987). the scores were interpreted as reflective of adequate auditory memory for complex'story material. both subjects fulfilled the criterion of adequate verbal expression on the narrative task battery. however, although both subjects were able to verbally express their ideas in a clear manner, their expressive abilities differed along the dimensions of spontaneous inferencing and coherence in favour of s2. b) correlation tests (see table 2) si's performance was below average on the following tasks: ι — t.o.a.l. subtest 2 (hammill et al. 1980) i — embedding test i — test of linguistic concepts — passive concept (wiig & semel, 1976) | , — description of schematic events, which was fragmented. si performed adequately on the p.p.v.t. — form a (dunn, 1965) s2's performance was average to above-average on all the above tasks. of significance was his much superior performance on the p.p.v.t, — form a (dunn, 1 9 6 5 ) / the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) comparative study of inferential comprehension strategies 7 t a b l e 2: correlation tests si s2 t.o.a.l. below average scaled score = 5 average scaled score = 10 embedding test poor percentage = 43% good percentage = 87% wiig — semel test std 1 level percentage = 70% std 6 level percentage = 100% p.p.v.t. average mental age = 12.7 yrs percentile = 45 above average mental age = 18 + yrs percentile = 94 schema test poor raw score = 27 good raw score = 41 c) main tests evaluation of spontaneous inferencing there was a marked difference between the subjects' spontaneous inferencing abilities, both quantitatively and qualitatively. spontaneous inferencing was measured quantitatively in units, each unit being an inferential proposition or item of information. this scoring system was developed for the purpose of the study (tombak, 1987). unit scoring was carried out by the examiner. si generated a total of 4 units (picture narrative — 2 units, poster narrative — 2 units), in contrast to a total of 30 units produced by s2 (picture narrative — 12 units; poster narrative — 18 units). si's narratives lacked elaboration, and were concrete and highly stimulus-bound, and there was inadequate thematic content. s2's inferences were complex narrative sequences elaborating on preceding and consequent events, motivations and internal states. test of language competence quantitative analysis:— si experienced great difficulty with inferential reasoning, and selected a low proportion (43%) of correct inferential responses, while s2 selected a high proportion (87%) of correct responses. qualitative analysis:— this analysis was devised to compare and contrast the nature of the deficient strategies used by the 2 subjects. as stated earlier, the responses were organized by the examiner into 12 categories of deficient strategies (see figure 2). the first ten of these were grouped into four strategy clusters, designated by the letters (a) — (d). each cluster corresponded to a number of ineffective ways of implementing a constructive strategy. strategy cluster a: divergent thinking ι figure 2: strategy analysis 1.1 concretism 1.2 conceptual syncretism 2. lexical syncretism 3. psychological explanation 4. linguistically-contradicted divergence 5. linguistically-unsupported divergence 6. literal comprehension difficulty 7. illogical inference i.t.o. real world knowledge 8. non-optimal inference i.t.o. real world knowledge strategy cluster b: convergent thinking strategy cluster c: utilization of real world knowledge strategy cluster d: causal reasoning die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 yael tombak and glenda shapiro a. strategy cluster a this cluster was related to difficulty with divergent thinking. 1.1 concretism concretism refers to the inability to go beyond the linguistic context presented. a concrete answer lacks hypotheticodeductive reasoning. eg. t.o.l.c item 5 (si) (e = examiner; s = subject). e: they talked to a policeman because ... s: because bob had bad luck. this category occurred frequently in si's responses as opposed to s2's, where no instances were noted. si relied heavily on linguistic context, reflecting deficient hypothetical reasoning. in contrast, s2's responses were hypotheticodeductive. 1.2 conceptual syncretism conceptual syncretism is a piagetian concept which refers to a tendency found in preoperational and concrete operational thought — to juxtapose rather than synthesise logical and causal relations (piaget, 1927). a syncretic response is characterised by an indiscriminate linkage of two verbal statements with no consideration of their conceptual relationship. eg. t.o.l.c trial item (si) e: they had to go to eat at a restaurant because... s: they had a turkey at home and they wanted to eat at a restaurant. this strategy occurred exclusively in si's responses. due to si's inability to go beyond th€ linguistic context into the realm of hypotheses, he adopted the strategy of randomly juxtaposing any two salient concepts presented simultaneously, and forming a syncretic connection. s2's reasoning, in contrast, was highly divergent and hypothetical. si's deficit was characteristic of preoperational difficulty with constructing relationships that reflect attention to and simultaneous retention of all critical relevant information. previous investigations have also documented difficulties in simultaneous analysis and synthesis of information in learning-disabled children (crais and chapman, 1987; gerber, 1981; klein-konigsberg, 1984). 2. lexical syncretism this term refers to the tendency to juxtapose any two lexical items indiscriminately, with no apparent conceptual basis for this fusion. eg. t.o.l.c. trial item (si) e: do you have any idea why ... they weren 't able to eat at home? s: because the house was trimming this tendency was a unique feature observed in si's responses, and appeared to be a primitive, and possibly deviant manifestation of conceptual syncretism, which resulted in distortion of the relationships depicted. si resorted to this preoperational strategy when he experienced a comprehension breakdown. a similar finding was also reported by klein-konigsberg (1984) who found that language-learning disabled children tended to attend to smaller sentence constituents when applying integrational strategies. 3. psychological explanation this refers to the preoperational tendency to provide a psychological explanation when a casual event explanation would be more appropriate (piaget, 1927). eg. t.o.l.c. item 1 (si) e: jack didn't leave a tip because ... s: he didn't-feel like leaving a tip. si tended to give psychological explanations of events, while s2 formulated hypothetical causal events. cluster a (1, 2, 3) represented deficits in divergent thinking. si's responses were overreliant on linguistic contest, and reflected analytic deficits. si lacked the ability to depart from reality. the strategies used by si interfered with divergence and the ability to formulate causal event relationships. snyder (cited by ellis weismer, 1985) also reported divergence deficits in a group of language-disordered children studied. b. strategy cluster β this cluster represented problems with converging to the linguistic context. 4. linguistically-contradicted divergence 7 ι this feature is associated with the tendency to ignore or misinterpret critical linguistic sequences, due to insufficient cognizance of linguistic information that suggests a contrary direction or focus of inferential convergence. eg. t.o.l.c. trial item (si) i e: they had to eat at a restaurant because ... s: they had a turkey at home and they wanted to eat at a restaurant. si used this strategy frequently, often ignoring or misinterpreting salient linguistic information. this feature also occurred in s2's responses to a lesser extent. it appeared that si's preoperational difficulty with simultaneous analysis and synthesis of information, resulted in unpermissible divergent responses. / eg. t.o.l.c. item 6 (si) e: eric was grateful to his uncle fred because ... s: (selects alternative a:) uncle fred bought himself a moped ... because his uncle didn't have a bike and then he bought one. this strategy occurred frequently in si's responses, in those the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) comparative study of inferential comprehension strategies i n s t a n c e s when he did attempt to diverge beyond the linuistic context but it did not occur in s2's responses. this strategy was used when the linguistic context was not fully u n d e r s t o o d , due to fragmented lexical schemata. poor assimilation and accommodation strategies may account for such deficient schemata. 6. literal comprehension difficulty this refers to difficulty in comprehending the basic relationships depicted, due to vocabulary deficits. eg. t.o.l.c. trial item (si) e: do you have any idea why ... they weren't able to eat at home? s: because the house was trimming. literal comprehension deficits were rare in si's responses and absent from s2's responses on this test. strategy cluster β (4, 5, 6) represented deficits in linguistic convergence. si failed to perceive several lexical implications and their interactions simultaneously, reflecting a preoperational tendency to attend to only one feature or property at a time (wiig & semel, 1984). s2, on the other hand was able to attend to the full scope of the linguistic information presented, resulting in "lawful divergence" (phillips, 1971). difficulties in simultaneous analysis and synthesis have been noted in language-learning disabled children (crais and chapman, 1987; ellis weismer, 1985; kleinkonigsberg, 1984) as well as younger normal children (paris and lindauer, 1976). c. strategy cluster c this cluster was related to ineffective utilization of real world knowledge. 7. ,,·illogical inference in terms of real world knowledge this feature refers to the formulation of inferences which are implausible in terms of real world knowledge. eg. t.o.l.c. item 5 (si) ! e: they talked to a policeman because ... s: ... because they rode on a crowded bus. only si formulated inferences that were implausible in terms of real world knowledge. it seemed that si had not acquired comprehensive schemata, as indicated by his performance on the schema test. his schemata appeared to lack refinement, and resisted absorption of new information. this deficit could also be related to inadequate accessing as well as induction of schemata (carroll, 1986). 8. non-optimal inference in terms of real world knowledge this feature is characterised by the formulation of plausible, but unlikely inferences due to inefficient utilization of real world knowledge. eg. t.o.l.c. item 1 (si) 9 e: jack didn't leave a tip because ... s: he didn't feel like it ... he was unkind. si tended to make illogical inferences, in contrast to s2 whose inferences were always plausible, although not always probable. strategy cluster c (7, 8) was concerned with the utilization of schematic knowledge in generating logical inferences. fragmented schemata result in implausible or non-optimal inferences. this strategic failure could be caused by poorly induced schemata or failure to access the appropriate schemata timeously. d. strategy cluster d this strategy was related to causal reasoning. 9. inversed cause-effect reasoning this feature refers to reasoning which is characterised by inadequate distinction between and sequencing of cause and effect events. inversed causal reasoning is characteristic of preoperational and concrete operational thinking and is associated with egocentrism and a tendency towards syncretic perception (phillips, 1971). eg. t.o.l.c. item 5 (si) e: they talked to a policeman because ... s: (selects d:) bob lost his money sometime before they got to the mall... because they couldn't pay for the bus. the expression of the causal relationship was inversed by si and an effect was formulated instead of a cause. s i ' s responses were characterised by deficient causal reasoning as his concept of 'because' was associated with a sequential meaning, rather than a true concept of causality. s2's reasoning was characterised by explicit delineation of causeeffect relationships and he was able to distinguish clearly between cause and effect. 10. egocentric reasoning egocentric explanations are characterised by presupposition of the listener's knowledge of the speaker's internal reasoning process. egocentric reasoning is a characteristic of preoperational thought. eg. t.o.l.c. item 1 (si) e: he didn't leave a tip because ... s: (selects a) the restaurant closed when he arrived. e: why do you think that's a good answer? s: because he didn't leave the waiter a tip. e: and c), 'the food and service were excellent? s: yes, the food and service were excellent. egocentric reasoning was a common feature of si's reasoning while only one instance was observed in s2's responses. egocentric explanations are characteristic of preoperational reasoning, and are caused by a lack of concern for the listener's perspective (piaget, 1923). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 yael tombak and glenda s h a p i r o strategy cluster d (9, 10) was concerned with the role of causal reasoning in inferencing. si's reasoning was characterised by poor comprehension of cause-effect relationships and egocentrism, reflective of a cognitive developmental lag (phillips, 1971). s2 was able to engage in formal-operational explicit causal reasoning. 11. interceding inference when a final inference relies on an intermediate step or inference, the task is complicated since a faulty interceding inference may lead to the induction of a faulty final inference. eg. t.o.l.c. item 9 (si) lori took the bus downtown because it was her mother's birthday. she left the fashionable stores with tears in her eyes. e: lori cried because ... s: maybe her mother didn't have any money with her so she could buy clothes and that ... the interceding inference that 'lori went to town to buy her mother a birthday present' was not included. si's inferential reasoning frequently broke down as a result of faulty interceding inferences. s2 was generally able to generate correct interceding inferences. 12. alternative inference this category was related to difficulty with divergent conceptual shifting. eg. t.o.l.c. item 6 (si) e: eric was grateful to his uncle fred because ... s: because his uncle let him use the bike for a long time. e: can you think of another reason why he was grateful? s: because his uncle let him ride it. si consistently offered a paraphrase of previous explanations as an alternative inference, retaining the same conceptual basis for all interpretations (wiig & secord, 1985). s2's responses were characterised by alternative interpretations and a more divergent orientation. si's responses reflected deficits in divergent conceptual shifting, resulting in overreliance on linguistic context. this finding was in agreement with that of snyder (cited by ellis weisman, 1985) who found that language-disordered children made fewer inferences than age peers. difficulty with conceptual shifting has also been documented in the learning disabled population (wiig & semel, 1976). the difference in divergence abilities appeared to be diagnostically significant. this deficit appeared to be central to si's inferential disability. divergent shift analysis sl'.s responses were characterised by few conceptual shifts (total = 3 conceptual shifts) and a low proportion (30%) of matching inferences. s2's responses were divergent, with a high level of conceptual shifting (total = 10 conceptual shifts) and a high proportion of matching inferences (90%). eg. poor conceptual shifting item 6 (subject 1) e: eric was grateful to his uncle fred because ... s: (1) because his uncle could let him use the bike ... (2) because his uncle let him ride it. number of matching inferences in above example = 0/2. neither of the above inferences matched the correct responses listed for item 6 (b, d). eg. good conceptual shifting item 1 (subject 2) e: jack didn't leave a tip because — s: (1) because the restaurant wasn't good. the food was bad and the service was bad. " " (2) he never had any small change on him. number of matching inferences in above example = 2/2. these 2 inferences above matched the correct responses listed for item 1 (b, d). congruency analysis si tended to ignore congruency between response alternatives, reflecting difficulty with simultaneous analysis and synthesis, suggesting a cognitive lag. this difficulty has been noted in the language-learning disabled population (crais and chapman, 1987; ellis weismer, 1985), as well as in younger normal children (paris and lindauer, 1976). test of inferential comprehension 1 both subjects performed adequately on this test, which relied primarily on schematic knowledge, rather than linguistic context. however, s2's responses were more divergent, and contained more conceptual shifting. test of inferential comprehension 2 this test was analysed in terms of the effect of factor variation on inferential ability (see table 3). it was found that the factors or forced reliance on schematic knowledge, reversible embedding and passivization, and unclear intersentential relationships, had an adverse effect on only si's performance. both subjects' performance was adversely affected by complex vocabulary level and the presence of an interceding inference. however, s i ' s problems resulted in more extensive utilization of the deficient strategies described in the t.o.l.c. analysis. table 3: results of inferential comprehension test 2 j factors si s2 ! vocabulary ( ) ( ) schematic knowledge ( ) n.e. embedding (nr) n.e. n.e. (r> ( ) n.e. passivization (nr) n.e. n.e. (r) ( ) n.e. microstructure ( ) / n.e. interceding inference ( ) · ' ( ) key: nr = non-reversible r = reversible n.e. = no effect on performance ( ) = adverse effect on performance the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a comparative study of inferential comprehension strategies 11 non-reversible passivization and embedding had no effect on the subjects' comprehension, since the paragraph content was highly predictable due to the presence of semantic constraints. s i ' s breakdown in inferential reasoning, precipitated by some of the factors listed above, paralleled his inferior results on the correlation tests. this confirmed previous findings of such deficits in the learning-disabled population (wiig & semel, 1976; 1984). s2's performance was not affected by the influence of the factors studied, with the exception of vocabulary level and presence of an interceding inference. s2's responses were generally hypothetico-deductive and formal-operational, in contrast to s i ' s concrete syncretic reasoning. \ although both subjects' comprehension was affected by the level of vocabulary complexity, the subjects reacted differently to this factor. si resorted to a syncretic response, beforel attempting a strategy of overreliance on real world knowledge. s2 also ignored difficult lexical items but did not use primitive syncretic strategies. instead, he used a more appropriate strategy of imposing linguistic coherence by integrating what he had understood with his real world knowledge. with regard to the interceding inference factor, si made an incorrect interceding and final inference. s2's deduction of the interceding inference was influenced by residual preoperational difficulty with distinguishing real world from imaginary events (phillips, 1971). the relationship between imagination and inferential ability has not been addressed in the literature, but may be of interst for further investigation. conclusions the findings of this study suggested that the nature of learning-disability could be conceptualised in terms of a verbalcognitive interactional model. the study of inferential ability^permits generalizations about verbal and cognitive skills, since both verbal and cognitive knowledge are required to engage in inferential reasoning. cognition higher levels of logical reasoning i (i) u language higher level linguistic concepts verbal reasoning (ill u figure 3: interactional model of verbal-cognitive dynamics the main conclusion of this study was that the performance discrepancies documented, pointed to deficiencies in verbal-cognitive ability or 'verbal thought' (vygotsky, 1962) (see figure 3). the language-learning disabled child presented with:— — cognitive deficits that interfered with the growth of formal verbal reasoning and the acquisition of higher level linguistic concepts. this would be in agreement with bryen (1981) who asserted that "... this linguistic delay is not caused by inability to acquire certain linguistic symbols, but rather by reduction or delays in the acquisition of logical structures that determine their meaning". — linguistic deficits that possibly interfered with the development of higher levels of logical thinking and conceptual thought, as asserted by bruner (cited by lerner, 1976), and piaget (1967). however, the exact interactional dynamics between cognition and language in learning disabilities is still a topic of controversy as reflected in the following conclusion:— "the degree to which language delay contributes to or is a function of ... cognitive delay must still be determined" (gerber, 1981). however, it must be noted that a limitation of the study was the use of only 2 subjects which restricted a generalisability of the study. the study should be replicated on a larger sample in order to verify results. in addition, future research should address the issue of subjective evaluation by making use of more than one rater, and ensuring inter-rater reliability." this study highlighted the fact that comprehension is a multi-faceted process and that various aspects of this ability should be considered in therapy. the results of this study, when considered within the theoretical framework proposed earlier, suggest that therapeutic intervention could be systematically organized to focus on various components considered by the model of inferential ability described. this study outlined certain areas of particular importance for therapy with a patient with inferential deficits and strategic breakdown. therapy should consider such areas as schematic induction and accessing, a higher level linguistic deficits. therapy could focus on the comprehension of causal relations and other connective relationships. therapy should also stress comprehension of anaphoric devices and memory strategies (gerber, 1981; klein-konigsberg, 1984). therapy should emphasise lawful divergence and formulation of plausible hypotheses. finally, the therapist should stress the importance of the listener's perspective and encourage explicit reasoning and an analytical orientation. this study generated some implications for further research. developmental studies of inferential abilities in both normal and learning-disabled populations, are needed. other factors of the inferential comprehension model outlined earlier, may be investigated, such as the influence of level of abstraction, text organization or other categories of inference, on inferential strategies. the relationship between inferential ability and imagination has not been addressed in the literature, and constitutes an interesting area for investigation. the relationship between inferential comprehension and academic performance also needs to be considered in more depth, and the relationship between cognitive and linguistic deficits in learning disability warrants more attention. finally the construction of assessment tools for evaluating inferential comprehension skills, is required. the study of inferential ability holds interesting theoretical and practical implications for both speech therapists, educationalists and researchers. the continued investigation of this area is important, in view of its potential to clarify many controversial issues related to language pathology. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 references berry, μ. language disorders in children. appleton-century crofits, new york, 1969. bransford, j.d. and franks, j.j.: the abstraction of linguistic ideas. cognitive pshychology, 2, 3 3 1 3 5 0 , 1971. bryen, d.n. language and language problems. in: a. gerber and d.n. bryens (eds). language and learning disabilities. university park press, baltimore, 1981. carroll, d.w. psychology of language. brooks/cole 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d.n. bryen (eds). language and learning disabilities. univerity park press. baltimore, 1981(b). hammill, d.d., brown, v.l., larson, s.c. and wiederholt, j.l. test of adolescent language. pro-ed, austin, texas, 1980. johnson, m.k., bransford, j.d. and solomon, s.k. memory for tacit implications of sentences. journal of experimental psychology 98(1), 2 0 3 2 0 5 , 1973. kail, r.v., chi, m.t., ingram, a.l. and danner, f.w. constructive aspects of children's reading comprehension. child development, 48, 6 8 4 6 8 8 , 1977. klein-konigsberg, e. semantic integration and language learning disabilities: from research to assessment and intervention. in: g.p. wallach and k.g. butler (eds). language learning disabilities in school-age children. williams & wilkins, baltimore, 1984. lerner, j.w. children with learning disabilities: theories, diagnosis and teaching strategies. houghton mifflin company, boston, 1976. moates, d.r. and schumacher, g.m. an introduction to cognitive psychology, wadsworth publishing company, inc., belmont, california 1980. yael tombak and glenda shapiro nelson, n.w. beyond information processing: the language of teachers and textbooks. in: c.p. wallach & k.g. butler (eds). language learning disabilities in school-age children. williams and wilkins, baltimore, 1986. parades, k. drawing conclusions. frank schaffer publications, inc. california, 1980. paris, s.g. and carter, a.y. semantic and constructive aspects of sentence memory in children. developmental psychology, 9(1), 109-113, 1973. paris, s.g. and lindauer, b.k. the role of inference in children's comprehension and memory for sentences. cognitive psychology, 8, 2 1 7 2 2 7 , 1976. penn, c. a linguistic approach to the detection of minimal language dysfunction in aphasia. unpublished undergraduate research report, department of speech pathology and audiology, university of the witwatersrand, 1972. phillips, j.l. piaget's theory: a primer. w.h. freeman and company, san francisco, 1971. piaget, j. the language and thought of the child (1923). in: h.e. grohen and j.j. voneche (eds). the essential piaget. routledge & kegan paul, london, 1977. piaget, j. judgment and reasoning in the child (1927). in: h.e. groher and j.j. voneche (eds). the essential piaget. routledge & kegan paul, london, 1977. piaget, j. six psychological studies. university of london, 1967. reed, s.k. cognition: theory and applications. brooks/cole publishing company, montery, california, 1982. semel, e.m. and wiig, e.h. clinical evaluation of language functions. charles e. merrill publishing company, a. bell & howell company, columbia, ohio, 1980. thorndyke, p.w. the role of inferences in discourse comprehension. journal of verbal learning and verbal behaviour, 13, 4 3 7 5 0 6 , 1976. tombak, y. inferential comprehension strategies in a languagelearning disabled child. unpublished undergraduate research report, department of speech pathology & audiology, university of the witwatersrand, 1987. vygotsky, l.s. thought and language, 5 m.i.t. press, massachusetts, and john wiley & sons, inc., new york, 1962. westby, c.e. development of narrative language abilities. in c.p. wallach and k.g. butler (eds). language-learning disabilities in school-age children. williams & wilkins, baltimore, 1984. wiig, e.h. and secord, w. test of language competence. charles e. merrill publishing company, a. bell & howell company, columbus, ohio, 1985. wiig, e.h. and semel, e.m. language disabilities in children and adolescents. charles e. merrill publishing company, columbus, ohio, 1976. wiig, e.h. and semel, e.m. language assessment and intervention for the learning-disabled. charles e. merrill publishing company, a. bell & howell company, columbus, ohio, 1984. the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a comparative study of inferential comprehension strategies appendix 1: test of language competence (wigg & secord, 1985) subtest 2: making inferences <d & 31 φ ο ) ο c d j s — ο c q ) cd i i <3 ε ΐ § ..·* ε ω ϋ -π q< ϋ aj j « ϊ « ω c — to ο ε ι . jjg ε ϋ υ (0 c •βΰ: s μ s 2 υ c c ·ι •σ _ . 3 2 •c ξ ει3 bo 2 £ . ίτ s 5d ε 25. ο ε c3 υ ώ oj >, > j5 to τ3 bo j3 qj t χ £ •c ™ ώα α α λ j3 g 3 qj l . a 3 £ > " ο oj c ! ι a a s 8 8 υ υ ο ϊ ΐ ι έ τ3 • > ο „ . ε β β i 8 a i § ο 53 -ό α. 1 3 « a •ΰ s-s g -w ο ο 5 =β » « s >, £ s ώ ? h d • cd ό j3 5 <u •β h (u π w aj 3 to j3 g £ ο a l i w ο l j £λ c/i 1) s £ '••zil i η si 01 to υ ί qj xi μ ·£ -π • ο ζ 52 ^ 1ί u 32 qj 'c ϊ -β ~ >-) ιλ oj tfl u ί 3 ί 1/5 λ (λ re .b • • re •a " -π ο »η ϋ 60 α α 2 ^ c ο λ 0) w 3 .. c™ 3 e j3 j3 c qj λ 12 s qj 1) χ ε ε ο (λ s "s (λ qj χ § 2 ο 5 r ϋ a ω υ λ. έ ϊ ϋ to <u •β « j3 · ό « s ju s * s " α ϊ s s l i s ο δ~ c . 8 0-3 w « ό jy ο υ η 2 2 ε 2 2 d • j3 j3 5 5 •π 2 > 0) > cao μο .3 •t? ™ 0j ο •π ξ π > sj5· t3 «>2 ™ -3 υ u υ c «» « u s-^o ά s ζ ο ί j3 •β •8 υ re 60 •ο τ3 τ3 {jj (η -c ε ο οο 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"2 — λ α; s αϊ χ η χ u υ τ3 • • 4) . •£ ό ^ .s 1 ρ 5 « qj ϊ ϋ 3 0j " co ν> λ 2 ε ο η ^ ο -ό co •π -ο to oj -ex ε η hq ε 2 qj oj a> j 5 ji • υ 'β, iu j3 1 ε — ° 2 ° o .. •ο 5p a s *j c « s i i l 3 '5 s> j3 co t3 i s s s s έ a s si ~ δ i s i ο t; <u "s •s s ω ο ·η c ρί d-2 iu ο υ τ3 t3 <u c « λ iu * a ao-s · u t3 .5 d,.1;» 2 "3 js s -m c « c en 3 t3 oj s i £ ό j ή >, 2 .tl qj d ĵ h ch 3 c h o • μ § iu α 2 >< s § co w ε s h ό 3 si 0> ia λ χ bb £ •1 ε 1 1 1 . to q. ο jii ί3·ο g 1 • 1 $ o crt -ir crt o, " "d iu • λ i c 2 <υ α> s ε ε s t/ί qj c •s ω to xt . 2 μ i i s co v) 00 s.s c: 10 i s § c „ •α β =3 ? m 11 to 'θ ^ 53 co sd η <u s 1; 00 c j= aj _ i t ε • 60 2 a a i ! ±j ο (λ • g to 1 j3 1 ε ε 3 j r v) ο qj 01 λ £ 2 (s £ 2 3 1 s s-g s · ! cj cq t3 ^ 2 ο l i si t3 v -c ^ 00 re g ο ε " « m ν a υ a> 5 a > 0 ε « to „ 0) "73 •sag s 0 t3 l. <u x) 05-"8=3 >—i qj t3 2 ο 1 1εξ§ j3 s o • die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 yael tombak and glenda shapiro appendix 2: test of inferential comprehension 1 a. inference of event 1. antecedent inference a. alan came home from school. he gave his mother the teacher's note. why had the teacher sent the note? b. paul went to the shops to buy yoghurt. he came home without the yoghurt. why did paul come home without the yoghurt? 2. interceding inference a. mrs ray received a dress by post. she had to take it back to the shop. why did mrs ray have to take the dress back? (adapted from paredes, k.: drawing conclusions, card 23(3). frank schaffer publications, inc., california, 1980). b. john had to pay a lot of money for the repairs. on his way home, he did not give the beggar any money. why didn't john give the beggar any money? 3. future inference a. mrs dean wanted a certain book about gardening. the bookshop did not have it. what do you think mrs dean will do? (adapted from paredes, k: drawing conclusions, card 27(2). frank schaffer publications, inc., california, 1980). b. greg pressed his face against the window. he wanted to see how the chefs made pizza. suddenly the window steamed up. what do you think greg will do? (adapted from paredes, k: drawing conclusions, card 27(2). frank schaffer publications, inc., california, 1980). b. inference of subjective state 1. reaction-based inference a. leah had a test. afterwards, she tore the test paper into little bits. how did leah feel about the test? b. dave teased eric. then, he pinched him. how did dave feel about eric? 2. stimulus-reaction based inference a. steve told his dad about the movie. his dad said he would go see it the next day. what did his dad think of steve's description of the movie? b. dad asked mat to bring his toolbox. "i left it over at larry's. he needed it." dad muttered something under his breath. how did dad feel about the toolbox being left at larry's house? (adapted from paredes, k.: drawing conclusions, card 27(2). frank schaffer publications, inc., california, 1980). 3. stimulus-based inference a. at last, merilyn had almost finished the painting. she had worked many months on it. all her friends praised her. how do you think marilyn will feel when she finishes the painting? (adapted from paredes, k.: drawing conclusions, card 15(2). frank schaffer publications, inc., california, 1980). b. shelly's aunt sent her a present. it contained an ugly pair of green socks. how do you think shelly will feel about the present? · appendix 3: test of inferential comprehension 2 a. inference of event 1. antecedent inference + vocabulary a. paul walked slowly down the hall, wondering what to do. as he stood before the door of the principal's office, he felt ashamed. he considered going home rather than facing miss conlin. she would be so disappointed in him. paul had always been an excellent student and he was never known to lie or cheat. it was only because his mother had been ill and he had to help take care of his brothers and sisters that he'd had to do it. paul took a deep breath and knocked lightly on the principal's door. miss colin called out "come in!" give some reasons why paul had been sent to the principal's office. (adapted from falstein & miller, 1980. predicting outcomes, cart 35: 'the best policy'.) b. as mr dean loped down the passage towards the manager's office, he felt that he was a despicable person. mr dean mounted the flight of stairs, considering all plausible alternatives as to his course of ensuing; action. he realised that the possibility of squirming jhis way out of this tricky situation was highly remote. the manager would be highly disappointed by his treacherous behaviour. mr dean had always been considered a jreputable employee and had never been known to engage in fraud, sabotage or forgery. it was only because of the dire financial straits of his family that he had felt compelled to participate. mr dean tapped briskly /on the manager's door, and he was told to enter. give some reasons why mr dean had been called to the manager's office. 2. interceding inference + schematic information a. granny jean was really proud of her grandchildren. she visited them almost everyday. she really enjoyed the visits to them. since the sun was shining, she decided to take a walk, rather than drive. spring was in the south african journal of communication disorders, vol.35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a comparative study of inferential comprehension strategies 15 the air, and the blossoms looked beautiful. by the time granny jean reached the house, the sky had clouded over. granny enjoyed the tea and thought the scones were particularly delicious. she soon felt very tired. granny realised that she would need to hurry since it was late and she still wanted to visit a friend of hers. she got up to leave. however, she realised that she would have to go back by taxi. give some reasons why she had to go back by taxi. b. uncle tim was the laziest man anyone had ever heard of. he was so lazy that he never walked anywhere. one day, uncle tim decided to visit a friend of his. as usual, he took his car. he always drove, since he was too lazy to walk. the drive was very enjoyable, and the gardens looked picturesque. uncle tim finally reached the house. he watched tv at his friend's house, and uncle tim thought that the western was particularly exciting. finally, uncle tim decided to leave, because he wanted to get to bed early. however, he soon realized that he would have to walk home. give some reasons why he had to walk home. 3. future inference ± reversible embedding a. marlene got a beautiful new watch for her birthday. she looked after it carefully and never let anyone touch it. lisa was her best friend. she loved beautiful things but no-one ever trusted her with anything. this was because lisa was a very careless girl. she didn't know how to look after things properly. although lisa begged marlene to lend her the watch, she always refused. one day, marlene and lisa went to the movies. marlene fell asleep. lisa decided to wear the beautiful watch for a few minutes even though it was to dark to see the time. : ι what do you think will happen next? the boy the girl knew, the boy had seen, had liked to collect stamps. the girl a stamp collection that grandfather had given to the family. the girl, the boy who liked stamps had tried |to persuade, never brought the stamps grandfather had given to school. one day, the friends convinced the girl the boy had seen, to bring the valuable stamp collection that grandfather had forbidden to take to school. the boy the girl knew, was very excited that they would see the stamps, that many collectors really wanted. the girl, the boy knew would bring the stamps, did not know how much the stamps were wanted by collectors. what do you think will happen next? b. inference in subjective state 1. reaction-based inference ± reversible passivization a. this is what michele was planning to do. as soon as shirley would look away, she would take her pencilbox. she would then keep her favourite ice cream rubber for her own collection. then she was planning to scatter all the other contents over the classroom. that would make shirley appear careless. then the teachers wouldn't believe her claim that someone may have stolen the beautiful rubber. in fact, they would all shout at shirley for being so careless and losing it. how did michele feel about shirley? why do you think so? b. a revenge had been planned by john. eric would be invited by john to a party. he would be given cold drinks by john. since the cold drinks would contain a sleeping powder, it would knock him out. eric would be carried by john to a friend's house. he would then be locked in a dark cupboard. eric would then be threatened by john. he would threaten to keep him there if he would not apologise. he would then be . made to promise never to tell anybody of what had happened. how did john feel about eric? why do you think so? 2. stimulus-reaction based inference ± microstructural aspect a. hannah henessee was a young woman whose husband was away in the army. she had to take care of the farm and the children. when hannah returned home one day, she discovered that the indians had kidnapped her children. they had carried the children away across the wide dangerous river. hannah swam across the deep water and walked into the indian camp. she demanded that the indians return her children. the indians were so surprised that they allowed her to take her children home. how did hannah feel about the indians? how did the children feel about hannah? (adapted from falstein & miller, 1980, predicting outcomes, card 37: ά revolutionary heroine'). i b. alex black was a young boy whose parents were away on holiday. relatives took care of the child in the meanwhile. everybody spoke of the highwaymen that had kidnapped many people. many caves in a nearby mountain provided a good place to keep hostages. a short trip by train led across desert towards the mountain. terrified faces met the entry of a young boy with his silver gun. soon, the group of hostages sped back to town by train. how did alex feel about the highwaymen? how did the hostages feel about alex? 3. stimulus-based inference ± intermediate inference a. when the don family visited the old ranch, roy was 7 the first'to explore the cellar. the most exciting thing he found that day was an old sheaf of papers containdie suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ing diary notes and maps. one of the maps was crumpled, faded and very interesting. this map contained directions for finding a treasure. it took him some time, but roy finally figured out the directions. he walked three steps to the left of the old farmer's barn, then he turned right and measured out three meters in that direction. finally he reached the spot from which he could see two apple trees. the directions said that if he would walk to the ditch behind the tree on the right and dig down two meters he would reach the treasure chest. roy had been digging for about ten minutes when his spade struck the lid of the chest. how will roy feel when he sees the contents of the chest? how will his family feel when they hear of the find? find? when the bascomb family moved into the old house, john was the first one to explore the attic. the most interesting thing he came upon that day was an old trunk filled with books and papers. one book's pages were cracked, yellow and particularly hard to read. this book contained a recipe for making gold. it took him a while, but john finally gathered all the ingredients. gold, after all, was something everyone could use more of. one day, while his family was out, john boiled twelve eggs. he then mixed them with manure from a white cat and added the juice of four grapefruits. he boiled that mixture for three hours. the recipe said that if any metal, such as tin or iron, was dipped into the mixture it would turn to gold. john had a tin can and three iron nails. how will john feel after he dips the metals in the mixture? how will his family feel when they hear what he had done? (adapted from falstein & miller, 1980, predicting outcomes, card 31: 'the alchemist'). the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 33 communication abilities of non-standard language speaking children: a follow-up study erna alant, d. phil (pretoria) department of speech therapy and audiology, university of pretoria abstract there has recently been a growing awareness among speech and language pathologists about the problems of the non-standard language speaker when entering the school situation where standard language is predominantly used. this study deals with the preschool nonstandard language speaker and aims to investigate whether and to what extent the children's language and interaction patterns change after one year's exposure to a formal school situation. results indicate that although certain language skills do change, the functional interactions patterns of these children tends to remain the same. these findings are interpreted within a social context and implications for intervention discussed. opsomming daar is 'n groeiende bewuswording binne die geledere van die spraak en taalterapeute oor die probleme rakende die nie-standaardtaalspreker veral wanneer die nie-standaardtaalsprekende kind die skoolsituasie betree waar standaardtaal hoofsaakhk gebruik word. hierdie studie handel oor die voorskoolse nie-standaardtaalspreker en poog om na te vors of, en in welke mate die kmders se taal en interaksiepatroon verander na een jaar se blootstelling aan 'n formele skoolsituasie. resultate dui daarop dat hoewel sekere taalvaardighede verander het, die funksionele interaksie patroon van die kinders neig om meer konstant te bly. hierdie bevindings wordgemterpreteer binne 'n sosiale konteks en implikasies vir intervensie word bespreek. in the recent literature on language evaluation, much emphasis has been placed on the assessment of functional language, particularly in relation to non-standard language speakers. this pragmatic approach reflects an awareness of the difficulties involved iri comparing and describing communication abilities of children merely by looking at the formal structure of language (labov 1972, trudgill 1983, erickson and omark 1981). the inappropriateness of labelling the use of non-standarci language structures as 'pathological or deviant' due to inflexibility in the application of syntactic, phonological or other language rules, has contributed to an increasing consciousness of the equality of language variations as potential codes for the transmission of various kinds of messages (davis 1985, sturm 1984, edwards 1979, labov 1972). this acceptance of the equality of language variations (davis 1985), does not deny the existence of a standard language in society as represented by reading and writing. it acknowledges that societies need standard languages in order to function effectively, just as "schools have to accept and teach standard language if only because one' of the primary purposes of education is literacy" (davis 1985: 191). the consequence of schools aiming at familiarizing children with standard language as required for reading and writing, is the frequent existence of a 'mismatch' or 'discontinuity' between the language children use at home and at school (labov 1972, trudgill 1983, cox and jones 1983, adler 1979). die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 34, 1987 "... some children have little or no experience of the interactional demands of the school because of the type of conversational interaction which they have experienced at home, and so they are less able to cope with classroom talk" (mctear 1985:21). the nature of the discontinuity between home and school language is, however, not clear and could include a complex combination of social and linguistic aspects ranging from the use of different language structures to different communication styles (farran 1982). the question arises as to what extent children's language proficiency can change in coping with the more formal school situation after exposure to the educational system. it would be interesting to determine whether the language abilities and communication styles of children can be modified effectively in order to facilitate interaction at school after some experience with formal schooling. most of the longitudinal research on the language abilities of children exposed to schooling has been done by the american headstart programmes (moore 1979, kellaghan 1977), as well as the projects on the educational priority areas (epa) in britain (cox and jones 1983). these studies indicate that children who were part of these projects enjoyed only temporary advantages in adapting to the formal school situation and that they gradually drifted back towards the performance level of their companions who had no exposure to preschool education (moore 1979). explanations for these findings varied from ineffectively or poorly directed pro© sasha 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 erna alant grammes (kellaghan 1977), to the acceptance that language is part of a social structure and, therefore, that exposure to some hours of language or educational stimulation does not effectively change the interaction style of the individual (sturm 1984). the measurement of effective participation in a school context is, however, problematic in view of the difficulties involved in developing relevant communication parameters for indicating learning performance. school achievement gives some indication of children's ability to cope with scholastic demands, although only the results or outcome of learning behaviour is reflected. the process of learning itself is not considered in this kind of evaluation. in this respect it is pertinent to differentiate between "basic communication proficiency" which refers to interpersonal communicative skills and "cognitive academic language proficiency" which refers to the understanding and ability to manipulate meanings inherent in the language itself as proposed by cummins (1981) and discussed by skinner (1985). alhough these skills are interrelated, the nature of language proficiency required in different contexts varies in relation in the degree of context-dependency as well as cognitive demands (skinner 1985). different communication skills can therefore be identified in the formal learning situation, including interactive skills and the more cognitively orientated academic language skills. depending on the general approach to teaching, a more interactive (less authoritarian) or on the other hand, a representative interaction style (frequently associated with a more formal, authoritarian academic situation), could dominate. an interactive model of learning emphasizes the ability of the child to participate in the teaching situation by using a variety of language functions, i.e., to initiate, to respond, or to ask for clarification. interaction takes place primarily between pupil and teacher (coulthard 1977, britton 1973). formal instruction, however, also involves at least to some extent the ability to listen to relatively long and cognitively demanding verbal instructions or explanations in order to respond appropriately in the context, i.e., representational skills as defined by russel and russel (1979). different communication styles can therefore be identified in the teaching situation and should be noted when evaluating the communication abilities of children in the school situation (alant 1984). it is against this background that the present study sets out to investigate children's communication performance in two contexts: a more cognitively demanding representative context in which comprehension questions relating to a story are asked similar to the question-answer situation at school, and a less cognitively demanding conversational context where children and an adult simulate communication skills required in interaction with the teacher in the classroom. in view of this approach two questions demand to be posed, namely whether and to what extent the communication skills of children on a preschool level have changed after one year of exposure to the formal school situation and secondly, whether there is any significant association between overall school performance and communication ability as defined in the two contexts. methodology seventy-seven afrikaans-speaking children were tested on a preschool level. all of these were prospective schoolbeginners in the following year at a specific school in eersterust. the whole population of children that could be located was included in the study. twelve months later the same children, were retested at the end of their first school year. only forty-one of the original sample could be located at the school and were therefore included in the study. all the children tested were from the nantes area which is one of the poorer areas in eersterust, a community on the periphery of pretoria. it should be noted that, although close to the city, this township is relatively isolated from the larger afrikaans-speaking community in pretoria, and this has been contributed to the development of certain linguistic differences between the two afrikaans-speaking communities. these linguistic variations include differences in vocabulary, syntactic structures as well as pronunciation (claassen and van rensburg 1983). the average gross household income of people in eersterust was determined by a survey in 1979 (lotter, strijdom and schurink 1979) and reported to be less than r300 a month per sub-economical four-roomed house. as most of the housing in the nantes area is sub-economical, this could be taken as a reflection of the average income of this subdivision of the township. the average number of dependents per household was at least eleven (lotter et al. 1979:19). table 1 gives a brief description of the subjects used in the study. as the same children were tested on both occasions, only the relevant information will be given at the point of the second testing. table 1: description of subjects at the end of their first school year variable description number of children 41 male/female distribution 48,8% female; 51,2% male mean age 6,96 (sd = 0,53) scholastic achievement at the 6,96 (sd = 0,53) end of the first year 65% pass, 35% fail ι materials 1 ι the story: all children were exposed to a story and were required to answer questions about it. the same story and questions were used on both testing occasions. although the effect of exposure to the story during the first testing could have influenced performance on the task in the second testing, this influence was considered minimal. firstly, there was a twelve month break between the two testings, which generally is regarded as a sufficient period for retesting (dunn and dunn 1981). secondly, no answers were given to the children during the first testing situation, therefore no feedback was provided in terms of the correct answers. the story 'the fox and the crab' was'adapted from berry (1969) as modified by alant (1984) for use with five-and-ahalf year olds in a comprehension situation (see appendix 1). the story was lengthened for the purpose of testing comthe south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication abilities of non-standard language speaking children: a follow-up study 35 prehension by including more characters (factual material) while maintaining the basic story together with the inferences required to complete the ending. the story was told on video-tape (with facial clues and gestures only, in order to stimulate stories or narratives occurring in normal communication). a nursery school teacher as well as the teachers of the beginning classes at the school were asked to view the tape and to evaluate its appropriateness with regard to middle class biases in vocabulary, cultural prejudice, content, and age appropriateness. some minor changes were suggested after which the story was recorded for use in the pilot and main study. conversational themes: the conversational themes, were developed from the pilot study undertaken before the first testing. these topics centered around the children's interests and activities at school and at home, e.g., the family and favourite television programmes. procedure: each child was tested individually at school in a classroom specially equipped for the testing of children. during the first phase of the testing the children were required to observe the video-story (4 minutes) after which the comprehension questions were put to them. immediately after this interaction, the therapist having watched the video with the child, proceeded to initiate a conversation (12 minutes). the reason for this specific procedural sequence is that observation of the television story was considered to be less threatening to the children at the beginning of the interaction. the same therapist interacted with the children on both occasions in order to control for idiosyncratic communication differences. the complete contact with the child was recorded on video-tape for analysis at a later stage. however, the influence that the presence of the video equipment might have had on the performance of the children has to be considered. similarly the presence of a standard language speaker as a conversationalist could have had an inhibiting influence on the children. these two/factors were held constant during both testings in order to compare the children's behaviour in the same situation under similar circumstances one year later. j i verbal analysis: i , story situation: accuracy of answers: four questions were asked, based on the story (appendix 1). these questions were ranked from easy to difficult, that is, from questions demanding immediate reproduction of facts to questions relating to answers based on inferences drawn from the story. the grading of the questions was first tested by alant (1984) and proved to be satisfactory. the specific sequence of questions was deemed important as easy questions could be a motivating factor in the beginning of an interaction. probing: probing was used in order to prevent inhibited children from being discredited for lack of understanding. although the effectiveness of probing can be questioned, particularly with this sample of children (faegans and farran 1982, labov 1972), probes could contribute to an increase of verbal behaviour (stalnaker and creaghead 1982; warren, mcquarter and rogers-warren 1984). a probe was defined as a verbalization from the therapist followed by a pause (approximately one second) during which the child could be given an opportunity to respond. probing was used when children did not respond or when they responded with "don't know" or other short replies. non-directive probing was used at first, followed by more direct probes depending on the vagueness of the answers. functional analysis of conversation: the functional categories developed by dore (1977) were adapted for use in the analysis of conversation between the therapist (adult) and child (appendix 2). this analysis only describes the kinds of utterances used in the interaction (structural-functional) whereas the transactional aspects inherent in the semantic development of the conversation were not taken into account (mctear 1985). all the interviews were transcribed for use in the functional analysis. audi'o-recordings were used in order to enable the analyzers to do the functional analysis with the written as well as the audio-information. the inclusion of both transcript and audio-material in the analysis was necessary in order to facilitate reliable judgements of utterances, particularly in view of the fact that the function of an utterance cannot necessarily be deduced from the structure of the utterance (willes 1981). two groups of two analyzers each worked together so as to control their interpretations of the functional categories in order to increase reliability of the rating. an average of 96% agreement between raters was calculated for each interaction. scholastic achievement: an overall indicator of the children's academic achievement was obtained from the class teachers in the form of their final class mark. this mark constituted the average performance of the child on all the different levels, i.e., reading, writing, comprehension test, oral language and arithmetic. although it could be argued that scholastic achievement as defined above is too broad for comparison with the above testing procedure, language can be seen as an important, although not necessarily the only, factor influencing performance on all these levels. due to the complexity of factors that could influence school performance (e.g., visual problems) present findings should therefore only be interpreted tentatively. statistical analysis: descriptive measures such as means, standard deviations and standard error of the means were calculated to describe the performance of both groups on different variables. the means of specific variables were used so that certain features of the groups could be represented graphically. the die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 erna alant u-test of wilcoxon mann-whitney was used to test for differences in population means. results the results will be discussed in three broad categories: — the children's performance on the comprehension story; — the functional analysis of communication over the two testings; — the relationship between scholastic achievement and communication performance on the last testing (i.e., after the children had had eleven months' exposure to formal schooling). the children's performance on the comprehension story table 2 shows differences in the means of the children's performance on the different variables between the first (preschool) and second (school-going) testing. table 2: test for difference in means with respect to accuracy of response and probing needed to elicit responses variable t-value probability accuracy question 1 1,27 0,2098 question 2 4,74 0,0001»» question 3 2,87 0,0065»» question 4 2,88 0,0064»» total 4,91 0,0001»» probing question 1 0,64 0,5253 question 2 2,24 0,0305» question 3 -0,83 0,4119 question 4 1,18 0,2433 total 1,99 0,0537 ** = significant on 1% level, * = significant on 5% level. the above table indicates that there are significant differences between the means of most of the questions with respect to the accuracy of the responses, whereas there are relatively few significant differences on the amount of probing necessary to elicit responses from the children. functional analysis of conversation figures 1 and 2 graphically represent the mean number of utterances within each category for each testing. key: therapist x x x x x child: 3iack qo = open question qyln = yes/no question qs = specific question qc = question for clarification qh question repeated rvln = y :s/no response rf = factual response rc = clarifying response rr repeating response d description s 'statement aa acknowledgement, acceptance ap acknowledgement: positive an acknowledgement: negative oa organization device: attention op organization device: politeness oc organization device: contact ρ performatives int interruptions irr in elevant utterances qo qyln figure 1: functional analysis of conversations between therapist and child in 1984 the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication abilities of non-standard language speaking children: a follow-up study x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x 15,48 x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x 8,05 x x x x x x x x x x 8,05 x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x 0,03 0,05 0,03 qo qyln qs key. therapist xxxxx child: black 24,05 x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x . x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x x l 18 i x x x x x q» qyln qs qc qh ryln rl rc rr d s aa a p an oa op oc ρ inl irr open question yes/no question speeific question question for clarification question repeated yes/no response factual response clarifying response repeating response description statement acknowledgement: acceptance acknowledgement: positive acknowledgement: negative organization device: attention organization device: politeness organization device: contact performatives interruptions irrelevant utterances 1,25 2,05 2,5 x x x x x x x x x x x x x x x x x x x x 0,03 x x x x x 0,55 0,65 0,13 0,03 x x x x x 0,55 0,13 ap op figure 2: functional analysis of conversations between therapist and child in 1985 these figures indicate that there are no great differences between the therapist's and children's utterances for the two testing situations. table 3 reflects significant differences between the means on the different categories for the therapist's as well as the children's utterances. table 3: significant differences between means on categories used jby the therapist and child for the first and second testing table 4: test for the difference in means between the two groups (children that failed and passed) with respect to the story variables therapist child i probaprobacategory t-value bility category t-value bility qo 5,03 0,0001 φ φ qc -3,14 0,0037** d 2,37 0,0244 φ oa 3,58 0,0000 φ φ clarification of abbreviations in appendix ii . ** = significant on 1% level, * = significant on 5% level. correlation between overall scholastic achievement and communication parameters tables 4 and 5 represent the differences between the means of the story and conversational variables of two groups of children, group 1 representing the children who passed the first year of schooling (65% in total) and group 2 representing those who failed (35% in total). variable t-value probability accuracy question 1 (values were the same for accuracy one class level) question 2 -0,52 0,6065 question 3 -1,37 0,1778 question 4 -2,21 0,0336* total -2,20 0,0038* probing question 1 2,25 0,0326** question 2 1,27 0,2136 question 3 2,65 0,0120* question 4 1,27 0,2124 total 2,41 0,0210* significant on 1% level, * = significant on 5% level. from tables 4 and 5 it is clear that there are some differences between these two groups on the story variables, although fewer significant differences seem to be indicated between the first and second testing on the functional use of language. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 erna alant table 5: significant differences in means with respect to the functional categories used by the therapist and child therapist child category qr aa t-value 2,55 2,84 probability 0,02* 0,01** category ry t-value -1,94 probability 0,05* clarification of abbreviations in appendix ii ** = significant on 1% level, * = significant on 5% level. discussion of results children's performance on the comprehension story: accuracy of the responses: there is a highly significant difference in the children's accuracy of response between the first and second testing, reflecting definite growth in semantic understanding of the story during the twelve months. this improvement in the children's comprehension behaviour is reflected in questions two to four, with question one not showing any significant difference. this absence of a significant difference on question one can be expected in view of the inherent nature of the question as it simply demands the name of the animal which is the main character of the story. the highly significant difference between the means on question two is, however, interesting considering the demands made on memory and recall of the children as they were required to name all the animals that the fox met. this finding is in agreement with developmental research reporting increased ability to remember factual detail as age increases (bloom and lahey 1978). question three indicates the ability to analyse the purpose of the actions in the story by describing the plan that the fox had. the significant improvement in answers on this question is in congruence with the research done by peterson and mccabe (1983) where they emphasize the older child's tendency to move away from describing action sequences to expressing relationships (cause — effect or intentionality) between actions. they explain this phenomenon in terms of the children's increase in control over their environment in that they become better able to participate in events whereas the purpose of these events might not have been evident to them before. question four emphasizes the ability to constructively process information by demanding that the children make inferences from the story. the present data confirm normal developmental research reporting an age effect in the constructive processing of information (small and butterworth 1981, paris, lindauer and cox 1977). weissmer (1983) also reported fewer inferences from children aged 5,5 — 6,7 compared to those aged 7,7 — 9,2. in general the language performance of these children indicates an increased ability to cope with the two main language proficiency vectors as formulated by cummins (1981), i.e., the ability to determine and communicate meaning in the absence of contextual clues and the ability to think in more 'cognitively demanding' situations. although this improved performance could also be interpreted as the result of the children's familiarity with the testing situation it is doubtful whether this is the case particularly in view of the twelve month gap between testings. probing necessary to elicit responses: only question two indicates a significant difference (at the 5% level) between the means of the two testings, implying that more probing was done on the second than on the first testing. this finding is contrary to what is expected as it implies that the children needed more encouragement to answer the questions on the second testing. this finding raises questions as to the influence of probing on the accuracy scores of the children. the association between probing and accuracy for this particular procedure has, however, been computed, and indicates a highly significant neg,.:t<ve correlation (1% level) between the two variables. as probii.0 increased, the accuracy of the responses, in fact, decreased, which means that the present finding points to improved listening and memory-recall abilities of the children rather than improved accuracy due to an increase in probing. a second important implication of this finding is that the children were less at ease in coping with the questionanswer situation at the time of the second testing. the asymmetric nature of the interaction has thus not shown any decline; rather the children might have become more conscious (as indicated by question 2) of the inherent inequality in the adult-child interaction as discussed by french and woll (1981) and romaine (1984). this increase in awareness could be indicative of an authoritarian teacher-pupil relationship. functional analysis of conversation: from figures 1 and 2, it is clear that the pattern of functional categories for the two testings stayed virtually the same, i.e., a high frequency of questions from the therapist, while the child mostly responded. this information confirms the notion that the same interaction (e.g., adult-child) tends to elicit similar functional behaviour (gallagher and prutting 1983). the children showed little initiative (little additional information was given, for example few descriptions (d), stories (s) or questions (q) were forthcoming) which could also be a reflection of the asymmetric nature of the interaction (romaine 1984). i the test for the difference between the means for all the categories, indicate that the therapist used significantly more open-ended questions (qo), descriptions (d) and organizational devices (oa) to attract the child's attention, and encourage interactions during the second testing. the child, however, did not experience the interaction any differently from the first in that there was no notable increase in the child's initiation, descriptions or statements. romaine (1984:22) describes this phenomenon as follows: / "distribution of power is clearly delimited and free conversation is not expected. attempts to elicit nar' ratives and spontaneous speech by breaking out of the question/answer format violate the norms governing the event. according to wolfson, the informant's reaction to this may be surprise, confusion, suspicion or even resentment". the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication abilities of non-standard language speaking children: a follow-up study 39 the lack of response from the children could, however, also indicate an inability to adapt to the dynamics of the convers a t i o n due to either insensitivity or insecurity on their part (mctear 1985). unfamiliarity with the prevalent conversational rules could thus have contributed to the seeming lack of response from the children (willes 1981). the finding indicating a significant decrease in the children's questions for clarification during the second testing is interesting, in view of the fact that this behaviour could indicate a lesser need to ask for clarification due to improved comprehension. as there were no significant differences in the other functional categories of the children, it is difficult to verify this interpretation. a more likely interpretation could be that the children were more inhibited as they had become more conscious of the asymmetric nature of the relationship. scholastic performance of the children: after having described the performance of the children in both testings, it is important to get some measure of the effectiveness of the children's performance at school, in order to understand the prerequisites for learning within the school context. although the children who failed and those who passed at the end of their first school year differed significantly in their performance on isolated questions in the story, the total accuracy as well as the total probing score indicate significant differences on a 5% level. the children who passed therefore obtained significantly better accuracy scores on the total performance and they also needed less probing on the four questions in order to respond. one could therefore conclude that these children seemed to cope better with the situation demanding more cognitive academic language proficiency (cummins 1981). as far as the functional categories are concerned, there is only one significant difference between the two groups' functional language categories, while there are two significant differences on the categories used by the therapist with the two groups. the significant difference in the frequency of yes/no responses between the two groups of children is most interesting, particularly as tile academic achievers tended to use more yes/no replies. traditionally a high premium was placed on the syntactic completeness of utterances, and restricted verbalization was frequently equated with limited language abilities (bernstein 1973, lee, koenigsknecht and mulhern 1975, crystal, fletcher and garman 1977). new theoretical insights, however, stress that structural completeness is no prerequisite for effective communication (labov 1972). the higher frequency of yes/no responses in this study could therefore rather be related to better understanding on the part of the children and an inability to express themselves more explicitly. as for the changes occurring in the therapist's utterances when talking to children of different academic achievement, it is notable that she had to repeat her own questions (qr) more often to the children who were academically poorer, whereas she also accepted more of their verbalizations (aa), possibly in an attempt to encourage further verbalization. she therefore tried to compensate for the child's apparent difficulties in the situation by accepting a greater variety of utterances. it should be underlined in conclusion, that the present study aims at describing children's communication behaviour in two contexts by using certain methodological and analytical procedures. data can, therefore, only be interpreted within the context of the study. it is no intent of the author to generalize the present findings to other language skills or communication situations. in terms of the theory of discontinuity, it could be argued that the children who had failed their first year of schooling had difficulty in orientating themselves to the situations demanding more cognitive academic language proficiency. this problem in orientation could be due to many factors, including cognition (which could according to selowsky (1980) also be related to malnutrition), difficulty in coping with the standard language as required in the more formal story situation, as well as a delay in the development of meta-linguistic abilities needed for the making of inferences in a given situation (wallach and butler 1984). as far as functional language is concerned, no big differences in the children's performances were noted between preschooland one year of schooling-level, indicating that the children's conversational abilities as defined by these categories did not show a significant change or improvement. due to the minimal differences found between the skills of the children who had failed and those who had passed academically, it can also be said that conversation skills as defined in this study did not influence learning performance in the school. the model adhered to in the classroom therefore seems to be of an authoritarian nature (britton 1973) which demands little initiative and active participation on the part of the children. in the same way the interaction model prevalent in the children's daily life could also be of a more authoritarian nature, as is suggested by romaine (1984). the question arises as to the relevance of trying to change or improve conversational abilities within the context of an authoritarian teaching model and possibly also a parent or adult dominated society. this is a difficult and complex question to answer. the problem remains, however, as to how these children will be able to cope with a different level of academic achievement, where an interactive approach to learning is more prominent, for example, at secondary school or university. in the case of these children, they are all from the same geographical area and therefore isolated from contact with children from other areas. although this aspect facilitates adaptation of the children to the school situation, it could also be considered as a very protective learning environment, which has the disadvantage that, once confronted with the broader society, the children might experience more difficulties due to the 'mismatch' between educational and communication strategies in the different contexts. there is, however, no merit in regarding the problem of different interaction styles (which reflect different ways of life according to labov 1972 and luckmann 1975) in isolation from the social situation in which they occur. intervention strategies should therefore only be initiated after extensive contact and collaboration with the communities involved, in order to prevent a different communication style from being mistaken for a pathological interaction model in the context. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 erna alant the implications of these findings for language assessment and remediation are multiple. firstly, it is important to realize that there is no objectively defined concept of pathology. deviancy is defined within a particular context, which implies that there is no 'ideal' communication model within which therapists remediate. therapy should be directed at meeting the needs of the patient which presupposes an understanding of the environment and context within which the individual lives. the general interactive style of the school context as well as the environment has to be considered before deciding that functional behaviour is inappropriate or limited. secondly, the range of language skills tested should be closely considered, particularly when working with school-going children. the evaluation of functional communication skills does not necessarily reflect the child's cognitive academic language proficiency as indicated by the poor correlation between school performance and functional communication illustrated in this study. finally, it is clear that when preparing children for formal learning within a context as described here, it is important to focus on cognitive academic language proficiency in order to facilitate the transition from home to school environments. acknowledgements this research is part of the 'eersterust project' of the department of speech pathology and audiology of the university of pretoria. i would like to express my sincere appreciation for the invaluable contributions of all the team members: annemarie beukes, heila van den berg, alta kritzinger, ingrid van zyl, rialette gous, santie meyer, marina hurter and felicity van rensburg. the assistance of mrs. m. botha as well as prof s.h.c. du toit in the computerisation and statistical analyses of the data is also greatly appreciated. finally, the dedicated participation of the teachers and children at the school contributed greatly to the success of the project. references adler, s. poverty children and their language new york: grune & stratton, 1979. alant, e. the development of a procedure for analysing communication of preschool children. d.phil. thesis, university of pretoria, 1984 (unpublished). bernstein, b. 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(eds.) pragmatic assessment and intervention issues in language. california: college-hill press, 1983. kellaghan, t. the evaluation of an intervention programme for disadvantaged children. windsor: nfer publishing company, 1977. labov, w. the logic of non-standard english. in giglioli, ρ (ed). language and social context, new york: penguin, 1972. lee, l.l.; koenigsknecht, r.l. and mulhern, s. interactive language development teaching. evanston: northwestern university press, 1975. lotter, j.m.; strydom, h.g. and schurink, w.j. eersterust: 'n sosiologiese studie van 'n kleurlinggemeenskap. pretoria: rgn, 1979. luckmann, t. sociology of language. indianopolis: the bobbsmerrill company, 1975. mctear, m. children's conversation. oxford: basil blackwell, 1985. moore, s. past research and current perspectives on head start and follow through. viewpoints in teaching and learning, 55, 3, 75-82, 1979. paris, s; lindauer, b. and cox, g. the development of inferential comprehension. child development, 48, 1728-1733, 1977. peterson, c. and mccabe, a. developmental psycholinquistics: three ways of looking at a child's narrative. new york: plenum press, 1983. russel, d. and russel, e. listening aids through the grades. new york: collumbia university, teachers college, 1979. romaine, s. the language of children and adolescents: the acquisition of communication competence. oxford: basil blackwell, 1984. selowsky, m. preschool age investment in human capital. in j. simmons (ed.) the education dilemma: policy issues for developing countries in the 1980's, new york: pergamon press, 1978. skinner, d. access to meaning: the anatomy of the language/ learning connection. journal of multilingual and multicultural development, 6, 2, 97-116, 1985. small, m. and butterworth, j. semantic integration and the development of memory for logical inferences. child development, 52, 732-735, 1981. ' i stalnaker, l.d. and creaghead, n.a. an examination of language samples obtained under three experimental conditions. language speech and hearing services in schools, 13, 2, 121128, 1982. ' sturm, j. deficit and difference: a false dichotomy in an educational perspective. in k. deprez (ed.), sosiolinquistics in the low countries. amsterdam: john benjamins publishing company, 1984. trudgill, p. accent, dialect and the school. london: edward arnold, 1983. wallach, g.p. and butler, k.g. language learning disabilities in school-age children, london: williams and wilkins. 1984. warren, s.f.; mcquarter, r.j. and rogers-warren, a.k. the effects of mands and models on the speech of unresponsive language delayed preschool children. journal of speech and hearing disorders, 49, 43-52, 1984. weissmer, s.e. constructive comprehension abilities exhibited by language-disordered children. journal of speech and hearing research, 23, 2, 175-184, 1983. . willes, m. learning to take part in classroom interaction. in p. french and m. maclure (eds.). adult-child conversation. london: croom helm, 1981. the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication abilities of non-standard language speaking children: a follow-up study 41 appendix 1 story unit 1 ε 3 ε.3 ε.2 ε.3 eendag// stap ou jackals in die bos./ hy loop en spog te lekker,/ want hy kan tog so: vinnig hardloop.// toe hy nog so stap, sien hy vir olifant onder die boom staan.h "goeie more ou olifant" se jakkals./ "kom ons hardloop reisies, dan kyk o.ns wie van ons twee hardloop die vinnigste."// ou olifant dink toe so 'n bietjie en se toe "agge nee ou jakkals jy is gans te vinnig vir my."/ ou jakkals lag te lekker./ "ja ou olifant, ek sal jou sommer ve:r wen."ii en so stap jakkals toe aan.// 2 = partially correct repetition of actions, e.g., hanged on tail 1 = no response/response out of context/do not know question 4: who do you think won the race and why? the why part of the question is scored only: 4 = in context explanation, e.g., crab won because he made a clever plan 3 = in context, but concrete, e.g., crab, because he jumped on the fox's tail 2 = vague, out of context, e.g., fox, because he is faster 1 = no response/do not understand/do not know probing analyses: unit 2 toe jakkals nog so stap,/ sien hy vir skihpad.l "goeie more skilpad./ kom ons hardloop reisies dan kyk ons wie van ons twee is die vinnigste."/ skilpad dink toe so 'n bietjie/ en se: "agge nee ou jakkals jy is gans te vinnig vir my."// ou jakkals lag te lekker. dis tog te lekker vir hom om te weet dat al die diere te bang is om teen hom reisies te hardloop.// en so stap jakkals toe aan...11 unit 3 toe jakkals nog so stap, sien hy vir krap op die grond./ "goeie more ou krap. kom ons hardloop reisies, dan kyk ons wie van ons twee is die vinnigste."// ou krap dink toe so 'n bietjie...// en toe kry hy 'n baie goeie plan./ "goed ou jakkals, kom ons hardloop reisies dank kyk ons wie van ons twee is die vinnigste."// ou jakkals is stom geslaan./hy kan nie glo dat krap teen hom wil reisies hardloop nie.ii unit 4 die twee begin toe hardloop./ maar net toe jakkals begin hardloop, spring krap op jakkals se stert en khou daar vas./ jakkals hardloop baie vinnig tot by die wenpaal./ en toe hy by die wenpaal kom/ skud lhy sy stert en kyk om om te sien waar die krap is.// huuu. j en daar sien jakkals vir krap op die grond! "ag ou jakkals," se die krap toe "ek wag al lankal hier vir jou op die grond." t i verbal analyses: j accuracy: ! question 1: who walked in the veld? 4 = fox 3 = description of animal, no name 2 = wrong animal 1 = no response/did not understand question 2: whom did he meet there? 4 = all three correct 3 = two correct 2 = one correct 1 = none correct question 3: what was the clever plan of the crab? 4 = indication of relationship between action and intention 3 = repeat actions involved, e.g., jumped onto tail and clung onto it all the probes on each question were calculated and categorized according to the following scoring system: 1 = 0-5 probes 3 = 11-15 probes 2 = 6-10 probes 4 = 16-20 probes s = smile 1 4 ε = eye widening/ eye narrowing 1—4 f = frowning 1—4 hn = head nod hs = head shake il = illustration italics = emphasized capital letters = stressed with more loudness so: = the last sound prolonged / = pause (untimed duration shown by number of ii) ii — longer pause appendix 2 functional categories used for the analysis of the conversations between therapist and child. adapted from dore (1977). requests/questions: qo : open question, e.g., tell me... qy/n : yes no question, e.g., do you know this? qs : specific question, e.g., what are you doing? qc : question for clarification (related to previous utterance) e.g., what?) qr : repetition of previous question responses: ry/n : yes/no response rf : factual response to the question rc : response on request for clarification rr : repetition of previous response descriptions: d : giving of additional information, descriptions die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 erna alant statements: s : statements not directly related to the previous utterance acknowledgements (non-requests): aa : accepting an utterance, e.g., hmm... ap : positive acknowledgement, e.g., that was good an : negative acknowledgement, e.g., no, try again organizational devices: oa : utterance to draw attention, e.g., justin, look here... op : utterance indicating politeness, e.g., thank you oc : utterance to maintain contact, e.g., mmmm and then... performatives: utterances aimed at changing behaviour ρ : utterances aimed at changing behaviour, e.g., don't do that, no, what are you doing? additional categories used: int : interruptions irr : irrelevant utterances these two categories were indicated by putting the specific category in brackets e.g. τ : waar werk jou pa? κ : saam met sy tjomme τ : ja, en waar werk jou pa? κ : daar by die swembad qs (rf) aa...qr rf c/o jan smuts and gordon aves blairgowrie randburg 2194 p.o. box 84518 greenside 2034 smile education systems (pty) ltd. we all know about the smile phonic workbooks r2,99 each. we all know about "leergenot fonemiese werkboeke" r2,99 each. we've all enjoyed smile and learn book i. but perhaps you don't know about peg-a-pattern (a language based perceptual programme) learn to think (early leadership with logic) early learning animal puzzles at smile education systems we know that language skills are important. we encourage parents to communicate with their children. we promote learning through perceptual and cognitive development. .perhaps we can be of help to you. pop in and see us or write to smile education systems, p.o. box 84518, greenside 2034, for a free catalogue and pfice list. / the south african journal of communication disorders, vol. 34, 1987 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the role of speech therapy in the head and neck service m . i . d i n n e r , m.b., b.ch. ( r a n d ) , f.r.c.s. ( l o n d ) , f . r . c . s . (ed.) consultant plastic surgeon to the head and neck clinic at the johannesburg general hospital. summary the vital role of the speech therapist, in the multi-disciplinary approach to the rehabilitation of patients subjected to ablative surgery for malignant disease of the head and neck region, is reviewed. the role of the surgical techniques of speech rehabilitation of the laryngectomised patient, who has failed to respond to the therapist's instruction in oesophageal speech rehabilitation, is high-lighted. the deliberate pharyngeal fistula created from the pharynx to the skin surface, is connected by a "speech device" to the tracheostomy stoma. the diversion of expired pulmonary air into the pharynx allows for immediate articulation. opsomming 'n oorsig word1 gegee van die belangrike rol van die spraakterapeut in die multi-dissiplinere benadering tot die rehabilitasie van pasiente wat ablatiewe chirurgie van die kop en nek gehad het vir kwaadaardige toestande. rehabilitasie met spraak in die laringektomie pasient sluit chirurgiese tegnieke in, in gevalle waar esofagele spraakonderrig deur die terapeut onsuksesvol was. die opsetlike faringeale fistel tussen die farinks en vel word aan die tracheostomie stoma gekoppel deur middel van 'n ,,spraak apparaat". die omleiding van uitgeasemde pulmonale lug deur die keelholte maak direkte fonering moontlik. the role of the speech therapist in rehabilitation of communication in patients who have been subjected to surgery of the head and neck region, is an essential phase in the return of these patients to a useful and meaningful existence with their families and in their communities. ablative surgery for the cure of carcinomatous lesions involving one or other of the anatomical structures vital for normal articulation is responsible for the condition referred to as "the surgically induced dysarthrias". ablative surgery for any lesion involving: the tongue the floor of the mouth the alveolar margin the soft or hard palate the pharynx the larynx is frequently radical and extensive. together with the heroic attempts at saltydskrif van die suid-afrikaanse vercniging rir spraak cn cchvvrhcclklinde, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 m.i. dinner vaging the patient from his disease, are the concomitent drawbacks of extensive cosmetic disfigurements, and the functional disabilities of dysphagia and dysarthria. the rehabilitation in these patients to a level of social acceptability in the surgically induced dysarthrias, represents a very trying challenge to the speech therapist in such a unit. a team approach on the head and neck service is responsible for the very marked improvement in duration and quality of survival of these unfortunate patients. where surgery is adjudged the treatment of choice by the team, the team approach becomes conspicuous. the team of "drastic surgeons" will commit themselves to as wide and extensive surgery as is required to ensure cure, to be followed by a team of "plastic and reconstructive surgeons" who will primarily reconstruct the defect to the limits of physical possibility, thereby fulfilling two of the first important aims of the treatment of such patients: 1. to cure the patient of his disease 2. to restore his cosmetic deformity to as near normal physical appearance as possible. it is at this stage that the vital role of the speech therapist becomes obvious, in order to eventually enable this patient to communicate adequately. these patients experience great difficulty in attempting to articulate due to either the loss of the lip obicularis muscle, or of tongue musculature or loss of mandibular support for the tongue or floor of the mouth musculature. they must of necessity be taught the art of substitute movements in order to articulate the sounds producing intelligible speech. however it is the re-education and rehabilitation of speech in the alaryngeal patient that remains the greatest challenge to the speech therapist in such a unit. speech rehabilitation in the laryngectomised patient the patient, who for the price of cure of cancer of the larynx must be subjected to total laryngectomy with or without removal of the pharynx, is immediately exposed to the traumatic disability of the inability to communicate. the rehabilitation of the laryngectomee in the majority of cases involves the learning of the techniques of oesophageal speech. this requires the controlled expulsion of swallowed air from the stomach and oesophagus and the articulation of this air as it enters the oral cavity. this patient must be taught the techniques of rapid swallowing of air and its controlled release through the pharyngeal musculature and through the crico-pharyngeal sphincter.1 this method is both laudible and reliable in many cases. however it is in those estimated one-third of laryngectomised patients who remain resistant to the speech therapist's every efforts and that never acquire the art of oesophageal speech that other methods of rehabilitation have been devised and conceived. it is for this group of patients and for those having undergone a total laryngopharyngectomy in whom the absence of pharyngeal musculature precludes them from developing the techniques of oesophageal speech, that further mechanical and surgical methods of rehabilitation will be discussed. journal of rhe south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) speech therapy in the head and neck service 45 history the first attempt at construction of an artificial larynx anti-dated the first laryngectomy by billroth in 1873. gussenbauer reported in 1874 on the construction of an artificial larynx with a vibrating reed which transmitted air directly from the tracheostoma into the open pharynx. later in 1940 the first battery powered instruments were devised which produced a buzzing monotone, which when applied to the skin of the patients' neck, caused "sound" to be transmitted into the pharynx which could be subsequently articulated for speech. progressive modifications have improved the nature of the sound and subsequent speech produced by the so-called electro-larynx. these substitute laryngees have many inherent drawbacks such as the expense, the repeated battery failure and the cumbersome nature of always having to carry the device, without which the patient immediately becomes non-communicative. the need to develop a reliable surgical technique for vocal rehabilitation was therefore great. the concept of diverting pulmonary air from the tracheostomy stoma into the oral cavity is not a new one. in the late 1950's asai in japan2 and conley in the u.s.a.3 designed operations to reconstruct a vibrating mechanism to serve as a sound source for oral communication. the sound source was constructed by creating a pharyngeal fistula, and a skin tube which connected the trachea to the pharyngeal fistula. it was conley who used a vein graft to connect the trachea to this pharyngeal fistula. the patient could then divert all expired air into the pharyngeal fistula by obliterating the tracheostoma. with this large volume of air entering into the oral cavity, the patient was able to articulate and thereby immediately become communicative. many problems were encountered with the asai type of dermal tube, such as stricture of the fistulous tract, and reflux of food and salivary secretions into the trachea and resultant inhalation pneumonia. such problems remained unresolved with these techniques which led to further developments in the operative techniques. figure 1 figure 2 showing tracheostomy stoma and deliberate pharyngeal fistula air tunnel device o s t o m y tracheostomy end pharyngeal end figure 3 device in situ tydskrif van die suid-afrikaanse vercniging vir spraak en cehoorheelkunde, vol. 22, desemher 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 m.i. dinner it was montgomery4 who was responsible for the formation of a fistulous tract from the pharynx on to the skin surface. (fig. 1). it was decided to connect the tracheostomy to the pharynx by indirect means which would thereby avoid the problem of food and saliva entering the trachea. the operation required the formation of a skin or mucosal lined tube from the pharynx to the cervical skin. the dimensions of the tunnel varies from 3 to 6 mm. in internal diameter and at least 3 cm. in length. the outer end of the tunnel is placed at a higher level than the inner end to discourage the leakage of saliva by the anti-gravity situation of the tunnel. after a period of two to three weeks, allowing the operative site to heal satisfactorily, the tracheostoma could then be directly connected to the pharyngeal fistula by means of a simple device called the "air tunnel device"5 (fig. 2) which had a snug fitting attachment of the one end to the tracheostomy stoma and the end piece into the pharyngeal fistula (fig. 3). expired pulmonary air was easily diverted from the tracheostomy via this pharyngo-cutaneous tunnel directly into the oral cavity. with each expiratory effort the air is diverted deliberately into the oral cavity for articulation by the patient. all that was required by the speech therapist was to teach the patient to co-ordinate his expiratory efforts and the obliteration of the tracheostoma end of the simple "air tunnel device" in order for the patient to begin speaking. with increase in sophistication of the devices, a one-way valve was included in the circuit at the pharyngeal end to prevent salivary leak from the pharyngeal fistula. further sophistication led to the development and inclusion of a vibrating reed in the circuit of the "air tunnel device". the "reed-larynx" of taub and spiro 6 , 7 included a vibrating reed with a basic frequency of 130 c.p.s. the speed and tension of the vibration of this reed could be altered thereby altering the quality, pitch and tone of the sound produced as it entered the pharynx for articulation. this indeed appeared to be the ideal surgical method of speech rehabilitation of the laryngectomee. very much less intensive speech therapy was required for such patients to learn to speak in comparison to oesophageal speech. the art of articulation could be very rapidly learnt within two to three weeks of surgery, and speech therapy could then be devoted to the refining of articulation, phrasing and inflection of speech. over enthusiasm with surgical reconstruction for the rehabilitation of speech however high-lighted many of the problems associated with any biological fistula. although the problems which exist can be mastered by the individual and highly selected patient, these problems remain a drawback to this method of speech rehabilitation i.e. the problems of persistent salivary leak through the fistula, persistent excoriation of the surrounding skin of the neck, and the occasional leakage of saliva and food stuffs into the tracheostoma. therefore the "air tunnel" and reed fistula devices represent a very satisfactory method of speech rehabilitation but only in highly selected patients. the problem remains therefore, to prognosticate which patients will prove resistant to the speech therapists' efforts in the instruction of oesophageal speech, to determine which patients should be submitted to these procedures at the time of laryngectomy. journal of he south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) speech therapy in the head and neck service 47 indications for surgical rehabilitation patients with the extended laryngectomy and laryngo-pharyngectomy which includes the pharyngeal musculature, and therefore precludes the patient from the ability to speak by the oesophageal method, is an indication for the primary reconstruction of such a deliberate pharyngeal fistula for speech rehabilitation. the creation of a pharyngeal fistula in routine laryngectomy should therefore be retained as a secondary procedure.for patients who have failed to respond to the techniques of oesophageal speech. objective speech evaluations in the reed fistula and air tunnel device patients, by tests such as selective quantitative measures, measures of intelligibility and selective qualitative measures may highlight certain advantages of these methods of speaking. in addition, an important consideration is the relative short time interval that takes place between the laryngectomy and speech rehabilitation. however many drawbacks still remain with these fistulae such as the leakage, the excoriation and inhalation. in addition shedd et al5 have shown on selective quantitative measures of speech proficiency for speakers using the air tunnel, the reed fistula and oesophageal speech, that the general speech effectiveness was not significantly different for either of the three types of speakers. for this reason oesophageal speech remains the overall mainstay for speech rehabilitation in the vast majority of laryngectomised patients, except for the highly selected patient who may be subjected to operation for surgical rehabilitation of speech. conclusion many problems remain to be solved to restore these unfortunate patients, suffering from malignancy of the "head and neck" region, to a useful existence and social acceptability following radical ablative and curative surgery. the combined multi-disciplinary approach is emphasised in their rehabilitation and it is this approach that is responsible for the advances towards the ultimate goal of cure, cosmetic acceptability, and social communicability. references 1. snidecor, j.c. (1962): speech rehabilitation of the laryngectomized springfield, illinois, thomas, 46-72. 2. asai, r. (1960): laryngoplasty j. japan broncho-esophagological soc., 12,1-3. 3. conley, j.j. (1959): vocal rehabilitation by autogenous vein graft ann. otol 68:990. 4. montgomery, w.w. (1972): post-laryngectomy vocal rehabilitation arch. otol, 95, 76. 5. shedd, d.p.; bakamjian, v.; sako, k.; schaaf, n.g.; mann, m.b. (1974): post-laryngectomy speech rehabilitation by a simplified single stage surgical method. /. surg., 128, 505. tydskrif vn die suid-afrikaanse verniging vir spraak en ehoorheelkunde, vol. 22, desemer 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 m.i. dinner 6. shedd, d.p.; bakamjian, v.; sako, k.; schaaf, n.g.; barba s.; mann, m. (1972): reed fistula speech rehabilitation after laryngectomy. am. j. surg., 124,510. 7. taub, s. and spiro, r.h. (1972): vocal rehabilitation of laryngectomees, am. j. surg., 124, 87. south african leading suppliers of: audiometers auditory trainers hearing aids sound proof rooms etc. contact eric c. lewis and hillary j. reichenberg the needler westdene hearing aid organization (pty.) ltd. i / p.o. box 28975, s andring ham. • 2131. ; telephone: 45-7262. journal of he south african speech and hearing association vol. 22 december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e communicative abilities of mild mental r e t a r d a t e s ruth bluestone b . a . ( s p . & h . therapy) ( w i t w a t e r s r a n d ) department of speech therapy, johannesburg hospital, johannesburg. summary the interpersonal communicative abilities of five mild mental retardates are investigated and described. one test of interpersonal communication was chosen from the literature. in the test situation, the experimenter taught each subject/speaker how to play a simple board game. each speaker then taught the game to a listener of similar mental age. the channels of communication, both verbal and nonverbal, used by the speakers to explain the game items, were determined. the speakers' speech style (productivity, vocabulary and utterance structure) was evaluated qualitatively. results indicated that all the speakers used both verbal and nonverbal communication behaviours to explain the rules of the game. unlike the experimenter, the speakers utilized nonverbal behaviours (pointing and manipulation of the game material) as a distinct mode of communication. the speakers used an egocentric speech style and they all, unlike the experimenter, used speech to help the listener play the game correctly. the communicative ability of the speakers was not found to be commensurate with their mental ages and it was postulated that their inferior cognitive abilites predisposed them to use both primitive nonverbal behaviours and an egocentric speech style. opsomming die onderlinge kommunikasie vermoe van vyf matig verstandelikvertraagde persone is getoets en beskryf. een toets van onderlinge kommunikasie is gekies uit die literatuur. in die toetssituasie het die proefnemer elke proefpersoon/spreker geleer hoe om 'n eenvoudige bordspeletjie te speel. elke spreker het toe die speletjie aan 'n luisteraar van soortgelyke verstandelike ouderdom geleer. die bane van kommunikasie, sowel verbaal as nie-verbaal wat ter verduideliking van die spelitems deur die sprekers gebruik is, is vasgestel. die sprekers se spraakwyse (produktiwiteit, woordeskat en uitdrukkingstruktuur) is kwalitatief geevalueer. uit resultate wil dit voorkom dat alle sprekers sowel verbale as nie-verbale kommunikasiegedrag gebruik het om die spelreels te verduidelik. anders as die proefnemer, het die sprekers as 'n duidelike kommunikasiemetode gebruik gemaak van nie-verbale gedrag (wys met die vinger en manipulasie van die spelmateriaal). die sprekers het gebruik gemaak van 'n egosentriese spraakwyse en het almal, anders as die proefnemer, van taal gebruik gemaak om die luisteraar te help om die speletjie korrek te speel. die kommunikasievermoe van die sprekers was nie eweredig aan hulle verstandelike ouderdom nie en is dit gepostuleer dat hulle laer kognitiewe vermoe tot die gebruik van sowel primitiewe nie-verbale gedrag en egosentriese spraakwyse aanleiding gee. the speech therapist, in dealing with the problems of communication, must of necessity deal with the problem of mental, retardation and the associated communication problems arising from this condition. lillywhite and bradley 1 4 state that of all the types of human problems resulting in major communication disorders, mental retardation is perhaps the least understood, the most puzzling and the most neglected by speech and hearing specialists. · a great many studies have demonstrated that language deficiencies in the form of speech defects occur in retarded children. 7 ' 1 2 ' 2 1 ' 2 4 ' 2 6 the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication of retardates 81 the reported incidence figures vary considerably, but one fact that can be gleaned from the literature is that mental retardation and linguistic retardation are correlates. individuals are classified as being mentally retarded when their intelligence quotients (iq) fall below a certain limit. the american association on mental deficiency designates five different categories of retardation.4 the present study was concerned with those subjects classified as mild or educable mental retardates, that is, those having an iq between 50 and 75. 2 3 the reported incidence figures of the speech and language problems amongst this subgroup of mental retardates, varies considerably. most researchers2 3' 2 4 ' 2 6 however do indicate that the mildly retarded child presents with many more speech and language problems than would be found in the normal population. according to the above writers, 2 4 ' 2 4 ' 2 6 the mild or educable retardate is very rarely unable to communicate at all and does acquire some usable language. the child therefore can be said to acquire a phonology, a morphology and a syntax, although these aspects may not be adequate for his age. an important consideration is how the child uses his acquired language to communicate2 2, for as well as learning the syntax and vocabulary of language, the child must learn to use them appropriately in different situations and with different communicative partners. the field of pragmatics is therefore concerned with how language is used to communicate and emphasis is given on how a person uses his language, apart from the structure or content of the language system itself.9 the language of an individual may therefore be assessed in two ways, namely, intrapersonally and interpersonally. in the former method, one investigates how language develops within the individual15 by assessing aspects such as the child's vocabulary, sentence structure and articulation. in the field of mental retardation, comparisons are then made between the mental retardate's intrapersonal language and the language of the normal child, of similar mental or chronological age. in interpersonal assessment, however, the focus is on the flow of behaviour between a speaker and a listener. this method, according to siegel2 5 seems to be especially cogent in the study of communication disorders since speech events are almost always interpersonal, involving both a listener and a speaker. the present study was concerned with the question of how mildly retarded speakers utilize their existing language to communicate and for this reason the latter method of investigation was chosen. in everyday communicative situations, the involved and complex patterns of exchange between speaker and listener are not easy to study and evaluate. interpersonal communication tasks in which the communication episode can be readily observed and objectively described have however been developed by a number of die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 82 ruth bluestone researchers.1 , 2 ' 5 ' 1 0 , 1 3 , 1 5 ' 1 6 there are no formal tests in this area and therefore the experimenter is reliant on his/her ability to adapt the material and tests used in the literature to meet the needs of the subjects under study. m e t h o d o l o g y aim to describe the interpersonal communicative abilities of mild or educable mental retardates. subjects ten subjects, five speakers and five listeners, were used. the speakers constituted the primary subjects of this study and it was their communication that was studied. none of the speakers participated as listeners and vice versa. a control group of normal subjects was not used as this study was not concerned with comparing the communicative abilities of normal and mentally retarded speakers. from the literature it can be seen that mental retardation and linguistic retardation are correlates,7' 1 2 ' 2 1 · 2 4 ' 2 6 and that the mild mental retardate presents with many more speech and language problems than would be found in the normal population. 2 3 ' 2 4 ' 2 6 criteria for speaker selection 1. intelligence: all speakers were required to be classified as mild or educable retardates, that is, to have an iq between 50 and 7 5 . 2 3 2. mental age: all speakers were required to have a mental age (ma) above 8 years. this particular ma was chosen for the following reasons: ma seems to be a more accurate predictor of speech and language abilities than chronological age. 8 ' 1 4 in addition, only after eight years of age is the normal child able to use his language most effectively for the purpose of communication.1 7 3. hearing: to eliminate inadequate peripheral functioning as further possible etiology of linguistic impairment, speakers were required to have normal hearing. 4. schooling: all speakers were required to have spent a minimum of two years in a normal school environment and a minimum of four years in a special education class in a private or government school. at the time of the study they were all required to be attending the same private school and to have been exposed to the same teacher for a minimum of two years. speakers who had just joined the class or who had recently begun attending the school, were not included in the study, ι 5. previous training or therapy: apart from receiving special education in the school, none of the speakers had received any form of additional training in the form of speech therapy. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication of retardates 83 6. sex: due to the lack of availability of speakers and the importance of selecting speakers according to ma and iq, this factor could not be controlled for and all speakers were females. 7. home language: all speakers were required to be english speaking and to have been exposed to a single home language. 8. test factors: all speakers were required to have been tested on the same iq test (wechsler intelligence scale for children) by the same tester (school psychologist) at approximately the same time (six months prior to the study) and under the same conditions (the school environment). criterion for listener selection five listeners were selected and each speaker was paired with a listener of similar ma. the rationale for matching dyads according to ma is as follows: research has shown that both adults and children alter their encoding strategies as a function of the age and ability of the listener with whom they are p a i r e d . 1 9 rosenberg et a l 1 8 and hoy and mcknight1 0 found that retarded children communicate more and more effectively when placed with listeners of similar linguistic ability than when placed with listeners of superior linguistic ability. if ma is an accurate predictor of linguistic ability8' 1 4 then pairing dyads according to ma ensures homogeneity and according to the literature cited a b o v e 1 0 ' 1 8 homogeneity facilitates verbal interaction. pilot study there are no formal tests of interpersonal communication and although a number of test paradigms have been set up by a number of different researchers,1' 2 · ' 1 0 ' 1 3 ' 1 5 ' 1 6 each test assesses a different aspect of communication and in addition some tests are more effective than others. as a result, a detailed pilot study (which cannot be elaborated on in the present article) was carried out. the primary aims of this pilot study were: to select appropriate tests of interpersonal communication that have been used in the literature; to administer and thereafter evaluate the efficacy of these tests; and on the basis of the above findings to select the most effective test in terms of the present study and the population being assessed. description of chosen test on the basis of the results of the above pilot study, one test of interpersonal communication, developed by hoy & mcknight;1 0 was chosen as the most effective test for the purpose of this study. certain modifications were however introduced. basically, in this test situation, the speaker is required to explain the rules of a simple board game to a listener. the test consists of the following equipment: die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 84 ruth bluestone 1. a game board: a 46 centimetre square with six (7,6 centimetre wide) stripes, alternately blue and yellow, running horizontally across the board and a black line running vertically down the centre of the board, delineating each player's side. 2. two movers: one red and one green car. 3. a dice: a four centimetre cube with three blue and three yellow surfaces. from the pilot study, it was determined that in order to teach the listener how to play the game, the speaker must convey ten items of game information. in addition, different channels of communication can be used to explain each item. the three main channels are the verbal (v), gestural (g) and manipulative (m) where gesture is defined as a hand movement in the air and manipulation as actual touching and moving of the game material. 1 0 during the pilot study it was observed however, that it is difficult to separate out a gestural response from a manipulative one and therefore these two channels were combined into one nonverbal channel. during the study therefore, only three channels of communication were used: 1. verbal channel (v) where speech alone is used to explain a game item. 2. verbal-gestural-manipulative channel (v-g/m) where speech is used together with gesture and/or manipulation. 3. gestural-manipulative channel (g/m) where gesture and/or manipulation is used without speech. testing testing involved the following four steps: 1. the experimenter taught the speaker how to play the game. the speakers were each instructed individually and as far as possible the experimenter's instructions to each speaker were standardized. one channel of communication (v-g/m) was selected and the same speech and nonverbal behaviour was used to explain each game item. 2. the experimenter and speaker played the game twice. this was done to ensure that each speaker had understood the rules of the game. speakers were said to have understood the rules if they were able to play the game correctly twice in a row, without any prompting. they were said not to have understood the game if they hesitated before moving, made an incorrect move or asked questions about the game. ' an independent rater was used to help the experimenter note the above responses and in addition a tape recording was made of each speaker's verbal behaviour. | 3. the speaker taught the game to a listener. each speaker's verbal explanation' of the game was tape recorded for later analysis. in addition, the nonverbal aspects of the the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication of retardates 85 description were rated by both the experimenter and an independent rater. the experimenter and rater each had a score sheet with the items to be communicated listed vertically and the channels of communication listed horizontally. the experimenter and rater sat on either side of the dyad and thus were unable to observe each other's score sheets. 4. the speaker and listener played the game twice. once the speaker had finished explaining the game to the listener, they too played the game twice. so that this could be later analyzed, a tape recording of their verbal interaction was made. transcription of the data the speech of the speakers, both while explaining the game and during both playings of the game, was transcribed. any comments made by the listeners, were also transcribed. if during the playing of the game with the experimenter, the subjects or the experimenter used speech, this was also transcribed. analysis of the data the data analysis procedures, suggested by hoy & mcknight,1 0 were used. the following areas were considered but will not all be discussed in the present article: 1. the number of game items communicated by each speaker. 2. the channels of communication used by each speaker. 3. speech style. (a) productivity (i) total number of words (ii) total number of utterances (b) vocabulary (i) number of different words used (ii) type token ratio as defined by carroll.3 (b) utterance structure (i) number of imperatives (ii) number of declaratives (iii) number of questions the above procedures were used: 1. to analyse the speech used by the experimenter to explain the rules to each speaker. 2. to analyse the speech used by each speaker to explain the game to a listener. 3. to analyse the speech used by each speaker whilst playing the game with the listener. results a n d discussion 1 . number of game items explained by each speaker ( s ) . the mean number of items communicated by the group is equal to 8,8. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 86 ruth bluestone from table i it can be seen that five ss omitted one game item and that only one out of the five ss omitted two items. table i: total number of game items explained by each speaker regardless of channels used. (total is equal to 10) si s2 s3 s4 s5 8 9 9 9 9 2 . the channels of communication used by each s. from the above table (table i) it can be seen that a total of forty four game items were explained by the group. of these, two were explained through the v channel, eighteen through the v-g/m and twenty four through the g/m channel. the output of the group must be evaluated in terms of the input they received. although ss were not told how to go about the task, they did have a model, the experimenter's (e) description, upon which to base their explanations. the question to be asked is whether there is any correlation between the way the ss explained the game items and the way the ε explained them in terms of the channels of communication used. from table ii it can be seen that the ε used one channel, the v-g/m, to explain each item. the ε therefore used this channel 100% of the time. on average, the ss used this channel only 41% of the time. as a table ii: the percentage of game items explained through each of the three channels, including a comparison between channels used by the experimenter (e) and speakers (ss) to explain the game. v v-g/m g/m ε si 100 fless8ssb«t 12 t s s e e t e 88 s2 44 56 s3 11 44 44 s4 11 56 33 s5 44 56 mean 4 41 55 the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication of retardates 87 group, they used the g/m channel more frequently, that is, 55% of the the results depicted in table ii therefore indicate that all the ss in this study relied to some extent, some more than others, on a nonverbal channel of communication (the g/m channel) to explain the rules of a game to a listener. the above results correspond with those obtained by hoy & mcknight. 1 0 3 . speech style u s e d to explain the rules of the game, (a) productivity the results depicted in table iii indicate that as a group the ss used fewer words and utterances than the e. if the ss used a nonverbal channel more frequently than the ε to explain the game items (see table ii) then it can be expected that they will use less speech than the ε to explain the items. this large discrepancy between the e's and ss' productivity, indicates, therefore, that the verbal channel does not constitute a primary mode of communication for the ss in this study. the e, on the other hand, utilised the verbal channel as a primary mode of communication and gesture and/or manipulation was used by the ε only to supplement verbal instructions. the ss, unlike the e, used gesture and/or manipulation as a separate, substitutive channel of communication. table iii: a comparison between the productivity of the ε and ss. number of words number of utterances ε 149 17 mean ss 53 5,8 (b) utterance structure in terms of utterance structure, there are similarities between the way the ε explained the game items and the way the ss explained them in that they both utilised a predominantly declarative speech style. a declarative speech style seems to be the most appropriate style to use to inform a listener about the rules of a game. thus, even though the ss in this study, did not utilise verbal communication as their primary mode, the speech they did use was utilised in the most effective way possible in terms of informing the listener about the rules of a game. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 88 ruth bluestone 4 . speech style used whilst playing the game with a listener. in this section, a comparison cannot be made between the e's and ss' speech style, as the ε did not use speech whilst playing the game with any of the ss. thus once the rules had been explained, the ss understood them and did not need an additional explanation. unlike the e, the ss all used speech whilst playing the game with a listener. speech was used only during the first playing of the game. table iv: a comparison between the number of words used during the explanation and during the first game. n u m b e r o f w o r d s u s e d s p e a k e r s s i s 3 s 5 s 2 s 4 p l a y i n g 4 4 35 3 4 3 0 2 4 e x p l a i n i n g 18 5 1 6 1 6 8 6 7 table iv indicates that there is an inverse relationship between the number of words used to explain the game and the number of words used whilst playing the game: ss who used the least amount of speech to explain the game used the most speech whilst playing the game. thus, as the number of words used whilst playing the game decreased, so the number of words used whilst explaining the game increased. as a group the ss all used a nonverbal channel of communication to explain the rules of the game. unlike the e, they all used speech whilst playing the game with a listener. there seems therefore, to be a relationship between the use of nonverbal communication to explain the rules and subsequent use of speech whilst playing the game. g e n e r a l discussion it is generally accepted that a speaker can encode a message through a number of different channels:2 0 (1) the speech mechanism; (2) the hands and arms; (3) the face and (4) other body parts. verbal language is therefore only one method of human communication. the results of this study indicate that all the speakers encoded information both verbally (by means of speech) and nonverbally (by means of gesture and/or manipulation). the speakers used nonverbal communication both to supplement; and as a substitute for verbal communication. it may therefore ' be postulated that nonverbal communication constituted an important mode of communication for the mentally retarded subjects in this istudy. in order to evaluate the above, it is important to consider the type of nonverbal communication used by the speakers. only hand and arm gestures were used and more specifically, the speakers used either pointing or manipulation of the game material to explain the items. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication of retardates 89 although it has been determined that the speakers used nonverbal behaviours as a distinct mode of communication, the exact nature of nonverbal communication and its relationship to verbal communication is not clear. two different views have been postulated. one point of view is that nonverbal communication includes any code items that are not part of language.9 these behaviours (nonverbal) according to jancovic et a l 1 1 are nothing but primitive substitutes for more complex verbal forms and are therefore more trivial in comparison to verbal communication behaviours,n the alternative view states that although language may receive a visual-gestural encoding, it still must be considered as language. in addition the nonverbal channel has the possibility of being elaborated to the same extent to which the verbal channel is known to be elaborated. 1 1 the writer believes that although we can view communication as a matrix of both verbal and nonverbal channels, and although there is the possibility of interdependence between channels, speech must be seen as the most sophisticated form of adaptive behaviour. 2 0 in addition, some forms of nonverbal behaviour must be viewed as primitive precursors to later verbal forms. the writer believes that because pointing is evident in the prelinguistic child9' u ' 2 0 and because this type of nonverbal behaviour disappears from the child's repertoire when more complex verbal forms a p p e a r , 1 1 pointing must be viewed as a primitive and unsophisticated form of nonverbal behaviour. with regard to the results obtained in the present study, the following two questions need to be answered: 1. why did the mental retardates in this study rely to such a great extent on nonverbal communication? every communication system places demands upon cognitive function, but the extent of the demand varies with the sophistication of the system.20 verbal language requires a sophisticated use of linguistic rules, in addition to cognitive function. nonverbal communication, on the other hand, places less of a demand upon cognitive function. the important relationship that exists between cognition and language cannot be ignored. if, as stated above, the form of communication used, depends on cognitive ability, then analysis of the communication channels used by the speakers, can give insight into their cognitive development. zigler, as cited by weisz, 2 7 holds the view that persons of differing iq but similar ma will manifest cognitive differences inherently related to iq. thus retarded persons will be cognitively inferior to non-retarded persons of similar ma. if the mental retardates in this study are functioning inferiorly on a cognitive level, then this can account for their frequent use of a primitive nonverbal communication system. a corollary to this view is that the mental retardates frequent use of the nonverbal die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 90 ruth bluestone channel indicates that they are functioning inferiorly on a cognitive level. 2. was the communication used by the speakers effective in producing listener understanding? the effectiveness of communication and listener understanding were not evaluated in an objective manner. the results of the study do seem to indicate, however, that the explanations given by the speakers were not in fact effective in producing understanding of the game. all the speakers understood the rules of the game, yet they all, unlike the experimenter, used speech whilst playing the game with the listener. this seems to indicate that, had the speakers not used speech, the listeners would not have been able to play the game correctly. it may be postulated that two interrelated factors affected communication, namely, the speakers' use of nonverbal communication channels, as well as their inadequate role-taking abilities. in order to play the communication game effectively, the speaker must realize that effective communication can only occur if he (the speaker) makes appropriate consideration of the other participant/s in the communication process. 1 7 this awareness of communication as a two-way process is known as role-taking.5 role taking abilities are only fully developed after eight years of age and prior to age eight, communicative efforts are governed by limitations in cognitive development,17 cognition, language usage and communication are inextricably related 1 7 and it therefore may be postulated that the speakers in this study are delayed cognitively and that their cognitive limitations affected the nature of their communications. if, as the results of this study suggest, communication was non-communicative, then the nature of non-communicative language must be discussed. piaget, as cited by ginsburg & opper 6 , uses the term egocentric speech to define the speech of the young child. results of this study seem to indicate that the speakers used egocentric communication. they internalized the rules of the game and as such they were meaningful and communicable to themselves. they then transmitted the rules without first recoding them. the rules were obscure to the listener and they were unable to play the game. in order to overcome this difficulty, and because the speakers were motivated to play '.the g a ^ e , they used speech to help the listener. the use of egocentric speech indicates that underlying idiosyncratic cognitive systems are not fully developed. 1 7 in addition, egocentric speech is characteristic of the speech of the young child, below eight years. if as indicated above, the speakers in this study used an egocentric speech style, then one can postulate that their underthe south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication of retardates 91 lying cognitive systems are not fully developed and that in additiom, their communicative behaviour is not commensurate with their mental ages. conclusion the results obtained in this study indicate that in interpersonal communication situations, mildly retarded speakers utilize and rely to a great extent on nonverbal communication channels. the verbal channel does not therefore constitute the primary communication mode for these speakers. in terms of speech therapy for the retarded, therefore, the following needs to be considered. should speech therapy aim to make the mildly retarded child predominantly verbal or should attempts be made to increase, not exclude the child's use of nonverbal communication behaviours? in order to plan appropriate therapy for the mentally retarded child, factors such as his language needs, age and degree of retardation must be considered. the older, school-going, mildly retarded individual should potentially be able to acquire the specific skills necessary for certain jobs. speech therapy or classroom training should therefore be aimed at helping this child become integrated into a predominantly verbal society. the child should be helped to acquire the skills, both verbal and otherwise, that are necessary for specific jobs. although the mild retardate's use of nonverbal communication should not be ignored, attempts should be made to make this child's verbal communication skills at least commensurate with his mental age. speech therapy for the low grade retardate (the moderately or severely retarded) cannot however always be aimed at teaching the child a fully developed adult system of communication. the goal of therapy with this retardate should be to provide the child with a system of communication that is both effective and functional. the writer feels that for the low grade retardate, facilitation of nonverbal communication, should constitute the primary focus of therapy. it may be that the use of nonverbal communication is a means by which retarded children, who are too low on a cognitive level to learn to speak adequately, can learn to communicate. references 1. beveridge, m. c. (1976): patterns of interaction in the mentally handicapped. in language and communication in the mentally handicapped, berry, p. (ed.) edward arnold. 2. beveridge, m. c., & tatham, a. (1976): communication in retarded adolescents: utilization of known language skills. american jnl. of mental deficiency, 81(1), 96-99. 3. carroll, j. b. (1964): language and thought. foundations of modern psychology series, prentice-hall, inc. n. j. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 92 ruth bluestone 4. davison, g. c., & neale, j. m. (1974): abnormal psychology: an experimental-clinical approach. john wiley & sons. ν. y. 5. flavell, j. j., botkin, p. t., fry, c. l., wright, j. w., & jarvis, p. e. (1968): the development of role taking and communication skills in children. john wiley & sons. ν. y. 6. ginsburg, h., & opper, s. (1969): piaget's'theory of intellectual development: an introduction. prentice-hall, inc. n. j. 7. goertzen, s. m. (1957): speech and the mentally retarded child. american jnl. of mental deficiency, 62(2), 244-253. 8. graham, j. t., & graham, l. w. (1971): language behaviour of the mentally retarded: syntactic characteristics. american jnl. of mental deficiency, 75(5), 623-629. 9. hopper, r., & naremore, r. (1978): children's speech: a practical introduction to communication development. harper & rowe. 10. hoy, ε. α., & mcknight, j. r. (1977): communication style and effectiveness in homogeneous and heterogeneous dyads of retarded children. american jnl. of mental deficiency, 81(6), 587-598. 11. jancovic, m., devoe, s., & wiener, m. (1975): age related changes in hand and arm movements as nonverbal communication: some conceptualizations and an empirical exploration. child development, 46(4), 922-928. 12. karlin, i. w., & strazzulla, m. (1952): speech and language problems of mentally deficient children. j. speech hear. dis., 17, 286-294. 13. krauss, r. m., & glucksberg, s. (1969): the development of communication: competence as a function of age. child development, 40(1), 254-265. 14. lillywhite, h. s., & bradley, d. p. (1969): communication problems in retardation: diagnosis and management. harper & rowe. 15. longhurst, t. (1972): assessing and inreasing descriptive communication skills in retarded children. mental retardation, 10(2), 42-45. 16. longhurst, t., & reichle, j. (1975): the applied communication game. j. speech hear. dis., 40(3), 315-319. 17. muma, j. r. (1975): the communication game: dump and play. j. speech hear. dis., 40(3), 296-307. 18. rosenberg, s., spradlin, j., & mabel, s. (1961): .interaction among retarded children as a function of relative language skills. jnl. of abnormal and social psychology, 63(2), 402-410. 19. sachs, j., & devin, j. (1976)': young children's use of age appropriate speech styles in social interaction and role playing. jnl. of child language, 3, 81-98'. 20. sanders, d. a. (1976): a model for communication. in communication assessment and intervention strategies, lloyd, l. (ed.) university park press. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication of retardates 93 21. saunders, ε. α., & miller, c. j. (1968): a study of verbal communication in mentally subnormal patients. brit. jnl. of dis. of comm., 3(1), 99-110. 22. schiefelbusch, r. l. (1967): introduction. in language and mental retardation, schiefelbusch, r., copeland, r. & smith, j. (eds.) holt rinehart & winston, inc. 23. schlanger, b. s. (1973): mental retardation. bobbs-merrill studies in communicative disorders. 24. sheehan, j., martyn, m., & kilburn, k. (1968): speech disorders in retardation. american jnl. of mental deficiency, 73(2), 251256. 25. siegel, g. m. (1967): interpersonal approaches to the study of communication disorders. j. speech hear. dis., 32, 112-120. 26. spreen, o. (1965): language functions in mental retardation: a review i. american jnl. of mental deficiency, 69(4), 483-493. 27. weisz, j. r. (1976): studying cognitive development in retarded and nonretarded groups: the role of theory. american jnl. of mental deficiency, 81(3), 235-239. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t e l e x . t e l e x c o m m u n i c a t i o n s , i n c . direct wireless fm auditory training system look at these features!!! transmitter: 'special cardioid directional michrophone for improved signal/noise ratio. * auxiliary input for radio, tv or tape with "talk-over" switch. receiver: *two versions availablenormal and high frequency emphasis. * tone, compression and fm/mic balance controls provided. * selection of earphones available. * three operating modesfm alone, + hearing aid and hearing aid alone. * channel selection by plug in moduleallows freedom of movement from one class to another without changing the receiver. general: *32 different channells !!! * dry cell or rechargeable energy source. * robust construction with michrophone protection cover. hearing is bliss 203 lancet hall, 207 jeppe str., johannesburg. 2001 syd bliss hearing aids (pty) ltd. tel. 29-1239 books on speech therapy and audiology are stocked at these bookshops campus bookshop westdene medio boeke 34 bertha street 35-36 nedbank plaza p.o. box 31361 175 beatrix street braamfontein 2017 pretoria johannesburg tel: 26336 & 33487 tel: 39-1711 westdene services logans university bookshop 76a king george street, (pty) ltd hospital hill 229 francois road hillbrow durban johannesburg tel: 25-3221 tel: 39-1711 pro rege bookshop campus westdene b o o k s h o p / / tomstraat 86 ί boekhandel / p.o. box 343 1 cnr. grotto & main roads potchefstroom 8875 rondebosch tel: 8875/6 ι tel: 692-407 i literary services (pty) ltd. the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 35 augmentative and alternative communication in south africa: accessibility and implementation erna alant centre for augmentative and alternative communication department of speech pathology and audiology university of pretoria abstract this paper deals with the development of a community -based service for the implementation of augmentative and alternative communication (aac) strategies for people with severely limited verbal expression. the concept of community-based intervention is explained and the process of training as done in the centre for augmentative and alternative communication (caac) is described. data of pre and post training evaluations is discussed as well as follow-up data obtained in the various training contexts. finally, critical issues related to the follow-up data are discussed. opsomming hierdie artikel handel oor die ontwikkeling van 'n gemeenskapsgebaseerde diens vir die implementering van aanvullende en alternatiewe kommunikasie (aak) strategiee vir mense met ernstig beperkte verbale ekspressie. die konsep vangemeenskap-gebaseerde intervensie word verduidelik en diefroses van opleiding soos dit plaasvind in die sentrum vir aanvullende en alternatiewe kommunikasie (saak) word beskryf. data van voor-en na-opleiding evaluering sowel as opvolg inligting verkry binne die verskillende opleidingskontekse, word bespreek. laastens word sekere kritiese vraagstukke met betrekking tot die opvolg data, uitgelig. the difficulties involved in sustained use of augmentative and alternative communication (aac) strategies within the broader community have recently received much attention in the literature (calculator & lucko, 1983; mirenda, 1992). various authors have pointed out the limited use of communication boards (calculator & dollaghan, 1982) and gestural and electronic systems in real life situations (allaire, gresardetal. 1991). reasons for failure in using these systems range from client characteristics (for example, no ability to generalize skills), to a stronger environmental emphasis (for example, limited training in significant others' use of the systems), to attitudinal problems of people relating to the disabled and nonspeaking person (blackstone, 1989; gorenflo & gorenflo, 1991). these authors agree, however, that failure to implement a system can usually be attributed to a combination of factors within the person's environment. although primary caregivers are important in the training of aac strategies, they also need a supportive framework that is conducive to reinforcing the use of the communication systems. the involvement of peers, educational staff and other interested parties is vital to the successful implementation of a communication system (cumley & beukelman, 1992; van tatenhove, 1992). the concerns in south africa, as in other developing countries, with problems of affordability, equitability, accessiblility and appropriateness of health services, neccessitate a cautious approach when rendering aac services. improvement in communication ability has to do with the increase in the quality of life of the individual and cannot be separated from the infrastructure for health and social development within a particular country. this is particularly relevant when addressing issues of technology and sustainability. the aims of the paper are threefold: 1. to discuss the issue of community-based rehabilitation as a background to the proposed service model 2. to describe the service model used for the implementation of aac strategies in the centre for augmentative and alternative communication (caac) based at the university of pretoria, by focussing on the aims and the process used for training 3. to highlight critical issues relating to the follow-up visits to various training contexts. the concern about making technology more apppropriate for developing countries has become a major issue in the socioeconomic development debate concerning less developed countries. rifkin and walt (1986) have identified two schools of thought in relation to the implementation of technology in developing countries. the first maintains that if technology could be successfully implemented, it would transform the society so that a new value system would develop. this approach focusses on the efficacy of interventions and the need to transfer existing technologies as quickly as possible. intervention models and approaches are emphasized, for example, the centre-based models of aac (bjackstone, 1989) in which the team of experts evaluate and recommend appropriate intervention strategies within a particular context. the second school of thought holds that the society must evolve in its own way and must therefore develop its own infrastructure for dealing with and using technology. in this way the technodie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 39, 1992 ® saslha 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 logy would be adapted or changed to suit the particular culture and resources. technology is effective or appropriate when, within itself, it is an integral part of the development of the society to which it is transferred. this approach focusses on the process through which intervention might be accepted. this second approach can be described as the primary health care approach, also known as "comprehensive health care" about which rifkin and walt (1983, p. 560) have the following to say: "briefly, we see primary health care as being concerned with a developmental process by which people improve both their lives and life-styles. good health is a key factor to this process." central to the second approach is the concept of equality, implying accessibility to health services; the need of a multi-sectoral approach to health problems; and community involvement. snell and browder (1986) have referred to community-referenced instruction and focus on the philosophy of normalization and applied behaviour analysis. they have stated that normalization assumes the importance of teaching skills for adult life in the community and sets some guidelines for social validation of the results. according to the second model, aac implementation can only succeed if integrated within the existing health network and based on active community involvement or participation. this implies that all decision-making and initiative should be taken by the community itself in order to assume responsibility for the intervention procedure as well as for the maintenance of the process. the stress placed on involving significant others in the training of disabled people in the use of aac strategies emphasizes the importance of understanding and recognizing the infrastructure of the community within which individuals live. the issue is not so much one of introducing people to aac, as the maintainance and extension of a communication system once it is in use. the involvement of the community in the decision-making and in the implementation of aac strategies is thus mandatory. abrams (1992, p.3) has emphasized this aspect by stating that "the essential element which determines a genuine developmental process is who ultimately makes the decisions". a significant issue, however, revolves around who should constitute the community that is involved. the heterogeneity of opinion within a specific community necessitates the careful description of which people are involved in a particular decision-making context. it is clear that there is need for an infrastructure or network that can reinforce the programme. however, it has been stressed that such infrastructures can not be sustainably developed on their own without all. others progressing simultaneously (abrams, 1992). to use the infrastructure of health seems logical, although rifkin (1986, p.241) has emphasized that it is not possible to build self-sustaining community participation through health services activities alone. firstly community participation is a process of changing individual perceptions in the course of time as the dynamics of community members change. also, when asked what communities want, health services are not necessarily regarded as primary needs. in addition, not many people in the community have had any experience in providing health care and they see little scope for involvement. while the provision of a single-section health service programme (e.g. an immunization programme) often builds credibility, it also limits the possibility of widespread and sustained community participation because these programmes tend to be more specialized in nature. "community people will gladly accept the benefits, but not as easily accept the responsibility people have expected" (rifkin 1986, p.243). it is against this background that the introduction of an aac service model for developing countries becomes interwoven with a very complex set of social networks. erna alant the definition of the term "community" as used in this paper refers to all people involved in the training context, e.g a school or training centre context including, for example, the staff, parents, aides and other interested parties. the intervention model appropriate technology acc team < j »· community sustainability i upgradability figure 1: aac intervention model (adapted from emmett et al., 1991) figure 1 represents the basic components of the aac service model to be discussed. it centres around making intervention and technology an integral part of community participation and decision-making in order to provide a basis for a sustainable service that has some potential for upgradability. the aims of the project in the caac are to evaluate and develop a community-based service for the implementation of aac strategies for people with limited verbal expression. in this paper, the process used in the caac is illustrated in terms of the evaluation of both the training sessions and the changes that took place as observed during follow-up visits within three specific contexts. it is important to emphasize that working with severely handicapped people implies a long-term commitment as most of these clients will need assistance for the rest of their lives. data presented therefore are those of the initial stages of ongoing interaction with the training contexts. process of training used in the caac institutions or individuals approach the caac for information relating to aac strategies. this is followed by an informal visit of caac staff to the particular venue. discussions centre around motivating people to see that "the way things are now, is not the only way they could be" (hope & timniel, 1984, p.4). if a request for training is received, the following steps are followed. 1. a visit to the institution/ school or home in order to familiarize the staff with the environment of the trainees and to make a video-tape recording of the children with specific problems to which the caac staff should pay special attention during training. the reason for this is that much emphasis is placed on the relevance of training in each context. the language preference of the trainees as well as the clients is determined in order to adjust training to the needs of the context. 2. the trainees are asked to fill in a questionnaire on attitudes and skills/ knowledge of aac in order to provide some background to the trainers in terms of the level at which training should be directed, as well as to the extent of homogeneity of the group. ^ 3. a one-day training session is held, mostly in situ, focussing on aac principles and multi-component communication systems. graphic, gestural and technological systems are introduced (see an example in appendix 1). 4. after the training sessions an evaluation questionnaire is developed in order to assess the efficacy of the training session the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aac in south africa: accessibility and implementation 37 i n terms of knowledge in aac. aotiroximately three months after training, the first follow5 to the training context is done in order to determine the "mtus of trainees regarding the use of aac. this informal pro^ s s is aimed at documenting what has occurred within the context since the first visit and at identifying the variables responsible for the occurrence (meyer & janney, 1989; wacker, 2989) an important additional aim is the identification of needs within the context for further training and support. c o n t e n t o f training programmes the primary aim of the training sessions is to expose people to the concept of aac, multi-component communication and the various ways in which normalization into the community (snell & browder, 1986) can be achieved. emphasis is placed on a number of issues. 1. the importance of developing an infrastructure for the disabled person within which s/he can communicate. in order to achieve this, no fewer than five people (preferably more) from a particular community have to be selected for any one training session. everyone in the individual's environment, teachers, aids, friends or caregivers, is encouraged to attend (cumley & beukelman, 1992). during the training session, it is strongly suggested that the trainees establish an aac interest group within their context in order to establish an organizational structure which would facilitate further regular contact with the caac as well as disseminate information on a local level. various authors (abrams, 1992; hope & timmel, 1984) have emphasized that the sustainability of development of a service is far more dependent upon organizational capacity than appropriate technology or state support. 2. the purpose of aac is discussed in terms of two aims: firstly, augmenting verbal interaction in situations where the individual has little or no functional speech; and secondly, using aac strategies to give entrance into literacy in cases where people cannot read, but will be taught to read in future. this function of aac strategies is receiving much attention in the international aac community at present as reflected in the number of papers presented on this topic at the fifth conference of the international society for augmentative and alternative communication (isaac) (1992) in philadelphia. 3. in teaching communication, the focus is on facilitating community-referenced skills snell & bowder, 1986). the usefulness to the individual ofjwhat is taught is emphasized in order to facilitate normalization. 4. much use is made of stories and role-playing (werner & bower, 1982) in order to help trainees act out problem-solving situations similar to those encountered in their own context and in this way to increase' the relevance of the teaching context. description of specific training context ρ e r 30 a 2 0 9 alma amari eerateruat zodwa tahegofataong figure 2: % respondents from various schools 100 η male female figure 3: sex of respondents parent teacher occupat. speech class other therapist therapist aid η relationship figure 4: relationship of respondent to disabled person component communication, thus emphasizing that the aim is to facilitate communication or to facilitate literacy and not to teach the child "bliss symbolics" or any other symbolic system. figure 2 provides an analysis of the training contexts used in the data presented in this paper. three of the contexts are afrikaans speaking (welkom, pretoria and eersterust) while two contexts are northern sothoand zuluspeaking (attridgeville and mamelodi). all these training contexts were schools for severely handicapped children. information given during the training sessions reported on in this paper, centred around the use of graphic symbol systems as most trainees were ignorant of the use of these systems for communication. due to exposure to the deaf community, most of the trainees had some superficial exposure to gestural systems before. even so, the main emphasis was on multitrainee characteristics most of the trainees in these schools were female teachers, with parents forming the second biggest group (figures 3 and 4). although most of the people trained had some form of postmatric training, 18 % of them had only between 8 -10 years at school (figure 5). it is interesting to note that although the importance of including peers in training sessions is emphasized, none of the contexts have included these participants on an initial training level. this can be attributed to two factors: firstly, to the non-disabled people's need to acquire knowledge about aac strategies before introducing them to disabled die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 8 1 0 y e a r s at school 12 y e a r s at school 2 3 y e a r s after s c h o o l figure 5: qualifications of respondents 4 years after school i n e e r v i c e t r a i n i n g s p e c i a l d i p l o m a s p e c i a l d e g r e e n< figure 6: respondents' special training received less 1 year 1 2 y e a r s 3 5 y e a r s m o r e 5 y e a r s figure 7: respondents' exposure time to disabled people people and peers; and secondly, to the nature of the specific population at these training centres, most of whom are severely cognitively restricted. fifty six percent of trainees had had no previous training to work with disabled people (figure 6), although 59% (figure 7) had been working with disabled people for more than five years. preand posttraining evaluations figures 8 to 10 indicate preand posttraining differences in responses to attitudinal questions towards nonspeaking people and aac strategies. although it is acknowledged that attitudes are not changed overnight, these differences in responses reflect an openness to information and training that is a most valuable starting point for intervention. they also indicate that the training provided in the initial stages has made erna alan 120 m a y b e i before i after figure 8: will using nonverbal means of communication prevent talking? 100 yes n o u n c e r t a i n i before β after figure 9: will people who cannot talk ever learn to read? figure 10: who should teach disabled people to communicate? some positive impact on the trainees. figures 11 to 14 relate more specifically to the training in graphic symbol systems. once again, the differences in preand posttraining responses are clear and reflect a positive change. although encouraging in the initial stages of intervention, these results do not guarantee successful intervention. the supportive structure, appropriate knowledge and skills of all involved as well as the disabled person him /herself will determine whether this potential for change will manifest the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 39 i before i after 1. objective : to communicate 2. what : symbols etc on board 3. don't know 4. other figure 11: what is a communication hoard? i before i after 1. functionality 2. useful / small / easy to use 3. not too many items at a time 4. combination 5. don't know 6. other • figure 12: what important features should a communication hoard incorporate? e x t e n s i v e b r i d g e a b s t r a c t don't know o t h e r i before i after 1. symbols more extensive 2. bridge to literacy 3. more abstract / comprehensive 4. don't know 5. other figure 13: how does a symbol system differ from pictures? • m before i 1. slow / time consuming 2. others don't understand system 3. limited messages 4. inconsistent responses from user 5. users become dependant on it i after 6. becomes soiled 7. motivation / team use 8. don't know 9. other figure 14: what are the biggest problems in using a symbol system? follow-up data at three training contexts: discussion of issues table 1 represents the data after the first formal follow-up visits done by caac staff to three of the five contexts in which training took place. various important issues are highlighted in these observations. 1. all the training contexts had implemented some aac strategies in the work context. although the implementation was limited, it was clear that the need for the use of these systems was realized. this response to the initial exposure appears to reflect the intensity of the need experienced by nonspeaking people and their significant others to make contact with each other. 2. few additional efforts were made to obtain information on aac or to make contact with other institutions using aac. in fact, the isolation of institutions working with severely handicapped people and the lack of supporting infrastructure could be seen as a reflection of the fragmentation that characterizes south african communities at present. 3. the extent to which people in the various contexts attempted to make technology suitable for their clients could be related to their general orientation in terms of resources. people who were mainly focussed on using internal resources found it easier to make adjustments for clients e.g context 1. context 2, however, in which no attempt at making communication technology had been made, was strongly orientated towards external resources with a preference for buying 'ready made' equipment. the fact that there are no financial resources to do this at present therefore limits their efficacy. these differences indicate the heterogeneous nature of communities not only in orientation, but also in terms of empowerment (the ability to take control over one's own life). context 3 represents a more affluent financial context. what is interesting, however, is that even though the financial constraints may be less, the overall evaluation of aac and supportive structures are very similar to the other two contexts. very limited parent contact after the initial training was evident, together with limited implementation. the fact that most of the better qualified people were from this institution also made no difference. finally, and perhaps the most significant issue in terms of further intervention, is related to the fact that none of the contexts was able to develop an aac core group or committee to take responsibility for further contact and dissemination of die suid-afrikaanse tydskrif vir kommunikasieafykings, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) erna alant table 1: follow-up data of three training contexts 1 = poor 2 = average 3 good criteria context 1 context 2 context 3 potential aac clients 21 12 24 number of trainees 14 18 39 language afrikaans northern sotho afrikaans time laps 6 months 4 months 4 months present feeling about aac 3 2 3 attempts at implementation 3 2 3 number of clients introduced 8 3 8 attempts to obtain additional information 2 2 2 attempts at making relevant technology 3 1 2 nature of technology boxes for object boards books, pictures, adapted switch for tape recorder none communication boards tins contact with other institutions using aac 1 1 2 has an aac core group been established? no no no who are involved in the aac group all teachers selected teachers all who want to participate contact with parents after aac training session 2 1 1 nature of parent contact at present limited: parents work late & children stay with domestic helpers parent contact identified as problem: they are not involved & do not come to the school limited problems experienced with aac implementation at present problems identified with individual children: no general problems identified teachers not orientated towards individual children: only general problems identified teachers identify their own problems in class. no general problems identified. i nature of problem in inplementation limited expertise limited time for implementation too many children in class carryover: parent & domestic worker involvement limited teachers are not really orientated towards individual children more class aides needed limited parent involvement negative attitudes in environment guilt no interest limited expertise limited use of switches carryover: \ limited parent contact poor positioning of children for communication comments/impressions of caac team after follow-up interaction good participation from all involved non-threatening discussion between caac and participants good problem solving developing between people orientated towards internal resources good participation much pride in school little focus on individual children parent contact needed for rasing funds positive attitudes not specific to aac strong orientation towards external resources good participation from people attending no general problems identified only individual cases group support amongst staff limited the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) fj^c in south africa: accessibility and implementation • f rmation. although various aspects could be contributing lo this, it could be seen as reflecting an insecurity amongst peole in establishing an infrastructure for the ongoing support of aac strategies. this problem may be consistent with rifkin's statement (1986) that as few people have had any experience in providing health care (or related therapeutic services) they are unsure whether they can make a meaningful contribution. the development of such an infrastructure obviously demands much more support and effort from all involved in order to ensure that whatever was implemented would be sustained over a long period of time. it could also be a reflection of the complexities involved in the process of commmunity participation as highlighted by tumwine (1989). the focus on implementation of aac strategies could be described as a single section health service because it deals with the implementation of specific communication strategies. although this could be negative in that it is a specialized intervention process, the emphasis on networking with other social and health contexts as well as sharing responsibility in creating and maintaining these networks would ensure that aac services would be accessible and meaningful to all those in need. this raises the issue of whether a selective technology approach (for example, focussing on aac strategies) and a primary health care approach are mutually exclusive concepts as described by rifkin and walt (1986). the need for both these approaches is emphasized in the following: "just as much as we have an awareness of the need to alleviate pain and suffering by developing better technical facilitites and more specialized services, so too is there a growing concern about the preponderance of... infectious diseases that relate to poverty and squalor of a large section of our population" (alant 1989, p. 132). the importance of maintaining and developing specialized treatment and technological advancement can therefore not be disregarded in the process of providing primary healthcare for all. this suggests a creative interaction between externally-orientated involvement (e.g. the emphasis on technology or specialized treatment) and internally-orientated approaches (primary health care with a strong communitybased focus) in order to develop a humanistic approach towards community-based rehabilitation. a humanistic perspective implies that people become conscious of the alternatives available to them, become motivated to choose and produce the necessary structures to make these alternatives possible. [ community-based rehabilitation is a creative interaction between community members and professionals and is characterized by a process of mutual understanding and respect, vital to any meaningful intervention. mutual understanding implies ongoing critical appraisal of the models used by both therapist (or developer) and community. certainly, in the caac experience the fundamentals in working with communities lie in the acknowledgement that " the view of the community how communities view problems and the solutions that make sense are often worlds apart from the views of institutions or professionals" (grace 1991, p.l) and similarly, that "no conception of development that aims to project solutions onto society can succeed in humanizing society" (alant 1989, p.132). 41 acknowledgement i would like to express my sincere appreciatiion to the caac team and the communities who are partners in this process. this research project is funded by the human sciences research council programme for social affordability. references abrams, l.j. (1992). redefining rural development and the emerging role of new development organisations. paper presented to standing committee for water supply and sanitation. johannesburg. alant, c.j. (1989). development and health care: some sociological comments. in c.j. alant (ed.), sociology and sodety. johannesburg: southern books. allaire, j., gresard, r., blackman, t. & hostler, s. (1991). children with severe speech impairment: caregiver survey of aac use. augmentative and alternative communication, 7, 248 255. bjaras, g., haglund, b. & rifkin, s. (1991). a new approach to community participation. health promotion international, 6(3), 199 2 0 6 . blackstone, s. (1989). augmentative communication services in the schools. asha, 1, 61 64. calculator, s. & dollaghan, c. (1982). the use of communication boards in a residential setting. journal of speech and hearing disorders, 14, 281-287. calculator, s. & d'altilio-lucko, c. (1983). evaluating the effectiveness of a communication board training program.journal of speech and hearing disorders, 48, 185-192. cumley, g. & beukelman, d. (1992). roles and responsibilities of facilitators in aac. seminars in speech and language, 23(2), 111 119. emmett, a. b., phillips, h. & barendse, β. (1991). social and economical aspects ofwater provision and sanitation in developing areas. pretoria: human science research council publisher. gorenflo, c. w. & gorenflo, d. w. (1991). the effects of information and augmentative communication technique on attitudes towards nonspeaking individuals. journal of speech and hearing research, 34, 19 26. grace, h. (1991). views from the tugboat. unpublished material presented at the kellogg seminar, south africa. hope, a. & timmel, s. (1984). training for transformation. mambo press: gweru. meyer, l. &janney, r. (1984). user-friendly measures of meaningful outcomes: evaluating behavioral interventions. journal of the association for persons with severe handicaps, 24(4), 263 270. mirenda, p. (1992). school to postschool transition planning for aac users. seminars in speech and language, 13(2), 130 -142. rifkin, s. (1986). lessons from community participation in health programmes. health policy and planning, 13, 240 -249. rifkin, s. & walt, g. (1986). why health improves: defining the issues concerning 'comprehensive primary health care' and 'selective primary health care'. soc. sci. med.. 23(6), 559 566. snell, m.& browder, d. (1986). community-references instruction. journal of the association for persons with severe handicaps, 22(1), 1 1 1 . tumwine, j. (1989). community participation as myth or reality: a personal experience from zimbabwe. health policy and planning, 4(2), 157 161. van tatenhove, g. (1992). using competent aac users as peer trainers. paper delivered at the fifth conference of the international society for augmentative and alternative communication, philadelphia. wacker, d. (1989). introduction to special feature on measurement issues in supported education: why measure anything?journal of the association for persons with severe handicaps, 24(5), 254. werner, d. & bower, b. (1982). helping health workers learn. gwero: mambo press. white, o. r. (1988). probing skill use. in n. haring (ed.), generalization for students with severe handicaps: strategies and solutions. seattle: university of washington press. ι die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 erna alant appendix 1 laudium 24 june 1992 one day course: introduction to augmentative and alternative communication programme aim: to expose staff and parents to the use of aac systems in teaching and communication. the purpose of this session is to introduce people to the concept of aac. this initial course will not be adequate preparation for the implementation of aac strategies. further support for implementation will be necessary. objectives: to give a summary of why aac strategies are important for use with severely disabled people to identify the different problems relating to communication with severely disabled children to discuss briefly different symbolic and gestural systems to discuss certain ways of implementing these systems in a school and home context to discuss the importance of the establishment of an aac core group in laudium to ensure further follow-ups and exchange of information between caac and the laudium centre staff and parents. time schedule: 08.00 08.30-09.30: 09.30-10.30: registration introduction: what is augmentative and alternative communication (aac)? problem statement: what are the problems confronting us when working with the severely disabled person? what can be done about these problems? roleplay tea how can these strategies be implemented? the importance of establishing a core group for aac at the centre filling in of evaluation questionnaire 10.30-11.00 11.00-11.30 11.30-12.30 12.30-13.00: the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) case report of a brain-injured child; illustrating a teamwork approach to rehabilitation by f. t. lubinsky. b.a.log.(rand) — speech therapist. in collaboration with; mr. c. o. ovendale. m.b.b.ch.(rand) f.r.c.s. (eng.) — surgical registrar. a. burr. m.c.s.p. — physiotherapist. j. sprott. o.t.(rand). — occupational therapist. on the 25/1/62 a boy aged 11 years, whom we shall refer to as john, was admitted to the transvaal memorial hospital. he had been knocked down by a motor vehicle, and was practically moribund. at that time, there was very little hope for his recovery. six weeks later when he regained consciousness he had a paralysis of the right side. he ate and slept but showed very litte interest in his environment. he used to cry and laugh raucously from time to time, other than that he did not vocalise at all. at this stage he was being treated by the physiotherapist; his physical condition improved and he was able to manipulate his hands and to walk with a limp. he then received occupational therapy. john's response to stimuli improved gradually, and three months after the accident the speech therapist was called in to treat him. he made remarkable progress and his speech came back completely after four weeks of intensive therapy. in order to present a comprehensive picture of the factors which contributed to john's rehabilitation, i am including reports of his treatment by the surgical registrar in charge of the case, the physiotherapist, the occupational therapist and the speech therapist who treated him. the importance of teamwork in this case can not be over emphasised. surgeon's report. on admission it was apparent that john had suffered a very severe head injury. he was deeply unconscious, and his breathing was sterterous. general examination revealed a laceration of his scalp and a simple fracture of his right clavicle. there were no other external injuries. examination of his central nervous system showed marked brain damage, since he was deeply unconscious, had a partial paralysis of his right arm and leg, and had a dilated right pupil, which did not react to light. there was spasticity of the right arm. on testing his babinsky reflexes, both great toes were upgoing. x-rays, which were of poor quality due to the patient's condition, showed no fractures of his skull or jaw. there was some bruising of his left lung and a possibility of a fracture in the left 6th and 7th ribs. he was treated conservatively by hypothermia, hiberration, antibiotics and general nursing care. the next morning his condition was unchanged, but due to his poor respiration and the moist sounds in his lungs a tracheotomy was decided upon. this was done under local anaesthesia on 26th january, 1962. on 29th january, 1962, his condition was still the same and he remained deeply unconscious. further x-rays were therefore done, which showed no fracture in the skull or lumbar spine, and a cerebral anteriogram showed no evidence of an intracranial spaceoccupying lesion. his general condition improved, but he remained deeply unconscious and paralysed on his right side for many weeks. the tracheotomy tube was removed after about one month. about five weeks after the accident he started swallowing and so could be fed by spoon instead of via a tube. he then rapidly improved and was soon running about the ward, but still had complete aphasia. : physiotherapist's report. ι when treatment was commenced on john, the boy was unconscious and spastic, both feet being plantaflexed and the legs adducted the arms, wrists and fingers were flexed 6 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) and the shoulders adducted. the initial treatment therefore, consisted of purely passive movements to all limbs. it was noticed that his right side was more spastic than his left, the arm being particularly so, and he protested more on having the right elbow extended than any other joint. when he began to regain consciousness he became more and more co-operative and passive movements gave way to active movements till ultimately we were able to get him walking, although the right side still remained spastic, and he walked in a similar manner to any other hemiplegic. he never spoke but understood what we asked him to do and still protested when the right elbow was extended. this was afterwards put in plaster and when the plaster was removed some weeks later the spasticity in the arm was very much less. the general spastic condition became rapidly better and within a short while he was walking normally and only had a slight tension in the right elbow flexors. at this stage the physiotherapy was stopped as it was felt that he would now do better at occupational therapy. occupational therapist's report. john started receiving occupational therapy when he started walking. however, for some time before this the occupational therapist had made contact with him in the ward. the assessment on his first treatment revealed an extremely low concentration span, aphasia, and an urge to explore. he also continually tried to go out of the room during the first three or four treatments. john had a pleasant personality. on the physical side he showed general weakness on the right side of his body and his right elbow was kept in a slightly flexed position. later testing showed lack of colour and space perception, some inco-ordination and difficulty 'in carrying out instructions although he seemed to understand them. it became extremely obvious that although he received and understood most, if not all stimuli given, there was a breakdown in the effector pathway. because^ of the very low concentration span a large variety of simple, easy and quickly accomplished activities had to be found, and it was felt that games were the most satisfactory. games were also used to produce excitability and thus encourage the use of the one or two sounds he was able to make. activities involving blowing — such as soap bubbles — were also used extensively to encourage the movements which the speech therapist was trying to obtain. these activities were carried out mainly in groups and it was obvious that john enjoyed being with other children. he showed a great liking for small children and quite happily joined in games with them. for a certain period each day individual treatment was given. during this time writing, drawing and colouring-in were stressed. throughout the time john was being treated continual progress was noticeable. almost every day some obstacle or difficulty was overcome. after his dramatic recovery of speech his general recovery also seemed to increase more rapidly. speech therapist's report. i first saw john on the 24/4/62. his physical appearance was normal apart from the weakness on his right side. oral peripheral examination showed the speech mechanism to be normal, although there was some weakness on the right side. his chewing, sucking and swallowing reflexes were normal, though he could not move his lips or tongue voluntarily when required to do so. manual manipulation and hand-eye co-ordination were poor. he had been right handed previous to the accident. he often smiled or laughed for no apparent reason. his laughter had a bizarre sound and could be heard right across the ward. in the initial interview i could get no response from him other than his laugh. the nurse in his ward told me that he needed constant surveillance and was fond of wandering around the hospital. the staff were very fond of him and he was popular with the other patients. it is possible that he had some disturbance of social perception as he reacted in the same pleasant manner to everybody. it was impossible to get a family history, as john's mother did not keep appointments which were made for her to see me. he had been in standard four at school and was allegedly of "normal" intelligence before the accident. he used to be a disturbing influence in the class, often inciting the other children to mischief. during subsequent sessions in the first week of therapy i found him mobile in attention and activity. he was unduly attracted december, 1962 journal of the south african l o o p e d i c society 3 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) by the doings of others and by the presence of normally inconspicuous background stimuli. his concentration span was short. john's perception of his environment fluctuated. he was able to match object to object and he could copy a simple pattern with his left hand. he reacted strongly to food and would sit down and wait to be served as soon as he saw it arriving. he apparently lacked the ability to integrate his experiences and to organise space and form. john's problem was one of expressive aphasia with verbal apraxia and agraphia. he did not verbalise at all. the nurses said that he grunted occasionally, but during the first week of therapy i did not hear him vocalise. upon being shown a noise making toy cow, he tried to imitate the sound which it made "moo", by moving his lips slightly without any voice. he used some gestures for communication and was able to respond to simple commands. in the field of auditory perception, there appeared to be some disturbance, which manifested itself in distractability and erratic responses. he appeared to be suffering from some limitations of broad conceptualization and generalization. john displayed emotional lability and would burst out laughing periodically. as his condition improved he showed concern with orderliness. he used to help the nurses to tidy the ward. naturally, this helped to make him well liked. therapy the aims of therapy were:— (1) to establish a good relationship with john, giving him a constant, secure social contact. (2) to help him to acquire more language, and to integrate his experiences while controlling his behaviour. (3) to encourage a desire for communication. (4) to stimulate the production of speech. john had therapy four days a week, sometimes twice a day. to counteract emotional lability and distractability i tried to be consistently calm and accepting, though firm. he was only given one stimulus at a time to help him to integrate this experience. therapeutic sessions lasted till he showed fatigue. at the commencement of therapy john was unco-operative and displayed little interest. he would get up and walk out of the room. every day brought some improvement and gradually he took more interest in the therapy. his concentration span improved and he showed less fatigue. his environment became more meaningful to him and he could relate more effectively to it. during the second week of therapy john was taking an interest in the welfare of the other patients. many of them were bedridden and he was very helpful to them. his understanding had improved sufficiently for him to do errands for them. the fact that john was in such a warm friendly environment contributed in a large measure to his improvement. the group work in occupational therapy had done much to improve his social relationships. the nursing staff also helped a great deal in making john socially well adjusted. they gave him physical tasks which he could accomplish successfully. i asked them to use simple language when talking to john without demanding a response from him, and they were most co-operative. he was now using more gestures to indicate his wants. i did not inhibit this as i felt that it was helping him to make contact with others and to overcome his frustration in being unable to communicate. john was given play situations structured in such a way that communication was important. he was required to nod his head and say "uh" for "yes" and "uh-uh" for "no". to begin with he just nodded his head. after being given a lot of auditory stimulation for the sound, he accompanied the nod with "uh". he said "uh" meaningfully for the first time on 9/5/62. i discussed this with the nurses and the occupational therapist, and asked them to reinforce this sound as much as possible. again they were extremely co-operative. in the third week john's communication through gestures was greatly improved as well as his understanding. the other patients used to talk to him and he would grin or laugh at them and say "uh". he was now ready for auditory stimulation of simple words, accompanied by objects and pictures, as well as co-operative and, competitive play with language stimulation. words with labial sounds were emphasized. in addition, lip, tongue and breathing exercises were given in the form of games. he could now approximate his lips when blowing, and tongue movements were improving; the motokinesthetic method was used to teach him to journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) say "ma ma", the first day he did not respond but on the second day, he said "ma ma" voluntarily. this was on the 17/5/62. he was thrilled and once again i elicited the staff's co-operation in order to reinforce this word. he went around saying it the whole of that day. the next day he was able to say "ba ba" when his mouth was stimulated moto-kinesthetically. on the 22/5/62 his speech returned dramatically. he was suddenly able to speak english and afrikaans fluently. it was as if being able to say those two words had opened the door to language and speech! follow-up report. john was discharged from hospital on 1/6/62. he was seen in the out-patients department on the 16/7/62. he was talking well and intelligently, though he had no memory for recent events. when reminded, however, he remembered everything in detail. on physical examination it was found that he had full passive movement in the right arm and normal reflexes, although all muscle power was slightly reduced. his legs were weak. his mother seemed to be concerned about him and he was obviously happy to be home again. schooling. john has gone back to standard 4. his work is not up to the standard of his classmates, and as a result he needs individual tuition. he is scared of being laughed at and is very shy and quiet in class; this shows a marked difference in his personality, as he used to be very lively and interested in everything. in spite of this change, he has friends and is not rejected by the other boys. the teacher finds him very helpful in class. occasionally he still laughs for no reason. he speaks english and afrikaans fluently, although his speech is slightly indistinct at times. he; has settled down in the class and is not restless. he attempts to do all the work although he often cannot manage it. summary. in summary, the above report constitutes the case reports of a child who has had traumatic brain damage. his rehabilitation programme has been described from the viewpoint of the surgeon, the physiotherapist, the occupational therapist and the speech therapist. these specialists worked together in close co-operation with the medical and nursing staff. john's progress was watched and compared in different spheres of activity. in my opinion john's remarkable recovery was due to the intensive treatment which he received on all levels, and to the teamwork approach. because of the co-operation of the staff it was possible to manipulate his environment successfully. they all helped to create an atmosphere which was conducive to his relearning of speech and language. john is still attending the hospital regularly as an outpatient and he will probably reach his maximum recovery in several months time. it is hoped that with the passage of time when he recovers from the emotional setback, he will become a well integrated member of society. i should like to reaffirm that rehabilitation can only be achieved with the co-operation of all the specialists involved. mutual knowledge of each other's contribution and role is necessary for successful co-operation. opsomming. die voorafgaande artikel is 'n gevals rapport van 'n kind wat 'n wondende breinbesering opgedoen het. sy rehabilitasieprov gram is gesien vanuit die oogpunt van die sjirurg, die fisioterapeute, die beroepsterapeute en die spraakterapeute. die spesialiteite het in noue samewerking met die mediese personeel en die verpleegsters behandling toegedien. die kind se vordering is dopgehou en vergelyk deur die persone wat hom behandel het. na die skrywer se mening is sy merkwaardige herstel te danke aan die intensiewe behandeling wat hy ontvang het op die verskillende vlakke en as gevolg van die span werk. met behulp van die samewerking van die personeel is sy omgewing suksesvol verander. almal het bygedra om 'n atmosfeer, wat die leer van spraak en taal bevorder, te skep. die kind besoek nog die hospitaal as 'n buitepasient en sal waarskynlik binne 'n paar maande sy maksimum herstellingspeil bereik. ons vertrou dat hy met die tyd van die emosionele terugslag sal herstel en dan 'n goed aangepaste lid van sy sosiale omgewing sal word. (i wish to thank the superintendent of the johannesburg general hospital, as well as the supervisor of the hospital speech therapy department for their permission in allowing us to publish this case history.) december, 1962 journal of the south african l o o p e d i c society 3 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) visualization of change of sound characteristics on the level of the vocal cords r. l u c h s i n g e r , m.d. promenadengasse 18, ch-8001 zurich, switzerland summary the c o n s t r u c t i o n is reported of an apparatus for producing short s t r o b o s c o p i c films, e m p l o y i n g a n e w phase-shifting device. this apparatus provides the clinician w i t h a reliable record of the m o d e of vibration of the vocal cords (in b o t h the o p e n i n g and closing phases) alongside a tape-recording o f the voice. this makes it possible t o correlate recordings of t h e frequency and intensity and transitions of the v o i c e with a series of s t r o b o s c o p i c investigations. opsomming die konstruksie van 'n n u w e apparaat vir die produksie van kort stroboskopiese films w o r d bespreek. 'n n u w e fase-verskuiwingstegniek w o r d ingespan vir hierdie doel. hierdie apparaat voorsien die terapeut van 'n betroubare weergawe van die w y s e van vibrasie van die stemlippe (in b e i d e o o p en geslote fases), asook 'n b a n d o p n a m e van die stem. dit maak dit dus m o o n t l i k o m o p n a m e s van die frekwensie, intensiteit en oorgange van die stem te korrelleer met 'n reeks s t r o b o s k o p i e s e ondersoeke. in 1961, e. nielsen and the author of this paper8 reported on the construction of an apparatus for stroboscopic films. a 16 mm-reflex paillard camera was modified so that continuous speeds of up to 70 pictures per second could be obtained. the philips stroboscope pr-1900 provided an adequate electronic flash of short duration and of great light-intensity. the optical system, with a solidly mounted laryngeal mirror which is contained in a small box, directs the light of the stroboscope to the vocal cords and transfers the picture of the vocal cords to the camera. by means of a system of mirrors and prisms, the .subject of the experiment can observe his own vocal cords and make the convenient adjustments for the picture. to be able to film the entire course of movements, it was necessary to provide the shifting of phase of the flash, from zero to 360°. at the time, this was done by mechanical means, with a subsequent 2 to 8-fold slowdown of the released light-impulses, depending on voice-pitch, up to 300 hz. since the flashes of the stroboscope often occurred irregularly and the mechanical change of phase was subject to a certain degree of inertia, a change to electronic change of phase was eventually resorted to. journal of the south african speech and hearing association, vol. 20 december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) visualization of change of sound characteristics of the vocal cords 43 through a change of the optical apparatus made by the firm of blattner and picard, the volume of light reaching the vocal cord could be increased. the apparatus has been described in detail by luchsinger and pfister6 in connection with slow-motion exposures with the use of an electro-glottograph by cl. van michel6, and further explanations therefore are not necessary. the apparatus for electronic shifting of phases was developed by the firm of spring-elektronik of zurich. the frequency of the singing sound is registered by a laryngeal microphone. special switches serve to determine the basic frequency. the stroboscope is activated by a switch which results in an increasing time-lag with respect to the basic frequency. by means of the phase-shifts produced in this manner, a vibration of the vocal cords per one second can be observed. since the camera can take only 70 pictures per second, frequencies in excess of 70 hz are slowed down 4 to 8' times. even when no sound is produced, the apparatus transmits impulses to the stroboscope. therefore, the vocal cords are continuously illuminated. as soon as the subject of the experiment emits a sound, the apparatus automatically switches into operation, depending on the frequency of the sound. the spectrogram of the voices is determined through a "terzbandpegelmeter". experiments: (a) sustained sound of falsetto (e' baritono), 280 hz, 72 db, figure 1. terzbandpegel f a l s e t t s t i m m e ι λ ι λ ο ο λ ο ο ι λ ο ο ο λ ο ο ο ο ο ο ο ο ο ο ο ο ο ο ο ο ο ο nnm«ili)(oeoo cn (ο ο hz figure 1. sustained v o w e l of falsetto. tydskrif tan die suid-afrikaanse vereniging vir spraak en cehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 r. luchsinger (b) sustained sound of an alto, pitch 217 hz and c' (261 hz); see illustrations of voice characteristics fig. 2 and 3. ί i — 1 _ i 1 —· γ ΐ λ ί λ ο ο γ ο ο ο ί λ ο ο ο ί λ ο ο ο ο ο ο ο ο ο ο ο ο ο ο ο ο ο ο 7 hz ojt-̂ lotdcooojtdoul̂ oocnooloooolooooooooo — co 1 rrrflflplildididoflldomrooplooidoo -i <n ™ figure 2. alto voice. (transitions: dotted lines — covered voice, dark lines — uncovered voice.) figure 3. a l t o v o i c e , t o n e a (217 hz) (c) attempt to obtain the change of the covered and uncovered voice of this singer .on the level of the larynx, with approximately equal soundintensity (72 decibels at 1 meter distance) vowel /ae/, which changes into a vowel nearing the joj. the intensity measurement was done by means of a sound-level meter of the radio corporation. to register the moment of change of sound-characteristics on the film the subject of the experiment had to release an additional flash at the time of the journal of the south african speech and hearing association,.vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) visualization of change of sound characteristics of the vocal cords 45 transition, which was reflected into the camera. thus, in the course of the picture series, it can be observed whether there is an actual change in the movement of the vocal cords. figure 3 shows the relative opening width of the vocal cords during the socalled predominantly covered singing sound. the amplitudes of the individual pictures were measured first in the center, then likewise in the center of the measurable lateral sections of the vocal cords, and their average values were entered on the curve of relative width in millimeters. two series of about 50 pictures were then evaluated. figure 2 shows the change of the sound characteristics from the open to the covered singing sound, with the distinct increase of the partial tones which has been demonstrated by various authors. discussion of findings: from the stroboscopic pictures one can see in the case of the falsetto (which lies opposite the high-pitched headtone and is thinner, and less expandable than the natural voice) only few partials, with an almost unchanged opening of the rima glottidis, as has been very well described by large and co-workers.5 proceeding now to the analysis of the change of sound characteristics for the above-mentioned singer (with equal pitch and of more or less unchanging voice-intensity), it must be mentioned that realization of such an intentional change in sound characteristics under experimental conditions requires a great deal of dexterity. change of sound characteristics with 256 hz. partial tones from beginning to end, increases the basic sound (256 hz) and the partials appear distinctly at the time of the transition to the predominantly covered sound. but it seems important that after the transition to the covered sound the amplitudes of the vibrations of the vocal cords increase significantly. this obviously has to do with the adaptation to the higher cavities and the low position of the larynx, which has already been noted by pielke, arnold and luchsinger.7 of interest are the findings by husson and dijian3, who, in four out of five cases showed, by means of x-rays, a distinct thinning of the vocal cords in the case of predominantly covered singing. there is no doubt that there also exist couplings of the higher cavities on the activity of the vocal cords, h. rubin and ch. hirt9 have found, by means of slow-motion pictures, that in the case of very high-pitched voices there appear at the time of the "edgetone" of the vocal cords waves of a riblike pattern on the surface of the mucous membrane of the voice-generator. the same phenomenon, though only in the form of thin stripes, could be observed by the writer through slow-motion film, in the case of a 14-year old boy at sol5 (1700 hz). on the basis of the electrical speech synthesis, the voice apparatus, according to flanagan2, can be described as a well-cushioned volume/speed-generator. according to this theory, the vocal tract and the sound generator are not closely dependent on each other, and changes of the voice canal have insignificant influence on the vibrations of the vocal cords. finally, the glottographic studies of fabre1 should be mentioned, which · husson4 described as early as 1960 in his book "la voix chantee". he states tydskrif van die suid-afrikaanse vereniging vir spraak en cehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 r. luchsinger that the covered sound flattens the angle of the glottographic curve and at the same time increases the height of the glottogram. these studies are not in contradiction to the above-mentioned findings, but should be subject to further verification. references 1. fabre, p. (1958): un procedee electrique percutane description del 'accoloement glottique au cours de la phonation.bull acad. nat. med. 66-69. 2. flanagan, l. (1965): synthesis, speech analysis and perception. springer, berlin. 3. husson, r., and dijian, a. (1952): tomographic et phonation. /. radiol. , electrol. sci., 23, 127-135. '4. husson, r. (1960): la voix chantie. gauthier villars, paris. 5. large, j.s., and von leden, h. (1972): the male operatic head register versus falsetto. folia phoniat. 24, 19-29. 6. michel, van ci., luchsinger, r., and pfister, k. (1970): electroglottographie et cinematographie laryngee ultra-rapide. folia phoniat., 22, 81-91. 7. luchsinger, r., arnold, g., and pielke, g. (1970): lehrbuch derstimmheilkundel. band springer-verlag, wien. 8. nielsen, e., and luchsinger, r. (1961): ueber den ausbau einer neuartigen kurzfilmapparatur fur laryngo-stroboskopie. folia phoniat., 13,81-91. 9. rubin, h., and hirt, h. 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(reds.): infant communication development, assessment, and intervention. new york: grune & stratton, 1983. sheppard, j.j. "motor components of social vocalizations in infants" pp. 126-130 in the proceedings of the 18th congress of the international association oflogopedics andphoniatrics. washington, d.c., 1980. smith, b.l. & oiler, d.k. "a comparative study of pr e_ meaningful vocalizations produced by normally developing and downs syndrome infants" in journal of speech and hearing disorders, 46, pp. 46-51, 1981. starr, p., chinsky, r., canter, h. en meier, j. "mental, motor and social behaviour of infants with cleft lip and/or palate" in cleft palate journal, 14, pp. 140-147, 1977. strydom, l.m. development of communication between african mothers and their infants in the first year of life. referaat: biennial meeting of the society for research and child development, toronto, april 1985. super, c.m. "environmental effects on motor development: the case of african infant precocity" in developmental medicine and child neurology, 18, pp. 561-567, 1976. trevarthen, c. "communication and cooperation in early infancy: a description of primary intersubjectivity" in bullowa, m. (red.): before speech: the beginning of interpersonal communication. cambridge: cambridge university press, 1979. uys, i.c. "'n medekonsultasiemodel vir spraak--en gehoorterapie in die rsa" in hay, i.s. & uys, i.c. (reds.): taalverskeidenheid en taalpatologie. pretoria: universiteit van pretoria, 1985. aspekte van tydre'eling in normale en verbaal-apraktiese spraak matilda de jager, b(log) (pretoria) departement spraak.heelk.unde en oudiologie, universiteit van pretoria opsomming die doel van hierdie ondersoek is om inligting te verkry in verband met 'n aspek van tydreeling van spraakproduksie, naamlik segmentele tydsduur in afrikaans. vier normale sprekers en 'n apraktiese spreker is as proefpersone gebruik. uit die resultate blyk dit dat daar wel temporale reels in afrikaans voorkom. deur segmentele tydsduur by die apraktiese spreker te bestudeer, kan verdere insig in die afwyking asook terapieleidrade verkry word. abstract the aim of this research report is to obtain information concerning an aspect of timing of speech production, namely, the duration of speech segments in afrikaans. four normal speakers and an apraxic speaker were used as subjects. from the results obtained it is evident thai timing rules do exist in afrikaans. by analyzing the productions of the apraxic speaker in terms ofsegmental duration, more insight into this disorder, as well as therapeutic guidelines can be obtained. huidige kennis oor temporale organisasie of tydreeling van spraak is hoofsaaklik gegrond op studies wat uitgevoer is in engels. omdat daar nog geen studies in die verband in afrikaans gedoen is nie, bestaan daar 'n groot behoefte aan inligting omtrent die toepassing van tydreeling deur normale afrikaanssprekende persone. tydreeling is een van die twee belangrikste komponentevandie beplanning erf programmering van spraak. motoriese kontrole vir spraakaksies vereis dus akkommodasie en koordinasie in tyd en ruimte van die artikulatoriese gebeure vir die produksie van opeenvolgende segmente in die spraakketting (lofqvist & yoshioka, 1981). verskeie navorsers het die belang van temporale inligting as deel van die gestoorde motorprogram vir spraakaksies gedemonstreer (cooper & allen, 1977). volgens bell-berti en harris (1981) het vroe'ere modelle van spraakproduksie nie daarin geslaag om wel spraakproduksie te verklaar nie, juis omdat dit tydreeling beskou het as 'n byproduk © sasha 1986 van artikulatoriese gebeure in plaas van as 'n integrate organiserende parameter van motoriese spraakbeplanning. die aspek van tydre'eling wat in hierdie studie ondersoek word, is segmentele tydsduur. navorsing in verband met segmentele tydsduur le veral klem op 3 aspekte. die eerste aspek is kontekstuele invloed op segmentele tydsduur. volgens disimoni (1974 a) is die kontekstuele invloed op segmentele tydsduur deel van die tydre'elingsisteem van elke taal en word dit aangeleer deur die sprekers van die taal. die tweede aspek is temporale kompensasie, met ander woorde die effek wat inwerk om die duur van die interne segmente van artikulatoriese eenhede te modifieer in herhaalde produksies. temporale kompensasie is ook nie 'n eienskap van alle tale nie (disimoni 1974 b) en die feit dat dit eers na 9 jaar ten voile aangeleer is, dui daarop dat ontwikkeling plaasvind tot 'n volwasse gesofisitikeerde, akkurate tydreelingsmeganisme. die derde aspek is die invloed van die konsonantkombinasie (kk) op segmentele tydsduur binne eenlettergrepige woorde. uit navorsing gedoen, blyk dit the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a s p e k t e van tydreeling in normale en verbaal-apraktiese spraak j n temporale reel in engels is met betrekking tot kkd a t worting naamlik dat die duur van die kv* in 'n kvk-en ^vkk e e n h e i d ongeveer dieselfde bly in verhouding tot d.e t a l c duur ten spyte van die feit dat die kv en kvk twee derdes t o n k v k k in werklikheid die helfte van die totale uiting e n ' a a k (walsh 1984). uit al bogenoemde blyk dit dus dat reels "'n opsigte van aspekte van segmentele tydsduur verband hou met 'n spesifieke taal. dit sou interessant wees om ondersoek in t e stel na die voorkoms daarvan in afrikaans. k e n n i s oor tydreeling kan ook as basis dien vir navorsing oor neuromotoriese spraakafwykings, byvoorbeeld verworwe verbale apraksie. volgens kent en rosenbek (1983) is verbale apraksie 'n programmeringsafwyking wat 'n afwyking in tydreeling en koordinasie tot gevolg het. die siening dat tydreelingsabnormaliteite apraktiese spraak kenmerk, hou dus belofte in vir die begrip van die afwyking. uit studies gedoen deur freeman, sands en leavitt (collins, rosenbek & wertz, 1983) en collins et al. (1983) blyk dit dat reels in verband met duurverhoudings behoue bly by die apraktiese spreker alhoewel produksie wel uitermate verleng word, relatief tot normale produksie. daar bestaan egter ook teenstrydige studies oor duurverhoudings by apraktiese sprekers (bauman, wangler & prescott in collins et al. (1983); disimoni en darley 1977). collins, rosenbek en wertz (1983) voel dus dat verdere ondersoek na bogenoemde verskynsels benodig word en dat voortgesette studie van vokaalkonsonanten lettergreepduur nodig is om die huidige bevindinge oor apraksie te bekragtig. hierdie studie is dus 'n eerste poging om 'n aspek van tydreeling, naamlik segmentele tydsduur in afrikaans by normale en verbaal-apraktiese persone te bestudeer. daar sal gepoog word om inligting te bekom in verband met aspekte van tydreeling in afrikaanse eenlettergrepige woorde van kvken kvkkstruktuur ten einde afleidings te maak ten opsigte van temporale reels in afrikaans. deur die aard van die verskil en ooreenkomste tussen normaalsprekendes en 'n apraktiese spreker ten opsigte van bogenoemde te bestudeer, kan verfynde beskrywing van segmentele tydsduur by verworwe verbale apraksie ook verkry word. i m e t o d e j 1. d o e l s t e l l i n g s ' — om te bepaal of daar 'n neiging tot 'n konstante kvpersentasie oor drie herhalings van dieselfde woord is by 'n proefpersoon om intraproefpersoonkonstantheid te bepaal. — om te bepaal of daar 'n neiging tot 'n konstante kvpersentasie bestaan in kvken kvkk-eenhede waar die kv dieselfde samestelling'het. „ — om te bepaal wat die invloed van verskillende vokale op die kv-persentasie is in kvkk-eenhede met dieselfde inisiele konsonant en eindkonsonantkombinasie. — om te bepaal hoe die apraktiese spreker vergelyk met die normale ten opsigte van bogenoemde. 2. p r o e f p e r s o o n s e l e k s i e vier afrikaanssprekende volwassenes (2 mans en 2 vrouens) wat geen geskiedenis het van spraak-, gehoorof neurologiese afwykings nie, is geselekteer. die apraktiese proefpersoon wat geselekteer is, is 'n 43-jarige afrikaanssprekende man met normale gehoor wat voldoen aan die kriteria vir die seleksie van η proefpersoon met verworwe verbale apraksie soos voorgestel deur kent en rosenbek (1983). die kriteria is: (a) probeer-en-tref •kv = konsonant-vokaal | k v k = k o n s o n a n t v o k a a l k o n s o n a n t kvkk = k o n s o n a n t v o k a a l k o n s o n a n t k o m b i n a s i e die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 41 artikulatoriese soekbewegings en pogings tot selfkorreksie, (b) disprosodie sonder uitgebreide periodes van normale ritme, klem en intonasie, (c) foutonkonstantheid by herhaalde produksie van dieselfde uiting en (d) duidelike probleme met inisiasie van 'n uiting. drie jaar en 4 maande het verloop nadat die proefpersoon 'n serebro-vaskulere insident gehad het. 3. m a t e r i a a l die toetsmateriaal wat geselekteer is, is betekenisvolle afrikaanse woorde of eenhede wat saamgestel is volgens die fonotaktiese reels van afrikaans. dit bestaan uit die segmente kvk en kvkk. die materiaal bestaan uit 4 groepe woorde, naamlik: 1. /sat; sanj sant; sent/ 2. /katj kan; kants kant/ 3. /fak; fill; falk; folk/ 4. / p a k ; pal; palk/ 4. a p p a r a a t e n p r o s e d u r e op name van die spraaksein is gedoen in 'n klankdigte eenheid met behulp van 'n nakamichi 550 stereo bandopnemer en 'n omnidireksionele mikrofoon. die normale sprekers is gevra om die toetsmateriaal drie maal deur te lees. die apraktiese spreker moes die woorde agter die ondersoeker aan herhaal totdat 3 korrekte produksies van 'n woord verkry is. die woorde is in 'n toevallig geselekteerde volgorde aangebied. die sprekers is daarop gewys dat die woorde duidelik maar sonder onnatuurlike klem op enige deel daarvan uitgespreek moet word. daar is nie gebruik gemaak van 'n aanvangsfrase nie aangesien die apraktiese spreker dit nie kon lees of herhaal nie en eenvormigheid in die prosedure sover moontlik verkry moes word. vir die ontleding van die spraaksein is die visuele korrelaat daarvan op 'n hewlett-packard 1200 b-tipe ossilloskoop vertoon. senheiser h d 40-oorfone is gebruik sodat die ondersoeker die visuele en ouditiewe sein kon vergelyk. elke segment van 'n toetswoord is afsonderlik gemeet. deur dieselfde woord by al die proefpersone direk na mekaar te analiseer, is gepoog om die metingsbetroubaarheid te verhoog. sodoende is groter konstantheid ten opsigte van die punt van aanvang en eindiging van 'n segment verkry en is dieselfde segmente met dieselfde amplitudeinstelling gemeet. resultate en bespreking 1 k o n s o n a n t v o k a a l as p e r s e n t a s i e v a n t o t a l e d u u r o o r d r i e h e r h a l i n g s v a n d i e s e l f d e w o o r d by d i e n o r m a a l s p r e k e n d e i n d i v i d u die statistiese metode van meervoudige variansie-ontleding is gebruik om die resultate te verwerk en die bespreking te rig. tabel 1 statistiese data met betrekking tot die konstantheid van die kv% oor 3 herhalings van dieselfde woord by 'n individu (kolommefaktor soos verkry deur meervoudige variansie-ontleding) woordgroepe kolommefaktor 5% peil 1% peil vryheidsgrade 1. /sat; san; sant; sent/ 0,11 3,40 5,61 2 en 24 2. / k a t ; kan; kant; kant/ 1,09 3,40 5,61 2 en 24 3. /fak; fal; falk; f=ik/ 1,58 3,40 5,61 2 en 24 4. / p a k ; pal; palk/ 0,15 3,63 6,23 2 en 18 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 matilda de jag e r volgens tabel 1 is die f-verhouding van die kolommefaktor in die woordgroep /sat; san; sant; sent/, 0,11. hierdie waarde wys op onbeduidende verskille ten opsigte van kv as p e ^ n t a s . e van totale tydsduur omdat die kleiner is as 3,40 (5% peil) en 5 61(1% peil) met 2 en 4 vryheidsgrade. dieselfde tendens word ook by die drie ander woordgroepe waargeneem. die feit dat elke woord dne keer herhaal word by 'n individu, lewer nie statistics beduidende verskille op ten opsigte van kv as persentasie van totale tydsduur nie. daar bestaan dus wel 'n neiging tot 'n konstante kvpersentasie oor drie herhalings van dieselfde woord by 'n individu. intraproefpersoonkonstantheid kom dus voor. die feit dat daar wel 'n neiging tot 'n konstante kv-persentasie oor drie herhalings van dieselfde woord is, impliseer dat temporale kompensasie wel binne 'n kv-lettergreep in kvken kvkkwoorde in afrikaans by die proefpersone voorkom en bydra tot hierdie neiging. daar kom, met ander woorde, minder variasie in die duurpersentasie van die lettergreep as in die duurpersentasie van die segmente waaruit die lettergreep bestaan, voor. disimoni (1974b) het die ontwikkeling van temporale kompensasie bestudeer by kinders met die ouderdomme 3, 6 en 9 jaar. hy vind dat temporale kompensasie eers na 9 jaar ten voile aangeleer is en dit dui dus daarop dat daar ontwikkeling plaasvind tot 'n volwasse, gesofistikeerde, akkurate, tydreelmeganisme. sharkey en folkins (1985) hipotetiseer ook dat verskillende ontwikkelende motoriese prosesse die varieerbaarheid van spraak bei'nvloed op verskillende ouderdomme en dat variasie afneem met ouderdom. by die volwasse afrikaanssprekende proefpersone kom daar dus 'n intrapersoonlike temporale reel met betrekking tot konstante kv-persentasie oor drie herhalings van dieselfde woord voor. daar moet egter in gedagte gehou word dat hierdie konstantheid nie absoluut is nie. daar kom wel 'n geringe mate van variasie voor omdat daar motories-ekwivalente bewegingspatrone bestaan in spraak (sharkey en folkins, 1985). die grense van variasie is egter baie kleiner by die volwassene as by die kind. 2. konstantheid van konsonant-vokaal as persentasie van totale duur in 'n kvken kvkk-eenheid volgens tabel 2 is die f-verhouding van die ryefaktor vir die woordgroep /sat; san; sant, ecnt/', 7,07. hierdie waarde wys op beduidende verskille tussen die woorde binne die groep ten opsigte van die kv as persentasie van totale duur omdat dit groter is as 3,49 (5% peil) en 5,95 (1% peil) met 3 en 12 vryheidsgrade. dieselfde tendens word ook by die woordgroepe/kat; kan; kant; ksnt/ en /fak; fal; falk; folk/ waargeneem (sien tabel 2). by die woordgroep /pak; pal; palk/ is die f-verhouding van die tabel 2: statistiese data met betrekking tot kv as persentasie van totale duur in kvken kvkk-eenhede (ryefaktor soos verkry deur meervoudige variansie-ontleding) woordgroepe ryefaktor 5% peil 1% peil vryheidsgrade / s a t 5 aan; sant5 acnt/ 2. /kat; kan; kant; k 3 n t / ' 7,07 25,62 3,49 5,95 3.49 5,95 3 en 12 3 en 12 3. /fak; fal; falk; font/ 5,67 3,49 5,95 (nie beduidend op die 1% peil nie) 3 en 12 4. /pak; pal; palk/ 2,81 4,26 8,02 (nie statistics beduidend nie) 2 en 9 ryefaktor egter 2,81 wat kleiner is as 4,26 (5% peil) en 8,02 (1% peil) met 2 en 9 vryheidsgrade. daar is egter wel 'n verskil in die kv-persentasie, alhoewel hierdie verskil dan nie statistics beduidend is soos by woordgroepe een tot drie nie. uit bogenoemde resultate blyk dit dus dat daar nie by die proefpersone 'n neiging is tot 'n konstante kv-persentasie in 'n kvken kvkk-eenheid nie. die temporale reel in engels, naamlik dat die duur van die kv in 'n kvken 'n kvkk-eenheid ongeveer dieselfde bly in verhouding tot die totale duur ten spyte van die feit dat die kv in kvk twee derdes en in kvkk in werklikheid die helfte van die totale uiting uitmaak (walsch 1984), kom dus nie by die afrikaanse proefpersone voor nie. uit walsch (1984) se studie blyk dit dat in uitinge wat volgens die fonotaktiese reels van engels saamgestel is, byvoorbeeld / s ps/ en λ pst/, daar soveel konsonantkombinasieverkorting plaasvind, dat die kv-persentasie / s / vir albei uitinge ± 50% is en dus neig om konstant te bly. hierdie verskynsel kom egter nie by die afrikaanse proefpersone voor nie. vir proefpersoon 1 was die persentasie v i r / s a / in /sat/ byvoorbeeld 68,14% teenoor die 51,25% v i r / s a / in /sant/. konsonantkombinasieverkorting vind dus nie in so 'n mate plaas dat die / n t / in / s a n t / dieselfde persentasie beslaan as die / t / in / s a t / nie. konsonantkombinasieverkorting kom egter wel in afrikaans voor, byvoorbeeld vir proefpersoon 1 was die gemiddelde duur van die / t / in / s a t / 137 ms terwyl die / t / in /sant/, 100 ms was. waar die doel van konsonantkombinasieverkorting in engels volgens walsch en parker )1982) dus is om vasgestelde duurverhoudinge te behou vir die kv-gedeelte in kvken kvkkeenhede, blyk dit nie die geval te wees by die afrikaanse proefpersone nie. 3. die invloed van verskillende vokale op die kvpersentasie in kvkk-eenhede met dieselfde inisiele konsonant en eindkonsonantkombinasie uit tabel 3 blyk dit dat die gemiddelde persentasie van / s a / en / s 1/ in kombinasie met die konsonantkombinasie/nt/ nie noemenswaardig van mekaar verskil nie (slegs met 0,50%). daar kan dus afgelei word dat dit 'n normale spreker ± dieselfde tyd neem om / s a / en/ic/te produseer. die gemiddelde persentasie van /fa/ in kombinasie met / l k / is 2,94% meer as vir /fo/ en die afleiding kan dus gemaak word dat dit die normale spreker effens langer neem om /fa/ as /f o/ te produseer. vir die produksie van / k a / en aa/ in kombinaise met / n t / is die gemiddelde persentasie 5,78% meer vir / k a / as vir ao/ . dit neem dus die normale'spreker 5,78% langer om / k a / in kombinasie met / n t / te produseer as om as/ in dieselfde kombinasie te produseer. dit wil dus voorkom asof die vokaal wel 'n geringe invloed op die kv-persentasie van totale vluur het. ; tabel 3: vergelyking ten opsigte van kv as persentasie van totale duur by woorde met dieselfde samestelling, waar slegs die vokaal gevarieer word kv-persentasie (van die toetswoorde) / a a n t / / a c n t / a a n t / a s n t / ' / f a l k / /folic/ 1 51,25 48,56 1 34,41 27,35 1 43,63 43,62 2 55,30 54,44 2 39,18 30,81 2 56,59 51,10 3 55,06 58,31 3 37,98 29,87 3 56,51 52,33 4 61,63 64,00 4 38,40 38,81 4 57,45 55,05 * 55,81 56,32 37,49 31,71 53,46 50,52 5 69,31 . 65,77 5 53,44 42,03 5 65,30 61,53 * gemiddelde kv % vir normale pp e the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) /î spkete van tydreeling in normale en verbaal-apraktiese spraak n e g e m i d d e l d e persentasie vir normale proefpersone van / s a / en /lc/ (55,18% en 56,32%) in kombinasie met / n t / is aansienlik 3 ger as die gemiddelde persentasies van / k a / en a»/(37,49% en 3171 % ) i n kombinasie met / n t / . die persentasie wat / n t / beslaan w die totale woordduur word dus bepaal deur die klankomgewing waarin dit voorkom. soos daar dus in engels die tem°orale reel bestaan dat vokale langer is voor 'n stemhebbende as ? n s t e m l o s e konsonant (house & fairbanks en peterson & lehiste a a n g e h a a l deur disimoni (1974b)) kan daar gese word dat daar 'n t e m p o r a l e reel by die afrikaanse proefpersone bestaan, naamlik dat 'n / s / plus 'n vokaal 'n groter persentasie van die woord uitm a a k as 'n / k / plus 'n vokaal wanneer dit geproduseer word voor die konsonantkombinasie / n t / . konsonantkombinasieverkorting moet dus in 'n groter mate inwerk op / n t / wanneer dit v o o r a f g e g a a n word deur 'n kontinuant plus 'n vokaal, as deur ' n plosief plus 'n vokaal. die verkorting van die duur van 'n konsonant in 'n konsonantkombinasie moet in antisipasie van die v o l g e n d e konsonant uitgevoer word (walsch & parker 1982). hierdie verkorting moet dus op grond van 'n temporale reel wat verband hou met die klankomgewing beplan word. 4 vergelyking van die produksie van die apraktiese spreker met die van die normale proefpersone die z-waarde vir die drie herhalings van elke woord wat deur die apraktiese spreker geproduseer is, is bereken en word voorgestel deur figure 1.1 tot 1.15. uit al die grafieke blyk dit duidelik dat daar onkonstantheid is in die herhaalde produksie van dieselfde woord by die apraktiese spreker in teenstelling met die konstantheid wat by normale sprekers voorkom (sien 1). daar bestaan ook nie konstantheid ten opsigte van die kurwe van elke grafiek nie en verskeie tendense word waargeneem. uit figure 1.1, 1.7 en 1.12 kan waargeneem word dat daar met herhaalde produksie nader beweeg word aan die normale produksie. adaptasie vind dus plaas. figure 1.2, 1.8 en 1.15 toon aan dat die laaste herhaling wel die naaste aan die normale produksie is, maar dat daar nie geleidelike adaptasie voorkom nie. uit figure 1.11 en 1.13 word waargeneem dat die eerste produksie die naaste aan die normale was terwyl daar met die tweede en derde produksie eers weg en toe weer nader aan die normale produksie beweeg is. figuur 1.10 is die enigste grafiek wat aantoon dat met die produksie van /fal/ daar met elke herhaling verder weg beweeg is van die normale produksie. figure 1.6 en 1.14 toon aan dat die eerste produksie die verste van normale produksie is en dat daar met die tweede produksie nader daaraan beweeg word. die derde produksie is egter weer swakker. die tendens wat die meeste voorkom is die in figure 1.3; 1.4, 1.5 en 1.9, waar die beste produksie op die tweede herhaling en die swakste produksie op die derde herhaling voorkom. > die eerste twee tendense kan aanduidend wees van adaptasie met herhaalde produksie wat 'n kenmerkende simptoom van apraksie is (darley, aronson en brown 1975). die ander tendense is slegs 'n weerspie'eling van die onkonstante produksie van die apraktiese spreker. 43 figuur 1: grafiese voorstelling van die zwaarde by die apraktiese spreker. 10 r 5 -· 4,14 2,60 , 0 , 3 7 / s a t / figuur 1.1 1 0 7,62 -.4,72 2,67 / s a n / figuur 1.2 10 -2,52 . . 1,25 /sfcnt/ figuur 1.3 10 5 -• 10,98 . . 2,74 1,52 / s a n t / figuur 1.4 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 1 1 , 9 0 /kat/ figuur 1.5 / t a n / figuur 1.6 a a n t / figuur 1.7 matilda de j a g e r 10 -0 , 9 6 1 0 . . 5 -• 2,12 1 , 5 5 1 , 8 4 / l e n t / figuur 1.8 / f a l k / figuur 1.11 1 0 4 , 8 9 / f a k / figuur 1.9 2 5 j2 0 1 5 . . . 2 4 , 7 4 1 0 -/ f a l / figuur 1.10 10 5 . 4 , 5 0 / f a l k / figuur 1.12 1 0 5 -8 , 4 5 4 , 2 9 2 , 0 7 / p a k / figuur 1.13 the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a s p e k t e van tydreeling in normale en verbaal-apraktiese spraak 1 0 5 . . 2 , 2 4 1 , 5 4 1 , 4 3 /pal/ figuur 1.14 1 2 , 8 7 2 , 4 0 uit bogenoemde is dit dus duidelik dat daar onkonstantheid bestaan ten opsigte van die segmentele tydsduur in die herhaalde produksie van 'n woord deur die proefpersoon met verbale apraksie. onkonstantheid en variasie van die foutpatroon oor herhalings van dieselfde woord is een van die klinies mees waarneembare en kenmerkende eienskappe van apraktiese spraak (kent & rosenbek, 1983). in teenstelling daarmee produseer die normale spreker elke herhaling met bykans dieselfde duur vir elke segment. 'n verdere verskynsel wat waargeneem word, is dat die z-waarde van die verskillende woorde soos geproduseer deur die apraktiese spreker, verskil. die z-waarde is aanduidend van die mate waarin 'n produksie van die normale afwyk. volgordelike rangskikking van die z-waardes is moontlik en word voorgestel in tabel 4. die afleiding wat moontlik hieruit gemaak kan word, is dat hoe hoer die z-waarde is, hoe meer afwykend is die produksie en dat die moeilikheidsgraad van die produksie van die verskillende woorde varieer by die apraktiese spreker. deur die afleiding te maak dat 'n die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 45 moeilike produksie meer afwykend sal wees as 'n makliker produksie, kan daar op grond van die z-waardes bepaal word watter spesifieke produksies vir die spesifieke spreker makliker of moeiliker is, byvoorbeeld vir die w o o r d e / ' / f ^ / en /falk/ is die gemiddelde z-waardes onderskeidelik 7,31 en 1,83. daar kan nie regstreeks gese word dat dit vir die apraktiese spreker makliker is om 'n / a / as//o/ te produseer nie want z-waarde vir /fal/ is 13,25 wat dus weer hoer is as die z-waarde vir / f o l k / . tabel 4: volgordelike rangskikking van die mate waarin geproduseerde woorde van die apraktiese spreker afwyk van die normale soos aangedui deur die z-waarde van elke produksie. daar kan wel afgelei word dat dit vir hierdie spreker makliker is om 'n / a / te produseer in kombinasie met 'n inisi'ele /{/ en finale / l k / as wat dit vir hom is om 'η /=/ te produseer in dieselfde klankomgewing. hierdie feit ondersteun die stelling dat persone met verbale apraksie dikwels probleme ondervind met 'n spesifieke klank wanneer dit in 'n spesifieke klankomgewing voorkom (van der merwe, 1985). deur gebruik te maak van hierdie metode van ontleding waarin die z-waarde vir elke produksie addisioneel tot ouditiewe analise van simptome bepaal word, kan daar dus met groter akkuraatheid vasgestel word presies waar die spesifieke pasient se probleem le. veral in 'n gevorderde stadium van terapie kan so 'n analise waardevolle terapieleidrade verskaf. die onkonstantheid ten opsigte van kv as persentasie van totale duur by herhaling van dieselfde woord deur die apraktiese spreker word verder gei'llustreer deur tabel 5. hierin word aangetoon dat die gemiddelde konstantheidsvariasie vir proefpersone 1 tot 4 onderskeidelik 3,43%; 3,97%; 4,29% en 4,13% is. die normale omvang is dus 3,43% tot 4,29% en die gemiddelde konstantheidsvariasie-persentasie vir die normale proefpersone is 3,95%. by die apraktiese spreker is die gemiddelde konstantheidsvariasiepersentasie 10,97% wat dus ver buite die normale omvang en baie hoer as die gemiddeld van die normale is. dit dui dus daarop dat daar groter variasie is ten opsigte van die kv-persentasie van totale duur by herhaling van dieselfde woord deur die apraktiese spreker as by die normale spreker. hierdie variasie ten opsigte van kv as persentasie van totale duur dui weer eens op die onkonstantheid en variasie in die produksies van die apraktiese spreker. onkonstantheid en variasie is egter ook kenmerkend van kinderspraak. sharkey en folkins (1985) haal disimoni (1974b) en tingley en allen (1975) se studies aan waarin gevind is dat die varieerbaarheid van baie van die parameters van spraak afneem met ouderdom tot by puberteit. nadat 'n kind geleer het om 'n taak suksesvol uit te voer, word die onderliggende motorprosesse verfyn deur verhoogde antisiperende komponente van die r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 matilda de j a g e r tabel 5· vergelyking tussen die normale sprekers en die apraktiese ' spreker ten opsigte van kv%-konstantheid oor 3 herhalings van dieselfde woord. voorstelling deur middel van konstantheidsvariasie-waardes. 3 g •c u i woorde sat san sant sent kat kan kant k nt fak fal falk folk pak pal palk gemiddelde kon· stall theidsvariasie vir elke proefpersoon proefpersoon 1 1,68 4,95 4,60 0,98 3,10 1,82 0,78 4,82 4,29 5,92 6,28 3,02 3,08 3,22 2,91 3,43% proefpersoon 2 0,87 1,93 2,91 4,02 6,77 3,37 2,71 4,68 2,53 6,14 6.73 3.74 10,61 0,81 1,76 3,97% proefpersoon 3 7,86 0,96 1,05 0,25 1,66 1,40 2,27 2,68 23,02 0,71 5,17 3,76 1,70 3,38 8,55 4,29% proefpersoon 4 0,76 3,11 8,95 2,15 3,69 4,92 2,69 9,63 0,56 4,74 3,76 4,65 5,42 3,88 3,11 4,13% ap 6,16 11,66 12,64 13,64 3,87 14,35 19,28 9.98 12,86 5,20 7.99 23,08 4,20 11,35 8,32 10,97% omvang van normale konstantheidsvariasie 3,43%-4,29% gemiddelde konstandheidsvariasie-persentasie vir normale proefpersone 3,95% tabel 6 toon verder aan dat die kv-persentasie van dieselfde woord baie groter is by die apraktiese spreker as by die normale sprekers. byvoorbeeld vir die woord / k a t / is die kv-persentasie vir die apraktiese spreker gemiddeld 65% en vir die normale sprekers slegs 44,30%. uit die roudata was dit duidelik dat segmentele tydsduur oor die algemeen baie langer is by die apraktiese spreker as by die normale sprekers. hierdie verlengde segmentele tydsduur resulteer dus in stadiger produksie. dit is egter ook opvallend dat die vokaal in elke woord heelwat meer verleng word as die konsonante in dieselfde woord. dit bevestig kent en rosenbek (1983) se bevindings dat vokaalverlenging en stadige produksie kenmerkend is van apraktiese spraak. die hoe kv-persentasie wat voorkom by die apraktiese spreker is dus die gevolg van die oormatige verlenging van die vokaal. die persentasie wat die kk uitmaak van die totale duur van die woord is dus nou korter by die apraktiese spreker as by die normale sprekers. dit moet egter nie gei'nterpreteer word as dat die apraktiese spreker die kk vinniger produseer nie. die duur in millisekondes van die kk is steeds langer as die normale duur. die persentasie wat dit van die totale woordduur uitmaak, is egter kleiner omdat die kv-gedeelte, as gevolg van oormatige vokaalverlengings, so 'n groot persentasie van die totale woordduur beslaan. tabel 6: vergelyking tussen normale sprekers en 'n apraktiese spreker ten opsigte van die kv-persentasie ap = apraktiese proefpersoon. woorde omvang van kvpersentasie by normale sprekers gemiddelde kvpersentasie vir die normale sprekers kv-persentasie by die apraktiese spreker / s a t / 63,75 68,74 67,13 72,59 / s a n / 61,21 68,40 64,80 78,92 / s a n t / 5 1 , 2 5 6 1 , 6 3 55,81 69,31 / s t i l t / 48,56 64,00 56,33 65,77 / k a t / 41,90 45,90 44,30 65,00 / k a n / 46,86 52,62 49,56 69,80 / k a n t / 34,41 39,18 37,49 53,44 a s n t / 27,35 38,81 31,71 42,03 / f a k / 54,56 61,30 57,79 67,33 / f a l / 62,06 63,63 62,78 81,33 / f a l k / 43,63 57,45 53,54 65,36 / f o l k / 43,62 55,05 50,52 61,53 / p a k / 39,81 4 9 , 5 1 45,55 60,39 / p a l / 28,12 57,01 48,36 71,14 / p a l k / 31,00 37,89 35,46 51,32 bewegingskema, deur meer ekonomiese gebruik van energie en deur minder variasie by die herhaling van 'n taak (sharkey & folkins, 1985). di simoni (1974b) het byvoorbeeld gevind dat kinders eers na 9 jaar die temporale reel van temporale kompensasie aanleer, met ander woorde, verfyning geskied ook op die gebied van tydreeling. dit wil dus voorkom asof hierdie beheer weer verlore gaan by die apraktiese spreker en resulteer in onkonstantheid in die toepassing van tydreeling. dit is dus moontlik om die afleiding te maak dat tydreelingvariasie wat in apraktiese spraak voorkom, ooreenstemming kan toon met die tydreelingvariasie in die spraakproduksie van kinders. waar die kind nog nie volkome beheer oor tydreeling ontwikkel het nie, het die apraktiese spreker moontlik weer die beheer verloor. kent en forner (1980) stel ook voor dat groter variasie in kinderspraak verband kan hou met die feit dat hulle spraak stadiger is as die van volwasse spraak en dat stadige spraak predisponerend is tot verhoogde tydreelingsfoute. stadige produksie is ook kenmerkend van apraktiese spraak (kent & rosenbek, 1983) en kan dus saam met foutiewe programmering die oorsaak wees van die variasie in die toepassing van tydreeling by die apraktiese spreker. in die produksie van die aprakties spreker word dieselfde tendens as by die normale spreker waargeneem, naamlik dat 'n kontinuant plus 'n vokaal in kombinasie met / n t / 'n groter kvpersentasie het as 'n ploffer plus 'n vokaal in kombinasie met / n t / (sien tabel 3). daar kan dus afgelei word dat hierdie temporale reel by hierdie spesifieke apraktiese spreker behoue gebly het. i i alhoewel die produksie van die apraktiese spreker uitermate verleng word relatief tot normale produksie en dus dui op afwy kende programmering van segmentele tydsduur, demonstreer verskeie studies dat duurverhoudings wel behoue bly by hierdie sprekers. collins, rosenbek en wertz (1983) bestudeer die verhouding tussen vokaalen woordduur by normale en apraktiese sprekers in langerwordende woorde. die resultate toon dat die vokaal korter word in verhouding met die duur van die basiswoord namate die woord langer word by die normale en by die apraktiese sprekers. collins et al. (1983) haal ook vir freeman, sands en leavitt aan wat demonstreer dat die engelse fonologiese reel, naamlik dat vokale langer is voor 'n stemhebbende as voor 'n stemlose konsonant, ook toegepas word deur apraktiese sprekers. uit bogenoemde kan daar dus afgelei word dat sekere aspekte van temporale programmering, byvoorbeeld segmentele tydsduur, the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a s p e k t e van tydreeling in normale en verbaal-apraktiese spraak afwykend is by die apraktiese spreker terwyl ander, byvoorbeeld duurverhoudinge, intakt is. gevolgtrekkings met betrekking tot die normale sprekers daar bestaan 'n neiging tot 'n konstante kv-persentasie oor drie herhalings van dieselfde woord by 'n individu. hierdie konstantheid is egter nie absoluut nie omdat daar motoriesekwivalente bewegingspatrone in spraak bestaan. hieruit kan ook afgelei word dat temporale kompensasie wel by afrikaanssprekende proefpersone voorkom en bydra tot die neiging van 'n konstante kv-persentasie oor herhalings van dieselfde woord. daar bestaan nie 'n neiging tot 'n konstante kv-persentasie in kvkk-eenhede byvoorbeeld / s a t / teenoor / s a n t / nie. die temporale reel in engels, naamlik dat die duur van die kv in 'n kvken kvkk-eenheid ongeveer dieselfde bly in verhouding tot die totale duur (walsh 1984), kom dus nie by die afrikaanssprekende proefpersone voor nie. konsonantkombinasieverkorting kom dus in 'n mindere mate in afrikaans voor as byvoorbeeld in engels en dus nie met die doel om vasgestelde duurverhoudinge te behou nie. -verskillende vokale het 'n geringe invloed op die kvpersentasie van die totale duur van kvkk-eenhede met dieselfde inisiele konsonant en eindkonsonantkombinaise. die kv-persentasie word dus bepaal deur die klankomgewing waarin dit voorkom. uit die toetsmateriaal kan afgelei word dat daar 'n temporale reel in afrikaans bestaan, naamlik dat 'n kontinuant plus 'n vokaal 'n groter persentasie van die woord uitmaak as 'n plotter plus 'n vokaal wanneer dit geproduseer word voor die konsonantkombinasie / n t / . met betrekking tot die apraktiese spreker deur ontleding van 'n apraktiese spreker se spraak in terme van segmentele tydsduur en die bepaling van 'n z-waarde vir elke produksie, kan daar in 'n groot mate bepaal word met watter klanke in watter spesifieke klankomgewing die spreker die meeste probleme het. deur hierdie metode van analise 'addisioneel tot ouditiewe aiialise van apraktiese simptome toe te pas, kan waardevolle terapieleidrade veral in 'n gevorderde stadium van behandeling ^erkry word. daar bestaan onkonstantheid en variasie van die foutpatroon ten opsigte van segmentele tydsduur in die herhaalde produksie van 'n woord by die apraktiese proefpersoon. i daar bestaan onkonstantheid van die kv-persentasie met die herhaling van dieselfde woord. daar is dus groter variasie ten opsigte van die kv-persentasie by herhaling van dieselfde woord deur die apraktiese spreker as by die normale spreker. variasie van tydre'eling in die produksie van die apraktiese spreker kan moontlik verband hou met die tydreelingsvariasie in kinderspraak. ι die temporale reel wat by normale sprekers voorkom, naamlik dat 'n kontinuant plus 'n vokaal in kombinasie met / n t / 'n groter kv-persentasie het as 'n ploffer plus 'n vokaal in kombinasie met / n t / , het behoue gebly by hierdie apraktiese spreker. die kv-persentasie by die apraktiese spreker is deurgaans groter as vir die normale sprekers en dit bevestig kent en 47 rosenbek (1983) se bevindinge, naamlik dat vokaalverlenging en stadige produksie kenmerkend is van apraktiese spraak. aangesien hierdie slegs 'n eerste poging was om die programmering en toepassing van tydreeling in afrikaans te bestudeer, bestaan daar nog 'n groot behoefte aan verdere kennis en navorsing op hierdie gebied. bedankings die skryfster wil graag mev. a. van der merwe, departement spraakheelkunde en oudiologie, universiteit van pretoria, bedank vir haar leiding met die uitvoer van die studie waarop hierdie artikel gegrond is. verwysings bell-berti, f. en harris, k.s. a temporal model of speech production. phonetica, 38, 9-20, 1981. collins, m.; rosenbek, j.c. en wertz, r.t. spectrographic analysis of vowel and word duration in apraxia of speech. journal of speech and hearing research, 26, 224-230, 1983. cooper, m.h. en allen, g.d. timing control accuracy in pormal -speakers and stutterers. journal of speech and hearing research, 20, 55-71, 1977. darley, f.l.; aronson, a.e. & brown, j.r. motor speech disorders. w.b. saunders company, philadelphia, 1975. disimoni, f.g. influence of consonant environment on duration of vowels in the speech of three, six, and nine-year old children. j. acoust. soc am, 55, 362-363, 1974a. disimoni, f.g. some preliminary observations on temporal compensation in the speech of children. j. acoust. soc. am, 56, 697-699, 1974b. disimoni, f.g. evidence for a theory of speech production based on observations of the speech of children. j. acoust. soc. am, 56, 1919-1921, 1974c. disimoni, f.g. en darley, f.l. effect on phoneme duration control of three utterance length conditions in an apraxic patient. journal of speech and hearing disorders, 42, 257-264, 1977. kent, r.d. en forner, l.l. speech segment durations in sentence recitations by children and adults. journal of phonetics, 8,157168, 1980. kent, r.d. en rosenbek, j.c. prosodic disturbance and neurologic lesion. brain and language, 15, 159-192, 1982. kent, r.d. en rosenbek, j.c. acoustic patters of apraxia of speech. journal of speech and hearing research, 26, 231-249, 1983. lofqvist, a. en yoshioka, h. interarticular programming in obstruent production. phonetica, 21-34, 1981. sharkey, s.g. en folkins, j.w. variability of lip and jaw movements in children and adults: implication for the development of speech motor control. journal of speech and hearing research, 8-15, 1985. tingley, b.m. en allen, g.d. development of speech control in children. child development, 46, 186-194, 1975. van der merwe, a. terapieprogram vir verbale ontwikkelingsapraksie met toepassingsmoontlikhede vir ander spraakafwykings, pretoria: universiteit van pretoria, 1985. walsch, t, modelling temporal relations within english syllables. journal of phonetics, 12, 19-35, 1984. walsch, t. en parker, f. vowel length and "voicing" in a following consonant. journal of phonetics, 9, 305-308, 1981. walsch, t. en parker, f. consonant cluster abbreviation: an abstract analysis. journal of phonetics, 10, 423-437, 1982. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) adm\nced for tomorrow. the μ α κ ό m a 4 1 progressive. the latest technology* built to meet tomorrow^ needs head-on. that's the maico ma41. it's a portable audiometer with reliable circuitry and features that you require in an office audiometer. like speech and narrow band masking, talk forward and talk back, and the new b71 bone vibrator. t h e ma41 is sophisticated enough for all applications, yet it's remarkably easy to use. so you can concentrate on your patient. n o t the machine. t h e maico ma41. a top-of-the-line portable that's advanced for t o m o r r o w . . . but available today. from maico ^ r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) partners in basic education.html partners in basic education the publication of this special edition of the south african journal of communication disorders, ‘speech-language therapists and audiologists as partners in basic education’, contributes to our transformation. it is part of a series of other activities under the auspices of the south african speech-language-hearing association, aiming to reposition our professions so they can contribute effectively to development in south africa. at the 2010 saslha conference, ‘new directions’, there were several inputs highlighting the national crisis in basic education and the potential role the professions could play in improving education outcomes. the conference led to formation of the education task team, who considered a series of activities to advance our future practice. it was recognised that interventions in basic education must be relevant to the south african context and that new and different knowledge was needed. as a first step it was imperative to document the current issues and available knowledge – hence the idea for this dedicated special edition of sajcd. it is envisaged that research in the domain of basic education will continue to grow as we shape our practices in a rapidly changing social milieu. we are also aware that south africa is part of a global community that must participate in the international dialogue on practice. we have therefore invited professor barbara ehren, an expert in school-based interventions, to provide a response to the lead article which contextualises the argument for renewed roles for speech-language therapists and audiologists in basic education in south africa. we recognise that we are at the beginning of a seemingly daunting task, but believe that an accumulation of relevant knowledge as well as strategic actions on our part will result in positive contributions to nation-building. harsha kathard editor: special edition sajcd anatomical and spectrographic analysis of the voice in disease: a report of five cases w.a. k e r r , m.r.c.s., d.l.o., department of otorhinolaryngology, johannesburg hospital. (head: d.r. haynes) and l.w. l a n h a m , ph.d. head, department of phonetics & general linguistics, university of the witwatersrand, johannesburg summary five cases are presented. one is a case of ventricular p h o n a t i o n of iatrogenic origin and the remaining four had undergone l a r y n g e c t o m y for carcinoma of the larynx. points of interest are discussed, particularly the constant ventricular fold p h o n a t i o n of the first case and t h e clear harmonic structure present in the voice of o n e of the l a r y n g e c t o m y cases w h o has b o t h esophageal speech and pharyngeal p h o n a t i o n . opsomming v y f gevalle w o r d voorgele. die een is 'n geval van ventrikulere fonasie van iatrogeniese oorsprong, terwyl die o o r b l y w e n d e vier gevalle laringektomie ondergaan het vir karsinoma van die larinks. a s p e k t e van belang w o r d bespreek, veral die t e e n w o o r d i g h e i d van harmoniese struktuur in die stem van die eerste geval m e t ventrikulere fonasie, a s o o k in die stem van een van die laringektomie-gevalle wat b e i d e esofageale en faringeale fonasie gebruik. the authors do know that much has been written on this subject and that a comprehensive reference to the many authors would be impossible in this article. but they have recorded some publications in the list of references and acknowledge the work of such authorities as: negus, c. and c.l. jackson, kallen, bateman, kirchner, arnold, huizinga, van den berg, moore, norris, conley, tapia, tato, moolenaar bijl and the bell telephone company. this paper is comprised of two sections first (part i), the discussion of the spectrographic evidence, second (part ii), the anatomical analysis and case histories. editor's note: we gratefully acknowledge a grant-in-aid for the publication of this article from the national cancer association of south africa. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 82 w.a. kerr and l.w. lanhamlll-λλ1 j journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) anatomical and spectrograph analysis of the voice in disease 83 it is hoped that the association of the disciplines of acoustic phonetics and otorhinolaryngology, as well as the method of presentation, may be of interest in south africa; and, if so, this report will be a fitting tribute to professor p. de v. pienaar who has worked for many years in this country in speech therapy on the foundations of phonetics. part i the physical analysis of the different "voices". "voice" refers to the manner in which the upper vocal tract is made to function as a resonating system bringing out the distinctive qualities of vowels and vowel-like speech sounds (i.e. oral and nasal resonants such as 1 and r, m and n), whose qualities depend on the resonances of the vocal tract. in this section of the paper the acoustic properties of the different voices are analysed in an attempt to correlate this analysis with states of the esophageal sphincter, the pharynx and the organs of normal speech. the acoustic properties are extracted by means of a spectrograph^ analysis. the measurement of pharyngeal pressure is resorted to in one case in order to confirm pharyngeal constriction. in physical properties each of the voices of the five cases are different in their own way and are examined in the order of, first, the case of ventricular phonation followed by the four cases of esophageal speech including case d, an interesting case who has two distinct "voices". the aim of this analysis is to identify features which may contribute to a classificatory framework of voice without vocal folds, and to an understanding of some of the compensatory mechanisms involved in producing intelligible speech. spectrographic anal ysis of speech sounds the kay sonagraph model 6061-b was used to provide spectrograms showing the acoustic properties of the speech sounds made by our five cases. the spectrograms show frequency on the vertical axis from 0-8 khz., amplitude in varying degrees of darkness in lines and smudges made by the stylus of the sonagraph, and frequency/amplitude changes in time on the horizontal axis (12,33 cm = 1 sec.). the sonagraph provides fine-grained analysis on the vertical axis in a narrow-band display in which the instrument registers conflated intensity in bandwidths of 45 cps; variations in frequency over very brief intervals are therefore registered separately. the wide-band display conflates intensity over bandwidths of 300 cps. wide-band analysis provides fine-grained analysis in the time dimension. the analysis of variations in time in narrowband spectrograms is coarse, as are variations in frequency in broad-band displays. in the analysis of speech sounds which depend on the glottal note, a narrowband spectrogram highlights harmonic structure. the spectrogram marked normal ii shows a harmonic structure with a fundamental of approximately 120 cps in the region; of 19 to 20 on the horizontal cm scale. the resonances of the supra-glottal vocal tract amplify, selectively, harmonics in the glottalnote and these amplified harmonics are seen to be darker and thicker at a/b tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 84 w.a. kerr and l.w. lanham whisper i "(wide) i i 12 13 i "» , i (1 3! her, (high pitch) 5 , , a , , , , 0 i 11 ι \ ζ ι i 3 ι 11 . 1 : h her (1ow pi tch) whisper ii (narrow) 11 12 13 4 i s i ii i / « a i 3 i 1 ο i 1 1 > i 2 ' 1 3 i 1 => ι ! ̂ ί 1 s. i 1 7 i 1g 1 i ο 1 journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) anatomical and spectrograph analysis of the voice in disease 85 and c in the vertical scale. resonance bars appear much more clearly at equivalent points on the wide-band normal i spectrogram. wide-band spectrograms highlight resonance properties on which the distinctive quality of vowels and resonant consonants depend and such resonance properties are the products of the cavities of the supra-glottal vocal tract. wide-band displays obliterate harmonic structure. resonance bars are normally termed "formants" and the formant structure for the vowel [3:] of ken emerges as f1 = 550, f2 = 1340, f3 = 2250 (approximate centre frequencies of lowest three formants). fine-structure analysis revealing the pulses of the glottal note shows in wide-band spectrograms in the thin parallel vertical lines rising vertically through most of the visible frequency scale where vowels are articulated. each of the highly regular (in time and amplitude) pressure pulses from the vibrating vocal folds is shown by a vertical line which also thickens and darkens as it enters the bandwidth of a formant. glottal pulses up to 500 per second are discernible in wide-band spectrograms. aperiodic noise, at whatever point in the vocal tract it is created, shows as striations in wide-band displays: i.e. as irregular vertical lines of varying lengths as seen at normal i 10. here the consonant [s] is seen as randomly distributed energy concentrated mainly above 3.5 khz which, in time, has a relatively gradual onset and continues for approximately 16 csecs. noise in the form of a burst, i.e. instantaneous onset and rapid decay is seen at case ai 7 corresponding to the release of the [t] of to. aperiodic high-intensity noise is also clearly shown by whisper i where random, irregular frequency/ amplitude components are seen to be amplified by resonances; compare the ill-defined, but discernible, formant 2 of [3:] in her in whisper i and [3:] of ken in normal i. an aperiodic noise component in narrow-band spectrograms appears as a horizontally elongated smudge rather than a thin vertical line. the representation of noise in the two different spectrographs samplings are clearly shown by whisper i (wide band) and whisper ii (narrow band). the means of identifying areas on the spectrograms presented here is in terms of coordinates on the horizontal and vertical scales. in illustration, the square box in the centre of spectrogram whisper i is 7 to 8 g to j. the title over each spectrogram should be interpreted thus: case dv esophageal (wide) is a wide-band spectrogram identified by the number v and representing the voice of case d who has esophageal voice. note that v and vi are wide and narrow-band spectrograms of the same utterance. the means of interpreting the pharyngeal pressure graphs are discussed below. voice types in this study the five cases range, in their speech, from high to relatively low levels of intelligibility (with some fluctuation in individual cases) and the correlation between these differences with the different means of exciting the resonators is attempted below. resonators function in response to an input in which a driving force is involved. in the human voice the driving force is always an air flow which passes a point of constriction and the resonators of the upper vocal tract can be excited in three different ways. the air flow may be interrupted at the point of tydskrif van die suid-afrikaanse verenigingvir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 86 w.a. ker and l.w. lanham case all ventricular (narrow) _ ρ parents to see doctor kerr journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) anatomical and spectrograph analysis of the voice in disease 87 constriction by rapidly alternating closed and open phases. in normal voice lung air is interrupted in highly regular and rhythmical vibratory cycles by the true vocal folds which are drawn medially and, in varying degrees, laterally, into a state of vibration. these vibrations are a consequence of the bernoulli effect in which an accelerating air flow through a narrowing channel sucks the elastic edges of the constrictor together. closure brings a change in pressure at the point of constriction and is followed by rapid opening. the vibrations of normal phonation set up pressure pulses which are highly regular in time and amplitude and only vibrators having the properties of the vocal folds, violin strings, etc. can produce a stream of pressure pulses of this kind. these pulses create a periodic sound wave with an inherent harmonic structure, i.e. the energy in the vibrations is largely concentrated at points in the frequency scale which are multiples of the fundamental (the lowest frequency component). very little turbulence occurs in this type of interrupted air flow even as the closed phase of the vibratory cyclc is approached and there is, therefore, little concomitant aperiodic noise. a vowel as a relatively "pure" note or tone is produced by resonators linked to a vibratory source of this kind. the resonators amplify harmonics set up by the glottal note which fall within their bandwidth and four clear resonance bars (formants) can be seen in wide-band spectrograms in the normal voice (wide normal i 3 to 4 in the articulation of the first vowel of parents). to the extent that irregularities develop in time (frequency) and amplitude in the vibratory pattern of the vocal folds, the ear identifies harshness or roughness. a variation of frequency of as little as 1 cps can give rise to perceived roughness.24 changes in the harmonic structure give rise to perceived differences in pitch (intonation). in the narrow-band spectrogram normal ii11 a to i, a higher pitch corresponding to roughly 160 cps falls to a lower pitch of 123 cps at 21 a to p. a resonating system can, however, also function by receiving impulses in the form of sharp raps or taps. the forefinger flicking the throat just above the superior edge of the right lamina of the thyroid produces a spectrogram such as that labelled finger-flicks. each rap sets up a noise burst of very brief duration with aperiodic noise properties in which energy is distributed over the 8 khz. visible on the spectrogram. there is no inherent harmonic structure in the noise burst and even a rapid succession of such raps at rates of over 100 per second does not set up a harmonic structure. there is, therefore, no possibility of frequency modulation which would be perceived as pitch variation or intonation, even if the rate of rapping is varied significantly.* the vocal tract functions as a resonating system in response to the "rapping" input by amplifying frequencies in the noise bursts falling within the bandwidth of the resonators. the energy at such amplified frequencies decays relatively slowly and the emergent formants can be discerned at finger-flicks 1 and 2 a and b as horizontally extended smudges. a third driving force for exciting resonators is continuous turbulence causing * our discussion implicitly rejects s c r i p t u r e ' s 1 9 ( 1 9 0 6 ) t h e o r y that no overt o n e s emanate from glottal vibrations, o n l y air puffs w h i c h cause the resonators t o sound w i t h their o w n frequencies. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 88 w.a. kerr and l.w. lanham ϊ kha i b f f l j p . .̂l· . . . . h . , ; , , 16 1 7 i .1 i j 1 1 ί γΐ ll " i 1 •> ι < · ' 1 ' i 1 s > > < 1 15 «>· i k t j ι '* • o'h make her a home case ci i esophageal (narrow) case ci 11 esophageal (wide) journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) anatomical and spectrographic analysis of the voice in disease 89 friction of relatively high amplitude emanating from a point of narrow constriction at which air escapes without any interruption of the air flow. whispering is an excellent example of resonators functioning with this type of input. the point of constriction is a small v-shaped opening at the posterior end of the glottis and the vocal folds do not vibrate. whisper i (wide-band, and ii (narrow-band) show strong, transient, aperiodic noise components over the whole of the visible frequency scale and strong amplification of those frequencies falling in the bandwidths of resonators, in particular; see formant 2 in whisper ii 11 to 14 c and the corresponding area in the narrow-band display of whisper ii. this is spectrographic evidence of the discernible quality differences of whispered vowels. continuous turbulence is, for the human body as a sound producer, highly uneconomical in rapidly draining the air reservoir. for esophageal speech with its small air reservoir it is impracticable. one reason for discussing whisper here is that esophageal "burping" (see below) with a high level of concomitant friction, is seemingly far more effective than esophageal "rapping" with little friction. a point of interest connected with whisper is that, although totally lacking in harmonic structure (see whisper ii), an auditory impression of pitch variation can be created by so altering the constriction at source that the energy is differently distributed in the frequency scale. the difference between "lowpitch whisper" and "high-pitch whisper" in whisper i and ii (representing a conscious effort by the normal voice recorded on these spectrograms) is that formant i (at level a/b) and formant 2 (at level c) have, respectively, less and more energy concentrated at these relatively low frequencies. formant 3 (at e/f, i.e. 2.5 khz) shows the approximate point where the low-high energy distribution becomes inverted. in esophageal "voice" air flow from a reservoir in the upper esophagus is interrupted by crude vibrations of the esophageal sphincter which alternatively opens and closes the esophageal lumen. in esophageal sphincter vibration the closure of the valve-like exit to the air reservoir is probably brought about by muscle tension after the opening caused by air pressure. if this is the case then this vibration is not a consequence of the bernoulli effect. each opening releases a burst of noise into the resonating system at irregular, variable rates. muscle tension and air pressure would regulate the rate of vibration. case β illustrates how close this type of vibration can come to "rapping" or "tapping"; compare case bi 1 to 3 with finger-flicks. here rapping is seen to be irregular in time with an average rate of roughly 42 per second. case ci 8 to 14 shows a somewhat more rapid, regular rate of rapping at approximately 44 per second. the corresponding sections on the narrow-band spectrograms bii, cii show a total absence of harmonic structure and the formants appear as smudges darkened in the vertical bars of the raps. spectrographic evidence attests to the absence of frequency modulation in esophageal voice. a significant variation in esophageal sphincter vibration begins to show in comparing bi and ii with ci and ii (particularly 1 to 4) and is clearest when ei enters the comparison. the actual noise bursts recede in prominence and continuing aperiodic noise components over wide bandwidths are the main input to the resonators. the raps apparently smooth out into a succession of air puffs somewhat more rapid and regular, and lower in amplitude (hereafter tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 90 w.a. kerr and l.w. lanham case civ esophageal' (narrow) journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) anatomical and spectrograph analysis of the voice in disease 91 referred to as "burping" in contradistinction to "rapping"). the distinction between rapping and burping is significant because the voice of case β is very "croaky" and of low intelligibility; that of case c is unpleasantly croaky, but of high intelligibility; that of ε not at all croaky, breathy, but pleasant, and highly intelligible. although our postulation as to the site of constriction which produces random aperiodic noise components is unconfirmed experimentally, we suggest that friction noise emanates from the esophageal sphincter where the manner in which the air flow is interrupted ranges over vibratory cycles with tight closure, high esophageal pressure and "clean" break on opening (rapping), to burping with weaker, probably incomplete, closure and considerable concomitant friction. a third possible state is a still weaker interruption with a more or less open lumen allowing a continuous air flow. this would seem to be the nature of the esophageal air mechanism in oral fricatives such as [s]. if turbulence is not a consequence of esophageal vibration then pharyngeal constriction is the next most likely source. pharyngeal pressure measurements show that case d uses this mechanism and provides evidence of a vibratory mechanism involving the pharynx. we are doubtful, however, whether case c has pharyngeal constriction. case c burps without embarrassment and makes no attempt to cover the esophageal voice by pharyngeal constriction. compare spoken and sung make in ci, ii at 5 to 6 and ciii, iv at 5 to 8. the prominence of the raps recedes as the vibrations speed up* and the quantity of random, aperiodic noise is greater. in case ε the significant absence of strong noise bursts in ei is worth investigating. two significant dimensions of esophageal voice emerge from this discussion: (a) the manner in which the esophageal sphincter controls the release of air; (b) the presence and nature of pharyngeal constriction. in classifying cases of the types dealt with here it is useful to distinguish the three types of source input to the resonating system: type x pressure pulses with a harmonic structure and true frequency'modulation (friction noise may be present, but is a minor contributor). type y vibrations of low frequency in the form of noise bursts lacking a harmonic structure (rapping and burping). type ζ continuous, relatively uninterrupted friction noise. none of our cases is classified as z, but experiments with a normal vocal tract show that pharyngeal constriction could set up a "voice" of this kind. obviously there is overlap within this categorisation. ζ can clearly overlap with x and y;x and y are, as a rule, mutually exclusive. the phonation of a normal voice is only type x; a succession of glottal stops or catches cannot be produced at a rate fast enough to provide any real semblance of type y. ventricular phonation in the one case discussed below, is * t h e superior-inferior branches of tne laryngea. nerve seem t o c o n v e y the same instruction t o the cricopharyngeus muscle as it did t o muscles of the larynx. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 92 w.a. kerr and l.w. lanham 'incase 01v esophageal (narrow) λ ί » — λ , age case bv "esophageal («μδίγ <r , t l , khz 1 khz ; ι ι ι ι 1 | " t \ 7 ~ i t 7 ~ " l t i " · · . t s ! l« ι i ? ι it) ι 19 i 28 1 1 ong journal ofthesouth african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) anatomical and spectrographic analysis of the voice in disease 93 type x. esophageal voice is type y, but case d is a particularly interesting case of both x and y. a summary of the cases discussed below: normal case a case β case c case d case ε ventricular folds intact; no functioning vocal folds laryng e c t o m y laryng e c t o m y laryng e c t o m y laryng e c t o m y t y p e x t y p e x t y p e y t y p e y t y p e s y and x t y p e y discussion of cases ventricular phonation: case a. this voice is highly intelligible with a fair degree of hoarseness or roughness. case a is capable of a sustained high level of power. he has limited pitch variation in intonation although the stretch of speech represented in spectrogram all shows little frequency modulation. (the fundamental at all 2/3 is roughly 168 cps.) with effort, case a can raise his pitch to a fundamental frequency of about 300 cps. the lowest harmonics in all are seen to be very strong, but harmonic structure weakens rapidly as the frequency rises and above 2.5 khz, formants are brought out mainly by high frequency aperiodic noise amplified in the resonance bars of the highest formants. contrast this with normal ii where harmonic structure shows gradual decrease in amplitude, but continues throughout the visible frequency scale and brings out even the highest formants. in the region ai17 to 18, frequency variation is a maximum of 16 cycles around a mean of approximately 178 cps and this variation is a major contributor to the hoarseness of the voice. ventricular phonation in case a is therefore periodic to a high degree and these findings apparently differ from those of moore 1 2 : when ventricular folds vibrate, they are quite aperiodic the laryngological report shows, however, that case a is an exceptional one of ventricular phonation. this case is important in showing how ventricular phonation can approach normal phonation quite closely. esophageal voice.: case b. this voice is very "croaky" and of the four esophageal cases has the lowest level of power and intelligibility. the nature of the "voice" is a major contributor to this lack of clarity. all recordings of this case produce an extreme type y "rapping" at slow, highly irregular, rates. at bi 1 to 3, (the diphthong [ei] of age) there are 9 raps at frequencies ranging from 30 to 61 per second. the irregularity at bi 13 to 15 is even more striking. the poor definition of formants seen at bi 2 to 3 b, and e to h, is a consequence of the manner in which the resonators are excited. a striking difference between this voice and other more successful esophageal voices is the absence of random aperiodic noise outside the noise bursts of the raps and, in consequence, the weak, shadowy, formant structure. a comparitydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 94 w.a. kerr and l.w. lanham l|t!r;l;: ; n o r m a l i ...1.. . — « « t o · * " l u ' aec<jnak' ' t j ' 1 " 1 1 1 " " " ' " case d g r a p h d v i i journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) anatomical and spectrograph analysis of the voice in disease 95 son of bi with ci and dili illustrates this. the almost blank vertical strip at bi16' to 17.5 (the nasal consonant [n]) shows no impulses being transmitted to the resonators and contrasts in this respect with an equivalent nasal consonant of ci 4. apparently, random aperiodic components produced by turbulence play a major role in filling out resonances to produce quality differences. the "rapping" of case c (see ci) is much more successful because the rate is faster and more regular and a good deal of energy is located in aperiodic components outside the noise bursts. the raps themselves do not differ significantly in amplitude between cases β and c. another contributory factor to the poor quality of case β speech is the poor timing of the rapping mechanism which switches off for nasals and resonants. case c. this is a voice of considerable power and very high intelligibility although sometimes unpleasantly harsh. it is closest to the "rapping" version of type y but, interestingly, the "burping" mode is evident when this case attempts to sing. the spectrographic definition of formants, particularly the higher formants, tends to be clearest with "speaking" rather than "singing" (i.e. rapping rather than burping), but both are highly intelligible. in neither version is there any sustained harmonic structure and the weak auditory impression of a pitch change between sung and spoken make is due not to the different rates of rapping or burping, but partly to the lengthening of the vowel in sung make and partly to greater energy at the higher frequencies (although this is not as clear as in high-pitch vs low-pitch whisper in whisper ii). case c burps at a rate of approximately 72 per second at ciii 8 and raps at 47 per second at ci 12, but with a high degree of irregularity. cased. the two "voices" of this case can be seen by comparing di, ii 3 to 10 and dili, iv 1 to 5. the harmonic structure (with vibrato) emerges clearly in the former and the fundamental frequency is approximately 215 cps at di 9.3. harmonics are strong below 3 khz., but hardly discernible above that. in di there is a clear definition of formants and the spectrogram is not too unlike that of a normal woman's voice although there is a high degree of accompanying aperiodic noise. dili, iv 1 to 5 shows burping with an absence of harmonic structure although the burps, with energy mainly below 4 khz., bring out a fairly clear formant structure. vibrations at dili 3 are fast, approximately 110 per second. (in our data case ε gave the fastest esophageal sphincter vibration of 120 per second.) spectrograms di, ii were made from a recording in 1966 when the morale of this case was said to be high. dili, iv were made early in 1973 when the case was somewhat depressed. dv, vi also date from the latter period and represent the response of this case to a request to emulate her 1966 voice making the same utterance so long with high emotion expressing surprise. the harmonic structure is more tenuous, intermittent and without vibrato; most of the energy is in the first harmonic which moves from approximately 240 cps at dvi 4 to about 400 cps at dvi18. like di, ii there is a clear auditory impression of frequency modulation. it was seen quite early that case d was stifling her esophageal voice by pharyntydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) w.a. kerr and l.w. lanham journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) anatomical and spectrographic analysis of the voice in disease 97 geal constriction apparently involving the pharyngeal constrictors and the back of the tongue. pharyngeal constriction is a common feature of case d's voice except for rare breaks, sometimes occurring in speech and sometimes in pharyngoscopic investigations, when the esophageal burping is clearly audible to the embarrassment of case d whose pharyngeal constriction is apparently an attempt to cover up the true esophageal voice. the site of case d's type x voice which reaches such high fundamental frequencies, is a question of some interest. obviously, there is an extremely delicate balance in muscle function, hence the vibrato. the pharyngeal pressure graphs dvii represent our attempt to obtain firm evidence of the action of the pharyngeal mechanism. 2 ' 3 , 2 5 they support our belief that type x voice is produced by pharyngeal constriction because of the clear indication of phases of total closure. pharyngeal pressure was measured with a beckman rm dynograph recorder using 4-bore polyvinyl tubes perfused at .055 ml/minute connected to p23aa statham transducers. the pressures for case d and for normal (right graph and left graph respectively) were taken in the pharynx about 2 cms and 1 cm respectively above the esophageal sphincter and show a swallow (marked s) and then speech (marked p) for the utteranceican't. during the utterance the normal voice shows two spikes of slight pressure in the pharynx probably corresponding to the "hold" (closure of the vocal tract) of the consonant [k] of can't, but there is no significant increase in pressure elsewhere. case d, on the other hand, shows very high pharyngeal pressure (in comparison with norms for phonation) throughout the utterance which could only be achieved by phases of total adduction. (the utterance was quite abnormally prolonged by case d.) the high pressure is, however, not sustained and can be seen to fall drastically and quickly rise again. this, we believe, could be due to the inability to maintain the high degree of pharyngeal constriction in achieving type x voice and the need to release pressure before allowing it to build up again. the whole mechanism of esophageal air release linked with the pharyngeal pseudoglottis is not fully understood by us, but we suggest that there is spectrographic evidence that true type x voice can only be sustained for limited periods followed by a break with some degree of constrictor abduction. in dili, iv 12 there appears to be about 4 csecs of type x voice (note a semblance of harmonic structure at div 12 b to c) preceded by weak type y voice from 8 to 11. an interesting question is whether the vibrations in the latter stretch and 1 to 4 in the same spectrogram are vibrations of the esophageal sphincter as well as of the pharyngeal constriction. their rate of 110 per second is within the range of esophageal sphincter vibrations. in auditory impression, case d's 1973 voice is squeaky, "squeezed" and lowpowered, particularly when in the true type x mode, with an intelligibility level between that of cases β and c. it is not at all harsh or croaky. in 1966 the voice was stronger and clearer and the ready ability to achieve frequency modulation is known to have deceived at least one experienced laryngologist in telephone conversation with case d. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 98 w . . kerr and l.w. lanham journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) anatomical and spectrographic analysis of the voice in disease 99 casee. this voice is husky, not unduly harsh and maintains a high, very even, level of power. with case c it is the most intelligible of the four esophageal voices. it contrasts with c in being typically "burping" rather than "rapping" and demonstrates how a clear formant structure can be brought out with a non-harmonic source. (see ei 2 to 3.) the clear formant structure and, consequently, the high intelligibility, are due to turbulence which provides components from very low in the frequency scale to at least 5.5 khz. the rate of burping in the region of ei 2 to 3 varies around a mean of approximately 85. significant aspects of the five cases points arising from our study (all of which call for deeper investigation) which have significance in speech therapy and surgical procedures in laryngectomy are: a) the nature of compensatory mechanisms in "speech without a larynx". b) the tendency to "cover" the esophageal croak with pharyngeal constriction and the effects thereof. c) the superiority of the "burping" mode of esophageal sphincter action, i.e. relatively fast and regular vibration with a good deal of concomitant friction noise, as the most effective means of exciting upper vocal tract resonators. d) the presence of a pharyngeal vibrator producing true pitch modulation. e) the ability to create an impression of pitch modulation without harmonic structure by a shift of energy in aperiodic noise components from a relatively low to a higher bandwidth. f) the effectiveness with which ventricular phonation can, over a period of time, substitute for the function of the true vocal folds. part ii anatomical analysis and case histories. case a. mr. w.p. mr. w.p. is now 33 years old. in 1944, at 4 years of age, he was examined by a laryngologist who found laryngeal papillomata. these were removed and, at the same time, a diathermy needle was used on the vocal cords. this operation was followed by laryngeal obstruction and tracheostomy became necessary three weeks later. within three months the cords had become "adherent" and a course of dilatation with bougies was started and continued until august 1945; but no improvement had been achieved and the patient was referred to dr. c.l. jackson in philadelphia where further treatment, including laryngostomy and plastic closure, was carried out by dr. jackson and dr. charles m. norris. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african speech and hearing association, vol. 20 december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) anatomical and spectrograph analysis of the voice in disease 101 the patient was first examined by w.a.k. in 1948 because of a recurrence of papillomata and stenosis; and direct laryngoscopy confirmed the presence of both, as well as the fact that the cords were not adherent but were hard, fibrous and immobile. he was not seen again until 1963 and, in the interim, he had developed a weak, high-pitched voice which had not been present in 1948 when it was just a whisper. preliminary mirror examination revealed pale, immobile, rounded vocal cords which were lying in partial adduction but not in contact on phonation. the ventricular bands, however, were mobile and came into contact on phonation; and they showed, also, apposing edges which were more than normally smooth. radiological examination, using a contrast medium, confirmed the clinical findings of ventricular phonation and of rounded vocal cords. see figs. a 1 and a 2. apart from this, he had developed a tracheocele at the site of previous surgery, from the increased intratracheal pressure resultant on the laryngeal stenosis. see fig. a 3. a laryngofissure operation was performed by w.a.k. in september 1963 when the hard, fibrous, immobile vocal cords were excised down to cartilage and a skin graft was applied, care being taken not to traumatise the healthy, smoothsurfaced ventricular bands. at the same time the tracheocele was excised. this operation has been only partially successful and an ellipsoidal stenosis has recurred at the site of the vocal cords; but mr. w.p.'s ventricular phonation has continued to improve up to the present time and is not accompanied by general contracture of the upper sphincter muscles of the larynx; this was recorded by saunders.17 he usually keeps his abdominal muscles in contraction when he speaks; a dry atmosphere improves his voice and he is quite certain that it is also improved by smoking (15 cigarettes a day). iced drinks cause immediate, temporary deterioration as well as does a humid atmosphere. he can sing in tune and was a member of a boys' choir up to puberty ; then the pitch of his voice lowered but it never 'broke'. his almost lifelong courage and his determination to speak, coupled with the numerous surgical procedures, have given rise to an increasing voluntary muscular control of his ventricular bands, as mentioned by pressman;14 and to mucosal changes towards the thin and adherent type which is present on true vocal cords. his condition is of the type which has been described as vicarious by jackson7 and by arnold and pinto.1 case β. mrs. j.s. mrs. j.s. was 40 years of age when she underwent the operation of laryngectomy by mr. c.p. wilson in london in 1953; and he found it necessary to remove more than the usual segment of trachea. the hyoid bone was preserved and the epiglottis removed. the patient was first seen by w.a.k. in 1954 as she had not been able to develop anything more than a just-audible voice. clinical examination revealed a recessed laryngectomy stoma lying at the level of the suprasternal notch, thus confirming that a considerable amount of trachea had been removed. however, in spite of speech therapy and encouragement from other laryngectomees, this lady has never developed satisfactory speech. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) w.a. kerr and l.w. lanham ε 1 journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) anatomical and spectrographic analysis of the voice in disease 103 radiographic assessment in 1973 has shown a functioning cricopharyngeal sphincter and the patient swallows food without difficulty; but it has not been possible to obtain an air column in the oesophagus up to this sphincter; see fig. β 1, in contrast to cases d and e, figs. d1 and el where the sphincter is sharply defined between well marked pharyngeal and oesophageal air columns. the area a. to b. in fig. β 1 measures about 2.5 3.0 cm. which is longer than the normal length of the cricopharyngeus, of 1 to 2 cm., as given by batson,4 and by dey and kirchner.5 w.a.k. does feel that, in case b, some loss of normal muscular function has taken place in the inferior pharyngeal constrictor and, particularly, in the upper end of the esophagus, ref fig. β 1, b to c; and that her defective voice is partly due to these changes. case c. mrs. g.a. mrs. g.a. was 37 years of age when she underwent laryngectomy by w.a.k. in may 1950. at operation the cricopharyngeus on the left was found to be adherent to an enlarged thyroid gland. care was taken to minimise trauma to the former, the hyoid bone was preserved and the epiglottis removed. the infrahyoid muscles were preserved and overlapped to strengthen the pharyngeal repair. recovery was normal and within one month of the operation the patient had started esophageal speech. after six months the voice was satisfactory, though harsh, and her air intake was noisy. radiographs by dr. e. samuel16 in 1951 and 1953 demonstrated satisfactory air columns in the pharynx and esophagus but no sharply defined cricopharyngeus. further studies by dr. stanley lazar1 0 in june 1973 confirm the satisfactory air columns, figs. cl and c2 and show that the area a. to b. in case c is almost 3.0 cm. in length. this is much longer than in cases d and ε and resembles, somewhat, the corresponding area in case b; but the upper esophageal air column in case c is wide and normal right up to b.; whereas, in case b, it has always been narrow and tapering. this difference in the two cases may explain, at least in part, why case c has a powerful and intelligible voice but case b's voice is weak and lacks clarity. in 1953 it was first noted by samuel16 that case c's pharyngeal air column was larger immediately after speech than before it, fig. c3; and this interesting observation has been confirmed by lazar1 0 in 1973, in cases c and d. figs. c4 and d4. cased. mrs. b. mcl. mrs. b. mcl. was 39 years of age when she underwent laryngectomy by w.a.k. in february 1951. the hyoid bone was preserved, the epiglottis removed and trauma to the pharyngeal constrictors was minimised. the infrahyoid strap muscles were preserved and overlapped to strengthen the pharyngeal repair. many authors have stressed the importance of preserving these structures, when possible, so as to give the patient every opportunity of developing satisfactory s p e e c h . 7 , 8 , 1 8 ' 2 2 , 2 3 tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 104 w.a. kerr and l.w. lanham the patient was given a postoperative course of orthodox high-voltage radiation for over one month. by october 1951 she had developed good speech and, even from that time, she has always insisted that her voice is pharyngeal and she points to the region just below the hyoid bone on each side. repeated clinical and radiological examinations have confirmed a functioning cricopharyngeus muscle and excellent esophageal and pharyngeal columns of air. ref. figs. d 1, d 2 and d 3. fig. d 4 demonstrates the enlarged pharyngeal air column immediately after the sudden cessation of speech and this was referred to in the discussion on case c. fig. d 2 is a radiograph taken during relaxed esophageal speech and the 'lip' ' a ' 9 can be seen in close contact with the lower anterior margin of the cricopharyngeus, in which is a small area of calcification. this part of the cricopharyngeus can be seen to be in vibration and w.a.k. is of the opinion that this is the site of case d's pseudoglottis for esophageal s p e e c h . 1 1 , 1 5 , 2 1 fig. d 3 demonstrates the pharyngeal air column during pharyngeal phonation with emotion. note that the tongue is in approximation to the posterior pharyngeal wall and reference to the graph d vii shows high hypo-pharyngeal pressure during this type of phonation.20 furthermore, light palpation with one finger just above the cricopharyngeus, during this phase, reveals vibration which is maximal at this point;1 1 and mirror examination of the hypo pharynx shows two antero-posterior folds in this region which are in apposition during pharyngeal phonation, the fold on the left side having a sharp, fibrous e d g e . 6 ' 8 ' 1 3 , 2 0 apart from the ability to 'blow her nose', provided a 'reasonable-sized' mass of secretion be in it, this lady can phonate immediately after a bolus of food has passed the cricopharyngeus; and can also phonate with her tongue partially protruded. casee. mr. d.g.c. mr. c. was 58 years of age when laryngectomy was performed by w.a.k. in 1959. the epiglottis was removed and the hyoid bone preserved. the usual care was taken to minimise trauma to the cricopharyngeus, and the infrahyoid muscles were preserved and overlapped to strengthen the pharyngeal repair. within 3 weeks of the operation this patient had started esophageal speech, within 3 months it was fair, and within a year it was good. he has always maintained that his voice comes from the region of the cricopharyngeus. in march 1965 x-rays were taken to demonstrate his good esophageal air'reservoir; and also the hypertrophy of the cricopharyngeus. ref. fig. ε 1. through the years his voice has, if anything, improved. his air intake is silent and his voice has never been loud nor raucous. he can say normal sentences without effort and, as a business executive, he has been capable of conducting interviews throughout the usual working day. journal of the south african speech and hearing association, vol. 20, •december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) anatomical and spectrographic analysis of the voice in disease 105 acknowledgements pharyngeal pressure measurements were made by mr. c.g. bremner f.r.c.s. of the department of surgery in the university of the witwatersrand; and his assistance is gratefully acknowledged, as well as that of dr. michael denny, radiologist, his partners and radiographers for their kindness and generosity in carrying out numerous radiographical examinations on all the patients. in particular, we thank dr. monty said and dr. stanley lazar, as well as miss j. robb and her radiographer colleagues. the anatomical photographs were taken by a.r.j. kerr, a.m. shevitz and mark hudson whom we thank; also, nursing sister pauline green s.r.n, for carrying out tape recordings and typing, as well as routine nursing duties. references 1. arnold, g.e. and pinto, s. (1960): ventricular dysphonia. laryngoscope, lxx, no. 12, p. 1612. 2. bateman, g.h., dornhurst, a.c. and leathart, g.l. (1952): oesophageal speech.b.m.j., 2: pp. 1177-78. 3. bateman, g.h. (1953): oesophageal speech after laryngectomy. acta otolaryngology, xliii, fasc. 11-111, pp. 133-139. 4. batson, o.v. (1955): the cricopharyngeus muscle. annals of o.r.l., 64, no. 1, p. 52. 5. dey, f.l. and kirchner, j.a. (1961): the upper esophageal sphincter after laryngectomy. laryngoscope, lxxi, no. 2, p.99 and pp.112-114. 6. equen, murdock. (1956): the rehabilitation of the laryngectomee. arch, of otolaryngol., 64, no. 1, pp. 1-2. 7. jackson, c. and c.l. (1942): diseases and injuries of the larynx. the macmillan co. new york, 2nd ed. p.76 and p.456. 8. kallen, l.a. (1934): vicarious vocal mechanisms. arch. otolarngol, 20, pp. 460-503. 9. kytta, jyrki. (1964): finnish oesophageal speech after laryngectomy. acta otolaryngol., supplementum 195, p. 86. 10. lazar, stanley. (1973): personal report. 11. moolenaar-bijl, annie. (1953): the importance of certain consonants in esophageal voice after laryngectomy. annals ofo.r.l., lxii, no. 4, p. 980, fig. 2. 12. moore, g.p. (1971): organic voice disorders. prentice-hall inc., englewood cliffs, n.y., p. 80. 13. negus, v.e. (1929): the mechanism of the larynx. heinemann, p. 350. 14. pressman, j.j. (1954):· sphincters of the larynx. arch, of otolaryngol., 59, no. 2, p. 236. 15. robe, evelyn y.;moore, g.p.; andrews, a.h.; holinger, p.h. (1956): speech after laryngectomy. laryngoscope, lxvi, no. 4, p. 399. 16. samuel, eric. (1951 & 1953): personal reports. 17. saunders, w.h. (1950): dysphonia plica ventricuiaris.^nna/s ofo.r.l., lxv, no. 3, p. 668. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) •this is one of our slogans to help you remember the name of the world's finest cassette tapes. we think our tapes are better than most because of the smooth way things go around inside. never any flutter problems. use the letters basf, create your own slogan, send it to us at p.o. box 6547, johannesburg, and win a sp-y glass or an elephant or a matchstick or whatever. we're sure you can do better than us. the better your entry, the better your prize. if it's worth recording it's worth recording on basf. the world's finest cassette tapes. : waiseomoiteowf # 2 5 8 "5 journal of the south african speech and hearing association, vol. 20 december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) anatomical and spectrograph analysis of the voice in disease 107 18. simpson, i.c.; smith, j.c.s. and gordon, margaret t. (1972): laryngectomy: the influence of muscle reconstruction on the mechanism of oesophageal voice production. j. laryngology and otology, 86, no. 10, pp. 961-990. 19. scripture, e.w. (1906): elements of experimental phonetics. chas. scribner's sons, new york. 20. scripture, e.w. (1916): speech without using larynx. /. physiology, 50, pp. 397-403. 21. svane-knudsen, v. (1960): the substitute voice of the laryngectomized patient. acta otolaryngol. 52, fasc. 1, pp. 85-93. 22. vrticka, k. and svoboda, m. (1961): a clinical and x-ray study of 100 laryngectomized speakers .folia phoniat., 13, pp. 174-186. 23. warner, jennifer. (1971): vocal rehabilitation following total laryngectomy./. laryngology and otology, lxxxv. no. 6, p. 578. 24. wendahl, r.w. (1963): laryngeal analog synthesis of harsh voice quality. folia phoniatrica, xv. 25. zinner, e.m. and fleshier, b. (1972): intraesophageal pressures during phonation in laryngectomized patients. j. laryngology and otology, lxxxvi, no. 2, p. 138. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) f a c t o r s causing s e v e r e d e a f n e s s in c h i l d h o o d . b y w. hatchuel, m.b. b.ch., (rand), m.r.c.p.e., d.c.h. in order to diagnose deafness, it is as well to bear in mind its causes. it is of interest therefore, to analyse the records at the st. vincent's school for the deaf, in johannesburg, and to enumerate the causes of deafness as recorded • there. t.b. meningitis 3 meningococcal 1 type not recorded 15 rubella in pregnancy _5 40 there are 221 children attending st. vincent's school for the deaf. twelve of these children have been termed "aphasic" and are excluded from this analysis. the remaining 209, are children who have been referred to the school as being severely deaf and who require education in a school for the deaf. m the factors causing deafness have been tabulated from the diagnoses recorded by doctors and other persons referring the children to the school. the analysis represents only an overall guide to the causes of severe deafness in children of school going age. factors in the causation of deafness i hereditary causes. 2 families with 3 affected siblings: 17 families with 2 affected siblings: 10 families with 1 affected child, and other affected close relatives waardenburg's syndrome association with ectodermal dysplasia congenital absebce of auditory canals associated with cleft palate α infection inflammatory conditions affecting middle and inner ear etc. encephalitis measles gastro enteritis pneumonia meningitis 57 6 34 10 1 1 1 _4 57 40 7 6 1 1 1 19 iii drugs kantrex * streptomycin quinine iv perinatal causes "spastic paralysis" kernicterus birth injury prematurity v trauma vi miscellaneous mother in concentration camp during pregnance progressive deafness of unknown aetiology 1 2 1 4 10 2 3 2 j3 10 2 2 vii convenital sporadic deafness 95 * two cases of 'streptomycin toxicity" also included under t.b. meningitis. heredity plays a prominent role in the causation of deafness, and in fact, accounted for more than a quarter of the cases. this is strikingly shown by the presence of 50 children in the school all of whom have a background history of family deafness; two families each have 3 children attending the school, another 17 families have two children in attendance and a further 10 14 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) are children from families where either a parent or a close relative is affected. there are certain well described hereditary syndromes in which deafness may appear as a feature. embryologically the cochleae and ossicles form part of the 'first arch', and originate from the neural crest of the ectodermal tissues. in 1958, mckenzie grouped a number of conditions, which could result from abnormal development of the stapedial artery during intra-uterine development. ttiese conditions are transmitted genetically as a dominant gene with variable penetrance and they have as a common feature the possibility that deafness may exist. under the term 'first arch syndrome', mckenzie included such conditions as :1. the treacher-collins syndrome 1. the treacher-collins syndrome (mandibulofacial dysostosis). 2. pierre robin syndrome (hypoplasia fo the mandible with glossoptosis) 3. mandibular dysostosis. 4. deformities of the external and middle ear. 5. congenital deaf-mutism. 6. hypertelorism. 7. cleft lip and cleft palate. 8. waardenburg's syndrome. examples of these varied conditions are to be found among children attending this school.· the waardenburg syndrome. one child shows evidence of the condition. in its fully-developed form it is characterised by a grey forelock of hair, a white patch of vitiligo (depigmentation) on the forehead, eyes of two different colours (heterochromia of the irides) wide epicanthic folds and deafness. only one or other of these features may appear in individual members of an affected family (i.e. the condition may occur genetically with incomplete penetrance of the affected gene). in the one affected child attending the school, there [is heterochromia of the irides and deafness. | the association of deafness with various forms of ectodermal;dysplasia is also well documented in the.literature. at st. vincent's, one child has congenital absence of the auditory canals. another ; has a sibling bom with complete absence of hair, and a third has multiple congenital anomalies which include, among them, deafness, cataracts, and under-developed thumbs. there are four children with cleft palates. surveys among children with cleft palates show an incidence of deafness amounting to up to 20%. this may result from a number of causes. in some, the deafness and cleft-palate are different features of the same inherent genetic defect (e. g. 'the first arch syndrome'). in others, it follows an increased tendency towards middle-ear infection, occurring as a result of the defective swallowing mechanism and short eustacian tube which may accompany the condition. thus fifty-eight children attending the school acquired their deafness as a result of hereditary factors. this accounts for slightly more than a quarter of the cases. it would therefore be wise to study the family history, whenever cases of congenital deafness occur. genetic counselling prior to marriage could become a potent force in the prevention of the condition. in all certainty, no person with a family history of hereditary deafness should be encouraged to marry into another similarly affected family. infections. infections are a major factor in the aetiology of deafness. firstly, there are the acute inflammatory conditions affecting the middle-ear and spreading to the mastoids and inner-ear (7 cases). these conditions are eminently treatable during their early phase and should rarely progress to deafness in this era of antibiotics and surgery. such calamities do occur however. the very nature of their preventibility makes it im .erative that every ear infection either acute or chronic be treated vigorously. any deterioration in the hearing patterns as shown by an audiogram, should result in medical reassessment of the child by the doctor; because early treatment, whether by antibiotics or by surgery, may be an important factor in the conservation of maximum hearing. discharging ears must never be accepted as 'natural' and always require attention. the second group deserving attention are viral infections. these may affect the brain and cochlear apparatus. encephalitis (6 cases) may leave in its wake a terrible trail of brain damage and cochlear degeneration. a child's inability to understand and to speak after a severe encephalitis may often be ascribed to brain injury, but may 15 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) also be due to lesser or greater degrees of dysaudia. a number of common infectious diseases which are often considered harmless by lay persons, may be accompanied by similar neural damage. the damage caused by measles (1 case), gastro-enteritis (1 case) and pneumonia ( i case) are examples. the latter two (gastro-enteritis and pneumonia) may well have been local manifestations of general viral or bacterial infection affecting the cochlea or brain, -although vascular insufficiency may also play a part. a third group of infections the meningitides ' (19 cases are playing an increasingly common a third group of infections the meningitides (19 cases) are playing an increasingly common role. lives formerly lost from meningitis, are now being saved. a few, however, must pay for the privilege of life by surrendering their hearing. the organisms causing the meningitis may either affect the eighth nerve or the cochlea and deafness may ensue. tuberculous meningitis (3 cases) deserves a word on its own. streptomycin is the principal drug used in the treatment of tubercolosis. this drug may, however, cause a severe hearing loss when given in excessive doses. it is often difficult to know which factor has caused the deafness, i.e. the disease or the treatment. in the early days of modern anti-tuberculosis treatment, doses of streptomycin which today are considered excessive, were administered, and this was a significant factor causing deafness. today, streptomycin is given to thousands of patients suffering from pulmonary tuberculosis, without ill effect, so that it would appear to be the tuberculosis meningitis, itself, rather than the streptomycin which now causes the hearing defect. earlier cases, however, probably suffered hearing damage as a result of excessive treatment. a feature of meningitis which deserves mention is the suddenness with which deafness can supervene, and the still unaccountably long delays between the onset of the deafness, the diagnosis and subsequent treatment. such delays in early infancy inevitably cause loss of speech or retardation of language development. early therapy can do much to assist in the conservation of existing speech. infection may affect a child prenatally as well as postnatally. thus rubella during the first three months of pregnancy (5 cases) is now wellestablished as a cause of disordered teratogenesis. it may cause one, or a number of congenital abnormalities, including deafness, cataracts, microcephaly and congenital heart-lesions. no harm is done if the infection occurs after the sixteenth week of pregnancy. it is not, however, inevitable that rubella will cause deafness; and the incidence of deafness following infection of the mother during these critical weeks seems to vary from year to year. this variation is probably an expression of the vinilehce of the particular organism prevalent in any given epidemic. it is probable, too, that the critical time is not during the entire period of 16 weeks. it is confined to a much shorter period of intra-uterine development, for it has been shown that individual congenital defects can be produced experimentally by inflicting damage at definite critical periods ofgrowth. the concept that the growing foetus is defended from all harm during intra-uterine existence is now obsolete. infection may harm the embryo or foetus at any time during pregnancy. it is not feasible, therefore, that an apparently' minor infection affecting the pregnant mother could result in damage to the developing foetal auditory apparatus, and be responsible for a number of the cases so often diagnosed as 'idiopathic'? : drugs. the role of streptomycin has already been discussed. other drugs are also known to cause deafness: five injections of kanamycin given as treatment for boils at the age of six months resulted in deafness in one child. in another, deafness followed malaria, and it is surmised that this was probably the result of quinine therapy. cerebral palsy. only five children attending the school are also suffering from cerebral palsy. these five probably do not represent the total incidence of cerebral palsy as a cause of deafness, since a number of cerebral palsied deaf children are being treated in johannesburg, at the forest town school for cerebral palsied children. this group of children has been reviewed recently. among the five cerebral palsied children attending st. vincent's three have been diagnosed as spastic, and two are reported as having' followed kernicterus. it is apparent from the survey at; forest town that kemicterus (bile staining the basal 16 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ganglia at birth, occurring in excessively jaundiced babies) is the commonest caust of deafness among the cerebral palsied, particularly among the group of children who are athetoid. anoxia at birth (2 cases) is another factor and is also probably the cause in a number ,of children who are both spastic and deaf. prematurity is often cited as a cause of deafness. in this series 3 cases were recorded as being due to prematurity, although, without knowing the birth weights of the entire series, it would be unwise to give this statistical significance. in a series studied recently in newcastle however, prematurity was not a significant however, prematurity was not a significant factor nor was it in wolman's series. it is probable nor was it in wolman's series. it is probable that many cases previously attributed to prematurity alone were actually cases of kernicterus of prematurity, followed by deafness, and that others were due to birth injury and anoxia associated with prematurity. one hopes that here too, preventative and therapeutic measures will eventually be effective. two children in the school suffer from epilepsy (i.e. about 1%). this is the average incidence of epilepsy for any population, so that significance cannot be attributed to this association. it is, however, interesting to speculate whether the factor causing the epilepsy be it hereditary or acquired also caused the deafness. trauma was the probable cause in two cases. the largest group still consists of children in whom no cause is apparent. these cases are referred to as 'congenital sporadic deafness' or 'idiopathic deafness'. when diagnostic methods improve, and as research reveals hitherto unknown reasons for deafness, this group will diminish proportionately. it is probable that out of these 92 children, there are some with recessive genes for deafness, where family histories are not sufficiently! well known to reveal other cases of deafness in [the family. other cases may well be due to kerni'cterus, the diagnosis having been missed at the time of damage since the conditions was less well known a number of years ago. one wonders how many cases of 'idiopathic' congenital deafness are due to intra-uterine drug toxicity when ototoxic drugs have been administered during pregnancy. the recent thalidomide disaster (where it was shown that thalidomide administered to pregnant mothers caused limb and other defects), and a parallel example in the known relationship between rubella and deafness, make it very likely that a casual relationship between deafness and other drugs that have been administered to pregnant mother, will eventually administered to pregnant mothers, will eventually be found to exist. what do we learn from this survey? we learn of children whose deafness arose from preventible conditions, and we learn that deaf-ness is often present from birth. increasing awareness of the causes of deafness should assist in preventing many cases. a few well-chosen quesr tions can often identify a child who has been subject to the known factors causing deafness (i.e. to identify the children as having been 'at risk'). the fact that deafness, when present in childhood, usually dates from birth, should make us watchful for its presence from earliest infancy. wherever and whenever possible, the condition should be diagnosed before the age of two years. in this way treatment by amplification with a hearing aid and audiotherapy may be started at an early age. summary. records at the st. vincent's school for the deaf in johannesburg were analysed, and the causes of deafness were enumerated. 209 children were included in the analysis. the remaining 12 children have been termed 'aphasic' and were therefore excluded from the study. the following factors as causes of deafness were discussed: hereditary causes, infection, drugs, perinatal causes. trauma, miscellaneous and congenital sporadic deafness. this analysis represents an overall guide to the causes of severe deafness in children of school-going age. 17 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) opsomming. verslae van die st. vincent's skool vir dowes in johannesburg is ontleed om die oorsake van doofheid vas te stel. 209 kinders is in die studie ingesluit. die orige 12 kinders, wat as 'asfasies' bestempel is, is uitgesluit. die volgende faktore is as oorsake van doofheid bespreek: oorerflike oorsake infeksie, verdowingsmiddels, trouma, diverse en aangebore sporadiese doofheid. die ontleding kan beskou word as 'n algemene gids tot die oorsake van hoegraadse doofheid by skoolgaande kinders. references. 1. mckenzie j. (1958) the first arch syndrome. arch. dis. childh. 33 477-86. 2. digeorge a.m., olmstead r.w., harley r.d. (1960). 'waardenburg's syndrome'. j. pediat 57. 649-699. 3. robinson g.c., miller j.r., & bensman j.r. (1962). 'ectodermal dysplasia with sensori-neural deafness and other anomalies'. paediatrics 30. 797. 4. swan c., tostevin a.l., moore b., mayo h., & barham black g.h. (1943). 'congenital defects in infants following infectious diseases during pregnancy'. med. j. aust. (ii) 201. 5. liggins g.c., phillips l. i. (1963) 'rubella embryopathy'. brit. med. j. (i) 711. 6. clayton jones e. (1947) 'rubella as a cause of congenital deafness in england'. lancet 252 1 56-61. 7. hatchuel w. (1962). 'the importance of performing adequate hearing tests in children with cerebral palsy. s.a. med. j. 36. 13. 237. 8. hatchuel w. & jacobs r. (1963) 'hearing loss in cerebral palsied children'. paper read to the paediatric section of the 44th congress of the s.a. medical association. in publication. 9. barton μ.e., court a.d. & walker w. (1962). 'causes of severe deafness in school children in northumberland & durham'. brit. med. j. (i) 351. 10. wolrnan b., (1963) 'deafness in children'. arch. dis. childh. 38. 375. 11. whetnall e. (1956) 'discussion on the management of deafness in young children'. proc. r. soc. med. 49. 455. 18 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 saloshni moodley, sandhya chetty and jenny pahl the school-based speech-language therapist: choosing multicultural texts saloshni moodley, sandhya chetty & jenny pahl disciplines of audiology and speech-language pathology school of therapeutic and rehabilitative sciences university of kwazulu-natal abstract school-based speech-language therapists have a pivotal role in the transformation of education as directed by current education policy. the revised national curriculum statement, for example, foregrounds a multicultural perspective in education, which impacts on the choice of learning and teaching support materials. inappropriate support materials could create barriers to learning. folktales were selected as an example of multicultural learning and teaching support materials. the responses of 10-year-old mainstream learners to five folktales reflecting a diversity of cultures were explored. five girls and five boys in grade 5 participated in the study, which was conducted in three phases. a questionnaire, a focus group interview, and audio-visual recordings were used to gather data. the qualitative method of constant comparison was used to analyse emerging themes. five main themes were identified. findings revealed that some participants responded most positively when folktales reflected their culture, gender, or physical characteristics. participants' views on less familiar cultures were influenced by the mass media. the results highlighted the importance of the text as 'mirror' and as 'window'. the potential of folktales as multicultural learning and teaching support materials, the powerful influence of the educator on learners' responses, and the need for an anti-bias approach within education are discussed. implications for future research and practice are highlighted. key words: speech-language therapist, educator, cultural diversity, folktales, multicultural learning and teaching support materials, barriers to learning, anti-bias approach introduction the department of education employs a number of speech-language therapists to render speech and language therapy services within schools. these speech-language therapists are regarded as educators and registration with the south african council of educators (sace) is mandatory. an 'educator' is defined as "any person... who provides professional educational services, including professional therapy... at an institution" (education labour relations council [elrc], 2003, p. e3). within this article, the term 'educator' therefore refers collectively to the speech-language therapist and the teacher. a number of policy documents seek to transform the south african education system into one that is unbiased, inclusive, and multicultural. at present, the most pertinent documents are education white paper 6 on special needs education (department of education, 2001) and the revised national curriculum statement grades r-9: schools (department of education, 2002a). the principles espoused in these documents present a challenge to all schools and educators to change their thinking and their practice. while the revised national curriculum statement (rncs) outlines a multicultural curriculum for grades r to nine, education white paper 6 is focused on restructuring the current dual system of education, which segregates learners on the basis of disability. at present, learners who are identified as having.special educational needs (e.g. physical disabilities; specific learning difficulties) are removed from the mainstream sector and placed within 'special schools'. thus only a small percentage of learners are receiving specialised support and education (department of education, 2001). the white paper, however, acknowledges that all learners need support, and hence support should be provided in all classrooms to ensure the full participation of all learners. it has therefore introduced a key shift away from focussing on the intrinsic problems of learners, to identifying and minimising barriers to learning. a barrier to learning is anything that hinders the learning and development of a learner. such barriers could thus be societal (e.g. poverty), systemic (e.g. an inflexible curriculum), or located in the learner (department of education, 2001). educators are expected to fulfil the important responsibility of addressing barriers to learning when implementing the rncs. this implies that the classroom environment, teaching strategies, and learning and teaching support materials, for example, must be adjusted to respond to learner diversity within every classroom. this transformation, which is needed so that the existing resources can be used optimally (department of education, 2001), has implications for the present role of the school-based speechlanguage therapist. j within an inclusive education system, the speechlanguage therapist will have a consultative and collaborative role in district-based and institution (school)-based support teams (department of education, 2001). support has been redefined in the white paper to encompass training, mentoring, monitoring, and consultation. as part of the support team, the speechlanguage therapist will help to develop strategies to identify and manage barriers to learning at learner, educator, curriculum, and institutional levels (department of education, 2001). they also have a responsibility to interpret the rncs, as it is pertinent to their redefined role in curriculum delivery. a perusal of the rncs reveals that the-speech-language therapist would be most involved with curriculum delivery within the literacy learning programme, which focuses on language acquisition, language development, and communication. it has been well documented that reading or telling stories to children within the home and the classroom promotes language development (champion, katz, muldrow, & dail, 1999; galda, ash, & die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the school-based speech-language therapist: choosing multicultural texts 41 cullinan, 2001; owens & robinson, 1997). story reading can also be used as an intervention tool (champion et al., 1999; owens & robinson, 1997) to improve listening skills, vocabulary, literacy skills, language comprehension, and verbal expression (owens & robinson, 1997). furthermore, the rncs acknowledges that "listening to stories is also part of the foundation for literacy" (department of education, 2002c, p. 9). thus an integral part of one's role as a school-based speech-language therapist could be the use of story reading to address the needs of multiple learners in the classroom. within such a learning programme, sharing children's literature with the learners would involve much more than merely reading aloud. rather, it would be an interactive process where the speech-language therapist would facilitate each learner's participation and comprehension by asking and answering questions, responding to the learners' comments, and relating learners' responses to their life experiences. while it is important to consider how children's literature would be used within the classroom, it is also pertinent to reflect on what type of literature would be selected. booysen (1996) claims that reading aloud to children within the classroom gives educators the opportunity "to introduce children to quality literature" and enables children "to recognise that reading good literature is something which adults prize" (p.411). it can be argued that the type of literature that one would regard as 'quality or good literature' would be strongly influenced by the one's personal preferences. according to outhwaite (1994) school-based literacy in south africa continues to reflect western middle class values, beliefs, and norms. this implies that anglo-centred literature and the english language are valued (lemmer, 1996). given the linguistic and cultural diversity of learners and the multicultural perspective promoted by the rncs, choosing literature that continues to reinforce anglo-centred cultures could act as a significant barrier to learning. research has shown a strong link between culture and learning (nieto, 1996). learners who do not see a reflection of themselves in their schooling may feel that they are not valued by the educator, the school, or society (montgomery, 2001). learners may become dissociated and, resistant towards a curriculum that alienates them (gardner, 2001) which may impact negatively on their school performance. furthermore, cultural identity serves an important function in people's lives as it facilitates a sense of peoplehood (schultz, 1995) and enables the individual to answer the question "who am i?" all educators must acknowledge that they direct learners towards particular actions, values, and language, through the learning materials (e.g. stories) they present in the curriculum. thus there is a pressing need for a transformation to a multicultural perspective as cultural dissonance between the school and culturally diverse learners could create a barrier to learning. the term 'culture' refers to the values, beliefs, and behaviours, traditions, symbols and ideas that are shared by a group of people (kavanagh & kennedy, 1992; locke, 1992). it includes explicit features (e.g. language and dress) and implicit features such as attitudes and family relationships (kavanagh & kennedy, 1992; locke, 1992; nieto, 1996). the term 'multicultural' therefore encompasses the diversity of cultures or subcultures that exist within a given society. as ford (1999) states: "... a multicultural perspective indicates a transformational change from the dominant eurocentric perspective shaped through socialization... to an inclusive view of multiple perspectives and multiple realities" (p. 14). advocates of multiculturalism in schools support the inclusion of multiple perspectives and an attitude of social justice within education (willis <fc johnson, 2000). they believe that this will enrich education and enable learners to understand issues related to difference, dominance, power and privilege (locke, 1998). these beliefs are fundamental to the rncs. both education white paper 6 and the rncs emphasise that educators have a responsibility to accommodate and manage diversity by providing a flexible curriculum that can be accessed by all learners. while it is acknowledged that the educator has to review all aspects of the curriculum for a multicultural perspective, the focus of the discussion is on the learning support materials (viz. stories) used within the curriculum. the discussion has emphasised that a bias towards learning and teaching support materials that reflect only anglo-saxon english-speaking cultures, would encourage learners to view the world from only one perspective. it would exclude the multiple realities and perspectives of learners. the educator has an important role in fostering the learner's thinking about literature, culture, and diversity (althanases, 1998). by carefully selecting the literature that is used as learning and teaching support materials, speechlanguage therapists could provide learners with opportunities to view or take part in the lives of people from diverse cultures and with different or similar life experiences. a number of authors (bieger, 1996; gillespie, powell, clements, & swearingen, 1994; sims bishop, 1992) have highlighted multicultural literature as a valuable tool in providing multiple perspectives within the curriculum. gillespie et al. (1994) have pointed out that multicultural literature has an important role to play in developing three perspectives that are pertinent to a multicultural society. multicultural literature can show us how we are connected through common experiences, needs, and desires; it can help us to celebrate the cultural differences that enrich society, and it can help us to understand how social and political forces affect our lives. these outcomes are closely linked to the overall contribution of the languages learning area to the curriculum, namely, to encourage "intercultural understanding, access to other views, and a critical understanding of the concept of culture" (department of education, 2002b, p. 7). thus educators need to make informed choices about the types of multicultural literature that would be appropriate as learning and teaching support materials. 'multicultural literature' refers to literature such as stories, poems, prose, and plays that reflect the multiple values, experiences, and perspectives of various cultural groups. taylor (2000) describes multicultural literature as literature that focuses on people whose histories, contributions, and identities have been undervalued, distorted, or omitted in the school curriculum and society. any 'multicultural literature programme' should reflect the principles of inclusiveness and the deconstruction of stereotypes. the speech-language therapist who wishes to function within the tenets of the south african department of education (2002b) needs to examine which type of storybooks with multicultural themes would be a suitable vehicle for the promotion of multicultural awareness and understanding. the rncs (2002b) echoes views stated in the literature that educators have to provide learners with opportunities to make connections, and to celebrate the differences and similarities among humans (sims bishop, 1992). using stories about different cultures, it is believed, will facilitate tolerance and understanding (booysen, 1996). folktales have been recommended as a good springboard (booysen, 1996) for discussions about different cultures as they are said to be reflective of their culture of origin (bieger, 1996; sims bishop, 1992). it has been suggested that all children enjoy folktales or stories set in other cultures and times (wade, 1990, cited in booysen, 1996). folktales are fictional stothe south african journal of communication disorders, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 saloshni moodley, sandhya chetty and jenny pahl ries that do not have a particular location in space or time, and either concern royalty or common people, or animals behaving like people (rosenberg, 1997). they are ideal for 'read-alouds' because they originate from the oral tradition (bieger, 1996). there is an extensive body of research that investigates learner response to multicultural literature in linguistically and culturally diverse classrooms (althanases, 1998; galda et al., 2001; jordan & purves, 1993; naidoo, 1992; webster, 2001; willis & johnson, 2000). these researchers used multicultural literature that was either overtly inter-racial, depicting diverse children interacting with each other, or that aimed to show how to cope with racism and discrimination. stories like folktales, which do not focus on integration but aim to show the distinctive experience of belonging to a specific cultural group (sims bishop, 1992), were not used. the studies mentioned above focussed on the responses of high school learners in the usa and britain. thus there is a paucity of research on learners' responses to folktales even though folktales have been described as a rich source for developing understanding about cultural diversity. there also appears to be a lack of south african studies and a lack of studies using primary school learners. consequently, there is a need to explore the phenomenon of learners' responses to folktales as one type of multicultural literature. the purpose of this study was therefore to explore primary school children's responses when folktales reflecting a diversity of cultures were read to them. the findings would contribute to the body of knowledge available on children's responses to culturally diverse literature. based on her research findings, saccardi (1994) proposed that children's responses to books could enable educators to make wise choices when selecting books for use with children. thus the information from the present study could inform educators on how best to handle multicultural practice and how to address possible barriers to learning within the curriculum. methodology aim to explore the responses of a group of ten-year-old learners within mainstream education when folktales reflecting a diversity of cultures were read to them. critical questions. what were the participants' responses to the folktales? why did the participants have these responses to the folktales? research design in the study, the term 'response' included written and spoken responses, spontaneous responses such as laughter, and non-verbal responses such as nodding to show agreement or shrugging as a sign of doubt or indifference. a qualitative approach best enabled the researcher to gather data that represented 'responses' as defined in this study. researchers using a qualitative approach gather data, in the form of written or spoken language, by interacting personally (pidgeon, 1996) with participants. they attempt to understand or discern phenomena "in terms of the meanings people bring to them" (mcmillan & schumacher, 2000, p.395). the present researcher supports the interactive nature of qualitative research where the researcher interacts with each participant as an individual. this interaction closely resembles the relationship between the educator and the learner. furthermore it is deemed 'good practice' for researchers to provide clarification of their methodological stance, as it is believed that the researcher's ideology influences the research. the present researcher agrees with denzin and lincoln (1998) that qualitative research is a multicultural process because it is shaped by the gender, racial, ethnic, and cultural perspective of the researcher. denzin and lincoln also stress the intimate relationship between the 'multiculturally situated researcher' and the focus of the research. in addition it is crucial for the researcher to understand the political and socio-cultural dynamics of the research context because such dynamics also impact on the data collected within that context. it is within these beliefs that the study attempted to describe and explore learners' responses to culturally diverse folktales. the research design for the study was based on grounded theory (glaser & strauss, 1967, as cited in pidgeon, 1996). a grounded theory research design has certain distinguishing characteristics. the data collection and analysis phases of the research occur simultaneously. the researcher can move between the two phases and the emerging analysis shapes the data collection procedures. the researcher creates analytic codes and develops categories from the data, not from preconceived concepts. furthermore there are specific methods of data analysis available to the researcher, for example, constant comparison and theoretical sampling (pidgeon, 1996). based on the characteristics of a grounded theory research design mentioned above, the present study was originally structured into two phases. during phase 1, four folktales were read aloud to the participants and the participants answered a questionnaire about their responses to each folktale. phase 2 consisted of a focus group interview. based on the data that emerged during phase 1, a third phase was added to enable the researcher to collect more data on emerging questions and themes. this change is in keeping with the flexible nature of a grounded theory research design, which enables the researcher to collect additional data and follow up on questions. research site the site in question was an urban primary school catering for mainstream learners and learners with special educational needs (lsen). the site was selected because the population of learners at the site represents a cross section of learners in terms of socio-economic status, race, culture, and language. furthermore, the results would inform the researcher's understanding of how the educational policies regarding multiculturalism and literacy may be applied to the practice of speech-language therapy within education. < j participants ' participants had to be ten-year old, fifth, grade 'mainstream' learners at the research site. research by lemmer (1988) and sims (1983) showed that it was possible to successfully interview ten-year old learners on their responses to storybooks. there is also a paucity of research with this age group (sims, 1983). ten-year olds were therefore selected for the study. learners in mainstream grade 5 classes were selected because the department of education (2002b;. 2002c) highlighted that learners in grade 5 can be expected to ask and respond thoughtfully to critical questions that do not have obvious answers; to express and justify their own opinions with reasons; and to understand how interviews work as a means of obtaining information. the teachers of the grade 5 classes were asked to identify learners who would be able to follow grade-appropriate instrucdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the school-based speech-language therapist: choosing multicultural texts 4 3 dons, read a questionnaire and record answers legibly, and participate in a group interview, all within the medium of english. lsen were excluded as their specific difficulties with receptive, expressive, and written language would affect their ability to read the questionnaire, record their answers in writing, and express themselves verbally during the focus group interview. naidoo (1992) found that the girls in her study responded more frequently during small group discussions than whole class discussions. in light of naidoo's finding and considering that the sample in the present study would need to be of a manageable size for the focus group interview in phase 2, the researcher decided that a sample of 10 learners would be appropriate for the study. furthermore, an equal number of boys and girls were needed to control for possible gender bias. the subsequent list of names identified by the teachers was divided into two groups according to gender. five girls and five boys were randomly selected from these groups. all the learners who had been selected were willing to participate in the study and written informed consent was obtained from their parents, see appendix a for a profile of the participants. folktales the folktales had to fulfil the general criteria for authentic and accurate multicultural literature outlined in appendix b. webster (2001) pointed out that similarities between the cultural backgrounds of the participants and the texts might hinder the participants from 'entering the story'. thus the researcher wished to minimise participant discomfort and enable each person to respond and comment without feeling that his or her culture was being criticised. folktales that were culturally, historically, and geographically distant to the participant and that did not mirror the culture of any specific participant were therefore deemed suitable for this study. the folktales had to highlight the theme of family relationships, which are an implicit feature of the concept of culture (locke, 1992). four folktales, from russia, china, czechoslovakia, and cambodia were selected. these folktales were distant to the cultures of all participants and were read to them during phase 1. data collection instruments a questionnaire schedule (appendix d) and an interview schedule (appendix e) were used to collect the data. the questionnaire schedule comprised a total of nine questions, with both open-ended questions and dichotomous-response questions (mcmillan & schumacher, 2000). the researcher developed the questionnaire specifically for this stydy, by drawing from saccardi's (1994) project on children's responses to books in general and jordan and purves' (1993) research on reader's responses to culturally diverse texts. saccardi (1994) categorised children's evaluations of the books they had read or listened to, according to a framework that included the children's feelings about the books, their reasons for liking or disliking a book, what the books reminded them of, and their judgements of the books. jordan and purves (1993) examined the data obtained in their study according to a set of questions within four categories namely, expectations, judging, stereotyping, and interpreting. the present researcher generated questions for the questionnaire in this study by using jordan and purves' (1993) categories and saccardi's (1994) framework. for example, under the category of judging, saccardi, and jordan and purves looked at the reasons that participants gave for liking or disliking a text. the present researcher used this information to frame questions 1 (what did you like about the story?) and 2 (what didn't you like about the story?) on the questionnaire. questions 1 and 2 would, for example, elicit a descriptive response from the participants. the reasons for these responses would be explored further during the focus group interview in phase 2. procedure pilot phase once ethical clearance was obtained from the university of durban-westville's research committee, a pilot phase was conducted. the aims were to familiarise the participants with the data collection procedure for phases 1 and 2, and to determine whether they would be able to listen and attend for the duration of the session, to understand and complete the questionnaire, and to participate during a group interview. the researcher read an illustrated storybook titled 'herb, the vegetarian dragon' to them. all 10 participants were able to concentrate adequately, to read and understand the questions and to record their answers in writing without any difficulty. the questionnaire was therefore not revised. participants were also able to take turns when answering the researcher's questions during the group interview. phase 1. this phase consisted of four sessions, one for each folktale. during each video-recorded session, a different folktale was read aloud to the participants. before reading the folktale to the participants, the researcher explained the vocabulary that may have been difficult or unfamiliar to them and answered any questions that they asked about the vocabulary. they were asked what their expectations were of the folktale, based on its country of origin. thereafter, the folktale was read aloud and the participants were shown the illustrations at appropriate points in the story. the participants then gave written answers, via a questionnaire, about their responses to that folktale. the researcher read through each completed questionnaire once they were handed in and asked for clarification from respondents where necessary. this strategy was adopted as a form of 'member checking', which was used to enhance design validity (mcmillan & schumacher, 2000). in addition, the use of the same data collection methods (viz. audio-visual recorded observation and self-administration of the questionnaire) on different occasions is a type of methodological triangulation used to verify the findings of the study. the transcribed data from the video-recordings and the completed questionnaires were analysed after each session. based on the analysis of the data from the questionnaires and transcripts, the focus group interview schedule was constructed. phase 2. using the focus group interview schedule (appendix e), the researcher conducted the 60-minute interview with all ten participants. the session was video-recorded. the transcription of the interview was analysed. phase 3. the russian and chinese folktales were presented as planned during phase 1. participants were able to say what they would expect from these folktales. when the czechoslovakian folktale was introduced to the participants, they did not know what to expect from such a folktale. their uncertainty may have been due to their unfamiliarity with czechoslovakia. the folktale was possibly "too distant" from their experiences. it was determined that, by this stage of the data collection, each participant appeared to be quite aware that folktales were inherent to all cultures and therefore might not be uncomfortable with an african folktale. thus it was included in a third phase. the south african journal of communication disorders, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 4 saloshni moodley, sandhya chetty and jenny pahl data analysis multiple data sources were used, namely, transcribed data from the video-recordings of the story-telling sessions, written responses to the nine questions on the questionnaire; one completed questionnaire per participant for each of the five folktales, transcribed data from the video-recording of the focussed group interview, and the researcher's reflective journal and field notes. the presence of related themes in the data collected from multiple sources enhanced the credibility of the interpretation. the method of constant comparison (mcmillan & schumacher, 2000) was used to analyse the data. the first step in this process involved line-by-line coding, which entailed studying each line of the data and providing a topic or descriptive name. the second step involved focused coding, where the researcher chose a limited number of topics, which reappeared often in the initial line-by-line coding, and used these to sift through the data. by comparing and contrasting the topics, the researcher was able to organise the topics into categories and identify patterns of similarities among the categories (mcmillan & schumacher). when identifying themes and subthemes in the data, 'member categories' and 'researcher categories' were used (mcmillan & schumacher). member categories represented the data from the participants' perspective while researcher categories represented the meaning of the phenomenon to the researcher (mcmillan & schumacher). results and discussion five main themes were identified as follows. • the family • retribution • the influence of mass media on our cultural knowledge and worldviews • texts as 'mirrors' • children's views on the purposes of stories as all the folktales focused on the broad theme of family relationships, the first theme emerged as a result of the nature or content of the folktales. the second to fourth themes represented retable 1. the influence of the mass media on cultural knowledge: searcher categories while the fifth theme was a member category derived directly from the participants' responses. in the ensuing section, only two of the main themes, namely, 'the influence of the mass media on our cultural knowledge' and 'texts as mirrors', will be discussed. the reader is referred to moodley (2003) for a detailed discussion of the other themes and related subthemes. the possible reasons for the participants' responses in relation to these two themes will be explored. in addition, the implications for future research and practice will be highlighted. finally, the study will be critically evaluated. the influence of the mass media on our cultural knowledge the participants' responses to the folktales underscored the powerful influence of the mass media on our cultural knowledge and views of the world. participant va (see appendix a), for example, expected the russian folktale to be about 'red indians' because the illustrations showed the characters wearing moccasins, clothing made from soft buckskin with fringes and beadwork, and feathers in their long, plaited hair. that is, they were dressed in a manner similar to the traditional portrayal of native americans in the mass media. furthermore, the participants expected the chinese folktale to be about martial arts, possibly because cinema and television tend to emphasise that aspect of chinese culture. mass media has been cited as one of the ways in which children learn stereotypes and acquire cultural knowledge (gay, 2002; ford, 1999). for many learners, mass media is the sole source of information about cultural diversity and what is viewed on television is more striking and persuasive than what is discovered from books or classrooms (gay, 2002). the participants' responses showed that there were several reasons why they preferred television as a source of information. participants regarded television as more entertaining than books and believed that it gave one a 'better idea' or clearer picture of the culture and people. they stressed that the information conveyed on television was more memorable than that in books. the participants' responses in table 1 further emphasise the persuasive influence of the mass media. i excerpt from the focus group interview j res: now if you spit in somebody's face it means.. .do you know what it means? j | ml: saying goodbye. miss.. .because miss i once watched a jim carey movie and when they greeted each other they spit at each other. res: they did? which country was the movie in? i ml: i saw it on a jim carey movie one or two. i ι res: if it's a jim carey movie, do you think they really do things like that? ml: it's a culture miss. it's a culture. res: it's about a different culture? voices: yes, miss. res: which culture is this? ce: they want to say hello. res: by spitting? ce: yes, miss, (other participants said 'yes' in the background) ml: because miss, we can say hello and goodbye miss, they can't note: the spitting incident occurred in the russian folktale. the goldsmith spat in the shaman's face to show his disgust at the shaman's behaviour. res = researcher die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the school-based speech-language therapist: choosing multicultural texts 45 based on what he had seen in a movie, ml believed that spitting was a way of greeting and part of the 'culture' of the group portrayed in the movie (see table 1, lines 2 & 6). ce and the other participants agreed with ml (lines 10 & 12). these responses underscore the power of mass media, especially as the participants embraced what was seen in the movies as the truth. similarly, beach and freedman's study (as cited in benton, 1999) confirmed the tendency of learners to blur reality and fiction when discussing images portrayed in the mass media. thus the messages transmitted via the mass media are extremely influential and should not be ignored as much of this information is inaccurate and often prejudicial (gay, 2002). other authors concur. banks (2001) has discussed how the mainstream media in the usa has controlled the construction of the native american identity. it is important to remember that south african children are exposed to films that are produced mainly in the usa or the uk that reflect the values and perspectives of scriptwriters and producers from those societies. for example, even the popular animated film 'the lion king', which might be regarded as an african story, was produced in the usa. one could therefore argue that the mainstream film and television media in the usa also exert a tremendous influence on south african society. va's expectation that the russian folktale would be about 'red indians' and the references to 'jim carey movies' in table 1, illustrate this influence. these examples confirm the importance of media literacy within the rncs, where the ability to recognise the influence of radio, television, film, and advertising on people and societies is an important learning outcome. texts as mirrors it was suggested earlier that cultural dissonance between the leaner and the text, for example, would present as a barrier to learning. learners "need to locate themselves, their life and learning experiences, culture, values, language and physical characteristics within the books they are exposed to at school" in order for them to relate to school and the school culture (taylor, 2001, p.24). this implies that texts must act as mirrors that reflect learners' lives. several authors (bieger, 1996; cairney, 1995; sims bishop/1992) have recognised the importance of literature as 'a mirror'. those who see their own experiences reflected in literature or in texts are affirmed (bieger,1996; sims bishop, 1992). in exploring the importance of the text as mirror, the discussion will focus on the responses of participant nq to the african folktale. nq's response to this folktale was distinctive from her responses to the other folktales. the african folktale was the only one of the five folktales that she would recommend her friends to read. it was evident from the researcher's analysis of the videorecordings, from comments recorded in the researcher's reflective journal, and from nq's responses on the questionnaires, that nq found most of the folktales uninteresting. on the video-recordings of phase 1 nq appeared distracted when the folktales were read out to the participants. she did not focus on the researcher while the story was read and would either shrug or smile when asked for her opinion during the discussions. the researcher, also observed these responses during the reading of the cambodian folktale even though nq described this folktale as 'not boring'. there was a noticeable difference in nq's attentiveness and responsiveness to the african folktale (see appendix c for a synopsis). at times, she leaned towards the researcher while listening and she provided a spontaneous verbal response for the first time (see table 2, line 6), during the discussion of the african folktale. table 2. excerpt of written and spoken responses to the african folktale part a: written responses to the question 'how did the story make you feel? why?' ch: bored. no humour. ni: bored. very bored. because it was not interesting. nq: happy. because it was nice. sn: happy, 'cos it was exciting. va: happy. it was nice and interesting. part b: spoken responses nq: it's nearly the same story. cinderella also married the prince. res: why did you think that story was 'nice'? nq: because it was an african story. res: was that because it had things that were familiar or because it was set in africa? nq: it was set in africa. res: va, why did you think the story was nice? va: because it was about a girl. i liked about nyasha. note: res = researcher it can be asserted that nq responded positively to the african folktale because she was able to locate herself, her physical characteristics and language (taylor, 2000) within the folktale. jordan and purves' (1993) research suggest that some learners were hesitant about entering the story realms of other cultures. in addition, they found that cultural differences between the learner and the text also hampered the close identification of the learner with the text. thus one cannot ignore the possibility that the cultural distance between nq and the first four folktales may have presented a barrier to her participating to a greater extent in the discussion of the folktales. the participants' identities in terms of their gender, race, culture, family background (see appendix a), and personalities, influenced their responses to the folktales. it is possible that nq related to the main characters in the african folktale because they were female. this was va's reason for liking the story (see table 2, line 12). the comments in table 2 highlight that three of the five female participants in the study responded positively to the african folktale. these three participants (nq, va & sn) were also the most similar to the main characters in terms of 'race' and home languages, which may have maximised their participation in the discussion. the results have gender implications as the text as mirror appeared to be of special significance to these three participants. naidoo (1992) emphasised the need to create opportunities for girls' voices to be heard along with boys' voices. in a similar vein, the department of education (2002a) stresses that it is important to free the potential of girls and boys. it appears from the results that, by selecting texts that girls can identify with, one can create the impetus for them to participate more actively in the discussion of texts. during the focus group interview ce stated that he found it difficult to understand "different things" and agreed that he prethe south african journal of communication disorders, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) saloshni moodley, sandhya chetty and jenny pahl ferred stories about people who were similar to him. when children are allowed to choose texts independently, they tend to choose texts that reflect their own culture and interests, and are therefore familiar (bieger, 1996). other researchers have also discovered that learners preferred stories of their own culture (e. g. altieri as cited in webster, 2001). the department of education (2003) notes that issues of identity become increasingly significant to learners in the intermediate phase (grades 4 7 ) and educators need to consider the relationship between language, culture and identity. establishing a sense of personal identity is an important theme in children's lives. it has been suggested that each person has three identities (locke, 1998). we have a global identity because all of us belong to the human race; a shared group identity as we belong to a cultural group or groups; and a unique personal identity as each of us differs from the other because of our unique experiences (locke, 1998). it is important to be aware that membership of a cultural group impacts on personal identity (locke, 1998), which may be why ce indicated a preference for stories about people who were similar to him. implications for future practice and research the literacy learning programme is intended to create opportunities for each learner to understand and value their culture and identity, and that of others (department of education, 2003). educators need to realise that the learning process is never value free. power relations and ideology are ever present in the curriculum (gay, 2002; shor, 1999) and therefore to educate is to encourage learners in a given direction. this implies that as a facilitator of learning, one would need to discern when to accept learners' comments and when to explore their points of view. in addition, one would need to make learners aware that a point of view is not the truth, which is closely linked to facilitating the development of critical literacy and critical thinking. a strategy that would enable one to facilitate critical thinking amongst learners is an anti-bias approach to education. such an approach promotes transformation, as there is increased awareness of how oppression and bias serve as barriers to learning (elrc, 1997) for the learner and the educator. like all educators, the speech-language therapist needs to think carefully about the power that he or she has to influence the lives of learners. it is acknowledged that the speech-language therapist's focus on language learning and remediation through story reading is important. however, the discussion has focussed on how the types of learning and teaching support materials influence the response of the learner. the speech-language therapist therefore needs to have a broader focus and consider the impact that his or her choice of text has on the learner. nq's responses to the african folktale in particular highlight this point. learners are influenced by their literary experiences, which could provide educators with opportunities to nurture learners' selfesteem, cultural sensitivity and critical thinking. educators need to lay the foundation skills for critical thinking during grades 1 to 3. the speech-language therapist in schools and the teacher can begin this process by asking the right questions, such as 'who is the story about? whose point of view is reflected in the story?' educators are ultimately responsible for choosing texts and therefore need to be aware of the values portrayed in their choices. texts used solely to promote language learning would still need the educator to determine if the chosen texts promoted negative stereotypes or affirmed some cultural groups at the expense of others. such texts may create a barrier to learning for some learners. some of the folktales that were selected for this study failed to capture the interest of the participants or to stimulate their active participation during the discussion. not all participants responded in the same way and there needs to be an awareness of this level of diversity. an interesting area for further investigation would be learners' responses to other kinds of multicultural texts such as plays or poems. such information would augment our knowledge of different multicultural learning and teaching support materials. some speech-language therapists and teachers may disagree with the need for a multicultural, anti-bias perspective. however one must avoid the trap of believing that a multicultural perspective is only necessary when there is a diversity of learners in terms of race, culture or language. "an unbiased inclusive perspective can and should be present whether or not people of color are present" (hooks as cited in ford, 1999, p. 195). change begins with the educator. few educators have been trained to work with learners in a democratic style within multicultural and multilingual contexts (elrc, 1997). most educators currently active in south african schools were taught within a system of apartheid education and were raised during a divided, oppressive, and authoritarian era. the educators' schooling and life experiences have impacted on their identities, perceptions and beliefs, and their assumptions about learners and about themselves. consequently, "a conscious and definite strategy is required to bring about the paradigm shifts necessary to enable us to create a new society in which all differences and similarities amongst people are recognised, appreciated and drawn upon" (elrc, 1997, p. 7). every educator therefore should adopt an anti-bias approach to education. a further area of investigation would be to determine the type of facilitative skills that speech-language therapists and teachers require when using texts to promote critical literacy and critical thinking within an anti-bias approach. speech-language therapists also have a vital role to play in enabling lsen in 'special schools', to achieve the same learning outcomes as learners in the mainstream learning context. educators may believe that by focusing on the use of multicultural texts to foster critical literacy and critical thinking skills, the speech-language therapist would be trespassing on the domain of the teacher. educators may believe that this is beyond the: speechlanguage therapist's scope of practice because the speech^ language therapist usually has focused on language-learning difficulties. however, in order for the changes mandated by education white paper 6 and the rncs to be implemented successfully, all speech-language therapists and teachers need to consciously change their attitude towards their roles and responsibilities. educators can no longer afford to work in isolation. collaboration and consultation are crucial if speech-language therapists and teachers are to provide an equitable, inclusive and cost effective service (department of education, 2001) to all learners. a critical evaluation of the study every researcher has to make methodological choices when designing a research study. two of the researcher's.decisions may have constrained the results of the present study. first, the decision to focus on 10-year old learners-within grade 5 did not take into account that there are varying levels of ability amongst learners within the same age group and within a single grade (department of education, 2003). it may have been more appropriate to randomly select participants from all learners in the same grade, regardless of age. such a decision also would die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the school-based speech-language therapist: choosing multicultural texts have eliminated the possibility of teacher bias in identifying participants for the study. teachers may have suggested names of learners whom they perceived as 'well-behaved' rather than 'troublesome' in class. second, the researcher chose folktales that were written in english because english is the language of teaching and learning at the research site. however, seven of the participants spoke zulu as their home language and english as their first additional language. consequently, the use of english as the medium for the folktales, for the questionnaires, and for all spoken interactions, could have constrained the results. the participants' output, for example, may have been limited given that seven of them were responding in their additional language. conclusions the following conclusions may be drawn from this study. folktales that were set in ancient times and were not true to life were judged as boring by the participants. such folktales appeared to be poorly matched to the interests and contemporary realities of 10-year old learners in grade 5. however folktales that were filled with humour and action, or that mirrored aspects of the learners' lives or identities, were better able to capture their interest and stimulate their participation in the discussions. the results of the study emphasise the importance of texts as mirrors. it was found that cultural distance between the learner and the text may hinder the learner's response to the text. all educators need to facilitate the full participation of all learners (department of education, 2003). from this study it can be concluded that one way of enhancing the potential of all learners, would be to ensure frequent opportunities for them to see themselves reflected positively in texts, balanced with texts that act as windows onto other peoples and worlds. this study reflected the pervasive influence of the mass media on the learners' cultural knowledge and understanding of diversity. the messages conveyed in the mass media, especially television, appeared to be more potent than the information contained in books. there is a tendency for learners to blur reality/and fiction and to embrace what was depicted in the mass' media as truth. critical literacy and media critique are therefore crucial for all learners. the educator has an important role in facilitating the learner's {enjoyment of and critical thinking about texts. a multicultural, anti-bias perspective is a crucial aspect of an educator's role as a facilitator of learning. critical self-awareness by educators is an essential first step, with a pressing need for examination of their own biases, assumptions, and worldviews. final thoughts multicultural literature or texts have considerable educational potential. however, it is in "the meeting of minds" between the educator and learner that this potential is fulfilled or unleashed (naidoo, 1992, p. 138). every speech-language therapist and teacher has to begin the essential process of change if they wish to be the kind of educator envisaged within the rncs, to become lifelong learners, researchers, mediators of learning and "key contributors to the transformation of education in south africa" (department of education, 2002a, p. 9). only then can one aspire to the motto of 'unity in diversity' emblazoned on the,south african coat of arms. acknowledgements this article is the culmination of a thesis submitted to the university of durban-westville (now the university of kwazulu-natal) by the first author, in partial fulfillment of the requirements for the degree master of communication pathology (speech-language pathology), under supervision of the second and third authors. references althanases, s.z. 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(1995). preface. in f. schultz (ed.), multicultural education 95/96 (2n d ed.). connecticut: the dushkin publishing group. shor, i. (1999). what is critical literacy? journal for pedagogy, pluralism & practice, 1 (4). retrieved september 25, 2001, from http://www.lesley.edu/journals/ippp/4/shor. htm#do sims, r. (1983). strong black girls: a ten-year-old responds to fiction about afro-americans. journal of research and development in education, 16(3), 21-28. sims bishop, r. (1992). children's books in a multicultural world: a view from the usa. in e. evans (ed.), reading against racism (pp. 19-38). buckingham: open university press. steptoe, j. (1987). mufaro's beautiful daughters: an african tale. london: hamish hamilton. taylor, s.v. (2000). multicultural is who we are: literature as a reflection of ourselves. teaching exceptional children, 32(3), 24-29. webster, j.w. (2001). effects of ninth graders' culture-specific schemata on responses to multicultural literature. the journal of educational research, 95(1), 12-25. willis, a.i. & johnson, j.l. (2000). a horizon of possibilities: a critical framework for transforming multiethnic literature instruction. reading online, 4(3). retrieved april 16, 2001, from http://www.readingonline.org/articles/ art_index.asp?href=/ articles/willis/index.html r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) http://www http://cela.albany http://www.lesley.edu/journals/ippp/4/shor http://www.readingonline.org/articles/ the school-based speech-language therapist: choosing multicultural texts appendix a description of participants participant family structure/religion home languages/ gender li ο mother, father, 2 brothers, aunt, 2 cousins β christian ® zulu; english used with brothers and cousins ® male ml ® mother, father, 3 brothers, 2 aunts, uncle, cousin ο christian/church-going o zulu ο male nq ® mother, father, 2 brothers, 2 sisters, aunt, uncle β christian • zulu; english ® female m o β mother, father, brother, 2 sisters β christian/church-going ® zulu; english used with older sister ® male ce ® mother, sister, grandmother, aunt, uncle, 6 cousins ο christian ® zulu; english ® male ni ® mother, aunt, grandmother ® christian » english ® female th ° mother, stepfather, step-brother ® hindu ® english ® male sn ο mother, father, sister ® christian ® zulu; english ® female ch ® mother, sister ο christian ® english; afrikaans ® female va ® mother, father, sister, brother ® christian ® zulu ® female / / j a p p e n d i x β | criteria for selecting the folktales (adapted from gillespie, powell, clements, & swearingen, 1994; sims bishop, 1992) ο the culture and the characters should be portrayed as multifaceted, that is, strong three-dimensional characters. ο the cultural dimensions should be presented authentically. ο the folktale should not promote stereotypes. ο the language and dialect in the folktales should be presented authentically. ο the illustrations should contain authentic representations of scenes and people from the different cultural groups. furthermore the illustrations should be attractive and able to capture and hold the attention of the target audience. the south african journal of communication disorders, vol 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) saloshni moodley, sandhya chetty and jenny pahl appendix c synopsis of the african folktale 'mufaro's beautiful daughters' this folktale is similar to the plot of cinderella. it is about mufaro's two daughters, manyara and nyasha. manyara, who is vain, proud, and very jealous of her sister, pretends to be loving in front of mufaro. nyasha, by contrast, is genuinely industrious, kind and humble. the king wishes to marry one of them and asks mufaro to choose which daughter should become the queen. however, mufaro asks the king to make the decision. manyara is determined to become queen and will do anything to be chosen. using magical powers, the king tests the two sisters, without their knowledge, to determine who is worthy to be his wife. the folktale shows how manyara's true character is revealed and how nyasha is chosen to marry the king because of her gentleness and honesty. note: this folktale contained seventeen detailed full-page colour illustrations of all the significant details of the story. appendix d questionnaire for phase 1 please read this section and sign before answering the questions. i understand: • what the study is about • that all my details will be kept confidential. signed: 1. what did you like about the story? 2. what didn't you like about the story? 3. was the story about what you expected? 4. what surprised you about the story? 5. what did this story show you about people? 6. what did the story make you think about? 7a. how did the story make you feel? (for example: bored, sad, happy, confused, irritated, curious angry) 7b. why? 8a. would you tell your friends to read this story? 8b. why 9a. was there anything that you did not understand? 9b. what was it? appendix ε | focus group interview schedule • tell me what you thought of the folktales? ® how would you feel about reading other stories like this? « if all the stories had been fun or enjoyable, which one best showed you about another culture? • in what ways were the people in the stories just like you/different from you/your family/friends? • how did you feel about a story when you thought that the people in the story were very different from you? ® how did you feel about the story when it was about a boy? ® how did you feel about the story when it was about a girl? • how have the folktales changed your ideas about how people from other countries/race groups/ cultures could be different from you? 3 · i n what ways did the stories make you think about how people are different or about how people are the same? • how. did the stories show you that people from another culture can have problems just like you? • would you like to read more books about people who are the same as you or people who are different from you, or both? ® in what ways did the stories remind you of your own family/school/friends/home? β what sort of books do you think should be in the library? what sorts of books don't we have enough of? / • in which/what ways have your experiences been similar to the experiences of the people in the story die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) information for contributors n a t u r e of publication jhe south african journal of communication disorders publishes reports and papers concerned with research, and critically evaluative theoretical and philosophical conceptual issues dealing with aspects 0 f human communication and its disorders, service provision, training and policy. jfte south african journal of communication disorders will not accept material which has been published elsewhere or that is currently under review by other publications. manuscript style and requirements preparation of manuscript articles must he accompanied by a covering letter providing the author's address, telephone and fax numbers and e-mail address. articles must be typed on a4 pages in double spacing and in a font size of 12. three print outs of the article must be submitted. one exact copy of the article on disk must be submitted. filenames must include the first author's initials and a clearly identifiable key word and must he type-written on the last line of the last page of the reference list (for retrieval purposes only). articles must not exceed 30 pages. title page the title page of one must contain: title of the article. full names of the authors. institutional affiliation. abstract of the article in the language of the article. the title page of the remaining two copies must not contain the authors' names or institutional affiliations. abstracts and key words each article must contain an abstract of no more than 200 words. all abstracts must be in english, irrespective of the language in which the article was written. . each article must provide 5-7 key words for indexing purposes. body of article ] all contributions are required to follow strictly, the style specified in the publication manual of the american psychological association (αρα pub. man., 2001). i • headings are not numbered. the order of importance is indicated as follows: j main heading in capitals and bold print. sub-headings in upper and lower case, and bold print. sub-subheadings in upper and lower case bold and italic print. sub-sub-sub-heading in upper and lower case and italic print. • major headings, where applicable, must be in the order of introduction, method, results, discussion, conclusion, acknowledgements and references. • all paragraphs should be indented. tables, figures and illustrations all tables, figures and illustrations must he numbered and provided with titles. the title of tables, which appear above, and of figures, which appear below, must he concise but explanatory. allow for 50-75% reduction in printing of tables, figures and illustrations. each table, figure or illustration must appear on a separate page and be print ready. preferable not printed on colour printers. do not include more than 10 tables, figures or illustrations. references : references must he citedin the text by surname of the author and the date, e.g., van riper (1971). where there are more than two authors, after the first occurrence, et al. may he used from the start. the names of all authors must appear in the reference list, which must he listed in strict alphabetical order in triple spacing at the end of the article. all references must he included in the list, including secondary sources, (αρα pub. man. 2001) only acceptable abbreviations of journals may be used, (see dsi1 abstracts, october; or the world list of scientific periodicals). the number of references should not exceed much more than 30, unless specifically warranted. examples locke, j.l. (1983). clinical psychology: the explanation and treatment of speech sound disorders. j. speech hear disord., 45:339-341. penrod, j.p. (1985). speech discrimination testing. in j. katz (ed.),handbookofclinicalaudiology (3rd ed.). baltimore: williams & wilkins. davis, g. & wilcox, m.j. (1985). adult aphasia rehabilitation: applied pragmatics. san diego, ca: college-hill. editing articles must be revised for grammar and style prior to submission. the manuscript style of the article must be strictly according to the guidelines provided. only articles complying with the above requirements will be accepted for review. reviewing system the peer review of refereeing system is employed as a method of quality control of this publication. peer reviewers are selected by the editor based on their expertise in the field and each article is sent to two independent reviewers to assess the quality of the manuscript's scientific and technical content. the blind peer review system is employed during which the names of the author/authors are not disclosed to the reviewers. the editor retains the final responsibility for decisions regarding revision, acceptance or rejection of the manuscript. deadline for contributions 30th january each year. queries, correspondence & manuscripts address to: the editor, south african journal of communication disorders south african speech-language-hearing association p.o. box 5710 the reeds 0158 south africa copyright the copyright of all articles printed in the south african journal of communication disorders is reserved by the south african speech-language-hearing association (saslha). r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) an investigation into some of the adjustment problems of the adolescent stutterer frume t . lubinsky, b.a.log. (rand), m.a. (rand). extract from a thesis submitted for the degree of master of arts, at the university of the witwatersrand, johannesburg, december, 1964. theoretical discussion as observed in urban western society, many aspects of adolescent development are associated with increased tension and conflict, particularly in the social sphere. developmental tasks which are regarded as important include learning an appropriate sex role, achieving emotional independence from parents and getting along with peers.* interaction with, and social acceptance by members of the opposite sex becomes increasingly important as the adolescent moves towards maturity. t h e home is an important influence in the adolescent's adjustment and increased conflict between parents and children can lead to hostility and aggression. acceptance of the physical self, attitude towards physical appearance and anxiety about health are also factors which may influence adjustment. in addition, the emotional "lability" associated with adolescence can lead to an intensification of conflict in all the above areas •of adjustment. perusal of the relevant data relating to the adjustment problems of the normal adolescent, and research evidence on adjustment together with awareness of the problems related to stuttering, of the social nature of stuttering, and of the relationship between frequency of stutter and communicative stress, led to the formulation of the hypothesis investigated. in essence this states t h a t : ' t h e relative a d j u s t m e n t of adolescent stutterers is poorer than t h a t of adolescent non-stutterers, with regard to health, h o m e environment, emotions arid social interaction, a n d that a d j u s t m e n t problems in the social and emotional areas are positively related to stuttering severity.' / experimental study aim of the investigation. t o ascertain the relative adjustment of a group of stutterers and non-stutterers in the adolescent age group, as measured by an adjustment inventory, and to determine the relationship between stuttering severity and adjustment in the areas studied. subjects. t h e r e were 50 stutterers i n the experimental group and 50 non-stutterers in the control group. they were all between 13 and 19 journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) adjustment problems of the adolescent stutterer 5i years of age and attended high schools in the johannesburg area. their fathers' occupations ranged from manual semi-skilled workers to professionally highly-qualified and administrative executives. religious groups included jews, protestants and catholics. t h e sex ratio was approximately 6 boys to 1 girl and the experimental group consisted of 11 severe, 19 moderate and 20 mild stutterers. assessment instrument. t h e bell adjustment inventory was used. it is a paper and pencil test, and as such many criticisms have been directed against it. however, writers agree that it has better than chance validity, and it has been extensively used to measure adjustment in divergent fields of psychological research, as well as in a number of investigations in the field of speech therapy.1 t h e inventory purports to assess the home, health, social, emotional and "total" areas of personal adjustment. scores on the four separate measures in the inventory are interpreted by bell in the following way: home a d j u s t m e n t : high scores are indicative of unsatisfactory adjustment to home environment. health a d j u s t m e n t : high scores are indicative of unsatisfactory health adjustment. social a d j u s t m e n t : individuals scoring high tend to be submissive and retiring in their social contacts, whereas low scores indicate aggressiveness in social contacts. emotional a d j u s t m e n t : individuals with high scores tend to be emotionally unstable.2 t h e test is self-administered, takes 25 minutes to complete and can be accurately scored in three minutes. a south african research worker has described it as a simple, practical tool for the investigation of adjustment.9 procedure. subject selection was limited by the following criteria: (a) all subjects were white south africans. (b) all subjects were english-speaking. (c) none had gross sensory or motor impairment. t h e goal in sampling was to obtain the maximum comparability of both groups on all the pertinent variables except stuttering. subjects were matched according to age, religion of parents, socio-economic status in terms of fathers' occupations, educational levels as indicated by class and school progress, sex and the school which they were attending. subjects were only included in the control group, if the writer was satisfied that they had no speech defects of any description. t h e following definition of stuttering was used as the criterion for differentiating stutterers from non-stutterers, for inclusion in the experimental group: "any or all of the following were regarded as speech disfluencies . . . (a) repetition of words, parts of words, phrases and sounds. (b) prolongation of words, parts of words, phrases and sounds. (c) breaks in forward flow of speech, such as blocking, stickings, grimaces and interjections."1 0 stuttering severity was rated on a nine-point rating scale, as used and recommended by sherman and her co-workers.1 1-1 2 t h e writer visited schools in different suburbs, covering a cross-section of the community and the adjustment tests were administered during school hours. selected subjects were told that they were helping in a tydskrif van die suid-afrikaanse logopediese vereniging, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 f. τ. lubinsky research project, and were assured that their questionnaires would be treated confidentially. results method of analysis. t h e group means in each of the adjustment areas measured were compared pair-wise. as differing variances made the use of the conventional student's " t " test impossible, the modified " t " test by welch and cited in brownlee was used. ' for the purpose of this study results exceeding the 5% level of significance were regarded as statistically significant. t h e test statistic " t " with modified degrees of freedom was used to ascertain differences in mean scores between the matched groups of stutterers and controls in all the areas measured. comparisons were also made between severe stutterers and all controls, moderate stutterers and all controls, and all stutterers and all controls. results showed no marked difference between the responses of mild stutterers and controls. accordingly mild stutterers' and controls' mean scores were pooled and compared with the pooled moderate and severe stutterers' mean scores. t h e " t " test with modified degrees of freedom was-also used to examine the effect of severity of stuttering on adjustment scores. .a contingency table of controls' and stutterers' scores in relation to bell's norms was set up, to determine whether stutterers' and controls' scores, clustered around the area of "average", as described by bell, or whether they respectively clustered around the "worse than average" and "better than average" scores. it was felt that this would provide information suggestive of trends in the subjects' responses to items in this test. analysis was also carried out with a view to finding out which of the individual questions discriminated best between stutterers and controls. eight comparisons were made for each question and the similarity of response was tested by means of a chi-squared test. discussion and interpretation. t h e results of the present study indicated significant differences in the responses to items on the bell adjustment inventory, between the experimental sample and the matched control group, in all adjustment areas measured. all adjustment scores excepting " h o m e " increased with the severity of the stutter. an interesting phenomenon was observed in the close similarity between the responses of the mild stutterers and the control group, in all areas. although mean scores are all within the normal range described by bell, a larger proportion of stutterers' total adjustment scores are classified as "worse than average" in terms of bell's norms.2 a certain amount of "faking" by endorsement of the socially desirable response is to be expected. t h e observed scores may therefore be regarded as conservative estimates of the subjects' "actual" evaluation of their adjustment problems. t h e stutterers' mean scores on the " h o m e " scale of the bell adjustment inventory indicate less satisfactory home adjustment than the mean scores journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) adjustment problems of the adolescent stutterer of the matched non-stuttering group. t h e present results are in agreement with duncan who also found a significant difference in the responses of stutterers and non-stutterers to the home scale on the bell adjustment inventory. it may be feasible to presume that less satisfactory parent-child relationships between stutterers and their parents, as discussed by other workers in the field, cause adolescent stutterers to feel less well-adjusted than non-stutterers in their home surroundings. scores on the health scale indicate poorer adjustment of the stuttering group, and displayed a tendency to increase with stuttering severity. however, this scale appears to measure various different aspects of health, and the question as to whether physical or emotional states are influencing the test results remains largely unanswered. it is thus difficult to interpret these results, and they cannot be viewed in relation to previous work. significant differences were not observed between all stutterers' and all controls' mean scores in the social scale. it should, however, be noted that when comparing the pooled groups of mild stutterers' scores, plus controls' scores, versus moderate stutterers' scores, plus severe stutterers' scores, a significant difference was observed. in addition, in this area mild stutterers' responses indicate better social adjustment than those of all the controls. t h i s leads to the assumption that the mild stutterers' scores have caused the lack of significant difference between the two major groups. t h i s is indicative of increased "social aggressiveness" in inverse ratio to stuttering severity. t h e items which showed significant values of chi-squared in three or more comparisons, were mainly in the social area, and specifically concerned speaking to the class, in front of an audience and to strangers. examination of the findings in this area show that the adolescents in the experimental group who were rated as "severe" and "moderate" stutterers, appear to experience more social problems than non-stutterers and mild stutterers. further, problems appear to be mainly concerned with "difficult" speaking situations. results obtained in similar studies approximated those of the present study. in the emotional area a significant difference is observed between all the stutterers' mean scores and the mean scores of their matched controls groups. more significant differences were observed in this area than in the other areas under investigation. t h i s indicates that as measured by this test, the stutterers examined regard themselves as less "emotionally stable" than the non-stuttering sample. stutterers' scores in this area appear to be proportionately related to stuttering severity. emotional instability, may, therefore, be said to be related to severity of stuttering symptom. u p o n chi-squared analysis the most discriminating item in this area was found to b e : " d o you consider yourself rather a nervous person?" t h e present results tend to support the findings of bender, using the bernreuter personality inventory, as well as those of dahlstrom and craven, boland, walnut and pizzat, who in different studies administered the m.m.p.i. to stuttering and matched control groups.4 on the other hand, there is considerable empirical evidence in disagreement with the present findings.4 tydskrif van die suid-afrikaanse logopediese vereniging, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 f. τ. lubinsky in the main, however, the weight of carefully controlled experimental evidence seems to favour the opinion that stutterers experience increased adjustment difficulties of an emotional nature. comparisons in the total adjustment scores have yielded significant differences between all the comparisons made, with the exception of mild stutterers versus all controls, thus further substantiating the obtained difference in amount of adjustment difficulties experienced by stutterers and non-stutterers in the adolescent age group. scores in this area also appeared to have a positive relationship with stuttering severity. as no studies were available which employed the whole of the bell adjustment inventory in a similarly designed experiment, the significance of these findings cannot be evaluated in relation to other studies. conclusion: before drawing conclusions from the obtained results, it is necessary to enumerate the limitations of the present study: (a) t h e groups studied cannot be regarded as representative of the total population, as selection of subjects was largely based on availability. (b) test responses are dependent upon subjects' insight into, and evaluation of their own problems. (c) limitation of the testing instrument used and the accepted difficulties associated with measuring " a d j u s t m e n t " . " ' 1 3 (d) it is not possible to deduce from this study whether the observed adjustment disturbances are causally related to stuttering, or whether they are the result of the stutterers' disrupted communication. considering the above, it is obvious that the findings of the present study can only be regarded as superficial. however, each type of research material has its special value, and can be used to supplement other findings, thus furnishing a more complete picture of the adjustment problems association with stuttering. t h u s , the following conclusions which are drawn from this study may contribute towards a broader understanding of the behaviour and problems of the adolescent stutterer: (a) although the magnitude of difference was not always large, the bell adjustment inventory elicited different responses from stutterers and nonstutterers in all the areas studied. marked differences were apparent in the emotional area, whereas the most discriminating items, emphasising "stressful" speaking situations, were observed in the social area. in addition severe and moderate stutterers' responses showed less satisfactory adjustment than the mild stutterers in all areas excepting home adjustment. (b) although this test does not measure frustration or anxiety, these results indicate increased emotional instability in the stuttering group, thus supporting the point of view that during adolescence the stutterer experiences more problems of an emotional nature than the "normal" adolescent. this might be due to the frustration and anxiety experienced journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) adjustment problems of the adolescent stutterer in social situations, together with the general emotional "lability" of the adolescent. (c) t h e severity of the stutter appears to have a marked effect on relative adjustment in the social and emotional areas during adolescence. (d) although the adolescent stutterers' relative adjustment to the home situation is poorer than that of the "normal" adolescent, this difference is not very great, and appears to have no relation to stuttering severity. (e) t h e adolescent stutterers' adjustment as shown by the total score on this test, is poorer than that of the adolescent non-stutterers examined. this also appears to be positively related to stuttering severity. t h e writer is of the opinion that the most interesting finding in the present experiment, is the manner in which the mild stutterers' responses approximated the controls' responses. t h i s should lead to further investigation of problems of adjustment and personality attributes associated with varying degrees of stuttering severity. in terms of bloodstein's3 developmental phases it appears that the mild stutterers in the present sample have not advanced beyond the second developmental phase, and that they do not feel markedly different from their peers. therapists dealing with stutterers in the adolescent age group should take cognisance of the varying degrees of problems which may be experienced by mild and severe stutterers, and this should be an important consideration when planning individual and group therapy. t h i s study has only examined the problems of the adolescent stutterer from a general point of view. it therefore becomes apparent that there is scope for further and more specific research in this field. studies taking into account the different ethnic, cultural and sub-cultural groupings specific to south africa might also yield interesting and useful results, which would assist in the planning of therapy. opsomming hierdie studie is gerig op 'n beter begrip van die aanpassingsprobleme waarmee die adolessent wat hakkel, te kampe het. 'n empiriese ondersoek is aangevoer, om die relatiewe aanpassirig van hakkelaars en nie-hakkelaars, met betrekking tot emosionele, sosiale, huislike en gesondheids aanpassing, te ondersoek. 'n vergelyking is ook getref met die aanpassings van matige, gemiddelde en ernstige hakkelaars. die bevindings dui aan dat daar in alle gebiede wat ondersoek is, verskillende reaksies uitgelok is by hakkelaars en die wat nie hakkel nie. terwyl die limitasies van die studie voor oe gehou moet word, mag daar tot die gevolgtrekking gekom word dat adolessente hakkelaars meer emosionele aanpassingsprobleme ondervind. hierdie moeilikhede, asook probleme van sosiale aanpassing, blyk in direkte verhouding te wees met die e m s van die hakkel-simptoom. references 1. allen, r. m . (1958): personality procedures. new york: harper and erothers. 2. bell, η. m . (1934): manual for the adjustment inventory. student's form. california: stanford university. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 f. τ . lubinsky 3. bloodstein, ο. ( i 9 6 0 ) : development of stuttering. 11—developmental phases. j. s. h. d., 25, 219. 4. bloodstein, o. (1959): a handbook on stuttering for professional workers. chicago: national society for crippled children and adults inc. 5. brownlee, k. a. ( i 9 6 0 ) : statistical theory and methodology in science and engineering. new york: john wiley and sons. 6. davidson, η. h. and gottlieb, l. s. (1955): emotional maturity of preand post-menarche girls. j. genetic psychol., 86, 261. 7. duncan, η. m . (1949): home adjustment of stutterers versus non-stutterers. j. s. h. d „ 14, 255. 8. havighurst, r. j. (1956): research on the developmental task concept. school review, 64, 215. 9. holtz, s. (1959): a factor analysis of temperament and personality. m.a. thesis, university of the witwatersrand, johannesburg, south africa. 10. johnson, w. (1961): measurement of oral reading and speaking rate and disfluency of adult male and female stutterers and non-stutterers. j. s. h . d. monograph supplement, 71. 11. sherman, d. (1952): clinical and experimental use of the iowa scale of severity of stuttering. j. s. h. d., 17, 316. 12. sherman, d. (1955) ·' reliability and utility of individual ratings of severity of audible characteristics of stuttering. j. s. h. d., 20, 11. 13. tindall, r. h. (1959): relationships among measures of adjustment in readings in the psychology of adjustment. new york: mcgraw-hill book company, inc. journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) are we good behaviourists? margaret m a r k s , m . a . sub-department of speech, pathology and audiology, university of the witwatersrand behaviour therapy is becoming fashionable. it may be timely for speech pathologists to stand still in the face of the hurtling bandwagon and to say—before we leap on, let us look; what is behaviour therapy? where do we fit in? does this bandwagon straddle both fields—speech therapy and psychotherapy? the aim of this article is to pose the question: for speech therapists, is the fashion of behaviour therapy a force or a fad? we as speech pathologists and speech therapists have always been cognisant of the limitations imposed by the fact that we are not psychotherapists. how do we stand then, vis-a-vis behaviour therapy—this specialised branch of psychotherapy? it could be viewed by some as an "insidious enemy, luring us to cross over the fence and assume territory that is not ours, but i would say, rather, that it can be seen as a mediating field showing that the shadowy no-man's-land is rather a both-men's-land, offering firm ground to workers on each side, provided that each knows and understands the region. behaviour therapy gives us no more licence to deal with deep-seated emotional problems than we had when the prevailing psychoanalytic ideas set definite limits; instead, it places on us additional responsibilities to those posed by study in our own area: if we are to utilise the techniques of behaviour therapy we must have a thorough knowledge of the underlying theoretical principles. only when we understand the implications of learning theory will we be able to apply behaviour therapy techniques in our treatment and, carrying this even further, will we be able to devise methods based on a rigorous scientific approach to the problems of the person with defective communication skills. certain techniques appear tantalisingly simple to carry out—if we utilise them without really understanding all the implications, then we, as speech therapists, are guilty of superficial work, and do much to make the use of behaviour therapy a fad, instead of the force it can be. what has brought us to this stage, where a consideration of the relationship between the two fields seems inevitable? a survey of our history shows that, while retaining its integrity, speech therapy, covering as it does many areas which overlap into other studies, must needs be influenced by outside' trends. perhaps the changed thinking about the problematic subject of stuttering highlights this best. we can trace the movement from the approach of the elocutionists, with the stress on breathing and on the mechanics of speech; past the psychoanalytic era when stuttering was considered as a fixation at anal or oral level, dependtydskrif van die suid-afrikaanse logopediese vereniging, vol. 15, nr. : des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 margaret marks ing, (as one critic has stated) which way one viewed it; through the neurological ideas with the stress on the establishment of cerebral dominance; to the semantic school with its beliefs in re-evaluation, and its product—the 'happy stutterer'. now, under the influence of behaviour therapy, we are again concentrating on the actual stuttering behaviour. some may feel that, in a new guise and protected by a new jargon, we are ready to commit the same sins as an earlier and as well-meaning a generation; can this orientation not give rise to the same unhappy consequences of 'distractive therapy' that resulted from the slow speaking, deep-breathing, rhythmic armswinging approach advocated by therapists of the early nineteen hundreds? it is necessary to ask—is this new therapy anything more than a series of psuedo-scientific gimmicks? is behaviour therapy a cob-web cleansing wind, or is it merely a breeze from a new direction, which will blow sporadically and ineffectually, only to end in a whimper? will students in ten years' time, looking through old clinic reports, discard the late 1960's as the years of the 'smarty party'?* i believe that the relevance of behaviour therapy to speech pathology and therapy is more than this, that it can add new dimensions to our understanding of communication problems, and to their therapy. i have stated elsewhere that speech therapists have always been concerned with the alteration of behaviour and have, even before the term came into existence, been behaviour therapists.1 we are attempting to change behaviour, whether it is the behaviour causing the defect, and/or the actual defective behaviour and/or the behaviour resulting from the defect. once we have accepted this fact, we should use everything in our armoury —and in any other specialist's armoury—which can help us to change undesirable behaviour. it is impossible, within the scope of this article, to do more than mention some definitions and descriptions of behaviour therapy. it is hoped that brevity will not do it a disservice and that readers will refer to the literature written by the authorities, to realise all the subtleties implicit in the study of this approach to therapy. the writings of wolpe and eysenck are basic to an understanding of behaviour therapy; several review articles, such as that of rachman's in the first issue of behaviour research and therapy, place previous work in historical perspective.5 an interesting overview, and comparison with the 'medical model', is given by ullmann and krasner in their introduction to the book which they edit.6 / briefly, one could phrase the arguments of behaviour therapy as: certain learned responses, or sets of responses of the organism can be considered undesirable or harmful to the organism; or prevent the organism from acquiring certain other responses which would be more beneficial. the therapists assume that this behaviour has been learned, or acquired, *i am indebted to the 1967 final year students, sub-department of logopedics, university of the witwatersrand, for this phrase. (a smarty is a small chocolate lentil given as a reward to reinforce a desired response.) journal of the south african logopedic society, vol. is, no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 21 are we good behaviourists? according to certain laws, and that behaviour which has been learned can, also by adherence to the principles derived from a study of learning, be unlearned, by being treated in various ways. in this way behaviour can be modified to the benefit of the organism. ullmann and krasner state that: „ , charfge of behaviour, no distinction is made between adaptive and maladaptive "wolpe! in his psychotherapy by reciprocal inhibition, describes the scope of his text: , , . , , tn this book a new theory' of psychotherapy is presented . . one that is basea on the growfng body of knowledge of the processes by which change is wrough m the behavior of organisms-modem learning theory-the fruit of the efforts of pavlov thorndike, watson, tolman, hull, skinner and their followers.* he presents the logic of the approach briefly: onlv three kinds of processes are known that can bring about lasting changes in an organism's habit of response to a' given stimulus situation: growth, lesions and learmng since neurotic behavior demonstrably originates in learning, it fs only to be expected that its elimination will be a matter of unlearning. in what does treatment consist? eysenck is of the opinion that: treatment is in essence a very simple process. in the case pi surplus conditioned responses, treatment should consist in the e x t i n c t ^ o n o f these responscs in the case of deficient conditioned responses, treatment should consist in the building up of the missing stimulus-response connections. ullmann and krasner say that: the working behaviorist asks three questions: . , ' (a) what behavior is maladaptive, i.e. what subject behavior should be increased °r(b)ecwhaetdlvironmental contingencies currently support the patient's behavior? (c) what environmental changes, usually reinforcing stimuli, may be manipulated to alter the subject's behavior?6 . , . . , , once we have this framework in mind, it is of relevance for the speech therapist to view the field of speech pathology within it. there are various ways in which the relationship between speech therapy and behaviour therapy can be viewed: (a) existing speech therapy principles and techniques can be rephrased in learning terminology; ' (b) existing behaviour therapy techniques can be used in the treatment of people with communication defects; (c) learning theory principles can be used in the treatment of people with communication defects. the third possibility seems to have the widest implications and appears to be the least limiting; some benefit can, however, be derived from a consideration of the other two. to consider the first possibility, we can refer to the work of authors who may or may not be avowed adherents of behaviour therapy. from his writings, it seems as if dr. van riper can be described as one type of—'ist'—not behaviourist, analyst, semanticist, but therapist. this pragmatic approach allows for many theoretical orientations and, as with any therapy which works, can be interpreted in many ways; however it is probably not assuming too much to view some of his ideas tydskrif van die suid-afrikaanse logopediese vereniging, vol. is, nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 margaret marks as being within a learning framework, to interpret his progressive approximation technique as identical to the behaviour therapists' shaping, or to see cancellation easily transposed to learning terminology.7 brutten and shoemaker, by using the phrase determining critical stimuli put much of the work we do with parents of young stutterers into a learning theory framework.1 to cite another example, dunlap's negative practice could be rephrased as reactive inhibition.2 this example shows that while rephrasing we can do more than practise semantic exercises; we could follow yates' work where he utilised not only the concept of reactive inhibition but, through massed practice, established conditioned inhibition, i.e. where the habit of not performing the undesired responses was made to replace the habit of performing it.9 this type of thinking indicates the way in which rephrasing terminology can give rise to greater and more scientific application than existed before. the value of viewing existing speech therapy principles and techniques from a learning standpoint is that, if they are accepted as such, they can be carried out with more scientific conviction than they have been. if a therapist is to carry out shaping, or establish conditioned inhibition, he should do so with an awareness of all the implications of these procedures, an awareness based on knowledge of learning theory, and one which will take into consideration important factors such as schedules of reinforcement. if he has not got this knowledge, small wonder that the desired pattern of response is soon replaced by the older and stronger incorrect response. the second way to consider the relationship is by applying existing behaviour therapy techniques to speech therapy cases; the psychologist who is specialising in behaviour therapy techniques considers speech as behaviour, subject to the same laws as any other behaviour. aberrant speech responses can, they believe, be extinguished or modified in the same way as any other undesirable responses (e.g. phobias, tics and smoking). a survey of the articles in journals such as behaviour research and therapy and in texts on behaviour therapy indicates the interest shown in the field of communication defects. reports have been given on the utilisation of systematic desensitisation of the anxiety of stutterers, of people with voice defects, or of those suffering from aphasia; much work has been done utilising operant conditioning with non-verbal children and adults; modification of stuttering behaviour has been attempted, using wolpe's reciprocal inhibition techniques to reduce anxiety, and various other techniques (e.g. aversive conditioning) to alter the actual stuttering response. it can be predicted that, as speech is so overt a series of responses, the modification of defective speech will arouse more and more interest among the behaviour therapists. this must be welcomed by speech therapists, who are always aware of the necessity for, and the benefit to be derived from, co-operation with related specialists. if, however, one would ask that speech therapists using behaviour therapy techniques should have a deeper understanding of its techniques, one could also wish that behaviour therapists would benefit journal of the south african logopedic society, vol. , no. : december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) are we good behaviourists? 23 from the experience of speech therapists, by becoming more knowledgeable about the speech defects with which they wish to work. the speech therapist knows for example, the often harmful effects of teaching a stutterer to inhibit his stuttering; he knows the implication of teaching language, as opposed to teaching speech, to the non-verbal child. this kind of knowledge would be of great practical value to the behaviour therapist, and would serve to make for greater economy in his work with speech or language-handicapped people. this leads us to the third approach: the awareness that the speech therapist should have a thorough understanding of learning theory. this consideration differs from the other in that it stresses the principles of learning theory, rather than the practices of therapy based on learning theory, practices which are often devised by behaviourand not by speechtherapists. if we merely accept these practices and apply them, we take over their inherent limitations as well as their advantages. we are being narrowed by the thinking and work of the behaviour therapists who are not necessarily conversant with all the implications of speech and language problems. although behaviour therapy is not long out of its infancy it is close to, if not already in, the schools stage. we must be aware of the disadvantages of partisanship—of belonging, for example, to the skinnerian as opposed to the hullian school. by virtue of the fact that we have not trained as psychologists, we have a certain distance which allows us to see and, to some extent, to reconcile behaviour therapy viewpoints (just as the psychologist, not orientated to any one particular approach in speech therapy, may have an overview of our field). coupled with our knowledge of communication defects, a thorough study of learning theory can place us in a sound position from which to draw up our own theoretical framework, within which we can devise principles and techniques that will help us in our treatment. as with any series of techniques, the use of behaviour therapy can become merely technical and mechanical. it would be unfair to behaviour therapy, and, on a more practical basis, to our cases if, through superficial understanding and application of the techniques, we misuse them, and so cause other workers to become disenchanted with the ideas implicit in this type of therapy. our understandable anxiety to find keys to aid in the solution of therapy problems has sometimes led to frenetic hyperactivity, when we try haphazardly to fit any key into the keyhole. we must guard against a tendency to overlook the relationship between key and keyhole; or to attempt too casual a movement of key in the lock, and then to discard this key as not fitting, without giving it time to prove itself the correct one. in working with people we cannot allow ourselves to become casual. if behaviour therapy is to work, if any therapy is to work, it must be based on a thoughful, scientific, persistent approach. any approach can become a fad, if we allow it to; it would be more than a pity if we allow tydskrif van die suid-afrikaanse logopediese vereniging, vol. 15, nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) margaret marks this to happen with behaviour therapy which could become, if used correctly, a strong and effective force in our work. summary as behaviour therapy is becoming fashionable, it is important for speech pathologists to ask the question—for us, is behaviour therapy a force or a fad? this article discusses the way in which speech therapy is influenced by outside trends, and cites, as an example, the developments in stuttering therapy. some definitions and descriptions of behaviour therapy are given briefly, and particular reference is made to the work of wolpe and of eysenck, and to the review articles of rachman, and ullmann and krasner. the interest of behaviour therapists in the field of communication disorders is shown by the number of relevant articles in texts and in journals such as behaviour research and therapy which contain reports of the use of techniques such as systematic desensitisation with stutterers, voice cases and aphasics; operant conditioning with non-verbal children and adults, etc. an indication is given that behaviour therapists could benefit from the knowledge of speech therapists, e.g. as regards the dangers of teaching a stutterer to inhibit his stuttering; or the difference between teaching speech and teaching language to the non-verbal child. the relationship between speech therapy and behaviour therapy is viewed in three ways: (a) existing speech therapy principles and techniques can be rephrased in learning terminology; . (b) existing behaviour therapy techniques can be used in the treatment ot people with communication defects; (c) learning theory principles can be used in the treatment of people with communication defects. the third possibility is seen as having the widest implications. it would be unfair to behaviour therapy and on a more practical basis, to our cases if, through superficial understanding and application of the techniques we misuse them and so cause other workers to become disenchanted with the ideas implicit in this type of therapy. in working with people we cannot allow ourselves to become casual. therapy must be based on a thorough, scientific, persistent approach. behaviour therapy can become, if used correctly, a valuable force in our work,/ opsomming omdat gedragsterapie deesdae mode geword het, is dit belangrik vir die spraakpatoloog om homself die vraag te vra, is gedragsterapie 'n gemotiveerde krag of bloot ?n gier? i ons vind in hierdie artikel 'n bespreking oor die invloed van neigings van buite, op spraakterapie, en stel as voorbeeld die ontwikkeling op die journal of the south african logopedic society, vol. , no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) are we good behaviourists? 2 5 gebied van hakkelterapie. verskeie definisies en beskrywings van gedragsterapie word kortliks gegee en daar word spesifiek na die werk van wolpe, eysenck, rachman, ullmann en krasner, verwys. die groot aantal toepaslike artikels wat die afgelope tyd verskyn het, toon die belang van gedragsterapeute in die veld van kommunikasieafwykings. as voorbeeld word behaviour research and therapy, genoem, hierdie werk bevat verslae oor die gebruik van tegnieke, soos bv. sistematiese weerstandsopbou met hakkelaars, disfonie en afatiese gevalle: operante kondisionering met nie-verbale kinders en volwassenes, ens. dit blyk ook dat gedragsterapeute baat by die kennis van spraakterapeute, veral met betrekking tot die gevare wat bestaan om bv. 'n hakkelaar te leer om sy hakkel te inhibeer; of die verskil tussen die leer van spraak en die leer van taal aan die nie-verbale kind. die verhouding tussen spraakterapie en gedragsterapie word op'drie wyse beskou: (a) bestaande spraakterapeutiese beginsels en tegnieke kan herbenoem word volgens die ,leer'-terminologie; (b) bestaande gedragsterapietegnieke kan gebruik word in die behandeling van mense met kommunikasieafwykings; (c) leerteoriebeginsels kan gebruik word in die behandeling van mense met kommunikasieafwykings. hierdie laasgenoemde moontlikheid word gesien as die met die grootste implikasies. dit sal onregverdig tesnoor gedragsterapie, en op meer praktiese basis, teenoor ons gevalle wees as ons, deur 'n oppervlakkige begrip en verkeerde toepassing van tegnieke, ander se belangstelling laat kwyn. ons mag nie onverskillig wees wanneer ons met mense werk nie. terapie moet gebasseer wees op 'n deeglike, deurtastende en wetenskaplike benadering. gedragsterapie kan, wanneer dit korrek toegepas word, 'n belangrike bydrae by ons werk lewer. references 1. brutten, e. j. and shoemaker, d. j. (1967ί: the modification of stuttering, prentice hall inc., englewood cliffs, n.j. 2. dunlap, k. (1932): habits: their making and unmaking. liveright inc., n.y. 3. eysenck, h. j. (ed.) (i960): behaviour therapy and the neuroses. pergammon press, oxford. 4. marks, m. (1966): stuttering viezved as a sequence of responses. paper' presented at the international seminar on stuttering and behavior therapy, carmel, california. 5. rachman, s. j. (1963): introduction to behaviour therapy, behaviour research and therapy. 1, 3-16. 6. ullman, l. p. and ,krasner, l. (1965): case studies in behavior modification. holt, rinehart and winston inc. 7. van riper, c. (1963): speech correction: principles and methods. (4th edition.) prentice hall inc., englewood cliffs, n.j. 8. wolpe, j. (1958): psychotherapy .by reciprocal inhibition. stanford university press, stanford, calif, and witwatersrand university press, johannesburg. 9. yates, a. j. (1958): the application of learning theory to the treatment' of tics. journal of abnormal and social psychology. 56, 175-182. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 15, nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a review of speech therapy services in ten cerebral palsy schools in the republic of south africa a u d r e y s h a v e l l , β .a. logoped1cs (witwatersrand) 'senior speech therapist, forest town cerebral palsy school, forest town, johannesburg summary information o n speech therapy services at ten cerebral palsy s c h o o l s in south africa was obtained by means of a questionnaire. the results compared the numbers of children receiving treatment o n a n o u t p a t i e n t and in-patient basis; the percentage of children diagnosed as cerebral palsied, minimal brain dysfunction, aphasic and unclassified in each school; the percentage of speech, voice, hearing and language disturbances in each diagnostic category, the freq u e n c y of speech therapy treatments and types of assessments used; the speech therapists w h o c o m p l e t e d the questionnaire also gave their o p i n i o n on the value of joint assessments, case conferences and use of a c o m m u n i c a t i o n board as well as topics they w o u l d like to discuss. opsomming deurmiddel van 'n vraelys, is inligting van spraakterapeute verkry aangaande dienste gelewer b y skole vir serebraal-verlamde kinders. die resultate vergelyk o.a.; aantal kinders wat behandeling as binneof buitepasiente, ontvang; die persentasie gediagnoseer as serebraal-verlam, minimaal breinbeseerd, afaties of nie-geklassifiseerd, by elke s k o o l ; d i e aantal met spraakstemgehoor en taalgebreke in elke diagnostiese afdeling; h o e dikwels elke kind behandeling ontvang; diagnostiese middels gebruik b y elke afsonderlike skool. b o g e n o e m d e spraakterapeute is o o k gevra o m hulle mening uit te spreek oor sekere aspekte van behandeling, d.i. die waarde van gesamentlike ondersoek, gevalle besprekings, die waarde van 'n k o m m u n i k a s i e b o r d , en ook onderwerpe van belang wat hulle graag sou w o u bespreek. p r i o r t o 1 9 4 8 n o o r g a n i z e d facilities for t h e t r e a t m e n t o f t h e c e r e b r a l palsied existed in s o u t h africa. in 1 9 4 8 , a small g r o u p of a n x i o u s p a r e n t s f o r m e d an a s s o c i a t i o n called t h e t r a n s v a a l a s s o c i a t i o n for t h e care of t h e c e r e b r a l palsied ( t . a . c . c . p . ) t o p r o v i d e t r e a t m e n t and s o m e form o f e d u c a t i o n for t h e i r c e r e b r a l palsied c h i l d r e n . this a s s o c i a t i o n o p e n e d t h e f o r e s t t o w n cerebral palsy s c h o o l in j o h a n n e s b u r g in j a n u a r y 1 9 4 9 , u n d e r t h e p r i n c i p a l s h i p of mrs elaine c l e m o n s , a s p e e c h t h e r a p i s t a n d wife of t h e late a l a n c l e m o n s , l e c t u r e r in l o g o p e d i c s at t h e u n i v e r s i t y of t h e w i t w a t e r s r a n d . t h e original e n r o l m e n t of t h e s c h o o l w a s eleven p u p i l s a n d t h e staff c o n s i s t e d of o n e s p e e c h t h e r a p i s t , o n e p h y s i o t h e r a p i s t a n d o n e a i d . t h e s c h o o l w a s e n t i r e l y s u p p o r t e d a t first b y t h e t . a . c . c . p . from u n s o l i c i t e d d o n a t i o n s a n d a small m u n i c i p a l grant from t h e j o h a n n e s b u r g c i t y c o u n c i l . after t h e t . a . c . c . p . b e c a m e a registered welfare o r g a n i z a t i o n p u b l i c a p p e a l s for f u n d s w e r e m a d e a n d later a n n u a l g r a n t s from t h e t r a n s v a a l e d u c a t i o n d e p t . , assisted in maintydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheeikunde, vol. 21, desetnber 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 audrey shavell taining the school until 1954.' in october 1955 the special education act was passed by parliament and the forest town cerebral palsy school, the pretoria cerebral palsy school and the vista nova cerebral palsy school in cape town became state aided, retrospective from 1st april 1954, under the department of education, arts and science. approximately 90% of the total costs are subsidized by the department of national education, the body which presently controls education for all types of handicapped children in the republic of south africa. in 1955, the cerebral palsy division of the national council for the care of cripples in south africa was established. the regional associations, organizations, schools, homes and training centres catering for the cerebral palsied affiliated lo the cerebral palsy division of the national council for the care of cripples. the formation of the cerebral palsy division provided the impetus for the establishment of further schools, training and employment centres. the ten schools from which the data for this study were collected are all represented on the cerebral palsy division of the national council for the care of cripples in south africa. method speech therapists working at the following schools completed a questionnaire in 1973. (1) the forest town school for cerebral palsied children, johannesburg; (2) the pretoria school for cerebral palsied children; (3) the vista nova cerebral palsy school, cape town; (4) the cape receife school for cerebral palsied, port elizabeth; (5) the brown's school for cerebral palsied, pinetown, natal; (6) the west rand school for cerebral palsied children, krugersdorp; (7) the muriel brand school for cerebral palsied, state mines, transvaal; (8) the martie du plessis school for cerebral palsied, bloemfontein; (9) the frances vorwerg school for cerebral palsied children, johannesburg; (10) the new hope school for cerebral palsied children, pretoria. the questionnaire was designed to obtain some comparable data on the total enrolment at each school; number of patients receiving in-patient treatment and schooling; number of patients receiving out-patient treatment; the percentage of-children diagnosed as cerebral palsied, minimal brain dysfunction, aphasic or unclassified in each school "; the percentage of children-having speech, voice, hearing or language problems (in each diagnostic category; the number of children receiving speech therapy in each school and the frequency of speech therapy treatments; the number of children not receiving speech therapy because of staff shortages; the different forms of assessment used in each school; the opinions of the speech therapists working in the cerebral palsy schools on the value of joint assessment of patients, on case conferences, on the use of a communication board or other similar non-vocal system of communication and the topics they would like to discuss if it were possible for speech therapists attached to cerebral palsy schools to meet. journal of the south african speech a hearing association, vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a review of speech therapy services in ten cerebral palsy schools 47 the schools are situated in different towns or cities and have been opened for between two and twenty-five years so it is not possible to make direct comparisons between the different schools in terms of size of total enrolment and percentages of in and out-patients. it is interesting to note that the school which has the highest out-patient attendance is also a training centre for medical and para-medical students of the university of the witwatersrand, students of goudstads.e onderwyskollege, pretoria college of occupational therapy, the b.g. alexander nursing college and student social workers. the results of this wide dissemination of knowledge can be seen in the increasing number of early referrals, not only of the physically disabled but also of children with learning difficulties, serious language disorders, and suspected minimal brain dysfunction, as well as 'at risk' babies who are referred for developmental observation. babies have been referred, in the last category i.e. for developmental observation from the age of six weeks. the majority'of out-patients in all the schools are children below the age of three, which is the official age of admission in the cerebral palsy schools. the remainder are children attending normal schools or those who do not attend any school but come to a cerebral palsy school for one or more of the therapies. due to lack of adequate alternate facilities, children who have 'soft neurological signs', learning disabilities and serious language disorders are admitted to the cerebral palsy schools if it is felt that they will benefit from the school facilities. the percentages of these children at each of the schools can be seen under the minimal brain dysfunction and aphasic categories in the following tables. results one thousand, five hundred and fourteen children were receiving treatment and/or education at the time this survey was undertaken, 85,73% on an inpatient basis and 14,3% on an out-patient basis. considering the four major diagnostic categories 56,19% were classified cerebral palsied, 34,66% as minimal brain dysfunction, 3,90% as aphasic and 5,03% as unclassified. the definitioh of cerebral palsy was the one formulated in the educational services act, 1967 (act 41 of 1967 as a m e n d e d ) 1 : criteria for the admission of pupils to schools for the cerebral palsied cerebral palsied children means children with disturbed function caused by a defect of or damage to the brain tissue, whose chief problem is not however, that of mental retardation. the defect may be localised or diffuse, and may occur before, during or at any time after the birth of the child. where organic brain damage is the cause of neuro-motor, perceptual, or communication deviations, these defects may be present singly or in * combination. aphasic children are included if they are able to fit into the organization of the school, and if they can benefit from the education which is provided for cerebral palsied children. the children must be educable. the children's main problem is cerebral palsy (or aphasia) and not any of the other handicaps listed in schedule i in the act. tydskrif van die suid-afriaanse vereniging vir spraak engehoorheeikunde, vol. 21, deseber 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) audrey shavell -ο ω ω βο c -a i s c s " c cu d 60 2· ο c "s <l> s3 ϊ « λ cu < s3 <l> 60 μ s3 .—ι s μ c ρ <l> c 2 c "" "ci c i ό <υ -ο <l> £ £ « ω· ω μ i n u o < ω e oo α> λ cu ο ο v5 00 ~ s3 ρ c -s α» — ο £ c <l> -o ε v5 ζ 'ξ. "λ cu ο η ο ο ο -c ο &0 on ο efi ο on e£ (n 6? ο 6? 00 6? 6? to 6? γλ •<a-_ oo oo γλ γλ γλ ο οο" r-" ο" c-f o" to ô" to in" <—ι '—1 * * * * * γλ ess •«a· γλ br e£ (n ess to « oo « ο "τ, on 00 o . ^ c5 i q\ c>" •«a·" oo" •<t \£ o" γλ * * * * * •«aδ? οο ess 00 e£ oo •«a« ο 00 efi oo efi — ο ^ — ^ (n oô {ν {n οο" \ό to to tf" oo" oo" oo" on" •<a·" {ν (n tito (n •«a{ν γλ γλ γλ * * * * * •«a« to es on efi to e£ on to ess 00 « γλ 6? 'λ. (ν (n ^ l/t. to {n on. >.ο to on on" (n r-" to ct •«a-" ô" to titiγλ •«ato to to * * * * vo, δ? γλ efi es es r ^ γλ oo γλ « 6? γλ to to to oo" ct ô" {n on" •"a-" γλ css « e£ « « ^ •«a* γλ t-^ {n γλ c-γ c-t ô" o" to on 00 on on on on .on on on oo ο ο •«a00 on (n •«ato (n 00 γλ γλ · . 1 1 in — 1 journal of the south african speech and hearing association vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a review of speech therapy services in ten cerebral palsy schools 49 aphasia, is not defined in the act, but eisenson's3 recent definition probably covers the children in this category at the various cerebral palsy schools. we shall be using the term developmental aphasia to refer to the impairment for a child to acquire symbols for a language system. the impairment must be of sufficient degree to interfere with the child's ability to communicate. the use of the term developmental aphasia, or one of its synonyms, implies that the child's perceptual abilities for auditory (speech) events underlies this impairment for the acquisition of auditory symbols. his expressive disturbances are a manifestation of his intake or decoding impairment. a child cannot produce language if he cannot decode the speech to which he is exposed, or if the speech remains for him sounds without sense. the definition of minimal brain dysfunction was that formulated by professor c.h. de c. murray and his committee of inquiry into the education of children with minimal brain dysfunction:9 children with minimal brain dysfunction have average or above average intellectual ability, and the motor function, vision, hearing and emotional adjustment are adequate, but they manifest specific learning disabilities or behavioural disabilities which are associated with deviations of the functioning of the central nervous system. dysfunction of the central nervous system manifests itself in different ways and in various combinations of the deviations mentioned below: impairment namely of perception, conceptualisation, language, memory, control of attention, impulse and motor function. in a recent survey murray7 found that in practice all the cerebral palsy schools are admitting children with minimal brain dysfunction and subnormal intelligence in addition to those with average and above average intelligence. the unclassified group included children with one of the undermentioned diagnosis:spinabifida, lymphangioma, pituitary dwarfism, tumour, progressive cerebrocerebellar deterioration, cerebral damage and microcephaly, freidrich's ataxia, muscular dystrophy, hydrocephalus, epilepsy, crit-du-chat syndrome, congenital developmental anomalies, lesch-niehan syndrome, awaiting diagnoses. table ii shows a comparison between the number of pupils and number of speech therapists working at each school; the number and percentage of children with speech, voice, hearing and language problems in each school; the percentage of children receiving speech therapy; the percentage of children not receiving speech therapy in each school because of a shortage of speech therapists, and the percentage of speech, voice, hearing and language problems in each diagnostic category in each school. eight hundred and fifty-one, or 56,2% of the one thousand, five hundred and fourteen children enrolled at the ten cerebral palsy schools at the time of this survey had speech, voice, hearing or language problems. 72,26% of the 851 tydskrif van die suid-afriaanse vereniging vir spraak engehoorheekunde, vol. 21, deseber 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 audrey shavell ° 0 · ° ' 0) u w li/ — u <° u £ £ — a> c 2 c a> o, α) α,-τ α 3 s « ο < ο a, o l i o π u c q « ο c . c a> <u 22 d, j f f l ^ s ο s, oi.so eg υ c — ~ o> c ra _ c a> ο q, a> α — x> a) ~ ν ι». ε a> π ίο. o a , u o . o ξ ό c — u £ zv a> 0ο ' co υ 0) ' ο ω a 0 α> c/j ο c α 3 u-c « ό ο h 2 -ο = >> £ = ·> s: α 5 γ · υ to ~ r « 0> 0> i^ ^ υ aj u 0) t̂ 0) q, x: α. o qi co η 5 3 & e ; · : » ι · ο. ο 5 a. s.s z u s c/3 0. _ £ cj ο ο a η w "o ο s υ co u o o o o o o ^ t n o t l/ί so 00 no.— ο ο " " > ^bx χ s " γ-) ol ο ο ο ο ο ο ο ο ο ο ο ο ο ο ο ο ο ο ο ο as « bs as as as as a? as as as on νο cn •sf ο on οι 00 00 no_ r-ρ . no. on 00_ vq οο" ̂ f" oo" ̂ r" — * ο" ι/ί <ν" γ-)" no" νο it) it) γit) <-<-00 un 6s 6s 6s as as ar as as as as a? on it) it) ο on οι it) ο on '—ι —, 00„ ι/ι 00, ο . (n ο" vo oo" o" oo" tn γ-" οο" γ-)" ο" no it) γ-) it) cn γno ι/ί it) 6s as as as as a« as as no ο on 00 <ν r-00 ο on ο . <n 00_ νο, m γί 00, οο" 1/ί 1/ί ι/ί oo" οο" no" it) <n as 6s a? as as 6s a? 6s a? no it) ο it) 00 on ο vo γno tn 00, γί o . on ο^ —^ c^ _γ o" no" ι/ί <n γ-" oo" γ")" οο" — " γνγ 00 00 no r-γί νο <-γι/ί on r6? as as 6fi as 6? as as as as as νθ_ — ^ o . o, —^ γί 00, 00_ <ν <-o" cf no" <ν" on" οο" ο" no" no it) it) it) γί γit) it) it) it) it) γί r-ο <n 00 οο it) γ") <ν on 00 no no <ν ο <ν γ") γ-) un (ν — 00 no ο ο 00 r r-i on — ol it) γno <n 00 <-r-γί no no — γί it) no ol ο η r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a review of speech therapy services in ten cerebral palsy schools 51 children needing speech therapy received treatment and 16,80% who needed speech therapy were not receiving treatment because of a shortage of speech therapists at the various schools. in answering the questionnaire the speech therapists at two schools commented that they felt patients would benefit from more intensive therapy if more staff were available (schools ii and x). this question of the frequency of treatment is a very worrying one facing speech therapists at cerebral palsy schools. should we try and spread our efforts among as many children as possible, seeing most patients once or twice weekly or should we treat less patients more intensively depending on their needs? after twenty years in this field the writer believes that three times weekly is the minimum and that best results are achieved with daily therapy or therapy four times a week. most of the children with serious language problems and/or severe physical disabilities require daily treatment to retain and reinforce what they have learned. neurologically impaired children have notoriously poor memory spans; increasing the frequency of treatment increases the success ratio. there are also children at all the cerebral palsy schools whose speech therapy has been stopped although they have not achieved their maximum potential, because more urgent cases must also be given a chance. in a recent study done at the west rand cerebral palsy school 8 it was found that taking these children again for an intensive period of therapy, after termination of speech therapy, led to further improvement. increasing the number of speech therapy posts at cerebral palsy schools would relieve the tremendous pressure conscientious therapists labour under and would give these children a chance to function more adequately in society. we should remember that it is through speech more surely than through any other form of expression that the majority of cerebral palsied children may be given the opportunity to reveal their intelligence, their personality and their character. three hundred and thirty-six, or 54,63% of the six hundred and fifteen children under treatment at the time of this survey were receiving speech therapy twice a week or. less than twice a week. if one accepts that adequate speech therapy means three or more sessions a week, half of the group were receiving insufficient treatment. in fact if we examine the percentage of the schools separately we see that in five of the ten schools more than 50% were not receiving sufficient speech therapy. these were:school i 64,64% receiving less than 3 treatments per week school ii 82,05% receiving less than 3 treatments per week school vi 54,65% receiving less than 3 treatments per week school ix 50,00% receiving less than 3 treatments per week school x 74,19% receiving less than 3 treatments per week tydskrif van die suid-afrihaanse ve'reniging vir spraak en gehoorheeikunde, vol. 21, deseniber 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) audrey shavell " u αϊ ^ .. i s σ; ck cts cf\ ô a*; c* ĉ ^ (ν (ν ιλ θ" ' ί on ιλ ο ' t ό ο ο γ λ μ ' ί ' / ί γ λ γ λ ' / ^ γ ^ βϊ ( ^ " t t ^ m d i l ^ m v o o n ^ — vo —ι — tjγ-> (ν ζ os j ε ! γ — ο τ ι ο ^ ο — ο ο ο ο π α m u ^ t ( n ( n o o o o o o o ω ε * ^ ^ ο ο ο ^ ο ο ο ο ιε s s s ! o h £ o o o s o o — — — — ο — (ν * — — c ε ι> ο s 1η γλ ν ο ο ο ^ ^ ο ο ' ί ο ο ο (ν μ <ν <ν <υ c «> c 1) ω ~ > ω c3 ^ t5j ι. η η α o o n k " > ( n r o t < x > o o r υ-> μ π (ν tj· γ** j s s s : ο lα) u. η α u. η α ο <ν ο ί!7ι ο ο ο •ο c ε ύ .2 α> μ •ο c ε -η l i t t. e λ -ϊ u η ρ α» α» t-c υ α» 3 u α £ ζ βί m (ο ο ί ν ο ο ^ ο ο (χ) —ι — ο ο̂ "3" "3" (ν r<χ> — — γ*-> — ( χ ) γ 0 γ ( ν ο ( ν γ 0 0 — 00γ-ι/->"3-(ν<χ><χ> — — c! = ξ > > > = ξ > < χ r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) areview of speech therapy services in ten cerebral palsy schools 53 i a s s e s s m e n t of patients in the ten c e r e b r a l p a l s y schools nine of the ten schools used a battery of tests to assess speech, hearing and language abilities of their patients. five of the ten schools did not include details of hearing tests in their replies but almost certainly have some system of hearing screening and/or free field testing and/or formal audiometric assessment. table iv gives details of the types of tests used. s c h o o l hearing a r t i c u l a t i o n language r e a d i n g &, o t h e r t e s t s 1 free field hearing p h o n e t i c illinois test of psychodetailed examitests i n v e n t o r y linguistic a b i l i t i e s n a t i o n of s p e e c h filtered music a f r i k a a n s p e a b o d y p i c t u r e vom e c h a n i s m , hearing tests & english c a b u l a r y test b r e a t h i n g , basic pure t o n e a u d i o r e n f r e w n o r t h w e s t e r n s y n t a x f u n c t i o n s &, m e t r y articulas c r e e n i n g test p h o n a t i o n . s p e e c h a u d i o tion r e e l scale assessing m e t r y a t t a i n l a n g u a g e skills in w e p m a n a u d i t o r y m e n t infancy p e r c e p t i o n test h o u s t o n test for lang o l d m a n f r i s t o e guage d e v e l o p m e n t • w o o d c o c k audir e y n e l l d e v e l o p m e n t a l t o r y p e r c e p t i o n l a n g u a g e scales t e s t r e n f r e w w o r d f i n d i n g r o y a l n a t i o n a l v o c a b u l a r y scale i n s t i t u t e for t h e r e n f r e w f l o y d a c t i o n deaf p i c t u r e p i c t u r e test screening test v o c a b u l a r y test for of hearing y o u n g c h i l d r e n (modified from w a t t s ) r e n f r e w bus s t o r y e i s e n s o n e x a m i n i n g for a p h a s i a & related d i s t u r b a n c e s sklar a p h a s i a scale 11 f r e e field g o l d m a n illinois test of p s y c h o g a t e s r e a d i n g h e a r i n g tests f r i s t o e linguistic a b i l i t i e s r e a d i n e s s pitch p i p e s a r t i c u l a p e a b o d y p i c t u r e von e a l e s a n a l y s i s t i o n t e s t c a b u l a r y t e s t basic c o n c e p t i n v e n t o r y m c d o n a l d , c h a n c e l a n g u a g e e v a l u a t i o n s c h u e l l a p h a s i a d e t a i l e d e x a m i n a t i o n of s p e e c h m e c h a n i s m , b r e a t h i n g , basic f u n c t i o n s & p h o n a t i o n iii w e p m a n a u d i r e n f r e w illinois test of p s y c h o u . c . t . s c h o l a s t i c t o r y p e r c e p t i o n a r t i c u l a linguistic a b i l i t i e s t e s t s t y c a r test of t i o n r e y n e l l d e v e l o p m e n t a l d e t a i l e d e x a m i hearing a t t a i n l a n g . scales n a t i o n of s p e e c h m e n t r e n f r e w f l o y d a c t i o n m e c h a n i s m , t e s t p i c t u r e test v o c a b u l a r y t e s t for y o u n g c h i l d r e n r e n f r e w bus s t o r y r e n f r e w word f i n d i n g v o c a b . scale n o r t h w e s t e r n s y n t a x b r e a t h i n g , basic f u n c t i o n s & p h o n a t i o n table iv continued tydskrif van die suid-afriaanse vereniging vir spraak engehoorheekunde, vol. 21, deseber 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 i audrey shavell s c h o o l hearing a r t i c u l a t i o n l a n g u a g e r e a d i n g & o t h e r t e s t s s c r e e n i n g test e i s e n s o n e x a m i n i n g for a p h a s i a a n d related d i s t u r b a n c e s a b b r e v i a t e d schuell a p h a s i a test m y k l e b u s t p e a b o d y p i c t u r e voc a b u l a r y test h u t t o n c u r r i e semi d i a g n o s t i c test iv free field h e a r i n g t e s t s pitch pipes p u r e t o n e a u d i o m e t r y s p e e c h a u d i o m e t r y p h o n e t i c i n v e n t o r y illinois test of psycholinguistic abilities . v w e p m a n a u d i t o r y p e r c e p t i o n test p e a b o d y p i c t u r e voc a b . test illinois test of psycholinguistic abilities vi i n f o r m a l h e a r i n g t e s t s w e p m a n a u d i t o r y p e r c e p t i o n test p h o n e t i c i n v e n t o r y a f r i k a a n s e a r t i k u l a s i e o n d e r s o e k illinois test of psycholinguistic abilities p e a b o d y p i c t u r e voc a b u l a r y test v e r b a l l a n g u a g e dev e l o p m e n t scale basic c o n c e p t invent o r y p r e s c h o o l language d e v e l o p m e n t scale t e a c h e r s a u d i t o r y & l a n g u a g e kit d e t a i l e d e x a m i n a t i o n of s p e e c h m e c h a n i s m , b r e a t h i n g , basic f u n c t i o n s & p h o n a t i o n vii illinois t e s t of p s y c h o linguistic a b i l i t i e s viii a u d i o m e t r i c t e s t s a r t i c u l a t i o n t e s t s a p h a s i a t e s t s ' ix g o l d m a n f r i s t o e w o o d c o c k a u d i t o r y discrimin a t i o n p h o n e t i c i n v e n t o r y p e a b o d y p i c t u r e voc a b u l a r y test illinois test of psycholinguistic abilities n a t i o n a l b u r e a u of e d u c a t i o n a l & social r e s e a r c h r e a d i n g & lang u a g e t e s t s / x a f r i k a a n s e a r t i k u l a s i e o n d e r s o e k p e a b o d y p i c t u r e voc a b u l a r y test illinois t e s t of p s y c h o linguistic a b i l i t i e s r e n f r e w l a n g u a g e scales a n a l y s i s of s p e e c h s a m p l e s of c h i l d r e n neales a n a l y s i s of r e a d i n g a b i l i t y table iv. tests used to diagnose hearing, articulation, language and reading in cerebral palsy schools. journal of the south african speech and hearing association, vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a review of speech therapy services in ten cerebral palsy schools 55 reference to table iv indicates the increasing need felt by speech therapists working at cerebral palsy schools to assess their patients as objectively, scientifically and comprehensively as possible. the multifaceted problems presented by patients at a cerebral palsy school are of a very complex nature and without utilizing objective testing procedures one could easily underestimate the severity of a language disorder and/or auditory perception problem while one deals with the inhibition of pathological reflex patterns and facilitation of more normal movements and vice-versa. no single patient is given all the tests, but it is important for the speech therapist to have a wide enough battery of tests to adequately assess all aspects of speech and language. filtered music hearing testing has been successfully used as a hearing screening technique at school i for the past year. the use of this method enables one to test the hearing of very young and/or retarded and/or hyperactive and/or unco-operative c h i l d r e n 1 3 . the v a l u e of j o i n t a s s e s s m e n t of patients by physiotherapist, o c c u p a t i o n a l t h e r a p i s t a n d speech t h e r a p i s t speech therapists working at eight of the ten schools in this survey felt there was real merit in joint assessment of the patients. this is particularly valuable when dealing with the severely handicapped cerebral palsied patient. in the writer's opinion it is one of the best methods of 'in-service training' for therapists and teaches the speech therapist to see her patient as a 'whole' — the essential basis of all the modern techniques of t r e a t m e n t . 2 , 1 0 , n · 1 2 case c o n f e r e n c e s regular case conferences are held at seven of the ten schools at varying intervals ranging from every six months to every twenty-four months depending on the enrolment at the various schools. speech therapists in all these schools found the regular case conference a most valuable opportunity for an interchange of ideas about the patient. problems and difficulties being experienced by one member of the team can be discussed and a combined programme devised to overcome or reduce them. since the majority of our patients attend the cerebral palsy.schools in south africa from infancy to late adolescence, we have to live with our failures as well as our successes and it is at the case conference that one sees the integration of the various therapeutic, educational, psychological and social services. as the children mature, their needs change and the emphasis often alters from intensive therapy and formal education to reduced 'maintenance therapy' and pre-vocational training. the value of the case conference is enhanced if all members of the team know in advance which patients are to be discussed each week, so that they can adequately prepare formal reports including the most recent test results in each department. as assessment should ideally be an 'on-going process' the case conference provides the ideal opportunity to obtain the latest information on the patient from every aspect. this in turn leads to a deeper understanding and appreciation of the patient's problems and difficulties. tydskrif van die suid-afriaanse vereniging vir spraak engehoorheeikunde, vol. 21, deseber 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 audrey shavell the u s e of communication b o a r d s or other n o n v e r b a l systems o f communication this question was included because it is felt that therapists are becoming more realistic. as our experience in this field increases we appreciate that some severely handicapped cerebral palsied patients will never communicate 'easily' on a verbal level and the effort of vocalization and oral communication frequently triggers off such severe spasm or such fluctuations of muscle tone that the patient is rendered completely 'speechless' and very frustrated'. by providing an alternate non-verbal means of communication early in the therapy programme we can break this vicious circle and reduce the pressure for verbalization and frustration at not being able to indicate simple everyday wants and needs. mcdonald and schultz 6 lucidly explain how the early use of communication boards for severely handicapped children, facilitates the development of inner language and the desire to communicate. hagen, porter and brink 4 reported on the use of a non-verbal electro-mechanical communication device for retarded children with cerebral palsy. five of the ten schools in the present survey were using or had used a non-verbal communication system. details will be found in table v. s c h o o l t y p e of n o n v e r b a l c o m m u n i c a t i o n s y s t e m used i p i c t u r e , p i c t u r e a n d w o r d , w o r d s o n l y , m o u n t e d o n c a r d b o a r d o r hardb o a r d covered in t r a n s p a r e n t p lastic. p a t i e n t uses h e a d , arm or foot t o p o i n t a n d i n d i c a t e n e e d s a n d c a n f o r m u l a t e s e n t e n c e s . ii m a g n e t i c p i c t u r e c a r d o n wheel chair iii p r e v i o u s l y t r i e d c o m m u n i c a t i o n b o a r d . n o w e x p e r i m e n t i n g w i t h p a g e t ' s g e s t u r e language s y s t e m . iv t y p i n g used a s a n a l t e r n a t e m o d e o f c o m m u n i c a t i o n . vi p i c t u r e b l o c k b o a r d ; m o v a b l e p i c t u r e c a r d b o a r d o n " c o u n t i n g f r a m e " p r i n c i p l e a t t a c h e d t o w h e e l ch air. table v. description of non-verbal communication systems used in cerebral palsy schools. / / / t r a i n i n g in h a n d l i n g the n e u r o l o g i c a l l y impaired patient work with the neurologically impaired patient is highly specialized and one of the questions asked the therapists was whether they had received special training in this field on (a) an under-graduate level (b) post-graduate level. their replies are analysed in table vi. at the present time the only post-graduate course available in south africa is the diploma for therapists in special education (cerebral palsied) at the journal of the south african speech and hearing association, vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a review of speech therapy services in ten cerebral palsy schools university of south africa. this course does not include actual principles or techniques of treatment. five of the twenty-six speech therapists in the present survey had completed a bobath course in the neurophysiological treatment of cerebral palsy either in london or when dr and mrs bobath visited south africa or with a 'bobath trained' teacher. two therapists had attended professor margaret rood's course on sensory stimulation techniques. the need for a theoretical and practical course on a post-graduate level for therapists dealing with neurologically handicapped patients is becoming ever more urgent. it should include a detailed study of normal development from birth to three years of age and all the neurophysiological techniques of treatment. the final question of the survey requested the speech therapists to list the topics they would like to discuss if it were possible for speech therapists working at cerebral palsy schools to meet. the forty topics listed appear in the appendix. conclusion (1) the far-sighted policy of the department of national education in allowing pre-nursery school children and young babies to receive treatment on an out-patient basis at the cerebral palsy schools in south africa is highly commendable. this policy has led to a decrease in the numbers of severely handicapped, immobile older children because starting treatment at a really young age has many advantages. some of these are: (a) the prevention of contractures and deformities or reduction in severity of contractures and deformities. (b) the inhibition of pathological reflex patterns and facilitation of normal postural reactions and movement sequences enable the children to be more mobile and independent which in turn widens their environment and favourably influences language development. (c) the prevention of the development of poor patterns of behaviour, learning and attitudes by correct 'early' handling and supportive counselling of parents of young patients. (d) achieving maximum mental growth and development. elizabeth kong states: on the whole the results have been most encouraging. furthermore, it is striking that there are fewer mentally retarded children among the cases of cerebral palsy treated early. we believe that their normal motor experience has given these children a chance to develop their normal potentials, whereas the children treated later lack this experience and do not have the same chance to develop normally, so that, unless they are of superior intelligence, they are likely to attain only a subnormal performance. in cases where treatment has not been started until the second year of life the results have not been so satisfactory.5 (2) the question of the placement of children in the minimal brain dysfunction and aphasic categories in cerebral palsy schools will have to be considered. there is no doubt that these children benefit from the educational programme and therapies but if their numbers continue to increase, tydskrif van die suid-afriaanse vereniging vir spraak engehoorheeikunde, vol. 21, deseber 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 audrey shavell school number of speech therapists number received undergraduate training in c.p. number + details of post graduate training i 6 2 2 bobath, 1 rood, 3 diploma in special education (university of south africa) ii 3 3 0 iii 3 2 1 bobath, 1 rood, 1 m.a. psychology iv 3 1 1 diploma in special education (cerebral palsy) v 1 1 0 vi 3 1 1 bobath + diploma in • special ed (hearing) 1 diploma in special •education (cerebral palsy) vii 4 2 i 1 bobath, 3 diploma in special education (cerebral palsy) viii 1 1 0 ix 1 1 0 x ' 1 1 0 totals 26 15 therapists received 1-2 . months undergraduate training 5 therapists bobath trained; 2 shortcourse in rood method; 8 therapists d.s.e. cerebral palsy; 1 therapist d.s.e. hearing. table vi. details of numbers of speech therapists at each of the ten , schools who had received underand/or post-graduate training in cerebral palsy schools. provision of separate facilities for them will have to be made. one of the ten schools in the present survey already has 54,78% of its total enrolment in the minimal brain dysfunction group. the child with a serious language impairment, associated behavioural anomalies, perseveration, disinhibition, short attention span, and a poor memory needs more than journal of the south african spch and hearing association, vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a review of speech therapy services in ten cerebral palsy schools 59 two or three weekly sessions of speech therapy. he or she needs an organized, 'structured' nursery school or pre-grade programme and daily speech and occupational therapy to overcome his learning, perception and language disabilities as rapidly as possible. if these children are excluded from cerebral palsy schools an alternate programme of schooling and treatment will have to be evolved for them. although they are difficult to handle especially when very young, they are among our most rewarding cases and our regret is that video-taped progress records have not been kept. if treatment of these children is started early many of them can go to normal schools in standard i or ii. (3) merely comparing the ratio of speech therapists to the number of children receiving speech therapy at any given school can lead to a false impression because the frequency of treatment is excluded. success in this work depends very largely on the intensity and frequency of treatment, repetition and reinforcement being the keys. the numbers of speech therapy posts at cerebral palsy schools should be increased so that: (a) all children who require speech therapy will receive sufficient treatment (b) there is time for "in-service" training of new staff, lectures, case demonstrations, joint 'team' assessments, case conferences and student training. the original formula for the appointment of speech therapists at cerebral palsy schools was drawn up many years ago when these schools catered . almost exclusively for the 'pure' cerebral palsied child with, a visible motor problem. the population of the cerebral palsy schools currently include as many and in one case more children with 'soft neurological' signs who have a higher incidence of language disorders and problems in conceptualization. if we compare the percentage of language disorders in the cerebral palsy group to that in the minimal brain dysfunction group it will be seen that in six out of the ten schools the percentage is significantly higher in the minimal brain dysfunction group. this difference is increased further if we add the aphasic group to the minimal brain dysfunction group. (4) speech therapists working at cerebral palsy schools should familiarise themselves with the latest tests and should critically evaluate the construction of new tests, their validity, reliability and suitability for south african children so that they select appropriate tests to pin-point the child's problems. an urgent need for afrikaans translation and standardization of language tests exists. (5) the general impression gained from the one hundred percent return of questionnaires and the detail in which most therapists completed the questionnaire, is that speech therapists working at cerebral palsy schools find this work both rewarding and challenging. although we may not see results as quickly as our colleagues in general speech therapy practice, there are many advantages to working as a member of a,dynamic team tydskrif van die suid-afriaanse vereniging vir spraak engehoorheeikunde, vol. 2 , deseber 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 audrey shavell where medical consultants assess patients together with therapists. in addition, members of the team are accessible for repeated assessments and discussions and are also receptive to suggestions. by virtue of our geographic isolation from leading centres in britain, the united states of america and europe, our.therapists have not become exponents of one method or technique but are attempting to use an holistic eclectic approach. this freedom of choice of treatment results in a very real sense of responsibility on the part of the therapist. a successful eclectic approach is possible only when the therapist has a sound knowledge of the different techniques, including appreciation of their common denominator and is therefore able to select the most suitable approach to meet the child's needs at a particular time. for this reason provision of post-graduate training in the habilitation of the neurologically impaired patient is becoming a matter of urgency. acknowledgements most sincere thanks are extended to the principals and speech therapists of the ten cerebral palsy schools who so willingly co-operated in completing the questionnaires on which this survey was based. references (1) act no. 41 of 1967 (1968): to provide for the establishment, maintenance, administration and control of, and the rendering of financial aid in respect of schools at which certain classes of education are provided for conferring upon provincial councils powers in respect of certain classes of education and for matters incidental thereto. republic of south africa government gazette, extraordinary. vol. 42, no. 2253, december. (2) bobath, b., bobath, k. (1972): the neurodevelopmental approach to treatment. in physical therapy sen'ices in the developmental disabilities. ed. paul pearson, c.c. thomas, springfield, 111. (3) eisenson, j. (\912)\ aphasia in children harper and row, n.y. (4) hagen, c., porter, w., brink, j. (1973): non-verbal communication: an alternate mode of communication for the child with severe cerebral palsy. /. speech & hearing dis., 38, 4, 448. / (5) k5ng, e. (1966): very early treatment of cerebral palsy. develop. med. child neurol., 8, 198-202. (6) mcdonald, e.t. schultz, a.r. (1973): communication boards for cerebral palsied children. j. speech & hearing dis., 38, 1, 73. (7) murray, c.h. de c. (1973): report to the management committee of the national cerebral palsy division of the national council for the care of cripples in south africa. (8) oosthuizen, i., pelser, j.w. (1973): the use of respirator in the treatment of cerebral palsied children. physiotherapy, 29, 2. journal of the south african speech and hearing association, vol. 21 december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a review of speech therapy services in ten cerebral palsy schools 61 (9) report of the committee of inquiry into the education of children with minimal brain dysfunction. (no. 72/1969), government printer, pretoria. (10) rood, m. (1969): the use of sensory receptors to activate, facilitate and inhibit motor response, autonomic and somatic changes in developmental sequence. unpublished notes, university of southern california and instructional course, south africa. (11) vojta, v. (1973): early treatment of children at risk for cerebral palsy. analysis of end results. monatsschrift fur kinderheilkunde, 121, 271. (12) voss, d.e. (1972): proprioceptive neuromuscular facilitation: the p.n.f. method. chapter 5 in physical therapy in the developmental disabilities, pearson, p. ed., c. c. thomas, springfield, 111. (13) waldman, h.l., cocroft, c.l., ludi, b. (1974): filtered music: a hearing test for young children. sa medical journal, 48, 1772. appendix topics for discussion suggested by speech therapists at the cerebral palsy schools (1) the basis for selecting cases for speech therapy at cerebral palsy schools (2) when should speech therapy be terminated? (3) the frequency of speech therapy especially for aphasic patients (4) improved programming and methods of presentation and work for children with congenital auditory imperception (5) views and methods employed by therapists with language cases (6) later incidence of and type of language problems in children who initially had delayed speech (7) similarities and differences in symptomatology and treatment of receptive aphasia and the hard of hearing child (8) the concept of childhood aphasia (9) techniques for activating a paralyzed velum in cases of upper motor neurone lesions (10) how to improve breathing for the cerebral palsied child (11) the diagnosis of aphasia in the cerebral palsied child (12) intellectual capacity or level and speech therapy. should speech therapy be provided for children with low i.q. levels? (13) positioning and techniques to facilitate mouth movements and techniques of inhibition of pathological reflexes tydskrif v die suid-afriaanse vereniging vir spraak engehoorheeikunde, vol. 21, deseniber 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 audrey shavell (14) drooling (15) specific hearing tests (16) devising and instituting home programmes (17) handling the infant cerebral palsied child and his mother (18) ideas on running parent counselling groups (19) the role of the social worker in the cerebral palsy school (20) use of non-verbal communication in cerebral palsy. (21) the.speech therapist's role in remedial reading & spelling training of brain injured children with poor language.'should we treat dyslexics in cerebral palsy schools? (22) diagnostic procedures (23) treatment of the athetoid child (24) standardization of language and auditory discrimination tests on south african children (25) translation and standardization of language and other tests into afrikaans (26) tests and training programmes to improve afrikaans language problems ^ e.g. generative grammar (27) feeding the cerebral palsied child (28) orientation of treatment of severe cerebral palsy cases who will never talk (29) motivating the cerebral palsied child and motivating parents to develop independence (30) is under-graduate training in cerebral palsy satisfactory? (31) language therapy vs. speech therapy which one should enjoy preference? (32) recent research in speech therapy techniques for the cerebral palsied child (33) how professional are we? (34) group opinion on our medical orientation (35) exchange of ideas on therapy approaches with the cerebral palsied child (36) discussion on newest developments in the cerebral palsied field medical and therapeutic (37) minimal cerebral dysfunction in the cerebral palsy schools evalua' tion and handling (38) compiling and carrying out an integrated therapy and educational programme (39) record keeping, test results, doctors reports etc. (40) experimental work execution and results journal of the south african speech and hearing association, vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) audiometry weber and rinne tests as compared to pure-tone thresholds • thompson, alison κ., b.a. (sp. & η. th.) ( w i t w a t e r s r a n d ) speech therapy department, general hospital, johannesburg summary results of the audiometric weber and rinne tests were compared t o pure t o n e thresholds in 1 8 5 bantu patients. the frequency of 1 0 0 0 hz was selected as being most suitable for weber and rinne testing. t h e weber w a s found t o be of limited diagnostic value even w i t h unilateral c o n d u c t i v e losses whilst the rinne displays a fair degree of efficiency and is of value as a routine supplement t o audiometric threshold tests. opsomming resultate van die o u d i o m e t r i e s e weber en rinne t o e t s e is m e t s u i w e r t o o n drempels vergelyk. 1 8 5 b a n t o e pasiente is as proefpersone gebruik. die frekwensie van looohz is as die geskikste vir die weber en rinne t o e t s e gereken. die weber is, selfs met eensydige geleidings verlies, van beperkte diagnostiese waarde gevind, terwyl die rinne 'n redelike graad van doeltreffendheid g e t o o n het en aanvullend b y die o u d i o m e t r i e s e drempel t o e t s e gebruik kan word. at the hearing clinic at baragwanath hospital, johannesburg, routine audiometric weber and'rinne tests were fairly frequently found to be inconsistent with pure tone thresholds. in the present study, a large number of pure tone audiograms were compared with audiometric rinne and weber results. in recent years, very little has appeared in the literature concerning the weber and rinne tests. that which has appeared deals almost exclusively with testing by means of tuning forks. most authors stress the need to include the weber and rinne in a battery of tuning fork tests including the schwabach and gelle t e s t s . 1 ' 3 , 6 , 8 , 1 1 , 1 ? reliability of these tests has been questioned by these workers but they are nevertheless considered to be useful in supplementing audiometric results. testing by means of the audiometric bone vibrator has certain advantages over testing by means of tuning f o r k s . 2 , 8 , 1 3 the bone vibrator maintains its , intensity output at any desired level, whereas the tuning fork fades rapidly in intensity, especially in the high frequencies. 1 1 in addition, the bone vibrator permits a standard presentation which is independent of the ear of the o p e r a t o r . 5 , 1 3 materials and methods hearing assessments of 185 south african bantu of both sexes with an age range of 12 to 75 years were analysed. these were taken randomly from the tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheeikunde, vol'. 21, desember 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the breckwoldt laryngo-reflectoscope by dr. g. h. breckwoldt a s s o c i a t e p r o f e s s o r of s p e e c h , s t . l o u i s u n i v e r s i t y , m i s s o u r i , u . s . a . introduction a l t h o u g h t h e b r e c k w o l d t l a r y n g o r e f l e c t o s c o p e * s h o u l d p r o v e a u s e f u l i n s t r u m e n t i n t h e c o n s u l t i n g r o o m of t h e m e d i c a l d o c t o r p a r t i c u l a r l y t h e e . n . t . s p e c i a l i s t t h e a u t h o r d e s i g n e d i t e s p e c i a l l y for t h e s p e e c h t h r a p i s t . t h e l a t t e r w o u l d n e v e r a t t e m p t t o t r e a t a n a r t i c u l a t o r y d i s o r d e r w i t h o u t t h o r o u g h l y e x a m i n i n g t h e i n d i v i d u a l ' s s p e e c h m e c h a n i s m . w h y s h o u l d h e e v e r v e n t u r e o r b e f o r c e d t o h a n d l e a v o i c e d i s o r d e r w i t h o u t h a v i n g h a d a s m u c h a s a l o o k a t t h e i n d i v i d u a l ' s v o i c e m e c h a n i s m ? a v o i c e d i s o r d e r c a n n e v e r b e j u d g e d b y e a r a l o n e ; i t m u s t b e e x a m i n e d v i s u a l l y . t h e t h e r a p i s t h a s t o l e a r n h o w t o e x a m i n e t h e l a r y n x of t h e v o i c e d e f e c t i v e a s w e l l a s h e l e a r n s t o e x a m i n e t h e facial, o r a l , p h a r y n g e a l , d e n t a l , e t c . , c o n d i t i o n of t h e s p e e c h d e f e c t i v e . a f t e r h a v i n g s t u d i e d t h e a n a t o m y , p h y s i o l o g y , n e u r o l o g y a n d p a t h o l o g y of t h e v o i c e m e c h a n i s m , h e s h o u l d b e t r a i n e d i n a v o i c e l a b o r a t o r y t o g a i n p r a c t i c a l e x p e r i e n c e i n t h e t e c h n i q u e s of v o i c e e x a m i n a t i o n , w i t h o u t w h i c h a n y k i n d of t h e r a p y ( u n l e s s g i v e n u n d e r t h e d i r e c t a n d c o n s t a n t s u p e r v i s i o n of a m e d i c a l m a n ) m i g h t b e d a n g e r o u s . o n c e t h e s p e e c h t h e r a p i s t k n o w s n o t o n l y h o w t o l o o k a t a l a r y n x , b u t a l s o w h a t i n d e t a i l t o l o o k for, h e w i l l b e a g r e a t a s s e t t o h i s p r o f e s s i o n . c a s e s w h o c o m e t o t h e t h e r a p i s t a n d w h o s e v o i c e e x a m i n a t i o n s h o w s o r g a n i c d e f e c t s w i l l b e r e f e r r e d t o a m e d i c a l d o c t o r o n t h e o t h e r h a n d t h e m e d i c a l m a n w i l l b e a b l e t o s e n d t o t h e v o i c e l a b o r a t o r y * the author could have coined a homogeneous greek word like "antilamposcope" (from antilampo": to reflect light) but preferred to give the instrument the mnemonically more suitable graecolatin name. t h o s e v o i c e c a s e s w h o d o n o t r e q u i r e m e d i c a l t r e a t m e n t , b u t a r e i n n e e d of v o i c e t h e r a p y . t h i s c o o p e r a t i o n b e t w e e n t h e v o i c e l a b o r a t o r y a n d t h e m e d i c a l p r o f e s s i o n w i l l e n s u r e t h a t v o i c e c a s e s w i l l r e c e i v e t h e b e s t p o s s i b l e c a r e . 1. history of indirect laryngoscopy t h e f i r s t s u c c e s s f u l l a r y n g o s c o p i c o b s e r v a t i o n k n o w n w a s n o t t h e e x a m i n a t i o n of a p a t i e n t o r s u b j e c t b y a d o c t o r , b u t a n a u t o l a r y n g o s c o p y p e r f o r m e d , i n 1854, b y a n a r t i s t . i t w a s t h e f a m o u s s p a n i s h s i n g e r a n d t e a c h e r of s i n g i n g m a n u e l g a r c i a . h e w a s c u r i o u s a b o u t t h e f u n c t i o n i n g of h i s l a r y n x , a n d u s i n g a d e n t a l m i r r o r for o b s e r v i n g , h e w a s t h e f i r s t p e r s o n t o s e e t h e v o c a l folds of a l i v i n g h u m a n b e i n g . i n 1857, t h e p h y s i c i a n c z e r m a k h a d t h e i d e a of p e r f o r m i n g g a r c i a ' s l a r y n x e x a m i n a t i o n w i t h a n a r t i f i c i a l l i g h t . i n 1858 h e p u b l i s h e d h i s l a r y n g o s c o p i c f i n d i n g s ( i n s i t z u n g s b e r i c h t , m a t h . n a t . w i s s . a b t . , xxix» 5 5 7 · cf. p a n c o n c e l l i c a l z i a : " q u e l l e n a t l a s , h a m b u r g , 1940, p . 3 0 ) a n d a p l a t e w h i c h illus t r a t e s a n a u t o l a r y n g o s c o p y , t h e f i r s t p i c t u r e e v e r p u b l i s h e d of t h i s t y p e of e x a m i n a t i o n . t w o y e a r s l a t e r , i n i 8 6 0 , c z e r m a k p u b l i s h e d h i s b o o k " d e r k e h l k o p f s p i e g e l u n d s e i n e v e r w e r t u n g fur p h y s i o l o g i e u n d m e d i z i n " l e i p z i g , (cf. p . c a l z i a : q u e l l e n a t l a s , p . 3 0 ) , i n w h i c h w e find t h e f i r s t i l l u s t r a t i o n of a ' l a r y n g o s c o p y p e r f o r m e d o n a p a t i e n t . s i n c e t h e n , e x c e p t for c h a n g e s i n m a t e r i a l a n d q u a l i t y of t h e l a r y n x m i r r o r , h e a d m i r r o r a n d l i g h t , t h e t e c h n i q u e of i n d i r e c t a u t o a n d h e t e r o l a r y n g o s c o p y h a s r e m a i n e d t h e s a m e . t h e o r i g i n a l i t y of t h e b r e c k w o l d l a r y n g o r e f l e c t o s c o p e , d e s i g n e d b y t h e a u t h o r i n 1962 l i e s i n t h e i n t r o d u c t i o n of a t r a n s p a r e n t m i r r o r w h i c h e n a b l e s b o t h t h e e x a m i n e r a n d t h e e x a m i n e e t o h a v e a n e f f o r t l e s s 0 journal of the south african logopedic society august, 1963 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a n d p e r f e c t v i e w of t h e l a r y n x . t h e i n s t r u m e n t c o m b i n e s all a d v a n t a g e s of a u t o a n d h e t e r o l a r y n g o s c o p y a n d h a s t h e r e f o r e m u l t i p l e u s e s . i t c a n b e o p e r a t e d w i t h a c o n t i n u o u s o r a s t r o b o s c o p i c l i g h t s o u r c e . 2. description of the laryngoreflectoscope t h e d i m e n s i o n s of t h e i n s t r u m e n t a r e m a d e t o f a c i l i t a t e t h e r e f l e c t o s c o p i c e x a m i n a t i o n w i t h t a b l e a n d c h a i r s of a v e r a g e h e i g h t , s o t h a t a p a r t f r o m a b r i g h t l a m p (_|_ 100 w a t t ) * o r a l a r y n g o s t r o b o s c o p i c l a m p * * n o f u r t h e r e q u i p m e n t is r e q u i r e d . t h e i n s t r u m e n t (cf. f i g 1) c o n s i s t s of:(1) a r e f l e c t o r ( 3 ^ " d i a m . ) , of t h e t y p e of a m e d i c a l h e a d m i r r o r , t h e c e n t r a l v i e w i n g h o l e of w h i c h is b l o c k e d u p ; (2) a p l a n e t r a n s p a r e n t mirror ( 3 " x 6 " ) , of t h e m i r r o p a n e t y p e : (3) t w o ball j o i n t s , o n e a t t a c h e d t o e a c h m i r r o r ; (4) t w o g o o s e n e c k a t t a c h m e n t s , ( e a c h 1 2 " i n l e n g t h ) , w h i c h a r e e x t r e m e l y f l e x i b l e b u t r e m a i n s t a b l e in e a c h d e s i r e d p o s i t i o n ; fig. 1 the ideal light (i.e. daylight type) is the burton lamp (n.1277), made by the burton manufacturing company, el segundo, california. with an adjustment to narrow its light beam the laryngo-synchronstroboscope ks 3 has proved ideal in conjunction with the laryngo-reflectoscope. the ks 3 instrument is made by r. timcke, hamburg, germany. 1 journal of the south african logopedic society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) (5) (6) (7) t w o b a l l j o i n t s , o n e a t t a c h e d t o t h e t o p of e a c h g o o s e n e c k ; t w o j o i n t c o n n e c t o r s , s e c u r i n g t h e m i r r o r s t o t h e g o o s e n e c k ; a g o o s e n e c k h o l d e r d i a m . , h i g h ) , i n t o t h e t o p of w h i c h t h e t w o g o o s e n e c k s a r e a t t a c h e d a n d t h e b o t t o m p o r t i o n of w h i c h h a s a s h o r t c o a r s e s c r e w t h r e a d p r o j e c t i o n ; (8) a riser b l o c k ( 1 " d i a m . , 3 ' h i g h ) w i t h m a l e a n d f e m a l e c o a r s e t h r e a d ( | " d i a m . ) e n d i n g s t o m a t c h t h e t h r e a d o n t h e b a s e of t h e g o o s e n e c k h o l d e r ; a n a r m ( 1 3 ^ " l o n g , 1 " w i d e , 3 / 8 " t h i c k ) , w h i c h a t o n e e n d h a s a n u n t h r e a d e d h o l e ( § " d i a m . ; t h e c e n t r e b e i n g f r o m t h e e n d p o i n t of t h e a r m ) a t t h e o t h e r e n d a t h r e a d e d h o l e ( | " d i a m . ; t h e c e n t r e b e i n g f r o m t h e e n d p o i n t of t h e a r m ) , i n t o w h i c h t h e g o o s e n e c k h o l d e r s c r e w s ; (9) ( 1 0 ) a c t y p e t a b l e c l a m p , s u i t a b l e t o c l a m p o n t a b l e t o p e d g e s of a t h i c k n e s s b e w e e n 2 ± " t o f'; ( 1 1 ) a w i n g s c r e w ( 1 " d i a m . ) f i t t i n g i n t o t h e t o p of t h e c c l a m p a n d h o r i z o n t a l l y s e c u r i n g t h e a r m t o it; (12) a laryngoscopic mirror; (13) a light source. t h e i n s t r u m e n t c a n b e b e n t t o l o w p o s i t i o n s (cf. f i g . 2) o r c a n b e e x t e n d e d b y m e a n s of t h e r i s e r b l o c k . t h e " l a r y n g o r e f l e c t o s c o p e " is s t o r e d in a n e s p e c i a l l y t a i l o r e d b o x , w h i c h k e e p s e a c h p a r t s e c u r e l y in p l a c e a n d m a k e s s h i p p i n g p o s s i b l e . fig. 2 & * *. ** <«*»*» λ \ ri-v •π8"' journal of the south african logopedic society august, 1963 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) fig. 3 august, 1963 journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 3. uses (a) t h e l a r y n g o r e f l e c t o s c o p e is u s e d for indirect laryngoscopy and laryngostrob o s c o p y . t h e r e f l e c t o r , r e p l a c i n g t h e h e a d b a n d a n d m i r r o r , g i v e s t h e e x a m i n e r m o r e f r e e d o m of m o v e m e n t . t h e t r a n s p a r e n t m i r r o r , a p a r t f r o m i t s r e f l e c t o s c o p i c u s e , s e r v e s a s a p r o t e c t i n g s h i e l d . (n.b.: f o r t h e e x a m i n a t i o n of i n f e c t i o n s u s p e c t c a s e s a l a r g e r g l a s s s h i e l d c a n b e m o u n t e d o n t h e i n s t r u m e n t ) . ( b ) t h e l a r y n g o r e f l e c t o s c o p e is u s e d t o instruct students of voice science and voice p a t h o l o g y . i t f a c i l i t a t e s : i. t h e f o c u s s i n g of l i g h t ( o n h i m s e l f o r a s u b j e c t ) ; ii. t h e s t u d y of h i s o w n l a r y n x (cf. f i g . 3); iii. t h e s t u d y of h i s o w n l a r y n x , w h i l e o t h e r s w a t c h ; iv. t h e e x a m i n a t i o n of a l a r y n x , w h i l e t h e e x a m i n e e h a s a s i m u l t a n e o u s l o o k ; v . t h e e x a m i n a t i o n of h i m s e l f b y a n o t h e r p e r s o n , w h i l e h e l o o k s a t h i s o w n l a r y n x a t t h e s a m e t i m e ; v i . t h e d e m o n s t r a t i o n of a s u b j e c t ' s l a r y n x , w h i l e a g r o u p of b e t w e e n 6 8 p e o p l e l o o k o n . ( c ) i t is i d e a l l y s u i t e d t o s h o w t h e l a r y n x t o certain cases for pedagogic reasons. e x a m p l e s a r e p e o p l e w h o s m o k e , d r i n k o r i n d u l g e in v o c a l a b u s e , f r o m w h i c h t h e y w i l l n o t r e f r a i n , u n l e s s t h e y a r e s h o w n t h e d a m a g e t h e y h a v e d o n e t o t h e i r v o c a l m e c h a n i s m . c o l o u r p h o t o g r a p h s of l a r y n g e a l n o r m a l i t y a n d a b n o r m a l i t i e s a r e s h o w n t o m a k e t h e s u b j e c t u n d e r s t a n d h i s / h e r o w n c o n d i t i o n . p e o p l e w h o h a b i t u a l l y p h o n a t e w i t h h a r d g l o t t a l o n s e t s a n d c a n n o t r e f o r m t h r o u g h a u d i t o r y o r k i n e s t h e t i c c o n t r o l w i l l , a s a r u l e , b e n e f i t f r o m t h e v i s u a l a p p r o a c h w i t h t h e l a r y n g o r e f l e c t o s c o p e . p r o f e s s i o n a l s p e a k e r s a n d s i n g e r s , v o c a l l y h a n d i c a p p e d b e c a u s e of u n d u e w o r r y a b o u t t h e i r v o i c e s , w h o a r e e x a m i n e d w i t h t h e i n s t r u m e n t , s p o n t a n e o u s l y b e c o m e r e a s s u r e d a b o u t t h e i r l a r y n x . i n h i s s p r a c h h e i l k u n d e ( p . 1 6 1 , s e q . ) h . g u t z m a n n s t a t e s t h a t c a s e s of a p h o n i a s p a s t i c a , b o t h of t h e a d d u c t o r a n d t h e a b d u c t o r t y p e , a s w e l l a s s e v e r e d y s p h e m i c s c a n f r e q u e n t l y i m p r o v e r e m a r k a b l y , if t h e y a r e t a u g h t t h e u s e of a u t o l a r y n g o s c o p i c e q u i p m e n t . 4. conclusion p r a c t i c a l e x p e r i e n c e s h o w s t h a t , t h a n k s t o t h e t r a n s p a r e n t m i r r o r a n d t h e e x t r e m e flexib i l i t y of t h e i n s t r u m e n t , t h e l a r y n g o r e f l e c t o s c o p e is a p a r t i c u l a r l y e a s y t o h a n d l e , effici e n t d e v i c e for v o i c e e x a m i n a t i o n , s t u d e n t t r a i n i n g a n d r e h a b i l i t a t i o n w o r k . summary t h e l a r y n g o r e f l e c t o s c o p e is a n i n s t r u m e n t d e s i g n e d for i n s t r u c t i n g s t u d e n t s in t h e t e c h n i q u e s of v o i c e e x a m i n a t i o n a n d is u s e d for t h e d e m o n s t r a t i o n of t h e l i v e a n a t o m y a n d p h y s i o l o g y of t h e l a r y n x . i t is a l s o u s e d t o s h o w t h e l a r y n x t o c e r t a i n v o i c e c a s e s for p e d a g o g i c a n d t h e r a p e u t i c r e a s o n s . t h e i n s t r u m e n t c a n b e u s e d w i t h a c o n t i n u o u s o r s t r o b o s c o p i c l a m p . note the laryngo-reflectoscope was designed by the author and first built in june, 1962. it was shown and/ demonstrated at the scientific exhibits of the congress of the international assocaition of logopedics and phoniatrics, at padua, aug./sept., 1962, and of the convention of the american speech and hearing association, in new york, nov.1962. journal of the south african logopedic society august, 1963 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society trends in the field of habilitation of the cerebral palsied by f. m. tragott vorwerg. a short time ago, i completed a world tour of centres for the cerebral palsied. the advantages of present day air travel are such, that i covered over 100,000 miles in 20 countries. not only did i enjoy a "world's eye" view of facilities for the cerebral palsied, but i was able to examine these facilities, exchange views with hundreds of people dedicated to the many fields of work in cerebral palsy habilitation and discuss the work we ourselves are doing in south africa. it is impossible in an article such as this to describe all i saw, or discuss at length the wealth of knowledge gained by such a unique experience. however, a few general impressions may be of interest. of outstanding importance is that those working for the cerebral palsied belong not only to their own local community, but to an international family,. the members of which want to help each other. all over the world, there are those who want to share our problems, add to our knowledge, and are keenly interested in what we are doing in the union. we have long known of advances in our work in such countries as the united states and in australia. one was elated and humbled to hear of work being done in many backward areas (e.g. asia) for the cerebral palsied. elated at the high standard of knowledge of professional workers and humbled, because limited facilities in medicine, health, social welfare and education in poorly developed countries have presented formidable obstacles which have not prevented progress. the concept of cerebral palsy habilitation has changed. it is now universally acepted that treatment and education are only the first stages of a complete programme for the cerebral palsied. education which does not lead to economic independence or a useful daily life is wasteful and in many respects a failure. in all countries, realistic thinking and planning are replacing the over-optimistic generalisations which marked the initial development of work in our field. the days of fancy slogans telling us that all the cerebral palsied can become "normal citizens", if given treatment, are passing. this misguided publicity led parents to expect the impossible and filled them with hopes which were beyond realisation. there is much bitterness and heart-break as a result. professional workers with enthusiasm and great emotional impetus to be leaders in a new field of work, find, instead of expected miracles, acute frustrations and innumerable problems which still remain unanswered. it is quite wrong to call the cerebral palsied the "world's forgotten children." no other form of handicap has received so much attention of recent years or created so many controversies. many of the cerebral palsied have received years of skilled training in all aspects of habilitation. despite this, they remain severely handicapped in locomotion, hand function, speech and scholastic ability. pioneering efforts, initiated in every instance by parents, were almost entirely devoted to children with cerebral palsy. this is understandable. these children, however, are now almost grown up. the question arose—everywhere i went: "what happens to the children leaving cerebral palsy centres who need vocational training, or care which will provide a useful daily life?" in particular, parents are demanding some assurance that their children will have understanding care if they require it, when they (the parents) are no longer living. we have this problem in south africa, and it is occupying the full attention of the cerebral palsy division of the national council for the care of cripples, who hope the establishment of a village settlement will be the answer. vocational training and employment placement of the cerebral palsied was a main topic of discussion everywhere. australia, new zealand, the united states, canada and great britain have initiated special programmes to deal with this. from all reports received it is evident that the number of cerebral palsied who can be placed in the open labour market is pitifully small. a few remarks regarding the therapies. it is almost universally accepted that physio-occupational and speech therapies are essential services in the cerebral palsy unit. however, i visited centres where occupational therapists were not employed from choice. such therapy was shared by the physio-therapist and the teacher and, i may add, very successfully. then, too, it was very noticeable in vocational workshops in the united states, that the occupational therapist was often conspicuous by her absence. training was being r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 1 journal of the south african logopedic society september initiated and carried out by personnel direct from the fields of industry, commerce and the like. frequently, these people had had little or no previous association with the handicapped and yet were achieving startling results. a point put to me was that for years, the cases concerned had been managed by therapists with continual attention to their handicaps. in these workshops, the handicaps are taken for granted. in an environment geared to the function of a normal factory or office, the client is concerned with his worth as a potential employee, his output as a worker, his training to do a job, despite any handicaps. more important, with new feelings of personal worth and the realization that economic independence might be within reach, improvement in skills developed almost spontaneously, and these without the specific technical attention of doctors and therapists. in the field of physiotherapy, no one system has been evolved for the treatment of cerebral palsy. the most progressive centres are guided by the needs of the individual patient. thus, he may respond to one single method or parts of many methods, or even to just the personality and common sense of a therapist with only her general training and perspicacity to guide her. il is heartening to find that those whom we accept as authorities in this field are not quite so hide-bound as of yore. each is beginning to accept the ideas of others. many physiotherapists are asking if there is not such a thing as "too much physiotherapy" for the cerebral palsied. some centres are experimenting on reducing the time given to treatment. it might be significant that in one centre, where great stress was laid on physiotherapy of a specific type (to the extent that i felt it was a discipline) there was a large number of behaviour problems among the cases. the fact that great emphasis was laid on the use of braces and appliances with consequent restriction of movement could also be a causative factor. however, i visited only one cerebral palsy centre for children where physiotherapy was not available. parents took their children to the local hospital after school hours for treatment. medical officers reported no adverse effects from this arrangement, while the education of the children benefited through less interruption in the schooling programme. the essential place of physiotherapy in the habilitation programme is beyond dispute. physical improvement in the severely handicapped cerebral palsied case under treatment is slow and rarely spectacular. those parents who doubt the value of physiotherapy services should see as i did the chronic deformities developed over the years in adult cerebral palsy cases who had not had the benefit of treatment and training. born at a time when no services were available, these men and women, fine and intelligent people, are today so deformed and handicapped as to be inmates in a home for custodial care. lack of adequate communication in speech and writing is universally recognized as one of life's greatest handicaps. the speech therapist is of vital importance in the cerebral palsy habilitation scheme. it is significant that all countries report a shortage of trained speech therapists. one no longer hears of "speech defects" but of "language disorders" which covers a much wider field. the ability to sjieak and have understanding of the written and spoken word touches on all subjects in the schooling programme. consequently, the speech therapist plays an important part in the teaching of reading, writing and arithmetic—all aspects of language development. teachers and speech therapists must work closely together, more so than we have expected in the past. in new zealand where this is fully realized, students for speech therapy courses must be qualified teachers before they are accepted for training and this is also the case in parts of australia. such "teacher-therapists" are not concerned only with speech defectives as we accept the term, but are making important contributions towards solving educational problems of so-called "normal" children in the ordinary schools. the employment of therapists in schools for the cerebral palsied by official bodies (such as government education departments) shows a varying degree of control. this varies not only from country to country but frequently from province to province within those countries. in the schools (these are better designated as habilitation centres) the controlling body is the education department. such departments accept full responsibility for educational staff (teachers). many will not accept the therapists on the same basis. it was not unusual to find that teachers are paid by an official department with accepted privileges, such as pension schemes, vacation pay, etc., while therapists have to be paid by a voluntary organization who impose their own conditions of service. sometimes two official departments are involved: eg. education and health—in which conditions of service have little in common. it is unsatisfactory as it leads to feelings of resentment and is not conducive to good teamwork. this leads to another point—what constitutes "teamwork" in the cerebral palsy unit? i visited many centres and was met with the remark— "teamwork is the basis of our success." i found on investigation that a wholistic concept of teamwork did not exist. certainly there was a good r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society team of doctors, another of therapists and another of educationalists. unfortunately the teams never met together. in one instance, the "medical" teams (employed by voluntary agencies) and the "educational teams" (employed by a state department) only communicated with each other in writing. many teachers complained to me that they were regarded as only a "necessary evil" in the habilitation programme and there was lively discussion on this point at the pan pacific conference in sydney. in the educational sphere, the most noteworthy progress is shown in the development of special techniques for teaching the brain-injured. here the united states leads the way, but valuable research is being done in great britain and france. may i add with pride that the work which has been carried out at the forest town teaching school for spastics in johannesburg for several years is equally meritorious. the controversial question of criteria of admission to cerebral palsy schools is not quite the contentious issue it used to be. where state departments control or subsidise schools for the cerebral palsied, the i.q. level of admittance is high, in most places no less than 80. children who do not fall within this "educable" category are catered for by the voluntary cerebral palsy associations. the best of these organizations do not run "centres of ineducable children" but "assessment centres." here children benefit by long or short term treatment and training and dependent on the result, placement may be made. this solves the great problem of the "border-line" case, gives the benefit of any doubt to the child, and makes possible, after careful training and observation, a more accurate placement. in south africa, most attention has been directed to "educable children." throughout the world, voluntary cerebral palsy associations have not left out the "other children." many of the socalled "ineducables" prove otherwise if given time and opportunity. it is not out of place to remind such organizations that if they are working for the cerebral palsied, the funds they raise should be utilised for the benefit of all the cerebral palsied who may need assistance and not for a selected group with this condition. many of the schools in australia have separate units for the non-educable children. the staff are paid and facilities provided by the cerebral palsy associations. with typical australian terseness, they are called "minding groups" and provide a much needed service. it should not be forgotten that the parents of the so-called ineducable cerebral palsied child need help to lighten an almost unsupportable burden. a brief mention of one or two outstanding impressions in closing:—the importance of careful diagnosis and medical assessment. south africa has much to learn here. treatment and education of cerebral palsy cases must begin at the earliest possible age. the department of education, arts, and sciences are to be congratulated on the work being done here for the pre-school group. great britain could learn from this. there are enormous sums of money devoted to cerebral palsy work in progressive countries overseas. because of this, there are better facilities for the training of staff, and equipment is plentiful and of a much higher standard than that obtainable here. while it is accepted that specially designed buildings make for better working conditions, they are not an absolute essential. i saw units which ran the gamut in accommodation— from disused garages, dark basements, old houses to the most modern buildings of special technical design. let me forever dispel the idea that only a single-storey building can be used. in great britain, such a building is hard to find and in france, one centre operates on several floors of a block of business offices. in all these places, a high standard of achievement is evident. there is no one country which can offer perfection in every aspect of cerebral palsy work and the state-aided schools in the union can hold their own with any i saw overseas. it was an honour for me to be able to describe what we are doing in south africa, as part of a great international movement. regardless of colour, race, creed, politics or geographical boundaries, men and women throughout the world are united in a common cause: to improve the welfare of the cerebral palsied; to find the cause of the condition and its prevention. to all those interested in this work, i bring good wishes and warm greetings in many languages from many friends valuable to our cause. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 73 caregiver-child interaction in a rural village in south africa belinda κ seeff and melissa a bortz department of speech pathology and audiology, university of the witwatersrand abstract the aim of this study was to describe the caregiver-child interaction in a south african rural village. a social interactional approach was adopted and a triangulation of methods was used. the interaction of nine caregiver-child dyads was observed during a semi-structured play situation, and the caregivers were interviewed concerning their beliefs about, and attitudes towards their child's communication. interactions were rated according to an interactional profile and common themes found during the interviews, were identified. interview results showed that although the majority of caregivers assigned importance to interacting and playing with children, their reported actions were not congruent with this. caregivers played a dominant role during the social play interactions. support was found for the utilisation of the social interactional approach and a triangulation of methods. results obtained have important implications for the south african speech-language pathologist. opsomming die doel van hierdie navorsing was om oppasser-kind-interaksies binne 'n landelike gemeenskap van suid-afrika te beskryf. nege oppasser-kind-interaksies is waargeneem tydens 'n semi-gestruktureerde spelsituasie, en onderhoude is met die oppassers gevoer, om hulle houdings en oortuigings met betrekking tot hulle kind se kommunikasie vas te stel. die interaksies is volgens 'n interaskieprofiel beskryf, en temas wat deurlopend tydens die onderhoude voorgekom het, is ge'identifiseer. uit die onderhoude het dit geblyk dat die oppassers se handelinge nie ooreeengestem het met die meederheidsmening dat spel en interaksie met kinders belangrik is nie. die oppassers het 'η dominante rol gespeel tydens die interaksies . die', resultate het die benutting van die sosiale interaksionele benadering en 'n triangulasienavorsingsmetodiek gesteun. die verkree resultate hou belangrike implikasies in vir die praktiserende spraaktaalterapeut in die suid-afrikaanse konteks. 1. introduction "the profession of speech, language and hearing therapy is under pressurej in south africa to provide services to the majority of the population" (mckenzie, 1992). however, a prerequisite to providing appropriate services, is an understanding of the cultural beliefs and practices of this majority in relation to speech and language issues. this is based on taylor's (1986, p. 16) assertion that "social and cultural factors undergird all clinical activities in speech, language and audiology". at present the lack of information regarding these issues, is seen as a major obstacle to the provision of appropriate services to the diverse, multicultural south african population. therefore, it is essential that exploratory research in this area is undertaken. upon recognising the relevance of social and cultural factors in the field of speech-language pathology and audiology, a pragmatic or social-interactive approach may be adopted when focusing on the area of language acquisition. this approach gained popularity in the late 1970's, when researchers, such as bates (1976) and snow (1977), challenged the conclusiveness of chomsky's nativist theory of language acquisition. they concluded that it is not only the nature of the child, but the nature of the social interactive setting in which language is learned, which influences the pattern of language acquisition. after long ignoring the importance of the social setting for learning, attention was turned to assessing the support for language learning that children gain from their environment, as well as from those with whom they interact. in accordance with this, numerous researchers (bruner, 1975; bullowa, 1979; kretschmer & kretschmer, 1979; snow & ferguson, 1977) have supported the notion that "competence in communicating must be learned within the course of everyday caregiving and play transactions between the child and the caregiver" (cole & st.claire-stokes, 1984, p.200). other authors have highlighted the importance of social play interaction in the acquisition of essential language and communication skills (bruner, 1986; craig & gallagher, 1986; reifel, 1992). as a result, most recent studies concerned with children's communicative interactions, condie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 74 belinda κ seeff & melissa a brotz centrate on describing interactions during social play (guttman & frederiksen, 1985). in addition to this, duchan (1989, p. 16) postulates that "if children learn most of their language in their everyday interactions with those in their environment, then it becomes expedient for speech-language pathologists to examine what occurs in these interactions." emphasis is placed on the dyadic nature of the adultchild interaction (garrard, 1988) and it's potential importance in the language development of the child. therefore, the study of the nature of everyday caregiving and play interactions between caregivers and children is of vital importance in the understanding of early communication development. at present, nearly all developmental and intervention data available is based on the assessment of "normal, white mainstream children from middle-class, two parent families" (westby & erickson, 1992, p . v l ) . goldberg (1977) points out that often, this western experience is taken to be normal and even when attempts are made to adapt an approach to local experience, the premises remain western. an example of this is the hanen early language parent program (manolson, 1985) which is based on traditional western assumptions concerning various cultural issues related to child language. van kleeck (1992) provides a critique of the application of this program to non-mainstream cultures. she postulates that the failure often experienced, is due to non-mainstream cultural values and beliefs, that impact on interactive patterns, opposing those of the program. therefore, this study endeavoured to establish a preliminary data base of specific non-western cultural values and beliefs. a further rationale for this study related to the dire shortage of speech-language pathologists and audiologists in south africa. aron (1991) estimated that of all the people who require speech therapy in south africa, only 1.81% receive it from the approximately 558 working therapists. this situation mirrors the world wide lack of adequate resources and personpower needed to continue providing effective speech services on a oneto-one basis. thus, the need arises to move away from the traditional, individualistic type of therapy setting and at the same time explore the feasibility of alternative intervention models. one such intervention model is the family-centred approach (westby, 1990) where the parents, and specifically the mother, become ideal candidates as intervention partners. this is based on the knowledge of many western mainstream cultures, where it is assumed that the parents, and particularly mothers, are the primary caregivers (schieffelin & eisenberg, 1984; westby, 1990). however, consideration of the south african experience, where it is common for children to spend "considerable periods of time away from one or both parents" (reynolds, 1989, p.34), highlights the need for investigation into the applicability of this type of intervention model within the south african context. in 1978, penn stressed the need to "embark on the journey of acquiring knowledge of developmental and social linguistic norms within our country, as a prerequisite for accurate diagnosis and treatment" (p.242). sixteen years later, it is clearly evident that despite the growing recognition of the impact of sociolinguistic factors on both the acquisition of, and attitudes towards communicative competence, traditional western based assessment and therapeutic procedures continue to be implemented. as the ramifications of this concept are particularly hard felt in our multi-cultural south african population, it is essential that speech-language pathologists and audiologists begin establishing a much needed database of diverse socio-cultural beliefs and practices. in light of this, the purpose of this study was to describe the nature of caregiver-child interaction, in a rural village in the eastern transvaal. 2. methodology 2.1. aims the aims of this study were: • to describe the caregivers' practices, attitudes and beliefs concerning their interaction with their children, from information gathered during interviews held with the caregivers. • to observe, transcribe and analyse the interactions between the caregivers and their children through the medium of social play. 2.2. research design an exploratory descriptive design was utilised. this design implies that a qualitative approach was adopted. in describing the holistic, qualitative approach, patton & westby (1992) assert that a description and understanding of the social environment or context is essential for an overall understanding of what is to be observed. in accordance with this, the researcher lived with the people in the village for the period of six days in which the semi-structured observations and interviews took place. the benefits of living with the people during the performance of research, proved to be two-fold: familiarity with the subjects was established. by working with the people in the context of their lives, a relationship of trust between the researcher and the subjects was encouraged (reynolds, 1989).ι this was necessary in order to secure the co-operati'on of the subjects, which giddens (1989) views as being an essential factor in increasing the reliability of the data to be obtained. | • in addition to being able to observe the subjects in their natural environment prior to the implementation of the research, the researcher was able to sketch a general description of the village and its inhabitants. 2.3. description of village as a result of the absence of any official information pertaining to the village, a brief description of the village and its inhabitants, as seen through the eyes of the researcher, is provided. , / manzini village is one of the villages situated in the nsikazi region of the eastern transvaal, located between the towns of white river and nelspruit. the predominant language spoken in the village is siswati. the village consists of mud, brick and corrugated iron houses, on small plots founcl scattered on the hills characteristic of the area. the south african journal of communication disorders, vol. 41,1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) caregiver-child interaction in a rural village in south africa 75 as no farm land is available to the people, they are unable to generate their own resources. through discussion with the village dwellers, it was established that the village is seen as a labour reserve for the surrounding farms, as well as the nearest towns. of the people who remain in the village, income is generated by activities such as selling petty goods, running shebeens and repairing cars. however, it was observed that the majority of people living in the village were unemployed. as many of the men work varying distances away from the village, the daily population of the village is comprised largely of women, children and those adolescents who have finished or left school, and cannot find work. the daily activities of the women mainly consisted of cleaning the inside and outside of their houses, fetching water, cooking food and sitting under a tree talking to their neighbours. it was observed that the large population of children generally played in groups of varying ages, as they wandered from house to house. in accordance with reynold's (1989) findings during research on a squatter settlement, adults were rarely observed to be involved in the activities of the children. also in common with reynold's (1989) findings, were the materials used by the children during play. the main materials used included balls and cars; a variety of items found in the environment, such as stones, sticks, water, tins and bottles; as well as items that were found in their homes, such as percussion drums and spades. 2.4. subjects a purposive quota sampling procedure was used when selecting subjects (cohen & manion, 1991). information presented in table 1, shows that the age of the children range from 2.11 years to 3.9 years, with a mean age of 3.4 years. this age range was selected as the fundamentals of communicative behaviour are mostly present by this stage (gesell, 1978). the intellectual functioning, hearing and visual acuity of each child was informally assessed by the researcher, as well as the caregiver involved, to be within normal limits. although it has been shown that the education of the caregiver may have an effect on "several aspects of child's health" (yach, ricliter, cameron & dewet 1993, table 1. description ofjsubjects dyad age of caregiver age of child 1 child's gender language education level of caregiver 1 24 yrs 3.4 yrs f siswati std. 3 2 29 yrs 2.11 yrs μ siswati std. 7 3 29 yrs 3.0 yrs f siswati std. 9 4 37 yrs 3.0 yrs μ siswati std. 3 5 30 yrs 3.7 yrs μ siswati std. 6 6 32 yrs 3.8 yrs f siswati std. 8 7 22 yrs 3.0 yrs f siswati std. 3 8 32 yrs 3.6 yrs μ siswati std. 3 9 30 yrs 3.9 yrs μ siswati std. 2 die suidafrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 p.22), prior observation revealed the difficulty in imposing the criteria of age and education. therefore, although no specific age range and education level were specified, the researcher attempted to limit the range of these variables as much as possible. the age of the caregivers ranged from 22-39 years, with a mean age of 30 years. the caregivers had no previous training in speech and language or related areas. 2.5. methods and procedures in order to determine the nature of mother-child interaction during play, a triangulation of methods was employed (mcneill, 1990). this implies that more than one research method was used in "an attempt to strengthen the validity of empirical evidence by reliance on more than one approach" (bulmer, 1991, p.45). following a pilot study, using one caregiver-child dyad, the following two research methods and procedures were adopted: 2.5.1. interviews when addressing issues relating to children of diverse cultures, westby (1990) postulates that interviewing provides a means for understanding the environment of the child, as well as the perceptions and values of the families concerned. semi-structured interviews were utilised in order to describe the practices, attitudes and beliefs of the caregivers in relation to their interaction with their children. this implies that although questions were preset, the researcher was free to modify the sequencing and wording of the questions (cohen & manion, 1991). this facilitated greater understanding on the part of the caregiver, and hence increased research reliability. in accordance with the naturalistic component of qualitative research, no attempt was made to manipulate, control or eliminate situational variables (westby, 1992). thus, interviews took place both inside and outside the houses, depending on the preference of the caregiver involved. both open and closed ended questions were used. as the researcher's knowledge of siswati was limited, a siswati speaking researcher was used as an inr ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 76 belinda κ seeff & melissa a brotz terpreter during the interviews. the questions were asked by the interpreter, and the responses given by the c a r e g i v e r s were i m m e d i a t e l y transcribed orthographically. in order to fulfil the first aim of this study, specific questions were asked in an attempt to gain an understanding of the caregivers' beliefs, attitudes and practices in relation to the following issues: • the content of interaction with the child. • the value assigned to talking to children. • how children acquire language abilities. • the value assigned to children talking. • the value assigned to playing with children. • the quantity of play interaction between the caregivers and their children. • the types of games and materials used during play interaction between the caregivers and their children. mcneill (1990) points out that there is no guarantee that what people say in interviews is a true account of what they actually do. this potential weakness inherent in the interviewing method, was addressed by the utilisation of the triangulation of methods. thus semistructured observations of the caregiver-child interactions during social play, were performed. 2.5.2. observations semi-structured observations were employed in order to fulfil the second aim of the study of transcribing and analysing the interaction between the caregivers and their children during social play. in the context of this study, the term 'semi structured' implies that although the situation was structured in that the caregiver was requested to play with the child, the course of the caregiver-child interaction was not controlled or predetermined by the researcher. in accounting for the possible weakness of subjectivity often associated with observation methods (bless & achola, 1990), video recordings were utilised. this served to increase the objectivity and hence the reliability and validity of the study. according to cole & st.claire-stokes (1984) a video analysis procedure systematically examines specific behaviours of both the caregiver and the child as they interact. a phillips video recorder (model vkr 684/00), using 6v panasonic batteries, powered by a portable generator, was used. based on the prior observation of the children at play, as well as the pilot study, an attempt was made to provide each dyad with situationally appropriate play materials. these materials included metal tins, sticks, sand, water, a toy car, a ball and bottles. however, it was noted that during the play interactions, the caregivers and their children often used other objects within their environment, such as small planks of wood, a scarf, string, cardboard boxes, and plastic ice-cream containers. this was viewed as a strength of the exploratory nature of the research design in that strictly specifying and limiting play materials to be used, would have been indicative of the researcher's bias, and hence negatively effect the reliability of the study. the video recordings took place in a secluded area, outside the subjects' houses. this was done in order to ensure adequate lighting needed to achieve quality video recordings, as well as to prevent interruptions caused by remarks and questions by the curious onlookers. the total interaction time of each caregiver-child dyad was approximately 20 minutes. in recognising the cultural inappropriateness associated with using a video recorder, recording equipment was set up, but actual recording only began after approximately five minutes. this time was necessary for the subjects to become familiar with the recording set-up, as well as the procedure. the recording procedure required the researcher to be present during the caregiver-child interactions. although familiar with the subjects, the researcher was aware of williamson, karp, dalphin & gray's (1982, p.207) assertion that it is impossible to "observe human beings without influencing their behaviour". the researcher was aware that as she was from a different culture, this may have further influenced the subjects' behaviour. in order to maximise the representativeness of the video recorded sample, information and instructions, adapted from cole & st.claire-stokes (1984), were given to each caregiver (see appendix a). 2.6. processing and analysis of data the processing and analysis of the data obtained was dependent on the research method utilised. 2.6.1. interviews answers to questions were translated by the interpreter into english during the interview. the data was then transcribed orthographically. in accordance with cohen and manion's (1991) procedure of analysing interview data, the researcher identified common themes, as well as individual variations, in the beliefs and practices of the caregivers regarding interaction with their children. 2.6.2. semi-structured observations data obtained from the semi-structured observations was transcribed orthographically by two trained people whose first language was siswati. the data was ithen translated into english by the interpreter. j in keeping with the social-interactional model adopted, focus was placed on analysing certain interactional components of the caregiver-child interactions. in line with the exploratory nature of this study, the profile of interactional behaviours was only drawn up after the researcher had lived with and observed the people, and obtained the video recorded data from the pilot study. thus, the researcher was not confined to preconceived variables and the inclusion of new interactional variables was made possible (salter ainsworth, 1977). • interactional profile the interactional behaviours and their descriptions are presented in appendix b. this profile was adapted from bedrosian, wanska, sykes,,smith & dalton (1988) and conti-ramsden & dykins (1991). the interactional behaviours were classified into verbal and non-verbal behaviours. in addition, a breakthe south african journal of communication disorders, vol. 41,1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) caregiver-child interaction in a rural village in south africa 77 down of the total number of utterances made by the caregivers and children was also calculated. it must be noted that it was possible for an 'utterance' to be analysed a number of times into different categories. frequency counts were done and percentages calculated by the researcher. • inter-rater reliability . thirty percent of the data was randomly selected and independently recoded as suggested by contiramsden & dykins (1991). two raters, a qualified speech-language pathologist and a final year speechlanguage pathology student, performed this task. this suggestion, made by conti-ramsden & dykins (1991) was followed in order to reduce experimental bias and i n c r e a s e the reliability of the study (silverman, 1977). raters were familiarised with the required analysis scheme by means of oral instructions. they were required to make coded judgements relating to the verbal and non-verbal behaviours of the caregivers and children. inter-rater reliability of between 75-100% was obtained utilising the following equation provided by mcreynolds & kearns (1983, p.86): number of agreement 100 total number of agreements and disagreements 1 = % agreement 3. results and discussion the results obtained from interviews and observations, and the discussion thereof, are presented below. 3.1. interviews • the content of caregiver-child interaction the results illustrating the content of the caregiverchild interaction, as perceived by the caregivers, are presented in figure 1 below.] it, should be noted that the nature of the question allowed caregivers to respond positively to more than one category. the content of interactions, as reported by the caregivers, consists mainly of instructions given by the caregiver, with very few questions or stories featuring in these interactions. the four'caregivers, who reported that they mainly answer questions when interacting with their child, all commented that they do not interact with their child unless the child asks questions. τ η g i v e i _> j , l _ s. ι ask tetl stories a n s w e r instructions questions questions • the value assigned to talking to children five out of the nine caregivers thought it important to speak to their children. three caregivers thought it unimportant to speak to their children, and one caregiver was unsure of what to answer. bearing in mind the fact that results in figure 1 show interactions to consist mainly of instructions, it is interesting to note that five caregivers thought it important to speak to their children besides when instructing them or sending them on errands. these caregivers suggested the following reasons for speaking to children: "the caregiver shows her love for the child." "the relationship between the caregiver and the child would be improved so that the child will no longer be scared of the caregiver." "the child learns new things and it helps him or her to grow. you can show them the way in life." "the caregiver can tell if the child is ill and if he or she can hear properly." it can therefore be seen that the value that caregivers assigned to talking to their children related to issues of wellbeing, relationships and education. • how children acquire language abilities all nine caregivers believed that a child learns to talk through interacting with other people. however, a number of caregivers highlighted various aspects of interaction, as being crucial to language acquisition. one caregiver identified the interaction during play with other children as a contributing factor to the child's speech development. another caregiver highlighted the role of the child him/herself in language acquisition. she proposed that by interacting with other people and asking questions, the child learns how to talk. furthermore, two caregivers highlighted the mother or caregiver as playing a major role in the language acquisition of the child. they explained that the child learns to talk when he or she is in the mother's lap. the mother's role is to talk to the child during this period, before it is time for the child to go and play with other children. the caregivers stated that this occurs at approximately two years of age, when the child begins to speak. one caregiver stated that it is at this age that the mother begins to shape the child's speech. analysis of the responses given by the caregivers show that there are similarities between their attitudes— and beliefs relating to language acquisition, and traditional western beliefs. among these similarities is the support for the social-interactional approach to language acquisition (bates, 1976). the influence of the caregiver in particular, on the child's language acquisition, is also in accordance with western researchers who have proposed that there are special properties of a mother's speech that play a significant role in language acquisition (bernstein & tiegerman, 1989). in addition to this, the notion expressed by the caregivers, that at two years of age the child begins to talk, is supported by the western language universal concept that children begin to understand and say words in approximately their second year of life (bloom & lahey, 1978). figure 1. content of caregiver-child interaction. die suidafrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 78 belinda κ seeff & melissa a brotz • the value assigned to children talking figure 2 illustrates that only one out of the nine caregivers interviewed, thought it unimportant for a child to learn to talk. she claimed that "the child will end up talking unnecessary things." the remaining eight caregivers reacted favourably to the idea of their children talking a lot. they felt that it is through talking a lot and asking questions that a child learns about the world around him/her. two caregivers believed that it shows intelligence when a child talks a lot, while one caregiver thought it important as "then the child will be able to cope at school and become clever." once again, similarities between the caregivers' values and beliefs and traditional western values are highlighted: van kleeck (1992) asserts that talking is a behaviour highly valued in most western cultures. this is also in accordance with demuth's observations (1986) of the basotho community where caregivers assigned great value to talking. the view expressed that talking is seen as a vehicle for further growth and learning, is related to schiefelbusch & bricker's (1981) assertion that the acquisition of language allows for the development of knowledge and functions that are essential for future learning. • the value assigned to playing with children figure 3 shows that eight out of nine caregivers assigned importance to playing with their children. practical reasons, as well as those relating to relationships not important 1 ά ιϊΐϊίτΐί 1 ^ u u i i important 8 figure 2. the value of children talking. and cognitive development were given by the caregivers to support their beliefs. these included: "playing with your child shows your love for it." "it keeps the child at home so that they won't wander off into other peoples' homes." three caregivers viewed play as an activity which " r e s u l t s in advances in c o g n i t i v e d e v e l o p m e n t " (guttman & frederiksen, 1985, p. 165). one caregiver proposed that playing will help the child in his school work. she explained that "if a child learns how to build a house, then at school he will know how to draw it." another caregiver stated that "it helps the child develop intelligence." three caregivers saw play as a means to ensure the successful performance of household chores in the future. this idea was elaborated upon by one caregiver who stated that "the child learns something for the future in the home situation she learns to cook and do household chores." in support of this, reynolds (1989) points out that children in non-western societies learn by 'observation and imitation', and thus imitate adults in their play in preparation for adult roles. • the quantity of caregiver-child play interaction five caregivers reported to play with their children. the amount of time spent playing ranged from less than 20 minutes per day, to less than 20 minutes per month. only one caregiver reported to play with her child for more than 20 minutes per day. four caregivers reported that they did not play with their children. the reasons given for not playing with their children are presented in table 2. it is significant to note that although eight caregivers assigned importance to playing with their children, their reported practices did not appear to be congruent with their attitudes and beliefs. the researcher hypothesises that the short and infrequent play interactions that reportedly take place, may be explained by the attitude expressed by the fourth caregiver. she believed that she would loose her respected status if she played with her child. this is directly related to reynold's (1989) observations that she made whilst observing childrenjin a squatter settlement near cape town. she observed that few adults involved themselves in the play of children, as this was regarded as being undignified. | table 2. reasons for not playing with children n o t important 1 important 8 figure 3. the value of playing with children. the south caregiver reason for not playing with children vi "i have too much work." vii "i don't know what to do when playing with the child." viii "i have time to play but never think that i should." iv "there is time to play, but the mother will loose her respected status if she plays with the child people will think that you are not right in your head,." ican journal of communication disorders, vol. 41,1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) caregiver-child interaction in a rural village in south africa 79 • types of games played and materials used the caregivers stated that the games that they play with their children consist primarily of ball games, sangoma games, and a variety of domestic activities such a s cooking, washing and building. it is significant to note that the domestic games played are in accordance with the view expressed by the caregivers that play is a medium through which children learn to perform household chores. the materials that the caregivers reported to use during play, corresponded to those used by the children in reynold's (1989) study. these materials could be classified into ready made toys, such as a skipping rope, a ball and a car; and those found in the environment and adapted for play, such as water, sand and tins. 3.2. semi-structured observation 3.2.1. verbal behaviours • total number of utterances results displayed in table 3 show that the caregivers were more verbal than the children. they were responsible for at least two thirds of the total utterances spoken, with an average percentage of 80%. this can be compared to the average of 20% of the total utterances made by the children. one caregiver-child interaction served to epitomise the disproportionate number of caregiver utterances, as compared to the number of utterances said by the child. here, 99% of the total number of utterances were made by the caregiver, whereas the child only said one utterance throughout the interaction. • spontaneous vs response utterances table 4 shows that 80% of the caregivers' utterances were spontaneous. this implies that the caregivers seldomly responded to a previous action, question, instruction or statement made by the children. when the table 3. total number of subjects' utterances table 4. spontaneous versus response utterances caregivers did respond to the children, almost all of the responses were verbal (99%). during one caregiver-child interaction (no. 8), the caregiver responded to the child only four times out of her total of 74 utterances. during this interaction it appeared as if a combination of a lack of spontaneity and interest on the part of the child, as well as the preoccupation of the caregiver in her own activities, contributed to a general lack of responsiveness from both parties. a general lack of spontaneity on the part of the children was noted, as only an average 19% of their total utterances were spontaneous. thus, the majority of the utterances made by the children (81%) were in response to an action, instruction, question or statement made by the caregivers. it is significant to note that out of the total 21 response utterances made by the children, at least half of the utterances were in reply to questions asked by the caregivers. • topic maintenance and shift a general interpretation of the mean percentages of topic maintenance and topic shift on the part of the caregivers, shows an expected proportion of topic shifts as compared to topic maintenance. however, closer inspection of the range percentages associated with individual caregivers, reveals that a disproportionate amount of topic shifts occurred during one interaction. here the caregiver used 58% of her utterances to shift topics and only 42% to maintain them. on the whole, the caregivers shifted topics almost three times more than the children. this is in contradiction to conti-ramsden & friel-patti's (1991) findings that normal, western, middle-class children shifted the topics approximately three times more than their mothers did in a naturalistic play setting. in addition to this, conti-ramsden & friel-patti (1991) assert that by introducing fewer topics than their children, mothers adjust their conversation style to match their child's, and allow the child to influence the flow of information exchanged in the conversation. as this did not occur in the course of any of the interactions observed, a lack of adjustment on the part of the caregivers, was demonstrated. • function of utterances: • instructions: table 6 indicates that on average, nearly half of the caregivers' utterances functioned as instructions. these results support the impression gained from the intertable 5. topic maintenance and topic shift caregivers children range mean range mean spontaneous utterances % 63-95% 80% 0-38% 19% raw score (50) (4) response utterances % 5-37% 20% 62-100% 81% raw score (12) (21) caregivers children range mean range mean topic maintenance % 42-83% 65% 79-100% 89% raw score (39) (15) topic shift % 17-58% 35% 0-21% 11% raw score (23) (2) caregivers children range mean range mean utterance total % 66-99% i 80% 1-34% 20% raw score (63) (16) die suid afrikaanse tydskrif vir kommunikasieafwy kings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 80 belinda κ seeff & melissa a brotz views where the caregivers indicated that the majority of their interactions with their children take the form of instructions. they also relate to harkness's findings (1977) regarding the speech of mothers and children in the kokwet community in western kenya. she found that mothers or caregivers relied on instructions for communication. furthermore, van kleeck (1992) cites non-western, rural black communities in america who believe that it is the adult's role to issue directives and the child's role to obey them. the general lack of assertiveness on the part of the children was illustrated as only an average of 11% of their utterances served as instructions. • statements: on average, just over one third of the caregivers' utterances were statements, whereas almost half of the children's utterances were statements. this is in agreement with harkness's findings that "children's communication is more often in the form of statements" (harkness, 1977, p.313). • questions: results in table 6 show that the relative proportion of questions asked by the caregivers was approximately half that of the children. snow (1977) points out that questions serve the purpose of language elicitation in the process of facilitating language acquisition. therefore, the relatively small number of questions asked by the caregivers becomes significant in terms of the role that these caregivers play in the language acquisition of their children. ' in addition to this, 54% of the total number of questions asked by the caregivers, were not answered. it was noted during a number of interactions that the caregivers asked numerous questions without allowing any time for the child to respond, before producing the next utterance. this fact, together with the subjective observation by the researcher, leads to the conclusion that the majority of questions asked by the caregivers were probably used rhetorically. it is interesting to note that 44% of the total number of questions asked by the children served the purpose of asking for clarification. extreme examples of this were found in two caregiver-child interactions (no.6 & no.8) where all the questions asked by the children were requests for clarification. 3.2.2. non-verbal behaviours results in table 7 reveal almost no non-verbal responses from the caregivers. only one caregiver responded once non-verbally to an action performed by her child. in contrast to this are the number of nonverbal responses on the part of the children. the majority of the children's responses were non-verbal and related to instructions given by the caregivers. 3.3. general discussion the results obtained from the interviews and observations serve to support the social-interactional approach to language acquisition. it is evident that the interactions between caregivers and their children in the manzini village facilitate the acquisition of communicative competence that is appropriate to the specific social and cultural c o m m u n i c a t i o n context (schiefelbusch & pickar, 1984). as taylor & payne (1994) point out, cultural styles of verbal interaction do not impede language development, but may manifest in varying patterns of verbal expression. this has particular relevance in the south african context where a multitude of different cultures p r o v i d e diverse interactional environments which in turn result in varying communicative behaviours. thus, the need to investigate these interactional environments to determine the nature of communication expected, is highlighted. the fact that results obtained from the performance of the two research methods employed were congruent with one another, serves to highlight the strength inherent in triangulation. thus, the reliability of the study was increased and the researcher was able to gain greater insight into the phenomena under study (bless & achola, 1990). this was illustrated when the caregivers' belief that through play "the child learns household chores for the future", was supported by the observation that most of the activities that took place during the caregiver-child interactions consisted of performing household chores. in line with this^ the researcher is of the opinion that by observing and imitati ι table 7. non-verbal responses j table 6. function of subjects' utterances caregivers children range mean range mean instructions % 27-73% 44% 0-36% 11% raw score (26) (2) statements % 6-55 % 37% 0-88% . 48% raw score (23) (10) questions % 2-34% 19% 9-100% 34% raw score (12) (4) the south caregivers children 1 range mean range !mean response to question % 0% 0% 0-7% 1 2% i raw score (0) (.3) response to instruction % 0% 0% 8-83% 37% raw score (0) (7) response to action % 0-13% λ% 0-6% / raw score (λυ (.1) response to statement % 0% / ' o % 0-7% 1.8% raw score (0) (.3) ican journal of communication disorders, vol. 41,1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) caregiver-child interaction in a rural village in south africa 81 ing perceived adult roles during play, the children learn what they need to know in order to become "competent members of their society" (skinner, 1989, p.181). finally, it is interesting to note that a difference occurred between the caregiver's interactions with female children as compared to male children. upon analysing the interactions, it became evident that an interaction between a caregiver and a male child tended towards a parallel play situation, whereby the caregiver focused on her own activities and encouraged the male child to perform male orientated tasks, such as building a house or garage. more interaction took place between a caregiver and a female child as they focused on a common activity such as washing or cooking. based on these findings, the researcher agrees with rogoff's (1982) assertion that through everyday activities and social interactions, culturally shared meanings pertaining to gender are constructed and internalised. 4. summary in this study, the nature of caregiver-child interaction in the rural village of manzini has been described using semi-structured observation and interviewing methods. the following phenomena were found: 4.1. interviews the majority of the caregivers thought it important for their children to talk, which they learn to do through interacting with people in their environment. although playing with children was generally viewed as being important, short and infrequent play interactions take place between some of the caregivers and their children. the content of interaction between the caregivers and their children consists mainly of instructions given by the caregivers. the type of games which the caregivers play with their children, are mainly centred around domestic activities. play materials consist primarily of objects found in the environment. 4.2. semi-structured observations the caregivers appeared to interact more with the female children than with the male children. a dominant role was played by the caregivers during the play interactions with their children. this was demonstrated in the following ways: • they mainly instructed the children and often asked questions without allowing time for the child to reply· they responded minimally to actions, questions, instructions or statements made by the children. • they shifted topics often and were responsible for the majority of utterances spoken. the children generally took on a submissive and obedient role as was illustrated in the following ways: they made few utterances. • they tended to maintain the topics introduced by the caregivers. • their main interactional behaviour consisted of nonverbal responses to instructions given by the caregivers. 5. conclusions and implications the clinical implications of this study are highlighted by the current cultural integration taking place within south africa. as a result, the western urban clinician is often faced with the task of diagnosing patients from non-western cultures. therefore, it is essential that speech-language pathologists and audiologists do not fall into the trap of adopting the attitude that "what is 'normal' in our culture is 'right', and that cultures that are 'different' are likely to be 'wrong' or inferior" (tulkin 1977, p.569). although ideas of improving the current models of assessment have been entertained over the past few years (taylor, payne, kay & anderson, 1987), this study provides concrete evidence to highlight the urgency of researching and developing culturally valid and sensitive assessment tools. the views and corresponding actions of the manzini caregivers have particular relevance when considering the possibility of utilising these caregivers as intervention partners in the therapeutic process. although it is not possible to categorically oppose the utilisation of these caregivers as intervention partners in the traditional western milieu, the researcher cautions that the values held by the caregivers living in the manzini village are not entirely congruent with those held by western urban speech-language pathologists. accordingly, it should not be assumed that if these caregivers were to be shown a different way of interacting with their children, they would respond positively to changing their present communicative practices. furthermore, the ethical implications of western urban clinicians inviting themselves into a rural village, and introducing communication behaviours that are "good and right... and in the interest of progress" (goldberg, 1977, p.592) need to be highlighted. although acknowledging the good intentions of the western urban clinicians, goldberg (1977, p.593) points out that "the greatest harm is often done by those who think that they are doing good". by imposing the values of western cultures on this rural community, the clinicians would encourage the genocide of the community's communicative practices (crago, 1992), and hence their cultural attitudes, meanings and values that underlie these behaviours. the above notwithstanding, it is crucial that the large rural population within our country, is not ignored. rather, culturally sensitive intervention should take place in the rural context, whereby the urban clinician must be acutely aware of his/her own cultural bias which may affect the type of intervention he/she hopes to provide. communicative beliefs and practices should be exchanged between the urban clinician and the rural caregivers. by doing this, the present reciprocal ignorance, which "frequently translates into prejudice and apathy" (adler, 1979, p.203) would be overcome. in addition, the caregivers would be able to make informed decisions concerning their beliefs and practices. furthermore, whilst acknowledging the obstacles that cross-cultural communicative differences present for the speech-language pathologist, in the pursuit of appropriate assessment and intervention procedures, it die suidafrikaanse tydskrif vir kommunikasieafwy kings, vol. 41, 1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 82 b e l i n d a κ seeff & m e l i s s a a b r o t z is crucial t h a t l a n g u a g e universale are n o t overlooked. it is the k n o w l e d g e and application of these universale, which m a y p r o v i d e a k e y to the formulation and i m p l e m e n t a t i o n o f a p p r o p r i a t e a s s e s s m e n t a n d intervention p r o g r a m m e s . a s the s u n s h i n e s b r i g h t l y on a n e w s o u t h africa ( a r c h b i s h o p d e s m o n d t u t u , 19 a p r i l 1 9 9 4 ) , w e as s p e e c h l a n g u a g e pathologists are faced with the challenge of p r o v i d i n g effective services to the majority o f the s o u t h african population. as the present study has clearly d e m o n s t r a t e d , this c h a l l e n g e can only be m e t if we c o n t i n u e o n the long b u t r e w a r d i n g j o u r n e y to acquiring k n o w l e d g e o f attitudes, beliefs and practices o f all cultural g r o u p s w i t h i n our country. r e f e r e n c e s adler,s. 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(1989). working with sociology: methods of research. in a.giddens : sociology. london. policy press. goldberg,s. (1977). ethics, politics and multicultural research. in p.h.liederman, s.r. tulkin & a.rosenfeld (eds.). culture and infancy: variations in the human experience. new york. academic press. guttman.m. & frederiksen.c.h. (1985). preschool children's narratives: linking story comprehension, production and play discourse. in l.galda & a.d. pellegrini (eds.)(1985). play, language and stories: the development of children's literature behaviour. usa. ablex publishing corporation. harkness,s. (1977). aspects of social environment and first language acquisition in rural africa. in c.snow & c.a.ferguson (eds.). talking to children: language input and acquisition. london. cambridge university press. kretschmer,r.r. & kretschmer.l.w. (1979). language development and intervention with the hearing impaired. baltimore. university park. manolson,a. 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(1989). childhood in crossroads: cognition and society in south africa. claremont. david phillip publisher pty. ltd. reifel,s. (1992). play and language in early childhood introduction. play and culture. vol 5. 2. 103-106. rogoff,b. (1982). i n t e g r a t i n g context and c o g n i t i v e development. in m.e.lamb & a.l.brown (eds.). advances in developmental psychology. vol 2. new york. hillsdale. lea. salter ainsworth.m.d. (1977). infant development and mother-infant interaction among uganda and american families. in d.h.liederman, s.r.tulkin & a.rosenfeld : culture and infancy: variations in the human experience. new york. academic press. ! schiefelbusch.r. & pickar,j. (1984). the acquisition of communicative competence. baltimore. university i park press. i schiefelbusch.r.l. & bricker.d. (eds.)(1981). early language acquisition and intervention. baltimore. university jpark press. | schieffelin.b.b. & eisenberg.a.r. (1984). cultural variation in children's conversation. in r.schiefelbusch & j.pickar. the acquisition of communicative competence. baltiiiiore. university park press. silverman,f.h. (1977). research procedures in speech pathology and audiology. new jersey. prentice-hall. skinner,d. (1989). the socialisation of gender identity: observations from nepal. in j.valsiner (ed.). child development in cultural context. toronto. hogrefe and huber publishers. snow,c. (1977).mother's speech research: from input to interaction. in c.snow & / c.a.ferguson (eds.). talking to children: language input and acquisition. london. cambridge university press. snow,c. and ferguson,c.a. (eds.)(1977). talking to children: language input and acquisition.london. cambridge university press. ^ taylor,o.l. (ed.)(1986). nature of communication disorders in culturally and linguistically diverse populations. san ' diego. college hill press. the south african journal of communication disorders, vol. 41,1994 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) caregiver-child interaction in a rural village in south africa 83 taylor,o.l., payne,k,t., kay.t. & anderson,n.b. (1987). distinguishing between communication disorders and communication differences. seminars in speech and language. vol 8. 4. tavlor ο l. & payne, k.t. (1994). language and communication differences, in g.h. shames, ε. h. wiig & w.a. secord (eds.). human communication disorders: an introduction (4th ed.). p. 136-173. new york: macmillan publishing company. tulkin.s.r. (1977). dimensions of multicultural research in infancy and e a r l y c h i l d h o o d . in d . h . l i e d e r m a n , s.r.tulkin & a.rosenfeld (eds.). culture and infancy • variations in the human experience. new york. academic press inc. tutu,d. (1994) : tv1 news. jhb. sabc. van kleeck,a. (1992). future trends in language intervention: addressing cultural bias in service delivery. south african journal of communication disorders. vol 39. westby,c.e. (1990). ethnographic interviewing: asking the right questions to the right people in the right ways. journal of childhood communication disorders. vol 13(1). 101-113. westby,c. & erickson.j. (1992). prologue. topics in language disorders. 12(3). v-vii. appendix a information and instructions given to caregivers williamson, j.b., karp.d.a., dalphin, j.r., & gray.p.s. (1982) : the research craft: an introduction to social research methods. boston. little, brown and co. yach,d., richter,l.cameron,n. & dewet,t. (1993). maternal education and child health: emerging evidence from birth to ten. paper presented at birth-ten seminar on methods and findings of the first years. witwatersrand medical school. rsa. address correspondence to ms b. seeff, department of speech pathology and audiology, university of the witwatersrand, ρ ο wits, 2050, johannesburg, south africa. acknowledgments the authors would like to thank ms μ schneider, senior clinical tutor, university of the witwatersrand, for her valuable assistance in conceptualising and formulating this study. behaviourtype description verbal utterance ! / a verbal expression consisting of a word, phrase or sentence. this does not include utterances expressed while singing. spontaneous an utterance not related to the previous action, statement, instruction or question of the interaction partner. response an utterance related to the previous action, statement, instruction or question of the interaction partner. topic maintenance , continued engagement with the previous set of concerns. instruction an utterance requiring an action from the listener. — question a request for information, opinion, permission, conformation or clarification. — statement/comment an utterance which contains information about a topic or an ongoing action. non-verbal response a non-verbal reaction related to the previous action, statement, instruction or question of the interaction partner. adapted from bedrosian, wanska, sykes, smith & dalton (1988) and conti-ramsden & dykins (1991). die suidafrikaanse tydskrif vir kommunikasieafwykings, vol. 41, 1994 each caregiver was told that the researcher's aim was to observe how she and the child played together. the interpreter used a direct translation of the word 'play', that is 'dlala'. the interpretation of this was left up to the caregiver. it was further explained to each caregiver, that the researcher's intention was not to assess whether the caregiver's interaction with her chilli was right or wrong, and therefore their interaction should be as natural as possible. .each caregiver was informed that the researcher would not interact with her during the recording. appendix β r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 74 the communicative effectiveness index: its use with south african stroke patients claire penn and kelly milner department of speech pathology and audiology peter fridjhon department of statistics university of the witwatersrand abstract the functional communication of a group of 28 south african stroke patients was examined using the communicative effectiveness index (ceti). it was translated into afrikaans, sotho and zulu and administered to the significant others of 22 aphasic patients with left hemisphere damage and 6 patients with right hemisphere damage. results were related to the results of standardised language testing and to case history factors such as cultural factors and time since onset. the ceti was readministered in the case of eight of the aphasic subjects after a mean period of six months in order to assess its sensitivity to recovery. results showed that the ceti seems applicable across different language groups, that it is sensitive to change across time as well as sensitive to the communication disorders resulting from both right and left hemisphere damage. further it appears to correlate well with overall level of severity. it does not appear to differentiate patients in terms of time since onset. its potential use as a relatively culture free assessment tool in the south african context is discussed. opsomming diefunksionele kommunikasie van 28 suid afrikaanse pasiente is deur middel van die kommunikasie-effektiwiteitsindeks (kei) ondersoek. die indeks is in afrikaans, sotho en zulu vertaal en op die familielede van 22 afasie pasiente met linker-hemisfeerskade en 6 pasiente met regter-hemisfeerskade toegepas. die resultate is, waar moontlik, in verband gebring met die resultate van gestandardiseerde taaltoetse en aspekte in diegevalsgeskiendenis soos kultuur en die tydsverloop sedert die aanvang van die insident. die kei is weer na 'n periode van ses maande op 8 van die pasiente toegepas, om sodoende die sensitiwiteit vir herstel te evalueer. resultate dui aan dat die kei toepasbaar is op verskillende taalgroepe, en dat dit sensitief is vir herstel sowel as die kommunikasie-probleme as gevolg van beide linker en regterhemisfeerskade. dit korreleer goed met die algemene graad van die probleem. die kei onderskei egter nie pasiente ten opsigte van die tydsverloop sedert die aanvang van die insident nie. die potensielegebruik van die kei as 'n relatiefkultuurvrye evaluasie-instrument in die suid afrikaanse konteks, is bespreek. ι certain characteristics of the south african stroke population may be identified as being unique. these characteristics present a challenge to both the clinician and researcher, and often make it difficult and inappropriate to adapt some of the traditional approaches to assessment and treatment to local patients. the first factor to consider is that of multilingualism. the majority of aphasic patients in this country are bior multilingual (penn & beecham, 1992). most patients however are tested and treated in their second or third languages as most clinicians are currently unilingual. in addition despite several informal attempts (eg. semela, 1978) there have been no properly standardised versions of tests developed for aphasia. probably of even more importance, however, is the fact that the tests are not culture-free. even for english speaking south african aphasic patients, many of the test items of the aphasia tests currently in use are inappropriate for cultural reasons. another difficulty lies in the type of facilities available for the treatment of aphasia. despite the fact that the causes of aphasia, such as stroke, are amongst the highest in the world in the south african population, the facilities for treatment and rehabilitation are very inadequate (fritz & penn, 1992). the amount of time spent in an acute care hospital is much shorter than in other countries. in addition, there are (with very few exceptions) no rehabilitation hospitals or facilities available to the patient on discharge. within the hospital setting, very few patients have access to a range of rehabilitative therapies, except in urban areas. given that there are many vacant and unfilled posts in state health institutions, it is rare that an aphasic patient in any setting other than an urban one, will be seen by a speech-language therapist. the fact that there are unrealistic medical aid limits, exacerbates the problem, so that most patients after discharge are not able to afford private therapy rates. certain sociopolitical factors also have their impact on aphasia rehabilitation. due to a long history of inequality and educational disadvantage, the majority of aphasic patients in south africa are economically disadvantaged. many patients reside a long way from available facilities, and geographical distance and lack of transport are factors to be borne in mind. further, many patients are poorly educated, either functionally illiterate or barely literate, making the application of for® saslha 1992 the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) c o t s a n u n i c a t i v e effectiveness index: lised tests inappropriate. finally, high levels of unemploy1 1 1 3 jjj-eak up of family structure, no access to insurance etc, ke for a very mobile and inaccessible aphasic population. m a t h e aphasia clinician, working in a large hospital can norlly e x p e c t to see the patient during the acute phase only. after discharge, unless the patient is resident near the hospital d rhobile, it is unlikely that there will be follow up. the burden of rehabilitation thus often lies on the caregivers and those working in the community. for these reasons, there is an urgent need to re-address s o m e o f the basic tenets in aphasia. there has been a move in recent years towards a societal view of aphasia. this view hinges on the observation that a p h a s i c patients often have many communicative strengths which enable them to function relatively well in a social context, in contrast to their performance on traditional language measures (aten, 1986; goldblum, 1985; holland, 1980; penn, 1985). this shift in approach is reflected not only in the assessment measures used for aphasia, but also in increased acknowledgment and awareness of the importance of the context of the aphasic patient and on the estimation of the perceived effect of the disability on others in the environment. for example, some recent research has compared spouse and clinician ratings of aphasia. a study conducted in 1976 by helmick, watamori and palmer compared spouse and clinician ratings on the functional communication profile (sarno, 1975). they found considerable differences between spouse and clinician ratings, with spouses tending to underestimate the severity of the aphasia. this, it was suggested could lead to unrealistic expectations of the spouse. muller and code (1983) have also indicated that both spouse and aphasic persons are significantly more hopeful about eventual outcome than aphasiologists. holland (19 77 as cited by zraick & boone, 1991) on the other hand suggests that such a finding relates to the clinical biases of the speech therapists in evaluating aphasia. shewan and cameron (1984) found that in many instances spouses used in their study were unaware of aphasic-spouses' difficulties, although a better understanding of problems was noted in the groups of subjects receiving treatment than those that were not currently enrolled in speechtherapy. interestingly no difference in spouse patient agreement across severity was noted. j much of the disagreement among researchers may relate to differing methodologies of the studies as well as to the type of tool used to measure the impact of aphasia. it is of note, further, that although in recent years patients with right hemisphere lesions have been treated by speech language therapists and have been identified as having considerable social and pragmatic difficulties, no research on spouse attitudes appears to have been undertaken. a tool which has been developed recently which holds the promise of becoming a useful measure of spouse attitude both for aphasic and right hemisphere patients is the communicative effectiveness index (ceti) (lomas et al., 1989). the communicative effectiveness index (ceti) was developed in canada by a group of researchers interested in devising a relevant measure of functional communication for aphasic patients. first described by lomas et al.,, 1989, the index was drawn up on the basis of interviews with groups of aphasic patients and their spouses. a series of communication situations was generated from these interviews and through applications to groups of stable and acute patients, a final index of 16 situations was derived (see appendix 1). the ceti is administered to the spouse (or significant other) of the patients and involves the use of the visual analogue scale (vas). 1 its use with south african stroke patients 75 the results of the preliminary study by lomas et al. (1989) suggested that the ceti was both a valid and reliable tool as a measure of communication and an index of improvement as a result of treatment and/ or spontaneous recovery. however, lomas et al. called for additional research using this tool. furthermore, the authors pointed out that the ceti is not meant to be a substitute for standard testing, nor a comprehensive test of language functioning. neither is the ceti meant to discriminate between types of aphasia or act as a predictive tool. it does, however, reflect the severity which the effects of the aphasia have on communicative effectiveness, as perceived by a person in the environment who is likely to experience these effects on an everyday basis. the potential of the ceti as a tool for use in the aphasic population of south africa seems particularly good for a number of reasons. firstly it is based on interviews with aphasic patients and spouses and relates to the communication categories of basic need, health threat, life skill and social skill. as such, these items seem to be less sensitive to cultural and linguistic aspects, to literacy level and to socioeconomic status than many of the other tests/measures currently available. it also appears to be sensitive to the communication problems found in the right hemisphere stroke population. secondly it is administered to the spouse or caregiver of the patients and is concerned with everyday functional language behaviours. it thus focuses on a societal view of aphasia and identifies areas of strength and weakness relevant to those in the environment of the aphasic patient. for a number of reasons which are outlined above, in the majority of cases, rehabilitation and recovery of function of the aphasic patient is more likely to take place in a home setting, in the context of the family rather than in a coordinated rehabilitation setting. the attitude of the caregivers thus becomes a particularly important element in any consideration of aphasia. thirdly, the method of adminstration is simple, flexible, short and versatile, involving the use of the visual analogue scale which appears not to be dependent on literacy, numeracy level or education of the patient and the family. it is applicable in both the acute and relatively stable/chronic phases of aphasia. the purpose of the study was therefore to explore the use of the ceti within a south african context, in the hope that it will prove a culturally relevant index for the south african aphasic population by being flexible, socially valid and providing the clinician with some therapy guidelines as well as being amenable to a broad community based approach to rehabilitation. method the objectives of the study were as follows: to translate the ceti into sotho, zulu and afrikaans to administer it to a range of aphasic patients in each of four language groups (english, afrikaans, zulu, sotho) to administer it to a group of patients with right hemisphere damage to compare, where possible, results of ceti to the results of standardised language testing to examine the relationship between scores obtained on the ceti and overall severity of aphasia to examine the relationship between performance on the ceti and certain case history factors, eg.time since onset of the problem and racial/cultural background to readminister the ceti, where possible, after a period of time to assess its sensitivity to recovery and/or improvement following therapy to determine whether there is any characteristic item differentiation between groups. the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 76 claire pen, kelly milner, peter fridjhon it was hypothesised that: 1. the nature of the aphasic deficit in a group of south african aphasic patients would be highlighted by means of the ceti. 2. there would be a difference between the scores of patients tested on the ceti after a period of recovery. 3. the patients with right hemisphere damage may show a communicative deficit as highlighted by the ceti. 4. there would be some correlation between the type of standardised test profile that the patient displays and the results on the ceti. subjects a multicultural group of 28 adult stroke patients was used in this study. the subjects were divided into three groups: group a. 14 subjects were diagnosed as aphasic patients in that they had a single episode, cerebral vascular accident of sudden onset and had left hemisphere (lh) damage in the language areas, as confirmed by the report of a neurologist and /or speech language pathologist. this group of patients had a single ceti administered. the mean age of this group was 57 years and the mean time since onset of aphasia was 14 months. group b. an additional 8 aphasic subjects, who fulfilled the same criteria as patients in group a were tested on two occasions (designated b1 and b2). four members of this group were stable (ie. first tested at more than six months post onset) and four were acute or "recovering" (to use the terminology of lomas et al.) that is less than six months post onset. the purpose of this was to allow for a comparison with the data of lomas et al. (1989). the mean number of months between first and second testing for these two groups was 3 months for the acute group and 13 months for the stable group respectively. the mean age of this group was 56 years. group c. the remaining six subjects had a communication problem resulting from a right hemisphere (rh) stroke, as determined by the report of a neurologist. these patients were included in the study because the communication effects of right hemisphere damage have been well documented and are sensitive to societal measures of performance such as the ceti. the mean age of these patients was 52.5 years and the mean time since onset was 4 months. for various reasons outlined in the introduction, the selection of a homogenous group of aphasic patients is particularly difficult in the south african context. criteria for subject selection were thus restricted to the following: each subject should have a spouse and/or significant other spending at least three days a week with him/her, (in order to ensure accuracy in filling out the ceti) and each subject should have as a home language one of the following four languages: english, afrikaans, zulu or sotho (as the measure was translated in these languages only). other factors such as age, gender, educational level, time since onset of the problem and previous therapy were not controlled for. details pertaining to the subjects are portrayed in table 1. .the age rangeofthe subjects wasfrom 19-82 years. 18english speaking patients, 3 afrikaans-speaking patients, 6 zulu speaking patients and 3 sotho patients were used in the study. information pertaining to the spouse or significant other who completed the ceti is also provided in table 1. patients were identified by speech therapy departments and clinics in the johannesburg areas and were tested over a period of two years. method 1. translation of the ceti. the canadian version of the ceti was translated verbatim into three languages: afrikaans, sotho and zulu. these languages were selected on the basis of their being most commonly used by patients in the area of johannesburg. translations were undertaken by first-language qualified speech-language and hearing therapists in the appropriate home language and were checked for accuracy by an additional native speaker and by the department of african languages at the university of the witwatersrand. none of the conten t of the ceti was altered because the authors of the test (lomas et al., 1989) have suggested that the items have universal application. 2. administration of the ceti. the ceti was administered to all the subjects in the following way: the authors provided a broad background to graduate or student therapists who were working with the particular patient. student therapists were instructed on the use and administration of the ceti in accordance with the directions set out by lomas et al. (1989). the spouse or significant other was interviewed and informed of the purpose of the study. the ceti was then completed, following a brief discussion of the vas with the spouse/caregiver. 3. additional testing. in addition, formalised testing of the patients took place. in most cases a standard aphasia test (eg. the boston diagnostic aphasia examination (bdae), goodglass and kaplan 1972; the western aphasia battery (wab), kertesz 1982) or translated versions thereof were administered over one or two test periods with the patients. the procedure followed the designated instructions in the manual. formalised testing was not always possible, however, for the following reasons: the patient was still in the acute phase and therefore difficult to test, a translated version of the standard test was not available or the patient had been discharged before standardised testing could be undertaken. in such cases, an informal judgement of type and severity of aphasia was made on the basis of unstandardised assessment tasks (eg. a language sample) and discussion with the therapists of the patients. where sufficient data were available a severity rating, using the severity rating scale of the boston diagnostic aphasia examination (goodglass & kaplan, 1980) was also undertaken. the purpose of this testing was to provide some baseline of comparison for the results obtaine'd on the ceti. ί 4. follow up testing. for the eight lh patients whom it was possible to follow up, a ceti was readministered (mean time interval 6 months; range 3 months 15 months). this time period was selected in order to ensure, as far as possible, that the period of spontaneous recovery was past (kertesz, 1982). follow-up testing was done on a previously marked ceti as lomas et al. suggest, giving the spouses the benefit of seeing where their previous judgement had been (guyatt, borman, townsend & taylor 1985). the time interval between the two testing sessions for the repeat group was generally longer than in the case of the lomas et al. (1989) study. scoring method and analysis of data the scoring of the ceti involves the use of-'the visual analogue scale. not only is it assumed to be particularly sensitive to changes in performance over time as bond and lader (1974) have suggested, it is also considered relevant for the type of population used in this study as jacobson (1986) and others have shown that it is not reliant on literacy and numeracy levels. the south african journal of communication disorders, vol. 39. 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communicative effectiveness index: its use with south african stroke patients table 1: subject characteristics 77 ss sex age time since onset first language result of std testing severtiy therapy person interviewed group a aphasic subjects, single testing 1 μ 56 3y;2m zulu expressive severe y wife 2 f 46 -;2m zulu wab:aq 12.5 severe y niirse-aid 3 μ 64 -;4m soth wab:aq 76.8 mild y son 4 μ 41 -;3m eng bdae:1 severe y wife 5 f 51 5y eng wab:aq 57 severe y husband 6 μ 24 ly;4m eng cadl: anomic mild y father 7 f 82 -;lm eng wab:aq 90.4 mild y daughter 8 μ 59 -,8m, eng bdae:1 severe y wife 9 f 70 3y eng wab:aq 85.7 mild y husband 10 μ 47 l y eng wab:aq 92.6 mild y wife 11 μ 63 -,8m afr wab:aq 68 y daughter 12 f 78 -;lm eng wab:aq 45 ν husband 13 μ 58 eng wab:aq 77 mild y son 14 μ 61 3y eng bdae: 2 severe y wife group β aphasic patients with repeat testing 15 f 59 ly;3m eng wab:aq 37.9 severe y husband 16 f 57 -;3m afr wab:aq 46.7 mild y son 17 f 57 6 y eng wab:aq 65.6 mild y husband 18 μ 72 3y eng y wife 19 μ 52 -;lm zulu wab:aq 82.8 mild y brother in law 20 μ j65 -;5m soth wab:aq 12.3 severe y son / 21 μ 53 -;2m zulu wab:aq 56.7 severe ν wife 22 f 36 -;9m zulu bdae:3 mild y mother 1 group c right hemisphere group ! 23 f j 60 —4m soth wab:aq 89.5 mild y wife 24 μ ' 6 1 / -;3m eng wab:aq 89.4 mild ν 25 μ 67 -;lm eng wab:aq 79.4 cousin 26 f 69 -;lm eng severe sister 27 f 39 —4m zulu wab:aq 92.8 mild y mother 28 f 19 -;9m , afr wab:aq 79.9 mild y niece key and explanation to table 1 -: information not available first language: english (eng), sotho (soth), zulu or afrikaans (afr) aphasia type/score: determined by formal testing using bdae or wab where possible, otherwise by informal observation and/or therapist report. wab aqs reported when available. sev: severity as rated on the severity rating scale of the boston diagnostic aphasia examination (goodglass & kaplan, 1980) prev ther: history of previous therapy (y: yes; n: no) other: significant other interviewed th south african journal of communication disorders, vol. 39 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 78 claire penn, kellymilner, peter fridjhon the position on the scale of each response was calculated by measurement on a 100 millimeter scale and an overall percentage score was thus obtained for each item and for each patient, moved to full decimal point. scores for each item were calculated and means for each item across the three subjectgroups were calculated. statistical testing as the sample sizes were small and the normality of the population questionable, non parametric measures were used to test group differences namely the mann whitney u test and the wilcoxon matched pairs signed-rank test (siegel, 1965). group differences were tested between groups a, β and c, between group a and β combined (representing the lh group) versus group c, and between the two testing periods of group β (referred to as b1 and b2). statistical testing was also undertaken for the variables of severity, time since onset and linguistic/cultural background, with the lh group (groups a and β combined).this was done in order to relate the subjects' performance on the ceti to case history factors known to relate to aphasia test performance. severity. the overall severity of the aphasia, as measured on a standard test or on the boston diagnostic aphasia examination severity rating scale (goodglass & kaplan, 1980), was characterised and patients divided into mild versus severe aphasic patients (ie. for groups a and b). 10 patients were classified as mild and 9 as severe patients on this scale. the severity level of three of the patients was not possible to assess either because of missing data, or because their classification was equivocal (eg. in the case of conduction aphasia). time since onset. the cut off point of six months, which is the period traditionally considered as reflecting a period of spontaneous recovery, was selected (kertesz, 1983). in groups a and β combined (that is the lh subjects),ten subjects had a time since onset of less than six months and 11 subjects a time since onset of more than six months. linguistic/cultural background. aphasic patients (that is groups a and b) were split into two groups reflecting their relative racial/cultural background. for the purposes of this study the groups used were white (including english and afrikaans speakers) and black (including sotho and zulu speakers). the numbers were 7 (black) and 15 (white) respectively. this split, though acknowledged to be crude, reflects in some way the split created by sociopolitical divisions and rehabilitation services offered in this country to date. an analysis of differences by language was also done in order to ensure that the translation of the ceti did not affect the results obtained. item analysis. in order to gain some insight into the specific nature of the communication problems experienced by the subjects in this study, an item analysis was undertaken, using a measure splitting the scores obtained into quartiles. as there were no scores in the bottom quartiles, the first and second quartiles were combined into one catogory, hence deriving the following three ranges: 0-49, 50-74 and 75 -100. this was done by means of a matrix (see appendix 2) whereby items that were not consistent across groups were identified. (inconsistent items were off the major diagonal of the matrix). this analysis was undertaken for the aphasia group as a whole, and for comparing the two testing sessions for group b. it was also undertaken for the rh group as well as for the variables of severity, time since onset, and culture, using the aphasic patients (that is groups a and b). sample size prohibited such a breakdown in the case of the rh group (group c). results and discussion of results results of statistical testing a. group scores on the ceti the means of the subjects' scores in each group for each item are presented in table 2. this table reveals the following trends: 1. no significant difference exists between the overall scores for groups α, β1 and c. this confirms that the ceti not only seems sensitive to south african aphasic disorders but also to the problems following right hemisphere damage. the fact that no differences existed between the scores of groups a and β justifies their combination in certain of the analyses undertaken. for group a (lh) a mean score (across all items) was 58.2% with a range of 35 79 %. for group β (testing period 1) the mean score was 59% (range 35-77%) and for group c the mean was 70% ( range 40 86%). this was done using the mann whitney u test (between a and β1 u=k; ns; between a and c u=k; ns). 2. for group b, there was a significant difference between the scores obtained for the two testing periods (59% versus 70% respectively) with a mean improvement of 10.6% across time (wilcoxon matched pairs testing, t=14, p=.05). this was true for both the stable group and the acute group (the mean difference in improvement being 12.5 percent and 8.8 percent respectively). this difference was found to be significant (mann whitney u test; u=5; p=.05) suggesting that both groups showed improvement on the second testing. the results are, however, somewhat problematic because of the small sample size of the two groups and because of the unexpected results in one of the stable patients (subject 22) who made a very large improvement (32%) from first to second testing arid therefore skewed results for the stable group. | these findings confirm the results of lomas et al. (1989) and suggest that the ceti is sensitive to changes across time. not all patients in this group showed a positive change across time however; two subjects' scores went down (subjects 15 table 2: mean scores per group across ceti items ceti item 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 total .. group a 68 59 72' 63 79 69 61 65 62 51 55 36 66 37 44 35 58 group b1 66 50 59 64 75 56 59 56 77 55 68 44 67 35 52 53 ' 5 9 group b2 82 64 79 71 84 73 75 67 94 67 81 50 61 44 62 70' 70 group c 55 63 86 56 64 53 67 60 73 51 70 52 52 40 56 ' 51 70 (scores are given in percentages) the south african journal of communication disorders, vol. 39 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) c o u n i c a t i v e effectiveness index:its use with south african stroke patients 79 and 20 by about 1.1 and 5% respectively). looking at the individual subject profiles of these two patients, they were both severe and both were receiving speech-language therapy at the time of the second testing. thus the negative change in ceti scores might be accounted for in terms of more realistic attitudes having been developed by the spouses. as discussed earlier, research has indicated that spouses whose partners are enrolled in therapy tend to become increasingly aware of the aphasic individual's difficulties (shewan & cameron, 1984). what is very interesting to note here, is that there is a change in the stable patients, despite claims made that a plateau is reached after a period of time. changes in long term patients do however persist (eg sarno, 1975; aten, 1986) particulary if these changes are measured on functionally relevant test measures. it is therefore not surprising that while the four chronic patients had no significant changes on standard test scores over time, they did reveal differences on the cetibecoming, perhaps, more "experienced" aphasic persons. 3. the mean score for the right hemisphere group (group c) was 60.1% confirming that the right hemisphere patient does have substantial communication deficits frequently not detected by traditional tests (myers, 1984; sherratt & penn, 1990). interestingly the extent of the deficit in the rh group is not significantly different from the lh groups (mann whitney test), confirming the severe societal implication that such a defect has for the patient and the need for communication therapy for right-hemisphere brain-damaged subjects. b. analysis of aphasia patients in terms of subject characteristics the results of the analysis undertaken using aphasic subjects from groups a and β in relation to the variables of severity, time since onset and culture are as follows: 1. severity. a significant difference in the ceti score was obtained between patients who were classified as mild aphasia (with a mean of 70%) and those classified as severe (mean of 51%) (mann whitney u; u=15; p<.05). this finding supports the results of lomas et al. (1989) in sugggesting that the ceti has some validity in that it correlates with other broad measures of severity and therefore has the potential to discriminate accurately between different levels of patients. 2. time since onset. ten subjects had a time since onset of less than six months and 11 subjects had a time since onset of more than six months (data on one subject was missing). there was no significant difference found between misan scores of these two groups (u=k; ns). once again this may indicate that spouses become more aware of the difficulties faced by the aphasic person with time.jthus the plight of the acutely aphasic individual may be under-'emphasized, while the chronic patient may be viewed more realistically. 3. cultural and language aspects. there was no significant difference found between ceti scores across any of the linguistic groups (english, afrikaans, sotho and zulu) or the two cultural groups (7 black and 15 white subjects) in terms of overall ceti means in groups a and b1 (u=k; ns). this confirms the hypothesis that the ceti is a relatively culture-free assessment tool, tapping areas of universal relevance to aphasic patients. it also suggests that the translation of the ceti did not appear to affect its reliability . c. item analysis (refer appendix 2) 1. item analysis for aphasic patients. the following items having a consistent level of severe difficulty across each of the aphasia groups (group a and b): item 12 (starting a conversation with people who are not close family), item 14 (being part of conversation when it is fast and there is a number of people involved), item 15 (participating in a conversation with strangers) and item 16 (describing or discussing something in depth). of moderate difficulty were: item 8 (saying the name of someone whose face is in front of him/her) and item 7 (having one-to-one conversation with spouse). of least difficulty to the groups was item 3 (giving yes and no answers appropriately). such an analysis confirms that communication situations with high social and cognitive demands are perceived as more impaired after a stroke than others. such findings also provide directions for intervention in terms of a possible continuum of management contexts. 2. item analysis differences in retested patients (appendix 2.2). the differences between items for patients in group β over the two testing periods was analysed. the assumption underlying this analysis was that certain aspects of communicative behaviour may show a particular sensitivity to change over time. no items deteriorated but interestingly, four items showed an improvement across time in group β namely: item 1: (getting someone's attention), item 3: (giving yes/no answers appropriately). item 11: (responding or communicating anything without words) and item 12: (starting a conversation with people who are not close family). the differences in item difficulty between b1 and b2 confirm the modality effect for spontaneous recovery described by lomas and kertesz (1978), that is that certain modalities (for example comprehension) improve at different rates from others and demonstrate that as the individual interacts with persons of the environment, s/he becomes more functional in the way that s/ he uses language (penn, 1983; aten, 1986 ). 3. item analysis for the right hemisphere group (refer appendix 2.1). the profile of the rh group was very different in terms of item complexity from the profile of the lh groups. for example, item 15 (starting a conversation with strangers), which presented the aphasic group with severe difficulties did not seem to be too taxing for the rh patients . this is a strong confirmation of the literature which documents the rh patients' relative lack of sensitivity to the environment and to the social situation (millar &whitaker, 1983; myers, 1984). in contrast, understanding writing (item 13) appeared less difficult for the aphasic patients than for the rh patients, suggesting that the visuo-spatial deficits of the rh patients may well be interfering substantially with the communicative process. 4. item analysis by severity (appendix 2.4). there were several items which differentiated the mild from the severe aphasic patient; namely items 8, 9, 10, 12, 13, 15 and 16. of particular significance was item 8 saying the name of someone whose face is in front of him/her. this item provided maximum differentiation between the mild and the severe aphasic groups, highlighting that it is in the area of lexical specificity that the aphasic individual's language is typically impaired. anomia is well documented as a primary symptom of the aphasia deficit and it is interesting that it is this item, on a functional measure such as the ceti, that should differentiate mild from severe patients so clearly. 5. item analysis by time since onset (appendix 2.5). there was a surprising finding that many items were rated by spouses as being more difficult in the group who were tested more than six months post onset (ν 12) compared to those who were tested before this cut-off point (n9). examples of such items include 10 and 14 , (involving conversational skills), 9 (communicating physical problems) and 13 (understanding writing). this finding requires some explanation. it is hypothe south african journal of communication disorders, vol 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 80 claire penn, kelly milner, peter fridjhon thesised that the spouse may have become more realistic about the aphasic patient's problems with time. based on the results of the subjects in group b, this is not to say that they will not improve across time, but the tendency for early stage aphasic patients to be overrated in terms of their abilities has been documented previously (helmick et al., 1976; muller & code, 1983) and is confirmed by these results. the difficulties involved in conversing spontaneously, being involved in group situations and in understanding writing may well only emerge as the patient attempts to re-enter pre-morbid social and/or occupational arenas. 6. item analysis by culture (appendix 2.3). the seven black patients in groups a and β were considered for separate analysis to determine whether any differences emerged when compared to the group of white patients. the results of this analysis suggest that overall performance on the ceti is similar for both black and white subjects. on item 15, however, black patients performed better than white (participating in a conversation with strangers) and white patients performed better than black on item 2 (getting involved in a group conversation) and on item 5 (indicating understanding of what is being said). it is not possible to offer an explanation for these findings at present, but they could be suggestive of possible cultural effects of items. it is suggested that these variables require validation through further research. general discussion the results of this study suggest the following: the ceti seems to be a useful tool in the context of south africa in that it was successfully applied to a multicultural group of south african aphasic patients and reveals results comparable to those found by the original authors of the test on a group of canadian patients. equivalent results were obtained for aphasic patients regardless of racial, cultural or linguistic background. further, it appears to be sensitive to effects of severity and to recovery aspects and also highlights the communication deficits remaining after right hemisphere stroke. explanations for some of these results seem worth exploring. the fact that the results concur with those of lomas et al. (1989) confirms the strong societal impact which aphasia has, regardless of culture, language and country of origin. though attitudes to disability may change from culture to culture, the essence of the aphasic deficit, that is communication disability, must surely be universal in its effect. the analysis procedure used in this study made possible an investigation of specific item difficulty both within and between groups. unfortunately lomas et al. (1989) have not reported the results of their item comparison. it appears however that the present analysis of individual items has yielded some interesting results which may well have therapeutic implications. the fact that the zulu and sotho speaking patients, for example, were found to be less affected for group conversation than their white counterparts reflects possible differences in cultural attitudes towards such a disability, as well as suggesting possible directions for the context of rehabilitation. this aspect should be explored in future studies, for if we are to provide adequate aphasia rehabilitation services to the vast black population of this country, it is imperative that we begin to develop some knowledge of the african understanding of such a disorder. the method of free interviews to generate items within different cultural contexts, would appear to be a most interesting and valuable area for further research. it should be remembered that the original items selected from a pool of 36 items in the lomas study were generated by only 14 canadian aphasic patients. there is therefore a strong possibility that some additional items may well be derived in a local study of this nature. another dimension for comparison with the lomas study lies in the results obtained when comparing the eight patients who were tested twice on the ceti. it should be noted that in the lomas et al (1989) study the ceti was readministered only six weeks after its first administration, and that an improvement was noted in the ceti score only for the recovering (acute) group of subjects, but not in the stable group (more than six months post-onset). however in the present study, (where the mean time interval between test periods was 13 months for the stable group and three months for the recovering group respectively) an improvement was seen in both groups. this finding highlights the need to measure the effect of the improvement over a longer period of time than six weeks. in south africa, few patients receive intensive therapy following the stroke, whereas in the lomas et al. study, it should be noted that recovering patients were more likely to have received intensive therapy. the findings that stable patients continued to improve, and in contrast to the lomas et al. study, showed a significant change with time, thus may be accounted for in terms of the different time period used in the studies. the case of subject 22 in group β is particularly interesting. a younger subject, she showed a large amount of change, despite the fact that the period traditionally defined as the period of spontaneous recovery had long passed. not only is the patient relatively young,, confirming the writing of lomas and kertesz (1978) and others, regarding rate and amount of recovery in younger stroke patients, but she had also received intensive therapy and support from those in her environment and it is felt that the results seen here reflect the value that such stimulation has, well beyond the period of plateau in language skills, in overall communicative effectiveness. the use of the term "recovering" by lomas et al (1989) to describe the patient whose neurological picture is unstable, is perhaps a misnomer, because in contrast to the lomas study even the stable patients in the present study appear to be "recovering". the results for the right hemisphere patients are particularly fascinating. the ceti seems to be sensitive to the communication problems that such patients are having. though there is no difference in overall score on the ceti for these patients and the aphasic patients, the item-analysis has highlighted specific problems in different areas. this certainly lends support to the notion that right hemisphere patients need to be referred for communication therapy even if their results on standard measures of language are not significant. this population is very often overlooked in referral to jthe speech and language therapist. nevertheless the societal and familial ramifications of this type of disorder may well! be amenable to appropriately directed therapy. for example item 5 (indicating understanding of what is being said), which proved to be more difficult for the rh than the lh groups, indicates a need for socially directed compensatory training in such patients. conclusions the results of the present study suggest that a measure such as the ceti appears to have some validity on a south african stroke population regardless of cultural and linguistic background. as this measure focuses on the societal and contextual ramifications of aphasia, it becomes a viable alternative to some of the approaches currently being used in assessment as well as providing some guidelines for intervention, not only the south african journal of communication disorders, vol. 39 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) c o u n i c a t i v e effectiveness index:its use with south african stroke patients 81 with the aphasic patient but also for the patient with comm u n i c a t i o n problems resulting from right hemisphere damage. . the writers suggest that the ideal south african aphasia test should have the following properties: * it should be relatively culture free hence applicable to all aphasic patients in south africa, regardless of linguistic, cultural, social and educational backgrounds * it should be administered in the patient's home language, preferably by someone who is culturally and linguistically compatible with the patient * it should be easy to administer and not reliant on factors such as expensive equipment, tape recording of samples (because of the contextual restraint imposed by so many of the testing environments) * it should be relevant to the context (familial, social and occupational) of the patient * it should be sensitive to changes in the patient's status and thus be reflective of either spontaneous recovery or of therapy * it should have desired psychometric properties including reliability and validity in a preliminary way, it is hoped that this study involving the use of the ceti has shown that such a goal is within our reach. although no claims can be made about its being comprehensive, diagnostic or definitive, this approach clearly has promise, in that it appears to be both relevant and flexible for local patients. acknowledgements the writers wish to express sincere thanks to the following persons for their assistance during this study: dilys jones and beverley aron of the department of speech pathology & audiology, university of the witwatersrand ; the speech therapists at johannesburg, hillbrow and coronation hospitals; speech-therapy students: marion flink, precious jenga, tamar mehl and florence mthoba. this study was supported by a grant from the human sciences research council. reference list j aten, j. (1986). functional communication treatment. in r. chapey, (ed.), language intervention strategies in adult aphasia. new york: williams and wilkins. bond, a. & lader, m. (1974).the use of analogue scales in rating subjective feelings. british journal \of medical psychology, 47, 211 -218. fritz, v. & penn, c. (eds) (1992). stroke: caring and coping johannesburg witwatersrand university press. goldblum, g. (1985). aphasia: a societal and clinical appraisal of pragmatic and linguistic behaviours. south african journal of communication disorders 32, 11-17. goodglass, h. & kaplan, e.(1972). the assessment of aphasia and related disorders. philadelphia: lea and febiger. guyatt, g„ berman, l., townsend, m. & taylor, d. (1985). should study subjects see their previous respons e? journal of chronic diseases,38, 1003 1007. helmickj., waltamori, t. & palmer, j. (1976). spouses understanding of communication disabilities of aphasic patients jourwai of speech and hearing disorders, 41, 238 243. holland, a. l. (1980). communicative abilities in daily living: a test of junctional communication for aphasic adults. baltimore: university park press. jacobson, m. c. (1986). speech intelligibility and articulatory dynamics of reconstructive oral cancer patients. unpublished doctoral dissertation, university of the witwatersrand, johannesburg. kertesz, a. (1979). aphasia and associated disorders. new york: grune and stratton. kertesz, a.(1980). western aphasia battery. new york: grune and stratton. lomas, j., pickard, l., beste, s., elbard, h., finlayson, a. &zoghaib, c. (1989). the communicative effectiveness index: development and psychometric evaluation of a functional communication measure for adult aphasia. journal of speech and hearing disorders, 54, 113 124. lomas, j. & kertesz, a. (1978). patterns of spontaneous recovery in aphasic groups: a study of adult stroke patients. brain and language, 5, 388 401. millar, j. & whitaker, h. (1983). the right hemisphere's contribution to language: a review of the evidence from brain damaged subjects. in s.j. segalowitz (ed.), language functions and brain organization. new york: academic press. muller, d. & code, c. (1983). psychosocial adjustment to aphasia. british journal of disorders of communication, 18, 23 29. myers, p. s. (1984). right hemisphere impairment. in a. holland (ed.) language disorders in adults. san diego: college hill. penn, c. (1985). the profile, of communicative appropriateness : a clinical tool for the assessment of pragmatics. south africanjournal of communication disorders, 32, 18 24. penn, c. & beecham, r. (1992). discourse therapy in multilingual aphasia: a case-study. clinical linguistics and phonetics, 6,(1), 11-25. sarno, μ. t. (1975). the functional communication profile. new york: institute of rehabilitative medicine. semela, j.j. (1978). an investigation into the breakdown of the concordial system of zulu-speaking aphasics. unpublished undergraduate research project, university of the witwatersrand, johannesburg. shewan, c. & cameron, h. (1984). communication and related problems as perceived by aphasic individuals and their spouses. journal of communication disorders, 17, 175 -187. sherratt, s. & penn, c. (1990). discourse in a right-hemisphere braindamaged subject. aphasiology, 4, (6), 539 560. siegel, s (1965). nonparametric statistics for the behavioral sriences. new york: mcgraw-hill. zraik, r. & boone, d. (1991). spouse atitudes towards the person with aphasia. journal of speech and hearing research, 34, 123 128. appendix 1: communication situations used in the communicative effectiveness index ceti items 1. getting someone's attention 2. getting involved in group conversations that are about him/her. 3. giving yes/no answers appropriately. , 4. communicating his/her emotions. 5. indicating that he/she understands what is being said to him/her. 6. having coffee time visits and conversations with friends and neighbours 7. having a one-to-one conversation with you. 8. saying the name of someone whose face is in front of him/ her. 9. communicating physical problems such as aches and pains. 10. having a spontaneous conversation. 11. responding or communicating anything without words. 12. starting a conversation with people who are not close family. 13. understanding writing. 14. being part of a conversation when it is fast and there are a number of people involved 15. participating in a conversation with strangers. 16. describing or discussing something in depth. the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 82 claire penn, kelly milner, peter fridjhon appendix 2: item comparison matrices (the numbers refer to item numbers of the ceti.) 2.1: comparison of item difficulty for lh (group a ) versus r h (group b ) patients group a mean score <49% 50-74% 75%+ <49% 14 12 group c 50 74% 15; 16 1; 2; 4; 6; 7; 8; 9 10; 11; 13; 5; 75+% 3; 2.2 comparison of item difficulty on repeat testing for group β black subjects <49% 50-74% 75+% <49% 14 b2 50 74% 12 2; 4; 6; 7 8; 13 15; 16 75+% 1; 3; 11 5; 9; 10 2.3 comparison of item difficulty for black vs white subjects black subjects <49% 50-74% 75+% <49% 12; 14; 16 15; white subjects 50 74% 2; 1; 3; 4; 6 7; 8; 9; 10 11; 13 75+% 5 2.4 comparison of item difficulty for severe vs mild patients. severley aphasic subjects ! <49% 50-74% 75+ ! <49% 14; 1 i mildly aphasic subjects 50 74% 2; 10; 12; 15 16; 1; 3; 4; 6; 7; 11 1 75+% 8 9; 18 5 2.5: comparison of itemdifficulty for subjects tested in stable versus recovering subjects < 6m <49% 50-74% 75+% <49% 12; 16; 10; 14; 15 > 6m 50 74% 5; 1; 2; 3; 4; 6; 7; 8; 11 / 9; 13; 75+% the south african journal of communication disorders, vol. 39 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ® in-the-canal hearing aids with acoustimed's exclusive "anti-feedback" technology unlimited venting without whistling more usable gain than behind-the-ear aids user-controlled noise reduction easily handled battery drawer the acoustic advantages of in-the-canal hearing aids are well known. however, until now their use has been limited by acoustic feedback which causes oscillation (whistling). acoustimed has developed a technique for controlling the phase response of hearing aids to prevent oscillation. full details are a trade secret but results are spectacular. we can now make in-the-canal hearing aids that have more usable gain than behind-the-ear models and they do not oscillate regardless of how large we make the vent. with the phantom model afp (power) version it is possible to correct nerve deafness with high frequency loss as great as 90db. the phantom models af and afp have a simple but effective noise control. when the volume is turned down low frequency noise is reduced more than the essential high frequencies. this unique feature'has the effect of improving the signal-to-noise ratio in noisy conditions. because of the miicrophone position phantom hearing aids have better high frequency performance than since there is no efficient and hav'e behind-the-ear models and tubing they are more a smoother frequency response. previously in-the-canal hearing aids could be used only for mild hearing loss due to feedback problems. with the new phantom hearing' aids there are less feedback problems than with behind-the-ear models. tnis allows us to make phantom aids which work better than many behind-the-ear pp hearing aids. phantom hearing aids are made in 3 basic models. the approximate fitting range is illustrated in tnis diagram. performance is controlled by transducer selection. frequency 125 250 500 ik 2k akhz acoustimed hearing services 327 bosman building cor. eloff and bree streets, johannesburg tel: (311) 337-2977 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) information for contributors theoretical and philosophical mnce^uiahsi a n d c n t ? c a " y evaluative of human communication « t s η 6 a h n g w i t h a s p e c t s ing; and p o l i c y . " d ' t s d l s o r d e r s > s e ™ c e provision; trainunder review hy other ̂ t t ^ ^ ° γ * * i s manuscript style and requirements quired to follow strictly he s^le z ™ ^ i c o n t r i b ^ ° n s are rewith complete internal consistent p „ „ , ' p u b · m a n · ) , quality type-written m a n z c ^ z t n t ^ 0 t n p l e " s p a c e d high margins should be submitted ̂ tiev^hoi p a « e s · -nd wide identical disc copies o 7 £ p a w l ) t n w τ ™ 0 extension ,wp5); (2) in a s a ^ n l v l n 1 w o r d p e r f e « 5.1 (with an names shouzin ludetheirst a u t w ^ ' t ? e x t 6 n s i o n a s c ) · able keyword or abbreviatio^w f t f a " d 3 d e a r ' y i d e n t i f i " the last line of t h e a * p a g e o f x % / ^ * ^ e w r i « e n on purposes only). p g ° f t h e r e f e r e n c e list (for retrieval warranted. the fllpage of twozttil ^ a d d l t l ° n a l k n g t h i s article, name of authorfs) ^ ^ contain the title of the accordance address).in not required to p ^ d ^ ^ 1 ^ f h o r s are copies, the first page should contain oriy tĥ tirie s t τ * all copies, should contain only a n a b s ^ « h nn f of english and a f r i k a a n s afrit.. a b s t r a c t (100 words), written in seas contributor·! mo,• raans abstracts will be provided for overorder of m ^ o t s s m ^ p l i m b l e s h o u l d * in the a c k n o w i ^ d g e ^ s s g 1 ^ conclusion, be indented. "^tjumvces. all paragraphs should s ™ e t p s u s r u , d w i e c c h s hrf l d b e « « karate the copies sem ε ί ^ ρ ΐ ^ γ η ι τ γ p u r p 0 s e s a " d u s e d f o r p u b h c a t i o „ h o w e v f " m u s t s , rtan , h n e d r a w i n g s t h a t a r e references after the first o c c u « ^ « λ * * τ ^ m ° t e t h a n ^thors, for six or more wherf«a/ m v· author will suffice, except authors shouldtppeati^tl^e referenr^r°^ n a m s °f all strict alphabetical order i s s ® ' ̂ s h ° u i d b e i i s t e d » references should betnc udx f d °f the artide· a " ces, (αρα pub. man. l983 p l 3 ) o n t ' ' " ^ ΐ , " ® journals may be used, (se« d s h ^ o t m c ^ ^ n t v. k r e v * a t * o n s ° f list of scientific periodicals). °t t^ w o r l d exceed much more than 25, unless z x l n y t ? ^ ^ n « examples locke, j.l. (1983). c ] i n i c a ] h o l 3m4erof s p e e c h s o u n d wilkins. m 1 d e d j b a ]t«nore: williams & editing ^ ^ ι τ ^ ^ η ι ^ " γ 6 d t 0 for revision. required. the i t " m a d e * t h e is fina. editing f o r s ^ ^ : ^ ^ · ^ ^ * 10 reprints with°ut — -11 ̂ provided free of s z ^ ^ s z s z s r t h e pre t o d 4» " arrangement. p p b e a c c e p t e d until 31s't july by ι queries, correspondence & manuscript i ., , s i r s box 31782, b r a ' a m l ^ ^ t o ^ r u k i ^ r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) inligting vir bydraers die suid-afrikaanse tydskrif vir kommunikadeafitykings publiseer verslae en artikels wat gemoeid is met navorsing, of handel oor krities evaluerende, teoretiese en filosofiese konseptuele kwessies wat oor menslike kommunikasie en kommunikasieafwykings; diensverskaffing; opleiding en beleid gaan. die suid-afrikaanse tydskrif vir kommunikasieafivykings sal nie artikels aanvaar wat reeds elders gepubliseer is, of wat tans deur ander publikasies oorweeg word nie. manuskrip styl en vereistes: manuskripte behoort deur 'n dekkings brief vergesel te word wat die skrywer se adres en telefoonnommers bevat. daar word van alle bydraes verwag om die styl, soos gespesifiseer is in die "publication manual ofthe american psychological assoc. (3rd ed., 1983) (αρα pub. man."), nougeset te volg met volledige interne ooreenstemming. manuskripte moet getik, van hoe gehalte en in drievoud spasiering met wye kantlyne wees. vier kopiee van die manuskrip moet verskaf word. twee hiervan moet identiese skyfkopiee van die artikel wees; (1) in "wordperfect" 5.1 (met 'n uitbreiding .wp5); (2) in ascii kodes met 'n uitbreiding .asc). leername behoort die eerste skrywer se voorletters en 'n duidelike identifiseerbare sleutelwoord of afkorting daarvan in te sluit en moet op die laaste lyn van die laaste bladsy van die verwysingslys getik word (slegs vir naslaan doeleindes). as 'n reel moet bydraes nie 25 bladsye oorskry nie, maar langer artikels sal aanvaar word indien die addisionele lengte dit regverdig. op die eerste bladsy van twee van die afskrifte moet die titel van die artikel, naam van die skrywers(s), en instansie (of adres) verskyn. in ooreenstemming met die "αρα pub. man." se styl word daar nie van skrywers verwag om enige kwalifikasies te verskaf nie. op die eerste bladsy van die twee oorblywende afskrifte moet slegs die titel van die artikel verskaf word. die tweede bladsy van alle afskrifte moet slegs 'n opsomming (100 woorde) in beide engels en afrikaans bevat. afrikaanse opsommings sal vir buitelandse bydraers voorsien word. hoofopskrifte moet, waar van toepassing, in die volgende volgorde verskaf word: metode, resultate, bespreking, gevolgtrekking, erkenn1ngs en verwysings. alle paragrawe moet ingekeep word. ! tabelle en figure wat op afsonderlike bladsye (een bladsy per tabel/illustrasie) moet verskynj moet vir referent doeleindes gekopieer word en slegs die kopiee moet jinisieel verskaf word. figure, grafieke en lyntekeninge wat vir publikasie gebruik word, moet egter oorspronklike weergawes wees en moet in swart ink op wit papier van 'n hoe gehalte wees. die oorspronklikes sal slegs verlang word nadat die artikel vir publikasie aanvaar is. letterwerk wat op bogenoemde verskyn moet eenvormig wees, professioneel gedoen word en daar moet in gedagte gehou word dat dit leesbaar moet wees na 'n 50% verkleining in drukwerk. letterwerk by illustrasies moet onder geen omstandighede getik word nie. verklarings of legendes moet nie in die illustrasie nie, maar daaronder, verskyn. die opskrifte van tabelle (wat boaan verskyn), en die onderskrifte van figure, (wat onderaan verskyn), moet beknop, maar helderend wees. numering moet deur middel van arabiese syfers geskied. tabelle en figure moet in die volgorde waarin hulle verskyn, genommer word. die aantal tabelle en illustrasies wat ingesluit word, word deur die redakteur bepaal (gewoonliknie meer as 6 nie). verwysings verwysings in die teks moet voorsien word van die skrywer se van en die datum, b.v., van riper (1971). wanneer daar egter meer as twee skrywers is, moet daar na die eerste verskaffing van al die outeurs, van "et al." gebruik gemaak word. in die geval waar daar egter ses of meer outeurs ter sprake moet "et al." van die begin af gebruik word. al die name van die skrywers moet in die verwysingslys verskyn wat aan die einde van die artikel voorkom. verwysings moet alfabeties in trippel spasiering gerangskik word. al die verwysings moet in die verwysingslys verskyn, insluitende sekondire bronne, ("αρα pub. man." 1983, p. 13). slegs aanvaarbare afkortings van tydskrifte se titels mag gebruik word, (sien "dsh abstracts, october"; of "the world list of scientific periodicals"). die aantal verwyings moet nie meer as 25 oorskrei nie, tensy dit geregverdig is. let op die volgende voorbeelde: locke, j.l. (1983). clinical psychology: the explanation and treatment of speech sound disorders./. speech hear. disord., 48, 339-341. penrod, j.p. (1985). speech discrimination testing. in j. katz (ed.), handbook of clinical audiologg (3rd ed.). baltimore: williams & wilkins. davis, g.a. & wilcox, m.j. (1985). adult aphasia rehabilitation: applied pragmatics. san diego, ca.: college-hill. redigering manuskripte wat aanvaar is, mag na die skrywer terruggestuur word vir hersiening. addisionele kleiner veranderinge mag ook op hierdie stadium aangebring word, maar 'n nota ter aanduiding van alle veranderinge wat op die manuskrip voorkom, moet verskafword. die artikel word dan aan die redaksionele komitee vir finale redigering van styl, duidelikheid en konsekwentheid teruggestuur. herdrukke: 10 herdrukke sonder omslae sal gratis aan die outeurs verskaf word. sluitingsdatum vir bydraes: bydraes word verkieslik teen 31 mei elke jaar verwag, maar artikels sal nog tot 31 julie vir aanvaarding oorweeg word. navrae, korrespondensie en manuskripte: moet geadresseer word aan die redakteur, die suid-afrikaanse tydskrif vir kommunikasieafwykings, die suid-afrikaanse spraak-taal-gehoor vereeniging, posbus 31782, braamfontein, 2017, suid afrika. p r i n t e d b y v 4 r p r i n t i n g w o r k s , p r e t o r i a r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a study of european speech defective school children in pretoria l. weiss, b.a. log. m.a. the scope of this study: 63 schools with a total school population of 33,482 children were studied. these excluded all special schools and all schools not administered by the transvaal education department. among these children, 1,513 were found to have speech defects severe enough to enable teachers to diagnose the children as having "something" wrong with their speech. this figure represents 4.5 per cent, of the school population studied. findings 1. among the speech defective children studied 38 per cent, were dyslalic, and 28 per cent, were dysphemic. 2. the ratio among the sexes was on an average 2.2 boys to 1 girl increasing to 3 boys to one girl among the dysphemics. 3. some interesting differences were found in the incidence of speech defectives children in different types of schools. it was found that the largest incidence occurred in the afrikaans medium high schools, 5.2 per cent, while the lowest incidence of only 2.2 per cent, occurred in the english medium high schools. the results though very interesting and giving us much food for thought, are not completely reliable, since surveys were in most instances done by school teachers, and since there are very few english medium high schools in pretoria. the discrepancy in the primary schools was not as great, the afrikaans school with 4.8 per cent, and the english schools again lower with 3.7 per cent. dual medium schools cannot be compared as only three schools were available for study, although it can be stated that the incidence of spaech defectives was higher than among any of the other types of schools. 4. it was also found that youngest children in the family had a significantly higher incidence of speech defects, than children in other positions. results of therapy: this included only a few schools, where children were treated once or twice a week, for a period from 6 to 10 months. response to therapy was on the whole very gratifying, 92 per cent, of the children showing definite improvement, including almost 50 per cent, who were completely rehabilitated in such a short time. may i conclude by stating my firm belief that the speech defective school children must be helped, and that we can help him to attain his rightful place in the community by helping him while he is still at school. ride & a i e t g f) the greatest name in cycling o n terms 7s. 6d. weekly from all raleigh cycle dealers r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 journal of the south african logopedic society december organic d y s l a l i a by alice rummel, b.a. log rand speech is the highest and most fundamental human attribute and without it one is set outside the possibilities of constant communication with his fellows. speech is also an important tool for social adjustment, and must conform to the environment. when listeners recognise speech as defective, impaired social relationships arise which further inhibit and distort speech. as the defect gets progressively worse the individual's social relationships become impaired. thus it is not sufficient to know only what kind of defect the person has, but also what kind of person has a speech defect. the speech defect alone has no meaning but must be considered in relationship to the whole personality, since speech and personality are closely linked. there are four aspects necessary for the production of normal speech: 1. phonatory — concerned with the voice or laryngeally controlled air stream. 2. articulatory — here the stream is modified by articulatory organs of the mouth and throat. 3. linguistic — which must conform to an arbitrary code of meanings for communication. 4. auditory. in these processes of vocal control and articulatory modification, the chief guide "as to the accuracy of conformity to the code is the oral communication of others, this interpretation being an integral part of the function of speech." many faculties are concerned in the completion of this fourfold picture. if one fails to develop, speech fails, even though the other functions are normal. psychologically, articulation, which is the moulding of speech sounds, is not a special faculty in itself, but is rather an amalgamation of several abilities that develop side by side during the first years of life. it is largely these abilities that determine the onset of speech. if one of these abilities are late in dteveloping, speech will be delayed, defective or both. the factors underlying articulation are both sensory and motor. they are:— 1. discrimination and acuity to sounds of high frequency. 2. memory span for individual speech sounds. 3. speed of muscle movement. 4. specialization of movement. froeschels and jellinek define dyslalia as concerning "all disorders occurring in articulation. if sounds are produced1 incorrectly or replaced by others, or if they are entirely lacking, then the person is dyslalic". the classification of dyslalia is mainly based on etiology. there are three main divisions: a. organic. b. functional. c. psychological. these divisions, however, may overlap and are interrelated, and have no clearly defined boundaries. there is seldom an organic factor alone, but usually there is some introduction of a psychological factor. organic dyslalia presupposes structural deformity or abnormality and thus implies a disorder of articulation due directly to the fact that some part or parts of the articulatory apparatus are so defective anatomically and physiologically that they are unable to perform their primary functions of chewing, sucking and swallowing, or their secondary derived function of articulating with a great degree of perfection. there are any number of possible oral deformities, e.g. cleft lip, paralysis. of the lip or lip inadequacy due to shortness, trauma or other cause; abnormalities in size, symmetry or functional efficiency of the tongue, tongue-tie, growttis on the tongue and paralysis; disturbed dental relationships such as all types of malocclusion, spaced or missing, misplaced or supernumerary teeth or other dental conditions that may interfere with usual articulatory adjustments necessary for good speech production; cleft palate, abnormally highly arched palate, and short cleft or paralysed velum. these are some possible causes of organic dyslalia. a deformity of any one of the structures of the oral region tends to cause a distortion of the other adjacent structures, since their anatomical and functional relationships are so close. because of these close relationships, the condition and functioning of the oral structures should be carefully noted, in order to determine their possible role in causing the given speech defect. if the basis of the speech defect is organic, surgical and medical attention may be needed; if it is functional or psychological in origin, the treatment should proceed from the approach indicated. examination procedures van riper states that the mouth and throat of all cases should be examined. although the case may effect a good acoustic result of speech in spite of a physical anomaly, such an organic abnormality will be some handicap in speech r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society development. the presence of an organic abnormality is not important unless it stands in functional relationship to defective speech sounds. diagnosis should not be made hastily. other causal factors may also be of great importance besides the organic defect. each part of the articulatory organs should be examined thoroughly. the structure itself should be examined not only in quiescence but also in its relation to the appropriate speech sounds. all evidence of a handicapping abnormality and all compensatory movements should be recorded. other factors such as intelligence, auditory acuity, motor inco-ordinations and especially emotional hi^ory and background of the case should be taken into consideration. defects caused by mouth deformities are usually structural in origin. however, the deformity of the mouth is not always the explanation for the speech defect. thus: 1. structural anomalies of organs of articulation may occur but there is no speech defect. 2. acceptable speech can be produced by adjustments of the articulatory organs which are mechanically quite different from adjustments usually made in speech. 3. there is more than one way of producing a particular speech sound. for example, in the production of the " t " sound, if the patient cannot elevate the tip of the tongue he can use the blade. the severity of the speech involvement depends upon the extent of the abnormality, and also upon the degree of compensation by the articulatory organs before the restoration of the function of the imperfect structures has been achieved. the ability to compensate differs with every individual case even if the extent of the deformity is similar. this difference may depend on differences in auditory awareness of speech peculiarity, kinesthetic sensitivity, intelligence, motivation and environmental stimulation. van riper suggests that bright children from homes with high speech standards will learn compensatory methods more easily than those less inligent children from homes with poor speech standards. this ability to compensate involves the child's residual diathesis or x-factor. the commonly-accepted postulate is that the usual adjustment of the articulators used for a given sound is the easiest, but by no means the only possible adjustment by which the given sound may be produced. although a person has a structural abnormality and cannot employ the usual manner of articulation, he may learn a new method for producing the sound, thus developing a unique skill. thus his structural abnormality does not interfere with his speech. but if the individual lacks this ability to acquire unique skills, his speech will be defective. in his speech difficulty then due to his structural anomaly or to his lack of facility? this facility is complex — "made up of mutually supporting factors such as the individual's health, endocrine drive, general vitality, intelligence, hearing acuity, efficiency of motor co-ordination, motivation and training for good speech afforded by his social environment." if these factors are in his favour, he can make successful compensations for any marked structural deviations. if these factors are against him a slight deviation may prove more of an obstacle than he can overcome without special help. this is not the only important factor in the individual with congenital malformations and other structural abnormalities. these anomalies themselves may be a specially, narrowly localized deviation and present an uncomplicated problem, or the anomaly may be evidence of a constitutional inferiority, with characteristic reduction of impetus in any project which requires individual initiative and stamina. thus in drawing up a programme for speech rehabilitation, this xfactor must be taken into consideration. it should be considered in the broad spheres when evaluating the child, not only in his ability to learn speech, but also his reactions in meeting other demands for initiative, resourcefulness and stamina. van riper says that there are two methods for minimizing the influence of organic abnormalities: 1. reconstruction of defective organic structure through surgery and orthodontia. 2. teaching of compensatory movements in speech sound production. orthodontia has seen great advancement and changes in dental, palatal and jaw structures have now been accomplished. cases, especially children with marked mouth deformities should be referred to the appropriate specialists so that reconstruction work can be carried out. thus effort will not be wasted in teaching compensatory movements where medical or dental care should first be instituted. palatal abnormalities are frequently associated with those of the jaws and orthodontic projection or retraction of the jaw can facilitate tongue contact with the roof of the mouth. a wide variety of surgical repair and construction work can be carried out, e.g. scar tissue can be excised and grafts can be made which will provide the necessary mobility. high palatal arches can be lowered and the velum can be modified. the most desirable time for surgery is during childhood. the speech therapist should recommend to the parents that it be done and see that it is carried out. the paralyzed structures can occasionally be helped by exercise adminisr ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 1 journal of the south african logopedic society december tered by a physiotherapist. there is usually recourse to more biological functions and tying up of the specialized movement with gross muscular action. the case may also need a hearing aid. the teaching of compensatory movements can be initiated if the case cannot be helped by surgery or orthodontia. since all speech sounds may be produced in a variety of ways, e.g. the art of the ventriloquist demonstrates compensatory activity of that of the lips and jaws. normal speakers may have profound anatomical abnormalities and produce sounds with a perfect acoustic end result. one must take into account and try to minimize the following factors in teaching compensatory movements: (i) complexity of performance (the fewer adjustments the better); (ii) ease of transition from other sounds; (iii) amount of facial distortion; (iv) distinctness of kinesthetic and tactual sensations ; (v) motivation and co-operation of the subject; an organic anomaly often causes unfavourable emotional and social attitudes. the reason for this is that any peculiarity of appearance, behaviour or speech tends to interfere with favourable adjustment. these attitudes may be prevented or minimized by adequate structural repair before the child can become sensitive about his appearance. reactions to deformities should be made objective. let the child face his problem squarely and learn to deal with any difficulties which he may encounter. on the other hand, the child's abnormality must not be kept in consciousness all the time. parents and teachers should stress other social graces, e.g. good grooming, friendly mannerisms, conversational ability, music, etc. therapy: all possible medical, surgical and orthopraxic procedures must be tried as early in childhood as possible because: 1. it prevents fixation of defective motor patterns in the nervous system, which will be displaced only with great difficulty, if at all. 2. it allows deformed parts an opportunity of reshaping into a normal mould after surgical repair by means of the natural processes of growth. 3it brings cosmetic improvement very early and therefore avoids the social insecurity and selfconsciousness brought about by physical deformities. if normal structure has not been obtained through medical, surgical or dental care, training should begin as early as possible to teach the child functional compensations for his structural deficiencies, and differences from the normal. "mechanically, standard speech is dependent upon normal anatomical structure." when anatomy is not normal, functional compensations should imitate as nearly as possible the mechanics of the correct sound rather than its placement in the mouth. after successful surgical repair, previous compensations must be eliminated, unless they are mechanically efficient in the production of the desired sounds. an isolated sound may be formed in a non-standard way with some facility, but when combined with other sounds or into blends these non-standard methods may not produce the desired acoustic result. thus the compensatory method must be considered as to wether it can be used together with other sounds, i.e. its usefulness for ordinary conversational speech. if structural anomalies of teeth, tongue and mouth remain, after surgery, compensations must be developed. the decision should only be made after careful analysis based on knowledge of mechanical properties. however, one must keep in mind the individuality of each case. thus in a programme of treatment and training the surgical repair comes first. the case can then proceed to exercises to strengthen the parts required, and go on to the correction of defective sounds. the prognosis depends on the severity of the deformity and on the efficiency of repair and amount of speech training. the operation alone may have no noticeable effect on his speech. postoperative training is a great deal more than half of his speech rehabilitation. complete or even partial surgical repair may be impossible. also it may be impossible to wholly compensate for any deficiencies by mechanical means. this needs special speech training. often the very badly deformed cases require not so much direct speech training as mental hygiene. conclusion. in this article an attempt has been made to cover some aspects in the field of organic dyslalia. details of the many defects of organic dyslalia have been avoided. instead a short resume indicating some important aspects of the field have been given. the importance of organic factors is obvious, and should not be overlooked, nor must too much emphasis be laid on them, because an individual may display normal speech in spite of organic abnormality. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) speech therapy for the cerebral palsied child a plan of treatment based on the bobath technique by g l e n d a s h a p i r o b.a. log. (rand) and r u t h j a c o b s b.a. log. (rand) (with acknowledgement to the principal and management committee of the forest town school for cerebral palsied children) the speech therapist engaged in treating the cerebral palsied child has usually looked to the sphere of physiotherapy for guidance and help, and has always reaped the benefit of the techniques and principles propounded by such eminent authorities as phelps, collis and temple fay. now, once again, the speech therapist can benefit from a physiotherapy technique, and gain a wealth of knowledge to help her in her therapy with the cerebral palsied child. here the writers refer to the approach to treatment devised by mrs. b. bobath. t h e t h e r a p e u t i c p r o g r a m m e general principles 1. the therapist must endeavour to normalise the muscle tone of the child's whole body in the reflex inhibiting posture (r.i.p.) before she attempts to teach speech to the child. the speech therapist should employ all the r.i.p.'s that will normalise muscle tone in the spine, neck, head, tongue, peripheral speech mechanism and prevertebral muscles. cerebral palsy is not a difficulty concerning individual muscles, but is rather a deficiency in movement and co-ordination, as the nervous impulses to the muscles are not directed in the normal way. there is also lack of inhibition from the higher centres in the central nervous system. if the therapist concentrates on treating only one muscle, she will probably produce spasm in other muscles, thus often stimulating spasticity in other parts of the body. the athetoid child must be taught to maintain muscle tone and control and grade movement. 2. training through the visual sensory field is used more as an aid than as a basic technique. preferably, training should be done through the proprioceptive pathways. cerebral palsy is a sensory motor handicap, and the cerebral palsied child usually has a deficient or distorted sensory intake. therefore the therapist should encourage the teaching of the "sensations" of normal movement and use the visual pathways as an aid only. 3. the child unhampered by the difficulties produced by cerebral palsy usually achieves head control at about six months, and at this time begins to babble. one cannot have a selective activity without first achieving fixation. in the cerebral palsied child the head and neck must be controlled before speech can function as an adequate means of communication. thus, one may summarise the problem, and say that the foundation stone of speech therapy for the cerebral palsied child is to first achieve head and neck control. the therapist must at first try to achieve total inhibition of any movement of the body which effects the head or neck. at a later stage the child should be able to speak and move simultaneously without spasm. ultimately the aim should be to create a speech function which is independent of the rest of the body. 4. the speech therapist must not allow any deterioration of muscle tone while giving her speech lessons. it is of the utmost importance that the speech therapist is aware of the spasm that can and does occur when the child initiates speech. this spasm must be inhibited. therefore, the therapist must first inhibit the primitive reflex patterns, and aim to build up higher and more organised reflex and voluntary activity on a developmental scale. 5. breathing should be taught on the basis of releasing spasm or normalising tone. bobath suggests that depending on where the spasm occurs, the therapist should manipulate and vibrate either the spine, thorax or larynx to improve exhalation. the concept of blowing exercises to improve breathing has been found to create diaphragmatic, thoracic and head/neck spasms. this, of course, is most undesirable, and can only cause further handicap to the child. instead the vibratory movement initiated by the therapist, as in the bobath method, helps to achieve relaxed breathing and frequently a long sustained sound without pressure or blocking occurs. ! 6. once' vocalisation has been induced and if the child is in a well controlled r.i.p. and vocalises spontaneously, the therapist must facilitate speech journal of the african logopedic society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sounds by manipulating the tongue, lips and face. the therapist must be careful not to reinforce wrong patterns of posture or movement. if the child has an extensor spasm he must be positioned so that the head is in the midline or flexed. similarly if the pattern is one of flexion, the head must be up-right. usually the child with an extensor spasm will articulate "g" and "k" sounds more easily than he will other sounds. the child with flexor spasticity will find the "b", "p" and " m " sounds easier to articulate. the easiest sound to facilitate is "b". the voiceless sounds are the most difficult ones to initiate and should be left to the last stages of therapy. vowels should be taught first and then consonants, and finally the combinations of vowels and consonants. alveolar sounds are facilitated, by the therapist moving her finger up and down under the front of the mandible. this forces the tongue up to the alveolar ridge. velar sounds are obtained by moving the finger up and down under the mandible towards the back of the tongue. the other sounds are facilitated in a similar way depending on where they are made in the mouth. 7. the therapist must allow the child to experience all the stages of normal speech development. thus, therapy may follow the same phases of development as in the normal child, based on the preliminary feeding patterns of chewing, sucking and swallowing. the child is placed in the r.i.p. most suitable for him and is helped by the therapist to chew, suck and swallow. hard foods are used for chewing exercises, while tubing and straws are used to help the child to suck. the swallowing reflex is stimulated by the therapist massaging and gently pressing the front of the throat, whilst the lips are held together. at all times the therapist must observe where the spasm occurs, and then position the child accordingly. the technique of "upside down feeding" is also used if the child drools incessantly. another way of obtaining lip closure to reduce drooling, and when the muscle tone is low, is by the technique of "pinching" round the mouth. if the child continually bites when stimulated on the front and sides of the gums, this primitive "bite" reflex must be inhibited by the therapist placing the child in a suitable r.i.p., holding the jaw down and stimulating the area round the lips, teeth and gums. when these areas have eventually been desensitised so that the child will not automatically bite when stimulated, the grip on the chin area is gradually reduced and finally eliminated. 8. the abnormal movements of the tongue must be corrected. it is of no avail to drill the cerebral palsied child with endless tongue exercises, without first reducing the spasm or overflow movements in the tongue, i.e. the tongue must be relaxed and controlled through an r.i.p. which normalises muscle tone in the head, neck and spinal regions. it has been found that it is far easier to achieve control of the tongue by first establishing jaw control. one of the key points, in this connection, is under the chin. here, once again muscle tone must be normalised. if the child has a forward tongue thrust the therapist must position the child so that his chin is not in a downward position, resting on the chest. conversely if there is an extensor thrust of the head and neck, paper may be placed under the chin. the child must hold this in position while the therapist endeavours to pull it away. this is for learning control of the extensor spasm in the neck. 9. voice quality can be affected by any change of muscle tone. spasms occurring in the laryngeal areas cause considerable deviations in the quality of the voice. since the athetoid and ataxic child have fluctuating muscle tone, one may find the voice quality and volume to be equally fluctuating. the vocal quality of the spastic child is often whispered and jerky. when treating the spastic child the stimulus must be graded e.g. beginning with a slow movement and increasing the speed, as greater speed will give rise to increased tone. with the athetoid and hyperkenetic child the therapist positions the child, gradually reducing her hold and eventually gives control over to the child. control is always from proximal to distal with the spine being stimulated for head control. 10. the speech therapist should use more than one reflex inhibiting posture during a therapy session. these r.i.p.'s follow the movement patterns of the development of the normal child. what is achieved in one position, should also be tried in another position. there must be a carry-over into all positions such as sitting, standing etc. to achieve such a carry-over, the therapist should first initiate various movements of the limbs, and the shoulder/neck regions whilst the child is vocalising. conclusion the writers wish to point out that the above discussion represents only one of the methods used in their treatment of the cerebral palsied speech defective child. other techniques are employed concomitantly with the bobath technique. june, 1961 journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) march j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c society 3 some general aspects concerning stuttering which indicate fields of research by m. aron m.a. t o consider in any detail the information that is contained in the literature on stuttering is a formidable and confusing task. it includes broadly the many and conflicting theories as to its etiology, the nature and development of the symptom itself (often theoretical), the stutterer himself in relation to his handicap and the attitudes of the audience to the stutterer and his symptom. much time has been spent on the constitutional (physio-neurological) concomitants that attempt to explain the phenomenon. the psychological element has also been considered in some detail. however, the writer has the impression that there is comparatively little information on stuttering that could be viewed from a cultural and sociological standpoint. the limited material that is available only seems to emphasize the neglect of this field. the purpose of this paper is to briefly discuss, by way of the literature, some factors related to stuttering that indicate further fields of research — particularly those fields that have cultural and psycho-sociological implications. i n c i d e n c e the greater majority of studies conducted to ascertain the incidence of stuttering have, unfortunately, been limited to the united states. there are relatively few studies from other parts of the world. the average incidence taken from 15 sources (1) is 0.80% — the highest being 3.5% and the lowest 0.55%. apart from the united states and england, the writer has only discovered studies from cyprus (1.85%), denmark (0.90%), accra, gold coast (3.5%) and westphalia, germany (1.00%). t h e average figure of 0.80% is probably not accurate as the data from the studies have been derived from varied approaches. the methods used, the criteria of selection, the age-groups studied etc., appear to differ from study to study. the incidence figure itself does not appear to be very important to our understanding of the stuttering problem. what does appear highly relevant is whether stuttering is a universal disorder, and whether the incidence varies markedly in any way in various parts of the world. attention was first drawn to this particular aspect when snidecor (2) in 1947 reported that no stuttering existed among the bannock and shoshone indians of north america, and neither did they have a word to describe stuttering. on the other hand, lemert (3) in 1953, reported that stuttering did exist among three indian groups of the northwest pacific coast. w o r d s describing stuttering were found in the languages of these people. this discrepancy between groups of north american indians is perhaps not so surprising when one considers the cultural differences between them. sheeh an (4) felt that there was more similarity between the culture of the kwakiutl indians (among whom stuttering was found by lemert) and our own culture than there is between the cultures of the bannock and shoshone indians and the kwakiutls. he stated that the latter tribe has a competitive culture not unlike our own. morgenstern (5) has given us some information about the non-existence of stuttering among some groups. he received his information from anthropologists and other workers in various parts of the world. there appear to be six main groups that do not exhibit stuttering and neither do any of these groups have a word in their languages to describe the stuttering phenomenon. the groups are: 1) the napishianas of british guiana. 2) the patamanas and akawaio of british guiana. 3) the garia in the territory of new guinea. 4) the kelabits. west borneo. 5) the malayan aborigines, malaya. 6) the sonthals, bhuyana and gatwas, (from behar) and the turis and tantis (from orissa) assam, india. however, it is felt that the reports of these workers (not speech pathologists) must be taken tentatively until objective studies can be done to either corroborate or refute this information. should it be correct, then it seems appropriate that detailed cultural and psychor ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c s o c i e t y sociological studies of these groups should be done. the results of such studies might very well throw light on factors associated with stuttering in other culture groups. johnson (6) considers that the non-existence of a word to describe stuttering among the bannock and shoshone indians suggests a significant explanation for the absence of stuttering among these people. his semantogenic diagnosogenic theories as to the onset of stuttering account for this. the writer feels that the non-existence of a word to describe stuttering is not necessarily an etiological factor. it is feasible to argue that a disorder like stuttering must first be detected by a group of people and then a word created to describe the observation. however, it is agreed that the use of the term "stuttering" in the evaluations that people make concerning their childrens' speech (including the normal non-fluencies that are exhibited by children) can contribute greatly to the onset of stuttering. remarking on the fact that some cultures do not exhibit stuttering as we know it, lemert (7) said this measurably strengthens the hypothesis that cultural settings are dynamic factors in the growth of stuttering. . . . the process by which cultural values are sieved through family organization before they impinge upon the child is an important variable in any explanation of stuttering. it would be helpful to know how other culture groups regard the development of speech in their children and the role that language plays in their various societies. this area is plainly a fertile ground for future research, t h e s e x r a t i o the particular kind of sex ratio that occcurs among stutterers continues to be a puzzle. writers have firmly established that stuttering occurs more frequently among males than females. some studies have reported a ratio of approximately 3:1 and others approximately 5:1 (1). apart from the organic constitutional factors that have been put forward to explain the differences between the sexes (earlier myelinization in girls, motoric differences in favour of girls, etc), cultural factors appear to play an important role. the most important premise to consider is that females tend to develop language at an earlier rate than males and that the co-ordination necessary for the speech act appears to be established earlier in girls. this has been explained in terms of constitutional differences. however, some have put forward the hypothesis that this difference might be due to the different parental attitudes towards the sexes. these attitudes are a reflection of the society we live in. our culture tends to place more responsibility on the male child in order to prepare him for manhood and the role of the bread-winner. it is conceivable that, in certain cases, the pressures that are brought to bear by our society (mirrored in the parents) become too great for the young male child who might still be constitutionally immature. the standards of speech and speech fluency might prove too high for certain children and this could possibly cause a breakdown in the very area in which the child is inadequate, namely the motor act of speech. the sex ratio of stutterers has been dealt with in some detail by schuell (8). the data that she found in one of her studies led her to believe that the attitudes of parents are culturally determined, rather than being based upon actual observation of behaviour of a particular child. she has said the following: it seems clear that insecurities, anxieties and tensions would tend to be increased by the contradictory attitudes prevalent in our culture; first, the demand that the male child exhibit independence, fearlessness, selfcontrol and a certain amount of aggressiveness; and second, that he must at. the same time be submissive, orderly, and obedient; that he must conform to standards of parents and teachers derived from attitudes diametrically opposed to those which clinical psychologists consider conducive to healthful modes of behaviour. schuell said further that she felt that the crucial point seemed to lie in the tendency of parents and teachers to expect equal performance from children who are not developmentally equal. her conclusion about the sex differences, she feels, suggests johnson's theory that stuttering is a semantogenic and diagnosogenic disorder. the child, to some extent, interiorizes the negative evaluations made by his immediate adult society. morgenstern (5) reports that some of the data sent to him from various parts of the world indicated that the sex ratio is of the same type as that for stutterers in other communities. he found it difficult to believe that the same purely environmental (culturally determined) stimuli which might create a higher incidence of stuttering among boys than girls in our society, would be found in other culture groups, some of which differ considerably in terms of social customs and mores. t h e writer believes that the sex ratio is organically rather than culturally determined. cultural or environmental influences may "trigger-off" or aggrevate inadequate physical r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) march j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c society elements to which the male child appears to be more prone. it would be interesting to speculate whether the incidence of stuttering will be any higher for females in our civilization after a number of generations. females are assuming fuller responsibility and independence in our society and it is possible that this may cause changes in parental attitudes towards the young female child. however, more detailed study of our culture and others in this regard may throw more light on the general problem of the sex ratio. little has been written about the effects of our culture on the onset or originality of stuttering. still less is known about other culture groups that do or do not stutter. some cognizance should be taken of those society groups that do not stutter. the attitudes expressed toward the sexes, the language standards, etc., in these groups may become relevant points of departure for further analysis of the sex ratio for stutterers in those communities that do stutter. s c h o l a s t i c r e t a r d a t i o n it has been acknowledged by writers that stutterers experience the school situation as being difficult and threatening. some investigations have indicated that stutterers are scholastically retarded. studies have reported retardation ranging from 6 months up to 1.6 years (1). sources have indicated that the level of intelligence has not been found to be a causative factor for this retardation (1). the main reason that has been put forward to explain the scholastic retardation is that the stuttering child is likely to lack a measure of concentration due to his being prone to be excitable, restless and threatened by the demands made in the classroom. demands for oral work are frequent, and the stutterer is placed in an emotionally charged situation where he is expected to answer questions or recite before his class mates. the writer has observed that stutterers are frequently marked down because of their inability to express themselves or to recite adequately. it has also been observed that some parents of stutterers are inclined to enrol their child in school at a. slightly later age. it is presumed that this is done to allow for a period of time in which the stutterer may "outgrow" his speech difficulty. the reasons that have been suggested to explain the scholastic retardation of stutterers . tend to be psychologically orientated. children jf^ who are inclined to be withdrawn, or non|i'|j. fluent (but not stuttering), or excitable when | j | | called upon to express themselves, may c o n j a i l ceivably react adversely to the abuse ana re-jh® marks that others in the classroom and p l a y s s | | ground express. the abuse offered by children.imsa it is felt, follows closely the nature and evaluations associated with the social customs of the particular society they live in. the information available on this aspect still needs to be verified by further study. insufficient data has been accumulated to make this a definite factor associated with stuttering. late enrolment in schools and the problem of intelligence should both be investigated in fuller detail .workers would also need to know the frequency of poor marks being given to the stutterer due to his impediment, the extent to which these poor marks contribute towards failure, the attitudes of the .staff to this particular speech problem and the methods used to handle them in the class-room situation. this type of information might guide the speech therapist and lend weight to recommendations which can be made to the staff of schools a s to the various methods of handling the stutterer. s o c i o e c o n o m i c f a c t o r s some mention has been made in the literature of the effects of socio-economic factors influencing the incidence of stuttering. it is thought that the particular level of socioeconomic standing of a family group would affect the type of attitudes displayed towards the children and thereby affect the standards of speech in the home. it has been observed that children from the upper social levels show a greater linguistic development, use larger sentences and have more mature sentence forms at earlier ages than the children in homes of low socioeconomic standing. (9) the type of environment and attitudes displayed by parents which afford few stimulating opportunities for effective speech learning can occur, of course, at all socio-economic levels, but are more inclined to do so in the poorer and more deprived homes. it is noted by darely (10) that parents of stutterers came predominantly from the middle and upper socio-economic classes. these parents tended to be better educated than their control 'group counterparts and they " . . . tended to set rather high standards for themselves, their mates, their children and their neighbours." he also reported that the parents of stutterers expressed more dissatisfaction with their own abilities and accomplishments than did the control group of parents. johnson (11) commented on darely's observations and said that what was probably more important than the socio-economic class was \" . . . the degree of 'upward mobility' (drive or intensity of determination and effort to rise socio-economically) of the family." families that are "upwardly mobile" may, suggested [johnson, be expected to experience to a greater r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c society than usual degree the tensions attendant upon competitiveness to place high values on the absence of defects and good or superior speech in their children, which, " . . . they consider important in the competition for status." morgenstern (5) found similar data as reported above. a higher incidence of stuttering was noted among children of semi-skilled manual workers than among children of unskilled labourers in england. semi-skilled workers appeared to have a better chance of 'getting ahead" and were more socially orientated as regards status level. morgenstern felt, therefore, that the semi-skilled labourer was likely to be ambitious for his children and to prize the advantage of adequate speech. evaluations made of a child's speech and the degree to which he is pushed to develop " g o o d " speech, which may be beyond his capacity, may cause the child to react adversely to this strain and therefore may result in tension and stuttering. on the other hand some writers (12, 13) have found no evidence that stuttering is influenced by social status or extremes of environmental conditions. t h e knowledge available concerning the influence of socio-economic levels on the incidence of stuttering is limited and comparatively recent. it appears that the main influence of a high socio-economic level in a home is that high standards will be set for children in regard to the expectations that are made for conforming behaviour and for adequate or "superior" speech. these high expectations can create tensions in the child, resulting in anxiety and a possible awareness of the speech activity that he performs. the consideration of this aspect would indicate that cultural and psychological components are operating as a possible precipitating factor. difficulties, it is felt, will be encountered in assessing this aspect as this type of investigation involves the study of various social strata which are dynamic in nature and continually changing. s t u t t e r i n g a m o n g t h e b a n t u the above mentioned factors, among others that have been associated with stuttering and that can be considered from a cultural and sociological point of view, were taken by the writer as a basis for an investigation on the nature and incidence of stuttering among a bantu group of school-going children. a set field programme was organised and each school in selected urban african residential areas was .carefully screened for stutterers. each stutterer was then interviewed in some detail, observed for symptoms, and where possible, home visits were made. the data collected and evaluated indicated that the incidence of stuttering appears to be the same for any group of stutterers that we know of, namely 1.28%. the sex ratio, onset of stuttering, familial incidence of stuttering, the symptoms exhibited, the methods by which the subjects attempted to eliminate the disorder, are all similiar to what other investigators have reported. n o real differences were found to exist that would differentiate this group of stutterers from any other studied. there are many words, some onomatopoeic in nature, in all the languages that describe the phenomenon of stuttering. the invesigation, however, had many limitations. due to it being an exploratory study, no experimental groups (controls) were used. the information offered as to the background of the subjects was often inconsistent and could not be checked. parents were not always available for interviewing. the use of an african social worker trained to participate as an interpreter did not eradicate the social and language barriers that existed. it is felt that further study of this problem must now follow. there is a vast field of research for speech therapists in this country because of the almost unique situation that exists among the bantu. for there are large communities of bantu still leading comparatively simple lives. on the other hand, there are groups who have been urbanized for several generations and have, to varying degrees, assimilated the demands of urban life. further, a most fruitful situation to consider, is the almost perceptible changes that are taking place due to the transition of the rural african to urban life. these three broad types of situations could provide excellent material for the purposes of comparison — particularly in regard to the influences of these various environments on such aspects as are related to our work. the speech standards set in the homes, the influence of the many languages on individuals, the customs revolving around the general subject of language and speech all become important factors to observe in these comparative situations. w e can only surmise whether the incidence of stuttering among the rural and urban bantu would be the same. provision for control groups should be made, especially control groups in the various environmental strata — rural, urban and transitional. due to the difficulties encountered it would seem necessary and relevant for a team of workers to approach this field of research. such a team, it is envisaged, should include not only speech pathologists, but psychologists and sociologists among others. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) march j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c society c o n c l u s i o n s the above account clearly indicates that further study is necessary to fully understand the factors that have been associated with stuttering. comparatively few workers have investigated the disorder in sociological terms and this field appears to be neglected as an area of research. in addition, far too few studies have dealt with groups of people in parts of the world other than america, england and a few european countries. this pertains particularly to the groups of primitive peoples that still exist. most of the material available on stuttering seems to have originated at the desks of writers and in the laboratories attached to clinics. it might be argued that the psychological studies dealing with stuttering consider the sociological point of view. however, it is felt that the term "psychological" is becoming too broad in nature and does not take fully into account the dynamic cultural and social reactions, positive and negative, among people in any group. it is not claimed that further data from a sociological and cultural point of view would solve the riddle of stuttering. but it is thought that we can become more aware of the influences of the social environment which could direct us in making further more positive attempts in dealing with the prophylaxis of this disorder. it would seem a tragedy to ignore the many fields still open for study. the world is rapidly changing and primitive peoples are gradually becoming assimilated to other ways of life. malinowski (14) one of the great anthropologists of our time, has said that within a generation or two the native communities now available for scientific study will have practically disappeared — " t h e need for energetic work is urgent, and the time is short." 6. j o h n s o n , wendell. " p e o p l e in q u a n d a r i e s . " h a r p e r a n d b r o s . , n e w york, 1946. 7. l e m e r t , ε. m. " s o c i a l p a t h o l o g y , " c h a p t e r 6. mcgraw-hill, n e w york, 1951. 8. schuell, η. m. " s e x differences in r e l a t i o n to s t u t t e r i n g : p a r t i . " j . s p e e c h d i s o r d e r s . vol. ii, n o . 4, 1946. 9. mccarthy, dorothea. " l a n g u a g e development in c h i l d r e n . " chapter 9 in m a n u a l ol child p s y c h o l o g y , ed. carraichael, l . second e d i t i o n . j o h n wiley & sons, inc. n e w york. 1954. 10. darely, f . l . " t h e r e l a t i o n s h i p of p a r e n t a l a t t i t u d e s a n d a d j u s t m e n t s to the development of s t u t t e r i n g . " chapter 4. s t u t t e r i n g in children and a d u l t s ed. j o h n son wendell. u n i v e r s i t y of m i n n e s o t a p r e s s , minneapolis, 1955. 11. j o h n s o n , wendell. " s p e e c h h a n d i c a p p e d school childr e n . " r e v i s e d e d i t i o n . h a r p e r b r o s . , n e w york. 1956. 12. morley, muriel. " t h e d e v e l o p m e n t a n d d i s o r d e r s of speech in c h i l d h o o d . " e . & s. l i v i n g s t o n e l t d . , e d i n b u r g h . 1957. 13. mcallister, a. h. " c l i n i c a l s t u d i e s in speech t h e r a p y . " u n i v e r s i t y of l o n d o n p r e s s , london. 1937. 14. malinowski, b r o n i s l a w . " a r g o n a u t s of the w e s t e r n p a c i f i c . " george r o u t l e d g e a n d sons, l t d . , l o n d o n . 1922. westdene products ( p t y . ) l t d . specialists in medical literature recommend— speech problems of children edited by wendell johnson, price 38/3 this book offers authorative information on speech disorders; it points the way to a full, normal and well-adjusted life for uncounted thousands of children. the chapters express the viewpoints and reflect the practical experience of the authors and of 20 other experts. order your copy now! johannesburg: 23 essanby house, 175 jeppe street. cape town: 408 grand parade centre, castle street. durban: 60/67 national mutual building smith street. pretoria: 210 medical centre, pretorlus st. b i b l i o g r a p h y 1. aron, m. l . " a n i n v e s t i g a t i o n of the n a t u r e and incidence of s t u t t e r i n g a m o n g a b a n t u group of s c h o o l g o i n g c h i l d r e n . " m.a. d i s s e r t a t i o n . u n i v e r s i t y of the w i t w a t e r s r a n d . 1958. 2. snidecor, j . c. " w h y the i n d i a n d o e s not s t u t t e r . " quart. j . s p e e c h , vol. 33, 1947. 3. l e m e r t , ε . m. " s o m e i n d i a n s w h o s t u t t e r . " j . s p e e c h h e a r i n g d i s o r d e r s . vol. 18. n o . 2, 1953. 4. sheehan, j . " f i l m a n d d i s c u s s i o n on s t u t t e r i n g . " copy of t a l k given to the s t a f f of the l o s a n g e l e s mental h y g i e n e clinic. 1957. b y p e r m i s s i o n s.a. l o g o pedic society. 5. m o r g e n s t e r n , j . j . " p s y c h o l o g i c a l and social f a c t o r s in c h i l d r e n ' s s t a m m e r i n g . " p h . d . d i s s e r t a t i o n . univers i t y of e d i n b u r g h . 1953. (microfilm). r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the aristotelian mode of thought underlying research and theorizing in the field of stuttering* michael l. goodgoll, b.a. log. (rand) introduction it is the writer's contention that the difficulties inherent in the field of speech therapy have been underestimated and misunderstood. it is a common supposition that the problematic nature and outcome of therapy are caused by insufficient factual knowledge, and that the remedy is further research in order to build up our store of basic facts. it is believed that when this is accomplished, a creative theorist will arrive to conceptualize and organize this data into a comprehensive theory indicating the significance of, and the interrelationships between the facts as known, thereby providing a scientific basis for therapy. this leads to an acceptance of all research as being valuable in that, if nothing else, it contributes to our basic store of knowledge. for the speech therapist, both facts and theories are tools. theoretical understanding alone is insufficient; in addition the therapist has to apply his knowledge in actual therapy. it is essential, therefore, that the theories and facts he brings into the therapy situation be of the type that allows him to take cognizance of the individuality of each patient, in order to devise an effective therapeutic programme. it is the individuality of each case that, in the writer's opinion, is the crucial problem in speech therapy. in 1931 kurt lewin11 criticized contemporary psychology for its acceptance of an aristotelian mode of thought. lewin considered that this acceptance precluded our understanding of the individual as an individual. this paper will discuss lewin's criticisms in order to assess how applicable they are to the field of stuttering research and theory. by implication, a similar discussion could be held on other areas in speech therapy. / some characteristics of aristotelian thought aristotle considered that not all physical processes are lawful, and used the regularity or frequency of occurrence of an event as a criterion of lawfulness. only events certified by their repetitive nature as being lawful were considered to be conceptually intelligible and • b a s e d on a s t u d y p r o j e c t p r e s e n t e d ' t o t h e s u b d e p a r t m e n t of s p e e c h p a t h o l o g y a n d a u d i o l o g y , u n i v e r s i t y of t h e w i t w a t e r s r a n d , 1968. journal of the south african logopedi society, vol. 16, no. , dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e aristotelian mode 27 thus of scientific interest. individual events, i.e. those occurring only once or infrequently, were considered to be fortuitous or due to chance and therefore not lawful. it follows from this that for aristotle the individual event, the exception to the rule, does not constitute disproof of the rule. a further aspect of aristotelian thought is to consider that having defined a particular class of events because of the frequent occurrence of those events, one has also defined the essential nature of those events. according to aristotle, every object tends towards perfection and the realization of its own nature in so far as this tendency is not hindered or disturbed by outside forces. but, since this nature is for aristotle that which is common to the class of objects, we find that the class is both the concept and the goal of the object, i.e. it both defines the object and explains its behaviour. in summary, aristotelian thought has as maxims: (a) frequency implies lawfulness. (b) individual events are fortuitous. (c) exceptions to the rule are not counter-arguments. (d) class defines essence. group versus individual characteristics. lewin, in discussing the effects of aristotelian thought on research states:t h e fact that lawfulness and individuality are considered antitheses has two sorts of effect on actual research. it signifies in the first place a limitation of research. it makes it appear hopeless to try and understand the real, unique course of an emotion or the actual structure of a particular individual's personality. it thus reduces one to a treatment of these problems in terms of mere averages . . . it implies in addition to this limitation a certain laxity of research. (psychology) is satisfied with setting forth mere regularities. the demands of psychology on the stringency of its propositions go no further than to require a validity in general or on the average or as a rule." that this attitude is widespread in the field of stuttering is demonstrated by the following statements: west: does stuttering have one cause? i do not know, but its uniformity of manifestation from person to person would suggest a uniformity of etiology. t h e differences of stuttering p h e n o m e n a from case to case may be explained as individual variations due to physical, cultural, physiological, or even pathological deviations — factors independent of the syndrome of stuttering.1' bloodstein: . . . the complex life situations out of which stuttering grows can never exactly duplicate themselves from case to case. but it is clear that we can generalize about these situations, and a true explanation is achieved only by abstracting from them certain unvarying features . . . .3 tydskrif van die suid-afrikaanse logopediese vereniging, vol.16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 μ. l. goodgoll eisenson: in spite of considerable individual variability, general tendencies could nevertheless be observed for stutterers taken together as a group. 5 freund: our above description of the processes underlying the pathogenesis of stuttering leaves open the enormous individual differences and tries to underline only the common features.1 the question to be asked is whether theories of stuttering based on an exclusion of individual differences, an emphasis on group tendencies and the abstraction of regularities across individuals, can form the basis for comprehending and integrating the unique characteristics of each stutterer. theorists appear to accept that concentrating on and selecting common features is all that is necessary for an understanding of stuttering. therefore, there is some reason to feel that on a theoretical level workers in the field of stuttering accept aristotle's dictum that regularity defines the sphere of scientific interest. it would, however, be incorrect to say that these same workers are insensitive to the importance of taking into account the individuality of each case. they all advocate in their therapeutic suggestions that the therapist must treat every case as an individual. in actuality it is the empathy and intuitive understanding of the therapist on which they rely for the recognition of individual differences and unique personality characteristics — these differences being considered somehow to transcend scientific analysis. faced with so many variations amongst stutterers, some theorists accept the eclectic view that stuttering can result from many different factors. however, this is merely a means of coping intellectually with the diversity. the therapist, faced with his individual case, is not given any indication which factors are important and to what degree. to say that all factors are important to various degrees is mere common sense. of what use then are the theories? research and theorizing have a reciprocal relationship — research stemming from theoretical issues and in turn providing data which must be included into a coherent theory. as an example of this relationship and as an exemplification of an acceptance' of the aristotelian approach, we will examin'e the fairly acceptable proposition: stuttering increases as the speaker is required to formulate the linguistic content. this statement was |made by eisenson5 as a result of reviewing a number of studies dealing with changes in the incidence and severity of stuttering in various speaking situations. one of the studies eisenson quotes is by newman, on the adaptation effect in two situations — reading and self-formulated speech. newman: : ! reported that stutterers had been shown to adapt to both reading and journal of the south african logopedie society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the aristotelian mode 29 spontaneous speech. no mention was made of any discrepant findings. it is on these results that eisenson bases his conclusions. however, some time later (nine years), newman14 reported that of his twenty subjects, six did not adapt in the reading situation and seven did not adapt in the self-formulation situation. the fact that individual stutterers showed in some cases opposite behaviours was not considered important enough to report; nor was it considered an invalidation of his conclusion. this is a clear example of how individual differences are ignored for the sake of conceptual neatness. yet it is theories based on this sort of evidence that form the context for decisions in therapy. the end result is that if the patient is typical and shows problems or symptoms in common with other stutterers, we feel secure in applying to him whatever theoretical understanding we have of the average stutterer. however, if he does not fit within the bounds of the average stutterer, and presents individual and unique characteristics (which is the rule rather than the exception) and if we rely for our understanding on the above type of theory, then we are forced to limit our understanding to what is not unique and individual about him. we are thus, in a sense, treating fictional stutterers. use of statistics. lewin, in discussing the effects of aristotelian thought on psychology, writes: the statistical procedure . . . is the most striking expression of this aristotelian mode of thinking. in order to exhibit the common features of a given group of facts, the average is calculated. this average acquires a representative value and is used to characterize . . . the properties of the . . . child.1 1 it is necessary to examine closely the part played by statistics in under-emphasizing individual characteristics — statistics by its very nature being concerned with properties that are descriptive of the group or aggregation itself, rather than with properties of particular members (ferguson"). j. g. taylor1 5'1" has severely criticized the use of experimental design as a palliative for the scientist's uneasiness concerning the logical consistency of psychological theories. it satisfies his desire for logical consistency in that he can test any hypothesis, even the most trivial, in a rigorous mathematical manner, and thereby avoid the problem of producing theories or explanations of general validity, which will enable us to understand the individual as an individual. the use of tests of significance of the difference between means has received specific criticism by r. bakan1 — their misuse indicating a deep-rooted acceptance of the aristotelian approach to psychology. bakan's criticism revolves around the confusion between induction to the aggregate and induction to the general. general statements apply to all members of the population to which they refer. a general tydskrif van die suid-afrikaanse logopediese vereniging, vol.16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 μ. l. goodgoll statement is therefore critically testable, since any exception is a threat to its validity. aggregate-type propositions refer to the class of members considered as a group, and are concerned with characteristics of the class and not any particular member of the class. in a typical experiment setting out to test an hypothesis concerning stuttering, a group of stutterers and a group of normals are tested under similar conditions. after the tests have been scored, and statistical calculations done on the data, it might be found that the means differ significantly at the 1% level of significance. what may legitimately be inferred from this result? — only that the mean of all normals is different from the mean of all stutterers on this test (accepting that the sample is random and reflects the characteristics of the population from which it was drawn). the test of significance does not relate to the characteristics of each member of the population. it is thus invalid to draw any conclusions as regards the characteristics of an individual stutterer. if the original hypothesis was concerned only with the characteristics of the class, then this statistical procedure would be valid. one example of this confusion is contained in johnson's well-known proposition that at the time of onset of stuttering it is not possible to differentiate between the child who stutters and the child who does not stutter by examining their speech behaviour. johnson10 compared the nonfluencies of a group of children thought to stutter and those of a group of non-stuttering children. his statistical analysis of the scores obtained attempted to answer the following questions: (a) what are the distributions of the nonfluency measures for the two groups respectively? (b) what difference in the nonfluency measures can be demonstrated between the two groups? (c) to what extent do the various distributions of nonfluency measures for the two groups overlap? johnson concludes that the question of whether or not a given child is or is not stuttering at any given moment cannot be answered by measuring or observing the nonfluency of his speech.w however, the question of whether or not a given child is or is not stuttering was not originally asked, and it is highly apparent that johnson's statistical treatment of his data, being concerned with group tendencies, does not allow for any conclusions regarding individual stutterers. much of the discussion centred on johnson's conclusions has been concerned with the following inference: johnson's attitude seems to be that because there is insufficient regularity! in the characteristics of stuttering-type nonfluencies across individuals, the nonfluencies themselves journal of the south african logopedie society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the aristotelian mode 31 are of little scientific importance. he therefore suggests that we direct our attention away from the child's speech to the child's environment. other workers have felt that the mere fact that we cannot classify the child according to his speech behaviour does not imply that a study of his individual speech pattern is not relevant to our understanding of stuttering. johnson's argument is thus based on an invalid statistical inference and an acceptance of the aristotelian maxim that regularity defines the sphere of scientific interest. a further experimental procedure is to test groups of stutterers under different conditions. again, a t-test might show significant differences in mean scores. here the experimenter can legitimately infer that the mean of the general population of stutterers would be lower or higher under condition one than under condition two. but this applies only to the specific task done under these two conditions, and not to the general conditions themselves. (bakan1). an illustration of this problem is brown's experiment showing that stutterers stutter mainly on nouns, verbs, adjectives and adverbs (grammatical factor). from his results brown4 made two inferences: (a) all stutterers would show this effect; (b) they would show this effect in all situations. these experimental findings have been generally accepted in the field, and used in support of hypotheses concerning the learned nature of stuttering. however, brown conducted his experiment with adult stutterers in a reading situation, and more recent experiments have shown that stuttering is not related in the same way to the grammatical function of words when measured in spontaneous speech (hejnas); nor is there a similar relationship in the speech of young children who stutter (bloodstein and gantwerk3). both of brown's inferences appear, therefore, to be incorrect. it is important to note that the restricted nature of brown's conclusions became apparent only more than two decades later when the above-ment'^ned two experiments were conducted. up to this time theorists and therapists had accepted that brown's conclusions were generally valid. this discussion is not intended as a blanket criticism of statistics. the point being made is that statistics are of little use in arriving at an understanding of the individual person and how, for instance, the many factors characterizing stuttering are integrated in one person. confusion of class and essence. johnson has frequently emphasized that we should be aware of the way we use language to convey reality. statements are at different levels of inference or abstraction. he has specifically pointed out the error of confusing descriptive tydskrif van die suid-afrikaanse logopediese vereniging, vol. 16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 μ. l. goodgoll statements such as i repeat sounds or / stutter with animistic statements such as / am a stutterer or i repeat sounds because i am a stutterer.9 the latter two statements imply that there is some force or entity within the person which produces the overt behaviour we describe as stuttering. this confusion, according to johnson, results from semantic problems. it is also possible to see a deeper reason: abstracting common features of stuttering and then positing these common features as an explanation, is essentially the aristotelian maxim of identifying class with essence, i.e. what is common between objects or events is also the true nature of these events. the idea of a force underlying the behaviour of the class of events, stems from aristotle's identification of class and goal. developmental psychology has been criticized essentially for this fault. researchers dealing with norms of child behaviour or development tend to use the norms discovered through empirical investigation as explanatory devices. for instance, children are observed to be negativistic at a certain stage of development, and negativism is subsequently posited as the explanation for their behaviour. there are more subtle examples of this type of thinking. stuttering has been found to develop in stages, but it is invalid to explain a child's speech behaviour by saying he is, for example, a transitional stage stutterer. luper and mulder advise the following procedure in planning therapy: first of all, after reviewing available information, the examiner estimates the relative stage of development of the stuttering, for example he may decide that the child has reached phase two . . . . h e then considers recommended treatment procedures for that phase of stuttering. f o r example, the phase two stutterer needs to change some basic evaluations about himself as a speaker.1 2 luper and mulder thus accept that having classified the child as a phase two stutterer on the basis of how similar he is to the average phase two stutterer, he therefore is a phase two stutterer and can be treated on the basis of this classification. lewin writes: so long as one rewards as important and conceptually intelligible only such properties of an object as are common to a whole group of objects, the individual differences of degree remain without scientific relevance, for in the abstractly defined classes these differences more or less disappear." obviously it is necessary to have some conceptual framework by means of which to organize complex and diverse facts; but if one's conceptual framework is of the kind that screens out all hut what is common between individuals, it must preclude a true understanding of the individual. i the non-aristotelian approach having examined the thesis that aristotelian thinking underlies some aspects of research and theorizing on stuttering, we can now ask what a non-aristotelian approach implies. | ι journal of the south african logopedie society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the aristotelian mode 33 briefly, it consists of an acceptance of the following proposition: all events are lawful, independent of their frequency of occurrence. this leads to an extraordinary increase in the demands made upon proof. the exception becomes completely valid disproof of a general type proposition. as taylor writes: a genuine scientific law must account for the exception as well as the rule, and this implies that a successful experiment must involve a more detailed investigation of individual cases than is customary. t h e experimenter cannot rest content with a demonstration that the treatment produces the expected results in some subjects; he cannot have a true understanding of the laws of the system unless he can show that the same laws, operating on a subject who differs from the others in some particular respect, must produce different results.10 the criterion for acceptance of a theory within the non-aristotelian frame of thinking therefore lies in the ability of the theory to predict individual differences, when within the general terms of the theory we substitute values derived from an individual. taylor's statement has an important implication: the differences in subjects' responses in an experiment are understood by taking into account the individual characteristics of each subject. the fact that subjects respond differently can thus become proof, not disproof, of the law being investigated. taylor's masterly and definitive work the behavioural basis of perception17 exemplifies the type of theorizing and experimenttation which is possible in the field of psychology. an acceptance of the above proposition also implies that processes or events not occurring regularly or frequently are valid fields of scientific investigation. the unusual stutterer, who presents atypical characteristics, or the child with an unusual type of speech pattern, are of great importance since they might allow us to discern most clearly how stuttering is constituted in one individual. therefore, in spite of the fact that it is unlikely that the experimenter would find a similar case, the detailed study of such individual cases is of scientific importance. taylor1'1 has argued that a psychological theory should not consist of a catalogue of variables in terms of their frequency of occurrence, but should explain how these variables hang together in the individual. it is this approach to the problem of stuttering that the writer considers will offer us the greatest possibility of attaining an understanding of the individual stutterer. summary as a direct result of the prevalence of aristotelian thinking in the field of speech pathology, research and theorizing has tended to ignore the individual, his unique characteristics and differences, and tydskrif van die suid-afrikaanse logopediese vereniging, vol.16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 μ. l. goodgoll to concentrate on what is common between individuals. the therapist is therefore faced with being unable to utilize effectively any particular theory, since none of them explains the unique attributes of the individual case with which he has to deal. a non-aristotelian approach to research on stuttering seems to hold more promise of attaining an eventual understanding of the individual stutterer. opsomming as gevolg van die oorheersing van die aristoteliaanse denkwyse op die gebied van die spraakpatologie, vind ons dat die individu met sy unieke eienskappe en verskille, misken word deur navorsers en teoretici. daar word meer gekonsentreer op wat algemeen is in verskillende individue. die terapeut vind dit moeilik, of selfs onmoontlik om effektief gebruik te maak van enige teorie, aangesien nie een die unieke kenmerke van die individu wat sy behandel, bespreek nie. dit blyk dat 'n nie-aristoteliaanse benadering vir navorsing oor hakkel ons nader sal bring aan die uiteindelike kennis van die individuele hakkelaar. references 1. bakan. r. (1967): on method: toward a reconstruction of psychological investigation. san francisco, josse-bass inc. 2. bloodstein, o. q958): stuttering as an anticipatory struggle reaction. stuttering: a symposium (ed.) j. eisenson. new york, h a r p e r and bros., pp. 1-69. 3. bloodstein, o. and gantwerk, b. f. (1967): grammatical function in relation to stuttering in young children. journal of speech and hearing research, 10, 786-789. 4. brown, s. f. (1937): the influence of grammatical function on the incidence of stuttering. journal of speech disorders, 2, 207-215. 5. eisenson, j. (1968): a perseverative theory of stuttering. stuttering: a symposium, (ed.) j. eisenson. new york, h a r p e r and bros., pp. 223-271. 6. ferguson, g. a. (1966): statistical analysis in psychology and education. (2nd ed.) mcgraw-hill. 7. freund, h. (1966): psychopathology and the problems of stuttering. illinois, charles c. thomas. 8. hejna, r. f. (1955): a study of the loci of stuttering in spontaneous speech. dissertation abstracts, 15 1674-1675 9. johnson, w. (1958): introduction: the six men and the stuttering in stuttering: a symposium (ed.) j. eisenson, new york, harper and bros., pp. xi-xxiv. / 10. johnson, w. (1959): the onset of stuttering. minneapolis, university of minnesota press. 11. lewin, k . (1931): the conflict between aristotelian and galileian 'modes of thought in contemporary psychology. journal of general psychology, 5, 141-177. 12. luper, h . l. and mulder, r. l. (1964): stuttering therapy for children. new jersey, prentice hall. 13. n e w m a n , p. w. (1954): a study of the adaptation and recovery of the stuttering response in self-formulated \ speech. journal of speech and hearing disorders, 19, 450-458. 1 journal of the south african logopedie society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e aristotelian mode . . . 3 5 14. n e w m a n , p. w. (1963): adaptation performance of individual stutterers: implication for research. journal of speech and hearing research, 6, 293-294. 15. taylor, j. g. (1958): scientific method in psychology iv. british journal of statistical psychology, 11, 133-] 35. 16. taylor, j. g. (1958): experimental design: a cloak for intellectual sterility. british journal of psychology, 49, 106-116. 17. taylor, j. g. (1962): the behavioural basis of perception. n e w haven, yale university press. 18. west. r. (1958): an agnostic's speculations about stuttering. stuttering: a symposium, (ed.) j. eisenson. n e w york, h a r p e r and bros., pp. 167-222. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a n o t e on pitch control in e s o p h a g e a l speech a. traill ( m . l i t t . ( e d i n ) ) department of linguistics, university of the witwatersrand, johannesburg. summary an unusual case of esophageal pitch control first discussed in this journal is re-examined in the light of additional data. it is claimed that high-pitched stressed vowels show evidence of diplophonia, a possibility not described in earlier studies of this case. opsomming 'n buitengewone geval van esofagale toonhoogte kontrole wat van te vore' in hierdie tydskrif bespreek is, is weereens ondersoek in die lig van addisionele gegewens. daar word beweer dat hoe toonhoogte klem-vokale tekens toon van diplofonie, 'n moontlikheid wat nie vroeer in hierdie geval beskryf is nie. in two p a p e r s , 1 ' 2 published in this journal, l. w. lanham and w. a. kerr (lk) discuss a case, mrs b. mcl, who had two modes of esophageal phonation, a low-pitched mode and a high-pitched mode. the case is noteworthy not only because of the impression created during speech of wide pitch variation (so much so that it is known to have deceived . . . even the most experienced ear as to the true nature of the voice),2 but also because the high-pitched mode of phonation is rare amongst laryngectomees. lk claim that the two modes of phonation alternate in speech, and that the transitions from one to the other are abrupt. the mechanism for pitch regulation therefore does not involve a continuous variation of tension in the esophageal sphincter but a switch from one vibratory source to another. it is of interest to learn that the esophageal sphincter is the vibratory source for both high and low-pitched phonation. lk's figures d2 and d3 from their earlier paper (reproduced below as figures 1 and 2) illustrate the two adjustments of the sphincter for the lowand high-pitched modes of phonation respectively. the acoustic output of the configuration in figure 1 is described by lk1 as consisting of . . . vibrations of low frequency in the form of noise bursts lacking a harmonic structure . . . and that of figure 2 as consisting of . . . pressure pulses with a harmonic structure and true frequency modulation . . . the purpose of this note is to present additional data from this case which suggest that lk's account is incomplete. the acoustic evidence presented below indicates firstly that both modes of phonation may take place at the same time and secondly (indeed as evidence for the ' first claim) that both modes may produce pulses with harmonics. this complex mode of phonation thus constitutes a third type. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 96 a. traill figure 1. lk's figure d2 showing the cricopharyngeal articulation during low-pitched esophageal phonation. fig d 3 figure 2. lk's figure d3 showing the cricopharyngeal articulation during high-pitched esophageal phonation. this investigation was prompted by a recording of conversational speech produced by mrs mcl. an auditorily prominent feature of the pitch variation was that a particularly high pitch appeared with long stressed vowels, as part of "expressive intonation". the "voice" quality at these points was distinctive, giving an impression of being "squeezed" and mildly harsh. scale magnified spectrograms were made of 20 sees, of speech in order to establish the acoustic nature of this peculiar auditory effect. in almost every case of these auditorilydetermined pitch prominences, there was evidence of diplophonia. figure 3 illustrates the relevant sections of the spectrograms. at the points marked with arrows there are unrelated harmonics. figure 3(a) shows clearly how a harmonic at about 1,28 khz varies in pitch independently of the one at about 0,43 khz which remains,, largely level. in figure 3(b) and (c) one can see pitch differences between two pairs of successive harmonics, one pair, rising and falling in pitch while the other pair remains stationary. these unrelated pairs are therefore not harmonics of the same fundamental frequency (fo). unrelated harmonics that vary in pitch in these ways are readily detectable. however, it is obviously not necessary that unrelated harmonics should show precisely these kinds of pitch variation; they may in fact have the same pitch pattern and these patterns may be level. in such cases mere inspection is not sufficient to determine relatedness of harmonics and the south african journal of communication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pitch control in esophageal speech 97 it is necessary to calculate whether they could be related to fo and to one another. k h z ( a ) ( b ) ( c ) ( d ) figure 3. narrow band scale-magnified spectrograms of four utterances produced by mrs mcl showing diplophonia. the unrelated harmonics are marked with arrowheads. figure 3(d) has four clear harmonics with frequencies of 320 hz, 640 hz, 1 610 hz and 1 720 hz at the point opposite the arrow on the baseline. visual inspection of the different pitch intervals between the higher pair and between the lower pair suggests a possible anomaly. assuming that the lowest harmonic is the fundamental, then successive higher harmonics are expected at 640 hz, 960 hz, 1 280 hz, 1 600 hz, 1 920 hz etc. the second, harmonic occurs at the expected frequency and the next visible one is the lower of the two higher ones at 1 610 hz. allowing for a margin of error for manual measurement, this will be the fifth harmonic of fo = 320 hz (320 hz x 5 = 1 600 hz). the next harmonic in this series will occur at 1 920 hz, thus showing that the second of the two higher harmonics at 1 720 hz is not part of the series and must have an independent fo. put differently, the vibratory source producing this harmonic is not the same as the one producing the others. before leaving this point we should consider the possibility that the relationship between the higher pair of harmonics is actually being obscured by the fact that a number of harmonics are of such weak intensity that they are not visible. for instance assuming fo = 70 hz, the fifth harmonic will occur at 350 hz, the ninth at 630 hz, the 23rd at 1 610 hz and the 25th at 1 750 hz. once again, the margin of error could account for the discrepancies between these frequencies and those observed in 3(d) and, of course, one would have to assume that die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 98 a. traill fo was not visible. one might thus be tempted to challenge the claim that 3(d) shows evidence of diplophonia. however, this would be incorrect for two reasons. firstly, a range of 25 harmonics is never found in the acoustic record of this case; nine to ten harmonics seems to be the limit. secondly, suggestion that there is a weak fo at 70 hz is contrary to the perception of a high-pitched fo at that point. we may safely accept therefore that 3(d) does show diplophonia. it is of interest to note that in those cases where the fundamental frequency of the unrelated harmonics is clear, (figs. 3(b) (c)), it is relatively high for both. therefore both harmonics may presumably be identified with the crico/pharyngeal adjustment in figure 2, that is, for mrs mcl's high-pitched phonation. of course, it cannot be ruled out that a third configuration could have existed corresponding to the cases of diplophonia. diplophonia is usually regarded as a bizarre or abnormal type of phonation when the vocal folds are involved. however, in mrs mcl's case this evaluation is hardly appropriate. the diplophonia adds to the perceived range of expressive pitch variation which makes her speech so unusual and satisfactory. it is worth asking whether there is anything distinctive anatomically that could produce so flexible a vibratory source. l k 2 claim that mrs mcl's . . . pseudoglottal vibration is the product of a relatively intact musculature and considerable effort . . . and, as has been noted, they locate it at the site of the cricopharyngeal sphincter in (fig. 2). they discuss a number of muscular adjustments that distinguish the shape of this sphincter in high-pitched and low-pitched phonation. in their earlier paper they also refer to a pair of antero-posterior folds in the hypopharynx which they claim are . . . in apposition during pharyngeal phonation. the latter possibility is not mentioned again in the later paper. the anatomical picture is therefore complex and there is no way to relate it precisely to the acoustic output. however, it may be worth speculating that the "relatively intact musculature" lk refer to could be expected to play a crucial role in producing this unusual type of esophageal pitch control. references 1. w. a. kerr and l. w. lanham. (1973): anatomical and spectrographic analysis of the voice in disease: a report of five cases. journal of the south african speech and hearing association, 20, 1, pp, 81-105. j 2. l. w. lanham and w. a. kerr. (1975): pitch in esophageal speech. journal of the south african speech and hearing association, 22, pp. 31-41. j the south african journal o ommunication disorders, vol. 27, 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) r e p u b l i c h e a r i n g c o n s u l t a n t s cptyj a i d l t d , 7 3 2 medical c i t y e l o f f cor. jeppe s t r e e t johannesburg, transvaal t e l e p h o n e 2 3 6 6 8 5 p . o . 8 o x 5 2 0 4 1 s a x o n w o l d 2 1 3 2 hearing aids. we specialize in the supply and fitting of hearing aids for all hearing losses, especially for nerve deafness recruitment bone conduction cases. cross aids: cros bicros multicros etc. bone conduction aids for body, earlevel, glasses (speciality by viennatone) binaural fittings we import and stock : — viennatone, qualitone, microson, phonak hearing aids. moulds: soft, hard, skeleton, vented, occluded etc. repairs: all aids supplied with a scientific performance report after repair. special prices for dealers and institutions. accessories: teacher — pupil, parent child, individual audiotrainers, very reasonably priced. group audio trainers. tv — wireless infrared transistor receiver sets made by sennheiser. audiometers: screening, diagnostic, research, era and electrocochleography c.o.r. and peep show. impedance bridges. manufacturers of sound proof booth and sound proof rooms. hearing aid testing set by " f o n i x " u.s.a. phonak noise generator with different frequencies, pure tone and warble tone, for everyday's use. we repair and calibrate audiometers. sound level meters, calibrators. industrial noise consultants. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 27,· 1980 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society editorial in the last edition of the journal we were able to read articles dealing with some of the many types of defects handled by the logopodecian. in this issue of the journal, there are three articles on language disorders in children. during the past decade an increasing interest in the study of language and its disorders has been shown. one of the findings resulting from this growing interest is that if the language function is disturbed in any way, difficulties ranging from complete lack of speech to a deficiency in reading can be found. since reading is an important aspect of the language functwn, an article on the teaching of reading to the cerebral palsied child by ε. m. harrison is presented in this issue; isaac jolles presents his views on the teaching of language and conceptual thinking to the brain-injured child, and an interesting case history of an aphasic child, compiled jointly by dr. law and mrs. shavell concludes thai section of the journal in which the emphasis has been on language disorders. an article on organic dyslalia by a. rummel is indicative of the fact that the often so-called dull subject of dyslalia, when correctly handled, can make interesting reading and stimulate one to think of dyslalia from many new and different angles. berea cycle works toys and cycles cycles for hire 59 kotze street, hillbrow, johannesburg. phone 44-1214 we specialize in educational toys r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) editorial it is with pride that we present the first bilingual issue of the journal of the south african logopedic society. the first students are to graduate, in the coming year, from the speech therapy department at the university of pretoria, where the course is conducted in afrikaans. in anticipation of this we feel that it is fitting that this journal should contain the two official languages of south africa. it is significant that all but one of the contributions to this issue of the journal are from south africans. in the past we have relied upon the contribution of articles from overseas authorities, but in this issue we have attempted to reflect that speech therapy in south africa is reaching a stage where it too can make a contribution to the field. original research is increasing with a greater number of people taking postgraduate degrees. we hope that in the near future we shall be able to publish the results of these research projects. for the present, however, we have attempted to give a glimpse of the work that is being done. as such, the articles contributed by speech therapists are of a more practical nature, while the contributions from our medical practitioners relate to those spheres of medical science which have direct bearing on the work of speech therapists. it is, therefore, with pleasure that we present the december 1962 issue of the journal of the south african logopedic society, and hope that the wide variety of subjects covered by our contributors, will provide something of interest to every reader. december, 1962 journal of the south african l o o p e d i c society 3 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) redaksioneel dit is met trots dat ons die eerste tweetalige uitgawe van die tydskrif van die suid-afrikaanse spraakheelkundige vereniging aanbied. die eerste studente van die universiteit van pretoria, waar die kursus in afrikaans gedoseer word, gradueer in 1963. na aanleiding hiervan meen ons dat dit gepas is dat die tydskrif in albei die landstale van suid-afrika gedruk word. dit is opmerklik dat al die bydraes, behalwe een, in die tydskrif van suidafrikaners kom. in die verlede het ons staat gemaak op bydraes van oorsese gesaghebbendes, maar in die uitgawe het ons gepoog om aan te toon dat spraakheelkunde in suid-afrika die stadium bereik het om ook 'n bydrae te lewer tot spraakheelkunde as 'n wetenskap. aangesien meer terapeute nagraadse studie onderneem, word belangrike oorspronklike navorsing gedoen. ons hoop om in die nabye toekoms die resultate van hierdie navorsingskemas te publiseer. ons wil egter nou net 'n beeld skep van die werk wat gedoen word. dus is die artikels, bydraes deur die spraakterapeute, van meer praktiese belang, terwyl die bydraes van ons mediese praktisyns in verband staan met daardie aspekte van die mediese wetenskap wat van direkte belang is vir die spraakterapeute. dit is dus 'n voorreg om die desember 1962 uitgawe van die tydskrif van die suid-afrikaanse spraakheelkundige vereniging aan te bied, en ons is vertrou dat die groot verskeidenheid van onderwerpe wat bespreek word iets van belang vir elke leser sal verskaf. journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) an investigation of some aspects of stuttering-like speech in adult dysphasic subjects lesley caplan, b.a. (sp. & η. th.) (witwatersrand) speech therapy department, groote schuur hospital, cape town summary some dimensions of stuttering-like s y m p t o m s of five dysphasic patients were considered and c o m p a r e d t o several aspects of stuttering w h i c h are generally w e l l k n o w n and d o c u m e n t e d . the nature and a m o u n t of the dysfluencies of dysphasia were e x a m i n e d , and, although the a m o u n t o f non-fluency appeared t o justify the label of stuttering, the nature of the dysfluencies was m u c h like that observed in normal speakers and not that considered t o b e the distinguishing features of stuttering. the loci of t h e dysfluencies in the sequence o f dysphasic speech were investigated and the majority of subjects were found t o experience more difficulty o n the function words o f language rather than o n the c o n t e n t or lexical words which precipitate d y s f l u e n c y in stutterers. all subjects experienced the greatest difficulty o n words in the initial p o s i t i o n in the sentence as is found w i t h stutterers. for m o s t of the subjects the frequency o f dysfluency was highest o n longer words and it was observed that subjects generally experienced more difficulty on c o n s o n a n t s than o n vowels. under c o n d i t i o n s of propositionality it s e e m e d that there was s o m e increase in the frequency and severity of the dysfluencies of dysphasics w h i l e the adaptation task y i e l d e d divergent results. opsomming sommige aspekte van s i m p t o m e , soortgelyk aan hakkel, b y vyf disfasiepasiente, is m e t verskeie algemeen b e k e n d e en reeds b e w y s d e kenmerke van hakkel vergelyk. die aard en h o e v e e l h e i d o n v l o t h e d e van die disfasie-pasiente is ondersoek en a l h o e w e l die h o e v e e l h e i d o n v l o t h e d e die kenteken van hakkel regverdig, was die aard van die o n v l o t h e d e in 'n groot m a t e soortgelyk aan die o n v l o t h e d e wat b y normaalsprekendes v o o r k o m . die o n v l o t h e d e is dus nie verwant aan die onderskeidende kenmerke van hakkel nie. die spesifieke posisie van o n v l o t h e d e in die opeenvolging van die spraak van disfasie-pasiente is ondersoek. die meerderheid van die proefpersone het groter p r o b l e m e o p funksiewoorde van die taal ondervind en nie soseer prob l e m e gehad m e t die i n h o u d of leksikale w o o r d e soos hakkelaars nie. s o o s gevind b y hakkelaars, het al die proefpersone die grootste mate van moeilikh e d e ondervind m e t w o o r d e in die inisiele posisie van die sin. die frekwensie van die o n v l o t h e d e was o o k hoer b y die meerderheid van die proefpersone. daar is o o k waargeneem dat daar oor die algemeen meer p r o b l e m e o p konsonante as o p ander w o o r d e ondervind w o r d . dit het voorgekom asof 'n t o e n a m e in die frekwensie en erns van die o n v l o t h e d e b y die disfasie-gevalle ontstaan onder t o e s t a n d e van proposisionering, terwyl die aanpassingstaak uiteenlopende resultate gelewer het. journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) s o m e aspects of stuttering-like speech in adult dysphasic subjects 53 in many instances in the literature mention has been made of brain-injured adults, who have stuttering-like speech. various authorities cite cases of aphasia showing symptoms suggestive of stuttering and make reference to the repetition of sounds and syllables, hesitancies and the use of superfluous words accompanied by tension, in dysphasic speech. in attempting to explain the association of stuttering and aphasia writers have provided phrases such as "dysphasia with stuttering" (oltuszewski), "aphatic stuttering" (kussmaul), and "stuttering in aphasia" (froeschels)1. various pathologies of the central nervous system like parkinsonism, the extrapyramidal dysarthrias, as well as a number of pyramidal and cortical dysarthrias present symptoms that resemble stuttering — retarded rate of speech utterance that may be irregular and jerky, defective intonation, and a tendency towards perseveration where there may be a difficulty in the production of initial sounds3·6. in considering the field of stuttering etiology and symptomatology, theories and descriptions are in conflict with each other. it was st. onge2 0 who recommended the use of the "syndrome" concept to distinguish different types of stutterers in an attempt to eliminate some of this confusion. he propounded an approach directed towards isolating the particular symptoms of stuttering into consistent and meaningful entities, rather than viewing the disorder indiscriminately, as a mixture of psychological, motor and other signs. he suggests the separation of stutterers into three groups. i) the stutterer with no indication of constitutional or psychogenic symptoms, who simply manifests a phobia about speech. ii) the psychogenic stutterer who employs stuttering as a symptom in a more extensive disturbance. iii) the organic stutterer who manifests intolerance of non-fluency as a result of some structural abberation. it is this last alternative that bears relevance to the present study. in reviewing the literature on stuttering, various authorities have put forward a concept of stuttering as a sub-clinical aphasia. travis21 expounded a theory of cerebral dominance, karlin12, a psychosomatic theory of a delay in myelinization, west25 wrote of stuttering and epilepsy and eisenson7, a perseverative theory that stressed a neurological basis for stuttering. attention has been briefly focused above on these writers in the field of aphasia who make reference to stuttering-like symptoms, and, on authorities in the field of stuttering who, in turn, stress neurological factors. mention should also be made of the research by goldman-eisler and others who have shown that normal speakers too, manifest dysfluency at specific loci in the speech sequence and that this dysfluency is an integral part of the speech process2·2 2. it seems pertinent then to question and consider the relationship between stuttering and aphasia. one may approach this from the etiological point of view, but in this study, the writer has chosen to examine symptomologically tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 5 4 lesley caplan some dimensions of the stuttering-like speech of dysphasics, and to compare them with some dimensions of stuttered speech as reported in the literature. method an attempt will be made to examine the repetitive pattern of dysphasic speech in terms of the amount and nature of dysfluency; further, the loci of dysfluencies in the sequence of dysphasic speech will be investigated. an attempt will also be made to determine whether the dysfluencies of dysphasia are susceptible to the influences that bring about changes in stuttering behaviour. it is hypothesized that under conditions of propositionality, i.e. where communicative stress and meaningfulness of the presenting situation is increased, dysphasics will show an increase in the frequency and severity of dysfluency, while on the adaptation task where there are repeated sayings of the same phrases, a reduction of stuttering symptoms will manifest itself. subjects five adult aphasic patients, three males and two females were used as experimental subjects, one male and one female being afrikaans speaking. all subjects were classified by their speech therapists as predominantly expressive aphasics23, who were able to communicate spontaneously and meaningfully. an important criterion for selection was that the subjects should manifest some degree of non-fluency in their speech. the subjects also showed a variety of specific language disturbances, the most notable being anomia and apraxia. the subjects ranged in age from 41 to 62 years. no experimental group of stutterers was used as the symptomotology and the modification of stuttering behaviour has been extensively documented. procedure (a) spontaneous speech samples. johnson1 0 indicates that taperecorded samples of speech from adults can be obtained by using the "job" task, where the subject is encouraged to talk for 2-3 minutes on his chosen, likely or future vocation. a modification was introduced, in view of the emotionality of some subjects as regards their occupations, and topics such as daily activities, hobbies, family set-up and in some cases, vocations were suggested. / to obtain a second speaking sample, a picture from the thematic apperception test (tat) was used. johnson1 1 suggested the use of card no. 10 of the tat where the subject is asked to tell a story based on the picture, and points out that although the tat task might be more emotionally loaded than the "job" task, the type of speech samples elicited are very similar. the spontaneous speech samples were used.to provide data on the nature and amount of dysfluency and the loci of dysfluencies in the sequence of dysphasic speech: spencer brown6 was probably the most prominent journal of the south african speech and hearing association, vol. 19, deceber 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) some aspects of stuttering-like speech in adult dysphasic subjects 55 investigator in this field. he isolated four factors that he felt precipitate stuttering. he postulated that the grammatical function of words, their position in the sentence, the length of words and the phonetic characteristics of the initial sounds of the words, were important in evoking stuttering. it seems interesting to determine whether these factors are also important in accounting for the dysfluencies of dysphasia. (b) propositional speech sample. in view of the fact that propositionality appears to be a factor common to both aphasia and stuttering7'9 and because various authorities, particularly eisenson7, have drawn attention to the variability and inconsistency of stuttering and related it to the degree to which the stutterer is attempting to convey meaning, it was important to include this phenomenon in the experimental design. a test was devised to produce conditions of propositionality. it was based partly on an idea put forward by newman16 in his article on adaptation in self-formulated speech and partly on a procedure being used by the department of phonetics and general linguistics in collaboration with the engineering faculty at the university of the witwatersrand13 in teaching engineering students the art of communication. the task involves the recorded description of an arrangement of geometrical figures (fig. 1). the drawing used was based on the series of figures lanham1 3 described in his course for engineering students. the subjects were instructed as newman16 suggested to describe the drawing in such a way that a listener could make an accurate reproduction of the figure solely on the basis of the recorded directions. to increase communicative responsibility, it was pointed out that the recording would be played to first year students to determine their ability to follow directions. figure 1. diagram used t o elicit a propositional speech sample. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 lesley caplan (c) adaptation task. a definition of adaptation relevent to this study is one postulated by schaef19, where he considers adaptation as " . . . . the reduction of the frequency of the stuttering response with repeated and continued elicitation of verbal behaviour under constant stimulus conditions". in response to st. onge's20 plea for the differentiation of stutterers into various clinical syndromes, newman16 postulates the use of the adaptation effect as a "discriminating tool". this provides then, a rationale for the employment of this phenomenon. it seems that an indication of the adaptation trends of aphasic patients may well provide a model of the adaptation trend to be expected in the organic stutterer. in this study adaptation was determined in two ways. in the first, a questionand-answer technique devised by schaef19 for stutterers was used. five questions were asked, and each question had to be answered using the stem of the question in the answer; e.g. "what city is this?" "this city is ". five questions constituted one trial, and each subject was given three consecutive trials, where the same questions were asked and the same answers given. the second involved repetition of five sentences selected from "arthur the young rat" on three consecutive trials11. the number of sentences was arbitrarily selected on the basis of the assumed capabilities of the most severe aphasic subject. (d) analysis of the spontaneous speech sample. a 150-word segment of speech was selected from the spontaneous speech sample elicited by using johnson's "job" and tat tasks. the criteria for selection of the 150-word segment were that the particular segment should not be interrupted by any unduly long pauses and that it should comprise portions of both the "job" and tat tasks. this 150-word segment was analysed in terms of the following factors:the nature of the dysfluencies. the dysfluencies were identified and categorized from a transcript made of the relevant segments of the speech sample. the categories were those suggested by johnson1 0 and are: interjections of sounds, syllables, words and phrases; part-word repetitions; word repetitions; phrase repetitions; revisions; incomplete phrases; broken words; prolonged sounds. the severity of the dysfluencies. for this purpose three measures were used: i) the rate of utterance: this dimension was chosen because it is considered to be a measure of stuttering independent of listener evaluations and, therefore, one of the most objective methods available. it is cbmputed in words per minute and represents the ratio of verbal output to speaking t i m e 1 0 · 1 1 . ii) a rating scale of the severity of dysfluency was used. experimentation has shown that a 9-point equal-appearing interval scale of severity can have internal consistency and is reliable27. three judges who were practicing speech therapists, rated the severity of the dysfluencies. iii) the frequency of stuttering as computed of the total dysfluency index also gave some indication of the severity of the dysfluencies in the journal of the south african speech and hearing association, vol. 19, decetnber 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) s o m e aspects of stuttering-like speech in adult dysphasic subjects 5 7 speech samples. this represents the most comprehensive dysfluency analysis where all dysfluencies in the speech sample are identified, classified and tabulated. the sum of the category index constitutes this measure. the following formula was used for the computation: tdi = (n/a) 100 where η = total number of dysfluencies, and a = verbal o u t p u t 1 1 . the loci of the dysfluencies. i) grammatical function of words: having analysed the nature and type of the dysfluencies in the speech sample, every word that was considered to be dysfluent was tabulated in terms of its grammatical function in the speech sequence. the parts of speech considered were nouns, verbs, adjectives, adverbs, articles, prepositions, pronouns and conjunctions. in addition the total number of each of these parts of speech in the sample was enumerated, e.g. the number of dysfluent nouns was determined as well as the total number of nouns in the speech sample, and the ratio of dysfluent nouns to the total number of nouns was presented as a percentage. ii) the phonetic factor: again having tabulated all the dysfluent words as described above, the initial sounds were tabulated and the percentage of words beginning with a particular sound out of the total number of words beginning with that sound in the speech sample, was computed. the total number of dysfluent consonants and the total number of dysfluent vowels were counted and represented a percentage of the total number of consonants and vowels in the entire speech sample for each subject respectively. iii) position of word in the sentence: the position of the words identified as dysfluent in the sentence was determined. the total number of words that occurred first, second, third etc; in the sentences in the speech sample were also counted in order to find out what percentage of the first, second, third etc., words in the sentences were dysfluent. iv) word length: the same procedure as described above was applied in the investigation of this factor. again the length of each dysfluent word was determined and the number of words of a particular length were coupled as a percentage of the total number of words of that particular length in the entire speech sample. (e) analysis of the adaptation task. the responses obtained, employing the question-and-answer technique19 and repetitions of sentences from "arthur the young rat" were subjected to frequency counts. the number of words considered to be dysfluent on the first, second and third trials were numbered and presented as a percentage of the total number of words uttered in each trial. adaptation was computed using the following formula: (a-b)/a where a and b were the number of words identified as dysfluent on trials one and two, for example. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 5 8 l e s l e y caplan (f) subjective comments by judges on the speech samples. prior to being asked to rate the severity of dysfluencies in the speech samples, the judges were asked to "comment on" the speech samples. the judges were completely unaware of the objectives of this study project and unfamiliar with the subjects used in the study. the comments were considered in terms of what the judges believed the speech problems of the subjects were. results and discussion an attempt will be made to discuss any of the similarities or differences found in the responses of dysphasics when compared with the findings on stuttering as presented in the literature. 1. the amount, nature and loci of dysfluencies. the data for the amount of the dysfluencies of dysphasia and their nature were obtained from the sample of spontaneous speech. it is interesting to note the total dysfluency index for each subject and to compare this with the norms given by johnson1 1 in determining whether or not the amount of dysfluency justifies labelling the aphasic "a stutterer". despite the wide range of dysfluencies manifested by both stutterers and non-stutterers, it seems that three of the five subjects in this study could possibly have been considered stutterers (table 1). however the nature of the dysfluency in dysphasic speech and the nature of stuttering appear to differ. in order to identify the dysfluencies in the speech of the dysphasics and to differentiate them from moments of stuttering, the eight categories suggested by johnson1 0 were employed. subjects si. s2. s3. s4. s5. t o t a l d y s f l u e n c y i n d e x 34 16 27,33 14 38,67 nature of the dysfluen cies interj e c t i o n s 16 5,3 11,33 3,33 18 nature of the dysfluen cies part-word r e p e t i t i o n 4 ,67 1,33 1,33 7,33 / nature of the dysfluen cies word r e p e t i t i o n 3,33 2,(57 9,33 1,33 6,67 nature of the dysfluen cies revisions 4,6 3,33 1,33 2 3,33 table i. percentage of dysfluencies and the nature of dysfluencies in a 150-word sample of the speech of dysphasic subjects. journal of the south african speech a hearing association vol. 19, deceber 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) some a s p e c t s of stuttering-like speech in adult dysphasic subjects 59 all subjects manifested the greatest number of dysfluencies in the category of interjections. the dysfluencies categorized as word-repetitions, part-word repetitions, and revisions also occurred frequently, and to a much lesser extent than interjections (table 1). it is important to note that the disorder of stuttering encompasses much more than moments of dysfluency and that dysfluency per se does not constitute the whole of the problem known as stuttering11. in view of the information already cited, it appears that the non-fluencies shown by the subjects in this experiment are similar to the non-fluencies exhibited by normal speakers, and not those considered to be the distinguishing features of stuttering10. from the results then, two apparently conflicting aspects emerged, and in order to determine whether the aphasic subjects did, in fact, appear to "sound" like stutterers, three judges were invited to comment on the speech samples. as mentioned, these judges were qualified speech therapists who were not aware of the speech and language problems of the subjects nor of the objectives of this study. the judges drew attention to patterns such as hesitancy and repetitions in speech, use of interjections as anti-expectancy devices, circumlocutions as well as manifestations of anxiety and tension. generally it seems, that on the basis of trained listener evaluations, symptoms that have been regarded as peculiar to dysphasia, (anomia, incomplete sentences, sequencing difficulties) can be re-interpreted and viewed within the framework of stuttering behaviour. it seems plausible that other factors (apart from those mentioned) like anxiety and tension, as well as disturbances in spontaneity of expression, could be significant in contributing to the evaluation of stuttering. the amount of dysfluency manifested by the subjects appeared to justify the label of stuttering while the nature of the dysfluencies seem to be that revealed in the speech of normal speakers and not that which many authorities consider to be the distinguishing features of stuttering. despite this, the findings should not be considered an impasse and the comments of the judges in evaluating the speech as stuttered speech emphasizes this point. it appears that here are other more subtle attributes of the dysfluencies that contribute to the diagnosis of stuttering. the sample of spontaneous speech obtained in the "job" and tat tasks yielded the data for the analysis of the loci of dysfluencies. the grammatical function of words. the majority of subjects produced results contrary to those expected from stutterers. more difficulty was experienced in the function words of language (prepositions, articles, pronouns and conjunctions) rather than on the content or lexical words (nouns, adjective, adverbs, and verbs). the postulate that stuttering tends to occur on those words that are focal points in the speech sequence, i.e. where the transmission of meaning is most important, and where the speaker's emphasis and the interest of the listener is concentrated, is not demonstrated by the findings with the dysphasic cases in this study. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheekunde vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 0 l e s l e y caplan it is interesting to examine these results in relation to the data on the loci of stuttering in the speech sequence of primary stutterers, as reported in the literature. bloodstein2 indicates that in phase 1 stutterers, stuttering occurs on the "small" parts of speech — the pronouns, conjunctions and prepositions and a modification occurs with the development of stuttering. it is precisely on these "small" parts of speech that the dysphasic subjects had difficulty. weiss's24 concept of central language imbalance, or cluttering, is also worth ' considering as it seems that the initial stage of stuttering and that of cluttering have been described as identical and that the development of this "imbalance in speech" into stuttering is dependent on the reactions of the individual to the primary disorder. it is possible, therefore, to assume that.in dysphasia there is a situation comparable with the postulated undifferentiated primary stages of stuttering and cluttering. word length. in considering the effect of word length (as calculated by number of letters) on the frequency and severity of dysfluencies in dysphasic speech, the greatest frequency of occurrence of dysfluencies was found on the longer words for four of the five subjects: dysfluencies occurred 100% of the time on the longest words and for one subject the second longest word elicited the most dysfluency. these results were confounded to some extent, by the occasional occurrence of severe dysfluency on short words and minimum dysfluency on longer words. wingate26 has explained the finding that longer words tend to evoke more dysfluency, in terms of the fact that longer words involve a more intricate pattern of motor co-ordination. this has neurological implications. position of the word in the sentence. the most prominent characteristic of the data here, is the fact that all five subjects showed the greatest frequency of dysfluency on the words in initial position in the sentence. the percentage of dysfluency on initial words was 27% in one case, 16% in another, and in three of the cases at least 10% greater than the scores obtained on the words in other positions. these results approximate those observed in stuttering, where there is "a gradient of stuttering increasing with proximity to the initial words". (quarrington, conway & siegel17). the phonetic factor. in observing the results obtained in determining the influence of the phonetic factor in precipitating dysfluency, it was obvious that this was a markedly variable factor, differing from individual to individual. no particular sound could be determined to precipitate dysfluency, but it was observed that subjects experienced more difficulty on initial consonants than on initial vowels. this tendency has been described in the literature on stuttering. it seems that consonants involve more tension of the articulators and are more difficult to utter, requiring rather highly organized and co-ordinated movements17. although a variety of explanations have been offered for the findings as regards the loci of dysfluency, an interpretation that seems to be highly relevant in terms of this study, is one presented by wingate26. in accounting for the fact that word length and position of the word in the sentence are important factors in precipitating dysfluency, wingate has postulated a journal of the south african speech and hearing association, vol. 19, deceber 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) s o m e aspects of stuttering-like speech in adult dysphasic subjects 61 physiological explanation that might provide some support for the hypothesis that stuttering is a form of apraxia. he indicates that it is the initial sounds that are the focal points of attack and are the points at which the transition from inactivity to "energizing of motor functions" occurs. further, luria's15 description of an apraxic disturbance is relevant here. he considers that there is a loss in the selectivity of the innervation of the articulatery movements, manifesting itself in an inability, on the part of the patient, to assume the correct position of tongue and lips in the production of speech. wingate26 has also pointed out that the conspicuousness of the word in the speech sequence is not the most important factor, but that the longer the word, the more intricate the pattern of motor co-ordination required. in addition, the more intricate and complex the movements required of the patient, the more demanding the act of "motor planning" will be and the more inaccessible is the motor schema for that word. these interpretations could well be incorporated in the concepts of ideokinetic and ideational apraxias5·1 8. the factors of word position, word length and phonetic characteristics do . seem to play an important part in precipitating dysfluency in both stuttering and dysphasia, while the grammatical factor revealed what is generally noted in the primary stage of stuttering. 2. propositional aspects and the adaptation effect were the phenomena investigated in determining whether the dysfluencies of dysphasics are susceptible to influences that bring about modifications in stuttering behaviour. average severity rating frequency of dysfluency. % rate of utterance in words per min. f r e e prop. f r e e prop. f r e e prop. s i . 7,33 7,33 '34 26 35,39 25,73 s 2 . 2,33 2,33 16 38 118,5 37,73 s3. 3 3,66 27,33 37,14 72,49 139,07 s4. 2,33 2,33 14 14 88,41 43,86 s5. 6 5 38,67 64 66,37 29,88 table ii. comparison of severity and frequency, and rate of utterance on a 150-word sample of the free speech of dysphasic subjects and the propositional speech task. tydskrif van die suid-afrikaanse vereniging· vir spraak en gehoorheelkunde. vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 2 lesley caplan propositionality. three measures were used to determine the effect of propositionality on dysphasic dysfluency. on an equal-appearing interval scale, ratings of the severity of dysfluency showed no change from the free speech sample to the propositional task, while the frequency count also indicated no real change. however, the assessment of the rate of utterance, revealed a reasonably marked reduction in the rate of verbal output under conditions of propositionality (table 2). the measures used did not reveal a trend in the results, although there is evidence of consistency with individual subjects. despite the inconclusiveness of these results, it does seem that with more rigorous experimental procedures, there could be an increase in the severity and frequency of dysfluency when subjects encounter a situation in which their ability to propositionalize is focussed upon. the adaptation effect. on the question-and-answer technique devised by schaef19 adaptation scores approximated those found in stutterers. there was a decrease in the frequency of dysfluency from one trial to the next. on the test requiring repetition of presented sentences from "arthur the young rat" most of the subjects manifested positively accelerated adaptation curves i.e. there was an increase in the frequency and severity of dysfluency on the three consecutive trials involved in the task (table 3). it seems that these results can be explained by considering the effects of fatigue on responses of dysphasic patients. the increased fatigue during the second task (three consecutive repetitions of a single sentence) appears to have been greater than that in the first task, because each response on the first task was separated from succeeding responses by a question from the examiner. the subjects were, therefore, given a rest period in which some recovery could have occurred. goldstein8 referred to the evidence of fatigue in brain-damaged patients and he pointed out that fatigue results in manifestations resembling catastrophic responses, and that perseveration is considered by some authorities to be a catastrophic response or an attempt to avoid catastrophe. it seems then, that in dysphasics, repetition of a response rather than producing an inhibitary potential affiliated to fatigue2, results in unobstructed, persisting responses related to fatigue. the fact that fatigue is a behavioural response, characteristic of stressful situations8, and that the factor of stress played a major role in accounting for stuttering in terms of a breakdown theory where there is a failure in the neuromuscular organization of the individual, could account for the increase in the frequency of dysfluency on successive repetitions of the same material. this finding does seem to reject the hypothesis that a reduction of dysfluency will manifest itself in the speech of dysphasics during repeated readings of journal of the south african speech and hearing association, vol. 19, deceber 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) s o m e aspects of stuttering-like speech in adult dysphasic subjects. 6 3 νο οο on (ν ο ο ο νο 00 ττ ο ο ο ο ρί (ν ιλ fo on rc/3 ο c/3 cvj ο «λ ο ο γ ο ο · νο ο ο rίγί <n on 00 <n " ο ο ο 00 ο ο ο ο ο νο «λ 'ί(ν ιλ ιλ ιλ ^ ο ο ο ο γ"» ο ο ο ο ο fo fo ιλ ^ rcvj ιλ \ © o n cvj ο ιλ ο ο r t ιλ ο ο νο ιλ o n (ν (ν (ν r1/w rγιλ 1/w \ © vo «λ ο ο cs (ν νο ο νο ο (ν νο ^ 'ίιλ γί ^ ο <*γ ο ο ο ο ο ο ο ο fo «λ <s on νο γcvj <n ιλ o n cvj νο ο ο οο' ο ο ο ο ο o n νο (ν νο \ © ο νο ο ο γ-" ο ο ο ο ο νο <ν ιλ (ν on cs 00^ (ν ^ ο ο ο cs οο" ττ ο ο ο ιλ (ν " (ν (ν fo on cvj fo 00 (ν c n cvj cvj ο «λ ιλ r> οο" ττ ο ο ο ιλ <ν (ν fo rm <s on cs ο ο ο ο ττ ο ο ο ο ίon fo ιλ <ν fo ^ ο ιλ ο γ-" ν ο rt ο ιλ <s (ν «λ ίc> (ν fo <ν γνο γon νο \ © <ν (ν \ © cvj ο ο νο ο γ*^ ττ ο vo ο ο o n (ν «λ (ν (ν 'ίwm <ν ιλ ιλ on «λ cs cs ο ο <ν ο ττ ττ ο ο ο ο (ν «λ ί'ίο i 3 ή < o q tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 4 lesley caplan the same material. however, it appears that methods of eliciting adaptation do tend to bias results. possibly with further experimentation, and with refinements in techniques, the adaptation effect may be revealed to be a potential "discriminating tool" in the investigation of non-fluencies, irrespective of the origin16. conclusion as noted above the results of this study appear inconclusive although some trends can be identified. it cannot be said that the dysfluencies of dysphasia are alike or unlike those of stuttering, nor can anything be said as regards the behaviour of these dysfluencies under certain conditions. the nature and amount of the dysfluency of dysphasia were examined, and although the amount of dysfluency appeared to justify the label of stuttering, the nature of these dysfluencies differs from those observed in stuttering. despite this, trained judges were inclined to evaluate the speech as stuttered speech and it seems, therefore, that other more subtle attributes of the dysfluencies must be considered as contributing to the diagnosis of stuttering. possibly anxiety and tension as well as the retardation in the spontaneity of expression, are the operative factors. the loci of the dysfluencies in the sequence of dysphasic speech were investigated. in terms of the grammatical function of words, the majority of subjects experienced more difficulty on the function words of language, rather than on the content or lexical words which precipitate dysfluency in stutterers. all subjects experienced the greatest difficulty on words in the initial position in the sentence as is found in stutterers. for most of the subjects dysfluency was most frequently precipitated by longer words and consonants generally created more difficulty than vowels.· in investigating the phenomena that modify stuttering behaviour, propositionality and the adaptation effect were considered. under conditions of propositionality some increase in the frequency and severity of the dysfluencies of dysphasics was observed, while on the adaptation task divergent results were obtained. the study has, however, yielded a number of diagnostic, therapeautic and re-' search implications. possibly one of the most important, and in response to st. onge's20 plea for the division of stuttering symptoms into separate syndrome complexes, is the need for differential diagnosis in relation to the problem of stuttering. by knowing what type of dysfluencies predominate and whether the dysfluencies are susceptible to the adaptation effect, and in what way, the clinician may well be provided with a further clue in her attempts to make a differential diagnosis and plan appropriate therapy. in conjunction with other measures, these factors may prove instrumental in determining whether a child's dysfluencies are normal, the result of stressful environmental pressures in an organically normal individual, the overt manifestations of a word-finding difficulty, or symptoms of an inadequate neurophysiological organisation. journal of the south african speech and hearing association, vol. 19, deceber 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) s o m e aspects of stuttering-like speech in adult dysphasic subjects 65 in the treatment of any disorder of speech or language where dysfluencies manifest themselves it may be important, therapeutically to be aware of the factors that are instrumental in determining the occurrence of the dysfluencies and to desensitize the patient to the influences of these factors. propositionality, it seems, can be considered to be responsible for much of the inconsistency and variability observed in dysphasic and stuttering responses, and the need to heighten the patient's level of tolerance to aspects of this phenomenon and to desensitize him to those factors that precipitate difficulty is important, difficulty is important. in conclusion this study could possibly be most profitably viewed as a preliminary in the investigation of the stuttering-like symptoms in expressive disorders of any type. examination of the hesitancies of normal speech, dysphasic and stuttered speech may well provide some data to add to the understanding of the process of language formulation and how it breaks down. further study along these lines may provide added information as to the nature of stuttering. references 1. arend, r., handzel, l. and weiss, b. (1962): dysphasic stuttering. folia phoniatrica, 14; 55-66. 2. bloodstein, 0 . (1969): a handbook on stuttering. national easter seal society for crippled children and adults, chicago, illinois. 3. brain, r. (1961): speech disorders. butterworths, london. 4. brown, s.f. (1945): the loci of stuttering in the speech sequence. j. speech dis., 10; 181-192. 5. canter, g.j. (1969): the influence of primary and secondary verbal apraxia on output disturbances and aphasic syndromes. paper presented to the annual meeting of asha, chicago, illinois. 6. critchley, m. (1970). aphasiology and other aspects of language. edward arnold (pub) ltd., london. 7. eisenson, j. (1958): a perseverance theory of stuttering. in: stuttering: a symposium. harper and row publishers, new york. 8. goldstein, k. (1948): language and language disturbances. grune and stratton, new york. 9. head, h. (1915): hughlings jackson on aphasia and kindred affections of speech. brain, 38; 1-27. 10. johnson, w. (1961): measurements of oral reading and speaking rate and dysfluency of adult male and female stutterers and nonstutterers./. speech hearing dis., monograph supplement no. 7, june; 1-20. 11. johnson, w„ darley, f.l. and spiestersbach, d.c. (1963): diagnostic methods in speech pathology, harper and row, new york. 12. karlin, i.w., (1947): a psychosomatic theory of stuttering./. speech dis., 12; 319-322. 13. lanham, l.w., (1968): lecture notes in phonetics and linguists ii, university of the witwatersrand. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 6 lesley caplan 14. lewis, d. and sherman, d; (1951): measuring the severity of stuttering. j. speech and hearing dis., 16; 320-326. 15. luria, a.r. (1966): higher cortical functions in man. tavistock publications, london. 16. newman, p.w. (1954): a study of adaptation and recovery of the stuttering response in self-formulated speech./. speech hearing dis., 19; 450-458. 17. quarrington, b., conway, j. and siegel, n. (1962): an experimental study of some properties of stuttered words./. speech hearing res., 5; 387-394. 18. reef, h. (1967): apraxic dysarthria./. s.a. logo. soc., 14; 37-44. 19. schaef, r.a. (1955): the use of questions to elicit stuttering adaptation./. speech hearing dis., 20; 262-265. 20. st. onge, k.r. (1963): the stuttering syndrome./. speech hearing res., 6; 195-197. 21. travis, l.e. (1931): speech pathology. d. appleton and co., new york and london. 22. van riper, c. (1971): the nature of stuttering. prentice-hall inc., englewood cliffs, new jersey. 23. weisenburg, t.h. and mcbride, e. (1935): aphasia: a clinical and psychological study. the commonwealth fund, new york. 24. weiss, d.a. (1967): similarities and differences between cluttering and stuttering. folia phoniatrica, 19; 98-104. 25. west, r. (1958). an agnostic's speculations about stuttering. in: stuttering: a symposium. harper and row publishers, new york. 26. wingate, h.e. (1967): stuttering and word length. /. speech hearing res., 10; 146-152. 27. young, μ .a. and prather, e.m. (1962): measuring the severity of stuttering using short segments of speech. /. speech hearing res., 5; 256-262. journal of the south african speech and hearing association, vol. 19, deceber 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) o u r n a l o f s o u t h a f r i c a n l o g o p e d i c s o c i e t y a r l editorial ύ^ηεν writing about speech therapy, as about any therapy, both the etiological and therapeutic aspects of speech disorders must be taken into account. we are pleased to print in this issue of the journal, articles which lay different stresses on these various aspects of speech and hearing defects. miss aron, who has recently returned from the united states and canada, stresses the therapeutic aspect of stuttering in her article, with particular reference to certain aspects of psychotherapy implicit in stuttering therapy. the relationship between stuttering therapy and psychotherapy, in this case, learning psychotherapy,, is indicated by miss marks in her article, and she also discusses the theoretical implications of considering stuttering as one aspect of the learning situation. one of the leading educationalists in this country is dr. behr,. .who has specialised in the problems of the deaf and hard-of-hearing child in this country and over-seas. we welcome his contribution "understanding the hard-of-hearing child," as being of great interest and value to speech therapists, and to teachers and parents of the aurally handicapped child. the two articles which describe case histories (in the case of miss whiting—diagnosis, and in the case of mrs. lubinsky, therapy) indicate the advance of practical work done in speech therapy in south africa, and further contributions along these lines would be welcomed for the journal. speech therapists in private practice miss m. marks, b.a. log. (rand) 5, jackal street, kensington. phone 24-2376. mrs. f. t. lubinsky. b.a. log. (rand) 26, caledon street, emmarentia extension, phone 46-3222. mrs. hilary meyersohn. b.a. log. (rand) 1 myer street, parkdene, boksburg. phone 52-2046. mies g. davidson, b.a. log. (rand) 1106, marble arch, goldreich street, hillbrow. johannesburg. phone 43-0463. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 99 spraakdiskriminasie by bejaarde gehoorapparaatgebruikers liza van wyk, isabel uys en maggi soer departement kommunikasiepatologie, universiteit van pretoria opsomming in hierdie studie is die invloed van veroudering op die spraakdiskriminasievermoe van bejaarde gehoorapparaatgebruikers ondersoek. 'n opname-metode is gebruik en dertig proefpersone, met dieselfde graad van perifere gehoorafname, is in twee groepe van vyftien persone elk verdeel. groep 1 het bestaan uit bejaarde gehoorapparaatgebruikers wat geen of geringe spraakdiskriminasieprobleme ervaar, terwyl groep 2 ernstige spraakdiskriminasieprobleme ervaar. 'n verskeidenheid toetse, naamlik die sintetiese sinsidentifikasietoets, die verspringende spondeewoordtoets en die aanbieding van monosillabiese woorde tesame met 'n ipsi-kompeterende spraakboodskap, is gebruik om hul spraakdiskriminasievermoe in verskillende luistersituasies te bepaal. 'n selfevaluasieskaal is ook deur die bejaardes voltooi. die resultate van hierdie studie toon dat die verouderingsproses en die effek hiervan op veral sentrale ouditiewe prosessering, bydra tot die kompleksiteit en uiteenlopendheid van bejaarde gehoorapparaatgebruikers se spraakdiskriminasieprobleme. die resultate beklemtoon verder die noodsaaklikheid van volledige intervensieprogramme vir bejaarde gehoorapparaatgebruikers. abstract this study investigates the influence of aging on the speech discrimination abilities of elderly hearing instrument users. a survey method was used and thirty subjects, with the same degree of peripheral hearing loss, were divided into two groups of fifteen persons each. group 1 consisted of elderly hearing instrument users who experienced little or no speech discrimination problems while group 2 consisted of persons with severe speech discrimination problems. the synthetic sentence identification test, the staggered spondaic word test and phonemically balanced words with an ipsi-competitive speech noise, were used to ascertain their speech discrimination capabilities in different listening situations. the elderly also completed a self-evaluation scale. the results of the study indicate that the aging process and changes in central auditory processing contribute to the complexity and diversity of elderly hearing instrument user's speech discrimination problems. the results also stress the importance of comprehensive intervention programmes for elderly hearing instrument users. sleutelwoorde: spraakdiskriminasie, bejaarde gehoorapparaatgebruikers, sentrale ouditiewe prosessering. die verouderingsproses blyk die dominante oorsaak van gehoorprobleme by bejaardes te wees (working group on speech understanding and aging, 1988). histopatologiese en morfologiese studies bevestig veranderinge in die totale gehoorsisteem wat die perifere gehoormeganisme, die koglea, gehoorsenuwee, breinstam en die temporale lobbe insluit (willott, 1991). hierdie ouderdomsverwante veranderinge in die ouditiewe sisteem kan ouditief presenteer as 'n perifere gehoorverlies, 'n sentrale ouditiewe prosesseringsprobleem of as 'n kombinasie van die twee verskynsels. 'n verskeidenheid ander faktore kan ook gekoppel word aan die gehooren spraakdiskriminasieprobleme wat bejaardes ervaar. metaboliese veranderinge, vaskulere abnormaliteite, nierprobleme, medikasie, bepaalde mediese behandeling en geraasblootstelling kan ook die gehoor van die bejaarde bei'nvloed (willott, 1991). bepaaldejfaktore soos neuro-anatomiese veranderinge as gevolg van die verouderingsproses, degenerasie van bepaalde kognitiewe funksies soos geheue, aandag, spoed van prosessering en ook linguistiesouditiewe funksies blyk 'n negatiewe invloed op die totale ouditiewe prosesseringsvermoe van die bejaarde te he (lemme & hedberg, 1988; marshall, 1981; cohen, 1987 & willott, 1991). die passing van gehoorapparate word beskou as 'n primere rehabilitasiestrategie om gehoorgestremde bejaardes se gehoor te verbeter (hull, 1985). 'n groot persentasie van die bejaarde gehoorapparaatgebruikers ervaar egter steeds probleme met kommunikasie en veral met spraakdiskriminasie in die teenwoordigheid van agtergrondgeraas, ten spyte van klankversterking (stach, 1994). hierdie probleme presenteer egter nie in dieselfde mate by gehoorapparaatgebruikers met dieselfde graad van perifere gehoorafname nie (stach, 1994; hull, 1985). spraakdiskriminasieprobleme is in die verlede veral toegeskryf aan die afname in perifere gehoorsensitiwiteit die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 100 liza van wyk, isabel uys & maggi soer (jerger, jerger, oliver & pirozzolo, 1989; humes & roberts, 1990). resente navorsing dui egter daarop dat die ouderdomsverwante veranderinge in die sentrale ouditiewe sisteem ook tot spraakdiskriminasieprobleme kanbydra (rodriguez, disarno & hardiman, 1990; jerger, et al., 1989; marshall, 1981). 'n kombinasie van die effek van 'n perifere gehoorverlies en die afname in sentrale ouditiewe prosessering is nie uitgesluit nie (willott, 1991). daar is dus geen uitsluitsel oor die ware aard en oorsake van spraakdiskriminasieprobleme soos wat dit presenteer by bejaardes nie, maar die betrokkenheid van die sentrale ouditiewe sisteem geniet toenemende aandag in die jongste navorsingsliteratuur (rodriguez, et al., 1990; jerger, et al., 1989). klem word tans ook veral geplaas op die gebruik van sentrale spraaktoetse om sentrale ouditiewe funksionering te evalueer (stach, 1994). die motivering vir hierdie studie word gerig deur bepaalde kontroversies, leemtes en 'n behoefte aan kennis oor gehoorprobleme en veral spraakdiskriminasieprobleme soos wat dit presenteer by die bejaarde en veral by die bejaarde gehoorapparaatgebruiker. vanwee die kompleksiteit van die bejaarde se ouditiewe probleme bestaan daar ook leemtes ten opsigte van die toetsing, diagnose en rehabilitasie van die bejaarde met gehoorprobleme. hierdie leemtes en 'n behoefte aan meer kennis van die bejaarde se unieke ouditiewe probleme moet dus aangespreek word. metode doel die hoofdoelstellings van hierdie studie is om die invloed van veroudering op die spraakdiskriminasievermoe van bejaarde gehoorapparaatgebruikers, met dieselfde graad van perifere gehoorverlies, te ondersoek en om te bepaal waarom sommige bejaarde gehoorapparaatgebruikers meer probleme met spraakdiskriminasie ondervind as ander (van wyk, 1997). die hoofdoelstellings word gerealiseer in die volgende subdoelstellings: 1. om spraakdiskriminasie in stilte van twee groepe bejaardes, naamlik bejaardes met geringe spraakdiskriminasieprobleme en bejaardes met ernstige spraakdiskriminasieprobleme, te bepaal en te vergelyk. 2. om die spraakdiskriminasievermoe van die twee genoemde groepe in komplekse luistersituasies te bepaal en te vergelyk. 3. om die twee groepe bejaardes se subjektiewe ervaring van hul gehoorprobleme en die baat wat hul vind by die dra van gehoorapparate te bepaal en te vergelyk. 4. om te bepaal of daar 'n verband is tussen die twee groepe se subjektiewe evaluasie van hul gehoorprobleme (sonder gehoorapparate) en die objektiewe oudiologiese evaluering van hul perifere gehoorstatus. 5. om te bepaal of daar 'n korrelasie is tussen die bejaardes se subjektiewe evaluasie van hul gehoorfunksionering en die objektiewe meting van hul spraakdiskriminasievermoe in verskillende luistersituasies. navorsings ontwerp die bepaalde navorsingstrategie wat in hierdie studie gebruik is, is die opname-metode (jacobs, haasbroek & theron, 1992). die kwalitatiewe-kwantitatiewe aard van hierdie navorsing verseker die realisering van die doelstellings (jacobs, et al., 1992). proefpersone dertig bejaardes is op 'n afhanklike, ewekansige wyse geselekteer en in die twee navorsingsgroepe verdeel (jacobs, et al., 1992). die proefpersone het aan die volgende kriteria voldoen: 1. afrikaans moet die moedertaal wees, aangesien alle toetsstimuli in afrikaans aangebied is. navorsing toon dat sentrale toetse wat nie in die klient se moedertaal aangebied word nie, aanleiding kan gee tot swakker resultate wat nie net verklaarbaar is op grond van sentrale ouditiewe funksionering nie (lemme & hedberg, 1988). 2. persone vanaf 65 jaar word vir die doeleindes van hierdie studie beskou as bejaard en is dus ingesluit. ouderdomme wissel tussen 65-90 jaar. deur die insluiting van bejaardes oor die totale ouderdomspektrum kan bepaal word of daar 'n verband is tussen veroudering en die mate waarin spraakdiskriminasieprobleme voorkom (willott, 1991). 3. sowel mans as vrouens is geselekteer, om te verseker dat spraakdiskriminasie by die bejaarde populasie, soos wat hulle in die samelewing leef, ondersoek word (marshall, 1981). 4. normale middeloorfunksionering is 'n vereiste om sodoende te verseker dat dit nie 'n invloed op die perifere gehoorstatus van die bejaardes het nie (margolis & shanks, 1985). 5. bejaardes met binourale, geringe tot gemiddelde, sensories-neurale hoefrekwensie-gehoorverliese is geselekteer. hierdie oudiometriese konfigurasie is kenmerkend van presbikusie (willott, 1991). dit impliseer gehoorverliese waarvan die gemiddelde suiwertoondrempels (by 500 hz, 1000hz en 2000hz) >25db en <56db is (yantis, 1994). vir hierdie studie is bejaardes met gemiddelde suiwertoondrempels van 40db-50db geselekteer om eenvormigheid te verseker. die hoer frekwensies is ook in ag geneem, aarigesien hierdie gehoordrempels 'n belangrike invloed op spraakdiskriminasie het. drempels tussen ongeveer 50db-70db by 4000hz en 60db-80db by 8000hz is aanvaar en dit pas in by die beskrywing van presbikusie (willott, 1991). i 6. bejaardes se mediese geskiedenis moet vry wees van enige serebro-vaskulere insidente, seniliteit enjenige geslotehoofbeserings of enige ander siektetoestand, aangesien dit moontlik 'n negatiewe invloed op die toetsresultate kan he (willott, 1991). die bejaardes mag ook geen ototoksiese middels of enige ander medikasie gebruik wat 'n remmende invloed op die werking van die sentrale senuweesisteem kan he nie (rodriguez et al., 1990; jerger et al., 1989; marshall, 1981). ' 7. alle proefpersone is aan 'n siftingsprosedure onderwerp, om te bepaal of kognitiewe en ook linguistiese vaardighede intakt is, aangesien hierdie faktore ook die spraakdiskriminasievermoe kan bei'nvloed. (cohen, 1987; lemme & hedberg, 1988). / die volgende materiaal en apparaat is gebruik om die dertig bejaardes vir hierdie studie te selekteer (van wyk, 1997): the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) spraakdiskriminasie by bejaarde gehoorapparaatgebruikers 101 'n gevalgeskiedenisvorm is gebruik, om identifiserende inligting en ook ander inligting soos die mediese geskiedenis, aanvang van gehoorverlies en kommunikasieprobleme, op te teken (rosenberg, 1978); die mini mayo mental scale is gebruik om kognitiewe funksionering te evalueer (folstein, folstein & mchugh, 1975); . subtoetse van die bostonse diagnostiese afasietoets is gebruik om linguistiese vermoe te evalueer (goodglass & kaplan, 1983); . alle oudiometriese toetsing is met 'n gsi 16-oudiometer uitgevoer en voldoen aan die vereiste van die sabs 0154-1983 (suid-afrikaanse buro vir standaarde, 1994). die oudiometer is geyk op 1995-01-04. tdh-50poorfone, gemonteer in mx-51-kussings is vir suiwertoonoudiometrie gebruik. 'n b-17-beengeleier is vir beengeleidingstoetse gebruik. toetse is in 'n klankdigte kamer van industrial acoustics company inc. uitgevoer en die toetsomgewing voldoen aan die sabs 0182-1982standaard (suid-afrikaanse buro vir standaarde, 1994). 'n gsi-33-middelooranaliseerder is gebruik om immittansietoetsing uit te voer. 'n heine alpha nica tron 2-otoskoop is gebruik om die otoskopiese ondersoek op die proefpersone uit te voer. bejaarde gehoorapparaatgebruikers, wat die phonakgehoorsentrum (pretoria) tussen januarie 1993 en januarie 1995 besoek het, is tydens die seleksie van proefpersone genader. bejaardes wat hul gehoorapparate daagliks vir ongeveer twee jaar gedra het, is geselekteer vir die studie. sodoende is verseker dat bejaardes reeds aangepas het by die dra van gehoorapparate en is eenvormigheid ten opsigte van klankversterking verseker. op grond van die bejaardes se suiwertoondrempels en subjektiewe evaluasie van hul gehoorprobleme is dertig bejaardes op 'n afhanklike, ewekansige wyse vanuit 'n totale populasie van 485 bejaardes geselekteer en in twee groepe verdeel, naamlik bejaardes met geen of geringe spraakdiskriminasieprobleme en bejaardes met ernstige spraakdiskriminasieprobleme. sowel groep 1 as groep 2 het bestaan uit sewe vrouens en agt mans. die dertig persone is telefonies gekontak waartydens 'n afspraak vir 'n konsultasie gemaak is. | tydens 'n konsultasie is 'n gestruktureerde onderhoud gebruik om 'n volledige gevalgeskiedenis van die bejaardes te verkry en die kognitiewe en linguistiese vaardighede is ook geevalueer. 'n otoskopiese ondersoek is op elke proefpersoon voor die oudiologiese toetsing uitgevoer. 'n timpanogram is van elke proefpersoon verkry en elke proefpersoon moes aan die gestelde norme voldoen soos bespreek in die literatuur om as proefpersoon geselekteer te word (margolis & shanks, 1985). 'n volledige suiwertoonoudiogram is verkry, spraakontvangsdrempelbepaling en spraakdiskriminasietoetsing in stilte is ook uitgevoer (van wyk, 1997). die uitvoering van hierdie prosedures stem ooreen soos bespreek in bestaande literatuur (van wyk, 1997; yantis, 1994; penrod, 1994). tabel 1 verskaf 'n opsomming van die eienskappe van die dertig proefpersone wat vir hierdie studie gebruik is (van wyk, 1997). materiaal en ap par a at die materiaal en apparaat wat in hierdie studie gebruik is, word in twee onderafdelings bespreek, naamlik: a. materiaal en apparaat gebruik vir die insameling van data die volgende apparaat is tydens die insameling van data gebruik (van wyk, 1997): die gsi 16-oudiometer (geyk op 1995-01-04) is ook gebruik tydens die uitvoering van spesiale spraaktoetse. alle toetse is in dieselfde klankdigte kamer uitgevoer soos reeds voorheen gespesifiseer. 'n tweekanaalbandopnemer, naamlik 'n marantz stereo cassette deck sd-255, is aan die gespesifiseerde oudiometer gekoppel vir die uitvoer van die spraaktoetse. 'n hoekwaliteit tdk d90-kasset is gebruik vir die opneem van die kompeterende boodskap, die onsinsinne en ook die digotiese toetsprosedure, wat gebruik is tydens die uitvoering van die komplekse spraaktoetse. tabel 2 verskaf 'n oorsig van en motivering vir die verskillende toetse en materiaal wat tydens die studie gebruik is: die siftings-, die basiese en ook die spesiale sentrale-toetse, asook die selfevaluasieskaal. b. materiaal vir die optekening en verwerking van data response van die proefpersone in die verskillende toetse, is op bestaande responsvorms, wat in die kliniese opset gebruik word, opgeteken (van wyk, 1997). statistiese verwerkings is gedoen met behulp van 'n ibm 370rekenaar en die statistical packages for social sciences program, universiteit van pretoria (theron, 1995). dataversamelingsprosed ures die volgende dataversamelingsprosedures is in hierdie studie gevolg en word in twee onderafdelings bespreek, naamlik: a. dataversamelingsprosedures wat uitgevoer is tydens die navorsing alle spraaktoetse en spesiale toetse is uitgevoer deur gebruik te maak van bandopnames. sodoende is verseker dat die aanbieding van toetse op 'n konstante wyse plaasgevind het en is die toetsgeldigheid en -betroubaarheid verhoog (penrod, 1994). spraakdiskriminasietoetsing in stilte is uitgevoer by 50db, 40db, 30db, 20db en lodb bokant die spraakontvangsdrempel. by 50db bokant die spraakontvangsdrempel is bepaal of 'n "rollover" voorkom (penrod, 1994). die sintetiese sinsidentifikasietoets is by dieselfde aanbiedingsintensiteit as bogenoemde uitgevoer ten einde die verskillende resultate met mekaar te vergelyk (kaplan, et al., 1984; van wyk, 1997; willeford, 1985). die verspringende spondeewoordtoets is so aangebied dat die proefpersone die spondeewoorde in die regsnie-kompeterende (r-n-k); regs-kompeterende (r-k); links-kompeterende (l-k) en links-nie-kompeterende (l-n-k) luistersituasies moes herhaal (kaplan, et al., 1984). die toets is by 40db bokant die gemiddelde suiwertoondrempels by 500hz, 1000hz en 2000hz aangebied (lukas & genchur-lukas, 1985). die monosillabiese woorde tesame met die ipsidie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 102 liza van wyk, isabel uys & maggi soer m ak si m u m ko rr ek te sp ra ak di sk ri m ina si e re gt er oo r 10 0 % 10 0 % 10 0% 96 % 10 0 % 10 0% 10 0% 96 % 10 0% 10 0 % 96 % 10 0% 10 0 % 88 % 10 0% 98 ,4 % < n < n o o < n c d < n o < n c o o 2 c o o o c o < n o o i c o o o o c o o o c o ^ o o o o o j | 91 ,5 % m ak si m u m ko rr ek te sp ra ak di sk ri m ina si e lin ke roo r ο ο ο , η ο ο ο ο ο ο ^ , ο ο ^ , ο o o o g o o o o o o g o o g j o 98 ,9 % o i a i c o o o o c o o o c o o o c o ^ o j 91 ,5 % so d ( d b ) re gt er oo r c q c q c q c q c q c q c q c q p q c q c q c q c q c q c q ό ό ' ό ό ό ' ό ό ' ό ό ό ό ό ό ' ό ό ο ο ΐ β ί ο ο ί ο ο ο ί ο ΐ ο ΐ λ ο ο ί ο ο 43 ,7 db fflfflfflfflfflfflfflfflfflfflfflfflfflfflffl ό ό ό ό *"0 *"0 ό *"0 *"0 ό ό *ό *ό *ό *ό ο ο ι η ο ο ο ο ο ι ο ι ο ο ο ο ι ο ι ο 46 ,3 d b so d ( db ) lin ke roo r cqcqcqcqcqcqcqcqcq cq ffl ffl cq ffl ffl ό ό "ό ό "ό ό ό ό ό ι ο ι λ ι λ ο ο ο ο ο ι λ ι ο ι ο ι λ ο ι λ ι ο 45 ,3 db mfflfflfflfflfflwfflfflcqfflfflcqcqcq ό ό ό ό ό "ό ό "ό "ό ό "ό ό *"0 o o l o i f l o w w w o m o o o w l f l 46 ,7 d b st d ( db ) re gt er oo r fqcqfqcqpqcqpqcqpqcqpqp^pqp^p^ ' " ο ' ό ' ό ό ό ' ό ό ' ό ό ' ό ' ό ό ό ό ό o p i c o l o c o o o o w o n o n o n o 42 ,2 db pq pq pq pq pq pq pq" pq pq pq pq pq pq pq pq ό ό *"0 ό *"0 *"0 *"0 ό *"0 ό *ό "ό "ό *"0 *"0 ( n c o i o o o o o o o o c o t > c o o o o o o c o 45 ,5 db st d (d b ) lin ke roo r mfflfflfflfflfflfflfflfflfflfflfflfflfflffl ό ό ό ' ό ' ό ό ' ό ' ό ' ό ό ό ό ' ό ό ό o l o l o o t > t > o o c o ( n c o o c o t > c o o 42 ,2 d b p q p q p q p q p q p q p q p q p q p q p q p q p q p q p q ό ό ό *"0 ό ό *"0 ό ό ό *"0 " ό " ό *"0 0 ( n l o l o c o c o t > < n t > c o o c o t > 0 ( n ι ο ι ο t f t f t f t f t f t f t f t f t f t f t f t f t f 45 ,6 d b im m it ta ns ie m et in gs re su lt at e re gt er oo r < < < < < < < < < < < < < < < a j a j a j o q j o j q j a j o a j a j q j o a j q j h h h h h h h h h h h h h h h ο ο ο ο < < < < < < < < < < < < < < < α ι α ι < υ < υ ( υ < υ < υ ω ω < υ < υ < υ < υ < υ < υ ρ , ο , ο . ο . ο . ο ο ο . ο ο ο ο ' 1 ' 1 ' 1 ρ ρ η ρ η η η η η η η ρ η η η •χ* -μ-::im m it ta ns ie m et in gs re su lt at e lin ke roo r ο ο < < < < < < < < < < < < < < < a j a j a j a j a j a j a j a j o a j a j a j a j a j q j h h h h h h h h h h h h h h p * * < < < < < < < < < < < < < < < c i u v a o i c o i u c o v u u o ) ^ o o o o o o o o o o o o g g g η η η η ρ η η ρ η η η ρ η η η -μ•'.· -χo to sk opi es e on de rso ek no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l no rm aa l l in gu is ti es e ve rm oe (t ot al e aa nt al pu nt e) in ta kt (1 19 ) in ta kt (1 19 ) in ta kt (1 19 ) in ta kt (1 19 ) in ta kt (1 19 ) in ta kt (1 19 ) in ta kt (1 19 ) in ta kt (1 19 ) in ta kt (1 19 ) in ta kt (1 18 ) in ta kt (1 19 ) in ta kt (1 19 ) in ta kt (1 19 ) in ta kt (1 18 ) in ta kt (1 19 ) 11 8, 9 in ta kt (1 19 ) in ta kt (1 19 ) in ta kt (1 19 ) in ta kt (1 18 ) in ta kt (1 19 ) in ta kt (1 19 ) in ta kt (1 19 ) in ta kt (1 19 ) in ta kt (1 18 ) in ta kt (1 19 ) in ta kt (1 18 ) in ta kt (1 16 ) in ta kt (1 16 ) in ta kt (1 16 ) in ta kt (1 19 ) 11 8, 2 k og n iti ew e ve rm oe (t ot al e aa nt al pu nt e) in ta kt ( 37 ) in ta kt ( 36 ) in ta kt ( 37 ) in ta kt (3 8) in ta kt ( 37 ) in ta kt ( 38 ) in ta kt (3 8) in ta kt ( 36 ) in ta kt (3 7) in ta kt ( 37 ) in ta k t( 35 ) in ta kt ( 38 ) in ta kt (3 5) in ta kt ( 37 ) in ta kt ( 36 ) 36 ,8 in ta kt ( 36 ) in ta kt ( 37 ) in ta kt ( 35 ) in ta kt ( 38 ) in ta kt ( 36 ) in ta kt (3 8) in ta kt ( 35 ) in ta kt ( 32 ) in ta kt ( 33 ) in ta kt (3 8) in ta kt ( 37 ) in ta kt ( 34 ) in ta kt ( 32 ) in ta kt (3 2) in ta kt ( 37 ) 35 ,3 k ro n olo gi es e ou de rdo m 65 jr 0 m nd e 65 jr 2 m nd e 67 jr 1 1 m nd e 69 jr 1 1 m nd e 70 jr 7 m nd e 73 jr 9 m nd e 73 jr 1 0 m nd e 74 jr 6 m nd e 75 jr 1 m nd 76 jr 6 m nd e 77 j r 10 m nd e 80 jr 4 m nd e 81 jr 1 1 m nd e 82 j r 7 m nd e 84 jr 6 m nd e 74 jr 1 m n d e 65 j r 6 m nd e 67 jr 1 1 m nd e 69 jr 1 1 m nd e 70 jr 1 0 m nd e 72 j r 0 m nd e 73 j r 2 m nd e 74 jr 6 m nd e 75 jr 2 m nd e 76 jr 4 m nd e 77 jr 1 0 m nd e 78 jr 1 0 m nd e 82 jr 4 m nd e 83 j r 11 m nd e 84 jr 1 m nd 84 jr 4 m nd e 75 j r 3 m n d e g es la g y p ro ef pe rs oo nno m m er c c t o d o i o h i n w ' i l f i t o c o d o l o h h h h w n c 1 c j n w n n i n n c 1 g ro ep •η g e m . ( n g e m . c cu -g μ =3 >> c ο μ ιλ ω c 'α ce ω c -q txo d ο < the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kdiskriminasie by bejaarde gehoorapparaatgebruikers tabel 2: oorsig van die verskillende toetse toetse motivering vir keuse van toetse verwysing 1. siftingstoetse * mini mayo mental dien as siftingsinstrument om kognitiewe vaardighede soos orientasie, aandag, lees, leer, rekenkunde, abstraksie en algemene kennis te evalueer. folstein, et al., 1975 * bostonse diagnostiese afasietoets dien as siftingsinstrument om linguistiese vaardighede soos, woordvindingsvermoe, ouditiewe begrip en verbale uitdrukkings te evalueer. goodglass & kaplan, 1983 2. basiese toetsbattery * gevalgeskiedenis bevat identifiserende inligting van bejaarde, asook inligting soos, aanvang van gehoorverlies, simptome, oorsake, mediese geskiedenis en kommunikasievaardighede. rosenberg, 1978 * otoskopiese ondersoek evalueer status van eksterne oorgedeelte, oorkanaal en timpaniese membraan. yantis, 1994 * suiwertoonoudiogram (lugen beengeleiding) bepaal luggeleidingsdrempels by 125hz-8000hz en beengeleidingsdrempels by 250hz-4000hz ten einde die graad en aard van die perifere gehoorverlies te bepaal. yantis, 1994 * spraakontvangsdrempel (sod) ingesluit om te bepaal waar proefpersone 50% van spondeewoorde kan identifiseer. dien ook as basis waarvolgens die intensiteit vir aanbieding van ander toetsstimuli bepaal word en om std te kontroleer. penrod, 1994 * spraakdiskriminasie in stilte bepaal spraakdiskriminasievermoe in stilte om die spraakdiskriminasie kurwe te verkry waar bejaardes hul fg-maksimum en 50% korrekte spraakdiskriminasie behaal. penrod, 1994 laubscher & tesner, 1996 * akoestiese immittansiemeting 1 evalueer middeloorfunksionering om onder andere die statiese beweeglikheid en fisiese volume te bepaal margolis & shanks, 1985 1 3. spesiale sentr|ale-toetse * sintetiese sinsevalueer sentrale ouditiewe funksie en spraakdiskriminasievermoe. differensiale diagnostiese toets om te onderskei tussen kogleere, retro-kogleere en sentrale letsel. jerger, et al., 1989 kaplan, et al., 1984 willeford, 1985 muller, 1981 * verspringende spondeewoordtoets (vsw-toets) ^ evalueer spraakdiskriminasievermoe in onder andere, komplekse luistersituasies en kompenseer vir die perifere gehoorverlies. kaplan, et al., 1984 lukas & genchurlukas, 1985 * monosillabiese woorde en die aanbieding van 'n ipsi-konipeterende boodskap identifiseer spraakdiskriminasieprobleme tydens die aanbieding van 'n ipsi-kompeterende boodskap (sein-tot-ruis-verhouding : + 5 db). penrod, 1994 stach, 1994 4. self-evaluasie skaal * "hearing handicap inventory for the elderly" (hhie) subjektiewe inligting deur die bejaarde verskaf wat aanvullend is tot die objektiewe oudiometriese data; evalueer situasieen emosionele veranderlikes van 'n gehoorverlies wat 'n invloed kan he op alledaagse funksionering; verskaf inligting oor evaluasie sonder en met gehoorapparate. ventry & weinstein, 1982 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 104 liza van wyk, isabel uys & maggi soer kompeterende boodskap is aangebied 40db bokant die spraakontvangsdrempel. die sein-tot-ruis-verhouding was +5db (penrod, 1994). die selfevaluasieskaal is twee keer tydens 'n gestruktureerde onderhoud voltooi. tydens die eerste sessie het die proefpersone die skaal voltooi asof hulle nie gehoorapparate dra nie en die tweede keer is die skaal voltooi asof hulle gehoorapparate dra (ventry & weinstein, 1982). b. data-optekeningen dataverwerkingsprosedures response van die 30 proefpersone is opgeteken op die verskillende responsvorms, soos reeds bespreek. die dataop tekeningsprosedures, wat betref die resultate van die oudiometriese toetsing, stem ooreen met die optekeningsprosedures wat in die praktyk gebruik word. al die relevante toetsresultate is vir elkeen van die 30 proefpersone opgeteken op 'n individuele responsvorm. tydens die analise en prosessering van die data is daar gebruik gemaak van beskrywende en nie-parametriese statistiek (theron, 1995). data is verwerk met 'n ibm 370rekenaar en die statistical packages for social sciences program, universiteit van pretoria, (theron, 1995). in tabel 3 word 'n opsomming van die statistiese prosedures verskaf wat gebruik is om elke subdoelstelling te beantwoord (van wyk, 1997). resultate tabel 4 bied 'n opsomming van die twee navorsingsgroepe se gemiddelde resultate op die verskillende toetse (van wyk, 1997). dit blyk duidelik dat daar 'n beduidende verskil tussen die resultate van die twee groepe is, behalwe ten opsigte van die totale prestasie met en sonder gehoorapparate. 1. suiwertoonresultate van die bejaardes die gemiddelde suiwertoondrempels vir groep 1 is 42,2db vir beide ore. groep 2 se gemiddelde suiwertoondrempels is 45,6db vir die linkeren 45,5db vir die regterore. daar is dus nie 'n beduidende verskil tussen die resultate van groep 1 en groep 2 op die 5% vlak van beduidenheid nie. daar is ook nie 'n beduidende verskil tussen die regteren linkerore van elke groep afsonderlik nie (p < 0,05). 2. spraakdiskriminasievermoe in stilte die maksimum-gemiddelde prestasie by 40db bo die spraakontvangsdrempel vir groep 1 was 98,9% vir die linkerore en 98,4% vir die regterore. die maksimumgemiddelde prestasie by dieselfde intensiteitsvlak vir groep 2 was 91,5% vir beide ore. groep 2 presteer beduidend swakker as groep 1 by al die verskillende intensiteitsvlakke (p < 0,05). 'n tweede afleiding is dat daar geen beduidende verskil tussen die linkeren regterore van elke groep afsonderlik vir die toets bestaan nie (groep 1: ρ = 0,1056 en groep 2: ρ = 0,180). daar is verder geen toename in spraakdiskriminasieprobleme, soos ouderdom toeneem nie. daar is ook nie 'n beduidende verskil tussen die spraakdiskriminasieresultate van mans en vrouens nie (p = 0,2049). die "rollover-" fenomeen, in beide ore, is by drie bejaardes in groep 2 ge'identifiseer. 3. spraakdiskriminasievermoe in komplekse luistersituasies die resultate in die verskillende komplekse luistersituasies is soos volg: 3.1. prestasie in die sintetiese sinsidentifikasietoets groep 1 se maksimum-gemiddelde prestasie is 68,0% in die linkeren 66,9% in die regterore. groep 2 behaal 24,6% vir die linkeren 22,7% vir die regterore. groep 2 presteer dus beduidend swakker as groep 1 tydens die aanbieding en identifikasie van die sinne met 'n sein-tot-ruisverhouding van odb (p < 0,05). ander resultate dui daarop dat daar geen beduidende verskil tussen die prestasie van die linkeren regterore van elke groep se ssi-pi-funksie afsonderlik is nie (p-waarde vir groep 1 is 0,1056 en vir groep 2 is dit 0,2049). die gemiddelde ssi-pi-funksie is vir beide groepe beduidend swakker as die fg-pi-funksie, maar groep 2 (p = 0,000) se resultate wyk meer af as die van groep 1 (p = 0,0003). die "rollover-" fenomeen, in beide ore, het voorgekom by sewe bejaardes in groep 2. die tweede diagnostiese prosedure van die ssi-toets is om die ssi-ikb-resultate met die ssi-kkb-resultate te vergelyk. daar is 'n beduidende verskil tussen die ssiikb-resultate van die twee groepe, waar die sein-tot-ruisverhouding +10db, odb en -lodb is. die prestasie van groep 2 is beduidend swakker as die prestasie van groep 1 (p < 0,05). met 'n sein-tot-ruis-verhouding van -20db was daar egter geen beduidende verskil tussen die twee groepe nie. die ssi-kkb-resultate, met die sein-tot-ruisverhoudings odb, -20db en -40db, dui daarop dat groep 2 beduidend swakker gevaar het as groep 1. daar is egter geen beduidende verskil tussen die linkeren regterore van elke groep se resultate afsonderlik nie (p = 0,1474 vir groep 1 en vir groep 2 is ρ = 0,2241). ssi-ikb-afwykings is by albei groepe groter as ssi-kkb afwykings. ander resultate is dat daar geen beduidende verskil tussen mans en dames se prestasie is nie (p = 0,7938). 3.2. toetsresultate van die verspringende spondeewoordtoets ten opsigte van die totale prestasie-korrekte diskriminasie, behaal groep 1, 56,7% in die linkeren 82,7% in die regterore. groep 2 behaal 36,1% in die linkeren 58,3% in die regterore. na aanleiding van die 5%-vlak (p < 0,05) van beduidenheid is daar 'n beduidende verskil tussen die twee groepe se prestasie in die vier verskillende luisteromstandighede (r-n-k; r-k; l-k en l-n-k).' dit geld vir sowel die rou-vswen "corrected"-vsw-resultate. resultate toon verder dat daar nie 'n beduidende verskil tussen die r-vswen c-vsw-resultate van groep 1 is nie (p < 0,05). vir groep 2 is daar egter 'n beduidende verskil tussen die r-vswen c-vsw-resultate by al vier die luisteromstandighede (vir r-n-k is ρ = 0,0004; vir r7k is ρ = 0,0004; vir l-k en l-n-k is ρ = 0,0007). dit blyk dus dat groep 2 beduidend meer probleme as groep 1 in beide linkeren regteroor kompeterende situasies ondervind. / 3.3. prestasie tydens die aanbieding van monosillabiese woorde en 'n ipsi-kompeter'ende boodskap die maksimum-gemiddelde prestasie vir groep 1 se linkerore is 63,7% en vir die regterore 66,7%. die maksimum-gemiddelde prestasie vir groep 2 is 48,3% vir the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) spraakdiskriminasie by bejaarde gehoorapparaatgebruikers 105 tabel 3: 'n opsomming van die verskillende statistiese prosedures wat gebruik is om elke subdoelstelling te beantwoord subdoelstellings prosedures beskrywing van statistiese verwysings 1. om die spraakdiskriminasievermoe van die twee navorsingsgroepe in stilte te bepaal en te vergelyk. 1.1 die algemene liniere metode is gebruik om die rekenkundige gemiddelde vir elke groep vir die verskillende toetsresultate te bepaal; 1.2 die mann whitney u-wilcoxon rank sum wtoets (5% vlak van beduidenheid) is gebruik om te bepaal of daar 'n beduidende verskil tussen die resultate van die twee groepe is. theron, 1995; jacobs, et al., 1992 2. om die spraakdiskriminasievermoe van die twee groepe in komplekse situasies te bepaal en te vergelyk. 2.1 die algemene liniere metode is gebruik om die rekenkundige gemiddelde prestasie van elke groep in die verskillende toetse te bepaal; 2.2 die mann whitney u-wilcoxon rank sum w-toets (5% vlak van beduidenheid) is gebruik om te bepaal of daar 'n beduidende verskil tussen die resultate van die twee groepe is; 2.3 die kendall en spearman-toetse is gebruik om te bepaal of daar 'n beduidende korrelasie tussen die resultate van die verskillende spesiale spraaktoetse is. theron, 1995. theron, 1995; jacobs, et al., 1992. theron, 1995; jacobs, et al., 1992. 3. om die twee groepe se subjektiewe ervaring van hul gehoorprobleme en die baat wat hulle vind by die dra van gehoorapparaat te bepaal en te vergelyk. 3.1 die algemene liniere metode is gebruik om die rekeningkundige gemiddelde vir die prestasie met en sonder gehoorapparate te bepaal; 3.2 die mann whitney u-wilcoxon rank sum w-toets (5% vlak van beduidenheid) is gebruik om te bepaal of daar 'n beduidende verskil tussen die resultate van die twee groepe is. theron, 1995; jacobs, et al., 1992 theron, 1995; jacobs, et al., 1992 4. om te bepaal of daar 'n korrelasie is tussen die bejaardes se subjektiewe evaluasie van hul gehoorprobleme en die objektiewe oudiologiese evaluering van hul perifere gehoorstatus. j 4.1 die kendall en spearman toetse is gebruik om te bepaal of daar 'n beduidende korrelasie tussen die resultate van die verskillende spesiale spraaktoetse is. theron, 1995; jacobs, et al., 1992 5. om te bepaal of daar 'n korrelasie is tussen die bejaardesjse subjektiewe evaluering van hul gehoorfunksionering en die objektiewe meting van hulle spraakdiskriminasievermoe. ] 5.1 die kendall en spearman toetse is gebruik om te bepaal of daar 'n beduidende korrelasie tussen die resultate van die verskillende spesiale spraaktoetse is. theron, 1995; jacobs, et al., 1992 tabel 4: opsomming van die verskillende toetsresultate gemiddelde maksimum prestasie, (%) fg-maksimum l r ssi-maksimum l r c-vsw l r monosillabiese woorde en 'n ipsi-kompeterende boodskap l r hhie(totaal) sonder met gehoorapparate groep 1 98,9 98,4 68,0 66,0 56,7 82,7 63,7 66,7 56,3 76,8 groep 2 91,5 91,5 27,7 22,6 36,1 58,3 48,3 48,5 50,9 65,2 • vir vergelykingsdoeleindes is die c-vsw-tellings omgeskakel na persentasie korrek en dit is gebaseer op die resultate van die kompeterende luistersituasies. • die hhie-prestasie is ook omgeskakel na die persentasie waarin geen probleme ondervind word nie en slegs die totale tellings word aangetoon. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 106 liza van wyk, isabel uys & maggi soer die linkerore en 48,5% vir die regterore. op die 5%-vlak van beduidenheid is groep 2 se prestasies vir beide ore beduidend swakker as die van groep 1 (linkerore: ρ = 0,0011; regterore: ρ = 0,0002). daar is egter nie 'n beduidende verskil tussen die prestasie van die linkeren regterore van elke groep afsonderlik nie (vir groep 1 is ρ = 0,1501; en vir groep 2 is ρ = 0,1378). groep 1 se waardes is hoer as 60% is en dui op geringe spraakdiskriminasieprobleme, terwyl groep 2 se resultate beduidend swakker as 60% is en dit dan op ernstige spraakdiskriminasieprobleme dui (p = 0,0353). 4. die bejaardes se subjektiewe evaluering van hul gehoorprobleme ten opsigte van die persentasie waarin die bejaardes geen probleme ondervind sonder en met gehoorapparate nie, behaal groep 1 onderskeidelik 56,3% en 76,8%. groep 2 behaal 50,9% sonder gehoorapparate en 65,2% met gehoorapparate. daar is dus 'n beduidende verskil tussen die resultate van elke groep, afsonderlik, sonder en met hul gehoorapparate. alle metings is uitgevoer op die 5%vlak van beduidenheid. ten opsigte van groep 1 se resultate is daar 'n beduidende verskil (p = 0,0015) op die totale prestasie met en sonder gehoorapparate! groep 1 se bejaardes is dus van mening dat die gebruik van gehoorapparate 'n beduidende bydrae lewer tot die kompensasie vir hul gehoorprobleme. ook ten opsigte van die emosionele(p = 0,0029) en die situasieveranderlikes (p = 0,0022) is daar 'n beduidende verskil sonder en met gehoorapparate. groep 2 se resultate dui ook daarop dat die bejaardes beduidend baat vind by die dra van gehoorapparate. net soos in die geval van groep 1 is daar 'n beduidende verskil tussen die prestasie sonder en met gehoorapparate vir die totale prestasie (p= 0,0010) en ook die metings van die emosionele(p = 0,0022) en situasieveranderlikes (p = 0,0010). op die 5%-vlak van beduidenheid is daar egter nie 'n beduidende verskil tussen die twee groepe se prestasie op die totale prestasie (p = 0,6331), die emosionele(p = 0,9834) en situasieveranderlikes (p = 0,2889) sonder gehoorapparate nie. die afleiding kan dus gemaak word dat beide groepe bejaardes se subjektiewe evaluasie van hul gehoorprobleem ooreenstem. ten opsigte van die evaluasie met hul gehoorapparate is daar nie 'n beduidende verskil op die totale prestasie (p = 0,1008) en die emosioneleveranderlikes (p = 0,3489) nie, maar daar is wel 'n beduidende verskil wat die situasieveranderlikes (p = 0,0201) aanbetref. groep 1 se resultate dui daarop dat hulle beduidend meer baat vind by die dra van gehoorapparate in verskillende luistersituasies as groep 2. hierdie resultate het belangrike implikasies vir die studie, aangesien dit die gebruik van objektiewe metings verder kan ondersteun. 5. die bejaardes se subjektiewe evalue* ring van hul gehoorprobleme teenoor die objektiewe meting van hul gehoorstatus en spraakdiskriminasievermoe resultate toon daar is 'n beduidende korrelasie tussen die ssi-toets en die aanbieding van die monosillabiese woorde en 'n ipsi-kompeterende boodskap (p = 0,000); tussen die vsw-toets en die aanbieding van die monosillabiese woorde en 'n ipsi-kompeterende boodskap (p = 0,031) en tussen die vswen ssi-toets (p = 0,000). die feit dat die toetsresultate korreleer, verhoog die toetsbetroubaarheid en -geldigheid van die studie. daar is verder 'n beduidende korrelasie tussen die bejaardes se subjektiewe evaluasie van hul gehoorprobleem en die objektiewe evaluasie van hul perifere gehoorstatus (p = 0,031). geen beduidende korrelasie bestaan egter tussen die bejaardes se evaluering van hul gehoorprobleme en hul spraakdiskriminasievermoe in verskillende luistersituasies nie. daar is geen beduidende korrelasie tussen die selfevaluasieskaal en die ssi-toets (p = 0,091); die vsw-toets (p = 0,934); en die aanbieding van die monosillabiese woorde met 'n ipsi-kompeterende boodskap (p = 0,2820) nie. geen beduidende korrelasie bestaan ook tussen die bejaardes se evaluering van die baat wat hulle vind by gehoorapparate en hul spraakdiskriminasievermoe in verskillende luistersituasies nie. daar is dus geen beduidende korrelasie tussen die prestasie met gehoorapparate en die ssi-toets (p = 0,839); die vsw-toets (p = 0,842) en die aanbieding van die monosillabiese woorde met 'n ipsi-kompeterende boodskap (p = 0,724) nie. bespreking bejaardes in groep 2 ervaar beduidend meer spraakdiskriminasieprobleme as die bejaardes in groep 1, ongeag die feit dat hulle suiwertoondrempels korreleer. hierdie resultate ondersteun die aanname dat spraakdiskriminasieprobleme 'n nie-perifere basis kan he en dus nie net verklaarbaar is op grond van suiwertoonresultate nie (marshall, 1981; rodriguez, et al., 1990). spesiale spraaktoetse is in hierdie studie gebruik om sentrale ouditiewe prosessering te ondersoek. die ssi-pi-funksie is swakker as die fg-pi-funksie (willeford, 1985). tydens die bepaling van die ssi-pifunksie het die "rollover-" fenomeen by sewe bejaardes van groep 2 voorgekom, terwyl hierdie fenomeen by slegs drie bejaardes voorgekom het tydens die bepaling van die fgpi-funksie. hierdie resultate kan aanduidend wees van aantasting van die ouditiewe senuwee of inperking ivan sentrale ouditiewe prosessering (kaplan, gladstorie & katz, 1984). j die tweede diagnostiese prosedure van die ssi-toets is om die ssi-ikben die ssi-kkb-resultate te vergelyk. met behulp van hierdie prosedure is dit moontlik om 'n sentrale letsel te identifiseer en is dit ook moontlik om te onderskei tussen breinstamletsels en temporale lobletsels (kaplan, et al., 1984). groep 2 het beduidend swakker gevaar as groep 1, maar albei groepe se resultate wyk ook af van die norme wat geld vir volwassenes (kaplan, et al., 1984). alhoewel geen bestaande norme beskikbaar is vir bejaardes nie, kan bestaande norme wel sinvol gebruik word om die bejaardes se resultate op 'n kwalitatiewe wyse te beskryf. afwykende resultate dui dus nie noodwendig op die spesifieke plek van letsel nie, maar kan wel aandui dat ouderdomsverwante veranderinge die funksie van die sentrale ouditiewe senuweesisteem negatief be'invloed (kaplan, et al,,1984; willeford, 1985). verder kom groter ikb-afwykings as kkb-afwykings by beide groepe voor (kaplan, et al., 1984). alhoewel hierdie resultate volgens die bestaande'norme op 'n moontlike breinstamletsel kan dui, kan hierdie afleiding nie noodwendig vir die bejaarde populasie gemaak word nie, the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kdiskriminasie by bejaarde gehoorapparaatgebruikers 107 v a n w e e die kompleksiteit van hul gehoorprobleme. afleidings kan wel gemaak word dat ouderdomsverwante v e r a n d e r i n g e wat voorkom in die sentrale ouditiewe s i s t e e m aanleiding kan gee tot die spesifieke uitvalle soos g e m e e t op hierdie toets by die bejaarde populasie (willott, 1991). die kwalitatiewe ontleding van die vsw-toetsresultate dui daarop dat bejaardes in beide groepe, meer probleme o n d e r v i n d in die kompeterende (veral links-kompeterende) luistersituasies (lukas & genchur-lukas, 1985;). hierdie resultate bevestig probleme in sentrale ouditiewe prosessering, wat onder andere manifesteer as geheue-, lees-, spelen spraakdiskriminasieprobleme. die resultate dui verder daarop dat bejaardes nie almal in dieselfde mate probleme met hierdie toetsprosedure ondervind nie. bejaardes wat dus swakker presteer in hierdie toets, se aantasting van die sentrale senuweesisteem blyk meer uitgesproke te wees as die bejaardes wat minder probleme ondervind. tydens die aanbieding van monosillabiese woorde en 'n ipsi-kompeterende boodskap behaal groep 2 swakker resultate as groep 1. hierdie resultate kan ook moontlik toegeskryf word aan die ouderdomsverwante veranderinge in die sentrale ouditiewe senuweesisteem, maar ook aan die degradering van die ouditiewe boodskap deur die gelyktydige aanbieding van 'n ipsi-kompeterende boodskap (marshall, 1981). wanneer die ouditiewe sein gekompliseer word en boodskapoortolligheid afneem, ondervind bejaardes probleme met die prosessering van 'n ouditiewe boodskap (marshall, 1981). die verskil in resultate van die twee groepe dui ook moontlik daarop dat die plek van aantasting in die ouditiewe sisteem verskil en bevestig ook die groter betrokkenheid van die sentrale ouditiewe senuweesisteem by groep 2 (penrod, 1994; stach, 1994). die meting van 'n bejaarde se gehoorverlies is slegs een komponent van die totale intervensieproses (ventry & weinstein, 1982; taylor, 1993). gehoortoetse kan wel 'n gehoorverlies kwantifiseer en spraakdiskriminasieprobleme identifiseer, maar dit bied nie voldoende inligting om die effek van die gehoorverlies op die bejaarde se alledaagse funksionering te jbeskryf nie. deur gebruik te maak van die bejaardes se subjektiewe evaluasie van hul gehoorprobleme kan waardevolle data ingewin word vir intervensie (cox, 1996; ventjry & weinstein, 1982). deur gebruik te maak van selfevaluasieskale kan die oudioloog inligting verkry oor die bejaarde se selfpersepsie van sy gehoorgestremdheid, wat deur bepaalde persoonlike, houdingsen situasiefaktore bei'nvloed word (taylor, 1993). op die langtermyn is dit tog die bejaarde gehoorapparaatgebruiker self wat die sukses van die gehoorapparaatpassing beoordeel (cox, 1996). gevolgtrekkings en aanbevelings gesien in die lig van bogenoemde bespreking is dit duidelik dat die intervensie van bejaardes met gehoorprobleme veel meer behels as die evaluering van perifere gehoorstatus. hierdie populasie het unieke oudiologiese probleme en bepaalde behoeftes en in die lig hiervan kan die volgende gevolgtrekkings en aanbevelings geformuleer word: longitudinale navorsing kan gebruik word om die verloop van spraakdiskriminasieprobleme te monitor, en kan dus aanvullend tot die resultate van hierdie studie wees. alhoewel norms vir bejaardes nie beskikbaar is nie, beklemtoon hierdie navorsing die gebruik van spesiale spraaktoetse om spraakdiskriminasie ook in komplekse luistersituasie te evalueer. spesiale toetse moet dus gebruik word om die basiese toetsbattery aan te vul. die gebruik van selfevaluasieskale word sterk aanbeveel ten einde 'n holistiese beeld van bejaardes en bejaarde gehoorapparaatgebruikers se ouditiewe funksionering te verkry. die resultate van die selfevaluasieskale is aanvullend tot die objektiewe toetse wat gedoen word. deur gebruik te maak van hierdie skale word die suksesvolle intervensie van bejaardes verder verseker. resente navorsing fokus op die sogenaamde "collaborative" (samewerkende) benadering (kricos, 1997). hierdie rehabilitasieprogramme is nie net gerig op die seleksie en passing van gehoorapparate nie, maar fokus ook op ander probleemoplossingstrategiee, soos die aanvaarding van en aanpassing by gehoorverliese, die gebruik van alternatiewe luistersisteme, spraakleesopleiding en die aanleer van ander kommunikasiestrategiee ten einde te verseker dat bejaarde gehoorapparaatgebruikers effektief kan funksioneer in alledaagse luistersituasies (kricos, 1997). die resultate van hierdie studie kan ook aangewend word om die gehoorprobleme wat bejaardes ondervind, aan die familie van die bejaarde gehoorapparaatgebruiker te verduidelik. familielede het dikwels beperkte insig in die hantering van en kommunikasie met bejaarde gehoorapparaatgebruikers (kricos, 1997). deur ook opjeiding en inligting aan hierdie mense te verskaf kan die suksesvolle gebruik van gehoorapparate deur die bejaardes verder verhoog word (kricos, 1997). die insluiting van die meting van ouditief ontlokte potensiale kan ook in toekomstige navorsing gebruik word om die sentrale ouditiewe funksie van bejaardes te ondersoek (martin & cranford, 1989). resultate wat voorspruit uit sulke studies kan in verband gebring word met bestaande navor sings data en dus groter insig verskaf in die ouditiewe probleme van bejaardes. die gebruik van ouditief ontlokte potensiale, ten einde die sentrale ouditiewe funksie van bejaardes te evalueer, geniet tans beperkte aandag in suid-afrika en ook in die bestaande literatuur. bibliografie cohen, g. (1987). speech comprehension in the elderly: the effects of cognitive changes. british journal of audiology, 21, 221226. cox, r.m. (1996). the abbreviated profile of hearing aid benefit (aphab) administration and application. phonak fokus: news, ideas, high technology, acoustics, 21, 2-14. folstein, m.f., folstein, s.e. & mchugh, p.r. (1975). mini mental state examination: a practical method for grading the cognitive state of patients for the clinician. journal ofpsychian research, 12, 189-198. goodglass, h. & kaplan, e. (1983). the boston diagnostic aphasia examination. philadelphia: lea & febiger. hull, r.h. (1985). assisting the older client. in katz, j. (ed.), handbook of clinical audiology (3rd ed.). baltimore: williams & wilkins. humes, l.e. & roberts, l. (1990). speech-recognition difficulties of the hearing-impaired elderly: the contributions of audibility. journal of speech and hearing research, 33, 726735. jacobs, c.d., haasbroek, j.b. & theron, s.w. (1992). effektiewe navorsing: navorsingshandleiding vir tersiere opleidingsdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 108 liza van wyk, isabel uys & maggi soer inrigtings. universiteit van pretoria: pretoria. jerger, j., jerger, s., oliver, t. & pirozzolo, f. (1989). speech understanding in the elderly. ear and hearing, 10(2), 78-89. kaplan, h., gladstone, v.s. & katz, j. (1984). site of lesion testing: audiometric interpretation, vol ii. baltimore: university park press. kricos, p.b. (1997). audiologic rehabilitation for the elderly: a collaborative approach. the hearing journal, 50(2), 10-19. laubscher, a.m.u. & tesner, h.e.c. (1966). enkellettergrepige woordelyste in afrikaans. ongepubliseed. universiteit van pretoria. lemme, m.l. & hedberg, n.l. (1988). auditory linguistic processing. in lass, n.j., mcreynolds, l.v., northern, j.l. & yoder, d.e. (eds.), handbook of speech-language pathology and audiology. toronto: b.c. decker, inc. lukas, r.a. & genchur-lukas, j. (1985). spondaic word tests. in katz, j. (ed.), handbook of clinical audiology (3rd ed.). baltimore: williams & wilkins. margolis, r.h. & shanks, j.e. (1985). tympanometry. in katz, j.(ed.), handbook of clinical audiometry (3rd ed.). baltimore: williams & wilkins. marshall, l. (1981). auditory processing in aging listeners. journal of speech and hearing disorders, 46, 226-240. martin, d.r. & cranford, j.l. (1989). evoked potential evidence of reduced binaural processing in elderly persons. the hearing journal, 42(7), 18-23. muller, a.m.u. (1981). die afrikaanse sintetiese sinsidentifikasietoets. ongepubliseerd. oudiologie-afdeling: tygerberg hospitaal. penrod, j.p. (1994). speech threshold and recognition/ discrimination testing. in katz,j. (ed.), handbook of clinical audiology (4th ed.). baltimore: williams & wilkins. rodriguez, g.p., disarno, n.j. & hardiman, c.j. (1990). central auditory processing in normal-hearing elderly adults. audiology, 29, 85-92. rosenberg, p.e. (1978). case history: the first test. in katz, j. (ed.), handbook of clinical audiology (2nd ed.). baltimore: williams & wilkins. stach, b.a. (1994). hearing aids and older people. the hearing journal, 47(3), 10-42. suid-afrikaanse buro vir standaarde. (1994). guide to national and international acoustics, electro-acoustics, vibration and ultrasonics publications. pretoria. taylor, k.s. (1993). self-perceived and audiometric evaluations of hearing aid benefit in the elderly. ear and hearing, 14(6) 390-394. theron, s.w. (1995). persoonlike gesprekke. departement menslike hulpbronbestuur. universiteit van pretoria. van wyk, m.e. (1997). spraakdiskriminasie by bejaarde gehoorapparaatgebruikers. ongepubliseerde m.kommunikasiepatologie verhandeling, universiteit van pretoria: pretoria. ventry, i.r. & weinstein, b.e. (1982). the hearing handicap inventory for the elderly: a new tool. ear and hearing, 3(3), 128-134. willeford, j.a. (1985). sentence test of central auditory dysfunction. in katz, j.(ed.), handbook of clinical audiology (3rd ed.). baltimore: williams & wilkins. willott, j. f. (1991). aging and the auditory system: anatomy, physiology and psychophysics. san diego: singular publishing group, inc. working group on speech understanding and aging. (1988). speech understanding and aging. journal of the acoustical society of america, 3, 859-895. yantis, p.a. (1994). puretone air-conduction threshold testing. in katz, j. (ed.), handbook of clinical audiology (4th ed.). baltimore: williams & wilkins. the south african journal of communication disorders, vol. 44, 1997 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c s o c i e t y o c t o b e r editonal 'j'he first summer school held by the south african logopedic society in september was a pronounced success. the course dealt with "dysaudia," and there is no doubt that the bringing together of audiologists, teachers of the deaf, audiometrists, ear, nose and throat specialists, speech therapists, and others bore fruitful results in terms of discussion and exchange of ideas. although we are unable, through lack of space, to print, the summer school papers in this journal, roneoed copies will be made available to those members who attended the course and to others on application. we are fortunate, however, in having an article in this issue by one of the speakers at the summer school, dr. haynes. it is rare that one is able to present an article by an ear, nose and throat specialist who has also made an intensive study of audiometries. the paper "the relation between speech therapy and psychotherapy" by joan philips is .likely to provoke comment. it certainly seems necessary to clarify the limitations of the speech therapist a s far a s psychological treatment is concerned. in "speech recording in stuttering therapy" by erica stern, a beginning is made of potentially important research. it is hoped that miss stern and others will continue to work in this field to our mutual benefit. finally, it is our real privilege to have amongst our contributors dr. m. k. wright. a little while' a g o dr. wright expressed the rather revolutionary opinion that speech therapists should be in a position to teach the neurologists how to classify aphasia. the present article is a culmination of an idea first thought of in 1949. it is a great stride towards a sounder and more useful analysis of l a n g u a g e disorders. peter rothenberg electrical and industrial instruments manufacturers of instruments under the registered trade mark "pret,j industrial and electro surgical instrument repairs 98c mooi street, johannesburg box 3904 phone 23-0730 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society june itoria during the past few years, members of the medical and dental professions, teachers, psychologists, etc., and also the public in general, have come to recognise and accept logopedics as an important and necessary element of the modern society in which we live. however, the scope of logopedics is still very much in the dark. the general impression seems to be that speech therapists deal only with speech defects, per se. λ pressing need exists to establish the fact that logopedicians, although generally known as "speech" therapists, are interested in and also in a position to treat patients with other problems. in this issue of the journal, articles indicative of the wide scope of logopedics, are presented, for example, reading difficulties, and also problems of language development in a brain-injured child, both of which, although not directly concerned with "speech" defects, nevertheless are within the speech therapist's realm, as they have as their basic essence, the factor of communication. finally, an article on recent research work done in the field of voice science is a further indication that the field of logopedics is wide and varied, and that the interest of speech therapists is not limited only to the more obvious speech defects. 54 wingate mansions cor smit & nugget streets, hospital hill, j o h a n n e s b u r g phone 44*0860 tpying and roneoing undertaken especially theses and students' notes. bessie dembo r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pg48-55.html communication after mild  traumatic brain injury – a spouse’s perspective samantha jayne crewe-brown alexandra maria stipinovich ursula zsilavecz department of communication pathology, university of pretoria correspondence to: a m stipinovich (alex_stipinovich@telkomsa.net) abstract individuals with mild traumatic brain injury (mtbi) often perform within normal limits on linguistic and cognitive assessments. however, they may present with debilitating communicative difficulties in daily life. a multifaceted approach to mtbi with a focus on everyday communication in natural settings is required. significant others who interact with the individual with mtbi in a variety of settings may be sensitive to communicative difficulties experienced by the individual with mtbi. this article examines communication after mtbi from the perspective of the spouse. a case study design was implemented. the spouses of two individuals with mtbi served as the participants for this study. semi-structured interviews were held, during which each participant was requested to describe the communication of their spouse with mtbi. the content obtained from the interviews was subjected to a discourse analysis. the results show that both participants perceived changes in the communication of their spouse following the mtbi. the results further show that mtbi affected communication of the two individuals in different ways. the value of a ‘significant other’ in providing information regarding communication in natural settings is highlighted. the implications of these findings for the assessment and management of the communication difficulties associated with mtbi are discussed. keywords: mild traumatic brain injury, spouse’s perceptions, communicative competence, discourse analysis, social interaction mild traumatic brain injury (mtbi) is said to account for the majority of patients admitted to hospital with brain injuries (cassidy et al., 2004), representing the greater population of all treated traumatic brain injuries worldwide (tay, ang, lau, meyyappan & collinson, 2010). to date, the majority of research in the area of traumatic brain injury (tbi) has focused on severe tbi (king, hough, walker, rastatter & holbert, 2006b). despite an increased awareness of mtbi, this therefore is the least understood form of brain injury (king et al., 2006b). the majority of behavioural research in the field of mtbi to date has been neuropsychologically based (duff, proctor & haley, 2002) with the impact of mtbi on communicative competence remaining largely unknown (whelan, murdoch & bellamy, 2007). mtbi is associated with a constellation of symptoms, including physical, cognitive, emotional and behavioural symptoms, that vary in terms of degree and rate of recovery after injury (tay et al., 2010). the cluster of symptoms following mtbi has been coined the post-concussive syndrome (pcs) (alexander, 1995) and has been reported in up to 50% of individuals who sustained an mtbi (satz et al., 1999). the majority of individuals who sustain an mtbi show spontaneous and complete post-injury recovery within a few weeks to a few months. however, some continue to present with symptoms after this time, with approximately 15% of these individuals complaining of disabling symptoms for as long as 1 year after sustaining their injury (alexander, 1995; duff et al., 2002). the most common symptoms encountered after mtbi may be grouped into three categories: (i) cognitive complaints (including difficulties with memory, attention and concentration); (ii) somatic complaints (including headache, fatigue and sensitivity to noise or light); and (iii) affective complaints (including depression, irritability and anxiety) (mcallister & arciniegas, 2002). as stated above, the majority of behavioural research in this field has been neuropsychologically based (duff et al., 2002). neuropsychological sequelae of mtbi have been found to include difficulties with reasoning, information processing, verbal memory and attention to detail, as well as slowed reaction time and reduced error recognition (kwok, lee, leung & poon, 2008; leininger, gramling, farrell, kreutzer & peck, 1990; voller et al., 1999). the frontal lobes of the brain are vulnerable to injury in tbi (mcdonald, flashman & saykin, 2002). given the role that these frontal regions play in the executive functions of regulating and organising behaviour, impulse control, self-monitoring, planning and reasoning skills, even individuals with mtbi demonstrate a strong tendency to exhibit executive dysfunction (mcdonald et al., 2002). impairment in executive abilities may have wide-ranging effects on an individual’s ability to function effectively in daily life and can impair job performance, activities of daily living and interpersonal relationships (mcdonald et al., 2002). furthermore, effective communication is reliant on cognitive skills, including attention, memory, word-retrieval ability, the formulation of thoughts, complex information processing and executive functioning (green, stevens & wolfe, 1997). even when the medical categorisation is ‘mild’, the effects of the brain injury may therefore have a severe effect on the person’s ability to communicate effectively (king et al., 2006b). barrow et al. (2003) warn that current methods of language testing might not provide sufficient cognitive load to expose the subtle difficulties that affect the functional performance abilities of individuals with mtbi. as a result, the identification of individuals with mtbi who might benefit from speech-language therapy remains tenuous. king et al. (2006b) agree, stating that testing procedures must incorporate tasks that are sensitive to the affected skills of individuals with mtbi. the administration of tasks of higher-order linguistic function demanding frontal lobe support has provided better insight into the language disorders associated with tbi (whelan et al., 2007). such tasks include reaction time measures examining speed and accuracy of naming, tasks requiring the organisation of substantial quantities of information, the processing of abstract language and the filtering out of environmental interference (barrow et al., 2003; king et al., 2006b; mathias, beall & bigler, 2004; whelan et al., 2007). recent research by whelan et al. (2007) aimed to profile the language abilities of an individual with mtbi using tasks hypothesised to demand frontal lobe support. difficulties were found in activities requiring complex lexical-semantic operations such as sentence construction, multiple definition formulation, absurdity detection or correction and passive/temporal structure completion (whelan et al., 2007). in addition, research by barrow et al. (2003), king, hough, vos, walker & givens (2006a) and king et al. (2006b) revealed compromised speed of word retrieval in individuals with mtbi during time-pressurised conditions. however, in contrast to the finding of word-retrieval deficits during confrontation naming, king et al. (2006b) found no significant deficits with regard to word retrieval in the discourse of participants with mtbi. they concluded that the increased cognitive load imposed by the speeded task of confrontation naming may have resulted in greater error occurrence than the discourse task did. daily work and home activities routinely involve time-pressured situations and multilevel processing (barrow et al., 2003). this may explain why individuals with mtbi who perform within normal limits on standard linguistic and cognitive assessments often present with debilitating difficulties in communicative and cognitive activities of daily life (kim et al., 2009; mcdonald et al., 2002). according to whelan et al. (2007), the real-life consequences of subtle cognitive-linguistic impairments after mtbi remain largely unexplored. the field of pragmatics is concerned with the communicative consequences of various cognitive and linguistic deficits on interaction (prutting & kirchner, 1987). pragmatic aspects of language are closely linked to judgements of a perceived level of social competence. social competence requires a complex repertoire of behaviours, including the integration of one’s knowledge of the world with cognitive, social, behavioural, psychological and linguistic processes (hartley, 1995). as communication involves the interaction of the individual with his/her environment, the environment in which communicative functions occur is considered a major determinant of communicative behaviour. for this reason, communication assessment and rehabilitation requires a multifaceted approach including a focus on everyday communication in natural settings (galski, tompkins & johnston, 1998; snow & ponsford, 1995). functional rating scales designed to determine the effect of deficits upon communicative activities and life participation are available. the pragmatic protocol (prutting & kirchner, 1987), for example, is a descriptive taxonomy designed to provide an overall communicative index for school-aged children, adolescents and adults. it consists of 30 pragmatic aspects of language and is completed by the clinician after observing 15 minutes of unstructured, spontaneous interaction between communication partners in a natural setting. according to lomas et al. (1989), the likelihood that clinician-assessors observe patients in true daily-living situations is slim. for this reason, rating scales that are reliant on reports made after direct observations by a significant other who spends substantial time with the client in a variety of settings are also available. the communicative effectiveness index (ceti) (lomas et al., 1989) is a functional communication measure for aphasia that gives the clinician first-hand evidence on the communicative performance of the individual with aphasia as observed by a significant other. this scale has also been found to provide a valuable measure of change in functional communication ability (lomas et al., 1989). a possible disadvantage to using a rating scale to examine communicative competence from the perspective of a family member, however, is that views are directly addressed as opposed to being carefully elicited. this may prevent unexpected and possibly valuable information from being disclosed. an alternative approach to gaining understanding of an individual within his/her environment is that of discourse analysis (da). da is a qualitative approach to the measurement of individuals’ perceptions (vyncke, 2000). in this approach, the content of the discourse obtained during a semi-structured interview is examined. as an individual’s choice of words to convey perceptions and experiences gives rise to individual versions of reality (willig, 1999), da provides valuable insight into an individual’s experience and interpretation of the topic discussed. in this study, da was used to examine the perceptions and experiences of spouses regarding the communication of two individuals with mtbi. in so doing, information regarding the impact of mtbi on communication in natural settings was obtained. method aim the aim of the study was to describe the communication of two individuals with mtbi from the perspective of the spouse. research design a case study design was selected within the framework of qualitative research. case studies aim to analyse a situation precisely and in detail in order to provide insight into the phenomenon being investigated (titscher, meyer, wodak & vetter, 2000). in this study, information was obtained from two participants through semi-structured interviews, the content of which was subjected to da. participant selection criteria the participants in this study were the spouses of two individuals with mtbi. trauma has been found to have different effects on individuals with differing kinship relationships (kreutzer, gervasio & camplair, 1994a; leach, frank, bouman & farmer, 1994). a common methodological limitation of previous research into family functioning after tbi is that data from relatives with different kinship relations are often combined (kreutzer, gervasio & camplair, 1994b). in this study, the perceptions regarding the communication of the two individuals with mtbi were therefore confined to the perceptions of the spouse. the participants were to be proficient in either english or afrikaans. they should have been living with their spouses for a minimum period of 1 year before the mtbi, ensuring familiarity with their spouse’s pre-morbid communication abilities. participants were to be residing with the individual with mtbi at the time of the interviews. a description of the participants (referred to as p1 and p2) is included in table i. selection and description of the individuals with mtbi two individuals with mtbi were selected according to the delineation of mtbi provided by the american congress of rehabilitation medicine (acrm) (1993). the individuals selected were therefore to have sustained traumatically induced physiological disruption of brain function, manifested by at least one of the following: loss of consciousness (loc) for up to 30 minutes; any loss of memory regarding events immediately before or after the accident; any alteration in mental state at the time of the accident; and focal neurological deficit(s) that may or may not have been transient. post-traumatic amnesia (pta) was not to have exceeded 24 hours after 30 minutes and the initial glasgow coma scale (gcs) score was required to have been 13 15, 30 minutes after the injury was sustained. the majority of individuals with mtbi show complete recovery of their symptoms within 1 3 months after injury (levin et al., 1987, in alexander, 1995). however, some exhibit persisting difficulties beyond 3 months after injury (e.g. alexander, 1995; kwok et al., 2008; leininger et al., 1990). a further selection criterion was therefore a post-injury interval of 3 months or longer to ensure that any change in communication associated with the injury would have stabilised and become part of the person’s communicative repertoire. as stated above, the individuals with mtbi were required to have been living with their spouses (the participants) for a year prior to the injury, and since the injury. the individuals with mtbi were selected by means of purposive sampling (strydom, 2005). patient records from a private hospital as well as patient records from the private practice of a neurologist were examined for individuals who met the selection criteria. information pertaining to duration of loc and duration of pta was not indicated in the hospital records. individuals were therefore initially selected based on the gcs score alone. information pertaining to loc and pta was obtained from the spouse. a description of the individuals with mtbi (referred to as mtbi1 and mtbi2) is provided in table ii. the spouse of mtbi1 is p1 and the spouse of mtbi2 is p2. as indicated in table ii, mtbi1 sustained a frontal lobe haemorrhage due to the injury. individuals with mtbi whose initial injuries include complications such as depressed skull fractures, contusions and subdural or epidural haematomas are more likely to have persistent cognitive deficits. however, the majority of such patients experience resolution of these symptoms, even if only after some delay (mcallister & arciniegas, 2002). mtbi1 was included in this study because his gcs score remained within the limits posited for the classification of mtbi, and he had sustained his injury 6 months prior to the interview. according to p1 and p2, loc was less than 30 minutes. according to mtbi1’s spouse (p1), mtbi1 presented with notable word-finding difficulties in the first week after the accident. however, she stated that he was orientated to place and person and that he was aware that he had been in an accident. research ethics the research was granted ethical clearance by the research proposal and ethics committee of the faculty of humanities, university of pretoria. the individuals with mtbi and their spouses were provided with a verbal and written explanation of the nature and purpose of the study, and gave written consent confirming their voluntary participation in the study. those who agreed to participate were assured of confidentiality at all times during the study. the participants were also free to withdraw from the study at any time. material and equipment for data collection a semi-structured interview was used to obtain the required data, which were then subjected to a da. da, as defined by willig (1999, p. 2) is concerned with, among other things, ‘the ways in which language constructs experiences …’. people use their discourse to construct versions of their social world (potter & wetherell, 1987). to adequately allow the participants to construct the individual versions of their social worlds, the interview attempted to create a ‘conversation encounter’, placing equal importance on the interviewee’s answers and the researcher’s questions (potter & wetherell, 1987, p.165). the researcher provided only two topic-introducing requests, attempting to guide the conversation rather than prescribe neutral and passive questions as in the case of a traditional interview (potter & wetherell, 1987). following the topic-introducing requests, the researcher proceeded with follow-up questions (e.g. ‘is that all?’), probing questions (e.g. ‘ok, tell me a little more about that’), specifying questions (e.g. ‘and how did you handle that?’), direct questions (e.g. ‘and for how long did that continue?’) and interpreting questions (e.g. ‘is that what you mean by …?’), so as to adequately understand the participants’ answers (kvale, 1996). the following two topic-introducing requests were presented within the interview: • request 1: ‘what do you think communication entails?’ communication is a multifaceted commodity encompassing non-verbal and verbal behaviour. individuals may differ in their judgements regarding appropriateness of social behaviour. cultural background, for example, shapes values, belief and stereotypes, and influences how individuals react with others (hartley, 1995). judgements made by the spouses regarding the communication of the individual with mtbi were likely to be made within the framework of their understanding of communication. by asking this question, attempts were made to obtain an idea of what communication meant for each participant and therefore what would be important for them with regard to their spouse’s communication. • request 2: ‘tell me about your spouse’s communication.’ in phrasing this request, no reference was made to communication difficulties. in this way, participants were free to comment on either positive or negative aspects of their spouse’s communication. no time frame in relation to the mtbi was specified in request 2. the omission of a time frame gave the participants the freedom to highlight or foreground any information pertaining to their spouse’s communication, within the context of their subjective understanding of communication that they felt was relevant at the time of the interview. as the participants were familiar with the individual with mtbi both before and after the accident, it was hoped that any changes that they may have noted in their spouse’s communication and which they ascribed to the mtbi would be spontaneously presented. where necessary, the follow-up, probing, specifying, direct or interpreting questions described above were asked in relation to the mtbi for the purpose of clarifying the participants’ responses. the conversations were recorded using an aiwa tp-510 cassette recorder and a hitachi vm e53e audiovisual cassette recorder for later analysis. procedure pilot study a pilot study was conducted to determine the clarity of the proposed topic-introducing requests, the adequacy of the recording equipment, and the time it would take to set up and conduct the interview. the selection criteria stipulated for the main study were used to select a single participant for the pilot study. the two requests posed were found to be understood by the participant. no changes to the questions or data collection and analysis procedures were therefore necessary. data collection procedure the interviews took place in the participant’s home or place of work. recording equipment was set up as unobtrusively as possible. the individual with mtbi was not present during the recording. the interviews ranged from 30 minutes to 1 hour in length. after completion of the interviews, the researcher analysed the discourse into themes according to the guidelines provided by potter and wetherell (1987) and wetherell, taylor and yates (2001). four weeks after the initial interviews, the participants were re-interviewed by the researcher to ensure that the data collected during the interviews had been interpreted correctly. the re-interview gave the participants opportunity to comment on the researcher’s interpretations (kvale, 1996). in this way, trustworthiness of the results was enhanced (de vos, 2002; lincoln & guba, 1985). data recording procedure the data (discourse) from the tape and audiovisual cassettes were transcribed in standard orthography in the relevant language so that the discourse could be easily analysed. data analysis procedure the content obtained during the interview was subjected to a da to obtain a qualitative description of the participant’s perceptions of the spouse with mtbi’s communication. da examines the content of the conversation, rather than aspects of structural organisation (jaworski & coupland, 1999). da therefore examines and interprets the meaning behind what is being said in the conversation. the transcription of the interview marks the start of the analysis process. the interviews were transcribed using standard english or afrikaans orthography. the discourse was read carefully by the researcher, as well as by a second professional with experience in da, thereby ensuring confirmability and trustworthiness (de vos, 2002; lincoln & guba, 1985). after reading the transcript repeatedly, the researcher recorded recurring images, words and issues next to the text in the first draft. the words and images used in the discourse were carefully studied and placed into categories based on similarities between them. themes were then identified within these categories according to the frequency with which they occurred, the information that followed regarding those themes, and the amount of discourse that was linked to each particular theme. patterns that occurred within themes were identified and viewed as sub-themes within the main theme. trustworthiness lincoln and guba (1985, p. 290) refer to the ‘truth value’ (or trustworthiness) of qualitative studies. measures implemented in this study to ensure trustworthiness included credibility, transferability, dependability and confirmability. credibility refers to the accuracy with which the participants are represented and described (lincoln & guba, 1985). to ensure credibility, the individuals with mtbi were selected according to the criteria provided by the acrm (1993). the individuals with mtbi, their spouses and the data collection and analysis procedures are described in detail. the semi-structured interviews were conducted in the participants’ first language to facilitate accurate expression and their responses recorded so that they could be transcribed word-for-word. transferability refers to the applicability of the findings to another context or group of people (lincoln & guba, 1985). the purpose of this study was not to generalise the findings to all individuals with mtbi. multiple variables influence the communication interaction of individuals, including those with mtbi. however, the analysis of communication following mtbi in natural settings is hoped to have relevance to other individuals with mtbi. dependability refers to whether or not the findings would be consistent if the enquiry were replicated (lincoln & guba, 1985). dependability was ensured by implementing a pilot study. furthermore, a follow-up interview was held with the participants to provide them with the opportunity to confirm the data and interpretations thereof. confirmability, also referred to as neutrality (de vos, 2002), emphasises the importance of the findings reflecting the questions posed by the study and the participants’ responses, rather than the researcher’s biases or prejudices. confirmability was facilitated by providing the opportunity for the participants to define communication. this definition, in turn, formed the context in which their description of the communication of the individuals with mtbi was interpreted. secondly, the omission of a time frame or reference to communication difficulties in the second topic-introducing question of the semi-structured interview ensured that their responses were in no way influenced by the researchers’ bias that mtbi may impact on communication. opportunity for the participants to confirm the data and the interpretations thereof was facilitated by the implementation of a second interview. a second observer assisted in the interpretation of the data, thereby strengthening confirmability. results and discussion participant 1 when asked for her view on what communication entails, p1 referred to communication as involving the verbal expression of one’s feelings: ‘... to express yourself ...’ ‘... to tell someone how you’re feeling ...’ p1 also recognised non-verbal components such as body language and facial expression: ‘... like they say “body language”...’ ‘... like how your body can talk and your facial expressions can also be part of communication ...’ p1 further emphasised communication for the purpose of interaction within the context of a relationship: ‘... you want to communicate with someone ...’ ‘... to tell someone how you’re feeling ...’ in summary, p1’s view of communication involved both verbal and non-verbal expression (including expression of emotions) within the context of a relationship. any changes in mtbi1’s communication that impacted on his verbal and non-verbal communication, or any changes in his communication that affected their relationship, were therefore likely to be noted by p1. when asked to describe mtbi1’s communication, p1 commenced by stating that he communicates well. she also mentioned that he is well liked and that he is an extrovert. however, throughout the interview process it became clear that she had noted numerous changes in his communication since the mtbi. three themes were identified in the da of p1’s description of mtbi1’s communication, namely loss of temper, word-retrieval difficulties and role change. loss of temper p1 stated that mtbi1 communicates well, but that he loses his temper more frequently since the accident: ‘no, he communicates well. it’s just that his temper ... he sometimes is a little short-tempered with the children ...’ ‘yes, he ... it’s [mtbi1’s temper] a lot shorter than it was before the accident.’ ‘... it’s just that he loses his temper extremely quickly ...’ the communicative consequence of feelings of anger or irritability may be loss of temper. loss of temper is therefore considered a form of communication. as p1 considered communication to entail the expression of emotions, any changes in mtbi1’s expression of emotions were likely to be noted by p1. according to p1, mtbi1’s loss of temper affected his ability to communicate and interact effectively with his family. his loss of temper appears to have affected p1’s relationship with him as well as his relationship with their children: ‘we fight a little more.’ ‘he sometimes becomes quite ugly with them.’ [the children] communication-related personality and psychosocial change has been found to profoundly influence an individual’s integration back into the family system (ylvisaker, szekeres & feeney, 2001). irritability and associated loss of temper is a common symptom in the first 3 months after mtbi, usually resolving thereafter (acrm, 1993). mtbi1’s loss of temper has persisted beyond 3 months. as stated, mtbi1 sustained a frontal haemorrhage. individuals with mtbi whose initial injuries include complications such as haemorrhage may be more likely to have persistent deficits (mcallister & arciniegas, 2002). emotional control requires a certain level of arousal. the reticular activating system (ras) influences the arousal level of the brain. the ras is sensitive to axonal damage owing to its multiple projections. decrements in arousal are therefore frequently associated with tbi, resulting in decreased cortical activation necessary for behavioural control. this, in turn, may result in irritability, poor frustration control and increased anger or rage (hartley, 1995). p1 mentioned factors that appear to trigger or contribute to mtbi1’s loss of temper. these include the use of alcohol, his children and his word-finding difficulties: ‘… if he has any alcohol in him then he gets angry, which wasn’t really the case before the accident.’ ‘if the children are here for just an hour or two he will “go off” at one of them …’ ‘… then he will give her a harder hiding than he ought to, or about something silly that doesn’t actually justify a hiding.’ ‘he basically gets angry if you don’t immediately know what he’s talking about.’ the ras, and therefore the brain’s arousal state, is influenced by stressors (including alcohol and anxiety). according to alexander (1995) individuals with mtbi have reported increased sensitivity to modest alcohol use. symptoms of pcs have been found to increase when individuals with mtbi are placed under stressful conditions (hanna-pladdy, berry, bennett, phillips & gouvier, 2001), resulting in inappropriate communication in stressful situations (ylvisaker et al., 2001). the environmental factors (children and alcohol) that are now considered by p1 to contribute to mtbi1’s loss of temper were present before his accident. it is possible that, since the mtbi, mtbi1’s cortical activation required for behavioural control in the presence of such stressors has been affected. mtbi1’s loss of temper may also be associated with executive dysfunction. the executive control centre is the point of integration of internal and external stimuli (hartley, 1995). executive functions within the control centre influence deliberate cognitive, social, academic, vocational and communicative behaviours (ylvisaker & feeney, 1998). executive dysfunction is a common consequence of mtbi owing to the high incidence of damage to the frontal lobes of the brain (kim et al. 2009). mtbi1 sustained a frontal haemorrhage. the possibility therefore exists that he sustained injury to his executive control centre, resulting in the excessive display of emotions, evident in his loss of temper. of significance in p1’s description of mtbi1’s loss of temper were her comments that he is remorseful once he has lost his temper with his children and that he does not exhibit this behaviour towards other people: ‘he says he often feels sorry right away … then he will say sorry, and then he feels very bad about it.’ ‘and he also won’t easily become aggressive with other people.’ mtbi1 therefore appears to possess some insight into his behaviour as well as the ability to perceive situations, to integrate these perceptions with stored knowledge, to determine a possible course of action and then to monitor his behavior in certain situations. these are all functions of the executive control centre (hartley, 1995). however, in the presence of stressors (such as alcohol or his children), he appears less able to exert control over his behaviour. mtbi1’s ability to exert control over or adapt his communication interaction to suit certain contexts and certain communication partners supports the notion that social competence cannot be interpreted unless communication and context are treated simultaneously (prutting, 1982). this, in turn has implications for the assessment of mtbi1’s communication and the identification of his loss of temper by a clinician. unless the clinician observes mtbi1 in the presence of the environmental stressors discussed above, the communicative consequence of irritability, manifested as loss of temper, may go undetected. the value of obtaining the subjective perceptions and reports of a significant other who spends time with the individual with mtbi in a variety of personally relevant settings is thus illustrated. word-retrieval difficulties in addition to mtbi1’s more frequent loss of temper, p1 reported that he experiences word-retrieval difficulties: ‘… and he sometimes forgets certain words, like when a person gets older… stupid little words, then he’ll, he won’t be able to get to the word. i’ve actually noticed that since the accident.’ ‘yes, it [word-retrieval difficulty] happens regularly. it actually happens a lot. it’s as if he can’t place the word, or remember the thing’s name.’ ‘... he searches for the word and then after a little while he’ll say, “man, there it is.” after two or three minutes the word will come.’ as p1 emphasised the importance of the verbal expression of how one feels in her definition of communication, it was likely that she would be sensitive to any change in mtbi1’s verbal communication. p1 further stated that the frustration experienced by mtbi1 when unable to express himself owing to these word-finding difficulties aggravated his loss of temper: ‘no, he becomes angry with himself. he can’t handle it [word-retrieval difficulty]. he doesn’t like it at all.’ ‘… he basically gets angry if you don’t immediately know what he is talking about.’ as word retrieval is a basic process in communication, a deficit in this area may significantly impact on an individual’s overall communicative ability (king et al., 2006a). word-retrieval difficulties typically affect communication by slowing interaction and by increasing hesitations and pauses in discourse (hartley, 1995; ylvisaker et al., 2001). a number of studies have assessed word retrieval following mtbi (e.g. barrow et al., 2003; king et al., 2006a; king et al., 2006b). deficits in word retrieval were found to be associated primarily with increased time taken to retrieve words. these deficits were ascribed to centralised cognitive slowing and reduction in the supervisory function governing control, memory and initiation processes (barrow et al., 2003; king et al., 2006a; king et al., 2006b). as indicated by the quote above, p1 also indicated that with time mtbi1 is able to access the target word. king et al. (2006b) found that participants with mtbi exhibited no significant difference when compared with non-injured control participants regarding word retrieval during discourse tasks. a formal tool of word finding in discourse was used in the study by king et al. (2006b). it was argued that the cognitive load imposed by the discourse task was not sufficiently high to detect the subtle word-retrieval difficulties exhibited by the same participants during the confrontation naming task (king et al., 2006b). in contrast to these findings, word-retrieval difficulties during conversation were reported by p1. discourse that takes place during stressful work or home activities involving multilevel processing may constitute sufficient cognitive load to elicit word-retrieval difficulties. this, again, has implications for clinician-based assessments and highlights the value of obtaining reported observations of a significant other who interacts with the client in a variety of settings. role change in her definition of communication, p1 highlighted the importance of communication within a relationship. in her description of mtbi1’s communication, she indicated a change in their relationship since the accident, with her having to assume a parent role: ‘… after the accident i took the role of being a parent. like he was almost like one of the children.’ ‘so basically he’s now almost lost his role.’ communication is ongoing and cyclical. communication interactions or relationships evolve over time as the communicative behaviour of one individual interfaces with that of another within an ongoing situation (hartley, 1995). the range of physical, cognitive and behavioural difficulties exhibited by the injured individual may result in a loss of peer-based and reciprocal relationships, with the spouse often being forced to take on a parental role (kreutzer et al., 1994a). role change experienced by spouses of individuals who have sustained a tbi has been reported in the literature and is considered to be a reason for the increased stress, depression and anxiety experienced by the spouse (e.g. kreutzer et al., 1994a; leathem, heath & woolley, 1996). in summary, p1 reported changes in mtbi1’s communication since his accident. these changes included more frequent loss of temper, particularly in the presence of environmental factors including children and the use of alcohol. she also reported word-retrieval difficulties, as well as a change in roles with her having to assume the role of parent. valuable information regarding mtbi1’s communication was provided by p1 which might not have been obtained through the administration of formal tools in unnatural settings, or even through clinician-based observation. participant 2 when asked to describe her view of what communication entails, p2 placed emphasis on verbal expression: ‘for me talking stands above everything.’ p2 also made reference to communicative behaviour as reflecting one’s attitude: ‘... your attitude of how you behave and what you radiate as a person.’ like p1, p2 referred to communication within the context of relationships: ‘you must have good communication to build up a good relationship ...’ given p2’s views on communication, she was likely to be sensitive to any changes in mtbi2’s verbal expression, attitude and behaviour or the influence of these changes on his relationships. when asked to describe mtbi2’s communication, p2 stated that her husband likes to speak and that he likes to express his emotions: ‘he likes to talk. he likes to express his emotions, by talking and also by showing how he feels. he’s not someone who likes to keep things to himself.’ throughout the interview process, p2 made reference to numerous changes in mtbi2’s communication interaction since the accident. three themes were identified in the da of p2’s description of mtbi2’s communication, namely adynamia, memory loss and social withdrawal. adynamia according to p2, there was a change in mtbi2’s drive and motivation since the accident. she described this change in the following way: ‘he is still a perfectionist, but he’ll sometimes still say, “ag no, i don’t feel like doing that now.” that little spark that should be there is no longer there.’ ‘he doesn’t have that motivation.’ ‘the driving power is gone.’ ‘because he’d go and sit and sit still for hours and do nothing, but it didn’t bother him …’ ‘yes, and that’s not how he was. he was always busy, always kept busy.’ a lack of drive or motivation may not be considered by everyone to constitute a communication difficulty. however, in her description of what communication entails, p2 stated that communication represents one’s attitude and behaviour. therefore, any changes in mtbi2’s behaviour or attitude were likely to have been noticed by p2 and reported by her in her description of his communication. lack of motivation, as described by the term adynamia , often occurs in individuals who have been affected by tbi (hartley, 1995). the basal ganglia and their connections to the limbic system are regions in the brain that are involved in motivation. because of the likelihood of damage to the anterior and mesial temporal lobe (part of the limbic system) and to the basal ganglia, changes in motivation and emotional responses within subcortical and limbic input are common after tbi (hartley, 1995; ylvisaker et al., 2001). despite having sustained a mild brain injury, mtbi2 reportedly also exhibited changes in motivation. individuals with executive dysfunction may also exhibit adynamia (hartley, 1995). the frontal lobes modulate and regulate the expression of internal drives and affective states. depending on the nature of their injury, individuals with executive dysfunction may be unable to formulate and initiate goal-directed behaviour, to the point where expression of emotion or desire is lacking (hartley, 1995). as stated, executive dysfunction is a common consequence of mtbi and can have far-reaching effects on ability to function in daily life, on job performance, and on interpersonal relationships (kim et al., 2009; mcdonald, et al., 2002). in the case of p2, mtbi2’s loss of drive and motivation affected their relationship. she emphasised that mtbi2 has made progress with regard to his ability to start something and finish it. however, this change in her husband remained an adjustment for her: ‘ag, yes, it’s going a lot, he’s probably actually quite fine now to me, it was more the first year and a half was a bit, you could notice it [adynamia] easily … it was sometimes very frustrating.’ ‘but it’s sometimes just an adjustment for a person from how he was to what he was then.’ [after the accident] memory loss p2 reported a change in mtbi2’s memory since the mtbi: ‘yes, you know, with regard to memory, this is actually a thing he ... he genuinely always had a memory like an elephant, but i don’t know, these days you can tell him something and he will swear high and low that you didn’t tell him.’ ‘he still has blanks and at times there are things he cannot really remember.’ ‘yes, ag, things like places we’ve been to ... yes, small silly things that he generally would have remembered.’ residual memory problems in mtbi typically resolve after 3 months. however, impairment in retention can persist (levin, 1989). the effect of memory loss on communication includes slowed interaction, repetition in conversations and social breakdown (ylvisaker et al., 2001). although individuals with mtbi often score within normal limits on standard memory tests, close relatives frequently report considerable everyday memory problems (kim et al., 2009). this again supports the notion that information regarding the injured individual’s functioning in daily, natural settings is essential in the identification of difficulties that may go undetected on formal testing. memory difficulties in individuals with mtbi may be associated with medial temporal or diencephalic pathology (kim et al., 2009). however, individuals with injury to the frontal lobes may also exhibit disruptions in the memory process and of the functions that facilitate memory. this is because the executive control centre controls memory processes by generating strategies to enhance storage and retrieval of information (hartley, 1995). social withdrawal p2 described mtbi2 as having become withdrawn in the first 18 months following the mtbi, participating less in social interactions: ‘... with regard to his communication, he was withdrawn directly after the accident. he was quieter ...’ ‘yes, so he became a little more of an introvert ... and he didn’t speak much at that stage ...’ ‘it was frustrating at times because he had always spoken a lot and always said how he felt and what he was thinking and explained his reasoning ...’ the reasons for mtbi2’s reduced social interaction after his accident are unclear. this social withdrawal may be a consequence of his adynamia, or lack of motivation. motivation influences an individual’s attentional processes and thereby affects social interaction by either dampening or stimulating efforts at processing appropriate responses (prigatano, 1987). parker (1996) also reported that reduced motivation after tbi can impair efforts at social interest within individuals. in her definition of communication, p2 emphasised that in addition to verbal expression, behaviour also contributes to an individual’s communication. the possibility exists that mtbi2’s adynamia affected his behaviour, resulting in social withdrawal. in summary, when viewed from the perspective of p2, mtbi2’s communication interaction appears to have been affected by adynamia, memory loss and social withdrawal. p2 stated that there have been improvements with regard to mtbi2’s drive and motivation as well as his social interaction, and that these two aspects of his communication were most problematic in the months following the accident. his memory difficulties, however, appear to have persisted over the 3 years following his accident. table iii summarises the themes identified from p1 and p2’s perceptions of their spouses’ communication after mtbi. conclusion the results of this study show that the brain injury was perceived by both participants to have affected communication interaction of the individuals with mtbi. the results further show that the perceived effect of the injury on communication was not the same for each individual with mtbi. in certain cases, the communicative consequences of the mtbi (for example, the frequent loss of temper reported by p1) appeared to be the product of the interaction between the organic pathology and environmental factors. these findings are seen to have numerous implications for the field of speech-language pathology. firstly, the range of communicative difficulties reported by the participants in this study necessitates the involvement of the speech-language therapist (slt) in the assessment and management of communication of individuals with mtbi. individuals with mtbi usually return to work and are expected to perform at the same cognitive-communicative level as they did before their injury. the communicative demands placed on them are often higher than those placed on individuals with moderate or severe brain injuries. the slt has a role to play in educating hospital staff as well as family members, colleagues and employers of individuals with mtbi regarding possible consequences of mtbi that may result in communication problems. a second implication of this study pertains to the identification by the slt of communication difficulties in individuals with mtbi. the word-finding difficulties described by p1 and the memory difficulties reported by p2 might have been identified during the administration of standardised cognitive-linguistic assessment tools, provided that the cognitive load of the assessment tasks was high enough to expose subtle difficulties in these areas. however, the more frequent loss of temper reported by the one participant, for example, is considered a product of the interaction between the (mild) organic pathology and environmental factors. the need for contextually relevant assessment procedures that focus on communication in natural and personally relevant settings is highlighted. a third implication pertains to the management of communication difficulties associated with mtbi. in this study, information was obtained not only regarding communication of the individuals with mtbi, but also on the effect of these difficulties on interpersonal relationships and functioning within natural settings. this, in turn, has implications for the compilation of personally and contextually relevant management programmes by slts. furthermore, the complex nature of the difficulties reported necessitates the involvement of a team in the management of individuals with mtbi. the use of formal assessment procedures as well as functional rating scales is lacking in this study. inclusion of such procedures would have facilitated triangulation of the data. it is recommended that future research into the communication of individuals with mtbi in natural settings should include a greater number of participants as well as a broader range of 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(2001). communication disorders associated with traumatic brain injury. in r. chapey (ed.). language intervention strategies in aphasia and related neurogenic communication disorders (4th ed.). philadelphia: lippincott williams & wilkins. table i. description of participants p1 p2 gender female female primary language afrikaans afrikaans number of years of education 14 14 current occupation technologist landscaper occupation at time of spouse’s mtbi technologist landscaper number of children three none home environment house in residential area house in residential area table ii. description of individuals with mtbi mtbi1 (p1’s spouse) mtbi2 (p2’s spouse) date of injury 27 september 2003 24 february 2001 time since injury at time of first interview 6 months 3 years glasgow coma scale (gcs) score, according to hospital records 14/15 13/15 duration of loss of consciousness, according to spouse <30 minutes <30 minutes duration of post-traumatic amnesia, according to spouse orientated to place and person within 24 hours, but presented with notable word-finding difficulties for 4 5 days <24 hours number of years married to/living together with spouse 5.5 years 4 years primary language afrikaans afrikaans number of years of education 12 12 occupation prior to mtbi unemployed (previously a supervisor in a retail business) landscaper employed at the time of interview? no yes table iii. summary of the themes identified from the participants’ perspectives of communication after mtbi p1 p2 loss of temper adynamia word retrieval difficulties memory loss role change social withdrawal the syndrome of early infantile autism g . j. newstadt, m . b . , b . c h . (rand), d . p . m . (rand).* department of psychiatry & mental hygiene, university of the witwatersrand, johannesburg and department of psychiatry, johannesburg hospital . . . but it has been delayed till i am indifferent, and cannot enjoy it; till i am solitary and cannot impart it . . . dr. samuel johnson. psychosis in children is not common. although it had been recognized since the early 20th century, it was not until 1943 that kanner first described the condition known as early infantile autism. the reasons for this delayed recognition are implicit in the manifold changes which occur normally in the young child. young children may show wide variations in mobility, speech, mood and learning ability, and it is precisely these fluctuations which render differentiation from normality difficult. psychosis is a conflict between the ego, or self, and reality. it follows therefore that the psychotic child shows some aberration or withdrawal from reality. in his original paper, kanner felt that the condition was a specific form of childhood psychosis characterized by profound withdrawal and lack of contact from the very first years of life, an obsessional demand for sameness in the environment, a lack of communication in the use of language, and a preference for relationships with inanimate objects. today autism is regarded as a syndrome occurring in early childhood, usually before the second year of life, and is characterized by an apparent difficulty in family social relationships. it is possible to delineate a pure or nuclear form in which no evidence of brain damage is demonstrable, and a mixed form in which elements of other diagnosable conditions are present. a third or borderline group exists which contains children who show features of the autistic syndrome, without gross social withdrawals i.e. some dysphasias, agnosias and apraxias. prevalence. although no adequate epidemiological studies have yet been published, small surveys in the united kingdom have suggested that one or two children out of every three thousand births are affected. the incidence is 3 to 4 times higher in boys than in girls. it is rare, though possible, to find more than one autistic child in a family. clinical features according to mildred creak, the following nine points describe items of behaviour commonly seen in children showing autistic behaviour. * present address: department of psychiatry, albert einstein college of medicine, yeshiva university, bronx, new york, u.s.a.' journal of the south african logopedic society, vol. 12, no. 1 : september 1965 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e syndrome of early infantile autism 7 normal children can show any of the behaviour mentioned at some time in their lives. autistic children, however, show these patterns for years on end and to the exclusion of any other. the oddness of the autistic child is discernible all day and every day. 1. gross and sustained impairment of emotional relationships with people. this shows itself in: (a) the child's aloof and distant manner. the child behaves as though its fellow human beings did not exist, unless he is approached by people he likes. (b) persistent tendency to turn away from people or look past them when spoken to. (c) autistic children are never cuddly and never respond to being picked up. although parents may claim that they can "get through" to their autistic child, the children always lack outward signs of warmth towards people who do not know them. 2. self-examination. preoccupation with parts of his body (i.e. hands and feet) long after the baby stage, with a tendency to examine these objects as though they had appeared spontaneously, is commonly seen. 3. preoccupation with objects, or certain characteristics of them, without regard to their accepted function persisting long after the baby stage. this may be shown in one or more of the following ways: (a) collecting objects of all kinds to carry around and showing great anger if any one is lost. (b) great attachment to one special object such as a box, a piece of cloth etc., with distress if such an object is lost. (c) making lines and patterns with objects regardless of their real use. (d) tendency to examine objects in peculiar ways e.g. listening to, biting on, and scrutinizing from peculiar angles. (e) odd play with objects e.g. spinning them, flicking bits of string. 4. sustained resistance to change in the environment and a striving to maintain order or sameness. t h i s may show itself in one or more of the following: (a) great difficulty in changing routines and severe reactions to even minute changes. (b) resistance to learning new things. (c) great distress if familiar objects such as furniture are changed. 5. behaviour leading to suspicion of abnormalities of the special senses in the absence of any obvious physical cause. this may show itself in one or more of the following ways: (a) speech: i. no reaction to speech or voice. ii. positive attempts to get away from some noises which occasion distress. iii. apparent deafness. (b) vision: i. no reaction to things seen. ii. some interest in moving objects but little interest in stationary objects. t y d s k r i f v a n die suid-afrikaanse logopediese vereniging, vol. 12, nr. 1: september 1965 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 g. j. newstadt ' iii. positive attempts to get away from some objects seen, iv. apparent blindness or short-sightedness. (c) apparent indifference to pain or thermal changes. (d) willingness to taste unusual objects with or without food faddiness. 6. abnormalities of mood. these may show in one or more of the following ways: (a) outbursts of violent and prolonged rage and distress with screaming, tears, stamping, kicking, biting, etc., brought about by change of routine, a special fear, interference by others, or for no discernible reason at all. during these outbursts the child cannot be comforted even by someone he knows and loves. (b) periods of laughing and giggling, for which the reasons may be obscure. (c) lack of fear of real dangers. 7. speech disturbances. these may show in one or more of the following ways: (a) no speech at all, either from birth or it may have begun and been lost. (b) fragments of speech and contractions of words. (c) persistent simple speech as for a two year old. (d) reversal of pronouns e.g. "me" for "you", "he" instead of " i " . (e) parrot-like repetitions of words, phrases, sentences or even long poems and songs without regard to meaning. (f) frequent use of a special voice different from that of the normal one, sometimes with special peculiarities of pronunciation. (g) strange pedantic type of speech. in general the child has difficulty in communicating all but the simplest of his needs by means of speech. he may prefer to use gestures in order to show what he wants instead of asking. if these measures fail to achieve his goal, he may take people by the hand and lead them to the desired object.. 8. disturbances of movement and general activity. these may show in one or more of the following ways: (a) great overactivity, with or without sleep disturbances. (b) immobility. (c) special movements which may include rocking, head banging, jumping, twisting, flapping, writhing, spinning, facial grimacing, odd ways of walking, unusual movements of hands, repetition of the same movements, and extreme pleasure in bodily movement such as swinging, rocking, riding in cars, etc. 9. a background of serious retardation in which islets of normal, near normal or exceptional intellectual function may appear. this means that, on the whole, the child is well behind his age group in performance. unlike his normal counterpart of the same age, the autistic child requires his mother's supervision all or most of the time. in contrast to this extreme inadequacy he shows himself to be more than usually capable of performing certain tasks such as calculations, puzzles, singing and remembering music, reading and writing, memorizing long lists of dates and names, poems, odd facts, etc., even if oblivious of the meaning. journal of the south african logopedic society, vol. 12, no. 1: september 1965 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e syndrome of early infantile autism 9 aetiology there is no known illness or injury which automatically produces this behaviour and no one knows why various conditions should be accompanied by autism in some children and not in others. schools of thought in this state of uncertainty many theories tend to flourish, but two schools of thought may be delineated. firstly, there are those who believe the cause to be sociological, and secondly, there are those who believe that the primary cause is organic. it seems to the author that the two theories are not mutually exclusive, and it is probable that both views are correct; the organic or sociological factors expressing themselves to different degrees in individual cases. 1. psychodynamic and sociological. from the sociological viewpoint as typified by kanner and rank, autism is the mother's and/or parents' inability to create a warm emotional climate—the frigidaire atmosphere— which prevents the child's ego from developing its capacities for the externalization and taming of the drives. the result is, in rank's words, 'a fragmented ego'. the personality structure of these children represents fragments of various stages of development showing high achievement of some of the executive functions of the ego, while other manifestations of the ego or instinctual drives remain crippled or on a much lower level. other workers believe that early infantile autism represents a fixation at, or a regression to, the most primitive phase of extrauterine life, and the most conspicuous symptom is that the mother, as representative of the outside world, seems not to be perceived by the child. fundamental to the condition is a primary inability to distinguish between lifeless and living objects, as well as an inability to-distinguish the self from inanimate objects in the environment. parental attitudes are thought to be of some importance in the genesis of the condition. fathers of autistic children are described as often being highly intelligent with academic careers, but cold, detached, obsessional, and unable to form warm relationships. some workers have found that almost all such parents are grossly disturbed, inconsistent, hypochondriachal, pseudodelinquent, or even psychotic. in this regard goldfarb believes that the speech disturbance seen in these children, is largely determined by abnormal speech models seen in the parents. 2. genetic and constitutional factors. there is no factual evidence available to support the thesis that autism is an inherited condition, although the frequent occurrence of similar traits in the progenitors is suggestive of a hitherto unexplained hereditary element. this contrasts with adult schizophrenia in which simple genetic mechanisms are demonstrable. autism probably bears little relation to schizophrenia as seen in the adult. 3. physical causes. autism may be associated with definite organic diseases, but aside from these, current investigations suggest that hormonal, t y d s k r i f v a n die suid-afrikaanse logopediese vereniging, vol. 12, nr. 1: september 1965 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 g. j. newstadt biochemical, neurological and perceptual abnormalities may be of primary significance, and this field is presently being explored. the foregoing aetiological factors are not entirely convincing, but it must be borne in mind that methodological problems are aggrevated by the relative rarity of the syndrome, by varying therapies employed, and by adequate evaluation of the outcome, which is rendered difficult by the long period (years) required for follow up. differential diagnosis the diagnosis of autism often requires the expert services of a child psychiairist but florid cases are difficult to miss. however, the following conditions must be distinguished from autism. 1. mental subnormality. here there is usually uniform retardation in verbal and performance ability but some cases may show features of autism. unevenness of mental development so common in autistic children is rarely seen in defective children. 2. obsessional neurosis. in older children, severe obsessional neurosis or the rare condition of schizophrenia of the adult type may stimulate autism. 3. problems of deafness or aphasia. these can often prove difficult to exclude since autistic children rarely co-operate with objective testing procedures. careful observation by the parents can help to establish the diagnosis. deaf children are usually normal in other respects, although they may also show autistic behaviour, in which case there is little purpose in differentiating them from 'nuclear' autistic children. 4. conditions causing brain damage. brain damage, regardless of aetiology, may be associated with autistic behaviour, but signs of organicity such as spasticity, or epilepsy are usually associated. treatment at present, there is no treatment which can cure a child who shows autistic behaviour. it is therefore necessary to have realistic goals in therapy, without developing therapeutic nihilism. much can be done to help these children develop their potentialities, and compensate for their disabilities. the main aims in therapy are: (a) to modify general behaviour until the child is socially acceptable even if a little odd by ordinary standards. (b) to extend the range of motor and verbal abilities and to increase understanding of everyday life, so that the child learns to care/for himself. (c) to teach the child skills which will enable him to gain employment and earn a living in open, or, if necessary, sheltered employment. (d) to develop any special talents that the child may have, and to widen his knowledge, so that he can find interest in life. (e) to exploit his potential so as to make him an integral part of the community. medical advice should be sought as soon as possible after the diagnosis is suspected. therapy should naturally be directed towards the entire family. it journal of the south african logopedic society, vol 12, no. 1: september 1965 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e syndrome of early infantile autism 11 is important, however, that mothers should have some time to themselves, in view of the great burden placed upon them by such children. in the realm of speech therapy much can be done to correct and improve the child's powers of communication. vocalization should be encouraged and the therapist must be careful to use speech suitable for the child's level of understanding, so as not to discourage him. at the same time his understanding and vocabulary may be increased by the gradual introduction of new words and phrases whenever he shows some spark of interest. it may fall within the speech therapist's realm to help correct the distorted body image, commonly accompanying autism, and the familiarizing of the child with parts of its body may be essential. the child should, wherever possible, be maintained in its own hoirie, and institutionalization should be avoided. s u m m a r y the theoretical orientation, symptomatology, aetiology, and management of early infantile autism has been reviewed. the important role of psychiatrist, speech therapist and parents, in the therapy of this condition is stressed. it would seem that although the cure of autism can rarely be accomplished, early diagnosis and adequate therapy can produce improvement in many cases, and above all, prevent aggravation of the condition by a failure to understand it. opsomming die teoretiese orientasie, simptomatologie, etiologie en hantering van vroee, infantiele outisme word bespreek. die belangrike rol van die psigiater, spraakterapeut en ouers in die terapie by so 'n toestand word beklemtoon. alhoewel outisme selde genees kan word, kan vroegtydige diagnose en toereikende terapie tog verbetering in baie gevalle bewerkstellig en belangriker nog, verswakking van die toestand deur 'n gebrek aan begrip, uitskakel. references i. bender, l . (1947): childhood schizophrenia amer. j. orthopsychiat., 27, 68. 2 browne, i. (1965): problems of infantile autism in biochemical approaches to ' mental handicap in children london: ε & s livingstone & co. ltd. 3. creak, m . (1961): preliminary report of workshop on autistic children british medical journal, i i , 899. 4. creak, m. (1963): autistic children british journal of psychiatry, 109, 84. 5. creak, m. (1960-1961): report to the society for autistic children. 6. esman, a. h. (i960): childhood psychosis and childhood schizophrenia amer. j. orthopsychiat., 30, 391. 7 goldfarb, w., braunstein, d „ lorge, i. (1956): a study of speech patterns in a group of schizophrenic children amer. j. orthopsychiat, 30, 391. 8. goldfarb, w., braunstein, d., scholl, m. (1959): the speech of schizophrenic children amer. j. orthopsychiat., 29, 481. 9 mahler, m. s „ furer, m., settlage, c. f. severe emotional disturbances in childhood in american handbook of psychiatry new york: basic books. t y d s k r i f v a n die suid-afrikaanse logopediese vereniging, vol. 12, nr. 1: september 1965 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 g . j. newstadt 10. meyers, d., goldfarb, w. (1962): psychiatric appraisals of parents and siblings of schizophrenic children amer. j. psychiat., 118. 902. 11. rayner, e. w. (1963): childhood schizophrenia leach, 33, 130. 12. schulman, j. l . (1963): management of the child with early infantile autism amer. j. psychiat., 120, 250. 13. singer, μ . t . , wynne, l . c. (1963): differentiating characteristics of the parents of childhood schizophrenics, childhood neurotics and young adult schizophrenics amer. j. psychiat., 120, 234. 14. wing, l . autistic children london: national association for mental health. journal of the south african logopedic society, vol. 12, no. 1: september 1965 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society relationships between stammering and aphasia by marion fleming, f.c.s.t. although i have been a practising speech therapist for over 30 years, have had a wide variety of experience in treating stammerers of many ages and types, have read and studied as widely as possible in a busy professional life, i have never yet heard or read an explanation of the aetiology of stammering which is even remotely satisfying. it cannot be denied that no method of treatment has yet been found which is successful in every case, or even in more than a comparatively small percentage of cases. nevertheless, new theories are constantly put forward and each advocate claims to have discovered the treatment par excellence for this strange malady which has been known to exist for many centuries. the cause has been attributed to faulty breathing — the "cure," therefore, being breathing exercises, etc. the cause has been attributed to weakness of the tongue — the cure being intensive exercises or even, in the middle ages, surgical operation or the use of some mechanical device for supporting the tongue during speech. there have been psychological explanations by the dozen — emotional problems of the individual being blamed for the "conflict between the desire to speak and the desire to remain silent" (macdonald ladell) ( 1 ) . the speech difficulty has been attributed to a discrepancy between the rate of thought and the rate of utterance(2); to the lack of "complete maturation for highly-corticalized, one sided gradient for smooth verbal expression"*3*; to a difference in the speed of impulses sent out from the right and left hemisphere; and (taking a further step towards the neurological rather than the psychological explanations which have held the field for so long) to some slight undetected lesion in the central nervous system, probably in the region of the corpus striatum. cluttering has been defined as "a speech defect wherein excessive rapidity, slips of the tongue, iterations and indistinctness predominate" (a. moolenaar-bijl)(4). the confusion and the distinction between clutteriug and true stammering still, however, remains somewhat vague — leopold stein in treating of cluttering writes as follows: "the over-rapid speech and re-iteration bring to mind disturbances of speech caused by diseases of the mid-brain." he compares it to the type of speech which is "found in patients suffering from organic diseases of the striopallidar system (e.g. encephalitis lethargica, pseudobulbar palsy). occasional fits of weeping and outbursts of temper seem to support this assumption. the impairment of the co-ordination between mentation and verbalisation is the distinctive feature of some types of aphasia."(5) in another chapter he makes the following statement: "numerous investigations of the stammerer's constitution which are, however, not yet sufficiently complete, emphasize the striking frequency of signs relating to an inferiority of the lower brain centres (strio-pallidum, thalamus, hypothalamus) and the vegetative nervous system."(8) these opinions intensify rather than reduce, the confusion which prevents a clear-cut division between cluttering and stammering. the distinctions made by freund and quoted by stein in his book are as in figure i. in the opinion of the writer, many of these statements are only valid in a limited number of cases and cannot be taken as a general guide. what does emerge is that whatever the underlying organic condition may be, the resultant disorder is intellectual in nature. it is in the formulation of thought that the fundamental imperfection is found. consequently the most satisfactory explanation of stammering would seem to be that which was propounded by c. s. bluemel, namely that hesitation in speech is due to a corresponding hesitation in thought. his particular method of treatment is not one which would appeal to every speech therapist nor be likely to succeed with every stammerer — there are too many other complications to be considered in relation to stammering. nevertheless, as an explanation of the fundamental "predisposition" which has been postulated in vague terms for many years, it would seem to be more satisfactory and is certainly more definite than most of the explanations which have been put forward up to date. the psychologists have held the field for many years with their assumptions that stammering as a symptom can be explained in terms of emotional trauma of every variety — ranging from interference with the patient's native handedness (causing resentment), jealousy, neglect, over-protection, etc. to marital disharmony in the adult. the "precipitating" factor is considered to range from severe illness, frights and shocks of various kinds, to such emotional trauma as are listed above. speech being an expression of thought and emotion, why should such experiences seize particularly upon speech unless there is a fundamental weakness in the ability to formulate thought. if one wishes (unconsciously) to cease to hold communication with one's r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society november fellow-men, why not a hysterical aphonia rather than stammering? if one merely wishes (unconsciously) to escape the hurly-burly of life or a transitory unpleasant experience, why not "nervous dyspepsia" or a hysterical paralysis? if one wishes (unconsciously) to attract attention and prominence, there are other ways of doing so than by stammering. it seems reasonable to assume that the underlying cause upon which the neurosis is able to seize, is an inherent weakness in verbal imagery. this leads us to a consideration of "specific abilities." again there does not appear to be any satisfactory explanation of the vast differences which are found in any group of society. in regard to intelligence woodworth says the following:— "differences in intelligence are shown to depend in some slight degree, at least, on the stimulation received from the home and school environment, but most of the variation of intelligence in the population remains unaccounted for unless it be by heredity. intellectual sex differences are slight and are largely dependent on social custom, but the most striking, like the girl's superiority in language, and the boy's in mechanical interest, may depend on heredity."(8) vant to our subject if the above quotation read: "siblings of identical heredity will select different environments," etc. in considering the stammerer one is considering in many cases the "odd man out" — the person who hesitates and stumbles in a family of fluent speakers or maybe the one who has simply gone one step further in a rather inarticulate family. he may be a stammerer in a family of stammerers. the "specific ability" in relation to speech, may be undeveloped just as in many people artistic ability is undeveloped for reasons which probably cannot be explained any more than the manifestation of genius or special talent can be explained. it does not seem possible to account neatly and definitely for individual variations in specific ability — "ability resides in organic structure, but as we cannot practically observe a living man's brain structure our evidence of his abilities always comes down to a matter of observed or probable performance."(10) miss kingdon-ward in her book on stammering (1941) makes the statement that "any thorough study of stammering must include some study of aphasia." let us then examine the usual conceptions of aphasia and try to discover any connection between these and the preceding remarks on awareness of the disorder concentration on the disorder speech in the presence of strangers speech when at ease brief definite answers repetition of at first faulty sentences essay writing, spelling stammering yes yes worse better difficult often worse normal figure i. cluttering no no better worse easy better mostly equally faulty (7) we start here from the premise that girls possess greater language ability than boys, and it is wellknown that the incidence of stammering is far higher in boys and men than in girls arid women. but while heredity and environment are considered to play equally important parts in the development of specific abilities, there is again no clear-cut explanation to account for individual differences in children who are subject to the same hereditary and environmental influences. woodworth gives the following, which goes part of the way only:— . . . "each individual selects his own environment in large measure and siblings of different heredity will select different environments. they prefer different toys, companions, radio programmes and reading matter, and so expose themselves to different influences. they are sure to be treated differently for it is practically impossible to treat two persons alike if they differ in intelligence or personality."(9) it would be more relestammering. head defined aphasia as "a disorder of symbolic formulation and expression" the symbols in this case being words — words heard, words read, words uttered, words written, words used as tools in the formulation and expression of the person's thought. there have been many classifications of the different forms of aphasia — the basic one being, of course, the division into sensory and motor, receptive and expressive (or executive). head's further subdivision, although it is now considered too limiting and not truly descriptive of the many manifestations found in aphasic patients, still remains for the writer the most helpful as a general guide both to diagnosis of individual symptoms and to treatment. his four categories are as follows:— verbal aphasia — "defective power of forming words, whether for external or internal use." nominal aphasia — "a disturbance in the use of words as names and a difficulty in appreciating r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society the nominal significance of words" syntactical aphasia — "lack of that perfect balance and rhythm necessary to make the sounds uttered by the speaker easily comprehensible to his auditor." semantic aphasia — "characterised by want of recognition of the ultimate significance and intention of words and phrases apart from their direct meaning." (the writer has frequently found that patients who have made considerable recovery from one of the first three, are left with the inability to grasp the full significance of a passage — i.e. the semantic form). in the aphasic all the manifestations are caused by damage to the brain, to the "organic structure" mentioned above, either to the cortex itself or to associative fibres linking one area of the cerebrum with another. according to the beliefs of some neurologists, knowledge of the site of the lesion will indicate the type of language impairment which may be expected. how then, does all this link up with our hypothetical view of the basis of stammering? is it not permissable to assume that in the person who stammers certain cells have failed to develop to the normal extent, there is incomplete maturation of the central nervous system — a weakness which deviates so slightly from the normal that it may not even be revealed until the person is subjected to some particular stress or strain or great fatigue. supposing the child who stumbles and stammers in his eagerness to tell his mother: "i saw a b-b-bunny rabbit" has really some weakness in verbal imagery which makes him akin to the aphasic suffering from an inability to remember names — nominal aphasia. the usual explanations of stammering, of becoming conscious of the sound " b " , speech-conscious, worried about speech, etc., would still hold good, but what of the hundreds of children who are subjected to similar influences and "wrong handling" by parents and still come through the experience unscathed. one might, in the same way, compare the aphasic suffering from syntactical aphasia to the stammerer who (quite apart from the actual stammer) has great difficulty in expressing himself in words. the stammerer who is incapable of clear thinking, of giving definitions, who is amnesic and loses the thread of his discourse — has a kinship with the semantic aphasic. finally the extra-ordinary contortions of the speech organs performed by many stammerers in their attempts to utter are akin to the apraxia of the mouth which is seen in so many patients suffering from "verbal" aphasia. has apraxia been clearly explained except in terms of the outward form? one can find other correspondences — for example, there is the stammerer who expresses himself fluently in writing where the act of uttering is difficult; there is the aphasic in whom the power to paper paper paper paper paper paper paper paper paper paper paper paper is the third most important commodity in the world! transvaal paper & manufacturing co. ( p t y . ) ltd. i specialists in 1 s t a t i o n e r y scholastics, transparent tapes, pads and envelopes, printings, i . j i n i i v m l n i . typing papers, pen-carbon books, accounting books, carbons. 9 w r a p p i n g krafts, tissues, greaseproof, twines, tapes, bags all shapes and • sizes "for butcher, baker and candle-stick maker." i ο n o m f s t i r serviettes, d'oyleys, plates, toilet tissues, drinking cups, o . w n i i v > ι iv-. shelving papers, etc. 53 simmonds street phone 33-7723 j o h a n n e s b u r g . r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society november write is relatively unimpaired where the power to utter is grossly impaired; there is the stammerer whose speech is more fluent in reading aloud than in conversation; there is the aphasic to whom the printed word conveys considerably more meaning than the spoken word. finally let us consider the type of stammer which is often manifested in aphasics who have made a considerable degree of recovery. this is generally labelled a pseudo-stammer and attributed to a lack of co-ordination between brain and muscle. it may be likened to the attempts of an unskilled carpenter to hit a very small nail on the head with a very small hammer — he is unlikely to aim perfectly the first time he tries. the same applies to any skill — to the golfer or tennis player learning to hit the ball, to the sculptor chiselling a block of stone. woodworth draws a distinction between a man's ability and his capacity. may not the skill i.e. the "capacity," which is destroyed in the aphasic, be innately lacking in the stammerer, just as the ability of a henry cotton or a "little mo" or an epstein to develop a special skill is innately lacking in me. in conclusion i should like to describe one patient whose symptoms stimulated me to think on these particular lines. she is a woman aged 48, happily married with three healthy children. the stammer is reputed' to date from the age of 3, but became noticeably worse about the age of nine when it was attributed by a psychiatrist to unconscious jealousy of a more brilliant and attractive sister. when she was referred to me for treatment, the stammer was of the clono-tonic variety. it does not affect dny particular consonants and is non-variable. she is an artist by profession, in a very unusual individual medium, and her visual sense is highly developed. she is also intensely musical. her auditory sense is, therefore, developed in one direction but upon investigation it was found thai her sense of words is exceptionally poor. she has no real interest in them acoustically as musical sounds, and her vocabulary is poor in relation to her cultural background. her memory span for words is abnormally short. it was found that she had great difficulty in remembering more than three nonsense syllables spoken in sequence. we gradually trained her to repeat five with effort. she also complained that she could not remember telephone numbers for even a few seconds. we trained her first of all to repeat telephone numbers, then car index numbers. after that we proceeded to poetry, first of all selecting poems with very short lines. she had difficulty in repeating even one short line, but after some weeks of practice became able to repeat a verse of four lines. gradually, we introduced poems with longer lines. the next step was to read short stories asking her to re-tell them in her own words. she had great difficulty in doing this, but improved with practice. we also set her to define various objects or words and to paraphrase proverbs and the like, but she invariably described such activities as "torture." during this time we were constantly building up her confidence and helping her with the emotional difficulties which had grown up around her speech. she reported that when she was nervous on social occasions she "reversed her sentences." she is undoubtedly one of the relatively few patients i have known whose speech is infinitely better when she is paying particular attention to it. these are random thoughts upon a controversial subject and it may be that my conclusions are nonsensical. on the other hand it may be that they will stimulate others to further investigation on these lines or provide a missing link in investigations which have already been begun. it is certainly upon these lines that the writer intends to carry out research. if these conclusions are true, the treatment of stammering will be to some extent revolutionised and undoubtedly simplified. the psychiatrist, the neurologist and the speech therapist would work in .close co-operation, each making a contribution, for, whatever may be the ultimate origin of stammering, the influence of emotional trauma will always play an important part. references: (1) t h e stammerer unmasked by r. macdonald ladell — 1940. (2) speech and voice by leopold stein — 1942. (3) speech pathology by lee e d w a r d travis — 1931. (4) article on cluttering in " t w e n t i e t h century speech and voice correction" edited b y emil froeschels — 1948. (5) speech and voice b y leopold stein — 1942. (6) ibid. (8) p s y c h o l o g y : a study of mental life b y r. s. w o o d worth (18th edition) — 1946. (9) ibid. (10) ibid. macmillan publishers st. martins st., london, w.c.2 • "trippingly on the tongue" by mona swann. 1955. lod. • "forward to drama"— book i by g. h. holroyd. 1956. 6s. 6d. • "spoken english" by a. g. mitchell. 1957. 7s. 6d. • "an approach to choral speech by mona swann. 1956. 4s. 6d. • "english speech rhythm in theory and practice" by b. lumsden milne. 1957. 4s. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) some reflections on the genetics of mental disorder by ingram f. anderson. m.b.b.ch.(rancl) department of medicine and clinical genetics unit, johannesburg general hospital. "heredity, the only one of the gods whose real name we know . . . brings gifts of strange temperaments . . and impossible desires." — oscar wilde. a study of aberrant mental mechanisms involves consideration of the interaction of the soma, psyche and multiform environment. such a vast field cannot be surveyed critically or even adequately in a dissertation of this nature. the title of the paper is thus employed advisedly: "some" because the scope is necessarily limited, "reflections" because here are mirrored my thoughts and those of others which may not be true images, "genetics" indicates etiologic restriction and "mental disorder" is used in the broad sense. the average medical-man, like the man in the street, has very little occasion to come up against cases of mental abnormality. the latter are locked away early — out of harm's way, out of society's way, out of medicine's way . . . however most of the major advances in genetics and especially in cytogenetics in the last few years have evolved against this very background and notably within its parameters, as exemplified in the case of mongolian idiocy. the recent splurge of spiders across the erstwhile neatly-lined pages of the medical journals has seemed to many to represent the soap-bubble interest of a narrow speciality. on the contrary, the implications have been widespread and diverse, and have impinged upon the whole broad structure of medical-biology. it is noteworthy that the layman has always been aware of an hereditary component in mental illness, as evidenced by everyday statements such as, "there's madness in x's family. comes through the father's side it does!" the medical world has been tardy in accepting such a situation and only in the last few decades has it given concrete formulation to the concept. the current explosion of activity and interest in human genetics has again focussed attention on the domain of the psychiatrist. whereas psychiatric genetics previously appeared to be an empiric exercise and its applications in mental disease were thought to denote a state of irreversibility, it now provides a point of vantage for research and therapeutic application. thus a genetically determined biochemical disturbance may not only point the way to new means of diagnosis but offers possibilities of correction at the molecular level. with these introductory remarks it will be propitious to pass on to a consideration of (a) mental deficiency and (b) the psychoses. (a) mental deficiency. about one out of every thousand whites in this country is in a mental asylum because of mental deficiency. the problem comprises elements of considerable philosophic and social importance; it provokes the question of why people are different and what determines their individuality; it limelights the paradox of human rights and raises the polemic aspects of eugenics as these reflect in the mirror of human ecology. almost half of the institutionalised cases are simple oligophrenics. so-called simple mental deficiency involves the genetics of intelligence. the latter is a tenuous entity, dependent on multifactorial inheritance and it is safe to say that its precise nature remains a matter of controversy. one reads in the book of job: "but where shall wisdom be found? and where is the place of understanding? man knoweth not the price thereof; neither is it found in the land of the living. the deep sayeth it is not in me and the sea sayeth it is not with me. it cannot be gotten for gold, neither shall silver be weighed for the price thereof. whence then cometh wisdom? and where is the place of 'understanding? . . . " for our purposes, we note that the simple moron has no distinctive characters and statisically lies at the negative end of the journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gaussian distribution of intelligence. in contrast to this somewhat ubiquitous entity, great strides have been made in our understanding of two definitive types of mental defect, namely, mongolism and phenylketonuric oligophrenia. (1) mongolism. it is convenient to discuss this in terms of a collocation of the three time factors in the biologic picture. on the largest scale is evolution, with man the result of a long line of ancestors and himself the potential ancestor of a long line of descendants. the interest here is historic. when langdon-down published his classic paper on "an ethnic classification of idiots", in 1866, he described mongolism for the first time, characterising the mongol as, " . . . a representative of the great mongolian race". crookshank in 1931 added the hypothesis that these cases were derived from mongolian ancestors and further that they represented an atavistic return towards the orang-utang. there is no scientific validity for this idea and the anomaly can be readily recognised in the mongol race itself. because of this confused inference attendant on the name, the designation langdon-down syndrome has been preferred by many. on the intermediate time-scale we consider the individual as such — his life history. mongolism exceeds all other morbid conditions of severe mental retardation in number, constituting some 5 to 10% of asylum inmates. there are approximately 125 mongols at the institution at witrand. the incidence in the population is nearly one in every 600 births. as a comparative measure it is salutory to note that the incidence of hypertensive disease is 5%, of all forms of congenital heart disease about 1%, while myelomatosis accounts for 3 per 100,000 of the population. ι the child with mongolism is usually born into a normal family with parents and siblings ofjten above average intelligence. an enormous j psycho-social problem is at once generated \ and cannot be elaborated upon here. apart from the mental subnormality, mongols jexhibit extensive physical abnormality,, proneness to infection being quite a feature. the advent of the antibiotic era has seen a rise in the mean survival age of the mongol. on the smallest time scale are events at the dynamic intracellular level. interest here centres on the chromosome constitution. in man each cell contains 46 chromosomes: 22 pairs of autosomes and a pair of sex-chromosomes. in 1959 lejeune and his co-workers discovered that the mongol possesses an extra autosome — a state of aneuploidy (i.e. an abnormal number of chromosomes). basically two mechanisms underlie the chromosomal aberrations in mongolism: non-disjunction and translocation. non-disjunction is the common type. during meiosis there is failure of separation of two homologous chromosomes. thus one daughter cell will come to contain both components of an autosome pair and the other cell neither. the former, after fertilisation will be trisomic (i.e. it will have three instead of two of a certain chromosome, in this case number 21 on the denver classification), and will have a diploid number of 47. this situation is seen typically with older mothers and may be related to mechanical factors operating in an old ovary with "old" ova. less commonly translocation occurs. this involves the breakage of two non-homologous chromosomes and an exchange of fragments between them. the greater part of chromosome 21 becomes attached to one or other fragment leading to a normal diploid number of 46, but in fact there exists a virtual trisomy 21. in addition translocation allows of the formation of a carrier state and the defect may therefore be perpetuated through several generations. in essence then, whatever the mechanism, an additional chromosome is overtly or occultly present. a great many genes — each controlling specific metabolic processes — lie a'on^ its length. however, the relationship of the cytology to either the biochemistry or to the pathology remains obscure. it is important to realise that the mongol is abnormal from the moment of conception. a degree of developmental irreversibility is attendant at birth and therapy must therefore be more or less ineffective, t h e r e is no rationale for the use of thyroid extract, alpha glutavite, siccacell therapy (injection of dried foetal brain cells) or large doses of vitamin e. (2) phenylketonuria. a somewhat brighter vista is revealed when we look to the inborn error of metabolism, phenylketonuria. this is the paradigm of a genetically determined endecember, 1962 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) zyme-block. it is transmitted as a single autosomal recessive, the homozygous state being necessary for phenotypic expression. the enzyme, phenylalanine hydroxylase, is at fault and there follows failure of oxidation of the essential amino-acid, phenylalanine, to tyrosine. various intermediate products accumulate proximal to the block and act deleteriously on the nervous system causing profound mental subnormality. treatment takes the form of a phenylalanine-low diet, and if commenced immediately after birth, offers a reasonable chance of preventing the mental disturbance. although the heterozygotes are mentally and physically quite normal, they can be detected by means of blood tests (the phenylalanine-load test) and this fact can be utilised in eugenic counseling. finally, very simple tests are available for diagnosis and have been employed routinely in many maternity centres overseas. this logical application in preventive medicine could be profitably employed in this country. (b) the psychoses. whereas the mental defective lies outside our conceptional world and symbolises all the horror of mute animalism in man, the psychotic may be regarded as a rather interesting eccentric with whom one can still maintain a somewhat narrow contact and communication. professor l. a. hurst stands uniquely and eloquently in relation to psychiatry in south africa as the protagonist of the hereditary discipline in this field. his researches, disciples and numerous publications on the subject testify cogently to his dynamic influence in a school formerly dominated solely by the environmentalists. he has moreover succeeded in impregnating a matrix of genetic precepts not only into the crude clay of his own speciality, but into the ground-substance of related medical divisions. the endogenous psychoses have been shown by the work of f. j. kallmann in america and eliot slater in britain, to be determined on an autosomal hereditary basis. the genetic mechanism is single recessive in schizophrenia and irregular dominant in manic depressive psychosis. one has illustrated in the case of phenylketonuria how a mutant gene, via the enzyme-block hypothesis, creates a disturbance of cellular chemistry ultimately manifesting in grave mental disintegration. the same basic process is believed to underlie the endogenous psychoses, but it is far more subtle, as yet elusive and cannot be so elegantly demonstrated. it is central to the understanding of the etiogenesis of these psychoses to appreciate the remarkable shift in emphasis implicit in the foregoing statements. for, whereas such mental diseases have been attributed to traumatic psychological experiences, which cause a disturbed and maladjusted psyche, it is now postulated that there is a primary genetic error underlying and indeed creating a disruption at the intracellular level: an imbalance in internal neuronal metabolic milieu. without elaborating on the detailed biochemistry and in broad terms, mental mechanisms depend upon the interaction of four (or more) endogenous neurohormones, adrenalin, nor-adrenalin, acetylcholine and serotonin. a delicate state of homeostasis between these substances is a pre-requisite for mental normality — imbalance is believed to underlie the genesis of the psychoses considered here. interestingly enough, many of the drugs used as therapeutic agents have been found to act upon and interfere with the biochemical patterns of the aforementioned neurohormones and have thus furnished further evidence for the indictment of these latter substances in the etiology of the psychoses. professor hurst is a strong advocate for the employment of such therapeutic agents as the monoamine oxidase inhibitors (e.g. iproniazid) and the chemically unrelated substance, imipramine in the pin-pointing of the peccant chemical sequences. while much remains to be propounded and still more remains to be clarified, it is apparent that the kaleidoscopic conundrum of the endogenous psychoses has assumed a new colour and format in terms of basic genetic concepts and the elaboration of the latter in the direction of enzyme chemistry, neurochemistry and neuropsychopharmacology. while these "reflections" have been rather terse and incomplete, they do highlight the emergent fact of an operative genetic component in many forms of mental disorder. armed with this evidence our knowledge can be translated into practical application in the form of eugenic counseling. a clinic for the provision of this service to the community has been inaugurated at the johannesburg general hospital under the aegis of 2 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) professor hurst. genetic advice is furnished in a wide variety of circumstances, not least of all in cases of mental disorder. present policy is in line with similar clinics in europe and america: the odds are stated, the genetics of a particular disease is explained and no attempt is made to influence parents as to whether or not they should have children. however, the role of the counselor is not entirely passive as one emphasised at the recent pretoria congress on genetics: "with regard to the counselor, these very developments in cytologic and biochemical genetics have altered the milieu in which he acts, in as much as his prognostications change in emphasis from passive empiricism to definitive understanding in terms of enzyme-blocks, protein derangements or cytopathogenetics. in addition to mere advice, he is able to thrust back further the barriers of uncertainty and to detect heterozygotes and late onset cases . . . thus far from being an inactive advisor, the counselor, as i see it, converts to the status of active moderator." in conclusion, it is almost tautological to stress that mental disorder constitues a formidable challenge to the medical world and to society in general. psychiatry has lagged a little behind the rapid progress made in general medicine — having been snared in a network of classifications and bedevilled with nebulous concepts of "psyche-pathology". it is therefore all the more gratifying to see it caught up now on the giant tidal wave of human genetics — physiologic genetics — and elevated from the esoteric depths of conceptual thinking to the crest of eclectic, concrete formulation and application. summary. there appears to be a lack of appreciation of the problem of mental disorder on the part of both the medical profession and the layman. the ^urrent interest in medical genetics has seemed to many to be a somewhat narrow speciality. however, mental disorder and genetic research have in fact been mutually fructifying. only recently has the hereditary component in mental illness been accorded concrete status in the face of the former prevailing environmentalist doctrine. consideration is given to examples within the broader classifications of, (a) mental deficiency and (b) the psychoses. (a) simple oligophrenia is briefly alluded to against the polygenic background of intelligence. the discoveries in the cytogenetics of mongolian idiocy are discussed arid it is noted that though the key to etiogenesis is now known, the door to the related biochemistry and pathology remains closed. phenylketonuria is presented as the perfect example of an inborn error of metabolism. heterozygotes for the condition can be detected by means of blood tests and this constitutes a step forward in terms of eugenic counseling. treatment with a low phenylalanine diet at birth offers chances of a happy outcome. in view of the success of therapy, and ease of diagnosis, a plea is made for the routine testing of all neo-nates (as practised overseas). (b) of the psychoses, manic depressive psychosis and schizophrenia are shown to be genetically determined. furthermore, the role of the neurohormones, acetylcholine, nor-adrenalin, adrenalin and serotonin in brain physiology is mentioned. disturbance at the genetic level leads to disturbance in the chemical homeostasis of the aforementioned substances, manifesting ultimately in mental aberration. many of the drugs used in the treatment of these endogenous pyschoses have furnished further indictment of the part played by the neurohormones in the genesis of mental illness. with entry into the realm of genes, molecules and atoms, our understanding of the psychoses is placed on a fundamental and firm footing. a genetic counseling unit has been established at the johannesburg general hospital under the aegis of professor l. a. hurst. various problems of a medico-genetic nature are dealt with, not least of all, those in the field of mental disorder. it is a happy augury that psychiatry, which has somewhat lagged behind the rapid progress made in general medicine, has attained a clear scientific approach with the incorporation of the basic science of genetics into its discipline. opsomming. dit lyk asof beide die mediese professie en die leek nie die erns van geestesgebreke insien nie. die huidige belangstelling in mediese genetika word deur meer as een as 'n baie beperkte rigting van spesialisasie beskou. geestegebreke en genetiese navorsing het egter, gesamentlik baie vrugte afdecember, 1962 journal of the south african l o o p e d i c society 3 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gewerp. dit was maar onlangs wat die rol wat oorerwing speel in geestesgebreke sy ware status bereik het, in vergelyking met omgewingsleer. spesiale aandag word geskenk aan voorbeelde binne die wyer klasifikasie van, (a) swaksinnigheid (b) sielsiekte. (a) daar word kortliks verwys na eenvoudige oligofrenie, gesien teen die poligeniese agtergrond van intelligensie. uit die bespreking van die ontdekkings in die sitogenetika van mongoolse idiootheid is bemerk dat die oorerflikheids oorsake nou bekend is, maar die verwante biochemie en patologie is nog onbekend. fenielketonurie word voorgehou as die perfekte voorbeeld van 'n aangebore defek van metabolisme. heterosigote vir die toestand kan opgespoor word deur middel van bloedtoetse en dit is reeds vordering in eugeniese raadgewing. behandeling met 'n lae fenielalanien dieet met geboorte dui op 'n goeie prognose. na aanluiding van die sukses. van terapie en die vergemakliking van diagnose, word 'n beroep gedoen vir die roetine toetsing van alle pasgebore babas (soos oorsee gedoen word). (b) van die sielsiektes word die maniesdepressiewe psigose en die gesplete persoonlikheid geneties bepaal. verder word die rol van neurohormone, asetielkolien, nor-adrenalien, adrenalien en serotonien in brein-fisiologie genoem. steuring op die genetiese vlak lei tot steurings in die chemiese homeostase van die bogenoemde stowwe, wat uiteindelik geopenbaar word in geestesafwykings. baie van die verdowingsmiddels, wat gebruik word vir die behandeling van hierdie psigoses, het verdere aanduiding verskaf van die rol wat neurohormone, in die veroorsaking van sielsiektes, speel. met die toetrede tot die gebied van genes, molekules en atome, het ons begrip 'n vaste grondlegging gekry. 'n genetiese raadgewingseenheid is in die lewe geroep by die johannesburg algemene hospitaal onder die beskerming van prof. l. a. hurst. verskei probleme, van mediesgenetiese aard, word ondersoek; waaronder ook probleme op die gebied van geestesgebreke. dit is verblydend dat psigiatrie, wat agtergeraak het by die snelle vooruitgang van algemene medisyne, 'n suiwer wetenskaplike benadering geniet, met die insluiting van die basiese wetenskap van genetika. references. 1. opening vistas in psychiatry. l.a. hurst. witwatersrand university press, 1959. 2. applications of genetics in psychiatry and neurology. l. a. hurst. s.a. jnl. of lab. and clin. med. 1958. 4/3. p.169. 3. converging advances in psychiatric genetics and the pharmacology of psychotropic drugs. l. a. hurst. medical proceedings 1961. 7/20. p. 417. 4. the genetics of mental deficiency. i. f. anderson. the leech. oct. 1962. 5. genetic prognosis. i. f. anderson. 2nd. congress of s.a. genetics society, pretoria. 1st october, 1962 (in the press). 6. phenylketonuria in a mentally defective population. i. f. anderson, (in the press). 7. the strategy of the genes. c. h. waddington. george allen and unwin. ltd., london. 1957. journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) an investigation into the language and generalization abilities in the brain-injured and non brain-injured mentally retarded child ilana o k e n introduction and aims j. l. khanna in his book "brain damage and mental retardation" reports a study by mednick and wild in which they found that the brain-injured child has a diminished degree of generalization responsiveness. (1968, 9.) it would seem that if a child has difficulty with generalization, he should also have difficulty in language development where a word must come to stand for an action or an object in many different situations and contexts. one of the most salient features of the mentally retarded child is his impoverished verbal behaviour, i.e. his delayed and impaired language. (1964, 18.) luria regards the basic symptom of the mentally retarded child, or the oligophrenic child as he terms it, as a profound disturbance in the operations of abstraction and generalization which manifests itself in, and dominates the whole of cognitive functioning. (1963, 11.) in terms of the above the writer felt that it would be interesting to conduct a comparative study of two groups of mentally retarded children, one of them brain-injured, the other non brain-injured, to see if there is any relationship between the differences in their language and generalization abilities, for if there is, this could be of great therapeutic and prognostic value. goldstein has described the brain-damaged adult as being deficient in the use of the "abstract attitude". perhaps this, as well as the concept of "rigidity" in the brain-injured child's thinking as postulated by goldstein, werner and others (1954, 13) (1966, 6) can be viewed as a diminished generalization ability, and these ideas have led the writer to investigate this field in the brain-injured child. most of the research on the language of the retardedis confined primarily to the study of speech. the research that is^cited on the "language" of mentally retarded children tends to reveal only that these children are defective on various measures of language without actually describing retarded children's language pattern. in using the illinois test of psycholinguistic abilities, (the itpa), the writer attempted to describe various areas of strengths and weaknesses within the two samples of retarded children, investigating: (i) whether the frequently stated assumption that the brain-injured child has a "peaked profile" and that the mentally retarded child has journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the brain-injured and n o n brain-injured mentally retarded child 33 a "relatively flat profile" exists, and whether this differentiation exists in the language abilities of the two diagnostic groups; (ii) whether retarded children differ psycholinguistically from average children of comparable mental age; (iii) whether there is a "typical" profile for the brain-injured mentally retarded and the non brain-injured mentally retarded. the writer was unable to find any test of generalization which could be used (other than complex equipment involving machinery) and, therefore, thought that it would be advantageous to devise a simple test which could be used diagnostically, therapeutically and prognostically. the writer views generalization as the grouping together of stimuli or objects which are similar, but not identical, to form a class, a category or a concept. parsins, skill et al state that this process is "the categorization of the particular, concrete objects of his situation into classes". (1955, 20.) hubert alexander clearly differentiated abstraction from generalization. he says that these processes are the reverse of each other, for generalization is the process of grouping like units together into classes, whereas abstracting is a process of selecting out attributes by focusing upon them. (1967, 1.) however, the writer feels that generalization involves abstracting to the extent that objects or events are grouped together by virtue of the certain abstractable traits which they have in common. rosenstein feels that concept formation is a progression from perception, to abstraction to generalization. he feels that concept formation is dependent on abstraction, and that concept utilization on generalization. (1961, 15.) (1963, 16.) strauss and kephart regard generalization as being essential in the development of concepts. they feel that generalization first occurs on a perceptual level, where the child makes perceptual responses to his object world by classifying, e.g. four cornered figures are classified as "squares" irrespective of their size, colour, whether they are solid figures or outline shapes. this is generalization of shape. as the child develops, a transition occurs from the perceptual generalizations to generalization over a less immediate or direct route. categorizations are now made according to function, use, location and later according to higher level groupings. (1955, 20.) the basic theme of the book "a study of thinking" by bruner, goodnow and austin is that virtually all cognitive activity is dependent on the process of categorizing. (1957, 5.) bruner developed this theme further by emphasizing that the development of a language system is a prerequisite to making generalizations beyond immediate environmental situations. (1966, 8.) rosenstein also feels that the development of concepts is greatly aided by language and other symbols. (1963, 16.) many learning theorists have differentiated between primary and secondary stimulus generalization. irv bialer defines primary stimulus generalization as "a response to superficial sensory similarity of stimuli which have been given otherwise distinctive characteristics in the form tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 liana oken of different labels". he says that in secondary stimulus generalization the utilization of learned equivalence is required. (1961, 4.) leventhal says that categorization is assumed to be on a perceptual level in the case of primary stimulus generalization and on a conceptual lever in the case of secondary stimulus generalization. he distinguishes between perception and conception in terms of: 1. speed and locus of action. perception operates quickly and· refers to objects present in the environment. conception operates more slowly on the basis of symbolic, non-sensory bound cues. 2. susceptibility to the influence of irrelevant and redundant information. perception is more greatly influenced by these than is conception. vygotsky views the formation of concepts as a developmental sequence of generalizations, at first grouping syncretic heaps together, i.e. with no apparent principle in mind, then progressing to a higher level of generalization where he groups according to unique associations, e.g. toys "belong" in his playpen, he then proceeds to group according to some functional relationship, and the epitome of categorization in vygotsky's system occurs with the mastering of the superordinate. (1962, 22.) (1967, 19.) experimental methodology 1. subjects: ten subjects were used in this study. five of these children formed, the brain-injured group, and the other five the non brain-injured group. all the subjects were mentally retarded and enrolled in special classes in government schools in johannesburg. for the purpose of classifying the subjects into the two experimental groups, the writer used a combination of the riggs and rain classification system (1952, 14) and the system proposed by schulman, kaspar and throne. (1965, 17.) the criteria for selection into the "brain-injured" group are some of those laid down for the riggs and rain "organic" group, and the "non brain-injured" group are equivalent to schulman et al group 2, i.e. "patients at the low end of the normal distribution curve". four out of the five subjects in the non brain-injured group fit into the riggs and rain group of "unexplained", i.e. children who, in spite of fairly detailed case histories, can be called neither familial nor organic without resorting to inference rather than to fact. the fifth child's retardation is of the familial type. / (a) brain-injured group: the subjects used in this group were selected in terms of meeting with one of the following criteria: (i) diagnosis of brain-injury by a neurologist; (ii) case history indicating anoxia at birth; (iii) encephalitis before baby aged six months; (iv) epilepsy diagnosed medically; three of the subjects had been 'diagnosed as brain-injured by neurologists. b5 had hemiparesis on the right side, b4 had frequent grand journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e brain-injured and n o n brain-injured mentally retarded child ' 35 mal epileptic attacks and b2 had nystagmus in the right eye. the case histories of b1 and b3 indicate anoxia at birth. b4 had encephalitis at two weeks, which was followed by the epileptic attacks, and b5 was the second of a stillborn twin, weighed \ \ pounds at birth, suffered from anoxia at birth and was given a transfusion immediately after birth. (b) non brain-injured group: the children in this group were selected in terms of the following criteria: (i) no organic cause present in the case history; (ii) no organic symptomatology present; (iii) these children were diagnosed as mentally retarded on the basis of an intelligence test. (c) intelligence: before a child is admitted to a special class in a government school, he has to be assessed by the school psychologist. the child's intelligence is tested on the south african individual scale. thus the intelligence of all the children was tested on the same scale, and all the tests were done after january 1968. the iq scores of the subjects ranged from 65 to 80. (d) socio-economic class: four of the subjects were at gresswold school and the other six were in the "coaching class" at emmarentia primary school. both schools are in the northern suburbs of johannesburg, and all the children were of middle-class parents. none of the children were, or had ever been institutionalized; all children lived at home. (e) chronological age: the chronological ages of the children ranged between 7 and 11 years. because of difficulties in getting children of the same chronological age (ca) and iq, the subjects were matched in pairs as closely as possible with respect to ca, iq and sex where possible. (f) further criteria for selection were: (i) the subjects had to be ambulatory and have sufficient motor coordination to carry out the tasks, e.g. pointing, picking up blocks; (ii) children with severe personality and emotional problems were not used; however, some of the children in the brain-injured group did show some of the "strauss-type" behaviour symptoms, but none of these problems was severe; (iii) the children had to be able to express their basic needs and understand simple directions; (iv) the children had to be able to differentiate shapes of a triangle, circle and square. they had to be able to post the appropriate shape in the "post box" task; (v) the teachers of the children reported that none of the childrenhad difficulty with colour perception, and none had any hearing difficulty. 2. procedure: (a) conditions for the experiment: the environment in which the experiment was carried out was familiar to all the children. eight tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 liana oken of the children were tested at their schools, and they were taken out of their regular class one at a time and were tested in a classroom at the far end of the school. the situation was controlled as far as possible for both extraneous auditory and visual stimuli. the two children not tested at school were tested at their homes, at a table in a quiet room. (b) the tests administered were: i. the itpa. ii. a generalization test devised by the writer which was administered following a pause of five minutes after the completion of the itpa. (c) standardization of the generalization test: the generalization test was given to 12 "normal" children aged between and 7 years. these 12 children formed the standardization group. they lived in either gresswold or emmarentia, and were, therefore, children of the same socio-economic class as the subjects in the experimental groups. the purpose of giving this test to the normal children was to roughly standardize the test, to get an idea as to how normal children would perform on this test so as to be able to compare the performance of the experimental groups with the normal group. 3. materials: i. the itpa: this is a diagnostic test of language abilities. it is a battery of nine subtests, each subtest assessing a particular aspect of the global area of language ability. the itpa was administered in the recommended order and in accordance with the instructions laid out in the manual. (1961, 12.) the only exception was a five-minute pause after the visual-motor sequencing subtest. this pause was given to all subjects, as the writer felt that the test was a long one, and that the pause would overcome, to a certain extent, the element of fatigue. ii. the generalization test: (a) theoretical framework on which the generalization test is based: generalization or categorization, as has been shown by several authorities (strauss and kephart, rosenstein, vygotsky and others) is a developmental phenomenon, and proceeds from the concrete perceptual to the more complex conceptual mode. the child at first operates on the basis of superficial, sensory bound cues and groups according to what he "sees" and what "is". he then proceeds to group according to more conceptual aspects, not to what "is" iri the present, but according to less stimulus bound and more symbolic cues. he now begins to group dissimilar looking cues into one group and regards them as being "the same" in terms of their functions, uses, locations, etc. the test is, therefore, divided! into three levels, all increasing in complexity. there are three pretest items, the purpose of which is to illustrate to the child that he must group items together that constitute one category, e.g. "squares". journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e brain-injured and n o n brain-injured mentally retarded child 37 section 1 of the test involves grouping together of blocks of different sizes, shapes and, later, colours into particular categories. here the child is required to generalize in terms of the objects he sees before him—this is on a concrete perceptual level. section 2 of the test involves the child choosing one picture out of three that can be grouped with three other pictures, all of one category or stimulus class. here the child is required to form the generalization in terms of the picture that he sees. section 3 requires the child to select one word out of four that does not fit into the category. here the child is required to generalize three of the words into a category or higher level concept, and verbalize the word that does not fit into the desired category. each item of every subtest is graded in difficulty, and thus it is expected that a child who fails item (d) in the first section of the test will not pass items in the second section of the test. (b) description of the generalization test: pretest: in this part of the test, nine blocks are used, three identical squares, three identical triangles and three identical circles. they are identical with respect to colour, size and shape. the three squares and the circle are placed in front of the child and the child is instructed to place all the blocks that are "the same" into the tester's hand. if the child succesfully completes item (a) by himself, the same procedure is carried out for pretest items (b) and (c). if the child fails item (a), the tester shows the child how to succesfully complete the task, and explains to the child that the three squares are the same because they all look alike, all have four sides and all are "squares". the child is then given item (b) to do. if the child fails item (b), he is again shown how to successfully complete the task, and the tester explains the reasons for the grouping. the child is then given item (c). should he fail this item, the test is then stopped. w = white tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 l i a n a oken section 1: in this section, blocks of various sizes, shapes and colours are used, and the child has to group those objects that are the "same". sameness of shape is the type of grouping required. the five items are: blocks for'item (a) are randomly placed on the table before the child. the child is again instructed to place those blocks that are "the same" into the tester's hand. if the child is able to do this without assistance, the test is continued in the same manner. if the child is unable to do the item, or groups according to colour, the tester shows the child the correct way of grouping. the child is' then given item (b) to do; if the child fails to do this correctly, the tester again shows and explains the correct grouping; if the child then fails item (c), the test is stopped. section 2: in this part of the test, white cards 2\ inches/by 3} inches with clear pictures pasted on them are used. the child is required to group pictures together that are of the same category. the following categories are used: (a) animals; '(b) furniture; (c) people; (d) parts of the face; (e) jewellery. before commencing the test, the tester explains to the child which is the "top row" and which is the "bottom row". the child is then required to indicate which row is which on command. the child is then instructed to show the tester which card on the bottom row is "the same as, the same thing as, goes with" the journal of the south african logopedic society, vol. 17, no. 1: december 1970 (c) r r = red β = blue y = yellow r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e brain-injured and n o n brain-injured mentally retarded child 39 three cards in the top row. the instructions are given to the child in these three ways to ensure that he understands what is required of him. if the child completes the item successfully, the test is continued in the same manner. if the child fails item (a) the tester shows the child the correct way of grouping, explaining that they are all of one category, e.g. animals, and the child is then given item (b) to do, and the same procedure is followed as that in section 1. the cards used in this section of the test are placed on the table in the following order: (a) 1. elephant 2. cat 3. horse 4. dog 5. boy 6. car (b) 1. cupboard 2. chair 3. table 4. dress 5. bed 6. flower (c) 1. mother 2. boy 3. father 4. dog 5. girl 6. table (d) 1. eyes 2. ears 3. mouth 4. nose 5. apple 6. dress (e) 1. brooch 2. watch 3. necklace 4. chair 5. girl 6. ring section 3: this section has an example given to the ch: explain what is required of him, and five items then follow. in the example item the words "dog, cow, ball, pig" are given and, if the child responds correctly, the test is continued as in sections 1 and 2. if the child fails to give the correct response, the tester explains to the child why "ball" is the word that does not fit. the child is then given item (a) to do and, if he fails, he is given the correct response and an explanation as to the reason. if the child then fails item (b), the test is stopped. the series of words used in this section of the test are: (a) hat boat shoes coat (b) car train ship mountain (c) fork banana apple grape (d) river sea sand swimming-pool (e) lamp light ball sun (c) general points in the administration of the test: 1. after three successive failures in any part of the test the test was stopped. 2. after each failure the child was shown the correct response. 3. when the child performed correctly, the tester acknowledged this by saying "good, that's right". 4. after each item in all sections of the test, the tester asked the child why he had grouped the objects, pictures or words in the way that he had, and the child's verbal responses were recorded. (d) scoring of the generalization test: every item of the test was weighted with a score one more than the score preceding it. thus passing item (a) yielded a score of 1, passing item (b) yielded a score 1 + 2, i.e. 3, passing item (c) yielded tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr.: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 liana oken a score of 6, i.e. 1 + 2 + 3. the total number of points in the test was 120. results 1. the itpa: t a h i j : i: m e a n itpa proeile and r a n g e s or b r a i n i n j u r e d m e n t a l l y retarded groui' + 3 00' representational level anioin-sc.qnential + 3 00' decoding association encoding autom. sequential + 3 00' 1 2 3 4 5 6 7 8 9 + 3 00' and. visual and. vocal visual motor vocal motor and. vocal and. vocal visual motor + 3 00' + 2-50 + 2 0 0 + 150 + 1 00 + -50 00 -50 — 1 00 / s . 1 5 0 / 1/ s \ 2 00 f s 2 5 0 3 0 0 the total language age scores of the two groups did not yield significant differences between the two groups, yet as can be seen from the above profiles the two diagnostic groups performances differ. both groups have "peaked profiles" but these profiles are peaked in different areas, i.e. the groups show different strengths and weaknesses on the various subtests. the brain-injured groups performance on visual subtests was inferior to its performance on auditory subtests on all levels. when this result was subjected to statistical analysis it was found to be significant at the ,001 level of confidence. the non brain-injured groups performance was poorer in the auditory channel for all subtests except auditory-vocal journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the brain-injured and n o n brain-injured mentally retarded child 41 t a b l e 2: m e a n itpa profile and r a n g e s of n o n b r a i n i n j u r e d m e n t a l l y retarded g r o u p . + 3-00 representational level antom-seqnential + 3-00 decoding association encoding an torn. sequential + 3-00 1 2 3 4 5 6 7 8 9 + 3-00 and. visual and. vocal visual motor vocal motor and. vocal and. vocal visual motor + 3-00 + 2-50 -f 2 · 00 -!-1 · 50 -h 1 -00 + -50 00 -50 1 0 0 — 1-50 \ \ -2-00 \ >ν -2-50 -3-00 sequencing. the result of this score was influenced by the extreme range in this subtest due to the heterogeneity in performance of the subjects in the group on this test. when the students t test was applied to this result, the difference was not found to be statistically significant. the non brain-injured group were statistically inferior to the braininjured group on the auditory-vocal automatic subtest at the ,02 level of significance. the brain-injured group was inferior to the non brain-injured group in the whole decoding process, and thus although the non brain-injured group were poorer in their auditory as compared with their visual subtests, their performance on auditory decoding was superior to that of the brain-injured group. a t test was performed to see whether the difference between the groups performances on decoding and encoding were significant or not. the difference between the brain-injured groups encoding performance was not statistically significant, the non braininjured group were statistically superior to the brain-injured group in the decoding process at the ,001 level of confidence. in both groups motor encoding was superior to vocal encoding. both groups performed extremely poorly on both association subtests, the tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. : des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 liana oken brain-injured group were more inferior due to their deficit in the visual channel. the range for each subtest was calculated. this is the difference between the uppermost and lowest scores on a particular subtest. it is interesting to observe the size of the ranges on the particular subtests. mostof the subtests show fairly large ranges indicative of heterogenous performances by the subjects in the groups, however, both the association subtests have relatively small ranges indicating that all of the children in the two groups performed poorly on these subtests. it seems as though in this sample of brain-injured and non brain-injured mentally retarded children, all the children had difficulty in this area irrespective of their individual differences. within each diagnostic group a t test was performed to determine whether the groups abilities in encoding and decoding differed significantly. the difference between the brain-injured group's decoding and encoding abilities was significant at the ,001 level of confidence, and the difference between the non brain-injured group's decoding and encoding abilities was significant at the ,01 level. when the mental ages of the subjects in both groups were compared with their language ages, it was found that these scores do not correlate well, but that there was a considerable difference between the two. the difference was found to be significant at the ,001 level of confidence. ii. results on generalization test: (a) standardization group: the following general trends in performance were observed: (i) children between and 4 \ were able to complete all perceptual groupings and up to (d) of section 2., thus their scores were approximately 45. (ii) children between 4j and were able to complete all perceptual and concrete conceptual groupings. they were able to complete up to section 3's (d), thus their scores were approximately 91. (iii) children over 5j were able to complete the whole test successfully. thus their scores were 120. (b) experimental groups: t a b l e 3 : r e s u l t s o n g e n e r a l i z a t i o n t e s t o f t h e b r a i n i n j u r e d a n d n o n b r a i n i n j u r e d g r o u p s brain-injured non brain-injured 1. 106 47 2. 15 105 3. 98 58 • 4. 37 0 5. 14 36 total: 270 246 m e a n : 54 49-2 journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e brain-injured and n o n brain-injured mentally retarded child 43 the brain-injured groups performance on this test was superior to the performance of the non brain-injured group, but when a t test was performed on the above data it showed that the difference was not statistically significant. the reasons for the lack of significant results could be due to the following: 1. small size of groups, and large range of possible scores. 2. heterogeneity in performance of subjects closely matched for ca and iq. the subjects performance on this test was compared to the performance of normalchildren in the standardization group. the generalization ability of both the brain-injured and non brain-injured groups appeared to be far inferior to their mental ages. discussion from the findings of the present study one cannot emphatically state that there is a "typical" profile for the diagnostic groups, but it does seem that there are certain trends in performance of the two groups. in the gallagher study it was reported that there were tendencies for the brain-injured group to be superior to the non brain-injured group on items tapping the visual channel. (1957, 7.) in the present study the brain-injured group were significantly inferior in the visual channel for each process, but the deficit of the non brain-injured group in the auditory channel, though evident was not statistically significant. strauss et al regard perceptual deficits as being characteristic of the brain-injured child. they say that "brain-injured children show a disintegration in the visual-perceptual field" (1947, 21.), and they use as their diagnostic tests of "brain-injury" tests of visual perception, e.g. the werner-strauss marble board. bateman reports that children who show a visual motor disability on the itpa are the children with "perceptual disorganization" or the "strauss-syndrome" children. (1965, 2.) the deficit in the automatic sequential level which has been reported in the literature on the itpa with mentally retarded children was evident in the non brain-injured group. their performance was poor over the entire automatic-sequential level, but they showed the greatest deficit on this level in the auditory-vocal automatic subtest. the writer wishes to postulate that the poor performance on this subtest is related to their deficient generalization ability indicated on the generalization test. when children learn the grammar of their language they are not formally taught these rules. they hear different grammatical structures in their environment and from this they formulate a rule which they have to generalize in order to produce novel utterances. however they do not hear a rule in one way, but in a number of ways, i.e. in a number of different utterances all obeying that rule, and they have to automatically generalize the rule which they have learnt in situation a to situation b. therefore a child who is deficient in his generalization ability will be deficient in a subtest tapping his ability to learn grammatical rules automatically. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 l i a n a oken the greatest deficit in both diagnostic groups was in the association process. bateman and wetherell report that the type of association process assessed by the itpa can be considered either as a retrieval or organization and generalization stage. they feel that it is impossible to determine on an auditory-vocal association deficit alone whether the problem is one of retrieval or organization and generalization. however they feel that the visual-motor association subtest is more heavily weighted with organization. (1965, 3.) since both groups in this study performed poorly on both the association subtests, the writer feels that these two tests are both tapping generalization ability. in the performance of the subjects on the generalization test it was interesting to observe the manner in which the children of the different groups made their generalizations. some of the responses of the braininjured children were bizarre and unrelated to the stimulus presentations particularly in section 2 of the test. in this section some of the braininjured children tended to make their groupings according to an association between one of the pictures in the bottom row and one of the pictures in the top row, e.g. boy and horse cause "boy sits on a horse". these associations tended to be on the basis of contiguity as in the above example, or activity between the two objects, e.g. boy and horse cause they both "go". an interesting observation was the clear difference between grouping or generalizing on the perceptual and conceptual levels. subjects b3, b4 and b5 experienced no difficulty in section 1, yet were unable to do the items in section 2. the performance of these subjects on the association subtest was their most inferior performance. subject m4 had no difficulty in doing the pretest items, yet was unable to group stimuli differing in one respect, i.e. size. the subject showed the poorest generalization ability on the generalization test, and his itpa scores showed the poorest deficits on auditory-vocal and auditory-vocal automatic subtests. an important factor in generalization ability seemed to be the verbalization accompanying the grouping. the most successful subjects were those who were able to give the name of the category they were grouping, and it seemed as though appropriate use of verbal activity was the important factor, yet the subjects who merely named the picture they selected, e.g. "cause it's a dog" were more successful than those subjects who made no verbalizations. this point seems to illustrate luria's thesis of speech regulating behaviour and also strauss and kephart's idea that the use of the category word unifies perceptions and later conceptions. the findings of this study support the use of the itpa as a diagnostic tool. the writer does not feel that a diagnosis can be made from the results on this test alone, but analysis of the profile can point in the direction of a particular diagnosis.! knowledge of etiology seems to be important as it indicates the type of therapy programme to be used. if the child is found to be brain-injured, the therapy or remediation journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e brain-injured and n o n brain-injured mentally retarded child 45 prograifime should stress the auditory avenue, i.e. an auditory approach to language training, as the stronger avenue can be used to facilitate the weaker. bateman and wetherell feel that an important implication in the education of retarded children can be derived from the knowledge of a deficit in automatic rote aspects of language usage. the need for repetition, over learning and drills seems obvious, yet by making all learning situations meaningful to the child the retarded child will handle these tasks exclusively at the representational level, thus further strengthening his already relatively strong representational skills and neglecting the automatic-sequential abilities which are in need of exercise. (1965, 3.) because the performance of both groups of children is deficient in the association process of the itpa, therapy and education for the retarded child should place a direct emphasis on the formation of concepts, abstractions and generalizations. the generalization test as it stands can be used prognostically, as, the child who performs superiorly on it should be more successful in therapy and achieve more in a shorter period of time than a child who shows poor generalization ability, as he will form concepts and thus learn language quicker. the generalization test as it stands or modifications of it can be used therapeutically to train children in generalization. the performance of the child on the generalization test can also be a valuable therapeutic guide indicating from what point to begin therapy, whether one need work on a very concrete perceptual level or on a more conceptual level. conclusions the total language age scores of the two groups did not yield significant differences between the two groups. however, when the performance of the two groups were broken down and analysed significant differences in areas of strengths and weaknesses were observed. both groups performed most inferiorly on the association subtests of the itpa, and this performance correlated well with the poor performance of the subjects on the generalization test. the writer feels that there is a close inter-relationship between language ability and generalization ability, and this illustrates the importance of giving the child certain forms of non-language or perceptual training before beginning language therapy as it has been shown that these pre-language training procedures form the basis for conceptual development. summary five brain-injured children were compared with five non brain-injured children on the itpa and a generalization test devised by the writer. these children were aged between 7 and 11 years, and their iq scores tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 l i a n a oken were between 65 and 80. all the children were in special classes in government schools in johannesburg, and were free of auditory, visual and physical disabilities. the results of this investigation were presented and discussed in terms of whether any difference in language ability of the subjects in this study was present, so as to see whether there was a "typical" profile for each diagnostic group. it was concluded that there are different types of peaks in the profiles of the two groups, and that both groups have poor generalization ability. a close inter-relationship' between language and generalization abilities was considered to exist. opsomming vyf kinders met breinbesering is vergelyk met vyf kinders sonder breinbesering deur middel van die itpa en 'n veralgemeningstoets wat deur die skrywer opgestel is. die kinders se ouderdomme was tussen 7 en 11 jaar, en hulle ik's tussen 65 en 80. alle kinders woon spesiale klasse in staatskole in johannesburg by, en was sonder gehoor, gesigs en fisiese gebreke. die resultate van hierdie ondersoek was bespreek in terme van die moontlike verskil in taalvermoe van die twee groepe. daar was gepoog om te sien of daar wel 'n profiele was wat „tiperend" is van elke diagnostiese groep. die afleiding is gemaak dat daar verskillende soorte pieke in die profiele van die twee groepe voorkom, en beide groepe het 'n swak veralgemeningsvermoe. dit het geblyk dat daar 'n noue verband tussen taal en veralgemeningsvermoe was. references 1. alexander, h. g. (1967): language and thinking. d. von nostrand co., inc., new york. 2. bateman, b. (1965): "the role of the illinois test of psycholinguistic abilities in differential diagnosis and programme planning." american 'journal of orthopsychiatry, 35, pp. 465-472. 3. bateman, b. and wetherell, j. (1965): "psycholinguistic aspects of mental retardation." mental retardation, 3, 2, pp. 8-14. 4. bialer, 1. (1961): "primary and secondary stimulus generalization as related to intelligence level." journal of experimental psychology, 62, 4, . pp. 395-402. 5. bruner, j. s., goodnow, j. j. and austin, g. a. (1957): a study of thinking. john wiley & sons, inc., new york. 6. copelowitz, l. b. (1966): "perceptual and conceptual defects of the braini n j u r e d child (including the cerebral palsy)." unpublished dissertation for the degree of b.a. logopedics, university of the witwatersrand. 7. gallagher, j. j. (1957): "a comparison of brain-injured and n o n braininjured mentally retarded children on several psychological variables." monographs of the society for research in child development, 22, 2, n o . 8. hamilton, j. (1966): "learning of a generalized response class in mentally retarded individuals." american journal of mental deficiency, 71, i, pp. 1 0 0 1 0 8 . • 9. k h a n n a , j. l. (1968): brain damage and mental retardation. charles c. thomas. springfield, illinois, u.s.a.| 10. leventhal, d. s. (1966): "a study of the roles of perceptual and conceptual categorization." dissertation abstracts, 27, 118, pp. 316-317. journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the brain-injured and n o n brain-injured mentally retarded child 47 11. luria, a. r. (1963): the mentally retarded child. p e r g a m o n press, new york. 12. mccarthy, j. j. and kirk, s.a. (1961): illinois test of psycholinguistic abilities—examiner's manual. university of illinois, institute for research on exceptional children, urbana illin. 13. mcmurry, j. g. (1954): "rigidity in conceptual thinking in exogenous and endogenous mentally retarded children." journal of consulting psychology, 18, 5, pp: 366-370. 14. riggs, μ. m. and rain, μ. e. (1952): "a classification system for the mentally retarded." the training school bulletin. 49, pp. 75-84. 15. rosenstein, j. (1961): "perception, cognition and language in deaf children." exceptional children. .27, pp. 276-284. 16. rosenstein, j. (1963): "concept development and language instruction." exceptional children. 30, pp. 337-343. 17. schulman, j. l., kaspar, j. c. and throne, f . m . (1965): brain damage and behaviour. a clinical experimental study. charles c. thomas. springfield. illinois. 18. siegal, g. m. (1964): "prevailing concepts in speech research with mentally retarded children." asha, 6, pp. 192-194. 19. silverman, t. r. (1967): "categorisation behaviour and achievement in deaf and hearing children." exceptional children. 34, 4, pp. 241-250. 20. strauss, a. a. and kephart, n. c. (1955) :psychqpathology and education of the brain-injured child. g r u n e & stratton, new york. 21. strauss, a. a. and lehtinen, l. (1947): psycho pathology and education of the brain-injured child. g r u n e & stratton. new york. 22. vygotsky, l. s. (1962): thought and language. m.i.t. press. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a preliminary assessment of radical surgery in cleft palate deformities d a v i e s , d a v i d , f.r.c.s.* whiting, d.m., b.a. log. ( r a n d ) , l.c.s.t. miller, b.h., b.d.s. ( r a n d ) , d . orth. f.d.s. r.c.s. (eng.) cremin, b.j., m.b.b.s., m.r.c.s., m.c.r.a., f.f.r. morrison, g., f.c.s. (s.a.) *plastic surgery, groote schuur hospital, university of cape town summary the d e v e l o p m e n t and aims of the single stage repair of c o m p l e t e clefts of the lip and palate are presented together with a preliminary account of results. opsomming die ontwikkeling en die doelstellings van 'n enkele stadium herstel van gesplete lip en verhemelte word aangebied saam met voorafgaande bepalinge van die resultate. in the repair of cleft lip and palate deformities surgeons have always considered these two entities as separate deformities when corrective surgery was undertaken. indeed many authorities 5 · 6 · 1 1 · 1 2 · 1 3 today, still prefer to repair the lip alone at any age from 48 hours after birth to 3 months; followed later by correction of the hard palate deformity, and at the age of one year to eighteen months, a final operation to close the soft palate defect. some indeed even regret the fact that the two deformities are associated. consider this quotation from brown and mcdowell1; it is unfortunate that cleft lips so frequently coexist with cleft palate causing many surgeons to be preoccupied with closing part of the palate at the same time the lip is closed. aside from the probability that early surgical treatment to the palate may result in unnecessary dental damage, it seems to us that good repair of the lip is difficult enough to require the surgeons undivided attention in the process. perusing the literature we can see that there are those who follow the conventional pattern described above of lip repair hard palate repair soft palate repair. veau1 4, who did much to stimulate modern cleft palate surgery, repaired lip and hard palate together, followed later by repair of the soft palate. many followed this technique and schmid8, nordin and johanson7, schrudde and stellmach9, combined this with an immediate autogenous bone graft to close the alveolor gap. others such as slaughter11, schewendiek10 and longacre3, feel that the lip should be closed early, and at six months the soft palate should be repaired leaving the hard palate unrepaired until the age tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 19 desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 of 6-8 years. in this interval an obturator is used to fill the defect in the hard palate. the rationale is that early closure of the soft palate aids early and normal speech function while the untouched hard palate allows normal development of the maxillary arches, thus leading to less bony deformity and orthodontic disability. at the red cross war memorial children's hospital in cape town, our predecessors dr. norman peterson and dr. d.s. davies, followed the early pattern of lip hard palate soft palate closure, and later changed it to lip and hard palate soft palate closure. in 1964, we felt that a unilateral cleft lip and palate deformity should be treated as one congenital deformity and repaired at one operation. our rationale for this was firstly technical; all the structures are easily accessible and the operation is in many ways easier than the multistage procedures. secondly, the operation was completed in one stage which held many advantages for mother and child,·especially as a large number of our patients came from far flung country districts, and under poor socio-economic conditions it is always easier for the mother to care for these infants if the palate has been reconstructed at an early age. thirdly, we felt that the orthodontic aspect of this congenital deformity had been stressed at the expense of speech. normal speech, after all, should be the prime objective of all surgeons working in this field, and if this more extensive operation held forth the promise of improved speech results because of early complete closure, then it should be completely investigated. surgical procedures a series of operations was started2 and an effort was made to standardise the operation so that in our assessment of the speech and orthodontic results there should be as few variables as possible. we plan to complete 50 cases with a z-plasty lip repair, autogenous rib bone graft to alveolar gap, one layer vomerine mucosa repair of hard palate defect and a push back of the soft palate with a millard4 island flap. the next 50 cases will have z-plasty repair of the lip, no bone graft to alveolar gap, vomerine mucosa repair of the hard palate, and a 2 flap wardill16 push back repair of the soft palate with tvo millard island flap. finally 50 cases with z-plasty repair of lip and simple modern von langebeck15 repair of palate with no push back of the soft palate. no patients will be excluded from this series because of the size of the congenital defect, and there will be no particular selection of cases-t'o any of the above series. with this series we should be able to show whether early surgery of this magnitude is dangerous for the child or not; whether primary bone graft inhibits maxillary growth; whether early closure of the palate predisposes to more normal speech; whether early radical surgery leads to poorer orthodontic results and finally whether an island flap repair or a push back procedure has any advantages over a simple palatal closure. journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a preliminary assessment of radical surgery in cleft palate deformities 5 we have so far completed 95 cases and it seems possible at this stage to say that the procedure is not technically difficult and there does not appear to be any added risk for the child. blood loss over the series has averaged 10% of" the blood volume, and the last twenty cases have lost only from 15 to 50 c.c. of blood, for a 2 hour procedure. obviously these operations must be done by a cohesive team and under the best anaesthetic conditions. it is clear from the above that we believe in early closure to achieve normal muscular action, at as early an age as possible. this principle should extend to simple clefts of the secondary palate, and bilateral complete clefts as well. ten of these have been closed as a one stage procedure. complete unilateral repairs have been done at 10 days of age, but in view of possible associated cardiac anomalies, which often manifest themselves only in the first month of life, we have now fixed our optimum age at 3 months. by this time the child should weigh more than 4,5 kgs. and have a normal haemoglobin level. obviously it is too early to draw any but the most sketchy and preliminary conclusions from this series. there is no place in any competent team for the plastic surgeon who attempts to assess his own results; these must be reviewed by a speech therapist and an orthodontist. speech assessment the format of the speech assessment used in our clinics is specifically designed for its clinical implications for future management of each individual case. velopharyngeal competence is judged objectively on tests and subjectively in spontaneous speech on a 4 point scale. mixed or deficient nasal resonance is noted when present. articulation is assessed in words first with the nose open and then all errors are checked with nostrils closed to determine whether the error is due to inadequate intra oral air pressure or incorrect placement of articulators. errors in tongue-tip consonants are checked with particular reference to irregularities in the anterior maxillary arch and upper dentition. a particular note is made as to whether articulation deteriorates in spontaneous speech or not. speech classification for cleft lip a n d palate a r e s o n a n c e a1 normal resonance. a2 slightly excessive nasal resonance. a3 medium nasal resonance. a4 gross nasal resonance. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 β a r t i c u l a t i o n b1 no articulation errors. b2 one or two articularion errors only. (nb phonetic equivalents such as s,z,; t,d; k,g,; i.e. voiced and voiceless counterparts are counted as 1 error.) b3 three or more articulation errors, but intelligible. (nb a patient with only 2 articulation errors in words, but whose articulation deteriorates in spontaneous speech is classified as b3.) b4 multiple articulation errors unintelligible. examples of: 1. s,z; r (2 errors) 2. s,z,; t,d (2 errors) 3. s , z „ sh, ge (2 errors) 1 . s,z,; sh, ge; ch,j. (3 errors) 2. s,z,; t,d„;r (3 errors) 3. s,z,; sh; ch; r (4 errors) b4 plosives as glottals, distortions or omissions of sibilants. c l a s s i f i c a t i o n e x a m p l e s αι b1 normal speech. αι b3 normal resonance, 3 or more articulation errors. a2 b2 slight nasal resonance, 1 or 2 articulation errors. a3 b1 medium nasal resonance, no articulation errors. a4 b4 gross nasal resonance. multiple articulation errors; unintelligible. to be classified as b2, a child's articulation errors remain the same in spontaneous speech as in words. the child who has only one or two articulation errors in words but whose articulation deteriorates in spontaneous speech is classified as b3. the results of the speech assessment together with results of x-ray, hearing evaluation, and case history will indicate whether the residual speech defect is due to:/ a) anatomical anomalies of 1) velopharyngeal mechanism or 2) anterior maxillary arch and dentition. b) incompetence of function c) other factors such as hearing loss, developmental lag, mental retardation, or cultural deprivation, etc. we include some preliminary figures from the one stage repair series, but it must be emphasised that this is an incomplete series, and we feel that some of these cases can be expected to improve as they grow up. journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a preliminary assessment of radical surgery in cleft palate deformities unilateral cleft lip and palate one stage repair series a1 a2 a3 a4 complete assessment incomplete assessm ent total 11 11 4 1 27 19 4 6 b1 b2 b3 b4 complete assessment incomplete assessment total 6 9 9 3 27 19 4 6 table i analysis of speech results assessments between 1.1.70 and 30.4.72 20 cases age range — 4 yrs. 9 yrs. assessment between 1.1.68 and 31.12.70 7 cases age range — 4 yrs.-10 yrs. incomplete assessments — 19 cases in may '72 a1 a2 a3 a4 total 9 6 4 1 2 0 b1 b2 b3 b4 total 5 7 6 2 2 0 table ii analysis of complete assessments at follow-up between 1.1.71 30.4.72 orthodontic assessment no pre-surgical dental orthopaedics has been carried out on the maxillary arches of these patients. orthodontic assessment is made on:1. models pre-operative intra oral impressions of both upper and lower jaws are taken in the operation theatre immediately before the operation with the child anaesthetised. they are cast in stone and trimmed so that the correct relationship is shown between the upper and lower dental arches. these models are repeated usually at yearly intervals or at the appropriate time to show dimensional changes. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 19 desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 a1 a2 a3 a4 total group total + island flap 4 7 2 1 1 4 27 — island flap 7 4 2 13 27 b1 b2 b3 b4 total group total + island flap 3 3 6 2 14 27 — island flap 3 6 3 1 13 27 table iii speech results in relation to island flap in the 27 cases fully assessed. age b1 b2 b3 b4 total 4 2 1 3 2 8 5 3 4 2 9 6 1 1 2 7 1 1 2 8 1 1 2 9 1 2 3 10 1 1 total 6 9 9 3 27 table iv articulation and age at assessments of the 2 7 cases. 2. ' cephalometric x-rays / these are true lateral views of the skull and jaws taken with the head held in a fixed position, and at a standardised target film distance. they are therefore, strictly comparable to show growth changes in a longitudinal study. a sample series of 30 cases was used for a preliminary survey. in this instance only the pre-operative and most recently .taken dental models were used for assessment. the average age at operation was 6,7 months with a range from 4 months to two years. final models of the dental arches were taken at an average age of 3 years, the oldest being 5 years and 10 months. journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a preliminary assessment of radical surgery in cleft palate deformities 9 b1 b2 • b3 β 4 total maxillary arch and dental a n o m a l i e s 0 5 3 8 dysfunction 0 2 1 3 other factors 0 2 3 • 5 undetermined 2 3 5 normal articulation 6 6 totals 6 9 9 3 η table v analysis of causes of articulation errors. results show that 47% of these patients have a class iii relationship of the incisor teeth, i.e. the lower incisors occluding in front of the upper. the remaining 53% have a class i (or normal) occlusion. the'maxillary minor segment showed varying degrees of collapse in 66,7% of cases. this was assessed by relating the teeth on the minor segment to the opposing mandibular teeth and noting the amount of collapse towards the midline. although the percentage of cases showing class iii incisor relationship and collapse of the minor segment may appear to be high, these figures compare quite favourably with those of other published series. also in many of these cases, simple orthodontic treatment is all that will be required to bring about correction. it will however, be necessary to follow up a larger number of cases over a longer period of time before any final conclusion can be reached regarding growth of the dento-facial complex. radiological assessment the radiological assessment of these cases consists of static and dynamic studies which are pre and post-operative. the static studies are cephalometric measurements which are performed in the first few months of life, using an infant cephalostat and-sedationv the dynamic studies are a joint examination done by a team which consists of at least the surgeon, radiologist, and speech therapist. the parents are also , often invited to attend. children from 3 years upwards are examined by a pulsed image intensifier using a 5 inch (magnification χ \ vz ) field projected " onto a television screen. the length and mobility of the soft palate, and its capacity for sustained naso-pharyngeal closure, during repeated set sentences, are noted and assessed. a simultaneous speech videotape recording is also tydskrf van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 made and interesting or difficult cases are immediately played back and restudied. the videotape can later be transferred by kinescope camera onto 16 mm. film for further study on an analector camera. the advantages of this method over 35mm. cine radiography are that it enables the team to make a definite and immediate assessment, as development and projection facilities are not required (except for the delayed studies). the irradiation exposure to the child, which can be considerable with cine radiography, is also greatly reduced. the soft tissues of the pharynx are so well visualised in these lateral studies that no contrast material is required. a 70 mm. camera study is also routinely performed (this involves no extra irradiation as it directly photographs the output phosphor of the image intensifier). these films are taken at 3 per sec. for 1,5 sees, using the sounds of mmh; aah; eeh and ssh to record palatal mobility and velopharyngeal closure. the films are then mounted as four strips in a plastic envelope that is conveniently kept with the patient's hospital record folder, so that comparative studies are always available. we feel that thorough long term assessment of these children will, in time, produce interesting figures of an unusual operative approach to the problem of cleft palate deformities. acknowledgement we would like to thank the medical superintendent of the red cross war memorial children's hospital for permission to publish these figures and record our gratitude to professor louw and professor cywes for their continuing encouragement. finally, we must acknowledge our debt to the murray trust fund without whose generous gifts we would not have been able to undertake this research. references 1. brown, j.b. and mcdowell, f. (1945) surgical repair of single cleft lips. surg. gynae. obstet. 80,12. 2. davies, d. (1970) the radical repair of cleft palate deformities. cte/ir palate j. 7,550. 3. longacre, j.j. (1970) cleft palate deformation: charles c. thomas. springfield, illinois. 4. millard, d.r. (1962) wide and/or short cleft palate. plast. reconstr. surg. 29,40. 5. millard, d.r. (1971) in cleft lip and palate. grabb, c.w., rosentein, s.w. and bzoch, k.r. (eds.), little, brown, boston, 6. musgrave, r.h. (1964) the unilateral cleft lip, in reconstructive plastic surgery, converse, j.m. (ed.), saunders, philadelphia. journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a preliminary assessment of radical surgery in cleft palate deformities 11 7.· nordin, k.e. and johanson, β: (1955) fortschur, kiefer gesichts chir., 1,168. 8. schmid, e. (1955)fortschur, kiefer gesichts chir., 1,37. 9. schrudde, j. and stellmach, r. (1959) fortschur, kiefer gesichts chir., 5,247. 10. schweckendiek, h. (1966). primary veloplasty, in treatment of patients with clefts of lip, alveolus and palate, schuchardt, k. (ed.), georg thieme verlag, hamburg. 11. slaughter, w.b. and pruzansky, s. (1954). the rationale for velar closure as a primary procedure in the repair of cleft palate defects. plast. reconstr. surg., 13,341. 12. tennison, c.w. (1971), in cleft lip and palate. grabb, c.w., rosenstein, s.w. and bzoch, k.r., little, brown, boston. 13. trusler, h.m., bauer, t.b. and tondra, j.m. (1955). the cleft lip problem. plast. reconstr. surg. 16,174. 14. veau, v. (1938). bec-de lievre. masson et cie, paris. 15. von langenbeck's surgical procedure. (1951) in cleft lip and palate, holdsworth, w.g., heinemann medical books. 16. ward ill's surgical procedure (1951) in cleft lip and palate, holdsworth, w.g., heinemann medical books. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) s p e e c h t h e r a p y in c o l o u r e d schools, b y dorothy cornelius b.a. log. (rand) introduction. the need for a regular speech therapy service has been recognized by the transvaal education department as an essential part of education. this year a speech therapy post was specially created to cater for pupils with speech, voice and hearing defects in coloured schools. apart from facilities at the university of the witwatersrand speech, voice and hearing clinic, only meagre amenities existed for coloured speech defective children in the witwatersrand area. working conditions. the writer is at present attached to five the writer is at present attached to five schools. each school is visited approximately five times in three weeks. in addition a clinical service is run in the afternoons to cater for those children from schools which are not serviced. the clinic has its headquarters at the rand college of education for coloureds in coronationville. a classroom is used and essential items of furniture have been provided by the college. surveys of speech defectives. surveys were carried out during february and march this year. the following method was used to determine the number of speech, voice and hearing defectives at the schools: i 1. teachers were given lists with the following screening guide. (a) stuttering: excessive repetition and hesitation of words, syllables and phrases. i (b) voice disorders: e.g. voice too loud, too harsh, too soft, too high, too low, breathy. (c) articulation errors varying from complete ommission to substitution and distortion of sounds, e.g. lisp ('s' difficulty) and brei ( v difficulty). (d) severe language disturbance involving (d) comprehension and expression. (e) cleft lip and palate: speech usually very nasal. (f) hard of hearing: teachers were given 7 points to addist them to detect children in this category. approximately 60% of the teachers were able to determine the speech disorders in their classes. the remaining 40% felt they were not able to detect these defects immediately and they suggested that they observe their classes more exactly for several weeks in order to establish the cases more thoroughly. in these cases the writer did the surveys herself. during the first terms of the year the grade i classes were omitted from the surveys; except for the. obviously severe cases which had to come to the notice of teachers. 2. children were asked to count from 1 to 10, and were also asked several questions about their families, friends, hobbies etc. stutterers, cases of oral inactivity and articulatory errors were detected during these initial speech activities. results of survey. results of the survey of speech defectives carried out at 7 primary schools and 2 high schools, revealed the following data:19 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) table i. a detailed analysis of speech defectives in 9 coloured schools in johannesburg. school. no. of pupils no. with speech defects. % per school. a 389 36 9.3% β 534 40 7.5% c 546 75 14.0% d 593 70 12.0% ε 1012 117 11.0% f 311 57 18.3% g 185 35 19.0% η 992 62 6.2% i 946 60 6.3% table ii: number and percentage of different speech defects per school. no. with cleft school speech defects dysphemi s /lalia /audi a /phonia /logia palate. a36 6 (1.5%) 26 (6.7%) 3 (0.8%) 1 (0.2%) β 40 19 (3.7%) 15 (2.8%) 6 (1.1%) c 75 21 (3.8%) 42 (7.7%) 6 (1.0%) 3 (0.5%) 3 (0.5%) d 70 19 (3.2%) 37 (6.0%) 7 (1.1%) 2 (0.1%) 3 (0.5%) 2 (0.2%) ε 117 33 (3.4%) 61 (6.0%) 8 (0.8%) 6 (1.6%) 9 (0.8%) 1 (0.1%) f 57 16 (5.0%) 21 (7.0%) 12 (3.8%) 5 (0.6%) 3 (0.9%) g 35 11 (5.0%) 12 (6.4%) 6 (3.2%) 2 (1.0%) 4 (0.2%) η 62 29 (3.0%) 20(2.0%) 11 (1.1%) 2 (0.2%) i 60 16 (1.7%) 27 (2.9%) 13 (1.3%) 3 (0.3%) 1 (0.1%) table iii. total percentages of speech defects. dyslalia 47.1% dysphemia 30.8% dysaudia 13.0% dysphonia 4.0% dyslogia 4.0% cleft palate 0.9% discussion of results. from table 1 it can be seen that there is a. marked tendency for speech defectives to increase from 7.5% in the coronationville area (higher income group) to 19% in the booysens area, where the socio-economic standards are much lower. schools c and d with percentages of 14% and 12% respectively, although situated in a central area in the city, have children on their roll who live in the area known originally as western native township. formerly these families lived in the city but have since been evacuated. many of the children attending these two schools live in riverlea, fordsburg, ferreirastown and doornfontein. poor home conditions and very low standards of living in these areas may be contributing factors to the increased incidence of speech, voice and hearing defects in these schools. the two high schools included in the survey 20 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) cater for pupils from std. 6 to matric. when compared with the primary schools wide discrepancies may be noticed. the contrast in results suggests that the number of speech defects decreases over the years; either because many of the children have "out grown" their defects, or alternatively, have left the school before completing their education. the high school population is not representative of the population as a whole because children from the lower socioeconomic groups leave school earlier as compulsory education does not as yet apply to coloured schools. therefore, it would seem desirable to study speech defects in a more random sample of the adult population before making any generali zations. dysphemia. the incidence of dysphemia was found to be disturbingly high. in schools f and g the incidence is 5.1% and 5.9% respectively. in the areas where these schools are situated there is undeniable evidence of unstable or grossly irregular home life with recurrent patterms of illegitimacy, divorce and turbulent familial relationships. in school ε 3.3% of the speech defectives were stutterers and a quarter of these children were living at an orphanage. it would therefore appear that a contributory factor would be the unmet emotional needs and unsatisfactofy social relationships. in these cases stuttering might perhaps act as a vehicle to attract attention, love and affection. on the other hand it may be seen as a reaction to the strain of gross poverty and neglect. this higher incidence of stuttering among the lower socio-economic groups would seem to be the converse of the findings of other research workers in the field. from the investigations it could be concluded that stutterers were from could be concluded that stutterers were from predominantly j middle and upper class families. dyslalia. j children with articulatory disorders constitute the bulk of speech defectives. 47% of all the cases in this 'study were found to have articulatory errors, ais seen in table iii. the most common errors, are the 's', v and 'th'. errors varied from complete om'mission to substitutions of other sounds -and distortions of the particular sound. in many cases it was noted that the tendency to 'brei' (guttural v ) was a familial occurence; usually adopted from parents who invariably came from the cape districts where this is an accepted form of speech. in one family, four of the five children used to 'brei'. 'th' defects were found frequently among the afrikaans speaking children as this consonant blend is absent in afrikaans. these children often used 'de' as a substitute. dysaudia. the highest rate of hearing defects was noted in schools f and g. an explanation for this high rate may be that neglected colds lead to ear infections. because of the lack of medical and surgical treatment, some of the middle ear infections lead to permanent, hearing impairment. dyslogia. mentally defective cases constitute a great problem. because of the complete lack of special schools, a large percentage of these children are accomodated in schools for normal children. the impression was gained from discussions with a number of teachers that nothing much can be done for these backward children. they make very little progress as the classes are large and overcrowded (approximately 40 to 50 per class) and teachers are unable to give individual attention to these children. cleft palate. the incidence of cleft palate is approximately 1 in 1,000. however, no definite conclusions can be drawn as the sample was far too small. there is however reason to believe that the incidence of cleft palate is quite high in the coloured community. possible etiologial factors. in addition to the factors named above regarding possible casual factors of speech defects, the writer will venture to present a number of problems which affect the coloured community in particular, and which might possibly contribute to speech defects. in many cases speech defects were found to have no organic origin, but were a reflection of a disturbance in the whole emotional growth of the child. 21 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) children who do not talk at achool or who stutter have been found to be using various mechanisms of defence to cope with the situation at home or at school. a case in point was that of an 8 year old boy who sometimes spoke to peers in his classroom, but as soon as he was addressed by a member of the staff, he immediately became silent. an examination of conditions at home revealed that the prevailing attitude towards the children was 'children should be seen and not heard'. if the children spoke out of turn they were punished. the school itself should not be excluded as a possible factor contributing to the problem of stuttering, particularly as so many of the teachers show a complete ignorance of the problem and do not know how to treat a stutterer they may have iri their class. the child is often exposed to a teacher who is over-demanding and severe and who may con stantly ridicule and correct the child's speech. such a child may develop additional feelings of inadequacy and so aggravate the existing problem. a factor which may also promote the high incidence of speech disorders in primary schools is the abrupt plunge into formal learning without any previous preparation. the complete lack of nursery schools with trained staff does not give the child an opportunity to develop emotionally, physically and socially at his own pace.. studies have shown that where the community is not sufficiently integrated there is a greater incidence of social disorganization. since speech is viewed as an aspect of social behaviour it may be said to be a means of performing social roles. in the writers experience and general observation there appears to be very little group cohesion among members of the coloured community. there are several reasons which may be advanced for this; one of these being that members of the community have themselves created divisions in terms of class groups. for the most part these class groups are arbitrarily acquired and maintained. the following case related to the writer by a speech therapist illustrates the above point: a 7 year old boy who had previously coped adequately at school suddenly showed a marked decline in his standard of work. in addition he became very morose and withdrawn and refused to speak. to observers who were unaware of his previous performance he even seemed retarded. an examination of home conditions revealed that there were two other children in the family who were attending a european school. these children it appeared, were lighter skinned than the boy in question who was unable to pass for white. this family thus had difficulty in having him classified with the others. it was also discovered that the other two children had previously attended the coloured school from which they were later removed. this produced a tremendous emotional disturbance in the child hence his poor performance at school and his refusal to talk. some case records a few cases have been selected to illustrate etiological factors and some therapeutic aids that have proved to be effective. case 1: john, a 17 year old boy, was unable to control the pitch level of his voice. he would begin in a low pitch (suitable for his age and physical development) and then would suddenly become tense and revert to a high, tremulous voice. innitially, interviews with parents did not reveal anything significant and on ly after prolonged exploration of the history and self-concept of the case and his environment did the etiology become clear. the boy admitted that he forced himself to use the high pitch long after puberty. he was afraid that his parents would accuse him of smoking with the other teenagers in the district once his lower register became apparent. it was subsequently· found that the parents used various harsh disciplinary methods to subdue his emerging personality and were suspicious of every move and sign of independence. generally his behaviour annoyed and irritated them. in an attempt to ward off these attitudes he experienced increased anxiety and adopted behaviour patterns that were immature, embarrassing and anti-social. it was therefore necessary to give parental guidance and also build up the boy's confidence in himself. as therapy progressed he gradually gained control over his voice arid was able to relax. once he had learnt to use his new pattern consistnetly another problem arose. he was afraid to use the new voice at home because of the reaction it might evoke from his listeners. thus further home visits were made in order to gain the 22 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) parent's continued co-operation and understanding. case 2. peter, aged 7 years was the youngest of seven children. he was referred for therapy because of his stutter and additional aggressive tendencies. the interview with his guardian disclosed that he had had an extremely unstable emotional life. until recently he had lived with his parents who were about to be divorced. he had often witnessed their quarrels and violent figjits and on these occasions he would become hysterical. once his parents had separated he lived with his paternal grandmother who gave him very little affection and attention. inconsistent discipline, scolding, nagging, impatience and occasional indulgence added to his insecurity. his home conditions have considerably improved since he now lives with his maternal grandmother who is understanding and is able to build up a feeling of security. through psychodrarna and participation in a group, he has been able to free himself of much inner tension and internalized hostility. he has since made good progress. case 3: patrick, a 13 year old decondary stutterer who was completely lacking in self-confidence, had acute feelings of inadequacy and suffered increased rejection from his parents, particularly his mother, who had stuttered herself as a child and was violently aggressive towards him. at the onset of therapy he was severely emotionally disturbed and his pattern of stuttering was characterized by frequent and sudden spasms, inspiratory gasps, closing of his eyes, oscillation of the jaw, turning his head to one side and clenching his hands. his whole body was tense and rigid during each block. therapy aimed at increasing and supporting his morale by drawing attention of his assets and so changing his self-concept. his fear of stuttering was broken down by providing positive speaking situations |in which he experienced success. after a few months he had improved considerably. his teacher reported that his school work had also improved and he showed more self-assertion and initiative in class. j difficulties encountered in therapy. one of the most urgent problems facing the writer is the lack of professional consultants e.g. psychologists and neurologists, from whom to obtain additional recommendations and to whom children can be referred for differentiated tests. this is particularly important in cases of dysphasia, dyslexia etc. the achievement of accurate hearing assessment is also difficult as the only available audiometric facilities are at the johannesburg general hospital. many parents are unable to take their children in for testing as they cannot afford to lose a day's wage, by taking the time off from work. for many even the busfares are too costly and therefore the children are never tested adequately. an added difficulty is that of working in a newly established clinic where facilities are, as yet, crude. there is a lack of adequate equipment and the atmosphere of stimulation and cooperation from other therapists is lacking. need for educating the community regarding the role of speech therapy. greater recognition needs to be given by the community to the value of speech therapy. here the school can play an important role as it has a recognized status. it is seen as an educational institution and as such its activities are accepted as furthering the aims of education which the community desires. many parents are as yet suspicious of the therapist's intentions as they have not previously encountered this aspect of education. speech therapy is often regarded as 'learning to talk snobbishly' and the significance of the service as a remedial innovation is not clearly understood. by its inclusion as a free school service and the facilities of parental counselling which it offers, many of these barriers may be broken down. in addition, positive promotion by the school administration and talks to parent-teacher associations will increase the co-operation and recognition which is so urgently needed, if the speech therapist is to fulfill her function to the community. conclusions. the school setting provides opportunities for early detection of speech problems and for work 23 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) of a remedial nature. it is often an effective medium for reaching the child who has both speech and emotional problems. in numerous cases speech problems appeared to be tied up with unfavourable home conditions. thus it is essential to work with all those factors which have a bearing on the child's development, i.e. the family, school and social milieu. although no definite conclusions can be drawn at this stage, the study does seem to point out that a larger percentage of speech defects were found among children from the lower socioeconomic groups. this work has been of an exploratory nature and it is felt that many challenging aspects regarding the coloured community are open to further research. in this paper only pertinent problems have been briefly outlined. summary. for the first time this year a post for a speech therapist was made available to cater for the needs of speech defectives in coloured schools. results of the survey suggest that a large percentage of children require speech therapy. a detailed analysis of the results has been given in tabular form. the writer has ventured to give a number of possible etiological factors and has also presented some of the problems which appear to affect the coloured community in particular. opsommihg. vir die eerste keer, is daar gedurende hierdie jaar 'n pos vir 'n spraakterapeut geskep, sodat aan. die behoeftes van die nie-blanke skoolkind voldoen kan word. die resultate van die opname dui op 'n hoe persentasie van kinders wat spraakterapie benodig. 'n uitvoerige ontleding van die resultate is in tabelvorm gegee. die skrywer het gepoog om verskeie etiologiese faktore vas te stel en het verder ook gedui op sekere probleme wat blykbaar net betrekking het op die nie-blanke gemeenskap. 24 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) profiles o f outpatient speech-language therapy and a udiology clients at a tertiary hospital in the western cape 49 profiles of outpatient speech-language therapy and audiology clients at a tertiary hospital in the western cape w endy overett and harsha kathard division o f communication sciences and disorders, university o f cape town a b s t r a c t this stu d y d e s c r ib e d trends in the dem ographic, diagn ostic, a n d attendan ce va ria b le s o f first-tim e clien ts who a tten d ed the speech l angu age therapy a n d a u d io lo g y o u tp a tien t d ep a rtm en t (o p d ) a t a te rtia ry h o sp ita l in the w estern c ape o v e r a f iv e -y e a r p e r io d (19992003). a retro sp ective, d e scrip tive su rve y w a s co n d u cted a n d d ata w ere c o lle c te d fro m h o sp ita l records. the d a ta w e re coded, a n a lyse d d es crip tive ly a n d re p rese n ted in tables, fig u r e s a n d graph s. the d ia g n o stic c a teg o ries o f h earin g loss a n d v o ic e d iso rd e r m ade up the h ighest p e r c e n ta g e o f referrals. the la rg e st p e r c e n ta g e s o f clien ts w ere re fe rred fr o m the ear, n o se a n d throat (ent) d ep a rtm en t a t the stu d y hospital, f o llo w e d b y the edu cation sector. d em o g ra p h ic trends in d ica ted th a t the h ig h est p e r c e n ta g e o f clien ts a tten din g the o p d w as in the a g e ca teg o ry o f 7-12 ye a rs, that sim ila r p e r c e n ta g e s o f m a le a n d fe m a le clien ts a tte n d e d the opd, an d th at english w a s the language th a t a clien t w as m o st likely to speak. g eograph ically, the highest p e r c e n ta g e o f clien ts a tten d in g the o p d w a s fr o m the k lip fo n tein region. a tten d a n ce d a ta r e v e a le d th a t a p p ro x im a tely 70% o f clien ts a tte n d e d o p d appoin tm ents within a three-m onth tim e p e ­ rio d a n d a tten d ed no m ore than tw o appointm ents. p erc en ta g e o f appoin tm ents a tte n d e d d e c r e a s e d with in creasin g num bers o f sch ed ­ uled appointm ents. im p lica tio n s f o r research a n d se rv ic e d e liv e ry a re discussed. key words: speech-language therapy and audiology services, healthcare, service delivery, client profiles, attendance introduction this study aimed to describe the client population profiles of those attending the speech-language therapy and audiology outpatient department (opd) at a tertiary hospital in the western cape in south africa over a five year period (1999-2003). to achieve this aim, the demographic, diagnostic and attendance data of a study sample were determined. the impetus for this study arose from difficulties the researcher experienced while attempt­ ing to engage with service planning for speech-language ther­ apy services in a post-apartheid era at a tertiary hospital in the absence o f knowledge o f descriptive client data. in the south african public sector, slt & audiology ser­ vices have traditionally been located in both the health and educa­ tion sectors. in the health sector these services have been consid­ ered as part o f allied health service delivery with emphasis on rehabilitation (allied health professionals technical committee, 2004). although health services are essential, they fail to reach many people in south africa due to a lack o f resources. histori­ cally, health service delivery in! south africa has been shaped by the medical model and complied with apartheid ideology (bhagwanjee & stewart, 1999; hall, haynes & mccoy, 2002). public health services were characterised by racial and geographi­ cal disparities, fragmentation and duplication o f services and were hospital-centred with minimal emphasis on primary health care (phc). the combined influences o f the medical model and apart­ heid ideology resulted in an inequitable provision o f services in terms o f accessibility, appropriateness, funding and co-ordination across the variables o f race, class, gender and level o f urbanisa­ tion (bhagwanjee & stewart, 1999). the healthcare system was divided, inefficient and grossly inequitable (hall et al., 2002). speech-language therapy (slt) and audiology services in south africa have been shaped by such socio-political contex­ tual realities and are also grossly inequitable (pillay, kathard & samuel, 1997). services in south africa have been biased toward providing a better quality service to a white, middle class, eng­ lish and afrikaans first language speaking population, whilst pro­ viding a poorer service to a black african first language speaking clientele (pillay, 1996 cited in pillay et al., 1997). public sector slt & audiology services have historically been based in hospi­ tals and special schools, with minimal service delivery at commu­ nity level. similar to the national profile, services in the western cape have been urban-based with few speech-language thera­ pists and audiologists working in rural areas beyond the cape metropole. health sector provision o f slt & audiology services have been limited to services at tertiary hospitals, with little avail­ able at primary or secondary levels in the western cape (allied health professionals technical committee, 2004), thus limiting access and availability o f services to the majority o f the popula­ tion. the current service delivery situation is untenable given the prevalence o f disability in the western cape. the data from the 2001 census (statistics south africa, 2004) regarding the numbers o f people with communication, hearing or multiple dis­ abilities point to the need for slt & audiology services in the city o f cape town and in the western cape. the need for acces­ sible services, coupled with appropriate planning, and importantly the knowledge to assist such planning, is essential to meet the service delivery needs o f this population. over the last decade, systemic changes have taken place within the health system which have had a bearing on slt & audiology services. subsequent to south africa's first democratic elections in 1994, the national department o f health set about transforming and restructuring the healthcare system (hall et al., 2002; forman, pillay & sait, 2004). these changes included a policy shift to a primary health care (phc) approach within a dis­ trict health system (dhs), with intent to realise a social model of health. the aim o f such transformation has been to improve the quality o f care provided and create a more equitable service. there is a critical need for relevant knowledge to inform such planning processes. in order to ensure cost-effective improvement and development o f existing health services, the efficacy o f health programmes needs to be validated through research showing that such services are necessary, appropriate and accessible, within the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 50 wendy overett and harsha kathard specified contexts (bhagwanjee & stewart, 1999). several studies within the slt & audiology profession, have examined client profiles to facilitate service planning. inter­ nationally studies by broomfield and dodd (2004); edwards, cape and brown (1989); enderby and davies (1989); enderby and petheram (2000); heron (2001); and petheram and enderby (2001) have provided critical data to influence service planning. in south africa a limited number o f studies have examined client data in different contexts (klop, 1998; schneider, 1992 and swanepoel, 2005). klop (1998) conducted a study in the area o f quality man­ agement in a private healthcare practice in cape town. the out­ comes o f the study were intended to help implement quality man­ agement programmes. client profiles in terms o f disorders, age, geographical location, gender, home language and referral agents were compiled from 197 clients seen by the researcher in her prac­ tice from 1994 to 1996. she found that the majority o f clients at­ tended for language disorders, followed by stuttering, almost half were between three and six years o f age, 63% o f the clients were nale, almost three quarters o f her clients were afrikaans-speaking and most o f the clients were drawn from an area within a 10 km radius o f the practice. her clients were referred from other health­ care professionals, educators and former clients. from a smaller group o f clients she found that only two out o f 64 clients withdrew from therapy. schneider (1992) collected data from records, reports and case files to determine the nature and prevalence o f communica­ tion disorders seen in six hospitals in gazankulu. community based speech and hearing workers were then interviewed about their work situation, organisation of their time and intervention strategies used with communicatively disordered people in order to evaluate the efficacy o f their work. the most common disorders seen at the hospitals in gazankulu by these speech and hearing workers were hearing disorders. swanepoel (2005) conducted an exploratory descriptive study which critically described an infant hearing screening pro­ gramme conducted at two maternal and child health clinics in hammanskraal. quantitative and qualitative methods for data col ! lection were used his study showed poor follow-up return rates i to the clinic. | in south africa, apart from these studies by klop (1998), f schneider (1992) and swanepoel (2005) there is limited data to contribute to service planning. the unique characteristics and challenges o f developing countries demand that contextual and local research be done in conjunction with international .studies (swanepoel, 2005). speech-language therapy research in the united kingdom has emphasised the importance of ongoing gathering information on services and client populations for speech-language therapy services. as with south africa, inequalities in services for the speech and language impaired in the united kingdom’s national health service have been documented (enderby & davies, 1989). if there is to be efficient planning in healthcare it is important that this process be informed with regard to the size and needs o f the population to be served (enderby & davies, 1989). the collation of client data profiles may serve in questioning some o f the basic premises regarding provision o f services and should lead to con­ sideration o f alternative forms of provision which meet the needs o f the speech and/or language disabled and hearing impaired popu­ lation (enderby, 1989). to monitor equity concerns in south africa, comparative data are necessary to understand the multifaceted nature o f client profiles which include race, age, gender, urban/rural location and socio-economic status (ntuli & day, 2004). the first steps how­ ever, are to collect data from current service sites, as was the inten­ tion o f the present study. the demographic, diagnostic and atten­ dance data o f clients receiving services at a tertiary level o f health­ care could be valuable in planning equitable and appropriate ser­ vices. reliable data concerning the types o f speech, language and hearing disorders referred, age and sources o f referral, and the ef­ fect o f cultural and socio-economic profiles o f the population on referral patterns are vital for planning services (broomfield & dodd, 2004). comparison o f records may show service trends, admission patterns and familial trends (lubker & tomblin, 1998) over time. it was important to collect data gathered over time so that changes in service provision could be examined with the pur­ pose o f informing debate and planning (petheram & enderby, 2001). the compilation and analysis o f data, timeous reporting and use o f consistent up-to-date health information, are all key aspects o f healthcare planning and management. the lack o f information regarding the health sector has contributed significantly to the slow process o f transforming the health system (ijumba & day, 2004). thus the results o f this study, with its focus on demographic, diag­ nostic and attendance data, has potential to influence service deliv­ ery changes with regard to slt & audiology services. methodology aim this study aimed to describe trends in the demographic, diagnostic, and attendance variables of first-time clients who at­ tended the slt & audiology outpatient department (opd) at the tertiary hospital being studied over a five year time period (1999 2003). study design a retrospective descriptive survey was conducted, to collect demographic, diagnostic and attendance data o f a sample o f clients. sample i the study population included all the hospital records o f new clients who had attended the speech-language therapy and audiology opd o f the tertiary hospital under study during a 5 year period from january 1, 1999 to december 31, 2003. this period of time was selected as data were readily available and would give a sufficiently large number o f records for trends over the years to be examined. due to the large number o f clients in the population (2,819), a sample o f one-third o f the population data were drawn, using a stratified random sampling procedure (katzenellenbogen, joubert & abdool karim, 1997), stratified according to the year in which the client was first seen. the sample consisted of 929 cli­ ents, on which the analysis was conducted. data collection and analysis the clients' names were retrieved from the client registers and record cards. the data collection form, devised by the re­ searcher, was then utilized to capture the data from the hospital records (appendix a). data were electronically captured onto a spreadsheet as raw data and then entries were coded by the re­ searcher. in instances where data were missing on the form (where it was not indicated as missing in the records), the records were die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) profiles o f outpatient speech-language therapy and a udiology clients at a tertiary hospital in the western cape 51 reviewed again by the researcher to retrieve this information. after the data had been entered into the computer and checked, client names and folder numbers were removed to ensure anonymity o f the clients. attendance data were then converted to number o f appointments attended, time frame over which these appointments were attended and the percentage o f appointments attended. the co d ed data were transferred from the spreadsheet into a computer driven statistical package (statistical package for the social sci­ ences) (spss inc, 1995) and frequency and percentage distribu­ tions as well as contingency tables were generated. in instances where a data collection form had missing data, after being re-checked by the researcher, information which was unavailable, was categorised as such. if a record for a client had missing data for two or three o f the three diagnostic variables, the record was excluded from analysis o f diagnostic variables and at­ tendance variables, but was still included in the analysis o f demo­ graphic variables. in instances where there was no clear atten­ dance data for two or more attendance variables, that client was excluded from the analysis o f attendance information. however, if only one o f these variables was missing, the data were still in­ cluded in the overall attendance analysis. due to the descriptive nature o f this study, analysis of variables was conducted via descriptive statistics (hite, 2001), as used in other similar studies (enderby & petheram, 2000; petheram & enderby, 2001). frequency and percentage distributions were used to describe the demographic, diagnostic and attendance data. frequency data were converted into percentage data for each year and for the total sample. contingency tables (cross tabulation) were used to show relationships between variables. inferential statistics were not used as this form o f data analysis is not appropriate for a descriptive study (hite, 2001). reliability and validity reliability o f the data collection procedure was ensured by defining the exact methods o f measuring and checking of work (katzenellenbogen, et al., 1997). in this study a standard, reliable data collection form (appendix a) was used to collect data. cross­ checks o f information from the hospital record sheet to the slt & audiology folder also enhanced j the reliability o f the data collec­ tion process. | areas o f concern for validity included the reality that hospital records are generally produced for clinical, administrative or monetary ends rather than research purposes (abramson, 1990) and that different clinicians ma>| have used different terminology when describing diagnoses. terminologies were therefore exam­ ined and then grouped in broad categories. data collection was verified by the researcher as it was entered into the computer. instrument, observer and client variations can be evaluated by repeating measures o f a sub-sample o f the study sample (katzenellenbogen, et al., 1997). in this study a random sample of ten percent o f the clients from each year was selected for re­ collection o f data (n=93) by an independent researcher. the data were then coded and the codes were compared to those found for the same clients by the researcher. there was 95% agreement across all the variables, indicating good inter-observer reliability. a large sample was chosen to enhance the validity o f the study as confidence intervals become narrower as sample size in­ creases (katzenellenbogen, et al., 1997). the data were analysed quantitatively using spss to ensure the data were analysed in a consistent manner thereby ensuring valid and reliable results. the results were interpreted by the researcher who also engaged with a process o f peer review to enhance the quality o f the interpretation. ethical considerations the head o f the speech-language therapy and audiology department, the medical superintendent of the tertiary hospital be­ ing studied, and the ethics committee o f the university o f cape town were consulted with regard to gaining access to the hospital files. it was not, however, possible to gain consent from the cli­ ents, due to potential difficulties locating clients and the number of records being reviewed. however, confidentiality was strictly maintained by removing any identifying information after the data had been checked and coded. access to the files may be consid­ ered ethical on the grounds that there was no risk o f harm to indi­ viduals, there was potential public benefit, and investigators' pro­ tected the confidentiality o f the individuals whose data they stud­ ied (council for international organisations o f medical sciences, 1991). the community will stand to benefit from this research if changes, taking into account the findings o f this study, are made within the healthcare setting with regard to equity in service provi­ sion and aligning the services to the needs o f the population. results and discussion the number o f clients varied each year ranging from 178 to 197 clients, with a total sample size o f 929 clients on which these results are based. the results and discussion are presented in rela­ tion to the aims o f the study. the total number of clients varied across the aims because o f missing information as explained in the methodology. the quantitative results are represented in tables and graphs and the main trends are described and then discussed. diagnostic data speech-language therapy and audiology diagnosis ; in this study recorded reported medical diagnoses have been managed as inter-related diagnostic categories with slt & audiology diagnoses. the percentage of clients within each slt & audiology diagnostic category is presented in figure 1. j speech-language therapy and audiology diagnostic categories o f j those attending the opd appeared to remain fairly consistent over the five-year period, with minor variations across the years. ! j the common diagnoses o f those attending the slt & audi­ ology opd included hearing loss (n=255; 30%), voice disorders (n=l 77; 21%) and neurogenic communication disorders. the ; types and percentages o f diagnoses remained relatively similar across the five years. there are several significant issues surrounding the types o f disorders seen at the slt & audiology opd and the percentage of clients attending the opd for the management o f each disorder (figure 1). the reason for the high percentages o f clients attend­ ing the opd as a result o f a hearing loss or voice disorders, may be due to the fact that this slt & audiology opd is situated in a tertiary hospital, with specialized equipment and facilities suitable for assessing and treating these disorders. due to the fact that hearing loss and voice disorders, as well as neurogenic communication disorders (for which the third highj est percentage of clients attended the opd) are medically based and are treated by the medical profession in conjunction with speech-language therapists and audiologists, clients may be likely to attend this hospital which offers both services. hearing loss, voice and neurogenic communication disorders are often ac­ quired and therefore there is a ‘loss’ o f function, making the disor­ der noticeable and igniting a desire or need to restore lost function. the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 52 wendy overett and harsha kathard v s p e e c h a n d a u d i o l o g y d i a g n o s is figure 1: percentage of clients per speech-language therapy and audiology diagnostic category who attended the speech-language therapy and audiology opd at a tertiary hospital in the western cape from 1999-2003 (n=859). the proximity and connections to the ent department, who made the largest percent­ age of referrals to the slt & audiology opd, may also account for the high per­ centages of clients who attended the opd as a result of a hearing loss or voice disor­ der. the highest percentages of clients were diagnosed with hearing losses, voice disorders, neurogenic communication dis­ orders or fluency disorders, which are ‘noticeable’ disorders and thus easier to detect than less ‘visible’ disorders (mclaren, solarsh & saloojee, 2004) and are likely to impact on everyday life. less ‘visible’ disorders, such as a language im­ pairment, may not be as easily noticeable in everyday situations and thus not as eas­ ily detected. these less ‘visible’ disorders are then not as likely to be referred to slt & audiology services. it is also possible that because the department is actually referred to as a “speech therapy” rather than “speech-language therapy”, it may not be obviously associated with managing language disorders, a reality that the pro­ fession has experienced internationally. referral sources the results for referral sources ap­ pear in figure 2. from the year 2000 on­ wards there was an increase in referrals from community clinics and from wards at the study hospital. when examining individual cate­ gories of clients with a specific disorder or from a specific referral source, particu­ lar trends were found. these results are based on the clients within a specific cate­ gory only and thus the percentages and numbers are based on these individual categories and not on the full sample. the majority of clients who attended the slt & audiology opd as a result of a voice disorders (n=137; 76%) were re­ ferred from the ent department. fifty percent (n=41) of referrals from commu­ nity clinics, 80.5% (n=33) o f referrals from occupational health centres and 83% (n= 10) of referrals from old age homes or residential care were referred to the slt & audiology opd as a result of a hearing loss. the majority o f the referrals to the opd from wards were for dysphagia, neurogenic communication disorders or a combination of these (n=31; 97%). the education sector referred 50% (n=28) of paediatric clients with multiple difficulties to the opd. referral sources (figure 2) would also have shaped the client diagnostic pro­ files discussed above. as mentioned, the ent department made a high percentage of referrals to the slt & audiology opd. this trend is understandable in light of the discussion around the types of disorders seen most frequently at the opd. the second major referral agent to the opd was the education sector. this situation may be attributed to the limited slt & audiology services within mainstream schools (f. lewis, personal communica­ tion, february 18, 2005), resulting in re­ ferrals to the health sector. j i demographic data | i age groups age group results, presented in table 1, illustrate that the largest percent­ age (n=l 65; 18%) of clients who attended the opd were within the age group of 7 12 years. the following results are based on sub-categories of clients. clients attend­ ing the opd with a hearing loss or tinni­ tus covered the full range of ages, al­ though the majority of these clients were between 30 and 79 years o f age (n= 181; 72%). the majority of clients who at­ tended the slt & audiology opd as a result of a voice disorder were between 30 t t& <x. <x. 'fe.<9* %. %,■ v . \ ^ >cs. " \\\% x v x r e f e r r a l s o u r c e <> '■v figure 2: percentage of clients per referral source who attended the speech-language therapy and audiology opd at a tertiary hospital in the western cape from 1999 2003 (n=859). a bbreviations used: c t : c a p e t ow n oa h : o ld a ge h om es en t: e ar, n ose, t hroat die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) profiles o f outpatient speech-language therapy and a udiology clients at a tertiary hospital in the western cape 53 ancj 49 years o f age (n=98; 54%). clients with a neurogenic com­ munication disorder spanned a wide range o f ages, although the highest percentage fell within the age group o f 50-59 years (n=27; 24%). the majority o f clients who attended the opd as a result of dysphagia were between 50 and 69 years of age (n=10; 67%), while clients with both dysphagia and a neurogenic communica­ tion disorder were slightly older, between 60 and 79 years (n=23; 62%). the majority of clients presenting with fluency disorders, however, were under 18 years o f age (n=64; 90%). a similar trend occurred for clients attending as a result o f a phonology/ articulation/oral motor disorder, language disorder, language and learning disorder or multiple difficulties although the majority were under the age o f 12 (n=20; 87%). while the highest percent­ age o f clients attending as a result o f language disorders was in the under six year age group (n=15; 65%), children attending the slt & audiology opd with language and learning disorders or multi­ ple difficulties had a greater percentage in the 7-12 year old cate­ gory (n=25; 83% and n=35; 62.5% respectively). despite the high number o f clients with a hearing loss or voice disorder attending the opd (which in this study were found predominantly in the adult population), the majority o f the caseload attending the slt & audiology opd was found to be between 7 and 12 years o f age (table 1). o f this age group only a minority attended the opd for a hearing loss or voice disorder. however, this age group had the majority o f the clients with flu­ ency disorders, phonology/articulation/oral motor disorders, lan­ guage and learning disorders, as well as those with multiple diffi­ culties. a reason for this high percentage o f 7 to 12 year olds at­ tending the opd under study in relation to the under six popula­ tion, may be due to the close proximity o f another tertiary hospital, which specializes in paediatric intervention. the high percentage of 7 to 12 year olds attending the opd (who are primary school age children) alludes to the lack o f services within the education system, who were also the second highest referral agent. despite the inclusive education policy intention regarding inclusive educa­ tion (department of education, 2001), there seems to have been minimal support for learners with communication difficulties in mainstream schools in the western cape. the researcher has also perceived a general lack o f knowltable 1: number and percentage of clients per age group who attended the speech-language therapy and audiology opd at a tertiary hospital in the western cape from 1999-2003 (n=910) j age number percent 0 6 years 69 : 7.58 7-12 years 165 18.13 13-18 years 39 4.29 19-29 years 79 8 .6 8 30-39 years 118 12.97 40-49 years 115 12.64, 50-59 years 107 11.76 60-69 years 101 1 1 .1 0 70-79 years 87 9.56 80+ years 30 3.30 total 910 ' 100 edge amongst educators, many health professionals and the public, o f slt & audiology services, resulting in ‘late’ referrals o f indi­ viduals. anecdotal parent reports have indicated that parents who had voiced their concerns regarding their child’s delayed language development have been told by health professionals ‘not to worry’ or that their child will ‘grow out o f it’. thus, instead o f the child receiving early intervention, intervention was only available upon entering school where there are high demands on communication skills and the child’s difficulties begin to impact on academic per­ formance. this scenario again relates to the ‘visibility’ o f certain disorders (mclaren et al., 2004), as these language and learning disorders are often only detected in an academic environment and are not immediately obvious in everyday situations (das, 2001). examination o f the results pertaining to the adult popula­ tion attending the speech-language therapy and audiology opd showed that there was a slight decrease in percentage o f clients attending the opd within each 10 year category from 30 to 69 years, with a slightly larger decrease in therapy attendance at 70 to79 years and a large decrease in therapy attendance in the over 80 year old category. an explanation for the greatest number o f adults attending the opd being between 30 and 49 years o f age may be due to the large number o f clients attended the opd as a result o f a voice disorder and the fact that the majority o f clients with voice disorders were in this age group. this finding o f a decrease in therapy attendance amongst clients with increasing age, however, seems to follow a general trend in rehabilitation, where services are less accessible and avail­ able to the older population. although disability is more prevalent in the older population, it seems that older adults are unable to access hospital based outpatient services. blake (1981) in the united states o f america, claims that in terms o f age group, par­ ticipation in the rehabilitation service seems to be inversely related to the need for such service. rehabilitation may be more o f a pri­ ority for younger people, or services may be more accessible to them, than for the older population. rehabilitation has previously been driven both philosophically and financially by the goal o f restoring individuals to productive employment, resulting in better opportunities for younger clients, although this is now changing to include a focus on older clients (raia, 1992). the motivation to attend rehabilitation may be greater for the younger adults due to their need to regain employment, as well as to pursue social goals. a study at groote schuur hospital in the western cape, south africa (whitelaw, meyer, bawa & jennings, 1994) confirmed this trend and reported that greater numbers o f stroke clients under the age o f 65 years old, who had been inpatients, were referred (as outpatients) to physiotherapy and occupational therapy services, while fewer clients above the age o f 65 were referred. further­ more, a greater number o f the younger adults presented for and received therapy than older adults. another study in the western cape, examining rehabilitation services at bishop lavis rehabili­ tation centre, documented that 50% o f the population attending these services were 60 years old or younger (rhoda, 2001). in light o f the above discussion regarding services for dif­ ferent age groups o f clients, the current study revealed that a large percentage (n=71; 64%) o f clients with a neurogenic communica­ tion disorder (without dysphagia) were under the age o f 60 years. however, 70% (n=26) o f those with both dysphagia and a neuro­ genic communication disorder were over the age of 60. this pos­ sibly indicates a greater degree o f disability in the older age groups, where multiple disabilities are perhaps more likely. this trend o f multiple disabilities in the older population may also ex­ plain the reduction in the number of these older clients attending outpatient rehabilitation. elderly clients may not only be more the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 54 wendy overett and harsha kathard affected by a stroke, but may also have more problems reaching therapists than younger clients (whitelaw et al., 1994). there is also greater attrition of older clients than younger clients due to stroke (whitelaw et al., 1994). gender slightly more than half of the sample who attended the opd was male (n=470; 52%). more females than males presented with voice disorders, language disorders or no specific speech-language &/or audiology diagnosis. it was unexpected to find similar percentages of male and female clients attending the opd, as the belief was that there would be many more males than females as found in other studies (for ex­ ample broomfield & dodd, 2004; enderby & petheram, 2000; klop, 1998), although direct comparisons could not be drawn as some studies did not include audiology clients and some were based only on paediatric populations. this trend, however, be­ comes clearer when one considers gender in relation to the different disorders. as found in the present study, as well as other studies (coyle, weinrich & stemple, 2001), voice disorders are more prevalent amongst females than males. this study found that a large percentage of clients (n=180; 21%) attended the opd for the management of a voice disorder and because many o f these clients were female the number of females attending the slt & audiology opd was increased. there are two possible explanations as to why there were more female than male language disorders found in this study. firstly, more males presented with language disorders coupled with learning disorders and were thus categorised as such. secondly, it was found that more of the language disorders fell into the 0-6 year old category. there is a perception that ‘boys develop more slowly’ or ‘boys are slower to talk’ (phillips, 2004:500) and they might therefore be brought later for therapy, when they would more likely be diagnosed as having a language and learning difficulty. of all the other disorders (apart from language disorders) found mostly in children, all had higher percentages of males than females. many studies have commented on the greater likelihood of reading difficulties or dyslexia in males than in females (owens, 1999) and that children with dyslexia have delayed language devel­ opment. also, as expected, more males than females attended the opd for the intervention of fluency disorders (guitar, 1998). home language the majority of clients attending the opd were classified as having english or afrikaans as their home language, with a minor­ ity speaking xhosa or another language (table 2). table 2: number and percentage of clients per language group who attended the speech-language therapy and audiology opd at a tertiary hospital in the western cape from 1999-2003 (n=910) this is interesting considering that 55% of the population in the western cape speak afrikaans as a home language, 24% speak xhosa as a home language and 19% speak english as a home lan­ guage (south africa.info reporter, 2002). there are several possi­ ble reasons for the mismatch between the population profile and the profile of clients attending the slt & audiology opd. firstly, english may be the preferred language of interven­ tion for several reasons. the majority of speech-language thera­ pists and audiologists in the slt & audiology opd at this tertiary hospital in the western cape were english first language speaking with afrikaans as a second language. also, many children were being schooled in english, as english was the language most com­ monly used as the medium of instruction (alant, 1989). thus they may choose to receive therapy in english. thirdly, there were no xhosa-speaking speech-language therapists or audiologists at the study hospital and no formal access to interpreters, resulting in lim­ ited provision of services to the xhosa-peaking population. this situation is of grave concern given the multilingual nature of the population in the region. another possible reason for xhosa-speaking clients not ac­ cessing services in the opd clinic may be due to cultural reasons. cultural groups vary in their view of disability and therapeutic in­ terventions and such differences may impact who is likely to attend the hospital (swartz, 1998; swanepoel, 2005). furthermore, the hospital in the present study has historically been a ‘white’ hospital, and there may still be misconceptions about who can access ser­ vices at this hospital. in many communities in south africa there is little awareness of slt & audiology services, due to lack of re­ sources and facilities, and therefore people are unaware that ser­ vices are available. access to services is also influenced by socioeconomic status of people. although poverty is not confined to one racial group in south africa, it is most prevalent amongst the black popu­ lation (swanepoel, 2005). many of the xhosa-speaking population in the western cape, the majority of whom would be black, may have a limited income. the costs of travel to the hospital as well as multiple treatment fees may be prohibitive. geographical location the health districts in cape town were used to categorise the areas from where the clients who attended the opdlcame. i table 3: number and percentage of clients per geographical location who attended the speech-language therapy and audiology opd at a tertiary hospital in the western cape from 1999-2003 (n=910) geographical location number percent central 209 22.97 eastern 2 2 2.42 khayelitsha 39 4.29 klipfontein 258 28.35 mitchells plain 117 1 2 .8 6 northern panorama 46 5.05 southern 150 16.48 tygerberg 39 4.29 outside cape town . 21 2.31 m issing data 9 0.99 total 910 10 0 language for therapy number percent english 501 55.05 afrikaans 298 32.75 xhosa 82 9.01 other 18 1.98 m issing data 11 1.21 total 910 1 0 0 .0 die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) profiles o f outpatient speech-language therapy and audiology clients at a tertiary hospital in the western cape 55 table 3 shows the number and percentage of clients from each area. it can be seen that clients attended from many different areas. this is not sur­ prising given the lack of slt & audiol­ ogy services in the community or even at a secondary level of care (allied health professionals technical commit­ tee, 2004). some of the areas, however, would have been covered by slt & audiology services at another tertiary hospital in cape town. attendance the majority of clients attended the opd over a very short period of time, for example many attended within a three month period (n=513; 71%) or attended two appointments (n=506; 70%). number of appointments and time frame results showed very similar trends, with a drop-off with increasing number of scheduled appointments or longer period of time over which these appointments were scheduled. almost half of all the clients (n=353; 49%) at­ tended only one appointment. only 9% (n=67) of clients attended more than five appointments. given that long-term therapy was often indicated, these find­ ings were noteworthy in relation to ser­ vice planning. the high number of clients who only had one booked appointment may be due to the fact that certain clients would have been placed on a waiting list for therapy and therefore not been given further scheduled appointments immedi­ ately. they may then not have wanted therapy when it was offered, due to changes in circumstances between the time of the assessment and the date when therapy was offered. additionally, there are some cases for which one attendance may be all that is indicated. some clients may have needed an initial assessment with no necessary follow-up. it is likely that once their concerns had been ad­ dressed, they no longer felt the need for further intervention. enderby and da­ vies (1989) reported that 60% of newly referred children required assessment and advice only. while this explanation might be applicable to some cases, the data in case files, the nature of the disor­ ders and personal experience suggest that many required additional intervention. the lack of understanding of the nature of interventions offered by the profession of slt & audiology by the community, as well as the location of the services within a tertiary hospital envi­ ronment, may have contributed to poor attendance rates. many clients have the expectation that a hospital is a place which one attends when ill and that it is a once-off attendance, possibly with a fol­ low-up appointment. many expect treat­ ment that is tangible, such as medication or surgery. clients arrive with the ex­ pectation that they will be given some­ thing to ‘cure’ them in a once-off ap­ pointment. therefore, they may not have been prepared for the active role that is required of them in the therapeutic proc­ ess. also, they may have been unwilling or unable to commit themselves to fur­ ther intervention as recommended. the high rate of non-attendance may also reflect the economically disadvantaged nature of the population served, and the low priority given to slt & audiology services given other life circumstances (broomfield & dodd, 2004). a further explanation for low at­ tendance rates could relate to different perceptions of a disorder by a therapist and a client, or the client having a differ­ ent understanding of the nature of a dis­ order. negotiating between explana­ tions of illness increases the possibilities of compliance or adherence to treatment (swartz, 1998). thus, explaining the nature of the diagnosis in ways that the client can understand and relate to their understanding of the world, may im­ prove attendance and compliance to therapy. also, discussions prior to com­ mencing therapy about the nature of therapy and the respective roles of the parent and the therapist may well in­ crease parent satisfaction (roulstone, glogowska, peters & enderby, 2004), which may improve attendance rates for children. the same principle could be applied to adults. with an increasing number of scheduled appointments, percentage of appointments attended dropped. the only diagnostic categories which had more than 10% of clients attending in excess of five appointments were for the categories o f fluency disorders (n=15; 28%), paediatrics with multiple difficul­ ties (n=12; 25%), language disorders (n=5; 24%) and phonology/ articulation/ oral motor disorders (n=3; 13%). it is possible that the motivation for treat­ ment of these disorders may have been greater than for other disorders. data presented by enderby and davies (1989), which included many but not all types of communication disorders included in this study, indicated that the children who received regular therapy, attended once a week for an average of 16 weeks. roulstone et al. (2004) found that of the 71 children allocated to speech-language therapy in their study, 68 attended sessions offered, al­ though nearly 18% of appointments were either cancelled (by the therapist or clinician) or not attended. klop (1998) in her private practice found that only two out of 64 clients dropped out of therapy. the differences in findings be­ tween these studies confirm the impor­ tance of understanding how contextual realities influence service provision. 4 0 t im e p eriod figure 3: percentage of clients who attended their scheduled appointments at the speech-language therapy and audiology opd at a tertiary hospital in the western cape from 1999-2003 across different time periods (n=719). the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 56 wendy overett and harsha kathard limitations there are several limitations of this study which need to be considered. there has been minimal research into client profiles attending slt & audiology services in south africa. therefore, the researcher had to rely on the methodology and literature from other countries and other healthcare disciplines to conduct this study. while such literature was useful, it was not directly appli­ cable to the slt & audiology contexts in south africa. the study was also limited to the data from one tertiary hospital examined over a five year time period. the conclusions therefore are only applicable to the tertiary hospital being studied during the speci­ fied time period. due to the nature of the study, records used were not de­ vised specifically for research purposes and thus may not have been maintained with the care that would be expected in a planned investigation. notably, as diagnostic labels vary in use across slt & audiology services and medical categories, specific diagnoses are open to different interpretations. for example, a patient’s pri­ mary medical diagnoses may be a “cerebral-vascular accident” with slt & audiology services referring to “neurogenic acquired communication disorders” . this resulted in difficulties during the data collection phase which included missing records, incomplete records, and information recorded in an inconsistent manner within and between records. this is a common limitation of retrospective studies such as those by farmer (1990) and schneider (1992). a further problem associated with the description of communication disorders is that many disorders (for example learning difficulties) are not clearly defined (lubker, 1997). limitations in the interpretation of the results included lack of comparison data from other sites, limited ability to generalize the findings of this research to other service sites, and that the in­ terpretation was speculative in nature. due to the descriptive na­ ture of the study, no causal or correlational assertions could be drawn (hite, 2001). despite such limitations, the findings can in­ form the restructuring of services in the region. the difficulties encountered with the use of records points to the need for good record keeping, which is essential for plan­ ning of healthcare services (rhoda, 2001). inadequate records can distort research results, prevent clients from being involved in re­ search and negate the quality of research (farmer, 1990). there­ fore, methods of recording client information and treatments used need to be reviewed (farmer, 1990). this information is not only useful for research, but also when assessing cost-efficiency of a service (rhoda, 2001). the limited access to slt & audiology services in the western cape, as reflected in the poor attendance rates obtained in this study, point to the need for slt & audiology services at all levels, and particularly at a primary level, of care (rhoda, 2001). services need to be provided in line with the primary health care approach within the district health system (hall et al., 2002; for­ man, et al., 2004). ideally, the services should be integrated at all levels of care and should strive towards community based rehabili­ tation. as a starting point, therapists’ participation in community outreach programmes would be advantageous. conclusion this study found that the highest percentages o f clients at­ tending the slt & audiology opd at a tertiary hospital in the western cape attended for a hearing loss (n=250; 29%) or voice disorder (n=180; 21%) and that the ent department at the study hospital (n=203; 24%) and the education sector (n=l 11; 13%) re­ ferred the highest percentages of clients. in terms of age, the high est percentage of clients attending the opd were between 7 and 12 years old (n=165; 18%). overall there were similar percentages of male and female clients who attended the opd. english speaking clients predominated (n=501; 55%), followed by afrikaans speak­ ing clients (n=298; 33%). only a small percentage of clients were xhosa speaking (n=82; 9%). patterns of attendance showed that almost half of all the clients who attended the opd attended only one appointment (n=353; 49%). in total just over 70% of clients attended either no more than two appointments (n=506; 70%) or attended within a three month period (n=513; 71%). with an in­ creasing number of scheduled appointments, percentage of ap­ pointments attended decreased. given the poor attendance rates and the high number of cli­ ents in the 7 to 12 year age group seen at the slt & audiology opd, there is a definite need for more adequate service provision in schools. the department of education in the western cape has very limited slt & audiology services (f. lewis, personal com­ munication, february 18, 2005). however, the department of education (2001) emphasises the need to optimize the expertise of specialist support personnel, such as therapists, psychologists, re­ medial educators and health professionals within the school set­ ting. in the long term therefore, the service provision for learners in inclusive settings must be given urgent consideration. cur­ rently, the education sector in the western cape does not have the capacity for individual intervention in ordinary classrooms, but plans to provide preventative services and services to educators (f. lewis, personal communication, february 18, 2005). one of the major challenges facing the slt & audiology profession is to provide equitable services for the multilingual populations. the scarcity of xhosa-speaking therapists in the western cape is a source of concern. in the long term it would be advantageous to train and employ professionals speaking african languages. however, given the language diversity in the country, it is critical that practitioners become skilled to manage multilin­ gual and multicultural populations (swanepoel, 2005). for exam­ ple, the inclusion of interpreters to support clinical practice is im­ portant. however, there were no available interpreters at the slt & audiology opd under study, despite repeated requests to the hospital authorities in this regard. while service delivery to multi­ lingual populations remains a challenge, it is important that steps are taken to create equitable practices. references l abramson, j. 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(2002). s a ’s population by province. re­ trieved february 21, 2005, from http://www.southafrica.info/ ess_info/sa_glance/demographics/popprov.htm statistics south africa (2004). retrieved june 22, 2004, from super c ro ss. s p a c e t im e r e s e a r c h w w w .i n f o .g o v .z a / annualreport/2003/statssa03.pdf statistical package for the social sciences inc. (1995). statistical p ackage f o r the social sciences. chicago, illinois: spss inc. swanepoel, d. (2005). infant hearing screening at m aternal and child health clinics in a developing south african community. university o f pretoria: unpublished dphil dissertation. swartz, l. (1998). culture and mental health: a southern african view. cape town: oxford university press. whitelaw, d., meyer, c., bawa, s., & jennings, k. (1994). post­ discharge follow-up o f stroke patients at groote schuur hospi­ tal a prospective study. south african medical journal, 84:11-13. the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.southafrica.info/ http://www.info.gov.za/ 58 wendy overett and harsha kathard appendix a data collection form demographic information date in file_ client's n a m e:________________________ date o f birth: folder number:_____________ gender: male female home language:_____________ full residential address: monthly family income: n o o f dependants: hospital category: free ho hi h2 h3 private marital status: single w idowed married divorced n ot given n a occupation: pensioner grant other:________________________________ diagnostic information medical d iagn osis:__________________________________________________ speech/audio diagnosis: referral source: date assessed: attendance information (write every date) dates attended therapy sessions: dates cancelled therapy sessions: dates o f appointments missed: d ie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) article information authors: deidré breytenbach1 alta kritzinger1 maggi soer1 affiliations: 1department of speech-language pathology and audiology, university of pretoria, south africa correspondence to: deidré breytenbach email: deidre1bez@gmail.com postal address: 12 birch avenue clubview, extension 2, pretoria dates: received: 28 nov. 2014 accepted: 30 may 2015 published: 09 dec. 2015 how to cite this article: breytenbach, d., kritzinger, a., & soer, m. (2015). audiology practice management in south africa: what audiologists know and what they should know. south african journal of communication disorders 62(1), art. #114, 9 pages. http://dx.doi.org/10.4102/sajcd.v62i1.114 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. audiology practice management in south africa: what audiologists know and what they should know in this original research... open access • abstract • introduction • method    • aim    • objectives    • research design    • ethical considerations    • respondents    • materials    • procedures    • data analysis • results and discussion    • existing knowledge of audiology practice management tasks    • required knowledge to perform audiology practice management tasks    • differences between the existing levels of knowledge and the required levels of knowledge necessary to perform practice management tasks as perceived by the respondents    • comparison between existing and required levels of knowledge for public and private working environments    • strengths, management challenges and training needs as perceived by respondents    • recommendations regarding audiology practice management training • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ background: in future, the south african department of health aims to purchase services from accredited private service providers. successful private audiology practices can assist to address issues of access, equity and quality of health services. it is not sufficient to be an excellent clinician, since audiology practices are businesses that must also be managed effectively. objective: the objective was to determine the existing and required levels of practice management knowledge as perceived by south african audiologists. method: an electronic descriptive survey was used to investigate audiology practice management amongst south african audiologists. a total of 147 respondents completed the survey. results were analysed by calculating descriptive statistics. the z-proportional test was used to identify significant differences between existing and required levels of practice management knowledge. results: significant differences were found between existing and required levels of knowledge regarding all eight practice management tasks, particularly legal and ethical issues and marketing and accounting. there were small differences in the knowledge required for practice management tasks amongst respondents working in public and private settings. conclusion: irrespective of their work context, respondents showed that they need significant expansion of practice management knowledge in order to be successful, to compete effectively and to make sense of a complex marketplace. introduction top ↑ audiology in south africa has, over the past five decades, advanced from a combined profession of speech and hearing therapy into two interweaved, but autonomous, professions of audiology and speech-language therapy (edwards, 2009; swanepoel, 2006). audiology has now diversified within this multiracial, multilingual, and multicultural context as a hearing healthcare profession aimed at providing quality services to meet the diverse needs of the entire population (swanepoel, 2006). audiologists are offered a wide selection of practice opportunities across a number of work settings in south africa. the country has a large public sector and a smaller but fast-growing private healthcare sector (bakker, 2008). according to lefemine (2012), the private sector in south africa attracts the majority of the country's health professionals. consequently, there is a shortage and maldistribution of key healthcare workers across the rural-urban and public-private divides (swanepoel, 2006; ward, sanders, leng & pollock, 2014). annually, an estimated 6116 infants will be born with or acquire permanent bilateral hearing loss, with approximately 92% born in the public health sector (swanepoel, storbeck & friedland, 2009). therefore, one of the main challenges in the public health care sector is a shortage of audiologists (kanji & kara, 2013). as part of improving the healthcare system and ensuring that all south africans have equitable access to essential healthcare services, the south african government is introducing the national health insurance (nhi) system. in future, the department of health aims to purchase services from accredited private service providers (matsoso & fryatt, 2013; ward et al., 2014). the strategy aims to increase the number of health care personnel indirectly by enjoining those in the private sector to provide services to the general public (george, quinlan, reardron & aguilera, 2012). the success of private audiology practices is, therefore, also important for the future engagement between sectors in order to address issues of access, equity and quality of health services by increasing private sector participation. the future of private audiology practices depends on how well audiologists are able to take their clinical training and practice management skills to the marketplace (metz, 1996). this basic and longstanding requirement also applies to the future of audiology practices in south africa. a successful audiologist must provide exceptional patient care and customer service regardless of the setting, but if equal attention is not paid to the business aspect of the practice the success of the practice could be risked (gnewikow, gnewikow & cieliczka, 2009; hosford-dunn, roeser & valente, 2008). according to clark and benson (2008) audiologists must understand the difficulty of balancing the need to serve the public in the highest ethical manner and also making a living by operating a business. the practice management requirements of the private audiology practice may also differ from the audiologist's patient-first professional motives (hosford-dunn et al., 2008). therefore, practice management is the most underestimated challenge to the private audiologist, since every audiology practice becomes a business that must also be managed effectively (gnewikow et al., 2009; traynor, 2006). although a wide variety of core audiology skills need to be mastered prior to working as an audiologist, practice management proficiency is of equal importance in any environment. audiologists must be able to use many management skills in practice that may not have been acquired in undergraduate training (clark & benson, 2008). there appears to be a lack of recent research regarding practice management needs amongst south african audiologists. in a country-wide south african survey by wemmer (2007) a significant number of respondents (35%) indicated that their undergraduate education left them unprepared for practice management, whilst 22% indicated that it had not been included in the undergraduate curriculum. in another south african study conducted by bakker (2008), 86% of respondents did not receive practice management training in their undergraduate studies. according to a survey of audiologists (n = 256) in the united states of america (usa) and canada (henson, williamson & jacques, 2006) it was clear that practicing audiologists in those countries also felt they did not have the required business skills to compete in the marketplace. respondents reported great deficits in management and business knowledge that impacted their work and careers (henson et al., 2006). it is not currently known how practice management training is perceived by audiologists in south africa. it was therefore important to conduct a survey to determine context specific management challenges, strengths and training needs as well as the self-perceived existing and required levels of practice management knowledge amongst south african audiologists. this survey included eight practice management tasks that may be considered as the most important body of knowledge for business, namely accounting, finance, marketing, legal and ethical issues, organisational behaviour and human resources, operations and systems management, strategic management, and managerial decision-making (henson et al., 2006; henson, presley & korfmann, 2008; hosford-dunn et al., 2008). the results may identify differences between the existing levels of knowledge and the required levels of knowledge of the respondents. this may lead to the formulation of recommendations regarding practice management training for south african audiologists. method top ↑ aim the aim of the study was to determine the self-perceived existing and required levels of practice management knowledge amongst south african audiologists. objectives to determine the existing levels of knowledge necessary to perform practice management tasks as perceived by the respondents. to determine the required levels of knowledge necessary to perform practice management tasks as perceived by the respondents. to determine if there are differences between the existing levels of knowledge and the required levels of knowledge necessary to perform practice management tasks as perceived by the respondents. to determine if there are differences between the existing levels of knowledge and the required levels of knowledge between respondents working in public settings and private settings. to describe strengths, management challenges and training needs as perceived by the respondents. to describe the respondents’ recommendations regarding practice management training for south african audiologists. research design a descriptive survey using electronic questionnaire distribution was used to investigate audiology practice management amongst south african audiologists. a web-based survey was deemed the most effective method to gather the opinions of as many south african audiologists as possible. ethical considerations ethical clearance to conduct the study was obtained from the research ethics committee of the faculty of humanities at the university of pretoria (reference number: 26162289). the data was collected anonymously and treated with confidentiality. no identifying information of the respondents was reported and internet protocol addresses were not tracked. an informed consent letter formed part of the web-based survey and was the first page that respondents viewed once they clicked on the link. by completing the web-based survey respondents gave their consent to participate in the study on a voluntary basis. respondents the population of interest was registered audiologists and dually qualified speech-language therapists and audiologists working in public or private settings in south africa – whether they are involved in practice management or not. a non-probability, convenience sampling strategy was employed. because a large number of audiologists are still dually qualified, it was not possible to determine how many of the professionals are practicing only as audiologists. at the time of data collection there were 1749 audiologists and dually registered speech-language therapists and audiologists registered with the health professions council of south africa (hpcsa, 2013), but email addresses could not be obtained. the hpcsa does not supply practitioner contact information such as email addresses, but postal addresses may be purchased from them (hpcsa, 2013). in addition to their professional registration, some audiologists also joined professional organisations such as the south african association of audiologists (saaa) and the south african speech-language-hearing association (saslha). the email was sent to the databases of saaa (n = 326) and saslha (n = 1300) as their member databases are updated annually, and they were able to send the survey to all their members. since there was no effective way to determine which of the saslha members practice only as speech-language therapists, a number of redundant emails were sent to speech-language therapists. some audiologists are also registered with both the saaa and saslha, meaning that some respondents might have received an invitation to participate twice. an email message providing the web address where the respondent could link directly to the survey was thus sent to a total of approximately 1626 prospective respondents. a total of 147 respondents completed the survey indicating a minimum response rate of 9%. a description of the respondents is given in table 1. table 1: description of respondents (n=147). according to table 1 the respondents consisted mostly of females (97.9%), which is consistent with the population of audiologists in south africa (wemmer, 2007). ages ranged between 23 and 61 years with a mean age of 34.9 years. the majority of respondents were dually qualified as speech-language therapists and audiologists (65.4%) with a bachelor's degree obtained from the university of pretoria (55.1%). the small sample size and the fact that most respondents graduated from one tertiary institution influenced the generalisability of the findings, especially findings regarding training. the largest group of respondents were full time employees (41.8%) working in a private practice (54.6%) located in an urban area (74.3%) in the gauteng province (47.5%). very few respondents worked in a public setting (30.8%) compared to those who worked in a private context (69.2%). it is possible that private practitioners had a greater interest in the topic of practice management than respondents working in a public setting, and therefore more respondents from a private context participated in the study. there is also incongruity regarding the number of respondents employed in each province and the size of each province. some provinces, such as the northern cape, were underrepresented in the survey. there were a few missing values (n = 11) as demographic information was obtained last in the web-based survey, and some respondents did not complete all the questions. materials a web-based survey was developed by consulting previous studies regarding practice management (henson et al., 2006), and refined after a pilot study was completed. structured closed-ended questions and open-ended questions were used in the survey. section a was assigned to training and education in practice management to gather information regarding the level of training respondents have received in practice management. this section requested the respondent's opinions regarding the need for practice management training, and when and how it should be presented. their opinions on what the content, duration, and format of such training should entail was also requested. section b was assigned to management in practice. this section was used to determine the respondents’ challenges as well as strengths in practice management. in this section the researcher also determined the existing and required levels of knowledge necessary to perform practice management tasks as perceived by the respondents. questions in this section were based on a study conducted by henson et al. (2006), which included eight areas which may be considered as the most essential knowledge for business, namely accounting, finance, marketing, legal and ethical issues, organisational behaviour and human resources, operations and systems management, strategic management, and managerial decision-making. section c was assigned to demographic information to gather information about the profile of respondents and their audiology practices. according to haslam and mcgarty (2014), demographic information should be gathered at the end of a survey as respondents tend to lose interest when too much demographic information is asked in the beginning. procedures a pilot study was conducted to pre-test the web-based survey. the preliminary survey was sent to nine respondents. they recommended changes to the flow of the questions and the format of skip-questions to enhance the efficacy and practicality of the survey. for the main study, saaa and saslha sent an email message to their databases. the email message consisted of a cover letter addressed to prospective respondents, inviting them to participate in an anonymous web-based survey. the message also provided the web address to link directly to the survey. surveymonkey was used to collect the data online. two weeks after the first email was sent, a second email was sent reminding prospective respondents to complete the survey and informing them of the closing date. the survey was open for participation for three months as data collection coincided with december 2013 and january 2014 school holidays. data analysis the data from surveymonkey was exported into the statistical package for the social sciences (ibm spss, version 22) for statistical analysis. results were quantitatively analysed by calculating descriptive statistics such as percentages, frequency distribution, measures of central tendency and standard deviation. this assisted in organising and summarising the data. the z-proportional test (maree, 2007) was used to determine if two groups of respondents differed significantly on selected characteristics. content analysis (leedy & ormrod, 2010) was also used to analyse qualitative data derived from open-ended questions. underlying patterns, key themes and trends were identified by thorough and systematic examination of the text data collected from the web-based survey. results and discussion top ↑ existing knowledge of audiology practice management tasks respondents were requested to evaluate their perceived existing levels of knowledge regarding eight practice management tasks and rate them as very low, low, high or very high on a 4-point likert scale. very low and low results and high and very high results were combined to summarise the data. the results are presented in table 2. table 2: existing levels of knowledge (n=147). results in table 2 indicated that respondents’ existing knowledge of practice management tasks were mostly low or very low for all eight practice management tasks. operations and systems management was the practice management task respondents reported they knew the most about (56.1%). operations and systems management is an integral part of an audiologist's daily tasks, which includes managing the processes that produce and distribute products and services such as diagnostic hearing tests and the fitting of hearing aids. respondents may therefore mostly report a high level of existing knowledge regarding operations and systems management. accounting was the task they knew the least about (37.4%). the results were in agreement with henson et al. (2008), who found that accounting was the task that chiropractors in the usa knew the least about. knowledge of accounting is necessary to make financial decisions – from purchasing equipment and supplies to expanding services and determining salaries (traynor, 2008). accounting is a specialised field and would not have been included during undergraduate studies. according to clark and benson (2008) audiologists must have an understanding of basic bookkeeping and accounting. required knowledge to perform audiology practice management tasks respondents were requested to indicate required levels of knowledge regarding eight practice management tasks and rate them as very low, low, high or very high on a 4-point likert scale. very low and low results and high or very high results were combined to summarise the data. the results are presented in table 3. table 3: required levels of knowledge (n=147). results in table 3 indicated that the respondents’ required levels of knowledge regarding practice management tasks were high or very high for all eight business tasks. respondents were aware of the high need for practice management knowledge. respondents were of the opinion that they required the most knowledge about the practice management task of marketing (95.8%). marketing is the creation of demand for a particular product or service by establishing public awareness (taylor, 2015b; traynor, 2006). audiologists have to market their services and qualifications to the community to create greater awareness of the available services, but must also follow the ethical rules regarding advertising (hpcsa, 2008). this is especially applicable to private practitioners, where marketing is integral to their success (taylor, 2015b). therefore, the development of marketing skills should be as much a priority as the development of hearing evaluation skills (kotler & keller, 2009; staab, 2008). finance, accounting and other business functions will be irrelevant in the absence of a sufficient demand for products and services in order to make a profit (kotler & keller, 2009). legal and ethical issues (95.2%) were also rated highly. finance (91.8%), accounting (91.7%) and strategic management (91.7%) were considered by the respondents to be equally important. an ability to understand the financial drivers of a successful practice is a fundamental and long-lasting skill set that will benefit any professional regardless of his or her work setting (traynor, 2008). respondents realised the importance of this by rating the required levels of knowledge highly. organisational behaviour, managerial decision-making, operations and systems management were rated lower in terms of required knowledge. differences between the existing levels of knowledge and the required levels of knowledge necessary to perform practice management tasks as perceived by the respondents by combining the two tables, differences in knowledge can be highlighted. the difference between the required and the existing levels of knowledge levels is indicated in table 4. table 4: difference between respondents’ existing levels of knowledge and required knowledge necessary to perform practice management tasks (n=147). as indicated in table 4 the difference in knowledge is the difference between the percentages of respondents who described their existing and required levels of knowledge as high or very high. this result was not obtained from the respondents directly but rather serves as an informative way to summarise the data and highlight differences in knowledge as previously done by henson et al. (2006). as indicated in table 4 the z-proportional test revealed statistically significant differences between the required and existing levels of knowledge for all eight practice management tasks (p < 0.05). the results are in agreement with henson et al. (2006), who also found a significant difference between required and existing levels of knowledge amongst respondents in the usa and canada. the majority of the respondents (95.2%) in the current study were of the opinion that audiologists need high or very high levels of knowledge about legal and ethical issues to effectively manage audiology practices. in reality only 39.5% were of the opinion that they possessed high or very high knowledge about legal and ethical issues. the results were in agreement with naudé and bornman (2014), who found that despite the fact that knowledge of ethics in audiology grew between 1980 and 2010, retrospective analysis identified gaps in the current knowledge. this was the largest difference amongst the practice management tasks followed, again, by the difference in knowledge about accounting (54.4%) and marketing (52.3%). this disparity may partly be due to a lack of opportunity for audiologists to acquire fundamental knowledge of practice management. according to traynor (2006) it is not surprising that audiologists perform outside their educated expertise in these areas. comparison between existing and required levels of knowledge for public and private working environments table 5 indicates a comparison between the existing and required levels of knowledge amongst respondents working in public or private settings. table 5: comparison of existing and required levels of knowledge between public (n=41) and private (n=92) working environments. according to table 5, there were small differences between existing knowledge in private and public settings. the z-proportional test however, revealed statistically significant differences between existing levels of knowledge regarding marketing (p = 0.001), organisational behaviour and human resources (p = 0.049) and operations and systems management (p = 0.000). respondents working in a private setting had a higher existing knowledge regarding these three tasks. respondents working in a private setting may gain more experience regarding marketing as they have to actively market their practices. it is possible that respondents working in the public sector might be overburdened by the demand for their services and therefore have limited knowledge regarding marketing. respondents working in the private sector are solely responsible for organisational behaviour and human resources. in a public setting these responsibilities are handled collectively. the z-proportional test revealed no significant differences between respondents working in a public and/or private context regarding their required levels of knowledge in all eight of the practice management tasks. the results indicated that there is a great need for knowledge regarding practice management irrespective of the working environment. respondents work in a variety of employment contexts throughout their careers with various common traits; for example, they all have to conform to legal and ethical constraints. therefore, the required level of knowledge regarding legal and ethical issues is high, regardless of the employment context. strengths, management challenges and training needs as perceived by respondents respondents indicated in the text data section that their biggest strengths were patient satisfaction, successful marketing, and starting their own practices. respondents indicated that a lack of training, knowledge, experience and sufficient finances were their biggest challenges in practice management in south africa. in the open comments section of the survey, one respondent stated that ‘a lack of knowledge and education before starting your own private practice is the biggest challenge in practice management in south africa’. the majority of respondents indicated that training is required to overcome these challenges. recommendations regarding audiology practice management training according to table 6, the majority of respondents (80.8%) believed that there is a need for practice management and that such training should be offered at an undergraduate level. taking into consideration that audiologists working in both public and private settings had a low existing level of knowledge, training at an undergraduate level would be ideal. in reality, just under a quarter (22.7%) of the respondents indicated that it was presented as an undergraduate module, emphasising the need for change regarding practice management training. continuing professional development (cpd) activities were also rated highly (57.7%). for audiologists to maintain their registration with the hpcsa they have to obtain 60 cpd points in a two year cycle (hpcsa, 2011). therefore, cpd activities will be a good means to address the need for practice management training and acquiring cpd points. table 6: summary of training recommendations (n=147). when asked who should co-ordinate practice management training, individuals with practice management experience (59.6%), and departments of audiology at universities were rated highly. the latter indicated that respondents wanted to learn from lecturers with experience in the field, and that universities are held in high regard by the respondents. according to fasokun, katahoire and akpovire (2005), experience is regarded as more important than knowledge amongst adults in south africa, therefore respondents may have rated individuals with experience highly. respondents recommended that practice management training should be presented as a short course (45.7%), or as on-the-job training (43.1%), but distance learning was not favoured (4.82%). since respondents were mostly young female professionals in their thirties, employed full-time in private practices (table 1) with little spare time, having to balance both career and family life they may have preferred short courses or in-service training. according to fasokun et al. (2005) adult learners are physically, psychologically and culturally different from young learners. as a result of differences, adults apply habitual styles when learning. owing to their individual needs, adult learners may easily feel left out of learning activities, and this may be why distance learning was not favoured by respondents (baloglu, 2007; fasokun et al., 2005). the majority of respondents (60%) preferred assignments throughout the course. according to gibbs and simpson (2004), adult learners consider coursework to be fairer than exams and measure a greater range of abilities. the quality of learning has also been shown to be higher in assignment-based courses (gibbs & simpson, 2004). marketing was rated as the most important topic to be included in training (93.5%), which is in agreement with the required levels of knowledge as indicated by the respondents in table 3. respondents have to promote their private practices, since these are essentially small businesses. according to staab (2008), audiologists must understand the fundamental principles of marketing and have basic marketing skills. great emphasis was placed on basic marketing skills as marketing the profession is also important for the future of audiology. marketing was closely followed by legal and ethical issues (91.5%). ethical considerations should go hand in hand with promoting a practice (solodar & williams, 2007). audiologists have a professional code of ethics and standards as well as guidelines for good practice (hpcsa, 2008; saslha, 2011) that ensures high ethical standards and which provide the foundation for good customer service. according to taylor (2015a), a trusting relationship with the audiologist is rated highly by patients. for this reason audiologists inherently place a large emphasis on legal and ethical issues. conclusion top ↑ this study found significant differences between respondents’ self-perceived existing and required knowledge in all eight practice management tasks. legal and ethical issues, as well as marketing and accounting, revealed the biggest differences. respondents recognised that they need significant expansion of their practice management knowledge, skills and attitudes in order to be successful irrespective of their work context. the success of private audiology practices is also important for the future engagement between private and public sectors when the national health insurance system is implemented. to address these needs audiology programmes should incorporate aspects of all eight practice management areas that compose what is considered the most important body of knowledge for practice management (henson et al., 2006; hosford-dunn et al., 2008). according to henson et al. (2006), there are many options for audiologists in the usa and canada seeking additional practice management education. this may include web-based learning, professional association conventions, continuing professional education activities, manufacturer support, mentoring, books and educational opportunities outside those tailored to the profession. despite the assistance provided by these individual opportunities, simpson (2011) states that one of the most prevalent means of business education for audiologists remains that of “trial and error”. according to bakker (2008), audiologists receive excellent clinical training, but limited or no formal preparation for the challenges that the management of a private practice brings. audiology practice management is a specialised field as audiologists face unique challenges such as marketing restrictions stipulated by the hpcsa (2008). there are several alternatives that may address this need as perceived by the respondents, such as future research into the content and methods taught in undergraduate training programmes in south africa to make specific recommendations for incorporating additional practice management training, as recommended by respondents. according to henson et al. (2008) giving up clinical modules to practice management modules or extending programme durations will be difficult as the focus of most university programmes internationally is on clinical training, as this is the core professional function. therefore, postgraduate training, continued professional education and short courses as recommended by the respondents, can be considered. henson et al. (2008) recommended an industry-wide effort to develop and manage a practice management education programme designed specifically for healthcare professionals. this effort could be led by a national or international association and developed at universities that offer audiology programmes (henson et al., 2008). taking into consideration what audiologists know and what they should know and using their recommendations to make improvements, practice management training has the potential to enhance all aspects of the profession, improve service delivery, empower practitioners, create awareness of the profession and increase satisfaction of both providers and patients (hosford-dunn et al., 2008). a limitation of the current study is the fact that the results reported on are derived from a small sample of audiologists and dually qualified speech-language therapists and audiologists in south africa. the response rate was below the desirable rate described in the literature (maxwell & satake, 2006). as a result, the findings may be biased and cannot be generalised to the greater population of audiologists. despite these limitations the data was stable as similar findings were reported by other studies (bakker, 2008; henson et al., 2006; wemmer, 2007), and significant conclusions could be drawn about what respondents know and what they should know. recommendations for further studies include that the same study be conducted with speech-language therapists. most of the respondents (65.4%) were dually qualified as speech-language therapists and audiologists. therefore, some of the respondents might still practice as speech-language therapists as well; hence, it is assumed that speech-language therapists would have similar practice management training needs, although this should be investigated further in a separate study. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions a.k. (university of pretoria) was the supervisor of the research study. m.s. (university of pretoria) was co-supervisor. d.b. (university of pretoria) conducted the research. a.k., m.s., and d.b. compiled the article. references top ↑ bakker, l. (2008). a study to investigate south african audiologists in private practices’ knowledge of strategic planning and comparison of international norms for small business management. unpublished master's dissertation, university of pretoria, pretoria. baloglu, a. (2007). a flexible mobile education system approach. the turkish journal of educational technology, 6(4), 1–12. clark, t.m., & benson, d. (2008). private practice issues. in h. hosford-dunn, r.j. roeser & m. valente (eds.), audiology: practice management. (2nd edn.). (pp. 128–148). new york: thieme. edwards, a.l. 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(2007). educating audiologists in south africa: internationally recognized specialists or locally relevant generalists? unpublished master's dissertation, university of the witwatersrand, johannesburg. 17 otitis media and language performance in learning disabilities ν g maritz, β log (pretoria) i c uys, d phil (pretoria) β louw, d phil (pretoria) department of speech therapy and audiology university of pretoria abstract this study was designed to determine the influence of otitis media on the language performance of learning-disabled children and nonlearning-disabled children. four experimental groups were used, viz: learning-disabled children, divided into those with and without a history of recurrent otitis media and average academic achievers again divided into those with and without a history of recurrent otitis media. the language performance of each experimental group was determined using the clinical evaluation and language function (wiig and semel, 1980j. the results indicate that recurrent otitis media impaired the receptive and expressive language performance of the subjects used in this study. the impairment of receptive language was greater than for expressive language. implications for diagnosis, treatment and further research are discussed. opsomming hierdie studie is uitgevoer om die invloed van otitis media op die taalvermoens van leergestremde kinders en nie-leergestremde kinders te bepaal. vier eksperimentele groepe is gebruik, nl. leergestremde kinders verdeel in die met en sonder 'n geskiedenis van herhaalde otitis media en gemiddelde akademiese prestasies weer eens verdeel in die met en sonder 'n geskiedenis van herhaalde otitis media. die taalvermoens van elke eksperimentele groep is bepaal met die "clinical evaluation of language function" (wiig en semel, 1980). die resultate het getoon dat herhaalde episodes van otitis media 'n negatiewe invloed het op die respektiewe en ekspressiewe taalvermoens van die proefpersone gebruik in hierdie studie. reseptiewe taalvermoens is meer aangetas as ekspressiewe taalvermoens. implikasies vir diagnose, behandeling en verdere navorsing word bespreek. learning-disabled children exhibit specific communication problems and are at present referred to as "specific language impaired children "i or "language learning impaired children" (wiig and semel, 1982; sak and ruben, 1982). these children have difficulty understanding or using language, spoken or written, which may lead to impaired ability to listen, think, speak, read, write, spell or do mathematical calculations. perceptual handicaps, brain injury, minimal brain dysfunction, dyslexia and development aphasia, also result in learning disabilities (u.s. office of education, in wiig and semel, 1982). while the influence of otitis media on language development has been investigated, (kessler in northern and downs, 1984; hornsby, 1984) its influence on the language development of learning impaired children has, however, been neglected in the literature. 1 in an effort to list the specific language impairments exhibited by learning-disabled children, many authorities are inclined to fragment and oversimplify complex language processes and to disregard the interrelationship between them. although the symptoms, as described in the literature, cannot be regarded as separate entities, the following impairments are mentioned: wallach and butler (1984) state that learning disabled children often have delayed or deviant auditory perception, synthesis, analysis, memory, discrimination and comprehension abilities. difficulty with concept formation and metalinguistic skills, impoverished and delayed vocabulary skills and delayed rather than deviant language form are mentioned by rapin (1979). eisen (1962) and gottlieb, zinkus and thompson (1979) add delayed phonological, morphological, and syntactic abilities, as well as poor divergent and convergent language production abilities. wiig and semel (1982) found that children with learning disabilities experience delays in achieving communication competence and developing mature styles and social register in interpersonal communication. within the framework of language learning disabilities, it is, however, clear that language cannot be separated from learning, aspects such as analysis and synthesis cannot be separated from auditory perception and language form, content and use cannot be separated from metalinguistic skills. with regard to the influence that otitis media has on language development, research findings can be divided into two groups. the first group of researchers found that otitis die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 © sasha 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) \ 18 a g maritz, i c uys and β louw media has a negative influence on language content and form. children with recurrent otitis media were found to have poor auditory perception, decoding and discrimination abilities (eisen, 1962; gottlieb, et al. 1979; hugo, 1985; sak and ruben, 1982). these children also exhibit a higher incidence of delayed conceptualization, attention and soundblending abilities (eisen, 1962; kessler in northern and downs, 1984). according to rapin (1979) these children have impoverished and delayed vocabulary. children with recurrent otitis media were found to have reduced complexity of syntax, and exhibit phonological development delay. learning impaired children are often poor readers according to kessler in northern and downs (1984) and it is important to note that hugo (1985) and rapin (1979) found that children with recurrent otitis media are often low academic achievers at school. the second group of researchers found that children with a history of otitis media, but whose hearing was normal at the time of testing, suffer little if any deficit, at least in terms of vocabulary, language comprehension, syntax and reading level (owrid, 1970). a possible explanation for the above-mentioned contradictory results is that single or infrequent bouts of middle-ear infection do not have a marked adverse effect on language and speech development or education progress (mustain, 1979). paradise (1983) has, however, stated that methodological weaknesses are present in the above-mentioned research. there is uncertainty about the validity of diagnosed otitis media reported as occurring in early life. there is an absence of information concerning the hearing-thresholds accompanying otitis media episodes and some subjects presented with otitis media at the time of testing. further, the matching of subjects is questionable. only a small number of subjects were tested and the tests used had questionable reliability. it is interesting to note that recurrent otitis media may have an influence on neurological development. studies have shown that the first five years are the most important for brain maturation, with particular emphasis on the second year. there is a critical period in neurological development when the brain is more susceptible to language acquisition (vernon and rothstein, 1968). the first four years form this critical period for the acquisition of language (rubin, 1984). webster (1984) found that the brains of animals with obstructed ear canals often do not mature normally. hearing is thus essential for the development of the auditory pathways in the peripheral and central nervous system. this statement is alarming, as recurrent otitis media may thus impair the development of complex auditory functioning, as well as communicative and cognitive abilities (hornsby, 1984). the effect of recurrent otitis media on the language performance of learning-disabled children has been neglected in the literature. literature has shown, (van rensburg, 1981), that learning-impaired children experience a higher incidence of recurrent otitis media than average academic achievers. the purpose of this study is to determine the effect of recurrent otitis media on the language performance of learning-disabled children, with normal hearing. methodology subject selection 352 questionnaires were distributed to 5 english medium primary schools in pretoria which have remedial classes. the questionnaires were completed by the parents of standard two pupils and collected by class teachers. of the questionnaires distributed 82,5% were returned. 15,75% of the returned questionnaires could not be used due to the fact that they were incomplete or spoiled. the effective percentage of questionnaires that could be used was 69,88% and the effective number of potential subjects, 246. the 24 subjects used in this study were selected by using the table of random numbers method where ' 'the purpose of randomness is to permit blind chance to determine the outcome of the selection process" (leedy, 1985, p. 148). six subjects were allocated to each experimental group (illustrated in table 1) with an even distribution of 3 male subjects and 3 female subjects per group. subjects in experimental groups 1 and 3 were also required to satisfy howie's definition in northern and downs (1984, p. 13): "an otitis-pronechild has the condition 6 or more times before the age of 6, or whose initial episode of otitis media was due to pneumococcus and occurred before the age of 1 year." this information was obtained from the questionnaires. the subjects used english as their home language and had average intelligence, as indicated by the school files. they varied in age from 9 years 6 months to 10 years 3 months (the mean being 9 years 10 months). the experimental groups are described in table 1. the learning-disabled children (experimental groups 1 and 2) showed a discrepancy between intellectual ability and academic achievement, as indicated by the school files. the non learning-disabled children (experimental groups 3 and 4) showed a correlation between intellectual ability and academic achievement, as indicated by the school files. table 1: description of experimental groups (n = 24) group 1 (n = 6) group 2 (n = 6) group 3 (n = 6) group. 4 (n = 6) learningdisabled children with a history of otitis media learningdisabled children without a history of otitis media non-learningdisabled children with a history of otitis media non-learningdisabled ' children without a history of otitis media apparatus and material 1. questionnaire a questionnaire was compiled to select and allocate children to the four experimental groups required for the study. this questionnaire was used to determine the prevalence of otitis media among the subjects. the questionnaire was completed by parents. / the use of questionnaires in research have certain limitations. the researcher does not have direct access to the original data and the questionnaire is an impersonal probe (leedy, 1980). the information obtained using questionnaires may thus have questionable reliability. leedy (1985) provides practical guidelines to reduce impersonality and improve reliability. these the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) otitis media and language performance in language disabilities 19 guidelines include the usage of an initial letter, precise and simple language, courtesy, and 'easy to complete' questionnaire, the inclusion of countercheck questions and an offer of results to the respondent. the questionnaire utilized in this study, was compiled using these guidelines. 2. clinical evaluation of language functions — celf (wiig and semel; 1980) the aim of the celf is to provide differentiated measures of selected language functions in the areas of phonology, syntax, semantics, memory and word-finding and retrieval. these measures were designed to probe specific language processing and production abilities of school-age children. the subtests were designed to assist in the identification of children with learning disabilities, to provide a differential diagnosis of language areas involved through selected language probes and finally to identify areas which require language intervention. a summarized overview of the subtests is provided in table 2. the celf does, however, not provide an in-depth assessment of phonology or pragmatics (wiig and semel, 1980). the celf consists of 3 groups of subtests, viz.: language processing, production and supplementary subtests. in this study the supplementary subtests of the celf (which assess phonology) are considered to form part of the language form/production subtests. this decision is supported by bloom and lahey (1978) who state that language form consists of 3 components, viz.: phonology, morphology and syntax. this decision will also facilitate the discussion of relevant related literature. data collection procedure a comparative design was used. a comparison was made between the language performance of the four experimental groups of subjects on the celf (wiig and semel, 1980). the celf norms have been standardised on the population of the united states of america. it was thus necessary to compare the language performance of subjects included in this study and the existing celf norms. the research design consisted of a systematic evaluation of group differences where stimuli were controlled (smit, 1983). the 24 subjects were individually evaluated in their respective home situations. the tester followed the standardised instructions and administration procedures provided in the celf diagnostic examiner's manual (wiig and semel, 1980). data analysis subtests for each of the 24 celf test forms were totalled, by adding the scores obtained for each item. this information was then statistically analysed by using an ibm 370 computer. the sas programme was utilized and procedures employed were the general linear models procedure, the multiple analysis of variance method (with a 5% level of significance) and duncan's multiple range test (ferguson, 1984). these procedures were used to compare the language performance of the four experimental groups. results the results entail an evaluation of the applicability of the celf to the 4 experimental groups, a description of the level of language performance of each experimental group and an evaluation of intergroup tendencies. evaluation of the applicability of the celf to the 4 experimental groups great caution should be exhibited when using the celf to subtests description of each subtest la n g u a g e c o n te n t / p r o c es si n g s u bt es t s \ 1 word and sentence structure assesses the child's ability to process and interpret selected word and sentence structures la n g u a g e c o n te n t / p r o c es si n g s u bt es t s \ 2 word classes 1 evaluates the child's ability to perceive relationships between verbal concepts and identify word pairs la n g u a g e c o n te n t / p r o c es si n g s u bt es t s \ 3 linguistic concepts evaluates the ability to process and interpret oral directions which contain linguistic concepts requiring logical operations la n g u a g e c o n te n t / p r o c es si n g s u bt es t s \ 4 relationship and ambiguities evaluates the ability to process and interpret logico-grammatical and ambiguous sentences la n g u a g e c o n te n t / p r o c es si n g s u bt es t s \ 5 oral directions j evaluates the accuracy, fluency, and speed in naming colours, forms, and colour-form combinations in a sustained confrontation-naming task la n g u a g e c o n te n t / p r o c es si n g s u bt es t s \ 6 spoken paragraphs! evaluates the ability to process and interpret spoken paragraphs and recall salient information presented la n g u a g e c o n te n t / p r o c es si n g s u bt es t s \ 7 word series assesses the accuracy, fluency and speed in recalling and producing selected automaticsequential word series la n g u a g e c o n te n t / p r o c es si n g s u bt es t s \ 8 names on confrontation evaluates the accuracy, fluency, and speed in naming colours, forms, and colour-form combinations in a sustained confrontation-naming task la n g u a g e c o n te n t / p r o c es si n g s u bt es t s \ 9 word associations evaluates the quantity and quality of the retrieval of semantically related word series from long-term memory la n g u a g e c o n te n t / p r o c es si n g s u bt es t s \ 10 model sentences assesses productive control of sentence structure in a sentence repetition task la n g u a g e c o n te n t / p r o c es si n g s u bt es t s \ 11 formulated sentences evaluates the ability to formulate and produce sentences when word and sentence form choices are limited and when semantic and syntactic constraints are introduced by a word which has to be included la n g u a g e c o n te n t / p r o c es si n g s u bt es t s \ 12 processing speech sounds evaluates the ability to discriminate between speech sounds (phonemes) in minimally different word pairs la n g u a g e c o n te n t / p r o c es si n g s u bt es t s \ 13 producing speech sounds evaluates the accuracy in articulating selected elicited speech sounds (phonemes). table 2: summarized overview of the subtests of the celf |wiig, e. and semel, e., 1980) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 a g maritz, i c uys and β louw evaluate the language performance of south african subjects. it is important to realize that the celf norms are not necessarily representative of the south african population of school-age children. the celf might for example be unable to identify learning-disabled children from average academic achievers, within the south african population. furthermore, the celf might identify non-existent problem areas in language or may be unable to identify these areas which will have a detrimental effect on the treatment and therapy process. the language performance of experimental groups 1 and 2 (learning-impaired children) was significantly lower than the celf norms. the differences between the language performance of experimental groups 3 and 4 (average academic achievers) and the celf were not significant. a description and comparison of the language performance of experimental groups 1 and 2 on the celf the average performance or arithmetic mean of experimental groups 1 and 2 for each subject, together with the celf norms are listed in table 2. table 3 indicates the celf subtests for which the performance of experimental group 1 was significantly lower (at the 5% level of significance) than experimental group 2. celf subtests standardised celf norms usa population average performance of arithmetic mean of each experimental group (standard deviation in brackets) celf subtests standardised celf norms usa population group 1 group 2 group 3 group 4 1 word and sentence structure (2,30) (2,88) (3,10) (2,94) 38 22* 34,6* 40 36* 2 word classes (2,50) (2,68) (2,88) (2,94) 30 26* 30 34,6 36 3 linguistic concepts (2,40) (2,73) (3,06) (3,17) 34 24* 31* 39 42 4 relationship and ambiquities (2,30) (2,73) (3,14) (3,39) 36 22* 31* 41 48 5 oral directions (2,40) (2,23) (3,18) (3,06) 32 24* 25* 40 39 6 spoken paragraphs (1,00) (1,30) (1,37) (•1,77) 8 4* 7* 7,8* 13 7 word series: item 1 accuracy (1,10) (1,30) (1,30) (1,30) 7 5* 7 7 7 time for item 1 (2,19) (2,14) (1,50) (1,20) 10 20 19 9* 6* word series: item 2 accuracy (1,00) (1,20) (1,70) (1,70) 12 4* 6* 12 12 time for item 2 (2,58) (2,73) (2,14) (1,55) 20 27,6 31 19* 10* 1 8 confrontation naming (2,45) (2,37) (2,91) (2,86)i 32 25* 23* 35 34 time (4,40) (4,94) (4,96) (4,90) ! 100 80,6* 110,5 112,5 . 100 ] 9 word associations (1,55) (1,64) (2,50) (2,45) 20 10* 11* 26 25 10 model sentences (2,19) (2,59) (3,50) (3,79) ι 36 20* 28* 51 60 11 formulated sentences (2,35) (2,64) (2,98) (3,06) 25 23* 29 37 39 12 processing (5,09) (5,25) (5,30) (5,25), 115 118 115 117 115 13 producing speech sounds — blends (3,53) (3,53) (3,35) (3,53) 50 52 52 50 / 52 producing speech sounds — final position (2,08) (2,08) (2,08) (2,08) 18 18 18 18 18 production speech sounds — initial position (2,19) (2,19) ('2,19) (2,19) 20 20 20 20 20 table 3: a summary of the celf norms and the performance of the 4 experimental groups on each celf subtest key: * language performance of that specific experimental group was lower than the celf norm for the subtest standard deviation. the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) otitis media and language performance in language disabilities 21 a description and comparison of the language performance of experimental groups 3 and 4 on the celf the average performance or arithmetic mean of experimental groups 3 and 4 for each subtest, together with the celf norms are listed in table 2. table 4 indicates the celf subtests for which the performance of experimental group 3 was significantly lower (at the 5% level of significance) than experimental group 4. table 4: the comparison of the language performance of experimental groups 1 and 2 table 5: the comparison of the language performance celf subtests comparison of the language performance of experimental groups 1 and 2 1 2 3 4 5 6 7 word and sentence structure word classes linguistic concepts relationship and ambiguities oral directions spoken paragraphs word series: item 1 accuracy time for item 1 word series: item 2 accuracy time for item 2 8 confrontation naming time 9 word associations 10 model sentences 11 formulated sentences 12 processing speech sounds 13 producing speech sounds — blends producing speech sounds — final position producing speech sounds — initial position ' key: '* performance of group 1 (at the 5% level of significance) was significantly lower than group 2 for the specific subtest. discussion the celf norms were standardised on a usa population of school-age children. the evaluation of the applicability of the celf to the south african population, has indicated that the celf is applicable to experimental groups 3 and 4, and thus the average academic achievers in this study. it is important to realize the the celf was standardised by using a group of 100 subjects, while experimental groups 3 and 4 consisted of 6 subjects each. the sample population used in this study might not reflect the characteristics resident in the general population accurately. this conclusion is supported by leedy (1985), who states that the larger the sample, the higher the degree to which the sample population will approximate the qualities and characteristics resident in the general population. the preceding discussion has indicated that the celf (wiig and semel, 1980) appears to be a reliable instrument for the identification of learningdisabled children within the south african population. the celf norms were also found to be representative of the average academic achievers in this study. comparison of the language celf subtests performance of experimental groups 3 and 4 1 word and sentence structure 2 word classes 3 linguistic concepts 4 relationship and ambiguities * 5 oral directions 6 spoken paragraphs * 7 word series: item 1 accuracy * time for item 1 word series: item 2 accuracy time for item 2 8 confrontation naming time 9 word associations 10 model sentences * 11 formulated sentences * 12 processing speech sounds 13 producing speech sounds — blends producing speech sounds — final position producing speech sounds — initial position key: * performance of group 3 (at the 5% level of significance) was significantly lower than group 4 for the specific subtest. the inter-group tendencies of the four experimental groups will now be discussed, but as the purpose of the study was not to give an in-depth identification of individual characteristics, this will not be included in this discussion. it is interesting to note that the language content/processing subtests on which experimental groups 3 and 4 differed, also occurred in those subtests for which experimental groups 1 and 2 differed. experimental groups 1 and 3 thus exhibited lower levels of language performance than experimental groups 2 and 4 for the celf language content/processing subtests. experimental groups 1 and 3 consisted of subjects with a history of recurrent otitis media, implying the presence of the fluctuating hearing loss. the presence of a fluctuating hearing loss does not permit the subject with recurrent otitis media to adapt to constant auditory perceptions. this in turn inhibits the development of normal perceptual abilities and may influence language development negatively (kessler, in northern & downs, 1984). the difference exhibited by experimental groups 3 and 4 for the language content/processing subtests was not as great as the difference exhibited by experimental groups 1 and 2. this can be attributed to the fact that experimental group 3 consisted of subjects with average academic achievement. another reason may be that learning-disabled children may be genetically more susceptible to language and learning problems (teele, klein & rosner, 1980). this factor, together with a history of otitis media, may have a more severe influence on language performance. downs (1977) states that recurrent otitis media may result in a syndrome referred to as "irreversible-auditory-learningdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 a g maritz, i c uys and β louw disaster" and emphasizes that language and learning skills, especially those based on auditory functions are irreversibly damaged by otitis media. the question that poses itself is whether learning-disabled children have a higher incidence of otitis media than children with average academic achievement. research performed by van rensburg (1981) indicated that learning-disabled children have a remarkably higher incidence of otitis media than children with average academic achievement. further research is, however, necessary to confirm this statement. it is interesting to note that tlje language form/production subtests on which experimental groups 1 and 2 differed are the same as on subtests on which experimental groups 3 and 4 differed. experimental groups 1 and 3 exhibited lower levels of language performance than experimental groups 2 and 4 for the celf language form/production subtests. recurrent otitis media appears to exert a negative influence on language form in experimental groups 1 and 3. language form is based on, and also develops simultaneously with language content (bloom and lahey, 1978). a deficit, deviancy or delay in language content will thus influence the development of language form. in experimental groups 1 and 3 (subjects with a history of otitis media) the presence of a fluctuating hearing loss due to recurrent episodes of otitis media had a marked negative influence on the language form of experimental groups 1 and 3. bloom and lahey (1978, pp. 23) state that "children learn language as they use language both to produce and understand messages." language form problems, caused by recurrent otitis media are usually subtle and are difficult to identify unless the child is tested formally (bloom and lahey, 1978; rapin, 1979). this factor may account for the fact that the language form subtests, for which experimental groups 1 and 2 differed, are identically reflected in the results of experimental groups 3 and 4. the celf (wiig and semel, 1982) might not be an instrument that is sensitive enough to identify differences between the experimental groups in this study. according to wiig and semel (1982) the results of the celf should be complemented by the administration of standardized measures of receptive vocabulary development and an analysis of the spontaneous speech sample. the results of this study indicate that recurrent otitis media has a negative influence on language content and form, as has been demonstrated by experimental groups 1 and 3. the influence of recurrent otitis media on the language performance of learning-disabled children has not been evaluated previously. although the size of the population tested in this study was limited, the results indicate that recurrent otitis media may have an adverse effect on the language performance of learning-disabled children. the sample population used in this study might not reflect the characteristics resident in the general population accurately, as the larger the sample, the higher the degree to which the sample population will approximate the qualities and characteristics resident in the general population. the results of this study are important from a clinical point of view. it is essential that speech pathologists and audiologists realise the implications that recurrent otitis media may have on the language performance of learning-disabled children, as well as children with average academic achievement. extensive benefits would be gained if recurrences of otitis media could be prevented or substantially reduced in frequency (northern and downs, 1984). paradise (1980) has suggested five different ways in which the incidence of otitis media episodes may be reduced, viz. adenoidectomy with or without tonsillectomy; antimicrobial prophylaxis; the use of tympanostomy tubes, the frequent and liberal use of myringotomies; and polyvalent pneumococcal vaccine. current literature and the results of this study stress that the clinician should obtain information concerning the occurrence and incidence of otitis media for all children evaluated. this will enable the speech therapist/audiologist to identify at risk children and also extend existing knowledge, concerning the influence that otitis media has on language performance. this study represents the implementation of an exciting recent research direction that should be explored. recommendations for further research are: — to conduct a similar study, using a larger sample, in order to reflect the characteristics of the general population more accurately. — to determine whether children with certain craniofacial characteristics may make them more prone to recurrent otitis media. sharon (1985) suspects that these children have comparatively elongated faces, similar to the findings reported by bresolin, shapiro and shapiro (1984) in children with chronic nasal construction, who breathe through their mouths. — the standardisation of the celf on different language groups in south africa. conclusion this study indicates that the celf appears to be applicable to the south african population of english-speaking schoolage children. the celf also appears to be a reliable instrument for the identification of learning-impaired children within the south african population. further research; is, however, necessary in order to standardize this test for the south african population. recurrent otitis media appears to have a negative influence on the language content and form of learning-disabled children and children with average academic achievement. further research with a larger sample population iis necessary to confirm these research findings. references bloom, l. and lahey, m. language development and language disorders. new york: wiley, 1978. bresolin, d., shapiro, g.g. and shapiro, p.a. facial characteristics of children who breathe through the mouth. pediatrics, 73, 6 2 2 6 2 5 , 1984. / downs, m.p. the expanding imperatives of early identification in bess, f.h. (ed): childhood deafness: causation, assessment and management. new york: grune and stratton, 1977 eisen, n.h. some effects of early deprivation on later behaviour: the quandom hard of hearing child. journal of abnormal social psychology, 65, 338,1962. ferguson, g.a. statistical analysis in psychology and education. singapore: mcgraw-hill, inc., 1984. the south african journal of communication disorders, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) otitis media and language performance in language disabilities 23 gottlieb, m.e. zinkus, p.w. and thompson, m.a., chronic middle -ear disease and auditory perceptual deficits. clinical pediatrics, 18 (12), 7 2 5 7 3 2 , 1979. hornsby, b. overcoming dyslexia. kenwyn: juta and co., ltd., 1984. hugo, r. normatiewe evaluasies van otitis media as sekondere patologie. opvoeding (suid-afrikaanse tydskrif|, 5(2), 83—88, 1985. leedy, p.d. practical research planning and design. new york: mac-millan publishing company, 1985. mustain, w.d. linguistic and educational implications of recurrent otitis media. ear, nose and throat journal, 58, 62—68, 1979. northern, j.l. and downs, m.p. hearing in children. baltimore, maryland: the williams and wilkins, co., 1984. owrid, h.l. hearing impairment and verbal attainment in primary school children. education research, 12, 209—214, 1970. paradise, j.l. otitis media in infants and children. pediatrics, 65, 9 1 7 9 4 3 , 1980. paradise, j.l. long term effects of short term hearing loss — menace or myth? pediatrics, 71, 647—648, 1983. rapin, i. conductive hearing loss. effects on children's language and scholastic skills. a review of literature. annals of otology, rhinology and laryngology, 88, (supplement 60), 3 1 2 , 1979. rubin, r.j. the effects of recurrent middle ear effusion in preschool years on language and learning. audiology in practice, 1 (supplement 3), 5 7 , 1984. sak, r.j. and rubin, r.j. effects of recurrent middle ear effusion in pre-school years on language and learning. journal of developmental and behavioural pediatrics, 3, 7—77, 1982. sharon, b.j. the face in otitis media. pediatrics, 75, 131, 1985. smit, g.j. navorsingsmetodes in gedragswetenskappe. pretoria: haum opvoedkundige uitgewers, 1983. teele, d.w. klein, j.o. and rosner, b.a. epidemiology of otitis media in children. annals of otology, rhinology and laryngology, 89, 5—6, 1980. van resnburg, y.j. chroniese otitis media by die kind met leerprobleme. voorkoms en gevolge. unpublished research study (b.log). university of pretoria, 1981. vernon, m. and rothstein, p. prelingual deafness. archives of general psychiatry, 19, 3 6 1 3 6 7 , 1968. wallach, g.d. and butler, k.g. language learning diabilities in school-age children. london: williams and wilkins, co., 1984. webster, d.b. the effects of recurrent middle-ear effusion in preschool years on language and learning. audiology in practice, 1 (supplement 3), 2, 1984. wiig, e.h. and semel, e.m. clinical evaluation of language function. columbus, ohio: charles e. merrill publishing company, 1980. wiig, e.h. and semel, e.m. language assessment and learning disabled. toronto: merrill publishing company, 1982. -2play [ τ ί and l u schoolroom have moved to bigger a n d better premises at shop 6l the rosebank mews 173 oxford road rosebank jhb. play & schoolroom, specialists in the field of child education have been offering assistance to both professionals and parents for nearly thirty years. their expertise and advice range through pre-school education, perceptual training, primary and remedial education and adult education. play and schoolroom are sole agents for learning development aids which includes an excellent selection of materials of interest to the speech therapist. they also offer an interesting range of aids and books to foster and develop language and communicative skills. their stock of educational books and toys is exceptionally wide. you are invited to view their superb range in their new beautifully laid out showroom. phone 788-1304 po box 52137 (as before) saxonworld 2132 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 35, 1988 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a legacy of sound advice and equipment philips hearing aids audiometers fm systems head office: 1005 cavendish chambers, 183 jeppe street p.o. box 3069, johannesburg 2000. tel: (011) 337-7537. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 49 the communicative and cognitive deficits following closed-head injury lesley irvine, ba (sp. & h. therapy) (witwatersrand) marlene behrmann, ma (speech path.) (witwatersrand) department of speech pathology and audiology, university of the witwatersrand, johannesburg. the communicative and cognitive deficits of three closed-head injured patients were investigated within the framework of language form, language use and cognitive ability. a battery of tests was administered and results indicated a degree of cognitive impairment in all subjects. the balance between the language form and language use skills was subject-specific. these findings supported the current view of heterogeneity within the closed-head injured population as well as the view that a language disorder may result from an underlying cognitive deficit. the results are discussed in the light of the existing literature on head injury. the theoretical and clinical implications are considered. opsomming die kommunikatiewe and kognitiewe vermoens van drie geslotehoofl>eseringspasiente is ondersoek binne die raamwerk van taalvorm, taalgebruik en kognisie. 'n toetsbattery is gebruik en volgens die resultate was daar 'n mate van kognitiewe en kommunikatiewe aantasting in al drie proefpersone. die verhouding tussen taalvorm en gebruiksvaardighede was proefpersoonspesiflek. hierdie bevindinge ondersteun die huidige sienswyse van heterogeniteit binne die gesiotehoofi>eseringspopulasie sowel as die opvatting dat 'n taalafwyking die gevolg van 'n onderliggende kognitiewe afwyking kan wees. die resultate word teen die agtergrond van bestaande literatuur oor geslotehoofbesering bespreek. daar is ook op beide die teoretiese and kliniese implikasies ingegaan. closed-head injury (chi) has recently been termed "the invisible epidemic" (holland, 1982) in view of the well documented dramatic increase in the incidence of this disorder (annegers, grabow, kurland and laws, 1980). the primary source of the pathophysiology in chi is that of blunt trauma to the brain which results in discontinuation of neural substance and shearing and straining of the axons in the white brain matter (hagen 1984). while there seems to be agreement concerning the neurological symptoms of this disorder, considerable controversy still surrounds the neurobehavioural and linguistic sequelae. hagen (1984) has called for controlled, systematic research into the communicative and cognitive deficits which follow chi in order to clarify the existing confusion. from a clinical point of view, the need for further research is pressing in view of the fact that decisions regarding management of chi individuals must be made;, i / j the language symptomatology resulting from chi constitutes an area of much controversy. some writers have considered the language disturbance to be an aphasia (luria, 1970) while others have argued that the language djsorder is unique and clearly distinguishable from classical aphasia (holland, 1982). sarno (1980, 1984) has identified three subtypes of chi subjects, each subtype demonstrating some degree ofllanguage impairment. the one subtype exhibits the traditional aphasic symptoms whilst the remaining two subgroups display subclinical aphasia or a language processing problem without the overt manifestation of classical aphasia. according to sarno (1980; 1984), the typical features of all chi subjects include reduced word fluency, impaired comprehension of complex oral commands and an anomia. it has been suggested that such subtle language problems may only be detected through the use of sophisticated neurolinguistic assessment procedures. additionally, the subtype differences and heterogeneity inherent in the chi population may only be identified on such measures (sarno, 1980). the heterogeneity of these chi subjects is increasingly well recognised and samo's (1980; 1984) classification provides further evidence for the fact that there is no one type of language disturbance resulting from closed-head injury. hagen (1984) has viewed the language problems of the closeddie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 head injured from a very different perspective to that of sarno (1980; 1984). he has argued that chi is characterised by 'confused' language or "a receptive/expressive language that may be intact phonologically, semantically and syntactically yet is lacking in meaning because the behavioural responses are irrelevant, confabulatory, circumventory and tangential" (hagen, 1984: 246). it appears from this definition that the language disorder extends beyond a problem of language form or content, and that the disturbance may be reflected in another area such as that of language function or use. milton, prutting and binder (1984) have supported this view and have stated that the chi subject is communicatively incompetent since language function is typically impaired in this population. they have adopted the premise that language may be divided into the components of form or structure, content and usage. through adopting a more holistic view of language as a component of communication, they have identified the use of language in social context as the major area of deficit in subjects with closed-head injury. this broader communication problem of the chi population has been attributed to one or more of the following factors — psychiatric disturbances, memory problems or a pervasive cognitive deficiency (russell, 1971; holland, 1982). ylvisakerand holland (1985) have recently suggested that the language disruption is secondary to a deficit in conceptual or cognitive processing. while previous research has recognised the existence of cognitive problems such as poor abstract thought and slow speed of processing in chi subjects (hagen, 1984), the contention of a causal relationship is novel. the nature of the relationship between language disturbance and the cognitive deficit remains unresolved. it is, however, a critical issue in terms of rehabilitation of these subjects. the purpose of this study therefore is to examine the language disorder resulting from closed head-injury in relation to the holistic concept of communicative competence as well as in relation to cognitive functioning. it is submitted that a description of the language disturbance from a broader perspective is valuable from a theoretical perspective. furthermore, the clearer definition of the nature of the disturbance should be of assistance in the future management of the chi individual. © sasha 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 lesley irvine and marlene behrmann method subjects three english-speaking adult males who had sustained closedhead injuries as a result of motor vehicle accidents were selected as subjects for this study. the ages of the subjects ranged between 24 to 27,4 years (mean 25,2 years). mean coma duration of the subjects was 11 weeks (range 3-21 weeks), thus indicating a severe head injury according to the criteria prescribed by russell (1971). all subjects were neurologically stable at the time of testing with a mean post-injury time of 39 months (range 15-52 testing as there are no language tests currently available for the specific assessment of chi, it was necessary to utilise and modify tests designed for other disorders such as aphasia. the following tests were administered in order to evaluate the communicative and cognitive functioning of the subjects: a. language form testing — this involved the administration of the boston diagnostic aphasia examination (goodglass and kaplan, 1972) which was utilised to provide an overall account of the language pattern of the subjects. more specific receptive language testing comprised the administration of the revised token test (mcneill and prescott, 1978) and a linguistic test designed to measure performance on complex sentences (penn, 1972). this latter test is designed to assess competence with respect to complex sentences such as relative and complement constructions. the subject was required to answer questions about each of the twenty seven sentences presented to him. sentences were analysed by drawing the deep syntactic structure of the sentence and by observing at what point the subject failed. expressive language testing involved the syntactic analysis of the subjects' output using the language assessment remediation screening procedure (larsp) (crystal, 1982). the data for the months). subjects were all pretraumatically right handed and had completed at least eleven years of schooling. family reports indicated that subjects were of average intellectual capacity prior to the accident. no previous history of sensory or motor deficit was reported nor was any history of drug or alcohol abuse noted. hearing was within normal limits for all three subjects at the time of testing. further relevant clinical and biographical details are included in table 1 below. analysis consisted of a spontaneous interactive language sample which was elicited by one of the authors and simultaneously videotaped and audiotaped through a one-way mirror set-up. topics such as the subject's accident, his family structure, and his hobbies and interests were discussed during this conversational interchange. the sample was then transcribed according to the suggestions of crystal, fletcher and garman (1976) and profiles were completed for each subject. further expressive language testing involved the administration of the expressive component of the linguistic test designed to assess the subject's performance on complex sentences (penn, 1972). the subject was required to repeat twenty five complex sentences and responses were analysed both qualitatively and quantitatively. b. language use testing consisted of the administration of the communicative abilities of daily living (cadl) (holland, 1980). in addition, the interactive sample was analysed on a protocol of communicative skills, the profile of communicative appropriateness (penn, 1983). this profile rates the subject's responses to the interlocutor, control of semantic content, cohesion, fluency, sociolinguistic sensitivity and non-verbal communication. (see table 2 for example of this profile.) the south african journal of communication disorders, vol. 33, 1986 table 1: relevant clinical and biographical details for all subjects age subject 1 24 subject 2 24.1 subject 3 27.4 sex male male male premorbid laterality right right right educational level standard 9 apprentice mechanic matric diploma in electronics time since injury to testing (months) 15 52 50 coma length (weeks) 3 10 21 present motor problems l arm hemiplegia bilateral paresis of both arms bilateral extreme spasticity occupation unemployed unemployed unemployed receiving speech therapy yes, since may 1983 no therapy presently yes, since november 1980 immediate post-trauma cat scan results diffuse cerebral oedema with small parietotemporal bleed on left. diffuse cerebral oedema and high intracranial pressure. extensive cerebral involvement including brain stem and right cortical areas. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e communicative and cognitive deficits following closed-head injury table 2: profile of communicative appropriateness (penn, 1983) features of sampling. name unit of analysis person eliciting sample i ii iii iv v vi comments request 2 s reply 1 s clarification request 1-8 \ pi .£ acknowledgement 1-8 \ pi .£ teaching probe others topic initiation topic adherence "s.atopic shift 2 i | lexical choice s ε § o u ο idea completion idea sequencing others ellipsis tense use reference c oh es io r lexical substitution forms c oh es io r relative clauses c oh es io r prenominal adjectives c oh es io r conjunctions c oh es io r others fl ue nc y interjections fl ue nc y repetitions fl ue nc y revisions fl ue nc y incomplete phrases fl ue nc y false starts fl ue nc y pauses fl ue nc y word-finding difficulties fl ue nc y others \ so ci ol in gu is tic se ns iti vi ty polite forms , \ so ci ol in gu is tic se ns iti vi ty reference to interlocutor \ so ci ol in gu is tic se ns iti vi ty placeholders, fillers,[stereotypes \ so ci ol in gu is tic se ns iti vi ty acknowledgements | \ so ci ol in gu is tic se ns iti vi ty self correction | \ so ci ol in gu is tic se ns iti vi ty comment clauses j \ so ci ol in gu is tic se ns iti vi ty sarcasm/humour ; \ so ci ol in gu is tic se ns iti vi ty control of direct speech \ so ci ol in gu is tic se ns iti vi ty indirect speech acts! \ so ci ol in gu is tic se ns iti vi ty others , / n on -v er ba l co m m un ic at io n vocal aspects: intensity n on -v er ba l co m m un ic at io n pitch n on -v er ba l co m m un ic at io n rate n on -v er ba l co m m un ic at io n intonation n on -v er ba l co m m un ic at io n quality n on -v er ba l co m m un ic at io n nonverbal aspects: facial expression n on -v er ba l co m m un ic at io n head movement n on -v er ba l co m m un ic at io n body posture n on -v er ba l co m m un ic at io n breathing n on -v er ba l co m m un ic at io n social distance n on -v er ba l co m m un ic at io n gesture and pantomime n on -v er ba l co m m un ic at io n others totals key* i = inappropriate; ii = mostly appropriate; iii = some appropriate; iv = mostly appropriate; v = appropriate; vi = one. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 lesley irvine and marlene behrmann the ratings on this profile were completed by two trained speech and language pathologists who observed the videotapes independently and then completed the score sheet according to uieir observation of the relevant dimensions. both raters had been trained in the use of the profile with the inter-rater reliability being calculated at 0.92 (using the pearson product moment correlation) and hence significant beyond the 0.05 level of significance. communicative competence was analysed quantitatively by computing the overall ratings of appropriate and inappropriate behaviours. c. cognitive testing consisted of the administration of the south african wechsler adult intelligence scale — s.a. wais (national institute of personnel research 1969). scoring was completed according to the prescribed procedure. testing was carried out individually and extended over a number of morning sessions in an attempt to eliminate fatigue as a confounding variable. in order to reduce anxiety, rapport was established with each subject prior to his being tested. results the overall results across the language tests are presented in table 3. in order to allow for comparisons between very different tests and to obtain an overall view of the subjects' performance, the results are presented qualitatively. thus, performance is classified as being either good, mediocre or poor. exhibit a recognisable aphasic profile but problems in both comprehension and expression were observed, a common finding of chi (levin, 1981). the results of the receptive language tests revealed a variation in performance across subjects but consistency across tests. on both the token test (mcneil and prescott, 1978) and the receptive section of the linguistic test for complex sentences (penn, 1972), a severe impairment was noted for si (scores 8 and 45% on the two tests), a moderate receptive language deficit was recorded for s3 (scores 13 and 80,5%) and almost intact language reception was noted for s2 (scores 15 and 96%). holland (1982) has stated that language comprehension problems may persist well into the recovery phase following chi and that comprehension breaks down as the complexity of the material increases. a qualitative analysis of the results of the present study revealed that no one sentence type or grammatical construction presented more difficulty than any other, although increased sentence length was more problematic for all subjects. this may have resulted from short term memory problems, a recognised concomitant of chi (hagen, 1984). table 4 below sets out the major results of the larsp analyses (crystal 1982) for all subjects. table 4: results obtained by all subjected on the revised larsp profile (crystal 1982). table 3: results of subjects' performance on receptive and expressive language testing test results bdae subject 1 subject 2 subject 3 bdae — + + revised token test — + + complex sentences — comprehension + + spontaneous speech — larsp profile + + complex sentences — expression _ + + key: + = good performance ± = mediocre performance — = poor performance a. language form testing the profiles obtained for the subjects on the bd ae were atypical of the aphasic syndrome profiles described by goodglass and kaplan (1972). subjects 2 and 3 (ss2 and 3) were credited with a severity rating of 4 indicating some loss of facility in speech and comprehension. s2 and s3 performed similarly on the various subtests. they showed above mean performance on all subtests with the exception of the verbal agility, animal naming and writing mechanics sections. it is possible that the poor verbal agility score is attributable to the dysarthria which both subjects demonstrated. levin (1981) has observed that a dysarthria frequently accompanies language disturbance in the early stages of recovery post-chi and may persist following language restoration. subject 1 was given a severity rating of 2, suggesting that conversation about familiar subjects is possible although many si s2 s3 total number sentences 313 142 142 mean number sentences per turn 4,6 7,9 2,2 mean sentence length 4,17 10 7,4 total spontaneous utterances 174 125 80 number of clauses 198 212 152 number of phrases 551 698 465 number of word endings 263 276 205 as is evident from this table, ss 2 and 3 presented with well preserved expressive syntactic skills. they demonstrated retention of all constructions with equal balance between phrase, word and clause levels. both these subjects exhibited a high frequency of stage v utterances as well as utterances at stages vi and vii. few (—) features were marked and both demonstrated a high frequency of spontaneous utterances. sections β and d of the profile revealed less interaction with the conversational partner for s2 than for s3. j si presented with a definite expressive syntactic breakdown as evidenced by his larsp sample. he exhibited a high percentage of problematic and unanalysed utterances, a shorter mean sentence length than the other subjects and a high proportion of utterances around stage v with few utterances beyond this stage. many (—) features were marked including omissions and concord errors. the results of the expressive section of the linguistic test of complex sentences supported the above findings. subjects 2 and 3 scoring 80% and 76% respectively, while si scored 0%. si was often unable to recall linguistic elements. in addition, he tended to produce the incorrect word order of the sentence. it is possible, however, that his poor performance resulted from his inability to cope with the memory demands of the task. thus his langauge impairment may be secondary to cognitive disorganisation — an acknowledged pattern of breakdown (hagen, 1984; ylvisaker and holland, 1985). / the south african journal of communication disorders, vol 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the communicative and cognitive deficits following closed-h b. language use testing the results of the cadl (holland, 1980) revealed relatively well p r e s e r v e d functional skills for all three subjects. this finding was u n e x p e c t e d in view of the results of milton et al. (1984) who proposed that chi leads to an impairment in pragmatic skills. however, these writers used a societal rather than a clinical profile and this renders comparisons impossible. percentage values were computed from the raw scores of the injury cadl. si scored 96% followed by s2 who scored 94% and finally, s3 who obtained 86%. depressed scores were noted on the divergences items as well as on the humour, metaphor and absurdity items. holland (1982) has stated that these items rely on subtle reception of language. the inability to comprehend such items was noted in all three subjects. the results of the profile of communicative appropriateness (pca) (penn, 1983) supported the findings of the cadl (see figure 1 below). appropriate g mostly £ appropriate co a. some jj inappropriate e & •5 mostly as inappropriate inappropriate key : o si s2 s3 response to interlocutor control of semantic content cohesion fluency sociolinguistic sensitivity non-verbal communication dimensions of pca figure 1: performance of all three subjects on the profile of communicative appropriateness the ratings suggested that all three subjects exhibited relatively well preserved communicative abilities. specific areas of breakdown were noted for all the subjects and although these deficits were not overriding, they were sufficient to penalise the subjects in a conversational context. si was rated as mostly inappropriate on the cohesion and fluency scales, possibly as a result of his anomic and syntactic deficits. he was rated as appropriate on the nonverbal communication scale and mostly appropriate on the response to interlocutor, control of semantic content and sociolinguistic sensitivity scales. s2 demonstrated certain problems in interaction largely owing to dysarthria and apparent insensitivity to the interlocutor. apart from poor non-verbal communication, s3 demonstrated well preserved pragmatic skills. some difficulties were noted with suprasegmental features such as vocal intonation, quality and rate of output. once again, this may be attributed to the presence of a dysarthric component in his speech pattern. the differing patterns of performance and the relative preservation of the most pragmatic skills on the pca is unexpected in view of the recognised broad nature of the language deficit of chi. pragmatic abilities are reportedly depressed in the chi population (holland, 1982) and often serve as the pivotal differential diagnostic feature between chi and aphasia. the above findings indicate that pragmatic skills are not completely preserved in any one subject and that whilst an impairment exists, it is not as severe as has been documented in the literature (holland, 1982; milton et al., 1984). the difference between the results of the present study and previous research may be attributable to the fact that different studies utilise differing profiles for analysis and different contexts for data elicitation. c. cognitive testing results of the cognitive testing indicated that each subject had suffered a certain degree of intellectual impairment although the exact degree was subject-specific. s1 obtained a full scale iq score of 75,5 whereas s2 scored 102,5 and s3 scored 82,5. since all subjects had completed at least 11 years of schooling and their families reported no pretraumatic intellectual deficit, one may assume that the depressed cognitive results are associated with the head injury. these findings are supported by hagen (1984) and by levin, benton and grossman (1982) who stated that intellectual impairments are the major residual feature of chi. si's functioning was borderline and a close correlation was noted between his verbal and performance scores. he performed poorly on those tests which required memory skills for example, the digit span and repetition tests. s2 performed at an average level and there was good agreement between his verbal and performance scores. as with si, s3's functioning was borderline and while his verbal score was average, his performance score was much poorer. he demonstrated impaired functioning on all tasks involving spatial-synthetic and visual-constructive abilities. although ssl and 3 performed comparably on the cognitive testing, their language skills differed markedly. this suggests no direct relationship between language abilities and cognitive performances. in sum, the results of the testing in all three areas revealed different patterns of performance for all three subjects. all subjects presented with a degree of language impairment in both form and use. the nature and degree of the impairments, and the balance between language structure and language use skills was subject-specific. these varying patterns lend support to the notion die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 lesley irvine and marlene behrma of heterogeneity within this population (sarno, 1980: 1984). cognitive impairments were noted in all subjects thus supporting the finding of sarno (1980) that "while aphasia sometimes occurs in chi, the far more predominant language disturbances are those that result from the cognitive impairment itself." discussion si performed poorly across all tasks with the exception of his score on the cadl (holland 1980). his results parallel levin et al.'s (1982) finding that patients with a generalised language impairment present with depressed functioning as noted on both the verbal and performance scores of the wais (nipr 1969). s2 performed well in all the areas tested with the exception of specific problems in interaction such as insensitivity to the interlocutor. these results suggest relatively good preservation of language form, use and cognitive skills. it is hypothesised, however, that the few areas of deficit noted on the language use tasks are sufficient to reduce communicative competence and to impede the free flow of conversation. s3 presented with an inconsistent pattern in that he performed relatively well in the areas of language expression and pragmatic skills but exhibited some problems in subtle reception and in cognitive processing. there are several possible explanations for this variation in performance. coma duration and neurological dynamics could possibly account for the differences, as each subject presented different types of brain damage. other variables which may play a significant role in the explanation are non-medical variables such as motivation and personality functioning since affective disorders are a well recognised by-product of chi (hagen, 1984; sarno and levin, 1985). a crucial feature which appears to be operating, however, is the degree of cognitive impairment. this seems to be the main indicator of retention of language skills. it seems from the results that there is a close relationship between the degree of cognitive deficit and the retention of language skills. the variablity of the findings may also be attributed to the fact that the closed-head injured group are a heterogenous group and that individual patterns rather than a single group pattern characterizes this population. this notion is considered in the chi literature (sarno, 1980; sarno and levin, 1985) and is becoming increasingly well accepted. ~~~ a further issue which must be addressed is that of the crucial relationship between language use and language form skills. there does not appear to be a clear dissociation between these as has been suggested in previous studies (milton et al., 1984). this discrepancy gives rise to further debate concerning the applicability of pragmatic competence as a differential diagnostic feature between aphasia and closed-head injury. conclusion the finding that cognitive deficits are a predominant sequela of the closed-head injured population is consistent with the literature (ylvisaker and holland, 1985). the results of this study suggest 'that there is no one type of language disorder associated with chi but that the interaction between language use and language form skills are subject-specific and may be attributed to other factors such as cognitive impairment. the implications of this finding for remediation are many. in view of the heterogeneity, it is essential that the clinician assesses each closed-head injured subject individually without relying on the predicted findings from the literature. furthermore, it is essential to decide whether the cognitive dysfunction should be remediated if it underlies the language disturbance or whether the surface language symptoms should be treated. there are many questions and too few answers at this stage. there is little doubt, however, that chi presents the speech-language pathologist with a "unique and complex diagnostic, prognostic and treatment challenge." (hagen 1984 :245). references annegers, j.f., grabow, j.d., kurland, l.t. and laws, e.r. the incidence, causes and secural trends of head trauma in olmsted county, minnesota. neurology, 30, 912-919, 1980. crystal, d., fletcher, p. and garman, m. the grammatical analysis of language disability: a procedure for assessment and remediation. london: edward arnold, 1976. crystal d. profiling linguistic disability. london: edward arnold, 1982. goodglass, h. and kaplan, e. boston diagnostic aphasia examination. usa: lea and febiger, 1972. hagen, c. language disorders in head trauma. in a. holland (ed.) language disorders in adults. houston: college hill press, 1984. holland, a. communicative abilities of daily living a test of functional communication for aphasic adults. baltimore: university park press, 1980. holland, a. when is aphasia aphasia? the problem of closed head injury. paper presented at the conference of clinical aphasiology, oshkosh, wisconsin, 1982. levin, h.s. aphasia in closed head injury. in m.t. sarno (ed.) acquired aphasia. new york: academic press inc., 1981. levin, h.s., benton, a.l. and grossman, r.g. neurobehavioural consequences of closed head injury. oxford: oxford university press. luria, a.l. traumatic aphasia: its syndromes. psychology and treatment. the hague: mouton, 1970. mcneil, m.r. and prescott, t.e. revised token test. university park press, baltimore, 1978. milton, s.b., prutting, c.a. and binder, g.m. appraisal of communicative competence in head injured adults. paper presented at the clinical aphasiology conference, seabrook island, california, 1984. national institute for personnel research south african wechsler adult intelligence scale. translated and adapted with permission, 1969. , penn, c. a linguistic approach to the detection of minimal language dysfunction in aphasia. unpublished undergraduate research report, department of speech pathdlogy and audiology, university of the witwatersrand, 1972. j penn, c. syntactic and pragmatic aspects of aphasic language. doctoral thesis, department of speech pathology and audiology, university of the witwatersrand, 1983. russell, w.r. the traumatic amnesias. london: oxford university press, 1971. sarno, m.t. the nature of verbal impairment after closed head injury. journal of nervous mental disorders, 168, 685692, 1980. sarno, m.t. verbal improvement after chi: report of a replication study. journal of nervous mental disorders, 172, 475479, 1984. / sarno, m.t. and levin, h.s. speech and language disorders after chi. in j.k. darby (ed.) speech and language evaluation in neurology: adult disorders. new york: grune and stratton, 1985. ylvisaker, m. and holland, a.l. in d.f. johns (ed.) clinical management of neurogenic communicative disorders. boston: little brown and co., 1985. the south african journal of communication disorders, vol. 33, 1986 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ν ε w from amtronix — computerized impedance system z0174 features , ( t t analog meters for compliance and pressure permit easy visualising of test. digital displays for ear canal volume and static compliance. tympanometric pressure may be read digitally. tympanometric gradient is calculated and digitally displayed. digital displays for frequency and intensity for stimuli. expanded reflex mode reveals latency, amplitude, growth and morphology. 5 jolss evoked potential testing with cadweli instrumentation objective detection of audiologic and vestibular dysfunction . the simple solution for complex audiologic cases auditory evoked response to evaluate middleand late-lat'ency responses from the higher centers of the cortex eng to evaluate central and peripheral vestibular dysfunction bsep to objectively localize deficits to the cochlea, the auditory nerve, or the brainstem auditory pathways 40-hertz evoked response audiometry to objectively measure hearing thresholds electroneurography to obtain objective measurements of facial nerve function c audiometry rooms amtronix (pty) ltd., p.o. box 630, bedfordview 2008 phone (011) 615-7647 teletex 4-50033 amtron r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) reviewer acknowledgement open accesshttp://www.sajcd.org.za/ page 1 of 1 the editorial team of the south african journal of communication disorders recognises the value and importance of peer reviewers in the overall publication process – not only in shaping individual manuscripts, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank the following reviewers who participated in shaping this issue of the south african journal of communication disorders: alida ellis amisha kanji anna-mari olivier bea staley christine rogers daleen klop edwin maas fatemah camroodien-surve guilherme m. de carvalho hannelie kemp hilary gardner jaishika seedat jane le roux jenny pahl joanne barratt 75 karyn casey katherine vorster lebogang ramma luanet smit lucia scheepers maggi soer marinda uys meera rijhumal melissa bortz mershen pillay prawin kumar sue rumble ursula l. zsilavecz zandile blose we appreciate the time taken to perform your review successfully. in an effort to facilitate the selection of appropriate peer reviewers for the south african journal of communication disorders, we ask that you take a moment to update your electronic portfolio on www.sajcd.org.za for our files, allowing us better access to your areas of interest and expertise, in order to match reviewers with submitted manuscripts. if you would like to become a reviewer, please visit the journal website and register as a reviewer. to access your details on the website, you will need to follow these steps: 1. log into the online journal at http://www. sajcd.org.za 2. in your ‘user home’ [http://www.sajcd.org. za/index.php/sajcd/user] select ‘edit my profile’ under the heading ‘my account’ and insert all relevant details, bio statement and reviewing interest. 3. it is good practice as a reviewer to update your personal details regularly to ensure contact with you throughout your professional term as reviewer to the south african journal of communication disorders. please do not hesitate to contact me if you require assistance in performing this task. rochelle flint submissions@sajcd.org.za tel: +27 21 975 2602 fax: +27 21 975 4635 south african journal of communication disorders sajcd the autistic child: an approach to handling joyce izikowitz, b.a. log. (rand) johannesburg, south africa 'if a child has a body, but one that will not do what he wants it to—if he has-eyes that see, but do not see things the way other eyes see them—if he has ears that hear, but that have not learned to hear the way other ears do—he cannot tell anyone what his difficulty is, it just seems to him he is always wrong.'16 autism is a syndrome of disturbance, the origin of which is not clear. first described by kanner in 1943, autism was considered as a specific form of childhood psychosis characterized by non-goal directed behaviour, lack of speech and communication, emotional withdrawal and unresponsiveness to the social environment and a fixation with inanimate objects.10 today, two main schools of thought still exist as regards etiology—the organic and the sociological. as a result, manifold theories have been expounded which in turn have provided the blue prints for various approaches in regard to the handling of these children. for many years workers in the field of exceptional children have known therapeutic failure with the non-verbal autistic child, and to date there is little available in the literature in regard to therapeutic handling. the time has come to stop fighting about terminology and labels and to try to understand the problem. the efforts and results of a group of therapists over the past few years are recorded here in the hope that those working in the field of reeducation will find constructive, usable techniques with which to try. to help the 'autistic' child. working principles 1. principle of perceptual orientation. observing the behaviour of the 'autistic' child, we note that he appears to be 'perceptually disorientated'. we think that his 'use' of mannerisms, i.e. rocking, head banging, etc., and his preoccupation with the sameness of objects is ah attempt to investigate and stabilize the environment, as opposed to his reaction to people, who, in an ever-changing situation appear to be a threat to him. it is as if the child cannot organize and attribute meaning to sensory stimuli, and thus behaves in a bizarre manner. 2. principle of child development. a wealth of information has been gathered about normal child development, and we know that maturation is dependent upon physical, mental and emotional growth which proceeds in a well-ordered sequence of events.7·15 journal of the south african logopedic society, vol. , no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the autistic child: an approach to handling 27 piaget" stresses the interaction between the child (genetic endowment) and his environment, and the wholeness of the learning situation. dewey2 stresses the fact that the child's development requires a development of experience. the problem of direction of the desired experience is one of adult selection of appropriate stimuli for instincts and impulses selected for use in the gaining of the new experience. therefore, a structural setting must be piovided with selected stimuli for the child. mowrer13 states that all learning is conditioning, of which problem-solving is a derivative. he stresses the emotional nature of conditioned responses and views behaviour as a continuous on-going function of the informational feedback from all the senses—a function of the total psychological field. 3. principle of brain function. we studied the child within a neurological framework, and applied the techniques one would use for an individual handicapped by: (a) agnosia: all types are characterized by loss of ability to comprehend the meaning, or to recognize the importance of various types of stimulation; these are receptive defects. (nielsen, brain, de jong)> (b) aphasia: a non-functional impairment in the reception, manipulation and/or expression of symbolic content of language. (osgood). (c) apraxia: the inability, as a result of an organic brain lesion, to execute familiar, purposive, more or less automatic movements, when there is neither motor paralysis, sensory disturbance, ataxia or any intellectual impairment. (worster-drought). the sense modalities must function efficiently in order to receive the stimuli, which in turn must be taken via the neuronal pathways to the specific areas for integration and interpretation, before one can respond in the correct way to a situation.1 these principles were used as the foundation for our study project and as the starting point to study each child. perception is a learned process—we learn to see, to hear, to move and to feel in varying stages. the child experiences a situation and reflects back on this experience and so the sequential steps to learning are founded. knowledge of our environment is invaluable to us, as it creates a stability by enabling us to react appropriately. this knowledge is obtained through a spontaneous process of reception of all the sensations, i.e. sensory, motoric, proprioceptive and integrative, of the stimuli in the areas of the brain for concept formation.6·17 (fig. 1.) study project ten children between the ages of fourteen months and five years were seen for initial evaluation. they were tested on all the developmental patterns necessary for the acquisition of learning. a complete history was taken as part of the routine procedure and the following factors (table 1) were listed: age, sex, position in family, siblings, socio-economic backtydskrif van die suid-afrikaanse logopediese vereniging, vol. is, nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) joyce izikowitz the learning process fig. i. ground, birth trauma, milestones of development, speech development, difficulty with eating. symptoms. all the children displayed the following symptoms to some greater or lesser degree: (a) lack of emotion and contact with people; (b) little or no reaction to sound; (c) inadequately developed speech repetoire ranging from mute to a few words used inappropriately; (d) non-goal directed behaviour, i.e. odd mannerisms—whirling around, twisting, flicking movements of hands, head banging, rocking; (e) attachment to objects and perseveration in play; (f) upset at change of routine; (g) non-establishment of laterality and/or cerebral dominance; (h) no body concept or realization that body parts belonged to themselves and that they could control actions; (i) inability to chew or swallow correctly. the ultimate objective was to develop communication and to alter the reinforcing environment so that adequate behaviour was' learned and inadequate behaviour eliminated. therapeutic procedure. the following procedure was used for all the children, with slight variations for the individual child: (a) the stimuli to be presented were carefully selected and presented within a developmental framework; (b) operant conditioning procedures were used: food was used as a reinforcer; the children were fed at the school and taught a hard-food orientation programme. punishment was used for any unacceptable journal of the south african logopedic society, vol. , no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the autistic child: an approach to handling 2 9 behaviour i.e. non-goal directed behaviour such as twirling, head-banging, rocking. effective new behaviour was rewarded and reinforced.9 (c) as it was difficult to determine the stimulus and perceptional repetoire when the child responded to a complex situation, and as we were unable to determine what aspect he was responding to, or what was controlling his response, all the sensory areas were stimulated together in a holistic setting. · · , f (d) verbalization was used continually, following the principles ot luria, i.e. that perception can' be controlled and modified through speech.12 (e) i. aim: the child was made aware of every situation visually, tactually and auditorally e.g. visual attention: the door; tactile: the shape of the door; movement: need to get to, reach out, open and close the door; auditory: the closing sound, the banging sound; speech: continual verbalization was reinforced. . . . . ii. method: this was based on increased stimuli: acquisition and maintaining ot attention was the first step. auditory "1 integrated rewarded visual i > concept > adequate «ngram for tactile j through experience response learning reinforced punishment t incorrect '• response iii. result: a combination of—look hear feel response reinφ 4. φ which led to forced positively see say move or negatively (f) the children were 'blinkered' visually for commands and both rewarded and punished according to behaviour. (g) one therapist worked with the child, together with an aide—they had to adapt to the child and approach him on his level in order to develop a relationship. (h) concrete real-life objects were used—not toys or pictorial representations. (i) conditioned positive reinforcement was immediate. (j) the fixation on objects or visuo-motor perseveration was used constructively and as a starting point for therapy. the child was made actively 'aware'. the holistic approach to therapy ι language development. the prerequisites are that the child must hear sounds and locate and attend to the source. therefore the child was made aware of all sounds, what made the specific noise and from what direction the sound came. speech was moulded on whatever noises the child made which were immediately put into a meaningful context and conditioned positive reinforcement was used. to establish the auditory feedback system, the motor-kinaesthetic technique was used in front of a tydskrif van die suid-afrikaanse logopediese vereniging, vol. , nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 joyce izikowitz mirror to make the child aware of the various movements made by the oral-peripheral mechanism and to draw his attention to the speaker's face and imitate her movements. the train-ear, speakers and recorders were used to increase the intensity of the sound and to channel the sound directly to the ears. whole words were used at all times.1·5 2. visual development. the child was 'blinkered' and through the aid of torches was taught to fixate visually on any object, follow specific movements, in pursuits and to locate objects. the beam was then discarded and the objects only were presented to*him and he was made to feel each one and follow the placement visually. whatever the child responded to visually was the starting point to illuminate with a torch beam. the original object was then removed and the child would follow only the beam. the beam was then focused on another object. 3. movement development. he was taught how to move all body parts and how to negotiate spatially. the therapist moved his hands and arms through the required movements. he was taught movements along a developmental pattern of crawling, leading through to skilled activities.3·11 4. tactile develop ent the child was made to feel all surfaces and to recognise them through continuous "rubbing". he was taught to reach and grasp objects and move them into required positions and to differentiate between objects through touch alone.3 observations the following interesting factors were noted: 1. speech development. this followed the normal developmental sequence: (a) mouthing of words with or without sound; (b) echolalia, i.e. repetition of what was said to the child, e.g. where ° is the ball?—where is the ball?; (c) repetitions and hesitations, similar to stuttering behaviour; (d) reversal of word order; (e) reversal of pronouns; (f) some difficulty in pronunciation—substitution of his own words; (g) difficulty with abstract thought and logic—transference of reasoning; (h) speech without 'communication'; (i) spontaneous speech in interaction with the environment. 2. behaviour. (a) emotionally they were highly sensitive and anxious. (b) they progressed from passive, still children to hyperactive and destructive, to children with acceptable behaviour. (c) they realized that body parts were attached to themselves and were responsible for specific movements, e.g. full functioning of pencil control, ball playing, etc. ; (d) they showed spontaneous reactions with peers in play. journal of the south african logopedic society, vol. , no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the autistic child: an approach to handling 31 d if fi cu lt ie s w it h ea ti ng pr es en t pr es en t pr es en t p re se nt p re se nt sp ee ch d ev el op m en t si le nt ba by d el ay ed s pe ec h t h o u gh t to b e ha rd o f he ar in g m u te si le nt ba by d el ay ed s pe ec h t h o u gh t to b e ha rd o f he ar in g o dd w or ds si le nt ba by d el ay ed s pe ec h t h o u gh t to b e ha rd o f he ar in g o dd w or ds si le nt ba by d el ay ed s pe ec h t h o u gh t to b e ha rd o f he ar in g r an do m n oi se s si le nt ba by d el ay ed s pe ec h t h o u gh t to b e ha rd o f he ar in g m u te m ile st on es o f d ev el op m en tph ys ic al n or m al n or m al n or m al n or m al n or m al b ir th tr au m a in d u ce d ; a no xi a ca es ar ea n se ct io n n o ap pa re nt de fe ct s c ae sa re an se ct io n c or d ar ou nd ne ck so ci oec on om ic b ac kg ro un d m id d le c la ss je w is h m ot h er i n f at he r' s bu si ne ss m id d le c la ss je w is h m o th er — t yp is t f at h er — sa le sm an m id d le c la ss c h ri st ia n m o th er — h ou se w if e f at h er — b us in es sm an l o w i nc om e f at h er — l ab ou re r m o th er — h ou se w if e m id d le c la ss -c at h ol ic e du ca te d si bl in gs 2 b oy s 0 η 1 b o y 1 g ir l 2 si st er s 1 b o y po si ti on in f am ily t h ir d se co n d t h ir d t £ se co nd η co s s s u< s do 14 m on th s 4 ye ar s 5 ye ar s 5 ye ar s 2 ye ar s ca se n o. < w pi ν s m % ph u-t tydskrif van die suid-afrikaanse logopediese vereniging, vol. is, nr. : des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 joyce izikowitz d if fi cu lt ie s w it h ea ti ng pr es en t pr es en t pr es en t p re se nt pr es en t sp ee ch d ev el op m en t si le nt b ab y d el ay ed s pe ec h t h o u gh t to b e ha rd o f he ar in g m u te si le nt b ab y d el ay ed sp ee ch t h o u gh t to b e ha rd o f he ar in g m u te si le nt b ab y d el ay ed s pe ec h t h o u gh t to b e ha rd o f he ar in g n oi se s si le nt b ab y d el ay ed sp ee ch t h o u gh t to b e ha rd o f he ar in g n oi se s si le nt b ab y d el ay ed sp ee ch t h o u gh t to b e ha rd o f he ar in g m u te m ile st on es o f d ev el op m en tph ys ic al n or m al i n or m al n or m al n or m al n or m al b ir th tr au m a n o ap pa re nt de fe ct s u nk no w n c ae sa re an se ct io n p re m at ur e r h n eg at iv e t ra n sfu si on s b re ec h pr es en ta ti on so ci oec on om ic b ac kg ro un d m id d le c la ss je w is h f at h er — b us in es sm an m o th er — h ou se w if e m id d le c la ss je w is h f at h er — e d u ca te d m o th er — h ou se w if e l o w i nc om e w or ki ng p ar en ts c hr is ti an lo w so ci oec on om ic c hr is ti an si bl in gs 2 b oy s a do pt ed 2 b oy s a do pt ed o n ly po si ti on in f am ily se co nd fi rs t m id d le fi rs t fi rs t se x t, 2 t, 2 2 a ge 5 ye ar s 2 ye ar s 4 ye ar s 4 ye ar s 2 ye ar s ca se n o. ffl vo 1 q rej ' 00 as < 0 journal of the south african logopedic society, vol. , no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the autistic child: an approach to handling 33 (e) their behaviour was modified through reinforcement and punishment and there was no symptom substitution. (f) they responded spontaneously in situations, and not only to a specific stimulus in a conditioned manner. the children could be handled by more than one person as long as the methods were the same and handling was consistent. it was significant that the four children who progressed the most were the children who were never given the label of 'autism' and therefore were treated as 'normally' as possible, but with increased stimulation. parents of autistic children are as varied in their personalities and the way they deal with children as is any other group of parents. case history child x was 4 years old when we first saw him. he was generally unresponsive to his environment, rocked himself, curled up in the foetal position, masturbated continually, and had not developed speech. he had previously been diagnosed as deaf, aphasic, retarded and autistic. at the age of three years he was enrolled in a nursery school class where he would not communicate, acted in a bizarre manner at times and had to have a constant supervisor. he made no progress and was subsequently referred for speech therapy which was discontinued as x again failed to show any improvement. when he was first assessed by a team of specialists, no firm conclusions were drawn, except that his primary difficulties were consistent with a picture of autism, and that he needed help. salient points from case history. normal pregnancy, but an emergency caesarean section was performed at 7\ months, as there was foetal distress. he was the second child in the family—the sibling being a boy aged 6 years. the parents were educated, middle-class people. physical milestones of development were normal. speech was undeveloped and behaviour bizarre. x was observed daily for a few weeks and a programme was drawn up for, him as follows: (a) he was to be punished for masturbating; (b) as he drooled slightly and could not eat hard foods, but was living on slops, he was to be given meals at the school and taught how to chew and swallow and eat correctly; • (c) his only interest was hub-caps—so all teaching was to be done through hub-caps at first, leading to the reward of a hub-cap for the correct response. this proved very successful, and he was taught visual pursuits, movement size, shape,1 colour, number and reading in this manner. all the previously described techniques were applied. today, x at the age of 6 years, is reading at second grade level in an adjustment group. he has spontaneous speech and spontaneous reaction to people and situations in the environment. he no longer masturbates and only occasionally has a temper tantrum. his vocabulary and speech tydskrif van die suid-afrikaanse logopediese vereniging, vol. is, nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 joyce izikowitz are two years above his chronological age, but when upset, he rambles into nonsense jargon, e.g. schoolage for school and garage, and loses logical thought processes. emotionally, he still withdraws, but these periods are few and far between. he plays with other children and reacts spontaneously, laughs, cries and is affectionate to people. he still has a long way to go, and at present we are teaching him logical' thought processes through reading. we have learned much from our successes and our failures, but know far too little and have a great deal to learn. there is no specific treatment for autism, but much can be achieved using the above methods. in reviewing the present situation, we can only arrive at the following conclusions: (a) the necessity for a more holistic approach. (b) the need to treat the cause rather than the symptom. (c) the importance of following the sequence of normal child development within a neurological framework. (d) the need to provide maximum sensory stimulation in all areas in a structured systematic way and to select the stimuli. (e) the need to modify the behaviour through operant conditioning. (f) we are dealing with the problem of labels. it was significant that three of the children who displayed symptoms in keeping with autistic behaviour, when given a maximum sensory stimulation programme were found to be minimally brain injured. summary autism has been considered within a neurological framework of child development. a study has been carried out on ten children. etiology, frequency of symptoms and aspects of therapy have been described. a case study of one child has been presented. opsomming outisme is hier beskou binne die raamwerk van die kind se ontwikkeling. 'n studie is uitgevoer op tien proefpersone (kinders). die etiologie, frekwensie van simptome en aspekte van terapie is beskryf, en 'n frevallestudie van een kind is voorgedra. acknowledgements to the staff of crossroads school—centre of , educational therapy, and forest town school for cerebral palsied children,/' references 1. critchley, m. (1966): the parietal lobe. hafner pub. co., new york, ia. de jong, r. (1967): textbook of ν euro-examination. hoeber. 2. dewey, j. (1902): the child and the curriculum. chicago, university of chicago press. 3. doman-delacato (1968s): proceedings from intensive orientation course— institutes for human porential—philadelphia. 4. ewing, i. r. and ewine, a. w. g. (1961): new opportunities for deaf children. university of london press ltd., warwick square, london e.c.4. journal of the south african logopedic society, vol. is, no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the autistic child: an approach to handling 35 5. ε wing, sir a. and ewing, lady e. (1964): teaching deaf children to talk. manchester university press, u.s.a. the volta bureau, washington 7, d.c. 6. foss, β. m. (1966): new horizons in psychology. penguin books ltd., harmondsworth, middlesex, england. 7. gesell, α.: the first five years of life. methuen & co. ltd., london, w.c.2. 8. hebb (1961): organisation of behavior. science editions, inc., new york. 9. hilgard & marquis (1964): (2nd ed.) conditioning and learning. methuen & co. ltd., london. 10. kanner, l. (1949): problems of nosology and psychodynamics of early infantile autism. american journal of orthopsychiatry, 19, 416-26. 11. kephart, n. c. (1965): the slow learner in the classroom. charles e. merrill books, inc. columbus, ohio. 12. luria (1961): the role of speech in the regulation of normal and abnormal behavior. pergamon press, london. 13. mowrer, o. .(1960): learning theory and the symbolic process. 14. piaget, j. (1947): the origin of intelligence in children. international universities press, new york. 15. schilder, p. (1964): contributions to developmental ν euro-psychiatry. international universities press, inc., u.s.a. 16. soffen, η. b. (1965): perceptual training. seminar on children with learning and behavioral problems. borguess hospital, kalamazoo. p. 65-71. 17. vernon, m. d. (1962): the psychology of perception. penguin' books ltd., harmondsworth, middlesex, england. tydskrif van die suid-afrikaanse logopediese vereniging, vol. , nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) audiometry weber and rinne tests as compared to pure-tone thresholds • thompson, alison κ., b.a. (sp. & η. th.) ( w i t w a t e r s r a n d ) speech therapy department, general hospital, johannesburg summary results of the audiometric weber and rinne tests were compared t o pure t o n e thresholds in 1 8 5 bantu patients. the frequency of 1 0 0 0 hz was selected as being most suitable for weber and rinne testing. t h e weber w a s found t o be of limited diagnostic value even w i t h unilateral c o n d u c t i v e losses whilst the rinne displays a fair degree of efficiency and is of value as a routine supplement t o audiometric threshold tests. opsomming resultate van die o u d i o m e t r i e s e weber en rinne t o e t s e is m e t s u i w e r t o o n drempels vergelyk. 1 8 5 b a n t o e pasiente is as proefpersone gebruik. die frekwensie van looohz is as die geskikste vir die weber en rinne t o e t s e gereken. die weber is, selfs met eensydige geleidings verlies, van beperkte diagnostiese waarde gevind, terwyl die rinne 'n redelike graad van doeltreffendheid g e t o o n het en aanvullend b y die o u d i o m e t r i e s e drempel t o e t s e gebruik kan word. at the hearing clinic at baragwanath hospital, johannesburg, routine audiometric weber and'rinne tests were fairly frequently found to be inconsistent with pure tone thresholds. in the present study, a large number of pure tone audiograms were compared with audiometric rinne and weber results. in recent years, very little has appeared in the literature concerning the weber and rinne tests. that which has appeared deals almost exclusively with testing by means of tuning forks. most authors stress the need to include the weber and rinne in a battery of tuning fork tests including the schwabach and gelle t e s t s . 1 ' 3 , 6 , 8 , 1 1 , 1 ? reliability of these tests has been questioned by these workers but they are nevertheless considered to be useful in supplementing audiometric results. testing by means of the audiometric bone vibrator has certain advantages over testing by means of tuning f o r k s . 2 , 8 , 1 3 the bone vibrator maintains its , intensity output at any desired level, whereas the tuning fork fades rapidly in intensity, especially in the high frequencies. 1 1 in addition, the bone vibrator permits a standard presentation which is independent of the ear of the o p e r a t o r . 5 , 1 3 materials and methods hearing assessments of 185 south african bantu of both sexes with an age range of 12 to 75 years were analysed. these were taken randomly from the tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheeikunde, vol'. 21, desember 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 alison κ. thompson records of patients tested at the hearing clinic over an 18 month period. a maico ma-10 audiometer calibrated to i.s.o. 1964 hearing threshold levels ' was used for testing. the test room was not ideally soundproofed despite the fact that it was lined with acoustic board. conventional pure tone airand bone-conduction audiograms were obtained for each patient. both the weber and rinne were tested at an intensity of 15 db above the patient's threshold of audibility (vibrator placed on the midline of the forehead).8 this is sufficient intensity for clear audibility yet it minimises cross-hearing by being close to the patient's threshold. testing by the weber and rinne methods at several frequencies was considered laborious and unnecessary. a test frequency of 1000 hz was investigated and finally utilised for the following reasons: 1) an increase in the force of vibrator application results in an improved, threshold. the greatest change in intensity due to differential force occurs at 250 hz whilst only slight changes occur at 1000 h z . 4 · 9 2) middle ear lesions influence the vibratory mechanism of the inner ear thereby providing an artefact of poorer bone conduction thresholds.1 although this phenomenon is not yet fully explained, it appears to occur most frequently in the lower frequencies where the conductive loss is generally at a m a x i m u m . 7 3) with lower frequencies the rinne is more likely to be negative in normal ears whereas the reverse is true with higher frequencies. 1 1 the centrally situated 1000 hz is hypothetically more reliable. 4) with frequencies below 1000 hz there is a possibility of confusion between the tactile sensation and hearing. this is enhanced with presentation at higher intensities. 5) a frequency of 1000 hz is situated at the centre of the critical frequency range, and is likely to reflect most successfully both conductive and sensorineural losses. 6) tones below 1000 hz appear to be most affected by ambient noise. this assumes importance when the test environment is not completely soundproof. in rinne testing a conductive loss of 15 db reverses the response at ± 500 hz (i.e. b-c better than a-c), whilst a 20 db loss is required to reverse the response at 1000 h z . 1 0 the test is thus slightly less sensitive at 1000 hz. however, as the levels of odb to 20 db are considered to constitute the normal hearing range, the required sensitivity is present. the audiograms were classified by two audiologists into 11 broad categories of bilateral hearing characteristics. (refer to categories listed in tables i and ii). conventional interpretation criteria were applied. those classified differently were discarded. two assessments were made regarding the weber and rinne results in relation' to each audiogram: 1) correct/error according to the characteristic of airand bone-conduction thresholds at 1000 hz only. journal of lhe south african speech and hearing association, vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) audiometric weber and rinne tests and pure-tone thresholds 65 2) correct/error as to whether the results reflected the total loss characteristics of the given ear/s as indicated by thresholds over the range of 2508 000 hz'. criteria for assessment of the weber test were based on research by g r o e n . 1 · 3 · 7 lateralisation appears to involve the recognition of interaiiral phase and time as well as intensity differences. lateralisation occurs iri normal ears owing to: a) one stronger vibrating cochlea, as a result of better sound conduction to that cochlea. b) a phase difference between the two sound waves entering the cochleae, the bone conducted tone being lateralised in the cochlea with the leading phase. in normal ears (owing to slight anatomical differences) phase advances may overcome relative amplitude deficiencies of up to 6 db. owing to this phenomenon, a 5 db amplitude difference between bilateral ear thresholds was accepted in the obtaining of a midline response. lateralisation was expected at differences of 10 db or above. criteria for assessment of the rinne test were based on the findings of s h e e h y . 1 0 at 1 000 hz an air-bone gap of less than 20 db is accompanied by a rinne positive response. a rinne negative response occurs with a gap of 20 db or more. theoretically, there is a point around 20 db where both a-c and b-c appear equally loud. this "indifferent" rinne was accepted as correct with an air-bone gap of 20 db only. results and discussion tables i and ii summarise the results in the present study. these were analysed statistically using the cochrans q test, binomial test and poisson test. the results at 1 000 hz only were compared with the total results for each audiogram in order to determine whether the result at 1 000 hz only was able to reflect the total loss characteristics of the ear/s. for both the weber and rinne tests there was no significant difference between the total results and the results at 1 000 hz only (p < 0,05). testing at 1 000 hz is therefore suitable as a test frequency although, clearly, it cannot indicate precipitous high or low frequency loss. the weber test is generally far less efficient than the rinne test. this is demonstrated by the finding that in the weber test, three loss combinations demonstrated highly significant response errors (p < 0,005). these were bilateral normal (a), bilateral equal sensori-neural (e) and bilateral conductive ears (c). these findings are interesting in that combinations a (56,3% error*) and ε (55,5% error) have bilaterally equal cochlear reserve and the weber response should therefore be central. that this does not occur indicates that * all percentages apply to results at 1 0 0 0 hz o n l y . tydskrif van die said-afrikaanse vereniging vir spraak en gehoorheeikunde, vol. 21, desember 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a lison κ , t hom pson ο e las λ m v . q o o " j t3 ι ο ο ο 73 χ ) ^ [λ ο "ο ^ % » 3 μ ο ο ο ο £ " ω e 3 ο '' ° £ ο οζ. οο ο ο cm ζ . c ο ν τ; ο ο ο e ο 3 ζ ο ό , ο •υ ω ω ο "3 -α ο — ' •s α. = ; ο ω as j2 ω 3 "ε "ε 01 7) ; ν 8 λ 8 .3 η xj _ c £ ο 2 s λ ^ -t1 c prh (l> ο η w ο c5 θ" v νο νθ" γ-1 η co — kh co s ε δ oa ζ ο ο" ν ο ο , θ" v ο ο ζ £ ο ο ο" ν ο cm ο cm ο <υ — > co £ 3 co — c c ο d u oa en" ο n o ο cn) ra s ο ίϋ c/2 <l> ^ ^ c3 <d v i ϋ > ο i— vi 00 -g — 3 • "o o _e ^ ο tn ^ ο <u ~ υ = ο s ο c co " 3 _ cr 3 uj ο ca ο 3 s -o « e 7= ο c d u ο z i e 00 j s ! d ' ra c e _ e • ω ·ά 5 ·= 2 ·ά s •c c ,-rr (l> 00 ο ο ο ο ϊλ ϊλ « c js c — ο . — <l> co c/3 c2 c/3 journal of the south a frican -speech and h earing a ssociation. v ol. 21. d ecet/tber 1974 reproduced by sabinet gateway under licence granted by the publisher (dated 2012) audiometric weber and rinne tests and pure-tone thresholds 67 pu re t on e t hr es ho ld r es ul ts (b il at er al h ea ri ng c om bi na ti on ) g ui de t o e xp ec te d r es ul ts fo r r in ne % e rr or o f w eb er r es ul ts w he n c om pa re d to t hr es ho ld r es ul ts a t: ο pu re t on e t hr es ho ld r es ul ts (b il at er al h ea ri ng c om bi na ti on ) g ui de t o e xp ec te d r es ul ts fo r r in ne n um be r of pa ti en ts 1 00 0 h z on ly 25 0 h z 8 00 0 h z * (t ot al r es ul ts ) d eg re e of si gn if ic an ce e rr or r es ul ρ a. bilateral both +ve 32 3,1 6,3 no significance normal b. one normal +ve 11,8 11,8 no significance one conductive —ve 34 8,8 17,7 no significance c. bilateral conductive both v e 15 10 10 no significance d. one normal +ve 0 0 no significance one sensorifalse —ve 23 8,7 8,7 no significance neural e. bilateral equal both -i-ve 18 11,1 11,1 < 0 , 0 5 sensori-neural f. bilateral unequal one -l-ve sensori-neural and one false —ve 8 6,3 6,3 no significance g. one normal +ve 0 0 no significance one mixed false —ve 20 30 25 < 0 , 0 5 h. one sensorineural 35,7 35,7 < 0 , 0 5 one mixed 14 21,4 28,6 < 0 , 0 5 1. one sensorineural false — ve 20 20 no significance one conductive v e 5 40 40 no significance j. one conductive —ve 16,7 16,7 no significance one mixed false —ve 6 0 < 16,7 no significance k. bilateral mixed 10 10 10 < 0 , 0 5 * rinne result compared to thresholds over this range to assess agreement with total loss characteristics of ear. table 11. comparison of the agreement between the rinne and pure tone threshold results. tydskrif run die suid-afrikaanse vereniging vir spraak en gehoorheeikunde, vol. 21, deseniher 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 68 alison κ. thompson either the patient resists believing he can hear the tone centrally (in spite of being prepared for this possibility during testing) or that the test is more sensitive than desired in that a slight deficit in the conductive mechanism results in lateralisation in normal ears. no definite trend was found as to the ear selected for response; neither the ear where pathology or loss was judged present nor the better functioning ear was selected. in the bilateral conductive combination (60% error) similar factors are present in that frequently the degree of loss is practically equal in both ears. a central weber was expected, but seldom occurred. although the weber is considered to be primarily a test for determining presence of unilateral conductive loss, results did not support this very well (23,5% error; significant at ρ < 0 , 0 1 ) . the weber appears to be reliable in two combinations only i.e. bilateral unequal sensori-neural hearing loss (25% error) and unilateral sensori-neural hearing loss (13% error). however, in the former case there was only a small group of eight patients and thus these results are questionable. the trend indicates that the weber is more efficient where cochlear reserve is not equal in both ears. an inherent limitation of the weber is that it is not possible to interpret responses obtained when a mixed loss is present, or when there is a combination of sensori-neural loss in one ear and conductive loss in the other. the response obtained, from the patient may thus prove misleading. on considering the results for the rinne, all results for similar categories i.e. normal, conductive, etc, were compared to assess whether results for any given category were comparable irrespective of the hearing characteristics of the contralateral ear. on analysis, results within each category did not differ significantly (all at ρ < 0,05) thus confirming test consistency. the rinne is generally efficient in depicting normal hearing and conductive losses. (an arbitrary response was usually given with a conductive loss around 20 db, thus reducing efficiency in this region). ears with a sensori-neural loss demonstrated a significant incidence of errors (p < 0,05) in only two combinations i.e. with a mixed loss (35,7%) and in the bilateral equal sensorineural group (11,1%). the latter is of borderline significance only. sensorineural loss is therefore depicted less efficiently but results are still of value in diagnosis. mixed losses give the least reliable results. the use of masking to prevent the false-negative response in unilateral severe sensori-neural loss has long been a problem. the general difficulties in establishing effective masking levels are equally relevant here. the writer suggests that the false-negative response be accepted as it stands. in the present study, masking was not used. however, on analysis of results, the false-negative appears consistently where one would expect it to occur. the history, plus weber and schwabach tests, can be employed to provide further information (the present study found the weber to be reliable in this category). there is, nevertheless, no totally satisfactory solution to ;this problem. the greatest limitation of the weber and rinne tests is that inconsistencies may occur in any patient's responses for a variety of psycho-acoustic, ana. journal of llic jioulh african spccch and hc<iring a.ssocialion. i 'ol. 21. 1),\ ,inh,:> iy74 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) audiometric weber and rinne tests and pure-tone thresholds 69 tomical and physical reasons. as with any test requiring a subjective response, these tests are only as efficient as the patients' preparedness and ability to judge what is presented to him. unsophisticated patients may be more suggestible and erratic in this regard. although findings based on the audiometric weber and rinne cannot be directly compared to those obtained with tuning forks, owing to the slight differences in frequency levels and presentation, trends of test efficiency can be extracted. neither of these tests are sufficiently reliable to substitute for threshold tests. however, the findings of this study suggest that the rinne is of value as a supplement to threshold testing. a result at variance with the threshold, levels alerts the tester to the need for closer investigation. the weber can be used reliably to help identify a unilateral sensori-neural loss but, clearly, its general inefficiency makes it of little diagnostic value. acknowledgements i wish to thank dr b.l. wolfowitz for his suggestions on presentation and mrs j.e. anderson for assisting with classification of results. also, mr g.l. kimble and the department of statistics, c.h.d., johannesburg for the statistical analysis; and dr l. faivelsohn, medical superintendent of baragwanath hospital for his permission to publish. references 1. allen, g.w. and fernandez, c. (1960): the mechanism of bone conduction. annals of otol, rhinol, and laryngol, 69, 5-28. 2. davis, h. and silverman, s. (1970): hearing and deafness, 3rd edition holt, rinehart & winston, new york. 3. groen, j.j. (1962): the value of the weber test. in schuknecht, h.f. (ed.), otosclerosis international symposium, chap. 14. little, brown & co., massachusetts. 4. harris, j.d., haines, h.l. and myers, c.k.,(1953): a helmet-held bone conduction vibrator. laryngoscope, 63, 998-1007. 5. jesberg, s. (1923): recording of functional hearing tests. laryngoscope, 33, 379-383. 6. johnson, e.w. (1970): tuning forks to audiometers and back again. laryngoscope, 80, 49-68. 7. naunton, r.f. (1963): the measurement of hearing by bone conduction. in jerger, j . ( e d . ) , modern developments in audiology, chap. 1. academic press, new york. 8. newby, h.a. (1965): audiology principles and practice, 2nd edition. vision press, london. 9. nilo, e.r. (1968): the relation of vibrator surface area and static application force to the vibrator-to-head coupling. j. of speech and hearing res., 11,805-810. ivdskrif van die suid-afrikaanse vereniging vir spraak-en (jehoorheelkunde, vol. 21. detember 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 alison κ. thompson 10. sheehy, j.l. et al. (1971): tuning fork tests in modern otology. arch otolarvng., 94, 132-138. 1 1. sonnenschein, r. (1933): fundamental principles of functional hearing tests. arch. otolaryng., 18,599-613. 12. tschiassny, k. (1946): tuning fork tests. annals of otol., rhinol., and laryngol., 55,423-430. 13. watson, l.a. and tolan, t. (1949): hearing tests and hearing instruments. williams and wilkins, baltimore. ja u d i o m e t r y equipment hearing aids noise control and and maico iriteracoustics grason-stadler siemens mad sen widex willco eckstein linco h i l l a r y r e i c h e n b e r g e r i c c. l e w i s / the needler westdene hearing aid organisation (pty) ltd. p.o. box 28975, sandr i n g h a m 2131 t e l e p h o n e : 45-7262 journal of the soulli african speech anil hearing associaiion. i nl j/, december 19~4 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) do you have an illegal racket? government notice r2237 of 3 0 / 1 1 / 7 3 and the onus is on you to ensure their prosets d o w n m a x i m u m safe noise levels in factories and workshops. it has been done to protect your workers from damage to their hearing. lection. a sure w a y of c o m p l y i n g w i t h the law is to u s e b r u e l & k j a e r sound level meters. they conform to natonal and international standards. β &· κ personal noise dose m e t e r : it's c o m p a c t , p o c k e t sized a n d p r a c t i c a l . t h e w o r k e r w e a r s it w h e r e v e r he w o r k s w h e r e v e r he g o e s . h i s d a i l y n o i s e d o s e is m e a s u r e d . c o n f o r m s t o i e c ft 1 2 3 . β & κ miniature sound level meters: e s s e n t i a l t o o l s for n o i s e a b a t e m e n t e n g i n e e r s , i n d u s t r i a l h y g i e n i s t s a n d all o t h e r s w h o s e j o b it is t o k e e p n o i s e a t t o l e r a b l e l e v e l s . m e a s u r e s t o i e c s t a n d a r d s for s o u n d l e v e l m e t e r s . sole distributors: t e l k o r / / / / / j o h a n n e s b u r g : 29 w e b b e r sireet, setby, p . 0 box 776 4 . phone 8 3 6 1 3 0 1 . c a p e t o w n : 41 2 voortrekker road. p.o. box 26. m a i l l a n d c p. phone 51 3311. p o r t e l i z a b e t h : 4 0 u i t e n h a g e road. p.o. box 2 0 0 1 , p.e. phone 2 4 0 8 1 . d u r b a n : p.o. box 729. durban. associated w i t h dowson & dobson ltd. l'lienck & a s s o o a journal o the south african spe and hearing association, vol. 21, december 974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) amplivox hearing services (pty.) ltd. suite 322-3 bosman building, cor. eloff & bree streets p.o. box 9076 johannesburg tel. 23-6419 23-6431 we are suppliers of the following: hearing aids amplivox,dahlberg,oticon, rextonand cosmocord — covering all types of hearing aids. , audiometers amplivox, amplaid, peters and tracor manual and automatic audiometers of all types. i acoustic booths and sound level meters tracor, amplivox and acos. deaf school equipment peters, connevans and amplivox speech training and group hearing aids. ear defenders gunfender, sonex, super sonex, interceptor, auralgard, sonogard and supamuff from amplivox. / / amplivox hearing services t h e a c k n o w l e d g e d experts r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a i d s f o r • the development of perception • the acquisition of speech and language skills • the improvement of motor co-ordination • helpful texts for therapists • educational toys, books and equipment • records for auditory training • catalogues on request • large variety of tests recently arrived ° play and schoolroom m (adjoining the constantia cinema) t e l e p h o n e s : 42-5350; 42-6529. p.o. box 52137, saxonwold, tvl. p l u s c o n s u l t 8 t y r w h i t t avenue, rosebank r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c society objective psychotherapy in the treatment of dysphemia arnold a. lazarus clinical psychologist (regd.) since many speech therapists feel that dysphemia is already "the disorder of too many theories," they regard outside opinion as an intrusion and a usurpation of their rights. others, imbued with a need for therapeutic teamwork, (a high-sounding concept which rarely works in practice) often err by accepting contradictory and fragmentary views which only,further confuse and complicate the issue. the present paper is an endeavour to increase the scope and range of the speech therapist's role by offering an objective rationale for the inclusion of certain behaviour therapeutic* techniques into the sphere of logopedics. the study of dysphemia may be conveniently divided into three parts: (i) the actual stutter (i.e. the analysis of clonic and tonic spasms associated with phonation, articulation and respiration which disturb the flow of speech. this would include accompanying tics and allied patterns of dysrhythmia in various areas of psychomotor activity).. (ii) the onset and underlying causes of stuttering. (in this connection, it should be emphasized at the very outset that attempts to reveal the genesis of stuttering through biochemical analyses, psychometric investigations, medical and neurological examinations, e e g recordings and the like have all proved nonspecific for any stutterlike pattern). (iii) the stutterer's psychological responses, with special reference to his attitudes and feelings in various speaking situations. in dealing with the problems associated with (iii), the speech therapist is handicapped by a paucity of effective techniques. on occasion, the anxieties which often exacerbate dysphemic responses are glossed over. in general reassurance or mild emotional support is offered, while relaxation and specific "assignments" are used as therapeutic adjuncts. on the other hand, many problems are left alone on the assumption that it is highly dangerous to *we are following eysenck's example of subsuming the theoretical concepts and practical methods of treatment derived from modern learning theory under the heading "behaviour therapy." dabble in psychotherapy. this is a crucial gap. in most practical essentials the speech therapist is willy-nilly a psychotherapist and the treatment of specific neuroses which have a bearing on the mechanisms of speech, may legitimately be placed within the province of logopedics. the present article outlines two techniques which, in time, may conceivably form an integral part of the therapeutic "modus operandi" of every speech therapist. although it has not been established that dysphemia is essentally a manifestation of unresolved conflicts and anxiety, even the pure organicists cannot deny that a stutterer's speech pattern usually deteriorates in anxietygenerating situations. it is empirically demonstrable that attitudes of hypersensitivity and self-consciousness tend to further inhibit the stutterer's verbalization and result in "secondary blocking." some stutterers, burdened by pervasive anxieties, find the mere thought of speech terrifying. the desensitization technique outlined below is not for them; it is indicated in cases where the individual is overwhelmed by anxiety and tension in specific speaking situations. it must be understood, however, that neither of the therapeutic techniques* dealt with is intended as a "cure" for dysphemia. when working towards a cure, the emphasis should be on a synthesis of different therapeutic procedures, so that consideration is given to the entire speech mechanism perse and to the socio-psychobiological features. but at the present stage of our knowledge, the complete elimination of a confirmed stutter is generally a therapeutic ideal rather than a practical objective. therapeutic idealism often results in objective nihilism and fails to achieve even those modest therapeutic goals which are well within the limits of our practical skills. those theorists (such as the pschoanalysts) for example, who insist on treating the so-called "total personality" are often so absorbed in the intricacies of their amorphous task, that they rarely achieve results comparable with *the practical application of learning theory to the treatment of tics which often accompany stutterlike patterns is dealt with towards the end of this paper. speech therapists will easily recognize the different emphasis which is placed on the well-known technique of "negative practice." r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) march j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c society those attained by therapists who use only simple vocal exercises. thus, on the assumption that it is wise to proceed with scientific humility and caution, we shall now outline two techniques which aim to alleviate rather than to eliminate the problem of dysphemia. (i) s y s t e m a t i c d e s e n s i t i z a t i o n b a s e d o n r e l a x a t i o n 4 w o l p e 2 has shown that specific anxieties can be eliminated if they are progressively opposed by muscular relaxation. thus, if a stutterer becomes anxious each time he answers the telephone, this response (anxiety) must be opposed by a new response (e.g. relaxation) which is physiologically incompatible with anxiety. the bond between the specific speaking situation and the anxiety will then be broken. this fact was clearly demonstrated in the case of a 19-year-old pharmacy student whose mild stutter became extremely pronounced each time he had to answer the telephone. " a s soon as the 'phone starts ringing i begin to feel butterflies in my stomach," he explained. " a s i get near the 'phone my fears get worse and by the time i lift the receiver to my ear, i just know that i'm going to stutter . . . by then i can't even open my mouth." he added that the mere thought of speaking on a telephone made him feel ansxious. systematic desensitization was applied as follows:he was first trained in an accelerated version of jacobson's3 progressive relaxation. while fully relaxed, he was asked to imagine the sound of a telephone ringing in the distance. (he was told to signal to the therapist if he experienced any feelings of anxiety while visualizing any of the given situations). as this failed to provoke any anxiety, he was asked to imagine the sound of a telephone ringing in the same room. this image also failed to generate any anxiety, but the thought of a telephone ringing right next to him provoked a fair measure of anxiety. his anxiety was opposed by relaxation again and again until he was able to tolerate, with complete tranquillity, the idea of a telephone ringing right beside him. the patient was seen three days later. he reported that he no longer experienced any anxiety when he actually heard the telephone ringing . . . "the butterflies are completely gone in that situation." he was then desensitized to the thought of approaching a ringing telephone. it required four sessions before he was able to *for a complete practical and theoretical exposition of systematic desensitization based on relaxation see wolpe2 chapter 9. contemplate picking up the receiver with no feelings of anxiety. at this stage he reported that his phobia for telephones had greatly diminished. "i don't panic any longer," he stated, "but i still stutter very badly over the 'phone . . . it's worst of all when i try checking an order over the 'phone." after nine additional desensitization sessions, there was no apparent difference between his telephonic speech and his verbalization in face-to-face situations. at the time of writing, he has maintained his improvement for over four years. equally good results were achieved in the case of a 19-year-old student whose stutter incapacitated her while out on a "date," while speaking in class and when answering the telephone. these three anxiety areas were treated concurrently and required 22 sessions for their complete elimination. the patient also reported an improvement in many general aspects of her speech. the follow-up in this case is also over four years. similarly, a 42-year-old business executive who had experienced great difficulty when talking to important clients and when ordering in a restaurant stated that "my new business contacts don't believe me when i tell them that i am a stutterer." he required only 13 desensitization sessions to effect this improvement. a case reported elsewhere4 was that of a 34-year-old engineer who received desensitization therapy for a speech disturbance characterized by lengthy and frequent "word blocks" accompanied by considerable tension and facial grimaces. when first interviewed he stuttered on about 12-25% of words, with "blocks" averaging 3-4 seconds. his attitude towards speaking situations was poor. he received 30 hours of therapy over 9 months. therapy sessions were usually held once a week. training in progressive relaxation was followed by systematic desensitization. among others the following anxiety-situations were treated: time pressures (especially speaking on the telephone as he conducted many of his occupational affairs by long-distance calls), telling jokes, public speaking, difficult 'audiences' i.e. specific people who provoked added speech difficulties. progress was gradual, but at the termination of therapy a substantial gain in speech fluency had been achieved. one of the principal skills in the administration of systematic desensitization is to proceed at a pace which is in keeping with the patient's level of anxiety. n o harm seems to ensue from proceeding at a pace that might prove too slow for a patient, but too rapid a pace can prove extremely antitherapeutic and lead to increased levels of anxiety. the desensitization procedure r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c society can be used with children5 but, as yet no one seems to have administered it to dysphemic children. (ii) t h e u s e o f m a s s e d p r a c t i c e in t h e t r e a t m e n t o f t i c s a s s o c i a t e d w i t h d y s p h e m i a yates 0 deduced a method of eliminating neurotic tics by building up a habit of "not performing the tic." according to hullian theory7 8 9 massed practice of a motor activity (e.g. a tic) causes reactive inhibition (ir) to build up. when ir reaches a certain critical point the subject requires rest i.e. he experiences a need not to perform the tic. t h e habit of not performing the tic becomes associated with drive reduction and is therefore reinforced. repeated massed practice will therefore build up a negative habit ("not-doing-the-tic") which will militate against the positive habit of doing the tic. yates's theoretical model was applied in the case of an 18-year-old youth with an extreme stutter who invariably twisted his mouth, screwed up his eyes and jerked his head forward and back during a "block." twelve years of intermittent speech therapy had been of no avail. he was referred to the writer for vocational guidance and was advised first to undergo therapy for the pronounced spasms and tics which seemed to impede his speech. t h e tics were treated concurrently but independently. each tic was given five one-minute periods of massed practice, with one minute's rest between each period. the same order of massed practice was employed throughout the treatment. he was first required to practice the jerking of his head for five trials. after three minutes rest he was asked to perform the mouth twisting movements and finally reproduced the eye-movements. the patient was instructed to carry out two sessions daily. he was supervised by the therapist twice a week. the tendency to screw up his eyes during a "block" was eliminated in less than three weeks. the mouth-twisting response and the head-jerking required more than a month of massed practice before they entirely disappeared. t o date, there has been no apparent symptom substitution, nor have any of the original tics or spasms returned. the overall improvement in his speech is really quite remarkable. his blocks are now far more infrequent and they are usually so momentary that they often pass completely unoticed by untrained observers. a prolonged follow-up of this case is being undertaken. d i s c u s s i o n it is premature at this stage, of course, to assess the value of the techniques outlined above in the treatment of dysphemia. the preliminary findings, however, are most encouraging and warrant further investigation. this introduces the query: " w h o should carry out the treatment, speech therapist, psychologist, or both?" w e therefore return to the consideration of therapeutic teamwork. in the opinion of the writer, therapeutic teamwork is tenable only where there is a clear-cut division of the skills involved. in the case of a therapeutic liaison between doctor and psychologist, for instance, the collaboration is usually fruitful. this is because the doctor remains responsible for the physical health of the patient and the therapeutic lines of demarcation are reasonably obvious to patients and therapists alike. it is difficult to decide whether therapeutic teamwork between speech therapist and psychologist is advisable — so much depends on their respective theoretical orientations, their therapeutic objectives, the patient's level of adjustment and so forth. by and large, it is our view that the speech therapist, given the necessary training," would be adequately qualified to " g o it alone" when confronted with cases similar to those presented above. *it must be understood that the desensitization technique is a highly specialised procedure. the therapist who employs desensitization requires tuition in (a) the construction of the relevant anxiety hierarchies (b) the application of hypnotic and ordinary relaxation procedures (c) the handling of anxiety which is aroused during a session (d) in assessing the optimal number and duration of the stimuli which should be presented in any given session. r e f e r e n c e s 1. e y s e n c k , h. j . (1959) " l e a r n i n g t h e o r y and b e h a v i o u r t h e r a p y . " j . ment. sc., 105:61. 2. wolpe, j . (1958) p s y c h o t h e r a p y b y reciprocal i n h i b i tion. s t a n f o r d university p r e s s and w i t w a t e r s r a n d u n i v e r s i t y p r e s s . 3. j a c o b s o n , e . (1938) p r o g r e s s i v e r e l a x a t i o n . c h i c a g o : u n i v e r s i t y of chicago p r e s s . 4. l a z a r u s , a. a. and r a c h m a n , s. (1957). " t h e u s e of s y s t e m a t i c d e s e n s i t i z a t i o n in p s y c h o t h e r a p y " . s . afr. med. 3. 31:934. 5. l a z a r u s , a.a. (1959) " t h e e l i m i n a t i o n of c h i l d r e n ' s p h o b i a s b y d e c o n d i t i o n i n g . " med. proc., 5:261. 6. y a t e s , a. (1958) " t h e application of l e a r n i n g t h e o r y to the t r e a t m e n t of t i c s . " j . abnorra. soc. p s y c h o l . 56:175. 7. hull, c. l . (1943) p r i n c i p l e s of b e h a v i o u r . n e w york appleton, c e n t u r y crofts. 8. hull, c. l . (1951) e s s e n t i a l s of behaviour. n e w h a v e n : yale u n i v e r s i t y p r e s s . 9. hull, c. l. (1952) a b e h a v i o u r s y s t e m . new h a v e n : yale u n i v e r s i t y p r e s s . r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) editorial in march 1962, professor c. j. dreyer succeeded professor hurst as chairman of the executive committee. we welcome him most cordially and assure him of our cooperation at all times. this issue of the journal of the south african logopedic society consists of articles by overseas contributors. ruth clark worked in south africa some years ago and we are privileged to publish her review of recent research on the parietal lobes, proprioceptive sensibilities and tactilc and kinesthetic abilities in speech production — avenues of investigation which offer exciting possibilities for future work. felix trojan and herta weihs have provided us with some idea of the continental approach to speech and voice therapy. their discussion of factors relevent to a correct diagnosis of a speech or voice disorder covers a wide field and is most interesting. 1 journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the relationships between measurements of stuttering behaviour myrtle l . aron, p h . d . department of logopedics, university of the witwatersrand, johannesburg in our attempt to ascertain the symptomatology of stuttering and the change and progress that might occur in particular situations and in therapy, evaluative procedures become essential. measurements of the dimensions of stuttering behaviour is part of the evaluative procedure. not all the dimensions have been established—there are many facets which remain elusive in terms of objective assessment. stuttering varies a great deal under certain known conditions but it can also vary for no apparent reason. the cyclic phenomenon in stuttering has been discussed by quarrington,11 and others, but it has not been explained satisfactorily.. an objective study of variability in stuttering is therefore difficult to make as any change that may occur may not necessarily be associated with manipulated conditions or the process of therapy. individual personality differences add to the problem of objective measurement in stuttering. however, these factors need not preclude our use of measurements and some attempt must be made to quantify data. this is not to say that we must belittle qualitative judgements. these finally are the most important. in many respects those measurements we can make at the present time reflect qualitative assessments. the need to attempt measurement, although we may not have all the answers, is supported by thurstone18 who states that: . . . it is better to formulate the law of comparative judgements in terms of the discriminal error, which is a psychological concept, than to wait until we shall understand physiologically . . . while conducting a study to ascertain the effects of a combination of tranquillizing and sedatory agents on the symptoms of stuttering, an array of measurements were used to assess stuttering speech. it is not the intention here to report on the effects of the drug as this has been considered elsewhere,1· 2 but it is relevant to report on the type of measurements made of the stuttering symptom and their relationships to each other. this latter aspect can be considered independently of any drug effects on the subjects who participated in the study. criterion of what constitutes stuttering. t h e construct and application of measurements and ratings of stuttering must take into account a criterion of what constitutes stuttering. this becomes particularly important when differentiations must be made between the non-fluencies that can be detected in normal speakers and stutterers. johnson has observed that "interjections, revisions, and phrase repetitions" can sometimes be considered as "normal" disfluencies.7 boehmler had indicated that two groups of judges (trained and untrained) classified part-word repetitions as "stuttering" as journal of the south african logopedic society, vol. 14, no. 1: september 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) yrtle l . aron frequently for stutterers as for non-stutterers.4 the judges agreed more when stuttering was severe and when "normal" non-fluencies were mild. williams and kent found that syllable repetitions and prolongations were more consistently identified as "stuttering" by judges.21 johnson listed eight features of speech which he thought to be representative of disfluencies and this became known as the iowa speech disfluency test.7 young used a modified version of this test, and considered five rather than the eight features, in view of the rarity of occurrence of "phrase repetitions, incomplete phrases and broken words."23 his categories were: (a) interjections. (b) part-word repetitions. (c) word-phrase repetitions (johnson considered these as two separate features). (d) prolongations, including broken words (johnson considered these as two separate features). (e) revisions, including incomplete phrases (johnson considered these as two separate features). young then used multiple correlation procedures to analyse the speech samples of stutterers as rated by listeners.23 as a result of these procedures he modified his categories further and this was the criterion adopted in the study under discussion. the categories were: (a) syllable and sound repetitions. (b) sound prolongations. (c) broken words (or broken utterances). (d) words involving apparent unusual stress or tension. in addition to the above, the writer added word repetitions with "syllable and sound repetitions" as she feels that this feature occurs fairly frequently, especially on short words. the criterion followed appears feasible to use as a classification for denoting stuttering moments and rating the severity of stuttering. severity ratings of stuttering. various measurements can be applied to ascertain the severity of stuttering. physiological changes can be noted such as alterations in· breathing, heart rate, electrical skin response, etc. the duration of the stuttering moments can also be measured. in a personal communication, van riper pointed out that there is still no adequate way of measuring the severity of stuttering.19 he felt that the problem lies in the fact that stuttering is a compound of fear and struggle. he considered the use of physiological measurements but suggested at the same time that these were subject to too many variables and would differ from subject to subject according to the nature of their symptoms. the use of physiological measurements, although theoretically plausible, were, for practical reasons, rejected for the purposes of this study. one satisfactory measurement of the severity of stuttering which has received some attention over recent years, is the use of an "equal-appearing intervals scale" to rate severity based on audible characteristics. the use of such a scale represents a classic psychophysical method. the subject (or experimenter) sorts a number of stimuli into specified categories where the intervals appear to the experimenter to be equal. sherman has done a great deal of work on severity scales, and together with lewis, she first applied a nine-point scale consisting of equal-appearing intervals where ι represented "least severe stuttering" and 9 represented journal of the south african logopedic society, vol. 14, no. 1: september 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the relationships between measurements of stuttering behaviour 17 "most severe stuttering."15 fifteen judges rated speech samples on this scale and their judgements were found to be satisfactorily reliable. there was evidence that this severity scale had internal consistency. this scale was applied to permanent records (tape recordings) of the audible characteristics of stuttering. sherman then used the same scale to ascertain if observers could make reliable judgements of continuous stuttered speech.13 she demonstrated that this method is reliable, and is experimentally and clinically useful for assigning a rank order position of severity. johnson suggests a seven-point equal-appearing intervals scale where he presents a description of the type of stuttering that each rating represents.8 cullinan et al. compared five-, seven-, .and nine-point equal-appearing intervals scales and found that the scales were significantly correlated and that reliable values could be obtained from any one of these.5 apart from measures of the severity of stuttering, the frequency with which stuttering occurs must contribute to the listeners' evaluation of the severity of the symptom. this aspect was studied by sherman and trotter who questioned the relationship between the frequency count of the moments of stuttering and measures of severity made on an equal-appearing intervals scale.16 from the data presented by eleven observers, they found that these two aspects were significantly and positively correlated, but they do point out that the relationship between the two measures is not strong enough to allow one measure tô predict the other. sherman et al. compared three measures of stuttering severity: (a) reading time. (b) frequency moments of stuttering. (c) scale values from listeners' ratings.17 all interrelationships were found to be statistically significant and the strength of the relationship was highest between the frequency counts and the rated severity. the visual characteristics of stuttering may be as important to measure as the audible characteristics when making severity ratings. it is difficult, however, to obtain such information for permanent records due to the expense of filming. it is necessary to establish, nevertheless, how close or how far severity ratings based on audible characteristics differ from those based on visual and audible features. in this regard a detailed study was conducted by williams et al., who studied the ratings of stuttering by audio, visual and audiovisual cues making use of synchronized photography and sound recording.22 they found that the frequency count of stuttering and scale values representing severity are more reliable when obtained by audio and audiovisual observation than when obtained by visual observation. they suggested that the use of audio cues alone is sufficient for obtaining useful and reliable measures of the frequency and severity of stuttering. it is possible, the present writer feels, to consider the relative importance and influence of visual cues when marking the severity ratings of stuttering during the stutterers' act of reading or speaking, where audible cues would also be· present apart from the visual characteristics. if the speech is recorded and played back at a later stage when the memory of the visual cues ceases to be influential, comparative data of tydskrif van die suid-afrikaanse logopediese vereniging, vol. 14, nr. 1: sept. 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) yrtle l . aron ratings could indicate whether visual cues added significantly to the initial ratings of severity. johnson has said that the advantage of a severity rating scale with stutterers ensures a certain degree of uniformity and comparability of judgements.8 he cautions that such a rating can have its limitations and that clinical judgements of stutterers are still important. a relevant point that can be considered here is the reliability of one observer to make severity ratings of stuttering. cullinan et al. found that judges tend to agree better with themselves than with other judges.5 their evidence suggests that it is not sufficiently reliable to use a single judge on a single rating scale. it would seem feasible and convenient to employ a single observer to make severity ratings which can be compared with ratings made by a group of judges. this should indicate the kind of agreement among the judges and the reliability of the single observer's judgements. sherman studied this aspect by comparing individual observers and found, in contrast to cullinan et al., that reliable scale values can be obtained from a single observer.14 frequency of stuttering moments. the frequency with which stuttering occurs contributes to the severity of the stuttering symptom. like severity, frequency of stuttering can increase or decrease, depending on the tension and anxiety felt by the stutterer in communicative situations. the counting of stuttering moments constitutes a basic measurement of the disorder. it is customary to have a subject read a passage and to mark the words stuttered on. it is also possible to count the frequency of stuttering during spontaneous speech where tape recordings can be transcribed and the moments marked and studied. as with the severity ratings of stuttering, visual cues exhibited by the stutterer can influence the experimenter's markings of the moments of stuttering while the subject is present and reading. two important dimensions of stuttering behaviour are calculated on the basis of the frequency count—adaptation and the consistency effect. adaptation. this is a well-known phenomenon in stuttering where stuttering moments tend to decrease progressively with successive oral readings of the same passage. there appear to be individual differences, however, where some stutterers do not show any adaptation or may even produce increased stuttering with every reading.8 newman considered the possibility of classifying stutterers into groups on the basis of their adaptation performances.10 he re-examined data on adaptation and found that there were instances where subjects did not reveal any adaptation. the first study to note the phenomenon of adaptation in stuttering was conducted by van riper and hull in 1934.20 they attributed the decrease in the stuttering moments to the stutterer's subjective adaptation, either to the situation or to the reading material. since then many studies have been published on this aspect and the general attitude appears to be that the stutterers experience less anxiety with each reading, thereby stuttering less. consistency. consistency effect of stuttering was first noted by johnson and knott who found a significant -tendency for subjects to stutter on the same words from reading to reading of the same.passage.9 johnson et al. feel that the importance of knowing the consistency in stuttering is that it may indicate journal of the south african logopedic society, vol. 14, no. 1: september 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the relationships between measurements of stuttering behaviour 19 how strongly stuttering responses are associated with stimuli or cues that have been conditioned.8 the anticipation and expectancy of stuttering is closely related to the consistency effect. reading rate. it has been commonly observed that stutterers take longer to read than non-stutterers. this time factor contributes to the severity of the problem. sander reported that reading rate was a highly stable measure of stuttering severity.12 he considered the relationship between reading rate and the frequency moments of stuttering, and concluded that the two measurements can be used as a tool for evaluating the speech improvement of stutterers. the computation of the reading rate in words per minute is outlined by johnson et a!.s the number of words contained in a reading passage is divided by the number of seconds taken to read it and this is multiplied by sixty to convert the final rate to words per minute. this measurement, requiring only the use of a stop-watch, is perhaps one of the most objective methods of assessing any change in stuttering. the severity of the stuttering symptom, together with the frequency of its occurrence, will directly influence the rate of reading. procedure in present study the study extended over fifteen weeks which were divided into five periods of three weeks each. forty-six subjects participated—37 were europeans (mean age: 26 years 6 months) and 9 were africans (mean age: 20 years 1 month). a number of testing procedures was administered to subjects individually once in three weeks. the purpose of these three-weekly assessment-interviews was to collect data pertaining to various aspects of the subjects' stuttering. apart from the measurements of aspects of stuttering, the subjects also completed a daily questionnaire for the duration of the experiment and made verbatim reports, but results of these are not pertinent to the subject matter under consideration. although the measurement of aspects of stuttering was done with a view to ascertaining the efficacy of medication, the measurements can be studied in isolation without any spurious effect from the drug. the purpose of this present report is to indicate the interand intra-relationships between the measurements themselves. m a t e r i a l the reading passage utilized was a slight modification of a portion of the "rainbow" passage by fairbanks.6 the passage was modified so that it could be divided into two sections—the first part consisting of 200 words, and the second part of n o words. during the first three assessment periods only the 200 word passage was presented, and during the last two assessment periods the complete 310 word passage was given. the extra n o word passage was included in order to ascertain whether any adaptation to the same passage (first 200 words) had occurred. thus the n o word passage, as the nonadaptation passage, acted as a control. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 14, nr. 1: sept. 967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 .. · myrtle l·.' aron : i. experimenter's severity' rating of stuttering on subjects'. reading. the rating .of the severity of stuttering was made by the experimenter. after the subject had read the passage. .. ' (a) the rating was made on a nine-point equal-appearing intervals· scale where " i " represented no. stuttering, "9v very, severe stuttering, and· "5" represented average stuttering. the other points on this scale represented values falling between these points. the.rating was made by'the experimenter immediately after, the subject hadcompleted his reading. · s ; · • ' *. · (b) a second rating on the same scale as described above was made when the tape-' recording of the reading was played back. this was done soon after the subject left the experimenter and' it \was felt necessary since it was possible that visual cues displayed by the subjects during the' reading might have affected the first severity rating made: . * v' . . (c) a.third severity rating was made, without reference'to the above two ratings, using the same scale. this was made when the tape-recording was played back approximately 10 days after the initial reading. this third rating was based predominantly on auditory characteristics. it was also considered a crucial one in that samples of taperecordings were to be played" to judges who would react only to these auditory cues, thus making comparative data possible. ..· 2. experimenter's severity rating of stuttering on subjects' spontaneous conversation. this rating was made on the same nine-point equalappearing intervals scale described above. spontaneous conversation took place when the subjects first arrived for the interview. at .the end of the interview, if the information was not volunteered in enough detail, the subjects were asked to comment on their speech, on the study, etc. this rating was' niade separately from the readings as it was felt that with many stutterers,. there is a marked disparity between the amount of stuttering in reading and in spontaneous speech performances. no attempt was made to structure the conversation and no tape recording was made. > 3. subjects'. severity rating on their own stuttering in reading. after a subject had read the passage he was asked to rate himself on the same scale used in the above measurements. the instruction to the subject was as follows: on the following scale, rate your stuttering on the passage you have just read. 1 2 . 3 4 5 6 7 8 ' 9 n o average very severe stuttering stuttering stuttering 4. subjects' severity rating of their own stuttering on a playback of the recording of the reading. approximately thirty minutes after the subject had recorded the reading passage, he was asked to hear the tape recording and to rate himself on the same scale. the instruction to the subject was: . the reading you have just made will be played back to you. listen to it and rate your stuttering on the following scale:' / the scale was presented in the same manner as in 3 above. it was felt that · the confrontation of hearing their speech might change their judgement of the severity which they had previously made on their reading. it was expected that, due to poor attitudes towards speech, the subjects would make a slightly higher rating than previously. this information could be of value for comparative purposes, in terms of self-judgements of the severity of stuttering based on the same material judged under different conditions. journal of the south african logopedic society, vol. 14, no. 1:. september 196j. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the relationships between measurements of stuttering behaviour 21 5. frequency count of stuttering moments during the subjects' reading. while the subject read, the experimenter markedon a copy of the reading passage the words on which stuttering occurred. during the last two periods of the study, when the additional n o word passage was introduced " together with the familiar 200 word passage, the frequency count was taken, separately for both passages. the tape-recording of the reading was played back later during the same day of the recording. a second frequency count was taken and no reference' was made to the markings on the first copy of the passage. this aspect was considered twice since it is possible that visual cues representing struggle responses, especially those associated with non-vocalized blocks, would be noticed during the· reading when the subject was present. it can be expected} therefore, that the frequency of stuttering is greater when taken during reading as compared with the count taken on the playback of the recording. 6. reading rate measured in words per minute. when the taperecordings were played back during the same day of the readings, theywere timed with a stop-watch. the reading rate was calculated according to the number of words contained in the passage (either'200 or 310 .words). as discussed previously, reading rate is probably the most objective.dimension of stuttering behaviour, since it does not rely on any subjective evaluation made by an observer. the amount of stuttering moments and the severity with which stuttering occurs, will directly influence the time it takes a stutterer to read. ' .. . 7. subjects' severity rating of stuttering for the same day, prior to the assessment-interview. the subjects were asked to rate their stuttering as it was for the same day, prior to the interview. the question was put to them in this way: what was your speech like today before coming here? was it the same as usual, slightly better, much better, slightly worse, much worse? this question was very familiar to them as it followed the same format as the daily schedule questions which they were completing. their answer was rated by the experimenter on the following scale: 1 2 3 4 5 much slightly ' slightly much better better same worse worse this rating was made as it was felt that the interview situation might have been perceived as being tense by some subjects, and the likelihood might have arisen that their speech symptoms, during the interview, might have been worse than the speech produced during the day, before coming to the clinic. at the same time the subjects were asked to comment on the "usualness" or "unusualness" of the day they had just experienced. this question was asked in order to elicit information as to whether anything untoward had occurred that could possibly affect their speech. reliability of experimenter's severity ratings. a month after the completion of the experiment, five judges rated the severity of stuttering from the recordings. the purpose of this was to test the reliability of the experimenter's ratings and the degree of agreement with judges. the judges were qualified speech therapists. recordings representing any two of the five assessmenttydskrif van die suid-afrikaanse logopediese vereniging, vol. 14, nr. 1: sept. 196 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 myrtle l. aron interviews for each subject were selected according to a set of random numbers and totalled ninety-two samples. these recordings were removed from the original tape reels, spliced together and placed, according to the randomized order, onto large reels. the instructions to the judges included the following: the tape samples you will hear have been made by persons who regard themselves as stutterers. in each sample the "rainbow" passage by fairbanks is read. in some instances a 2 0 0 word portion of the passage will be read, and in others a 3 1 0 word portion will be read. you are requested to make a rating of the severity of stuttering for each sample. this rating is to be made on a nine-point equal-appearing intervals scale on which a rating of i means "no stuttering", a rating of 2 means "very mild stuttering" and a rating of 9 means "very severe stuttering". a rating of 5 indicates "average severity". the other values on the scale represent equal intervals between 1 and 9. please give only one rating for each sample heard. the judges were requested to consider the same criterion of stuttering speech as did the experimenter. results and discussion comparison of the experimenter's severity ratings of stuttering with those made by five judges. judges rated any two recordings of the reading made by each subject out of a possible five. the judges' ratings were compared with each other and with the experimenter's. the results were inter-correlated where the ratings of the five judges were used, together with the experimenter's three ratings (factors ia, ib and ic referred to above). the correlation matrices depict the judges' and experimenter's ratings for the first and second recordings chosen, and the correlations between the ratings of the two recordings. the inter-correlations were derived from raw scores, means and standard deviations. table i : inter-correlations of the severity ratings of stuttering made by five judges and the experimenter for the first group of recordings heard i 2 judges 3 4 5 e i experimenter e2 e3 i-00 •93 1 00 •85 •91 1 00 , •86 •92 •92 i -00 •92 •94 •91 •90 1 00 •88 •88 •85 •88 •88 •88' 1 00 •90 •92 •85 •88 •89 •91 •96 i -00 •89 •91 •88 •88 •90 •95 < -97 i-00 significance at 1 % level = · 36 the matrices show high correlations for the experimenter's three severity ratings (reading, first and second playback). the correlations range from -95 to -97 for both recordings (table i and 2). the correlations between the experimenter's ratings and those of the judges ranged from · 85 to · 92 for the first recordings heard and from · 86 to · 93 for the second recordings heard. these are higher than the correlations between the two recordings for the individual judges (inter-judge), where they ranged from · 71 to · 87 (table 3), journal of the south african logopedic society, vol. 14, no. 1: september 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the relationships between measurements of stuttering behaviour 23 table 2 : inter-correlations of the severity ratings of stuttering made by five judges and the experimenter for the second group of recordings heakd judges experimenter i 2 3 ' 4 5 ei e2 e3 •00 •92 1 00 •85 •91 i -00 •92 •95 •92 γοο •93 •91 •90 •93 i 00 •87 •92 •89 •93 •90 γοο •88 •92 •88 •93 •90 •95 i-00 •86 •91 •86 •92 •90 •96 •96 i -00 significance at 1% level = 36 table 3 : inter-correlations of the severity ratings of stuttering made by five judges and the experimenter between the t w o groups of recordings heard second recording 1 2 first recordings judges 3 4 5 experimenter ει e2 e3 1 •82 •82 •78 72 •81 •76 •80 •80 . 2 •83 •87 •80 78 •84 •81 •85 •85 judges • 3 •79 •86 •85 76 •85 •80 •83 •84 • 4 •81 •85 •80 77 •83 •82 •84 •84 • 5 •76 •81 •79 7i •82 •77 •81 •82 exp. . . ei ' '73 •79 • "73 67 •75 •75 •79 •80 . e2 •72 •75 •72 67 •74 •76 •80 •80 • h3 •72 •74 •68 62 •73 •72 •76 •77 significance at 1 % level = · 36 or for the between-recordings for the experimenter, where correlations ranged between -75 to ·8ο (table 3). this last correlation is possibly affected by actual differences in the subjects' stuttering from one period to another—an effect by which the judges could not have been influenced. the correlations between the judges themselves (intra-judge) are all high and show a satisfactory measure of agreement. these findings support the evidence contributed by cullinan et al., where intra-judge reliability coefficients tended to be greater than the inter-judge reliability coefficients, i.e. the judges tend to agree better with themselves than with other judges.5 from the matrices it can be seen that the experimenter obtained very high correlations between her three ratings for each recording—the correlations for the first recording ranges from · 95 to · 97 and for the second from • 95 to · 96. this would indicate that there is little difference between the ratings of the severity of stuttering during the reading while the subject was present and a rating made ten days later from a recording. it appears then that, in this study, the visual cues displayed by the subjects while reading had very little effect on the severity ratings made. it can be postulated that tensions displayed during the actual reading (where stuttering is physically manifest and can be "seen") tydskrif van die suid-afrikaanse logopediese vereniging, vol. 14, nr. 1: sept. 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24ivlyrtle l . aron. are reflected in the mariner of reading itself so that they are auditorily detected in the recordings heard. from the results it would appear that the expeririienter's ratings are highly correlated with each other and are satisfactorily in agreement with the five judges. these ratings can therefore be considered as a reliable measurement of the severity of stuttering. this finding also supports sherman's observation that a single observer is sufficient to make reliable ratings of the severity of stuttering.14 c o m p a r i s o n o f s t u t t e r i n g m e a s u r e m e n t s over five p e r i o d s a correlation of 10 factors (points ia, ib, ic, 2, 3, 4, 5a, 5b, 6, 7, discussed above) to observe the nature of the relationship between the measurements themselves was carried out. the matrices for each period are presented in tables 4-8. the means and standard deviations for the respective periods are included alongside the relevant matrix. the ibm 704, 8k computer of the c.s.i.r., pretoria, was used in order to derive these matrices. although it may have been more convenient to refer to one table representing the five periods, the exact nature of the correlations would not have been evident as the scores would have differed due to trends over the five periods. partial correlations were calculated for each period between the experimenter's severity rating (factor ic) and reading rate (factor 6) eliminating any joint correlation with the frequency count of stuttering moments. this was done in order to establish whether the reading rate or the frequency count influenced the severity ratings made by the experimenter. experimenter's three severity ratings. t h e three ratings are highly correlated extending from · 93 to -98. there is a tendency for the correlations to increase from the first period to the fifth period. there is a steady decline in the means from the first to the fourth period (· 48 to · 42), and a decline in the standard deviations from 2 · 0 to 1-5 which indicates that the spread of the scores narrowed. these results may indicate progressive facility with the use of the scale on the part of the experimenter and/or familiarity of the subjects with the experimental situation. on the other hand the means and the standard deviations are increased during the fifth period. the increased standard deviations are probably due to the greater variability between the subjects during the last period of the study. the increased mean scores may also be due to this variability within the subjects, or to a worsening in the stuttering condition as the medication periods had passed. x the severity ratings correlate very 1 highly with reading rate ranging from • 79 to · 92. the correlations are also high with the two frequency counts which. range from · 46 to · 71. the range of correlations of the experimenter's ratings with the rating made for conversation declines steadily from -71 to -46—the correlations, however, are still significant (significance = · 29). the experimenter's severity ratings correlates comparatively poorly with the subjects' severity ratings of their own speech—ranging from · 37 to · 70. this is to be expected as the standards used by the experimenter and by the subjects must differ due to the element of subjectivity present on the part of the stutterers. journal of the south african logopedic society, vol. 14, no. 1: september 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e r elation sh ip s betw een m easu rem en ts of stu tterin g b eh aviou r 25 a 3 to'« ν a '••ft; 1 « 3ft; a; a; & c & to to ft; & to i "<3 λ α ft* * ^ pj α w ο 'ίο ν ο ο ο 00 t> ο ο "λν ο σ\ν h ο σ\ ο ο ο ή μ ν μ ο μ \0 ν ο η η μ w ο ο ̂ (j> ο ο̂ νι ο πί ο ο q \ t>00 νι ο πι ο ο (j) ' ο ""φοο πί ο t> ν ο fln σ\00 ο ν ο ν ν ν ο oco hco0o ν ^ 0*ΰ νίν η ο ν ο ο ο̂ \ο ν-»\ο \ο σ\ ο μ ο ο ο ό ό ο t> μ "̂-οο ν 00 ο "λ ο m ν-> ο ο ^ ν οο η ο owo \0 ιλί̂ολο 00 ο η 0 ό ό 6 ό ό |)|) 8 γο ο vo 00 ο̂ \0 ν μ (s m m θ\ m ο σ\ ο ο α\ α\\ο \ο w »rnnoo ο η ο ό ό ο ό ό ό π c? χ) ϋ λ χ) * η η η μ ffitiri v"»\0 t> λ 4-j & c ο c ω c •3 3 bo c τ3 c ω c ο ^ (u -β « s 2 ο. 6 « ο (u « s 2,9 λ qj ο _ £ * β bp £ co m̂ o οοό η ν h vi μ 00 σ\00 00 ν moo t> 00 q\ q\ q\ ο ο vi00 \θ \0 hh tj-00 v) vi f-λο ο ο "φ α\θ moo σ\οο 00 t> 00 00 00 vlosvim v» οί μ t ydskrif van die suid-a frikaan se l ogopediese v eren igin g, v ol. 14, n r. 1: sept. 1967 reproduced by sabinet gateway under licence granted by the publisher (dated 2012) 26 yrtle l . a ron « ο -§ gp co's ο 1 « oi υ υ co i ι--a a q vl ο ο ο ο ν ο ν ο m ο m σ\ ονο tn ο tμ ?ϊ ο 00 μ μ ο σ\\ο m ο ?? ο ο̂ σ\ μ m ο m ν-) ο t-« ο ν ν μ ?? ο t--\0 νο ο ο μ μ ν ο ο f» ό ό ό ^ ζ ό κ ν cfl α « £ ο t-t-υ-ν ρπ ttο ο ο t--00 v -) ό ο ν ν μ fov£> <s η ο ο ο ο ?? ο νο »/ί τί-\ο νο οο m μ ο ο ο ο ο ?? ο m \o τ |-η ιλ ν tf ο vo t**· fo os00 00 so fo ο on̂d «η νο 00 fo ο ο ο ο ο ο π ο η (γ|ιλη tf 0\η in h· ο ^ σ\ ο fn τίτίμ ο σ\ osv£> tfvo so 00 co ο ο ο ο ο ο ο < λ £ ) ο «β £ > * η η η ν fotfin îivd t"-[ο ω c •3 3 .6 0 c t3 •ο c 60 c n ·.u μ i s ô oj m g s's 2 o£ x .2 ω s jj u sb o j3 ,ο ελ c .2 js — (u u η a ° lu υ __ « « c "s copl, q μ t- μ ιλ^γ<ίν foo »/-ϊ\0 0 πί tf t-"ψ σ\ 00 f» t̂-00 μ μ μ μ tt "jj i> m μ μ μ ν ν osoo on ο m m e α <u tto \n πί t-ν μ μ \d tf t-ο «ηοο «η ν os ν os t"ό vd t̂ «ηοο tt^ttttt^^o so so ν fo m 0 μ fj 0 «0 δ tn χ* υ a η η η ν fo l-ΐλ »/ί\0 f» journ al of the south a frican l ogopedic society, v ol. 14, n o. 1: septem ber 1967 reproduced by sabinet gateway under licence granted by the publisher (dated 2012) t h e r elation sh ip s betw een m easu rem en ts of s tu tterin g b eh aviou r 27 •sv-s, "§ ip co's α οί ης οί υ κ co υ ο ο ο σϊ q vi ο νι ο ο ο ο ο 00 ro fηΐλ ο rο ο owo ι-" ο ο σ\ rο ο fn σ\\ο ο ο ί̂" t̂" ν "λ ο μ ν v l o ο ο r-00 μ ο 00 μ μ ν μ ο v i vivo ν ο 00 t-vi ν vi ο η ιλ ο ο flm ο ν ν -ί ο μ ο ο ο ο ο ο α οί co s ό « α μ £ ο ο h ^ h h ο ο ο ό σ\\ο ο μ ο ν ο «η t·» t-on ο μ ο ο ο ο ο ο ο ο to hn m \d onoo ο co tfr en on on on t-m ο »/ί\0 νο 00 ο μ ο ο ο ο ο ο ο ο ο 0\̂£> ν \d \d ν \d ροοο ο \d 00 on vtoo m ο on σ\ «ηνο w νο 00 ο μ ο ο ο ο ο ο ο ο ο ce χ υ & χ * μ η η ν fo ttin »/ί\0 t·» a jo ω c •3 3 ω c •d c ω c ϋ a \θ c 0> js g ω δ s b ,ο ελ c •3.2 j s ο u t! s « c'? ω ϋ copl, «ο q t--00 ν ο ν 'tonfohoo ν ο t-on t-t-t"» t--00 ffltt-n μ \d t-« •g co μ μ μ μ μ ν τί-τί-ο fo fo 0 e α u int̂ h oooo m m « η m «τί o\ tf t--'m 00 t·»t-m tt tt m oo tt tt t--\0 ν on tf tl-tf tt ιλ ιλ f(1 m \d m m 0 ν ο «ο 5 tn x u ca x μ μ μ ν m ttv) tt ydskrif van die suid-a fkaan se l ogopediese v eren igin g, v ol. 14, n r. 1: sept. 1967 reproduced by sabinet gateway under licence granted by the publisher (dated 2012) 28 ""m yrtle l . 'a ron fl? to'a ts ο α iv (a ο c k & co υ ο co i ο in £ 1' a ο " ο ro ο . ο μ ο m ο m m ο λ ο tt ο ο oo os ο o m ν ο ο νο ο ?? ο «ηοο ο en ο ό tj-vo ο ο μ μ m ο γ ο 'to ο ν ο η ν ν (fin ο t"ό ό «ο μ ο 00 00 vo ν t*-· μ ο ν ν m fovo 00 ο ο ο fo fo 't η μ ο <j> ο ο <j> ό οοο ν ν ν h h n ο on η fv osoo ν ό ο 't^o tf in ιηοο ο ο ο ο ο ο ?? ο osvo ^ μ >/ιοο μ ό ο ό ό ό tfo tr\ fovo ο c \ in in in ιηοο ο ο ο (j) (j) ο η ιλ o\ η ο in tf ο ό μ fovo ό ιηοο οο μ ό ό ό ό ό ο ό τ ϊ £ < & £} ο α χ * ι μ μ μ ν fo ^ ό ιπό t> λ •μ & c ο c ;s ω c '•τΐ 3 ω c τ3 τ3 c ω .3 4-* a jj ~ λ s χ ο <υ is η ο υ ω ,ο £λ c •λ ο <υ η « u υ s « c 'ρ μ ϋ • —ι c3 con, β q "β co os t-ο 00 f--̂οο 00 >λν oooovovovooo γ-ν οο ν tt -̂-ό ν μ ό 00 ν 00 t-m ν ό ο •̂•ososfom moo »nospnt--pnooovo ν ν η η η η ν η 00 γ -"·ν ν ο c s χ > υ c 3 £ > μ μ μ ν journ al of the south a frican l ogopedic society v ol 14, n o. 1: septem ber 1967 reproduced by sabinet gateway under licence granted by the publisher (dated 2012) t h e r elation sh ip s betw een m easu rem en ts of . stu tterin g b eh aviou r 29 to'a <3 ο o iv ft; u ft ο fti co u ο co i e j i -t3 rt ο in £ 1' a. <2 ό κ ν a ο « £ ο ο ο μ ο μ ο 00 ο m t·» ο ο ο μ on ο ο -φ γο ο νο ο ο ^ on -φ ο ο ο ν ν ο η η ν m ο μ νο 00 00 μ ο νο ν ο r -φ -φ m ο γο ν ν γon ο on ν ffν ν ο ο η η η tfn <j) <j) ο ο <j) ' ο νο ^ onvo t̂ο ν μ ο ο ο ο ο ο. fnooovo ο νο on r-vo on ν ο o n -̂m m i/n/ir̂ n « ό ό ό ο ό ό ο ό tj-vo μ r-vo ό η ^ ο on on-φ vi fn >/-100 ν η ό ό ο,ό ό ο ο ο ο α χ > υ α £ > * μ μ μ μ " η ν̂ νο f-λ •μ & c ο jo bc c '•β 3 b£i c t3 c b£i c <υ ω <υ a & ο ^ g « th ,ο £λ <« c •71 o q ό too os μ ν m μ ν os ο m ο os t-m ιτ,ο ο μ in ό \o moo m oo h· "β •>4 co h m h h n n n fflm o m m t s 0 11-ο ν 0 0 0 m hin t-ν t--1-ο tn m μ ν m >noo 00 1λ>λθ on •t't't't't't'n 'n m n ν ν μη μ v. £ «χ ) υ λ μ μ μ ν (fitfin in ό t-cop* t ydskrif van die suid-a fkaan se l ogopediese v eren igin g, v ol. 14,n r. 1: sept. 1967 reproduced by sabinet gateway under licence granted by the publisher (dated 2012) yrtle l. aron the partial correlations calculated for each period between the experimenter's severity rating and the reading rate, excluding the joint correlation with the frequency count, indicate that the actual speed of reading is an important element in the severity ratings made. the partial correlations are all high extending from · 72 to -88. thus it appears that the experimenter's severity ratings are most highly correlated with the reading rate and then with the frequency counts of stuttering moments. these latter two factors are regarded in the literature as being fairly accurate measures of stuttering behaviour, and the satisfactory correlation with the experimenter's severity ratings indicates the relative closeness between these three forms of stuttering measurement. experimenter's severity ratings of stuttering based on conversation. as pointed out the correlations between the ratings based on conversation and on the reading of the passage decline steadily to the fourth period, whereas the means of ratings based on conversation show no such trend—they rise from 4· 6 in the first period to 4· 8 in the second and third periods, falling to 4 • 2 in the fourth period, and then rise to 4 · 5 in the fifth period. this was not accompanied by any increase in the standard deviations—on the contrary, they declined from 2 · 0 to 1-7. it is possible, that because no set amount of conversation (or topic) was required from each subject, the choice of topic, the manner of expression, and the amount spoken might have influenced the experimenter from period to period. in this regard it would obviously have been better to set the subjects a particular topic of conversation during each period, which could be recorded, transcribed from the recordings, and then rated for severity. this is what johnson did with his " j o b " task where the subjects were asked to talk about aspects of their employment.7 subjects' severity ratings of their own speech on reading. t h e correlations between the subjects' ratings of their speech on reading and that based on the recording for the five periods are: -49, -71, -78, -71, -76 (all significant). the low correlation in the first period was probably due to the fact that that the subjects were not at that stage familiar with the routine of the experiment and rating scale. the correlations of the subjects' ratings and the experimenter's ratings of severity are also comparatively low with a wide range from · 37 to · 70. the role of subjectivity and personal feelings about stuttering cannot be discounted. the correlation with reading rate is low, extending from • 22 (not significant) to -65. an interesting observation is that the correlations of the subjects' ratings based on the recording (factor 4) with, that of reading rate, is always lower than the correlation between the subjects' ratings on their original reading and reading rate. this indicates that the stutterers rated subjectively and were probably influenced by their feelings about their speech, especially when hearing the recordings. the fact that reading rate is an objective measure indicates that the stutterer's feelings about his own performance should be viewed as a separate entity when comparing ratings and assessments of stuttering behaviour. the subjects' severity ratings of their speech on reading and on the recording correlates very poorly with their own ratings journal of the south african logopedic society, vol. 14, no. 1: september 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the relationships between measurements of stuttering behaviour 31 for their speech for the same day prior to the interview—they range from · 04 to · 32. these results are not surprising since the subjects' speech on reading is a situation not practically comparable with spontaneous speech which could be worse or better than while reading. reading does not constitute "spontaneous propositionality," and further the reading passage was chosen for its lack of emotional content, i.e. reading and spontaneous speech represent two different forms of communication. frequency counts of the moments of stuttering. t h e correlations between the two counts taken on the frequency of stuttered moments are extremely high, ranging from · 995 to 1 · 00. this indicates that there was little discrepancy between the two counts taken for each subject, which implies that any visual cues present in the first rating were at a minimum and had little influence on the frequency of the stuttered moments counted. the correlation between the frequency counts and reading rate rose from —-70 to —-76 between the first and second periods, and then declined steadily to —-64 in the fifth period. this was accompanied by a steady fall in the mean frequency counts from 43 to 25 over the five periods. the reading rate is affected by both the frequency of stuttering and the length of the blocks, and the frequency counts by the number of blocks only. the decreasing correlations, together with the fact that the mean number of frequency counts had fallen to a little more than half the original value, may suggest that the shorter blocks tended to be eliminated. following on from this it can be interpreted that the reading rate, towards the end of the experiment, tended to be influenced more by the length of t i e blocks than by the frequency with which they occurred. this is corroborated by the decline in the partial correlation between the experimenter's severity ratings and reading rate, where the joint correlation with the frequency counts was eliminated—the range was from • 88 to · 72 over the five periods. reading rate. this factor has already been discussed in terms of its correlation with the above eight factors. the partial correlations carried out for eaph period between the experimenter's severity rating (factor ic) and the reading rate (where the joint correlation with the frequency count was eliminated) indicate that the speed of reading influenced the experimenter's severity ratings to a large extent in the first period, but they declined towards the fifth period. the correlations are all high and extend from · 88 to · 72. subject's severity rating for their speech for the same day prior to the interview. this rating bears little relationship to the measurements taken. its inclusion was only to provide a rough indication of whether the ratings made on conversation during the interview corresponded with the subjects' report of their stuttering during the same day of the interview. no relationship was found—the correlations range from · 03 to · 23, none of which is significant. the form of speech exhibited in the clinic situation can be expected to differ from the type of speech produced outside this situation. in addition many extraneous factors could have influenced the subjects to make different assessments from the experimenter, e.g. the stutterers' subjective attitude towards speech, the experimenter's practice in making severity ratings. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 14, nr. 1: sept. 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 yrtle l . aron conclusion it was found in this study that a single investigator'can make valid ratings of the severity of stuttering. this was: supported by the high and significant correlations' between five judges and the experimenter. the extremely high correlations between the experimenter's three severity, ratings of the "same reading for individual subjects taken at different times, would seem to indicate that visual cues displayed by stutterers while reading had little effect on the severity ratings made: it was postulated that tensions, where physical manifestations accompanied stuttering, are reflected in the manner of speech itself, so that it can be detected from tape recordings. frequency of the occurrence of stuttered moments, may not necessarily be an adequate measure of stuttering change and severity. severity ratings of stuttering correlated most highly with reading rate. the frequency counts of the moments of stuttering also, correlated well, but not as. highly. the correlations between the frequency count and reading rate extended frpm • 64 to — •76. from the results it appeared that the reading rate, towards the end of the experimental period, tended to be influenced more by the length of the blocks than by the frequency with which they occurred. it is postulated that if the severity of stuttering undergoes change within the same individual over a period of time, this would be corroborated by change in reading rate, rather than frequency. thus it appears that frequency counts of stuttering, while a fairly reliable measurement in itself, is not a sufficiently reliable measure of stuttering severity when used alone. the frequency with which stuttering occurs is referred to in the literature as representing one measure of the severity of stuttering.3·8·23 it can be generalized from the results here that we should differentiate more clearly between the terms "frequency" and "severity" of stuttering. there is no doubt that the amount of frequency of stuttering will contribute to an impression of its severity, but it would appear that frequency as such should not be regarded as an independent and accurate measure of severity. reading rate, while being an objective measure of stuttering, also correlates highly with severity ratings, and therefore indicates that it is a reliable measure which can be taken of stuttering. however, it must be pointed out that this refers to reading only. to rely on rate of speech from transcriptions of spontaneous speech would be difficult as so many variables can confound the issue, e.g. the natural manner and fluency of expression apart from the stuttering moments, the content of what is expressed. in addition, some comparison of speaking rates with normal speakers using spontaneous speech-would have to be considered. the clinical impression that stutterers are poor judges of their own speech performance was borne out by the results of this study. this implies that we, should accept that different standards would effect the assessment of stuttering behaviour as compared to the assessment made by stutterers themselves. it would be relevant for therapists to consider their own rating of stuttering and what constitutes improvement, and separately the stutterers should make their own ratings as to what improvement they feel they are making. it is clear that journal of the south african logopedic society, vol. 14, no. 1: september 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the relationships between measurements of stuttering behaviour 33 we cannot equate both forms of assessment. while there is still a great deal to learn about stuttering behaviour, there is.an indication that we can go some way now in attempting to assess aspects of: it which have a relatively good measure of reliability. . , summary •the report is concerned with the types of measurements that can be made of stuttering behaviour and their relationships to each other. a review of the different measurements that can be taken was presented and the procedure of the experiment was outlined. it was found "that a single investigator can make reliable judgements of the severity of stuttering. three separate severity ratings on the same reading passage were found to be highly correlated. these severity ratings correlated highly.with reading rate, and to a slightly less extent, but still significant, with frequency counts of the moments of stuttering. ratings on conversational speech of stutterers, and "their own ratings of severity were also considered. it was felt that the therapist, should not attempt to^equate her assessment of stuttering, behaviour and any change towards improvement with those assessments of change that the stutterer himself might make. ' opsomming . die verslag handel oor die verskillende soorte metings wat van hakkelgedrag gedoen kan word, en hul verhouding teenoor mekaar. 'n oorsig van die .verskillende metings wat gedoen kan word, word verstrek, en die prosedure wat ten grondslag van die proefneming. le, word geskets. daar is bevind dat 'n enkele navorsingswerker 'n betroubare oordeel oor die erns van hakkel kan vel. daar is bevind dat daar 'n hoe mate van korrelasie tussen drie afsonderlike ernstigheidsbeoordelings van dieselfde leesgedeelte bestaan. daar was 'n hoe korrelasie tussen hierdie ernstigheidsbeoordelings en die lees-tempo, en, in 'n mindere maar nog steeds betekenisvolle mate, die frekwensietellings op die oomblikke dat daar gehakkel is. beoordelings van konversasie-hakkelaars, en hul eie ernstigheidsbeoordeling is ook in ag geiieem. daar word gemeen dat die terapeut geen poging moet aanwend om haar eie evaluasie van hakkelgedrag en enige verandering in die rigting van verbetering gelyk te stel met die evaluasies van veranderings wat deur die hakkelaar self gedoen word nie. references 1. a r o n , m . l . ( 1 9 6 4 ) : the effects of the combination of trifluoperazine and amylobarbitone on adult stutterers. ph.d. · thesis, university of the witwatersrand, · johannesburg. 2. a r o n , m . l . ( 1 9 6 5 ) : the effects of the combination of trifluoperazine and amylobarbitone on adult stutterers. m e d i c a l p r o c e e d i n g s , 1 1 , 2 2 7 . 3. b l o o d s t e i n , o . ( 1 9 5 9 ) : · a handbook on stuttering for professional workers. national society for crippled children and adults, inc., chicago. 4. boehmler, r. m. (1958): listener responses to non-fluencies'. j. speech hearing research, i, 132. . tydskrif van die suid-afrikaanse logopediese vereniging, vol. 14, nr. 1: sept. 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 34 yrtle l . aron 5. cullinan, w. l., prather, ε. m., and williams, d . e. (1963): comparison of procedures for scaling severity of stuttering. j. s p e e c h h e a r i n g r e s e a r c h , 6, 187. 6. fairbanks, g. (1940): voice and articulation drillbook. n e w york: harper and brothers. 7. j o h n s o n , w . ( 1 9 6 1 ) : measurements of oral reading and speaking rate and disfluency of adult male and female stutterers and non-stutterers. j. s p e e c h h e a r i n g disorders, monograph supplement 7, 1. 8. johnson, w . , darley, f. l., and spriestersbach, d . c. (1963): diagnostic methods in speech pathology. n e w york: harper and row. 9. johnson, w . , and knott, j. r. (1937): the distribution of moments of stuttering in successive readings of the same material. j. s p e e c h d i s o r d e r s , 2 , 17. 10. n e w m a n , p . w . ( 1 9 6 3 ) : adaptation performances of individual stutterers: implications for research. j. speech hearing research, 3, 223. 11. q u a r r i n g t o n , b. ( 1 9 5 6 ) : cyclical variation in stuttering frequency and some related form of variation. c a n a d i a n j. p s y c h o l o g y , 10, 179. 12. s a n d e r , ε . k . ( 1 9 6 1 ) : reliability of the iowa speech disfluency test. j. s p e e c h hearing disorders, monograph supplement 7, 21. 13. s h e r m a n , d . ( 1 9 5 2 ) : clinical and experimental use of the iowa scale of severity of stuttering. j. speech hearing disorders, 17, 316. 14. s h e r m a n , d . ( 1 9 5 5 ) : reliability and utility of individual ratings of severity of audible characteristics of stuttering. j. speech hearing disorders, 20, 11. 15. sherman, d . , and lewis, d . (1951): measuring the severity of stuttering. j. speech hearing disorders, 16, 320. 16. sherman, d . , and trotter, w. d . (1956): correlation between two measures of the severity of stuttering. j. speech hearing disorders, 21, 426. 17. sherman, d . , young, m . , and gough, k. (1958): comparison of three measures of the severity of stuttering. proceedings of the iowa academy of science, 65, 381. 18. thurstone, l. l. (1959): the measurement of values. chicago: t h e university of chicago press. 19. van riper, c. (1962): personal communication. 20. van riper, c., and hull, c. j. (1934): the quantitative measurement of the effect of certain situations on stuttering. c h a p t e r 8, i n stuttering in children and adults. ed., johnson, w., minneapolis: university of minnesota press, 1955. 21. w i l l i a m s , d . e . , a n d k e n t , l . r. ( 1 9 5 8 ) : listeners evaluations of speech interruptions. j. speech hearing research, 1, 124. 22. williams, d . e., wark, m . , and minifie, f. d . (1963): ratings of stuttering by audio, visual, and audiovisual cues. j. s p e e c h a n d h e a r i n g r e s e a r c h , 6, 9 1 . 2 3 . y o u n g , m . a . ( 1 9 6 1 ) : predicting ratings of severity of stuttering. j. s p e e c h hearing disorders, monograph supplement 7, 31. journal of the south african logopedic society, vol. 14, no. 1: september 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) e journal of the south african logopedic society teaching reading to the cerebral palsied child ε. m. harrison johannesburg school and treatment centre for cerebral palsied children it is generally accepted that the normal child, from the age of six years is ready for reading, as a result of the spontaneous accumulation of informal experiences, but the cerebral palsied child, because of brain damage has usually a reduced ability to spontaneously grasp the basic essentials of learning — be it reading, writing or arithmetic. therefore, the building up of the foundations on which learning develops is a primary requirement of the greatest importance, and the teacher must plan a programme of carefully graded experiences and activities to give the child >as solid a foundation as possible. in order to be able to plan a "readiness" programme, the teacher must appreciate and fully understand the cerebral palsy problem, entailing physical handicaps, learning difficulties and emotional disturbances, all of which occur in varying degrees, as no two children are alike. an initial assessment of each child by the doctor, psychologist, speech, occupational and physio therapists is essential, so that with this initial knowledge and a still more detailed assessment gained' as the programme is carried out, special attention is paid co the problems of each individual to enable him to gain the maximum benefit at his own rate of progress, and within his capabilities. this consideration of the developmental level of the child is most important, and the stages of development in the normal child are used as a guide. thus, the period in which each child achieves "readiness" will vary, and there is no set age at which the cerebral palsied child may be said to be ready for reading. if, however, throughout the "reading readiness" programme and the reading scheme, the child is made aware of, and develops a positive attitude towards his abilities and disabilities, with emphasis on the abilities, the confidence gained should ensure that there will be a real desire to read and that his first reader will present no problems. the following are some of the many contributory factors which cause the lack of "reading readiness" in the cerebral palsied child. 1) physical handicaps. 2) lack of experience and background. 3) a seeming lack of initiative to use opportunity even when experience and background are present 4) emotional disturbances. 5) visual and auditory perception and spatial concept difficulties; tactile and kinaesthetic sensory losses; visuo-motor lack; short attention and memory span; distractibility; speech involvement and hearing loss. the reading readiness programme for the nursery and kindergarten groups respectively as this begins in the nursery group in the cerebral palsy school where the ages range from two years, often much time has to be spent in first arousing the child to an awareness of its environment, and stimulating active participation before any activity will be productive. in the nursery group and kindergarten, the objectives of the programme are to develop language and the need to perceive, comprehend, discriminate, remember, perceive relationships, reason and be able to transfer what has been learned in one situation to a similar situation, or to make necessary modifications. the activities of the kindergarten in training perception must emphasize appreciation of spatial relationships, discrimination of figure-background and accurate recall of figure outlines, and the ability to reproduce these. it is at this stage, where pictorial representation of the concrete object is developed that further individual difficulties may be found, such as the inability of the child to reproduce on paper what he sees. the programme must always be graded, augmented and intensified to meet the specific needs of each child. the following are examples of activities to develop perception in the nursery group and kindergarten. nursery group — development of perception a—visual 1.—specific concrete activities sorting blocks, buttons and sticks into boxes. colour training. montossori sense training apparatus. play with plasticine and dough, water play, sand trays, paper mache moulding. (the sense of touch developed through these activities is invaluable to the child with visual perception difficulties, as it is through touch r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society and colour that he learns to discriminate shape) threading beads — putting colours together or grouping the different shapes. 2. finger painting potatoe cutouts. puzzles. the use of these is important. cut a simple picture into pieces, having first discussed the picture with the child', and then let the child put it together again. draw the trunk of a man — the child attaches legs, arms, and ears, and puts in the nose, eyes and mouth. a house is drawn and the child puts in windows and doors, etc. β—spatial concept shallow and deep boxes — objects are taken out and put into these shallow and deep tins are filled with sand. rods of different lengths are arranged. big and small balls are used for play. instructions such as "go far away", "stand near the door", "sit together" etc. give a sense of space. c—auditory soft and 'loud music. walk like elephants — "tramp, tramp" and then like fairies, "pitter patter" — these activities to music. percussion band. the child plays with tins filled with different objects and listens as he shakes. when the teacher shakes the tin, he tries to imitate the sound and names what is in the tin. sounds made by animals and things with which the child is familiar, e.g. ear, water, drum, etc. training in sound sequence is developed by the child listening to sounds and saying which he heard first or last, helped by association with concrete objects placed first and last. for example, when dramatising a story such as the "three bears" — father's gruff voice is heard first, then mother's medium pitched voice and finally baby bear's "teeny-weeny" voice. further development of perception in the kindergarten a—visual 1. filling geometric shapes into spaces (trial and error method should be discouraged and the child should be made to feel the shapes). 2. matching shapes. for the child who finds this difficult, colour-cue is used e.g. all squares blue, circles red, etc. 3. matching shapes drawn on cards; this entails figure-background discrimination. if the child is unable to recognize a shape drawn against a background, then the "space" is coloured to help the shape stand out. 4. matching cards on which patterns made up of strokes, circles, etc. are drawn. 5. puzzles. pictures are discussed, cut up and put together again. (this develops appreciation of the whole made up of the parts). 6. letters of the alphabet assorted — the child does not know them as letters. 7. matching pairs of words and also matching similar words. β—auditory this continues to be developed through singing; listening to sounds, e.g. the motor car passing, click of a typewriter, birds singing, voices in the street. also, the child supplies missing rhyming words, and in addition the following activities are used:— 1. the child "looks, says and listens." he then sorts the pictures into groups of like sounds e.g. jam, lamb, pram, and coat, boat, goat; bee, sea, key. 2. he "looks, says and listens" and picks out the odd picture e.g. sun, run, pan; skip, bill, table. 3. listens to the words sun, sit, sell and rubs, lips, bus and then says in which group he heard the " s " first or last. c—spatial concept this is further developed in the handwork and drawing class as "writing readiness," which is an essential part of "reading readiness." directional training, making of patterns in clay, trays with plasticine, sticks, coloured wool, etc., and finally on paper, develops perception of spatial organization and the child learns to perceive form with understanding. this process of analyzing wholes into parts before putting together again, is essential for the cerebral palsied child' who cannot spontaneously reproduce on paper what he sees. it is dear that for the cerebral palsied child writing entails far more than merely developing motor patterns. thus far, the programme will have been based on concrete and semi-concrete activities in which a great variety of materials were used, the importance of which is stressed by strauss and lehtinen who maintain that materials are constructed to dramatize or concretize a process of skill cflear of everything but the basic essentials and that they provide a crutch until skill and understanding are secure (1. p.137). the child should, by the end of the kindergarten training, be organised in his approach to tasks, be able to match words (which to him are at this stage just shapes), and have developed r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society perception of sounds, and be able to recognize, recall and reproduce concrete shapes. grade i here the reading readiness programme is based on developing finer vnsual amd! auditoryory discrimination through activities which lead to a real understanding of word components. visual discrimination in the drawing and handwork lessons the child continues the directional training e.g. up, down, curve to the right, to the left, slanting down to the left; and further concepts, such as shallow, deep, tall, etc, are developed. squares, triangles, circles, diamonds, ovals, etc. are built up making the child more aware of spatial organization; part whole relationships and visual discrimination is increased. simple representations of e.g. cars, birds, bunnies, flowers, egg-cups, etc. composed of lines, curves, etc. are built up using plasticene, coloured gummed paper, feltex and are finally drawn by the child. for example, when drawing the flower — the child makes a curve to the top, right, left and bottom, makes a circle in the centre and a curved stem. the children love these activities and the following is also thoroughly enjoyed. a pattern of shapes, i.e., circles, squares, triangles, strokes, half-moons etc. is built up on the flannel board, left there for a minute or two, then removed. the child must then reproduce this pattern in his book. the importance of this with regard to retaining a mental picture for later word recognition is obvious. letters of the alphabet — to the child the letters are still merely abstract shapes — are also built up on the flannelgraph and then reproduced. auditory discrimination this is further developed by training the child to listen to first, last and middle sounds. at first, the sounds given have an association such as toot (motor-car), boom (gun), tweet (bird), to help the child remember the sequence, especially when there is an auditory perception difficulty. then abstract sounds with no association are introduced, e.g. s, br, m. other activities are: giving words beginning with the same sound; blending sounds together as " s " and " t " ; " h " and " a " ; separating the sounds when the teacher gives a "double" one as "sw." the pattern game is played but this time the teacher "says" a pattern i.e. she says "circle, square, stroke", etc., and the child draws what he heard the teacher say. the child who can now discriminate, visually and aud'itorally, with understanding and reproduce abstract symbols, is ready to relate sounds to their visual symbols — i.e. ready for reading. reading programme the children are told that they are going to make their own reading books. large unlined scrap books are used and only three or four words written on a page. unlined1 books are used as there is less figure-background confusion than in the ordinary lined books. in the initial stages of the programme only three letter-words are used. word recognition: a varied group of words with pictures are written in the books and flashcards of words and pictures made for each child are used. the words and' pictures are matched with those in the book, then without the book and finally the words are used on flashcards alone. (the use of manipulative apparatus helps to reduce distractibility; increases concentration, enables the child to proceed at his own rate and develops interest and a sense of responsibility as the child works with and looks after his own cards.) artistic bookbinders transvalia buildings 21 stiemen's & mell street braamfontein — phone 44-6584 shop 8 in melle street. how important are your i t journals of speech and hearing disorders -fr "speech" -fr notes you can have these bound in attractive volumes to suit your needs. we specialize in binding your thesis according to your design and colour schemes to insure your success. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society sound recognition. two groups of words are given and the child gives the initial sound for each group. the picture of the words e.g. sun, sit, sip, are drawn and also for run, rat, rib. picture cards are made and the child puts them in their respective "s house" and "r house" — he has to say the word himself and listen for sounds. a third and fourth group of word's are given with the " s " and " r " sounds at the end of the word and the same procedure is followed. sounds have shapes. the words are written next to the pictures in the books, and the child looks for the matching symbols in the given words, and thus discovers the symbol for the sound'. the symbol is drawn on a chart with a picture representing the sound e.g. picture of a snake with the s. the words and pictures are used in the same manner as in "word recognition" described above. the child with visual or auditory perception difficulties is helped to remember the shape of the symbol s because of the association with a picture and appreciation of the fact that the first symbol is the first sound heard. the child with no speech is able to show his ability to recognize symbiols and words by matching them with the pictures. recognition and making of shapes the child at this stage is able to recognize, recall and produce concrete known objects. now he will have to recognize, as well as recall and reproduce, abstract symbols. a concrete association must be formed, not only to help recall and reproduce the symbol, but also to recognize and recall the sound for the symbol. the following example shows how this is achieved. the child has related the sound " b " with the symbol in his reading book. the picture of a bat and a ball is associated with the symbol and the initial sound of "bat" and "ball" is b. when writing the letter, the child says "bat" first, and then he says "ball" and so draws first a straight stroke representing bat and then draws a ball. this method prevents confusion of similar letters and reversals when writing and helps recognition of letters and sound recall. word building: when the child knows the sounds used in the first few groups of words, they are used to complete words. for example, the picture of the sun is drawn and next to it -un, is written. pictures of a rat with -at and bus with bunext to the picture are also used. the missing sounds are supplied by the child. the above procedure as from "word recognition" is repeated till all the consonants are known. i have found that by the time about ten consonants have been learned the child knows vowel sounds as well, and through constantly seeing and saying the words with the vowel in the middle, they have no difficulty in filling in the missing sound when given the picture and the word. when the child can recognize a number of words, a sentence describing a picture is written in the reader, e.g. the cat sits on a box in the sun. the sentence is written on cardboard, cut up into words and the child builds it up again. word building the child now "builds" or spells the words by saying the word and writing the sounds in the sequence they are heard. with the complete understanding of sound sequence the child is able to write any three letter-word. double letter sounds are learnt in the same way as the consonants and vowels i.e. by introducing the double soung e.g. "st" at the beginning and end of the words and then the middle sounds such as "ea," "ee" etc. (words and pictures used.) the story: the child colours in a simple picture and pastes it in his reader, and tells the teacher what to write. the child then "reads" the story. (only known words are used). finally the child chooses a picture, pastes it in his book and writes his own story. he really has achieved a "reader" of his own. in conclusion, i would like to point out that in the cerebral palsy class one often finds such children, as the aphasic child, the hard-of-hearing child, etc., each of whom presents their own particular difficulties and for whom more specially modified programmes must be adapted. this programme evolved at the johannesburg school and treatment centre for cerebral palsied children is based on a long term policy of study and much trial and error. the positive results obtained have encouraged us to continue on these lines, and we hope that this article will be of help to others confronted with the problems of cerebral palsy or other fields in which the above suggestions are applicable and useful. references (1) strauss and lehtinen: "brain injured child. vol 1. with acknowledgement to the principal and management committee of the johannesburg school and treatment centre for cerebral palsied children. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'ν biologies-gefundeerde hipotese in verband met die ontstaan van hakkel i . e . u y s b.a. log (witwatersrand), m.a. (u.p.) senior lektrise: spraakheelkunde, universiteit van pretoria, pretoria. opsomming 'n kritiese evaluasie van verskeie teoriee, s o w e l as navorsingsresultate o p die gebied yan hakkel, dui o p baie l e e m t e s , veral m e t betrekking t o t die geheelb e e l d van die probleem. b e w y s w o r d gelewer dat al die verskillende teoriee alleenlik sekere fasette van die p r o b l e e m verklaar, maar nie almal nie. die grootste o n d u i d e l i k h e i d is veral gevind t e n opsigte van die aanvang van hakkel. 'n studie van sekere biologiese verskynsels, wat spraaken taalgedrag t e n grondslag le, lewer 'n m o o n t l i k e verklaring vir s o m m i g e van hierdie onbeantw o o r d e vrae. hakkel w o r d b e s k o u as 'n versteuring in ritmiese p a t r o o n v o r m i n g as 'n t e m p o r a l e verskynsel. klem w o r d veral gele o p die fisiologiese o n v e r m o e t o t t y d s b e r e k e n i n g i n die uiting van lettergrepe. dit w o r d gesien as 'n onderbreking in die ritmiese vloei van spraak as gevolg van 'n koordinasieafwyking, inteenstelling m e t onderbrekings o p die supramorfemiese vlak (wat as normale spraak aanvaar w o r d ) as gevolg van besluite in verband m e t die o n t w i k k e l i n g van sinne. die h o o p w o r d uitgespreek dat hierdie h i p o t e s e as stimulus tot eksperimente sal dien. summary a critical evaluation of different theories and research data in the field o f stuttering p o i n t s t o a lack o f k n o w l e d g e as regards m a n y of t h e salient aspects, particularly in a holistic approach t o t h e p r o b l e m . different theories a c c o u n t for o n l y certain facets of t h e p r o b l e m , but b y n o means all of t h e m . the onset of stuttering still remains a riddle. a study of certain biological p h e n o m e n a underlying speech and language behaviour c o u l d y i e l d e x p l a n a t i o n s for s o m e of the unanswered questions. stuttering is seen as a disturbance in r h y t h m i c patterning, w h i c h is a temporal p h e n o m e n o n . the physiological inability for timing syllable utterance is stressed. this is seen as an interruption in the r h y t h m i c flow of speech d u e t o a disturbance in co-ordination, whereas interruptions at t h e supramorphemic level (which are a c c e p t e d as normal speech) are due t o decision-making in the generation of sentences. the h o p e is expressed that this h y p o t h e s i s m a y serve as a stimulus for further experimentat i o n . gegewens uit kalamazoo en illinois dui aaarop dat die voorkomssyfer van hakkel oor die afgelope aantal jare drasties afneem. daar kom deesdae amper 25% minder hakkelaars onder die skoolpopulasie voor as omtrent 20 jaar gelede.14 hierdie afname kan waarskynlik toegeskryf word aan die feit dat inligting oor tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 i.c. uys die voorkoming en behandeling van hakkel vandag algemeen bekend is. hakkel word nie vandag meer as 'n slegte, vuil gewoonte beskou nie, maar eerder as 'n kliniese probleem. maar dit is nie net vir die leek wat daar vandag meer kennis en inligting hieroor beskikbaar is nie. noukeurige navorsing het daartoe gelei dat wetenskaplike teoriee vandag op navorsingsresultate gebaseer word en baie van die raaiwerk oor hakkel is reeds geelimineer. die toestand vandag onlangs het van riper (1971) 'n nuwe boek oor „the nature of stuttering"14 die lig laat sien. hierin is 'n weelde van navorsingsresultate tesame met sy eie ondervinding in verband met hakkel saamgevat. hoewel dit nog glad nie die antwoorde op die probleem is nie, lewer 'n deeglike studie van die werk tog 'n baie beter insig op in verband met die aard en probleme van hakkel. hy kom tot die gevolgtrekking dat daar vandag eintlik nog net 'n antwoord op twee vrae gelewer moet word. 1. is daar verskillende oorsake wat lei tot verskillende tipes hakkel? 2. lei die een of ander organies-fisiologiese afwyking tot die aanvang van hakkel? indien wel, is dit moontlik om die ontwikkeling van verdere sekondere simptome, neurotiese neigings ens. volgens die leerteorie te verklaar. laat ons probeer om ons kennis in verband met beide hierdie aspekte te ontleed. verskillende oorsake hoewel van riper1 5 hom nie daaraan skuldig maak nie, wil ek graag hakkelgedrag tipeer in 'n poging om verdere riglyne te skep. van riper1 4 stel 4 spore van ontwikkeling voor waar die hakkel by die aanvang, sowel as tydens die ontwikkeling, duidelik van mekaar verskil. lste spoor dit kom voor by ± 50$ van alle hakkelaars. aanvang hakkel begin op die ouderdom van 2mi 4 jaar. vlotheid het voorheen voorgekom; dit begin geleidelik; die hakkel kom periodies voor; spraakspoed is normaal; lettergreep-herhalings sonder spanning of tremor kom voor; hakkel kom op die eerste woorde van die sin en op funksiewoorde voor; hy is onbewus van en nie gefrustreerd oor die onvlotheid nie. ontwikkeling herhalings neem toe; spoed word onreelmatig; herhalings gaan oor in verlengings; spanning en tremor kom voor en dit lei tot frustrasie, vrees en vermyding. dit klink asof hierdie tipe ooreenstem met die'idee van aangeleerde gedrag, waar die kind moontlik gediagnoseer is en die semantogeniese invloede gelei het tot die ontwikkeling van hakkel (verg. johnson). journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η biologies-gefundeerde hipotese in verband met die ontstaan van hakkel 49 2de spoor dit omvat ± 25% van alle hakkelaars. aanvang hakkel begin laat; vlotheid kom nooit voor nie; dit begin geleidelik; artikulasie is swak; spraakspoed is vinnig (uitbarstings); hersiening, gapings en herhalings kom voor sonder tremor of spanning; hakkel kom meestal op eerste woorde, inhoudswoorde en langwoorde deur die hele sin voor; die patroon varieer; die spraak is gefragmenteer selfs tydens vlot periodes; geen bewustheid, frustrasie of vrees kom voor nie. ontwikkeling spraakspoed neem toe; min verandering tree in; duur van onvlotheid neem toe; soms kom vrees vir situasies voor (nie vir woorde en klanke nie); oog-kontak is goed; hy steek nie die hakkel weg nie; hakkel bly primer herhalend; spraak is ongeorganiseerd. hierdie tipe stem baie duidelik ooreen met stamel omdat die idee van ongeorganiseerdheid, tesame met vinnige herhalende tipe spraak waarvan die spreker redelik onbewus bly, sinvol gekoppel kan word aan die beeld van die stamelaar. dit kan ook verklaar waarom daar nie tydens die ontwikkeling 'n merkbare toename in die erns van die probleem is nie (verg. weiss16). 3de spoor dit omvat ± \2% van alle hakkelaars. aanvang die hakkel kan op enige stadium na die aanname van taal begin; vlotheid het voorheen voorgekom; begin dikwels na 'n skielike trouma; artikulasie is normaal; spraakspoed is stadig en versigtig; stemlose verlengings kom voor; laringeale afbrekings kom voor; daar is baie spanning en tremors; die patroon bly konstant; normale spraak is vlot; hy is baie bewus van die probleem, is bevrees en gefrustreerd. ontwikkeling toename in frekwensie en frustrasie; begin spraakpogings oor; fiksasies van orale strukture en verlengings en bewing kom voor; worstelreaksies word waargeneem; spraakspoed neem af;hy weier om te praat en vermy; oogkontak is swak; stemlose toniese afbrekings met veelvuldige sluitings kom voor. die simptomatologiese beeld vanaf die aanvang by hierdie tipe herinner baie aan die een of ander organiese probleem, meer spesifiek 'n moontlike betrokkenheid van die ekstrapiramidale bane (insluitend die corpus striatum) wat kan lei tot 'n vorm van disartrie. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 i.c. uys 4de spoor omvat ±12% van alle hakkelaars. aanvang hakkel begin laat gewoonlik na 4 jaar; vlotheid het voorheen voorgekom; die aanvang is skielik; artikulasie is normaal; spanning en tremor kom voor; hy hakkel op inhoudswoorde; die patroon is konstant; hy is bewus van die probleem, maar nie gefrustreerd nie. ontwikkeling hakkel neem toe; dit is monosimptomaties en simbolies; woordvrese kom nie voor nie en vermyding is min; hy is baie bewus van die probleem, maar hakkel openlik; oogkontak bly goed en hy praat baie; patroon bly oor die algemeen baie stabiel. „they watch you as you react to it. and they are rarely emotional about i t " . 1 4 as gevolg van die kenmerkende laat aanvang, en die onderskeidende simptome, veral die feit dat hy bewus is van, maar nie negatief op die simptome reageer nie, klink dit na 'n tipe hakkel wat sal inpas by 'n neurotiese teorie. (verg. barbara1). aangesien die idee van hierdie 4 spore van ontwikkeling gegrond is op 'n deeglike studie van talle hakkelaars oor baie jare, is dit aanvaarbaar. die groot leemte van 'n teorie gebaseer op verskillende oorsake van verskillende tipes hakkel, le egter opgesluit in die gebrek aan verklaring van alle verskillende fasette van die hakkelprobleem. ons kan egter nie een van die teoriee summier verwerp nie, omdat daar, wat sekere aspekte betref, 'n waardevolle bydrae deur elk gelewer is. 'nevaluasie van die teoriee ν. α. v. navorsingsresultate hakkel as aangeleerde gedrag hakkel word vandag deur meeste gedragsielkundiges soos volg gesien:7 die oorspronklike hakkelmomente word geproduseer deur 'n onaangename emosionele ontwrigting en die hakkel verteenwoordig onderbrekings en disorganisasie van normale spraak.6 dit vind plaas a.g.v. klassieke kondisionering (respondent learning) wat verbind kan word met die werking van die outonome senuweestelsel. operante kondisionering tree in werking (deur die sentrale senuweestelsel) in die ontwikkeling van sekondere simptome. daar is egter 'n paar stellings in verband met hakkel as aangeleerde gedrag wat nadere beskouing verg: 1. hakkel ontstaan onder toestande van negatiewe emosie. hoewel navorsingsresultate nog onvoldoende is, bewys studies dat dit baie selde die geval is. 2. negatiewe emosie vererger normale onvlotheid. navorsingsresultate is tot so 'n mate weersprekend dat geen geldige afleidings daarop gebaseer kan word nie. journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η biologies-gefundeerde hipotese in verband met die ontstaan van hakkel 51 3. hakkel kan gekoppel word aan voorafgaande stimuli. ons kan alleenlik aflei dat verwagting in die geval van volwassenes wel 'n rol speel.1 7 4. straf kan hakkel laat afneem of toeneem. redelik uitvoerige navorsing bewys dat beide moontlik is. 5. positiewe versterking laat hakkel toeneem. daar is baie min bewyse om hierdie hipotese te ondersteun. 6. negatiewe versterking laat hakkel toeneem. dit is wel bewys. 7. hakkel is selfversterkend. die vreesvermindering wat voorkom tydens hakkel, versterk moontlik die gedrag, maar geen besliste bewyse is nog gevind nie. hoewel ons dus op hierdie stadium kan se dat klassieke en operante kondisionering sekere aspekte van hakkelgedrag verklaar, vereis die kerngedrag (veral die aanvang) 'n ander verduideliking. die leerteorie verklaar redelik bevredigend die ontwikkeling van hakkel, maar glad nie die ontstaan nie. hakkel as die sekondere gevolg van stamel volgens weiss (1964) is stamel „ . . . . the mother lode of stuttering".16 hierdie teorie word gegrond op twee verskynsels. i. in meeste gevalle word hakkel voorafgegaan deur 'n periode van maklike herhalings, verlengings, huiwerings en selfkorreksies. wanneer dit gepaardgaan met 'n sterk aanduiding van oorerwing, beskou freund8 dit as stamel. dit spruit daaruit dat die dryfkrag tot spraak groter is as die kapasiteit tot ekspressie. ii. nadat die hakkelaar gerehabiliteer is, bly daar nog sekere onvlothede in sy spraak oor, wat weer eens ooreenstem met en dus beskou kan word as stamel. een van die sterkste punte van hierdie teorie is die feit dat stromsta bewys het dat die normale onvlothede van die jong kind wat later begin hakkel het, wel verskil van die kind wat nie in 'n hakkelaar ontwikkel het nie. die moontlikheid bestaan dus wel dat daardie simptome as stamel beskou kan word. ongelukkig verklaar hierdie teorie nie die ontstaan van alle vorms van hakkel nie.8 nog 'n leemte is dat hierdie teorie 'n sekere persoonlikheidstipe aanvaar wat daartoe sal lei dat sekere stamelaars in hakkelaars sal verander.8,9 navorsingsbewyse is nog nodig voor hierdie hipotese aanvaar kan word. hakkel as 'n organiese afwyking daar is iets in die indruk wat die hakkelaar skep wat mens laat wonder of daar nie tog die een of ander organiese probleem is nie. navorsing i.v.m. lateraliteit, genetiese faktore, die kardiovaskulere stelsel, metabolisme, die senuweestelsel ens., lewer in so 'n mate positiewe resultate op dat dit lyk "asof 'n organiese teorie tog nie verwerp kan word nie. onlangse navorsing dui veral op die volgende moontlikhede: 1. dat onvolledige serebrale dominansie of bilaterale spraakverteenwoordiging tydskrif van die suid-afrikaanse vereniging vir spraak en cehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 i.c. uys in verband staan met hakkel (verwys jones2); 2. dat hakkel wel gekoppel kan word aan 'n familiele probleem; 3. dat daar 'n verband is tussen hakkel en allergiese toestande; 4. dat asemhalingsversteurings en spraakspoedversteurings nie net die gevolg van hakkel is nie; 5. dat daar aanduidings van 'n minimale versteuring in die sentrale senuweestelsel by hakkel teenwoordig is. die grootste leemte op hierdie gebied is egter myns insiens die feit dat 'n massa gegewens oor beperkte aspekte van die omvattende probleem ons visie in verband met die totale beeld vertroebel. in teenstelling hiermee is dit egter weer moontlik om volgens die neurokubernetika baie van die ander teoriee te omskryf en te verklaar. so bv. kan sheeh a n 1 2 se teorie i.v.m. die toenaderingsen vermydingsdryfkragte verklaar word volgens elektromiografiese bevindings i.v.m. die ooreenstemming van bewegingsfases en spierspanning. 'nbiologiese grondslag in 'n poging om 'n organies-fisiologiese basis vir die aanvang en kerngedrag van hakkel te soek, is dit miskien sinvol om te begin by 'n hipotetiese teorie wat op grond van bekende biologiese feite verdedigbaar is. as uitgangspunt kan die volgende hipotese gestel word: dat hakkel primer 'n afwyking in die temporale aspekte van spraak is a.g.v. 'n biologiese onvermoe om die motoriese opeenvolging van gegewe klanke, lettergrepe of woorde op die aanvaarde of vereiste momente in tyd te bemeester. motivering en verdediging die voordeel van 'n definisie van hakkelgedrag is, dat 1. die basiese aard van die probleem waargeneem kan word; 2. die aantal afbrekings getel kan word om die erns vas te stel; 3. die gedrag wat gemodifiseer moet word, vasgepen kan word. dit is aanvaarbaar dat daar graadverskille bestaan tussen die onvlotheid van nie-hakkelaars en hakkelaars. navorsingsresultate dui op die volgende:14·2 1. hakkelaars toon meer intrawoord-onvlothede. 2. hakkelaars toon meer verlengings van klanke en herhalings van lettergrepe en woorde. / 3. van alle onvlothede is woorddeel-herhalings makliker diagnoseerbaar as hakkel, terwyl invoegings, hersienings en frase-herhalings eerder as normaal beskou word. ' • 4. die erns van die hakkel word bepaal deur hoeveelheid a. lettergreepof klankherhalings; ' b. klankverlengings; c. gebreekte woorde; d. ongewone klem of spanning. journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η biologies-gefundeerde hipotese in verband met die ontstaan van hakkel 53 na aanleiding van bg. bevindings definieer van riper (1971) hakkel as volg: a stuttering behavior consists of a word improperly patterned in time and the speaker's reaction thereto". 1 4 wanneer 'n hakkelspasma voorkom, word die temporale eenheid van die motoriese patroon verbreek as gevolg van tydsdistorsies in die komponente klanke of lettergrepe waaruit die woord bestaan, bv. herhalings, verlengings, gapings en/of invoegings van ander ontoepaslike gedrag. spraak word beide motories en akoesties in tyd gerangskik die bewegings, klanke en lettergrepe moet in 'n voorgeskrewe volgorde voorkom. wanneer hierdie opeenvolging in spraakuiting merkbaar verbreek word, en dit as onaanvaarbaar bestempel word, kan dit gese word dat die persoon hakkel. hakkel is dus 'n afwyking in die tydsberekening en -besteding. hierby is betrokke 'n temporale verbreking van die gelyktydige en opeenvolgende programmerings van spierbewegings wat 'n voorvereiste is vir die produksie van of een van die woord se geintegreerde klanke, of een van die lettergrepe, of die presiese koppeling van klanke en lettergrepe waaruit die spesifieke motoriese patroon bestaan. dit is in werklikheid die kerngedrag in hakkel. dit is egter nog nodig om ter verdediging van hierdie stellings die volgende vas te stel: 1. die hoeveelheid temporale verbreking; 2. die strukture daarby betrokke; 3. die oorsprong van die asinchronie. alle gedrag is 'n integrale deel van die mens se konstitusie; dit is 'n integrale deel van die organiese geheel; dit is verwant aan struktuur en funksie, waar die een die ekspressie van die ander is. gedrag het dieselfde geskiedenis en oorsprong as bv. liggaamsvorm en fisiologiese funksies. met verwysing na die werke van luria,1 1 om maar een te noem, kan ons aanvaar dat gedrag (en hier meer spesifiek spraak en motoriese koordinasie) gereguleer word deur 'n sentrale beheermeganisme. die vloeiende uitvoering van enige beweging vereis sinergistiese interaksie van 'n aansienlike hoeveelheid spiere. oor die algemeen produseer 'n mens ± 220 lettergrepe per minuut (huiwerings en pouses ingeslote). dit is dus aanneemlik dat van 10 000-15 000 neuromuskulere veranderinge per minuut kan plaasvind. die kwessie van tydsberekening en -besteding in spraakgedrag mag nie onderskat word nie. eksperimente het bewys dat waar 'n melodie as stimulus aangebied word, variasies in toonhoogte, luidheid en kwaliteit geelimineer kan word sonder om herkenning te laat skade ly. die melodie word alleenlik onherkenbaar wanneer die interne temporale verhoudings vernietig word. die essensiele aard van 'n tydspatroon is 'n onderliggende pols of slag d.i. ritme. die ritme onderliggend aan spraak'blyk gebaseer te wees op ritmiese wisselings tussen stadiums of toestande. so bv. is daar stadiums van inisiasie en uitvoering van motoriese patrone (siklusse van aktivering en inhibisie). navorsing dui daarop dat hierdie tipe spraakpatroonvorming in tyd gebaseer is op 'n onderliggende ritmiese metriek: (volgens van riper 1 4 is hierdie navorsingresultate van belang) tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 i.c. uys 1. stetson beskou die lettergreep as die ware basiese eenheid van spraak. dit bepaal in 'n groot mate die spraakritme. die fisiologiese korrelaat is die asempols. hy vind dat, aangesien meeste lettergrepe uit 'n vokaalkern met konsonantgrense of stilte bestaan, die konsonante die lugvloei vertraag of stop. dit veroorsaak hindernisse in die vloeiende sametrekking van die torakswande. na aanleiding hiervan is toe vasgestel dat die asempolse rondom ± 6 per sekonde sentreer. 2. hudgins e.a. vind dat die relatiewe spoed van artikulasiebewegings vir die uitspraak van onsin-lettergrepe soos „ta-ta-ta" sentreer romdom 5,5-7,5 per sekonde. 3. lenneberg vind dat selfs sekere denkprosesse hiermee ooreenstem. wanneer mens in die gedagte so vinnig as moontlik tel, kan 'n spoed van omtrent 6 per sekonde gehandhaaf word. 4. brazier het onlangs interessante bevindings i.v.m. e.e.g.-resultate gepubliseer. hy vind dat daar oor die temporoparietal gedeeltes 'n basiese ritme van 7 siklusse per sekonde voorkom. hy bemerk dat kinders nie spraak en taal aanleer voordat 'n sekere mate van elektrofisiologiese rypheid ontwikkel het nie. hy definieer dit in terme van 'n toename in die frekwensie van hierdie dominante ritme wat met ouderdom vasgestel word. 5. molina e.a. merk op dat met elektriese stimulasie van die tailamus, spraak versnel kan word. hulle vind dat die vinnigste wat die persoon kan praat (in hierdie geval tel) ± 170 millisekondes per telling is. dit stem ooreen met ± 6 per sekonde. 6. black vind in verband met die lee-effek dat daar 'n sekere kritiese vertraging is wat maksimale spraakontwrigting meebring, nl. 2/11 sek., of anders gestel, ±1/6 van 'n sekonde. 4 , 1 3 7. cherry en taylor het in eksperimente met digotiese gehoor ook interessante bevindings gemaak. persone is gevra om sinne te herhaal nadat hulle dit gehoor het. die sein is toe reelmatig tussen die linkeren regteroor gewissel. hulle vind dat indien die oorskakelingspoed redelik stadig is, die persoon genoeg inligting links en regs ontvang om die sin met gemak te herhaal. wanneer die oorskakelingspoed te vinnig is, maak die persoon staat op die dominante oor om sodoende die stimulus van die nie-dominante kant in te vul. hulle beskou die kritiese oorskakelingspoed, wat spraakbegrip en -weergawe die meeste belemmer, as een keer elke 1/6 sekonde. hulle lei dus af dat 'n spraaksein die meeste deur hierdie spoed afgetakel word. 1 0 met inagneming van bogenoemde navorsingsresultate kan die hipotese dus gestel word dat temporale patrone vir spraak, waarop neuromuskulere outomatismes gebaseer is, 'n fisiologiese ritme van veranderinge van toestande openbaar nl. siklusse van ± 6 per sekonde. ritme en hakkel heelwat navorsing is al gedoen in verband met ritme en hakkel, waar 'n positiewe verband vasgestel kon word. journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η biologies-gefundeerde hipotese in verband met die ontstaan van hakkel 55 die ritme-effek dit is bewys dat die invoering van 'n definitiewe ritme hakkel verhoed of onderdruk, bv. spraak saam met die tik van 'n metronoom. resultate dui daarop dat 'n onreelmatige tik nie die effek het om vlotheid te versterk nie. hoewel ek geen definitiewe aanduidings in die literatuur kon vind nie, behoort dit interessant te wees om te weet waiter metronoomspoed vlotheid maksimaal sal stimuleer. indien in ag geneem word dat hierdie tipe stimulasie tydsberekening van motoriese patrone fasiliteer, kan dit nie summier verwerp word as 'n afleidingsmeganisme nie. van riper dui tereg daarop dat oordrag na gebruik van hierdie tegniek swak is, omdat spraak nie reelmatig ritmies is nie. faktore soos emosie, kommunikasietoestande ens. sal 'n invloed op ritmespoed uitoefen. tydsberekeningsmeganismes in hakkel kliniese waarneming bewys dat tydsberekening 'n belangrike faktor is in die voorkoms van hakkel. so bv.'belnvloed tydsdruk die hakkelaar se spraak. verskeie van die hakkelaar se simptome kan geinterpreteer word as soekende gedrag — gedrag wat daarop gerig is om die regte tydsberekening vir die uiting van 'n woord te bewerkstellig. wanneer sekondere simptome soos kopruk, spiersametrekkings ens. ondersoek word, sal gevind word dat dit ballistiese bewegings is wat die ontsnapping uit 'n toestand van fiksasie bewerkstellig. weer eens is met elektromiografiese navorsing gevind dat tydsberekening 'n belangrike rol speel.1 4 alleenlik wanneer hierdie skielike beweging uit fase is met die tremor, sal ontsnapping moontlik wees. terapeutiese tydsberekeningsmetodes verskeie metodes wat al met sukses aangewend is in terapie, kan beskou word as metodes waardeur die hakkelaar gehelp word met tydsberekening vir sy spraakpogings. hier kan genoem word, froeschels se koumetode, travis en bryngelson se metode waardeur die hakkelaar aangemoedig word om te praat terwyl hy skryf en selfs johnson se bonsmetode. koorlees en skaduspraak wanneer die terapeut en die hakkelaar saam lees dien die terapeut se spraakuiting as bykomende tydsein waardeur tydsberekening in die geval van die hakkelaar se uiting gefasiliteer sal word. min of meer dieselfde proses vind plaas in die geval van skaduspraak waar die terapeut eers die woord se en die hakkelaar dit dan vlot herhaal. hy het weer eens vooraf 'n voorbeeld van tydsberekening en spraakritme gekry. 5 · 1 4 sang nadoleczny, johnson e.a. vind dat minder as 10% hakkelaars onvlot is tydens sang. wingate maak die stelling dat, in teenstelling met metronoomspraak, dit nie die gereeldheid van ritmiese poise in sang is wat tot vlotheid lei nie, maar eerder 'n faktor betrokke by tydsberekening en intonasie. ons weet ook dat daar 'n baie noue verwantskap tussen intonasiekontoere en spraakritme bestaan.1 4 tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 i.c. uys adaptasie agnello vind dat hakkelaars in die besonder probleme ondervind met die oorgange wat nodig is in die uiting van snelseers (tongue twisters). in verband hiermee merk wingate op dat by die herhaalde lees van dieselfde stuk, die hakkelaar 'n verbetering toon in die tydsberekening vir motoriese koordinasiepatrone. ter bevestiging van hierdie stelling, vind besozzi en adams3dat die adaptasie-effek duideliker waarneembaar is wanneer die persoon die stuk elke keer hardop lees. adaptasie neem af wanneer stillees soms toegelaat word. neurologiese ritme lindsley en stromsta1 4, vind dat bilaterale e.e.g.-opnames van nie-hakkelaars toon 'n groter mate van gesinchroniseerdheid as die van hakkelaars. elektromiografiese studies deur travis14 dui weer aan dat aksiepotensiale van die maseterspiere bilaterale wanverhoudirigs in aankomstye tydens hakkel toon, wat nie voorkom tydens vlot spraak nie. studies deur chevrie-muller lewer ook bewys van asinchronie in stemlipfunksie by hakkelaars.14 hoewel hierdie studies nog nie afdoende bewyse van al die verskillende fasette lewer nie, mag die aanduidings daaruit verkry nie onderskat word nie. afleiding om terug te keer tot van riper 1 4 se definisie van hakkel, m.b.t. „ a word improperly patterned in time ".is daar sekere feite aan die lig gebring wat daarop dui dat dit eerder 'n geval is van „ . . . a syllable improperly patterned in time " wanneer verwys word na studies i.v.m. die diagnose van hakkel deur luisteraars, is dit duidelik dat die sterkste gereageer word op verbreking van die lettergreep. „not all of the interruptions to the forward flow of speech are signs of stuttering". „ of all the types of disfluency, part word repetitions are more likely to be classified by listeners as 'stuttering' and that certain other kinds of disfluency, most notably perhaps interjections, revisions, and phrase repetitions, are more commonly considered as 'normal' disfluencies". 'n verklaring hiervoor kan gevind word in 'n studie van die aanname van spraak en taal by die kind, normale onvlotheid en die aanvang van hakkel. volgens van riper 1 4 leer die kind woorde as motoriese eenheidspatrone. dit , is miskien meer korrek om te se dat die kind spraak op die morfemiese vlak as eenheidspatrone aanneem. elke opeenvolgende benadering word gemodifiseer tot die produk kommunikatief aanvaarbaar is, m.a.w., bekende motoriese patrone word omvorm en gefatsoeneer (shaped) en dit vereis terugvoering. hierdie patrone word dan gestabiliseer, afhangende van oefening, terugvoering en die kompleksiteit van die koordinasie. van riper 1 4 meen dat stabiliteit in 'n hierargiese volgorde verdeel kan word nl. die. klankvlak, lettergreepvlak, woordvlak en sinvlak, waar die klankvlak die meeste stabiel sal wees en die sinvlak die minste stabiel. journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η biologies-gefundeerde hipotese in verband met die ontstaan van hakkel 57 weer eens kan daarop gedui word dat die morfemiese vlak meer stabiel sal wees as die supramorfemiese vlak. meeste woorde val buite die grense van die morfemiese vlak. dus kan meeste woorde ook met reg beskou word as supramorfemiese strukture, tesame met die frase en die sin, omdat dit gedurig gegenereer word. in die normale onvlotheidsperiode kom afbrekings op die supramorfemiese vlak dikwels voor. hierdie ongeorganiseerde vorm van spraak word meestal deur luisteraars as aanneembaar beskou in die spraak van kinders, en volwassenes, juis omdat dit 'n funksie van besluite is wat nog geneem moet word. gedisorganiseerde spraak kan herken word aan afbrekings op die morfemiese vlak, waar hierdie afbrekings 'n funksie is, nie van besluite nie, maar van temporale motoriese koordinasie. dit is juis omdat die lettergreep die basiese fisiologiese eenheid van spraak is. spanning, emosionele reaksies en tydsdruk ens., sal dus die opeenvolging van spraak verbreek op die mees basiese vlak van integrasie die morfemiese vlak, of meer spesifiek, lettergreepvlak. emosionele druk sal die asempols versteur sodat tydsberekening vir die uiting van lettergrepe sal skade ly. hierdie onderbrekings op die lettergreepvlak word waarskynlik deur meeste outoriteite as woordonderbrekings gesien, omdat dit die vloei en selfs kommunikasie van die woord aantas. ons kan egter net weer eens verwys na die stelling dat woorddeel onvlothede die vinnigste as hakkel gediagnoseer word. op enige wetenskaplike gebied word gereeld verklarings gemaak en verduidelikings gelewer i.v.m. waarneembare gebeurtenisse. hierdie verduidelikings word gegrond op 'n verwysingsraamwerk. op die gebied van hakkel is daar egter twee faktore wat verduideliking en verklaring strem. 1, 'n massa navorsing i.v.m. sekere fasette van hakkel vertroebel en strem ons siening van die geheelbeeld. 2. omdat die aanvang en oorsprong van hakkel nie tot dusver vasgepen kon word nie, is navorsers geneig om daarvan weg te skram en hulle eerder toe te le op die aangebode simptomatologiese beeld wat hom makliker tot verklaring leen. die formulering van verduidelikings het egter al dikwels as stimulus tot eksperimentering gelei. miskien kan hierdie hipotese tog bydra tot 'n beter insig in die probleem van hakkel as 'n geheel: hakkel ontstaan as gevolg van 'n biologiese onvermoe om op die morfemiese vlak motoriese patrone temporaal te bemeester. as gevolg van hierdie disorganisasie in spraak, word verskeie ander gedragsvorms omvorm en aangeleer in 'n poging tot aanpassing en kompensasie. dit volg noodwendig dat waar 'n teoretiese orientasie soveel as moontlik verwys na die totaliteit van 'n probleem, die behandeling wat daarop geskoei is, omvattender sal wees en dus 'n groter kans sal he op sukses. bibliografie 1. barbara, d.a. (1965): stuttering: a psychodynamic approach to its tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 i.c. uys understanding and treatment. thomas, springfield, 111, u.s.a. 2. beech, h.r. and fransella, f. (1968): research and experiment in stuttering. pergamon press. oxford. .3. besozzi, t.e. and adams, m.r. (1969): the influence of prosody on stuttering adaptation. j. speech and hearing research, 12, 818-824. 4. black, j.w. (1951): the effects of delayed side-tone upon vocal rate and intensity. j. speech and hearing disorders, 16, 56-60. 5. bloodstein, 0 . (1950): hypothetic conditions under which stuttering is reduced or absent. j. speech and hearing disorders, 15,142-153. 6. bluemel, c.s. (1935): stammering and allied disorders. macmillan, n.y. 7. brutten, e.j. en shoemaker, d.j. (1967): the modification of stuttering. prentice-hall inc. n.y. 8. freund, h. (1966): psychopathology and the problems of stuttering. thomas, springfield, 111. 9. freund, h. (1952): studies in the interrelationship between stuttering and cluttering. folia phoniatrica, 4,146-168. 10. lenneberg, e.h. (1967): biological foundations of language. j. wiley and sons inc., n.y. 11. luria, a.r. (1966): higher cortical functions in man. tavistock. london. 12. sheehan, j. (1958): conflict theory of stuttering, in stuttering: a symposium, j. eisenson, ed., harper, n.y. 13. stromsta, c. (1959): experimental blockage of phonation by distorted side-tone. j. speech and hearing research, 2,286-301. 14. van riper, c. (1971): the nature of stuttering. prentice-hall inc., n.y. 15. van riper, c. (1972): speech correction. 5th edition. prentice-hall inc., n.y. 16. weiss, d.a. (1964): cluttering. prentice-hall inc., n.y. 17. wischner, g.j. (1950): stuttering behavior and learning. j. speech and hearing disorders, 15,324-335. journal of the south african speech and hearing association, vol 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sajcd 133 speech-perception-in-noise and bilateral spatial abilities in adults with delayed sequential cochlear implantation i oosthuizen, d swanepoel, c van dijk   department of communication pathology, university of pretoria ilze oosthuizen   department of communication pathology, university of pretoria; callier center, school of behavioral & brain sciences, university of texas, dallas, texas, usa; ear science institute australia, subiaco, australia, and ear sciences centre, school of surgery, university of western australia, nedlands, australia de wet swanepoel   department of communication pathology, university of pretoria catherine van dijk corresponding author: d swanepoel (dewet.swanepoel@up.ac.za ) objective. to determine speech-perception-in-noise (with speech and noise spatially distinct and coincident) and bilateral spatial benefits of head-shadow effect, summation, squelch and spatial release of masking in adults with delayed sequential cochlear implants. study design. a cross-sectional one group post-test-only exploratory design was employed. eleven adults (mean age 47 years; range 21 69 years) of the pretoria cochlear implant programme (pcip) in south africa with a bilateral severe-to-profound sensorineural hearing loss were recruited. prerecorded everyday speech sentences of the central institute for the deaf (cid) were used to evaluate participants’ speech-in-noise perception at sentence level. an adaptive procedure was used to determine the signal-to-noise ratio (snr, in db) at which the participant’s speech reception threshold (srt) was achieved. specific calculations were used to estimate bilateral spatial benefit effects. results. a minimal bilateral benefit for speech-in-noise perception was observed with noise directed to the first implant (ci 1) (1.69 db) and in the speech and noise spatial listening condition (0.78 db), but was not statistically significant. the head-shadow effect at 180° was the most robust bilateral spatial benefit. an improvement in speech perception in spatially distinct speech and noise indicates the contribution of the second implant (ci 2) is greater than that of the first implant (ci 1) for bilateral spatial benefit. conclusion. bilateral benefit for delayed sequentially implanted adults is less than previously reported for simultaneous and sequentially implanted adults. delayed sequential implantation benefit seems to relate to the availability of the ear with the most favourable snr. keywords: bilateral benefit, cochlear implant, head-shadow effect, sequential implantation, speech-in-noise perception, squelch, summation s afr j cd 2012;59(1):45-52. doi:10.7196/sajcd.133 cochlear implants (cis) are widely recognised as the most successful sensory prosthetic device in the medical world (wolfe & schafer, 2010). the widespread success has led to bilateral cochlear implantation becoming accepted medical practice in clinically suitable adults and children. the recent bilateral cochlear implantation position statement underscores the importance of bilateral implantation to enhance bilateral processing benefits for users (balkany et al., 2008). the advantages of binaural hearing may include a range of benefits such as improved listening or speech recognition in quiet and in noise, localisation, directional hearing, and bilateral spatial benefits, such as head-shadow effect, summation, and squelch (litovsky et al., 2004; cochlear corporation limited, 2005; litovsky, parkinson, arcaroli & sammeth, 2006; neuman, haravon, sislian & waltzman, 2007). the head-shadow effect is the strongest and most robust bilateral benefit effect demonstrated for spatially separated speech-in-noise tests (laszig et al., 2004; litovsky et al., 2006). in implanted adults, head-shadow effects of 3 11 db have been demonstrated (gantz et al., 2002; laszig et al., 2004). improved speech understanding in noise can be attributed to a second bilateral spatial benefit effect, namely the binaural summation effect. the latter can improve speech perception scores up to 19% in quiet and up to 16% in noise (tyler et al., 2002). summation effects previously reported vary in effect sizes of up to 6 db in some users and no effect or negative effects in others (gantz et al., 2002; laszig et al., 2004; litovsky et al., 2006; wolfe et al., 2007). the squelch effect is another possible advantage of bilateral hearing through bilateral cochlear implantation. it is a modest bilateral benefit with effects up to 2 db, although some reports indicate no effect or even negative effects (gantz et al., 2002; laszig et al., 2004; litovsky et al., 2006). bilateral implantation can be divided into the following categories: (i) simultaneous implantation where both ears are implanted during the same surgical procedure; (ii) sequential implantation with inter-implant intervals between 6 and 12 months on average; and (iii) delayed sequential implantation with inter-implant intervals of more than 2 years (manrique, huarte, valdivieso & pérez, 2007; peters, litovsky, parkinson & lake, 2007). in the south african context simultaneous implantation is not yet routinely employed. of all the patients of the pretoria cochlear implant programme (pcip) only 13% have received bilateral cochlear implants (bicis), all of which were sequentially implanted. the tygerberg programme is the only programme that has three simultaneously implanted adults (a. m. u. muller, personal communication, 17 november 2010). there are several reasons why patients in the south african context receive sequential cis, among others: limited reimbursement or financial resources to fund simultaneous implantation surgery; additional risk and difficulty of extended surgical procedures; the practice of preserving one ear for future technologies; difficulty in obtaining collaboration from medical insurance providers/medical aid funds for simultaneous bilateral implantation; and extended time needed for mapping two implants at the same time, which could lead to fatigue, especially in young children (laszig et al., 2004; litovsky et al., 2006). there are limited data on bilateral benefits of delayed sequentially implanted adults in previous studies. this might suggest that this population may not benefit from bilateral processing, such as sound localisation and speech-in-noise perception. it is clear from previous studies of bilateral implantation in adults that more robust improvements in speech-in-noise perception are typical of simultaneous-implant ci users (tyler et al., 2002; cochlear corporation limited, 2005; ramsden, et al., 2005; litovsky et al., 2006). galvin and colleagues (2010) aimed to determine if adolescents (≥10 years of age) gained additional perceptual benefit from sequential bilateral cis within 12 months. the results indicated that adolescents may gain additional benefit from a second cochlear implant (ci 2) regarding bilateral perception, even if their hearing loss is congenital and it is more than 16 years since the receipt of their first cochlear implant (ci 1). tyler, dunn, witt and noble (2007) found that sequentially implanted adults received significant bilateral improvement on at least one speech-perception test compared with either implant alone. they concluded that sequential implants can be beneficial for adults even after many years of monaural use and even with very different cis. however, although ramsden et al. (2005) reported a significant bilateral benefit for speech perception in quiet and in noise for sequentially implanted adults, it was concluded that sequential implantation with long delays between resulted in poor second-ear performance for some individuals and has limited the extent of bilateral processing benefit that can be obtained by these users. litovsky et al. (2006) found that all simultaneously implanted patients showed significant bilateral processing benefit on at least one of the speech-perception-in-noise measures, and the strongest bilateral benefit was measured for the head-shadow effect. some individuals with simultaneously implanted cis showed evidence of binaural squelch and summation (litovksy et al., 2006). it is possible that early second cochlear implantation for adults with sequential cochlear implantation might allow better acquisition of bilateral processing and bilateral spatial hearing, thus leading to improved speech-perception-in-noise performance (litovsky et al., 2006). previous studies did not routinely determine which ci was the superior functioning implant (cochlear corporation limited, 2005). it would appear that delayed sequential cochlear implantation could affect the extent of the experience of bilateral processing benefit in terms of speech-in-noise perception, especially spatially coincident speech and noise signals. bilateral implantation for adults in south africa currently occurs predominantly in a delayed sequential time frame. consequently, the question is how well these delayed sequentially implanted users are able to perceive speech in noise. the main aim of this study therefore was to determine the bilateral speech-perception-in-noise benefit in a group of delayed sequentially implanted adults. the following sub-aims were identified in order to attain the main aim: • to determine the speech-perception-in-noise ability (in spatially separated and spatially coincident speech and noise listening conditions) • to calculate the bilateral spatial benefits (head-shadow effect, summation, squelch, and spatial release of masking (srm)) using abovementioned results compared with normative data. materials and methods the study objective was to assess the speech-perception-in-noise abilities (with speech and noise spatially distinct and coincident) as well as bilateral spatial benefits (head-shadow effect, summation, squelch and srm) in adults with delayed sequential cochlear implantation. this study was approved by the institutional review board before any data collection commenced. participants eleven adult patients of the pcip were recruited, with a bilateral severe-to-profound sensorineural hearing loss, sequentially implanted with systems from cochlear™ with at least 1 year of bilateral use and recently mapped and balanced in terms of loudness between the implants. ten participants’ first language was afrikaans. only one participant spoke english as first language. the participant selection criteria are provided in table 1. table 1. selection criteria for participants criterion justification clients with sequential bilateral cochlear implants (cis) all clients should have been sequentially implanted (cis implanted during separate surgeries) (lustig & wackym, 2005) as the main aim of the study is to determine the bilateral processing benefits achieved in sequentially implanted ci users type of ci: all participants should be implanted with nucleus cis from cochlear™ to date, the pretoria cochlear implant programme (pcip) only implants nucleus products. this criterion ensured uniformity of the product, thus lessening variability of the outcomes model of ci: freedom, nucleus 22 or nucleus 24 these three models are products from cochlear™, with which the clients of pcip are implanted. other types of ci models such as double array implants were not included. this helped diminish variability of the outcomes of the study duration of time since implantation: participants must already have been using their second cochlear implant (ci 2) for at least a period of 1 year   the duration of at least 1 year’s use is to ensure that the map for this implant would have been stabilised (hughes et al., 2001). furthermore, the participant must have had time to become adequately adjusted to his/her bilateral cochlear implantation status in terms of wearing and using both devices. according to the literature, adult ci users typically reach their performance plateau within 6 months to 1 year post-implantation (teoh, pisoni & miyamoto, 2004). participants’ cis were required to have been bilaterally balanced with the company’s (cochlear™) software a month before the proposed test battery for data collection it is imperative to ensure even balance of the loudness of both devices, as sounds will lateralise to the louder ear if loudness is unbalanced (cochlear corporation limited, 2005). to remove the influence of binaural loudness summation on performance as far as possible, laszig et al. (2004) suggest that loudness balancing of unilaterally and bilaterally used processor programmes/maps be required aided pure tone thresholds (air conduction) between 25 and 40 db hl and aided speech discrimination scores of ≥70% clients with aided thresholds greater than 40 db hl and aided speech discrimination scores less than 70% may be viewed as not well adapted and thus not good ci users (moore & teagle, 2002) type and degree of hearing loss (prior to implantation): participants were required to have had a bilateral severe-to-profound (71 db hl to > 90 db hl) or moderate-to-profound (41 db hl to > 90 db hl) sensorineural hearing loss (clark, 1981 in harrel, 2002) prior to the implant the participants’ type and degree of hearing loss should correspond with candidacy criteria as accepted by the pcip. these criteria are based on the selection criteria of cochlear™, where bilateral severe-to-profound or moderate-to-profound sensorineural hearing loss is stated as first criterion for adults (cochlear corporation limited, n.d.) participants were required to be clients of the pcip at the university of pretoria     this ensured uniformity among participants. it was logistically more convenient for the researcher to conduct the fieldwork at the pcip as she had access to the premises as well as to clients’ records. the relevant information was therefore easily available and obtainable language: participants should be afrikaans and/or english speaking the participants must be able to participate in the required test battery. the majority of bilaterally implanted clients of the pcip are either english or afrikaans speaking. the researcher is also only proficient in these two languages. this ensured clear communication during informed consent and the course of fieldwork ages: the participants were required to be 18 years or older the study aimed to investigate the adult population of the pcip and this criterion also ensured that informed consent could be obtained from the participants themselves hearing loss aetiology was determined from medical records. participant ages ranged from 21 to 69 years at the time of testing (mean 47 years) with age at first and second switch-on ranging from 4.6 to 61.1 years (mean 37.7 years) and 16.6 to 64.6 years (mean 43.3 years) respectively (table 2). duration between the ci 1 and ci 2’s switch-on ranged from 16 months (1 year 4 months) to 12 years (mean duration 4.3 years). the duration of bilateral implant use ranged from 24 months to 54 months (mean duration: 49 months). most participants (9/11) can be considered as late implanted with unfavourable interval periods (>2 5 years). table 2. description of research participants no. age at test (years) age at hl onset (years) likely hl aetiology ci 1 switchon age (years) ci 1 description ci 2 switchon age (years) ci 2 description ci 1 and ci 2 interval (years) duration of bici use (years) 1 59.5 5 chronic otitis media 51.8 nucleus 24 m freedom 54.1 nucleus 24 ca freedom 2.5 5.4 2 69.10 9 mumps 59.2   nucleus 24m esprit 3g 64.5   nucleus 24ca esprit 3g 5.3 5.5 3 66.8 28 progressive 61.10   freedom 24ca freedom 64.6   freedom 24ca esprit 3g 2.8 2.2 4 66.3 31 progressive 55.9   nucleus 24m freedom 61.7   freedom 24ca freedom 5.10 4.8 5 60.3 35 progressive 45.10   nucleus 22m freedom 56.4   freedom 24ca nucleus 5 10.6 3.11 6 23 0 extreme prematurity & complications 19.5   freedom 24ca nucleus 5 21.11   freedom 24ca freedom 1.4 2 7 21.10 2 meningitis 4.6   nucleus 22 freedom 16.6   nucleus 24ca freedom 12 5.4 8 54.3 13 progressive 47.7   nucleus 24 freedom 49.1   nucleus 24ca esprit 3g 1.6 5.2 9 32.6 0 genetic 23.11   nucleus 24k nucleus 5 29.6   freedom 24ca freedom 4.7 4.1 10 44.6 22 post-traumatic mva 39.8 nucleus 24ca freedom 41.4 freedom 24ca freedom 2.8 3.2 11 20.11 0 congenital 7.1 nucleus 22m esprit 3g 17 freedom 24ca freedom 9.11 3.11 hl = hearing loss; ci 1 = first cochlear implant; ci 2 = second cochlear implant; bici = bilateral cochlear implant. materials and methods an audiometric booth, certified annually, was used to provide a sound-treated environment during testing. this was to ensure accurate and reliable pure tone and speech measurements. speech and noise were presented from separate loudspeakers with an angular separation of 90° between the speakers (figures 1 3). speech was always presented from the front and noise was presented from a different loudspeaker in order to direct the noise to the participant’s right and then his/her left ear. for spatially coincident speech and noise, speech and noise were presented from a single loudspeaker in front of the participant. fig. 1. test set-up to determine speech-perception-in-noise abilities: speech and noise spatially separated with noise directed to the right ear. speech was presented from the front loudspeaker (numbered 2) and noise was presented from the loudspeaker on the participant’s right-hand side (numbered 3).   fig. 2. test set-up to determine speech-perception-in-noise abilities: speech and noise spatially separated with noise directed to the left ear. speech was presented from the front loudspeaker (numbered 3) and noise was presented from the loudspeaker on the participant’s left-hand side (numbered 2). fig. 3. test set-up to determine speech-perception-in-noise abilities: speech and noise spatially coincident. speech and noise were presented simultaneously from the loudspeaker directly in front of the participant (numbered 2). pre-recorded everyday speech sentences of the institute for the deaf (cid) were used to evaluate the participants’ speech-in-noise perception at sentence level (alpiner & mccarthy, 2000). the afrikaans translated version of these sentences, by muller and de stadler (1987) was used for the 10 afrikaans-speaking participants. before presentation of each sentence list, a calibration tone was presented in order for the researcher to monitor the volume unit (vu) meter of the audiometer to ensure that the audiometer presented the recorded speech material at the specified level (wilber, 2002).sentences were presented through the specified loudspeaker as a closed set. participants were instructed to repeat each sentence as it was presented and no feedback as to correct or incorrect response was provided. continuous speech noise was selected, and presented simultaneously with the sentences at a fixed level of 55 db hl. an adaptive procedure was used to determine the signal-to-noise ratio (snr, in db) at which the participant’s speech reception threshold (srt) was achieved, thus the level where the participant achieved at least 50% performance. in this process the first sentence was presented at 0 db snr, i.e. speech and noise presented at 55 db hl. the speech signal level of the first sentence was increased in steps of 2 db until the participant could identify the first sentence correctly, based on the number of correct keywords. subsequently, the remaining sentences were presented adaptively in a one-up, one-down method with a 2 db step size. the test result was the average snr of the last six presentation levels. the measures for spatially separated speech and noise were conducted with the noise directed to the participant’s right ear (nr), with only the ci 1 switched on, then with ci 2 switched on and finally with both implants switched on at once (bici). subsequently the noise was directed to the participant’s left ear (nl) and then together with the speech from the front loudspeaker following the same procedure as for the nr condition. thus, there were nine possible listening configurations. however, results for spatially separated speech and noise were discussed in terms of noise ipsilateral to the ci 1 and noise ipsilateral to the ci 2. to estimate the bilateral spatial benefit, i.e. the effects of head shadow, summation, squelch and srm, the following calculations were used (van deun, van wieringen & wouters, 2010): head shadow 90° – the head-shadow effect arising from a shift in the noise position of 90° – was calculated as the difference in the srt value (in db) obtained with the left/right ear in the noise from the front (nf) versus nr/nl condition. head shadow 180° – this head-shadow effect was calculated as the difference in the srt value (in db) obtained with the left/right ear in the nl/nr versus nr/nl condition when there was a 180° change in the noise position. squelch – this is the enhancement in speech perception owing to the addition of an ear with a poorer snr. it was calculated as the difference between the srt values (in db) for the left/right ear and both implants in the nr/nl condition. summation – summation is produced by binaural redundancy (also known as diotic summation), that is the difference between bilateral and better ear performance in spatially coincident speech and noise (schön, müller & helms, 2002). subsequently, summation was calculated as the difference between the srt values (in db) of the ci 1/ci 2 and bicis in the nf condition. spatial release of masking (srm) – this is the improvement in speech perception as a result of spatial separation of speech and noise when listening with both ears. hence, srm was determined as the difference in bilateral srt values (in db) in the nf versus nr or nl condition. in support of the srm effect, the benefit of adding the better snr ear was determined. this implies the improvement in speech perception resulting from the addition of an ear with a better snr. thus, the difference between the srt value for the left/right ear and the bilateral srt in the nl/nr conditions was determined. this could possibly include all of the abovementioned spatial benefits because an ear is added in a situation with spatially distinct speech and noise. quantitative methods were utilised to analyse and process data electronically by means of a statistical software package (spss) (field, 2005). descriptive comparisons were made and the mann-whitney u-test was used to draw conclusions about the sample population on a 5% level of significance. the mann-whitney u-test is a distribution-free test and was selected because of the small sample size (steyn, smit, du toit & strasheim, 2003; miller & miller, 2004). reliability and validity to increase reliability as far as possible the following steps were implemented: • each participant was contacted personally, telephonically or via electronic mail to explain the purpose of the study to them and to obtain their consent to participate. • a qualified and registered audiologist performed the measurements. • a qualified service technician was involved to verify the use of the correct equipment and test set-up. • sound level measurements of the intensity of the signals to be presented in sound field were done before commencement of the testing procedures to ensure that the signals were presented at the specific intensity for each of the tests. • a specific test set-up was used for each participant with marked places for the participant and speakers, according to recent literature (cochlear corporation limited, 2005). • the clinical audiometer that was used was calibrated to ensure accurate measurements. the calibration standard of the international standards organisation (osi) is accepted in south africa. • recorded cid sentence test material was used for the speech-in-noise tests, to further enhance reliability and to avoid the presenting variability of using live voice. furthermore, the possibility of using speech reading or lip reading by participants to support their speech perception was eliminated by the use of recorded sentence test material which increased the reliability even more. to increase internal and external validity the following strategies were employed. before the test battery was conducted, each participant’s ci was mapped and balanced to ensure optimal functioning for the testing procedures. the same audiologist conducted the same measurements for each participant. all participants received the same information regarding the purpose of the study and their role during the study, as well as identical instructions during the measurements. during the tests, participants used the programme on their processors that they use for general listening in order to obtain a reflection of their everyday functioning. as the pcip only has a small population of sequentially bilateral implanted adults, the purposive convenient sampling method and selection criteria were vigorously implemented to select a representative sample of sequentially implanted adult clients of the pcip (leedy & ormrod, 2005). results and analysis speech-in-noise perception tables 3 and 4 illustrate the snr values for ci 1, ci 2, the superior performing implant and both implants (bici) in the spatially distinct speech and noise conditions and in the spatially coincident speech and noise conditions, respectively. from table 3 it is clear that in the unilateral listening conditions a performance advantage for the ear opposite the noise source was evident in 91% (n=10/11) and 55% (n=6/11) of participants with noise directed to ci 1 and ci 2, respectively. table 4 indicates that ci 2 was the superior performing implant for speech-in-noise perception with speech and noise being coincident for the majority of participants (n=9/11). table 3. snr values for ci 1, ci 2, superior implant and bilateral implant condition in spatially separated speech and noise (n=11)   spin with noise on ci 1   spin with noise on ci 2   ci 1 ci 2 superior ci bici   ci 1 ci 2 superior ci bici 1 24.67 db 17 db ci 2 15 db*   20.33 db 27.6 db ci 1 23 db 2 29 db 28.67 db ci 2 28 db*   28.67 db 28 db ci 2 28.33 db 3 26.67 db 9.67 db ci 2 3.67 db*   21.67 db 17 db ci 2 16.33 db* 4 29 db 13 db ci 2 14.33 db   28.33 db 20.33 db ci 2 24.33 db 5 28.67 db 23 db ci 2 14.33 db*   17.67 db 24.67 db ci 1 18.33 db 6 27.33 db 26 db ci 2 22 db*   18.33 db 27.67 db ci 1 22.33 db 7 19 db 20.33 db ci 1 23 db   9 db 26 db ci 1 17.67 db 8 21.33 db 9 db ci 2 9 db   20.33 db 25.67 db ci 1 20.33 db 9 28.5 db 23.67 db ci 2 23 db*   27.33 db 26.67 db ci 2 17 db* 10 19.67 db 19 db ci 2 14.33 db*   13 db 24 db ci 1 9 db* 11 27.33 db 25.67 db ci 2 26.5 db   29 db 26.33 db ci 2 23.67 db* mean 25.56 db 19.55 db 19.43 db 17.74 db   21.24 db 24.91 db 19.73 db 20.03 db * indicates bilateral benefit achieved (thus, perceive speech at lower snr compared with superior implant).   snr = signal-to-noise ratio; ci 1 = first cochlear implant; ci 2 = second cochlear implant; spin = speech-perception-in-noise ability; bici = both cochlear implants. table 4. snr values for ci 1, ci 2, superior implant and bici in spatially coincident speech and noise (n=11) participant spin with speech and noise presented from the front   ci 1 ci 2 superior ci bici 1 20 db 18 db ci 2 17.67 db* 2 23 db 22.33 db ci 2 22.67 db 3 18.67 db 9.67 db ci 2 12.33 db 4 23 db 20 db ci 2 20.67 db 5 22 db 22.67 db ci 1 18.33 db* 6 22.67 db 22 db ci 2 22.33 db 7 18.33 db 22.67 db ci 1 20.33 db 8 20.67 db 20 db ci 2 15 db* 9 22.33 db 21.67 db ci 2 22 db 10 18.33 db 16.33 db ci 2 12.33 db* 11 23 db 20.33 db ci 2 22.33 db average 21.06 db 19.61 db 19.15 db 18.37 db * indicates bilateral benefit achieved (thus, perceive speech at lower snr compared with superior implant). snr = signal-to-noise ratio; ci 1 = first cochlear implant; ci 2 = second cochlear implant; spin = speech-perception-in-noise ability; bici = both cochlear implants. figure 4 and table 3 demonstrate that with noise directed to ci 1 and ci 2, 64% (n=7/11) and 36% (n=4/11) of participants respectively demonstrated bilateral benefit during speech perception in spatially separated speech and noise. in contrast, with noise directed to ci 2 7 participants did not show a bilateral benefit but achieved a better snr value with their superior implant only (table 3). for 4 of these 7 participants (participants 1, 5, 6 and 7) their ci 1 remained superior in comparison to their performance with bilateral implant use. an average snr value of 19.43 db and 17.74 db was achieved respectively for the best performing ci and the bilateral listening condition with noise on ci 1. an average snr of 19.73 db and 20.03 db was achieved respectively for the best performing ci and the bilateral listening condition with noise on ci 2. thus, a bilateral benefit was present only when noise was directed to ci 1 and indicated an average improvement of 1.69 db. as displayed in figure 4, 36% of participants (n=4/11) (1, 5, 8 and 10) achieved bilateral benefit when speech and noise were spatially coincident. the observation point 9 in figure 4 emphasises the significantly better performance of participant 3 with his best performing implant, which was notably better than the other participants. a significant range of bilateral benefits in terms of snr in db was evident (15 22.67 db). an average snr of 19.15 db and 18.37 db was respectively achieved for the best performing ci and the bilateral listening condition. no statistically significant bilateral benefit (p>0.05) for speech perception in spatially separated speech and noise conditions (p=0.562 for noise on ci 1 and p=0.898 for noise on ci 2) or spatially coincident speech and noise (p=0.442) was found. fig. 4. speech-in-noise perception for the superior performing implant compared with the bilateral implant condition (n=11). a bilateral benefit is achieved when the participant perceives speech at a lower speech reception (sr) value (in db) with both implants (light bars) compared with the sr value (in db) of the superior performing implant (dark bars). box plots represent the median (thick horizontal line), lower and upper quartiles (ends of boxes), minimum and maximum values (ends of whiskers) and extreme values (dark circles). bilaleral spatial benefits the spatial benefits effects sizes are listed in table 5. the median head-shadow effect at 90° (0 db for ci 1 and ci 2) did not correspond significantly (p>0.05) with the ideal range of ≥3 db (schön et al., 2002; laszig et al., 2004; litovsky et al., 2006). the median head-shadow effect at 180° for both ci 1 (4 db) and ci 2 (5 db) fell within the accepted range (≥3 db) on the 5% level of significance. the median squelch effect for both ci 1 and ci 2 (0 db and 1 db, respectively) was within the accepted range of ≤2 db (laszig et al., 2004; litovsky et al., 2006; van deun et al., 2010) on a 5% level of significance. the median summation benefits for both ci 1 (0 db) and ci 2 (2 db) added to bici in the nf condition was within the accepted value range of ≤6 db (litovsky et al., 2006; wolfe et al., 2007; eapen, buss, adunka, pillsbury & buchman, 2009; van deun et al., 2010) at the 5% level of significance. the median srm benefit values were within the accepted range of 0 to 4 db (litovsky et al., 2006; van deun et al., 2010) only when the noise was directed to ci 1 at the 5% level of significance. an asymmetry between the values for noise directed to ci 1 versus ci 2 was observed, with greater values when the noise was presented to ci 1. in addition to the srm spatial benefit the improvement in speech perception in spatially distinct speech and noise from the addition of an ear with a better snr was calculated. this was calculated as the difference between the srt value for the left/right ear and the bici srt value in the nl/nr condition (van deun et al., 2010). the average value for adding the ear with the better snr to ci 1 (thus the contribution of ci 2) (9 db) is greater than the average value when the ear with the better snr is added to ci 2 (thus the contribution of ci 1) (5 db). the contribution of ci 2 therefore seems to be greater than the contribution of ci 1 for bilateral spatial benefit. table 5. bilateral spatial benefits effects sizes participant hs 90° ci 1 hs 90° ci 2 hs 180° ci 1 hs 180° ci 2 summation: with ci 1 added summation: with ci 2 added squelch: noise on ci 1 squelch: noise on ci 2 srm: noise on ci 1 srm: noise on ci 2 snr: better ear added to ci 1 snr: better ear added to ci 2 1 0 db 1 db 4 db 11 db 0 db 2 db -3 db 2 db 3 db -5 db 10 db 5 db 2 -6 db -6 db 1 db -1 db 0 db 0 db 0 db -1 db -5 db -6 db 1 db 0 db 3 -3 db 0 db 5 db 7 db -3 db 6 db 5 db 6 db 9 db -4 db 23 db 1 db 4 -5 db 7 db 1 db 7 db 0 db 2 db 4 db -1 db 6 db -4 db 15 db -4 db 5 4 db 0 db 11 db 2 db 4 db 4 db -1 db 7 db 2 db 0 db 12 db 6 db 6 4 db -4 db 9 db 2 db 0 db 0 db -4 db 4 db 0 db 0 db 5 db 5 db 7 9 db 2 db 10 db 6 db 2 db -2 db -9 db -3 db -3 db 3 db -4 db 8 db 8 0 db 11 db 1 db 17 db 5 db 6 db 0 db 0 db 6 db -5 db 12 db 5 db 9 -5 db -2 db 1 db 3 db 0 db 0 db 10 db 1 db -4 db 5 db 6 db 10 db 10 5 db -3 db 7 db 5 db 4 db 6 db 4 db 5 db -2 db 3 db 5 db 15 db 11 -6 db -5 db -2 db 1 db -2 db 1 db 5 db -1 db -4 db -1 db 1 db 3 db median 0 db  0 db  4 db*  5 db*  0 db* 2 db* 0 db* 1 db* 0 db*  -1 db 9 db 5 db * indicates effect sizes within the stated accepted value range. hs = head shadow; ci 1 = first cochlear implant; ci 2 = second cochlear implant; srm = spatial release from masking; snr = signal-to-noise ratio.   discussion speech-in-noise perception a bilateral benefit for speech-in-noise perception was found in the current study in the condition with noise directed to ci 1, yet it was not statistically significant. the majority of participants (64%; 7/11) demonstrated benefit with an average benefit of 1.69 db across the study sample. this improvement is significantly less than previously reported for simultaneously implanted adults, with an average bilateral benefit improvement of 5 db (cochlear corporation limited, 2005). the results are however comparable with previously reported bilateral benefit for sequentially implanted young adults (≤19 years of age) of 0.49 4.8 db in spatially separated speech and noise conditions (galvin et al., 2010). with noise directed to ci 1 and noise to ci 2, 64% and 36% of participants achieved a speech-in-noise-perception bilateral benefit, respectively. this is presumably because they were better able to process the speech signal when they listened with both their implants, as the spatial separation of the speech and noise sources better enabled them to segregate the speech signal from the noise (dunn, noble, tyler, kordus, gantz & haihong, 2010). the majority of participants (91% for ci 1; 55% for ci 2) demonstrated a performance advantage for the implant closest to the speech source compared with the implant closest to the noise source in unilateral listening conditions. this is known as a head-shadow benefit and was found to be a robust and significant benefit for speech-in-noise perception for dichotic listening conditions (listening condition where the speech and noise signals are spatially separated) in the vast majority of participants. this suggests some degree of bilateral benefit for speech-in-noise perception for the delayed sequentially implanted users in the current study (laszig et al., 2004). in the diotic listening condition (listening condition where the speech and noise signals are spatially coincident) no significant bilateral benefit for speech in noise was found among sequentially implanted adults. a bilateral benefit for speech-in-noise perception was observed in only 36% of participants (4/11) with the average benefit (0.78 db) less than the bilateral benefit of ≥1.4 db previously reported for simultaneously implanted users (tyler et al., 2002; cochlear corporation limited, 2005; ramsden et al., 2005; litvosky et al., 2006). most participants (9/11) demonstrated some bilateral speech-in-noise-perception benefit in at least one of the dichotic and/or diotic listening conditions. compared with previous studies of bilateral implantation in adults the current findings indicate that more robust improvements in speech-in-noise perception are typical of simultaneously implanted adult ci users than delayed sequentially implanted users (tyler et al., 2002; cochlear corporation limited, 2005; ramsden et al., 2005; litvosky et al., 2006). the concurrent stimulation of both peripheral and central auditory systems may lead to improved interaction between the ipsiand contralateral auditory pathways and provide more robust processing of signals (manrique et al., 2007). simultaneously implanted listeners required an snr of at least 6.8 db to achieve speech perception after 1 year, decreasing to 1.8 db after 4 years of bilateral simultaneous implantation (eapen et al., 2009). the latter snr is significantly lower than the snr values recorded for delayed sequentially implanted adults in this study (average snr: 18.83 db) despite most participants (6/11) having had bilateral experience of more than 4 years (table 2). the majority (9/11) of participants in the current study are delayed sequentially implanted users; the extent of bilateral benefits are limited further as a result of a lack of concurrent stimulation in auditory pathways compared with simultaneously and/or sequentially implanted adults (manrique et al., 2007). according to litovksy et al. (2006, 2009) a longer experience with bici use may be related to improvements in speech understanding in noise. a performance advantage is evident for 2 3 years after implantation after which a decline may be evident as users reach their performance plateau (manrique et al., 2007). since participants in the current study were evaluated at least 2 years post ci 2 they may already have reached their performance plateau phase, in contrast to benefits reported in previous studies that are typically measured between 3 and 9 months post implantation (cochlear corporation limited, 2005; galvin et al., 2010). bilateral spatial benefits the head-shadow effect at 180° was found to be the strongest and most robust bilateral spatial benefit for delayed sequentially implanted adults in this study. it was attained on at least 1 of the 2 unilateral ci comparisons for nearly all participants (9/11). furthermore, the median values of 4 db for the contribution from ci 1 and 5 db for the contribution from ci 2 to the head-shadow effect at 180° was well within the accepted range of 3 db except at 90° (laszig et al., 2004; litovsky et al., 2006; van deun et al., 2010). results suggest that the greater the spatial separation between the speech signal and the noise source, the greater the head-shadow effect for the delayed sequentially implanted adults with bilateral benefits comparable with those reported in simultaneous and sequentially implanted adults(laszig et al., 2004; litovsky et al., 2006; van deun et al., 2010). the squelch effect in general is small even in normal-hearing listeners where it is in the order of 3 db (eapen et al., 2009). it has been reported in only a few previous studies investigating bilateral benefit in adult ci users (laszig et al., 2004; eapen et al., 2009). current reports demonstrate a benefit of 2 db and even zero or negative effects in sequentially and simultaneously implanted adults (laszig et al., 2004; litovsky et al., 2006; van deun et al., 2010). the majority of participants in the current study (55% for ci 1; 64% for ci 2) also presented with a squelch effect within the accepted benefit cut-off of ≤2 db which is comparable with those previously reported for sequentially and simultaneously implanted adults (laszig et al., 2004; litovsky et al., 2006; van deun et al., 2010). four participants obtained a negative squelch effect during the condition with noise on ci 1 (participants 1, 5, 6 and 7) and when the noise was directed to ci 2 (participants 2, 4, 7 and 11). when the noise was on ci 1, however, and this implant was added in the bilateral test, the range of negative values was greater (ranging from -1 db to -9 db) than the range of negative values for when the noise was directed to ci 2 (ranging from -1 db to -3 db). this might be explained by the fact that using the ci ipsilateral to the noise source resulted in degradation of the snr at that ear (van deun et al., 2010). the decrease in snr might be more significant when the noise is near the ci 1, which was the inferior functioning ear in the condition with noise directed to the ci 1 for participants 1, 5, and 6 (van deun et al., 2010). furthermore, the negative squelch effect values obtained by participants 1, 2, 4, 5, 6, 7 and 11 may also be attributed to distorted timing cues because of the lack of integration between the processing of the two processors (ramsden et al., 2005). all participants demonstrated a significant bilateral spatial benefit (p <0.05) for summation when ci 1 and ci 2 were both used to listen in diotic conditions. the results correspond with previous reports on bilateral sequential and simultaneous adult ci users that demonstrated a summation benefit of up to 6 db and/or no effect or negative effects (litovsky et al., 2006; wolfe et al., 2007; eapen et al., 2009; van deun et al., 2010). srm values of 0 db up to 4 db for sequentially and simultaneously implanted adults were reported in previous studies (litovsky et al., 2006; van deun et al., 2010). only in the noise directed to ci 1 condition did delayed sequentially implanted users’ median srm benefit (median: 0 db) correspond significantly (p <0.05) with the reported value range in simultaneously and sequentially implanted adults. an asymmetry was however observed with the srm[b] values indicating greater values when changing the noise to the ci 1. therefore, it may be assumed that the majority of participants performed better with their ci 2 relative to their ci 1 for speech-in-noise perception. the improvement in speech perception in spatially distinct speech and noise from adding the ear with a better snr was calculated in support of the srm. the average value for adding the snr better ear to ci 1, thus the contribution of ci 2, was greater than the average value when the snr better ear is added to ci 2 (thus the contribution of ci 1). therefore, this may further denote the superior contribution of ci 2 for bilateral benefit during speech perception in spatially separated speech and noise for the delayed sequentially implanted adults in this study. conclusion a bilateral benefit for speech-perception-in-noise abilities was noted in delayed sequentially implanted adults. however, statistically this was not significant. the delayed sequentially implanted users’ head-shadow effect at 180°, squelch effect, and summation effect for both ci 1 and ci 2 corresponded significantly (p<0.05) with previously reported cut-off normative values for bilateral spatial benefits in simultaneously and sequentially implanted adults. delayed sequentially implanted adults may achieve some bilateral benefit even after many years of unilateral implant use. yet, the extent of the bilateral benefit is less robust than reported for simultaneous and/or sequentially implanted adults (tyler et al., 2002; cochlear corporation limited, 2005; ramsden et al., 2005; litovsky et al., 2006). most participants (9/11) attained some bilateral speech-in-noise-perception benefit in at least one of the dichotic and/or diotic listening conditions. this underscores the importance of understanding the extent of these abilities, as they play an essential role in the rehabilitation of delayed sequential ci users. a key benefit of delayed sequential bilateral implantation appears to be related to the advantageous aspect of having hearing on both sides so that the ear with the more favourable environmental snr is always available. outcomes for these delayed sequentially implanted adults provide an indication of the bilateral benefit which may still be attainable after the official cut-off interval of more than 2 years for the ci 2 is exceeded.   references alpiner, j. g., & mccarthy, p. a. 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(1987). cid sinne afrikaanse vertaling. unpublished. university of stellenbosch, cape town, south africa. neuman, a. c., haravon, a., sislian, n., & waltzman, s. b. (2007). sound-direction identification with bilateral cochlear implants. ear and hearing, 28(1), 73-82. doi:10.1097/01.aud.0000249910.80803.b9 peters, b. j., litovsky, r., parkinson, a., & lake, j. (2007). importance of age and postimplantation experience on speech perception measures in children with sequential bilateral cochlear implants. otology & neurotology, 28, 649-657. doi:10.1097/01.mao.0000281807.89938.60 ramsden, r., greenham, p., o’driscoll, m., mawman, d., proops, d., craddock, l., et al. (2005). evaluation of bilaterally implanted adult subjects with the nucleus 24 cochlear implant system. otology & neurotology, 25(6), 988-998. doi:10.1097/01.mao.0000185075.58199.22 schön, f., müller, j., & helms, j. (2002). speech reception thresholds obtained in a symmetrical four-loudspeaker arrangement from bilateral users of med-el cochlear implants. otology & neurotology, 23, 710-714. doi:10.1097/00129492-200209000-00018 steyn, a. g. w., smit, c. f., du toit, s. h. c., & strasheim, c. (2003). modern statistics in practice. pretoria: van schaik. teoh, s. w., pisoni, d. b., & miyamoto, r. t. (2004). cochlear implantation in adults with prelingual deafness. part 1. clinical results. the laryngoscope, 114(9), 1536-1540. doi:10.1097/00005537-200409000-00006 tyler, r. s., dunn, c. c., witt, s. a., & noble, w. g. (2007). speech perception and localization with adults with bilateral sequential cochlear implants. ear and hearing, 28(2) supplement, 86 90. doi:10.1097/aud.0b013e31803153e2 tyler, r. s., gantz, b. j., rubinstein, j. t. wilson b. s., parkinson a. j., wolaver a., preece j. p., witt s., lowder m. w. (2002). three-month results with bilateral cochlear implants. ear and hearing, 23(1) supplement, 80-89. doi:10.1097/00003446-200202001-00010 van deun, l., van wieringen, a., & wouters j. (2010). spatial speech perception benefits in young children with normal hearing and cochlear implants. ear and hearing, 31(5), 702-713. wilber, l. a. (2002). calibration: puretone, speech and noise signals. in j. katz (ed.), handbook of clinical audiology (5th ed., pp. 50-67). philadelphia: lippincott williams & wilkins. wolfe, j., baker, s., caraway, t., kasulis h., mears a., smith j., swim l., wood m. (2007). 1-year postactivation results for sequentially implanted bilateral cochlear implant users. otology & neurotology, 28(5), 589-596. doi:10.1097/mao.0b013e318067bd24 wolfe, j., & schafer, e. c. (2010). effects of accessory-mixing ration on performance with personal fm and cochlear implants. in: c. deconde johnson, d. e. lewis, h. e. mülder & l. m. thibodeau (eds.), achieving clear communication employing sound solutions 2008: proceedings of the first international virtual conference on fm (pp. 146-153). stäfa, switzerland: phonak ag. 63 communication intervention in an adolescent with profound cognitive impairment and autistic features ilze pansegrouw and erna alant department of communication pathology university of pretoria abstract the service delivery model currently used with a large proportion of profoundly cognitively impaired (pci) persons, results in the under-utilization of their potential and often contributes to social isolation. by providing communication and independence training the self-actualisation potential and the right to power and control, is recognised. this single case study describes the implementation of a communication intervention model with a pci adolescent. his mother was trained in the use of picture symbol task analysis as well as positive reinforcement to promote change in the adolescent's communication skills and independence. results indicated significant changes in the skills of both participants and highlighted the mother's need for support to meet the demands of change. opsomming diekenmerke van die diensleweringsmodel by 'n groot persentasie kognitief erg gestremde (keg-) persone, resulteer dikwels in die onderbenutting van hul potensiaal en vir sommige in sosiale isolasie. deur die voorsiening van kommunikasieintervensie en onafhanklikheidsopleiding word in die selfverwesenlikingspotensiaal van die keg-persoon voorsien en word sy/haar selfhandhawingsregte erken. hierdie enkelgevalstudie beskryf'n kommunikasie-intervensiemodel wat by 'n kegadolessent toegepas is. die moeder van die adolessent is in die gebruik van prentsimbooltaakanalises en positiewe versterking opgelei met die oog op verandering by die kommunikasievaardighede en onafhanklikheid van die adolessent. resultate het betekenisvolle verandering in die doelstellings van die studie aangetoon en die ondersteuningsbehoeftes van die moeder ten opsigte van die eise wat verandering meebring, is beklemtoon. key words: profound cognitive impairment (pci), communication intervention, independence training. introduction due to limited provision of services and facilities the needs of a significant proportion of cognitively impaired persons (cip) are not being met (alant & emmett, 1995). services such as speech therapy are often not accessible due to beliefs that poor progress in therapy indicates that these persons do not benefit'from such therapy (calculator, 1988a). consequently, a large percentage of cip persons reside in segregated "special-care" units where total physical care is the only form of service provided (lea, 1990). in addition, parents of those who reside at home report a lack of formal an informal societal assistance such as respite care to relieve caregiver stress (singer & irvin, 1991). the results of limited services to both parents and cip persons are far-reaching. it is known that the clinical picture of a large proportion of these persons relates to the nature of service delivery and the intervention approach (lea, 1990). the intervention approach to profound cognitive impaired (pci) persons (i.q. 20 and less) is clearly demonstrated in the categorisation of these persons as "untrainable" (grover, 1990). the term "untrainable" implies that the person does riot have the ability to benefit from education or training and is therefore dependent on total physical care (koordineringskomitee: jaar van gestremde persone, 1987). these persons represent approximately l%-2% of the cognitively handicapped population (subcommittee on mental retardation, 1987a). clinical features include the description of a high percentage of self injurious and socially unacceptable behaviour, as well as low motivation relating to the development of independence skills (sailor & guess, 1983). language and communication impairment represent the most pervasive problem of the majority of pci persons and have been linked to the high incidence of severe behavioural problems in this group of people (durandt, 1990; yoder & villarruel, 1988). due to frequent impairment in motor abilities, functional speech skills are often severely limited (sailor & guess, 1983). apart from the individual's inability to communicate, however, the inability to respond to the interaction attempts of primary caregivers often results in the gradual reduction of primary caregiver attempts to interact with the impaired person. this leads to low caregiver expectations regarding communication from the impaired person, reduced opportunities to support the development of language, communication and social skills and results in severe difficulty die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 ilze pansegrouw and erna alant in forming or participating in even the most basic social relationships (kirchener, 1991). primary caregivers often compensate and adapt to the impaired person in a way that contributes to the development of "learned helplessness" (yoder & villarruel, 1988). learned helplessness is seen in the anticipation of all needs of the impaired person and results in low demands for communication and low participation in domestic activities and household routines. these features result in reduced social environmental integration of the impaired person. one of the most important indicators of the quality of life, is the extent of a person's social integration (haring, 1991). from the above discussion the following principles of communication intervention can be formulated. these principles provide important criteria for successful intervention with pci persons: quality of life is determined by the extent to which the person is socially integrated in his daily environment. independence skills provide opportunities for active participation in daily activities and routines within the environment (haring, 1991). the quantity and quality of communication interaction between the pci person and the environment, relate closely to the communication skills of the impaired person. the pci person cannot be viewed apart from his/ her daily environment; this person is viewed as one component of the environment in which he lives and spends most of his time (gottlieb, 1988). the above implies that the term "client" comprises both the impaired person and his environment. in the following, the application of the aforementioned principles to develop a model for communication intervention with a pci person, is discussed. proposed model for intervention in this study a communication intervention model was developed to address the principles and important criteria i priority skills ψ social sub-skills independence sub-skills i i communication skills * a.d.l. all family/other environments caregivers i 4 daily environment primary caregiver i i priorities priorities and skill i i predictability psychological and security sub-skills context and responsiveness i sub-skills i i homeostasis social isolation and stress action and discourse skills related to communication and training ν programplanning key: * a.d.l. = activities of daily life * pci person = profound cognitive impaired person figure 1: client approach: communication intervention model the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) £ o i n i n u n i c a t i o n intervention in an adolescent with autistic features for intervention with pci persons. this model is presented in figure 1. figure 1 provides criteria to identify the daily environment and the primary caregiver as well as priority skills that were identified for the client. central to this model is the concept of quality of life, thus the facilitation of social interaction and the developm e n t of independence for active participation within this c o n t e x t . t h e functioning of the person is the product of int e r a c t i o n between the person and the environment ( e h r e n & lenz, 1989). figure 1 demonstrates a clear distinction between the family or other caregivers and the primary c a r e g i v e r as well as between the daily environment (where the person spends most of his time) and other environments w h i c h he might visit on occasion. the primary caregiver is identified as the person with whom the pci person has a high frequency of contact, who elicits a high frequency of communication initiations and responses from the person and with whom there exists a strong affective bond (owens & rogerson, 1988). for obvious reasons, this would be the most important starting point in intervention. figure 1 demonstrates that for the pci person, social integration, i.e., the acquisition of communication skills and becoming independent within this context, is a high priority. the extent of the person's ability to develop stable social relationships in order to achieve active social integration within the daily environment, provides and indication of the needs for support of the person. the development and maintenance of active, social integration is dependent on functional communication skills which eire prerequisites for the development and maintenance of social integration (rustin & ruhr, 1989). it follows that pci persons, who often do not develop functioned speech production skills and who do not have access to aac (augmentative and alternative communication) methods, will experience severe difficulty in forming and maintaining social relationships with others in the environment if support in the form of communication intervention is not provided. similarly, skills related to activities of daily living (activities occurring frequently and that eire essential for the maintenance of hygiene arid order within the daily environment) determine the level of independence within the daily environment (eshilian, haney & falvey, 1989). homeostasis (see figure 1) within the daily environment refers to environmental attempts which aim at creating predictability and security to maintain the existing structure and order of the environment (lund, 1986). radical change of environmental homeostasis (such as change as a result of intervention) poses a threat to environmental predictability and security and if not managed sensitively, can result in resistance to change (conti-ramsden, 1985). action and discourse routines on the other hand, refer to frequently occurring, highly predictable action or conversation events that, once they begin, unfold in the same manner each time they occur (lund, 1986). action routines thus refer to an event such as ball play where the action forms the main activity between the persons involved while discourse routines refer to an event such as greeting where the conversation forms the main activity between the persons involved. routines play an important role in the maintenance of homeostasis and are equally important to the development of social and communication skills (rowland & stremel-campbell, 1987). when looking at the primary caregiver, it can be seen in figure 1 that the psychological context, as well as skills profound cognitive impairment and 65 n r i n i ? t ° . c a ; i ! g i v e : responsiveness training are deemed priorities in this intervention model. socially constructed factors and processes are often the cause for the primary caregiver s social isolation and stress (lea, 1990) social isolation and associated stressors are found in the presence of stigmatisation and limited support services (lea 1990; helm & kozloff, 1986). limited knowledge and skill can, amongst others, result in counter productive interaction patterns such as limited primary caregiver responsiveness (calculator, 1988b). primary caregiver responsiveness is acknowledged as a key factor in the development of interaction and communication for the pci person (girolametto, greenberg & manolson, 1986). in considering responsiveness, the skills of the primary caregiver in terms of how much communication is expected of the pci person and whether utterances directed at the person are interaction and discourse orientated, are taken into account (siegel-causey & downing, 1987). it is against this background that a study was conducted to explore the applicability of the above model of communication intervention for a pci person adolescent with autistic features. specific priority skills and other skill areas were identified according to the model described in figure 1. methodology aims of the study the main aim of the study was to develop a communication intervention programme for a pci person by means of identified priority skills. the sub-aims were three-fold: firstly a pilot study was conducted to identify the needs of the subject and his mother relating to priority skills, to conduct an intervention trial and to develop relevant intervention materials. the second sub-aim was to implement the programme that was developed by describing the communication of the mother and her skills at training the subject and to describe the communication and independence at performing action routines, of the subject. the third sub-aim was to describe the results of identified priority skills of the subject and his mother during the six week intervention period as well as the effect of the withdrawal of intervention during week six. research design a quasi-experimental single case study with a multiple baseline (aba) design with withdrawal was selected for use in this study. the multiple baseline design for the measurement of change in behaviour patterns is well suited to execute aba comparisons (kearns, 1986). the mother-subject dyad was used whereby the behaviours of both were recorded. the research design is presented in table 1. it is known that motivation plays a significant role in the learning process and that repeated failure most often results in a decrease in motivation as well as task avoidance (haney & falvey, 1989). the "feed the cat" routine was completely unfamiliar to the subject. because both the "make the bed" and "set the table" routines were not completely unfamiliar to the subject it was decided to introduce these before the "feed the cat" routine to make sure that success was highly likely with the first two routines. a withdrawal period could establish whether changes in the subject and the mother could be attributed to the intervention. the action routines which were introduced one after suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 66 ilze pansegrouw and erna alant the other, were performed for the whole intervention period (not during withdrawal) because it is known that pci persons forget learning material which is not reinforced regularly and on a daily basis (brown, 1983). subject for the study, a fifteen (15) year old pci subject was selected from nine possible candidates at a school for autistic children in pretoria. the subject received individual speech therapy aimed at the development of speech production for the first six years in school. the production and imitation of a few single words are reported between the ages of two and four with a gradual decrease in vocalisations since then. the subject was introduced to aac at the age of eleven years. during the initial training stages, photographs of highly motivational objects and actions for the subject were used and after six months, makaton picture symbols (1985), were introduced. table 2 provides the psychiatric diagnosis of the subject, formal assessment results as well as a description of the communication and independence skills of the subject. mother the mother, who is the primary caregiver, took very good care of the subject. she has an honours degree in biochemistry but was not employed at the time of the study. other family members included the father and an older non-impaired brother. pilot study the pilot study consisted of two phases. phase one aimed at needs identification and the gathering of information on the pre-intervention state of priority skills of the subject and his mother. the information gathered during phase one, was utilised to conduct phase two of the pilot study. phase two was aimed at an intervention trial with the class teacher of the subject as well as the development of an instrument to measure change during intervention. phase 1: needs identified by the mother during phase one the mother expressed the view that increased independence in the area of a.d.l. was the subject's main need and that she would like to see the subject become independent in setting the table at home (an action table 1: research design routine which he has been exposed to at school), making his bed (inconsistent attempts at this had been made previously by mother) and feed the cat (to which he had no previous exposure). the mother expressed limited knowledge and self-confidence in training the subject. during video-recordings of two domestic action routines (loading the washing machine and unpacking the dishwasher), the subject indicated a strong need for positive reinforcement responses from his mother when he succeeded in certain parts of action routines. significant features of the mother's communication included the introduction and repetition of a limited amount of conversational topics with the subject, a high percentage of commands and low percentage of responsive utterances/actions. it was noted that due to the under-utilisation by the subject of his aac system (refer to discussion of pci subject), his communication intentions were often not understood by his mother. at the end of phase one, two priority skills, namely communication skills and skills at training the subject, were selected for the mother. for the subject, communication skills and independence at performing those action routines that were selected by his mother (setting the table, making the bed and feeding the cat), were identified. phase 2: development of action routines and preliminary testing during phase two a concrete positive reinforcement sticker chart (commercially available white, square, peeloff stickers) as well as three preliminary picture symbol task analysis charts were developed for each one of the three action routines that were identified by the mother. a task analysis is the "breaking down" (analysis) of a learning task into smaller, more manageable steps with the aim of introducing the task as a "chain" of related steps. this task analysis method is an acknowledged strategy in domestic independence training of cognitively impaired persons (sailor & guess, 1983). although three preliminary picture symbol task analysis charts were developed, only "set the table" was used in the intervention trial. the subject's teacher was asked to participate as "primary caregiver" in the trial with the aim of testing the usefulness and appropriateness of intervention materials. the teacher was trained to use the task analysis and positive reinforcement chart and the trial performance of "set the table" action routine was video recorded. for the purpose of this study only the primary caregiver week 0 1 2 3 4 5 6 1 6 13/7 13/7-20/7 20/7-27/7 27/7-3/8 3/8-10/8 10/8-17/8 17/8-22/8 22/8 set the table a bl bl bl bl a l a l β β β make the bed a bl bl bl bl a l a l β β β feed the cat a bl bl bl a l / a l β β key: a = baseline measurements β = measurements β1 = performance of action routines a l = withdrawal the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) u n i c a t i o n intervention in an adolescent with profound cognitive impairment and com"1 1 autistic features f r to discussion on proposed model for intervention) of tte subject was selected and the class teacher was only involved in the intervention trial. measurement instrument the measurement instrument was developed to record and describe information on the identified priority skills of the subject and his mother. (see introductory paragraphs 67 for the discussion and relevance of the selected priority skills). skills selected for measurement were identified by analysing each priority skill into sub-skills. the selected behaviours for observation were supplemented by observing video-recordings of week 0. sub-skills were either marked + (positive) or (negative). positive behaviours (+) were those where an increase indicated a positive change and negative (-) behaviours were those where an increase indicated a negative change. table 2: subject: psychiatric diagnosis, formal assessment results, communication and independence skills results date description 1. psychiatric diagnosis: 1979 (*c.a. 2 years) 2. formal assessment results: griffiths developmental scales: # speech and hearing: # personal/social: # mental age: # general quotient: reynell language developmental scales: # receptive: # expressive: peabody picture vocabulary test: 3. communication and independence communication and interaction: * requests: * protest: (*c.a. 15 years) 1992 1992 1992 1992 : use of picture symbols: independence: * action routines: selfcare: "profound mental retardation in a brain damaged child with a few autistic features such as spinning of objects, stereotyped, repetitive movements and handling of objects as well as poor interpersonal contact and relationships" 14 months 35 months 25 months 14 1 year 11 months below 1 year 2 years 1 month -the subject indicated a need for communication and interaction with adults but no such need with peers. during this time an increase in the use of picture symbols to request objects at home and with selected adults was reported. * he pulled people by the hand towards required object, brought object to adult or established eye contact + noises + pointing at object * pushed people and objects away or ignored requests, commands and communication of the partner * he used picture symbols only for request purposes when the aforementioned request strategies were not successful or when he was reminded to use his symbols. his picture symbol system comprised of ten symbols which were a combination of makaton (walker, 1985) and picsyms (carlson, 1985) picture symbols. he used one makaton sign (walker, 1972) namely "thank you/ please". this sign was used spontaneously to request permission (often when he was refused a request) and was also used to indicate confusion * he enjoyed domestic action routines such as unpacking the dishwasher or loading the washing machine and spontaneously participated. adult assistance was, however, required * although he was mainly independent regarding selfcare, he needed assistance with dressing, bath and tooth brushing key: * c.a. = chronological age d i e suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 68 appendix 1 provides the grouping of sub-skills of priority skills of the subject and his mother. appendix 2 provides the grid which was used to record and analyse data regarding sub-skills of the mother's skills at training the subject. the sub-skills of the other three priority skills, i.e. sub-skills of the mother's communication skills and the subskills of the independence and communication skills of the subject, were recorded onto three other grids. ilze pansegrouw and erna alant results of preliminary test results of phase two not only indicated the effectiveness of procedures but also highlighted the need for minor changes. a"theme symbol" was added as well as a separate column on the task analysis chart for positive reinforcement stickers. the mother suggested the use of "spot", "donald duck" and "ladybug" commercially available sticktable 3: picture symbol task analysis of action routines action routines size of task analysis chart sub-components of task analysis and picture symbol systems used size of symbols colour of carton to which picture symbols are attached size of coloured carton background placement of symbols on task analysis chart * other symbols in * other symbols in sequence: sequence: 1. plate (m) 1. pillow off (s) 2. placemats (s) 2. duvet off (s) 3. knife (m) 3. smooth (s) 4. fork (m) 4. pillow on (s) 5. glass (m) 5. duvet on (s) 6. serviette (s) set the table 34 χ 64 cm * theme symbol: set the table (s) 9 x 8 cm yellow 10 χ 9 cm theme symbol set the table 1. 2. 3. 4. 5. 6. make the bed 34 χ 42.2 cm * theme symbol: make the bed (s) 9 x 8 cm pink 10 χ 9 cm theme symbol make the bed 1. 2. 5. feed the cat 34 χ 64 cm * theme symbol: feed the cat (s) * other symbols in sequence: 1. bring the milk-bowl (m&s) 2. bring the food-bowl (s) 3. bring the milk (m) 4. fork (m) 5. bring the cat food (s) plus wrapper of cat food tin 6. fill with milk (s) 7. food in bowl (s) 8& 9. put down (s) 9 x 8 cm white 10 χ 9 cm theme-symbol feed the cat 2. 3. 4. 6. 8. 9. * each picture symbol was covered with desifix and attached to the chart with prestik. prestik was used so that the mother could, when necessary, change the sequence of the symbol arrangement on the chart placement inside of the kitchen cupboard door where the plates and the glasses are stored inside of the subject's clothes cupboard in his room inside o f kitchen cupboard door where the cat food is stored key: (m) = makaton (s) = self-developed symbols the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) o u n i c a t i o n intervention in an adolescent with autistic features e r s because the subject was familiar with these icons from watching animated videos and indicated enjoyment whenever he saw them. the mother of the subject was consulted regarding the size and placement inside the family home of the task analysis charts. these suggestions were combined with the results of the trial intervention to determine the features and application of training materials used in the main study. the main study training materials l&ble 3 provides information on the picture symbol task analysis charts of the three action routines and table 4 provides the features and placement of positive reinforcement stickers that were used as training material for the adolescent. more detail on the development of these materials can be obtained in pansegrouw (1994). the implementation of action routines were video recorded in the family's home during time slots when these activities would normally take place. "set the table" action routines were recorded at 19:00, "make the bed" at 07:00 and "feed the cat" at 10:30. profound cognitive impairment and 69 measurement recordings (b-phase; see table 1) were done at the same time in which these action routines would normally take place in the family's home. the first measurement video recording was made of the "set the table" routine seven days after the introduction thereof. on the same day the task analysis chart, instructions for use and training for the "make the bed" action routine was introduced to the mother. she received instructions to continue the "set the table" action routine during the following week. seven days after the "make the bed" action routine was introduced, this action routine was measured for the first time and the "set the table" routine measured for the second time. on the same day the "feed the cat" action routine was introduced to the mother. she received instructions to continue with the "set the table" and "make the bed" action routines in the following week. after seven days, the "feed the cat" action routine was measured for the first time and the "make the bed" routine for the second time. the mother received instructions to continue with the performing of the three action routines for another seven days and then to withdraw intervention for two weeks. on the last day of the two week withdrawal period, the third measurements of the "set the table" and "make the bed" as well as the second measurement of "feed the cat" routine were done. procedures data collection baseline video recordings (α-phase; see table 1) of the three action routines were done at the family home on the first day of the experiment (week 0). the mother was asked to introduce the subject to the three selected action routines one after the other. for the baseline recordings the mother received no training or task analysis charts. after the baseline recordings, on the same day, the mother received the task analysis chart, instructions for use and relevant training for the "set the table" action routine. ί training procedures and instructions training procedures included detailed instructions to the mother on how to perform and train action routines once a day. typed, as well as verbal instructions, specified utterances to be used an non-verbal guidance (such as pointing, gesture, physical guidance) to attract, direct and maintain the attention of the adolescent during the action routine. instructions to pause regularly in order to create opportunity for the subject to initiate communication and to demonstrate independence development, were given to the mother. she was also instructed to respond to all communication attempts and other noise/sounds that the subject table 4 : concrete positive reinforcement action routine 1 set the table make the bed feed the cat i sticker j spot (otto) donald duck lady bug colour of carton background yellow pink white size of stickers 2,5 χ 2,5 cm 2,5 χ 2,5 cm 2,5 χ 2,5 cm placement vertically in 4 cm column on the right side of the chart vertically in 4 cm column on the right side of the chart vertically in 4 cm column on the right side of the chart placement on task analysis chart 1 placement on task analysis chart 1 * theme symbol ~ picture symbol # positive reinforcement stickers 1 # 1 1 placement on task analysis chart 1 * theme symbol ~ picture symbol # positive reinforcement stickers placement on task analysis chart 1 * theme symbol ~ picture symbol # positive reinforcement stickers ~l 1 # 1 1 placement on task analysis chart 1 * theme symbol ~ picture symbol # positive reinforcement stickers placement on task analysis chart 1 * theme symbol ~ picture symbol # positive reinforcement stickers ~l 1 # 1 placement on task analysis chart 1 * theme symbol ~ picture symbol # positive reinforcement stickers placement on task analysis chart 1 * theme symbol ~ picture symbol # positive reinforcement stickers ~ ι ι ~i * 1 1 placement on task analysis chart 1 * theme symbol ~ picture symbol # positive reinforcement stickers die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 produced during the performance of action routines. instructions for the performance of the "set the table" action routine were as follows: mother was asked to place four each of plates, knives, forks, glasses, placemats and serviettes alongside each other in the cupboard where these objects are kept. she was asked to show the subject where the objects were placed. mother said "s. it is time now to set the table; we are going to eat." mother directed/physically cued subject to the task analysis chart. mother pointed to the theme symbol and said: "look, it is time now to set the table" (she directed the subject's attention to the theme symbol.) mother looked at the subject, pointed to the theme symbol and said, "s. please get the plates from the cupboard." mother directed the subject's attention to the plate picture symbol and pointed to the cupboard where the plates were kept. if he understood the instruction and performed the action without any trouble, mother said: "put a plate on the table for dad, put a plate down for α., a plate for me and a plate for yourself." mother was encouraged to compliment verbal instructions with gesture and facial expression. should the subject experience difficulty with any instruction, mother repeated the instruction and physically cued him through the action. after all the plates were placed on the table, the other utensils (forks, knives, placemats, glasses and serviettes) were placed on the table by using the same procedures and instructions. instructions for the use of positive reinforcement were as follows: after the performance of a correct action by the subject the mother was requested to do or say the following: "very good!" (positive reinforcement: verbal); smile (positive reinforcement: smile); squeeze his hand/shoulder (positive reinforcement: physical) and to place a sticker (positive reinforcement: concrete) in the left upper corner of the appropriate picture symbol. after the attachment of the sticker, mother pointed to the sticker and repeated: 'very good!" data analysis and statistical processing verbatim transcriptions of video material of the interaction between the mother and subject during action routines were done. due to the fact that the subject did not communicate verbally, his communication was described by recording occurrences of pointing, smiles, gesture, eye contact as well as communicative sounds and noises on the relevant recording sheets. (appendix 2 provides an example of a recording grid). recording was done by counting each occurrence of a sub-skill on the transcriptions. tallies were recorded onto the four different grids (see appendix 2). the friedman variance analysis (hollander & wolfe, 1973) was applied to the data to indicate p-valilze pansegrouw and erna alant ues (significance of change) of the sub-skills of the priority skills over the six week intervention period. the p. value indicates significance of change of the difference between week 0 and any other measurement between week 0 and week 6. raw scores were processed to tallies p e r minute and the average percentage change in relation to week 0 (baseline), calculated. the percentage change refers to the percentage change in relation to week 0. for equivalence of action routines, interpolation· was done to determine percentage change for week three of "set the table". in this way the change in priority skills for week 2 for both "set the table" and "make the bed" as well as week 3 and 6 (in relation to week 0) for all action routines, could be presented. at the comparison of the sub-skills for all action routines only the percentage change at weeks 3 and 6 are presented. this was done because the "feed the cat" action routine was only introduced in week 2 and measured one week later (see table 1). through these procedures, changes in sub-skills of priority skills at weeks 0 , 3 and 6 could be calculated for all action routines. results and discussion the results of intervention, i.e. a description of identified priority skills of the subject and his mother during the six week intervention period as well as the effect of withdrawal of intervention during week six, follows. figure 2 represents the overall results of the percentage change of the two priority skills of the mother (communication skills and skills at training the subject) and the two priority skills of the subject (communication skills and independence at performing action routines) in weeks three and six. from figure 2 it is evident that positive changes were seen in the results of the priority skills of the subjects. the subject benefitted from and developed new skills during the six week intervention period. at the time of the study, the chronological age of the subject was fifteen. he then was found to have a m.a. (mental age) of 25 months 4 0 0 3 5 0 3 0 0 2 5 0 2 0 0 1 5 0 100 5 0 0 % change 0 0 | 0 0 week 0 4 7 53 1 w3(tbc) w6(tbc) m/c ih s / c ees m/s μ s/i key: (tbc) = set the table; β = make the bed; c + weed the cat m/c = mother: communication skills s/c = subject: communication skills / m/s = mother: skills at training the subject s/i = subject: independence at performing action routines y figure 2: change of priority skills at weeks three and six x the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) £ , o n u n u n i c a t i o n intervention in an adolescent with autistic features and a g.q. (general quotient) of 14. according to existing y c h o m e t r i c categorisation the subject would be " u n t r a i n a b l e " which implies an inability to benefit from education/training and consequently being dependent upon physical care (grover, 1990; koordineringskomitee: jaar van g e s t r e m d e persone, 1987). results of this study support the view that clinical features are dynamic and often r e f l e c t the extent and nature of the service delivery model (lea, 1990). physical care as the only form of service delivery to the subject, would most certainly have resulted in the under-utilisation of potential. the subject's communication and independence skills when looking at figures 2, 3 and 4 a significant difference in results between weeks nil to three (during intervention) and weeks nil to six (after intervention withdrawal) in the priority skills of the subject, is seen. results in figure 3 indicate that in weeks nil to six independence skills either increased or remained nearly the same. from the same figure it can also be seen that communication skills (apart from picture symbol communication which he used to indicate that he wanted to terminate routines) decreased from weeks nil to six. from these results it seems that the subject did not lose/forget skills during intervention withdrawal but instead presented poor motivation and unwillingness to co-operate. it is known that regular, consistent practice of skills with a familiar person in the environment, as well as the provision of external structure to facilitate productive functioning are important requirements for intervention success with pci persons (siegel-causey & downing, 1987). during the withdrawal period provision of external structure and regular performance of action routines decreased significantly. for this reason it becomes clear that so called generalisation problems often reflect a situation where behaviour has generalised but where reinforcement profound cognitive impairment and 71 key: p/c = picture symbol communication; r/r/c = requests for recognition/confirmation; s/r = smiles for recognition; i/c = intentional communication; c/w/ a/ = performs commands without assistance from mother; sc/i = performs sub-components of action routines independent/without command from mother; a/c/pr = anticipates concrete positive reinforcement figure 3: subject: selected sub-skills of communication skills and independence (all action routines) for the regular use of the behaviour, was insufficient (johnson & koegel, 1982). increases were seen in the results of the subject's requests for and smiles for recognition, as well as anticipation of concrete positive reinforcement. these results indicate that the subject's related needs were addressed by providing his mother with positive reinforcement training. it also suggests that the often described clinical feature of poor inner motivation of the pci person to develop skills that would decrease dependence of persons in the environment, could be changed by providing motivation (positive reinforcement) as the first step in the learning process (sailor & guess, 1983; haney & falvey, 1989). when looking at increases in the results of the communication skills of the subject (figures 2, 3 and 4), it seems that the provision of picture symbol task analysis charts to introduce action routines, provided the context in which communication between the mother and the subject was encouraged through the provision of common, specific themes that facilitated interaction (lund, 1986; rowland & stremel-campbell, 1987). task analysis charts provided the subject with the opportunity to acquire new information slowly and to be provided with small amounts of information at a time required by most pci persons during the introduction of learning tasks (wilson, 1981). the mother's priority skills figure 2 results represent increases between weeks nil to three and weeks nil to six in the priority skills of the mother. when comparing overall percentage increases, the increases in the priority skills of the mother were not as high as those of the subject. however, figure 5 results, which represent high increases in both positive responses (identification, recognition and positive response to communication attempts of the subject) and concrete and verbal positive reinforcement, are significant. increases in positive responses and concrete and verbal positive reinforcement suggest that the training of the mother in the use of positive reinforcement was not only effective, but most likely contributed to increases in positive responses. the use of positive responses were not directly trained and could therefore possibly be viewed as a "spill-over" effect of positive reinforcement training. the significance of these results is underlined by the view that for the pci person, partner responsiveness is known to encourage and facilitate interest in and willingness to participate in communication interaction (girolametto et al., 1986). % c h a n g e 2 0 0 -10717 w e e k 0 w e e k 2 w e e k 3 w e e k β —— s e t t i n g t a b l e ~ ^ m a k i n g b e d * — f e e d i n g cat figure 4: subject: communication skills trends die suid-afrikaanse tydskrif vir kommunikasieafwy kings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 ilze pansegrouw and erna alant comparison in priority skills : the subject and the mother significantly fewer overall increases in the priority skills of the mother, when compared to those of the subject, are seen in figure 2. when adding the overall increases of the mother as presented in figure 2 (47% in weeks 0-3 and 53% in weeks 0-6 for communication skills and 105% in weeks 0-3 and 99% in weeks 0-6 for skills at training the subject), only a slight change (50%) in mother's communication behaviour over the six week intervention period is seen. the slower tempo of change of the mother could be viewed against the backdrop of the "set" of table management strategies that have developed over years in order to meet and cope with the daily demands of the pci person. due to limitation in formal and informal societal assistance, families develop rigid/stable strategies which are instrumental in maintaining environmental predictability, security and familiarity (see discussion of homeostasis under proposed intervention model). during the study a few of the family's rules and strategies were observed and mentioned by the mother. it follows that despite mother's willingness to participate in the study and to implement intervention strategies, demands to change management and coping strategies that have provided security and predictability over years, would require a much longer period of professional and social support. however, when looking at figure 2, it is seen that the communication skill of the mother was the only priority skill that showed an increase in week nil to six (after intervention withdrawal). a possible explanation for this could be found when comparing figure 4, 5 and 6. in figure 4 the highest scores during weeks nil to three for the three selected action routines are seen for "set the table" (in which the subject had most prior intervention experience), second highest for "make the bed" (less prior experience than setting table) and third highest for "feed the cat" (least prior experience). after withdrawal of in% c h a n g e — 86 — 6 0 47 47 sstl ν • h i -4 c . p / r v . p / r p / r l / 8 " w i 9 _ 8 0 r p / c t / u η w e e k 3 s i ! w e e k 6 key: c.p/r = concrete positive reinforcement; v.p/r = verbal positive reinforcement; p/r positive responses to communication of subject; l/s = looks at subject; u/s = uses symbols; i/r = ignore responses to communication of subject; p/c = physical contact; t/u = total utterances tervention (weeks nil to six), except for "feed the cat", results show a decline. figure 6 results indicate that, except for "set the table", mother's communication skills increased from weeks nil to six. sub-skills of mother's communication skills that increased at weeks nil to six (figure 5) were "looks at subject", "physical contact" and "total utterances". ignore responses were significantly less in weeks nil to six. these results indicate that for the subject and his mother a relationship existed between the subject's extent of experience and independence at action routines and the communication skills of the mother. it seemed that, as could be expected, increased independence of the subject at performing action routines, lessened the need for "supportive" communication from the mother and vice versa. conclusions the pci population is distinguished by it's heterogenicity and differences are the rule rather than the exception (yoder & villarruel, 1988). a single case design was selected and no generalisations on the basis of these results, can be made. however, it appeared that overall increases in the results of the priority skills of both the mother and the subject could be ascribed to the implementation of communication intervention. a significant decrease in the results of three of the four priority skills after the withdrawal of intervention, strengthens the aforementioned presumption. when taking into account that the results of the pci subject showed the highest increases overall, the most important conclusion points to the dynamic (vs static) nature of the subject's clinical features. when comparing results at the different measurements, motivation seemed to be a key determinant of the features of the priority skills of the subject as well as the communication skills of the mother. results indicated the necessity to target and provide positive reinforcement as well as consequent opportunities to perform skills together with a familiar person in the environment, in order to maintain the pci subject's motivation and willingness regarding intervention aims. the use of domestic action routines and the introduction and representation thereof by means of picture symbol task analysis charts, seem to have succeeded in the facilitation of interaction between the mother and the subject. results which indicated that increased subject independence (at action routines) reduced the need for "supportive" communication from the mother, point to the need for flexibility regarding the selection and period that the % change w e e k 6 figure 5: mother: selected sub-skills of communication skills and skills at training the subject (all action routines) • s e t t i n g table * m a k i n g bed " feeding c a t figure 6: mother: communication skills trends the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication intervention in an adolescent with profound cognitive impairment and autistic features subject is expected to perform each action routine. although in this study the action routine choice of the mother was used, mother's choices should be alternated with those of the subject. additionally the possibilities of increasing the number o f routines (alternating familiar and less familiar routines) or shortening the period of performance of each to less than a week per action routine, could be considered. due to the widely accepted acknowledgement of responsiveness as the facilitator of motivation and willingness to interact, increases in the mother's use of positive responses to the communication o f the subject (possibly indicating a side-effect of positive reinforcement training), are viewed as significant. however, the slower tempo of change in the communication skills of the mother highlighted the need for a realistic and sensitive attitude towards social and historical aspects, daily stressors and general needs of the mother. demands to change coping strategies and communication behaviours that were developed over years, necessitates a prolonged period of professional and social support. additional sources of support could include the active involvement of other family members as well as societal support. results of communication intervention with the pci subject indicated that these persons cannot be denied communication intervention on grounds of clinical features , or psychometric classification alone. poor progress during intervention does not indicate that the person is unable to benefit from intervention and therefore requires only physical care. to provide for the right of the pci person to develop and maintain a quality o f life equal to that of mainstream society, communication intervention must be aimed at the development o f social integration through the facilitation of functional communication and independence skills. the pci person forms one component of the environment in which he spends most of his time. for this reason primary caregiver skill development and sensitivity towards the environment cannot be overemphasised. references alant, e. & emmet, t. 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(1988). adults at the presymbolic level. in s.n. calculator & j.l. bedrosian (eds). communication assessment and intervention for adults with mental retardation. boston, mass.: college-hill. pansegrouw, i. (1994). kommunikasie-intervensie by 'n kognitief erg gestremde adolessent met outistiese trekke. ongepubliseerde m.log verhandeling,.universiteit van pretoria. rowland, c. & stremel-campbell, k. (1987). share and share alike; conventional gestures to emergent language for learners with sensory impairments. in l. goetz, d. guess & k. stremelcampbell (eds). innovative program design for individuals with dual sensory impairments. baltimore, maryland: brookes. rustin, l. & ruhr, a. (1989). social skills and the speech impaired. london: taylor & francis. sailor, w. & guess, d. (1983). severely handicapped students: an instructional design. boston, mass.: houghton mifflin. siegel-causey, e. & downing, j.e. 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(1981). curriculum selection for the deaf-blind; severely/profoundly handicapped. in s.r. walsh & r. holzberg (eds). understanding and educating the deaf-blind i severely d l e suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 74 ilze pansegrouw and erna alant and profoundly handicapped: an international perspective. the severely handicapped child. in n.j. lass, l.v. mcreynolds, springfield, illinois: charles c. thomas. j.l. northern & d.e. yoder (eds). handbook of speechyoder, d.e. & villarruel, f. (1988). effective communication for language pathology and audiology. philadelphia: b.c. decker. appendix 1: grouping of sub-skills of priority skills of the subject and his mother 1. mother: 1. total utterances (+) communication skills 2. total commands (+) 3. repetitive commands (+) 4. average repetitions (+) 5. physical contact (+) 6. looks at subject (+) 7. response to communication of subject: 7.1 positive (+) 7.2 negative (-) 7.3 ignore (-) 8. uses symbols (+) 9. positive reinforcement: 9.1 concrete (+) 9.2 physical (+) 9.3 verbal (+) 9.4 smile (+) 2. mother: skills at 1. uses symbols (+) training the subject 2. positive reinforcement: 2.1 concrete (+) 2.2 physical (+) 2.3 verbal (+) 2.4 smile (+) 3. subject: 1. looks at mother (+) communication skills 2. smiles (+) 3. smiles for recognition (+) 4. initiates physical contact (+) 5. intentional communication (+) 6. picture symbol communication (+) 7. requests recognition/confirmation during action routines (+) 8. protests (-) 9. anticipates concrete, positive reinforcement (+) 10. ignores commands (-) 1 11. distractible (-) 4. subject: independence 1. performs commands without assistance from mother (+) | 2. performs sub-components of action routines independent/ without commands from mother (+) ι 3. looks at symbols (+) > 4. communicates through symbols (+) 1 5. requests recognition/confirmation for performance of action routines (+) 6. protests (-) 7. anticipates concrete positive reinforcement (+) 8. ignores commands (-) 9. distractible (-) 10. mother performs own commands (-) χ the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication intervention in an adolescent with profound cognitive impairment and autistic features appendix 2: grid for recording and analysing data of the mother's skills at training the adolescent task se ; the ta ble make the bed feed the cat average week 0 1 2 3 6 0 2 3 6 0 3 6 3 6 measurement β 1 2 3 β 1 2 3 β 1 2 time (min) 8 9 9 10 2 12 4 2 4 9 5 mother mother mother (*) 1 use symbols 16 11 6 5 12 5 7 2 11 7 3 1.1 count/minute 2 1.222 0.666 0.5 6 0.416 1.75 1 2.75 0.777 0.6 1.2 % change 0 -38.8 -66.6 -93 -75 0 -93.0 -70.8 -.83.3 0 -71.7 -78.1 -78 -79 2. positive reinforcement 2.1 concrete 0 7 5 6 0 5 5 5 0 9 7 revised count 1 8.3 6.13 7.25 1 11 7 6 1 11.25 8.25 count/minute 0.125 0.903 0.681 0.725 0.5 0.916 1.75 3 0.25 1.25 1.65 306 513 % change 0 622.6 444.8 267 480 0 83.33 250 500 0 400 560 2.2 physical 1 2 3 2 1 1 2 0 1 1 0 count/minute 0.125 0.222 0.333 0.2 0.5 0.083 05 0 0.25 0.111 0 % change 0 77.77 166.6 257 60 0 -83.3 0 -100 0 -55.5 -100 67 -47 2.3 verbal 2 8 10 7 1 3 5 3 1 4 3 count/minute 0.25 0.888 1.111 0.7 0.5 0.25 1.25 1.5 0.25 0.444 0.6 % change 0 i 255.5 344.4 433 180 0 -50 150 200 0 77.77 140 220 173 2.4 smile 1 1 1 0 0 1 2 0 1 1 0 revised count 1 • 7 4 1 count/minute 1 0.125 0.111 0.111 0 0.5 0.583 1 0.5 0.25 0.111 0 % change 0 | -11.1 -11.1 -11 -100 0 16.66 100 0 0 -55.5 -100 11 -66 average 0 ' 181' 176 171 109 0 -25 86 103 0 59 84 105 99 d e suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the sklar aphasia scale in a foreign language marion fredman, m a . (rand) haifa, israel testing an adult aphasic patient is a complicated procedure liable to, depress and frustrate the patient if not handled correctly. testing a bilingual or polyglot adult aphasic is fraught with added difficulties. apart from the inconsistent responses which a patient may give due to severity of illness or confusion, the bilingual or polyglot patient may be faced with responding to questions in a language with which he was not completely familiar prior to illness. no test can replace extensive observation by a trained clinician. but a suitably designed test provides a starting point for observation and a guide to planning therapy. in a study carried out recently in haifa, israel (fredman2), the writer was faced with the problem of testing 20 adult aphasic patients in hebrew which was not their primary language. some patients had only had a scant knowledge of hebrew prior to illness. one patient was illiterate and others had only been literate in their home language .(table i). thus an aphasic test had to be selected which would lend itself to translation and adaptation into the hebrew language, and yet would not provide long or difficult passages for reading. the sklar aphasic scale (sas). was chosen because it aims at testing ". . . over learned functional communication skills" (sklar7). this scale was developed by dr. maurice sklar at wadsworth veterans hospital in lbs angeles, california, and studies have been reported establishing the validity of the scale, sklar6 and mccloud3. the sas attempts j o assess overt residual language behaviour and is based on the communication theory which ". . . affirms that a social communication occurs when a sign is (1) decoded (received and comprehended), (2) transcoded (transformed internally), and (3) encoded (transmitted orally or graphically)" (sklar7). thus, the sas material is organized into four subtests: (1) auditory decoding: this includes items measuring auditory verbal comprehension and the patient is only required to respond with a motor response or gesture. (2) visual decoding: this subtest attempts to test the patient's ". . . ability to recognize and analyse different types of graphic signs usually acquired with formal learning" (sklar7). (3) oral encoding: items previously presented for decoding are now presented for naming. the patient is also required to describe a picture and read a short news item. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 8,desember971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) marion fredman δ.a ' 1 1 i f ε ρ >s ^ a ο c >2 s «v, •β ε β a to β ε ο i s'o" ρ 53 3 ό ε ο ε 3 η ε ε ..s3 -22 < < < < < < εο-ί §>< c o < £ < < < < < ο > > > > > > | | > ί > > ί > > > > > ; > ε ϋ ϋ ϋ ϋ ϋ ϋ η μ ϋ η ϋ ϋ ω υ ϋ ύ υ υ υ ω .a § ο s s §·ο _ q β η -1 — ~ c ca .3 .2 fc 3 rt 3 η 3"o ca^ps-s 3 3 d o υ cu 3 cu 3 3 (§ £ 3 £ a (2 a < ο 3 ^ * ο (2 ο λ * a * < (n m (n f̂i <«sj psj ^ tjv. £ λ _ ^ ^ ό 3 <υ <υ β 3 3 h i s 3 3 ra ra ιϊ >5 « ι ϊ ι ϊ pq j ffi 2 j ffi κ o<£ ? eg uj3 (λ ο 3 ι-ο .v u γ/1 μ) · <= e 2 ε s s so ο c ω fg c" 0) υ υ p>t3 o o o o o o o " 0 0 0 0 0 0 0 3 o o o o o o o g cisiei!s.eieiei? · c ο « 5 co co co co co co co « π co co co j2 j2 £ co _g ϊί co co ulhlhlhl-ih^ce ctfctfctfctfctfcqctflh ε ε ε ε ε ε ε a c c ' c h c c c ^ d-ohd-ohohd-o,— i a a a 1 » 1 » s 1 ^ § a a <3s ο th c 3 ο υ c ο t3 c <υ ο. χ ά' w α ζ <3 ε k. •s. -ο 5 journal of the south african speech and hearing association, vol. , december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sklar aphasia scale in foreign language (4) graphic encoding: this tests the patient's ability to write items presented in previous subtests, to write about the picture presented in subtests 2 and 3, and to write progressively longer sentences dictated by the examiner. scoring is as follows: when a patient is able to respond without difficulty he is scored "o" indicating no impairment; if he requires some assistance he is scored "1" and no response or an incorrect response is scored as "2". sklar considers a score of "1" as a difficulty in transcoding ability. each subtest has a possible impairment score of 100 and a prognosis of retraining potential is made on the basis of the total impairment score obtained by dividing the sum of all the scores by 4. case 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 sas* lest 372 326 360 304 294 318 316 242 158 174 208 192 124 224 44 44 58 116 retest 374 204 256 296 88 178 172 148 90 142 146 172 26 42 36 24 16 119 sas test 372 326 360 304 294 318 316 242 158 174 208 192 124 224 44 44 58 116 362 364 retest 374 204 256 296 88 178 172 148 90 142 146 172 26 42 36 24 16 119 318 376 l.m.t.a. test retest 412 341 420 289 305 420 298 256 173 195 365 200 147 221 78 125 88 145 405 242 263 261 120 229 177 160 96 155 239 158 70 79 68 67 76 86 h.l.q. test 84 53 64 68 69 79 63 33 55 55 44 48 46 31 24 21 22 79 80 8 retest 85 54 27 59 24 41 44 39 21 29 42 34 21 22 26 20 20 21 74 78 * note· cases no. 1 and 2 as shown in table i are presented as no. 19 and 20 as they have no l.m.t.a. results. in calculating the r„ between the sas and h.l.q. they again appear as no. 1 and 2. table ii: raw scores because of the choice of test items in the sas, and the fact that it tests functional language ability it was found to be an easy test both to translate and to administer. the sas does not probe as deeply into the patient's linguistic problems as do tests such as the l.m.t.a. (wepman-jones8) or m.t.d.d.a. (schuell4), but it is for this very reason that the writer found it suitable for patients whose knowledge of the test language had not been extensive prior to illness. the passages provided to test reading comprehension are simple newspaper articles which the average israeli patient is used to reading. the objects chosen for naming are known ones in israel and were not tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 18,desember971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) m a r i o n fredman 6 sas sas l.m.t.a. h.l.q. case 1 2 3 4 5 6 1 8 test retest test retest test • retest test retest 1 ] 1 3 3 3 1 4.5 3 2 3 4 2 1 5 4 2.5 2 3 2 3 1 2 1.5 2 2.5 1 4 6 2 5 6 8 3 1 5 5 7 13 .4 . 5 6 11 12 12 6 4 5 8 4 1.5 6 8 4 7 5 • 6.5 9 1.5 7 7 7 14 8 8 8 6 7 9 8 6 8' ' 9 13 12 · 7 8.5 13 12 4.5 6 10 12 10 10 10 12 10 9 9 11 10 9 15. 14 4 5 16 17 12 11 6.5 .14 12 11 9 10.5 11 13 14 16 12 11 14 16 10.5 7 14 9 14 13 8.5 10 14 15 10 15 17.5 15 16 18 18 17 13 17 16 17.5 17 11 16 16 18 14 15 17 16 18 19.5 17 17 15 17 13 ' 18 ' 15 11 19.5 19 15 13 18 19.5 19 — — 18 20 — — 20 19.5 20 — — 17 13 — 19 17 table iii: rank scores test retest (1) anrf (5) ο/ λαιν scores (2) and (6) of raw scores case case di d? 1 di d 2 1 2 4 0 0 2 2 4 0 0 3 0.5 0.25 1 1 4 2 4 1 1 5 1 1 2 4 6 2.5 6.25 1 1 7 2 4 0 . 5 0.25 8 1 1 0 0 9 0 0 0 0 10 0 0 0 0 11 6 36 4 16 12 0 0 2 . 5 / 6.25 ,' o 13 0 0 0 / 6.25 ,' o 14 1 1 0 0 15 0 . 5 0.25 2 4 16 1.5 2.25 1 1 17 1 1 3' 9 18 0 0 2 4 test: r 8 = 0.93 ρ > 0.01 retest: r 3 = 0.95 ρ > 0.01 table iv: r„ between sas and l.m.t.a. journal of the south african speech and hearing association, vol. 18, december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) -sklar aphasia scale in foreign language ' changed for the purpose of translation. the divisions into subtests made it easy to omit items when the patients had been illiterate in hebrew. nevertheless, it was considered desirable to use scores obtained on the l.m.t.a. by 18 out of the 20 patients in order to provide a control, and indicate validity of the sas scores in hebrew. the results on the two tests and retests (table ii and iii) were ranked and the spearman rank correlation coefficient r8 was used to establish the correlation between the results on the two tests. a formula taking into account ties in ranking was used as described by siegel5. the r on the sas and l.m.t.a. test results was 0.93 with a level of significance of ρ = 0 . 0 1 (table iv). on the retests the , obtained was 0.95 at a level of significance of p = 0.01 (table iv). as the level of significance between the sas and l.m.t.a. is high, it may be concluded that the two tests measure the same disorder. the, l.m.t.a. was proved valid as a test of aphasia in hebrew, by bar-david1, therefore it was assumed by case. di d? 1 1 1 . 5 2.25 2 0 . 5 0.25 3 1 . 5 2,25 4 4 16 5 8 64 6 0 0 7 2 4 8 0 0 9 2.5 •6.25 10 1 1 11 1 1 12 3.5 12.25 13 1.5 2.25 14 2 . 4 15 3 9 16· 3 9 17 2.5 6.25 18 1.5 2.25 19 2 4 20 2 4 r s = 0.88 ρ > 0.01 table v: r s between sas test and h.l.q. test ((3) and (7) of raw scores) the writer that the sas was also valid. it should be noted that the "tell a story" item of the l.m.t.a. was omitted in the comparison of the two tests on the advice of wepman9 who maintained that there was no comparable item in the sas. the patients used in this study came from ten different countries and spoke seven languages. their ages ranged from 34 to 76 and their educational status from illiterate to university degree (table i). tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 18, desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) m a r i o n f r e d m a n 9* —> ό a s s s a a a a a a a ^ivo^oomomovoojq^moovo^oov ι—ι γπ ιη «λ ιλ"λ «λ β s •ο ηνονοο^ο^ονο'λ^-^'λμομ'λμ • oh 1 oh 1 ootto^oo^r^^rnooor^fnr-)'—ι^^ο^^ο^ •λ ιλ ιλ «λ l/"> l/">l/"> ·/">·/"> ·/"> •o' o) ε !/-> «λ «λ !/-> ^ifsj^ m<s<s <s en en en en en en α << ι/-) ι/-) ι/-) ι/-> ixrnrnrqt^^ttov^r^vottttoooovt '̂-jvopn • τ in in i/-> m ι/-> «λ -ν § << l/-> !/•>«/"> «λ «λ «λ •ο j 1—1 1—1 1—1 i—l 1—1 1—1 (n | ι/-> «λ «λ sa s -ν ε artnoo -̂ncsomvî f-vomoovot̂ ono^ α << ^ ^ cncn ^^(s^fommm i 1—(1—(1—(1—(1— <3 1—(1—(1—(1—(1— ο ο vi & (ν " β u κ •ο 3 α ^ * 3 co β σ s ο 8 8 5 = 2$ 8 8 η ο § 2 /isfg ' τ3 ·ο η ω ο ο ω ω .3 ο -μ s ο α λ 3 ϊτ -cm journal of the south african speech and hearing association, vol. is, december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sklar aphasia scale in foreign language as the purpose of the study carried out in israel was to establish the influence of therapy in hebrew on the home language of the bilingual or polyglot adult aphasic, a test in the patient's home language was also required. a home language questionnaire was devised which consisted of 20 questions to test activities which the patient's family could observe. the patient was tested in his home language and the sas before and after three months' treatment in hebrew. the correlation between the" home language questionnaire and the-sas is shown in table v. where improvement was made on the sas a similar improvement was indicated in the patient's home language (table vi). thus it may be seen that the sas proved to be a useful evaluating instrument in patients who had spoken a variety of languages prior to illness. this writer is of the opinion that the sas would be suitable in other languages in many parts of the world. summary the sklar aphasia scale was used to test 20 bilingual and polyglot aphasic patients in a project carried out in haifa, israel. the test was compared to the l.m.t.a. on 18 of the patients and proved to be valid. this writer believes that it is an easily translatable, adaptable scale which could be used for aphasics in other parts of the world where it is impractical to test the patient in his home language. opsomming die sklar afasieskaal is gebruik om 20 tweeen veeltalige afasiese gevalle te toets in haifa, israel. die toets is vergelyk teen die ..language modality test of aphasia" wat op 18 van die proefpersone uitgevoer is en dit het geblyk geldig te wees. die skrywer glo dat hierdie 'n maklik vertaalbare en aanpasbare skaal is wat gebruik kan word vir afasiegevalle in ander dele van die wereld waar dit onprakties of onmoontlik is om die geval in sy huistaal te toets. acknowledgement this study was supported in part by public health service research grant no. 06-12 1134-108-13 from the bureau of disease prevention and environment control of the united states government. the writer acknowledges with thanks the assistance given by dahlia bar-david in providing the l.m.t.a. scores for this study. references: 1 bar-david, d. (1971): adaptation of the wepman-jones language modalities test for aphasia into hebrew. j. communication disorders, vol. 4, 2 fredman, m. (1970): the effect of therapy given in another language, on the home language of the bilingual or polyglot adult aphasic. m.a. dissertation, university of the witwatersrand, johannesburg. tydskrif van die suid-afrikaanse verenigingvir spraak en gehoorheelkunde, vol. 18, desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ^ m a r i o n fredman 3 mccloud e. (1962): comparison of four aphasia tests administered to ?2 penons chapter 4 of m.a. thesis, umversity of california 4 schuell η (1965): administrative manual for the minnesota test for diff^ntial diagnosis of aphasia. university of minnesota press, minneapolis. 5 siegel, s. (1956): non-parametric statistics for the behavioural sciences. mcgraw-hill book co., inc. 6 sklar μ (1963): relations of psychological and language test scores and autopsy findings in aphasia. j. speech hearing research, vol. 6, no. 1. 7. sklar, m. (1966): sklar aphasia manual. western psychological services, california. 8 wepman, j. m., jones, l. v., bock, r. d. and van pelt, d. (1961): manual for language modality test of aphasia. university of chicago, education industry service. 9. wepman, j. m. (1969): personal correspondence. journal of the south african speech and hearing association,· vol. is, december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 43 ouerleiding by ouers wat swart babas met 'n gesplete lip en verhemelte corrieta campbell & brenda louw departement kommunikasiqjatologie universiteit van pretoria opsomming daar is aanduidings dat die oners vangesplete-lip-en-verhemeltebabas dikwels behoφe toon aan meer inligting omtrent hul baba segeboortedrfek as wat aan hulle verskafword. in suid-afiika bestaan daar egter nog 'n leemte in die literatuur omtrent die spesifieke behoeftes van die ouers van 'n swart baba met 'n gesplete lip en verhemelte. in hierdie studie is daar eerstens 'n bepaling gedoen van die ouers van swart gesplete-lip-en-verhemeltebabas se unieke behoφes en tweedens is daar, op grond van die verkree resultate, 'n inligtingstuk vir hierdie teikengroep saamgestel. op grond van die resultate verkry met behulp van die vyftien proefpersone wat aan hierdie studie deelgeneem het, is daar eerstens bevind dat die ouers van swartgesplete-lip-en-verhemeltebabas in suid-afrika eenderssoortige behoeftes as ouers van babas met dieselfde aangeboregebrek wereldwyd vertoon. tweedens is daar bevind dat die inligtingstuk wat as deel van die studie saamgestel is, 'n positiewe bydrae gelewer het tot die ouerleiding wat met die proefpersone in die studie uitgevoer is. die resultate hou dus ook belangrike terapeutiese implikasies in. abstract there are indications that the parents of babies with a cleft up and palate often require more information regarding their baby's birth defect than what is given to them. in south africa shortcomings exist in the literature covering the specific requirements of parents of black cleft lip and palate babies. in this study the unique requirements of parents of black cleft lip and palate babies was determined and, based on these results, an information pamphlet was prepared for this population group. based on the results obtained with the help of fifteen participants it was established, firstly, that the needs of black south-arfican parents of children with a cleft lip and palate are similar to the needs of parents of babies with the same birth defect world-wide. secondly, it was established that the information pamphlet which was compiled as part of the study made a positive contribution to parent guidance conducted with the participants. important therapeutic implications were also reflected by the results. < tot op hede het die.swart"gesplete-lip-en-verhemeltepopulasie in suid-afrika weinig belangstelling uitgelok (louw, 1986). bestaande navorsing oor die problematiek van hierdie aangebore gebrek is slegs op geselekteerde populasies uitgevoer. daar is op internasionale vlak 'n behoefte aan navorsing en kultureel aangepaste intervensieprogramme oor die problematiek van die gesplete lip en verhemelte binne anderskleurige populasies en dit neem voortdurend toe (toliverweddington, 1990). vroee intervensie, soos wat tans suksesvol in die blanke populasie van suid-afrika deur middel van ouerleiding toegepas word, kan moontlik die oplossing wees vir die uitgesproke behoefte aan hulp en leiding onder die swart bevolking (bzoch, 1989; brookshire, lynch & fox, 1980; louw, 1988). die implementering van vroee intervensie word voorgestaan omdat swart gesplete-lip-en-verhemeltepasiente soms glad nie by 'n hospitaal uitkom voordat chirurgiese sluiting van die baba se lip en verhemelte plaasvind nie. hierdie pasiente is ook dikwels buite bereik van 'n spraakterapeut nadat hulle die hospitaal verlaat het. swart ouers van gesplete-lip-en-verhemeltebabas in die rsa vertoon 'n unieke kultuur, taal en sosio-emosionele omstandighede. die vraag ontstaan dus of dit nie ook 'n unieke wyse van ouerleiding impliseer nie. kan die bestaande inligting oor ouerleiding van blanke gesplete-lip-en-verhemeltebabas sonder meer op hul swart ewekniee toegepas word? die belang van interkulturele veranderlikes in hulpverlening word tans sterk in die spraakheelkunde beklemtoon. wereldwyd begin spraakheelkundige organisasies hulself ten doel stel om kultureel diverse populasies ten voile te akkommodeer. daar is reeds in die vsa wetgewing in di£ verband ingestel (taylor, 1986). watter unieke kulturele kenmerke en behoeftes kom by die swart suid-afrikaanse bevolking voor? eerstens is kommunikasieprobleme in kruis-kulturele gesondheidsdienste 'n probleem. daar word tien verskillende swart tale in suidafrika gepraat. engels is dikwels 'n tweede of derde taal vir die swart suid-afrikaner. in 'n studie wat deur louw (1986) geloods is oor swart gesplete-lip-en-verhemeltebabas het 76% van die moeders min of geen engels verstaan nie en moes daar van 'n tolk gebruik gemaak word om effektiewe interaksie en oordrag te bewerkstellig. tweedens, ouers wat afkomstig is uit meer tradisionele en ongeletterde agtergronde, neig om kulturele gebruike en bygelowe aan te hang (smoot, kucan, cope en aase, 1988). dabuto-brown (1989) doen verslag dat die tipiese afrika-kultuur 'n baba met 'n erge wanformasie van die gesig, as onaanvaarbaar beskou. derdens, 'n aspek wat wetenskaplik moeilik peilbaar is, th south african journal of communication disorders, vol. 39 1992 sas 1 2 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 omdat dit in die westerse kultuur as 'n kriminele oortreding beskou word en dus selde aangemeld word, is kindermoord. strauss (1985) bevind dat dit dikwels binne 'n derde wereldsamelewing as 'n ritueel of tradisionele prosedure beskou word om 'n baba wat met 'n kongenitale afwyking gebore is om die lewe te bring. verder noem hy dat kinders wat met 'n kongenitale defek gebore word, dikwels as 'n slegte voorbode deur die familie beskou word en dus weggesteek of verwaarloos word. binne die suid-afrikaanse konteks word die kliniese waarneming gemaak dat 'n groot persentasie van die swart bevolking oningelig is met betrekking tot die beskikbare mediese ondersteuningsdienste vir 'n baba met gesplete lip en verhemelte. dit kan daartoe lei dat die ouers glad nie aanmeld vir mediese en ander beskikbare vorme van gespesialiseerde behandeling nie of, soos dabuto-brown (1989) aandui, dikwels in 'n baie laat stadium aanmeld vir sodanige hulp vir hulle baba. vierdens, word die voeding van swart babas met gesplete lip en verhemelte ook deur kulturele gebruike geraak. dit is baie belangrik vir 'n swart moeder om haar baba te borsvoed (louw, 1986). die babas word dikwels suksesvol geborsvoed sonder 'n voedingsplaatjie of enige gespesialiseerde opleiding. hierdie verskynsel kan toegeskryf word aan 'n drang om te oorleef en die beskouing dat die aankoop van 'n plaasvervanger vir moedersmelk, 'n onnodige uitgawe is (louw, 1987). vyfdens en laastens vertoon swart babas met hierdie gebrek ook eiesoortige ontwikkelingskenmerke (louw, 1986). hierdie verskynsel kan moontlik toegeskiyf word aan die feit dat die gemiddelde swart moeder in suid-afrika dalknie die voile implikasies van die afwyking besef nie en eerder met die onmiddellike situasie en behoeftes gemoeid is as om toekomsgerig te wees. die behoeftes van swart babas in suid-afrika wat met 'n gesplete verhemelte gebore word, is dus uniek hierdie waargenome verskille tussen die blanke en swart populasies noodsaak gevolglik aanpassings aan bestaande dienslewering en vroee intervensieprogramme (mcwilliams, morris & shelton, 1984), sodat dit toepaslik sal wees vir swart gesplete-lip-enverhemeltebabas binne die multikulturele opset in suidafrika. vanwee die kompleksiteit van die probleem en die nadelige invloed wat 'n gesplete lip en verhemelte op 'n kind se ontwikkeling kan uitoefen (fox, lynch & brookshire, 1978), beveel outoriteite aan dat vroee intervensie vir 'n gesplete-lip-enverhemeltebaba binne spanverband geskied (bzoch, 1989; krogman, 1979). macdonald (1978) meen dat die ouers beskou moet word as baie belangrike lede van die gesplete-lipen-verhemeltespan. die ouers speel ook by vroee ingryping 'n kardinale rol. die doel van vroee ingryping is eerstens voorkomend en tweedens fassiliterend. die spraakterapeut bereik die kind indirek deur sy ouers te lei. suksesvolle ouergesentreerde terapie bestaan uit drie komponente, naamlik inligtingverskaffing (wat weet die ouers?), beraad (hoe voel die ouers?) en opleiding (wat moet die ouers doen?). die wyse waarop vroee intervensie en meer spesifiek ouerleiding plaasvind, wissel van mekaar. geskrewe materiaal (inligting), byvoorbeeld pamflette (olmstead, hardwick & fortier, 1980), kan sinvol aangewend word aangesien dit die ouers tyd bied om na te dink oor hulle vrae en die ouers wat buite bereik van 'n spraakterapeut is, van inligting voorsien. aanpassings in die gebruik van geskrewe materiaal moet egter gemaak word wanneer daar met ongeletterde ouers gewerk word. pamflette kan as riglyn dien vir die spraakterapeut om inligting oor te dra. dit word egter in die literatuur beklemtoon dat inligtingverskaffing net 'n onderdeel van 'n ouerleicorrieta campbell & brenda louw dingsprogram uitmaak. die ander twee genoemde aspekte, naamlik beraad en opleiding, moet ook aandag geniet as die span die ouers en baba ten voile wil ondersteun (louw 1988). die bepaling van die spesifieke behoeftes van moeders van swart babas met 'n gesplete lip en verhemelte, wat as basis kan dien vir 'n ouerleidinginligtingstuk, kan dus as vertrekpunt dien vir ouerleiding tydens vroee intervensie met die spesifieke populasie. metode doel die doel van die studie is om 'n effektiewe inligtingstuk oor die gesplete-lip-en-verhemelteafwyking saam te stel wat sosiokultureel toepaslik is vir gebruik deur die plaaslike swart bevolking in suid-afrika. navorsingsontwerp hierdie studie is in die vorm van 'n tweegroepontwerp, wat 'n tussengroepontwerpmetode is, uitgevoer (smit, 1983). die toetspopulasie bestaan uit twee groepe proefpersone, wat op toevallige wyse geselekteer word. die variansie tussen die twee groepe word ook waargeneem. 'n onafhanklike veranderlike, naamlik 'n inligtingstuk, word by die een groep ingelyf, terwyl dit nie by die ander groep gedoen word nie. tussengroepsvergelykings word getref ten opsigte van die veranderlike, naamlik 'n vraelys, wat deur albei groepe beantwoord word. proefpersoonseleksie die proefpersone was vyftien moeders van swart babas met 'n onherstelde gesplete lip en verhemelte. hulle is op toevallige wyse geselekteer in hospitaalklinieke en in twee groepe verdeel. van groep 1 word inligting in verband met die moeders se kennis omtrent die gesplete-lip-en-verhemeltegebrek, die behoeftes en probleme wat hulle ondervind, asook die moeder se emosionele belewenis van haar baba verkry. op grond van die inligting soos verkiy van groep 1 is daar 'n inligtingstuk saamgestel. groep 2 word benut om die effektiwiteit van hierdie inligtingstuk te evalueer. proefpersone moes aan 'n suidafrikaanse swart groep behoort aangesien die studie gemik is op die saamstel van 'n inligtingstuk vir die moeders van swart suid-afrikaanse babas met 'n gesplete lip en verhemelte. die babas moes ten tye van die uitvoering van die studie nog geen chirurgiese behandeling vir die gesplete lip en verhemelte ontvang het nie. die teikenpopulasie van die studie is ouers van jong babas met 'n gesplete lip en verhemelte wat behoefte het aan inligting, beraad en opleiding met betrekking tot die hantering van hulle babas. die babas moes binne die ouderdomsgroep 0 tot 24 maande val. sodoende het 'n beperkte variasie in terme van behoeftes en ontwikkelingmylpale tussen die babas voorgekom (anderson, nelson & fowler, 1978). die babas moes geen ander kongenitale afwyking buiten die gesplete lip en/of verhemelte vertoon nie: sodoende verkiy die steekproef 'n meer homogene aard wat die kenmerke van die babas en die ouers se behoeftes betre'f (mcwilliams et al. 1984). tabel 1 verskaf'n opsommende weergawe van die kenmerke van die proefpersone. / materiaal en apparaat vraelys op grond van reeds gei'dentifiseerde vraagtukke en probleme wat algemeen by ouers van babas met gesplete lip en verhemelte presenteer (massengill & phillips, 1975; macthe south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ouerleiding by ouers van swart babas met 'n gesplete lip en verhemelte 45 tabel 1: algemene becld van die proefpersone wat by hierdie ondersoek be trek is. pp. no. moeder skolasties kind geslag kind ouderdom huistaal tipe spleet* 1 st. 10 v 6 mde n. sotho 1 2 st. 2 v 8 mde shangaan 5 3 st. 1 v 1,5 mde zoeloe 3 4 geen v 8 mde zoeloe 1 5 st. 7 v 7 mde tsonga 2 6 st. 5 v 6 mde swazi 2 7 st. 2 v 5 mde zoeloe 1 8 st. 5 v 8 mde n.sotho 2 9 st. 2 μ 1 md s.sotho 4 10 st. 8 μ 2 mde s.sotho 5 11 st. 3 μ 5 mde zoeloe 4 12 st. 2 v 5 mde s.sotho 2 13 st. 5 v 11 mde tsonga 3 14 st. 2 v 6 mde shangaan 4 15 st. 7 μ 3 mde zoeloe 1 * sleutel tot die klassifisering van tipes splete: (acpa-klassifikasie, bzoch,1989). 1 spleet van die lip en alveolus. 2 spleet van die velum. 3 spleet van die palatum en velum. 4 unilaterale splete van die lip, alveolus, palatum en velum. 5 bilaterale spleet van die lip, alveolus, palatum en velum. donald, 1978; starr, 1983), is daar 'n vraelys ontwerp vir die peiling van proefpersone se emosionele belewenisse en behoeftes en om hul kennis ten opsigte van hul gesplete-lip-enverhemeltebabas te bepaal. om die analise van die navorsingsdata te vergemaklik, is die vrae verdeel in vier kategoriee. op hierdie wyse word daar ook meer struktuur verleen aan die evaluasie-proses (smit, 1983). die kategoriee sluit die volgende in: die moeder se kennis aangaande die kind se afwyking en die moontlike oorsake van die gesplete lip en verhemelte by haar kind word geevalueer. moontlike probleme wat die baba en sy familie kan ondervind as direkte gevolg van sy gesplete lip en verhemelte word ondersoek. aspekte wat gedek word, is: gehoor, voeding, kommunikasiegedrag, finansies en kulturele aanvaarding van die baba. | daar word bepaal van watter behandelings en ondersteuningsdienste die moeder kennis dra. die familie se gevoelens jeens die mediese behandeling word ook ondersoek. laastens word die ouers eri direkte familie van die gespeltelip-en-verhemeltebaba se i emosionele belewenis van die baba, asook die vooruitsigte met betrekking tot opvolgbehandeling nadat die inisiele chirurgie voltooi is, met behulp van die vraelys ondersoek. die navorser voltooi self deur 'n verbale onderhoud, met behulp van 'n tolk indien nodig, die vraelys saam met die moeder van die gesplete-lip-en-verhemeltebaba. sodoende word 'n groter mate van eenvormigheid verkry in die wyse waarop die vraelys aangebied word (campbell, 1990). inligtingstuk. 'n inligtingstuk is saamgestel met die doel om te beantwoord aan die moeders van swart babas met 'n gesplete lip en verhemelte se behoefte aan inligting en emosionele ondersteuning, soos reeds gei'dentifiseer tydens die toepassing van die vraelys op die proefpersone in groep 1 (sien proefpersqonseleksie). die inligtingstuk is saamgestel uit reeds bestaande ouerleidingsprogramme, wat spesifiek ontwerp is vir gebruik tydens ouergesentreerde intervensie binne die gesplete-lip-en-verhemeltepopulasie (olmstead, hardwick & fortier, 1980; brookshire, lynch & fox, 1980; macdonald, 1978). die bestaande materiaal is aangepas by die swart bevolking in suidafrika se spesifieke kultuur, kenmerke en behoeftes, soos bepaal deur 'n literatuurstudie (louw, 1986; cole, 1981; cervenka, 1984; dabuto-brown, 1989; rampp, 1984) en deur die resultate van die bogenoemde vraelys. aangesien daar onder die gemiddelde swart bevolking in suid-afrika 'n hoer graad van geletterdheid in engels as in afrikaans blyk te wees, is die inligtingstuk in engels geskryf. daar is gebruik gemaak van prente van swart babas en die inligting is baie konkreet en visueel voorgestel om dit meer toeganklik te maak vir moeders wat nie kan lees nie of nie engels begryp nie. die inligtingstuk kan ook met ongeletterde ouers gebruik word, deurdat die spraakterapeut, met behulp van 'n tolk, die inligting verbaal oordra en toelig met die illustrasies wat in die inligtingstuk verskaf word. die inligtingstuk bestaan uit vyf afdelings, naamlik: die anatomie van die orofasiale strukture en die aard en oorsake van 'n gesplete lip en verhemelte. voeding van 'n gesplete-lip-en-verhemeltebaba. kommunikasie en taalstimulasie by 'n gesplete lip-enverhemeltebaba. middeloorprobleme by die baba met 'n gesplete lip en verhemelte en die hantering daarvan. die belang van chirurgiese en ortodontiese behandeling vir 'n gesplete-lip-en-verhemeltebaba en die belang van gereelde opvolgbehandeling nadat die baba uit die hospitaal ontslaan is. prosedure data-insameling hierdie studie berus op data wat van twee groepe proefpersone verkry is, naamlik, groep 1 en groep 2 (sien proefpersoonseleksie). the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 corrieta campbell insameling van data by groep 1: die proefpersone is by verskeie hospitale en klinieke gekontak en met behulp van 'n opgeleide tolk ondervra. die vraelyste is, met behulp van 'n tolk, mondelings met die proefpersone behandel en deur die navorser self ingevul. daar is doelbewus gepoog om geen leidrade of aanduidinge met betrekking tot die beantwoording van die vrae aan die proefpersone te verskaf nie. die antwoorde watgenoteer is, is uitsluitlik die van die proefpersone. insameling van data van groep 2: die proefpersone in hierdie groep is by dieselfde hospitale en klinieke as in die geval van groep 1 gekontak. die proefpersone is met behulp van 'n tolk bekendgestel aan die inligtingstuk wat op grond van die bevindinge uit groep 1 as vraelyste saamgestel is. daar is sorg geneem om te verseker dat die proefpersone die inligting ten voile begryp en alle vrae voortspruitend daaruit is deur die navorser met behulp van die tolk beantwoord. nadat die proefpersone aan die inligtingstuk bekendgestel is, is dieselfde vraelys as wat met groep 1 uitgevoer is, ongeveer 1 maand later met die hulp van 'n tolk mondelings op die proefpersone in groep 2 toegepas. die proefpersone se antwoorde is deur die navorser self aangeteken. data-analiee die proefpersone se response op die vraelyste is volgens die onderskeie kategoriee waaruit die vraelys bestaan daarna statistics geanaliseer en op grafiese wyse voorgestel. die betroubaarheid van die intergroepverskille is op statistiese wyse bereken (fisher se toets: zar 1984). die statistiese berekeninge is ook gedoen om vas te stel of die inligtingstuk wat aan die proefpersone in groep 2 bekendgestel is, voordat hulle die vraelys beantwoord het, wel 'n beduidende verskil in hul kennis omtrent die oorsake, behandeling en die noodsaaklikheid van opvolgondersoeke teweeggebring het. resultate resultate word weergegee in die vorm van 'n vergelyking tussen groep 1, wat nie aan die inligtingstuk blootgestel was nie, en groep 2 wat wel aan die inligtingstuk blootgestel was, se response op dieselfde vraelys. tabel 2: vergelyking van groep 1 en groep 2 se kennis oor moontlike oorsake van gespelete verhemelte. proefpersone wat kennis dra omtrent die moontlike oorsake van gesplete lip en verhemelte: groep 1 (n=8) groep 2 (n=7) p-waarde 0% 80% 0,01 beduidende verskil soos voorgestel in tabel 2, dra die proefpersone in groep 2 beduidend meer kennis van die moontlike oorsake van 'n gesplete lip en verhemelte as die proefpersone in groep 1. alhoewel daar nie 'n beduidende verskil is tussen die mate waarin die twee groepe proefpersone hul babas aanvaar nie, is dit tog opmerklik dat 100% van die proefpersone in groep 2 geantwoord het dat hulle hul baba aanvaar, terwyl slegs 70% van die proefpersone in groep 1 aandui dat hulle hul baba aanvaar (sien tabel 3). die twee groepe se antwoorde betreffende hul familielede se aanvaarding van die babas toon 'n verskil van tabel 3: vergelyking van groep 1 en groep 2 se aanvaarding van hulle gesplete-lip-en-verhemeltebabas. proefpersone wat hul babas aanvaar: groep 1 (n=8) groep 2 (n=7) p-waarde 70% 100% 0,24 nie-beduidende verskil proefpersone wie se families hul babas aanvaar: groep 1 (n=8) groep 2 (n=7) p-waarde 30% 40% 0,53 nie-beduidende verskil tabel 4: proefpersone se bewustheid van hulp en behandeling beskikbaar vir hul babas. groep 1 (n=8) groep 2 (n=7) p-waarde bewus van chirurgiese herstel van die spleet: 40% 100% 0,01 beduidende verskil bewus van ortodontiese behandeling en voedingsplaatjie: 10% 80% 0,002 beduidende verskil bewus van mediese behandeling van middeloorprobleme: 0% 100% 0,003 beduidende verskil bewus van voedingsen spraakterapie: 10% 100% 0|002 beduidende verskil tabel 5: vooruitsigte van opvolgbesoeke | 1 groep 1 (n=8) groep 2 (n=7) p-waarde 40% 100% p.i beduidende verskil slegs 10% wat te wagte kan wees aangesien slegs die moeders in groep 2 en nie hulle familielede nie, aan die inligtingstuk blootgestel was. volgens tabel 4 is daar ook 'n duidelike verskil tussen groep 1 en 2 se bewustheid van die hulp 'en behandeling wat vir hul babas beskikbaar is. daar was 'n statisties beduidende verhoging van die proefpersone in groep 2 (wat aan die inligtingstuk blootgestel was) se bewustheid van die volgende vier behandelingsmoontlikhede, naamlik chirurgiese herstel van die spleet, ortodontiese behandeling en/of'n voedingsplaatjie, mediese behandeling vir middeloorprobleme en voedingsthe south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ouerleiding by ouers van swart babas met 'n gesplete lip en verhemelte 47 en spraakterapie. laastens vertoon die vooruitsig van opvolgbesoek (sien tabel 5) nadat die babas se inisiele behandeling voltooi is, by die proefpersone in groep 2 ook beduidend beter as by groep 1 al groep 2 se proefpersone antwoord dat hulle sal terugkeer vir verdere behandeling en hulp, terwyl slegs 40% van die moeders in groep 1, wat nie aan die inligtingstuk blootgestel was nie, aandui dat hulle sal terugkeer vir opvolgbehandeling. bespreking van resultate die resultate wat van die proefpersone in groep 1 verkry is en die response van groep 2 op dieselfde vraelys word gesamentlik bespreek. dit moet deurentyd in gedagte gehou word dat groep 1 se response 'n weerspieeling is van die ouers wat nog min of geen ouerleiding on tvang het nie. die proefpersone in groep 2 het egter voor die invul van die vraelys ouerleiding ontvang deur middel van die verbale gebruik van die inligtingstuk wat ook saamgestel is as deel van hierdie studie. die inligtingstuk is gebaseer op die behoeftes, soos aangedui deur groep 1, met die beantwoording van die vraelys. ten spyte daarvan dat die diagnose van hulle kind se gebrek deur mediese personeel aan die ouers oorgedra is, blyk dit duidelik uit die resultate dat nie een van die proefpersone in groep 1 kennis gedra het van die moontlike oorsake van 'n gesplete lip en verhemelte nie. hierdie bevinding korreleer met resultate van 'n soortgelyke ondersoek wat deur slutsky (1969) uitgevoer is op moeders van gesplete-lip-en-verhemeltebabas. daar is bevind dat 76% van die moeders wat ondervra is pas na die geboortes van hul babas nog nooit van 'n gesplete lip en verhemelte gehoor het nie (mcwilliams et al. 1984). mcwilliams et al. (1984) maak die stelling dat hoe meer bekend die ouer van 'n gesplete-lip-en-verhemeltebaba met die afwyking is, hoe makliker sal dit vir die ouer wees om daarby aan te pas. die feit dat die proefpersone in groep 1 geen kennis gedra het van 'n gesplete lip en verhemelte as 'n kongenitale afwyking nie, dui daarop dat hulle nie genoegsaam bygestaan is ten opsigte van die aanvaarding en begrip van hul babas se geboorteafwykings nie. die proefpersone in groep i2 se basiese kennis aangaande die aard en oorsake van die igesplete-lip-en-verhemelteverskynsel was beduidend beter as die basiese kennis waaroor die proefpersone in groep 1 beskik het. 80% in groep 2, teenoor geeneen van die proefpersone in groep 1 nie, was bewus van sommige etiologiese faktore wat geassosieer word met 'n gesplete lip en verhemelte. die inligtingstuk het dus die ouers in groep 2 gehelp om 'n wye siening te ontwikkel van die aard en moontlike oorsaak van hul baba se geboorte-afwyking. ouers behoort die geleentheid te he 'om inligting oor die moontlike oorsake van 'n gesplete lip en verhemelte te ontvang. sommige ouers is tevrede met bloot algemene inligting, maar ander verlang meer inligting, veral as die afwyking familiaal blyk te wees (siegel, 1979). dit is nie die spraakterapeut se rol om genetiese raadgewing te verskaf aan die ouers nie, maar die moontlikheid van die genetiese aard van die spleet en beskikbaarheid van hierdie diens moet aan hulle oorgedra word. η ondersoek na die probleme wat die gesplete-lip-en-verhemeltebabas sowel as hul ouers ondervind het, is met die oog °p die saamstel van die inligtingstuk, op groep 1 se proefpersone geloods. hul response op die vraelys het getoon dat 70% van die proefpersone (groep 1) of hul babas wel direk as gevolg van die gebrek 'n probleem ondervind het. verder het 30% van die proefpersone meer as een probleem gerapporteer. volgens die resultate van die vraelys was die mees pre valente probleem die van voeding. hierdie bevinding sluit aan by rampp (1984) se bevinding dat die voeding van hul gesplete-lip-en-verhemeltebaba 'n algemene bekommernis is by die ouers van hierdie kinders. 87% van die babas wat voedingsprobleme ondervind in hierdie studie het dikwels verstik tydens voeding en 62% van die wat dikwels verstik, kry ook voedsel in die nasale ruimte tydens voeding. mc williams et al. (1984) het bevind dat vroee voedings-ervarings wat 'n baba en ouer ondervind hoogs relevant is vir psigososiale sowel as vir spraaken taalontwikkeling. voedingsprobleme kan oorkom word deur die nodige inligting oor voedingsmetodes en -hulpmiddels aan-die ouers te verskaf en hulle te ondersteun in die uitvoervan hierdie moeilike taak(louw, 1987). slegs 10% van die moeders in groep 1 was bewus van voedingsterapie (verskaf deur 'n spraakterapeut), teenoor 100% van die proefpersone in groep 2 wat wel daarvan bewus was. die moontlikheid dat groep 2 se ouers dus sal hulp vra en sal terugkeer vir opvolgsessies word dus ookgroter as in die geval van groep 1, wat nie aan die inligtingstuk blootgestel was nie. die mediese behandeling vir 'n gesplete lip en verhemelte is 'n voortgesette en duur proses. aangesien die populasie waaruit die proefpersone geselekteer is oorwegend onder die laer inkomstegroep in suid-afrika ressorteer en dikwels nie aan mediese fondse behoort nie, word die moontlikheid van finansiele probleme by die behandeling van die proefpersone se babas nie uitgesluit nie. wat interessant is, is dat die proefpersone in groep 1 se response op die vraelys die teendeel bewys het. 90% van die proefpersone antwoord dat daar geen finansiele probleme rakende die behandeling van hul gesplete-lipen-verhemeltebabas is nie. die rede hiervoor blyk te wees dat die provinsiale hospitale voorsiening maak vir pasiente in die laer inkomstegroep. hospitaalonkoste, konsultasiefooie, mediese behandeling en medikasie word feitlik 100% deur die staat gesubsideer. die antwoorde op die vraelys dui verder aan dat die vervoeronkoste van 40% van die proefpersone in groep 1 ook deur die hospitaal gedek word. ambulanse of treinkaartjies word voorsien aan behoeftige pasiente wat ver van die hospitaal woon. hierdie vervoerbystand het weer positiewe implikasies wanneer opvolgbesoeke moet realiseer. ten spyte daarvan dat die baba 'n baie duur behandelingsproses ondergaan, ontvang die ouers van swart gesplete-lip-en-verhemeltebabas bystand om die finansiele las te verlig. kostefaktore hoef dus nie 'n beperkende faktor in die kind se behandelingsproses te wees nie. die moeders en families se emosionele belewing van die baba met 'n gesplete lip en verhemelte en van sy deformiteit is ook met behulp van die vraelys ondersoek. dit is 'n groot skok vir 'n ouer/ouers om onverwags 'n baba met hierdie geboortedefek te aanvaar en te versorg (macdonald, 1978). die navorsingresultate van die proefpersone in groep 1 korreleer met hierdie stelling. die effektiwiteit van die behandelingsproses word beslis bevoordeel wanneer die baba se ouers hom of haar ten voile aanvaar (starr, 1983). dit is dus noodsaaklik dat die spraakterapeut ondersoek instel na die ouers van hierdie babas se emosionele reaksie op hul baba se geboortedefeken aandag daaraan skenk tydens die verskaffing van inligting aan die ouers. deur inligting op 'n gestruktureerde en empatiese wyse aan die ouers te verskaf (verkieslik in hulle moedertaal), kry die ouers nie slegs beter insig in hul baba se afwyking nie, maar word hulle ook gelei na begrip en aanvaarding van hulle eie gevoelens jeens hul baba met 'n gesplete lip en verhemelte (louw, 1988). volgens krogmann (1979) is die ouers van die baba belangrike lede van die multi-dissiplinere span. die ouers se samewerking sal noodwendig verbeter wanneer hulle positief voel oor die behandeling wat hulle baba ontvang. slegs die helfte van die proefpersone in groep 1 het positief gevoel oor die the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 behandeling wat hul babas gaan ontvang. dit was egter opmerklik dat 80% van di£ wat positief gevoel het, buitepasiente was by die gesplete gesigsdeformiteite kliniekvan die departement kaak-, gesigen mondchirurgie, universiteit van pretoria, waar die ouers nou saamwerk met 'n volledige multidissiplindre span. die uitgangspunt waarop hierdie navorsingsprojek gebaseer is, naamlik dat vroee intervensie binne multi-dissiplinere verband die ouers van jong gesplete-lip-enverhemeltebabas tot voordeel strek, word hierdeur ondersteun (bzoch, 1989). 'n verdere aanduiding dat 'n verandering van gesindheid deur effektiewe ouerleiding teweeggebring kan word, is die verskynsel dat 100% van die proefpersone in groep 2 (wat blootgestel was aan die inligtingstuk) aangedui het dat hulle positief voel oor die behandeling wat hulle gesplete-lip-enverhemeltebabas gaan ontvang. dit is egter moeilik om 'n persoon se houding deur middel van 'n enkele vraag en antwoord te evalueer (mcwilliams et al. 1984). die proefpersone se positiewe houding kan aan veel meer as bloot die inligtingsessie toegeskiyf word, byvoorbeeld persoonlikheidsverskille tussen die proefpersone in die onderskeie groepe. die twee groepe word verder met mekaar vergelyk in terme van die proefpersone se bewustheid van die hulp en behandeling wat beskikbaar is vir hul gesplete-lip-en-verhemeltebabas. soos deur middel van statistiese berekeninge bevestig, is daar 'n beduidende verskil tussen die proefpersone van groep 1 en 2 se kennis aangaande die volgende vier aspekte: chirurgiese herstel van die spleet, ortodontiese behandeling en voedingsplaatjies, mediese behaudeling vir middeloorprobleme en voedingsen spraakterapie. daar was deurlopend 'n hoer mate van bewustheid van beskikbare behandeling vir hulle babas onder die proefpersone in groep 2 as wat die in groep 1 getoon het. nadat die baba se gesplete lip en verhemelte herstel is, bestaan die kind se behandeling grootliks uit spraaken taalterapie (van riper & emerick, 1984). deurdat die ouers egter reeds deur middel van vroee intervensie opgelei word om die kind se spraaken taalontwikkeling optimaal te stimuleer, word latere ontwikkelingsafwykings voorkom (bloom & lahey, 1978). dit is dus belangrik dat 100% van die ouers ingelig moet wees omtrent spraaken taalterapie en nie slegs 10% soos uit die vraelyste van groep 1 blyk nie. taalverskille tussen die swart ouers van 'n baba met 'n gesplete lip en verhemelte en die oorwegend blanke span medici wat betrokke is by die behandeling van die baba, plaas deurgaans 'n beperking op die interaksie wat tussen hulle kan plaasvind. die feit dat spraakterapeute wat by hospitale en kliniek met swart pasiente werk, dikwels 'n swart assistent tot hul beskikking het, is dus 'n voordeel binne die vroee-intervensie-opset. die spraakterapeut behoort dus, met die hulp van 'n opgeleide tolk, soveel as moontlik inligting aan die ouers oor te dra en die kommunikasie tussen die ouers en die res van die multidissiplinere span te bevorder. nog 'n probleem wat direk binne die spraakterapeut se bemoeienis-area val, is die van middeloorpatologie. geen van die proefpersone in groep 1 was bewus van mediese behandeling vir middeloorprobleme nie, terwyl 30% van die proefpersone se babas reeds middeloorontsteking gehad het voor of ten tye van die uitvoer van die studie. 'n moontlike verklaring vir die ouers se oningeligtheid betreffende middeloorontsteking en die behandeling daarvan, mag wees dat hulle in so 'n mate met die baba se gesplete lip en/of verhemelte gemoeid was, dat hulle nie ag geslaan het op die baba se middeloorprobleme nie. middeloorprobleme het egter 'n hoe prevalensie by gesplete-lip-en-verhemeltepasiente (katz, 1987) en die ouers moet beslis tydens ouerleiding daarop attent gemaak corrieta campbell & brenda louw word, om sodoende die moontlikheid van 'n latere gehoorverlies en taalagterstand te beperk. gereelde besoeke aan gesondheidsklinieke kan byvoorbeeld aangemoedig word in ' n poging om voorkomend op te tree. ten spyte daarvan dat die proefpersone in groep 1 min of geen kennis gedra het omtrent die wetenskaplik gefundeerde behandeling wat hul babas gaan ontvang nie, het die navorsing wel getoon dat 100% van die moeders in groep 1 mediese behandeling bo tradisionele behandeling vir hul babas verkies het. dit is opsigself'n positiewe bevinding, veral gesien in die lig van dabuto-brown (1989) se bevinding dat die ouers van swart babas met 'n gesplete lip en verhemelte in die noordelike dele van afrika, ten spyte van beskikbare mediese dienste, grootliks op tradisionele medisyne vertrou. dit is veral belangrik dat die ouers van 'n baba met 'n gesplete lip en verhemelte bewus gemaak word van alle beskikbare hulpbronne en behandelingsmoontlikhede terwyl hulle nog binne bereik van die spraakterapeut en res van die multidissiplinere span is. die ouers wat ver van 'n hospitaal of kliniek woon, kan ook ten tye van die ouerleidingsessie aanbeveel word om terug te keer na die hospitaal, of 'n spraaken gehoorgemeenskaps-werkster vir verdere hulp en leiding te nader. laastens, beklemtoon macdonald (1978) die belang daarvan dat die ouers ook aktief moet deelneem aan die behandelingsproses. hulle moet deel he aan die beslissings rakende die behandeling van hul baba. dit is nie voldoende dat die ouers van 'n gesplete-lip-en-verhemeltebaba bloot ingelig word oor die behandelingsproses en passief optree nie. hulle moet in dialoog met die multi-dissiplinere span verkeer en aktief betrokke wees by die hulpverlening aan hulle kind. die voorafgaande word as ideaal vir samewerking tussen ouers en professionele persone gestel. aanpassings as gevolg van kulturele verskille sal noodwendig gemaak moet word. gevolgtrekkings en aanbevelings effektiewe ouerleiding bestaan uit inligtingverskaffmg, opleiding en beraad (louw, 1988). ongeag wanneer die spraakterapeut se eerste ontmoeting met die ouers van 'n gespletelip-en-verhemeltebaba plaasvind, behoort dit 'n opvoedkundige of opleidingsessie te wees (massengill & phillips, 1975). deur inligting te verstrek aan hierdie ouers help die terapeut hulle om hul kind se geboorte-afwyking en die behandeling wat dit vereis beter te verstaan en ook om hulself makliker met die geboortedefek te versoen. dit is ook belangrik dat die ouers van die gesplete-lip-en-verhemeltebaba emosionele steun van die res van die multi-dissiplinere span ontvang (starr, 1983). sodoende word die drie basiese beginsels van ouerleiding, naamlik inligtingverskaffmg, opleiding en beraad, bereik. huidige resultate dui daarop dat taalen kulturele probleme tot 'n groot mate oorkom kan word en dat effektiewe ouerleiding vir ouers van swart gesplete-lip-en-verhemeltebabas in suid-afrika 'n werklikheid kan wees. hierdie populasie was tot op hede baie verwaarloos. die resultate van die uitvoering van die vraelys met die proefpersone in groep 1 het bewys dat hulle beslis behoefte het aan inligting, opleiding en beraad betreffende die hantering en behandeling van hul babas. hierdie bevindinge word ook wyd gesteun deur die literatuur, wat aan toon dat die ouers van gesplete-lip-en-verhemeltebabas wereldwyd behoefte toon aan meer inligting oor, opleiding in en emosionele ondersteuningmet die hantering van hul babas. vanuit 'n kritiese oogpunt beskou, is die steekproef wat gebruik is vir die verkryging van die navorsingsresultate egter beperk, in vergelyking met die totale populasie waarop die gevolgtrekkings van toepassing is. tweedens kan die geldigthe south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ouerleiding by ouers van swart babas met 'n gesplete lip en verhemelte 49 jjeid van 'n intragroepvergelyking moontlik aanvegbaar wees, siende dat hierdie navorsingsontwerp minder veranderlikes binne die toetspopulasie sou meebring, indien die inligting oor 'n langer tydperk versamel sou word (smit, 1983). dit blyk egter uit die resultate van die studie dat al die proefpersone in groep 2 wel baat gevind het by die inligting wat aan hulle verskaf is. die inligtingverskaffing het plaasgevind met behulp van die inligtingstuk wat saamgestel is op grond van die proefpersone in groep 1 se behoeftes. die opgestelde inligtingstuk blyk dus 'n bruikbare instrument te wees om die swart ouers van gesplete-lip-en-verhemeltebabas in suidafrika van inligting oor hul baba se kongenitale gesigsdeformiteit te verskaf. opleiding en beraad is ook ingebou in die inligtingstuk ten einde meer effektiewe ouerleiding te bewerkstelligdie spraakterapeute by hospitale en klinieke kan die inligtingstuk aanwend as vertrekpunt vir 'n ouerleidingsprogram wat daarop gemik is om sowel die ouer as die kind op die lange duur te bevoordeel. uit die voorafgaande bespreking blyk dit dus duidelik dat die spraakterapeut in suid-afrika 'n verantwoordelikheid het betreffende verdere navorsing, die ontwikkeling en die implementering van hulpmiddels om die ouers van swart gespletelip-en-verhemeltebabas op te lei en te ondersteun. 'n vroee intervensiebenadering, kan met groot sukses binne hierdie teikenpopulasie toegepas word. * 'n kopie van die saamgestelde inligtingstuk is van die eerste outeur verkrygbaar. verwysings anderson. d., nelson, j. & fowler, s. (1978). developmental assessment schema. in w.h. northcott (red.), curriculum guide: hearing impaired children (0-3gears) and their parents. washington, d.c.: the alexander graham bell association for the deaf. bloom, l. & lahey, μ. (19 78). language development and language disorders. new york: john wiley. brookshire, b.l., lynch, j.i. & fox, d.r. (1980). a parent-child cleft palate curriculum. developing speech and language. tigard, oregon: c.c. publications. bzoch, k.r. (1989). communicative', disorders related to cleft lip and palate. 3de uitgawe boston: little brown. campbell, c. (1990). ouerldding by^swart babas met 'n gesplete lip en verhemelte. ongepubliseerde voorgraadse navorsingsprojek: universiteit van pretoria. | cervenka,j. (1984). african mask with cleft lip and palate: cleft palate journal, 21, 38-40. j cole, l.t. (1981). blacks with orofacial clefts: the state of the dilemma. asha, 22, 557-560. dabuto-brown, d.d. (1989). cranofacial clefts in a black african population. cleft palate journal, 26, 349-343. fox, d.r., lynch, j.i. & brookshire, b.l. (1978). selected developmental factors of cleft palate children between two and thirty-three months of age. cleft palate journal, 15, 239-245. katz, j. (1987). handbook of clinical audiologg. 2de uitgawe. baltimore: williams & wilkins. krogman, w.m. (1979). the cleft palate team in action. in h.k. cooper (red.), cleft palate and cleft lip: a team approach to clinical management and rehabilitation of the patient. philidelphia: saunders. louw, b. (1986). swart babas met gesplete-lip-en-verhemelte: 'n morftofunksionele studie. ongepubliseerde doktorale proefskrif: universiteit van pretoria. pretoria: universiteit van pretoria. louw, b. (1987). black south african cleft palate infants: a sociocultural perspective. the proceedings of the american cleft palate association 44th anniversarg meeting, texas maart 1987. louw, b. (1988). vroee intervensie by jong hoe risikokinders (0-3 jaar). communiphon, 285, 18-27. macdonald, s.k. (1978). perspectives concerning cleft lip and palate. massachusets:fprescription parents. massengill, r. & phillips, p.p. (1975). cleft palate and associated speech characteristics. nebraska: cliffs notes. mcwilliams, b.j., morris, h.l. & shelton, r.l. (1984). cleft palate speech. st. louis: mosby. olmstead, p., hardwick, h. & fortier, s. (1980). alaska cleft lip and palate series. alaska: alaska resource project. rampp, d.l. (1984). velopharengeal incompetencg. a practical guide for evaluation and management. texas: pro-ed. siegel, b. (1979). a racial comparison of cleft patients in a clinic population: associated anomalities and recurrence rates. cleft palate journal, 16, 193-197. slutsky, h. (1969). maternal reaction and adjustment to birth and care of cleft palate children. cleft palate journal. 6, 425-433. smit, g.j. (1983). navorsingsmetodes in die gedragswetenskappe. pretoria: van schaik. smoot, e.c., kucan, j.o., cope, j.s. & aase, j.m. (1988). the craniofacial team and the navajo patient. cleft palate journal, 25, 395402. starr, p. (1983). cleft lip and/or palate behavioral effects from infancy to adulthood. illinois: c.c. thomas. strauss, r.p. (1985). culture, rehabilitation and facial birth defects: internal case studies. cleft palate journal, 22, 56-61. taylor, o.l. jj986). treatment of communication disorders in culturallg and linguisticallg diverse populations. boston: little brown. toliver-weddington, g. (1990). cultural considerations in the treatment of craniofacial malformations in african americans. cleft palate journal, 27, 289-293. van riper, c. & emerick, l. (1984). speech correction: an introduction to speech pathology and audiologg. new jersey: prentice-hall. zar, j.h. (1984). biostatistical analgsis. 2de uitgawe, new jersey: prentice-hall. the south african journal of communication disorders, vol. 39, 1992 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) impedance measurements in the diagnosis of meniere's disease linda lloyd, b . a . ( s p . & h . t h e r a p y ) ( w i t w a t e r s r a n d ) speech therapy department, groote schuur hospital cape town summar y meniere's disease is discussed in terms of diagnostic difficulties, histological findings and treatments pointing to the use of impedance techniques with this condition. ten subjects were given a questionnaire, regarding the symptoms experienced at the time of testing and impedance measures were conducted. acoustic impedance values were higher in 80% of the affected ears when compared to the unaffected ears. four of these values were more than double those in the unaffected ears and three were above normal limits. therefore, increased endolymphatic pressure appears to be reflected in the test results. it is felt that impedance techniques should be.included in the test battery for the diagnosis of meniere's disease. opsomming meniere se sindroom word behandel in terme van diagnostiese probleme, histologiese bevindings en behandeling en dui.op die gebruik van impedanstegnieke vir hierdie toestand. aan tien proefpersone is daar 'n vraelys uitgedeel aangaandedie simptome wat ervaar is tydens toetsing en 'n opname van impedansmetings is gemaak. akoestiese-impedans waardes was hoer in 80% van die aangetaste ore in vergelyking met die onaangetaste ore. vier van hierdie waardes was meer as dubbel vergelyk met die van die onaangetaste ore, en drie was hoer as die normale perke. derhalwe, blyk dit dat verhoogde endolimfatiese druk weerspieel word in hierdie toetsresultate. die skrywer is van mening dat impedansmeting-tegnieke in die toekoms, moontlik in die toetsbatterei vir diagnose van meniere se sindroom ingesluit sal word. the difficulties in diagnosing meniere's disease have been mentioned throughout the literature, b o t h from the point of view of the audiologist and that of the ear, nose and throat specialist. little research has apparently been conducted into the possible application of the recently developed impedance techniques in the diagnosis of this disease. tydskrif van die suid-afrikaans vereniging vir spraak en gehoorheelkunde, vol. 22, deseber 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 linda lloyd meniere's disease meniere's disease, an inner ear condition, usually manifests itself as vertiginous "attacks" with nausea, accompanied by tinnitus and hearing loss. following the appearance of these symptoms, which may be severe, remission periods occur 2 2 . prosper meniere first described this disease in 1861 8 , 3 3 and considered the hearing loss as its cardinal symptom 3 2 . however today, there is confusion in the minds of many, as to the symptoms and pathological changes which should be ascribed to the disease, due mainly to the fluctuation of symptoms. meniere's disease is thus difficult to diagnose. 7,25,26,32 important factor in diagnosis appears to be that all symptoms vary simultaneously i.e. they appear to be directly related to one another, 3 2 , 3 3 but even this is in dispute 2 · 2 5 . while some authors consider the symptom triad necessary for diagnosis 6 , 2 6 others do not feel it is necessary 2 7 · 3 2 while yet a third group of authors have added the symptom of 'fullness in the ear' to those mentioned by meniere. 2 4 , 3 0 diagnosis is complicated by the fact that while the symptom triad may be present when the disease is fully developed18, any one of the symptoms may preceed the others by months or. years2. the term 'meniere's disease' has undoubtedly been applied to many other conditions, 3 2 a n d the writer feels that new diagnostic procedures should be investigated to assist in diagnosis. it has been hypothesised that the symptoms found in meniere's disease may be related to increases in edolymphatic pressure. recruitment and hearing loss are believed to result from hair cell distortion due to pressure increases in the scala media 3 2 . feldman 3 0 , 2 6 f e e l s that the symptom of fullness in the ear is the subjective impression of saccule dilation, while vertigo occurs when the pressure in the endolymph has built up to its height. the remaining symptom, tinnitus, has not yet been explained8. originally, endolymphatic hydrops (an accumulation of liquid in the endolymphatic spaces7) was felt to be an essential finding in meniere's disease 1 0 . this condition was found to have produced dilation of the saccule which occupied the whole vestibule and came into contact with the stapes footplate. dilation of the scala media was also found. however, some authors have had negative findings in this respect 3 2 . generally there is agreement that fluctuations in edolymphatic hydrops occur, linked to symptom f l u c t u a t i o n . 1 0 , 3 0 . many treatments, either medical or surgical, have been developed around the relief of increased endolymphatic pressure 7 , among these are attempts to control the formation and absorption of endolymph 21,31,30 o u e to symptom fluctuations, the success of these treatments is difficult to ascertain 7 , although generally, they have failed to give lasting relief 2 4 . the writer feels that pressure changes within the / endolymph may be detectable in the impedancei characteristics of the middel ear, via the oval window. impedance audiometry impedance audiometry was first introduced by metz, twenty five years ago. it is widely used in europe and the united states, as an important part of the battery of special audiometric t e s t s 1 4 . the techniques are used and designed to diagnose and distinguish between middle ear pathologies 4 . determination journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) impedance measurements in meniere's disease 51 of the ear canal volume, under various air pressure conditions, is the basis for all measures with the electroacoustic impedance balancing bridge28. sensori-neural pathologies, when tested using impedance techniques, appear as normal ears, providing the middle ear is normal. there has thus far been no real distinction between these, using impedance techniques, other than the detection of recruitment in the more severly impaired e a r s 1 2 . three basic impedance tests are generally used in order to gain a complete picture of the middle ear function:tympanometry — "the measurement of eardrum compliance" and mobility "under artificially induced air pressure changes in the ear canal" 1 6 . the measurement of the middle ear pressure is included in the test. acoustic impedance measurement the measurement of the amount of resistance to sound waves at the plane of the tympanic membrane5. acoustic reflex measurements — detection of impedance changes as a result of contraction of one or both middle ear muscles5. the absence of this reflex may have several pathological causes9·1 2 while jerger notes that a small percentage of normal ears do not exhibit this reflex12. the acoustic reflex is defined as "that level above the threshold of hearing, at which a sound is just capable of eliciting a reflex contraction of the stapedius muscle" 1 6 , this is usually at between 70 loodb sl 1 2 . the reflex test is considered by j e r g e r 1 2 to be the most objective test of recruitment so far constructed. in interpreting the results of these tests, normative data should be known, however this is not yet available excepting in the case of gross middle ear anomalies13. in metz's study in 1945 wide variation in impedance values were found28 and jerger reports an overlap between normal and disordered ears 1 2 . there would be great advantages to be gained if impedance techniques could be added to the diagnostic test battery for meniere's disease to confirm impressions already gained by the clinician12. this is especially true in cases of mental retardation or gross physical handicaps where other tests would not be suitable. when considering surgery, which may be unnecessary or dangerous, confirmation of diagnosis is important 2 1 . variables such as stress, anxiety, fatigue (all exaggerated in sufferers of meniere's disease), and intelligence factors could be eliminated due to the nature of impedance t e s t s 8 , 1 6 > 2 4 . these tests have been successfully used in the diagnosis of psychogenic deafness, retro-cochlear pathologies and sensorineural hearing loss with recruitm e n t 9 , 1 2 · 1 9 · 2 9 which according to fowler1 6 is a sign of cochlear pathology and therefore to be expected in meniere's disease. in subjects with meniere's disease, jerger 1 2 found type a tympanograms with normal acoustic impedance. the acoustic reflex was noted to occur at normal intensity levels i.e. 70 loodb but at reduced sensation levels, indicating recruitment. however, zwislocki 3 5 , feldman 5and friedman 6 feel that impedance is influenced by the inner ear, notably the compliance of the cochlear windows and the acoustic impedance at the cochlear entrance 3 5 , which in turn is controlled by conditions existing in the inner ear 3 4 . pathology of the inner ear that may in turn effect the middle ear via the cochlear windows tydskrif van die suid-afrikanse vereniging vir spraak en gehoorheelkude, vol. 22, desember 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 linda lloyd may show some anomaly in impedance testing as suggested by macrae19. according to histological findings, meniere's disease would qualify as such a disease. method subjects ten subjects were obtained by contact with ent specialists 6 males between the ages of 27 and 68 years with a mean age of 50 years, and 4 females between the ages of 35 and 62 years with a mean of 48 years 3 months. due to difficulty in obtaining subjects, it was necessary to include subjects in whom presbycusis could have influenced test results. all subjects were white south africans from various income groups as noted by their addresses of residence. the subjects were examined by ent specialists within 10 months of taking part in the study and a diagnosis of unilateral meniere's disease was made, based on the symptom triad and case history data. otoscopic examination, no longer than 4 months prior to the study, confirmed that no middle ear pathologies existed. control for the experiment was supplied by the unaffected ear of each subject which was expected to show the normal impedance values for that individual. procedure subjects were seen individually and took part in the following: completion of a questionnaire pure tone audiometry (air and bone conduction) impedance audiometry (tympanometry, acoustic impedance test and acoustic reflex measurements) questionnaire the questionnaire was given to ascertain a possible correlation between the symptoms experienced and the test results. questions were asked as to which of four symptoms were present, in which ear, with a description of the symptom where appropriate. the date of the last attack was also noted. pure tone audiometry bilateral tests in the ascending order, for air and bone conduction were carried out, using a maico ma 24 audiometer, calibrated to the iso 1964 reference standard and situated in an acoustically treated booth (iac series 1604-act). bone conduction was carried out for the speech frequencies and narrowband masking was used where appropriate, in air and bone conduction. impedance audiometry the madsen zo 70 electro-acoustic impedance balancing bridge was used to obtain the following three measures bilaterally: a tympanogram with readings taken for every pressure change of 50 mm of water. middle ear pressure was also measured. acoustic impedance was measured in acoustic ohms and calculated according to the mathematical formula. journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) impedance measurements in meniere'sdisease 53 thresholds for the acoustic reflex were obtained for 1000 hz, 2000 hz, 4000 hz, 500 hz, and 250 hz in that order, using the ascending method. auditory signals were provided by an amplivox 51 audiometer calibrated to the iso 1964 standard, the limits of the audiometer being as follows:250 hz — 75db 2000 hz 95db 500 hz — 85db 4 0 0 0 h z 9 5 d b 1000 hz 95db the reflex elicited was recorded for the stimulated ear. results and discussion q u e s t i o n n a i r e the symptoms included in the questionnaire were meniere's traid plus 'fullness in the ear' which is increasingly being thought of as symptomatic of meniere's disease 7 . 2 4 . 3 o , 3 3 although each subject had previously experienced all four symptoms, table i shows that at the time of testing, five felt free of symptoms and five reported symptoms. of these five subjects, all had tinnitus, four reported hearing losses, one had fullness in the ear and none experienced vertigo. the time that had elapsed since the last attack ranged from 1 to 11 months. symptoms experienced at the time of testing sub-subjects tinnitus hearing loss fullness in the ear vertigo none 1 x x 2 x x -3 x 4 x 5 x 6 x x 7 8 9 x x x x x 10 x total 5 4 1 0 5 table i. distribution of subjects according to number and type of symptoms experienced when tested. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkude, vol. 22, desember 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 linda lloyd it could be anticipated that not all symptoms would be experienced by each subject as symptoms are known to fluctuate,2·8 and only the active stage of the disease is characterised by v e r t i g o 2 6 · 3 2 . of the subjects later found to have hearing losses (seven in all), only four reported noticing such a loss. this may be due to compensation for the loss, by the good ear 2 3 · 3 2 for example in the case of subjects 5 and 7. tinnitus may also prove so disturbing that the hearing loss goes unnoticed 2 6 . increased endolymphatic pressure cannot be presumed because of the presence of a hearing loss and/or tinnitus as these are reported to become independent of pressure changes in the later stages of the disease 2 · 2 1 · 3 3 . only subject 8 experienced fullness in the ear which lindsay7 and f i c k 3 0 regard as an indication of increased endolymphatic pressure. it is felt that this subject could therefore show high acoustic impedance values. in the earlier stages of the disease, sataloff 2 6 r e p o r t s the occurrence of unpredictable remissions for a few days or years with an unpredictable number of symptoms remaining, although the later stages of the disease are characterised by the symptom t r i a d 8 · 2 6 . pure tone audiometry table ii shows that 7 subjects had hearing losses in the affected ear. bone conduction thresholds confirmed these losses to be sensori-neural. the only hearing losses seen in the unaffected ears were recorded for subjects 1 , 5 , 6 , and 8, all over 60 years of age who had falling sensori-neural losses. it is possible that presbycusic hearing losses may have been superimposed on the losses due to meniere's disease, thus giving the audiograms falling configurations wnich may not otherwise have occurred. sataloff states that with presbycusic losses, both ears will be affected at the same r a t e 2 6 . three shapes of audiograms were recorded for the effected ears:flat subject 5 rising subjects 2, 4 and 7 falling subjects 1, 6 and 8 controversy exists about expected audiometric configurations in meniere's disease. the report of the subcommittee on equilibrium and its management25 states that, in the early stages, audiograms may show flat or rising configurations. golding-wood8 feels that diagnosis may not be made unless the configuration is falling, as in the later stages of the disease. he also quotes wright (1942) and opheim and flottorp (1957) who found no typical audiogram for meniere's disease. ' journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) impedance measurements in meniere's disease 55 pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s 10 35 y rs bc ο ιη ο pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s 10 35 y rs <j c . ο ο ο ιη ο ιη ιη pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s co ei a\ > cj oa ο ο ο pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s co ei a\ > υ < ο ο ιη ο ο ο ο pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s co os 00 >1 00 (j oa ο σ\ ο σ\ ο σ\ pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s co os 00 >1 00 (j < ο ο ο σ\ ο σ\ ιη σ\ ο ο i pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s to os t>1 "3· -a(j « ο ο ο <ν ο <ν pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s to os t>1 "3· -aυ < ο in ο ο ο γλ ιη <ν ο <ν οο pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s to os vo >-. πί v oa ο ιη ο ιη pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s to os vo >-. πί <j < in γλ ο ο ιη ο ο ο ο οο pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s to β! ό >1 ο <j oa ιη ο ο tf ιη τί pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s to β! ό >1 ο (j < ο τ}· in cr, ο ο tf ο ιη τί ιη τί pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s os -a· 5» 00 -a<j oa ο <ν in <ν ο <ν pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s os -a· 5» 00 -a<j < ο ο ιη <ν ιη <ν ο ο ο <ν ιη ιη pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s to os m >h r(n <j oa ο ο ο pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s to os m >h r(n <j < ο ο ο ο ιη ιη ιη pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s to os o) 5" πί υ pa ο ο ο ο ο ο pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s to os o) 5" πί <j < ο ο ο ο ιη <ν ιη <ν ο <ν ιη pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s co β! -η i* πί <j oa ο τ}· § ο ιη pu re t on e a u d io m et ri c re su lt s in d ec ib el s fo r af fe ct ed e a rs s u b j e c t s co β! -η i* πί <j < ο ο in cr, ο ο tf ο ιη ο ο ν ν ν ν ν ν ν κ ε κ ε χ κ κ i l o s w r y a a z r o . ιη ο ο ο ο ο ο <ν ιη ο ο ο ο ο <ν ιη ο ο ο ο 1 <ν sr οο r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 linda lloyd rising audiograms were seen in subjects between 35 and 48 years of age where the losses were mild to moderate. it would seem that these subjects had not reached advanced stages of the disease, as meniere stated that deafness may become severe or complete in the later stages 3 3 . age appears to correlate with audiometric configurations although the literature does not support this. caparosa 2 , however, states that the disease most often begins in those over 30 years of age, and it would therefore be expected to reach its advanced stages in the later years of life. impedance audiometry tympanometry all subjects presented with bilateral type a tympanograms with the exception of subject 8 who had a type β tympanogram in the affected ear. tympanograms were classified according to jerger's descriptions1 2. if increased endolymphatic pressure is present and sufficiently great to influence impedance test results, the subjects should have shown less compliance in the affected ear than expected in'normal subjects. however, none of the subjects with type a tympanograms reported the feeling of fullness in the ear, which is felt to reflect inner ear pressure increases4·30. subject 8 who experienced fullness in the affected ear showed a type β tympanogram in this ear, indicating decreased compliance of the tympanic membrane. both the fullness in the ear and the tympanogram results could indicate inner ear pressure changes influencing the function of the middle ear. middle ear pressure all subjects, with the exception of subject 5, had middle ear pressures of ο mm of water bilaterally. subject 5 had bilateral middle ear pressures of — 25 mm of water. all are within normal l i m i t s 1 2 . normal middle ear pressures were to be expected if all subjects had normal middle ears, due to the pressure equalising function of the eustachian t u b e 1 7 otoscopic examination plus the results of tympanometry support the view that the subjects were all free of middle ear pathologies. the normal middle ear pressure recorded for subject 8 strengthens the hypothesis that the type β tympanogram was the result of interference with the normal movement of the stapes footplate due to inner ear pressure changes. acoustic impedance values table iii shows that acoustic impedance values were between 1045 and 6108 acoustic ohms with a mean value of 2760.7 acoustic ohms in the affected ear. the mean for the unaffected ear was 1519.1 acoustic ohms. the acoustic impedance values for the affected ears for the subjectswith symptoms were as follows: — subjects 1, 2 and 4 — normal subjects 6 and 8 — high in each case, the values recorded for the affected ears were higher than those recorded for the other ear. journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) impedance measurements in meniere's disease 57 bilateral acoustic impedance values in acoustic ohms s u b j e c t s 1 2 3 4 5 6 7 8 9 10 affected ear 1380 2360 3190 2162 2856 4983 1156 6108 1172 1680 unaffected ear 1045 1390 1380 1362 1214 1785 1733 2520 2184 1228 table iii. bilateral acoustic impedance values. the acoustic impedance values for the affected ears of subjects without symptoms were as follows: — subjects 5, 7, 9 and 10 — normal subject 3 high three of these subjects had higher values in the affected ear than in the unaffected ear. in subjects 3 , 5 , 6 and 8 acoustic impedance values in the affected ear were more than double that in the unaffected ear. according to j e r g e r 1 2 , normal subjects may have acoustic impedance values from 800 to 4200 acoustic ohms, but the majority range from 1000 to 3000 acoustic ohms, with 10% overlap between normal and pathological ears. in this study, three subjects had impedance values above 3000 acoustic ohms in the affected ear. if, as is presumed, the middle ear is normal, these results could be due to increase· endolymphatic pressure influencing test results i.3,-io,i8_ the acoustic impedance value of 3190 acoustic ohms for the affected ear of subject 3 is close to the normal limits and his other test results were all normal. however, this acoustic impedance value is more than double that for the unaffected ear, a phenomenon also noted for subjects 5, 6 and 8. jerger 1 2 feels this great difference in impedance values for the ears of one individual could be an indication of pathology. however, this comparison can be made only if one ear is normal 1 2 . inter-subject comparison is favoured in this study as normative data is insufficient for intra-subject comparison to be reliable 2 6 it is possible that individuals have different physical tolerances to increased endolymphatic pressure and, as a result, there is no single numerical value in acoustic ohms beyond which all subjects develop symptoms. a percentage increase over the individual's normal values may be the critical factor. all five subjects who experienced symptoms, plus three of those who did not, had higher acoustic impedance values in the affected ear, making a total of 80% of the subjects. the impedance value recorded for subject 8 may have been sufficiently high to influence the movement of the tympanic membrane hence the type β tympanogram, unlike subjects 3 and 6 whose impedance values were lower and whose tympanograms were normal. subject 8 also experienced fullness in the ear thought to be the subjective impression of increased inner ear pressure4. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorbeelkunde, vol. 22. december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 linda lloyd endolymphatic pressure may be sufficiently increased to influence the results of acoustic impedance tests but not sufficient to produce the symptom of fullness in the ear, hence the result for subjects 3 and 6 who had no fullness but had high impedance values. arnvig10 stated that symptoms appear to be able to preceed the development of increased endolymphatic pressure. this view could explain the results of subjects 1, 2 and 4 who had symptoms but normal acoustic impedance values in the affected ear. it can be seen that no clear link has been established between symptoms and endolymphatic pressure increases8. s υ β j ε c τ s decibel-values of acoustic reflexes at sensation levels below 60 db in affected ear s υ β j ε c τ s frequencies tested s υ β j ε c τ s 250 hz 500 hz 1000 hz 2000 hz 4000 hz s υ β j ε c τ s hl sl hl sl hl sl hl sl hl sl 1 75 40 85 45 95 55 90 40 90 30 2 75 35 80 50 75 55 3 4 70 45 80. 55 85 55 5 75 40 85 45 95 55 95 55 95 50 6 75 35 85 35 95 35 95 35 95 35 7 75 45 85 55 8 9 10 table iv. acoustic reflex thresholds at sensation levels below 60 db in affected ears. hl = hearing level sl = sensation level acoustic reflex threshold table iv shows the number and frequencies of acoustic reflexes for all subjects, elicited below 60db sl in the affected ear. the largest number of such reflexes was seen for 250 hz with the numbers decreasing as the frequency increased. journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) impedance measurements in meniere's disease 59 only 4 instances of reflexes at reduced sensation levels were recorded in the unaffected ears. they were:— subject 1 4000 hz at a sensation level of 50 db subject 6 4000 hz at a sensation level of 40 db subject 8 250 hz at a sensation level of 55 db 1000 hz at a sensation level of 50 db all these frequencies were felt to be influenced by presbycusis. subjects 3, 9 and 10 showed no reflexes below 60 db sl while subject 8 did not demonstrate any reflexes in the affected ear, and only two reflexes (at below 60 db sl) in the unaffected ear. in ears with normal hearing, no reflexes were elicited at below 60 db sl. in determining the reflex thresholds, jerger's definition of the threshold was used — the lowest level of the signal that can produce a deflection of the balance meter needle that can be observed 1 2 . the presence of the reflex shows an intact reflex arc and the good working order of the middle ear 1 1 · 4 . a reflex elicited at less than 60 db sl is considered by jerger 1 2 to be an indication of recruitment. fowler 8 , described recruitment as a site of lesion indicator, demonstrating cochlear pathology, and recruitment would thus be predicted in ears showing sensori-neural hearing loss. the results of this study support this prediction. results also corroborated evidence of other studies 12,13,35 a s hearing becomes poorer, so the sensation level needed to elicit a reflex decreases. the lowest recorded sensation level at which a reflex was elicited in this study was 30 db. jerger 1 3 noted 25 db as the lowest level beyond which a reflex will not occur, but ewertsen et a l 1 6 found reflexes at 10 db sl. of the three reflexes recorded for subject 8, all were in the unaffected ear and 2 showed recruitment, possibly due to presbycusis. the lack of reflex response in the other frequencies could be due to the fact that he has only a relatively mild hearing loss in those frequencies and therefore does not experience recruitment. feldman4 feels that a hearing loss should cause a sufficient decrease in loudness to eliminate the acoustic reflex (providing there is no recruitment). hearing thresholds in the affected ear of subject 8 were such that a reflex could be expected only at 250hz, due to the limits of the audiometer. no recruitment was shown in subjects with normal hearing in the affected ear. in agreement with fowler 1 6 , williams 3 2 and schuknecht 2 7 who associate recruitment with cochlear pathology. those subjects with no recruitment were also free of other symptoms of meniere's disease and could be considered to have complete symptom remissions. in this study, higher thresholds for the acoustic reflex may have been obtained by using the ascending method of tone presentation than if the descending method had been used. test results seem to depend on the stage of development of the disease which sataloff 2 6 feels, dictates whether a complete or partial remission occurs. any diagnosis of meniere's disease must be able to confirm the presence of recruitment which is one of the main features of the disease. this is clearly possible with impedance techniques. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkude, vol. 22, desember 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 linda lloyd conclusion the results of the impedance technique employed in this study indicates one abnormal tympanogram and acoustic impedance values higher in 80% of the affected ears when compared to the unaffected ears. four of these higher values were double the acoustic impedance in the unaffected ear of the same subject, and three of the values were above normal limits. recruitment was shown in all ears with hearing losses. the difference in acoustic impedance values between an individual's ears may be more important than the values per se. further studies using individuals who each experience several of the symptoms of meniere's disease at the time of testing may result in more reliable findings. the findings of this study are limited due to the inclusion of subjects who were in the age group where presbycusis can be expected and generalisations to the population of meniere's disease sufferers cannot be made, due to the small number of subjects used. some attempts should be made to correlate the acoustic impedance values with results from other tests, used in the diagnosis of meniere's disease. lamb and n o r r i s 1 6 feel that if impedance test results agreed with the ablb test, which according to fowler 8 , indicates cochlear pathology, impedance techniques would be shown to have validity as a test of cochlear function. impedance techniques could, after further research, have a place in a test battery for the diagnosis of meniere's disease, where these may find additional application in recording the gradual pressure increase in the edolymphatic spaces. in this way, attacks may be predicted and appropriate preventative, treatment given. the evaluation of treatments for the relief of increased endolymphatic pressure may be enhanced by the use of impedance techniques. references 1. altmann, f. & kornfeld, m. (1965): histological studies of meniere's disease. ann. of otol, rhinol, & laryngol, 74, 915. 2. caparosa, r.j., (1963): medical treatment for meniere's disease. the laryngoscope, 73, 666. 3. day, k.m., (1963): twenty-five years experience with meniere's disease. the laryngoscope, 73, 693. 4. feldman, a.s., (1963): impedance measurements at the eardrum as an aid to diagnosis. jshr, 6, 315 5. feldman, a.s., (1971): impedance measurement and the middle ear part 1. maico audiological library series, 9, report 7. 6. friedman, i., (1974): pathology of the ear. blackwell scientific publication, london. 7. godlowski, z., (1972): hyperosmosis of endolymph as primary pathogenic mechanism of meniere's disease, and its clinical management. acta oto laryngologica, supplement 229. ι 8. golding-wood, p.h. (1960): meniere's disease and its pathological mechanism. laryngol & otol., 74, 803. journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) impedance measurements in meniere's disease 61 9. grason-stadler, (1973): instruction manual for users of the grasonstadler model i720 otoadmittancemeter u.s.a. 10. hallpike, c.s. & cairns, h. (1938): observations on the pathology of meniere's syndrome. laryngol & otol., 53, 625. 11. jepsen, 0., (1963): middle ear muscle reflexes in man. in modern developments in audiology. (ed.) jerger, j., academic press inc. ltd., london. 12. jerger, j., (1970): clinical experiences with impedance audiometry. arch, of otolaryngology, 92, 311. 13. jerger, j., jerger, s. & mauldin, l.,(1972): studies in impedance audiometry, normal and sensorineural ears. arch, of otolaryngology, 96, 513. 14. johnson, e.w., (1973): clinical application of special hearing tests. arch, of otolaryngology, 97, 92. 15. kohut, r.i. & lindsay, j.r., (1972): pathologic changes in idiopathic labyrinthine hydrops, correlations with previous findings. acta oto laryngologica, 73,402. 16. lamb, l.e. & norris, t.w., (1969): acoustic impedance measurements. in audiometry for the retarded with implications for the difficult to test. (ed.) fulton and lloyd, the williams & wilkins co., baltimore. 17. lamb, l.e., (1971): impedance measurement and the middle ear part 111. maico audiological library series, 9, report 9. 18. lindsay, j.r., kohut, r.l. & sciarra, p.a.,(1967): meniere's disease: pathology and manifestations. ann. of otol, rhinol, & laryngol., 76, 5 19. macrae, j.h., (1973): acoustic neuroma and the acoustic impedance of the ear. jshd, 38, 345. 20. madsen electronics (1974): instruction manual for madsen model zo 70 electro-acoustic impedance bridge. u.s.a. 21. mawson, s.r., (1963): diseases of the ear. edward arnold ltd., london. 22. mccabe, b.f., wolsk, d. & arbor, α., (1961): experimental inner ear pressure changes functional effects. ann. of otol rhinol, & laryngol., 70, 541. 23. noach, m., (1973): lectures in audiology i, university of the witwatersrand, johannesburg. 24. pulec, j.l., (1972): symposium on meniere's disease meniere's disease: results of a two and one:half year study of etiology, natural history and results of treatment. the laryngoscope, 82, 1703. 25. report of the subcommittee on equilibrium and its management committee on hearing and equilibrium, (1972): meniere's disease: criteria for diagnosis and evaluation of therapy, for reporting. transactions of american academy of opthalmology and otolaryngology, 76, 1462. 26. sataloff, j., (1966): hearing loss. j.b. lippincott co., philadelphia & toronto. 27. schuknecht, h.f., (1963): symposium: meniere's disease. meniere's disease: a correlation of symptomatology and pathology. the laryngoscope, 73, 651. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkuiide, vol. 22, desember 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 linda lloyd 28. terkildsen, k. & scott-nielsen, s., (1960): an electroacoustic measuring bridge for clinical us t.arch. of otolaryngol, 72, 339. 29. thomsen, k.a., (1955): employment of impedance measurements in otologic and otoneurologic diagnosis (review). acta oto laryngologica, 45, 159. 30. van n. fick, i.a., (1966): meniere's disease: aetiology and a new surgical approch: sacculotomy (decompression of the labyrinth). laryngol & otol, 80, 288. 31. weiss, a.d., (1966): calorization in relation to otoneurologic diagnosis. in the vestibular system and its diseases. (ed.) wolfson, j.r., oxford university press, london. 32. williams, h.l., (1952): meniere's disease. charles c. thomas, illinois, u.s. a. 33. wilson, t.g., (1965): symposium: management of meniere's disease — historical aspects of meniere's disease. the laryngoscope, 75, 1491. 34. zwislocki, j., (1961): acoustic measurement of the middle ear function. ann. of otol. rhinol, & laryngol, 70, 599. 35. zwislocki, j., (1963): an acoustic method for clinical examination of the ear. jshr, 6,303 indispensable books for teachers of children having language learning problems developmental sentence analysis by professor laura lee (northwestern university) with a chapter by roy a koenigsknecht this is a grammatical assessment procedure for speech and language clinicians. price r 12.60 (r12.35 by post) interactive language development teaching by professor laura lee, roy a koenigsknecht, s mulhern the clinical presentation of grammatical structure. price r13.70 (r14.05 by post) obtainable from campus bookshop 34 bertha street / berthastraat 34 braamfontein 2017 p.o. box 31361 / posbus 31361 telephone / telefoon 72-8541 journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 3 η "d vnnfft. g.r. voogt department otorhinolaryngology η s . s c h o e m a n department mathematics and statistics medical university of southern africa 9 2 tb patients (7-7 years °>> α χ 5 0 0 audwmeter at the^a ^ ^ s i a r l d a r d ^ti-wdrug'o ^ and after treatment, usmga i c > streptomycin very shghuy ο d r u g s were gender specific. • dddel, soos hoorbare opsommis g wmsmsms^-1 hierdie middels geslagspesifiek is nut. κ ϋ ϊ , ototoxicity c; introduction tuberculosis mycobactenû and here a g ^ hon cases of active ^ ^ ^ ^ ' r ^ e n d i n e l l i , 1988). lion new cases annually (fnedman ( t b ) i n redue to the rising incidence of tube ^ ω ^ cent years and the ^ c r e a s ng b a c t e m e n > g t e r . standard anti-tuberculosis ( a n b t b ) ^ g 'l 1993), l i n g > pablos-mendez. kilburn, c a u * e n ^ ^ ^ medical treatment has to rely on accompaof drugs, like the a m l n o g l y c o s d e j ^ ^ ^ ^ o t o nying adverse toxic reactions such as η ρ t o m y c i n toxicity, etc. these aminoglycos^e mclud p ^ ^ and kanamycin. streptomycin has a s e * c o m . the eighth cranial nerve, v e s t i b d a r d a * £ ^ ^ moner than auditory damage. kanamyc 1 9 g 9 ) toxic, causing mainly cochlear damage ( c o l ^ aminoglycosides l r cells in cristae or maculae of the ear. u n c & k a m e r e r > these receptors never regener^ . 0 f having 1985). this places the p h f l c l s v ^ c o u l d result from to weigh the possibility of morbid**^hat coul ^ aminoglycoside administrftion against the ρ effects of the infection being treated. ofthe organ ofcorti,that partofthecoch ^ jo detect the highest systematihear. this damagmg process y ( s c h u k n e c h t , cally progresses s e c t becomes visible 1974). by the time this dama^ng e " h z ω ^ on a conventional has been lost hz), valuable time for p " ™ ^ 1 ^ to the high freand permanent d a a g e has been ^ d b y quency region in the cochlea. * m q h z ) hearregularly monitoring the high j t r e a t e d w i t h ing sensitivity of j ^ v j a n > 1 9 8 4 ) . aminoglycoside drugs (jonndort ^ ^ a t aminoglycoside drugs are admin d e t e r m i n e d b y so-called "ototox^ally safe dobages to ^ ^ standard audiometryganging ftt frequencies hz, while the real and e a r i y ^ m a g ^ ^ ^ g e n e r a . higher than 8000 hz. w i t h t h e a d v e 2 q ^ uon audiometers ^ 6 5 ) and with very good test-rete^t re h e a r i n g a c u i t y of it has become possible to momw o f o t o t o x t h e s e i n d i v i d u a l s t o d e t e c t ^ v e r y e a r j ^ icity, long before j ^ ^ ^ g ^ ^ u v e actions taken to halt it has also been demon, , „ kdskrifvir kommunikasieafwykings, vol. 43, 1996 die suidafrikaanse tydskrif vir λ r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 g.r. voogt & h.s. schoem. strated that cochlear toxicity is reversible in more than half of all cases, if detected early enough and appropriate steps taken (fee, 1980). recently many researchers have done further studies on high frequency hearing and thresholds, with the main aim of eliminating some of the differences that existed amongst the findings of previous researchers. okstad, laukli & mair (1988) compared high frequency air conduction (ac) and electric bone conduction (ebc) thresholds in adults; schechter, fausti, rappaport & frey (1986) and stelmachowicz, beauchaine, kalberer & jesteadt (1989) worked on age-related high frequency ac thresholds; frank (1990) examined high frequency ac thresholds in adults; and frank & dreisbach (1991) tested for repeatability of high frequency ac thresholds in adults. the vast range of differences between testing equipment, subjects and methodology resulted in considerable difficulties when an attempt at direct comparison of their results was made. there was, however, found to be reasonable agreement on high frequency ac thresholds and norms, but less on bone conduction (bc). therefore it would appear that many questions still need to be answered with regard to the exact stimulus pathways and precise components of the ebc sensation. with respect to these presently unanswered problem areas in ebc audiometry it would appear that the only truly reliable method of measuring the effect of ototoxic drugs on high frequency hearing using ebc, would be to compare each patient's post-treatment highest audible frequency test results with his own pre-treatment baseline results. as ototoxicity usually occurs bilaterally and given the fact that ebc cannot at the present time be effectively masked, the test results would indicate the bc hearing sensitivity of the "best" ear. this suits the purpose of this study as the only interest is determining the ototoxic effect of different anti-tb drug treatments on the highest frequency the subject can hear. methodology from patients having to undergo treatment for tb in a tb hospital, all 172 admitted to this hospital in one month were included in this study and followed up over a six month period. these included newly diagnosed tb patients receiving the standard tb medication (a standardised four drug combination of rifampicin, isoniazid, pyrazinamide and ethambutol), patients with resistant tb receiving kanamycin (15 mg/kg/day) and patients with resistant tb receiving streptomycin (15mg/kg/day). this group of patients consisted of 106 males and 66 females, ranging in age from 7 to 71 years old. from the test results of the original 172 subjects, 80 were excluded because they did not have measurable hearing above 8 khz, developed middle ear problems, did not show up for follow-up audiometry, absconded from the treatment regimen, had renal failure, their drug treatment was altered/stopped, or they were discharged from hospital. thus only data from 92 subjects was included in the analysis of the results. all of them had their normal hearing ( 7 8 khz ) and their high frequency hearing ( 8 8 khz ) tested twice in the week prior to commencement of any treatment, and thereafter once a month over a period of six months. the average thresholds of the first two of each type of audiogram of each patient were used as the baseline audiograms for each patient against which any later changes in hear ing was compared. as no effective masking was available for the high frequency tests, the test results indicated the "best ear" high frequency hearing for each patient. consequently, the results of standard audiometry of each p a . tient's left and right ears were also reworked to give a "best ear" test result, in order to be able to compare these results with those from the high frequency tests. a maico ma-41 audiometer was used for the standard audiometry and an audimax 500 for the high frequency tests. the audimax audiometer works on the principle of electrostimulation. the test signal is superimposed on a modulated carrier frequency and is delivered via mylarcoated electrodes into the skin over each mastoid. numerous studies have identified electrostimulation as a means of audio-transmission of electromechanical vibration in the bone and tissue structures surrounding the inner ear and the cochlea. it would therefore appear that the subject's bc hearing is being tested (sommers & von gierke, 1964). this audiometer tests frequencies from 200 hz right up to 20 khz, in 200 hz steps. the stimulus intensities can be adjusted from 0 to 120 electrostimulation hearing threshold levels (eshtl) in 1 eshtl step sizes. zero to 120 eshtl corresponds with zero to 60 db sound pressure level (spl) (voogt, 1987). even though the full frequency range audiograms were recorded every time for the high frequency tests, for the purpose of this study only the highest frequency that the subject was able to hear at the maximum stimulus intensity of the audimax audiometer, was taken into account. all test results for each patient were compared to their baseline test results to determine if any high frequency hearing loss (hfhl) had occurred. the hospital is built on a vast expanse of open field, resulting in very quiet surroundings. the hearing tests were performed in a large and unused dental examination room which is situated a considerable distance away from the main hospital buildings, resulting in an extremely quiet test environment. the treatment regimen for each subject was withheld from the audiologist until completion of the six month treatment period, and the information on the type of medication was given only as standard, streptomycin or kanamycin. therefore the test results were grouped into a kanamycin group (k-group), a streptomycin group (sgroup) and a standard anti-tb drug group (n-group). the test results of these groups were then statistically compared as were the results of males and females within each treatment group. results using standard audiometry, it would appear that none of the subjects in these treatment groups experienced any resultant loss of hearing, as no differences could be found between their final audiograms and their baseline audiograms. this, however, was not the case when considering their high frequency audiograms. in this case very clear resultant losses of hearing could be seen. therefore, only the high frequency audiometric data was statistically analysed. table 1 shows that the mean ages for the three groups were reasonably evenly matched, so the possible effect that age differences amongst the three groups could have had on the results, were negligible. table 2 reflects the characteristics of hfhl between the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) . . t v of aminoglycoside drugs in tuberculosis otot o x i c i t y o i * " the three « ^ ^ i t s e e n that in all three treatment from table 3 it c a n ° u s i g n i f 1 c a n t differences in averagehfhlbet n o t d e r specific, a m i n o g l y c o s ^ ^ ^ ^ w s w a s comprised of a comparison statistical analys g a n d n ) m r e s p t of of the three treatm nt g w a p i g ^ ^ d hfhl by the k x u e j ^ ^ ^ g r o u p s ( c h i highly significant mi p a i r w i s e comparisons m i s t showedthat the mean hfhl value b y the rank sum test sh f r o m ^ m e a n s m i n the k-group d i f f e r j g cimically the means the s-group a n d n p o u p ^ ^ ^ ^ ^ k . g r o u p i h o w . i n the sand n-groups dm & r e s u l t o f the mediever, suffered a marked tir cation they received. table l : age c h a r a c t e r i s t i c s ^ treatment discussion an unfortunate a ^ c t <,f o t o t o x i c i t y t o d ^ e f f e c t o r a y i t , „ f ττϊήι, b e t w e e n t h e three table 2: comparison of h t h l . deiw treatment groups. treatment group κ s ν η 23 12 57 age (yrs) mean 2,17 0,65 0,32 std. dev. 1,76 0,28 0,20 min. 0,20 0,20 0,00 max. 7,60 1,20 0,80 hearing tested regularly ̂ τ τ ^ ^ positive treatand femies were almosi t a b l e * c o m p a r i s o n o l hfffl· b e . » * » « λ » ϋ treatment groups»· lemaies w n u . » 1 hfhl (khz) treatment group male female k-group: η mean std. dev. 11 2,18 1,37 12 2,15 2,11 s-group: η mean std. dev. 5 0,68 0,23 7 0,63 0,34 n-group: η mean std. dev. 35 0,32 1 0,20 22 0,32 0,21 according to teale, uoioman « — whatsoever. it is also possible that this mil ^ r e d u c t i o n which reduction of 12,8 kjiz over * j linearly with ini s whether ^ ^ ^ t h e n . creasing age^ as t h e average ag ^ ^ & ^ ^ group was about 35 5 w h i c h a p . audible frequency of a b o u t 8 k h z b y g ^ pears to fit in well with the fact m a ^ a u d i showing a high frequency ^ ^ ^ e t al. (1989) 0metryfromthisageonwards_ s b d m a c t o w ^ b e g i n s at found that the loss m h * h * a , ( 1 9 8 6 ) 3 0 r s o l d · die suid-afrikaanse skrifvir kommunikasieafs, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 g.r. voogt & h.s. schoeman if this ageing factor is taken into consideration, then it can be deduced that in the s-group, the streptomycin treatment regimen actually had a fairly minor ototoxic effect, as the average hfhl of 0,65 khz should then be reduced by 0,32 khz, giving a 0,33 khz hfhl as a result of the streptomycin treatment. this may then also mean that the average high frequency hearing loss of 2,17 khz that occurred in the kgroup should be decreased by 0,32 khz to 1,85 khz, if the effect of ageing is to be taken into account. it therefore becomes clear that the kanamycin treatment regimen is more than three times more ototoxic than the streptomycin regimen (average hfhl of 2,17 khz vs. 0,65 khz). if the above-mentioned correction for the effect of ageing is taken into consideration, then it means that the kanamycin regimen is almost six times more ototoxic than the streptomycin regimen (average hfhl of 1,85 khz vs. 0,33 khz). conclusion this study showed that high frequency audiometry is superior to standard audiometry with regard to the early detection of ototoxicity and that the use of standard audiometry for detecting ototoxicity is really of no clinical value. furthermore it was found that the so-called "safe" levels presently used in anti-tb treatment still lead to ototoxic damage. these levels will most probably have to be revised. the kanamycin treatment regimen was found to be three times more ototoxic than that of streptomycin. ageing was also found to have a possible effect on the hfhl measured. if a correction was made for hfhl occurring as a result of ageing, then kanamycin was found to be almost six times more ototoxic than streptomycin. it was also found that kanamycin and streptomycin ototoxicity were not gender specific as males and females were equally affected. lastly it became quite clear that the specific effects of ageing on the high frequency hearing will require further long-term studies. references collins, t.f.b. (1989). tuberculosis understanding and managing the disease. south african national tuberculosis association. de vaal, j.b. (1994). aspects of aminoglycoside therapy. specialist medicine, xvi(10), 24-60. fee, w.e. (1980). aminoglycoside ototoxicity in the human. laryngoscope, 90(suppl 24), 1-18. fletcher, j.l. (1965). reliability of high frequency thresholds. j. aud. res., 5, 133-137. frank, t. (1990). high frequency hearing thresholds in young adults using a commercially available audiometer. ear hear, 11(8), 450-454. frank, t. & dreisbach, l.e. (1991). repeatability of high frequency thresholds. ear hear, 12(4), 294-295. frieden, t.r., sterling, j., pablos-mendez, α., kilburn, j.o., cauthen, g.m. & dooley, s.w. (1993). the emergence of drugresistant tuberculosis in new york city. n. engl. j. med., 328, 521-526. friedman, h. & bendinelli, m. (1988). preface in: m. bendinelli & h. friedman (eds.), mycobacterium tuberculosis. new york: plenum press. johnson, j.t. & kamerer, d.b. (1985). aminoglycoside ototoxicity: an update, with implications for all drug therapies. postgraduate medicine, 77(5), 131-138. okstad, s., laukli, e. & mair, i.w.s. (1988). high frequency audiometry: comparison of electric bone-conduction and airconduction thresholds. audiology, 27, 17-26. schechter, a.m., fausti, s.a., rappaport, b.z. & frey, r.h. (1986). age categorization of high-frequency auditory threshold data. j. acoust. soc. am., 79(3), 767-771. schuknecht, h.f. (1974). pathology of the ear. cambridge, massachusets: harvard university press. sommers, h.c. & von gierke, h.e. (1964). hearing sensations in electric fields. aerospace medicine., 35, 834-839. stelmachowicz, p.g., beauchaine, k.a., kalberer, a. & jesteadt, w. (1989). normative thresholds in the 8to 20-khz range as a function of age. j. acoust. soc. am., 86(4), 1384-1391. teale, c., goldman, j.m. & pearson, s.b. (1994). the association of age with the presentation and outcome of tuberculosis: a five year survey. j.ar.d., 6(4), 7-10. tbnndorf, j. & kurman, b. (1984). high frequency audiometry. annals of otology, rhinology and laryngology, 93, 576-582. voogt, g.r. (1987). early detection of ototoxicity by high frequency audiometry a case study. south african journal of communication disorders, 34, 67-70. the south african journal of communication disorders, vol. 43, 1996 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) november journal of the south african logopedic society pre-school language education for the brain-damaged child , ν r read at the 1956 summer meeting, alexander graham bell association for the deaf, june, 1956. a paper reaa j l b a n g s ) p h . d . it is essential that the speaker restrict his discussion in certain ways. in the first place, he does not have practical training nor expcnence in the academic education of the brain-damaged child and any comments made concerning this discipline would be based upon purely theoretical considerations. as a matter of fact the title of this paper should be "the language development of the preschool brain-damaged child," but in view of the over-all panel topic, the word education as inserted makes my presence more acceptable. there are so many facets to the generic term brain-damaged that we sometimes spend many professional years in happy argument with colleagues (who are obviously in error in their thinking) before we realize that we are not talking about the same child, the same age level, the same damage or even the same educational levels or processes. in view of this, i would like to define the various terms i shall be using. the children i am discussing are of preschool age and have central involvements which do not result in primary symptoms of athetosis, spasticity, ataxia or flaccidity. in other words, they are not cerebral palsied in the usual connotation of this term. it is, of course, true that these physically handicapped children may have some of the language problems with which i am concerned. it is possible that we do not all use the term language with the same concepts in mind. in this paper, language will refer to all of the symbolic processes which enter into human communication; it includes facial expression, emotional outcries, gestures and words whether they are perceived or used by the'children under discussion. the term speech, on the other hand, refers to the process of articulating words and though i am certain that speech problems of central etiology are commonly seen, i am not concerned with them in this paper. finally, the preschool children i wish to discuss are intellectually normal or dull normal, do not have significant sensory involvements of audition, and have given medical and/or psychometric evidence of brain-damage. though defective audition may play a considerable role among some of of these children, i am eliminating from discussion those with losses between 500 and 2000 cps in excess of 25 db. as well as those with precipitate losses above 1000 cps. it is not apparent that we are interested in, and working with, a rather homogenous group of children and i am sure that most of you have anticipated one of the most difficult problems confronting us; the procedures needed to identify these children adequately. proper evaluation is, in my estimation, the first step in the training process and, in many ways, one of the most difficult. inasmuch as we are interested in the brain-damaged, language-retarded child, the evaluative process usually starts in the home. parents become alarmed when their children fail to use words at appropriate age levels. their first stop is the pediatrician who then utilizes the services of the neurologist who in turn refers to the psychologist, audiologist and speech pathologist. this team provides the therapist with a delineation of the child's assets and liabilities, if the various members have done their work properly and, of course, providing each was able to conduct an examination. in addition, each member of the team conducts his habilitative-treatment function, though in many instances relying on the reports of other members when determining what to do. typing, duplicating, translating marie van der merwe's secretarial service (member of the s.a. society of translators and interpreters) 106 national mutual life ass. ass. building, cor. rissik & market streets, johannesburg. phones: office: 23-8084. evenings 46-1476 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society november language education i am concerned with the languageeducation process, so will devote a little time to a view of the team information as seen through the eyes of the teacher-therapist. from the medic, she wants to know the following: 1. does the neurological report show evidence of brain damage? 2. if drug-therapy is in progress, what is the contemplated effect on the child's behaviour, i.e. should it slow him down or speed him up? 3. are seizures to be expected or are they under drug control ? 4. if eeg results are positive are they focal or general and what interpretation does the psychologist make of the pattern? 5. if there is no apparent neurological evidence of brain damage, should the teacher observe the child for a period of time and report her observations before subsequent examinations are made? from the psychologist, the teacher-therapist wants to know: 1. the child's intellectual level. 2. his perceptual capacities — visual, auditory, tactual. 3. his social development levels, 4. if possible, some information regarding the parent-child relationships. the audiometric results should ultimately confirm the presence of hearing within normal limits and information from the speech pathologist should report the child's language level though in many instances the language evaluation is made after observation over a period of time by the therapist. after considering all of the information given her, the teacher is ready to begin language training and though training is a group process, each child's capacities are considered and each gets some individual work as he progresses. socialization is the first step in therapy. by socialization i do not mean just a reduction in the behavioral problems of the brain-damaged child. on the contrary, there are many specific processes to be altered and social behaviour changes accordingly. socialization in the sense i am using it involves alterations in the child's self-concept, development of parallel play, then cooperative play and establishment of identification with parents, teachers and other children. these changes are brought about by parent counselling, structured free play activities in which limits are gradually set up, and by providing each child with responsibilities commensurate with his age level. more specifically, these changes are effected by providing a therapy environment which minimizes previous frustrations such as a lack of oral communication, but provides recognition and builds up a sense of self-worthiness. parent counseling parent counselling is of paramount importance at this time. because of the child's language deviation, he is often overprotected and has usually been sheltered from his peers. he has seldom had the opportunity to play with a variety of children of his own age. the result is a dependent child whose parents are still undressing him, bathing him carrying him and catering to his every need, often even at the age of five years. paradoxically for the parents, they are usually confronted with a hyperactive, uninhibited and destructive child whose behaviour is so varied and unreasonable that it defies their understanding. parents are faced with a situation involving on the one hand their desire to overprotect, and on the other hand a rejection of their overtures by their offspring. the result is usually emotional confusion and ambivalence which is conveyed to the child. the teacher must also be able to accept the activities of her charges and not allow anger, frustration or impatience to appear. she must recognize that the same organic limitations which have caused the delay in language development may be responsible to some extent for the typical behaviour and inability to relate to others. by building a play environment in which the children feel accepted yet within which they are, to some extent, restricted according to the limitations set up by the therapist, speech therapists fully qualified are invited to apply for posts at the united cerebral palsy association of south africa, diagnostic clinic and treatment centre, situated at townsview, johannesburg. telephone 23-7034, or write secretary, box 10398, advising availability. part or full-time posts offered r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society the latter has actually provided her pupils with security. they then begin to identify themselves with the teacher, parents and peers. one of the important language by-products often seen in this period of training is the ability to express emotions appropriately. many of these children do not smile, laugh, cry or appear sad when confronted with situations appropriate to the expression of the emotion. part of the therapy programme, then, should be devoted to the development of situations which are funny or surprising to the group, with the therapist setting the example by an appropriate response. language stimulation the second step in training involves language stimulation. the children are given more play situations structured by the therapist in such a manner that communication among the children becomes increasingly important. the teacher, however, must g u a r d "against formal speech training during this phase. parents, siblings and relatives have constantly pressured these children to "say something," with a resulting frustration and finally rejection of speech by the child. de-emphasis on the act of speaking, accompanied by play situations normally requiring spontaneous communication, is imperative. at the same time the therapist must use simple language in abundance as she participates in the activities or develops the teaching situations. tape recording a complete therapy session and then listening to it will be helpful to teachers in this part of a training programme. it is quite difficult to confine your oral activity to stimulation and example and not to try to force a speech response from a pupil. listening to their part of the play session will reveal to teachers many of their errors. the language stimulation aspect of training, through properly directed co-operative and competitive play, will gradually bring about the child's awareness of a need for communication. at this point gestures and pulling may turn into jargon. an occasional word used by the therapist, or one of the children in the; group, will be repeated, possibly out of context with the actual play situation. again, no attempt is made to force a repetition or to emphasize speech per se. parent conferences on an individual and group basis should include discussions of the reasons for eliminating speech pressure, the development of a home stimulation programme that involves looking at and talking about familiar objects in the home or in suitable picture books, and considerable repetitive language during meals and other home group activities. the practice of showing off the child's new word to friends and relatives must be avoided. the next progression in therapy is concerned with the elaboration of vocabulary and useful speech. at this time field trips to zoos, farms, and other stimulating areas should be planned. the play activity within the classroom situation should be widely varied to provide for greater language example and stimulation. during this period useful words appear and become integrated into two word sentences. for the children language becomes a means of asserting themselves. the words which appear will be misarticulated more often than not, but no correction should be made. it is sometimes difficult at this time to keep from initiating speech therapy for articulation errors; however, the teacher will resist if she remembers that chronologically her charges may be four or five years of age, but so far as language development is concerned they now range between 16 and 20 months. from here on vocabulary development is accompanied by a school readiness programme. we frequently utilize the services of a good nursery school or kindergarten at this time by placing some of our children among normal speaking children for short periods of time each day. finally, they are left in the new school environment, but with a speech therapist observing and conferring with the new teacher when it seems essential. attention to articulation may accompany this phase of the programme. the programme i have outlined functions on several premises: 1—that these children by age four are in a language readiness state; 2—that language pressures and frustrations have added a strong psychological overlay to what was basically an organic problem; 3—that direct speech therapy or training will tend to further inhibit speech and language as well as to increase emotional problems; and 4—that the emergence of language follows socialization and development of a need for communication. dr. bangs is director of the houston speech and h e a r i n g centre, houston, texas. h i s paper was read as part of a panel discussion on " t h e education of aphasic childr e n " at the afternoon session, june 21, 1956. the volta bureau, reprinted with permission. miss bessie dembo 54 wingate mansions cor. smit & nugget streets, hospital hill, johannesburg phone 44-0860 typing and roneoing undertaken especially theses and students notes r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 3 editorial e t pierre de villiers pienaar it is with great and singular pleasure that the south african speech and hearing association dedicates this issue of the journal to pierre de villiers pienaar. professor pienaar, father of speech therapy and audiology in south africa, retired from the university of pretoria at the end of 1972 and is now professor emeritus of that university. those workers who have been associated with professor pienaar in the fields of speech pathology, audiology, phonetics and general linguistics are many indeed. the persons contributing to this issue were invited to do so in view of their associations with p. de v. pienaar. many more than are represented here have however had close links with him but the modest length of our journal prevents the publication of more papers than this issue is carrying. several who have had long standing contact with professor pienaar regret that they are unable to produce papers for this issue but at the same time express their very best wishes to him on the occasion of his retirement these are professors d.t. cole, c.m. doke, g. paul moore and c. van riper. the following contributors to this issue are honoured to be given the opportunity to pay tribute to pierre de villiers pienaar: professor aron, who covers the academic and professional life of p. de villiers pienaar, was a student in logopedics at the university of the witwatersrand and first worked as a clinician at the speech, voice and hearing clinic under his headship. professor westphal was a student in phonetics under professor pienaar at the university of the witwatersrand. dr. s.r. silverman of the central institute for the deaf, st. louis, u.s.a., professor r. luchsinger of zurich, and dr. p.h. damste of the university of utrecht, holland, have all had long professional contact with p. de villiers pienaar. margaret marks and isabella uys, senior lecturers, have both been students in logopedics under professor pienaar at the university of the witwatersrand and both worked with him at this university, mrs uys joining him later in the department of speech science, logopedics and audiology, university of pretoria. professor hay first joined professor pienaar at the university of pretoria working in the area of electro-acoustics and audiology, and on professor pienaar's retirement became head of the department of speech science, logopedics and audiology. professor l.w. lanham, head of the department of phonetics and general linguistics at the university of the witwatersrand, was a student in phonetics under professor pienaar, and dr william kerr, a distinguished oto-laryngologist in south africa has had professional liaison over many years in the area of voice disorders with p. de v. pienaar. we thank all those who contributed to this festschrift and join them in wishing pierre de villiers pienaar good health, and a contented, fruitful retirement. tydskrif van die suid-afrikaanse vereniging vr spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c s o c i e t y the cortical localisation of speech; 1. an analysis of preliminary difficulties m. wright. m.sc.. m.b.. b.ch. (formerly registrar at the national hospital for nervous diseases, queen square, london. at present electroencephalographer to tara hospital.) introduction. the initial premise of the discussion is that a lack of an accepted and relevant analysis of language, a s an aspect of human behaviour and experience, has necessarily caused a diversity in the classification, description and explanation of partial l a n g u a g e defects produced by localised cerebral d a m a g e . the formulation of the previous sentence reveals that a strong element of tautology may lie within it. hence advocates of any particular description of aphasic defects might agree that the premise essentially is a tautology, but assert that they possess the only relevant analysis of l a n g u a g e ; alternatively they could deny both the validity and the tautologous nature of the premise on the grounds that an accepted and adequate analysis of l a n g u a g e is not lacking (or perhaps is unattainable) and that diversity of terminology depends solely on disagreement concerning the physiological or psychological mechanisms whereby cerebral d a m a g e leads to partial failure of the l a n g u a g e process. the latter opinion seems untenable since the various terms applied to the aphasia reflect a divergence in the approach to l a n g u a g e behaviour rather than a disagreement on cerebral mechanisms ; "sensory" (aphasia) and "motor" (aphasia) presuppose an analysis of l a n g u a g e in the manner of clinical neurology, "expressive" and "receptive" a p h a s i a (weisenberg and macbride (10)) are a product of psychology, while "nominal" and "syntactic" are adjectives borrowed from the schoolroom study of grammar. such fundamental differences of approach preclude even a preliminary discussion of physiological mechanisms since the initial step in any scientific investigation, namely the formulation of a problem in relation to specific techniques, has a s yet been left undone. two examples (one hypothetical, another historical) derived from the neurological description of sensation illustrate and further emphasise the site of "pathology" in those clinical descriptions of language defects which presuppose on everyday familiar analysis of l a n g u a g e :— imagine the incredible difficulty which would result if the ascending fibre tracts in the spinal cord should have to be described without the analysis of sensation offered by the everyday words "pain," "sight" (vision), "touch" etc. the outcome could only be an anatomical description of nerve processes and pathological lesions, on which much useless philosophical comment could well be raised. however, confusion is averted b e c a u s e a n analysis of sensation does exist; moreover the analysis is both adequate and relevant since it is incorporated within every l a n g u a g e and thus can only be criticised a s being too subjective if it b e supposed that the whole of humanity is deluded. the second example concerns the deleterious effect on the physiology of sensation caused by the introduction of the two descriptive terms "epicritic" and "protopcrthic" sensation. walshe (9) has displayed the logical non sequiturs that are implied in the original definition of their terms and also the errors in clinical and physiological interpretations that may result from their use. the two terms are b a s e d on an evolutionary, and thus necessarily hypothetical, interpretation of certain clinical findings following nerve lesions ; they belong to abstract theory and not to observation nor convention ; they must stand or fall on an empirical test of their usefulness to neurophysiology and they are discarded because they are neither an adequate nor a relevant addition to the analysis of sensation. the argument that any particular classification of the ap hasia is b a s e d on an adequately instructed analysis of l a n g u a g e can only be refuted by showing that the analysis in question is not acceptable because it is not relevant. it is suggested that relevance in this c a s e can be equated with the notion "useful for physiological or experimental psychological investigations." thus an analysis of l a n g u a g e must at least contain terms definable by direct observation or by precise logical deduction from direct observation, and the formal statement of the analysis must have intrinsic logical r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c s o c i e t y o c t o b e r cohesion; once the latter criteria are met, there remains the empirical test of whether there is enough useful correlation between the formal analysis and the processes of l a n g u a g e a s revealed in normal and aphasic subjects. the result of the empirical test determines the adequacy and relevance of the analysis. it follows from the two preceding paragraphs that no purely introspective or "mentalistic" description of l a n g u a g e is acceptable b e c a u s e it must lack definitions b a s e d upon impersonal observation and b e c a u s e it has not peculiar authority, possessed by the terms for subjective sensations, of incorporation within the everyday language of all people. the apparent insight wisdom and complexity of these theories represent a very real intellectual danger since, like all "supraterrestrial edifices," their castles in the air can be suitably moulded to fit successively the earthy environment of diverse and discrete observations. no less dangerous are theories which openly eschew "introspection" but forthwith rise to the even more rarefied atmosphere of "total cerebral function," "oragnism a s a whole" and "integrated personality." a second premise may now be stated a s follows; the analysis of the content, logical form and everyday use of l a n g u a g e belongs to the field of modern logic. it is probably true that many neurologists and speech therapists have never even considered the significance of the specific analysis of l a n g u a g e a s a separate field of investigation ; the term language behaviour may indeed seem unreal, unnecessary or even misleading. the clinical neurologist has approached speech via the spinal cord and brain-stem, thus, not unnaturally, talks of "motor" and "sensory" aphasia. unfortunately the terms "motor" and "sensory" possess but a fraction of their "spinal usefulness" for even the simplest problems of cortical physiology; they are necessarily even less effectual a s descriptive elements of the cortical mechanisms underlying languarge. modern electrophysiological research on the cerebral cortex has produced a terminology which is so specific to the experimental operations employed that it can have no application to the analysis of aphasia. moreover electrophysiology is an aspect of biophysics rather than clinical neurology and its techniques and terms are even less comprehensible to the clinician (who is not trained specifically a s a scientist nor a s a physiologist) than are the methods of logic. the speech therapist, on the other hand, approaches cerebral mechanisms from the more detached discipline of psychology (which assertion is not derived from first hand experience and is open to correction). the logopaedic approach, while more promising, would do well to avoid introspective analyses of l a n g u a g e and especially to avoid the presumption that clinical neurologists are in any way better equipped to analyse language in the normal or the abnormal; to which, surely, the medical literature on ap hasia is testimony enough. there are several relatively recent publications by competent logicians dealing especially with the analysis of l a n g u a g e processes. those of morris (6, 7, and 8), carnap (2, 3 and 4),bloomfield (1) and longer (5) are particularly relevant to the theme. within their works there is general agreement on the framework of the logical analysis of l a n g u a g e ; the scope and the precision of development of ideas show convincingly that this field of logic is not one into which an amateur may stray without much purposeful effort. to quote from bloomfield (1, p. 54-55):— "the subject matter of linguistics, of course, is human speech. other activities, such a s writing, which serve a s substitutes for speech, concern linguistics only in their semiotic aspect, a s representations of phonemes or speech-forms. since the meanings of speech cover everything (designcrta, including denotata ; syntactic relations; pragmatic slants), linguistics, even more than other branches of science, depends for its range and accuracy upon the success of science a s a whole. for the most part, our statements of meaning are makeshift. even if this were not the case, linguistics would still study forms first and then look into their meanings, since l a n g u a g e consists in the human response to the flow and variety of the world by simple sequences of a very few typical speech-sounds. linguistics is the chief contributor to semiotic. among the special branches of science, it intervenes between biology, on the one hand, and ethnology, sociology, and psychology, on the other : it stands between physical and cultural anthropology. l a n g u a g e establishes, by means of sound waves and on the basis of communal habit, an ever ready connection between the bodies of individuals—a connection between their nervous systems which enables each person to respond to the stimuli that act upon other persons. the division of labour, civilization, and culture arise from this interaction. popularly and even, to a large extent, academicr ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c s o c i e t y ally, we are not accustomed to observing l a n g u a g e and its effects: these effects are generally explained instead by the postulation of "mental" factors. in the cosmos, langua g e produces human society, a structure more complex than the individual, related to him somewhat a s the many-celled organism is related to the single cell." evidently there has been no lack of effort on the part of logicians. therefore it seems to me significant that i can find no reference to such work in clinical descriptions of speech defects, and that in teaching neurology to logopaedic students there have been none who have heard of the logicians quoted above. at least an attempt at correlation would be interesting if not fruitful. formulation suitable for the empirical investigation the development of semiotic, the science of signs and languages, has been extended by morris (1938, 1946) in the vigorous manner of mathematical logic and also in the empirical tradition of objective psychology. in the following paragraph some of *he terms from semiotic are explained briefly, but there will b e no attempt to follow the precision characteristic of morris or carnap (1943). the description of l a n g u a g e processes (i.e., semiosis) may be divided into the related spheres of semantics, syntactics and pragmatics. semantics deals with any empirical observation or logical analysis concerning the relationships (i.e., the semantic relationships) existing between a linguistic expression and the object or event to which that expression refers; syntactics is concerned with the relations (i.e., syntactic relations) between two or more of the numerous symbols (generally words) within a l a n g u a g e ; pragmatics describes ι relationships (i.e., pragmatic relation) between linguistic expressions and the overt behaviour of such individual(s) who may utter or respond to the expressions. it is submitted that these notions constitute a preliminary analysis of language which does not outrage common sense and which presumably satisfies the logical criteria for a potentially "useful" analysis since it is a produce of competent logicians. it gives power, within limits, of abstracting three groups of entities (i.e., "objects of the physical world," "words," "human behaviour") and providing objective descriptions of relations existing within or between the groups. that a process of abstraction is involved is admitted, indeed it is axiomatic, but the abstractions are made deliberately and are well controlled; surely it is unreasonable to insist always that the process of l a n g u a g e "must be considered a s a whole" simply because it is impossible to do so. applying the three primary divisions of semiotic to descriptions of partial l a n g u a g e defects resulting from localised cerebral damage,it seems that any description in which specific reference can b e confined to the relations between words and objects to which they refer belongs to the field of descriptive semantics; any description in which specific reference can be confined to the relations between linguistic expressions (e.g., in the formulation of sentences) belongs to the sphere of descriptive syntactics, while descriptions in which specific and necessary reference must b e made to the patient's response to words (e.g., his understanding of words) belong to descriptive pragmatics. in any discussion of a partial l a n g u a g e defect, it is, therefore, important to decide whether reference to the patient (by name or personal pronoun) is incidental or whether it is a necessary part of the description. the' test situation should prompt the decision; if, for example, an object is shown and the patient names it, then the fact that the name is pronounced by the patient could be noted by several independent individuals and could b e described without reference to a particular patient; if, on the other hand, the patient's response to a written or spoken word is such that he apparently does not understand that world, then the defect can only be described by reference to the patient's behaviour. it is submitted that the common tests for ap hasi a and verbal agnosias can be classified into three groups which test the integrity of semantic, syntactic and pragmatic relationships respectively. further, the character of the test (the stimulus) and the observed response can be formulated so that an objective description may be given of any defect which is revealed. hence the terms semantic aphasia, syntactic aphasia and pragmatic aphasia are suggested on the grounds that they are readily and rather precisely defined from the test situation, and because they are derived from an adequate analysis of language. it then is necessary to decide if the analysis of language, and the terminology of l a n g u a g e defects derived from it, is not only adequate but also relevant. this is a matter for empirical investigation which must determine whether the proposed nomenclature "fits" defects actually encountered in clinical neurology. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d c s o c i e t y o c t o b e r elementary empirical testing this section must be the least complete within itself, for the field of possible amplification and application of terminology to clinical conditions is immense. one amplification will be introduced at once; each of the three primary types of application can be revealed by stimuli directed to the patient by one sensory channel (i.e., sight, hearing, touch) alone). it is thus possible to recognise visual, auditory and tactile varieties of semantic a p h a s i a ; visual and auditory subdivisions of syntactic aphasia, and visual and auditory varieties of pragmatic aphasia. the mode of subdivision is very similar to that used by nielsen (8) for types of agnosia and in the latter application has been proved very useful. a further amplification on the basis of the site of pathology will not be attempted since there is no s p a c e to present the evidence for cerebral localisation of the lesions producing each type of aphasia ; another amplification b a s e d on the type of "words" used in the test situation (i.e., "nouns" or "abstract words") suggests itself but i am not competent to apply the idea. the one application, which is chosen because it seems conclusive, is simply that types of a p h a s i a which would fall under the categories semantic, syntactic and pragmatic do occur in clinical neurology. semantic a p h a s i a s are described by nielsen (8) a s amnesic a p h a s i a s ; syntactic a ph a s ia is equivalent to the latter author's formulation aphasia, while pragmatic aph a s i a is called semantic aphasia by nielsen. the use of "semantic" by nielsen and his predecessors is indeed unfortunate and depended on the older and wider sense of the word semantic by which it included the whole of semiotic (i.e., it included semantics, syntactics and pragmatics). the case for renaming the older semantic aphasia, now calling it pragmatic aphasia, rests on the more authoritative claim of the modern analysis of l a n g u a g e and hence of "meaning." in my experience, the use of the proposed terminology gives a neater view of speech defects; it gives also further insight into the physiological mechanism of speech in the cerebral cortex, which insight is a powerful weapon upon the view that speech processes possess no precise cortical localisation; while finally it gives the most hopeful promise of clearing the "jargon" by which many descriptions of a p h a s i a induce a marked degree of pragmatic ap ha s i a among the audience. "pure" a p h a s i a s are very rare, but surely then, when they do occur, they should be studied by the best possible techniques among which the logical analysis of l a n g u a g e is certainly to be numbered. bibliography. 1. blomfield, l.—"linguistic aspects of science." international encyclopaedia of unified science, vol. 1, no. 4. chicago. university of c h i c a g o press, 1939. 2. c a r n a p , r.—"foundations of logic and mathematics.' international e n c y c l o p a e d i a of unified science, vol. 1, no. 3. chicago. university o! c h i c a g o press. 1939. 3. carnap, r.—"formalisation of logic.' c a m b r i d g e . harvard university press, 1943. 4. c a r n a p , r.—"meaning and necessity.' c h i c a g o : university of c h i c a g o press, 1947. 5. langer, s. k.—"philosophy in a new key." cambridge : harvard university press. 6. morris, c.—"foundations of the theory of s i g n s . " international encyclopedia of unified science. vol. 1, no. 2. c h i c a g o : university of c h i c a g o press, 1938. 7. morris, c.—"signs, l a n g u a g e and behaviour." new york : prentice-hal!, inc., 1946. 8. nielsen, j. m.—"agnosia, apraxia, a p h a s i a . " new york : paul b. hoeber, inc., 1946. 9. walshe, f. m. r.—"the anatomy and physiology of cutaneous sensation. a critical review." brain. vol. 6 5 : 48-112, 1942. 10. weisenberg, τ. h. and macbride.—"aphasia.' brattleboro : e. l. hildreth and co. inc., 1935. books on speech defects improving the child's speech : virgil a. anderson. price : 34/-. post 1/3 speech correction through story telling units : e. mcg. nemoy. price : 35/-. post 1/3. language and language disturbances : aphasic symptom complexes and their significance for medicine and theory of language. k. goldstein. price : 81/3. post 1/6. speech h a b i t a t i o n in cerebral palsy : marion t. cass. price : 25/6. post i / . cerebral palsy : j. f. pohl. price: 46/3. post i / . aphasia therapeutics : longerlch and bordeaux. price : 32/-. post i / . diagnostic manual in speech correction : wendell johnson et al. price: 23/3. post 1/3. speech improvement cards : bryngelson and glaspey. price: 55/6. post 1/6. stuttering : e. f. hahn. price : 25/6. post i / . vanguard b o o k s e l l e r s 23, joubert street, johannesburg telephone 23-3511 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) o u r n a l o f s o u t h a f r i c a n l o g o p e d i c s o c i e t y stuttering therapy an integration of speech therapy and psychotherapy. m. aron. the utilization of psychotherapy and speech therapy together is fast being recognised as an indispensable approach in the majority of the up-to-date speech clinics. the integration of these two procedures is seen most clearly in therapy with stutterers, and combined they have very reasonably the same objective in view. there are probably few today who still administer a purely mechanical and symptomatic approach to stuttering and on the other hand, few who ignore the symptom and are only concerned with psychotherapy. they are both necessary. the stutterer presents himself originally at the clinic as an individual with feelings of fear and embarrassment and he possesses a symptom which is regarded as being abnormal by his society. he is not presenting an isolated overt symptom—there are a chain of symptoms, affected by one another and having profound influence upon the internal and external aspects of behaviour. in the past it has been emphasized in many schools that speech therapy is dependent on other disciplines for its correct and stable maintenance, and that we must keep in mind the boundaries of our field. however, new techniques are continually being evolved where over-lapping into other fields cannot be avoided. progress in the fields of work dealing with people appear to be slowly amalgamating and inter-relating. if^we are going to look at a human being as a "gestalt" then perhaps we should look at the science dealing with him also as a "gestalt." that is not to say that we are eligible to practise in its entirety a science other than the one in which we are qualified; but we would be failing if we denied that we do use some necessary principles from other fields and that there is overlapping. the very nature of a speech disorder demands an organismic therapy. speech cannot be isolated from behaviour and personality. goldstein (1) comes to the following conclusion as to the nature of language — "language is a means of the individual to come to terms with the outer world and to realize himself," and eisenson (2) says "the function of speech is to cause response of thoughts, feelings or actions to occur in someone". language (speech) is a social institution and as such it cannot be removed from other aspects of our culture pertaining to ourselves and our thoughts without distortion to the picture as a whole. if we regard stuttering as avoidance behaviour (3, 5), and the stutterer as an individual on constant vigil so that he might avoid or postpone words and situations which are fearful to himself then we can expect an integrated approach of speech therapy and psychotherapy to be more fruitful. psychotherapy deals with the individual making new adjustments to life and finding more satisfying relationships where he is temporarly unable to do so for himself. sheehan (4) has said that stuttering not only expresses the nature of the stutterer s relationships but is in part determined by them. deep psychotherapy is of no concern to the speech therapist, but nevertheless the basic principles used, including mental hygiene, become incorporated in speech therapy. group therapy for stutterers practised in parts of the states and canada uses this combined approach. it deals with the handling of fear that the individual has generally and also the fears as regards his blocks, with the changes of attitudes towards himself, his speech and towards his particular societv group; as well as providing tools to enable him to appreciate the problem symptomatically and to change his pattern of stuttering. this approach is one practised by the "iowa school" (4, 5, 6, 7), and is the one used by douglas in toronto which i observed. because of the use of this particular approach in these groups, i.e., the integration of psychotherapy and speech therapy, it can be expected that problems and changes in the individual will continually occur. the material is dynamic, personal and individual and the therapy can be described as a process in itself. psychotherapy "is a procedure which is intended to make a progressive change in the patient" (8). also because of the elements constituting and causing language and speech, defects and the rehabilitation of these defects must also cause changes in the individual and in his total expressions, v r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) o u r n a l o f s o u t h a f r i c a n l o g o p e d i c s o c i e t y a r l if we regard a stutterer's progress as being due only to speech therapy in its strictest definition, then we are incorrect, for the changes that occur and make progress possible are due, by definition, to the psychotherapeutic and speech therapeutic aspects of therapy. this was clearly illustrated to me when i observed stuttering group therapy. the groups emphasized the part that attitudes and personalities play. while using a mechanical approach to stuttering, a group on its own accord (because of the very nature of a group) would, i feel, still make demands for psychological concepts to be made explicit as regards their problems. apart from the fact that group therapy is more expedient than individual therapy, it has many social and psychological facets. some of these are : (a) the group provides a ready "audiencereactor" and it can be considered as the first step in the stutterer's new social relationships. (b) it provides for the stutterer a number of people who, having worked together with him, can understand his problem more readily than the outsider, can emphasize, support and counsel. (c) the group can engage itself in feared activities and can enable the individual to do collectively what they otherwise might not have been able to do (9). (d) participation is made easier and more free than if an individual would have to attend meetings by himself. it is a more tolerable situation (10). (e) attitude and conflicts which previously the stutterer thought he alone was afflicted with, become rather common attitudes and conflicts that are exhibited by the group. three sudh groups were undertaken at the speech clinic at the toronto psychiatric hospital while i was employed there during 1955. douglas believes that the stutterer should be first educated in the problem of stuttering before dealing with the actual therapy. this should eliminate misunderstandings; clear up notions as to the cause, its nature and development; and indicate techniques and attitudes that will be used and sought after during the therapy process. the information helps to objectify his problem and will make clear to him the nature of his rehabilitation and make possible also for the intellectual appreciation of the problem. these groups were handled with three different approaches as regards the educational period and was extended where possible into the therapeutic situation. (a) the directive-diadactic approach. here the group was educated in the problem of stuttering as a group of speech students would be. this approach also carried over into most of the therapeutic sessions including personal problems. points were made and suggested but they were not pushed or stressed at all as regards the members acceptance or understanding of them. the least possible assistance was given in therapy unless it was made explicit by the members that they required assistance. (b) the socratic approach. this concept implies "that all knowledge lies within so that in reality education proper is a process of recollection or recognition. the truth so acquired is reached by a personal discovery." the word "educate" implying the same, derived from the latin, "educ", meaning "to lead out," "to draw forth," "to elicit." this approach was therefore non-directive, bearing similar principles to that used in "non-directive counselling." information was drawn out by asking the right questions at the right time. the members of the group disdiscussed problems in the order that they vacancy for speech therapist the eastern province cerebral palsy school, port elizabeth one speech therapist is required from the beginning of the first term 1957 applications should be addressed to: mrs. h. lurie, 30, wares road, port elizabeth. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a p r i l j o u r n a l o p t h e s o u t h a f r i c a n l o g o p e d i c s o c i e t y s desired and any point that was made in the group was made by the group itself. at times the clinician recapitulated in his own words what was being said. where possible this was carried over into therapy, but at times because of circumstances dealing with individual problems, it could not always be as non-directive as desired. the main responsibility was placed on the patient's shoulders and "support" was implied. he was encouraged to carry this responsibility rather than to lean on the clinician, (c) the directive explanatory approach. here the group was educated in the problem of stuttering most directively. they were taught as a group of children would be. each step was most carefully explained over and over again, simplified and illustrated. therapy was dealt with in the same manner and "laid on the line." (i.e., everything was handed to them on a platter). the three groups consisted of carefully selected stutterers. with the aid of tests, they were selected with regard to being intelligent and for being relatively free from the possibility of emotional breakdown (other factors were taken into consideration for selection). no attempt at all was made to establish controls or standards of any kind in these groups with a view to making later comparisons. although the approach to the three groups was different, the therapy for these groups remained, where possible, the same. that is, going into feared situations, practising nonavoidance; symptom-analysis (i.e., analyzing tricks of an avoidance, postponement, starting, release nature, etc.), changing the pattern, using prolongations, cancellations,. etc., besides the attention given to the personal problems (included here were those problems also arising because of specific speech assignments) of each stutterer. the third group was the least dynamic of the three. its members were prepared to accept the word of authority and laid all responsibility on this authority figure, hence cooperating little and avoiding tasks and assignments which required will and perseverence. the first two groups were, more dynamic. the material, presented was more versatile and mature in concept. more work was accomplished and to a great extent each member was aware of his own responsibility towards therapy. of the two, however, the second group (i.e., handled with the socratic approach) was by far the more fruitful, the more strenuous in terms of involvement, and the most interesting to observe. perhaps this was so because of the very nature of a more "non-directive" method. the members of the group were more personally threatened than would be otherwise. they were made to "discover" for themselves. with very little help from the clinician they made clear many pertinent facts about stuttering and discussed most of the basic problems that we are confronted with in the stuttering problem. they appeared to have an excellent understanding of the problem and related points raised in regard to themselves. the following are some comments made by some of the group members : in discussing various ways of measuring the severity of stuttering one patient offered the following—"measure the frequency of the stuttering and the distortion to communication —i.e., the ability to make sense." in discussing rationalization, one patient admitted, "i feel that stuttering is a kind of rationalization behaviour and i would feel bad if it were removed—it might account in our minds for our more basic inadequacies. perhaps we feel inadequate anyhow and that stuttered speech is not the only problem." in a general discussion of the definition of stuttering one patient said : "i feel it's a mental peter rothenberg (pty.) ltd. electrical and industrial instruments manufacturers of: instruments under the registered trade mark "prei." industrial and electro surgical instrument repairs 98, mooi street, johannesburg. p.o. box 2471 phones 23-0730 23-0888 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) o u r n a l o f s o u t h a f r i c a n l o g o p e d i c o e a r l speech block—the block escapes from speech and the stutterer lets it bother him and tries to avoid it and that is the problem. as regards my own stuttering, the physical manifestations seem useless in that they don't achieve anything. but i still feel disturbed—i sleep badly and have a nervous stomach." another patient remarked in reply to this: i am interested in your stomach and bad sleeping—your physical weaknesses may result because of suppressing your feelings, so that the mechanisms you use are more socially acceptable; its a penalty to pay!" the stutterer in question replied that "stuttering outwardly would be difficult and i would rebel against it. for me the indirect way might be better. i have to get out of it at all costs." (this particular patient could be termed an "interiorized" stutterer as differentiated from the "exteriorized" stutterer as described by douglass and quarrington in 1952 (11). one patient said: "i see the great importance of fear and i can accept its concepts intellectually, but cannot do so on an emotional level. overcoming fear will overcome the problem altogether and i can see that it is not the problem of fluency that is so important —in fact attempts to maintain fluency by "hook or by crook" might worsen the condition by increasing the anxiety." another said: "i find that i cannot avoid using my old devices as they are too mucn intact, but i see that i ought to stutter when i don't feel like it, so that i can consciously bring these old devices out and replace them by new better habits. but at the moment i have not got the courage to go out and have spasms on purpose." these statements also serve to indicate the need for the group to think and discuss on the lines of personal problems and adjustments. they were neither encouraged nor discouraged to approach the problem in this way rather than in any other way. during the latter part of the group sessions questions were asked the members in such a way as to give an indication to the clinician, as well as to the members themselves, of their understanding of the problem. the type of questions asked also indicate the nature of the therapy. some of the many questions asked were: what do we mean by the objective attitude? if you were a secondary stutterer but became completely and absolutely objective about your stuttering, do you think you would still continue to stutter? deaf? maico & amplivox h e a r i n g a i d s a most versatile range of instruments, scientifically fitted to your individual needs by fully trained audiologists westdene p r o d u c t s ( p t y . ) l t d . phone 23-0314 box 7710 29 essanby house, (second floor) johannesburg a n d at the hearing centre, cape town what is a starting device and when does it occur? must you know the rationale behind each step in treatment? why? why is it that immediate pain and penalty and suffering seem to be necessary in successful stuttering therapy? why must you fail during therapy? would you rather stutter and not have fear or would you rather have fears but not stutter? assuming a person is not just lazy, what other reasons could there possibly be behind his apparent lack of motivation in doing the work that is necessary in treatment? many answers to these questions were quite disorientated, and confused, while others, even on the same answer sheet, appeared to be quite reasonable. this in itsell is an interesting point and one which i would be tempted to connect with the problem of resistance mentioned later in this article. considering the total results of these three groups, i would say that when everything is boiled down, the same problems remain and these are likely to come up with whatever approach is used ,but incorporating r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) o u r n a l o f s o u t h a f r i c a n l o g o p e d i c s o c i e t y the same therapy mentioned above). stuttering can be considered as a defect of and hindrance to human relationships and as such must be dealt with as regards this relationship. whether the educational period should be included or not, i feel, is a matter for debate. the problems that occur and present themselves to the clinician most frequently are those problems concerned with changes that will occur within an individual in groups sucn as these. we ask the stutterer to go into feared situations, to attempt to face up and not to avoid speech situations, to change hid pattern of stuttering, to solve old attitudes and find new and better attitudes and hence we must expect changes with progress. as the demands of therapy increase so does the anxiety. this seems quite unavoidable if there is going to be any growth at all. the anxiety manifests itself in many ways but the most common, i find, is in the form of resistance. this resistance refers to breaking down of old habitual behaviour. it is difficult to surrender old habits and attitudes. to the stutterer, as to anyone else, resistance is not new. he has been adept in it long before coming to the clinic and he wii use it in many deft ways to fool both clinician and himself. at times in a given situation, it almost appears that a patient might be stupid when it comes to clarifying a certain point and seeing the rationale behind it-something which had been repeated often enough to him and which he had previously appeared to understand. the most intelligent at times fail to comprehend a point when it has personal implications and even when they do comprehend, they cannot or will not relate it to themselves emotionally. yet this must also be seen in its correct perspective. it is a problem of therapy, but, i feel, it is a necessary problem and one to be regarded as constructive rather than interfering. resistance gives the patient the power to pull in the reins in his own time and to make the situation more tolerable, and when he can go further without great harm he will do so. in this respect we must attempt to understand his dilemma. sheehan (4) has said that "when a stutterer has rejected the opportunity of dealing with word and situation fears, he provides a focal point for the analysis and understanding of his own resistances." the breakdown and realization of these resistances by the patient, i feel, becomes an important issue in therapy and is a vital barrier to cross to readjustment in the individual and as regards his speech. besides resistance to anxiety-provoking situations this problem could also possibly be seen in the light of resistance to change itself. a further problem in therapy coupled with resistance is the stutterer's self-perception. it is surprising what little stutterers really know about how they stutter and what they look like when they do, although they might be aware of the moment of difficulty. i have seen some describe fairly keenly the stuttering pattern of another in the group, but when it comes to themselves, they stee.r sharply away from it, deny that they exhibit the particular behaviour that they do and are often confident that they are in fact disguising their stuttering to a large extent to the outside world. in this respect it can be seen that they will go a long way in attempting to avoid symptom-analysis and bringing up to consciousness the exact nature of their stuttering behaviour. successful stuttering therapy results in obvious emotional and intellectual changes, growth in maturity and sensitiveness, a new objective awareness in the stutterer of his own sensations, reactions, and feelings, as well as an increased awareness of the same factors in the people with whom he comes into contact. in short he has gained "insight" and perhaps this rather abstract ability is the crux to the whole matter of success. working for the objective attitude can be considered as being analogus to that of gaining insight. insight comes from experiencing and underr ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) β j o u r n a l o f τηεί s o u t h a f r i c a n ! l o g o p e d i c s o c i e t y 1 a f ' r l l standing disruption, for without this unpleasant aspect, it woud not be significant. however, insight itself presents further problems to the clinician. what degree of insight should a patient have? how far should we go and how much can we, as clinicians, give? i think it would be reasonable to expect that in some patients a great deal of insight would be harmful and undesirable, particularly when the patient is not mature enough, or not emotionally prepared to face up to deeper problems. we should expect a patient to attain that amount of insight which is sufficient "for his use in the problem at hand. consideration must be given also as to the difference between "intellectual" insight and "emotional" insight, intellectual insight being ̂ where the patient' understands and can "see" the issue, but which does not effect a fundamental change emotionally. we see, therefore, that speech therapy can be related to psychotherapy in many ways when the above points, amongst many others, are taken into consideration, and i feel that therapists are very hesitant and reluctant to make this fact explicit. without attempting to use psychotherapy consciously, speech therapy, particularly when used with stutterers, nevertheless involves psychotherapy, and this fact, if studied carefully, cannot be denied. the dynamics of speech therapy in fact imply and make obvious a therapy based on human relationships. furthermore, theories of stuttering, preventative methods against stuttering developing, and many actual therapies, all amply indicate the significant part played by psychology and psychotherapy (3, 5,6,7,11). the issue that is suggested here revolves around the use and the implications of psychotherapy in the work of the speech therapist at the present time. i feel that it is not out miss bessie dembo 54 w i n g a t e mansions, c/r. smit and nugget streets, hospital hill, johannesburg. phone 44-0860 typing and roneoing undertaken, especially theses and students notes. of place to suggest that, at this stage, we as speech therapists ask ourselves—"what exactly do we do in speech therapy?"—to make quite clear the dynamics, criteria and principles we employ, in order to appreciate the scope of our work. references : 1. goldstein, k.—"language and language disturbances." grune and stratton, new york, 1948. 2. eisenson, j.—"the psychology of speech." appleton-century-crofts, inc., new york, 1938. "3. sheehan, j.—"an integration of psychotherapy and speech therapy through a conflict theory of stuttering." journal of speech disorders, 19 december, 1954. 4. sheehan, j.—"theory and treatment of stuttering as an approach—avoidance conflict." university of california, 1952. •5. van riper, c.—"speech correction : principles and methods." prentic hall, new york, 1954. 6. johnson, w.—"people in quandries." harper, new york, 1946. 7. bryngelson, h., chapman and hansen—"know yourself." burgess, minneapolis, 1950. "8. ingham, h. and love, l.—"the process of psychotherapy." mcgraw-hill 'book company, inc., 1954. 9. backus, o.—"the use of group structure in speech therapy." journal of speech disorders june, 1952. 10. bauman, s.—"an organismic approach to the therapy and practice of group therapy as a remedial technique in speech therapy." m. a. thesis, university of the wjtwatersrand, johannesburg. 11. douglass, e. and quarrington, b.—"the differentiation of lnteriorized and exteriorized secondary stuttering." journal of speech disorders, december, 1952. p.o. box 10482 telephones 22-4656 23-9432 abe etkind (pty.) ltd. wholesale merchants first floor, lincoln house. 57 pritchard street. johannesburg. world's finest hearing-aids. 3 transistor from £29/15/0 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sajcd cpd.indd vol 60 • december 2013 • sajcd 59 cpd december 2013 1. choose one correct answer: in patients with chronic kidney disease: a. distortion product otoacoustic emissions (dpoaes) detect cochlear damage prior to pure tone audiometry b. pure tone audiometry detects cochlear damage prior to dpoaes c. no signs of cochlear damage are evident throughout the course of the disease d. signs of cochlear damage are evident in the initial stage of the disease. 2. choose one correct answer: th e endolymph in the inner ear contains: a. high concentrations of potassium and sodium b. low concentrations of sodium and high concentrations of calcium c. low concentrations of sodium and calcium and high levels of potassium d. high concentrations of sodium and low levels of potassium and calcium. 3. choose one correct answer: cortically auditory-evoked potentials (caep) are believed to refl ect activity at the level of the: a. brainstem b. th alamus and higher auditory cortex c. cerebellum and frontal cortex d. peripheral auditory pathway. 4. choose one correct answer: th e p1 and n2 components of the caep typically have: a. long latencies in adults b. higher amplitudes in adults c. shorter latencies and higher amplitudes in infants d. longer latencies and higher amplitudes in infants. 5. choose one correct answer: in the study by almeqbel the p1 amplitude: a. changed signifi cantly when diff erent speech sounds were presented b. was similar for all three speech sounds presented c. was diff erent when comparing /t/ and /m/ only d. was diff erent when comparing /a/ and /g/. 6. choose one correct answer: th e early hearing detection and intervention guidelines by the hpcsa (2007) recommend that hearing screening: a. only be conducted on high-risk infants b. must take place before 3 months of age c. must take place before 4 months of age d. must take place before 8 months of age. 7. choose one correct answer: joubert and casoojee found that recording of hearing-screening results was done by: a. 27% of nurses b. 51% of nurses c. 80% of nurses d. all of the nurses. 8. choose one correct answer: based on joubert and casoojee’s fi ndings, infant hearing-screening results are recorded on: a. neither the road-to-health chart, nor the city of johannesburg blue card b. both the road-to-health chart and the city of johannesburg blue card equally c. patient-retained records only d. clinic-retained records mainly. 9. true (a) or false (b): th e lack of hearing-screening and associated record keeping can be ascribed to the high workload of nurses. 10. true (a) or false (b): subjective tinnitus can be caused by psychogenic disorders. 11. choose one correct answer: kanji and khosa-shangase found that the participants with temperomandibular disorder (tmd): a. more oft en reported tinnitus when compared to those without tmd b. less oft en reported tinnitus when compared to those without tmd c. more oft en reported the duration of their tinnitus to be constant when compared to those without tmd d. less oft en reported the duration of the tinnitus as constant in comparison to those without tmd. 12. choose one correct answer: th e study by erasmus et al. found that most of the respondents: a. th ought existing tools for written language assessment were age appropriate b. th ought that existing tools for written language assessments were suffi cient c. used formal tools to assess written language d. used informal tools to assess written language. 13. choose one correct answer: many studies in south africa found that english additional-language learners: a. oft en have a better understanding of mathematical concepts than their english fi rst-language peers b. display poorer phonological awareness skills than those of their english fi rst-language peers c. have lower self-esteem than their english fi rst-language peers d. none of the above. 14. choose one correct answer: speech-language therapists might be reluctant to manage reading and writing diffi culties in secondary schools because of: a. inadequate training b. lack of valid assessment material c. fear of change d. all of the above e. none of the above. cpd questionnaires must be completed online via www.cpdjournals.co.za. after submission you can check the answers and print your certificate. th e south african journal of communication disorders sajcd cpd a maximum of 5 ceus will be awarded per correctly completed test. 60 sajcd • vol 60 • december 2013 15. choose one correct answer: collaboration between speechlanguage therapists and the education system at district level should focus on: a. prevention and support for individual learners b. advocacy for the employment of speech-language therapists in schools c. the development and implementation of support programmes for teachers in areas of literacy and numeracy. d. policy development for prevention and support of learners with literacy and numeracy difficulties. 16. choose one correct answer: in order for speech-language therapists to strengthen their contribution in the education system, they need to: a. increase the number of learners receiving individual therapy b. build good relationships with teachers c. acquire a deeper understanding of the nature of learning, teaching and the educational process d. learn to speak an african language in order to assist more learners. 17. true (a) or false (b): inclusive education encourages speech-language therapists to use the ‘pull-out’ model for service delivery in schools. 18. true (a) or false (b): the use of animated picture stimuli vs. static pictures made no difference to the quality and quantity of grade 3 learners’ narratives. 19. choose one correct answer: the assessment of narratives can provide information about the child’s: a. comprehension of morphology b. social abilities c. attitude d. writing ability. 20. choose one correct answer: the language development survey was developed to identify: a. expressive language delay in adolescents b. receptive language delay in adolescents c. expressive language delay in toddlers d. receptive language delay in toddlers. 'ν elektromiografiese analise van die l1pfunksies van die gesplete lip-geval w i l m a u y s b.a. (log.) (pretoria) spraak-, stem en gehoorkliniek universiteit van pretoria opsomming 'n elektromiografiese analise van die lipfunksies van 'n groep gesplete lipgevalle, is vergelyk met die van 'n groep sonder so 'n strukturele afwyking. die toetsmateriaal het basiese bewegings van die lippe wat onderliggend is aan die bemeestering van labiale en labiodentale artikulasie, asook die uitvoering van sodanige artikulatoriese bewegings, beslaan. nadat syferwaardes aan die kwalitatiewe evaluasie (volgens die skaal van basmajian) geheg is, k o n rekenkundige gemiddeldes verkry word. hieruit blyk dit dat die eksperimentele groep minder spierspanning vertoon in die uitvoering van lipfunksies as die kontrole groep. omdat daar geen grense vir normaliteit bestaan nie, kan die mate van spanning egter nie as afwykend b e s k o u word nie. leidrade vir terapie kan uit die analise verkry word en o o k 'n m o o n t l i k e maatstaf vir objektiewe beoordeling van die geslaagdheid van die operasietegnieke. summary a comparison b e t w e e n the electro-myographic analysis of lip functions of speakers with a cleft lip and speakers w i t h a normal structure, is presented. lip m o v e m e n t s associated with labial and labiodental articulation were studied, as well as performance of these articulatory m o v e m e n t s . numeric values were awarded to qualitative evaluations (according to the scale of basmajian) in order t o c o m p u t e mean values. results indicate that, for the experimental group, less tension was present during the e x e c u t i o n of lip functions. as the range of normal tension has not yet been established, however this cannot be regarded as defective. certain suggestions for therapy can be drawn from this analysis, as well as a possible criterion forjudging the effectiveness of surgical techniques. / / die toestand van gesplete lip is baie afgeskeep in die spraakheelkunde, moontlik omdat ondersoekers meen dat die spraak van so 'n pasient baie selde beinvloed word. hierdie aanname word bloot gemaak op die akoestiese resultaat van die spreker, wat 'n subjektiewe evaluasie is, aangesien die mens as beoordelaar optree en spraak beoordeel in terme van dit wat hy hoor.3-7 by die gesplete lip is dit hoofsaaklik die m. orbicularis oris, maar ook bloedvaten senuweebaanverloop wat struktureel beinvloed is.5 deur operasies word die spleet herstel en daar word aanvaar dat daar dan funksioneel geen journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η elektromiografiese analise van die lipfunksies van die gesplete lip-geval 13 afwyking aanwesig sal wees nie. daar bestaan dus in die spraakheelkunde 'n versuim om vas te stel of die funksies van hierdie lip werklik normaal is objektief-wetenskaplik gemeet. is die operasie geslaagd? vind daar kompensatoriese werking plaas wat op die oog af nie waarneembaar is nie? kwalitatiewe afleidings behoort slegs gemaak te word, indien dit deur kwantitatiewe gegewens gestaaf kan word. die resultate verkry uit elektromiografie voldoen aan hierdie vereistes. om genoemde vrae te beantwoord, moet twee aspekte getoets word. primer moet die hoeveelheid spierspanning wat deur die aktiwiteit benodig word, bepaal word, en sekonder die senuwee-innervering wat aktiwiteit moontlik maak. elektromiografie is 'n ondersoekmetode wat uniek is in die opsig dat dit presies openbaar wat 'n spier doen op enige gegewe oomblik tydens enige beweging,1 omdat dit die elektriese potensiaal wat opgewek word tydens aktiwiteit, registreer.4 metode die doel van die studie was om die lipfunksies van die gesplete lip-geval te vergelyk met die van die normale en sodoende vas te stel: a) of die lipfunksies ooreenstem met die van die normale; b) of kompensatoriese werking ingetree het; c) of die operasietegniek geslaagd is; d) en hoe uit hierdie resultate, leidrade t.o.v. terapie verkry kan word. daar word gehipotetiseer dat die gesplete lip-geval minder spierspanning as die normale sal vertoon by die uitvoering van lipfunksies. die strukturele afwyking van die gesplete lip word as rede hiervoor aangevoor.5-6 proefpersone vier vroulike proefpersone is geselekteer deur die metode van afgepaarde vergelyking. twee proefpersone is 11 jaar oud (een kontroleen een eksperimentele proefpersoon) en twee is 19 jaar (een kontroleen een eksperimentele proefpersoon). die teenwoordiging van 'n gesplete lip het die eksperimentele groep van die kontrolegroep geskei. die volgende faktore is konstant gehou. taal a1 die proefpersone is afrikaanssprekend omdat daar 'n artikulasiebasisverskil tussen afrikaans en engels bestaan. gehoor suiwertoon-luggeleidingsoudiogramme toon aan dat al vier proefpersone normale gehoor het. intelligensie van die klasonderwyseres is verneem dat die 11-jarige proefpersone 'n bogemiddelde intelligensie het en die aanname is gemaak dat universiteitstudente 'n bogemiddelde intelligensie het. artikulasie die geoefende oordeel van finalejaar b.a. (log.)-studente is gebruik om die proefpersone se artikulasie te beoordeel. geen artikulasieafwyking is teenwoordig nie. tipe lipspleet 'n unilaterale spleet aan die linkerkant is by albei proefpersone van die eksperimentele groep teenwoordig en strek vanaf die inferior-grens van die bo-lip tot by die neusholte. tydskrif van die suid-afrikaanse vereniging vir spraak en cehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 1 4 wilma u y s operasies slegs een operasie ter herstelling van die gesplete lip is uitgevoer op elk van die proefpersone van die eksperimentele groep terwyl hulle nog babas was. op die een is 'n sekondere operasie uitgevoer om die volheid van die bo-lip te verbeter. hierdie operasie is reeds twee jaar gelede uitgevoer. (de palma et al het d.m.v. 'n elektromiografiese studie vasgestel dat die motoreenheid na so 'n operasie binne 21 rnaande regenereer en dat reinnervering weer plaasvind.)2 weens onvermydelike omstandighede kon die operasietegnieke wat gebruik is, nie vasgestel word nie. terapie proefpersone van die eksperimentele groep het nooit terapie ter verbetering van die lipfunksies ontvang nie. toetsmateriaal drie tipes toetsmateriaal is voorgeskryf. 1. basiese bewegings van die lippe wat onderliggend aan die bemeestering van labiale artikulasie is, bv., tuit en strek van die lippe en die trek van die mondhoeke afsonderlik na die onderskeie kante toe. 2. die vinnige sluiting en opening van die lippe deur die konsonant /p/ vir 5 sekondes lank so vinnig as moontlik te herhaal. dit dien as waarborg vir die bemeestering van labiale artikulasie. 3. 'n woordlys is opgestel wat bilabiale en labiodentale klanke in anlaut-, inlauten auslaut-posisies bevat het en al die vokale van afrikaans in inlautof auslaut-posisie. die woordlys is opgestel om die voorkomsfrekwensie van die klanke konstant te hou, koartikulasie sover as moontlik uit te skakel en om kort response aan te teken op die elektromiogramme sodat die evaluasie daarvan vergemaklik kon word. 'n disa-driekanaal elektromiograaf is gebruik met oppervlakte elektrodes wat uit silwer vervaardig is. die elektrodes het 'n deursnee van 2 mm. sodat dit lig is en gevolglik nie lipbewegings bemoeilik nie. elektrode-jellie is gebruik om elektriese kontak te verseker en die elektrodes is met kleefband op die vel vasgeheg. 'n stophorlosie is gebruik om die 5 sekondes van /p/-herhaling af te tel. die gronddraad is om die proefpersoon se arm gebind, en die twee elektrodes is eers op die bo-lip, aan weerskante van die filtrum geplaas en daarna op die onder-lip aan weerskante van die middellyn daarvan. met ander woorde, die. elektrodes is op die m. orbicularis oris geplaas wat na aan die oppervlakte gelee is en dus nie 'n naaldelektrode benodig nie. slegs die m. orbicularis oris word by die eksperiment betrek, omdat dit hierdie spier is wat struktureel beinvloed is deur 'n gesplete lip. by die analise van die elektromiogramme is die skaal van basmajian gebruik. hierdie skaal gee 'n kwalitatiewe interpretasie t.o.v. die hoeveelheid aktiwiteit aanwesig, nl., geen, waarneembaar, gering, gemiddeld, uitgesproke en baie uitgesproke.1 om statistiese verwerkings hieruit moontlik te maak, is syferwaardes vanaf 0 tot 5 in hierdie volgorde onderskeidelik aan die genoemde waardebepalings toegese. ', i al die toetsitems is geklassifiseer onder die batterye „gerond", „ontrond", „neutraal", „bilabiaal", „labiodentaal" en „rigtings", sodat dieselfde lipbewegings saam beoordeel sou word. journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ,'n elektromiografiese analise van die lipfunksies van die gesplete lip-geval 15 resultate rekenkundige gemiddeldes is verkry en die volgende aspekte is vergelyk: proefpersone teenoor batterye. eksperimentele groep teenoor kontrolegroep. battery teenoor battery. proefpersoon teenoor proefpersoon. uit die syfergegewens blyk dit dat die kontrolegroep vir al die batterye meer aktiwiteit in die onder-lip as in die bo-lip vertoon in teenstelling met die eksperimentele groep. ook vir die batterye: „gerond", „labiodentaal" en „rigtings" vertoon die kontrolegroep meer aktiwiteit in die bo-lip as in die onder-lip in teenstelling met die eksperimentele groep. vir die ander drie batterye is die teenoorgestelde waar. die volgorde waarin die batterye geplaas kan word in terme van die hoeveelheid aktiwiteit benodig, is soos volg: a) „gerond", met die bo-lip die mees aktiewe; b) „labiodentaal", met die bo-lip die mees aktiewe; c) „ontrond", met die onder-lip die mees aktiewe; d) „bilabiaal", met die onder-lip die mees aktiewe; e) „neutraal", met die bo-lip die mees aktiewe; en f) „rigtings", met albei lippe ewe aktief, aangesien die spiere van die hoek van die mond die werking veroorsaak. bo-lip onder-lip gesamentlik kontrolegroep 3,24 4,07 3,66 eksperimentele groep 2,9 1,99 2,45 tab el i — rekenkundige gemiddeldes verkry van totale hoeveelheid spierspanning. hieruit kan dus afgelei word dat die kontrolegroep meer van die onder-lip as van die bo-lip gebruik maak, terwyl die eksperimentele groep meer van die bo-lip as van die onder-lip gebruik maak. uit die laaste kolom blyk dit dat die aanvanklike hipotese aanvaar kan word die eksperimentele groep vertoon minder spierspanning tydens lipfunksionering. afleidings ten opsigte van die operasietegnieke wat op die twee proefpersone gebruik is, blyk die operasietegniek van die jonger proefpersoon meer suksesvol te wees. die verskil tussen die gemiddelde hoeveelheid aktiwiteit van die lippe van die twee jonger proefpersone is minder as die verskil tussen die twee ouer proefpersone. die bo-lip van die eksperimentele groep gebruik skynbaar meer aktiwiteit om te kompenseer vir die strukturele afwyking. daar moet dus in terapie gepoog word om die bo-lip meer aktief te kry, sonder dat inspanning gebruik word. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 19 desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 wilma uys die aandeel van die onder-lip in labiale artikulasie moet vergroot word sodat die verhouding tussen boen onder-lip nader aan die normale gebring word. daar kan egter nie beweer word dat hierdie spanning wat die gesplete lip-geval vertoon, afwykend is nie, aangesien daar geen grense vir normaliteit bestaan nie, en die kompensatoriese werking van die omliggende spiere nie bekend is nie. daar moet dus 'n studie gedoen word om al die spiere betrokke by artikulasie te oridersoek en norme vas te stel. slegs dan kan spierwerking as afwykend bestempel word en kan die mate van kompensatoriese werking van ander spiere bepaal word. elektromiografie leen hom ook tot studies waar koartikulasie bepaal moet word en dit kan met vrug hiervoor aangewend word. b i b l i o g r a f i e 1. basmajian, j.v. (1962): muscles alive. their functions revealed by electromyography. the williams and wilkens company, baltimore. 2. de palma, a.p., leavitt, l.a., hardy, s.b. (1958): electromyography in full thickness flaps rotated between upper and lower lips. plastic and reconstructive surgery, 21,448-452. 3. drillien, c.m., ingram., t.t.s., wilkenson, e.m. (1966): the causes and natural history of cleft lip and palate. e. and s. livingstone ltd., edinburgh. 4. fromkin, v.a. (1963): some phonetic specifications of linguistic units: an electromyographic investigation. working papers in phonetics. 3, 1-170. 5. pennisi, v.r., shadish, w.r., klabunde, e.h. (1969): orbicularis oris muscle in cleft lip repair. cleft palate journal, 6, 141-153. 6. slaughter, w.b., henry, j.w., berger, j.w., berger, j.c. (1960): changes in blood vessel patterns in bilateral cleft lip. plastic and reconstructive surgery, 26, 166-179. 7. spriestersbach, d.c., powers, g.r. (1959): articulation skills, velopharyngeal closure and oral breath pressure of children with cleft palates. j.s.h.r., 2,318-325. journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the brain-damaged child and learning problems enid m . harrison teacher at the forest town school for cerebral palsied children, johannesburg. what are the broad principles necessary for learning and how does a child learn? for a child to learn there is a spontaneous process of integration and interpretation of all sensations, sensory, motor and proprioceptive, through all the experiences of living. the essentials of what has been learned are applied to and developed step by step in further experiences, resulting in the generally accepted stages of development in the child. for example, at the age of five years a child should be able to draw a square, and a diamond at the age of seven. these are learned tasks. as kephart says, learning is not a mechanical addition of performances but a true development. the potential and rate of learning, however, differs with each child. some learn more quickly than others in all subjects or perhaps only in a few. some learn more easily visually, others auditorally. some have better memories, others better powers of concentration, observation, etc. the child with a high i.q. learns more easily than the child with an average i.q., but a factor of great importance is 'drive' and how the child makes use of his intelligence. the slow learner takes longer than the average child to acquire the basic readiness skills which are a prerequisite to learning in the classroom. on entering school at the generally accepted age, the child is not ready for formal education and learning becomes a problem. if, however, special attention is given as early as possible to help develop 'readiness' the child may well be able, at a later date, to take his place in the class and learn with the other children. for the retarded child the process of integration and interpretation is slower as are the stages of development, and the final level of attainment is lower in all aspects of learning. there is an overall limited ability to extract the essentials of what has been learned through experiences and to apply this to other experiences. the child's mental age is lower than his chronological age. in the brain-damaged child, however, the i.q. (as measured by the s.a. individual scale, for instance) may be well above average, and yet there may be slower stages of development and a lower level of attainment in some aspects of learning. the parts of the brain which are damaged do not tydskrif van die suid-afrikaanse logopediese vereniging, vol. 12, nr. 1 september 1965 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 enid μ . harrison function adequately and so there may well be difficulties in the process of integration and interpretation. the i.q. tests show a scatter of attainment. for example a nine-year-old child may fail an item at the four-year level and yet succeed in several items at the twelve-year level. the word 'may' is a must when discussing brain-damaged children because no two are ever alike. some may have no learning problems, others may have one or two or many problems to a lesser or greater degree. in all children learning problems can be the result of emotional factors or physical defects, such as a hearing loss or poor or faulty eyesight. in order to illustrate clearly some of the neurological learning problems of the brain-damaged child, we will exclude from this discussion the above factors and we will furthermore discuss the child with an average or above average i.q. assessment the initial assessment of the brain-damaged child is undertaken by a team of workers—paediatrician, neurologist, ophthalmologist, orthopaedic surgeon, psychologist, speech therapist, occupational therapist, physiotherapist and social worker. hearing tests are essential with all athetoids and any other children when there is a language or speech problem, and in this field, as in all others, the younger the child when tested the better. many children, in the past, have been classified as aphasic when the real problem has been a hearing loss. this was before the finer audiometric tests were applied by our speech therapists. guided by the report from the 'team' the teacher's assessment begins and continues in her daily contact with the child. at forest town school, assessment and treatment begin with babies of a few months and home training programmes are planned by the therapists concerned. at the age of 2i-3 years the children are admitted to the nursery section and the assessment and training of the child 'as a whole' continues. when working with cerebral palsied children we know there is brain damage, but there are many children with no physical involvement at all who have minimal brain damage. they have the same learning problems as the cerebral palsied child. several children of this type have been taught in our school. in this article, the term 'brain-damaged' is used as distinct from the term 'brain-injured' which is often used to imply that the child has, in addition, gross behaviour problems due to damage of the brain. this type of child is also handled at our school. the assessment of the results of the i.q. tests of the .brain-damaged child is most important and of great interest. the psychologist uses several tests, both verbal and performance, as there can be considerable discrepancy between these spheres of ability. looking at the result on only one test can be extremely misleading as can be seen from the following case. a child of four years had an exceptionally high score on the verbal scale. in the nursery school and kindergarten she was not tested for perception problems and her poor motor performance was thought to be the result of a severe hand involvement. in the grades, the teacher suspected journal of the south african logopedic society, vol. 12, no. 1: september 1965 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e brain-damaged child and learning problems 15 learning problems but the child's charm and verbal ability were such that she talked her way out of difficulties. she always had something of interest, not connected with the problem, to discuss. she also missed a great deal of schooling because of operations. eventually she was found to have space perception problems which have affected her work. although still excellent at languages, on a non-verbal test, the snijders-oomen test, she rates below average. as a teacher in this field for over twelve years one has learned through trial and error methods in the classroom, studying literature, and by working with and gaining knowledge from members of the 'team'. the work is not only rewarding but interesting, instructive and a constant challenge. the following cases are quoted to illustrate how inadequate development of certain basic readiness skills resulted in specific learning problems, and how, although the result in every case was an inability to learn to write, each child's lack of basic skills was different. this applies to all learning problems in brain-damaged children. also, failure to learn may be due to one, or a combination of factors. subject a, a child of six years old, with an above-average i.q., was unable to write. there was no physical hand involvement. she learned to read easily. visual and auditory perception was good and there appeared to be no other problems. she could copy simple drawings in plasticine but could not draw them correctly. she could draw straight or curved lines. she could see if her copy was not like the original and when working with plasticine would, with much trial and error, push the pieces into the correct positions. but when drawing or writing she did not know how to place the straight or curved lines in position. she wrote the letter κ like this this was ten years ago and there was no member of the staff who could help overcome the problem. then the idea occurred to me to see if moving her arm into the positions required for the lines in a drawing might help. i made her say the words describing the movement and position of her arm, as well as following the movement with her eyes. for example she put her arm straight out and said 'straight out'. then in attempting to draw a matchstick man she used this verbalization, associated with the position and movement, to draw arms straight out. it worked! we played at soldiers lying down, standing up with arms straight out, up, slanting and curved to the top, bottom etc. the children verbalized while carrying out the movements and interpreted, verbally, movements made by the other children. they gave orders to each other as to how to place their arms. remedial techniques tydskrif van die suid-afrikaanse logopediese vereniging, vol. 12, nr. 1 : september 1965 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 enid μ . harrison they followed their own and other childrens' arm movements with their eyes and 'felt' the position of the arms with their hands. pressure was exerted against their hands as they moved their arms into position to emphasize the feeling of the movement. matchstick, plasticine and gummed paper men were made and then drawn. so ά ' learnt to write by associating the position of the lines of a drawing with verbal directions, which were associated with arm positions, and then carrying out the associated movement. this was the beginning of what was called 'directional training' and this procedure has been used as a basis for much of my remedial work in developing learning readiness skills. ά ' is now in high school and doing very well, but of special interest is the fact that she has discontinued mathematics. in most cases where children have space perception difficulties, written number work seems to become a problem sooner or later. another child, who did not have nearly as high an i.q. as ά ' is in form iv and doing mathematics adequately. she had no space problems. subject 'b', a child with gross apraxia who could interpret drawings but could not carry out the motor movement, has learned to write through 'directional training'. subject 'c' could not copy a drawing either in plasticine or on paper. he could recognize pictures and drawings of squares, circles, etc., but could not analyse the contour lines of a drawing, for example a square, into meaningful parts. as a result fine discrimination was poor and so was reading. directional training not only helped 'c' to analyse drawings into lines straight out or curved to the top etc., so that he could write, but also enabled him to learn to read. though slow to begin with, he is now, at the age of twelve years, an excellent reader. subject 'd' could analyse, draw the parts and place them correctly but could not see their spatial relationship. for example, she wrote a κ like this subject έ ' could discriminate only if direction was excluded. to her, pictures of, for example, baskets with handles up or down or to the side were all the same and so were b's and d's, p's and g's, u's-and n's, etc. drawing, therefore, where there was direction was confused and she often worked from right to left. reading was, as a result, very poor and remained a problem for years. she had an above-average intelligence and her auditory work was excellent. subject 'f' could copy any drawing but could not recall it. verbalization, as used in directional training, was one of the methods which helped her to recall the 'picture'. for example she would say, 'b is a line straight down with a curve to the right at the bottom'. journal of the south african logopedic society, vol. 12, no. 1 : september 1965 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e brain-damaged child and learning problems 17 writing problems also include the inability to space letters and words, and to place letters correctly between lines. the disability here is not the failure to appreciate relationships within the whole, but the difficulty of relating one subject to another in space. the child, of course, must also have adequate eye-hand co-ordination in order to write. the cases quoted above illustrate how, in order to help the child overcome the lack of a basic readiness skill, experiences were made meaningful by using the child's abilities to reinforce the one which was inadequate. for example, the experience of positioning her body and arms was made meaningful for subject ά ' and was developed step by step in further experiences such as plasticine, gummed paper and drawing activities and finally writing. kephart, in his book, the slow learner in the classroom, shows very clearly the complicated processes by which all sensations are integrated and interpreted so that the child develops the basic readiness skills. the teacher must understand these processes so that she can lead the child through the missing stages of development. if the child has not achieved the 'readiness' on which learning in the classroom is based, the teacher must be able to find out why. the test used at our school, to find the 'why' of learning problems, was also developed through trial and error methods and is not standardized. it consists of a series of carefully graded activities in which the child's ability to recognize, analyse, synthesize, recall and follow instructions, visually and auditorally, are noted; as well as his approach to a task, his ability to concentrate and the length of the concentration span. in addition the test can be used as the basis of graded programmes of remedial work to develop basic readiness skills, from the nursery school upwards. training in learning for the young child begins in the nursery school, as well as training in socializing, forming of correct habits, language and motor development. through observation, the teacher begins to assess the child's potential and problems and, through play, helps the child to experience all sensations meaningfully. the kindergarten teacher continues to assess and help the child develop learning readiness. this training continues in the grades and it is then or later that new problems may become apparent. for example, the child in the kindergarten copies drawings but in the grades recall is necessary. very often a child in the grades may well develop a number concept and be able to write down simple sums, but later, when hundreds, tens and units are used, the child with space problems very often gets 'lost' in the positioning of figures on the page. the teachers in the standards must also be aware of the child's basic problems, even though these appear to have been overcome, as they may well appear in different and more advanced aspects of work at any stage. there must be close co-operation between all members of staff who handle a child and the case conferences, held regularly at our school, are invaluable because the child is discussed as a 'whole' from all angles. as with all children, the most important factor in teaching is for the tydskrif van die suid-afrikaanse logopediese vereniging, vol. 12, nr. 1 : september 1965 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 t h e editor teacher to make contact with the child, gain his confidence and inculcate a desire and love of 'learning' by helping the child to achieve success. the importance of the teacher understanding 'how a child learns' does not apply only to those who handle the slow learner, brain-damaged or retarded children. there are many children in normal schools who would be saved feelings of failure, frustration, fear and from becoming problem children if helped to achieve success in their first years at school. teaching, with a challenge, becomes really worth while! opsomming daar is indiwiduele verskille in die leerproses, selfs onder die sogenaamde normale kinders. die verskille word egter duideliker as ons te doen het met die afwykende kind. die verstandelik vertraagde kind sal stadiger vorder en nie so ver vorder as die normale kind nie. die breinbeseerde sal weer op sekere gebiede vinniger en op ander gebiede stadiger vorder a.g.v. die letsel. hulle mag probleme ten opsigte van die integrasieproses en interpretasie bied. om alle bykomende afwykings bv. gehoorverlies, uit te sluit, is spanwerk nodig. 'n volledige diagnose moet van elke pasient gemaak word. in die behandeling van 'n kind met persepsieprobleme kan gebruik gemaak word van taal en spraak om persepsie te verbeter bv. die verbalisasie van handbewegings in die uitvoering van 'n psigomotoriese aksie. die belang van basiese vaardighede wat die kind gereed maak vir die leerproses in die skool kan nie genoeg beklemtoon word nie. ook moet die kind in staat wees om te herken, analiseer, sintetiseer, herroep en instruksies te volg (visueel en oiiditief). die taak van die onderwyser wat werk met die breinbeseerde kind, is 'n uitdaging wat die moeite werd is. reference kephart, newell c. (i960): the slow learner in the classroom. columbus, o h i o : charles e. merrill books, inc. discussion of mrs. ε. m. harrison's paper t h e e d i t o r / ten years ago mrs. harrison, using a technique which she has termed directional training, experienced success when attempting to teach braininjured children to learn to write. it is interesting to examine this technique in the light of a recent postulate of the eminent russian psychologist and neuro-psychiatrist, professor luria. luria has long been concerned with the application of experimental method to the problems of behaviour, and rank's as an experimental psychologist of high repute. his interest in language is demonstrated by the importance which journal of the south african logopedic society, vol. 12, no. 1: september 1965 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aphasia in children suggestions for management and training h e l m e r r. m y k l e b u s t * much has been accomplished during the past 25 years in the development of programmes for handicapped children. a major reason for these accomplishments is the cooperative efforts of parents, teachers, and other lay and professional groups. those who have benefited most from these combined efforts include the deaf, blind, cerebral palsied, mentally retarded and the defective in speech. there is now another group requiring such consideration and cooperative efforts, the group of children with aphasia. this discusion is an attempt to outline some of the needs of aphasic children and to suggest ways for meeting these needs, especially in the home and in the school. w h a t is language? before considering the problem of aphasia, it is necessary to analyze briefly the nature of language. aphasia is a language disorder and we cannot understand the aphasic child's handicap unless we have knowledge of what language means for the normal child. language is a set of symbols used by human beings to represent objects, feelings and ideas. these symbols might be auditory (spoken word) or visual (written word and gestures). when the word cat is spoken, the speaker is using a sound (verbal symbol) to represent the actual cat. the person hearing the word cat spoken must know that the sound which he is hearing represents an actual cat and not, for example, a dog. otherwise the process of communication breaks down. the same process and principle occurs in written language. words have meaning and are symbols for something. the normal child gradually learns that the spoken sound for cat means a cat; he learns the same for all other words in his vocabulary. he first has an experience, such as playing with a cat; then he learns to associate the word cat with the object cat. after making this association he can use the word for the object. consequently we say that language is a set of symbols which people use to represent objects, feelings and ideas. the aphasic child's problem is * dr myklebust is professor of language pathology in the school of speech, professor of psychology in the college of liberal arts, professor of neurology and psychiatry in the medical school, northwestern university, evanston, illinois. one of not being able to make such associations, or he makes them only partly and with much greater difficulty than does the normal child. before discussing aphasia further, a brief consideration is given to how normal children learn this complex set of symbols called language. l a n g u a g e d e v e l o p m e n t children are not born with language. one of the most important things they must do during the first two years of life is to learn a language. when we study the language which a child must learn, we divide it into three parts on the basis of the way in which the symbols (words) are used. language is used for thinking; that is, for talking to oneself. this is called inner language. it is used also for understanding what others say; that is, we must receive language from others. this is called receptive language. a third way in which language must be used is in making our ideas known to others; that is, we must use words to express ourselves and this is called expressive language. dividing language into these three types, inner, receptive and expressive, helps us to understand how the child learns language and also what is wrong when a child has an aphasia. children must first have experiences, such as learning to recognize what is said to them before they can leam to speak. the child first develops some awareness of happenings, the meaning of experience. this is the beginning of his inner language. it takes the average normal child about eight to nine months to gain this necessary experience and inner language before he enters the next stage and begins to use receptive language. in other words, after eight or nine months he begins to understand a few words which are spoken by others. it takes him from four to five months more before he enters the third stage and begins to use expressive language·, he is twelve to thirteen months of age before he speaks his first word. often we assume that the child's first spoken word is his first language. actually it seems that no child learns to speak unless he first has learned something about what his experiences mean (inner language) and secondly, he has learned to understand some of what is said to him. in more technical terms we say that language develops in three successive steps; inner language develops first, receptive language second and 6 journal of the south african logopedic society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) expressive language third. this becomes of great importance in determining the type of aphasia in any particular child and also in giving him appropriate training. a few comments should be made concerning other difficulties which might occur to delay or interfere with the development of language. deafness interferes with the normal development of language, not because the child cannot associate the word with the object or experience, but because he cannot hear the spoken word. another important problem which interferes with language development in some children is fear and apprehension. if the language (words) they hear is largely for scolding, punishment and threats, they might become so arfaid that they act as though they cannot hear, or at least as though they cannot speak. all children, including the normal, deaf and aphasic, will leam language more easily if it gives them feelings of enjoyment and pleasure rather than feelings of fear and rejection. w h a t is aphasia? aphasia is a language disorder. the aphasic child cannot associate symbols (words) with his experiences. such difficulty varies from one aphasic child to another. however, most of these children fall mainly into two general types; those who cannot understand what other say and those who cannot speak. according to the types of language discussed above, this means that some have difficulty in developing receptive language while others have difficulty in developing expressive language. each of these will be considered separately because their problem and their needs are different. all aphasia is due to a disorder of the central nervous system. in medical terms it is referred to as a neurological disorder. increasingly in the fields of education, psychology and language pathology it is being referred to as a psychoneurological learning disorder. e x p r e s s i v e a p h a s i a the child who has expressive aphasia is unable to relate the words he hears to that part of the nervous system which is used in speaking. to use our familiar example; he hears and understands the word cat but because of deficiencies in certain nerve centres in the brain, he cannot say the word cat. expressive aphasia sometimes is mistaken for a simple speech disorder. while talking obviously is affected by expressive aphasia, it is not a speech problem as such. rather, it is; normally a difficulty with language symbols. the child with speech difficulties can say words even though they might be poorly articulated. the expressive aphasic's difficulty is to get words out; usually when he does say a word, it is well articulated. often these children cannot say any words until after three or four years of age. with appropriate training many have considerable speech by five or six years of age . at first when they are successful in saying words, it is as though they blurt them out unexpectedly; they surprise themselves and their parents. a moment after they have spoken a word, they cannot repeat it. this sometimes annoys both parents and therapists because they assume that if the child says the word once, he can say it again. actually this is not true. he cannot say the word again until the total circumstances are "just right". this might not occur for a few weeks or a few months because it is a combination of his activities, his interest and his nervous system. how to help him with these circumstances is discussed below under suggestions for training. the expressive aphasic rarely is confused with a deaf child because he understands what is said to him. occasionally he is confused with emotionally disturbed children because it is assumed that he can speak if he wants to. parents sometimes feel that he is stubborn and make strong demands on him to speak. such confusions are serious and add to the expressive aphasic's difficulties. r e c e p t i v e a p h a s i a the child who has receptive aphasia cannot understand spoken language; he hears the word cat but he cannot associate it with a real cat. he cannot interpret the spoken language of others; he cannot "receive" what they are saying so his difficulty is called receptive aphasia. it must be remembered that his problem is not due to deafness; he can hear but he cannot understand what he hears. in receptive aphasia the impairment is limited to being unable to understand speech sounds. other sounds, such as the cat's meow, the sound of the vacuum cleaner or the running of water, are understood. in rare instances it seems that a child might be able to hear but is unable to understand or to relate meaning to any sound. this condition is called auditory agnosia. in thinking about receptive aphasia, just as with expressive aphasia, it is a disorder of language. the receptive aphasic can hear speech but he cannot understand it because certain nerve centres in the brain, which have to do with the understanding of spoken language, are not working properly. parents usually become aware that there is something wrong in the receptive aphasic child when he is between two or three years of age; some parents notice something different and seek advice when the child is between eighteen months and two years. they often wonder whether he is deaf because the receptive june, 196 journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aphasic responds to sounds inconsistently; at times he hears faint sounds and at other times he might appear to be quite hard of hearing. other characteristics of these children are described below. it should be emphasized here that receptive aphasic children can be confused especially with children who have deafness as well as with the emotionally disturbed or the mentally retarded. such confusions must be guarded against by teachers and specialists. progress is being made in the development of ways to distinguish between children with receptive aphasia and those with other types of handicaps. the receptive aphasic child is more affected and more disturbed than the child with expressive aphasia. we think this is mainly for two reasons. first, the receptive aphasic is disturbed in all types of language; inner, receptive and expressive. because he cannot understand what is said to him, he has difficulty in organizing and in straightening out his daily experiences; that is,, he is delayed in his development of inner language. in addition, when he cannot understand speech, he cannot learn to use it; he is delayed in talking. remember that being able to comprehend spoken language is necessary in order to be able to learn to speak in the normal manner. the receptive aphasic is disturbed in all language areas while the expressive aphasic is disturbed mainly in one area, expressive language. this is important when we try to understand the receptive aphasic. some might say that the deaf child cannot understand spoken language either, so he and the receptive aphasic are alike. this is not true because there is an exceedingly important difference between the child who cannot hear speech and the one who can hear it but cannot understand it. the chief reason for this difference is that the conditions of aphasia and of deafness are so different. deafness is due to deficiencies in the ear. while there might be similarities between deafness and receptive aphasia, it must be emphasized that the differences are most important. it is clear that the problems and needs of the receptive aphasic are widely different from those of the deaf child and therefore the training and home management of these two types of children also should be different. receptive aphasic children can be helped a great deal. usually as they gradually learn to understand speech, they learn to use it expressively; that is, as they learn what words mean, they begin to talk. they make their best progress when the parents and language therapists work together. parents can begin the home training programme as soon as they learn that their child is aphasic; special handling in the home is desirable immediately. language training by a therapist often is begun by two to three years of age. it seems that for the best results this training should not be delayed beyond the age of three. with appropriate language training and home management many of these children develop understanding of speech by the age of five or six years. in many instances they enter the regular public schools but frequently are in need of special help, at least during the early grades. characteristics of aphasic children in order to understand the aphasic child's needs more fully, it is helpful to analyze his behaviour. his actions tell us important things about his difficulties. the characteristics described below pertain mostly to children with receptive aphasia, but they also can be applied in some ways to those with expressive aphasia. the expressive have fewer of these characteristics than the receptives. i n a t t e n t i o n aphasic children are easily distracted. they cannot devote attention to books and play, or to other activities such as dressing and eating, as well as deaf and other children. they give their attention to anything that is before them, whether or not it is important to them at the time. they are very active and grab things a great deal. the reason for their poor attention is that their difficulty prevents them from understanding their daily experiences and from separating the important from the unimportant. they are not being bad. they cannot control themselves well because they cannot grasp the true meaning of their surroundings and of their experiences. an important aspect of helping the child in the home and in the school is to be aware of this part of his problem. p e r s e v e r a t i o n after the aphasic child begins an activity, he might have difficulty in stopping it. sometimes he begins running and will run until he is very tired and loses control of himself. at such times he might laugh and giggle compulsively; this sometimes is thought of by parents and teachers as simple silliness. actually, the child starts running and he cannot stop of his own volition, so he shows signs of overdoing it. this same difficulty is seen in the child by his not being able to wait as a normal child. if you give him a crayon and a piece of paper arid sit down with him as though you were going to show him what to draw, you will find that he cannot wait for you. he begins scribbling without being able to get the idea that he is to wait for you so that you can do it together. journal of the south african logopedic society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) this is shown in many other ways. suppose that you can get him to understand that when daddy comes home, you are going for a ride in the car. he might be pleased and happy for a few minutes; then he will become very excitable and want to go immediately. you say that you are not going until daddy comes, but this does not help. he becomes more and more disturbed and demanding. in some children this problem becomes severe. again, they are not being bad. rather, they cannot tolerate having things on their mind and waiting until the logical time to go ahead with them. we call this not being able to wait. only through patient management and training do they learn to keep an "idea" in its place until the right time to carry it out. h e a r i n g parents of receptive aphasic children often state that at times their child seems to be able to hear while at other times he does not. it is not that these children cannot hear. they can hear but they have trouble in listening. this is like the trouble they have in paying attention. to be able to listen means that they can pay attention to one sound, such as to what their parents are saying, and not be disturbed by other sounds around them. this is especially difficult for the receptive aphasic. while his parents are calling him, he might be giving his attention to the sound of a car in the distance and therefore ignore the call of his parents. hearing and listening are not the same. listening is the use of hearing. disturbances of listening are common in these children. o t h e r c h a r a c t e r i s t i c s as we work with these children, many other characteristics are becoming known. it is not possible to discuss them in detail here but several will be mentioned. aphasic children often are awkward and clumsy in walking and in using their hands; they hold a pencil or button their clothes awkwardly. they are not shy like deaf or normal children; they make little distinction between strangers and friends. this is referred to as a disturbance of social perception. they are slow in developing control of their toilet habitsj. this too is different from deaf and normal children. apparently it takes the aphasic child longer to learn than certain feelings inside of him mean that it is time to tell mother that he should go to the toilet. confusion, misunderstanding and bewilderment are common. we can appreciate why this is true ι when we remember that many aphasic children at first do not understand gestures well either; they must guess most of the time as to what is expected of them. sometimes they guess wrongly, as did the little girl who was helping her mother clean. the mother said that she should empty the waste basket in the box on the porch. she had quite a surprise when she saw her daughter emptying the garbage into the box instead. perhaps this discussion of a few of the characteristics of aphasic children will be helpful in clarifying their problem and in indicating how they need help both in the home and in the school. w h a t causes aphasia? aphasia can result from many different causes. only a few can be mentioned. causes are of three types: (1) diseases, such as meningitis during infancy or german measles in the mother during pregnancy, might damage brain tissues and cause aphasia. (2) injuries occuring during delivery might cause minor brain hemorrhages or anoxia (lack of oxygen) and result in aphasia. (3) a defect in the development of certain brain tissues also might occur and cause an aphasia. it is interesting that at present it seems that receptive aphasia develops most frequently from the first two types of causes given here and that expressive aphasia develops most frequently from the last type. suggestions for management and training there are many important ways in which, parents can help their child to develop language. a few suggestions for home training are given below. o v e r s t i m u l a t i o n one of the aphasic child's greatest difficulties is his inability to tolerate normal stimulation. when he is confronted with the typical rushing about — television, toys, dressing, eating, visitors, going to the store and many other happenings in the home — he becomes over-stimulated. he cannot integrate and understand all of these experiences so he becomes distracted, bewildered, confused. this is not because he is mentally retarded, but because his mind does not get all the experiences to get together and make sense as easily as do other children. therefore, he should not be exposed to happenings which are beyond his ability to handle. for example, many parents have said that their child becomes uncontrollable at the super market. just think of the tremendous stimulation he is receiving in such a store. there are thousands of objects and colours, many people, and perhaps the child has to ride in an unfamiliar grocery cart, etc. the average child enjoys this stimulation and experience while to the aphasic it can be overwhelming. other common experiences which often june, 1961 journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) overstimulate these children, are going to a restuarant or being required to be present with guests in the home. there are many other such situations. it is necessary for the language therapist to help the parents learn to notice when their child is being overstimulated. when this occurs, it is wise to take him out of the situation and give him assurance in a calm, deliberate and patient manner. after being out of the happenings and being "protected" from them for a few minutes, often he is ready to come back to the activity. l i s t e n i n g receptive aphasic children especially are in need of help in learning how to give attention to sounds which are important. this is done by playing games which depend upon listening. toys which produce sounds, such as quacking duck or a growling bear, can be used. the parent and the child each should have the same kind of toy. to begin, you make the sound in full view of the child and he gradually learns to imitate it with his toy. the next step is for you to hold your toy behind your back and have the child imitate the sound. the third step is for you to hide and then make the sound; the child is to find you after he has listened for the sound. as he learns the game, he hides and you find him. the entire activity should be playful; not boisterous, demanding, or overstimulating. use one sound at a time. when the child is successful with one, go on to others. talk to him in single words while playing these games with him. the reason we do not begin by having the child listen to spoken words instead of to toy sounds is that usually he is not ready to listen for words until he has learned to listen for other (nonverbal) sounds. r o u t i n e s for e a t i n g the circumstances centred around eating, frequently are difficult for the aphasic child. he must be able to conform to the demands of the family and also to understand the varying routines for feeding himself. at times he is to use a spoon, then a fork; he is to understand which foods are eaten in what way. t o help him at such times, it is wise to have him seated next to the same person from meal to meal. with some children who are highly distractible, it is helpful to have them eat before or after the rest of the family so that the stimulation is less. some parents have found it helpful to give the child an appropriate plate, a spoon or a fork and put only one food on the plate at a time. this makes it easier for him than when he has his milk, several foods and a spoon, knife and fork before him from which to choose. t o i l e t t r a i n i n g aphasic children require more time than other children to learn toilet habits. usually they are not ready to begin such training until they have been helped with their distraction and until they have understanding of their daily experiences; that is, until inner language has begun to develop. when training is begun it should be done with patience and with consideration of the child's problem. this is difficult, as it was for the parents whose aphasic child was five years of age before he was trained successfully. we know that this child had good abilities so we assisted the parents with his problem for three years. he is now seven years of age and is doing well in public school. the training should consist of good timing, it should be consistent and it should be simple in demonstration. if no success is achieved in a few weeks, it is wise to stop all attempts for a week or two then start the training programme again. l a n g u a g e encourage language but do not demand speech. it is understandable why parents are greatly distressed when their child does not begin to talk at the expected age. however, demands that he say words for what he wants or any other demands that he talk, usually make the child's problem more difficult and may even further delay his beginning to talk. whenever he uses his voice for calling you or for indicating what he wants, you should accept it as though he were talking even though the sounds are nothing like real words. the sooner the child can use his voice for expressing ideas, no matter how simple, the sooner he will develop language and speech. for example, a child of three who had a severe aphasia, when shown a doll's dining room table, said "namnam". she was able to use a number of such sounds for daily experiences. when sounds like these are used, they should be understood by you and you might say. "yes, janie eat." encourage the child to try to understand and to express himself in any way that he can, including the use of gestures. such encouragement helps him to prepare for and to develop more normal language. p l a y most toys are made for children who have normal language and thus can use imagination and ideas in a normal way. many aphasic children get no enjoyment from a fire truck with a siren. they have not been able to make any association between a toy and the exciting experience of seeing the real fire truck pass. to make this association requires language and 1 journal of the south african logopedic society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a degree of imagination which they do not have at the usual age. to help your child learn to play, use toys which represent daily life — a toy car for daddy's car, a toy chair and table for the one he uses, a toy baith tub, some small figures to represent members of the family, a toy dog for the dog next door, a toy bed for his bed etc. as he associates these toys with his daily experiences, he will gradually learn to use them in playing games, such as "daddy comes home." "johnnie goes to bed" and "mary helps mommy clean." from these games you can go on to more imaginative and abstract play. development of the ability to "pretend" is very important because it is the basis of inner language; the child will not understand or use speech until inner language has begun to appear. discipline use patient firmness, not punishment. the usual methods of discipline are ineffective with aphasic children. this is because of the way in which they differ from other children in their needs and understanding. the discipline in most homes is based on the child's being able to understand that what he has done is not what was expected of him and the punishment is to make him realize that he is not to do it again. you see that typical discipline assumes that the child makes associations and used ideas well. if this type of discipline is used with aphasic children, they might become more distracted, more excitable and more difficult to manage. many parents have found the method of "firmness, without anger" helpful in managing their child. this means that definite yes or not lines are used and adhered to consistently from day to day; no is said firmly but not in anger. as a matter of fact, we find that we can say no firmly and then smile and get good results. apparently anger adds to his feelings of bewilderment and confusion. he learns to abide by the no more easily when he is not confused or threatened by' anger. j language therapy language training by professionally trained therapists is necessary for the best welfare of the aphasic child. more therapists trained especially in the techniques of language development are needed to meet this need. a few of the principles and proceedures which have been found beneficial will be described briefly. most of these suggestions assume that the therapist is working with only a few children at a time. some of the suggestions given above, in addition to those given below, are considered applicable to classroom situations after the child has entered a regular school. the training room the most suitable training room is one which is small, highly uncluttered and simply decorated. toys, materials and figures on the wall may serve as distracting influences. control proximity if the child is near you, he attends longer and controls his distraction. only after training can he engage himself successfully in the distance. your presence helps him assimilate experience and to integrate it meaningfully. gradually you can increase the distance between yourself and the child. the use of materials the use of concrete objejcts is desirable as compared to the use of pictorial materials. these objects should represent the child's daily life; they have the added advantage of permitting him to handle and to feel them. this simplifies the perceptual task. when pictures are used they should be simple and easily distinguished from the background. many children's books present a difficult perceptual task because the figure is presented against a field, a cloud, a sunset, etc. a strongly outlined drawing with a plain background is more useful, especially in early training. the use of concrete objects has another distinct advantage in that the child can manipulate them when expressing ideas. the language development approach the teacher and therapist should be aware of the child's total needs and pursue language training onl) at the level of his tolerance for stimulation and success. the training should be based on the child's major language problem. children having receptive aphasia usually require assistance mainly with inner and receptive language, whereas those having expressive aphasia need training only with expressive language. in all such language training the therapist should be aware that although articulation involvements might be present, the basic disorder is not a speech defect. correction of articulation should be deferred until language usage has met practical communication needs in daily life. a method which has proved useful for the development of language will be outlined briefly. for maximum results with this procedure, it is necessary to acquire some knowledge of the psychology of language, language pathology, and of educational methods used with young children, as well as training june, 1961 journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) and experience in the area of psychoneurology. the references given below are sources which provide an opportunity for background reading. the basic principle on which this method is based includes the assumption that the child must first have a meaningful experience and then relate or associate the symbol with it. therefore, in an organized manner, determined by the child's performance level, he is engaged in an activity. the activity is chosen from concrete experience. for example, doll figures representing the father, mother and child together with appropriate toy beds, a table and chairs, are presented to the child. these toys are presented one, two or three times at a time depending on the child's capacities. he is encouraged to relate the toys meaningfully; to place the father at the table, the baby in the bed, etc. this level of the activity reveals the child's capacities in inner language. some children require considerable training at this level because even their concrete daily experiences have not become logical. usually inner language is sufficiently developed so that he is ready to begin with receptive language when the parents bring him for training. in receptive language training the child is engaged in an activity as indicated above, and the therapist first gives him the symbol for objects he is using. this is referred to as the naming level; the child is given the names of the objects one at a time. for example, if he is engaged in putting the daddy figure in the bed, then the words daddy and bed would be given. timing is important. the symbol must be exactly appropriate to the act and the object at the time the child is performing it. after names of objects have been achieved, more complex language is introduced, such as "give the baby a ride" and "wash mary's hands". such directions should be given only when they can be done as part of the total play activity in which the child is engaged. during training on inner and receptive language, no demands are made to use expressive language (speech). after inner and receptive language have reached a level of practical usage, a third step — training in expressive language — is begun. children with basic problems of receptive aphasia, without a significant expressive involvement, begin using expressive language as soon as inner and receptive language have developed sufficiently. much emphasis on expressive language usually is unnecessary. thus training in expresive language is only for the expressive aphasics. the same principle as described above is used. the child is engaged in an activity and as he used a toy object, such as a car, the therapist asks, "what ir that?" this question should be a sincere request for information, not a demand. whatever utterance is given is accepted completely without correction. this naming of objects continued until some useful words or approximations have been achieved; the important factor is that the child's utterances become useful for communication rather than for perfection of articulation. the therapist then goes on to more complex language; as the child puts the toy dog in the car, she says, "where is the dog going?" the child can now reply by saying "bye-bye" or by using the phrases "go to the store," "for a ride", etc. the aphosie child's future parents and therapists frequently ask, "what shall wc expect from the aphasic child?" althoug specialized professional therapy for the aphasic child has only just begun, it is apparent that he has a good future. when parents learn more about his needs, when more therapists have been trained, when preschool and school age programmes have been developed, his future will be bright. such developments are forthcoming through the combined efforts of parents, teachers, psychologists, pediatricians, psychiatrists, neurologists, language pathologists, speech pathologists, audiologists and others. the aphasic child's problem is complex and difficult. this discussion has been an attempt to outline ways in which you can meet the challenge he presents. references: bender, l.: problems in conceptualization and communication in children with developmetal alexia, in psychopathology of communication, grune & stratton, new york, 1958. : psychopathology of children with organic brain disorders. c. c. thomas, springfield, 1956. eisenson, j . : examining for aphasia, psych. corp., new york, 1947. goldstein, k.: language and language disturbances. grune & stratton, new york 1948. gronnick, l.: aphasia, a guide in retraining. grune & stratton, new york, 1947. guttman, e.: aphasia in children. brain, 65, 205, 1942. head, h.: aphasia and kindred disturbances of speech cambridge university press, cambridge, 1926. myklebust, h. r.: aphasia in children, diagnosis and traning. in handbook of speech pathology. appleton-century crofts, new york, 1957. : auditory disorders in children. grune & stratton, new york, 1954. 1 journal of the south african logopedic society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) : the psychology of deafness. grune & stratton, new york, 1960. neilsen, j . : agnosia, aphaxia, aphasia. paul h. hoeber, new york, 1946. orton, s. t.: reading, writing and speech problems in children. w . w . norton, new york, 1937. penfield, w . : a consideration of the neurophysiological mechanisms of speech and some educational consequences. proc. amer. academy arts and sciences, 82, 5, 1953. penfield, w . and roberts l.: speech and brain mechanisms. princeton university press, princeton, 1959. piaget, j . : language and thought of the child. harcourt, brace, new york, 1926. strauss, a . and lehtinen, l.: psychopathology and education of the brain-injured child. grune and stratton, new york, 1947. wepman, j . : recovery from aphasia. ronald press, new york, 1951. wiesenberg, t . and mcbride, k.: aphasia. commonwealth fund, new york, 1953. june, 19631 journal of the south african logopedic society .13 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) some comments on dysphonia jorge perell6, m . d . barcelona many speech therapists lack confidence when presented with a dysphonic patient. the following represent the writer's personal thoughts on the problem of dysphonia. 1. it is stated that the often read title treatment of dysphonia is something of a misnomer for the speech therapist. the dysphonia per se is not treated, but rather the disease which causes it. since there are over a hundred different diseases which cause dysphonia, it follows that treatment is varied. 2. before undertaking treatment of a dysphonic patient, the speech therapist must understand the diagnosis of the patient — but at no time must she herself attempt to diagnose the condition. diagnosis must be made by a suitably qualified medical practitioner. 3. with regard to the professional speaker, it is thought that laryngologists are too eager to refer these patients to speech therapists when the usual treatment of silence, antibiotics or vitamins has failed. the writer mentions that there are many small deviations — laryngeal micro pathology which too often escape the eye of an inexperienced laryngologist e.g. (a) a small alteration of the free edge of the vocal fold. (b) alteration in the structure of the mucous membrane covering the vocal fold. (c) alteration of the mobility of the vocal fold. when should a speech therapist treat a dysphonic patient ' 1. dysphonias produced by abuse of the voice in singing, shouting, incorrect voice production. this may result in hyperkinetic laryngopathy, hypokinetic laryngopathy, ventricular band voice, vocal nodule, vocal polyp or contact ulcer i.e. phonoponosis. however, in the case of vocal polyp or vocal nodule it is essential that the aggravating conditions be eliminated by a competent laryngologist prior to the commencement of voice therapy. 2. dysphonias caused by paralysis of the recurrent nerve, laryngeal trauma or scarring stenosis. in the foregoing cases vocal rehabilitation appears to improve voice. 3. dysphonias produced by alteration in the voice as a result of puberty. in such cases results are generally obtained quickly. tydskrif van die suid-afrikaanse logopediese vereniging, vol.14, nr. 1: sept. 6 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 jorge perello when should a speech therapist not treat a dysphonic patient i. when dysphonias are the result of: (a) spastic dysphonia. (b) obsessive dysphonia. (c) neurasthenic dysphonia. in these cases the speech therapist can help only if she works in close co-operation with a psychiatrist. even so, these patients are difficult to. rehabilitate. 2. aphonias which are caused by an hysterical condition. the author makes the controversial point that the above mentioned patients should be diagnosed and treated by a phoniatrist and never by a speech therapist. 3. dysphonias which do not become worse after speaking or singing. these may be of a serious nature and must be handled by a laryngologist. 4. dysphonias which deteriorate with silence. 5. there has been a tendency to refer dysphonic patients who present no laryngeal pathology to speech therapists who, at times, have little success with these patients. the author makes the interesting point that the dysphonia may be caused by some other physical pathology. three such cases are mentioned: i. in a dutch singer the dysphonia was caused by arthrosis of the cervical vertebrae. ii. in a south african singer the dysphonia was caused by androgenic medical treatment. iii. in a businessman the dysphonia was caused by diaphragmatic hernia. when the afore-mentioned cases were given vocal thearpy, little or no success resulted. journal of the south african logopedic society, vol. 14, no. 1: september 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) some misconceptions about infantile autism ε . b . p e l t z , b . a . hons. (rand)* " i c a n ' t believe t h a t ! " said alice. " c a n ' t y o u ? " the queen said in a pitying tone. " t r y again: d r a w a long b r e a t h and shut y o u r eyes." alice laughed. " t h e r e ' s n o use trying," she said: " o n e can't believe impossible things." " i d a r e say you h a v e n ' t had m u c h practice" said t h e q u e e n . " w h e n i was y o u r age i always did it for half an h o u r a day. w h y sometimes i've believed as m a n y as six impossible things before breakfast." 3 for therapists to be as level-headed as alice, it might help to know which impossible beliefs about infantile autism have been dissipated recently. theories of autism. the first large follow-up study of autistic children put great emphasis on the prognostic importance of speech at five years of age (kanner and eisenberg1"). in this study involving thirty-one subjects it appeared that all but one who were not speaking at the age of five were found to be feeble-minded, and/or grossly disturbed at adolescence or as adults. somehow this statistic has remained with us, leading either to therapeutic pessimism and premature institutionalization or providing an excuse for halfhearted therapy. this follow-up also disclosed that psychotherapy and other psychiatric treatments had no effect. more recently a large follow-up study by rutter, greenfeld and lockyer30 found that of thirty-one, five-year-old non-speakers, seven learned to speak after the age of five years. in all cases these children were receiving good schooling or speech therapy. the use of operant conditioning with autistic children of five to thirteen years has shown even more optimistic results, e.g. lovaas1 8 taught speech to a nine-year-old girl, pamela, who had previously undergone four years of unsuccessful psychoanalysis. pamela even learned to amuse herself with spontaneous activity when alone, e.g. drawing (lovaas et a l 1 0 ) . / jenson and womack1 4 were using milieu therapy, before turning to operant conditioning to teach speech to a seven-year-old boy. hewett1 0 taught a previously intractable thirteen-year-old autistic boy to read, so that he could eventually communicate by writing. can we afford to reserve judgment on conditioning until follow-ups are reported? * n o w at t h e institute of psychiatry, l o n d o n . journal of the south african logopedi society, vol. 16, no. , dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) some misconceptions about infantile autism 37 in his first description of the autistic syndrome, kanner1 5 suggested that the primary defect was a disturbance in affective contact. on the other hand, rutter"' felt that autism is an impairment of language function. recently, many writers have claimed that it is caused by a cognitive or perceptual, rather than an affective difficulty. evidence for this thesis will be put forward later. rutter et al.: i t showed that the intelligence quotient of the autistic child is just as stable as in any other child and is a remarkably good predictor of the child's later intellectual, social and behavioural adjustment. social withdrawal, however, was found to diminish gradually with natural development, while children with the best outcomes in adolescence showed little change in intelligence quotient. in this study there were several children who remained completely without speech and yet had lost all evidence of social withdrawal. there are therapists who claim that although they have not succeeded over many years in teaching the autistic child speech, nevertheless they have reduced his autism. this is a wishful delusion. to evaluate therapy it is essential to know which symptoms are likely to remit spontaneously. rutter2 9 reported that: . . . it is striking that social withdrawal more than most symptoms tends to lessen considerably as the autistic child grows older. (p. 10) a major misconception which has been attacked is the interpretation of the autistic child's attraction to spinning objects. the autistic child can spend hours watching objects spin or twirling himself. hand flapping, which may be a related symptom, can take many forms, e.g. wiggling of the fingers, flicking at surfaces or oscillating of the hand. ornitz and ritvo2 1 considered hand flapping in response to a spinning top as diagnostic of autism. however, many autistic children later learn to suppress these behaviours. ornitz and ritvo2 2 mentioned that the vestibular system of the child may be pathologically involved. careful and detailed studies of the behaviour of autistic children (hand flapping in particular) have been carried out. sorosky et al. 3 3 showed that the average amounts of autistic behaviours over prolonged periods remain consistent. environmental variables were shown to have little or no effect on these behaviours. ritvo et al.2 7 felt that such findings could best be explained as resulting from an ongoing neuropathological process within the central nervous system. they showed that: (a) there is a statistically significant consistency in the frequencies of these behaviours among autistic children and within the same child. (b) once initiated, these behaviours are sustained at the same frequency, unaffected by fatigue and presumed changes in the ideational or affectual state. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 ε. β. peltz these motility patterns appeared in autistic children with varying degrees of severity of the disorder. ritvo et al. 2 7 postulated that the transient hand flapping and posturing seen in the startle reaction of the normal infant is never inhibited in the autistic child. they argued that there is an imbalance between excitation and inhibition mechanisms in the child. (another rational hypothesis is that these mannerisms have a self-stimulatory function.) ritvo et a l 2 7 strongly disagreed with the idea that withdrawal into fantasy could cause these behaviours, arguing that: all children regularly defecate and urinate and have fantasies about these behaviours. however, no-one would argue for the assumption that such fantasies actually produce the excrements in question. (p. 346) in view of the accumulating evidence towards a neurological basis for this behaviour, it would seem absurd to interpret flapping as a defence mechanism. i have seen one unfortunate autistic boy whose attraction to spinning objects was interpreted as a desire for the breast and for a long time he was allowed to unravel film and tape recorder reels undisturbed. this did not seem to satiate his longing. similar interpretations suggesting acting out therapy are quite detrimental, if one considers the consistent reinforcement of antisocial behaviour which this entails. another feature of infantile autism which has been over-burdened with naive interpretations is the autistic child's tendency to pronomial reversal. bettelheim1 claimed that autistic children will never echo / although they will echo other personal pronouns. this he related to their lack of a self-concept. rutter2 ! ) reported a study to test this inference, which found that when the position of the pronoun in the sentence was controlled, and obviously this is essential, autistic children did echo i as often as they echoed any other pronoun. the fact that / is rarely echoed under normal circumstances is simply a function of the fact that / usually comes at the beginning of a sentence, the part that is not commonly echoed. added evidence against a psycho-analytic interpretation of pronomial reversal is pointed out by fay 6 , i.e. that autistic children also fail to edit the demonstrative pronouns this and these to that and those. fay's autistic subject showed many more echoisms and errors in response to questions in which the carrier phrase was show me the than questions in which the phrase was point to the the writer has confirmed this feature of the comprehension of the autistic child on another child. surely linguistic or conceptual explanations are far more parsimonious than those in terms of aggression and rejection towards the interlocutor, j bettelheim1 has also claimed that the autistic child's lack of high level performance is the result of disinclination, which masks an journal of the south african logopedie society, vol, 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) some misconceptions about infantile autism 39 average or above-average level of intelligence. hingtgen and churchill11 showed that when motivational levels were elevated and when previously learned behaviours were being emitted consistently, autistic children still experienced extreme difficulty in learning low-level tasks. undoubtedly it is true that most autistic children are retarded in language development and that many never overcome these conceptual difficulties thus remaining without abstract language (rutter29). in view of these facts it is astonishing to note the tendency to interpret the autistic child's action to him during therapy. brawley et al.2 have shown that remarks like you don't have to hit yourself, steve. do you feel angry with yourself? was that (task) too hard?, actually increase the frequency of the undesirable behaviour. remarks that i have heard, e.g. are you feeling a little mixed-up today?, are probably even more unintelligible to the child. the parents of the autistic child are reputedly detached, refrigerated and obsessive, but some writers have not found this a consistent trait (rutter20). even if this is granted for the moment certain difficulties arise: (a) mothers may become detached and ambivalent in response to their disturbed child. (b) autistic children rarely have a history of the deprived circumstances of the institutionalised child. (c) it would have to be a very severe parental abnormality indeed to cause so gross a disorder as infantile autism in so short a time. it is always dangerous to argue from correlation to cause, and until some factual surveys appear, we should avoid the all too frequent judgments of the autistic child's parents. the early descriptions of autistic children also found that their parents were from the academic and professional communities. however, the broader clinical experience of the next two decades has shown that these children come from every socio-economic class. ornitz and ritvo2 1 reported that: while some of the parents are reported to be cold, isolated or refrigerated individuals, others have proven to be warm, loving and quite capable of raising normally affectionate siblings of their autistic child. a condition of family disruption and emotional turmoil may surround the infancy or childhood of autistic children or the disease process may develop in a normal emotional climate. (p. 78) autism as a cognitive dysfunction. rimland2 3 claimed that the autistic child is grossly impaired in a function basic to all cognition; the ability to relate new stimuli to remembered experience. new sensation can only be related to sharply limited fragments of memory, and the child therefore cannot derive meaning from his tydskrif van die suid-afrikaanse logopediese vereniging, vol. 16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 ε. β. peltz expsrience. consequently he cannot understand relationships, nor think in terms of concepts, symbols, analogies or abstractions. he cannot integrate his sensations into a comprehensible whole; his perception of the world is vague and obscure. however, on tasks in which the input does not have to be re-organised, the autistic child can show high-level performance, e.g. form boards. strong evidence for such a hypothesis is provided by the autistic child's pattern of cognitive abilities (rutter28). characteristically the child's immediate memory is good, but on tests of verbal concepts, abstraction or symbolization he is poor. this also applies to tests which do not require the child to speak. there is no evidence that the mutism is in any way elective. rutter 2 8 noticed in the maudsley series that the peaks of intelligence of the autistic child were found almost exclusively on the block design and object assembly tests of the wechsler intelligence scale for children, probably because these tests require the least in the way of comprehension of instructions. we have already discussed the facts from follow-up studies which support a language dysfunction hypothesis, viz. that the language difficulties must be considered as a primary phenomenon, not as a feature secondary to social withdrawal. rather, it is the comprehension defects which might lead to withdrawal. the typical lack of response to sounds, the frequency with which the autistic child is considered to be deaf and the difficulties with spoken instruction suggest a relationship between autism and receptive aphasia. rutter 2 9 mentioned that the audiometric responses of autistic children and of children with receptive aphasia are the same. possibly the autistic child's problems are not restricted to the auditory modality. while the aphasic's non-verbal responses are superior to those which require verbal input or output, the autistic child shows less scatter. davis4 felt that the language deficits in autistic children were directly related to the pervasive concreteness of all their behaviour. in a series of experiments, o'connor and hermelin have been unravelling the nature of the conceptual dysfunction. they have repeatedly highlighted the difficulty autistic children have in responding to structure in their environments. / these dysfunctions, as shown in recall tests, included: / (a) syntactic structure: hermelin3 demonstrated that autistic children recalled sentences and random arrangements of words equally well, while normal and sub-normal controls could only match their recall of sentences. the autistic children tended to remember the last part of any message whether sense or nonsense, while the controls regrouped the words, recalling the most meaningful parts. this throws light on a feature of autism, viz. echolalia. ι journal of the south african logopedic society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) some misconceptions about infantile autism 41 (b) semantic structure: when a series of words from two conceptual categories were presented (e.g. blue, horse, pig, red, dog, yellow), the normals and subnormals showed significantly more reclustering into concepts and thus higher recall than the autistics. (c) phonetic stress: under one condition sentences were presented with stress on the key words, under the second condition stress was on connecting words. it was found that autistics recalled the stressed words under both conditions, while normals recalled the key words. further experiments, with binary sequences, showed that autistic children have difficulty in detecting structure in any modality. when errors were analysed, the normals were found to have detected the dominant features of the sequences, while the errors of the autistics were random. this confirmed earlier work by o'connor and hermelin20 which showed that in learning tasks, autistic children, particularly those without speech, had difficulty in processing information given to them, while subnormal controls did not exhibit these difficulties. hermelin7 emphasised the autistic child's relative inability to vary his response according to the stimulus. reinforcement therapy. traditional psychodynamic methods of therapy, in all their diversity, have failed to demonstrate any reasonable degree of efficacy with psychotic children . . . . on the other hand the rapidly growing body of literature reporting results of behaviour modification methods attests to the potential power of this 'new' therapy. (leff,11 p. 397). together with this new approach has come a realization of the importance of speech therapy in the remedial programme for the autistic child. savage31 stated that intensification of normal speech stimulation methods produces poor results and operant conditioning is favoured by her as the most satisfactory behavioural approach. often, papers from practitioners of psychodynamic therapies explicitly incorporate basic tenets of reinforcement theory in their therapies. weiland and rudnick3 s made an eight-year-old autistic boy's receipt of his favourite toy contingent upon his verbalization of the word ball, widening the child's vocabulary until he was eventually able to sing songs. dubnoff5 successfully treated an autistic boy and reported: h e is expected to verbalize his demands before they are gratified. the demands and expectations are commensurate with what a child is able to produce at a given time and only appropriate behaviour is gratified. (p. 386) such therapy is a long way from an all-accepting permissive and indiscriminately rewarding psycho-analytic approach, and probably tydskrif van die suid-afrikaanse logopediese vereniging, vol.16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 ε. β. peltz the best therapy will evolve from collaboration. nevertheless leff17 cautioned that: it is in practiccs such as these that many therapists, either wittingly or unwittingly often make effective use of the basic principles of operant learning. the evidence suggests that therapeutic potency is a direct function of the degree to which these principles are systematically applied. (p. 403) perhaps the simplest hypothetical explanation for the unique success of behaviour modification techniques is that the autistic child is unable to learn under ordinary circumstances, (probably the result of some form of cognitive dysfunction). unfortunately, however, even more misconceptions than those attached to autism have shrouded the potential of reinforcement therapy. bettelheim's1 picture of an adult forcing responses from a robotlike child during conditioning is shared by laymen and dogmatic therapists alike. rimland24 confesses that when writing his book he was similarly prejudiced. however, he has since become a champion of operant conditioning and the lovaas school. hingtgen and churchill11 mentioned that sessions were characterized by a happy smiling child performing consistently. while training a thirteen-year-old autistic boy to read, hewett1 0 noted that his subject's interest in his education steadily grew despite gradual decreases in reinforcement. the child showed enjoyment of his work by laughing and vocalizing. he also frequently initiated new learning tasks by bringing the teacher pictures whose symbolic designation he was eager to master. the consistency and clarity of the operant situation allows even the autistic child an experience of mastery. the therapist who is thoroughly conversant with the reinforcement technique can broaden the operant approach greatly, e.g. schell et al.3 2 encouraged a game in which kipper, their autistic subject, returned a non-preferred cereal reinforcer while the therapist said no, no. then the therapist said candy, yes while giving the preferred candy. after twelve trials, kipper was saying no, no when given the cereal and a few times said kiki when the clinician asked what he wanted. other play activities included tickling and cuddling games· which caused psals of laughter. kipper was encouraged to say up' or down for being lifted into the air or slid down the therapist's knees. these verbal responses were shown to be dependent on their rewarding consequences. (more formal training! was also used.) a criticism of conditioning is that, it is situation-specific, i.e. it does not generalize. hingtgen and trost' 3 found that after training autistic children to initiate contact and vocal behaviour with each other in an experimental situation, these new behaviours were observed to journal of the south african logopedi society, vol 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) some misconceptions about infantile autism 43 increase in the ward setting as well as in the home. hewett1 0 and jenson and womack1 1 reported spontaneous speech developing once transfer out of the experimental situation was effected. an essential feature of reinforcement therapy is the training of the parents in techniques of conditioning. many parents have thus been enabled to take over the training of their autistic child — usually with great success, (e.g. wolf et al.,3" risley and wolf25). this allows the autistic child to be reintegrated into the family and to enter into natural communities of reinforcement. many atavistic behaviours have proved amenable to negative reinforcement (most often time out from positive reinforcement). tantrums have repeatedly been found to be maintained by adult attentiveness to them. often it is only when these behaviours are eliminated that teaching programs can begin. in this area we also find many therapists indulging a lay protest reaction against punishment techniques, but remember the far greater pain that we subject a child to without hesitation, when it is necessary to remove his tonsils or appendix. helen keller was lucky her teacher did not insist on using only hugs and kisses. if she had, helen keller would have ended up as a living vegetable. in practice, however, the reinforcement programme is heavily loaded with smiles, cuddles and sweets. punishment (except time out from positive reinforcement) is avoided as it involves many uncontrolled side effects. a great advantage of operant conditioning is the speed with which large improvements can be obtained. hingtgen et a l 1 2 taught two mute autistic children, over five years of age, who had not responded to all other therapy, to do the following, within three weeks: (a) use of the body — including imitation of blowing, crossing feet, chewing, etc. (b) use of objects — including imitated line drawing, folding paper, cutting with scissors, brushing teeth, etc. (c) vocal responses — seventeen sounds and eleven words were learned by the five-and-a-half year old girl, eighteen sounds and eighteen words by the six-and-a-half year old boy. this efficiency has never been approached by other therapies. in order to evaluate experiments of operant conditioning, a special research design is used in which successive measures of the same subject's behaviour are taken. the subject is his own control, in that his base-rate behaviour, recorded prior to therapy, is compared with his behaviour after the experimental manipulation. temporary discontinuance of the modification procedure (usually the reinforcement) tydskrif van die suid-afrikaanse logopediese vereniging, vol. 16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 ε. β. peltz is used typically to verify the effects of this procedure. such experimental designs can provide immediate and conclusive demonstrations of efficacy and are far superior to the anecdotal reports from other schools. to aid the autistic child, the reinforcement therapist breaks the tasks into infinitesimally small steps, each of which the child can master. however, it is essential to remember that these ingenious programmes are closely related to the reinforcement technique. 1 have seen a therapist, using the method of an operant experimenter, without using reinforcement. such practices are rather dubious considering that almost every article cn operant conditioning is at pains to demonstrate that the reinforcement is the only operative variable. in the field of infantile autism, the mutual interests of the speech therapist and the psychologist can best be served by close co-operation. the structuring techniques derived from speech therapy with the aphasic child can be applied fruitfully within the conditioning situation. davis4 suggests that one should control the stimulus modality by blocking others that might interfere, e.g. by covering the child's eyes and talking directly into his ear. further, the complexity of the task should be controlled by regulating the number of objects present, e.g. saying one word which the subject must associate with the only object in a clear visual field or a clearly defined movement. operant training derives its success from the fact that not only are specific behaviours taught, but the child learns how to focus and direct his attention. a promising development is the recent tendency of behaviour therapists to teach learning sets or strategies to autistic children. risley and wolf2li expanded their autistic subjects' vocabulary to phrases and sentences. they were then taught to generalize the grammatical form with appropriate substitutions, which could be called generative speech. there is little limit to the breadth of activities which can be taught through reinforcement. savage31 wrote: many people disagree with operant conditioning on the rather nebulous grounds of 'inhumanity'. h o w much less humane is it to deny a child an opportunity to acquire the tools of communication when the alternative is probably long-term care in a psychiatric hospital? people have objected to the method, suggesting that it does not teach language, but produces robot-like speech. in a m u t e autistic child, words acquired through operant conditioning form the basis of a language pattern. without this basis, a child will never learn language skills as a means of communication. with it. there is a chance that h e might. (p. 87) note: detailed descriptions of speech therapy using operant conditioning can be found in lovaas1", hewett1 1, risley and wolf2,;; stark et al.3 4 and brawley et al.2. journal of the south african logopedi society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) some misconceptions about infantile autism 45 summary recent studies throw light on certain widespread misconceptions about infantile autism and offer rational alteratives: (a) autism should not be considered a disturbance in affective contact but a cognitive and perceptual difficulty. this difficulty, rather than social withdrawal, is the central feature of the disorder. linguistic and problem solving studies tend to confirm this probability. (b) pre-occupation with hand flapping and spinning objects in autistic children does not require interpretation, as recent neurological studies indicate the strong probability of a neurological basis for this tendency. (c) a highly permissive approach is not likely to help the autistic child and may intensify atavistic behaviours. to hold parents of autistic children culpable is unjustified. progress in therapy and in the home is probably related to a systematic use of reinforcement. (d) the absence of speech by the age of five years no longer means a hopeless prognosis, as operant conditioning allows speech to be learned after this age. dealing with autism as a cognitive dysfunction, rimland-3 emphasises the child's inability to comprehend his environment and to integrate his sensations, while rutter-'j shows the similarity between autism and receptive aphasia. he claims that social withdrawal is secondary to language difficulties in autism. for this reason and because the autistic child seems unable to learn under ordinary circumstances, it seems that reinforcement therapy practised within the framework of speech therapy would show the best results. operant conditioning has been unjustly attacked on many accounts, but the hopeful prognosis and breadth of applicability it offers should be a spur towards dissipation of these misconceptions. opsomming onlangse studies werp lig op sekere algemene wanopvattings oor infantiele outisme en bied rasionele alternatiewe: (a) outisme moet nie beskou word as 'n versteuring in affektiewe kontak nie, maar wel as 'n kognitiewe en perseptuele afwyking. laasgenoemde is dan die sentrale kenmerk van die versteuring en nie soseer sosiale onttrekking nie. linguistieseen probleemoplossingstudies ondersteun hierdie moontlikheid. (b) die beheptheid van die outistiese kind met handgeswaai en draaiende voorwerpe benodig nie interpretasie nie. onlangse neurotydskrif van die suid-afrikaanse logopediese vereniging, vol. 16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 ε. β. peltz logiese studies toon 'η sterk moontlikheid van 'n neurologiese basis vir hierdie neiging. (c) 'n baie toelaatbare benadering word nie aanbeveel nie aangesien dit eerder atavistiese gedrag versterk. om ouers aanspreeklik te hou vir die kind se probleem is onregverdig en ongegrond. vooruitgang in terapie en ook tuis is blykbaar verwant aan die sistematiese gebruik van versterking. (d) die afwesigheid van spraak by 'n ouderdom van vyf jaar beteken nie rneer 'n hopelose prognose nie — operante kondisicnering maak voorsiening vir spraakaanleer selfs na hierdie ouderdom. by 'n beskouing van outisme as 'n kognitiewe disfunksie beklemtoon rimland2 1 die kind se onvermoe om sy omgewing te begryp en om sy sensasies te integreer. rutter™ wys op die ooreenkoms tussen outisme en reseptiewe afasie en beweer dat die sosiale onttrekkmg sekonder is tot die taalprobleme. hierdie is een rede waarom kondisioneringsterapie, beoefen binne die raamwerk van spraakterapie, die beste resultate toon, 'n verdere rede is dat die outistiese kind blykbaar nie die vermoe besit om onder gewone omstandighede te leer nie. operante kondisionering is al dikwels onbillik aangeval, maar die hoopvolle prognose en die toepassingsgeleenthede wat dit bied, behoort as aansporing te dien om hierdie opvattings uit die weg te ruim. references l bettelheim, b. (1967): the empty fortress. collier-macmillan, london. 2. brawley, e. r., harris. f . r.. allen, η. κ. e., fleming, r. s. and peterson, r. f. (1969): behaviour modification of an autistic child. behavioural science. 14. 87-97. 3. carrol, lewis: through the looking glass (1950): max parrish and co., london. , , 4. davis. b. j. (1968): a clinical method of appraisal of the language and learning behaviour of young autistic children. journal of communication disorders. 1, 277-296. . . 5. dubnoff. b. (1965): the habituation and education of the autistic child in a therapeutic day school. american journal of orthopsychiatry, 35, 385-386. , , ^ 6. fay, w. h. (1969): on the basis of autistic echolalia. journal of communication disorders, 2, 38-47. . . . 7. hermelin, b. (1966): psychological research. early childhood autism, (ed.) j. k. wing. pergammon press, oxford. 8. hermelin, b. (1967): coding and immediate recall in autistic children. proceedings of the royal society of medicine, 60, 563-564. / 9. hermelin. b. and o'connor, n. (1964): visual imperception.an psychotic children. british journal of psychology, 56, 455-460. 7 10 hewett. f. m. (1965): teaching speech to an autistic child through operant conditioning. american journal of orthopsychiatry, 35, 927-936. 11. hingtgen. j. n. and churchill, d. w. (in press): differentia! effects of behaviour modification in four mute autistic boys. 12. hingtgen. j. n., coulter, s. k. and churchill, d. w. (1967): intensive reinforcement of imitative behaviour in mute autistic children. archives of general psychiatry, 17, 36-43. , 13. hingtgen, j. n . and trost, f . c. (196(4): shaping co-operative responses in early childhood schizophrenics: ii reinforcement of mutual physical contact and vocal responses. presented at1 american psychological association. journal of the south african logopedic society, vol. 16, no. , dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) some misconceptions about infantile autism 47 14. jensen, g. d. and womack, m. g. (1967): operant conditioning techniques applied in the treatment of an autistic child. american journal of orthopsychiatry, 37, 30-34. 15. kanner. l. (1943): autistic disturbances of affective contact. nervous child, 2, 217-250. 16. kanner, l. and eisenberg, l. (1955): notes on the follow-up studies of autistic children. psychopathology of childhood: (eds.) p. h. hoch & j. zubin. grune and stratton, new york. 17. left, r. (1968): behaviour modification and the psychoses of childhood: a review. psychological bulletin, 69, 396-409. 18. lovaas, i. (1966): a program for the establishment of speech in psychotic children. early childhood autism. (ed.) j. k. wing, pergammon press, oxford. 19. lovaas, l, freitas, l., nelson, k. & whalen, c. (1967): the establishment of imitation and its use for the development of complex behaviour in schizophrenic children. behaviour research and therapy, 5, 171-181. 20. o'connor, n. and hermelin, b. (1965): sensory dominance in autistic, children and controls. archives of general psychiatry, 12, 99-103. 21. ornitz, ε. m. and ritvo, e. r. (1968a): perceptual inconstancy in early infantile autism. archives of general psychiatry, 18, 76-98. 22. ornitz, ε. m. and ritvo, e. r. (1968b): neurophysiologic mechanisms underlying perceptual inconstancy in autistic and schizophrenic children. archives of general psychiatry. 19, 22-21. 23. rimland, b. (1964): infantile autism. methuen, london. 24. rimland, b. (1965): breakthrough in the treatment of mentally ill children. reprint of a lecture. 25. risley, t. r. and wolf, μ. m. (1964): experimental manipulation of autistic behaviours and generalisation into the home. child development: readings in experimental analysis, (eds. s. w. bijou and d. m. baer). appleton-century-crofts, new york. 26. risley, j. and wolf m. (1967): establishing functional speech in echolalic children. behaviour research and therapy. 5, 73-88. 27. ritvo, e. r., ornitz, ε. m. and franchi, s. (1968): frequency of repetitive behaviours in early infantile autism and its variants. archives of general psychiatry, 19, 341-347. 28. rutter, m. (1966: behavioural and congnitive characteristics. early childhood autism (ed.) j. k. wing. pergammon press, oxford. 29. rutter, m. (1968): concepts of autism: a review of research. journal of child psychology and psychiatry, 9, 1-25. 30. rutter, m., greenfeld, d. and lockyer, l. (1967): a five-year to fifteen year follow-up study of infantile psychosis. 11 social and behavioural outcome. the british j o u r n a l of psychiatry, 113, 1183-1199. 31. savage, v. a. (1968): childhood autism: a review of the literature with particular reference to the speech and language structure of the autistic child. british journal of disorders of communication, 3, 75-87. 32. schell, r. e., stark, j. and giddon, j. j. (1967): development of language behaviour in an autistic child. journal of speech and hearing disorders 32, 51-64. 33. sorosky, a. d., ornitz, ε. m., brown, μ. b. and ritvo, e. r. (1968): systematic observations of autistic behaviour. archives of general psychiatry, 18, 439-449. 34. stark, j., giddan, j. j. and meisel, j. (1968): increasing verbal behaviour in an autistic child. journal of speech and jiearing disorders, 33, 42-47. 35. weiland, i. h. and rudnik, r. (1961): considerations of the development and treatment of autistic childhood psychosis. the psychoanalytic studv of the child, 16, 549-563. 36. wolf, m.. risley, t. r. and mees, h. (1964): application of operant conditioning procedures to the behaviour problems of an autistic child. behaviour research and therapy, 1, 305-312. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) june journal of the south african logopedic society tests designed to discover potential reading difficulties at the six-year old level katrina de hirsch, l.c.s.t. director, pediatric language disorder clinic, pediatric section, vunderbill clinic, columbia presbyterian medical centre, new york city. it is a well-known fact that our schools carry a fairly large percentage of educational and emotional casualties, bright: children whose life at school is a burden because they suffer from a more or less severe reading disability. we have only to look at the intake of a pediatric-psychiatric " ' dinic or at a sample of the youngsters referred to our child guidance centers to find a sizable number of intelligent children whose somatic complaints or vbehavioral disturbances developed only after they, had been exposed to the experience of continued failure at school. since remedial facilities in our private and public; educational institutions are few and far between, we shall have to find ways to prevent the occurrence of reading failure. in order to do this we need tools which enable us to predict with reasonable certainty which youngsters are liable to run into trouble in the first and second grades. once we select these children we may find that some of them simply need more time in which to mature, but that others might do very well, if given specific techniques, right from the start. careful selection and c o n s i s t e n t planning on our part might easily prevent a great deal of heartache and frustration later on. how then can we find out at the end of the kindergarten year, in the five-to-six-year-old group — and i stress this time since it is crucial as far as certain maturational processes are concerned — which children are liable to find the going rough? the remarks offered here are of an entirely tentative nature. at the' pediatric language disorder clinic, columbia-presbyterian medical center, we believe that we have evolved some procedures designed to predict future reading performance and we think that in a fair percentage of oases our prediction has been correct. we have not as yet done a statistical evaluation, but having experimented along certain lines, we are now trying to find out where such experimentation will lead us. we use the well-known intelligence tests as an over-all measurement of the child's basic intellectual endowment. among them the bellevuewechsler scale for children seems to be the most satisfactory. however, in a large percentage of cases these tests do not predict future success or failure in reading, s p e l l i n g , and writing. the better-known reading readiness tests, which we also use, do not seem to us to cover all the facets of behavior which we think are significant. the metropolitan readiness test, is probably the; best since it stresses comprehension not only of single words, but also of more complex verbal units. it does not, however, test ability to use verbal material and it fails to evaluate a variety of aspects which enter into reading performance. we agree with gillingham's observation that children with a mental· age under 6£ are not ready for the printed word (5). reading readiness is a function of development. we look on development, emotional and neurophysiological, as a progressive increase in complexity of behavioral patterns. studies on normal development show that psychological functioning and cerebral organization reveal a steady increase in differentiation and integration through adolescence. as the child grows older he has to cope with increasingly more differentiated and highly integrated organizations. among these more complex skills is the ability to use verbal tools. at the age of six children are supposed to have mastered oral symbols. we expect them to have organized an enormous number of'arbitrary phonetic signs into the pattern of language, a formidable achievement which by no means all children have accomplished at this age, as evidenced by the numerous youngsters who still show infantile speech patterns. once a child reaches first grade he is expected to cope with a secondary symbolic system, with visual signs which have to be correlated with meaning. in order to read a little word like "hat," a sequence of letters seen, a sequence in space has to be translated into a sequence of sounds heard, a sequence in time. we fed that without a measure of maturation — perceptual, motor, • the author wants to express her gratitude to dr. william s. i-angford for his constant and unfailing help and guidance. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society june conceptual and behavioral maturation — the child will be unable to cope with this task. the youngster whose neurophysiological organization still is primitive, the one whose language equipment is inferior, is the one who will probably ruu into trouble in the first , and second grades. it is this often very intelligent child whom we have to tingle out before he is exposed to reading failure children between 5$ and usua'ly make dramatic strides in over-all maturation, strides so dramatic, in fact, tlio· one occasionally feels one can literally see them blossoming forth. the best time to test them, therefore, is at the end of their year in kindergarten. since maturation and development involve the whole child, we observe the youngster's total behavioi in order to determine reading readiness. we usually direct our attention first to those who have trouble with integration of coordination. movement, like perception, requires patterning. a certain level of motor skills is not only essential for learning to write and print, but it is also indicative of the child's over-all maturity. the youngsters i refer to do not usually show the severe deviations in large muscular control which we find in cerebral palsied children, but they sometimes have trouble throwing a ball, riding a bicycle, skipping rope. we ask our children to throw darts, to walk on their heels, to hop on one foot. we do occasionally find some who not only have difficulty with the execution of these movements, but who also fail, as in ideomotor apraxia, to get the idea of the act itself. their over-all motility is often like that of younger children, and it is of interest that bender and yarnell (2) have commented on motility disturbances in children suffering from various forms of language disabilities. some have not attained the neurological maturation which enables them to execute movements of specific muscle groups. they retain some of the characteristics of the global, total motor response which is typical for the very young child. for instance, they turn the whole head when asked to flex the tongue. lags in integration and patterning of finer muscular control and a degree of dyspraxia, as described by orton (12), are observed relatively frequently, though occasionally this dyspraxia is confined to graphic activities. oseretsky's tests (4) provide an extensive survey of muscular skills and have been standardized in terms of normal development. ttiey are thus useful in determining in which areas a child's performance lags. unfortunately, these tests are difficult to administer and for practical purposes we have to rely on our own observations. we give our children identical tasks to perform in order to get a basis for comparison. we watch for jerkiness and arrhythmicity in the smaller muscles of the hand and tongue. the way in which a child handles construction toys will not only reveal his manual dexterity and the fluidity of his movements, but it also provides opportunities for observing many other facets of his behaviour: his span of attention, his frustration threshold, his curiosity and his zest. research of the last ten years — especially werner's work (17) — has revealed the close relationship between perceptual and motor functioning. basic to reading, of course, is the child's ability to cope with perceptual organization. the very young child normally has difficulty in breaking up the totality of a pattern; his perceptual organization is somewhat diffuse; single parts are poorly differentiated. however, the differentiation of small details and the understanding of the essential relationships between the parts and the whole are a sine qua non in reading. in the metropolitan readiness test we find a few items which require the child to discriminate between small visual details. in fact, much of the reading readiness work done in kindergarten and in the earlier part of the first grade is dedicated to the training of such discrimination, and any of the books used in this readiness work can be used for testing. the bender gestalt test (1), designed for evaluation of visuomotor functioning, is one of the most important in our battery. visually perceived configurations are offered to children with the request that they be copied. obviously the infant does not experience perception as the adult does. but the child who is expected to read and write must have visuomotor experiences similar to those of the adult. bender says the evolution of visuomotor gestalten is a maturational, not an educative process. it is true that the average 6-year-old does not usually copy all the figures correctly. developmentally there is a progression in the performance of the copied patterns from a controlled scribble at age 3 to all figures clearly perceived and reproduced at age 11. however, as silver (13) points out, it is of interest that many of our highly intelligent dyslexic children are unable to cope with this task even at 12 or 13. they are unable to grasp or retain visual patterns made up of discrete elements. in our children we not only observe difficulty with the handling of the pencil and trouble with manual control, but we also see immature forms (loops, perhaps, instead of dots) which are characteristic for the ages of 4 and 5. we note verticalization of horizontally oriented figures. we find, in other words, inability to correctly perceive and reproduce given configurar ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) june journal of the south african logopedic society tions — functions required in the reading process. many of our youngsters have great difficulty spacing these figures on paper. the ability to cope with spatial relationships is of primary importance since in reading and writing the child has to deal with a pattern laid out in space. a developmental lag in this area will thus show up in the youngster's reading performance. notions of space originally derive from the child's consciousness of his own body. we use the goodenough draw-a-man test (8) not as an intelligence measurement, nor as a way to evaluate the child's image of self in the emotional sense, though both are of interest. we use it primarily as a relatively reliable indioator of the child's body image, a concept which refers to his awareness of parts of his own body and their relationship to each other. this image is dosely related to spatial concepts and is often strikingly immature and primitive in the type of child we are discussing here. awareness of left and right, of course, is a significant aspect of the child's notion of space. since the ability to cope with the specific directional discipline of left to right progression is required for reading in our culture, this aspect deserves further discussion. as described earlier, we carefully watch the child while we test his finer muscular coordination. since most of the activities in which he is engaged are untrained and are not influenced by early conditioning, they are useful in determining the degree to which a youngster has established a functional superiority of one hand over the other. failure to establish such superiority may be related to familial factors; it may also indicate physiological immaturity and thus tend to show up in reading. we take note of early attempts to switch handedness as well as of family history with regard to laterality. in testing we evaluate strength, precision and speed. we carefully note eye dominance since crossed laterality may adversely influence reading performance. in the small child, awareness of concepts of right and left progresses slowly. the average child of six can demonstrate right and left on his own body — usually with the help of gestural (motor) responses — but not on anybody else's. that is why head's finger-to-eye test (9) (originally devised for brain-injured individuals and first used with children by simon (14) ), which calls for mirror imitation of the examiner's movements, had to be discarded in this form. it seemed to us that the test requires a level of abstraction which the six-yearold has not yet attained. ttie v. tk e c^omplimenti of ittidual disfruxitws (pty.) ltd. specialist suppliers of physiotherapy and rehabilitation equipment now at "cape york" telephone 252 jeppe street 23-8106 johannesburg p.o. box 3378 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 journal of the south african logopedic society junechild of six* however, should be able to imitate one's movements when sitting alongside one and watching one's gestures in a mirror. we have observed that a good many children who fail in this respect later develop reading difficulties. the horst's tests (14), which we include in our battery, are useful because they give us a clue as to whether or not the youngster is able to discriminate between identical shapes when they are presented in correct and in reversed form. spatial and directional concepts are not the only ones which are pertinent in reading. language, spoken or printed, is laid out in a time-space pattern. thus we have to investigate not only spatial but also temporal organization. it is of interest that a number of workers, like stambak (15) and mottier (11), have consistently found rhythmic difficulties in children suffering from reading disabilities, especially in those whose oral language is already somewhat insecure. we ask our youngsters to imitate tapped-out patterns of v a r y i n g difficulty and have observed that a goodly percentage of them fail in the repetition of even short and simple sequences. rhythm is a configuration in time, and fundamentally our children have trouble with all types of configurations. we further require that our children repeat a series of rionsense syllables," and find in the large majority of cases that they have strikingly short auditory memory spans. the correlation of this feature with language disability seems especially high. the child of six should be able to repeat at least four or five syllables, but most of our youngsters manage just three. there is another area which has so far received little attention and which is closely related to perceptual organization. we know that brain injury, and in fact any lowering of integrative efficiency, brings about an impairment in figurebackground relationships. weaknesses in figureground relationships have riot been systematically explored in children with severe reading disabilities. however, the indications are that these youngsters, though to a lesser degree than do brain-injured ones, have difficulties in this area. in order to cope with spoken or printed language the child must be able to pick out the figure from the background. for one to interpret a sentence heard (the spoken configuration), the message (like the tapped-out pattern) must stand out clearly. for one to decipher a printed sentence, the configuration must be well defined and sharply delineated against the page. i have seen innumerable youngsters look at printed material as if it represented a meaningless design. only if the figure does stand out_ will the sentence or the phrase have structure, or, in other words, meaning. some of our children have trouble separating figure from background. they do not discover, for instance, the significant design in one of the puzzles when asked to find the lion in the jungle. if one gives them raised geometric figures to reproduce graphically from touch, one often finds that they are drawn to the background, to the roughness of the cloth, for instance. the marble board test, which was originally designed to evaluate figure background relationships in brain-injured children, is difficult to administer. at the clinic we therefore use an adaptation of the figure background cards presented in strauss and lehtinen's book on brain-injured child (16). it has been established by goldstein's work (6) that a certain measure of abstract functioning is a requisite of language performance. the question then arises, what does abstract functioning mean at this early age? we know that the formation of abstract relationships is a developmental process which starts with perceptual and configurational relationships and develops in the direction of conceptual classification. this applies to both nonverbal and verbal behaviour. the small child who tries to use the toy toilet have you read these important books? westerman & ward: practical phonetics for students of south african languages. van riper: speech correction, principles & methods. anderson: improving the child's speech. mccullogh: speech improvement work and practice book university bookshop central news agency ltd. phineas court 34 bertha street braamfontein. phone 44-7523: 44-5185 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) june journal of the south african logopedic society for his own use while playing with it has not vet understood that a toy only represents the real thing. this experience a nonverbal one, comes later it is a tremendous step forward when the child first pretends to be a 4iurse or a pilot. some children are relat i v e l y concrete at the age of six. practically all brain-injured children are. but we find the group which has difficulties with various aspects of language function to be similarly concrete — if to a lesser degree — and this concreteness is by no means restricted to the verbal area. in order to test abstract behaviour on a nonverbal level, we give our youngsters block designs to copy, and watch whether they are able to analyze wholes into parts and as the next step bo synthesize these parts into wholes. guided by the goldstein-scherer tests (7), we give them a variety of objects to sort out, and observe whether they are able to isolate eating utensils, "things to eat with," so as to find out whether they have some form of categorical behaviour, at least on a perceptual level. the testing discussed up to this point has been confined to non-verbal tasks; we go from these to verbal ones. the ability to handle verbal tools is basic to reading. in order to cope with visual symbols the child must have mastered auditory ones, oral language. careful testing in this area often reveals significant gaps which are frequently overlooked. authors like orton (12), mccarthy (10), and borell-maisonny (3) have long stressed the close relationships between reading efficiency and oral language skills. first of all we have to make sure that the youngster fully understands spoken materia. units like "in front of," "inside," "beneath, which are fairly abstract concepts, are by no means always as securely established as we are • inclined to think. we place the child in front ol the dollhouse and suggest he put the baby next to the bathtub and so on. carrying out complex directions is not always easy for our children; many are unable to interpret a somewhat involved story; as a matter of fact, a few are not ready to listen at! all. some do not catch on when presented with an absurdity couched in verbal terms, although they are easily able to see the point if the absurd is presented in pictorial form. comprehension of language is one thing; use of language, another. we carefully check on artidilatory patterns! we note length of units and listen for difficulties in word finding. there are children who have a relatively good use of the idiom on an auditory perceptual basis; they sound as though they have a large vocabulary but some of them fail when asked to give a word on being presented with a picture. we are interested in vocal patterns — an unusual degree of monotony may reftect a difficulty with structuralization, perhaps a figurebackground problem. the child's ability to form correct grammatical constructions is of importance. grammar is an expression of structure, and the child who leaves out small connectives in the sentence may have difficulties with the temporal, spatial and causal relationships expressed by these words. we further want to know whether the youngster is able to tell a simple story and to bring out its salient features. some children's organization of verbal material is so poor that they never get their point across! they get so involved in the intricacies of the "three little pigs" that they ramble on indefinitely. in the beginning the child's spoken language is on a very concrete level. a three-year-old who says "brush" does not refer to the category "brush," to the object whose essential qualities are unchanging from situation to ^ situation. "brush" to him might mean one time, "brush my hair"; another time, "the brush is on die table." he does not use the word in a categorical sense. in testing abstract functioning on a verbal level we look for the youngster's ability to classify and categorize. we ask him to name all diningroom furniture. if he includes the wallpaper or the silver dishes on the sideboard he shows thereby that he has not yet understood the category "furniture." werner (18) cites the example of the boy who includes bread and a pipe with the bench, the saw and the hammer when asked to list his tools, explaining, "when you have finished working at the bench you want to eat and smoke a pipe." in other words, he grouped objects according to a concrete situation and not according to the more abstract category "tools." we use the columbia mental maturity scale to test categorical behaviour.. the intelligent boy who, when shown a picture of a hen, a stove, a pot and an egg, says that the egg and the pot belong together, "because you cook an egg in the pot," indicates that he is unable to free himself from the concrete and is not yet ready for classifications. we test the child's ability to give definitions. at the age of six children define objects in terms of function. a six-year-old who says, "you hold it up here," when asked what a violin is, behaves in a very concrete way, which, if persisting, is a poor prognosis in terms of academic functioning. if one asks a number of six-year-old children what a policeman is, one is apt to receive a variety of answers from: "he wears a blue suit, or "he stands at the corner" (which are concrete r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society june responses), to "he directs traffic." in the last response the child tries to cope with function, while in the first one he limits himself to description it is usually the child with a language difficulty who is more concrete than others are. most children who later develop reading disabilities seem to have trouble with patterning the units of words and sentences in spoken speech. orton (12) has shown how frequently these youngsters tend to reverse both oral and printed symbols. the same boy who says "crice ripsies" for "rice crispies" is the one who later on reads "was" for "saw" and "now" for "won." reversal and confusion in the order of sequences — which are closely related to temporal organization in the sense in which it has been discussed — are usually not confined to syllables and words. the whole sentence is often jumbled, showing again that it is in the area of organization and structuralization of both short and long units that children with language deficits have outstanding difficulties. most of our tests are designed to measure the child's ability to pattern, structuralize, and adequately respond to the endless stream of stimuli to which he is exposed at every moment. however, organization of perceptual and motor patterns is not the only area which presents difficulties for our children. many of them have trouble with integration of behavior. the result ifc hyperkinesis and lack of control. most children suffering from developmental language lags are enormously hyperactive. their trouble with inhibition and channeling of impulses seems to be but another aspect of their inability to organize stimuli (arising from inside as well as from outside) into behavioral configurations. hence they find it difficult to sit still several hours a day. such children (they may or may not be emotionally disturbed) are bound to have trouble concentrating. since they are unable to exclude a variety of stimuli, they are incapable of focusing their attention on a specific gestalt, or an assigned task. children in kindergarten are usually given a good many motor outlets, but once they get into first grade they find it difficult to cope with a more structured framework, since their frustration tolerance is low and their need for large muscular activity considerable. among the children whom we have tested during the last few years we have found a fairly steady, though small, number of youngsters whose perceptual deviations, trouble with figure-background relationships, outstandingly poor motor perform' ance and limitation in abstract behavior seem far more severe than is usual for the child who suffers from a developmental language disability. careful investigation of these cases has sometimes revealed a positive history, for instance, anoxia at birth. these youngsters do not necessarily show their usual positive signs on the classical neurological examination. however, more refined testing procedures show that they have difficulties at various levels of integration. watching these children copy the bender gestalt figures, one often finds a marked tendency to disinhibition, accompanied by compensatory rigidity. we find perseveration in various areas and a tendency to go to pieces when the number of stimuli becomes too great. many of these relatively subtle signs go undiscovered until the time when these children are confronted with a task which is as complex as is the mastering of oral and printed symbols. i do not want to give the impression that our testing takes a great deal of time. after some experimenting we have brought the time down to between 40 and 45 minutes. the tests are usually administered during one session, or, preferably, two. careful observation of the child as he functions in kindergarten, moreover, will eliminate many of the more formal procedures. in conclusion i should like to sum up a few points: maturation is largely a process of integration and differentiation. the child of six and older whose perceptual, motor, visuomotor and conceptual performance is still relatively primitive, the child who has trouble with structuralization of behavioral patterns, is the one who is liable to run into difficulties when he is exposed to reading, which requires the smooth interplay of many facets of behaviour. some of these children need more time in which to mature. postponing formal training and discipline for 6 to 12 months may prevent future regrading with its attending experience of failure and humiliation which might easily spoil the youngster's entire learning pattern. but our testing should do more than simply pick out the children who are not as yet ready for first grade. it should assist us in determining what type of help would be suitable for those youngsters who we feel are able to make the grade if given specific assistance and support. the hyperactive child, for instance, needs a teacher who has some tolerance for the child's specific difficulty. he needs, if possible, a setting which allows him a good1 many motor outlets while at the same time providing a somewhat istructured environment which protects him "from an excess of environmental stimuli. such a youngster would fare better if seated in the front of the room where he sees only the teacher and not his classmates. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) june journal of the south african logopedic society the child with an oral language disability, on the other hand, whose lags are confined to specific areas, might do all right if he were referred to a speech therapist and helped to establish more speech patterns and a more extensive vocabulary. another youngster might need assistance with straightening out his confusion in cerebral dominance, and help in establishing left-to-right progression. most of these children, as orton (12) has pointed out, usually do better with a phonetic approach to reading than with the whole-word attack. there are good reasons for this fact and they lie precisely in the direction we have discussed. the child who has trouble with the organization of visual patterns is naturally bewildered and confused if he is confronted with, what to him seem to be diffuse and undifferentiated configurations. he will benefit immensely if words are broken up into small phonetic units. this breaking-up process actually represents a transposal of spatial sequences into temporal ones. in this manner many youngsters are able to cope with single sounds, short auditory configurations which they slowly learn to fuse into larger entities. this procedure facilitates the structuralization of — for them — undifferentiated wholes and thus gives them a larger measure of security. there are, of course, exceptions. there are children who fail to respond to the phonetic method . these particular children fall into three categories: the hyperactive child does not always possess the span of attention required for the laborious sounding out of words. the process is too slow for him and he tends to get discouraged and frustrated. into the second category fall the youngsters who have trouble with abstract behaviour. the process of analyzing a word into its parts and then synthesizing the parts requires a certain level of abstraction. moreover, the very concept that a letter seen represents a speech sound heard is difficult for the brain-injured child (who is usually hyperactive as well) to grasp. in the third category falls the youngster who shows obsessive tendencies. he will stick compulsively to single sounds; he will be too anxious to blend, them successfully into words or to integrate them into meaningful sentences. thus the tests for prediction of future reading disabilities are not only designed to discover the child who is liable to run into trouble with reading, but are also meant to indicate the areas in which a child's performance lags. the tests should actually do more: they should provide a lead as to what specific techniques could be used to advantage in future training. precious time is thus saved, and some children, iat least, are spared the humiliating experience of failure in reading, writing and spelling (which are all important in the earlier grades), a failure which will often carry over into other learning experiences. not all children suffering from potential reading difficulties are primarily emotionally disturbed. however, their basic developmental lag in physiological-psychological functioning makes, them especially susceptible to adverse educational experiences and as a result they often develop secondary emotional difficulties very early.' we hope to discover some of these youngsters before they become educational and emotional casualties. references 1. bender, l. a. a visnal motor gestalt test and its clinical use. american orthopsychiatric assoc, new york, 1938. 2. bender, l., and h. yarnell. an observation nursery. ' am. j. psychiatry, 97:1158, 1941. 3. borell-maisonny, s. les troubles du language dans les dyslexies et les dysortographies. enfance, 5:400, 1951. 4. doll, e. the oseretsky tests of motor proficiency. educational publishers, minneapolis, 1940. 5. gillingham, a. avoiding failure in beading and spelling. independent school bull., nov. 1949. 6. goldstein, k. language and language disturbances. grune & stratton, new york, 1948. 7. goldstein, k., and m. scherer. abstract and concrete behaviour. psychol. monogr., 53:1, 1941. 8. goodenough, f. measurement of intelligence by drawing. world book, yonkers-on-hudson, new york, 1926. 9. head, h. aphasia and kindred disorders of speech, vol. i. cambridge univ. press, london, 1926. mccarthy, d. chap. 9 in manual of child psychology (leonard carmichael, ed.). (2nd ed.) wiley, new york, 1954. 11. mottier, g. tiber untersuchung der sprache lesegestorter kinder. folio phoniatrica, 3: no. 3, 1951. 12. orton, s. t. beading, writing and speech problems in children. norton, new york, 1937. 13. silver, a. diagnostic value of three drawing tests for children. j. pediat, 37:1, 1950. 14. simon, j. contributions a la psychologie de la lecture. enfance, 5:438-447, 1954. 15. stambak, m. le probleme do rhythme dans le developpement de l'enfant et dans les dyslexies devolution. enfance, 5:480-493, 1951. 16. strauss, α., and l. lehtinen. psychopathology and education in the brain-injured child. grune & stratton, new york, 1947. 17. werner, h. towards a general theory of perception. psychol. rev., 59:5, 1952. 18. comparative psychology of mental development. harper, new york, 1940. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) recent research on the parietal lobes, proprioceptive sensibilities and tactile and kinesthetic abilities in speech production ruth m. clark, ph.d.* introduction at the university of denver wc have been trying through research to understand more adequately the part the parietal lobes and proprioceptive sensibilities play in speech production, and to discover if the kinesthetic and tactile abilities of children having "functional" articulatory problems differ from these abilities for normal speaking children. a number of requests have been received asking for data on the above-mentioned researches. the purpose of this article is to review briefly these studies and give references for the benefit of interested colleagues. it is planned that a more adequate report on each study will soon be published, but for the present this overview will give the data requested so those interested can obtain the studies through inter-library loan. it is also hoped that some of the proposed topics listed in the dissertations for further research along these lines will receive attention. three studies will be reviewed in the order in which they were completed. i. the role of the parietal lobes in speech ( 3 ) . importance of the study for years the standard or acceptable approaches for speech training and speech re-training have been the use of sight and hearing. the study under review undertook to determine if, in addition to visual and auditory training, other sensory approaches existed or were feasible to use for speech learning. a study of the opinions of a number of individuals in the speech field, as well as neurologists, indicated that the use of a third sensory avenue, i.e., the stimulation of the tactile and proprioceptive senses, would be another approach to use in speech therapy. the literature in the fields of physiology, neurology and physiological psychology was reviewed t o ' discover the anatomical structures * ruth m . clark (ph.d., university of southern california, 1943) is the director of the s p e e c h clinic and professor of speech, university of denver, denver 10, colorado. which might be used in the teaching of a motor pattern through tactile and/or kinesthetic sensation. in addition to the anatomy of the somesthetic structures, their function was also discussed. in dealing with the "doubly-handicapped" person where the hard-of-hearing individual may miss all or part of the auditory stimulation, or the individual whose sight is impaired may miss most of the visual stimulation, "the urgency of investigating other approaches to speech learning is obvious." (3, p.3). purpose of the study the study was predicated upon the belief that there exists, in addition to visual and auditory avenues, other sensory approaches for use in learning and re-learning speech. the author investigated the possibility of utilizing cutaneous and kinesthetic sensations in the creation, or the improvement of motor patterns for speech. specifically he tried to answer the following questions: 1. what physiological mechanisms does this tactile and/or kinesthetic approach employ? 2. how do these physiological mechanisms function? 3. what cortical receptors receive these tactile and kinesthetic cue messages? 4. how do these cortical receptors function in possibly initiating, terminating, accelerating, or decelerating motor nerve messages destined for the peripheral speech mechanism? 5. how may this "new" sensory approach function in the learning of typical english speech sounds? results the results of the investigation indicated that it is generally believed that numerous exteroceptors and proprioceptors exist in the peripheral speech musculature. it is also believed that somesthetic pathways to the parietal lobe are employed by sensations resulting from touch, pressure and movement stimulation of the exteroceptors, and muscle-stretch and muscle-contraction stimulation of the proprioceptors. 1 journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) when the somesthetic spike potential reaches the parietal lobe it appears to possess unique opportunities not available to visual or auditory. spike potentials for initiating, facilitating, or inhibiting the motor movement patterns essential to speech production. (3, p. 116.) three anatomical characteristics of the parietal and frontal lobes provide these "unique opportunities". the author concluded that the nature of these peculiarly adequate sensori-motor connections, "enable the parietal lobes to play a significant role in laying down a cortical mnemonic neutral trace", which facilitates and synchronizes muscle movement patterns essential to speech. it was suggested that for the best results in securing correct motor patterns for speech, auditory and visual stimulations should be integrated with the "significant potential of somesthetic stimulations." (3, p. 149.) ii. the role of proprioceptive sensibilities in speech production (1) importance of study human speech is made possible by proper integration of highly complex neuromuscular reactions of almost the entire organism. in the production of speech, synergy and synthesis of muscular patterns are important. both synergy and synthesis have as their basis proprioceptive sensibilities. "one would be safe in saying that all speech involves muscle activity and all muscle activity involves proprioception". (2, p. 2.) the sensibilities arising from the deeper tissues of the body, principally from the muscles, ligaments, bones, tendons, and joints, are generally considered to be the proprioceptive sensibilities. the study under discussion did not attempt to advance the sense of proprioception to the exclusion of the other senses but rather to point out that the proprioceptive sense is an outstanding supplement to the other senses. purpose of the study according to the author the purpose of this study was two-fold: 1. to discover as nearly as possible the role of proprioception sensibilities in speech production as shown by correlation of information from the areas of physiology, neuro-anatomy, and physical and speech pathology. 2. to attempt to bring together a body of knowledge which will further the understanding of how proprioceptive sensibilities can be utilized in therapeutic procedures. it is suggested that these findings be tested in further studies. (2, p. 9.) results in the individual with a normal central nervous system, proprioceptive control is of such an automatic nature that it is usually given little consideration. "because of this lack of recognition and the apparent subservient status of proprioception to the other sense, which are often considered of greater importance, this sense is neglected in the training programme of those who do not have normal speech". (2, p. 174.) research in the area of physical medicine has shown that these deep sensibilities can be stimulated to enhance the h a b i t a t i o n and rehabilitation of those suffering from neuromuscular disorders. physical therapy has used various modalities successfully in rehabilitation techniques. dr. dittman (2) analyzed these modalities in terms of their effectiveness in setting up a "physical climate for speech", and in terms of their effectiveness in establishing mnemonic memory patterns in the cortex. several proprioceptive therapeutic techniques advanced by persons interested in neuromuscular rehabilitation were also presented. the author also "set up" a proprioceptive therapeutic programme consisting of three stages of progression. the majority of the proprioceptive modalities were considered to be applicable to the speech mechanism per se. however, the tentative conclusions arrived at through the study indicate that more functional research is needed to substantiate the concepts presented. the modalities discussed should supplement the conventional speech therapy techniques, rather than supplant them. iii. a study of lingual sensory characteristics accompanying "functional" disorders of articulation ( 2 ) . importance of the study it is generally conceded that about seventy-five per cent, or more of the speech problems encountered are disorders of -articulation, and therefore occupy the largest part of the speech therapist's load. in the majority of these cases no apparent cause is found for the faulty articulation and they are referred to as "functional". journal of the south african logopedic society june, 1962 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) many important studies have been performed in the area of "functional" articulatory speech problems, but much more needs to be carried on if we are to understand this large group of speech disturbances. research has produced a multiplicity of causal factors, but "conspicuous because of its almost complete absence from research studies is the mention of tactile and/or kinesthetic sense deviations as possible etiological factors". (2, p. 5.) purpose of the study dr. larson (2) wondered if the ability to "feel" existed to the same extent among children with functional articulatory disorders as among children with normal speech. he stated his problem as follows: the purpose of this study was to discover if functional articulatory subjects tend to have different kinesthetic and tactile ability from normal subjects as shown by testing bodily extremities (fingers) and an oral midline area (tongue). (2, p. 1.) procedure. three tests were developed and administered to sixty elementary and junior high school children. the experimental group was composed of thirty subjects with functional articulatory disorders. the control group of thirty was matched on the basis of chronological age, sex, intelligence rating, economic status, and family sibling pattern. the three tests developed were administered to both groups. the tests measured the ability to judge size of objects manually; size of objects orally; and size of small openings with the tip of the tongue. results. the data indicated that neither group showed any consistent superiority over the other when discriminating between sizes of objects manually. the control group excelled the experimental group somewhat in judging between sizes of objects lingually; however, it was not to any acceptable degree of reliability. on the test that compared the two groups on their ability to "discriminate differences between small holes with the tip of the tongue, however, the control group's superiority was decidedly significant beyond the 0 . 1 . per cent, level." (2, p. 116.) the author was extremely cautious in evaluating his results and said, though many children with functional articulatory problems exhibited a lower ability to make fine discriminations with the tongue-tip, no inference was given that tactile deficiency of the tongue-tip was necessarily a fundamental cause of articulatory disorders. "at best, this particular type of deficiency may be considered as one factor within a complexity of etiological patterns". (2, p. 134.) one of the outstanding contributions of this research was the chapter on suggestions for further study and the ingenuity and meticulousness used in devising the tests. references 1. dittman, helen h., "the role of proprioceptive sensibilities in speech production." unpublished doctor's dissertation, university of denver, denver, june, 1955, 231 pp. 2. larson, m.h., "a study of lingual sensory characteristics accompanying 'functional' disorders of articulation". unpublished doctor's dissertation, university of denver, denver, november, 1955, 149pp. 3. tyson, j. d., "the role of the parietal lobes in speech". unpublished doctor's dissertation, university of denver, denver, august, 1954, 149pp. 1 journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) march j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c society 1 the treatment in a child guidance clinic of emotionally disturbed children showing speech defects by yvonne blake ph.d when a child is referred to a child guidance clinic for a speech defect, the preliminary investigation should be thorough enough to indicate whether the trouble is essentially mechanical (i.e. due to wrong learning habits or to incorrect speech and breathing habits), organic (i.e. a physical defect or deformity affecting either the speech directly or the hearing of sounds) or psychological. obviously, psychotherapy would be essential in the latter cases (if the symptom is serious enough to merit treatment), whereas speech therapy and/or physical help would be necessary for the others. for the purposes of clear argument, it is helpful to assume that the child with organic or mechanical speech defects is psychiatrically healthy and that the psychiatrically ill child can spontaneously correct his speech defects after the emotional disturbance has been dealt with. although this is very often not true, it is a justifiable simplification to make just now. the psychotherapist is thus not a symptom remover; he recognizes the symptoms as an s.o.s. call that justifies a full investigation of the history of the child's emotional development, relative to the environment and to the culture. treatment is directed towards relieving the child of the need to send out the s.o.s. the psychotherapist interested in the dynamics of interpersonal relationships and in dynamic psychology generally, tolerates the symptom and tries to make sense out of it, and to understand the role it plays in the developing human personality. i do not wish to imply that clinics where the avowed aim is to remove the symptom have no value. mothers and children are grateful; and there is nothing to be said against such clinics except that they side-track the whole issue of etiology, of speech defects as a symptom that means something, as an expression of persisting infantile conflict that has value in the economy of the child. in most cases, cure of the symptom does no harm and when a cure could do harm, the child usually manages through unconscious processes either to resist cure or to adopt an alternative s.o.s. sign — one that may produce transfer to another type of clinic. often the symptom is easily seen to be quite a subsidiary phenomenon, a little bit of a huge problem of a human being engaged in trying to develop to maturity in spite of handicaps. it will thus be clear that from the psychotherapist's point of view, it is not initially of major significance whether the child shows through a speech defect or through some other symptom that he is emotionally disturbed, anxious and in need of help. this does not mean that during the course of treatment (often even during the first session) the child will not show why the symptom shown is the particular one of a speech defect rather than some other difficulty; but it does mean that treatment is highly individualized whether the child shows a speech difficulty or some other problem. children who are showing speech defects for emotional reasons cannot be grouped together any more significantly than those showing other disturbances — there may be an emphasis on oral difficulties in such children — particular concern say about oral aggression: biting, eating up, greed — but then again the underlying anxiety or need may be only indirectly concerned with speech or the mouth and more directly with relationships — especially interfamily relationships. i would like to illustrate these points by giving a short account of three cases that were seen by me — all referred for speech defects. t w o of the children were referred for stammering while the third child was described as "talking indistinctly, using jargon and refusing to co-operate with efforts to correct her speech defect." c a s e 1 billy, aged eight, was one of two boys in a good family. his elder brother (three years older than billy) was a straight-forward personality from the beginning and was doing r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c society well at school and presented no problem. billy had had a difficult birth, was not breast-fed after the first ten days and had been a restless, difficult baby from the start. he was even now less capable of taking or tolerating frustration, and was described as generally tensed and highly strung. the mother recognized the stammer for which he was referred as " a nervous symptom." at school, billy was thought to be intelligent but restless and his concentration was poor. it seemed from this history that billy's stammer could be associated with the difficulties evident even in infancy; the tense restless attitude had shown itself from very early on and from the mother's description could initially have been associated with the discomfort experienced in the feeding situation, which would tend to confuse the child and stimulate his aggression. billy came very readily to the playroom. he smiled at me and immediately started putting out the small toy figures and animals without waiting for any explanation or introduction. he remarked, with only the trace of a stammer, that he liked coming to the clinic. i suggested that perhaps he did not feel quite sure about coming and felt that i expected him to like it, even though he could not even know at this stage whether i was a likeable person or not. he looked rather surprised and then said with great difficulty and a noticeable blocking in his speech that he had been to two other clinics and "they were no good." i took up with him the fact that he obviously then, far from liking to come here, seriously doubted whether i'd be any good. i explained that i was not concerned with his speech as such, but that i hoped that we could together try to find out what worried him and what interfered with his ability to express himself freely. i pointed out that the toys, the art materials, and everything else in the room could be used freely by him in any way he chose. he started to build a fort, which was filled with wild animals. he said that they were all so fierce that if i was able to see inside the fort i'd run away. he brought the toy gorilla right up to my face saying "look they bite, grrrrr!" he put the toy into his mouth, bared, his teeth, and with the toy still held in his mouth threatened me wih his "grrrr" sounds. i suggested that he was showing me that the fort was himself, that the wild animals were, in fact, inside him, and that he felt that being so full of wild dangerous animal feelings, he had to keep me out for my own protection and keep the wildness inside himself — no wonder it was difficult for him to let out his speech freely because, if he spoke freely the wild animals may come out with the words. "and eat you up," he added. this pre-occupation of billy's with his "inside", effectively interfered with his outside activities; his continual efforts to deal with and control his "wild feelings" made it impossible for him to concentrate on anything else and his restlessness was associated with his efforts "to keep the animals down". these animals were located in his abdomen and there were many rituals and fantasies associated with placating them, trying to tame them, out-witting them and generally preventing them from destroying him and those he loved. as billy gradually worked through his anxieties and realized that his aggression could be used and expressed indirectly (and that even expressing it openly and directly occasionally did not cause complete destruction and over-whelming chaos in the world around him), he was able to integrate his personality more successfully and to accept his aggressive impulses as part of himself. the speech difficulties cleared up without the need for speech therapy; and after about fifteen months of weekly therapy sessions, billy had changed from a confused, disorganized personality who was seriously threatened and disturbed by his difficulties, into a boy who coped very satisfactorily and without undue tension or strain with both his internal and external "worlds". c a s e 2 peter, aged 10. peter was the youngest of four boys. he had had an uneventful infancy, had been a " g o o d " baby and had presented no problems until his fourth year when he developed a stammer. the mother felt that he really was still no problem but the father was very concerned about it, and evidently had been since the stammer first started. as the boy appeared so normal, he had been taken on for speech therapy soon after starting school — he attended a speech clinic for about 18 months and then had speech training at school. these latter sessions were still continuing when he finally came to a child guidance no blocking of speech but simply an audible clinic, but the stammer persisted. there was stammer. during the first few sessions, peter spent most of his time drawing — the drawings represented "patterns" he had done at school and, in fact, revealed very little beyond the fact that he was not wanting to go into his problem. when this was pointed out to him and it was suggested that he perhaps wanted and needed the stammer and that giving it up represented a bigger threat to him than coping with the difficulties it caused him, he denied this strongly and assured me (as he had assured his father and his teachers) that he "would do. anything to be cured". i asked him what, for example, was he willing to do. he thought for a while r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) march journal, o f t h e s o u t h a f r i c a n logopedic society 13 and then said he would even be willing to let his brother (two years older than himself -— the other two boys were 16 and 18 years respectively and not really important in his life, especially as they were away at boarding school) have his white mice. this led to a discussion of his pets, which the father had given him in the hope that the distraction would help him and cure the stammer. it became obvious that he received many gifts, a considerable amount of attention and enjoyed quite a few privileges from his father — all in the hope of "curing the stammer". the significance of his stammer now became more obvious and also his need not to give it up. as the fourth boy he evidently felt unable to compete directly with his brothers for his father's attention. the stammer was solving this difficulty and bringing him more attention and more material benefits than his brothers enjoyed. at the same time it did cause him considerable suffering and inconvenience, so that he did not have to feel guilty over his need to receive more than his brothers. it was necessary in this case to clarify also to the boy's father how his concern had in a sense encouraged the boy's symptom which seemed to have started as a "normal" speech difficulty of a three year old. as the youngest child, peter had early on felt the,need to compete with his brothers and had shown an over-eagerness to express himself in speech and to make his wants known; and the stammer developed into a problem only when the father became over-anxious about it. t h e father's concern transformed a temporary and very common difficulty into a chronic symptom. this symptom disappeared only when peter could prove to himself, with his father's cooperation, that he could have the attention, love and support he needed without clinging to his symptom. c a s e 3 maisie aged 5. maisie was the elder of two children — her brother being 20 months younger. the mother felt maisie had developed normally in most respects, but had never learnt to talk properly. her developmental quotient and her i.q. were above average and, except for her speech she was coping well. she was not "babyish" in other ways. she simply refused to speak clearly, and if her parents pretended not to understand her demands, unless verbally expressed, she screamed or refused her food. it became evident that to the mother, the most significant factor was the child's refusal of food and not the speech. t o the child it was neither food nor the speech which mattered most but her feeling of having been pushed out by her mother when her brother was born. the mother remembered only later on during treatment that maisie had been bottle fed until the baby was born, and had been abruptly weaned because the mother could not "have two babies" at the same time. maisie deeply resented the deprivation, she resented the attention the brother reccwed and expressed her hostility orally by refusing to "grow up" in this particular way. from these three examples it will be clear that the speech defect was in each case connected with the child's inter-personal relationships. it was only as he was able to sort these out that the need for the symptom disappeared, and development could proceed normally. i do see the point of view of the person, who not being concerned specifically with dynamic psychology, must ignore the meaning of symptoms and must try to cure them. but i do ask these specialists to give the psychotherapist credit for his point of view. the two disciplines should produce different kinds of child-specialists, each with a healthy respect for the other. the emotionally disturbed child needs treatment, which is geared to his specific needs, and which will reveal the meaning of the symptom — be it a speech defect or other difficulty — in the make-up of the child. the symptom is usually an organisation of extreme complexity, one that is produced and maintained because of its value to the developing human personality. the child needs the symptom because of some hitch in emotional development. the psychotherapist is thus concerned with the satisfactory development of the child rather than with the symptom as such. bookbinding r. korytowski 1 mylin court, 24 beit street. doornfontein. telephone 44-9602 four reasons why you should have your books, magazines and thesis bound by us: 1) modern linen in 30 colours. leather with beautiful grains 2) first class craftsmanship guarantee for unbreakable binding 3) quick delivery 4) well known for reasonable prices. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) jequiasaq journal of the south african logopedic society 7 the training of language and conceptual thinking in the child with brain damage by i s a a c jolles south suburban public school co-operative association of cook county hart school, homewood, illinois one of the most perplexing problems to the teacher of educable mentally handicapped children is the pupil who responds readily to the nonacademic program but who fails to make satisfactory growth in the reading activity. this problem confronts the teacher of brain-injured children whose intelligence level is well within the normal range. although this has not been definitely established through medical diagnosis, we have reason to believe 'that the inability of these children to comprehend oral instructions and/or to express their thoughts adequately is the direct result 'of some neurological impairment. before proceeding further with this discussion, a description of the type of child with whom we are concerned in this paper is in order. the most outstanding trait is the marked discrepancy between the iq's obtained on verbal and nonverbal tests of intelligence with the performance on the non-verbal test being superior. for example, in classes for children of normal intelligence one may find a pupil whose stanford-binet (verbal) iq is 85 but whose arthur (non-verbal) iq is 119. in special classes for the educable mentally handicapped one may find a pupil whose standford-binet iq is 69 but. whose arthur iq is 103. in either case the classroom manifestation of this difference in verbal and non-verbal abilities is the same, namely, slow progress in academic work (particularly reading) but quite adequate progress in those activities which do not require dealing with symbols, abstractions, and conceptual thinking. among the mentally deficient this type of child is prevalent enough to have caused the misconception among educators that the mentally handicapped are good with their hands but no good at "book learning." so much of one's intellectual functioning is dependent upon language that it is to be expected that this would b'3 frequently associated with mental retardation. the writer has made a crude study of the effectiveness of the children's primary sensory channels for learning in the classroom (auditory, visual, and kinesthetic.) this study involved an analysis of the children's response to various types of intelligence test items and the correlation of the successes and failures with the three sense modalities mentioned above. the children involved in this study were 69 pupils who were in special classes for the educable mentally handicapped. it was found that the children who presented symptoms of language deficiency were inefficient in their responses to test items involving auditory stimulation whereas those who manifested no such symptoms seemed to be relatively adequate in their responses to items involving auditory stimulation. such a disaovery should not surprise us, for it is obvious (as we have learned from the language development problems of deaf children) that language development depends so much upon a child's responsiveness to the spoken language of others. it should follow, then, that if the child has some neurological impairment which results in an inefficient auditory sensory channel, his language development will be retarded. likewise, his ability to form concepts will be impaired, for conceptual thinking is dependent upon abstract thinking through the use of language symbols. without language one cannot think in abstract terms; without abstraction it is most difficult to form concepts. we in north america learn about africa through some one else's experience, not by going there ourselves. this we can do through language. the child with a serious language deficiency cannot learn about other continents effectively through the experience of others. we should not be surprised, then, when a child of this type replies to the question, "where is chile?", by slaying, "in a can." likewise, he is unable to express the similarity between a plum and a peach, but he probably could see some relationship between them if they were actually within his presence. our problem is how to reach this type of child so that he can learn to think and to read with comprehension, at least within the limits of his intellectual potential. as far as this writer has been able to learn, there are no publications of research that would give information to a teacher on how to train such a pupil to form concepts. therefore, the writer collaborated with miss selma i. southwick, teacher of educable mentally handicapped children in the quincy, illinois, public schools in the development of an r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society instructional approach and a teaching sequence which we believe will b'e useful in achieving our goal. this method has been used by miss southwick during the past two years. in some of the cases progress has been unexpectedly good, in others somewhat slow. at least in most pupils we have observed progress beyond that which we have seen in the past. the approach which · we are using involves intensive training in the forming of concepts. the part that language development plays in this approach will be evident in the description of the teaching sequence which has been broken down into the following steps. 1. teaching the relationship of objects within the immediate experience of the pupil. the normal child accomplishes this step in his development through the use of a readiness work book; he checks objects which differ but in some way are alike and rdlate to each other. this relatively abstract approach (workbook pictures )is adequate for him because of his accurate interpretation of his environment, but in the case of the child with brain damage, be he mentally handicapped or normal in intelligence, this is not the case. he usually has a perceptual disorder which tends to make it difficult for him to interpret his environment accurately. in the usual workbook, he may not check the objects aorrectly; but, if he does check accurately, he cannot explain why he chose as he did. such an achievement is mechanical and cannot be interpreted as an indication of readiness for academic work. before using a workbook, this child needs a prolonged period of training wherein he has actual objects to manipulate. thus, he can feel likenesses and differences in form, in texture and in function; he makes use of his relatively efficient visual and kinesthetic sensory channels. the objects need' to be distinct in color, in form, and in function so that discrimination may be achieved more accurately. the color of the object must be in reasonably sharp contrast from its background. it's size must neither be so large that it completely obliterates the background (thus losing much of its perspective within the environment to the point of losing much of its meaning) nor so small that it becomes lost within the total field. the child needs to verbalize as he manipulates, for by so doing he employs his auditory sense to emphasize what he is experiencing visually and kinesthetically. this is most important in that it helps to develop the effectiveness of his auditory sense modality. verbalizing the experience not only increases the meaning of the experience for the child', but it also offers the teacher an opportunity to develop and to check the accuracy of the child's understanding of the particular situation. for example, in answer to the question: "how is the orange like the apple?" the child with the compliments of gallo (africa) limited distributors of 2)ecca, dsrunsivich, (qallolone, 2). and ^j^oludoi* (records r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) e journal of the south african logopedic society may say, "because the orange is an orange." 2. teaching the relationship of pictures of the above objects. the normal child effectively discriminates between the small pictures found in most readiness workbooks. the child with disorders in the language and concept areas may find it more meaningful to sort large, clearly defined pictures, for they help to compensate for his perceptual disability. here again the actual manipulation of the pictures tends to center his attention to a degree that more accurate interpretation is achieved. 3. drill on the relationship of pictures of objects not within the immediate experience of the child. all teachers are well aware of the value of pictures in extending the child's understanding of the world beyond his immediate environment. the normal child looks at the pictures, discriminates, and evaluates the messages presented', particularly as it relates to his past experiences. this is not true for the child with a concept disorder. for example, suppose the teacher presents the following pictures for study: 1. a person lying on a sofa. 2. a person sleeping in a bed. 3. a person sitting quietly under a shady tree. 4. persons playing basketball. 5. a person operating a machine in a factory. the child unable to form good concepts will find it difficult to understand why all the pictures except the last denote some kind of rest or relaxation. this child needs extensive opportunity to study pictures that have very distinct messages. as he discusses the pictures the teacher helps him to clarify his thinking by interjecting questions which help him to work out an accurate interpretation. for example, the child responds with "the orange is an orange," to the question stated above. the teacher then directs his thinking as follows: "yes, an orange is an orange. is an orange round like :a ball? is an apple round like a ball? can you eat an orange? can you eat an apple? can you eat a ball?" the teacher will note the similarity of this exercise to exercises in the traditional workbook. there are, however, important differences for the child we are discussing. this child must have concrete experiences in order to observe similarity, i.e., actual fruits if they are available, sharply defined pictures as a second best visual aid. the child works out his reasoning orally so that he hears his sequence of ideas which give him the correct concept regarding the apple and the orange. 4. teaching to transfer this type of thinking to other situations. 5. teaching the relationship between words, pictures and objects with stress being placed on pretoria school for cerebral palsy p.o. box 1511, pretoria. applications are invited for the post of speech therapist salary: (4 year course) £600 χ 30 — £960 four school holidays annually. to assume duties as soon as possible. apply: the principal, p.o. box 1511, pretoria. the meaning of words. 6. drill on the forming of concepts with words ivithout the aid of objects and pictures. 7. redrill on the transfer of this training to other situations. steps 4 through 7 of the developmental sequence follow the methods suggested above for steps 1 through 3. each problem which the child confronts must require a choice of solutions with the necessary reasoning involved in making the choice. for example, phonetic instruction in reading is of little value unless the child is required to transfer the learning of the drill period to actual reading situations that are meaningful to him. if he has learned the short sound of "a", then he should have to face an unknown word which is controlled by this sound so that the teacher will see that he applies his new learning correctly in order to help him pronounce this word. in conclusion, the type of child whom we have been discussing here must start slowly with a simple experience which is so very concrete that he can see it, hear it, manipulate it to the degree necessary to prove to himself its actual reality. for this reason we must adhere to the sequence mentioned above in the training of concepts as well as in the development of language itself. in other words, we start with the concrete objects, go on to pictures, then to the word, and finally to the printed word which is the ultimate in symbolism. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c s o c i e t y speech recording in stuttering therapy erica stern, b.a., dip. log. south africans generally, and school children in particular, have become increasingly radio-conscious within recent years. no doubt the advent of "springbok radio" has had a great deal to do with this. after school is over for the day, children enjoy listeningin to tales of adventure and travel, radio plays and dramatised broadcasts of stories, a s well a s a variety of other programmes. thus the pupil who is given the opportunity of making a recording of his speech is bound to win the admiration of his listeners when the recording is played back, since a tape (or wire) recorder is still a novelty, not being yet in everyday use. however, if a stuttering pupil is to derive enjoyment and benefit from the use of the recorder, certain considerations should be borne in mind by the speech therapist. firstly, children who are asked to speak impromptu into the microphone of a recording instrument are likely to be more hesitant in their speech than is usually the case. this will become apparent when the recording is played back. secondly, children are likely to be adversely affected upon hearing a recording of their own, non-fluent speech. the above points are illustrated by the case of jimmy, mentioned by prof. wendell johns o n . ( 2 ) it is the opinion of the writer, therefore, that a tape recorder should only b e used with stuttering pupils when it is possible to record a fluent sample of their speech, or at least speech that is decidedly more fluent than their usual way of speaking. hearing such a recording of. their speech will give a feeling of encouragement and satisfaction to the stutterers. | various recordings by university ! students. lucile cypreansen ( 1 ) reports interesting experimentation in the making of different types of recordings with a group of 14 university of nebraska men students (all of whom were stutterers), between the a g e s of 18 and 23 years, a s part of the speech -therapy programme during the first course of fifteen meetings. speech recordings were made from the 11 th to 14th meetings. 11th meeting. "each student tried the ' two-room' technique, speaking extemporaneously and reading aloud while shut off in a room by himself. in a connecting room, closed off by a door, the supervisor made electrical transcriptions of what w a s being said. the microphone of the recorder w a s placed in the room with the speaker. interesting results were noted. the speaker knew the recording w a s going on, but he did not know just when his speech was being recorded. speech patterns on the records showed much improvement over speech patterns used in daily speech. the subjects were pleased and encouraged by the results of the recordings. 12th meeting. "a type of 1 p s y c h o d r a m a ' was tried. the students were given a hypothetical incident to dramatise informally without previous practice. "two students were placed in the room with the microphone. they proceeded to carry on the dramatisation of the incident. there w a s very little stuttering noticed in this type of dramatisation. the supervisor and the rest of the group in the other room could hear over the connecting amplification system all that w a s said. parts of the dramatisations were recorded. later the recordings were played back to the group. the subjects were free and easy in this project and appeared to enjoy the performances thoroughly . . . "an assignment w a s m a d e for the next meeting. each student w a s to bring a threeor four-minute selection that he would like to read to someone else. 13 th meeting. "the selections assigned for oral reading were practised on the wire recorder. two students worked together on one recorder, recording and listening, and offering suggestions to each other . . . 14th meeting. "electrical transcriptions were made of readings of the material which had been previously assigned and practised on the wire recorder. the members of the group were allowed to take their records home to play for their families and friends. they were then returned and filed in the individual clinic folders." cypreansen reports that by the next (15th) meeting (which w a s the end of the first r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c s o c i e t y o c t o b e r course), "most of the members of the group appeared to have gained greater confidence in speaking situations . . . and several of the students appeared to show definite improvement in speaking habits." at the opening of the following term the students decided to continue with their group work. additional projects were undertaken and "the making of the recordings was to be continued." recorded programmes by primary school children. in the larger centres of the c a p e province, where classes for speech defective school children a r e carried on under the c a p e education department, the members of the itinerant staff have at their disposal a tape recorder, and a couple of reels for the use of each staff member. up to the present time, however', the writer has had only limited experience in the use of the tape recorder for dramatisation with stuttering pupils. the tape recorder offers some advantages over the presentation of "live" plays. (a) it is preferable to use the recorder in cases where the speech of the stuttering pupil has begun to show an improvement, but where the therapist fears that there is a possibility of the pupil's speech breaking down in front of an audience. (b) there is bound to be an improvement in the speech of the pupils after a number of rehearsals. "the adaptation effect (the tendency for stuttering to decrease with successive readings of the same passages) w a s first reported in 1937 by johnson and knott, and it has since been repeatedly confirmed in experimental studies . . . johnson and innes found that in five successive readings of a short p a s s a g e there was an a v e r a g e reduction in frequency of stuttering of approximately 50 per cent."® (c) if desired, the therapist can make more than one recording of the same programme, and select the best (or better one) to be played back. (the others can b e erased and that portion of the reel used again). (d) certain radio plays and broadcast programmes can be recorded easily which would be difficult to present on a stage. the recordings were made by 13 boys, whose speech was marked by stuttering in varying degrees, from standards 1 to 5 inclusive in primary schools in cape town. these pupils were receiving treatment in three groups of three each, and two groups, each consisting of two pupils. the four latter pupils were combined into one group for the purpose of the recording. the pupils were told that they could make a recording to be played back to their classes at the end of the second quarter (in june). one of the groups (consisting of three standard 5 pupils), preferred to write their own programme. thus "tintown calling," (a skit on "snoektown calling"), came into being. it incorporated the pupils' own ideas, with some help from the therapist. the pupils were particularly keen on sound effects, and brought tins, a cane and a knobkerrie for the purpose. for use with stuttering pupils (whom the writer prefers to treat in small groups of two or three), very suitable, graded plays are to be found in harrap's "new dramatic readers," books 1—4, and in the recently published series of five books entitled "prettige praatstories" (nasionale boekhandel). the three plays to be recorded by the groups were chosen from the above books by those taking part. each pupil was asked which part he would like to take. if only one pupil chose a particular part, he was given that part in the play. otherwise lots were drawn for the parts. thus no pupil felt that any favouritism had been shown, and all were afterwards perfectly satisfied with their parts. a typewritten script was given to each pupil to enable him to rehearse the play at home with his parents, brothers and sisters. the class teachers concerned showed keen interest in the idea and were eager to make the necessary arrangements for the performances (i.e., the playing of the recordings to the different classes). all the performances achieved great success. the listeners showed their appreciation by requesting, "can't we hear it again," and it w a s obvious that the stutterers, who were able to observe the reactions of the audience, derived great enjoyment from hearing the recordings they had made. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c s o c i e t y since rehearsals for the recordings were held for a comparatively short period of time, (owing to the illness of the therapist), and a s this method was only used a s part of the treatment that the pupils received, it is difficult to estimate the degree of improvement that the use of this technique brought about in the speech of . the pupils (if at all), and for how long it would have lasted. the writer would b e interested to know of the results obtained by other speech therapists using speech recording in stuttering therapy. bibliography. 1. cyprecmsen, lucile, "group therapy for adult stutterers," the journal of s p e e c h a n d hearing disorders, december, 1948, p a g e s 313-319. 2. johnson, wendell, "speech handicapped school children," harper a n d brothers, newyork, 1948. appendix. 3. johnson, darley and spriestersbach, "diagnostic manual in speech correction," harper a n d brothers, new york, 1952, p a g e 122. p.o. box 10482 telephones 22-4656 23-9432 abe etkind (pty.) ltd. wholesale merchants. first floor, lincoln house, 57 pritchard street, tohcamesburg. world's finest hearing-aids. 3 transistor from £29/15/0 wd the (^omplimentd 4 specialist suppliers of physiotherapy and rehabilitation equipment telephone 23-8106 236, jeppe street, johannesburg p.o. b o x 3 3 7 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) cleft lip and palate by d. h. walker. f.r.c.s.(ed.) plastic surgeon, johannesburg hospital and university of the witwatersrand. at least one in every thousand babies born will have a hare lip or cleft palate, or both. to have some idea of how to treat and repair these is not enough; the immediate method is of little value unless one tries to assess its possible effects on the life and behaviour of a young adult twenty years hence. there is a quotation attributed to professor t. p. kilner and used by sir harold gillies which epitomises the ideal end result — "they shall look well, speak well and eat well." it is unlikely that any one person can acquire and use all the skill, judgement and art needed to approach this ideal end-result. the methods used at present are in the hands of three groups of people:— (1) plastic surgeons and nurses. (2) orthodontists. (3) speech therapists. these are not given in any order of importance or priority but rather in a possible order of consultation. each is important in his or her own field and at a particular time — in the progress of treatment, any member may have top priority in helping the patient. it is our practice, whenever possible, to see the baby with cleft lip and/or palate on the day of birth or soon after. once a probable treatment plan has been laid down, the parents can be told of all the positive help that can be given to their son or daughter. it is known that about 20% of all cleft lip and palate patients have a family history of this anomaly; this should be recorded and constantly kept in mind. the help and advice of a skilled geneticist may be sought if a larger family is to be planned with reasonable safety in this group. of the remaining 80%, a large proportion is associated with poor living conditions or malnutrition — either immediate or in the past. the usual speculative factors of virus and other infections are quoted. however, a strong case may be deduced for the grave dangers of the use of steroids during the first three months of pregnancy. these substances need very special indications for their use and should probably be ordered for a pregnant woman only by doctors in consultation. all classifications are man-made and usually false in many respects. rigid classifications of natural phenomena are perhaps as good an indictment as any of the great mental trap of mankind — man's pathetic and frequent belief in the infallibility of his own reasoning. different centres and different countries use varying, variable and often conflicting classifications. it is suggested that a brief accurate description is one of the best forms cf classification. cleft or hare lip. (a) unilateral or bilateral. (b) incomplete or complete. cleft palate. (a) complete or incomplete. (the latter sometimes referred to as a posterior cleft of varying degree). (b) unilateral or bilateral. for example. hendrik v.d. merwe. unilateral complete cleft lip (l). palate intact, notched alveolus. john smith. bilateral cleft lip and palate. (l) lip cleft: incomplete. (r) lip cleft: complete. permutations of these allow for all but the rare anomalies. the extra writing of a few words is more than worth the extra clarity of the mental picture produced for any one who is at all familiar with the appearance of children with clefts. there is little, if any, room for the concept of repair of a cleft lip or palate as an december, 1962 journal of the south african l o o p e d i c society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) emergency procedure. when this form of request is made it generally relates to feeding difficulties. these can nearly always be overcome by (a) breastfeeding the baby as much as possible to encourage a normal sucking reflex, (b) completing the extra requirements by using a feeding bottle with a suitable teat. there are many examples of children growing to be well developed and articulate adults without any surgical procedures or any other treatment of their cleft lips and palates. one has recently seen an adult male with an untreated bilateral cleft lip and palate who is eighty-five years old. a further patient with not so severe a disability is a woman over sixty years old who has an untreated, wide cleft palate extending the whole length from the post-alveolar region to the uvula. this woman has perfectly intelligible speech and, although when young had difficulty in preventing certain foods and fluids from escaping via her nose, now has learnt to control this abnormality completely and eats and drinks in an exemplary manner. she has three female grandchildren, all of whom have identical clefts to her own, and informs us that this is a common abnormality in all female members of her family but is not found in the males. the eldest of the three grandchildren has already had her palate repaired and now rejoices in normal speech. to return to the question of early operation: one does occasionally repair, under local anaesthesia in the maternity hospital, a partial cleft lip of moderate degree — generally when the palate is intact and the lip presents the only defect. the patient should be about a week old and in excellent health. our more usual procedure is to ask the orthodontist to see a child with cleft lip and/ or palate in the maternity hospital during the b first week of life. it is possible with modern techniques, skill and materials to take dental impressions at this early stage and to make an accurately fitting prosthesis or obturator which closes at least the front of the cleft in the gum and palate completely. this is held in position by a light headcap which is attached by rubber bands to smooth, light, curved wires which project to the exterior from the small plate in the baby's mouth. with a little patient, gentle and persistent replacement the baby soon accepts the appliance and feeds quite readily with it in position. the object of this is to produce a better, more even alignment of the parts of the alveolus on either side of the cleft. not only will this, after a few months, make the operation easier and more successful, but it will improve the external contour and, internally, pave the way for a better palate repair. the success of such an appliance is largely contributed to by the child, since persistent palatal and facial movements such as occur in sucking, perform a strong and almost continuous moulding action, transmitted by the orthodontic appliance. it has been found, however, that there may be a rapid decrease in the degree of spectacular improvement if the method is not started in the first three months of life. after many years of argument and evidence, world authorities are still undecided as to the best age for surgical treatment. a general method for cleft lip is to choose any age over three months, or when the child weighs about twelve pounds or more and is in good health and gaining weight steadily. it is preferable for the child to be on a mixed diet. the presence of early erruption of teeth is not a bar to any of the usual standard operations. some teeth, badly out of position — "ectopic teeth" as they are called, may be safely removed at the operation for repair of the lip. the essentials of this operation are best considered in the form of priciples — there are dozens of technical variations in actual operative procedure — all aiming at the same end-result: a lip which on close inspection looks as though the patient once had an accident in the form of a cut lip (and possibly cut nostril floor) which has left a faint scar. the important points to look for are:— (i) that the nostril bases are on the same horizontal line and the nostril floors — from nostril margin to the septum — are of the same width. (ii) that the sides of the cleft are of the same length and hence the depth of lip below each nostril is the same on both sides. 6 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) (iii) that the muco-cutaneous junction (i.e. the junction of the skin and red margin) form a smooth continuous line, without "steps" and with the same depth of mucous membrane showing on both sides. there may or may not be a "cupid's bow". a large number of surgeons' names are attached to the operations described for repairing hare lips — all aim at the results described. some of the more common names are mirault, blair, kilner, rose, le mesurier, veau, tennison, and, more recently, millard. it is, in the end result, most important to avoid a "tight lip" — stretched from side to side. incidentally, a device preventing unreasonable side pull on recently inserted stitches is called a "logan's bow" and consists of a smooth u-shaped piece of metal fastened to the cheek by adhesive strapping so that it rests astride the newly repaired lip and relaxes the margins of the cleft. stitches remain in for a varying period, depending on tension and other factors, but most are out within a week. the patient is usually in hospital for about ten days. whenever possible some part of the gap in the gum and the nostril floor are repaired at the same time as the lip. a suitable age for cleft palate surgery is often considered to be between one and two years. at this age the child is beginning to make sounds which have a definite meaning and, as the end of the second year approaches to say simple words in imitation of adults and older children. surgical repair at this stage is done partly on the basis of the theory that learning to speak with a closed palate (rather than an open, unrepaired one) will produce fewer bad speech habits and their subsequent imprinting on the child's mind will be minimal, and partly to aid in normal eating. against repair at this time are the findings of a number of workers — including those engaged in a long term survey for the american orthodontic association. follow ups of the order'of twenty years have been done on patients who had radical repairs of cleft palates in the first year or two of life. many of these operations featured a very radical separation of soft parts from bone in the preceding lip repair as well as in the later palate repair. this usually takes the form of elevating as much of the lining as possible of both nasal and oral surfaces of the bony palatal shelves, so that soft parts may be moved towards the midline to close the cleft, and also displaced backwards to give length and mobility to the repaired palate. it is believed that this may, in some cases contribute towards severely retarded development of the middle third of the face, becoming most noticeable as adult life is approached. this is not, of course, conclusive evidence that the radical nature of the operation in the cases investigated was the direct and entire cause of the mal-development of the face and the palate. firstly the term "radical" must be qualified by knowing exactly the extent and technical nature of the dissection at the operation. secondly, the abnormality of a cleft palate may include anomalies of the blood supply and irregularities in the growth centres of the bones of the face — in number, position or behaviour — or in combinations of any of these. of major importance in the growth of the centre of the face in a forward direction, is the nasal septum, based in turn on the vomer, a bone which resembles a vertical partition, rising high in the naso-pharynx from the base of the skull. interference with the blood supply of the vomer may result in failure of the tip of the nose and upper lip to grow forward sufficiently — hence the occasional flat profile of the repaired upper lip. this deformity is sometimes contributed to by a slow inward collapse of the alveolar arches with a final contour that is small and pointed towards the front. as the information just outlined was collected it became important to know when, if the age of two years is too early, it might be reasonably safe to operate on a growing face in a relatively radical manner. it is now suggested that sufficient growth of the middle region of the facial skeleton has taken place by about the age of four years to minimize the risk of serious facial deformity after operation. nevertheless one should remember that there is no finality in this matter and the exact age for operation is often varied for different patients. if the child is intelligent enough to try and december, 1962 journal of the south african l o o p e d i c society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) use recognisable words before operation there should be a period of meetings with the speech therapist, frequent enough to develop friendly contact and confidence. this should culminate in a careful, unhurried tape recording and pre-operative speech assessment. general health before operation must be good and examination should show the child to be free of any other gross abnormality. it is not uncommon for congenital defects to occur together in the same patient, e.g. an abnormal heart, a hernia or a genito-urinary abnormality. these, or any other defects, do not as a rule prevent successful treatment of cleft lip and palate. from a plastic surgeon's point of view, one aim stands head and shoulders above the rest — normal speech. in order to promote the highest standards of work this aim should be taken literally. the best results should produce speech indistinguishable from that accepted in persons who have no cleft palate. it is believed that the anatomical and physiological factors contributing to normal speech include an active closing off of the oro-pharynx from the naso-pharynx while speaking. the main aid to this is probably a long, mobile soft palate capable of brisk, symmetrical muscle contraction. as he commences the operation by mobilising the soft parts and testing their displacement backwards and towards the mid-line, this thought must be uppermost in the surgeon's mind. as the dissection progresses each step should lead to a repair which consists, if possible, of a complete closure, using the patient's tissue in such a way that no artificial device will be needed later and no fistulae will remain or develop. at most, one's compromise on this arrangement should consist of an occasional case with a temporary obturator and the intention of planned fistula closure later. the application of these principles is made clearer by reference to the common types of cleft (the simplest first) and very brief descriptions of the operations commonly used in their repair. a. cleft soft palate only. sometimes referred to as a "posterior cleft" this may vary from a bifid uvula to the whole length of the soft palate ending in a v-shaped notch in the back edge of the bony hard palate. this latter deformity can be felt by gently putting a finger in the child's mouth. the older operation for the repair of this is associated with the name of langenbeck and consists of excising the edges of the cleft facing each other and thus displaying two layers of mucous membrane in a "sandwich-formation" with muscle as the filling on each side of the cleft. next a long incision is made in the soft and hard palate on the inner side of the teeth of the upper jaw. the extent of these incisions, on each side, is from the hamulus to the level of the canine tooth. the soft parts on either side of the cleft are then lifted cleanly off the bone and the greater palatine artery is carefully exposed on the underside of each strap-like flap. if the two strap-like flaps — attached back and front — have been sufficiently mobilised and the cleft is not too wide, they may be sewn together in the midline with two layers of stitches — one on the nasal side and one on the mouth side with the knots facing down into the mouth from the newly constituted roof. one of these layers of stitches should include muscle as it passes through the edges. if the cleft is wide and the greater palatine artery acts as a tethering mechanism under the flap, this may be divided without serious complications. what does produce serious complications is suturing under tension — this must be avoided. the disadvantages of the langenbeck operation are that it does not guarantee permanent lengthening of the palate as the raw undersurfaces of the flaps may scar, shrink and contract in the weeks and months following the operation and so pull forward the uvula and back edge of the soft palate. this minimises the chances of good closing off of the naso-pharynx and hence makes normal speech more difficult. it is, in any case, difficult to be sure of what one has achieved oil the speech side for at least three months after operation and sometimes not for a year or more. the name of victor veau, a french surjournal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) geon is sometimes associated with the operation which uses two long flaps in repair of a cleft palate, at first resembling von langenbeck's flaps, but dividing the front attachments of these flaps so that they are only living on their attachments to the soft palate. backward displacement and suturing in the mid-line are much easier but care must be taken to avoid the formation of a fistula towards the front of these flaps. a similar operation, but using two shorter flaps and permitting division of the greater palatine arteries with less risk of devitalising any part of the flaps, is known as the 'wardill operation'. this method described by wardill of newcastle, is sometimes called the ύ-υ' procedure since the shape of the incision at first outlines a v and then as the flaps slide backwards, come more to resemble a y. occasionally in a narrow cleft where the palate is already long, and favourable in other respects, the edges of the cleft may be paired as previously described and joined by stitches in the mid-line with little or no relaxing or releasing at the sides. carefully planned repairs of soft palate clefts only, should yield between eighty and one hundred percent normal speech. b. cleft soft palate and a variable amount of hard palate. — e.g. two-thirds or three-quarters cleft but still with the alveolus intact i.e. no 'gap in the gum'. the vomer, covered with mucous membrane, is normally well exposed and one can look into the naso-pharynx through the cleft in the palate. it is still possible to use the langenbeck operation for these clefts but one of the best procedures is the so called 'four flap' operation of wardill which uses two posteriorly based flaps for the main part of the repair and two smaller flaps based on the front of the hard palate, behind the teeth, to close tlhe extreme front of the cleft and avoid a fistula in so doing. cuthbert has also designed an operation for this type of cleft . . . particularly for use when the| vault of the palate is high and changes its direction suddenly as the cleft is traced from front to back. this operation is of the three-flap variety and avoids the risk of fistula . . . particularly at the hard/soft junction— an area notorious for fistula formation following a progressive build up of tension while stitches are being put in. cuthbert's operation consists of using a long flap from one side and dividing the other side of the cleft into two flaps, one based on the front and the other on the back. the long flap is made to follow a curved course across the cleft, from side to side and in doing so crosses in between the two short flaps which are stitched to it. this gives a very long, mobile repair and minimises very greatly the effects of any shrinkage or contracture from back to front. c. complete clefts . . . unilateral or bilateral . . . usually associated with a cleft lip as well. there is, of course, a gap in the gum and a cleft lip is generally present as well. an approach originally described by dorrance, has several advantages in dealing with the difficult region at the front of the hard palate. the method may apply to complete, unilateral and bilateral clefts. a flap of mucosa from the vomer (or flaps from both sides of this partition in a bilateral cleft) is mobilised and its free edge moved across to be tucked under a raw edge prepared in the un-united margin of the hard palate part of the cleft. when this has healed, almost the whole of the hard palate has been closed by the use of nasal lining only. the remaining part of the problem now resembles the closure of a cleft which has involved the soft palate alone. factors influencing the success of surgery are usually those of timing and technique. timing in the sense of operating in the optimum period, includes consideration of general health and weight in relation to age. timing must give consideration to the orthodontist — he must have started work early enough and have had long enough to have achieved maximum moulding before superadded surgical movement of soft tissues is undertaken. the speech therapist's orientation to timing must include the problem of whether or not the patient's operation has been delayed for so long that bad speech habits are in danger of becoming heavily imprinted on the brain. there may be danger from previous inexpert speech treatment elsewhere. no amount of palate and lip closing, howdecember, 1962 journal of the south african l o o p e d i c society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ever expertly done, can rectify serious mental blocks to normal speech. such cases call for the highest degree of understanding and skill in a speech therapist. as a generalisation it seems reasonable to say that fewer children with early adequate repairs of cleft palates need speech therapy than do those whose repairs are delayed until a fair-sized collection of badly pronounced words is in daily use. faulty surgical techniques are often perpetuated by operators who have been repairing cleft palates for many years and acquired experience without wisdom. the surgeon who is to achieve a high standard of results in his work, must be ruthless in his criticism of himself, and whenever an operation is unsuccessful, look first to himself and much later to the patient or instruments or type of operation for the cause of failure. briefly the surgeon must strive for a long mobile palate closed without perceptible tension, without rough handling of muscle and too severe an interference with blood supply. the swelling following the operation produces a marked degree of stiffness of the palate. this may persist in some mild form for weeks or months. for this reason one frequently suggests that no speech therapy should be started for about three months and during this time attention should not be drawn to the child's speech. the child should be allowed to make attempts to speak in the same way as any normal child — by imitation of the parents and older children. whenever the parents are able to show an appreciation of the principles underlying treatment these should be explained to them. the child himself, should never if possible, be allowed to feel that he is any different from other children. if and when any embarrassing situation arises — usually by a reference to the lip scar or speech peculiarities — the child should be encouraged to reply at once, if he is old enough, saying that he has had an operation and is getting better. several residual problems arise — some in the form of questions from speech therapists and parents. one of these problems is the occasional doubt as to whether speech therapy should be given in the presence of a fistula — can it be harmful in such cases? the answer to this may depend on the site of the fistula and the intensity of therapy. intensive efforts to master the technique of using the tongue to close off an anterior fistula, while still trying to produce normal speech with the rest of the palate and tongue, may produce a confused state of mind about certain sounds if an obturator is inserted later, or the fistula closed by a further operation. if an early operation or closure by obturator is not possible, it may be better to ignore wrong sounds produced by an anterior defect — if the rest of the anatomy is functioning reasonably well. a fistula further back — the common site in many repairs is the junction of hard and soft palates — may not need any special therapy at all since its closure may be effected by ordinary movements of the tongue and by muscle movements of the palate in which it exists. incidentally, it is most unlikely that speech therapy, if started more than two weeks after a successful operation, would ever cause breakdown of a surgical repair. removal of tonsils and adenoids in a cleft palate patient is usually a factor against normal speech rather than for it. unless the evidence for the removal of tonsils is very strong this operation should be avoided. if it has to be done this should be at least six to twelve months after the repair of the palate. the tonsils should be removed with special care and gentleness by an ear nose and throat surgeon who is familiar with the factors responsible for normal palate function in speech. great efforts should be made to retain the adenoids as they may play a vital part in avoiding nasal escape. plastic surgeons are often asked to predict the chances of normal speech. many clinics claim eighty per cent of normal speech after cleft palate repairs. there is probably more / 7 of the exceptional than the usual in this figure. it is probably safe to say that, with a child who is mentally normal, repairs of clefts of the soft palate only should yield normal speech in over eighty per cent of cases; repair of other clefts should yield normal speech in over fifty per cent of cases. post operative examination of the patient should not lead to judgements on the grounds 1 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) of appearance of the patient's repaired palate. an ugly asymmetrical repair may be found in a patient with completely normal speech, and a palate that looks very close to the normal anatomy may produce poor speech. the function is more important than the apparent structure. to return briefly to the question of obturators: can they ever do harm? it depends on what one means by "harm". a mechanically unsound obturator may cause dangerous ulceration by friction and pressure. a loose obturator or one which is too small because of the rate of growth of the patient may cause peculiar defects and the rest of the child's speech may be harmed by strenuous struggles by parents and speech therapists when all that is needed is a new obturator. this point should be checked repeatedly as the child grows. one 'type of obturator worthy of special mention is that which is made with a very thick centre section, protruding downwards towards the middle third of the tongue. this sometimes has the effect of forcing the patient to move the tongue away to produce certain sounds adequately. if the design is correct, the tongue may be forced backwards and a more effective naso-pharyngeal closure produced — resulting in reduced nasal escape. mention should be made of the problem of sub-mucous clefts. these are not rare and prove well the point that more than mere closing, in the mechanical sense, of a hole or a cleft is required for good or normal speech. a patient with a sub-mucous cleft has cleft palate speech, yet when his mouth is opened the palate at first appears intact. a strong light will reveal that the centre line of the palate — particularly the soft palate — has the appearance of a thin greyish strip. this area consists of two layers of lining only (oral and( nasal) with no muscle in between to complete the sandwich. when an attempt is made to speak or produce a vowel sound the muscle either side of this thin |area pulls upwards and backwards, but also 'outwards towards the side wall of the pharynx. normal closure is not possible and cleft; palate speech results. there can hardly be a better illustration of the importance of a functioning palate as opposed to a palate which is merely closed. december, 1962 median cleft lip — upper or lower — is so rare that it barely deserves a mention. it is amenable to treatment by the application of standard principles. cleft palates are associated with several other conditions, two of which are not uncommon: 1. the pierre robin syndrome. 2. acrocephalosyndactyly. 1. the pierre robin syndrome. this patient has difficulty in feeding; choking and going blue from birth. on examination the lower jaw is small and very far back. so is the tongue, so that its muscle mass may rise up into the naso-pharynx, block this cavity (partly) and orally the entrance to the larynx. there is a cleft soft palate. normal co-ordination between breathing and swallowing is not present and fluid may enter the child's lungs. this is dangerous and may prove fatal. early treatment in hospital is essential, and there may be a case for early use of obturators, or even the rare method of an early closure of the cleft palate which may force the tongue to assume a more normal position. if all goes well the lower jaw should grow forward during the early years of life. this deformity is typified by the description of it as "andy gumpism" or "the chinless wonder". 2. acrocephalosyndactyly. this is the label given to a child born with a tall skull, flattened from back to front, with a posterior cleft palate and fused fingers and toes. little has been said about the intelligence of the patient. this is not because it is unimporant but because little is known of its significance. individuals vary greatly, but there is reason to believe that the more intelligent the patient the more subtle can be the teaching. there is a good deal of resemblance to some of the problems of hand surgery. here too, the better the intelligence of the person, the more likely one is to achieve subtle movements. so it is with the palate and its fine structure — linked strongly to the brain above, inviting us never to be satisfied nor to lack criticism of our own efforts as long as there is the chance of giving our patient contact with his fellows by means of normal speech. journal of the south african l o o p e d i c society ι r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) summary it is at present believed that one person alone cannot carry out the best possible treatment of the patient with a cleft lip and palate. a good team consists of three groups:— 1. plastic surgeons and nurses. 2. orthodontists. 3. speech therapists. about 20% of all cleft lip and palate patients have a family history of this condition. of the remaining 80% a large proportion are born into families in which malnutrition is prevalent. the role of virus and other infections is uncertain. until more is known of the effect of steroids, these should probably only be given to pregnant women with the greatest caution and fullest consultation — particularly in the first three months of pregnancy. an average overall incidence of the deformity is still about one in a thousand births. an initial treatment plan may be made in the maternity hospital. the orthodontist can begin moulding the alveolar contour with a small splint attached by elastic bands to a webbing headcap. subsequent operations are generally easier and more successful. for classification prior to operation, it may be clearer to substitute a brief standard description rather than the ordinary textbook labels. hare-lip and cleft palate operations are rarely, if ever, emergencies — patients with even the severest forms of clefts can reach an otherwise healthy adult state with little or no treatment — although this should never happen in modern surroundings. there is no one age believed to be the best for either lip or palate repair — world opinion still differs on this subject. a general plan suggests that good results follow lip repair after the age of about three months and palate repair before the age of two years. there is some evidence for less interference with growth in the middle third of the face if the palate operation is less radical and/or delayed until the age of four years. lip repair aims at a fine white scar with nostril floors on the same horizontal level and the nostril base at the same distance from the mid-line on each side of the columella. the red margin should form a smooth line from right to left without any "steps" and with the same depth of mucous membrane on either side: the sides of the cleft should be of equal length. the patient is usually in hospital for about ten days. the prime aim of cleft palate repair is normal speech. it is believed that this is approached by a repair which produces a long, mobile soft palate with good muscular union. the soft palate should play a major role in closing off the oro-pharynx from the nasopharynx during speech. for cleft soft palate only, the langenbeck operation is not as satisfactory as the v-y or wardill type operation. for more extensive clefts, but with the alveolus still intact, use may be made of the wardill "four-flap" operation with a contribution from the mucous membrane of the vomer or septum. one of the best methods of ensuring a really long palate with minimal risk of a fistula, is the cuthbert "three-flap" operation. the two posterior flaps are of unequal length and the hard palate repair includes a short anteriorly based flap. repair of complete clefts, unilateral or bilateral, may include extensive use of the mucous membrane on either side of the vomer as a first stage. if this maneouvre is successful, the operation for the second stage in a few months time is reduced to the closure of the soft palate only. factors influencing the success of surgery are mostly matters of timing and technique — provided the patient is correctly . assessed and is fit for operation. timing and / technique are important in the work of all three groups mentioned at the outset. generally fewer children need speech therapy if repairs are early and adequate. the child whose operation is delayed long enough to allow the accumulation, of a .fair sized collection of badly pronounced words will almost always have difficulty in attaining normal speech. 12 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) whenever the parents are able to show an appreciation of the principles underlying treatment, these should be explained to them. the start of speech therapy may safely be delayed for weeks or even up to three months if swelling and scarring in the newly repaired palate take a long time to settle. at this time it may be well to allow he child to try and speak without correction — merely allowing the normal method of learning by imitation of adults and older children. speech therapy is rarely likely to be harmful at any stage. a possible hazard is intensive training in using the tongue to develop and control sounds in the presence of an anterior fistula while still trying to produce normal speech with the rest of the tongue and palate. it is unlikely that speech therapy started more than two weeks after operation could cause damage. tonsils should only be removed, in cleft palate cases, by an operator with knowledge of the problems of cleft palate repair. adenoids should be left whenever possible. although many clinics claim 80% normal speech after cleft palate repair, 50% is probably a good indication of a correct approach by a competent team. the post operative appearance of the palate may bear no relation to the quality of the speech produced. obturators may be uncomfortable and even harmful if their fitting and maintenance v are not submitted to frequent checks. obturators of a special kind, with thick centre sections may, in some cases, help to displace the tongue in a favourable manner. sub-mucous clefts are not rare and, although they present the appearance of a closed palate, the muscles are not attached in the mid-line and pull away between the layers of oral and nasal mucous membrane during speech. this failure of normal action is partlyj responsible for the "cleft palate" speech produced by these patients. median cleft lip is rarely seen. two abnormalities associated with varying degrees of post-alveolar clefts are:— (i) the pierre robin syndrome — characterised by a receding lower jaw and serious episodes of chocking when feeding the new born child is attempted, (ii) acrocephalo-syndactyly is a condition of a tall skull, flattened from before backwards in a child with fused fingers and toes and a posterior cleft palate. these conditions are, of course, congenital. the more intelligent the patient, the more subtle and hopeful can be the teaching. opsomming dit word vandag algemeen aangeneem dat een persoon alleen nie die beste behandeling moontlik aan pasiente met gesplete lip en verhemelte kan gee nie. die span sal uit drie groepe bestaan:— (1) plastiese sjirurge en verpleegsters. (2) orthodontiste. (3) spraakterapeute. omtrent 20% van alle gesplete lip en verhemelte pasiente het 'n familiegeskiedenis van hierdie toestand. van die orige 80%, kry ons 'n groot aantal pasiente in families waar ondervoeding voorkom. die rol wat virus en ander infeksies speel is onseker. totdat die effek van steroides meer bekend is, behoort dit baie versigtig en onder deeglike toesig alleenlik, aan swanger vrouens toegedien te word — veral gedurende die eerste drie maande van swangerskap. hierdie gebrek kom gemiddeld een uit 'n duisend gevalle voor. die aanvangsbehandeling kan al in die kraaminrigting plaasvind. die orthodontis begin om die alveolarelyn te vorm met 'n klein spalkie, wat met rekbande aan 'n weefselagtige mus vas is. die daaropvolgende operasies is dan gewoonlik makliker en meer suksesvol. om meer duidelikheid te verkry in verband met klassifikasie voor die operasie, mag dit beter wees om 'n kort standaard beskrywing, eerder as die gewone handboekbenaminge te gebruik. operasies vir haaslip en gesplete verhemelte is selde, indien ooit, noodgevallepasiente, met selfs die ergste graad van splete, kan andersinds nog 'n gesonde volwassenheid bereik, met weinig of geen behandeling nie — hoewel dit nooit vandag december, 1962 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) behoort te gebeur nie. daar is nie 'n spesifieke ouderdom, wanneer dit die beste is om die herstelwerk te doen nie — gesaghebbendes verskil nog oor die onderwerp. die algemene idee is dat die beste resultate gekry word wanneer herstelwerk aan die lip na die ouderdom van drie maande gedoen word en aan die verhemelte, voor twee jaar. daar is gegewens wat bewys dat die groeiproses, van die middelste derde van die gesig, minder gesteur word, as die operasie op die verhemelte nie baie groot is nie, en/of as dit uitgestel word tot die ouderdom van omtrent vier jaar. die doel van lipherstellingswerk is om 'n fyn wit litteken te kry, met die vloer van die neusvleuels op dieselfde horisontale vlak en die basis van die neusvleuels behoort ewe ver van die middellyn aan elke kant van die kollumella af te wees. die rooi lyn moet ook egalig wees van links na regs, sonder enige „trappies" en die slymvlies moet dieselfde diepte he aan elke kant: die kante van die spleet behoort ewe lank te wees. die pasient bly gewoonlik vir tien dae in die hospitaal. die hoofdoel van die herstelling van 'n gesplete verhemelte is om normale spraak te verseker. om dit te bereik behoort die operasie 'n lang, beweeglike sagteverhemelte met goeie spierverbindings -te lewer. die sagte verhemelte is belangrik vir die afsluiting tussen de neus-keelholte en mond-keelholte gedurende spraak. wanneer alleenlik aan die sagteverhemelte gewerk word, is bevind dat die v-y of wardill operasie meer bevredigend is as die langenbeck operasie. die wardill „vier-flap" operasie, met behulp van die septum se slymvlies, kan ook gebruik word, by groter splete, maar moet die alveolare rif nog onbeskadig wees. een van die beste metodes om 'n lang verhemelte, met 'n minimale gevaar van 'n fistel, te verseker, is die cuthbert „drie-flap" operasie. die twee agterste lappe is nie ewe lank nie en die herstelling van die hardeverhemelte sluit die derde lap, wat voor vas is, in. die eerste stadium van die herstelling van totale splete, uniof bilateraal, sluit 'n grootskaalse gebruik van die slymvlies, aan beide kante van die septum, in. as dit suksesvol is, sal die operasie in die tweede stadium, na 'n paar maande, net die sluiting van die sagteverhemelte beteken. twee faktore beinvloed gewoonlik die sukses van die sjirurgie: tydsberekening en tegniekop voorwaarde dat die pasient reg opgesom en geskik vir operasie is. tydsberekening en tegniek is belangrik by al drie die bogenoemde groepe. oor die algemeen het minder kinders spraakterapie nodig as die operasies vroeg en voldoende uitgevoer word. wanneer die operasie gelaat word totdat die kind al 'n hele aantal woorde verkeerd uitspreek, sal so 'n kind omtrent altyd sukkel om normale spraak aan te leer. wanneer dit duidelik is dat ouers die grondbeginsels van die behandeling verstaan moet dit aan hulle verduidelik word. daar sonder moeilikheid van 'n paar weke tot drie maande gewag word voordat met spraakterapie begin word, as die swelsels en littekens in die verhemelte lank neem om te genees. gedurende hierdie tyd is dit soms gewens om die kind toe te laat om te probeer praat, sonder dat hy behandeling ontvang — slegs om hom die geleentheid te gun om onder die normale omstandighede, van nabootsing, te leer praat. spraakterapie is gewoonlik nie skadelik in enige van die stadiums nie. die enige moeilikheid is intensiewe behandeling om die tong te gebruik om spraakklanke te vorm en beheer met 'n fistel voor, terwyl normale spraak met die res van die tong en verhemelte gevorm word. dit is onwaarskynlik dat enige gevaar bestaan as daar met spraakterapie begin word langer as twee weke na die operasie. in die geval van 'n gesplete verhemelte, behoort mangels alleenlik deur 'n dokter, met kennis van die probleme wat spruit uit die herstelling van 'n gesplete verhemelte verwyder te word. indien moontlik, behoort die adenoide nie verwyder te word nie. alhoewel baie klinieke daarop roem dat hulle 80% normale spraak kry na operasies aan 'n gesplete verhemelte, is 50% 'n goeie 1 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aanduiding van die regte benadering deur 'n bekwame span. die voorkoms van die verhemelte na die operasie is geen aanduiding van die kwaliteit van de spraak wat gevorm sal word nie. obturators kan ongemaklik en selfs gevaarlik wees as hulle nie pas nie, en as die versorging nie gedurig gekontroleer word nie. 'n sekere soort obturator, met 'n dik middeldeel, mag in sommige gevalle help met die plasing van die tong. splete, wat verberg word deur 'n normale slymvlies in die mond en neus, is nie 'n rare verskynsel nie en omdat die spiere, op die middellyn, nie verbind is nie, trek hulle uit mekaar as die persoon praat. hierdie gebrek aan normale aksie veroorsaak die tipe spraak wat by 'n persoon met 'n gesplete verhemelte gevind word. 'n sentrale spleet kom selde voor. twee abnormaliteite word geassosieer met verskillende grade van splete wat agter die alveolare rif voorkom:— (i) die pierre-robin sindroom —' herkenbaar aan 'n kort kakebeen en ernstige aanvalle van verstikking wanneer die pasgebore baba gevoed word. (ii) akrokefalo-sidaktilie is 'n toestand van 'n kort kakebeen en 'n lang kopbeen wat plat van voor af agtertoe loop, by 'n kind met vingers en tone wat saamgesmelt is en 'n gesplete verhemelte agter in die mond. hierdie toestande is natuurlik aangebore. hoe intelligenter die pasient is, hoe meer subtiel en veelbelowend is die onderrig. acknowledgements the author wishes to thank mr. j. b. cuthbert, head of the plastic surgery unit of the johannesburg group of hospitals, for many stimulating discussions and demonstrations; also professor dreyer and dr. g. gavron of the dental and oral hospital for information from their departments. in addition thanks are due to members of the staff of the speech therapy department of the johannesburg general hospital for their co-operation in assessing and handling many patients. december, 1962 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) page six journal of the south african logopedic society a method of achieving carryover of relaxation into life situations audrey shavell b.a. log. muscular relaxation as a therapeutic agent in the treatment of speech disorders has been widely used by speech therapists. the various methods of teaching relaxation are well known to speech therapists and do not warrant repetition of fundamental principles. this article is concerned with a method of obtaining carryover of the relaxed feeling and attitude into social situations. one often finds in general logopedic practice a patient who successfully masters tne tecnnique of general bodily, relaxation and differential relaxation in the clinic situation, but who finds it very difficult to obtain a carryover of relaxation into everyday living. a method of 'easing' the difficulties both children and adults experience in this direction which the writer found helpful will now be described. when the patient has reached the stage where he can relax voluntarily in the clinic situation i introduce the technique of psycho-drama i.e. we act out common everyday life situations in both a tense and a relaxed manner. we then analyse whether the tension is of any use to the speaker or serves any purpose in the speech. there is usually some initial resistance in the older child and adult to acting things 'out' but . this is soon overcome and the patient is then ready to tackle extra-clinic assignments. the first extra-clinic assignments are usually reallife situations that have previously been acted out at the clinic e.g. the dinner table, talking on the telephone, being kept waiting for an appointment at the doctor or dentist etc. etc. reports on the success of the assignments are written and then the situation is enacted at the clinic in both a tense and an easy manner. older children and adults then make a detailed assessment of the overt reactions of others to the forced tense speech or the smooth easy speech. most of the assignments are concerned with assisting the carryover of relaxation into life situations. this method is particularly successful in groups and has been used by the writer for all types of hypertense speech defectives. two cases have been chosen to illustrate the use of this method with patients of a widely differing age range and type of disorder. case a. a 25 year old adult male secondary stutterer was given a thorough and well planned mental hygiene programme to help him learn to 'know himself' and to eliminate 'mal-attitudes' towards himself and his speech. after four months of treatment a re-assessment of the patient's attitude towards his defect showed a decided increase in objectivity. the case was then taught relaxation using a combination of the fink and jacobson methods. complete voluntary relaxation was learned in approximately seven weeks, but the patient achieved little 'natural carryover' of relaxation into extra-clinic situations. the difficulties of obtaining carryover were aggravated by the fact that the case was extremely quick tempered and frequently flew into a rage before the thought of relaxation entered his head. (he appeared to have a very low frustration tolerance level.) the previously described method of achieving carryover of relaxation was used exclusively for four weeks with this case, by which time carryover into social situations was almost complete and a marked change in both personality and speech of the subject was noticeable. severity of the.stutter and duration of the blocks had decreased. after four months of therapy devoted to the elimination .of the actual stuttering symptoms, the case was successfully dismissed rehabilitated. he has been rechecked four times at six monthly intervals since his dismissal from the clinic and appears to have been completely rehabilitated. case b. a highly intelligent seven-year old severe tensionathetoid was actually taught relaxation through the previously described method of psychodrama. games like pretending to live in 'slow easy land' where we met 'sleepy joe', 'floppy flo', 'raggedy ann' and plop the rag doll or living in the 'land of the melting snowman' were used to introduce the idea of relaxation to a child to whom relaxation was so foreign. after the child had mastered the technique of relaxation, carryover of relaxation was worked on through acting out life situations in an 'easy relaxed' way. the therapist then accompanied the child into life situations (in the school-situation and through gentle reminders or 'secret looks' helped the child release excess tension in these situations. this was considered to be part of a secret game between the therapist and the child.) when the child had obtained a fair degree of carryover of relaxation in the school situation the mother was let into the 'secret' of 'slow easy land' and the 'land of the melting snowman' and taught to be like the inhabitants of these lands, to help the child obtain carryover of relaxation into the home situation. the writer does not believe that relaxation training is a 'panacea' to speech therapists, but that specific methods of ensuring, carryover of relaxation into social situations must be used for those patients who are taught general bodily relaxation. we so often find a case who relaxes well in the clinic situation but is quite unable to utilise his ability to relax in social situations, where he needs it most. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f s o u t h a f r i c a n l o g o p e d i c s o c i e t y sub-mucous cleft palate case histories by d. m. whiting, b.a.. log. (rand). l.c.s.t. the occurrence of sub-mucous cleft palate is rare, but even so, it is vitally important that the speech therapist be aware of the condition as a possible cause of nasal speech. she should be able to recognise the symptoms which lead to its diagnosis and refer all suspected cases to a surgeon who deals with cleft lip and palate for consultation before undertaking treatment. it has been my experience that sub-mucous cleft palate is a condition unknown and unrecognised by many in general medical, surgical and dental practice, whereas it is quickly recognised by surgeons concerned with the treatment of cleft lip and palate. the following case histories are presented to illustrate this observation, and to stress the importance of accurate diagnosis by the speech therapist in the handling of these cases. case a. a european girl, 14 years of age. she was referred for speech therapy three years previously with nasal speech. she received treatment at school for one year and at clinic for one year. further treatment was recommended but transport difficulties made this impossible. improvement was negligible. during the second year of treatment the possibility of a sub-mucous cleft palate was suggested, but not verified. on examination: hard palate—there was no bony union for the posterior two-thirds of the hard palate. this v-shap'ed notch of the posterior border was easily visible and palpation was unnecessary. the oral mucosa was intact. soft palate—there was a medial mucous line about ; 1/1 oth of an inch wide running from the base of the v of the hard palate the full length of the soft palate, which widened on phonation. this mucous line glowed red on illumination of the nasopharynx, confirming the absence of muscle union. the palate appeared short and the uvula was bifid. velopharyngeal closure was negative on tests and in speech. articulation was correct but weak. there was consistent nasal tone. this diagnosis of sub-mucous cleft palate was confirmed by the plastic surgery unit, and surgery was undertaken. further speech therapy should have followed immediately, but the girl had lost all interest and incentive and failed to attend in spite of arrangements being made to facilitate transport. had she been given the opportunity of surgical repair 2—3 years earlier, instead of the constant failure to improve with speech therapy, the results would probably have been more encouraging. cast b. an indian girl aged 9 years. her home language was ghurgurati and she attended an english medium school. she was referred from the dental hospital for examination and treatment on account of her very limited language ability. she presented a complicated picture. her birth and early history and subsequent neurological examinations revealed the probability of her being a brain injured child. she was very small for her age and there was a history of earlier tubercular infection. at birth the nose appeared flattened and was described by the father as being "almost absent." feeding proved very difficult as the child could not suck, and there was regurgitation through the nose. there was no family history of cleft palate or speech defects. an examination at another speech clinic two years earlier, failed to reveal any palate abnormality. on examination: nose—bridge appeared flattened and nasal airways narrow. teeth—malocclusion and abnormal structure of upper and lower incisors, (receiving treatment at time of examination). hard palate—there was a high narrow arch with a marked v shaped notch in the centre of the posterior border. soft palate—this appeared short and fairly mobile, there was a bifid uvula. velopharyngeal closure was negative both on tests and in speech. there was an overall nasal tone and nasal escape. articulation was grossly defective. it seemed to me that this was a case of submucous cleft palate and/or congenital short palate, in addition to a severe language retardation probably due to brain damage. however, controversial opinions were expressed regarding her palatal condition by others concerned with her treatment. she was then referred to a plastic surgeon for r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j 6 u f t n a l _ o f f l i £ s o u t h a f r i c a n l 0 0 0 p e d i c s o c i l g t v a p r i l α further opinion. he reported that this was certainly a case of sub-mucous cleft palate and that the soft palate was definitely short. on account of the child's generally poor physical condition, he advised that the case should be reconsidered for the possibility of surgical repair three years later. this examination should take place in 1957. it was decided to treat the language disturbance in the meantime, in spite of the complication of grossly defective articulation and language medium. case c. a coloured boy aged 11 years. this child was referred for treatment by an ear, nose and throat department, where he was receiving treatment for a discharging right ear. he was referred as a repaired cleft lip and palate. this was only partly true, his lip had been repaired at 2 years of age, but there had been no further operations of any kind. his young stepmother could supply no information concerning his early development and possible feeding difficulties. a sister, six years younger, had a repaired double cleft lip and palate. no other family incidence of cleft palate or speech defect was reported. the boy was very selfconscious of his grossly defective speech and fought back when teased. when examined he was found to be a friendly co-operative child and very anxious to be helped. on examination: lip—there was a repaired right cleft lip, the lip was mobile. teeth—right upper premolar and incisors were crooked. hard palate—there was a high narrow arch particularly anteriorly, and a marked v shaped notch medially at the posterior border. soft palate—there was a central transparent mucous line which widened on phonation, and appeared as a red line when the nasopharynx was illuminated, the palate appeared short with limited mobility and there was a bifid uvula. velopharyngeal closure was negative on tests and in speech. articulation was grossly defective with frequent use of the glottal stop and speech was frequently unintelligible. there was an overall nasal tone. the provisional diagnosis was sub-mucous cleft palate associated with a right cleft lip this was later confirmed by the plastic surgery unit, where he was put on the list for surgical repair. speech therapy was to be postponed until after the operation. case d. a european boy of 6 years of age. he and his sister were in the care of child welfare. his mother was deceased and no early history was available. his sister had a repaired cleft of the soft palate and normal speech with the exception of sigmatism. the boy's was a case complicated by multiple congenital abnormalities, spina bifida oculta, hypertonia and dextrocardia with a cystolic murmur. a few months before my examination the child had had encephalitis, and about six months after examination poliomyelitis (non-paralytic). he was very small for his age and had not yet been to school. he had been examined a few months earlier with a view to special treatment but no mention was made of a palatal abnormality. on examination: teeth—teeth were in a very poor condition and the upper incisors had been extracted. hard palate—there was no medial notch of the posterior border, but the shape of the posterior border resembled a wide v based anteriorly and spreading laterally to the regions of the hamular process. (i have only once before seen this in a case of congenially short palate). the soft palate appeared short with limited mobility, and on illumination of the nasopharynx a red mucous line appeared down the full length of the soft palate. the uvula was bifid. the pharynx was wide laterally. velopharyngeal closure was negative. articulation—there were some articulatory errors, but speech was intelligible. there was an overall nasality. the provisional diagnosis of sub-mucous cleft of the soft palate was later confirmed by the plastic surgery unit. there was no question of operation for the time being, in this case, on account of his general physical condition and multiple abnormalities. it was decided he should receive a short period of speech therapy to ascertain what improvement could be expected in spite of the condition. i should like to thank dr. medalie for his permission to investigate case d, and the plastic surgery unit, johannesburg hospital group for their help with all four cases. i should also like to thank professor p. de v. pienaar, director of the university speech, voice and hearing clinic, and the medical superintendent of the johannesburg general hospital, for permission to report on these cases. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 t h e editor teacher to make contact with the child, gain his confidence and inculcate a desire and love of 'learning' by helping the child to achieve success. the importance of the teacher understanding 'how a child learns' does not apply only to those who handle the slow learner, brain-damaged or retarded children. there are many children in normal schools who would be saved feelings of failure, frustration, fear and from becoming problem children if helped to achieve success in their first years at school. teaching, with a challenge, becomes really worth while! opsomming daar is indiwiduele verskille in die leerproses, selfs onder die sogenaamde normale kinders. die verskille word egter duideliker as ons te doen het met die afwykende kind. die verstandelik vertraagde kind sal stadiger vorder en nie so ver vorder as die normale kind nie. die breinbeseerde sal weer op sekere gebiede vinniger en op ander gebiede stadiger vorder a.g.v. die letsel. hulle mag probleme ten opsigte van die integrasieproses en interpretasie bied. om alle bykomende afwykings bv. gehoorverlies, uit te sluit, is spanwerk nodig. 'n volledige diagnose moet van elke pasient gemaak word. in die behandeling van 'n kind met persepsieprobleme kan gebruik gemaak word van taal en spraak om persepsie te verbeter bv. die verbalisasie van handbewegings in die uitvoering van 'n psigomotoriese aksie. die belang van basiese vaardighede wat die kind gereed maak vir die leerproses in die skool kan nie genoeg beklemtoon word nie. ook moet die kind in staat wees om te herken, analiseer, sintetiseer, herroep en instruksies te volg (visueel en oiiditief). die taak van die onderwyser wat werk met die breinbeseerde kind, is 'n uitdaging wat die moeite werd is. reference kephart, newell c. (i960): the slow learner in the classroom. columbus, o h i o : charles e. merrill books, inc. discussion of mrs. ε. m. harrison's paper t h e e d i t o r / ten years ago mrs. harrison, using a technique which she has termed directional training, experienced success when attempting to teach braininjured children to learn to write. it is interesting to examine this technique in the light of a recent postulate of the eminent russian psychologist and neuro-psychiatrist, professor luria. luria has long been concerned with the application of experimental method to the problems of behaviour, and rank's as an experimental psychologist of high repute. his interest in language is demonstrated by the importance which journal of the south african logopedic society, vol. 12, no. 1: september 1965 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) discussion on mrs. ε. m. harrison's paper 19 he attaches to the study of child development. in his opinion the study of language and its development is the key to our understanding of vital problems in human intellectual growth. in his book the role of speech in the regulation of normal and abnormal behaviour, luria has shown that the perception of a child can be controlled and modified through speech. this idea is contrary to the conventional way of thinking about perception as being merely a reaction which takes place through a sense organ. in order to substantiate this point of view, luria quotes certain experiments. experiment i. children aged 12-30 months were given small red and green boxes, the green empty and the red containing sweets. it proved very difficult for the children to select the correct boxes (i.e. those containing sweets) in a choice situation. however, when speech entered the experiment by the experimenter naming the colours of the two boxes and then asking the children to select the correct one, the significant cue stood out boldly and the children were able to make a correct selection. this experiment clearly demonstrates how speech can substantially modify a child's perception and by so doing permit "the working out of a system of stable differentiated associations." luria has further demonstrated this regulatory role which speech exerts on behaviour in his experimental work with brain-injured patients. of particular interest are his experiments with patients suffering from parkinsonism, where the motor system is directly affected but where, as luria states, the "verbal system" is considerably intact. experiment 2. a subject suffering from parkinsonism was asked to answer the following questions with his fingers: i. how many wheels are there on a car ? ii. how many brothers have you ? iii. how many points on the red star ? whereas formerly the patient had lost movement in his hand, when answering the foregoing questions movement was regained. according to luria what had occurred was that although the hands had lost their primary function, when used for the purpose of answering questions, they entered a complex verbal functional system where the defective movement was compensated for. in fact, by adding a new system of intact verbal afferentation to the defective movement, it is possible to switch the process to a new level and attain, as luria postulated, "a form of self-regulation" of a process which was previously inaccessible. returning to mrs. harrison's work, it seems apparent that her technique of directional training, where the children she taught verbalized while carrying out movement and interpreted verbally movements made by other children, can be closely linked to luria's ideas. she, too, was in fact .linking a relatively intact verbal system to a system which was defective, and by so doing enabled her pupils to compensate for their disabilities. it is indeed commendable that ten years ago mrs. harrison should have devised this technique, the theory behind which has only become accessible to us in a work published for the first time in 1961. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 12, nr. 1 .· september 1965 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 the editor opsomming die tegnieke wat mev. ε. m. harrison gebruik om sekere breinbeseerde kinders wat nie fisies gestrem is nie, te leer skryf, is in verband gebring met die werk en bevindings van die beroemde russiese sielkundige en neuropsigiater, prof. a. r. luria. luria stel dit dat spraak 'n regulerende invloed uitoefen op 'n kind se gedrag en 'n spesifieke invloed het op die ontwikkeling van sy verstandsprosesse. . deur die gebruik van die rigtingwysende opleiding het mev. harrison bewys dat breinbeseerde kinders, sonder fisiese stremming, maar wat nie deur die gebruiklike metodes kon leer skryf nie, tog die vaardigheid kon aanleer sodra as spraak met die spesifieke aksie van skryf verbind word. op dieselfde wyse het luria bewys dat sekere gevalle van parkinsonism? in staat gestel word om hulle hande suksesvol te gebruik wanneer die spesifieke beweging verbind word met die verbale meganismes. blykbaar word, deur die byvoeging van 'n nuwe stelsel van onbelemmerde verbale afferentasie by die afwykende beweging, 'n verskuiwing van die proses na η nuwe en suksesvolle peil bewerkstellig. hierdie peil kan nie deur die konvensionele opleidingsmetodes bereik word nie. references luria, a. r. (1961): the role of speech in the regulation of normal and abnormal behaviour. london: pergamon press. , , „ , . . . , luria, a. r. and yudowich, f. ia. (1959): speech and the development of mental processes in the child. london: staples press. journal of the south african logopedic society, vol. 12, no. 1: september 1965 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) article information authors: hanlie degenaar1 alta kritzinger2 affiliations: 1institute of psychology and wellbeing, north-west university, potchefstroom campus, south africa 2department of speech-language pathology and audiology, university of pretoria, south africa correspondence to: hanlie degenaar email: hanlie.degenaar@nwu.ac.za postal address: po box 6297, flamwood, klerksdorp 2572, south africa dates: received: 17 dec. 2014 accepted: 27 apr. 2015 published: 02 dec. 2015 how to cite this article: degenaar, h., & kritzinger, a. (2015). suck, swallow and breathing coordination in infants with infantile colic. south african journal of communication disorders, 62(1), art. #115, 10 pages. http://dx.doi.org/10.4102/sajcd.v62i1.115 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. suck, swallow and breathing coordination in infants with infantile colic in this original research... open access • abstract • introduction • aims • method    • participants    • material and data collection    • data analysis    • reliability and validity • results • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references • appendix a    • assessment protocol for suck, swallow and breathing coordination (ssbc) abstract top ↑ background: there appears to be a perception amongst parents and in popular literature that infantile colic is caused by feeding difficulties. limited support for this perception is found in scientific literature. whilst there is scientific evidence that suck, swallow and breathing are key components of successful feeding, these components and the coordination thereof in infants with colic have not been extensively researched. objective: the objective of the study was to explore the suck, swallow and breathing coordination in infants with infantile colic and compare it with infants without the condition. method: an assessment protocol for suck, swallow and breathing coordination was compiled from literature. this protocol was performed on a research group of 50 infants, independently diagnosed with infantile colic, and a control group of 28 infants without the condition. all participants were from two rural towns in the north–west province, south africa, selected with a snowball selection method and strict selection criteria. the study followed a static comparison group design. results: a significant difference in the key components of feeding and the presence of colic in participants of four age categories were found. the correlation between postural control and the presence of infantile colic were sustained in participants from 2–19 weeks old. conclusion: suck, swallow and breathing were found to be significantly associated with infantile colic. the findings should be investigated further. it appears that speech-language therapists may play an expanding role in infantile colic. introduction top ↑ infantile colic is a condition that commonly occurs in 10%–40% of typical, healthy and growing infants whether they are breastfeeding or bottle feeding (deshpande, 2003; kheir, 2012; søndergaard, skajaa & henriksen, 2000) but lasts only until the age of four months (cohen-silver & ratnapalan, 2009; kheir, 2012; savino, 2007). the description of infantile colic mostly used in literature is still based on the definition of wessel, cobb, jackson, harris and detwiler (1954). the condition is described as sudden onset periods of high-pitched crying without an explainable cause (kheir, 2012), exceeding three hours per day in duration (deshpande, 2003; gudmundsson, 2010) and lasting for more than three days within a period of three weeks (lucassen et al., 2001; savino, 2007). several factors have already been identified that may increase the risk of infantile colic. these include gastro-oesophageal reflux (heine, 2006), increased levels of gastrointestinal hormones (savino et al., 2006), flora (savino et al., 2010), esophagitis (berezin, glassman, bostwick & halata, 1995), low birth weight (søndergaard et al., 2000), maternal smoking (reijneveld, brugman & hirasing, 2000), lactose intolerance (kanabar, randhawa & clayton, 2001) and feeding difficulties (gudmundsson, 2010; miller-loncar, bigsby, high, wallach & lester, 2004). the etiology appears to be unknown (kheir, 2012; lucassen et al., 2001) and no standard treatment protocol for infantile colic has been indicated (hall, chesters & robinson, 2012). despite limited clinical evidence that feeding problems occur in infants with infantile colic (miller-loncar et al., 2004) the perception amongst the general public and the popular literature are that difficulties with sucking and swallowing causes colic (bailey, d’ auria & haushalter, 2012). advertisements and articles in baby magazines reinforce the perception that colic can be alleviated by certain bottles, teats and a change in handling the infant (catherine, ko & barr, 2008). this difference in the common perception of infantile colic and clinical evidence has not been investigated. successful feeding is determined by three factors, namely the infant’s oral-motor feeding movements, the sucking, swallowing and breathing coordination (ssbc) and the interaction during feeding with the caregiver (hall, 2001; morris & klein, 2001; swigert, 2009). it is generally accepted that infants with infantile colic have normal sucking and swallowing skills, adequate growth and adequate nutrition (deshpande, 2003; lucassen, 2010). miller-loncar et al. (2004) however found that infants with infantile colic had less rhythmic sucking, organised feeding behaviour and interactive responses during feeding than a control group. there is also evidence that the condition negatively impacts on infant-caregiver interaction (brown, thoyre, pridham & schubert, 2009; miller-loncar et al., 2004; rossetti, 2001) and adds to parental frustration (deshpande, 2003; hall et al., 2012), postnatal depression (vik et al., 2009), family stress (beebe, casey & pinto-martin, 1993) and family conflict (raiha, lehtonen, korhonen & korvenranta, 1997). based on these results there may be a relationship between infantile colic, ssbc and caregiver interaction. the feeding process, in particular ssbc, has not yet been investigated in infants with infantile colic. successful feeding in an infant younger than four months depends on a well-developed ssbc pattern (arvedson & brodsky, 2002; wolf & glass, 1992). at four months most neonatal reflexes, the moro, rooting, sucking, tonic neck reflex and palmar grasp, disappear (alexander, boehme & cupps, 1993; morris & klein, 2001) and successful feeding is less dependent on ssbc. the integration of reflexes into typical movement patterns may explain why infantile colic eases or disappears at age four months (savino & tarasco, 2010) and also strengthens the idea that ssbc may play a role in the condition. ssbc is a fundamental sensory motor pattern which organises the infant’s neuro-motor behaviour (oetter, richter & frick, 1995) and is present since birth in typical full-term infants (swigert, 2009). ssbc is considered as the first development pattern that involves successive, timed and sequenced movement of different structures (barlow, 2009) with a significant influence on the infant’s postural control, psychosocial development and emotional state (brown et al., 2009; oetter et al., 1995). that is because ssbc involves various bony structures, muscles, cervical and cranial nerves (barlow, 2009; seikel, douglas & drumright, 2010) and is also linked to the limbic system, reticular formation and autonomic nervous system (oetter et al., 1995; wolf & glass, 1992). a disturbance in ssbc could by implication disturb the infant’s sleep patterns, alertness, attention and sensory threshold (blanche, botticelli & hallway 1995; hemmi, wolke & schneider, 2011; oetter et al., 1995). ssbc is a complex, synchronised movement pattern for feeding in infants and involves three functional components synchronised by the hyoid complex. figure 1 displays the relationship between the three components of ssbc. figure 1: the relationship between the different components of ssak. as indicated in figure 1 the hyoid bone and the muscles attached to the structure are central to ssbc. the suprahyoid and infrahyoid muscles stabilise the hyoid bone which should be aligned with other bony structures involved in ssbc to achieve effective sequential movements (morris & klein, 2001; perkins & kent, 1986; wolf & glass, 1992). the hyoid bone provides coordination of muscle movement around the bony structures involved in sucking, swallowing and breathing (oetter et al., 1995, perkins & kent, 1986; seikel et al., 2010). any disturbance of the hyoid complex will disturb ssbc and a slight disturbance in ssbc may lead to a slight disturbance in the infant’s feeding process. the conclusion is that a subtle disturbance in the balance between the components of ssbc may cause a number of feeding difficulties in young infants. clinical observable factors could assist to identify and assess a ssbc disturbance. the diagnosis of infantile colic is currently characterised by parental perception of the infant’s behaviour and the elimination of other medical conditions (deshpande, 2003; kanabar, 2008; savino & tarasco, 2010) without reference to the feeding process. parents base their perception of colic on the acoustic characteristic of the infant’s cry and behaviour of fisting, flatulence and pulling legs towards the abdomen (deshpande, 2003; lester, boukydis, garcia-coll, hole & peucker, 1992; savino, 2007; st james-roberts, conroy & wilsher, 1996). parental descriptions of colic vary as perceptions are determined by socio-economic status, education, religion, previous experience of an infant with infantile colic, environmental factors, personality, parental age, marital status and the presence of a support system (rossetti, 2001). differences in descriptions are therefore not objective and reliable for assessment of the condition. observation of factors that may disturb ssbc may contribute to objectivity in the assessment of infants with infantile colic. postural control, feeding position, sucking rhythm and cranio-cervical position are four observable factors that determine the effective functioning of the hyoid complex and the ultimately ssbc (barlow, 2009; oetter et al., 1995; wolf & glass, 1992). the observable factors that influence ssbc are depicted in figure 2. figure 2: observable factors involved in disturbance of sucking, swallowing and breathing coordination. according to figure 2, postural control is the ability to align bony structures and maintain alignment during an activity (cupps, 1997) and is therefore essential for feeding (arvedson & lefton-greif, 1996; hall, 2001; morris & klein, 2001; rogers, 1996). poor alignment leads to less efficient feeding, increased energy expenditure, limited endurance and prolonged duration of feeding (hall, 2001; morris & klein, 2001; wolf & glass, 1992). feeding position is important since any external force on the hyoid complex or bony structures involved in breathing may disturb ssbc (morris & klein, 2001; oetter et al., 1995; perkins & kent, 1986). several authors have stressed the importance of the feeding position for infants (arvedson & lefton-greif, 1996; finnie, 1992; hall, 2001; harris, 1986; morris & klein, 2001; rogers, 1996; swigert, 2009; wolf & glass, 1992). sucking rhythm is determined by the overlapping nature of ssbc innervations from the cranial nerves (trigeminal, facial, glosso-pharyngeal, vagal, accessorius, hypoglossus), cervical nerves 1–7 and thoracic nerves 1–12 (seikel et al., 2010; wolf & glass, 1992). the overlapping function ensures the synergetic, rhythmic and synchronous flow between sucking, swallowing and breathing in infants (barlow, 2009; oetter et al., 1995; wolf & glass, 1992). any disturbance in the innervations of one of the components of ssbc may cause arhythmic sucking, swallowing or breathing, which will be an observable indication of a disturbance in ssbc. the cranio-cervical position is the alignment of the head and neck with slight neck flexion that optimally opens both the oesophagus and trachea (morris & klein, 2001; wolf & glass, 1992). if a neutral cranio-cervical position is not maintained, the mobility of the hyoid bone is affected (wolf & glass, 1992), thereby causing a disturbance in ssbc. it is clear that postural control, postural alignment (including cranio-cervical position and feeding position) and sucking rhythm should be included in a clinical assessment. infantile colic is associated with an increase risk for psychosocial conditions such as postnatal depression in the mother (vik et al., 2009), poor mother-infant interaction (brown et al., 2009), sleep disturbances and tantrums in the infant (hemmi et al., 2011), infant difficulties with emotional regulation (gomez, baird & jung, 2004), family strain and poor family relationships (canivet, jakobsson & hagander, 2000; räihä, lehtonen, huhtala, saleva & korvenranta, 2002). the presence of infantile colic is also associated with an increased risk for infant neglect, abuse, being shaken and death (barr, trent & cross, 2006). these factors suggest a continuum of risks (rossetti, 2001) in the infant and the family, which may influence early communication development and psychological well-being. difficulties that impact negatively on the development of swallowing and feeding skills often contribute to educational difficulties later in life (mckirdy, sheppard, osborne & payne, 2008), justifying the inclusion of infants with infantile colic in early communication intervention programmes. the presence of ssbc difficulties and the clinical assessment thereof may guide intervention and future research into the role of speech-language therapists in infants with infantile colic. aims top ↑ to explore the feeding in infants with infantile colic, the research had two aims. the first aim was to compile a clinical assessment protocol for ssbc. the second aim was to clinically assess and describe ssbc in a group of infants with colic (research group) and compare the findings with a group of infants without the condition (control group). method top ↑ ethical clearance was obtained from the research ethics committee of the faculty of humanities at the university of pretoria. all participants gave informed consent. for the first aim a literature study was conducted. for the second aim a comparative two-group research design was used to clinically observe ssbc in a group of infant participants who were independently diagnosed with the condition, in contrast with a control group without the condition. a non-randomised sample was selected of infants referred by local clinics or medical practitioners to a speech-language therapy practice in two rural towns in the north-west province of south africa. correlation coefficients were calculated to determine whether relationships exist between the ssbc in a group of infants with colic and those without the condition. participants a research group of 50 infant participants with colic and 28 control participants without colic were selected using a snowball selection procedure according to four age categories. the participants with infantile colic were independently diagnosed by their medical practitioners according to the wessel et al.’ s (1954) definition of the condition. the selection criteria were as follows: the infants had to be between 1 and 17 weeks old and born at 37 weeks gestation or later, as literature indicates the condition is present in infants 0–4 months old (savino & tarasco, 2010). the prenatal history was required to determine the presence of risk factors. no risk factors such as low birth weight, poor weight gain, growth retardation, prematurity, maternal smoking, congenital anomaly or any neonatal medical conditions (allergy, reflux, gastrointestinal difficulties and esophagitis) should have been present. participants should not have been using any medication, as this could influence behaviour and may have decreased the reliability of observations. the infants should have been cared for by the parents during the day, so that parental reporting on infantile colic would be reliable. the infants could be breastfed or bottle fed as literature indicates that infantile colic occurs in both breastfed and bottle fed infants (deshpande, 2003). the participants came from different socio-economic groups. some participants only had access to their community clinic where fees were minimal whilst other had access to private medical services. table 1a–d displays the characteristics of the participants. table 1a: description of participants according age category 1: 2-4 weeks (n = 26) table 1b: description of participants according age category 2: 5-8 weeks (n = 24) table 1c: description of participants according age category 3: 9-12 weeks (n = 14) table 1d: description of participants according age category 4: 13-19 weeks (n = 14) according to table 1 the participants in the two groups were fairly similar regarding gender and birth weight, but differed greatly regarding duration and frequency of feeds. fewer participants in the research group than in the control group were breastfed. material and data collection an assessment protocol was compiled from feeding assessment forms in literature (arvedson & brodsky, 2002; swigert, 2009; wolf & glass, 1992). descriptions of postural control in infants were added (alexander et al., 1993; bly, 1995). the content of the assessment protocol is described in table 2. the final assessment protocol is included in appendix 1. table 2: content of the assessment protocol for sucking, swallowing and breathing coordination. all participants were observed in prone, supine, supported standing and supported sitting for the appropriate postural control and alignment (alexander et al., 1993; bly, 1995; hall, 2001; swigert, 2009) followed by eliciting nutritive sucking. feeding by the mother was observed. the researchers have combined experience in the field of paediatric dysphagia and received training in neurodevelopmental assessment and therapy for infants, as well as neurodevelopmental care for preterm infants. a nominal value was given to absence or presence of items on the assessment protocol. data analysis participants were divided in age categories of 2–4, 5–8, 9–12 and 13–19 weeks old. since the number of participants in the different age categories was small, non-parametric statistics were applied to compare the components of ssbc (postural control, postural alignment and suck, swallow and breathing rhythm). the t-test with cohen’s d-values was used to determine the practical significance of the differences in the duration and frequency of feeding in the research and control groups. the chi-squared test was used to determine the statistical significance of differences between the research and control groups. cramer’s v-value was used to determine the effect size. the independent t-test and cronbach’s alpa test were used to determine the statistical significance and internal consistency of differences found in postural alignment and ssbc between the research and control groups. reliability and validity to ensure internal validity and reliability the participants in the research group were independently diagnosed by the family’s medical practitioner and the researcher was not part of the diagnostic procedure. all participants were assessed by the same clinician and all data entries were controlled by a second person. a second observer, blind to the presence or absence of infantile colic, was used to affirm the researcher’s observations. to enhance external validity, strict selection criteria were set and the assessment protocol was conducted during a scheduled feeding time. results top ↑ table 3a–c indicates the effect size of the difference in duration and frequency of feedings in the research and control groups of each age category. table 3a: effect size for the difference in duration and frequency of feedings in the research and control groups of each age category (age category 1: 2–4 weeks [n = 25]). table 3b: effect size for the difference in duration and frequency of feedings in the research and control groups of each age category (age category 2: 5–8 weeks [n = 25]). table 3b: effect size for the difference in duration and frequency of feedings in the research and control groups of each age category (age category 3: 9–12 weeks [n = 14]). the differences in duration and frequency of feedings of the research and control groups indicate medium and large effect sizes and a practical significance. feeding in participants with infantile colic took longer and was more frequent than in participants without the condition. table 4 provides a comparison of the results of the assessment protocol in the research and control groups in the age category 2–4 weeks. table 3c: effect size for the difference in duration and frequency of feedings in the research and control groups of each age category (age category 4: 13–19 weeks [n = 14]). almost all differences in postural control, postural alignment and suck, swallow and breathing rhythm (ssbr) between the two groups were significant (p < 0.05). it was only neck righting, grasp reflex, hand-to-mouth contact, pull to sit, supported standing and cup-shaped tongue that were not significant. a strong correlation between the postural control in prone and the presence of infantile colic was indicated by cramer’s v-value. participants with infantile colic took less weight on the shoulder girdle, had less neck extension and less hip flexion with pelvic elevation than expected for their age category on the assessment protocol. during postural adaptation for feeding the participants with colic did not assume a neutral cranio-cervical position and did not display hip flexion in one or both lower extremities. the infants with colic did not have a 1:1:1 ratio for suck, swallow and breathing or pausing between sucking cycles. table 4 indicates a correlation between postural control, postural alignment during feeding and ssbr and the presence of colic in participants in the age category 2–4 weeks. table 5 provides a comparison of the research and the control groups in the age category 5–8 weeks. table 4: comparison between participant groups in the category 1: 2–4 weeks (n = 26). statistically significant differences regarding postural control, postural alignment and ssbr were found. a correlation between the presence of colic and the absence of a neutral cranio-cervical position, quality of hip flexion and ratio of suck, swallow and breathing was found. cramer’s v-value indicated an effect size of greater than 0.5 for the findings for aspects of the above components of ssbc. during postural adaptation for feeding the participants with colic did not assume a neutral cranio-cervical position with a slightly curved back. they did not display hip flexion in one or both lower extremities and did not have a 1:1:1 ratio for suck, swallow and breathing with poor pausing between sucking cycles. table 5 indicates that the correlation between postural alignment during feeding and ssbr and the presence of colic was sustained in participants in the age category 5–8 weeks. table 6 gives a comparison of the results of the assessment protocol for the study and the control groups in the age category 9–12 weeks. table 5: comparison between participant groups in the category 2: 5–8 weeks (n = 24). again statistically significant differences regarding postural control were found between the study and control groups as well as a correlation with the presence of colic. all the aspects of postural alignment and ssbr were statistically significant with a strong correlation with the presence of colic. it appears that postural alignment and ssbr played an increased role in the presence of colic in the participants. table 6 also indicates a correlation between postural alignment, ssbr and the presence of colic in the age category 9–12 weeks. table 7 gives the results in the age category 13–19 weeks. table 6: comparison between participant groups in the category 3: 9–12 weeks (n = 14). once again statistically significant differences were indicated between postural control, postural alignment and ssbr of the study and control groups with a correlation between the presence of colic and the quality of postural control. cramer’s v-values indicate that the postural alignment and ssbr play an increasing role in the presence of colic. participants with colic had difficulty playing with hands to knees when in the supine position and rolling to the side. all participants in the control group were able to do so. the research group had difficulty pushing up on their elbows and shifting weight with the shoulder girdle. the research group also had difficulty with accidental rolling, stood with a wide base of support, had poor quality of supported sitting and showed difficulty when pulled to sit. again, table 7 indicates an even stronger correlation between postural alignment, ssbr and the presence of colic in the age category 13–19 weeks. the results, of all four age categories, indicate a large effect size and a correlation with the presence of infantile colic. table 8 displays the results of a t-test and a cronbach’s alpha validity coefficient. table 7: comparison between participant groups in the category 4: 13–19 weeks (n = 14). the results of the t-test indicate a statistically significant difference between the postural alignment and ssbr of all participants with and without colic. the cronbach’s alpha value indicates a good internal reliability for postural alignment across age categories. it is commonly accepted that poor postural control negatively impacts on postural alignment and disturbs feeding and swallowing (hall, 2001; redstone & west, 2004). this pattern is well-documented in infants with neurological difficulties (sheppard, 2008) but not in infants with colic. table 7 and table 8 indicate this same pattern of poor postural control with a negative impact on postural alignment resulting in a feeding disturbance. table 8: t-test results for postural alignment and ssbr in both participant groups. in the age category 2–4 weeks, five descriptors for postural control were found to be not significant (neck righting reaction, hand-to-hand or hand-to-mouth contact, grasp reflex, pull to sit and supported standing). in the age category 5–8 weeks, three descriptors for postural control and postural alignment were found to be not significant (presence of asymmetric tonic neck reflex, pull to sit and arm flexion to midline). in the age category 9–12 weeks, two descriptors for postural control were found to be not significant (supported sitting and supported standing). in the age category 13–19 weeks, only one descriptor for postural control was found to be not significant (ventral suspension). discussion top ↑ the main purpose of this study was to explore the ssbc in young infants with infantile colic. the participants with infantile colic took longer than the normal 20 minutes or less (arvedson & brodsky, 2002) to complete a feeding. they also fed more frequently with less than three hours between feeds. this may offer an explanation for the perception in general and in popular literature that infantile colic is associated with feeding difficulties. the finding also strengthens the rationale for exploring feeding difficulties in infants with infantile colic. an evaluation protocol for ssbc was compiled to clinically assess and compare a group of infants with and without the condition. the results indicate that ssbc can be assessed clinically and the assessment protocol could now be included in assessment and treatment planning for infants with colic. the results indicated that postural alignment and ssbr of participants with colic differed significantly from participants without the condition across age categories. the difficulties with postural control, postural alignment and ssbc appear to be subtle and present as feeding difficulty or infantile colic. redstone and west (2004) also indicate a correlation between the quality of postural alignment and the quality of feeding. the results highlight the importance of clinically assessing ssbc in infants with infantile colic in order to inform and influence clinical practice. the results are in agreement with miller-loncar et al. (2004), who also suggest that feeding difficulties are associated with infantile colic. the components of ssbc not statistically significant between the groups strengthen the importance of assessing ssbc clinically in infants with the condition. poor postural control and a negative impact on ssbc is found in infants with neurological difficulties (arvedson & lefton-greif, 1996; hall, 2001; lefton-greif & mcgrath-morrow, 2007; wolf & glass, 1992). although participants in the present study did not have neurological difficulties, a similar pattern emerged in the present study. with an increase in age, increasingly more aspects of postural control differed significantly between the research and control groups. literature indicates that infants develop more muscle control as reflexes diminish, enabling better postural adaptations for feeding (alexander et al., 1993; bly, 1995; redstone & west, 2004). the pattern of poor postural control impacted similarly, but in a subtle way, on postural alignment, resulting in a disturbance of ssbc. the feeding disturbance is much more subtle than in infants with neurological difficulties and may present as the symptoms parents describe for infantile colic. the findings suggest some truth in the perception that infantile colic is the result of feeding difficulties. infantile colic is further associated with the occurrence of communication-interaction difficulties between parent and infant, serious psychosocial difficulties, abuse and educational difficulties, which suggest a continuum of risk in infants with the condition. the results suggest the importance of a clinical assessment of ssbc and the involvement of a speech-language therapist for early feeding and communication intervention. although there appears to be some evidence of subtle disturbances in ssbc associated with infantile colic, the causes of colic still need to be investigated. due to the small sample size the findings of this study cannot be generalised. since a non-randomised convenient sampling method involving only two communities was used, bias may be present in the sample. it is recommended that further research should make use of larger sample sizes and involve more communities. conclusion top ↑ a need was identified to explore the importance of including ssbc as a possible contributing factor to infantile colic. considering the high prevalence (10%–40%) of infantile colic (deshpande, 2003), and by implication the risk for communication development delays, this article suggests that assessment of ssbc should be included in the diagnosis of infants with colic. literature provides well-documented treatment options for the components of ssbc (arvedson & brodsky, 2002; wolf & glass, 1992), which may improve the outcome of the condition in very young infants. speech-language therapists play an important role in the identification, intervention and outcome of feeding difficulties in young infants (asha, 2008). further research on the topic may expand the role of the speech-language therapists in early intervention. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions h.d. 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(1992). feeding and swallowing disorders in infancy: assessment and management. tucson, az: therapy skill builders. appendix a top ↑ assessment protocol for suck, swallow and breathing coordination (ssbc) the effects of electronic and other external control methods on stuttering: a review of some research techniques and suggestions for further research b y j o h n w f. bohr, b . a . h o n o r e s (pret.) s e n i o r r e s e a r c h officer, n a t i o n a l i n s t i t u t e for p e r s o n a l r e s e a r c h , s o u t h a f r i c a n c o u n c i l for s c i e n t i f i c a n d i n d u s t r i a l r e s e a r c h , j o h a n n e s b u r g . introduction d u r i n g t h e c o u r s e of a s e r i e s of s t u d i e s a i m e d a t d e t e r m i n i n g t h e r e l a t i o n s h i p b e t w e e n p e r f o r m a n c e u n d e r c o n d i t i o n s of d e l a y e d a u d i t o r y f e e d b a c k ( d a f ) a n d p e r f o r m a n c e o n t h r e e o t h e r t e s t s ( v i s u a l a n d a u d i t o r y r e a c t i o n t i m e s a n d t h e s t r o o p r e a d i n g t e s t ) , t h e a u t h o r ' s i n t e r e s t w a s a r o u s e d in t h e e x p e r i m e n t a l w o r k of c h e r r y , s a y e r s a n d m a r l u n d (5), o n t h e i n h i b i t i o n of s t u t t e r i n g b y m e a n s of e x t e r n a l c o n t r o l . t h e a u t h o r ' s e x p e r i m e n t a l w o r k in t h e field of d a f a m o n g 126 e n g l i s h s p e a k i n g s o u t h a f r i c a n u n i v e r s i t y s t u d e n t s , all of w h o m w e r e n o r m a l s p e a k e r s , i n d i c a t e d t h a t t h o s e s t u d e n t s w i t h a f o r m e r h i s t o r y of s t u t t e r i n g t y p i c a l l y s h o w e d a s m a l l e r d i s c r e p a n c y i n r e a d i n g t i m e s t h a n o t h e r s w i t h o u t s u c h h i s t o r y , w h e n p e r f o r m a n c e u n d e r t w o c o n d i t i o n s w e r e c o m p a r e d , v i z . r e a d i n g i). w i t h i m m e d i a t e a n d ii). w i t h d e l a y e d a u d i t o r y f e e d b a c k . i n n o r m a l s p e e c h t h e s u b j e c t c o n s t a n t l y m o n i t o r s h i s s p e e c h b y p e r c e p t i o n of h i s o u t p u t t h r o u g h b o t h e x t e r o c e p t i v e a n d p r o p r i o c e p t i v e c u e s . d a f b r i n g s a b o u t a d i s r u p t i v e effect o n t h e f o r m e r , a n d m a s k s t h e t i s s u e b o r n e a u d i t o r y c u e s t o t h e h e a r i n g m e c h a n i s m , w i t h o u t a f f e c t i n g t h e r e m a i n d e r of p r o p r i o c e p t i v e c u e s . i t m a y b e t h o u g h t t h a t t h e f u r t h e r d i m i n u t i o n of p r o p r i o c e p t i v e c u e s w o u l d m a k e c o h e r e n t s p e e c h i m p o s s i b l e , b u t t h i s is n o t t h e c a s e , a s h a s b e e n d e m o n s t r a t e d b y l a d e f o g e d (9). h e e x c l u d e d e x t e r o c e p t i v e s p e e c h m o n i t o r i n g b y m e a n s of a l o u d m a s k i n g n o i s e in e a r p h o n e s w o r n b y t h e s u b j e c t , w h o s e p e r c e p t i o n of t i s s u e b o r n e a c o u s t i c c u e s w a s a l s o m a s k e d b y t h e l o u d n o i s e in t h e e a r p h o n e s . i n a n a t t e m p t t o d i m i n i s h o t h e r p r o p r i o c e p t i v e c u e s t o t h e s u b j e c t , l a d e f o g e d h a d h i m s u c k a m e t h o c o c a i n e t a b l e t s , w h i c h p r o d u c e d l o c a l a n a e s t h e t i z a t i o n of t h e s u r f a c e of t h e l i p s , t o n g u e a n d m o u t h i n t e r i o r . e v e n u n d e r t h e s e c o n d i t i o n s of c o n s i d e r a b l e d i m i n u t i o n of b o t h e x t e r o c e p t i v e a n d p r o p r i o c e p t i v e c u e s , t h e s u b j e c t w a s a b l e t o p r o d u c e i n t e l l i g i b l e s p e e c h . p r o b a b l y t h e s u b j e c t w a s s t i l l a b l e t o p e r c e i v e a l i m i t e d n u m b e r of r e d u c e d p r o p r i o c e p t i v e c u e s c o n c e r n i n g m u s c l e s t r e t c h i n t h o s e a r e a s of t h e l i p s , t o n g u e a n d l a r y n x u n a f f e c t e d b y t h e a m e t h o c o c a i n e . 2. delayed auditory feedback (daf) w h e n a s p e a k e r is s u b j e c t e d t o d a f h e h e a r s h i s r e c o r d e d v o i c e a f r a c t i o n of a s e c o n d ( a b o u t 180 m i l l i s e c o n d s ) a f t e r u t t e r a n c e , t h r o u g h a h e a d s e t o r e a r p h o n e s . t h e s y s t e m is s o a r r a n g e d t h a t t h e d e l a y e d f e e d b a c k is a t a l e v e l h i g h e n o u g h t o m a s k t h e t i s s u e b o r n e a u d i t o r y c u e s t o t h e h e a r i n g m e c h a n i s m . t h u s t h e a u d i t o r y m o n i t o r i n g of s p e e c h is d i s r u p t e d , a l t h o u g h p r o p r i o c e p t i v e c u e s r e m a i n u n a f f e c t e d . w i t h m o s t s u b j e c t s t h i s d i s r u p t i o n of n o r m a l a u d i t o r y s p e e c h m o n i t o r i n g p r o d u c e s v e r y m a r k e d c h a n g e s i n s p e e c h . l e e , w h o p u b l i s h e d t h e first p a p e r o n d a f (10), r e f e r s t o t h e s e effects a s " s t a r t l i n g " a n d s a y s of d a f : " . . . i t w i l l c a u s e t h e p e r s o n t o s t u t t e r , s l o w d o w n w h i l e r a i s i n g h i s v o i c e in p i t c h a n d v o l u m e , o r s t o p c o m p l e t e l y " . w o r k i n g in t h e s a m e field s i m u l t a n e o u s l y w i t h l e e , b u t i n d e p e n d e n t l y of h i m , b l a c k r e p o r t e d (1) t h a t d a f : " . . . m a y p r o d u c e n e a r t r a u m a t i c effects t h a t i n c l u d e t h e b l o c k i n g of s p e e c h , facial c o n t o r t i o n s , t h e p r o l o n g a t i o n a n d s l u r r i n g of s o u n d s , a n d r e p e t i t i o n s of s o u n d s a n d s y l l a b l e s . " b l a c k s t a t e s t h a t t h e d i s r u p t i v e eff e e t of d a f is m o s t m a r k e d w h e n t h e d e l a y t i m e of d a f is b e t w e e n 180 a n d 2 2 0 m i l l i s e c o n d s , w h i c h a p p r o x i m a t e s t h e m e a n s y l l a b l e d u r a t i o n for a v e r a g e s p e a k e r s . a p p a r a t u s for p r o d u c i n g d a f h a s b e e n d e s c r i b e d b y b l a c k (1 a n d 2), b o h r (3 a n d 4), f a i r b a n k s a n d j a e g e r (6), h a n l e y a n d t i f f a n y (7), m a r p l e a n d m o r r i l l (12), a n d t i f f a n y , h a n l e y a n d s u t h e r l a n d ( 1 4 ) . t y p i c a l l y , a m o d i f i e d m a g n e t i c t a p e r e c o r d e r is u s e d . t h e r e c o r d e r is f i t t e d w i t h t w o journal of the south african logopedic society august, 1963 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) h e a d s ( o n e for r e c o r d i n g a n d t h e o t h e r for s i m u l t a n e o u s p l a y b a c k of t h e r e c o r d e d s i g n a l ) a n d t h e o u t p u t f r o m t h e p l a y b a c k h e a d is fed i n t o a n a d d i t i o n a l p l a y b a c k a m p l i fier. t h e s u b j e c t h e a r s t h e o u t p u t f r o m t h e p l a y b a c k h e a d , s u i t a b l y a m p l i f i e d b y t h e p l a y b a c k a m p l i f i e r , t h r o u g h e a r p h o n e s o r a h e a d s e t . t h e d e g r e e of d e l a y i n t h e s y s t e m is d e p e n d e n t u p o n a n u m b e r of f a c t o r s , v i z . p h y s i c a l s e p a r a t i o n b e t w e e n r e c o r d i n g a n d p l a y b a c k h e a d s , s p e e d of t a p e t r a n s p o r t , a n d t h e e x i s t e n c e o r o t h e r w i s e of d e v i c e s for l e n g t h e n i n g t h e t a p e l o o p b e t w e e n t h e r e c o r d i n g a n d p l a y b a c k h e a d s . t h e s y s t e m d e v i s e d b y t h e a u t h o r is illus t r a t e d i n f i g u r e s 1 a n d 2. i n f i g u r e 1 t h e m o d i f i e d t a p e r e c o r d e r a p p e a r s i n t h e c e n t r e w i t h t h e p l a y b a c k a m p l i f i e r o n t h e r i g h t . t h e h e a d s e t s h o w n is p a r t of a l a b o r a t o r y t y p e a u d i o m e t e r ; for field u s e t h e a u t h o r e m p l o y s e i t h e r a s e t of e a r p h o n e s o r a s p e c i a l l y c o n s t r u c t e d p o r t a b l e h e a d s e t c o n t a i n i n g t w o i n v e r t e d c o n e l o u d s p e a k e r s . i n f i g u r e 2 t h e t w o h e a d s c a n b e s e e n in t h e l o w e r c e n t r e . t h e v a r i a b l e l o o p c o n t r o l l e r is s h o w n c e n t r e d b e t w e e n t h e t w o r e e l s , w h i l e t h e s e t of i n t e r c h a n g e a b l e c a p s t a n s a r e d i s p l a y e d a b o v e t h e l e f t h a n d t a p e r e e l . b y m e a n s of t h e i n t e r c h a n g e a b l e c a p s t a n s , w h i c h c o n t r o l t h e s p e e d of t a p e t r a n s p o r t , a n d t h e v a r i a b l e l o o p c o n t r o l l e r it is p o s s i b l e t o o b t a i n d e l a y t i m e s r a n g i n g f r o m 122 m i l l i s e c o n d s t o 8 9 7 m i l l i s e c o n d s . t h e p h y s i c a l s e p a r a t i o n b e t w e e n t h e t w o h e a d s is s u c h t h a t a d e l a y t i m e of 183 m i l l i s e c o n d s is o b t a i n e d w h e n t h e t a p e is t h r e a d e d s t r a i g h t t h r o u g h b e t w e e n h e a d s a n d t h e s p e e d of t a p e t r a n s p o r t is 1 \ i n c h e s p e r s e c o n d . fig. 1 d a f system devised b y author 1 journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) fig. 2 modified tape recorder for daf 3. some south african results from daf experiments u s i n g t h e a p p a r a t u s d e s c r i b e d a b o v e , 126 e n g l i s h s p e a k i n g s e c o n d y e a r s t u d e n t s w i t h o u t c u r r e n t s p e e c h d e f e c t s w e r e t e s t e d a t t h e u n i v e r s i t i e s of c a p e t o w n , r h o d e s a n d n a t a l ( p i e t e r m a r i t z b u r g a n d d u r b a n ) . e a c h s u b j e c t w a s r e q u i r e d t o r e a d t h e g r a n d f a t h e r p a s s a g e t w i c e in s u c c e s s i o n . ( t h i s p a s s a g e b y v a n ' r i p e r (15) c o n t a i n s all e n g l i s h s p e e c h s o u n d s ) . f o r e a c h r e a d i n g t h e s u b j e c t w o r e a p o r t a b l e h e a d s e t . d u r i n g t h e first r e a d i n g h e h e a r d h i s v o i c e w i t h d i r e c t ( i m m e d i a t e ) f e e d b a c k t h r o u g h t h e h e a d s e t , a n d d u r i n g t h e s e c o n d r e a d i n g h e h e a r d , h i s v o i c e t h r o u g h t h e h e a d s e t w i t h a d e l a y t i m e of 183 m i l l i s e c o n d s . t h e r e s u l t s of t h i s t e s t s e r i e s a p p e a r i n t a b l e 1. t h e s e r e s u l t s r e v e a l t h a t d a f p r o d u c e s a m a r k e d r e d u c t i o n in r e a d i n g s p e e d for b o t h m a l e a n d f e m a l e s u b j e c t s . w h e n t h e m e a n s o n l y a r e c o n s i d e r e d , t h e r e is a c l o s e r r a t i o b e t w e e n t h e t w o r e a d i n g t i m e s for m a l e s t h a n for f e m a l e s . h o w e v e r , t h e r e is a g r e a t e r r a n g e o v e r w h i c h m a l e p e r f o r m a n c e s v a r y b o t h w i t h d i r e c t a n d d e l a y e d a u d i t o r y feedb a c k , a s s h o w n b y t h e l a r g e r s t a n d a r d d e v i a t i o n s for t h e m a l e s a m p l e u n d e r b o t h ' r e a d i n g c o n d i t i o n s . o n e of t h e f e m a l e s u b j e c t s r e p o r t e d h a v i n g a slight s t u t t e r a t a n e a r l i e r a g e . h e r r e a d i n g t i m e s w e r e 5 0 a n d 100 s e c o n d s for d i r e c t a n d d e l a y e d a u d i t o r y f e e d b a c k r e s p e c t i v e l y , g i v i n g a r a t i o of .50 b e t w e e n t h e t w o ' p e r f o r m a n c e s , w e l l below t h e m e a n s of b o t h f e m a l e a n d m a l e , g r o u p s . i n t h e m a l e s a m p l e t h e r e w e r e five s u b j e c t s w i t h a n e a r l i e r s t u t t e r i n g h i s t o r y . t h e i r p e r f o r m a n c e s a r e l i s t e d i n t a b l e 2. journal of the south african logopedic society august, 1963 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) table 1. reading times in seconds grandfather passage direct feedback daf „ ,. direct feedback ratio: daf 1. males mean 45.6* 61.8* .74 n = 58 standard deviation 6.3* 16.1* — 2. females mean 45.9* 65.1* .71 n = 68 standard deviation 5.0* 13.1* — * = significant beyond the .05% level. table 2. reading times (seconds), 5 male former stutterers subject direct feedback daf „ . direct feedback rat.o: daf a 43 33 1.303 β 45 56 .804 c i 46 48 .958 1 d 46 58 .793 ε 46 41 1.122 mean for group 45 sd=1.166 47 sd=9.325 .957 1 journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) if o n l y t h o s e m a l e s ( n = 5 3 ) w i t h n o r e p o r t e d s t u t t e r i n g h i s t o r y a r e c o n s i d e r e d t h e i r m e a n r e a d i n g t i m e s w i t h d i r e c t a n d d e l a y e d feedb a c k a r e 4 5 . 6 2 3 s e e s . ( s d = 6 . 5 6 ) a n d 6 3 . 1 3 2 s e e s . ( s d = 1 5 . 8 8 3 ) r e s p e c t i v e l y . a n f a n d t t e s t o n t h e r e s u l t s of n o n s t u t t e r e r s a n d f o r m e r s t u t t e r e r s r e v e a l e d a v e r y s i g n i f i c a n t d i f f e r e n c e ( . 0 0 1 ρ . 0 0 0 5 ) in t h e s t a n d a r d d e v i a t i o n s of t h e g r o u p s w i t h d i r e c t feedb a c k , b u t n o s i g n i f i c a n t d i f f e r e n c e b e t w e e n t h e m e a n s . u n d e r d a f , t h e s t a n d a r d d e v i a t i o n s of t h e g r o u p s d o n o t differ signific a n t l y , b u t t h e r e is a s i g n i f i c a n t d i f f e r e n c e b e t w e e n t h e m e a n s ( . 0 2 5 ρ .01). i n effect t h e 5 f o r m e r s t u t t e r e r s a r e l e s s a f f e c t e d i n r e a d i n g t i m e u n d e r d a f t h a n t h e 53 n o n s t u t t e r e r s . a l t h o u g h t h e s m a l l s a m p l e s i z e of f o r m e r s t u t t e r e r s p r e c l u d e s a n y final c o n c l u s i o n , t h e a u t h o r t e n t a t i v e l y i n f e r s t h a t t h e r e c o v e r e d s t u t t e r e r m a y h a v e d e v e l o p e d a t e c h n i q u e w h e r e b y h e t e n d s t o i g n o r e a u d i t o r y f e e d b a c k c u e s a n d t o r e l y m o r e h e a v i l y o n p r o p r i o c e p t i v e c u e s for s p e e c h m o n i t o r i n g . if t h i s h y p o t h e s i s h o l d s , it p r e s e n t s t h e p o s s i b i l i t y of u t i l i z i n g d a f a s a p r o g n o s t i c m e a s u r e d u r i n g s p e e c h t h e r a p y . t h o s e s u b j e c t s s h o w i n g t h e s m a l l e s t d i s c r e p a n c y i n r e a d i n g t i m e s u n d e r d i r e c t a n d d e l a y e d a u d i t o r y f e e d b a c k c o u l d b e e x p e c t e d t o b e n e f i t m o s t f r o m s p e e c h t h e r a p y , a n d v i c e v e r s a . a l t e r n a t i v e l y d a f c o u l d b e e m p l o y e d a s a n i n d i c a t o r of t h e p r o g r e s s of t h e s t u t t e r e r d u r i n g s p e e c h t h e r a p y . i t s h o u l d b e e m p h a s i z e d t h a t t h e s e s u g g e s t i o n s a r e p u t f o r w a r d t e n t a t i v e l y . a t t h i s s t a g e , a n d s h o u l d b e c o n s i d e r e d a s s u g g e s t i o n s for f u r t h e r r e s e a r c h , w h i c h w i l l i n d i c a t e w h e t h e r t h e y a r e w a r r a n t e d . a f u r t h e r s u g g e s t i o n e m a n a t i n g f r o m t h e s e p r e l i m i n a r y f i n d i n g s is t h e c o n s i d e r a t i o n b y s p e e c h t h e r a p i s t s of e m p h a s i z i n g , d u r i n g t h e r a p y , t h a t s u b j e c t s s h o u l d a t t e m p t t o r e l y m o r e h e a v i l y d u r i n g s p e e c h o n p r o p r i o c e p t i v e c u e s a n d a t t e m p t t o i g n o r e t h e a u d i t o r y s p e e c h c u e s , w h i c h i n t h e c a s e of s t u t t e r e r s a c t u a l l y h a m p e r s p e e c h a n d t e n d t o m e d i a t e s t u t t e r i n g , a s s h o w n b y t h e w o r k of c h e r r y , s a y e r s a n d m a r l u n d (5). 5. an experiment using external control for stammering a n u m b e r of f o r m s of e x t e r n a l c o n t r o l t o d i s t r a c t t h e s t u t t e r e r f r o m t h e a u d i t o r y c u e s i n h i s o w n v o i c e h a v e b e e n p r o p o s e d b y c h e r r y , s a y e r s a n d m a r l u n d (5) for e x p e r i m e n t a l a n d c l i n i c a l u s e w i t h s t u t t e r e r s . t h e s e i n c l u d e s p e e c h s h a d o w i n g , s i m u l t a n e o u s r e a d i n g f r o m t h e s a m e t e x t , o r f r o m d i f f e r e n t t e x t s , g i b b e r i s h , w h i s p e r i n g , r e v e r s e d s p e e c h , d a f , w h i t e n o i s e m a s k i n g , l o w p i t c h m a s k i n g , e t c . , all of w h i c h t e n d t o p r o d u c e i m p r o v e d s p e e c h p r o d u c t i o n b y s t u t t e r e r s i n r o u t i n e r e a d i n g . b e f o r e d e a l i n g w i t h h i s e x p e r i m e n t s i n e x t e r n a l c o n t r o l w i t h a s t u t t e r e r , t h e a u t h o r w i s h e s t o p r e s e n t a b r i e f r e c a p i t u l a t i o n of e a c h of t h e s e t e c h n i q u e s : a . s p e e c h s h a d o w i n g . t h e e x p e r i m e n t e r r e a d s a l o u d o r s p e a k s e x t e m p o r e , a n d t h e s u b j e c t a t t e m p t s t o c o p y t h i s s p e e c h p a t t e r n a l o u d , b u t d o e s n o t s e e t h e t e x t ( w h e n u s e d ) . b. s i m u l t a n e o u s r e a d i n g . t h e e x p e r i m e n t e r r e a d s a l o u d , w h i l e t h e s u b j e c t a l s o r e a d s a l o u d f r o m t h e s a m e t e x t . c. u s e of different t e x t s . b o t h e x p e r i m e n t e r a n d s u b j e c t r e a d a l o u d f r o m d i f f e r e n t t e x t s . d. gibberish. e x p e r i m e n t e r a n d s u b j e c t s t a r t r e a d i n g a l o u d f r o m s a m e t e x t ; w h i l e t e s t is u n d e r w a y e x p e r i m e n t e r c h a n g e s w i t h o u t w a r n i n g i n t o m e a n i n g l e s s s o u n d s ( g i b b e r i s h ) . e. w h i s p e r i n g . t h e e x p e r i m e n t e r r e a d s a l o u d , w h i l e t h e s u b j e c t r e a d s t h e s a m e p a s s a g e i n a w h i s p e r . f. r e v e r s e d s p e e c h . t h e s u b j e c t r e a d s a l o u d , w h i l e a r e v e r s e d s p e e c h r e c o r d i n g is p l a y e d b a c k t o h i m t h r o u g h e a r p h o n e s f r o m a g r a m a p h o n e r e c o r d o r t a p e r e c o r d i n g . g. d a f . t h e s u b j e c t r e a d s , a l o u d , h i s v o i c e b e i n g r e c o r d e d o n m a g n e t i c t a p e a n d p l a y e d b a c k t o h i m t h r o u g h a h e a d s e t a f r a c t i o n of a s e c o n d a f t e r t h e u t t e r a n c e of e a c h s o u n d . h. w h i t e n o i s e m a s k i n g . t h e s u b j e c t r e a d s a l o u d , w h i l e a b r o a d b a n d of n o i s e e v e n l y d i s t r i b u t e d t h r o u g h o u t t h e a u d i o s p e c t r u m , a n d e l e c t r o n i c a l l y g e n e r a t e d , is fed i n t o t h e h e a d s e t h e is w e a r i n g . journal of the south african logopedic society august, 1963 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) i. l o w p i t c h m a s k i n g . t h e s u b j e c t r e a d s a l o u d , w h i l e a s i n e w a v e of a b o u t 140 c y c l e s p e r s e c o n d ( c p s ) is fed i n t o t h e h e a d s e t h e is w e a r i n g . a l l t h e a b o v e f o r m s of e x t e r n a l c o n t r o l c a n h a v e t h e effect of i m p r o v i n g t h e r e a d i n g of s t u t t e r e r s . i t c a n b e s e e n t h a t t h o s e f o r m s l i s t e d f r o m a . t o e . a b o v e c a n b e a p p l i e d w i t h o u t a n y e l e c t r o n i c d e v i c e s , w h i l s t t h o s e l i s t e d f r o m f. t o i. r e q u i r e s o m e w h a t e l a b o r a t e a p p a r a t u s . c h e r r y et.al. h a v e d e m o n s t r a t e d t h a t w h i t e n o i s e m a s k i n g c a n p r o d u c e a different i a l effect o n t h e i n h i b i t i o n of s t u t t e r i n g , d e p e n d i n g o n t h e p o r t i o n of t h e a u d i o s p e c t r u m r e a c h i n g t h e s u b j e c t : w h e n t h e w h i t e n o i s e is s u p p l i e d t o t h e s u b j e c t t h r o u g h a l o w p a s s filter w h i c h p a s s e s all a u d i b l e n o i s e b e l o w 5 0 0 c p s , t h e m e a n r e d u c t i o n i n b r e a k d o w n ( s t u t t e r i n g ) t i m e i s 9 5 % , p l u s o r m i n u s 5 % . w h e n t h e w h i t e n o i s e is s u p p l i e d t o t h e s u b j e c t t h r o u g h a h i g h p a s s f i l t e r w h i c h p a s s e s a u d i b l e n o i s e a b o v e 5 0 0 c p s , t h e m e a n r e d u c t i o n i n b r e a k d o w n ( s t u t t e r i n g ) t i m e is o n l y 3 5 % . p l u s o r m i n u s 3 7 % . t h u s w h i t e n o i s e b e l o w 5 0 0 c p s p r o d u c e s a g r e a t e r i m p r o v e m e n t i n s p e e c h p r o d u c t i o n t h a n t h a t a b o v e 5 0 0 c p s . m e t r o n o m e t e c h n i q u e of u n o b t r u s i v e l y a c c e n t u a t i n g s p e e c h r h y t h m w h e r e b y h e c a n r e d u c e h i s s t u t t e r u n d e r n o r m a l c i r c u m s t a n c e s . w h e n e x c i t e d , h e o m i t s t h e m e t r o n o m e h a n d s i g n a l s a n d s t u t t e r s m o r e t h a n u s u a l . h e u n d e r w e n t t h e e x p e r i m e n t a l s e r i e s o n t h e c l e a r l y s t a t e d u n d e r s t a n d i n g t h a t h e w a s p a r t i c i p a t i n g i n t h e r e p l i c a t i o n of a s e r i e s of e x p e r i m e n t s o r i g i n a l l y p e r f o r m e d i n l o n d o n , a n d w a s n o t u n d e r g o i n g a f o r m of t h e r a p y . t h r e e r e a d i n g p a s s a g e s w e r e u s e d i n t h i s s e r i e s : a r a n d o m l y s e l e c t e d p a s s a g e f r o m a p e r i o d i c a l a n d t w o s t a n d a r d r e a d i n g p a s s a g e s , e a c h c o n t a i n i n g all t h e s p e e c h s o u n d s i n e n g l i s h . t h e t w o s t a n d a r d p a s s a g e s w e r e v a n r i p e r ' s g r a n d f a t h e r p a s s a g e (16) a n d a r t h u r t h e y o u n g r a t , b y j o h n s o n , b r o w n , c u r t i s , e d n e y a n d k e a s t e r (8). t h r o u g h o u t t h e s e r i e s of t e s t s t h e s u b j e c t w o r e a p o r t a b l e h e a d s e t , t h r o u g h w h i c h h e r e c e i v e d all i n s t r u c t i o n s a n d e x t e r n a l c o n t r o l s i g n a l s . t h i s p r o c e d u r e w a s f o l l o w e d s o t h a t t h e w e a r i n g of t h e h e a d s e t d i d n o t in i t s e l f c o n s t i t u t e a n e x p e r i m e n t a l v a r i a b l e . t h e r e s u l t s of t h i s e x p e r i m e n t a l s e r i e s a r e p r e s e n t e d in t a b l e 3. table 3. reading times (seconds) with and without external controls test sequence reading passage circumstances of test reading time 1. grandfather subject reads without external control 200 2. speech shadowing 63 3. simultaneous reading with experimenter 50 subject whispers. experimenter reads aloud 45 delayed auditory feedback (daf) 55 6. immediate auditory feedback 55 9. white noise masking at 110 db 60 10. 11. white noise masking at 117 db low pitch (140 cps) masking at 97 db~ 48 51 8. arthur the young rat subject reads without external control 96 12. low-pitch (140 cps) masking at 97 db 49 13. low-pitch (140 cps)masking at 97 db switched rapidly on and off 15. subject reads without external control 54 1 0 8 7. from a periodical subject reads without external control 200 14. subject reads without external control 155 t h e a u t h o r r e p l i c a t e d s o m e of t h e e x p e r i m e n t s i n , e x t e r n a l c o n t r o l w i t h a m a l e s t u d e n t , agetf 2 0 y e a r s . n o r m a l l y t h e s u b j e c t h a s n o d i f f i c u l t y i n s p e a k i n g i n t h e p r e s e n c e of a v e r y y o u n g c h i l d o r a p e t a n i m a l , a n d h e c a n s i n g o r c h e e r i n a g r o u p . w h e n i n t h e c o m p a n y of h i s p e e r s o r s u p e r i o r s , h o w e v e r , h e s t u t t e r s s e v e r e l y . h e h a s d e v e l o p e d a t h e r e s u l t s s h o w c e r t a i n a n o m a l i e s . f i r s t l y t h e r e is a c l e a r i n d i c a t i o n t h a t e x t e r n a l c o n t r o l w a s a s s o c i a t e d w i t h i m p r o v e d r e a d i n g . t h i s c a n b e s e e n f r o m t h e f i r s t s e r i e s (i.e. t e s t s 2, 3, 4 , 5, 9, 10 a n d 11) a s w e l l a s f r o m t h e s e c o n d s e r i e s ( t e s t s 12 a n d 13). s e c o n d l y r e a d i n g p e r f o r m a n c e a l s o i m p r o v e d when no external control w a s applied (tests 1 journal of the south african logopedic society 9 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 a n d 14). t h i r d l y i t a p p e a r s a s if t h e r e is a s e q u e n t i a l i m p r o v e m e n t i n r e a d i n g d u r i n g t h e c o u r s e of t h e t e s t s e r i e s , a s is c l e a r l y d e m o n s t r a t e d w h e n t h e t h i r d s e r i e s is e x a m i n e d . in t e s t s 7 a n d 14 n o e x t e r n a l c o n t r o l w a s a p p l i e d , b u t t h e p e r f o r m a n c e o n t e s t 14 w a s a c o n s i d e r a b l e i m p r o v e m e n t o n t h a t of t e s t 7. h o w e v e r , t h i s s e q u e n t i a l i m p r o v e m e n t d o e s n o t h o l d c o n s i s t e n t l y for t h e first s e r i e s ( t e s t s 1, 2, 3, 4, 5, 6, 9, 10 a n d 11) o r for t h e s e c o n d s e r i e s ( t e s t s 8, 12, 13 a n d 15), i n f a c t t h e p o o r e s t p e r f o r m a n c e s e q u e n t i a l l y w a s o n t e s t 15, w h e n c o m p a r e d w i t h t e s t 8. i t c o u l d b e a r g u e d t h a t f a t i g u e s e t in a t t e s t 15, a s a s u d d e n s t e p f u n c t i o n , a s t e s t 14 i m m e d i a t e l y p r e c e d i n g i t r e p r e s e n t e d a 2 2 % r e d u c t i o n in r e a d i n g t i m e o v e r t e s t 7. t o s u m u p t h e r e s u l t s of t h i s s e r i e s of e x p e r i m e n t s , it m a y b e s t a t e d v e r y t e n t a t i v e l y t h a t t h e r e a p p e a r s t o b e a t r e n d for i m p r o v e d r e a d i n g t o b e a s s o c i a t e d w i t h e x t e r n a l c o n t r o l . t h e s e e x p e r i m e n t s c e r t a i n l y d o n o t w a r r a n t t h e c o n c l u s i o n t h a t e x t e r n a l c o n t r o l p e r s e r e d u c e s s t u t t e r i n g . i t is a p p a r e n t t h a t c o n s i d e r a b l e f u r t h e r r e s e a r c h , u s i n g a l a r g e r s a m p l e a s w e l l a s c o n t r o l a n d e x p e r i m e n t a l c o n d i t i o n s a l t e r n a t e l y , is r e q u i r e d a field in w h i c h s p e e c h t h e r a p i s t s c o u l d p l a y a n i m p o r t a n t p a r t . 6. external control and stuttering r e s u l t s r e p o r t e d b y c h e r r y , s a y e r s a n d m a r l u n d (5) a n d m c l a r e n (11) i n d i c a t e t h a t c o n s i d e r a b l e s u c c e s s h a s a l r e a d y b e e n a c h i e v e d w h e n e x t e r n a l c o n t r o l is u s e d i n c o n j u n c t i o n w i t h o t h e r t e c h n i q u e s in t h e t r e a t m e n t of s t u t t e r e r s . m c l a r e n (11) e m p h a s i z e s t h a t n o o n e t e c h n i q u e c a n b e t h e i d e a l a p p r o a c h t o t h e p r o b l e m , a s s t u t t e r i n g is a n i n f i n i t e l y c o m p l e x p h e n o m e n o n , i n v o l v i n g s p e e c h i n t h e a c t of c o m m u n i c a t i o n a n d is i n t i m a t e l y a s s o c i a t e d w i t h h u m a n r e l a t i o n s h i p s . o v e r a p e r i o d of 3 y e a r s e x t e r n a l c o n t r o l h a s b e e n u s e d a t s t . m a r y ' s h o s p i t a l , l o n d o n , t o b u i l d u p a d y n a m i c t e c h n i q u e , a d a p t a b l e t o all a g e s a n d t y p e s of s t u t t e r e r s . m a c l a r e n (11, p . 4 6 0 ) s t a t e s : " t h e y o u n g p a t i e n t p r o v i d e d t h a t e n v i r o n m e n t a l s t r e s s e s c a n b e r e l i e v e d r e s p o n d s w e l l t o d i r e c t a u d i t o r y r e t r a i n i n g . " w i t h t h e o l d e r p a t i e n t t h e a n x i e t y a t t a c h e d t o t h e s p e e c h s i t u a t i o n o f t e n s p r e a d s i t s t e n t a c l e s t h r o u g h t h e w h o l e p a t t e r n of life. i t w o u l d b e a b s u r d t o e x p e c t t h a t a u d i t o r y r e t r a i n i n g a l o n e c o u l d b r i n g a n y r e a l relief t o s u c h p a t i e n t s . b u t h e r e o u r t e c h n i q u e h a s b e e n f o u n d t o b e of g r e a t v a l u e , for i t n o t o n l y s e r v e s t o s t r e n g t h e n a n d r e i n f o r c e t h e m e m o r y of n o r m a l i t y b u t it c a n b e u s e d a s a n i n s t r u m e n t b y w h i c h , in a v e r y p r a c t i c a l w a y , t h e s t a m m e r e r c a n b e b r o u g h t t o r e a l i s e i n a c t u a l e x p e r i e n c e t h e n a t u r e of h i s d i f f i c u l t i e s a n d t h e p r i n c i p l e s w h i c h m u s t b e f o l l o w e d if h e is t o f r e e h i m s e l f f r o m t h e m . " t h e r e l a t i o n s h i p b e t w e e n s t u t t e r i n g a n d e x t e r n a l c o n t r o l a w a i t s full e l u c i d a t i o n . m e a n w h i l e t h e h y p o t h e s i s p r o p o s e d b y c h e r r y , s a y e r s a n d m a r l u n d (5) h a s m u c h t o c o m m e n d it. a s t h e y s e e it, s t u t t e r i n g i s m a i n l y m e d i a t e d b y t h e s u b j e c t ' s a b n o r m a l p e r c e p t i o n of t h e l o w f r e q u e n c y c o m p o n e n t s of h i s o w n v o i c e , p a r t i c u l a r l y t h e b o n e a n d t i s s u e c o n d u c t e d l a r y n x t o n e s . t h e y d o n o t s u g g e s t t h a t t h i s a b n o r m a l p e r c e p t i o n is a cause of s t u t t e r i n g . t h e r o l e of e x t e r n a l c o n t r o l is t h e n t o d i m i n i s h t h e s t u t t e r e r ' s a w a r e n e s s of t h e l o w f r e q u e n c y l a r y n g e a l s t i m u l i b y m e a n s of m a s k i n g . if t h e s t u t t e r e r ' s b a s i l a r m e m b r a n e s a r e b r o u g h t i n t o v i b r a t i o n b y m e a n s of a l o u d t o n e in t h e r e g i o n of 140 c p s , all o t h e r h e a r i n g s t i m u l i a r e m a s k e d w i t h t h e r e s u l t t h a t t h e p e r c e p t u a l a b n o r m a l i t y is e f f e c t i v e l y b l o c k e d a n d s t u t t e r i n g is d i m i n i s h e d . 7. suggested further research on external control o n t h e b a s i s of t h e w o r k a l r e a d y d o n e i n b r i t a i n b y c h e r r y , s a y e r s a n d m a r l u n d a n d t h e s o m e w h a t i n c o n c l u s i v e r e s u l t s f r o m s o u t h a f r i c a n r e p l i c a t i o n of s o m e of t h e i r t e c h n i q u e s of e x t e r n a l c o n t r o l , t h e a u t h o r / c o n s i d e r s t h a t e x h a u s t i v e r e s e a r c h i n t h i s field p r o m i s e s w e l l for t h e d e v e l o p m e n t of p r a c t i c a l t e c h n i q u e s for t h e a l l e v i a t i o n of s t u t t e r i n g . t h e a u t h o r p o s e d t h e p r o b l e m of d e s i g n i n g a s m a l l , p o r t a b l e t r a n s i s t o r o s c i l l a t o r c a p a b l e of p r o d u c i n g a s t a b l e w a v e f o r m i n t h e v i c i n i t y of 140 c p s t o t h e a c o u s t i c r e s e a r c h l a b o r a t o r y of t h e c o u n c i l for s c i e n tific a n d i n d u s t r i a l r e s e a r c h . d r . j . f. b u r g e r 10 journal of the south african logopedic society august, 1963 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) d e s i g n e d a n d c o n s t r u c t e d a p r o t o t y p e m u l t i v i b r a t o r u s i n g t w o t r a n s i s t o r s t o p r o d u c e a v e r y s t a b l e w a v e f o r m , t h e f r e q u e n c y of w h i c h c a n b e v a r i e d v e r y s i m p l y b y c o n t r o l l i n g t h e p o w e r s u p p l y v o l t a g e . t h e r a n g e of f r e q u e n c y is f r o m 123 t o 165 c p s , w h i c h is t h o u g h t t o b e w i d e e n o u g h t o a c c o m o d a t e i n d i v i d u a l d i f f e r e n c e s in r e s o n a n t f r e q u e n c y of t h e b a s i l a r m e m b r a n e s of d i f f e r e n t s u b j e c t s . f i g u r e 3 s h o w s t h e c i r c u i t d i a g r a m of t h i s m u l t i v i b r a t o r , t o g e t h e r w i t h t h e w a v e f o r m p r o d u c e d a n d d e t a i l s of c h a n g e s i n f r e q u e n c i e s a s s o c i a t e d w i t h c h a n g e s in p o w e r s u p p l y v o l t a g e . f i g u r e 3 circuit diagram, multi-vibrator p o w e r s u p p l y mb. t h e f r e q u e n c y o f t h e m u l t i v i b r a t o r v a r i e s a c c o r d i n g t o t h e p o w e r s u p p l y v o l t a g e , a 3 s h o w n b e l o w . p o w e r supply f v o l t s ) 3 -4 5 6 9 frequency ( c y c l e s p e r s e c o w d ) 165 14-6 i3e i 23 wave form produced t i m e α b s 1-7 time ukjit6 b c • 2ό time units a -c «3·τ time units" owe complete cvclb journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t o d a t e , n o e x p e r i m e n t s w i t h s t u t t e r e r s h a v e b e e n p e r f o r m e d u s i n g t h i s m u l t i v i b r a t o r . h o w e v e r , it is s u g g e s t e d t h a t i t c o u l d b e l i n k e d w i t h a t r a n s i s t o r p o w e r a m p l i f i e r , m i c r o p h o n e , s w i t c h i n g s y s t e m a n d e a r p h o n e s i n a s m a l l p o r t a b l e s e t t h a t c o u l d b e w o r n b y a s t u t t e r e r o v e r a n e x t e n d e d p e r i o d . t h e p r o p o s e d s y s t e m is s h o w n in f i g u r e 4. t h e c i r c u i t h a s b e e n s o d e s i g n e d t h a t o u t p u t f r o m e i t h e r t h e m u l t i v i b r a t o r o r t h e m i c r o p h o n e c a n b e fed t o t h e e a r p h o n e s a f t e r a m p l i f i c a t i o n . t h u s , w h e n t h e s t u t t e r e r is l i s t e n i n g , h e s w i t c h e s t h e m i c r o p h o n e i n t o a n d t h e m u l t i v i b r a t o r o u t of c i r c u i t . f i g u r e ablock: diagram, multi-vibrator microphone, amplifier switching m i c r o p h o n e 1 journal of the south african logopedic society august, 1963 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) w h e n h e w i s h e s t o s p e a k , h e s w i t c h e s t h e m i c r o p h o n e o u t of a n d t h e m u l t i v i b r a t o r int o t h e c i r c u i t . t h i s t h e n p r o d u c e s t h e c h a r a c t e r i s t i c s q u e a l in t h e e a r p h o n e s s e t t i n g h i s b a s i l a r m e m b r a n e s i n t o v i b r a t i o n a n d o b l i t e r a t i n g all p e r c e p t i o n of v o i c e t o n e s . f o r c o s m e t i c r e a s o n s t h e e a r p h o n e s c o u l d b e of t h e h e a r i n g a i d t y p e . s h o u l d t h i s p r o p o s e d s y s t e m e v o k e t h e d e s i r e d effect of i n h i b i t i n g s t u t t e r i n g t h r o u g h t h e m a s k i n g of t h e s t u t t e r e r ' s p e r c e p t i o n of l o w f r e q u e n c y c o m p o n e n t s of h i s v o i c e , it is f u r t h e r s u g g e s t e d t h a t t h e r a p y c o u l d p r o c e e d a l o n g t h e l i n e s t h e h u l l i a n l e a r n i n g t h e o r y of r e i n f o r c e m e n t , i m m e d i a t e r e w a r d , m a s s i n g of r e i n f o r c e m e n t , r e a c t i v e / i n h i b i t i o n a n d c o n t r o l l e d i n h i b i t i o n a s p r o p o s e d b y w a l t o n a n d b l a c k ( 1 5 ) . i n effect , t h e n t h e e x t e r n a l c o n t r o l w o u l d c o n s t i t u t e a ' t e m p o r a r y " c r u t c h " t o t h e s t u t t e r e r d u r i n g t h e p r o c e s s of a u d i t o r y r e c o n d i t i o n i n g . w h i l e t h i s p a p e r w a s in p r e p a r a t i o n , t h e a u t h o r ' s a t t e n t i o n w a s d r a w n t o t h e . v o r k of p a r k e r a n d c h r i s t o p h e r s o n (8), of w h i t t i n g h a m h o s p i t a l , n r . p r e s t o n , l a n c a s h i r e . u s i n g a s m a l l t r a n s i s t o r t o n e p r o d u c i n g a p p a r a t u s w h i c h t h e p a t i e n t c o u l d s w i t c n off o r o n a t w i l l , w h e n d e s i r i n g t o h e a r o r s p e a k , t h e y s u c c e s s f u l l y t r e a t e d t h r e e s t u t t e r e r s , t w o of w h o m h a d r e c e i v e d n o b e n e f i t f r o m c o n v e n t i o n a l s p e e c h t h e r a p y . f i n a l l y , t h e a u t h o r ' s a t t e n t i o n h a s b e e n d r a w n t o t h e a s y e t u n p u b l i s h e d w o r k of d r . c . d . r o o d e ( d e p t . , of p s y c h o l o g y , u n i v e r s i t y of p o t c h e f s t r o o m ) o n e a r d o m i n a n c e a n d c e r e b r a l s p e e c h l o c a l i z a t i o n , a t t h e u n i v e r s i t y of o t t a w a . i n t h e l i g h t of t h i s w o r k it w o u l d a p p e a r t h a t r e s e a r c h i n t o e a r d o m i n a n c e m a y w e l l b e a m a j o r f a c t o r in e l u c i d a t i n g t h e a e t i o l o g y a n d t r e a t m e n t of s p e e c h d e f e c t s . summary s o m e r e s u l t s f r o m s o u t h a f r i c a n e x p e r i m e n t s w i t h d e l a y e d a u d i t o r y f e e d b a c k a r e p r e s e n t e d , f r o m w h i c h it is a p p a r e n t t h a t r e a d i n g p e r f o r m a n c e of m a l e f o r m e r s t u t t e r e r s differs from, t h a t of m a l e s w i t h n o r e p o r t e d h i s t o r y of s t u t t e r i n g . t h e c h e r r y s a y e r s m a r l u n d e x p e r i m e n t s i n t h e field of e x t e r n a l c o n t r o l s a n d s t u t t e r i n g a r e r e v i e w e d a n d s o m e r e s u l t s f r o m s o u t h a f r i c a n r e p l i c a t i o n of s o m e of t h e s e e x p e r i m e n t s w i t h a m a l e s t u t t e r e r a r e p r e s e n t e d . a t r a n s i s t o r m u l t i v i b r a t o r w i t h i n t e r e s t i n g r e s e a r c h a n d c l i n i c a l p o s s i b i l i t i e s is d e s c r i b e d . r e c e n t w o r k in b r i t a i n a n d c a n a d a is m e n t i o n e d a n d s o m e s u g g e s t i o n s for f u t u r e r e s e a r c h a r e m a d e . opsomming r e s u l t a t e v a n s u i d a f r i k a a n s e p r o e w e o p d i e g e b i e d v a n v e r t r a a g d e a k o e s t i e s e t e r u g v o e r i n g w o r d a a n g e b i e d , w a a r u i t b l y k d a t d a a r v e r s k i l l e in l e e s p r e s t a s i e b e s t a a n t u s s e n m a n l i k e g e w e s e h a k k e l a a r s e n m a n s m e t g e e n a a n g e m e l d e h a k k e l g e s k i e d e n i s . d i e c h e r r y s a y e r s m a r l u n d p r o e w e t e n o p s i g t e v a n e k s t e r n e k o n t r o l e s e n h a k k e l w o r d g e m e l d t e s a a m m e t n a v o r s i n g s g e g e w e n s u i t d i e h e r h a l i n g v a n s o m m i g e v a n h i e r d i e p r o e w e m e t ' n m a n l i k e h a k k e l a a r i n s u i d a f r i k a . ' n t r a n s i s t o r m u l t i v i b r a t o r m e t i n t e r e s s a n t e n a v o r s i n g s e n k l i n i e s e m o o n t l i k h e d e w o r d b e s k r y w e . o n l a n g s e w e r k i n b r i t t a n j e e n k a n a d a w o r d g e n o e m e n v o o r s t e l l e v i r t o e k o m s t i g e n a v o r s i n g w o r d v o o r g e l e . acknowledgements many persons and institutions made the present paper possible. whilst expressing his thanks to them, the author emphasizes that the views stated are his own and do not represent those of any person or institution mentioned below: the national council for social research of the department of education, arts and science gave financial assistance. dr. s. biesheuvel, former director of the national institute for personnel research and his successor, dr. d. j. gouws made apparatus and facilities available. the study was conducted for degree purpose at the university of pretoria under the joint guidance of prof. d. j. swiegers and dr. h. reuning. many members of the nipr assisted at various stages: mostly as patient and forebearing subjects. mr. d. r. de wet assisted in the design of the equipment, miss s. kaan and messrs. α. ο. h. roberts and j. shepherd advised on and assisted with statistical processing. the daf apparatus was modified by mr. t. dicker to the design of mr. j. kidd, both of the csir central workshops. mr. w. keet of the csir acoustic research laboratory assisted with initial daf experiments and dr. j. f. burger of the same laboratory designed and constructed the proto-type multi-vibrator. mr. r. serdyn of the csir took the photographs and miss e. woudstra of the nipr prepared the diagrams. professors e. pratt-yule, e. wild, c. danziger and r. albino and their colleagues and students made facilities available and co-operated in the experiments at the universities of cape town, rhodes (grahamstown) and natal (pietermaritzburg and durban). 1 journal of the south african logopedic society 13 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 9. b i b l i o g r a p h y 1. b l a c k , j . w . t h e effect of d e l a y e d s i d e t o n e u p o n v o c a l r a t e a n d i n t e n s i t y . j. s p e e c h a n d h e a r i n g d i s o r d e r s , 16, 5 6 6 0 . 1951. 2. b l a c k , j . w . t h e p e r s i s t e n c e of t h e e f f e c t s of d e l a y e d s i d e t o n e . j. s p e e c h a n d h e a r i n g d i s o r d e r s , 20, 6 5 6 8 . , 1955. 3. b o h r , j . w . f . a t e c h n i c a l n o t e o n t h e d e s i g n a n d c o n s t r u c t i o n of a n a p p a r a t u s for p r o d u c i n g d e l a y e d a u d i t o r y f e e d b a c k . p a p e r p r e s e n t e d t o t h e x i h t h a n n u a l c o n g r e s s , s o u t h a f r i c a n p s y c h o l o g i c a l a s s o c i a t i o n , s t e l l e n b o s c h , 1961, 8p. 4 . b o h r , j . w . f . v e r t r a a g d e a k o e s t i e s e t e r u g v o e r i n g b y p e r s o n e m e t e n s o n d e r s p r a a k g e b r e k e . referaat gelewer voor d e p a r t e m e n t e l e s i e l k u n d i g e s , s k o o l k l i n i e k , t r a n s v a a l s e o n d e r w y s d e p a r t e m e n t , pretoria, a p r i l 1963. 15p. 5. c h e r r y , c., s a y e r s , b. m c a . & m a r l u n d , p a u l i n e . e x p e r i m e n t s u p o n t h e t o t a l i n h i b i t i o n of s t a m m e r i n g b y e x t e r n a l c o n t r o l a n d s o m e c l i n i c a l r e s u l t s . j. p s y c h o s o m . r e s . , 1956, 1, 2 2 3 2 4 6 ; r e p r i n t e d in e y s e n c k , h . j . ( e d i t o r ) . b e h a v i o u r t h e o r y a n d t h e n e u r o s e s . o x f o r d : p e r g a m o n p r e s s , i 9 6 0 , 4 4 1 4 5 6 . 6. f a i r b a n k s , g . & j a e g e r , r. a d e v i c e for c o n t i n u o u s l y v a r i a b l e t i m e d e l a y of h e a d s e t m o n i t o r i n g d u r i n g m a g n e t i c r e c o r d i n g of s p e e c h . j. s p e e c h a n d h e a r i n g d i s o r d e r s , 16, 162-164. 1951. 7. h a n l e y , c. n . & t i f f a n y , w . r. a n inv e s t i g a t i o n i n t o t h e u s e of e l e c t r o m e c h a n i c a l l y d e l a y e d s i d e t o n e i n a u d i t o r y t e s t i n g . j. s p e e c h a n d h e a r i n g d i s o r d e r s , 19, 3 6 7 3 7 4 . 1954. 8. j o h n s o n , w . , b r o w n , c. f., c u r t i s , j . f . , e d n e y , c. w . & k e a s t e r , j. s p e e c h h a n d i c a p p e d children, n e w y o r k : h a r p e r , p . 4 2 2 , 1948. 9. l a d e f o g e d , p . t h e p e r c e p t i o n of s p e e c h . proc. s y m p o s i u m o n m e c h a n i z a t i o n a n d t h o u g h t p r o c e s s e s , 3 2 0 3 3 3 , 1958. 10. l e e , b. s. s o m e e f f e c t s of s i d e t o n e d e l a y . j. a c o u s t . s o c . a m e r . , 22, 6 3 9 6 4 0 . 1950. 11. m a c l a r e n , j . t h e t r e a t m e n t of s t a m m e r i n g b y t h e c h e r r y s a y e r s m e t h o d . in e y s e n c k ( s e e 5. a b o v e ) , 4 4 1 4 5 6 . 12. m a r p l e , ν . b. & m o r r i l l , s. n . a d e v i c e for t h e p r o d u c t i o n of d e l a y e d s i d e t o n e . , j o i n t p r o j e c t , n m 0 0 1 0 6 4 . 0 1 . 0 8 , r e p o r t n o . 8 p e n s a c o l a , o h i o s t a t e u n i v e r s i t y . 13. p a r k e r , c. s. & c h r i s t o p h e r s o n , f. e l e c | ' t r o n i c a i d i n t h e t r e a t m e n t of s t a m m e r . m e d . e l e c t r o n . biol. e n g n g . , v o l . 1. n o . l . 1 2 1 1 2 5 . 1963. 14. tiffany, w . r., h a n l e y , c. n . & s u t h e r l a n d , l. c. a s i m p l e m e c h a n i c a l a d a p t e r for v a r i a b l e s i d e t o n e d e l a y . j. s p e e c h a n d h e a r i n g d i s o r d e r s , 115, 5 9 6 0 . 1954. 15. v a n r i p e r , c. s p e e c h c o r r e c t i o n princ i p l e s a n d m e t h o d s . n e w y o r k : p r e n t i c e h a l l , 1 6 3 -1 6 4 , 1939. 16. w a l t o n , d . & b l a c k , d . a. t h e a p p l i c a t i o n of l e a r n i n g t h e o r y t o t h e t r e a t m e n t of s t a m m e r i n g . j. p s y c h o s o m . r e s . 3, 170-179; 1 9 5 8 a l s o r e p r i n t e d in e y s e n c k , h . ( s e e 5 a b o v e ) , 123-134. 1 journal of the south african logopedic society august, 1963 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) knowledge and attitudes of teachers regarding the impact of classroom acoustics on speech perception and learning knowledge and attitudes of teachers regarding the impact of classroom acoustics on speech perception and learning lebogang ramma university of cape town abstract this study investigated the knowledge and attitude of primary school teachers regarding the impact of poor classroom acoustics on learners’ speech perception and learning in class. classrooms with excessive background noise and reflective surfaces could be a bar­ rier to learning, and it is important that teachers are aware of this. there is currently limited research data about teachers’ knowledge regarding the topic of classroom acoustics. seventy teachers from three johannesburg primary schools participated in this study. a sur­ vey by way of structured self-administered questionnaire was the primary data collection method. the findings of this study showed that most of the participants in this study did not have adequate knowledge of classroom acoustics. most of the participants were also un­ aware of the impact that classrooms with poor acoustic environments can have on speech perception and learning. these results are discussed in relation to the practical implication of empowering teachers to manage the acoustic environment of their classrooms, limi­ tations of the study as well as implications for future research. k eyw ord s: classroom acoustics; background noise, reverberation, teacher's voice, s chool classrooms with poor acoustic environment (i.e. excessive background noise levels and too much rever­ beration) are not suitable for educational activities that requires listening (anderson, 2004; crandell & smaldino, 2000; dockrell, shield & rigby, 2004). excessive background noise in a classroom makes the communication between the teacher and i learners difficult because it can cover up part of the verbal mes ✓ ' i -ysage conveyed by the teacher to learners and vice versa (crandell & smaldino, 1994). similarly, too many reflective surfaces in the classroom (hence too much reverberation) can cause speech i sounds communicated by the teacher to the learners to bounce around the room, leading |to blurring of the final speech signal heard by the learners (guckelberger, 2003). this will make it hard for some learners to hear and understand what is being communicated to them due to poor speech perception. speech perception in this study refers to the process of hearing and un­ derstanding speech signals during normal human communication (massaro, 2001). poor classroom acoustics as a barrier to learning primary school children are more vulnerable to the effects of extraneous noise sources (shield & dockrell, 2004). therefore, classrooms with too much background noise and reverberation can have a negative impact on learners' speech perception, and i consequently their learning (anderson, 2004). several studies that investigated the impact of too much background noise in the classroom on learners’ ability to learn have shown marked nega­ tive effects of noise on learners’ reading and numeracy skills, as well as on overall academic performance (lundquist, holmberg & landstrom, 2000; mackenzie, 2000; maxwell & evans, 2000; shield, & dockrell, asker & tachmatzidis, 2002). meaningful irrelevant speech, such as noise from people speaking in an adja­ cent classroom, has been shown to affect speech understanding, and or learning, to a higher degree than other types of noises (boman, enmarker & hygge, 2005). poor acoustics in the class­ room have also been shown to have the following effects on learners: high levels of listening fatigue (hicks & tharpe, 2002); poor attentive behaviour, especially when the subject matter is complex or unfamiliar (anderson, 2004); degradation of the learners’ memory capabilities (boman etal., 2005). furthermore, apart from being a barrier to the learning process, noise can also be perceived as a nuisance by children. young children exposed to high levels of noise in their environments report high levels of annoyance with the specific sounds that they are exposed to (cohen, evans, krantz, stokols & kelly, 1981). that is, young children are sensitive to noises in their environment and can contact: dr lebogang ramma division of communication sciences and disorders university of cape town groote schuur hospital, f45 old main building observa­ tory, 7925 cape town, south africa email: lebogang.ramma@uct.ac.za the south african journal of communication disorders, vol 56, 2009 35 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:lebogang.ramma@uct.ac.za discriminate between those noise sources that annoy them and the ones that do not annoy them (dockrell & shield, 2004; manlove, frank & vernon-feagans, 2001). classrooms with poor acoustic environments impact negatively on the educational achievement and performance of all learners in the class (knecht, nelson & whitelaw, 2002), however there are certain categories of children who are at a higher risk for the negative effects of too much background noise in the classroom. these include young children at various stages of language devel­ opment, learners with home languages different from the lan­ guage of learning, as well as those with hearing loss (crandell & smaldino, 2000). a study by broom (2004) revealed that most south african primary school classrooms have learners who are learning in a language that is not necessarily their home lan­ guage. this means that most south african primary school learn­ ers belong to a category of learners who can be considered to be at a higher risk of the negative effects of poor classroom acous­ tics. there has not yet been a detailed national study looking at the status of the acoustic environment’of classrooms in south african schools. a pilot study conducted in 2006 involving measurement of background noise levels in 15 classrooms from 15 primary schools in the johannesburg metropolitan area showed that the majority of these classrooms had background noise levels that exceeded both the south african national standards (sans) and table 1: background noise levels and reverberation times (rt) measured in 15 johannesburg primary schools lebogang ramma world health organization’s (who) standards of 35-40 dba and 0.6 seconds for maximum background noise levels and maxi­ mum reverberation times respectively, recommended for an un­ occupied classroom (ramma, 2007). typical strategies for addressing poor classroom acoustics the practice in developed countries such as the united states of america for dealing with poor acoustic environments in a class­ room involve the use of services of professionals such as acousti­ cal consultants and educational audiologists. typical interven­ tions include physical modification to the classroom space to enhance its acoustic characteristics, and / or installation of hear­ ing-assistive technology to overcome the problem of noise in the classroom (american speech-language hearing association (asha), 2005). such intervention measures may not be feasible in a south african context due to the scarcity of skilled personnel such as acoustical consultants and audiologists required to pro­ vide these services, and budget constraints to pay for modifica­ tions and assistive technology that may be required in these classrooms. however, one way to address the problem of poor classroom acoustics in south african primary schools could be to work with teachers and to empower them to intervene when their class­ rooms are not acoustically appropriate. when given the right strategies, teachers responsible for day-to-day management of the classroom environment can play a crucial role in managing background noise levels and amount of reverberation in their classrooms. examples of simple and yet effective strategies that can be shared with teachers include: closing doors or windows (especially those facing noise sources such as traf­ fic noise from busy streets), padding learners’ chairs with old tennis balls (de villiers, 2003) or even removing most of the reflective materials (e.g. mirrors) from the walls to lower the amount of reverberation. other strategies may involve plan­ ning of lessons in a way that takes into account noise levels during the course of the day, with subjects that require more reading being taught during less noisy times than other sub­ jects (boman et al., 2005). location schools unoccupied background noise level unoccupied rt60 value suburban s1 39.9 0.87 s2 40.52 0.91 s3 41.85 0.86 s4 42.81 0.79 s5 45.2 0.98 s6 45.54 0.59 township s1 40.5 0.78 s2 41.04 0.88 s3 45.08 0.81 s4 52.52 0.66 school close to a noise source s1 40.94 0.72 s2 43.06 0.71 s3 48.02 0.95 s4 51.81 0.72 s5 62.5 0.51 36 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) knowledge and attitudes of teachers regarding the impact of classroom acoustics on speech perception and learning according to asha (2005), the negative effect of classrooms with poor acoustic environments is not self-evident to teachers. unless this information is brought to their attention, teachers do not usually treat poor classroom acoustics as barriers to learning (asha, 2005). the purpose of this study therefore was to explore the knowledge and attitudes of school teachers in selected south african primary schools regarding the impact of too much back­ ground noise and reverberation in the class room on learners’ speech perception and learning. for the purposes of this study, the criteria for adequate knowl­ edge would be met if the respondents indicated that they had some type of input about the subject matter (i.e. impact of poor classroom acoustics on speech perception), and if their responses in the questionnaire showed that they were aware of the impact that too much background noise and reverberation in the class­ room (i.e. poor classroom acoustics) or poor quality of the teacher’s voice would have on speech perception and the learning process . that is, a declarative knowledge about these topics at a relational level of understanding when using the solo taxonomy (biggs & tang, 2007). according to biggs and tang (2007), declarative knowledge refers to “knowing about things, or knowing what,” while a relational level of understanding requires one to, among other things, ‘relate’ things or concepts (p.79). in this study, teachers were required to relate impact of noise to speech perception and learning. m e th o d aim to explore the knowledge and attitude of teachers in selected south african primary schools regarding the impact of poor class­ room acoustics on learners’ speech perception and learning. objectives the objectives of this study were therefore as follows: ' [ j o determine teachersj knowledge of classroom acoustics (background noise and reverberation) and its impact on speech perception and learning in class. [ j o determine teachers' knowledge about the level of teacher’s voice during classroom communication and its impact on speech perception and learning. > [ j o ascertain teachers’ opinions and attitudes regarding class­ room acoustics, the level of teachers voice and the impact of these factors on speech perception and learning. [ j o identify strategies used by teachers to enhance speech per­ ception and audibility in class. [ j o determine whether there is any association between teach­ ing experience or type of qualification and knowledge of classroom acoustics. research design to meet the aims of this study a descriptive cross-sectional sur­ vey research design (bowling, 2009) using quantitative data collec­ tion methods was used. participants to qualify as a participant in the research, subjects had to be currently practising in the teaching profession at primary school level. therefore, participants included primary school principals, deputy-principals and classroom teachers. school principals and deputy principals at all of the three participating schools were also included as participants in this study because they are also directly involved in day-to-day classroom teaching. sampling purposive sampling was used to select participating schools. schools were selected such that one school was from a quiet jo­ hannesburg suburb, the other school was from a major johannes­ burg township and the last school was located in a johannesburg inner-city area (close to most noisy areas). at each school, partici­ pants were recruited to participate in this study by way of conven­ ience sampling. all teachers that were present at each of the schools on the day of the survey were invited to participate in this study (and all those who were recruited agreed to participate). a total of 70 teachers (including principals and deputy principals) volunteered to participate in this study. fifty-four of the participants were female and sixteen were male. forty-four had more than 10 years’ teaching experience and twenty-six had less than 10 years teaching experience. twenty-three of the participants had a four year university degree in education or higher while the remaining forty-seven had a diploma in education or equivalent. all of the participants reported using english as the primary medium of in­ struction in their classes. data collection procedure permission was first requested from gauteng education depart­ ment to conduct the study. this project was also approved by the university of the witwatersrand human research ethics committee (non-medical) (protocol number h070205). once permission and ethical clearance were granted, participating schools and partici­ pants in this study were selected as described above. school princi­ pals were contacted by telephone to request their permission and consent to participate in this study. if they gave permission, an appointment was made at a time convenient for the principal and the entire staff to go and administer the survey questionnaire. at all three schools, the survey was conducted either during the staff lunch break or at the beginning of the weekly staff meeting to avoid disrupting teaching activities. each participant was given an information sheet explaining the aims of the study and a consent form to indicate their willingness (or lack of) to take part in the study. after the aim of the study was explained to participants and consent forms were signed, each participant was given the survey questionnaire to complete. the researcher was physically present to answer any questions that arose during the completion of the questionnaire. questionnaires were collected immediately upon completion, and participants were thanked for their participation. the south african journal of communication disorders, vol 56, 2009 37 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) data collection tool a specially constructed questionnaire developed by the re­ searcher was used to gather information for this study. the ques­ tionnaire was anonymous and self-administered. it comprised mostly close-ended questions, and contained the following four sections (see appendix): [] section a: biographical information; g section b: specific knowledge on classroom acoustics; [] section c: opinion and attitude of participants regard­ ing classroom acoustics and its impact on classroom learning; and q section d: strategies used to enhance audibility and speech perception in the classroom. pilotstudy the questionnaire was piloted with 10 participants with similar characteristics to the intended study sample to establish reliabil­ ity and content validity (maxwell & satake, 2006) as well as to obtain representative and unbiased feedback about the ques­ tionnaire. the results of pilot testing revealed that teachers were not familiar with most of the technical terms or phrases that are commonly used when discussing room acoustics. the most prob­ lematic words or phrases were ‘reverberation’, ‘speech percep­ tion’ and ‘classroom acoustics.’ these words (and or phrases) were therefore replaced with more familiar words: reverberation was replaced with ‘too many reflective surfaces in the class­ room’; speech perception was replaced with ‘hear and under­ stand speech’ and classroom acoustics was broken into ‘background noise’ and ‘too many reflective surfaces.’ data analysis the results of the questionnaire were analysed using a statisti­ cal software package (statistica-9) to establish patterns of re­ sponses between different variables in this study. the statistical test chosen for this purpose was the pearson chi-square (x2). this test is commonly used to compare the observed results with results that are expected based on a certain assumption or ac­ cording to specific hypotheses (maxwell & satake, 2006). for instance, in this study it was expected that newly qualified teach­ ers (e.g. <10 years experience) and teachers with at least a four year university degree in education will be more likely to report knowledge about classroom acoustics than teachers who hold diplomas in education or teachers who have been teaching longer (> 10 years experience). results this section will present the findings of the study as follows: (1) teachers self-reported knowledge of classroom acoustics; (2) attitude regarding classroom acoustics and the level of teacher’s voice in the class and the impact of these factors on speech lebogang ramma perception in class; (3) strategies used by teachers to enhance speech perception in class, and (4) association between teach­ ing experience, type of qualification and knowledge of classroom acoustics. seventy teachers from three primary schools completed the survey questionnaire for this study. however, eleven of the sev­ enty questionnaires (16%) had to be discarded because the par­ ticipants left an entire section of the questionnaire blank. only fifty-nine (84%) questionnaires were used in the analysis, there­ fore the findings reported in the following sections will be based only on responses from these questionnaires (n=59). 1) knowledge regarding classroom acoustics twenty-one (36%) of the participants reported that their classes were next to a noise source. traffic was the most fre­ quently cited source of noise, followed by noise from other learn­ ers in the playground. participants were then asked whether they had any formal input on classroom acoustics while they were training to become teachers and / or while working as teachers. twenty three (39%) of the participants reported that they had some type of input on classroom acoustics during their training as teachers, and eight (14%) said they had received some input about classroom noise via in-service training workshops. participants were then asked to rate their knowledge regarding the following three factors: too much background noise, too much reverberation in the classroom and level of teacher’s voice and furthermore, the impact of these three factors on speech perception (hearing and understanding speech) and learning in the classroom. a five-point likert scale was used with the follow­ ing categories: limited, satisfactory, average, good and very good. most teachers (fifty-one; 86%) rated themselves as having aver­ age to very good knowledge about the level of the teacher’s voice and its impact on learning in the classroom (see figure 1). forty-three (75%) of the respondents felt they had average or good knowledge about background noise and its impact on teachers' self-rating of their own knowledge 0 0 l im ite d s a tis fa c to ry a v e ra g e g o o d v e r y g o o d rating o f own knowledge figure 1: teachers' self-rating of their own knowledge regarding classroom acoustics 38 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) knowledge and attitudes of teachers regarding the impact of classroom acoustics on speech perception and learning classroom learning. none of the respondents reported very good knowledge of background noise and its impact on learning. thirty-six teachers (62%) rated their knowledge of the impact of having too many reflective surfaces in the classroom on learning as average or good. none of the respondents rated their knowl­ edge here as being very good. almost all of the respondents (with the exception of four) felt that teachers need some input on classroom acoustics and other factors that influence or affect speech perception in the classroom. seventeen (31%) of those who responded felt that this input should be given during teacher training, while sixteen (29%) felt that this should be given both during teacher training and as part of in-service train­ ing. 2) attitude regarding classroom acoustics and teacher’s voice and its impact on speech perception and learning most of the respondents in the survey (thirty-eight; 64%) were of the opinion that the teacher can play an important role in con­ trolling factors that can impact on speech perception and learn­ ing in the classroom (e.g. background noise). forty-four (75%) of the teachers who completed the questionnaire reported that they were satisfied with their classroom environment in terms of facili­ tating adequate speech perception by learners in the classroom. an overwhelming majority (87%) of the respondents agreed with the statement that if learners’ speech perception is compro­ mised due to poor acoustics in the classroom then overall aca­ demic achievement will be negatively impacted. however, when respondents were asked to rate the impact that too much back­ ground noise, too much reverberation in the classroom, and low level of the teacher’s voice may have on speech understanding l and learning in the classroom, most were of the opinion that / i these factors will only have an average (even little or no) impact on classroom learning (figure 2). j impact of classroom acoustics/teacher's voice on classroom learning 35 n o im p a ct little im pact a w r a g e im pa ct m ore im p a ct m ost im pact rating of impact figure 2: teachers’ views of impact of background noise, rever­ beration & level of the teacher’s voice on speech perception in the classroom. 3) strategies used b y teachers to enhance speech perception and understanding in class twenty-eight (47%) of the respondents reported that they often needed to raise their voices when talking to the learners during normal teaching activities. only 19 (32%) reported that they con­ sidered the acoustic environment of their classroom when plan­ ning or preparing for their daily lessons. the most common strategies used by respondents in this survey to deal with noisy classrooms were; "to speak louder, more clearly and more slowly". some respondents reported varying their voices according to the noise conditions, while some addressed a noisy classroom environ­ ment by organising the learners’ seating arrangement in the class­ room to favour learners with limited english language communica­ tion skills. one respondent reported playing classical music while students did written work as a strategy to help them concentrate better. 4) association between teaching experience, type of qualification and knowledge of classroom acoustics tables la and l b show the results of a pearson chi-square analy­ sis regarding an association between the following variables: 1 -teaching experience and knowledge of classroom acoustics (table 2a). table 2a: association between teaching experience and knowledge of classroom acoustics knows about classroom acoustics row totals experience (no. of yrs teaching) yes no <10 9 11 20 >10 27 12 39 column totals 36 23 59 pearson chi-square x 2 = 2.150096, df= 1, p= 0.14256 the south african journal of communication disorders, vol 56, 2009 39 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 2 -type of qualification and knowledge of classroom acoustics (table 2b). table 2b: association between type of qualification and knowl­ edge of classroom acoustics lebogang ramma knowsledge about class­ room acoustics row totals type of qualifica­ tion yes no diploma 17 22 39 4 year degree or higher 7 13 20 column totals 24 35 59 pearson chi square x 2 = 0.9111253, df= 1, p= 0.33982 the results of this study showed that there was no association between teaching experience and the probability of being taught about classroom acoustics while training or while working (p = 0.05). there was also no association between the type of qualifi­ cation and reporting being taught about classroom acoustics while training or after qualifying as a teacher (p = 0.05). discussion school classrooms are the environments in which most of the learning activities at school occur. the quality of what the learn­ ers are expected to learn is therefore partially dependent on the environment in which they learn (i.e. the classroom environment). it is therefore important that the classroom environment should be free of extraneous distractions (e.g. too much background noise) that can interfere with the learning process. despite the fact that the suitability of learning spaces is planned by architec­ tural designers as early as the design of the school or classroom building (guckelberger, 2003), teachers are ultimately the people with more control of the daily management of that space. this was a view that was also held by the majority of the participants (64%) in this study it was encouraging to see that some of the participants had received some input on classroom acoustics either during train­ ing (36%) or after their training as teachers (12%). however, over­ all the results of this study showed that the majority of partici­ pants did not have adequate knowledge about the topic of class­ room acoustics and the impact that a classroom with a poor acoustic environment could have on the learning process. these findings are consistent with those of other studies, such as the one by dockrell et al. (2004), in which it was found that despite the fact that noise is a serious problem in urban schools in the united kingdom, teachers show little awareness of the impor­ tance of noise levels in their classrooms and of the need to moni­ tor noise for particular tasks and teaching contexts. participants in this study generally rated their knowledge of classroom acoustics and the importance of voice in classroom learning as high (average or better). however, it was evident from responses in later parts of the questionnaire that despite this high self-rated knowledge, most participants did not have ade­ quate knowledge of the impact that a sub-optimal classroom acoustic environment may have on the learners’ speech percep­ tion in class. for instance, almost half (44%) of the participants were of the opinion that excessive background noise in the class will only have an average impact on speech understanding in the classroom while a third (33%) of the respondents were of the opinion that deterioration in the teacher’s voice will have an aver­ age impact on speech understanding. one explanation for this observed high self-rating could be the fact that these topics, es­ pecially background noise and teacher’s voice are generally intui­ tive phrases to an average teacher. therefore, teachers may be familiar with the phrase or words because they are part of every­ day language in a school setting. however, that does not neces­ sarily mean that they are fully aware of the impact that these factors may have on speech perception and consequently learn­ ing in the classroom. participants also tended to assume that background noise had a greater negative impact on speech perception and learning than the teacher’s voice .this is despite the fact that the negative effect that background noise has in a classroom situation is due to the fact that it covers up part of the teacher’s voice and hence degrades the quality of the message communicated to the learn­ ers (crandell & smaldino, 1994). the teacher’s voice is therefore the most important variable in a classroom situation. any situa­ tion or event in the classroom that compromises the teacher’s voice is bound to have the most impact in the learning process. it was therefore expected that participants would rate the impact of the teacher’s voice on the learning process higher than any other factors or variable. surprisingly, a third (33%) of the teachers who participated in this study were of the opinion that the level of the teacher’s voice is less important than too much background in terms of impact on speech perception and learning in the class­ room. most respondents (75%) reported that they were satisfied, with / the suitability of their classroom environment as "a learning envi­ ronment. this is consistent with the findings of another study (manlove et al., 2001), in which teachers tended to be more ac-/ commodating of noisy classrooms and often dismissed excessive background interference as the “price of doing business.” this accommodating attitude is likely to be prevalent if the interfering 40 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) knowledge and attitudes of teachers regarding the impact of classroom acoustics on speech perception and learning noise is from learners on the school property (manlove et al., 2001) as opposed to noise sources external to the school envi­ ronment (e.g. traffic noise), even though meaningless, irrelevant speech (noise from an adjacent class or other learners in the playground) has been shown to have the greater effect on inter­ fering with speech perception than other types of noise (boman, enmarker & hygge, 2005). almost half of the respondents said that they often need to raise their voices above their normal talking levels when commu­ nicating with learners. this need to raise their voices could be an indication of excessive background noise levels in the classroom. doyle & dye (2003) advised that the best approach to dealing with interfering background noise in the classroom is to be aware of sources of noise (both extraneous and internal) and to start planning teaching activities with this in mind rather than simply talking louder. in the present study only 32% of respon­ dents said that they considered the acoustic environment of their classroom when planning their lessons. none mentioned any of the common strategies that involve physical modification of the classroom (e.g. carpeting the classroom floors, cushioning the legs of the learners’ chairs) as a strategy for enhancing the acoustics. implications of the study and future research this study showed that the majority of the teachers who took part in this study did not have adequate knowledge about poor classroom acoustics. teachers therefore need to be given more information on this and also to be trained to recognise the need for an intervention when working in classroom environments that are acoustically inappropriate. teachers also need to be trained on simple and yet effective)solutions to use when the classroom environment is not conducive to learning due to poor classroom /a co u s tic s . this should ide'ally be addressed in the curriculum during teacher training, asjwell as in refresher courses for later in-service training for teachers. the results of this study showed that there was no association between teaching experience or the type of qualification that the teacher holds and the likelihood of having received some | input on classroom acoustics. ■'this means that refresher courses should target all teachers who are currently working regardless of teaching experiences or the type of qualification they hold. while this study attempted to investigate key aspects of class­ room acoustics (e.g. background noise and reverberation), it was not possible to provide an in-depth investigation of this subject matter due to time and resource constraints. future studies should aim to explore the feasibility of training current teachers to manage the acoustic environment of the classroom to opti­ mise its use as a space for learning. limitations of the study since information for this study was obtained by using a ques­ tionnaire with predominantly close-ended questions, respon­ dents were limited on what they could say because they were not given the opportunity to elaborate on their responses. the ques­ tionnaire also contained many terms that were not necessarily familiar to the teachers. while an attempt was made to minimise the number of unfamiliar words during the piloting of the ques­ tionnaire, as well as during a briefing before completing it, some of the respondents may have found the questionnaire to be time consuming since they were dealing with a subject not necessarily familiar to them. lastly, this survey was conducted with teachers from only a three schools using non-random sampling and par­ ticipant selection methods. although an attempt was made to ensure that the schools selected were heterogeneous and repre­ sented diverse geographical areas, it is not possible to general­ ize the findings of this study to all teachers or schools in the johannesburg area or to other parts of the country. conclusion the results of this study showed that teachers who partici­ pated in this study did not have adequate knowledge about classroom acoustics. knowledge was especially lacking when it came to indicating how classroom environments with poor acoustics are likely to affect speech perception, and conse­ quently the learning process. given the linguistic diversity of most classrooms in south african primary schools, it means that most learners who have not mastered the language of learning are likely to be disadvantaged when the classroom environment is not acoustically suitable. this means that teachers need to be given the necessary input to manage the acoustic environment of their classrooms. different stakeholders, such as teachers, acoustics experts and educational audiologists should come together to address this issue. management of the acoustic envi­ ronment of the classroom should ideally also be addressed dur­ ing teacher training. for teachers who are currently working but do not have adequate knowledge about classroom acoustics and its impact on the learning process, refresher courses could be offered to equip them with strategies to better manage the acoustic environments of their classrooms. acknowledgement i thank the gauteng provincial department of education for granting me the permission to conduct this study. references asha (2005). guidelines for addressing acoustics in educa­ tional settings [guidelines]. available from www.asha.org/ policy. anderson, k. (2004). the problem of classroom acoustics: the typical classroom soundscape is a barrier to learning. semin hear, 25, 117-128. biggs, j.b. & tang, c. (2007). teaching for quality learning at university, (pp. 72-80). berkshire, uk: open university press. boman, e., enmarker, i. & hygge, s. (2005). strength of noise the south african journal of communication disorders, vol 56, 2009 41 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.asha.org/ effects on memory as a function of noise source and age. noise and health 7 (27): 11-26. bowling, a. (2009). research methods in health: investigating health and health services (pp. 185-235). new york, usa: open university press. broom, y. (2004). reading english in multilingual south african primary schools. international journal of bilingual education & bilingualism 7(6): 506-528. cohen, s., evans, g.w., krantz, d.s., stokols, d., & kelly, s. (1981). aircraft noise and children: longitudinal and cross sectional evidence on adaptation to noise and the effectiveness of noise abatement. j pers soc/psychol 40(2): 331-345. crandell, c.c. & smaldino, j j . (2000). room acoustics for listen­ ers with normal hearing and hearing impairment. in: m. valente, h. hosford-dunn & r. roeser (eds). audiology treat­ ment. (pp. 601-637) new york: thiem e,. crandell, c. & smaldino, j. (1994). the importance of room acoustics. in: r. tyler & d. schum (eds.). assistive listening device for the hearing impaired, (pp. 142-164) baltimore, md: williams & w ilkins.. de villiers, r. (2003). factors that influence the reception of spo­ ken language, in sound aspirations : a specialized and informa­ tive program for educators who work with learners with hearing loss in mainstream schools. tygerberg, south africa. carel du toit centre. unpublished. dockrell, j.e., shield, b.m. & rigby, k (2004). acoustic guidelines and teacher strategies for optimising learning conditions in classrooms for children with hearing problems. in: d.a. fabry, c. deconde & johnson, z. (eds), access: achieving clear com­ munication employing sound solutions-3003. proceedings of the first international fm conference, (pp. 217-227) cambrian printers ltd. great britain.. dockrell, j.e. & shield, b. 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(2000). noise sources and levels in uk schools. international symposium on noise control and acoustics for educational buildings. proceedings, turkish acoustical society, istanbul, may 2000: 97-106. manlove, e.e., frank, t. & vernon-feagans (2001). why should we care about noise in classrooms and child care settings? child & youth care forum, 30(1): 55-64. lebogang ramma massaro, d.w. (2001). speech perception. in n.m smelser & p.b. baltes (eds), international encyclopedia of social and behavioural sciences (pp. 14870-14875). amsterdam, the netherlands: elsevier. maxwell, l. & evans, g. (2000). the effects of noise on pre­ school childrens’ pre-reading skills. journal of environmental psychology, 20: 91-97. maxwell, l.d.& satake, e. (2006). research and statistical meth­ ods in communication sciences and disorders (pp. 279-313). boston, usa: thomson/delmar learning. ramma, l. (2007). rethinking our classrooms: assessment of background noise levels and reverberation in schools. educa­ tion as change, 11(2): 115-130. shield, b. & dockrell, j.e. (2004). the effects of noise on chil­ dren at school: a review. building acoustics 10: 97-116. shield, b.m., dockrell, j.e., asker, r., & tachmatzidis, i. (2002). effects of noise on attainments and cognitive performance of primary school children. report for department of health, march 2002. 42 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) knowledge and attitudes of teachers regarding the impact of classroom acoustics on speech perception and learning appendix speech perception survey questionnaire directions for completing the questionnaire: 1. please use ink pen 2. please mark with an “x” to indicate your selections a. demographic information 1. gender i i male i ifemale 2. number o f years teaching □ 0 1 q 2 5 0 6 1 0 o > 1 0 3. highest education qualification □ d i p . prim. ed. d b . prim ed. d b a ed. d m a . ed. d o th erj____________ 4. where did you qualify? specify training institution: ________________________ 5. current post at the school i iclassroom teacher | |deputy principal i iprincipal 6. grade currently teaching (please select one) □ o m i \ j 2 d 3 d 4 d 5 d 6 d 7 d 8 h |9 d l o i 7. grades taught in the past 5 years (select a maximum of 3) □ o m i \ b 2 d 3 d 4 d 5 d 6 d 7 d 8 d 9 d l o i l 8. current number o f learners in your class □ < 2 0 □ 2 0 2 5 0 2 5 3 0 d 3 0 -3 5 d 3 5 -4 0 d 4 0 -4 5 d > 4 5 9. primary language used as a medium o f instruction in class (please select 1) i lenglish i lisizulu i isesotho ^ a frik a a n s i lisixhosa i i o th e r______________ 10. number o f learners in your classroom who speak english as their first/home language (estim ate)________________ 11. is your school/classroom located close to a noise source (e.g. freeway, busy street etc.)? □ y e s d no 12. if yes above, please specify the nature of noise source: ___________________ the south african journal of communication disorders, vol 56, 2009 43 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) lebogang ramma 13.does your classroom have the following: a. double wall construction b. acoustical ceiling tile in hallways c. fully carpeted floor d. brick wall e. posters on the walls f. curtains/blinds in all windows g. concrete floors h. ceramic tiles on the floor i. ceramic tiles on the walls j. vinyl tiles on the floor yes no not sure yes no b. knowledge on speech perception and classroom acoustics 1. w hile you were training as a teacher, did your training curriculum include: a. background noise and its impact on learning b. reflective surface in class and their impact on learning c. teaching in a multi-language context d. optimizing speech understanding b y pupils in the classroom e. vocal hygiene and voice projection 2. since you started working as a teacher, have you had additional continuing education training on: yes no a. background noise and its impact on learning b. reflective surfaces in class and their impact on learning c. teaching in a multi-language context d. optimizing speech understanding by pupils in the classroom e. vocal hygiene and voice projection 3. are you aware o f any legislation, national education department policy or national standard that deals with any o f the following? yes no a. learner to teacher ratio in the classroom □ □ if yes, please specify: b. maximum background noise in the classroom if yes, please specify: □ □ c. maximum reverberation time in the classroom if yes, please specify: □ □ d. l anguage o f instruction in the classroom i f y es, p lea se sp ecify: □ □ 44 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) h ow would you rate your knowledge o f the follow ing factors and their impact on speech understanding and learning in the classroom: a. background noise ^ l im it e d □ s a tisfa c to r y | [average | [good | |very good b. reverberant classroom □ l im ite d □ s a tisfa c to r y | [average | [good | [very good c. signal to noise ratio □ l im ite d □ s a tisfa c to r y | [average | [good | |very good d. listening distance □ l im ite d l~~lsatisfactory □ [a v era g e i igood i ivery good e . hearing ability o f individual learners □ l im ite d □ s a tisfa c to r y | [average | [good | [very good f. linguistic experience o f the learners □ l im ite d ^ s a tis fa c to r y □ average □ g o o d | [very good g. leve 1 o f te acher ’ s voice □ l im ite d □ s a tisfa c to r y | [average | [good | |very good h. too many reflective surfaces in the classroom □ l im ite d □ s a tisfa cto ry | [average | [good | [very good do you ihink teachers need specific training on the above m entioned factors that influence/affect speech perception in class? yes no knowledge and attitudes of teachers regarding the impact of classroom acoustics on speech perception and learning □ □ i f you answered y e s in 6 above, when should this training occur? y e s n o a. during teacher training in teacher training colleges b. in service training as continuing education c. both (during training and as an in-service training) □ □ □ □ □ □ the south african journal of communication disorders, vol 56, 2009 45 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) lebogang ramma c. opinion regarding classroom acoustics and its im pact on speech understanding and learning 1. are you satisfied with your classroom environment as far as facilitating learners’ ability to hear and understand speech? yes no □ □ 2. i f no, please explain (use back page i f you need more space) 3. in your opinion who has the greatest control on the afore mentioned factors that influence hearing and speech understanding in the classroom? (please do not select more than 2 choices) i i classroom/school designers and planners i i school administrators (e.g. principal) i i classroom teacher i i national department o f education 4. rate the follow ing factors on how much impact they w ill have on speech understanding and learning in the class room? a. level o f the teacher’s noise i |n o impact i i little impact □ average impact i i more impact i |most impact b.too many reflective surfaces in the classroom i ino impact i ilittle impact i i average impact i |more impact | |most impact c. background in the classroom i ino impact i ilittle impact □ a v e r a g e impact i |more impact | |most impact d.hearing ability o f the pupils in classroom i |no impact i ilittle impact i i average impact i |more impact | |most impact e. reverberation in the classroom □ n o impact i ilittle impact q average impact i i more impact | |most impact f. linguistic experience o f the learners □ n o impact □ l it t le impact i i average impact i |more impact | |most impact g. listening distance □ n o impact □ l it t le impact i laverage impact □ m o r e impact □ m o s t impact 46 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) knowledge and attitudes of teachers regarding the impact of classroom acoustics on speech perception and learning 5. in your opinion, poor hearing and speech understanding in class w ill lead to: a gree d isagree n ot sure a. poor reading/spelling skills □ □ □ b. poor mathematics and science skills n □ □ c. behavior problems n □ □ d. attention and concentration problems □ □ □ e. poor academic achievement □ □ □ 6. in your opinion, what acoustic features in your specific classroom impact negatively on speech understanding? please list as many as you can: d.strategies to enhance hearing and understanding speech as well as audibility in the classroom 1. do you need to raise your voice when talking to your students during normal teaching activities? □ yes d n o 2. do you teach with: y e s n o a. d oor open n n b. w indows open □ □ c. fan on ' □ □ 3. do you consider the acoustic environment o f your classroom when you plan and prepare for your lesson? □ yes d n o 4. do you have learners with special listening needs (e.g. hearing impairment etc.) in your classroom? □ yes d n o 5. list some o f the things that you do or have done to improve speech understanding in class. list: 6. i f you have concerns about the status o f your classroom acoustics, what should you do to address that? list: 7. “ the south african journal of communication disorders, vol 56, 2009 47 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) journal of the south african logopedic society september e d i t o r i a l in this issue an attempt has been made to cover some of the so-called "physical" types of speech defect. greater emphasis is being placed on a wholistic approach to these problems, where the individual is treated as a whole and all his needs, not merely his handicap, are taken into account. it is generally considered that, where doctors and medical auxiliaries work together as a team, a fuller picture of the individual's needs is obtained, and a more comprehensive therapy programme can be planned. drs. jacobson and dreyer in their article on cleft palate have stressed the need for teamwork in this field, while mrs. vorwerg has shown how it is being employed in cenles for the cerebral palsied throughout the world. mrs. bauman, too, shows the need for considering the patient's psychological reactions to his handicap, as well as the actual teaching of speech and voice to the laryngectomee. this edition therefore, indicates the need for the speech therapist to relate her work to that of other workers in the field of rehabilitation. protefl holdings limited hearing aid division 201 philadelphia corner — jeppe & von weilligh streets p.o. box 7793 johannesburg phone 22-0511 distributors and stockists of: peters clinical and diagnostic audiometers multitone telesonic induction loop system (for complete freedom of movement for all pupils) multitone individual auditory trainers sonotone — multitone — oticon hearing aids conventional and spectacle — air and bone conduction ethically prescribed and fitted. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d c society projective interpretation of intelligence tests y. a. lejeune, ph.d. psychologist, johannesburg child guidance clinic. intelligence test results given in the form of iq· only a r e often very misleading, particularly where the subject is a deviate one, a s is the c a s e with most children seen at child guidance, or speech clinics. in all c a s e s a qualitative report is n e c e s s a r y , dealing with the subject's attitudes to ihe test situation and to the examiner, in order to determine whether the i.q. is a valid one or n o t ; a n d in addition a good test report must include some assessment of the subject's personality. this is particularly important where it is not possible to give a battery of personality tests a s an aid to diagnosis, a n d for this reason projective interpretation of intelligence test responses is useful, b e c a u s e it can throw light on aspects of personality which may not b e revealed in other diagnostic interviews. a standard intelligence test differs from a true projective test mainly in the d e g r e e of structuring of the stimuli presented to the subject. the questions a r e framed in such a w a y that there is—or should b e — v e r y little ambiguity, a n d in theory the questions should h a v e exactly the s a m e meaning for all subjects. in practice, however, there is a wide variation in the amount of ambiguity present in the test stimuli, a n d in many sub-test items there is ample opportunity for the subject to interpret the meaning of the stimulus in terms of his own personality drives. as a general rule, the more neurotic the subject, the more likely he is to produce these projective responses. some e x a m p l e s of responses to the s.a. individual s c a l e of intelligence m a y illustrate this point. leven a fairly structured test, " a r e you a little1 girl/or a little b o y ? " m a y produce a response which is emotionally determined. a response of "no, i'm b i g " is often related to feeling of insecurity, a n d frequently a girl m a y insist that she is a boy, even though she knows quite well that she is not. less often a boy says that he is a girl, b e c a u s e of a fear of his own masculinity. th ere is another group of items in the individual s c a l e , where the 1 questions a r e less structured, but which produce deviate responses in the less adjusted c a s e s . i would include in this category the comprehension tests, which usually produce a standard success or failure, but which m a y also reveal attitudes of dependence. or withdrawal. a very dependent child may preface his replies with "ask my mommy," a n d in one c a s e of a n overprotected child with hypochondriacal symptoms, the answer to " w h a t should you do b e fore beginning something difficult?" w a s " r e s t . " timid, over-anxious children, or ihose with strong guilt feelings, tend to produce response which stress the d a n g e r s of the outside world, a n d they will do this even when the test questions a r e moderately structured, e.g., "a snaxe, a cow a n d a bird a r e alike b e c a u s e they c a n all hurt you;" or, in the sentence-making test, "a boy swam in the river a n d cut himself on a stone a n d was drowned," instead of the more usual "a boy threw a stone in the river." distortions resulting from timidity may also app e a r in the memories of the reading p a s s a g e , if the subject " r e c a l l s " death or injury. sibling rivalry or interest in the birth of a new 'baby m a y also b e shown in these tests, e.g., in one c a s e of this type the s u b j e c t ' s responses to the differences test were in terms of origin—' a stone comes from the ground, and a n e g g from a hen, milk comes from a cow and water from a t a p " ; a n d this w a s followed b y what a p p e a r e d to be a birth-interest response on the similarities tesi—"a dog a n d a horse a r e the s a m e b e c a u s e they've both got big tummies." in addition to these test items, there a r e three sub-items on the individual s c a l e where the stimuli a r e so little structured that they might almost be thought of a s projective items. the first of these is the picture interpretation test occurring at y e a r 1 3 . the pictures themselves a r e not a s a mb ig uous a s those of a thematic apperception test, a n d the emotions depicted a r e fairly c l e a r ; but the c a u s e of the emotions is not clear, a n d for this reason the interpretations given m a y b e very revealing about the subject's anxieties or wishes. references to food deprivation, or quarrelling between the parents—"the father's left them, a n d they have nobody to look after t h e m " ^ do not necessarily reflect the real home situation, but these responses do indicate the n a t u r e of the child's phantasies and sources' of anxiety. another test of this type is the word a s s o ciation test. for the most part ihe normal child will give words which a r e inspired b y what he s e e s around him—"pencil, pen, block, e t c . " — b u t the more disturbed subject is likely to produce responses which a r e a s s o c i a t e d r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 j o u r n a l o f t h e south a f r i c a n l o g o p e d i c society may with p h a n t a s y . o n e girl sex-deliquent produced 35 b o y s ' n a m e s within one minute, an achievement which most people would find impossible to emulate. other subjects of the s a m e type m a y produce words associated with exhibitionistic behaviour—e.g., referring to dress, parties, ornaments, etc. another frequent type is the response met with a m o n g regressed or immature subjects, the food response, where a large number of the words a r e related to food or e a t i n g ; a n d a m o n g the more a g g r e s s i v e children the words may refer to fighting—weapons, battles, etc. the third test of this type is perhaps the most revealing of all, a n d h a s b e e n selected for special study. this is t h e . ball-and-field test, which from our point of view has two a d v a n t a g e s over all the other sub-tests in the scale. in the first p l a c e it a p p e a r s at two levels on the s.a. individual s c a l e — a t y e a r 9 a n d y e a r 12, so that nearly all primary school children, a n d a large number of high school children a r e likely to do the test. and in the second place, it is' the least structured of all the test items, a n d therefore produces more emotionally conditioned responses than any of the other items. subjects and procedure in the present s t u d y : ι the s u b j e c t s for this study were 200 children seen a t the j o h a n n e s b u r g child g u i d a n c e clinic, selected on the b a s i s of the most recent c a s e s who h a d done the ball-and-field test a s part of [the routine individual s c a l e examination. t?he a g e r a n g e w a s 5 y e a r s 7 months to 15 years, with a median a g e of 9 y e a r s 4 months.' mental a g e r a n g e w a s 6 years 3 months j to 15 years 8 months, median 9 y e a r s 2 months, a n d the i.q. r a n g e w a s 64 to 148, median 96. in all c a s e s the ball-and-field test w a s given a s part of the s.a. individual s c a l e , with the standard instructions, but in addition the reaction time a n d total time taken for the test were recorded, a s it w a s felt that deviations from the norm in time scores might indicate the· presence of anxiety. any comments on the'test b y the subject, or questions a b o u t it w e r e also noted. the records of the group were then divided into p a s s e s or failures, using the 9-year level scoring a s a b a s i s for a pass, and then these two groups were further sub-divided on the b a s i s of similarity of patterns. the psychiatric diagnosis for e a c h c a s e w a s then compared with others in the s a m e sub-group, in order to d e t e r m i n e d whether the ball-and-field patterns could b e correlated with patterns of personality organisation. results. a. p a s s e s : group 1—normal passes, with normal reaction time (below 7 " ) . ( s e e diagrams 1-3). this group consisted of 61 cases, of whom 44 were diagnosed a s "well adjusted." group 2—normal p a s s e s (similar to group 1) but with excessively long reaction t i m e s — over 7". there were 13 c a s e s in this group, all of whom were diagnosed a s responding to "excessive frustration" ; i.e., although not well-adjusted, these children were not typical c a s e s of maladjusted personalities. group 3—vertical lines (diagram 4). the 5 c a s e s in this group were all diagnosed a s "having marked feelings of deprivation, demanding indulgence, or narcissistic." diagram 5, a combination of " n o r m a l " hcrizonal lines a n d vertical ones (diagram 5) w a s produced b y a child referred to the clinic for stealing, a n d w a s diagnosed a s "feeling deprived, b e c a u s e of the mother's self-indulgence" ; but the stealing stopped after one interview with the child, and two with the mother, so that it was apparent that the maladjustment w a s not very deep-rooted. group 4—excessively careful filling of the field (diagram 6). *a11 5 c a s e s in this group were diagnosed a s obsessional, a n d 4 of them were enuretic. three were having difficulty at school b e c a u s e of "slow work." group 5—success followed b y flight from the field (diagram 7). the 3 c a s e s in this group were described a s "over-conscientious," but 2 of them showed, conversion symptoms, a n d one was referred for school difficulty. group 6—the " p h a l l i c " response (diagram 8). the naming of this pattern w a s a psychologist's hunch, but w a s borne out b y the problems shown b y the 7 c a s e s in this group. five of them were referred for sex difficulties, and the other 2 were enuretics, whose enuresis w a s related to over-stimulation of sex interests. group 7—confused p a s s e s (diagram 9). of the 19 c a s e s in this group, 16 were described in the psychiatric report a s "timid" or " a p prehensive", 14 of them were referred for school difficulty, although only 4 of them h a v e i.q.'s below 90. they a r e apparently children whose anxiety leads to confusion in thinking. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) may j o u r n a l o f t h e south a f r i c a n l o g o p e d i c society ! 1 group 8—normal pattern, long reaction time, a c c o m p a n i e d b y much questioning of the examiner.! these two c a s e s were both referred for nosed a s school difficulties, a n d were diagb e i n g dependent a n d submissive. i b. failures : ι in assessing the importance of these patterns, the questions should b e a s k e d : " w h a t causes failure on this test? in some c a s e s it may b e sheer intellectual i n a d e q u a c y , but in the c a s e s studied, 6 2 % of the children had mental a g e s over 9 years, a n d should h a v e passed the test at the 9 y e a r level, while a further 1 4 % h a d mental a g e s over 8 y e a r s 6 months, a n d might possibly h a v e p a s s e d it, as they p a s s e d other tests at the 9 y e a r level. in this group, therefore, it is possible that failure w a s due to emotional factors, related to the g e n e r a l neurotic pattern of failure on nonverbal tests, or to anxiety a s a result of the lack of structuring in the stimulus. the type of failure throws more light on this emotional factor. in none of the failure groups a r e there more than 1 0 % of the c a s e s a n d it is therefore not possible to talk a b o u t a "normal failure." group 9—single straight line (diagram 10). of the 20 c a s e s in this group, 11 were described a s being " n e g a t i v e " or. "resentful to the mother," a n d 9 were diagnosed a s "timid, dependent or overprotected." it would a p p e a r that this is the pattern of least effort, a n d that this m a y arise either from unwillingness to follow the test instructions, or from d e p e n d e n c e a n d helplessness. group 10—a circle with or without a line to the centre (diagram 11 a n d 12). 13 of the 16 c a s e s in this group were described a s timid,, insecure or withdrawn, and 15 oi them had i.q.'s below 90. this a p p e a r s to b e the pattern of the timid, i n a d e q u a t e personality, with a low i.q. group 11—drawing the ball (diagram 13). of the 9 c a s e s in this group, 5 were referred for stealing, a n d the other 4, referred for a g g r e s s i v e behaviour, c a m e from materially deprived homes. all 9 h a v e i.q., i.e, all these c a s e s h a v e a n interest in material possessions, and all h a v e difficulty in dealing with problems requiring abstract thinking b e c a u s e of the low level of intelligence. group 12—following the outline (diagram 14). these 8 c a s e s were all referred for school r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) may ^ ttz ϊα the other c h d d . ^ t h ot ' u j n α a s c a s e s the parents v e . e c h i l d r e n ' s restrictive ^ a ' o i ^ q { demands ihis a p p t h e t e γγ.γ.ογ their own ^ t h e i r " parents a r e a e s c n o e d α» ov ρ ^ live, so that it is not necessary exclude the outside v/orta. g : » p 1 5 g o i n g out o, the the 4 c a s e s m this 3 · . o u p ° e n c „ u r a g e l i s s f ^ s n s . because o, the parents' own timidity. b i r r e d κ school £ had i.q. s below 80 i h e y ^ ^ . children .aware of hei o/m ^ who attempt to ,cover ρ ' " b l e m . a grandiose solution to the pre ^ group l ^ j j o i n i n g the * d ^ mond (diagram 19). j h e reia diamond! a n d _faeld^on the conclusion: b e c a u s e of the small n u m b e m n e c ^ h group i u r t h e r investigation may b e n r e & s a y field of projective f ^ ^ ^ i i s o n a l i t y that relationships d o e r i s t b e t w e e pe ^ patterns a n d response j ^ t t e m s fn the ball-and-hela test. the u s a s s i s t a n c e ^ o f i^^erpretaaon may be ^ ^ s k d ^ ^ h m g between f a i l u ^ u e ment. s p o n s o i : sir ernest oppenheimer to whom we express out sincere thanks αιαπιυικα --, test is quite fortuuoiu, b ^ ,, h t obliged to j o i n tne two. this is ^ reaction, b e c a u s e in all t h s y m . of the like is towards jn® ^ | ο τ π 1 3 d f the bolism m a y ' b e u n d e r s t o o d ^ ^ m * ^ family background ο t n e . e cnu r_ c a m e from home where l " e r ® n t s i i n group 18—miscellaneous could only b e classified a s un<=lci* all this group has in c o m m o n ^ m ^ patterns a r e unlike all j ™ ® r ^ a r d s s i s t i c " ^ u ' o c ' r a s it i s possible that a n d 2 a s { r o m ^ m . the exceptional pattern ι sistence on doing things in o n . s or from social non-conformity. the finest selection i of speech and music i appreciation records for children 1 are always available on all speeds at 'the connoisseurs record shop5 i t & virf ^ fe p f * © s ® & g r a m o p h o n e 1 0 3 a eloff street p h o n e : 2 2 1 6 2 5 po. box 2400 22-5445 j o h a n n e s b u r g r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction quantifiers research design and method results discussion conclusion acknowledgements references about the author(s) joanine nel department of general linguistics, stellenbosch university, south africa frenette southwood department of general linguistics, stellenbosch university, south africa citation nel, j., & southwood f. (2016). the comprehension and production of quantifiers in isixhosa-speaking grade 1 learners. south african journal of communication disorders, 63(2), a138. http://dx.doi.org/10.4102/sajcd.v63i2.138 original research the comprehension and production of quantifiers in isixhosa-speaking grade 1 learners joanine nel, frenette southwood received: 03 aug. 2015; accepted: 10 feb. 2016; published: 20 may 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: quantifiers form part of the discourse-internal linguistic devices that children need to access and produce narratives and other classroom discourse. little is known about the development especially the prodiction of quantifiers in child language, specifically in speakers of an african language. objectives: the study aimed to ascertain how well grade 1 isixhosa first language (l1) learners perform at the beginning and at the end of grade 1 on quantifier comprehension and production tasks. method: two low socioeconomic groups of l1 isixhosa learners with either isixhosa or english as language of learning and teaching (lolt) were tested in february and november of their grade 1 year with tasks targeting several quantifiers. results: the isixhosa lolt group comprehended no/none, any and all fully either in february or then in november of grade 1, and they produced all assessed quantifiers in february of grade 1. for the english lolt group, neither the comprehension nor the production of quantifiers was mastered by the end of grade 1, although there was a significant increase in both their comprehension and production scores. conclusion: the english lolt group made significant progress in comprehension and production of quantifiers, but still performed worse than peers who had their l1 as lolt. generally, children with no or very little prior knowledge of the lolt need either, (1) more deliberate exposure to quantifier-rich language or, (2) longer exposure to general classroom language before quantifiers can be expected to be mastered sufficiently to allow access to quantifier-related curriculum content. introduction although language acquisition is fast and efficient until the age of approximately five years, becoming a proficient speaker of one’s mother tongue is an extended process which continues up to approximately the age of nine years (berman, 2004). later-developing language skills include the ability to use low-frequency syntactic structures such as passive constructions, subordinate clauses, and low-frequency adverbial conjunctions; past perfect marking and modal auxiliaries (nippold, 2004); and noun phrase elaboration (khorounjaia & tolchinsky, 2004). quantifiers, a further later-developing syntactic category, form part of the discourse-internal linguistic devices children need to (1) contrast and differentiate characters and objects within narratives and other spoken and written texts and (2) describe quantities in mathematical literacy. little is known about the development of quantifiers in child language, especially the production thereof, and particularly in children who speak an african language. this study investigates the comprehension and production of quantifiers by young school-going speakers with isixhosa as mother tongue. young children in south africa generally have low literacy levels (department of basic education, 2014; olivier, 2009), which are linked to poor language skills (klop & tuomi, 2007), specifically to an inability to comprehend and produce some of the above mentioned later-developing constructions used by the children’s teachers in the classroom. upon entering school, children are exposed to classroom discourse, which (1) comprises more formal spoken discourse and writing, (2) is often decontextualised in nature (see naremore, densmore & harman, 1995), and (3) contains complex syntax (see dunn davison et al. 2012). children acquire greater syntactic proficiency if they are exposed to linguistic input frequently containing multiclausal utterances rather than to simplified speech (huttenlocher, vasilyeva, cymerman & levine, 2002). there is thus an ‘on-going, cyclical relationship between literacy and later language development …, a process that is heavily supported by … [language input]’ (nippold, 2004, p. 6). apart from linguistic input, language and literacy skills are also affected by socioeconomic status (ses). children growing up in low ses environments may be poverty-situated in terms of not only their physical conditions but also their development of language and literacy skills (aram & biron, 2004; farran, 1982; klop & tuomi, 2007). tough (1982) states that ‘children from disadvantaged sections of the community [do not] generally lack language but their expectations about using language do not support learning’ (p. 13). the language and socialisation style to which children are exposed, (1) influence the type of language that the child will finally master, and (2) propagate certain information-processing strategies that affect later learning (farran, 1982). children from low ses backgrounds who have their first language (l1) as their language of learning and teaching (lolt) may thus be disadvantaged when compared to their middle class peers in terms of literacy attainment because of the type of language to which the former group receives exposure. however, children from low ses backgrounds who have their second or third language as lolt may be at an even greater disadvantage. the reason for this is that poverty-situated children with a non-l1 as lolt receive language input of inferior quality (lacking certain complex language structures) but also of inferior quantity (huttenlocher, vasilyeva, waterfall, vevea & hedges, 2007). research question we report here on an investigation of the comprehension and production of quantifiers by isixhosa-speaking grade 1 learners in schools situated in low ses areas who have either isixhosa or english as lolt. the following research questions were posed: what progress do these learners make in quantifier comprehension and production during their grade 1 year? how, if at all, does the answer to research question 1 differ for the english lolt and the isixhosa lolt groups? study rationale nippold (2004) concludes that the more that is learned about the nature of later language development (such as investigated in the current study), the relation it has to literacy, and the factors which underlie its growth, the more insight the researcher will gain into the difficulties that children encounter with language in the school context. such difficulties may manifest not only in children with specific or other language impairment, but also in children who develop typically according to the norms of their community but find themselves in contexts in which the quality and quantity of their linguistic input are not ideal for optimal language and literacy development. quantifiers quantifiers defined a quantifier is a word or short phrase which indicates the amount or quantity of an object that is referred to by the noun phrase which the quantifier modifies (southwood & van dulm, 2012a). the format of this quantification must allow a distinction between properties, on the one hand, and individuals possessing these properties, on the other (braine & o’brien, 1998; brooks & sekerina, 2005/2006; o’brien et al. 2003). quantifiers are functional categories (radford, 2004) lacking specific descriptive content. as such, they can modify any semantic noun class where grammatical restrictions do not prohibit such modification. because quantifiers modify noun phrases and determine the quantificational properties of noun expressions, quantifiers generally act as a type of determiner (radford, 2001). beghelli and stowell (1997) state that quantifiers can be categorised in several manners. radford (2004), for instance, categorises quantifiers as universal, existential, or partitive. universal quantifiers are defined as ‘free-choice’ quantifiers such as all/both (radford, 2009). in contrast, the meaning of existential quantifiers relates to the existence of some entity. for instance, some in there is some coffee in the pot refers to coffee that actually exists (unlike any in is there any coffee left?, which questions the existence of coffee) (radford, 2009). partitive quantifiers quantify part of the members of a given set, as some in some children like broccoli or any in do any children like broccoli? (radford, 2009). roeper (2007) distinguishes between collective and distributive quantifiers, where all is collective and every distributive. quantifiers can also be either prenominal (occurring before the noun, as in do you have any books?) or pronominal (standing on their own, as in do you have any?). both prenominal and pronominal quantifiers can occur in either the subject or the object position of a sentence. beghelli and stowell (1997) base their categorisation of quantifiers on the syntax of quantifier scope. scope pertains to the referential dependencies between the quantifier phrase and the clause in which it occurs (beghelli, 1993). for instance, the meaning of every is ‘all possible’, but every (1) has scope over the subject of the sentence in every boy sees the dog, (2) has scope over the object in the boy sees every dog, and (3) assumes scopal ambiguity in every boy sees a dog, where either every boy sees the same dog or every boy sees a different dog. the development of quantifiers in child language quantifier development has been studied intensively, and the relevant theoretical developments and empirical studies are rich and varied. in table 1, we provide a summary of the available findings on the age of acquisition of specific quantifiers. note that there is information available on quantifier acquisition in one of the languages relevant to the current study (english), but not on the other (isixhosa). afrikaans data are provided alongside english data in table 1 to show that there are differences in age of acquisition between these two typologically similar languages. it could thus be assumed that there will also be differences between english and isixhosa, which are typologically dissimilar. below the table, we provide a brief exposition of how the quantifiers in the table are formed in english and in isixhosa. table 1: age of acquisition of quantifiers per meaning and scope. no literature on the production of these quantifiers could be traced for afrikaans, apart from southwood and van dulm (2012a), which states that production of quantifiers by afrikaans-speaking children is mastered only after the age of 9 years. there is also a dearth of literature on child l2 acquisition of quantifiers. available studies (e.g. lakshmanan, 1995) focus on theoretical and psycholinguistic phenomena and how these would affect children’s developing l2 grammars, but there are little empirical data on child l2 acquisition of quantifiers. how quantifiers present themselves in english and isixhosa quantifiers in english english quantifiers include but are not limited to every, all, any, many/more/most, no/none, and some and are invariant forms which do not undergo any inflection. they can be prenominal as in all students are welcome or pronominal as in all are welcome (radford, 2001), but not all quantifiers can be used both prenominally and pronominally in english; for example, pronominal every is grammatical (as in every student wants to graduate) but pronominal every not (as in *every wants to graduate) (radford, 2001). some english prenominal quantifiers can occur as one-word units (when occurring with nouns, as in many people are relieved) or as part of constructions (when occurring with nouns or pronouns, as in many of the people/them are relieved). quantifiers can have generic reference, and then the zero article is used (as in all men are handsome) or specific reference, and then the definite article with or without of is used (as in all (of) the men are handsome). quantifiers in isixhosa the isixhosa quantifiers -nke ‘every/all’, -nye ‘some’, -phi ‘any’, -ninzi ‘many’ and -ngaphezulu ‘more’ have variant forms where different inflectional processes derive the quantifier, in contrast to inkoliso ‘most’ and a‘no/none’ which are invariant and where only a single morpheme acts as the quantifier. the quantifiers -nke ‘every’ and a‘none’ illustrate this difference between variance and invariance: the quantifier stem -nke combines with the quantifier root -oand the relevant subject agreement (according to the noun class of the noun that the quantifier modifies), as in (1). however, the isixhosa equivalent of every can also be expressed by the quantifier form elowo or by a combination of the adjective stem ngaand -nye (in the case of a distributive reading), as in (2): 1. wonke umntwana uyadlala wo-nke um-ntwana u-ya-dlal-a subject morpheme. second person. quantifier root-every noun class 1-child subject morpheme 1-aspect-play-present. final vowel ‘every child is playing’ (= all children – collective) 2. umntwana ngomnye uyadlala um-ntwana nga-um-nye u-ya-dlal-a noun class 1-child preposition-noun class 1-one (every) subject morpheme 1-aspect-play-present. final vowel ‘every child is playing’ (= every single one – distributive) whereas negation in english can occur by using a quantificational modifier with the noun (as in no child), such negation in isixhosa occurs on the verb. the isixhosa equivalent of the english quantifiers no and none is expressed by adding the negative prefix ato the verb, as in (3): 3. andizifuna iiapile a-ndi-zi-fun-a ii-aplile negative-subject morpheme.first person-object morpheme 10-want-present. final vowel noun class 10-apples‘ i want no apples’/‘i do not want apples’ research design and method design the current study forms part of a larger project on later-developing language skills in young school-going afrikaans-, english-, and isixhosa-speaking children (see nel, 2014). in this study, the comprehension and production of quantifiers at the beginning and end of the grade 1 year were assessed amongst isixhosa-speaking children from two schools, one with english as lolt and the other with isixhosa as lolt. data were collected in the lolt of the learners. the study was empirical and had a longitudinal and cross-sectional design: the nature of research question 1 (which asks what development in the comprehension and production of quantifiers takes place between the start and the end of grade 1) lends itself to a longitudinal design, by examining changes that occur over the course of a school year. in the cross-sectional part of this study, participants were grouped according to lolt to see if and how the level of mastery of quantifiers differs between these two groups (to answer research question 2). data were collected with an action research approach. the latter involves a cyclic process in which researchers follow a series of steps that include planning, observing, and evaluating the effects of a specific action which is to be researched (gray, 2004). participating schools and participants the study had to be conducted in two similar schools attended by l1 isixhosa-speaking learners, one with english as lolt and the other with isixhosa. the selection criteria for the schools were as follows: situated in communities with low ses a national quintile of 3 or lower (i.e. non-fee-paying schools) the same geographical classification (either both rural or both urban). we approached several schools about participating in the study. the only two that consented to participate also met the selection criteria. the english lolt school is parallel medium, with an afrikaans and an english stream. it is situated in a rural area 10 km from the nearest town centre. its 923 learners live on the surrounding farms and in various nearby informal settlements. the school has one educator per 34 learners and a national quintile of 1. the participants from this school (14 male; 16 female) had a mean age of 6.6 years (range 6.0 years – 7.6 years) at the first point of data collection. of the 30 english lolt participants, 21 were exposed to only isixhosa in their homes, one to isixhosa and isizulu, seven to isixhosa and english, and one to isixhosa, english, and afrikaans. thirteen of the english lolt participants were born in stellenbosch and never moved away. the region in which they had received input and in which language acquisition had taken place has thus been stable and homogenous in comparison to nine other participants. (no data were available on the remaining eight participants.) of those nine participants, four were born in cape town and their parents later moved to stellenbosch, whereas three were born in johannesburg and another two in the eastern cape. the ninth participant grew up in the western cape, but it is not specified where. the place of birth plays an important role, because it means that the regional languages and language varieties to which the participants may have been exposed are heterogeneous, and this might affect the characteristics of their language. unfortunately, there was no indication of the age at which the children’s families moved to stellenbosch. in terms of the exposure to other languages outside of the home, the english lolt participants formed a heterogeneous group: 18 attended a playschool or pre-grade 1 educational facility (21 facilities in total) during their early childhood years; no data on this were available for the remaining 12 participants. for seven participants, isixhosa was the language of instruction during their preschool years, for two english, for one afrikaans, for another one a combination of english and isixhosa, for three a combination of afrikaans, english, and isixhosa and for one a combination of afrikaans and english. no data on language of instruction was available for the remaining three of those 18 participants who attended a preschool facility. the isixhosa lolt school is in a township adjacent to the industrial area of the same town, 3.4 km from the town centre. it is one of two primary schools in the township. it has 1494 learners and one educator per 40 learners. its national quintile ranking is 1. at the first point of data collection, the mean age of the participants from this school (15 male; 16 female) was 6.8 years (range 6.0 – 8.11 years). of the 31 isixhosa lolt participants, only one was exposed to another language in addition to isixhosa at home, namely to afrikaans. sixteen of the isixhosa lolt participants were born in stellenbosch and never moved away. four of the other 15 were born in cape town and their parents later moved to stellenbosch whereas one was born in tygerberg hospital (which means that the parents lived somewhere in the western cape province at that time) and one in the eastern cape. another participant was born in the western cape but the specific place was not indicated. the children who were not born in stellenbosch will have language profiles that look dissimilar to those children who have stayed in the stellenbosch area their whole lives. it was however not indicated at which time in the children’s lives their families moved to stellenbosch. for 8 of the participants, it was not indicated where they were born. approximately a quarter of the children in the isixhosa lolt group had not attended a playschool during early childhood. twenty-three of the 31 participants attended a total of 17 different institutions, with some overlap between those institutions attended by the english and isixhosa lolt groups. the range of language input and the exposure to languages in the isixhosa group in these pre-gr 1 educational settings was wide: nine participants received input in isixhosa only, another nine in english and isixhosa, and one in english only. data collection material the quantifiers booklet of the receptive and expressive activities for language therapy (realt; southwood & van dulm, 2012b) served as data collection instrument. the realt material was designed for use as language intervention material with children from four to nine years who exhibit a language delay or have a language disorder, but can be used as an informal language assessment instrument (southwood & van dulm, 2012a). its authors also state that it is suitable for l2 speakers of english as well as for children from poverty-situated communities which can profit from directed language stimulation to aid with language development (southwood & van dulm, 2012a). since its publication, the english version was translated to isixhosa by the realt authors and these two versions were then used for data collection in this study. the quantifier section of the realt includes six different quantifiers: all (isixhosa: -nke), any (-phi), every (-nke/nga-+-nye), many/more/most (-ninzi/-ngaphezulu/inkoliso), no/none (a-) and some (-nye). four quantifiers (all/-nke, every/-nke/-nga-+-nye, no/none/a-, and some/-nye) have one set of a comprehension items and another set of production items, whereas any/-phi and many/more/most/-ninzi/-ngaphezulu/inkoliso have comprehension items only. each of these sets, apart from those of no/none/a-, has two subsets, one targeting quantifier meaning (five items each for comprehension and three for production) and another targeting quantifier scope (again five and three items for comprehension and production, respectively). the meaning items comprise stimulus questions based on a picture, requiring either yes/no or other one-word responses. the scope items comprise a picture selection task in which learners are presented with a verbal stimulus to which they respond by choosing that one out of three pictures that matches the stimulus. the realt assesses production of only every/-nke/nga-+-nye, all/-nke, some/-nye, and no/none/aas appropriate picture material could not be generated for any/ -phi and many/more/most/-ninzi/-ngaphezulu/inkoliso (southwood & van dulm, 2012a). every/-nke/nga-+-nye, all/-nke, and some/-nye each has six production items, of which the first three assess the meaning and the last three the scope of these quantifiers. the scope items differ in format from the meaning items, in that there are two parts to each scope item, namely an (a)-part which aims to elicit a response containing a quantifier with a specific scope, and a (b)-part which aims to elicit the same quantifier but with contrasting scope. the quantifier no/none/ahas only five production items which appear in a question answering task. data collection and analysis data were collected from each learner individually in his or her lolt by four fieldworkers. the quantifiers booklet of the realt was administered to 61 isixhosa-speaking grade 1 learners (30 with english and 31 with isixhosa as lolt) at the beginning of the first term of 2013 (henceforth also ‘february’). these learners were reassessed in the same manner in the fourth term of 2013 (henceforth also ‘november’). responses were documented on paper scoresheets. where spontaneous revisions occurred, the participant’s last response was recorded. if a targeted response was given, the fieldworker made encouraging remarks such as ‘good job!’ or ‘well done’. in the case of an incorrect or non-target response, the fieldworker followed up with a somewhat more elaborate version of the initial stimulus. correct responses to follow-up were scored as correct. no further opportunities for correct response were provided after the one follow-up. responses were then transferred from the scoresheets to custom designed excel sheets. the following were calculated separately for comprehension and production of each quantifier, with a score of 90% or more taken as an indication of mastery: the percentage of responses correct for each subtype per learner the average of these percentages for each subtype per lolt group the average percentage of all comprehension subtypes and of all production subtypes collectively per lolt group. the wilcoxon matched pairs test was used to compare the data collected at the beginning and at the end of the year for each lolt group separately, with p < 0.05 as significance level. the direction of significance (whether scores were better in february or in november) was determined by means of inspecting box and whiskers plots. the data for the english lolt group and the isixhosa lolt group were also compared to each other, in order to answer research question 2. this was done by means of the mann–whitney u test (with continuity correction), where english data collected in february were compared to isixhosa data collected then, and english data collected in november to isixhosa data collected then. the direction of significance was again derived from inspection of box and whisker plots. the programme used for statistical analyses was statistica 12. ethical considerations ethical clearance for the study was granted by the research ethics committee (humanities) of stellenbosch university (protocol number gl010812). permission to conduct the study was obtained from the principals and relevant teachers at the two study schools. informed consent was obtained from participants’ parents or legal guardians by distributing information letters and consent forms to them via the school. the letters explained in plain language and in the lolt of the particular school the general purpose of the study, the procedures to be followed during data collection and reporting of the findings, and the voluntary nature of participation. participants gave written assent after the fieldworkers had explained to them in isixhosa what research is and what tasks they would be expected to perform. participants and their parents or guardians were also informed that participation could be terminated at any point without them having to provide a reason for doing so or being penalised in any manner. confidentiality and anonymity were assured during all stages of the research process, amongst others by assigning participant codes instead of using participant names. reliability and validity the following measures were taken in order to increase the reliability and validity of the obtained data: the realt was administered exactly as stipulated in the manual (southwood & van dulm, 2012a). data were collected by a small number of fieldworkers (two per school), with no changes in school assignment between the beginning and the end of the year. all fieldworkers received the same intensive training on, amongst others, the research protocol and task administration and scoring. during data collection, responses were recorded and scored on the scoresheets in real time (directly after being given). each non-target response was written down verbatim. at the end of each data collection day, the first author verified the accuracy of the scoring. any ambiguity or inconsistency was cleared up with the fieldworker before the next data collection day. accuracy of data transfer to the excel sheet was checked. results quantifier comprehension english lolt group participants who had english as lolt did not obtain a 90% score on the comprehension tasks (meaning and scope) for any of the six quantifiers tested, neither in february nor in november, apart from on the comprehension task for meaning of no/none. in february, the average comprehension score for meaning of no/none was 76%, but in november it was 97% (table 2). despite the general lack of mastery, scores for comprehension of meaning increased statistically significantly from february to november, with the exception of some which remained the same (table 2). regarding scores for comprehension of scope, only every and many/more/most showed a statistically significant increase (table 2). table 2: english lolt and isixhosa lolt quantifier comprehension scores: descriptive statistics. isixhosa lolt group in the isixhosa lolt group, comprehension scores for the meaning subsets of a‘no/none’ and -phi ‘any’ indicated mastery in february, with a further increase in november. the meaning subset of -nke ‘all’ was fully acquired at the end of grade 1: the average percentage increased from 89% in february to 95% in november. the score for the meaning subset of -nke/nga-+-nye ‘every’ was 90% in february but decreased slightly to 88% in november. this quantifier was thus almost fully acquired during grade 1. the remaining quantifiers in the meaning subset had high average percentages and were almost fully acquired in november (table 2). the scores of the scope subset decreased slightly from the beginning to the end of the year, but this decrease was not statistically significant. the scores for the scope subset are not as high as those for the meaning subset, and comprehension of the scope of the assessed quantifiers were not mastered by the end of g1. quantifier production english lolt group in the english lolt group, quantifier production errors mainly included quantifier omission (such as the boys are kicking the balls instead of all the boys are kicking the balls), the use of definite articles instead of a quantifier (such as they picked the flowers instead of they picked some flowers), circumlocutions with negation (such as i don’t see red instead of there are no red balloons) and irrelevant picture description. no quantifiers were fully acquired by november as none of the average percentages were above 90, but scores for both the meaning and the scope subsets of all the quantifiers showed an increase from february to november. not all increases were statistically significant though (table 3). for the meaning subset of every, all and some, there was a statistically significant increase but not for no/none. for the scope subset, only the quantifier all showed a significant increase. both in february and november, meaning scores were higher than scope scores (table 3). table 3: english lolt and isixhosa lolt quantifier production scores: descriptive statistics. isixhosa lolt group quantifier production errors made by the isixhosa lolt participants mainly comprised quantifier omission, circumlocutions with negation (umtwana omnye akanaye unonkala ‘the other child doesn’t have a crab’ instead of oononkala bahamba ezinyaweni zabanye babantwana ‘the crabs are running over some of the children’s feet’), and irrelevant picture description or other irrelevant responses (such as bahamba ngenyawo ‘walking barefoot’ instead of abanye oononkala baqabela ngaphaya kweenyawo zabantwana ‘some crabs are running over the children’s feet’). the isixhosa lolt participants had production scores for meaning and for scope of 90% or higher in february and in november for all quantifiers. meaning and scope scores were almost similar in february and again in november. the increases or decreases from february to november show no specific pattern, and none of the differences between february and november were significant apart from the score for the scope subset of -nye ‘some’ which showed a significant decrease. despite this decrease, the november score was still above 90% (table 3). comparison of english lolt and isixhosa lolt scores a comparison between the english and the isixhosa lolt learners shows a clear distinction between these two groups in terms of both their comprehension and production skills, with the learners who have their mother tongue as lolt consistently obtaining higher scores (80% – 95%) than those who have their l2 as lolt (50% – 60%). for each quantifier, subset, and set, there was a statistically significant difference between the two lolt groups, apart from comprehension of the meaning of no/none/a(p = 0.507) and production of the meaning of all/-nke (p = 0.075). in these latter two cases, the scores of the isixhosa lolt group were however still higher than those of the english lolt group; see figure 1 which is a box and whiskers plot of the total scores for comprehension and production for the two lolt groups. table 4 is a summary of the ages of mastery of comprehension and production of the quantifiers assessed in the current study. figure 1: the comprehension and production total scores of all quantifier types (%) per language of learning and teaching. table 4: age of acquisition of comprehension and production of quantifiers based on data from the current study discussion based on the available literature on the age of acquisition of quantifiers (table 1), quantifiers seem to be early developing rather than later-developing, with the exception of the quantifier every. however, a distinction between meaning and scope is not always made in the relevant literature. from the data obtained in the current study, it is not conclusive whether quantifiers are earlieror later-developing in isixhosa l1 speakers: comprehension of a‘no/none’ and -phi ‘any’ has been mastered by the beginning of grade 1 (age 6.1 – 8.11) by isixhosa-speaking children, which could indicate early development. however, comprehension of the remaining quantifiers is only mastered later, pointing to later development. different quantifiers are thus mastered at different ages. this could be because of differences in the inflectional processes involved in the various isixhosa quantifiers. also, the complex processes which a child has to apply in order to interpret a quantified phrase correctly might play a role in why some quantifiers prove to be more difficult for learners than others quantifiers. in this regard, brooks and sekerina (2005/2006) state that: although quantifiers play a very important role in logical reasoning …, their acquisition may be delayed relative to other sorts of lexical items (e.g. nouns and verbs) because their complex patterns of usage often result in interpretive ambiguities. (p. 177) despite the fact that the isixhosa lolt group had not yet acquired the comprehension of -nke/nga-+-nye ‘every’, -nke ‘all’, -nye ‘some’, and -ninzi/-ngaphezulu/inkoliso ‘many/more/most’ by the end of grade 1, quantifier production is already fully acquired at beginning of grade 1. a possible reason why the production scores are higher than the comprehension scores could be that the production items, unlike the comprehension items, do not provide opposer and distracter pictures which could confuse the learners. as stated above, errors in the production data comprised the omission of a quantifier, circumlocutions, irrelevant picture description, and responses completely unrelated to the stimulus, but not substitution of one quantifier with another. the learners thus did not produce untargeted quantifiers as there was no stimulus priming other quantifiers. based on the results of this study, one can conclude that isixhosa grade 1 learners who have isixhosa as lolt have sufficient command of quantifiers when they enter grade 1 to allow them to understand classroom discourse containing this syntactic category. turning to the isixhosa-speaking learners with their l2 as lolt: none of these learners achieved a percentage correct score of 90% or more for quantifier comprehension (not even at the end of their grade 1 year), and their scores were significantly lower than those of their peers with isixhosa as lolt. despite the fact that the english lolt learners had various ages of first exposure to english, ranging from no exposure prior to entering grade 1 to exposure from birth or preschool entrance, none of them had mastered quantifier comprehension at school entry, and all required more than one year’s exposure to english classroom discourse to master quantifier comprehension. note however that there was a significant increase in the comprehension and production scores of english quantifiers from the beginning to the end of grade 1. the increase in the english lolt group’s scores was statistically significant. thus, despite the fact that these quantifiers are not yet fully acquired by the end of grade 1, significant development takes place between the beginning and the end of grade 1. in this regard, jordaan (2011) found that l2 learners who are integrated with l1 language learners catch up with these l1 language learners by grade 3. jordaan (2011) also states that although those l2 learners who are not integrated with l1 peers do make significant progress by the end of grade 3 on most of the language skills that she assessed, they do not reach the same level as those integrated into a l1 learning context. the learners in the english lolt group of the current study find themselves in the latter situation: they are l2 learners of english in a class consisting of mainly l2 learners of english. they have received and still receive limited english input, because their main (and, in many cases, only) source of english input is their teachers who are not english l1 speakers. although these learners are supposed to be taught through medium of english only (as per the language policy of the school), their teachers are ‘forced’ to code switch in class (between english and isixhosa) because of the learners’ low level of english comprehension and production at the beginning and, to a large extent, still at the end of grade 1 (personal communication with teachers). the school’s language policy is thus not always followed in practice, as it is not practical (or even possible) in all teaching contexts. this group of isixhosa-speaking learners is at a disadvantage compared to those in a classroom with isixhosa as lolt, because in the absence of code switched classroom discourse, they have limited ability to access complex english sentences such as those containing quantifiers. by contrast, isixhosa-speaking learners receiving their tuition in their l1 will be adequately prepared to understand quantifiers in the narratives and numerical literacy tasks they encounter in the grade 1 classroom. conclusion the study investigated the quantifier comprehension and production of children from low ses backgrounds who consequently might not receive adequate linguistic input at home for the acquisition of complex language constructions. when comparing the scores of these low ses learners with those obtained by the higher ses learners assessed by southwood and van dulm (2012a), it is clear that the age of acquisition is later for the low ses isixhosa l1 speakers who receive their schooling in their l1 and even more so for those who receive their schooling in english. children who are situated in low ses circumstances are generally impoverished in terms of the language input they receive, and the language development norms applicable to middle or high ses communities cannot necessarily be applied to low ses communities. this study rendered limited normative data on the acquisition of quantifier constructions by child speakers of isixhosa and contributed to the still small pool of normative data on the language acquisition of older children. in summary in this regard, there seems to be a general acquisition order for the meaning subset: -phi ‘any’ and a‘no/none’ are acquired earlier than -nke ‘all’, and -ninzi/-ngaphezulu/inkoliso ‘many/more/most’, -nye ‘some’, and nke/nga-+-nye ‘every’ are acquired thereafter. the findings of this study support the notion that child language acquisition has not been completed by the age of five years, thus challenging certain assumptions about language acquisition and developmental norms. despite the fact that children can generally construct most sentence types and decode complex semantic relationships in their l1 upon school entry, their language continues to develop in significant manners during at least their first years of school. the study had several limitations. these included a limited number study schools in only one geographical location; group generalisations instead of careful consideration of possible individual variation; combining the results of the two genders instead of searching for possible gender-related differences; considering grade instead of chronological age; and focusing on learner responses only instead of imbedding the study in classroom observations so as to ascertain the potential influence of teacher talk and pedagogical styles on learners’ linguistic knowledge. despite these limitations of this study, the findings have a practical implication: children with no or very little prior knowledge of their lolt will generally need either, (1) more deliberate exposure to quantifier rich language in their lolt, or (2) longer exposure to general classroom discourse in their lolt before quantifiers can be expected to be mastered sufficiently to allow access to quantifier-related curriculum content. without such exposure, children from low ses backgrounds for whom there is a mismatch between their l1 and lolt are unlikely to function optimally in the grade 1 classroom. acknowledgements the authors thank the staff at the department of african languages of stellenbosch university and dr mantoa smouse for assistance with the description of quantifiers in isixhosa and with the analysis of the isixhosa data. the authors also thank the fieldworkers who assisted with data collection. this material is based on work financially supported by the national research foundation. any opinions, findings, conclusions, or recommendations expressed in this material are those of the authors and therefore the nrf does not accept any liability in regard thereto. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions the study on which the article is based formed part of j.n.’s (stellenbosch university) phd project (of which f.s. 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(1982). language, poverty, and disadvantage in school. in l. feagans & d.c. farran (eds.), the language of children reared in poverty. implications for evaluation and intervention (pp. 3–18). educational psychology series. new york: academic press inc. today and tomorrow in the education of the deaf* s. r i c h a r d s i l v e r m a n , ph.d. director, central institute for the deaf, st. louis, missouri, u.s.a. summary the n e e d t o base programmes for y o u n g deaf children o n an understanding of the c o m p o s i t e of their capacities is stressed. a number of these capacities, a m o n g m a n y , are cited in regard t o sensory input and language acquisition and pertinent q u e s t i o n s associated w i t h t h e m are raised. opsomming die b e h o e f t e o m programme vir jong d o w e kinders te grond o p begrip van samestelling van hul vermoeens w o r d b e k l e m t o o n . 'n aantal van hierdie verm o e e n s , uit vele gekies, w o r d aangepas m e t betrekking tot sensoriese ontvangs en taalverwerwing en pertinente vrae wat daarmee in verband staan, w o r d geopper. author's note: it is a privilege for me to be invited to contribute to the journal of the south african speech and hearing association honoring my friend and colleague prof. pierre pienaar. i look back with pleasure and appreciation to my visit, in 1967, to south africa, arranged by prof. pienaar. the intellectual stimulation, the warm hospitality, and the new experiences made the trip a memorable one for mrs. silverman and me. i was invited to contribute an article on the education of the deaf. i suggested to the editor that i submit for consideration, my keynote presentation on the subject to the international congress on education of the deaf, in august of 1970 at stockholm. the suggestion was made for two reasons. first, the talk represented my current thoughts on the subject and second it had not appeared in the periodical literature. here it is unedited from the original version. the subject assigned me by your chairman for the opening lecture of this congress is "today and tomorrow in the education of the deaf." it appears to call for an updated version of my keynote address to the 1963 international congress in washington titled "the education of deaf children past and * keynote address to the international congress on education of the deaf, stockholm, sweden, august 17, 1970. reproduced-by-lpermission of the swedish union of teachers. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 s. richard silverman prologue."18 i hope that the omission of the "past" in the present assignment is not a deliberate rejection of the recent history of our profession and the lessons it has to teach. who knows, maybe it is an unconscious bow to the credo of rebellious youth for whom the past is irrelevant. what is more likely is that the planners wisely recognize the great abundance of stimulating and provocative activity now going on in the education of deaf children and in the interest of economy of time have chosen to focus on the significance of this activity for the future. furthermore, they rightly assume that those interested enough to commit their time, energy and means to attend the congress require no tutorial in the history of our field. we recall that the 1963 congress was organized sequentially from assessment and diagnosis of children, through their educational experiences to their economic, psychological and social accommodation to the world about them. however, reflection on activities since our last meeting, especially as they are expressed in the subjects of this congress, suggests that this necessarily brief exposition concentrate on a topic that is particularly timely today with stress on the questions it raises for tomorrow. i draw liberally on the writings of those who have given serious and sustained attention to the topic. this is the increasing emphasis on very young children. after all, they are the school children of tomorrow. this is not to say that it is the only one that merits attention or that it is unrelated to such topics as curriculum and the latter day concern for the formulation of objectives against a background of an overwhelming accumulation of knowledge, media, mental health, vocational and technical training, participation by more deaf persons in educational planning, professional training, organizational and administrative arrangements, philosophic outlook and realistic aspirations for the deaf including its relation to the "sub-culture" syndrome and a host of other problems of mutual concern. it simply expresses the opinion of your keynoter operating within the time and context assigned him. i am aware too, i hasten to point out, that the education of deaf children reflects the distinctive traditions, trends and aspirations for general education of each nation represented here. i trust, nevertheless, that these differences, whatever they may be, are put aside to consider problems singularly common to all deaf children. this audience does not need to be reminded how the encouraging progress in the identification and assessment of hearing impairment in young children has underlined the necessity and, yes, the opportunity for effective preschool programs. we all realize how important for learning and over-all development of children is the period from birth to the age of five. indirect, but importantly suggestive evidence from neurophysiology points to the substantial influence on the developing nervous system of sensory experience. and we are all familiar with the emphasis placed by psycholinguists on the notion of an optimal period for acquisition of language, particularly its structural features. the implication of all of this for parents, too, properly commands our earnest attention. i it is interesting to mention here that davis underlines the need for early treatment by suggesting a hypothesis about the etiology leading to an "aphasic", "language handicapping", "difficult learning" problem in children or whatjournal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) today and tomorrow in the education of the deaf 61 ever you choose to call them. in the latest edition of hearing and deafness7 he says: "it is postulated that the auditory system requires sensory input during the early years, particularly during the second year when the normal infant begins to learn speech, in order to complete its development, and that if this normal organization does not occur, it is more difficult to bring it about later, even though sounds are then made audible by amplification. the failure to recognize the partial hearing loss leads to false expectations and inappropriate management. the child develops what may be called a "habitual disregard" for sound as a means of communication. it makes no difference whether the hearing loss is hereditary, congenital, or acquired, but it is importanuhat the loss is present during the years when children normally learn to talk." "this interpretation is still a hypothesis, important is the clinical experience that young children in whom the partial hearing loss is detected early and who are given the benefit of early and habitual exposure to loud speech, with a hearing aid as soon as they are old enough, do develop speech and effective use of their residual hearing much better than children with similar audiograms who have not had the advantage of early auditory exposure and training. the practical implication of this hypothesis is, of course, to recognize early the auditory defect and to initiate the proper management." davis also suggests a new term. "dysmathia is a more appropriate term than congenital aphasia. dysmathia is an old greek word that means exactly what we want to say, namely, difficulty or slowness in learning. if we wish to be more specific and say difficulty in learning speech and language, we can form a new word, dyslogomathia. the familiar root logos carries the connotation of both speech and language." "in summary, true congenital aphasia based on an anatomical defect or birth injury does occur, but it is rare. dyslogomathia, based on partial sensory deprivation, is a more probable explanation in a majority of the cases in which children show some reactions to fairly loud sounds but do not spontaneously develop speech, and often have great difficulty learning speech later. further study should clarify the situation and allow us to accept, reject, or modify this working hypothesis." having agreed on the general propositions stressing the need we must ask what is a sensible program. obviously any program for tomorrow will exploit our expanding knowledge of assessment of those, capacities of children that are important for their educational management. for example, in studying auditory capacity we shall supplement, wherever possible, determination of auditory thresholds with information about perception of pattern, ability to use minimal auditory cues for "total" communication, attentiveness to sound and differential sensitivity. a pertinent experiment in our laboratory by gengel,10 studying differential sensitivity for frequency and its change with training, demonstrated a reduction in the difference limen in hearing impaired children after only limited practice. he found that a number of hearing impaired children discriminated differences of 4% at 2 standard frequencies, 250 and 500 hz (comparing rather favorably with normals) and suggesting that proper practise could greatly improve discrimination among vowels and voice-pitch journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 s. richard silverman changes. the point made here is that these features of auditory capacity need to be identified and subsequently cultivated. it emphasizes that we need to be cautious about regarding hearing in a simple two dimensional way. we look forward to making better use of improved description, if not always measurement, of all kinds of perceptual responsiveness and of intellectual, motor, emotional and social competence. granted the hopeful prospect that we shall be equipped with more useful information about young children we shall still face a number of alternatives for management that on first consideration are very appealing. consider, if you will, sensory stimulation and the options for channel, mode, and stimulus coding. here we are immediately confronted by the uni-multi-sensory issue. does a deliberate bisensory approach confuse and distract or does it reinforce with associated cues a primary channel of communication of another sense? and if it does either of these, how much, when and under what conditions? there is some evidence that tactual v o c o d e r s 1 2 , 1 7 or acoustic cues at the level of detectability, may help speechreading.8 the evidence for cooperation or competition between the auditory and visual senses is not all clear nor too abundantly at hand. we are not too much better off for convincing evidence for a bimodal unisensory tactic such as finger spelling combined with speechreading. some view these as the essential components of "total communication" to develop speech, speech reception and language, including reading.14 in the symposium last week, a number of systems cueing speech was discussed as an alternative bimodal approach. incidentally, they varied substantially in their primary objectives and in their relation to the utterances they are designed to cue. some are related to acoustic features, others to articulatory gestures, and still others to arbitrary differentiating cues for non-visible features. an impressive effort has gone into the coding of stimuli particularly auditory. the emphasis has been on making available crucial information-bearing elements of signals to the part'of the auditory channel that may possibly detect and transmit them most often in the low frequencies. clever methods of frequency transposition, insertion of discriminable surrogate signals and amplification of various sorts in association with particular training regimes are being attempted. here too the evidence for special methods of coding are not overwhelmingly convincing but impressionistic and anecdotal evaluation points to continued efforts in these directions. also we shall watch with interest the attempts, to adapt finger spelling to phbnetic correspondence and to expand and to refine syntactical features of the language of signs. / it becomes clearer as we ponder these alternatives for sensory input that we need to ask more fundamental questions such as the effects of a particular strategy on the operation of short term memory, the place of immediate, delayed, ambiguous or distorted feedback over any sensory system, and of the storage of rules of sequential probabilities of linguistic units. the task of improving our programs for young children is complicated further by the imposing and awesome array of theoretical alternatives and their application having to do with language acquisition. the ideas of piaget1 6 stressing that mental growth does not depend on quantitative addition of experience journal of thesouth african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) today and tomorrow in the education of the deaf 63 but that the development of thought and language is primarily qualitative has had substantial influence. thought precedes language and they are eventually interrelated. and even without language a child is capable of developing a logical-symbolic system. relevant to this we have said in hearing and deaf19 ness "there appears to be a significant movement to introduce the language of signs as a major mode of communication with young deaf children on the grounds that the capacity for thinking must be developed early and should not be confused with the capacity for using language. it is argued that we deter the development of thinking in deaf persons by emphasizing at the outset verbal means of communication, be they speech, the manual alphabet, or a combination of the two. in his book on the subject, furth9 indicates that by present methods we foster an 'experiential deficiency which would be avoidable if nonverbal methods of instruction and communication were encouraged both at home in the earliest years and in formal school education'. the assumption that this is the only alternative to certain conventional unproductive methods is open to question. for example, we must weigh carefully the accomplishment of parent guidance and the early intensive use of residual hearing, and also the impressive academic, vocational, and communicative attainment of many deaf persons." "the idea has been advanced that oral language be taught as a second language preceded by the language of signs aimed at cognitive development and that the latter be used to bring out the advantages of oral language. the sign language, it is suggested, ought to be enriched so that it is less rigidly concrete and situation-bound." "the 'oral-manual' controversy is not yet settled. it is encouraging, however, that numerous investigations are under way to study not only the linguistic, conceptual, and intellectual effects of modes of communication for deaf persons but also their influence on features of personality such as emotional maturity and self identity." skinner,20 as we know, emphasizes environmental conditioning and reinforcement. the child in discriminating the many stimuli in his environment emits sounds that get reinforced. the emphasis here in shaping verbal behavior is external and the child's internal structure is not of much importance. some of us believe that a primary cause of so called "oral failures" is the absence of a reinforcing environment for oral communication. skinner's views appear to be directly opposed to those of chomsky4 who postulates a theory of linguistic universals common to all cultures. chomsky asserts that a valid model of linguistic behavior must account for the extraordinary fact that we use language we have never heard before. very young children are able to construct and understand an impressive number of utterances that are quite new to them. from earliest childhood the human use of language goes far beyond what is "taught". therefore, there must be some fundamental process at work independent of input from the environment. in the absence of his ability to know what goes on in the mind the linguist imputes to it a finite set of rules that specifies the deep abstract grammatical structures that underlie sentences and then further transformational rules that relate these deep structures to tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 s. richard silverman surface structures (i.e. real sentences). the possibility of developing a better language program growing out of these ideas has become very intriguing to teachers of deaf children. the sequence of structured word strings in the language of normal children could be a model for teaching young deaf children. there would need to be contrived activities to do this for deaf children, not to mention a sorting out of "performance" and "competence" in our observations of a child's linguistic behavior. the reason for making the distinction is that it is in the description of linguistic competence that rules seem unavoidable as explanatory concepts.5in a meeting which we both attended, (princeton) i asked prof. chomsky, "how can we tap these (language) universale in creating a command of language in deaf children." i quote his answer: "one would expect that unless the appropriate stimulus conditions are realized, the instinctive behavior would not appear. it may be that the appropriate stimulus condition is hearing enough linguistic noises in your environment. so it just might be that there is no way to tap the system, any more than there is a way of initiating the system of flight in birds without putting them in the situation in which they have to flap their wings."6 note the phrase "appropriate stimulus condition". o'neil's15 word of caution about the application of psycholinguistcs to teaching is worthy of mention: linguistics thus seeks t o find explanations of the structures of language, for the relationships among structures, consistent explanations of the complicated and fragmentary data of language. it is further c o n c e r n e d t o offer explanations of t h e w a y in w h i c h t h e grammar is used and t h e w a y in w h i c h it is acquired and internalized b y infants growing up in s o c i e t y . t h e grammar d o e s not purport t o b e a m o d e l of h o w the human m i n d puts sentences together in speaking or takes t h e m apart in hearing. but t h e grammar d o e s presumably c o n s t i t u t e the k n o w l e d g e of his native language that the h u m a n b e i n g brings t o bear o n t h e tasks of speaking (and writing) and of hearing (and reading). very little of this is at all well u n d e r s t o o d , b u t there is m u c h interesting work in progress in psycholinguistics and s o m e tantalizing b i t s of information are emerging. much of the psycholinguistic research is entering areas of interest t o educators. but o n l y entering, n o t y e t there. it w o u l d b e a serious mistake t o begin building educational programs in areas where our understanding is so dim. in fact w e have nothing like a c o m p l e t e l y formulated grammar of any language, m u c h less a c o m p l e t e understanding of language in general. of interest to us, of course, is vygotsky's21 notion of "inner speech." it does suggest that we must develop ways, as i have said elsewhere, of rummaging around in the psyche of deaf children to study the relation of the symbols they use for expressing themselves be they oral, finger spelling or signs and their thought processes. this need is underlined by lennenberg's13 views that language behavior derives from peculiarly human cognitive processes like categorization and abstraction. it is a human mode of analysing experiences into conceptual units and rules that link them. the. child matures in this process biologically but language stimulation is necessary in his formative years. bronowski and bellugi2 tell us that "most of what we regard as objects in our environment, however, are sophisticated concepts. thus the logic by which a child unravels the sentences he hears and his experience of the environment together is much more than a capacity for language and expresses in miniature journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) today and tomorrow in the education of the deaf 65 a deeper human capacity for analyzing and manipulating the environment in the mind by subdividing it into units that persist when they are moved from one mental context into another." so even learning the name of an object by a deaf child is a much more cognitive act than heretofore supposed and should influence our methods accordingly. in hearing and deafness18 we have said, it is appropriate, in discussing the young deaf child, to mention the increasing amount of information and guidance available for parents of deaf children. although here and there an effort may be misguided, the proliferation of parent institutes and clinics, and of correspondence courses, reading lists, and literary output is one of the most constructive and forward-looking developments in the education of the deaf. one parent put it succinctly: . . . the tough thing about deafness is likely to be social isolation, social adjustment. there is no one in the world, and there never can be anyone, as important in determining any child's social adjustment as that child's own parents and his family at home. for that reason parents are important. in general there appear to be no universally accepted specific aims or procedures in guiding parents of very young children. the emphases vary. for some, the primary aim is to create realistic "acceptance" of the child's condition, and counseling is weighted toward psychotherapy. for others, the emphasis is on conveying information in order to create an understanding of sensory deprivation and its effect on the total development of the child in general and of his communication deficit in particular. whenever possible there is a growing trend toward carrying on parent "training" in homes and homelike settings, sometimes called demonstration homes, where, by demonstration and practice, parents learn to contrive and take advantage of natural situations in the home to sharpen perceptions and foster communication. of great interest to educators of deaf children is the knowledge likely to be gained from the programs of early education such as head start directed at "culturally disadvantaged" children3 in the u.s.a., in the u.s.s.r.1, and in the kibbutzim of israel. here too, vigorous schools of thought appear to be taking shape. on the one hand, there are those who would emphasize "cognitive" approaches that stimulate intellectual functioning. in its extreme form it has been labelled the "pressure-cooker" view, which aims to compensate for the lack of opportunity for perceptual development. others would stress the child's social and emotional growth without too much "structured" teaching. here, too, we need a better understanding of the role of shaped sensory experience in the cognitive development of infants.11 such evidence as exists for the value of particular procedures and programs of parent counseling is meager and is generally anecdotal or based on studies (frequently retroactive) of children's records. it will be helpful, for the parent programs we undertake, to evaluate all of the following: genetic counseling for deaf married couples and parents of deaf children; the use of the high risk register; the adaptations necessary because of differences in the intelligence, motivation, and education of parents; the emotional needs of parents; the special training necessary for those who counsel parents; and the implications of the concept of critical periods in development. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 66 s. richard silverman we have seen in these necessarily selective and illustrative remarks that the rising tide of proposed approaches is swamping teachers with more untested devices and strategies than they are prepared to absorb or evaluate. we also need to note that our investigators may be properly criticised for violating any number of principles of scientific inquiry having to do with accurate description of methods being compared, with recognition of individual differences among deaf children, with statistical treatment, with poor measuring instruments, with asking wrong questions, and with premature judgments that do not wait on longitudinal effects to appear. yet in the today and tomorrow of our field we must look to constructive collaboration of investigators and practitioners to the end that we may choose our alternatives on a rational basis. references 1. bronfenbrenner, u. (1970): two worlds of childhood. u.s. and u.s.sr. basic books, new york. 2. bronowski, j. and bellugi, u. (1970): language, name and concept. science, 168,669-673. 3. caldwell, b.m. (1970): the rationale for early intervention. exceptional children, 36, 717-726. 4. chomsky, n. (1964): current issues in linguistic theory. mouton, the hague. 5. chomsky, n. (1965): aspects of the theory of syntax. the m.i.t. press, cambridge, mass. 6. chomsky, n. (1967): general properties of language. in brain mechanisms underlying speech and language (page 73), darley, f.l. ed., grune and stratton, new york. 7. davis, h. (1970): chapter 4, in hearing and deafness, davis, h. and silverman, s.r. (eds.), holt, rinehart and winston, new york. 8. erber, n.p. (1970): auditory and audio-visual reception of words in noise by observers with normal and impaired hearing, unpublished ph.d. thesis, washington university, st. louis, missouri. 9. furth, h.g. (1966): thinking without language: psychologicalimpli. cations of deafness. the free press, new york. 10. gengel, r.w. (1969): practice effects in frequency discrimination by hearing impaired children. j. of speech and hearing research, 12, 847-855. 11. kagan, j. (1970): the determinants of attention in the infant. american scientist, 3,298-305. 12. kringlebotn, m. (1968): experiments with some visual and vibrotactile aids for the deaf. a merican a nnals of the deaf, 113,311-317. 13. lenneberg, e.h. (1967): biological foundations of language. m.i.t. press, cambridge, mass. 14. moores, d.f. (1970): psycholinguistics and deafness.american annals of the deaf, 115,37-48. 15. o'neil, w.a. (1968):'paul roberts' rules of order: the misuses of linguistics in the classroom. the urban review, 2,12-16. journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) today and tomorrow in the education of the deaf 67 16. piaget, j. (1954): the construction of reality in the child. translated by cook, m., basic books, inc., new york. 17. pickett, j.m. and pickett, r.h. (1970): communication of speech sounds by a tactual vocoder. j. of speech and hearing research, 6, 202-222. 18. silverman, s.r. (1964): education of deaf children past and prologue. in report of the proceedings of the international congress on the education of the deaf and the forty-first meeting of the convention of american instructors of the deaf, u.s. document no. 106, u.s. government printing office, washington, d.c., 113-122. 19. silverman, s.r. and lane, h.s. (1970): chapter \6, hearing and deafness, davis, h. and silverman, s.r. (eds.). holt, rinehart and winston, new york. 20. skinner, b.f. (1957): verbal behavior. appleton-century-crofts, inc., new york. 21. vygotsky, l. (1962): thought and language. m.i.t. press, cambridge, mass. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction method participants materials procedures data analysis results discussion development, faceand content validity of the neonatal feeding assessment scale outcome of the delphi process conclusion acknowledgements references about the author(s) mari viviers department of speech-language pathology and audiology, university of pretoria, south africa alta kritzinger department of speech-language pathology and audiology, university of pretoria, south africa bart vinck department of speech-language pathology and audiology, university of pretoria, south africa citation viviers, m., kritzinger, a., & vinck, b. (2016). development of a clinical feeding assessment scale for very young infants in south africa. south african journal of communication disorders 63(1), a148. http://dx.doi.org/10.4102/sajcd.v63i1.148 original research development of a clinical feeding assessment scale for very young infants in south africa mari viviers, alta kritzinger, bart vinck received: 08 jan. 2016; accepted: 07 aug. 2016; published: 26 oct. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: there is a need for validated neonatal feeding assessment instruments in south africa. a locally developed instrument may contribute to standardised evaluation procedures of high-risk neonates and address needs in resource constrained developing settings. objective: the aim of the study was to develop and validate the content of a clinical feeding assessment scale to diagnose oropharyngeal dysphagia (opd) in neonates. method: the neonatal feeding assessment scale (nfas) was developed using the delphi method. five international and south african speech-language therapists (slts) formed the expert panel, participating in two rounds of electronic questionnaires to develop and validate the content of the nfas. results: all participants agreed on the need for the development of a valid clinical feeding assessment instrument to use with the neonatal population. the initial nfas consisted of 240 items across 8 sections, and after the delphi process was implemented, the final format was reduced to 211 items across 6 sections. the final format of the nfas is scored using a binary scoring system guiding the clinician to diagnose the presence or absence of opd. all members agreed on the format, the scoring system and the feeding constructs addressed in the revised final format of the nfas. conclusion: the delphi method and the diverse clinical and research experience of participants could be integrated to develop the nfas which may be used in clinical practice in south africa or similar developing contexts. because of demographically different work settings marked by developed versus developing contexts, participants did not have the same expectations of a clinical dysphagia assessment. the international participants contributed to evidence-based content development. local participants considered the contextual challenges of south african slts entering the field with basic competencies in neonatal dysphagia management, thereby justifying a comprehensive clinical instrument. the nfas is aimed at clinicians working in neonatal intensive care units where they manage large caseloads of high-risk neonates. further validation of the nfas is recommended to determine its criterion validity in comparison with a widely accepted standard such as the modified barium swallow study. introduction clinical assessment is an important part of evidence-based management of neonatal dysphagia (thoyre, park, pados & hubbard, 2013). the purpose of clinical assessment is to establish the possible nature of the feeding problem, to explore the parent’s perception of the problem and the neonate’s readiness for oral feeding, to make a differential diagnosis and to determine the need for multi-disciplinary management (arvedson, 2008; rommel, 2006; thoyre et al., 2013). the two main components of such an assessment include a parent interview and medical chart review – to obtain the feeding, medical and developmental history – as well as the clinical feeding assessment (arvedson, 2008; lau & smith, 2011). with the development of a novel clinical assessment instrument, the researchers acknowledge the importance of comprehensive clinical assessment, but concurs with studies (arvedson, 2008; de matteo, matovich & hjartarson, 2005; rommel, 2006) that clinical assessment is not designed to replace objective instrumental assessment such as the modified barium swallow study (mbss). a clinical instrument should support an accurate diagnosis and description of the feeding profile related to oropharyngeal dysphagia (opd) in high-risk neonates. the use of validated instruments should be encouraged in clinical practice because it provides a common language among clinicians, facilitates the production of diagnostic data and promotes the evaluation of techniques and approaches used during clinical assessment (brandao, dos santos & lanzilotti, 2013). there is a high prevalence of low birth weight (lbw) and prematurity in south africa (who, 2012) contributing to neonatal opd. in the usa, the prevalence of feeding disorders in premature neonates is estimated between 10.5% and 24.5% (jadcherla, 2016). currently, no prevalence figures on feeding disorders associated with prematurity are available in south africa. the high prevalence of feeding disorders among the neonatal population supports the need for appropriate early clinical assessment and management of opd, providing an impetus for the development of a valid clinical instrument to contribute to differential diagnosis. in the south african public healthcare sector, there are resource constraints such as limited or no speech-language therapists (slts) to provide feeding services in some neonatal intensive care units (nicus) (strasheim, kritzinger & louw, 2011). slts working in hospitals are also required to manage large caseloads apart from neonatal dysphagia and then do not have the opportunity to specialise in the field. in addition, inexperienced community service therapists are frequently the only service providers in some settings (singh et al., 2015). existing dysphagia assessment instruments may not meet the needs in south africa. philbin and ross (2011) developed the ‘support of oral feeding for fragile infants’ (soffi) which includes a systematic approach to assessment of bottle feeding and clinical decision-making for intervention. the department of health in south africa promotes the world health organization guidelines (who, 2010) for infant feeding which recommend exclusive breastfeeding for the first 6 months of life (national department of health, 2015). the bottle-feeding approach of the soffi therefore has limited application in the healthcare sector in south africa. some reliable clinical instruments that are supported by high-level evidence do exist, but do not focus holistically on neonatal feeding. the neonatal oral motor assessment schema [nomas] (palmer, crawley & blanco, 1992) and the schedule for oral motor assessment [soma] (reilly, skuse & wolke, 2000) both focus on oral motor skills only (pressman, 2010; rogers & arvedson, 2005). these two scales do not address a feeding assessment from a bio-psychosocial perspective to diagnose opd. such a perspective acknowledges the impact of nicu environmental stressors on state regulation, internal physiological disruptions on the neonate’s subsystems and the resulting effects on the feeding process, as well as mother–infant interaction during feeding. a clinical assessment instrument should assist the slt to assess all neonatal systems that contribute to and interact with the feeding process. the instrument should consider the sequential development of the sensory systems emerging throughout gestation in a developmentally supportive approach (browne & ross, 2011; thoyre, 2007). such an instrument should also be comprehensive to facilitate the description of symptoms related to sensory and motor-based feeding difficulties (lau & smith, 2011) that may result in opd from 32 weeks gestational age. neonatal opd is any interference with the acts of feeding and/or swallowing that interrupts the oral or pharyngeal stage of swallowing compromising the development of typical feeding and swallowing skills and the neonate’s nutritional and respiratory status (arvedson, 2008; browne & ross, 2011; rogers & arvedson, 2005). the condition is typically only diagnosed from 32 weeks gestational age when nutritive sucking (ns) should emerge (rogers & arvedson, 2005; thoyre, 2007). to facilitate the assessment process, an instrument should provide prompts for observation of a variety of signs and symptoms related to neonatal opd. the purpose of neonatal feeding assessment is to accurately diagnose opd to prevent the negative sequalae of opd. such negative effects may include inadequate weight gain, dehydration, and limited oral sensory experience, which may continue to impact on infancy and early childhood. obtaining expert opinions on such a new instrument would be invaluable for the development and validation process. this article will report on experts’ opinion on the development of the content and face validity of a clinical feeding assessment instrument. method aims the aim was to develop and validate the content of a novel clinical feeding assessment scale to diagnose opd in neonates. the objectives to support the aim were (1) to determine if the panel of experts agreed about the need for a validated clinical feeding assessment scale, (2) to select appropriate items for inclusion in the neonatal feeding assessment scale (nfas) and lastly (3) to establish face and content validity of the nfas based on expert input. design the delphi method (hassan, keeney & mckenna, 2000) was used to gather quantitative and qualitative data from an expert panel during two rounds of consecutive questionnaires. qualitative data were obtained from open questions, and quantitative data from closed questions. the delphi method was used to guide improvement of content and face validity of the new instrument. this method allowed the researchers to investigate whether the nfas represented all facets of neonatal feeding skills. the primary strength of the delphi method is the objective exploration of issues that require judgement, such as the content and measurement methods when developing a clinical assessment instrument. because the delphi method is considered one of the most commonly used research procedures to establish content validity of an assessment instrument by an expert panel (hassan et al., 2000), this design was considered suitable for the purpose of this study. participants five expert panel members were included in the study. informed consent was obtained from all participants. participant selection criteria included a masters’ degree qualification in speech-language pathology from an accredited tertiary institution to guarantee a high level of expertise and at least 5 years clinical experience in the field of paediatric dysphagia. participants could reside in south africa or internationally. in table 1, a summary of participant characteristics is provided. table 1: participant description (n = 5). all participants had postgraduate qualifications in the field of speech-language pathology. both international experts had doctoral degrees in paediatric dysphagia which demonstrated their advanced knowledge. in addition, the international experts had more than 20 years of clinical experience working in paediatric dysphagia. this highlighted the long history of paediatric dysphagia intervention in the usa as well as the experts’ significant clinical experience. only one of the south african participants had more than 20 years’ clinical experience. materials the nfas will not be described in detail in this section because the purpose of the study was to develop and validate the content of the instrument. the nfas was based on other clinical assessment instruments, studies on neonatal feeding development, relevant literature on prematurity, lbw and paediatric hiv and/or aids in the south african context and recent studies on neonatal dysphagia. additionally, the first author’s clinical experience of service delivery in the private and public healthcare sectors in the nicu provided insight into local needs and knowledge of specific local constraints. two self-composed electronic questionnaires were used to obtain feedback from the expert panel on the content of the nfas. round one required a comprehensive overview of the nfas and round two required targeted responses in closed question format about the revised content, structure and format of the nfas. the two questionnaires contained questions on the relevance of separate sections and items relating to the different neonatal systems involved in feeding in the nfas. both questionnaires gave the participants the opportunity to offer recommendations on the addition or removal of sections and items, to comment on different scoring methods, and to judge the comprehensiveness of the scale and its relevance to clinical use in hospitals. open-ended and some close-ended questions were also included addressing face validity, user friendliness, and the format of the instrument and technical editing (dawson & trapp, 2004). for close-ended questions, reasons for answers had to be given. the questionnaires facilitated a deductive reasoning sequence to compile an authentic profile of neonatal feeding skill assessment. the first questionnaire focused on the content domains of skills related to neonatal feeding and swallowing (als et al., 1994; arvedson, 2008; arvedson & brodsky, 2002; bahr, 2001; brazelton, 1973; browne & ross, 2011; clark, 2009; da costa & van der schans, 2008; darrow & harley, 1998; dieckmann, brownstein & gausche-hill, 2006; gewolb & vice, 2006; hall, 2001, 2011; henning, 2002; hodgman, hoppenbrouwers & cabal, 1993; jadcherla, 2016; karl, 2004; nugent, 2007; prechtl & beintema, 1964; qureshi, vice, taciak, bosma & gewolb, 2002; rudolph & link, 2002; swigert, 2010; tsai, chen & lin, 2010; van haastert, de vries, helders & jongmans, 2006; wolff, 1959; wolf & glass, 1992) – see table 2. a draft version of the nfas accompanied the first questionnaire. table 2: content and rationale for expert panel questionnaire 1. the second questionnaire was developed based on the responses and feedback obtained in the first questionnaire. the nfas was adapted according to the experts’ feedback. the revised nfas was then sent to the expert panel along with the summary of changes recommended in the first round. the second questionnaire was used to further refine the content and face validity of the instrument (table 3). table 3: content and rationale for expert panel questionnaire 2. procedures clearance was obtained from the research ethics committee at the university where the study was conducted. the process of validation of a new assessment instrument commences with the initial development phase providing a sound theoretical foundation to link to clinical practice (st pierre et al., 2010). the initial phase of instrument development consisted of the review of available published scales, checklists and literature, and the researchers’ own clinical experience. the second phase employed the delphi method to request expert judgement on the new clinical instrument. the panel members’ identity was blinded to one another to enhance open participation in the instrument development process. the procedures followed in the study are depicted in figure 1. figure 1: flowchart of study procedures. the preliminary and revised instrument was sent to the expert panel to facilitate two rounds of questioning via email. the panel was blind to one another’s responses. the aim of the first round was to allow the expert panel to judge the validity of the content domains in the instrument. summarised feedback, to the panel, after round one served as the introduction of round two. the aim of the second round was to reach consensus on the recommendations of the first round, as well as on the content and the scoring system of the instrument. after the second round responses were received from the participants, the delphi process was concluded, as majority agreement and no new additional content was suggested, indicating that adequate consensus among panel members had been reached. the delphi method allowed rich data to be gathered because open and closed questions could be used to probe the participants’ views on the nfas. round one rendered descriptive data which was analysed according to emerging themes linked to the various content sections of the draft instrument. data analysis according to hassan et al. (2000), the delphi method is not intended to produce statistically significant results, but rather a synthesis of an expert group’s opinion. suggested changes according to the themes that emerged from the data will be discussed. sections of the data of round one and all of the data from round two were analysed quantitatively using frequency counts. results results will be presented according to the three objectives of the study. objective a determining agreement on the need for a validated feeding assessment instrument three themes were identified linked to the content sections of the first questionnaire. the first content theme was the need for a valid assessment tool. the second theme was content of the nfas and the last was scoring criteria. only the first theme’s results are discussed with this objective. questions 4 and 5 in the first questionnaire investigated the rationale for the development of the nfas. all participants (n = 5; 100%) agreed that the development of a valid clinical assessment tool was a relevant area of study and confirmed the need for such a tool. some participants also provided further comments to reflect their agreement. it was stated that: ‘…there is definitely a need for a well-researched assessment tool for use with infants…’ [participant 4, female, slt] however: ‘internationally still a huge lack of normative data regarding sucking and swallowing along with more global developmental aspects of feeding in young infants….difficulty lies in subjectivity of observation of skills that are not measurable…’ [participant 2, female, slt] one of the south african panel members commented that: ‘…in south african public healthcare an instrument would help with prioritisation of a large case load on assessment outcomes that are valid…and prevent over referral to video swallows….’ [participant 5, female, slt] in addition, one of the participants stated that a validated feeding assessment instrument might support clinicians in case management. the qualitative comments further supported the rationale for research to develop a validated feeding assessment instrument for use with the neonatal population. objective b content and item selection of the neonatal feeding assessment scale the content and item selection of the preliminary nfas was based on theoretical constructs related to neonatal feeding and the clinical assessment of feeding difficulty in early infancy. the instrument relies on physiological observations of the neonate during feeding and elicitation of oral responses. neonatal states were included so that the influence on feeding and state disruption as a result of feeding difficulty may be observed. the structure of the initial draft of the nfas included three different age categories – from 32 weeks gestational age to 4 months corrected age post term. these different age categories allowed for the inclusion of developmentally appropriate items. in table 4, the content of the nfas and the rationale for content selection are summarised. table 4: preliminary neonatal feeding assessment scale content and rationale for item selection. all five participants contributed to both rounds of the delphi process resulting in a 100% response rate. the results of rounds one and two are presented separately. the thematic analysis of the first theme of round one was discussed, and examples of panel member responses to complement the data were provided in the first section of the results; however, in this section results related to the second and third themes are presented. the closed question responses of rounds one and two are combined and will be presented in table format. results of round one the second theme addressed the content of the nfas, it was stated: ‘…it is a very comprehensive tool covering all necessary areas…’. [participant 1, female, slt] a similar comment was made by participant 2. however, it was stated that: ‘….section g [parent-neonate interaction] and h [use of compensatory strategies] are not that relevant to first-time assessment…i view it as part of treatment already…consider removing it from the current instrument’. [participant 5, female, slt] three of the participants indicated that these two subsections were too subjective and not directly relevant to initial assessment and diagnosis of opd. these subsections were then omitted from the final instrument. four participants also suggested revision of some of the items related to feeding and swallowing ability in the content domains in sections c, e and f. based on some participant’s feedback (n = 3), there was support for the notion of a comprehensive clinical assessment in the neonatal stage, despite indicating that the instrument was too lengthy. the recommended scoring system of the nfas (theme three) included allocation of marks if a skill and/or behaviour was present or absent. the clinician would then calculate a score for each section and a final score for feeding difficulties to conclude the assessment. the higher the score, the more likely a neonate could be diagnosed with opd. theme three dealt with the scoring criteria. statements were made, such as: ‘…consider simplifying the scoring system for ease of use…might be confusing in current format’ and ‘[y]ou need to score a concept to compare it to a gold standard to be able to validate it’ [participant 1, female, slt] another comment was: ‘…the scoring system will be easier if binary scoring in a checklist format is used in the final version of the instrument….with a good explanation of administration guidelines…’ [participant 4, female, slt] one of the south african participants stated: ‘the scoring system is a bit confusing in this format…instructions on how to assess the neonate should be expanded…since some speech therapists might lack experience….and need help…’ [participant 5, female, slt] three participants suggested clearer administration guidelines and using a different approach to score the data. results of round one led to the refinement of the initial scoring system. binary choices were included for each item in all sections, with clear administration and scoring guidelines in the revised instrument. the scoring method was refined with assistance from a biostatistician to include a binary (yes/no) outcome for each section and a total score that will enable comparison with a widely accepted gold standard for swallowing assessment, in this case the mbss. in summary, all participants agreed on the need for more research to develop a validated assessment instrument. three of the five participants agreed on the comprehensive nature of the proposed content for the draft nfas. lastly, all the participants recommended refinement of the scoring system. however, differences in opinion encountered in the feedback from participants in round one were analysed further to highlight how the south african panel members’ responses differed from the international participants’ contributions. these differences may be as a result of the disparity of resources between the developing and developed context of the participants, and challenges experienced in the local context that international participants may not be aware of. a difference in opinion was clearly evident between the two groups of panel members about the length of the instrument and item inclusion of which both components related to the comprehensive nature of the nfas. results of round two upon conclusion of round one, the nfas was revised according to recommended changes where the majority opinion (dawson & trapp, 2004) motivated the changes. to initiate round two, a summary of the first round’s recommendations and the revised instrument were sent to the participants. objective c face and content validity of the final version of the nfas the second questionnaire provided quantitative data that could be compared with some of the close-ended questions in round one. round two offered an opportunity for additional comments by the panel members if they felt that the previous round did not address all their concerns. the comparative results of the two rounds are depicted in table 5. table 5: quantification of degree of agreement among participants. according to table 5, the majority of panel members’ (n = 4) opinions regarding some of the concepts probed in round one and again in round two (closed questions) reflected increased agreement on the probed components of the final version of the nfas. one participant did not agree on the user friendliness, content and face validity in round one. to ensure scientific rigor, the delphi process holds researchers accountable by providing a true account of the participation responses. as participants responded via email, data could be saved and verified. no qualitative comments were received in round two. according to table 4, there were a number of disagreements in round one that was resolved in round two, which indicated high agreement among the panel. all members agreed on the format, the scoring system and the feeding constructs addressed in the revised final format of the nfas. the final content and checklist format of the nfas, which resulted from the delphi process, consisted of six sections with different items. the nfas is summarised in table 6. table 6: overview of the final neonatal feeding assessment scale. all the changes were made based on majority recommendations of the expert panel. according to table 6, one subsection in section a contained nine items relating to the discolouration of the neonate’s skin indicating lack of oxygen in the orofacial area. the majority of participants considered these items too subjective for accurate scoring, and therefore, it was removed. section b remained unchanged because participants suggested no changes. in section c, eight items relating to various stress cues were removed because of possible ambiguity, repetitiveness or vagueness indicated by three participants. section d was reduced from 17 to 12 items to screen muscle tone and movement in a more concise manner because five of the items were considered redundant by four participants. in the last two sections (e and f), items suggested by all the participants were added to ensure comprehensive observations of oral structure as well as neonatal feeding and swallowing skills. however, the international panel members recommended that subsections (in sections e and f) relating to physical symptoms of illness (e.g. oral thrush in neonates with hiv and/or aids), saliva management and feeding methods should rather be obtained from the neonate’s medical record or during the parent interview, and therefore, it was removed. in some of the subgroupings in sections e and f, where feeding skills relate to developmental level, two age categories were linked to assessment items and criteria leading to a reorganisation of items. all the participants agreed on the use of these age categories. age categories may enable serial assessment to build a feeding profile over time whilst the neonate is receiving hospital-based care. the components of comprehensive clinical feeding assessment that emerged were the observation of physiological status, state of alertness, stress cues, postural control and tone related to feeding position, oral-motor structure and function, non-nutritive sucking (nns) and ns, behavioural responses to feeding and symptoms of opd (dodrill, cleghorn, donovan & davies, 2008; lau & smith, 2011; thoyre et al., 2013). these components were all addressed in the revised nfas. the length of the instrument relates to the local need and aim of a comprehensive assessment tool which should include signs and symptoms reflecting the presence of opd in neonates. discussion need of the neonatal feeding assessment scale the need of a clinical tool to assess opd in high-risk neonates was established. in a review of oral feeding assessment instruments for infants younger than 6 months, the findings of pados et al. (2016) support the identification of this need. they concluded that there is a need for the development and testing of feeding assessment tools for young infants to guide optimal clinical practice. it is also suggested that such assessment tools should allow use for breast and bottle feeding for consistent assessment across feeding methods. meeting this need may facilitate more appropriate management of opd in neonates, because intervention will be guided by reliable and comprehensive assessment findings with an accompanying diagnosis. infants discharged with inadequate investigation into the feeding difficulties or unresolved feeding difficulties, lbw and prematurity are more at risk of developing failure-to-thrive than their term counterparts with appropriate weight for age (browne & ross, 2011). valid and reliable assessment instruments will help clinicians to objectively evaluate feeding (pados et al., 2016). development, faceand content validity of the neonatal feeding assessment scale the delphi method was used to develop the final format of the nfas and to establish face and content validity. this was achieved by convening an expert panel to assist with the further development of a novel clinical feeding assessment instrument. the interaction process was collaborative and yielded constructive comments supporting the validation of the nfas. the delphi process was helpful to consider appropriate feeding constructs for content selection, to develop a reliable scoring system and to enable transparency and replication of methodology. differences in opinion between the local and international participants emerged and may likely be ascribed to the working context in developing versus developed countries, emphasising the challenges present in the south african context. the participants’ comments supported the rationale of the study regarding the development of a neonatal feeding assessment instrument supported by evidence, but also highlighted the subjective nature of observation of skills related to neonatal feeding. this calls for more research on objective measurement of skills related to feeding difficulties in neonates. the south african participants did not see a need to shorten the nfas significantly because they felt that it ensures holistic and comprehensive clinical assessment that might be lacking in inexperienced clinicians. in contrast, the international participants were of the opinion that the instrument was too lengthy for clinical use in the initial version. this may be due to the international experts being more experienced than some of the south african participants in clinical practice, because both of the international experts had more than 20 years’ experience working in the field of paediatric dysphagia. the participant responses assisted the researchers in refining the content and items of the nfas. south african participants considered comprehensiveness as important in clinical service delivery in resource constrained settings. many inexperienced clinicians are conducting their community service year and require guidance. a comprehensive assessment instrument may prompt observations which may be missed when item descriptions are omitted. international participants focused on the subjectivity of some items which revealed that they were more experienced and therefore concerned with the levels of evidence to support the inclusion of sections and items, especially in a context where inexperienced slts may be using the nfas. no difference in opinion regarding the scoring criteria and guidelines was noted. however, one international participant was the only expert who recommended consultation with a biostatistician, demonstrating knowledge of instrument development acquired during her research career. owing to demographically different work settings marked by developed versus developing contexts impacting on healthcare service delivery, participants did not have the same expectations of a clinical assessment. the local participants were aware of inexperienced slts entering the public health system in their community service year and having to diagnose opd without mbss equipment. the nfas was designed to prompt inexperienced slts to include appropriate content domains during clinical assessment and supports a comprehensive approach to assessment of neonatal feeding problems such as opd. paediatric and adult dysphagia were formally included as a module in undergraduate speech-language pathology curricula in 2004 in south africa (see faculty of humanities undergraduate syllabi and regulations, 2004, university of pretoria as an example). there is thus only an 11-year history of formal professional training at universities in south africa. although dysphagia is now an established component of local speech-language pathology curricula, much research is still required. dysphagia is a relatively new, yet growing field in the profession in south africa with active pursuit of research (blackwell & littlejohns, 2010; pike, pike, kritzinger, krüger & viviers, 2016; singh et al., 2015). outcome of the delphi process the participants had the opportunity to critically evaluate the revised nfas as indicated by their change in responses in round two, leading to majority consensus (see table 3). one of the members who did not agree on the user friendliness of the draft instrument still indicated that the nfas was too lengthy despite revision. this concern already emerged in round one and was addressed through implementing the recommended changes (see table 6) and using a checklist format that improved effectiveness. the same participant indicated that the face and content validity were not completely adequate because many observations remained subjective in nature. the researchers attempted to include measurable items where possible to decrease subjectivity; however, this was not possible for all items. there remains a great need for further research on neonatal feeding skills and objective measurement technologies. the validity of content and items were supported by using current research on developmental skills and feeding abilities of neonates. the aforementioned concerns were addressed as far as possible in the final format of the nfas. when interpreting results in a delphi process, the majority opinion motivated the changes, but if a valid contribution is offered by a single participant or a minority, the researchers may choose to use it (okoli & pawlowski, 2004). in the revised nfas, local needs were paramount and the south african participants preferred a comprehensive assessment instrument. similar to the nfas, other researchers in health sciences also found the delphi method useful in contributing to the successful development of clinically relevant assessment instruments (crist, dobbelsteyn, brousseau & napier-phillips, 2004; da costa, van den engelhoek & bos, 2008; schulz et al., 2009; yousuf, 2007). the nfas is aimed at clinicians working in nicus, where they manage large caseloads of very young high-risk populations. an increased prevalence of high-risk neonates exists in developing countries such as south africa (who, 2012). early identification of opd whilst these neonates are still accessible in the hospital is important to allow opportunity to train mothers to manage feeding difficulties before discharge. in addition, opd appears to be more prevalent than growth problems in preterm neonates and is likely to continue into early childhood, thereby indicating the need for early intervention to address feeding difficulties and minimise caregiver stress (crist et al., 2004). the nfas aims to provide a developmentally supportive approach to assessment as proposed by thoyre et al., (2013). the nfas is minimally invasive because assessment is mainly through observation of a broad scope of skills before and during feeding to prevent overloading neonatal sensory systems with physical handling. studies by philbin and ross (2011) as well as browne and ross (2011) indicated that unnecessary physical handling may disrupt state regulation during this sensitive stage of neurological development. another characteristic of the nfas includes the parent/caregiver in family-centred service delivery. mothers contribute greatly to feeding assessment by providing information about their infant, and their experience and feelings surrounding the feeding challenges. a family-centred developmentally supportive approach relates to current evidence in the field of neonatal dysphagia (lau & smith, 2011; thoyre et al., 2013). conclusion in south africa, the field of paediatric dysphagia was formally introduced to curricula at universities in 2004, but was practiced many years prior to this introduction. issues such as resource constraints, inadequate infrastructure, new graduates required to manage large caseloads in the public health system, few expert clinicians in practice and feeding difficulties related to hiv and/or aids are some of the challenges faced in practice (blackwell & littlejohns, 2010; singh et al., 2015). inexperienced clinicians may benefit from structured guidance provided by the nfas in a resource-restrained context where patient prioritisation is key. the inherent limitations of the delphi method include judgements of a select panel which may not be representative of the opinions of all clinicians. the time-consuming nature of participation which may impact on the thoroughness of the panel members’ responses, may also be a limitation. the final version of the nfas reflects relevant areas of neonatal feeding prominently. the item selection clearly indicates the wide array of skills and components forming the foundation of neonatal feeding behaviour and responses that should be included in a comprehensive assessment instrument to be used by slts. the final content and checklist format of the nfas was compiled as the first step in validating the nfas and will be used in a future study 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( s p . & h . t h e r a p y ) ( w i t w a t e r s r a n d ) j.g. strijdom hospital, auckland park, johannesburg summary the jargon utterances of two groups of two subjects each, group a, children with normal speech and language development, and group b, children with delayed or impaired speech and language development, were recorded and transcribed. the data were divided into meaningful and non-meaningful categories. the former were analysed into morphemes in terms of distinctive features and phonemes. all subjects were, found to have essentially similar distinctive features, phonemes and morpheme structures with minor exceptions. intonation varied: group a used more sentence intonation, whereas group β used more word intonation. word approximations, standard and selflanguage words were found in all subjects. it was concluded that jargon appears to be a fusion of early phonological development and phonetic attempts, and that no significant difference exists between the two groups. opsomming die brabbeltaal van twee groepe bestaande uit twee proefpersone elk, groepp a, kinders met normale spraaken taalontwikkeling en groep b, met vertraagde spraak-en taalontwikkeling is opgeneem en neergeskryf. die gegewens is verdeel in sinvolle en nie-sinvolle kategorie. eersgenoemde is geanaliseer in morfeme in terme van onderskeidende kenmerke en foneme. daar is gevind dat al die proefpersone essensiele ooreenstemmende onderskeidende kenmerke het sowel as foneme en morfeme struktuur met klein verskille. intonasie het verskil. groep a het meer sinintonasie gebruik terwyl groep β meer woordintonasie gebruik het. woordapproximasies, standaard woorde, selftaalwoorde is gevind in alle proefkonyne. daar is tot die gevolgtrekking gekom dat brabbeltaal 'n vermenging van vroeer fonologiese ontwikkeling en fonetiese pogings skyn te wees en dat geen betekenisvolle verskil bestaan tussen die twee groepe nie. jargon is a type of infant utterance. these and other infant utterances are studied because it is assumed that there exists some correlation between prelanguage and language utterances and that these in some way prepare, determine or establish the bases for later language. also, their very nature e.g. a paucity or lack of vocalizations, may be used prognostically for later development. the investigator found the following characteristics or descriptions of jargon in the literature: tychkrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde. vol. 22. desember 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 diane hurwitz (1) "jargon", "gibberish", "unintelligible jabber" are all acceptable terms1·3·4· 6 , 1 2 , 1 3 , 1 5 , 1 8 (2) the earliest age of onset appears to be 3 months, with a peak at 18 months, and is usually gone by 2 y e a r s . 3 · 6 · 1 8 · 2 1 (3) it consists of sounds strung together, usually with repetition of morphemes but also varied sounds. 1 · 1 2 · 1 8 (4) characteristically it has adult intonation 1 · 1 2 · (5) it is unintelligble to the listener 5 · 1 2 (6) it appears to be non-symbolic. according to gesell & thompson 6 · the child is communicating but bloom & wyatt 2 1 · disagree. (7) it appears to be voluntary and controlled 1 , 1 2 (8) not all children use jargon 1 van r i p e r 1 8 · implies that the jargon of a child with delayed or impaired speech and language development would be similar to the above. clinically, some children using jargon have, on further analysis, been found to be using neologisms and/or having multiple articulatory errors and/or with impaired syntax. jargon must be distinguished from babbling. myklebust's17 definition that babbling is used: " . . . as the pleasureable use of vocalization . . . " appears apt. it begins at 3 months and extends to approximately 12 months which is the usual age when the first word is used. mowrer16 suggests that it is used primarily when the infant is contented, and not in the presence of the parent. experimental procedure hypothesis (1) the jargon of the child with normal speech and language development is an advanced stage of babbling. (2) the jargon of the child with delayed or impaired speech and language development will be different to (1) subjects there were two groups of two children each. group a were children with normal speech and language development. group β were children with delayed or impaired speech and language development. criteria for group a were that the child be between 1 5 and 19 months, that the intellectual and motor development appeared to be within normal limits (assessed subjectively from observation of child at play) and that the vocalizations were a gibberish with adult intonation. it did not matter if the child used words as well. the subjects were al, a girl of 17 months, who used only jargon; a2, a girl of 18 months, who used jargon and words. criteria for group β were that the child be older than 24 months, that a speech therapist diagnose the utterances as jargon, that intellectual and motor development may or may not be within normal limits. for this group jargon was not defined but obvious and gross articulatory and/or syntax errors were excluded. the subjects were, β1, a girl of 3 years, who used jargon and was at journal of the south african speech an hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) jargon in normal and language impaired children 65 the time of testing attending therapy; b2, a boy of 25 months who used jargon which was described by his parents as a "language of his own." all subjects had english as their home language. al's parents spoke hebrew as well, and bl's parents spoke hungarian. these foreign languages could have been an influence on the children and cannot be discounted. however, all the parents insisted that they only spoke english to their children, and that the foreign language was only for private interchange between the parents. socio-economic status was not considered but it did not appear to vary greatly. αι, a2 and b1 were all first children of the family. b2 was the third child. t e s t i n g a recording of the spontaneous utterances of each child was taken. the investigator visited each child at least once, so as to familiarise the child with herself and the taperecorder. the recordings were taken on one subsequent visit (except for a2, were recordings were taken over two visits). a sony portable/mains cassette taperecorder with an electret condenser microphone was used. the child was recorded in her bedroom whilst playing with toys and books provided by the investigator plus any other toys of her own. on most occasions the mother (or a sibling in the case of b2) was present at the recordings. the child played either with the mother or investigator. no attempt was made to correlate utterances with actions. if certain utterances appeared to have a target word or meaning, this was noted. the first 20-30 minutes of each recording for al, b1 and b2 were transcribed. for a2, her jargon utterances, plus about fifteen minutes of words were transcribed. the data were transcribed using a canon repeat-corder in broad phonetic notation using the symbols of the international phonetic alphabet, modified by the investigator with the help of professor l.w. lanham, department of phonetics and linguistics, university of the witwatersrand, johannesburg. the units of analysis were not phones i.e. speech sounds but phonemes, interpreted in terms of the investigator's english phonemic system. the symbols used were 'cover symbols' i.e. they stood for any sound that appeared to approximate that symbol eg /b/ [b, b, b h , p, p h ] . the symbol includes both voiced and voiceless cognates as one is unable to ascertain voicing without spectrographic analysis. the cover symbols used: stops: /b/ [b,b,bh,p,ph];/d/[d,d,dh,t,th];/g/[g,g,gh k, k h ] ; fricatives: /f/ [f, v] ;/s/ [s,z,x]; /s/ [s, z]; nasal resonants: /μ/ [ιη,φ]; /ν/ [η, η ο , α ] ; lateral resonants: /l/ [ 1, j ] ; any type of flag, trill or central resonant /r/; semivowels: /w/ ; /υ/ ; /h/ no affricates were used. consonant clusters were transcribed as consecutive consonants. τydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 22, desember 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 66 diane hurwitz the cover symbols for the vowels: i 3 a e 9 u ε a , 3 p that is, four front vowels; high raised mid, lowered mid, and low; four central vowels: two mid, one low, and one central but rather back, three back vowels; high, mid and low. all front vowels were unrounded and all back vowels rounded. there were three glides a i , a,u, i 3 length was not considered. the boundaries of the utterances were"difficuluo define and was done subjectively. a pause, period of silence or an interruption by another speaker indicated a boundary. pause and stress were used to determine smaller units within the longer utterances. the transcriptions were transcribed twice, with an interval of two weeks, by the investigator. agreement was found. analysis of the results the data were divided into three categories using intonation as the distinguishing factor: (1) clear, distinct utterances. (2) vague utterances eg. musings, wailings, singing. (3) exclamations and interjections. categories 2 and 3 were discarded and category 1 was sub-divided: certian shorter sequences appeared to be maximally stressed within a longer utterance and bounded on either side by silence, however minimal the period. these were called morphemes after the definition by gleason7. this term was chosen in preference to word which implies a sound-symbol relationship. a morpheme was composed of any number of syllables which was usually a consonant followed by a vowel; very rarely a vowel occurred in isolation as a syllable, but then it was always followed by a consonant and a vowel. each consonant and vowel was a phoneme as discribed by jakobson 1 1 : "a bundle" of distinctive features i.e. those features that establish contrast between phonemes. certain of the morphemes could be recognized as "babytalk" or standard english words and were called such, and included in the data for analysis. this approach was adopted because lanham1 4 feels that morphemes are phonetic attempts by the child to achieve a target word which would then be stressed. bloom1 postulates that the child during the jargon period is practising adult intonation. thus, as an adult would stress an important word, so the child stresses the meaningful morphemes. it is felt, and gruber9 supports this, that the child appears to be speaking language as opposed to babbling and he found that the morphemes corresponded to those of english. subjectively, the fact that all children already used recognizable words and that they demanded attention and responses from their listeners gives support for this approach. if, as it is postulated, the child is attempting to convey meaning then he will be setting up oppositions in the form of a system i.e. distinctive features. j a k o b s o n ' s 1 0 · 1 1 distinctive features were modified by the investigator on the suggestion of lanham 1 4 . only articulatory features i.e. of place and manner journal of the south african speech and hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) jargon in normal and language impaired children 67 were considered. they are as follows: each is binary, either a phoneme has that feature (+) or it does not (—). (1) vocalic / non-vocalic: where there is no obstruction of the airflow by the organs of articulation. (2) consonantal / non-consonantal: either complete or incomplete obstruction. (3) continuous / non-continuous: partial obstruction. (4) resonant / non-resonant: no friction and partial obstruction. (5) nasalized / non-nasalized: air flows through the nose, obstruction in the mouth. (6) lateral / non-lateral: air flows over the sides of the tongue. (7) front / non-front: sound is formed at the front of the mouth. (8) back / non-back: sound is formed at the back of the mouth. (9) low / non-low: the tongue is low in the mouth. (10) glide / non-glide: first vowel is followed by a movement toward another vowel. voicing was not recognized as a phonetic feature and thus is not included as a distinctive feature. the distinctive features are organized into phonemes as follows: /b/ /d/ ,/g/ + consonantal — vocalic — continuous + front + consonantal — vocalic — continuous — front _ + consonantal^ — vocalic — continuous + back if i /s/ in eld. 3 + consonantal — vocalic + continuous — resonant + front _ + consonantal — vocalic + continuous — resonant — front — back _ /m/ /n/ + consonantal — vocalic + continuous + resonant + nasalized + front + consonantal — vocalic + continuous + resonant + nasalized — front — back __ ydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 22, desember 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 8 diane hurwitz / l/ + consonantal — vocalic + continuous + resonant — nasalized + lateral — front — back /r/ + consonantal — vocalic + continuous + resonant — nasalized — lateral — front — back /w/ + consonantal + vocalic + continuous — resonant — front λ7 + consonantal + vocalic + continuous — resonant — front _ / h / + consonantaf 4vocalic + continuous — resonant + back _ / i / [ i , e , e , 3 , 3 ] — consonantal + vocalic + front — low i [u,d, a] — consonantal + vocalic + back — low _ / a / [ a e a , p ] — consonantal + vocalic — front — back + low _ the data were re-written in terms of the phonemic system. results and discussion morpheme structure the four most common morpheme structures were: cv, cvc, cvcv, vcv where the vowel (v) and the consonant (c) may o'r may not be identical with the morpheme. ' in group a cvcv appeared to be the most common form, closely followed by cvc; whereas for group b, cv was clearly the most common form; cvc and journal of the south african speech anil hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) jargon in normal and language impaired children 69 cvcv occurred less often, but more or less equally. vcv was used infrequently by a2, b1 and b2 and not at all by a1. all subjects excluding b2 had an additional idiosyncratic structure: a1 was cv l : where either /l/ can be regarded an established phoneme, thus cvc, or as a phonetic realisation of the vowel, thus cv. neither can be stated emphatically. a similar case occurred with b1 and cvn. . a.2 used ccv: either cj c2 v or cc can be recognized as a single element and c2 is listed as a distinctive feature of c r in this manner a new morpheme category does not have to be created. this notation can be used to simplify other morphemes used by β1 eg vcc vc; cvcc cvc, and others. only certain consonants appeared as c 2 so that it appears that this explanation is better than postulating the existence of clusters. if b1 did in fact have consonant clusters then it would be evidence of his abnormal development. burlings2, velten1 9, and winitz & irwin2 0 found similar morpheme structures for the period 16-21 months. distinctive features, phonemes and phonemic systems the following distinctive features were strongly established in all subjects: [± vocalic], [±consonantal], [±continuous], [±resonant], [±front], [±back], [±low], [+ nasal], [ glide]. the following are weakly or in the process of being established: [ nasal], [+ lateral], [+ glide]. only b1 used [ lateral] and it appears to be weakly established. the phonemic system common to all subjects was the following: consonants: /b/ /d/ /g/ ' /si ' /n/ ili /w/ vowels /i/ /u/ /a/ the strongest opposition was that of the consonants and vowels. this is the first opposition that the child learns.10· n all subjects showed strong opposition between non-continuants (i.e. stops) and continuants (i.e. fricatives and resonants). stops were the predominant type of consonant, and the only type to contrast in three places of articulation. for 3 subjects (excluding b2) nasal resonants seemed better established than fricatives because they contrasted both labially and dentally. b.2 used only a dental nasal: this violates jakobson's law of solidarity which states that one cannot have a [ front] before a [+ front] consonant. the reasons for this may be that the data were insufficient, inaccuracy of transcription or impairment of development. because fricatives occurred so rarely, and particularly labial fricatives it seems that the principle of "underarticulation" may be applied i.e. the child is aiming at a stop but produces a fricative. tydskrif van die suid-afrikaanse vercniging vir spraak cn gelworhcclkumle, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 diane hurwitz the results appear to be in agreement with j a k o b s o n 1 0 , 1 1 who states that the first opposition among type is stop vs. nasal, and not velten1 9 who states that it is stop vs. fricative. the acquisition of non-nasal resonants is a late acquisition: all subjects used /l/ infrequently. b1 used both /r/ and /l/ and this is usually an extremely late acquisition and is probably further evidence of his impaired development. all subjects used /w/ and this agrees with previous findings10·19 which indicate that it is the first semi-vowel to emerge. only a1 did not use /y/ and this is probably because she was younger and at an earlier stage of development. /h/ is difficult to transcribe and may have been confused with a voiceless vowel. b1 used it once, b2 more frequently. its absence in group a may be queried as velten1 9 found it established at 16 months. the many varied phonetic realizations of the vowels were fitted into jakobson's 1 0 , 1 1 primary triangle: front back i u a low the status of the vowels is difficult to ascertain, but if one assumes that vowel and consonant development run concurrently then it would appear that the oppositions do exist. however, goldstein8 states that at a certain period only the c is contrastive, this may be so in view of the word approximations. [+ glide] is weakly established: two glides were used by all subjects. burlings2 reported that his child used them at 18-19 months. the results with minor exceptions appear to be confirmed by j a k o b s o n ' s 1 0 , 1 1 studies. the distinctive features are similar to those of joan velten1 9 at 16 months with the exception that the investigator has set up three place distinctions instead of two. word approximations in.these attempts the child would variously try different vowels and consonants, but each was clearly recognizable eg. didi did8 bidi /gigi/ [kiti] kitty gidi gagi this seems to be strong support for the postulation that the other morphemes are also some sort of variation of some unknown target word. words these included both standard and self language words: all subjects had them but the number varied: a1 two, a2 many, β1 four, b2 only self language word eg. nana for mother. journal of the south african speech an hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) jargon in normal and language impaired children 71 intonation group a used recognizable english sentence intonation, with the occasional question intonation. a2 used word intonation when using words. group β used the same type of intonation as group a but to a lesser extent; they tended to give each morpheme separate intonation. intonation observed in group a confirms similar observations made by bloom.1 conclusion hypothesis 1 is rejected because it seems that the jargon of the child with normal speech and language development appears to be a fusion of the early stages of phonological development and phonetic attempts at a target, possibly occuring either before or simultaneously to the acquisition of the first words i.e. it is postulated that jargon belongs not to the pre-language but to the language period or alternatively represents a bridge between the two. it seems doubtful though that jargon can be said to be a language. hypothesis 2 cannot be accepted nor rejected: the jargon of the two groups appears to be essentially the same; if this is so, then group β may be said simply to have delayed speech. but if the various deviations discussed are accepted as such then one can conclude that group b's development is impaired. the implications of this study appear to be that if a child is using jargon beyond two years, his speech and language development is delayed but that he does seem to be able to learn oppositions. thus diagnosis should indicate those contrasts that he has and therapy directed towards those he has not. it would seem most appropriate to begin therapy at the holophrastic or twoword stage. references 1. bloom, 1. (1970): language development: form and function in emerging grammars. the mit press, cambridge, massachusetts and london. 2. burling, r. (1959): language development of a garo and english speaking child. word, 15, 45-68. , 3. cameron, j., livson, n., bayley, n. (1967): infant vocalizations and their relationship to mature intelligence. science, 157, 331-333. 4. concise oxford dictionary, 5th ed. 5. day, e.j. (1932): the development of language in twins: comparison of twins and single children. child development. 3, 3, 179-199. 6. gesell, a. & thompson, h. (1934): infant behaviour: its genesis and growth. mcgraw-hill book co., inc. new york & london. 7. gleason, h.a. (1961): an introduction to descriptive linguistics. (revised edition) holt, rinehart & winston, inc. new york. 8. goldstein, k. (1948): language and language disturbances. grune & stratton, new york. 9. gruber, j.s. (1973): playing with distinctive features in the babbling ydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 22, desember 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 diane hurwitz of infants. in studies of child language development. ferguson, c.a. & slobin, d.i. (eds.) holt, rinehart & winston, inc. new york. 10. jakobson, r. (1968): child language, aphasia and phonological universals. mouton & co., n.v. publishers, the hague. 11. jakobson, r. & halle, m. (1956): fundamentals of language. mouton & co., 'sgravenhage. 12. jones, m.v. (1972): language development: the key to learning. • charles c. thomas. 13. kornfeld, j.r. (1971): theoretical issues in child phonology. paper from the seventh regional meeting of the chicago linguistic society, april 16th-18th. chicago linguistic society, chicago, illinois. 14. lanham, l.w. (1974): personal communication. 15. milisen, r. (1966): articulatory problems. chap. 13 m speech pathology. rieber, r.w. & brubaker, r.s. (eds.). north holland publishing co., amsterdam. 16. mowrer, o.h. (1958): hearing and speaking: an analysis of language learning./. speech. heardis., 23, 143-152. 17. myklebust, h.r. (1957): babbling and echolalia in language theory. j. speech hear. dis., 22, 3, 356-60. 18. van riper, c. (1972): speech correction: principles and methods. (5th ed.) constable & co., ltd., london. 19. velten, h.v. (1943): the growth of phonemic and lexical patterns in infant language. language, 19, 281-292. 20. winitz, h. & irwin o.c. (1958): syllabic and phonetic structure of infants' early words./. speech. hear. res., 1, 250-256. 21. wyatt g.l. (1969): language learning & communication disorders in children. collier macmillan, canada ltd., toronto, ontario. journal of the south african speech an hearing association, vol. 22, december 1975 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) brclel & kjaer manufacturers of electro-acoustical instrumentation * audiometer calibration * hearing aid test sets * sound level meters * noise dose meters * artificial ears * artificial voice * artificial mastoid * frequency analysers for more information write or phone: sole s.a. agents: — telkor electronics (pty.) ltd. p.o. box 7764 johannesburg 200 telephone jhbg.: 836-1301 a l s o : dowson & dobson ltd. + durban — cape town — port elizabeth + member of the afrox group. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ii surgical procedures for the deafness due to otosclerosis d. r. h a y n e s , m.b., b.ch., (rand), d.l.o. (r.c.p. & s.) ear, nose and throat surgeon the history of otosclerosis is of interest and importance for the appreciation of modern surgical techniques. more than in any other branch of surgery is the technique and its meticulous execution able to determine the difference between success and failure in restoring hearing to the sufferer from the stapesfixing process of otosclerosis. modern operations on the temporal bone depend fundamentally on a knowledge of the anatomy of this intricate part of the body and i think it is safe to say that more has been learnt of the physiology of hearing since lempert established the fenestration operation than we knew before. the anatomy of the ear is most easily understood if represented diagrammatically and the accompanying sketches attempt this. for the convenience of describing the physiology of hearing, the anatomy is divided into three parts — the outer, the middle and the inner ears. the inner ear consists of the acoustic nerve endings and it is sufficient here to say that from the point of view of the surgery of otosclerosis the acoustic nerve must be intact before surgery can hope to succeed. f i g u r e 1 the middle ear consists of three small bones or ossicles which form a chain connecting the drum membrane with the oval window. by this means, sound vibrations which enter the outer ear are transmitted from the tympanic membrane via the ossicular chain to the oval window. the smallest of the three ossicles, the stapes or stirrup, consists of two legs or crura attached to an oval plate which is capable of moving like a trapdoor in the oval window. the trapdoor is hinged at its posterior end and the maximum excursions take place at the anterior end. it is important to appreciate this fact as will be seen when the pathology of otosclerosis is discussed. since the inner ear is filled with fluid and this is incompressible, vibrations of the stapes footplate require an outlet and this is provided by another window covered by a membrane and known as the round window. normally, sound waves enter the external ear canal and produce vibrations of the tympanic memberane. these are in turn transmitted through the ossicular chain to the oval window where vibrations are set (yj^dph fig. 1 fig. 2 otosclerosis journal of the south african logopedic society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) in motion in the fluid of the inner ear. it is these vibrations that stimulate the nerve endings in the inner ear and impulses are conveyed to the brain. f i g u r e 2 in the condition known as otosclerosis, there is an overgrowth of spongy bone starting at the anterior end ol the oval window and progressively involving the neighbouring structures. when the spongy bone encroaches on the footplate of the stapes, this structure becomes fixed and, as a result, is prevented from transmitting sound vibrations brought to it by the ossicular chain. as the condition progresses, the whole of the footplate may be involved and even the posterior end may become fixed although, as mentioned above, maximum movement takes place at the anterior end and it is here that the condition produces its maximum interference with hearing. versalius first described the two larger bones in the middle ear cavity in the sixteenth century and the stapes was described by ingrassis at a later date. it says a great deal for the observational powers of valsalva that he described fixation of the stapes as long ago as 1735 and we may be sure that his observation was not assisted in any way by any of the instruments that we consider essential for this type of miniature anatomy at the present time. it was more than a century later that toynbee recognised stapes ankylosis to be the cause of deafness and although his observations were not accepted without misgivings and reluctance by many of his colleagues, we have records of attempts to mobilize the stapes footplates for the relief of deafness in 1878. the first operations failed because of re-fixation of the ossicle and in 1897 passouw tried to by-pass the oval window by making a fenestra in the promontory but surgical procedures in this region were considered to be unjustified for the relief of deafness because of the risk of infection of the inner ear and secondary infection of the cranial cavity. in 1913 jenkins by-passed the oval window by creating a fenestra in the lateral semicircular canal and obtained1 an immediate improvement in hearing which unfortunately was short-lived. once again the surgeons were up against the serious risk of uncontrollable infection. modifications in technique and the advent of antibiotics led eventually to the revolutionary one-stage fenestration nov-ovalis of dr. julius lempert whose tenacity of purpose triumphed over the tremendous opposition of his fellow-otologists all over the world and established surgery of the aural labyrinth on a firm footing. not only did his work indicate surgical possibilities with the use of modern lighting and magnification but it also led to the refutation of many of the previously held theories of the physiology of hearing and enabled great advances to be made in the field of audiology. the ramifications of these advances are almost limitless and when one begins to speculate on the newly charted seas of otology since lempelt's first successful fenestration operation in 1938, the magnitude of his contribution to the world at large can be to a small extent appreciated. f i g u r e 3 the lempert fenestration operation by-passed the fixed foot-plate of the stapes and a new fenestra was made in the lateral semi-circular canal. the new fenestra was then covered by a flap of tissue consisting of the skin of the external canal attached to the tympanic membrane and in order to obtain the most perfect application of this tissue to the new fenestra the incus and the head of the malleus were removed. since the oval window was being by-passed, the ossicular chain was of course not required for its normal physiological function but because the mechanical advantage of the chain was lost the ultimate hearing level was also depressed to a small extent below normal. fig. 3 f e n e s t r a t i o n june, 1961 journal of the south african logopedic society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the fenestration operation reached a very high peak of technical perfection and the indications for operation were worked out to such a fine degree that predictions on the ultimate result could be given with a great degree of accuracy. in 1952, samuel rosen, employing the fundamental techniques of lempert, revived the operation for stapes mobilization and obtained considerable success. modifications were not long in appearing and because the operation was rapidly completed with very little discomfort to the patient it naturally had a tremendous appeal to the victims of otosclerosis. experience has shown that of all the stapes mobilization operations undertaken only 30 to 40 per cent can be anticipated to give good permanent results. as experience has increased in this operation, more and more hazards have come to light but in many cases it has been found that if the procedure is not successful or re-fixation of the stapes footplate occurs, further surgery may be undertaken. in those cases that failed after an initial improvement in hearing, rosen sometimes perforates the promontory and this procedure gives a very temporary improvement in some cases. f i g u r e 4 the operation for stapes mobilization is performed through the external ear canal and part of the skin of the canal attached to the tympanic membrane is elevated and reflected forwards. this exposes the middle ear cavity with its ossicles and the foot-plate of the stapes may be examined directly. mobilization can be effected by inserting a needle into the head of the stapes and rocking it back and forth until the adhesions of otosclerotic bone around the footplate are broken down. if this procedure does not succeed, mobilization of the footplate is achieved by exerting pressure on the footplate directly. it may be necessary in some cases to use a small chisel to break down a large focus of spongy bone around the anterior part of the window. when mobilization has been successfully achieved, it is usually possible to see the round window reflex. this consists of movement of the round window membrane on applying pressure to the stapes footplate. when 60 per cent of mobilized stapes began to re-fix, it became obvious that the mobilization operation would have to be altered while the principle of maintaining the anatomy of the middle ear should be adhered to. for those cases in which the otosclerotic process was confined to the anterior edge of the stapes footplate, fowler amputated the anterior cms of the stapes and fractured the footplate across its centre. the ossicular chain was in this manner maintained 16 journal of the south african logopedic society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) and vibrations could be transmitted through the posterior eras of the stapes. the operation is known as an anterior crurotomy. it gave a higher percentage of permanently successful results than the operation for stapes mobilization. f i g u r e 5 john shea, jnr., of memphis, tennessee, discussed the general principles of stapes mobilization with his orthopaedic colleagues and concluded that the procedures suggested up to that time were unphysiological and doomed for the most part to failure. he then decided to remove the pathological stapes and its footplate and replace them with prostheses. the oval window was considered to be the natural pathway for the transmission of sound waves to the inner ear and apart from anything else the chances of closure of a natural window in the labyrinth seemed to be smaller than the chances in the case of an artificial fenestra. cawthorne at king's college hospital had already attempted a modification of the lempert fenestration using the oval window but had encountered the difficulty of obtaining good application of the tympanic membrane over the window so it was obvious that a substitute for the stapes must be found. f i g u r e 6 shea's stapedectomy consists of removal of the stapes with its footplate and covering the oval window with a vein graft. connection between this and the incus is then effected by inserting a polythene tube between the articulating process of the long process of the incus and the vein graft lying over the oval window. so far, the results have shown 90 per cent success to the bone conduction level of hearing and most of the patients operated on by shea four years ago (when the operation was first performed) have maintained their improvement. needless to say, the operation had hardly been shown to be successful before "improvements" were suggested embodying the sound principles of the original operation. house uses a plug of gelatin sponge suspended from the incus by a piece of stainless steel wire and projecting into the oval window. schucknecht uses a small piece of fat or muscle cut from the ear in preference to the gelatin sponge and suspends it in a similar way in the oval window, i f i g u r e 7 portman of; bordeaux employs a vein graft to cover the oval window and uses the patient's own posterior stapedial crus to complete the bridge between the incus and the oval window. ruedi of zurich removes the stapes completely and then replaces the stapes fig. 6 s h e a s t a p e d e c t o m y fig. 7 s c h u c k n e c h t s t a p e d e c t o r y ι june, 1961 journal of the south african logopedic society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ."crura together with the articulating process to act as his prosthesis. cawthorne uses a twisted steel wire for the prosthesis bridging the stapedial gap. f i g u r e 8 some surgeons have been pessimistic about the future of this type of surgery, but it would seem that, at the risk of the unfortunate exception suffering irreversible damage to the hearing in one ear, one must have the courage to attempt the restoration of normal hearing to the patients suffering from otosclerosis. book i w i e w g h e a r i n g a n d deafness h a l l o w e l d a v i s and s. r i c h a r d s i l v e r m a n , editors holt, rinehart and winston, inc., new york, 1960 as a new science developing from its parent studies becomes an independent speciality, a new vocabulary and literature arises. so the new word "audiology" describing the science of hearing with all its experimental and clinical implications, came into being in the mid-forties, and the need for a text like hearing and deafness edited by hallowell davis (1947) arose. this book served to discuss most of the aspects of hearing and the problems of deafness, and the extensive knowledge and authority of the many contributors fulfilled the criterion established by the author: this book is written for the deaf and the hard of hearing and for their families, their parents, their teachers, and their friends. it is written for physicians, for educators, for social workers, and for all who are concerned with the conservation or improvement of remaining hearing or with the approach to normal living for those who have suffered either complete or partial hearing loss. it is written to answer the thousand and one questions that are continually being asked by all sorts of people about the nature of hearing and the problems posed by partial or complete loss of hearing. audiology has developed, both in depth and extent, so rapidly, and the editor of hearing and deafness is so aware of the needs created by this growth that, thirteen years after the first edition, a revised version has been published with dr. s. richard silverman as co-editor to dr. davis. the shift of emphasis in this edition is implicit in the omission of the sub-title "a guide for laymen". although the layman with impaired hearing, or with children who are deaf or hard of hearing, will still fig. 8 c a w t h o r n e s t a p e d e c t o m y fig. 9 t h e e u s t a c h i a n t u b e a drawing from a dissection of the eustachian tube showing its relationship to the middle ear space on one end and the nasopharynx on the other end. 1 journal of the south african logopedic society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ϋηά the answers to his questions, the main orientation is to students of audiology, and as such, makes this text essential to those readers who, like speech therapists, come to audiology from a closely allied but differently orientated field. as in the first edition, the sequence of the book is from inanimate nature to the individual human to complex social problems — from physical to biological to social. the editors describe this sequence as being "from physics, biology, medicine and surgery to modern studies of impaired hearing and hearing aids, and thence to special education and rehabilitation of adults with impaired hearing. the problems of the education of deaf and hard of hearing children are discussed next, and then the organised social efforts on behalf of the aurally handicapped; and finally, employment and vocational guidance." the second edition presents some new authors and aspects; and re-organization and addition of knowledge and viewpoints within the other chapters. some of these may be mentioned briefly as they serve to show how the altered scope of this edition has served to cover the enlarged audiological field. in his chapter on "the physics and psychology of hearing", dr. davis introduces the cencept of a threshhold zone, and, while discussing anatomy and physiology of the ear, elaborates on the biophysics and physiology of the inner ear, which are now better understood. the description and causes of the various impairments of hearing have been re-organised into a new chapter, called "hearing and deafness", and it is here that dr. davis and dr. fowler propose a more useful set of definitions for hearing impairments than those which existed before. the chapter on the medical aspects of hearing is brought up to date by dr. fowler, and the rapid development of treatment and prevention provides much new material, as does the new section on hearing conservation. surgical treatment has advanced much in the last decade, and details of the stapes mobilization, as well as the fenestration, are given by dr. walsh. "tests of hearing" and the chapter, new in this edition, on special auditory tests, will be of the greatest practical value to speech therapists interested in audiology, as will the discussion on the rehabilitative aspects of | the problem, given in the detailed and •explicit chapters on hearing aids, and their choice and use, together iwith dr. miriam pauls' section on speech reading and dr. carhart's on auditory training and the conservation of speech. the rehabilitative procedures with deaf and hard of hearing children are dealt with in more detail by the authors in this edition and the psychological, sociological and vocational aspects of the hearing-impaired are discussed in the light of increased knowledge of these problems. if the original edition was useful and informative, this edition can be considered invaluable. the thousand and one questions posed not only by the layman, but by the workers and allied professional workers in the new field, are admirably answered. hearing and deafness is a text which is indispensable to the student of audiology. margaret marks, m.a. stroke. a d i a r y of recovery by d o u g l a s r i t c h i e faber and faber, london, 1960 174 pages douglas ritchie was a well-known announcer on the b.b.c. when he suffered a severe cerebral haemorrhage in 1955. he was left with a right hemiplegia and severe aphasia. this book, started two years later, is his account of what happened to him, as he remembers it. although his language is of a relatively high standard, it is evident that his recovery is not complete. the narrative is at times confused, and it is difficult to see the point of certain passages. the book is nevertheless a remarkable achievement. it is a record of the thoughts that were going through this man's mind when he was virtually speechless, and should add much to our understanding of the aphasic's feelings. mr. ritchie's comments on speech therapy are revealing : "i liked miss f. very much, but loathed the time i used to spend at speech therapy." "every student seemed to like the reader's digest, and i had to read the first few paragraphs of many articles". "miss b's influence was not confined to speech, or language re-education as one might better call it. victims of ahasia did want to regain the power of language, but, above that, nearly all of them unconsciously craved for some emotional balance of which they had been robbed by the stroke. ability to help in this need was miss b's real quality." many aphasic patients, too, would benefit from reading the story of mr. richie's battle against great odds and his gradual adjustment to his difficulties. he also gives practical suggestions to other aphasics, and discusses some of the theoretical aspects of aphasia. he feels that by gaining an understanding of his condition, he had a better idea of the purpose of the various therapists who were working with him. pat allsopp. june, 196 journal of the south african logopedic society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society june case history of a brain-injured child (taken from notes on a demonstration given at the vacation course on "therapies in cerebral palsy" in johannesburg, october, 1957. reprinted with the permission of the national council for the care of cripples in south africa. by c. ordman, b.a. log (rand|) johannesburg school and treatment centre for cerebral palsied children. m. is a child who is not motor handicapped but who may be diagnosed as "brain'injured" on the basis of his history and symptoms. his behaviour may also be described as "autistic" (!) ( 2 ) . he is now four years eight months of age. history: his mother is r.h. negative. she had a. "blackout" during pregnancy and whooping cough in the ninth month. m. was a full term baby and weighed 6 lb. 11 oz. he held up his head at three months and sat up at seven months. at this stage he began to make queer movements of his arms and trunk, and these were diagnosed as "fits." initially, they occurred after mealtimes, but gradually their frequency increased. vomiting started at about the same time, and he began losing weight. at approximately twelve months he was hospitalised for two weeks. his condition continued to deteriorate. an e.e.g. taken at this time showed an abnormal record. an airstudy "seemed to indicate slight atrophy of the frontal part of the brain." (verbal report). he was described as hyperkinetic and overactive, and frequent head-dropping was noted. fits and vomiting continued until he was 16 months of age. his general condition then improved and he attempted to stand. at 20 months, the e.e.g. was repeated and again an abnormal record was found "but with considerable improvement." at this stage he was walking. he did not develop speech, took no notice of people, and was unmanageable. a third e.e.g. taken 17 months later showed "a normal record of cortical activity for his age." he was admitted to a school for cerebral palsied children in may, 1955, at the age of two years five months. observations behaviour. he stood with his legs apart rocking from side to side and humming. he was extremely disorganised. he did not use objects correctly. he would for example, upset his milk and then rub it in his hair. he was hyperactive in a purposeless destructive way. unless all cupboard doors were locked, he would inevitably fling the contents in all directions. he stamped on toys and pushed chairs over. he appeared to be unable to control this behaviour. when his activities were limited, he became very distressed. he beat his head, threw himself on the floor and uttered short cries. in the nursery school he had to be watched continually and a special nanny came to school with him every day. social response. he took very little notice of people and his facial expression seldom changed. he smiled only when he was pleasing himself or when he was being tickled. he never looked directly at anyone. when his attention was arrested, he stood looking with his eves down, and his head to the side. speech. he was usually silent, but babbled a little while throwing toys. again, he seemed to babble for his own satisfaction rather than for communication. the aims of therapy, were therefore:— 1) to establish a relationship with him. 2) to decrease his disorganised activity and make him less disturbed. 3) to stimulate his speech production and provide him with an atmosphere in which he would want to communicate. 1 shall discuss these three aspects of therapy separately, although i believe they are closely related. treatment 1) establishing a relationship with him. the therapist tried to make him feel that somebody was warm and affectionate towards him. he was cuddled most of the time, and spoken to in a calm, reassuring voice. in a concrete way a co-operative relationship was built up by rolling a ball to him and gently making him roll it back. similarly, the therapist would do a jigsaw puzzle and expect or aid him to pass her the pieces. he was encouraged to respond to relevant speech such as "give it to me", "pick it up" and "do you want a sweet?" r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) june journal of the south african logopedic society 2. decreasing his disorganised activity and making him less disturbed. limits were set regarding destruction and times for therapy. these were applied unemotionally and it was made clear that he would be punished. for destructive behaviour, but that the therapist still approved of him and loved him. he learnt that one behaved differently with different materials and that whereas he could not tear books, he could scribble on paper and knock down blocks. at first each session followed a pattern. m. knew that as soon as he came into the room he would have to sit down and perform an organised activity. after that he was allowed to play as he liked, until the therapist looked at her watch and said: "time to go now." using the watch may have acted as an objective factor of organised behaviour. m. knew that he could rely on the therapist not to interfere with his play as long as he was not destructive. this trust became mutual as he gained control. he was no longer watched so carefully and the therapist showed tthat she expected certain responses. this approach was carried over to the nursery school where his teacher expected him to take his turn serving milk to the other children. the occupational therapist helped him to play constructively by providing him with material which required purposeful activity, and which incidentally taught matching and discrimination of forms, sizes and colours. 3) stimulating speech. the therapist spoke to him at every opportunity without demanding, but expecting, speech from him. all his large movements and vocalisations were imitated, so that he would begin to imitate other people. he heard words such as "open" "close" "pull" "push" "up" "dwn" in their relevant contexts, and he began to repeat them. the therapist vocalised rhythmically as she drew regular patterns, and again m. imitated. his mother was given an outline of therapy and was asked to continue these activities at home. results m. has progressed well in every way. he now responds to people, communicates by smiling and speech, and reacts to instructions. socially he is becoming a real member of the nursery school group, and is beginning to take part in ring activities., he is fortunate in having understanding and . well-trained nursery school teachers who are able to assess his readiness for new responsibilities. if he is occasionally destructive it is usually because he is angry, and he is able to control this reaction. his play is organised and he concentrates for longer periods. he uses toys and different materials meaningfully. he is sufficiently organised, e.g. to turn the tap on, fill the basin with water, turn the tap off, select the relevant toys (boats, duck and fish) and sail them. at first he tended to repeat the same activity over and over again. as he progressed he not only chose different play materials, but used the same materials in different ways. on the emotional side, his facial expression now reflects joy, anger, recognition, mischief and so on. he uses speech to express his needs and to communicate. he shows interest in naming objects and his vocabulary is growing. he is beginning to look through picture books. he says three word sentences like "look a pic" (look at the picture) and "i wa a tic" (i want a stick). he enjoys meaningful sounds and repeats immediately that the car says "r-r-r" and the scissors "cut". as far as psychological assessment is concerned, this has always been difficult because of his behaviour disorder. the psychologist's report on a test given four months ago, was as follows: "m. has improved but it is still not possible to make an accurate assessment of his mental ability as he is too distractible and only able to concentrate for ten minutes at a time." he did, however, pass the sequin formboard and the wallin peg-board tests at the 36-41 months level, and he was able to correct his errors. summary in summary, i have described a child with history of probable brain damage. he had symptoms of disorganisation, temper tantrums, disturbance in social contact, . destructibility, hyperactivity, lack of concentration and possible perseveration. some of these symptoms may be associated with a diagnosis of autism. he is at a combined school and treatment centre and is making excellent progress. it will be some time before he is ready for formal school work, and it remaiv.s to be seen whether he will have special learning difficulties. befebences: (1). kanner "early infantile autism" journal of paediatrics, vol. 25 no. 3,. sept. 1944. (2) kanner, lee: "the conception of wholes and parts in early infantile autism." am. f journal of psychiatry, july 1951. vol. 108. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) transformational grammar and the case of an ndebele speaking aphasic a . traill department of linguistics, university of the witwatersrand introduction there is a refrain running through much of current linguistic theorizing which says that language is rule-governed behaviour. if i am not mistaken there is an uneasiness running through much of psychology and speech therapy which is based on the feeling that this linguistic view of language is somehow of great relevance to the understanding of normal and abnormal verbal behaviour but just what this relevance is, is not at all clear. this state of affairs is understandable if one bears in mind the following facts: firstly, linguistics is not a unified discipline. its practitioners agree that what they are doing is studying the structure of .human language, but beyond this there is little agreement as to what this structure looks like, whether it is universal and, very importantly, how one should formalize it. secondly, linguists study normal language and furthermore their descriptions are descriptions of langue in saussure's sense or competence in chomsky's sense. that is to say linguists qua linguists have nothing to say about how language is used (parole, performance) in listening, reading or speaking and writing, let alone describing the effects pathologies can have on these normal performances. all this is not to say that linguistics has had no influence in psychology or speech therapy. one finds phonemes, morphemes and syntax cropping up in both these fields and in a number of instances, more than lip service is paid to these concepts. it is no doubt due to the influence of men like r. jakobson that we find linguistic concepts circulating amongst aphasiologists (cf. jakobson 1964) and those concerned with language acquisition (cf. jakobson 1968), although one suspects that his influence should have been greater than it has been. quite recently, the so-called chomskyan revolution in linguistics has had repercussions in related fields, giving new direction to the interdisciplinary field of psycholinguistics (for a summary of research see fodor, bever and garrett 1968) and has given birth to what d. mcneill terms developmental psycholinguistics (examples of this new approach to the acquisition of language can be found in mcneill, 1966, bellugi and brown, 1964, menyuk, 1969). chomsky has stated on more than one occasion that linguistic theory is a psychological theory to the extent that it attempts to provide a formalization of the intuitive linguistic knowledge (competence) of the native speaker of a human language and journal of the south african logopedic' society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) transformational g r a m m a r : t h e case of an ndebele speaking aphasic 49 it is therefore not surpising to find linguistics having an impact on other disciplines. there is to my knowledge only one published attempt to apply the new theory literally to the field of language disorders and this is marshall and newcombe's study of syntactic and semantic errors in paralexia (marshall and newcombe, 1966). had the new theory stood still for long enough we would doubtless have had more examples of its application to the analysis of language disturbances in adults and children. the rationale underlying this recent work in psycholinguistics is as follows: the grammar of a language is a formalization of the intuitive linguistic knowledge which a native speaker of a language internalizes in the course of learning his language and which constrains what is to count as acceptable performance in the language. the formalization is effected by various types of rules operating at various levels of representation: the phonological level, the syntactic level and the semantic level. the theory provides a mechanism for mapping one level of representation onto another, but not in any order: the syntactic level is regarded as central in standard transformational theory and the syntactic representations are mapped onto semantic and phonological representations. the theory thus provides an integrated formalization of the informal observation that sentences in a language have pronunciation (phonological representation), meaning (semantic representation) and syntax (syntactic representation). furthermore, the pairings of meanings and pronunciations (sounds) with syntax mediating, is over an infinite domain. that is to say, one of the facts about native speaker competence which is accounted for in the theory, is that a native speaker of a language is, in principle, able to comprehend and produce an infinite number of sentences including typically ones which are wholly novel. put slightly differently, the grammar of a language provides a definition of the infinite set of grammatical sentences in that language. what the psycholinguists have done, is to regard this theory as a source for formulating hypotheses about linguistic performance. they have, in other words, attempted to predict psychological complexity from complexity in a grammar. if a certain sentence has η rules in its derivation in the grammar, and another sentence as n + 2 rules in its derivation, then the expectation is that the latter sentence will be more difficult to perform (recall, respond to etc.). early experiments had encouraging results, later ones were positively discouraging (see fodor et al op. cit. and schlesinger, 1966). marshall and newcombe's analysis showed that aspects of the transformational grammar of the paralexic they studied had been interfered with through a lesion caused by a. bullet. this suggested quite startling confirmation for the psychological reality of linguistic constructs and came from an unexpected source; clearly, the transformational grammar of english which they used was not written with the aim of explaining linguistic disturbances. nevertheless, there remains something of a paradox in this work. it is that grammars formalize competence; they do not provide a model tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 a. traill of performance. yet in some cases they successfully predict performance complexity while failing in others. an attempt to get round this was made by fodor and garrett (fodor and garrett 1966) by claiming that the relationship between competence and performance is not as was previously thought, a direct one; rather it is abstract. but 'this move is quite unhelpful and seems to me to provide no useful exit from the dilemma. we are merely left with some experiments that worked and others that didn't. one wonders why any experiments worked at all. it is in the context of the foregoing that i would like to discuss the aphasia of w.n., a mother-tongue speaker of ndebele,, a south-eastern bantu language of the nguni group, spoken in southern rhodesia,, and except for minor differences the same as zulu. my purpose in exploring his linguistic impairment in transformational grammatical terms is not in order to make a direct contribution to the controversy over the relationship between competence and performance, although it is clear that the results unavoidably bear on this; instead, i am primarily interested in recording and analysing the case of an extraordinarily specific impairment in a language quite unlike english in its superficial aspects. history of the case w.n., an adult male aged 52, was referred to the university of the witwatersrand's department of speech and hearing therapy from baragwanath hospital, johannesburg, where he had undergone surgery for a head wound on the left side of his head1 sustained during an assault. on the schuell test he was diagnosed as suffering from severe expressive aphasia.2 this diagnosis is, of course, based on his performance in english, but it is supported by my data consisting only of his performance in ndebele. he is currently undergoing therapy in english and, at the time my data were collected, he had had a certain amount of therapy, also in english. the data the data on which the analysis is based were collected during four half-hour interviews over two successive weeks! each interview was taped and transcribed immediately thereafter. this enabled one to supply any contextual clues necessary for interpretation'. it should be pointed out that the two hours of interviewing time yielded a small number of utterances (105), which is, of course, understandable in view of w.n.'s expressive difficulty. however, since his performance did not vary in quality from one interview to the next, and since, as will become clear later, i was not concerned to analyse his impairment with respect to the whole language, but was concerned rather with one aspect of ndebele structure, i found the sample quite adequate for my purposes. in fact, the structural aspect of ndebele journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) transformational g r a m m a r : the case of an ndebele speaking aphasic 51 in which i was interested, is so pervasive a feature in that language (or any bantu language) that it is unusual to find a sentence not manifesting this feature: this meant that nearly all w.n.'s utterances exemplified the difficulties he has with this feature. zulu-ndebele concordial structure while there are no authoritative sketches of zulu syntax in transformational generative (t.g.) terms, the theory is foi the most part explicit on the principles involved in accounting for concordial structure. this -does not mean that the theory dictates the solution in its ultimate details, but that it provides a set of constraints on the general form of the solution. put differently, it tells you where in the grammar various facts should be formalized. taking standard t. g. (the attribute "standard" has been introduced in order to distinguish earlier versions of the theory from recently proposed alternate models; chomsky, 1965, is regarded as a statement of standard t.g.) as the model for the following discussion, the components of a grammar and their inter-relationships can be represented as in figure 1 (adapted from fodor et al 1968). phrase s structure — y rules t ν lexicon τ a transformax tion rules deep structure s e m a n t i c c o m p o n e n t surface structure p h o n o l o g i c a l c o m p o n e n t semantic readings ^(meaning of sentence) phonetically interpreted ^strings (pronunciation of sentence) fig. 1 this grammar provides a specification of the meaning (semantic component) and pronunciation (phonological component) for each of the infinite number of grammatical strings enumerated by the syntactic component. the latter component consists of two sub-components, a base, in which phrase structure rules formalize those syntactic aspects of a sentence which affect the meaning of the sentence (categorial membership, e.g. χ is a noun, the χ is a noun phrase, and relational concepts, e.g. χ is the subject of the sentence), and a transformational component consisting of rules which produce surface structures through operations of deletion, substitution and adjunction on the strings provided by the base component. these transformational rules do not affect the meaning of the sentence; they provide the "syntactic trappings" (langacker 1968) of a language such as affixes, order of constituents, etc. once these rules have applied to produce a surface structure, the phonological component assigns a pronunciation to this structure. the lexicon consists of an unordered list of the lexical items in the language which are specified in terms of their phonological shape, their syntactic potential and their meaning. after the base sub-comtydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 a. traill ponent has operated to produce an abstract syntactic form, lexical items are. substituted from the lexicon at designated places, i t is the base structure with its lexical items which is the input to the semantic component. turning now to zulu, one finds a syntactic phenomenon which has traditionally been called the concordial system. this system can be characterized briefly and informally as a syntactic device which marks explicitly all those constituents in the sentence which are "governed by" a noun. furthermore, these explicit marks are phonologically "similar to" the prefix of the noun, whence the term alliterative concords in which "concord" refers to the syntactic relationship, and "alliterative" to the phonological one. (l)-(4) below illustrate this. 1. u.mu.ntu u.ya.hamb.a the person ' is going 2. i.si.tsha si.w.ile the dish has fallen 3. a.ma.hhashi a.mi a.ma.khulu ma.hle horses my big are beautiful ( m y b i g h o r s e s a r e b e a u t i f u l ) 4. a.ba.ntwana b.a.mi a.ba.khulu bahle children my big are beautiful ( m y b i g c h i l d r e n a r e b e a u t i f u l ) (full stops signify morpheme boundaries.) just what is meant by the term "alliterative concord" should be clear from these examples. as the governing noun changes, so do the prefixes on governed forms: possessives, adjectives, verbs, etc. traditional descriptions of this phenomenon have in the main simply listed the various noun prefixes and also the prefixes which appear on the governed forms. thus one finds lists of numbered noun prefixes possessive prefixes, adjectival prefixes, verb prefixes, etc. and a statement to the effect that possessives, etc. agree in number and class with the noun that governs them. thus, if the governing noun is class i then governed forms appear with the appropriate class i alliterative concords. in terms of figure 1, the account of this phenomenon is radically different. for example, in order to explain why concords appear where they do in sentences, we need to specify a set of syntactic conditions which formalize the notion of "governed constituent". these conditions are specified by the phrase structure rules of the base component. the explicit marking of the agreements is achieved through a transformational rule which marks governed forms with the class designation of the governing noun while at the same time capturing the alliterative aspect of the agreement by substituting the same phonological shape at appropriate positions in the sentence. in this treatment, therefore, concordial agreement is regarded as a "syntactic trapping" of zulu.' this follows from the fact that it is effected through transformational rules only. 1 journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) transformational g r a m m a r : t h e case of an ndebele speaking aphasic 53 as illustration, consider the following highly simplified steps in the derivation of i.si.tsha si.w.ile (the dish has fallen) 1. deep structure representation in terms of the phrase structure rules: sentence(s) n o u n p h r a s e (np) n o u n (n) "+ ν — animate + concrete + singular i verb p h r a s e (vp) i verbal (vb) i + verb ( + v ) i : 2. lexical entry for i.si.tsha (dish) in the lexicon [.tsha] [ < c l a s s 7 > < — a n i m a t e ; » < + c o n c r e t e > ] [ m e a n i n g ] 3. lexical substitution in (1) np i ν .tsha + ν class 7 — animate + concrete + singular i vp i vb i +v i .w.ile 4. (3) is the input to the semantic component and has a meaning assigned to it. 5. (3) is also the input to the transformational component which performs the following operations on the sentence: 5.1. t-agreement. this transformation copies specified features of the governing noun onto governed forms, in this case the verb. s i n p i vp i 1 ν i 1 vb i 1 .tsha 1 + v + ν i class 7 w.ile — animate + concrete class 7 + singular _ : tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 a. traill 5.2. t-class segmentalization. the effect of this transformation is to convert a representation of the form x to < + y>" x j n this to < + y > x , in this < + y > :class 7 > . the output of this rule is: < + y > < + v > case < + y > is the feature <class 7 > . np i ν class 7 1 + affix j + .tsha ν class 7 — animate + concrete + singular vp i vb i + v class 7 "ί + affix j w.ile class 7 5.3. at this stage in the derivation a lexical pass which scans the sentence to determine whether any segment created by a transformational rule requires to be spelt out, will substitute the following lexical entry for each occurrence of ρ ? 3 8 ! 7 ] . l + affix j [si.] [<class 7 > < + affix> < + singular>]. the effect of the lexical pass on the structure in (5.2) is: np i ν vp i vb i + v si. class 7 + affix + singular j + .tsha ν class 7 + animate + concrete + singular γ si. | class 7 i + affix l + singular 5.4. prothetic vowel spelling. for our purposes, at this stage of the derivation there are no further syntactic (transformational) rules to be applied. the structure in (5.3) therefore represents the input to phonological rules of which prothetic vowel spelling is the one required at this stage. its effect is to, copy the! vowel of the noun prefix before the consonant in the prefix. thus s i . u isi., or slightly more formally st.-> i s i . / + n , which says that si.· becomes isi. in the context of a journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) transformational g r a m m a r : t h e case of an ndebele speaking aphasic 55 following noun.3 this completes the derivation, whose successive stages were: (i) [.tsha 1 w.ile (after lexical substitution in base) class 7 (ii) γ .tsha l class 7 j (hi) class 7 .tsha (iv) si.tsha (v) isi.tsha [ w.ile 1 (t-agreement) class 7 j class 7 .w.ile (class segmentalization) si.w.ile (lexical pass) si.w.ile (prothetic vowel). there are many complications facing anyone attempting to write rules which both simply and generally formalize all the facts of concordial agreement in a language like zulu, and the above illustration is by no means supported by an explicit account of these rules. but whatever these rules look like ultimately, it seems clear that at least the steps above will be required. in the discussion of w.n.'s performance, i shall maintain an informal approach to these rules while at the same time believing that they are in general outline correct. the structure of the noun consider the following examples of nouns produced by w.n., as single word responses to questions. when there is an error, the correct form appears in brackets. 1. i.hhashi horse 2. in.konyane calf 3. aba.ntu people 4. u.dokotela doctor 5. i.gwatsha rabbit (u.nogwatsha) 6. i.zulu zulu (isi.zulu) 7. um.gwatsha rabbit (u.nogwatsha) 8. n.kunzi bull (in.kunzi) 9. ma.thambo bones (ama.thambo) 10. ba.twana children (aba.ntwana) 11. .ntwana child (um.ntwana) 12. .komo cow (in.komo) 13. •godi hole (um.godi) 14. .gwatsha rabbit (u.nogwatsha) 15. .bisi milk (ubisi) (l)-(4) are all correct, both with regard to prefix and stem of the noun, (5)-(7) have correct stems and structurally perfectly good prefixes, except that they are the wrong prefixes for those stems. (8)-(10) have correct stems but only partially correct prefixes: each one lacks an obligatory initial vowel, as can be seen from an examination of the tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 a. traill correct forms. (11)-(15) have correct stems but no prefixes at all as can be seen from (5), (7) and (14), and (10) and (11), the same stem can appear with various prefix errors. these errors are for the most part readily interpretable in terms of the description of the preceding section. what is of particular interest, however, is that if one bases an error classification solely on these examples, then one finds that it is not always possible to identify a unique locus for an error. that is to say, a particular error could be the result of a breakdown of one or another rule and it is not possible to decide which rule it is. consider, now, the following "explanations" of the errors. from the first category ((5)-(7)), (6) is, in terms of what has preceded, the best example to discuss. the noun isi.zulu (the zulu language) has the following derivation: a i. s a a np ν np i ν α . ά np i ν np i ν .zulu 1 class 7 class 7 + affix .zulu [ class 7 γ s,. class 7 |_+affix .zulu class 7 .zulu the form which was produced, i.zulu, is a noun in zulu, but its class designation is "class 5", and its meaning is "heaven" or "sky". recall that in the lexicon a noun stem is specified as to pronunciation (p), class membership (c) and meaning (m). in this case, the pronunciation is correct, and the intended meaning was without doubt "zulu language". therefore, in the triple (p, c, m) the error must be in (c). bearing in mind that the same stem can manifest different prefix errors, we could suggest that (c) is unstable varying between <class 7 > and <class 5 > and presumably others. if it is substituted into the base with (c) as <class 5 > , the error could be explained. but there is another explanation which locates the error, not in the lexical entry for the stem but in the lexical entry for the prefix, which has the general form: [pronunciation] [class], if we allow the specification for [class] to be unstable here, the error would be/equally well accounted for. instead of steps (3)-(4) above, we would have (3')-(5')· a third possibility is that the locus of error lies in the specification of the pronunciation of the prefix in the lexicon. thus, instead of having [si.] [class 7], [li] [class 7] would occur. summarizing these three suggestions, the error could be located in (a) unstable (c) of the stem, (b) unstable (c) of the prefix, (c) wrong (p) of prefix. the only common feature these explanations possess is that they all locate the error in the lexicon and not in the syntax. journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) transformational g r a m m a r : t h e case of an ndebele speaking aphasic 57 3'. a λ , np i ν li .zulu class 7 class 7 + affix 4 ' . np i ν iii .zulu ((5') involves a rule not previously discussed). 5'. s a /\ np i ν a a i .zulu errors (8)-(10) are to be explained in terms of the failure to apply the transformation which segmentalizes the features < d e f > or < i n d e f > on nouns in positive contexts. the rule of prothetic vowel spelling is therefore blocked: there is no formative to be spelled. it is worth noting that when w.n. does spell out this vowel, it is always correct. when he fails to do so, therefore, he is not failing at a superficial phonological level, but at a deeper syntactic one. the reader should consult footnote 3 for a slightly more detailed discussion of these facts. (11)-(13) also have alternate explanations. firstly (c) of the lexical entries for -these stems could be missing which would mean that "class segmentalization" could not apply. secondly, it could be suggested that the entries for the stems were perfect, that "class segmentalization" did apply, but there were no lexical entries for the prefixes. the effect of this would be that step (2) above would be reached in the derivation of these nouns, but on the failure of any lexical material being substituted for the prefix (there being no entries for the prefixes), the segment [class x l would be deleted in accordance with the lexical seg[+affix j ment deletion convention (lsd) (rosenbaum 1967). thirdly, the error could result from conflicting (c) specifications on the stem and the prefix. notice that [si.] substitutes in step (3) above just because both it and the segment preceding the noun are identically specified [class 71. l+ affix j if the (c) of [si.] was, say <class 5 > , there would be conflict and no substitutions could take place, with the result that lsd would delete the segment preceding the noun, giving the forms in (11)-(15). in the summary, the errors (11)-(15) could be attributed to (a) nonexistent (c) on stem, (b) non-existent lexical entry for prefixes, (c) conflicting (c)'s on stem and prefix. again, all these suggestions locate the error in the lexicon. the "diagnosis" at this stage is that all errors excepting (8)-(10) are to be traced to instabilities or misinformation in the lexicon. it is interesting to note that what is essentially an "agrammatism" in traditional terms is not being located in the syntactic component of the tydskrif van diesuid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 a. traill description at all but in the lexical sub-component. this in fact reveals a central feature of transformational grammars: it is that the pairings of meaning and sound involve long and complex chains of rules and dependencies such that a decision to represent linguistic information in a particular form and at a particular point in the description will have repercussions throughout the derivation of a sentence. it follows from this that in the case of a linguistic pathology located at a specific point in the description, we can expect to find repercussions throughout the system, and if we pursue the eifect of the inadequate lexical entries for w.n.'s nouns and normal prefixes beyond the noun itself, we can expect to find far-reaching effects on other parts of sentence structure. hopefully, this may enable us to fix more accurately the location of his particular breakdown. the agreement transformation in 5.1. the effect of t-agreement was informally sketched: specified features of the governing noun are copied onto governed forms. this rule captures the notion that certain forms in the sentence agree syntactically with certain nouns. it is only in a subsequent rule in which the agreement is lexically "spelled out" that we formalize the further notion that the syntactic agreement is phonologically alliterative. a point worth emphasizing, is that this set of rules embodies a dependency, namely that certain constituents depend for their correct surface shape on a governing noun's syntactic feature composition. put differently, governed forms acquire their class prefixes; nouns have a class prefix as an inherent specification. in the light of the preceding discussion of the structure of w.n.'s nouns, it should come as no surprise to learn that his t-agreement produces unaeceptable surface structures. in terms of the grammatical model, however, it is the details of these derivations which are of interest. a most significant fact about the pattern of agreement errors, is that while there are a number of different types of error, they all reflect noun prefix governed prefix example correct form 1. correct a. correct b. incorrect c. zero u.nogwatsha u.hleli i.hhashi u.lele in.komo baleka / / i.hhashi li.lele in.komo i.ya.baleka 2. incorrect a. incorrect b. zero i.zulu i.nzima ma.phoyisa dinga isi.zulu si.nzima ama.phoyisa a.dinga 3. zero a. incorrect b. zero ntwana i.nye not in data um.ntwana mu.nye journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) transformational g r a m m a r : t h e case of an ndebele speaking aphasic 59 the dependency mentioned above. the facts are summarized in the table below. there are no examples showing an incorrect or zero noun prefix matched with a correct governed prefix. this suggests very strongly that whatever else may be wrong with w.n.'s agreement rule, it always respects the dependency of governed forms on the governing noun; if the latter is inadequately or incorrectly specified, then the former will never show correct agreement. errors of the type (1c) (2b) (and the hypothetical (3b)) in the above table can be explained in a number of ways. firstly, t-agreement could have faired to copy the class feature onto a governed form, in which case the rule "class segmentalization" would fail, to apply with the result that no lexical substitution could take place, giving no governed prefix. secondly, it could not be held that t-agreement did apply, but class segmentalization did not, giving zero again. thirdly, both t-agreement and t-class segmentalization could have applied, but the lexical substitution of a prefix failed to take place (this type of failure was discussed above for noun-structure) with the resultant deletion of the segment f + ^ f f i x ] b y t h e l s d c o n v e n t i o n · what is clear from this discussion is that we are still no nearer establishing a unique locus for the errors. exactly why one should search for a unique locus derives, i think, from the feeling one gets from examining the errors, that w.n.'s concordial system does not work and one suspects intuitively that this disruption should be traceable to a unitary process in the grammar, rather than have it distributed over diverse rules. also, one can not shake the feeling that a unitary explanation will be a more parsimonious one, although i have no idea whatever about the relationship between occam's razor and an assailant's knife when the dissolution of language is being discussed. fortunately, there are a few crucial observations which suggest very strongly the interpretation that should be adopted. to say that w.n.'s concordial system does not work is misleading, for if one takes a careful look at what it is that is not correctly represented in his speech, one sees that there is evidence of a system of concordial prefixes but this system is inadequate with respect to normal zulu syntax because w.n.'s system is not alliterative.4 in other words, his system certainly allows for "agreements" (concord) between constituents; it even allows for these agreements to be pronounced in the form of prefixes. but, it does not require that the prefixes be alliterative. this is a crucial observation for we can now ask just where the notion "alliterative" is formalized in the grammar, and if this is done in one place, we shall have the locus of w.n.'s deficiency. a further observation which supports the contention that a system of agreement is in operation comes from the fact already noted that w.n. preserves the dependency of governed forms on a governing noun to the extent that we find no errors of the type incorrect governing noun prefix + correct governed tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 a. traill prefix. this means, that although it appears that the errors on nouns arise independently of the errors on governed forms, this is not in fact so; there is not complete freedom of choice for noun prefixes and governed prefixes. if this is so, a plausible suggestion would be that t-agreement always operates thus bringing governed forms into agreement with the governing noun. at a later stage the alliterative aspect of the agreement fails to materialize. the notion of alliteration is in fact uniquely located in the grammar: all concordial prefixes are alliterative simply because there is only one phonological entry for each class prefix. this means that the same phonological shape is substituted for each ["class x ] segment created [+affix j by t-class segmentalization. we need, therefore, recognize only one inadequacy in w.n.'s grammar in order to account for lack of alliteration and that is in the (c) specification for prefixes in the lexicon. the simplest solution would be to claim that he has no (c) at all but a list of entries for the prefixes specified as (p) [ < + affix> < + singular>]. the stage just prior to the substitution of an arbitrary prefix would then be ν class 7 + affix + singular (s) li. + affix + singular (l) .tsha (s) is the set of syntactic features and (l) the set of lexical features. the two sets are non-distinct (as opposed to being idenical (cf. chomsky 1965, p. 181)) thus allowing the substitution of < l i . > . this suggestion permits the substitution of any lexical entry specified γ + affix ] l + singular] to be substituted for any syntactic segment "class χ + affix + singular and any lexical entry specified " + affix "1 for any syntactic segment γ + afl l singular j class χ + affix . . _ singular this may be too powerful a rule since not all the possibilities it allows are found in the data. nevertheless, a sufficiently large number of the possibilities are attested for one to believe that the rule is correct in principle. in any event its power could quite easily be restricted.5 two further comments are required in order to complete the picture. firstly, under the present interpretation of w.n.'s deficiency, a completely successful marking of alliterative concordial agreement (1 (a) journal of the south african ogopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) transformational g r a m m a r : t h e case of an ndebele speaking aphasic 61 in the table above) must be regarded as quite fortuitous. we are, therefore, not allowing for the possibility of the correct operation of the process being distorted only at a later stage, shall we say during the motor-phase of production of a sentence. we have, in effect, formalized his error in the grammar and are thus making the significant claim that his competence is impaired rather than claiming his error is due to an inadequacy in his performance mechanism. indeed, given that we know next to nothing about performance, it seems we have no alternative. we shall see later when examining w.n.'s performance on comprehension that this conclusion is at best a nuisance and at worst of dubious correctness. the second comment concerns the question of how it is that one finds a certain prefix appearing on the noun and a different one on the governed form. the explanation is that the convention governing lexical substitution does not allow more than one substitution at a time. presumably any segment [class x ] could be the first to undergo [ + affix j lexical substitution, but, presuming it is the noun prefix which is first affected, then it will be the case that the verb concord will be affected in a subsequent substitution. clearly, in the case of w.n.'s lexicon, the result of the second substitution need not be the same as the first. the explanation adopted so far accounts adequately for all types of error except those where no prefix materializes on either nouns or governed forms. all one needs in order to account for this category is to allow for the failure of lexical substitution of affixes; lsd does the rest. in case this proposal seems extremely ad hoc, let me point out that its effect would be to produce "telegraphese", and there is ample evidence of the phenomenon in the data. testing receptive control of concordial structure during interviews, w.n. showed no evidence at all of comprehension difficulties. but, owing to the extensiveness of concordial breakdown in speaking, coupled with the fact that concords are "syntactic trappings", and, therefore, do not contribute meaning as such, i felt it necessary to determine the extent to which concords were preserved in comprehension. an extremely simple but revealing test indicated quite clearly that w.n. was able to utilize the anaphoric properties of concords in order to arrive at the underlying meaning of a proposition. the test was based on the fact that, whereas in english pronominal forms such as "the one who is lying down" are multiply ambiguous (who or what does "the one" refer to?), in zulu one is able to narrow down the ambiguity of reference to a particular noun class. for example, the forms olulele, olele, elilele, elele, are all glossed in english as "the one who/which is lying down", but in zulu the first is "the class 11 which is lying down", the second "the class 1 or 3 . . .", tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 a. traill the third "the class 5 . . ." and the fourth "the class 9 . . .". w n was presented with various toys, the nouns corresponding to which fell into various classes. he was then asked to point to the one (ones) which was (were) lying down, following the man, eating the food etc a typical situation would be as follows: a duck (lying down) a'cow (lying down) and a tortoise (standing). he would be asked: khomba ehlele (point to the one which is lying down). the only correct response in this case is to point to the duck. if he had been asked: khomba elele, only the . cow would qualify. he performed successfully on all these tests. notice what he has to do in order to give the appropriate response firstly he has to identify the class designation of the pronominal prefix i.e. as class 5 or class 11 or class 1, etc. since this is an acquired prefix (governed form), he has secondly to identify an object in the situation whose noun is a class 5, 11, 1, etc. noun. let us say he has to "recover" the deleted noun which determined the form of the alliterative concord. having done this, he is then able to respond correctly. it cannot be argued that the extralinguistic context facilitates his response in such a test since this context is ambiguous with respect to objects lying down. successful performance here demands perfect control of the concordial "signals". this could be phrased differently as the reverse application of the transformations effecting agreement: the problem which now arises is that we have shown w.n.'s concordial processes to be intact in reception, but to be impaired in production. he thus shows perfect competence on the one hand and imperfect competence on the other.* yet competence in the technical sense is monolithic; it is neutral with respect to comprehension or production. how is this conceptual tangle to be resolved? there are three approaches to this issue. firstly, and i believe this is what a lot of linguists would claim, the tangle is the result of an illegitimate exercise in applied linguistics: linguistic theory was not intended for bizarre forms of language. secondly, one could adopt the view of weigl and bierwisch (weigl and bierwisch 1970) that all aphasia involves a breakdown in the performance mechanism; that the competence remains intact but is blocked. thirdly, along with whitaker (whitaker, 1969) one could argue that both competence and performance may be affected in aphasia and, in the case under discussion, the performance mechanism concerned with the speaking modality has broken down. the distinction between the last two views is that m the latter, impaired competence is countenanced, whereas in the former it is not. if w.n. had shown a defect in both the listening and speaking modalities whitaker would, in the absence of evidence to the contrary, be willing to diagnose his competence as being impaired. whitaker discusses the above three positions extensively and, rather than reiterate his lengthy arguments! here, i should merely like to note that the position he adopts must be seen in the context of his model for the representation of language in the brain and his views on the journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) transformational g r a m m a r : t h e case of a n ndebele speaking aphasic 63 relevance of data from linguistic pathologies for assessing the explanatory power of a linguistic theory. but whether we adopt weigl and bierwisch's or whitaker's diagnosis in the present case, we are left with the same claim: w.n.'s deficit is a performance one; in whitaker's terms is would be attributed to the imperfect workings of the synthesizing "tracking" strategy in the mechanism for the speaking modality. exactly what this strategy is, and just how it would operate in the case of zulu concordial structure is something about which we can say nothing. this is, to say the least, an uncomfortable conclusion to arrive at, but in the context of current views on competence and performance it seems to be unavoidable. what then of the foregoing attempt to "formalise" w.n.'s nonalliterative concordial "system"? the positions i have just reviewed would doubtless regard this as wrong, and certainly if one accepts that competence is represented in the brain, that it is distinct from performance and, if one recalls the asymmetry between the listening and speaking modalities of w.n.'s performance, one is forced to agree with them. in order to legitimize the formalization i have attempted, it would have to be demonstrated that w.n.'s deficit at least cuts across all modalities, thus suggesting that competence has been affected (if i understand whitaker correctly, this would be his view)7. this follows from the assumption that competence is modality free. but this position reflects only a necessary condition for positing a competence deficit; it is not a sufficient condition simply because one cannot be sure, given an impairment in all modalities, that this is not perhaps a performance problem of a global nature. the global aphasia mentioned by weigl and bierwisch illustrates the undecidability of the problem: is this a total breakdown of the performance mechanism for all modalities with competence remaining intact; or is it a total destruction of competence with the consequence that the application of the performance mechanism is vacuous? (i wonder if the latter is a genuine possibility. if the domain of operation of the performance mechanism (competence) is removed, is there any reason why this mechanism should continue to exist?) owing to the general.limitations on our knowledge at present and on mine in particular, i do not propose to explore these questions any further. i should like, however, to make one observation concerning the type of information which would be necessary for the operation of whitaker's "tracking" strategy for that aspect of the speaking modality in zulu which involves making concordial agreement. if one accepts that w.n. suffers from a performance defect, then an examination of his errors in s.t.g. terms shows quite clearly that we need to recognize specifically syntactic "tracking" strategies which presumably must operate in real time prior'to and independently of phonological "tracking" strategies. the reason for maintaining this is that the syntactic tracking strategy which synthesizes the sentence at one level must, as the examples show, break down whenever a "segtydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 64 a. trai ment" categorized a s [ + affix] is "processed". w.n.'s difficulty cannot [class x j be relegated solely to inadequate operation of pronouncing strategies because his errors hinge on syntactic information. put differently, if by "performing a pronunciation synthesizing strategy" we mean the activation of a path through neuro-motor, myomotor and articulatory stages (liberman et al, 1967), it is not at all clear how a syntactic specification is carried through to these stages causing (?) a breakdown in operation. surely the proper functioning of this stage of production cannot be made to depend on syntactic information. put still differently, if an element [α β a b] is constantly (and variously) "mispronounced" in the first two 'phonemes' ab, and if ab also appears in other positions, but is never mispronounced there and, further, we discover that the first ab is in fact ab whereas the second is not, then • class x [ + affix obviously it is not just ab that is "difficult to pronounce"; rather it is ab when it is syntactically categorized as a class affix. an actual example is (abantu) babaleka ((the people) run away). w.n.'s performance interferes with the first ba, not the second. if performance strategies are, as is suggested above, sensitive to syntactic information presented in the competence formalization, it follows that this information must be duplicated exactly in the two components, once in competence and once in the tracking strategies. while i would hesitate to suggest that the brain hasn't enough room to accommodate this sort of duplication, i would venture no more than that it is surprisingly wasteful and is a direct consequence of claiming that competence has neurological correlates separate from performance. summary in summary, there are three points to mention: firstly, the attempt to analyse w.n.'s linguistic pathology in terms of a transformational generative grammar raised the problem of localizing the source of the defect (notice that the mere fact of being able to offer any localization in this grammar is an interesting result). secondly, the approach adopted, lead to the contradictory assertion that w.n.'s competence was impaired in production but not in comprehension. thirdly, this raised the vexing question of the relationship between' competence and performance and highlighted our ignorance of the operation of the latter. references bellugi, u. and brown, r. (1964) (eds.): t h e acquisition of language. m o n o graphs of the society for research 1 in child development, 29. chomsky, n. (1965): aspects of the theory of syntax. cambridge: m.i.t. press. journal of the south african ogopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) transformational g r a m m a r : the case of a n ndebele speaking aphasic 65 fodor, j. α., bever, t. g. and garrett, m . (1968): t h e development of psychological models for speech recognition. report n o . esd-tr-67-633 to the u.s.a.f. available from .the clearing house for federal, scientific and technical information. fodor, j. a. and garrett, m. (1966): some reflections on competence and performance in j. lyons and r. wales (eds.), psycholinguistic papers, e d i n b u r g h : e.u.p. jakobson, r. (1964): towards a linguistic typology of aphasic impairments. in α. v. s. de reuck and m . o ' c o n n o r (eds.) ciba foundation symposium on disorders of language. l o n d o n : j. & a. churchill ltd. jakobson, r. (1968): child language, aphasia and phonological universals. the h a g u e : mouton. langacker, r. w. (1968): language and its structure. new y o r k : harcourt, brace & world, inc. liberman, a. m., cooper, f. s., shankweiler, d. p. and studdert-kennedy, m . (1967): perception of the speech code. psychological review, 74, pp. 431 461. marshall, j. c. and newcombe, f . (1966): syntactic and semantic errors in paralexia. neuropsychologica, 4, pp. 169-176. mcneill, d. (1966): developmental psycholinguistics. in f. smith and g. miller (eds.), t h e genesis of language. cambridge: m.i.t. press. menyuk, p. (1969): the sentences children use. cambridge: m.i.t. press. rosenbaum, p. (1967): specification and utilisation of a transformational g r a m m a r . scientific report n o . 2 of the i b m corporation, new york. schlesinger, i. (1966): sentence structure and the reading process. t h e h a g u e : m o u t o n . weigl, e. and bierwisch, m . (1970): neuropsychology and linguistics: topics of common research. foundations of language, 6. whitaker, h. a. (1969): on the representation of language in the h u m a n brain. working papers, in phonetics, n o . 12. u c l a . footnotes 1. hospital records show that he suffered a fracture of the middle fossa of the skull, but i understand that this does not locate the fracture very precisely. beyond adding that he also had a right facial palsy, i am unfortunately unable to give a detailed medical diagnosis of the damage. 2. γη more detail, the diagnosis was aphasia with severe reduction of language in all modalities, complicated by sensori-motor complications. i am indebted to c. kell for supplying me with this diagnosis. as will become clear later, there is strong evidence to question the diagnosis and indeed i do not find this disagreement surprising; doubtless, the schuell test is confusing the aphasic impairment proper with the subject's bilingual inadequacies. 3. ε. b. van wyk has pointed out to me that this rule, as it stands, fails to reflect the fact that the appearance of what i have termed the prothetic vowel of the noun prefix is not a purely phonological matter. t h e presence or absence of a prothetic vowel reflects a semantic contrast (and therefore a deep syntactic choice) between, respectively, definite or indefinite n o u n s preceding or following a positive or negative verb, and a quantificational meaning something like "any x " where x is a noun following a negative verb. this means that the presence o r absence of a prothetic vowel in surface structure depends on certain deep syntactic features and the application (or not) of a segmentalising transformation; the final shape of this formative remains a phonological matter in zulu. t h e rule for prothetic vowel spelling presented in the text therefore requires a modification to reflect the syntactic conditions under which it may apply. in its present form, the rule does not reflect these conditions. 4. it is interesting to note that in the acquisition of their mother-tongue, zulu children pass through a stage of development which exactly parallels w.n.'s non-alliterative concordial system. 5. in this discussion, i am not concerned to write a rule which will completely account for the observed errors. my point is rather to isolate the general form of the disturbance. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 66 a. traill 6. w.n. actually shows more than just a breakdown of the alliterative concordial system. h e is unable, for example, to produce sentences containing embedded constructions, succeeding after much perseveration only to produce a co-ordinated paraphrase of such sentences. since this inability extends to right-branching structures as well, we could describe it more generally as a restriction on recursion in the grammar. 7. according to the schuell diagnosis, w.n. would thus show a disturbance in competence in english, but according to my test his receptive modality is intact for zulu. t h a t is his zulu competence is preserved. abstract an attempt is made to.explain certain expressive impairments in the speech of an ndebele speaking aphasic in terms of a transformational grammar. the impairment is eventually located in a part of the lexicon, but owing to the standard view of linguistic competence, this explanation poses problems which at present resist resolution. journal of the south african ogopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pierre de villiers pienaar m y r t l e l. a r o n , ph.d. (witwatersrand) head., department of speech pathology & audiology university of the witwatersrand, johannesburg summary the academic and professional background of the man w h o initiated and developed training programmes for s p e e c h therapists and audiologists in s o u t h africa is presented. the manner in w h i c h he d e v e l o p e d the profession, and pioneered work in p h o n e t i c s and linguistics is described, including p. de villiers pienaar's role in educational, academic, clinical and cultural institutions in s o u t h africa. opsomming die akademiese en professionele agtergrond van die man w a t die opleidingsprogramme vir spraakterapeute en o u d i o l o e in suid-afrika.ingestel en ontwikkel het, w o r d beskryf. die w y s e waarop h y die b e r o e p o n t w i k k e l het, sy pionierswerk o p die gebied van die fonetiek en linguistiek, a s o o k p. de villiers pienaar se rol in opvoedkundige, akademiese, kliniese en kulturele instansies in suid-afrika, w o r d bespreek. the study and practice of speech pathology and audiology in the republic of south africa has developed significantly since its introduction over a third of a century ago. pierre de villiers pienaar, with foresight and tenacity, was responsible for this development. at the time of his post-graduate studies in the late twenties at the university of utrecht, holland, and at the university of hamburg, germany, he recognized the possibilities of the rehabilitative application of facets emerging from the fields of phonetics and voice disorders. on his return to south africa, he presented during the period 1936-1938 the motivation to institute a training course in logopedics at the university of the witwatersrand, johannesburg. his foresight in introducing this training programme and his awareness of the need to develop high academic and clinical standards demonstrate p. de v. pienaar's remarkable ability to view the profession of speech and hearing therapy in a clear perspective. his timing and fundamental appreciation of the overview of the wider issues involved and his constant scrutiny of the profession, have led to what is today a respected scientifically based profession whose practitioners enjoy good status. there are now opportunities for the further development of academic, clinical and research facets in this area. pierre de villiers pienaar was born in 1904 near potchefstroom in the transtydskrif van die suid-afrikaanse vereniging vir spraak en cehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 myrtle l. aron vaal and matriculated in the first class at the boys' high school in potchefstroom. in 1922 he attended the johannesburg teachers' training college and the university of the witwatersrand, obtaining a bachelor of arts in education and later an honours degree in the first class. in 1926 he graduated with the degree master of arts, with distinction, at the university of the witwatersrand. the latter two post-graduate degrees were in the area of phonetics and general linguistics, particularly afrikaans phonetics, this subject-matter also being the topic for his doctoral degree (ph.d.) earned at the university of hamburg, germany in 1929. the department of experimental phonetics at the university of hamburg, under the headship of professor g. panconcelli-calzia, had a profound influence on de villiers pienaar. not only did this department provide the first course in logopedics at a university in germany, but it was attended also by carl meinhof and g; kloeke who became foremost dialectologists and linguists, both adding considerably to the linguistic background of de villiers pienaar. during the years 1926-1927 and 1930-1932, he taught in primary and high schools in johannesburg. he was appointed lecturer in 1933 in phonetics in the department of african languages under professor c.m. doke at the university of the witwatersrand and remained at this institution for twenty-three years pioneering the work in phonetics and speech pathology. professor doke was held in high esteem for his work and publication of basic texts dealing with african languages. he also held a modern outlook concerning phonetics and the teaching of this subject, and strongly supported p. de v. pienaar's purpose in instituting a professional qualification for speech therapists. the first trained speech therapists completed their two-year diploma in logopedics at the end of 1939 at the university of the witwatersrand and received their clinical training at the speech, voice and hearing clinic at the same university. this clinic was established in 1936 by p. de v. pienaar with a view to training speech therapists. pierre de villiers pienaar was appointed senior lecturer in phonetics and logopedics in 1938, and in 1944 to the chair of the department of phonetics and logopedics. the speech, voice and hearing clinic flourished steadily and with his appointment to the chair he assumed the directorship of this clinic. professor pienaar left the university of the witwatersrand in 1957 and joined the university of south africa for two years as professor of afrikaans and nederlands linguistics. during this time he put forward proposals to create a professional degree course in logopedics at the university of pretoria. for eleven years (1959-1969) he was professor and head of the department of speech science, logopedics and audiology at the university of pretoria, and director of the speech, voice and hearing clinic, attached to that department. professor pienaar retired from this position at the end of 1969 but in order to benefit from his considerable experience, the university of pretoria continued to retain his services and he was appointed a temporary lecturer for the period 1970-1972. p. de villiers pienaar is now a professor emeritus at the university of pretoria and continues his avid interest in speech science, and in the area of diagnosis and rehabilitation of voice disorders. during the first decade after p. de v. pienaar had started the training facility for speech therapists, he continued to develop the programme methodically and with far reaching aims. he attracted lecturers from the universities of journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pierre de villiers pienaar 9 iowa and wichita, usa (the senior lecturer in logopedics, a.b. clemons and a lecturer in logopedics, h. wise) and from hamburg (lecturer in voice science, g.b. breckwoldt). not only did the original two-year diploma in logopedics become extended to a three-year diploma, but in 1948 professor pienaar was responsible for the introduction of the four-year professional degree course β .a. logopedics (now called b.a. in speech and hearing therapy at the university of the witwatersrand). the study of the field of audiology was formally introduced as a two-year major in the four-year curriculum at both universities in 1962, but prior to this, professor pienaar was well aware of the close relationship between hearing impairment, with its concomitant speech and language problems, and the general field of speech therapy. apart from introductory aspects concerning the ear and basic audiological procedures taught in the speech science course (phonetics i), he introduced a specific course dealing with aural rehabilitation as early as 1946. the contents of the degree course demonstrate the eclectic view he holds generally about the study of communication disorders. taking cognizance of the needs of the areas to be covered to adequately train speech therapists, p. de v. pienaar designed the curriculum offered for the four-year degree course as a non-elective one, except for a language in the first year of study, i.e. all subjects, with their practicums, are directly related to the aim of training speech therapists and audiologists. although some courses might have undergone modification in recent years since he introduced them, intrinsically the content of the course today at both universities carries the stamp of his design. students are introduced to the clinical situation from the first year of study (in structured observation sessions) and conduct therapy with a variety of cases under supervision from the second year of study. clinical practicums are held in both university clinics as well as in hospitals, primary schools, cerebral palsy schools and in special institutions. for curriculum purposes the minimum number of clock hours required by students for diagnostic and therapeutic work in the areas of speech pathology and audiology is 750. normally, the average student accrues nearly 1000 hours, a considerable amount for an undergraduate degree programme. the importance of supervised student clinical practicums has always been stressed by p. de v. pienaar and the manner in which he originally conceived how a speech and hearing clinic should function in a university department has without doubt paid substantial dividends. in addition to providing student clinical material, the two university clinics function as major facilities serving the communities of johannesburg and pretoria and the country areas. professor pienaar not only introduced and developed the training programme at the two universities, but has also been most active over the years in improving and maintaining the standards practised in the profession. he is the watchdog of what he has created and continues to pursue avenues and issues about any item which might have immediate or far reaching effect on the profession. he has always held meetings, called for discussions and has initiated correspondence with personnel here and overseas, all aimed to improve academic training, clinical standards, the creation of new posts and to report on what is being done in this country and overseas. on a carnegie fellowship in 1952, p. de v. pienaar spent an extensive period on research in speech tydskrif van die suid-afrikaanse vereniging vir spraak en cehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 myrtle l. aron archives, logopedics and audiology in centres in europe, the united kingdom and the united states of america. on his return he incorporated many new facets in the academic and clinical work in the field. during 1962, and again in 1965, he received grants from the transoranje institute and the s.a. national council for the deaf to attend international conferences dealing with logopedics and audiology. at the time of these conferences he re-established and made new contacts and visited training institutions. professor pienaar was appointed honorary life president of the s.a. logopedic society nearly twenty years ago, the national body representing speech therapists and audiologists which has recently changed its name to the s.a. speech and hearing association. he exercises this role in a wide sense, drawing on outside organizations and professional persons in allied fields to take cognizance of the profession he has developed and nurtured. in 1966 de villiers pienaar instigated and convened an important round-table discussion on standards. this discussion was attended by representatives of several universities in south africa, the s.a. speech and hearing association and the supplementary health services committee of the s.a. medical and dental council, a statutory body maintaining the register for speech therapists and audiologists. the outcome of this round-table meeting resulted in far reaching implications. it led to a greater awareness of the profession and the role it plays in the rehabilitative service of any community in this country. it also led to modified and improved considerations taken up by the s.a. speech and hearing association. recently, this association introduced additional requirements for applicants seeking membership who have been trained in south africa or overseas, and in certain cases applicants now will have to undergo an examination before being admitted as full members. while demonstrating his awareness of the constant need to expand the field and improve on standards, p. de v. pienaar has also, since his earliest years in the profession, expended much effort on the establishment of posts for speech and hearing therapists in this country. he first persuaded the transvaal education department to employ speech therapists which they did from 1941. after this, also at his instigation, hospitals began creating more posts for therapists. scrutinizing the country as a whole he has always assessed specific developments taking place which might lead to rehabilitative or diagnostic services and therefore the employment of speech therapists and audiologists. he has always remained vigilant in his contacts with education departments throughout the country, medical and dental training departments, national health organizations and the defence departments. his contact with some of these institutions has also embraced the need to establish a base for'research to be conducted in the fields of normal and abnormal communication. today there are over 130 full-time posts in s.a. many therapists also conduct fulltime or part-time private practices. since the formal course in logopedics was introduced by p. de v. pienaar in the late thirties, over 380 speech and hearing therapists have graduated in this country. the number graduating in the profession will increase further when the university of cape town qualifies its first therapists after introducing a four-year professional degree course due to start in the very near future. this year the university of natal-westville introjourna of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pierre de villiers pienaar 1 1 duced a four-year professional degree in the field which will train indian theratte interests and activities of professor pienaar have been wider than his main nuroose in furthering the profession of speech pathology and audiology. his rademic work and teaching has revolved around phonetics and general linguistics and he has established speech science and language laboratories. he is also known as a pioneer in the study of experimental phonetics, particularly in relation to the phonemics of afrikaans, at both the universities of pretoria and the w i t w a t e r s r a n d . he has interested himself over many years w i t h t h e ohonetics of bushman dialects, diachronic linguistics in connection with the phonological structure of afrikaans, and the linguistic aspects of speech disorganization. concerning lexicological work he has collaborated with professors m.s.b. kritzinger and f.j. labuschagne on the verklarende afrikaanse woordeboek of w h i c h the 6th enlarged edition has just appeared.9 the research he has conducted in the field of afrikaans phonetics earned him the erepenning" award of the suid-afrikaanse akademie vir wetenskap en kuns in 1963. still today in his retirement professor pienaar is engaged in this work as well as establishing archives in linguistics and speech science in south africa. he has been appointed head of the speech archives sponsored by the department of national education and the human sciences research council. among his students who majored in phonetics, three have become heads of university departments of phonetics or african languages in south africa (l.w. lanham, d.t. cole and e.o.j. westphal). the membership or alliance pierre de v. pienaar holds with various bodies is extensive and reflects his wide interest within the area of normal and disordered human communication. his membership on committees or appointments to bodies include: the language advisory committee of the s.a. broadcasting corporation, from 1957-1968; the advisory committee for language laboratories of the government department of education, arts and science; the film board of the republic of south africa since its inception; the representative of the department of national education on the board of the transoranje institute for special education; the editorial board of folia phoniatrica, the journal published by the international logopedic and phoniatric society; the committee for controlling speech examinations and moderator for the university of south africa since its inception up until 1971; the commission appointed by the department of health to investigate the use and abuse of hearing aids in south africa. in addition to being a member of learned societies both national and international, he has also served for many years on clinical and technical committees of the s.a. national council for the deaf, the transoranje school for partially hearing children, the national committee for noise control and the s.a. speech and hearing association. p. de v. pienaar was an elected member of the „maatschappij der nederlandsche letterkunde te leiden." over many years he has given considerable advice and direction to professional and academic institutions in this country who turn to his experienced and objective counsel. the interests of pierre de v. pienaar also extend to wider cultural areas. he has published a novel1 0 and collections of short s t o r i e s 1 1 , 1 2 ' 1 3 , is editor and tydskrif van die suid-afrikaanse vereniging vir spraak en cehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 myrtle l. aron a contributor to the „kultuurgeskiedenis van die afrikaner" (three volumes)15 and was a founder member of die handhawersband, an afrikaans cultural association, and became the first editor of die handhawer. he has a keen interest in music and is well known for his deep knowledge about opera and singers, being particularly concerned with the art of singing. speech therapists in this country have for many years associated p. de v. pienaar with his work in voice and its disorders. his diagnostic acumen and therapeutic skill with voice disordered cases have earned the respect of several ent specialists who are increasingly referring cases of this nature to him and to other speech therapists. in his retirement he is continuing to work in this area, again pursuing developmental work which has been comparatively neglected compared to other disorders of communication. the dedication of this issue of the journal to pierre de villiers pienaar reflects, in small measure, the large tribute which speech therapists and audiologists in ' this country have for the man who has initiated their profession and developed it with such purpose and tenacity. he pioneered the field and its academic training. p. de v. pienaar's.steadfast application concerning the expansion and improvement of clinical, academic and research facilities will always be remembered with admiration and respect. he will always be known, not only as a phonetician and a linguist, but the father of speech therapy and audiology in south africa. we all wish him good health in his retirement and look forward to the fruits of the work he is now undertaking. list of publications of pierre de villiers pienaar 1. with t.h. le roux (1927): afrikaanse fonetiek. j.c. juta, johannesburg. 2. (1930): die fonoposotie in die fonotopie van afrikaanse afsluitings en vernouingsklanke binne die spraakmolekuul swets en zeitlinger, amsterdam. 3. (1939): praat u beskaaf. voortrekkerpers, johannesburg. 4. (1947): die afrikaanse spreektaal van schaik, pretoria. 5. (1945, 4th edition 1963): uitspraakwoordeboek van afrikaans. van schaik, pretoria. 6. with a.g. hooper (1948): an afrikaans-english phonetic reader. rand university press, johannesburg. 7. (1951): chapter entitled "speech disorganization", in social medicine, ed., e.h. cluver. central news agency, ltd., johannesburg. / 8. (1966): chapter entitled "speech pathology in south africa": in speech pathology, eds., rieber, r.w. and brubaker, r.s. north holland publishing company, amsterdam. 9. with kritzinger, m.s.b. and labuschagne, f.j. (1973): afrikaanse verklarende woordeboek. van schaik, pretoria. literary works ; 10. (1928): skakels van die ketting. de bus$y, holland. 11. (1934y.ruth e.a. kortverhale. nasionale pers, johannesburg. journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pierre de villiers pienaar 1 3 π 936)· magte e.a. kortverhale. nasionale pers, johannesburg. i3 (1940): die oorlogskind e.a. kortverhale. nasionale pers. johannesburg. cultural works t/i π 951v opera en sanger. afrikaanse pers, johannesburg. ! s e d i t o r with van den heever, c.m. (1945-1947-1950): kultuurgeskiedenis van die afrikaner. three volumes. nasionale pers, johannesburg. (1968): as editor, abridged and revised edition of kultuurgeskiedenis van die a frikaner, nasionale pers, johannesburg. ζβΐίίίαη & o n p r o p e r t y b r o k e r s p.o. box 5758, johannesburg tydskrif van die suid-afrikaanse vereniging vir spraak en cehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) apraxia dysarthria η. reef, m.b., b.ch. (rand), m.r.c.p.e., m.r.c.p.. (lond.) p a r t ι the diagnosis of apraxic dysarthria still puzzles many speech therapists, and some even doubt its existence despite the fact that it is firmly established in the literature, and at least one standard textbook on speech disorders devotes a whole chapter to the condition. this paper attempts to explain the condition, how it comes about, its clinical manifestations, and possible methods of treatment. consider the following case: john i. is aged seven years. he was born after a normal full term pregnancy, but labour was prolonged and forceps were applied towards the end of the second stage. he appeared to be a healthy infant and developed normally. he sat at five months, crawled at eight months, and walked at thirteen months. he said his first words at fourteen months which were "mamma" and "nanna". thereafter, his vocabulary slowly increased, and he began to use two to three word sentences only, at the age of three years. from an early age it was noticed that his speech was not clear and this -has persisted until now. in all other respects he is quite normal. his parents and siblings understand his speech, but strangers have great difficulty in doing so. he started going to school one year ago and there his speech disorder has become a source of embarrassment. the children tease him and ridicule his "baby talk". as a result, he has become sullen and withdrawn. he can be persuaded to go to school with great difficulty. he has had speech therapy since the age of five years, with little benefit. the family history background is quite normal. there is no suggestion of any emotional disturbance. the mother, father and two siblings are right-handed, and all speak normally. speech examination: this revealed that child's speech is at times almost unintelligible. he has little trouble with vowel sounds or short words, but long words and consonants cause him great difficulty. he regularly mispronounces the "k", "t", "w", "s", "d", and "g" sounds. there are many substitutions and omissions, especially of final sounds. when persuaded to speak very slowly, speech becomes much clearer. he can repeat individual sounds and words quite well. there was no evidence of dysphasia and intelligence as tested on the south african individual scale was above average. physical examination: this revealed no significant abnormalities, except that the reflexes in the right half of the body were slightly brisker than those on the left, and the right lower limb was slightly underdeveloped. he is right-handed. there was no evidence of any dysfunction in the lips, tongue, palate or larynx. his reading, writing, and spelling were within normal limits. into which diagnostic category can this child be placed? he shows evidence of a very mild left cerebral (dominant) hemisphere lesion, but this has not produced any physical defect in the function of the lips, tongue, palate and larynx. however, when he speaks a serious disorder tydskrif van die suid-afrikaanse logopediese vereniging, vol.14, nr. 1: sept. 6 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 η. reef appears. his higher speech centres are intact and there is no evidence of any weakness, ataxia, or sensory loss in the lower organs of speech, and no structural defect or hearing loss. psychogenic factors have been excluded. where then does the defect lie? he has been previously diagnosed as suffering from dyslalia, but has not responded to suitable therapy. the latter diagnosis thus appears to be wrong, for the following reasons: 1. there is evidence of slight brain damage (the possible cause being a forceps delivery). 2. the condition is far too severe and persistent. 3. therapy for dyslalia has been unsuccessful. 4. there is no apparent cause for dyslalia. it is thus suggested that the correct diagnosis is apraxic dysarthria. a consideration of apraxic dysarthria when the volume of sound and symbolic content of speech is normal, but the articulation and enunciation of the individual words and phrases are distorted, a patient is said to be suffering from dysarthria. apraxia implies that the motor disorder is due to a lesion in the highest motor centres of the cerebral cortex where voluntary movements are initiated, planned and synthesised, so that the correct result is obtained in the peripheral motor organ. the correct organisation of movements is called praxis, and a disturbance of this function is termed apraxia. it has nothing to do with the strength of muscle contraction, co-ordination or sensation. there are many definitions of apraxia, but most comprehensive is that given by worster-drought: "the inability, as the result of an organic brain lesion, to execute familiar, purposive, more or less automatic movements, when there is neither motor paralysis, sensory disturbance, ataxia, or any intellectual impairment." it is as if the patient retains the will to perform the act, and retains the neurological apparatus capable of performing the movement, but between the two there is a gap which he is unable to bridge. the patient knows what he wants to do but cannot do it. the essential feature of the condition is that voluntary movements are affected so that the same movement which cannot be carried out to command, or voluntarily, may still be carried out reflexly. e.g. a patient may not be able to protrude his tongue when asked to do so, but a moment later he may carry out this movement to lick his dry lips. similarly, a devout christian may not be able to make the sign of the cross on request, but will do so reflexly on entering a church. the movements of speech are carried out in an almost automatic manner, and must toe considered as the most highly skilled motor patterns that the body possesses. how these and other skilled movements, for example those of the hands, are carried out is still unknown but a study of apraxia does shed some light on the subject. electrical stimulation of the motor cortex in the frontal lobe or the motor centres in the extra-pyramidal system produces crude movements. journal of the south african logopedic society, vol. 14, no. 1: september 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) apraxia dysarthria 39 a lesion in the motor cortex will produce loss of movements or weakness for both voluntary and reflex movements. this is not apraxia. the lesion causing apraxia must be situated at a higher level, or in a higher motor centre. this higher level or centre is not a small discrete structure or isolated portion of the brain, but involves probably most of the cortex of both hemispheres. apraxia may be produced by lesions in either hemisphere and in almost any region. the most likely site for such a lesion is, however, anterior to the motor cortex in the dominant hemisphere. how are skilled movements organised in the cerebral cortex? if we desire to initiate or execute a movement, then this must be translated into some method whereby the motor cortex is stimulated. this transition from a psychological state to physical action in the motor cortex was always assumed to be" achieved by means of transcortical fibres. in other words, messages were conducted from areas of the brain said to be concerned only with psychological mechanisms to regions where they could be translated into physical action. we now know that this is probably not so, since these transcortical fibres can be severed with little effect on voluntary movements. another mechanism therefore has to be postulated, and we now believe that these stimuli descend to lower co-ordinating centres in the brainstem, e.g. the reticular formation, and then ascend again to stimulate the motor cortex. the acquisition or learning of a skilled movement in childhood starts as an almost unconscious process by first bringing into play all the sensory faculties, so as to see, feel and even "hear" the movement. these sensory experiences are then used to try and reproduce a similar motor phenomenon. by constant repetition kinetic engrams or "memories of movement" are stored in the neuronal circuits. these engrams then become part of our permanent motor repertoire and we can recall them whenever necessary. if we store faulty engrams, or cannot properly recall them, then we will have imperfect movements. it is these engrams which in turn stimulate the motor cortex. the process of carrying out a skilled movement can be summarised as follows: 1. the idea of the movement is formulated spontaneously, or in response to an external command. 2. correct psychic planning of the action. 3. correct mobilisation of the kinetic engrams. 4. stimulation of the motor cortex. if the first step is defective, this leads to a paucity or absence of voluntary movements. perhaps the catatonic form of schizophrenia is representative of this type of disorder. a disturbance in the second and third steps leads to apraxia. the following discussion on the various types of apraxia is based on the classification proposed by liepmann. ideational apraxia. if there is incorrect psychic planning of. the action, then the patient is said to suffer from ideational apraxia. the basic defect is a disorder of the conception of the required movement. patients know and understand each individual part of the movement, but mistakes tydskrif van die suid-afrikaanse logopediese vereniging, vol. 14, nr. 1: sept. 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) η. reef occur. they cannot reproduce them in the correct sequence and at the proper time. the usually quoted example of this condition is the patient who cannot light a. cigarette. he commits surprising errors without being aware of them. he will take out a match, place it in his mouth, and rub the cigarette against the matchbox. this type of apraxia will only affect a complex .movement. the patient, can still carry out simple movements when requested to do so, e.g. a symbolic gesture. the kinetic engrams are still intact, but they are mobilised incorrectly. idiokinetic apraxia. the patient knows what he should do and how he should do it, but cannot mobilise the necessary apparatus of action. the engrams are there, but he cannot voluntarily set them in motion. then suddenly he will do so in a reflex or automatic action. our earlier example of the person who could not make the sign of the cross falls into this group. another example is that of the patient who cannot wave goodbye on request, but will do so when the doctor leaves the ward, or he cannot point on demand to a specific object, but can do so if he suddenly develops the need for it. this type of .apraxia mainly affects symbolic gestures, and it is mainly the intentional or volitional use of the movement which is. disturbed. motor apraxia. in this type of apraxia it is postulated that there is a fault in the engrams themselves. they are either absent or faulty. if a patient, through some disease process, loses his motor engrams, then he will behave as if he is carrying out that movement for the first time. he may lose his engrams for only one specific function, e.g. an expert pianist will sit down at the piano and be. quite unable to play (instrumental amnesia). a patient may lose the ability to write (agraphia), or play some game at which he was previously skilled. if the engrams are there, but they are faulty, the movements are not lost, but they are performed incorrectly. bucco-linguo-facial apraxia belongs to this group. if the engrams for movement of the lips, tongue and palate are lost completely, then the patient becomes anarthric. if they are faulty, then a dysarthria will result. from the above discussion it can now be postulated that an apraxic dysarthria may arise in one of two ways: 1. the kinetic engrams may be at fault. 2. they may be incorrectly or incompletely mobilised. in this way the inability to reproduce certain sounds and the omissions and substitutions which form the basic symptoms of an apraxic dysarthria may be explained. translated into speech terms consonants, diphthongs and vowels are affected, in this order. this may be explained on the basis of the relative complexity of the sounds involved, and therefore on the complexity of the motor engrams involved. the more complex engrams would be affected first, and therefore consonants would be disturbed first. in very severe cases all three may be affected. the literature on the subject of apraxia is vast, and not all authors agree on the same classification. many, special types of apraxia have been described, of which one is of some clinical importance. journal of the south african logopedic society, vol. 14, no. 1: september 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) apraxia dysarthria 41 dressing apraxia. a highly specific disorder in which the patient loses the ability to dress himself. basically, this is due to a disturbance of body image and a failure to pay due attention to both the left and right, halves of the body and garment concerned. expressive aphasia could, according to. -our definition of apraxia, be classified as such a type of disorder. indeed, some authors follow this practice. this is incorrect, since the term apraxia refers only to motor functions,' and aphasia to the higher psychological or symbolic' functions of spee;h. the distinction, however, is probably a very fine one, and the same process may well be involved in both types of disorder. it is certainly no accident that dysarthria is seen so frequently in aphasic patients. part 2 by definition the disorder of apraxia dysarthria is due to an organic brain lesion and the patients who come for therapy do not suffer from any of the progressive diseases which lead to total incapacity or death. in practice the exact cause is of no great importance as the patient is usually seen long after he has sustained his brain injury and the neurologist and therapists are asked to diagnose and treat the residual disabilities. the pathological processes which may cause an apraxic dysarthria vary widely. in children the commonest causes are developmental disorders, . birth trauma, infectious diseases, and head injuries sustained during infancy. in adults caused factors are cerebro-vascular accidents and head injuries. • all these disorders may cause widespread damage so that the apraxic dysarthria is associated with other obvious neurological disabilities. such cases do not generally cause any diagnostic difficulties. even if the true nature of speech disorder is not recognised, the organic factor will be recognised. the only difficult group of cases are those patients where the speech defect appears as an isolated phenomenon set against a background of an otherwise apparently normally functioning nervous system. the clinical picture is nearly always the same. the patient, usually a child, is brought by the parents because his speech is not clear and it has become a social embarrassment. there has frequently been a delay in the development of speech, but this is seldom severe. the mother reports that the child understands speech very well and that within the immediate family circle he can make himself understood quite adequately. strangers, however, have great difficulty in understanding the child. his vocabulary may be very good. simple words are often pronounced quite clearly but multi-syllable words cause most difficulty. when the child talks quickly the condition becomes more marked. sometimes a word is pronounced clearly and a few sentences later the same word is unintelligible. as may be expected consonants are far more severely affected than vowels or diphthongs. the consonants are misplaced, transposed or omitted. substitutions are frequent and often the final sound of a word is left out. the following are typical examples: tydskrif van die suid-afrikaanse logopediese vereniging, vol. 14, nr. 1: sept. 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 η. reef ι . sang for swing. 2. otomo for tomato. 3. sutter for supper. 4. enil for pencil. 5. yell for yellow. 6. poto for potato. 7. bobo for bottle. it is often surprising how the older child with this type of disorder does not recognise or hear his own bad speech—as if he had an auditory imperception for his own speech. he will hopelessly mispronounce a word he has just heard and appear satisfied with his effort. yet it will be easy to establish that his hearing and interpretation of sounds are normal. such speech defects are normal in young infants when they are learning to talk. parents will often imitate them and use the same mispronunciation when talking to the child. when the child is young this type of speech is considered "cute". when such speech persists and becomes a firmly established pattern, then anxiety results and help is sought. firstly an attempt should be made to establish the organic nature of the disorder. this is done by searching for evidence of a possible neurological cause which may have arisen in the birth process or early development of the child. in some cases even although there does not appear to be any obvious neurological evidence of brain damage, the history may suggest possible brain damage, e.g. delayed milestones, unexplained convulsions or behaviour disorder. speech examination. this consists of an examination of the peripheral organs of speech to establish that there is normal function for all voluntary and involuntary movements, other than speech. 1. establish that the tongue and lips function normally for smiling, kissing, "pulling faces", licking the lips, protrusion and diadokinesis of the tongue. 2. test palate by examining the child's ability to swallow and by examining palatal elevation on stimulation or saying "ah". 3. assess co-ordination of respiration and phonation by watching and listening. the findings here will of course depend entirely on the site and degree of brain damage. from this point of view we may divide our patients into two groups: 1. those with very slight brain damage. there may be no abnormal physical signs, although this is rare. a very careful search will nearly always reveal some abnormality, e.g., excessive clumsiness, slight wasting on one side with a change in reflexes, involuntary movements which are very slight, unestablished laterality. 2. those with obvious signs of brain damage, e.g. the adult who has recently had a cerebro-vascular accident resulting in a hemiplegia with a unilateral facial weakness and no dysphasia. speech may be grossly dysarthric and obviously "the facial weakness alone cannot be responsible. this group can also include the child who has a spastic quadriparesis. the cranial nerves appear to function adequately on formal examination, yet speech is very indistinct. with these patients it is sometimes difficult to journal of the south african logopedic society, vol. 14, no. 1: september 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) apraxia dysarthria 43 decide whether the defect in neuro-muscular control of the lips, tongue and palate is responsible for the dysarthria or whether the lesion is situated at a higher level causing an apraxia. if a patient is old enough, a search should be made for disorders of perception, reading and writing as these often co-exist with an apraxic condition. where indicated a detailed assessment of intellectual functions should be carried out. finally, if clinical methods have failed to provide evidence of an organic lesion then one may have to resort to special investigations, such as an eeg examination. this may be more helpful and will sometimes reveal evidence' of cerebral dysfunction when all other methods have failed. differential diagnosis it is evident that apraxic dysarthria must be distinguished from dyslalia and developmental dysarthria. the latter condition can be excluded by careful local examination when the cause of the dysarthria will immediately become apparent. differentiating dyslalia from apraxic dysarthria gives rise to greater difficulty. most cases of apraxic dysarthria initially seem to be diagnosed as dyslalia and in this respect a question of terminology arises. dyslalia has really almost the same meaning as dysarthria. speech therapists have applied the term dyslalia to a group of children who articulate incorrectly due to one of the following five causes: 1. persistence of faulty habits of articulation. 2. imitation of faulty patterns of articulation. 3. the influence of defects of vision on articulation. 4. mental defect. 5. environmental and psychogenic factors. in fact, only the first of these five groups give rise to diagnostic difficulty. the other four can be readily excluded with a careful history and examination. if the dysarthria is severe and persistent, then it is hardly likely to be due to faulty habits. if the dysarthria is mild then difficulty may arise. the most important aid in making the correct diagnosis is the finding of an organic neurological disturbance. once this has been established then dyslalia or any other functional disturbance can be excluded. summary the nature of apraxic dysarthria is defined and a short description of its manifestations has been given. the relationship between apraxia and apraxic dysarthria is discussed. clinical manifestations and the diagnosis of the disorder are described in detail. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 14, nr. 1: sept. 196 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 η. reef opsomming die aard van apraktiese-disartrie word gedefineer en 'n kort beskrywing van die manifestasie van die toestand word gegee. die verhouding tussen apraksie en apraktiese-disartrie word bespreek. diagnose en kliniese manifestasie van die afwyking word meer volledig beskryf. references 1. m o r l e y , μ . e. ( 1 9 6 5 ) : the development and disorders of speech in childhood. edinburgh and london: e. & s. livingstone, ltd. 2. nathan, p. w. ( 1 9 4 7 ) b r a i n , 70, 449. ' ' „ t 3. worster-drought, c. (1952): diagnosis of nervous disorders. london: edward arnold. journal of the south african logopedic society, vol. 14, no. 1: september 1967 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society page een brain damage in children by dr. ruth clark perhaps one of the most neglected areas in the whole field of brain damage is one in which the damage is minimal and diffuse. more and more we are beginning to realize that slight brain damage may be the cause of some:types of learning disabilities, behavior problems and even juvenile delinquency. when we talk about brain-injured children, much of the nomenclature is confused and ambiguous. perhaps the following definitions will help clarify some of the terms used: , 1. congenital is a time-of-occurence concept. it means that the condition was present at the time of birth. it has nothing to do with heredity. 2. heredity is a causal concept and indicates that the. present characteristics are a result of the condition of the germ plasm. 3. endogenous is usually used in relationship to mental retardation and indicates that the condition is hereditary. 4. exogenous usually refers to the type of mental retardation that is not from heredity but from injury to the organism during the pre-natal, neo-natal or postnatal period. some authors use the term to indicate brain injury that is acquired but does not necessarily make the child mentally deficient. 5. mental deficiency can be, primary, i.e. of the endogenous type, or secondary, the exogenous type and merely means that the individual is intellectually functioning below the average. brain injury can cause mental deficiency. 6. amentia means without or lacking mentality and therefore, refers to mental deficiency. this term is further divided into: primary amentia —1 one whose familial background indicates a history of hereditary deficiency, and " secondary amentia — an acquired condition. 7. cerebral palsy is a result of brain injury. it is not a disease but aj syndrome, in which neuro-muscular dysfunction is the| outstanding symptom. cerebral palsy is a term applied to a disturbance of motor function resulting from damage to the brain before, during or after birth. it connotes a group of conditions. these conditions are very different, and consequently, the treatment of the different types of cerebral palsy requires totally different techniques. 8. dysphasia and aphasia are language disturbances. they are disorders of symbolic formulation and expression, and are a result of damage or lack of maturation of the associational areas of the brain. the dysphasias .failure .to properly, use the word "pencil" is notdue to a motor disability but rather, to a failure an associating ;and integrating three different aspects of the."pencil'.', .that is, the pencil as: (1) a real object of senses of sight, sound, smell, touch, etc.; (2) the sound of the word "pencil" which by convention, has come to represent the real object and (3) the neuro-muscular reaction involved in uttering the spoken word " pencil". since reading, writing, understanding and use of objects are associated with language, these skills may also be deficient when an individual suffers disturbances in the associational areas. aphasia and dysphasia like cerebral palsyare not diseases themselves; they are a symptom of a diseased process and are not essentially a speech problem, but rather a language disorder. since deaf children have language problems, aphasic children are frequently confused with deaf children. with the deaf, sounds are not heard; with the aphasic, sounds are heard but they are not translated into meaning. 9. emotional disorders are many times confused with mental deficiency, deafness and aphasia. while there is always, "or practically always, a psychological component accompanying the above-mentioned conditions, there can be emotional disturbances without brain damage of any sort. if the above, terms are kept clearly in mind and appropriate diagnostic instruments used to determine the real difficulty, .with children presented at speech clinics,·, therapy much , more appropriate for the individual case can be; instigated. while present diagnostic instruments are not refined enough in many cases to enable us to. see the complete and accurate picture of children presented for therapy, they give us a "better picture than we could otherwise obtain, and if we are aware of their limitations, we can more easily avoid the pitfalls that we might encounter if we were not forewarned. many children suffering from the conditions referred to above are recognized and usually some type of provision is made in'' their training for their particular handicap. -however, the child who has a very slight, non-localized brain injury frequently is not recognized and yet, he may have certain difficulties for which special allowances should be made. he with the more easily-recognized brain-injured child, is -apt to have perceptional,'' thinking and behavior difficulties. this minimal, diffuse brain injury results from many causes such as the mother running a high temperature before the child's birth, oxygen starvation before or during or after birth, severe childhood diseases, and almost any condition that will cause cerebral palsy or secondary amentia. characteristics of brain injury any serious student in this area realizes that there is a great deal of confusion regarding the characteristics r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) page eight journal of the south african logopedic society of brain-injured children. probably one reason is that the literature pertaining to the field emanates from many different areas and frames of reference. among personnel contributing to the literature are speech pathologists, students of mental deficiency, specialists from several areas in psychology and medicine, as well as educators. in spite of the confusions in the field, the following characteristics-of brain injury are fairly well accepted by the different writers: 1. brain lesions produce similar behavior regardless of the location of the lesions. 2. rigidity and perseveration — this refers to the inability to change easily from one "mental set" to another and the tendency to continue an acceptable performance. 3. perceptual difficulties — perception is the mental process which gives particular meaning and significance to a given sensation and therefore, acts as a preliminary to thinking. one basic characteristic of perceiving is that a perception is made as a whole, "all at once and nothing first". this power of integration is dependent upon an intact nervous system. brain injured children are frequently so attracted to minute details that they disregard the conceptual concept as a whole. some writers refer to this as forced responsiveness. such a reaction is exemplified by the child who is so attracted by a pretty button on a dress that he reacts to this unessential factor alone, disregarding the. essential factors in his environment. sometimes labeled as "inattentiveness," it is really the exact opposite: a complete attentiveness (to something which the normal person would not notice, and therefore an inattentiveness to everything else). 4. thinking disorders — clinical observations of these children have yielded evidence of peculiarities in thinking reasoning, and concept formation deviation markedly from the normal. the brain-injured child is easily prone to give responses which are uncommon, far-fetched, and often peculiar. he is attracted more easily by unessential and accidental details, relationships between object and picture are drawn vaguely, situations are imagined which extend beyond the present situation. 5. behavior disorders and disinhibition: some studies have shown brain-injured children to be erratic, uncoordinated, uncontrolled, uninhibited and socially unaccepted. they are apt to have extreme mood swings and while laughing and playing, burst into explosive crying when confronted with a difficulty. diagnosis the difficulties of properly diagnosing a child having minimal diffuse brain damage are many. frequently, the difficulty lies deep in the cerebrum and does not show up on an electro-encephalograph recording or in a neurological test. many times the only way a child can be classified as having minimal diffuse brain damage is by ruling out every other possibility. the problems of diagnosis are too manifold to be discussed nere. but it is this difficulty which has caused so many children who are probably slightly brain-injured to be classified as hard of hearing, mentally defective, problem children or psychotic. these children then receive therapy that is not structured for their true needs. diagnosis of the minimally brain-injured is one of the most challenging problems in the field today. when confronted with a child having perceptual thinking or behavior problems for which we can find no etiology nor reason, we might well consider the possibility of diffuse brain damage of a minimal amount. in that case different therapeutic procedures will be used than would be if we were working for example, with a behavior problem without any organic background or with a mentally retarded child of the familial type. therapy for the brain-injured child therapy is based upon controlling and helping the child to control the perceptual, conceptual and behaviorial problems which clinical observation and research have indicated to be peculiar to the braininjured child. the stimuli of an ordinary environment are simplified so that the child can build up a threshold of endurance to them. a few points for the speech therapist to keep in mind when working with braininjured children follow: 1. keep environmental stimuli reduced. (a) few, if any, pictures or decorations on walls. (b) quiet room. (c) all materials put away that are not in use. (d) furniture placed so as to give sense of space. 2. insofar as possible, use concrete objects and concrete words when beginning therapy. (a) dean is an example: in teaching him the names of knife, fork,, and spoon, the clinician had little success when she used pictures; as soon as she took him over to the dining room for bis speech lesson and had him use actual utensils, learning progressed. 3. keep materials simple. (a) pictures which contain too much will be overstimulating. ; (b) toys should not involve many ! different actions. ι 4. lessons should involve motor activity. (a) this is true of therapy with all young children, but especially so with brain-injured, since it reduces the distractibility. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society page in 5. many of the children need training in auditory recognition and amplification of sound should help in this respect. (a) they perceive words as a whole, and can not isolate parts. 6. mirror work may be helpful. (a) may involve too many distractions. 7. moto-kinesthetic cues have been found to be helpful. 8. probably no group therapy for a while. 9. if a child can read or write, these skills can be used in helping him speak. 10. many of the child's emotional needs can be met in speech therapy — make him feel secure and adequate. 11. always keep in mind the organismic approach and remember that anything that affects a part of the organism will affect the organism as a whole. 12. if a child is tending to perseverate, quietly shift to another, completely different activity, rather than attempting to continue that one. 13. music and rhythms may be of great advantage. 14. strauss and lehtinen feel that the use of situations such as a store, post office, or bank is not propitious with brain-injured children in academic education, since they involve many distractions and excitations with which he can not cope. this does not mean that learning by doing is not useful, but it need not be in terms of life situations; range of activity should be small. although there seems to be no literature on the subject, it is probable that situational frames of reference should not be employed in speech therapy. conclusions and implications since the etiology and diagnosis of minimal diffuse brain damage is notjclearcut and positive, the possibility of such a diagnosis might be considered when children with behavior problems, thinking and perceptual problems are presented to the speech clinic with this consideration therapeutic procedures will be quite different than they would be if there was not a possibility of brain damage. it is the author's belief that many children having slight brain injuries and classified as "ornery" or "spoiled" are not understood and may try to receive response by causing disturbances. if these children can be diagnosed and can be provided with a controlled environment and proper therapy, a part of our juvenile delinquency probfem may be solved. §§ b i b l i o g r a p h y 1. f r a z e u r , h . a . a n d h o a k l e y , p . , "significance of p s y c h o l o g i c a l ' test r e s u l t s of e x o g e n o u s a n d e n d o g e n o u s c h i l d r e n , " american journal of mental deficiency, 51:384-388, 1947. 2. g o l d s t e i n , k u r t , " c o n c e r n i n g r i g i d i t y , " character and personality 11:209-226, 1942-3. 3. j e l l i n e k , a u g u s t a , " p h e n o m e n a r e s e m b l i n g a p h a s i a , a g n o s i a , a n d a p r a x i a in m e n t a l l y defective c h i l d r e n a n d a d o l e s c e n t s , " journal o l speech disorders, 6.51-66. 1940. 4. n a n c e , l o r n a s . , "differential d i a g n o s i s of a p h a s i a in c h i l d r e n , " journal of speech disorders, 11:219-224, 1946. 4. s t r a u s s , alfred α . , a n d l e h t i n e n , l a u r a e . , psychopathology and education o l the brain-injured child, g r u n e & s t r a t t o n , n . y . , 1950. 6. s t r a u s s , a . a . and w e r n e r , h . , " d i s o r d e r s of c o n c e p t u a l t h i n k i n g in the b r a i n i n i u r e d c h i l d , " journal o l nervous mental disorders, 96:153, 1942. 7. w a l l i n , j . e., ch.ldren with mental and physical handicaps, p r e n t i c e h a l l , i n c . n . y . , 1949. 8. w e r n e r , h . , " t h e c o n c e p t of rigidity: a c r i t i c a l e v a l u a t i o n , " psychological review. 53:43, 1946. by r u t h m . c l a r k . p h . d . , a s s o c i a t e professor a n d d i r e c t o r , c h i l d r e n ' s speech clinic, university of d e n v e r , 2045 s o . y o r k s t r e e t . d e n v e r 19, c o l o r a d o . d r . c l a r k is a n h o n o r a r y m e m b e r of t h e s o u t h africa l o g o p e d i c s society, a n d lectured at t h e u n i v e r s i t y of w i t w a t e r s r a n d 1950-1951. §§ r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a p r i l j o u b n a l o p t h e s o u t h a ^ r i c a n l o g o p g b i c s o c i e t y <1 stuttering as learned behaviour theoretical and therapeutic implications by margaret marks, b.a., log. (rand), lt.c.l no theory concerning stuttering is justifiable without practical therapeutic implications. it is for this reason that i like to consider stuttering as a learned pattern of behaviour, the assumption being that what is learned can be unlearned, if not by the organism itself, then with the aid of therapeutic techniques. in attempting to discuss various authoritys' theories in learning terms i have divided theories into "exogenous" and "endogenous" groups—exogenous being these theories which postulate that the stuttering originated outside the organism; and endogenous being those which suggest that stuttering begin within the organism. it is self-explanatory that all the exogenous theorists (e.g., blumel (1); johnson (2) ; stein (3) fletcher (4)) would agree that something happens to the organism after birth which results in stuttering, i.e., that he leanis this stuttering pattern of behaviour. travis, 1931 (5), who is probably the most extreme of the endogenous group, sites unfavourable environmental factors as being contributory to the development of stuttering —"such accessory factors as prolonged emotional excitement, exhaustion and emotional shock may act upon the sub-soil of an insufficient cerebral dominance, and become the precipitating factors which allow the predisposing factors to manifest themselves in observable behaviour." he regards secondary symptoms as "largely reactions to, rather than an intergal part of, the stuttering condition." writers who believe in a precipitating condition which j acts upon a predisposing organism (e.g., karlin (6), in his "psycho-somatic theory; vari riper (7), in his predisposing— precipitating· and maintaining factors theory ; kingdon ward (8), in her theory of environment actings upon an organism with a "residual diathesis") all take into account the part played by the environment on the weak organism. these writers would also support the view that learning plays a large part in stuttering. if the actual stutterer can be divided into the original "block" or repetition," plus the "secondary symptom," we can consider that, while a few authorities consider the primary stage of stuttering to be a function of the organism, and not of its environment; all authorities seem to be of the opinion that the second stage of stuttering involves learning— the learning of (inadequate) patterns of behaviour which were originally intended to "avoid, postpone, disguise, start or release the speech abnormality." (van riper.) it can be argued, therefore, that the principles of learning can be applied to reduce these secondary symptoms of stuttering, if not to the actual elimination of the original "primary" stutter, which may or may not, be a function of learning. before discussing how this could be done, a brief outline of the fundamentals of learning is indicated. hull (9) (in his "principles of behaviour") gives as the four fundamentals of learning, drive, cue, response and reward. the drive—is a strong stimulus which impels the organism to action. it may be primary (physiological) or secondary (acquired). secondary drives are acquired on the basis of the primary drives, e.g., anxiety and fear are secondary drives based on the primary drive, pain. without drives the organism does not behave, and hence does not learn. cue : the drive compels a person to respond. cues determine when he will respond, where he will respond, and which response he will make. response: the way in which the person responds to a cue, when he is driven to a reward, is his response. reward: this is an event which produces a reduction in the drive like the drive it may be primary (physiological) or secondary (acquired) on the basis of a primary drive. without reward, there is no learning. to summarise the learning process — the drive impels a response which is determined by a cue. if this response is followed by a reward frequently enough, learning occurs, so that on the presentation of a certain situation (drive and cue) a particular response is made. i have attempted to rephrase elsewhere (10) some of the stuttering experts' theories in terms of these four fundamentals, e.g., johnson's theory: r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c s o c i e f y a p r i l drive: to avoid non-fluency—"to avoid expected stuttering"—johnson. cue : "the expectation of stuttering"—johnson, 'words which cause anxiety about stuttering"—brown. response: "tension, an expression of the anxiety and an attempt to avoid the anxiety . . . an anticipatory hypertonic, avoidance reaction' '—johnson. reward : the uttering of the word. most rewards can be stated in fletcher's words as "communication, the basis of society." to get the word out is the primary aim, or drive, of the stutterer. the acquisition of secondary symptoms could be described in learning terms as follows: communication—to get his words out—is the stutterer's drive. he responds to the cue of a feared word or situation by a "hypertonic" speech effort—i.e., he forces the word out, often using bizarre accompanying movements. eventually he is rewarded,, i.e., he gets the word out. then there comes into play the "gradient in the effect of reward"— i.e., if a number of different responses are made to a cue, and that the last of these responses is followed by reward, the connection to the last response will be strengthened most. therefore, a movement, a gesture, a vocalisation, which may have nothing to do with the actual utterance of the word, may be "learned" as it was the nearest action in time to the reward response. the act of stuttering may be specifically reinforced by virtue of its relatively close association with anxiety tension reduction accompanying the removal of a feared word. it seems as if there is a vicious circle where completion of the stuttered act results in a reduction of the anxiety tension evoked by the stimulus word, with consequent reinforcement of stuttering behaviour. secondary symptoms appear to be learned by the stutterer to help him get over a block. especially when first acquired, secondary symptoms probably serve largely as anxietyreducing agents. if we wish to change the stutterer's response, we must attempt to change either his drives, his cues, or his rewards (or all of these). established therapies have been directed towards these goals. mental hygiene and re-evaluation have aimed at changing the stutterer's drives and cues. negative practice of secondary symptoms aims at substituting a punishment for a reward when the response of the secondary symptom is made. i feel that stuttering therapy could be handled with greater confidence if we worked systematically on the basis of learning. the stutterer can be helped to react differently to cues (particularly feared situations) if he is helped to make a better general adjustment (e.g., encouraging "excitatory" traits in "inhibitory" personalities, salter (11); he could learn to respond to situations with relaxation instead of tension (jacobson's progressive relaxation (12) ; wolpe's reciprocal inhibition and specific desensitisation (12). as in negative practice, his secondary symptoms could acquire a punishment value, rather than a reward value (e.g., as the reward of a secondary stutterer is the utterance of the word, i am attempting to make the stutterer respond to a secondary symptom with a complete silence—the secondary " —" acquires punishment value by breaking communication, instead of reward value by continuing it). once therapists have accepted the principles of learning psychology, the possibilities of systematic therapy are limitless. as kingdon ward says "if we accept the factor of heredity we are committed to a passive acceptance of conditions which can never be wholly overcome—the post-natal environment can be modified to some extent." i believe that a scientific manipulation of the environment (drives, cues and rewards) and responses of a learning organism; can be one of our best leads in stuttering therapy. 1. bluemel, c.s.—"stammering and allied disorders," 1935. 2. johnson, w.—"speech handicapped school children," 1948. 3. stein, l.—"speech and voice," 1942. 4. fletcher, j. m.—"the problem of stuttering," 1928, 5. travis—"speech pathology," 1931. 6. karlin : psychosomatic theory of stuttering— "journal of speech disorders," 1947. 7. van riper—"speech correction," 1954. 8. kindon ward, w.—"stammering—a contribution to the study of its problems and treatment," 1941. 9. hull, c. c.—"principles of behaviour," 1954. 10. marks, m.—"stuttering behaviour and learning". thesis presented for b.a. log. degree, 1953. 11. salter—"conditioned reflex therapy." 12. jacobson—"progressive relaxation." 13. wolpe—reciprocal inhibition as the main basis of theraputic elfects : "arch. neurol, psychiat." 1954. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the identification process in early communication intervention (eci) by primary health care personnel in ditsobotla sub—district. jeannie van der linde, alta kritzinger, aniei redelinghuys university of pretoria abstract based on clinical observations, case finding for early communication intervention service delivery in rural areas, such ditsobotla sub-district, is limited. the study described the identification process used for infants and young children at risk for communication delay and disorders as part of a proposed incremental implementation of early communication inter vention services within the existing primary health care package. a descriptive survey design was followed. a rating scale was utilized and interviews were conducted with 20 randomly selected primary health care personnel and eight primary health care programme managers in ditsobotla sub-district in north west province. the aims were to describe the early identification methods/processes, resources and limitations and provide guidelines to introduce early communication in tervention services in a rural community. the results indicated that the identification process was limited. an incremental implementation of the different early communication intervention functions within the primary health care package ap­ pears feasible. implications of the findings may be applied to initiate early communication intervention services, based on integrated teamwork, in a rural district in south africa. key words: early communication intervention, early identification, referral systems, case finding, infants and young chil­ dren, at-risk, communication delay or disorders, primary health care r ural communities in south africa particularly bear a high burden of disability, which may be both the cause and the consequence of poverty (emmett, 2005). infants at risk of developmental delay and their families who live in poverty therefore face additional constraints that place them at increased risk for developmental disabilities (moodley, 1999). due to a worldwide increase in developmental disabilities in chil­ dren under three years (rossetti, 2001), it can be expected that the number of young children presenting with communication delay and disorders will also increase. multiple risks of communication delay and disorders in young children occur in the rural sub-district of ditsobotla in the north west province. from january to march 2005, 511 infants were born in the local hospitals and approximately 18% of them weighed less than 2500g (monthly hospital statistics, north west province, 2005), which indicates low birth weight and a concomi­ tant risk of developmental delay and disability (rossetti, 2001). according to the same hospital statistics, 5% of the mothers were adolescents, which poses a risk for maladaptive parenting and poverty if they are not supported by other women (werner, 2000) and 2.5% of the mothers had syphilis, a risk of bilateral sen­ sorineural hearing loss of sudden onset and progression in their infants (plante & beeson, 2004). approximately 5% of the infants were born to mothers with hiv/aids (monthly hospital statistics, north west province, 2005), with a risk of mother-to-child trans­ mission of the virus, and further risks of health and developmen­ tal difficulties, congenital hearing loss or the development of hearing impairment shortly after birth (swanepoel, 2004). de­ spite the different risk conditions and the clear indication to establish a sustainable early communication intervention (eci) programme in the sub-district, very few infants at risk were identified and referred to the first author during a year of com­ munity service employment. based on the one example of eci services in south africa not sufficiently meeting the needs of the mother and infant risk population, and a call from various authors to expand service delivery to include community-based eci services (kritzinger & louw, 2003; moodley, 1999; pickering et al., 1998), a research project was launched (van der linde, 2008). the aim was to investigate the existing identification and referral practices used in primary health care (phc) services of the specific sub­ district in order to determine needs and resources that should be considered when developing eci services. contact: prof. alta kritzinger department o f communication pathology university o f pretoria pretoria e-mail: alta.kritzinger@up.ac.za 48 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:alta.kritzinger@up.ac.za the id e n t if ic a t io n p r o c e s s in the underpinnings for the research study . „ mpreed over time in the field of early intervention. hence that ei iic s oariv intervention was shown to be linked to the the efficacy or eariy . „ at identification (rossetti, 2001). if under three years child s age the window of opportunity may be enhanced by neurode ° lopmental plasticity (dennis, 2000). early identification of risk conditions in infants should therefore be the primary function of i (kritzinger, louw & rossetti, 2001). developing and imple­ menting effective identification strategies, especially in rural ar­ eas is one of the biggest challenges in eci, as a lack of identifica­ tion will compromise the efficiency of the services (kritzinger, 2000). consequently, the efficacy of early identification of an infant at risk of developmental delay depends on a reliable refer­ ral system so that time delays between the detection of a prob­ lem and intervention services to the family may be minimised. furtherm ore, th e efficacy of a referral system is in direct rela­ tion to the outcomes that the system a ch ie ve s (equity project, 2000). by means of a smoothly functioning referral system the eci client and family, for example, receives diagnostic and th e ra ­ peutic services from a specialised team of medical and re h a b ilita ­ tive professionals, ensuring th a t phc is more unified and finan­ cially sustainable (equity project, 2000; n orth west department of health, 2003). it appears that limited referrals and improper coordination of referral systems are partially responsible for eci and its benefits being unknown in the south african health care system (kritzinger, 2000). integrating eci services into phc in rural communities in south africa has been recommended in various studies (fair & louw, 1999; kritzinger & louw, 2003; moodley, 1999). formalised by rossetti in 1996, the concept of communication-based services to the population of children birth to three years of age, is based on the finding that communication delay is the most prevalent characteristic of delayed development in children in this age group (rossetti, 2001). enhancing communication development should therefore be the main focus of any effective early interven­ tion programme (rossetti, 2001) hence the term early commu­ nication intervention. in the planning and management of eci services, the focus should be to develop strategies to prevent communication disor­ ders in all people, including rural and disadvantaged communi­ ties (kritzinger, 2000). as prevention of disability and communi­ cation disorders is the ultimate goal in eci, primary prevention programmes could be implemented at phc clinics. a transdisciplinary framework for eci public service delivery has been proposed by kritzinger and louw (2003), which may be integrated into the phc package of the department of health (2000). the phc package was designed to provide comprehen­ sive and integrated health services and not to be implemented through separate, vertical programmes where services are split primary health care personnel in ditsobotla sub-district according to disciplines, resulting in barriers to teamwork (van rensburg, 2004). consisting of eight different programmes, the package entails a standardised and comprehensive ‘basket’ of preventative, promotive, basic curative, rehabilitative and pallia­ tive services delivered at district level (department of health, 2000). linked together as a service delivery model for health care, there are eight programmes i.e., 1) non-personal health services (occupational and environmental health); 2) disease prevention and control; 3) maternal, child and women's health; 4) hiv/aids, sexually transmitted infections and tuberculosis; 5) health monitoring and evaluation; 6) mental health and sub­ stance abuse; 7) gender issues, and 8) school health services. these should be mutually supported by the health care profes­ sionals delivering these services (department of health, 2000; van rensburg, 2004). since teamwork is an essential approach in the implementation of the phc package, the opportunity for collaboration should be utilised by therapists to introduce eci services in communities. the transdisciplinary conceptual framework for eci describes collaborative partnerships with parents and caregivers, commu­ nity health nurses and doctors, speech-language therapists, audi­ ologists at phc clinics, and secondary caregivers at creches and day-care facilities (kritzinger & louw, 2003). according to kritz­ inger and louw (2003) eci service delivery may be introduced to be consistent with the developmental stages of young children and the contexts where caregivers can be reached. examples include services to the mother at antenatal clinics before the infant is born (providing preventative information on normal hearing and communication development); during the neonatal period in the postnatal ward (promoting mother-infant, attach­ ment and interaction, hearing screening and identifying risks for communication delay); during the postnatal period at immuniza­ tion clinics (follow-up hearing screening, identifying further risks and provide eci, advocacy for education); and during the toddler years at day-care centres and nursery schools (providing eci, training parents, facilitating a language and emergent literacy rich preschool curriculum to facilitate school readiness) (kritzinger & louw, 2003). with the exception of non-personal health services, integrating direct eci services into seven of the different phc programmes appears to be possible. the wide-ranging eci functions such as promotion of normal development, prevention of feeding difficul­ ties, hearing loss and communication disorders, parent training, screening, early identification and providing assessment and intervention correspond with the different services provided within the variety of programmes in the phc package. if certain eci functions are shared among professionals in phc, case finding of infants at risk for communication delays or disorders may be improved and appropriate eci services may be rendered to families at phc facilities. examples of successful integration of early communication intervention followed by were based on evithe south african journal of communication disorders, vol 56, 2009 49 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) jeannie van der linde, alta kritzinger, aniel redelinghuys paediatric health and developmental services in phc can be found (lequerica, 1997). according to lequerica (1997) it ap­ pears that such a one-stop phc service delivery model is pre­ ferred by families, and increases family participation. it is there­ fore important to investigate the feasibility of the integration of phc and eci programmes in a south african context where eci services are lacking. since the primary goal of research is to improve understanding of a phenomenon (leedy & ormrod, 2005), information produced by the current research study aims to identify certain problem areas. the research may also provide guidelines for identification and referral practices for eci in the phc context, which may be used to improve case finding in rural areas in south africa. the information gathered through the research may also support the facilitation of a transdisciplinary team approach to service deliv­ ery in eci in ditsobotla sub-district, where effective collaboration between the phc nurses, speech-language therapists, audiolo gists, and phc programme managers may be established. method aims and objectives the purpose of the study was to describe the characteristics of identification methods and referral practices for eci currently followed by phc personnel in the ditsobotla sub-district. the following objectives were formulated: □ to describe the features of the facilities in the phc con­ text in order to determine the capacity for implementing an eci programme for infants with risks for disabilities. g to describe the human resources available in order to determine the needs within the phc context. g to describe the early identification methods and re­ sources currently used by the phc personnel and man­ agers to detect health problems as well as developmen­ tal delay and disabilities in infants. [] to describe the referral systems, between different organizational departments in one facility, and the net­ works between different institutions, which are currently being used by phc personnel for eci services. g to describe the phc programme managers' views on how to implement an early identification and referral programme for infants with risks for disabilities and delays in an integrated phc and eci approach. research design a descriptive research study was conducted. a dominant-less dominant research design was selected, which entailed the use of a quantitative approach, the dominant component, and a qualitative approach, the smaller or less-dominant component (fouche & de vos, 2005). the quantitative approach implied a formalized approach with explicit control during data-collection (fouche & de vos, 2005). a questionnaire and a rating scale were used as methods of data collection. the qualitative compo­ nent consisted of semi-structured interviews with programme managers to obtain an in-depth understanding of data already collected and that may have needed further clarification (leedy & ormrod, 2005). to increase the reliability of the study, triangulation was used (de vos, 2005). triangulation results from a combination of qualitative and quantitative research approaches. it is based on the assumption that bias in a particular data source, investigator or method may be neutralized when used in combination with other data sources, investigators or methods (de vos, 2005). in the current study both data triangulation, i.e. more than one data source in this case the phc sisters and the phc programme managersand methodological triangulation, i.e. multiple meth­ ods or approaches such as a rating scale and face-to-face inter­ views, were used (de vos, 2005). research ethics the research proposal was approved by the research ethics and proposal committee of the faculty of humanities, university of pretoria. permission to conduct the research was granted by the north west department of health. all participants gave voluntary informed consent to participate in the study. information obtained from the participants was treated confidentially and reported anonymously. all efforts were made to conduct the research according to the ethical principles of no harm to participants, veracity, non-discrimination and sensi­ tivity to cultural and language differences between participants and the researcher. , participants the two target populations were phc personnel and phc pro­ gramme managers who were employed by ditsobotla sub-district, i which is part of the central district of north west department of i health. both groups had to be proficient in english in or^er to participate in the study. although setswana is the most com­ monly used language in the sub-district, it was found that the participants were sufficiently proficient in english to understand and answer the interview questions. selection of participants stratified random sampling was used to select the participants in group 1, the phc personnel (strydom.& venter, 2002). stratifiy cations entailed that the specific population was divided in strata, which were homogeneous with regard to some characteristics (strydom & venter, 2002). the entire phc personnel of ditsobotla sub-district were divided into two strata according to the size of the phc facilities: all the clinics operating for 8 hours and 10 hours per day were part of stratum 1, while all the phc hospitals 50 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the identification process in early communication intervention followed by primary health care personnel in ditsobotla sub-district and 24-hour clinics were part of stratum 2. the selection within the strata was random (strydom & venter, 2002) as the re­ searcher randomly selected the facilities to be included in each stratum. in group 2 all the phc programme managers of ditsobotla sub­ district who complied with the selection criteria received informa­ tion brochures and were invited to participate. in this case the number of possible participants was limited. non-random pur­ posive sampling was used since a group of participants to repre­ sent the population did not have to be identified (leedy & orm rod, 2005). description of participants -description of participants in group 1: approximately one third (20) of the phc personnel in the entire sub-district were included in the study, with each stratum equally represented. the charac­ teristics of the participants in group 1 are summarised in table 1. according to table 1 there were only a few differences between the participants of the two strata. the majority of the participants had nursing diplomas, all were working on a full-time basis, with an average of eight to 12 years working experience. the partici­ pants therefore had work experience which rendered them as informed research participants, although three participants had no formal training. table 1. characteristics of the participants in group 1 (n=20) course. the characteristics of the participants are summarised in table 2. according to table 2 most of the programme managers had qualifications and work experience. a variety of programmes in the phc package were represented by the managers, but those who managed the maternal, child and women’s health, mental health and the hiv/aids programmes could not be included as participants as they were attending a course during the time allo­ cated for data collection. table 2. characteristics of the participants in group 2 (n=8) c h a r a cter istic s tr a ta 1 (n= 10) s tr a ta 2 (n= 10) q u alificatio n 2: b c u r d eg ree 6: d ip lo m a 2: n o fo rm al tra in ­ ing i 3: b c u r d egree 6: d iplom a 1: n o fo rm al tra in ­ ing y ears o f ex p e ri­ ence 4 y ears 25 years a v erag e: 12,5 years i 1 y ears 26 years a v erag e: 8,4 years f irs t language 10: s etsw an a i 9: s etsw an a 1: a frik a an s e m p lo y m en t status 10: f u ll-tim e 10: f u ll-tim e t ype o f fac ility w h ere em p lo y ed 7: 8 -h o u r clin ic 3: 12-hour clinic 2: p h c h o sp ital 8: 2 4 -h o u r clinic qualifications masters de­ gree, b cur degree, nursing diploma to no formal training range: 1 lo y average: 4y experi­ ence in pro­ gramme managing phc facili­ ties visited hospitals clinics frail care centres prisons hospices schools creches business premises first lan­ guage 2: afri­ kaans 6 : setswa na all full­ time em­ ploy­ ment status phc pro­ gramme man­ aged geriatrics, chronic dis­ eases rehabilitation nutrition communicable diseases occupational therapy health promo­ tion nutrition school health environmental health description of participants in group 2 the participants in group 2 represented more than two thirds of the total of the phc programme managers. a total of 12 phc programme managers were working in ditsobotla sub-district. all the programme managers were asked to participate, and a pilot study was conducted with one of the programme managers prior to the data collection. that left 11 phc programme managers, eight of whom participated in the research. the other three pomaterial and apparatus the following material was exclusively developed for the data collection of the study: a summated rating scale for the description of the facilities (see appendix a). summated rating scales are widely used for the description of environments where phenomena have to be evaluated on a con­ tinuum of, for example, excellent to inadequate (leedy & ormrod, 2005). the rating scale used was a means to analyse facilities and describe the available human resources. the rating scale provided not only the background to the study, but also relevant data which could point to strengths and weaknesses in the identi­ fication methods and referral systems of the phc system in the ditsobotla sub-district. the rating scale was also used to deter­ mine the capacity of the facilities to implement the different eci functions. the content of the rating scale included the following physical characteristics: water and electricity supply, the educational at­ mosphere of the waiting rooms, developmental screening materi­ als available, space for interviews and screening assessments, filing cabinets and filing system. tential participants were either on leave or were attending a the south african journal of communication disorders, vol 56, 2009 51 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the human resources and services to infants were also re­ corded for each study site. face-to-face interviews to investigate the identification processes used by the participants in group 1 a structured interview was used to collect data on the identifi­ cation processes, which included questions on the identification methods and the referral systems used by phc personnel to iden­ tify and refer infants with developmental disorders or who are at risk for developmental delay. when the focus of a study is to in­ vestigate a process, in this case the identification process, struc­ tured interviews are especially suitable (greeff, 2002). although participants may not be as truthful in their responses as in the case of self-administered questionnaires, face-to-face interviews have the advantage of the highest response rate in survey re­ search (leedy & ormrod, 2005). face-to-face interviews with the participants in group 2 on the implementation of an eci programme with its emphasis on early identification a set of individual interviews with the participants in group 2 was necessary in order to triangulate data, which brought differ­ ent views on the current identification methods, referral systems and teamwork to the fore and therefore led to more accurate descriptions of the same aspects. furthermore the phc pro­ gramme managers’ opinion on the implementation of the differ­ ent eci functions within the phc package was obtained. the apparatus used during all the interviews w as an o lym p u s v n 240 p c digital voice recorder. t h e digital voice files were tran­ scribed and securely stored on a laptop computer. the first author w as the only person to have access to the data. procedures reliability a nd validity with triangulation the reliability of the data was increased, as it was collected by means of different instruments and results could therefore be compared. furthermore, two separate groups of participants were used to investigate the identification meth­ ods and referral systems, while the researcher’s own field notes further supported the data obtained in the interviews.' a second reviewer was utilized to verify the interview recordings of both groups of participants. the reviewer listened to the re­ cordings while reading the transcriptions. discrepancies between the text and voice recordings were discussed until agreement was found between the researcher and second reviewer. face validity of the instruments was ensured as the format of the measuring instruments corresponded with the objectives of the research. all questions of the interview schedules were rele­ vant and clearly formulated to ensure content validity. a senior speech-language therapist with working experience in primary health care reviewed the questionnaire and made suggestions to improve the relevancy of the questions. pilot studies o f the rating scale and interview schedules jeannie van der linde, alta kritzinger, aniel redelinghuys pilot studies were conducted to test the rating scale and the two interview schedules in order to increase the accuracy and reliability of the data. according to the selection criteria, two phc nurses and one phc programme manager were selected to be part of the pilot studies. the rating scale and interview schedules were adapted according to the results obtained in the pilot stud­ ies. procedures o f the m ain stu d y based on the two strata, the different facilities to be included in the study were randomly selected from a total of 17 phc sites in the sub-district. ditsobotla sub-district, previously named lichten burg is part of the greater taung local municipality and forms the central district in the north west province. the district is largely rural and has an unemployment rate of over 50%. the main in­ dustries are mining and quarrying, but agriculture is the focus (escom, 2007). during the first visit to a facility, permission was obtained to complete the rating scale. the researcher then filled in the rating scale without being intrusive. the completed rating scale was verified by one of the participants at each site so that a true re­ port of the facility was stored for data analysis. after explaining the reason for the visit, the facility manager introduced the re­ searcher to the potential participants in group 1. informed con­ sent was obtained from the participants in group 1 and the struc­ tured interviews were conducted according to the interview schedules. the interviews were conducted at the participants’ working facilities, in order to ensure that the participants did not have to travel and that they would be as comfortable as possible. the interviews were conducted in a consultation room at the fa­ cilities thereafter the researcher visited the participants of group 2 at the district office of ditsobotla sub-district. informed consent was obtained and the semi-structured interviews were conducted in each participant’s office. this made the participants feel comfort­ able and little hindrance was present due to the professional environment in which the interviews were conducted. data analysis \ the data of the structured interviews were analysed first, in order to determine which aspects needed further investigation and had to be included in the semi-structured interview schedule with participants of group 2. the data obtained from the first interviews were analysed quantitatively according to the sas system version 9.1 statistical computer software. as the analysis was done in microsoft excel, the data were stored electronically (babbie, 2004). ^ frequencies were calculated as data should be presented in a condensed form when the data consisted of a large number of observations (steyn, smit, du toit, & strasheim, 1998). basic graphical presentations were used to better understand the data 52 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the identification process in early communication intervention followed by primary health care personnel in ditsobotla sub-district posters or brochures on child development. only five clinics had television monitors for educational videos. and decide where further statistical analysis would be appropri­ ate. fisher’s exact test of independence was used for data with two attribute variables (leedy & ormrod, 2005). the rating scales were analysed numerically, as the data collec­ tion method was quantitative. procedures similar to those used to analyse the data from the structured interviews were therefore used for the analysis of the rating scale. in qualitative research the data analysis and interpretation are closely connected (leedy & ormrod, 2005). this had to be taken into account when the results of the semi-structured interviews were analysed and interpreted. the researcher listened to the voice recordings and supplemented the transcriptions with field notes. data were holistically read and re-read before the corpus was categorised according to themes. according to leedy and ormrod (2005) the researcher has to have a heightened and focused awareness of the data and subtle undercurrents during interviews have to be identified. regularities were noted during the data analysis and categories of meaning emerged that could be presented as descriptive results. results and discussion the results are presented and discussed in accordance with the objectives of the study. the capacity of the facilities for implementing an early identifi­ cation programme for infants at risk of disabilities the basic features of the facility, the waiting rooms and consult­ ing rooms were evaluated according to the rating scale (see ap­ pendix a) and described to determine the possibility of imple­ menting eci functions in these facilities. primary prevention ac­ tivities, such as talks to caregivers to promote normal communi­ cation and emergent literacy development, can possibly be imple­ mented in the waiting rooijns of the facilities, while identification and intervention of infants and young children, i.e. primary and secondary prevention, may be implemented in the consultation rooms. j the checklist results indicated that all phc facilities which were investigated had electricity and water supply, although some water shortages and power breaks occur. all buildings were per­ manent structures and three clinics were recently renovated. the travelling distance from lichtenburg, the town in the centre of the sub-district, is not more than 35 km. most of the roads are not tarred and the public transport is by minibus taxis. the implica­ tion is that a speech-language therapist or an audiologist may be able to visit two clinics in close approximation on one day. the results also indicated that not all facilities have the capac­ ity to implement eci functions in waiting rooms and/or consulta­ tion rooms, but patient information was adequately protected by means of secured filing cabinets. six of the ten clinics had limited seating space in the waiting rooms, which means that educa­ tional talks may not be possible. none of the waiting rooms had as only a few of the facilities have the capacity for all eci func­ tions to be implemented, an incremental implementation of eci services could be introduced. speech-language therapists and audiologists therefore need to determine which levels of preven­ tion can be implemented at which facilities in the sub-district. it may be possible that one facility only has the capacity to support the implementation of the primary prevention level in eci ser­ vices, while all three levels of prevention can be implemented at another facility. since the waiting room capacity in the majority of the clinics was limited, it may imply that educational talks cannot be given and that only individual screening, assessment and in­ tervention can be offered at the clinic. promotion of communica­ tion development and other information may be given to caregiv­ ers in the form of brochures in the local language. the availability, needs and limitations of human resources with-in the phc context a shortage of phc personnel will have an impact on the incre­ mental implementation of eci functions. since the phc personnel may not be able to assist the speech-language therapist and audiologist in some of the eci functions, the capacity and support of the human resources at the facilities need to be determined in order to establish which eci functions can be effectively imple­ mented in the facilities. according to the results there were community health nurses present at all the phc facilities investigated, but not all were qualified at the time of the investigation. there were limited health care professionals such as doctors, speech-language therapists, audiologists and paediatricians working in the sub­ district. although an inadequate arrangement, an itinerant doctor visited nine different phc clinics at least once a week. the tenth phc facility is a hospital where a permanent doctor was em­ ployed at the time of data collection. the phc personnel had limited knowledge regarding the avail­ ability of allied health care professionals at their facilities. the lack of knowledge of the different health care professionals work­ ing in the district may reflect an inadequate teamwork approach. ineffective communication and collaboration between phc nurses and other health care professionals, limited information regarding available services and no in-service training regarding the scope of practice of specialized services were further indica­ tors that an inadequate teamwork approach is present in ditsobotla sub-district. it was estimated by the participants that, on average, approxi­ mately 165 infants were seen at the ten different phc facilities on a daily basis. it is clear that the infant population of the sub­ district may be accessed through the phc facilities. limited hu­ man resources appear to be one of the reasons why screening for the south african journal of communication disorders, vol 56, 2009 53 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) jeannie van der linde, alta kritzinger, aniel redelinghuys communication and hearing disorders was not carried out in ditsobotla sub-district. the participants felt that it was the doc­ tors’ responsibility to screen for hearing and communication dis­ orders in young children as they are trusted by caregivers. an interesting finding was that the participants felt that parents and family members share responsibility in identifying communication delays or disorders in the child's development. human resources and an adequate team approach appear to be limited in ditsobotla sub-district. by implementing eci activi­ ties on a primary prevention level at all phc facilities the following may be achieved: introduction of speech-language therapy and audiology, promotion of eci services to both the phc profession­ als and the caregivers and provision of information on early iden­ tification, stimulation of infants and young children and communi­ cation developmental milestones. the introduction of eci to the phc professionals and caregivers may provide the basis on which the incremental implementation of other eci activities, such as developmental surveillance, can be achieved at phc facilities that have the capacity to accommodate such eci activities. eci implementation may be established by coordinating the services with certain phc programmes, i.e. non-personal health services, disease prevention and control, maternal, child and women’s health, hiv/aids, sexually transmitted infections and tuberculo­ sis, mental health and substance abuse, and health monitoring and evaluation. the early identification methods and resources currently used by the phc personnel posters on general health issues were numerous in the facili­ ties, but posters on infant and child development were absent. there is a great need to develop mass communication material in setswana and english for eci in this sub-district which has to be addressed by speech-language therapists and audiologists. the results clearly indicated that none of the facilities had checklists to use for developmental surveillance and therefore it appeared that phc professionals were not conducting any formal develop­ mental screening of infants and young children. appropriate checklists and case history forms for different south african con­ texts need to be developed so that children at risk of develop­ mental delays can be successfully detected and referred within the phc facilities (department of health, 2000). the results indicated that phc personnel use observation and that they talk to the child to determine if there is a problem in his/her communication development. talking to the child to de­ termine the level of communication development is a positive initiative, but the participants indicated that they do not have a guideline to assist them in identifying atypical development. the informal method of talking to the child which is currently used in the sub-district does not appear to be valid and the phc person­ nel are in need of locally developed, valid, reliable and easy to use identification methods. the participants clearly indicated a need for formalized and valid identification methods and in service training on how to identify infants and young children with communication delay or hearing impairment. the participants viewed their identification method as largely ineffective and unre­ liable. baby clinics, that form part of the mother, child and women’s health programme, were identified by the majority of the phc personnel as the best phc programme to implement the devel­ opmental surveillance of communication abilities in infants. the referral systems used by phc personnel to refer patients to speech-language therapists and audiologists. according to figure 1 the referral route is clear, but some diffi­ culties in making referrals are experienced. a total of 80% of the participants indicated that they experienced time delays when patients had been referred. a disturbing finding was that caregiv­ ers of infants and young children were asked to come back a number of times before the referral to the speech-language therapist was made. the distances between patients’ homes and the hospitals need to be taken into consideration, as patients usually cannot afford to travel far on a regular basis. due to the figure 1. the referral process used by participants to refer patients for speech-language therapy and audiology services i large number of patients to be seen by speech-language thera­ pists and audiologists and the transport problems, scheduled follow-up visits are irregular in the sub-district. therefore it would be best for the patient to receive eci services at the local clinic, instead of at the secondary health care hospjtal which may require further, more costly travel. participants in both group 1 and 2 felt that the referral process was not effective and their reasons were as follows: []-a ck of communication between professionals 54 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) intervention followed by primary health care personnel in ditsobotla sub-district teamwork: 03etter communication and cooperation between professionals [ j h e referral information is limited, resulting in the profes­ sional asking for the case history from the clinic [ j e w professionals, such as speech-language therapists, are currently working in the sub-district; thus only limited services are available in the district, and phc personnel are uncertain of whether services are available [referral books are not available for eci, and the phc person­ nel do not get feedback after the referral has been made [3-ong distances to the hospitals □the patients struggle with transport as they have little or no money for their trip [ j h e phc personnel receive little or no feedback from the speech-language therapists on their referrals the doctors visit clinics only a few times every week, which delays the referral process as the patient is referred to the doctor for an appointment the results from the current study indicated that few referrals were made to speech-language therapy and audiology services, which differs from developed contexts, such as the uk (enderby & petheram, 2000). in the uk many patients are referred to local speech-language therapy and audiology services, but the referral process also faces certain challenges. factors influencing the referral process in the uk include limited knowledge of the risk factors for communication delay, long waiting periods for appoint­ ments, epidemiological and demographic factors, such as long travelling distances (enderby & petheram, 2000). the lack of human resources, financial constraints on families who need eci i services and limited teamwork as reasons for poor referrals may be specific to rural communities in developing contexts. the sug­ gestions for improvement of the referral process clearly indicate that the participants were concerned about the difficulties and are positive about the implementation of an effective referral system: j | administrative suggestion's: , qmproving back-referral system by implementing referral let­ ters where back-referral is mandatory q)evising a simple and easy-to-use referral form on which pa­ tient information can be written with space provided for back referral to the referring sister (in addition to the road to health chart). [employm ent of a full-time speech-language therapist in the sub-district provide feedback to the sub-district on the referral process and schedule regular meetingsiwith provincial and national coordina­ tor in order to develop a new referral process the identification process in early communication [^developing a team to address the needs of the infants and young children and their families in the community information and training: qmproving the awareness of the phc personnel and training them in how to identify and refer infants and young children at risk for communication delay, instead of waiting for the doctor to make the referrals qnform the public regarding the services and initiate work­ shops for parents and teachers the suggestions for improvement are useful to establish eci services in the sub-district. practical aspects as well as manage­ rial and planning issues were included in the recommendations. it is clear that it was valuable to include the programme manag­ ers as participants in the research. the current teamwork approach and participant views on the implementation of an early identification and referral programme, and the integration of eci and the phc programmes through col­ laborative activities all the phc personnel and phc programme managers indicated that collaboration with other professionals would have a positive influence on case finding in eci. the phc personnel indicated that collaboration would positively influence the identification and referral of infants and young children at risk for communication delay, as infants and young children can be identified earlier and time-delays can be decreased in the referral process. the inclu­ sion of volunteers in collaboration with the phc personnel in or­ der to improve identification of infants at risk of communication delays needs to be explored further as volunteers can make regu­ lar home visits in the community to support families with special needs. the majority of the phc nurses indicated that teamwork should occur during early identification, referral and the early interven­ tion phases of eci service delivery. consequently it is essential to establish commitment, competencies and a supportive environ­ ment to ensure an effective collaborative teamwork model, so as to positively reinforce the implementation of eci services in ditsobotla sub-district. the phc programme managers did not only provide relevant reasons for including the specific eci function but also indicated the areas where collaboration should be implemented. the re­ sults indicated that the phc programme managers have a clear understanding o f eci and of the importance of these services. their knowledge of eci may therefore positively influence the implementation of eci functions by means of collaborative activithe south african journal of communication disorders, vol 56, 2009 55 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) jeannie van der linde, alta kritzinger, aniel redelinghuys ties in the district. since they understand the importance of early identification and eci, the phc programme managers appeared to be motivated and ready to assist in the implementation of such activities. consequently it is important to build on the partici­ pants’ interest in eci, which were stimulated by the current re­ search project. the programme managers discussed how and why the different eci functions should be implemented in ditsobotla sub-district: -to train m others to stimulate their infants and children the phc programme managers indicated that this function will be beneficial to the infants as well as the mothers. to screen the communication and hearing abilities in you n g children the majority of the phc programme managers indicated that this function can be integrated in the programmes. the school health programme was specified as a programme in which screening campaigns should be launched in order to identify young children in the following contexts: preschool playgroups, creches and in primary school. the health promotion programme does not need to be included in the screening of infants and young children. this function needs to be implemented at facility level and the speech-language therapist should work in collabora­ tion with the facility managers. -to determine risks for communication delay in you n g children and to provide intervention the phc programme managers indicated that this is an important function to be integrated as communication delays or disorders in infants and young children can be prevented or decreased. the programmes should be in­ cluded in the implementation of eci in the rural community as their resources are invaluable. infants and young children in need of special services have to be referred as soon as possible. the mother, child and women’s and the school health programmes are implemented in contexts such as pre-schools where it is fea­ sible to monitor the communication development of infants and young children. -to advocate the education o f children the phc programme managers indicated that communities should be made aware of the importance of education. this eci function may improve the future of many children. the school health programme needs to operate in collaboration with the schools in order to promote the importance of education. all programmes should be involved in promotional initiatives and the departments of health and educa­ tion need to collaborate. -to facilitate the im plem entation o f a language and literacy based preschool curriculum to ensure school readiness all the phc programme managers supported the integration of this func­ tion into the phc programmes. the departments of health and education need to collaborate on school readiness. the educa­ tors should be trained to stimulate the communication develop­ ment of young children and facilitate the skills to be acquired at preschool level. early learning centres and creches should be visited in collaboration with the school health programme. the training of the preschool personnel may also assist in identifying infants and young children at risk for communication delays. -to evaluate and m onitor the collaborative activities the phc programme managers explained that it is very important to dem­ onstrate progress and to identify the problem areas which may exist. statistics need to be monitored and the goals of the activi­ ties have to be kept in mind. the effectiveness of teamwork has to be evaluated and the phc programme managers have to have regular meetings in order to monitor progress in a collaborative way. -community awareness cam paigns on eci services and partici­ pation in health calendar day activities the eci programme should be integrated in the community by collaboration with the other phc programme initiatives. the importance of community campaigns as a way to provide focused information and to intro­ duce new programmes to people was emphasized by the phc programme managers. conclusion and implications since case finding and referrals are inadequate and eci ser­ vices have not yet been established in ditsobotla sub-district, certain limitations can be expected. the study found that the identification methods for infants at risk of communication delay or disorders are limited and unreliable, and that the referral sys­ tem appears to be ineffective in this impoverished rural district. against the background of difficulties to establish eci services in south africa, identified by kritzinger (2000), it appears that iden­ tification and referral are but two aspects of many influencing eci service delivery. inadequate access to eci facilities, the scarcity of facilities, limited knowledge about the benefits of eci among caregivers and health care professionals, and limited, employ­ ment of early communication interventionists (kritzinger, 2000) are other aspects which impact negatively on the professional obligation to expand eci services in south africa. 1 i in order to improve service delivery in rural areas and therefore make services more accessible to the communities, the findings indicated that the integration of eci functions within the phc package is feasible. the results of the study found an interest in eci among primary health care personnel and managers and a positive attitude to improve services. a formal approach to imple­ mentation was suggested, and collaborative partnerships be­ tween management, phc programme managers^and phc person­ nel are feasible in the sub-district. the incremental rollout of eci activities at phc facilities may also improve teamwork, as col­ laboration is essential to improve the efficacy of early identifica­ tion and referrals. kritzinger (2000) also described limited teamwork and limited 56 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the identification process in early communication intervention followed by primary health care personnel in ditsobotla sub-district knowledge of eci as problem areas in service delivery. the imple­ mentation of collaborative activities necessitates a commitment to integrated teamwork by all involved. the results of the current study showed a remarkable motivation by the participants for the implementation of eci. training of phc personnel in eci services and promotion of normal communication and literacy develop­ ment among young children form part of the different eci primary prevention functions. these functions may be phased in at phc facilities with sufficient capacity and human resources. further­ more, training packages must be developed to address the infor­ mation needs experienced by phc professionals, volunteers, parents and caregivers. the implementation of eci functions within the phc package may address some of the multiple problem areas in eci service delivery in south africa. the implementation of eci services in rural areas in south africa needs to be considered holistically, and the different programmes within the phc package should be used as a means to reach the communities. since the introduction of eci guidelines for speech-language therapists and audiologists in south africa by louw (1997), a theoretical framework for service delivery in the public sector has been described (kritzinger & louw, 2003). this framework pro­ vides a basis to assist in the planning of eci implementation. however, the potential of eci to prevent and minimise communi­ cation disabilities is not yet impacting on the south african health care system, especially in a rural district such as ditsobotla. the current research study indicated that difficulties may be ad­ dressed by means of integrating eci functions into the phc pack­ age. a diagrammatic representation of the proposed integration is provided in figure 2. e g entry level determine capacity of facilities, human resources and needs of community determine increments eci functions in primary prevention n o n-personal hea lth services promotion o f normal development -developmental surveillance planting increments disease maternal, child, hiv and m ental health school health prevention and wom an’s a 1 d s /s t i & substance & control health a n d t b abuse health monitoring & evaluation monitor increments implementing increments eci functions in secondary prevention disea se prevention and control providing eci and parent training planting increments i 1 m aternal, child hiv and m ental health and wom an’s aids /s t i & substance health health and tb abuse h ea lth m onitoring & evaluation monitor increments implementing increments determine increments eci functions in tertiary prevention disea se prevention and control rehabilitation o f disabilities planning increments 1 maternal, child h iv and m ental health and wom an’s a id s /s t i & substance health health and tb abuse hea lth m onitoring & evaluation monitor increments implementing increments figure 2. the incremental rollout of eci functions within the phc package the south african journal of communication disorders, vol 56, 2009 57 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) jeannie van der linde, alta kritzinger, aniel redelinghuys references babbie, e. 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(2004). communication and com m uni­ cation disorders. a clinical introduction. (2nd ed.). boston: pear­ son. rossetti, l.m. (2001). com m unication intervention. birth to three. (2nd ed.). canada: singular thomson learning. steyn, a.g.w., smit, c.f., du toit, s.h.c., & strasheim, c. (1998). moderne statistiek vir die praktyk. (6th ed.). pretoria: van schaik. strydom, h. & venter, l. (2002). sampling and sampling meth­ ods. in a.s. de vos (ed.). research at grass roots. for the social sciences and human service professions. (2nd ed.) (pp 197 209). pretoria: van schaik. swanepoel, d.c.d. (2004). infant hearing screening at m aternal and child health clinics in a developing south african com m u­ nity. unpublished doctoral thesis. pretoria: university of preto­ ria. van rensburg, h.c.j. (2004). national health care systems: struc­ ture, types and dynamics. in h.c.j. van rensburg (ed.). health care in south africa, (ppl-5 0)pretoria: van schaik. werner, e. e. (2000). protective factors and individual resilience. in j. p. shonkoff, & s. j. meisels (eds.). handbook o f early childhood intervention (2nd ed.) (p p ll5 -1 3 2 ). london: cam­ bridge university press. 58 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.doh.gov.za/docs/factsheets/ http://www.escom.co.za/content/adpendix%25 the identification process in early communication intervention followed by primary health care personnel in ditsobotla sub-district appendix a rating scale for the description o f human and physical resources at clinics/hospitals n a m e o f c lin ic / h o sp ital w a r d ___________________________ p o p u latio n o f ch ild ren u n d er 5 y ears served b y this c lin ic /w a r d :________________ d o cto rs: n u m b er___________________ n u rs in g staff: n u m b er_______________ n u rs e s in train in g : n u m b e r__________ n u m b e r o f v isits p e r w ee k by: d o cto rs____________ s p eec h -lan g u a g e th e ra p ist & a u d io lo g is t_________ o cc u p atio n al th e r a p is t__________ d ietician __________ p h y sio th e ra p ist___________ p aed iatrician___________ o th er h ea lth care w o rk ers_____________ a re a s o f e v a lu a tio n l im ited a d eq u a te g ood c o m m en ts water supplywater supply at facility electricity provision o f electricity the average number o f infants the sister sees daily toys available for developmental screening general impression o f waiting rooms 1. seating for patients 2. posters on general health issues 3. posters on the development o f infants general impression o f consulting rooms 1. space for confidential interviews with parents/mothers 1 2. desk and chairs for phc personnel 3. medicine cabinets 4. posters on general health issues i 5. posters on the development o f infants general impression o f reception area 1. filing cabinets to ensure confidentiality o f patient files o the south african journal of communication disorders, vol 56, 2009 59 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) devising a developmental test of auditory perception: problems and prospects a r n o l d a b r a m o v i t z , m . s c . (psychol.) senior lecturer, department oj -psychology, university of cape town when, about six years ago, i embarked on the development of a psychological instrument that would evaluate certain complex auditory abilities in both normal and handicapped children, i knew i was undertaking an important, difficult, but not impossible, task. i still consider the task to be both important and difficult. but now, older, wiser and sadder, i no longer believe that a single individual, with a uni-disci plinary background, can cope with what such an undertaking entails. we will one day have a developmental test, or series of tests, that will provide genuine assistance in the multi-faceted problem of the assessment of auditory perception, but it will require the pooled resources of a multi-disciplinary team of workers—psychologists, linguists, phoneticians, audiologists, otologists, paediatricians, speech therapists, speech trainers, educationists, musicians, neurologists, physicists, sound engineers, statisticians, and other specialists impossible to specify in advance. why should this be? we have, after all, a developmental test of visual perception devised largely by a single person (frostig2). why should auditory perception prove to be such a different kettle of fish? what work i have done, of which some account is given in this paper, leads me irresistibly. to the conclusion that the reception, processing and interpretation of acoustic signals constitute some of the most elusive and complex phenomena to attempt to examine, gauge and measure. to a certain extent, this is due to the transient, ephemeral nature of sound itself. you cannot pin it down or "freeze" it in the way that you can, through drawings and pictures, capture and secure certain aspects of visual perception. so, correspondingly, you will find very few items in children's intelligence tests that are directly concerned with the basic skills related to auditory perception as such. the only exceptions 1 can think of are tests of auditory memory span, involving digits, words and sentences, which invoke a minimum of higher symbolic processes. psychologists have, in general, been quite shy about the developmental processes governing auditory perception, and have done very little in the gathering of relevant normative data. i am aware that various tests of auditory perception are used by speech and hearing pathologists, but the ones i have come across fail to meet certain minimum criteria which a general test of auditory abilities applicable tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 18, desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) arnold abramovitz 14 smile, or the other in which his demeanour is one of disappointment. three practice items are included. d. discrimination of the basic psychological parameters of formal tonal patterns, viz. pitch, loudness, duration and interval. twenty-four pairs of tone combinations form the basis of this test. three notes are used, c, d and ε (above middle c) recorded from the outputs of a series of sine-wave oscillators. the tonal patterns are random combinations of these three notes, using one of two levels of intensity and one of two periods of duration for each of the notes, and one of two intervals between the notes. six practice items are presented in which the different types of "error" are emphasized by the examiner whistling or singing the "tunes". three drawings are again used to assist in communicating the instructions. the first drawing shows a man and a boy each playing a bugle. the second and third drawings show the man respectively pleased and disappointed. their difficulty is increased (a) by increasing the number of notes per pattern (from three to five), (b) by introducing "errors" with respect to parameters which are more difficult to discriminate, e.g. intensity and duration, and (c) by decreasing the number (from four to one) of "errors" per pair. subjects this test was applied to 205 children, aged five to ten years, drawn from a middle-class, white, primary school population (the "nonhandicapped" sample), and to 232 white children with a variety of handicaps and difficulties (the "handicapped" sample). the latter included children from schools for (a) the deaf, (b) the hard-of-hearing, (c) the cerebral-palsied, (d) the retarded, (e) the blind, and (f) children referred to the u.c.t. child guidance clinic for various emotional, behavioural and scholastic problems. in addition to the test of auditory abilities described above, these children were assessed on the national bureau group test (either 5-6, 7-8 or 8-11 years, amended for individual administration), as well as the goodenough draw-a-man test and the digit-span test of the wisc. scoring-system finding a reliable scoring-system for the auditory abilities proved to be the major stumbling-block. relying on the test as a purely objective multiple-choice instrument, it turned out that for each of .the six agegroups, 5 years to 10 years, only the second sub-test, auditory figureground discrimination, possessed adequate split-half reliabilities. it was hoped that a scoring-system which .took into account aspects of the child's responses other than picture-matching would result in higher reliabilities. this was found to be quite feasible for the older, more intelligent child, where verbal and other responses to the sounds could be quantitatively scored or rated. it was, however, seldom possible to elicit these kinds of reactions from children of lower mental ages or journal of the south african speech and hearing association, vol. , december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) developmental test of auditory perception: problems 15 children with communication handicaps. in the case of the first subtest, recognition of environmental sounds, it was found that a. threepoint scale (0, 1, 2) instead of a right-wrong criterion (1 or 0) resulted in somewhat larger odd-even correlation coefficients. the relevant quantitative data are tabulated elsewhere (abramovitz1)· results the reliabilities for recognition of environmental sounds were generally disappointing, especially at the 5-year and 10-year levels, but the corresponding standard errors of measurement, which roberts3 regards as more important than reliabilities for multiple-choice tests, were within reasonable limits. the reliabilities and standard errors of measurement for auditory figure-ground were uniformly good. it was decided, therefore, to proceed with the "handicapped" sample using these two sub-tests only—which could be administered in one session of 15-20 minutes. the next step was to establish the ability of these tests to discriminate between adjacent age groups. calculations of two-tailed levels of significance showed that the test in this form was not always suitable for accurate inter-age-level differentiations. this was not, however, the only objective of the study. having established the presence of a reasonably lawful developmental gradient, it was considered feasible to compile tentative norms for successive age levels. these were drawn up as quotient scores (via the calculation of percentile ranks), with 100 as the mean and 15 as the standard deviation. the quotient scores for the auditory tests were all reasonably close to those of the other ability tests, and it could be justifiably assumed that the auditory tests discriminated between different mental age levels to about the same degree as they did between corresponding chronological age levels. turning now to the "handicapped" groups, the first results to be considered are those for 19 subjects from a school for cerebral-palsied children, whose average age was about 10 years. although the average of their overall auditory quotients was not significantly different from that of their wisc quotients (about 80), the remarkable finding here was that mean figure-ground quotients were significantly lower (p=0,02) than single-sound quotients (75 vs. 91).-these subjects were not selected on the basis of any prior knowledge of their general perceptual abilities and in fact included children with purely motor handicaps. nevertheless, many children reported only one of each of the 20 double and triple sounds, a phenomenon which almost constituted a kind of negative auditory hallucination. this occurred in spite of the examiner's asking, or indicating by mime, very emphatically, for a more attentive reaction after each such failure. this was quite a dramatic phenomenon, and many of the trainers who were present during these sessions were clearly taken aback by the unexpected perfonnance of these children. they were about average when it came to identifying single environmental sounds, yet many were apparently unable to tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 18, desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) arnold abramovitz 16 establish the simultaneous presence of two sounds, each of which they had no difficulty with on its own. since t h e s e results pointed to more ominously defective auditory processes than seemed likely,· it was decided to test the hypothesis that they were simply due to perseveration arising from the previous presentation of 24 single sounds. sixteen of these subjects were retested four weeks later using slightly different instructions when presenting the first three double sounds (but in no other respect). if the subject failed to report both sounds, the examiner asked, "and what else did you hear?" (no extra points were awarded for correct responses arising from the new instruction on these three items). if this still failed to produce the correct response, the examiner would point out the two sounds concerned. after the third item no further help was given and the test was administered as before. the result of this simple change of instruction was quite as astonishing as the previous phenomenon. the average figure-ground quotients jumped from 78 to 99 (p=0,001). the average single sound quotients rose, non-significantly, from 92 to 97. the perseveration hypothesis was thus amply substantiated. this finding should not, however, be taken as having no bearing on these subjects' auditory abilities. many, if not most, real-life auditory situations do not allow for a "second chance". the auditory perseverator is a handicapped listener,, and his problem should not be minimized. after this experience, whenever there was a query about possible perseveration, the figure-ground test was always re-presented in toto, using the amended instructions described. the next group of subjects were taken from a home for retarded children, but their age-range extended from 7 years 6 months to 29 years 5 months, with a mean of 18 years 6 months. their iq's were not available, but were probably in the 25-60 region. each of the 45 children who could be tested (children below a mental age of about years could not) were also given a goodenough draw-a-man test. the results (using scores obtained from the amended instructions) showed (1) that mean figure-ground discrimination was significantly poorer (p=0,001) than single-sound. identification (61 vs. 72 months, test-age), (2) that the overall average auditory test-age was not significantly different from that for the goodenough draw-a-man test (66 vs. 68 months, test-age), and (3) that there were moderately high (0,45 to 0,64) positive correlations between these tests. sixteen children from a school for the deaf formed the 'next group of handicapped subjects. they were all tested (in the first instance) with hearing-aids fitted and adjusted, in the ordinary open-field manner adopted for hearing children. their average scores for single-sounds and figure-ground were almost identical, with a quotient-score of about 50. the question arose whether their hearing-aids were of real assistance to these children in this particular situation. it was hypothesized that, with the tape-recorder volume turned up to a subjectively comfortable listening level, and their hearing-aids removed, scores journal of the south african speech and • hearing association, vol. is, december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) developmental test of auditory perception: problems 17 obtained would be higher because of the elimination of one source of distortion in the reproducing chain. ten of these children were re-tested a week later and a comparison of the results showed that highly significant increases occurred. although one could not be sure to what extent a practice effect contributed towards this improvement, a comparison with the brain-injured group is instructive. in the latter case the improvement in the single-sound scores was only about 6% and was not significant, whereas with the deaf group the improvement was about 17% and highly significant (p=0,001). the corresponding figure-ground improvements were about 14£% (p=0,001). in the absence of an adequate experimental design, inferences can only be tentative, but might be framed as follows: (a) deaf children do not ordinarily show the kind of perseveration that is seen with cerebralpalsied and retarded children, and (b) some deaf children are fitted with hearing-aids which amplify auditory stimuli at the cost of a significant degree of distortion. (it was a moving experience to find a profoundly deaf child with her unamplified ear glued to the loudspeaker coming up with scores that were at least as good as hearing children of her age-level.) the next group consisted of 16 children taken from a school for the hard-of-hearing. of these, six were randomly chosen for testing without their hearing aids. the ten hearing-aided children had mean single-sound and figure-ground quotients of 71 and 74 respectively, while the six unaided children had quotients of 76 and 83 respectively, a positive difference of 7% and 12% respectively. this shows roughly the same trend as the deaf sample, but not as markedly. the inference again is that peripheral hearing loss does not show the same pattern as organicity. (one boy, diagnosed as very severely "dyslexic", sailed through figure-ground without a single error—and without his aid. one couldn't help wondering where his real problem lay.) next was a sample of 58 children from two primary schools, whose principals queried their general school progress. in one case (a school serving parents in the professional and higher managerial class) there was a significantly lower mean figure-ground quotient (86) than intelligence quotient (109) (p=0,05). in the other case, however, (a school serving parents of the artisan and lower clerical class) there was no s u c h ^difference (97 in each case). teachers of the children from these two schools were asked to assess each child's reading and spelling achievement on a five-point scale: excellent—good—fair—rather weak —very poor. nineteen children were rated as "rather weak" or "very poof" on either or both reading and spelling. the average single-sound quotient and intelligence quotient were each 95, but the average figure-ground quotient was down to 81,5 (p=0,06). it was difficult to resist making the tentative inference of handicapped listening ability, due at least in part to some kind of auditory perseveration. the results for an unselected group of 32 children referred to the u.c.t. child guidance clinic for a variety of behavioural, emotional tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 18, desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) arnold abramovitz 18 and s c h o l a s t i c p r o b l e m s showed that although the mean figure-ground l p n , 92 was not much lower than the iq (94), it was significantly ?p=0 05) lower than the mean single-sounds quotient (102). fifteen children from this group were selected on the basis of a reading and/or spelling r e t a r d a t i o n of at least 12 months. although the mean figureground quotient (95) was lower than the mean single-sounds quotient (100), the difference was not significant. this finding does not correspond with that for a similar group taken from the two schools mentioned above. without further data and analysis there is no way of resolving the anomaly. finally, a group of 21 blind children were compared with an equal number of roughly equated sighted children (mean age for blind about 10 years, for sighted about 9 years, both groups of average intelligence). the test could obviously not be administered in the usual way, and instead of presenting four drawings, the examiner asked the subject (in both the blind and sighted groups) to choose from four spoken alternatives, after each auditory stimulus. mean quotient scores for the auditory tests were in all cases higher for the blind children. in the case of single-sounds this difference (106 vs. 99) was not statistically significant, but for figure-ground the difference (108 vs. 77) was significant at the 0,001 level. this result does not necessarily signify that blind children have superior auditory perceptual abilities of the kind tapped by this test, but rather that their retention of the recorded material and (in particular) the spoken alternatives was better than that of the sighted children, due to the intensive auditory training received at their institution—a great deal of which was being obtained through the medium of the tape-recorder. this last statement could be put the other way around, of course. the results might be seen as an indication of the comparative lack of training in listening skills which normal school-going children receive, and a corresponding bias (after a certain age-level) in favour of visual modes-of information-gathering. as with most individually-administered instruments, a great deal of information which eluded quantitative scoring could be gleaned about the responses of the subject to the test situation in general and the auditory stimuli in particular. there were apparently great individual differences in emotional and motivational reactions—from delight to boredom to aversion—as judged by facial expression gesture, posture, spontaneous vocalizations, verbalizations, and so on. the first subtest, recognition of environmental sounds, seemed to elifcit a pattern which might be called "alertness to the (non-linguistic) auditory environment", involving an ability to retain a sort of auditory after-image while the decision or discrimination between the four alternatives was made. this presumably took place by matching the auditory after-image with each of the auditory images aroused by the pictures, but perhaps not without a certain amount of deductive reasoning in some cases. the child with low scores here displays a variety of reactions, from an overconfident belief that he recognizes the sound before seeing the. pictures journal of the south african speech and hearing association, vol. , december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 19 developmental test of auditory perception: problems and an inability to decentrate (in the piagetian sense) when necessary; . to a°blank reaction ab initio and then either a "don't know" response (guessing was not encouraged); or a choice by the process of elimination; or a response-set for one of the four illustrations (the bottom left-hand drawing seemed to be a favourite for many handicapped children). one was often inclined to make the diagnosis of "auditory agnosia" when quotient scores on this test were very low, but this would of course be extremely rash in the absence of a great deal-of supporting d%ta. the figure-ground test provided the most compelling example of deviant auditory behaviour, namely the perseveration already referred to in its extreme form, it occurred only three times in the 205 nonhandicapped sample. the term "negative auditory hallucination" has already been mentioned in this connection, but the change in response as a result of slightly altered conditions of administration showed how inappropriate such an interpretation might be. this auditory perseveration occurred at all age-levels in the transition from double to triple sounds (for which no additional instructions were given with any of the groups). the test seems to reveal firstly the ability to focus on one of the multiple sounds at a time, i.e. perceiving it as "figure", whde ihe other sound or sounds rapidly and in turn are relegated to "ground this inability seemed likely in many cases to be part of a general personality factor, a sort of submissive, deferential reaction to the examiner in particular, and perhaps to the social environment in general. some of these children seemed even prepared to doubt the validity of their own experiences if they thought they were expected to make self-reports of a certain class and no other. a child's reaction to the test as a whole often gave the examiner a strong impression of "listening ability", or the lack of it, and this did not necessarily correspond to his score on the test, or to his intelligence results, or to the audiometrist's report of his hearing acuity. with regard to the latter issue, when a child of at least average intelligence was referred for scholastic, behavioural or emotional problems and scored below a quotient of 85 on the auditory test as a whole, audiometry was recommended and in most cases carried out. the resulting audiograms were mostly within normal limits but at least 6 children were found to have slight (15-25 db) conductive losses and at least 3 children were found to have moderate (25-35 db) conductive losses, in at least one ear correspondingly, some of the children from the school for the hard-of-hearing (and even one from school for the deaf) had average or above-average auditory quotients. in spite of some of the interesting and useful group results obtained, the test as used was a truncated and relatively unrefined instrument, not really suitable for reliable individual assessment. this being so, what could be done to improve the reliability and validity of the two sub-tests used, and what sub-tests could be devised to replace the abandoned speech sound discrimination and tonal pattern discrimination tests? i think these are questions for our imaginary multitydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 18 desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) arnold abramovitz 20 disciplinary team to thrash out, but some of my own thoughts may not be out of place. _ as to the first question, i think the basic notions behind the two sub-tests used are reasonably sound. what is needed is to mount a full-scale programme in which a much larger number of subjects of diverse backgrounds' serve in the pilot runs and finally in the standardization sample. using a larger number and variety of sounds and matching pictures, those which don:t contribute to the reliability and validity of the test can be eliminated. with regard to' the second question, i must first of all ruefully admit to wanting to leave speech sound discrimination to the exclusive jurisdiction of speech and hearing specialists. this whole territory is a veritable minefield for the innocent psychologist. consider, for example, the almost impossible task of constructing a comprehensive test which, in addition to meeting the criteria already alluded to, will not favour one linguistic community over another. in connection with tonal pattern recognition, i now consider that the fourth criterion is misconceived, and that for this particular kind of skill, at least, one should not try to isolate the auditory modality from the visual and the kinaesthetic. all perception, as taylor's4 compelling work reminds us, is intersensory, and we specifically need tests of audiovisual, visuo-auditory and audiomotor skills. such tests exist of course. how suitable they are for the purposes of constructing an all-embracing developmental test of auditory perception remains an issue for debate and research. finally, a technical point, but a very important one, which applies to every kind of auditory test-stimulus. convenient as the ordinary taperecorder undoubtedly is (compared, say, to disc recordings), it has an inherent disadvantage. you cannot re-present a stimulus without a good deal of fuss and delay. what is needed is a tape-player which allows the examiner to re-administer a given item as often as he wishes with no waste of time. there is at least one such instrument on the market that i know of, namely the bell & howell "language master" (probably familiar to most readers of this journal) in which cards of varying dimensions carrying the magnetic tape are conveniently fed into the machine by hand. these cards could also have, behind them, the multiple-choice pictures, and the subject's score would depend, in part, on the number of times the item had to be presented before the correct picture was pointed to. there is an electronic-acoustic problem to be solved, namely altering the recording-head and circuit to provide an adequate frequency response, say 4 0 15khz + 3db. summary it is certain that many children whose auditory perception is queried by audiologists, speech therapists, educationists and psychologists elude the diagnostic screens presently available in each of these disciplines. journal of the south african speech and hearing association, vol. , december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) developmental test of auditory perception: problems 21 the need for a qualitative and quantitative psychological assessment of the child's auditory abilities and disabilities led to the development of a test which was intended to evaluate the following functions: (a) recognition of environmental sounds, (b) auditory figure-ground discrimination, (c) speech-sound discrimination (phonemic and mtonational) and (d)-tonal pattern discrimination (pitch, loudness, duration and interval). it was not intended to investigate threshold phenomena as such but rather to supplement and complement pure-tone and speech audiometry. the test was applied to 205 children, aged five to ten years, drawn from a normal school population, and 232 children with difficulties and handicaps varying both in degree and kind. only the first two sub-tests were found to be clinically and experimentally viable, and data for the curtailed test are presented. the following results are noteworthy: (1) the test measures functions which are positively related to both age and intelligence. (2) brain-injured, retarded and emotionally disturbed children generally test low on auditory figure-ground discrimination; this vulnerability is most likely due to perseveration. (3) previously unsuspected peripheral hearing losses may sometimes be detected by the use of the test. on the other hand, some children said to have high degrees of hearing loss test at or above their age-level. (4) many deaf and hard-of-hearing children test higher without their hearing-aids; this is probably due to amplification being achieved at the cost of distortion. (5) children of average intelligence with reading and/or spelling difficulties often test low on auditory figure-ground discrimination. (6) blind children who have received auditory training are equal to sighted children in recognition of environmental sounds, but superior in auditory figure-ground discrimination. this does not, however, necessarily signify superior auditory perception as such on the part of the blind. r .. in general it is concluded that the development of tests of auditory perception could add significantly to the psycho-educational assessment of both "normal" and handicapped children. ο opsomming daar kan met sekerheid aanvaar word dat baie kinders van wie die ouditiewe waarnemingsvermoe betwyfel word deur oudioloe, spraakterapeute, opvoedkundiges en sielkundiges, die diagnostiese toetse vandag tot hul beskikking ontglip. die behoefte wat daar bestaan vir 'n kwalitatiewe en kwantitatiewe sielkundige bepaling van 'n kind se ouditiewe vermoe en onvermoe het gelei tot die ontwikkeling van 'n toets wat gemik is op die evaluasie van die volgeiide funksies: 1. herkenning van omgewingsgeluide. 2. ouditiewe figuur-grond onderskeiding. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 18, desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22" arnold abramovitz 3. spraakklank diskriminasie (foneem sowel as intonasie-onderskeiding), en "4.: tonale patroondiskriminasie (toonhoogte, luidheid, duur , en interval). . dit was nie die bedoeling om drempelverskynsels te ondersoek me, maar slegs om 'n toets te ontwikk'el wat ter aanvulling kan dien by suiwertoonen spraakoudiometrie. die toets is uitgevoer op 205 kinders, met ouderdomme wat wissel van 5 tot 10 jaar, getrek uit 'n bevolking van normale skoolkinders en op 232 kinders met afwykings en belemmerings wat verskil betreffende die tipe afwyking asook die erns van die probleem. slegs die eerste twee subtoetse is klinies en eksperimenteel uitvoerbaar en data vir die verkorte toets word uiteen gesit. die volgende resultate kan beslis op gelet word: 1. die toets meet funksies wat in verhouding staan tot beide ouderdom en intelligensie. 2. breinbeskadigde, vertraagde en emosioneel-versteurde kinders gee 'n lae telling by toetsing van ouditiewe figuur-grond onderskeiding; hierdie kwetsbaarheid is moontlik toe te skryf aan perseverasie. 3. 'n perifere gehoorverlies voorheen onopgemerk, kan soms met behulp van hierdie toets opgespoor word. aan die anderkant weer toets sommige kinders van wie gese is dat hul hoe grade van gehoorverlies het, by of bokant hul ouderdomspeile. 4. baie dowe en hardhorende kinders toets hoer sonder hul gehoor apparate; dit is moontlik tewyte aan versterking verkry ten koste van distorsie. 5. kinders van gemiddelde intelligensie met leesen/of spelprobleme gee dikwels 'n lae telling by toetsing van ouditiewe figuur-grond onderskeiding. 6. blinde kinders wat reeds getiooropleiding ontvang het, behaal dieselfde resultate as siende kinders wat herkenning van omgewingsgeluide betref, maar is superieur wat ouditiewe figuur-grond onderskeiding betref; hierdie resultate dui nie noodwendig op superieure ouditiewe persepsie by die blinde nie. daar word ten slotte beweer dat die ontwikkeling van ouditiewe persepsietoetse baie kan bydra tot die psigo-opvoedkiyidige toetsing van beide „normale" en gestremde kinders. references / 1 abramovitz, a. (1967): auditory perception and the handicapped child. paper presented at the xviii annual congress of the s.a. psychological association, cape town, september 1967. (unpublished mimeograph). .2 frostig, m. et al. (1964): developmental test of visual perception. perceptual and motor skills, 19, 463-499. 3. roberts, a. d. h. (1962): the maximum reliability of a multiple-choice test. psychologia africana, 9, 286-293. 4. taylor, j. g. (1962): the behavioural basis of perception. yale university press, new haven, connecticut. journal of the south african speech and hearing association, vol. 18, december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction research methodology and design results discussion ethical considerations conclusion acknowledgements references about the author(s) mckinley andrews discipline of speech-language pathology, university of kwazulu-natal, south africa mershen pillay discipline of speech-language pathology, university of kwazulu-natal, south africa citation andrews, m., & pillay, m. (2017). poor consistency in evaluating south african adults with neurogenic dysphagia. south african journal of communication disorders 64(1), a158. https://doi.org/10.4102/sajcd.v64i1.158 original research poor consistency in evaluating south african adults with neurogenic dysphagia mckinley andrews, mershen pillay received: 25 mar. 2016; accepted: 11 sept. 2016; published: 23 jan. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: speech-language therapists are specifically trained in clinically evaluating swallowing in adults with acute stroke. incidence of dysphagia following acute stroke is high in south africa, and health implications can be fatal, making optimal management of this patient population crucial. however, despite training and guidelines for best practice in clinically evaluating swallowing in adults with acute stroke, there are low levels of consistency in these practice patterns. objective: the aim was to explore the clinical practice activities of speech-language therapists in the clinical evaluation of swallowing in adults with acute stroke. practice activities reviewed included the use and consistency of clinical components and resources utilised. clinical components were the individual elements evaluated in the clinical evaluation of swallowing (e.g. lip seal, vocal quality, etc.) methods: the questionnaire used in the study was replicated and adapted from a study increasing contentand criterion-related validity. a narrative literature review determined what practice patterns existed in the clinical evaluation of swallowing in adults. a pilot study was conducted to increase validity and reliability. purposive sampling was used by sending a self-administered, electronic questionnaire to members of the south african speech-language-hearing association. thirty-eight participants took part in the study. descriptive statistics were used to analyse the data and the small qualitative component was subjected to textual analysis. results: there was high frequency of use of 41% of the clinical components in more than 90% of participants (n = 38). less than 50% of participants frequently assessed sensory function and gag reflex and used pulse oximetry, cervical auscultation and indirect laryngoscopy. approximately a third of participants showed high (30.8%), moderate (35.9%) and poor (33.3%) consistency of practice each. nurses, food and liquids and medical consumables were used usually and always by more than 90% of participants. conclusion: infrequent use of clinical components and high variability in clinical practice among speech-language therapists calls for uniform curricula in the clinical evaluation of swallowing at south african universities and for continued professional development post-graduation. different contexts and patient symptoms contribute towards varied practice; however, there is still a need to improve consistency of practice for quality health care delivery. a research-based policy for the clinical swallowing evaluation for a resource-limited context is also needed. introduction the focus of this study was on practice patterns used by speech-language therapists in the clinical swallow evaluation of neurogenic dysphagia in adults with acute stroke. practice patterns are located relative to the ‘curriculum of practice’ (figure 1) and are defined as consistent activities that have widely led to improved health outcomes (carnaby & harenberg, 2013; mathers-schmidt & kurlinski, 2003). this is important for quality of health care and adequate standards of practice (carnaby & harenberg, 2013). practice is also defined as activity related to and influenced by theoretical knowledge, education and training (pillay, kathard & samuel, 1997). knowledge is moulded by social, political, gender, ethnic, cultural and economic influences (pillay et al., 1997), and as these influences play large roles in the south african context these will most likely impact speech-language therapists’ practice. policies are broad practice guidelines based on recent literature, providing the speech-language therapist with general advice on what to do in clinical procedures and how to achieve them (pillay et al., 1997). clinical practice activities are those procedures a professional performs and the resources they use so as to manage an adult with neurogenic dysphagia (pillay et al., 1997). this includes assessing clinical components in the clinical swallow evaluation. clinical components are the individual elements that make up the clinical swallow evaluation for which the speech-language therapist is responsible for evaluating. clinical practice is the procedure or protocol that is followed by all health professionals who manage adults with stroke (davis & taylor-vaisey, 1997; heinemann et al., 2003; van peppen, hendriks, meeteren, helders & kwakkel, 2007). this knowledge–theory relationship gives rise to evidence-based practice which is an effective and high-quality practice that is driven by knowledge from the latest research (american speech-language-hearing association, 2005) as well as by the speech-language therapist’s competency, experience and preference for practice (riquelme, 2015). evidence-based practice is a crucial part of health care delivery as it contributes towards improving health outcomes for those with neurogenic dysphagia due to acute stroke (straus, tetroe & graham, 2009). figure 1: the curriculum of practice. a narrative review of the literature on practice patterns of speech-language therapists during the clinical swallow evaluation of adults with neurogenic dysphagia post-acute stroke was performed. a limited amount of literature was available. all 12 studies included in the study showed that most clinical swallow evaluations comprise four main subsections: history, oral motor examination, voice and trial swallows; however, more specific elements still differ among speech-language therapists and have not been officially or extensively outlined by the literature (riquelme, 2015). key findings showed that clinical components utilised by more than 90% of speech-language therapists ranged between 24% and 63% across five studies, and the consistency of clinical component utilisation varied between 32% and 58% across three studies. there were infrequent assessments of the gag reflex, sensation and mental status as well as limited use of indirect laryngoscopy, pulse oximetry and cervical auscultation methods. little information was found on what resources are used during the clinical swallowing evaluation. mathers-schmidt and kurlinski (2003), bateman, leslie and drinnan (2007) and pettigrew and o’toole (2007) observed practice patterns of speech-language therapists in the usa, ireland and the uk. infrequent use of clinical components and low levels of consistent use of clinical components in the clinical swallow evaluation were reported in all three studies. carnaby and harenberg (2013) also found high variability of practice patterns among speech-language therapists in dysphagia evaluation. despite receiving both policies guiding clinical practice and relevant education and training, practice still seems to vary internationally among speech-language therapists. contextual and patient-specific factors will expectedly play a role in differing practice; however, it is expected that higher degrees of clinical components are utilised according to protocols and practice guidelines to ensure a certain standard of optimal health care and evidence-based practice. the occurrence of stroke and its resulting comorbidities continues to be highly prevalent in south africa. stroke is the second highest cause of death in the world and annually claims approximately five million lives (sajjad et al., 2013). over four million of these deaths occur in lowand middle-income countries, such as south africa (sajjad et al., 2013). stroke was the fourth leading cause of mortality in south africa after (1) tuberculosis, (2) influenza and pneumonia and (3) aids and was the leading reason for death in adults above the age of 65 years in 2013 (statistics south africa, 2014). about 67 000 of south africa’s population experience a stroke annually (maredza, bertram & tollman, 2015). dysphagia is a common symptom post-stroke and results in increased mortality and morbidity rates, poor nutrition and dehydration, prolonged disability, and decreased quality of life (gonzález-fonández, ottenstein, atanelov & christian, 2013b; guyomard et al., 2009). up to 50% of adults with stroke are at risk of aspirating and developing pneumonia (martino et al., 2005). the management of dysphagia post-stroke is therefore important for optimal health care. south africa faces a quadruple burden of disease which is aggravated by poverty, high levels of unemployment, socio-economic inequity and an ineffective health system (mayosi et al., 2012). the four epidemics include hiv and tuberculosis, non-communicable diseases and mental health disorders, deaths related to injury and violence and maternal, neonatal and child mortalities (mayosi et al., 2012). south african speech-language therapists are therefore often faced with adults with stroke who have additional diseases (mayosi et al., 2012) that complicate management and prognosis. the south african context can thus be a complex and challenging one for the speech-language therapist. dysphagia resulting from acute stroke is managed by speech-language therapists as it is within their scope of practice to conduct a clinical swallow evaluation. the health professions council of south africa (hpcsa) (2009) stated that the speech-language therapist’s scope of practice is determined by the level of their education, experience and skill. it also stated that services provided must be evidence-based and culturally and linguistically appropriate for the adult with neurogenic dysphagia. the speech-language therapist therefore needs to be up-to-date with clinical swallow evaluation guidelines and recent research in such practices. speech-language therapists fulfil this scope of practice by initially using the clinical swallow evaluation, which is a non-instrumental, behavioural assessment procedure involving identifying and interpreting various components of information from the patient, family and various health professionals. the primary goals are to conclude the presence, nature and cause of the dysphagia, and to determine the level of dysfunction, the risk for aspiration and whether nutritional status is adversely affected (pettigrew & o’toole, 2007). the result of such an evaluation aids the development of an appropriate swallowing management plan (gonzález-fonández et al., 2013b). due to the subjective nature of the clinical swallow evaluation and the grave complications dysphagia may cause it is vital for the speech-language therapist to be informed of the relevant knowledge and skills regarding the clinical swallow evaluation. mccullough et al. (2005) reported that when an adult with neurogenic dysphagia aspirates, silent aspiration occurs half of the time. silent aspiration also makes the speech-language therapist’s recent knowledge and skills important when performing a clinical swallow evaluation. silent aspiration occurs when a bolus is aspirated (enters the trachea below the level of the true vocal folds), but no cough reflex is produced as a result (smith hammond & goldstein, 2006). in south africa, because the dysphagia evaluation faces many challenges, as discussed below, it is thought that performing a thorough and optimal clinical swallow evaluation can be difficult. not only is there a dire shortage of trained and skilled health professionals involved in dysphagia management such as doctors and nurses (department of health, 2011; george, quinlan & reardon, 2009; mayosi et al., 2012), but they are also unequally distributed between urban and rural areas (mills et al., 2011). in 2011, south africa had 7.7 doctors and 40.8 nurses and midwives per 10 000 people in the country (department of health, 2011). in sub-saharan africa this is exacerbated by hiv, migration of staff to developed countries and a shortage of training institutions to train adequate amounts of health professionals (mills et al., 2011). such a shortage of health professionals makes obtaining information about the nature and history of the swallow more challenging, for example obtaining temperature records and a feeding history from a nurse, information from a radiologist regarding the location of brain insult as well as chest status or c-reactive protein information from doctors. there is also a shortage of medical facilities and reduced standard of care due to poor infrastructure and support (blackwell & littlejohns, 2010; mayosi et al., 2012; national development plan, 2012). south africa is culturally and economically diverse. the use of traditional medicine in south africa is a large trade, and for some living in rural areas it is their only option for health care (mander, ntuli, diederichs & mavundla, 2007). however, some prefer the treatment from traditional healers (called sangomas) to western medicine, and the speech-language therapist should consider their influence in the clinical swallow evaluation (blackwell & littlejohns, 2010). for example traditional healers may have recommended that specific thin fluids be consumed that in fact are not safe to swallow for an adult with neurogenic dysphagia. knowing such information is valuable during the clinical swallowing evaluation as it contributes information regarding the consistency of liquids the adult is expected to swallow at home. there are 11 official languages in south africa which often leads to difficulty in communicating effectively with the adult with stroke and their caregivers (blackwell & littlejohns, 2010). this makes identifying accurate swallowing history and background information from the caregivers and the adult with neurogenic dysphagia problematic. the adult with neurogenic dysphagia’s ability to follow the speech-language therapist’s instructions during the evaluation also gets adversely affected by such language barriers. the speech-language therapist must consider all these influential factors discussed during the clinical swallow evaluation in the south african context. there was a need to investigate the protocol that south african speech-language therapists follow during the clinical swallow evaluation of adults with neurogenic dysphagia post-acute stroke, as currently such practice is unknown. due to the life-threatening nature of dysphagia and the various challenges encountered in the south african context, it is important to explore what practice currently exists and whether it is of adequate standard to ensure safe and optimal management of those who have suffered acute stroke and resulting in dysphagia. the results of this study will ultimately contribute towards a uniform education and training curriculum for the clinical swallow evaluation among south african universities as well as the development of uniform guidelines and policies for such practices. any poor adherence to existing practice guidelines and clinical component utilisation may contribute towards motivating for uniform curricula. by providing uniform curricula, the quality of training is thought to improve, or at least generalise better clinical practice by increasing levels of preparedness for evaluating dysphagia (singh et al., 2015). aims and objectives the aim of the study was to explore the practice patterns that south african speech-language therapists follow in the clinical swallowing evaluation of adults with neurogenic dysphagia due to acute stroke. objectives included exploring practice patterns in terms of: the frequency of clinical component utilisation, the consistency of clinical component utilisation, the frequency of resources used and the factors contributing towards infrequent use of resources. research methodology and design a survey design was used for the study and exploratory and descriptive designs were also incorporated. a survey design is considered a valuable method of obtaining original data to describe a large population that cannot be observed directly, or are difficult to observe (leedy & ormrod, 2013). the study explored and obtained information and more understanding about practice patterns as they have not yet been fully researched (bless, higson-smith & kagee, 2006). the researcher performed a narrative review of the literature to inform the adaptation of a questionnaire from a study by bateman et al. (2007). a narrative review is a thorough review of published literature on a specific topic. it has been known to consist of relatively unsystematic methods, but is a good summary of up-to-date information (green, johnson & adams, 2006). the study was replicated and based on a questionnaire taken and adapted from a study by bateman et al. (2007), and thus all its clinical components were replicated and included in the current study. further modifications from a pilot study were applied to the questionnaire to improve its content and layout and overall feasibility (table 1). eight participants returned a feedback sheet electronically reporting questionnaire adaptations. participants had 2 weeks over august and september 2015 to participate in the pilot study. the south african speech-language-hearing association (saslha) recruited participants by e-mail and via the social media website facebook®. participants accessed the self-administered, electronic questionnaire on the web survey development company website survey monkey® over a time frame of 4 weeks in october and november 2015. table 1: description and rationale for the pilot study adaptations to the questionnaire. participants were selected via purposive sampling. only people with specific knowledge and skills were invited to take part, with the purpose of being able to provide data competently for the study (leedy & ormrod, 2013). training with regularly working with adults with neurogenic dysphagia enables one to be proficient in assessing this population and thus to provide valid data for the study (hpcsa, 2009). participants were practitioners who had a speech-language therapy degree in 2014 or earlier. the participants were currently working with adults with neurogenic dysphagia post-acute stroke in south africa. these participants, therefore, had sufficient and recent experience and knowledge with this population (hpcsa, 2009). a total of 38 participants completed the electronic questionnaire. babbie and mouton (2001) state that 5–25 participants in the interpretive paradigm is a sufficient sample size. most of the participants in the study (n = 17; 44.7%) had between 1 and 5 years of experience both as a speech-language therapist and working with adults with neurogenic dysphagia, and 23.6% (n = 9) of the participants were completing their community service year (first year of work) (figure 2). figure 2: biographical information of participants (n = 38): (a) years working as a speech-language therapist; (b) years working with adult neurogenic dysphagia; (c) number of adults with neurogenic dysphagia evaluated in a typical month; and (d) percentage of caseload of adults with neurogenic dysphagia in the last year. descriptive statistics were used to analyse quantitative data. raw data were converted into numerical data via coding (babbie & mouton, 2001). the frequency of clinical component and resource usage was determined by converting the frequency of codes into percentages (babbie & mouton, 2001). the consistency of clinical component use was calculated as how many clinical components were used with the same frequency across participants (bateman et al., 2007). those clinical components used with the same frequency by more than 75% of participants were grouped as highly consistent, those between 50% and 75% as moderately consistent and those below 50% as inconsistent (bateman et al., 2007). the small qualitative component was subjected to textual analysis, where themes were identified in the text and coded into numerical values (leedy & ormrod, 2013). the frequency of occurrence of themes was identified by counting how many times each code was recorded, and the themes were discussed (leedy & ormrod, 2013). results clinical components in the clinical swallow evaluation the frequency of use of clinical components by participants forty-one per cent of the clinical components (16/39) were usually or always used by more than 90% of the participants (n = 38). these included the following: medical history (100%); language abilities or cognitive communication abilities (100%); overall oral efficiency (100%); vocal quality preand post-swallow (100%); oral residue (100%); overall opinion of airway safety (100%); medical status (97.4%); variety of bolus types (97.4%); lip seal (97.3%); oral structures, muscles and functioning (97.3%); vocal quality (94.8%); nutritional status (94.7%); laryngeal elevation (94.7%); saliva control/management (94.7%); respiratory status (92.1%); and patient interview/perception of the problem (92.1%). forty-six per cent of clinical components (18/39) were usually or always utilised by a range of 50–90% of the participants, and 12.8% (5/39) were usually or always utilised by less than 50% (0% to 31.6%) of the participants. the consistency of use of clinical components by participants there was a high consistency of clinical practice among participants for 12 out of 39 clinical components (30.8%) (figure 3). these clinical components included the following: medical history (89.5%); medical status (89.5%); oral structures, muscles and functioning (86.8%); indirect laryngoscopy (86.8%); lip seal (84.2%); laryngeal elevation (84.2); vocal quality preand post-swallow (84.2); overall oral efficiency (81.6%); pharyngeal swallow initiation delay (81.6%); overall opinion of airway safety (81.6%); saliva control/management (76.3%); and oral residue (76.3%). participants showed a high consistency of practice by always using these clinical components, with the exception of indirect laryngoscopy, which was never used by more than 75% of the participants. although these clinical components were used highly consistently, no clinical components reached more than 90% consistency. figure 3: consistency of clinical component use. there were high rates of variability of clinical practice among the remaining participants (69.2%). clinical practice was moderately consistent for 35.9% of the clinical components (14/39) and inconsistent for the remaining 33.3% (13/39). these included evaluating head and neck control and posture (44.7%); trials with compensatory techniques (44.7%); various features of speech (39–42%); visual, auditory and/or motor abilities (34.2%); and sensory function (34.2%). the clinical components used least consistently included medication use, social history, background information and gag reflex (31.6%). resources in the clinical swallowing evaluation physical resources on average 37.9% of responses showed that physical resources (both medical and non-medical) were used with low frequencies in the clinical swallow evaluation (table 2). physical resources included consumables, medical instruments, food and liquid items, eating utensils and food and liquid modifying agents. more than half of the responses (57.3%) indicated limited access to physical resources such as medical instruments, adaptive eating utensils and food and liquid modifying agents. other reasons for using physical resources infrequently included patient-specific needs, theft and limited time, limited staff and limited funding. also, it was mentioned that other health professionals use certain resources instead; for example, occupational therapists issue adapted spoons. table 2: frequency and consistency of clinical components and resources utilised in the clinical swallow assessment by participants. medical resources: more than 90% of participants used consumable resources (e.g. gloves, tongue depressors) usually and always in the clinical swallow evaluation; however, over half (57.9%) of participants never and seldom used medical instruments such as stethoscopes and pulse oximeters. fourteen per cent of responses conveyed that little or no training with medical instruments was received, nor were there opportunities for experience with them. participants expressed a desire for such training as well as for mentoring from experienced clinicians specifically as they felt unprepared and uncomfortable in the work place. non-medical resources: more than 90% of participants used food and liquid items usually and always in clinical swallow evaluation, but only 36.9% usually and always used eating utensils. this may have been because examples given to participants were of adaptive eating utensils (e.g. dysphagia cups) and not typical ones (e.g. spoons and forks). participants may therefore have reported on the use of only adaptive eating utensils, not eating utensils in general, including typical eating utensils. just over half of participants (55.5%) usually and always used food and liquid modifying agents in the clinical swallow evaluation. human resources over 90% of participants consulted with nurses usually and always, and 86.8% of participants consulted with doctors and allied health professionals like physiotherapists and occupational therapists usually and always in the clinical swallow evaluation. it was reported that nurses were required for their knowledge regarding the patient’s feeding practices. occupational therapists and physiotherapists were consulted when evaluating head and neck control, positioning and visual and motor abilities. physiotherapists also provided information regarding the lungs while occupational therapists assisted with adaptive eating utensils. other human resources reported to be in the clinical swallow evaluation were ear, nose and throat specialists, neurologists, social workers, caregivers or family members and dieticians who confirmed whether the patient was malnourished and assisted with food and liquid consistency modifications. three participants also reported the use of a medical rehabilitation team. eleven per cent of responses showed that human resources like doctors and nurses were used with low frequencies in the clinical swallow evaluation. participants reported that human resources were simply not available. in summary, nurses, food and liquids and medical consumables were used usually and always by more than 90% of participants. almost a third (29.1%) of responses showed infrequent (never, seldom and half the time) use of all resources on average (table 2). discussion clinical components in the clinical swallow evaluation the frequency of use of clinical components by participants all those clinical components used frequently (41%) in the clinical swallow examination indicated evidence-based practice by participants, as these clinical components are all supported by the literature, are included in policies and in training and thus it is expected that they are frequently included (american speech-language-hearing association, 2004; bateman et al., 2007). the remaining 23 clinical components (59%) were used infrequently and are discussed here. fifty-eight per cent of participants identified medication use usually and always. this might have been due to poor education and training after graduation, or challenging circumstances in which to obtain such information. this remains, however, important information to identify in the clinical swallow evaluation as many types of medication can adversely influence dysphagia, such as anti-depressants, medication for blood pressure and for nausea, which can all cause xerostomia (balzer, 2000). these may need to be treated after receiving a stroke. any medicine that depresses the central nervous system can limit sensation, awareness and voluntary muscle control (balzer, 2000). even the act of swallowing medication can be a hazard in itself (schiele et al., 2015). it is important that the speech-language therapist not only identify which medication has been prescribed but also in which form the adult with neurogenic dysphagia is consuming it. general background information (education, vocational, socio-economic and cultural information) and social history were identified by 57.9% of participants usually and always. this important information is to aid decisions regarding what is assessed in the clinical swallow evaluation and how to go about planning management. one participant mentioned the importance of considering modified diets in accordance with cultural preferences. it is the speech-language therapist’s responsibility to conduct practice that is socially and culturally sensitive, especially in south africa where the population is culturally and linguistically diverse. considering culture and diversity consists of more than race and ethnicity and is often overlooked. it includes considering language, religion, customs, values, tastes, lifestyle, education, profession and age, among others. this reduces bias, endorses cultural understanding in practice and puts the adult at ease and increases compliance with the speech-language therapist (riquelme, 2013). it is also important to understand the adult’s beliefs with regard to matters such as death and certain medical procedures, such as nasogastric tube or percutaneous endoscopic gastrostomy insertion. other allied health professionals, such as physiotherapists and occupational therapists, are also expected to consider cultural differences in their practice (riquelme, 2007). difficulty in communicating, difference in language and/or poor availability of caregivers who can provide background information are often reasons for not assessing this information. limited and unreliable public transport services in south africa or the inability of the caregivers to afford transport are often reasons for their inability to get to hospital. riquelme (2007) recommends using a professional interpreter for language barriers because colleagues or family members may not disclose complete information due to cultural privacy beliefs and credibility of the message may be lost. such human resources are often not available in south africa posing a challenge for the speech-language therapist to adequately obtain accurate information in the clinical swallow evaluation. vocal prosody was evaluated by 57.9% of speech-language therapists usually and always. it provides information on the ability of the patient to control aspects such as intonation, rhythm and stress in their speech and can give clues as to whether dysarthria is present or not and which type of dysarthria it may be. the identification of dysarthria aids decisions regarding the presence of aspiration and gives clues to the nature of dysphagia as it can be predictive of aspiration (schroeder, daniels, mcclain, corey & foundas, 2006). it was perhaps not assessed as much because other speech characteristics provide them with more information regarding dysarthria or aspiration. there may also be poor education and training after graduation. some participants mentioned that a speech function assessment was performed informally, but was not always completed if the patient was medically unstable or due to time constraints where assessing swallowing function took priority. fifty-five per cent of participants identified visual, auditory and/or motor abilities frequently. these give the speech-language therapist an idea of the patient’s abilities and limitations. motor difficulties can affect the patient’s oral musculature and movements and goes hand-in-hand with safe head and trunk positioning for swallowing (american speech-language-hearing association, 2004; gonzález-fonández et al., 2013a). appropriate positioning is an integral factor in terms of safe swallowing. vision can affect feeding abilities and the ability to hear can affect the following of instructions. given the key role that sensation plays in dysphagia, it is concerning that sensation was often evaluated by only 31.6% of participants. mathers-schmidt and kurlinski (2003), bateman et al. (2007) and pettigrew and o’toole (2007) reported higher frequencies of utilisation of this clinical component, which were 74.2%, 56% and 76%, respectively. sensory feedback helps the triggering of the swallow, chewing and salivary flow and is critical for effective swallowing (rogers & arvedson, 2005). reasons for such poor utilisation of sensation in the clinical swallow evaluation are possibly due to limited resources such as sour, sweet and bitter bolus variations or varying temperature boluses. there are also no clear guidelines or satisfactory measurement techniques for interpretation of oral sensitivity testing (pettigrew & o’toole, 2007). it is also interesting to note that south african policies and guidelines do not delineate assessing sensory function in the clinical swallow evaluation. it may also be that speech-language therapists have forgotten how important sensation is in the swallowing process, indicating how continued education after graduating is so important. it was noted that the more experienced speech-language therapists were more likely to evaluate sensation than those currently completing their community service. this is surprising as those speech-language therapists currently completing their community service have recently studied and thus have knowledge and theory that is more up-to-date. this highlights the importance of both clinical experience and continued professional education. only 18.5% of participants usually and always used pulse oximetry methods, and as many as 63.2% of participants never and seldom used it. the reliability of using pulse oximetry to detect aspiration in the clinical swallow evaluation has received conflicting support in the literature (chong, lieu, sitoh, meng & leow, 2003; ramsey et al., 2003), and thus it seems speech-language therapists decide for themselves whether it should be utilised (bateman et al., 2007). this may indicate that speech-language therapists are acknowledging the varying support in the literature and using it according to their judgement in the clinical swallow evaluation, thus perhaps successfully translating knowledge into practice. other reasons for poor utilisation included poor training and poor availability of pulse oximeters (blackwell & littlejohns, 2010) to monitor the oxygen saturation levels in arterial blood during the act of swallowing. as many as 50% of participants never or seldom utilised gag reflex testing, and only 18.4% of participants assessed it frequently. there is varying clinical usefulness of this clinical component in the literature, and thus it seems speech-language therapists are using it as they see fit (mccullough et al., 2005; oliveira et al., 2015). other reasons for poor use were that it was uncomfortable for the patient and that the doctor assessed it. only 7.9% of participants usually and always used cervical auscultation procedures, while 81.6% participants never and seldom used it. this was mainly due to poor training and limited availability of medical equipment. there are conflicting results of the reliability of such a method in the literature, but cervical auscultation has been shown to have generally good input towards the overall picture of the patient’s swallowing ability when used in conjunction with other information obtained from the clinical swallow evaluation (lagarde, kamalski & van den engel-hoek, 2015; ramsey et al., 2003). indirect laryngoscopy was the only method that was never (0%) used usually or always. as many as 97.3% of participants never and seldom used it. it is evident that the use of this procedure is out of date, as there is very little supporting literature or recent research available on its relevance in the clinical swallow evaluation (ponka & baddar, 2013). the indirect laryngoscopy procedure observes the vocal folds at rest and during phonation and is therefore physically irrelevant as it does not provide information on vocal fold competence during swallowing (ponka & baddar, 2013). it is therefore expected that few speech-language therapists would be trained to perform such a procedure and those who were trained would perhaps not use it. this procedure is also most often performed by the ear, nose and throat specialist. the poor availability and cost of laryngeal mirrors and time constraints may also limit the frequency of its use. refer to methodology with regard to reasoning for including this clinical component. it is also valuable to observe evidence-based practice among participants in this study by the fact that this method is not utilised. the majority of participants (89.4%) usually and always carried out a clinical swallow evaluation before an instrumental evaluation. the remaining 10.6% of participants reported doing this less frequently. the clinical swallow evaluation provides important information regarding the patient’s oral motor and sensory functioning, ability to follow instructions and the nature of the swallow and it also provides a natural setting for eating and drinking. the clinical swallow evaluation is important for first considering the effectiveness of various postural swallowing techniques and adaptive feeding measures in preventing aspiration. their effectiveness is confirmed with an instrumental evaluation (gonzález-fonández et al., 2013b). omission of the clinical swallow evaluation could be due to doctors or radiographers summoning the speech-language therapist to the instrumental evaluation without the knowledge of an initial clinical swallow evaluation or limited human resources, resulting in less time to perform both a clinical swallow evaluation and an instrumental evaluation for every adult with a stroke. although more than 90% of participants displayed good clinical practice by frequently using 41% of clinical components in the clinical swallow evaluation, the remaining 59% of clinical components were used infrequently. despite receiving education, training and policies guiding practice it is understandable that frequency of clinical component utilisation would differ due to: (1) patient-specific requirements and the nature of the clinical swallow evaluation, which is applicable anywhere around the world, (2) the south african context where varying policies are established and (3) where resource availability is limited. each adult with neurogenic dysphagia post-acute stroke presents with varying difficulties and capabilities, thus requiring individual needs and adaptations in the clinical swallow evaluation. it is the speech-language therapist’s duty to use his or her discretion and tailor the clinical swallow evaluation individually to the needs of the adult with stroke and include or exclude clinical components as he or she sees appropriate (american speech-language-hearing association, 2004). the clinical swallow evaluation is thus exploratory in nature and is susceptible to change according to the speech-language therapist’s judgement (saslha, 2011). scope of practice and policies with guidelines for practice set by the hpcsa (2009) and saslha (2011) are vague and incomplete. clinical components that are supported by the literature and should be included in the clinical swallow evaluation are omitted, for example assessing sensation of oral motor structures. similar policies of international standards such as the american speech-language-hearing association (2004) or the speech pathology association of australia ltd (2012) provide in-depth and complete guidelines and scope of practice detailing all clinical components that should be used in the clinical swallow evaluation. speech-language therapists in south africa do not all have access to policies from saslha (2011) and some do not know that the hpcsa’s (2009) guidelines for scope of practice exist. speech-language therapists tend to rely on training from university, continued professional development events and advice from colleagues with regard to what the clinical swallow evaluation should include, instead of adhering to guidelines for practice (modi & ross, 2000). another reason why the clinical swallow evaluation is likely to vary among speech-language therapists is due to the south african context where availability of resources is limited. approximately three-quarters of african countries, including south africa, receive the lowest proportion of government funding for health care (29.5%) compared with high-income countries (42%; george et al., 2009). lowand middle-income countries have a greater lack of resources and poor access to health care compared with high-income countries. given the lower socio-economic status and the massive economic burden due to stroke in south africa there is a shortage of trained and skilled health professionals and a shortage of medical facilities and equipment for stroke (mills et al., 2011). the consistency of use of clinical components by participants high rates of variability in dysphagia practice were found in this study, consistent with the results of previous studies (bateman et al., 2007; carnaby & harenberg, 2013; martino, pron & diamant, 2004; mathers-schmidt & kurlinski, 2003). it was interesting that gag reflex testing was used inconsistently given its poor support in the literature (mccullough et al., 2005; oliveira et al., 2015). it seems that speech-language therapists are not sure whether or not to include this clinical component in the clinical swallow evaluation. social history and background information may not be used consistently due to time constraints where assessing the swallow is more of a priority. it is, however, surprising that current medication use is inconsistent and may be due to the speech-language therapist thinking that is the doctor’s area of expertise or that the cause of the dysphagia is due solely to the stroke. poor training at an undergraduate level and at a post-graduate level may also be a factor. consistency of clinical practice is desirable; however, it is neither rigid nor prescribed (carnaby & harenberg, 2013). it has been known to improve the quality of health care (carnaby & harenberg, 2013), and thus adaptations to consistency of practice are endorsed. a high rate of variability in clinical practice is expected in an economically developing country like south africa where different education and training programmes are established at different universities. singh et al. (2015) discovered that not only were these education and training programmes varied, but four out of six universities provided inadequate theoretical and clinical training. this leaves half of speech-language therapists feeling unprepared and insufficiently trained in adult dysphagia to perform a clinical swallow evaluation without supervision in the working world (singh et al., 2015). new speech-language therapists may omit assessing some clinical components in the clinical swallow evaluation due to nervousness or due to lack of theoretical knowledge, training and experience (singh et al., 2015). ideally, new graduates should practise under supervision of an experienced colleague for about 6 months (saslha, 2011), but often in south africa this is not possible due to the shortage of staff or due to the fact that new graduates are often the only ones placed at a health institution to increase outreach of health services to the public. the consequences of this include unsatisfactory and potentially unsafe patient management and the speech-language therapist avoiding contributing to the burden of limited access to health care. speech-language therapists do not always practise from research-based theory, but rather from experience. experience results in increased levels of confidence and influences practice. clinical competency and expertise, and preference and attitude towards practice also play a role in practice patterns (riquelme, 2015). practice in south africa is based on experience at an undergraduate level and in the working world as well as from the opinions of experienced colleagues, thus not being evidence-based (steele et al., 2007). barriers to continuing education include time constraints, geographical problems, lack of available courses and financial difficulties (steele et al., 2007). there can also be a lack of access to articles and research, poor aptitude in identifying information from articles and reduced perceived value and relevance of information found (nail-chiwetalu & ratner, 2007). canmeds, a framework for medical health professional competency of practice, highlights the importance of life-long learning and continued professional education as well as the translation, distribution and application of learned knowledge (frank, 2005). resources in the clinical swallowing evaluation physical resources more than half of responses indicated poor availability of resources. speech-language therapists are inclined to make alternative arrangements in evaluation contexts when resources are limited. for example, to adapt food and liquid consistencies without modifying agents by using the south african food amasi (fermented milk). this is a liquid with a thicker consistency than milk and is relatively cheap. speech-language therapists are forced to think ‘out of the box’ and to become practical with little or no resources in the clinical swallow evaluation. otherwise, infrequent use of resources was logical, and it seems the speech-language therapist uses physical resources sparingly. the amount of resources used was approximately the same in both public and private health sectors: 42.1% and 57.9%, respectively. however, about 75% of responses mentioning unavailability of physical resources came from participants in the public health sector. fifty per cent of the participants in the private health sector did not use resources due to unavailability, while the remaining 50% concerned poor training, time limits, patient-specific needs and gaps in protocol. the allocation of financial resources in the public health sector is inadequately managed. due to poor administrative and managerial capacities and infrastructure the availability of physical resources is often limited (mayosi et al., 2012). the private health sector receives financial contributions nine times the amount the public health sector receives; hence, there is more money appropriately allocated towards physical resources (harris et al., 2011). the public–private divide in health sectors in south africa shows an inequitable and inefficient distribution of resources. medical resources blackwell and littlejohns (2010) also detected poor usage of medical resources in the clinical swallow evaluation due to the absence thereof. it was mentioned that there is a lack of financial resources specifically for equipment, such as stethoscopes for performing cervical auscultation procedures and oximeters for conducting pulse oximetry procedures. there was a desire from participants to receive further training with the use of such medical resources; however, there may be a lack of funding or support for such training preand post-graduation. in the light of a context such as south africa, it is comforting to see that more than 90% of participants in the study had access to consumable resources usually and always. non-medical resources: infrequent use of food and liquid modifying agents could be due to limited availability and patient-specific needs. adults with stroke may not require thickeners and often do not like the taste of such products. the fact that their diet is modified at all is alone the cause for a lowered quality of life (swan, speyer, heijnen, wagg & cordier, 2015). infrequent use of adapted eating utensils may have been due to the fact that regular eating utensils are favoured over adaptive feeding tools as they are less expensive and do not stand out in a social eating situation. some adults with neurogenic dysphagia do not want to be seen in social situations eating with adapted eating utensils. some participants mentioned trying to aim for typical eating utensils in therapy. human resources: multidisciplinary teamwork is key for interprofessional communication and identifying common patient goals (trapl et al., 2007). there is little regard for other health professionals on the team. doctors and nurses have been reported to have a poor awareness and regard for speech-language therapists and their role in neurogenic dysphagia (albini, soares, wolf & goncalves, 2013). one note of concern was that staff changes often caused problems in terms of continuing recommended feeding practices and diets. speech-language therapists need to document their recommendations extensively and clearly after a clinical swallow evaluation so that other speech-language therapists and other health professionals can continue to engage in correct and safe feeding practices. there is a drastic shortage of health professionals in south africa compared with high-income countries, especially in the public health sector and in rural areas (george et al., 2009; mills et al., 2011). for every patient seen by a specialist in the private health sector 23 are seen by a specialist in the public health sector (george et al., 2009). reasons for such human resource shortages include migration of health professionals, the ageing of the nurse population and the increasing burden of disease and illness (george et al., 2009). the extension of the national antiretroviral treatment programme for hiv and aids has also drawn nurses away from other health services (george et al., 2009). it is evident that access to resources is most often a challenge in a context like south africa. reasons for poor resource use in the clinical swallow evaluation are indicative of south africa’s poor resource availability and insufficient training. the speech-language therapist therefore uses certain resources less frequently and needs to adapt the clinical swallow evaluation to suit the limited availability of resources and the needs of the adult with acute stroke. limitations as clinical practice represents one’s ability to manage a patient optimally, participants may have been more likely to report higher frequencies of clinical component use due to these relatively sensitive questions. this observational error could have occurred due to knowledge of scope of practice and service expectations and to avoid embarrassment (groves, 2004). the sample selection methods may have been biased due to using only one organisation to recruit participants. this may have obtained an unrepresentative sample of the population, as participants did not have an equal chance of being selected for the study (leedy & ormrod, 2013). a bigger sample size could have been obtained; however, due to the nature of electronic surveys, response rates are often low (cook, heath & thompson, 2000). generalisation of results must be considered with caution and observations can only be made with regard to the participants in this study. the qualitative data component was subject to theme identification by the researcher only, of which the reliability has been known to be poor. it is however widely accepted for researchers to review their own data, especially as it is not a mixed method study (carnaby & harenberg, 2013; mathers-schmidt & kurlinski, 2003). validity and reliability the researcher conducted a narrative review of the literature to adapt the already existing questionnaire from other validated studies (green et al., 2006). the reliability of the narrative review was increased by having external reviewers blindly review databases (leedy & ormrod, 2013). one hundred per cent inter-rater agreement was reached for any disparities between reviewers. construct validity was improved by keeping search terms consistent among reviewers and by selecting reviewers who were also speech-language therapists thus having an adequate understanding of the research topic and search terms (leedy & ormrod, 2013). a pilot study was conducted to identify any weaknesses in the questionnaire’s content and layout and with regard to its applicability in the south african context (leedy & ormrod, 2013). this improved internal consistency reliability and construct validity (leedy & ormrod, 2013). by having south african participants take part in the pilot study the terminology could be verified as appropriate or not and contextual factors influencing questions or answers could be commented on. developing a questionnaire that was similar to, motivated from and adapted from other, recent and validated studies increased the content validity and criterion-related validity (leedy & ormrod, 2013). reliability was also improved by eliminating interview bias by administering the questionnaire by only electronic means (leedy & ormrod, 2013). the questionnaire was worded and presented clearly and unambiguously, and without misleading tendencies or persuasion (babbie & mouton, 2001) to ensure a greater likelihood of truthful and relevant answers. ethical considerations ethical permission from the biomedical research ethics committee at the university of kwazulu-natal was granted in april 2015. participation in the study was voluntary and the participant could withdraw from the study at any time. consent was indicated by their signing the consent form, and all responses were kept confidential and anonymous (leedy & ormrod, 2013). participants were not subjected to any physical, psychological or disclosure dangers and were not obliged to participate. participants benefitted only by receiving feedback of the study’s results. copies of the completed questionnaires were kept confidential and will be stored electronically at the university of kwazulu-natal for up to 5 years post-completion of the study and thereafter digitally destroyed with two staff members who will bear witness to the procedure. arbitrary numbers were allocated to each completed questionnaire and raw data responses were shared with only the statistician (leedy & ormrod, 2013). conclusion varying adherence to official policies and fluctuating consistency of clinical practice among speech-language therapists in this study indicate a need for more uniformity of education and training curricula at south african universities as well as for more supervision after graduation. it is also apparent that continued professional development is important for updated knowledge and practice. a means by which speech-language therapists can access recent literature is vital in order to maintain knowledge and engage in evidence-based practice. policies set out to guide clinical practice need perhaps to be more detailed, more easily available and more recognised. a suitable clinical swallowing evaluation policy specifically for a resource-limited context is also needed, and more human, financial and physical resources are also essential. ultimately, the adult with neurogenic dysphagia post-acute stroke may not benefit fully from such a context and from inconsistent clinical practice in south africa. more research is needed with regard to the frequency of clinical component use, the consistency of its use and reasons why it is not used in the clinical swallow evaluation of adults with neurogenic dysphagia. reviews of what current curricula entail at south african universities are needed to determine how many hours of theoretical and practical training are completed and which clinical components are being taught. current policies and guidelines also need to be reviewed to address uniformity and comprehensiveness among them. a suitable clinical swallowing evaluation policy for a resource-limited context is also needed. more research is needed potentially to motivate for an improved curriculum at an educational level through which a more consistent clinical swallow evaluation protocol with a constant set of clinical components is taught at universities across south africa. this is in the hope that the use and consistency of clinical components by speech-language therapists in the clinical swallowing evaluation of adults with neurogenic dysphagia post-acute stroke will improve. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions m.p. was the supervisor of the 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(2007). the development of a clinical practice stroke guidelines for physiotherapists in the netherlands: a systematic review of available evidence. disability and rehabilitation, 29(10), 767–783. http://dx.doi.org/10.1080/09638280600919764 seema panday, harsha kathard, mershen pillay, cyril govender the homogeneity of audibility and prosody of zulu words for speech reception threshold (srt) testing *seema panday, #harsha kathard, #mershen pillay, *cyril govender *university of kwazulu-natal #university of cape town abstract t h e a im o f t h i s i n v e s t i g a t i o n w a s t o d e t e r m i n e w h i c h o f 5 8 p r e s e l e c t e d z u l u w o r d s d e v e l o p e d by p a n d a y e t a l . ( 2 0 0 7 ) c o u l d b e u s e d f o r s p e e c h r e c e p t i o n t h r e s h o l d ( s r t ) t e s t i n g . t o r e a l i z e t h i s a i m t h e h o m o g e n e i t y o f a u d i b i l i t y o f 5 8 b i s y l l a b i c z u l u l o w t o n e v e r b s w a s m e a s u r e d , f o l l o w e d by an a n a l y s i s o f t h e p r o s o d i c f e a t u r e s o f t h e s e l e c t e d w o r d s . t h e w o r d s w e r e d i g i t a l l y r e c o r d e d b y a z u l u f i r s t l a n g u a g e m a l e s p e a k e r a n d p r e s e n t e d a t 6 i n t e n s i t y l e v e l s t o 3 0 z u l u f i r s t l a n g u a g e s p e a k e r s ( 1 8 2 5 y e a r s , m e a n a g e o f 2 1 . 5 y e a r s ) , w h o s e h e a r i n g w a s n o r m a l . h o m o g e n e i t y o f a u ­ d i b i l i t y w a s d e t e r m i n e d b y e m p l o y i n g l o g i s t i c r e g r e s s i o n a n a l y s i s . t w e n t y e i g h t w o r d s m e t t h e c r i ­ t e r i o n o f h o m o g e n e i t y o f a u d i b i l i t y . t h i s w a s e v i d e n c e d by a m e a n s l o p e o f 5 0 % a t 5 . 9 8 % / d b . t h e p r o s o d i c f e a t u r e s o f t h e t w e n t y e i g h t w o r d s w e r e f u r t h e r a n a l y z e d u s i n g a c o m p u t e r i z e d s p e e c h l a b o r a t o r y s y s t e m . t h e f i n d i n g s c o n f i r m e d t h a t t h e p i t c h c o n t o u r s o f t h e w o r d s f o l l o w e d t h e p r o ­ s o d i c p a t t e r n a p p a r e n t w i t h i n z u l u l i n g u i s t i c s t r u c t u r e . e i g h t y n i n e p e r c e n t o f t h e z u l u v e r b s w e r e f o u n d t o h a v e a d i f f e r e n c e i n t h e p i t c h p a t t e r n b e t w e e n t h e t w o s y l l a b l e s i . e . t h e f i r s t s y l l a b l e w a s l o w i n p i t c h , w h i l e t h e s e c o n d s y l l a b l e w a s h i g h i n p i t c h . i t e m e r g e d t h a t t h e t w e n t y e i g h t w o r d s c o u l d b e u s e d f o r e s t a b l i s h i n g s r t w i t h i n a n o r m a l h e a r i n g z u l u s p e a k i n g p o p u l a t i o n . f u r ­ t h e r r e s e a r c h w i t h i n c l i n i c a l p o p u l a t i o n s i s r e c o m m e n d e d . k e y w o r d s s p e e c h r e c e p t i o n t h r e s h o l d , z u l u , z u l u f i r s t l a n g u a g e s p e a k e r s , h o m o g e n e i t y o f a u d i ­ b i l i t y , a c o u s t i c a n a l y s i s , p r o s o d i c f e a t u r e s the selection of words for srt testing in languages other than english has recently received much attention in the literature. this follows nissen, harris, jennings, eggett & buck’s (2005) assertion that it is essential that srt testing be conducted in the language of the listener. given this imperative and to attain valid and reliable srt results, research has been conducted in many languages such as arabic (ashoor & proshazka, 1985); tiwi (plant, 1990); walpiri (plant, 1990); brazilian portuguese (harris, goffi, pedalini, gygi & merrill, 2001); korean (harris et al., 2003); polish (harris et al., 2004); mandarin (nissen et al., 2005) and taiwanese mandarin (nissen, harris & dukes, 2008). however, srt word lists in african languages such as zulu have received very little or no attention although zulu is spoken by almost 8.5 million people in south africa (grimes, 1992). there­ fore, it is necessary that a linguistically-matched srt word list be formulated according to specific criteria to enable the appropriate assessment of hearing of the many zulu speaking south africans, the majority of whom reside in the province of kwazulu-natal (kzn). panday, kathard, pillay & govender (2007) have described the developmental process of adapting criteria for srt word lists by considering zulu linguistic structure. the adaptation of the origi­ nal srt criteria to suit the linguistic structure of the language, for 60 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, which the list is being developed, has received strong support in international literature. evidence of the development of srt word lists in other mother tongue languages is seen in arabic word lists (ashoor & proshazka, 1985); walpiri & tiwi (plant, 1990); manda­ rin (nissen et al. 2005) & taiwanese mandarin (nissen et al. 2008). panday et al. (2007) have reported on the identification and selection of fifty eight zulu words that met the following lin­ guistic criteria i.e. the words were bisyllabic, phonetically dissimi­ lar, familiar, low tone verb imperatives. these criteria were adapted from the original srt criteria as specified by hudgins, hawkins, karlin & stevens (1947) i.e. the words had to lie famil­ iar, bisyllabic, equally stressed words (spondees) that were pho­ netically dissimilar, and which had to be homogeneous for audi­ bility. the focus of this paper is to describe which of the fifty eight preselected zulu words met the criterion of homogeneity of audibility. in addition, a description of the prosodic features of the most homogenous words selected was made, so that the words finally selected from this process could be used for srt testing within a selected zulu first language speaking population. contact: seema panday discipline of audiology university of kwazulu -n atal westville campus durban south africa email: pandavse@ukzn.ac.za tel: 031-2607623 ' vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:pandavse@ukzn.ac.za the homogeneity of audibility and prosody homogeneity of audibility has been described as the ease at which the words are understood when spoken at a constant level of intensity (silman & silverman, 1991). it is regarded as one of the most important criteria for the selection of srt test materials (nissen et al., 2005). homogeneity of audibility of words in a list can be achieved in two ways, i.e. by selecting only those words that reach the listener's ear at the same intensity or by recording the individual words in such a way that they all tend to be heard at the same level of production (beattie, svihohee & edgerton, 1975). schill (1985) explained that in order to meet the criterion of homogeneity of audibility, the percentage of words correctly recognized must increase rapidly with a relatively small increase in intensity. this is usually illustrated through the use of the per formance-intensity curve (brandy, 2002). the performance inten­ sity curve is the more recent term used for the psychometric func­ tion which describes the relationship between some measure of performance and a stimulus (kruger & kruger, 1997). the performance intensity curve serves to illustrate how well the speech sample (words in the list) is correctly identified as a function of various intensity levels. the steepness of the curve determines the precision with which the threshold can be ob­ tained (hudgins, hawkins, karlin & stevens, 1947). nissen et al. (2005) added that the steepness or slope of the performance intensity curve is an important factor to consider in selecting words for srt testing. hence, these aspects were considered when determining which of 58 zulu words preselected by panday et al. (2007) met the criterion of homogeneity of audibility. however, obtaining ideal steep performance intensity curves together with homogeneity of audibility has posed serious chal­ lenges over the years. the literature seems to indicate that the l number of words selected is reduced when the criterion for ho-i mogeneity of audibility is applied. this was seen when the original srt word list in english was (hirsh, silverman, reynolds further reduced to 22 words reduced from 84 words to 36 words eldert & benson, 1952) and was (bowling & elpern, 1961). i bowling and elpern’s (19,61) findings were supported by re­ search conducted by curry'and .cox (1966) who found similar results. the range of intelligibility between the words in the curry and cox (1966) study for normal hearers was 8%/db compared to 10%/db in the bowling and elpern (1961) study. the homoge­ neity of audibility of the words suggested in the above studies was also challenged by beattie et al. (1975). these authors ques­ tioned whether the word differences noted in the bowling and elpern (1961) study were due either to .inconsistencies in the recording process or due to the selection of the words. later, young et al. (1982) explained these discrepancies by presenting a more stringent methodological framework for deter­ mining how words for srt testing in english met the criterion of homogeneity of audibility. young et al. (1982) postulated that of zulu words for speech reception threshold testing previous studies were confounded by the learning effect that occurred within the word lists. bowling and elpern (1961) and beattie et al. (1975) tested the same randomized words at sev­ eral intensity levels using a 2db step increase in the intensity. young et al. (1982) regarded this as a confounding factor as the participants were possibly performing better because of having learnt the words in the list rather than using hearing acuity to determine loudness or clarity of the words. more recently, however, nissen et al. (2005) utilized a detailed mathematical model to determine which of 138 mandarin words met the criterion of homogeneity of audibility. these authors pro­ vided a motivation for the use of the logistic regression model for the measurement of homogeneity of audibility. the logistic re­ gression model according to nissen et al. (2005) provided a de­ scription of the slope at 50% of the performance intensity curves of each word, the estimated threshold of intensity at which each word was heard and individual performance intensity curves for the words. this allows the researcher to rapidly identify those words that are being heard easily compared to the words that were not (nissen et al., 2005). the advantage of using this model is that the rate of change of intelligibility is accurate and available instantly. in addition, nissen et al. (2005) described favourable results with regard to the slope at 50% for mandarin words. there was an almost equivalent performance with that of the english words. the 11.3 percent per decibel (%/db) obtained in the nissen et al. (2005) study was perhaps due to a digital adjustment made to the intensity of each of the words, so that the 50% of each word selected was equal to the mean pure tone average of the participants in the study. this adjustment controlled for variability of the performance intensity curves and thereby improved the overall homogeneity of audibility of the words. clearly, the measurement of homogeneity of audibility of the words for srt testing is not a simple issue. homogeneity of audi­ bility of the words and the performance intensity function of each word are not only influenced by methodological and procedural variables as described earlier, but can also be influenced by sev­ eral other factors that have been recently discussed in the litera­ ture. some of these factors include, the type of stimuli used (kruger & kruger, 1997), the number of syllables in the words (chetty, 1990), the recording (nissen et al., 2005) and calibration of equipment (lyregaard, 1997), the choice of the speaker used for the recording of the words and most importantly the structure of language. it is important that test material consists of items familiar to the listener. the items must represent the real world of the listener (chermack & musiek, 1997). this contention appears relevant to the measurement of homogeneity of the words in zulu. therefore, apart from the acoustic-phonetic characteristics of the words, the the south african journal of communication disorders, vol 56, 2009 61 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) seema panday, harsha kathard, mershen pillay, cyril govender lexical processes, such as the semantic, syntactic and content of the words can also influence the way words are heard. conse­ quently, a "steeper performance intensity curve results when the task is simple, the stimuli are familiar, and most homogene­ ous" (kruger & kruger, 1997, p. 234). therefore, within the pre­ sent study the 58 preselected zulu words were items that were most familiar in the zulu language. this is also in keeping with the suggestions made by borg, wilson & samuelsson (1998) who highlighted the importance of selecting familiar items for srt testing. panday et al. (2007) provide a detailed explanation of how the 58 preselected zulu words met the criterion of familiar­ ity. another factor that influences the homogeneity of audibility of the words is the number of syllables in the word. bisyllabic words were traditionally used for srt testing. however, the study con­ ducted by nissen et al. (2005) obtained steep performance inten­ sity curves with trisyllabic words. one could argue that the in­ crease in the number of acoustic cues in the trisyllabic words can affect the steepness of the curve because the increase in the acoustic cues available to the listener allows the word to be eas­ ily identified at lower intensities. therefore, measurement of ho­ mogeneity of audibility in the present study could be influenced by the number of syllables in the zulu words. however, given that there is no reference point for what constitutes an acceptable number of acoustic cues, it would be inappropriate to perform cross-linguistic comparisons between bisyllabic words versus trisyllabic words without a fuller semantic-syntactic linguistic analysis. a more critical factor influencing the validity of measure­ ment of homogeneity of audibility, however, is whether the words are presented in recorded versus monitored live voice testing (nissen etal., 2005). recorded and monitored live voice testing methods are both recommended for clinical use (american speech-language hear­ ing association [asha], 1988; brandy, 2002; roeser, valente & horsford-dunn 2000; silman & silverman, 1991; stach, 1998). however, in terms of measuring homogeneity of audibility of the words, it is advised that recorded materials be used (nissen et al., 2005). the use of recorded materials standardises the com­ position and presentation of the test words. furthermore, the recorded method allows for uniform presentation of the test words (asha, 1988). therefore, recorded material was chosen in the present investigation to ensure favourable performance in­ tensity curves. moreover, researchers should be cognizant of the choice of speaker used in the recording of the stimuli. the stimuli must not only be presented in the language of the listener, but the speaker presenting the stimuli must be of a similar linguistic and dialecti­ cal background as the listener (nissen et al., 2005). in light of this suggestion, the speaker in the present investigation was a male zulu first language speaker from kzn. a male speaker was considered, as recent literature has indicated no clear gender differences influencing the homogeneity of audibility (cambron, wilson & shanks, 1991; nissen etal., 2005). thus, the results of homogeneity of audibility may or may not be influenced by the factors discussed above. however, the unique structure of the zulu language may impact on the outcome of homogeneity of audibility of 58 preselected zulu words and de­ serves some discussion and investigation. the consonant system in zulu is considered more complex than that of english. apart from the known stops, fricatives, and ap proximants, zulu also has three prominent click sounds (doke, 1930). the click sounds are orthographically transcribed as /c/ (dental click); /q/ (palato-alveolar click); and the /x/ (lateral click) (doke, 1930). these click sounds appear frequently in the vo­ cabulary of zulu. this has certain implications for the measure­ ments of homogeneity of audibility of the words, i.e. inclusion of click phonemes in the word list may influence the variability in the performance intensity curves of the words that have click sounds. click sounds have a higher spectral energy and this may result in improved audibility of the words that contain clicks. therefore, the structural variation in the language and the fact that zulu is also a tonal language (rycroft & ncgobo, 1979) could influence the measurement of homogeneity of audibility and pose a possi­ ble challenge when determining those words that are most ho­ mogenous. in addition, the role of tone has three distinct functions in zulu, i.e. semantic (affecting the meaning of words), grammatical, and emotional (cope, 1982). these tonal variations may influence the meaning of the stimuli, thus having further implications for speech understanding and identification. tonal variations are lexically significant in zulu (rycroft & ncgobo, 1979), implying that changes in the pitch of the word may correspond with changes in the meaning of the word. hence, the introduction of acoustic analysis via pitch extraction and en­ ergy values is suggested in addition to evaluating the word for i homogeneity of audibility. the inclusion of acoustic analysis i would confirm the tonal patterns of the verbs in zulu. inherent in an acoustic analysis of words is the description of the prosodic features of a language. in considering the prosodic features of zulu, we find that they are different from those of english. there­ fore, an evaluation of the prosodic features of a language via appropriate acoustic analysis serves to improve the validity of the zulu words selected for srt testing. prosodic features of speech usually include length, accent, stress, tone and intonation (fox, 2000). furthermore, intonation refers to the patterns relating to the rise and fall, and the stress in a language (kent & read, 1992).-in considering zulu, we find that it is a “non-stress” language (rycroft & ngcobo, 1979) e.g. ■ bisyllabic words such as “ham ba" meaning ‘go’ in english, do not 62 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the h om ogeneity of audib ility and prosody of zulu w ords for speech reception threshold testing have equally stressed syllables. stress is not used to indicate emphasis nor is it used to differentiate words or syllables as seen in english (cope, 1982). instead, the prominence on syllables is often used to describe emphasis. this can be seen e.g. when low tone bisyllabic verbs are used in srt testing, the lengthening of the vowel on the first syllable results in the second syllable gain­ ing prominence. similarly, plant (1990) reported that the prominence or stress of the trisyllables in tiwi was on the penultimate syllable of the tiwi words. plant (1990) therefore, suggested an acoustic analy­ sis of the words to confirm the prosodic patterns of the tiwi words before the words were considered for inclusion in srt testing. thus, it is strongly suggested that the prosodic features of the selected zulu words also be analyzed acoustically. an acoustic analysis via pitch extraction and energy values of the vowels would serve to confirm the tonal patterns of the verbs selected i.e. to examine whether they are low tone vs high tone verbs. the words selected for srt testing, therefore, would be homogenous in terms of the prosodic features of zulu as well as for audibility. the importance of acoustic analysis in srt word list develop­ ment, however, is lacking in the literature, but the above motiva­ tion together with the understanding of basic acoustics serves as a basis for the inclusion of acoustic analysis in the present inves­ tigation. furthermore, brandy (2002) indicates that the acoustic analysis of speech is important, as speech sound perception is dependant on both acoustic -phonetic factors and the higher order linguistic processing. contributions to the field with regard to selecting words for srt testing in languages other than english are acknowledged. how­ ever, factors influencing the outcome of homogeneity of audibility together with the uniqueness of the zulu language, suggest a need to determine which of the zulu words proposed by panday et al. (2007) meet the criterion of homogeneity of audibility and to describe the prosodic features of the most homogenous words. thus, the research question for this investigation was: which of the 58 preselected zulu words by panday et al. (2007) could be used for srt testing within a zulu speaking population in kzn? method aim the aim of the investigation was to determine which of the 58 preselected zulu words could be used for srt testing within a zulu speaking population in kzn. the following objectives were generated to achieve the above aim. objectives 1. to determine which of the 58 preselected zulu words met the criterion of homogeneity of audibility. 2. to describe the prosodic features, specifically pitch and en­ ergy contours, of the most homogenous words selected in objec­ tive 1 research design a descriptive cross sectional design was adopted in this study (connolly, c, statistician, medical research council, per­ sonal communication, august 2009). such a design was consid­ ered suitable as it provided the data at a fixed point in time (maxwell & satake, 2006). a quantitative approach was followed because the study involved the analysis of responses to the audi­ bility of the words at different intensity levels. this was followed by an analysis of the prosodic patterns of the zulu words. the methodological framework for each objective is described below. objective 1: to determine which of the 58 prese­ lected zulu words met the criterion of homogeneity of audibility participant selection criteria the following participant selection criteria were adopted for this part of the study. qrhe participants had to be between the age of 18 25 years, as hearing sensitivity is judged to be at its peak during this age period (jerger, 1970). qrhe participants had to speak zulu as their first language and had to have been permanent residents of kzn for more than 10 years. this criterion ensured that the participants would be famil­ iar with the items selected for testing and that there would be no confounding dialectal factors. qrhe participants could have been male or female, as gender specificity was not investigated. the participants were required to have had no previous expo­ sure to industrial or recreational noise, no exposure to ototoxic drug consumption and must have reported no previous medical, neurological or acquired illnesses. further, participants had to have normal hearing. no family history of hearing loss should be reported. the above factors could contribute to auditory disorders that could confound the results. bess and humes (2003) de­ scribe the above factors as exogenous and endogenous factors, which could result from varying degrees of hearing loss. the above factors were evaluated using a case history questionnaire and were further confirmed by otoscopic examination, pure tone audiometry and immittance testing. the participants had to have no exposure to hearing testing before their participation in this study (robinson & koenings, 1979). this criterion was necessary in order to control for any learned effects regarding any of the behavioral measures used. sampling method purposive nonprobability sampling was used for this part of the south african journal of communication disorders, vol 56, 2009 63 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) seema panday, fiarsha kathard, mershen pitlay, cyril govender the study. zulu first language speakers attending the university of kwa -zulu natal were targeted as the study population. adver­ tisements for participants included posters and an email advert on the university lan. the advertisement included the specific criteria for participation in the study. thirty-two participants re­ sponded to the original advertisements. however, once the sam­ ple selection criteria and the hearing testing process via case history, otoscopic examination, pure tone audiometry and immit tance testing were completed, only thirty participants were con­ sidered suitable for the study. the two participants who did not meet the selection criteria were referred for further audiological testing and ent management. participants thirty normal hearing zulu first language speaking (zfls) stu­ dents from kzn were included as participants to realise this first objective of the study. the mean age of the participants was 21.5 years. there were 22 male and 8 female participants. thirty adults were considered adequate, as the minimum number used for the evaluation of homogeneity of audibility in other studies was reported to be between twenty and twenty five (nissen et al., 2005). materials and apparatus words fifty eight bisyllabic, low tone zulu verbs were measured for homogeneity of audibility. the process resulting in the selection of the fifty eight words is described by panday et al. (2007). bisyl­ labic low tone verbs were selected according to careful considera­ tion of zulu linguistic structure. furthermore, the 58 preselected words were subjected to analysis at two levels i.e. analysis in terms of commonality of the words in the zulu language, a linguis­ tic rating strategy in terms of familiarity and phonetic dissimilarity and tone (refer to panday et al., 2007). recordings in order to achieve objective 1, 58 preselected words had to be recorded onto compact discs (cd). the recording was done in a recording studio. the equipment and the procedure for the re­ cording was according to the guidelines stipulated by lyregaard (1997); asha (1988) and nissen et al. (2005) for recorded mate­ rials. the u87a p48 type neuman microphone was used for the recording. the akg cover/windshield was used over the micro­ phone to prevent distortion, especially when plosive sounds were produced. the microphone was positioned approximately 15cm from the speaker at 0 degree azimuth. the microphone was con­ nected to a sound mixer (mackie 32-8-2 8-bus mixing console) in the control room. the recordings made were normalized to odbhl levels. the recording of the words was preceded by a cali­ bration pure tone signal which is according to the recent iso 8253-3 specification for recorded materials. the calibration sig­ nal was weighted, using a frequency-modulated tone at 1 khz, which had a bandwidth of at least 1/3 octave (nissen et al., 2005). the modulating signal was sinusoidal and had a repetition rate of 4-20hz. the calibration tone lasted 60 seconds and was followed by an instruction read by a male zulu first language speaker. the zulu words were recorded in diverse, random se­ quences, on six different tracks on the cd. fifty-eight words were recorded on each of the six tracks. the six tracks were randomi­ zations of the same 58 words. the fifty-eight words were re­ corded with a 5 second pause between each word (lyregaard, 1997). each word was preceded by a carrier phrase “yithi” which means “say" in zulu. the zulu first language speaker was ad­ vised to read the words in the natural tone that the words are spoken in accordance with the dialect used in the durban pietermaritzburg region of kzn. the recordings were transferred from the mixer desk to the carilon audio system computer hard drive. the wavelab software package was used to edit the words. the words were normalized to peak at odb and were adjusted once all recordings were done. the editing software allowed for the words to have the same rms power as the 1000hz calibra­ tion tone in an initial attempt to equate all the words. the use of a constant rms allows for the output of the signal (the presenta­ tion of the words) to remain constant. this is a standard method of controlling any fluctuations in the signal and has been de­ scribed in other studies such as ramkissoon et al. (2002) and nissen et al. (2005). the recordings were then produced onto a cd using the nero start smart cd writer. the choice of speaker for the recording of the cd the speaker selected for the recording of the cd was a male zulu first language university student who resided in the durban pietermaritzburg region where zulu is the main language spoken. therefore, the dialect used in the recording was matched to that of the material selected and to the participants in this study. re­ cent research has indicated minimal gender influences on the recording of the material and the overall homogeneity of audibility of the words (cambron, wilson & shanks, 1991; nissen et al., 2005). j procedure ^ procedure for the measurement of homogeneity of audibility the measurement of homogeneity of audibility using the recorded words occurred in two sessions i.e. session one involved testing of the participants for normal hearing and session two involved the measurement of homogeneity of audibility. prior to any testing, the university of kwa zulu-natal ethics committee approved the study. informed consent was obtained from each participant before com­ mencing with testing. the testing of the participants for normal hearing was conducted using standard audiometric procedures. these procedures included a detailed case history, otoscopic exami­ nation, immittance audiometry, air conduction testing for frequen­ cies 125 hz to 8khz. an isolated industrial acoustics company (iac) twin audiometric-soundproof booth of double wall construc64 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the hom og en eity of au d ib ility and prosody of zulu w o rds for speech reception thr esh old testing tion was used as the test environment for the pure tone testing and speech evaluation. these requirements were set by the american national standards institute [ansi] (1977) to meet the noise level requirements. all equipment used in session one and two was calibrated prior to testing (june 2005). appendix a re­ flects the pure tone averages for all participants. based on the results of the basic battery in session one, the participants were selected or excluded from the study. the ex­ cluded participants were referred for further diagnostic testing and appropriate management at the local clinic, hospital or uni­ versity clinic. thirty participants had normal hearing based on the results of the basic battery and were therefore included in ses­ sion two i.e. for the measurement of homogeneity of audibility of the words. the participants were seated in the test room while the re­ searcher and two zulu first language speaking scorers were in the control room. each participant was instructed in zulu by a zulu first language speaker. the speaker was trained by the re­ searcher in terms of the instructions and procedure to be fol­ lowed. the instructions orientated the participants to the nature of the task. the instructions specified the participant’s mode of response and indicated that the test material was speech. in­ structions were given for participants to repeat the words that they heard verbally, including those words presented at the faint­ est listening levels. the verbal response is supported in the lit­ erature by lyregaard (1997). the scoring of participant’s re­ sponses was done independently by the researcher and the two zulu first language speaking scorers. the researcher included this scoring method in order to improve the reliability of the scor­ ing process. the 58 words (appendix b) were captured onto a scoring form developed by the researcher. the participant’s re­ sponse was scored with a tickjfor an accurate, and a cross for an inaccurate response or if there was no response. the researcher randomly selected the test ear because only one ear of each participant was tested for the homogeneity of audibility of the words. the fjarticipants had normal hearing in both ears and it did not matter which ear was selected for testing. j the participants were instructed verbally by a zulu first language speaker. thereafter, the recorded material was presented to each participant. the recording began with the 1000hz calibration tone, followed by a recorded instruction in zulu. the instructions were routed through the gsi 61 audiometer using tdh-49 earphones. the intensity level of the instruction was at 30dbhl. at the onset of testing for homogeneity of the words, the attenuator dial was set at odbhl. at this level one recording of 58 words was played to the participant. the number of correct and incorrect words was recorded by each of the three scorers on the scoring form. the attenuator was raised in 5db steps and a second recording was administered. a different recording was then played successively at each 5db increment until 100% identification was reached for all 58 words. the participants were given a 5 minute rest period after three recordings were played. the rest period was incorporated in order to improve co­ operation from all participants and to eliminate fatigue. further­ more, the participants were reinforced by the researcher through non-verbal reinforcements. all thirty participants were tested in the same way. procedure for analysis of homogeneity of audibility fifty eight bisyllabic words were played back via a cd player to the participants. the participants were instructed to repeat the words heard. there were 3 scorers used to assess the responses of the participants in terms of the audibility of the words. the fifty eight words were presented at different sound intensity levels viz. at 0, 5, 10, 15 and 20 decibels. the kappa test of agreement according to agresti (1990) was used to assess the consistency of the scorers. the kappa test was chosen since the responses were binary and it was a suitable test of agreement between two or more scorers. results indicated a good agreement amongst all three scorers at 0.05 level of agreement. the good inter-rater reliability across all three scorers allowed the researcher to choose the scores of one of the zulu first language scorers for application of the logistic regression equation. the use of the logistic regression equation led to the analysis of homogeneity of audibility. logistic regression was used since the data was binary (nominal) in nature. appendix c describes the motivation and procedure used regarding the logistic equations, as stipulated by agresti (1990). this was done using computer­ ized statistical analysis i.e. spss version 11.6. a statistician at the medical research council of south africa (durban) assisted with the statistical analysis. the average percentage correct iden­ tified by each participant for each word was calculated using the above equation. the performance intensity curve for the most homogenous words was identified. the steepness of the curve was calculated using a logistic regression plot .the raw scores for the 58 words were inserted into a logistic regression equation that was designed to calculate the percentage correct at each intensity level. using the regression equation, the calculations for the range of threshold (50%) and the slope of the curve was as­ certained for each word. this model provided the researcher with a method of estimating, at any given intensity, the performance of the words in terms of percentage. the most homogenous words were selected and the cd recording was edited. this con­ sisted of 28 words. these words were then considered for the acoustic analysis of the prosodic features outlined in objective two of the study. the south african journal of communication disorders, vol 56, 2009 65 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) seema panday, harsha kathard, mershen pillay, cyril govender objective 2: to describe the prosodic features, spe­ cifically the pitch and energy contours of the most homogenous words selected in objective one sample material the twenty-eight zulu words identified as being most homoge­ nous were included as material for this objective of the study. the recorded words were used for the acoustic analysis. apparatus and choice of tests the multispeech model 3700 by kay-elemetrics corporation was the most suitable apparatus for the present investigation. it is a digitally driven system. the accompanying software pro­ grams enable the system to analyze the pitch contours of the signal, determine the fundamental frequency of the input signal and measure the spectrographic waveform patterns of the speech signal. procedure the input signal for the multispeech 3700 analysis was via the cd recording. the multispeech main program software was used. four display window settings were created. display a represented the digitized sound wave, display b was a wideband spectro­ graphic analysis, and c and d represented the pitch contour and energy contours respectively. however, for the purposes of this study the pitch and energy contour settings were most relevant. each of the 28 words was recorded on the cd and was analyzed acoustically. there was a separate pitch contour and energy con­ tour for each word, which allowed for ease of analysis and com­ parison. analysis all 28 words were carefully analysed for the acoustic properties that were relevant for this study. the following parameters were used: pitch contours energy contours the pitch contours and energy contours of each syllable within a word were analyzed via visual inspection. this entailed identify­ ing the highest points for pitch and spectral energy for each sylla­ ble of the word, by placing the cursor on the highest point of the contour and reading the values. thereafter, differences in the pitch and overall spectral energy for each syllable were deter­ mined using descriptive statistics. data was tabulated. the differ­ ence values for pitch and energy were calculated as such values could be used to confirm the prosodic features of zulu (e. gro enewald, lecturer, university of pretoria personal communica­ tion, october 2006). the use of pitch was particularly important as the prosodic features in a language are usually indicated by the rise and fall in the pitch of the word (kent & read, 1992). furthermore, the similarities in the pitch and energy content of the words could confirm the homogeneity of the words acousti66 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, cally. the results of the study are outlined below. results the results are presented according to each of the two objec­ tives outlined in the method. results for the measurement of homogeneity of au­ dibility the data for the homogeneity of audibility was treated statisti­ cally using the logistic regression analysis technique. the esti­ mates of the regression model are indicated in table 1. all slopes and intercepts were significant at the 0.05 level of significance. the calculations of the threshold intensity and slope are also provided. these values are calculated using the equations out­ lined in appendix c. table 2 indicates the slope obtained at 50%, the slope at 20 to 80% and the estimated threshold obtained according to the regression model for each of the words. table 1. estimates of the regression model word a p word a p banga -2.393 0.227 linda -2.267 0.24 bheka -1.351 0.179 loya -3.017 0.237 bhema -1.586 0.173 lunga -3.856 0.262 chela -3.014 0.307 minya -3.662 0.237 cinga -2.91 0.258 pheka -1.897 0.162 dansa -1.974 0.222 phonsa -2.001 0.175 dinga -2.7 0.133 qoba -1.105 0.203 donsa -2.165 0.234 sefa -1.817 0.077 faka -0.283 0.257 shada -1.978 0.304 finya -3.268 0.175 shaya -0.433 0.186 geza -1.85 0.228 thanda -1.729 0.156 goba -1.827 0.168 thatha -2.689 0.242 gonda -2.578 0.617 thela -2.877 0.271 gqoka 0.104 0.167 thenga -2.871 0.353 gxeka -1.121 0.3 thola -2.313 0.439 hlala 0.921 0.214 vala -1.199 0.216 hleka -1.205 0.19 veza -3.942 0.273 hlenga -2.347 0.226 vula -2.794 0.207 hluba -2.587 0.193 vuma -2.527 0.195 hola -2.524 0.178 washa -1.109 0.383 jaha -2.197 0.22 wina -3.401 0.26 jeza -2.94 0.322 xola -2.262 0.321 khaba -2.013 0.288 yanga -1.908 0.261 khanya -1.385 0.229 yeba -2.566 0.261 kheta -2.227 0.26 yeka -2.061 0.316 khipa -2.581 0.254 yenza -2.222 0.214 landa -1.377 0.178 yifa -2.024 0.154 letha -2.334 0.206 yona -2.94 0.322 lima -2.288 0.158 yosa -3.489 0.2 „ 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the homogeneity of audibility and prosody of zulu words for speech reception threshold testing the data recorded in table 2 indicates that on average the is greatest at this point. for a unit change in x (intensity level) we see estimated threshold intensity (softest level) at which all the words the largest increase in the probability of audibility (p(x) = 1). the measwere heard was 9.66dbhl. on average the 50% correct recogniurement of homogeneity of the word list is dependent on those chosen tion point occurred at about 9.66dbhl. the slope at 50% was an to have a steep threshold slope, important statistic to calculate, since it represents the steepest slope on the logistic curve. this indicates that the rate of change table 2. summary of the slope at 50%; slope at 20 to 80% and the estimated threshold. word slope at 50% (0.5*0.5*b) *100 slope at 20 or 80%: (0.2*0.8*b)*100 (-)a/b = threshold word slope at 50% (0.5*0.5*b) *100 slope at 20 or 80%: (0.2*0.8*b)*100 (-)a/b = threshold banga 5.675 3.632 10.542 linda 6 3.84 9.446 bheka 4.475 2.864 7.547 loya 5.925 3.792 12.73 bhema 4.325 2.768 9.168 lunga 6.55 4.192 14.718 chela 7.675 4.912 9.818 minya 5.925 3.792 15.451 cinga 6.45 4.128 11.279 pheka 4.05 2.592 11.71 dansa 5.55 3.552 8.892 phonsa 4.375 2.8 11.434 dinga 3.325 2.128 20.301 qoba 5.075 3.248 5.443 donsa 5.85 3.744 9.252 sefa 1.925 1.232 23.597 faka 6.425 4.112 1.101 shada 7.6 4.864 6.507 finya 4.375 2.8 18.674 shaya 4.65 2.976 2.328 geza 5.7 3.648 8.114 thanda 3.9 2.496 11.083 goba 4*2 2.688 10.875 thatha 6.05 3.872 11.112 gonda 15.425 9.872 4.178 thela 6.775 4.336 10.616 gqoka 4.175 2.672 -0.623 thenga 8.825 5.648 8.133 gxeka 7.5 4.8 3.737 thola 10.975 7.024 5.269 hlala 5.35 i 3.424 -4.304 vala 5.4 3.456 5.551 hleka 4.75 ! 3.04 6.342 veza 6.825 4.368 14.44 hlenga 5.65 i 3.616 10.385 vula 5.175 3.312 13.498 hluba 4.825 3.088 13.404 vuma 4.875 3.12 12.959 hola 4.45 2.848 14.18 washa 9.575 6.128 2.896 iaha 5.5 ' 3.52 9.986 wina 6.5 4.16 13.081 ieza 8.05 ! 5.152 9.13 xola 8.025 5.136 7.047 khaba 7.2 ■" 4.608 6.99 yanga 6.525 4.176 7.31 khanva 5.725 3.664 6.048 yeba 6.525 4.176 9.831 kheta 6.5 4.16 8.565 yeka 7.9 5.056 6.522 khipa 6.35 4.064 10.161 yenza 5.35 3.424 10.383 landa 4.45 2.848 7.736 yifa 3.85 2.464 13.143 letha 5.15 3.296 11.33 yona 8.05 5.152 9.13 lima 3.95 2.528 14.481 yosa 5 3.2 17.445 summary statistics slope at 50% slope at 20 or 80%: threshold intensity mean 5.986 3.831 9.657 standard deviation 2.037 1.304 4.85 maximum , 15.425 9.872 23.597 minimum 1.925 1.232 -4.304 range 13.5 8.64 27.901 the south african journal of communication disorders, vol 56, 2009 67 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) seema panday, harsha kathard, mershen pillay, cyril govender figure 1. performance intensity curves for zulu words finally selected o o level (db) -----bhema ----finya -----goba — hlala — hlaka -----hlenga -----hluba — hola -----jaha -----kheta -----landa -----letha -----lima -----loya -----phonsa -----sefa ----vuma ----yifa ----yosa ----average of all ----bheka ----dansa ----gqoka ----dinga ----lunga ----pheka ----qoba ----shaya ----thanda ----vula ----yenza figure 2. performance intensity curves for zulu words not selected 0 . 7 5 0 . 5 0 . 2 5 5 2 . 5 0 2 . 5 5 7 . 5 1 0 1 2 . 3 5 1 7 . 2 0 2 2 . 2 5 --------c i n g a --------g x e ka --------b a n g a ------c h e la ------g e z a ------j e z a ------kh an ya ------k h ip a ------k h e t a ------i in da ------m i n y a ------l o y a ■------s ha d a ------th ath a ------th el a ------th en ga ------th ol a ------w as h a ------w i na ------x o l a ------k h a b a ------fa ka ------y o n g a ------do ns a ------y o n a 1 -----a v e r a g e o f a l l ------y e k a \ ------qo nd a v e za ! l e v e l s (d b ) the mean slope at 50% was found to be 5.986%/db (sd= 2.037). therefore, the words that were above the mean slope were considered most homogenous. these words had the steep­ est slope and satisfied the criterion of homogeneity of audibility. twenty eight words were therefore considered fairly homogenous on the basis of the above analysis. the performance intensity curve of the 28 words is described in figurel. a description of individual performance curves is available from the authors. fig­ ure 2 illustrates the performance intensity curves for the words not selected. the mean slope of the words selected as indicated in figure 1 was 5.9865%/db. this figure also clearly indicates that the words selected had the steepest slope compared to the words not selected in figure 2. figure 2 indicates that the slope at 50% for each of the words was more gradual. the gradual slope indicates that for these words to be identified correctly the words had to be presented at higher intensity levels compared to the words identified as being most homogenous results emerging from the analysis of the prosodic features of the words the twenty eight words selected in objective 1 were analyzed / acoustically for their prosodic features. table 3 indicates the re­ sults obtained for each of the twenty eight words. the majority of the words (89%) indicate a relatively lower pitch value in the first syllable compared to the second syllable. the pitch values in table 3 also indicate a difference in pitch between syllable one and two. the magnitude of the difference value serves to con68 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the homogeneity of audibility and prosody of zulu words for speech reception threshold testing firm the change in pitch between syllable one and two. this conthe penultimate syllable, and therefore prominence is noted in firms the presence of tonal patterns in the selected zulu verbs the second syllable. fifty eight bisyllabic low tone verbs were measured for homogeneity of audibility and were then further sub­ jected to an acoustic analysis for the description of prosodic features. twenty eight words were most homoge­ nous, because they had the steepest perform ance curves. statistically, words that were identified with a greater than 5.98%/db slope, were considered to be most homogenous. the performance curve is used to illus­ trate how the words were heard at different intensity levels. the critical element of the performance curve is the steepness or the slope of the curve. the mean slope of these twenty eight words was 5.98%/db. the mean slope, therefore, is comparable to that of other languages and this is indicated in table 4 below. figure 1 also indicates variability in the curves generated. however, closer inspection of the twenty eight words selected (see figure 1 in the results section) illustrates that the majority of the curves appear similar in shape with a distinct sshaped curve. in contrast, however, the remaining 30 words were very different in shape (see figure 2 in the results section). these table 3. pitch and energy values: syllable 1 and 2 i the majority of the words (89%) show a similar pattern regard­ ing pitch, and this serves to confirm the presence of prosodic patterns in zulu. eleven percent (3/28) did not indicate this pat­ tern. this finding could have been influenced by the speaker plac­ ing artificial stress on the first syllable, similar to that when a spondee word is uttered. this limitation was expected as the speaker was a student of audiology and the common use of spon­ dee words in clinical practice may have influenced this produc­ tion. the energy values of the vowels in each syllable also indi­ cated a difference between syllable one and two. generally, a higher energy value was noted in the second syllable of the words with the exception of seven words. the difference in the energy values obtained may also be-due to the prosodic features of zulu, whereby in isolation, low tone verbs may indicate lengthening of the south african journal of communication disorders, vol 56, 2009 69 words indicated a more gradual slope than the words consid­ ered as most homogenous. the gradual slopes indicate that for these words to be identified correctly the words had to be pre­ sented at higher intensity levels compared to the words identi­ fied as being most homogenous. the results obtained in the present study, when compared to studies of other languages indicate both similarities and differ­ ences. table 4 provides a summary of the data obtained across different studies regarding the homogeneity of the word lists. i.e. low tone verbs. discussion no word pitch value syllable 1 pitch value syllable 2 difference in pitch between syllables energy value syllable 1 energy value syllable 2 difference in energy values between syllables 1 banga 107 113 6 67.83 73.9 10.1 2 gxeka 107 144 37 69.75 73 3.5 3 cinga 176 125 51 73.91 67.4 6.5 4 khanya 81 106 25 68.05 67.01 0.9 5 thela 106 135 29 60.3 68.8 8.5 6 khaba 108 132 24 69.12 75.4 6.2 7 kheta 104 125 21 55.1 60.9 5.8 8 jeza 79 152 73 69 69.18 0.2 9 donsa 139 93 46 69.9 69.31 0.6 10 khipa 85 121 36 66.38 72 5.6 11 chela 82 130 48 60.25 74.06 13.6 12 xola 109 131 22 66.64 60.3 1.3 13 yonga 88 104 16 70,28 69.26 1 14 yona 88 104 16 66.26 67.6 1.3 15 linda 87 98 11 65.91 66.08 0.8 16 veza 91 97 6 68.63 75.3 6.7 17 loya 106 127 21 72.06 63.6 8.5 18 thenga 151 141 10 60.2 46.1 14.2 19 wina 108 136 27 52.3 61.2 8.9 20 faka 81 106 25 68.63 75.8 72 21 washa 87 98 11 66.65 67.6 0.9 22 yeka 82 130 48 66.38 72 5.6 23 minya 105 151 46 49.2 56.9 7.7 24 thola 96 130 34 66.64 70.81 4.2 25 shada , 85 121 36 70.26 74.81 4.6 25 shada ' 85 121 36 70.26 74.81 4.6 26 thata j 85 127 42 68.63 74.81 6.2 27 qonda jl0 7 139 32 69.75 72.81 3.1 28 geza 1109 146 37 66.71 69.1 7.4 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) seema panday, harsha kathard, mershen pillay, cyril govender 'researcher/s language type of stimuli and number of words evaluated scale of measurement mean slope @ 50% present study zulu bisyllabic verbs (28) dbhl 5.98%/db (6%/db) hudgins et al. (1947) english bisyllabic s p o n d e e s (36) db 7.2%/db young et al. (1982) english bisyllabic spondees (15) dbspl 10%/db c ardenas & marrero (1994) spanish trisyllables and fo u r syllables (24) db 8%/db c hristensen (1995), as cited in nissen e t al. (2005) spanish trisyllables (12) db 11.1 %/db g reer (1997), as cited in nissen e t al. (2005) italian trisyllabic db 7.3%/db ~ nissen et al. (2005) m andarin t risyllabic (24) db 11.3%/db nissen e t al. (2008) taiwan m andarin bisyllabic db 9.6/db table 4. overview of the mean slope values across studies. table 4 indicates that there are differences in the slope at 50%/ db across languages. the mean slope at 50% for the studies that utilized trisyllables compared to the bisyllables appear to be steeper e.g. 11.3%/db in the nissen et al. (2005) study compared to the 6%/db in the present study. the steepness of the curve, however, is directly influenced by the type of stimuli used (kruger & kruger, 1997). in addition, the number of syllables in the stimuli influences the steepness of the slope. trisyllabic or polysyllabic words are more redundant than bisyllabic words. redundancy in speech audiometry is defined as “ the abundance of information available to the listener due to substantial content of the speech material and the capacity of information inherent in richly inner­ vated pathways of the central system”( stach, 2003 p. 227). thus, the abundance of information present within the speech signals of trisyllables or polysyllables allows for the words to be heard at softer levels, contributing to a steeper slope (stach, 1998). furthermore, while the concept of redundancy is not highlighted as a criterion in the selection of srt materials, stach (1998) warns that the more redundant the stimuli is, the more immune the sig­ nal is to detecting a hearing loss. therefore, the current research­ ers maintain the argument in support of using less redundant stim­ uli in the present study, i.e. bisyllabic zulu words, as they may be more sensitive than trisyllabic or polysyllabic words in determining srt. notwithstanding the differences obtained in the present study compared to other languages, the aim of determining which of the 58 preselected zulu words met the criterion of homogeneity of audibility was realized in this investigation. an accurate replica of scores for the slope at 50% between and among studies is not possible, as languages used are different and the methodologies followed were different in determining the slope at 50%. another explanation for the more gradual slopes obtained in this study compared to the earlier studies conducted in english could be related to the differences in the linguistic structure of the lan­ guages. the use of spondees with equal stress explains the ease of identification at low intensity levels. brandy (2002) confirms this by stating that the performance intensity function for spondaic words is very steep. the average level for 100% correct recognition to be obtained would usually occur at 27.5dbspl (7.5dbhl). this is supported by earlier statements made by egan (1948) that spon­ dees have the highest homogeneity of audibility in comparison to other stimuli. it has also influenced subsequent researchers i.e. ashoor & proshazka,1985; plant, 1990; harris et al. 2001; nissen et al. 2005 to confirm homogeneity of audibility in their studies by drawing comparisons that are very closely related to the spondee words in english. the criterion to assess the steepness of the slope for languages that do not have spondees e.g. zulu, may however need to be al­ tered. this is based on the fact that the zulu words are different in stress pattern and structure to those of english, so the reference data used to evaluate the steepness of the slope should also be different. there is a strong possibility that the normal hearing zulu first language speakers in the present study may have had difficulty identifying the bisyllabic words in zulu due to the lack of promi­ nence of the first syllable, but required the intensity of the signal to be slightly higher for 100% recognition. this could, therefore, serve as a possible explanation for the mean threshold intensity for 100% correct recognition in the present study being 9dbhl. in addition, the morphological structure of the bisyllabic verbs usually has a /-a/ bound to the verb root (rycroft & ncgobo,,1979). i the presence of the /-a/ sound in the second syllable together with the prominent high tone may account for the poor recognition of the first syllable. thus, under difficult listening conditions, recogni­ tion of the first syllable may have been compromised, because of the lack of similar acoustic and morphological cues in the first syllable compared to the second syllable (chetty, 1990). scrutiny of the performance intensity curves for the zulu words indicates that the words that had the click sound jn -th e first sylla­ ble e.g. /qonda/ and /gxeka/ had the steepest slopes at 50% i.e. 15.425%/db and 7.5 %/db respectively. these click sounds carry a higher spectral energy content acoustically, and thus, could account for the greater recognition of these words at the lower intensity levels. however, the words such as /finya; dinga; lima/ 70 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the hom ogeneity of a ud ib ility and prosod y of zulu w ords for speech reception thr esh old testing appeared to have had more gradual slopes at 50%. these words may be regarded as softer due to the fricatives and lower inten­ sity vowel sound /i/ being used. the variation in the acoustical energy content of the consonants and vowels of zulu may there­ fore have implications for the steepness of the slope. chetty (1990) briefly alludes to the influence of the acoustic properties of vowels and consonants on the steepness of the curve. within the present study, it would appear that the acoustic properties of the vowel and phoneme combinations could have contributed to the slope patterns observed. apart from chetty (1990), previous researchers have not referred to the influence of the energy con­ tent on the steepness of the slope. however, the present re­ searchers are of the opinion that for a language like zulu, the argument is relevant and worthy of noting. this point introduces a new lens through which homogeneity with respect to audibility is viewed in languages where spondees are not available. further, qualitative comments made by participants indicated that they often heard the second syllable at the lower intensities, but had difficulty with hearing the first syllable. this reinforces the possi­ ble influence of prosody on the steepness of the slope. apart from the possible lower acoustic energy of the first sylla­ ble, the actual recording of the materials could have also affected the performance of the listeners. nissen et al. (2005) explain the importance of high quality digital recording in the development of materials for srt. while every attempt was made to adhere to this recommendation in the present study, the recording of the words in terms of vu meter peaking were +/-2db across the words. manual adjustments had to be introduced to the vu set­ tings between the calibration tone and the words. furthermore, the six randomizations were individually recorded due to a lack of i software to help to randomize the recordings automatically. i these limitations in recording, could have possibly affected the performance of the listeners with regard to the recognition of the words (refer to panday (2006) for further explanation about the recording process in this investigation). i despite the resource constraints and time limitations of this study, all data obtained were verified at several levels of analysis and therefore, remain reliable. perhaps an implication of this would be to re-record the most homogenous words after introduc­ ing an intensity adjustment digitally. this has been done histori­ cally and more recently by nissen et al. (2005): the variability of the curves is reduced and the steepness of the curves is im­ proved. this could also account for the reason why the slopes obtained in the nissen et al. (2005) study were similar to the data obtained in the original english studies. from a methodological perspective, homogeneity of audibility has been assessed using different mathematical, statistical and procedural methods. young et al. (1982) have raised the histori­ cal discrepancies noted in the english word lists regarding homo­ geneity of audibility. these researchers articulated concerns re­ garding the definition of homogeneity. earlier studies (bowling & elpern, 1961; curry & cox, 1966; beattie et al. 1975) reported on the intensity level at which words were first identified correctly, and made no provisions in their analysis if the word was missed in subsequent presentations (young et al., 1982). in addition, the rate at which words were intelligible was not specified in the ear­ lier studies. the present study considered these earlier limita­ tions and utilized a more stringent mathematical model to calcu­ late accurately the threshold of intensity and the slope of the psychometric function, taking into account the performance of participants across all lists. in addition, the rate at which words became intelligible can be easily calculated using this model. the model has also been described by nissen etal.(2005). while the present study followed a 5db change in the intensity levels, the studies discussed above, including the nissen et al. (2005) study used a 2db intensity change. the use of the 5db intensity change was adopted so as to maintain a consistent pattern with the manner in which srt is usually established (gelfand, 1997). the difference in intensity change, however, could account for the more gradual slope in the present study. the performance intensity curve with 2db levels would have more reference points for calculating percentage correct responses. the steepness of these curves would certainly improve the overall slope and shape of the curve. future studies should con­ sider decreasing the increments between the different intensity levels, thus ensuring that many more levels are assessed. another issue to be considered is the learning effect. young et al. (1982) articulated concerns regarding the learning effect that could unfold if the same words are presented with several ran­ domizations at the many reference levels discussed above. while the use of randomization is considered to eliminate the learning effect, one could also argue that with 13 presentations of the same words to a participant, there is a strong possibility that the participants learn the words and their performance would there­ fore appear better. this could also account for the excellent per­ formance noted in the nissen et al. (2005) study. given the above, careful consideration must be afforded to the choice of intensity level changes and the number of randomizations se­ lected. while the possibility of improving the performance curves exists, the potential impact of ‘the learning effect’ requires fur­ ther investigation. in summary, it is clear that selecting homogenous words in any language presents a challenge. several factors can influence and affect the outcome. these may well include the linguistic, meth­ odological and procedural variables. these challenges reinforce the need for the adaptation of the original criteria for srt, at many levels, when materials are developed and selected for srt testing. the reference data for evaluating homogeneity of audibil­ ity in english simply cannot be applied stringently to that of zulu the south african journal of communication disorders, vol 56, 2009 71 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) seema panday, harsha kathard, mershen pillay, cyril govender or any other language. the concept of homogeneity of audibility is achievable in any language, but the criterion used to select the most homogenous words must suit that language. this study described the selected words acoustically via an acoustic analysis system. the information obtained for the pitch contours is relevant to the present study. the majority of the words analyzed (25/28), indicated a similar pitch contour i.e. there was a difference in the pitch between the first and sec­ ond syllable. syllable one was consistently lower in pitch than syllable two. these findings follow the prosodic patterns of the zulu words selected i.e. low tone verbs. similarly the energy con­ tours of the vowel sound in each word indicated differences be­ tween the two syllables. however, the patterns for 3/28 words indicated that the first syllable was higher in pitch than the sec­ ond syllable. this finding could have been influenced by the speaker placing artificial stress on the first syllable, similar to a spondee word. a possible recommendation for future research would be to ensure that several recordings of the words are made and judged by listeners of the language before the final recording is accepted. this is supported by nissen et al. (2005). nevertheless, the overall similarity between the pitch contours and energy contours for the majority of the words confirm that not only are the words homogenous in terms of linguistic and audiological variables, but most of the words were acoustically homogenous too. in addition, the use of the acoustic analysis to confirm the prosodic features in the language may be seen as an additional method for selecting words for srt testing. this ap­ proach was clearly supported by plant (1990), whereby spectro graphic analysis supported the stress patterns of trisyllabic words in tiwi. the application of acoustic analysis in the development of speech materials is in its infancy. however, the findings of the present study support the inclusion of acoustic analysis together with measurement of homogeneity of audibility as suitable ‘tools' to be used in the selection of words for srt testing. conclusion the findings in this investigation have important implications, both clinically and in terms of future research in the field. the constitution of the republic of south africa (act 200 of 1993), as amended by act 109 of 1996, clearly confirms the importance of the eleven official languages of the country and the linguistic rights of individuals. in this context, the present investigation could be seen as a step towards the selection of srt materials that are appropriate, relevant and scientifically designed to cater for the audiological needs of zulu first language speakers in kzn. similar research needs to be considered for the other official languages in south africa, apart from english. in terms of the diagnostic significance, it is clear that the meas­ urement of srt is fundamental to the initial audiological process. however, the value of the test is lost when the materials used are not appropriately selected. in fact, the danger of over and under­ diagnosis is evident. thus, research of this nature provides the necessary steps towards improving the service delivery for zulu first language clients in kzn. however, while the selection of an appropriate srt word list was achieved in this study, the data obtained is limited to the adult normative population. hence, there is a need for future research in terms of the wider clinical population. references agresti, a. 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(2000). speech reception thresholds for non-native speakers of english: digit pairs vs spondee words. unpublished doctoral dissertation, university of illinois, urbana champaign, illinois. ramkissoon, i., proctor, a., lansing, c. & bilger, r. c. (2002). digit speech recognition threshold (srt) for non-native speakers of english. american journal of audiology, 11, 23-28. robinson, d. d., & koenings, m. j. (1979). a comparison of procedures and materials for speech reception thresholds. journal o f am erican a u d io lo g y society, 4, 227-230. roeser.j. r., valente, m., & horsford-dunn, h. (2000). audiology diagnosis. usa: thieme medical publishers. rycroft, d. k., & ngcobo, a. b. (1979). say it in zulu. pietermarizburg:university of natal press. schill, s. (1985). threshold for speech. in j. katz (ed.), handbook of clinical audiology. baltimore: williams & wilkins. silman, s., & silverman, c. a. (1991). audiology diagnosis. principles and practice. new york: academic press. i stach, b. a. (1998). clinical audiology: an introduction. san diego: singular publishing. stach, b. a. (2003). comprehensive dictionary of audiology llus trated. canada: library of congress. wilson, r.h., zizz, c.a., shanks, j. e., & cuasey, g. d. (1990). norma­ tive data in quiet broadband noise, and competing message for northwestern university auditory test no.6 by a female speaker. journal of speech hearing disorders, 55, 771-778. young, j.r., dudley, b., & gunter, m. b. (1982). thresholds and psy­ chometric functions of the individual spondaic words. journal of speech and hearing research, 25, 586-593. the south african journal of communication disorders, vol 56, 2009 73 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.lmd.ucla.edu/drofiles/drofz01.htm seema panday, harsha kathard, mershen pillay, cyril govender appendix a pure tone average scores n pta(right) pta(left) 1 .00 .00 2 5.00 .00 3 13.30. 8.30 4 .00 .00 5 6.67 6.67 6 .00 .00 7 .00 .00 8 .00 -5.00 9 .00 .00 10 .00 -5.00 11 15.00 .00 12 .00 10.00 13 5.00 5.00 14 6.67 3.33 15 .00 .00 16 .00 .00 17 5.00 6.67 18 .00 .00 19 .00 .00 20 .00 .00 21 .00 .00 22 3.33 .00 23 5.00 5.00 24 3.33 5.00 25 13.33. 11.67 26 5.00 5.00 27 5.00 5.00 28 5.00 5.00 29 0.00 0.00 30 5.00 5.00 some basic background on the logistic model: since the binomial distribution is used, we might expect that there will be a relationship between logistic regression and chi square analysis. it turns out that the 2x2 contingency analyses with chi-square is really just a special case of logistic regression. with chi-square contingency analysis, the independent variable is dichotomous and the dependent variable is dichotomous. logistic analysis does not restrict the independent variable to be dichoto­ mous. generally when one uses binary data the linear regression is not an appropriate model at all, in fact the data usually takes on an s-shaped curve. our statistical effort to transform the s-shaped curve to a linear one requires us to employ the logistic distribu­ tion. figure: 1. s-shaped linear approximation to logistic re­ gression curve. for a binary response y and a quantitative explanatory variable x, we allow p(x) to show the probability of a success when x takes on any of its values for example in our data let x represent the sound intensity levels and y denote the success or failure (audible or not respectively.) then when x = 10, mathematically we write, ap p end ix b: fifty eight words considered for assessment banga hlala loya veza bheka hleka lunga vula bhema hlenga minya vuma chela hluba pheka washa cinga hola phonsa wina dansa jaha qoba xola dinga jeza sefa yanga donsa khaba shada yeba faka khanya shaya yeka finya kheta thanda yenza geza khipa thatha yifa goba landa thela yona gonda letha thenga yosa gqoka lima thola gxeka linda vala appendix c motivation for logistic regression logistic regression: p(x) = prob(y|x). read, the probability of y given x. we also define the odds of success as: p ( x ) odds = l p ( x ) the log of the odds is known as the logit. the simple logistic model is of the form, (for only one explanatory variable, x): logit[/>(x)] = log (i) / p(x) n lp ( x ) = a + fix this transformation, namely the logit (log of the odds), yields a linear function of the explanatory variables x. estimation of the 74 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) parameters of interest in the logistic regression is done similarly to linear regression once the transformation has been applied. that is, we will have estimates for a and (5 which represent the intercept and slope respectively (these are generally calculated by some software package). solving for p(x) in equation (1) above gives, the h om ogeneity of a u d ib ility and prosody of zulu w ords for speech reception thr esho ld testing a + fix p(x) = 1 + e a + fix (2) therefore, p is the proportion correct at any given intensity level. by inserting the intercept and slope into equation (2) we can pre­ dict the percentage correct at any given intensity level. any line drawn tangent to the curve in figure 1, has a slope equal to p*p(x)*[l p(x)]. the steepest slope occurs at p(x) = 0.5. the x value at this slope is usually called the threshold, (intensity re­ quired for 50% intelligibility). a simple equation to calculate threshold is given by x = log ( p / l p ) a p (3) at p = 0.5, a x = ■ p (4) db level exp(a + word a p (x) p) 0.05028 p(x) geza ■1.85 0.228 -5 744 0.08892 0.04788 geza -1.85 0.228 -2.5 162 0.15723 0.08166 geza -1.85 0.228 0 717 0.27803 0.135873 geza -1.85 0.228 2.5 73 0.49164 0.21755 geza -1.85 0.228 5 42 0.86935 0.329599 geza -1.85 0.228 7.5 824 1.53725 0.465057 geza -1.85 0.228 10 752 2.71828 0.605874 geza -1.85 0.228 12.5 183 0.731059 4.80664 geza -1.85 0.228 15 819 0.827784 8.49943 geza -1.85 0.228 17.5 763 0.894731 15.0292 geza -1.85 0.228 20 755 0.937614 26.5757 geza -1.85 0.228 22.5 727 0.963736 46.9930 geza -1.85 0.228 25 632 0.979164 from (4) above we can work out the threshold value example of calculation: p 0.228 estimates of a and (5 are obtained from software package being used (here spss). let us consider the word geza at sound inten­ sity level x = 5. the slope at 50% (p(x) =0.5) or at threshold (x=8.1140) is given by the formula: geza p(v= ea+px e18̂ 22̂ 0 .4 9 1 6 4 4 2 ft , ~ l+ e -u*w [*) ~ 1 .4 9 1 6 4 4 2 i a -1.85 p 0.228 p (x )[l 7?(jc)]/?100 = 0.5(1 0.5)(0.228)100 = 5.7 therefore the level at which audibility has a 50% chance occurs at 8.114 db for the word geza. the plot of p(x) vs db level (x) gives the logistic curve below, g eza thus the logistic model is of the form and p(5) is thus we have the proportion correct at the 5db level. for the lodb level substitute x= 10 in the above. for the 15db level substitute x=15 in the above, and so on. until we arrive at a list like the one below. 1.2 1 0 .8 0.6 0.4 0.2 0 -i ■ s e r i e s l calculations for the other words continue in a similar way. the south african journal of communication disorders, vol 56, 2009 75 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) abstract introduction the lexicon: nouns and predicates bantu language acquisition aims and objectives ping assessment tool methods main study ethical considerations results discussion acknowledgements references about the author(s) ramona kunene nicolas department of linguistics, university of the witwatersrand, south africa saaliha ahmed department of linguistics, university of the witwatersrand, south africa citation kunene nicolas, r., & ahmed, s. (2016). lexical development of noun and predicate comprehension and production in isizulu. south african journal of communication disorders, 63(2), a169. http://dx.doi.org/10.4102/sajcd.v63i2.169 original research lexical development of noun and predicate comprehension and production in isizulu ramona kunene nicolas, saaliha ahmed received: 10 june 2016; accepted: 24 june 2016; published: 28 july 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract this study seeks to investigate the development of noun and predicate comprehension and production in isizulu-speaking children between the ages of 25 and 36 months. it compares lexical comprehension and production in isizulu, using an italian developed and validated vocabulary assessment tool: the picture naming game (ping) developed by bello, giannantoni, pettenati, stefanini and caselli (2012). the ping tool includes four subtests, one each for subnoun comprehension (nc), noun production (np), predicate comprehension (pc), and predicate production (pp). children are shown these lexical items and then asked to show comprehension and produce certain lexical items. after adaptation into the south african context, the adapted version of ping was used to directly assess the lexical development of isizulu with the three main objectives to (1) test the efficiency of the adaptation of a vocabulary tool to measure isizulu comprehension and production development, (2) test previous findings done in many cross-linguistic comparisons that have found that both comprehension and production performance increase with age for a lesser-studied language, and (3) present our findings around the comprehension and production of the linguistic categories of nouns and predicates. an analysis of the results reported in this study show an age effect throughout the entire sample. across all the age groups, the comprehension of the noun and predicate subtests was better performed than the production of noun and predicate subtests. with regard to lexical items, the responses of children showed an influence of various factors, including the late acquisition of items, possible problems with stimuli presented to them, and the possible input received by the children from their home environment. introduction research on the emergence of early lexical comprehension and production is very important for both enhancing our understanding of language acquisition and diagnostic purposes. in the south african context, improving numeracy and literacy skills remains a huge challenge in the public education sector (department of basic education, 2014). language policies favour l1 learning in the foundation years (ages 6–9 years), yet psycholinguistic measures of children’s competencies are not included in either educational or political initiatives. existing literature is very limited regarding the cognitive performance of children who speak a south african indigenous language (also linguistically classified as a bantu language) in their early language acquisition. the other challenge is finding locally appropriate standardised tools that are relatively easy to use in any given language. it is heartening, however, to note that several researchers in speech and language therapy have adapted several international standardised tests to the local context and are starting to include crucial information in the measurement of children’s typical and atypical development. having normative data allows for interventions in delayed or impaired language as well as effective language teaching and learning (kathard et al., 2011; pascoe & smouse, 2012). despite an increase, there are still too few academic studies on the comprehension and production of south african bantu languages. those available include studies focusing on phonological development (gxilishe, 2004; pascoe & smouse, 2012); nominal morphology (gxilishe, 2008); morphosyntactic development of the noun classes (kunene, 1979; tsonope, 1987); the development of the passive construction (bortz, 2013; demuth, 2003); and pragmatic development in late language acquisition (kunene-nicolas, 2015). although these studies have greatly advanced our knowledge of less-studied languages, no one has managed to present comprehensive linguistic research on the developmental aspects of the lexicon inventory of the bantu-speaking child, similar to that regarding children who speak western languages, such as english, french, and italian. researchers tend to focus on particular aspects within linguistic theory (berko gleason & bernstein ratner, 1993, pp. 326–327). to date, the available literature on early language acquisition has confirmed, through the study of many languages from different language typologies, that certain stages of language acquisition are universal (harley, 2014). it is, therefore, widely accepted that all children begin their trajectory towards language through comprehension, while their motoric and cognitive apparatus lags in terms of language production. this study seeks to investigate the development of noun and predicate comprehension (pc) and production in isizulu-speaking children between the ages of 25 and 36 months. the study is part of an international research collaboration that aims to investigate speech and co-speech gesture production and comprehension development in children. it compares lexical comprehension and production of two romance languages, italian and french, and two south african bantu languages, isizulu and sesotho, using an italian developed and validated vocabulary assessment tool. this paper presents the preliminary findings of the lexical development of isizulu speakers. the lexicon: nouns and predicates we use words to communicate about everything related to our physical environment, including events, activities, people, objects, places, relations, properties, and states of being (clark, 1995, p. 1). words stored by language users are drawn from the lexicon that can also be understood as our mental dictionary. bates and goodman (1997) found that, as children transition from the first word stage to sentences and extended discourse, while learning productive control over the basic morphosyntactic structures of their native language, the emergence and elaboration of grammar are highly dependent upon vocabulary size. the lexicon is therefore linked to phonology, comprehension and production, and grammar (gentner, 1982). the child’s lexicon is dependent on the development of meaning construction and categorisation skills (markman, 1991). measuring comprehension and production of nouns and predicates is increasingly used as an important diagnostic and prognostic tool in atypical populations (stefanini, bello, caselli, iverson & volterra, 2009). as such, the macarthur communicative development inventory (cdi) was initially developed to study the relationship between the lexical and grammatical development of english-speaking children (bates, dale & thal, 1995; fenson et al., 1994; fenson, marchman, thal, dale & reznick, 2007) but has since been adapted for use in more than 62 languages. it is well documented that typically developing children are accurately able, by 3.5 years of age, to produce most of the basic morphosyntactic structures of their languages such as relative clauses, the passive construction and other complex forms (bates & goodman, 1997; demuth, 2003). our present study seeks to look at one component of the lexicon: the comprehension and production of the nouns and predicate categories of words in isizulu. nouns and predicates are characterised by differences in their perceptual and cognitive complexity (davidoff & masterson, 1996; gentner, 1982; gentner & boroditsky, 2001), which leads to distinct mental representations (slobin, 2008). in the cross-linguistic study by caselli et al. (1995) the authors highlight the noun-verb sequence in early acquisition as proposed by the ‘whole object constraint’ (markman, 1991). gentner (1982) reported the late appearance of verbs, which are more complex in structure than the underlying semantic structure of nouns. o’grady (1987) pointed out that nouns are used as ‘arguments’ or ‘primaries’ that refer to entities or a class of entities, whereas verbs and adjectives are often used as predicates or ‘secondaries’ (caselli et al., 1995, p. 162). this means that, for a child to produce verbs and adjectives successfully, nominal arguments have to be in place. the acquisition of verbs will therefore be affected by the child’s mastery of nouns. these theoretical arguments, however, have been challenged recently by the appearance of language groups that show children mastering verbs at a faster rate in mandarin (cheng, 1994) and korean (gopnik & choi, 1995). literature does, though, confirm that verbs, adjectives, and function words appear later in early child acquisition (caselli et al., 1995). this study therefore seeks to document the development of the noun and predicate in isizulu. bantu language acquisition bantu languages are typologically similar and share several typical grammatical features. isizulu is a south eastern bantu language of the nguni cluster spoken primarily in south africa (especially the southeastern areas of kwa-zulu natal), but it also has speakers in neighbouring countries. isizulu is highly mutually intelligible with other nguni languages, such as isindebele, isixhosa, and siswati. in 2011, south africans citing isizulu as their home language numbered 11.5 million, or 22.7% of the population, the language that has the highest number of speakers (census, 2011). isizulu is a subject-verb-object (svo) language with a high number (about 15) of noun classes, triggering the agreement of verbs, adjectives, and other elements. in other words, ‘nominal and verbal modifiers follow the noun and verb respectively, and grammatical morphology is prefixed to both nouns and verbs’ (demuth & suzman, 1997, p. 2). the subject can be dropped and it is therefore a pro-drop language as well (gxilishe, villiers & villiers, 2007; kunene, 2010; suzman, 1985, 1991). it has a very rich system of tense and aspect. these are expressed in a variety of simple tenses with optional aspectual affixes, compound tenses allowing composition of many of the simple tenses, and a large number of auxiliary verbs (buell, 2005, p. 6). demuth (2003, pp. 1–4) gives a thorough overview of south african bantu language acquisition studies of siswati, isizulu, isixhosa, setswana, and sesotho. most studies have looked at the noun class prefix and nominal agreement, consonants and clicks, acquisition of word order, relative clauses, and morpho-phonology (for a review on studies of bantu language acquisition, see demuth, 2003; and for a contemporary overview of studies on sa bantu language see gxilishe, 2008; pascoe & smouse, 2012). from existing literature, we know that child speakers of isizulu, sesotho, siswati, and isixhosa have fully acquired the nominal class system by the age of three years. we also know, from a study of isixhosa-speaking children (gxilishe et al., 2007), that the plural agreement is better produced than the singular subject agreement. despite the numerous studies on the isizulu verb (or related languages), we have not come across literature that documents the acquisition of verbs, adjectives, and adverbs or the noun and its morphology. studies on south african bantu languages are definitely increasing, but as yet there has been no study that has looked at simultaneous comprehension and production during lexical development. aims and objectives we focus on the lexical development of comprehension and the production of nouns and predicates from a speech perspective. specifically, this article seeks to explore the lexical development of isizulu using the adapted assessment tool with three main objectives. these are to: test the effectiveness of the adaptation of a vocabulary tool to measure isizulu comprehension and production development. test the universal finding that both comprehension and production performance increase with age for a less-studied language, isizulu. present our findings on the comprehension and production of the linguistic categories of nouns and predicates. ping assessment tool early childhood development research shows a strong interdependence between vocabulary, phonology, and grammar in both typical and atypical populations (marchman & thal, 2005; stoel-gammon, 2011). if children who show delays in their expressive vocabulary repertoires can be identified in time, this could assist in early intervention for children at high risk for language impairment, as shown in the studies by desmarais, sylvestre, meyer, bairati and rouleau (2008) ellis and thal (2008). constructed and validated in italy, the picture naming game (ping) was specifically developed to assess lexicon production and comprehension in children between the ages of 19 and 37 months, involving the consideration of both nouns and predicates, and based on the italian mb-cdi. previous studies have shown that it is extremely relevant to investigate the relationship between vocabulary comprehension and production as well as between nouns and predicates, as these skills and their relationships are indicators of both the level of language development and conceptual organisation. in general, studies using the ping tool with italian children proved that the comprehension subtests were easier than the production subtests, thus allowing for their administration in younger children and resulting in fewer errors. similarly, children found the noun subtests easier than the predicates subtests. therefore, lower variability was found in vocabulary comprehension compared with production, and in nouns compared with predicates for hearing children (bello et al., 2012; rinaldi, caselli, di renzo, gulli & volterra, 2014). the ping tool consists of two sets of colour pictures and contains two tasks; comprehension and production tasks which in turn contain four subtests. the first set has 22 images (20 test pictures and two pre-test pictures) of objects and tools, animals, food and clothing (e.g. a fork, a lion, bananas, gloves) and is used in evaluating the comprehension and production of nouns in the noun comprehension subtest (nc) and the noun production subtest (np), respectively. the second set contains 22 images (20 test pictures and two pre-test pictures) showing actions, location adverbs, and/or adjectives (for example, to push, close by or far away, big or small) and is used to evaluate the comprehension and production of predicates in the pc subtest and the predicate production subtest (pp), respectively. the original ping test for italian children was adapted from the italian mbcdi and the items had different levels of difficulty. it included items that were ‘easy’, ‘moderately easy’, and ‘difficult’, based on the italian normative sample (bello et al., 2012; pettenati, sekine, congestri & volterra, 2012; pettenati, stefanini & volterra, 2009; stefanini et al., 2009; stefanini, recchia & caselli, 2008). in this paper, we report on the adaptation of ping to isizulu. the ping tool has already been successfully adapted to other languages and cultures. for example, a study by pettenati and colleagues provided the first occasion for a cross-cultural comparison of gestures and vocabulary production and comprehension of 22 italian and 22 japanese children between 25 and 37 months of age (pettenati et al., 2012). the ping tool was also used to assess vocabulary production and comprehension in toddlers in a study carried out in australia by hall, rumney, holler and kidd (2013). the australian study focused on a group of 50 typically developing children between 18 and 31 months of age, investigating the interrelationship between play, gesture use, and spoken language development. methods stage 1: translation of the ping lexicon into the target languages translation of the set of nouns (20 target nouns in the comprehension task +20 target nouns in the production task +2 × 2 = 4 lexical items for the pre-tests) and the set of predicates (20 target verbs and/or adverbs and/or adjectives in the comprehension task +20 target verbs and/or adverbs and/or adjectives in the production task +2 × 2 = 4 lexical items for the pre-tests) was carried out in isizulu by the researcher, who is a native speaker of isizulu and a linguist, together with two isizulu-speaking research assistants, who are also linguists. the translation was further tested in a pilot study of native zulu adults for validation (see stage 2). of particular interest in the international collaborative comparative study is the different language typology of romance languages that are analytic and bantu languages that are agglutinative. in the initial adaptation, a conscious decision was made to adapt the protocol questions as closely as possible to the original italian version, that is, questions were to be ‘neutral’ so as not to give a clue to the answer. for example, in the italian version, the question would be translated to ‘show me running’, which does not provide any clue to the participant for the comprehension task and, therefore, the speaker cannot get a clue on the referent. a participant could choose any item he or she deemed fit. however, because of the noun class system, agreement concords, and morphosyntax structure of bantu languages, the question must have the relevant noun class and subject concord, which may give a clue to the item. for instance, in isizulu, a semantic translation for the above example would read ngikhombise ogijimayo (show me the person that is running): this would not allow a speaker to select a different card in the task because the question requires the speaker to select a card with a person who is doing something, for example, running. stage 2: pilot study with adults twenty two adults (11 males and 11 females) participated in the zulu adult pilot study. participants were drawn from the pre-dominant isizulu speakers of kwa-zulu natal, the south-east region of south africa. participants were university students from various communities in the kwa-zulu natal area, 60% of whom were from the empangeni area. the other 40% were from surrounding areas: pongola, harrismith, durban, eshowe, and pietermaritzburg. applying a neutral questioning style did not work. participants would reformulate the question or stop the interviewer to ask for more clarity. if the questions were amended, participants answered with no difficulty. the inclusion of the class prefixes did not affect the results but rather assisted the participant in understanding what was requested of him or her. this was indicated by the fact that once the correct class prefixes were used, the participants would indicate that they did not recognise an item, or they would give an answer if they did. with the neutral questions, the participant would simply halt the interview, seek clarification, and personally supply the class prefixes. when the interviewer asked why the participant reformulated the utterances, all participants stated that the ‘neutral’ utterances were grammatically correct, but ambiguous and confusing. it is interesting to note that all 22 participants corrected the utterances. agreement between participants was 95% for the comprehension subset and 86% for the production subset. four items under the np subset produced either no responses or ‘i do not know’ answers, referring specifically to bidet, radiator, penguin, and seal. under the pp, two predicate task words produced a low frequency of correct target words (spinning, heavy, far apart). stage 3: modification of the material from the adult pilot results, it became clear that the isizulu version of ping needed further adaptation before the pilot study with children was initiated. the adults seldom produced words in isizulu for ‘seal’ and ‘penguin’ and so these items were changed to ‘snail’ and ‘crocodile’, respectively. as both ‘radiator’ and ‘bidet’ are foreign cultural objects, these two items were replaced by ‘heater’ and ‘toilet’. some pictures were specifically cultural, such as the picture of the ‘roof’, which was a european type of roof, but in order to allow a systematic comparison with other languages in the four-language project, some items were retained for future adaptation. stage 4: pilot study with children after the changes to the above-mentioned picture items, a pilot study was conducted with 15 zulu children. the group included five children aged 25 months (±1 month), five children aged 30 months (±1 month), and five children aged 36 months (±1 month). this was done in order to test the corresponding adaptation of ping on a small sample in case further adaptation was needed before going onto the main study. participants were drawn from kwa-zulu natal, the same area where the adult pilot study was conducted. data was collected from the urban townships of empangeni and ngwelezane on the northern coast of kwa-zulu natal. the principals and caregivers were very helpful in providing the researchers with the children’s clinic cards. these vaccination cards aided the researchers in selecting participants for the appropriate age cohorts. the files provided by the teachers also gave the researchers additional information, including, for example, whether a child had been born prematurely or had a learning disability and needed to be excluded from the selected participants. we worked with nine crèches to ensure that our three age groups were exact. many crèches could not form part of our participant sample because those children were bilingual and would alternate between naming items in english and isizulu. we finally chose two schools from the city centre of empangeni and four schools in the ngwelezane township. administration of the ping tool began with a familiarisation phase that involved playing various card games, counting games, and naming games with the children. researchers also played with the children in the school playgrounds on the swings and slides. once the researchers felt that the children were comfortable enough, they asked the children to play a game with them in front of the camera. main study the main study for the isizulu data was collected from soweto in the gauteng province. the move from kzn was purely logistical as the researchers were all gauteng based. monolingual isizulu-speaking children were chosen with the help of their caregivers. children’s vaccination cards were examined to exclude premature babies or those with any recorded pathologies. all crèches require clinic or vaccination cards in order to enrol the child. the caregivers also assisted in selecting children, who they said showed no language delays in comparison to their peers. all selected children had parental consent (see the ethics section). forty-nine children from four neighbouring crèches participated in the study. nine children were excluded from the data sample for various reasons: some children did not complete the two tasks, some children were bilingual and code-switched regularly, some children spoke too softly for the camcorder to record sound, and one child was sleepy and had to go for a nap. for this study, 36 participants were chosen with 12 per age cohort in consideration of gender balance. there were a total of 19 females and 17 males across the different age cohorts (table 1). table 1: zulu participants age groups. procedure the procedure of this study followed those of previous studies (bello et al., 2012; pettenati et al., 2009, 2012; stefanini et al., 2008, 2009). the tool began with the comprehension task picture, followed immediately by the production-eliciting picture of the noun sets. there was a short break after the noun items and then the predicate items would be elicited, again starting with the comprehension task picture, followed by the production-eliciting picture of that set. the following section details the procedure that was followed in our study. after the familiarisation period, during which we played different card games with the children, all children were tested individually at their schools. three sets of pictures per set were presented to each child on a small table. the first part of the task was comprehension, in which a child was asked ‘where is the cat? show me the cat’ for a noun comprehension item or ‘what is this child doing? what is this one doing?’ for the pc item. the second part of the each subset was production, in which the child was asked, ‘what is this?’ for the np subset or ‘what is he doing?’ for the pp subset. the third card was a distractor to eliminate the choice by luck. a total of 22 cards were presented for the noun subtest, and another 22 cards were presented for the predicate subtest. the first two sets were pre-test cards to ensure that the child understood what was expected. the data was based on the remaining 20-card set per subtest. for the comprehension task, only one prompt was considered. for the production task, if the child struggled with producing the correct item, a second prompt was used. all elicitations were filmed for later data coding and analysis. two research assistants and the researcher of this study collected the data. all researchers are first-language, native speakers of isizulu, linguists with fieldwork experience in the collection of data from children. coding and transcription of the data the coding system was adapted from previous studies (bello et al., 2012 pettenati et al., 2012). all the children’s responses were coded later from the video data with an annotation system that was designed for the purpose of coding for gestures as well as for wordings from the child and the experimenter. all tasks administered to the children were coded on elan, a linguistic annotation tool created by the max planck institute (elan, n.d.; wittenburg, brugman, russel, klassmann & sloetjies, 2006). for the comprehension subtests (nc and pc), if the child indicated (either by pointing, showing, or verbalising) the photograph corresponding to the item indicated by the adult researcher, the answer was considered correct. if the child selected the no target photograph or did not respond at all, the response was coded as incorrect or no response, respectively. similarly, in the production subtests, if the child produced the target lexical item, their response was coded as correct. if the child produced a non-target item or did not respond at all, their response was coded as incorrect or no response, respectively. for some photographs, more than one answer was accepted as correct; for instance, for the ‘diaper’ item, some children called it ipampers referring to the brand of disposable nappies or ‘ikhimbi’ also referring to a brand of disposable nappies. for the production subtest, children were prompted twice if their initial response was incorrect. if a correct response was produced after the second prompt, the answer was considered to be correct. synonymous items were considered to be correct synonyms, for instance ilorri (a lorry) and itruck (a truck) for the truck item. responses that had a semantic relationship to the item depicted were coded as nts, no target, but semantically correct to measure if the concept was in place even though the production was not successful. incorrect responses occurred where the production was not the target response nor semantically related, for instance, isidudu (motorbike) for ‘truck’. validation and reliability three trained native isizulu-speaking research assistants and the researcher independently coded the verbal transcription, that is, orthographical transcription directly from the film footage. two different research assistants, who are also trained linguists, coded the classification of the speech responses as well as those of gesture. disagreements were resolved through discussion. after the annotation phase was completed, all data was exported to excel for an ultimate verification (internal consistency on the coding) and statistical analysis. ethical considerations ethical considerations guided the pilot study as well as the main study. all children who participated were recruited on a voluntary basis after their caregivers signed an informed consent form, which was provided in their language, and after they themselves agreed to participate at the start of the task (‘nouns’ or ‘predicates’). parents or members of the crèche were welcomed in the room during the administration of the tool. the tasks were interrupted or ended if a child verbalised a desire to stop, or expressed discomfort by crying and/or withdrawing. children’s identities were kept confidential, and data obtained from this project were not disclosed to any third party. the wits hrec non-medical ethics committee granted ethical clearance for the study (protocol number h13/08/43). results children’s responses were analysed according to the coding criteria listed in the method section. for our first objective, we analysed the comprehension and production tasks across the three age groups to test whether the ping assessment tool was effective in detecting the development of comprehension and production in isizulu. our second objective overlapped our first, and so our first finding addresses both of our objectives. for the comprehension and production tasks, an analysis of variance, anova, was run with the age group as the independent variable. the correct answers for the comprehension and production task items are illustrated in table 2. table 2: comprehension and production task scores per age group. a significant difference across the age groups emerged at (f[2.69] = 3.143, p < 0.05 for the comprehension task. post-hoc bonferroni analysis showed that the effect of age was significant at 0.05 among all age groups throughout the entire sample, but was not significant between the 25-month-old and the 30-month-old groups. similarly, for the production task, there was a significant age effect across the whole sample at (f[2.69] = 6.567, p < 0.05. post-hoc bonferroni analysis showed that the difference was not significant between the 25-month-old and the 30-month-old groups. however the 36-month group performed significantly better than the two younger groups at p < 0.003 to the 25-month group and p < 0.035 to the 30-month group. lexical item composition in order to test the comprehension and production tasks per lexical categories, we looked at the performance of the nouns and predicates across the age groups. we performed an anova between groups per lexical subset. the comprehension of the noun and predicate subtests was better performed than the production of noun and predicate subtests across the age groups. in table 3 and table 4, zulu children performed better at labelling the correct items for nouns (f[2,33] = 3.70, p < 0.04) than labelling the correct items for predicates (f[2,33] = 0.94, p < 0.40) with post-hoc test bonferroni confirming that there was a significant difference between the 36-month group and the 25-month group at p < 0.03. there was no significant difference between the 25-month and the 30-month groups, nor between the 30-month and the 36-month groups for the noun subtest. for the pc subtest, post-hoc bonferroni test confirmed that age had no significant effect, although there was a developmental trend between the different age groups. table 3: lexical comprehension noun and predicate subtest means (sd) per age group. table 4: lexical production noun and predicate subtest means (sd) per age group. for the production of nouns and predicates, we noted a similar pattern in that children performed better at labelling the correct items in the np subtest (f[2,33] = 7.4, p < 0.002) than in the pp subtest (f(2,33) = 0.96, p < 0.393). post-hoc bonferroni tests confirmed that there was a significant difference between the 36-month group with both the 25-month group and 30-month group, at p < 0.003 and p < 0.02, respectively. for the pp subtest, the post-hoc bonferroni test confirmed that age had no significant effect across the three age groups. the 36-month children had an equal chance of correctly labelling pp items as the children in the 25-month and 30-month groups, despite the developmental trend we observe in table 3 and table 4. percentage of correct responses per item for our third objective, we present our findings on the performance of the lexical items. in order to have a better understanding of the performance on the comprehension and production task, as well as noun and predicate subtests, we ranked the items in terms of correctness according to the total sample shown in table 5. table 5: percentage of correct answers for comprehension and production provided by (n = 36) children. comprehension task under the noun comprehension subtest, three items were perceived correctly by all 36 children; ‘doll’, ‘hat’, and ‘boots’ had a 100% response rate across all ages. five items had less than 50% success; ‘mountain’, ‘snail’, ‘elephant’, ‘bib’, and ‘hammer’, meaning that fewer than 18 children across the three age groups found these items ‘difficult’. the photograph of the mountain showed a rising mountain of the european alps, a type of geographical feature that is not commonly seen in south africa. it was interesting to note that the children had difficulty identifying ‘snail’ and ‘elephant’, but managed easily to identify the domestic animals such as ‘cow’. the ‘bib’ and ‘hammer’ were also not easily identified: the children gave answers that focused more on the baby who was wearing the ‘bib’ and did not respond at all to the ‘hammer’ or said, angazi (i do not know). under the pc subset, there were seven items that had less than 50% success; ‘walk’, ‘behind’, ‘close’, ‘full’, ‘outside’, ‘to embrace’, and ‘short’. some of the responses for ‘walk’ were uhamba kuphi (walking where?), as the picture showed a young boy walking along the passage of a house. the smaller children would either focus on the clothes the child was wearing or on the distractor card, which showed a young boy playing with toys. this performance did not show a developmental trend, which meant the 36-month-old children also had a similar chance of not perceiving or identifying ‘the walking’ from this picture. the item ‘embrace’ also produced some interesting comments across the age groups, similar to ‘kiss’ found in the pp subtest. the older the children, the more they avoided discussing intimacy with responses like bayaganga (they are being naughty) or they would simply avoid looking at the picture and focus on other pictures. the adjectives ‘short’, ‘full’, ‘outside’, and ‘behind’ were very difficult items that showed a distinct developmental pattern with responses that were semantically related, so for ‘short’, a child would say yincane (it is small) referring to a short pencil in the picture, and yet the prompt was for them to point to the object, which does not necessitate a verbal response. production task overall, production items scored lower than comprehension items, as seen in table 5. under the production subtests, for the np, the items ‘comb’ and ‘socks’ had the highest response rate at 92%, with children from all age groups correctly labelling these items. ten items had a success rate of less than 50%; the items were: ‘gloves’, ‘diaper’, ‘picture’, ‘truck’, ‘book’, ‘beach’, ‘lion’, ‘crocodile’, ‘roof’, and ‘flags’. the 36-month-old group was more familiar with the leather gloves depicted in the picture with most children saying izandla/into yezandla zikamama (hands or something for my mum’s hands). glove sizes in south african shops start for children who are about 4 to 5 years of age, and mittens are not commonly found. the older children labelled the item ‘diaper’ correctly, compared with the young children who tended to call it ipenti (a panty). the ‘picture’ item was also more familiar to the 36-month-old group, even though most children across the age groups identified it as a tv, because the picture looked like a flat screen tv. the picture depicted a lone beach with a blue sky, the ocean, and a strip of sand. the picture also garnered ambiguous responses from the adults in the pilot study. the item ‘truck’ produced the semantically related ‘a car or a bus or a big car’. this item did not display any developmental trajectory, as 36-month-old children were equally likely to produce ‘car’ rather than the target word itruck or ilori. the ‘book’ item mostly produced ibhayibheli (a bible) across age groups as well. the ‘beach’ item produced equally random responses, with children either focusing on the water in the photo or on the sky. the wild animals ‘lion’ and ‘crocodile’ produced very interesting responses such as ikgokgo (a monster) or some onomatopoeia sounds illustrating that ‘this is a scary thing that will eat me’. a few children avoided even looking at the picture or quickly pushed the card to the researcher. the ‘roof’ item depicted a european type roof and a portion of a house with trees surrounding it. most responses were either indlu (house) or isihlahla (a tree). this picture did not reveal an age pattern because the responses were random. the item ‘flags’ was extremely difficult, with no child giving a correct response. most responses were iafrica (africa) or yiduku (head scarf), and these semantically related responses increased with age. in the pp subtest, the following seven items were difficult for the children: ‘to turn’, ‘empty’, ‘in front of’, ‘heavy’, ‘far’, ‘inside’, and ‘long’. the item for ‘to turn’ depicted a group of children on a merry-go-round. children’s responses included bayadlala/bahleli (they are playing or they are sitting). this response did not reveal a developmental trajectory because the responses were random across all age groups. for the adjectives and adverbs ‘empty’, ‘in front of’, ‘far’, ‘inside’, and ‘long’, the responses did not show correct labelling across all ages. these items showed a developmental pattern when considered in the light of that the responses showed that the children acquired this concept with age. interestingly enough, five of these items were in the same set at the pc subtest, which shows consistency in the production of these categories. all the children had difficulty perceiving the item ‘heavy’. this item depicted a young child carrying a brown torn box while grimacing. children’s responses focused on the child or the box being torn. discussion our study begins with an italian picture naming assessment tool being adapted to a bantu language, isizulu. the tool is designed to directly observe the lexical composition of vocabulary in two related tasks; comprehension and production. to our knowledge, most studies on isizulu or related bantu languages have either directly observed either comprehension or production, but never both at the same time. several pilot studies in both adult and children populations enabled us to alter obvious elements of cultural bias. although some other problematic items remained, we decided to preserve our initial goal by keeping as many items as necessary for our systematic comparison with two romance languages, italian and french, as well as another south african bantu language, sesotho. certain items such as the picture of a ‘roof’ did not depict a ‘roof’ as seen by many south african children. some items such as ‘to turn’, which depicted a merry-go-round produced unexpected results in that one would expect most children to have been exposed to a merry-go-round as these are commonly found in parks, but instead the children focused more on the people in the picture than on what they were doing. despite the cultural differences that may have stemmed from the images of our stimulus, we note that our findings confirm what has been long documented in literature: that comprehension comes before production. in a related cross-linguistic comparison, japanese children showed a lower lexical production compared with the italian children (pettenati et al., 2012) which resulted in the authors finding that cultural factors could influence the design of the test which was originally for italian children. in terms of development, our results show how age affects both comprehension and production: 36-month-old children performed better than 30-month-old children who in turn performed better than 25-month-old children. our statistical analysis did not discern a significant difference between the 25-month-old group and the 30-month-old group for comprehension, but it detected a significant difference between the 36-month to the 25-month and 30-month groups in terms of production. this was not surprising as, in the first study by bello et al. (2012), it was found that noun comprehension increases between 19 and 30 month, followed by a plateau. the zulu children also showed this plateau, which meant there was little difference between the 25-month and 30-month groups. the pc showed a similar trend, even though the scores were lower than those of the noun comprehension. it is, however, very interesting to note that there was no significant difference in pc among the groups, which may mean that predicates in this task, with the exception of adverbs and adjectives, may be mastered earlier. gxilishe et al. (2007) found that isixhosa-speaking children between 24 and 30 months correctly employed subject agreement markers on different verb roots. in terms of production, our findings showed an overall effect of age, which meant that production does indeed lag behind comprehension. moreover, the larger number of culturally foreign pictures in the noun comprehension subtest suggests that it may be necessary to further adapt the assessment tool to more effectively evaluate the isizulu lexicon. children used a semantic description strategy to try and explain unfamiliar items, which shows that though they may have the concept, the lexical item is not ‘concrete’ enough for them to relate to their physical environment. if perception is difficult, it is harder to retrieve the semantic representation from the lexicon and, as such, retrieval will be impaired (harley, 2014). the production of the noun category showed an age effect but the predicate category did not show a similar difference. the higher number of adverbs and adjectives in the pp subtest was difficult for all the age groups, which could explain the lack of a significant difference. alternatively, if verbs are acquired earlier, it shows that the children have reached a plateau phase between the ages of 24 and 36 months. further research on the vocabulary spurt in isizulu would shed more light on this issue. limitations the lack of a child inventory like the macarthur bates cdi for isizulu and related languages is a disadvantage. we have no idea which items are acquired first, nor do we have the exact age of the vocabulary spurt in isizulu. future analysis should look at the gender effect. although gender-related data is available in this study, it has not yet been analysed. it would be interesting to see whether girls have an advantage over boys, as has frequently been reported in western languages. conclusion developing normative lexical data on zulu-speaking children or those speaking other related bantu languages is important for research for both acquisition and clinical purposes. finding a standardised assessment tool that can be used for south african bantu languages is an ongoing challenge. the ping assessment tool has proved to be robust and effective in directly assessing a child’s lexical vocabulary. for further research into isizulu, the tool would need further adaptation by replacing some images with items of local content. the literature states that children begin with language comprehension and, when the motoric and cognitive apparatus develops, language production follows suit. this is a universal linguistic parameter. children start with objects and events around their immediate environment and quickly learn people’s names, concrete objects around them, and familiar routines coming from their home environment. the first words will therefore largely depend on this input, and cultural as well as linguistic constraints may affect this development. this study shows that as children get older, comprehension and production improve. it would therefore be very important for researchers or speech therapists to factor input into their intervention therapies. children will understand and talk more about what they know and what surrounds them. some linguistic phenomena like adjectives and adverbs are complex and not yet acquired by the zulu child at 36 months. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions r.k.n. was the project leader and was responsible for the experiment, data collection and data management. s.a. performed most of the coding, prepared the samples, and contributed to the conceptualising and analysing of the data samples. a qualitative analysis was done by both authors. references bates, e., dale, p.s., & thal, d. 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(r.c.p. & s.) registrar, johannesburg general hospital. it is only recently that a method for measuring hearing in terms of speech discrimination has p a s s e d from the field of laboratory research to the practical field within easy reach of the practising otologist. we may well ask how large a part machines are entitled to play in the practice of medicine and i have heard audiometry condemned by one of the eminent american otologists on the grounds that it does not make a diagnosis and it is not necessary in the treatment of ear disease. in both respects i think he is wrong, but his being wrong is not quite a s obvious a s his being right appears to be. the majority of cases of meniere's disease may be diagnosed on the history alone. nobody, however, would think of making a diagnosis of the disease without carrying out a complete clinical examination of the patient, including tuning fork tests. nobody should diagnose the condition without carrying out tests of labyrinthine function. and, when all this has been done, there will remain a small number of c a s e s in which audiometry gives the final clue to diagnosis when the other tests have failed. the course of disease is of tremendous importance in its treatment and in assessing the progress of hearing or of deterioration of hearing, audiometry plays perhaps an even greater part than it does in the diagnosis. modern neuro-otology, a s this branch of surgery is called by cawthorne, would scarcely be justified if it were not' for our ability to measure and record patients' hearing. speech audiometry by itself is not a complete measurement of hearing ability and in the first place pure-tone audiometry should be employed. there are a great many advanta g e s to the use of speech audiometry but unfortunately it cannot provide all the answers usually required in assessing hearing. the disadvantages of speech audiometry are for the most part of a technical nature. it is easy, for instance, to obtain a perfectly satisfactory pure-tone audiogram from an unintelligent subject. in fact, my experience has been that the unintelligent subject usually gives a more consistently reproducible audiogram than the intelligent, introspective type of person. if standard, comparable results are to be obtained in speech audiometry, the subjects must be reasonably intelligent and, to a certain extent, educated. in this regard, i must mention the speech audiograms that were taken of a professor of l a n g u a g e s at one of the american universities. his mother tongue was german but he taught in english and french and spoke all three l a n g u a g e s fluently. in spite of this the speech audiograms in the three l a n g u a g e s showed a very much better discrimination for the german word lists than for either of the other two. here w a s a highly educated, intelligent man whose audiograms for the extra languages might have been interpreted a s showing a hearing loss when there was none in fact. in exactly the same way, differences in dialect may give results in speech audiometry for uneducated subjects which are not commensurate with the pure-tone audiograms. to overcome these difficulties to a certain sxtent, the monitored live voice may be employed instead of calibrated records but this does not altogether obviate the undersirable features of the test. it becomes obvious now that assessment of hearing must be done with pure-tone and speech audiograms side by side. a good exercise is to forecast the speech audiogram after examining the amount of residual hearing for the accepted speech frequencies on the pure-tone audiogram. this can usually be done with a fair degree of accuracy in the c a s e of conductive deafness. with many cases of perceptive deafness, however, the forecast is found to be grossly inaccurate and this applies particularly in those cases exhibiting the phenomenon of recruitment. here it is of interest to mention that an intelligent adult can obtain a high discrimination score even if he has no hearing for frequencies above 500 c.p.s. using the master hearing aid such a s that used for research in hearing aids by the british medical research council, it is possible to cut out all frequencies above 500 c.p.s. and yet obtain good speech audiograms, even with p.b. word lists. in practice, speech audiograms can be done quickly, especially when a rough assessment r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c s o c i e t y of hearing for speech is made according to the pure-tone audiogram. in c a s e s of conductive deafness, the curve will be parallel to the normal curve. in perceptive deafness, the curve flattens out a s the percentage of discrimination increases and it may never reach the 100% level. when the phenomenon of recruitment is present, the percentage discrimination actually falls with the increase of intensity above a certain level and it is therefore essential in cases of recruitment to complete the audiogram in order to get the whole picture. conductive deafness. from the patient's point of view, the most important aspect of hearing is his hearing for speech. with conductive deafness, the speech audiogram follows a regular pattern and can be a s s e s s e d with a fair degree of accuracy from the pure-tone audiogram. our experience with fenestration surgery has led us to believe that if we wish accurately to determine the improvement or otherwise of hearing following surgery we must have speech audiograms a s well a s pure tone audiograms. the best illustration of this is a feature that i have noticed repeatedly with fenestrations, regardless of how expert the surgeon might be. in attempting to a s s e s s the suitability of c a s e s for fenestration, the otologist usually regards the patient with a rising curve in the high frequencies on pure tone audiograms a s having the better prospects of success than the patient with a straight curve or with a curve dropping in the high frequencies. yet there is a very large proportion of fenestrated cases whose post-operative puretone audiograms show a very successful rise in the hearing over the speech frequencies but a marked! drop in the high frequencies. in other words, the post-operative curve is reversed. if an a g g r e g a t e of all frequency changes were to be made in these cases, the sum would probably b e zero. the speech audiograms give a completely different picture in these successful fenestrations and the curve is merely moved bodily to the left which is much more in keeping with the general clinical expectations. this fact is then a very important one in making preand post-operative speech audiograms an essential part of fenestration surgery. perceptive deafness. the attempt to match hearing aids to puretone audiograms has been a failure. this may b e possible in cases of conductive deafness but with perceptive deafness trial and error becomes a necessity for fitting a hearing aid. once again, the speech audiogram is in itself a very much better indication of suitability for hearing aid than is the pure-tone audiogram by itself. if recruitment is shown to be present on a speech audiogram, then it is at once obvious that pure amplification of sound over all frequencies will not benefit the patient. these are the c a s e s in which there is an indication for'modification of the hearing aid by means of automatic loudness control. the speech audiometer in a c a s e of this sort acts a s a master hearing aid and if the speech audiogram shows a marked degree of recruitment it may be assumed that the patient will not benefit from the use of a hearing aid. recruitment. speech audiograms in themselves may give a very much better indication of the degree of recruitment present than the more tedious and difficult tests of loudness balance. they have the further a d v a n t a g e of indicating recruitment when both ears are affected, whereas the pure-tone audiograms are of use only when one ear is affected and the other ear normal. if loudness balance tests are to be reliable, they must be carried out over several frequencies and the time necessary to do this is considerable. furthermore, the patient is easily fatigued and usually two or three attempts are necessary to complete the test. the only condition in which recruitment regularly occurs is meniere's disease and for this reason speech audiometry is an essential part of the investigation of this condition. in spite of the fact that most modern audiometers are fitted with loudness balance attachments, the only satisfactory way of carrying out accurate tests for loudness balance is by the use of two separate, equally calibrated or corrected audiometers or their equivalent. the tests should be done for at least three frequencies and because of this the test is scarcely to be regarded a s of great value to the practising otologist. speech audiometry is readily available nowadays to any otologist and speech audiograms are easily done so that here is a practical indication of recruitment that has a tremendous diagnostic value. occasionally, a mild degree of recruitment is present in cases of presbyacusis and it may, of course, occur immediately after trauma to r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c s o c i e t y o c t o b e r the labyrinth. in the latter condition, the recruitment tends to disappear with the p a s s a g e of time after the trauma. children. speech audiometry has a special place in the assessment of hearing in children. puretone audiometry is notoriously inaccurate in children and it is extremely difficult to reproduce accurate audiograms. speech audiograms, however, may be very successfully employed in children of a v e r a g e intelligence over the a g e of four years. if records are made with a carrier phrase, such a s "you will now say . . .," there is very little difficulty in obtaining accurate audiograms which maintain the interest of the child. these audiograms are used in children up to the a g e of 10 or 12 years and in the occasional c a s e s of meniere's disease encountered in this a g e group, the above remarks on the assessment of recruitment apply even more strongly. social adequacy index. the social adequacy index is designed to give an indication of the intelligibility oi speech for a particular subject. it is a combined index of hearing ability and interpretation and the pure-tone audiogram plays no part in arriving at the index. while there is no practical value to assessment of percentage of hearing, the social adequacy index has a definite value and gives a truer reflection of "social hearing ability" than does a percentage figure b a s e d upon pure-tone audiometry. unfortunately, there are far too many factors which influence hearing and the s.a.i, takes into account only two of them, so that it cannot truly be regarded a s an index of social adequacy. the index can b e determined if speech discrimination does not reach the 100% level even at the highest amplification. it cannot be determined, however, if recruitment is present and the percentage discrimination actually decreases with an increase in amplification. malingering. numerous tests for feigning deafness have been devised and naturally some tests are better than others, but the malingerer simulating deafness may be difficult to detect with certainty. a new test is being carried out in sweden in which the speech audiometer is used and it a p p e a r s to b e almost impossible to simulate deafness effectively when this test is employed. the suspected malingerer is given an article to read and a tape recording of his speech is made. this recording is played back to the patient after a time lag of one third of a second. if he is in fact malingering, he finds it impossible to concentrate on what he is reading and begins to falter and stammer and becomes utterly confused within a few seconds. conclusion. i have attempted to show that speech audiometry should be regarded a s an essential part of modern otology. only a few years ago, otology consisted for the most part of surgery of suppurative ear disease. in the last 15 years, great advances in otologic surgery have coincided with advances in the treatment of infections of all kinds. contrary to frequently expressed opinion, the relief from treatment of suppurative ear conditions has made possible a greater concentration on the surgical treatment of deafness and has thereby widened the scope of otology. lempert designed the modern fenestration operation and thereby brought practical hearing within the reach of millions of sufferers from otosclerosis. hallpike described the pathology of meniere's disease and cawthorne designed his operation for labyrinthectomy which can be regarded a s a cure for unilateral meniere's disease. there is a considerable emphasis at the present time on the plastic surgery of the tympanic membrane and it is to be hoped that these procedures will b e productive of more useful hearing in the future. we have to await the results of the operation for mobilization of the stapes in otosclerosis and we may be on the brink of a further big advance here. because of the advances in otologic surgery, new standards have been set in all the auxiliary services and we have now reached the stage where speech audiometry is an essential auxiliary service. i do not suggest that b e c a u s e we have speech audiometry, that the older methods of investigation and examination may be discarded. on the contrary, i emphasise that complete examination of hearing now consists of clinical examination, including tuning fork tests, pure-tone and speech audiograms. it is only by accepting this a s a new standard in practical otology that we can hope to achieve the best results from management of the deaf patient, all the time. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) bevindings op die gebied spraakstem en gehoorgebreke by skoolgaande kinders deur i. c. uys, b.a.log. (rand;) b. prade, b.a.log. (rand). d e p a r t e m e n t s p r a a k h e e l k u n d e u n i v e r s i t e i t v a n p r e t o r i a . „ d i e t e r m d i a g n o s t i s e r i n g is v a n d i e w o o r d d i a g n o s e a f k o m s t i g , ' n m e d i e s e t e r m w a t b e t e k e n o m , d e u r d i e u i t k e n n i n g e n b e s t u d e r i n g v a n d i e s i m p t o m e , d i e a a r d v a n d i e s i e k t e t e b e p a a l . d i t is b e g r y p l i k d a t h i e r i n o o k d i e u i t k e n n i n g v a n d i e o o r s a k e v a n d i e s i e k t e o p g e s l u i t is m e t d i e o o g o p ' n d o e l t r e f f e n d e b e h a n d e l i n g d a a r v a n . m e t d i e o p k o m s v a n d i e p s i g o s o m a t i e s e g e n e e s k u n d e w o r d o o k d i e v o l g e n d e g e d a g t e in d i e b e g r i p d i a g n o s e v e r v a t , nl. d i e i n v l o e d v a n d i e s o m a t i e s e s t e u r i n g s o p d i e p s i g i e s e l e w e e n o m g e k e e r d . w e e n s d i e v e r s k e i d e n h e i d v a n d e n k s t r o m i n g s in d i e p s i g o l o g i e , is d i t b e g r y p l i k d a t d a a r g e e n e e n h e i d s b e e l d t e n o p s i g t e v a n d i e p s i g o l o g i e s e d i a g n o s t i s e r i n g o p g e b o u k a n w o r d n i e . " n a a a n l e i d i n g v a n b o g e n o e m d e is d i t d u s d u i d e l i k d a t o o k d i e s p r a a k t e r a p e u t m e t d r i e u i t e r s b e l a n g r i k e p r o b l e m e t e k a m p e h e t : 1. d i e p r o b l e e m v a n s u b j e k t i e w e i n t e r a k s i e t u s s e n p e r s o o n l i k h e d e . 2. d i e p r o b l e e m v a n s e m a n t i e k . 3. d i e p r o b l e e m v a n v e r s k i l l e n d e d e n k s t r o m i n g s in d i e s p r a a k h e e l k u n d e . v o o r d a t o o r g e g a a n w o r d n a o n d e r s o e k e g e d o e n t e r p l a a t s e , k a n d i e v o l g e n d e b e v i n d i n g s a s a g t e r g r o n d d i e n v i r ' n k o n t r o l e . bevindings in amerika 1. white house conference on childhealth and protection, special education, 1931. v r a e l y s j t e is r o n d g e s t u u r in s t e d e m e t ' n b e v o l k i n g v a n o o r d i e 10,000. d i e v o o r k o m s s y j f e r v a n s p r a a k g e b r e k e h e t g e v a r i e e r t u s s e n 1 9 . 0 2 1 . 4 % . d i e g e m i d d e l d e is d u s y a s g e s t e l a s 5 % . 2. opnames gedoen deur mills en streit i n t e n s i e w e o p n a m e s is in h i e r d i e g e v a l g e d o e n d e u r m i d d e l v a n i n d i v i d u e l e o n d e r s o e k e v a n e l k e k i n d . v a n a l l e s k o o l g a a n d e k i n d e r s is 10% m e t s p r a a k g e b r e k e g e v i n d . . e r n s t i g e s p r a a k g e b r e k e h e t v o o r g e k o m b y 4 5 % v a n h i e r d i e k i n d e r s . 3. opnames gedoen deur wilbert pronovost. p r o n o v o s t v i n d d a t 7 . 8 % v a n a l l e s k o o l g a a n d e k i n d e r s in n u e n g e l a n d ( v . s . a . ) s p r a a k g e b r e k e h e t . 4. bevindings van die a.s.h.a. komitee (1950 white house conference.) b e r e k e n i n g s w a t v o l g e n s d i e v e r s l a g d i e l a a g s t e is w a t w e t e n s k a p l i k v e r d e d i g k a n w o r d : 6 % v a n d i e t o t a l e b e v o l k i n g t o o n s p r a a k g e b r e k e . 5. opnames gedoen deur milisen. h i e r d i e v e r s l a g s p e s i f i s e e r m e r e n d e e l s d i e v o l g e n d e s p r a a k g e b r e k e : ( a ) d i s l a l i e : 1 5 % 2 0 % g e v i n d i n d i e g r a d e , m e t ' n d u i d e l i k e v e r m i n d e r i n g t o t d i e o u d e r d o m v a n 9 1 0 j a a r . ( b ) d i s f e m i e : ( s t u d i e s g e d o e n d e u r m i l l s e n s t r e i t 1942, b u r d i n 1940 e n r o o t ) . h u l le v i n d ' n n e i g i n g t o t t o e n a m e i n h a k k e l t u s s e n d i e 2 d e e n 5 d e g r a d e e n d a a r n a ' n v e r m i n d e r i n g in d i e p e r s e n t a s i e s . ( c ) d i s f o n i e : v a n d i e t o t a l e b e v o l k i n g is ( + — ) 1 % g e v i n d , t e r w y l 5 % 1 5 % v a n a l l e s p r a a k g e b r e k k i g e s o o k s t e m g e b r e k e g e t o o n h e t . bevindings in suid-afrika 1. opnames gedoen deur die universiteit van die witwatersrand. o p n a m e s w a t g e d u r e n d e d i e t y d p e r k 1962 1 9 6 3 in j o h a n n e s b u r g g e d o e n is, h e t d i e v o l g e n d e r e s u l t a t e g e l e w e r : (a) engelsmedium skole: g e m i d d e l d e a a n t a l k i n d e r s p e r s k o o l is 5 3 3 . g e m i d d e l d e a a n t a l k i n d e r s m e t s p r a a k g e b r e k e is 6 0 ( 1 1 . 8 % ) . (b) afrikaansmedium skole: g e m i d d e l d e a a n t a l k i n d e r s p e r s k o o l is 5 2 8 . g e m i d d e l d e a a n t a l k i n d e r s m e t s p r a a k g e b r e k e is 5 3 ( 9 . 5 % ) . v o l g e n s b o g e n o e m d e g e g e w e n s b l y k d i t d u s d a t d i e g e m i d d e l d e a a n t a l s k o o l k i n d e r s m e t s p r a a k g e b r e k e i n j o h a n n e s b u r g 10.7% is. 1 journal of the south african logopedic society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 2. opnames gedoen deur die universiteit o p n a m e ^ w a t gedurende die tydperk 1962 -1963 in pretoria gedoen is, het die voigende resultate gelewer: ( a ) per sfcool is 395 gemiddelde aantal kinders met spraakgebreke is 62 (18.2%). fh") afrikaansmedium skole: ( ) gemiddelde aantal kinders per skool is 504 gemiddelde aantal kinders met spraakgebreke is 75 (15.2%). die gemiddelde persentasie spraakgebrekkige kinders in pretoria blyk dus 16.7/0 te wees. b e s p r e k i n g v a n o p n a m e s g e d o e n i n s u i d a f r i k a 1. vraelyste is aan skoolhoofde gestuur waarvolgens onderwysers moontlike spraakgebreke kon uitken. 2 individuele onderhoude is gevoer in elke skool. die spraakterapeut het elke kind persoonlik gesien en 'n paar vrae gestel. na aanleiding van die resultate gevind met hierdie gekombineerde vraelys en individuele onderhoudsmetode, kon boge noemde afleidings gemaak word. voordele van hierdie metode. (a) 'n spraakterapeut sien elke kind persoonlik, dus is die moonhkheid dat η spraakgebrek ongesiens verbygaan skraal. (b) die onderwysers ken die kinders in hulle klasse beter, en aangesien hierdie persone die vraelys vooraf kry kan hulle die spraakterapeut bystaan in haar ondersoek. nadele van hierdie metode. (a) party kinders is skaam en praat nie ^ ; maklik met v r e e m d e mense me. dus bestaan die moontlikheid dat hulle spraakgebreke nie opgemerk sal word nie. (b) hakkelaars mag dalk oorgeslaan word ( omdat hulle soms vlotheidspenodes beleef. (c) breinbeseerde kinders is gewoonlik moeilik om dadelik te herken. (d) getalle mag groter wees as gevolg van onsekerheid. m o o n t l i k e r e d e s v i f i d i e h o e persentasie g e v i n d in pretoria 1 alleenlik laerskole, d.w.s. kinders van g aad l tot en met standerd 5 is ingesluit fn die opnames. soos genoem in vori^e studies, is daar 'n duidelike a f n a m i n spraakgebreke namate die kind ouer word. die vermoede bestaan dus dat die persentasie aansienlik laer sal wees as e s k o l e by die opnames sou ingesluit word. 9 dit is ook 'n bekende feit dat meeste van die kinders wat artikulasiegebreke toon gedurende die ouderdom van 5 jaar tot 8 f a a r dte probleem ontgroei selfs sonder spraakheelkundige behandeling. alle gradeklasse is ingesluit in die op names en dit kan waarskynlik vtr die hoe persentasie verantwoordelik wees. 3 soos vantevore genoem is, het die vraelys individuele onderhoudsmetode sy^nad y ele. aangesien die kinders net vir 'n tort rukkie gesien is, kan onsekerheid of selfs verbyga g ande fisiese of psigiese probleme l a s e i d i n g daartoe gegee het, dat die kind as 'n spraakgebrekkige bestempel word. die verskil tussen die tipe van opname gedoen ter plaatse, en die metodes wat in amerika gebruik is mag ook η invloed hg op die uiteenlopende resultate. 4. spraakheelkundige dienste is eebrei in pretoria nie en omdat omtrent feen opnames of behandeling vantevore h i l r toegepas is nie, is die moonthkheid s s spra g ak p gebrekklges reeds terapie ontvang het en gerehabiliteer is, in η mate uitgesluit. 5 i n 'n wetenskap soos spraakheelkunde het ons te kampe met die probleem van subjektiewe interaksie tussen persoonhkhede asook die probleem van semantiek. eile persoonlike ?iening en o f ntasie van elke spraakterapeut sal die resultate noodwendig moet beinvloed. 6 in die wye sin van die woord is p r e t 0 " £ 6 · meer eentalig as johannesburg. op die huidige stadium is dit nog me duideiik, indien wel, hoe hierdie feit die resultate van die opnames kan beinvloed nie. 7. alleenlik 'n minimum van skole kon gedoen word as gevolg van die beperkte stette die resultate wat dus we ver£ ν is kan nog nie as 100% geldig of vers n w o o r s i g e n d van die totale bevolking beskou word nie. 16 a u g u s t , 1 9 6 3 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die behoefte aan verdere navorsing 1. dit is dringend dat 'n intensiewe studie gemaak word, waarin 'n beter verteenwoordigende aantal skole gebruik word. 2. vir 'n studie om geldig en waardevol te wees, is objektiwiteit belangrik en dit kan alleen verkry word indien 'n groter aantal spraakterapeute die opnames doen en sodoende die probleem van subjektiwiteit en persoonlike orientasie uit te skakel. 3. die behoefte word ook gevoel aan navorsing in verband met die waarde van die verskillende opnamemetodes en die verskil in resultate wat hulle meebring. 4. weereens mag dit interessant wees om navorsing te doen op die gebied van verskille tussen engelsen afrikaansmedium laeren hoerskole. 5. in die keuse van monsterskole moet die verskillende ekonomiese en sosiale standaarde van die gebied waarin die skole voorkom, in ag geneem word. ten slotte kan net genoem word dat hierdie studie in sigself alleenlik waardevol is as 'n aansporing tot verdere navorsing. opsomming 'n opname in verband met die persentasie van spraakgebrekkige skoolkinders is in pretoria gedoen en daarna vergelyk met die bevindings van opnames wat gedoen is in johannesburg en amerika. die persentasie is aansienlik hoer in pretoria. verskeie faktore kan as oorsaak genoem word, maar daar kan tot geen finale slotsam gekom word, voordat beter beheerde studies in verband met die saak gedoen is nie. die studie kan dus alleenlik dien as 'n aansporing tot verdere navorsing op hierdie gebied. summary a survey of the incidence of speech defects among school children in pretoria has been carried out and compared with the findings of surveys done in johannesburg and america. the percentage was found to be significantly higher in pretoria. a number of factors could be responsible for this fact, but no final conclusion can be reached until better controlled studies have been carried out. it is therefore felt that this study only serves the purpose of encouraging further research in this field. bibliography 1. van riper, c. speech correction, principles and methods. n.j.: prentice-hall inc., 1954. pp. 10, 33-36. 2. milisen, r. incidence of speech disorders. in ed. travis: handbook of speech pathology london: peter owen ltd., 1959. pp. 246-260. 3. — speech disorders and speech correction. white house conference report, 1950. j.s.h.d. 1952, pp. 129-137. 4. nel, b. f. sonnekus, m.c.h. opvoedkundige studies. no 33. negende jaargang. august, 1963 j o u r n a l o f the south a f r i c a n l o s o p e d i c society 17 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language development of the cleft palate child l o r e t t a h o r n , b.a. (sp. & h. t h e r a p y ) ( r a n d ) speech therapy department, general hospital, johannesburg summary the itpa was used in an assessment of the psycholinguistic abilities of three cleft palate children and three m a t c h e d normal children, of ages ranging from 48 m o n t h s to 66 m o n t h s . the data obtained revealed that the cleft palate children manifested a general depression in t h o s e areas sampled b y the itpa, in particular in areas testing expressive abilities. a transformational analysis of the language samples of the cleft palate children s h o w e d the relative immaturity of the syntactic structures used b y these children. in spite of the limitations of this s t u d y , there was a clear indication of a language retardation in the cleft palate group. several factors present in the early d e v e l o p m e n t of cleft palate children could adversely affect the acquisition of language skills. the implications of these findings for speech therapy are important. opsomming drie kinders met gesplete verhemeltes is vergelyk met drie normale kinders ten opsigte van psigolinguistiese vermoens deur middel van die itpa. die ouderd o m m e van die kinders het gewissel van 4 8 maande t o t 66 maande. die toetsresultate het a a n g e t o o n dat die kinders m e t gesplete verhemeltes oor die algemeen swakker gevaar het in die toetsgebiede van die itpa, in besonder in die items wat uitdrukkingsvermoe t o e t s . die analiese van die taalvoorbeelde van die kinders m e t gesplete verhemeltes was gebasseer o p 'n generatief-grammatiese benadering. hierdie analiese het g e t o o n dat die sintaktiese strukture soos gebruik deur hierdie kinders relatief o n o n t w i k k e l d was. nieteenstaande die tekortkominge van hierdie ondersoek is daar tog 'n duidelike aanduiding van vertraging in die taalstruktuur van die kinders met gesplete verhemeltes. die aanleer van linguistiese vaardigheid w o r d in die vroee ontwikkeling van hierdie kinders deur verskeie faktore b e i n v l o e d . die bevindings in hierdie verband is belangrik vir spraakterapie. literature on the subject of cleft palate and communication problems has been concerned primarily with the adequacy of articulation, and a great deal of information is available on the speech characteristics of individuals with clefts. most investigators have dealt with the speech output in terms of the defective elements which make it acoustically different from normal speech. discussions of cleft palate communication problems usually exclude information about language skills. only recently has attention been directed tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 19 desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 loretta horn beyond the 'mechanics of the speech production of the cleft palate child to the fundamental language structures which are basic to communication. many problems associated with the occurrence of cleft palate, such as parental reactions to the defect, modified feeding methods, hearing loss, overprotection and lack of rewards for early speech attempts, and the unintelligibility of early speech, may have adverse effects on the development of language. clinical observation and parental reports have frequently indicated an apparent retardation in language acquisition, and some texts6· 2 1 make reference to the retardation of communication skills of cleft palate children. there has, however, been a paucity of systematic research into the language development of cleft palate individuals. relatively few studies have been carried out to experimentally investigate the language of children with clefts. it was felt, therefore, that consideration of this subject would yield useful information on the cleft palate problem and the factors influencing language acquisition. some investigators have attempted to study the language abilities of cleft palate children. bzoch3 reported a considerable delay in early speech developmental patterns in over 50% of his cleft palate subjects. further studies, directed more specifically towards language development, have yielded conflicting results. spriestersbach, darley and morris20 used measures of language such as mean length of response, structural complexity score and vocabulary size, and found that cleft palate children were retarded on measures of verbal output and vocabulary usage, but that they demonstrated no general language retardation. in a study using more extensive measures of language morris16 found that the cleft palate children were significantly retarded " . . .on every measure of communication skill for which comparisons with normal children were possible". smith and mcwilliams19 used the illinois test of psycholinguistic abilities to assess the language skills of 136 cleft palate children of three to eight years of age. they reported a depression in all nine areas of language evaluated. philips and harrison17 evaluated the language abilities of 137 cleft palate children and compared these with 165 noncleft children. they made use of the peabody picture vocabulary test, mecham's verbal language development scale, together with items selected from the kuhlman binet, the stanford-binet, the cattell, and the baker's detroit test of learning aptitude, as measures of language comprehension and expression. the children tested were between the ages of 18 and 72 months. the cleft palate subjects were found to be retarded in both receptive and expressive language abilities. the older cleft palate children (6 year level) were found to have a relatively greater degree of retardation in language skills, which implied that the language delay had not been overcome with maturation. they stressed the need for language stimulation programs for pre-school cleft palate children. from the studies mentioned above, it appears that children with cleft palates are often retarded to some degree in language development. decreased verbal output and more simple language structures have been reported. these findings support the hypothesis that the consequences of cleft lip and palate are much more than those of an anatomical defect alone. journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language d e v e l o p m e n t of the cleft palate child 19 studies of this type have been based on quantitative measures of language which, although they did indicate gross developmental changes, did not yield information about the language structure as a whole. rather, they stressed different, isolated aspects of utterances without giving attention to the linguistic system which underlies the verbal activity of the speaker. it is this abstract system of rules enabling the individual to generate the sentences in his language, that linguists seek to describe. advances in linguistics, in particular the transformational model of grammar developed by chomsky5, have made possible more accurate and meaningful descriptions of language structure, and this has resulted in increased interest in the study of child language. the development of transformational generative grammar has had considerable influence on current research in language development. due to the limitations of the previously used language measures the present study included an analysis of language based on the transformational generative model, thereby taking into consideration the system of rules assigning structural description to utterances. in the present study the writer was concerned primarily with the children's acquisition of syntax, i.e. methods of combining words into sentences. in a surprisingly short period of time children acquire almost full knowledge of the grammatical system of their native language. it is postulated that in acquiring language the child incorporates a system of rules which formulates underlying regularities enabling him to generate utterances. the grammar of the linguist aims to describe the linguistic knowledge internalized by fluent speakers of a language; i.e. their linguistic "competence". the syntactic component of the grammar has different levels: phrase-structure level. at this level underlying strings which implicitly define the basic grammatical relations in the sentence are formulated by means of rules specifying the arrangement of lexical items. transformational level. more complex sentences are derived from base structure strings by the application of transformational rules, which involve operations of addition, deletion, substitution and re-arrangement of constituents. the distinction between deep structure and surface structure is central to the theory of transformational grammar. the deep structure of a sentence, which is the representation of the meaning of the sentence, is transformed by syntactic rules into a structure which is ultimately spoken or written, called the surface structure. morphological level. at this level inflectional rules, dependent on the previous application of sequential rules, are applied. in addition to the linguistic analysis of syntactic structures, a further measure of language skill was employed in the present study. in an attempt to compare the various psycholinguistic abilities of cleft palate and normal children, the illinois test of psycholinguistic abilities (itpa) was used. although this language test has been found to have limitations12 it appears to be a comprehensive test of children's language status. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 2 0 loretta horn factors influencing the language development of the cleft palate child. it is important to realize that the learning processes underlying the development of language are themselves dependent upon the existence and maintenance of certain conditions in the organism and environment. the psychosocial environment of the infant and young child during the years of language acquisition has to be taken into account when.considering the development of language. several psychosocial factors operating in the cleft palate population may have major impact on the total development of communication skills. from the very beginning the life experiences of the baby with a cleft are different to those of noncleft infants. appearance, feeding, dentition, surgery and general care often cause much concern. parental reactions of disappointment, guilt, defensiveness and resentment are frequently encountered. spriestersbach and sherman21 pointed out: .. .in few other clinical diagnoses is there as much likelihood of finding parental feelings of guilt, rejection and overcompensation, any of which would influence the interpersonal relationships between parent and child and in turn affect communication skills of the child. the reactions of parents to the birth of a cleft palate child have been investigated and reported.22 we must stress the importance of looking beyond the anatomical defect to the child himself and his parents. the role played by reinforcement in early language development has often been noted. the vocalizations of the cleft palate baby may not be rewarded to the same extent as those of the normal infant due to the lack of a warm, pleasurable relationship with the mother. artificial feeding methods, and the possible deprivation of normal oral experiences, together with a failure to satisfy the basic sucking and hunger drives of the infant can adversely affect the development of speech and language. a well recognized aspect of the cleft palate problem is the effect on speech intelligibility. it is felt that parental reactions to the early defective speech patterns may cause or aggravate the problems in language development. the utterances of the child with a cleft palate are often so different to those of the normal child, due to structural inadequacies, that they may be greeted with much less enthusiasm by parents. parents' failure to recognize early « utterances or even outright rejection of such vocalizations could result in deprivation of normal feedback and reinforcement. speech models and language stimulation through "imitation with expansion" by parents are felt to play an important role in language learning. brown and bellugi2 spriestersbach and sherman21 pointed out that in his failure to improve his approximations of the speech models he hears the cleft palate child may tend to withdraw from the activity and make fewer attempts to perfect his linguistic skills. parents may fail to expand the immature utterances of the cleft palate child because they do not expect better attempts from'the child, or because the unintelligibility of utterances makes such repetition and expansion impossible. 1 journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language d e v e l o p m e n t of the cleft palate child 21 it is common to find that cleft palate children have varying degrees of hearing loss. conductive losses often occur intermittently, especially at an early age. the possibility of a hearing loss during the important years of language acquisition has to be taken into account in the study of cleft palate children's language development. it is clear that there are several factors which could adversely influence the development of language in the child with a cleft palate. method the aim of the present study was to investigate the language skills of a group of cleft palate children. an experimental group of children with clefts, and a matched control group without clefts were compared with regard to their performance in the psycholinguistic areas tested by the itpa, and the complexity of syntactic structures used. subjects. the experimental group consisted of 3 children with complete clefts of the lip and palate (2 unilateral and one bilateral), of ages 48 months, 54 months and 66 months. these children were all being treated at the speech and hearing clinic, university of the witwatersrand. the control group consisted of 3 normal children aged 47 months, 51 months and 63 months. the children in the two groups were all boys, of matched socio-economic status. all had intelligence quotients in the normal to bright-normal range, and none had hearing losses of "educational significance"7 materials. the illinois test of psycholinguistic abilities was administered to each subject. certain modifications of the test were introduced as suggested by phillips18, who reported on the use of this test with english children. the stimulus materials used to obtain samples of language from the children consisted of two books with brightly-coloured pictures depicting everyday activities, toy motorcars, and a set of pictures chosen by the investigator to elicit certain responses. sentences consisting of vocabulary items present in the speech of young children, but containing syntactic structures more complex than those present in the sample of the child's spontaneous speech were, constructed for each child. for example, a child who gave no evidence of applying a passive transformation in the language sample obtained was presented with sentences containing this construction. the child was first required to repeat the sentence after the investigator, and thereafter he was asked to point to the appropriate picture, demonstrating his understanding of the sentence. such sentence imitation and comprehension tasks have been suggested as means of assessing the linguistic competence of children.9·1s: the distinction between competence and performance makes adequate assessment of tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 2 2 loretta horn children's linguistic levels difficult. the description which is of the greatest relevance is clearly the measure of competence, not that of performance. the majority of research studies have been based on linguistic descriptions of utterances produced, and to a lesser extent utterances understood by children at various stages of development. the present study is limited in that it is based, to a large extent, on performance. the repetition and comprehension tasks were applied to only some transformations, in an attempt to measure the competence of the child in these areas. procedure. the subjects were tested individually in familiar surroundings. the itpa was administered to each child, after hearing and intelligence had been tested. on another occasion the spontaneous speech of the child in response to the stimulus materials and the investigator's conversation was tape-recorded. the children were later presented with the repetition and comprehension tasks, which were based on the samples previously obtained. the speech sample of each child consisted of about 60 to 80 utterances. all utterances were taperecorded and later written out in traditional orthography. the language samples were then analyzed according to the transformational rules and restricted structures tabulated by m e n y u k 1 3 · 1 4 . the syntactic structures of the cleft palate children were compared with those of the normal children of matched ages. analysis of syntactic structures. the analysis of structures in this study was based on the model proposed by menyuk as a technique for describing children's grammar. the model is based on a generative grammar approach to linguistic structure. in the studies of m e n y u k 1 3 1 4 and brannon1 it was found that differences in levels of language development could be detected in terms of the transformational rules acquired, and the restricted structures present at successive age levels. there is similarity in the sequence of acquisition of structures through the developmental period. it was, therefore, felt that an analysis according to the rules exemplified in menyuk's descriptive model would yield information about the level of language development of the two groups tested. the samples were compared in terms of the use of the phrase structures, transformations and morphophonemic entities listed by κ m e n y u k 1 3 ' 1 4 . / menyuk's table of syntactic structures includes 14 simple transformations such as passive, negation, question and imperative, together with 12 generalized transformations such as conjunction, relative clause, complement and adjective. the list also includes various structures which are restricted to a children's grammar. on the phrase structure level these involve restrictions in the formation of the verb phrase, noun phrase, prepositions, articles and particles. transformational restrictions include contraction deletion., no question, pronoun restriction, etc., and morphological deviations in the verb form, noun form, possessive and pronoun are listed. journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language d e v e l o p m e n t of the cleft palate child 2 3 results from the norms of the itpa the language age and standard scores for each subject were computed. the two youngest cleft palate children had language ages which were below their chronological ages. the language ages of the cleft palate group were all below those of the normal group. in order to compare the performance of the subjects on the various subtests the ranges were calculated for each subtest, as recommended in the itpa manual, mccarthy and kirk 1 l . two of the cleft palate subjects demonstrated a significant deficiency in the vocal encoding and motor encoding subtests, while the eldest cleft palate subject showed no significant weakness in these areas. the control subjects all showed relatively normal and stable patterns of performance in all areas, with no significant differences between the subtest performances. to enable comparison between the performances of the two groups a composite profile was plotted using the means of the standard scores for each different subtest. (figure 1.) the results of this study indicated that the cleft palate children performed significantly poorer than the normal children on the following subtests: vocal encoding, motor encoding, auditory-vocal automatic and visualmotor sequential. figure 1. indicates that the cleft palate subjects tended to show a general depression in the psycholinguistic areas tested by the itpa. analysis of syntactic structures. the description and classification of the linguistic data using menyuk's table of transformations and immature structures yielded valuable information about the syntactic structures present in the language samples of the two groups. clear differences were revealed between the language structures of the cleft palate children and the normal children. the most marked difference between the two groups was the large proportion of structures restricted to children's grammar appearing in the language samples of the cleft palate group. these were much less common in the samples of the control group. at the two youngest age levels tested such unique forms constituted over 50% of the utterances, whereas restricted forms accounted for a much smaller percentage of the normal children's utterances. at the phrase structure level there was frequent omission of noun phrases, articles and prepositions. the utterances were clearly indicative of rules applied in the early stages of language acquisition. the tendency toward the lack of expansion of a syntactic class on the phrase structure level, tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 2 4 loretta horn, representational l e v e l aut0m.-se0. decoding association encoding autcm beq . 1 2 3 4 5 6 7 8 9 aud. v i s . audvoc v i s mot. voc mot aud-voc. audvoc. v i s mot . ,'v a / / s \ — · " — / ' . s / \ / \ / v \ \ \ % • / ν \ • \ \ / / • • \ « \ / φ + 3 . 0 0 + 2 . 5 0 +2.00 + 1 .50 + 1 . 0 0 + . 5 0 .00 . 5 0 1 . 0 0 1 . 5 0 2 . 0 0 2 . 5 0 3 . 0 0 normal group cleft palate group figure 1. profiles of the two groups (cleft palate and noncleft palate) on the itpa. resulting in an immature syntactic structure, was much more marked in the cleft palate group than in the normal group. there was clear evidence of late development of the auxiliary and model verbs, and the omission of the contracted form of the auxiliary "be" (contraction deletion) was often present in the samples of the experimental group. the language structures of the control group were more frequently well-formed, including correct expansion of the auxiliary node. at the morphological level there were omissions, substitutions and redundancies particularly of the verb form. in the use of generalized transformations the' normal children at the younger age levels were again superior. while the normal children frequently expanded sentences through the use of conjunctions, the cleft palate children showed journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language d e v e l o p m e n t of the cleft palate child 25 very limited ability in the use of conjunctions. restricted structures, involving omission of syntactic classes, violation of selectional restrictions and incorrect application of transformational operations were more numerous than correct transformational structures in the utterances produced spontaneously and in repetition by the younger cleft palate children. a marked difference, for example, between the control and experimental group was noted in the structure of interrogative utterances. wh-questions used by the cleft palate children were predominantly formed by the simple addition of an interrogative word to the declarative sentence structure, e.g. "where it is?" yes/no questions were formed by means of the application of intonational markers, without the inclusion of the auxiliary verb. these types of structures were clearly indicative of an early stage in the acquisition of transformational structures. the normal group revealed a greater linguistic competence through the earlier use and inversion of the auxiliary verb for generating correct question transformations. at the five-year age level the differences in the syntactic structures used by the two children were less marked. both had acquired basic syntactic structures, and there was no-significant difference between the base structures used by the normal child and the cleft palate child. on the transformational level the normal child used the correct form of the auxiliary verb more consistently, and gave evidence of greater syntactic competence in the application of generalized transformations. at each of the age levels considered in this study, but especially at the two younger age levels, the normal children gave evidence of more advanced linguistic competence through the decreased occurrence of restricted forms, and the greater proportion of grammatically correct transformations present in their language samples. discussion the cleft palate subjects in this study tended to show a general depression in those areas sampled by the itpa. the normal children were generally superior in the nine psycholinguistic areas investigated. figure 1. demonstrates the similarity in the shape of the profiles of the two groups, but clearly the difficulties of the normal subjects were not as marked as those of the children with clefts. the itpa revealed that the cleft palate children had a significant disability in the area of encoding, relative to their own performance in other psycholinguistic areas and in comparison with the performance of the normal children. the marked difficulty demonstrated in the vocal expression of ideas could be due to factors present in the early developmental period of the cleft palate children. less satisfying mother-child interaction, fewer speech models and decreased reinforcement of deviant speech patterns may have an adverse effect on the development of language skills. the possible effects of temporary hearing losses in the earlier stages of language development in these children tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 2 6 loretta horn must not be overlooked. the deficiency in the motor expression of ideas (i.e. gesture) can be associated with the general shyness, inhibition and dependency observed in the cleft palate group. these children are often overprotected by parents, and although parents might not view the child as "defective" they often feel he is "special" or "different" in some way, and therefore react to him in unrealistic ways. these children have often been found to be dependent on their parents, shy, and lacking in general spontaneity and initiative. another interesting finding was the significant difference between the performance of the two groups on the auditory-vocal automatic subtest. this is a form of grammar test requiring the use of increasingly less familiar english inflections, in a sentence completion task. to learn such grammatical rules the child requires adequate speech models, and it is postulated that a poor mother-child relationship, together with the unintelligibility of the child's early utterances could make the process of imitation with expansion less spontaneous, and the provision of speech models less frequent. these factors may also reduce the chances of reinforcement contingent on the child's vocal responses. these, and numerous other factors present in the early developmental period of the child with a cleft, together with the possibility of temporary hearing loss at some stage, could account for the deficiency found in this aspect of linguistic performance. the inferiority of the cleft palate children on the visual-motor sequential subtest has also been reported by smith and mcwilliams'19. they reported the consistent weakness of the cleft palate children in visual memory as an "interesting, although somewhat perplexing, finding". these writers considered the possibility of a general visual-motor deficit in cleft palate children. it appears that this area requires more extensive investigation. the results of this study are limited by the small number of children tested. it must be stressed that the results reported are not taken as being conclusive, but are merely an indication of the areas of difficulty found in the cleft palate population. developmental trends in the acquisition of syntactic structures have been described in studies by m e n y u k 1 3 · 1 4 and brannon1. the increased use of various transformational structures and decrease in the occurrence of deviant forms in the generation of structures during the normal process of language acquisition have been described. although a limited sample of language was obtained, and only selected syntactic structures were considered in this study, there was clear evidence of greater syntactic maturity in the language of the normal group as compared with the matched cleft palate group. the immature structures used by the two youngest cleft palate children were characteristic of the syntactic forms found in the utterances of much younger children. the occurrence of restricted structures, the late development of the auxiliary node, the lack of selectional restrictions and the limited use of transformational operations indicated that the cleft palate children were delayed in their acquisition of syntactic structures as compared with the control group. the writer feels that this immaturity of syntax could be journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language d e v e l o p m e n t of the cleft palate child 2 7 accounted for in terms of the unique problems associated with the occurrence of cleft palate. the possibility of undetermined degrees of hearing loss at earlier stages in the development of these children must be kept in mind. once again the failure of the cleft palate children to modify and transform the early patterns into more complex grammatical structures at the same age level as the normal children could be due to parents' failure to recognize or accept the early distorted speech attempts, resulting in deprivation of normal feedback and reinforcement. many of the factors present in the early developmental period of the cleft palate child could have an impeding effect on the acquisition of language skills. the results of this investigation give an indication of the problems involved in the development of communication skills in the cleft palate population. the findings reported here have significant implications for diagnostic and therapeutic procedures with cleft palate children. the assessment of children with clefts should include a thorough evaluation of language skills in addition to the traditional speech analysis. the therapist must be aware of the possibility of delay in language acquisition when counselling and interviewing parents of children with clefts. speech therapists are often concerned only with the adequacy of the speech production, and give no attention to the language abilities of the cleft palate child. in the consideration of treatment, the concept should be changed from speech correction to the facilitation of language development together with improvement of speech production. what the parents often need is information, together with counselling and emotional support. they need information about the cleft palate syndrome, as ignorance about such matters as etiology, feeding problems, surgery and speech therapy often leads to increased tension in the parent-child relationship. these parents also need information concerning language development. activities such as the provision of good speech models, continuous stimulation and motivation, the imitation of the child's utterances with expansion, and constant reinforcement of speech attempts come spontaneously within the normal parent-child relationship; in the interaction between the cleft palate child and his mother the spontaneous occurrence of these activities cannot always be assumed. the speech therapist must be prepared to train and advise mothers, and approach treatment with a knowledge and awareness of language acquisition processes. the habilitation program for the preschool child should include facilitation of language growth and development, and the positive aspects of inter-personal relationships through language should be emphasized. conclusion the descriptive method used in this study for investigating syntactic structures indicated a developmental immaturity in the language of the cleft palate group. the data obtained from the itpa results also indicated a general language depression in this group, with particular weaknesses in vocal tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 2 8 loretta horn expression, gestural output, auditory-vocal automatic abilities and visual memory in comparison with the normal children tested. it appears that there is some degree of language retardation in cleft palate individuals; but the factors responsible for this delay cannot be isolated. the generalization of these findings to pre-school cleft palate children on the whole can be made only tentatively, due to the limited number of children tested in this study. clearly, not all children with clefts exhibit a retardation in language skills. references 1. brannon, j.b. (1968): a comparison of the syntactic structures in the speech of 3and 4-year old children. language and speech, 11 (3), 171-181. 2. brown, r. and bellugi, u. (1964): three processes in the child's acquisition of syntax. in e.h. lenneberg (ed.), new directions in the study of language, m.i.t. press. 3. bzoch, k.r. (1959): a study of the speech of a group of preschool cleft palate children. cleft palate bulletin, 9(1), 2-3. 4. chomsky, n. (1964): formal discussion. monographs of the society for research in child development, 29(1), 35-39. 5. chomsky, n. (1965): aspects of the theory of syntax. cambridge, mass., m.i.t. press. 6. grabb, w.c. and rosenstein, s.w. and bzoch, k.r. (eds.). (1971): cleft lip and palate: surgical, dental and speech aspects. little, brown and company, boston. 7. hayes, c.s. (1965): audiological problems associated with cleft palate. proceedings of the conference: communicative problems in cleft palate. asha reports no.l, 83-90. 8. jacobs, r.a. and rosenbaum, p.s. (1967): grammar 2. ginn and company, boston. 9. lackner, j.r. (1968): a developmental study of language behaviour in retarded children. neuropsychologia, 6,301-320. 10. lee, l. (1966): developmental sentence types: a method for comparing normal and deviant syntactic development in children's language. /. speech and hearing dis., 31,311-330. 11. mccarthy, j.j. and kirk, s.a. (1961): illinois test of psycholinguistic abilities: examiner's manual. institute for research on exceptional children. univ. of illinois, urbana, illinois. 12. mccarthy, j.j. and olson, j.l. (1964): validity studies on the illinois test of psycholinguistic abilities. institute for research on exceptional children. univ. of illinois, urbana, illinois. 13. menyuk, p. (1963): syntactic structures in the language of children. j. child development, 34,407-422., 14. menyuk, p. (1964): syntactic rules used by children from pre-school through first grade. child development, 35, 533-546. 15. menyuk, p. (1969): sentences children use. m.i.t. press. journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) language d e v e l o p m e n t of the cleft palate child 2 9 16. morris, h.l. (1962): communication skills of children with cleft lips and palates. j. speech and hearing dis., 5, 79-90. 17. phillips, b.j. and harrison, r.j. (1969): language skills of preschool cleft palate children. cleft palate journal, 6, 108-119. 18. phillips, c.j. (1968): the itpa: a report on its use with english children, and a comment on the psychological sequelae of low birthweight. british j. of communication dis., 3(2), 143-149. 19. smith, r.m. and mcwilliams, b.j. (1968): psycholinguistic abilities of children with clefts. cleft palate journal, 15, 238-248. 20. spriestersbach, d.c., darley, f.l. and morris, h.l. (1958): language skills in children with cleft palate. j. speech and hearing res., 1, 279-285. 21. spriestersbach, d.c. and sherman, d. (1968): cleft palate and communication. academic press, new york and london. 22. tisza, v.b. and gumpertz, e. (1962): the parents' reaction to the birth and early care of children with cleft palate. paediatrics, 30, 86-90. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) e d i t o r i a l the field of speech therapy in south africa, as elsewhere, is dynamic and one must therefore expect changing ideas, needs and trends. in recent years there has been a growing awareness that we have based the practice of our profession on research studies that have been carried out elsewhere. the time has come for south african therapists to attempt their own research and become more acquainted with the unique conditions that exist in the country in which they work. s. bauman and m. aron have in their article indicated the need for research in south africa. we hope that this contribution will stimulate the initiation of many research projects. m. marks has brought to our attention another important need in our profession: namely the importance of a closer co-operation between allied professions in the treatment of speech disorders. her particular emphasis is on the need for a teamwork approach to cleft palate rehabilitation in south africa. south african therapists have always relied on the knowledge of those who have studied elsewhere. visitors from overseas and those of us who have travelled, have brought the knowledge that nutures our profession. a. g. epstein, having recently visited our country, presents in his article some new and interesting ideas on the testing of articulation disorders. in this issue we have therefore attempted to indicate some of the most urgent needs of speech therapy in south africa as well as presenting some new ideas. it is our earnest hope that further interest in these fields will be stimulated. i journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t o n a l responses o f m e n t a l l y r e t a r d e d b r a i n i n j u r e d c h i l d r e n b y betty hunt bradley columbus state school, columbus, ohio. in recent years there has been an increased interest in auditory disorders of children and this has been extended to include the problem of auditory disorders in mentally retarded braininjured children. the mentally retarded braininjured child may reveal some difficulties in responding to auditory stimuli or may exhibit communication problems, but there may be other children with similar etiological backgrounds responding to auditory stimuli or may exhibit communication problems, but there may be other children with similar etiological backgrounds who do not have these problems, but rather encounter difficulties in other areas such as visual perception. problem it is the purpose of this study to present auditory stimuli, tones played on an autoharp, and to determine if mentally retarded brain-injured children respond in terms of specific perceptual difficulties, or if. there is a similarity of performance related to other factors such as mental age. this investigation is related to attempts for experimental validation of certain descriptive classifications used in educational research classes with mentally retarded brain-injured children as a basis for differential teaching methods rather than employing a teaching curriculum based on the categorization of so-called typical behaviour of "the organic child." the theoretical background for this diagnostic teaching approach has been based on the formulations of dr. lise gellner who has stated that learning handicaps as well as mental retardation result from specific perceptual losses due to biochemical damage somewhere in the cerebral systems of vision and audition. a summary of her position stated in her booklet entitled, " a neurophysiological concept of mental retardation and its educational implications," is as follows: "mental retardation is due to different kinds of learning handicaps resulting from structural or biochemical damage somewhere in the cerebral systems of vision and audition. there is a dichotomy of the visual and auditory pathways in the brain which accounts for the existence of two central systems of vision and audition. one of these systems serves the integration of visual and auditory impulses emanating in the retina of the eye or the cochlea of the ear, with kinesthetic impulses from the somatic structures (muscles, joints, etc.) of the body; the other system serves the integration of siich visual or auditory impulses with impulses emanating from all autonomic structures (inner organs, blood vessels, etc.). each of these four cerebral systems extends, from the respective sense organs, via some important specific ganglia in the midbrain to specific projection area in the cerebral cortex. if these systems are intact, the result is normal seeing or hearing, but impairment anywhere in one or several of these four systems results in disturbance of function (gellner, 1959)." each of these disturbances is termed a disability since there is a direct negative effect on the performance of the child. it is gellner's contention that classroom materials and methods of presentationshould be based on the child's highest ability area rather than forcing responses to materials which are frustrating to him because of perceptual disability. this does not imply that gellner does not recognize that there are some auditory disorders caused by cortical lesions, but she feels these are not as severe in their effect on learning as brain stem lesions due to the fact that many times they do not affect both sides of the brain and adjustments and retraining can be introduced. methods for this study 70 mentally retarded children 6 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) who were residents of the columbus state school at columbus, ohio, were selected. the ss were divided.into two groups: (a) thirty five-mentally retarded children diagnosed as brain-injured and classified as having severe difficulties responding to auditory tasks such as language comprehension and verbal fluency, and (b) thirty-five mentally retarded children diagnosed as brain-injured and classified as having minimal difficulties responding to auditory and language materials. as far as can be determined, these children do not have sensory hearing loss. medical diagnoses indicated that brain damage was the primary cause of retardation. these diagnoses as to etiology were made by a classification committee of the receiving centre of the columbus state school. the 70 mentally retarded brain-injured children were selected from a larger group of children who had a diagnosis of brain-injury and who had also received classifications on the basis of criteria in her behavioral descriptions of the four disability groups. the perceptual abilities were determined by performance of the children on certain tasks or materials that gellner states are indicative of a disability area, for example, perseveration, echolalia, poor vocabulary, speech defect, and withdrawn behavior. the groups were matched with respect to ma, ca, and iq obtained on the stanford-binet intelligence scale. table 1 presents identifying information concerning the two groups. neither by matched groups nor by matched pairs are the group differences on ca, ma and iq statistically significant. the assumption of homogeneity of variance was met. electroencephalogram findings yielded additional evidence concerning factor of brain-injury within this group. the social histories indicated no other mentally retarded members of the immediate families. there was one exception to this whereupon other factors were felt to be responsible for injury to two members of one family. in many cases, although not all, there was a personal history of illness or injury to which the subject's condition was attributed. the basic procedure consisted of obtaining judgements on the difference of tones and tonal patterns played on the "new golden autoharp". the tones were presented three seconds apart and were of 2.6 seconds duration. the autoharp was selected because of its availability and the lack of familiarity with the instrument by the children. instructions for section a. "listen, i am going to play one sound on this harp." (examiner points to the instrument and demonstrates.) "now, i will make another sound. you tell me if these two sounds are the same, alike, partners, or if they are not the same, do not sound alike, are not partners. after the tones w e r e demonstrated, the e. said, "see, the sounds table 1. descriptive statisiics on ss. i i ca ma iq group { n range μ sd range μ sd range μ sd bi-ad i 35 9.1-21.3 15.30 2.8 5.7-11.3 7.75 1.5 38-79 55.91 9.4 h-nad 35 9.6-22.6 14.90 3.0 5.5-10.8 7.77 1.5 37-75 57.34 11.0 ad — auditory disability nad — no auditory disability r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) are the same." this was reversed for the opposite example and there were two examples administered for each section, one exemplifying the same tones or tonal patterns, one differences. instructions for section b. " i am going to play a little song on this harp. it has three sounds. listen.," e. demonstrates. "now, i am going to make a song with three more sound. you tell me if the songs are partners , alike, the same, or if they do not sound alike, are not the.same, are not partners." as in previous sections, two examples were given. instructions for section c. "listen, i am going to play some big sounds that go together. they are called chords." e. demonstrates. "now, i will play them again. you tell me if they sound the same, are alike, partners, or if they are not the same or partners." examples were given. if the ss failed to grasp directions, they were repeated one time. description of instrument. one test involving identification of tones and tonal patterns consisting of three sections was administered to each subject individually. section a was composed of 55 separate items each involving identification of two tones. twenty-five of these tones were identical or repeat tones and 30 tones were different involving tone differentiations of one tone as well as tones spanning two octaves. there were five items differentiated by one tone; nine items including tones within the same octave; ten items involving tones in concurrent octaves and six items involving tones separated by more than one octave. seventeen tones were directed upward in scale, i.e. from low to high, 13 downward, high to low. there were no tones given that were separated by exactly one octave. repeat items involved two bass tones, seven tones in lower octave, seven in middle octave, and nine tones in high octave range. section β consisted of identification of three tones. three tones were played, an interval, three more tones. five of these tones were repeated on second administration. all but one item involving differences included some tones of at least one octave separation. section c consisted of 10 chords, five involving repeat chords and five different chords. these were chords available on the autoharp and produced by pressing down on labeled key. two of the five chords were very similar involving fine discriminations, i.e. g major and g minor. results. results have been analyzed and presented in tabular form. table 2 shows the t ratio based on related samples for two paired groups of mentally retarded brain-injured children. the difference in scores between the mentally retarded brain-injured children with minimal auditory handicaps and the mentally retarded braininjured children with severe auditory handicaps table 2. performance of the matched pairs of mentally retarded brain-injured children on tone judgements. group mean sd t brain-injured nad ** 57.94 10.11 2.70 *** brain-injured ad * 52.03 8.3 * ad designates auditory disability. ; ** nad designates no auditory disability. *** ρ .05. the probabilties used are for a two tailed test of significance. 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) was significant beyond the .05 level. this allowed for a rejection of hypothesis i which stated in null form that: "mentally retarded brain-injured children without sensory hearing loss classified as having minimal difficulties in responding to auditory stimuli will not receive higher scores at a significant level (..05) than mentally retarded brain-injured children without sensory hearing loss having severe difficulties in responding to auditory stimulia bartlett's test revealed variances between the two groups to be homogeneous. correlations between performance of the groups and ca, ma and iq were insignificant, ranging from -.12 to .29. when a separate analysis was made in accordance with performance on each section, there were significant differences at the .05level on identification of two tones, section a; and identification of chords. section c, favoring the non-auditory group. differences were not significant for section b, three tones, but the trend was in the expected direction of higher scores for nonauditory mentally retarded brain-injured children. as was expected, the tone differentiations involving judgements of one tone separation were more difficult for both groups than tones involving differences of an octave or more. discussion. as gallagher has indicated in his book, the area of auditory perception has been almost neglected in terms of experimentation with braininjured and non brain-injured groups. werner and bower, in 1941, compared three groups of children: endogenous, exegenous, and normal, on their ability to reproduce melodic patterns. (ca: 6 years 10 years.) each child was asked to reproduce vocally a petternplayed on the piano. there were no differences noted in rate of errors but some subjective differences were noted in terms of organization of patterns, i there ha\|e been some studies regarding presentation of|auditory material to mentally retarded brain-injured children, but these seem more directly related to language development rather than judgements of tonal attributes. results of this experiment indicated differences in matched pairs of mentally retarded brain-injured children beyond the .05 level favoring the children with minimal, problems responding to auditory materials. there has been more discussion recently as to the need for individual tutoring of mentally retarded braininjured children based on their individual problems rather than relying on stereotyped behaviour patterns of these children. barnett, ellis and pryer suggest description of children iri terms of behaviour measures with the elimination of the term, "brain-injury." these results may indicate that the type of materials and the methods of presentation and stimulation may be a factor in their performance level rather than complete reliance upon etiological factors. however, in gallagher's sample the general mental ability factor accounted for approximately four times as much variance as did the perceptual factors. the results from this study in connectioc with other related studies seem to concur with gellner's suggestions that there is no one "organic" type of behaviour which is elicitec from mentally retarded brain-injured children. if hyperactivity, motor restlessness, mental age level, and clinical pictures, as described by strauss and bender, were primary factors in performance of mentally retarded brain-injurec children, one would predict similar scores from children matched on basis of etiological factors, ca, ma and iq. this did not occur. gellner thinks the problem of children who are described often as having difficulties with echolia, chattering, poor spontaneous speech, perseveration, word finding difficulty and difficulty in communicating especially with unfamiliar material and good speech patterns may have difficulty with musical tones due to injuries involving nuclei serving loudness and pitch. this assumption requires more experimentation and refinement with the present experiment, serving as an exploratory study involving identifications of tones rather than discrimination of pitch and loudness. summary. auditory stimuli, tones played on the autoharp were presented to two groups of mentally retarded brain-injured children. these children were paired on the basis of ca, ma and iq. they were differentiated into two groups: (a) thirty-five classified as having severe difficulties responding to auditory tasks such as language comprehension and verbal fluency, and q r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) (b) thirty-five children classified as having minimal difficulties responding to these materials. these groups were differentiated on the basis of criteria stated by dr. lise gellner as indicative of auditory disabilities. results showed differences significant beyond the.05 level suggesting higher performance level for mentally retarded brain-injured children with minimal auditory handicaps. there was little positive relationship shown between performance on tonal judgements and mental age as obtained on the stanford-binet intelligence scale and chronological age. the implications in terms of curriculum planning are discussed. opsomming. gehoorstimuli, tone gespeel op 'n outoharp is aan twee groepe van breinbeseerde, verstandelik-vertraagde kinders gebied. hierdie kinders is vergelykbaar volgens kronologiese, ouderdom, verstandsouderdom en i.k. hulle is in twee groepe verdeel. (a) vyf-en-dertig is geklassifiseer volgens ernstige probleme i.v.m. reaksie op ouditiewe take bv. taalbegrip en verbale vlotheid en (b) vyf-en-dertig is geklassifiseer omdat hulle minimale probleme op hierdie gebiede vertoon. hierdie groepe is gedifferensieer op gronde van kriteria wat deur dr. lise gellner gestel is as 'n aanduiding van ouditiewe orivermoens. die resultate dui op beduidende verskille vanaf die .05 peil wat weer op 'n hoer graad van optrede dui by die verstandelik-vertraagde kind met minimale gehoorsgebreke. daar is blykbaar geen positiewe verband tussen reaksie op toonbeoordelings, verstandsouderdom, soos deur die stanford binet intelligerisieskaal vasgestel en kronologiese ouderdom nie. die gevolg van hierdie bevindings ten opsigte van die beplanning van 'n kurrikulu m word bespreek. references. bamett, c., ellis, n.r., and pryer, margaret. "learning in familial and brain-injured defectives." amer. j. ment. defic. 1960, 64, 894. gallagher, j.j. " a comparison of brain-injured and non-brain-injured mentally retarded children on several psychological variables.." child dev. pub., 1957, monographs of the society for research in child development, inc., vol xxii, serial no. 65, 1957, no. 2, 17. gellner, lise. " a guide to the differential diagnoses of the four organic roots of mental deficiency," personal communication. gellner, lise. " a neurophysiological concept of mental retardation and its educational implications." chicago: levinson research foundation, 1959. hunt, betty. "differential responses of mentally deficient brain-injured children and mentally deficient familial children to meaningful auditory material." amer. j. ment. defic., 1960, 64, no. 5. patterson, ruth and hunt, betty. "performance of brain-injured and familial mentally deficient children on visual and auditory sequences. amer. j. ment. defic., 1958, 63, 72-80. werner, η., and bowers, m. "auditory motor organization in two clinical types of mentally deficient children." j. genet. psycgo., 1941, 59, 85-99. 10 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the investigation of the disintegration of phonemic discrimination on a perception and production level in adults with aphasia* j. levinsohn, b.a. log. (rand) it has been established for some considerable time that the role of audition in learning to speak is extremely important. the perception of auditory stimuli determines the child's ability to understand as well as to produce speech. cherry14 suggests that speech perception (i.e. understanding) and speech production, are the same phenomenon in the normal individual. schuell, jenkins and jimenez pabonir> go one step further and show how the auditory mechanism is also responsible for monitoring speech. the authors conceive of the language system as being dependent on the auditory system for processed information and regulation and control, mediated through feedback loops. the perception and production of speech sounds are based on the discrimination between the essential (phonemic) signals and the nonessential signals which are determined by the linguistic signals to which the child is exposed — this process is carried out by the auditory mechanism. (bauman1). luria1 2 explains that the auditory-articulatory system is responsible for learning of discrimination between speech sounds, which enables the individual to understand and produce speech. the link between perception and production in the normal person's language ability is stressed by luria: t h e p r o n u n c i a t i o n , i.e. t h e a r t i c u l a t o r y s t r u c t u r e of words, takes place on a basis of p h o n e m i c hearing: however, t h e articulation of sound itself plays an active role in t h e formation of p h o n e m i c hearing. modern investigators, basing their evidence mainly on clinical observation, show that it is this auditory mechanism that breaks down in the aphasic (ebbin2). schuell15 considers an auditory impairment to be basic to the aphasic's difficulty and concludes from a study on fifty-six aphasics that there is always some impairment of auditory processes in aphasia. she clarifies the nature of the auditory breakdown by explaining that the aphasic patient is unable to retain an auditory configuration or to summon it when required, i.e. there is a breakdown in the process of reauditorization. • b a s e d o n a s t u d y p r o j e c t p r e s e n t e d t o t h e s u b d e p a r t m e n t o f s p e e c h p a t h o l o g y a n d a u d i o l o g y , u n i v e r s i t y o f t h e w i t w a t e r s r a n d , 1968. journal of the south african logopedi society, vol. 16, no. , dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the investigation of the disintegration of 49 guttman,4 street,18 miller13 and karlin et al8 show, through experimentation, that some auditory impairment existed in the aphasic subjects tested. eisenson3 uses luria's explanation of the auditory analyser (situated in the secondary division of the auditory cortex of the left cerebral hemisphere) to explain that the process of auditory perception is not merely a passive receiving of stimuli but includes the analysis and integration of these stimuli. thus it has efferent as well as afferent functions. the auditory analyser is closely associated with the cortical apparatuses of the kinesthetic (articulatory) analysis. it has so far been established that: (a) audition is vital in the normal individual's understanding and production of speech; (b) many investigators feel an auditory disorder to be basic to the aphasic's language breakdown; (c) neurological findings confirm the link between perception and production both structurally and functionally. it seems feasible to postulate that dividing the aphasic's symptoms into those of understanding speech and those of producing speech is artificial, thus the receptive-expressive classification of aphasia is questioned. it seems possible that both receptive and expressive symptoms exhibited by the aphasic involve an auditory dysfunction. it has been felt for a number of years that some aspect of hearing accounted for receptive problems. wernicke's sensory aphasia was based on a loss of normal auditory control and kleist's word-sounddeafness occurred when the patient failed to appreciate speech sounds. it is only recently, that an imperfect auditory process has been used to explain the aphasic's expressive problems. keenan9 shows that where the auditory stimuli of language cannot be retained, both understanding and expression of language become impaired. thus receptive and expressive language impairments are not different forms of aphasia, but rather different manifestations of one underlying impairment. if audition is basic to the aphasic's problem of expression, and if the auditory perception centre and the articulatory centre are closely related, the articulatory errors made by an aphasic subject should be similar to his errors in the perception of phonemes, i.e. the phonemic disintegration shown by an aphasic subject should be the same on a perceptual (intake) and production (output) level. on this hypothesis the following experiment was carried out. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 50 j. levinsohn procedure subjects. seven aphasic subjects were used in the experiment. they formed a fairly representative sample as the major variables of sex. age, educational level and economic standing were represented. as one test required standardization on a normal population, six 'normal' subjects were also used and were chosen so as to represent the variables mentioned above. aphasic subjects. s a β c d ε f g sex .. f μ μ μ μ μ f age . 28 52 38 30 60 67 20 education .. st. 8 univ univ univ m a t r m a t r matr economic level .. l u u μ l m μ u m normal subjects. s a β c d ε f sex f μ f f μ μ age 21 19 45 60 44 58 education .. univ univ st. 8 m a t r matr u n i v economic level .. u μ lm u l μ abbreviations: univ: university education u: upper income group m: middle income group l: lower income group u m : upper-middle income group l m : lower-middle income group f: female m : male. tests used. a battery of tests was given to each aphasic,subject: (a) hildred schuell's short examination for aphasia.1' this was used to determine whether the subject was aphasic and, if so, what type. the following aspects of language were examined: (i) auditory: this includes tests of i auditory recognition, retention span and comprehension. journal of the south african logopedic society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the investigation of the disintegration of 51 (ii) reading: tests of visual and auditory word recognition and reading comprehension were included. (iii) speech and language per se: here tests of cranial nerve involvement, sensorimotor involvement and functional speech were included. (iv) writing: the subject was tested on revisualization, spelling and functional writing. the scores obtained by the subjects determined to which of the five groups they belonged. schuell states: probably 90% of aphasic patients fall into one of the five main groups, when classified according to pattern of impairment. schuell offers the following explanation for each of the five groups: group (i): this is characterized by an almost total loss of all language functions. group (ii): only auditory processes are impaired, but the impairment is reflected in defective speech, reading and writing. group (iii): shows the same pattern as group (ii) but is complicated by specific visual impairments. group (iv): there is an involvement of auditory and sensorimotor processes. group (v): scattered auditory, visual and motor (usually cranial nerve) impairment compatible with generalized brain damage is found. some language is usually retained. (b) pure-tone audiometry. according to the specific hypothesis of this study, tests were needed which would determine the subject's hearing acuity, thus enabling the experimenter to establish whether phonemic errors, if present, were caused by a hearing loss or a perceptual problem. thus an audiometer was used to establish the subject's threshold of detection for pure-tones. this was also necessary as a control measure. knowledge of the subject's pure-tone threshold would enable the experimenter to compare this with the speech reception threshold and the speech discrimination results, and establish whether there was any similarity. (c) audiometric speech reception thresholds: this test establishes the threshold at which a subject is just able to hear speech. this is essential as it must be known whether the words in a phonemic discrimination test were inaccurately perceived or merely not heard. (d) phonemic discrimination perception test. the hutton, curry and armstrong semi-diagnostic test" was used. this particular test was chosen as it appears to be well standardized, includes discrimination between vowels as well as consonants, and the words used are tydskrif van die suid-afrikaanse logopediese vereniging, vol. 16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 j. levinsohn fairly common ones. the purpose of a perception speech discrimination test in this study is to establish the aphasic's ability to distinguish between the phonemes presented aurally. the subject was required to mark off on a sheet of words grouped in fours, the stimulus word e.g. bowl, bail, ball, bull formed one group, and bowl was the stimulus word. (e) phonemic discrimination production test. the schuell picture test for consonants and the picture test for vowels were used.17 both tests consist of a series of pictures. each card contains two pictures and the names of the pictures differ from each other by one phoneme only; i.e. the names are minimal pairs, e.g. pea and bee. these form one series of the consonant test and shed and shared form one series of the vowel test. from these tests, the aphasic's ability to distinguish between phonemes aurally was assessed. (f) it was considered interesting to note whether the hypothesis could be extended to include discriminations produced in spontaneous speech. thus, a sample of each subject's speech was recorded and errors transcribed. an attempt was made to keep the testing procedure standard for all subjects. the physical environment, instructions and rest periods were similar for each subject. each subject was tested over two sessions to avoid fatigue, and the order of test presentation was constant. a two-room set-up was used for the phonemic-perception discrimination test. results (a) the results of normals on the vowel discrimination test: all subjects were able to discriminate adequately between the phonemes presented by the pictures. (b) results of the shorter schuell test: all seven subjects showed aphasic symptoms, and could be classified into one of the five schuell groups. as can be seen all groups, except group one, were represented. subject schuell group a 2 β 4 c 5 d 3 ε 3 f 2 g 2 summary of symptoms for / each group / only auditory processes impaired involvement of ' a u d i t o r y and sensorimotor processes scattered auditory, visual and motor impairment auditory processes impaired plus specific visual involvement as d above only auditory processes impaired as f above journal of the south african logopedic society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e nvestigation of the disintegration of 53 (c) results of hearing tests: summary table of each s u b j e c t ' s audiogram, average level of speech range and speech reception threshold. a verage intensity speech receptii on s age pure-tone hearing for speech range threshold a 28 right ear: normal right ear: 8 db right ear: 5 db lift ear: normal left ear: 8 db left ear: 0 db β 52 right ear: 8000 cps right ear: 0 db right ear: 0 db at 25 db right ear: left ear: normal left ear 2 db left ear: 0 db c 38 right ear: 8000 cps right ear: 3 db right ear: 0 db at 50 db right ear: left ear: 8000 cps left ear: 13 db left ear: 10 db at 40 db d 20 right ear: normal right ear: 7 db right ear: 0 db ί eft ear: normal left ear: 3 db left e a r : 0 db ε 60 right ear: 4000 cps right ear: 7 db right ear: 0 db at 40 db 8000 cps at 50 db l.eft e a r 4000 cps left ear: 8 db left ear: 10 db at 45 db 8000 cps at 70 db f 67 right ear: 4000 cps right ear: 13 db right ear: 35 db at 50 db 8000 cps at 55 db left e a r 4000 cps left ear: 32 db left ear: 40 db at 55 db 8000 cps at 65 db g 21 right ear: normal right ear: 1 db right ear: 10 db left ear: 4000 cps left ear: 26 db left ear: 25 db at 25 db 8000 cps at 50 db five out of seven subjects showed normal bilateral hearing. the remaining two showed a unilateral loss in the left ear with a conductive-type loss for the speech frequencies. one could, therefore, expect almost a 100% speech discrimination score for all the subjects. four out of seven subjects showed a sensori-neural type of loss in the high frequency range. it seems unlikely that this is caused by presbycusis as the mean age of the subjects showing this was forty-six years. also, as the case histories of the subjects do not reveal any possibility of a noise-induced loss, it was hypothesized that the loss was the result of the aphasic condition rather than any specific auditory disorder. the subjects showed a lower hearing threshold for pure-tones than for speech. this points to cortical pathology (which is known in these subjects) and also the possibility of speech discrimination difficulties. (d) similarity between phonemic discrimination on a perception and a production level was shown. tydskrif van die suid-afrikaanse logopediese vereniging, vol.16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54 j. levinsohn "α ρ fu 0 κ tq c a "a ~ ε 5 a ο a, e ο 3 -q ο a ft. c. υ <1 . ο a η. ο <1 £ 3 ό ο ό c λ > .η ο, .2 tλ rt -ο ίλ 3 c ϊ ο j • g>° "λ ε s λ ο ii-jjjbo λ u ϊλ & 3 c ή ° ί h e * ο c ο λ ο ιj i f f l μ ο λ _ο c . ο •ο ".β (λ 3 c •2*0 μ c "j u c u rt ο >j j s e a c λ c ο (λ c ο ο 3 •ο ο •ο c π) c. ο ο § | · c c ω> c ο c ί ο •ο μ ct ο ι* m c υ .β (λ •3 "ο ο c. — '3 j) c tn c c u c ο •ο i α 1 ω ' . . „ ρ3 cq ι ξ c s ο ο u ό _ ο c • ω ο > λ 5 c ω "2 ce •ο τ3 ο c " cs "rt ή c c hh π ; 3 •ό c 5 ο ™ λ ο c > 3 •ο ο ό c ; ω ο ι s o 3 — α α c c cd ^ -ο 5 ω . ο α> (α ί> > u> 'δ r« ο. c (λ · cj (λ 71 3 c «2 | ι ι ε c « c ο s <υ ι r-l m νη \£> γνu 3 ο · ο (λ γ3 ο (λ « ο ϊ ο ω « •β» ^ g a a s * σζ ο rj c m •s ^ μ ° 8 "2 •o -9 « ω υ g-" •ξ .ξ ο c ί ο •ο μ c λ ο u •ο a έ ce 5 3 ® s ϊ ιg ιμ ca i = c a s ω c c u rt ο ο γ 1 c ο . '2 υ u ·3 ρ (λ ίλ cd .β _ο ^ c c. c ' 2 · c 5 ο α ο ο c ο ^ u οι ό u s u hj chj tvrf ^ ili o h j: —1 ce cq m η c ct c ο (λ c ο ο journal of the south african logopedic society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e investigation of the disintegration of 55 a 0 κ 3 3 >"a kj c a ε c a f 's. "a ο ft, c g q; a n. ο «2 ο k. k. 3 ό ο c ο ο c c ω ί ί , ο οτ -α -ο rt cz -i. ω u s tο m m > —' rj c bo ο c i g c c ω ί ί , ο ο + τ3 -ο ω ω ? ' ο > mm e 6 0 ρ s ίλ js £ "ω ιc §ξ c c cs ω ο οτ ό ό d ra > ο ω ρ mm > ο > s υ ο j ο, c 2 .2 u ^ 2 c ε •3 λ ε<« ή 2 3 ιυ (λ •a u 2 η s ε tο ω · γι ο u >dh ζ π) •ο π) ε ο ζ 8 s ..ϋ g •—ο ce "· < e c «η ω ε < ° ί · 2 ο-^.ξ s . g | α» ο u l> " ω c ; s o § * £ ^ ω r. μ" « • α » , » c ξ*° § s ο e g c ο * a a 2 t c ra rt aj i j j f t ο ^ c*i r^ ζ u c nj c ο <s1 c ο ο ο > .a is c ί ο •ο " ίλ c >, cs ~ s ο ° ο 2 •ο c λ c ο ίο ce g ή •c ο •3 3 ω ο β; c λ ο ο c ο ίλ c ο . 3 « e '3 2 | 8 m s ^ s . 3 5 2 s g θ ό · ε ά , ε . s h s — r-t -ο c 2 3 > am π g i ° «1 •6 c ο μ ° ο ο y c i"3 λ ο m 2 i . e χι ct ο χ .& ε · a · ε ο · _ ιλ d •s ή α _ w c 3 ο —' 5ρ •q ιλ ο ο u i j : « ri c ct c ο (λ c ο ο •ο ' 2 c g ι. ο ί 3 · ο η οτ3 ο 3j< c12 £ υ β,βο " rj •g ο ω c ο m ο -κ ω> γ— ιμ λ α) c . s 5 • " ε ο c 'c τ-, * 8 c ο^[β -ο ^ ι"u 2 2 * ιο ο m ο-ι > ο > tydskrif van die suid-afrikaanse logopediese vereniging, vol. 16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 j. levinsohn "s i z* s5 ^ "o tl -21 "a kj c a .2 hj ft. -a ο •3 ho s a ft. « κ a ft. a to q, (λ w ω ο >-λ i ο ό μ α <υ ucq ο ό μ cq ω 3 ό ο > c a ο c •ο .2 ω w !υ ο α, λ -α cq . ο <υ cd ά. ο « <u c λ ° cq υ c .-β c ο <λ c ο υ ο -α μ λ v— cq 0j u. cq 3 ό ο τ3 ο c <λ i s •α c ^ ο m υ ω c ο c ? ο ό μ cq α, ε ο λ ο. ε ο 8 s c i (2 — η ο i i * 3 ο. ε ο •c 3 ιλ — (ν ο > ο ο cl, η •ό > v— <4~ <u •5 ο \ = —1 μ 3 ό ο •ό c λ ή ο. 3 "" ο ο μ ο ο ε α ο h-t j: ρη u μ c c μ •2 § ο υ ο > α ε ο. ο £ u μ c . c τ3 1ο u of | ^ ιλ u τ3 χ> λ + 3 ,2 υ υ « £ £ 5 journal of the south african logopedi society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the investigation of the disintegration of . 57 ζ ο ρ υ 3 ο g α. ο ζ υ cc ω cc υ u) υ σ ω ζ ο ι a ? ί-α) α. < -ι | 55 σ σ 3 ιλ .6 ζ ~ "3 -α ^ δ <υ s « -ο o h 2 β co α a ttj c 3 . 0 1*1 o. "a ο •ο ο ^ 3 ft. •ο ho ΐ «2 u1 ο to υ kh kh • o > ί -α ο .ο is c ϊ ο ό μ cq ο υ _> l· c ? ο « ό % co w ω c ο ο . ί η .5 μ j λ — (ν χ cd ^ cd rt ο 4 > c <? ο d. c c s ο ο " ό _ ίο ·<-> s c 1— flj cq-s — (ν s λ .5 ϋ '•3 ή ^ s » § ό. o -s ω ο 0) > ο u •ό _ •χ cd cd ~ υ c ιu cq ό λ χ ο υ _> cd ά c ? ο — ό % μ 2 cd s c £ ο cq υ χ cd ε . · — (λ 3 "ΐί ο ο ω ο u ε 3 . s c ? ο ό 2 μ 2 cd w u c λ ο cq ο cd ι1 1 ο υ ό _ •a a ω c cd χ c ? ο ό cqt3 cq ο · (λ cd ή α. ο | _ο c υ ε « ο —1 ε . (λ ii. u · (λ cd ^ α ο ω _ο υ ε cd ο •sjs fc-5. r * 1λ <d i 3 .. i s ο ο ω is.s χ * o. ε ο 3 ό ο cd'-c. ι3 υ ο i ! c ο υ c . s .2 c q, λ ρ 3 9η c ο > tydskrif van die suid-afrikaanse logopediese vereniging, vol.16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 58 j. levinsohn discussion (a) intra-subject responses on perception and production levels tended to be related. this was seen either as the same substitution of one phoneme for another on the perception and production tests or as a trend or error pattern observed in both tests (e.g. a breakdown in front:back contrast of consonants). the degree of similarity differed for each subject and although all showed some phonemic breakdown which existed on both the input and the output levels, all subjects but one also showed phonemic breakdown on one level and not on the other. however, owing to the limitations of the tests used (to be discussed more fully later) although the results do not support the hypothesis fully, neither do they negate it. (b) little similarity existed between phonemic errors in isolation and in spontaneous speech. (c) a number of relevant factors, not specifically related to the hypothesis, were noted: (i) the subjects' phonemic errors were not random and inconsistent but followed a phonemic trend or pattern. this is in accordance with schuell's results.1"' (ii) there was a strong similarity between auditory-type aphasic symptoms and phonemic discriminatory ability. (iii) the severity of the aphasia seemed closely linked to the degree of phonemic breakdown. diagnostic and therapeutic implications (a) a full audiometric assessment should be one of the tests used for testing aphasics. i (b) if some form of auditory breakdown is evident in all aphasic patients it is likely that other cases of cerebral dysfunctioning also have neural auditory impairments. : (c) if auditory perception and spieech production are linked, auditory training with patients should be done. accurate listening and phonemic discrimination should aid speech production and influence the use of language. journal of the south african logopedic society, vol. 16, no. 1, dec 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the investigation of the disintegration of 59 limitations and evaluation of study (a) only seven aphasic subjects were used in the experiment. it is impossible to draw conclusions and generalize test findings based on so small a sample. (b) the scope of the study did not allow the author to draw up identical tests of phonemic discrimination for perception and production. factors such as the phonetic environment of the phoneme being tested and the fact that blends were included in the perception test but not in the production test, reduce the reliability of the tests used. (c) as aphasics are known to show perseveration difficulties it is possible that a repeated response was noted as a phonemic error. (d) as the phonemic discrimination tests demanded a word-naming ability, it was difficult to discriminate, with some subjects, whether the difficulty was one of word-naming or of phonemic breakdown. (e) one cannot state definitely that the disintegration of phonemic discrimination was the result of a cortical or a retrocochlear disorder. (f) the fact that little similarity was shown between perception and production test results and spontaneous speech can be attributed to the fact that the samples of speech elicited were inadequate as they were too short. implications for research (a) the results of this study as well as experimental evidence and clinical observation seem to indicate that auditory impairment may be the core of most aphasics' difficulties. however, the exact nature of how audition affects or causes other aphasic symptoms is not understood. in terms of the particular symptom analyzed in this study, further experimentation is needed to determine the relationship between auditory perception and a breakdown in phonemic discrimination on an articulatory level. (b) it is extremely important to establish at what level of auditory perception the aphasic breakdown occurs. hirsch,5 offers four levels of perception: (i) detection. this is the threshold at which sound is just heard. (ii) discrimination. the listener compares one speech sound with another. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 j. levinsohn (iii) recognition or identification. the listener compares incoming sound stimuli with his memory of sounds and words. (iv) comprehension, i.e. recognition sustained over a long period of time. the testing of an aphasic patient on these four levels would also test the functioning of the auditory analyser (a term used by luria1 2) to note whether the auditory defect was one of analyzing, comparing, or synthesizing received auditory stimuli. (c) all subjects in this study showed some degree of phonemic breakdown. does this breakdown mirror the child's acquisition of phonemic discrimination? jakobsen ar.d halle7 state: the linguistic, especially the phonemic, progress of the child and the regression of the aphasic obey the same laws by implication. if this were indeed so, one could determine the aphasic's level of phonemic disintegration and assign this to the particular developmental level of phonemic competence of the child. therapy would aim at teaching the aphasic the next and following stages through which the child normally progresses. summary as more stress is being placed on the auditory disability of aphasics, the validity of dividing aphasic symptoms into expressive and receptive disorders is queried. the reflex-arc seems too simple a configuration to explain the complex functioning and breakdown of language. it is postulated that the auditory disorder is basic to aphasic symptoms on the level of understanding as well as that of production of language. thus, if an aphasic patient shows a breakdown in the perception of phonemes, it seems likely that the auditory imperception will affect the production of the same phonemes. aphasic subjects were presented with tests of phonemic discrimination on a perceptual and a production level and the similarity of phonemic errors was noted. the results of the experiment seemed to indicate that^a' hearing loss did not account for the subject's phonemic disintegration. however, it was not possible to control certain factors thus this result is not conclusive. the similarity between errors on an input level and those on an output level was poor, according to the result of the perception and production tests used in the study. however, despite the inadequacies of the tests used, all subjects showed'some degree of similarity and this tends to support the hypothesis. the errors in phonemic journal of the south african logopedic society, vol. 16, no. , dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the investigation of the disintegration of 61 discrimination indicated by both perception and production tests were not random and inconsistent, but followed a trend. it was noted that the severity of the aphasic symptoms seemed closely linked with the degree of phonemic breakdown. also, the subjects tested showed a significant similarity between auditory-type aphasic symptoms and phonemic discriminatory symptoms. little similarity existed between phonemic errors in isolation and in spontaneous speech. opsomming aangesien meer klem geplaas word op die ouditiewe onvermoe van afasie gevalle, word die geldigheid van 'n verdeling van afatiese simptome in ekspressiewe en reseptiewe versteurings in twyfel getrek. die refleksboog blyk 'n te eenvoudige konfigurasie te wees om die komplekse funksionering en afbraak van taal te verklaar. dit word veronderstel dat die ouditiewe versteuring onderliggend is aan afasie simptome op die vlak van begrip asook op die vlak van taalproduksie. as 'n afatiese pasient dus 'n afbraak toon in die persepsie van foneme, blyk dit dan waarskynlik te wees dat die ouditiewe onvermoe die produksie van dieselfde foneme sal aantas. fonetiese diskriminasietoetse is op 'n perseptuele sowel as produksie vlak gegee, en die ooreenkoms van fonemiese foute is aangeteken. die resultate dui daarop dat 'n gehoor verlies nie die oorsaak is van die geval se fonemiese disintegrasie nie. sekere faktore kon nie konstant gehou word nie, dus is daar nie afdoende bewys vir hierdie resultaat nie. volgens die uitslag van die persepsie en produksietoetse wat gebruik is in die studie kon afgelei word dat die ooreenkoms tussen foute op ontvangsvlak, en die op vlak van weergawe swak was. ten spyte van die ontoereikendheid van die toetse wat gebruik is, het alle proefpersone 'n mate van ooreenkoms getoon en dit ondersteun die hipotese. die foute in fonemiese diskriminasie wat aangetoon is deur beide persepsieen produksietoetse was nie lukraak en onkonstant nie, maar het 'n definitiewe lyn gevolg. ' daar is opgemerk dat die erns van die afatiese simptome nou verwant blyk te wees aan die graad van fonemiese afbraak. die proefpersone wat getoets is het ook 'n beduidende ooreenkoms getoon tussen ouditiewe-tipe afasie simptome en fonemiese diskriminatoriese simptome. klein ooreenkomste het bestaan tussen fonemiese foute in isolasie en spontane spraak. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 16, nr. 1, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 j. levinsohn references 1. bauman, s. (1964): an organismic approach to some concepts of dysphasia with particular reference to the work of a. r. luria and soviet scientists. paper presented at the conference on aphasia at the university of pretoria. june 1 6 t h 1 7 t h , 1964. 2. ebbin, s. c. b. (1967): speech sound discrimination of aphasics when inter-sound variable is varied. journal of speech and hearing disorders. 10, 1. 120. 3. eisenson, j. (1968): developmental aphasia: a speculative view with therapeutic implications. journal of speech and hearing disorders, 33, 3. 4. g u t t m a n , b. j. (1967): investigation of speech reception and discrimination in adults with aphasia. unpublished study project for b.a. log., university of the witwatersrand. 5. hirsch, i. j. (1966): auditory perception of speech. vol. iii. ulca f o r u m in medical sciences, 1966. 6. hutton, c., curry, ε. t. and armstrong, μ. b. (1959): se'mi-diagnostic test materials for aural rehabilitation. journal of speech and hearing disorders, 24, 4, 321. 7. jakobsen, r., and halle, m. (1956): fundamentals of language. m o u t o n & co., gravenhage. 8. karlin, i. w., eisenson, j., hirschenfang, s., and miller, m. (1959): a multi-evaluational study of aphasic and non-aphasic right hemiplegic patients. journal of speech and hearing disorders, 24, 369. 9. keenan, j. s. (1968): the nature of receptive and expressive impairments in aphasia. journal of speech and hearing disorders, 33, 1. 10. licklider, j. c. r. (1952): on the process of speech perception. journal of the acoustic society of america, 24, 6. 11. liebermann, c. s., cooper, r., shankweiler, b. and studdert-kennedy, b. j. (1967):' perception of the speech code. psychological review, 74, 6. 12. luria, a. r. (1958): brain disorders and language analysis. language and speech, 1, 14. 13. miller, μ. h . (1960): audiological evaluation of aphasic subjects. journal of speech and hearing disorders, 25, 333. 14. price, l., david, c. s. and goldstein, r. (1965): abnormal bikesy tracings in normal ears. journal of speech and hearing disorders, 139-144. 15. schuell, h., jenkins, j. j. and jimenez-pabon, e. (1965): aphasia in adults. hoeber medical division, h a r p e r and rowe, n.y. and london. 16. schuell h . (1953): audiological impairments in aphasia. significance and retraining techniques. journal of speech and hearing disorders, 18, 14. 17. schuell, h. (1967): a short examination of aphasia. neurology 7(a), 1957. 18. street, b. s. (1967): hearing loss in aphasia. journal of speech and hearing disorders, 22, 60. 19. weisenberg, t. and mcbride, m. (1965): aphasia — a clinical and psycho logical study. oxford university press, n.y. journal of the south african logopedic society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sajcd 218 editorial this edition of the sajcd showcases some of the best research currently being carried out in the field of communication sciences and disorders, both locally and abroad. you will find here a stimulating mix of audiology and speech pathology papers – linked together by the developing contexts in which the work was carried out, and the desire to build the evidence base for our work in this context. i am extremely proud of the journal’s growth over the last few years – both in terms of the number of papers submitted (we are very often run off our feet as we try to manage them!) and also the quality of the papers and the peer reviews we receive. our website http://www.sajcd.org.za/index.php/sajcd/index has almost 300 registered users who regularly download papers, carry out reviews or submit papers of their own. in addition to these regular users, we have an impressive set of stats about the number of ‘casual’ visitors to the site each day and the frequency with which papers are downloaded by interested parties from all over the world. our small journal is widely read. the editorial board has a responsibility to support and develop the academic writing and reviewing skills of all interested members of the profession. this is a commitment that we take seriously, especially given the small size of our professions and our developing context where funding for postgraduate training and research support is often limited. in some cases, an editor (together with input from anonymous peer reviewers) may work intensively with first-time authors – sometimes over rather extended periods of time – to ensure that a paper is ready for publication and meets the required standard of the journal. we are proud of the support we have given and the generous feedback we receive about this developmental approach – it makes the editorial process worthwhile. this will be my last volume of the sajcd as editor. it is time for another editorial team to take over. i want to thank my co-editors: vivienne norman who has given of her time and expertise so generously and efficiently over several years, and dunay taljaard who acted as a co-editor for this year’s edition. our editorial board consists of a stalwart group of individuals who support and advise the core editing group; thank you for your support, wisdom and dedication. peer review is a key component of high-quality scholarly publishing; reviewers are asked to make a considerable investment of their time and energy in carrying out this work. thank you to everyone who has carried out peer reviews for the journal over the past few years – your contributions are greatly appreciated. michelle pascoe editor-in-chief abstract background to the research survey the research method results of the survey discussion and implications of the results conclusion acknowledgements references footnote about the author(s) thandeka mdlalo speech therapist, livingstone school, durban, south africa penelope flack discipline of speech language pathology, university of kwazulu-natal, south africa robin joubert discipline of occupational therapy, university of kwazulu-natal, south africa citation mdlalo, t., flack, p., & joubert, r. (2016). are south african speech-language therapists adequately equipped to assess english additional language (eal) speakers who are from an indigenous linguistic and cultural background? a profile and exploration of the current situation. south african journal of communication disorders, 63(1), art. #130, 5 pages. http://dx.doi.org/10.4102/sajcd.v63i1.130 original research are south african speech-language therapists adequately equipped to assess english additional language (eal) speakers who are from an indigenous linguistic and cultural background? a profile and exploration of the current situation thandeka mdlalo, penelope flack, robin joubert received: 23 may 2015; accepted: 29 nov. 2015; published: 18 mar. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract this article presents the results of a survey conducted on speech-language therapists (slts) regarding current practices in the assessment of english additional language (eal) speakers in south africa. it forms part of the rationale for a broader (phd) study that critiques the use of assessment instruments on eal speakers from an indigenous linguistic and cultural background. this article discusses an aspect of the broader research and presents the background, method, findings, discussion and implications of the survey. the results of this survey highlight the challenges of human and material resources to, and the dominance of english in, the profession in south africa. the findings contribute to understanding critical factors for acquiring reliable and valid assessment results with diverse populations, particularly the implications from a cultural and linguistic perspective. background to the research survey this article presents an aspect of a larger phd study, the aim of which was to critically evaluate and interrogate the use of language assessment tools, in their current form, within the south african context and to produce guidelines for adaptations to these tools that will better accommodate english additional language (eal) speakers. these guidelines and principles could be used by language professionals to manage the assessment process and interpretation of findings from eal speakers in a more accurate, appropriate and equitable manner. the term ‘eal speaker’ is used here to specifically refer to south african multilinguals who are non-mother tongue speakers of english and are from indigenous language and cultural backgrounds1. the larger study makes use of a specific screening tool as a model, to exemplify and illustrate the argument. in this study, the cultural and linguistic relevance of this commonly used screening tool is interrogated from four different viewpoints: firstly, the perspective of the children, who are the target population of the tool; secondly, that of the parents and community, who play a significant role in the socialisation of the children; thirdly, from the perspective of the academics from an indigenous language and cultural background, who provide an academic perspective of the tool; and, finally, that of speech-language therapist (slt) practitioners who administer the tool and interpret the findings. as language assessments are conducted on people who exist within a cultural context, the cultural capital is embedded in language (peltier, 2010; seidman, 2008; westby, 2009). since the larger study focuses on the relationship between language and culture and adopts an ecological approach to the problems addressed in the study, a conceptual model that encompasses a strong ecological and cultural component was selected; that is taylor’s (1986) cultural framework for viewing normal and pathological communication. as part of this larger study, a national survey was conducted with slts to establish current practices in assessment and intervention, training and challenges experienced when working with a client who is an eal speaker. the discipline of speech language pathology (slp) has a clientele, both in south africa and globally, which is becoming increasingly multilingual and multicultural (jordaan, 2008; williams & mcleod, 2012; wium, 2010). the assessment of diverse populations needs to take into account and to accommodate this diversity of languages and cultures (gopaul-mcnicol & armour-thomas, 2002; mcleod, 2014; tabors, 2008). the provision of a culture-fair assessment, however, presents many challenges to the profession (caesar & kohler, 2007; landsberg, 2005; mcleod, verdon & bowen, 2013; pillay, 2003). these include the limited knowledge and understanding that therapists have of the cultures and language groups from which their clientele may come. knowledge of the language and cultural background of clients is significant for the therapist as it influences the outcome of assessment and interpretation of their findings, especially when the therapist is likely to use their own worldview as a basis for this process. it also aids the slt in discriminating between a language disorder and language difference in eal speakers (n. miller, 1984; thordardottir, 2011). language pathology may include: difficulty in understanding or expression of the meaning of language, problems with understanding or appropriate use of the grammatical or morphological (involving units of meaning) rules, appropriate use in social context and problems with speech sounds, patterns or rules of organisation (shipley & mcafee, 2004). the difficulties described here manifest in whatever language the individual uses. it is thus a language problem and not a second language (l2) difficulty. on the other hand, there may be language differences in the production by the individual, in the process of learning a l2 (i.e. undergoing bilingualism). these differences, which may be perceived as errors by a non-informed ear, will only manifest in the l2 or language being developed rather than the mother tongue. they may be influenced by factors such as language, culture and frame of reference. appropriate training plays a crucial role in facilitating increased linguistic and cultural understanding of the client’s background (du plessis, 2010; higgs, 2010). as these challenges are relevant for the south african context there is a need for research to address the gap in the assessment of our diverse population. this is the rationale for the survey, the outcome of which is discussed in this article. the research method the broader phd study used a mixed methods approach with multiple data collection methods such as a survey, focus groups, individual interviews, test administration and consensus methods. the methodological design was comprised of two phases with the national survey being part of the preparatory phase, in order to set the foundation for and support the rationale for the research. apart from establishing the assessment and therapeutic interventions that slts use with their clientele, the survey also assisted in providing an indication of the profile of the south african slt. a national survey of 1000 slts, registered with the health professions council of south africa (hpcsa), was thus conducted using random sampling. questionnaires with open and closed-ended questions on areas related to employment, clients, caseload, choice of language for practice, current practices in assessment and intervention, training and challenges were sent to slts on the register. firstly, a pilot study was conducted by sending 100 questionnaires to slts (10%) from this national register and the questionnaire was revised, taking into account these responses. based on the responses received, changes were made, such as rephrasing of ambiguous questions on language use and current management and extension of some of the options provided in questions on caseload, employment and experience with eals. the survey questionnaires were then sent to 1000 hpcsa registered slts via the postal service and a 15% (∑150) response rate was achieved. despite the relatively low response rate, the results are consistent with findings of global and local research (jordaan, 2008; von dulm & southwood, 2013), which had similar response rates. data were analysed using the statistical package for social sciences (spss 18). the data were organised into simple frequencies and presented in tables and graphs. results of the survey the results of the survey show that 99% of slts sampled were from english or afrikaans speaking backgrounds and competent in these languages (figure 1). furthermore, 89% of these slts had eal speakers in their caseload and 86% of the slts used english in the assessment of these eals. the results also suggest that english standardised language assessment tools, which have been normed on populations predominantly in the us and uk and are inappropriate for eal speakers, remain the tests most commonly used by slts to assess this population and they are administered in english. figure 1: a bar chart showing the language competence percentages of slts in sa (data to be interpreted with caution due to low response rate). there are several reasons given by the therapists for the choice of english in assessments, but the most common is the therapist’s self-proclaimed restricted competence in other african languages, as reflected in the quotes below: ‘i feel equipped when the goal is to improve english language comprehension and expression’. ‘i only work in english medium schools where i have an understanding of culture or background and thus sensitivity thereof’. ‘i feel equipped because i don’t take on children if therapy is not in english’. ‘my level of competence in understanding, speaking and thinking about all languages (except english) is insufficient in providing quality accountable service’. although some of the therapists are content with the use of english, as reflected in their responses, others expressed some concerns: ‘assessment tools and programmes are foreign to these children (referring to eal speaking children) regarding the language as well as cultural barriers’. ‘there are several reasons why these assessment tools present with these barriers and these include a different language, culture, experience or dialect’. discussion and implications of the results because of the low response rate to the questionnaires, the findings should be viewed with some caution in terms of conclusiveness. they do however provide an interesting insight into the direction of a broader picture of the profile of slts and their test usage in sa. the survey findings suggest that eal speakers are currently mostly being assessed by slts who come from different linguistic and cultural backgrounds to those of the clients (saslha, 2012, 2013; von dulm & southwood, 2013). this information accentuates the issue of the relationship between language and culture. language represents a powerful tool of self-definition and expression and becomes a means through which various cultural and social groups can find unique expression (han & price, 2015, jandt, 2000; ji, zhang & nisbett, 2004; tabors, 2008). it can thus be argued that language is a cultural phenomenon (ball & peltier, 2011; riley, 2007; sardar & van loon, 2004). bearing this in mind, it becomes essential for professionals in the language field to understand and always draw on mother tongue, socio-cultural meanings when involved in the assessment of language of multilingual and multicultural populations (gopaul-mcnicol & armour-thomas, 2002; solarsh & alant, 2006; westby, 2009). in south africa, the majority of eal speakers use an african language as their mother tongue (http://www.statssa.gov.za), and the majority of slts do not. the survey results indicate that eal speakers are thus currently being evaluated by slts who do not speak or understand an african language. in addition, feedback on the questionnaire also reveals that slts have restricted understanding of the cultures linked to these languages. it can thus be assumed that the slt will use their own linguistic and cultural background as a frame of reference for interpreting the assessment results and this in turn may further influence the language choice and use in assessment as well as interpretation of results. the picture thus emerging from the results of the survey places the slt in a very powerful position as they can attach their own cultural and linguistic worldview to the meaning of the assessment and criteria for success. this powerful position further raises the question as to whether the meaning that the slt attaches to their assessment, serves the interests of justice and equality as they relate to the client. issues of justice and equality underpin current discussions within the profession pertaining to hegemonic discourses, language and practices that reproduce them (kathard & pillay, 2013, 2015). the nature and number of comments from some of the respondents suggest that they concur that the current situation is not ideal and indicate the need for a greater research effort into the creation of more culturally and linguistically relevant language assessment materials for eal speakers in south africa. as a result of the challenges mentioned by the slts in the survey, specifically a paucity of culturally and linguistically relevant tests developed for the south african population (naudé, louw & weideman, 2007; pascoe & norman, 2011), most evaluations are conducted using tests developed and normed on populations that are predominantly from the us or uk. that these tests are not ideal in their current form for assessing a south african eal speaker who is from an indigenous language and cultural background goes without saying and this is confirmed by research into language development and assessment (caesar & kohler, 2007; gopaul-mcnicol & armour-thomas, 2002; moro, 2008; pierce & williams, 2013). tests currently used by slts in south africa are predominantly based on a linguistic, cultural and social context that is largely european and american. the guidelines for the administration of these tests do not refer to the south african multilingual and multicultural population. the test developers thus do not expect them to be used on populations outside of those stipulated in the test. one of the reasons that the slts provided for mostly conducting the assessment and therapy of eal speakers in english is the demand for the use of english by the parents of the eal speaking children. these demands are linked to the perception by parents of eal children that english is the language linked to progress in education. despite the recognition of 11 official languages in sa, english remains the dominant language in all sectors of society (burger, 2011; green, 2008; kamwangamalu, 2000; landsberg, 2005; muendane, 2006), including education (republic of south africa, 2011). many african eal speaking children from an indigenous language and cultural background are thus taught in settings where english is the medium of instruction (moi). the language of learning and teaching (lolt) in many south african schools is english (lafon, 2007; landsberg, 2005). many slts therefore try to justify their persistence in assessment and intervention in english even for eal speakers, the evidence of which is clear in the survey results, which showed that 86% of the slts used english in language assessments and therapy. the results of this survey are particularly crucial, because of the many eal speakers from indigenous cultural and linguistic backgrounds in south africa who are in schools where english is the moi and who are referred by teachers for language assessments to slts. even though the curriculum may be presented in english, this is not the mother tongue of these south african children, nor is their cultural background reflected (higgs, 2010; landsberg, 2005; ntuli, 2002). african language and culture influences the knowledge and belief system of the eal speaker (lemmer, meier & van wyk, 2006; metz & gaie, 2010) and therefore influences their response to the tests, which have been predominantly normed on us or uk populations, societies whose language and culture is different from theirs (higgs, 2003; kroes, 2005; makgoba, 1999; semali, 1999). therefore, the background, values and stories of the eal speaker, such as found in traditional oral african culture manifesting in african signs and symbols (maathai, 2009; mutwa, 1998), tend to be disregarded, devalued, ignored or only superficially addressed (d. miller, 2012) when resources for evaluations do not reflect the african experience. as the majority of eal speakers in south africa are african language mother tongue speakers, it can be said that the child is treated as a tabula rasa when the african worldview (behrens, 2010; mucina 2013; ntuli, 1999, 2002) they bring is ignored. the children’s choice, based on their frame of reference, is excluded as an option in the assessment tool scoring system. the outcome may likely thus create a distorted reflection of the language ability of an eal speaker from an indigenous language and cultural background and the slt may thus, unintentionally, pathologise a child who presents with a language difference. conclusion the results of the study indicate that the average slt assessing an eal child is still predominantly either an english or afrikaans speaking woman, who is not competent in an african language. saville-troike (1986, p. 48) maintains that ‘whether we realise it or not, each of us sees the world from a culturally conditioned perspective that we share with the other members of the group’. thus, the frame of reference of these slts is based upon their own socio-cultural background, which in turn influences their interpretation of the child’s response. these findings have implications for the selection and training of slts in south africa and suggest a direction for postgraduate research in this discipline. the current recruitment of african language speakers for training in the profession needs to be intensified to accommodate the assessment and management of this population. sections of the speech-language pathology curriculum pertaining to bilingualism and cultural and linguistic diversity need to be enhanced for more effective preparation of the slts who will work with eal speakers. in addition, postgraduate research that addresses these discrepancies should be encouraged. although it is necessary that further research be conducted to create more culturally and linguistically relevant tools for the eal population, the practising slts remain accountable for accessing research-based evidence on the assessment and management of the eal population. failure to do so constitutes a contravention of the profession’s ethical code of conduct. it is hoped that the outcome of this research will create greater sensitivity in the application of non-standardised language screening tests to eal speakers in this country. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions this article is based on a phd study conducted by t.m. 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(2012). speech-language pathologists’ assessment and intervention practices with multilingual children. international journal of speech –language pathology, 14(3), 292–305. http://dx.doi.org/10.3109/17549507.2011.636071 wium, a.m. (2010). speech-language therapists in previously disadvantaged schools: factors affecting support. paper presented at the saslha perspectives on our professions conference, pretoria, south africa, 19–20 april 2010. footnote 1. not a homogenous group there may be interand intra-linguistic and cultural variability abstract introduction intervening early with dysphagia the need for a contextually relevant and valid dysphagia screening tool methodology the screening tool (refer to appendix 1) results of main study validity using cohen’s kappa discussion conclusion acknowledgements references appendix 1 about the author(s) calli ostrofsky department of speech and hearing therapy, university of witwatersrand, south africa jaishika seedat department of speech and hearing therapy, university of witwatersrand, south africa citation ostrofsky, c., & seedat, j. (2016). the south african dysphagia screening tool (sads): a screening tool for a developing context. south african journal of communication disorders 63(1), art. #117, 9 pages. http://dx.doi.org/10.4102/sajcd.v63i1.117 original research the south african dysphagia screening tool (sads): a screening tool for a developing context calli ostrofsky, jaishika seedat received: 28 jan. 2014; accepted: 27 apr. 2015; published: 16 feb. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: notwithstanding its value, there are challenges and limitations to implementing a dysphagia screening tool from a developed contexts in a developing context. the need for a reliable and valid screening tool for dysphagia that considers context, systemic rules and resources was identified to prevent further medical compromise, optimise dysphagia prognosis and ultimately hasten patients’ return to home or work. methodology: to establish the validity and reliability of the south african dysphagia screening tool (sads) for acute stroke patients accessing government hospital services. the study was a quantitative, non-experimental, correlational cross-sectional design with a retrospective component. convenient sampling was used to recruit 18 speech-language therapists and 63 acute stroke patients from three south african government hospitals. the sads consists of 20 test items and was administered by speech-language therapists. screening was followed by a diagnostic dysphagia assessment. the administrator of the tool was not involved in completing the diagnostic assessment, to eliminate bias and prevent contamination of results from screener to diagnostic assessment. sensitivity, validity and efficacy of the screening tool were evaluated against the results of the diagnostic dysphagia assessment. cohen’s kappa measures determined inter-rater agreement between the results of the sads and the diagnostic assessment. results and conclusion: the sads was proven to be valid and reliable. cohen’s kappa indicated a high inter-rater reliability and showed high sensitivity and adequate specificity in detecting dysphagia amongst acute stroke patients who were at risk for dysphagia. the sads was characterised by concurrent, content and face validity. as a first step in establishing contextual appropriateness, the sads is a valid and reliable screening tool that is sensitive in identifying stroke patients at risk for dysphagia within government hospitals in south africa. introduction there are many challenges surrounding effective identification of patients who present with dysphagia within government hospitals in developing contexts. some of these challenges include timing of identification of a swallowing difficulty, timing of the assessment and use of non-standardised contextualised protocols for assessment and intervention (seedat, 2013). the lack of standardisation contributes to variable service delivery from one patient to the next. this is problematic. for decades, speech-language therapists (slts) from less developed contexts have relied on internationally developed tools to guide assessment and intervention in dysphagia, as these had a research and evidence-based underpinning (emanuel, wendler, killen & grady, 2004). two key factors have necessitated a revision of this almost standard protocol of merely implementing internationally developed tools on the south african population. firstly with disease profiles, unemployment rates, dietary intake, accessibility of services and socio-economic status changing dramatically over the last two decades within countries across the world, it is becoming increasingly difficult to compare patient profiles from developed contexts with those from less developed and developing contexts (mamdani, 2011). direct application and use of guidelines without any tailoring or modification is becoming increasingly inappropriate and inadequate to meet the needs of the clients from less developed contexts. linked to this is the status of government health care institutions in developing contexts. in south africa, financial restrictions and budgets dictate what equipment, if any, hospitals have (cullinan, 2006). challenges around availability of equipment, malfunctioning equipment, stolen equipment and servicing of equipment remain significant obstacles with dysphagia service provision in government hospitals. having necessary objective measures in dysphagia intervention such as videofluoroscopy is considered a luxury, with even basic consumables, such as mouth care kits for oral hygiene, often unavailable. secondly, whilst knowledge and awareness around swallowing and swallowing impairments have improved, this has an implication for the workloads of slts employed at hospitals. regardless of its status as a priority for hospital-based slts, dysphagia is but one amongst an array of other speech therapy services patients at hospitals require (american speech-language and hearing association, 2013; health professions council of south africa, 1988; south african speech-language and hearing association, 2009). consequently time, human resources and efficiency of services are compromised for the increasing number of patients that need to be seen who present with dysphagia as well as other speech and language communication disorders. this has also been influenced by the increasing prevalence of chronic disorders such as strokes and hiv, cancer (head and neck) and degenerative neurologic conditions as a result of lifestyle changes, eating habits and poor medical follow-up (blackwell & littlejohns, 2010; brainin, teuschl & kalra, 2007; connor et al., 2008; crary et al., 2013). other reasons limiting direct implementation of internationally developed tools pertain to institutional ‘culture’ amongst health care institutions in south africa. multidisciplinary team management is not ideal (martens, cameron & simonsen, 1990; seedat, 2013). hence, it remains challenging to rely on other health professionals as part of team management due to poor role clarity and limited knowledge of each other’s role and responsibilities when working with the patient with dysphagia (blackwell & littlejohns, 2010). a need for a contextualised, specific, valid and reliable dysphagia screening tool that could address some of the aforementioned barriers was identified. intervening early with dysphagia dysphagia, characterised by difficulty with the passage of food from the mouth to the stomach, is defined as a swallowing disorder affecting the oral, pharyngeal or oesophageal phase of swallowing (falsetti et al., 2009). dysphagia is commonly a symptom of neurological disease such as stroke (blackwell & littlejohns, 2010). the association between stroke and dysphagia has been established, with reports ranging from one-third to two-thirds of acute stroke patients presenting with dysphagia (perry, 2000). whilst exact statistics on the incidence of dysphagia amongst stroke patients in south africa are not readily available, one may surmise that given the increasing prevalence of strokes (connor & bryer, 2006; connor et al., 2008), there is likely a consequent increase in associated dysphagia. early evaluation of dysphagia amongst stroke patients may decrease one’s vulnerability to co-morbidities (hinchey et al., 2005), such as aspiration pneumonia, malnutrition, dehydration, airway obstruction or even death (perry, 2000). additional considerations for the patient accessing a government hospital in south africa are (1) financial implications – patients who are breadwinners of the family need to return to work and increased length of hospitalisation impacts this – and (2) an increased likelihood of the patient acquiring other hospital-acquired infections and co-morbidities. early detection facilitates optimal management, minimises occurrence of dysphagia-related complications, as well as other co-morbidities, and can improve the prognosis for dysphagia (blackwell & littlejohns, 2010; heckert, komaroff, adler & barrett, 2009; marik & kaplan, 2003; martino, pron & diamant, 2000). cost efficiency for the hospital department, for the hospital and for the patient are important considerations in any resource-constrained and developing context. the need for a contextually relevant and valid dysphagia screening tool a standardised screening tool facilitates identification of a disorder (martino et al., 2000). many screening tools for dysphagia with established reliability and validity exist (martino et al., 2009; trapl et al., 2007). mamdani (2011), however, cautions against readily accepting and implementing tools developed in first world countries to populations in developing second and third world countries. as noted above, populations, environments, systems and so on may be very different, necessitating modification of internationally developed tools (mamdani, 2011). it is important that a screening tool considers context-specific variables, resources, logistics and systemic rules. the high demand on health care professionals and the government health care system itself increases the likelihood of subtle problems, further medical compromise and delayed identification of dysphagia only when the patient is at a critical stage or when the dysphagia becomes more ‘overt’ to the casual observer. the availability and use of a context-appropriate screening tool can relieve the demand on staff, resources and time through its simplicity, whilst maximising dysphagia detection. as it stands, implications for early, reliable and efficient dysphagia identification and management within this context, given the challenges, are discouraging. competency, knowledge and commitment of the administrator of the screening tool must be given consideration in the development of a contextually relevant and appropriate tool. optimal features of a screening tool are presented in table 1. table 1: guidelines to adhere to when developing a screening tool. problem statement the availability of numerous screening tools, each validated and proven reliable, raised the question of the need to develop yet another screening tool. the dilemma of which existing screening tool to validate on the south african population led to the development of a new screening tool. the new tool incorporated the proven benefits of existing tools whilst heeding their limitations and simultaneously ensuring cultural and linguistic sensitivity for the general south african population. it also considered the realities of acute hospital wards, the staff available, time available and access to resources. however, the question remained: would the newly developed dysphagia screening tool facilitate valid and reliable identification of dysphagia, amongst patients presenting with stroke as their underlying medical pathology? methodology aim to assess the reliability and validity of a newly developed dysphagia screening tool to identify dysphagia in acute adult patients presenting with stroke. design a quantitative research methodology using a non-experimental, correlational cross-sectional design was used. a retrospective component was necessary to review patient files after administration of a diagnostic dysphagia assessment. this is discussed below. process and sample three government hospitals in south africa were the research sites. necessary ethical approval was obtained from the university of witwatersrand human research and ethics committee (medical; protocol no. m120215). there were two cohorts of participants: 18 slts and 63 stroke patients. convenience sampling was used to recruit both cohorts. the participants with dysphagia were recruited by the recruited slt participants. the patient sample adequately represented patients attending government hospitals in south africa from varying financial, sociolinguistic and cultural backgrounds. the patient sample received the sads (dysphagia screening) and following this, within 24 hours, a diagnostic dysphagia assessment. 63 patients were screened and 62 received a diagnostic dysphagia assessment. the slt sample were clinicians working within the government hospitals from which the patient sample was recruited. the clinician sample was responsible for conducting the sads and the diagnostic dysphagia assessment. although they may be regarded as research assistants, they have been described as a participant sample, as they had to adhere to inclusion and exclusion criteria and be recruited by employing convenience sampling. further, it was necessary for the slts to consent to participate in the study. data collection figure 1 provides an illustration of the procedure that was followed for data collection. figure 1: process followed for data collection the pilot study evaluated aspects of the design and procedure of the research, as well as the developed research tool in terms of feasibility, usefulness and ease of administration (clark-carter, 2010; mcburney & white, 2010). the screening tool (refer to appendix 1) the south african dysphagia screening (sads) tool consists of four sections and 20 test items. the items within each subsection are described below. section 1 the items in section 1 were aimed at determining the alertness of the stroke participant. a patient’s compromised state of consciousness may have implications on their ability to swallow safely or alert the slt to possible swallowing difficulty that is the patient is experiencing (martino et al., 2009). section 2 items in this section provide subjective interpretations of the screening results. regardless of the answer, items in section 2 do not categorise the patient as a ‘refer’ but need to be considered. the first item in section 2 evaluates the patient’s position. according to tanner (2007), swallowing whilst seated in an upright position achieves maximum protection of the airway and reduces the chances of aspiration. thus, incorrect positioning may compromise airway protection. the second item in section 2 requires the patient to count. this item serves a two-fold function. it allows the slt to gain an impression of the patient’s voice, as well as insight into the patient’s receptive language understanding. assessment of swallowing requires patients to follow instructions (e.g. open your mouth), be alert and have a degree of understanding that will enable an appropriate assessment. inability to understand simple instructions may have implications on ability to swallow safely or alert the slt to possible swallowing difficulties that the patient may be experiencing (martino et al., 2009). voicing provides information on laryngeal functioning (cichero & murdoch, 2006). careful attention is to be directed to the patient’s voice quality prior to and after each delivery of food or liquid in order to ascertain whether food is entering the larynx, thus potentially leading to aspiration (murray, 2000). if a patient is unable to produce voicing when they receptively understand the instruction, this may be indicative of possible respiratory problems, vocal fold involvement or laryngeal weakness (cichero & murdoch, 2006). the third item of section 2 evaluates the patient’s ability to perform a volitional dry swallow. a lack of rapid and forceful elevation of the larynx during a dry swallow as well as lack of observed palpitation of the neck during a dry swallow is an indicator of possible increased risk of a swallowing difficulty (perlman & schulze-delrieu, 1998). section 3 the items in section 3 determine the oral motor skills of the stroke participant. the behaviours or functions, as well as structures of the oral mechanism need to be carefully observed during the oral motor exam, as these affect the patient’s ability to chew or swallow safely (groher, 1997; shipley & mcafee, 2004). deficits may affect the oral preparatory phase of swallowing, in terms of poor oral control because of lip and tongue weakness, lingual weakness, reduced range of motion and in-coordination, with bolus formation, manipulation, chewing and swallowing being affected (langmore, 2001; shipley & mcafee, 2004). the patient’s ability to cough voluntarily needs to be determined as there is an increased risk for aspiration in patients who have a weakened voluntary cough (smith-hammond et al., 2001). observation of facial asymmetry and lip symmetry must be included as facial weakness commonly occurs after a stroke, most typically in the lower facial muscles (geyer, gomez, sheppard & akhtar, 2009). section 4 this section involves the food trial. the patient must be presented with small amounts (5 ml) of food of different viscosity. presentation is to progress from consistencies that are the easiest for the stroke patient to manage to the most difficult for the patient to manage (shipley & mcafee, 2004). thus, pureed foods (e.g. banana beaten with a fork and mixed with water to form a puree consistency, yogurt and mageu, a traditional yogurt drink), followed by a soft solid (e.g. mash potatoes, pap, which is similar to mash, and boiled vegetables) and, lastly, a liquid (i.e. water). pureed foods easily form a bolus and chewing is not required. with a soft solid, chewing is required for bolus formation. liquids, however, are the most difficult to manage as they do not form a bolus and swallowing requires the least amount of voluntary and reflexive control, increasing the possibility of aspiration (shipley & mcafee, 2004). furthermore, unless oral care is good in the patient being assessed, choking on the water will place the patient at risk for aspiration and aspiration pneumonia as a result of bacteria from the oral cavity. section 4 includes observable signs that can allude to dysphagia when swallowing. these include food spillage, food pocketing, coughing after swallowing and a delayed, absent or painful swallow (shipley & mcafee, 2004). test administration the administration of the sads involves four subsections as noted above. for each item, the administering slt is required to indicate ‘yes’ or ‘no’ based on the patient’s performance on an item. each subsection requires either a ‘yes’ or ‘no’ response. difficulty with any item would result in termination of the screening and the patient is referred for further diagnostic evaluation. pass and fail criteria the test administrator has the responsibility to pass or fail the patient. items in section 2 are items that are subjective descriptions and are therefore not referral criteria. a fail on any of the items in section 1, 3 or 4 of the screening tool is indicative of risk of dysphagia, thus a positive result would be indicated on the screening tool. if a fail is indicated in section 3, the screening is to be discontinued. within section 4, if a fail is indicated in subsection a, the screening is to be discontinued. if a fail is indicated in section 4, subsection b, the screening is to be discontinued. the sads was designed to be simple and quick to administer. ease of administration and interpretation were vital prerequisites in the development of the sads. as part of the study protocol to establish reliability and validity, the results of the sads were correlated with a subsequent diagnostic dysphagia assessment. the pilot study the pilot study was conducted at a government hospital different to those used in the main study. upon completion of the screening and diagnostic assessments, the respective slts were required to complete a questionnaire probing the content of the sads. the responses allowed the researcher to determine the need for items to be added, omitted or modified on the screening tool. based on the results of the pilot study and the questionnaire, the following adjustments were made: modification of the item relating to receptive ability of patient. if the patient presented with poor receptive understanding, the screening was continued and the patient was not referred based on that criterion. this patient was to be assessed with caution. patient position: the patient needs to be positioned with caution, and upright positioning was not a referral criterion. addition of item: volitional swallow. results of main study there were 63 participants who received the sads. however, only 62 participants underwent the diagnostic assessment. hence, the calculations for the screening versus the diagnostic assessment reflect these numbers. all further calculations take this missing frequency into consideration. from the sample, 30% (n = 19) of the participants passed the screening with the sads, and 69.84% (n = 44) were referred from the screening (see table 2). one stroke participant who was screened was unavailable at the time of the diagnostic assessment and was not followed up. hence, only 62 stroke participants received the diagnostic dysphagia assessment, results of which are seen in table 3. table 2: screening results from the sads (n = 63) table 3: assessment results from diagnostic dysphagia assessment (n = 62). results of the diagnostic assessment indicated that 52.23% (n = 33) of the participants presented with dysphagia and 46.77% (n = 29) of the participants did not present with dysphagia. reliability using cohen’s kappa the evaluation of the relationship between the dysphagia screening tool and the diagnostic dysphagia assessment battery was done using correlation coefficients (schiavetti & metz, 2002). cohen’s kappa was used to determine the agreement between two dichotomous variables (wood, 2007). using cohen’s kappa, measures of positive agreement and negative agreement provided information regarding the types of agreement that presented between the screening tool and the diagnostic assessment. the results are presented in table 4. table 4: results of cohen’s kappa the percentage of agreement refers to the agreement between the results of the sads and the diagnostic assessment (wood, 2007). thus, 80.64% of the screenings elicited the correct results (i.e. correct pass and referrals). however, the calculation of percentage of agreement has been critiqued as not being an adequate measure of inter-rater reliability. thus, cohen’s kappa, which is a preferred measure of inter-rater reliability, as opposed to percentage agreement, incorporates a calculation of hypothetical probability of chance agreements (wood, 2007). thus, the probability that stroke participants presented with dysphagia was calculated. the probability that the participants were referred was also calculated. the calculations of probability were then used to calculate cohen’s kappa. the probability that participants were referred based on the screening and presented with dysphagia plus the probability that a patient passed the screening and did not have dysphagia (wood, 2007) was calculated to be 0.51. probability for chance agreement refers to the probability that the participant had dysphagia as well as the probability that the participant was referred by the screening and did present with dysphagia was 0.60. the correlation coefficient for kappa can range from –1.0 to + 1.0; a kappa of 1.0 is indicative of perfect agreement and a kappa of zero shows a poor correlation between the two variables (wood, 2007). according to wood (2007), for the purpose of medical studies and diagnosis, a kappa that lies between 0.40 and 0.70 indicates an appropriate inter-rater reliability; the values calculated for this study were thus appropriate, as can be seen in both the percentage of agreement and probability of chance agreement. validity using cohen’s kappa validity is the ability of a test to measure what it is intended to measure (rust & golombok, 1999). content validity (how accurately the questions used in the assessment tool, i.e. the sads, tap into what is being asked without the response being influenced by other variables), face validity (the degree to which an assessment measures what it appears to measure) and concurrent validity (how well the results of one assessment correlate with another assessment designed to measure the same thing, i.e. the sads and the diagnostic dysphagia assessment) were calculated (rust & golombok, 1999). concurrent validity relies on timing; hence, the sads and the diagnostic dysphagia assessment were conducted within 24 hours of each other. the following measures were used in combination to optimise content validity of the sads: clinical judgements and input from experienced slts working in the area of adult dysphagia were incorporated in the initial conceptualisation of the tool (schrock & coscarelli, 2007). these slts were not included as part of the sample of slts recruited into the study. a review of existing dysphagia screening tools in terms of content, as well as each tool’s evidence base, was central to the content of the developed screening tool. each question in the sads directly assessed a particular objective (i.e. a sign or symptom of dysphagia), allowing direct evaluation of an objective. feedback from the slt participants confirmed that reading level and use of vocabulary within the sads were appropriate to enable any health care professional working in an acute health care context to conduct the screening. technical difficulties with instructions and ambiguity of instructions were also considered during the development and construction of the screening tool and were addressed in the pilot study. this did not arise as a concern during the main study. content under-representation, which may interfere with content validity, was avoided by ensuring that the items were adequately able to identify swallowing abnormality and risk of aspiration without indicating severity of dysphagia. the slt participants confirmed the overall face validity and appropriateness of the sads. the percentage of agreement referred to in table 4 was 80.64%. thus, concurrent validity of the sads revealed that it correlated very well with the longer diagnostic assessment conducted. the cohen’s kappa was used to establish this form of validity. sensitivity and specificity a measure of sensitivity and specificity of the sads was calculated. the measures of sensitivity and specificity are binary classification statistical measures. sensitivity measures the proportion of true positives, which are correctly identified as such (i.e. the percentage of dysphagic patients who are correctly identified as having dysphagia). specificity measures the proportion of true negatives which are correctly identified (i.e. the percentage of patients with normal swallowing who are correctly identified as not having dysphagia; haynes, smith & hunsley, 2011). the results were 96.97% sensitivity and 62.07% specificity, as can be seen in table 5. the results showed the sads to be sensitive in detecting patients at risk for dysphagia. the specificity of the sads is lower than its sensitivity; however, the sads was still deemed to be adequate in identifying patients not at risk for dysphagia, when they do not present with the disorder. the specificity calculation indicates that participants were unnecessarily referred as being at risk for dysphagia when, in fact, they did not present with the disorder. table 5: sensitivity and specificity of the sads referral items there were particular items that were more sensitive in detecting signs and symptoms of dysphagia than others. the items in table 6 were the most common referral items in the sads in order of frequency. table 6: most common referral items and percentage of participants that were referred. discussion analysis of the results suggested that the sads was a valid screening tool for dysphagia, with high inter-rater reliability. it was specific in being able to detect stroke patients who present with dysphagia. the percentage of agreement score, 80.64%, suggested high concurrent validity, showing that the results from the sads correlated substantially with the independent diagnostic assessment to which it was theoretically related (frick, barry & kamphaus, 2009). results that were described showed that minimal and minor modifications were necessary to improve overall content validity of the sads, which was achieved. face validity was also acknowledged by the various administrators of the tool, who were qualified clinicians working in adult dysphagia and knowledgeable of contextual challenges and facilitators. a cohen’s kappa value of 0.6 deemed the sads as having appropriate inter-rater reliability (0.40–0.70 suggests good inter-rater reliability for medical studies; wood, 2007). the sensitivity of the sads in detecting risk for dysphagia with the chosen population of patients was 96.96%, suggesting high sensitivity (abramson & abramson, 2008). specificity was slightly lower at 62.06%, but, according to logemann, veis and colangelo (1999) that it still fell in the range of 50%–80% meant that it was adequate. the study showed a sensitivity and specificity pattern of high sensitivity and lower specificity (logemann et al., 1999). there was one false-negative, which was concerning from a dysphagia perspective in terms of complications that could occur from late identification (heckert et al., 2009). it is likely that given the acuteness of the screening (within 24 hours of admission), dysphagia may not have been initially present, as heckert et al. (2009) also found. it is also possible, that further medical deterioration may have occurred subsequent to the screening (heckert et al., 2009). protocols to prevent such omissions need to be considered. from a time perspective, it was confirmed that the sads took 10 minutes or less to complete. it was deemed resource conservative and could be easily administered. whilst the feasibility of the sads for the current context was not the goal, establishing the validity and reliability empirically was the first step in working toward feasibility. the study was able to establish this. conclusion the absence of standardised diagnostic dysphagia assessment protocols across government hospitals in south africa meant that the researchers had to rely on the fact that the protocols used at each hospital in the study were thorough and comprehensive in correctly diagnosing dysphagia in the stroke participants. this was acknowledged as a limitation of the study. an implication of the study is to establish the feasibility of using the sads in an acute government hospital in south africa. whilst different variables were considered in the development of the sads to facilitate contextual feasibility, this was not an aim of the study. there is therefore a need to establish the exact effects of the context in the implementation of the tool, as the validity, reliability and sensitivity of a measure cannot exist independent of the context. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions c.o. 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(2007). understanding and computing cohen’s kappa: a tutorial. retrieved december 2013, from http://wpe.info/papers_table.html appendix 1 the south african dysphagia screening tool id e n tity c o n stru c tio n f o llo w in g t ra u m a tic b rain injury: a c a se s tu d y 17 identity construction following traumatic brain injury: a case study a yesha s abat*, legini m oodley#, h a rsh a k a th a r d m' ^ d ep artm en t o f s peech t h erap y & a u d io lo g y , u n iv ersity o f k w az u lu n atal, s o u th a frica ^d epartm ent o f s peech t h erap y & a u d io lo g y , u n iv ersity o f k w az u lu n atal, south a frica >t' d iv isio n o f c o m m u n ic atio n s cien ces and d isorders, u n iv ersity o f c ap e t ow n, s o u th a frica a b s t r a c t this co n stru ctio n o f s e l f id en tity p r e a n d p o st-t ra u m a tic b ra in in ju ry (tbi) in a sin g le case s tu d y is described. a life h isto ry resea rch m e th o d o lo g y w as e m p lo y ed to ex p lo re the ex p erien c e o f a s u rv iv o r o f tbi, u sin g a sin g le case s tu d y design.. the p a rtic ip a n t w as a 31 y e a r o ld w hite s o u th a fric a n m a le who su sta in e d t b i w h ile on d u ty in the arm y. m u ltip le in terview s w ere c o n d u c te d w ith the p a r tic ip a n t to a llo w in -d ep th exp lo ra tio n o f his s e l f id en tity fo r m a tio n p r e a n d p o st-t b i. d a ta a n a lysis en ta ile d tra n scrib in g the interview s, c ra ftin g a resea rch s to r y (n a rra tive an a lysis) a n d an a n a lysis o f th e narrative. the re su lts illu m in a ted the em e rg en c e a n d d ev elo p m e n t o f a re sis­ tance id e n tity as a p r o d u c t o f ea rly p r e -t b i experience, the loss o f s e lffo llo w in g t b i as w ell as the em erg en ce o f a p o s itiv e self-identity. the e m b e d d ed issu es o f co m m u n ic a tio n a n d se lf-id en tity are explained. the p a r tic ip a n t’s n a rra tive esp o u sed a h o p efu l optim ism , stro n g ly ch a llen g in g the d o m in a n t d isa b ility discourse. the sp e cific stj-engths a n d lim itations, a n d p o te n tia l va lu e o f u sin g life h isto ries as b oth a m e th o d o lo g ic a l a n d clin ic a l to o l w hen w o rkin g w ith t b i su rv ivo rs is described. im p lica tio n s f o r resea rch a n d clin ic a l p ra c tic e in the f i e l d o f sp eech a n d l a n g u a g e t herapy (slt) is also p ro vid ed . key w ords: t rau m atic brain injury, n arrativ e life h isto ry m eth o d o lo g y , self-id en tity , life ex p erien ce, resistan c e identity, loss o f self, co m ­ m u n ic atio n im pairm ent. in t r o d u c t io n t rau m atic b rain in ju ry (tb i) exerts a p ro fo u n d im p act on an in d iv id u a l’s life. t h e effects are p erv asiv e and d evastating. a co m p lex range o f co m m u n ic atio n d ifficu lties, in clu d in g specific d istu rb an ces su ch as ap h asia and d y sarth ria, are p ro d u ce d (h ilari & b yng, 2001). in ad d itio n , tb i also results in co g n itiv e, p h y s i­ cal, em o tio n al, b eh av io u ral, an d p sy ch o so cial se q u ela e (h artley, 1995). u ltim ately , the p erso n w ho su rv iv es a t b i has to n eg o tiate a series o f life-alterin g exp erien ces. t his p ap e r draw s on th e life ex p erien ce o f a t b i su rv iv o r to ex p lo re the d ev e lo p m e n t o f self id e n tity p reand post-t b i. t h ere is a b u rg eo n in g in terest in ex p lo rin g ch an g es in id e n ­ tity fo llo w in g illness in the d iscip lin es o f p sy ch o lo g y , so cio lo g y and m ed ical an th ro p o lo g y (frank, 1995). w ith in the n arrativ e re­ search trad itio n , the su b jectiv e ex p erien ce o f t b i (n o c h i, 2000; 1998) has b een explored. s p eech -]an g u ag e th e ra p y (s l t ) p ro fe s ­ sio n als have also w itn essed a tran sitio n in research o rien tatio n to w ard s the u se o f q u alita tiv e research m ethods for ex p lo rin g the co n seq u e n ces o f c o m m u n ic atio n d iso rd ers, su ch as ap h asia (pound, parr, l in d sa y & w o olf, 2000; d am ico, o elsch laeg er, & s im m o n s-m ack ie, 1999; and parr, b yng, g ilpin, & ireland, 1997). t h e cu rren t stu d y is p rem ised on the n o tio n th at k n o w led g e o f se lf-id e n tity inform s clin ical p ractice. it is stro n g ly alig n ed w ith the p o sitio n taken by h ag stro m an d w ertsch (2004), w ho assert th at clin ician s need to u n d ersta n d w ho the p erso n is in o rd er to h elp h im /h er w ith co m m u n icatio n . s ervices w o u ld b e m ore re le ­ v an t i f clin ician s had th e k n o w led g e to u n d erstan d th e in d iv id u al in th e co n tex t o f h is/h er life circu m stan ces. s elf-id en tity fo rm a tio n is a co m p lex p ro ce ss sh a p ed b y p erso n al, so cial and tem p o ral factors (sarbin, 2000). t w o su b sy s­ tem s u n d erlie self-id en tity , n am ely p erso n a l id en tity and social identity. p erso n al id en tity refers to th e u n iq u e co n stitu tio n and b io g rap h y o f the ind iv id u al, su ch as p referen c es and p erso n a lity traits, w h ereas social id en tity refers to d escrip tio n s o f self, b ased on m em b ersh ip and id e n tifica tio n w ith a certain so cial group (de la r e y , 1991). id en tity is a th e o ry o f s e lf th a t is d ev elo p ed and su stain ed th ro u g h a p ro cess o f inner co n c u rre n ce ab o u t w h at th e s e lf is like (s ch len k er, 1987). t he cre atio n o f se lf-k n o w le d g e relies on sev eral co m p o ­ n en ts viz. p erso n a l m em o ry o f th e p ast, co n c ep tu alisin g societal roles and in teractio n w ith th e e n v iro n m en t (n eisser, 1988). a tb i su rv iv o r’s m e m o ry o f p re-m o rb id ex p e rien c e shapes h is/h er self identity, w h ich often has u n d erg o n e a critical ch an g e fo llo w in g the h ead injury. f o llo w in g a m ark ed life-alterin g event, n ew m e an ­ ings are assig n ed to th e in d iv id u a l’s so cial in teractio n s, thus re ­ sh ap in g h is/h er id en tity d ev elo p m en t. n e is s e r’s (1988) co n c ep t o f the ex ten d ed s e lf has im p licatio n s for a co n tin u in g life h isto ry in that in d iv id u als relate th e ir p ast s e lf d uring th e co n stru c tio n o f th eir p re se n t and fu tu re n o tio n s o f th e ir self-identity. a s th e m e an ­ in g an d statu s o f a life ev en t ch an g es for an in d iv id u al o v er tim e, so does h is/h er d efin itio n o f th e self, sin c e a p erso n a l sense o f s e lf co n tain s p ast and p rese n t ex p erien ces and ex p ectatio n s for the fu tu re (b ru m fitt, 1998). t hus, as self-id en tity is co n tin u o u sly c o n ­ stru cted an d reco n stru cted , s l t s n eed to be se n sitiv e to this p ro c ­ ess b y u n d ersta n d in g th e in d iv id u al as a d y n am ic so cial being (h ag stro m & w ertsch , 2004). t h e ex p e rien c e o f co m m u n ic atio n im p a irm en t is em b ed d ed w ith in th e p ro ce ss o f se lf-id e n tity fo rm atio n . t he irony lies in the p ro b lem itself, in th a t co m m u n icatio n , w hich is req u ired as a form o f ex p re ssio n o f self-id en tity , is co m p ro m ised (b ru m fitt, 1998). a n in d iv id u al w ho has su stain ed t b i has to n eg o tiate n ew w ays o f co m m u n ic atin g and en g ag in g in v ario u s so cial activ ities, and re ­ n eg o tiate co m p lex ch allen g es w ith red u c ed flu id ity and flex ib ility (s h ad d en & a gan, 2004). t h ey are ju d g e d b y th o se w ith w h o m th ey en g ag e so cially as eith er co m p ete n t o r n o t b y v irtu e o f the su ccess o f th e ir co m m u n ic ativ e in teractio n s. t h eir selfid en tity rests critica lly on how w ell th ey are ab le to n eg o tiate these in te rac­ tions, as th e ir p ro jec ted id en tities are su b je ct to so cial evaluation. c o m m u n ic atio n is cen tral in sh ap in g se lf-id e n tity fo rm a tio n as the in d iv id u al w ith t b i co n ten d s w ith an altered self, as ch aracterised b y n ew w ay s o f th in k in g , u n d ersta n d in g , ex p ressin g an d sense m aking. the south african journal o f communication disorders, vol. s3, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 18 ayesha sabat, legini moodley and harsha kathard w hat challenges m ay slts face when w orking with tbi survivors via a self-identity lens? issues o f identity construction post-tb i m ay seem daunting, since identity constructs have typi­ cally not been w ithin the traditional know ledge base o f slts. self-identity is the traditional domain o f psychology in clinical disciplines and the inclusion o f self-identity in the slt discourse creates the challenge o f negotiating boundary crossing across dis­ ciplines. furtherm ore, slts m ay be reluctant to take on m ore than they should due to large caseloads and lim ited healthcare funding (shadden & agan, 2004). finally, identity loss and reconstruction in the aftermath o f tbi is an elusive concept and m ay be difficult to target as a tangible therapeutic goal. however, given the inex­ tricable link betw een com m unication and self-identity it is neces­ sary to intervene w ithin a fram ew ork that places the w hole indi­ vidual at centre stage. the notion that a sense o f s e lf is m aintained in even the most im paired com m unicator (brumfitt, 1998) sup­ ports the need to understand the preserved se lf o f an individual with acquired com m unication impairment therapeutic intervention m ay be enhanced b y understand­ ing the relationship betw een therapeutic outcom e and self understanding. pound (1993) explored the attitudes o f aphasic speakers and their therapists to aphasia and found that slts who were interviewed focused alm ost exclusively on what they deem ed the devastating consequences o f im paired com m unication follow­ ing stroke. on the other hand, people with aphasia reported both the negative and positive aspects o f their altered lives and equated the importance o f com m unication in their lives with other m ajor life issues, such as driving, em ploym ent and the ability to execute activities o f daily living. therefore, i f clinicians are to provide a service that is person-centred, it is critical to acknowledge that it is not sufficient to focus exclusively on the individual’s com m uni­ cation im pairm ent but to gain a deeper understanding o f other per­ tinent life issues that feature robustly in his/her reality. clinicians therefore should attem pt to understand who the person is in order to effectively m anage the consequences o f com m unication diffi­ culties. traditionally, research on the psychosocial issues pertain­ ing to tbi has been am assed within quantitative research fram e­ works. as a consequence o f the m ethodological choices, the un ­ derstanding o f tbi has been relayed from an etic (or outsider) professional perspective. m any o f these studies have utilised quantitative positivist research designs to explore com plex con­ cepts such as the chronic physical, emotional, and social changes post-tbi; quality o f life following tbi; functional perform ance after tbi; and rehabilitation outcom e follow ing tbi (corrigan, bogner, m ysiw, clinchot & fugate, 2001). the process o f know l­ edge production in the field is therefore likely to benefit from an epistem ological shift w hich creates understanding o f the personal experiences o f people who live in the afterm ath o f tbi. the inclusion o f the experiential dom ain m ay assist in cre­ ating knowledge to support the current paradigm shift in the reha­ bilitation field from the medical m odel tow ard the social model o f disability, w hich em phasises the interaction o f disease and disabil­ ity w ithin the larger am bit o f society (jordan & bryan, 2001). w hile the medical m odel has centralised the focus on impairment, the social model requires a deeper understanding o f disability w ithin a social context o f disabling barriers. social barriers must be rem oved as an essential prerequisite for em powering people with disability (pound et al., 2000). the significance o f generating an integrated understanding o f disability has lead to the blurring o f boundaries betw een slt, sociology and disability theory (pound et al., 2000). in light o f the foregoing discussion, a life history research m ethodology was utilized in this study to explore self-identity formation. the personal biography highlights the issues most im­ portant to the individual in his or her context (atkinson, 1998). the life history narrative allow s participants to engage in a proc­ ess o f self-reflection, thus enabling them to explore and construct self-narratives about them selves located within a broader social, political, and historical milieu, thus generating broader contextual m eaning from the individual’s experience (cole & knowles, 2001). life history research allows the opportunity for the indi­ vidual to ably foreground the se lf in relation to im pairm ent over time (kathard, 2003). life history research offers a heightened sensitivity to the com plexity o f tbi by adding a hum an dim ension to the experi­ ence o f tbi and is particularly valuable in understanding the changing dynamics o f individuals who experience fluctuating perform ance as they recover (hartley, 1995). the story o f a tbi survivor purveys not only what the disability m eans to the indi­ vidual along a temporal continuum , but also conveys the rich per­ sonal m eaning that s/he has attached to it. critically, life history m ethodology has the potential to generate know ledge which slts can apply to their practice especially when w orking in a culturally and linguistically diverse context, such as south africa. this study responds to the follow ing question: what is the nature and the p rocess o f self-identity construction in an individ­ u al who has sustained traumatic brain injury? m eth o d o lo g y a im s o f the study 1. to explore the nature and process o f self-identity construction preand post-tbi 2. to consider the im plications o f the findings for research and clinical practice in the field o f slt research design a qualitative, life history research m ethodology was util­ ized (cole & knowles, 2001) to explore the p articipant’s self identity form ation using a single subject case study design. life history research values depth over breadth, thus the aim is not population representativeness (cole & knowles, 2001). single­ subject m ethodologies are w idely accepted and relevant as a le­ gitim ate technique for exploring the depth o f experience o f apha­ sia and dysfluency (kearns, 1999) and therefore also have appli­ cability for tbi. im portantly, single case study designs used in qualitative research can contribute to practice, theory, social is­ sues and action and thus hold value in facilitating a deeper under­ standing o f the com plex process o f self-identity construction post tbi. p articipant selection criteria purposeful sam pling was im plem ented to select an infor­ m ation-rich case for in-depth study. this strategy is useful when the purpose is to gain a deep understanding o f the particular case, in the absence o f any desire to generalise the findings to all cases (m cm illan & schumacher, 2000). the participant was s e l e c t e d on the basis o f his experience and understanding o f tbi in his lifeworld. the participant was required to: • be an adult who w ould have sustained a closed head injury at least two years prior to the interview and needed to have lived with tbi in order to relate preand post-tbi experience die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) identity construction following traumatic brain injury: a case study 19 . have adequate cognitive ability that would enable him /her to provide a narrative account o f his/her experience o f tbi via a series o f in depth interviews (nochi, 1998) . have an inform ation-rich story to share (nochi, 1998) < have a degree o f self-aw areness and insight into the fact that s/he had sustained tbi in order to provide useful inform ation for theory-building (nochi, 1998) • v oluntarily participate in the study because life history m eth­ odology necessitates a personal sharing o f life experience and sustained engagem ent with the research process (cole & knowles, 2001) • be able to share his/her experience in english so that re­ searcher and participant could com m unicate in a com m on language for the purposes o f facilitating an in-depth explora­ tion o f his/her life experience • be able to share his/her story with adequate verbal com pe­ tency or via alternative or augm entative com m unication if considered appropriate m ethod o f data collection m ultiple in-depth interviews were conducted to enable the researcher to obtain m eaningful insights that reflected how the individual made sense o f the event o f tbi in his/her life. the content o f the interviews was shaped by focussing on topics o f interest or significance to the participant (clandinin & con­ nelly, 2000). see a ppendix a for the interview schedule used i during data collection. the interview schedule was developed | using a tkinson’s (1998) guidelines. the interviews were videoand audio recorded, thus ena­ bling the researcher to observe the kinesics and non-verbal com | m unication o f the participant, lending greater depth to the infor­ m ation shared. audio tape-recording o f the interview sessions i allow ed both the researcher and the participant to cross-check the data gathered, thus enabling a means o f validating the data. the interviews were supplem ented by sources o f inform ation from the participant’s personal journal, photograph album s and m edicalrecords. / r esearch procedure the procedure com prised three main phases, namely, a screening phase, a pilot phase, and main study (table 1). all phases were im plem ented at ja rehabilitation institution in i kwazulu natal, south a frica for individuals who have sustained strokes and head injuries. three participants were interviewed during the screening phase. two participants m et the criteria for selection as they had inform ation-rich stories. one participant was chosen for the pilot and the other as the main case study. d uring the pilot phase, the interview schedule, interview proc­ ess, logistics o f data collection and analysis procedures were refined. in the m ain study the participant was interview ed on three occasions. each interview was approxim ately ninety minutes. the interview s were audio and video recorded. the participant narrated his life story to the researcher. it was critical to establish a com fortable rapport with the participant, in light o f the sensi­ tive and intensely personal nature o f the interviews. exposure o f o n eself during the research process involves issues o f respect, trust, fairness, truth telling and justice (cole & knowles, 2001; c landinin & connelly, 2000). a sem i-structured interview ap­ proach was adopted, thus prom oting flexibility during the inter­ view process (atkinson, 1998). the participant was able to move backw ard and forward along a temporal dim ension as part o f the storytelling process (clandinin & connelly, 2000). description o f the participant the participant selected was a 31 year-old white south african male, paul carstens (name changed to protect identity), w ho sustained tbi on n ovem ber 4, 1991 while on duty in the south african army. he was 18 years old at the time when he was involved in an explosion causing him to sustain a head in­ ju ry and killing his friend who was assisting him. paul was in a com a for six m onths follow ing the accident, having sustained severe brain injury. prior to the accident, paul had ju st com pleted secondary school and embarked on m ilitary service. he described him self pre-m orbidly as a relaxed, fun-loving, unconventional individual who possessed good com m unication and interpersonal skills. at the time o f the interviews, which were conducted in september 2003, at least 12 years post injury, paul was receiving psycho­ therapy and speech-language therapy to address cognitive and com m unication difficulties. in terms o f cognitive abilities, paul was experiencing subtle m em ory, attention, concentration and organisational difficulties. he also presented with m oderate dys­ arthria, thus his speech intelligibility was com prom ised. other conditions included arthritis; restricted m obility (he was using crutches); im paired vision in his left eye due to optical nerve damage; and perm anent dental m isalignm ent caused by injury to his mandible. t able 1: outline o f research procedure ph ase 1: sc r een in g phase 2: pilo t study phase 3: m a in study s three participants were interviewed. since they fulfilled the selection criteria em­ ployed, two were randomly selected for participation in the study. from these two participants, one was chosen for the pilot study and one for the main study. 1 s the participant was interviewed over one one hour and one two-hour sessions. the interviews were audio_ and video recorded. the participant narrated his life story to the researcher. the following aspects were pilot tested: interview schedule, interview process, logistics and data analysis procedures. the participant was interviewed over three one-and-a-half -hour sessions. the interviews were audioand video recorded. the participant narrated his life story to the researcher. the data collected were qualitatively analysed. the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 20 ayesha sabat, legini moodley and harsha kathard ethical considerations qualitative researchers can be considered as guests in the private spaces o f the participants’ world (stake, 1994). there­ fore, it was im perative to adhere to a strict code o f ethics. ethical clearance was obtained from the u niversity o f k w azulu natal ethics committee prior to the study. inform ed consent was ob­ tained from the participant and ethical issues o f anonymity, con­ fidentiality, w ithdraw al and the role o f researcher and participant were highlighted. the participant was treated with fairness by prom oting open discussion and negotiation. he was also in­ form ed o f the intended (video and audio) recording o f the inter­ view sessions. w ritten inform ed consent to record the interviews was obtained from the participant at the outset. in order to ensure an authentic representation o f the participant’s story, he was pro­ vided with the storied (recorded) representation o f his narrative to enable him to validate the information shared (stake, 1994). r igour and trustworthiness the researcher’s reflexive position during the research process is valued as a critical technique for establishing trustw or­ thiness (cole & knowles, 2001). in order to achieve this, num er­ ous strategies o f trustw orthiness were employed. prolonged and persisten t fie ld w o rk involved the use o f m ultiple in-depth inter­ view s and ongoing contact with the participant over the course o f the process spanning two years. the interviews were conducted in the p a rtic ip a n t’s language to ensure that the situation was con­ ducive to storytelling. verbatim accounts o f conversations in the form o f direct quotes were representative o f the participant’s m eaning o f his experience. low inference descriptors refer to literal descriptions used and understood by the participant, as opposed to the abstract language used by the researcher. these add more depth to the data (m cm illan & schumacher, 2000). therefore, in portraying p au l’s account o f his life experience, accurate descriptions from the interviews were used to enhance trustworthiness o f the data. furtherm ore, while in-depth interviews form ed the core data collection technique, triangulation or m ulti-m ethod strate­ gies o f data collection were also em ployed to increase validity (medical records, journals and photo albums). m ultim ethod strategies increase the credibility o f findings by yielding different insights around the central topic (m cm illan & schumacher, 2000). m em ber checking was also employed. this entailed re­ turning the recorded version o f his story to the participant for validation and verification. m em ber checking is an important aspect o f life history m ethodology, as it indicates respect for the individual and enhances the truth-value or fidelity o f the narrative (frank, 1997; a tkinson, 1998). m ethodological challenges the participant was able to narrate his story with consider­ able ease, despite the presence o f dysarthria and subtle cognitive difficulties. organizational and m em ory problem s were m ildly evident during the narration. for example, at certain points in the narration, he reached a blank and was unable to continue with a certain thread o f thought and had to be prom pted. a t other times his narrative tended to be tangential and he thus needed to be re­ directed to the focus o f the question that was asked. fortunately, m em ory blanks were rare as reliance on good m em ory is a criti­ cal aspect o f identity construction (shadden & agan, 2004; neis ser, 1988). interviews were audio_ and video recorded to facilitate the transcription process. the participant and researcher negoti­ ated methods o f clarification, w hich included requesting repeti­ tion and/or elaboration o f a spoken word(s) if they were unclear to the researcher and speaking at an increased vocal intensity to increase the clarity o f his speech. the option o f com m unicating graphically or via the w ritten m ode in instances o f com m unica­ tion breakdown was also available. however, the participant did not find it necessary to use these alternatives. in life history re­ search, particularly when w orking with people experiencing com ­ m unication disorders, it is critical that the researcher is a skilled listener to allow the personal story to unfold meaningfully. d ata analysis the data analysis w as conducted at three levels. the first level o f analysis entailed generating transcripts from the inter­ views conducted. this was followed by narrative analysis (polkinghom e, 1995), w hich produced the research story through m eaningful interaction w ith the interview data (transcripts). the third analytical level involved an analysis o f the narrative (polkinghom e, 1995) in w hich the research story was examined for com m on themes and concepts in relation to the critical re­ search question. d uring this process the researcher steered clear o f im posing prior theoretically derived concepts on the data. instead, careful inspection o f the narrative facilitated the genera­ tion and developm ent o f new concepts from the research data via an inductive analysis. the em erging them es were then discussed in relation to available literature. resu lts and d isc u ssio n for the purposes o f this paper, the results are presented as ex­ cerpts from the research story, as well as verbatim excerpts from the transcripts. the results and discussion are integrated. the em erging themes listed below describe the evolution o f the par­ ticipant’s self-identity: 1. d eveloping a resistance identity as a product o f early pre-tbi experience 2. m oving from loss o f se lf to reconstruction o f se lf post-tbi 3. c onstructing a positive self-identity post-tb i i d eveloping a resistance identity as a product o f early pre-tbi experience 1 i in attempting to understand the process o f identity form a­ tion and the shifts in self-identity, it was critical to explore the role that early childhood experiences have played in shaping p a u l’s self-identity. his early life experiences reflected a child­ hood characterised by disappointm ent, sadness, confusion and a sense o f abandonment. paul experienced resentm ent and deep pain at being separated from his parents at an early age when he was sent to boarding school: ‘we were sent up to eshowe. i begged and p le a d e d f o r her (my mother) to take m e back. i think i was causing her more pa in than anything else. she drove all the w ay to eshowe with us in the car, w hich made her happy. she drove back alone a n d she cried a ll the w ay hom e ... g o in g to school, leaving home ... that had to have been the saddest experi­ ence o f my childhood. ’ p a u l’s feelings o f loneliness and sadness were further intensified die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) identity construction following traumatic brain injury: a case study 21 by the reality that his fam ily unit had been split by his p aren t’s divorce when he was four years old. this was clearly a traumatic experience for him, as reflected in the following excerpt: lm y p a ren ts were divorced when i was f o u r ye a rs old. i was too yo u n g to understand what was happening. i d id n 't even know it was happening. b u t soon enough, the reality o f it was etched into our lives. forever. we w orked around it though. m y p arents made sure o f that. ’ paul could not seek solace in his relationship with his older brother, as they were not close. a s a result, he needed to adopt a strategy that would enable him to survive at boarding school away from all that was fam iliar and safe. he depended on him ­ self. paul developed a firm sense o f individuality that became central to his quest for survival at such a tender age, where paren­ tal love and support is so critical to o n e ’s feelings o f safety, secu­ rity and acceptance: six ye a r-o ld boy wants his mommy. a lone in a strange place. b egged a n d pleaded, p lease take me back. i hated being aw ay fr o m mom. i f e l t hurt, rejected, abandoned. i cried. i waited. they d id n ’t com e back f o r me. this w as it. i had to be strong, smart, independent. f ig h t m y own battles. b e my own person. chris, m y brother, a n d i w e r e n ’t close. i could n ’t depend on him. we fo u g h t a ll the time. i built a p ro tec­ tive w all around me. i needed to f e e l safe, in control. i needed to be me. ’ his experience at school was challenging and m ingled with a sense o f longing for his parents. paul also had a dire need to prove his worth to a father who underm ined his ability: ‘l ife a t school w as f u l l o f challenges, especially when mum a n d d a d were so f a r a w a y...m y d a d a n d i ju s t never clicked... it was a strange relationship that we shared. i think my dad j u s t dem anded too much fro m me. i couldn ’t deliver and he used to g ive m e these lectures about not being go o d enough a t a n yth in g .' p au l’s initial reaction o f w ithdraw ing into a silent safe space within h im self to help him deal with the feelings o f abandonm ent he was experiencing, led to him developing a firm sense o f self identity^ d efining o n e’s self-identity is critical to determ ining how one acts in a given environm ent and relates to others (schlenker, 1987). paul was determ ined to be different; to affirm his individuality: | 7 w as a rebel, especially in high school. the anti-trendy, anti-groupie. chris, on the other hand was very much a groupie. i d id m y own thing} m ade my own rules. a n d broke them! that d id n ’t win me too m any frie n d s b ut i had two really g o o d fr ie n d s who understood me. i f w e d id anything we w ould do it three different ways. each to his own. i d id n 't care f o r convention. i still d o n ’t. i broke all the rules! ’ p a u l’s need to adopt a strong persona and not to succum b to peer pressure and group convention was his w ay o f negotiating this challenge. it was never im portant to him to fit in. his outspoken defiance o f social convention is reflected in his discourse and ultim ately linked to who he was. p au l’s strong sense o f inde­ pendence was further reflected in his assertion that he did not have m any heroes growing up. he cited h im self as his source o f inspiration, indicating a certain lack o f w onder and perhaps even trust in the adults in his lifeworld. paul has attributed the person he has becom e to his own effort: ‘t h a t’s w here i developed a ll m y independence fr o m (boarding school) because i h a d to sta n d on m y own two fe e t ...i was never brought up by m y p a ren ts...w h a t i am now is basically self-created...1 was never around m y parents that m u ch ...m y inspiration to do anything had to come fr o m me. ’ p au l’s experience as w hite, english and m iddle-class unfolded within a broader socio-political context. h is experiences unrav­ elled in south a frica during a turbulent social and political p e ­ riod (1980 to 1991). d uring this tim e m ilitary service was still com pulsory for young w hite males under the previous apartheid regime. the im position o f m ilitary service was not always m et with enthusiasm especially since at the critical age o f 18 years, one is usually looking forw ard to travelling and furthering o n e ’s education. in this particular case, paul indicated a strong dislike for the army: 7 hated the army like hell! ’ ironically, his life-altering event occurred in this very context (the army). his sentim ents could be understood within the con­ text o f his tendency to challenge authority and live life by his rules. p aul’s narrative thus spoke resolutely o f his need to locate h im self in a w orld that he often encountered as unfriendly and cold. w hat paul viewed as being different from the rest was later to becom e his w ay o f adapting to lifestyle changes as a person living with an acquired disability. his sense o f self-identity was thus valued as a means o f claim ing his place in a hostile world. it was w ithin this protective space that he retreated in order to feel safeguarded against sources o f pain and disappointm ent. clearly, initial experiences had created a resistance identity; that is, nega­ tive experiences produced a sense o f resistance to convention and anything that underm ined his self-worth. this resistance was ultim ately em bedded pre-m orbidly in p aul’s sense o f identity . this was his w ay o f surviving. a lthough paul retreated into a protective space, he devel­ oped skills that helped him survive in the face o f adversity. h is encounter o f life as a young person fashioned a resilience that was going to prepare him for a greater challenge later in life. in a sense, p au l’s resistance identity harboured strength o f spirit that led to the critical shift in the w ay he was to view his w orld and his place in it: with further intent to resist the restraints and inher­ ent expectations im posed by society on one who has a disability. p a u l’s process o f self-identity form ation is thus best understood w ithin the context o f his early life experiences. the emerging transition o f his self-identity was “norm al” and expected, how ­ ever it m ay not have taken the trajectory it did, had his life cir­ cum stances been different. m oving from loss o f self to reconstruction o f self following tbi p au l’s initial experience follow ing tbi was characterised by a sense o f loss a loss o f m any functions, including his speech: ‘all m y m ovements in the mouth, like m oving my tongue fro m side to side were very slow there was absolutely nothing com ing o u t ’ he experienced the frustration at not being able to project his voice: the stu p id nurses, they used to run a cold bath a n d p u t m e in. i c o u ld n ’t talk. i c o u ld n ’t say anything. i used to try and hit th e m !’ paul endured a transition at this stage from having a strong and the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 22 ayesha sabat, legini moodley and harsha kathard boisterous voice to support his personality and define his sense o f self, to momentarily losing that voice. a t a broader level, p a u l’s sense o f self experienced a shift which was defined by loss fol­ lowing the tbi. o ther losses included a certain degree o f loss o f mobility, partial loss o f independence and econom ic em pow er­ ment, loss o f form er friendships as friends were uncom fortable about p aul’s acquired disability and loss o f a certain public image that he always tried to project. sense o f self is dram atically affected b y tbi and is experi­ enced by survivors o f tbi as a complex, m ulti-layered phenom e­ non (nochi, 1998). individuals with tbi often experience conflict in trying to reconcile the disparity created by the self-image they m aintain and society’s perception o f who they really are. the dom inant public narrative has the tendency to impose negative labels on people with tbi. this creates conflict w ithin the indi­ vidual, leading to a sense o f loss o f self. n ochi (1998) has identi­ fied this phenom enon as loss o f s e lf as perceived by others. l a­ bels generally im ply negative images o f disability and prom ote a deficit-based, pathologically oriented view o f people with dis­ abilities, thus discounting their individuality and casting them into pre-existing categories. this perspective o f people with dis­ abilities is espoused by the medical model, w hich perpetuates the notion that illness is a form o f social deviancy. p a u l’s resistance identity then gradually resurfaced as his recovery progressed and he began to challenge the public narrative. he regained his speech, his voice, which was a critical step in the transition. he spoke strongly o f his need to be acknow ledged as an individual with unique traits that preclude any form o f categorisation: 7 am priceless. i am unique. e verything about me marks who i am. m y thumbprints. m y voice. i am an individual. a n d no one can take that away fr o m m e.’ [em phasis mine] paul thus once again asserted his identity forem ost as an individ­ ual who has never blindly followed convention. the fact that he was physically challenged did not feature resolutely in his self­ appraisal. he spoke o f his frustration due to the limitations in­ curred by his injuries, such as not being able to drive or su rf any­ more. interestingly, he did not cite his rem aining com m unication difficulties as a constraint im posed by the head injury. instead, he chose to value his voice and saw it as instrum ental in affirming his identity. p a u l’s com m unication difficulties and the utility o f speech-language therapy were raised by the researcher. however, he did not attribute m uch significance to these aspects, choosing to talk about other critical aspects which concerned him e.g. his lim ited mobility. w hilst his speech m ay have had a dysarthric quality, rendering it unclear at times, w hat m attered to paul was that, ultimately, he was able to com m unicate his m essage. d e­ spite the consequences o f his impairm ent/s he did not view him ­ se lf entirely as defined by a disability. the w ay that society p e r­ ceived him however, was apparent to him and to this end, paul experienced the effects o f this negative perception, w hich con­ flicted with his own understanding o f h im self and w hat he was capable o f achieving: ‘life is n ’t always sm ooth sailing when yo u have a disability. people treat y o u differently. the trick is learning how to deal with prejudices. i t ’s n ot easy. som etim es i g e t really angry like when i go to the till to p a y and m y fia n c e is with me and they ask her f o r the money. i t is as though i d o n ’t exist! talk to the m an! ... i have a short fu s e ! i do try to be patien t sometimes. b u t i j u s t g e t so angry when p e o p le talk over me! i wish they w ould see me and treat me like they w ould any­ one else. i know that m y body has been injured b ut m y brain is still happening! ’ [emphasis his] paul faced the challenges o f societal prejudice during his daily course o f events. it was perhaps because o f his perceived com­ m unication (dis)ability and m arked physical im pairm ents, such as his unsteady gait w hilst w alking which necessitated the use of assistive devices like crutches, and his injured eye, that the cash­ ier in the above exchange treated him as described. however, paul used his voice once again to speak out against the prejudice. h e used his ability to com m unicate to his advantage. his experi­ ence o f disability and the subsequent restrictions it imposed on his m ovem ent was exacerbated by the discrim ination displayed towards him, em bodied in a form o f social prejudice that exists against people with disabilities: 7 see that i f i t in perfectly into society. b u t society, i feel, has a problem with me. i am a person! i think that people need to give us a chance. they have to learn to accept and adapt to p eo p le with disabilities. society lim its its e lf by lim ­ iting us. ’. if paul accepted the labels and associated expectations that soci­ ety im posed upon him and his disability, then he would have to relinquish the validation o f his self-image as a unique individual (nochi, 1998). his narrative resonated w ith the sentim ent that he was not w illing to accept society’s labels and was clearly deter­ m ined to carve out a positive self-identity, and receive acknowl­ edgem ent for the person that he is; a determ ination historically rooted and linked to his resistance identity. p a u l’s construction o f self-knowledge and ultim ately the reconstruction o f his self via new experiences is a deeply com plex concept. a ttem pting to engage with this com plex process can only serve to deepen an understanding o f the lived experience o f tbi in all its m ultifari­ ous components. constructing a positive self-identity post-tbi in exploring the process o f positive identity construction post tbi, issues o f attitude, hope and illness as m oral re­ awakening were central features. m oral re-aw akening refers to a renew ed sense o f spirituality that is drawn from an experience o f illness or disability (frank, 1997). a ttitu d in a l dim ensions p au l’s story resonated with courage, hope and an ultim ate acceptance o f all that has occurred in his life thus far, with spe­ cific reference to the accident and resulting injuries. he ac­ know ledged, after an ongoing period o f grieving (at', least four years post injury), that life goes on. w ith this acceptance o f the w ay his life unfolded, paul chose to adopt an attitude that would facilitate his transition into a new life with optim ism and strength o f spirit: 7 have two choices: i can either be happy and accept what is happening a n d look fo rw a rd to the future, or be sa d and re­ g re t what is done ’ p au l’s attitude was infused with hope. he chose to use the ex­ perience o f the accident in his favour. instead o f allow ing him self to be paralysed with sadness, resentm ent and regret at the course his life has taken, paul resolved to pursue his^ challenges with courage and hope. rem arkably, the very event that had caused his life to be steered in a direction he did not anticipate, had also enabled him to discover certain truths about himself: 7 used to be very naive and'carefree. b u t the accident has transform ed m y life, the way i see things. i fe e l more grounded. i ’m able to see the lighter side o f things. i used to die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) identity construction following traumatic brain injury: a case study 23 be a very negative guy. ’ evidently, the accident had changed p au l’s life transform ing the way he saw and experienced his world. he had been thrust from complacency to an appreciation o f life with all its com plexity and contradiction. paul felt that the accident had granted him the op­ portunity to reconstruct h im self positively. m oreover, while paul was initially plagued by feelings o f insecurity and loneliness fos­ tered by a less than ideal fam ily dynam ic, he later (post-tbi) experienced greater stability due to im proved personal relation­ ships. p a u l’s reaction to the accident, resultant injuries and the pervasive im pact it had exerted on his life and sense o f self clearly contradicted the conventional notion that traum atic ex­ periences produce an ongoing sense o f loss and devastation (schlenker, 1987). he chose to com m unicate his responses in a positive way, thus constructing a positive social identity, which in turn influenced his actions and responses to certain life events. while the experience o f loss is a real part o f the experience, paul’s story highlights the fact that it does not continue indefi­ nitely, thus contradicting the m edical notion that people live in a continual state o f loss. m oral re-awakening p au l’s self-narrative echoed with hope and optim ism for the future. his plans included sharing his life with his significant other and creating vocational opportunities for himself. he em­ phasised the role o f spirituality in his positive reconstruction: ‘the one and only thing i can rem em ber fr o m m y coma is saying god, p lea se d o n ’t let me go. i was literally begging g od ju s t to let me live, especially f o r my mother. since then ' religion has becom e so im portant to me. i t ’s brought m y life into perspective. i t has made me realise w hat is really impor­ tant to me. i value m y mom a n d m y fia n c e equally. a n d my religion supersedes them. i have also learned to take g o o d care o f myself, to value m y general well-being. a n d fa m ily is the m ost im portant thing to me. ’ in this vein, p a u l’s narrative is closely aligned with f rank’s (1995) quest narrative, w hich encounters suffering boldly, ac­ cepts illness and uses it heroically. q uest narratives involve per­ severance and are oriented tow ard the future. illness is thus not viewed as an interruption that m ust be overcome b ut rather as a challenge that must be m et andj from which the individual can gain som ething meaningful. illness is seen as a critical event that becom es an occasion to turn an inner gaze and to engage in a moral questioning o f who we arel(frank, 1997). p a u l’s narrative reflects the polyphonic nature o f a quest narrative w here m ultiple voices echo complex, interw oven and often contradictory values and stories and represent an affirm a­ tion o f identity (frank, 1995). thus, in p a u l’s life story, living with an acquired disability was n ot view ed entirely as fatalistic but was em braced as part o f his com plex life experience. the sense o f hope that paul fostered represented new meanings that he created o f h im self through the experience o f trauma. k leinm an (1988) contends that the experience o f a critical event need not be experienced as a self-defeating exercise but can be used as a con­ duit to deeper and better things. hope is b o m from the personal and cultural dilemmas that are induced by illness, forcing one to turn to sources o f m eaning that are already present in our lives (kleinman, 1988). a lthough paul was often plagued by despair and repeatedly questioned his fate, there was an overriding sense o f resolution and motivation: ( 7 believe that g od is supreme. h e is in charge o f absolutely everything. a n d i f h e w anted this to happen, there had to be a way. i t h a d to be h is will. i f g od is willing, who am i to question that? h e has helped to improve m y life. things can only g e t better. i believe that g od gives us gifts. i f we d o n 't use them, he takes them away a n d in so doing takes a chunk o f our lives away. m y g ift fro m h im is to help p eo p le by sh a r­ ing m y experiences with them a n d i ’m trying to p u t back into society w hat i ’ve taken out. to search within m y se lf a n d make a difference to o th e rs’ lives. t h a t’s why these m otiva­ tional talks that i give are so im portant to me. sharing m y experiences also helps me com e to term s with w here i am right now. ’ through his spiritual growth, paul was able to reach out to others, sharing his experiences with them and strengthening his self identity. paul saw his ability to do this as a divine gift and in so doing recognised that his own life experiences could be used as valuable lessons not only to others but to h im self as well. h is desire to help others resonates w ith.k leinm an’s (1988) suggestion that illness heightens o n e’s aw areness o f other peo p le’s suffering, thus m aking one m ore inclined to behave in ways that would help to reduce the suffering o f others and allow one to assume respon­ sibility for others. the m otivational talks paul presented, p ro ­ vided a valuable opportunity for his personal growth following the accident. in giving to others, p a u l’s feelings o f self-worth were reaffirm ed. he used his com m unication skills positively and to his benefit, despite the dysarthria. paul was able to view the events o f his life as m eaningful and purposeful, thus em pow­ ering him w ith hope and the ability to perceive and m aintain an im portant role in society. it is alm ost as if, in living a post traum atic life, p aul’s traum a has becom e the source o f his work, which in turn has becom e a source o f community, nurturing po s­ sibilities o f new role-taking and m eaning-m aking (frank, 1997). im plic a tio n s, rec o m m en d a tio n s and lim itatio ns the study holds significant im plications at various levels. the contributions o f life history research are linked to its intellec­ tual and moral purpose and its potential to provide insight into individual lives (cole & knowles, 2001). the present study holds the potential to provide a research m ethodological tool for exploring in greater depth the lives o f the people w ith whom cli­ nicians work. life history research can be utilised to engage at deeper levels w ith individuals who experience tbi and its conse­ quences, as illustrated in p au l’s case. im portantly, the study has also shown that even when p eo ­ p le present with com m unication im pairm ent they have stories to tell and as such should be granted the opportunity to be heard. life history research has the potential to provide a platform upon w hich discourse around individuals with disabilities, who have been m arginalized from the dom inant research dialogue, may be informed. p au l’s story highlighted this notion and illum inated the com plexity o f issues underlying self-identity and com m unication. the use o f life histories as a clinical m ethod can be ex­ plored w ithin slt contexts. w hile com m unication is the focus o f intervention, it is also pivotal to creating self-identity. therefore, when applied to the understanding o f an individual who has sur­ vived a tbi, com m unication is the instrum ent used to generate a life story account o f experience. b y understanding the critical dual role o f com m unication as both an intervention need, as well as in constructing self-identity, clinical interventions can becom e m ore client-centred. the know ledge produced in this study can thus encourage clinicians to understand their clients' com m unica­ the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 24 ayesha sabat, legini moodley and harsha kathard tion needs as they relate to the individual’s sense o f se lf in his/her life context. w hen com m unication is view ed in this way, it m ay assist the clinician in thinking through intervention goals for the individual and to understand the types o f intervention that are necessary. clinicians who have read p au l’s story at a general hospital in johannesburg, south a frica and sandwell, england have indi­ cated that life history has potential as a clinical tool. w hilst clini­ cians often use a case history, this tool traces the history o f the disorder while the life history interview offers potential to under­ stand how individuals live with disorders. b y developing client centred therapy goals, the clinician is able to generate relevant functional com m unication intervention. they also reported that using life histories in therapy w ould highlight the importance o f other life issues (em ploym ent, housing, relationships, physical m obility, inability to drive) w hich are im portant to consider when setting intervention goals and strategies. a lthough com m unica­ tion was an im portant issue, it rem ained em bedded within an identity frame. however, time constraints were cited as a con­ cern and lim itation to the clinical im plem entation o f life histories. furtherm ore, the slts reported that reading this particular narrative challenged their perceptions o f people with disabilities as they acknow ledged that positive experiences could emerge from an event such as tbi. this notion resonates with p ound’s (1993) assertion that it is critical for slts to develop a height­ ened awareness and deeper understanding o f the m ulti-faceted nature o f individuals’ responses to disability, in order to appreci­ ate a different perspective and to cultivate positive attitudes amongst professionals. she m aintained that if therapists adopt negative attitudes to disability by focusing on impairm ent, it is likely to lead to negative stereotyping o f people w ith disabilities. this attitude hinders the recognition o f the potential o f people w ith disabilities to take control over their changing lives. clini­ cians are encouraged to critically evaluate their own beliefs and attitudes to ensure that their practice removes, rather than creates, disabling barriers. w hen applied to p a u l’s case, it w ould have been easy to interpret p a u l’s experiences in general, and his com ­ m unication difficulties in particular, as negative events. his nar­ rative, however, proved otherwise. in the field o f tbi particularly, slts m ust be cognisant o f w hat role they can play in strengthening the positive self-identity trajectory. the com m unication intervention program therefore depends on the clinician’s ability to consider issues o f the client’s potential and his/her understanding o f disability. in p a u l’s story for example, his optim istic appraisal o f experience could well be overlooked in a therapy program that is not sensitive to the com ­ plex processes underlying the construction o f his positive self identity post tbi. it w ould be imperative to engage w ith p a u l’s affirm ing attitude and inner self if relevant therapy goals and in­ tervention plans are to be produced. the intim ate link between his com m unication and self-identity w ould be the key to fostering optim al intervention. life history research also engages with the spiritual and m oral dimensions o f the individual. as discussed, p au l’s story resonated w ith a sense o f moral awakening. his experience o f tbi has ignited a deeper life m eaning and spiritual awakening that forms the basis o f how he lives, com m unicates and interacts with people. through understanding these deeper dimensions o f the individual, clinicians m ay be able to sharpen their insight into the m ultifaceted nature o f hum an experience. w hile the body/ im pairm ent aspects o f interventions have received prim ary atten­ tion in the speech-language pathology literature, issues o f spiri­ tuality w ould appear to have received marginal coverage (jordan & bryan, 2001). h owever, p au l’s story implies that clinicians should understand and interact with issues o f spirituality where they are apparent i f they are to engage with personally meaningful interventions. the use o f narratives in aphasia therapy is endorsed by pound et al. (2000) who encourage slts to sharpen their listening skills and hone in on their ability to facilitate storytelling, as the value o f narrative m edicine can be used as a pow erful tool for fuelling therapeutic interventions and m easuring outcom es. the very act o f telling o n e’s story has potential to produce a therapeu­ tic and cathartic effect for the storyteller. em pirical research that has been conducted on the use o f narrative constructions with diverse populations experiencing chronic conditions has indicated that narratives o f emotional experiences have produced positive changes in these individuals (nochi, 2000; parr et al., 1997). practically, for the individuals whose lives were irrevoca­ b ly affected by the experience o f tbi, this study could be used to inform and educate the public about the issues raised. societal notions o f disability need to be challenged to facilitate the suc­ cessful integration o f people with disabilities. again, intervention should encompass the gam ut o f the personal experience o f dis­ ability, extending beyond a focus on the personal to the social creation o f disability. the study has social and political implica­ tions in that the issues o f disability that have been raised have the potential to influence the w ay society perceives people with dis­ abilities. instead o f view ing “pathology” and “norm al” as dispa­ rate entities, they can be seen and appreciated as varieties along a continuum o f m odes o f being-in-the-w orld (papadim itriou, 2001, p. 10), thus encouraging clinicians as well as the public to appreci­ ate disability as a continuum o f hum an diversity. a t a theoretical level, the issues raised in the study are congruent with the m ove tow ard em bracing the social model of disability and procuring subjective perspectives on the experience o f disability (hilari & byng, 2001; frank 1997; n ochi, 2000; n o­ chi, 1998; parr et al., 1997). the study contributes to a growing body o f research on the personal m eaning ascribed to certain life experiences, such as acquiring a disability. furtherm ore, the study has highlighted issues o f com m unication that are embedded within a self-identity development. the strengths o f the study include the data collection m ethod, nam ely a series o f multiple, in-depth interviews, thus yielding value laden, inform ation-rich data. furtherm ore, by virtue o f the life history m ethodology im plem ented, an emic (insider) perspective is provided, as the narrator was able to con­ struct his self-identity and life via the narrative process. a pilot study was conducted in order to evaluate the efficacy o f the inter­ view schedule (data collection tool), interview process, data analysis, and the overall logistics o f the interview procedure, thus enhancing the trustw orthiness o f the main study. a single case study design facilitated an in-depth exploration and understanding o f what it means to be a survivor o f tbi. m oreover, the research story was analysed qualitatively, facilitating insight and a deeper understanding o f the experience o f tbi w ithin the broader land­ scape o f the participant’s lifeworld. as described under participant selection criteria, the par­ ticipant was required to have sufficient cognitive and com m unica­ tive ability to be included in the study. these were not stipulated as exclusionary criteria, but rather to facilitate the process and provide relevant know ledge about the particular case. since this is still a developing m ethodology, future research could look to including people with severe cognitive and com m unication diffi­ culties to expand the know ledge base. this w ould require refin­ ing the current m ethodology considerably. for example, encour­ die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) identity construction following traumatic brain injury: a case study 25 aging the narrator to em ploy a lternative and a ugm entative communication (aac) devices, drawing, symbols, and ges­ tures to convey a m eaningful story. the stance o f the re­ searcher in this instance m ay also change. instead o f using open ended questions, s/he m ay need to use forced alternative questioning in order to procure inform ation from the narrator. a limitation worth noting is that im posed by the con­ straints o f language and text. however, even within linguistic and textual restrictions, it is possible to provide a m eaningful representation o f one’s life within the text (clandinin & c on­ nelly, 2000). m em ory also im poses restrictions on the narra­ tive, as events are selectively revealed, thus despite prolonged engagement with the participant, his/her revelations will always be constrained. this is, however, the nature o f retelling experi­ ence but should be considered particularly when interviewing participants who have m em ory problem s. conclusion this study explored the process o f self-identity construc­ tion pre and post tbi, using a life history m ethodology. the results highlighted the interaction o f com plex variables underly­ ing the process o f self-identity form ation in a survivor o f tbi. the self is seen as central to action. the role o f com m unication in negotiating and representing self-identity is illuminated. the participant’s narrative highlighted his life experience in the p e­ riod preceding and following a head injury. the story revealed how critical early life experiences, fashioned through interac­ tion with significant others (family, peers), shaped self-identity and the ability to negotiate significant life changes incurred by the head injury. the evolution o f a positive self-identity is traced. p au l’s self-identity was constructed via his dialogue. his com m unication was entw ined with all aspects o f his life and served to present a particular social persona. paul used his communication strengths positively in constructing and affirm ­ ing his altered post injury self-identity. illness as an experience o f moral awakening is highlighted, as p au l’s deep spirituality enabled him to nurture hope for the future, to look forward to living and sharing his life with his significant other. in this re­ gard, paul has becom e the ultim ate architect o f his own social reality. a c k n o w ledg em ents this article is based on a dissertation submitted to the u niver­ sity o f k w azulu n atal b y the first author, under supervision o f the second and third authors, m s ilegini m oodley and prof. har sha kathard, in partial fulfilm ent o f the requirem ents for the degree m asters in c om m unication pathology (speechreferences atkinson, r. 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(eds.). coping with handbook o f qualitative research. london: sage publications ltd. appendix a interview schedule the fo llo w in g questions were u sed as a gu ide during the interview. the interviews u nfolded in the direction the pa rticip a n t took, with som e guidance being offered by the researcher. ❖ w here / when were you bom , earliest childhood m em ories, what was your fam ily like, describe your parents, siblings, grandparents? ❖ tell me about your linguistic, cultural, social and racial background ❖ tell me about the most significant events in your life ❖ w hat academ ic qualifications do you have? ❖ tell me about your earliest childhood memories ❖ w hat were your experiences like at school? ❖ do you see education as playing an im portant role in o n e’s life? ❖ w ho were your role models? ❖ w hat did you want to becom e on graduating from school? ❖ describe the political climate w hen you were growing up ❖ tell me m ore about the accident ❖ how has having sustained a head injury changed your life? ❖ h ow do you view disability? ❖ w hat are the challenges you face as a person with a disability? ❖ h ow has the accident im pacted on your relationships with fam ily and friends ♦♦♦ d id you find the rehabilitation services rendered to you follow ing the accident effective? ❖ w hat are your hopes for the future? ❖ is there anything we m ay have om itted from your life story? ❖ do you have any com m ents about the interviews and all that has been discussed? ❖ d id you find that talking about your life was a therapeutic experience? ❖ d id it have a cathartic effect on you? die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) vol 57 • december 2010 • sajcd 51 configurations of self-identity formations of adults who stutter harsha kathard vivienne norman mershen pillay school of health and rehabilitation sciences, university of cape town correspondence to: h kathard (harsha.kathard@uct.ac.za) clinicians require a close understanding of the experience of stuttering in order to offer meaningful and personally relevant interventions for adults who stutter. the individual’s unique experience of stuttering can be revealed through understanding how they construct themselves, i.e. their self-identity. silverman (2001) encouraged growth of researchers’ scientific repertoires and argued that when a person who stuttered sought help, he/she did so as a whole person who lived in complex ways with stuttering. silverman’s plea for such personal knowledge was a result of her observation that research which was reduced to numbers and facts had little practical value for the clinician. noting this methodological and conceptual gap in research, the study (kathard, 2003) upon which this article is based, examined how adults who stutter made sense of themselves, having lived with stuttering since childhood. kathard’s study (2003) was preceded by studies that emphasised the importance of understanding self and stuttering (fransella, 1968, 1972; shearer, 1961; sheehan, 1970). these early theorists offered varied explanations about self, self-construction and stuttering and applied them to interventions. sheehan (1970) explained stuttering by using ‘role-conflict’ theory and considered it as a role-specific behaviour. in his view stutterers have dichotomised understandings of themselves (in role as fluent speaker and role as stutterer). as a consequence of living with stuttering over a prolonged period, they developed understandings of themselves as stutterers rather than as fluent speakers, and this role was resistant to change. while he argued that an acceptance of selfconcept in a stutterer role was important at an initial stage of treatment, it was expected that by the end of an intervention the stutterer would accept himself as a normal speaker by seeing himself in a fluent speaker role. the intervention therefore required a radical reinvention of self to that of a normal speaker. shearer (1961) also described stutterers as having dichotomised and conflicting self-concepts – ‘a horrible stuttering self ’ and a ‘free-speaking normal self ’ (p. 115). the intervention was directed at reconciling these conflicting self-concepts with the intention of achieving a free-speaking normal self. he added that relapse occurred when the stutterer no longer perceived him/herself as a stutterer and therefore did not monitor his/ her speech and the environmental cues which elicit stuttering. fransella (1968) investigated the self-concept of a stutterer as a person using kelly’s personal construct theory (pct). kelly (1955) made three important contributions that have relevance for this study. firstly, he argued that in order to understand the human condition and behaviour, one has to understand it from the vantage point of the person living with that behaviour – the insider view. secondly, when a person makes sense of him/herself he/she does so by generating self-constructs which occur as a network of constructs in relationship with each other. thirdly, he coined the term ‘constructive alternativism’ which elucidated the idea that people have alternatives in how they choose to construct themselves, e.g. fat/thin, happy/sad. the process of successful change is achieved when a person is able to construct an alternative understanding of him/herself as the basis for effecting the necessary behaviour change. fransella (1968) investigated how the person who stutters constructed him/herself as a person using a combination of repertory grid and semantic differential techniques. using this method, she reported that stutterers have two primary understandings of themselves – as an individual and as a speaker. firstly, as an individual he/she is unique and different to all other people, including those who stutter. secondly, as a speaker, he/she holds the negative stereotypical view of themselves as stutterers. the intervention was therefore aimed at helping the stutterer as a speaker to develop a network of self-constructs to revise his/her selfconstruction to that of a fluent speaker and to experiment with fluency. fransella (1972) further tested her hypothesis that stuttering would decrease as the person took on the fluent speaker role. intervention focused on improving the meaningfulness of the fluent speaking role, rather than improving fluency, in adults with developmental stuttering. her hypothesis was confirmed and this strengthened the impetus for self-reconstruction as a basis for achieving improved fluency. evesham and fransella (1985) were also concerned about relapse and hypothesised that stutterers were less likely to relapse if they were able to construct themselves as fluent speakers. they tested their hypothesis with a group of 48 participants who received fluency training in the first week of intervention. participants were then divided into a technique group – intervention focused on prolonged speech techniques – and a pct group who were assisted in reconstructing their fluent speaker role. while all subjects improved their fluency, it was concluded that the pct group had a lower relapse rate (measured by fluency) than the technique group. despite the reported benefit of pct in fluency intervention by evesham and fransella (1985) and support from abstract it is important for clinicians to understand how adults who stutter construct who they are, i.e. their self-identity, in order to offer personally meaningful interventions. early research on stuttering and self-concept provided initial knowledge, but there has been a dearth of further research in this field. this article, the third in a series of papers emanating from a doctoral study, provides new insight into the configurations of self-identity formations of adults who stutter. previous articles from the study described how ‘able’ (positive self-identity) and ‘disother’ (negative self-identity) self-identity formations developed over time. this paper describes the configurations of self-identities, able and disother, evident across participants’ stories. the study used a life-history methodology in which 7 adult participants (5 men and 2 women) shared their experiences of living with stuttering through open-ended interviews. the data from the interviews were analysed at two levels. the first level of analysis resulted in a description of the types of self-identity formations (positive and negative) and processes (personal, social and temporal) shaping the self-identity formations. this result was represented as a research story for each participant. the second level of analysis described the configurations of the self-identities, able and disother, across the research stories. the main findings, illustrated through three research stories, were that the two types of self-identity formations, able and disother, were present in singular and dual configurations. the dual presentation of self-identity formations occurred in co-existing, competing and coalescing configurations at particular time periods, illuminating the complexity of the stuttering experience. the clinical implications are discussed. keywords: life-history methodology, self-identity configurations, stuttering 52 sajcd • vol 57 • december 2010 self-identity formations of adults who stutter stewart and birdsall (2001), pct did not have prominence in the us literature (dilollo, niemeyer & manning, 2002). while the value of self-reconstruction as a basis for change is recognised in stuttering research, it is also evident that most interventions require the stutterer to take on a fluent speaker role or self-reconstruction as a fluent speaker with intention to improve fluency. although fransella (1968) acknowledged that stutterers had self-constructions of themselves as unique beings, her intervention did not build on these attributes but was directed instead towards self-reconstruction as a fluent speaker. kathard’s (2003) study added to the knowledge base by approaching the study of self-identity as the basis for understanding the personal experience of stuttering. it differed from prior studies on self as it focused on describing the development of self-identity formations as well as the personal, social and temporal processes shaping these selfidentity formations in adults living with developmental stuttering. to achieve this, a purposefully created self-identity theoretical framework coupled with a narrative life history methodology was used. the theoretical framework differentiated between role and selfidentities. while people play many different roles they only become ‘identities’ when people internalise understandings of themselves (mishler, 1999), i.e. an identity of being a stutterer only occurs when the individual attaches such meaning to him/herself. these self-identities are constructed from different subject or ‘i’ positions, e.g. as a child at school, as a child at play, as an adult in a meeting, emphasising that identity formations are constructed from several subjective positions which vary across contexts, relationships and over time (somers, 1994). a person may also construct more than one self-identity of himself/ herself. critical to this paper is the understanding that self-identities are also dialogic, i.e. when an individual has more than one self-identity, these identities occur in varying relationships to each other and may be, for example, in conflictual or co-operative relationships (hermans, 2002), with power dynamics between them influencing their relative dominance. previous studies have taken primarily a psychological approach to self-identity formation. this study combined the ‘bodily’ experience of stuttering, the thoughts, feelings, actions and motivations (psychological), as well as the social and temporal processes that influence identity formation. the social processes highlight how self-identity is shaped by social values and actions evident in daily interactions with family, friends, schools and other social institutions. simply put, if people who are significant in one’s life construct stuttering as a bad thing and broader society holds a similar view, then the person who stutters may internalise this negative influence. it was also acknowledged that lives are dynamic and over time an individual may develop new or revised understandings of themselves. these changing formations suggest that self-identities are always in ‘process’ of developing from past to present and through to the future (mishler, 1999). over time, self-identities could be stable or flexible (valsiner, 2002) as they are shaped by changing social and personal dynamics in everyday circumstances. a qualitative, narrative life-history methodology was best suited to research self-identity formations within the framework described above. qualitative research in general has gained popularity in communication science research because it offers varied research approaches, all of which are analytical by nature and systematic in their execution (cresswell & miller, 2000). such research is valuable in communication disorders because it seeks to understand complex, sociocultural phenomena through exploration, generates rich descriptive data, encourages a focus on individuals in context, and values the participant’s point of view (dilollo & wolter, 2004; tetnowski & damico, 2001). a narrative, story-telling approach was used because stories are considered the best way to understand experience (clandinin & connelly, 1994). in telling their story, individuals combine their past actions and life events into a whole narrative form (polkinghorne, 1996) which illuminates their self-identity. the self-story is ideal because it reveals fuller life configurations, weaving together bodily/ stuttering experiences, emotions, thoughts, contexts, actions, social systems, power and values. participants use words combined as whole, meaningful stories, considered as valid data in studies of self-identity (plummer, 2001). the life-history orientation was applicable because it provided the opportunity to obtain first-hand, retrospective, historical accounts of individuals’ personal experiences (hatch & wisniewski, 1995; plummer, 2001). narrative methodology also allows the participant the freedom to construct him/herself against the dominant discourses influenced by the medical model which traditionally present a view of living with impairment as a personal tragedy. this article is the third in a series of articles emanating from the kathard (2003) study. the first article (kathard, pillay, samuel & reddy, 2004) described the processes shaping the negative self-identity as ‘disother’. the term was coined to explain an individual’s self-identity as different or ‘other’, specifically on the basis of stuttering as a (dis)order. the term (other), appropriated from postcolonial studies (boehmer, 1995), is a relational concept in which the individual constructs him/herself as different (other) in a negative way. this negative self-identity and strategies for self-management were similar to those described in previous studies (fransella, 1968; petrunik & shearing, 1983; shearer, 1961; sheehan, 1970). interrelated social processes (e.g. labelling, norming, judging) combined with personal processes (e.g. discoveries of difference; negative self-judgement, self-colonisation) and temporal burdening resulted in the strengthening and sedimenting of selfidentity as disother. the article also highlighted the importance of factors such as gender, race, culture and stuttering which intersect in self-construction. in the second article in the series kathard (2006) describes the processes underlying the discrete formation of the positive self-identity as able, similar to self as a unique being referred to by fransella (1968). selfidentity as able was based on participants’ positive sense of self as a fuller human being and was not confined to a self-limiting description related to stuttering. participants strengthened and reinforced selfidentity as able by using enabling philosophies for self-development; resourcing themselves to create advantage, broadening their framework for communication and how to enhance it; and developing emotional literacy, personal acceptance of themselves and creating counternarratives. the multiple processes leading to strengthening self-identity as able included improving communication and fluency, but were not limited to it. while previous articles described the processes shaping the discrete self-identity formations able and disother, the aim of this paper is to describe the varying configurations of these self-identity formations evident across the research stories of participants in the study. given the word limitations for this manuscript, excerpts are drawn from three research stories which provide robust illustrations of the findings. method participants participants were recruited through a local stuttering self-help group, hospital-based speech-language pathology units, private practices and general public notices. purposive sampling was used to select those with information-rich stories (plummer, 2001). criteria for inclusion were that they: (i) had stuttered since early childhood; (ii) had informationrich life stories; (iii) were willing to share their stories in english or the language of their choice; and (iv) were able to commit to prolonged engagement with the researcher through a minimum of three in-depth interviews. a fluency assessment was conducted by a qualified speechlanguage therapist at the university clinic to confirm the presence of developmental stuttering, and a brief screening interview ensured that participants had information-rich stories. information-rich stories were those which had details about critical events, were contextualised, and had the necessary personal, temporal and social elements. five men and two women of varied race, age, social and occupational backgrounds vol 57 • december 2010 • sajcd 53 self-identity formations of adults who stutter were selected to participate in the original study (kathard, 2003). however, excerpts from three of those participants were included in this article to illustrate the results within the word limits of the manuscript. procedure the research process was explained and written consent to participate was obtained before the in-depth individual interviews (rubin & rubin, 1995). during these life-history interviews the researcher created open-ended opportunities for participants to share stories about their experiences with stuttering throughout their lifespan to achieve an in-depth and interconnected understanding (samuel, 2009) of their nuanced life experiences. the interviews were not intended to focus on therapy experiences, unless relevant to the individual’s experience. a significant effort was made to develop a respectful and trusting research relationship (measor & sikes, 1992), to create an environment conducive to truthful personal story-telling. because participants stuttered, the researcher and participants discussed ways to promote easy and respectful communication (kathard, 2009) during the interviews. indepth interviewing was achieved using a series of matrix-like probes to explore personal, social and temporal (kathard et al., 2004) aspects of their story systematically. participants were also encouraged to provide additional documents (e.g. letters, diaries), support material (e.g. video recordings) and artefacts (certificates, photos) to reinforce the authenticity and depth of the story-telling process. two senior researchers evaluated each recorded interview and made suggestions for enhancing the quality of interviews. their suggestions included strategies for enhancing appreciative listening, ways to allow the story to unfold freely, and the strategic use of probes. all participants were interviewed at least three times with each interview lasting approximately 2 hours. the total interview time for each participant ranged from 6 to 10 hours. the researcher engaged with participants over a period of 1 year for the purposes of data collection, review of stories and analysis. all interviews were audio-recorded, transcribed verbatim, checked for accuracy by the researcher and research assistant, and verified by a senior researcher. the study received ethical approval from the university of durban-westville ethic committee. pseudonyms have been used to ensure participants’ anonymity. data analysis the first level of analysis was representational narrative analysis (freeman, 1996; polkinghorne, 1996). in this process the interview data (raw data) were analysed in relation to the research question and represented as a biographical research story for each participant. a thick description of the participant’s context was embedded in the research story. this description allowed the researcher to capture detail, density and depth of the individual experience, thereby allowing the reader the opportunity to feel that he/she understood the experience (charmaz, 1995; plummer, 2001). the stories characterised individuals, described emotions and actions, and located individuals in specific social and temporal contexts. the research story was a good representation device because it integrated the types, processes and configurations of self-identity formations. the task of the researcher was to ensure authentic and fair interpretation of the individual’s experience. it is well recognised that the storied experience is unlikely to mirror the actual experience. therefore, further steps were taken to ensure that the research story represented personal truth as accurately as possible. each participant therefore critiqued his/ her personal research story and suggested changes to make the story a closer representation of their experience. the second level of analysis involved a detailed analysis of research stories into the themes related to the configurations of self-identity formations. the themes were generated through a process of constant comparison between and within cases (miles & huberman, 1994). in this paper excerpts from the research stories (first-level analysis) are combined with the second level thematic analysis across stories. rigour and trustworthiness the rigour and trustworthiness of the study were enhanced through various substantive and ethical validating processes (angen, 2000) applicable to qualitative narrative research. substantive validation was firstly achieved by evaluating the suitability of the methodology in relation to the research question. the choice of life-history methodology was clearly applicable to this study as it was able to generate robust data to understand self-identity formations. secondly, various measures were in place to ensure that the study was credible (lincoln & guba, 1985). credibility of the data collection process was enhanced through in-depth interviewing, member-checking, prolonged engagement, and peer review and debriefing (cresswell & miller, 2000). further to member-checking during the interview process, the research stories were also presented to participants to ensure that their experiences were truthfully represented. peer-review and debriefing was conducted throughout the research process (lincoln & guba, 1985). the researcher, assisted by senior researchers, reflected critically on the process before and after each interview to ensure that her own thoughts and opinions were kept in check. the depth of story telling was enhanced by prolonged engagement (plummer, 2001). in addition to the minimum of three indepth interviews with participants, two additional contacts were made during the analysis process. contact with participants was sustained for approximately a year, allowing the researcher and participants the opportunity for critical reflection and refined data collection. this process also assisted in the development of a trusting relationship, so that sensitive aspects of the story could be probed over time. while triangulation for the purposes of verification (begley, 1996) was not applicable to this study (i.e. personal truth could not be verified through any other method other than personal story-telling), the relevance of triangulation for the purposes of completeness of analysis was considered. the researcher’s analysis of self-identities as the unit of analysis was strengthened by the input of two experienced life-history researchers of different theoretical backgrounds. one expert considered the validity of the analysis of self-identity formations from a disability and impairment perspective, while the other reviewed the plausibility of interpretation from a psychosocial theoretical standpoint. this process assisted in achieving a unit of analysis triangulation (knafl & breitmayer, 1991). ethical validation required that several ethical issues relevant to the methodology were considered. for example, the researcher was cognisant of potential power imbalances between the researcher and participant (kathard, 2009), only used authorised information in research stories and took the necessary steps to ensure that participants’ stories were fairly represented. results and discussion the findings on the configurations of self-identity formations able and disother occurring across the research stories are presented. a brief overview of the configurations within the stories is also provided at the end of the results section. owing to the word limits of the manuscript, excerpts from the stories of only three of these participants are used to illustrate the findings. data excerpts in this paper are from kathard (2003) and also appear in kathard et al. (2004) and kathard (2006). the biographical profiles of participants in the three stories used in this paper are as follows: gareth, a 65-year-old white man, is a retired architect with a university degree. he rated his stuttering as mild at the time of the interview, which correlated with the clinician’s rating. he attended speech therapy weekly for approximately 3 months when he was at primary school. his father and brother were disfluent but were not diagnosed with stuttering. hennie, a 29-year-old white man, is an accountant with a university degree. he rated his stuttering as moderate to severe, which concurred with the clinician’s rating of severity at the time of the interview. hennie had attended the university speech therapy clinic for 6 months at the time of the interview. there was no family history of stuttering. 54 sajcd • vol 57 • december 2010 self-identity formations of adults who stutter kumari, a 36-year-old indian woman, is an accountant. she rated her stuttering as mild at the time of the interview, which concurred with the clinician’s rating. she had never attended speech therapy. singular self-identity formations at varying points in the stories, the singular self-identity formations (disother or able) were evident. during her early years and throughout adulthood, kumari retained a single, dominant self-understanding of herself as disother (kathard et al., 2004): kumari: i stuttered when i was four. i was detached, isolated and lonely. i had friends, but no best friends because rangini went to another school. my self-esteem was low. rock bottom. i was fashioned out of fear ... i was a fearful, stuttering girl. i gorged on negativity and i couldn’t connect with anyone. the void grew bigger as i grew older ... even if i had a small, simple request like leaving a few minutes early from work, i set myself up for failure. i feel (my abusive father’s) imposing presence. i am a child again, terrified. i stutter, radiate negativity. in contrast, hennie’s story revealed a singular self-identity as being able: hennie: the stuttering was never always such a big problem as it is now. i don’t believe the stuttering, i.e. the speech and the blocks itself, has evolved or changed that much. my father never really punished us. they were easier-going than the rest. i really don’t recall any talk or them being worried about my speech at that time. life was very nice. stuttering was there but i never let it rule my life. i was okay. hennie’s dominant experience of being able occurred in childhood. although he stuttered as a child, stuttering received little negative meaning in his personal and social context. he did not attach negative meaning to stuttering in his early childhood years. therefore, stuttering had little salience and his self-identity as able was constructed on the basis of other positive life experiences. in contrast, kumari’s story during childhood indicated a singular and stable self-identity as disother, created through complex social and personal circumstances over time (kathard et al., 2004). her experience resulted in negative self-definition linked to stuttering as well as her early traumatic experience of abuse. the prominence of a singular negative positioning of self in a world which is dynamic and changing may seem unlikely, yet kumari’s selfidentity as disother had been prevalent for many years of her life. these prolonged experiences of singular negative self-understanding resulted from conservative social and personal forces that act in the interests of minimising complexity, ambivalence and conflict (hermans, 2002). this stable, albeit self-oppressive and rigid knowing of self, is favoured because it fits in with a hierarchical structuring of the world where children, women and people with impairments/disorder occupy lesser positions. in such instances, the self becomes less multi-voiced and more monological. when the disempowered self as disother is reinforced in this monological direction there is a loss of potentiality, and this results in a severe miniaturisation of human beings (sen, 2006), i.e. people have diminished views of who they are. in contrast, hennie’s self-identity as able reveals that it is possible to live with stuttering without being negatively defined by it, as he constructs himself within a discourse of possibility. hennie’s story of positive self-identity is not uncommon in children who may not have internalised understandings of themselves in relation to stuttering. while participants’ self-identities reflect their sense of stability about who they are during their childhood, kumari’s and hennie’s selfunderstandings were very different to each other. further to the singular identity formations, the stories also revealed dual self-identity configurations. dual self-identity configurations co-existing self-identity formations co-existing configurations occurred when both self-identity formations (able and disother) were present in an individual’s story over a particular time period, but were different across contexts. for example, in gareth’s story self-identity as able was prominent on the playground while self-identity as disother was prominent in the classroom, as reported by kathard et al. (2004). gareth in the classroom: at school i never got away with it altogether. the stutter was there and growing. i wanted to forget about it and be like everyone else or better than everyone else. but they wouldn’t let you forget. we hear the dreaded footsteps marching down the corridor. they are two classes away, one class away, and then they are here. the threesome: the principal, the nurse and the school inspector. society watchdogs! we knew what they were looking for, all the misfits, all the problems. maybe they would forget about me. then they start: come to the front when we call your name and problem; mcdonald and hastings – head lice; smith – can’t see well; lovemore – cripple; blake – stutterer. i just want to disappear into the ground. is this all they know about me? hey, remember i came second. they fill out the forms. i remain silent. powerless. they make it unbearable. everyone knows i am a stutterer, but this is a painful public display. gareth in the playground: fortunately, there was always the other side and i gave as good as i got. playground and friends were a real joy. i had a talent and passion for soccer. we get to the field, in teams. captain: gareth blake. coach: gareth blake. manager: gareth blake. i am the team. they played in my team. i hand out the carefully painted badges. i select the team, coach them, talk about the game plan and we play ball. we run, shout, kick and scream. stuttering is furthest from my mind (kathard, 2006). bakhtin (1981) explained that utterances which produce the story of the self come from a particular voice influenced by cultural circumstances and socio-political realities. in society, the power one has is derived in part from social, institutionalised power. for example, there is a relative socially inscribed power that men have over women, boss over worker, and teacher over learner. endowed with socially inscribed power, gareth feels more powerful as a team leader on the playground than in his position as a child who stutters being examined by school authorities. self-identities are contextual and relational, and it is therefore possible to have different understandings of oneself across different contexts (valsiner, 2002). it was possible for the participants to have understandings of themselves as both able and disother – existing fairly separately across contexts. given such fluidity, it is possible to construct self-identity differently across contexts, and therefore to experience stuttering and communication in varied ways across contexts. these multiple selfunderstandings challenge the singular, reductionist discourse promoted by the medical model, which defines the person by the impairment. it emphasises that human lives are plural (sen, 2006), and that there are different ways of living with stuttering. the challenge, even within multidimensional theories of stuttering, is for clinicians and society in general to acknowledge these fluid, multiple, and co-existing selfidentity formations in order to transcend the idea that living with stuttering is necessarily a personal tragedy. competing self-identity formations in the research stories self-identity formations able and disother were sometimes both available in a given context. each self-identity, underpinned by a particular set of beliefs and ideologies, competed for dominance within this context. the competing relationship and dialogue between the self-identities results in a struggle or conflict. contexts and situations are dynamic, and therefore these competing configurations also fluctuate. hennie: imagine this. i walk in the door, tall, blond, macho, strapping; rugby-playing hennie. i am feeling fine. next to me is the guy in the wheelchair. his problem is obvious. i look normal. i am ok for now [feeling able] i open my mouth to speak and … no. the game is not over yet. not over till i stutter. then it happens. out of the blue. it takes me by surprise because i don’t know exactly when it will pop up, and until it does vol 57 • december 2010 • sajcd 55 self-identity formations of adults who stutter i am normal. you’re not in control of your mouth and that is it. (kathard et al., 2004.) so now a new struggle starts. i have to struggle from being a stutterer to get back to a normal. the only way i can do that is by not stuttering. then that tune plays in my head. don’t stutter. don’t stutter. you battle on. lean over to the normals, from the dark side. lean back from the dark side to the normals, lean back again to the dark side. if you stop and choose silence you lose the race. so i persist. from dark to normal. through all this you just hope that you can make them understand that there is more to this person than just the stutter. i am also another normal behind that abnormal stutter. there is still that normal man with the wit and knowledge to speak his mind. the worst is that sometimes i forget that normal man and then i am the abnormal. abnormal. competing selves present in biographies gave a deeper sense of the complex experience of stuttering. the dialogue between selves, competing for prominence from different ideological positions (salgado & hermans, 2005) created an internal communication fraught with struggle about ‘who am i?’ within a given context. given the dynamic nature of contexts, the selves are constantly positioned and repositioned moment by moment as the communication is negotiated strategically, giving a sense of the effort required in interaction. this ‘unstable equilibrium’ (james, 1982) is an emotionally draining experience, and therefore people must find ways to resolve such instability. viewed differently however, competing selves could be considered as a positive development because this configuration signals that the self has an alternative position, especially when working against a powerful negative self-identity. sen (2006) explained that when the force of a bellicose identity, such as self as disother, is challenged by the competing self-identity, the illusion of a singular, dominant identity is disrupted, allowing recognition of other positive facets of human affiliation and enhancing the possibility of choice. this notion of dual self-identity is not new and aligns with kelly’s (1955) concept of constructive alternativism, i.e. people have alternative ways in which they can reconstruct themselves to enable processes of self-change which has been applied in stuttering intervention by fransella (1968, 1972). however, this study does not only foreground the discrete selfconstructions but importantly the nuanced power struggle between these self-constructions. coalescing self-identity formations in some stories there were harmonising relationships between the seemingly oppositional self-identities at particular points in the story. gareth: through university i was a stutterer and having observed me in the studio presentations they would have said that’s a stutterer. but down the line a different picture emerges. gareth the architect, gareth the father, gareth the grandfather. gareth the stutterer is still there but somewhere in the background. these days i give little attention to my speech and i speak to everyone. i have even become somewhat of a community spokesperson on the forums i sit on. there are just so many other things that occupy my mind now. the self-identities appear to ‘coalesce’, suggesting that there was a harmonising relationship between them and an ‘acceptance’ of the selfidentity as disother. while it seems rather unlikely that a coalition of apparently different selves was possible, the stories suggest that it is. in a study of a ‘coalition of opposites’, bhatia and ram (2001) explain that an understanding of selves must transcend the simplistic pushpull metaphor. the ability to accept the self as both disother and able appears to exist within a symbiotic relationship – one of ambivalence – within a loop that is dynamic in nature. such ambivalence becomes a useful basis for negotiating different selves. in the research stories participants seemed to negotiate living with stuttering successfully when they had accepted stuttering and negotiated their self as disother within their multi-voiced realities. this suggests that being able to bring disparate selves into a harmonising relationship is useful for living successfully with stuttering. configurations within stories although excerpts from the three stories have been chosen to illustrate the different configurations, it must be noted that each story has varied configurations over time. for example, while hennie’s story begins with his self-identity as able, during school and university years and into adulthood he presented both co-existing and competing selfidentity formations. gareth’s self-identity formations changed over his lifespan. while he presented with competing self-identities in different situations in his school life, his experience did not suggest a single dominant negative self-identity at any point. in early adulthood his story revealed competing self-identity formations while in later adulthood he experienced a coalescing of self-identity formations. in contrast, kumari had a self-identity as disother for many years of her life, and it was only in early adulthood that she began to develop her self-identity as able. kumari: i gradually got to view many positive things about myself. mind power became a habit and my new way of living. i learned to trust my logic and intuition and began to recreate myself to become who i want to be. kumari’s competing self-identity formation slowly gained dominance as she gradually reinvented herself in adulthood. conclusion the findings across stories indicated that the configuration of the self-identity formations disother and able occurred in singular and dual configurations. the dual configurations illuminated coexisting, competing, and coalescing relationships between selfidentity formations within and across research stories. these varied configurations highlighted the participants’ subjective, fluid, multiple and complex understandings of themselves as they lived with stuttering over time. while the idea of positive and negative self-identity formations has already been introduced in this and other studies, the complex relationships between the self-identity formations illuminated in this study have important clinical implications. clinical implications life-history interview in assessment for interventions to be personally meaningful, a thorough understanding of the client’s experience of stuttering is necessary. this article described the varied configurations of self-identity formations, using the life-history interview. while it was used in this study as a research method, clinicians could use life-history interviews as a clinical method and engage each client in the personal telling of his/her story in the clinical assessment process. the case-history interview traces the history of stuttering, while the life-history interview invites the client to share how he/she has lived with stuttering in his/her social world over time. by taking this approach the client is co-opted into the assessment process and takes an active role in crafting and sharing his/her story, laying the foundations for participation in his/her own change process. in valuing this subjective/personal truth as legitimate knowledge the clinician gains a fuller empathetic understanding of the client’s reality as a basis for an intervention that is personally meaningful (hagstrom & wertsch, 2004). the techniques for conducting a life-history interview are described in detail in various life-history methodology texts. applied to stuttering, the following strategies were found to be useful (kathard, 2009): • at the outset of the assessment the clinician must reassure the client that the intention of sharing his/her story is not to assess the frequency of stuttering or observe his/her struggle, but rather to hear the details about the experiences he/she thinks are most relevant. however, that he/she may block or struggle is likely and there should be an open negotiation about how communication breakdown on 56 sajcd • vol 57 • december 2010 self-identity formations of adults who stutter the part of the listener and speaker (e.g. long silences, interruptions, loss of eye contact) will be managed. • given that the intention is to hear the client’s experience, the client has the freedom to select the issues he/she wants to talk about, in terms of events and critical moments which shaped his/her life most. the task of the clinician is to offer a non-directive space in which to generate the story and to listen deeply and non-judgementally. while the clinician can probe aspects of the story, he/she should not redirect the course of storytelling during the initial phase. • the process may appear innocent and non-threatening, but it has potential to excavate truths that the client has masked or obliterated which may be unpleasant for him/her. the clinician should therefore be vigilant and proceed cautiously, allowing the client to share what he/she is comfortable with initially and other aspects of the story may emerge later in the process. for example, a person who experienced abuse as a child who stuttered may not talk about it at the initial stages of the process but may do so later when a secure relationship has been established with the clinician. the story may also cause issues to surface which are beyond the clinician’s scope of practice and therefore warrant referral to a relevant source. • some clients have difficulty telling a story and they can be assisted through reflective diary keeping, free writing and including artefacts (letters, poems, drawings). in a multilingual context, clients should be provided with opportunities to share their stories in the language/s in which they feel most comfortable, allowing them the freedom to use informal language, gesture, code mixing and switching to enhance their story telling. some clients are not candidates for this type of narrative methodology and therefore the clinician needs to decide on its use on a case-by-case basis. • the clinician has the task of placing the story within a larger sociocultural context and should probe the temporal and social contexts during which critical events occurred. for example, the stories in this study were shared by participants who lived through apartheid in south africa and their experiences as people who stuttered were also shaped by their broader social reality. for some, discrimination was not experienced only as a consequence of stuttering, but also by virtue of their race. some participants reported their experiences during a particular era when schools took the view that children should be ‘seen and not heard’ and illuminated how this reality shaped their experience of stuttering. by listening to the story, the clinician should be able to identify the patterns of self-identity formations evident in the client’s story. for example, are the two formations able and disother evident in the story? when do they occur in the story – across context and time; which is the dominant self-identity strand? this mapping would allow the clinician to interpret the client’s behaviour as part of his/her selfidentity formation, i.e. what he/she does is related to who he/she is in a particular context. for example, if a client has a self-identity as disother in a classroom, he/she may be silent in an attempt to pass for normal – his/her behaviour therefore is part of his identity management. a mapping of the self-identity formations will also assist the clinician in targeting the contexts for intervention and appreciating that different strategies may be necessary across contexts. understanding the power dynamics this study illuminated that while the individual can have both positive and negative understandings of themselves, when in a competing relationship they cause issues of conflict, power and ambivalence to surface, i.e. political dimension. this power struggle within and against oneself speaks to a layer of struggle that is an inherent part of the experience. the client must therefore be empowered to negotiate his/ her own internal power struggle as part of a repertoire of skills to enable the desired intervention outcome. when using self-identity as a lens the clinician is obliged to ask questions such as: which of the self-identities is dominant and why? how can the ambivalence between self-identities be creatively managed? how can the relationship between self-identity formations shift from a competing to harmonising relationship? narrative intervention this study was not intervention-based. however, narrative approaches to intervention may be useful in facilitating self-change in adults who stutter. the methodology is derived from constructivist theory based on the assumption that people have the ability to deconstruct and reconstruct themselves to create new realities. the advantage of the narrative approach is that the client can create a personally meaningful intervention by connecting his/her past with his/her future by determining the desired outcomes and realities within his/her range of competence (biggs & hinton-bayre, 2008). the alternative story is seen as an opportunity for the client to gain greater control of their lives by constructing different views of themselves and taking the necessary actions to achieve a new vision. there are different ways of achieving the alternative story. for example, polkinghorne (1996) explained that clients described life plots that were agentic or victimic. in the victimic plot, which is similar to self-identity as disother, a person constructed him/herself in a negative way and was characterised by blame and lack of progressive movement. in contrast, the agentic life plot was one in which the person was actively engaged in advancing towards an attainable goal. the task of the clinician was to assist the client in uniting all the elements of his/her life into a story that reveals his/her identity and actions and then to challenge and confront the victimic plot through a process by which he/she detaches him/herself from the story as he/she creates a new story coupled with relevant action. dilollo et al. (2002) used narrative therapy in stuttering intervention, based on the rationale that therapy outcomes are more likely to be successful and sustainable when the self is deconstructed from the stuttering-dominated self to the self that takes on the fluent speaker role. they provide a useful narrative methodology to achieve this. appreciation of fuller self-identity in contrast to dilollo et al. (2002), who focus on the fluent speaker role in the self-reconstruction process, the authors of this paper offer different perspectives on the reconstruction process and fluent speaker role. self-construction/reconstruction does not limit the able identity only to a fluent speaking role. the able identity (kathard, 2006) is crafted from a more all-embracing positive sense of self which includes the role as better communicator and fluent speaker but is not limited to it. the clinical implication is therefore that while fluency and improved communication are part of a positive self-identity there are other personal successes like being in a position of power, successful at work and relationships that empower individuals and drive a positive change. the clinician should therefore capitalise on an asset-based approach by focusing on strengths to build on. this perspective offers the possibility of constructing and acknowledging a more complete able self-identity and using it as a catalyst to drive further positive self-construction including that of good communicator/fluent speaker. the self as able is more robust and resilient and therefore not easily disrupted or dislodged by episodes of stuttering as the person has a wide-ranging resource base of skills including communication skills. furthermore, while other studies promote fluency and attainment of a self-concept as a fluent speaker as the end goal of intervention, this study suggests that there are different ways of living positively with impairment. self as disother and able could coalesce – allowing the idea of one within the other – a coalition of opposites. it is suggestive of a compassionate living of different selves, acknowledging that disother is part of one’s story but not the only story. finally, the findings have implications for relapse. while fluency has traditionally been used as an indicator of relapse, perkins (1979) argued that lapses in self-identity as a stutterer would be a more robust indicator than the narrow confines of maintaining fluent speech. in agreement with perkins, the authors of this paper tentatively suggest vol 57 • december 2010 • sajcd 57 self-identity formations of adults who stutter that a lapse or a dislodging of self-identity as able and the resurgence and strengthening, of self-identity as disother, together with negative identity management strategies e.g. avoidance, or concealing stuttering to pass for normal, are other indicators of relapse. therefore, the aim of interventions should focus on strengthening self-identity as a basis for improved communication. focus of change: self and society while intervention efforts focus on the individual as the locus of change, this study also points to the powerful social system which constructs stuttering in a negative light. people who stutter live in environments which have negative views of stuttering and hold general negative stereotypes of stuttering (blood, blood, tellis & gabel, 2003). society plays a critical role in shaping both positive and negative selfidentities. while we might continue to work with the individual, the clinician is equally challenged to change the attitudes of society to become accepting of people who stutter for who they are – as people (who stutter) – as part of a continuum of diversity. acknowledgements we thank the participants for generously sharing their stories and express our gratitude to the national research foundation (south africa) for supporting the project financially. references angen, m. j. 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(2002). forms of dialogical relations and semiotic autoregulations within the self. theory & psychology, 12(2), 251-265. journal of the south african logopedic society june chronaxy measurement of the nervus recurrens and its applications by g. h. breckwoldt, ph. d. department of phonetics and logopedics, university of the witwatersrand. the various experiments, briefly outlined in the previous number of this journal (cf. journal of the s.a. logopedic society, vol. 4, no. 2, p.10. seq.) led r. husson to measure "in situ" the excitability of the n. recurrens of man and to discuss the practical uses of his measurements, (cf. r. husson: "la mesure 'in situ' de l'excitabilite recurrentielle chez l'homme et ses applications . . . ", bulletin de l'academie nat. de med., no.s 1 et 2, 1955.) husson says that moulonguet's experiments, which proved that there exists a congruity between the action potentials of the n. recurrens and the vibrations of the vocal folds, has made it possible to measure the chronaxy of the recurrent nerve. he works out a simple basic formula to determine the maximum frequency: 1000 maximum frequency = ν == . (r. hussonκ c ibid., p. 1) in this formula c is the chronaxy of the recurrent nerve in milliseconds, and its refractory period lasts κ chronaxies. this formula makes it possible to calculate the highest note a subject can produce, if (through some method or other) one knows the chronaxy of his recurrent nerve. conversely, the highest note sung by a subject makes it possible to calculate his chronaxy. there is another important finding worth mentioning in this connection: the chronaxy which is calculated from the n. recurrens is the same as the one which is easily measured on the motor point of the sternocleidomastoid muscle. husson describes the simple method of measuring the chronaxy: — the subject holds in his hand the anode electrode, and the examiner applies the cathode electrode to the motor point of the m. sternocleidomastoideus. the study of just over 100 subjects, mostly singers with well trained and well established voices, made it possible for husson to draw up a table, which gives the values of the recurrent chronaxy for each type of grown-up voice, i.e. from the ultra high soprano of chronaxic value 0.055 to the deepest bass of chronaxic value 0.170. the following table shows the correlation between the measurements of n. recurrens chronaxy and the voice classification of singing voices: chronaxy values male voice in milliseconds female voice very high tenor middle tenor low tenor intermediary voice intermediary voice high baritone middle baritone deep baritone intermediary voice intermediary voice high lyric bass deep lyric bass middle bass middle bass deep bass deep bass 0.055 0.060 0.065 0.070 0.075 0.080 0.085 0.090 0.095 0.100 0.105 0.110 0.115 0.120 0.130 0.140 0.150 0.160 0.170 ultra-high soprano ultra-high soprano very high soprano high soprano middle soprano low soprano , intermediary voice high mezzo soprano middle mezzo soprano deep mezzo soprano intermediary voice high mezzo contralto middle mezzo contralto deep mezzo contralto intermediary voice intermediary voice contralto contralto contralto (r. husson, ibid., p.6) r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) june journal of the south african logopedic society this table shows that for each sex there are not only 3 or 4 types of voice, but that there is an infinity of voice types, one leading into the other. all chronaxic values are possible between 0.055, and 0.170. many voices, therefore are intermediary among the classical types of voice. this explains the difficulty some singers have to fall into one particular category; i.e. with regard to their innate voice range. chronaxic values only determine pitch, but in no way intensity or timbre. looking at husson's table, one might be surprised at finding that men and women have identical excitability of the n. recurrens and consequently the same chronaxic values. a man and a woman of identical recurrent chronaxies present a voice range with a difference of exactly one octave. this difference is due to the fact that the man uses a monophasic recurrent conduction (chest register), whereas the woman uses a biphasic recurrent conduction (head register). nevertheless a man can make use of his biphasic register in high tones (falsetto voice), but he cannot keep it up continuously without experiencing fatigue. a woman can also use her monophasic register in deep tones, but not for a prolonged time without feeling fatigued. research has also been done on the voices of children, and e. j. garde and husson found that in children, aged 8-15 years, whom they examined, the chronaxies were ranging from 0.060 to 0.160, i.e. exactly as in adults. it would be interesting to know, if the recurrent chronaxy before and after pubertal voice change remains the same or undergoes changes. the publications i have read do not contain any information on this subject. research in this field might give revealing results. on the other hand, research has been carried out to show that certain medications influence the chronaxy of the recurrent nerva (e.g. the diminishing effect of thyroxine). a change in the recurrent chronaxy, which is of particular interest to the logopedician, is the one which has been observed in cases of phonasthenia. husson writes about his findings in this field and says that in phonasthenia the change in recurrent chronaxy is most noticeable. in each case one always finds, simultaneously: 1. a decrease of the rheobase; 2. an increase of the chronaxy. in addition to this most important observation, there is another research result of the laboratory of physiology of the sorbonne, which especially concerns the logopedician: — it has been found in phonasthenia that 1. the dyschronaxy, which appears, is always unilateral; 2. the affected vocal fold is always the more "controlled" one (which means the right fold in right-handed persons, the left fold in left'handed ones). an exception to this rule has not been found. husson gives a couple of examples of cases of phonasthenia, showing the obvious correlation between handedness and recurrent chronaxy: subject recurrent chronaxy right left miss b., aged 34, left-handed 0.098 0.165 miss d., aged 21, right-handed 0.072 0.061 miss m., aged 24, right-handed 0.151 0.104 master p., aged 6, left-handed 0.109 0.132 mrs. s., aged 42, right-handed ... 0.320 0.098 (r. husson, ibid., p.6) huson observed that as phonasthenia progresses the chronaxy of both vocal folds increases, but it always remains raised in the fold which is the more "controlled" one (cf. handedness). if phonasthenia cases are given suitable medication or only a period of strict vocal rest, one will see the following results: with the compliments of: messrs. a. loewenthal metals (pty.) ltd. 13, maraisburg road industria west johannesburg or p.o. box 6546 telephone 35-6744 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society june 1. increase of .the rheobase; 2. decrease of the chronaxy, descending to its •·"•• normal physiological level. the value of these findings to the logopedician is evident. even the latest laryngo-stroboscope does not give the examiner as revealing a result as the measuring of the recurrent chronaxy. laryngo-stroboscopic examination may reveal very clearly a difference in amplitude in the vibration of both vocal folds, but never gives any information whether the amplitude is e.g. abnormally increased in the one fold or abnormally decreased in the other. a chronaxic measurement dispels all doubt: the vocal trouble is situated in that side which has the higher recurrent chronaxy. the logopedician will be able to adiapt his therapy accordingly. he may, now, find himself confronted with new therapeutic demands. this does not mean in any way that previous therapeutic approaches like relaxation and breathing exercises should be abandoned. on the contrary, in addition to therapy which in the past, has proved successful, we may, now, be able to . develop measures based on chronaxic measurement and thus create a more intensive, possibly more speedy, therapy. in the above i have tried to give a brief description of the researches, which have taken place at the sorbonne and deal wath aspects of voice physiology which have caused an upheaval in the scientific world. husson has a great number of followers among the leading figures of phonetic science. one of the first and foremost personalities, who have subscribed to husson's new theories, is g. panconcellicalzia. his publication "breathing in phonation, new and old aspects" (die stimmatmung, das neue, das alte), leipzig, 1956, is based on hijsson's ideas. putting things in a nutshell, calzia states in this book that: "the motto of the classical old italian school of singing was: 'chi ben respira, ben canta.' (who breathes well, sings well). that was wrong. it would have been more correct to say: 'chi ben canta, ben respira', because husson has proved that the activities, in the larynyx and pharynx contract the breathing and not vice versa. in spite of these new findings some phoneticians and logopedicians still adhere to the old historical sentimentality." (calzia, die stimmatmung, p. 14). in a recent publication we still find an enthusiastic adherence to what calzia calls "the old historical sentimentality." i am referring to the book "the voice and its disorders" by margaret greene, london, 1957, which i reviewed in the previous number of this journal (cf. vol. 4, no. 2, p. 15, seq.). the author characteristically calls a chapter, which deals with the breathing mechanism, "the vocal excitor" (cf. m. greene, ibid., ch.2). husson's ideas have not been accepted everywhere, and it appears that some scientists, who repeated his experiments, have not come to the same conclusions. . during an international symposium on the psysiology of the larynx, organized by the french society of phoniatrics, held in paris in october, 1955, some scientists, e.g. a. fessard and b. vallancien, tried to disprove some of husson's and laget's experiments. they came to the conclusion that their experiments were incompatible with the theory that the frequency of vocal fold vibration is neurogenically determined, (cf. folia phoniatrica* 1957, vol. 9, no. 1, p.62, seq., and ibid., 1957, vol. 9, no. 3, p.152, seq.). the danish scientist k. faaborg-andersen comes to similar conclusions in his experiments, (cf. acta physiologioa scandinavian 41, supplementum 140, 1957). in june, -1957 a high speed film was shown at baden-baden, which also disproved some of husson's findings, i.e. vocal fold-vibration and phonation only occurred, when there -was a subglottal air supply, (cf. personal correspondence with r. luchsinger, zurich, june, 1957.) long before husson published his experimental results, i had theoretically assumed that the vooal folds are centrally "steered" or initiated. to this conclusion one comes most logically, if one is familiar with the integrative action of the neuro-muscular system*. husson is no doubt right in his idea of neimrchtonaxy of the vocal folds. one cannot help visualizing the recurrent chronaxy acting like an electric motor on the phonation process. but in all acts of normal phonation subglottal functions must be taken into consideration as much as laryngeal functions. the synthesis of infra-laryngeal, laryngeal and supra-laryngeal functions makes up normal phonation. it would be a misjudging of the integration and synchronization of psycho-physical functions to say that the vocal mechanism modifies (or even steers) the breathing or, vice versa, that the breathing modifies the voice functions. in the normal individual the balanced interaction of all functions is the standard. in an abnormal situation we get an unbalanced interaction. if a person is suddenly thrown into an unusual emotional upheaval, his voice will be affected and so will be his breathing. the same applies in an abnormal physical situation. if a person has to run two miles without stopping, his breathing will • it should be remembered that both nerve and muscle are developed from previously undifferentiated neuromuscular tissue (cf. c. l. meader and j. h. muyskens: handbook of biolinguistics, toledo, 1950, iv, p.57:) "research on sobbing might prove interesting in this connection. in the spasmodic interaction of diaphragm and larynx in sobbing it. is impossible to allot a predominant role toeither functioni r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) june journal of the south african logopedic society be affected, and, in trying to speak or sing, his voice will be equally affected. we cannot separate breathing and voice in phonation**. they are both neurogenic and act upon each other, whatever occasional time-lag in synchronization may occur. whether we accept husson's ideas or not, his publications are very stimulating; they invite a repetition of his experiments and further researches in the field of normal and abnormal voice production, e.g. voice studies during puberty, male falsettos, hysterical dysphonics and aphonics and subliminal phonation. it is to be expected that the chronaxic measurement of the recurrent nerve will not remain, a study for research only, but may become as much a routine examination in the practice of the logopedician and phoniatrician as laryngoscopy and laryngostroboscopy. it can serve as a periodic examination to check up on the progress of therapy. it may lead the way e.g. to a new type of specific relaxation therapy, which will take the question of hand dominance into consideration. bibliograhpy amado, j. h.: rapport a.f.e.p.l., 16-17 oct. 1952, annates d' oto-laryng., 1953, 70. no.s 2-3. amado, j. h.: rev. laryng. 1954, suppl ffevr. 284. dumont, p.: etude chronaxim6trique sur le larynx, thfese, paris, 1933. eyrifes, ch..: encyclop. mid.-chlrurg., vol. o.r.l., 20623 a 10, paris, nov., .1955. faaborg-andersen, k : acto physiologlca scandinavia, • ' • '41, supplementum 140, 1957. fessard and vailancien: fol. phon., 1957, 9/1, 63, and ibid., 1967, 9/3, 152, seq. garde, e. j.: la voix, collection "que sals-je?", presses univ. france, idit., paris, 1954. goerttler, k . : zeitschr. f. anat. u. entwickl., bd. 116 1950. 352-401, 36 flg. greene, m. c. l.: the voice and its disorders, pitman med. publ. co., london, 1964. gutzmann, h.: sprachheilkunde, berlin, 1924. hildernesse, l.' w . : logop. en phon., 1956, 28/1,2,3. hlldernesse and husson: logop. en phon., 1956, 28/10, 11, 12, and 1957, 29/3. husson, r.: fol. phon., 1952, 3/4, 240. husson, r. and chenay, c.: c. r. acad. sciences, 1953, 236, 1.077. husson, r.:' bulletin de l'acadim. nat. de mid., no. 1 & 2, 1955. husson, r.:' encyclop. mid.-chirurg., vol. o.r.l., 20623 β 10, paris, nov., 1955. krmpotic, j.: rev. laryng., portmann, suppl. de f<5vr., 1957. ' " laget, p.: j . physiol., 1953, 45, 147. meader and muyskens: handbook of biolinguistlcs, toledo, 1950. moulonguet, α.: rev. laryng, tivr., 1954, suppl., 110127. panconcelli-calzia, g.: die stimmatung, das neue, das alte, leipzig, 1956. portmann, humbert, robin, laget, husson: c.r. soc. biol., paris 12 fevr., 1955. 149, 269. ranson and clark: the anatomy of the nervour system, saunders, london, 8th ed., 1947. winckel, f.: funk und ton, 1953, iii, 124-132. westdene products (pty.) ltd. 23 essanby house 175 jeppe street johannesburg. (branches in cape town, durban & pretoria) are specialists in medical literature. we recommend: language for the pre school deaf child — by grace harris lassman, teacher of the deaf, formerly instructor of speech, john tracy clinic, los angeles, u.s.a. price 51/the development and disorders of speech in childhood — by muriel e. morley, speech therapist-in-charge of the speech therapy unit, the united newcastleupon tyne teaching hospitals. price 52/6. ("this book presents a classification of development disorders of speech. the findings relating to various types of speech disorder are given and principles of treatment described.") artistic bookbinders braamfontein — phone 44-6584 21 stiemens street: transvalia buildings shop 8 in mell street. how important are your φ journals of speech and hearing disorders φ "speech" φ notes ι these can be bound in attractive volumes to suit your needs. we specialise in binding your thesis according to your design and colour scheme to insure your success. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) some observations on group work with adult stammerers by r. fawcus l.c.s.t. m. a. fawcus l.c.s.t. organisation of the groups. the london county council has for many years held evening classes for adult stammerers. until 1956, general relaxation was a fundamental part of treatment. the present approach dates from this period, when one of us was appointed as a speech therapist and "non-avoidance" techniques were introduced. the classes are now affiliated to the city literary institute, which holds a wide variety of classes in the arts and the humanities. students from the age of 16 years enrol in the evening groups for adult stammerers with no more formality than the completion of a short form, and the payment of a fee of 25 shillings. this fee entitles them to attend twice weekly over the entire academic year (a period of nine months from october to june). there are now three therapists, each taking two groups a week, and groups are now available four nights a week. those stammerers who come twice weekly (approximately 50% of the total this year) seldom see the same therapist on both evenings. we feel that this policy not only helps to sustain their interest, but helps them to gain a broader view of the problem. facilities for individual discussion are always made available when necessary, particularly on a thursday evening, when two therapists are present both before and after the regular class session. more often than not on this evening, one or two students stay on for an informal discussion after the class, or else come in early for a talk. we find very few stammerers requiring regular individual help. little or no attempt is made to "screen" stammerers who want to join the classes, and the main factor determining which group or groups the student joins will be the particular evening on which he wants to come. this results in a fairly random selection, with a present age range of 16 to 55 years. in addition to this wide age range, there are varied racial, social and educational backgrounds. this year we have students from ceylon, ghana, india, ireland, libya, nigeria, south africa and the west indies. nonetheless, the common problem of stammering makes this a homogenous group in the psychotherapeutic sense. a total of 50 students have enrolled since the end of september: 28 of the total enrolment are new students, and the remainder are in their second or third year. these are "open groups" in the sense used by anthony (1957) since students are enrolling at intervals throughout the year. it is advocated that the homogenous group should be run on closed lines, but not only would this be impossible in practice, but we believe there is a positive value in exposing the stammerers to the stress both of new members and visitors (such as speech therapy students) joining the group. whilst our attendance varies from 7-13 students, our experience confirms anthony's statement that 8 is the "ideal" number for a therapeutic group. origins and rationale of our approach. working with groups of stammerers over a period of 6 years has led to a growing conviction that the stammerer is basically a normal speaker, with normal and understandable speech fears, sometimes resulting in withdrawal, sometimes in aggression, but all within the range of normal human behaviour. dean williams, considering research findings on stammering comments: "according to present day knowledge, it appears most reasonable to conclude that those persons who come to be classified by themselves or 7 by others as stutterers are not distinctive from other persons, either neuro-physiologically or either in respect to basic personality structure". from our experience, the really neurotic stammerer stands out in a group by his persistent resistance to treatment, by his failure to become an integrated part of the group, or by other abnormal patterns of social behaviour. evidence seems to suggest that the incidence of neurosis 16 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) amongst stammerers is much the same as that among the population as a whole. the question of whether stammering is or is not a symptom of neurosis is, of course, a perennially controversial one. one tends, naturally, to interpret evidence according to what one believes, but we are increasingly impressed by the essentially normal behaviour of stammerers. we have therefore based our approach to the problem on the assumption that the stammerer is a "normal" person with a normal speech mechanism, and that the stammering can be considered as a functionally autonomous disorder of communication. qualitatively and quantitatively he has the same kind of emotional problems as the normal speaker, plus those anxieties arising secondary to the stammer. it is in fact, a functional speech disorder in the purest sense. physical symptoms, such as biochemic, cardiac and respiratory changes which have been noted in the extensive literature on the subject are again held to be the effect rather than the cause of stammering, since none of these seem to be incompatible with either the symptoms of fear experienced by a normal speaker or with what one can see and hear the stammerer doing when he stammers. to illustrate our point with an example: there are still therapists, particularly in europe, who set out to re-educate the stammerer's breathing pattern on the basis of their findings of abnormal pneumographic recordings. during so-called "normal" or fluent speech, we have found only one or two stammerers who showed a sufficiently abnormal breathing pattern to interfere with speech in any way. yet during stammering the majority of stammerers will exhibit an abnormal pattern for any one or more of the following reasons: (a) because he wants to say as much as he can on a single breath (to avoid the "difficulties" of stopping and starting again), so that he continues speaking on residual air. (b) because he makes an "anticipatory inspiration", an habitual reaction to a feared word which probably has its roots in the mistaken advice to take a deep breath by a well-meaning parent, teacher or friend, or because he feels he needs a good breath force to break through his block! (c) during a clonic stammer, there will be an abnormal expiratory pattern, as air is released during the tremor. (d) in a tonic block, air is held in the lungs under pressure beneath the level of a closed glottis. to give re-education exercises is wholly to miss the point and entirely misinterpret these symptoms. all that is required is for these to be pointed out to him, and for him to understand how the first two increase the overt abnormality, and the last two are the direct result of what he is doing with his vocal cords or muscles of articulation. as stammering decreases, so these "symptoms" of abnormal breathing decrease or disappear. if breathing exercises are claimed to be effective, then it is important to realise that this is either due to the effects of suggestion, where the stammerer's conviction of their efficiency overcomes his fear of stammering (which is highly unlikely) or where, in concentrating on his breathing, they serve as a distraction device. the block can obviously be eliminated if the stammerer is really thinking so hard about his breathing, and how to control it, that he is too busy to do the other things which normally interfere with his speech. this interference will be discussed in a later section. basically, our approach is two-fold: the first and most important is to change attitude towards the stammer; the second is to bring about change and modifications in the abnormal speech behaviour. in practice it is found that work on changing one always affects and re-inforces the other. without a profound change in attitude towards stammering, little can be expected in the way of progress. this is why we feel that therapies directed towards achieving speech fluency without adequate work on attitude is bound to have limited or transient effect. it is easy enough to achieve fluency by various means in the clinical situation through general relaxation, suggestion and distraction techniques. emphasis tends to be placed on fluency as a criterion of progress. the stammerer is greatly encouraged by this fluency, but it is based on the flimsiest of foundations, and he is correspondingly depressed and discouraged, when under stress conditions he blocks as severely as before. we december, 1962 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) could have learned a great deal more about stammering if it had really been understood why methods had apparently succeeded which had no business to succeed at all! so often the prestige of the therapist, distraction, and suggestion generally, were responsible in cases where the techniques, methods or exercises used have been given the credit. this would not matter if we could rely on such therapies to be successful with most stammerers and also for the effects to be lasting. one can well understand why demosthenes' pebbles could have been successful! we may imagine the distraction afforded by trying to speak with a mouthful of pebbles, and the concentration required not to swallow them! in our present day, one can appreciate the strong suggestion involved when diagnosis and treatment are carried out under extremely clinical conditions, with remedial exercises, hypnotherapy, sedation, investigations into respiratory, cardiac and nervous function, etc. the stammerer becomes convinced that his stammering is a manifestation of a physical abnormality, if he did not already believe this to be so. the same thing seems to occur after extensive psychotherapy, particularly psychoanalysis, where the patient becomes convinced that his stammering is symptomatic of some deep emotional conflict. the stammerer echoes "i am convinced that if i could find the cause, my stammering would be cured." many causes are found for him, some he will accept, others he will reject. this often prevents his looking objectively at his stammering behaviour as something he is doing — both to interfere with speech and to increase the abnormality of his behaviour. as dean williams says, "as long as one functions as though an 'it' makes things happen, he is not motivated to observe cause and effect relationships in his behaviour, for 'it' is both cause and effect". further, "he talks and acts as though he believes either that there exists a little man inside him eager to grab certain words, or that certain words are possessed of physical properties such that they get stuck in his throat". we are basically in agreement with the semantogenic approach to stammering (johnson 1957). we feel, however, that a full consideration of this theory is not within the scope of this paper. we profess to an eclectic philosophy, drawing our information from fields related and unrelated to speech pathology. the psycho-physiology of stammering. when an individual stammers we are confronted by several different categories of behaviour. when he anticipates difficulty we may observe avoidance of a specific word, rearrangement of words or a total avoidance of speech. some will interject a sound, word or phrase whilst others will resort to such activities as taking a breath or swallowing to delay blocking. this behaviour is almost always initiated consciously and the stammerer is usually well aware of this fact. some will complain, however, that it happens so quickly that it is apparently automatic. the actual blocking or repetition appears to represent a loss of conscious volitional control. we would suggest that this is mainly due to a lack of feedback of information, made worse by the stammerer's emotional state. we would not consider that his general tension, however severe, is the cause of blocking. it is by exerting specific laryngeal tension that he directly interferes in the process of phonation, either disrupting the production of voice or preventing it altogether. the laryngeal activity clearly described by kenyon (1943) has been largely ignored by most workers. not only can one observe glottal closure or clonus on vowels and diphthongs, but an identical action occuring on both voiced and voiceless consonants. we are all familiar with the phenomenon of the distorted voiced plosive which a stammerer may produce as an ejective: e.g. p'read and p'utter. another common feature is the emission of a constricted flow of air which will permit the utterance of a voiceless sound but does not involve the vibration necessary for a voiced consonant or following vowel. one can imitate these phenomena by holding one's breath as lightly as possible and then "trying" to phonate. further information may be gained by employing a throat microphone with a suitable amplifier and comparing the sounds resulting from both geuine arid assumed stammering. our observations would tend to confirm ; the conclusions reached by dean williams (1955) in his electromyographic studies, namely that there was no significant difference between action potentials produced by stammerers and those 1 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) by normal speakers simulating stammering. the stammerer undergoes all the normal physical manifestations of a state of fear, which he identifies as "feelings of stammering". these are, however, easily recognised in most speech therapy students if they are required to simulate stammering or other speech disorders in everyday, communicative situations. the stammerer usually interprets these features as predictable constituents of stammering behaviour, losing their true identity in the total subjective pattern. the interference in phonation is sustained until the stammerer is compelled to give up through lack of oxygen or until he is satisfied that sufficient effort has been expended, (c.f. van riper, 1956). some stammerers appear to depend upon a specific time-lag before releasing the word, whilst others wait until they have performed some efficacious movement or ritual. although different in form, there are basic similarities between blocking and repetitive stammering; the one involving a deliberate tonic closure whilst the other represents the employment of insufficient effort or will to overcome a corresponding resistance of the mechanism, giving rise to oscillation or "hunting" (wolf, 1959). when the stammerer is in a state of panic he perceives his own behaviour only through vague tactile and kinaesthetic impressions. visual feedback is usually not operative and auditory feedback has either broken down, or is wrongly interpreted. the feeling of relief and even success on utterance of the word serve as adequate reinforcement for the conviction that the word will not "come out" without invoking this blind intervention. his lack of awareness of what has actually occurred is manifest in his firm belief of the "difficulty" of certain sounds and words and his incredulous rejection of any suggestion that he is] interfering. ! this general pattern of behaviour is discernable in individuals widely divergent in temperament, intellectual ability, social background arid experience. there is an interesting parallel in some of the findings quoted by sargarit (1957) from his studies of indoctrination, which may give a clue to some of the factors in the development and perpetuation of stammering. "the normal extravert, for instance, seems to be 'got at' more easily, and his new patterns maintained, by quite crude and nonspecific group excitatory methods, provided that they result in a strong, continued and often repeated emotional arousal .the obsessional person or the intravert may be more unresponsive to such an approach". sargant offers ample evidence of the ways in which emotion, confusion, hunger and general debilitation facilitate the establishment of new attitudes and corresponding changes in behaviour . the study of cybernetics promises to be a further aid in our understanding of the problem. many attempts have been made to interfere with the stammerer's auditory feedback, delaying it or eliminating it with the aid of "white" sound. some of the inferences drawn from such intervention are rivalled only by those of the stammerer himself, without the advantage of expensive or ingenious equipment. the laryngeal behaviour in stammering is of paramount importance in that it involves little or no conscious perception of feedback. there appears to exist a dichotomy between motor skills learnt with the aid of visual and kinaesthetic feedback and those dependent upon auditory feedback. in view of the remarkable rapidity with which articulatory skills are acquired and applied, and the comparative ease with which they are performed by the vast majority of human beings, are there not grounds for the assumption that learning to articulate is purely a matter of organising the maturing 'endogenous' behaviour patterns to meet the requirements of one's linguistic environment? (gesell 1942, ballard and bond 1960). even some stammerers with a high degree of insight find it hard to believe that effort on their part will not facilitate speech but inhibit it, that their simple movements of lips, tongue or larynx which resemble speech sounds are in fact only caricatures of the real process. we would suggest that stammering and some of the dysphonias represent patterns of learned interference dependant upon some element of 'unconscious control'. when a stammerer realises that a situation demands communication, this realisation gives rise to an emotional reaction. it is this reaction which disrupts the hierarchies subserving homeostatic control of behaviour. in stamdecember, 1962 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mering and a few other activities including, some have suggested, arithmetic and sport, initial failure is taken by society to be a sign that the individual is in fact incapable of improving his performance. when the demand is as frequent as it is in speech, reinforcement of negative attitudes is especially facilitated. therapy. a. change of attitude towards stammering. this is principally carried out through: (1) elimination of avoidance at every possible level. (2) re-evaluation of audience reactions and social penalties. (3) building up his resistance to these social penalties, and to communication stress, both within and without the group situation. (4) encouraging observation and discouraging theory. (5) increasing his knowledge of the psychology, physiology and phonetics of stammering, and of normal speech. (6) development of a sense of humour in studying stammering, audience reactions, and speech situations as a whole. undoubtedly, avoidance re-inforces the fear of specific sounds, words and situations, and is probably one of the most important maintaining factors in this functionally autonomous disorder. whilst avoidance continues, however subtle the avoidance may be, this is a fairly sure sign that the stammerer's attitude has not undergone sufficient change. he is obviously still embarrassed and anxious to hide the fact that he is a stammerer as far as this is possible. we are all familiar with substitutions of one word for another, but avoidance takes many forms: using the selfservice store for motives other than convenience; using ticket machines rather than approach a booking-office clerk; giving the bus conductor the correct change for your fare, to avoid stating your destination — the list is endless. the stammerer will not be prepared to abandon avoidance in its many manifestations until he is really convinced of the fact that it is largely responsible for maintaining his speech fears, and secondly, that when he begins to eliminate avoidance his speech fears begin to decrease. only so much can be accomplished by discussion: in the final analysis, he must begin to enter the situations and use the words he is tempted to avoid before he can really discover how pernicious avoidance is. this can be a difficult step, and here the well-integrated group can be of immense value. students are sent out in pairs to enter various "avoided" situations, to study their own reactions and those of the listener as objectively as possible. this results in a decrease in both the emotional attitude and in the physical concomitants of fear. one of the most important effects of such an assignment is the very illuminating reevaluation that takes place on audience reactions. we believe that it is the stammerer's assessment of "what the listener thinks" that largely determines his attitude towards his stammer, and we must recognise that imagined social penalties are just as potent in their effect as real penalties. it is just because he is anxious not "to make a fool of himself" and to invoke such penalties,that so much of his energy is devoted towards postponing, disguising and avoiding stammering. the ironic fact is, that far from achieving its purpose, much of this behaviour only adds to the overt abnormality. it is essential, therefore, if we are to discourage such avoidance, and reduce the stammerer's fear and embarrassment, that we encourage him to look more closely and objectively at how people behave when he stammers. with this in mind, he is asked to report not only on his own behaviour and feelings, but to study the behaviour of the listener. such observations can then be confirmed or denied by his partner. it frequently comes as a revelation that such a high proportion of people show so little reaction, even in the face of marked abnormality. he realises that those who do react are anxious (not unnaturally) to help him, or are as embarrassed as he is, and look away to spare them both! no attempt is made to convince the stammerer that really adverse reactions cannot occur on occasions, but he discovers from his / own experience how rare these are, and furthermore begins to appreciate that the listener probably has bigger problems than he has! through the experience itself, by relating it afterwards, and then through group discussion, he comes to recognise the psychological common denominators underlying much human behaviour. practical experience of this kind, even during a single evening, results in a marked decrease in 2 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) much of his previously subjective evaluation, and a not surprising reduction in the frequency and severity of his blocks. he comes to realise that his own emotional feelings may have caused him to make the most exaggerated interpretations of audience reactions frequently on the slimmest possible evidence of previous unpleasant experience. bizarre assignments may merely appeal to a sense of bravado, and tend to favour overcompensation, but the right type of assignment, and the good natured penalties of other members of the group, all help to build up the stammerer's emotional "resistance" to social penalties should they occur. as we have already said, however, with increasing experience of every kind of feared and previously avoided situation, he grows steadily more objective and less emotional in his approach to the people to whom he must speak. humour, which tends to arise quite spontaneously when these outside activities are related, is undoubtedly a tremendously potent factor in producing a change in attitude. we never have to ask a stammerer to tell a funny story about stammering — almost every assignment they carry out seems to be potentially humourous, and they waste no time in making the most of the story! our libyan student has his own favourite assignment: first he asks an unsuspecting member of the public what they think about stammerers. having removed the ground from under their feet with this question, he then proceeds to ask what advice they would give to help a stammerer. the final coup de grace is to pose the following question: "if you had a sister, would you be prepared to give her hand in marriage to a stammerer?". our favourite response: "well, of course. after all, he can't help it, can he?" direct observations and experience discourage the kind of theorising which tend to handicap ithe stammerer in his thinking, and which seldom have little to add to the knowledge of either student or therapist. we give a broad joutline of both past and current therapy, {so that he may consider them against the background of his own practical experience in the group, and in carrying out assignments. through this, and the study of stammering behaviour about to be described, we set out to dispel the myth and mystery surrounding stammering, and to encourage as far as we possibly can an enlightened and objective co-operation from the members of the group. b. modification of stammering behaviour. when a member of the group has reached a stage at which he has been able to give up some measure of avoidance, and most of the delaying techniques he has previously employed, he is then encouraged to adopt his new, experimental approach towards modification of his stammering behaviour. within this group, using communicative situations (e.g. answering questions, interviewing, giving short talks, reading aloud and play reading) he must first endeavour to free himself of both avoidance and interjection. the deterioration in fluency which may result calls for immediate reassurance and support. senior members of the group prove particularly helpful at this stage. when stammering occurs, he is encouraged to consider whether or not it was his own interference which prevented the utterance of the word. it is suggested that he rejects the idea of forcing out the word. when he stammers, he normally feels he has little or no control over the situation. with the encouragement and friendly militance of the group, he will still stammer, but his total emotional reaction becomes markedly reduced. he is better able to take note of what is happening, and can begin to deal with the problem. communicative demand is built up in such a way that when blocking occurs it is often greeted by laughter from everyone including the speaker. his gradual refusal to "conform" to the usual rules, requirements and rituals of the stammering, and his adoption of a more phlegmatic approach, are strongly reminiscent of sargant's principles of resistance to "brain-washing". it is our belief that the emotional reactions of fear, and of aggression, must be extracted from the everyday speech situations, to allow a more mature approach. this is also achieved by the open discussion of the feelings which surround stammering. the therapist must alternate between a directive and non-directive role, taking advantage of the friendly rivalry soon developed within the group. it is important to note that the group is rarely aggressive towards any one member. we are, in fact, continually impressed by the tolerance shown towards new members and towards those december, 1962 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) few who verge on the psychoneurotic, exhibiting a degree of acceptance rarely found in many other social groups. understanding of the mechanics of stammering is fostered by straightforward descriptions of the anatomy and physiology of the systems involved, together with an outline of basic phonetic principles. practical application of these principles is achieved by use of a mirror and throat microphones (ex. r.a.f. and u.s.a.a.f. originally suggested by an r.a.f. wireless fitter attending one of our hospital groups). we were interested to learn of similar work being carried out by breckwoldt (1962) in which his "laryngoreflectoscope" can be used to show stammerers their laryngeal activity. he observes that gutzman mentioned the value of autolaryngoscopy in his "sprachheilkunde". these "feed-back" techniques help the stammerer to achieve control of his behaviour through increased understanding. he must then begin to employ his new approach to blocking in "field work". the change in behaviour requires constant stabilisation for at least a period of several months. those who attend irregularly through choice or circumstance tend to take the longest period. we have found, however, that there is rarely a relapse where a major alteration in behaviour and attitude occurs. conclusion. therapeutically, class organisation is unique: although we are allowed to limit our regular attendance to 7 or 8 students in a group, should attendance drop below this, then classes can automatically be closed. in this respect, we enjoy no special privileges. far from being a disadvantage, we realise that this has proved to be an excellent discipline and a stimulating challenge. it has encouraged us, of sheer necessity, to evolve an approach which is designed to integrate a group as rapidly as possible; to create an atmosphere of informality which the students enjoy; and finally, a therapy designed to produce reasonably rapid results. as therapy has been streamlined and developed in this direction, two trends have been noticeable: that few stammerers now cease attendance without reason or explanation, and secondly, a much higher proportion reenrol for the second or third year which is necessary in many cases. our therapy has evolved from experience and observation of many stammerers, just as the stammerer in the group must finally learn from his own observations and experiences. atmosphere in the group is hard to describe. as we have stressed, informality and humour are an essential part. it seems to have been evolved in much the same way as the therapy. these are a few of the factors which have helped to determine it: in the first place, these are students in a study group, not patients in a clinic: they are treated as people with a common problem, not patients with a defect; secondly, they are free to come and discuss particular difficulties before or after class, and individual help is made available whenever necessary; thirdly, every member is given an equal opportunity to participate and succeed (and it is surprising how many students volunteer to participate on their first evening, and find, perhaps for the first time, that they are laughing about their own stammer as well as everyone else's); finally, no attempt is made to create an "easy" atmosphere to facilitate fluency — on the contrary — but the tolerance and humour of the group reduce any emotional trauma to a level which the student can handle, however new or embarrassed he may be. for the past three years, students have completed a comprehensive questionnaire within a few weeks of joining the group. this helped us to know much more, in the absence of initial interviews, about the stammerer and his attitudes, environment, personality and problems. this year, however, it was decided that some way must be found of measuring progress as objectively as possible so that we can systematically assess the results achieved by this particular approach. measurement of progress in stammering has always presented special problems. we hope that the form which has been prepared will go a considerable way in overcoming the difficulties of objective evaluation. the form is simple and complete. it will be given to the stammerer four times: at the commencement of the session, and then at the end of the first, second and third terms. it is divided into four parts: the therapist's check list for symptoms of stammering; the stammerer's check list of situations he avoids; the stammerer's own check list of 2 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) stammering behaviour (e.g. looking away from the listener, taking a breath before a difficult word); finally, his check list which indicates his assessment of audience reactions: (put a tick against the things people do when you stammer: look away laugh look embarrassed or uncomfortable try to help you out with a word appear impatient behave sympathetically treat you as if you are stupid appear superior or condescending generally react unfavourably show little or no reaction.) a decrease in the number of items ticked will be an indication of both changes in attitudes and of decrease in severity and abnormality of speech behaviour. summary. the london county council has for many years held evening classes for adult stamr merers. since 1956, when one of the authors was appointed as therapist, general relaxation as a fundamental form of treatment was abandoned in favour of "non-avoidance" techniques. groups consist of stammerers ranging in age from 16 to 55 years. in addition to this wide age range, there are varied racial, social and educational backgrounds. 8 is considered to be the "ideal" number of students for a therapeutic group. the approach to therapy has been based on the assumption that the stammerer is a "normal" person with a normal speech mechanism, and that stammering can be considered as a functionally autonomous disorder of communication. basically the approach to the problem is two-fold: ;the first and most important is to change the attitude towards the stammer; the second is:to bring about change and modifications in the abnormal speech behaviour. therapies which do not attempt to effect a change in attitude towards stammering, but are directed towards achieving speech fluency, are bound to have limited or transient effect. opsomming. die londonse distriksraad het vir baie jare aandklasse gereel vir volwasse hakkelaars. sedert 1956, toe een van die skrywers as 'n terapeut aangestel is, is algemene verslapping as 'n grondbeginsel in terapie afgeskaf tengunste van die „nie-ontwykings" tegniek. die groepe bestaan uit hakkelaars, wat wissel in ouderdom van 16 tot 55 jaar. behalwe vir die groot verskil in ouderdomme, het die groep ook persone ingesluit met 'n verskillende rasse-, sosiale en opvoedkundige agtergrond. agt studente word beskou as die ideale aantal per groep. die benadering tot terapie is gebaseer op die veronderstelling dat die hakkelaar 'n ,.normale" persoon is met 'n normale spraakmeganisme, en dat hakkel as 'n funksioneeloutonomiese gebrek van kommunikasie, beskou kan word. die benadering tot die probleem is basies tweeledig: die eerste en belangrikste is om die houding teenoor die hakkel te verander; die twede is om veranderings en wysigings in die abnormale spraakpatroon teweeg te bring. behandelings wat nie mik om die houding teenoor die hakkel te verander nie, maar wat gesteld is om vlotheid van spraak te verkry, moet noodwendig beperkte en verbygaande resultate lewer. references 1. ballard. c. f. .& bond, ε. k„ "clinical observations on the correlation between variations of jaw form and variations of oro-facial behaviour, including those for articulation". speech pathology & therapy, 2, 55-63. (1960). 2. breckwoldt, g. h., "the laryngo-reflectoscope " (unpublished m.s.s.) (1957). 3. foulkes, s. h. & anthony, e. j., "group psychotherapy". london: penguin books. 4. gesell, α., "morphologies of the mouth and mouth behaviour". american journal of orthodontics, 27, 397. (1942). 5. johnson, w., "perceptual and evaluational factors in stuttering". handbook of speech pathology, ed. travis, l. e. new york: appleton century crofts. (1957). 6. kenyon, e. l„ "the etiology of stammering: the psycho-physiological facts which concern the production of speech sounds and stammering". journal of speech disorders, 8, 337-348. (1943). 7. sargant, w., "battle for the mind — a physiology of conversion and brain washing". london; wm. heinemann. (1957). 8. van riper, c., "speech correction". new york: prentice hall. inc. (1956). 9. williams, d. e., "masseter muscle action potentials in stuttered and non-stuttered speech". journal of speech and hearing disorders, 20, 242-261. (1955). 10. williams, d. e., "a point of view about 'stuttering' " journal of speech and hearing disorders, 22, 390-397. (1957). 11. wolf, a. a. & wolf, e. g., "feedback processes in the theory of certain speech disorders". speech pathology and therapy, 2, 48-55. (1959). december, 1962 journal of the south african l o o p e d i c society 3 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) an application of learning theory to the secondary aspects of stuttering m a r g a r e t m a r k s , b.a. (log), m.a. (witwatersrand) senior lecturer, department of speech pathology & audiology, university of the witwatersrand, johannesburg summary t h e c o n c e p t s of primary and secondary stuttering are re-evoked t o provide a framework for a discussion of the theoretical division of stuttering into a series of responses. t h e stuttering behaviours of an advanced stutterer are divided into those of awareness, avoidance, t h e ' m o m e n t of stuttering', a release response and the utterance of the word. one set of responses, t h o s e of avoidance, are treated w i t h i n various learning t h e o r y paradigms, n a m e l y , t h e mowrer-ullman h y p o t h e s i s , chaining, superstition, and an avoidance-escape d i c h o t o m y . a l t h o u g h n o direct therapeutic implications are d e d u c e d from these analogies, the value for the speech pathologist of a k n o w l e d g e of the principles and t e c h n i q u e s of learning t h e o r y , is stressed. opsomming die k o n s e p t e van primere en sekondere hakkel w o r d weer eens bygebring o m 'n raamwerk te verskaf vir 'n bespreking van die teoretiese verdeling van hakkel in 'n reeks response. die hakkelgedrag van 'n gevorderde hakkelaar w o r d ingedeel in b e w u s t h e i d , vermyding, die „ o o m b l i k van hakkel", 'n vrylatingsrespons en die uiting van die w o o r d . een stel response, vermyding, w o r d b e s k o u uit verskillende leerteoretiese paradigmas, naamlik die mowrer-ullman hipotese, aaneenskakeling, b y g e l o o f en 'n vermydings-ontvlugtingsdigotomie. a l h o e w e l geen direkte terapeutiese implikasies afgelei word van hierdie analogies nie, word die waarde van b e k e n d h e i d m e t hierdie beginsels en tegnieke van die leerteorie vir die spraakheelkundige b e k l e m t o o n . although the terms primary and secondary stuttering have fallen into disrepute, and for good semantic reasons, it seems that a case could be ma'de to conjure them up again, to differentiate between the 'actual' stutter (block, dysfluency, classically conditioned response); and those behaviours which the individual uses in an attempt to cope with this undesirable stutter. while the writer is cognizant of the fact that these two aspects of the stutter are not necessarily mutually exclusive, and that the behaviours described as primary and secondary can co-exist and be displayed by the same stutterer at different times and indeed even in the same stuttering incident, it is the aim of this article to focus on the secondary aspects of the responses which constitute the efforts of the more advanced stutterer to deal with his dysfluency. journal of the south african speech and hearing association, vol. 20 december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) an application of learning theory to stuttering 69 there are many theories which attempt to explain the original, or primary speech breakdown, but there is little serious opposition to the theory which best explains the acquisition of secondary responses, namely, that theory derived from the laws of learning. van riper1 1 does not feel that the onset of stuttering can be explained only by learning, but he states t h a t . . we are convinced that much of the behavior which goes under the name of stuttering is learned behavior. we can account for its variability of symptoms and its consistency of pattern in no other way. we have watched it being learned.'2 the only other theoreticians who attempt to explain the secondary responses are those who are psychodynamically oriented and, although many speech pathologists would reject such descriptions of secondary symptoms as being revealing of'motor patterns of nursing . . . . cannibalistic muscle patterns, analretentive and anal-expulsive' (coriat, as quoted by glauber3), more acceptance is shown of the principles behind such phrases as 'aggressive symptoms' and 'secondary gains', and some of the intractability of severe stuttering is often ascribed to the stutterer's 'need' to retain his stutter, rather than to the therapist's need to know more about the alleviation of his patient's abnormal speech behaviour. neurophysiology is a field which could provide a rationale for some of the bizarre responses which comprise advanced stuttering; within this framework we could possibly seek an explanation for the distractive devices which remain, like albatrosses round the stutterer's neck, in the form of secondary behaviours. these, and other phenomena noted in stuttering, may become logical when considered in neurophysiological terms. generally, however, as it has come to be accepted that most, if not all, the secondary responses are learned, the understanding of their acquisition has subsumed a knowledge of the laws of learning, while the therapeutic implications have been based on the principles of behaviour modification. once the worker is committed to this theoretical viewpoint, he stands to benefit from the findings and knowledge of an extensive literature; he is also faced with the responsibilities which such a commitment, and such a literature, imply. the writer has, in an earlier issue of this journal6, discussed these responsibilities, and considered the difficulties which can arise from a limited understanding, and consequent application, of learning theory as it pertains to stuttering. for many speech pathologists not formally trained in learning theory, it seems a far cry from the puzzled rat that does not know which way to turn, and from the eccentricities of pigeons' pecking (and of the people who pick out what pigeons should peck at), to the human creature struggling to talk. however, we must realise that a simplistic view of the relationship between animal and human behaviour no longer exists. most contemporary learning theorists have accepted the complexity of animal behaviour, and are even more aware of the almost unchartable vastness of complicated human behaviour. they are aware, for example, that cognition and language must be considered when accounting for many aspects of human functioning. terrace,9 when defining a particular operation of the learning process (stimulus control) states that 'many topics such as perception, psychophysics, thinking and psycholinguist i c s . . . are directly suggested by this definition, and (there are) numerous other topics that are not so directly relevant.' tydskrif van die suid-afrikaanse vereniging vir spraak en cehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 margaret marks as previously stated, it is probably in a description of the secondary, acquired behaviours, the speaker's attempts to do something about the feared word or situation, that concepts culled from learning theory are most directly applicable. some speech pathologists have attempted to use procedures, notably those of reinforcement, to demonstrate control of stuttering. the disparity of results, particularly those of experimenters using punishment, lead brutten and shoemaker1 to their two-factor theory, a concept which supports the present writer's view, stated in 19665, that previous workers had thought of 'the stutter' in too molar, and not molecular enough, a manner and that, in most stuttering incidents shown by an advanced stutterer, there is a.sequence of responses which comprise the motor act of stuttering. in this paper, an attempt is made to represent, diagrammatically, this series of responses and to discuss how learning theory can be used to explain one set of these responses, i.e. the avoidance responses. the following responses are suggested as being relatively typical of an incident of stuttering; although not all the behaviours occur each time the person stutters, they appear with enough frequency to warrant inclusion: is the discriminatory stimulus the awareness of approaching difficulty are the avoidance responses is the ' m o m e n t of stuttering' — primary stuttering is the release response is utterance of the w o r d figure 1: a stuttering incident comprising a series of responses. a brief description of each of these sets of responses is given. / a awareness. something in the stimulus configuration of the speaker's environment acts as a discriminatory stimulus, which initiates the series of responses. β avoidances. these are the responses which have been called by therapists, starters, postponements, interjections, etc. for;this paper they will be described only as avoidances. they will be discussed in more depth later, but a graphic representation here indicates their nature. if 'town' is the feared word in the sentence 'i'm going to town', the following diagrams represent two types of avoidance responses: journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) an application of learning theory to stuttering 71 (i) i'm going to., going to., t-t-town β ε (ii) i'm going to the city α β / ν ε i'm going to figure 2: representations of avoidances. in (i), the avoidances were not effective as, in addition to using them, the person experienced the stutter c, before uttering the word and so achieving his goal, that of communication. in (ii), the avoidance, this time one of circumlocution, was successful, and he did not experience c, the moment of stuttering, and its consequent d, the release response. although the desired word was not said, the goal of communication was reached. c the moment of stuttering, is represented by various behaviours; the order in which they are listed below indicates increasing amounts of tension. ο it is possible that there is, in some incidents of stuttering, no 'moment of stuttering', i.e. the stutterer may experience awareness and may utilise responses described under β but, even if he had not done so, would have experienced none of the behaviours described immediately below. r v / v ^ repetition, either easy or tense, but not as tense or rapid as the behaviours described as tremors. this stage could, depending on the phoneme stuttered on, be represented thus , i.e. as a prolongation. neither of these (repetition and prolongation) is actually a dysfluency, in that they do not interfere with the rhythm of speech, or cause a break in the flow of continued speech. block, the actual cessation of ongoing speech movement; it seems as if this occurs mainly, if not only, on stops and vowels. i tremor, 'fast little vibrations... produced by highly tensing the i muscles that form a fixed posture'. (van riper 1 0 ) tydskrif van die suid-afrikaanse vereniging vir spraak en cehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 margaret marks clinical evidence has lead to the impression that it is the attempt, on the part of the speaker to do something about this moment of stuttering, which gives rise to so much aberrant behaviour. exactly what aspect of this response is so fearful, is a matter of conjecture; it may be, as van riper1 0 implies, the feeling of impotence when the stutterer gets thrown into a tremor; it is also possible the present writer believes, that it is the sound of repetitive speech, behaviour which was considered as 'stuttering' in childhood, and therefore taboo. parents often bring their children back to a therapist, saying, in effect: 'we're so pleased; he's stopped stuttering. of course, he does stop and take a deep breath, but he's not stuttering.' advanced stutterers, with visually bizarre responses, would rather use these, if they bring with them a reduction in the sound of 'stuttered' speech they do not see what they look like, but can hear that the feared stutter is not vocalised. 'you'll never get me to speaspeaspeak like that; it sounds ridiculous' is the gist of statements of many stutterers with severe blocks, often accompanied by very visible struggle responses. it may be that the feared aspect of the stuttering moment is not the same for each stutterer, or, indeed, may vary from one stuttering incident to the next, in the same speaker. d a release response, which terminates the moment of stuttering. an effortful release is usually more necessary when the moment of stuttering has comprised a block or tremor, than when the speaker is repeating or prolonging, as, in the latter two cases there is little or nothing to be released from. this is seen as a release, rather than an avoidance response, thus supporting van riper's11 contention that 'it is both psychologically and semantically unwise to stretch the term avoidance to include these escape reactions'. ε utterance of the word. this continuation of communication is the reinforcement of all that has gone before. once a framework such as the one above is tentatively established as a theoretical point of view, certain questions can be asked, and certain paradigms from learning theory evoked as possible explanations, or as areas deserving further study. each of the five aspects described could be rephrased in terms of some aspect of learning theory, but only avoidance behaviours and some of their learning theory correlates will be dealt with in this paper. when the patient comes to therapy, he has his set of premiums: negative for the moment of stuttering, positive for avoidance behaviours. many therapies are based on the principle of trying to get him to change these premiums, i.e. to want to get to the moment of stuttering; and to want to stop the avoidance behaviour. however, it has been the experience of many therapists that, even though the stutterer tries to stop avoiding, the 'habit' dies hard. learning theory offers various explanations for behaviours which are deleterious to the well-being of the individual and which are, nevertheless, maintained, behaviours described by wolpe12 as neurotic: 'any persistent habit of unadaptive behaviour acquired by learning in a physiologically normal organism'. theories based on the principle of learning must account for their persistence in the face of their lack of efficacy in coping in the best possible way with the. noxious situation. journal of the south african speeh and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) an application of learning theory to stuttering 73 brutten and shoemaker1 state that both wischner and sheehan use the mowrer-ullman hypothesis to explain this persistence: 'according to mowrer and ullman, if all things are equal, a response will be reinforced or extinguished depending on whether the rewarding or punishing consequences, respectively, follow the cessation of behaviour more closely in time.' thus the concept of time is considered a crucial factor in the acquisition and retention of aberrant responses. another concept which bears scrutiny is that of chaining, first described by skinner in 1938,8 and later defined by ferster and perrott2 as the phenomenon which takes place when a stimulus maintains the preceding performance and also makes possible the next performance in the chain. if, for example, within the behaviours described as β above, there is a sequence of b ( 1 ) leading to b < 2 ) leading to b < 3 ) which eventually leads, albeit painfully, to reinforcement e, utterance of the word, each response in the chain is necessary, as it makes ε possible. an early work of luper's4 although not explicitly using the term 'chaining' seems to imply the concept, as does a recent experiment reported by prins and lohr7. data from experiments on chaining must lead us to speculate on certain topics, e.g. how certain elements of the chain are learned i.e. is it possible that they are differentially learned, and will need, therefore, different types of extinguishing procedures? why are some elements in the chain (which could be called the 'core' of stuttering) present in all incidents of stuttering, while others occur infrequently? why are some 'distractions' maintained as part of the chain, while others are extinguished? how can information about extinguishing chain behaviour aid in stuttering therapy? superstitious behaviour is another description which aids in the understanding of seemingly irrational behaviour. this describes elements in the response not directly instrumental in gaining reinforcement, but which, through association with the operant behaviour, become part of the response gestalt. the classic examples are those of skinner's pigeons who emit certain responses immediately before the ones which are effective in gaining the desired goal (e.g. turning around before pecking the switch which releases the food, where turning around becomes a superstitious response). although they were coincidental to the desired behaviour, the responses become part of the total response pattern. it does not seem to be stretching analogies too far if we describe at least some of the stutterer's avoidance responses as superstitious, or ritualistic behaviour. when he considers the intransigence of some of these avoidance behaviours, the clinician will recognise their similarity to superstitious responses, traditionally difficult to eliminate. as with chaining, we must attempt to utilise knowledge gained by the learning psychologist, in an attempt to break this superstitious behaviour. animal experimentation has shown that there is a difference between the learning processes involved in avoidance and escape. avoidance behaviour is learned by the rat who is faced with an electric grid between it and its desired goal; acquisition of this type of behaviour is different to the learning of behaviours which a second rat must acquire when it is already on the grid and has to discover how to get off — escape behaviour. it seems important to differentiate between these two sets of responses in the stutterer (behaviours β and d), as it is probable that they are learned differently, require different tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 74 margaret marks methods of extinction, and that one set may be more difficult to extinguish than the other. no direct therapeutic implications have been drawn from the analogous nature of stuttering behaviour and that observed by experimental psychologists in their work with controlled units of behaviour, but it seems that a consideration of the relationship between certain aspects of learning and of stuttering could be of benefit to those who seek to help stutterers. there is a rich field of knowledge gained from experiments based on learning theory, and it seems desirable that speech pathologists and therapists adopt and adapt principles and techniques derived from this valuable source of data. references 1. brutten, e.j. and shoemaker, d.j. (1967): the modification of stuttering. prentice-hall inc., new jersey. 2. ferster, c.b. and perrott, m.c. (1968): behavior principles. appletoncentury-crofts, new york. 3. glauber, i.p. (1968): the psychoanalysis of stuttering. in eisenson, j. (ed.), stuttering: a symposium. harper and bros, new york. 4. luper, h.l. (1956): consistency of stuttering in relation to the goal gradient hypothesis./, of speech and hearing dis., 21, 336-342. 5. marks, m. (1966): stuttering viewed as a sequence of responses. paper presented to international seminar in stuttering and behavior therapy. published in gray, b.b. and england, g. (1969) stuttering and the conditioning therapies. monterey institute for speech and hearing, california. 6. marks, m. (1968): are we good behaviourists? /. of the south african logppedic society, 15,19-25. 7. prins, d. and lohr, f. (1972): behavioral dimensions of stuttered speech. /. of speech and hearingres. 15, 61-71. 8. skinner, b.f. (1938): the behavior of organisms. appleton-centurycrofts, new york. 9. terrace, h.s. (1966): stimulus control. in honig, w.k. (ed.) operant behavior: areas of research and application appleton-century-crofts, new york. 10. van riper, c. (1963): speech correction, principles and methods. (4th edition) prentice hall inc., new jersey. 11. van riper, c. (1971): the nature of stuttering. prentice-hall inc., new jersey. 12. wolpe, j. (1958): psychotherapy by reciprocal inhibition. stanford university press, stanford and witwatersrand university press, johannesburg. journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) philips hearing aid services a division of s.a. philips (pty) ltd. hearing aids portable audiometers group teaching systems philips hearing aid services head office 1005 cavendish chambers, 183 jeppe street, p.o. box 3069, johannesburg. p h i l i p s @)44923 tydskrifvan die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) experiments on the elasticity of the vocal cords d a m s t e , p . h . , m.d. a n d wieneke, g.h., ph.d. af deling foniatrie, universiteits kno-kliniek, catharijnesingel 101, utrecht, nederland summary regulation of vocal p i t c h occurs b y changes in the length and t e n s i o n o f the vocal folds. because the young's m o d u l u s of t h e vocal cord ligament c o u l d b e a factor w h i c h determines the difference b e t w e e n male and female voices, this was made an object o f research. n o differences could b e s h o w n . s o m e of the problems and t h e limited accuracy of t h e s e experiments are reviewed. opsomming beheer van s t e m t o o n h o o g t e vind plaas deur veranderinge in the lengte en spanning van die s t e m v o u e . aangesien y o u n g se m o d u l u s van die stemlipligam e n t 'n faktor kan w e e s wat die verskil tussen manlike en vroulike s t e m m e bepaal, was dit die o n d e r w e r p van navorsing. geen verskille w o r d a a n g e t o o n nie. s o m m i g e van die p r o b l e m e en die beperkte akkuraatheid van hierdie eksperimente w o r d bespreek. when the pitch of the voice rises, the length of the vocal cords increases. all specialists in voice agree with this, no matter how they differ in other opinions. the mechanism by which the length of the vocal cords increases is well known; the backward turning of the cricoid cartilage in respect to the thyroid ,by the pull of the cricothyroids increases the distance from the arytenoids to the farthest attachment point of the vocal cords. the amount of stretch of the vocal folds which can be effected by this physiological mechanism was specified by sonninen12 with the help of x-rays. from this research came a paper on the lengthening mechanism, more accurate than that given by r. schilling10 in 1940. van den berg5 proposed by means of experiments with cadaver larynges, that the vocal cords can stretch to a maximum of 30% of their original length. in addition, the tension (in other words the elasticity modulus) increases approximately proportional to the traction exercised on the tissue. falsetto tones are produced by the fully stretched position of the vocal ligament and conus elasticus. these tones are at one end of the vocal, register scale, and at the other end are the tones of the chest register, the normal speaking voice of man. this type of voice is generated by the completely relaxed and supple vocal folds, in which all parts participate,in the vibration. for a melodious speaking voice, journal of the south african speech and hearing association, vol. 20 december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) e x p e r i m e n t s on the elasticity of the vocal cords 15 , f u r s e above all for singing, it is important that higher tones are proh d in a mixed or a middle register. in this case the tensing of the ligament h t h e cricothyroid is combined with the tensing and shortening of the muscles h c o n t r a c t i o n of the internal and external thyroarytenoids. thus the vibraγ of the ligament remains coupled with that of the muscle mass, which gives e to the full tone of the normal register. in falsetto register the vibration is γ ot t r a n s m i t t e d to the whole vocal fold, only the medial edge vibrates. this "suits in a weak, thin tone. the voice can be voluntarily controlled to a great extent, and any individual can make a large variety of vocal sounds. f r o m just the sound of the voice it is possible to form an idea of the person, his character and his mood. one has, as it were, an acoustic face, from the sound of the voice. damage to the voice is just as disturbing as a facial scar. a woman with a voice which has become masculine through the use of androgens, has suffered an irreparable mutilation. her acoustic impression has lost a great deal of prettiness. she can shave or wax away her facial hair, but her cracking baritone cannot be hidden, except by not going out or by keeping quiet. the problem of virilisation of the voice became noticed in the years after 1960 through the introduction of anabolic s t e r o i d s . 1 ' 2 ' 6 , 9 it is not possible to guess how many women have been made victims by the unchecked use of these drugs. it is still a real problem. when one has seen it once, it is apparent that it is not rare, particularly the early stages of voice virilisation. in the early stages the symptoms are not so obvious. characteristic symptoms are: unsteady vocal pitch which wavers between two timbres; a light and darkone. it is the lack of control which gives the voice a subjective strange sensation. the range is not decreased, rather the lower range increased, and the higher tones less well controlled than before. this is only noticed by women who sing. vocal cord oedema comes especially into consideration for differential diagnosis; the pitch range in the higher tones is severely limited through this. however this is not the case in the early stages of virilisation. mirror examination shows a great difference. in vocal cord oedema there is a widening of the vocal folds, which are lighter coloured. laryngeal stroboscopy shows greater vibration amplitude and a widening of the wavecrest. there is frequently nothing special to see in virilised vocal cords. only in a later stage is there sometimes a change in colour, to a dark yellow. what change in the vocal folds is responsible for the change of voice in the woman whose voice becomes masculine? that is the question which many have put, and which has many different answers. some have sought the cause outside the larynx, in timing of conduction of impulses in the nervous system. we can forget this possibility, as it is based on a most improbable theory of vocal cord vibration. serious thought has been given to the opinion that the change is due to a change in muscle-tissue in the vocal folds, the enlargment being directly caused by the anabolic* effect of testerone and other steroid compounds. another opinion is that change in the mucous membrane causes the change in voice timbre. perello9 has studied a section from a mutated * by this is meant the property to promote the synthesis of muscle protein. tydskrif van die suid-afrikaanse vereniging vir spraak en cehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 damste and wieneke larynx and reports a thickening of the middle layer of epithelium. in the same article he gives the increase in volume and power of the thyroarytenoids and the inspiration muscles as causes of the deepening of the voice. in differential diagnosis of vocal cord oedema, it is possible to find arguments which make the thickening of the epithelium as one of the causes of a voice change less probable. it is also known that steroids, to which the androgen hormone belongs, have an effect on the composition of connective tissue. since the connective tissue in the vocal folds (coni elastici and vocal cord ligaments) greatly determines the sort of voice and its quality, the hypothesis is that changes in this shall account for masculine voice in women. some physio-chemical arguments have been discussed by damste.7 experiments in 1963-1964, we studied the possibility of whether the elasticity of the connective tissue in the edge of the vocal cords, could be determined by measuring the elasticity. experiments were carried out on a score of larynges. the results were in many cases not completely reliable due to complicating circumstances and that is the reason why the work has not been published until now. on closer examination of the data we feel that it is still useful to publish the method used, and a few of the results, as a guide and a warning to potential researchers. the plan was to determine the young's modulus of a satisfactorily large number of vocal cords from men, women, women with masculine voices and possibly children and to see if the values of the young's modulus in the four groups were significantly different. method the elongation of the vocal cord and the force was measured with the apparatus shown in figure 1. the ends of the specimen were clamped. one end was fixed to the support and one to the arm of a lever made from a light and stiff hollow pipe. on the other side of the axis of rotation the end of a spring was attached. the spring could be stretched by displacing the other end by a nylon thread which is wound round an axis behind the black knob (below right in figure 1). the force exerted by the spring is indicated in grams on a gauged scale. the long arm of the balance indicates the elongation of the specimen in tenths of a millimeter. procedure an experiment with forces from 0-60 grams in 5 grm intervals was done within a minute, the time necessary to write or to dictate the numbers. more time was necessary for the preparation of the specimens. to get a solid attachment of the ligament a piece from the thyroid cartilage and from the arytenoid was taken with it. the measurement was done after the specimens had lain in a physiological salt solution for ten minutes. measurements with more or less dried out specimens were not reliable. journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) e x p e r i m e n t s on the elasticity of the vocal cords 17 figure 1. the apparatus with which the stress-strain curves of the vocal cord were measured. the vocal cord was fixed on the left side with two clamps. in the middle is the scale for force, to the right the scale for increase in length. see text (methods) for further explanation. tydskrif van die suid-afrikaanse vereniging vir spraak en cehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 damste and wieneke results figure 2. tension 6 as a function of the elasticity ε of the right vocal cord from a woman who died at 40 years. an example of the results is shown in figuie 2. the stress (force/area of the cross-section) is given against the strain (increase in length/length with 0 gram force). the cross-section of the vocal cord was calculated from the weight with the assumptions that (a) the area of the cross-section is equal over the whole length (b) the mass density of the tissue is 1 grm.cm-3. in these preliminary measurements the results of 8 male vocal cords and 10 female were considered. in all cases the stiffness (young's modulus measured as a slope on the curve: δ6/δε) increased greatly with increasing strain (to 15 *). the value journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) e x p e r i m e n t s on the elasticity of the vocal cords 19 f the strain, above which the curves rise steeply, shows noticeably great differences. these differences were clearly correlated with the age of the patient on death. the relation between the age and the strain where the young's modulus is one half of the maximum value measured in the experiment is shown in figure 3. also, the young's modulus at the beginning of the 8 • • ο ο η ο 8 _l 0 25 50 75 100 [ y e a r ] age • figure 3. value of the elasticity ε 5 at which the young's modulus of the vocal cord is equal to half the maximum measured value set out against the age of the person at death. shaded blocks = male, open circles = female, correlation co-efficient = 0.8. . curve (0-5 grf) shows the dependance on age. for example the young's modulus measured from a girl of 6 years was 350 grf.cm-2 and from a woman of 40 years 550 grf.cm-2. the maximum error of the apparatus is about 20% in this range. in the normal voice range the elasticity at small stresses will be important. the young's modulus in the range of strain less than 25% does not show significant differences in vocal cords from males and females without masculine voice change. this is partly due to the lack of precision of the measurements but mainly to the influence of the age of the person. conclusions from these measurements no significant difference between the young's modulus for low stress values in males or females could be determined. consequently no conclusion can be drawn as to how far masculine changes of the female voice are a result of change in the young's modulus. tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 damste and wieneke possibly age has a greater influence on the vocal cords than use of drugs. we must first have a better insight into the changes in the vocal apparatus due to age, before it can be concluded that the changes in voice with the use of virilising drugs are due to changes in elasticity. it seems advisable to investigate other factors which have an effect on these changes. one can think of the increase in the mass of the intrinsic laryngeal muscles. the accuracy of the elasticity modulus is one of the obstructions to interpret low strain (<25%) values. in view of the discovered differences the maximum error had to be smaller than 40 grf.cm-2 (7%). to achieve this, the measuring apparatus had to meet the following requirements: the zero length must be measured with an accuracy of ±0.2 mm; the elongation with ± 0.02 mm; the force with ± 0.05 grf; the weight with ±0.5 mgr. maximum error. this includes the uncertainties with regard to the true length of the vocal cord, the varying cross-section and deviations in mass density. in the statistic analysis the effect of age has to be taken into account. discussion the conclusions do not confirm our hypothesis that the young's modulus in men and women with virilised voices have lower values than in normal women. therefore they are not in agreement with the results of bauer4 which did confirm this hypothesis. he described a clear relationship between the young's modulus and the sex (ratio 2:1) and could also discern the effects of voice mutating substances. bauer calculates the values for the young's modulus at a 50 grm weight. according to our measurements the tissue is then already in the range of a high young's modulus, at which it probably does not reach during normal voice use. the value of the young's modulus according to bauer, is somewhat smaller than that found by us: 600-1300 grf.cm-2 against 1800-4500 grf.cm-2 measured with a stress of 50 grm. references 1. arndt, h.j. (1963): stimmschaden bei frauen durch androgene und anabole hormone. deutsche med. woch. 88: 2336-2339. 2. bauer, h. (1963): die beeinflussung der weiblichen stimme durch androgene hormone.folia phoniatrica 15: 264-268. 3. bauer, h. und konig, w. (1967): physikalische und histologische untersuchungen am normalen und einem weiblichen virilisierten kehlkopf. arch. ohr. nas.-kehlk. heilk. 188: 358-363. 4. bauer, h. (1968): die beziehungen der phoniatrie zur endokrinologie. folia phoniatrica 20: 387-393. 5. berg van den, jw. (1960): current probl. phoniat. logop., karger, baselnew york 19-34. 6. damste, p.h. (1964): virilisation of the voice due to anabolic steroids. folia phoniatrica 16:10-18. 7. damste, p.h. (1964): virile changes in the voice induced by androgens. excerpta medica intern. congress 85: 158-160. journal of the south african speech and hearing association, vol. 20, december 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) e x p e r i m e n t s on the elasticity of the vocal cords 21 9. 10. 11. 12. ί έ ρ η (1967): voice change in adult women caused by virilizing agents journ. of speech and hearing disorders, 32: 126-132. perello j. (1964): virilization de la laringe femenina.^cta o.r.l. iber.amer xv, 2: 139-141. schilling, r. (1940): uber den spannungsmechanismus der stimmlippen hals-nasenund ohrenarzt 31: 1γ2. sonninen, a. (1956): the role of the external laryngeal muscles in length adjustment of the vocal cords in singing. acta otolaryngol suppl. 130, stockholm. sonninen, a. (1962): paratasis-gram of the vocal folds and the dimensions of the voice. proc. 4th intern. congr. phonetics (helsinki), ed. mouton, den haag 250-258. for all y o u r m e d i c a l b o o k a n d j o u r n a l r e q u i r e m e n t s consult t h e s p e c i a l i s t s p . b . m a y e r 902 n o r w i c h house heerengracht c a p e t o w n telephone 2-9231 tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheelkunde, vol. 20, desember 1973 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society the treatment of the cleft lip and palate patient a. jacobson, b.d.s. (rand), m.s. (orth.) (chicago) and c. j. dreyer, b.sc.(s.a.), b.d.s., h.d.d. (rand.), department of dentistry, university of the witwatersrand. introduction children with cleft lips and/or palates are cripples in the truest sense of the word. the physical appearance of these children is unpleasant, mastication and deglutition is upset, and the speech is often unintelligible. as a result of these aberrations the child is likely to become a psychological misfit, yet these children, other than their physical defect, are normal and should become wellintegrated and useful adult citizens. the treatment of these individuals is usually of such long duration and complexity that a co-ordinated treatment plan should be formulated for them by a cleft-palate unit, and not by each individual who happens to be treating such a patient at the time. the member of a cleft-palate unit will, by virtue of discussion, be able to appreciate all the problems which may be associated with this type of physical deformity. this paper is designed to present a broad appreciation of the various aspects of the treatment of cleft lips and palates. incidence and cause the incidence of cleft palate in the white race is approximately one in 800, the incidence being less in negroes. the figures among investigators vary from' 1 in 665 to 1 in 2,000. the causes of this deformity are not fully understood, heredity still being the most significant cause. german measles in early pregnancy is another possible causative factor. malnutrition in animals has in instances produced clefts. varieties of clefts a cleft lip is the result of the non-fusion of the medial nasal process with the lateral nasal and maxillary process during the 6th to 7th week in utero. a cleft palate results from the lack of fusion of the palatine processes with each other and the nasal septum. palatal fusion is usually completed at the end of the 4th month in utero. thus it can be seen that a teratogenetic factor present between the 7th week and 4th month can be responsible for a cleft. also, the timing of the onset of this teratogenetic influence and its duration during this period, determines the type of cleft, since fusion of the palate is from anterior to posterior. a cleft through the alveolar ridge does not necessarily pass through the incisive suture2; clefts are present before the ossification of the maxillary elements. the variety of clefts is infinite, but for practical purposes veau's1 classification is the most acceptable. type i is a cleft of the soft palate or uvula. type ii is a cleft of the hard and soft palate extending no farther forward than the incisive foramen. the vomer in this type may be suspended from above and free from each side, or attached to either side. type iii is a complete uni-lateral cleft of the alveolar arch and hard and soft palate (usually associated with uni-lateral cleft lip). in this type the vomer is usually attached to that side of the palate which is opposite to the cleft in the alveolus. type iv is a complete bi-lateral cleft of the alveolus and hard and soft palate. the vomer and premaxilla are not attached to either side, but are suspended from above (associated with bi-lateral cleft lip). it is noteworthy that the width of the cleft is greater, and the shortening and deficiency of the lateral elements are usually more marked in types i and ii than in complete clefts involving the alveolus. effects of the deformity the cleft palate child for obvious reasons is a person who finds social and mental adjustment most difficult. the facial disfigurement is unpleasant and attracts the attention of all. adults react with obvious pity, especially the parents, who, in an effort to compensate for the deformity, may allow the child to become selfish. this adds to the difficulties of the child when associating with playmates. children are apt to remark publicly in order to embarrass or ridicule those less favoured than themselves. the nasal speech is imitated by taunting playmates, with the result that the child, in order to disguise his conspicuous nasal tone, may adopt compensatory tongue and lip movements which result in incorrect speech habits. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society september he dreads ridicule, is sensitive to the extreme and often adopts an attitude of open rebellion. he is unhappy, uncomfortable and at a serious disadvantage in this competitive world. a cleft extending through the alveolus frequently results in one or more missing or abnormal teeth and a cleft through the palate invariably affects the pattern of eruption and correct positioning of teeth. in the event of a tooth bud being split, two abnormally small teeth or supernumeraries are formed. the hygiene of the nose and throat is impaired by a cleft in the hard or soft palate thus acting as a predisposing cause to a variety of inflammatory lesions which are readily communicated to the middle ear via the eustachian tube. all inflammatory lesions of the upper respiratory tract should thus be promptly treated as negligence can cause a loss of hearing. surgical treatment the cleft lip can only be effectively treated by means of surgical repair, but the cleft of the palate may either be treated by means of surgical procedures and/or by means of a prosthetic appliance. the former has, in latter years, become the method of choice due to vastly improved surgical techniques and the great advances in anaesthesia, both of which have contributed to the low mortality rate and improved end result. surgical treatment has, however, not supplanted the use of all prosthetic appliances. the earlier routine practice of indiscriminate placing of surgical wires through the cleft segments, thereby forcing or holding the jaw together, has fallen into complete disfavour. the effects of cicatrix contraction is also well recognised, so much so that at one period surgeons were moved to postpone closure of the hard palate until school age. this postponement was based on the assumption that any operations on the hard palate would retard the normal growth process of the maxilla. investigations by means of cephalometric roentgenograms have shown that people with cleft palates exhibit the same stability of skeletal pattern as individuals with no such deformity. the jaw relationships remain the same as do their rates of growth. investigations have shown that there are cases in which the hard palate has been operated on at an early age without any deleterious effect to the ultimate growth of the jaws, but this area involves one of the principle growth centres of the face and interference with the regional blood supply, particularly the posterior palatine vessels, tends to inhibit growth. brodie and slaughter 3 studied the results of 1,349 surgically treated cases and concluded that surgery does inhibit normal growth. they claim that the interference is directly proportional to the amount of injury to growth centres and to the diminution of blood supply to the parts concerned. they strongly suggest that there be no unwarranted trauma to soft tissue and no interference with its blood supply. the object of the modern surgical procedures employed for the treatment of cleft palates is to restore continuity between the two portions of the hard and soft palate and still to preserve a normal palatal and dental arch form with a flexible soft palate of sufficient length to effect velopharyngeal closure. this closure is essential for normal speech. most children with type iii or iv clefts have their initial operations during their first three months of life. in a uni-lateral cleft, type iii, the adjacent parts of the upper lip are brought together in order to establish the integrity of the lips thereby establishing the proper labial forces on the denture. this lip musculature will assist in bringing the displaced anterior segments of the upper jaw together. repair of the bi-lateral cleft lip, type iv, is usually carried out in two stages: the one side is first repaired and at a later date in the first year the opposite side is treated in a similar manner. the soft palate is usually also operated on during this early period. some surgeons prefer to repair the hard and soft palate simultaneously, while others prefer to postpone the operation on the hard palate. the premaxillary segment is kept intact whenever possible. the approach and differences of opinion to this problem are beyond the scope of this paper. prosthetic treatment the earliest problem confronting the prosthodontist may be the construction of a temporary obturator to facilitate feeding prior to the surgical treatment. the patient with a type iii and iv cleft usually has one or more teeth absent in the line of the cleft. rudimentary teeth or those in poor occlusal relationship to the rest of the arch are frequently removed; a prosthetic appliance in these cases carries the necessary dental replacements. this appliance is essential for aesthetic reasons, the production of proper speech sounds and the support of the labial musculature. one of the most important functions of a prosthetic appliance is, however, the substitution for an ununited hard or soft palate by means of a suitable material when surgical treatment is contraindicated. an efficient prosthetic appliance will subserve speech, improve the appearance and assist the patient in obtaining some degree of oral resonance. it is necessary for the prosthetic r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society appliance to cover the extent of the cleft laterally and antero-posteriorly. it should be sufficiently long antero-posteriorly to enable comfortable contact with the pharyngeal muscles during contraction. care is taken to see that these muscles approximate the appliance with sufficient pressure to establish a proper air seal. too forceful a contact on the other hand will cause an irritation of the muscular tissue and also tend to dislodge the appliance. the prothesis should be just wide enough to permit easy and comfortable soft palatal movement without loss of contact of the tissues with the prosthesis during speech activities and deglutition. the prosthesis is vaulted as much as is anatomically desirable in order to provide the oral spaciousness necessary for free tongue movements. reduction of this oral space by an insufficiently vaulted palate will create further unnecessary speech obstacles. after orthodontic treatment a dental prosthesis is frequently used to act as a retaining appliance, particularly in the prevention of a collapse of the buccal segments. a prosthetic appliance should be comfortable, of light weight, tissue tolerant, smoothly finished to facilitate cleaning, and above all, correctly planned. since alterations become necessary during growth, it is desirable that the appliance be easily modified by extensions or reductions to it. acrylic westdene products (pty.) ltd. specialists in medical literature recommend— speech problems of children edited by wendell johnson, ; price 38/3 this book offers authoritative information on speech disorders; it points the way to a full, normal and well-adjusted life for uncounted thousands of children. the chapters express the viewpoints and reflect the praotical experience of the authors and of 20 other experts. order your copy now! johannesburg: 23 essanby house, 175 jeppe street. cape town: 408 grand parade centre, castle street. durban: 66/67 national mutual building, smith street. pretoria: 210 medical centre, pretorius st. resins satisfy most of these requirements and is consequently the material of popular choice. orthodontic treatment the orthodontist often only sees the cleft palate patient after the lips, soft palate and frequently hard palate have been repaired. surgery to the lip re-establishes the bucco-labial muscular band which exerts a constricting effect on the two maxillary segments. pre-surgically the segments of the maxilla are often widely separated. after surgical treatment of a type iii cleft the patient presents an arch form of a fairly typical nature. there is an approximation of the alveolar segments anteriorly, the smaller segment usually being over-rotated to become contained within the premaxillary alveolar section of the larger segment. there is some concomitant narrowing of the posterior portion of the palate. the effect on the maxillary alveolar process is such that it is now lingually positioned in relation to the mandibular arch, particularly in the anterior region. the deficiency of the upper jaw frequently gives the patient an appearance of having a lower jaw prognathism. laminagraphy4 has shown that the moulding action of a repaired lip and palate is not necessarily confined only to the alveolar bone; the arrangement of the tral>eculae of the whole maxilla is affected. in many cases an approximation is established between the turbinate and the nasal septum. this has been postulated as a possible explanation for the distorted nasal speech sounds described as hyponasality superimposed on the hypernasal quality. this construction of the maxilla may also be present before any surgical intervention of the palate. the prime objective in orthodontic therapy in these cases is the establishment of correct arch form and occlusion and thus the improvement of appearance, mastication, deglutition and speech. to achieve this the orthodontist has to expand the maxillary arch in such a way that the maxillary teeth will articulate correctly with the mandibular teeth. the effect of an expansive force ιο the cleft palate differs radically from the effects in noncleft cases. ordinarily, expansion in the non-cleft involves the movement of individual teeth through bone, but the same expansive forces, when applied to the cleft palate does not move the teeth through bone per se, but actually moves the two segments of the maxilla apart. tooth movement is minimal, the entire maxillary bone housing the teeth becomes repositioned. for this reason the type of expansion in cleft palate cases frequently improves nasal ventilation in that the turbinates are moved away from the nasal septum, particularly in the anterior region. the expansive phase can be completed r p n i f l l v i n 9. tri λ mnntli<: r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society september in the type iv clefts of the lip and palate, the buccal segments are usually collapsed and the premaxillary segment is located well ahead of the maxillary arch. it is suspended from the cartilagenous nasal septum which scott v claims to be one of the cardinal growth centres for the face. this anterior segment consists of teeth and alveolar bone; no muscular tissue is attached. the size of the segment varies, the larger the segment the more teeth it accommodates.. surgical repair of the lip envelops this protruding maxillary mass retarding its forward growth and this helps to establish a more normal relationship with the two buccal segments of the maxilla after they have been expanded. the teeth in the anterior segment are usually severely lingually inclined and malformed and may have to be extracted. further orthodontic treatment is usually necessary at about 12 years of age when most of the permanent teeth have erupted, to align the teeth and establish an occlusion. a prosthetic appliance with the necessary tooth replacements is frequently used as an orthodontic retaining device. early treatment is almost always indicated because the deformity is less in younger patients and results are obtained more rapidly. if the maxillary teeth are aligned and repositioned, the mandibular arch tends to accommodate itself to the upper before severe mandibular deviations are allowed to become established. unfolding the maxillary arch at an early age allows for the normal function and development of the jaws, prevents the perverted forces of crossbites to distort the growth pattern and aggravate the condition. the psychological advantages must naturally not be overlooked. it may be correct to assume that early correction will assist with the normal development of the functions of speech. if the deformity is slight it may be advisable to postpone treatment until the eruption of the permanent teeth. apart from cleft-lip-palate problems, cases are frequently complicated by antero posterior skeletal dysplasias. these are readily diagnosed by means of cephalometric roentgenology and will require additional treatment for these malocclusions. problems of the speech therapist the first problem a child with a cleft palate encounters is that of feeding. with co-operation and advice this is not an unsurmountable problem. the second is one of making himself understood through the use of speech. this is more complex in that the ability of being able to express one's thoughts in a language takes time, and involves the ultimate in neuro-muscular control of the speech mechanism. speech is usually not established until the end of the second year of life, but the actual sounds used in speech are acquired very much earlier. speech is at first confined to vowel sounds, but at about the 10th week the lips and tongue begin to play their part and consonant sounds make their appearance. the change from vowel sounds to the use of sounds which more nearly resemble language is a gradual and complicated process involving observation, initiation, imitation, repetition, association of ideas and images, ability to understand and the precise control of the speech apparatus. the development of speech in the cleft palate child is for a time similar to the normal, but since the oral and nasal cavities remain undivided, there is a distinct nasality in all sounds. a form of speech which has a marked deviation from the normal begins to develop. the child is becoming accustomed to the sound he hears himself producing. unfortunately these abnormal auditory images are associated with the normal speech sounds he hears and is attempting to imitate. the child is invariably not conscious of the fact that his speech is any different from that of his associates. some time later he begins to realise that it is only with difficulty that he is able to make himself understood. frequently it is when his playmates ridicule his attempts at speech that he begins to appreciate that he is different from others. faulty speech habits are being developed and these habits are difficult to eliminate in later years. the production of normal speech in the cleft palate patient is the ultimate objective of the speech therapist. the ability of the therapist to attain this goal depends largely on the success of the earlier treatment. the degree of nasality is usually proportionate to the efficiency of the palatopharyngeal sphincter, nasality being absent in the highly successful surgical cases having a completely functional soft palate. in cases where an anatomical deficiency remains and normal physiological function is impossible, the speech therapist is obliged to make the best possible use of the existing musculature by means of exercise. perseverance and co-operation of the patient are of major importance in the establishment of modified speech habits. obturators are fitted to patients where surgery is either contraindicated or where secondary operations are deemed inadvisable. this will assist in the separation of the oral and nasal cavities. where neither of the above alternatives are possible, the only course a therapist can adopt is to train the patient to direct his voice and breath in a manner that the maximum amount possible passes through the mouth and minimum through the nose. the intelligence quotient of a patient likewise plays an important role in effecting a good result; the more intelligent the child, the greater the liker ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society lihood of the therapist achieving a result. if intelligence is decidedly below normal there is every likelihood that the child's speech will remain defective despite the ability of the patient to correctly articulate individual sounds and also to seal the nasal cavity from the pharynx thereby preventing any nasal escape. where operative procedures have not been entirely successful, the prognosis in the mentally retarded is poor; the ability to co-operate and/or concentrate make the elimination of faulty habits particularly difficult, if not impossible. since children with cleft palates are prone to inflammatory lesions of the pharynx, the middle ear is frequently infected. infections of the ear, if neglected, frequently lead to deafness, which in turn hinders speech re-education. in many instances the patient is obliged to make use of a hearing aid. the age at which the cleft palate is repaired is important. in cases operated on between one and two years of age, before the production of consonant sounds are learnt, provided the result of surgery is successful, normal speech may be attained without the aid of special training. the bad habits acquired before operation may. not have had a chance to obtain a persistent hold. these defects are not lost immediately after the operation, the change and loss of nasality is gradual. the longer the operation is delayed, the more difficult it becomes for the patient to rid himself of his acquired faulty speech habits. with the compliments of clinical emergencies (pty.) ltd. 207 jeppe street. phone 22-0458. conscientious effort on the part of the therapist and patient alike is usually sufficient to overcome most of these difficulties. where an incompetent palato-pharyngeal closure persists, the patient is talight to make the best possible use of the artificial and anatomical structures at his disposal. among other factors that influence the result of speech therapy is the personality of the patient, his or her environment and of course the therapist patient relationship. discussion and conclusion the problems involved in the treatment of a cleft palate individual are obviously vast. only the surgical, prosthetic, orthodontic and speech problems have been mentioned, but the psychologist, otorrhinolaryngologist, dentist, pediatrician and sociologist may also have to play an important part in the treatment of these unfortunate individuals. a cleft palate patient is, therefore, not a dental problem, neither is he a surgical problem, nor is he a speech problem or a psychological problem; he is an individual and a personality and should be regarded as such. the most efficient and satisfactory method of treating every variety of cleft palate is through a group of people adequately prepared by close professional association conducting a truly integrated and co-ordinated care programme. ideally, the patient should be jointly examined by this clinical team and the total care programme fully outlined. full records should be kept and the patients recalled from time to time and the problems jointly re-evaluated. these multi-professional teams are not easily organized, neither are they easily managed. a suitable alternative however, particularly in a region or country where no such clinical team exists, would be the formation of a discussion group, where a single case is examined and the records studied by all. each member should be called upon to present his aspect of the case and thei difficulties he expects to encounter. in this way each member of the group would glean an understanding or appreciation of his colleagues' difficulties and likewise the possibilities of therapy. bibliography 1. veaux, v. d i v i s i o n palatine, p a r i s 1931. masson e t cle. 2. jacobson, alex. e m b r y o l o g i c a l evidence for t h e none x i s t e n c e of t h e p r e m a x i l l a in man. off. j . d . a s s . of s.a., 10, 189, 1955. 3. slaughter, w a y n e , b. and brodie, allan g. facial clefts and t h e i r surgical m a n a g e m e n t in view of recent research. j . of p l a s t i c and reconstructive s u r g e r y , vol. 4, no. 4, j u l y 1949. 4. subtelny, j a c o b d. and brodie, allan g. an a n a l y s i s of orthodontic e x p a n s i o n in uni-lateral cleft lip and cleft palate patients. am. j . orth. vol. 40, sept. 1954, pp. 686. 5. scott, j. h. brit. d . j . 79, 278, 1953. 6. scott, j. h. and brash, j. c. a e t i o l o g y of i r r e g u l a r i t y and malocclusion of t h e teeth, ed. 2, london 1956, d e n t a l board of t h e u n i t e d k i n g d o m . 7. p r u z a n s k y , samuel and l i s , e d w a r d f. cephalometrlc r o e n t g e n o g r a p h y of infants; sedation, i n s t r u m e n t a t i o n and research. a. j o u r n a l orth. vol. 44, march 1959, pp. 159. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction methods ethical considerations results and discussion conclusion acknowledgements references about the author(s) amisha kanji department of speech pathology and audiology, university of the witwatersrand, south africa katijah khoza-shangase department of speech pathology and audiology, university of the witwatersrand, south africa citation kanji, a., & khoza-shangase, k. (2016). feasibility of newborn hearing screening in a public hospital setting in south africa: a pilot study. south african journal of communication disorders, 63(1), a150. http://dx.doi.org/10.4102/sajcd.v63i1.150 original research feasibility of newborn hearing screening in a public hospital setting in south africa: a pilot study amisha kanji, katijah khoza-shangase received: 20 jan. 2016; accepted: 08 may 2016; published: 21 july 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract objectives: the current pilot study aimed to explore the feasibility of newborn hearing screening (nhs) in a hospital setting with clinical significance for the implementation of nhs. context-specific objectives included determining the average time required to screen each neonate or infant; the most suitable time for initial hearing screening in the wards; as well as the ambient noise levels in the wards and at the neonatal follow-up clinic where screening would be conducted. method: a descriptive, longitudinal, repeated measures, within-subjects design was employed. the pilot study comprised 11 participants who underwent hearing screening. data were analysed using descriptive statistics. results: the average time taken to conduct hearing screening using otoacoustic emissions and automated auditory brainstem response was 18.4 minutes, with transient evoked otoacoustic emissions taking the least time. ambient noise levels differed between wards and clinics with the sound level readings ranging between 50 dba and 70 dba. the most suitable screening time was found to be the afternoons, after feeding times. conclusion: findings highlight important considerations when embarking on larger scale nhs studies or when planning a hospital nhs programme. current findings suggest that nhs can be efficiently and effectively conducted in public sector hospitals in south africa, provided that test time is considered in addition to sensitivity and specificity when deciding on a screening protocol; bar recognised personnel challenges. introduction early detection of hearing loss is the initial stage to any early hearing detection and intervention (ehdi) programme and is conducted by means of newborn hearing screening (nhs). the implementation of nhs programmes has evolved over the years, particularly in developed countries, with universal newborn hearing screening (unhs) being the recommended and most widely practiced approach in these contexts. however, nhs programmes in south africa have not been standardised, nor uniformly implemented nationally, with documented differences between the public and private healthcare sectors. these differences in the approach to screening, screening protocols and the overall lack of nhs services in south africa have all been documented in national surveys (meyer & swanepoel, 2011; theunissen & swanepoel, 2008). a variety of objective screening measures may be employed within a nhs programme. these include otoacoustic emissions (oaes), automated auditory brainstem response (aabr) and a combination of oae and aabr (berninger & westling, 2011). whilst oaes are simple, fast and cheaper, they provide limited assessment of the auditory system. oaes are also negatively impacted by vernix, middle ear fluid and ambient noise (choo & meinzen-derr, 2010). in contrast, the aabr provides more information regarding the auditory system and provides better detection of auditory neuropathy in infants. however, the aabr requires more knowledge and expertise to conduct, which limits the number of screening personnel who can utilise it. it is also typically more costly and requires a longer test time to conduct (choo & meinzen-derr, 2010) when compared to oaes. these are all factors that may influence the implementation of a comprehensive screening programme in different contexts – particularly in resource constrained contexts such as south africa. limited studies have documented the test time during screening that has excluded preparation time. the entire screening activity (from start to finish) is what defines the success of a programme and is important when positioning notions of feasibility. the technical focus on the time related to the test procedure is also not aligned with models of clinical feasibility studies and is especially not aligned with the current study context (public healthcare) as is the grander intention of this pilot study. cebulla and shehata-dieler (2012) concluded that conducting aabr screening, using the mb11 beraphone, reduces test time when compared to other portable screening equipment. various ehdi position statements recommend the use of different screening measures for different screening contexts. the joint committee on infant hearing (jcih), for example, recommends the use of oae or aabr for infants admitted to well-infant nurseries and aabr for infants admitted to the neonatal intensive care unit (nicu) (jcih, 2007). the hpcsa (2007) position statement, on the other hand, recommends the use of aabr for infants admitted to the nicu and oae for screening during immunisation visits at primary healthcare clinics within the south african context. review of the literature, however, indicates that the ideal hearing screening measure is yet to be defined (guastini et al., 2010), with various protocols currently being used in different contexts. such diverse recommendations call for further exploration and definition of feasible and context-specific screening protocols. such exploration would have to include deliberating on the entire ehdi process, including follow-up as well as diagnostic or interventional components of ehdi. aspects such as coverage rates, referral rates, recording and tracking systems, as well as follow-up rates, are crucial in such feasibility studies. the feasibility of screening protocols may also include consideration of ambient noise levels within the screening environment, particularly as ambient noise levels may influence oae screening outcomes. presence of undetected and unmonitored high ambient noise levels may result in higher referral rates or false-positive rates (olusanya, 2010), which not only influences the efficiency of the nhs programme but has cost implications for the programme. in addition, it can cause unnecessary emotional distress for parents due to false-positive hearing screening results (poulakis, barker & wake, 2003). there are a number of studies that have explored the feasibility of nhs. some of these studies have focused on coverage rates, referral rates and tracking systems associated with unhs (ng, hui, lam, goh & yeung, 2004; pisacane et al., 2013). other studies have focused on the feasibility in terms of the type of screening protocol employed (kumar et al., 2014; qi et al., 2013). feasibility studies are commonly performed in many clinical areas. these studies usually commence with some small-scale investigation or pilot study to determine the feasibility of conducting a larger scale study. pilot studies also assist in assessing feasibility in terms of the process, resources, management and scientific aspects such as treatment efficacy (thabane et al., 2010). the current pilot study focused on the process involved with screening procedures and logistical aspects as it aimed at exploring the feasibility of nhs in a public hospital setting, thereby assisting in guiding a larger scale study. the south african public healthcare setting faces significant challenges with regard to numerous factors including burden of disease, limited resources, issues of linguistic and cultural diversity influencing the healthcare provision, socio-economic status of the population served etc. all these factors have been documented to play a major role in the provision of public healthcare throughout all levels of care, which includes audiology services. it is within this public health sector context that the current study was located. methods objectives of the pilot study determine the average time required to screen each neonate or infant. determine the most suitable time for the initial hearing screening in the wards. determine the ambient noise levels in the wards and at the neonatal follow-up clinic. the time taken to conduct the hearing screening is critical when screening services are planned in any environment, but more so in an under-resourced environment where personnel:infant ratio is unfavourable and time limitations exist, irrespective of whether the screening personnel consists of a highly skilled audiologist, speech therapist, trained nursing staff or volunteers. within the south african context, the general shortage of healthcare personnel, with a high demand to capacity ratio for audiologists, poses a significant challenge for feasibility of implementing nhs. furthermore, the fact that there are still no promulgated minimum standards of training for professionals other than audiologists to conduct nhs creates further challenges. it is for these reasons that it becomes important to establish normative data around time taken to conduct screening as this evidence allows for approximations of how many newborns or infants can reasonably and accurately be screened within a given time period. the second objective of the study was to ensure that the hearing screening did not disrupt other nursing duties and/or ward rounds. determining the appropriate time for hearing screening could also inform the researcher as to possible times at which caregivers would be present in the wards in order to obtain informed consent. such information is crucial for the sustainability of a nhs programme and for ethical practice. it would allow for efficient information counselling when caregivers are present. by identifying suitable times for screening, it is also possible to describe less suitable times that may impact on reliability, validity and sustainability, which is of particular relevance in the current context where efficiency and expediency are key. the third objective of this particular pilot study was to ensure that the ambient noise levels did not exceed those suggested in literature. measurement of the ambient noise levels in the screening environments also allowed the researcher to make the necessary adaptations to minimise these, which in turn contribute to the reliability and validity of hearing screening results. establishment of noise levels in paediatric wards and clinics has implications for newborn and infant care. it has the potential to guide best practice by limiting noise exposure to newborns and infants through appropriate noise assessment and monitoring programmes (neille, george & khoza-shangase, 2014). research design a descriptive, longitudinal, repeated measures, within-subjects design was employed. this research design was deemed appropriate as it made use of the same hearing screening measures on the same group of participants over time and allowed for all the necessary test–retest, between and within subject comparisons to be made (schiavetti & metz, 2006). participants a total number of 15 babies were discharged or being queried for discharge during the pilot study period. of these 15 babies, 11 caregivers provided consent, three caregivers did not volunteer to participate and one baby was discharged before the initial hearing screening could be conducted. all 11 participants were booked for a follow-up hearing screening on the same day during their neonatal follow-up (6 weeks after discharge) to ensure that there were no false-negative screening results, and for assessing the appropriateness of implementing screening within the neonatal follow-up clinic should the neonate have missed in-ward screening as is often the case within the south african context. neonates admitted to the nicu or high care wards (after birth) and transferred to ‘step down’ wards once medically stable, and for whom consent was obtained from the caregiver were included in the study. neonates or infants who were previously discharged, returned home and were then readmitted to any of the wards were not enrolled in the study at the time of initial, in-hospital hearing screening. procedures hearing screening was conducted using the accuscreen oae/aabr screener. transient evoked otoacoustic emission (teoae) screening was conducted (frequency range: 1.5–4.5 khz). this was followed by distortion product (dp) otoacoustic emission (dpoae) screening that was conducted using the most comprehensive protocol on the machine with a 4/6 frequency pass criterion. aabr screening was conducted at the default level of 35 dbnhl using high forehead, cheek and nape of the neck electrode placements. the average time required to screen each neonate or infant was established by recording the time taken to screen using all three screening measures and included the time taken to ensure appropriate probe fit and acceptable impedance. these times were available when downloading the data from the screening equipment and were recorded by subtracting the starting time from the time of completion. these recordings were then added and divided by the number of screening sessions in the study. the most suitable time for the initial hearing screening in the wards was determined through field observation as well as through informal discussions with relevant personnel in the respective wards. the researcher engaged in collaborative discussions with consultant paediatricians and head nursing staff in the wards to establish the most suitable time for the initial hearing screening. ambient noise levels in the wards and the neonatal follow-up clinic were measured using a low-cost quest sound level meter, which is affordable, readily accessible, easy to use and has applications that include community and audiometric measurement or analysis. the sound level meter was placed at the caregiver’s bedside and the maximum noise level was measured and recorded for each screening session. the initial hearing screening was conducted over a period of a week. following completion of the initial hearing screening, results were explained to caregivers, and follow-up appointments were provided. follow-up hearing screening was conducted approximately four to 6 weeks after the first phase in the morning, on days that coincided with neonatal follow-up clinic at the respective hospitals. data analysis data were captured onto an excel spreadsheet and were analysed using descriptive statistics. measures of central tendency such as the mean were used to summarise data. data were also summarised using tabulated descriptions (schiavetti & metz, 2006). ethical considerations ethical clearance was obtained from the university medical ethics committee (m1211103) and permission was also obtained from relevant authorities at the research sites where the study was conducted. informed consent was obtained from caregivers, and anonymity was ensured by assigning numbers to the completed data collection sheets. the home languages of the caregivers of participants were not recorded; however, all caregivers were able to speak and understand english and therefore did not require the use of an interpreter. results and discussion from the initial hearing screening, six participants presented with an overall bilateral refer result for dpoae, four presented with a bilateral refer for aabr, and seven participants presented with an overall bilateral refer result for teoae. three participants presented with a bilateral pass result for dpoae, one participant presented with a bilateral pass result for teoae and a bilateral pass result for aabr was present in two participants. a unilateral pass result for dpoae was present in two participants, with three participants presenting with a unilateral pass result for teoae and aabr (table 1). aabr could not be completed on two participants as they were restless and difficult to calm (figure 1). the high referral rate on one or more of the screening measures is consistent with literature that has also indicated a higher referral rate at the initial hearing screening in comparison with the repeat hearing screening (chen et al., 2012; colella-santos, hein, de souza, do amaral & casali, 2014). referral rates have also been documented to decrease with an increase in age (khoza-shangase & harbinson, 2015; van dyk, swanepoel & hall, 2015). figure 1: outcomes of hearing screening protocol employed during data collection. table 1: initial hearing screening result for each measure per participant. of the 11 participants, six attended neonatal follow-up clinic with five participants having undergone a second hearing screening. the caregiver of the one participant had left the clinic following consultation with the paediatrician. two of the five participants presented with pass results on all screening measures and were subsequently booked for behavioural audiometry at 6 months corrected age. both participants attended the 6-month follow-up and presented with visual reinforcement audiometry results that were within normal limits. one participant underwent a third hearing screening due to incomplete results at the follow-up screening. pass results were obtained for all screening measures, but there was no attendance at the 6-month follow-up. two participants obtained bilateral refer results on both dpoae and aabr measures and were subsequently booked for a diagnostic abr. however, both participants did not attend this follow-up appointment. these findings highlight the poor follow-up return rate in nhs programmes, which has been a widely reported challenge in both developing and developed contexts. the poor follow-up return rate in the current pilot study is consistent with findings from a community-based screening programme in nigeria where more than half of the participants did not return for the second screening even though services were offered free of charge (olusanya & akinyemi, 2009). these findings highlight the need to explore contextual factors (other than cost) that influence follow-up return rate, such as the influence of socio-economic status, cultural and linguistic factors within the south african context. description of participants in pilot study the pilot study comprised 11 participants. two of the caregivers of participants were zimbabwean, and the remaining nine were south african. with regard to ethnicity, all 11 participants were black african, with nine of the 11 participants being female and two being male. the ethnic profile of participants is reflective of the national estimates of the general south african population as well as the differences in access to, and use of public versus private healthcare facilities. black africans constitute approximately 80% of the total population in south africa and predominantly make use of public sector health services (statistics south africa, 2013a, 2013b, 2014). the average gestational age was 30 weeks, with six participants being classified as very low birth weight, one as low birth weight and two as extremely low birth weight. one participant had a normal birth weight of 2880 g, and for another participant the birth weight was not recorded in the file (table 2). table 2: description of participants. none of the participants had been admitted to the nicu, but all had a prolonged hospital stay. the mean stay in high care was 7 days, with a longer stay in the kangaroo mother care (kmc) ward for an average of 14 days. three of the 11 participants underwent phototherapy due to neonatal jaundice. with regard to retroviral disease (rvd) exposure, two participants were rvd exposed, seven were unexposed and the rvd status of two participants was unknown. medication considered to be ototoxic was administered to eight of the 11 participants during their hospital stay. these ototoxic drugs consisted of gentamycin, amikacin and vancomycin, with gentamycin having been the most frequently administered drug in seven of the participants. time required per screening measure for each neonate the average time to complete teoae screening was one minute per ear. dpoae screening time was slightly longer with the average time of two minutes per ear, and aabr screening time was similar to dpoae with an average time of two minutes per ear (one minute, 55 seconds). the average time taken to complete the hearing screening with all three measures was 18.4 minutes as this included obtaining good probe fit and ensuring that participants were calm when conducting each screening measure (table 3). table 3: time taken to complete each of the screening measures at the initial screening in minutes and seconds. the researcher observed three factors that influenced the time taken to complete each of the screening measures. the first factor was the state of the newborn or infant, the second factor was the signal-to-noise ratio for oae screening and the third factor was the eeg for the aabr. preferably, the newborn or infant should be resting quietly in a bassinette or crib, and if needed may be held (asha, 2015). the best results were obtained for babies who were awake but calm, or for sleeping newborns or infants with a good signal-to-noise ratio on oae screening and a good eeg, as these factors resulted in a shorter test time. with regard to oaes, particularly dpoaes, the larger the dp to noise ratio, the quicker the criteria for the dp are met, which in turn results in a shorter test time (hall, 2000) and a good eeg as an influencing factor is consistent with reports that the newborn’s state of consciousness influences the time to complete the assessment (sena-yoshinaga, almeida, côrtes-andrade & lewis, 2014). these findings have important implications for screening programmes as they indicate both the time requirements as well as possible influencing factors, which, if managed, would lead to the success of a screening programme, especially in an under-resourced environment. current findings are consistent with those reported in a number of studies that have reported aabr test time to be longer than when assessing using oaes. this has been based on the premise that additional time is required for electrode placement (berg, prieve, serpanos & wheaton, 2011; meier, narabyashi, probst & schmuziger, 2004; norton et al., 2000). however, longer test time for aabr has also been noted in the study by van dyk and colleagues that employed teoae and the mb11 beraphone, which does not require placement of disposable electrodes (van dyk et al., 2015). contrary findings have been reported in the study by sena-yoshinago and colleagues who reported an aabr screening time close to that of teoae, with a mean assessment time of 32.9 seconds (sena-yoshinaga et al. 2014). these authors further concluded a shorter test time for newborns that were in stage 1 of consciousness (deep sleep, no movement, regular breathing). most suitable days and times for screening from the discussions with nursing staff, it appears as if the afternoons were better suited for initial hearing screening, as ward rounds were usually completed. it was easier to identify babies who were going to be discharged or being queried for discharge during this time. the noise levels were significantly less because student training in academic hospitals usually occurs on ward rounds during the morning. the most suitable time for screening appeared to be between feeding times when babies were generally comfortable, satisfied and sleeping. these are ideal conditions for hearing screening where objective measures are utilised and sleeping is the preferred neonatal state of arousal. babies were reportedly weighed on tuesday and friday mornings at the one hospital, unless they weighed < 1500 g, in which case they got weighed daily. based on the initial aims of the pilot study, these were therefore identified as the most suitable days for hearing screening at this research site. to prevent babies from being omitted from screening on days that the researcher was not in the hospital, it seemed best to screen babies on the days they got weighed (e.g. tuesdays and fridays in this case). babies at the second hospital were weighed everyday but mondays and thursdays were recommended days by paediatricians for the initial hearing screening from 11:00 onward following completion of ward rounds. these recommended differences amongst hospitals highlight the need for audiologists to explore the site-specific, routine care offered at the respective hospitals prior to the implementation of nhs. caregivers were usually present at all times in two of the wards at the first hospital and were always present in the kmc ward at the second hospital. difficulties were sometimes experienced in the high care wards at both hospitals due to a lack of accommodation for mothers in these wards. some of these mothers had to be admitted to another ward for medical care whilst their babies were cared for by nursing staff in these wards. ambient noise levels ambient noise levels should also be taken into consideration when deciding on the most appropriate time to conduct hearing screening, especially in the wards within a hospital-based context. the noise levels not only have an effect on the screening time, but also on the sensitivity and specificity of the objective screening measures employed within an nhs programme (salina, abdullah, mukari & azmi, 2010). although khoza-shangase and harbinson (2015) have suggested that in order for oae measures to be reliable, ambient noise levels should not exceed 50 dba to 55 dba of noise; current sound level readings ranged between 50 dba and 70 dba in the kmc wards (table 4), and screening in the current sample was deemed possible. table 4: sound level recordings within the screening environments at the first hospital. the average sound level was 59.6 dba, making screening in these wards possible. some authors have reported that accurate oae screening results are obtained when sound levels do not exceed 65 dba – 68 dba (olusanya, 2010; salina et al., 2010). screening was not conducted in the high care ward as there were only two babies during the pilot study that were being discharged. the one caregiver left the hospital prior to having her baby’s hearing screened, and the second baby was transferred to a different ward where the screening was then done. however, this baby was full term with a normal birth weight, and the caregiver was being referred to a nearby clinic for follow-up after discharge. sound level readings ranged between 48 dba and 60 dba in the kmc ward at the second hospital. the high care ward at this hospital was not a suitable environment for hearing screening due to multiple cribs per cubicle, noise generated by alarms on incubators and a high volume of medical and nursing staff conducting routine care and training of medical students during the course of the day. similar noise sources have been reported in a study conducted at private and public sector hospitals in south africa (neille et al., 2014). it was therefore decided that babies in cribs would be tested in the last empty cubicle used for storage in the high care ward or an empty cubicle in the kmc ward, where ambient noise levels could be controlled. the average sound level in the screening environment at the neonatal follow-up clinic at the first hospital was 57.25 dba. these sound levels were lower at the second hospital and ranged between 40 dba and 50 dba as the follow-up hearing screening was conducted in the audiology department due to a lack of available consulting rooms in the clinic. the audiology department was a short distance away from the clinic, which allowed for fairly easy access to the participants. limitations it is acknowledged that the data used to describe the context are site-specific and need to be explored on a larger scale for similar contexts. it is further acknowledged that the limited sample size in the current pilot study prevented the generalisation of findings. these findings need to be considered when planning for larger scale nhs studies or when planning a hospital-based nhs programme. larger scale studies on the implementation of a nhs programmes are necessary in the south african context. conclusion findings suggest that nhs can be conducted in public sector hospitals in south africa, provided that test time is considered in addition to sensitivity and specificity when deciding on the screening protocol to be adopted. these factors have even more relevance within the south african context where limited resources are an important consideration. furthermore, high sensitivity and specificity of the adopted screening protocol can possibly facilitate use of non-audiologists in screening programmes where minimum standards of training screeners have been adhered to. implementation of an nhs programme over a 12-month period, with consideration of test time, ambient noise levels, test sensitivity and specificity, may provide more information regarding the feasibility in a hospital setting. it is recommended that the impact of ambient noise levels on the time taken to complete screening as well as the screening outcomes be further explored in future studies. current findings seem to indicate ambient noise levels at the edge of the desired maximum limits within the screening contexts; therefore, careful monitoring of noise levels as part of any screening protocol is highlighted as important. careful attention to these factors would improve the efficacy of neonatal screening programmes within the high demand to capacity ratio south african audiologists function under. acknowledgements this work is based on the research supported in part by the national research foundation of south africa (unique grant no: 92673). competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions a.k. was responsible for conceptualisation, data collection, analysis and write-up of the paper. k.k-s. made conceptual contributions, supervised the pilot project and was involved in the write-up of the paper. references asha. 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(2010). a tutorial on pilot studies: the what, why and how. bmc medical research methodology, 10, 1–10. http://dx.doi.org/10.1186/1471-2288-10-1 theunissen, m., & swanepoel, d. (2008). early hearing detection and intervention services in the public health care sector in south africa. international journal of audiology, 47, s23–s29. http://dx.doi.org/10.1080/14992020802294032 van dyk, m., swanepoel, d., & hall, j.w. (2015). outcomes with oae and aabr screening in the first 48h-implications for newborn hearing screening in developing countries. international journal of pediatric otorhinolaryngology, 79(7), 1034–1040. http://dx.doi.org/10.1016/j.ijporl.2015.04.021 o u r n a l o f s o u t h a f r i c a n l o g o p e d i c s o c i e t y understanding the hard of hearing child by a. l. behr, d.ed., ph.d. the great american philosopher william james once said: "all life comes back to our speech—the medium through which we communicate." experience and research alike demonstrate that human feelings have their sources in language (1). it is largely through language that the feelings of one person towards another are created. provocative language of the mildest sort influences profoundly personal and social relationships. an investigation with some eighty children proved that those who were mildly though repeatedly prohibited and scolded, developed a measure of hostility to the experimenter. they were unwilling to do him a personal favour, or to repeat a simple task, or to stay for play with interesting toys. on the other hand, those who were spoken to kindly and encouragingly reacted quite differently. they showed a greater willingness to do the experimenter a favour, to repeat a task and to stay when invited to play with new toys (2). it must, therefore, be clearly realized that in a language situation, the words connote more than their conventional meaning. words have a personal meaning as well, and it is the latter that has the determining value. for example, listen when someone says: "no!" is the word convincing? does it mean "no" to the person speaking or to the person listening? is it deceptive and does it really mean "perhaps"? the answer lies in the relationship felt between the speaker and the hearer (3). the meanings which children give to words spoken by their' parents and teachers are not always the accepted customary meanings, but are modified and altered in a special 'way by the personal feelings which arise through the use of those words. the author s experience with normal hearing children leads him to believe that these children always attach an implicit meaning to words and spoken language in general, as distinct from the conventional adult meaning, and that it is very often difficult for the adult to realize that what he means by a word, phrase or sentence, and what the child means, is not the same. if adults are not always certain what the hearing child means by a word, how much more difficult does it not become with hard-of-hearing children? many teachers concerned with hard-ofhearing children, in their anxiety to teach these children conventional language, often lose sight of the child as an individual. the child is forgotten, but the language development is regarded as paramount. the author's plea is that an understanding of the child as an individual must come first. everything else is subservient to this. if the child is understood, his language will be understood, for his language is merely a vehicle for formulating his needs, his experience, his intentions, and his thoughts. being hard-of-hearing does not have the same meaning in every child, as the degree and the type of impairment of hearing vary. one type of impairment may limit the distance at which the child can hear conversation to 2 or 3 feet. moreover, if such a child can do lipreading, he may give the impression that he can hear at a considerably greater distance. another type of hearing impairment causes the child to hear some sounds well and others in distorted form. on the whole, the hard-of-hearing child, unlike the profoundly deaf child, has been seriously neglected both medically and socially (4). this may be due to the fact that the handicap is not readily discovered. sometimes five or six years elapse before the hearing impairment becomes known (5). the behaviour and social responses of the hard-of-hearing child have been misunderstood by his parents, his teachers and his playmates. too often he has been considered stupid in school, has failed repeatedly in his class work, has been accused of paying no attention and showing no interest in his lessons. at home he has been scolded for not attending when spoken to, for disobedience, for failure to carry out instructions that he did not hear. he has been left out of games by his playmates, laughed at for making irrelevant replies to the questions they have put and, unable to understand the reason for their derision, he has become a lonely, dissatisfied, often unhappy and emotionally disturbed person. unable to make a proper adjustment with his playmates, he becomes unusually retiring and dependent upon his parents. thus, impairment of hearing in a child may start a series of disturbances which can seriously affect his ability to develop normally. while attention may be directed to him ber ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) o u r n a l o f s o u t h a f r i c a n l o g o p e d i c s o c i e t y a r l cause of his hearing difficulty, consideration must first be given to him as >an individual, growing physically, mentally, emotionally and socially. the early detection of hearing loss is extremely important. numerous cases of children brought to the hearing clinics for aural rehabilitation need not have reached that point in hearing impairment had adequate measures been taken early on. in one of the states of the u.s.a. a hearing conservation programme was initiated. all children on entering school in that state were subjected to a medical examination and those found to suffer from chronic diseases of the ears and upper respiratory tract were given prompt treatment. this treatment saved these children from possible permanent hearing impairment. in order to detect the hard-of-hearing child as soon as possible and to prevent possible hearing impairment in children with diseases of the' ear or respiratory tract, the author makes a plea for the appointment of audiometrists, who would make the rounds of the schools and examine all children who enter school for the first time. children in need of treatment would then be referred to an otologist. a recent study conducted at columbia university on 38 hard-of-hearing children between the ages of 13 and 18 years, disclosed that the adjustment to wearing a hearing aid was a rather difficult process both from the technical and the emotional point of view (7). young children make the easiest adjustment to their handicap, particularly children in the age group 3 to 6 years, and this is one important reason for early case finding. yet, even when a successful adjustment is made in childhood, as this study shows, the period of adolescence with its numerous problems, may be particularly difficult and results in a refusal to wear the aid. the child's motivation may be personal or the result of the attitude of his parents and his friends or all of these. personal and emotional factors may thus emerge leading to conflicts which may interfere with the acceptance of treatment. once the hard-of-hearing child has been discovered he is subjected to an intensive programme of speech audiometry, auditory training, lipreading, language comprehension and the like. but, often, in our enthusiasm to help him overcome the handicap, we forget the child as an individual. bringing speech and language to the hardof-hearing child is not enough. . we should concern ourselves with the whole child, with the child as a unique and distinct personality. educating the hard-of-hearing child involves more than an intellectual process. it involves, too, his emotional and social adjustment. since the child's speech and language mirrors his personality, an understanding of his personality will make us understand what is implicit in the language he uses. 1. dollard, j. and others.—"frustration and aggression." (yale university press, 1930.) 2. johnson, μ. w.—"language and children's behaviour." the elementary school journal, university of chicago, november • 1955. p. 141-145. 3. johnson, m. w.—"verbal influences on children's behaviour. (ann arbor, michigan university press, 1945.) 4. sutherland, d. a. and miller, m.—"rehabilitating the hard-of-hearing." (the child, october 1944 u.s. government printing office, washington 25, d.c.) 5. ibid. 6. lesser, a. j.—"some principles in the development of services for children with hearing im pairment." (the journal of speech and hearing disorders : federal society agency, u.s.a., june. 1950, 15, 101-105). 7. gates, a. t. and kushner, r.e.—"learning to use hearing aids : a study of factors influencing ths decision of children to wear hearing aids.' (teachers' college, columbia university, new york, 1946.) η boek vir u! d r a m a en spreekkuns in die skool juin du toit prys 18/posvry. vanwee die steeds toenemende belangstelling in spraakleer en voordragkuns, in toneelspel en dramatisering, in skoolkonserte en kunswedstryde, het die behoefte aan deskundige leiding op hierdie gebied al hoe ernstiger geword. hierdie werk van juin du toit, lektrise in drama aan die toneelskool op worcester, voorsien aan 'n groot behoefte. dit behels die beginsels in verband met voordragkuns, toneelspel, dramatisering, mimiek, spreekkoorwerk, spreekkuns, liggaamshouding, debatte en openbare redevoering en verstrek ook 'n uiigebreide reeks voorbeelde en oefeninge wat nuttig deur die onderwyser aangewend kan word. hierdie is een van die beste (indien nie die beste nie) handleidings vir skole op hierdie gebied, oorsese publikasies ingesluit. skryfster het hiermee pionierswerk verrig, waarvoor die onderwysprofessie haar dankbaar sal wees. daarby is die werkie van 'n netjiese en duursame band voorsien. bestel by: afrikaanse pers-boekhandel joubertstraat 76, johannesburg r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) page ten journal of the south african logopedic society sound games for dyslalias the practical application of van riper's theoretical chart. by joan streit, b.a. log. van riper1 advocates a nine step programme in the correction of defective articulatory sounds. the nine stages are as follows: 1. cannot make the sound nor discriminate it from its error even when word pairs are pronounced by another individual. 2. cannot make the sound but can hear the error in another's speech. 3. can make the sound in isolation but only after strong stimulation by teacher. 4. can make the sound in isolation without requiring stimulation. 5. can use the sound in nonsence syllables in all positions. 6. can use the sound in isolated words when careful. 7. can use the sound in careful speaking of prepared sentences. 8 can use the sound habitually in swift unemotional speech. 9. can use the sound habitually,., in swift emotional speech. . ... using this outline as a basis, an attempt has been made to construct games which can be used for motivation and stimulation in the implimentation of these steps·. the speech teacher in a public school situation finds herself confronted with the problem of handling a number of dyslalic children simultaneously so that therapy takes place primarily in a group situation. since the time is not available to establish rapport with each individual child, the speech therapist must construct an atmosphere wherein this can be established through play and pleasant speaking situations. keeping in mind the scientific approach as advocated by van riper, the following games have been devised for each individual stage, in order that they may provide (a) play and pleasant speaking situations. (b) an adequate group situation. stage 1. leave out — only for testing purposes. stage 2. (a) the card game. this was originally bought as a game called "speed' which includes picture cards of aeroplanes, trains, ships and cars. to each vehicle is then assigned a sound e.g. for a thetacism group the sounds are: aeroplane-th, ship-f, train-d, and carvoiced-th (f and d are used as they are most commonly substituted for th); for a sigmatism group the sounds are: aeroplane-th, ship-f, train-s, and car-z; and finally for a rhotacism group they are: aeroplane-r, ship-g, (afrikaans), train-1, and car-w. in this game, the pictures of all the 'planes, ships, trains and cars are placed in a pack. for this stage, the teacher holds the pack and raises the top card. should this be a ship, she says "f" and the first child to recognise that this is the ship sound and says "ship" is rewarded with the card — and so on through the pack. the child with the most cards at the end is the winner of t i e game. in this way the children are learning to discriminate the correct and wrong sounds. (b) finding the sound. an article is hidden by the therapist. when the child is near the hiding place, she says "th, r, or s" and she says "f, w, or th" when far from the object. (c) the hidden window game. the therapist hides behind a picture of a window so that her mouth is obscured. the children in front of the window attempt to pick out the correct sound from the sound series which, she makes. if they make an error, they can open the window to make sure. it should be noted that the correct sound is presented in sequences of similar and different sounds. a charm is rewarded to the first child to notice the correct sound. the child with the most charms at the end of the game is the winner. stage 3. (a) the train game. this game consists of railway tracks drawn in the shape of a figure 8 with different coloured stations at different points and a cardboard train. each child then chooses his station and each has a turn at pushing the train to the accompaniment of the therapist saying the sound to be learned, stopping at each station to refuel with water or coal. this is devised to teach the sound in isolation. (b) hiding the cards. the cards (with the sounds already given them in game (a) of stage 1), are hidden away by the therapist and when each is found, the child says the appropriate sound to the teacher in order to win the card. stage 4. (a) the card game — same as game in stage 2 (a) but this time the children join in. each child has a, turn in picking up the top card but being careful to say only the appropriate sound, and the rest guess'which picture was chosen. if the wrong sound is given e.g. f for th, they forfeit by replacing that card into the pack plus one of those which they have already won. (b) the train game — the game is the same as stage 3 (a) but is now continued with the .children advanced to saying the sound themselves. stage 5. (a) the ladder game. the material consists of paired objects all of which entails an object climbing r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society page een a ladder in order to reach a goal e.g. a little charm of humpety-dumpety climbs the ladder to get to the top of the wall, a charm of sailor sam climbs a ladder to get into a ship. each step of the ladder is a vowel sound and the charm represents a consonant, thus making a nonsense syllable. when the charm lands on a step he blends witn it e.g. humpty-dumpty equals s he blends on each step and becomes — soo, ahsah, etc. (b) the ping-pong game. for this game the pingpong table is drawn with people at each end. the ball is a counter. the object of this game for two to play and win a point for each correct saying of the nonsence syllable which the therapist says first. if said incorrectly, the opponent gains an extra point. the greatest number of points determines the winner. these games provide the amount of stimulation required to keep a child's interest while attempting to form the new habit through nonsence syllable exercises. stage 6. (a) secrets. to establish the new sound in words, this game is played by drawing on separate slips of paper, pictures of words containing the sound in all positions e.g. for the th sound — three, thumb, thief, path, birthday-cake, etc. each person takes one, the remainder being left in the box. the object of this game is for each person to ask the one on his left "have you got three, thumb, thief, etc.?" and so on through the list until each picture is discovered. one may not ask more than one object in one turn. (b) climbing the house. this is based on the game of "snakes and ladders". a large house is drawn with ladders leading to and from two windows on the top floor. in conjunction with this game the book "speech through pictures"2 is used. each child has a turn at throwing a dice and should they throw, for example, a five, that person has to say correctly what each of the five 'th, r or s" pictures to which the therapist points. if one picture is said incorrectly, then the person can only move four steps instead of the five which he threw. i (c) the thinking game. this game is also played / with the book "speech through pictures".2 the book is opened at the page containing the sound to be learned. one childj thinks of a specific picture on the page and the others, question him until they guess the right one. the person who guesses correctly, merits the next turn. questioning consists of "are you thinking about?" — thumb, thief, etc. the answer has to be "no, i am not thinking about the thimble, thumb, etc?" stage 7. (a) the games of climbing the house and ladders (same as stage 6 (b) and stage 5 (a) are played also for this stage, substituting nonsence syllables and words by sentences from "work and practice" book.3 the ladders are therefore still being used as motivation for exercises. stage 8. (a) nursery rhyme game. for this stage, the therapist uses the rhyme of "this is the house that jack built' with appropriate pictures to illustrate each new character e.g. "this is the flour that lay in the house that jack built". thus using the "th" sound in swift unemotional speech. for sigmetisms pictures of "simple simon" are used. (b) finger plays. another idea at this stage, is to make use of the numerous finger plays learnt from nursery schools such as "cherry stone", "incy-wincy spider', "five straight soldiers"4 for sigmatisms, and " 1 humpety, thumpety", "fee, fi, fo, fum"5 for thetacisms, etc. the writer feels that finger plays help distract the attention from the speech sound being taught. (c) story game "th, r or s" objects may be placed in front of the children and they can be asked to tell a story about all the objects on the table. (d) "i went to market" and "i spy". other wellknown games are those of "i went to market to buy a thimble, a birthday-cake, etc." or "i spy with my little eye something with a s sound e.g. bracelet, socks, etc." stage 9. (a) dramatisations and conversational situations. this consists of letting uie children act out the nursery mymes, tinger plays and stories from nemoy-davis6 and thus letting ihem use the sound in swift emotional speech. (b) they should also be allowed to speak freely of the events of the day, etc. by the time stage 6 has been completed, it is often still necessary to allow the child to discriminate by saying contrasting sounds. the following game is used in this procedure. the contrast game. pictures of words beginning with conflicting sounds e.g. f and th in the case of 1 hetacisms; or tli and s for sigmatisms are drawn the words can be sick and thick, sink and think, mouse and mouth or fin and thin, free and three, fort and thought, etc. each child has a turn in thinking of one and the rest have to guess what he is thinking about but have to point to the object which they mean so that the therapist can see if they mean the right name for that particular object. this game is played in exactly the same manner as the game in stage 6 (c). the writer has found the above games to have been of some value in relation to the aims as initially set out. they do not and are not planned to cover a complete speech therapy programme but are designed primarily to aid the speech therapist who find's it difficult to equip herself with expensive toys and motivating games. one cannot overlook the importance of parental and teacher co-operation or the value of regular practice but it is hoped that these games will find some small place in the speech therapist's programme. ' v a n r i p e r " s p e e c h c o r r e c t i o n . " p a g e 148 f m c c l a u s i a n d , miller and o k i e . " s p e e c h t h r o u g h p i c t u r e s . " " m c c u l l o u g h . " w o r k and practise b o o k . " ' b o y c e & b a r t l e t t . n u m b e r r h y m e s a n d f i n g e r plavs 5 b a r r o w s & h a l l . j a c k i n t h e b o x . ' n e m o y & d a v i s . c o r r e c t i o n of defective c o n s o n a n t s o u n d s . r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c s o c i e t y the relation between speech therapy and psychotherapy by joan philips, b.a.. m.sc. any therapist dealing with human beings must establish a good relationship with the patient, and must know how to use this relationship skilfully in order to achieve success. to that extent it is true that in a sense every speech therapist must b e her own psychotherapist. the problem i s : how far can and should she consciously attempt to act a s such, and where should the dividing line be drawn? it is important to try and arrive at an answer to this question because in my experience some speech therapists tend to step right outside their province and to deal with psychological aspects of the problem for which they have neither sufficient training nor the kind of relationship with their patient which will enable them to adopt successfully the role of psychotherapist. we can, to begin with, distinguish between two main types of speech defects:— (1) mechanical defects, e.g., those due to organic conditions such a s cleft palate, failure to enunciate clearly, inability to pronounce certain consonants, faulty accent, etc. (2) defects involving, or related to personality difficulties, i.e., symptoms of disturbance within the personality which take the form of speech defects, e.g., stammering or refusal to speak. into this class will also fall certain cases of lisping, lalling and mispronunciation, which may, for example, b e part of a general tendency on the part of the individual to remain infantile. in dealing with the first type of defect the task of the speech therapist is more or less straightforward. primarily, her job is education or rej-education in the technique of good speech. nevertheless, she enters at once into a therapeutic relationship with the patient, and to some extent, if the patient be a child, with his parents. for one thing, the existence of the defect will in all probability already have produced secondary psychological difficulties, e.g., shyness, feeling of inferiority, reluctance to enter new situations. the therapist has to deal—though indirectly—with these aspects of the patient's personality a s well a s with his speech. it is also important that she understand a good deal about his background and past history, b e c a u s e the way in which she teaches will obviously be adapted and modified according to the sort of response she can elicit from her patient. when dealing with a child, it is also clearly important that she should be able to establish good rapport with the parents. to this end the speech therapist must have a good understanding of behaviour and its meaning, and of the technique of handling individuals in need of help. but she should use it a s the good teacher does—not obviously and self-consciously, but a s part of her general approach. she is teaching the patient, not analysing him, and her psychotherapy must at all times b e subordinate to her p e d a g o g y . true, removal of the speech defect will probably have psychological effects on the patient —in many cases there will be growth and change, a better adaptation to life—but these should come a s a result of the speech therapy a s such, not a s a result of attempts on the part of the speech therapist to use a determinedly psychological approach. let us turn now to the second type of defect—that involving or relating to the personality a s a whole. it is here that there is most confusion about the role of the speech therapist, and where, with the best intentions in the world, real harm may be done to the patient by an overenthusiastic speech therapist trying to take over the functions of psychotherapy proper. in the first place, it seems that there is a failure to appreciate that these defects are neurotic symptoms. now a neurotic symptom is a compromise solution of a conflict intolerable to the personality. an unconscious wish or impulse-seeking realisation is opposed by other forces within the personality, such a s conscience, fear of loss of love, fear of social disapproval. by producing a symptom the individual succeeds in keeping the conflict within bounds and giving expression to the warring elements. for instance, among the many factors contributing towards the development of a stammer are on the one hand, the unconscious wish to b e extremely aggressive verbally and on the other, the fear of this aggression and the need to repress it. the stammer represents the compromise. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c s o c i e t y o c t o b e r speech is crippled (i.e., aggression is controlled), but at the same time the listener is irritated (i.e., aggression is expressed). the stammerer is punished by the disability (as demanded by his sense of guilt) but there is also some secondary gain (he draws attention to himself). this oversimplified description of a neurotic symptom should serve to show what a very economical and convenient device it is for the neurotic individual. small wonder, then, that he clings so tightly to his disability. every speech therapist must know from her own experience how deep can b e this reluctance to b e cured, despite the strongest conscious wish to return to normality. it must b e emphasised that while a physical defect may be surgically removed with very little effect on the body a s a whole, a neurotic symptom cannot b e dealt with except in relation to the whole personality. to try and "cure" it by removing it may well mean that you are simply blocking up one channel of discharge for the personality without providing an alternative outlet. here is an example of what i m e a n : a boy of fifteen came to me for treatment for continuous diarrhoea, which had been diagnosed by physicians a s psychogenic. two years previously he had started treatment by speech therapy for a severe stammer. the stammer had disappeared, and he had been discharged a s "cured," but shortly afterwards the speech symptom had been replaced by this new symptom of diarrhoea. now it should have been clear from the history of this boy, a s told by his mother, and from the very first interview with him that he w a s a deeply disturbed individual, and that the mere removal of the symptom of stammering would do little towards relieving his severe psychological problems. in these cases the onus is on the speech therapist to decide whether the speech defect is a comparatively simple, superficial symptom which is likely to respond to speech therapy a s such, illumined with psychological understanding, or whether it is a symptom of really deep psycho: • logical disturbance. if the latter, the patient should b e advised to seek psychological treatment in the first place. after improvement ot his psychological condition it may still be necessary for him to seek treatment for the speech defect. this would be a far safer course to adopt, and probably more profitable, too, b e c a u s e the adjusted individual can absorb instruction far more easily than the maladjusted. it may be argued that, in the light of these considerations, what the speech therapist needs is not less, but more psychology in her dealings with her patients. if more attention were paid to her psychological training and if she were taught more of the theory and technique of psychotherapy, would she not be better equipped to deal with all types of speech difficulties, including those which have deep psychological roots? in order to answer this we must examine more closely what the practice of psychotherapy implies and where it differs from speech therapy. we have seen that, in dealing with a conflict within himself, one of the devices adopted by the individual is to repress—i.e., banish into the unconscious—the undesirable thoughts, wishes and impulses. an unequal conflict then rages -within the personality—unequal, because one of the combatants is hidden, unknown. one of the objects of psychotherapy is to bring the repressed feelings and thoughts back again into consciousness. one way in which this is done is by re-living the original conflict within the therapy, only this time, feelings, wishes and thoughts which were originally directed towards the patient's parents, teachers, siblings, etc., are now directed towards the therapist, who represents now one, now another of these people at different stages of the treatment. when the patient discovers that he can bring out all the forbidden ideas and emotions with totally different results from those which he anticipated and dreaded, a change takes place in his attitude. once he is aware of both sets of conflicting feelings, he can make a conscious choice between them, instead of producing a neurotic symptom. he can accept some of his feelings and critically reject others, instead of having to repress them under pressure of fear, guilt and shame. this is again an oversimplification, but at least it may help to clarify what part the therapist must play in this struggle. he must b e prepared to accept all types of feeling from the patient, both positive and negative. his task is not to judge, nor to criticise nor to teach. the speech therapist, on the other hand, must definitely have an educative approach, and like all educators can only achieve good results if she is able to establish a clear positive transference. she needs the conscious co-operation of the patient. she cannot afford to work directly with the unconscious or to encourage free play of aggression, hatred, guilt, suspicion, etc. therefore, she cannot be both educator and therapist, r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) o c t o b e r j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d i c s o c i e t y 1 5 any more than the psychotherapist can set out to cure a neurosis and at the same time teach good speech. the two functions must remain separate. attempts to combine them can only result in poor therapy and confusion for both patient and therapist. the speech therapist may here interject that she attempts nothing so deep in the way of psychological treatment, but limits herself to fairly superficial interpretations of the patient's behaviour and difficulties. in some cases, it is true, this may be harmless, since the interpretations have no effect at all. in that case, why make them in the first place? in other c a s e s they may touch upon and stir up anxieties which are far deeper than the therapist anticipates and which she then finds herself unable to deal with. or, a s in the c a s e of the fifteen year old boy, the attempt to probe into deep psychological causes is felt by the patient a s an attack, from which he tries to escape by giving up the speech symptom and choosing some other form of symptom. it is not my intention to decry speech therapy a s demanding less knowledge or less skill than psychotheraphy. the two professions, although closely allied, are completely separate. they rely on. different bodies of knowledge and different techniques of practice, and this must be borne in mind by clinicians of both professions if they are to achieve the best results in their respective spheres of work. vacancy for speech therapist the pretoria school for cerebral palsied children, p.o. box 1511, pretoria. phone : pretoria 20626 m i s s b e s s i e d e m b o 54 wingate masions, c/r., smit and nugget streets, 1 hospital hill, i johannesburg. phone 44-0860 typing and roneoing undertaken, especially theses'and students notes. d e a f ? 'the latest miracle of modern s c i e n c e » truly a product of the new electronic age, the a l l t r a n s i s t o r bonochord "tr3" •k no 'b' battery—just one standard cell! •k 500 hours' life from a carbon pen cell; the operating cost—a mere 2/6 a year (8-hour day)) * the tr3 is the smallest all-transistor aid in the world working from a standard pen cell—the size of a packet of book matches—yet robust and strong. w e i g h t — a mere 3 ozs.l . + crystal clear, true tone, simple to use, easy to conceal, comfortable and convenient. 4r purchaseable over 6 or 12 months, trade-in terms acceptable; there is a 12 months' guarantee of, trouble-free service under all normal conditions. do n't delay in hearing for yourself how much this can mean to you. there is no obligation—just phone or write for the name and address of our nearest agent. bonochord size i 2nd floor si <fe villiers street (africa) (pty) ltd. automutual house johannesburg p.o. sox 4127 telephone 23-2698 9 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l of t h e south a f r i c a n l o g o p e d c society speech therapy at the pretoria school for cerebral palsy * mt7.tc-f.nt silansky, b.a., diploma logopedics, former speech therapist, pretoria school of cerebral palsy. in south africa the last 5 y e a r s h a v e seen a growing interest in the many-sided problems of c e r e b r a l palsy. for the maximum rehabilitation of the child with c e r e b r a l palsy, the services of the paediatrician, orthopaedic surgeon, neurologist, psychologist, physiotherapist, s p e e c h therapist, o c c u p a t i o n a l therapist a n d educationist a r e r e q u i r e d ; bui this ideal combination is seldom attained·. the pretoria school lor cerebral palsy, started b y p a r e n t s of children afflicted with this condition, w a s o p e n e d in 1950, with 3 pupils a n d 1 therapist, a n d h a s since i n c r e a s e d to 41 children a n d a staff of 3 t e a c h e r s (one a nursery-school teacher), 3 physiotherapists, 1 occupational therapist, 2 s p e e c h therapists, a matron a n d 4 african " h e l p s . " unfortunately the female professional staff is constantly changing a n d there is never a full complement. t h e author worked a s s p e e c h therapist at this school for 21 months u p to july 1954. only children suffering from c e r e b r a l palsy are admitted to the school, but doubtful c a s e s are received a n d kept under observation for 3-6 months until the d i a g n o s i s c a n b e e s t a b lished." j types o f cerebral palsy. i " c e r e b r a l | palsy is a term u s e d to d e s i g n a t e crny paralysis, w e a k n e s s , inco-ordination or functional aberration of the motor system resulting from a pathological condition in the motor centres of the brain. the d i s e a s e m a y b e so localized a s to c a u s e only motor symptoms. more frequently, however, the brain d a m a g e is diffuse a n d m a y a l s o c a u s e c o n vulsions, mental retardation, s p e e c h defects, behaviour d i s t u r b a n c e s a n d sensory losses of varying d e g r e e s , particularly in h e a r i n g a n d v i s i o n . " 1 during the first 3£ y e a r s of the school the following were the number a n d types of cerebral palsy in the children handled, a n d the proportion of these with s p e e c h d e f e c t s : 's.a.m.j. 28:1074 (dec.) 19s4 reprinted with permission. types spastic atheioid flaccid mixed ataxic rigid aphasic unclassied total total number 19 . 6 1 3 4 3 s 41 number with speech defects 14 4 1 2 3 3 3 30 ' thus 11 children (i.e., 2 7 % ) h a v e normal or a d e q u a t e speech a n d do not require s p e e c h therapy. c a s e s h a v e to b e chosen carefully a s there is insufficient time to give s p e e c h therapy to all who a r e in n e e d of it. sometimes a complete lack of co-operation from the home willrender therapy ineffective in spite of the intelligence of the child. in selection, younger children a r e given preference to older ones a n d the more intelligent to the more dull. it is important to spend not more than 20minute periods daily on therapy, a s the children tire easily and their span of attention is short. individual treatment is preferred, but w h e r e 2 c a s e s are similar in respect of a g e , intelligence and therapy they a r e taken together. approaching the problem. in a p p r o a c h i n g the problem of s p e e c h therapy, e a c h c a s e is treated individually a n d ά s e p a r a t e programme worked out for e a c h child ; there is no set line of therapy for ail spastics or all athetoids. however, the therapy for spastics will involve g a i n i n g greater mobility of spastic muscles, w h e r e a s that for the athetoid group will involve gaining g r e a t e r control over the affected muscles, while the a t a x i c c a s e , in which the c e r e b e l l a r lesion c a u s e s a loss of b a l a n c e a n d a diminished s e n s e of a w a r e n e s s of muscle feeling a n d placement, will to a l a r g e extent call for a kinaesthetic a p p r o a c h to therapy. obviously therefore it is n e c e s s a r y to know the physical d i a g n o s i s before starting the speech programme;· at the school it is supplied b y the • paediatrician, who b a s e s it on a full history a n d physical examination. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) may t o c o m p l e t e p s y c h o l o g i s t s report is cdso ° v h . i d intelligence tes is done on ^ ^ g i n t ° a c c < a i i ' c h i l d r e n is notwholly a p p l i c a b l e to for normal children is r , ^ m a y h a v e c h l l d r e n with h a n d i c a p s — a fair k f * s s £ ssssuts λ ^ *»» over a long period. f o r t h i s r e a s o n , the ^ e ^ y a i u a b ! e source m e e t i n g s the physical, b y progress (or re t r o g r « s i o r i s d ^ the staff, as> well a s the emo t q of the .child. the p a χ , w h e n discuss a n y problem a n d is given a a n d n e e d , e 1 · · a t c s i a r e n o t e t b y a p a n e l p s y c h o l o g i c a l ° t h e c h i l d . a t reguo f d o c t o r s w n o r e e x a m i n e h e ^ ^ lar intervals during the y e a r ^ t q a n d l e e c h h a n d i c a p a r e the child s p , , , s i c a . e d _ n t h e important fac l oi= to c s p e e c h treatment. . speech evaluation. s p e e c h i e ^ ^ ^ h l ^ r s p a l s y m a y b e drrecfly due to ^ ^ ^ or they m a y occur, a s m } { a c t o r s . through o.ther o r g a n i c ο i o l l o w . f o r the purposes cf c i a « m c a a o n , ^ \ t r ^ g u s e f f l s c n b m e the s p e e c h s s f s e r w h k the children fall. τ d e l v e d . s p e e c h c e r e b r a l q a l s y h a v e foued to d e v e ο . ^ delay m a y b e o n e of the following : ' ( a ) s p e e c h is a n a c q u i r e d skill . t h e normal child h e a r s the words, <md sees m ^ t o n g u e m o v e m e n t s of .he p e o p i e b r a i _ v i s u a l or auditory p ™ » ^ otivati ^ s ^ u e ^ n e c e s ^ r y ^ r the development of s p ( b ) h e v e n if hearing h e a i v e s u p the task. s p e e c h , s i n c e all his w o n . a _ — stimulated. eastern-. d e f i e d e v e n with c e r e b r a l palsy is often d ^ i normal stimulation due 10 his m ^ h d \ r o t n , " t spoken to around him. u u . i e " h a n d i c a p p e d r e a d to, or sung to a s a ρ p l a y m a t e s . in fact it ib t>i η frequent to h e a r a mo,ner , a y · w • ^ don't talk to him much he a o e ? η understand, so v™at r e a l l i y the child with c e r e b r a l j e n ° e x d e r i e n c e , n e e d s more stimulation a n d mo e ^ d i _ the child m a y h a v e ^ g r o u n d g o * physical a n d mental de^e oprnent. ?„g slow rate of s p e e c h development (g) the child m a y b e mentally retarded. 2. c e r e b r a l p a l s y ^ ^ ^ * velops s p e e c h it may b e c h a ς o f jerky, indistinct s o u n d , d u e t o ^ j 'speech moving m a n j a w or t i m e s the m e n t i s severely u v u l a a r e so spastic a . j a n d λ d f f l s l o ^ u n s ^ i b i e to the 1 ί 5 γ o r a a n i c or structural defects. s p e e c h 3. u r g a n i c 01 rviuied children c a u s e d defects m a y occur m p a l , ea^cn by a n o m a l i e s of ° r £ u f i s t 0 n o m h e c.n.s. than ' ^ o s e c a u s e d b y o f the athetoid group. i n e t ϊ α η y γ defect in the sounds such often it involves h e a r or disc s s. sh, ch, ne c r ι t h e r e i o r e s g u i s s s ? s o ^ s c ^ r e c i l y f d produces them incorrectly or not at all. 5 stuttering. stuttering m a y o c c u r ^ n g cerebral-palsy children, p e r n a p s a» a re.ult o^ confused, c e r e b r a l d o m i n a n c e r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f t h e south a f r i c a n l o g o p e d c society . s p e e c h . due to spasmodic or uncontrolled breathing musculature, the breath is said to \-e "out of p h a s e . " the child may b e unable to direct the flow of air through the mouth dur. s p e e c h , or movement may b e so inhibited q s to cause' shallow breathing insufficient for normal speech. 8. aphasia. this defect is a n impairment of linguistic function due to d a m a g e of the speech centre a n d a s s o c i a t e d tracts. e i s e n s o n 5 s t a t e s : "those patients whose outstanding difi i c u l t i e s a r e in the comprehension of l a n g u a g e , c'ooken or written, may b e classified a s belonging to the receptive type. where the predominant difficulties consist of an impairment of ability in speaking, word finding, oral reading, spelling, or writing, the patient may b e classified a s a n expressive a p h a s i c . " very often it a p p e a r s a s if the child's lack of response to speech is due to deafness, but in an aphasic hearing is usually unaffected. if the child develops a certain amount of speech, sentence structure is distorted, " s m a l l " words are often left out, while writing is characterized by "mirror" formation of letters a n d words. the speech defects found at the school a r e enumerated in the right-hand column of the table on p a g e 13 (one child m a y h a v e more than one defect). speech examination. before speech therapy is begun, a thorough speech examination must be m a d e to determine the possible c a u s e or causes of the delay or defect in the speech. the treatment will depend on these factors. the examination will include : 1. a physical examination of the speech organs to discover a n y structural malformation. j 2. a test' of the ability of the child to move tongue, lips, uvula, j a w s , etc., for a d e q u a t e speech performance. 3. a test of all the speech sounds in initial, medial a n d final positions, using pictures or objects. from this phonetic inventory omissions, distortions, a n d substitutions of sound during speech c a n b e detected. 4. a crude hearing test is given and if possible an audiometer test. 5. force a n d direction of the breath, a s well a s whether it is in co-ordination with the act of speech, a r e noted. 6. sucking, chewing a n d swallowing a c t s are g a u g e d . 7. voice factors such a s pitch a n d quality a r e noted. 8. a recording of the child's speech is taken to determine understandability and, after intervals, to determine progress if any. recordings a r e v a l u a b l e for therapy, a s they provide excellent auditory stimulation. very often the child h a s no idea what his speech sounds like, and the recordings allow him to hear himself and his defects. therapy and techniques. the child who, from the a g e 2 j years onwards h a s little or no speech is treated for delayed speech. at all times the child is e n c o u r a g e d to m a k e sounds, to b a b b l e , to indulge in all manner of vocal play. he must be taught to watch the lips, hear the sounds a n d feel the placement a n d voice vibrations. s p e e c h must b e a p l e a s u r a b l e activity a s well a s a necessary one. for stimulation, toys, pictures, rhymes, songs, g a m e s and dramatizations a r e used, depending on the a g e a n d amount of speech the child already has. at the school there a r e regular singing periods apart from the speech lessons, in which the nursery group a n d the older groups a r e separately taken. the children sing a n d dramatize english and afrikaans songs, a n d from their obvious enjoyment of the whole procedure it is clear that they are being stimulated and motivated to vocalize. in this group, too, there is a certain amount of healthy competition, and e a c h one tries to sing well so i'hat he or she will b e chosen to be the "matrosie," or "little miss muffet." the mother must b e instructed to b a b b l e with the child, to talk, sing a n d read to him. while she is doing his physical exercises with him, she can rhythmically count or sing in time with the actions. defects in the limited speech at this stage a r e ignored. any attempt to vocalize or say a n e w word is praised. at the s a m e time it is important to strengthen the speech musculature. the organs of speech h a v e a primary function other than for speech. the act of chewing a n d swallowing employs the s a m e muscles a s those used for speech. therefore practice in b a s i c functions, such c s chewing, sucking and swallowing form an important part of therapy. the mother is instructed to encourage the child to eat "hard foods" a n d to swallow all liquids through a straw. this procedure is adopted at school, too. in this manner the muscles of speech a r e strengthened and drooling, so often found in cerebral-palsy children, is diminished. the "chewing-method" is successful in achieving "improvement of the functions of the mouth a n d speech organs, a s well a s of the voice."6· in d e l a y e d speech, all types of cerebralpalsy a r e similarly treated. in an atmosphere r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 1 j o u r n a l of t h e s o u t h a f r i c a n l o g o p e d c society may of quiet, r e l a x a t i o n is practised, using a r a g doll to illustrate floppy l e g s a n d arms, or dem o n s t r a t i n g the difference b e t w e e n the ;eel of t e n s e m u s c l e s a n d soft muscles. later, when the d e v e l o p m e n t of s p e e c h is progressing, differentiation is m a d e b e t w e e n the types 01 c e r e b r a l p a l s y , so that a p p r o p r i a t e metnods of e x e r c i s i n g c a n b e given. strictly s p e a k i n g , though, there is not much difference in the m e t h o d s a d o p t e d for s p a s t i c s a n d athetoids. it h a s b e e n s a i d that " t h e r e a r e 3 w a y s to treat the s p e e c h of the s p a s t i c p a r a l y t i c : first, r e l a x a t i o n ' ; s e c o n d , r e l a x a t i o n ; a n d third, rel a x a t i o n . " " t h e s a m e m a y b e s a i d to a p p l y to the t r e a t m e n t of athetoids. if the affected m u s c l e s c a n b e r e l a x e d , the s p a s t i c c a n b e t a u g h t to m o v e them in the d e s i r e d direction, a n d the a t h e t o i d c a n learn to control them. whilst in a r e l a x e d position the child is then given b r e a t h i n g e x e r c i s e s , first on his b a c k , a n d later in a sitting position. t h e child learns the " f e e l " of correct· b r e a t h i n g b y gently pushing the rib c a g e in a n d out. to promote g r e a t e r b r e a t h force there a r e m a n y g a m e s which the child c a n play, such a s blowing out a c a n d l e , b l o w i n g b u b b l e s , or blowing up a b a l l o o n . later h e c a n c o m b i n e b r e a t h i n g a n d a r t i c u l a t i o n b y vocalizing a sound, e.g., ' a h , a n d at the s a m e time s e e i n g how far a toy a e r o p l a n e will fly—the flight lasting a s long a s the vocalization. t h e child is a l s o t a u g h t to direct the air through the mouth. here a g a i n , blowing g a m e s a r e used, a s well a s e x e r c i s e s for improving tlie m o v e m e n t s cf the soft p a l a t e . t h e t o n g u e isj s u b j e c t to a g r e a t e r amount of involvement c a u s i n g s p e e c h d e f e c t s than a n y other of the articulator}o r g a n s . t o n g u e exercises, therefore, a r e given in the majority οι c a s e s . ih order to e n c o u r a g e the child to m o v e the itongue up, out, to the sides, or round the mouth, h e is instructed to lick a lollipop b y p l a c i n g it in a c e r t a i n position on the mouth, or outside the mouth. as a variation, a r u b b e r m a s k with a m o v a b l e t o n g u e is used, a n d the child h a s to imitate its actions. t h e r u b b e r " f u n n y m a n " is u s e d , too, for lip exerc i s e s to stretch the lips into a smile;_ to pucker them or o p e n them into a n " a h " position. with the u s e of g a m e s , j a w a n d u v u l a exerc i s e s a r e similarly given. if the child u s e s c e r t a i n s o u n d s incorrectly o w i n g to functional or o r g a n i c c a u s e s , the sounds a r e practised, not in isolation, but in words. f o r "this purpose s c r a p b o o k s containing l a r g e pictures illustrating the particular words a r e u s e d for e a c h child. for e x a m p l e , if a child subsitutes "f" for " t h " in his s p e e c n , l a r a e illustrations of a thumb a n d a t h i m c i e are" p a s t e d in to a s c r a p b o o k . parents h a v e to help find the pictures a n d the child c a n p a r t i c i p a t e b y cutting them out a n d p a s t i n g them in (if his p h y s i c a l h a n d i c a p permits). another set of c a r d s roughly d r a w n b y the therapist a n d duplicating the pictures provide m a n y a n d v a r i e d g a m e s to stimulate further p r a c t i c e on the sound. t h e " f e e l " of the sound on tne child's h a n d often provides the c u e lor correct imitation a n d motivation, e.g., letting tne child feel the b r e a t h force a s the therapist rep e a t s a n explosive c o n s o n a n t . all physical e x e r c i s e s to g a i n m u s c l e strength a n d control, a n d s p e e c h sound e x e r c i s e s a r e done m iront of the mirror so that the child c a n m a k e u s e of all sensory stimuli, visual, auditory a n a tactile. t h e treatment of a p h a s i c s is a n interesting c h a l l e n a e to a n y s p e e c h therapist. it is a n a t t e r of stimulating the child through a u d i tory visual a n d k i n a e s t h e t i c m e a n s until a meaningful response is elicited. o n e oi the children at the s c h o o l , a mixed type of e x pressive-receptive a p h a s i a , responded d r a m a tically to t r e a t m e n t : it b e g a n b y the cmld holding a felt ball, noting its size, s h a p e , a n d texture a n d hearing s e v e r a l repetitions of the word " b a l . " at the s a m e time she w a t c h e a the formation of the word in the mirror. alter s e v e r a l w e e k s of c o n s t a n t repetition, s h e respeondc-d b y s a y i n g " b a l " when s h e s a w tne ball. from then on, s e n t e n c e s w e r e constructed around this word, a l w a y s dramatizing the action, e.g., "skop die b a l . " mew words w e r e then introduced until a n e x t e n s i v e v o c a b u l a r y w a s built up. t h e results w e r e far b e t t e r for the e x p r e s s i v e impairment than fcr the receptive. in treating the h a r d o f h e a r i n g child, lipr e a d i n g is taught and, t o g e t h e r with the visum c u e s , kinaesthetic a n d a g r e a t d e a l of a u a i t o r y stimulation is given. e a r p h o n e s a t t a c h e d t c the recording m a c h i n e a r e a n important a i d to stimulate h e a r i n g . t h e school a s yet d o e s not p o s s e s s a " t r a i n e a r . " in the one c a s e w h e r e a h e a r i n g a i d h a s b e e n p u r c h a s e d ior a hard-of-hearing child, the results w e r e disa p p o i n t i n g ; the p a r e n t s could not afford a r e l i a b l e set, a n d the child, owing to low intelligence, could not a d j u s t herself to > this a p p a r a t u s . "it is urgent that all d e a f c e r e o r c , p a l s y children of g o o d ability who h a v e resid u a l c a p a c i t y to benefit from the u s e of h e a r ing a i d should b e given auditory training from ' the b e g i n n i n g of their education.''^. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l of t h e s o u t h a f r i c a n l o g o p e d i c society results. what is the aim of the s p e e c h therapist in dealing with these children? evans^ says, "perfect s p e e c h is usually a n impossibility . . after all p o s s i b l e repair or help to the m e c h a nism h a s b e e n secured, aim for practicality rcther than normalcy. if the s p e e c h sounds ccceo'able e v e n if not h i g h g r a d e , it should ™ a c c e p t e d b y the clinician a n d the effort r x c i ^ d " in judging the results of nearly i ν oars' therapy, therefore, the question h a s not b e * n whether the child c a n now s p e a k normally but, rather, whether in the very slow oroce-s of developing or improving his speecn, certain a o a l s h a v e b e e n r e a c h e d a n d maintained. for instance, c a n a now lift his tongue into a position to s a y t ? c a n β now blow out a c a n d l e directing the flow οι air through the mouth? has c s t o p p e d drooling? is d correctly substituting " t h " m words instead of " f " ? it is extremely difficult to a s s e s s the results objectively. t h e following is a s u b j e c t i v e attempt to a s s e s s the children's progress at speech ; number speech improved delayed speech 7 cerebral-palsy b organic or structural defects hard-of-hearing. speech stuttering voice disorders breathing disorders a p h c s l c s ί i difficulties. the difficulties e n c o u n t e r e d in the s p e e c h therapy of 'children with c e r e b r a l p a l s y h a v e posed m a n y problems, most important of which a r e i relaxation a n d breathing. t h e therapist m a y spend months trying to r e l a x a spastic or athetoid in supine or prone position only to find that there is no c a r r y o v e r m a sitting or standing position, a n d certainly no carry-over during the a c t of s p e e c h . similarly, the child m a y learn a form of correct silent breathing, yet during s p e a k i n g it m a y b e quite "out of p h a s e , " or entirely i n a d e q u a t e for speech. in other words the c a r r y o v e r is often a b s e n t h e r e too. the therapist must query whether a spastic muscle c a n b e completely r e l a x e d , or whether an athetoid muscle c a n b e controlled. particularly during speech, when a r t i c u l a t o r a n d breathi ng muscles a r e in action, how n e a r to normal c a n the parts b e conditioned, so that a d e q u a t e s p e e c h c a n b e a c h i e v e d ? a h a n d m a n i p u l a t e d iron lung, used in the united s t a t e s for t e a c h i n g correct breathing, should b e tried here, a s well a s all the stimulating " g a d g e t s " for motivating speech. app a r a t u s h a s b e e n constructed which lights -up or rings bells when the child s a y s a particular word correctly. another important problem at the school is that of achieving an a c c u r a t e assessment c i the child's hearing ability. crude hearing te<=ts a r e not very r e l i a b l e a n d the results a r e subjective. tests using the pure-tone audiometer a r e difficult to u s e in a young child, since h e does not know what is required 01 him a n d h e tires easily. it is even more dnficult to a s s e s s the a c c u r a c y of such a test when given to children of sub-normal intellig e n c e . varying d e g r e e s of hearing-loss s e e m to b e relatively common a m o n g palsied chilaι 1 1 ι 2 2 1 5 3 total in group 13 10 1 2 2 7 15 3 ren a n d this aspect h a s b e e n sadly n e g l e c in e x a m i n a t i o n a n d therapy cmd for record purposes. a difficulty peculiar to south african therapist is that of l a n g u a g e . naturally, e a c h child is given therauy in his h o m e l a n g u a g e but sometimes there is a confusion of both langu a a e s in the home a n d the child h a s tnis a d d e d difficulty to c o p e with. also, although there is a wealth of s p e e c h sound material at h a n d in english, the therapist must compile all afrikaans material from m a g a z i n e s , boons, verse etc. an afrikaans phonetic s p e e c n b o o k ' w o u l d b e of great h e l p to s p e e c h therapists. the present classification of s p e e c h defects h a s not proved very satisfactory. d e l a y e d s p e e c h a n d c e r e b r a l p a l s y s p e e c h include too w ' d e a variety of defects. leather's r e c e n h v dublished classifications should b e of g r e a t e r v a l u e 'or diagnostic a n d therapeutic purposes a n d to gain a more o b j e c t i v e assessment ot results. with c e r e b r a l p a l s y there is no "full understanding of the implications of the injury to the total orgctnism."i° to i n c r e a s e the understanding, the g r e a t e s t co-operation is n e c e c s a r v between the s p e e c h therapist a n d the physiotherapist. indeed, fu.ll c o o p e r a n o n is n e c e s s a r y among all staff m e m c e r s of a school to co-ordinate p h y s i c a l a n d educational methods. summary. c e r e b r a l p a l s y is p r o l o n g e d a n d difficult, a n d in its treatment it is n e c e s s a r y for workers in v a r i o u s fields to pool their observations a n d e x p e r i e n c e . s p e e c h therapy is one of the primary n e e d s communication b e t w e e n individuals for social a n d e c o n o m i c n e e d s b e i n g so essential. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 1 j o u r n a l of t h e s o u t h a f r i c a n l o g o p e d i c society may experience of 41 children at the pretoria school for cerebral-palsy is described. types of cerebral-palsy a n d speech defects found in these children a r e detailed. methods a n d techniques in speech therapy a r e reviewed. results a n d difficulties a r e discussed. my thanks are due to dr. b. epstein, chairman of the board o! management of the pretoria scnool for cerebral-palsy, for his encouragement and assistance, and for allowing me cccess to files and recoras. references. 1 perlstein μ a and b a m e ^ η. e. (1952) : j. amer. med. assoc., 148, 1389. 2 pohl j. f. (1950) : cerebral-palsy. 2nd ed., p. 165167.' st. paul, minnesota: bruce publishing'co. 3. rutherford, b. r. (1948) : give them a chance to talk, 1st ed., p. 3. minneapolis, minnesota: burgess publishing co. 4 kastein, s. (1952) : notes on speech therapy, 1st ed., p. 7. british council for the v/elfcre of spastics. 5 eisenson, j. (1946): examining ior aphasia, 1st ed., p. 4. new york: the psychological corporation. 6. sittig, e. (1947) : j. speech -dis., 12, 194 (quoting froeschells). 7. evans, m. f. (1947): ibid., 12, 97. 8 ε wing i. r. and a. w. g. (1954) : speech and the deaf child, 1st ed., p. 127. manchester: university press. 9. leather, d. (1954): int.-j. phoniatry, 6, 38 (separatum). 10' clemons, e. s. (1953): j. s. afr. logopedic soc., special congress ed., p. 48 (johannesburg univ. witwatersrand). the conquest of stuttering c. van riper director, speech clinic, western michigan. college kalamazoo, michigan, u.s.a. western michigan college of education. for centuries the treatment of stuttering h a s wrecked itself on the rock of symptom avoidance. the various therapeutic methods^ used, relaxation, rate control, unusual modes oi speech, h a v e b e e n focussed on the s a m e goal which h a s b e t r a y e d e v e r y stutterer's own attempts to h e a l himself: the attempt to speak without stuttering. such c n effort carries within itself, even when successful, the seeds ot its own eventual failure. for a v o i d a n c e c r e e d s fear w h e n we flee from fear, w e magnify it. the situation a n d word fears so long conditioned in the adult stutterer c a n haralv ce e r a s e d by; such measures. according to modern teaming theory, anxiety conditioned responses never extinguish completely. o n e pairing of the shock with the conditioned stimuli restores them to almost full strengtn. and so we find the discouraging frequency of r e l a p s e s in stuttering therapy. moreover, much of the older methods did little more than to repress the symptoms. the powenul suggestion employed b y most therapists can ind e e d produce such repression temporarily, ^ut stuttering, like murder, will out ! w e may b e a b l e to hold down the coiled spring of tne disorder for a time, but so long a s it is intact a n d a s strona a s ever, it will eventually e s c a p e from our grasp. w e a r e but mortals with no ability to sustain a repression for long. no matter how confident we b e c o m e , existence will sooner or later c a u s e morale to efco. no environment, however favourable, will b e without its moments of trauma. to build fluency upon an attitude a l o n e is to use fiux instead of mortar for the foundation. ana. so at these i n e s c a p a b l e moments of e g o weakness, the fears invade our minds a g a i n , and the stuttering returns to haunt our lives. is there no w a y to exorcise this evil ghost whose strength seems almost of the supernatural? the psychoanalysts have tried a n d most of them confess failure since speech, their · healing tool, is itself affected. the myriad devices, methods a n d tricks which have b e e n used upon stutterers since the dawn of history give us little hope of s u r c e a s e from that direction. witchcraft and surgery, vocal training a n d hypnosis, in none of these have we found consistent effectiveness. our inability to c o p e with the severe stutterer after all these y e a r s still reflects discredit upon our profession. perhaps we h a v e b e e n working in the wrong direction. the stutterer does not need to b e taught how to talk normally. he already h a s that skill, a s much of his speech attests. suppose, instead of trying to k e e p him from stuttering with all of its attendant evils, we try to train him to modify his symptoms in the direction of fluency. the immense variety of stuttering symptoms suggests that among them there might b e a few types which society would not dunish. among them there should r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) vol 57 • december 2010 • sajcd 43 development of semantic processes for academic language in foundation phase eal learners giselle meirim heila jordaan amy kallenbach meera rijhumal department of speech pathology and audiology, school of human and community development, university of the witwatersrand, johannesburg correspondence to: h jordaan (heila.jordaan@wits.ac.za) the most significant issue for quality in education is ‘the all pervasive and extremely powerful influence of language which is unambiguously implicated in learning … and the need for pupils to have as good a grasp of the language of teaching and learning as possible’ (taylor, muller & vinjevold, 2003, p. 65). the purpose of this study was to track the development of some of the semantic processing skills underlying the development of english as the language of teaching and learning in grade 1 3 english additional language (eal) learners. the rationale is based on the widely acknowledged fact that language competence and proficiency are central to educational success (bashir, conte & heerde, 1998; hoff, 2005; owens, 2008; westby, 1994). one of the reasons for this is that literacy is inherently a language-based activity, rooted in well-developed oral language skills (linan-thompson & ortiz, 2009; scarborough, 2001; snow, tabors & dickenson, 2001). this study focuses specifically on semantics, which deals with the expression and understanding of meaning and refers to the mental dictionary of words or the lexicon (de villiers, 2004). significantly, semantic knowledge plays an important role in the acquisition of early literacy and comprehension skills (linanthompson & ortiz, 2009). therefore, research on the acquisition of these language skills in the south african context is critical, since low levels of literacy are currently of serious concern (howie, 2009; kgosana, 2010; tyobeka, 2006). in education, language proficiency involves more than the ability to communicate in everyday conversational contexts, but is specifically related to the use of language for academic purposes. cummins (2000, p. 67) defines academic language proficiency as ‘… access to and command of the oral and written academic registers of schooling’. academic language proficiency is not acquired as naturally as basic interpersonal communication skills and develops through exposure to formal education (cummins, 2000; hoff, 2005). this implies that educators should facilitate this development with explicit teaching strategies addressing the language implicit in various learning areas. the language skills that should be developed during the foundation phase and their importance for academic development have been well described (hoff, 2005; mclaughlin, 1998; owens, 2008). those pertaining to semantics include: rapid growth in vocabulary and conceptualisation, growth in knowledge of word formation processes, and the increasing ability to learn new words from context, a skill known as fast mapping (hoff, 2005). there is research to show that the acquisition of these skills can be facilitated through explicit teaching of vocabulary and assisting children to make use of context to acquire words (maynard, pullen & coyne, 2010). however, these skills may not be explicitly addressed because language for academic purposes as a distinct register is not always recognised. in addition, there is evidence to suggest that teachers in south africa are not only unaware of their responsibility to meet the language-related needs of learners but also lack the methodological skills to promote effective learning of academic language because they have not had the necessary training (mroz, 2006; o’connor & geiger, 2009; uys, van der walt, van den berg, & botha, 2007). however, the most compelling reason for investigating academic language development in the south african education system is that many learners must accomplish this in a second/additional language. as a result of our political history and the socio-linguistic influences operating within the country and by extension in education, the second language is almost always english (braam, 2004; de klerk, 2002; de wet, 2002; ntshingila, 2006). eal learners are effectively learning the language of instruction through the language of instruction (cummins, 2000), which may have an impact on their academic development. cummins (2000) has suggested that eal learners acquire basic interpersonal communication skills (bics) in about 2 years, while cognitive academic language (calp) skills are acquired in a period of 4 9 years, depending on the quality of english instruction they receive. regarding the language of instruction, research conducted internationally (cited in genesee, paradis & crago, 2004, p. 168), as well as in south africa (heugh, 2000; macdonald, 1990), has provided strong evidence to suggest that learners develop academic language proficiency more effectively in their home language or alternatively, in bilingual/ multilingual education, where teaching occurs in both the first and second languages. education policies in south africa strongly support the use of home language and/or bilingual instruction (e.g. language in education policy (liep), 1997), but in reality, the implementation of these policies has been slow (alexander, 2010; beukes, 2008; carstens, 2006; kamwendo, 2006). recently, there does seem to be a renewed will to implement home language instruction since the current minister of abstract it is widely acknowledged that language competence is central to educational success, primarily because literacy is inherently a language-based activity. vocabulary knowledge specifically plays an important role in the acquisition of reading comprehension skills. language in education practice in south africa is currently highly controversial, as the implementation of home language or bilingual instruction policies has not been achieved in many schools. the aim of this study was to investigate the development of language skills in foundation phase english additional language (eal) learners attending schools where english is the language of learning and teaching. a 3-year longitudinal investigation of the acquisition of some of the processes underlying language for academic purposes was undertaken using the semantics subtests of the developmental evaluation of language variation criterion referenced edition (seymour, roeper & de villiers, 2003). the results indicated that the majority of eal learners improved with increased exposure to english in the academic environment and by the time they were in grade 3, were performing at a higher level than english first language learners in grade 2. however, the effects of this protracted period of development on literacy attainment should be investigated. the significant individual variation in the learners’ performance has implications for assessment and instruction of eal learners and for the collaborative role of teachers and speech language therapists in the education system. keywords: academic language, eal learners, foundation phase education, semantic development 44 sajcd • vol 57 • december 2010 semantic development basic education has announced that from 2011, the language chosen by the learner as the language of learning and teaching (lolt) shall be taught as a subject, or as a first additional language, from grade 1 and not from grade 2, as is currently the case. the teaching of english would therefore occur alongside mother tongue instruction for those learners who choose english as the lolt. english will subsequently not replace the home language in the early grades (motshekga, 2010). however, the implementation of home language instruction and teaching of english in the foundation phase does not in any way absolve teachers of the responsibility for facilitating the learning of academic language. the principles are applicable to the teaching of any language. reasons for the hitherto lack of implementation of the liep include: the majority of south african parents believe that english is the language of empowerment and aspire to have their children educated in english (gules, 2005; kgosana, 2006); insufficient resources have been made available to give effect to home language and/or bilingual instruction (manyike, 2007; pandor, 2005); but more importantly the marked heterogeneity in the language backgrounds of learners and teachers, particularly in gauteng, results in the inevitable choice of english as the lolt (adler, 2001; granville, janks, joseph, mphalele, ramani, reed & watson, 1997; webb, 2004). table i reflects the heterogeneity in the language backgrounds of the grade 1 learners in the three schools participating in this study. these figures clearly show that the implementation of home language instruction would be problematic in this context. this raises an important question: how do foundation phase learners manage to acquire english for academic purposes? this study attempts to address this question, since there is limited research on the extent to which eal learners acquire the processes underlying academic language, and there have been few attempts to record their progress in the development of these skills over time. the study aims to reveal specific aspects that should be taught in this phase of education and to provide guidelines for the training of educators. the findings may also contribute to an understanding of what can reasonably be expected from eal learners in the foundation phase so as to formulate valid assessment standards for academic language. in this regard, the collaborative role of the classroom teacher and the speech-language therapist (slt) is relevant. slts have an intimate knowledge of the nature, development and functions of oral and written language. the slt may act as the school’s ‘language expert’ (owens, 2004), who assumes the roles of co-teacher and consultant, as well as direct service provider, and is fully integrated in the classroom. the slt is uniquely qualified to assist the classroom teacher in assessing each child’s level of functioning, analysing the language requirements of various curricular activities and materials, and developing intervention strategies. the slt could thus be a valuable resource in developing the academic language skills of the learners. the results of this study provide support for this collaboration, which is currently largely lacking in the south african education system (o’connor & geiger, 2009). typically, the evaluation of language is a difficult task, as language is multi-dimensional and not easily measured. teachers tend to evaluate learners according to criteria based on the content of their language and not the processes that underlie language. in this study, the processes underlying vocabulary development were assessed using the semantic subtests of the developmental evaluation of language variation criterion referenced edition (delv-cr) (seymour, roeper & de villiers, 2003). the delv-cr is an individually administered diagnostic test designed to identify language disorders in 4 9-yearold children. although it was constructed for use with children whose first and primary language is english and to identify language disorders in children regardless of whether they speak mainstream american english (mae) or african american english (aae), it was considered appropriate for use in the south african context for a number of reasons. first, it assesses the processes and properties of language that go beneath the surface structure to tap knowledge that is universal to all speakers of english. second, its focus on critical aspects of academic language makes it particularly valuable for the purpose of this study. third, it can be used with children aged 4.0 9.11 years and is therefore appropriate for children in the foundation phase of education who are generally 6 10 years old. the delv-cr edition is the culmination of many years of research and conceptual advances in the areas of language acquisition and communication disorders. it was field tested on 1 014 4 9-year-olds from working class backgrounds in all regions of north america. sixty per cent of the sample were speakers of aae and were matched for parental education level (high school and lower) to the mainstream american children in the sample. approximately one-third of the children at each age and in each dialect group were language-impaired. despite its american origin, the delv is considered to be highly appropriate for assessing the development of language for academic purposes in any context, because it is specifically designed to capture many aspects of language that are important for success in early schooling and the transition to literacy (de villiers, 2004). it provides a profile of strengths and weaknesses and therefore has implications for areas and methods of teaching and intervention. method aim the main aim of the study was to determine how foundation-phase eal learners acquire the semantic processing skills underlying language for academic purposes. design the study falls within the quantitative, descriptive paradigm, and is longitudinal in nature. a longitudinal design is considered to be the most appropriate method of obtaining information on the process of language acquisition, which is dynamic and influenced by a number of variables, all of which can affect performance on a single measure (de bot, lowie & verschoor, 2005). repeated measures over time are essential to obtain an accurate reflection of language abilities. the eal learners were therefore followed up over a period of 2 years and withingroup comparisons of their performance in grades 1 and 2 and in grades 2 and 3 were conducted. participants in consultation with the gauteng department of education, participants were purposively selected from three schools in the inner-city area of johannesburg east, gauteng. when the study commenced, information sheets and consent forms were distributed to all the parents of grade 1 learners at each school, and those children whose parents gave table i. number and proportion of grade 1 learners speaking each language at three inner-city schools in johannesburg, gauteng sepedi 26 8.1% isizulu 135 42.06% sesotho 25 7.79% chinyarwanda 3 0.93% setswana 24 7.48% nyanja 5 1.56% siswati 1 0.31% swahili 2 0.62% tshivenda 8 2.49% tshona 5 1.56% xitsonga 8 2.49% french 29 9.03% afrikaans 7 2.18% portuguese 1 0.31% english 10 3.12% malawian 1 0.31% isindebele 2 0.62% cameronian 1 0.31% isixhosa 22 6.85% unknown 6 1.87% total 321 100% vol 57 • december 2010 • sajcd 45 semantic development informed consent for their participation were considered for inclusion in the study, provided they met the criteria for selection. the response rates at the three schools varied between 60% and 75%. the participants varied in socio-economic status, but were mainly from middleto low-income families. the lolt in all three schools was english, and the foundation phase teachers spoke english as either a first or additional language. all the learners at all three schools were eal. the sample size was initially 56 when the learners were in grade 1 but was reduced to 35 when the learners were in grade 3, as a result of attrition. the learners were selected according to the following criteria: • isizulu had to be their dominant first language, as it is the most widely spoken in south africa, and is the most commonly spoken language in gauteng (statistics south africa, 2001). furthermore, the reason for choosing learners from only one language group was to restrict the influence of the first language on the results of the test. • the learners were required to be developing typically in every respect including speech, language and hearing functioning. this was established from school records. research instrument: semantic subtest of the diagnostic evaluation of language variation: criterion-referenced (delv-cr) for the reasons outlined in the introduction, this test is considered to be an appropriate measure of academic language. the semantic subtest of the delv-cr consists of the following three components: verb and preposition contrast items the verb and preposition contrast items examine a child’s vocabulary organisation (seymour et al., 2003). the ability to organise words flexibly for efficient retrieval is a skill that develops throughout the school-age years (aitchison, 1987). the delv-cr assesses the organisation of verbs because they are less influenced by cultural variation than nouns; verb meanings are central to language development (tomasello & merriman, 1995); and verb lexicons have been shown to be vulnerable in languageimpaired children (rice & bode, 1993). items on this subtest analyse the ability to provide suitable verb contrasts at the appropriate hierarchical level. the verbs examined in the delv-cr include motion, grooming, breaking, corresponding, and dressing (seymour et al., 2003). the child is required to provide verbs to complete a sentence about a picture, for example: ‘the man isn’t walking, he’s … crawling.’ preposition organisation is also tested because there is a limited set and prepositions are less variable across different dialects of english. the preposition contrast items use the same structure as the verb contrast items. the purpose of this subtest is to examine the child’s skills in producing spatial and grammatical prepositions that are in contrast to the ones used in the prompts (seymour et al., 2003). the child is shown a picture, and is required to complete a sentence, for example: ‘she’s not looking at the radio, she’s listening … to the radio.’ quantifier items quantification is based on the connection between word meaning and logic, is found in all languages and occurs frequently in the language of mathematics. the use of quantifiers provides insight into how well the child’s developing grammar can manage the complex constructions that are used in everyday discourse (seymour et al., 2003). this sub-test has eight components, three of which analyse the child’s acquisition of the meaning of the quantifier ‘every’, as well as the understanding of the syntactic constraints that govern its production; another three items which examine the understanding that ‘every’ only affects the noun that follows it; and two which analyse the understanding of the syntactic constraints that regulate the production of ‘every’ across sentences (seymour et al., 2003). the child is asked to point to pictures being spoken about, for example: ‘every man is riding a horse.’ fast-mapping items fast mapping is a language skill found in all children regardless of cultural or linguistic background. learning verbs in particular is highly dependent on understanding grammar and interpreting sentence context. it is also a skill that is required in the classroom when acquiring new vocabulary, and is therefore important for academic success. this component of the semantic sub-test examines the ability to derive the meaning of an unfamiliar word from the context it is used in, after a few exposures. the first group of items included in this sub-test, teaches the child the task by using real verbs in the prompt. the second group of items makes use of novel verbs. for each item, the child is provided with a series of three pictured episodes, while the administrator expresses an action (e.g. real verb: ‘the boy is pouring juice. novel verb: ‘the girl is zanning the apple to the clown’). the child is then expected to respond to a number of questions about the characters and objects in the series of pictures, by pointing to one of four smaller pictures, using what he/ she understands about word order and word endings. the verbs used in this component consist of three variations: transitive verbs, transfer verbs and complements (seymour et al., 2003). procedure for data collection the participants were initially assessed at the end of grade 1 to ensure sufficient exposure to english to participate in the study. the second assessment was conducted towards the end of the grade 2 year and the third assessment at the end of the grade 3 year. participants were assessed individually on the delv-cr by the researchers who are experienced in language testing and familiar with the test procedure. this ensured a degree of reliability in the results obtained. the test was administered and scored according to the instructions in the manual. although the participants were given verbal encouragement throughout the testing they were not given any indication of the correctness of their responses so that any changes observed over the 3-year period would not be due to learned knowledge of the test items. ethical considerations the ethics committee for research on human subjects, university of the witwatersrand, approved the study (protocol no.: h080404). furthermore, approval was obtained from the gauteng department of education (gde) to conduct the research in an educational setting, and subsequently informed consent was obtained from the principals and teachers of the selected schools. because participants in the study were under the age of 18, informed consent was obtained from their parents/ legal guardians. in addition, assent was obtained from the children concerned (greig & taylor, 1999). the information sheets and consent forms included details regarding the general purpose of the study and the voluntary nature of participation in the study was emphasised. in addition, confidentiality and anonymity of responses and results was assured. reliability and validity in the context of this study, it was considered important to establish the validity of the semantic subtest of the delv-cr as a measure of academic language skills. validity may be defined as ‘the agreement between a measure and the quality it is believed to measure’ (kaplan, 1987, p. 254). a word definition task was administered to the learners in grade 3, and the results were correlated with the results obtained on the total semantics score of the delv-cr. snow (1990) states that word definitions are largely learned and practised at school and a word definition task is therefore considered to be reflective of academic language skill. specifically, the oral vocabulary subtest of the test of language development-primary (told-p) (newcomer & hammil, 1985) was administered. this subtest consists of 20 items which assess the ability to provide oral definitions for common english words. the learner is required to provide a brief explanation, a synonym or two major characteristics (e.g. function and appearance) of the word. each child’s score was calculated on the basis of the percentage of correct answers obtained. a pearson’s correlation coefficient revealed a strong positive correlation between the scores on the two tests [r=0.61 with a 46 sajcd • vol 57 • december 2010 semantic development t-stat (4.49) > critical value (1.6909), alpha level (0.05)], thus providing convergent evidence that the delv-cr is a valid measure of academic semantic skills (kaplan, 1987). reliability of the test results for each participant was established using a measure of inter-tester reliability. at each test session, approximately onethird of the children were assessed by two examiners at the same time, with one administering and both scoring the test. since administration and scoring of the test was conducted according to instructions in the manual, 100% agreement between testers was obtained. data analysis the performance of the learners on the five semantic subtests of the delv-cr at each data collection period was compared using descriptive measures of central tendency (mean) and variability (range) as well as inferential statistics (kaplan, 1987). specifically, the wilcoxon’s matched pairs signed rank test was used to conduct a within-group comparison of scores obtained in grades 1, 2 and 3. this non–parametric procedure was considered to be preferable to the parametric t-test because it does not make assumptions about the distribution of the data (kaplan, 1987). item analyses were conducted by calculating the proportion of participants getting each item correct on each subtest. this provided a clearer indication of strengths and weaknesses in semantic processing skills. results and discussion development of semantic processing skills the primary aim of the study was to track the semantic processing skills of eal learners over 3 years, using the semantic subtest of the delv-cr. the children from the three schools were treated as a single group since an analysis of variance (anova) revealed no significant differences between the learners from the different schools at the grade 1 level (f=1.2; p=0.31). in addition, no significant difference was found for gender (t=0.35; p=0.36), and thus the need to take gender differences into account was disregarded. fig. 1 illustrates the scores (in percentage) attained by the participants on each subtest of the semantics section of the delv-cr over 3 years. the results of the wilcoxon signed rank test to determine whether there were statistically significant improvements from grades 1 to 3, are reflected in table ii. statistically significant differences at the 1% level are indicated by an asterisk (*). the participants improved significantly from grades 1 to 2 on all measures except preposition contrasts and the fast mapping of novel verbs. they improved significantly on all measures from grades 2 to 3. these results indicate that exposure to english in an academic setting, over 3 years, does in fact result in a significant improvement in the learners’ ability to provide verb and preposition contrasts, to understand quantification, and to fast map novel and real verbs, all of which are important for academic purposes. this is a most encouraging finding, as it confirms that the eal learners were able to acquire the oral language skills required for schooling over time and that they benefited from the instruction they were receiving. however, there may still be doubt over the scholastic effects of this protracted period of development. this is an important implication of these results, and future research should investigate the literacy attainment of these learners and their ability to cope with the language demands of the curriculum beyond the third grade. the quantifier subtest seems to be an area of strength, in that the learners obtained an average of 63% in grade 1, which improved to 71% in grade 2 and 82% in grade 3. this may be because quantification is widely used in the language of mathematics, which we can assume the learners are exposed to in the numeracy learning area. this provides evidence for the benefit of explicit language instruction in the context of subject teaching (clegg, 1996). the learners also did relatively well table ii. statistical comparison of scores obtained in each grade on each subtest difference total semantics verb contrasts preposition quantifiers fast mapping: fast mapping: between score contrasts real verbs novel verbs z-value p-value z-value p-value z-value p-value z-value p-value z-value p-value z-value p-value grade 1 & 2 4.913 0.000* 5.246 0.000* 0.726 0.468 3.692 0.000* 3.692 0.000* 0.309 0.757 grade 2 & 3 30.972 0.00000* 6.583 0.00002* 4.33 0.01984* 7.388 0.00362* 5.777 0.00091* 6.888 0.00002* fig.1. mean scores (in %) obtained by the eal learners over a period of 3 years on the semantics subtest of the delv-cr. vol 57 • december 2010 • sajcd 47 semantic development on providing preposition contrasts, with average scores of 61% and 62% in grades 1 and 2, and an improvement to 72% in grade 3. the greatest improvement was seen in the acquisition of the ability to provide verb contrasts, where the learners improved from an average of 24% in grade 1 to 46% in grade 2 and 66% in grade 3. verb and preposition contrast items assess vocabulary organisation. this is an important skill because no matter how different children’s experiences and subsequent vocabulary are, the lexicon must be organised in a hierarchical pattern in order to efficiently retrieve words when needed (capone & mcgregor, 2005; seymour et al., 2003). furthermore, adequate semantic networks are essential to reading comprehension, writing cohesion, retention and recall (nicolosi, harryman & kresheck, 1989). the eal learners in this study have therefore made significant progress in their ability to organise their verb lexicon hierarchically, which would allow for easier retrieval and semantic networking, which in turn facilitates reading comprehension. fast mapping refers to the ability to guess the likely meaning of a new word after a few exposures (de villiers, 2004). this skill is important for vocabulary learning (seymour et al., 2003) and the ability to fast map novel words is particularly important to eal learners in the academic environment, as they are continually exposed to new words representing academic concepts. the learners’ fast-mapping skills improved significantly from an average of 46% in grade 1 to 55% in grade 2 to 68% in grade 3. individual variation in performance it should be noted that despite the generally positive results reported above, there is substantial individual variation in the scores obtained on each subtest (table iii), suggesting that there were children who did not do as well as the mean scores would suggest. table iii shows that the range of scores (lowest to highest) within each subtest remains similar across the 3 years. the total score for the semantics section of the delv-cr ranges from 24 to 41/50 in the third year of the study. paradis (2005) suggests that this wide variation in individual scores, which is more characteristic of second than first language acquisition, indicates that eal children are acquiring english at varying individual rates, despite having similar language experiences. although there are many affective, attitudinal, personality, social, situational and cognitive variables that may determine success in the language-learning situation (baker, 1993), the variable that most consistently correlates with language-learning success is aptitude (de bot et al., 2005). language-learning aptitude is distinct from general intelligence and includes intrinsic skills such as the ability to: identify and remember sounds of the language; recognise how words function grammatically in sentences (lexical organisation); induce grammatical rules from the input; and recognise and remember words and phrases (fast mapping) (carroll, 1981). de bot et al. (2005) claim that recent approaches emphasise the information processing components of aptitude such as working memory and phonological memory. phonological memory is assessed on non-word repetition tasks and is involved in the acquisition of vocabulary (hoff, 2005). french and o’brien (2008) and hummel and french (2010) have shown that phonological memory in children plays a role in learning a second language in the classroom. it is interesting that a different body of research reveals limitations in working memory capacity (leonard, 2003; maniela-arnold & evans, 2005) and poor non-word repetition (phonological memory) skills (botting & conti-ramsden, 2001; dollaghan & campbell, 1998; ellis weismer, tomblin, zhang, chynoweth & jones, 2000; tager-flusberg & cooper, 1999) in children with language impairment. further research on working memory and phonological memory in eal children may enable one to distinguish those who are merely slow to learn from those who are language-impaired, and may enable one to identify those at risk for language impairment (kohnert, windsor & yim, 2006). comparison with english first language (efl) learners although a comparison with efl learners was not an explicit aim of this study, an interesting issue arising from these findings is the relative standing of the eal participants in relation to a peer group. any comparison with the american criterion group participating in the development of the delv-cr would be problematic because of the different cultural environments and education systems in the usa and south africa, but there are limited data available on the performance of south african children on the delv-cr. one available study was conducted by alborough (2007) on 42 grades 1 and 2 efl learners in three schools in johannesburg. a comparison between the mean scores obtained by the learners in this study with those obtained by the participants in the alborough (2007) study is reflected in figure 2. the actual scores are contained in table iv. although statistical comparisons were not conducted, the graphs in figure 2 and the values in table iv suggest that the eal learners did not perform as well as the efl learners in grades 1 and 2, with large differences between them in grade 1 and slightly smaller differences between them in grade 2. however, the grade 3 eal learners were doing as well or outperforming the grade 2 efl learners on all subtests except for the verb contrast items, suggesting that they may catch up to their efl peers by grade 3. it is once again interesting to note that the eal and efl learners do not differ substantially on the preposition contrast or quantifier subtests, suggesting that where there is specific teaching of concepts in a subject area, such as mathematics, all children regardless of language background can learn the vocabulary of the curriculum. this phenomenon is discussed by clegg (1996), who points out that table iii. means and range of raw scores in each grade for each subtest mean scores range of scores (lowest to highest) subtest total possible grade 1 grade 2 grade 3 grade 1 grade 2 grade 3 verb contrasts 10 2.4 4.31 6.58 0 7 2 9 3 10 preposition contrasts 6 3.64 3.75 4.33 1 6 1 6 2 6 quantifiers 9 5.7 6.6 7.38 3 9 2 9 5 9 fast mapping: real verbs 10 3.64 4.87 5.77 1 7 1 8 4 8 fast mapping: novel verbs 15 4.44 4.67 6.88 1 9 1 11 2 11 total 50 19.69 24.2 30.97 12 32 13 36 24 41 table iv. comparison between mean scores (in %) attained by eal and efl learners on each subtest verb contrast preposition contrast quantifiers fast mapping: fast mapping: total score real verbs novel verbs grade 1 eal 24% 60% 63.33% 36% 29.33% 39.4% grade 1 efl 57% 68.33% 72.22% 53% 41.33% 55.4% grade 2 efl 71% 66.67% 72.22% 57% 41.33% 59.2% grade 2 eal 45% 75% 42.22% 66% 32.67% 48.6% grade 3 eal 65.8% 72.22% 82% 57.7% 45.87% 62% 48 sajcd • vol 57 • december 2010 semantic development one of the benefits of instruction in an additional language is that there is concurrent learning of curriculum content and the language which is the vehicle for this. this is in contrast to the teaching of a language as a subject. item analysis the results on individual items of the semantics subtests are examined in greater detail in table v, which displays the proportion (in percentage) of participants getting each item correct on each subtest. the results were compared across the 3 years, in order to provide a clearer indication of areas of strength and weakness. verb and preposition contrasts the results on the verb contrast subtest in the first 2 years indicate that the eal children experienced difficulty in providing two different verbs for the same pictured scene. the percentage of correct responses for contrast 2 (e.g. ‘the man isn’t entering the building, he’s … going out’) in both the first (16.43%) and second (32.89%) year of exposure to english was significantly lower than that obtained for contrast 1 (e.g. ‘the man isn’t walking, he’s … crawling’) (31.79% and 58.22%, respectively). however, after the third year of instruction in english, the difference between contrast 1 and 2 was reduced. these results suggest that over time the eal learners increased their verb vocabulary, and were able to organise these verbs in a more structured manner in their lexicons (de villiers, 2004). the results on the preposition contrast subtest indicated that the eal learners in the study were able to manage prepositions better than verbs, although they had more difficulty with abstract, grammatical prepositions (e.g. ‘he’s not climbing in the morning, he’s climbing … at night’) than with spatial prepositions (e.g. ‘she’s not lifting the chair, she’s sitting … on the chair’). quantifiers the learners improved in their ability to understand the quantifier ‘every’ and that it only affects the noun that follows it (e.g. ‘is every dog eating a bone’) (83.33% in the third year), as well as the conditions that regulate the production of ‘every’ across sentences (e.g. ‘the boy saw every fish. he raised his eyebrows’) (90.74% in the third year). it can therefore be concluded that a good proportion of the eal children in this study know the range of structures within which the word ‘every’ applies (seymour et al., 2003). these results were consistent across all years, confirming that this area of language does not appear to be difficult for eal learners and has been successfully developed in grade 3. fast mapping of real and novel verbs the results of this subtest showed that transitive verbs (e.g. ‘the boy is pouring the juice. which one was the pourer?’) appear to pose a greater difficulty than transfer verbs (e.g. ‘the postman is handing the letter to the boy. which one got handed?’) in both the real and novel verb fastmapping tests. although the learners improved from 37.78% to 45.37% for real verbs in grades 1 and 2 and from 42.76% to 62.5% for novel verbs in grades 2 and 3, they continue to experience difficulties in this area. with reference to real transfer verbs, a significant improvement was also noted over 3 years, as learners obtained 51.19% in grade 1, followed by 74.07% and 82.40% in grade 2 and 3, respectively. interestingly, although the eal learners demonstrated an improvement in their ability to use novel transfer verbs over the 3 years, the difference in test scores was minimal (i.e. 55.36% in grade 1, 58.67% in grade 2, and 59.72% in grade 3). this minimal difference was also evident in the first 2 years with regard to complement verbs, where the test scores table v. proportion of participants (in %) getting each item correct on each subtest in each grade grade 1 grade 2 grade 3 verb contrasts contrast 1 contrast 2 contrast 1 contrast 2 contrast 1 contrast 2 motion 41.07% 12.50% 77.78% 33.33% 91.66% 72.22% grooming 44.64% 5.36% 77.78% 8.89% 94.44% 33.3% breaking 16.07% 33.92% 35.56% 51.11% 38.88% 86.11% corresponding 10.71% 10.71% 24.44% 28.89% 25% 55.55% dressing 46.43% 19.64% 75.56% 42.22% 86.11% 75% overall total 31.79% 16.43% 58.22% 32.89% 67.22% 64.44% preposition contrasts abstract/ grammatical 63.10% 55% 63.10% spatial 58.33% 74.81% 89.81% overall total 60.71% 62.22% 72.22% quantifiers meaning of ‘every’ 56.94% 61% 75% scope of ‘every’ 50% 82% 83.33% across sentence boundaries 54.76% 62% 89.91% within sentence boundaries 67.86% 81% 90.74% overall total 63.01% 71% 82.09% fast mapping: real verbs transitive 31.0% 37.78% 45.47% transfer 51.19% 74.07% 82.40% complement 46.63% 63.70% 64.81% overall total 41.97% 56.44% 64.19% fast mapping: novel verbs transitive 36.79% 42.67% 62.5% transfer 55.36% 58.67% 59.72% complement 36.79% 39.11% 50% overall total 42.98% 46.81% 57.41% semantic total score 44.75% 54.62% 67.73% fig. 2. mean scores (in %) obtained by the eal learners from grades 1 to 3 and the efl learners in grades 1 and 2 in alborough (2007). vol 57 • december 2010 • sajcd 49 semantic development were 36.79% (grade 1) and 39.11% (grade 2). within the third year of exposure to english, however, the difference in test scores with regard to complement verbs improved from 39.11% to 50%. in general, the eal learners performed progressively better on every verb type for both real and novel verbs, over a period of 3 years. however, the generally poor results obtained (with the exception of fast mapping of real transfer verbs), suggest that the learners experience difficulty in abstracting the meaning of verbs from the syntactic context of a sentence. ultimately, this has implications for their academic achievement, as an inability to fast map new words effectively may hinder their ability to learn academic concepts. de villiers (2004) suggests that the results from the fast-mapping items should be compared with the results from the verb-contrast items, in order to assess the ability to learn from linguistic context. this comparison indicated that the fast-mapping results in the third year of research (64.19% for real verbs, 57.41% for novel verbs) corresponded within 5% with the verb-contrast results (65.83%). these results reinforce the fact that the learners experience difficulty in acquiring english verbs merely from linguistic context. they may therefore benefit from explicit or direct teaching of english verbs and lexical organisation skills. roeper (2004) states that teachers should attempt to remove the ambiguities for eal learners by establishing linguistic contexts that support and make these skills contextually clear. vocabulary knowledge, according to adamson (1993), is the most important aspect of oral english proficiency for academic achievement. he suggests that vocabulary taught to eal learners should be explicit, and closely linked to the students’ learning needs in their subject matter classes. measures that are thought to be useful in making the classroom more accessible to these learners include common redundancy techniques such as repetition, explanation, giving examples, explicit boundary markers, visual supports, questioning and corrective feedback, and motivating learners to extend their utterances (scarcella, 2009). slts have specialised knowledge of these techniques and can be employed effectively in the classroom to assist teachers. conclusion this study has a few limitations which should be considered in the interpretation of the results. first, the investigation was limited to the assessment of semantic processing skills and excluded other equally important aspects of language processing such as pragmatics and syntax, which are also central to academic language. these processes are also assessed on the delv-cr and should be included in further research to provide a more comprehensive picture of language development in the foundation phase. second, participants were from a specific educational context in johannesburg, gauteng, where all the learners are eal. this limits generalisability of the results to other contexts in which eal and efl learners are integrated in the same classes. the influence of different educational contexts can be investigated in future studies. despite these limitations, this study has highlighted both aspects that are cause for concern and positive aspects in the development of semantic processing and vocabulary acquisition skills by foundationphase eal learners. while their significant improvement in these skills over the 3 years is positive, we do not know the consequences of such a protracted period of oral language acquisition for the development of literacy skills. this should be ascertained in future research studies. the children showing limited development over the 3 years suggest firstly, that not all eal children acquire language skills as efficiently as others and secondly, that there are children with possible language-learning disabilities whose difficulties manifest in the additional language as a lack of progress in vocabulary acquisition and organisation skills. further studies on information-processing abilities such as working memory and phonological memory may shed light on the underlying nature of these difficulties, as well as a possible aptitude for language learning among children learning through second languages in an academic context. the study confirms that there is an urgent need for establishing collaboration between teachers and slts in the education system so that language learning may be maximised. the fact that the learners showed better performance on those aspects, which we know are directly addressed through content teaching, further substantiates the basic premise that language skills can be successfully developed through explicit instruction. specifically, this study highlighted the need for instruction in vocabulary acquisition and organisation, both of which are critical for reading comprehension and therefore literacy attainment. finally, some of the eal learners in this study seem to exhibit weaknesses in verb learning, which parallel the difficulties experienced by children with language impairment (paradis, goldberg & crago, 2005). it is precisely this overlap that may lead to incorrect identification of eal learners as language-impaired, but it also raises an important theoretical question: ‘is it not a particular vulnerability in the language, i.e. the english verb system, rather than a specific deficit in the learner that results in the observed difficulties in both eal and impaired learners?’ a positive response to this question has significant implications for the definition of language impairment as a specific deficit in the language faculty (gopnik, 1990; rice, 2003; wexler, 2003). it is possible that language-learning skills are distributed on a continuum, and that those children labelled as ‘language-impaired’ are merely functioning at the lower end of the continuum. this matter warrants further investigation. however, regardless of whether the problem is due to slow eal learning or language impairment, intervention is critical since ‘language 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(2003). lenneberg’s dream: learning, normal language development and specific language impairment. in y. levy & j. schaeffer (eds.), language competence across populations: towards a definition of specific language impairment. mahwah, nj: lawrence erlbaum associates. western and traditional medicine: cultural beliefs and practices o f sa muslims with regard to down syndrome 27 western and traditional medicine: cultural beliefs and practices of south african muslims with regard to down syndrome tasneem dangor* and eleanor ross# *speech pathology and a udiology, school o f hum an and c om m unity developm ent, university o f the w itwatersrand ^social w ork, school o f h um an and c om m unity d evelopm ent, u niversity o f the w itw atersrand a b s t r a c t the aim o f the study was to investigate the beliefs a n d practices o f caregivers a n d traditional healers within the south african m uslim community regarding d ow n syndrome. an exploratory-descriptive research design was utilized which incorporated individual interviews with 10 caregivers o f persons with d ow n syndrom e as w ell as 10 traditional healers fro m the south african m uslim community. common beliefs em anating fr o m both groups relating to the cause o f d ow n syndrom e included the notion tha t this condition was genetic in origin and that such children were p erceived to be gifts fr o m god. others attributed d ow n syndrom e to a p unishm ent fr o m g od or the result o f curses fr o m people. treatment included the use o f inscriptions fr o m the quraan, w ater that had been p ra y e d over and herbal medicines. some caregivers seem ed reluctant to approach western health care professionals due to negative p a s t experiences. the main reasons f o r consulting traditional healers were cultural beliefs a n d pressure fr o m fa m ily members, their holistic approach and the perso n a l nature o f their interventions. collaboration between allopathic medicine and traditional healing was advocated by alm ost all o f the traditional healers. these fin d in g s underline the need f o r culturally sensitive rehabilitation practices in speech-language pathology and audiology; and collaboration between w estern health care practitioners a n d traditional healers. key w ords: m uslim traditional healers; down syndrome; cultural beliefs intro ductio n differences in socio-cultural experiences, ethnic histories and family backgrounds are likely to influence people’s w orldviews regarding the aetiology o f illnesses and disorders, and the par­ ticular healing m ethods followed by individuals (battle, 2002). in terms o f worldviews, there has been a tendency to distinguish between two m ain types o f health conventions, the so-called m odem approach that is located within a western m edical para­ digm and the traditional approach, w hich is based on indigenous b elief systems (hall, 1994). w estern biom edical or allopathic medicine,, is rooted in anglo-saxon and judeo-christian value bases (tjale & de villiers, 2004) and initially tended to view disease as a form o f biological m alfunctioning, w ith ill health m anifesting in chemical, anatom ical or physiological changes (ross & deverell, 2004; tjale &jde villiers, 2004). h ealing was perceived as the scientific process o f treating disease through appropriate m edical, surgical j and chem ical interventions (chalmers, 1996). however, m ore recently, there have been at­ tempts by the w orld health organization (w ho, 2002) to inte­ grate the biom edical m odel with a social model to form a b i­ opsychosocial model w hich considers bodily functions and structures, activities perform ed by an individual, level o f partici­ pation in societal activities, and the influence o f personal, and environm ental factors on functioning, disability and health. a m ajor cause o f the pre-em inence o f w estern m edical practice, specifically in south a frica, was its connection with the coloni­ alist and later apartheid regimes w hich stressed the superiority o f w estern m edical practice (tjale & de villiers, 2004:2). u niversity o f the w itw atersrand e-m ail: rosse@ um thom bo.w its.ac.za private b ag 3 tel. +27 11 717-4481 po w its fax. +27 11 717-4573 2050 johannesburg . south a frica w ithin traditional m edicine, the terms diseases, disorders, disabilities and ailments are often used interchangeably and are generally seen as arising from natural, social, spiritual or psycho­ logical disturbances that create disequilibrium expressed in the form o f physical or mental ill health. traditional healing endeav­ ours to restore harm ony and equilibrium through natural, spiritual and psychological healing w hile the concepts o f curing and heal­ ing are also often used interchangeably (du plessis, 2003). how­ ever, the problem involved in distinguishing between western biom edical and traditional healing systems is that in the process they tend to becom e polarized and the one system is often viewed as superior to the other. for example, the late edw ard said in his canonical text on orientalism (1995) discussed the skewed view o f the other, including the islamic world, w hich was based on w estern cultural hegemony. despite the existence o f cultural hegem ony, in m any countries, people from all socio-econom ic and educational strata often utilize both biom edical approaches as well as traditional practices, creating a m edical syncretism that integrates both models and has im plications for treatm ent or m an­ agem ent o f disorders and com pliance with therapy (m uela, r ib­ era, m ushi & tanner, 2002). south african speech-language therapists and audiologists are expected to render culturally sensitive and appropriate ser­ vices to families from diverse cultural, linguistic, religious and ethnic groups. hence, they need to be aware o f the beliefs and practices o f these different groups in relation to health, illness and disability, and ways o f restoring well-being. one com m unity that forms an essential part o f the fabric o f south african society is the m uslim community. however, it is acknowledged that not all m uslim s form part o f a hom ogeneous community; nor do they share the same cultural ideologies in relation to health and heal­ ing, illness and disability. down syndrome is a disabling condition that affects over two m illion people worldwide (the n ational down syndrome society, 2004). in south africa, m any children with d ow n syn­ the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:rosse@umthombo.wits.ac.za 28 tasneem dangor and eleanor ross drome are currently undiagnosed. nevertheless, the condition w ould appear to be prevalent with a hospital /clinic diagnosis esti­ m ated to occur in less than 20% o f cases (christianson, 1995). however, despite the relatively high prevalence o f the condition, there would seem to be a paucity o f research focusing on the views o f mem bers o f the south african m uslim com m unity re ­ garding the causes and m anagem ent o f d own syndrom e or the healers that are com m only consulted in this regard. speech-language therapists and audiologist have an im por­ tant role to play, not only w ith respect to the cognitive, speech, language and hearing sequelae o f down syndrome, but in support­ ing people with d own syndrome and their families and caregiv­ ers, more specifically in multicultural settings. attitudes o f caregivers and healers often play a major role in deciding whether the child will go to school and be placed in a stimulating environm ent that promotes learning, either a special school or inclusive educational setting or rem ain at home. m an­ agem ent approaches are often influenced by cultural and religious beliefs and practices and also depend on socio-econom ic factors as well as access to facilities and resources, including mem bers o f the m ultidisciplinary team. a lthough caregivers and parents form an integral com ponent o f an effective intervention program m e in a natural setting, formal and more structured therapy should not be overlooked (bernstein & tiegerman, 1999). furtherm ore, therapy does n ot take place w ithin a vacuum, but occurs w ithin a social and cultural context. culturally sensitive practice is likely to make clients feel more com fortable in therapy; can potentially increase client compliance; and increase the likelihood o f successful treat­ m ent and interventions being achieved (d avis-m cfarland, 2002). culture and religion are inextricably intertw ined within the south african m uslim b e lie f system. a m uslim is one who sub­ mits to one g od and is a follower o f the teachings o f prophet m u­ ham m ad, who is regarded as the final messenger. w ithin islam, illness, disease and disability are all seen to be a llah ’s (g od’s) will, sent down by god. adherents o f islam are expected to act w ith compassion towards the poor, the sick and the disabled. m uslims also believe that the prophet m uham m ad was sent as a m ercy to mankind, given the wisdom by a llah with regard to healing. this approach to healing is know n as prophetic medicine (tibb-an-nabawi). it is not restricted to spiritual healing, but in­ stead balances the healing o f the soul and the physical being, so as to prepare man for the hereafter (jauziyah, 1999). the birth o f a child with a disability is not easily accepted w ithout feeling sorrow and having negative emotions. w hat helps people to deal with these feelings is the worldview to which one subscribes. caring for a child with a disability or disorder is seen as a form o f ibadah (worship). another w ay o f approaching this experience is as a challenge or test from god. d evout muslims believe that g od does not give them a test w ithout providing m ethods, which they can use to deal with this tragedy. adherents to islam are advised to share their tragedy w ith others, perform additional prayers, give extra charity and request others to pray for them (sakr, 1996). islam considers the world as a place in w hich difficulties and calamities are natural components. by know ing that difficulties are placed upon everybody and not ju st the individual, the feelings o f distress can be shared particularly with other fam ily mem bers (bayanzandeth, bolhari, ghasemabadi & ramasani, 1997). in m any eastern cultures, including the south african m us­ lim culture, families exist w ithin extended fam ily systems that form part o f collectivistic com m unities (tom oeda & bayles, 2002). a great deal o f respect, authority and decision-m aking is accorded to the elderly mem bers, as they are perceived to have acquired great wisdom. the illness o f one individual is usually seen as a predicam ent affecting not only the nuclear family but also m embers o f the extended family, and one is expected to re­ spect the advice given by older fam ily mem bers. d uring such times, one is also expected to make use o f the agents that god has provided. this includes a responsibility to seek adequate medical (or other) advice. in this regard, western health care professionals and/or eastern traditional healers m ay be consulted (bayanzadeth et al., 1997). there are three m ain groups o f m uslim traditional healers: firstly, there are m oulanas who are spiritual healers that occupy an essential and honoured position within the m uslim culture and are consulted by m any south african m uslim s for psychological, m edical and social problems. they are defined as pious islamic scholars who are well learned in all aspects o f the religion o f is­ lam. secondly, there are hakeem s, also know n as m uslim physi­ cians, who are also consulted by the south a frican m uslim com­ munity. their services include the providing o f ointm ents and m ixtures, which are m ade from herbs that are know n to have bene­ ficial healing properties and are designed to restore imbalances in the body humors i.e. blood, phlegm, bile and spleen. in addition, g ift healers, who are blessed with supernatural powers, also assist the south african m uslim families with healing/treatm ent o f vari­ ous illnesses and disabilities (desai, 1998). a lthough accurate figures are not available regarding the num ber o f south a frican m uslim s who consult w ith m uslim tradi­ tional healers, it is estim ated that approxim ately 8 out o f 10 black south africans consult w ith various types o f traditional healers in conjunction with or in preference to western trained medical prac­ titioners (keeton, 2004). the w orld h ealth o rganisation (who) also recognizes traditional healing as an integral part o f the pri­ m ary health care system in developing countries (w orld health organization, 1978:429). consequently, several studies have fo­ cused on traditional healers’ approaches to various disorders. for example, in terms o f a frican traditional healers, du plessis (2003) investigated their approaches to hiv/aids; de andrade & ross (2005) explored beliefs and practices in relation to hearing impair­ ment; while platzky & g irson (1993) focused on stuttering. a ccording to d agher & ross (2004) beliefs regarding the causation o f birth anom alies are not always grounded in empirical science, but are often understood from a m agico-religious or cul­ tural perspective (tjale & de villiers, 2004). for example, badat (2003) interviewed a group o f m oulanas from the g auteng mus­ lim com m unity regarding their approaches to cleft lip and palate. a com m on b e lie f was that cleft palate is g od sent and should not be questioned. participants in her study acknow ledged the exis­ tence o f various superstitious beliefs and practices in the muslim community. for instance, if a pregnant w om an handled a sharp object during the time o f an eclipse, her baby was likely to be born w ith a birth anomaly. in b adat’s (2003) study, emphasis was also placed on prayer and tarweez, which is an inscription from the m uslim holy scriptures w ritten on a piece o f cloth and usually w orn in the form o f an amulet. however, despite the relatively high prevalence o f down syndrome w orldwide, and the fact that m any speech-language therapists and audiologists render services to these individuals and their families, few, if any studies have focussed on the approaches o f south african^m uslim traditional healers and caregivers in relation to this condition. for these rea­ sons the study aim ed to investigate the beliefs and practices of caregivers and traditional healers within the south african muslin1 com m unity in g auteng regarding down syndrome. it was antifl' pated that this research w ould have im portant implications f°r d ie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) western and traditional medicine: cultural beliefs and practices o f sa muslims with regard to down syndrome 29 cross-cultural awareness and culturally sensitive rehabilitation practices for various disciplines functioning in m ulticultural set­ tings; im proved referral systems and collaboration betw een w est­ ern trained health care professionals and traditional healers; incor­ poration o f cultural issues surrounding health and illness into the training curricula o f health care professionals; and further re ­ search. it was also felt that the study was both relevant and timely, given the recent prom ulgation by the south african governm ent o f the traditional health practitioners bill in 2004, w hich is de­ signed to incorporate traditional practitioners into the formal healthcare system and regulate their practice (keeton, 2004). m e t h o d o l o g y aim the aim o f the study was to investigate the beliefs and practices o f caregivers and traditional healers w ithin the south african m uslim com m unity regarding down syndrome. objectives objectives with respect to the caregivers were: 1. to obtain information regarding the time o f diagnosis, the person who conveyed the diagnosis, and participants’ under­ standing o f the term d ow n syndrome; 2. to probe personal and cultural beliefs regarding the aetiol­ ogy o f d own syndrome; 3. to elicit views regarding the m anagem ent o f d own syn­ drome w ith regard to the use o f traditional healing, medical approaches, speech-language therapy and audiology and other param edical interventions; 4. to ascertain whether caregivers had consulted w ith medical doctors, speech-language therapists and audiologists and other param edical professionals; and to explore their experi­ ences w ith these w estern trained professionals. objectives with respect to the traditional healers were: 1. to elicit from the traditional healers, personal and cultural beliefs about the aetiology o f down syndrome; 2. to examine the various m ethods used by the traditional heal­ ers to m anage/treat d own syndrome; 3. to probe attitudes o f traditional healers towards allopathic m edical practitioners and collaboration w ith western m edi­ cine; ; 4. to explore the views o f traditional healers regarding the rea­ sons for being approached by caregivers in relation to down syndrome. research design an exploratory-descriptive research design, incorporating a two-group, parallel study was employed. the rationale for adopt­ ing an exploratory-descriptive design was that it allowed explora­ tion o f a relatively unchartered area, while providing the opportu­ nity for obtaining a rich and detailed description o f m uslim tradi­ tional healing in relation to d own syndrom e (terreblanche & durrheim, 1999). the two group, parallel study, enabled the re ­ searchers to conduct individual interviews w ith a group o f care­ givers and a group o f traditional healers and thereafter to com pare the findings and extract differences and similarities from the data. due to tim e constraints, triangulation or the use o f m ultiple m eth­ ods (denzin & lincoln, 1998) was not undertaken and other m eth­ ods o f data collection were not selected. participants a purposive, non-probability sample o f 10 caregivers o f children with down syndrom e as w ell as 10 traditional healers was recruited from the lenasia, g auteng area. w ithin the purposive sam pling paradigm , “snow ball sam pling” was em ployed. prospec­ tive participants w ithin the m uslim com m unity were approached. t hey in turn were asked to obtain perm ission from other potential participants before giving their contact details to the researcher. a dvertisem ents were also placed in the local com m unity new spa­ per and on the islamic radio station, inviting mem bers o f the m us­ lim com m unity to volunteer for participation in the study. h ow ­ ever, it is acknow ledged that using a volunteer sample m ay have introduced sources o f bias. p articipan t inclusion criteria the participants were required to be south african m us­ lims, as they were likely to have an understanding and knowledge o f the com m unity’s cultural beliefs that influence their decisions. confirm ation o f the diagnosis o f down syndrome needed to have been m ade by a medical practitioner. the 10 caregivers needed to be direct and prim ary caregivers o f the child with d own syndrome and could be any m em ber o f the affected individual’s immediate family. t he traditional healers needed to be specifically trained or to have acquired some years’ experience in traditional healing so that they w ould be able to com m ent on the type o f traditional heal­ ing approaches adopted in relation to down syndrome. they also needed to have been consulted with respect to at least one person with d own syndrome. d escription o f participants the caregivers were all female and w ere all o f indian ex­ traction. eight o f the caregivers were m others, one was a sister and one was a grandm other to the person with down syndrome. the ages o f the caregivers ranged from 21 to 80 years. five o f the indi­ viduals w ith down syndrome were males and five w ere females and their ages ranged from one to 30 years. the traditional healers com prised five m oulanas, two hakeems, two spiritual healers and one herbalist. n ine o f the h eal­ ers were m ale and one was female. in terms o f ethnic group, eight were indian, one was black and one was o f m ixed descent. the period o f time spent practising traditional healing ranged from two to 22 years. r esearch instrum entation the study incorporated two sem i-structured interview schedules presented in the form o f individual interviews. copies o f the interview schedules for the caregivers and traditional healers are set out in a ppendices a and b respectively. several o f the questions were adapted from studies by bham & ross (2005) and badat (2003) and included both open and closed-ended items. both schedules were divided into two sections, nam ely a section on biographical information and a section on inform ation pertain­ ing to beliefs and practices in relation to down syndrome. content validity o f the interview schedules appeared to be dem onstrated as sufficient aspects covering the content o f the topic were investigated. in addition, a university researcher who was fam iliar w ith the area o f traditional healing scrutinized the inter­ view schedules. this person was o f the opinion that the schedules the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 30 tasneem dangor and eleanor ross had face validity as they appeared “on the face o f it” to measure w hat they purported to measure. research protocol pre-testing the interview schedule a fter ethics clearance was obtained from the u niversity ethics committee for r esearch on hum an participants, the inter­ view schedules were pre-tested on persons with sim ilar characteris­ tics to the target group. these persons were excluded from partici­ pation in the final study. due to difficulties experienced in recruit­ ing sufficient participants, pre-tests were conducted with only one m oulana and one caregiver. the pre-tests indicated that the inter­ view was fulfilling its purpose as the participants stated that they understood all the questions. thus no am endm ents were made. data collection follow ing the pre-test, the inform ation sheets and consent form s were sent out to the prospective participants. the researcher contacted both caregivers and traditional healers by telephone and invited them to participate in the study. individual appointments were made and thereafter, interviews were carried out with the traditional healers and caregivers. in order to com ply with m uslim traditions, the researcher who conducted the interview s attired her­ se lf in the appropriate m uslim dress for a female, w hich is a cloak and a head scarf, and was accom panied by a male figure to all in­ terviews with persons o f the opposite sex. she also used the appro­ priate greetings on arrival and on term inating the interviews. interview s with caregivers an d traditional healers: all the interviews w ith the caregivers took place in the com ­ fort o f the participants’ hom es and at times that were convenient for them. m ost o f the interviews with the traditional healers were conducted in places w here the traditional healers usually consulted with their patients. these areas were in the yards or gardens, close to the traditional healers’ hom es or in their offices. a t the begin­ ning o f the interviews, participants were shown pictures o f children with d own syndrom e so as to ensure correct recognition o f the syndrome. a lthough the original intention was to audiotape the interviews, participants tended to be suspicious o f and resistant to this procedure. hand w ritten field notes were therefore made o f all the responses provided by the participants. data collection contin­ ued until 10 caregivers and 10 traditional healers had been inter­ viewed, because at this point data saturation appeared to have been achieved. a ccording to leininger (1994 in m axwell & satake, 2006), saturation implies that the researcher has perform ed a “thick” description in an exhaustive effort to extract as much m eaning as possible from the data until no m ore can be said about the topic. d ata analysis the closed-ended items were analysed using descriptive statistics involving simple frequency counts, while semantic con­ tent analysis was applied to the open-ended questions in order to highligfit com m on them es expressed by participants. content analysis is a research m ethod for assem bling and analysing the content o f a text (terreblanche & durrheim, 1999). m orse (1994) has divided content analysis into two types, nam ely semantic con­ tent analysis (m anifest) and inferred content analysis (latent), se­ mantic sontent analysis is used to convey what the participants have said, while inferred content analysis infers or goes beyond w hat was said or written. n eum an (2003) em phasises the need to ensure the trustwor­ thiness or truth value and authenticity o f the qualitative framework (com parable to the positivist notions o f validity and reliability) by adopting the criteria developed by guba & lincoln (1989), namely credibility, transferability, dependability and confirm ability. by using semantic rather than inferred content analysis, the researcher aim ed to establish credibility (paralleling internal validity) o f the data as representing the “real w orld” as perceived by the partici­ pants. in terms o f transferability (which is com parable to the posi­ tivist construct o f external validity or generalizability), it was an­ ticipated that the information obtained from this study would be applicable to other therapy situations as well as to professionals who encounter clients from the m uslim com m unity in south af­ rica. in order to enhance dependability (the alternative to reliabil­ ity) o f data analysis, the same person conducted all the interviews and systematic steps adapted from terreblanche & durrheim (1999) were followed. these steps included: firstly, familiarization and immersion, which involved putting into sim pler terms by means o f reading through, m aking notes, draw ing diagram s and brain storming to obtain a general idea o f the findings; secondly, inducing themes, w hich im plied inferring general rules or classes from specific instances in a bottom up process; thirdly, coding, w hich encom passed the m aking o f different sections o f data as being instances o f or relevant to one or more o f the researcher’s themes; fourthly, elaboration, w hich involved synthesising infor­ m ation in a linear sequence; and fifthly, analysing data, interpre­ tation and inspection which included going back to all the above steps to make sense o f the data. in order to reduce researcher bias and establish confirm ability (or objectivity) o f the data, correspon­ dence checking advocated by pretorius & de la r ey (2004:31) was undertaken, whereby the prim ary researcher’s categorization o f them es was checked by her research supervisor for correspon­ dence. once agreem ent had been reached regarding categorization o f themes, these were quantified. resu lts and disc u ssio n part one: results from the interviews with the caregivers o rientation to the syndrom e i time o f diagnosis eight out o f the 10 caregivers stated that their children were diagnosed at birth. however, one participant stated thatithe first diagnosis was made during her pregnancy via an am niocentesis test. a nother mother reported that her son was only diagnosed about six months after birth. | persons who m ade the diagnosis the entire sample that was interviewed stated that their children were diagnosed w ith d own syndrome by either a gynae­ cologist or a paediatrician. understanding o f d own syndrom e nine o f the participants appeared to be aware o f the main features and characteristics o f children with down syndrome. re­ sponses included: ‘genetic disability with one less chromosome, m ongolian; l ow ears with w eak m uscle tone; d ry skin a n d prone to upper respiratory tract infections; f loppy child with stum p f i n ­ gers and two segm ents on the baby fin g er; two years slow er than norm al children. som e have a leaking heart a n d som e are mentally reta rd ed ’. however, a m other o f a four-year-old child with down die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) western and traditional medicine: cultural beliefs and practices o f sa muslims with regard to down syndrome 31 syndrome adm itted that she did n ot understand the m eaning o f the term down syndrome. genetic counselling seven o f the 10 participants inform ed the researcher that they had not been for genetic counselling. one m other gave the following reason for refusing to go for genetic counselling: ‘as a m uslim i had a child a n d was never g oing to abort, thus i fo u n d it meaningless. a fter m y d ow n syndrom e son i had two p erfectly norm al twins. ’ in contrast, one m other found that the genetic coun­ selling was useful. "my fa th e r fin a lly accepted m y son, as m y f a ­ ther was very sensitive a n d defensive a n d sa id i f anyone sa w my son they w ould laugh. ’ beliefs o f caregivers regarding the cause o f down syndrom e p ersonal beliefs regarding the aetiology o f d ow n syndrom e it should be noted that the participants tended to regard terms such as “heal” and “cure” as synonyms, w hile concepts such as “illness, disorder, disease, ailm ent and condition” were used interchangeably. a com m on b e lie f m entioned by five o f the participants was that all illnesses and birth conditions were due to g o d ’s will. this belief was sim ilar to findings by b ham & ross (2005) that m any o f the m uslim participants w hom they interviewed felt that strokes were due to g od’s will. two participants were convinced that the child was a gift from god and one must w illingly accept it and not question, ‘ why me g o d ?' o ne m other stated: ‘this is a heaven special child and only fo rtu n a te peo p le g e t these children.' a further two participants attributed the cause o f the condition to genetic factors and understood the scenario o f trisom y chrom osom es. inter-m arriage was also related to genetic factors, as one o f the participants felt that if m arriages occurred between husbands and wives who were too closely related, the risk o f having a child with down syndrome was high. one participant felt that the age o f the m other or father was one o f the causes o f down syndrome. this idea is supported in the research literature as the maternal age related risk for down syndrome is low er at age 20 (one in 1734 births), but higher at age 35 (one in 386 births) (h arperv 1998). , i c ultural beliefs regarding the aetiology o f d ow n syndrom e in addition to personal beliefs regarding the aetiology o f down syndrom e, caregivers were also asked i f they were aware o f the existence o f any cultural beliefs in their com m unities relating to this condition. four o f the participants explained that according to their culture, having a child with a disability, such as d own syn­ drome, was regarded as a punishm ent from god. punishm ent was directed to the m other, who was perceived to have committed wrong deeds in her past life. o ne caregiver em phasised that these were cultural beliefs, not islamic beliefs. furtherm ore, cultural beliefs assum ed by the com m unity were found to be closely linked to beliefs held by m any o f the participants themselves. this find­ ing was consistent with the results obtained by bham & ross (2005). several o f the m uslim caregivers and traditional healers whom they interviewed m entioned cultural beliefs regarding stroke being a form o f punishment. four o f the participants also suspected jadu (evil curses) from fam ily and friends. o ne participant added: ‘these beliefs are myths which need to be eradicated fr o m our thought patterns. in line with these findings, d agher & ross (2004) noted that the a fri­ can traditional healers in their study believed that cleft palate was caused by ancestors, spirits and witchcraft. in a sim ilar vein, three participants m entioned that m any people in their culture were u n ­ aware o f the cause o f d ow n syndrome. for example, one partici­ pant noted, ‘these ignorant p eo p le often laugh a t my son. ’ m anagem ent o f down syndrom e six o f the caregivers reported that they had consulted tradi­ tional healers regarding the m anagem ent o f their children with down syndrome. several o f the participants explained that m any o f the elderly mem bers o f their com m unities and fam ilies insisted on the use o f traditional healing. this finding was in line with the views expressed by those o f tom oeda & bayles (2002) who m ain­ tain that in collectivistic cultures such as those o f indian m uslim s in south africa, m embers o f the fam ily group tend to exert a direct influence on decisions about treatm ent options. one caregiver noted that her son was constantly being ad ­ m itted to hospital and that doctors had told her that he was not going to live long. she then approached a m oulana who gave her the tarweez and advised her to read a few verses from the q uraan in order to improve his condition. 7 was happy with the results as my s o n 's condition im proved and he also stopped crying so much ’. a nother caregiver m entioned that she took her granddaughter to a m oulana. she reported that the m oulana had read from the quraan for her granddaughter and thereafter her speech had becom e clearer. in this respect, it should be noted that traditional medicine has been shown to have several benefits, including reduced anxiety through a shared, unquestioned b e lie f in the powers o f the healer (h am m ond-tooke, 1989). one o f the participants explained that she did n ot approach traditional healers as she and her husband felt that one should ask god directly for help. she added that she and her husband read from the quraan on a daily basis and they had seen trem endous im provem ent in their daughter’s health. a nother participant shared a sim ilar view and encouraged people to read the quraan daily, as it contained shifa (cure) and a m ercy for all mankind. one participant was convinced that her daughter was a gift from god and that she had to accept her the w ay she was. a nother participant explained that her brother was physically disabled and this factor m otivated her to take care o f g od’s creatures h erself and not seek cures for disabilities. one participant inform ed the researcher that a h akeem had provided him with a herbal ointm ent to strengthen his son’s legs. “soon after treatm ent my son sta rted walking. h e also p ro vid ed m y son with a syrup f o r his constipation and this too was useful a n d i have lots o f fa ith in this h akeem a nother participant re­ ported that he approached a h akeem , not to cure his son o f down syndrom e but m erely to get her rem edy for his heart condition. she provided a diet to follow which included goat’s m ilk and som e herbal powders. the father noted that his son lost w eight and he then discontinued the diet and was not satisfied w ith the h ealer’s managem ent. a nother participant explained that her h akeem had provided her with a herbal mixture in a liquid, but her son, who was very small at time, did not drink it. thus she was not sure if it would have been effective. the caregivers’ attitudes towards western m edicine a pproaching m edical d octors] six o f the caregivers stated that they had approached m edi­ cal doctors. these participants were convinced that the doctoi the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 32 tasneem dangor and eleanor ross could assist them with this m edical condition. one o f participants explained that the doctor she approached was very encouraging and provided her with advice and m anagem ent strategies. a nother participant reported that her doctor introduced her to other m oth­ ers/caregivers o f children w ith down syndrome, which helped her deal with her feelings towards her child and contributed to more effective care and m anagem ent o f the condition. four parents stated that they had independently searched the internet and read books to assist them in the m anagem ent o f their children. t hey found the doctors to be unhelpful in terms o f giving advice, and lacking in counselling skills regarding dealing with parents’ feelings. a nother m other inform ed the researcher that her doctor had told her that her baby was going to be deaf. h owever, she explained that she and her husband used to read from the quraan and that her daughter hears perfectly well. conse­ quently, she no longer takes the doctors’ theories o r their progno­ ses in respect o f her child seriously, but perseveres with faith. a pproaching p aram edical professionals o f all the participants who were interviewed, nine stated that they had approached speech-language therapists to assist in the rem ediation process o f their children with d own syndrome. a m ong the nine children who did attend therapy, seven were cur­ rently attending, either privately or at schools. all nine caregivers stated that they had experienced success in therapy. however, one m other explained that she term inated therapy as she felt that her son had reached a plateau at the age o f 12 years. exam ples o f use­ ful aspects o f therapy included buying toys that depicted every day routines in order to facilitate basic identification; encouraging the child to vocalize and to expand his or her sentences; avoiding b aby talk; and using gestures to com plem ent verbal input. the im pression gained was that caregivers had insight into the speech language therapy services provided for their children and had im­ plem ented the advice o f speech-language therapists. the one par­ ticipant who did not approach a speech-language therapist noted that her daughter started talking spontaneously and she therefore did not find the need for speech-language therapy intervention. n one o f the participants m entioned using audiological services. five o f the caregivers reported that they had consulted with other param edical professionals including physiotherapists, occu­ pational therapists, paediatricians, cardiologists and counsellors. those that had approached these param edical professionals re­ ported being satisfied with their services. however, two o f the caregivers m entioned that they did n ot find the need to seek pro­ fessional help as their children were developing adequately. care­ givers articulated the view point that they felt m ore secure and re­ laxed about going to professionals who understood their culture and their use o f alternate remedies. part two: r esults from the interview s w ith the traditional healers ten traditional healers were interviewed, all o f who reported that they had treated children w ith down syndrome. beliefs regarding the cause o f dons syndrom e p articipants’ views were elicited on the causes o f the down syndrome as it was felt that the cause w ould reflect societal beliefs about the condition. five o f the participants were o f the opinion that the aetiology o f d own syndrome could be attributed to ge­ netic factors. one o f the participants added that when family mem bers inter-m arry this behaviour also causes the child to be b o m with some kind o f anomaly. five o f the participants attributed down syndrom e to god’s will. t hey noted that babies that are bom with such a disorder are all in g o d ’s (a llah’s) hands and we should avoid questioning god. furtherm ore, such an experience was considered a ‘test’ for the parents. ''keep in m ind that sickness is given to the p a tie n t as a trial f o r the p a tie n t h im se lf or h e rse lf a n d f o r their f a m i l y this finding was consistent w ith the islamic b e lie f that the rew ard in the life to com e is based on how one reacts to a ‘te st,’ nam ely how one treats a disabled child (sakr, 1996). one participant also men­ tioned in passing that abortion, am niocentesis and sterilization were contrary to the teachings o f islam. a further theme that em anated from the responses o f four o f the participants related to cultural beliefs in curses, also known as jadu, and evil eyes o r evil spirits (jinn) from other people. hall (1994) suggests that some people are believed to have native pow­ ers, which they utilize together with medicines or charm s to inflict hurt on others. c am pbell (1998) maintains that supernatural and m agico-religious b e lie f systems distinctive to each culture, are often alien to and not easily understood by allopathic practitioners. two out o f the 10 participants attributed the condition to an im balance betw een h ot and cold in the body, w hich caused the child to be b o m with down syndrome. this im balance was re­ ferred to by the hakeems as a disequilibrium in the b o d y ’s hu­ m oral system. it was believed that this im balance could have oc­ curred during the m other’s pregnancy. they believed that the prac­ tice o f looking at the symptoms in isolation, provided only short­ term relief, rather than long term healing. they thus advocated a m ulti-dim ensional approach, which took into account an under­ standing o f patients them selves, their life contexts and life styles, and finally the ways in w hich their spirit-m ind-body interacted w ith each other in an attem pt to achieve balance and healing, thereby attem pting to establish hom eostasis o f the spirit-mind body. in this w ay one could heal the w hole patient and not just alleviate the symptoms. this type o f approach appeared to be de­ rived from unani tibb or tibb, w hich is a holistic healing system based on the philosophies o f h ippocrates, the father o f western m edicine (sykiotis, kalliolias & papavassiliou, 2006), and the well know n islamic scholar, philosopher and physician ibn sina. tibb is a type o f natural m edicine which takes into account the individ­ u a l’s body, mind and soul. tibb was practised about 150 years ago and is the foundation on w hich m odem medicine is based. unani tibb is recognized in south africa, largely due to it. being cost effective and providing an effective understanding o f the aetiology o f illness. the principles o f tibb are in accordance with the q uraan and the teachings o f the prophet m uham m ed (sina, 2004). it was clear that the traditional healers who were inter­ view ed were concerned w ith the reasons w hy a particular disease has occurred and that the search for causality was perceived to be one o f their greatest assets. in contrast with the finding that the traditional healers who were interviewed, were concerned with the reasons why a particular disorder had occurred, g reen (1988) sug­ gests that western m edical practitioners tend to show m ore concern w ith control as opposed to considering the root o f the problem. the im portance o f holistic healing highlighted by the two hakeem s, is also shared by m any black south african traditional healers, who believe that i f the m ind is healed the body takes care o f itse lf (d agher & ross, 2004). this assum pti6n contrasts with that o f western medicine, w hich contends that i f the body is healed the m ind takes care o f itse lf (hall, 1994). one o f the h akeem s noted that he usually asked h im self the follow ing questions derived from selzer (2004) during his consul­ tations, namely: ’1) what does a symptom mean? 2) h ow should it die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 55, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) western and traditional medicine: cultural beliefs and practices o f sa muslims with regard to down syndrome 33 be listened to? 3) what does this p a tie n t’s sym ptom mean in this particular p a tien t as opposed to another patient? 4) what does this sym ptom tell us about the totality o f this p a tie n t fr o m the sym p to m ’s picture? 5) h ow can i as a practitioner, be o f the greatest help to this p erson in his wholeness, a n d assist his soul m ind body com plex to achieve its healing? ’ (selzer, 2004:10). one o f the participants stated that the ruh (soul) asks god to be b o m in that state, i.e. with d ow n syndrome. he added that god provides healers and parents with the know ledge to cope with a child with d own syndrome. he further noted that g od pun ! ishes the parents by giving them a child with d own syndrome, so that the parents can becom e more conscious o f god and becom e more loving. a fem ale spiritual healer attributed the aetiology o f down syndrome to a virus, and believed that som ething had gone wrong in the m other’s womb. she explained that it was a natural devel­ opment and that there was a negative influence, w hich disturbed the developm ent o f the foetus. inform ation regarding m anagem ent o f dons syndrom e three m oulanas indicated that they w ould provide the p a­ tient w ith a tarw eez (an inscription o f verses from the q uraan on a | piece o f paper). a tarweez is usually w orn around the neck or | attached to the child’s clothing. the tarw eez serves to provide the child with protection against any evil and eradicates any evil pro ! jected onto the child. one o f the moulanas noted, ‘for every ill­ ness there is a cure, and m uslim s are encouraged to believe in the unseen’. this participant also encouraged people to approach i m edical professionals for treatm ent as god has made them avail­ able in order to help people. a nother participant noted that he had used tarweez to help stabilize the child, and the child then started “thinking and talking” , i one m oulana m entioned that he gave his patients oils, w hich were either part o f a m ixture or on their own to be applied to the body and head. in addition, he provided them with five | different types o f seeds. h e encouraged them to drink alm ond milk, which he first prayed over. the m oulana also m entioned the i use o f holy w ater (w ater that he prayed over), which he provided to m ost o f his patients. a nother m ethod that he used was to advise his patients to put salt on their bodies at night, as it ‘cools the body and makes life easy ’. j the same m oulana m entioned the use o f honey in com bi ; nation w ith hot water. he em phasised that honey was a cure for m any illnesses as stated b y the prophet muhammed. j the hakeems reported that they would exam ine the patient 1 and establish which hum our was [blocked or not functioning opti­ mally. treatm ent included changing a certain aspect o f the tem 1 peram ent o f one o f the four hum ours by providing herbal m edica­ tion. this herbal m edication often consisted o f an infusion o f powders that assisted in balancing the hum ours, attem pting to harness the b o d y ’s energy to treat itself. one o f the hakeems noted that when the illness was evi­ dent from birth as in children with d own syndrome, eradicating or achieving hom eostasis o f spirit-m ind-body was impossible. in­ stead they assisted these children by providing m edication in the form o f herbs that m inim ized the degree o f the problem. he ex­ plained that he had once provided a child with d own syndrome with a herbal balm to aid his joint/w alking pains as the leg was i very cold. a nother point that he m entioned was that children with i d own syndrom e often straggled to talk as ‘the tongue was drier a n d colder than it should b e he therefore provided m edication to increase the moisture and heat |on the tongue and this process helped to increase blood flow to the tongue. he believed that this action made the tongue m ore mobile, thereby prom oting speech production. in addition, he stressed the fact that treatm ent was ‘holistically based taking into account the m o th er’s pregnancy, the child, the effect o f the condition and his environm ent’. herbal treatm ent was identified by two o f the participants. a herbalist noted that he provided a child, w ith d ow n syndrome who had a severe hearing problem, w ith a herb m ixture in the form o f porridge, which the child had to eat every m orning. h e also provided him with a mixture, which he had to take in the m orning and at night. the herbalist stated that this child used to be hospitalised every m onth, but after his treatment, doctors were am azed at his im proved health. his m ain m edicines were made from plants, herbs and pow der o f seeds and roots, juices, leaves and minerals. on probing the specific herbs that the healer pre­ scribed for children with d own syndrome, he replied that it was his secret. ham m ond-tooke (1989) suggests that m any herbalists possess know ledge o f natural substances, which have an authentic rem edial effect but are n ot always w illing to share this know ledge out o f fear that this knowledge will be appropriated b y others which highlights the need to protect the intellectual property rights o f traditional healers. one participant em phasised the fact that no m atter what approach to m anagem ent o r treatm ent a person pursued, success and recovery were all in g od’s hands. two o f the participants believed that spiritual healing was a necessary procedure that had to be im plem ented as part o f the treatm ent o f d ow n syndrome. firstly, perm ission is sought from god to w ork on the child. thereafter they scan the body from the spiritual realm and then intervene via touch therapy. m any traditional healers believed that the cause o f d own syndrom e was due to evil spirits that had possessed the m other and the child. the spiritual healing is a process that helps to dispel the evil spirits and cleanse the patient. a nother spiritual healer m entioned that she w ould m eet both the m other and child and then clear the m other o f evil spirits that she had been carrying during pregnancy. she noted that her treatment, w hich included a com bination o f touch therapy, reiki, automatic writing and m as­ sage, helped to rem ove any negativity within the child or m other and assisted with various difficulties. one participant noted that counselling o f the parents forms an integral part o f his treatment. he dem onstrated to the parents how to approach their child with love, and com forted them by assisting them to deal w ith their spiritual needs. v iew s o f traditional healers regarding the reasons for being approached by caregivers o f children w ith down syndrom e the issue o f culture and pressure from fam ily mem bers was strongly em phasized by eight participants. one healer noted that the elderly mem bers o f the m uslim com m unity tend to feel that alternative m ethods o f healing should be attempted. he ex­ plained that m any o f these elderly people have a strong b e lie f that some ailm ents are caused by unseen forces. they also believe that religion holds a cure for m any ailments, and can improve the well being o f the child. a nother participant shared a sim ilar view and stated that ‘many peo p le have fa ith in what their grandparents believed as they grew up strong a n d h e a lth y ’. this theme was articulated by four o f the healers. one o f the participants rem arked, ‘ we w ork with uncondi­ tional love. m any o f our peo p le maintain that modern doctors are g enerally in a hurry a n d they do not give enough time, care and the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 34 tasneem dangor and eleanor ross attention, in contrast to traditional h ealers’. several o f the tradi­ tional healers em phasized the im portance o f establishing a rela­ tionship of trust and unconditional positive regard with people w ho consulted them. this approach is similar to that advocated by m any western counselling professionals (e.g. manning, 2001). t he argum ent p ut forw ard was that western doctors derived most o f their answers from the patient, whereas traditional healers con­ firm ed what their patients conveyed to them. a m oulana em pha­ sised the fact that h e took the tim e to converse with children with d own syndrom e as m any m ight be m entally handicapped. 7 g reet them and hear their stories and i see a little world open, beauty and not ju s t a child with down syndrome. i m ake the child com fortable and make the child develop a liking towards me and build up his co nfidence’. another participant explained that he sat with these children, was sensitive to their needs and paid par­ ticular attention to the w ay in which he addressed them. this them e of a holistic approach was encapsulated in the responses of four participants. one o f the h akeem s noted that caregivers tended to approach him m ore often than m edical pro­ fessionals as h e provided a holistic approach to assessm ent and treatment. a spiritual healer attributed the popularity o f her treat­ m ent to her approach being a com bination o f physical and spiri­ tual dimensions. this preference for a holistic approach to treat­ m ent was consistent with results docum ented by b ham & ross (2005) and badat (2003). previous successful results with other patients was a com ­ m on them e m entioned by three participants. thus these patients usually recom m ended other persons to their traditional healers. o ne o f the spiritual healers mentioned that she was well known w ithin her com m unity and i f the illness or condition recurs she goes back to the birth o f the child to discover the original cause. 'moreover, ju s t like people have fa ith in certain doctors, they believe ou r hands are g o o d a t healing. m any peo p le perceive my approach a t a lower level and one that is m ore affordable. there has been a revolution in that many people approach traditional h ea lers’. t he herbalist stated: ‘h erbalists can help cure things, such as bone fra ctu res a n d we can also help control illnesses such as diabetes. therefore we are successful like the doctors in treating people. likewise, we are able to control a n d manage conditions such as down syn d ro m e’. three participants em phasized that when all else fails within the world o f m odem m edicine, people tend go back to their roots in order to find a cure. this finding is similar to the assertion by c am pbell (1998) that traditional healers are usually well respected, accepted and trusted by their com m unities be­ cause they are culturally and religiously congruent with their own beliefs and practices. one traditional healer expressed the view: ‘t hey com e for security; dependent on you for a cure .. .they usually com e and see us to alleviate them from guilt. they w ant some kind of rein­ forcem ent that it is not their fault’. finally, one participant stated: ‘t hey think they’ve been cursed’. the traditional healers’ attitudes towards allopathic m edical practitioners and collaboration with w estern m edicine nine out o f th e 10 traditional healers w ho were inter­ viewed reported that at som e point they had advised the parents o f children with down syndrom e to approach a m edical doctor. o ne o f the participants expressed the view that he would like to w ork with doctors and therefore advised parents to approach die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 m edical practitioners. a spiritual healer reported that she had re­ ceived a prophecy to w ork with doctors. a nother participant ar­ ticulated the opinion that if his treatm ent was unsuccessful he then referred to doctors. in line with these findings, it has been noted that some traditional healers take a keen interest in primary health care training provided by m odern form al m edicine (van w yk, van o udtshoom & gericke, 2003) furtherm ore, a m oulana adm itted that jadu was not always the cause o f the ch ild ’s condition and in these cases he would re­ fer to m edical professionals for help. another m oulana mentioned that he regularly sat with doctors and consulted with them. most o f the participants referred patients to doctors as they felt that some children needed surgery, particularly those with heart prob­ lems. in contrast, one o f th e hakeems stated that he did not refer to medical doctors as m ost o f the patients that cam e to him had often given up hope and lost faith in m edical doctors as they had not experienced success with allopathic medicine. five o f the participants had referred their patients to speech-language and hearing therapists. one participant reported that he had not referred to a speech-language therapist, because w henever a child had presented with a speech or language prob­ lem , his treatm ent had proved successful ‘and with time the child sta rted to talk in long sentences, understand better a n d his think­ ing po w er increased’. n ine o f the participants reported that they did not consult with other m edical or param edical professions. the time factor was noted to be one o f the reasons for not consulting with other w estern trained professionals. t he herbalist stated that he did not approach other professionals, as he preferred to control the child’s condition with the use o f herbs. t he entire group o f traditional healers who were inter­ viewed supported collaboration with health care professionals and expressed a keen interest in learning about m odem m edicine and the roles o f the various team mem bers involved in the rehabilita­ tion of the child with down syndrome. they also felt that there was a need for the m odem world to be acquainted with traditional healing and that western professionals should respect this form of healing. for example, a spiritual healer stated that she would do her w ork and they (m edical doctors) would do theirs and the com­ bined effect was likely to produce optim al results for the patient. o ne participant stressed the fact that islam proclaim s that we should go out and find a cure, because h e believed that for every disease there was a cure, thus alternative m ethods should be en­ couraged, including m edical doctors’ approaches to healing. a m oulana supported collaboration with western m edical profes­ sionals as he felt that a disorder can be both spiritual and medical in aetiology and hence both realm s can potentially help in differ­ ent ways. one hakeem conveyed the view that his work included providing a balance with the hum ours, to m inim ize harm emanat­ ing from them and that other professionals were needed to aid the child with down syndrom e in other avenues. for example, he stated ‘the speech-therapist will assist the child in her expertise o f language and sp e e c h ’. in fact, two o f the participants men­ tioned that at the tim e o f the study they were collaborating with western practitioners especially when surgery was required or when their m edicine was n ot healing their patients. however, one m oulana, although in favour o f collabora­ tive treatm ents, was som ew hat dubious about th e feasibility of collaboration as w estern m edicine often failed to appreciate the connection between the body and the soul. he also e x p r e s s e d deep concern regarding the negative views that he p e r c e i v e d m any m edical doctors to hold in relation to traditional healers a n d the services they offer. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) western and traditional medicine: cultural beliefs and practices of sa muslims with regard to down syndrome 35 sum m a r y of m a in fin d in g s, lim itatio ns, r ec o m m endatio ns a n d conclusio ns sum m ary o f m ain findings in summary, com m on beliefs that em anated from both the caregivers and the traditional healers with reference to the cause o f down syndrome, included the notion that this condition was genetic in origin and that such children were perceived to be a gift from god. other frequent responses attributed down syndrome to a punishm ent from god and also a result of jadu (curses from people). com m on treatm ent/m anagem ent approaches mentioned by both the caregivers and the traditional healers included the use o f tarweez and w ater that had been prayed over w hich was p ro ­ vided by m oulanas and spiritual healers, and herbal m edicines prescribed by hakeems. both groups em phasized the need to treat children with down syndrom e with patience and unconditional positive regard, and to focus on their strengths. some caregivers seemed reluctant to approach m edical doctors relative to tradi­ tional healers and this reluctance was attributed to their negative past experiences with medical practitioners. furtherm ore, nine o f the caregivers had approached speech-language and hearing thera­ pists com pared to five o f the traditional healers. both groups re­ ported m aking lim ited use o f other param edical professionals. t he main reasons given for consulting traditional healers were cultural beliefs and pressure from fam ily m em bers, their holistic view o f m anagem ent, and the personal nature o f their approaches. c ol­ laboration between m odem m edicine and traditional healing was advocated by alm ost all o f the traditional healers. h owever, these findings need to be critically evaluated. a critique o f the study revealed several lim itations. lim itations firstly, theorists such as bhopal (1997) have questioned whether research in ethnicity and health is racist, unsound, or im ­ portant science. it is the contention o f the present w riters that such research can potentially enhance awareness of the beliefs and practices"of different groups in relation to traditional healing. sec­ ondly, as the researcher who conducted the interviews was from the same religion and part o f the sam e south african com m unity as m any o f the participants, they took for granted the fact that she was acquainted with their cultural beliefs and practices, and con­ sequently failed to elaborate and provide explanations for m any o f their answers. thirdly, as some cultural beliefs were seen to be sacred or even offensive to caregivers or the children concerned, participants were initially reluctant to adm it having such beliefs for exam ple, jadu and the evil eye, and instead seemed to fam ish socially desirable responses. only once the researcher was able to establish rapport with the participants, were some o f them able to adm it that they subscribed to such beliefs. a third lim itation re­ lated to the fact that participants were unw illing to allow the re ­ searcher to tape-record the interviews. she was therefore com ­ pelled to m ake hand written notes, which occasionally tended to detract from the flow o f the interviews. fourthly, little inform a­ tion was given regarding the type o f herbs used for treatment. pre­ sumably, the traditional healers felt that the researcher m ight ex­ pose their secrets to pharm acists and other persons who might ap­ propriate their knowledge. the fifth lim itation was related to the failure to use triangulation, which would have added rigor, breadth, and depth to the investigation (denzin & lincoln, 1998). triangulation refers to the process o f “enhancing the value o f a theory by using m ultiple m ethods and perspectives to investigate the truth” (m axwell & satake, 2006:7). a further limitation re ­ lates to the lack o f generalizability o f the data. however, a counter argum ent is that the issue o f generalizability is irrelevant to re­ search o f this nature as the purpose o f the study was n ot to obtain generalizable findings but rather to elicit a rich and thick descrip­ tion o f the phenom enon under investigation. r ecom m endations d espite these lim itations inherent in the research design and methodology, im portant recom m endations can be made in respect o f culturally sensitive rehabilitation practices in speech language pathology and audiology; collaboration between western health care practitioners and traditional healers; theory and future research. c ulturally sensitive rehabilitation practices in speech-language p ath o lo g y a n d audiology a lthough the findings cannot be generalized to the entire south african m uslim community, they suggest that some m em ­ bers o f this com m unity tend to place a great deal o f em phasis on cultural and religious beliefs. it is therefore recom m ended that speech-language therapists and audiologists need to adopt cultur­ ally sensitive practices when m anaging children with d own syn­ drom e from this com m unity as cultural beliefs m ay influence how people perceive affected individuals and how they are treated or m anaged. for example, the m uslim belief that disability is from god, m ay im pact on the m anagem ent process and needs to be taken into consideration when undertaking diagnostic evaluations and planning therapy interventions with this client population. in addition, inform ation on treatm ent recom m ended by traditional healers is useful to western health care professionals, as they need to be aw are of other form s of treatm ent that parents m ay be utiliz­ ing as these interventions m ight be useful or harm ful when used in com bination with m odem medical treatm ent methods. further­ m ore, the finding, regarding the influence o f elderly and extended fam ily m em bers, has im plications for both counselling and ther­ apy in term s o f the guilt which may be felt if certain remedies are not im plem ented or traditional healers are not consulted. such findings also underscore the im portance of involving the extended fam ily in therapy and adopting fam ily-focused interventions. c ollaboration between western health care practitioners and traditional healers the fact that alm ost all o f the traditional healers who were interview ed supported collaboration with health care professionals and expressed a keen interest in learning about m odem medicine, highlights the need for collaboration between the these two sys­ tems o f medicine. however, the finding that very few o f the tradi­ tional healers m ade referrals to param edical professionals was possibly related to the fact that the participants were not know l­ edgeable about the services provided by these practitioners. t here would thus appear to be a need for these param edical profession­ als to create public awareness o f their services and the roles they can potentially play with respect to children with down syn­ drome. m oreover, approxim ately 80% o f south africans make use o f traditional healers and an estim ated 250 000 and 300 000 tradi­ tional healers are currently practising in south africa. this wide­ spread use o f traditional m edicine has to do with issues o f afforda­ bility, cultural acceptability and accessibility (du plessis, 2003). it the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 36 tasneem dangor and eleanor ross is therefore recom m ended that western health care practitioners be educated regarding the roles o f traditional healers and the m edi­ cines they use, so that there can be greater collaboration and m u­ tual respect. the south african health m inistry is currently looking for w ays to incorporate inform al medicine into the formal health sector, and the recent prom ulgation o f the traditional health prac­ titioners bill (2004) is designed to facilitate this process. theory and f uture r esearch this exploratory-descriptive study represents an effort, in some small m easure, to enhance theoretical understanding o f the south african m uslim com m unity’s m ultifaceted approach to health, illness and disability. however, while respecting these cul­ tural beliefs and practices, one cannot endorse their effectiveness without further evidence-based research. m oreover, in view o f the fact that the small sample size and the use o f snowball sampling precluded generalization o f results to the broader population o f caregivers and traditional healers, it is recom m ended that this re­ search be replicated on a larger, more representative sample. given the point raised by one o f the traditional healers regarding the ap­ parent contradiction o f such practices as abortion, sterilization and amniocentesis, w ith the teachings o f islam, future researchers need to explore the views o f traditional versus western health care pro­ fessionals regarding the ethics o f traditional healing and western health care in relation to these practices. finally, it w ould seem to be an opportune time to begin the process o f m onitoring the im ple­ m entation o f the new traditional health practitioners bill in south a frica and assessing its effectiveness in prom oting collaboration between western m edicine and traditional healing over the next few years. in conclusion, the findings that several participants attrib­ uted down syndrom e to genetic factors as well as g od’s will, and m any o f the traditional healers had referred patients to western professionals, suggests a degree o f medical syncretism whereby “biom edical know ledge transm itted in health m essages coexists, interacts and merges w ith local pre-existing ideas and lo­ gics” (m uela et al., 2002:403). m oreover, the fact that m uslim hum oral medicine is partly rooted in the writings o f hippocrates, the father o f w estern m edicine (sykiotis et al., 2006), coupled with the 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(2004). hakims’ holistic approach to health. muslim views, cape town: university of western cape. sykiotis, g.p., kalliolias, g.d., & papavassiliou, a.g. (2006). hippo­ crates and genomic medicine. archives o f medical research, 37, 1, 181-183. terreblanche, m, & durrheim, k. (1999). research in practice: applied methods fo r the social sciences. cape town: university of cape town press. the national down syndrome society. retrieved on 5th may 2004 from htttp://www.pcsltd.com/ndss/ tjale, a., & de villiers, l. (eds.). (2004). cultural issues in health and health care: a resource fo r southern africa. cape town: juta. tomoeda, c.k., & bayles, k.a. (2002). cultivating cultural competence in the workplace, classroom and clinic. asha leader, 7 (60): 4. van wyk, b.e, van oudtshoom, b, gericke, n. (2003). medicinal plants o f south africa. pretoria: briza. world health organisation. (1978). the alma-ata conference on pri­ mary health care. who chronicle, 32: 409-430. world health organization (who). (2002). towards a common lan­ guage fo r functioning, disability and health (icf). retrieved on 12th september 2003 from http://www.who.int/icl7beginners/bg/ pdf. the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.pcsltd.com/ndss/ http://www.who.int/icl7beginners/bg/ 38 tasneem dangor and eleanor ross appendix a i n t e r v i e w s c h e d u le f o r c a r e g i v e r s section a biographical information gender of caregiver: age of individual with down syndrome: relation of caregiver to individual with down syndrome: section b information relating to down syndrome orientation to the syndrome 1. when was__________ first diagnosed with down syndrome? 2. who made the diagnosis? 3. what do you understand by the term down syndrome? 4. has anyone explained the features of this syndrome to you? please explain. 5. have you received any genetic counselling? beliefs regarding causation 6 . what do you believe is the cause of down syndrome? 7. what do people in your culture generally believe causes down syndrome? management of the syndrome 8. with regard to the person with down syndrome that you take care of, did you approach any traditional healer such as a moulana or hakeem? 9. if yes, what advice, treatment or management did he or she rec­ ommend? 10. did the advice/management that he or she recommended, meet your expectations. in other words were you satisfied? 11. if you did not approach a traditional healer, was there any reason for not approaching a traditional healer? 12. did you approach a medical doctor? 13. if so, please describe the advice / management approach that he or she recommended and your degree of satisfaction with such ad­ vice. 14. did you consult any other medical or paramedical professionals? 15. if so, please state which professionals you consulted and describe the management approaches they recommended. 16. did you approach a speech-language and hearing therapist? 17. if so, please describe the advice / management that he or she rec­ ommended and your degree of satisfaction with such advice. 18. if you did not consult with a speech-language and hearing thera­ pist, was there any reason for not consulting such a professional? 19. are there any other views or comments you would like to share with me in relation to caring for a person with down syndrome? appendix b interview schedule for traditional healers section a biographical information gender: type o f healer: number o f years practising as a healer: section b information relating to down syndrome beliefs regarding causation 1. what do you believe is the cause o f down syndrome? 2. what do people in your culture generally believe causes down syndrome? management of the syndrome 3. have you ever been consulted regarding a child with down syndrome? 4. i f yes, please can you explain the type o f advice, management or treatment that you provide for such children? 5. have you ever advised parents o f children with d own syn­ drome to approach a medical doctor? 6 . have you ever referred any o f these children to a speech language and hearing therapist? 7. have you ever consulted with any other medical or paramedi­ cal professionals with regard to children with d own syndrome? general 8 . do you feel that traditional healers and western trained profes­ sionals such as doctors and therapists can work collaboratively to treat / manage children with down syndrome? please ex­ plain. 9. what are the reasons you think parents/caregivers o f children with down syndrome consult with you instead of, or in addi­ tion to western medical practitioners? 10. d o you have any other view s or comments you would like to share with me in relation to the treatment or management o f individuals with down syndrome? 1 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 2 journal .of the south african logopedic society. november ^iditoriai the field of speech therapy is dynamic, and one must expect changing ideas and trends. in our last journal the theme was "stuttering" and in this issue the emphasis is on speech disorders of organic origin. marion fleming, in her article on "relationships betiveen stammering and aphasia," suggests that stuttering may have an organic basis, and this reflects the feelings of a growing number of therapists today. ' the study of the brain-injured child is another aspect which has evoked interest in recent years, and dr. jack bangs discusses this subject with emphasis on language education. katrina de hirsch and jeanette jefferson jansky also add to our knowledge of the brain-damaged child with their paper on "word deafness" finally, dr. breckivoldt's "new aspects of voice physiology" fulfils a need which we, with our limited knowledge of language, have felt for some time. the contribution is based on recent german and french literature, and makes us more aware of european fields of research. this issue therefore indicates current ideas and needs, and should, we hope, stimulate further interest in these fields. tape recorders lightweight portable models from / 1 5 / ' u f > w c r d s 3 f and 7-jspeeds. unbreakable children's records lp. record specialists. hillbrow home electric (pty.) ltd. phone 44-8843. curzon theatre buildings p.o. box 3525 kotze street, hillbrow, johannesburg r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) editorial in an age which has seen transition both swift and encompassing, it is an achievement for a publication such as this journal to reach its twentieth year. the south african logopedic society is a relatively small one; it has experienced set-backs and frustrations, but this achievement does reflect the continuing growth and interest in the field of speech therapy in south africa. those who pioneered this project in 1948 faced a more difficult task than we do today. scientific research was meagre and unsophisticated: each therapist was his own scientist. the public was uninformed, so that there was a paucity of cases; therapeutic practices and techniques were experimental and often unreliable. today, thanks to the endeavours of the past, there is a growing interest in research, a variety of cases and welldefined techniques to meet them. for some time the need has been felt for a cumulative index of the journal, and it is appropriate that it should be published in this issue. apart from its intrinsic function, perusal of the writings since 1948 indicates some interesting trends. it is evident that the chief concern of therapists in south africa has been therapy; the patient has been the central figure. that this attitude is laudable, none will deny, and it is to be hoped that nothing will diminish the concept of therapy as the major force in our work. however, the need for an empirical approach to our particular problems is becoming urgent. we need to become aware of the finer aspects of speech and language, as well as the disorders arising from these, among the polyglot groups in this country. this is only one facet of the research potential that exists in our field; it is for the speech therapist, despite inadequate financial resources, to seek the means of instigating research programmes into speech, language, communication and hearing problems which are peculiarly south african. this plea is made in the belief that research will not be done for its own sake, but will enhance the knowledge and ability of the worker in her role as therapist. a new trend observed in the field recently, and an important one, is the application of psycholinguistics to our work. we publish a study based on a system of generative grammar, which discusses the relationship between articulatory and syntactic difficulties, and suggests therapeutic procedures as well as possibilities for further investigation. another important trend revealed by examination of the cumulative index is the swift development of learning theory and its practical application which has become a dominant force in our field during the past decade. in 1957, margaret marks wrote an article entided stuttering as learned behaviour: theoretical and therapeutic implications * in this issue we have reached the stage where the same writer discusses are we good *j. s. afr. logoped. soc., 1957, 4, 10-12. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 15, nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) editorial 4 behaviourists? (p. 19)—a considerable step from experiment to philosophy in ten years. of the five articles published in this issue, two others discuss work directly influenced by learning theory viz: the effect of operant conditioning techniques on dysphonia in childhood, and the part operant conditioning plays in altering the speech and behaviour of autistic children. valuable therapeutic measures have emerged from both studies, as well as suggestions for research. we are fortunate in being able to publish an article by one who may be described as the doyen of speech therapists—dr. c. van riper. research will probably disclose that more has been written on stuttering than on any topic in the field—certainly this is true of the journals of the-s.a. logopedic society—with the predictable result that it is difficult to discern a clear line of thought in any aspect of the problem. in his review of the prognostic factors in stuttering, van riper has succeeded in indicating this line, to the benefit of therapists and students. it is regrettable that lack of funds should prevent the continued publication of two issues a year. in the halcyon days of cheap printing, there were years when it was possible to do this; we hope that it may be possible again in the future. we look forward to the next twenty years of publication of this journal in the same spirit that directed the. achievements of the past—a spirit compounded of curiosity, enquiry and concern which will engender the progress we hope to see in the future. journal of the south african logopedic society, vol. 15, no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) redaksioneel in 'η eeu waarin verandering so vinnig. en ingrypend plaasvind, is dit voorwaar 'n prestasie vir 'n tydskrif soos hierdie om sy twintigste jaar van publikasie te bereik. die suid-afrikaanse logopediese vereniging is relatief klein en het menige terugslag en frustrasie deurleef, tog weerspieel hierdie prestasie die steeds groeiende belangstelling in spraakterapie in suid-afrika. die persone wat bemoeid was met die publikasie van die eerste uitgawe van die tydskrif in 1948, se taak was moeiliker as ons taak vandag. wetenskaplike navorsing was beperk en onwetenskaplik: elke terapeut was sy eie wetenskaplike. die publiek was oningelig, en gevolglik was daar 'n tekort aan gevalle; terapietegnieke was in 'n eksperimentele stadium en dikwels onbetroubaar. te danke aan pogings van die verlede, is daar vandag 'n groeiende belangstelling in navorsing; 'n verskeidenheid van gevalle en duidelik gedefinieerde tegnieke om daarby aan te pas. vir geruime tyd was daar 'n behoefte aan 'n samevattende indeks van die tydskrif en dit is toepaslik om dit in hierdie uitgawe te publiseer. raadpleging van geskrifte sedert 1948 toon behalwe die intrinsieke funksie daarvan 00k sommige interessante neigings. dit is voor die hand liggend dat die terapeut in suid-afrika in die eerste plek in terapie belang gestel het; die pasient was altyd die sentrale figuur. hierdie benadering was voorwaar prysenswaardig en die hoop bestaan dat terapie steeds die dryfveer in ons werk sal bly. die noodsaaklikheid van 'n empiriese benadering word egter steeds dringender. bewuswordihg van die fynere aspekte van spraak en taal, asook die belemmerings wat hieruit mag voortspruit, binne die veeltalige gemeenskapsgroepe in hierdie land, is noodsaaklik. hierdie is maar een aspek van die navorsingspotensiaal wat hierdie veld vir ons inhou; die onus rus op die spraakterapeut om, ontoereikende finansiele bates tenspyt, die middele te vind vir die loodsing van navorsingsprojekte op die gebied van spraak-, taal-, kommunikasieen gehoorprobleme wat tipies suid-afrikaans is. hierdie oproep word gemaak met die hoop dat navorsing gedoen sal word, nie vir sy eie belang nie, maar om die kennis en bekwaamheid van die werker in die rol van terapeut te bevoordeel. 'n belangrike nuwe neiging, is die toepassing van psigolinguistiek op spraakheelkunde. ons publiseer 'n studie gebaseer op 'n stelsel van generatiewe grammatika wat die verwantskap tussen artikulatoriese en sintaktiese probleme bespreek, en heelkundige prosedure asook moontlikhede vir verdere ondersoek voorstel. ondersoek van die samevattende indeks bring 'n ander belangrike rigting aan die lig, nl. die vlugge ontwikkeling van die leerteorie en die praktiese toepassing daarvan. hierdie rigting het gedurende die afgelope dekade in 'n oorheersende dryfveer, binne die gebied van spraakterapie ontwikkel. in 1957 het daar uit die pen van margaret marks 'n artikel onder die titel tydskrif van die suid-afrikaanse logopediese vereniging, vol 15, nr. : des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 redaksioneel *stuttering as learned behaviour: theoretical and therapeutic implications? verskyn. ons bereik in hierdie uitgawe die stadium waar die skryfster die onderwerp are we good behaviourists? (bl. 19) bespreek—'n aansienlike sprong van eksperiment na filosofie in tien jaar. van die vyf artikels wat in hierdie uitgawe verskyn, bespreek twee ander werke wat regstreeks deur die leerteorie be'invloed word, nl. die invloed van operante kondisioneringstegnieke op disfonie by die kind, en die rol wat operante kondisionering speel by die verandering van spraak en gedrag van outistiese kinders. albei studies het waardevolle heelkundige norme sowel as navorsingsmoontlikhede blootgele. ons is in die bevoorregte posisie om 'n artikel te kan publiseer deur die persoon wat beskryf kan word as die doyen van spraakheelkunde—dr. c. van riper. ondersoek sal aan die lig bring dat daar meer oor hakkel as oor enige ander onderwerp binne die gebied van spraakheelkunde geskryf is—dit is ongetwyfeld waar in die geval van die tydskrifte van die s.a. logopediese vereniging—met die voorspelbare verwagting dat dit moeilik is om 'n duidelike gedagtelyn met betrekking tot enige aspek van die probleem te onderskei. van riper slaag daarin om in sy oorsig: prognostic factors in stuttering, hierdie lyn aan te wys ter bevoordeling van terapeute en studente. 1 dit is betreurenswaardig dat 'n tekort aan fondse die voortgesette publikasie van twee uitgawes per jaar verhinder; ons hoop egter dat in die toekoms ons daarmee kan voortgaan. ons sien met gretigheid uit na die volgende twintig jaar van publikasie van die tydskrif en glo dat dit in dieselfde gees, wat die dryfveer was van die prestasies van die verlede, sal geskied—'n gees bestaande uit weetgierigheid, belangstelling en ondersoek wat die vooruitgang waarop ons hoop in die toekoms, sal aanhits. *tydskr. s.a. logoped. veren., 1957, 4, 10-12. journal of the south african logopedic, society, vol. 15, no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sajcd 86 assessment of speech in neurological disorders: development of a swahili screening test n miller, g mshana, o msuya, c dotchin, r walker, e aris   institute of health and society, speech and language sciences, university of newcastle, newcastle-tyne, uk nick miller   kilimanjaro christian medical centre, moshi, kilimanjaro region, tanzania gerry mshana oliva msuya   department of medicine, north tyneside general hospital, north shields, uk catherine dotchin richard walker   department of medicine, muhimbili university college hospital, dar es salaam, tanzania eric aris   corresponding author: n miller (nicholas.miller@ncl.ac.uk) assessments for acquired motor-speech disorders that look at movements of the articulators would appear at first glance to be universal. this may be true for the most basic non-speech aspects of movement. we argue that assessments for speech motor control must be attuned to language-specific variables to be fully valid. we describe the rationale for, and development of a motor-speech-disorder screening test for swahili speakers which includes impairment measures as well as measures of intelligibility and speech-voice naturalness. we further describe its initial validation in terms of content validity, feasibility of administration and scoring without requirements for lengthy training and technical expertise and application to groups of people with and without parkinson’s disease in tanzania. results indicate that the protocol is ready to use in so far as it is acceptable to users (clinicians, patients), is feasible to use, shows good inter-rater reliability, and is capable of differentiating performance in healthy speakers and those whose speech is disordered. we highlight needs for further development, including issues around training, development of local norms for healthy speakers and for speakers with a variety of neurological disturbances, and extension of the tool to cover culturally valid assessment of impact of communication disorders. keywords: speech disorders, assessment, swahili, neurological, parkinson’s s afr j cd 2012;59(1):27-33. doi:10.7196/sajcd.86 communication changes are a feature of many neurological conditions. yet in many african languages there is a lack of specifically designed assessments of communication. swahili is one such language. it is spoken as a first or second language by over 60 million people, predominantly in east africa. in tanzania, kenya, uganda, the comoros and the democratic republic of congo it serves as a national language. nevertheless there are no standardised assessments for motor-speech disorders. this article reports the development and initial validation of a swahili protocol to evaluate speech changes in neurological disorders. it is intended for use by health professionals involved in managing people with neurological problems. as such it reflects an example of the challenge to devise what pascoe and norman (2011) have termed contextually relevant resources. speech (taken here to include voice) disorders affect an individual’s ability to pronounce the sounds they need to say words and make themselves understood. language disorders affect the ability to understand or retrieve words and sentences, whether in spoken or written form. language and speech impairments can appear together or arise independently of each other. our focus here is on speech. speech changes may represent the first or only signs of changing neurological function (ball, willis, beukelman & pattee, 2001; harel, cannizzaro, cohen, reilly & snyder, 2004). typically though, they co-occur with a range of other motor and cognitive impairments. speech assessment is therefore important from a (differential) diagnostic perspective. clinically it can also provide sensitive, non-invasive outcome measures of decline or recovery and of the effects of drug, surgical and behavioural interventions. speech evaluation plays an important role too, since communication changes exercise a profound social and psychological influence on the person with the disorder, and their family, even when changes are not so severe as to make speech unintelligible (miller, noble, jones, allcock & burn, 2008). speech impairment can be measured in different ways. a subsystems approach (duffy, 2005; kent, 2009) singles out breathing (capacity; control over inspiration-expiration; co-ordination with vocalisation), voice (laryngeal function; voice loudness, pitch and quality), velopharyngeal efficiency (degree of hyperor hyponasality) and articulation (pronunciation of sounds and syllables) to assess underlying speech motor performance. it is also vital to assess the consequences that changes across these subsystems might have for overall intelligibility. many speech assessments exist (duffy, 2005; kent, 2009). in so far as breathing for speech, voice loudness, rate of tongue movements in producing sounds and similar measures would appear to reflect universal aspects of motor performance, it is tempting to assume that these batteries can be applied without further consideration to any language. this may be true of the most basic speed, sustainability, force and range of movement tasks divorced from meaningful words. however, as soon as one deals with variables specific to a given language and the impact of changes on intelligibility, it is imperative not to simply translate assessments from other languages but to adapt or construct them anew for the target language (pascoe & norman, 2011; wild et al., 2005). some examples illustrate this point. human spoken languages use a vast array of sounds. however, they differ in which sounds precisely are used, which sounds contrast with others to signal differences in meaning, which sound combinations are permissible, and where in a word sounds may appear – whether it can occur initially, medially and finally or only one of two of those options; in which positions in words they differ in the nature and functions of stress and intonation patterns used. so, for instance, english does not have the implosives of igbo (nigeria) and hausa (nigeria, niger and regions of west africa) or the clicks of nama (namibia, botswana). luganda (uganda) operates with 5 vowels, twi (ghana, ivory coast) with 15, english, including diphthongs, with nearer 20. hindi (india) and english both use aspirated and non-aspirated /p/ sounds. while in hindi they signal differences in meaning (/kapi/ (copy) /kaphi/ (meaningful)), in english they do not (their distribution is determined by surrounding sounds). swahili and english both have a /ŋ/ sound, but in english this cannot occur in initial position in words. both languages have /m/, /t∫/ and /t/ sounds, but while the combinations /mt∫/ (mchuzi, curry/sauce) and /mt/ (mtori, banana soup/porridge) at the start of a word are permissible in swahili, they are not in english. contrasting intonation patterns form part of the grammatical systems of languages (e.g. signalling a statement versus a question), but how these are applied across languages is not uniform. further, in most european languages changes in tone on a vowel signal predominantly affective nuances. in many other languages a system of tones operates that signifies contrasts in word and grammatical meaning, depending on whether the word is spoken with a rising, falling, high or low pitch (wong, perrachione, gunasekera & chandrasekaran, 2009). a further important observation regarding cross-language differences in speech disorders centres on cultural variables in perceptions of change. while one may be able to ascertain that a person can generate a given force in the lips when pronouncing /p/ or sustain /a:/ at 60 decibels for 10 seconds, such measures bear no direct relationship to the speaker’s and listeners’ perception of if, how and why that represents a problem or not. the acceptability of different rates of speech or loudness levels, the significance of different alterations to voice quality (breathy, creaky; harsh, soft), the tolerance for amount and degree of dysfluencies are all strongly rooted in languageand culture-specific variables (altenberg & ferrand, 2006; bebout & arthur, 1992; kita, 2009; mackey, finn & ingham, 1997; yiu, murdoch, hird, lau & ho, 2008). given that languages differ in their sound structure and use and the perception of change in neurological disorders is strongly influenced by sociolinguistic and cultural variables, it follows, as argued above, that simply translating an assessment devised around the structure and rules of one language will be invalid if applied to a structurally different one. the solution is either to adapt an extant test to the structure of the new language or create a test specifically tailored to the new language. we aimed to create a screening assessment for speech-motor dysfunction in swahili speakers covering quantification of underlying speech-motor impairment and activity limitation levels (intelligibility and speech naturalness) (kent & kent, 2000; yorkston, strand & kennedy, 1996). given the context in which the assessment is designed to be applied (by clinicians from all backgrounds, since it may well be the case that there is no trained speech-language therapist (slt) available; health services with minimum resources), the aim was to select measures that could be accomplished with minimum training in application, scoring and interpretation, without technical equipment beyond paper, pencil and (stop)watch and if possible a simple audio-recording device. in this initial development phase we also aimed to ascertain whether the assessment was suitable for purpose, i.e. to detect differences between speakers with and without a neurological illness and be sensitive to possible changes in speakers over time. methods assessment rationale impairment measures the underlying impairment to speech in neuromuscular disorders stems from alteration in the range, strength, sustainability, stability and co-ordination of movements of the muscles/movements involved in breathing, phonation, velopharyngeal function and pronunciation (duffy, 2005). assessment of these variables is typically achieved through maximum performance speech tasks (duffy, 2005; kent, kent & rosenbek, 1987) that challenge the patient to produce a sound or word as fast, loud, long, high or low as possible. we followed a subsystems approach to assessment, adapting standard recommended clinical tasks with demonstrated validity (kent, 2009) that assess breath capacity and control for speech, voice loudness, pitch and stability, and tongue and lip movement, and fulfilled the conditions required for minimal equipment and training (appendix a). the following paragraphs elucidate. prolongation of /a:/ for as long as possible gives an estimate of air reserve for speech (kent, 2009). the task can also serve as a basis for voice assessment through attention to perceived control and appropriateness of loudness and pitch, stability (tremor; inappropriate swings in pitch or loudness), and voice quality (e.g. harsh/strained (spastic) v. breathy/weak (flaccid), diplophonic (cord palsies)). these can be measured instrumentally, but for present purposes of minimal technical outlay they can be scored perceptually (naked ear) using rating scales. control over loudness, pitch level and range can be further evaluated by asking the speaker to produce /a:/ at gradually increasing and decreasing loudness and gradually rising and lowering pitch levels. speech diadochokinetic tasks (ackermann, hertrich & hehr, 1995; gadesmann & miller, 2008; ziegler, 2002) gauge tongue and lip movement parameters. the sound in the syllable is chosen to challenge a given movement, e.g. /pa/ for lips, /ta/ for tongue tip, /ka/ for tongue dorsum. one can measure time to produce 10 repetitions or number of repetitions in 5 seconds. qualitative observations record how well the individual is able to remain on target – for instance do repetitions of /ba/ drift to what is heard as /ma/ because of velopharyngeal insufficiency? does /pa/ drift to and from /ba/ from misco-ordination between oral and laryngeal gestures, or to /fa/ from decreased excursion or strength of lip movements? important information (co-ordination of movements; speech planning; apraxic difficulties v. neuromuscular, dysarthric impairment) can be gained through alternating syllable tasks (see diadochokinetic tasks above). the individual repeats sounds as fast as possible that contrast in place of articulation, e.g. /pa-ta-ka/. time to produce 5 or 10 repetitions and ability to remain fluent and on target are measured. ideally real words are used (as done in the protocol with swahili words paa, taa, kaa), (i) since this aids understanding of the task, and (ii) because they relate more closely to real speech performance (clark, 2003; kent, 2004). activity limitation impairment measures do not necessarily relate to how far changes affect communication (hartelius & miller, 2010). to gauge the impact of changes on day-to-day activity other assessments are required. for this purpose we included a diagnostic intelligibility screen and speech naturalness rating (appendices b & c). diagnostic intelligibility tests (dit) (kent, weismer, kent & rosenbek, 1989; weismer & martin, 1992) address the problem of extremely poor intraand inter-rater reliability of rating scales for assessment of intelligibility (schiavetti, 1992). in dit patients repeat a list of words and a listener (with no knowledge of what the intended words are) responds with what they believe has been said. depending on availability and/or aims of the assessment, listeners can be clinical colleagues, family members, or untrained strangers unfamiliar with the person’s speech. since scores can differ between listener groups it is essential that on retest (e.g. after therapy) the same scorers are used. by totalling words recognised and analysing the pattern of mishearings one achieves a measure of intelligibility, as well as suggestions for sound contrasts that a speaker might have difficulty signalling. dit depend on devising matched parallel lists of words that differ by one sound from each other (minimal pairs, e.g. tea-pea, pay-pie, coat-code), and reflect the sound distributions, combinations and range of sound frequencies of the language. the protocol offers four parallel lists for swahili following these principles. for administration, the examiner can either select one of the lists, or to minimise rater learning effects or retest familiarity effects where the test is frequently applied, select one word randomly from each row to arrive at varied but matched sets of 25 words. to estimate the overall impression of speech acceptability in the context of the gender, age and cultural expectations of the community the screening test employs a 1 5 naturalness/ disorderedness rating scale (1 – definitely a problem with speech; 5 – definitely no problem with speech) (appendix c). evaluation may be based on impressions from speech during general case history taking. the sentences included in appendix b provide a more controlled task for comparisons across time and persons which are attuned to syllable (articulatorily simple v. complex), word (frequency), phrase length (shorter v. longer) and grammar and associated intonation (commands v. questions v. statements) patterns that constitute prominent variables in change perception. the sentences can also provide data to supplement ratings of pitch, loudness, stability of speech/voice (see above). time to say the sentence(s) can be used as a reliable measure of speaking rate alongside previous diadochokinetic timing for maximum syllable rate. in many neurological disorders speech output is more greatly affected when a speaker has to formulate responses themselves rather than repeat or read a prepared sentence (bunton & keintz, 2008; ho, iansek, & bradshaw, 2002). accordingly, speech examinations commonly include having a person describe an everyday activity (kent, 2009). this affords a more realistic appraisal of the impact of the underlying impairment on day-to-day communication, as well as how speech production interacts with broader language and cognitive status. in the protocol here contrasting tasks offer the possibility of examining contrasts in loudness, pitch, stability, voice quality and naturalness between simple repetition tasks (saying ‘paa’, repeating single words in the intelligibility test) and the self-formulated speech while describing a common activity (appendix a, making porridge). swallowing assessment swallowing and speech disturbances are not directly related to each other, but they do frequently co-occur and management of both often falls to the same person, in westernised countries typically an slt. hence we included as part of the screen the 150 ml water swallow test (nathadwarawala, nicklin, & wiles, 1992) that has been shown to be valid and reliable at quantifying swallowing efficiency. validation procedure the speech-motor and intelligibility measures chosen for the test have proven validity as measures of speech performance (duffy, 2005; kent, 2009; kent et al., 1989; ziegler, 2002). the current protocol was also reviewed independently by six slts specialising in acquired neurological speech disorders to judge its suitability as a screen for assessing acquired motor-speech disorders. our aim was also to examine whether conducting the test was feasible in a community with minimal training (given the lack of slts and requirement to conduct brief training of other professionals); whether it was acceptable to users; and whether the newly devised materials could potentially detect differences in performance across individuals with and without a neurological disorder. to this end we piloted the tasks on a group of people with parkinson’s disease (pd) and a group matched overall for age and gender who were non-neurologically impaired. this was to establish the feasibility of the materials and tests, not specifically to examine differences between people with and without pd, which is the subject of a separate report. participants we assessed people with pd and control participants. they were recruited from a community-based prevalence survey (dotchin et al., 2008) in hai district, tanzania. participation was by voluntary informed consent following uk and tanzanian ethics committee approved procedures. results are based on 26 people with pd (7 female) and the overall matched group without pd from the same district. the people with pd were assessed before they commenced medical therapy, and 19 of them again 12 months later, after 3 months on medication. four had died and 3 were too ill for reassessment. median age of individuals without neurological illness was 76 years (interquartile range (iqr) 67 78) and for those with pd median 78 years (iqr 70 84) (p=0.10). for the latter, mean estimated duration of symptoms was 5 years (range 0.25 19). as regards overall motor status their mean unified parkinson's disease rating scale (updrs) (goetz et al., 2003) score was 50 (range 24 97). procedures a tanzanian pd nurse specialist received 3 hours’ induction and training from an experienced uk slt covering the rationale and procedures for the test, how to make the sound recordings (edirol r1 and akg c420 headmounted microphone) and scoring of items. laminated directions sheets for field use for all tasks and for live scoring were provided. people with pd were assessed before they commenced pharmacotherapy and approximately 12 months later after 3 months of levodopa treatment. speech assessment by the nurse specialist took place in the participant’s home at the same time as assessments of their motor, cognitive, mood and social status (often in the presence of other family members). recordings were downloaded to laptop computer on site and returned on compact discs for cross-checking and analysis in the uk. data processing time for sustained ‘ah’ was noted at the time of assessment. counts for number of repetitions in 5 seconds of ‘paa’ (roof in swahili), ‘kaa’ (charcoal) and ‘paa-taa (light)-kaa’ were made at the time of assessment. following standard practice speakers attempted each maximum performance task twice. the better performance was taken as their score. results for /a:/ and syllable repetitions were compared across groups and time. speech rate for the sentence ‘wale watoto wanafanya kazi kwa bidii shambani’ (those children are working hard in the field) was calculated from the acoustic waveform in syllables per second using praat (boersma & wennink, 2011). sound pressure level variability (standard deviation (sd) of mean fundamental frequency) was measured from praat based on the same sentence. to complete intelligibility test scoring, six native swahili-speaking tanzanian medical elective students studying in the uk heard recordings in random order of participants with and without pd saying words from the four parallel word lists (appendix b). recordings were played free field (dell inspirion laptop connected to fostex personal monitor 6301b loudspeaker) in a quiet clinic office with volume setting the same for all tracks. they were blind to word-list number, speaker identity and group. half the listeners heard tracks in reverse order. for each speaker they wrote down which word they believed they heard. the derived intelligibility score was the percentage of words correctly recognised across all listeners. measurement of the 150 ml swallowing test (ml per second) was calculated from volume drunk and time taken from records at the time of testing. results validity and feasibility the screening test was deemed to have sufficient face validity as independently judged by health and other workers in the community where it was to be applied. content validity was independently confirmed by review from a panel of speech-language pathologists experienced in neurological speech disorders asked to judge whether the test adequately and appropriately screened key dimensions for a speech-voice assessment in people with neurological disturbances. neither group recommended any changes to the content or delivery of the protocol. feasibility was confirmed. time to complete all sections typically took around 15 25 minutes. with the exception of one control speaker who did not understand the nature of the syllable repetition task, all participants were able to comprehend instructions and carry out the tasks correctly. the nurse specialist was able to detail performance counts/times for items requiring live scoring. ten per cent of counts and timing for ‘paa’/‘kaa’ and ‘paa-taa-kaa’ were randomly selected and calculated from the audio-recordings by an experienced slt blind to initial measurements. there was a high correlation (spearman’s r 0.96) for counts between raters with no significant difference for either control speaker recordings or people with pd. the time to repeat ‘paa-taa-kaa’ correlation of measures was similarly high (r 0.95) and there was no statistically significant difference between raters. there were some issues around audio-recording (see discussion) which impacted on the quality and completeness of some data sets. for this reason there were variable numbers of individual scores employed for the analyses that follow. group comparisons were conducted only on pairs where there were valid matched recordings available. differences between groups table 1 displays results obtained from the participants with and without pd. columns 2, 3, and 5 present the descriptive summaries for the different groups/times while columns 4 and 6 record results for statistical tests looking at possible differences between groups/times. statistically significant results are shown in bold. on the prolonged /a:/ task, single syllable repetition rates and overall speech rate people with and without pd as groups did not perform statistically significantly differently to each other. on the more taxing multisyllable alternation task (paa-taa-kaa) there was a statistically significant difference between people with pd and controls and between baseline and follow-up for people with pd. table 1. summary statistics for groups tasks and measurements pd time 1 median/mean (sd/iqr) pd time 2 median/mean (sd/iqr) pd time 1 v. 2 control median/mean (sd/iqr) pd1 v. control prolonged /a:/ (secs) 9.04 (4.47) 10.16 (4.12) z 1.06 p 0.29 9.71 (4.38) z 0.524 p 0.60 paa in 5 secs 13.64 (5.57) 12.00 (4.45) z 0.34 p 0.74 12.44 (5.54) z 0.18 p 0.86 kaa in 5 secs 14.05 (6.21) 12.67 (4.54) z 0.44 p 0.68 13.57 (4.84) z 0.03 p 0.97 time to repeat paa-taa-kaa x5 (secs) 5.61 (1.62) 4.92 (0.43) z 4.71 p <0.001 4.5 (0.48) z 4.84 p <0.001 speech rate (syllables/sec) 0.17 (0.034) na na 0.17 (0.022) z 0.82 p 0.41 loudness/sound pressure level db n=24 48.21 (4.60) na na n=24 46.0 (6.83) z 1.13 p 0.27 loudness variability sd db n=24 4.22 (1.2)     n=24 3.86 (1.51) z 0.70 p 0.48 intelligibility (% total all listeners) n=26 72 (51-78) na na n=14 75.5 (72-89) z 2.13 p 0.03 disorderedness based on sentences (1 5, 5 normal) n=18 1.75 (1-2.5) na na n=26 4 (3.5-5) p <0.007 swallowing ml/sec 6.5 (3.73-10.89) 10.19 (6.44-12.38) z 1.7 p 0.089 19.68 (15.06-26.90) z 5.15 p <0.001 pd1 = people with pd before medication; pd2 = assessment after medication commenced; sd = standard deviation; iqr = interquartile range; na = task not assessed; n = number if not 26. the effects of altered voice and articulation were also clear in the intelligibility and disorderedness ratings. people with versus without pd scored significantly differently (p=0.03) on words correctly recognised by naïve listeners. people with pd were perceived by listeners to be significantly more disordered (p=0.007) in their speech than those without, based on perceptual rating of the sentence repetitions. differences between people with and without pd were statistically significant for the water swallow test (ml/sec). there was no statistically significant change (p=0.09) in performance between baseline and follow-up for the people with pd. discussion we have developed the first preliminarily validated screening test in swahili for speech changes in neurological disorders that is not simply an unadapted translation from english and that addresses activity limitation measures (intelligibility; naturalness) as well as impairment performance. the nurse specialist was able to acquire the skills to apply and score the test after minimal training, indicated by the absence of any data loss due to misinstructions for tasks, misapplication of tasks or misscoring. the test was acceptable to participants. there were no objections to or questioning of words and tasks used. no one refused to carry it out, whether for ethical, practical or comprehension reasons. from the large variability in performance on some tasks it appears participants occasionally appeared to give suboptimal responses. it remains to be established from further observation and analysis whether this relates to cultural influences in carrying out unaccustomed testing or whether it pertains to issues around examiner training in eliciting maximum performance. a major problem encountered, that affected quality and analysis of data, concerned difficulties with audio-track labelling and with simultaneously controlling audio-recording equipment and attending to speech performance in order to deliver live scores. these point to issues in training and methods employed for detailing live performance that must be addressed in later training development. the test tasks were able to differentiate performance levels and correctly detected differences that were expected between people with and without pd (‘paa-taa-kaa’ repetitions, ackermann et al., 1995; ho, bradshaw, cunnington, phillips & iansek, 1998; ziegler, 2002), intelligibility (miller et al., 2007) and swallowing (miller et al., 2009). the fact that betweenand within-group differences on the single-syllable repetition tasks did not reach statistical significance is unsurprising, given that the nature of speech changes in pd may not be sufficiently severe to register on impairment measures. the fact that the more challenging syllable-alternating task (ho et al., 1998) did detect significant differences supports this interpretation. similarly, on the water swallow test, the time between baseline and follow-up may not have been sufficient to expect significant changes in people with pd, especially given that they received medical intervention in the interim. as pd is a progressive condition one would expect deterioration in function over 1 year but this is likely to be counter-balanced by the drug therapy they received for 3 months before the second assessment, which had a major impact on motor function in some cases (dotchin, jusabani, & walker, 2011). the protocol is ready to use. however, there are several features that ideally require further development or need local norms against which to interpret performance. the screen should also be tested on larger numbers and on other groups of people with neurological illness (e.g. stroke). monitoring the ability of a wider group of people to apply the protocol would also be helpful rather than the one trained tester employed here. next steps also include the development of culturally appropriate questionnaire measures of perceptions of change and perceived impact of speech changes. acknowledgements. this study was partly funded by a grant from the british academy uk-africa academic partnerships. references ackermann, h., hertrich, i., & hehr, t. 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(2002). task-related factors in oral motor control: speech and oral diadochokinesis in dysarthria and apraxia of speech. brain and language, 80(3), 556-575. doi.org/10.1006/brln.2001.2614 appendix a. speech and voice changes in people with parkinson’s disease © nick miller, gerry mshana, richard walker speech and intelligibility assessment protocol (swahili version available on request)   ideally these tasks should be recorded on audio or video recorder for later scoring and comparison with later assessments. for the intelligibility test it is imperative. use a new sound track for each task.   t = time on stopwatch   ddk (diadochokinetic repetition repeat ‘paa’ for 5 secs   t say ‘paa’ (roof) as many times as you can until i say stop (i.e. after 5 seconds). demonstrate with syllable /ma/ until person has understood the task. elicit twice. score: total number of repetitions of the syllable in the time on watch (as close to 5 secs as possible) repetitions in 5 secs enter time on watch (e.g. 4.94) and total repetitions (e.g. 21)   1st attempt:   2nd attempt: appendix a. speech and voice changes in people with parkinson’s disease (continued) repeat ‘kaa’ (charcoal) for 5 secs   t instructions as for 'paa'       repetitions in 5 secs   live 1st attempt   live 2nd attempt repeat ‘paa-taa-kaa' 5 times   t can you say for me ‘paa-taa-kaa’ as fast as you can until i say stop? elicit twice. score time in seconds to say 5 complete sets time to repeat 5 times: 1st attempt:   time to repeat 5 times: 2nd attempt intelligibility list ‘i have some words i would like you to repeat after me. just repeat them in your own time at your own speed’. examiner: remember not to record you saying which word it is. remember to pause recording after person has said the previous word and restart after you have said the next word but before they reply. circle which word list was used number: 1 2 3 4 words correctly recognised by: listener 1 2 3 4 5 6               mean overall score for listeners 1 6   say /ah/ as long as possible   t ‘i want you to say /ah/ for as long as you can. like this, look (demonstrate till person has understood what to do). ok, now take in as deep a breath as you can and then slowly let it out saying 'ah' as long as you can. start watch as soon as person starts ‘ah’. elicit twice. score in secs. trial 1 secs     trial 2 secs sentences for repetition person repeats sentences after examiner in their own time. same instructions for recording as for intelligibility. this time it doesn’t matter though if scorers can hear the stimulus sentences. examiner: make sure you say commands as commands, questions as questions; if person doesn’t, no need to correct them. use sentences below after ‘intelligibility’ words   describe how to carry out everyday activity please can you describe to me from start to finish how ‘mtori’ (banana porridge) is prepared?         appendix b. intelligibility test items © n miller, g mshana, r walker (swahili version available on request) aim: the patient says the following words, one at a time, in their habitual voice/rate/loudness method: either the individual reads one of the lists (can give them the list beforehand so they can check any words not familiar with), or the examiner says the word and the speaker repeats it after them. for retest purposes the same method (reading or repetition) must be employed. if using repetition the examiner should take care not to record themselves saying the stimulus word. easiest way to avoid that is to have recorder on pause (not stop) when the examiner says the word; press start and give signal for speaker to say the word; put back on pause before next word by examiner. note: examiner to say the word in natural, habitual way, making sure not to overemphasise any sounds/syllables or say the word in a deliberate fashion. say the word only once unless the person has not heard it clearly and requests a repeat. if they repeat back the wrong word leave it and go onto next item – but record in field notes that item x was given as ‘abc’. this needs to be taken into account when calculating scores. sets of words for swahili diagnostic intelligibility screening test item number list 1 list 2 list 3 list 4 1 kana kaba kala kata 2 piga pita pika piku 3 pana pande panda panga 4 baba babu bana basi 5 cheza cheka chepe chema 6 asali asili asile sifa 7 nazi kazi vazi ngazi 8 choka choma chora chota appendix b. intelligibility test items (continued) 9 njoo njaa njia njiwa 10 sikio pitio salio kilio 11 moja hoja ngoja onja 12 paka baka taka waka 13 duma dume dua dubu 14 nyani nyati nyama nyavu 15 tatu tano taka taga 16 kaa paa zaa vaa 17 waa twaa kwaa duwaa 18 ninakula tunakula wanakula watakula 19 bandua bangua pangua pungua 20 walipata watapata ulipata utapata 21 wewe hehe yeye nene 22 pima kima hima lima 23 kaja haja paja naja 24 tuma tupa tua pua 25 nawa tawa kawa sawa   sentence repetition task aim: person reads/repeats sentences below in their normal voice, loudness and rate. method: either: individual reads the sentences out loud in normal voice (give them the sentences to look through first to check they know the words). or: speaker repeats the sentences after the examiner note on protocol sheet whether read or repeated. for retest use the same method. make sure the commands are said like commands, the questions like questions. instructions: i’m going to say some sentences/i want you to read some sentences. just say the sentence in your normal voice in your normal way. sentences for people to repeat/read 1 hapana, usiende pale! 2 alisema uje au uende? 3 wale watoto wanafanya kazi kwa bidii shambani. 4 kaka ana kuku kumi na tano? 5 ameenda sokoni kuuza kahawa yake. 6 pita huku haraka! appendix c. disorderedness/naturalness rating scale ‘how sure are you that this person has a problem with their speech?’ 1 2 3 4 5 yes, definitely yes, maybe i’m not sure no, maybe not definitely not 12. fint/rg initial problems encountered in the ttpganlzation and " integration of a speech ψήijgapy depart ment in a transvaal provtncial hospital. •bx d. m. whiting. b.a. (loĝ . (adapted from a paper presented for the degree of bachelor of arts in logopedics at the university of the witwatersrand). the purpose of this paper is to present some of the problems encountered in organising a speech therapy department in a general hospital, as it is felt that the problems differ quite widely in some respects, from those encountered in an ' education department clinic. in february 19^7 a new venture was undertaken at the pretoria general hospital:to provide treatment for yet another group ' s^s® ? a n ? i c a pp e d speech, language and hearing disorders. hitherto there had been no speech therapy pro-vided at this hospital. p accommodation. the question of accommodation proved to be the first problem encountered. the department was opened several weeks later in one small room 11 ft. χ 15 ft., three walls of which were 7 ft. high beaver-board partitioning, dividing it off from n™ filtlit ih6,°ccypati°nal therapy department, another new department to be started at the same time. this was at +?f α £ hospital in what was inappropriately known as 2°m ' * s t o r e ro°m cleared for the use of these two departments with concrete floors, no running water, poor aif l?? 811(1 w l t h l i t t l e protection from the wind and rain which blew in unmercifully at times. the noise and 陣βα?ίϊ0ΐν ϊ™ t h e 0ccupational therapy side made it quite impossible to hear oneself speak at times. some of |the difficulties which arose from these conditions were:1. : the lack of waiting facilities. 2. ; the absence of facilities to separate a child from his mother during case history taking and the discussion of his problems. 3* the problem of gaining rapport with patients, children or adults, who were fully aware that every one the other side of the partition could over-hear all we were discussing. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 13. however, this was the start from which it was hoped to build up a "better department, as the work "became recognized, and the necessity to provide more'' suitable accommodation was realized. sixteen months later the department was moved to a newly opened branch of the hospital. the new accommodation consisted of two rooms and a small entrance hall, together with the use of the stoep and the passage for waiting room facilities. the smaller room was used as a testing room and office, and the larger as a treatment room. these are in pleasant surroundings and comparatively quiet. the floors are wooden, and there is hot and cold running water, good light and ventilation. (later, when a second speech therapist was appointed, another room was added to this). equipment. as speech therapy was new at this hospital, little was known of the requirements of such a department. there was no difficulty in getting initial equipment passed. but rather externally, in locating the best sources of supply of equipment other than that which was available in hospital stocks internally, in locating exactly what helpful stocks were ' carried by each specific department in the hospital. each department existed in relation to other already existing departments, there was a certain amount of overlap in the stocks carried by certain departments, and no one individual could be found who could supply all the necessary information as to what each supplied, and who had to sign the requisitions for each (some by the matron, some by the secretary and some by the superintendent himself). educational propaganda. how were we to bring to the notice of the medical staff, that this new department was now open and ready to treat patients? ί a circular was drawn up to the effect that these facilities were now available and listing, with short explanatory notes, the types of speech, language and hearing disorders which should be referred for treatment. this was sent to all honorary staff, and all wards and departments in the hospital. personal contact with physiotherapy, occupational therapy and social services departments proved very valuable in bringing the work of this new department to the notice of the medical staff. one surgeon in particular has done a great deal towards helping establish this department, not only by planning a very workable scheme of integration for his patients r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 1 . requiring speech therapy, "but also in stressing the importance of speech therapy for these cases to all medical students under his tuition in addition to his qualified medical assistants. the social services department and doctors serving on the panels of certain medical "benefit societies in addition to their hospital work, have been the source of patients beine referred for treatment from external sources, such as the municipal health clinics, iscor, the railways, and the pensions department. several nursery schools in pretoria have also made use of these facilities. stimulating co-operation and integration with medical staff. this has proved by far the most difficult problem that has had to be tackled, and the one in which the least results have so far been achieved* this problem has become increasingly difficult since the department was moved, as there is far less chance of personal contact and keeping track of the ever changing resident medical staff. the apparent lack of interest and co-operation from many of the medical people is probably due part to the fact that thev are very busy, in part to the tendency to be wary of anything that is new and in part to ignorance. they have very δ little knowledge of speech defects, their etiologies, and ° f ° o r r ? c t i o n > trough no fault of their own. they therefore do not realize that their assessment of the patient a? ttantn?jual γ t h e p h y 8 l c a l > intellectual and esouon" rfpffo???' m a y h a v e a n important bearing on his speech h t h * p r ^ n o s i s a n d p l a n of treatment. there seems to snctfon ^ t j « r + r n y ° f t h e m t 0 r e ^ a r d spee°h as an isolated ninetion, rather than as our primary means of communication and an integral part of the total personality. t^soiva!^0^1 1 1 w h i c h w e £ b speech .therapists, must learn fes^ir j o u r own efforts, to show the medical proxm ΐ ? 1,fr w e w a n t t 0 k n o w a n d without building able + ο exni rmη "fst ^ a r n m e d l c a l terminology, and be δ explain clearly and concisely what it is we require sρeech cnrrppt° g u ? t e 5 e n r y ' spe&king to the american speech correction association "i:t is up to you to make your medical wants known, yourselves will have to educate the physician". m e d i c a l m e n have been regarded as superior ?a v?,l e a i?t to expect this from, not only their ί ',ϊ members of the staff. this must always alissl .?i n d contacting them for information and assistance if one is to build up an attitude of co-operation. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 1 . a farther problem to combat is the tendency of many medicos t 0 withhold from the patient, in the case of an adult, and from the parent, in the case of a child, the true diagnosis. this has "been particularly evident in the case of dysphasias and dyslogias. they most assuredly have their reasons for this tendency, and it would "be unethical to contradict, to the patient, the diagnosis given to him "by the doctor. whereas if the patient and/or parents could acquire an understanding ' of the problem and its future implications, it would facilitate the planning of treatment and the discussion with them of the program tr "be followed. * moreover, it helps them to adjust more adequately to the problem as it stands in the present, and as it will alter in the future. there is also the need to maintain the interest of the doctors in the progress of their patients undergoing speech therapy. as compared with other treatments, this is often a long-term treatment its results "being slower and less obvious. often, at any one time, the progress in social and economic adjustment is of more importance than that of the actual improvement in the speech, as many of these problems arise from the patient sattitude and reactions to his specific speech diffic u ii y ^ jt' 1 8 e8sen"tial for us to consider each patient as an individual, interpreting his difficulties in the light of his own personality, particularly as one so often finds that doctors and staff of other departments are too "busy to consider him -in this light. integration with other departments. for the smooth running of any one department, it is essential to co-operate with other departments. therefore it is necessary to know something of the nature of their work and how they operate, and to maintain friendly though disciplined relations with the staff of each of them. this is "by no means, always easy, many departments "being cramped, understaffed and very "busy. it "becomes far easier when one realises rthat their haste and irritability is generally a reflection of their working conditions, and is not directed at one personally. this integration involves:telephone exchange, workshops, linen room, stores, dispensary, kitchen, the porters, and administration staff as well as the wards, radiography, physiotherapy, occupational therapy, and social services •departments. administration. this has two aspects. firstly that of securing the assistance and co-operation of the general administrative staff of the hospital wherever necessary, e.g. in connection with accounts, typing, signing of orders, .roneoed material, registration of r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 1 patients, and supplies. secondly, that of the administrative side of the department itself. this takes up a considerable time, and involving many items: e.g. requisitions, the checking up of " equipment ordered and not yet received, letter writing registration cards, the correlation of attendance schedules with other departments, searching for data in bedcards and files, copying of relevant data for records, supervising the follow-up and rechecking of all temporarily discharged patients, and attendance register of patients, files on each patient covering the treatment he is receiving, together with the many other items which arise from the handling of specific problems and patients. there are several other problems which could be discussed at some length, which i shall just mention here:1. development of a plan of co-operation with all other speech therapists employed by other organizations in the same area, so as to prevent overlap and at the same time provide the best treatment available for each particular patient. 2. associations and integration with civic groups, organizations and institutions in the area and further afield, whose assistance and advice might prove valuable during the treatment of any one patient. only some of the more important problems encountered in setting up a speech therapy department in a general hospital have been discussed here. many others are met in establishing such, a department but none are unsurmountable. there are frequently times when one feels inclined to let things slide because they seem too difficult jto surmount for the time being, and the results seem so slow in coming. it is at such times that it is essential for us to remember that we "belong to a profession which is still very young in this country, and which has to fight every inch of the way towards recognition. the part each and every one of us has to play towards this end is never to let circumstances overwhelm and defeat our ultimate purpose. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η ondersoek na sekere biolinguistiese verskynsels by hakkel i . c . u y s , b . a . log. (rand), m . a . (pretoria) hakkel is waarskynlik die kommunikasie-afwyking wat, op die gebied van die spraakpatologie, die meeste aan navorsing onderworpe was. veral gedurende die jare 1930 tot 1940 is verskeie studies gedoen in verband met die kenmerke van hierdie probleem. terapeute het meer bewus begin raak van die eienskappe en probleme van die hakkelaar en, afhangende van hulle persoonlike orientasie, is teoriee saamgestel wat as verwysingsraamwerk moes dien vir die verklaring van hakkelgedrag. in terme van hierdie verduidelikingsraamwerk dui die toestand vandag nog op 'n primitiewe stadium van ontwikkeling, met 'n massa teoriee en navorsingresultate wat weersprekende verslae lewer van 'n beperkte omvang van feite. die aanneemlikste verklaring hiervoor is die gebrek aan volgehoue, versigtige, gekoordineerde en sistematiese navorsing, met die doel om 'n verklaring of beskrywing van die funksionele verhouding tussen alle beskikbare feite te gee. ook wat hierdie navorsing betref, moet onthou word dat die geheel belangriker is as die som van die dele. sekere van die elemente wat alreeds ondersoek is, is die voorkoms van hakkel onder verskillende kulturele omstandighede. die resultate van hierdie ondersoeke het egter gegewens aan die lig gebring wat nog steeds onverklaarbaar voorkom. hoewel volgehoue studie 'n verband met die voorkoms, van hakkel in verskillende kulture aan te beveel is, sal verklarings vir verskillende verskynsels alleenlik gevind kan word in 'n biolinguistiese benadering tot die aard van die hakkelgedrag onder hierdie verskillende omstandighede. 'n biolinguistiese benadering word aanbeveel, omdat sulke studies 'n verband met die mens en sy gedrag, die lewende organisme bestudeer soos hy gemodifiseer word deur 'n bepaalde omgewing—in hierdie geval grootliks 'n linguistiese omgewing. doel van die studie soos in die geval van vorige navorsing, is dit die doel van hierdie studie om die voorkoms van hakkel te ondersoek, in omgewings waar die taal die belangrikste kulturele onderskeid aantoon. omdat 'n biolinguistiese benadering gevolg word, word egter gepoog om 'n stappie verder te gaan as om net die voorkoms van hakkel te bepaal. dit is nodig om verklarings te gee om aan te toon waarom hierdie verskynsels openbaar word. sulke verklarings kan gevind word in die verband tussen die voorkoms van hakkel en sekere linguistiesfonetiese verskynsels. vorige studies, waarin engelssprekende hakkelaars tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. : des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 68 i. s. uys gebruik is, het reeds bewys dat hakkelaars meer op konsonante, as op vokale, hakkel. in die praktyk is egter gevind dat: 1. in afrikaans die aanvangsvokaal (veral in die geval van 'n beklemtoonde lettergreep) met 'n glottale afsluiting net voor vibrasie, d.w.s. 'n harde aanset, begin word. 2. in engels 'n sagte aanset, d.w.s. 'n geleidelike adduksie van die stemlippe tot by die punt van vibrasie, asook 'n geleidelike aanvang van vibrasie, by aanvangsvokale gebruik word. 3. afrikaanssprekende hakkelaars wel geneig is om dikwels op vokale te hakkel, veral waar hulle in die inisiele posisie van 'n woord of morfeem voorkom. die hipotese, onderliggend aan hierdie eksperimentele studie, is dus dat die harde aanvang of aanset van vokale (d.w.s. glottale afsluiting), by afrikaanssprekende hakkelaars tot 'n hoer frekwensie van hakkel lei, as wat die geval is by engelssprekende hakkelaars, wat die sagte aanvang of aanset gebruik. die benadering tot 'n studie van hierdie aard is fisiologies en linguisties-foneties (dus biolinguisties), omdat die glottale afsluiting en die betekenis en belang daarvan, sowel as sekere kenmerke van foneem-realisering in verskillende tale aandag geniet. 'n studie van die biolinguistiek beklemtoon die harmoniese werking van alle liggaamstelsels in spraaken taaluiting. lenneberg beklemtoon die feit dat taal, soos enige ander gedragspatroon, as 'n manifestasie van ingewikkelde fisiologiese prosesse beskou kan word. die spraakprosesse is dus gemodifiseerde of gefragmenteerde biologiese funksies. tydens spraakproduksie word die spiere teen so 'n vinnige tempo geaktiveer (of gedeaktiveer) dat dit alleenlik deur outomatismes, wat uit ingewikkelde tydspatrone bestaan, uitgevoer kan word. temporale patroonvorming (in teenstelling met temporale wanorde) is dus klaarblyklik op 'n onderliggende fisiologiese ritme gegrond. hierdie feite is veral interessant wanneer dit in die lig van die eienskappe van afrikaans en engels, as spreektale, beskou word. engels is 'n aaneenvloeiende taal, waar sinsritme meer deur intensiteitsmodulasie aangedui word en waar koartikulasie 'n sterk invloed uitoefen. afrikaans daarenteen is meer segmenteel van aard, in die sin dat pouses (selfs tussen lettergrepe) met 'n harde aanset van die daaropvolgende vokaal, algemeen voorkom in die spraakpatroon. hierdie afbakeningsfunksie van die glottale afsluiting bei'nvloed dan ook die spraakritme tot 'n groot mate. y terwyl hakkel as 'n fragmentasie van die spraakproses, of 'n spraakritmeversteuring, beskou word, kan die hipotese gestel word dat hierdie natuurlike neiging tot fragmentasie van spraakritme by sekere tale ook 'n merkbare invloed op die voorkoms van hakkel sal uitoefen. voorafgaande studie hoewel verskeie taalkundiges al op die verskille in vokaalaanset by afrikaans en engels gedui het, is hierdie verskynsels nog nooit weteni journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ondersoek na sekere biolinguistiese verskynsels by hakkel 69 s k a p l i k bepaal nie. 'n voorafgaande studie, om die metode van aanset by verskillende normaalsprekende taalgroepe te bepaal, is dus genoodsaak. vir hierdie deel van die studie is gebruik gemaak van die spraakmonsters wat verkry is van drie groepe proefpersone nl. britse engels, verkry van volwasse persone wat minder as 'n jaar in suidafrika' woonagtig is, suid-afrikaanse engels, verkry van engelssprekende suid-afrikaners en afrikaans, verkry van afrikaanssprekende suid-afrikaners. die spektrograflese analise wat gemaak is van vokaalaanset, is uitsluitlik gebaseer op vokale aan die begin van 'n beklemtoonde lettergreep, hetsy aan die begin van 'n woord, of aan die begin van 'n tweede, beklemtoonde lettergreep. klem is konstant gehou aangesien dit 'n faktor is, wat vokaalaanset kan be'invloed. die spektrograflese analise het 'n baie duidelike graadverskil openbaar, sodat die vokaalaanset geklassiflseer kon word onder hard, medium en sag. die resultate dui op 'n sterk verskuiwing van sagte na medium en harde aanset by die drie groepe, in die volgorde: britse engels, suid-afrikaanse engels en afrikaans. die volgende groepneigings kom duidelik na vore. britse engels: 'n baie sterk neiging tot die sagte aanset (75%) word gemerk, veral wanneer dit vergelyk word met die medium (2%) en harde aanset (4%). suid-afrikaanse engels: die gebruik van die sagte aanset (67%) kom ook hier die sterkste na vore, hoewel die medium (30%) en harde aanset (3%) ook gebruik word. afrikaans: die voorkoms van medium (54%) en harde aanset (47%) is byna eweredig versprei by hierdie groep, terwyl die sagte aanset nie eenkeer voorgekom het nie. hoewel hierdie bevindings ooreenstem met vorige gegewens en verwagting, kan daar tog op twee interessante verskynsels gedui word, nl. die wedersydse invloed wat by afrikaans en suid-afrikaanse engels aangetref word en die feit dat die invloed van die inisiele klank op aanset sterker is as die invloed van klem. eksperimentele ontwerp en prosedure proefpersone: volwasse hakkelaars, bo die ouderdom van 16 jaar, is as proefpersone gekies. keuring, op grond van die erns van die hakkel, het geskied op grond van die volgende kriteria: (a) dat die persone hulleself as hakkelaars beskou; (b) dat die eksperimenteerder simptome van onvlotheid, met gepaardgaande gedragsmanifestasies van sekondere hakkel waargeneem het. op hierdie wyse is die resultate verkry van: (i) 12 engelssprekende, suid-afrikaanse manlike hakkelaars. (ii) 11 afrikaanssprekende suid-afrikaners, 9 mans en 2 dames. toetsmateriaal dieselfde toetsmateriaal is gebruik wat in die voorafgaande studie met die normale sprekers gebruik is, ,nl. 'n woordelys bestaande uit 140 tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 70 i. s. uys geselekteerde woorde. alledaagse engelse woorde is vir die engelssprekende groep aangebied en bekende afrikaanse woorde vir die afrikaanssprekendes. daar is vir verskeie redes besluit om liewer van woordelyste as van spontane spraak of die lees van sinne, gebruik te maak. (a) daar bestaan nog geen genoegsame bewyse in verband met die voorkoms van wat beskou kan word as 'n aanvangsklank in die middel van 'n sin me. die moontlikheid van ko-artikulasie moet dus geelimineer word. · (b) verskeie veranderlikes, wat die eksperimentele resultate kan beinvloed, moet konstant gehou word, bv. verwagting en posisie van die woord in die sin. (c) die aanbieding van woordelyste kan ook beheer uitoefen oor faktore soos woordlengte, grammatikale funksie, betekenisvolheid en verskeidenheid van aanvangsklanke. (d) terwyl twee taalgroepe betrek is kan die aanbieding van woordelyste sorg dra dat die spraakmonsters op fonetiese grondslag ooreenalgemene prosedure elke proefpersoon is indiwidueel getoets. die woorde is een vir een aangebied en geen tydsbeperking is gestel nie. die beoordeling van die voorkoms van hakkelspasmas is gedoen deur twee opgeleide spraakterapeute, tydens die opname, asook volgens die bandopname. hierdie prosedure is konstant gehou vir alle proefpersone. resultate en bespreking die resultate is deur middel van twee statistiese prosedures verwerk vergelyking binne die groepe is verkry met die wilcoxon simmetrietoets, terwyl vergelyking tussen groepe vasgestel is met die normaalbenadenng vir die verskil tussen twee verhoudings. hierdie toetse het veral geskik geblyk te wees, omdat die studie van 'n relatief klein getal proefpersone gebruik gemaak het. om tot 'n slotsom te kom i.v.m. die hipotese, is die volgende verhoudings statistics bepaal: 1. die verhouding in die voorkoms van hakkel tussen aanvangsvokale en aanvangskonsonante by elke persoon. / 2. die verhouding tussen die twee groepe met betrekking tot die voorkoms van hakkel op aanvangsvokale en aanvangskonsonante. 3. die verhouding in die voorkoms van hakkel tussen vokale en konsonante aan die begin van die tweede, beklemtoonde lettergreed bv elke persoon. j 4. die verhouding tussen die twee groepe met betrekking tot die voorkoms van hakkel op vokale en konsonante aan die begin van die tweede, beklemtoonde lettergreep. journal of the south african logopedic society, vol. 17, no 1: december 197 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ' η ondersoek na sekere biolinguistiese verskynsels by hakkel 71 dit dien vermeld te word dat twee van die afrikaanse hakkelaars vroulik is. vorige navorsing het aangetoon dat laringeale spasmas dikwels by vrouens voorkom, soos ook hier opgemerk kan word uit die resultate van een vroulike proefpersoon. die resultate vir beide vroulike proefpersone is egter behou in die ontleding, eerstens omdat bevind is dat die uitsprake nie verander het wanneer die persone weggelaat word nie, en tweedens om die aantal proefpersone in die groepe naastenby gelyk te hou. 1. die verhouding in die voorkoms van hakkel tussen aanvangsvokale en aanvangskonsonante by elke persoon. t a b e l i : d i e v o o r k o m s v a n h a k k e l o p a a n v a n g s v o k a l e en a a n v a n g s k o n s o n a n t e by e n g e l s s p r e k e n d e h a k k e l a a r s proefpersone aanvangsvokaal aanvangskonsonant totaal l . m 35 24 59 2.m 4 19 23 3.μ 13 14 27 4.μ 18 4 22 5.μ 11 36 47 6.m 18 40 58 7.μ 33 55 88 8.μ 30 39 69 9.μ 3 17 20 10.μ 25 42 67 11.μ 2 10 12 12.μ 11 7 18 203 307 510 uit hierdie tabel kan afgelei word dat die nulhipotese van geen verskil tussen die voorkoms van hakkel op aanvangsvokale en aanvangskonsonante op die 5%-peil van betekenis verwerp word. hieruit blyk dit dus dat die voorkoms van hakkel op aanvangsvokale betekenisvol minder is as die voorkoms van hakkel op aanvangskonsonante. t a b e l i i : d i e v o o r k o m s v a n h a k k e l o p a a n v a n g s v o k a l e en a a n v a n g s k o n s o n a n t e by a f r i k a a n s s p r e k e n d e h a k k e l a a r s proefpersone aanvangsvokale aanvangskonsonante totaal l . m 10 6 16 2.m 2 13 15 3.μ 20 39 59 4.m 5 16 21 5.μ 4 9 13 6.m 53 25 78 7.μ 17 13 30 8.μ 34 2 36 9.μ 4 2 6 10.v 60 6 66 11.v 32 9 41 241 140 •381 tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17,nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 72 i. s. uys in hierdie geval word die nulhipotese nie op die 5%-peil van betekenis verwerp nie. die afleiding is dus dat daar geen betekenisvolle verskil bestaan tussen die voorkoms van hakkel op aanvangsvokale en aanvangskonsonante nie. 2. die verhouding tussen die twee groepe met betrekking tot die voorkoms van hakkel op aanvangsvokale en aanvangskonsonante. in die volgende tabel word 'n uiteensetting gegee van die voorkoms van hakkel op aanvangsvokale, om sodoende groepneigings met mekaar te vergelyk. t a b e l i i i : d i e v o o r k o m s v a n h a k k e l o p a a n v a n g s v o k a l e b y b e i d e g r o e p e proefpersone aanvangsvokale engels 203 afrikaans 241 die persentasie hakkel op aanvangsvokale by engelssprekende hakkelaars is dus 24.2%, terwyl dit by afrikaanssprekende hakkelaars 31.3% is. bespreking die verkree waardes dui aan dat daar op die 5%-peil van betekenis wel 'n . verskil bestaan tussen die twee groepe. die afrikaanssprekende hakkelaars het dus betekenisvol meer op aanvangsvokale gehakkel as die engelssprekende hakkelaars. wanneer hierdie resultate vergelyk word met 'n soortgelyke studie wat deur hahn in amerika uitgevoer is, word gevind dat dieselfde neiging, wat in die voorafgaande studie met normale sprekers gevind is, homself hier herhaal. die amerikaanse hakkelaars (wat van 'n sagter aanset gebruik maak as die engelssprekende suid-afrikaanse t a b e l i v : d i e v o o r k o m s v a n h a k k e l o p a a n v a n g s k o n s o n a n t e b y b e i d e g r o e p £ proefpersone aanvangskonsonante engels 307 afrikaans 140 hakkelaars) het slegs op 2.9% van die aanvangsvokale gehakkel. weereens neem die engelssprekende suid-afrikaners die middelgroep in, terwyl die afrikaanssprekende hakkelaars die meeste op aanvangsvokale gehakkel het. journal of the south african logopedic society, vol. 17, no. 1: december 197ό r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) η ondersoek na sekere biolinguistiese verskynsels by hakkel 73 die persentasie hakkel op aanvangskonsonante by die engelssprekende hakkelaars is dus 36.5% terwyl dit by die afrikaanssprekende hakkelaars 18.2% is. bespreking soos in die geval van aanvangsvokale, is ook hier 'n betekenisvolle verskil gevind tussen die twee groepe. op die 5%-peil van betekenis, het die afrikaanssprekende hakkelaars minder op aanvangskonsonante gehakkel as die engelssprekende hakkelaars. op grond van hierdie betekenisvolle bevindings kan dus afgelei word dat die twee taalgroepe van mekaar verskil met betrekking tot die voorkoms van hakkel op aanvangsvokale en aanvangskonsonante. 'n ander motivering vir hierdie stelling word gevind in die vergelyking binne die groepe—dat die engelssprekendes betekenisvol minder op aanvangsvokale gehakkel het as op aanvangskonsonante, terwyl die afrikaanssprekendes geen betekenisvolle verskil toon nie. 3. die verhouding in die voorkoms van hakkel tussen konsonante en vokale aan die begin van die tweede, beklemtoonde lettergreep, by elke persoon. sekere verskynsels in verband met foneemrealisering en hakkel dien as motivering vir 'n analise van die voorkoms van hakkel op die tweede, beklemtoonde lettergreep. indien ladefoged se siening korrek is, behoort die begin van die tweede lettergreep (veral omdat dit beklemtoon is) weereens 'n aanvangsklank te he, wat vergelykbaar is met die aanvangsklank by die eerste lettergreep. die feit dat klem tot 'n verhoogde voorkoms van hakkel lei kan ook hier in ag geneem word. indien hierdie verskynsels 'n sterk invloed sou uitoefen op die voorkoms van hakkel, kan verwag word dat dieselfde patroon, as wat gevind is in die geval van aanvangsklanke, homself hier sal herhaal. t a b e l v : d i e v o o r k o m s v a n h a k k e l o p v o k a l e en k o n s o n a n t e a a n d i e b e g i n v a n d i e t w e e d e , b e k l e m t o o n d e l e t t e r g r e e p b y e n g e l s s p r e k e n d e h a k k e l a a r s aanvangsvokaal aanvangskonsonant proefpersone van 2e lettergreep van 2e lettergreep totaal l . m 17 5 22. 2. μ 3 0 3 3.μ 2 0 2 4.μ 0 0 0 5.μ 4 4 8 6.μ 4 10 14 7.μ 12 3 15 8.μ 0 1 1 9.μ 1 2 3 10.μ 12 16 28 11.μ 5 2 7 12.μ 1 1 2 61 44 105 tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des.1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 74 . s. uys die nulhipotese kan hier nie op die 5%-peil van betekenis verwerp word nie, met ander woorde, geen verskil word gevind tussen die voorkoms van hakkel op vokale en konsonante aan die begin van die tweede, beklemtoonde lettergreep by hierdie groep nie. t a b e l v i : d i e v o o r k o m s v a n h a k k e l o p v o k a l e en k o n s o n a n t e a a n d i e b e g i n v a n d i e t w e e d e , b e k l e m t o o n d e l e t t e r g r e e p by a f r i k a a n s s p r e k e n d e h a k k e l a a r s proefpersone aanvangsvokaa! van 2e lettergreep aanvangskonsonant van 2e lettergreep totaal l . m 3 4 7 2.m 1 2 3 3.μ 3 15 18 4.m 0 2 ' 2 5.μ 4 1 5 6. μ 3 4 7 7.μ 1 3 4 8.μ. 12 4 16 9.μ 1 0 1 1 10.v 15 0 1 16 11.v 17 2 19 60 38 98 net soos in die geval van tabel ii is weereens twee berekenings gedoen (met en sonder die vrouens) en beide berekenings dui daarop dat die nulhipotese nie op die 5%-peil van betekenis verwerp kan word nie. daar bestaan dus geen betekenisvolle verskil tussen die voorkoms van hakkel op konsonante en vokale aan die begin van die tweede, beklemtoonde lettergreep nie. t a b e l v i i : d i e v o o r k o m s v a n h a k k e l o p v o k a l e a a n d i e b e g i n v a n die t w e e d e , b e k l e m t o o n d e l e t t e r g r e e p b y b e i d e g r o e p e aanvang svokaal proefpersone van 2e lettergreep engels 61 afrikaans 60 in vergelyking met die resultate van tabel ii kan hier gesien word dat dieselfde patroon herhaal word, nl., dat daar in beide gevalle geen betekenisvolle verskille bestaan nie. ./' 4. die verhouding tussen die twee groepe met betrekking tot die voorkoms van hakkel op vokale en konsonante aan die begin van die tweede, beklemtoonde lettergreep. terwyl die voorafgaande bespreking aangetoon het dat die patroon, wat gevind is in die geval van aanvangsklanke homself alleenlik in die geval van die afrikaanssprekende hakkelaars herhaal, is die twee groepe weer met mekaar vergelyk in 'n pogihg om die groepneigings vas te stel. journal of the south african logopedic society, vol. 17, no. : december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 'η ondersoek na sekere biolinguistiese verskynsels by hakkel 75 tabel vi is 'n aanduiding van die voorkoms van hakkel op vokale aan die begin van die tweede, beklemtoonde lettergreep en stem ooreen met die analise van aanvangsvokale in tabel iii. die persentasie hakkel op vokale aan die begin van die tweede, beklemtoonde lettergreep is dus: engels: 25.4% en afrikaans: 27.3%. bespreking volgens analise met die normaalbenadering word gevind dat daar op die 5%-peil van betekenis geen verskil tussen die twee groepe bestaan nie. wat betref die aanvangsvokale is daar wel 'n verskil tussen die twee groepe gevind en wel dat die afrikaanssprekende hakkelaars betekenisvol meer op aanvangsvokale gehakkel het. omdat die spraakmonsters in bogenoemde twee gevalle nie gelykwaardig is nie, is dit nie moontlik om 'n definitiewe vergelyking te tref nie. daar kan egter sekere verskynsels aan die hand gedoen word wat aanleiding kan gee tot hierdie verskille. die sterk neiging onder engelssprekendes om te streef na 'n vloeiende spraakmelodie, wat veral deur vokale oorgedra word, kan aanleiding gee tot die verskynsel van ko-artikulasie, met ander woorde, dat dit moeilik is om te bepaal wanneer daar binne die woord nog 'n aanvangsklank voorkom. die invloed van die inisiele klank blyk dus nog sterker te wees as die invloed van klem op die voorkoms van hakkel. die herhaling van dieselfde patroon in beide gevalle van die afrikaanssprekende hakkelaars is verklaarbaar op grond van die feit dat afrikaans, soos noord-duits 'n afgebroke „springerige" kwaliteit openbaar. kort pouses kom dikwels tussen lettergrepe voor (in teenstelling met engels) en dit kan dui op 'n nuwe aanvang voor 'n tweede, beklemtoonde lettergreep. die invloed van die inisiele klank op die voorkoms van hakkel, kan dus in beide gevalle geld. 'n vergelyking tussen die twee groepe met betrekking tot die voorkoms van hakkel op konsonante aan die begin van die tweede, beklemtoonde lettergreep word in tabel viii gestel. dit is weereens vergelykbaar met die voorkoms van hakkel op aanvangskonsonante soos aangedui in tabel iv. t a b e l v i i i : d i e v o o r k o m s v a n h a k k e l o p k o n s o n a n t e a a n d i e b e g i n v a n d i e t w e e d e , b e k l e m t o o n d e l e t t e r g r e e p by b e i d e g r o e p e aanvangskonsonant proefpersone ' van 2e lettergreep engels 44 afrikaans 38 die persentasie hakkel op konsonante aan die begin van die tweede, beklemtoonde lettergreep is dus: engels: 18.3% en afrikaans 17.3%. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 76 i. s. uys weereens is daar op die 5%-peil van betekenis geen verskil tussen die twee groepe gevind nie. die engelssprekende hakkelaars het egter betekenisvol meer gehakkel op aanvangskonsonante as die afrikaanssprekende groep. dieselfde verklaring wat voorgehou is in die geval van die voorkoms van hakkel op vokale kan moontlik hier van toepassing wees. uit bogenoemde bespreking kan die afleiding dus gemaak word dat, in die geval van die engelssprekende hakkelaars, die aanvangsklank van die tweede, beklemtoonde lettergreep nie nog 'n aanvangsklank in die ware sin van die woord is nie·. die vloeiendheid van die taal, koartikulasie en sinsritme oefen klaarblyklik 'n sterk invloed uit. in afrikaans oefen die neiging tot fragmentasie 'n sterk invloed uit en het die harde aanset 'n sterk afbakeningsfunksie. dit is dus verstaanbaar dat dieselfde patroon hier gevolg word by die aanvang van die tweede, beklemtoonde lettergreep. die hipotese wat gestel is, dat hakkel meer by afrikaanssprekendes sal voorkom op aanvangsvokale, is dus bewys. op grond van die ondersoeke wat uitgevoer is met die 3 groepe normale sprekers, blyk dit ook asof die harde aanset wat by afrikaans voorkom, die oorsaak van hierdie verskynsel is. gevolgtrekkings die primere doel van hierdie studie was om.die invloed van sekere biolinguistiese verskynsels op hakkel te ondersoek. die navorsing is dus ook veral gerig op laringeale funksie onder twee verskillende omstandighede: 1. laringeale funksie in foneem-realisering by twee tale: afrikaans en engels. 2. laringeale funksie as gevolg van foneem-realisering, by hakkel. die resultate bevestig grotendeels die hipotese: 'n sterk verskuiwing van sagte na medium en harde aanset van vokale is waargeneem by die drie groepe normale sprekers, in die volgorde: britse engels, suidafrikaanse engels en afrikaans. dit beaam weereens die stelling dat engels, as spreektaal meer aaneenvloeiend is, waar spraakritme eerder deur intensiteitsmodulasie as deur onderbreking gehandhaaf word. afrikaans daarenteen, toon hoofsaaklik die harde vokaalaanset, wat veral voorkom op aanvangsklanke. aangesien hierdie verskynsel homself herhaal het in die geval van die tweede, beklemtoonde lettergreep, word hier bevestiging gevind vir die bewering dat afrikaans, as spreektaal, meer segmenteel van aard is, deurdat die afbakeningsfunksie van die glottale afsluiting deur 'n kort pouse voorafgegaan is. die resultate het verder aan die lig gebring dat suid-afrikaanse engels eienskappe van beide britse engels en afrikaans toon. die resultate van die hakkelaars kan dus nou in die lig van die voorkoms van hierdie linguistiese verskynsels verklaar word: afrikaansjournal of the south african logopedic society, vol. 17, no. : december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ' η ondersoek na sekere biolinguistiese verskynsels by hakkel 77 sprekende hakkelaars het betekenisvol meer op aanvangsvokale gehakkel as engelssprekende hakkelaars. die gevolgtrekking kan dus gemaak word dat die glottale afsluiting, wat 'n algemene verskynsel in die afrikaanse spreektaal is, lei tot 'n laringeale hakkelspasma. die relatief sagter aanvang wat deur suid-afrikaanse engelse gebruik word, het betekenisvol minder hakkelspasmas ontlok, terwyl amerikaanse studies bewys dat hakkel selde op aanvangsvokale voorkom. aangesien hierdie selfde patroon homself uitsluitlik in die geval van die afrikaanssprekende hakkelaars op die tweede, beklemtoonde lettergreep herhaal het, bevestig dit die vermoede dat aanvangsvokale in afrikaans ook in die middel van 'n woord kan voorkom. uit hierdie studie blyk dit dus dat 'n biolinguistiese benadering tot 'n verklaring van die voorkoms van hakkel positiewe resultate oplewer. daar is egter nog sekere vrae wat deur verdere navorsing beantwoord moet word: 1. wat is 'n aanvangsklank en wanneer kom dit voor by normale sprekers uit verskillende taalgroepe? 2. sou die resultate dieselfde gewees het indien sinne gelees is of spraakmonsters van spontane spraak verkry is? 3. wat is die frekwensie van laringeale spasmas tydens die voorkoms van hakkel? uit hierdie vrae blyk dit dat daar nog 'n hele nuwe veld braak le. dit kan wees dat daar in die beantwoording van hierdie vrae 'n oplossing vir die raaisel van hakkel gevind kan word. opsomming verskeie navorsingsprojekte het al gepoog om die voorkoms van hakkel in verskillende kulture vas te .stel, sonder om 'n verklaring van die voorkoms en aard van hakkelgedrag deur middel van 'n biolinguistiese benadering aan te bied. linguisties-fonetiese faktore, soos vokale aanvangsmetodes, dui op 'n verskil tussen afrikaans en engels. die harde aanset van aanvangsvokale in afrikaans blyk 'n oorsaak te wees van 'n verhoogde voorkoms van hakkel op aanvangsvokale. 'n biologiese proses (laringeale spanning, glottale afsluiting en verhoogde subglottale lugdruk) aan die een kant en 'n linguistiese verskynsel (die spesifieke eienskappe van foneem-realisering in verskillende tale) aan die ander kant, veroorsaak klaarblyklik die patologiese reaksie (laringeale hakkel). summary various research projects have aimed to explain the occurrence of stuttering amongst various cultural groups, without offering an explanation of the occurrence and nature of the stuttering behaviour in terms of a biolinguistic approach. linguistic phonetic factors, such as vocal initiation, indicate a difference between english and afrikaans. the hard attack on the initial tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 7 8 i. s. uys vowels in afrikaans appear to result in an increased frequency of stuttering on these initial vowels. a biological process (laryngeal tension, glottal closure and increased sub-glottal pressure) on the one hand, and a linguistic phenomenon (the specific properties of the phonemic system in different languages) on the other hand, appear to be the cause of the pathological reaction (laryngeal stuttering). bibliografie 1. brown, s. f. -a further study of stuttering in relation to various speech sounds. q.j.s., vol. 24, 1938, p. 390-897. 2. brown, s f . : stuttering with relation to word accent and word position. journal of abnormal and social psychology. vol. 33, 1938, p. 112-130. 3. brown, s. f . : the loci of stuttering in the speech sequence. j.s.d. vol. 10, 1945, p. 181-192. 4. h a h n , e. f . : a study of the relationship between stuttering occurrence and phonetic factors in oral reading. j.s.d. vol. 7, 1942, p. 143-151 5. judson l. s. and weaver, a. t . : voice science. appleton-century-crofts inc., new york, 1965. · 6. ladefoged, p . : three areas of experimental phonetics. oxford university press, london, 1967. 7. le roux, τ. h. and pienaar, p. de v . : afrikaanse fonetiek. juta & kie bpk., kaapstad en johannesburg, 1927. 8. lenneberg, ε. h . : biological foundations of language. john wiley & sons new york, london, sydney, 1967. 9. luchsinger, r. and arnold, g. e . : voice-speech-language. clinical communicology: its physiology and pathology. wadsworth publ. co. inc., belmont, california, 1965. •10. mcdonald ε. t . : articulation: testing and treatment : a sensory-motor approach. stanwix house inc., pittsburgh, 1968 11. mcadcr c l and muyskens, j. h . : a handbook of biohnguistics, part 1. herbert c. weller, toledo speech clinic, inc., ohio 1962. journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 56 sajcd • vol 58 • october 2011 cpd october 2011 1. true (a) or false (b): the music perception test (mpt) was designed to evaluate rhythm, timbre, pitch and melody. 2. true (a) or false (b): audiologists can use the mpt as a counselling tool. 3. true (a) or false (b): all participants performed poorly on the rhythm section of the mpt. 4. true (a) or false (b): a variety of tests evaluating music perception in hearing aid users are available. 5. true (a) or false (b): approximately 15% of individuals with mild traumatic brain injury (mtbi) complain of debilitating symptoms up to 1 year after injury. 6. true (a) or false (b): mtbi will always have a mild impact on an individual’s communication abilities. 7. true (a) or false (b): discourse analysis is a quantitative approach to examine individuals’ perceptions. 8. true (a) or false (b): one of the participants in the mtbi study, p1, viewed loss of temper as a form of communication. 9. true (a) or false (b): irritability and associated loss of temper are always permanent consequences of mtbi. 10. true (a) or false (b): executive function is associated with the frontal lobes of the brain. 11. true (a) or false (b): individuals with mtbi do not experience word retrieval difficulties. 12. true (a) or false (b): the terms dizziness and vertigo both refer to exactly the same symptom. 13. true (a) or false (b): vertigo is a perception of motion when there is an external source for that sensation. 14. true (a) or false (b): the vertigo symptom scale evaluates two areas, namely the experience of dizziness and psychological symptoms. 15. true (a) or false (b): the afrikaans vertigo symptom scale presented with good sensitivity and poor specificity in relation to vertigo. 16. services for people with communication disorders: a) are often well understood b) are well resourced c) often have low priority in health care systems d) are well established worldwide. 17. indigenous knowledge should be used: a) with caution b) to drive the process of development of contextually relevant resources c) in conjunction with external and scientific knowledge to produce locally relevant resources d) b & c. 18. adaptation of a test developed elsewhere: a) is the best way to develop local assessment resources b) is not necessary when used in another context c) could assist in developing local knowledge and resources d) none of the above. 19. studies in the local context are necessary to: a) determine the prevalence of communication disorders in south africa b) obtain legislative support for service delivery c) describe the status of services currently available d) all of the above. 20. speech-language therapists in public hospitals: a) fulfil different roles in neonatal nurseries, as determined by their context b) have sufficient time to participate in ward rounds c) are all involved in discharge planning d) all of the above. cpd questionnaires must be completed online via www.cpdjournals.co.za. after submission you can check the answers and print your certificate. the south african journal of communication disorders sajcd sajcd 120 the occurrence of high-risk factors for hearing loss in very-low-birth-weight neonates: a retrospective exploratory study of targeted hearing screening a kanji, k khoza-shangase   department of speech pathology and audiology, school of human and community development, university of the witwatersrand, johannesburg amisha kanji katijah khoza-shangase corresponding author: a kanji (amisha.kanji@wits.ac.za) the current study aimed at determining the type and frequency of high-risk factors for hearing loss in a group of very-low-birth-weight (vlbw) neonates in a tertiary hospital in south africa with the objective of collating evidence that could be used in arguing for or against revisiting targeted hearing screening in developing countries. furthermore, the study aimed at investigating the relationship between the identified high-risk factors and hearing screening results. in a retrospective data review design, data were collated from files from the vlbw project; this included hearing screening records, as well as records from participant medical and audiology files. records of 86 neonates with birth weights ranging between 680 g and 1 500 g were reviewed. findings indicated that neonatal jaundice, exposure to human immunodeficiency virus (hiv), mechanical or assisted ventilation, and neonatal intensive care unit stay greater than 48 hours were the most frequently occurring high-risk factors for hearing loss in the current sample. these factors are consistent with those listed in the high-risk register of the health professions council of south africa for the south african context. findings confirm the complexity of risk factors, and the influence that a variety of factors such as poor follow-up or return rate might have on the implementation of early hearing detection and intervention. the importance of establishing context-specific risk factors for effective implementation of targeted screening protocols where universal newborn hearing screening is not yet a reality was highlighted by the current study. keywords: hearing loss, risk factors, very low birth weight, neonates, targeted newborn screening, developing country s afr j cd 2012;59(1):3-7. doi:10.7196/sajcd.120 there has been a considerable increase in the survival rate of very-low-birth-weight (vlbw, <1 500 g) neonates over the last few decades as a result of improvements in medical care (ruegger, hegglin, adams & bucher, 2012). this increase is particularly recorded in developed countries where improved outcome following medical intervention in the neonatal intensive care unit (nicu) has been well documented (darlow, cust & donoghue, 2003). while these improvements and advances are readily adopted by developing countries, implementation is often accompanied by poorly resourced health services (ballot, potterton, chirwa, hilburn & cooper, 2012).within the south african context, an overall survival rate of 72% among vlbw neonates admitted to a public sector hospital in gauteng has been reported (velaphi et al., 2005). this increase in survival rate raises concern regarding the associated, increased rates of neurodevelopmental disability among these vlbw neonates (claas et al., 2011). rates of disability among surviving vlbw neonates may be higher in developing countries such as south africa (ballot, chirwa & cooper, 2010) as the setting and resources in these contexts differ markedly to those in developed countries. factors such as increased length of hospital stay (mokhachane, saloojee & cooper, 2006), and increased risk of the surviving neonate being subjected to a variety of complications while in hospital (wood et al., 2000) are known to result in a range of problems such as cerebral palsy, cognitive impairment, blindness and hearing impairment (hack, 2007). although vlbw in isolation has not been documented to have a severe impact on hearing, it is frequently associated with multiple risk factors that can affect hearing in a collective manner (cristobal & oghalai, 2008). the probability of sensorineural hearing loss has been found to increase as the number of coexisting risk factors increases, with the probability being nearly double for those with five or more risk factors for hearing loss (bielecki, horbulewicz & wolan, 2011). these risk factors may differ across communities and contexts (olusanya, luxon & wirz, 2004) and there is paucity of data on the high-risk factors for hearing loss among vlbw neonates within the south african context. establishing the rate of occurrence of these risk factors in this population can contribute towards efforts aimed at early identification of hearing loss. benefits of early identification of hearing loss have been well documented, and include increased access to more prompt and appropriate intervention (hpcsa, 2007; jcih, 2007). evidence of positive benefits from early hearing detection and intervention (ehdi) led to the establishment of a high-risk register by the joint committee on infant hearing (jcih) (kountakis, skoulas, phillips & chang, 2002). although the use of the register as a sole screening method has limitations, such as missing 25 50% of neonates with hearing loss (kountakis et al., 2002), it is believed to be useful as a referral protocol and necessary for the identification of infants who may require monitoring and follow-up screening (johnson, 2002). it can be argued that this necessity holds particularly true in contexts where universal newborn hearing screening is not yet feasible, such as in most developing countries. the risk factors for permanent congenital and early-onset hearing loss documented by the jcih are usually adopted in such screening programmes, but these may be expanded to include other risk factors appropriate to the context, especially in developing countries (olusanya et al., 2004). modifying risk factors to make them context-relevant is crucial as the literature has shown that adoption of an evidence-based model of care allows for best practice. for example, kountakis et al. (2002), based on findings from their study conducted at hermann hospital in houston, texas, identified 11 variables not included in the jcih (1994) high-risk register which had a statistically significant correlation to hearing loss in their context. the jcih (2007) high-risk register has since been updated to include a few of these risk factors. although the hpcsa (2007) position statement on ehdi has led to the initiation of newborn hearing screening programmes in both the public and private healthcare sectors in the country, these programmes remain mostly unstructured, disorganised and uncommon because they are unauthorised and not mandated by hospital management in these sectors (swanepoel, storbeck & friedland, 2009). the lack of success in implementation of newborn hearing screening in south africa can be attributed to a number of factors. firstly, priorities within the health sector are focused on saving lives rather than addressing quality of life in individuals with non-threatening conditions such as hearing loss (swanepoel, hugo & louw, 2006). secondly, when assessing the number of qualified audiologists in the country in relation to population size, there is an evident shortage of manpower in the public healthcare sector (olusanya et al., 2004) which makes achievement of goals of early detection of hearing loss and early intervention difficult, unless middle-level workers and/or nurses are trained to perform hearing screening. the hpcsa (2007) has recommended a list of high-risk factors to be used for targeted or risk-based screening. these high-risk factors are based on those specified in the year 2000 jcih position statement for ehdi programmes, with two additional risk factors that are considered contextually relevant to the south african context, namely hiv and malaria (hpcsa, 2007). reviewed evidence indicates that risk factors for permanent congenital and early-onset hearing loss may vary across communities. current authors support the view that one should not consider the risk factors listed by the jcih with the same relative importance because of considerable variation of situations and time periods in different countries (korres et al., 2005). we support olusanya’s (2008) argument that a need exists for developing countries to be guided by empirical evidence on the relevant risk factors for each community and population when making the decision to embark on targeted screening, hence the importance of the current study in the vlbw population within a south african context. while the reviewed studies have focused on neonates in the nicu and well-baby nurseries, no studies pertaining to high-risk factors have been conducted in a developing country like south africa where vlbw has been reported to contribute significantly to the total number of neonatal admissions. furthermore, in developing countries where there are limited healthcare resources and high patient numbers, it is often not possible to provide full tertiary support to every vlbw neonate (ballot et al., 2010). this reality highlights the need for further research in the vlbw population cared for in other settings (i.e. high care, low care or kangaroo mother care), where the need for newborn hearing screening has not yet been identified and prioritised, or published as evidence from developing countries. the identification of the type and occurrence of high-risk factors for hearing loss in vlbw neonates is one such important research area which can assist audiologists with the development of appropriate, efficient and sensitive targeted hearing screening protocols, particularly when manpower shortages prevent or restrict screening of all neonates in all neonatal wards. method aims the main aim was to describe which of the hpcsa (2007) high-risk factors for hearing loss were present in a group of vlbw neonates. secondary objectives were to determine the occurrence of these risk factors in the sample, and to establish whether any one or combination of these risk factors was independently or jointly related to distortion product oto-acoustic emissions (dpoae) screening results. research context the study was conducted at a tertiary level hospital in gauteng, south africa. the hospital has a fully operational nicu and established neonatal clinics, as well as an audiology department. participants inclusion criteria inclusion criteria stipulated that participants had to have been part of the vlbw project, weighing 1 500 g or less, with complete hearing screening records for analysis, and must have had the initial hearing screening within the neonatal period. sample the sample comprised 86 participants (35 males and 51 females) with a gestational age range of 26 40 weeks (mean = 31 weeks). the birth weight range was 680 1 500 g (mean = 1 199 g). participants had been a part of the vlbw project which was a longitudinal study aimed at determining the functional and developmental outcomes of vlbw infants 12 15 months of corrected age. these participants had been assessed at follow-up visits by a paediatrician, nurse and allied medical disciplines. design the current study employed a passive, archival, quantitative research design as it involved a retrospective record review with no manipulation of variables, and the researcher used existing documents to analyse variables across time and condition (devlin, 2006). data collection and analysis data were obtained from archived hearing screening records which were part of a vlbw project that was conducted between july 2006 and february 2007. the hpcsa (2007) high-risk register was used to identify potential risk factors for hearing loss for each participant in the current retrospective study. each identified risk factor was recorded next to each participant’s code. data for each participant were collated onto an excel spread sheet for ease of data handling and analysis. ethical considerations ethical clearance (protocol number: m060546) was obtained from the medical research ethics committee and informed consent was obtained from caregivers for the vlbw project. data were only utilised retrospectively for the current study following approval from the medical research ethics committee (protocol number: m090565), as well as permission from the postgraduate committee. for the purposes of the current study, confidentiality and anonymity of the participants was maintained by ensuring that a research coding system was utilised instead of participant names and hospital identity numbers. reliability and validity owing to the current study being a retrospective record review, reliability and consistency of case history data were maintained by ensuring that data were obtained from medical record reviews rather than caregivers’ reports. limited patient recollection of events may result in recall bias (panacek, 2007). similarly, inaccuracies of medical records may also occur (panacek, 2007). the current study ensured accurate case history data by cross-checking the information recorded on the speech, hearing and feeding assessment form to the original nicu admission records. standardisation of ‘pass’/‘refer’ criteria was also maintained throughout analysis of dpoae screening results. validity was enhanced by considering the influence of environmental and patient factors that could affect dpoae screening results. therefore, frequencies below 1 khz were eliminated from statistical analysis because these frequencies are most affected by acoustic ambient noise, and external and internal artefacts. reliability and validity of the test protocol adopted for the vlbw project was deemed appropriate. hearing screening had been performed through the use of dpoae through the biologic audx dpoae screener. participants who did not pass the initial test in one or both ears, as well as those who were discharged before completion of screening, were referred to the audiology department 6 weeks after discharge (which corresponded to their neonatal follow-up), for a follow-up screening. those participants who passed the initial screening were also referred for a follow-up screening. data analysis data were collated and tabulated nominally. this was done in order to identify the dominant trends which emerged in relation to high-risk factors. descriptive statistics were then utilised to illustrate and make sense of findings. data obtained were compared against the high-risk factors for hearing loss as defined by the hpcsa (2007). analysis of a relationship between the most frequently occurring risk factors and dpoae screening results was also performed using two-way contingency tables and the chi-square test. analysis using all five risk factors in combination was not performed because of sample size constraints. ‘pass’/‘refer’ criteria for the analysis of dpoae results were adopted. initial dpoae screening results were descriptively analysed by frequency, as either ‘pass’ or ‘refer’. owing to reported high ambient noise levels in a hospital (olusanya, somefun & swanepoel, 2008; olusanya, wirz & luxon, 2008), which primarily affect the low frequencies, 250 hz and 500 hz, 750 hz and 1 000 hz were not included within the ‘pass’/‘refer’ criteria. reliable data using dpoaes should be expected at 2, 3 and 4 khz (gorga et al., 2000); therefore, in the current study, ‘pass’/‘refer’ criteria were assessed using 2, 3, 4, 6 and 8 khz. an overall ‘pass’ result required a unilateral or bilateral ‘pass’ result at, at least four of the five frequencies. results a summary of the findings from the current study is depicted in table 1. table 1. frequency of occurrence of risk factors among vlbw neonates ( n =86)   frequency percentage risk factors for hearing loss as indicated by the hpcsa (2007)     neonatal jaundice 76 88.37 hiv exposed 15 17.44 nicu stay greater than 48 hours 13 15.11 mechanical/assisted ventilation 13 15.11 exposure to ototoxic medication 9 10.46 associated syndrome (11th chromosome deletion) 1 1.16 syphilis 1 1.16 other risk factors (not specific to hearing loss) present in data of study sample prematurity 85 98.83 hmd 18 20.93 ivh grade ii 9 10.46 hypoxia/birth asphyxia 8 9.30 renal dysfunction 8 9.30 hyperglycaemia 5 5.81 eclampsia 4 4.65 ivh grade i 3 3.49 hypoglycaemia 3 3.49 anaemia 2 2.32 choriamnionitis 2 2.32 ivh grade iii 1 1.16 vlbw = very low birth weight; nicu = neonatal intensive care unit; hmd = hyaline membrane disease; ivh = intraventricular haemorrhage. from the risk factors stipulated by the hpcsa (2007) high-risk register, neonatal jaundice (88.37%) was the most frequently occurring risk factor found in the current study, followed by exposure to hiv (17.44%), nicu stay for more than 48 hours (15.11%) and mechanical or assisted ventilation (15.11%). of participants presenting with neonatal jaundice (n=76), 31 (41%) were male, 25 were recorded as having received phototherapy and only 3 received exchange blood transfusions. with regard to hiv status, the remainder of the sample presented with 45 participants who were not exposed to hiv, 16 whose hiv status was unknown and 10 whose caregivers refused informed consent for hiv testing. the other risk factors for hearing loss listed by the hpcsa (2007) had a frequency of less than 15% as seen in table 1. other risk factors reported in the literature and believed to be clinically significant although not listed on the hpcsa (2007) register were prematurity (98.83%), birth asphyxia or hypoxia (9.30%), hypoglycaemia (3.49%) and hyperglycaemia (5.81%) as indicated in table 1. in the current study, prematurity was found to be the most frequently occurring among the other risk factors which were thought to be clinically significant. some significant risk factors occurred in combination with each other. for example, 3 participants were premature with exposure to hiv, 54 were premature with neonatal jaundice, while 1 had exposure to hiv with neonatal jaundice. further analysis revealed that 8 participants presented with a combination of three risk factors: neonatal jaundice, prematurity and exposure to hiv (7); prematurity, neonatal jaundice and mechanical or assisted ventilation (1). a combination of four risk factors was present in 10 participants. findings from the hearing screening through dpoae revealed that of the total baseline sample of 86 neonates who were expected at follow-up, only 27 returned for a follow-up, outpatient screening. all 86 participants presented with a combination of risk factors but most were found to pass the initial and follow-up screening (figure 1), suggesting a lower referral rate among the vlbw participants included in the current study. of the 27 participants who returned for follow-up screening, 15 passed the initial and follow-up screening. fig. 1. results for initial and follow-up distortion product oto-acoustic emissions (dpoae) screening. chi-square analysis using 5% level of significance (α=0.05) revealed a relationship that was not statistically significant (χ²<5.99) between the most frequently occurring risk factors and dpoae screening results. the most frequently occurring risk factors were included in the analysis independently, as well as in combination with each other. these risk factors included prematurity, neonatal jaundice and nicu stay for greater than 48 hours, exposure to hiv and mechanical/assisted ventilation. results indicate that whether these most frequent risk factors existed in isolation or in combination, the overall screening results were not influenced. records of these participants having undergone diagnostic evaluations were not present in the patient files, and this had been hypothesised to be possibly due to poor follow-up attendance, an important indirect finding which emanated from the current study. discussion in achieving the aim of identifying the type and occurrence of risk factors for hearing loss in a group of vlbw neonates, the current study revealed the presence of five most frequently occurring risk factors. four of these risk factors (neonatal jaundice requiring exchange blood transfusion, mechanical/assisted ventilation, nicu stay greater than 48 hours and exposure to hiv) are listed on the hpcsa (2007) high-risk register. the fifth risk factor thought to be clinically significant in the current study was prematurity. this is in contrast to a study conducted in kuwait, where it was found that of the 105 newborns, birth weight below or equivalent to 1 500 g, ototoxic medications, mechanical ventilation for greater than 5 days and meningitis were the most prevalent risk factors (al-harbi, barakat & al-khandary, 2008). these findings highlight that although both these studies were conducted in developing countries and even with the presence of guidelines for high-risk factors for hearing loss, differences in type, frequency and occurrence of risk factors for hearing loss still exist. hence, continual investigation of the relative importance of specific high-risk factors is necessary for assessment, refinement and modification of clinical protocols to ensure clinical practice that is relevant to the context (korres et al., 2005). the most frequently occurring high-risk factor in the current study was neonatal jaundice, presenting in more than half of the total sample, with a higher frequency in females than males. the higher occurrence in females is contrary to findings which documented an observed higher risk of neonatal jaundice in males (olusanya, akande, emokpae & olowe, 2009). this finding may however be influenced by the fact that the current study sample comprised more females than males, and it therefore should be interpreted with caution. the high percentage of neonates presenting with neonatal jaundice in the current study is also consistent with reports that state that the burden of neonatal jaundice is likely to be substantially higher in africa compared with the developed world (olusanya et al., 2009). although hyperbilirubinaemia requiring exchange blood transfusion is listed as a risk factor for hearing loss, the frequency of neonatal jaundice necessitating phototherapy was greater than exchange blood transfusion. this is consistent with reports from another developing country, nigeria, where the need for phototherapy reportedly exceeded exchange blood transfusion, with those who received phototherapy also being at significant risk for sensorineural hearing loss (olusanya et al., 2009). these findings from the current study may have also been influenced by the unit policies at the hospital during this time period, whereby all neonates, irrespective of birth weight, were provided with standard neonatal care which included blood transfusions or phototherapy as needed (ballot et al., 2010). prematurity (although not listed on the hpcsa (2007) high-risk register) was also a frequently occurring coexisting risk factor with neonatal jaundice in the current study. it is assumed that the earlier the occurrence of neonatal hyperbilirubinaemia, the more likely it is to affect the auditory pathways and it is therefore thought that preterm infants have a higher risk of developing hearing impairment, even with lower bilirubin levels (nickisch, massinger, ertl-wagner & von voss, 2009). this has clinical significance as it highlights the importance of close monitoring of preterm neonates with coexisting risk factors, as well as the clinical importance of using both otoacoustic emissions and automated auditory brainstem response in neonates with neonatal jaundice to ensure that auditory neuropathy is not missed. in the current study of vlbw neonates, exposure to hiv was only present in 17.44% of the neonates. this unexpected finding is contrary to reports which state an association between hiv and an increased risk of low birth weight (rollins, coovadia, bland, patel & newell, 2007). owing to the fact that in the current study, the hiv status could not be established in approximately one-fourth of the sample, the authors acknowledge that this finding is only an approximate and may be influenced by sample size since some caregivers in the current study refused to give consent for hiv testing. although the risk of hearing loss is reported to increase with the number of existing risk factors, the true impact of the combination of risk factors and their cumulative effect on hearing outcome could not be clearly established because of poor follow-up return rate, the small study sample size and a lack of diagnostic data. poor follow-up return rate further precluded the confirmation of hearing impairment in this population, as well as gleaning of information regarding intervention. this highlights the need for audiologists to ensure that efforts are made to improve follow-up return rate (kanji, khoza-shangase & ballot, 2010). the sample size of the current study was small and was further reduced because of incomplete medical information and screening results, which resulted in the final sample being too small for generalisability of the results to larger and broader contexts. the inclusion of high-frequency tympanometry testing and automated auditory brainstem response testing could have added another dimension to the current study, as it would have assisted in distinguishing between conductive, sensory and neural types of hearing impairment. false-positive and false-negative findings could have impacted on the screening results and hence influenced the results related to the correlation between the type of risk factors and dpoae screening results. the analyses performed in the current study are exploratory and should only be used as a basis for further research. although exploratory, these findings do highlight that although vlbw is not considered a risk factor for hearing loss, this population does present with multiple risk factors for hearing loss as listed on the hpcsa (2007) high-risk register. this therefore has clinical implications for the audiologist who needs to ensure that the vlbw population forms part of the priority client load that should be monitored, even though vlbw on its own is not considered as a risk factor for hearing loss, i.e. targeted hearing screening needs to extend beyond the nicu to high care, low care and kangaroo mother care wards where vlbw neonates may be admitted instead. conclusions the list of risk indicators for hearing loss still requires constant modification and more detailed categorisation in terms of severity as risk factors may be influenced by the resources, community and diseases present in different contexts during different time periods. the less frequently occurring risk factors need to be investigated further by audiologists as this may lead to growing evidence regarding the inclusion of additional risk factors on the high-risk register – one that is context-specific and context-relevant, ensuring appropriate, early referrals among relevant medical professionals and audiologists. even though findings from the current study cannot be generalised to the larger population, and even though conclusions regarding the association between high-risk factors and hearing loss cannot be drawn without further analyses, current findings call for further research in this population taking into consideration current limitations. acknowledgements. some aspects of the vlbw project pertaining to follow-up return rate have been published. we would like to thank prof. peter fridjhon for his statistical assistance as well as prof. daynia ballot from the department of paediatrics and child health. references al-harbi, m., barakat, n., & al-khandary, m. (2008). hearing screening in at risk newborn. journal of medical sciences, 8(7), 648-653. ballot, d. e., chirwa, t. f., & cooper, p. a. (2010). determinants of survival in very low birth weight neonates in a public sector hospital in johannesburg. bmc pediatrics, 10, 30. doi:10.1186/1471-2431-10-30 ballot, d. e., potterton, j., chirwa, t., hilburn, n., & cooper, p. a. (2012). developmental outcome of very low birth weight infants in a developing country. bmc pediatrics, 12(11), 1-10. doi:10.1186/1471-2431-12-11 bielecki, i., horbulewicz, a., & wolan, t. (2011). risk factors associated with hearing loss in infants: an analysis of 5282 referred neonates. international journal of pediatric otorhinolaryngology, 75(7), 925-930. doi:10.1016/j.ijporl.2011.04.007 claas, m. j., bruinse, h. w., koopman, c., van haastert, i. c., peelen, l. m., & de vries, l. s. 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(2007). performing chart review studies. air medical journal, 26(5), 206-210. doi:10.1016/j.amj.2007.06.007 rollins, n. c., coovadia, h. m., bland, r. m., patel, d., & newell, m. l. (2007). pregnancy outcomes in hiv-infected and uninfected women in rural and urban south africa. journal of acquired immune deficiency syndrome, 44(3), 321-328. doi:10.1097/qai.0b013e31802ea4b0 ruegger, c., hegglin, m., adams, m., & bucher, h. u. (2012). population based trends in mortality, morbidity and treatment for very preterm and very low birth weight infants over 12 years. bmc pediatrics, 12(12), 1-12. doi:10.1186/1471-2431-12-17 swanepoel, d., hugo, r., & louw, b. (2006). infant hearing screening at immunization clinics in south africa. international journal of pediatric otorhinolaryngology, 70(6), 1241-1249. doi:10.1016/j.ijporl.2006.01.002 swanepoel, d., storbeck, c., & friedland, p. (2009). early hearing detection and intervention in south africa. international journal of pediatric otorhinolaryngology, 73(6), 783-786. doi:10.1016/j.ijporl.2009.01.007 velaphi, s. c., mokhachane, m., mphahlele, r. m., beckh-arnold, e., kuwanda, m. l., & cooper, p. a. (2005). survival of very-low-birth-weight infants according to birth weight and gestational age in a public hospital. south african medical journal, 95(7), 504-509. wood, n. s., marlow, n., costeloe, k., chir, b., gibson, a. t., & wilkinson, a. r. (2000). neurologic and developmental disability after extremely preterm birth. new england journal of medicine, 343, 378-384. doi:10.1056/nejm200008103430601 . a new theory on the relationship of stuttering and handedness. (an extract from a paper presented for the degree of b.a. log. at the university of the witwatersrand). patricia r. samuels. many investigations have "been carried out on the relationship of laterality and stuttering, and the majority of these are familiar to all speech therapists. however, recent investigators have forsaken the long established association postulated "by travis and his co-workers, and have introduced a new concept. the relationship reported by these investigators is not one of cause and effect, "but one which pre-supposes a common causal factor for "both left-handedness and stuttering. this theory has "been investigated "by berry, west, neilson, hunter and others and is "based on twinning. berry in an attempt to find a common denominator for twinning and stuttering collected data on 250 duplicate "births. the problem she presented was "does stuttering appear more frequently in twinning families than in families without records of duplicate "births?". the questionnaire covered points in regard to history of handedness in direct and collateral lines and & history of speech defects in the same manner. in respect of the present discussion she found that in regard to sinistrality in these families, representing 1,205 children, approximately 1 in 10 was left-handed. jones reported that in the united states b% of the population was left-handed; there are, therefore, two-and-a-half times more sinistrals in the twinning families than in the general population. as regards speech in twinning families, there were 66 stutterers in these 1250 twinning families. this represents 5*5$ of the total number of children and is therefore much higher than the normal expectancy, for in this case expectancy would "be 1 in 18, instead of the normal expectancy of 1 in every 100 children. in an attempt to find a common denominator berry states that the frequency of left-handedness, of retardation in the onset and development of speech, and in the case of twinning, a higher incidence of stuttering is greater in these families. thus it may "be postulated, on the assumption that lefthandedness is inherited, that stuttering too, is due to heredity. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 33.. twinning, stuttering and left-handedness seem to occur together and to have properties in common. the single siblings in these families tend to have a norm of one (l) in 35 being stutterers. this is very high and, therefore, contra-indicates the assumption that twinning per se produced stuttering or that left-handedness per se produced stuttering. the factor in the germ plasm producing twins may be a gene which establishes an abnormal biochemical relationship "favourable to the retardation of a single axiate production, and unfavourable to normal speech". is it possible that the genie force, favourable to twinning and stuttering, may show itself in some process connected with vitamin metabolism?. the theory just expressed may be reiterated for handedness. left-handedness and twinning may be part of the same basic phenomenon, although they have no direct effect on each other. there are many theories which we may follow in establishing a common basis for left-handedness, twinning and stuttering. for example, if we followed tauterbach's hypothesis, it may well be that left-handed stutterers lost their mates in utero, they were, in origin, twins. another line of reasoning which may be pursued is that of hkwman it might be argued that the interference with fetal circulation, which may occur in twinning, could affect both the centres normally dominant in establishing speach and handedness. "all in all, whatever "theory one accepts, the best answer to the question of sinistrality, stuttering and twinning seems to reside in a genie constitution". neilson, hunter and walker in a study on stuttering in twin types found that the percentage amongst 200 twin pairs was 20%, which is very much higher than that for the general population. west, neilson and berry state that "there are three groups which are innately atypical: the stutterers, the lefthanders and the twinners. they are by no means identical but there is considerable overlapping. in view of the strongly hereditary factors of all three it is difficult to think of one as being the cause of the others; one is inclined rather to suppose that all three rest upon some common, hereditable factor of structure or biochemistry". thus these investigators postulate that these two rarities of socity, stuttering and left-handedness, may be linked by one causal factor, a genie force as yet unknown to science. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 3k· ' references. berry, m. west, neilβon & berry neilson, hunter & walker "a common denominator in twinning and stuttering". (j.s.d. march 1938). "heredity of stuttering". (q.j.s. 1939). "stuttering in twin types (j.s.d. december 19*4-5) r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) speech and the laryngectomized by mary a. doehler d i r e c t o r of e s o p h o g e a l s p e e c h , m a s s a c h u s e t t s e y e a n d e a r i n f i r m a r y , b o s t o n , m a s s a c h u s e t t s s i n c e s p e e c h is t h e m o s t c h a r a c t e r i s t i c h u m a n a c t a n d t h e f i r s t m e a n s b y w h i c h s o c i a l r e l a t i o n s h i p s a r e e s t a b l i s h e d a n d k e p t i n t a c t , i t s l o s s s e r i o u s l y t h r e a t e n s t h e l a r y n g e c t o m i z e d p a t i e n t ' s f e e l i n g of s e c u r i t y a n d b a l a n c e , b o t h i n t h e f a m i l y a n d i n t h e c o m m u n i t y . t o c o m p l e t e a s a t i s f a c t o r y r e h a b i l i t a t i o n o r a d j u s t m e n t i n v o l v e s s e v e r a l s t e p s , n o n e of w h i c h s h o u l d b e n e g l e c t e d . i s h a l l d i s c u s s t h e s e f a c t o r s a s i s e e t h e m , in o r d e r of t h e i r i m p o r t a n c e t o t h e p a t i e n t , a s i a t t e m p t t o e v a l u a t e t h e t e a c h i n g p r o g r a m . 1. the mental and emotional preparation of the pupil prior to surgery t h e r e c a n b e n o s e t r u l e s e s t a b l i s h e d in t h i s p r e o p e r a t i v e p r e p a r a t i o n s i n c e e a c h p e r s o n ' s r e a c t i o n t o a n y c r i s i s o r s t r a i n is d e t e r m i n e d o r m e a s u r e d b y o n e ' s o w n p e r s o n a l i t y s t r u c t u r e , a n d o n e ' s o w n w a y i n p r e v i o u s l y d e a l i n g w i t h c r i s e s . m a n y t i m e s t h e s u r g e o n w i l l p r o v i d e t h e n e c e s s a r y p s y c h o l o g i c a l h e l p . a g a i n , a w e l l t r a i n e d s p e e c h t h e r a p i s t c a n b e of g r e a t v a l u e t o t h e p r o s p e c t i v e p a t i e n t . i n a n y c a s e , t h e p r e p a r a t i o n s h o u l d b e b a s e d u p o n a c r i t i c a l e v a l u a t i o n of t h e p e r s o n a l i t y of t h e p a t i e n t t h r o u g h a p e r s o n a l i n t e r v i e w . i t is a d v i s a b l e a t t h i s t i m e t o i n c l u d e a m e m b e r of t h e f a m i l y . d u r i n g t h e i n t e r v i e w t h e p u p i l s h o u l d b e e n c o u r a g e d t o d i s c u s s t h e m a n y p r o b l e m s h e w i l l h a v e t o face. n a t u r a l l y , t h e l o s s of h i s v o i c e a n d t h e r e s u l t i n g s o c i a l a n d e c o n o m i c p r o b l e m s a r e t h e m o s t s e r i o u s . if p o s s i b l e , it is a d v a n t a g e o u s a t t h i s p o i n t t o h a v e t h e p u p i l m e e t s o m e o n e a b o u t h i s o w n a g e a n d s o c i a l s t a t u s w h o h a s d e v e l o p e d a g o o d v o i c e a n d r e t u r n e d t o w o r k . t h e n e w p a t i e n t m u s t c o n s t a n t l y b e r e a s s u r e d t h a t l o s s of s p e e c h is o n l y t e m p o r a r y . 2. patient's approach to his convalescence h o w m u c h t h e p a t i e n t a p p r e c i a t e s h i s p o s t o p e r a t i v e c o n d i t i o n d e p e n d s u p o n h i s a g e , e d u c a t i o n , e x p e r i e n c e , a n d g e n e r a l p e r s o n a l i t y m a k e u p . 3. speech re-education i a m n o t in s y m p a t h y w i t h b e g i n n i n g ins t r u c t i o n p r i o r t o s u r g e r y , b u t i d o r e c o m m e n d t h a t t h e p u p i l b e g i v e n t h e b a s i c f a c t s of h o w e s o p h a g e a l s p e e c h w i l l b e p r o d u c e d . t h i s s h o u l d b e c o n f i n e d t o a c o n s i d e r a t i o n of t h e g e n e r a l c h a r a c t e r i s t i c s of e s o p h a g e a l s p e e c h q u a l i t y of t o n e a n d c o n t r o l of a i r w i t h o u t , a t t h i s t i m e , b u r d e n i n g t h e p u p i l w i t h t h e m e c h a n i c s a n d p r o b l e m s a s s o c i a t e d w i t h i t s p r o d u c t i o n . h e m u s t b e a d v i s e d t h a t , for a t i m e , h e s h o u l d c o m m u n i c a t e b y w r i t i n g a n d in n o c a s e r e s o r t t o w h i s p e r i n g . a l s o , i t s h o u l d b e s t r e s s e d t h a t m u c h of h i s s u c c e s s in a c q u i r i n g h i s n e w v o i c e d e p e n d s a l m o s t e n t i r e l y o n h i s d e t e r m i n a t i o n t o p r a c t i s e r e g u l a r l y . i h a v e f o u n d t h a t t h e e a r l i e r i n s t r u c t i o n is b e g u n f o l l o w i n g s u r g e r y t h e m o r e s a t i s f a c t o r y t h e r e s u l t s . i h a v e f o l l o w e d f o u r r a t h e r s i m p l e s t e p s in d e v e l o p i n g t h i s v o i c e a n d a l w a y s r e f r a i n f r o m d i s c u s s i n g s u r g e r y w i t h t h e p a t i e n t . t h e s e f o u r s t e p s a r e : 1) o p e n m o u t h 2 ) c l o s e m o u t h 3) s w a l l o w a i r ( s a m e a s o n e s w a l l o w s food o r d r i n k ) . 4 ) o p e n m o u t h a t o n c e a n d w i t h l i p s t r y t o s a y " b a . " y o u w i l l n o t e t h a t , i n t h e v e r y first a p p r o a c h t o t h i s p r o g r a m , 1 c a l l a t t e n t i o n t o t h e u s e of 1 journal of the south african logopedic society august, 1963 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) t h e l i p s in f o r m i n g s o u n d . o v e r t h e y e a r s i h a v e u s e d p h o n e t i c s o u n d s . t h i s i b e l i e v e h a s s e v e r a l a d v a n t a g e s t h e p u p i l is n o t c o n f r o n t e d w i t h t r y i n g t o s a y w o r d s w h e n a t t h a t t i m e , h i s m e n t a l r e a c t i o n is t h a t h e c a n n o t s p e a k , a n d s p e e c h is m a d e of w o r d s e i t h e r s i n g l y o r in s e q u e n c e . m a n y of t h e s e p h o n e t i c s o u n d s a r e w o r d s in t h e m s e l v e s , s u c h a s b e , bi, m e , m i , ti, t o m e n t i o n a few. m y e n t i r e a p p r o a c h is g e a r e d t o w h a t t h e p a t i e n t h i m s e l f c a n a c c o m p l i s h a n d d o w e l l . s i n g l e s y l l a b l e s h a v i n g b e e n a r t i c u l a t e d a n d e n u n c i a t e d w e l l , 1 t h e n p r o c e e d t o d o u b l i n g , t r i p l i n g , a n d t h e u s e of m o r e a d v a n c e d r h y t h m s , t h u s e n a b l i n g t h e p u p i l n o t o n l y t o l e a r n t o c o n t r o l t h i s a i r , b u t a t t h e s a m e t i m e g i v i n g h i m m u c h v a r i e t y i n p i t c h . . t h e s e r h y t h m s a r e m o r e f u l l y e x p l a i n e d i n m y m a n u a l " e s o p h a g e a l s p e e c h " a n d t h e r e c o r d i n g w h i c h i h a v e m a d e for h o m e p r a c t i c e . 4. solving the practical problems of living without a larynx t o m a n y p u p i l s t h e d a y s i m m e d i a t e l y foll o w i n g s u r g e r y a r e t h e m o s t f r u s t r a t i n g . m a n y q u e s t i o n s a r i s e i n h i s m i n d s u c h a s t h e c o n t r o l of m u c o u s , a b i l i t y t o b r e a t h e , p r o b l e m s of e a t i n g , d r e s s i n g a n d m a t t e r s of p e r s o n a l h y g i e n e . s o m e of t h e s e c o u l d h a v e b e e n e x p l a i n e d p r i o r t o s u r g e r y , b u t t h e y b e c o m e m o r e r e a l i s t i c o n c e s u r g e r y h a s b e e n p e r f o r m e d . t h o s e c l o s e l y a s s o c i a t e d w i t h t h e p u p i l s h o u l d a p p r o a c h t h e s e p r o b l e m s w i t h a v e r y p o s i t i v e a t t i t u t e , n o t o n e of s y m p a t h y b u t r a t h e r , o n e of c o m p l e t e u n d e r s t a n d i n g . t h e p u p i l s h o u l d b e a s s u r e d t h a t h e w i l l b e a b l e t o e a t a n d d r e s s a s h e d i d p r i o r t o s u r g e r y , t h a t h e c a n s h o w e r , m a k i n g s u r e t h a t t h e s t o m a is c o v e r e d a t all t i m e s . h e r e t h e i m p o r t a n c e of t e a m w o r k w i t h t h e d o c t o r , n u r s e , f a m i l y , s o c i a l w o r k e r s , a n d s p e e c h t h e r a p i s t is of u t m o s t a s s i s t a n c e t o t h e p u p i l . m a n y y e a r s a g o t h e p a t i e n t c o u l d a n t i c i p a t e o n l y l y e a r s of s i l e n c e , b u t t o d a y , w i t h n e w surgijcal t e c h n i q u e s a n d t h e a d v a n c e m e n t in b e t t e r t e a c h i n g m e t h o d s of e s o p h a g e a l s p e e c h , t h e r e is m u c h e n c o u r a g e m e n t for t h e p a t i e n t t o l o o k f o r w a r d t o a n o r m a l a n d v e r y s a t i s f a c t o r y life in t h e f u t u r e . summary t h e s u d d e n l o s s of s p e e c h i n t h e l a r y n g e c t o m e e is a t r a u m a t i c a n d f r i g h t e n i n g e x p e r i e n c e . h e m u s t b e p r e p a r e d b e f o r e t h e o p e r a t i o n for w h a t is t o f o l l o w a n d b e rea s s u r e d t h a t t h e l o s s of s p e e c h is o n l y t e m p o r a r y . p r i o r t o s u r g e r y t h e p a t i e n t s h o u l d b e g i v e n t h e b a s i c f a c t s of h o w e s o p h o g e a l s p e e c h w i l l b e p r o d u c e d . h e m u s t b e a d v i s e d t h a t i m m e d i a t e l y a f t e r t h e o p e r a t i o n h e s h o u l d c o m m u n i c a t e i n w r i t i n g , b u t o n n o a c c o u n t r e s o r t t o w h i s p e r e d s p e e c h . t h e r a p y f o l l o w s f o u r r a t h e r s i m p l e s t e p s : (i) o p e n m o u t h ; (ii) c l o s e m o u t h ; (iii) s w a l l o w a i r ( s a m e a s o n e s w a l l o w s food o r d r i n k ) ; ( i v ) o p e n m o u t h a t o n c e a n d w i t h l i p s t r y t o s a y " b a " . p h o n e t i c s o u n d s a r e u s e d in p r e f e r e n c e t o w o r d s , w h i c h m a y , i n t h e e a r l y s t a g e s , h a v e a c q u i r e d n e g a t i v e a s p e c t s for t h e p a t i e n t . a s t h e r a p y p r o g r e s s e s , m o r e a d v a n c e d s y l l a b l e s a n d r h y t h m s a r e u s e d . p e r s o n a l p r o b l e m s w i t h r e g a r d t o a d j u s t m e n t s h o u l d b e d e a l t w i t h a s t h e y a r i s e . opsomming d i e s k i e l i k e v e r l i e s v a n s p r a a k is v i r d i e l a r i n g e k t o m i e ' n t r o u m a t i e s e e n v r e e s a a n j a e n d e o n d e r v i n d i n g . d i e p a s i e n t m o e t d u s v o o r d i e o p e r a s i e v o o r b e r e i w o r d v i r w a t g a a n v o l g e n h y m o e t g e r u s g e s t e l w o r d d a t d i e s p r a a k v e r l i e s n e t t y d e l i k s a l w e e s . v o o r s j i r u r g i e s e b e h a n d e l i n g m o e t a a n d i e p a s i e n t a l d i e b a s i e s e feite i n v e r b a n d m e t e s o f a g e a l e s p r a a k e n d i e p r o d u k s i e d a a r v a n g e g e e w o r d . h y b e h o o r t a a n g e r a a i t e w o r d o m d i r e k n a d i e o p e r a s i e d e u r m i d d e l v a n s k r i f t e k o m m u n i k e e r e n n o o i t g e f l u i s t e r d e s p r a a k t e g e b r u i k n i e . t e r a p i e w o r d in 4 e e n v o u d i g e s t a p p e v e r d e e l : (i) m a a k m o n d o o p ; (ii) m a a k m o n d t o e ; (iii) s l u k l u g ( s o o s k o s e n v l o e i s t o w w e g e s l u k w o r d ) ; (iv) m a a k m o n d o o p e n p r o b e e r d a d e l i k m e t d i e l i p p e , , b a " s6. f o n e t i e s e k l a n k e w o r d v e r k i e s l i k g e b r u i k b o w o o r d e , o m d a t w o o r d e a a n d i e b e g i n ' n n e g a t i e w e r e a k s i e b y d i e p a s i e n t k a n o n t l o k . n a m a t e d i e p a t i e n t m e t t e r a p i e v o r d e r , w o r d m e e r g e v o r d e r d e l e t t e r g r e p e g e b r u i k . p e r s o o n l i k h e i d s p r o b l e r n e t e n o p s i g t e v a n a a n p a s s i n g s m o e t h a n t e e r w o r d w a n n e e r h u l l e t e v o o r s k y n k o m . 1 journal of the south african logopedic society 19 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l of t h e s o u t h a f r i c a n l o g o p e d i c society editorial l o g o p e d i c s . like all new sciences, is still having an uphill sfruagle in this country. both the medical a n d lay public h a v e yet to learn that the h a n d i c a p p e d in speech can derive great benefit from trained workers in th« held, a n d that s p e e c h therapy is desirable and a v a i l a b l e . ' the university of the v/itwatersrand has pioneered ihe training of speech therapists a n d h a s maintained a high standard of a c a d e m i c achievement c o m p a r a b l e with most lcgopedic centres in the world. of the four provinces in south africa, the transvaal h a s t a k e r the lead m providing s p e e c h therapy services in hospitals, w h e r e a s in the c a p e there a r e more school posts than in a n y other province. it is honed that those in authority will s e e the need for establishing similar facilities in au parts of the country. in practice, the furtherance of speech therapy deoends on public interest a n d demand. likewise, the creation of posts must b e determined by th~ number of a v a i l a b l e speech therapists. few matriculants in this country o r a w a r e of s p e e c h therapy a s a career, and a s a result, there a r e insufficient g r a d u a t e s to meet the potential demand. the executive committee of the south african lcgopedic society recognizes the n e e d to e n c o u r a g e young men and women to train as *p»ech therapists, a n d h a s a l r e a d y taken steps in this direction. in addition a programme is being worked out to make speech therapy better known to the medical a n d auxiliary professions. members of the south african lcgopedic s o c i e y c a n therefore look forward with confidence to the future of speech therapy in this country. vacancy for speech therapist the pretoria school for cerebral palsied children, p.o. box 1551, pretoria, telephone 20626, has 1 vacancy for speech therapist. enquiries: principal's office. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) therapy for a group of tongue thrust swallowers and their mothers nigel bligh b.a. log. (rand), m.a. (rand) department of speech pathology & audiology, # university of the witwatersrand, johannesburg summary a brief description of tongue thrusting and a s s o c i a t e d problems i s given. the therapy programme for a group of t o n g u e thrusting chddren and their mothers is d e s c r i b e d traditional swallow retraining was used w i t h the group of children in c o n j u n c t i o n w i t h exercises for strengthening and increasing oro-sensory awareness o f t o n g u e and lips. a therapist guided the mothers discussions while t h e y observed therapy. results indicated that therapy was successful. the c o n c l u s i o n s suggest further avenues of research. opsomming 'n kort beskrywing van infantiele slukpatroon en verwante p r o b l e m e w o r d gegee. die terapieprogram vir 'n groep kinders m e t infantiele slukpatroon en hul moeders word beskryf. tradisionele slukheropleiding is gebruik m e t hierdie groep kinders tesame met oefeninge vir die versterking en verhoging van orosensoriese b e w u s t h e i d van die t o n g en lippe. 'n terapeut h e t die moeders se besprekings gelei terwyl hulle terapie waargen e e m het. resultate het daarop gedui dat terapie suksesvol was. die gevolgtrekkings b i e d verdere kidrade vir navorsing. one of the perennial problems the speech therapist shares with the orthodontist is the tongue thruster. on the surface this appears a simple difficulty to correct. it is however, extraordinarily resistant to therapy. ihis article will discuss some relevant problems and a suggested therapy programme. symptoms a n d problems a s s o c i a t e d with t o n g u e t h r u s t incorrect swallow pattern the classification of simple, complex and retained infantile swallow3, will be disregarded as it is irrelevant to the rehabilitation programme. the main identifying feature is a forward movement of the tongue, generally against or between the teeth, during swallowing, with deviant usage of severa muscle groups, e.g. supra and infrahyoid, massefer, temporalis, and orbicularis oris. * now at 626 e. minnehaha parkway, minneapolis, minn. 55417, usa. journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) therapy for a group of t o n g u e thrust swallowers and their mothers movement of the lips and contraction of the muscles of mastication are often evident during swallowing as a.lip-seal is used instead of a tongue/palate seal.18 the individual resists attempts to part the lips during a swallow. effect on orofacial structure as a result of regular incorrect pressure of the tongue on the teeth3 and the added pressure of the muscles of deglutition, mandibular growth and natural dental alignment may be affected.15 top and occasionally, bottom teeth may protrude. irregular spacing is not uncommon. the type of dental involvement will depend on the nature of the incorrect swallow. the malocclusion may prevent a natural relaxed position of the mouth at rest, so that the lips will not exert the optimal pressure necessary for facial development. the loss of regular pressure may lead to a high vaulted palate.1 1>1 5 there appears to be loss of tone and strength in the lips and tongue.1-1 0* individuals who swallow incorrectly seem to have excessive muscle activity and develop muscle patterns that are not as clearcut or definite as those of normal swallowers.10 medical history tongue thrusters often have a history of tonsil, adenoid and respiratory involvement, which can lead to other problems associated with tongue thrust, 1 7 i.e. chronic mouth breathing, either from necessity or habit. this in turn causes a tongue rest position with tongue tip away from the alveolar ridge.3 sucking problems there is not infrequently a problem of sucking as a baby. it has been suggested that nipples that allow the milk to flow too freely lead to incorrect swallowing.15 thumb and finger sucking is common, accentuating dental misalignment9, and incorrect swallow patterns.3 speech a study by fletcher et al4 found a relationship between tongue thrust swallowing pattern and sibilant distortion. although not automatically involved, typically speech has tip-dental production of tip-alveolar sounds.3·1 0 speech will often be accoustically acceptable but visually unacceptable. therapy therapy for tongue thrust given either by the orthodontist or speech therapist, is frequently described in the l i t e r a t u r e . 3 · 6 · 1 0 · 1 6 ' 1 8 it involves basically either the re-training of the musculature involved in swallowing, or the use of a habit-breaker appliance. results are often equivocal. one of the main difficulties would appear to be the evocation of adequate motivation to form new h a b i t s . 6 ' 1 5 * confirmed in personal communication with dr c. overstake. .. tydskrif van die suid-afrikaanse vereniging vir spraak en cehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 3 2 nigel bligh additional unverified observations (i) there is an impression of lowered kinesthetic and orosensory awareness, e.g. tolerance to extremes of temperature, inability to move the tongue accurately on demand1 8, and difficulty in moving the tongue without concomitant lip and jaw movements. (ii) the difficulty seems to be commoner amongst girls than boys. of sixteen tongue thrusters receiving therapy at the speech & hearing clinic, university of the witwatersrand, five were boys. in a study by mims et al9 discussing the relationships between thumb sucking and open-bite malocclusions, there were 24 boys and 52 girls. (iii) there seems to be a familial tendency to tongue thrust. 1 3 method the aims of the study were (a) to investigate an approach to therapy for tongue thrusters, (b) to investigate certain aspects of group therapy, i.e. group size, age range and variation in therapist, and (c) to explore a method of parent counselling. group t h e r a p y programme subjects there were six girls and three boys ranging in age from four and a half to eleven years. the four and a half-year old was taken despite evidence in the literature14 that tongue thrusting is a normal developmental stage because his. teeth were already being pushed out of alignment and there was a definite familial tendency. this familial tendency was noted in the two sets of siblings in-ihe group and two of the other children. five of the children were being seen for individual articulation therapy once a week, in addition to the weekly group therapy for tongue thrust. because it was a group project, it was unnecessary to eliminate those children who did not have speech defects purely because this was a speech clinic.17 it will be noted that both the size of the group and the age range, are in conflict with most of the recommendations in the literature 8 / therapists / one graduate therapist and six speech and hearing therapy students at the university of the witwatersrand participated in the weekly group therapy. the student therapists were involved in individual articulation therapy for tongue thrusters on a second afternoon. initially the graduate therapist took the group with the students observing. therapists then alternated as group leader with the others observing and later participating. after each session there was a seminar to discuss the therapy'administered and plan the following week's session. the effects on the group of alternating therapists were noted throughout. journal of he south african spch a hearing association, vol. 19, dcmbr 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) therapy for a group of t o n g u e thrust swallowers and their mothers 3 3 therapy aims 1. to eliminate any causal or maintaining factors of tongue thrust. 2. to explain to the children why they were coming for therapy and to generate motivation. 3. to correct the swallow pattern. 4. to correct the rest position of tongue and lips. 5. to increase proprioception, kinesthesia, tone and strength of tongue and lips. therapy procedures throughout therapy all drill work and explanations were presented in a suitably motivating and understandable fashion. 1. all children were under observation by orthodontists. four of them had been referred for therapy before orthodontics would be attempted. three children were encouraged to stop sucking their thumbs and one had his tonsils and adenoids removed. 2. (a) the children learnt that they were exerting lvilbs of thrust on their teeth 2 000 times a day, i.e. each time they swallowed3'11 (ehrlich3mentions 6 lbs). the children were encouraged to discuss what effect this would have on their looks. (b) they learnt the hygienic reasons for breathing through their noses rather than through their mouths. (c) they were taught that with better control and proprioceptive awareness of their lips and tongues they would be better able to place them where they wanted to and keep them there. 3. the following rules were learnt (overstake10):(a) put your teeth and lips lightly together. (b) place the tip of your tongue on the alveolar ridge. (c) suck the food onto your tongue. (d) then push your tongue onto your palate and swallow. (e) your tongue must not move forward. 4. there were intermittent reminders for the children to "look nice and feel nice", i.e. to have their mouths shut and tongue tips resting lightly on the alveolar ridges. 5. tongue and lip therapy was divided into: (a) movement lips were spread and pursed as in an exaggerated "oo-ee". tongue was moved sideways, in and out, up and down. instructions were given to place the tongue in specific positions. the main aim was to get independent tongue movement, i.e. without concomitant lip and jaw movement and to achieve better awareness of tongue position in the mouth. (b) icing is a technique advocated by physiotherapists and speech therapists working with cerebral palsied children. used for any length of time ice acts as an anaesthetic. for shorter periods it seems in most cases to tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 3 4 nigel bligh encourage relaxation, 7 , 1 2 increases the blood supply to the surface areas and encourages increased proprioceptive awareness. empirical use indicates that it is a useful technique to use in articulation therapy. with this group it was used in conjunction with resistance exercises. (c) resistance is a technique for strengthening and improving coordination of muscles.7 the amount of resistance offered must never be greater than the muscle strength, i.e. the individual must always be able to complete the movement. resistance should obviously increase as the muscle gets stronger.5·12 the children's tongues or lips were iced and the following resistance exercises were then done:-* i) as the child protruded the tongue the tip was gently resisted by the therapist or by another child holding a wooden spatula. ii) the child moved the tongue towards one side while movement was resisted with the spatula from the other. iii) the child elevated or depressed the tongue tip with resistance from the other direction. this generally required two spatulas, one above the tongue to aid movement, and one below to resist, and vice versa. assistance was necessary for those children who had difficulty elevating or depressing the tongue. iv) lip movement was gently resisted by the therapists' fingers held at each corner of the mouth, as the child spread or pursed his lips. at the end of each session the children were given a home programme to encourage carry-over of all therapy activities. a resistance technique that may be worth investigating, especially for swallow retraining, is the use of a v2" cube of sponge rubber securely attached to a cord that the therapist pulls to resist the tongue motion while swallowing.7 c o u n s e l l i n g programme six mothers were counselled regularly and one irregularly. the aims were to explain the rationale behind therapy, and to motivate parents to carry on with the programme at home. initially the mothers were counselled briefly and given the week's home programme after the group therapy by the graduate therapist with the students observing. subsequently the mothers observed the entire therapy session through a one-way mirror with therapists taking it in turn to guide observation and discussion.. the children were all aware of the fact that their mothers were observing. the discussion revolved around the nature of tongue thrust and the associated problems, what therapy was aiming at and the difficulties inherent in treating the problem. as therapy progressed, discussion of different approaches, techniques and reactions of the various children were encouraged. * adapted from suggestions b y miss j . blair, head of the d e p t . of physiotherapy, university of the witwatersrand. journal of he south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) therapy for a group of t o n g u e t h r u s t swallowers and their mothers 35 results and discussion by the very nature of the disorder and its prognosis, tongue thrust therapy has a tendency to be both dull and rather discouraging.3 it is difficult to alter oral patterns that are so closely related to reflexes.18 tongue thrust therapy in therapy all children showed a definite improvement in the manner of swallowing, and the elimination of concomitant problems, i.e. mouth breathing, thumb sucking, etc. there was a consistent improvement in articulation. the mothers reported an increased awareness of the problem and its associated difficulties. all reported good carry-over during therapy. there was a definite but incomplete regression when regular therapy stopped, due to university examinations. for this reason all the children were referred to the dental clinic of the university of the witwatersrand to be fitted with habit breaker plates. dental impressions and x-rays were taken and the children were given simple plates with exaggerated rugae to remind them of the correct tongue tip position. these were to be worn during the break from therapy. in view of the therapy the children had had, it was felt unnecessary to make use of any type of grid to prevent forward movement of the t o n g u e . 1 3 ' 1 5 during the therapist discussions, it was suggested that the use of straws for drinking11 did not assist the tongue in the correct movement for swallowing, but in fact, tended to encourage both a forward tongue movement and an excess of movement in the orbicularis oris. it was therefore discontinued as a therapy tool. group therapy the children enjoyed therapy and co-operated well. it was found that activities that fostered movement and laughter were more successful than others and resulted in better group cohesion. the large number in the group proved entirely satisfactory and manageable and made several of the activities more feasible. even though therapy was geared to a very physical level, personality changes were evident, e.g. the shyer children became more open and the rather sophisticated child became more pleasingly child-like. one of the older girls, who was resistant to all previous attempts to deal with her problem benefitted from the opportunity to share a common experience with the others. not only did she see that there were several other children in the same position, but she also soon became a leader in the group. the age range proved to be an advantage in that the older children were not only encouraged to assist the younger ones, but in fact did a great deal to help them. the potential danger that the older children would dominate the younger8 was not realised. it was however, evident that the group had to be confined to primary school children. because of the disparity of abilities, it was found to be important to eliminate any element of competition and to tydskrif van die suid-afrikaanse vereniging vir spraak en ehoorheekunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) nigel bligh 3 6 n n r e n t r a t e on co-operation.2 this meant that the therapist had to be very p e r c e p t i v e to the reactions of the children both to each other and to their own achievements. the therapy programme was aimed mainly at providing guidance for the home programmes, i.e. therapy was not merely thirty minutes of drill to be forgotten until the next week. thus all homework activities grew out of the preceding session or led logically towards the next. it did not seem to be important to the children that the therapist varied from session to session. it was almost as though the important inter-relationships were inter-child relationships and the therapist was there mainly to guide activities. the therapists found therapy entertaining and challenging. the discussions after each session ensured continuity and resulted in some novel and stimulating ideas and an ever improving therapeutic approach. parent counselling the parents were an integral part of the therapy programme. they knew exactly what their children were doing in therapy and why they were doing it. they became interested in the whole programme and accepted the fact that prognosis was not very good. they were receptive to any new approaches that were tried. the therapists felt that the interest shown by the mothers contributed to the excellent attendance, the fact that homework was always done and to the general positive attitude to therapy. additional positive effects of this form of counselling were: (a) the mothers saw how the therapists handled the children. (b) parents often spontaneously noted factors about their children that led to greater objectivity and greater reception to therapist suggestions. (c) the group discussion often revolved around an incident in therapy that did not necessarily involve tongue thrusting but was relevant to the child. for optimal effectiveness, this type of approach required two therapists one with the children and one guiding the parent discussions. conclusions it was felt generally that this approach to therapy with tongue thrusters was successful in that both mothers and children were motivated to work on the problem. overall results were most encouraging. ideas were generated that might lead to better carry-over and, finally, total rehabilitation. these included: 1 1. planning the programme so that therapy could gradually be terminated to ensure complete rehabilitation. journal of the south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) therapy for a group of t o n g u e thrust swallowers and their mothers 2. using dental study models and x-rays before and after therapy not only as an objective measure of progress but also as a motivating force and an excellent means of explaining the problem. 3. investigating different types of habit breakers and using them in conjunction with the therapy programme. 4. developing the home programme further, extending this to a more active participation by the teacher and the group at the school. 5. investigating the use of aids such as straws, in correcting swallowing patterns. the group therapy techniques were successful and could be applied with advantage to other problems. in fact it would be interesting to investigate whether factors such as large group size, identification with one therapist, etc., would be as apparently insignificant with a group of children whose problem was more psychological. general investigations into the factors contributing towards general cohesion in group therapy for speech defectives may well be rewarding. the method of counselling mothers would probably be excellent for other difficulties especially where a greater understanding of therapeutic approach and handling of the children is required. acknowledgement i would like to thank the following students in the department of speech pathology and audiology, university of the witwatersrand for their co-operation, enthusiasm and suggestions: misses f. janks, c. linton, n. moss, y. sarfin, b. shakinovsky and m. weinberg. my colleague, mrs m. noach, gave many suggestions, especially with regard to the habit breaker plate. references 1. carrell, j.a. (1968) disorders of articulation. foundation of speech pathology series. prentice hall. 2. deutsch, m. (1954) the effects of co-operation and competition upon group process in d. cartwright and a. zender, eds. group dynamics research and theory. tavistock publications ltd. 3. ehrlich, ann beard (1970) training therapists for tongue thriist correction. charles c. thomas. 4. fletcher, s.g., casteel, r.l. and bradley, d.p. (1961) tongue thrust swallow, speech articulation and age./. speech hearing dis., 26, 201-208. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 19, desember 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 3 8 nigel bligh 5. gardiner, m.d. (1935) the principals of exercise therapy. g. bell and sons limited. 6. hanson, m.l. (1967) some suggestions for more effective therapy for tongue thrust./. speech and hearingdis., 32, 75-79. 7. knott, m. and voss, d.e. (1968) proprioceptive neuromuscular facilitation patterns and techniques, 2nd ed. harper & row. 8. macdonald, e.t. (1967) articulation testing and treatment: a sensory motor approach, stanwix house, inc., pittsburgh. 9. mims, h.a., kolas, c. and williams, r. (1966) lisping and persistent thumb-sucking among children with open bite malocclusions. j. speech hearing dis., 31,176-178. 10. overstake, c.p. (1970) an investigation of tongue thrust swallowing and the functional relationship of deviant swallowing, orthodontic problems and speech defects. ash a national convention. 11. rogers, j.h. (1961) swallowing patterns of a normal population sample compared to those of patients from an orthodontic practice. amer. j. ortho., 47, 674-689. 12. rood, m.s. (1956) neurophysiological mechanisms utilised in treatment of neuromuscular dysfunction. amer. j. ofocc. therapy, 4,no.2, pp 220 et seq. 13. salzman, j.a. (1971) training therapists for tongue thrust correction. book review. amer. j. ortho., 59, p.411. 14. shelton, r.l. (1963) therapeutic exercises and speech pathology. asha, 5, 855-859. 15. straub, w.j. (1961) malfunction of the tongue part ii. the abnormal swallowing habit. its causes, effects and results in relationship to orthodontic treatment and speech therapy. amer. j. orth., 47, 596-617. 16. straub, w.j. (1962) malfunction of the tongue part iii. amer. j. orth., 48,486-503. 17. subtelny, j. daniel and subtelny, joanne e. (1962) malocclusion, speech & deglutition. amer. j. orth., 48, 685-697. 18. wood, j.m. (1971) tongue thrusting, some clinical observations. j. speech hearing dis., 36, 82-89. journal of i he south african speech and hearing association, vol. 19, december 1972 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 sajcd • vol 57 • december 2010 maximising health literacy and client recall of clinical information: an exploratory study of clients and speech language pathologists friderike schmidt von wühlisch michelle pascoe division of communication sciences and disorders, faculty of health sciences, university of cape town correspondence to: f schmidt von wühlisch (friderike.svw@gmail.com) clients in the health care sector frequently struggle to understand and remember details of clinical information and reasons underlying their treatment. as a result, they often do not adhere to clinical instructions and recommendations, which contributes to a reduction in the effectiveness and efficiency of health care interventions (kessels, 2003). therefore, to support clients in managing their own health, clients need to be provided with a documented record of client-specific clinical information (osborne, 2008a & 2008b; santo, laizner & shohet, 2005). this poses specific challenges for people who have low literacy skills as they have fewer means to either improve their health literacy (e.g. through the internet) or review health advice because they cannot read written materials. in the field of speech-language pathology, little research has been conducted with regard to health literacy and client recall. however, speech-language pathologists (slps) frequently provide vast amounts of information that clients need to understand, apply and review in order to manage their (or their child’s) health. this study responds to the need to investigate conventional and unconventional strategies of maximising health literacy and client recall post consultation. health literacy: a background health literacy is defined as ‘the degree to which individuals have the capacity to obtain, process, and understand basic health information and the services needed to make appropriate health decisions’ (institute of medicine (iom), 2004, p. 1). clients with low health and general literacy skills may have poorer health, higher expenses for health care, a higher rate of hospitalisations, lower self-efficacy for preventive care practices and compliance to treatment regimens (ross, 2007). this is true regardless of socio-economic status. people can have years of education and have high functional literacy (reading, writing and numeracy skills), but their health literacy skills can still be limited (williams, baker, parker & nurss, 1998). health literacy skills are not bound to race or age, even though the interagency coordinating council (2002) stated that 80% of the population aged 60 years and older in the usa alone have insufficient health literacy skills. health literacy problems have grown as clinicians and health care system providers expect clients to assume more responsibility for their care at a time when the health system is progressively more fragmented, specialised, complex and technologically sophisticated. the complexity of written and verbal health information and the shortage of health information in languages other than english make it difficult for individuals with low general literacy skills and language differences to communicate effectively in health care (zagaria, 2006). a majority of printed health education materials, regardless of their topic, require relatively high literacy skills that may not exist among many of their target population (gal & prigat, 2005). in the health care sector, and especially in speech-language pathology, where written information is frequently provided, this may lead to extreme frustration on the part of the client. people with speech, language, visual, hearing and intellectual disabilities experience even greater challenges when they need to apply high-level health literacy skills (hester & stevens-ratchford, 2009). clinicians often overestimate their clients’ literacy skills because many clients develop compensatory behaviours. physical characteristics, such as appearance or the clients’ ability to communicate well, are often inaccurate indicators of their literacy level. even when clinicians have worked with clients for years, they are frequently surprised at the poor reading skills of some of their most articulate clients (kelly & haidet, 2007). while some clinicians only provide verbal information to clients, this approach has the potential to disempower clients, as they are unable to refer back to information when they are at home or may not remember what has been discussed. numerous studies on health literacy have been published in various fields, including nursing, paediatrics, psychology, oncology, hiv/aids and pharmaceutics. topics range from ways to improve health literacy to issues around client-provider communication (bellardie & harris, 2008; chang & kelly, 2007; sanders & brosco, 2005). the limited research carried out in speech-language pathology and audiology is striking given that the iom (2004) identified speaking and listening as areas in need of improvement in health literacy research and intervention. two studies relevant to these professions were identified, which focused on the readability of educational materials for clients with cleft lip and/or palate and their families, as well as the effects of reader and text variables on understanding of health information in adults (harris, fleming & mcdougall, 2003; kahn & pannbacker, 2000). these studies suggest that individuals with communication difficulties and their carers are at an even greater risk of not understanding written materials. there is currently no consensus among health professionals and researchers about which interventions should be incorporated into clinical practice. abstract limited research has been carried out in the field of speech-language pathology with regard to ways of maximising health literacy and client recall. however, speech-language pathologists (slps) frequently provide vast amounts of information that clients need to understand, apply and review in order to manage their (or their child’s) health. this exploratory study aimed to contribute information about ways in which slps can overcome low health literacy and poor client recall so that treatment effectiveness is improved. a case-study design was used with specific focus on four clients receiving treatment for dysphagia, voice disorders (including laryngectomies) and cleft lip and/or palate management in cape town. strategies which may be able to maximise health literacy and client recall of clinical information were trialled and evaluated by clients and their slps, using semi-structured interviews. the researchers proposed a combination of high-tech strategies which assisted in all the cases. no single solution or universal tool was found that would be appropriate for all. there is a need to evaluate the long-term effectiveness of the combined strategies across a wider population, at different stages of rehabilitation and in diverse contexts. implications and suggestions for future related research are presented. keywords: adherence, effectiveness, health literacy, intervention, recall vol 57 • december 2010 • sajcd 23 health literacy and client recall regardless of the guidelines that have been provided to improve health literacy, the issue of client recall of health care instructions and its effects on the actual outcomes of management is still present. client recall: a background an important aspect in providing health information to clients, in addition to issues of health literacy, is that of clients’ recall of information and instructions after consultations. recall (both short and long-term retention) of health information and recommendations are prerequisites for adherence to treatment (kessels, 2003). this is an important point to consider in light of the widely held assumption that only good health literacy skills are responsible for an increase in adherence to recommendations. it is apparent that the speechlanguage pathology and audiology professions pay minimal attention to issues around clients’ memory of health information, even though retention of vast amounts of important information (i.e. diagnosis and recommendations) is critical to treatment outcomes. some clients find little logic in what happens during and after consultations. this is because they face the stress of a medical crisis, often without the presence of a significant other person or while in great pain, confusion or depression (rao, 2007). forty to 80% of medical information presented by clinicians is forgotten immediately and nearly half of the information that is actually remembered is incorrect (kessels, 2003). in light of the above, parkin and skinner (2003) found that even when clinicians assume that their clients would recall the health information that was provided, this might not necessarily be the case. there are various explanations for clients’ tendency to forget clinical information. with reference to the clinician: complex language and the provision of too much and disorganised information can make it difficult for a client to recall information. with reference to the client: level of education, stress, anxiety and state of health at the time of consultation; increasing age; perceived unimportance and complexity of information; differences in role expectations regarding rights, duties and responsibilities; and clients ‘switching off ’ as a result of feeling overwhelmed by the emotional impact of the information that they receive may affect recall (north, cornbleet, knowles & leonard, 1992). it would seem to be important to address recall of clinical information as well as health-literacy skills during consultations with all clients and especially with the elderly, considering that the general ageing process can create difficulty in recalling clinical information (kessels, 2003). further issues around information exchange and compliance: the south african context south african slps meet clients representing many different language and dialectal groups, and with a range of literacy abilities. these variables can have an influence on the outcomes of health care. south african clients’ cultural backgrounds also play an important role in the utilisation of health care (kagee, 2004). knowledge of clients’ cultural backgrounds is a vital characteristic for any health professional working in the south african context, e.g. some families may prefer traditional health and healing practices to westernised therapy processes (zhang & bennet, 2001). if clients choose not to adhere to treatment prescribed table i. strategies and their advantages/disadvantages in intervention strategy advantages disadvantages written materials allows recall and revision of important clinical information only for people who have good literacy skills easy to file, store and copy cultural mismatch: some cultures heavily favour oral language, appropriate for speedy review and reference and written materials are less likely to be used as a means for accessing information illustrations aid understanding of complex information a certain level of visual literacy is required very useful for clients with low literacy skills some information is too abstract and complex to be depicted looks interesting and eye-catching in illustrations telephonic contact human contact which can be speedily accessed: best at times of crisis clients may not have a telephone of their own (or no airtime) useful for reminder calls clients may not be willing to call their clinician builds a relationship between slp and client client and clinician need to share a language mobile phones widely available audio-visual materials does not require literacy skills clients need access to equipment human contact: listening to a voice is reassuring recording consultations might inhibit open discussions durable and relatively inexpensive could be translated into any language minimally adds to clinician’s workload can be shared with other significant persons sms cellphones are widely used (over 70% of south africans make use of clients need to have good literacy skills and be familiar with the mobile phones) (internet world stats, 2010) technology best when recommendations are simple and can be given in point form might be less used by older clients who are not used to this form a tool for quick reminders of communication by using the ‘please call me’ function, clients can get into telephonic need for good manual dexterity contact with the slp at no cost not for life-threatening situations as there is too much room clients use from the privacy of their own home and caregivers do not for misunderstandings need to leave the patient unaccompanied restrictive (often too much information that needs to be conveyed) can be time-consuming cannot provide practical demonstrations or immediate feedback reminders on mobile serves best as a post-consultation reminder of important points need for good manual dexterity phones people carry mobile phones with them at all times so reminders restrictive (often too much information that needs to be would be immediate conveyed) not all mobile phones have this function additional time is needed to type reminders into mobile phones all mobile phones operate differently so slps need to get accustomed to them first personalised clinical tailored to the unique needs, interests and concerns of the individual clinicians find it time-consuming to prepare information more effective in assisting clients adhere to recommendations than general information materials unnecessary information is eliminated information is more relevant to the individual 24 sajcd • vol 57 • december 2010 health literacy and client recall by an slp because of their cultural beliefs, they might be perceived by the clinician as non-compliant. for example, slps may advise parents to stimulate their children’s speech and language from an early age, but in some cultures it is not customary to speak to children directly until they reach a certain age (marfo, 1993). what may also increase the perception of non-compliance, especially in the south african population, is that there is a culturally determined tendency to accept information non-interactively, without objections or questioning, even when the information may not be entirely understood (marfo, 1993). this characteristic may be explained by tactics of saving face, different child-rearing practices, perceived unequal power relations between clients and professionals, short duration of consultations and a hesitancy to be open with authoritarian figures such as medical doctors (cilliers, 2005). clients might also prefer a rather ‘paternalistic style’ of client-provider relationships in consultations which means that the health professional is primarily made responsible for the treatment and well-being of the client. however, clients’ choice of a more passive role in consultations seems to be reasonable given that they do not have the medical resources or knowledge to reach treatment decisions or the authority to implement them. regardless of how this ‘passivity’ or ‘noninteractivity’ is explained, it raises the prospect of reducing clients’ roles in decision making, as well as their success in managing their own health. south africa is a linguistically diverse country where 11 official languages are spoken (big media publishers, 2007). nevertheless, south african public health care is still characterised by a large language divide between clients and clinicians. isizulu and isixhosa have the highest number of first-language speakers in the country, but the majority of south african health professionals are proficient only in english and/ or afrikaans (schwartz, 2004). according to penn (2007), the majority of health interactions in south africa are mediated by a third party, and more than 80% of these interactions between clients, a third party and health professionals take place across linguistic and cultural barriers. where a language mismatch exists between client and clinician, the presence of a properly trained interpreter can be invaluable. when cross-cultural communication is improved, it may lead to increased client involvement in care, better adherence to treatment regimens, a higher quality of care, and better overall health outcomes (cooperpatrick, gallo, gonzales, thi vu, powe, nelson & ford, 1999). in south africa, more than 9 million adults are illiterate (unesco institute for lifelong learning, 2010). furthermore, 2.9 4.2 million people, i.e. 1 in every 5 south africans over the age of 20 years, have not received formal education (nelson mandela foundation, 2004). even though countless south africans can speak several languages, their literacy skills in all of these may be limited. many older generations of people who speak african languages and were educated under the apartheid system, as well as many of the younger generations – as a result of the sudden switch to english as the language of learning and teaching (lolt) in grade 4 – cannot read and write in their mother tongue. additionally, their literacy skills in english and afrikaans, which were the only languages allowed for education during the apartheid era (before the riots in 1976), are not sufficient because of inadequacies in the education that was provided under apartheid (kagee, 2004). today, despite the efforts of the state and non-government organisations (ngos), there are still various challenges in the provision of literacy classes that have to be solved (pretorius, 2004). this means that even when written materials are translated, they may be of little assistance to clients with the above profile. long waiting times at clinics or lengthy time lapses between appointments also affect compliance (mcdonald, garg & haynes, 2002). furthermore, clients typically define adherence in terms of their view of good health and they only seek treatment approaches that are (in their view) manageable, tolerable and effective. many clients only consider medication rather than behavioural regimens to be treatments (kagee, 2004). this is an important factor to consider in light of the nature of slp interventions, which typically require behavioural changes and adherence to therapeutic strategies. poverty is another variable that affects compliance (kagee, 2004). reduced self-efficacy and the demands and stresses of daily survival, work and family life may contribute to the lack of acknowledgement of the importance of complying with treatment regimens. practical solutions for improving health literacy, client recall and compliance post consultation clients often forget or misunderstand information if clinicians do not provide additional materials to ensure that when they leave the clinical setting, the information they have is clear, accurate, complete and available for review and discussion with other professionals or family members (kessels, 2003). there are various studies that tested different interventions (alone and in combination) to improve compliance. these explored, for example, the benefits and concerns related to pictographs (penn, frankel, watermeyer & muller, 2009), video/audio recordings (rao, 2007), short message service (sms/ text messages) (international institute for communication and development, 2006), telephonic contact/follow-up (osborne, 2008a), and personalised clinical information (osborne, 2008b). almost all the interventions that were found to be effective in long-term health care were complex and included combinations of aspects such as more convenient health care, ongoing counselling, and continual reinforcement of recommendations. the complexity of the problem of client non-adherence suggests that no single solution is likely to be helpful, and strategies are more functional when combined (kagee, 2004). table i provides an outline of the strategies and their advantages/disadvantages in intervention. some of the strategies presented in table i are ‘high tech’ (i.e. highly advanced and specialised technology is used) and some are ‘low tech’ (i.e. less advanced technology is involved). while most of the above information aids could be used effectively, not all of them are appropriate for people with complex difficulties, low literacy skills and financial/other resources who live in remote/rural areas. clients with low health/general literacy skills would typically have fewer means to improve their health literacy skills or review health advice because they cannot effectively access health care materials (ross, 2007). clients who live in remote areas cannot attend for frequent therapy – which would provide them with a chance to review information – and some clients are more likely to experience difficulties with compliance as a result of poverty. however, examples of strategies which could support these clients in reviewing information, as well as being in contact with their slp post consultation, are audiovisual materials, telephonic contact and sms/text messages. in the presence of limited financial and other resources in the south african health sector, it is important that issues around client adherence are fully understood and compliance is improved in order to enhance the effectiveness of treatments. with more clients having to take charge of their own health management as a result of financial constraints and (contact) time restrictions with health professionals, there is a dire need to maximise compliance (mcdonald et al., 2002). clients need the opportunity to be in contact with their slp and get feedback when they experience difficulties in treatment. when such difficulties are, for example, associated with dysphagia, potentially severe consequences could result. health professionals and other stakeholders need to commit to being innovative and empowering their clients to access and use health information through culturally appropriate, cost-effective and user-friendly strategies (parker, ratzan & lurie, 2003). from an ethical point of view, slps might be seen to run the risk of overlooking the principles of non-maleficence and beneficence, if the profession does not invest in means to maximise health literacy and client recall of clinical information in populations that are ‘high risk,’ i.e. groups of individuals who are negatively affected by one or more of the many variables that influence health literacy, client recall and general compliance with treatment. vol 57 • december 2010 • sajcd 25 health literacy and client recall method aims the aims of this study were to: (i) trial technology/strategies which may be able to maximise health literacy and client recall of clinical information; and (ii) evaluate the outcomes of the technology/strategies employed from both the slp’s and the client/caregiver’s perspective. research design a single-subject (case-study) design was used with four cases. traditionally, the focus of single-subject designs is the use of systematic methods for applying interventions and documenting their effects repeatedly in single individuals over a longer period of time (maxwell & satake, 2006). this study only investigated individuals at the first stages of their treatment. this type of design was used nonetheless because it allowed for richness of data in four individual cases. outcomes of intervention were evaluated by means of semi-structured interviews, subsequent to which data were qualitatively analysed. participants this study made use of two groups of participants: slps and clients/ caregivers. clients with voice disorders (including laryngectomies), dysphagia or cleft lip and/or palate were the focus of the study. this is because clients’ understanding and recall of information relating to these disorders is most critical to compliance with treatment (fagan, lentin, oyarzabal, isaacs & sellars, 2002; low, wyles, wilkinson & sainsbury, 2001; sataloff, 2006). selection criteria for slps were that they had to be practising currently in the greater cape town area, and had to have at least 1 year’s post-qualification experience in managing at least one of the disorders that formed the focus of the study. selection criteria for clients were that they had to have one of the selected disorders or be a caregiver of a child with an unrepaired cleft lip and/or palate or a voice or swallowing disorder. they had to speak a language other than english as their first language because issues which might arise from the language divide between professionals and clients increase the potential for misunderstandings. clients also had to have a poor socio-economic background (i.e. live in informal settlements or rural areas), as these clients might be more likely to experience difficulties with compliance as a result of poverty (kagee, 2004). in addition, clients had to have low health and general literacy skills as determined through an informal health literacy screening tool (see appendix a). it was important to know the level of health/general literacy skills of participants, as clients with low health/general literacy skills typically have fewer means to improve their health literacy skills or review health advice because they cannot understand or read health care materials, thus indicating their need for additional strategies to assist them in this regard. clients were excluded when they had any additional cognitive, psychological or intellectual disorders, as these were likely to affect their ability to give consent and their ability to express their opinion and perceptions. one reason for including slps as well as clients in this study was because little research has focused on investigating slps as well as clients as key role-players in the clinical process (hester & stevens-ratchford, 2009). few studies mentioned caregivers and the issues that come with low health literacy and problems in recalling clinical information. for this reason the present study also included the caregivers of children. clients and slps were recruited at two large public hospitals and a community rehabilitation centre in the western cape. sampling purposive sampling was used with participants selected based on the researchers’ knowledge of their characteristics and the purpose of the study. a total of four participants were needed (i.e. one participant with a voice disorder, one with dysphagia, one with a cleft lip and/or palate and one with a laryngectomy). a small sample size was sufficient as this is an exploratory, qualitative study where the focus was on richness and detail of discussions. procedure this study was conducted in accordance with the declaration of helsinki. the principles that were followed were the principle of respect for people (which includes confidentiality and their autonomy), the principle of non-maleficence/beneficence and the principle of justice. each participant had to be legally competent, informed and show comprehension before they were invited to sign a consent form voluntarily. where people could not write, they were able to sign with a thumbprint. the consent forms were read out and explained to them in their preferred language. a trained interpreter was used for this to ensure that the content of the consent form was translated accurately. a combination of strategies was devised to assist in: (i) maximising health literacy and client recall; and (ii) ensuring an open channel of contact between clients and their slps post consultation. advantages and disadvantages of various strategies (see table i), information drawn from the literature as well as suggestions by kessels (2003) and rao (2007) were considered when deciding on strategies to be trialled. the following strategies were selected to be trialled in combination: (i) audio-recordings in the form of a cd/cassette, (ii) ‘please call me’ sms/ text message, and (iii) telephonic follow-up. the reason for this is that an audio-recording of the consultation in the form of a cd/cassette is only efficient in assisting health literacy and recall of clinical information, whereas ‘please call me’ sms/text message and consequential telephonic follow-up would only serve to allow for routine reminders, enquiries, discussions and feedback post consultation. in south africa, radio ownership increased from 73% in 2001 to 76.6% in 2007 (south africa online, 2010) and these days even cheap radios include a cd player. even people without their own cd player are likely to be able to use a neighbour’s or relative’s cd-player. the ‘please call me’ sms function is a standard message (no typing required) that can be sent free of charge to another person’s mobile phone in order to alert them of this individual’s request for telephonic contact. low-tech (e.g. written, illustrative) strategies were not included in this study as these were already used by the slps. however where slps provided low-tech strategies, the proposed high-tech strategies were always added as a further strategy. even though only the hightech strategies were focused on in the study, this mix of low-tech and high-tech strategies ensured the provision of visual, auditory and tactile elements in information exchange during and post consultation. trialling the use of technology/strategies to maximise health literacy and client recall of clinical information was a key concept to be introduced at a client’s first consultation, given that this is typically where health literacy, recall and other variables to compliance determine clients’ understanding, eventual recall and resultant adherence to treatment regimens. firstly, slps were familiarised with the procedures of the three chosen strategies to prevent potential problems from occurring during consultations. slps conducted initial assessments according to their routine clinical procedure and made recommendations to their client. whenever important information and recommendations were to be provided, the slp gave a signal to the researcher to audio-record that information. when all information was recorded and the consultation was concluded, this audio-recording was given to the client in addition to any low-tech materials that the slp usually provides. the purpose and use of this recording together with the use of the ‘please call me’ function of their mobile phone was explained by the researcher. clients were also given a date for a follow-up appointment (after at least 3 but not more than 6 weeks). the reason for keeping the time interval below 6 weeks was that it has been reported that recall decreases over time even when strategies have been used to improve recall of clinical information and health literacy. this time period gave the client an opportunity to independently manage their own health while using the proposed strategies. the researcher made notes based on information 26 sajcd • vol 57 • december 2010 health literacy and client recall from the assessment and recommendations so as to have a record of each participant’s treatment regimen for comparisons with the slp’s observations and for later use in data analysis. data collection the outcomes of the technology/strategies employed during the period between the first consultation and the first follow-up appointment were evaluated from both the slp’s and client’s perspective. firstly, clients were interviewed through short semistructured interviews to probe more deeply into their experiences and views on the effectiveness of the strategies in assisting with understanding and recalling clinical information. subsequently, a questionnaire using a likert scale and open-ended questions as well as a subsequent semi-structured interview was conducted with slps. the purpose of the questionnaire was to assist in organising data and further in-depth discussions while allowing slps time to think about their responses. the subsequent interview gave the researcher an opportunity to probe more deeply into the positive or negative experiences reported by the slp after having used the strategies. analysis an immersion/crystallisation style was used when analysing the data. for this purpose, data of slp and client individual interviews were transcribed. patterns that emerged from the data had to be identified and matched with patterns in the literature review/other scientific knowledge so as to enhance internal validity. themes suggested by ammenwerth, brender, nykänen, prokosch, rigby and talmon (2004) were considered, adapted and combined to form five themes against which the data were analysed. the themes were: 1. improvement of knowledge and recall of medical information (long and short term). 2. satisfaction related to the value that is placed on the strategies or the extent to which the participants found them to be helpful. 3. is the combination of the strategies usable in the intended environment and for the intended purpose? if not, what are slps’ and clients’ attitudes towards using the strategies in future and suggestions on improvements? 4. do users need more training and guidance in order to use the strategies appropriately? 5. possible effects that the combination of these strategies has on structural or process quality (e.g. time saving, clinical workflow). results case study 1 (client with a laryngectomy) in this case study, strategies that were used included counselling, illustrations, audiorecording, the option of a ‘please call me’ sms/text message and telephonic followup. the client reported that she forgot some details when she eventually arrived at home, which is when she used the audio-recording to refresh the information in her mind, thus indicating her need for a strategy to review information once she was at home. she also found it helpful to listen to a voice during the day when she was alone at home, to review information and for reassurance. she explained: p1: during the weeks when i was so alone, i would sit and i put the tape on and just listen. r: so was it also just that you could listen to the speech therapist’s voice? p1: yes. nevertheless, this particular client continued to have poor recall and health literacy skills, possibly related to emotional aspects, poor social factors and additional stressors of daily life. she spent much of her energy on longing for her previous life and coming to terms with her present situation, rather than performing self-care and managing her own health and future through the use of strategies. she felt hopeless and confused, which may have further clouded her judgement and prevented her from effectively managing her own health. the client also struggled to deal with her partner’s rejection and reluctance to accept her condition. this agrees with a finding by bunning (2004), who explained that knowing what a child or partner was like before being affected by a disability can make it difficult for significant others to accept the ‘new’ person, which in turn makes it more difficult for the client to be enthusiastic about complying with treatment regimens. it is not known whether or not the client would have been better equipped to manage her own health after she had time to deal with her situation, regain confidence and t ab le i i. c as e st ud y 1 c as e nu m be r sp ee ch -l an gu ag e pa th ol og y li te ra cy s ki lls r es id es in h om e la ng ua ge em pl oy m en t li vi ng s it ua ti on r ep or te d he al th li te ra cy se rv ic e pr ov id ed fo r sk il ls c as e 1 po st op er at iv e co un se lli ng a fte r to ta l c an no t r ea d or w ri te r ur al a re a a fr ik aa ns u ne m pl oy ed st ay ed w ith h er h us ba nd sa id th at s he h ad g re at d iffi cu lty (f em al e ag ed 5 6) la ry ng ec to m y in a ny la ng ua ge in in fo rm al h ou si ng w ith n o un de rs ta nd in g te rm s an d m os t ru nn in g w at er o n a fa rm o ut in fo rm at io n ab ou t he r co nd iti on of th e c ap e to w n ar ea tr ea ti ng s lp ye ar s of e xp er ie nc e in th e fi el d an d in st ra te gi es th at a re u su al ly e m pl oy ed h om e la ng ua ge em pl oy ed a t w or ki ng in p ub lic h ea lt h fe m al e 27 • v er ba l i ns tr uc tio n en gl is h te rt ia ry h os pi ta l • e du ca tio n • d em on st ra tio n • r ep et iti on • i llu st ra tio ns • a ss is t w hi le in de pe nd en ce is e st ab lis he d • i nf or m at io n br oc hu re s an d pa m ph le ts • p ro vi de s w or k nu m be r an d oc ca si on al ly m ob ile p ho ne n um be r vol 57 • december 2010 • sajcd 27 health literacy and client recall practise using the combined strategies to her advantage. the researchers and the slp wondered whether or not the effectiveness of the combined strategies might be realised at a later stage. discussions with the slp continued to investigate what could be done differently for clients with laryngectomies who are illiterate, come from rural areas and have a disadvantaged socio-economic background. the slp saw the value of the combined strategies, but she was aware that they might not be a single universal technique to use with any client. she explained: with laryngectomies i don’t really know. i think if they don’t have easy access because they often need medical attention … you know none of the strategies might be superb … because it’s not just depending on them. it’s not like a dysphagia where you say; remember to put your head down when you swallow! ahm … there can be infections, there can be small stomas, there can be … prostheses fall out and then what you’ve taught them is just for if everything is fine. if everything isn’t fine they need medical attention so … therefore, no single strategy might be effective because there will always be unforeseen problems that need immediate attention from various professionals. this highlights the need for regular contact – face to face or through sms/text message or telephone. finally, it was observed that the slp was caring and spoke to the client in a manner which was clear and in accordance with the client’s level of language, a factor which was viewed to play a significant role in this case. case study 2 (caregivers of a child with cleft palate) in this case study, strategies that were used were counselling, an audiorecording and the option of a ‘please call me’ sms/text message and telephonic follow-up. management in this case was effective; determined by the slp’s and the client’s accounts, as well as their ability to follow treatment guidelines. however, it was not clear whether the success was due to: (i) the combined strategies being of real assistance; (ii) the caregivers being insightful and motivated from the beginning; or (iii) a combination of both. nevertheless, the clients did not have any written information to refer to, which suggests that the combined strategies were important when clients wanted to review information. in addition to being able to review information, the caregivers felt it was also beneficial to share information with others. the mother reported that her neighbour had commented on the use of the audio-recording as follows: she say it’s nice, doctor give to you the cd, reminding you every time your baby … they say yes it’s nice talk (not audible). this case provided a contrast to case study 1. in the first case, the client experienced socio-emotional difficulties that impacted on her compliance, but in this case the parents were practical and pro-active about their child’s future health. the slp saw the value of the combined strategies but had concerns about their future use. among the reasons for this concern was the issue of interpreters and that she felt the strategies were not practical because they would take time and she would have to invest in a system that would record and burn cds. she would also always have to find a quiet room, which is not easy in a hospital, and it would require a lot of additional planning which would be more of a burden than of assistance. she further explained that these particular clients might also struggle with making sense of the information later at home, when it is out of context. alternatively, the slp suggested that only a mobile phone number instead of a cd be provided as it was quicker and easier, there was less room for misunderstandings and no need for additional expensive equipment to be bought. however, if clients do not contact the slp to ask for clarifications, they might misunderstand or not remember information and implement the wrong feeding technique. in the questionnaire, this slp indicated that there is a difference between disorders and the need for the combined strategies, which is similar to what the slp in case study 1 suggested. this slp explained that in cases of voice clients for example, cds with clinical information would be more practical where principles of therapy are more generic and you can easily record and make sense of them. another example that she provided was that of articulation therapy for children, where she could record a session and the caregiver could follow the whole programme at home. in cases of clients with dysphagia or laryngectomies, this is more difficult as disorders are more acute or critical, and hands-on guidance, as well as practical demonstration, is needed. in these cases, visual tools like a video-recording would probably be more appropriate because information is presented visually and in context, whereas an audiorecording might be less clear especially if out of context. however, she explained that having to create video-recordings might be just as impractical as audio-recordings. it would initially take additional consultation time and she would have to invest in a system that would record videos or dvds. this question of whether this specific combination of strategies would perhaps be more effective with disorders that are less severe, complex and acute stood out after having analysed these two case studies. case study 3 (adult client with dysphagia) in this case study, strategies that were used were counselling, illustrations, written information in point-form, an audio-recording, the option of a ‘please call me’ sms/text message and telephonic follow-up. one advantage of the combined strategies which stood out most in this case study was that the strategies and materials provided clients with an opportunity to comprehend and recall aims and rationales for treatments. the slp in this case explained that: … the client seemed like he had more resources to work with, he was more motivated to do his task … he was more motivated because table iii. case study 2 case number speech-language literacy resides home employment living reported health pathology service skills in language situation literacy skills provided for case 2 provision of information, no english literacy urban area somali unemployed lived in a small house able to ask important (caregiver aged 33) counselling and feeding skills, but proficient with the husband’s questions during recommendations for in somali brother and his family consultations with premature infant with only an occasional cleft palate misunderstanding treating slp years of experience in strategies that are home employed at the field and in working usually employed language in public health female 14 • verbal feedback • counselling • information brochures and pamphlets • provides work and occasionally mobile phone number english tertiary hospital 28 sajcd • vol 57 • december 2010 health literacy and client recall he could take ownership and responsibility for his therapy because he had something in his hand you know to look back at and to refer back to all the time. so for me i feel that now, where you actually give the client a tape or you give the client the page, then it’s them taking the responsibility and saying; ok i need to work on my thing now. so i think it’s quite beneficial because if the clients leave without something, then i often find that they forget everything and they don’t take that responsibility. when asked whether they would have still forgotten even in the presence of having the illustrations and the recommendations in pointform, the clients explained: the tape provides more clarity. look we got the exercises but this is just a picture and the picture cannot speak … but the patient and the speech therapist speak with each other. she explains what is going on and he follows her advice. there is an understanding between the two because what is discussed in the session is recorded on here. it is something that happens in real-time. furthermore, the couple felt that access to ‘please call me’ sms/text message and regular telephonic contact would have been most beneficial initially when the client had first come out of the hospital. he had experienced various difficulties with his speech in addition to frequent aspiration and it would have made them feel safer knowing that they could receive immediate support when needed. here, it is indicated that at the initial stages of treatment, clients’ need for professional support and empowering strategies to manage their health is vital. the slp thought the combined strategies were appropriate for all disorders listed; namely dysphagia, voice disorders, laryngectomy and cleft lip and/or palate management. all these disorders require the therapist to obtain regular feedback from clients because the status of these disorders frequently changes and new difficulties arise. for example, there might have been spontaneous recovery or regression in the client’s therapeutic process. she explained: especially with the dysphagia clients, i noticed that they often recover quickly or they have different problems … so i feel they need to be monitored closely because maybe on the first day you see that your aims are specific and then the next time that you see them the aims are different because … there has been spontaneous recovery, there has been some regression. so, in order for my therapy process to be guided, i need to get that constant feedback from the client all the time. when aims become obsolete in the event of regression or improvement of a disorder, clients can review the information, realise that it is not sufficient any more, and become conscious of their need to contact their slp to solve current problems. she agreed that this is also where ‘please call me’ sms/text message and subsequent telephonic follow-up become central. she was worried that when this does not occur, clients become overwhelmed by the changes and resultant needs associated with their disorders if not followed-up immediately. … i feel worried that their disorder might change and they get lost in the system and then who does the follow-up, if we aren’t there to do the follow-up for them? so it becomes a critical issue. this adds to findings by zagaria (2006) who found that, when lacking appropriate support, clients become overwhelmed when having to manage their own health and by the pressures of achieving therapy goals. the above perspective provides a reason why these strategies would be effective in the treatment of the disorders focused upon in this study, as well as in any other disorders treated in speech-language pathology. overall, the slp was enthusiastic when asked whether or not she felt that she would like to routinely use the combined strategies. she explained: … i would definitely use the strategy if i had something set up here at the centre and say for instance they gave me this in a budget and they gave me the resources to be able to do it, then i would have done it. table iv. case study 3 case number speech-language literacy resides home employment living reported health pathology service skills in language situation literacy skills provided for case 3 was educated about finished school informal afrikaans unemployed his wife, a domestic they explained that (male aged 41) reasons for swallowing at grade 4. settlement worker, was the sole they occasionally difficulties and received says he has provider of the family had difficulties recommendations for difficulty reading (with two children). understanding feeding as well as exercises complex text they lived in informal some written or for dysarthria housing with no running verbal information water or electricity. during the day, the client’s sister took care of him. his wife sometimes pushed the client in his wheelchair more than 5 km to the clinic. when they had enough money, they would hire a taxi. the only mobile phone which they owned had been lost recently. the sister’s mobile phone was therefore used in cases of emergency treating slp years of experience in the strategies that are home employed at field and in working in usually employed language public health female 2 • illustrations english & community • keeping aims at a minimum afrikaans clinic • repetitions • using teach-back method • written instructions for caregivers vol 57 • december 2010 • sajcd 29 health literacy and client recall even though the slp saw the value of the combined strategies, she had some concerns which would have to be addressed. for example, she emphasised that she would have to set up a system for recording information that was not intrusive to the client, and instead of having the ‘please call me’ smss come to her personal mobile phone, have a computer system at the centre that would receive smss/text messages. she explained that this is important as she works in a team setup and clients frequently have difficulties that have to be addressed by a team of experts. this further emphasised the usefulness of the ‘please call me’ sms/text message and telephonic follow-up when clients are managed by various health professionals. the slp in this case study was noticeably more positive, motivated and enthusiastic about implementing the combined strategies in future compared with the therapists in the first and second case study. case study 4 (adult client with a voice disorder) in this case study, strategies that were used were counselling, written information in point form, an audio-recording and the option of a ‘please call me’ sms/text message and telephonic follow-up. the client reported that even though she had understood everything once she had left the consultation for the first time, she felt the need to listen to the audio-recorded information frequently because it contained further details than the written information provided for her. she explained: you know i got all this information on a piece of paper but it is better for me to put on the tape and listen to it ... the additional detail to information that is on the tape is helpful yes. the client also found that the combined strategies gave her the opportunity to manage her voice disorder on a long-term rather than a once-off basis. as a result of dedicating time, sitting down and following written instructions while listening to the cassette, she may have felt more as though she was doing a whole treatment session rather than just reading a sheet of written clinical information in point-form which could be less engaging after a period of time, or it might not be appropriate to her learning style (e.g. she might prefer a range of audio, visual or pictorial materials). one slp opinion that stood out from this discussion was that, irrespective of the presenting disorders, clients (at the institution where she works) all have low socio-economic backgrounds and similar education levels, which is why the combined strategies would serve them all in maximising health literacy skills, recall and compliance – and not just clients with selected disorders. the slp explained: … they will use their last money because they are concerned about their health … so you can’t come and waste their time. you need to give as much as you can especially for the people who live far … they need to leave feeling that it was worth that r60 or whatever that they gave out. health professionals have to make every effort to ensure that clients understand their treatment regimen and can manage their own health when they return home so that motivation and treatment compliance can be improved. this has also been mentioned by most therapists in this study which confirms slps’ awareness of the importance of these variables. the slp raised some concerns that would have to be addressed if the combined strategies were to be used in future: for example, (i) that clients might not have the insight to realise that they need to question certain aspects of therapy or acknowledge their need to contact the therapist for assistance; and (ii) when clients have a problem, they usually consult someone in their community who they regard as being wise (e.g. a traditional healer or a community leader), which could ultimately result in the combined strategies being ineffectual as they would not be used. the researcher and the slp agreed that, should the combined strategies be implemented at an institution, it would allow people to become used to their presence and they might use a combination of strategies or just some part of them more readily and effectively. she also highlighted that it is important to understand that cultural influences are particularly strong in rural areas. in this case, the slp would have to investigate a client’s needs and preferences after which a joint decision could be made on a strategy which allows for regular contact with the slp and also maximises that client’s health literacy, recall and resultant compliance to treatment. once more, this slp was noticeably more positive, motivated and enthusiastic about implementing the combined strategies in future compared with the therapists in the first and second case studies. discussion management of three out of the four case studies was judged to be effective as determined by the slps’ and the clients’ accounts, as well as their ability to follow treatment guidelines. various factors played a role in each particular case, but subjective opinions largely showed that the strategies assisted clients in maximising health literacy and client recall, while ensuring an open channel of contact between clients and their slps post consultation. table v. case study 4 case number speech-language literacy resides home employment living reported health pathology service skills in language situation literacy skills provided for case 4 counselling for the moderate literacy urban area afrikaans employed as she was in possession she explained that (female aged 58) prevention of vocal skills in english in a house a tea-lady of a cd/tape-player she occasionally abuse and misuse and afrikaans as well as a house had difficulties in telephone and would learning about her occasionally use her or other family daughter’s mobile members’ medical phone if needed conditions because of difficulties in understanding medical written or verbal information treating slp years of experience strategies that she usually uses home employed at in the field and in language working in public health female 8 • written instructions english tertiary hospital • teach-back method • informing caregivers and significant others about the client’s disorder and treatment 30 sajcd • vol 57 • december 2010 health literacy and client recall clients in all four case studies listened to the audio-recorded information and were aided through being able to review the detailed conversation. furthermore, clients in case studies 1 and 2 found listening to a voice more reassuring, personal and human compared with written information. these are important findings, as much of the literature usually provided to clients goes unread (kessels, 2003). as described by osborne (2008a), some participants were reluctant to get into telephonic contact. in some cases there were technical issues, whereas in other cases participants just did not feel the need to contact their slp even though their follow-up appointment showed that it would have been helpful had they contacted their slp for guidance on selected issues. in most cases, provision of the combined strategies was time well spent, especially when clients were at ‘high risk’ and had ready access to the equipment needed to utilise the strategies. some slps indicated the cost-effectiveness of using the combined strategies in that if clients were to start using these strategies early in their treatment process, recovery could be achieved more quickly as clients can review information in their own time and through regular telephonic contact, clients can be assisted continually, not just at follow-up appointments. in addition, the strategies would not require expensive equipment. for example, most professionals have access to the internet and generally clients have access to phones, mobile phones and cd players (kreutzer, 2009). cassettes, which were used in some of the case studies, are rapidly becoming outdated, which is why cds/dvds, widely and relatively inexpensively available in south africa, would be more appropriate. an initial investment would need to be made for a portable cd burner and audio-recorder. however, this equipment should be useful for many other tasks in hospitals/clinics. slps would need time to develop the best equipment and procedure (through clinical trial and error) so that they could make informed and effective decisions for when and how to use these strategies without them becoming an added burden. all the effort would be a waste of time if interpreters are not readily available, both at times of audio-recordings and during telephonic follow-up. furthermore, slps made it clear that the combined strategies are not a blanket technique for all clients. clients would need to (i) have access and experience in using the equipment needed to utilise the combined strategies; and (ii) be insightful, motivated and have enough problem-solving skills to use the strategies effectively. a client’s stage of recovery and resulting coping skills, as well as cultural influences and familial circumstances, are also variables that have to be considered as possibly interfering with effective use of strategies by clients. when considering all participants’ opinions, it became clear that the clients’ overall experience and value of the combined strategies, was positive and that without them they would have had difficulties in dealing with the information and managing their health post consultation. however, at times it seemed that clients would be satisfied with any strategy which is novel and makes them feel confident in managing their own (or their child’s) health. slps were generally positive about the combined strategies. slps of case studies 3 and 4 were noticeably more positive, motivated and enthusiastic about implementing the combined strategies in future than the therapists in the first and second case studies. it was not clear whether this was because they were younger and had spent less time in practice than the former slps, who were more wary of the challenges faced and the role of the combined strategies. therapists who have been in the field for many years have settled perceptions about the most appropriate information exchange in practice. they have had much experience of clients’ lack of adherence to treatment regimens, despite their efforts to assist clients in complying. on the other hand, younger therapists may like to experiment with various avenues of information exchange with their clients, which could be a reason for their enthusiasm about the combined strategies. clinical implications slps need to be aware that motivation and insight may impact considerably on compliance and treatment outcomes – with or without strategies – and therefore should also consider ways of maximising these. slps would have to investigate obstacles to compliance, a clients’ stage of recovery (and resultant coping skills), personal situations, learning styles and ways of thinking and problem-solving when wanting to maximise information uptake. subsequently, both parties could jointly decide on a strategy that allows for regular contact with the slp and also maximises that client’s health literacy and recall post consultation. it would be inappropriate to expect that the combined strategies could solely assure that health literacy and recall are maximised. a caring and supportive therapist is necessary for clients to feel motivated and confident to take control of the management of their health. at the same time clients have to be insightful enough to realise when they need assistance and make contact so that no time is wasted and their condition does not deteriorate. therefore, when slps identify a client who is at ‘high risk’ for non-compliance, they should initially contact the client to encourage recall and problem solving and at the same time teach the client to initiate contact. slps need to acknowledge that any strategy which makes clients feel confident because they are equipped and thus empowered to manage their (or their child’s) health is vital when wanting to assure continued service delivery and success in treatment (moon, cheng, patel, baumhaft & scheidt, 1998). these combined strategies might not only have different functions and possibly different outcomes for different disorders, but they might also have different outcomes at different stages of a client’s recovery. the strategies should be adapted or provided as they have been proposed, to most clients who seek speech-language pathology treatment for any disorder, especially those with low literacy skills and who do not have the financial means to attend frequent therapy sessions or contact their slp telephonically. a preliminary framework (see appendix b) could serve as a decisionmaking framework for slps who want to maximise health literacy, recall and compliance in clients. this framework is preliminary because it only focuses on the disorders and settings from this preliminary study. future research exploring the combined strategies for other disorders in different settings would assist in making this framework more holistic and complete. future research should also investigate a larger more representative sample including a range of disorders in various settings across the country and at different stages of a client’s recovery. clients from high socio-economic backgrounds with well-developed literacy skills may be affected by some of the variables to compliance that have been identified in this study and in the literature. participants with good health literacy skills should be included in future studies to identify the needs and issues that play a role in their compliance. further research topics could include (i) whether or not the issues that these clients experience are similar or different to those of clients with low health literacy skills; and (ii) which strategies could be of assistance to their compliance with speech-language pathology treatments. limitations this study was limited in that the long-term effectiveness of the combined strategies was not explored. ideally these strategies should have been used with clients right through their treatment process. another procedure that could have been conducted was to perform a quiz with clients right after the consultation and then again before the next follow-up appointment to generate objective data that would show (i) how much information the client initially understood and recalled; and (ii) how much information they could recall and describe after having used the strategies at home. vol 57 • december 2010 • sajcd 31 health literacy and client recall conclusion this study provided insight into various strategies that are available for information exchange. almost all the interventions that aim to improve compliance are complex (kagee, 2004). there is no one solution or universal tool for maximising health literacy and recall in the presence of various factors that impact the utilisation of the combined strategies and compliance. it depends on each client and their treating slp which aspect of the combined strategies they see fit to use. future challenges for slps will be to effectively manage barriers such as clients’ varying levels of literacy, motivation, insight and problemsolving skills; the lack of support from families; the need for trained interpreters; and lack of funds and resources. it is important that slps not only consider health literacy and client recall issues in their everyday practice but that this profession with its methods of analysis and sensitivity to the communication process can unquestionably make a contribution to health literacy and client recall in general, particularly in south africa with its disease burden and where there are many barriers to care. the cycle of low health literacy and education levels, poor income and health and the inaccessibility to information technology can only be broken if information is brought to those who are underserved. acknowledgements acknowledgements to all the participants who volunteered their time, and especially to the therapists who assisted in finding clients. thanks also to martha geiger and vivienne norman for comments on an earlier draft. references ammenwerth, e., brender, j., nykänen, p., prokosch, h. u., rigby, m., & talmon, j. 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(2010). adult literacy and skills training programme (alstp) country profile: south africa. retrieved 8 june 2010 from http:// www.unesco.org/uil/litbase/?menu=4&programme=52 williams, m. v., baker, d. w., parker, r. m., & nurss, j. r. (1998). relationship of functional health literacy to patients’ knowledge of their chronic disease [electronic version]. archives of internal medicine, 158, 166-172. yin, h. s., forbis, s. g., & dreyer, b. p. (2007, august). health literacy and pediatric health [electronic version]. current problems in pediatric adolescent healthcare, 37, 258-286. zagaria, m.e. (2006). low health literacy: a safety concern among the elderly [electronic version]. u.s. pharmacist, 31,28-34. retrieved 8 june 2010 from http://www. uspharmacist.com/content/d/senior%20care/c/11540/ zhang, c., & bennet, t. (2001). multicultural views of disability: implications for early intervention professionals [electronic version]. infant-toddler intervention: the transdisciplinary journal, 11, 143-154. 32 sajcd • vol 57 • december 2010 health literacy and client recall appendix a. informal health literacy screening tool adapted from chew et al. (2004) and yin et al. (2007) 1. how often are medical forms and pamphlets written in a way that is difficult for you to read and understand? always often sometimes occasionally never 2. how often are medication labels written in a way that is difficult for you to read and understand? always often sometimes occasionally never 3. how often are medical forms difficult for you to understand and fill out? always often sometimes occasionally never 4. how often are written recommendations for therapy/treatment difficult for you to understand? always often sometimes occasionally never 5. how often are verbal recommendations for therapy/treatment difficult for you to understand? always often sometimes occasionally never 6. how often do you have problems getting to your clinic appointments at the right time because of difficulty understanding written instructions about when and why you must come to the clinic? always often sometimes occasionally never 7. how often do you have problems learning about your (or your child’s) medical condition because of difficulty understanding written or verbal information? always often sometimes occasionally never 8. how often do you need someone (like a family member, friend, hospital/clinic worker or caregiver) to help you read and understand hospital materials? always often sometimes occasionally never appendix b. preliminary framework for speech-language pathologists when making practical decisions to assist client health literacy and recall o u r n a l o f s o u t h a f r i c a n l o g o p e d i c s o c i e t y negative practice in dysphemic therapy a case history by f. t. lubinsky, b.a., log. (rand). , peter smith was 13 years old when he came to the speech clinic. he was in standard v. he lived in a small country town where his father practised as a doctor. he displayed severe clonic blocks in his speech, and had very marked secondary symptoms, e.g., before every block he gasped for breath and said 'uh-uh" on a rising and falling tone. during the stuttering block his right leg moved jerkily, and his right hand tapped his side vigorously. mrs. smith brought peter into town at the beginning of july, 1954, to attend the speech clinic. she said that she and her husband were very concerned about peter's speech, which had become much worse since he was in standard v. his teacher at that time was very strict, and peter was afraid of him. in the initial interview mrs. smith said : "my two daughters who are younger than peter are cleverer than he is at school, and this gives him an inferiority complex." the interviewer noted that peter was extremely shy and appeared to lack self-confidence. he was very anxious about his speech, and very eager to improve. the following recommendations were made after the initial interview : (1) peter should have intensive speech therapy during the holidays whenever he could come to johannesburg. (2) the danger of their anxiety relaying itself to peter, and thus making his speech "worse, was explained to the parents. they were advised to ignore his speech symptom.' tests given at the commencement of therapy. (1) clarke thurstone neurotic tendency test. results showed him to be more neurotic than the average. (2) iowa attitude scale, where his score indicated that he had a very bad attitude to his speech. 2, 3). (3) iowa rating of severity of stuttering. he was rated as "7. very severe: stuttering on more than 25 per cent, of the words very conspicuous tension: blocks average more than 4 seconds: very conspicuous distracting sounds and facial grimaces : very conspicuous distracting associated movements of body, arms, or legs." (4) recordings were taken of his speech in reading and conversation, in which he averaged twenty blocks a minute. he used so many secondary symptoms that his speech was almost unintelligible. therapy altogether he had four periods of intensive therapy, which co-incided with his school holidays. (1) 26 hours ; (2) 32 hours ; (3) 20 hours ; (4) 8 hours. first period of therapy. (1) he was given a great deal of recognition and acceptance, and a very good rapport was quickly established between peter and the therapist. (2) an extensive mental hygiene progamme was carried out, orientated to his personal needs. his fears were discussed,' (a) fears of speaking situations, and (b) other fears. the therapist helped him work though many of his fears, mainly through discussion and assignments. his secondary symptoms were explained to him as means of trying to avoid, and thus "run away" from stuttering. as peter was such an intelligent boy, he got insight into his problems and mechanisms very quickly. (3) parallel with this mental hygiene programme, the therapist gave the case negative practice to alleviate his very severe secondary symptoms. the following procedure was carried out: (a) he recorded his speech and talked while looking into a mirror. this helped him to recognise and identify his secondary symptoms. he was also required to describe them. (b) he then had to imitate his secondary symptoms while recording and looking in the mirror. he then listened back to the recordings and compared his imitations to the real stutter. (c) when his imitations were exact replicas of his stutter, he recorded his reading while using the secondary symptoms before (i) every word, then (ii) every other r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) o u r n a l o f s o u t h a f r i c a n l o g o p e d i c s o c i e t y a r l word, then (iii) only words beginning with certain letters, then (iv) at the beginning of sentences, then (v) at the beginnings of sentences in certain paragraphs. peter was required to read chorally with every recording of his readings that he had made, using the secondary symptoms where he had used them in the recorded passages. (d) exactly the same procedure was carried out while he was conversing, except that while he was speaking with the recorder, he looked in the mirror as well. he spent approximately two to three hours a day on negative practice while he was receiving therapy. when he left johannesburg he was told to continue with it for thirty minutes a day, and to use it sometimes when talking to his parents and friends. the therapist advised him to be careful not to develop new stuttering symptoms, and to treat them by using negative practice if they did occur the results of the first period of therapy were very dramatic, and indicated that this case had benefitted a great deal from the parallel approach to attitude and secondary symptoms. recordings, when compared with the first ones showed a marked improvement, there were considerably fewer blocks, and the speech was much more intelligible. the 2nd, 3rd and 4th periods of therapy. therapy was continued along the same lines as that of the first period. he was also using many secondary symptoms in dramatised and later, real life situations. if, while using this controlled speech, a secondary symptom "slipped out" he had to say the whole sentence again as a punishment. at the end of each period of therapy he was told to practise at home. he did this very conscientiously and his mother helped him a great deal. results of therapy. (1) on the neurotic scale he scored average. (2) attitude scale found a great improvement in the way he felt about his speech. (3) severity of stuttering, he scored "4 average : stuttering on about 5 to 8 per cent, of words; tension occasionally distracting ; blocks average about one second , stuttering pattern characterized by an occasional complicating sound of facial grimace; an occasional distracting associated movement." his parents found him much more self-confident than before. he progressed very favourably at school, and he was no longer afraid to speak. conclusions. this case clearly demonstrated the advisability of a parallel approach to stuttering: utilising the technique of negative practice, and carrying out a mental hygiene programme concurrently. i have found these therapies most successful in the cases of adolescents with severe secondary symptoms and bad attitudes towards their stuttering. the attitude approach helps them to overcome some of their anxiety, and mental tension, while they feel that they are helping themselves by carrying out a speech programme. i have found that negative practice is most successful when carried out on an intensive level, otherwise the case is inclined to tire of it and become disheartened. negative practice is a difficult technique, and must be presented to the case as a challenge. when he sees it as a challenge, he derives great satisfaction from its accomplishment. i should like to thank professor p. de v. pienaar, director of the university speech voice and hearing clinic, for permission to report on this case. the south african guild of speech teachers the secretary, 16, the braids road, emmarentia iohannesburg. phone 41-4337. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction the passive research method and design instruments, administration and scoring results discussion returning to the research questions conclusion acknowledgements references footnotes about the author(s) anneke p. potgieter department of general linguistics, stellenbosch university, south africa citation potgieter, a.p., (2016). lexical and grammatical development in trilingual speakers of isixhosa, english and afrikaans. south african journal of communication disorders, 63(2), a141. http://dx.doi.org/10.4102/sajcd.v63i2.141 original research lexical and grammatical development in trilingual speakers of isixhosa, english and afrikaans anneke p. potgieter received: 28 aug. 2015; accepted: 09 feb. 2016; published: 20 may 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: there is a dearth of normative data on linguistic development among child speakers of southern african languages, especially in the case of the multilingual children who constitute the largest part of this population. this inevitably impacts on the accuracy of developmental assessments of such speakers. already negative lay opinion on the effect of early multilingualism on language development rates could be exacerbated by the lack of developmental data, ultimately affecting choices regarding home and school language policies. objectives: to establish whether trilinguals necessarily exhibit developmental delay when compared to monolinguals and, if so, whether this delay (1) occurs in terms of both lexical and grammatical development; and (2) in all three the trilinguals’ languages, regardless of input quantity. method: focusing on isixhosa, south african english and afrikaans, the study involved a comparison of 11 four-year-old developing trilinguals’ acquisition of vocabulary and passive constructions with that of 10 age-matched monolingual speakers of each language. results: the trilinguals proved to be monolingual-like in their lexical development in the language to which, on average, they had been exposed most over time, that is, isixhosa. no developmental delay was found in the trilinguals’ acquisition of passive constructions, regardless of the language of testing. conclusion: as previously found for bilingual development, necessarily reduced quantity of exposure does not hinder lexical development in the trilinguals’ input dominant language. the overall lack of delay in their acquisition of the passive is interpreted as possible evidence of cross-linguistic bootstrapping and support for early multilingual exposure. introduction background currently, half of the world’s children are estimated to be growing up learning two or more languages due to the nature of the home and/or community contexts in which they are being reared (grosjean, 2010). this phenomenon is especially common in asia and africa, including linguistically and culturally diverse south africa, where high population density in the many low socio-economic status (ses) areas increases cross-linguistic contact. despite the global pervasiveness of early multilingualism, there is a relative lack of studies on the effect of multilingual acquisition on linguistic development. this has led to divided opinions on the (dis)advantages of early multilingualism (montanari, 2010, p. 103). some argue that our ability for multilingual acquisition is part and parcel of our ‘human language making capacity’ (meisel, as cited in montanari, 2010, p. 103). common lay opinion, however, largely holds that children growing up in multilingual contexts will necessarily suffer developmental language delay – this perhaps on grounds of anecdotal reports of children showing a (initial) delay in vocabulary development when their two or more languages are considered separately, and perhaps on grounds of many parents’ conviction that exposure to more than one language ‘confuses’ a young child. objectives on empirical grounds, the study aims to inform the above debate, the outcome of which has serious implications for child language professionals, child rearing practices and language-in-education policies. the second aim of the study is to contribute to the as yet extremely limited pool of information on developmental norms for speakers of southern african languages, both monolingual and multilingual. without such norms, speech-language pathologists cannot perform accurate developmental assessments of the linguistic abilities of the majority of south african children. in addition, where monolingual norms are available, they are often, for lack of another option, used for the assessment of bilingual children. as a result, an increasing number of bilinguals are being mistakenly diagnosed with specific language impairment (sli) and word finding disorder, rather than credited as typically developing bilinguals who are likely to catch up to their monolingual peers, given sufficient time and exposure (cf. cost action is0804, n.d.; paradis, 2010; thordardottir, rothenberg, rivard & naves, 2006). this misdiagnosis is largely driven by the fact that bilingual children typically have a smaller vocabulary size in each language than monolinguals do (bialystok, luk, peets & yang, 2010). contribution to the field given the limitations of previous multilingualism research in that it focused mostly on bilinguals (cf., for example, blom, 2010; cornips & hulk, 2008; hoff et al., 2012; hulk & cornips, 2006; unsworth, 2007, 2008), the study reported on here investigates firstly the added effect of a third language in the simultaneous acquisition process. in contrast to the purely observational methodology of many previous studies on trilingualism, the present study employs experimental tasks for data collection and involves a detailed analysis of linguistic data. secondly, in investigating the simultaneous acquisition of isixhosa, south african english (hereafter ‘english’) and afrikaans, the focus is on a germanic-bantu combination of language families that has, to my knowledge, never been investigated in the context of early bilingual or trilingual language acquisition. finally, the present study allows for the testing of blom’s (2010) claim that when their weaker language in terms of exposure is considered, multilinguals will exhibit developmental delay, contrary to what the majority of studies on multilingual first language acquisition report regarding grammatical development in the input dominant language (cf., for example, genesee, 2001; meisel, 2001; nicoladis & genesee, 1997; paradis & genesee, 1996). the passive the acquisition of the passive according to deen (2011, p. 155), the passive might very well be the most widely researched grammatical construction in the field of child language acquisition due to the apparent delay in its acquisition. in the case of monolingual english children, research suggests that these learners generally take 5 years or longer to fully acquire the rules relating to passive constructions (baldie, 1976; demuth, moloi & machobane, 2010, p. 238; de villiers & de villiers, 1973). in the case of dutch (the language from which afrikaans largely derives), ‘hardly any’ uses of the passive have been noted in the speech of monolingual children of preschool age, that is, of 4 years and younger (gillis & de houwer, 1998, pp. 28, 35). surprising then is the spontaneous use of the passive in the speech of children as young as 3 years that has been reported in the case of southern african bantu languages, including isizulu (suzman, 1985, 1987, 1990) and sesotho (demuth, 1989, 1990; demuth et al., 2010); the eastern bantu languages kiswahili and kigiriama (alcock, rimba & newton, 2011); and north american inuit and mayan languages (demuth et al., 2010, p. 238). studies have shown that in those languages in which passive constructions are produced relatively early, adult speech generally exhibits a high percentage of such constructions (cf. deen, 2002, for kiswahili; alcock et al., 2011, for kigiriama; kline & demuth, 2008, for sesotho). isixhosa is similar to sesotho in terms of both language typology and the manner in which logical subjects may be questioned (the latter possibly increasing the frequency of passives – cf. demuth et al., 2010). as such, given the reported age of acquisition of the passive by sesotho monolinguals, it is highly likely that isixhosa passives too are acquired earlier than english and afrikaans passives in the case of monolingual children. by choosing to investigate trilingual participants who are acquiring a combination of languages in which the passive is acquired at different rates among monolinguals, an enquiry into the possibility of cross-linguistic grammatical bootstrapping is made possible. if at an age at which isixhosa monolinguals, but not yet english or afrikaans monolinguals, have typically acquired the passive, isixhosa–english–afrikaans-developing trilinguals perform on par with or better than english and afrikaans monolinguals, this would indicate that they may be using their more advanced knowledge of isixhosa passives to support the development of the passive in their other two languages. a brief cross-linguistic comparison the following brief description of passive constructions in the three languages of interest to this study will focus first on the two morphologically reduced germanic languages, english and afrikaans, before moving on to the highly agglutinating bantu language isixhosa. (for an in-depth comparative grammatical description of passives in these three languages, cf. potgieter, 2014). at the very least, the english and afrikaans passive verbal sequence contains a passive participle, that is, a non-finite verb which encodes passive voice, and a free morpheme in the form of a passive auxiliary. in the case of regular english verbs, the passive participle is derived by attaching a passive morpheme in the form of the -ed or -(e)n suffix to the verb stem (ouhalla, 1999, p. 170) as in the cat was stroked (by the boy). in the case of regular afrikaans verbs, this participle is derived by attaching the prefix geto the verb stem, as in die kat is (deur die seun) gestreel (the afrikaans translation of the english example). in english, the passive auxiliary be can take various forms (i.e. be, been, is and was/were) depending on the tense or aspect that is being expressed. in a similar fashion, the afrikaans passive auxiliary is phonetically realised as some form of wees (‘be’), that is, as wees, word, is or was. as illustrated in the examples above, an english passive sentence may optionally contain a by-phrase and an afrikaans passive sentence a deur-phrase, where the complement of the preposition by or deur thematically corresponds to the expression functioning as the subject in the active counterpart of the sentence. passives containing this type of phrase are often referred to as ‘long’ or ‘agentive’ passives, as opposed to ‘short’ or ‘agentless’ passives where the agent is left unspecified through the omission of this phrase. one function of the optional byor deur-phrase is to place emphasis on a ‘heavy/lengthy’ agent argument (ponelis, 1989, pp. 324–326). turning to isixhosa, a sentence is marked as expressing the passive voice through the use of a bound morpheme that is attached to the verb stem. this affix commonly takes one of two forms: -iwor -w-, the addition of the latter morpheme resulting in various (morpho-) phonological changes (louw & jubase, 1963, p. 111). contrary to english and afrikaans, isixhosa does not indicate tense by means of a free morpheme in the form of a passive auxiliary. the agglutinating nature of isixhosa verbal morphology renders the main verb finite in that tense is indicated by means of a specific affix on the verb itself. the affixes that mark the tense of passive isixhosa verbs are generally the same ones also found with active verbs, except in the case of the perfective, which uses two distinct markers. example (b) in (1) below illustrates the passive counterpart of the active sentence in (a): as shown in (1) above, isixhosa allows for long passives through the use of a copular noun phrase (here, ngujohn) introduced by a copular prefix which serves the same semantic function as the english preposition by and the afrikaans preposition deur in the context of passive sentences. the form of this prefix (here, ng-) is determined by the class of the noun to which it attaches (louw & jubase, 1963, p. 106). although the isixhosa copular noun phrase, like the english by-phrase, may occur only postverbally, its exact postverbal position may change in line with discourse factors (du plessis & visser, 1992, p. 84). like english and afrikaans, isixhosa allows expletive passive constructions in which the structural subject position is thematically empty due to the object argument (in isixhosa, regardless of it being definite or indefinite) remaining in its original position. in english and isixhosa, the latter is a postverbal position, both languages being underlyingly svo. in such constructions, the isixhosa passive verb takes the expletive prefix ku(du plessis & visser, 1992, p. 70). unlike in the other two languages, the structural subject position in isixhosa expletive passives is not filled by a free morpheme (such as there or daar) but is left phonetically empty. underlyingly, however, this position is filled by an existential pronominal element that is associated with ku(du plessis & visser, 1992, p. 72).2 an example of an isixhosa expletive passive is given in (2) below, the definite object argument being italicised: research questions given the objectives outlined in previous section, the primary research question that drove this study is: does trilingual exhibit developmental delay when compared to monolingual? if so: does this delay occur both in terms of lexical and grammatical development (the latter being gauged on grounds of knowledge of passive constructions)? does this delay occur in the case of all three languages, or only in the language(s) that are weaker in terms of quantity of input? research method and design participants a total of 41 four-year-old children were recruited for participation: 11 isixhosa-english-afrikaans developing trilinguals (mean age 54.1 months), 10 monolingual isixhosa controls (mean age 55.2 months), 10 monolingual english controls (mean age 54.1 months) and 10 monolingual afrikaans controls (mean age 51.2 months). seven of the trilinguals were female and the remainder male, with each monolingual group being equally divided in terms of gender. all participants qualified as typically developing on grounds of parents’ answers to those questions in a language background questionnaire (lbq) that enquired as to developmental milestones, a possible history of (periods of) hearing impairment and general concerns about the child’s linguistic development. all participants were from homes with low ses. (cf. potgieter & southwood, 2016, for more information on how ses was calculated and for an assessment of the suitability of the lexical measure used in the present study for use with low ses individuals). among prospective trilingual participants, an age of first exposure before 4 years in the case of each of the child’s three languages (cf. potgieter, 2014, for justification), as well as a reported ability to communicate meaningfully in all and only the three languages of interest to this study, were considered as selection criteria. as for the monolingual groups, the typical high level of sociolinguistic diversity of most low ses areas in the western cape made finding prospective participants with exclusive exposure to only one language nearly impossible. as such, participants were considered suitably monolingual if their parents reported that they are unable to speak and/or understand any language other than the one of interest to the extent that they can coherently converse in that language. also, if an additional language was spoken in the home, exposure had to be limited enough to prevent the child from being able to regularly and spontaneously produce words in that language. setting the trilingual participants were sourced from eight different crèches (i.e. day-care centres) situated in townships and low-income informal settlements. these crèches mostly serve children from a range of different racial, cultural and linguistic backgrounds. as such, their child populations consist predominantly of englishand afrikaans-speaking so-called coloured3 children; followed in number by isixhosa-speaking black children; and then black children of immigrant descent, speaking other indigenous african languages as first language (l1), with mostly english as second language (l2). the levels of multilingualism in these groups vary, but the majority of the children are at least functionally bilingual, knowing either english or afrikaans (to varying extents) as one of their languages. at the time of the study, the trilingual participants from these crèches were receiving exposure to at least two languages in the home environment and at least three in the community and/or crèche context (afrikaans and/or english being the primary media of instruction at the relevant crèches). the isixhosa monolinguals were recruited from three crèches in a particular township and informally from a number of homes in a low-income suburban area; the english monolinguals from three crèches in a low-income suburban area; and all the afrikaans monolinguals from the same crèche in a farmworker community. ethical considerations ethical clearance for the study was obtained from the research ethics committee: humanities (nhrec nr rec-050411-032) of stellenbosch university. the objectives and procedures to be followed in the study were discussed verbally and presented in writing (as an informed consent form) to the parents of the child participants. the lack of financial compensation for participation and any hazard or direct benefit to participants was clearly communicated. participants were assured that participation would be anonymous, voluntary and could be discontinued at any point. signed informed consent from the parents and assent from the children were obtained (children indicating such assent with an ‘x’). all data have been protected either in a locked cabinet or, in the case of electronic data, on a password-protected laptop. instruments, administration and scoring language input information regarding the trilingual participants’ language exposure was gathered by means of a specially designed parental lbq in conjunction with a teacher report (cf. potgieter, 2014, for copies of these instruments) and analysed using the utrecht bilingual language exposure calculator (ubilec; unsworth, 2011a, 2011b, 2013). the lbq mainly enquires as to the child’s language exposure over time and at the time of testing, within various contexts, and includes a section requiring an hour-by-hour description of a typical day in the child’s life (both during the week and over weekends), with specific information on the languages used in each context and their relative distribution. to control for varying literacy levels among the low ses respondents, the lbq was administered as an oral interview conducted, in the case of the trilinguals, in the respondents’ homes and in the case of the monolinguals, mostly telephonically. the respondents’ l1 was employed in all cases, using a cultural and linguistic broker where necessary. all interviews were audio recorded, transcribed and (where necessary) translated. the results of teachers’ reports on the purpose and distribution of various languages in the crèche context were used to verify or correct parents’ reports on this matter. the ubilec (unsworth, 2011a, 2011b, 2013) consists of an lbq and an accompanying microsoft excel spreadsheet that quantifies the collected exposure data, calculating values for the following four variables in the case of each language: (1) current amount of exposure (caoe) as percentage of the child’s waking hours in a typical week; (2) cumulative length of exposure (cloe) in years, accounting for varying amounts of exposure over time; (3) traditional length of exposure in years (tloe), that is, age at testing minus age at onset of acquisition; and (4) quality of current input (in terms of ‘nativeness’, measured on a scale of zero to five). although the regular ubilec lbq was not employed in the present study, the specially designed lbq elicited the necessary degree of detail concerning language exposure to render its results suitable for quantification via the ubilec spreadsheet. lexical measure the vocabulary tests employed in this study are the language impairment in a multilingual society: cross-linguistic lexical tasks-isixhosa (litmus-clt-xho; southwood & potgieter, 2013), cross-south african english (litmus-clt-sae; southwood, 2012b) and cross-afrikaans (litmus-clt-af; southwood, 2012a). the aim of the research action behind the design of these instruments, and the 31 other language versions, was to disentangle bilingualism and sli and to profile bilingual sli in children from bilingual migrant communities in europe (cost action is0804, n.d.). as such, the design of these instruments enables the fully comparable assessment of lexical ability across a multilingual child’s different languages (cf. haman, łuniewska & pomiechowska, 2015). the litmus-clts consist of four sections: noun production, verb production, noun comprehension and verb comprehension. the comprehension sections constitute a picture-selection task and the production sections a picture-naming task. testing was conducted in as quiet a room as possible on the crèche premises, except in the case of the few isixhosa monolingual participants who did not attend the crèche and had to be tested at home. the trilingual participants were tested three times (once in each of their languages), with a week in between each testing. this period was deemed sufficient to minimise the chance of practice/priming effects. in addition, every effort was made to counterbalance the order of the language tests between children, taking into account the availability of assistants and participants, as well as crèche schedules. practice/priming effects are, however, unlikely, given that the different language versions of the litmus-clts differ in their target word selection, the difficulty rating of words being the variable that was controlled for in their design. in the case of the monolingual participants, a single testing session for each child was necessary. the order in which the four sections of the litmus-clts were administered was counterbalanced within each language group in the case of both the trilinguals and monolinguals. in the scoring of the production items, the soft score option (crediting regional variants and synonyms) was employed. see potgieter and southwood (2016) for more information on this decision, as well as some of the difficulties surrounding the scoring of responses to the isixhosa version of this instrument. grammatical measure the instrument employed to test the acquisition of passive constructions is a subsection of southwood and van dulm’s (2012a, 2012b, 2013) language therapy instrument known as receptive and expressive activities for language therapy (realt). this instrument was designed to enhance the language intervention process in the case of l1 and l2 englishand afrikaans-speaking children with sli or a language delay/disorder stemming from some other condition (southwood & van dulm, 2012b, p. 1) and has since also been translated into isixhosa. included in the target population of this instrument are children from low ses communities whose general and classroom-relevant linguistic skills may be developed through the type of language stimulation that the use of this instrument can offer (southwood & van dulm, 2012b, p. 1). the passives subset of the realt tests both the comprehension (by means of a picture-selection task) and production (by means of a sentence-completion task) of a number of different types of passive constructions, that is, short passives, long passives, actional passives, expletive passives and reversible long passives (i.e. long passives in which the expression denoting the animate agent argument and that denoting the animate theme argument are interchangeable, even if such an alteration renders the interpretation somewhat improbable, for example, the cat was chased by the dog versus the dog was chased by the cat). in each testing session, the comprehension and production halves of the passive test were interchanged with the two halves of the vocabulary test to prevent the child from becoming bored with either test. as the realt was not designed to serve as a formal test instrument but as language therapy material, the researcher developed her own scoring system: a mark of one was awarded for every answer in the comprehension section that corresponded with the number of the target item, and a mark of zero for every incorrect answer. as for the production items, the child’s verbatim response was entered in a spreadsheet and a score of zero, one or two awarded, depending on the extent to which the response approached or deviated from the target answer. in short, an exactly on-target passive sentence or accurate passive sentence using a different yet suited passive verb was awarded two marks; a passive sentence with a morphological error on the verb or a long passive sentence that is on target except for an error in the agentive phrase was awarded a mark of one, and any answer that does not constitute a passive sentence was awarded a mark of zero. see potgieter (2014) for a more complete description of the scoring process and the justification behind it. results results of the trilingual group’s language exposure measures table 1 presents, in the form of descriptive statistics, the results of the quantification of the trilinguals’ exposure data through means of the ubilec excel spreadsheet. for the purposes of the present study, only the variables of caoe and cloe are reported on. to enable a comparison of cloe across children of slightly varying ages (i.e. between 4.00 and 4.99 years), cloe in years was recalculated to present a percentage portion of the child’s age in years. results revealed that, at the time of testing, the majority of the trilinguals’ exposure was, on average, in the medium of english at 49.1%, followed by isixhosa at 34% and then significantly less afrikaans at 16.6%. however, by far the majority of the cumulative exposure that these children were exposed to over time took the form of isixhosa at an average of 58.2%, with english and afrikaans trailing behind at around 19% each. table 1: trilingual group’s (n = 11) language exposure data, as percentage. results of the lexical measure descriptive statistics the trilingual and different monolingual groups’ scores on the three different language versions of the litmus-clt were not normally distributed; hence, median and iqr (rather than mean and range) have been used in the reporting of these data in table 2. table 2: monolinguals’ (n = 10 per language group) versus trilinguals’ (n = 11) median scores on the litmus-clts, as percentages with iqr below it. across all three language groups, in both the monolingual and trilingual data, the total scores for comprehension are higher than the total scores for production, for example, 67.97% vs 35.94% in the isixhosa monolingual data and 62.5% vs 34.38% in the isixhosa trilingual data. this lag between the development of comprehension and production skills has been widely reported in the literature on child language acquisition and has been found to exist across many languages among both monolinguals and bilinguals. see, for example, benedict (1979); harrisa, yeelesa, chasina and oakley (1995); windsor and kohnert (2004); and for studies on the acquisition of grammatical agreement by monolingual isixhosa speakers, gxilishe, smouse, xhalisa and de villiers (2009) and smouse, gxilishe, de villiers and de villiers (2012). also note that the scores on the noun sections are consistently higher than the scores on the verb sections. consider, for example, the isixhosa monolinguals’ noun total of 59.38% versus their verb total of 48.44% and the isixhosa trilinguals’ noun total of 56.5% versus their verb total of 43.75%. these data align with a large body of studies that has shown the acquisition of nouns to precede the acquisition of other lexical categories across many languages, with some studies using bilingual participants (cf. chan & nicoladis, 2010, for references to numerous relevant studies). comparison across monolingual groups the kruskal–wallis (non-parametric) anova test was used to test for significant differences between the three monolingual groups’ overall test scores, total comprehension scores and total production scores ( p < 0.05 qualifying as significant). results revealed a significant difference between the three language groups in terms of their overall test scores (h(2) = 9.11, p = 0.01). bonferroni-adjusted post hoc tests revealed this to be due to the overall scores of the isixhosa group (mdn = 53.1) being significantly lower than the overall scores of the english group (mdn = 67.6), p = 0.049, and the afrikaans group (mdn = 75.4), p = 0.02. a second significant difference between the three language groups is found in the case of the total production scores (h(2) = 15.09, p < 0.01). this is again due to the isixhosa group’s total production scores (mdn = 35.9) being significantly lower than those of the english group (mdn = 54.7), p < 0.01, and those of the afrikaans group (mdn = 71.9), p < 0.01. in terms of total comprehension scores, however, the english (mdn = 80.5), afrikaans (mdn = 79.7) and isixhosa (mdn = 68) monolingual groups do not differ from one another significantly (h(2) = 4.39, p = 0.11). this overall pattern of results is also reflected in participants’ scores when the respective sections of the litmus-clts that test knowledge of verbs and nouns are considered in their own right, rather than subsumed under the overall score or total comprehension/production scores (cf. the descriptive statistics in table 2). comparison between monolinguals and trilinguals the non-parametric mann–whitney u test was used to test for significant differences between, in the case of each of the three languages, the monolingual and trilingual participants’ overall test scores, total comprehension scores and total production scores. in the case of both english and afrikaans, the trilingual group (mdns: english = 43.8, afrikaans = 31.3) scored significantly lower than the monolingual groups (mdns: english = 67.6, afrikaans = 75.4) on the test as a whole (english: z = −3.38, u = 6.5, p < 0.01; afrikaans: z = −3.63, u = 3; p < 0.01). on the comprehension sections of the english and afrikaans tests too, the trilingual group (mdns: english = 62.5, afrikaans = 54.7) was significantly outperformed (english: z = −2.36, u = 21, p = 0.02; afrikaans: z = −2.92, u = 13, p < 0.01) by the monolingual groups (mdns: english = 80.5, afrikaans = 79.7). finally, this same pattern is found in the case of the production sections (english: z = −3.45, u = 5.5, p < 0.01; afrikaans: z = −3.27, u = 8, p < 0.01), with the trilinguals (mdns: english = 20.3, afrikaans = 18.8) faring significantly worse than the monolingual groups (mdns: english = 54.7, afrikaans = 71.9). in the case of isixhosa, however, there were no significant differences between the trilingual and monolingual groups’ performance on any of the three compared measures, that is, not in terms of their overall test scores (z = −0.67, u = 45; p = 0.5), total comprehension scores (z = −0.67, u = 45; p = 0.5) or total production scores (z = −0.49, u = 47.5, p = 0.62). this overall pattern of results is again also reflected in participants’ scores on the verb and noun subsections. results of the grammatical measure descriptive statistics medians and iqrs are again applicable to the non-normally distributed scores on the passives subset of the three relevant language versions of the realt, reported in table 3. table 3: monolinguals’ (n = 10 per language group) versus trilinguals’ (n = 11) median scores on the realt, as percentages with iqr below it. note firstly that, as in the case of the lexical measure, all participant groups generally have lower scores for production items than comprehension items. consider, for example, the english monolinguals’ total production score of 2% versus their total comprehension score of 52.9% and the english trilinguals’ total production score of 0% versus their total comprehension score of 45.7%. paradis (2010, p. 675) points out that production tasks are even more demanding for bilingual children than for monolingual children and cautions that such tasks may therefore produce an inaccurately poorer picture of bilinguals’ knowledge of a specific structure than is actually the case. secondly, note that in the case of the trilinguals’ performance in each language, the median score for the comprehension section as a whole is close to 50%, the iqrs also being limited to no lower than 7% and no higher than 10% above 50%. the comprehension sections of the realt present the child with a choice between three pictures – one picture being the target, one the opposer and the other the distractor. as such, a score of 33% for comprehension may be said to represent chance level. in order to ensure that the trilinguals’ scores for comprehension in each language, despite being relatively low, are still significantly higher than the chance level, a sample t-test was run on these data. results confirmed that this was indeed the case for the isixhosa (t(10) = 8.39, p < 0.01), english (t(10) = 4.72, p < 0.01) and afrikaans (t(10) = 7.02, p < 0.01) data. comparison across monolingual groups care was taken in the design of the realt to ensure that each test item, across the different language versions, targets the same structure and is comparable in terms of its degree of difficulty (southwood & van dulm, 2012b, p. 4). however, this instrument was not designed with a statistical across-language comparison of results in mind; the statistical analysis reported below should therefore be interpreted with caution. the kruskal–wallis non-parametric anova test was used to test for, in the case of overall test scores and comprehension scores, significant differences between the three monolingual groups. because the english and afrikaans production data evidently suffered from floor effects (the median scores for all but one of the production subsections being 0%), these data were not deemed fit for statistical analysis. as such, the total production scores were compared in a descriptive fashion only. the anova tests revealed a significant difference between the three language groups in terms of their overall test scores (h(2) = 7.55, p = 0.02). bonferroni-adjusted post hoc tests revealed this to be due to the total scores of the isixhosa group (mdn = 50.4), being significantly higher than the total scores of the afrikaans group (mdn = 30), p = 0.02. this significant difference in terms of overall test scores must be a result of differences in terms of production as the isixhosa, english and afrikaans monolingual groups do not differ significantly from one another in terms of their total comprehension scores (h(2) = 0.86, p = 0.65), their scores for the comprehension of long actional passives (h(2) = 5.5, p = 0.06) or their scores for the comprehension of short actional passives (h(2) = 0.11, p = 0.95). recall that in the case of the litmus-clt data too, the three monolingual groups did not differ significantly in terms of comprehension skills. it is clear from the raw median scores on the realt, however, that the english and afrikaans monolinguals fared much worse than the isixhosa monolinguals in terms of their total production scores and their scores on all the production subsections. comparison between monolinguals and trilinguals the participants’ percentage scores on the following test variables were statistically compared, using the mann–whitney u test: overall scores, total comprehension scores and scores for the comprehension of long and short actional passives, respectively. no significant differences were found in the case of any of the three languages (all u-values < 55 and all p-values > 0.17). total production scores were again compared in a descriptive fashion only, using raw median scores. these scores were highly similar across the trilingual and relevant monolingual groups, that is, 48% vs 51% in the case of isixhosa, 0% vs 2% in the case of english and 0% across both groups in the case of afrikaans. discussion the results of the study are discussed below in the same order as which they were presented in above. to conclude the discussion, the research question (and sub-questions) presented in previous section are answered. results of the lexical measure comparison across monolingual groups the 4-year-old english and afrikaans monolinguals in this study are on par with one another in terms of lexical development, but their isixhosa monolingual counterparts seem to have significantly lower (at least productive) vocabulary skills. possible explanations include: (1) a perhaps inevitable slight imbalance in the degree of difficulty of the litmus-clt-xho and that of the other two language versions; (2) culture-related differences between child-rearing practices and child-socialisation styles in black african versus so-called cape-coloured groups (the english and afrikaans monolinguals belonging to the latter cultural group and the isixhosa monolinguals to the former); and (3) despite a shared ses level, possibly lower print exposure among the ‘deep’ township isixhosa monolinguals than among the english monolinguals from more suburban areas and among the afrikaans monolinguals who live on farms but attend a crèche that has a small library. comparison between monolinguals and trilinguals in terms of overall test scores, comprehension scores and production scores, the trilingual group fared significantly worse than the monolinguals on the english and afrikaans tests but performed on par with the isixhosa monolinguals. these findings are not surprising when considering the differing amounts of exposure that the trilingual versus monolingual groups have had to the respective languages. on average, the trilinguals have a cloe to english that equates to only 19% of their lifetimes and their caoe per week to english amounts to an average of not more than 49%. in the case of afrikaans, the trilingual group’s average cloe equates to only 18.4% of their lifetimes, and their average caoe is only 16.6%. it is therefore not surprising that the trilingual group was consistently outperformed by the english and afrikaans monolingual groups, who have a cloe and caoe to the respective languages of close to 100%. the trilingual group average for cloe to isixhosa equates to 58.2% of their lifetimes and their caoe to isixhosa to 34%. this means that, with a cloe to isixhosa that is roughly three times that of their cloe to other languages, but still nearly 40% less than that of monolinguals, the trilingual group was able to keep pace with their monolingual isixhosa counterparts. thus, the trilinguals in this study do show lexical developmental delay when compared to age-matched monolinguals, but only in the two languages that are weakest in terms of input quantity (measured in terms of cloe), despite these trilinguals’ exposure to their strongest language also being significantly less than what monolinguals are privy to. results of the grammatical measure comparison across monolingual groups recall that there was no statistically significant difference between the three monolingual groups in terms of their comprehension of passives, but that (on grounds of descriptive analysis) the english and afrikaans monolinguals clearly fared much worse than the isixhosa monolinguals in terms of production. this constitutes the exact opposite pattern of that found in the monolingual litmus-clt data, in which the isixhosa group was consistently outperformed by the english and/or afrikaans group. let us assume that the significantly lower litmus-clt scores among isixhosa monolinguals are not a result of an imbalance in difficulty rating between the different language versions of the test. the opposing production patterns in the three monolingual groups’ lexical and grammatical test data may then be argued to indicate that, even if cultural child-rearing practices perhaps lower the quantity of child-directed input that the isixhosa monolinguals receive, the negative effect of lowered quantity of exposure on the acquisition of passive constructions is cancelled out by the positive effect of the (assumed) higher frequency of such constructions in the isixhosa child-directed speech that these children do receive. recall from a previous section that the ability to produce passive constructions seems to emerge in english and dutch monolinguals only after the preschool years, whilst the context-appropriate spontaneous use of the passive voice in the speech of children as young as three years has been reported for a number of other southern and also eastern bantu languages (cf. alcock et al., 2011; demuth, 1989, 1990; demuth et al., 2010; suzman, 1985, 1987, 1990). hence, the fact that the monolingual isixhosa 4-year-olds in the present study seem to be more capable of producing passives than english and afrikaans monolinguals is not surprising. comparison between monolinguals and trilinguals the low median scores for both the trilingual and monolingual groups across languages, especially in the case of production, indicate the high degree of difficulty that passive constructions pose to the 4-year-old participants in this study (cf. table 2). importantly, however, despite receiving less exposure to all three of their languages, the trilingual group is managing to keep pace with the monolingual groups. this was shown statistically for comprehension and seems similar for production when raw median scores are considered. recall that, in the case of the afrikaans and english versions of the litmus-clt, the trilinguals scored significantly lower than the monolinguals. it thus seems plausible that, at least as far as comprehension is concerned, the trilingual participants are transferring grammatical knowledge of passive constructions in isixhosa (obtained through greater exposure to this language over time, perhaps coupled with the higher frequency of passives in southern bantu languages) to their knowledge of english and afrikaans. if so, this would constitute a case of cross-linguistic grammatical bootstrapping, confirming that the assumed relatively high frequency of passive constructions in the input that a developing trilingual receives in one of her three languages (here, isixhosa) can enhance its acquisition in her other two languages (here, afrikaans and english).4 considering the low median scores on the english and afrikaans production sections, both the trilinguals and monolinguals scoring 0% on almost all subsections, it is evident that in the case of these two languages, the average four year old from a low ses context, even if monolingual, cannot yet produce passives. the bootstrapping effect mentioned above thus seems to be limited (at least at this stage in the trilinguals’ language development) to the comprehension of passives. returning to the research questions in light of the statistical comparison of the trilingual and monolingual groups’ test scores in each of the three languages and assuming that a significant difference indicates developmental delay, the simple answer to the question ‘do trilinguals exhibit developmental delay when compared to monolinguals?’ is ‘yes, but only in certain respects’. recall that sub-question (a) asked whether the developmental delay occurs both in terms of lexical and grammatical development. results showed it to occur only in in the case of lexical development (in as far as lexical proficiency can be assessed by a vocabulary test) and not in the case of grammatical development (in as far as knowledge of passives may be taken as an indication of grammatical proficiency). importantly, this lexical delay among trilinguals is seen to occur in the case of both production and comprehension across both nouns and verbs. given the floor effects in both the monolinguals’ and trilinguals’ english and afrikaans realt production data, the reported absence of a delay in the trilinguals’ grammatical development is based on a statistical comparison of comprehension data only, although the raw production data show a similar trend. the fact that the trilinguals do not exhibit developmental delay with regard to passives in any one of their three languages is an important, unexpected finding in light of the literature on bilingualism showing grammatical developmental delay to commonly occur in the case of the language of less exposure (cf., for example, blom, 2010; paradis, nicoladis, crago & genesee, 2010). for a discussion of the differential effect of input on lexical versus grammatical development found in this study, see potgieter (under review). sub-question (b) enquired as to whether the developmental delay among trilinguals manifests itself in all three languages or only in the language(s) that is weaker in terms of quantity of input. the answer here is that the developmental delay is only found in the case of the two languages to which the trilingual group, on average, received the least exposure over time, that is, english and afrikaans. when the average amount of input that the trilingual group was receiving at the time of testing (i.e. caoe rather than cloe) is considered, the reason why there are significant differences between the trilinguals’ and monolinguals’ scores in the case of the english test, but not in the case of the isixhosa test, is less clear – the trilinguals had a higher average caoe to english compared to isixhosa (and afrikaans). afrikaans, however, provides a simpler picture of the relationship between input and lexical development in being the language to which the trilinguals received the least exposure both in terms of cloe and caoe, and also the one in which the trilinguals exhibit the largest developmental delay. overall, the results of the present study align with the findings of a multitude of bilingualism studies in which participants’ lexical development lagged behind that of monolinguals in the case of their language of less exposure (cf., for example, macleod, fabiano-smith, boegner-page & fontolliet, 2012; thordardottir, 2011; thordardottir & brandeker, 2010, in press). the results further support those of bilingualism research in proving again that necessarily reduced exposure does not hinder lexical development in the input dominant language (in terms of exposure over time). significantly, the present study has shown this to be the case even when input in the dominant language constitutes as little as 58.2% of multilingual participants’ overall language exposure over time (as opposed to the approximately 100% exposure monolinguals receive). conclusion the study has shown that, among low ses developing trilingual learners of isixhosa, english and afrikaans, necessarily reduced input does not lead to a delay in their acquisition of the passive in any of their three languages, or to a delay in lexical development in their input dominant language, isixhosa. the lack of any delay in their acquisition of the passive could be a result of cross-linguistic bootstrapping in the form of transfer of advanced knowledge of passives in one language to their knowledge of passives in the other two languages. this finding contributes theoretically to our understanding of the interaction between multilinguals’ different language systems. it is also of practical value in indicating that exposing a child to multiple languages from a young age may support the earlier development of certain features in the child’s languages. in addition, the study has shown that it is possible for young children exposed to as many as three languages to attain a monolingual-like vocabulary in one language plus a certain amount of vocabulary in an additional two languages, a benefit that monolinguals are not privy to. finally, in its assessment of both monolingual and trilingual speakers of isixhosa, south african english and afrikaans, the study has contributed to the limited pool of normative data on lexical and grammatical development among speakers of southern african languages. despite the use of a larger number of participants that is typical of trilingualism research, the generalisability of the results of the study is admittedly limited by this number. hopefully, this study has served to set the scene for larger scale research into multilingual language acquisition within the south african (and more broadly, the african) context. only on grounds of sufficient research we may increase the accuracy of developmental assessments of children speaking local languages and ultimately cultivate full public understanding (specifically among parents and teachers) that childhood multilingualism does not necessarily pose a developmental hindrance but definitely offers children a valuable sociolinguistic skill – a skill that increases a child’s communicative and cultural resources and, in doing so, breaks down barriers. acknowledgements competing interests this study was made possible by the financial assistance of the harry crossley foundation and 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(2011b). utrecht bilingual language exposure calculator (ubilec): questionnaire and notes on completing the excel file. unpublished material. unsworth, s. (2013). utrecht bilingual language exposure calculator (ubilec): excel spreadsheet. unpublished material. vasilyeva, m., huttenlocher, j., & waterfall, h. (2006). effects of language intervention on syntactic skill levels in preschoolers. developmental psychology, 42(1), 164–74. whitehurst, g., ironsmith, m., & goldfein, m. (1974). selective imitation of the passive construction through modeling. journal of experimental child psychology, 17, 288–302. windsor, j., & kohnert, k. (2004). the search for common ground: part i. lexical performance by linguistically diverse learners. journal of speech, language and hearing research, 47, 877–890. zeller, j. (2008). the subject marker in bantu as an antifocus marker. stellenbosch papers in linguistics, 38, 221–254. footnotes 1. on the copula status of ng-, cf. du plessis and visser (1992). 2. for (minimalist) generative analyses of the expletive construction in bantu languages, cf. zeller (2008). 3. in south africa, this term is used to refer to persons of mixed ethnic origin, this mixed ancestry having roots in two or more of the following areas/groups: europe, asia and various indigenous khoisan and bantu tribes. although this term is viewed as derogatory in certain contexts, no suitable alternative has unfortunately yet been established – hence the cautious use of the term here. the term ‘black children’ is used with similar caution to refer to children of bantu descent when specific ethnic/tribal affiliation is either irrelevant, or when wanting to refer to this group as a whole. 4. this type of implicit learning effect caused by the naturally or experimentally increased frequency of passive constructions in the input has already been reported to occur within a single language (rather than cross-linguistically). specifically, increasing the frequency of passives in the input that english monolingual participants received led to their earlier comprehension of passives (cf. bencini & valian, 2008; brooks & tomasello, 1999; huttenlocher, vasilyeva, cymerman & levine, 2002; huttenlocher, vasilyeva & shimpi, 2004; savage, lieven, theakston & tomasello, 2003) and to their earlier production of passives (cf. de villiers, 1984; vasilyeva, huttenlocher & waterfall, 2006; whitehurst, ironsmith & goldfein, 1974). journal of the south african logopedic society september the initiation of pharyngeal voice and early speech lessons in the laryngectomee s. bauman, m.a. certain established speech therapy procedures exist for the laryngectomized patient and are easily found in the literature which exists today (y). there does however, appear to be a need for more explicit details concerning the initiation of voice and early speech lessons. surgical removal of the vocal cords does not necessarily result in permanent aphonia. the human organism with its ability to adapt can, in most cases, readjust and produce, with the tissues of the pharynx, a fricative noise which can be modified to resemble voice. in some cases where trauma or necessary surgical procedures have eliminated a large amount of tissue at the back of the tongue and in the pharyngeal wall, so that an adequate closure is not possible, the production of the psuedo voice is difficult, if not impossible. for these patients an artificial aid is required. the mechanical or electrical larynx should be considered.3 with most other laryngectomeees the speech therapist attempts to teach the oesophageal voice method ( 0 v m) or the pharyngeal voice method ( p v m ) . in the 0 v μ air is swallowed, like food, and driven into the oesophagus. by putting pressure on the stomach muscles the air is forced back up and with throat constriction vibration is set up which resembles a belch. this sound is modified to become the new voice. in the p v m the air is swallowed deep into the pharynx, "locked" there, and then forced out. the resultant vibration is the beginning of the new voice. the 0 v μ is sometimes unacceptable to patients, especially women, because of the emphasis on assuming a kinaesthetic set similar to that required for belching. in addition, the early belches are fairly loud explosive sounds which seem somewhat uncontrollable and disquieting. in the ρ v μ it seems that the shorter passage of air, in and out, requires less time and effort and is therefore easier and quicker. the initial voice, although softer, appears to be smoother in quality, more even-flowing and continuous. finally it is less interrupted in phraseology. most patients master the p v m without difficulty.4 to aid them it is sometimes advisable to begin with explanations and activities to suggest the ο v μ (up to the point of the belch) in order to stimulate the mental image and kinaesthetic impression of the action required. (see stage v). whatever the technique attempted, it is not essential for the speech therapist to be able to demonstrate the new voice pattern. some authorities (5. ρ 15; 6. ρ 5.) believe this to be essential, but the writer has found it unnecessary. the use of aerated-sherbet mixtures is also a matter of some controversy. gaseous liquid intake is advocated by some speech therapists who maintain that it helps the patient to swallow air and then regurgitate it. for the p v m liquids appear to be dispensable. during practice sessions, the patient swallows a great deal of air, even to the extent of becoming uncomfortably flatulent. aerated liquids only too quickly hasten his discomfort. stages in the initiation of the pharyngeal voice method stage 1: the therapist should start with relaxation1 in order that the patient gets an understanding of (a) tension, force and pressure, (b) too flaccid a physical attitude, (c) optimal tonicity. this is the basis of therapy, as specific areas of tension in an overall relaxed body, are the keys to success. the generally relaxed physical attitude aids in attaining a relaxed state of mind, free from overanxiety and hampering fears. stage ii. the patient proceeds directly from the relaxation couch to relaxed walking. often a person can become quite tense sitting still and trying to relax, but many tensions disappear when the patient is walking along with a comfortable, easy stride, with arms free and swinging and breathing deeply. with a slight quickening of the pace it is easy to gulp in air (like a fish) and swallow it by forcing it right back past the pharynx. stage iii. ask the patient to hold his breath and feel tension in the region of the diaphragm. rather than use technical terms such as "tense your diaphragm", it is advisable for the therapist r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society ^september to say "feel tension here", and to indicate manually exactly where the tension is required. the case should get the kinaesthetic stimulation by feeling how the therapist herself stiffens the 'area and makes it tense. | now the therapist should put it to the patient that when the area of the diaphragm is tensed, some other part of the body becomes tense. by 'tensing the diaphragm the back of the throat is tensed and the back of the tongue is raised slightly. (partly reciprocal action and partly suggestion.) stage iv: the patient should copy the therapist's action of: (1) placing the tip of the tongue against the gums of the lower teeth, (2) keeping the centre of the tongue flat on the floor of the mouth, (3) and raising the back of the tongue to make a posterior closure (as for the 'k' sound.) this action is called "locking" and the case must be conditioned to take up this position quickly and efficiently, on demand 8 : he must take in air, swallow it into the back of the throat, hold his breath, feel tension in the area of the diaphragm and throat and immediately "lock." stage v. explain to the case how normal speech is produced:— (1) the air is breathed in through the mouth and nose and goes to the lungs. it then comes up from the lungs— (2) the vocal cords come together (almost in an unconscious way), (3) air passes through them and sets up vibrations. (4) these vibrations become voice. the laryngectomee has no vocal folds and the air which he breathes in, enters the hole in the throat and passes into the lungs and also comes out through the same opening in the throat. air taken in through the mouth and nose is swallowed down, as if to the stomach, just as food is swallowed into the stomach. the explanation of pharyngeal voice is as follows:— (1) swallowed air comes up the oesophagus to the back of the throat. (2) certain tissues are brought together by constriction at the back of the throat to take the place of the vocal cords. (3) the air will pass these approximating tissues and set up vibrations, (4) these vibrations result in voice. nelson (8 ρ 19) says that the air comes up to "vibrate against the fold of the oesophagus, scar tissue and bones of the throat, and the palate and other resonators." this is valuable information for the speech therapist, but need not be available to the patient. just as we approximate our vocal folds almost unconsciously, the laryngectomee will approximate areas at the back of the throat without being burdened with anatomical details which he cannot understand very well and which will confuse him and thereby make him nervous and anxious. the normal speaker is not aware of how he moves his vocal folds and therefore the laryngectomee should not be required to give his adaptation undue attention. a kinaesthetic understanding is more important than many detailed and scientific explanations. it is of the utmost importance that the therapist should let the patient find his own adaptation as regards the approximation of tissues for producing voice. stage vi. the co-ordinating phase: guide the patient as follows:— (1) walk briskly and easily. (2) gulp in air through the mouth, (3) swallow the air past the back of the mouth, (4) hold it there by tensing the diaphragm and throat. (5) "lock" very effectively. (6) push the air out immediately after the "lock". do not say "k" which is the position being held, but let the sound come out "ah." (the sound must be "triggered" off immediately after a very firm "lock".) (8 ρ 44). the resultant sound will be the voice which is to be developed. keep repeating this procedure many times, allowing short rests if the patient becomes very bloated from swallowing too much air. occasional failure to produce this voice is to be expected as the skill is only newly acquired and has yet to be firmly established and perfected. the patient should attempt to retain and recall the kinaesthetic impression of what he did when he produced an adequate sound and try to reproduce it over and over again. failure may be due to the exertion of too much diaphragm pressure or to an inadequately firm "lock." this procedure is repeated for as many lessons as required in order to enable the patient to produce voice on demand. once he can produce the sound (voice) on demand, he can dispense with the walking activity for by this time he is able to swallow air effectively and is not dependent on the inrush of air provided by the brisk walking. when seated the 1 aticnt should be in a comfortable chair with a back support. the legs should not be crossed. (8 ρ 46). by shaping the mouth the voice changes from a noise to recognizable vowel sounds. practice is then directed towards lengthening the vowel sounds. the patient then proceeds to practice diphthongs. the case can now be made aware of his ability to make buccal sounds. if possible, this ability r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 journal of the south african logopedic society should not be made clear to him until such time as he has learned to produce voice. patients who realise that they can communicate with buccal speech often perfect its use quite skilfully and then persist in using it, to the detriment of learning to use the new voice. the ability to produce sounds which are not dependent on voice suddenly widens the whole horizon of the patient. the unvoiced consonants and the vowels or diphthongs are blended together to produce the first nonsense words. similarly, voiced consonants and vowels or diphthongs are blended. care should be taken to ensure that the patient blends effectively from the start. blending should not be isolated drill but should be practiced through the introduction of meaningful words almost immediately. this provides strong motivation for the patient. from monosyllabic words the patient attempts two and three syllabled words. phrases and sentences should be introduced without delay. it is not uncommon to find a laryngectomee experiencing some difficulty with "i", "r", "m" and "n" sounds. these sounds should not be allowed to effect the patient unduly and he should not avoid these sounds. by attempting them to the best of his ability each time they confront him, he will find that they will "develop" in the speech pattern without much difficulty. the "h" sound is the only one which the laryngectomee does not master. the clinician should prepare the case for a possible increase in coughing when the speech activity first begins. this should disappear about a week after the introduction of voice activity. he may also feel discomfort from flatulence which is caused by the uneconomical loss of air into the stomach. this flatulence disappears as he becomes more proficient. any indications of voice from the trachea should be eliminated by decreasing general tension and the force and pressure on the diaphragm. (8, "). as soon as the patient is speaking in sentences, the clarity of the speech performance should be checked frequently by giving formal and informal intelligibility tests. the therapist alone, and then an audience, listen and watch the speaker (auditory and visual cues) and then listen without watching (auditory cues only). audibility and intellegibility are also checked over the telephone and from a playback on a tape recorder. (auditory cues only). when the laryngectomee has regained the art of producing voice and speech, he should reintroduce into his speaking activities all the auxilliary actions that accompany dynamic communication such as a facil expression, pleasant hand movements and short phrases which the normal person continually uses such as "oh, really", "is that so," "pardon", etc. throughout therapy and especially in the initial stages the patient should feel that the whole september procedure is easy, and because of their anatomical structure, perfectly natural and attainable. \ often the patient presents a psychological picture not unlike that of the dysphemic. social situations are feared and communication is avoided, because it is easier to withdraw than to watch the reactions of the auditors. they are responsive to the reactions of the listeners (whĉ hear this somewhat unfamiliar voice) in just the same way as the stutterer reacts when he sees the listener uncomfortable in the face of his nonfluency. the emotional reactions of the patient are not overcome as rapidly as speech is learned. this aspect of rehabilitation cannot be hurried. it resolves itself slowly when the patient learns to forget the past and brings hope and fortitude to the future. bibliography 1. b a n g s , jack, l. b i b l i o g r a p h y ; e s o p h a g e a l speech. journal of speech d i s o r d e r s . 1947. vol. 12 pp. 339-341. 2. anderson, john, o. b i b l i o g r a p h y on oesophageal speech. j o u r n a l of speech d i s o r d e r s . 1954. vol. 19, no. 1, pp. 70-72. 3. b a n g s , j . "speech after l a r y n g e c t o m y " . journal of speech d i s o r d e r s . vol. 11. no. 3. sept. 1946. 4. sawkins, john. "voice w i t h o u t a l a r y n x . " the medical p r e s s . a u g u s t , 1949. 5. sommerville, a. "speech t h e r a p y for t h e l a r y n g e c t o m e e . " south african l o g o p e d i c society congress e d i t i o n 1950. pp. 13-18. 6. t e a c h i n g oesophageal speech. n e w s b u l l e t i n of t h e college of speech t h e r a p i s t s . j u l y 1954. no. 46, pp. 4-8. 7. jacobson, edmund. p r o g r e s s i v e r e l a x a t i o n . u n i v e r s i t y of chicago p r e s s 1938. 2nd. edit. 8. n e l s o n , charles, r. p o s t l a r y n g e c t o m y speech. f u n k and w a g n a l l s co. n e w york, 1949. 9. marland, p. m. "a direct method of t e a c h i n g voice after total l a r y n g e c t o m y . " speech vol. 3, 1949. pp. 4-13. miss bessie dembo 54 wingate mansions cor. smit & nugget streets, hospital hill, johannesburg phone 44-0860 typing and roneoing undertaken, especially theses and students' notes. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) case history of an eighteen-year-old stutterer by joy bloch. b.a.log.(rand). an intelligent 18-year-old male stutterer, who has been receiving speech therapy at the university of the witwatersrand speech, voice and hearing clinic, for the past two years, was asked to write on his experiences as a stutterer. his response, in the writer's opinion, contains much valuable information, and appears to indicate many insights and a change of attitude. it is presented here (with his permission), in the hope that it will be of interest to therapists in this field. a brief outline of his case history, together with an outline of the type of therapy given, will be included to supplement and place in context his contribution. in order to preserve the case's anonymity he will be referred to as "peter". case history peter lives with his mother and his sister, who is six years older than he is. his father died when he was in his final school year. he started stuttering when he was about 2\, when he began forming sentences. he was fairly slow in starting to speak. other developmental milestones were normal. there is no history of stuttering in the family. he obtained a first class matriculation pass, and is at present repeating his first year as a medical student. he intends becoming a psychiatrist. he has had a variety of therapies at various times, including speech therapy, hypnotherapy and psychotherapy. he was first seen at the university speech clinic when he was six, and he received a short period of therapy. after this he received therapy in the school situation. he was interviewed again at the clinic when he was 14, but did not receive therapy. he returned to the clinic in may 1961, and for a year received both group and individual therapy. apparently he did not relate well in the group, and it was decided that he receive only individual therapy this year. in conjunction with speech therapy he is receiving psychiatric treatment. it is reported that he had severe guilt feelings on the death of his father, and tends to be dominated by his sister and his mother. he apparently sets high standards for himself. he has threatened to commit suicide on several occasions. an account of his reactions to therapy and his general behaviour pattern will be given later in this paper. description of symptom peter is a severe secondary stutterer. when he was seen at the clinic in may 1961, his stutter consisted of tense repetitions and non-vocalized blocks accompanied by secondary symptoms of lip tremor, pursing of the lips, constant head nodding and jerking, and clicking of the tongue. he kept eye-contact for a part of each block. according to the interviewing clinician: "he frequently gave up the speech attempt. this was his most characteristic method of handling severe blocks. at these times, when tension was extreme during the spasm, he would almost break down and cry, remain silent, or would say "leave it" or "it doesn't matter". when pressed to continue he would become almost catastrophic. his obvious anxiety at his stuttering manifested itself in such physical symptoms as blushing, sweating and constant movements." when first seen by the present clinician his stutter consisted of tense repetitions, drawing out of the end part of a word to carry him on to the next, and some non-voca^ lised blocks accompanied by somewhat bizarre secondary symptoms of head nodding, eye-blinking, tremor of lips and jaw, and facial grimacing. he frequently blushed during a block, and occasionally broke out into a sweat. he used starters such as "well", went back on words that ;he could not say, and on rare occasions, when he had a particularly severe block, tended to give up the speech attempt completely. he sounded as 2 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) though he was "running short of breath", his general speech pattern having a very breathless quality. he maintained a certain amount of eye-contact during a block. he reported tension in the stomach area when stuttering. therapy peter received therapy on similar lines from two different clinicians. his previous clinician reported many of the difficulties encountered by the writer. peter was resistant to therapy from the start. he appeared to be arrogant and was resentful of the clinic, since here he had to face his stuttering and himself as a stutterer. moreover, he was treated as a stutterer, and this seemed to increase his resentment. he maintained that he would never accept himself as a stutterer, as this was tantamount to an admission of failure on his part, as what he wanted was complete fluency. he blamed all his failures and inadequacies on his stuttering, including academic, social and emotional failures. initially the writer had difficulty in establishing an adequate working relationship with peter. he made several attempts to discontinue therapy, usually giving very immature reasons. he would become excited and emotional when his immature rationalisations were pointed out to him, and this served only to increase his aggression and resentment. gradually the writer came to accept him as he was, and indicate her acceptance of him by not responding to him as other people usually did, i.e. with aggression and pity. this seemed to be a turning point in therapy, as from then on peter became more co-operative, and less prone to bouts of extreme excitability and aggression. peter was subject to periods of extreme depression. when depressed, he would frequently j respond by becoming silent and looking down, or alternatively would become excited and start to shout. when shouting, his speech was often fluent. peter talked freely aiid frankly about his feelings, and would place the ultimate blame for his depression! on his stutter. an attempt was made to discuss with him his assets and liabilities. to him, all his assets (he was quite frank about these and maintained he was superior to others in every way except in speech) were outweighed by the liability of his stuttering. this attitude hampered attempts to modify his stuttering, in that in the therapy situation, knowing that he was regarded as a stutterer, he was quite willing to stutter "openly" without avoidances. however, he was extremely reluctant to do this in any situation outside the clinic, especially with people who were not aware of his stuttering. in the clinic situation peter was able to stutter easily, with relatively little struggle, and was able to modify his symptoms in the various ways suggested, always being aware of what he was doing, and being able to discriminate the form the modifications took. he "did not like" the easy, "open" stuttering as the "stutterings lasted longer" than those of his usual pattern. the lengths of the easy and tense blocks were timed with a stop watch, and although the average difference in duration was negligible, peter maintained that the easy blocks "felt longer". peter was often loath to use the taperecorder when working on his stutter, as it made his "greatest liability" even more real to him. although he used the tape recorder frequently, he always appeared upset when hearing the play-back, and when he was depressed would refuse to use the recorder at all. peter admitted to having a fear of talking on the telephone. this was discussed, and he eventually carried out several telephone assignments in the clinic situation only. he would not 'phone outsiders. he reported that he used the telephone at home only when necessary. as therapy progressed, a change became evident in his symptoms. he rarely gave up speech attempts completely. he eliminated the use of starters to a certain extent, and would carry through with his blocks until he was able to release the word. he was also able to maintain eye-contact for most of the time, except when having a particularly severe block. i would now like to present his contribution on: "my experiences as a stutterer." "it must be difficult, well nigh impossible for non-stutterers to imagine what it is like to be a stutterer. to be reluctant to enter a shop to buy a box of matches or to pick up december, 1962 journal of the south african l o o p e d i c society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a telephone, to be loath to speak to members of the opposite sex — nonsense! speech is as natural as breathing, walking or eating — to be done automatically, without thought. as a stutterer, i will try to explain why a stutterer acts as he does and what he experiences due to his inability to converse freely on a purely physical level. stutterers are only bound to one another by the bond of their stutter and therefore there is no specific "stuttering-type". the following lines, while they might well be applicable to many stutterers, only refer specifically to myself and must not be taken to be typical of all stutterers. if stutterers all conformed to one mental attitude, treatment of stuttering would be a comparatively easy matter. however — "vive-la-difference!" as a stutterer i soon developed the "giant in chains" attitude. what would i not achieve if i had normal speech! i do not think that i might be but a mediocrity if i did speak fluently. as i cannot, as it were, prove my mediocrity by normal means of expression, and i am forced to take a back seat due to my stutter, the stutter is then blamed for all my failures. it is a convenient scapegoat. however, the stutter is not completely guiltless. to a very appreciable extent, it has governed my growth of personality besides affecting me on a physical level. due to the stutter, i have learned to converse practically in monosyllables and to say in a very few words almost what i intend to convey. brevity precludes excess stuttering! a certain sharpness of tongue results and because these few words can usually be said without stuttering, we find our "fettered gaint", the "false fluency" having gone to his head, ironically being labelled a "chatterbox". also in my case, trying to be noted not for how i speak, but for what i say, i do not exactly exercise tact in my speech. for one who has a speech difficulty, i manage quite well to make my likes and dislikes known in no mean manner. incidentally i am also quite a successful heckler of university lecturers, no mean achievement for a stutterer in a most competitive field! of course, due to my failure in person to person relationships, i have tried to make up for this shortcoming by constantly trying to prove my superiority, or at least my "uninferiority" in other fields of endeavour, e.g. sport. to this end i improved myself in these fields — for example becoming a good dancer — and thus have tried to show that i am "one of the boys" even if i am a stutterer. but to my mind, all of these assets do not outweigh the liability of my stutter. the stutter, in fact, has assumed dimensions out of all proportion to its actual place in my personality make-up. undoubtedly it has become the most important factor in my life and due to my inability to rid myself of it — for i feel that i do not need it any more — i spend much time in deep bouts of depression which alternate with forced gaiety. no stutterer wants to continue stuttering all his life. one outgrows the need for this escape mechanism from the responsibilities of everyday life — for what better escape is there than a speech defect which prevents the stutterer from speaking freely? i find i have outgrown the need to stutter, but i am "stuck with it". my frantic efforts to disguise, hide or loose it, often using misguided methods, only makes the stutter worse and i experience a deep sense of guilt in failing myself and the people interested in my welfare by not speaking fluently. i, as a stutterer, developed a deep sense of frustration and resentment against my fate and also an infinite propensity for self-pity. in an effort to hide my stutter i exhibited a strange mixture of arrogance and shyness. to most people i present the facade of a terrible "holier than thou" attitude of aloofness, my reasoning being rather to be thought "stuck up" than to reveal myself as a stutterer. i find it hard to believe that people can accept me together with my stutter and at times i feel apologetic for subjecting them to my stutter. sometimes i feel aggressive, as it were daring them to laugh at me, and i might add, being slightly disappointed when they do not! but i am also shy, as i am terrified of being found out as a stutterer and exposed to / laughter or, as happens more often, pity. for i have found that on the whole people are more sympathetic and understanding, which rather rankles, as i do not like being placed in a position whereby people have cause to exhibit sympathy. i would much rather be the dispenser of sympathy than the recipient. on many occasions i have preferred to be thought arrogant, a fool,. or simply mad, 2 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) rather than reveal the fact that i stuttered or that i stuttered badly, for in normal speech, not resorting to monosyllables, it is practically impossible to hide a stutter completely. also i have let people think a statement of mine means one thing, when i meant something totally different, rather than have to explain myself and stutter over the explanation. one recent example of the misunderstanding caused by my stutter happened at university. a girl in my class, whom i rather fancied, was wearing a low necked blouse with a star of david very much in evidence round her neck. referring to the medallion, i asked her pleasantly whether she was advertising. to my consternation she misunderstood the remark and rather than have to stutter the explanation — at that time she did not know that i stuttered — i left her with a totally erroneous impression of my harmless little remark. there are many such examples of times i have awkwardly kept silent whilst with people, being though a boor because of my taciturnity. i have also agreed with complete lies to escape the embarrassment and bother of "stutter-explaining". being "imperfect in speech", i have set myself a very high standard of "perfection" which even a superman would find taxing. every success is deprecated, but failures are magnified out of true proportion, and of course blamed on my stutter. what ingenuity is evidenced in blaming even moderate success on my stutter! if i had not stuttered the success would have been far greater. this preciosity is perhaps the most lasting and far-reaching effect of my stutter. perhaps i can learn to live with the physical fact of my stutter, but unless i revise my thinking very radically, psychologically i will never be able to make the most of my opportunities and become adjusted to the restrictions imposed by my handicap." in the writer's opinion, peter's paper reflects an intellectual insight and appreciation of his problems. it also seems to indicate a growing awareness of the need to face up to and accept the fact of his stuttering. once he has achieved this, the path of therapy should be easier. summary an intelligent 18-year-old male stutterer, who attends the speech clinic, university of the witwatersrand, was asked to write on his experiences as a stutterer. as his paper, in the writer's opinion, contains meny insights and a change of attitude, it was presented in the hope that it would be of interest to therapists in the field. an outline of his case hisory, together with a brief outline of the type of therapy given, were included to place his contribution in context. opsomming 'n intelligente, agtienjarige hakkelaar, wat by die spraakkliniek van die universiteit van die witwatersrand behandeling ontvang, is versoek om sy ondervindings as 'n hakkelaar te beskryf. aangesien sy beskrywing, volgens die opsteller se mening, -n insig in sy probleem en 'n verandering van houding toon, word dit aangebied met die hoop dat dit van belang mag wees vir terapeute op die gebied. 'n oorsig van sy gevalsgeskiedenis, tesame met 'n kort oorsig van die terapie toegepas, is ingesluit om 'n geheelbeeld van sy bydrae te gee. references. van riper, c. "speech correction — principles and methods". prentice-hall inc., new jersey. revised edition — 1954. booklet. "on stuttering and its treatment". report of a conference held at nassau, bahamas in jan. 1960. sponsored by the speech foundation of america. december, 1962 journal of the south african l o o p e d i c society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pdf file abstract introduction methods results discussion inter-rater reliability scoring criteria conclusion acknowledgements references appendix 1 about the author(s) mari viviers department of speech-language pathology and audiology, university of pretoria, south africa alta kritzinger department of speech-language pathology and audiology, university of pretoria, south africa bart vinck department of speech-language pathology and audiology, university of pretoria, south africa marien graham department of statistics, university of pretoria, south africa citation viviers, m., kritzinger, a., vinck, b., & graham, m. (2017). preliminary psychometric performance of the neonatal feeding assessment scale. south african journal of communication disorders, 64(1), a163. https://doi.org/10.4102/sajcd.v64i1.163 original research preliminary psychometric performance of the neonatal feeding assessment scale mari viviers, alta kritzinger, bart vinck, marien graham received: 21 may 2016; accepted: 22 sept. 2016; published: 30 jan. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract objective: the objective was to determine the preliminary psychometric performance of a new clinical feeding scale to diagnose oropharyngeal dysphagia (opd) in neonates. methods: twenty neonates with a median gestational age of 35 weeks were evaluated using the neonatal feeding assessment scale (nfas) and modified barium swallow studies (mbss). the results were compared. results: nine of the 20 participants presented with opd on the nfas. comparison of the scale’s results with instrumental mbss indicated that all participants without opd were correctly excluded (100% sensitivity). the specificity was 78.6%, indicating that three participants were falsely identified with opd on the scale. inter-rater reliability was determined on 50% (n = 10) of the sample. substantial agreement (80%) was obtained between two raters in five of the six sections of the scale and on the diagnostic outcome. conclusion: the preliminary performance of the scale appears to be promising. a further validation study will take place. introduction in a developing country such as south africa there is a need for valid clinical assessment instruments for use by local speech-language therapists (slts) in neonatal dysphagia (viviers, kritzinger & vinck, 2016). such a need was also identified by botha and schoeman and indirectly implied in the south african practice guidelines for paediatric dysphagia, as no standardised clinical assessment instrument is recommended to use with neonates (botha & schoeman, 2011; sashla, 2011a). due to a lack of regulated service delivery and instrumental assessment equipment available for diagnosing dysphagia in the public healthcare sector, comprehensive clinical assessment may be even more important in developing countries such as south africa than in developed countries. a limited number of slts experienced in the administration and interpretation of modified barium swallow studies (mbss) or fiberoptic endoscopic evaluations of swallowing are practising in the public and private healthcare sectors. since objective assessment measures were encouraged there has been a rise in demand for mbss in the paediatric population, but inadequate radiology infrastructure remains a concern (hiorns & ryan, 2006). pados, park, estrem and awotwi (2016) found a lack of validated feeding assessment scales for infants younger than 6 months that are supported by high level evidence in a recent review. they concluded that the early feeding skills assessment instrument (efs) was one of the instruments that had some supportive psychometric development and testing in the neonatal population. however, no supportive data on the content validity offered by experts in the area of neonatal feeding for the efs has been published. two additional instruments with the most extensive psychometric testing are the neonatal oral motor assessment schema (nomas) (palmer, crawley & blanco, 1993) and the schedule for oral motor assessment (soma) (reilly, skuse & wolke, 2000), which focus on oral motor skills of the neonate and infant (pressman, 2010; rogers & arvedson, 2005). these two scales do not consider the impact of environmental and internal disruptions on the infant’s physiological subsystems and its resulting effects on the feeding process and mother–infant interaction. in comparison, the efs aimed to assess oral feeding readiness in a more holistic manner. it is thus recommended that a wider range of infant systems and feeding skills should be evaluated in a comprehensive neonatal clinical assessment instrument than was included in the discussed instruments. because neonatal dysphagia services are an important component of early intervention, an assessment instrument should incorporate the principles of family-centred developmentally appropriate care, an asset-based approach, team collaboration and evidence-based practice (asha, 2008; ensher & clark, 2009; gooding et al., 2011; saslha, 2011b; thoyre, shaker & pridham, 2005). as the parent’s first and enduring caregiving task after birth is to feed the infant, the primary caregiver should be central to the dysphagia assessment process. the value of parental description of the feeding difficulty and observation of a typical feeding routine between the mother and infant during clinical assessment may hold direct benefits for parental compliance during intervention. in contrast, during a mbss the parent may not be elete central to the assessment procedure. to respond to the need for a valid neonatal dysphagia assessment instrument for use in resource-constrained developing countries, the neonatal feeding assessment scale (nfas) was developed and approved, using expert collaboration through the delphi method (viviers et al., 2016). panel members agreed on a need for a validated nfas. south african panel members favoured a comprehensive instrument while international members contributed to evidence-based item inclusion and the use of an objective scoring system (viviers et al., 2016). clinical assessment will never replace the gold standard of mbss but may contribute significantly to complex clinical decision-making in neonatal dysphagia. the research question posed for the current study was, ‘what are the preliminary psychometric properties of the newly developed nfas to diagnose oropharyngeal dysphagia (opd)?’ methods aims and objectives the aim of the study was to determine the preliminary psychometric performance of the nfas to diagnose opd. the objectives were to determine the sensitivity, specificity and accuracy of the nfas in comparison to the mbss and to verify inter-rater reliability. design a comparative within-subject design (meline, 2010) was used to investigate the psychometric properties of the nfas by comparing the nfas and mbss results. participants neonates admitted to a 29-bed neonatal intensive care unit (nicu) at a tertiary academic hospital in gauteng province, south africa, were purposively selected. mothers were verbally informed of the study and through a brochure in english, setswana or afrikaans, the most prominent languages spoken in the city where the study was conducted. written or verbal (in case of illiterate participants) informed consent was obtained from all mothers. twenty neonates were selected. the participant inclusion criteria were that the neonate should have a high-risk status such as prematurity, low birth weight (lbw), exposure to hiv or another risk factor (e.g. craniofacial anomaly), predisposing the neonate to feeding and swallowing difficulties; be an in-patient in the nicu; be medically stable for assessment as determined by the treating physician; be within the age range of > 32 weeks gestational age to 4 months corrected age post-term at time of assessment. neonates younger than 32 weeks gestational age are expected to display feeding and sucking difficulties as a result of immaturity and are typically not fed orally; they were not included. participant characteristics are presented in table 1. table 1: participant characteristics (n = 20). according to table 1 the participants were born at a mean premature gestational age of 35.15 weeks (sd = 3.066). the mean birth weight of the participants was low, 2.17 kg (sd = 0.845) and the mean length of stay in the nicu was 6 days. additionally, the sample consisted of slightly more female participants (60%). other risk factors contributing to feeding difficulties were hiv exposure in utero or during delivery (30%, n = 6), respiratory distress syndrome (55%, n = 11) and hyperbilirubinaemia (55%, n = 11). prematurity (80%, n = 16) and lbw (85%, n = 17) were the most significant known risk factors for opd (pados et al., 2016). materials the newly developed feeding scale (nfas) and an mbss data collection form (based on arvedson & brodsky, 2002; hall, 2001; swigert, 2010) were used. the mbss form indicated the stages of swallowing (oral, pharyngeal and oesophageal stages), the presence or absence of any form of dysphagia, and penetration or aspiration in the pharyngeal stage. in addition, a parent interview schedule included pre-, periand postnatal information and a description of the feeding problem according to the parents (based on arvedson & brodsky, 2002; hall, 2001; swigert, 2010). medical records were used for additional information. the development and content of the nfas were discussed in a previous study (viviers et al., 2016). the item selection in the sections of the nfas was based on theoretical constructs related to neonatal and early infant feeding and the clinical assessment of feeding skills. the instrument relies on physiological observations of the infant during feeding, how infant state is influenced by feeding and how feeding may subsequently disrupt a regulated state in the infant with feeding difficulties and an associated display of stress cues (figure 1). figure 1: nfas sections and items. the mbss was performed using a fluoroscope (sysco 19” version multi diagnosteleva fd screening machine from philips, amsterdam, netherlands) with dvd recording capabilities. procedures clearance was obtained from the research ethics committee at the university and the medical ethics committee at the tertiary academic hospital where the study was conducted. the mothers of the participants were interviewed, medical files were reviewed, a clinical feeding assessment was conducted using the nfas and a mbss was performed. the mbss was conducted within 7 days of the clinical assessment. the interviews, medical file review and clinical feeding assessments were conducted by the first author, a qualified slt, and three graduate students in speech-language pathology. all data collectors were trained. training was provided in a 6-hour session on the content, administration and scoring of the nfas. after the training session each trainee was expected to accumulate four practice assessments before data collection was initiated. inter-rater reliability data was obtained for two of the four data collectors (excluding the first author) on 10 infants (50% of sample). two senior slts working at the hospital conducted the mbss while blinded to the infants’ feeding history and diagnostic outcome of the clinical assessments. because feeding is an integrated process, with infant responses in the different sections occurring simultaneously, the order in which sections of the nfas are completed may vary. a breastfeeding session was observed, or the mother was asked to prepare the bottle feed (expressed breast milk or formula) or supplemented breastfeeding with tube feeding if the infant was not fully breastfed. the complete data collection procedures for the nfas are presented in appendix a. scoring instructions for each section are indicated on the instrument. a binary yes or no system is used. the outcome of each section is a yes or no conclusion regarding the possible presence of opd. each section score is transferred to the last page of the instrument, where the overall diagnostic outcome of the assessment is calculated. when a score of three or more yes responses is obtained, the assessment outcome indicates that opd is likely to be present. at least one of the three yes responses required for reaching the final diagnosis of opd must either be obtained in section e or f (viviers et al., 2016). during the mbss a solution of barium sulphate was reconstituted by mixing the powder with the mother’s expressed breast milk or recommended formula. during fluoroscopy the pulsed mode with appropriate collimation was used to limit radiation exposure (hernanz-schulman, goske, bercha & strauss, 2011; scott, fujii, behrman & dillon, 2014). a nuk (bonn, germany) medicpro first choicetm 120 ml infant bottle with a medicprotm disposable thermoplastic elastomer (tpe) teat size 1 was used. participants were positioned with appropriate supported seating in a tumble forms 2 feeder seattm, warrenville, united states. data analysis frequency distributions were calculated for the nfas data. criterion validity was determined by calculating sensitivity (%) and specificity (%) scores based on the comparative data sets. sensitivity determines the probability of the presence of opd, whereas specificity reveals the probability that opd will truly be absent when using the nfas (dawson & trapp, 2004). positive predictive value (ppv) and negative predictive value (npv) indicate whether the nfas predicted the true positive and true negative diagnoses correctly (dawson & trapp, 2004). the higher the percentage score derived for ppv and npv calculations, the better and more valid the predictive ability of the instrument (dawson & trapp, 2004). cohen’s kappa with accompanying asymptotic standard error (ase) was used to investigate the inter-rater reliability coefficient, together with p-bar calculations for the results obtained by two independent raters. the interpretation of the inter-rater reliability calculations (kappa) according to dawson and trapp (2004) and landis and koch (1977) are provided in table 2. a kappa value of greater than 0.41 was considered a minimal reliability criterion (dawson & trapp, 2004). accuracy of agreement between the nfas and the mbss diagnosis of opd was also investigated. table 2: interpretation guidelines for kappa values for inter-rater reliability. results neonatal feeding assessment scale results the nfas was administered on a sample of 20 participants to determine preliminary psychometric properties. the clinical assessment results were compared to the mbss results to determine which participants presented with true opd. table 3 presents the data obtained from the nfas assessment. table 3: nfas results (n = 20). according to table 3 nine infants (45%) presented with opd on the nfas. positive identification of opd could be explained by the participant characteristics (see table 1) and the previously stated associated risk factors in the sample. as per scoring guidelines, the nine participants obtained a minimum score of three yes responses in the five sections, with one of the yes responses in either section e or f of the nfas. in sections c (stress cues during feeding) and f (clinical feeding and swallowing evaluation) the highest number of indicators were observed in those neonates diagnosed with opd. some of the neonates were not attached to heart rate and respiratory monitors. therefore certain items could not be scored in sections a and b (physiological status and state of alertness), resulting in low scores in the combined section. as a result of the low scores in the physiological status and state of alertness sections, the contributions of these sections to diagnose opd should be investigated further in a larger sample. the nfas results were then compared to the mbss results to determine validity. criterion validity criterion validity determined the extent to which the nfas agreed with the gold standard (mbss) measuring the same variable. measures to determine criterion validity included the predictive ability, sensitivity, specificity and accuracy of the instrument. the comparative results are presented in table 4. table 4: comparison between the mbss and nfas results (n = 20). sensitivity and specificity when comparing the mbss and nfas outcomes in table 4, all six neonates who presented with opd were correctly identified with the nfas; however, three were incorrectly identified, resulting in a false positive rate of 21.4%. this comparison revealed the nfas presented with a sensitivity of 100% when identifying opd in neonates. the specificity of 78.6% reflects the probability of the nfas to determine that a neonate does not present with dysphagia. predictive diagnostic ability of the neonatal feeding assessment scale the ppv and npv were calculated using the data in table 4. the ppv was 100% (6 / 6 × 100) and the npv was 78.6% (11 / 14 × 100). the higher the ppv and npv (closer to 100%), the better the new assessment scale is at diagnosing opd when compared to the gold standard (parikh, mathai, parikh, chandra sekhar & thomas, 2008). based on the ppv and npv scores the nfas showed adequate predictive ability to determine when opd would be present or absent. it was concluded that among those participants who had opd the predictive ability of dysphagia being present was 100% and among those participants who did not have opd the predictive ability of not having dysphagia was 78.6%. diagnostic accuracy of neonatal feeding assessment scale compared to modified barium swallow studies the overall accuracy was calculated using the specificity and sensitivity data. the accuracy of agreement on diagnosis of opd between the nfas and mbss was 85% (11 + 6/20 × 100). the closer the accuracy score is to 100%, the better agreement there is between the newly developed instrument and the gold standard (dawson & trapp, 2004). the nfas therefore presented with good preliminary sensitivity (100%) (dawson & trapp, 2004). specificity was also considered to be good (dawson & trapp, 2004) at 78.6%. an assessment tool with a high specificity, sensitivity, ppv, npv and accuracy is considered valuable in clinical practice (lalkhen & mccluskey, 2008). the participants not diagnosed with opd on mbss presented with oesophageal dysphagia or normal swallowing ability. apart from the six participants diagnosed with opd on the nfas and the mbss, the mbss revealed additional results as expected. based on mbss results, 40% (n= 8) of the participants presented with oesophageal dysphagia, 10% (n = 2) had opd co-occurring with oesophageal dysphagia and four participants had normal swallowing. two of the six neonates diagnosed with opd on the nfas presented with this co-occurrence. inter-rater reliability inter-rater reliability for all the sections and diagnostic outcome of the nfas between two independent raters were determined using half of the sample (n = 10). a kappa value of greater than 0.410 was considered a minimal reliability criterion and a p-bar value of 0.50 (dawson & trapp, 2004). the inter-rater reliability calculations of each section of the instrument are presented in table 5. table 5: inter-rater reliability of sub-sections and diagnostic outcome of the nfas (n = 10). the inter-rater reliability for two of the five sections of the instrument demonstrated substantial agreement beyond chance. in the combined sections a and b as well as for section d, the assessment criteria were clear (0.90–1.00 p-bar), therefore rendering the kappa calculation obsolete for these sections. for section c the results indicated only slight agreement, which may be due to the variability of infant state during the feeding process. thus the variability inherent to infant state may have increased the difficulty to evaluate this section objectively. the two raters agreed on the instrument outcome in 90% (n = 9) of the cases. the agreement on diagnostic outcome between the two raters was considered substantial beyond chance with an ase of 0.241 (dawson & trapp, 2004). discussion the preliminary performance of the nfas indicated that it is a valid method of assessing neonatal feeding skills, guiding clinicians to diagnose opd and thereby potentially facilitating early detection and management of opd. according to demauro and colleagues, dysphagia is a significant disorder in preterm infants in developing countries, and valid assessment instruments can compensate for the lack of population-based studies (demauro, patel, medoff-cooper, posenscheg & abbasi, 2011). the prevalence of opd (45%) found in this sample was higher than in some other studies (demauro et al., 2011). in 2014, zehetgruber and colleagues reported a prevalence range of dysphagia in their sample of preterm and lbw infants of 25%–35% (zehetgruber et al., 2014). the higher prevalence rate in this study may not be accurate because prevalence cannot be determined on such a small sample as utilised in this study. the nfas provides more descriptive information on feeding skills, such as detailed information on stress cues and infant state, than the mbss. therefore it may also offer more intervention guidelines to inexperienced clinicians. criterion validity the high sensitivity and specificity of the nfas provide evidence of the ability of the scale to accurately diagnose the presence of opd and in turn to also recognise the absence of opd, rendering very few false positives. there appears to be limited information on the sensitivity and specificity properties of comparable assessments for oral motor difficulties in neonates and infants, such as the efs, nomas and soma (da costa, van den engel-hoek & bos, 2008). the diagnostic accuracy (85%) of the nfas and its good predictive ability (dawson & trapp, 2004) in clinical use showed that the scale is capable of measuring what it intends to measure. as expected of a direct instrumental observational procedure, the mbss gave additional diagnoses. different types of dysphagia exist in neonates, depending on the stage of swallowing that is affected (pados et al., 2016). different types of dysphagia can also co-occur. the mbss diagnosed oesophageal dysphagia and clearly showed the co-occurrence of the two types of dysphagia, opd and oesophageal dysphagia. because the focus of slts is on assessment and intervention of opd, preliminary results indicate that the nfas could serve this purpose. all participants who truly presented with opd were identified. when relying on clinical assessments only in contexts where mbss is not available, the three false positive opd results may not be viewed as disadvantageous. further research is required to determine whether subsequent assessments on the same neonate using the nfas may show different results. inter-rater reliability the preliminary testing of the nfas showed that acceptable inter-rater reliability was present. due to the substantial agreement beyond chance achieved in the inter-rater reliability results, it appears that more than one clinician is likely to obtain the same results when using the nfas. the pre-assessment training and test administration guidelines may be sufficient to support a clinician to obtain consistent results when administering the scale. the nfas compares favourably with other widely used instruments investigating components of feeding skills, such as the nomas (palmer et al., 1993) and the soma (reilly et al., 2000), which presented with good inter-rater reliability for clinical use in neonates and infants older than 8 months, respectively. a 2008 study by da costa and van der schans determined the inter-rater reliability of the nomas ranged from moderate to substantial agreement (kappa: 0.40–0.65) (da costa & van der schans, 2008), although palmer et al. (1993), the developers of the scale, did not test the final scale for reliability. the soma presented with a kappa of <0.75 on a sample of 10 infants, indicating excellent agreement beyond chance (reilly, skuse, mathisen & wolke, 1995). the authors of the efs (pados et al., 2016) stated that intraand inter-rater reliability had been found to be stable and acceptable, but no data were provided to support this statement (da costa & van der schans, 2008). the preliminary results thus indicate good reliability (dawson & trapp, 2004) of the nfas. scoring criteria the weighting of the different sections of the nfas, in contributing to the diagnosis of opd, could not be determined adequately in this study due to the small sample size. it appears that state observation (section b) may be difficult to score due to the fleeting nature of infant states and fluidity between some state changes during a feeding session. simultaneous observation of different feeding skills in the infant is required when using the nfas. while focusing on the oral area to observe aspects such as non-nutritive sucking (nns) and the neonate’s behavioural response to nns during feeding, there may also be subtle stress cues and state changes taking place, with the result that some of the state changes and stress cues may be missed. in premature and lbw infants, state is influenced by a variety of factors, such as energy expenditure and endurance during feeding (arvedson & brodsky, 2002; thoyre, park, pados & hubbard, 2013). nugent, keefer, minear, johnson and blanchard (2007) concurred that the accuracy of state observation requires that clinicians gain clinical experience and attend continued professional development training opportunities in the observation and interpretation of neonatal and infant behaviour. because state regulation not only impacts on feeding but on the full spectrum of infant behaviour, it may not directly contribute to the diagnostic process during feeding assessment. observation of state regulation is, however, recognised in the literature and other studies (browne & ross, 2011; nugent et al., 2007). evaluation of state regulation may help the clinician to support the parent to identify infant states and understand that certain activities are more appropriate while the infant is in one particular state than another. for example, feeding is best supported when an infant is in one of the alert states (stage 4, quiet alert) without showing distress (browne & ross, 2011; nugent et al., 2007). feeding in itself also acts as the initial primary regulator of physiological state, as the very young infant uses primitive brainstem–visceral circuits during feeding as the underlying mechanism for state regulation (browne & ross, 2011). conclusion in summary, neonatal dysphagia will remain a complex problem that requires multidisciplinary, multidimensional assessment and treatment. in order to increase effective management of neonatal feeding and swallowing difficulties, the standard of clinical assessment should improve in developing countries where services are not well regulated. the use of validated neonatal feeding assessment instruments should take priority to support evidence-based practice (miller, 2009; pados et al., 2016). a comprehensive clinical assessment instrument addressing the overall feeding process in neonates that also provides systematic guidance in clinical decision-making for the diagnosis of opd is recommended. the nfas highlights the subtleties of the feeding process and describes procedures of observation and elicitation that should not be overlooked during clinical assessment. multidisciplinary team members and newly qualified or inexperienced clinicians should be able to use such an instrument if sufficiently prompted by the systematic procedures for administration outlined in the tool. the different sections and items in the nfas may assist to describe the feeding profile of high-risk neonates and consequently enable early and accurate clinical diagnosis of opd in the absence of available instrumental assessments in resource-constrained contexts. the validity of an assessment instrument is its real capacity to measure what it proposes to measure. this preliminary attempt at validation of the nfas was performed by comparing it to the mbss. a larger sample will be utilised to determine psychometric properties of the nfas for clinical use in a follow-up study. in addition, the contribution of the different sections of the nfas to the eventual diagnosis of opd in a neonate will also be investigated. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions m.v. was the project leader, collected and analysed data, and was responsible for preparing the manuscript. a.k. was also responsible for preparing the manuscript. b.v. only made initial contributions to research design. m.g. provided statistical support throughout the project. references american speech-language-hearing association (asha). 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(2005). the early feeding skills assessment for preterm infants. neonatal network, 24(3), 7–16. http://dx.doi.org/10.1891/0730-0832.24.3.7 viviers, m.m., kritzinger, a.m., & vinck, b. (2016). development of a clinical feeding assessment scale for neonates in south africa. south african journal of communication disorders, 63(1), a148. http://dx.doi.org/10.4102/sajcd.v63i1.148 zehetgruber, n., boedeker, r.h., kurth, r., faas, d., zimmer, k.p., & heckmann, m. (2014). eating problems in very low birthweight children are highest during the first year and independent risk factors include duration of invasive ventilation. acta paediatrica, 10, e424–e438. http://dx.doi.org/10.1111/apa.12730 appendix 1 table 1-a1: data collection procedures for the nfas. page twelve journal of the south african logopedic society the treatment of habitual dysphonia joan h. van thai, m.b.e., f.c.s.t. from time to time patients consult a laryngologist complaining of hoarseness and loss of voice for which no cause can be found either in the larynx or its nerve supply. indirect, laryngoscopy commonly shows a deficiency in the approximation of the vocal folds, occasionally interference by the ventricular bands during phonation and various other laryngeal dysfunctions. by "loss of voice" they may mean a variety of things, but hardly ever real aphonia; loss of carrying power of voice, restriction of range of pitch, changes in its quality such as huskiness, cracking or harshness all enter into the picture, which is too varied to be described in all its kaleidoscopic manifestations. the patients in question are either professional voice users (in which category one should include amateur performers, and people who do a lot of talking in the course of their work, such as interviewing, telephoning etc.) who find their voices no longer adequate to meet the demands made on them, or people who have become justifiably alarmed about their chronic hoarseness and wisely consult a laryngologist, and in both instances are reassured about their condition, told it is due to habitual misuse of the voice and referred to the speech therapist. much now depends on the importance which the patient attaches to the quality of the voice whether they make use of the services of the speech therapist, available to them free of charge under the national health service, so that the question of expense does not enter into it. the decision may depend on common sense, but it may also be influenced by a psychological overlay of the dysphonia; thus refusal may be due to difficulty in getting time off from work for someone not a professional voice user, or to an unconscious desire to retain the symptom which is of some value to the patient whose dysphonia is of a psychogenic nature. similarly agreement to have treatment may be on a rational basis, the necessity to recover the voice for professional or social reasons, or it may be for the sake of being interesting and satisfying a subconscious urge for attention. those who refuse voice therapy are of no further interest; but a careful assessment of the reason for the vocal dysfunction must be made in those who seek rehabilitation. the situation may be the uncomplicated one of a teacher, public speaker or the like on whose voice special demands have been made without their having been trained to meet these requirements; it may be a singer who has been badly taught, or who has misunderstood his instructor's directions and explanations. these people are in a category where corrective work is required, and. this work is on the borders of normal voice training and "voice therapy": a routine as set out below can be followed. psychogenic dysfunctions can approximate' closely to hysterical aphonia — an unconscious desire to shake off responsibilities, e.g. a headmaster who had, suffered from laryngitis and been unable for that reason to address the end of term assembly began to have recur-1 ring bouts of loss of voice — he carried on with his work with enthusiasm except if addressing the assembled school. (given insight into' his recurring dysphonia he recovered completely with a minimum of direct voice training). in many instances however there is no hysterical element in the voice change, but it is expressive of a state of mind of the patient. normally the voice expresses our feeling; thus in "people in quandaries" of a persistent nature the harsh and cracked, feeble and husky, low constricted or high pitched strident sound reflects their emotional condition, e.g. a harassed housewife who had suffered much grief and worry over a period of two or three years, torn between her duty to a widowed mother and to her husband, her whole posture and facial expression as well as her feeble, croaking voice portrayed her mental stress; indirect laryngoscopy showed that the right vocal fold made a spasmodic abductor movement posteriorly during phonation, though the anterior part and the l.v.c. adducted normally. considerably more in the nature of reassurance and relief from tension by relaxation and freely talking about her troubles was done concurrently with vocal retraining than would be envisaged for cases of vocal dysfunction only due to ignorance of good technique. it would be equally wrong to assume that there must be psychological complications in these cases as it would be to take the opposite view. thus, as in all cases referred for speech therapy, a full case history has to be compiled. it is wise, however much of ones time one devotes to this at the first interview, to take some of the preliminary steps in vocal retraining from the start, since these people usually expect that something be done. to affront the patient at this early stage by too obvious delving would have a very serious affect on rapport, particularly if there are no psychological complications. no harm can be done by doing postural exercises, even if soon after the course of treatment has begun one realizes one is dealing with a psycho-neurosis beyond the scope of the speech therapist, in· that case one should hand over to the psycho-therapist and voice therapy is contra-indicated. in the less serious psycho-^ genie cases a combination of counselling and direct voice correction can safely be undertaken. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society page thirteen the routine of voice correction must include: 1. postural exercises. 2. simple breathing exercises. 3. exercises in projection of the voice. 4. establishing of good habits of voice production in speaking and reading; for singers — also in song. postural exercises it is the posture of the head and neck that is of supreme importance; unless the patient has to stand and speak, and must therefore acquire a good stance, it simplifies matters to do these exercises seated. a mirror allowing him to see head and should is essential. there is invariably misplaced effort, even though where there is failure in adduction of the vocal folds the first impression is the opposite; the deficient adduction may be due to activity of the abductors, contrary to the law of reciprocal innervation, when these should relax. let the patient be seated on a chair that offers good support to the thighs and the back, without tilting the head forward or back.· 1. ensure that the chin is held at the correct angle; commonly it is tilted slightly upwards, sometimes it is pushed forward as well; occasionally, but not very often, the chin is tucked in. stand behind the patient, take his head between your hands and firmly but gently move it from side to side, down and up in a forward direction, and finish with the head held straight, chin on a horizontal plane. let the patient bring the back of his fingers, held straight, under the chin to feel the position; care must be taken he does not tilt his hand up to meet the chin if he happens to be holding the chin thus. gradually he must learn to do without looking in the mirror or feeling the position of the head with his hand, and become aware whether he is holding his head straight wtihout strain, witout such aids. 2. let the patient bend the head forward and straighten it again, | several times running. this to be done without jerks, j and at a moderate pace. 3. negative practice—bend head forward; straighten; crane a little; straighten again. the craning phase must be much shorter than each of the others. 4. jaw exercises — patient places a hand on either cheek and gently strokes downwards bringing the mandible down and so opening the mouth about an inch. close again and repeat several times. open and close jaw effortlessly without stroking. (chewing exercise as recommended by e. froeschels should also be done.) breathing exercises no elaborate breathing exercises need be done, except possibly by singers and those who have to speak in large auditoria. there is every likelihood, however, that these patients have some unpropitious habits, such as raising the shoulders, over-breathing or keeping the thorax rigid; nearly all will exhale with a fricative sound (not a consonant) which indicates constriction of the pharynx or oral cavity, when they breathe out through the open mouth. n.b.—be sure that they open the mouth in the manner practised under jaw exercises, neither too little nor too much; do not allow them to close the mouth till the end of the expiratory phase, unless practising breathing out with formation of speech sounds, such as m. 1. place hands on sides, just below the sternum, with finger tips meeting. no pressure to be exercised by the hands. breathe out through nose as a preliminary, fingers will overlap a little. now breathe in to a count of two, out for two; both through the nose. the hands are there to feel the lateral movement; watch for shoulder heaving, swaying of the torso and other useless extraneous movements. 2. breathe in throygh the nose, out through the mouth, silently. take the exercises at the normal respiratory rate of about 17 to the minute. 3. slightly prolong the expiratory phase, but leave the inspiratory as before. 4. while breathing out change the position of lips and tongue, as if you were about to whisper "a-u" three or four times running; vary the exercise with "a-i" but still make no sound. 5. allow the breath to "pour out" audibly without friction, for the same vowel series. "ha-hu, ha-hi"* (n.b.—do not use the word whisper to the patient, for he will certainly start to use a forced whisper if you do. do not encourage audible exhalation with the articulatory organs static, this is more likely to lead to strain, and these exercises are preparatory to training in voice projection, which is similarly better done on a series of syllables than on a single vowel.) *a random pattern of vowels may prove satisfactory taken with the chewing technique. humiming 1. find a note comfortably about the middle of the patient's range. let him hum "mmm" softly for two seconds or so, placing a finger on the lips the while to feel the vibrations reaching them. 2. prolong the humming a little growing louder and r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) page fourteen journal of the south african logopedic society then allowing the sound to diminish again. pluck the lip while doing so, and a "twanging" sound should be heard if the voice is well projected, with full nasal resonance. it is possible to miss the twanging in spite of satisfactory resonance if " n " is being sung instead of "m", however.) in the case of singers who have learned a wrong technique it is better to practise on speaking glides at first instead of on a sung note. similarly there are people who believe they are unable to sing and demur at sung exercises, for whom speaking glides only should be used. 3. either hum on a series of singing notes, or on a spoken glide on "m". for singers gradually increase the range of the notes up and down the scale. other voice projection exercises. 4.. open mouth, as practised before, and sigh out gently on a descending glide. no hard attack (glottal stop) no scraping. : gradually reduce the sighing element and emit " a " or another vowel on a descending or ascending glide without constriction in any part of the vocal apparatus. 5. using " m " as initial, practise a series of syllables with the vowels practised during breathing exercises, "ma-mu, ma-mu, ma-mu" "ma-mi, ma-mi, ma-mi" "ma-mu-ma-mi, ma-mu-ma-mi". 6. proceed to words with similar sound patterns e.g. english dutch may moon mijn moe my man mijn man sentences my mother made some de molenaar maalt nie marmalade/ one morning/ meer/ voo r maandag/ last month. maar mijn meel is op. the common error of constricting the voice at the end of a sentence can be overcome by the following simple device — pretend you are going to say a word or two more but donot say them aloud. in the above practice sentences the patient is told the words up "to the second stroke, but instructed only to speak those up to the first stroke "marmalade" or "meer" aloud, and say the rest "in his head". next tell them the remainder of the sentence, allow them to speak aloud to "morning" or maandag", but say the rest in their heads. finally allow them to speak the whole sentence, but still keep up the pretence that there is a word or two to follow. 7. practice on words of little importance. induce the patient to transfer his technique, so far depending on the propitious initial m, to other words and phrases. in order to avoid any strain that may be set up by an earnest attempt to remember the words of •the. exercise, it is best at this point to use such devices as counting, repeating the names of the days and months, familiar telephone numbers, conventional phrases of greeting etc. the device "think another word'is to come" can again be used, e.g. count to ten but imagine you are going on to eleven; say "good morning" pretend you were about to say "good morning, sir" and change your mind about "sir". reading aloud. this is a useful medium for establishing correct habits, but it has many pitfalls. for those who are not accustomed to reading aloud it is unpropitious, since it causes stress militating against the use of their new technique, and if they never will have to readaloud in their daily life it is purposeless to practise the art. for those who are accustomed to read aloud there is the pitfall of an acquired special reading voice, so that such .practice causes relapse, thus it should be postponed till the last stages of rehabilitation of voice. speeches. these can be more safely introduced at the intermediate stage. the subject matter will depend on the interests of the speaker — ranging from the retelling a film recently seen to an expert snort lecture on biochemistry. material to learn by heart. particularly where reading aloud is to be avoided and where there is little originality of thought for speeches, it is well to provide practice sentences of all kinds, and rhymes to suit the individual, but always short ones so that there is no effort to remember them. when the patients have reached a point where they are quite sure of using the right technique and have shaken off wrong •habits, allow them to go to teachers of speech or song if they wish tp improve further or to learn to address audiences. the speech therapist must emphasize that 1 shouting does not make for audibility, but correct projection does and clear articulation is needed for intelligibility. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 82 sajcd • vol 57 • december 2010 cpd december 2010 1. low health literacy/recall skills and intercultural differences may affect clients regardless of their: a) socio-economic status b) age c) race d) all of the above. 2. almost all the interventions that aim to maximise health literacy and ability to recall clinical information: a) are too expensive and time consuming to implement b) are complex and need to be designed to meet each individual client’s needs c) are too modern and won’t be easily accepted by clients d) are only for use by clients who are technology-orientated. 3. true (a) or false (b) – click on the correct answer: health literacy refers to the extent to which individuals can effectively obtain, process, and understand health information in order to make appropriate decisions about their (or their child’s) health. 4. assessment of children’s speech in south africa: a) is a challenge because of a lack of resources in all languages b) should always occur in english and afrikaans c) should always occur in the speech-language pathologist (slp)’s first language d) is something that most slps feel very confident about. 5. parent involvement: a) is seldom used by slps working with children’s speech in south africa b) is optional in bowen and cupples’ (2006) pact programme c) is best encouraged through home programmes d) was used by most slps in the survey carried out in the western cape, as well as in a british study by joffe and pring (2008). 6. the most desirable emergent literacy areas to assess are: a) alphabet knowledge and concepts about print b) those that contribute to and are predictive of later reading and writing, and are amenable to change through intervention c) representations of the orthography of written language and name writing – invented spelling d) oral language, including syntactic, lexical and narrative abilities. 7. true (a) or false (b) – click on the correct answer: the combination of limited proficiency in the language of education, minority status and a low socio-economic status is reported to be a strong predictor that a child will fail to learn to read and write well. 8) self-identities are based on: a) other people’s reactions to individuals b) the meaning attributed to individual characteristics c) individuals’ understanding of themselves d) early life experiences . 9. self-identities: a) occur in isolation only b) may co-exist in varying relationships c) remain static throughout an individual’s life d) are always in conflict. 10. roeper (2004) states that teachers should attempt to remove the ambiguities for english additional language learners by establishing linguistic contexts that support and make these skills contextually clear. measures that teachers may use to assist learners include: a) repetition, explanation, giving examples, visual supports b) drill work c) reinforcement d) recitation. 11. language skills that develop during the foundation phase are important for academic development and teachers can therefore play a role in the effective learning of academic language. teachers in south africa: a) are trained to develop language learning skills b) are too busy to work on language learning during classroom teaching c) may be unaware of this responsibility as well as lack the necessary training d) can access speech-language therapists to assist in classroom language intervention. 12. knowledge acquisition at an ‘awareness level’: a) is the lowest level of knowledge acquisition b) can change practices c) improves outcomes d) is easily translated into practical situations. 13. teacher confidence is directly related to teacher competence and their ability to facilitate learning. a) high levels of confidence may negatively impact on teaching b) high levels of confidence are a positive attribute and may benefit learners c) high levels of confidence indicate a lack of knowledge d) high levels of confidence indicate a lack of skill. cpd questionnaires must be completed online via www.cpdjournals.org.za. after submission you can check the answers and print your certificate. the south african journal of communication disorders sajcd vol 57 • december 2010 • sajcd 83 the south african journal of communication disorders cpd 14. children with fetal alcohol spectrum disorder (fasd): a) have many areas of weakness related to alcohol exposure b) display negative sequelae of prenatal alcohol exposure, but may also have positive characteristics c) have no protective factors d) have a significant risk profile. 15. children with fasd demonstrate: a) normal language development with the right stimulation b) deviant language development c) different language development depending on alcohol exposure d) language impairment, communication delay, verbosity and possible processing disorders. 16. aural rehabilitation services in developing countries receive low health care priority: a) because there are less people with hearing loss in developing countries b) due to competing health care demands from diseases with high mortality rates such as hiv/aids c) because training in aural rehabilitation is a problem d) due to poor awareness among professionals. 17. a south african sample of hearing aid users reported: a) no benefit from hearing aids in the majority of cases b) benefit only with binaural hearing aids c) general satisfaction and benefit from hearing aids d) no limitations to participation after using hearing aids. 18. hearing impairment: a) affects quality of life, as it may have an adverse effect on physical, cognitive, emotional, behavioural and social functioning b) is an exclusive feature of an individual c) affects individuals regardless of the environment d) requires audiological rehabilitation only. 19. professional voice users include individuals who are directly dependent on vocal communication for their livelihood. these individuals include: a) factory workers and teachers b) singers, actors, teachers and clergy c) doctors, accountants and lawyers d) labourers, domestic workers and office assistants 20. teachers are at risk for developing voice disorders. factors that affect teachers’ vocal hygiene include: a) the fact that the majority of teachers are female b) stress related to the teaching environment c) poor awareness of voice problems d) large numbers of students and classroom design requiring teachers to use a loud voice for extended periods and in potentially dusty environments. tongue troubles • ϊς s.b. v, renen. my first experience of tongue troubles begins during a reading lesson when i was brought out to the front of my class at a junior school and asked whether i was trying to annoy ray teacher or attract attention by reading in such a hesitant and tense manner. when i was unable to give a satisfactory reply it was taken for granted that i was just being awkward and i was beaten before the whole class and ordered to stop "stuttering". prom that point onwards i took the-same path as hundrede of perfectly normal "stutterers" had taken before me and, however much i regret it, others will continue to suffer unless an attempt is made to change the attitudes and policies, the evaluations, of parents and teachers concerning the child as a person and speaker. prom that moment onwarde i apparently ceased to be a "normal" child to so-called "normal" people, and i was looked upon as somebody quite different. in fact i was looked upon as a stutterer. at high school teachers soon realised that in standard vii there was a stutterer, who thue had to be handled gently. i wae never to be asked to read aloud or recite in fact my stutter was to be made as obvioue as possible to all the others in the class. fortunately for me i was. able to hold my own amongst the boys as i excelled at sport. if i could not speak normally to my superiors (i never stuttered otherwise) i could at least run faster, or tackle better than anyone else my age, which gave me some sense of satisfaction and c onfi dene e. everything went on quite normally until i left school. i was a stutterer well enough by now everybody knew it in spite 5 ^em jpretending that they did not. then something happened which brought my "stutter" horribly to the forefront, bince myj childhood days i always had the ambition of one day becoming a soldier. i had been at school during the war but by now i had annexed a matriculation certificate, two athletic: records and a fine testimonial, i accordingly applied for admission to an officers' cadet course. my application was accepted and i was called before a selection board. i remember entering the room feeling confident and at ease but all of a sudden i found myself face to race with a major general. he asked me a question and i , opened my mouth to answer, but i was concentrating more on the thought "don't stutter now or show him that you are at stutterer" than the reply to his question. the result r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) . rejected as unsuitable for training as an officer. here i was brought face to face with the truth i was a stutterer. could anything "be done about it? i racked my brain, i read books;· in fact, i even thought of doing away with myself. then i was referred to a speech therapist. it was not long before i was walking into shops and asking the prices of different articles definitely faking as i asked, though it required some courage in the first instance. i was beginning to face up to my problem more objectively as i stopped trying to hide the fact that i stuttered from others. slowly it dawned on me that if i walked up to a person and stuttered yes, stuttered as if it· was the most common thing in the world he would not notice that there was anything particularly defective about my speech, and would therefore not react differently towards me. to prove to myself that it was the way i reacted to people first that mattered i purchased the most "zoot" tie (yellow with pink elephants) and colourful socks, which i wore to a party soon afterwards. as i entered the room i could feel the people looking at the tie but i reacted as if everything was perfectly normal the result nobody even remarked about my tie. as i sat down i made sure to show my socks, and one girl burst out laughing at them. i asked what the joke was, and then she suddenly seemed to come to her senses, as she could not answer me. that evening was certainly a triumph for me, slowly but surely i was gaining confidence. if i could wear that tie without myself feeling conspicuous, it would be accepted as part of me. if i therefore stuttered without feeling ill at ease or self conscious it would be accepted as my manner of speech. i enrolled at a public speaking class next and the first evening everyone had to rise and say why he had come to the class. the first said that they found it necessary for business purposes to be able to talk fluently and easily in public, etc. then came my turn no worrying about stuttering this time i faked for an extra long period on my first word and watched all th<p faces turn towards me. some became uneasy in their seats,!as i went along but that was just what i wanted; for years i had always been the one to tense up. they seemed quite bewildered as i went on to explain that i had joined the class in order to familiarise myself with public speaking. that a stutterer wanted to learn public speaking seemed too absurd for.them, until i explained that it was only by such means that i could rid myself of the tenseness which every stutterer experiences. everybody speaks in a. hesitant manner at times but only the stutterer becomes tense, i am re-applying for admission to the cadet scheme, and although i may be rejected again, it will certainly not be because of my belonging to the company of moses, charles lamb, r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 19. king george vi and somerset maugham to mention "but a few "stutterers". editor's note; mr v. renen received treatment for 15 months at the pretoria hospital. his success in overcoming his stutter was largely due to his own courage and persistance, and the insight which he gained into his problem. during this period he "became interested in starting the pretoria demosthenes (stutterers') club, of which he was elected chairman, a position which he filled admirably. we hope his experience will prove stimulating and encouraging to our readers and we wish him every success for his future. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a l i n g u i s t i c a p p r o a c h t o t h e d e t e c t i o n o f m i n i m a l l a n g u a g e d y s f u n c t i o n in a p h a s i a claire p e n n , b.a. (sp. & h. therapy) (witwatersrand) department of speech pathology and audio logy, university of the witwatersrand, johannesburg summary linguistic tests, based on an expressive language sample and clinical tests of aphasia, were administered to a minimally impaired aphasic subject in an attempt t o compare their relative utility and sensitivity. tests based on a linguistic framework were found to be far more sensitive to the errors in the subject's language than traditional clinical tests. specifically, the linguistic tests isolated difficulties with the processing of d e e p structure relations of c o m p l e x sentences. various reasons for the results are suggested and s o m e points are made regarding the validation of theoretical constructs through aphasic language data. a suggested m o d e l for the classification, testing and therapy of aphasic disorders, based on linguistic theory, is postulated. opsomming 'n minimaal afasie pasient is onderwerp aan linguistiese toetse, wat gebaseer is o p 'n ekspressiewe taalmonster en kliniese t o e t s e van afasie. daar is g e p o o g o m onderskeidelik die bruikbaarheid en sensitiwiteit van die t o e t s e te vergelyk, daar is gevind dat toetse wat o p 'n linguistiese raamwerk gebaseer is, meer sensitief is t.o.v. van die foute wat in die taal van die proefpersoon v o o r k o m , in vergelyking met die konvensionele kliniese toetse. die linguistiese toetse het meer probleme t.o.v. die verwerking van diep struktuurverwantskappe van gekompliseerde sinne uitgelig. verskeie motiverings vir die resuitate, sowel as aspekte betreffende die geldigmaking van teoretiese samestellings deur afatiese taalgegewens is aangevoer. 'n voorgestelde patroon vir die klassifikasie van afasie, wat o p linguistiese teoriee gebaseer is, is gepostuleer. during t h e past few years, t h e t h e o r y of g e n e r a t i v e g r a m m a r a n d experim e n t s based o n this t h e o r y have d o n e m u c h t o increase o u r k n o w l e d g e of t h e s t r u c t u r e o f n o r m a l language. it has b e e n s h o w n t h a t s u c h an a p p r o a c h has had p a r t i c u l a r l y valuable a p p l i c a t i o n in t h e testing of language c a p a b i l i t i e s . o n l y very r e c e n t l y has it b e e n suggested t h a t t h e s e m e t h o d s m a y also p r o v e useful in t h e area of language p a t h o l o g y , n o t a b l y , a p h a s i a . t h e t h e o r y of g e n e r a t i v e g r a m m a r p r o p o s e d originally b y c h o m s k y 2 is based o n t h e fact t h a t t h e s p e a k e r of a language can p o t e n t i a l l y c r e a t e a n d u n d e r s t a n d an u n l i m i t e d n u m b e r of s e n t e n c e s . t h i s a b s t r a c t c a p a b i l i t y is referred t o as t h e c o m p e t e n c e of a s p e a k e r a n d is c h a r a c t e r i z e d as a s y s t e m of rules w h i c h can g e n e r a t e an infinite n u m b e r of s e n t e n c e s in a language a n d assign a s t r u c t u r a l d e s c r i p t i o n t o e a c h s e n t e n c e . this s y s t e m o f rules of linguistic d e s c r i p t i o n c o n s i s t s of t h r e e m a i n c o m p o n e n t s t h e s y n t a c t i c , s e m a n t i c a n d p h o n o l o g i c a l c o m p o n e n t s . 2 · 6 · 8 · 1 4 tvdskrif van tlic suid-afrikuanse vereniging vir spruak cn gi'lioorhcrlkiinde, vol. 21, dcscmber 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 claire penn the syntactic component which is viewed as the central device in the grammar, generates the sentences of the language, assigning to each both an underlying phrase-marker (which represents the deep structure of the sentence) and, by means of transformational rules, a derived phrase-marker (which represents the surface structure). the meaning of the sentence is derived mainly from its deep structure by means of semantic rules of interpretation and the phonetic realization (i.e. the sound) of the sentence is derived from its surface structure by means of phonological rules. fig. 1 provides a schematic representation of the model of generative grammar as discussed above and shows how its components are presumably related. syntactic component deep structure surface structure s e m a n t i c a l l y i n t e r p r e t e d d e e p s t r u c t u r e ( m e a n i n g ) p h o n e t i c a l l y i n t e r p r e t e d surface s t r u c t u r e ( s o u n d ) fig. 1. the components of a linguistic description (adapted from fodor et a l . 4 ) studies on the relationship between generative linguistics and aphasia are stillrather limited in number and seem to be more concerned with the validation of linguistic hypotheses than with the more practical issues of aphasia which would concern the language pathologist. for example, aphasic language data has been used to help confirm the reality of the theoretical distinction between competence and performance, the former being what the speaker-hearer actually knows about the language and the latter referring to how he actually uses the language. some findings have indicated that in aphasia competence is intact while certain performance features are not. (see for example, the work of schuell et a l 1 9 , taylor and a n d e r s o n 2 1 , weigl and bierwisch 2 4 ). other researchers feel that aphasia has provided sufficient evidence to warrant a modification of the traditional competence-performance d i s t i n c t i o n 2 6 . further examples of aphasic language being used to validate linguistic hypotheses may be found in the work of linguists such as blumstein 1 , goodglass7 journal of e soth african speech and hearing association, vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a linguistic approach to minimal language dysfunction in aphasia. a n d ' t r a i l l 2 2 who have indicated that aphasic language breakdown is systematic and logical and provides much proof for the distinctiveness of certain rules or levels of the grammar.* . it is evident from the above discussion that while there is an increasing . amount of current research being undertaken on the more theoretical issues of linguistics, as related to aphasic language, there has been a dearth of studies on the clinical application in this area. nevertheless, there seems to be sufficient evidence to suggest that linguistic methodology may contribute a great deal to the clinician's understanding of aphasic language, and provide, in particular, added insight into the classification, testing and therapy of aphasic disorders. methodology can be developed within the framework of generative linguistics that not only provides insights into the nature of the language deficit in aphasic patients, but is also sensitive to the. severity of the aphasia deficit. . , further psycholinguistic studies should be able to develop more precise methods of assessing language deficit in aphasia. (schuell et al.19) the rationale for.the present study stems from the writer's impression that many speech therapists may not be sufficiently aware of the dynamics of language and the factors involved in its comprehension and use. a number of currently used clinical tests of aphasia are apparently insensitive to certain aspects of language breakdown, particularly when this breakdown is minimal in nature. on the other hand, linguistic methods, since,they are so closely related to a model which attempts to account for the entire knowledge a speaker-hearer has about his language 2 , could enable the clinician to test the patient's language in detail and thus assess his abilities more accurately. the present study was thus designed to test the efficacy of linguistic methods for the detection of aphasic impairments in the hope of providing some practical evidence towards an area of cooperation which is as yet rife with theoretical facts, but limited in clinical application. method the aim of this study is to determine the value of tests based on current linguistic theory in discovering minimal areas of language difficulty in an aphasic subject. an attempt will be made to compare such tests with some currently popular clinical tests of aphasia in order to determine their relative utility and sensitivity. * it is interesting to note that m a n y o f the aphasic language studies undertaken recently w i t h i n a linguistic framework have served to confirm the work o n normal language which has cast s o m e d o u b t o n the validity of s o m e of the main constructs of c h o m s k y ' s original theory. for e x a m p l e , aphasic language data seems to confirm the ideas of mccawley (cited b y w h i t a k e r 2 6 ) w h o suggests that syntax and semantics cannot easily be separated in reality and that semantics, not syntax is the central point in the grammar. see also, l a n h a m 1 0 for a discussion of recent linguistic theory. tydskrif van die suid-afrikaanse vi'rt'niging vir spraak en gchoorhcidkunde, vol. 21, dcscmbcr 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 claire penn suhjhcts experimen tal subject the subject, h.j., a white male aged 57 years, was selected for the purposes of tins study according to the following criteria: firstly, he had suffered damage to that part of the central nervous system necessary for language and had displayed evidence of a loss of linguistic skills two necessary criteria for aphasia, according to tikofsky 2 2 . secondly, he had an adequate pre-morbid acquisition of language and damage to the central · nervous system was stabilized. there were no signs of dysarthria or apraxia and little disintegration of intellectual functioning features which commonly confuse characterizations of aphasic language. he could express himself fairly well and make himself understood. this was an important criterion of selection since testing relied on the expressive avenue to a large extent. finally, and most important for the purpose of this study, the subject showed aphasic impairments which were relatively subtle and would thus potentially go undetected by a therapist or doctor relying on clinical tests which are linguistically unsophisticated. his therapist in fact described him as having "totally adequate speech" with no receptive difficulty. control subjects 4 control subjects with normal language and no history of brain damage were selected in order to assess the suitability of the experimental tasks for nonaphasic subjects. a wide age-range (from 12-73 years) was chosen specifically to ensure'that the test items were appropriate for any particular age or intellectual level. till·'. tf.sts κ μ ρ loved i.n τη κ s t u d y in testing the language abilities of an adult who supposedly has full linguistic competence, the number of potential point? of breakdown is extremely large. it would appear virtually impossible and certainly uneconomical to test every aspect of the linguistic system. it was therefore decided that potential areas of difficulty could best be deduced from an expressive sample, which may be considered as a starting point in a linguistic analysis. 1. tests for expressive speech. the tests employed to elicit expressive speech were: / a. spontaneous narrative speech, where the subject was requested to discuss an incident of interest (adapted from l u r i a 1 2 ) . b. two sequences of pictures from the picture arrangement subtest of the wechsler adult intelligence scale where the subject was asked to describe each sequence. c. the description of six pictures chosen from the thematic apperception test — an item used successfully by many authors (e.g. vvepman and j o n e s 2 5 ) to elicit a sample of expressive speech. , journal of the south african speech and hearing association, vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a linguistic approach to minimal language dysfunction in aphasia 2. linguistic tests on the basis of a linguistic analysis of this expressive sample, tests were designed to assess the subject's competence with respect to a specific aspect of the grammar, namely .complex sentences. a complex sentence is one, in generative grammar terms, whose initial phrase-marker contains more than one node labelled " s " (i.e. where there is sentence embedding). an example of such a sentence is: by a series of transformations, this sentence appears in the surface structure as "the man who is happy eats fruit". the types of complex sentences tested in this study were relative sentences and complement sentences. four types of complement sentences and 4 types of relative sentences were tested. table i provides a brief summary of the linguistic features of each type of complex sentence.9 in addition to the 8 types of complex sentences tested, some items were included containing more than one embedding. various methods were used to test the subject's competence with regard to these complex sentences. main tests recall of sentences. in this task, the subject was required to repeat sentences to him orally by the examiner. 25 such sentences were presented, all involving embedded sentences. this method of sentence repetition has been used by several workers as a measure of linguistic competence, (e.g. goodglass7, luterman and b a r 1 3 , m e n y u k 1 7 ) . comprehension of sentences. this method, adapted from w r i g h t 2 8 and l u r i a 1 2 involved asking the subject questions about specific aspects of the sentence presented to him. 27 such items were compiled. additional tests recall of paragraphs. in this test, the subject was required to recall two paragraphs containing a large number of embedded sentences. the hypothesis made tydskrif van die suid-afrikaanse vrniging vir spraak en hoorhkunde, vol. 21, dsmbr 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ° claire penn relative sentences complement sentences (where the embedded sentence is embedded on a np of the matrix sentence and in some way qualifies that np) types examples 1. a sentence the man who embedded on a is happy, eats subject np fruit. where the matrix subject equals the embedded subject. 2. a sentence the event the embedded 011 a paper reports subject np is untrue, where the matrix : subject does not equal the embedded subject. 3. a sentence the man caught embedded 011 an the mole which object.np where had walked on the matrix object his lawn, equals the embedded subject. 4. a .sentence i fed the tabby embedded on an cat the gardener object np where chased. the matrix object does not equal the embedded subject. types examples a. noun phrase complements (where the np is rewritten as a sentence so that the underlying sentence may function as the subject or object of the matrix sentence) 1. where the the fact that sentence james was stuacts as a pid, worried subject. mary. 2. where the mary denied sentence acts that james as an object. was actually stupid. b. verb phrase complements (where the complement sentence is immediately dominated by the constituent vp.) 1. where the mamany students trix sentence tend to avoid equals the emhard work, bedded sentence. 2. where the the fat sermatrix sengeant ordered tence does not the men to equal the emmarch, bedded sentence. / 1 / table 1. descriptions and examples of complex sentences. journal o the south african spe and hearing association, vol. 21, december 974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a linguistic approach to minimal language dysfunction in aphasia with respect to this test was that the subject would recall significantly fewer embedded sentences than normal control subjects. use of words in a sentence. words were given to the subject which optionally or obligatorily take an embedded s e n t e n c e 2 7 and he was asked to use them in a sentence. where possible, he was then asked questions about his own sentence. it was hypothesized that if the subject showed general difficulty with the use of complex sentences, he would, in this task, either avoid the use of an embedded sentence altogether or show breakdown and confusion. performance tests. these tests, which require a non-verbal response were included to ensure a valid interpretation of the subject's verbal responses on the preceding tests. such tests, since they require more concrete responses (e.g. pointing) from the subject than the other tests, were inappropriate for certain types of complex sentences viz. the complement sentences, since these contain abstract relationships which cannot easily be portrayed by visual means. thus relative sentences only were investigated in this test by means of two types of performance response. firstly, where the subject had to carry out 9 commands all containing complex sentences using tokens from the token t e s t 3 . secondly, where the subject had to point to one picture out of a series of 4 which correctly portrayed the complex sentence presented to him by the investigator. four such items were included. control of performance variables all test sentences were controlled for with respect to certain features of a non-linguistic nature known to affect responses on linguistic tasks. this is a very important consideration when attempting to tap the 'competence' of a subject, since it is necessary to eliminate all performance variables. sentence length. all test sentences were balanced for syllable length (10 or 11 syllables each) so that memory factors could be controlled for. control sentences were administered to the subject before testing (i.e. simple sentences without embedded structures) to ascertain the number of syllables the subject could recall and comprehend without difficulty. it was presumed that if difficulty should occur in test sentences, this would be a function of sentence complexity rather than length. abstraction level and frequency. in view of the fact that aphasic patients often encounter difficulty with words of an abstract nature and similarly have difficulty with words used i n f r e q u e n t l y 1 9 , an attempt was made to include in the test sentences fairly concrete words which appear frequently in everyday vocabulary and which were noted to be present in the subject's spontaneous speech.* semantic constraints. in many cases, the comprehension of a sentence is facilitated by the semantic constraints found within that s e n t e n c e . 4 , 1 2 i.e. words which are commonly associated together give clues as to the relation* unfortunately, the feature of abstraction could n o t b e c o n t r o l l e d for as successfully in c o m p l e m e n t s e n t e n c e s as in relative sentences, since the semantic structure of the former involves more abstract attitudinal factors. tydskrif van die suid-afrikaanse vrniging vir spraak en hoorhkunde, vol. 21, dsmbr 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 claire penn •ship between sentence constituents. to control for the possibility of the subject in this study relying on such constraints, these were as far as possible, deliberately avoided so that the subject would rely maximally on grammatical relations within the sentence. an example of such a sentence is "the man who likes squirrels, eats nuts." 3. clinical tests the clinical tests for aphasia used in this study were selected on a pragmatic rather than a theoretical basis that is irrespective of the theories underlying each test and the writer's bias for or against a particular theory of aphasia. instead, the writer consulted some clinicians experienced in aphasia therapy and asked them what aphasia tests they felt to be currently most popular and useful. a further criterion for the selection of these tests was that they should be well standardized and easy to administer. the four tests selected were: a. the minnesota test for the differential diagnosis of aphasia (mtdda) which is a widely-used test that has been standardized on a large aphasic population and is very comprehensive. b. the sklar aphasia scale (sas) which is based on a modern theory of aphasia and is quick and easy to a d m i n i s t e r 2 0 . c. the token test which is purported to be highly sensitive in the detection of minimal receptive aphasic disorders3. d. luria's tests for receptive speech which are currently very popular and test many aspects in some d e t a i l 1 2 . table ii serves to summarize the tests administered to the experimental subject. expressive tests linguistic tests clinical tests 1. narrative 1. main tests 1. mtdda speech. a. recall b. comprehension 2. wais picture 2. additional tests 2. sklar aphasia arrangement a. recall of scale subtest. , paragraphs b. performance 3. tat cards responses. 3. token test ' c. use of words / in a sentence. 4. luria's tests 3. control for receptive sentences. 1 speech. table ii. summary of tests administered to the subject. journal of e south african speech and hearing association, vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a linguistic approach to minimal language dysfunction in aphasia p r o c e d u r e h.j: was tested over a six-week period for a total of about 20 hours, during which time, the expressive, linguistic and clinical tests of aphasia were administered. each interview was tape-recorded and transcribed immediately afterwards. while administering the clinical tests of aphasia, the investigator attempted as much as possible to conform to the test procedures laid down by the respective test manuals. however, during administration of the linguistic tests, there was less strict application of standard test procedures and instructions or test items were repeated where necessary. this was done in an attempt to assess as closely as possible the subject's underlying linguistic competence by eliminating performance variables such as poor attention span and memory, known to affect test responses. the control subjects were tested on linguistic tests only. method of a n a l y s i s responses on both expressive and linguistic tests were analyzed within a framework of generative linguistics. the deep structure relations of each sentence were investigated and the linguistic contexts of irrelevant linguistic features e.g. pauses were noted. results tests for expressive speech on a surface level, h.j's response to the expressive tests confirmed his therapist's diagnosis of "slow, but totally adequate expressive speech." though a few word-finding difficulties were evident, very few errors of syntax or sequencing were noted and speech was fairly fluent. the only consistent feature of this expressive sample was the presence of a number of long pauses. a detailed analysis of the linguistic context of these pauses revealed a systematic breakdown in the subject's expression. it was found that in many cases, these pauses occurred in the position of a sentence boundary within sentences i.e. in complex sentences. for example: • we caught the boat / / which was taking us to madagascar. it was a job / / to get her onto the boat. in phrase-marker terms, the loci of such pauses were thus: (s1//(s2)) and (si (s2)//s1) linguistic tests the results of the linguistic tests confirmed the generality of h.j.'s difficulty with complex sentences. main tests recall. in general, the recall of each type of sentence replicated expression. while a number of sentences were repeated correctly, in many cases, for both relative and complement sentences, a pause occurred in the position one would expect from an analysis of the subject's expressive speech viz. he fretydskrif van die suid-afrikaanse vrniging vir spraak en ghoorhkunde, vol. 21, dsmbr 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 claire penn quently paused at the sentence boundary within a sentence. furthermore, he frequently requested the repetition of the sentences by the investigator before he was able to recall them. with the control sentences on the other hand, (i.e. those containing no embedded constructs), the subject never requested the repetition of a sentence and, furthermore, showed no evidence of the pausing described above. since these control sentences were matched with the test sentences for everything except sentence-embedding, it seems valid to assume that the pauses and the need for repetition noted jn test sentences were thus related to the specific linguistic features of these sentences. comprehension. this task proved to be a highly sensitive detector of linguistic difficulty. for all types of complex sentences, h.j. showed a consistent confusion of the deep relations within the sentence. an example of this is: the girl the thin boy saw was athletic. examiner subject's response was the boy athletic? the boy was athletic. did the girl see the boy? the girl saw the boy. was the girl thin? the girl was thin. was the girl athletic? the girl wasn't athletic. did the boy see the girl? the boy saw the girl. was the boy thin? the boy was athletic so i think he wasn't thin. thus it appears that the subject is showing lack of comprehension characterized by a gross crossing of sentence boundaries. at the same time, he is showing inconsistency i.e. in the same sentence, he indicates that "the girl sees the b o y " and "the boy sees the girl". once again, h.j. repeatedly requested a repetition of the test items. these factors, together with the fact that questions on control sentences were consistently answered correctly and • never had to be repeated, seem to provide further evidence for the hypothesis that the subject's area of difficulty lies in the processing of complex sentences. a d d i t i o n a l t e s t s results of additional tests confirmed to a large ex'tent findings on the main tests. in the paragraph recall task, h.j. recalled only 5 out of a total of 23 embedded sentences (as opposed to an average of 16 with the normal subjects). he tended to avoid a complex sentence where possible when asked to use words in a sentence optionally taking an embedded sentence, and long'pauses were evident when he was given words which obligatorily take an embedded sentence. furthermore, he showed hesitancy and confusion on the performance tasks involving the comprehension of complex sentences. clinical t e s t s the mtdda. h.j. displayed extremely mild errors on this test. of chief interest to the writer were his responses to the test items involving oral and aural language abilities. in the two sections involving auditory skills and speech and language skills, he made i6v2 errors out of a total of 266. the journal, of [lie south african speech and hearing association, vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a linguistic approach to minimal language dysfunction in aphasia majority of these errors seemed to be related to an impairment in auditory retention span. the sas. h.j.'s score on the sas was 5,5% indicating "n o impairment" according to the test manual. the token test. h.j. made only one error out of a total of 51 items on this test. though the authors of this test do not specify the number of errors which need to be made before a subject is considered aphasic, it appears most unlikely that a single error would indicate this. luria's tests for receptive speech. h.j. made 3 errors on luria's tests. one of these errors which occurred in the test for "complex grammatical constructions" involved precisely that sentence construction which was examined in linguistic tests viz. the complex sentence, and thus indirectly confirmed the results of these tests. table 111 summarizes the subject's performance on the linguistic tests and clinical tests for aphasia. linguistic tests results 1. recall of complex sentences. 2. comprehension of complex sentences. 3. recall of paragraphs. 4. use of words in a sentence. 5. performance responses. 6. control sentences. 1. errors made on 1 5 out of 25 sentences. 2. errors made on 20 out of 27 sentences. 3. 5 out of 23 complex sentences recalled. 4. evidence of delay and confusion. 5. errors made on 6 out of 13 sentences. 6. no errors made. clinical tests results 1. mtdda 2. s.a.s. 3. token test 4. luria's tests for receptive speech. 1. "simple aphasia" with most errors in the visuo-motor section. -· 2. "no impairment". 3. 1 error made out of 51 instructions. 4. 3 errors made. table 111. summary of subject's responses on linguistic tests and clinical tests for aphasia. tydskrif van die suid-afrikaanse vrniging vir spraak en ghoorhkunde, vol. 21, dcmbr 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 claire penn qualitative analysis of the subject's responses during testing, the ease with'which h.j. performed on the respective tests was noted, since it was felt that such an observation would help to confirm quantitative results. in general he appeared to find it much easier to respond to clinical tests than to linguistic tests. he completed most items in the former with relative facility and showed little fatigue. on the other hand, he showed consistent difficulty with the linguistic tests — he frequently requested rest periods and many delayed responses were noticed. his comments after testing confirmed the fact that linguistic tests were more difficult. he further reported that he would feel 'insulted' if some of the items from the clinical tests were given to him normally because of their extremely basic nature. responses of c o n t r o l subjects the performance of the control subjects on the linguistic tests was indistinguishable from what one would expect from a normal speaker of english. though the group was small, this was taken as evidence for the suitability of the tests for non-aphasic subjects of differing ages and intellectual abilities. discussion linguistic t e s t s v e r s u s clinical t e s t s the results of this study seem to have confirmed to a large extent the hypothesis that tests based on a linguistic framework are more sensitive in detecting areas of subtle difficulty in-an aphasic patient than some currently used clinical tests. the possible reasons for this are manifold: firstly, one of the most striking features of the linguistic tests in comparison to the clinical tests is that the former were based on a large expressive sample of speech. a linguistic analysis of this sample provided very important guidelines for further testing. the clinical tests on the other hand, provided only limited samples of speech and were thus not adequate for the purposes of a language analysis. the scoring methods on the clinical tests precluded many important features of the subject's performance. for example, some errors on the sas were noted as being 'grammatically inappropriate' but the pass-fail system of scoring ignored the nature of these errors. this appears to be a major shortcoming of many clinical tests if one considers the chief aim of testing to be a detailed description of a patient's language abilities. 1 8 / / the linguistic tests used in this study attempted to assess both the expression and reception of the subject with regard to the grammatical structure in question. this is considered to be of great importance, since only with a knowledge of b o t h avenues, can one hope to gain a near adequate characterization of language c o m p e t e n c e . 2 · 2 1 a shortcoming of the clinical tests (with the possible exception of luria's tests) is that very rarely are the same specific language elements examined in equal depth in expression and reception. it would seem that in such tests, reception is regarded as an entity rather than as an important part of language, in fact more "rudimentary" than expressive language. 2 1 journal of the south african speech and hearing association, vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a linguistic approach to minimal language dysfunction in aphasia thus, though the writer is not suggesting that the clinical tests used here were totally insensitive to areas of difficulty in the subject's language, the reasons outlined above may possibly account for the fact that they were of limited value in detecting the specific areas of difficulty encountered b y the subject viz. an inability to extract or retain the deep structure relations in complex sentences. it is thus not surprising that he reported little difficulty on clinical tests. a linguistic e x p l a n a t i o n of r e s u l t s the question that remains to be answered concerns a linguistic characterization of the subject's difficulties. is the confusion he is showing with complex sentences reflective of a basic lack of competence or can it be related to performance variables? it might be tempting to suggest, as w h i t a k e r 2 6 does, that since the modalities of both reception and expression are involved, the competence is impaired, but such a proposal cannot account for the variability in the subject's responses. he did not show consistent difficulty and his responses were seldom totally incorrect. furthermore, there was evidence of paraphrasing, which according to fodor et a l . 4 , is an indication of intact competence. clearly then, h.j.'s difficulties seem to be related to performance variables. it is less easy however, to specify the actual nature of these performance variables. one possible interfering variable, suggested by workers such as schuell et a l . , 1 9 is a decrease in retention span. according to this theory, h.j. might not be retaining the sentence long enough to recall it or to perceive its deep relations. a further possible interfering variable has been indicated by l e n n e b e r g 1 1 who suggests that faulty 'timing' in aphasia may lead the subject to rely on surface structure rather than deep structure clues for comprehension. though h.j.'s performance may indeed be related to one or b o t h of these performance variables (or many of the others which were not controlled for and which cannot be specified) it is the writer's belief that these variables are not generalized over the entire language as schuell et a l . , 1 9 suggest. rather, they occur within the specific linguistic context of an embedded sentence. h.j. is unable to relate portions of semantic information from one sentence to another when these sentences are in the matrix-embedded relationship. this idea is supported by the fact that he showed no difficulty with the control sentences and lends confirmation to the belief that the " . . . best explanations of performance have come from a consideration of features from the underlying grammar." 2 some t h e o r e t i c a l c o n s i d e r a t i o n s some results of this study have been of interest in helping to clarify a controversial issue arising out of linguistic theory, namely the derivational theory of complexity (dtc). this theory predicts that sentence comprehension involves the diverse application of linguistic rules necessary t o generate a sentence. thus, for example, a subject would take longer to comprehend a passive sentence than an active one since the former is transformationally more complex. tydskrif van die suid-afrikaanse vrniging vir spraak en hoorhkunde, vol. 21, dsmbr 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 claire penn if one considers the adjective in transformational grammar terms, the length of the derivational history of a sentence·is greatly increased by the addition of an adjective before a noun. for example, the phrase "the good m a n " is derived from 3 basic transformations — " t h e man who is good" " t h e man good" "the good man". thus in terms of the dtc, recall or comprehension of sentences containing adjectives would be poorer than recall of a simple sentence, or for that matter, one containing a relative clause only, this supposedly being the first step in an adjective transformation. the dtc would thus predict that h.j. would have great difficulty with sentences containing adjectives. this however, was found clearly not to be the case. even in the token test where commands involve up to 4 adjectives per sentence (i.e. in transformational terms, 12 additional transformations), he showed no difficulty at all. ι in a like manner, h.j.'s performance on test sentences where the relative pronoun or complementizer had been optionally deleted, also proved to be of interest. according to the dtc, a sentence such as "the dog the girl saw was fat." (where the relative pronoun "which" has been optionally deleted) is more complex than a sentence such as "the ball which the boy kicked was blue", (where the relative pronoun is retained). the reason for this is that an additional transformation is involved in the former; in addition deletion of the relative pronoun is felt to eliminate certain surface structure cues which normally facilitate the comprehension of underlying deep structure relations. the dtc would thus predict that h.j. would show more difficulty in sentences where these surface structure cues (i.e. the relative pronouns or complementizers) had been deleted. again this was found not to be the case — h.j.'s performance did not differ significantly, in either case. it seems obvious from the above examples, that we cannot explain certain test findings in terms of the dtc and that for adjectives and the optional deletion of relative pronouns and complementizers anyway, this theory should be viewed with suspicion. this has, interestingly enough, been the general conclusion of experiments involving the language performance of normal subjects 5 . thus the test data, in addition t o helping to confirm that linguistic methods are useful for the study of aphasia, have also provided some insight into an area of grammar and have supported the idea that aphasia can legitimately be used as a testing-ground for linguistic theory, (cf. marshall and n e w c o m b e 1 6 . ) conclusion and implications / on the basis of the data obtained in this study, it may be concluded that a linguistic approach to the testing of aphasia seems to be very useful for the characterization of a patient's language abilities. furthermore it appears that such tests are sensitive to subtle and specific areas of language breakdown and thus seem superior to many clinical tests which often measure a general language ability rather than specific features. test findings have also helped to provide evidence for certain issues arising out'· of linguistic theory. however, there are certain shortcomings to the present study which make conclusions highly tentative and which suggest the need for a great deal of journal of e south african speech and earing association, vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a linguistic approach to minimal language dysfunction in aphasia further research. one aphasic subject only was used, and a highly specific aspect of the grammar was investigated. similarly, tests were limited to the oral and aural language abilities. a linguistic consideration of h.j.'s reading and writing may have helped t o broaden our understanding of his problem. finally, and probably most important, the hypothesis, tests and results of this study were considered within the framework of a theory which is not, as yet, conclusive and which is constantly changing in the light of empirical facts. as such, all conclusions and implications are only as valid as is the theory. nevertheless, the present study has served t o highlight an approach to the classification, testing and therapy of aphasic disorders which appears to be very fruitful. the writer wishes to suggest that the following figure might help t o provide a guideline to the clinician concerned with characterizing aphasic language in generative grammar terms; reception expression competence performance competence performance phonology syntax semantics fig. 2. proposed model for the classification and testing of aphasia such an outline has the following implications for diagnosis, classification and therapy: it suggests that language breakdown may occur on a number of levels, i.e. the three levels of the grammar phonological, syntactic and semantic and that each level must be considered in detail when studying aphasic language; an attempt should be made to assess the subject's reception and expression with respect to these levels and, furthermore, diagnosis should aim at discovering whether the subject's problem is one of competence or performance, using linguistic methods of testing. it has been shown that the experimental subject has a defect of a specific syntactic structure, evident in both reception and expression and related t o performance features rather than a competence breakdown. thus he may be tydskrif van die suid-afrikaanse vrniging vir spraak en ghoorhkunde, vol. 21, dsmbr 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 claire penn fitted.into the appropriate categories of the above model. such a characterization has helped to provide therapy cues for the subject. since reception is basic to expression, this aspect should be worked on initially; since the defect is one of performance and not competence, therapy should involve the teaching of the successful application of the rules, rather than the rules per se. finally, since h.j. has difficulty with a particular syntactic structure, therapy should be concerned specifically with the complex sentence — teaching him how to relate accurately features in the embedded sentence tp features in the matrix sentence.* the above model has helped to provide a highly systematic characterization of the subject's language capabilities which is essential for an adequate therapy programme. in addition, it has helped to reduce the 'confusion in terminology' which is so apparent in the field of aphasia t o d a y . 1 5 although, as mentioned before, there is a great need for further research both in the area of aphasic language and in the area of generative linguistics, the writer feels that cooperation between these disciplines is essential. not only can generative linguistics provide an extremely exciting and valuable contribution to aphasic research, but it can also use the wealth of language data available from aphasia in helping to validate some of the basic theoretical constructs. it is the writer's belief that such inter-disciplinary 'cross-fertilization' will do much to increase our knowledge of aphasic, and,-indeed, normal language, in the years ahead. references 1. blumstein, s.e. (1973): a phonological investigation of aphasic speech. mouton: the hague. 2. chomsky, n. (1965): aspects of the theory of syntax. m.l.t. press, cambridge, massachusetts. 3. derenzi, e. and vignolo, l.a. (1962): the token test: a sensitive test to detect receptive disturbances in aphasics. brain, 3, 665-678. 4. fodor, j.α., bever, t.g. and garrett, m. (1968): the development of psychological models for speech recognition. m.l.t. press, cambridge, massachusetts. * it is interesting to n o t e that the findings in the present study confirm findings in the literature 5 regarding the value of the c o m p l e x sentence as a measure of linguistic c o m p e t e n c e . t h e writer w o u l d suggest that even in cases w h o do not necessarily show obvious b r e a k d o w n in c o m p l e x sentences as h.j. does, the a d o p t i o n of such items in assessing aphasic language (and indeed, other areas of language p a t h o l o g y ) may prove e x t r e m e l y useful. journal of e south african speech and hearing association, vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a linguistic approach to minimal language dysfunction in aphasia ι 5. fodor, j.a. and garrett, m. (1967): some syntactic determinants of sentential complexity. perception and psychophysics, 2(7), 289-296. 6. garrett, μ. (1967): psychological theories and linguistic constructs. m.l.t. press, cambridge, massachusetts. 7. goodglass, h. (1968): studies on the grammar of aphasics. chap. 5 in developments in applied psycholinguistic research. rosenberg, s and koplin, j.h. (eds.) macmillan, london. 8. griffiths, p.d. (1968): a critical examination of competence, unpublished report, dept., linguistics, university of edinburgh, scotland. 9. jacobs, r.a. and rosenbaum, p.s. (1968): english transformational grammar. blaisdell publishing co., london. 10. lanham, l.w. (1973): how do we do linguistics now? a question for academic linguists in the mid-70's. unpublished report, dept., phonetics and general linguistics, university of the witwatersrand, johannesburg. 11. lenneberg, e.h. (1967): biological foundations of language wiley, new york. 12. luria, a.r. (1970): traumatic aphasia: its syndromes, psychology and treatment. mouton press, the hague. 13. luterman, l.b. and bar, a. (1971): the diagnostic significance of sentence repetition for language impaired children. / speech and hearing dis., 36(1), 29-39. 14. lyons, j. (1971): generative syntax. chap 6 in new horizons in linguistics, lyons, j. (ed), pelican, london. 15. macmahon, m.k.c. (1972): modern linguistics and aphasia. british j. dis. comm., 7(1), 54-63. 16. marshall, j.c. and newcombe, f. (1966): syntactic and semantic errors in paralexia. neuropsychology, 4, 169-176. 17. menyuk, p. (1971): the acquisition and development of language. prentice hall, new jersey. 18. osgood, c.e. and miron, m.s. (1963): approaches to the study of aphasia, u. of illinois press. 19. schuell, h„ jenkins, j.j. and jimenez-pabon, e. (1964): aphasia in adults. harper and row, n.y. 20. sklar, m. (1966): sklar aphasia scale .manual. w. psychological services, california. 21. taylor, o.l. and anderson, c.b. (1968): neuropsycholinguistics and language re-training. unpublished report, indiana u. 22. tikofsky, r.s. (1966): language problems in adults. chap. 11 in speech pathology. rieber, r.w. and brubaker, r.s. (eds.). n. holland publishing co., amsterdam. 23. traill, a. (1970): transformational grammar and the case of an ndebele speaking aphasic. j. of the s.a. logopedic soc. 17, 48-66. 24. weigl, e. and bierwisch, m. (1970): neuropsychology and linguistics: topics of common research. foundations of language, 6, 1-18. 25. wepman, j.m. and jones, l.v. (1969): five aphasias: a commentary on aphasia as a regressive linguistic phenomenon. chap 13 in disorders of communication. mckrioch, d. and weinstein, e.a. (eds.), hafner. tydskrif van die suid-afrikaanse vrniging vir spraak en ghoorhkund, vol. 21, dcmbr 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 claire penn 26 27 28 paudiiq bookshop ( p t y ) ltd. lampuo boekhandel (edms) bpk. books y o u s h o u l d possess brown, r. a first language: the earl y stages price r13,30 postage 35 cents. b a r a d o n , α., & leopold (eds.) child language: a book of readings price r12,05 postage 35 cents. t r a v i s , l.e. (ed.) handbook of speech pa tholog y & < audiology <revised) price r25,40 postage 35 cents. c. v a n riper the treatment of stuttering price r10,95 postage 35 cents. k a t 2 , j. (ed.) handbook of clinical audiology price r17,40 postage 35 cents. jerger, j. (ed.) modern developments in audiology' (revised) price r 15,60 postage 35 cents. and other books /en ander boeke: p h i n e a s h o f , phineas court, b e r t h a s t r a a t 3 4 , 34 b e r t h a street b r a a m f o n t e i n , b r a a m f o n t e i n , johannesburg, johannesburg, posbus 31361, , p.o. box 31361, b r a a m f o n t e i n 2017, | b r a a m f o n t e i n 2017, t e l : 724-8541 t e l : 724-8541 whitaker, h.a. (1969): on the representation of language in the human brain. working papers in phonetics 12. ucla, los angeles. whitaker, h.a. (1972): unsolicited nominalizations by aphasics: the plausibility of the lexicalist model. linguistics, 78, 62-71. wright, p. (1972): some observations on how people answer questions about sentences./. verb. learn. verb. behav., 11, 188-195.' journal of e south african speech and hearing association, vol. 21, december 1974 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction oral care aspects for the patient with dysphagia methodology data analysis results discussion conclusion acknowledgements references about the author(s) jaishika seedat department of speech pathology and audiology, university of the witwatersrand, south africa claire penn department of speech pathology and audiology, university of the witwatersrand, south africa citation seedat, j., & penn, c. (2016). implementing oral care to reduce aspiration pneumonia amongst patients with dysphagia in a south african setting. south african journal of communication disorders, 63(1), art. #102, 11 pages. http://dx.doi.org/10.4102/sajcd.v63i1.102 original research implementing oral care to reduce aspiration pneumonia amongst patients with dysphagia in a south african setting jaishika seedat, claire penn received: 28 aug. 2014; accepted: 27 apr. 2015; published: 16 feb. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract oral care is a crucial routine for patients with dysphagia that, when completed routinely, can prevent the development of aspiration pneumonia. there is no standardised protocol for oral care within government hospitals in south africa. this study aimed to investigate the outcome of an oral care protocol. participants were patients with oropharyngeal dysphagia, with either stroke or traumatic brain injury as the underlying medical pathology, and nurses. all participants were recruited from one tertiary level government hospital in gauteng, south africa. 139 nurses participated in the study and received training on the oral care protocol. there were two groups of participants with oropharyngeal dysphagia. group one (study group, n = 23) was recruited by consecutive sampling, received regular oral care and were not restricted from drinking water; however, all other liquids were restricted. group two (comparison group, n = 23) was recruited via a retrospective record review, received inconsistent oral care and were placed on thickened liquids or liquid restricted diets. results showed that a regimen of regular oral care and free water provision when combined with dysphagia intervention did prevent aspiration pneumonia in patients with oropharyngeal dysphagia. the article highlights two key findings: that regular and routine oral care is manageable within an acute government hospital context and a strict routine of oral care can reduce aspiration pneumonia in patients with oropharyngeal dysphagia. an implication from these findings is confirmation that teamwork in acute care settings in developing contexts must be prioritised to improve dysphagia management and patient prognosis. introduction aspiration pneumonia is serious and can be a fatal complication of oropharyngeal dysphagia (marik & kaplan, 2003). aspiration of food, reflux and oral bacteria, as well as oropharyngeal dysphagia itself, contributes to aspiration pneumonia (langmore, 1991). martin et al. (1994) and robbins et al. (2008) confirm a strong association between dysphagia and aspiration pneumonia due to the aspirated material being heavily colonised with bacteria. a complication of the relationship between pneumonia with aspiration and oropharyngeal dysphagia is that not all patients shown via imaging studies to have dysphagia with or without aspiration develop pneumonia (martin et al., 1994). studies investigating water protocols have queried why this would be (becker, tews & lemke, 2008; bronson-lowe et al., 2008; carlaw et al., 2012; frey & ramsberger, 2011; garon, engle & ormiston, 1997; karagiannis, chivers & karagiannis, 2011; nevitt, 2010; panther 2005, robbins et al., 2008; scott & benjamin, 2010). panther (2005) introduced the frazier free water protocol, based on the premise that water has a neutral ph and, whilst providing a safe means of assessing patients with thin liquids, also allows small amounts of water that may be taken into the lungs (i.e. aspirated) to be absorbed into the body pool, with no risk of aspiration pneumonia. despite thickened liquids being the most frequently used technique for patients with dysphagia in acute and chronic rehabilitation facilities, studies have shown that this is the consistency most patients are non-compliant with (logemann et al., 2008; robbins, langmore, hind & erlichman, 2002). the lack of standardisation of viscosity with thickened textures and poor quality control thereof, unsuitability of thickening agents for patients with diabetes and a lack of empirical evidence to support the clinical perception that a thicker viscosity reduces the occurrence of aspiration support the use of water (provided the oral cavity is clean) for assessments and management of dysphagia (frey & ramsberger, 2011; steele & swigert, 2006). previous studies on oral care and dysphagia have focused predominantly either on patients in residential and long-term care facilities (langmore, skarupski, park & fries, 2002; sarin, balasubramaniam, corcoran, laudenbach & stoopler, 2008) or patients in critical and intensive care settings (grap, munro, ashtiani & bryant, 2003; rello et al., 2007). a paucity of evidence exists focusing specifically on oral care, dysphagia and aspiration pneumonia within a general acute medical ward. a general medical ward within an acute government hospital, such as in south africa, differs from residential care facilities and high care facilities on several levels: funding. for privately funded and government subsidised facilities, resources, consumables and human resources differ. this may have implications for frequency, efficiency and willingness to engage in a routine such as oral care. patients, staff turnover, pace of work, workloads and sustainability of interventions (such as oral care) differ, which may affect implementation of procedures (mojoyinola, 2008). training of staff. nurses in general medical wards do not receive any specialised training on oral care protocols (mathivha, 2002; scribante & bhagwanjee, 2008). this has implications for consolidation and integration of how oral care relates to dysphagia and dysphagia to aspiration pneumonia (miller & rubenstein, 1987). the expected protocols and routines with patients differ amongst the respective contexts. oral care is not identified as an essential routine in a general medical ward (south african nursing council [sanc], 2004). against this backdrop, the study addressed the possibility of a reduction in occurrence of aspiration pneumonia amongst patients hospitalised for oropharyngeal dysphagia in a general medical ward in an acute hospital, as has been documented internationally to be possible for patients in high care settings (fields, 2008) and residential care facilities (yoneyama et al., 2002). oral care aspects for the patient with dysphagia colonisation of micro-flora and gram-negative bacteria is guaranteed with inactivity of the oral structures such as when there is no tooth brushing or rinsing of the mouth (jones, 1998; theilade, 1986). for patients with dysphagia, reduced or no activity of the oral cavity is common. tooth brushing and general oral care are often easily neglected routines by nurses for dependent patients within general medical wards (such as for patients with dysphagia), with tooth brushing being viewed as a routine worse than nappy changing (adams, 1996; wårdh, andersson & sörensen, 1997). for patients with dysphagia there is the added complication of a resultant decrease in saliva production (berry & davidson, 2006). the primary functions of saliva, in addition to its lubrication function in bolus formation, are its contribution to taste sensation, its cleansing purpose as well as its role in neutralising acid produced by bacteria on tooth surfaces (berry & davidson, 2006; jones, 1998). for patients not receiving oral care, after three days of undisturbed maturation, gram-negative bacteria become more prevalent from the accumulation and formation of hundreds of species of bacteria (marsh & martin, 1992). gingivitis may be evident in less than 10 days without plaque removal (donoghue, 1987). this coupled with the highly vascular presentation of the mucosal tissue contributes to tissue destruction and consequent communication between the bacteria in the plaque and the blood stream (kite & pearson, 1995). during episodes of aspiration, the likelihood of bacterial transfer to the lungs is increased. a reduction in saliva production reduces the release of bacterial and fungal suppression agents thereby increasing the presence of gram-negative bacteria, which in patients with dysphagia who are aspirating, leads to aspiration pneumonia. oral care and hygiene is a simple and cost-effective method that could reduce the above-stated complications from both a dental and respiratory perspective. the medical and psychosocial benefits associated with regular oral care are especially significant for the patient with oropharyngeal dysphagia who is susceptible to aspiration pneumonia. therefore, this study aimed to investigate whether it was possible to reduce the occurrence of aspiration pneumonia for patients presenting with oropharyngeal dysphagia by implementing a regular routine of oral care. methodology aim to determine the outcome of an oral care regimen combined with free water provision for patients with oropharyngeal dysphagia, with a specific focus on aspiration pneumonia. design a quantitative, quasi-experimental parallel group design was necessary to determine the outcome of the regimen introduced. concurrent change in the dependent variable, aspiration pneumonia, with introduction of the independent variables (i.e. oral care and water provision) were surmised. sample the sample consisted of two groups of participants, each with oropharyngeal dysphagia. the study group was 23 patients recruited using consecutive sampling. these participants received the scheduled oral care and were given unlimited amounts of water, which were recorded. a retrospective record review, via consecutive sampling, was used to select a pathology-matched (described below) comparison group (n = 23), who did not receive consistent or regular oral care. the participants in the comparison group were on liquid restricted diets; however, records confirmed that all these participants consumed various amounts of liquid, which were documented by nurses. both groups of participants received dysphagia intervention (described below). there were equal numbers of male and female participants with dysphagia in the study. there was no significant difference in the gender composition between the participants of the study and comparison group. participants from both groups were diagnosed with either stroke or traumatic brain injury as their primary medical diagnosis. the groups were matched for primary diagnoses as each group had similar numbers of patients with stroke and traumatic brain injury, with more stroke patients in the sample overall (stroke n = 32, traumatic brain injury n = 14; i.e. the groups were matched for pathology). all participants had a confirmed diagnosis of oropharyngeal dysphagia. no participant from either group presented with aspiration pneumonia at the initiation of dysphagia intervention (entry into the study), although signs of aspiration were observed and aspiration pneumonia developed over the course of intervention. this is detailed below. the number of nurses who participated in the study was 139. they received training on oral care by the researcher (speech-language pathologist) and each nurse participant was responsible for implementing the oral care according to a protocol (refer to figure 2). the researcher provided the dysphagia intervention for the participants in the study group and the resident speech-language pathologist at the site provided dysphagia intervention for the participants in the comparison group. both had a minimum of five years’ experience working in adult neurology and adult dysphagia specifically. dysphagia intervention for the study group during the course of intervention, a minimum of one meal a day was observed for each participant in the study group. participants were not restricted in their water consumption, except during meals and half an hour after a meal (refer to figure 1). during all meals participants were repositioned in their chair or bed. dependent participants were fed by the nurse. figure 1: mouth care and water provision schedule followed for the study group. figure 2: procedure for oral care. the following strategies were incorporated into nurse training and implemented during meals: confirming correct food consistency prior to commencing with the meal. pacing – allowing sufficient time for bolus preparation and swallow. amount – amount offered had to align with competency of patient. observation of patient between mouthfuls. ensure clearance of oral cavity. monitor patient level of wakefulness and responsiveness to the meal. adjust accordingly. during the course of intervention, different participants transitioned from oral to non-oral feeding and from non-oral to oral feeding based on presenting symptomatology. participants on non-oral feeding remained within the study and continued to receive oral care and free water. participants in the study group followed the oral care and free water regimen seen in figure 1. each participant received tooth brushing before breakfast, after which the participant rinsed out their mouth. this was done manually for dependent participants using a suction machine. water was provided half an hour after breakfast and regularly until lunch time. prior to any water consumption the participant’s mouth was rinsed. participants or caregivers completed this routine in addition to the nurse, researcher and research assistant. the amount consumed was documented. the same protocol followed for lunch, tea and dinner. during the night, the participant did not consume any meals and received only water, if requested. in addition to incorporating the principles of free water provision described above, dysphagia management incorporated recommendations of cichero and murdoch (2006), cook and kahrilas (1999), langmore and miller (1994), logemann (1997) and logemann (1983) with a combination of direct (involving food) and indirect (involving exercise) strategies, thermal-tactile stimulation, postural changes and behavioural techniques: diet modifications: thin liquid (water), pureed foods, soft foods and solids. viscosity and texture modifications excluding thickened liquid texture. exercise and facilitation techniques: strengthening exercises, thermal stimulation. postural adjustments: head tilt, chin tuck, head rotation, elevation. compensatory: pace of feeding, amount of bolus, presentation mode. manoeuvres: supraglottic swallow, super-supraglottic swallow, effortful swallow and mendelsohn manoeuvre. other: tube feeding. the techniques and manoeuvres were used as and when necessary for each participant based on their presenting dysphagia symptoms initially and their subsequent outcome measures. dysphagia intervention for the comparison group (based on information from the retrospective record review) records for 13 of the 23 participants revealed that they were referred late (from between three and seven days after being admitted) and after repeated notes in the file indicating that the participant was presenting with difficulty swallowing food or drinking liquids. referrals to the speech-language pathologist most frequently came via the dietitian. common trends that were noted across the participant’s files in terms of the dysphagia intervention provided included: participants were placed on liquid restricted diets (i.e. they were not to consume any liquids, including water). mouth care was requested frequently for each of the participants. mouth care was not performed by the speech-language pathologist. dysphagia management for the day was often incomplete or restricted because of poor oral hygiene of the participant. this happened on several days for each of the participants. specific therapeutic management strategies were vague. notes revealed that participants were re-evaluated daily to determine if they were managing on the recommended consistency or if there was a need to modify the consistency of the diet. the supraglottic swallow manoeuvre and patient positioning during feeding were recommended most frequently across the group. none of the participants was suspected of aspiration pneumonia during the initial consultation with the speech-language pathologist. however, during the course of intervention, aspiration pneumonia was suspected with seven participants (based on signs and symptoms during the bedside evaluation, as well as temperature recordings), following which recommendations for a nasogastric tube were made. this request for each of the participants continued for five to nine days, before the feeding tube was inserted for four of the seven participants, who received oral feeds in the interim. three participants remained on oral feeds before being discharged. despite repeated requests for participants on nasogastric tube to have oral care, notes suggest that this was not done. when aspiration was suspected, there were recommendations for more frequent temperature monitoring. no notes of the requested additional recordings were found in the files. barium swallows and chest x-rays could not be performed timeously due to malfunctioning equipment. there were notes by the speech-language pathologist querying that some participants were consuming liquids despite the recommendation of no thin liquids (based on information from the participants, information from the input/output chart and symptoms observed during the bedside evaluation). requests to nurses for this to be discontinued and no liquids to be given continued over several days, after which no further mention of this was made. it is unclear how this was monitored, followed up or resolved. it is important to note that information presented was derived from the notes in the participants’ medical files. it is likely that more dysphagia management was done with each participant than what was recorded. the limitations of the information obtained from the record review are acknowledged. to address the aim, the following comparisons between the study group and the comparison group were documented: amount of water consumed: would the study group participants consume more water, as there were no restrictions on drinking water except at mealtimes and half an hour after meals, than the comparison group who were on liquid restricted diets? for the study group, water consumption was recorded by the nurse providing the water or by the participant or caregiver. for the comparison group, the information was obtained from the patient input/output chart in the medical file. for the participants in the comparison group it was significant that despite the recommendation by the speech-language pathologist that the participant be restricted from thin liquids, recordings on the input/output chart by the nurses showed intake of water, tea and coffee for each of the participants. this finding is discussed below. there was the probability that participants from both groups may have consumed more water than what was recorded. this is acknowledged as a limitation of the study. oral care and aspiration pneumonia: would oral care reduce occurrence of aspiration pneumonia? although none of the participants from the study group was diagnosed with aspiration pneumonia at their entry into the study based on signs and symptoms, and observation of temperature recordings, aspiration was noted during the course of intervention. eight participants (n = 3 with stroke and n = 5 with traumatic brain injury) from the study group exhibited irregular signs of coughing with puree consistency and episodes of throat clearing after consumption of liquid (water). of these, two participants presented with episodes of choking at least once per meal over two days. dysphagia management was tailored to accommodate these difficulties with the eight participants and temperature recordings showed no change over the duration of these incidents, despite signs of aspiration at the bedside. these difficulties resolved prior to discharge. this finding is discussed below. of the 23 participants in the comparison group, records revealed that seven participants presented with signs of aspiration and subsequently developed aspiration pneumonia during the course of management. all participants from the comparison group were discharged from hospital with recommendations to remain on thickened liquids only and for positioning during meals and pace of feeding to be monitored. the lack of detail in the notes from the medical file prevented a closer analysis of the dysphagia management; however, for the seven participants who were aspirating recommendations for insertion of a nasogastric tube were made. as noted, only four of these participants had a nasogastric tube inserted; the remaining three continued on oral feeds. there were notes by the speech-language pathologist requesting that the participants remain in hospital until the swallowing improved (or aspiration resolved); however, a shortage of beds at the site prevented longer hospitalisation for the seven participants. five participants were discharged home, one to a nursing facility and one participant was transferred to a different acute care hospital. the schedule for oral care has already been described under the dysphagia intervention section. it can be viewed in figure 1. the actual oral care routine has been detailed in figure 1. it provides a step-by-step protocol for how the oral care should be done, the structures and surfaces that need to be cleaned and the equipment and resources that are needed to achieve this, all with diagrams. a troubleshooting section is also included for common difficulties that may be encountered when completing oral care for a patient. a limitation of the current study was the exclusion of videofluroscopy pre-intervention for each participant in the study group to confirm swallowing function. the presence of aspiration pneumonia was however monitored throughout the intervention period based on changes in patient symptomatology, patient reports and temperature monitoring. for the study group, a chest x-ray and videofluroscopy were completed at the end of intervention to essentially confirm no lung infection (aspiration pneumonia) and adequate swallowing. for the comparison group, only participants with overt symptoms of aspiration pneumonia could be referred for a barium swallow if the equipment was working at that time. the discrepancy in the use of a different imaging study for participants in each group is explained in the discussion. research process and data collection ethical considerations the research process followed is shown in figure 3. the study was conducted at an acute tertiary level public hospital in johannesburg, gauteng. necessary ethical approval and consent was obtained from the university of the witwatersrand human and ethics committee (medical) prior to commencement (m091166). figure 3: research and data collection process. within a larger study (seedat, 2013) nurses were initially observed as part of a hospital ethnography. nurse-patient interactions and nurse routines were amongst the different elements observed. these observations informed the need for, the content and length as well as means of implementing an oral care training protocol for nurses. the training protocol underwent several phases of modification until it was shown to be the most practical and efficient for nurses working within a general medical ward in an acute government hospital. the training is not described in detail within the current article, as this training process is described in an article currently in preparation. information included in the training with the nurses included details of when oral care needed to be implemented (figure 1), the protocol to be followed, use of equipment and troubleshooting suggestions for non-compliant patients (figure 1). the oral care schedule was self-devised but based on principles of the frazier free water protocol (panther, 2005). a training manual accompanied the hands-on training on the oral care routine that nurses received. the training protocol was designed to be particularly sensitive to resource and time constraints experienced by nurses working in an acute general medical ward whilst facilitating skill refinement by providing continuing professional development certification on completion of the training. data for the study group was collected daily over a period of four months. the duration and composition of dysphagia intervention was participant specific and varied. to limit the potential for aspiration, the study group participants did not consume any liquids aside from water for the duration of their dysphagia intervention. this was monitored and documented by the nurse who was implementing the oral care. cubicle nursing meant that one nurse was responsible for three to four patients during their shift. as can be seen in figure 3, the patient with dysphagia therefore had to be identified and recruited into the study first. thereafter the nurse responsible for that participant was recruited into the study and received the training. each nurse was trained once. nurses were usually allocated to the same patients they were caring for in their previous shift. nevertheless, it was necessary for nurse training to happen daily, as nurses did rotate. for the comparison group, records for one calendar year were reviewed until the required number of participants were recruited. during the dysphagia and oral care provision, the nurse participant recorded each implementation of oral care for the participant and documented the amount of water consumed, after each consumption. the researcher, to ensure adherence and consistency of oral care implementation and water provision, monitored both these recordings daily. the oral care protocol specified that participant’s mouths were cleaned prior to any water consumption and after each meal consumed, to prevent pooling and bacteria build-up from residue in the oral cavity, commonly seen in patients with oropharyngeal dysphagia. during the documentations, nurses commented on difficulties encountered during the oral care routine. these were addressed by the researcher and research assistant as the records were reviewed regularly throughout the day. incomplete records could also be followed up immediately with the nurse responsible. dysphagia intervention was provided simultaneously by the researcher. when the participant was able to safely swallow two different food consistencies based on subjective bedside evaluation, and after consultation with the attending doctor, a decision for discharge was made. prior to discharge the participant had a videofluroscopy and chest x-ray. following this, the participant was discharged and monitored for a period of three months thereafter by the researcher, after which time they were given an outpatient appointment or were told to contact the resident speech-language pathologist at the hospital for any changes to eating and swallowing. for reasons pertaining to non-maleficence, it was deemed unethical to withhold oral care and water provision to patients with dysphagia; hence, a retrospective record review was instead used to recruit the comparison group participants. these participants had received the ‘standard’ dysphagia management, which included inconsistent oral care, and were ‘restricted’ from thin liquids. similar inclusion and exclusion criteria were used to recruit the study and comparison group participants. participants in the comparison group did not routinely undergo a barium swallow. there was no nurse training that accompanied the comparison group, as this was not a component of standard dysphagia intervention. data analysis the statistical analysis software was used, incorporating non-parametric statistical procedures. the 95% confidence level was used throughout, unless otherwise specified. the wilcoxin two-sample test, kruskal-wallis test and spearman’s rank correlation were used to make within-group comparisons for the study group. skewness of the data (large variation) prevented the use of parametric procedures, hence non-parametric statistical procedures. results aspiration pneumonia across the sample, seven participants presented with aspiration pneumonia. the fisher’s exact test showed that there was a significant, moderate association between the occurrence of aspiration pneumonia and group: all seven were participants from the comparison group (p = 0.0092). this is seen in figure 4. four of these participants underwent a barium swallow preceded by a chest x-ray that confirmed lung infection in the absence of any other infection, which suggested aspiration pneumonia. the remaining three participants received only a chest x-ray because of malfunctioning equipment. figure 4: presence of aspiration pneumonia within the study and comparison group. all 23 participants in the study group received a chest x-ray and videofluroscopy at the end of their period of dysphagia intervention. correlating with figure 4, none of the participants who received regular oral care presented with aspiration pneumonia at the end of their period of dysphagia intervention. incidents of penetration and aspiration with coughing, throat clearing and choking were prevented from becoming aspiration pneumonia largely due to the strict oral care regimen and water intake preceded by mouth rinsing, monitoring of intake by the nurse and the daily communication between nurse, the speech-language pathologist and participant or caregiver. amount of water consumed analysis was completed looking at the relationship between the amount of water consumed and the duration of intervention. adherence to an oral care regimen, monitored dysphagia intervention and unrestricted water consumption (except at meal times) led to the following hypotheses: (1) the study group would consume more water and (2) the longer the duration of intervention (per participant), the more the water consumption. the first hypothesis was not proven. the comparison group consumed more water than the participants in the study group did. aligning with this unexpected finding, the result showed poor monitoring of food and liquid intake for the participants in the comparison group by nursing staff and noncompliance with recommendations of no thin liquid intake, at various levels. notes in the participant’s files revealed poor follow-through of recommendations made by the speech-language pathologist for nurses to order specific diets for participants. with regard to the second hypothesis, for the study group there was indeed a significant, positive correlation between these variables (i.e. water consumption increased as the duration of intervention lengthened; correlation coefficient, r = 0.84; p < 0.0001). this is evident in figure 5. however for the comparison group, there was no significant correlation between these variables (r = 0.014; p = 0.95), showing that the total amount of water consumed by patients did not increase with increased duration of intervention. figure 5: relationship between water consumed and days of intervention for the study and comparison group. oral care overall, there were three meals that were not accompanied by oral care for the study group participants. time constraints due to workload and routines considered more priority, contributed to these care sessions being incomplete (qualitative data can be viewed in seedat, 2013). there was a positive correlation between the oral care provided and the absence of aspiration pneumonia indicated by the chest x-rays. this suggested that oral care prevented build-up of oral bacteria. regular cleaning ensured good clearance of gram-negative bacteria amongst participants who were susceptible to aspiration. the overall result was no occurrence of aspiration pneumonia amongst any of the study group participants. to determine if there was a significant difference between the stroke and traumatic brain injury participants for aspiration pneumonia, amount of water consumed and duration of intervention, a glm (general linear model) analysis was completed for each of the listed variables. no significant differences were noted between the two underlying pathologies for any of the variables. discussion as with the findings of yoon and steele (2007), poor to no oral care amongst the comparison group participants culminated in seven participants acquiring aspiration pneumonia. yoon and steele highlight that regular oral care shows a decrease in respiratory pathogens that lead to aspiration pneumonia; hence, oral care decreases occurrence of aspiration pneumonia, as was noted amongst the participants from the study group. as was seen amongst participants from the study group, even with episodes of aspiration, if the oral cavity is free of bacteria, then no bacteria is transferred to the lungs to enable development of infection (i.e. aspiration pneumonia), a sentiment reiterated by panther (2005). the finding of the comparison group supports findings of wårdh et al. (1997), which showed that unless monitored, oral care is a routine often disregarded in a general medical ward. notes by the speech-language pathologist confirmed lack of tooth brushing and poor if any rinsing of the oral cavity before or after meals, which inevitably resulted in a build-up of bacteria on the surfaces of the oral cavity (yoon & steele, 2007). dry and cracked lips, tongue and oral cavity immediately opens up a pathway for infection, allowing communication between the bacteria in the oral cavity and the blood stream, increasing the chances of bacterial transfer to the lungs (kite & pearson, 1995; millins, gosney, jack, martin & wright, 2003). in essence the bacteria overwhelm an already impaired host-defence system, especially seen in patients with neurological impairment such as stroke (byers & sole, 2000). thus, participants in the comparison group by virtue of poor oral care and oral hygiene were more susceptible to acquiring aspiration pneumonia. findings of the study confirmed that this was the case with seven participants. as with the study group, each participant in the comparison group received individual assessment and management strategies based on the underlying cause of the swallowing difficulty and presentation of the dysphagia. although there was minimal detail of dysphagia management provided for the comparison group participants, it was noted that poor inter-professional communication adversely affected patient prognosis (logemann, 1994). for instance, the repeated requests for oral care may have been alleviated with direct communication with nurses and nursing managers. a lack of accountability served to perpetuate poor follow-through of recommendations made by the speech-language pathologist. logemann (1994) notes that successful management of the patient with dysphagia cannot be achieved by any one professional alone. a routine of oral care falls within the realm of the nurse (sanc, 2004) and, as was noted from the results of the study group participants who presented with instances of penetration and aspiration, it can minimise if not prevent occurrence of aspiration pneumonia. a further point to elucidate the shortcoming of poor team management of dysphagia, and particularly inclusion of the patient or caregiver, was seen in the noncompliance with recommendations of thickened liquids for the comparison group participants. colodny (2005), rosenvinge and starke (2005) and logemann et al. (2008) have confirmed that patients are more likely to be non-compliant with recommendations made if they have no understanding of why it is necessary. similar reasons underlie why nurses too do not enforce recommendations by allied health professionals (begley, 2009). improved compliance with oral care and water provision that was noted by the nurses caring for the participants in the study group was due to two primary reasons: (1) an understanding of why oral care and water provision was important for patients with dysphagia, with an understanding of how these routines needed to happen, and (2) monitoring of these routines. hence, involving patients in decisions being made about their health and nurses of their role in patient management resulted in positive patient prognosis (begley, 2009; rosenvinge & starke, 2005). the large amounts of water consumed by the comparison group, which was not expected, further reiterates the need for inclusion of patients, caregivers and nurses in education about what the dysphagia management entails. over and above the medical and hydration benefits of using water, its ability to quench one’s thirst adds to it being more acceptable and less aversive than a thickened liquid by patients with dysphagia (colodny, 2005; logemann et al., 2008). the current study confirms the benefit of water use in dysphagia intervention (i.e. for assessment and management). simply explained, the human body is composed of approximately 60% of water. any water that is consumed is absorbed by aquaporin channels within the lung where the blood vessels redistribute the water into the blood stream (effros, jacobs, schapira & biller, 2000; panther, 2005). hence the need for caution to be heeded in how water is used and under what oral hygiene circumstances (free of bacteria), as was seen in the different outcomes for the study and comparison group participants. the use of videofluroscopy for participants in the study group, and barium swallow for four participants in the comparison group was noted as a limitation of the study. having experience working within a government hospital, the researcher was aware that: (1) it was impossible to rely on equipment being in working order at any time and (2) patient waiting lists added to the delay in a procedure being conducted. for the purpose of the study, and with knowledge that the site had access to only barium swallow, videofluroscopy, shown to be more advantageous than barium swallow (rofes et al., 2010), was selected as the imaging study of choice at a different hospital to that where the study was conducted. this procedure had no bearing on the intervention provided to the patients as it was conducted at the end of the intervention period. despite the benefits that would have been gained conducting a videofluroscopy pre-intervention and post-intervention, the intent of the study was to conduct the oral care regimen in a typical acute government context. for this reason, the use of bedside evaluations was the primary dysphagia tool. studies have shown that in contexts where equipment and access to resources are limited, bedside assessments are still able to provide a clinician with valuable information about swallowing and what may be going wrong. whilst lacking objective information to support what the clinician may be observing (singh & hamdy, 2006), a bedside evaluation and management offers the clinician immediate feedback and allows the clinician to implement changes and modifications to the course of management as necessary (mccullough & martino, 2013). conclusion it is possible to reduce adverse medical effects of aspiration including fatality by implementing a cost-effective and low-resource oral care protocol for patients with dysphagia. an oral care and water provision regimen in addition to increasing patient compliance with dysphagia recommendations successfully prevents occurrence of aspiration pneumonia and prevents instances of aspiration from developing into aspiration pneumonia. this is something that holds potential value for resource constrained acute medical contexts, worldwide. the results seen amongst the eight patients from the study group who were aspirating during the course of intervention, but who did not develop aspiration pneumonia, confirms that it is possible to prevent the occurrence of aspiration pneumonia amongst patients who are aspirating, as long as oral care is implemented, the oral cavity remains clean when the patient consumes water and the oral cavity is cleaned after meals, to prevent aspiration of pieces of bolus residue within the oral cavity when the patient may be sleeping, for instance. the findings concur with those of el-solh et al. (2003), who note that a lack of bacteria in the oral cavity prevents the build-up of infection in the lungs. hence, as is possible in a chronic care context, reducing occurrence of aspiration pneumonia in an acute care context can also be attained (yoneyama et al., 2002). the oral care regimen tested in the current study was able to take cognisance of time and resources available to nurses working within an acute government hospital context. the added ‘limitation’ of the study was the regular monitoring of the nurses that occurred during the data collection. thus it must be queried whether the oral cavity and water provision would have proceeded as it did, had the monitoring not occurred. not documented in the study but which the findings of the study by seedat (2013) showed, was that nurses requested more monitoring of the routines they conducted with patients. nurses felt that this showed that their supervisors were interested and invested in what they were doing. lack of monitoring meant that nobody was interested in whether a routine was completed or not, which they noted was particularly true for oral care. hence, whilst regular monitoring of all nurses performing mouth care routines may not be a feasible notion within an acute government hospital context, the study does confirm that given the benefits associated with oral care, there needs to be a higher priority placed on the need for this routine to be done and monitored from time to time. as patient input/output details are recorded within files, formal recording of mouth care, with random checks, may offer an answer. despite the limitations of the study, which have already been acknowledged, some implications were identified. there is a growing need for more information dissemination amongst nurses. similarly, patients and caregivers need to be more involved in decisions being made about their swallowing difficulty. relevant professionals (for example nurses and speech-language pathologists) need to be better informed on aspects relating to the pathophysiological underpinning of aspiration pneumonia, consequences of aspiration pneumonia, symptomatology and the role of oral care in this process (evans, 2001; seedat, 2013). to enhance service delivery in dysphagia, improved inter-professional collaboration and information sharing with dentistry and respiratory specialists also holds value. linked to this is the value of advocating the importance of inter-professional management of dysphagia at an undergraduate level and promoting inter-professional training, skill refinement and knowledge sharing in dysphagia. as south africa is a developing country, south african health professionals have varying levels of access to journals, the internet and electronic support groups, which makes carry-over of this information to relevant health professionals challenging. hence, national and provincial forums offer an ideal platform for such a protocol to be shared amongst clinicians. the current study confirmed the combined benefit of oral care as well as free water provision to two specific target populations (i.e. patients with stroke and patients with traumatic brain injury, who presented with oropharyngeal dysphagia). the outcome of this schedule of oral care and water provision, and the oral care protocol itself, have not yet been proven for other populations, who may require additional considerations and modifications to be made. for example, head and neck cancer post-surgical patients, patients with dementia, patients with degenerative neurological conditions where muscle fatigue must be considered and patients with underlying respiratory conditions such as chronic obstructive pulmonary disease. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions j.s. 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(1987). oral health care for hospitalized patients: the nurse’s role. journal of nursing education, 26, 362–366. millins, b., gosney, m., jack, c.i.a., martin, m.v., & wright, a.e. (2003). acute stroke predisposes to oral gram-negative bacilli–a cause of aspiration pneumonia?. gerontology, 49, 173–176. http://dx.doi.org/10.1159/000069171 mojoyinola, j.k. (2008). effects of job stress on health, personal and work behaviour of nurses in public hospitals in ibadan metropolis, nigeria. ethno-med, 2(2), 143–148. nevitt, j. (2010). the frazier free water protocol improves compliance with modified diets. retrieved february 2013, from http://www.nurseweb.ucsf.edu/conf/cripc/ebpabstract/nevitt/.pdf panther, k. (2005). the frazier free water protocol. swallowing and swallowing disorders, 14, 4–9. http://dx.doi.org/10.1044/sasd14.1.4 rello, j., koulenti, d., blot, s., sierra, r., diaz, e., de waele, j.j. et al. (2007). oral care practices in intensive care units: a survey of 59 european icus. intensive care medicine, 33(6), 1066–1070. robbins, j., gensler, g., hind, j., logemann, j.a., lindblad, a.s., brandt, d. et al. (2008). comparison of 2 interventions for liquid aspiration on pneumonia incidence. annals of internal medicine, 148, 509–518. http://dx.doi.org/10.7326/0003-4819-148-7-200804010-00007 robbins, j., langmore, s., hind, j.a., & erlichman, m. (2002). dysphagia research in the 21st century and beyond: proceedings from the dysphagia experts meeting, august 21, 2001. journal of rehabilitation research and development, 39, 543–548. rofes, l., arreola, v., almirall, j., cabré, m., campins, l., garcıa-peris, p. et al. (2011). diagnosis and management of oropharyngeal dysphagia and its nutritional and respiratory complications in the elderly. gastroenterology research and practice, article #818979, 13 pages. http://dx.doi.org/10.1155/2011/818979 rosenvinge, s.k., & starke, i.d. (2005). improving care for patients with dysphagia. age and ageing, 34, 587–593. http://dx.doi.org/10.1093/ageing/afi187 sarin, j., balasubramaniam, r., corcoran, a.m., laudenbach, j.m., & stoopler, e.t. (2008). reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions. journal of the american medical directors association, 9(2), 128–135. http://dx.doi.org/10.1016/j.jamda.2007.10.003 scott, a., & benjamin, l. (2010). implementation of a free fluid protocol in an aged care facility. in h. roddam & j. skeat (eds.), embedding evidence-based practice in speech and language therapy: international examples (pp. 184–188). chichester, uk: john wiley & sons. http://dx.doi.org/10.1002/9780470686584.ch27 scribante, j., & bhagwanjee, s. (2008). national audit of critical care resources in south africa–nursing profile. south african medical journal, 97(12), 1315–1318. seedat, j. (2013). knowledge translation in dysphagia – a south african study. doctoral dissertation, department of speech and hearing therapy, university of the witwatersrand, south africa. retrieved from http://hdl.handle.net10539/13429 singh, s., & hamdy, s. (2006). dysphagia in stroke patients. postgraduate medical journal, 82(968), 383–391. http://dx.doi.org/10.1136/pgmj.2005.043281 south african nursing council (sanc). (2004). charter of nursing practice, 2004. retrieved february 2014, from http://www.sanc.co.za/pdf/charter%20presentation.pdf steele, c., & swigert, n.b. (2006). npo until dysphagia screen. paper presented at the american speech-language and hearing association convention (session 1956), miami, fl. theilade, e. (1986). the non-specific theory in microbial etiology of inflammatory periodontal diseases. journal of clinical periodontology, 13(10), 905–911. http://dx.doi.org/10.1111/j.1600-051x.1986.tb01425.x wårdh, i., andersson, l., & sörensen, s. (1997). staff attitudes to oral health care. a comparative study of registered nurses, nursing assistants and home care aides. gerodontology, 14(1), 28–32. yoneyama, t., yoshida, m., ohrui, t., mukaiyama, h., okamoto, h., hoshiba, k. et al. (2002). oral care reduces pneumonia in older patients in nursing homes. journal of the american geriatrics society, 50(3), 430–433. http://dx.doi.org/10.1046/j.1532-5415.2002.50106.x yoon, m.n., & steele, c.m. (2007). the oral care imperative: the link between oral hygiene and aspiration pneumonia. topics in geriatric rehabilitation, 23, 280–288. http://dx.doi.org/10.1097/01.tgr.0000284771.24711.6a 1. editorial. ί the seed was planted and took root. the fruit will bo both plentiful and sound, we hope, and perhaps the first bud is noted in the form of the first s.a.l.s. journal. the development of logopedics in south africa is ably traced in the presidential address, and wo now havo a group of workers united in enthusiasm, scientific interest, and the desire to progress sincoroly in· tho theory'and practice of speech therapy. in that a large part of our approach to the individual is an attempt to understand the influence of cultural forces on his particular personality, we can envisage with satisfaction a future in which there will be not only a body for co-ordinating the activities of speech therapists in south africa and elsewhere, but there will be a body which will co-ordinate the activities of various workers in differing,but related fields, to the benefit of the deviate individual. when the speech defective person can be treated synoptically, with thorough investigation and broadth of understanding, our efforts to achieve health and adjustment will bg enriched. we hope that this journal will -aid in expressing the views and knowledge of our members, that it may be a common forum for a critical and unbiased approach to speech problems: that we will not only bo able to indicate new paths for research, but retest, discard or confirm old theories and practices, so often accepted as fact, though their basgs are merely assumptions. each member is invited to submit all corroborations, disagreementŝ or discussions an any published article, and it is hoped that lively and provocative stimulation will be forthcoming. the bud is small but it is opening. give it the "warmth of your critical thought and it will bear rich fruit. good luck.' ! rhona a. gorvy. editorial c ommittee. editor: rhona a. gorvy. sub editor: zelda penn. secretary: sheila g. been. ' committee members: claire sischy, thelma stohr,' madge l. rosendorff. all correspondence to be addressed to: the secretary, 17, illova mansions, illova. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die nut van die ,,ιτρα" vir die spraakterapeut asook 'n ondersoek na die moontlikh eid van 'n vertaling en a an passing by suid-afrikaanse omstandighede e l s i e c. l o t t e r , b . a . log. (pretoria) inleiding die een eienskap wat die mens by uitstek van elke ander vorm van lewe onderskei, is sy linguistiese vaardighede. die mens is 'n kommunikerende wese; hy kommunikeer met sy medemens deur middel van taal. taal in sy breedste begrip kan omskryf word as elke vorm van kommunikasie waardeur gedagtes en gevoelens gesimboliseer word: skrif, spraak, tekens, gesigsuitdrukking, gebaar, pantomime en selfs ook kunsvorme (battin and haug4). ons wil ons hier egter beperk tot daardie aspekte wat binne die gebied van die spraakterapeut val, die mens se psigolinguistiese-vermoens. osgood en miron8 omskryf psigolinguistiek as die gebied wat te doene het met die wyse waarop ons boodskappe produseer. en die manier waarop hierdie boodskappe ontvang en ge'interpreteer word. die woord „psigolinguisties" kan dus gebruik word om alles wat gebeur wanneer die mens kommunikeer, te beskryf. „psigolinguistiese vermoens" is dan daardie vermoens of vaardighede wat die mens in staat stel om sinvol te kommunikeer. hierdie vaardighede is van 'n baie hoe en uniek-kenmerkende orde; daarom is daardie instrumente wat gebruik kan word om dit temeet en te omskryf, onmisbaar en regverdig dit gedetailleerde bestudering (darley6). waar die spraakterapeut haar beywer om hulp te verleen aan diegene wat tekort skiet t.o.v. die een of ander aspek van linguistiese vermoe, kan sy met vrug gebruik maak van sodanige instrumente. soos die naam aandui, wil die ..illinois test of psycholinguistic abilities" daarop aanspraak maak dat dit die psigolinguistiese vermoens van 'n mens peil. indien dit wel die geval is, moet dit as 'n nuttige instrument beskou word. die konstruksie van hierdie instrument berus op 'n wetenskaplike aanvaarbare model, nl. die van osgood. die skematiese model van die itpa self voorsien 'n duidelike en logiese beeld van die vlakke waarop kommunikasie geskied, die vernaamste kommunikasiekanale en die prosesse wat by kommunikasie betrokke is, soos dit deur die toets gemeet word. aangesien hierdie studie beoog het om nie alleen die moontlikheid van 'n vertaling van die ..illinois test of psycholinguistic abilities" na te gaan nie, maar ook ondersoek in te stel of die spraakterapeut enige tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 18, desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) elsie c. lotter 24 nut van hierdie instrument kan he, is gepoog om soveel inligting as moontlik aangaande die toets en sy gebruik byeen te bring. die ontstaan en konstruksie van die toets is nagegaan en die subtoetse is volledig ondersoek en beskryf. alle moontlike kritiek op die toets as geheel en ook die afsonderlike subtoetse is versamel en geevalueer. ten einde die kring om die spraakterapeut en die itpa nouer te trek, is toepassingsvlakke binne die gebied van die spraakterapeut beskou. dit is gevolg deur 'n uiteensetting van die kliniese nut van die itpa soos dit tot op hede in praktiese ondervinding uitgekristalliseer het. dit is nou duidelik dat al hierdie gegewens nie in hierdie verslag bespreek kan word nie; daar sal slegs kortliks op 'n paar van die aspekte gewys word. die spraakterapeut en die itpa hierdie studie is onderneem as 'n voorlopige ondersoek, met die oog op verdefe ondersoek na die diagnostiseringsinstrumente (spesifiek die itpa) vir psigolinguistiese vermoens, in die besonder in suid-afrika en by die afrikaanse en engelse taalgroepe. die redes vir die keuse van die itpa word ten beste toegelig deur 'n vergelyking van die itpa met ander toetse vir psigolinguistiese vermoens; hierdeur word daardie eienskappe wat tot voorkeur van die itpa lei, duidelik. uit sodanige vergelyking met verskeie engelse (amerikaanse) en afrikaanse toetse, het die volgende kenmerke van die itpa na vore gekom: 1. die ouderdomsgebied wat gedek word, nl. 2-6 tot 10-13 jaar, strek vanaf die belangrike tydperk van taalaanname of net daarna en omvat 'n relatief wye area. 2. daar word altesaam 12 spesifieke aspekte van die mens se psigolinguistiese vermoens getoets; die toetsing is dus nie beperk tot 'n enge gebied nie. 3. die toets kan binne 60 tot 80 minute afgeneem word. 4. op grond van die toetsresultate word 'n profiel getrek waarvolgens die kind as't ware met homself vergelyk word, eerder as met 'n „gemiddelde telling". 5. die profiel wat verkry word, bied nie alleen 'n verklaring van die kind se taalprobleme nie, maar dien ook as leidraad vir die opstelling van 'n terapieprogram. wanneer darley6 'n aantal toetse met betrekking tot taalvermoens bespreek, spreek hy die volgende mening uit: „the itpa is perhaps the most comprehensive test of children's language status.," ook m. f. berry5, waar sy toetse vir die vasstelling van defekte in verskeie aspekte van taalgedrag beskryf, beskou die itpa as verreweg die mees omvattende en hoogs gestandaardiseerde toets. dit is van nut by diagnose, die aanvanklike opstelling en deurlopende toepassing van 'n terapieprogram en prognose. die diagnostikus wat 'n diagnostiese instrument ter hand neem, kan 'n swak toets voordelig gebruik of 'n goeie toets sonder welslae. 'n toets kan so goed of so swak wees as die persoon wat dit gebruik, se journal of the south african speech and hearing association, vol 18, december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) n u t van ,,ιτρα" en ondersoek na aanpassing by s.a. omstandigbede 25 vermoe om doeltreffende ondersoek uit te voer. deur die beperkinge en gebreke van 'n toets in gedagte te hou, kan die diagnostikus die instrument na sy hand plooi en die toetsresultate realisties gebruik om tot betekenisvolle gevolgtrekkings te geraak. hierdie opmerkings geld ook ten opsigte van die itpa. die vernaamste kritiek op die itpa handel oor die gebrek aan kwalitatiewe analise van die verbaie uiting. die diagnostikus sal dus 'n ander toets/metode gebruik om die verbaie uitinge van die kind, wat wel vir die verbaie uitingstoets volledig aangeteken word, tesame met 'n voorbeeld van die kind se spontane spraak, kwalitatief te ontleed. dit is belangrik om in gedagte te hou dat die k i n d ' s o m s 'n grondige rede vir 'n skynbaar „verkeerde" respons het en verdagte antwoorde moet verder nagegaan en ontleed word. die soort kind wat ondersoek word, moet ook steeds in gedagte gehou word sodat daar nie net blindelings kwantitatiewe analise van gegewens plaasvind nie. die ondersoeker wat sy instrument goed genoeg ken, kan daardie instrument ten spyte van tekortkominge en gebreke dinamies gebruik vir die spesifieke doel wat hy in gedagte het. aanduidings is reeds gegee van hoedat die itpa vir sekere doeleindes deur die spraakterapeut gebruik kan word. daar is haas geen gebied waarmee die spraakterapeut te doene kry, waarby nie taal betrokke is nie. op baie van hierdie gebiede is die itpa reeds aangewend as ondersoekmedium: verstandelike vert r a g i n g , breinbeskadiging en afasie, serebrale verlamming, gesplete verhemelte^ artikulasieprobleme, hakkel, leesprobleme, agtergrondsfaktore wat tot 'n taalagterstand lei, en swaksiendes waar taalprobleme ook voorkom. ander gebiede waar die itpa nog nie gebruik is nie, maar wel nuttig kan wees, is by die volgende: sg. „brain-different" kinders (berry5), vertraagde spraakontwikkeling, ouditiewe versteurings en psigoneurologiese spraakversteurings. die ondersoeke wat reeds uitgevoer is, het in sommige gevalle slegs versameling van inligting ten doel gehad, in ander gevalle ondersoek na die uitwerking van sekere remediele prosedures. verskeie van hierdie ondersoeke is ook al deur verskillende persone saamgevat, bespreek, gei'nterpreteer en verwerk. dr. barbara bateman 1 · 2 · 3 het op hierdie gebied omvattende werk gedoen. die navorsing wat onderneem is, was meestal nie uit die oogpunt van 'n spraakterapeut nie, maar wel van die remedierende onderwyser. die bevindings en gevolgtrekkings waartoe geraak is, is egter vir die spraakterapeut van ewe veel nut. die grootste hoeveelheid navorsing is onder verstandelik vertraagdes onderneem, veral met betrekking tot hulle skolastiese onderrig, asook aspekte van leesen skryfvaardighede by verskillende soorte gevalle. in suid-afrika kry die spraakterapeut met hierdie kinders te doen en het dus belang by die ondersoeke. daar is ook ondersoeke spesifiek uit die oogpunt van die spraakterapeut onderneem en van hierdie ondersoeke is 'n aantal in suidafrika deurgevoer. gegewens wat hier verkry is, kan egter nie oor 'n tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 18, desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) elsie c. lotter 26 eroot mate van geldigheid en betroubaarheid beskik (sever dit die kwantitatiewe analise betref) voordat die norme en standaarde by suidafrika aangepas is en nuwe skaalpunte opgestel is nie. uit die ondersoeke waar die itpa gebruik is, blyk een aspek baie duidelik: die resultate wat verkry word, het altyd kliniese implikasies. die itpa bly steeds 'n diagnostiese toets met die oog op. remediering. die vernaamste doel van die itpa is egter om 'n kind, nie met andere nie, maar met homself te vergelyk. in terapie wordsteeds met 'n indiwidu gewerk, vir wie 'n indiwiduele terapieprogram opgestel en gewysig moet word volgens indiwiduele behoeftes. om hierdie redes is dit die kwalitatiewe ontleding van die itpa profiel wat in die praktyk vir die spraakterapeut van kardinale belang is. goldstein is van mening dat toetsresultate slegs geevalueer kan word deur ontleding van die wee waarlangs die toetsling sy resultate bereik het. enige kwantitatiewe beoordeling ten opsigte van welslae of mislukking is 'n bron van foutering tensy dit volg op 'n kwalitatiewe ontleding en nie sodamge ontleding voorafgaan nie. die nut van 'n kwantitatiewe verwysingsraamwerk moet egter nie uit die oog verloor word nie. die spraakterapeut werk nie net met een geval nie en kruisvergelyking van afsonderlike gevalle is nuttig ten opsigte van terapieleidrade. om hierdie rede is die ondersoek onderneem na die moontlikheid van 'n suid-afrikaanse weergawe van die itpa. aangesien daar in suidafrika hoofsaaklik twee taalgroepe (onder blankes) voorkom, nl. engels en afrikaans, is dit ook wenslik om oor 'n afrikaanse instrument-vir die meting van psigolinguistiese vermoens te beskik. 'n voorlopige vertaling van die itpa is dus opgestel en op 'n groep afrikaanssprekende kinders toegepas, terwyl die oorspronklike weergawe van die itpa op 'n groep engelssprekende kinders toegepas is. die toetsgroepe wat gebruik is, was te klein om enige ware afleidings en gevolgtrekkings toe te laat. nogtans kon sekere riglyne op grond van die toetsresultate getrek word. die vertaling a. die keuse van proefpersone (1) geslag. beide geslagte is gebruik, ten einde die moontlike invloed van geslag op die resultate te verminder. (2) ouderdom. aangesien slegs 'n klein aantal proefpersone gebruik kon word, is dit vir hierdie voorlopige ondersoek gera'de geag om proefpersone te gebruik uit die hoogste ouderdomsgroep waarvoor die hersiene uitgawe van die itpa gestandaardiseer is, nl. 10-0 tot 10-3 jaar. sodoende sou al die items van elke subtoets toegepas kon word, sonder dat daar te gou 'n plafon bereik is. (3) skolastiese oorwegings. alle proefpersone is uit st. 3 getrek; dit was egter nie moontlik om al die proefpersone (vir elke taalgroep afsonderlik) uit dieselfde klas te trek nie. ten einde die moontlikheid uit te skakel dat gegewens wat van so 'n klein monster verkry is, journal of the south african speech and hearing association, vol 18, december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) nut van ,,ιτρα" en ondersoek na aanpassing by s.a. omstandigede 27 oormatig deur uiterstes beinvloed word, is gepoog om proefpersorie te gebruik van wie die gemiddelde taalpunt (skoolpunt) binne die grens van 15 punte van die gemiddelde van die standerd af le. die engelse toetsgroep is eerste getoets, daarna is die afrikaanse groep uitgesoek om so nou moontlik ooreen te stem. in die engelse skool het die st. 3 leerlinge se ouderdom ooreengekom met die hoogste ouderdomsgroep waarop die itpa gestandaardiseer is. in die afrikaanse skool was st. 3 leerlinge egter oor die algemeen ouer; nogtans is besluit om hierdie proefpersone te behou, ten einde ander faktore konstant te hou. (4) agtergrondsfaktore. die twee laerskole waaruit proefpersone getrek is, is in dieselfde omgewing gelee. daar is ook nagegaan dat die ouers van die proefpersone in ooreenstemmende beroepsgroepe val. (5) ander faktore. die volgende is vermy : (a) merkbare artikulasieof ander spraakprobleme; (b) breinbeskadiging sover bekend; (c) gehoorsprobleme sover bekend; (d) emosionele ontwrigting sover bekend. o p grondslag van hierdie oorwegings is 'n e n g e l s s p r e k e n d e en 'n a f r i k a a n s s p r e k e n d e groep saamgestel, elk b e s t a a n d e uit vier dogters en vyf seuns. b. die toetsmateriaal: die vertaling die volgende toetse maak gebruik van gesproke taal en moes dus vertaal word: (1) ouditiewe ontvangs. (2) ouditiewe assosiasie. (3) grammatikale sluiting. (4) ouditiewe sluiting. (5) klanksaamvoeging. (1) ouditiewe ontvangs: hier is meestal van direkte vertaling gebruik gemaak, op grond van die aanname dat veral by die relatief eenvoudige woordeskat van die eerste items, die moeilikheidswaarde van die konsepte wat begryp moet word, dieselfde sal bly by vertaling in afrikaans. bv item 1: do dogs eat?—kan honde eet? waar die engelse woord egter nie deur 'n enkele afrikaanse woord met dieselfde betekenis vertaal kon word nie, is 'n nuwe sin saamgestel. • bv. item 44: do canines manufacture?—kan reptiele vervaardig? " soos in die engels, is in hierdie vertalings die sinsvorm konstant en eenvoudig gehou, terwyl die respons net bestaan uit „ja/nee". (2) ouditiewe assosiasie: hier is deurgaans van direkte vertalings gebruik gemaak, behalwe by die volgende drie items: item 10: i dress a doll, i bounce a . . . in die direkte vertaling is die analogie, vanwee die sinsvorm, hier nie meteens duidelik nie. daar is derhalwe gebruik gemaak van: ek dra 'n pop, ek bons 'n . . . item 28: churches have aisles, cities have . . . in die direkte vertaling kom die woord „paadjies" vir ,.aisles" te veel ooreen met 'n moontlike vorm van die verlangde respons: derhalwe, tydskrif van die suid-afikanse vereniging vir spraak en gehoorheelkunde, vol. , desember r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 elsie c. lotter die parlementsgebou het wandelgange, 'n dorp het . . . item 42: years have seasons, dollars have . . . (quarters). hier is uit die staanspoor aangeneem dat „dollars" 'n woord kultuurvreemd aan die afrikaanse kind is, en dit is dus vervang deur „gellings". (3) grammatikale sluiting: hierdie was die moeilikste subtoets om te vertaal, aangesien die grammatika van engels en van afrikaans baie verskil. ook die moeilikheidswaarde van veral sommige meervoudsvorme verskil by 'n vertaling, bv. foot—feet, voet—voete. die volgende soorte items moes verander word: (a) sommige meervoudsvorme (items 22, 23, 30, 32); (b) sterk vorme van die verlede deelwoord (items 26, 27). dit was ook nodig om sommige van die.stimulusprente te verander. daar is deurgaans gepoog om dieselfde soort probleem te behou— meervoudsvorm, werkwoordverbuiging, voorsetselvorm ens. hierdeur is sommige afrikaanse taalverskynsels, bv. die verkleinwoord, agterwee gelaat en ander taalvorme, bv. die sterk verlede deelwoord, wat minder in afrikaans as in engels voorkom, wel ingesluit. (4) ouditiewe sluiting: by die vertaling van hierdie subtoets is gepoog om dieselfde aantal lettergrepe per item weer te gee, met weglatings in dieselfde posisies. sommige items kon direk vertaal word, bv. item 4: tele/one—tele/oon. ander items moes verander word, bv. item 17: / uper i arket— / oente / inkel. (5) klanksaamvoeging: dieselfde beginsel as by die vorige is hier gehandhaaf, nl. direkte vertaling sover moontlik, met veranderinge waar nodig om dieselfde aantal lettergrepe te behou. bv. item 1: f-oot—v-oet. item 6: c-u-p—k-o-p. by die onsinwoorde is die vertaling so direk moontlik gedoen, d.w.s. die klankwaarde van die vokaalklanke is verafrikaans. bv. item 26: [a: fi: ]—so behou. item 27: [ν λ m]—[v oe m], ooreenkoms met bestaande' afrikaanse woorde is sover moontlik vermy. c. die eksperimentele prosedure die aanbieding van subtoetse is in dieselfde volgorde behou vir beide die afrikaanse en die engelse toetsgroepe, nl. die volgorde wat deur die toetsopstellers voorgeskryf is (kirk, mccarthy and kirk7). by die afrikaanse weergawe is instruksies in afrikaans gegee, 'maar steeds in ooreenstemming met die voorgeskrewe prosedures. d. die verwerking van resultate by die aanvang van hierdie ondersoek is die moontlikhede van verwerking van die toetsresultate noiikeurig ondersoek. daar is tot die gevolgtrekking geraak dat geen betekenisvolle statistiese bewerkings moontlik sou wees nie en wel om die volgende redes: journal of the south african speech and hearing association, vol 18, december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ,,ιτρα" en ondersoek n a aanpassing by s.a. omstandigbede 29 (1) ten einde die aanpassing van die toets by suid-afrikaanse standaarde op 'n statistiese grondslag te plaas, sou dit nodig wees om vir beide engelsen afrikaanssprekende groepe 'n nuwe verwagte frekwense verspreiding op te stel, op grond van die resultate van 'n groot aantal proefpersone. (2) betroubaarheid en geldigheid kan nie met die gegewens van 'n klein monster ondersoek word nie. (3) geen beduidenheid van verskille tussen die amerikaanse en suid-afrikaanse groepe kan bereken word nie. (4) 'n blote vergelyking van die engelse en afrikaanse groepe is wel moontlik maar sou van weinig nut wees sonder 'n gemeenskaplike verwysingspunt met betrekking tot die gestandaardiseerde amerikaanse gegewens. op grond van hierdie gegewens is besluit om alleenlik 'n kwalitatiewe analise van die toetsresultate te onderneem. die doel van hierdie ondersoek is immers nie om 'n aanpassing en vertaling van die itpa te standaardiseer nie, maar slegs om die moontlikheid van sodanige navorsing te ondersoek. vir hierdie doel is 'n kwalitatiewe analise dus van groter waarde as statistiese gegewens wat, op grond van die klein monster, geen ware betroubaarheid en geldigheid inhou nie. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 18,desember971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 elsie c. lotter gegewens is dan wel op die volgende wyses ontleed: (1) (a) die profiele van die afrikaanse groep is vergelyk met die van die engelse groep. : (b) .die profiele van al die lede van die toetsgroep is met mekaar vergelyk. _ (2) vir elke, subtoets is die gemiddelde routelling van die engelse en afrikaanse' toetsgroepe met mekaar vergelyk, sowel as met die routelling op elke subtoets wat met 'n skaalpunt van 36 ooreenstem (aangesien skaalpunt 36 as geniiddeld gebruik is by die s'tandaardisering van die itpa—kirk, mccarthy and kirk7). • (3) beduidende teenstrydighede, soos deur die· opstellers verduidelik (kirk, 'mccarthy-and kirk7) word, gebruik om die psigolinguistiese vermoens van afrikaanssprekende en engelssprekende kinders, soos dit ooreenstem met die waarde soos dit deur die opstellers in volgorde geplaas is. (5) toetsitems van die verskillende subtoetse waar daar 'n verandering nodig was by die vertaling, word ^ ondersoek met betrekking tot die aantal foutmakers op daardie items, in beide die engelse en afrikaanse weergawes. !11 -.-journal of. the south african speech and hearing association, vol: 18, december.' 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) n u t van ,,ιτρα" en ondersoek n a aanpassing by s.a. o m s t a n d i g e d e 31 e. die resultate i. vergelyking van proflele die volgende kan hier opgemerk word: (1) die proflele van die engelstalige groep is meer homogeen en verloop platter as die proflele van die afrikaanstalige groep. (2) by die afrikaanstalige groep verloop die proflele van die dogters oor die algemeen effens meer gelyk as die van die seuns. (3) die proflele van die engelstalige groep verloop op 'n effens hoer vlak as die van die afrikaanstalige groep. (eg. groep se proflele verloop meestal tussen 36 en 44, ig. groep s'n-meestal tussen 28 en 36 met uitsondering van 'n klein verhoging by_ontvangs en assosiasie.) (4) albei groepe toon homogene hoe prestasie in klanksamevoeging. (5) die toets waarby die mees homogene prestasie van die afrikaanstalige groep voorkom (met uitsondering van klanksaamvoeging) is ouditiewe reeksgeheue—prestasies strek van 28 tot 39. die mees homogene prestasie by die engelstalige groep, daarenteen, strek slegs oor 4 punte, nl. 36 tot 40, by visuele assosiasie. ~subtoets no. 1 2 3 4 5 " 6 7 8 9 10 11 12 (gemiddelde roupunttelling groep e)— (gemiddelde roupunttelling groep a) 1 . 8 0 . 4 3.6 3.9 7.5 1 . 6 1 . 2 1 1 . 2 . 5.4 .7 3 . 6 2 . 1 {gemiddelde roupunt'telling groep χ)—~ {gemiddelde roupunttelling groep e) 1 . 0 0 . 2 4 . 8 0 . 7 5 . 3 1 . 7 · 2 . 8 6 . 7 2 . 2 . 1.5 4.9 6 . 5 {gemiddelde roupimtlelling groep x)— {gemiddelde roupunttelling groep a) 0.8 -0.2 1 . 2 2.2 , 2 . 2 "-0.1 4.0 4.5 3.2 " 2 . 2 1.3 8 . 6 tabel i—verskille tussen roupunt-gemiddeldes van die verskillende groepe. groep a = afrikaanstalig; groep ε = engelstalig; groep x = amenkaans. •ii. intertoets-vergelykings op grond van roupunttellings r· (]); op grond van hierdie vergelykings blyk dit weereens dat die engelstalige groep oor die algemeen beter presteer as die afrikaanstalige groep (die routelling-gemiddelde van die engelstalige •groep.is hoer as did van die afrikaanstalige groep in 9 van die 12 subtoetse). (2) die engelstalige groep se'gemiddelde roupunttellings is oor die algemeen ook hoer as did van die amerikaners (nl. in 8 van die 12 subtoetse). die afrikaanstalige groep presteer swakker as die amerikaanse groep in 8 vari die 12 subtoetse. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, • vol·. 18, desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 elsie c. lotter (3) albei die suid-afrikaanse groepe verkry 'n hoer gemiddelde roupunttelling as die amerikaners in subtoets no. 3 (visuele reeksgeheue), 6 (visuele assosiasie) en 12 (klanksaamvoeging). (4) die grootste verskil tussen die gemiddelde roupunttellings van die suid-afrikaanse groepe kom voor by toets no. 8 (verbale uiting), waar die gemiddelde roupunttelling van die engelstalige groep 11,2 hoer as die van die afrikaanstalige groep is. subtoets no. aantal ti wat versk letslinge i 10 toon aantal ti wat verskil letslinge 1 0 toon subtoets no. groep ε groep a groep ε groep a 1 2 3 4 5 6 7 8 9 10 11 .12 1 1 1 1 1 6 1 2 2 7 1 1 1 2 totaal 2 9 12 5 tabel ii—verskille tussen subtoeis-skaalpunt en gemiddelde skaalpunt—aantal toetslinge in elke subtoets wat 'n betekenisvolle verskil toon. groep a = afrikaanstalig; groep ε = engelstalig. iii. vergelyking van betekenisvolle teenstrydighede by die twee suid-afrikaanse groepe (1) die engelstalige groep toon betekenisvolle teenstrydighede op slegs 5 subtoetse, die afrikaanstalige groep op 6 subtoetse. (2) die totale aantal positiewe teenstrydighede ( + 10) vir albei groepe saam, is 11; hiervan val 9 in die afrikaanstalige groep. dfe totale aantal negatiewe teenstrydighede ( 10) is 17; hiervan val 12 in die engelse groep. as toets 11, ouditiewe sluiting (waar al die lede van die engelstalige groep besonder swak vaar) egter uitgeskakel word, is daar 10 teenstrydighede waarvan 5 in elke taalgroep val. die afrikaanstalige groep het dan 'n totaal van 14 en die engelstalige groep''n totaal van 7 betekenisvolle teenstrydighede, wat die waarneming ten opsigte van die groter heterogeniteit van die afrikaanstalige groep se profiele, ondersteun. 1 iv. vergelyking tussen toets-items van elke subtoets in hierdie afdeling word slegs die toetse wat 'n afgebakende aantal toets-items bevat, bespreek. die volgende toetse kan nie op grond van journal of the south african speech and hearing association, vol december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) n u t van ,,ιτρα" en ondersoek na aanpassing by s.a. omstandigbede toets-items beskou word nie: visuele sluiting, verbaie uiting, handgebare uiting. toets no. aantal items nommers van items waar mee r as vier foutmakers voorkom toets no. aantal items afrikaanse weergawe engelse weergawe 1 2 3 9 11 25 20 13 17 15 13 14, 4, 11 9 10 12, 18 12 tabel iii—items van verskillende subtoetse waarop meer as 4 foutmakers voorkom. die items van die subtoetse van die itpa is in 'n sekere volgorde volgens moeilikheidswaarde gegradeer. hierdie afleiding word gemaak uit die feit dat dit moontlik is om 'n toetsling se plafon te bereken op grond van die hoeveelheid items waarop hy agtereenvolgens misluk; net so word die sg. basale peil bereken op grond van die aantal items waarop hy agtereenvolgens welslae behaal. wanneer die itpa by 'n besondere kultuurgroep aangepas wil word, sal dit nodig wees om ondersoek in te stel of die moeilikheidswaarde van die toetsitems dieselfde bly (op grond van die aantal foutmakers, in elke ouderdomsgroep, op elke toetsitem). die moontlikheid dat die item kultuurvreemd is, moet in elke geval ondersoek word. ook moet die aantal items wat vir die berekening van die plafon en basale peil gebruik word, in gedagte gehou word. slegs dan kan 'n tentatiewe nuwe gradering van items aangepak word. so 'n itemskommeling kan dus nie op grond van die resultate van hierdie ondersoek oorweeg word nie. die enigste veronderstelling wat hier gebruik kan word, is die volgende: waar daar in die hoogste ouderdomsgroep meer as 50% foutmakers voorkom op 'n spesifieke item, behoort daardie item in die tweede helfte van die betrokke subtoets gegradeer word. op grond van hierdie aanname sou, vir die toetsgroepe wat in hierdie ondersoek gebruik is, die volgende subtoetsitems hoer opgeskuif moet word: (a) subtoets 1: items 13 by afrikaans en 10 by engels. (b) subtoets 2: items 12 en 18 by engels. -(c) subtoets 3 : item 12 by engels. (d) subtoets 9: items 4, 11 en 14 by afrikaans. (e) subtoets 11: item 9 by afrikaans. die items waar daar 100% foutmakers voorkom, kan moontlik kultuurvreemde items wees. by verskillende toetse is wel sulke items gevind. v. ondersoek na items wat in die afrikaanse vertaling verander is (1) die volgende van hierdie items is blykbaar deur die afrikaanse groep moeiliker gevind as deur die engelse groep, aangesien daar meer foutmakers voorgekom het: tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 18, desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) elsie c. lotter . toets 1: items 24, 44. toets 9: items 23, 26, 27. toets 11: items 24. dit is moontlik dat dit die verandering in die vertaling is wat hierdie items moeiliker maak; op grond van die groot heterogeneiteit van die profiele, asook die feit dai die profiele van die afrikaanse kinders oor, die algemeen laer as die van die engelse kinders le. is dit egter moeilik om betekenisvolle afleidings te maak. (2) die volgende veranderde items is blykbaar deur die afrikaanse kinders makliker gevind as deur die engelse groep: toets 1: items 37, 45. toets 11 : items 18, 21, 25, 27. toets 12: items 6, 19, 21, 22. • dit is "moontlik dat die verandering by die vertaling hierdie items makliker gemaak hot, veral in toetse" 1 en 9 waar die engelse kinders gemiddeld beter as die afrikaanse kinders presteer het. bespreking van resultate die bespreking van die bevihdings berus op 'n baie tentatiewe grondslag, hoofsaaklik as gevolg van die klein aantal proefpersone. nogtans kom daar uit die gegewens sekere riglyne te voorskyn, wat gevolg kan word wanneer 'n meer intensiewe en omvattende ondersoek onderneem word. op grond van die vergelyking tussen die verskillende profiele en gemiddelde roupunttellings, is dit duidelik dat daar heelwat veranderinge nodig isal wees voordat die kwantitatiewe resultate van die itpa, soos v e r k r y r . v a n ; suid-afrikaanse toetslinge, met 'n, voldoende mate van geldigheid gemterpreteer kan word. die engelstalige toetsgroep se profiele toon 'n daling by ouditiewe sluiting; b y ' n aaripassing van die itpa aan suid-afrikaanse omstandighedel s a l r d u s veral .aan hierdie toets aandag gegee moet word ten opsigte' vair toepaslike." kriteria. daar moet ook in gedagte gehou word dat drie items..van.hierdie toets bykans 100% foutmakers in die engelss'prekende toetsgroep opgelewer het. in die v i s u e l e sluiting-subtoets, waar albei die suid-afrikaanse toetsgroepe s w a k k e r as diecamerikaanse standaardiseringsgroep presteer, sal nuwe kriteria ook waarskynlik nodig wees. die afrikaanstalige groep presteer relatief goed in ontvangs en assosiasie (op die voorstellingsvlak). ook by hierdie subtoetse is dit baie waarskynlik dat :n nuwe skaaltellingsbewerking nodig sal wees. ten opsigte van die klanks a a m v o e g i n g s t o e t s moet nuwe norme ook veral oorweeg word, aangesien beide suid-afrikaanse groepe hierin hoer as die amerikaners presteer. hierdie hoer prestasie kom in 'n mindere mate ook voor by visuele reeksgeheue en visuele assosiasie. navorsing kan hier aang e v o e r word met betrekking tot die invloed van onderrigmetodes in suid-afrika eh die iverenigde" state van amerika; dit. is moontlik dat die suid-afrikaanse skoolkind meer op die visuele aangewese is by skoolwerk, dit wil se daar word meer skryf en leeswerk van hom verjournal of the south african speech and hearing association, vol, 18; december -1971: r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) n u t van ,,ιτρα" en ondersoek na aanpassing by s.a. omstandigbede 35 wag as van die amerikaanse skoolkind. in baie amerikaanse skole speel sg. "show-and-tell"-klasperiodes 'n vername rol en daar word dikwels van die kind vereis om sy skoolwerk voor te dra. dit is dus moontlik dat hy minder visueel gerig is as die suid-afrikaanse kind, of minder gerig op die doelbewuste ontleding en sintese van woorde. die feit dat die engelstalige toetsgroep se proflele op 'n hoer vlak as die afrikaanstalige toetsgroep se proflele verloop, kan beskou word as nogmaals.'n aanduiding van die behoefte aan nuwe stelle norme en skaalpunte vir elke groep. dit kan egter ook beskou word as 'n aanduiding daarvan dat die engelstalige suid-afrikaanse kind oor 'n sterker algemene psigolinguistiese vermoe as die afrikaanstalige. kind beskik. daar kan in hierdie rigting as volg gespekuleer word: engelse kinders geniet oor die algemeen meer vryheid as afrikaanse kinders ten opsigte van spraakgeleenthede en uiting; in baie afrikaanse huisgesinne word van kinders verwag om nie in volwasseries se geselskap mee te doen nie, slegs te praat wanneer daar met hulle gepraat word, ens.̂ daar is dus 'n sterk faktor van inhibisie teenwoordig; moontlik ook 'n volkskaraktertrek van inkennigheid. hierdie faktore kan 'n invloed op. die ontwikkeling van die afrikaanse kind se psigolinguistiese vermoens uitoefen anders gestel: die basiese vermoens is wel teenwoordig maar kan nie vryelik tot uiting kom nie. hierdie verskynsel word veral betekenisvol in die lig daarvan dat die ouderdomme van die afrikaanstalige toetslinge eintlik bokant die ouderdomsgrense van die itpa val. die relatiewe areas van sterk en swak psigolinguistiese funksionering by die twee toetsgroepe soos dit in hierdie ondersoek na vore^gekom het, openbaar geen betekenisvolle patroon van vermoens of onvermoens vir die engelstalige groep nie, en slegs 'n aanduiding van 'n relatiewe sterkte • in die visuele kanaal by die afrikaanstalige groep. die moontlike implikasie hiervan is reeds bespreek. die verskille tussen die groepe wat by die intertoets-vergelykings gevind is, kan van nut wees by die aanpassing en vertaling van die itpa. 'n verskynsel wat deeglik nagegaan sal moet: word, is die heterogenei'teit van die afrikaanstalige toetsgroep se proflele. . die ongelyke verloop kan moontlik die gevolg van die vertaling wees; d a a r kom egter 'n ewe groot mate van variasie by vertaalde en nie-vertaalde toetse (bv. die reeksgeheue-toetse) voor. aangesien die toetsmonster so klein is, is dit moontlik dat daar toevallig onder die spesifieke gekose toetslinge groot veranderlikheid voorkom, wat nie die geval by 'n ander toetsgroep, bestaande uit dieselfde aantal toetslinge, sou wees nie. by 'n werklike vertaling en aanpassing van die itpa, sal die toetsitems van elke subtoets waarskynlik in 'n nuwe volgorde gegradeer moet word ten einde dit steeds moontlik te maak om op stelselmatige wyse by elke subtoets 'n basale peil en 'n plafon uit te ken, soos reeds bespreek is phillips9 het gevind dat die subtoetsitems van die itpa herrangskik moet word wanneer die toets op britse skoolkinders toegepas word, aangesien die moeilikheidswaarde van die items nie dieselfde is vir britse en amerikaanse kinders nie. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 elsie c. lotter phillips het verder bevind dat sekere subtoetsitems kultuurvreernd aan die britse kind is; dieselfde oorweging geld by suid-afrikaanse kinders. op grond van hierdie resultate wat uit die voorlopige ondersoek verkry is, wil dit voorkom dat veral die volgende items in gedagte gehou moet word: (a) wat beide taalgroepe betref: toets 4, item 30: " a rabbit has a tail; a train has a . . . (caboose)." toets 4, item 42: "years have seasons; dollars have . . . (quarters)." (b) wat meer spesifiek die engelstalige groep betref: · toets 1, item 45: "do beverages quench?" toets 2, item 49: hier word 'n stimulusprent van 'n kompas aangebied, en daarna 4 ander prente wat o.a. 'n soort kompas insluit. toets 11, item 21: / a n / a / a u s (santa claus). 23: /ovie/tar (movie star): 27: ea/ter/unny (easter bunny). (c) wat meer spesifiek die afrikaanstalige groep betref: toets 2, item 30: 'n stimulusprent van 'n tennisraket word aangebied; die verlangde responsprent is 'n bofbalkolf, maar die 4 alternatiewe prente sluit ook 'n roeispaan in en die afrikaanse kinders het meestal lg. as respons aangewys. toets 2, item 35: die stimulusprent, 'n uurglas, skyn onbekend te wees. 39: ook hier skyn die stimulus-prent, 'n televisielugdraad onbekend te wees. om werklik geldige afleidings te maak, sou dit nodig wees om vir elke item nie alleen die aantal foutmakers na te gaan nie, maar ook die soort fout wat gemaak is, dit wil se watter alternatiewe respons is mees dikwels as die korrekte aangewys. die afrikaanse vertaling van die grammatikale sluitingstoets sluit twee items waarop 100% foutmakers voorkom in; dit is nl. die twee items waar die sterk vorm van die verlede deelwoord verlang word. dit het tydens die afneem van die toets, duidelik geblyk dat hierdie werkwoordvorme nog nie aan die kinders in die betrokke ouderdomsgroep bekend is nie. dit sou miskien meer toepaslik wees om twee verkleinwoorde in die plek daarvan te stel; hierdie woordverbuiging kom selde in engels / amerikaans voor, net soos wat die sterk verlede deelwoord betreklik selde in afrikaans voorkom. verdere bespiegelinge aangaande die resultate van die ondersoek is wel moontlik; aangesien sodanige bespiegelinge egter o[vgeen vaste grondslag kan berus nie, word hiermee volstaan. die vertaling van die itpa wat in hierdie studieverslag aangebied word, word nie voorgehou as geslaagd of misluk, of selfs as voorbeeld van die lees waarop die vertaling geskoei moet word nie. dit word bloot voorgels as die mees direkte vertaling van die toets wat moontlik was. benewens die feit dat die itpa self 'n amerikaans-georienteerde instrument is, moet in gedagte gehou word dat die kriteriumtoetse waarmee die konkurrente geldigheid bepaal is, ook amerikaanse toetse is. journal of the south african speech and hearing association, vol 18 december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ,,ιτρα" en ondersoek na aanpassing by s.a. o m s t a n d i g e d e 37 bestaan daar suid-afrikaanse toetse wat as kriteriumtoetse aangewend kan word? . . die hoofdoel van die ondersoek wat hier onderneem is, is herhaaldelik reeds gestel as die bekom van leidrade vir die opstelling van 'n eie suid-afrikaanse toets vir psigolinguistiese vermoens. as hierdie ondersoek en bespreking slegs meehelp tot 'n besef van die behoefte aan eie, suid-afrikaanse instrumente vir die ondersoek en diagnose van taalgestremdes, het dit in sy doel geslaag. uit 'n ondersoek na die toepassingsvlakke van die itpa op die gebied van die spraakheelkunde asook die kliniese nut van die itpa, het die hoe nuttigheidswaarde van hierdie toets te voorskyn gekom. een van die vernaamste uitdagings aan die suid-afrikaanse spraakterapeut is om, benewens die taak van ondersoek, diagnostisering en hulpverlening, ook die taak van intensiewe navorsing op te neem en sodoende kultuur-eie wetenskaplike instrumente daar te stel. opsomming aangesien die spraakterapeut in suid-afrika met twee taalgroepe (engels en afrikaans) te doene kry en oor geen kultuur-eie toets vir psigolinguistiese vermoens beskik nie, is 'n voorlopige ondersoek uitgevoer na die moontlikheid van 'n aanpassing van die itpa by suid-afrikaanse omstandighede, asook 'n vertaling in afrikaans, 'n voorlopige vertaling, en wel so direk as moontlik vertaal, is opgestel en toegepas op 'n klein groepie afrikaanssprekende kinders, terwyl die oorspronklike itpa op 'n groepie engelssprekende kinders toegepas is. uit die resultate van hierdie voorondersoek het dit duidelik geblyk dat heelwat verandennge nodig sal wees vir 'n aanpassing en vertaling van die itpa. die ideaal is steeds die opstel van 'n eie suid-afrikaanse toets. summary since the speech therapist in south africa deals with two language groups (english and afrikaans), and has no specifically south african test of psycholinguistic abilities available, a preliminary study was conducted to investigate the possibility of adapting the itpa to south african conditions, as well as translating the test into afrikaans. a preliminary translation, as direct as possible, was prepared and administered to a small group of afrikaans-speaking children, while the original itpa was administered to a group of english-speaking children. the results of this pilot study indicate that an adaptation and translation will necessitate many modifications. the construction of a south african test to assess psycholinguistic abilities is urgently required. bibliografie 1. bateman, b. d. linguistic abilitit tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol. 18, desember 1971 1 bateman b. d. (1968): interpretation of the 1961 illinois test of psycholinguistic abilities. special child publications, seattle, washington. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 ' ' • elsie c. lotter 2," bateman, β. d. (1965): the illinois lest of psycholinguistic abilities in ' current research. institute for research on exceptional children, university . of illinois.. . . . 3: bateman, b. d. (1965): the role of the illinois test of psycholinguistic abilities in differential diagnosis and programme planning for mentally retarded. american journal of orthopsychiatry, vol. 35. .4., battin, r. r. and haug, c. (1964): speech and language delay. charles c. thomas, springfield, illinois. "5. berry, m. f. (1969): language disorders of children: the bases and diagnoses. appleton-century-crofts, educational division, meredith corporation, new york. 6. darley, f. l. (1964): diagnosis and appraisal of communication disorders. prentice-hall, englewood cliffs, n.y. 7. kirk, s. α., mccarthy, j. j.· and kirk, w. d. (1968): examiner's manual: illinois test of psycholinguistic abilities, rev. ed. board of trustees of the university of illinois. 8. osgood, c..e. and miron, m. s. (eds.) (1963): approaches to the study of aphasia. univ. of illinois press, urbana. 9. phillips, c. j. (1968): the itpa: a report on its use with english children. british journal of communication disorders, vol. 3, no. 2. journal of the south african speech and hearing association, vol 18 december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society the post operative progress of a child suffering traumatic cerebral lesion c. w. law, m.b., f.r.c.s. (neurosurgeon) * this case report is submitted to illustrate the progress made by a six-year-old child following a cerebral gun-shot lesion. it includes a copy of the neurosurgeon's notes on the case and the speech therapist's original assessment. the child's vocabulary on initial testing consisted of only three words; detailed1 assessment revealed, however, an almost purely expressive aphasia. in spite of his restricted vocabulary and limited natural "speech" recovery, prognosis was considered hopeful. neurosurgeon's notes: report on child p.d. aged 6 years. first seen and examined on the 19.1.57. chief complaint: child was accidentally shot by a 0.22 rifle at 5.30 p.m. on the 18.1.57 history: child was able to walk for a short distance after the shooting but then collapsed. was taken by a 'doctor to bloemhof hospital and later transferred to wolmaranstad. the doctor undoubtedly saved this child's life, by the prompt administration of plasma and dextron. at 11 p.m. telephonic arrangements were made for his admission to a johannesburg nursing home, and the theatre was prepared for immediate operation. a pint of group ο blood was ordered at the same time. examination: on admission at 3 a.m. i examined the child. grossly shocked and of a waxy whiteness. pulse 200, thready, with questionable systolic pressure of 60. respiration exceedingly shallow, and variably rapid. skull: there is an entrance wound 2" above the left zygema and about 2 " in front of the line of the audrey shavell, b.a. log (rand)* senior supervisor, university speech, voice and hearing clinic. external meatus. no powder marks visible. the whole of the left side of the scalp was soft and bulging. a jagged exit wound just to the left of the midline in the posterior parietal region was oozing blood' clot and brain tissue. the child could be roused by painful stimuli. pupils : absolutely pin point and fixed. gross left sided facial paralysis. left ear full of dried blood, no rupture seen. no bleeding from nose or mouth. total flaccid paralysis of the right side. a saline cut-down was immediately set up and replaced with the blood1 on its arrival. arrangements were made with the anaesthetist to commence operation as soon as condition improved slightly as local anaesthetic was not sufficient for cleaning purposes. straight portable x-rays of skull taken with artery forceps used as a marker for the entry wound. there was a grossly comminuted disruptive fracture of the left side of the cranium. operation notes the whole scalp was carefully cleaned, with spirits and spirit soap. the two wounds were separately cleaned with saline irrigation and hydrogen peroxide. the exit wound was then carefully de'brided as the amount of bruised tissue was tremendous. the wounds were then joined by a slightly curved incision. exuded brain tissue was present in the subgalea'l space and contused oedematous brain oozed forth under great pressure between a number of opened fracture lines. an attempt was made to preserve a pericranial layer. loose fragments of bone were removed and other attached pieces which were displaced inwards were removed by nibbling. the dura was ruptured along the line of the wound and innumerable cortical vessels were ruptured and oozing continually. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) e journal of the south african logopedic society steady work with suction and the electocautery gradually reduced the chaos to some order and the child's desperate condition improved. the wound area was continually sluiced and warmed saline and ηό 3 in view of the grave danger of infection. only grossly damaged cerebral tissue was removed, haemostasis achieved, gelfoam employed and the area protected by strips of gutta percha while an attempt to close the dura was made, but complete closure was impossible. hitch sutures were employed to prevent further dura stripping. a pericranium was reconstructed. the scalp was sutured in two layers and a drain inserted through a separate slab incision. the child received 500 ccs of whole blood on the table, and1 then i.v. saline was commenced. he received 1,000,000 units of penicillin on the table. 20.1.57 child is holding his condition. slight movement is present in the right arm, but to date no movement of the right leg. he is taking small amount of fluid by mouth, so the i.v. drip has been discontinued. 22.1.57 the wound is well healed and sutures removed. no evidence of infection. there is one small area near the exit wound which is bulging, and arrangements for a protective guard1 have been made. 24.1.57 there has been no increase in size of the slight bulge in the scalp wound of the left parietal region, the midline comprehension is good, but no speech to date. occasional movement has been seen to date in the right arm, but none in the right leg. to continue on phenobarb gr. 1 t.d.s. plastic repair to be considered very much later. university speech, voice and hearing clinic report name: p . d / age: 6 years. date of examination: 25-3-57. brief medical history: child was accidentally shot while travelling in a car approximately two months ago. the bullet entered the left temporal lobe and came out of the left occipital lobe. sheared motor cortex and broca's area. angular gyrus probably also damaged. was left speechless with a complete right sided hemiplegia. movement is gradually returning to the right side. * acknowledgement is made to witwatersrand university speech, voice and hearing clinic for permission to publish the material on this case. physical defect: right hemiplegia. is able to walk unassisted. does not use right hand as an assisting hand. can ride a tricycle alone. laterality: handedness: prior to accident right. has one brother who is left-handed. now uses left hand entirely. points, eats and uses left hand for all skilled activities. eyedness: right on repeated testing. footedness: not tested, refused to co-operate. intelligence: prior to accident — apparently normal. present functional intelligence appears unimpaired. educational history: has never been to school or nursery school, so estimate of degree of retention of previous learned material could not be made. home language: afrikaans. present vocabulary: tong, hek, nee. comprehension of spoken language: he understands everything, according to parents. method of communication at home: by gesture. behaviour problems: none, according to parents. oral peripheral: appearance and movement of all parts of the speech mechanism are normal. no evidence of paralysis or atrophy was seen. a detailed examination was not possible as the child was very nervous. form and shape perception: appears intact. has retained concepts of big and small and showed no confusion or trial and error behaviour on these tests. hand-eye co-ordination and manual manipulation: good for his age. has complete control of left hand. memory for coloured objects: remembered 5 out of 8 single colours. failed memory for double and three colour sequences, but immediately saw that his responses were incorrect and spontaneously corrected them. pictorial associations: the child was shown 12 sets of pictures, each set consisting of 4 single pictures and 2 mounted pictures with a recess for a third. he was required to select from the single pictures the one that was associated1 with the mounted picture, e.g. aeroplane, bird, , car, engine, kite, antelope. he scored 8out of 12, which is at the 7 year level. he is also obviously capable of making associations. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 1 journal of the south african logopedic socie december tests for primarily receptive aphasic disturbances: a.—agnosias: 1. visual agnosias: (a) common objects intact. (b) pictures intact. (c) colours intact. (d) forms intact. 2. auditory agnosias: (a) recognition of sounds: coughing, whistling, humming, etc. refused to co-operate. (b) word identification: all correct. 3. tactile agnosias: (astereognosis) left hand — intact. right hand — intact. b. aphasias: 1. auditory verbal comprehension: answers to questions by gesture or pointing, or following commands, intact. 2. ability to remember and execute complex (double) commands intact. tests for predominantly expressive disturbances: a. apraxias: 1. non-verbal: (a) body parts. intact. (b) simple skills. intact. (c) pretended action. intact. 2. verbal repetitive speech: (a) repetition of numbers. (b) repetition of words. (c) repetition of sentences. was unable to repeat any of above material. was acutely aware of his own inadequacies and reacted in a shy manner, burying his head in his father's lap and refusing to look at the therapist or the testing material. b. aphasias: 1. there is no automatic speech or singing present. 2. other expressive language activities like spelling, writing from dictation, arithmetic, oral reading, clock setting were not tested, as the child has not had the opportunity of learning them prior to the accident. conclusions: 1. this child appears on initial testing to be an almost pure expressive (motor) aphasic. 2. intelligence pri!or to the accident is not known, but from the parents' reports seems to have been normal. no intellectual retardation appears to have taken place. 3. none of the typical signs of the "brain-injured child", viz. catastrophic reaction, perseveration lack of emotional control, hyper-irritability and distractability were seen during his two-hour observation at this clinic. prognosis: appears to be favourable in view of his age and the apparent absence of the disturbing characteristics usually found in the brain-injured child. accurate prognosis for the regaining of language and speech is always difficult to make, but after a trial period of intensive therapy it will be possible to comment on factors such as speed of learning, retention of learned materials, fatigueability, etc. miss bessie dembo 54 wingate mansions cor. smit & nugget streets, hospital hill, johannesburg phone 44-0860 typing and roneoing undertaken, especially theses and students' notes. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) e journal of the south african logopedic society presentation of case to group of neurologists at the first meeting at which he was presented, it was considered that should speech return, it would be at the best indifferent. as far as the right hand was concerned, the opinion was, that at the very best, this would be merely a support. an interesting medical question was as to whether the plate should be inserted at this stage, in view of the fact that further skull growth would make the plate too small in the future, but in view of his extreme activity it was decided that he should be afforded the added protection as he continually disregarded his protective skull cap. follow-up report medical & surgical condition: post-operative recovery was uneventful in that he has never suffered from fits, dizziness, double vision, headaches, etc. he wore an alluminium protective cage until august, 1958. on 14-8-58, a plastic plate was inserted into the left side of the head. he was hospitalised for only five days, has since worn no protective head covering. he was referred to an orthopedic surgeon in july 1957 and was fitted with a fulllength brace for the right leg which he wore for two months. speech and language: because of transport difficulties it was not possible to arrange immediate therapy for this child; it was therefore decided to give the parents a home programme and' observe the natural recovery. six months after the operation, he started using single words. this was soon followed by the use of sentences. general vocabulary increased. at the last re-check (14-10-58), it was found that he has a complete vocabulary and converses in full sentences. when fatigued he occasionally omits a verb, e.g. ek nie skool toe gaan for ek wil nie skool tot gaan nie. he has full and complete movement of all parts of the speech mechanism, diadochokinesis normal, basic functions normal, no articulatory errors. memory and concentration are excellent. he is a very observant child, playful, has a long attention span and mixes well with other children, both siblings and school peers. hemiplegia still has a slight limp and has only recently begun to use the right hand in a few activities, e.g. when he wakes in the morning, stretches both arms up and recently began opening right hand. he does not use the right hand as an assisting hand. all skilled activities are quickly and accurately performed with the left hand. he writes very well with his left hand and according to his father has the best hand-writing of all the children in the family. schooling: he commenced school in january, 1958 and is one of the best pupils in his class. he manages all subjects easily except for arithmetic. he appears to have some difficulty in grasping number concepts. this must be watched as it may be an indication of impairment of the abstract attitude as defined by goldstein. he gets on extremely well with the children at school and is very fond of school. conclusion: this case has been reported in some detail, to illustrate the importance of making a detailed assessment of speech and language in aphasic patients. when first seen, eight weeks after the accident, the child's vocabulary consisted of three words. prognosis might therefore have superficially appeared to be very poor. detailed testing revealed, however, a much brighter picture and subsequent development has attested to the accuracy of the original diagnosis and prognosis. this advertisement sponsored by george ingram chemist and nemzer's fisheries r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sajcd 124 vocabulary used by ethno-linguistically diverse south african toddlers: a parent report using the language development survey a gonasillan,1 ma(aac); j bornman,1 phd; m harty,1,2 phd 1 centre for augmentative and alternative communication, university of pretoria, pretoria, south africa 2 communication sciences and disorders, university of cape town, cape town, south africa corresponding author: j bornman (juan.bornman@up.ac.za) objective. the primary aim of this study was to ascertain the relevance of the vocabulary of the language development survey (lds) for typically developing south african toddlers who attend ethno-linguistically diverse early childhood development centres. rationale. the need for exploration of the expressive vocabulary of this population stems from the diverse linguistic contexts to which toddlers are exposed on a day-to-day basis in south africa. many parents prefer english as the language of learning and teaching for their child. as a result, toddlers interact with ethno-linguistically diverse peers from a young age, usually within their early childhood development centres. method. an adapted version of the lds was presented to 40 middle-class parents in mpumalanga. vocabulary commonly used by toddlers was determined and a comparison of parent responses made between the present study and the original american-based survey. results. results revealed that nouns were used most often by toddlers, in keeping with research on vocabulary acquisition. significant correlations between the two groups were evident in 12 of the 14 categories. parents reported that nouns, verbs, adjectives and words from other word classes were used similarly by toddlers, despite differences in their linguistic exposure. conclusions: these findings suggest that the lds is a valuable clinical screening tool for speech-language therapists who deliver services to toddlers within the south african context. keywords: ethno-linguistically diverse, monolingual, parent report, toddlers’ language development, vocabulary s afr j cd 2013;60:10-15. doi:10.7196/sajcd.124 irrespective of culture, the ability to use and understand language is essential to life, as language provides a mechanism for establishing interpersonal relationships, regulating the behaviour of others, satisfying needs and desires, exploring and organising the environment and exchanging information and additional messages with others (cole, 1982). toddlers must be taught the function of language and how to produce and use it in ways which are congruent with other members of their culture. parents and other competent language users therefore prepare toddlers for learning language by first assisting them in experiencing and appreciating the pleasure, knowledge and security that emanate from social interaction. research has indicated that the quality of the language input during these early years not only impacts significantly on the development of oral language skills, but also on later success in literacy (bleses, vach, jørgensen & worm, 2010; kelly, 2010; rijlaarsdam et al., 2013). within the social constructivism approach to language development (vygotsky, 1978) the role of more competent adult role models cannot be underestimated in the development of a child’s language skills. parents are the first communication partners a young child encounters and certainly remain the most influential during the early years (schiff & lotem, 2013). parents engage in the process of scaffolding, whereby they guide their child from simpler to more complex language forms. scaffolding allows children to perform tasks that would normally be slightly beyond their ability without that assistance and guidance from the competent adult language user. as such, parents are experts in understanding and describing their child’s language abilities. research evidence shows that parents are good informants regarding their child’s expressive language development and are able to provide accurate information pertaining to their child’s language abilities (feldman et al., 2005). for this reason professionals often rely extensively on parent report as a supplementary assessment tool for understanding the language acquisition of young children (dale, bates, reznick & morisset, 1989; kelly, 2010). parent diary studies have been used for over 50 years to explore the gradual development of child vocabulary (berko, 1958; bleses et al., 2010). however, because of the impracticality of these studies they were replaced with vocabulary checklists which are more structured, practical and easy to use (rescorla, alley & christine, 2001). vocabulary checklists used in research with toddlers are the macarthur communicative development inventory (cdi) (fenson et al., 2000) and the language development survey (lds) (rescorla, 1989). the lds, used in this study, was developed more than 20 years ago as a simple and inexpensive screening tool to identify expressive language delay in toddlers (rescorla & achenbach, 2002). it can be completed in about 10 minutes, requires only primary school literacy skills, needs no professional staff for administration and is easy to score (rescorla et al., 2001). furthermore, it has good psychometric properties (rijlaarsdam et al., 2013). the lds is a highly reliable instrument. rescorla (1989) reported cronbach alpha consistency of 0.99 for a 1-week test-retest in a sample of 81 toddlers, while rescorla and alley (2001) reported a test-retest reliability of 0.97 (p<0.001) using the pearson correlation in a sample of 66 toddlers whose mothers completed the lds on two occasions, an average of 23 days apart. the validity of the lds has been demonstrated by numerous studies. in an epidemiological survey of 422 toddlers, rescorla and alley (2001) reported excellent concurrent validity, with high correlation between reported and tested vocabulary (0.69 and 0.74). predictive validity measured by correlations between the lds and the reynell expressive language scale were also very high (0.78 and 0.81). using language test performance as the ‘gold standard’ for ‘true’ delay, the lds sensitivity has generally been 80% or better and the lds specificity 85% or better (rescorla, 1989; rescorla & achenbach, 2002; rescorla & alley, 2001). in summary, research shows that the lds has good reliability, validity and clinical utility. since its inception, the lds has undergone continuous revision with the goal of maximising coverage of important vocabulary items and minimising redundancy (rescorla, 1989). the most recent revision contains 309 different words arranged in 14 semantic categories. this length seems sufficient to cover a large enough range of early vocabulary without being overwhelming (rescorla, mirak & singh, 2000). the rationale for the development of vocabulary checklists is based on the assumption that language vocabularies of typically developing toddlers contain many of the same items. chomsky (1965) first introduced this notion with his concept of a universal grammar. subsequent researchers supported the idea that, irrespective of ethnic or linguistic background, children move through the same stages of early language development at a fairly predictable rate (cole, 1982). clark (1993) states that, globally, toddlers tend to talk about similar things such as people, food and body parts, while cunningham-anderson and anderson (1999) report that the rates and sequences of language development tend to be similar, regardless of how different the languages may be. caselli, casadio and bates (1999) also found that the onset and subsequent growth of nouns, predicates, function words and social terms between english and italian proved to be similar. this is evident as many of the same words appear in multiple checklists such as the cdi (fenson et al., 1993) and the lds (rescorla et al., 2001). hence the applicability of vocabulary checklists in monolingual contexts is well established (dale et al., 1989). a recent study by barrat, khoza-shangase and msimang (2012) emphasises the need for culturally and linguistically appropriate assessment tools in this country because of multilingualism and ethnic diversity. south africa holds within its constitution 11 official languages (south african constitution, act 108 of 1996) and approximately 36% of homes are bilingual and often use a combination of languages (statistics south africa, census, 2011). in addition to these ‘gold standard’ formal assessment measures mentioned by barrat et al. (2012), speech-language therapists should also gather information about the child’s language functioning with parent-report measures such as the lds (rescorla, 1989; rescorla & alley, 2001) or the cdi (fenson et al. 2000), particularly for toddlers with varied cultural and linguistic systems (kelly, 2010). the applicability of an easy-to-use screening checklist (such as the lds) that compensates for parents who speak english as a second or third language (rescorla, 1989) thus came under review. however, the data demonstrating that parents from bilingual homes are easily able to complete the checklist in english irrespective of whether or not english is their first language, all stem from the usa (rescorla, 1989; rescorla et al., 2000). therefore, the applicability of the lds in a multilingual context rich in ethnic diversity such as south africa has yet to be established. this research aimed to ascertain the relevance of the vocabulary of the lds for typically developing 2-year-old south african toddlers who attend ethno-linguistically diverse early childhood development centres. method objective the primary aim of the study was to ascertain the relevance of the vocabulary of the lds for typically developing 2-year-old south african toddlers who attend early childhood development centres that use english as the medium of instruction, through parent report. two sub-aims informed the primary aim of the study: (i) to describe what south african parents report as commonly used vocabulary items by toddlers; and (ii) to compare parents’ responses using the lds-sa (present study) and the lds (original survey conducted in pennsylvania, usa). design a comparative cross-sectional survey design using an existing checklist was employed. comparisons were made using the spearman rank order correlation coefficient (r). based on these results the lds checklist was verified for toddlers developing within an ethno-linguistically diverse context in south africa. participants parents were recruited from eight similar privately owned early childhood development centres within the emalahleni area, using a purposive sampling approach. emalahleni, also known as witbank, is a growing metropolis within the mpumalanga province. it is a mining community and home to diverse ethnic and linguistic groups. early childhood development centres were contacted and asked to participate if they had 2-year-old toddlers, were within the specified demographic area and were willing to assist the researchers in recruiting parents from their school. eighty per cent of parents who completed the survey instrument were mothers of the toddlers and their ages ranged from 22 to 42 years old. fifty per cent of participants had obtained a college or university degree, 25% a partial college qualification, 20% had completed grade 12 and 5% grade 10 or 11. the majority of parents (80%) were married, while 13% were single. the remaining 7% either did not disclose their marital status or were divorced. less than half (45%) did not have any additional children, implying that they were first-time parents. of those who had more than one child, 40% had only one other child while 13% indicated they had two or more other children. only 3% had more than two other children. all parents were employed and could afford to send their child to an early childhood development centre. ninety-five per cent of parents earned a household income of more than r4 500 per month. the remaining 5% who earned an income less than this amount were primarily from single-parent households. a monthly income of less than r4 500 is not taxable according to the south african revenue service (sars). an equal percentage of parents spoke isizulu or english at home (33%), with 25% speaking afrikaans, 5% sepedi and 3% speaking either siswati or setswana. thus, a total of 6 of the 11 official south african languages were spoken at home. additionally, 74% of parents also spoke english to their child at home. all early childhood development centres used english as the medium of instruction, although toddlers were from varying ethno-linguistic backgrounds. materials a demographic questionnaire was developed to obtain biographical data from parents. it was designed according to the hollingshead (1975) four-factor index of social status and included gender, marital status, education level and occupation of parents. parents were also requested to disclose their monthly income, report on the general development and language development of the child and describe what their home language was, whether multiple languages were used in the household and whether english was spoken to the toddler at home. together with the demographic questionnaire, the lds formed the main instrument used during data collection. the 309 different words included in the lds are arranged in 14 semantic categories (191 nominals and 118 non-nominals) (rescorla et al., 2000). the categories are: food, toys, vehicles, places, actions, outdoors, animals, body parts, household, people, personal, clothes, modifiers and other. all words within these categories can be classified as nouns except for those in the categories action, modifiers and other (rescorla et al., 2000). before distribution of the checklist to participants in the pilot study, a subject matter expert panel was used to determine the suitability of vocabulary for the south african context (gonasillan, 2011). the panel consisted of 2 teachers, 1 occupational therapist, 4 speech-language therapists, 2 augmentative and alternative communication (aac) specialists and the mother of a child with language impairment. the duration of their experience of working with children ranged from 6 to 24 years. it was agreed that 22 vocabulary items on the original checklist be replaced by their south african equivalents in order to ensure cultural, metric and linguistic equivalence (bornman, sevcik, romski & pae, 2010). these items are shown in table 1. the suitability of the suggested vocabulary adaptations was then tested with five typically developing preschool children. their ages ranged from 3:0 years to 6:11 years. the results confirmed the adapted vocabulary items for use in the pilot study. pilot study a pilot study was conducted to ensure accuracy of materials and procedures before commencing the main research project. the researcher selected 1 of the 8 early childhood development centres as a pilot site in a geographical area similar to the main study. ten parents were invited to participate, 5 of whom agreed. the pilot study confirmed the clarity of written instructions for parents and the appropriateness of the visual layout for the demographic questionnaire and checklist (lds-sa). it also determined the suitability of the data collection method. no modifications were necessary to either the data collection procedures or the written instructions and visual layout of the forms. procedures the forms were sent home in a sealed envelope in the toddlers’ school bags. parents were requested to return the completed form to the principal within the week of receiving it. eighty forms were distributed by principals, and of 60 returned forms, 40 indicated that the parents agreed to participate in the study, 15 did not wish to participate and 4 parents committed to the study but did not return their forms before the specified cut-off date. only one set of data was excluded as the specific toddler did not meet the required 2-year-old age specification. therefore a response rate of 50% was obtained. data analysis descriptive statistics formed the basis of the data analysis procedure. information from the biographic questionnaire and lds-sa were coded in an excel spreadsheet. inferential statistics were applied to the data and comparisons were drawn between the south african study (lds-sa) and the pennsylvanian sample described by rescorla et al. (2001). in rescorla et al.’s survey mothers within the pennsylvania community completed the checklist (n=422) as part of a larger epidemiological survey of language abilities of toddlers. rescorla et al. (2001) provide the frequencies for each of the items on the checklist in an appendix which was included in the published manuscript. these data were used in the comparative analyses. the spearman rank order correlation co­efficient (r) was computed for each semantic category and the strength of the correlation between categories for the lds-sa and lds samples was assessed. results commonly used vocabulary items in the south african context parents were asked to complete the checklist by marking one of two columns to indicate the presence or absence of the item in the child’s current lexicon. for this sample (n=40) a percentage value for every word was computed, based on the number of toddlers reported to produce that word relative to the total sample. using these data, 24 items were reported in the lexicons of 90-100% of the sample of 40 typically developing toddlers. these high-frequency words can be regarded as ‘commonly used’ items within the vocabulary of toddlers from this context (table 2). thirteen of these items were nouns and 8 were verbs. the remaining 3 items fell into the other category and included the social phrase hi/hello; the negative no and numbers one, two, three, etc. no items from the modifiers category could be classified as high-frequency vocabulary items within this sample. comparisons between the frequency of vocabulary item use for the two samples the use of items across the 14 semantic categories was initially investigated by determining a percentage of word use within each semantic category for each of the two samples and then comparing the data. generally, parent responses from the south african study appear similar to the responses reported from the american-based study (rescorla et al., 2001). the bar graph in figure 1 shows small differences between word usage from the two samples with one category indicating no difference at all (toys). besides the categories of actions and modifiers (which obtained response differences between the two participant groups of 20% and 11% respectively) the remaining 11 categories showed differences of 10% or less. the category places was the only category in which parents from the current study reported lower use of vocabulary items than those parents who formed part of the american study (rescorla et al., 2001). in all of the remaining categories the parents of the current study reported higher usage of the vocabulary items on the checklist. this highlights the similarity of parent responses on the checklist. fig. 1. differences between categories for the lds-sa and lds. word frequencies (word usage) from the two samples were compared using the spearman rank order correlation coefficient (r) across the 14 semantic categories. a high correlation statistic indicates that high-frequency words used within one sample were also very common in the lexicon of the other sample. the results of these analyses can be viewed in table 3. the correlation between 10 of the 14 categories was significant at the 5% level. this further indicates that the parent-reported usage of lexical items from the two studies was similar. the highest correlations (r≥0.60) were found for the places, body parts, personal, toys, people and other categories. clothes, vehicles, outdoors and animals were not statistically significant (p≥0.05). assessment of the individual percentages for items in these categories showed that jersey, boots, gloves, slippers, coat and belt within the clothes category, bus, motor bike, trolley and plane within the vehicles category, snow in the outdoors category and chicken and snake within the animals category appeared to be items which displayed the greatest discrepancy between the two samples. overall, parents from both the south african and american samples showed that their 2-year-old toddlers used similar vocabulary, regardless of their linguistic background. the lds-sa therefore presents as one possible method for capturing the vocabulary used by south african toddlers in the context in which the data were collected. discussion the 24 vocabulary items found to be commonly used by south african toddlers correlate with research results on early acquisition of vocabulary. nelson (1973) found that the majority of early words of 18 toddlers consisted of nouns and included family members, toys, food items, parts of the body, and items of clothing. similarly, commonly used vocabulary items by the south african toddlers fell within the categories vehicles, toys, people, clothes, animals, body parts, food and household. these data suggest that commonly used words within the south african context are also embedded within routine activities in the toddlers’ lives, in keeping with experiences from other western societies where parents assist the language learning process by using familiar phrases for regular routines (trivette, dunst & hamby, 2004). the literature states that as expressive vocabulary grows, the majority of words developed are nouns, although differences along the developmental journey are acknowledged (caselli et al., 1999). gentner (1982) argued that nouns must precede verbs in early language development because the concept of an object (noun) is easier to grasp than an action (verb). this idea, however, has been challenged recently in cross-linguistic studies. for instance, it seems that for korean and chinese children knowledge of nouns does not develop in the same manner as in children learning english (choi & gopnik, 1995; tardiff, 1996). tardiff (1996) claims that verbs may actually predominate over nouns in early language acquisition for many chinese children. makin, campbell and diaz (1995) suggested that while nouns are developing, there is a simultaneous large increase in words related to actions. results from this study suggest that there is a 20% difference in the usage of items in the action category between the two groups of toddlers. this would seem to imply that the ethno-linguistically diverse toddlers in this study were using more verbs than the monolingual participants in the original study. one explanation may be that they are all in an early childhood development centre which provides them with many opportunities for interaction and engagement. the likelihood of activity settings which are structured to enhance communicative development and to create learning opportunities would be evident within the centre’s environment. research is needed in order to probe this issue further. while building their vocabulary in their second year of life, toddlers are becoming more physically active (anisfeld, 1984). their words therefore reflect all the important aspects of daily life, including those for touching, tasting, climbing, falling, exploring, getting hurt, seeking comfort, turning away, rejecting food or attention, as well as getting and giving kisses and cuddles (makin et al., 1995). traditionally there has been concern about the overall impact of exposure to ethno-linguistically diverse contexts (mclaughlin, 2006). interventionists have feared that conflict between different languages may delay the acquisition of one or all of the languages being acquired. however, caselli et al. (1999) discovered that the onset and development of nouns, predicates, function words and social terms were quite similar for both english-speaking and italian-speaking children. as was evident in this exploratory south african study, many toddlers were exposed to languages other than english, either within their home or early childhood development centre; however, the comparison with the original survey revealed similar trends in the acquisition of vocabulary. the close agreement of parent responses from both the south african-based study and the original american one is supported by the p values shown in table 3. in many categories the south african toddlers appear to use more vocabulary items than their monolingual peers (see figure 1). the categories clothes, vehicles, animals and outdoors were the only four categories in which the positive correlations were not statistically significant (p=0.1688; p=0.1541; p=0.0517 and p=0.0997 respectively). in addition, places is the only category where the original participants showed greater usage of vocabulary items. this is not surprising given the fact that clothes, vehicles and places are more heavily linked to geographic and cultural or community factors (such as weather and the availability of amenities such as hospitals and zoos). once again this highlights the importance of ensuring that items on a modified assessment measure are sensitive to such differences. overall, although only a small sample of the larger south african community was drawn, results from the south african study confirmed the vocabulary on the lds-sa as useful for toddlers developing within the south african context. additionally, despite ethno-linguistic differences between parents, south african toddlers used similar vocabulary to communicate about their everyday life activities. study limitations an obvious methodological limitation of the study was the small number of participants (n=40) compared with that of the original survey (n=758). this may have impacted on the comparisons drawn between the two studies. south african participants, according to their disclosed biographical information, were from the middle-class socio-economic group only and were literate. this was influenced by the recruiting procedures used. data from parents who did not send their toddlers to early childhood development centres or who were illiterate were not included in the study. the group of participants was therefore not a true reflection of the south african population. results cannot be generalised beyond the context in which the data were collected. conclusions and recommendations the most important clinical implication of this study is that it confirmed that the lds-sa may be one language screening tool that could be used with 2-year-old toddlers from ethno-linguistically diverse south african backgrounds. it meets the general benchmark of a screening tool, i.e. being brief, simple to administer, having objective scoring procedures, good psychometric properties, clear instructions and scientific and financial acceptability (bleses et al., 2010). this study also provided evidence suggesting that, although the south african toddlers were from ethno-linguistically diverse contexts, the acquisition of vocabulary followed the same trend as reflected in their monolingual peers from the original study, as reflected by the close similarity of parent responses. it also provides insight into understanding which vocabulary items are commonly used by typically developing south african toddlers who are acquiring english in conjunction with another language. many south african toddlers from low socio-economic backgrounds do not have access to early childhood development centres. in future, inclusion of parents with 2-year-old toddlers from different settings (e.g. community clinics) is recommended. using the same checklist with non-literate south african parents would be useful in determining the impact that parental literacy levels may have on the language development of their toddlers. translation of the checklist into south africa’s eleven official languages would enable inclusion of ethno-linguistically diverse participants who do not speak english in research concerning language development in south african toddlers. many south-african-based speech-language therapists are faced with the challenge of assessing/treating multilingual children with language impairments on a daily basis (pascoe et al., 2010). the data from this study suggest that the lds-sa is an appropriate screening tool to document the vocabulary of south african toddlers developing language within an ethno-linguistically diverse context. the vocabulary on the lds-sa therefore serves as a resource in guiding intervention efforts of south african speech-language therapists. acknowledgements. the authors wish to thank all the principals and parents who participated in this study. this study was completed in partial fulfilment of the requirements for the first author’s master’s degree in the centre for augmentative and alternative communication at the university of pretoria. we also acknowledge the financial assistance of the national research foundation (nrf) towards this research project. opinions expressed in this paper, as well as the conclusions drawn, are those of the authors and not necessarily attributable to the nrf. references anisfeld, m. 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(1978). mind in society: the development of higher psychological processes. cambridge, ma: harvard university press. 1 j o u r n a l of t h e s o u t h a f r i c a n l o g o p e d i c society may experience of 41 children at the pretoria school for cerebral-palsy is described. types of cerebral-palsy a n d speech defects found in these children a r e detailed. methods a n d techniques in speech therapy a r e reviewed. results a n d difficulties a r e discussed. my thanks are due to dr. b. epstein, chairman of the board o! management of the pretoria scnool for cerebral-palsy, for his encouragement and assistance, and for allowing me cccess to files and recoras. references. 1 perlstein μ a and b a m e ^ η. e. (1952) : j. amer. med. assoc., 148, 1389. 2 pohl j. f. (1950) : cerebral-palsy. 2nd ed., p. 165167.' st. paul, minnesota: bruce publishing'co. 3. rutherford, b. r. (1948) : give them a chance to talk, 1st ed., p. 3. minneapolis, minnesota: burgess publishing co. 4 kastein, s. 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(1953): j. s. afr. logopedic soc., special congress ed., p. 48 (johannesburg univ. witwatersrand). the conquest of stuttering c. van riper director, speech clinic, western michigan. college kalamazoo, michigan, u.s.a. western michigan college of education. for centuries the treatment of stuttering h a s wrecked itself on the rock of symptom avoidance. the various therapeutic methods^ used, relaxation, rate control, unusual modes oi speech, h a v e b e e n focussed on the s a m e goal which h a s b e t r a y e d e v e r y stutterer's own attempts to h e a l himself: the attempt to speak without stuttering. such c n effort carries within itself, even when successful, the seeds ot its own eventual failure. for a v o i d a n c e c r e e d s fear w h e n we flee from fear, w e magnify it. the situation a n d word fears so long conditioned in the adult stutterer c a n haralv ce e r a s e d by; such measures. according to modern teaming theory, anxiety conditioned responses never extinguish completely. o n e pairing of the shock with the conditioned stimuli restores them to almost full strengtn. and so we find the discouraging frequency of r e l a p s e s in stuttering therapy. moreover, much of the older methods did little more than to repress the symptoms. the powenul suggestion employed b y most therapists can ind e e d produce such repression temporarily, ^ut stuttering, like murder, will out ! w e may b e a b l e to hold down the coiled spring of tne disorder for a time, but so long a s it is intact a n d a s strona a s ever, it will eventually e s c a p e from our grasp. w e a r e but mortals with no ability to sustain a repression for long. no matter how confident we b e c o m e , existence will sooner or later c a u s e morale to efco. no environment, however favourable, will b e without its moments of trauma. to build fluency upon an attitude a l o n e is to use fiux instead of mortar for the foundation. ana. so at these i n e s c a p a b l e moments of e g o weakness, the fears invade our minds a g a i n , and the stuttering returns to haunt our lives. is there no w a y to exorcise this evil ghost whose strength seems almost of the supernatural? the psychoanalysts have tried a n d most of them confess failure since speech, their · healing tool, is itself affected. the myriad devices, methods a n d tricks which have b e e n used upon stutterers since the dawn of history give us little hope of s u r c e a s e from that direction. witchcraft and surgery, vocal training a n d hypnosis, in none of these have we found consistent effectiveness. our inability to c o p e with the severe stutterer after all these y e a r s still reflects discredit upon our profession. perhaps we h a v e b e e n working in the wrong direction. the stutterer does not need to b e taught how to talk normally. he already h a s that skill, a s much of his speech attests. suppose, instead of trying to k e e p him from stuttering with all of its attendant evils, we try to train him to modify his symptoms in the direction of fluency. the immense variety of stuttering symptoms suggests that among them there might b e a few types which society would not dunish. among them there should r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) may j o u r n a l of t h e s o u t h a f r i c a n l o g o p e d i c society v,e certain forms which would not frustrate communication a n d which would b e tolercble both to the stutterer and his listener. the u t h c r of this paper, once a severe stutterer, -derating upon these principles, h c s learned to gutter so fluently, so briefly a n d ecsily that neither he nor his auditors react to it. he o w e s his b a s i c concept to an old man, 82, whom ne met long a g o a n d who possessed a host of tiny blockings so small a s to b e almost unnotice" b l e queried a s to whether or not he had v̂ ad a l w a y s blocked in that fashion, the eld man said, " o h , no. until ten y e a r s a g o or so, i s'uttered very b a d l y , jerked a n d fought myself struggled a n d contorted my mouth. but i'm'too old a n d tired now to work that hard. so i stutter this w a y . " the development of stuttering m a k e s it clear that most of the abnormality of cduh stuttering is largely that of learned a v o i d a n c e reactions conditioned to phonetic or semantic cues or of struggle response conditioned to tremors m the articulatory, phonctory or respiratory structures. o n e stutterer learns one set of symptoms while another b e c o m e s the victim of a different set of learned responses. these ere constantly b e i n g reinforced in three w a y s : by anxiety reduction, by repression, a n d by escape from punishment. the stutterer expects a certain amount of abnormality ; the occurrence of its satisfies the fear, and so the word is uttered only when the anxiety h a s fed upon enough abnormality to satiate its hunger. secondly, the stutterer often d e t a c h e s himseh psychologically during the moment of stuttering. he almost " b l c c k s c u t . " he surrenders all responsibility for his behaviour. he gives up control. ajs soon a s the word h a s b e e n uttered he convulsively hurries on to the rest of his communication. there is much repression here. thirdly, the struggle a n d a v o i d c n c e are themselves! highly punishing a n d unpleasant. the utterance of the word, therefore, is an e s c c p e from punishment. therefore those struggle" reactions occurring just prior to the escape a r e strongly reinforced. the tremors themselves a r e punishing b e c a u s e of their irustration. they convince the stutterer of his incbility to move his recalcitrant tongue or mouth. vibrating c s they do at very fast speeds and maintained b y tension, they provoke the stutterer to begin the random interrupter struggle which c r e a t e s so many bizarre symptoms. unfortunately, tne more one struggles, the greater the tension grows and the fester run the tremors. occasional s u c c e s s e s in jerking out of these tremors by some cut of p h a s e movement merely fixates the interrupter device used. the c a s e finds himself confronted by three alternatives, all evil ; to stop e n d postpone, to let the block run on until the fear is satisfied and the tension a n d tremor die out, or to struggle blindly in the hope that b y chance he may b e a b l e to jerk himself, out c-f the tremor a n d proceed. there is also a fourth alternative : voluntarily to slow down and, b y decreasing the amplitude, to dampen cut the tremor, but the stutterer seldom discovers this by himself. during therapy, we e n c o u r a g e the ^stutterer to stutter cpeniy but experimentally. we stress the n e e d for varying the stereotyped reactions, for modifying them in the direction of normal utterance! ' w e reward all modifications in this direction a n d fail to reward all those which i n c r e a s e the abnormclity. w e teach our c a s e s to c e a s e reinforcing their disorder in the way mentioned a b o v e . w e train them to wrestle with their blockings, to learn to pull out cf their tremors voluntarily, to insert prior to the e m e r g e n c e of the word some voluntary control. w e get them to sally forth into the situations of real life hunting out their fears a n d then modifying the stuttering which they precipitate. " w e help them to maintain close contact with their stuttering rather than remain d e t a c h e d from it. w e facilitate their realitytesting so that their p a r a n o i a will not augment their true social penalties. in short we teach them to live with their stuttering easily so that instead of a curse itb e c o m e s at worst a minor nuisance. in essence, what w e do is to t e a c h them to stutter fluently. when they can, the fears subside and so d c the blockings. hidden in all of this is a potent psychotherapy leading io the understanding and a c c e p t a n c e of self a n d to self mastery. there a r e undoubtedly many possible routes up the formidable mountain of stuttering. certain of these paths m a n y therapists and stutterers h a v e climbed, only to b e confronted by failure. here is another, poorly charted c s vet, but one of "great premise. w e invite you to join our expedition. sponsor: radio μ annie. 42 kotze street, j o h a n n e s b u r g , phone 44-7055 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) article information authors: renata mosca1 alta kritzinger1 jeannie van der linde1 affiliations: 1department of speech language pathology and audiology, university of pretoria, south africa correspondence to: renata mosca email: mosca.speech@gmail.com postal address: po box 39283, moreleta park, pretoria 0044, south africa dates: received: 04 feb. 2015 accepted: 29 june 2015 published: 16 oct. 2015 how to cite this article: mosca, r., kritzinger, a., & van der linde, j. (2015). language and communication development in preschool children with visual impairment: a systematic review. south african journal of communication disorders 62(1), art. #119, 10 pages. http://dx.doi.org/10.4102/sajcd.v62i1.119 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. language and communication development in preschool children with visual impairment: a systematic review in this original research... open access • abstract • introduction • method    • study design    • study inclusion criteria    • study selection    • data collection process and data items    • risk of bias in selected studies    • data analysis • results and discussion    • study characteristics    • risk of bias within and across studies    • language and communication characteristics of young children with vi • conclusion • acknowledgements    • competing interests    • authors’ contributions • references • appendixes abstract top ↑ background: language and communication difficulties of young children with visual impairment (vi) are ascribed to intellectual disability, multiple disabilities and autism spectrum disorder (asd) rather than their sensory impairment. consequently, the communication difficulties of children with vi may have been underestimated and undertreated. objectives: this report aims to critically appraise recent peer reviewed literature relating to communication and language development in children with vi. method: a systematic search of the literature (2003–2013) was completed using the prisma guidelines, and primary and secondary search phrases. nine publications were reviewed in terms of the strength of recent evidence. thematic analysis was used to describe the early language and communication characteristics of children with vi. results: all the selected articles (n = 9) were from developed countries and participants from seven of the studies had congenital vi. five of the studies received an evidence level rating of iii while four articles were rated as iib. two main themes emerged from the studies: early intervention, and multiple disabilities and asd. language and communication development is affected by vi, especially in the early stages of development. speech-language therapists should therefore be included in early intervention for children with vi. conclusion: recent evidence on the early language and communication difficulties of children with vi exists, but children in developing countries with acquired vi appear to not be investigated. the identified language and communication developmental characteristics may assist speech-language therapists to build a knowledge base for participation in early intervention for young children with vi and their families. introduction top ↑ the impact of visual impairment (vi) on the communication development in young children has been underestimated and undertreated (house & davidson, 2000; james & stojanovik, 2007). underestimation and undertreatment may be because communication difficulties in children with vi are ascribed to intellectual disability and autism spectrum disorder (asd; house & davidson, 2000) or multiple disabilities (chen, 2001) rather than vi. another reason may be that speech-language therapists are not trained to treat this population as their main focus of training with regard to sensory impairment is on communication delay associated with hearing impairment (james & stojanovik, 2007). early research on children with vi focused more on general development (carvill, 2001; davidson & harrison, 2000; good, jan, burden, skoczenski & candy, 2001; prechtl, cioni, einspieler, bos & ferrari, 2001) than on communication difficulties. communication-related studies were predominantly descriptive and mostly relied on expert opinion (chen, 1999; goldware & silver, 1998; tedder, warden & sikka, 1993), whereas the current trend in research is towards a high level of evidence. there is a need to review recent research to examine the strength of the evidence and to describe language and communication development in young children with vi. since the visual system is complex and the causes and effects of vi are numerous and intricate (holte et al., 2006), children with vi form part of a heterogeneous population. approximately 70% of children with vi present with multiple disabilities (chen, 2001), and there are more than 80 known genetic and chromosomal syndromes that may result in deafblindness (holte et al., 2006). the joint commission on infant hearing therefore endorses the ophthalmological assessment of all infants with confirmed hearing loss (blumsack, 2009). multiple disabilities affect clinical decision-making during assessment and diagnosis as the characteristics of disorders may mask or mimic each other (house & davidson, 2000). for example, the social communication difficulties of children with vi may be mislabelled as autistic tendencies (ibid). information is needed to help identify and improve the understanding of language and communication characteristics in young children with isolated vi and those with vi as part of multiple disabilities. vi may affect the play, motor, cognitive, social and communication skills of young children (chen, 2001) as typical development occurs through unrestricted interaction with the environment (glass, 2002; owens, 2005). despite complexity and diversity within the population, children with vi are unified by a significant absence of visual experiences that shape development. developmental difficulties of young children with vi and the nature of the development of the visual system suggest the need for intervention within the first 12 months of life (davidson & harrison, 2000). increased information about language and communication development in young children with vi may improve early identification of communication difficulties, assist in goal setting and draw attention to the need for early communication intervention for this population. children with vi, and especially those with additional impairments, may require direct language instruction in order to develop language skills (chen, 2001), highlighting the need to include speech-language therapists in the early intervention team for children with vi. early intervention, as an evidence-based strategy (asha, 2008; saslha, 2011), is known to augment young children’s development and promote better long-term functional outcomes for both the child and the family (fazzi, signorini, bova, ondei & bianchi, 2005). there is a need to review recent research to examine the strength of the evidence and to describe language and communication developmental characteristics in young children with vi. this will assist speech-language therapists to build a knowledge base for participation in early intervention for young children with vi and their families. the research questions posed in this systematic review were twofold: what is the strength of recent research evidence regarding early language and communication development skills of children with vi, and what are the children’s characteristics in these developmental areas? method top ↑ study design a systematic review was conducted to answer the research questions posed. the prisma (preferred reporting items for systematic reviews and meta-analyses) statement (moher, liberati, tetzlaff & altman, 2009) was used to structure the systematic review. the prisma checklist helps ensure the transparent and complete reporting of systematic reviews (ibid). this research project received ethical clearance from the research committee of the department of speech-language pathology and audiology, and the research ethics committee of the faculty of humanities of the university of pretoria. study inclusion criteria the inclusion criteria comprised of articles pertaining to communication, language and speech development and characteristics thereof in young children (birth to five years) with any form of vi. vi is defined as the loss of any aspect of vision that diminishes the ability to see. the international classification of diseases (icd-10, update and revision 2006) identifies the following ranges of vision: normal (equal to or better than 20/70), moderate (20/70–20/200) and severe vi (20/200–20/400). moderate and severe vi are grouped as low vision. blindness is categorised over three ranges: blind (20/200–20/1200), blind with light perception and blind with no light perception (who, 2012). no limit was placed on the type of study selected. based on relevance to the subject field, the following electronic databases were searched: medline, scopus, psycinfo and pubmed. since the concepts communication, language and speech are used interchangeably in databases, these three concepts were coupled with development or characteristics in separate searches of each database. the main search phrases were ‘communication development’ and ‘communication characteristics’, for example, ‘communication development in children with vi’ and ‘communication characteristics in children with vi’. these phrases were used in two respective searches in each of the four databases. for the related search phrases, ‘language’ and ‘speech’ replaced ‘communication’ as the main phrases. a total of 24 searches were conducted across four databases. this electronic search strategy, limited to 2003–2013, resulted in the retrieval of a total of 1661 articles from the initial search. an age limitation of birth to five years was then applied. the last search was run in november 2013. study selection all the english language article titles were reviewed and duplicate articles were removed (162 articles remained). the abstracts of the selected articles were then reviewed. the remaining nine articles meeting the inclusion criteria and discussing communication development and/or characteristics thereof were selected (see figure 1). the full articles were reviewed to identify the communication, speech and/or language development or characteristics of children (birth to five years) with vi. to avoid bias, consensus was reached between the three authors regarding the final inclusion of articles. figure 1: review phases used to identify articles for inclusion. data collection process and data items data collection took place by studying each article and extracting information to form summaries of the articles, displayed as mind maps. in terms of data items, information was collected from each article on: characteristics such as title, authors, year of publication, country where study was conducted, participant age range and number, method, level of evidence and visual status of participants. the developmental communication characteristics of participants detailed in the article, including communication, language and speech development. as it is widely accepted in the field of speech-language therapy, the asha level of evidence rating scale (asha, 2004) was used to categorise the articles in the final selection according to the level of evidence. these ratings are discussed within the results section of this article. risk of bias in selected studies the criteria for the assessment of risk of bias were modified from the cochrane collaboration’s tool for assessing risk of bias (higgins, altman & sterne, 2011). the following criteria were included: steps taken to avoid selection bias, blinding of participants, personnel or outcome assessors (when information about the study that might lead to bias in the results is concealed), the presence of control groups or tools, the involvement of more than one clinician in evaluations, inter-rater agreement and the use of validity, internal item consistency and/or reliability testing. none of the selected articles specifically described an assessment of risk of bias other than providing statements pertaining to possible bias. decisions on the risk of bias were made by consensus between the authors. data analysis thematic analysis (de vos, strydom, fouché & delport, 2005) was used to organise the information extracted from the selected studies and to synthesise results. main themes were identified within the data and sub-themes were assigned from the study outcomes. results and discussion top ↑ study characteristics the characteristics of the nine selected articles are presented in table 1. table 1: summary of articles selected for review. selected articles in table 1 ranged from 2005 to 2012 and were all conducted in developed countries. however, it is estimated that there are 285 million people in the world with vi (who, 2014), 90% of which reside in developing countries (who, 2010). seven of the nine articles described participants with congenital vi. of the remaining two studies, one investigated vi acquired at eight weeks old and the other study did not provide the aetiology of vi in the mother-child dyads. the prominence of congenital vi in the study sample may be characteristic of current research in developed countries. conversely, gilbert and foster (2001) state that vi in developing countries is usually acquired. the cumulative participant age range for all nine articles was birth to 28 years. participants older than five years were included in the studies as mental disability resulted in functioning below a developmental level of five years of age. the number of participants varied widely across each selected study, from one to 83 individuals. five of the selected articles were longitudinal studies (ashkenazy, cohen, ophir-cohen & tirosh, 2005; funnell & wilding, 2011; parr, dale, shaffer & salt et al., 2010; peltzer-karpf, 2012; rattray & zeedyk, 2005) of which three utilised the most participants of the nine studies. it is remarkable that such large samples could be recruited as vi is a low incidence disability and participant attrition is a disadvantage of longitudinal research. in the study with the greatest number (n = 83) of participants (parr et al., 2010), this was achieved through a retrospective review of case notes collected over 32 years. in the study by peltzer-karpf (2012), a meta-analysis from four studies was conducted. participants in the study by ashkenazy et al. (2005) were recruited from a specialised unit for children with vi in a large child development centre. the strength of recent research evidence of the early language and communication skills of children with vi shows that five of the articles (ashkenazy et al., 2005; dammeyer, 2012; funnell & wilding, 2011; parr et al., 2010; peltokorpi & huttunen, 2008) achieved a level iii rating. these studies were either comparative investigations, retrospective and prospective case studies, or survey designs. the remaining four articles received a higher rating of iib as they were identified as well-designed quasi-experimental studies. two studies (absoud, parr, salt & dale, 2011; hoevenaars-van den boom, antonissen, knoors & vervloed, 2009) developed assessment tools. peltzer-karpf (2012) made use of neuroimaging to compare study group results, and rattray and zeedyk (2005) conducted a longitudinal study with a static four-group comparative design. none of the articles achieved a level of evidence of iia and above. it appears that controlled studies with randomisation may advance research in this field. by using randomisation, with a representative sample, comparisons could be made between participants with various conditions presenting with vi or between age-matched peers without vi (de vos et al., 2005). this would assist in singling out the impact of vi on language and communication development. however, as children with vi are a diverse population, randomisation is a challenging task. there are many possible contributing factors besides vi that can influence developmental functioning. identified factors include multiple disabilities, extended hospitalisation (and therefore environmental deprivation), age of identification, economic status, caregiver behaviour, intellectual ability and behavioural difficulties. although most of the study designs and methods still represent the lowest level of evidence, the difficulty of conducting research on children with vi should be considered. there appears to be a move to more sophisticated designs and objective methods such as the neuroimaging used by peltzer-karpf (2012), which may provide a new avenue in research. in summary, the validity of recent research on the language and communication characteristics of children with vi appears to be increasing in level of evidence. four (n = 9) of the studies (absoud et al., 2011; dammeyer, 2012; hoevenaars-van den boom et al., 2009; parr et al., 2010) highlighted the lack of assessment tools, and peltokorpi and huttunen (2008) required the modification of two tools to exclude visually loaded items. this can result in subjective, informal evaluations and/or multidisciplinary consensus diagnoses (davidson & harrison, 2000). the lack of appropriate communicationand language-related assessment tools for children with vi further limits the level of evidence that studies can achieve. risk of bias within and across studies the prisma statement (moher et al., 2009) regards the assessment of risk of bias as one of the key characteristics of a systematic review as biases pose a threat to the validity of a review. the selected articles were assessed according to the identified criteria (table 2). it was not always possible to identify if the criteria for the assessment of risk of bias were met, as explicit statements were not found in the articles. the conditions that could not be reliably labelled as absent or present were therefore recorded as ‘unclear’ instead. table 2: six criteria for risk of bias within and across studies. according to table 2, hoevenaars-van den boom et al. (2009) was the most unbiased study and met all the selected criteria for assessment of bias (higgins et al., 2011). peltzer-karpf (2012) met the least measures of bias, as ‘control groups’ was the only criterion identified in the article. in dammeyer (2012) only two of the six criteria were identified. assessment criteria for bias not met does not necessarily imply bias, but rather that the description and rationale of methodological procedures were unclear. all but one article, dammeyer (2012), clearly stated the use of some form of control and all the studies, except peltzer-karpf (2012), mentioned the involvement of more than one clinician during the evaluations. most of the selected studies, except funnell and wilding (2011), peltzer-karpf (2012), and rattray and zeedyk (2005), provided statements on possible biases in their studies. seven of the selected articles (n = 9) met at least three out of six criteria, which indicates that risk of bias is being considered in recent research. language and communication characteristics of young children with vi by means of a thematic analysis (appendix a) the language and communication characteristics of children with vi were identified from recent research. the studies by parr et al. (2010) and peltokorpi and huttunen (2008) were allocated to both main themes as they discuss early intervention, asd and multiple disabilities. the first main theme identified in analyses of the nine studies was early intervention (appendix a). the early developmental difficulties described in the studies highlighted a need to support caregivers and children with vi during early stages of language and communication development. the study by dammeyer (2012) identified possible early predictors for language delays in children with vi. delayed walking was associated with cognitive and language delays in participants with charge syndrome. the study also found that difficulties in vision, hearing and motor skills have a compounding effect on language, and cognitive and social development in participants with usher and charge syndromes (ibid). it appears that the more severe the multidisabilities, the greater the impact on the participant’s development. by means of longitudinal neuroimaging studies, peltzer-karpf (2012) identified that language acquisition follows the same pattern for participants with vi as for sighted controls, but that the progression is slower. with age and maturity the initial gap between the participant with vi and the participant with normal vision diminished. the author found that language delays were more prominent in the early stages of development. multifaceted training programs focused on developmental progression instead of age-matched abilities were recommended from an early age to help overcome this initial delay sooner and to optimise neuroplasticity (ibid). funnell and wilding (2011) showed that phonology and articulation development were not impacted by the vi, but receptive and expressive language delays were evident from the age of two years when preschool assessments commenced. peltokorpi and huttunen (2008) found that language and communication were impacted from the preverbal stages in children with charge syndrome. this delay resulted in limited intentional communication with a greater dependency on gestures and protesting. the researchers recommended that early intervention be based on parent-child interaction. parents that are competent and adaptive communication partners help to support communication development (funnell & wilding, 2011). parr et al. (2010) found that basic form vision in children with optic nerve hypoplasia (onh) and septo-optic dysplasia (sod) is insufficient to support the development of early social and communication skills. rattray and zeedyk (2005) identified three non-visual, alternative communication means to maintain the quality of communication interactions between mothers and their young children with vi. touch, vocalisations and facial orientation are recommended to help mothers fulfil their important role in language acquisition in children with vi. all the mothers in the study instinctively used active touch and increased vocalisations as modes of communication. children with vi used active touch during shared attention as a tactile form of communication. although still a means of communication, the rate of vocalisation was affected by the presence of vi in the mother or child. all the mothers and children made use of facial orientation during shared attention but to a lesser degree than touch and vocalisations, indicating that facial orientation is not as important as an alternative communication means (rattray and zeedyk 2005). lastly, ashkenazy et al. (2005) found that the emotional and behavioural status of children with vi impacts on their receptive and expressive language abilities. early identification and treatment of emotional and behavioural problems in children with vi is therefore important, as delayed language development may be ameliorated. recent research therefore suggests that children with congenital vi show the greatest delays in the early stages of development when language and communication acquisition are more dependent on visual input. the greater the degree of vi, the more likely children with vi are to present with early social and communication difficulties (parr et al., 2010). it could be that during the early years, when children are dependent on caregivers for language development, parents may not be aware of how to adapt their interactions to stimulate development through alternative, non-visual means. it is clear that speech-language therapists need to play a greater role in early intervention for children with vi. the second main theme identified (appendix a) was asd and multiple disabilities. absoud et al. (2011) ascribed the high rate of children with vi that present with social communication difficulties and asd to multiple factors, including visual status, age, gender, and psychological and neurological functioning. by developing an observation instrument for early accurate identification of social communication difficulties and asd in preschool children with vi, early intervention strategies can be implemented (absoud et al., 2011). parr et al. (2010) found that children with vi due to onh and sod, especially in the presence of significant cognitive impairment and/or profound vi, are also at risk of asd. there was, however, no evidence that additional neuroanatomical abnormalities, other than those associated with onh and sod, further increased the risk of asd. according to parr et al. (2010), the co-occurrence of vi and asd in a child significantly affects receptive and expressive language abilities. the authors offer an explanation that asd may result as secondary condition to vi due to sensory deprivation, hormonal influences or genetic factors, but these mechanisms require further investigation (ibid). peltokorpi and huttunen (2008) state that children with charge syndrome frequently demonstrate asd traits. contributing factors to this behaviour may be reduced parent-child interaction due to long periods of hospitalisation and poor health, first smiles emerge later in children with charge syndrome, which, with possible facial paralysis, can affect non-verbal communication, and the children display more stereotyped behaviour than other children with deafblindness (ibid). however, children with charge syndrome demonstrated better language and communication abilities than children with asd (ibid). according to hoevenaars-van den boom et al. (2009), asd can be overdiagnosed and mistreated in children with deafblindness due to similarities in behaviour, especially when intellectual disability co-occurs. despite the tendency of overdiagnosis, there appears to be a high prevalence of asd in children with deafblindness. communication and language are the main areas affected by congenital deafblindness and children often remain at a preverbal stage (hoevenaars-van den boom et al. 2009). the co-occurrence of visual impairment, intellectual disability and asd has a compounding effect. children with asd, deafblindness and intellectual disability show greater difficulty with communication functions, pragmatic skills, transitioning, problem solving, play and stereotyped behaviour than in the absence of asd (hoevenaars-van den boom et al. 2009). therefore, social interaction and communication skills should guide the diagnosis of asd in children with deafblindness. asd symptoms may present in children with deafblindness due to extreme isolation from people and the environment. the inclusion of pragmatic skills across multiple studies may be because the early development of these abilities depends heavily on vision (dale & salt, 2008). the results of the systematic review confirm the observation by chen (2001) that a characteristic of children with vi is that there are almost always associated conditions, which complicates diagnosis and management. according to house and davidson (2000), speech-language therapists may manage children with vi in the same way as they would treat children with hearing loss, as it is the sensory difficulty that they are most familiar with. however, the presence of multiple disabilities, such as deafblindness, has an accumulated effect on language and communication development as both visual and hearing input are limited. these complex difficulties require the use of different approaches and techniques to stimulate language and communication abilities. the participants with vi in the studies by funnell and wilding (2011), hoevenaars-van den boom et al. (2009), peltokorpi and huttunen (2008), and peltzer-karpf (2012) all presented with language and communication difficulties. in the study by parr et al. (2010), 58% of the participants presented with at least one social, communication and/or restrictive or repetitive behaviour. the studies by absoud et al. (2011), ashkenazy et al. (2005), and rattray and zeedyk (2005) described language and communication characteristics, but did not state how many of the participants demonstrated difficulties. in the study by dammeyer (2012), 15 of the 26 participants with usher syndrome and three of the 17 participants with charge syndrome presented with little or no language delay or intellectual disability. this may be because of the relationship between intellectual ability and language competence (dammeyer (2012). in summary, language and communication difficulties were common in the participants of the study selection. an identified study limitation of the systematic review may be inclusion of participants that were older than five years. during the database searches, filters were set for the age range of birth to five years old, as identified by the inclusion criteria. however, participants that were older were included in the selected studies due to intellectual disabilities. conclusion top ↑ the finding that no studies were identified from developing countries, points to a great research need. of the approximate 19 million children with vi (birth to 14 years) worldwide (who, 2014), an estimated 23% are blind and live in the developing region of sub-saharan africa (kello & gilbert, 2003). south african speech-language therapists can expect to encounter children with vi more often than therapists in developed countries. the children’s profile of vi and associated disorders and delays may also be different from those living in developed countries. the aetiology of the vi in developing countries is mostly acquired due to a lack of resources combined with stressful environments (gilbert & foster, 2001), while participants in seven of the nine selected studies presented with congenital vi. it appears that recent research is not yet investigating the communication and language development of children in developing countries with acquired vi. the lack of appropriate assessment tools for children with vi may also limit research on the developmental characteristics of this population. the trend in research should be towards developing appropriate assessment tools, such as the studies by absoud et al. (2011) and hoevenaars-van den boom et al. (2009). following on improved assessment measures, effective language and communication stimulation techniques should be developed for caregivers of children with vi to use during the difficult early stages of development. investigating the language and communication difficulties of young children with vi is challenging. the visual system is the most complex sensory system, but the least mature at birth (glass, 2002). thus, the causes and effects of vi are numerous and intricate (holte et al., 2006). conducting research with this diverse population is complicated, especially with the common co-occurrence of other conditions. based on this systematic review, there is recent evidence on the early language and communication difficulties of children with vi. however, intellectual disability, asd and multiple disabilities do interfere with the identification of language and communication difficulties in children with vi. six of the nine articles (absoud et al., 2011; dammeyer, 2012; funnell & wilding, 2011; hoevenaars-van den boom et al., 2009; parr et al., 2010; peltokorpi & huttunen, 2008) attempt to address this problem. the impact of vi itself on communication remains unclear because the effect of vi on language and communication development cannot yet be separated from the primary conditions. language and communication development in children with vi is not a large or popular research field in speech-language therapy. therefore, the carryover of research into clinical practice may be limited, resulting in undertreatment and underestimation of the language and communication difficulties in young children with vi. the language and communication developmental characteristics revealed in this systematic review may assist speech-language therapists to build up a knowledge base for participation in early intervention for young children with vi and their families. to add to this knowledge base, future research needs to focus on describing the language and communication developmental characteristics of children with acquired vi in developing countries, especially within sub-saharan africa. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions r.m. 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(2014). visual impairment and blindness. geneva: who press. appendixes top ↑ appendix a: summary of main themes, sub-themes and study outcomes relating to communication and language characteristics of young children with vi. abstract introduction research method and design ethical considerations results and discussion discussion research implications acknowledgements references about the author(s) claire fouché-copley discipline of audiology, university of kwazulu-natal, south africa samantha govender discipline of audiology, university of kwazulu-natal, south africa nasim khan discipline of audiology, university of kwazulu-natal, south africa citation fouche-copley, c., govender, s., & khan, n. (2016). the practices, challenges and recommendations of south african audiologists regarding managing children with auditory processing disorders. south african journal of communication disorders, 63(1), a132. http://dx.doi.org/10.4102/sajcd.v63i1.132 original research the practices, challenges and recommendations of south african audiologists regarding managing children with auditory processing disorders claire fouché-copley, samantha govender, nasim khan received: 10 june 2015; accepted: 18 apr. 2016; published: 09 june 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract audiologists managing children with auditory processing disorders (apd) encounter challenges that include conflicting definitions, several classification profiles, problems with differential diagnosis and a lack of standardised guidelines. the heterogeneity of the disorder and its concomitant childhood disorders makes diagnosis difficult. linguistic and cultural issues are additional challenges faced by south african audiologists. the study aimed to describe the practices, challenges and recommendations of south african audiologists managing children with apd. a quantitative, non-experimental descriptive survey was used to obtain data from 156 audiologists registered with the health professions of south africa. findings revealed that 67% screened for apd, 42% assessed while 43% provided intervention. a variety of screening and assessment procedures were being administered, with no standard test battery identified. a range of intervention strategies being used are discussed. when the relationship between the number of years of experience and the audiologists’ level of preparedness to practice in the field of apd was compared, a statistically significant difference (p = 0.049) was seen in that participants with more than 10 years of experience were more prepared to practice in this area. those participants having qualified as speech-language therapists and audiologists were significantly more prepared (p = 0.03) to practice than the audiologists who comprised the sample. challenges experienced by the participants included the lack of linguistically and culturally appropriate screening and assessment tools and limited normative data. recommendations included reviewing the undergraduate audiology training programmes, reinstituting the south african apd taskforce, developing linguistically and culturally appropriate normative data, creating awareness among educators and involving them in the multidisciplinary team. introduction the only currently available international prevalence of auditory processing disorders (apd) in the paediatric population is estimated to be between 2% and 5% (chermak, silva, nye, habrouck & musiek, 2007). determining the prevalence of apd in children remains a challenge, as children presenting with mild symptoms of apd may go undetected because of the subtle symptoms, while conditions such as attention deficit hyperactivity disorder (adhd) and learning disorders (ld) can influence differential diagnosis (baldry & hind, 2008). apd, or alternatively central auditory processing disorders (capd), is a particular type of hearing difficulty that occurs along the auditory pathway and involves the central auditory nervous system (cans), typically presenting with normal hearing sensitivity or a normal audiogram (american academy of audiology [aaa], 2010; british society of audiology [bsa], 2011). apd is idiopathic in nature, and some authors suggest that it may even have no anatomical site of pathology (aaa, 2010). the difficulties experienced by children with apd are their inability to separate meaningful auditory information (speech) from non-meaningful information (background noise) which obscures the auditory messages conveyed to the brain (aaa, 2010). apd occurs across all ages and typically manifests as poor attention to auditory stimuli, difficulty attending to foreground acoustic information in the presence of background noise, difficulty with auditory memory and delayed receptive language development (bantwal, 2011; medwetsky, 2011; witton, 2010). several classification profiles further complicate the diagnosis and management of the disorder. initially stemming from a single entity, apd branches into several diverse pathways, manifesting as listening, reading, spelling and even attention difficulties, creating further detriment in the ability to cope with everyday activities (sharma, purdy & kelly, 2012). the implications for academic progress can be considerable, with the listener becoming frustrated, irritable and often unable to follow instruction, which also impacts on their social and emotional development (mcmahon, 2011; witton, 2010). therefore, the multifaceted nature of apd calls for effective differential diagnosis from a team comprising diverse professionals. a valuable member of this team includes the audiologist and speech-language therapist and audiologist (sta). assessing and managing apd is part of the scope of practice for audiologists (hpcsa, 2008); however, based on the literature, they lack confidence in managing apd because of several challenges (baldry & hind, 2008; the canadian interorganizational steering group for speech-language pathology and audiology [cisg], 2012; logue-kennedy et al., 2011). these challenges relate to determining the anatomical origin of apd, which affects defining the disorder and results in inadequately formulated guidelines regarding appropriate test batteries, as well as a lack of management options (ferguson, 2014). in addition, south african audiologists confront the challenges relating to linguistic and cultural diversity, as the country has eleven official languages and various cultural groups. the current status of service delivery within the south african context further places constraints on apd services offered by audiologists. most audiology services are unequally distributed in urban areas and are provided mainly through the private sector (pascoe & norman, 2011). according to the department of health, kwazulu-natal (doh, 2010), more than half of the population live in rural settlements, suggesting that these individuals have limited access to basic services. an increase in non-communicable diseases, such as the hiv/aids and tuberculosis (tb), further exacerbates poverty and under-development (bradshaw et al., 2003). healthcare resources are therefore directed towards fighting disease, while persons with communication disorders receive low priority and limited resource allocation (pascoe & norman, 2011). given the association between disease and hearing loss, audiologists, especially those working within the public health sector, are overwhelmed with the burgeoning demands for service delivery with the focus being placed on the management of more commonly occurring conditions. it is therefore, a challenge to provide audiology services to children presenting with apd and other auditory pathologies. the 1802 audiologists and stas registered with the hpcsa in 2013 provided services to a culturally and linguistically diverse population of approximately 54 million people (statistics south africa, 2014). however, the majority of the audiologists in south africa either speak english or afrikaans (pascoe & norman, 2011), therefore creating a mismatch between audiologists and their linguistically diverse clients in terms of language, which further impacts on service delivery (pascoe, rodgers & norman, 2013). the majority of the south african population (23%) are first-language isizulu speakers, whilst only 14% are first-language english speakers (statistics south africa, 2014). due to the lack of linguistically appropriate assessment tools, there are few standardised normative data available, therefore influencing the reliability and validity of screening and assessment measures (ferguson, 2014). this impacts on appropriately diagnosing and managing children presenting with apd. in an effort to address some of the above-mentioned challenges, the south african taskforce was established in 2001. its aim was to establish an appropriate test battery for both the fluent first-language, english-speaking child and one who is non-proficient in english, that is second-language english speaker. as a result, the south african low linguistically loaded capd test protocol was created to cater for individuals with a basic understanding of the english language (saleh, campbell & wilson, 2003). however, it has been challenging to apply within the south african population because several of the apd tests recommended were developed in the united states and influenced by foreign data with the linguistic load disadvantaging children with different dialects (ferguson, 2014). the south african taskforce (2001) document recommends two dichotic tests (one being linguistically loaded and another non-linguistically loaded), one monaural low redundancy speech test, one temporal pattern test and one binaural interaction test. however, the two popular dichotic tests, namely, the dichotic digits test and the frequency (pitch) pattern test, were developed over 40 years ago and do not provide adequate supporting documentation and normative data, while the dichotic cv test is also not appropriate for younger children or for populations with a high degree of linguistic diversity and is proven to show a great degree of variability in school-aged children (bellis, 2003). the above challenges therefore question the reliability of some of the common assessment tools available to audiologists, who may therefore have to rely on several assessment tools, making the diagnosis of apd a challenge. it is important that appropriate screening and diagnostic protocols are used in order to facilitate detection, which in turn can favour appropriate intervention. bellis (2003) recommends that in order for intervention to be successful, a ‘tripod’ approach should be implemented, which includes a combination of environmental modifications, compensatory strategies and direct skills remediation. therefore, it is necessary to identify the nature of the apd before determining the way forward in terms of selecting appropriate intervention strategies or making the necessary referrals (bellis, 2003). bellis (2003) further emphasises that the interdependency between several practitioners, such as the speech-language therapist, psychologist, social worker, teacher, physician and parent, is significant in determining the child’s difficulties, strengths and progress. the audiologist plays a significant role in the management of the apd programme and therefore needs to ensure collaboration among the different team members (bellis, 2003). by understanding the challenges experienced by audiologists, areas requiring attention will be highlighted that have been overlooked, thereby facilitating the development of contextually appropriate guidelines and protocols to meet the professions demands. this will enable audiologists to become more equipped to provide a service of high quality and that which complies with ethical standards (knudsen et al., 2012). further research in the area may also provide information on how to create more cost-effective and realistic solutions to suit the south african context. it is also of benefit to determine how audiologists in south africa are practicing in the area of apd and how various challenges are being accommodated for. the study therefore aimed to determine the practices, challenges and recommendations of south african audiologists regarding managing children with apd. the study included an open-ended question, allowing participants to report on their own personal opinions of challenges restricting them from practicing in the area of apd and to provide recommendations to improve apd services in south africa. such information can be used in policy formulation and to improve service delivery. research method and design aims the study aimed to describe the practices, challenges and recommendations of south african audiologists regarding managing children with apds. this was done by surveying the practices and challenges of audiologists regarding the screening, assessment and intervention of children with apd. in addition, the study outlined the recommendations provided by the study participants with regards to managing children with apd. the study was situated within a positivist paradigm, with a quantitative, non-experimental descriptive survey design being used. sample a total of 189 of 1802 audiologists and stas accessed from the national hpcsa register for 2013 consented to participate in the study. a total of 156 questionnaires were considered for analysis yielding a response rate of 8.6%. the participants were accessed from two separate hpcsa registers namely, the audiology and speech therapy and audiology registers. the participants predominantly practiced in pretoria, the western cape and kwazulu-natal, with fewer responses from the other six provinces. the common languages spoken by the audiological caseload of the participants included english, afrikaans and isizulu. there appeared to be an equal percentage of responses from audiologists and stas. of the 156, 49% were in private practice, 19% were at public health sector and 17% were at schools. most of the participants had an undergraduate bachelor degree (ba, 80%, n = 125), 29 (19%) had a masters (ma) and two had completed their doctorate (phd, 1%). the details are reflected in table 1. table 1: demographical profile of study participants. data collection method a questionnaire survey was used to collect the data. permission was granted by the apd ireland research group, to adapt their questionnaire entitled: current and future service provision for children with auditory processing disorder in ireland (apd ireland research group, 2008), with the number and sequences of the questions being amended to match the objectives of the current study. the apd ireland research group (2008) questionnaire comprised two phases, the first phase being quantitative and the second phase being qualitative. the current research only used and adapted the first phase of the questionnaire and consisted of 11 questions (38%), which were reworded to suit the context of the study, while an additional 18 questions (62%) were formulated based on extensive literature and research studies performed in the field of apd such as american speech-language and hearing association (asha), 2005), aaa (2010), bellis (2003), ferguson (2014) and elsisy (2013). seven of the open-ended questions from the previous study were converted into closed-ended questions. an open-ended question was included in order to obtain participants’ recommendations. data collection procedure all audiologists and stas were given an equal opportunity to participate in the study. the questionnaire, information letter and consent form with an electronic link to the online survey site, survey monkey, were posted to all the audiologists and stas on the hpcsa register. the participants were given a choice of either responding by means of an electronic questionnaire or a hardcopy questionnaire. an acknowledgment of consent had to be completed on the survey monkey electronic questionnaire before proceeding with the questionnaire. respondents were given a time frame of 12 days to complete the questionnaire. reliability and validity a pilot study was conducted, which revealed that the electronic platform used to collect data, together with the questionnaire and related documents, was easy to access and complete. an adapted questionnaire was used to improve the reliability of the data collection tool. additional questions included in the survey were formulated based on extensive literature and research studies performed in the field of apd. ethical considerations ethical approval was obtained from the humanities and social sciences research ethics committee of the university of kwazulu-natal (certification number: 1186567), and permission was granted from the hpcsa to access the member’s list. the current study follows the recommendations provided by alcser, antoun, bowers, clemens and lien (2011), which supports the participant’s rights of free will, privacy and confidentiality. permission was obtained from the apd ireland group (2008) before adapting the questionnaire. participant information was profiled by using research participant numbers and coded accordingly. participation in the study was voluntary, there were no risks and the participants were entitled to withdraw from the study at any stage. the researcher completed an online ethics course to ensure that all ethical issues pertaining to the study had been addressed. results and discussion the results are presented with respect to the study’s two objectives, the first being to describe the practices and challenges of audiologists regarding the screening, assessment and intervention of children with apd and the second objective was to describe the recommendations provided by participants. objective one screening of the 156 respondents, 60% (n = 93) reported to have screened children for apd, with 40% (n = 37) indicating that they did not follow any formal guidelines and/or policies related to screening. common guidelines that were used by audiologists included the rsa capd taskforce (2001) document (29%, n = 27), the asha) (2005) document (31%, n = 28), the bellis (2003) guidelines (33%, n = 30) and the aaa (2010) guideline. the school teacher was the primary referral source to audiologists (52%, n = 69), with 96% (n = 89) of referrals consisting of children presenting with poor academic performance at school, 64% (n = 59) inattentiveness and/or distractibility and 45% (n = 42) poor speech and language development. in the current study, the most common concomitant childhood disorders often associated with their apd caseload were adhd, ld and speech-language conditions as illustrated in figure 1. figure 1: common concomitant childhood disorders associated with auditory processing disorders. the participants used several combinations of formal and informal screening tools, such as the chapps, fisher’s and scan c, which are illustrated in table 2. table 2: common screening tools administered by south african audiologists. assessment of the 156, 42% (n = 66) assessed children for apd, the four common assessment tools being the low linguistically loaded dichotic digits test (32%, n = 24), the frequency (pitch) pattern test (31%, n = 23) the low-pass filtered speech test (28%, n = 21) and the linguistically loaded dichotic sentence test (25%, n = 19). twenty percent (n = 15) of the participants administered electrophysiological tests, while additional tests included those that were more speech and language driven. intervention a total of 43% (n = 67) participants provided interventions for children presenting with apd. of the 67 who provided interventions, 83% (n = 55) used preferential seating as an intervention strategy, 80% (n = 54) emphasised the importance of gaining the child’s attention before speaking and 77% (n = 52) recommended repeating and rephrasing the instruction. a total of 61% (n = 41) recommended the use of frequency modulated (fm) systems, while 51% (n = 34) recommended compensatory strategies. little focus was placed on direct skills remediation and auditory training. there appeared to be a statistically significant relationship between the number of years of experience and the provision of intervention for apd, as 59% (p = 0.00) with more than 10 years of experience, and only 31% with less than 10 years of experience provided interventions. forty-six percent (n = 72) of the participants provided onward referral to other practitioners, the most common being made primarily to occupational therapists (56%, n = 40), psychologists (51%, n = 37) and a second audiologist (51%, n = 37). an open-ended question was included, where the participants could document further concerns with regards to managing children with apd, of whom 51% (n = 79) indicated their challenges. the pass/fail criterion provided by certain screening tools was a concern to the participants (49%, n = 39), while tools were considered either ‘too complicated’, ‘too long to administer’ or ‘too boring for children’. participants further indicated that the time taken to assess the child and write a full apd report could not be justified for the amount charged for an apd evaluation, which most medical aids do not cover (5%, n = 4). therefore, audiologists may potentially avoid practicing in the area of apd and rather refer elsewhere. they reported a lack of standardised screening and assessment tools with minimal supporting documentation and/or normative data. cultural and linguistic issues were also a common concern, as many south african children are not affluent in english and are disadvantaged when using the above measures to asses for apd. in addition, there was a perceived lack of collaboration between the audiologist and the slt (6%, n = 5). the different roles between the audiologist and speech therapist in identifying and managing apd were unclear to the participants. they were unfamiliar with which practitioner to refer children to, potentially resulting in delayed intervention or none being provided. eighteen percent (n = 14) of the participants indicated that they may have benefitted from additional theoretical and clinical preparation during their undergraduate programme, while others were restricted by budget constraints and hospital policies to continue with training and development in this area (19%, n = 15). a lack of adherence from parents and teachers to comply with the assessment and intervention programmes was another concern raised. a few of the participants (13%, n = 10) attributed this to the lack of awareness among teachers, parents and other practitioners. informal screening questionnaires were often delivered incomplete, while teachers did not always see the need for classroom modifications, particularly when accommodating larger classes. there appears to be a concern regarding the lack of communication between the various members involved in the multidisciplinary team who need to be involved in managing children with apd. discussion the findings of the present study revealed that a variety of test procedures are being administered by audiologists to manage children with apd. these findings are due to linguistic and cultural variations, a lack of standardised protocols, limited normative data and minimal supporting documentation to secure a diagnosis. audiologists are not familiar with who to refer to or how to manage children with apd, despite it being part of their scope of practice. as a result, children who do not have an apd are either over referred, or worse, children presenting with an apd are not referred at all and go undiagnosed. the multicultural nature of south africa calls for the sensitivity of clinical practice to accommodate the south african context, which is often challenging for the audiologist. vaughn, jacquez and baker (2009) suggested that in order for healthcare providers to follow an ecological approach to assessment and intervention, additional training regarding culturally sensitive practice is crucial. according to the aaa (2010) and the asha (2005) document, both verbal and non-verbal assessment tools are recommended in order to paint a clearer picture of the cans, the underlying processes and the possible location of dysfunction. however, despite having these tools available, most audiological assessment tools for apd are not suitable for the linguistically rich context of south africa, and the country’s 11 different languages, making the assessment and diagnosis of apd challenging. apd tests are also not standardised to suit the south african population, questioning the reliability and validity of the screening and assessment measures within the south african context (saleh et al., 2003). the contextually specific challenges of south africa – which include poverty, malnutrition, limited access to medical and educational facilities, increase in burden of disease, culturally and linguistically inappropriate test materials – all restrict effective service delivery. these findings were similar to a study performed in india, which is also a linguistically diverse and enriched country. in addition, india, with a population of 1.2 billion, consisting of 22 different languages and served by 1750 audiologists registered with the indian speech and hearing association, presents challenges similar to those in south africa (bantwal, 2011). the challenges include linguistic and cultural issues, similar to the present study. these statistics differ to those of a survey reported on the united states, which indicated that more than 80% of the population spoke english as their first language (united states census bureau, 2011). based on the above findings, practitioners need to consider the linguistic background of the client before administering the test battery. there is considerable criticism about the many informal and formal screening tools administered, with the chapps (the most commonly used screening tool) and the screening instrument for targeting educational risk not serving as clear indicators as to whether a full diagnostic apd evaluation is warranted rather only highlighting areas of the child’s weaknesses (emanuel, 2002). the fisher’s auditory problems checklist was criticised for its limited categorical organisation (wilson et al., 2011). despite the scan being one of the most popular formal screening tools administered on an international level, with 50% sensitivity, it has been criticised due to its poor test–retest reliability, its linguistically loaded nature (elsisy, 2013) and its inability to adapt to other cultures and languages (logue-kennedy et al., 2011). bellis (2003) also cautioned that children with apd may pass the scan tests and that it should therefore be administered in conjunction with other screening measures. as identified in the current study, audiologists are administering several screening tools before recommending an audiological evaluation due to the lack of test reliability and validity in using one screening tool. the findings of the present study are congruent with that of the study conducted by logue-kennedy et al. (2011), where more than half of the participating audiologists indicated that very few screening tools were used for apd, often due to a lack of experience in the area. the majority of the audiologists in the above-mentioned study did not feel competent to practice in the area of apd, more so than the half of educational psychologists that comprised the sample, despite audiologists being the primary practitioner to manage children with apd (hpcsa, 2008). therefore, audiologists offered advice about managing apd based on their observation and information from a variety of sources, rather than administering apd tests (logue-kennedy et al., 2011). in a study conducted by chermak, traynham, seikel and musiek, (1998), which aimed to determine audiologists’ knowledge and use of apd assessment tools in the united states, less than half of the participants felt competent to administer apd assessments. eighty percent of the participants received training in the field of apd, yet less than half felt confident in the area and reported having only spent as little as an average of 3 hours clinical contact with the apd population throughout their training. a study performed by the canadian interorganizational steering group for audiology and speech-language pathology (cisg, 2012) mirrored these findings, where less than half of the audiologists assessed children for apd. those participants not providing apd services reported that they tended to prioritise other audiological disorders and focused on services such as hearing aid fittings, which were considered a priority over apd. the language used on tests appears to be a significant barrier, as the tests should be able to reflect valid sensitivity and specificity and account for subject variables, such as higher order functions, chronological age and language, which are often not documented in the common assessment tools of today (elsisy, 2013). as a result, audiologists are selecting a range of tests and creating their own test batteries, potentially allowing for gaps in apd assessment. speech and language assessment tools are also often being administered to account for these gaps, which are not always effective in comprehensively assessing and diagnosing apd, unless the auditory signal of the test material is degraded or altered in any way (vanniasegaram, cohen & rosen, 2004). bellis (2003) emphasised that audiologists should not screen a child for apd if they cannot support the child with the necessary assessment procedures and/or intervention tools. while it is acknowledged that intervention strategies should be geared to each child’s specific needs, as they present differently, for the purpose of this study, information was obtained on common, generic strategies that are used, with three of the most common being: environmental modifications, compensatory strategies and direct remediation of skills, as recommended by bellis (2003). the findings of the present study indicated that less than half of the participants provided intervention services. these finds were similar to that of the study conducted by logue-kennedy et al. (2011), where more than half of the study sample did not offer interventions in the area of apd and the minority who did indicate that their strategies only consisted of offering advice to the client, with no formal intervention protocol. most of the participants offering intervention strategies in the form of advice were slts, their intentions being to manage underlying speech and language impairments rather than manage the apd itself (logue-kennedy et al., 2011). the united kingdom has few referral systems in place for children with apd, despite the wide range of referring practitioners available (which includes parents; schools; ear, nose and throat specialists; slts and paediatricians). similar to the present study, audiologists in the study performed by emanuel, ficca & korczak (2011) recommended a variety of strategies, including direct auditory training of listening skills, which was not a significant intervention practice in the present study. despite several interventions services that are available to audiologists, the multidisciplinary team experiences challenges in reaching a consensus regarding the diagnosis. it is therefore recommended that in the interim, parents are provided with suggestions on how to support their children with apd (slauterbeck, 2009). it can also be challenging for audiologists to engage with clients on a professional and ethical basis, if they do not have a clear understanding of their client’s cultural values and beliefs. despite the fact that the emphasis on child healthcare is improving in south africa, the country continues to follow westernised, traditional, biomedical methods of assessment and intervention, which cannot always be effectively applied to the context of south africa (vaughn et al., 2009). the westernised methods tend to believe that illness is often caused by natural influences, while the africanised methods attribute illness and disease to supernatural forces or higher powers (vaughn et al., 2009). parents and caregivers alsoj need to understand the assessment and intervention programmes recommended by healthcare providers in order for them to fully invest into the programme (popich, 2003). it can further be inferred that the identification and management of children with apd, particularly those living in poor socio-economic backgrounds, where intervention programmes are not deemed necessary by family members and caregivers, may prove to be challenging for the audiologist. audiologists attempting to provide services within the education sector in south africa encounter many challenges due to a number of reasons, including the poor socio-economic conditions of their schools, their limited access to schools, overcrowded classrooms, poor teacher–child ratios and poor scholastic learning environments, to name a few (department of basic education [doe], 2010). the above-mentioned challenges are of particular concern for children already presenting with an apd or a learning disorder. teachers are typically the first people to refer a child with apd to the audiologist, as also identified in the present study, yet are not always adequately equipped to handle the demands of the curriculum or address the requirements of learners with special education needs (pottas, 2005). the challenges presented to the audiologist in attempting to facilitate team collaboration often results in a lack of carryover to the real-life context, such as the classroom. the above challenge may stem from a lack of awareness created amongst the team members and/or their training received in the area of apd, bringing into question the current quality of apd service delivery in south africa. the challenges presented in the current study are similar to those addressed in international studies. whitelaw (2012) suggests that audiologists are frustrated by the lack of supporting documentation for the screening and assessment tools for apd, while bellis (2003) suggests that audiologists may not wish to practice in the area of apd due to the time taken to screen, assess and diagnose the condition. according to the study conducted by chermak et al. (2007), audiologists are unfamiliar with identifying which practitioners to refer to once a child had been screened for apd or once a diagnosis had been made. whitelaw (2012) believes that audiologists avoid practicing in the area as they become despondent with the perception that apd cannot be cured. it is postulated that similar aspects are contributing factors as to why apd is not commonly managed in south africa. the finding of this objective is concerning, as ethical and responsible practice is aligned to timeous and effective intervention strategies. objective two an open-ended question was included where the participants could provide recommendations with regards to managing children with apd. a total of 78 participants provided recommendations, which were categorised into five common themes and are presented below. reassessing the curricula of training audiologists/speech-language therapists and audiologists, and prioritising training at an undergraduate level one of the common themes emerging from the current study was that the participants felt that there was little opportunity to manage children with apd during their undergraduate clinical training programme. participants stated that they could have benefitted from additional theoretical coursework and clinical training. this may be achieved by allocating additional clinical hours to the area of apd. therefore, a re-evaluation of the audiological undergraduate training curricula, with regard to apd, should be considered. one of the participants reported that: ‘lecturers are not always equipped to deal with proper explanations to students therefore my training was insufficient’. (audiologist, bachelor’s degree, 0–5 years of experience) reinstating the south african auditory processing disorder taskforce to create standardised assessment tools, intervention strategies and policies another theme emerging from the current study was reinstituting the south african taskforce, in order to develop standardised policies and guidelines. these guidelines may encourage confident training and practice among audiologists in the area of apd. a team steering the development of appropriate screening and assessment tools to suit the south african context, may improve the provision of apd services among audiologists in south africa. the following was reported by one of the participants: ‘no golden standard/universal definition – so what exactly are we testing and managing? pass-fail criterion – some recommend 2 standard deviations (sd’s) and others 3 sd’s; so are our tests really sensitive enough for apd identification and diagnosis?’ (audiologist, master’s degree, based in academia) as previously discussed, there are no single criteria by which apd screening and assessment results can be measured, due to the heterogeneity of the disorder and the network of childhood disorders often associated with apd. previous results suggest that often audiologists avoid practicing in the area of apd, not only because of their perceived inadequate training provided during their undergraduate training programme but also due to the lack of standardised and contextually appropriate assessment tools available to south african audiologists. upon personal observations, there appears to be a developing awareness amongst other practitioners, teachers and parents in the area of apd, as the numbers of referrals to the audiologist increase. however, contextually and linguistically appropriate assessment tools are still a concern. it can therefore be inferred that soon enough, south african audiologists may be placed in an ethical dilemma if the numbers of referrals from teachers and healthcare practitioners start to increase, whilst the paucity of contextually and linguistically inappropriate guidelines and assessment tools continues. it therefore becomes difficult for audiologists to determine the extent to which an apd exists, and the nature thereof. assessment directs intervention, and if assessment is inappropriate or fails to take into account cultural and linguistic variability, then the results may be inaccurate and biased. therefore, audiologists should consider the development and adaptation of assessment tools and procedures to meet the diverse needs of the population. intervention should also be culturally appropriate and relevant for the population served (pascoe & norman, 2011). collaboration between the speech-language therapist and the audiologist slt assessment tools and the assessment tools administered by the audiologist should complement each other in order to determine whether an apd diagnosis exists (bellis, 2003). participants recommended that audiologists and slts work in cohesion with each other, rather than arguing the disorder from two different perspectives. one of the participants stated the following: ‘the speech therapy and audiology approaches to apd are so very different and my perception is that the slt’s role is much better known and there are more test and assessment materials for the slt management of apd, other than fm systems. i would recommend that the slt be the main profession doing apd assessments and therapy’. (audiologist, bachelor’s degree in audiology, based within the hospital setting) creating awareness within the education system two smaller themes emerged from the study, with one being that awareness should be created among educators. the participants felt that children presenting with signs of apd are often referred to other practitioners first and are unaware of the audiologists’ role in the management of apd. bellis (2003) emphasises the importance of early identification and the implications on the child’s academic and social development. awareness created amongst teachers may therefore encourage the early identification of children at risk for an apd: ‘main concerns are that other allied professionals are conducting management that is often eg. educational psychologists. they are even offering courses to train teachers and ignoring the scope of practice of the slt and audiologist’. (audiologist, master’s degree, in academia setting) cpd activities the participants reported that attending additional workshops and courses providing training in the area of apd will help drive the management of apd in south africa. the following was stated by one of the participants: ‘i attended a two day course led by dr wayne wilson which was very helpful to understand apd and current issues. such courses are needed to stay informed’. (audiologist, bachelor’s degree, in the school setting) research implications creating standardised and reliable assessment tools that are culturally appropriate and linguistically suitable for south african children may aid the future development of the scope of apd and equip audiologists with the necessary tools to make an accurate diagnosis. research projects should be dedicated towards developing, standardising and validating test materials. as the current study sample comprised audiologists and stas only, very little information has been provided regarding the present practices of slts, specifically from a linguistic perspective. similarities and/or discrepancies between the slt and the audiologist will be able to offer rich information for future curricula development. the present study was also based on a quantitative paradigm. future research using a mixed-method design of both qualitative and quantitative information may provide richer data with regards to the perspectives of audiologists in managing children with apd. an updated study on the current south african audiology training programmes would be beneficial in providing information where prioritisation is required for future training. clinical implications reinstituting the south african taskforce would encourage the development of new and updated policies and guidelines in south africa, with regards to the present apd intervention trends. the taskforce could also serve as a lobbying body for resource allocation and awareness creation in the area of apd. this should include lobbying for additional human resources and training therapists from diverse backgrounds to address the cultural and linguistic issues and post creation. it is hoped that the present study will attract audiologists into the field of apd, should training workshops on a theoretical and practical level be supported. educating medical aids and insurance companies on the present state of apd as a disorder, and motivating for the effective implementation of apd procedure codes, may shed light on effective practices in the area of apd. limitations a study sample comprised less than 10% of the study population and may therefore not be a true representation of south african audiologists. information bias may also have occurred, as the responses obtained were dependent on the participants’ willingness to complete the research tool. due to the lack of consensus with regards to the definition of apd and the training thereof, the participants’ responses were based on their own understandings of apd, and therefore, variable responses may be expected. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions this article is based on a masters study by c.f.c., who was supervised by n.k. and co-supervised by s.g. the paper was drafted by c.f.c. and the supervisors contributed substantially to all subsequent drafts and the final article. references alcser, k., antoun, c., bowers, a., clemens, j., & lien, c. 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(2010). childhood auditory processing disorder as a developmental disorder: the case for a multi-professional approach to diagnosis and treatment. international journal of audiology, 49, 83–87. http://dx.doi.org/10.3109/14992020903289808 abstract introduction method results ethical consideration discussion conclusion acknowledgements references appendix 1 appendix 2 about the author(s) nomfundo f. moroe department of speech pathology and audiology, school of human and community development, university of the witwatersrand, south africa kirstie hughes department of speech pathology and audiology, school of human and community development, university of the witwatersrand, south africa citation moroe, n.f., & hughes, k. (2017). parents are aware of the ototoxic effects of chemotherapy in paediatrics undergoing cancer treatment: professional versus parental views: a pilot study. south african journal of communication disorders, 64(1), a183. https://doi.org/10.4102/sajcd.v64i1.183 original research parents are aware of the ototoxic effects of chemotherapy in paediatrics undergoing cancer treatment – professional versus parental views: a pilot study nomfundo f. moroe, kirstie hughes received: 31 aug. 2016; accepted: 20 nov. 2016; published: 27 feb. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the primary goal of chemotherapy is to cure cancer and its symptoms. hence, in recent years, there has been an increase in cancer paediatric survival rate. however, there have also been adverse side effects such as ototoxic hearing loss because of chemotherapy. therefore, this study aimed at exploring whether the parents of children undergoing chemotherapy are aware of ototoxic effects of chemotherapy. methods: a non-experimental quantitative study was conducted to collect data through questionnaires, one for paediatric oncologists and the other for parents. a convenience sampling strategy was employed to recruit 11 paediatric oncologists and 7 parents from two public hospitals in gauteng. the questionnaires were analysed quantitatively, using descriptive statistics. results: about 55% of paediatric oncologists indicated informing parents about the ototoxic effects of chemotherapy. on the contrary, 71% of parents reported having been informed by paediatric oncologists about the possible hearing loss because of chemotherapy; however, 57% of the children are receiving a combination of cisplatin and cyclophosphamide despite being aware of their ototoxic nature. conclusion: this study paves the way for qualitative studies to ascertain how parents are informed about the possible side effects such as hearing loss because of chemotherapy treatment. the mode in which parents are informed about the possible side effects related to chemotherapy is critical, considering that a high number of children are still receiving chemotherapeutic drugs that are directly linked to hearing loss. introduction cancer is listed as one of the leading causes of mortality, not only internationally but also within the south african context (mqoqi, kellet, sitas & jula, 2004). in south africa, cancer in the adult population is reportedly the highest in the continent (mqoqi et al., 2004), while little to no data could be obtained for the paediatric population. it is a well-documented fact that chemotherapy, which is a preferred treatment for cancer, has adverse effects on the individual’s hearing sensitivity (de andrade, khoza-shangase & hajat, 2009). this knowledge is particularly important in the management of the paediatric population, as language development, academic progression and social interaction and integration rely heavily on hearing ability (knight, kraemer & neuwelt, 2005). therefore, healthcare workers, especially in the paediatric oncology team, have a responsibility to inform parents of children undergoing cancer treatment about the ototoxic effects of chemotherapy in this population. cancer is defined as the uncontrolled division of abnormal cells which results in tumours (cooper, 1992). in most cases, these tumours are often not immediately identified; they usually form gradually resulting in an increasing mass of cancerous cells in the body (cooper, 1992). it should be noted that not only is there diversity in the type of cancers that may be encountered, but there is also diversity in the manifestation of this disease as individual cancers of the same type may present differently (cooper, 1992). because of late diagnosis and management, the abnormal cancer cell may enter the system of normally functioning organs and tissues, thus leading to the abnormal functioning of the normally functioning cells (cooper, 1992). ‘cancer is a major public health problem in the usa and many other parts of the world. one in four deaths in america is due to cancer’ (jemal et al., 2008, p. 71). locally, in south africa, the burden of disease with regard to cancer appears to be rapidly rising. adewole et al. (2013) estimated that the burden of cancer is expected to increase to greater than 85% by year 2030. the incidence of cancer in southern africa, in particular, appears significantly higher compared with the rest of the continent (mqoqi et al., 2004). however, the exact statistic regarding paediatric cancer is not readily available, especially in south african public healthcare sectors (childhood cancer foundation of south africa, 2014), while in the united states, after accidents, cancer is the leading cause of death in paediatrics aged between 1 and 14 (jemal et al., 2008). historically, surgery and radiotherapy were the primary treatment options for cancer until the 1960s when chemist paul ehrlich developed and introduced drugs, which he termed chemotherapy, to manage infectious diseases (devita & chu, 2008). in recent times, however, various alternative options are available for the treatment of cancer, inclusive of surgery, radiation therapy and chemotherapy, or, depending on the individual case, a combination of these may be used (sikara, 2008). according to the childhood cancer foundation of south africa (2014), cancer within the paediatric population is complex and often occurs in the developing cells within the child’s body. treatment for these cancers is, therefore, equally complex and thus requires specialised care by paediatric oncologists. chemotherapy, as explained by nygren (2001), is the intravenous or oral administration of a combination of chemicals which kill cells to eliminate or reduce the encountered malignancy, based on the patient’s histology. chemotherapy involves the administration of cytotoxic drugs, in an attempt to kill off all cells of a cancerous nature (nygren, 2001). with the use of chemotherapy, there has been an increase in paediatric cancer survival rates currently estimated at 75% – 80% (rheingans, 2007). since the primary goal of treatment is to cure cancer and its symptoms, considerations regarding the toxic nature of chemotherapy or the quality of life in paediatrics living with cancer are usually secondary (wolfe et al., 2000). many adverse effects, which occur directly as a result of chemotherapy, have been well-documented in the literature. a large variety of chemotherapeutic agents, such as platinum compounds including cisplatin, carboplatin, nitrogen mustard and bleomycin, are common components in chemotherapeutic regimes and are also strongly associated with hearing loss (de andrade et al., 2009). cisplatin, in particular, has been identified as a commonly used, robust chemotherapeutic agent, which often aids in the success of treatment, despite its highly ototoxic nature (de andrade et al., 2009). according to knight et al. (2005), cisplatin and carboplatin were absolutely vital in the treatment of a broad spectrum of cancers occurring during childhood. these agents, however, have demonstrated significant ototoxic effects, with literature indicating a particularly high susceptibility to ototoxic hearing loss, as a direct result of exposure to these agents (de andrade et al., 2009; gurney et al., 2007), especially in the paediatric population. schlauch and nelson (2009) reported concern that ototoxic drugs cause reductions in the hearing sensitivity of high-frequency sounds. this occurs as a direct result of the damaging effects of the medication on the outer hair cells of the cochlear (gurney et al., 2007; schlauch & nelson, 2009). although the exact mechanism of the damage is unknown, the end result is generally a bilateral, permanent sensorineural hearing loss, with a 26% – 90% incidence reported in young children, on cumulative doses of cisplatin (castelon-martinez et al., 2014). there are sufficient data indicating hearing loss is a long-term side effect resulting from chemotherapy (gurney et al., 2007; laverdiere et al., 2005). this sensorineural hearing loss significantly affects language development, verbal abilities and reasoning skills in the paediatric population, regardless of the severity of the hearing loss (frymark et al., 2010; gurney et al., 2007). the negative effects of this ototoxic hearing loss on language development in paediatrics need mention as it is usually under reported. hearing loss induced by ototoxicity may vary in severity from patient to patient (frymark et al., 2010) and is unique in the paediatric population, in that it may have grave implications for many other aspects of the child’s life, including educational attainments, speech and language development, and socialisation (bale, smith & white, 2005). according to hoover, lewis, moeler, pitman and stelmachowitz (2004), specific areas of difficulty as a result of a decline in hearing sensitivity include delays in vocabulary, decreased verbal ability and immature language and reasoning. results of a study conducted by bale et al. in 2005 revealed that children with high-frequency hearing losses, which is often characteristic of ototoxicity, present with significant delays in phonological development and, therefore, further delays may be noted in literacy development, as phonological awareness precedes literacy. it is, therefore, vital that parents of children who undergo chemotherapy are informed about the possible side effects of chemotherapy. literature states that ‘the principle of informed consent obligates physicians to explain possible side effects when prescribing medications’ (wells, 2012, p. 1). however, some authors have argued that informing patients about the side effects may cause harm and distress (benedetti, lanotte, lopiano & colloca, 2007). this distress may manifest though a variety of non-specific symptoms such as psychological distress, poor adherence to treatment, unnecessary consultation and over prescribing medications to treat these affects (barsky, saintfort, rogers & borus, 2002). however, disclosure or non-disclosure of possible side effects may present challenges ethically, as physicians are bound by the principle of non-maleficence (wells, 2012). therefore, wells (2012) recommended engaging a pragmatic approach in minimising the possible side effect which may arise because of disclosure, while maintaining patient autonomy through contextualised informed consent. the contextualised informed consent involves: taking into account the possible side effects, the person being treated, and the disease involved to tailor the information provided about medication side effects to provide the most transparency with the least potential harm. (p. 5) for further discussion on the pros and cons of the contextualised informed consent approach, the reader is directed to wells (2012). for this study, the authors advocate for the use of this approach where the paediatric oncologists, while the goal is to save lives, should also inform the parents about the possible side effects such as hearing loss that may arise as a result of chemotherapy. the paediatric oncologists also need to consider that with the use of chemotherapy, there is an increase in paediatric cancer survival rates (rheingans, 2007). therefore, they should be transparent about the side effects as they may impact on the quality of life of the paediatric population undergoing cancer treatment. therefore, the current pilot study seeks to establish whether paediatric oncologists inform parents about the possible ototoxic effects that the paediatric population undergoing chemotherapy may develop. furthermore, the study also investigates whether parents of children undergoing chemotherapy are aware of these possible ototoxic effects, which may impact on the family’s quality of life and on the affected child’s language development and scholastic performance. method objectives the aim of this study was to explore whether paediatric oncologists inform parents about the possible ototoxic side effects of chemotherapy, and to explore whether the parents of children undergoing chemotherapy are aware of ototoxic effects of chemotherapy. study design a quantitative, non-experimental study was conducted to collect data through questionnaires. two questionnaires, openand close-ended questionnaires, were conducted to collect data. the first questionnaire (appendix 1) was tailored for paediatric oncologists and the second questionnaire (appendix 2) was for the parents. this study forms part of a larger qualitative study with a focus on the quality of information given to mothers of children who are undergoing chemotherapy. prior to conducting a qualitative study, a quantitative study (this pilot study) through the use of questionnaires was conducted to ascertain whether mothers are aware of the possible hearing loss associated with chemotherapy. on confirming that mothers are aware, a qualitative study was undertaken. sampling strategy a convenience sampling strategy was employed to recruit 11 paediatric oncologists and 7 parents from two public hospitals in gauteng. inclusion criteria only paediatric oncologists with a minimum of 12 months experience were included in this study to ensure that recruited paediatric oncologists were familiar with protocols observed in the management of paediatrics undergoing chemotherapy treatment. only parents of children who have undergone chemotherapy consisting of either cisplatin or carboplatin within the last 2 years were included in the study. the age and the gender of the children were not collected for this study. description of participants a total of 11 paediatric oncologists were recruited from two public hospitals in gauteng and 7 parents from the same hospitals were recruited from the inpatient and outpatient paediatric oncology department. data collection tools two different questionnaires were administered to the two groups of participants in this study. the questionnaire for the oncologists was a modified version of a questionnaire developed by khoza-shangase, mupawose and mlangeni (2009). this questionnaire was adapted in order to better fit the context of paediatric oncologists practicing in south africa. the questionnaire for parents was developed by the researcher after conducting a comprehensive literature review. both questionnaires were semi-structured and consisted of closeand open-ended questions to enhance the findings of the research and to provide a more comprehensive subject matter (denscombe, 2010). the questionnaires for the doctors sought to elicit information regarding the years of experience as a paediatric oncologists (figure 1), their knowledge of the protocols in the management of paediatric cancer patients and the referral rate to audiologist for the management of a possible hearing loss. with regard to the questionnaire designed for parents, the focus was on the length of the period their child has been undergoing chemotherapy treatment, the type of chemotherapy they were receiving, whether they were informed about the effects of chemotherapy on hearing and whether they have noticed any changes on their child’s hearing since undergoing chemotherapy. figure 1: paediatric oncologists work experience in years (n = 11). data collection procedure ethical clearance was obtained from the medical ethics board of the university of the witwatersrand (m150221), as well as from ceos and head of the departments (hods; paediatric oncology ward) from the two public hospitals included in the study. furthermore, an approved copy of the study proposal was forwarded to each hospital. following approval, questionnaires were distributed to the oncologists and parents for completion via the hods with the aid of oncology nurses. each participant was given the information letter, detailing the study as well as consent form. only participants who signed informed consent forms were included in this study. participants were aware that they could withdraw from the study at any point without any negative consequences. personal details of the participants and hospitals were not mentioned in the research report to ensure anonymity. the oncologists were requested to complete the questionnaire regarding their current perceptions concerning ototoxicity protocols in the management of the paediatric population, while the parents were invited to complete a questionnaire exploring length of treatment, hearing status of the child and information received regarding chemotherapy and ototoxicity. both the administered questionnaires were completed in the absence of the researcher, thereby ensuring confidentiality and anonymity. the completed questionnaires were collected by the researcher in sealed envelopes, from the hods and nurses. data analysis data from the questionnaires were analysed using descriptive statistics to describe specific trends and to summarise measures of some characteristics of the sampled data (durrheim, 2006). for this study, the responses from both the paediatric oncologists and parents were analysed quantitatively and the results were reported through percentages to indicate the trends and to summarise the findings. validity and reliability prior to the commencement of this study, a pilot study was conducted with one paediatric oncologist, who was not included in this study, to assess any potential problems with the data collection tool and to ensure reliability of the study. there were no changes made to the research tool based on the results from the pilot study. a pilot study was not conducted with the parents. furthermore, in order to achieve a greater reliability, the study was closely observed and executed by both the researcher and the study supervisor who also acted as a peer reviewer throughout the study. results paediatric oncologists information to parents regarding chemotherapy and ototoxicity the results of this study indicated that 55% (n = 6) of paediatric oncologists offered information regarding the effects of chemotherapy and its impact on hearing, while 45% (5) reported offering no information regarding chemotherapy, despite being aware of its possible negative impact on hearing. a study conducted by mckenna, collier, and blake (2009) found that accessibility, support and degree of information offered by healthcare professionals to parents impact on the parent’s confidence when making long-term decisions in the interest of a child undergoing chemotherapy treatment. the finding of this study is some paediatric oncologists provide information to the parents which may guide them when making long-term decisions with regard to the type of treatment for their children. therefore, the amount and quality of information given to parents regarding ototoxicity and chemotherapy are imperative as this helps guide the treatment process (figure 2). figure 2: percentage of paediatric oncologists offering information regarding ototoxicity to parents of children receiving chemotherapy (n = 11). failure to provide parents with information may be counterproductive in empowering and informing parents about early identification and management of any ototoxic hearing loss. caradini, cigana, selistre, rosito and brunetto (2007) reported that early detection of potential platinum-based drug–induced ototoxicity may lead to clinical decisions concerning drug dosage, as well as enrolment in early intervention programmes, which may include both the speech therapist and the audiologist. the lack of information rendered to parents by professionals, therefore, undermines the importance of referring patients to audiologists for early intervention programme during or following chemotherapeutic treatment. de andrade et al. (2009) found that 50% of oncologists in their study presented with a limited awareness regarding the role of the audiologist in patients undergoing cancer treatment. this is concerning as it suggests that paediatric patients are not referred timeously and accordingly for the management of hearing loss during and after chemotherapy treatment. audiology referrals since 55% (n = 6) paediatric oncologists highlighted being aware of the possible chemotherapy effects on hearing, it was crucial to determine whether the paediatric oncologists referred to the audiologists for the assessment of the auditory system before, during and after the administration of chemotherapy on the paediatric population (figure 3). figure 3: percentage of paediatric oncologists who refer to audiologists for possible hearing loss management (n = 11). the results indicated that 55% (n = 6) of participating paediatric oncologists within the study refer to an audiologist during or following the course of treatment, whereas 45% reported never referring to the audiology department (n = 5). it is worth noting that these are the same paediatric oncologists who inform parents about the possible effects of chemotherapy on the hearing status. this apparent lack of referrals to audiologists impacts on the early identification and intervention of children who may present with ototoxic hearing loss because of chemotherapy. according to khoza-shangase, barrat and jonosky (2010), patients generally only notice hearing deficits once a communication difficulty is present, indicating possible ototoxic progressions, as communication difficulties indicate losses in the frequencies responsible for speech. therefore, these results highlight the need for education on the benefits of early hearing identification and intervention. of the six paediatric oncologists, 9% (n = 1) indicated referring to the audiologists at the end of therapy, and 18% (n = 2) indicated referring for audiological assessment before therapy commences so as to obtain a baseline audiogram. the remaining paediatric oncologists (27%, n = 3) reported that they only refer to the audiologist when the patient starts presenting with hearing loss symptoms. these results are concerning as prior to treatment, all patients should be referred to the audiologist to obtain the baseline audiogram and ongoing audiometric evaluations (vasquez & mattucci, 2003). these results call for the involvement of audiologists, who are knowledgeable professionals in the prevention, monitoring and management of hearing and hearing-related difficulties because of chemotherapy (katz, 2002). a study conducted by bhagat et al. (2010) highlighted the importance of ototoxicity monitoring protocols in patients undergoing chemotherapy treatment in order to screen for any hearing loss symptoms post exposure to known ototoxic agents. parents type of chemotherapy received by the paediatric patients undergoing chemotherapy because of the nature of the study and how data were collected (questionnaires given to the hods of the oncology department, and not directly to the parents), it was not possible to verify the reliability of the responses given by the parents. however, for the qualitative study, this limitation will be addressed as permission to access the patient files has been requested. the majority of children (57%, n = 4) received a combined dosage of both cisplatin and cyclophosphamide, which are known strong ototoxic agents (figure 4). moller, langguth, deridder and kleinjung (2011) argued that the simultaneous use of multiple ototoxic medications should be avoided whenever clinical circumstances permit, as concomitant use of these may increase a patient’s risk of permanent hearing loss. also, caveletti, fabbrico, minoia, frattola and tredici (1998) stated that alternating chemotherapeutic regimens may be viewed to be advantageous in the treatment of cancer, as these utilise many active agents at one time in the combat of cancerous cells. a small number of children received carboplatin (29%), despite literature noting it to be less ototoxic in nature than other platinum compounds such as cisplatin (lokich & anderson, 1998). it must be noted, however, that treatment efficacy profiles between cisplatin and carboplatin differ distinctively based on the type of cancer being treated and, therefore, the type of chemotherapy administered will dependent on the cancer being treated. a small number of participants (14%) were noted to be receiving cisplatin chemotherapy. figure 4: percentage of children receiving various chemotherapeutic regimens (n = 7). information received by parents a large majority of parents (71%, n = 5) were informed about the possible negative effects of chemotherapy, whereas 29% (n = 2) did not receive any information (figure 5). it is encouraging that the majority of the participants were informed about the possible negative effects of chemotherapy on hearing. mckenna et al. (2009) noted that parents become more involved in decision-making in management of children with cancer when doctors provide adequate information regarding cancer outcomes on paediatrics. this may, therefore, advocate for the role of the audiologist in the public sector with regard to educating people about the possible ototoxic effects of chemotherapy; according to khoza-shangase et al. (2010), it is absolutely vital that patients be aware of the effects of treatment on hearing, in order to further pursue management options. figure 5: graph presenting percentage of parents who received information from paediatric oncologists (n = 7). overall results from the questionnaire administered to the parents appear to indicate that a majority of parents of children receiving platinum-based chemotherapeutic treatment were informed about the possible negative effect of this treatment on hearing before the commencement of therapy. furthermore, a majority of parents participating within this study indicated that their primary source of information regarding chemotherapy-related sequel was the medical professionals directly involved with the case. this is a particular point of interest as literature has found that parents tend to rely primarily on the input of their oncologists and medical staff for information regarding treatment, course, side effects and prognosis of the child’s cancer (massimo, wiley & cassari, 2004). this necessitates effective communication of all information between professionals and parents, in order for parents to be properly educated regarding chemotherapy-induced ototoxicity and promote further detection and management where necessary. ethical consideration ethical clearance was obtained from the medical ethics board of the university of the witwatersrand (m150221). discussion limitations of the study this study comprised only 11 paediatric oncologists and 7 parents of children undergoing chemotherapy treatment. therefore, the results of this study may not be generalised to a larger population. these results should be seen as preliminary findings of a larger study with a bigger sample size. furthermore, the percentages used are not of statistical significance as the study comprised a small sample. however, this is a pilot study, hence the small sample size. initially, the study sought to engage doctors in the public and private sector. however, during data collection, it was observed that the paediatric oncologists, who participated in this study, although they were recruited from the public sector, are also the same doctors who work in the private sector, thus, lowering the number of sites for data collection. conclusion the findings of this study are promising as in general it seems that parents are being informed about the ototoxic effects of chemotherapy. although the number of oncologists who inform parents about possible hearing loss in paediatrics undergoing chemotherapy is still low (only 55%) it is however a step in the right direction. on the contrary, the majority of the parents (71%) indicated being aware of the effects of ototoxic effects, a more encouraging outcome. however, what is concerning about these results is the fact that, as much as parents are aware of the ototoxic effects of chemotherapy, the majority of the children (57%) are receiving a combined dosage of both cisplatin and cyclophosphamide, which are ototoxic in nature (moller et al. 2011), while a small number of children received carboplatin (29%), despite literature noting it to be less ototoxic in nature than other platinum compounds such as cisplatin (lokich & anderson, 1998). the selection of chemotherapeutic drugs to include in a patient’s regimen is commonly based on the patient’s histology (nygren, 2001), as each individual’s cancer symptoms may present differently, and therefore necessitate specific chemotherapeutic agents (cooper, 1992). however, knowing the side effects directly linked to chemotherapy treatment, these results highlight the need for other considerations to be implemented in order to minimise the side effects of chemotherapy in paediatrics who survive cancer. some authors have suggested administering low levels of chemotherapeutic agents known to cause hearing loss in children (knight et al., 2005), the involvement of audiologists in the management of children undergoing chemotherapy (de andrade et al., 2009; khoza-shangase et al. 2010) and educating health professionals involved in the treatment of children diagnosed with cancer (khoza-shangase et al., 2010). however, even with these suggestions, the incidence of sensorineural hearing loss has not decreased, especially in developing countries like south africa (bale et al., 2005). the results of this study indicated that a small number of paediatric oncologists refer to audiologists for the management of possible high-frequency hearing loss that a child may present with during or post chemotherapy treatment. de andrade et al. (2009) advocated that the presence of an audiologist within the paediatric oncology team will enhance the management of paediatric patients undergoing chemotherapy, as the audiologist may provide valuable input and expertise in the management of this population. there is, therefore, a need for conducting further studies, such as the ongoing qualitative study looking at the quality and the mode in which the information is given to the parents to ascertain how parents are informed about the possible side effects of chemotherapy. this mode in which parents are informed about the possible side effects related to chemotherapy is critical, considering that a large number of children are still receiving chemotherapeutic drugs that are directly linked to hearing loss. it is important to establish the quality of information given to the parents to understand if they are made aware of possible options, such as choosing carboplatin, which is less ototoxic, over cisplatin and cyclophosphamide, which are highly ototoxic (de andrade et al., 2009; lokich & anderson, 1998), where possible. this study was concerned with finding out whether parents were informed and aware of the possible hearing loss as a result of their children receiving chemotherapy. conducting a qualitative study with a focus on the quality and the mode in which the information is given to the parents will be beneficial in informing health professionals about the quality of information given to parents. this will assist in establishing a comprehensive resource for parents of children undergoing chemotherapy. acknowledgements competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions n.f.m. was the project supervisor and wrote the manuscript. k.h. was responsible for data collection and analysis and writing up of the research report. references adewole, i., dangou, j., denny, l., harford, j., bello, i. m., odedina, f. et al. 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(2000). symptoms and suffering at the end of life in children with cancer. the new england journal of medicine, 342(5), 326–333. https://doi.org/10.1056/nejm200002033420506 appendix 1 adapted questionnaire (khoza-shangase, mupawose, & mlangeni, 2009) addressed to paediatric oncologists. how long have you been practicing in this department at this hospital? where have you practiced before this department? to your knowledge, do chemotherapeutic drugs have any effect on hearing ability? yes   no   uncertain   is there a hearing ototoxicity monitoring programme in place for children receiving chemotherapy? yes   no   if yes, please provide a brief description? is any information offered by you regarding ototoxicity to the parents of the child receiving chemotherapy? yes   no   if yes, please provide a brief description of this information? are you aware of the negative hearing-related sequelae involved, with regard to quality of life issues, which may arise as a result of chemotherapy? yes   no   if yes, please state whether or not this knowledge generally affects the prescriptive dose of chemotherapy allocated? yes   no   to your knowledge, what is an audiologist? during the course of chemotherapeutic treatment, are paediatric patients ever referred to an audiologist? yes   no   if yes, please state at what stage is the referral is made? thank you for your time. appendix 2 questionnaire addressed to the parents of children who are currently receiving or who have received platinum-based chemotherapy. how long has your child been receiving chemotherapy? prior to the commencement of the treatment, were you provided with any information regarding chemotherapy and hearing? (please tick) yes   no   if yes, please state whether or not you felt this information to be adequate and satisfactory? yes   no   please state whether or not you have noticed any changes in your child’s hearing since the beginning of the chemotherapeutic treatment? yes   no   if yes, please explain this? if any, please list additional sources which you may have consulted for further information regarding chemotherapy-induced sequelae? what are your perceptions of your needs, as a parent, regarding the information given to you by the paediatric oncologist? thank you for your time. communication development o f a young child with foetal retinoid syndrome: a seven-year follow-up study 39 communication development of a young child with foetal retinoid syndrome: a seven-year follow-up study alta kritzinger (corresponding author) and lizanne steenkamp clinic for high risk babies (chrib), centre for early intervention in communication pathology (ceicp), department o f communication pathology, university of pretoria abstract the aim o f the a rticle is to d escrib e the com m unication develo p m en t o f a ch ild with f e ta l r etin o id syn d ro m e (frs) fr o m six m onths to seven y e a r s o f age. l ittle is known a b o u t this ra re a cq u ire d syn drom e a n d its long-term im plications, e s p ec ia lly on a child's com m unica­ tion developm ent. a descriptive, ex p o s t f a c to research design w a s u sed to stu d y the p a rticip a n t's com m unication d evelo p m en t f r o m 1 9 9 6 when the fa m ily en ro lled in an e a r ly com m unication intervention p ro g ra m m e. annual s e r ia l a ssessm ents o f the p a rtic ip a n t an d h er fa m ily w ere co n d u cted a n d the d ata w ere s to r e d in a research d a ta b a se a fter each assessm ent. the results a re d esc rib e d a cco rd in g to a 4 -lev el assessm en t fr a m e w o rk a n d in d ica ted consistent, b u t m o d era te to m inor d ela ys in the p a rticip a n t's com m unication d evelo p m en t with a m ild h ea rin g loss in the right ear, a sso c ia te d with e a r anom alies. although p r e n a ta l exposure to isotretinoin m ay h ave serio u s effects on the unborn f e tu s a n d even ca u se death, the p a r tic ip a n t d id n o t d isp la y a ll the sym ptom s o f frs d e s c r ib e d in the literature. the fa v o r a b le fa m ily circum stances, ea rly com m encem ent o f intervention, a n d su p p o rtin g ea r ly ed u ca tio n a l environm ents w e re p ro te c tin g f a c to r s that co u ld h ave co n trib u ted p o s itiv e ly to the p a rticip a n t's com m unication developm ent. the im portance o f k n ow ledge accum ulation abou t ra re syn d ro m es such a s f r s in com m unication p a th o lo g y a n d a u d io lo g y is d isc u s se d a n d g u id elin es f o r e a r ly identification, a ssessm en t an d trea tm en t a p p lic a b le to the ca s e a re p r o p o s e d as an intervention option. key w ords: fetal retinoid syndrome, communication development, rare syndrome, early communication intervention, longitudinal study introd uction since its licensing in 1982, isotretinoin, the main com­ pound in roaccutane®, has successfully been used for the treat­ ment o f cystic acne that occurs predominantly in women between the age o f 15 to 44 years (honein, paulozzi & erickson, 2001). the increase in use o f isotretinoin among women o f this child­ bearing age group raised serious concerns regarding the possibil­ ity o f pregnancy during the use o f this powerful teratogen. experi­ mental studies on animals and descriptive research utilizing hu­ man subjects found serious implications for embryonic and foetal growth when isotretinoin was used by the mother (moerike, pant­ zar & de sa, 2002). the complex o f symptoms in infants prena tally exposed to isotretinoin is known as foetal retinoid syn­ drome (frs) or retinoic acid embryopathy and these infants may display an array o f morphological, sensory and developmental disorders (adams, 1990; moerikejet al., 2002). isotretinoin is classified as a category x drug, i.e. contra­ indicated during pregnancy (kassis, sunderij & abdul-karim, 1985) and its use is rigorously controlled. although a pregnancy prevention programme was initiated by the drug distributor in 1988 (leach, dominguez, ruszkowki & rudy, 2001), isolated cases o f pregnancy during the use o f the drug are still reported (atanackovic & koren, 1999). according to kuznar (2001) preg­ nancies during the use o f isotretinoin may occur as a result of false-negative pregnancy tests or lack o f information about con­ traceptive methods. christiansson (personal communication, 1997) added that isotretinoin, although an expensive drug, was also known to be used by women to induce the abortion o f an unwanted pregnancy. the misuse o f the drug for these purposes may now have stopped since the legalization o f abortions in south africa in 1996. it is, however, useful to document rare cases of frs in order to contribute to the limited knowledge base of the syndrome and to use the information for prevention, early identification, individualised early intervention services and to facilitate family to-family contact where children are affected by by this rare syn­ drome. knowledge about frs is particularly important to speech language therapists and audiologists, since limited data exists on the long-term influence o f prenatal exposure to isotretinoin on a child's speech, language and hearing development. shprintzen (1997) describes frs under a category of syn­ dromes related to speech, language, hearing and cognitive disor­ ders, and reports that children with frs are expected to display serious conductive hearing loss, speech and language delays, as well as learning difficulties. the only study on the development of children with frs reported that 52% o f the subjects had low intel­ ligence levels (adams, 1990). in contrast with the dearth o f stud­ ies on developmental aspects o f children with frs, the terato­ genic effects o f the drug on prenatal development are described in detail. knowledge about the chemical composition o f isotretinoin may assist in understanding the congenital anomalies caused by the drug. isotretinoin is an analogue o f vitamin a, which implies that vitamin a and isotretinoin are similar in terms o f chemical composition, but differ in characteristics. vitamin a is the alcohol retinol, which metabolizes to form the aldehide retinal, which metabolizes to form retinoic acid. the natural form o f retinoic acid is an all-trans derivate, tretinoin, which is a potent vitamin a derivate. isotretinoin is the 13-cis form (this form changes directly to the all-trans form) that differs stereo-chemically from tretinoin, i.e. in terms of the direction of the acid tail. the acid tail is the non-polar tail region o f the molecule (rosa, wilk & kelsey, 1986). since isotretinoin and vitamin a have the same chemical composition, both influence the structures that develop from the neural crest cells in early embryonic life. excessive consumption o f vitamin a during pregnancy may cause anencephaly, ocular abnormalities, morphological abnormalities of the limbs, labial the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 40 alta kritzinger and lizanne steenkamp clefts and abnormalities o f the kidneys and adrenaline glands in the infant (carlson, 1999). consumption o f isotretinoin during pregnancy, however, causes different abnormalities in the developing embryo and fetus. the origin o f morphological and sensory impairments, and subsequent communication dis­ orders in children with frs, can be traced to the effects of isotretinoin during embryogenesis (during the 3rd to 8th week o f gestation). tran­ scription factors are one o f the groups o f mole­ cules responsible for initiating patterns o f gene expression resulting in the extensive developmen­ tal changes characteristic of embryogenesis. hox genes are some o f the most important transcrip­ tion factors that attach to specific deoxyribonu­ cleic acid dna sequences in order to assist in regulating the development o f a specific area in an organism that produces proteins. there are ap­ proximately 60 amino acids regulating gene ex­ pression or expression o f transcription factors in such an area (emery & mueller, 1992). hox genes are arranged in a specific sequence on the chro­ mosome, and gene expression occurs along the cranio-caudal axis o f the embryo in this sequence. mutations of these gene sequences may cause a change o f direction in gene expression. an exces­ sive amount o f retinoid acid causes the cells o f a specific a n terio r rhombomere (segments of the embryological hindbrain giving rise to motor nu­ clei of certain cranial nerves) to form the struc­ tural equivalent o f a p o s te r io r segment. the change in direction o f gene expression causes morphological abnormalities of the rhombomeres as well as changes in the neural crest cells (carlson, 1999). the teratogenic capacity o f isot­ retinoin therefore may cause a mutation o f the gene expression sequences. according to monga (1997) and webster, johnston, lammer and sulik (1986) isotretinoin disrupts the normal activity o f the cephalic neural crest cells as well as the migration o f the mesen­ chymal cells (loosely organized embryonic con­ nective tissue, regardless o f its origin). the dis­ ruption manifests itself clinically, since the major­ ity o f structures affected in children with frs originate in the mesenchymal and neural crest cells, causing neural tube defects, as well as ear, craniofacial and heart anomalies (sadler, 1995). mesenchymal cells originate from the mesoderm, the middle germinal layer of the em­ bryo and give rise to the pharyngeal arches (jacobs & meiring, 1997). the cascading effect of isotretinoin, that disrupts the migration o f mesen­ chymal and neural crest cells, may therefore influ­ ence the development o f the pharyngeal clefts and arches, specifically causing ear and craniofacial anomalies. the typical pattern o f symptoms o f infants prenatally exposed to isotretinoin involves the craniofacial structures, heart, thymus gland, brain and cranial nerves. the morphological and sen­ sory impairments that can be expected in children with frs are summarized in table 1. t a b le 1: p o ssib le co n g en ita l a n o m a lies in ch ild ren p ren a ta lly ex p o se d to iso tretin o in . structure or system possible anomalies described in the literature craniofacial structures • micrognathia: unusually small mandible or maxilla • midfacial hypoplasia • facial asymmetry • hyperthelorism • facial nerve hypoplasia • isolated cases o f cleft lip and palate hearing and vestibular system • absence o f the pinna or microtia (small pinna) • constricted external auditory meatus • protrusion o f bone marrow in the middle ear cavity • abnormal ossicles • absence o f the chorda tympani and stapedius muscle • abnormalities o f the membranous labyrinth in the vestibule • impairment o f the auditory nerve • hypoplastic lateral semicircular channel • enlarged vestibular aquaduct and endolymphatic sac cardiovasular system • defects o f the aorticopulmonary septum thymus gland (part o f the lymphatic system) • ectopia (abnormal position o f the thymus gland) • hypoplasia o f the thymus gland central nervous system • abnormal genesis o f the cerebellum • hydrocephaly • microcephaly • impairments o f cranial nerves (optical, occulomotor and trochlear nerves) • neural tube defects skeletal system • shortened limbs or digits (sources: guirgis, wong, & tychsen,, 2002; ishijima & sando, 1999; moerike et al., 2002; sadler, 199if it is clear from table 1 that many o f the characteristic o f frs may also be associated with other syndromes displaying cranio-facial anomalies. as a result of the rareness o f the syndrome, it may not be diagnosed correctly during a physical examination at birth. anomalies o f the external ear, and concomitant hearing im­ pairment, however, may be detected during newborn hearing screening. paediatric audiologists may therefore play an important role in identifying infants with frs early and facilitate the process o f diagnosis and appropriate early communication intervention (eci). i according to table 1 prenatal exposure to isotretinoin may cause a diver­ sity o f anomalies in children. lammer et al. (1985) found that exposure to isotreti­ noin mostly occurs very early in pregnancy, before completion of organogenesis. according to monga (1997) the critical periods for exposure to isotretinoin are before 28 days gestation and after 63 days o f gestation, and it appears' that the tim­ ing o f exposure to the drug is the determining factor, and not so much the dose o f exposure. 1 frs is therefore an acquired congenital disorder caused by a powerful tera­ togen, resulting in the mutation o f gene sequences, which produces a unique pat­ tern o f impairments that may hold long-term consequences for a child's develop­ ment. although the morphological impairments o f frs are present in an infant at birth, these infants may be identified late since the syndrome is so rare. the dearth 1 o f research on the long-term consequences and development of children with frs may add to delayed identification, diagnosis and intervention o f these children. in addition, insufficient knowledge about genetic disorders is ayself-identified need > among speech-language therapists and audiologists in south africa (khan, 1999). opportunities to study young children with genetic disorders should therefore be used in order to increase knowledge and early intervention options. the rationale for the study is based on the need to accumulate long-term data on the communication development o f children with frs. documenting cases die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) communication development o f a young child with foetal retinoid syndrome: a seven-year follow-up study 41 o f rare syndromes such as frs may contribute to the knowledge base o f the syndrome, assist speech-language therapists and audi oiogists in providing appropriate eci services to families with young children with frs, and contribute to its ultimate prevention. the following research question was posed: what is the character­ istic nature of communication development over a seven year pe­ riod in a specific case o f a young child diagnosed with frs? m e t h o d m ain aim the main aim of the study was to describe the communica­ tion development o f a single case o f a young child diagnosed with frs, from six months to seven years, in order to contribute to the limited knowledge base about the developmental consequences o f exposure to isotretinoin in children. sub-aims • to describe the physical appearance of the young child with frs • to describe the hearing abilities and changes over time o f the child from six months to seven years o f age • to describe the communication development of the child with frs, from six months to seven years, over seven data collec­ tion sessions r esea rch d esig n a longitudinal case study design was used since it provides for multiple measurements o f the participant's communication de­ velopment over time. since the measurements were carried out over seven sessions o f early communication assessment and en­ tered into an electronic research database after each session, the principles of an ex post facto method were applicable. no manipu­ lation o f variables occurred. data were collected by means o f ob­ servation, studying of available documents, audiovisual material and interviews with the family. a rich description of the case in terms o f different child development and family variables, and pos­ sible causes or contributing factors over a seven year period, was achieved (de vos, strydom, fouche & delport, 2002; leedy & ormrod, 2001). the research database utilized was specially de­ signed to store longitudinal data o f infants at risk for communica­ tion disorders and their families and has been in operation for the past nine years (kritzinger, 2000). r ese a rc h p a rticip a n t convenience nonprobability sampling was used to select the participant as she presented to the researchers when the parents sought early intervention services (leedy & ormrod, 2001). the following two criteria were applied in selecting the participant for the study: • the participant presented with prenatal exposure to the terato­ gen isotretinoin and the diagnosis o f frs was made by a ge­ neticist • the parents o f the participant gave written informed consent for the conduction o f the research and publishing o f the results description o f the participant and fam ily in order to provide a basis for the interpretation o f the re­ sults of the study, and consistent with a family-centered and asset based approach to eci, family strengths and resources in addition to risk factors are reported. a rich description o f the participant’s characteristics and her family is provided in table 2, the different characteristics are provided in the middle column o f the table, with the corresponding risk and protective factors for com m unication development identified in the left and right columns. t ab le 2: c h a r a cter istics o f p a r tic ip a n t an d fa m ily in d ica ted as r isk an d p r o te c tiv e fa cto rs. risk factor (rossetti, 2001) characteristic protective factor (werner, 2000) u se o f isotretinoin during pregnancy by bio­ logical mother 1 1. prenatal history • none not married 1 father unknown | 2. circumstances o f biologi­ cal parents • a ge o f mother 23 years, i.e. within ideal age category (rossetti, 2001) none 3. duration o f pregnancy • full-term none : 1 4. birth weight • normal, 2900g 5 days o f vomiting (withdrawal from isotreti­ noin) 1 5 days tube feeding 5. perinatal conditions • normal birth • normal apgar scores: 7/10 and 9/10 (r ossetti, 2001) • initial feeding problems resolved after five days biological mother voluntarily gave her up for adoption 8 weeks in hospital without attaching to a single caregiver 6. mother-infant attachment • adoptive mother started visiting participant in hospital 10 days after birth • placed in foster care with adoptive parents at age 8 weeks n one 7. role o f adoptive parents as prim ary caregivers • stable attachment and home environment since placed in foster care • adopted by foster parents n one 8. role o f siblings • adoptive brother and sister are involved and supportive • close relationships established risk for cns and sensory impair­ ments, and developmental delay (moerike et al., 2 0 0 2 ) 9. diagnosed with frs at 6m • identified early • early commencement with intervention: speech-language and occu­ pational therapy • good health risk for learning difficulties 1 10. roles o f day mother and teacher in nursery school and prim ary school • stable and supportive relationship with day mother • the same teacher is involved from nursery school until primary school • small class in a private school the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 42 alta kritzinger and lizanne steenkamp according to table 2 there were many protecting factors in the participant's life, even though the risks for development in­ clude the fact that she was prenatally exposed to isotretenoin and given up for adoption. it appears that the serious risks associated with prenatal exposure to a teratogen, such as abrupti placentae, intra-uterine growth retardation, still birth, foetal distress, preterm birth and low birth weight (rossetti, 2001) did not occur in the participant. it is clear that her adoptive family, early commence­ ment o f intervention and supportive educational environments played protective roles (werner, 2000) and that chronic health problems and emotional adjustment problems often associated with young children in foster care, did not occur in the participant (vig, chinitz & shulman, 2005). m a teria l since data were collected by an experienced early commu­ nication assessment team and stored in an early intervention data­ base, the reliability of the data was increased and could therefore be used retrospectively. the chrib assessment protocol (kritzinger & louw, 2002) was used and adapted to assess the client and family during seven serial assessment sessions, when the participant was aged 6 months, 12 months, 20 months, 29 months, 45 months, 74 months and 84 months respectively. the chrib assessment protocol mainly consists of a collection o f criterion-referenced assessment instruments that allow a flexible and appropriate description of a young child's communication development according to a continuum o f expected sequences or developmental criteria. norm-referenced methods, which compare a child's development to a specific population of typically devel­ oping children, are used to a limited extent in this assessment pro­ tocol (see kritzinger & louw, 2002 for a complete list o f early communication assessment instruments included in the chrib assessment protocol). the chrib assessment protocol was used to collect data on the participant's different developmental areas and a 4-level early communication assessment framework (see figure 1) was used to describe her communication functioning in a holistic man­ ner. level 1: describe physical appearance and determine sensory abilities level 2: describe communication functioning and feeding skills level 3: describe general development level 4: determine risk and resilient factors f ig u re 1: 4 -lev e l ea r ly co m m u n ica tio n a sse ssm en t fra m ew o rk . according to figure 1 the first level forms the basis o f an early communication assessment and usually involves a multidis­ ciplinary evaluation, which proved to be necessary in this case of a child with frs. knowledge about a young child's physical ap­ pearance and sensory abilities allows the identification o f a ge­ netic syndrome or sensory impairment, which determines the outcome o f the next three levels o f the assessment framework. assessment data from different disciplines, such as a clinical genetics, pediatric audiology and speech-language therapy were integrated to determine the participant’s underlying conditions. the second level involves the description of all commu­ nication skill areas, i.e. communication functions, listening skills, receptive language, expressive language (which included the phonetic repertoire, babbling patterns, phonological devel­ opment, vocabulary and sentence structures), early literacy skills, mother-child communication interaction and feeding skills. since the main goal was to conduct a communication assessment of the participant, the description of level 2 com­ prised the focus o f the evaluation. level 3 includes assessment areas that may be used to compare the outcomes o f the communication assessment with and determine the extent o f the participant’s developmental difficulties. general developmental areas such as fine and gross motor, self-help and social skills, cognition, play patterns, and general behaviour are included, and typically assessed by an occupational therapist and educational psychologist. based on the systematic description and outcomes o f levels 1 to 3, in level 4 all risk and resilient factors within the participant as well as in her environment were considered. the participant’s environment may change her development and her development may change her environment over time, thereby acknowledging the reciprocal relationship between a child’s environment and constitution (rossetti, 2001). level 4 therefore permits a realis­ tic view o f a child at a certain point in time, where risks are identified but resilient or protective factors may be used to plan communication intervention and guide parent support efforts (see also table 2). p ro ced u res validity and reliability the chrib assessment protocol has been used exten­ sively for clinical purposes (kritzinger & louw, 2002) and in previous research studies (bam, kritzinger & louw, 2003; hone, 2000; kriek, 2002; kritzinger, louw & hugo, 1996), thereby contributing to the validity and reliability o f the data collection instrument and process. the collection o f instruments that comprises the chrib assessment protocol was carefully selected and found to measure the different components o f early communication skills that it intended to measure. the g en etic s creen ing c h ecklist (kritzinger & louw, 1998), one' o f the as­ sessment instruments o f the chrib assessment; protocol, added to the suitability of the data collection procedures, since this instrument allowed a full description of the physical charac­ teristics o f the participant’s syndromic anomalies. guidelines for early communication assessment recom­ mended by rossetti (2001) and coggins & timler (2000) were followed. preference was given to criterion-referenced measur­ ing instruments over norm-referenced, standardised assessment procedures. the chrib assessment protocol also proved to be consistent and dependable as a measure o f the participant's communication developmental levels and to track her progress over seven years. ’ / although the nature o f the study was retrospective, data were entered into the database shortly after each data collection session, thereby ensuring comprehensive and detailed data stor­ age. the same researcher entered the data into the database at each data collection time. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) communication development o f a young child with foetal retinoid syndrome: a seven-year follow-up study 43 ethical considerations since the nature of the enquiry was intrusive and sensi­ tive information was revealed, careful consideration was given to informed consent, confidentiality and the right o f the family to withdraw from the research if they so wished (de vos et al., 2002). the adoptive parents were invited to participate in the research and the implications were discussed with them. they gave written consent to the researchers to carry out the longitu­ dinal study and publish the results. data collection procedures, storage and analysis a play-based arena assessment approach was used, where one researcher acted as a facilitator to elicit and observe communication behaviours from the participant (rossetti, 2001), while another researcher interviewed the parents to al­ low them to report their views about the participant's progress. the remainder of the team observed from behind a one-way mirror, and the team's findings were discussed with the parents as integrated recommendations for further intervention. the team consisted of two speech-language therapists, a paediatric audiologist, an occupational therapist and a community health nurse. data were recorded on the data collection sheets o f each assessment instrument used in the chrib assessment proto­ col. data were then stored in the chrib electronic database, as well as in a paper-based file and on video recordings. these three data sources were used as triangulation of measures (de vos et al., 2002) to analyze and describe the participant's de­ velopmental progress over seven years. r e s u l t s s ub -aim #1: p h y sica l a p p e a ra n ce o f th e p a rticip a n t using the 4-level early communication assessment framework (see figure 1) as a guideline, a detailed description o f the physical appearance and genetic anomalies o f the partici­ pant is provided in table 3. the results were obtained by means o f clinical observations, guided by the g en etic s creen ­ ing c h ecklist (rritzinger & louw, 1998) and a report from the clinical/geneticist who diagnosed the participant with frs. information about internal structures and systems o f the partici­ pant was unavailable since instrumental procedures, such as x rays, were not used to obtain data. according to table 3 most o f the participant's physical features were similar to the profile of children with frs de­ scribed in the literature (kassisi et al., 1985; moerike et al., 2002; monga, 1997). both the participant's ears displayed anomalies, with the right ear more affected than the left. ac­ cording to charkins (1996) the right ear is often more affected when both ears display anomalies in children with genetic syn­ dromes since nervus facialis is often not in the expected loca­ tion. disruptions in the embryological development on the dor­ sal ends o f the first and second pharyngeal clefts could have caused the extensive anomalies of the pinnae (sadler, 1995). the participant is currently undergoing a series of reconstruc­ tive surgical procedures on the pinnae. the participant also displays morphological features that appear to be unique to her and not ascribed to frs. o f all the craniofacial structures involved, the pinnae appear to be most affected in the participant. according to charkins (1996) the kind of morphological anomalies occurring in the partici­ pant have the potential to affect her self-image. table 3: morphological anomalies present in the participant. prenatal exposure to isotretinoin may cause a characteristic pattern of dysmorphic features o f structures that originate from the first and second pharyngeal arches and the first pharyngeal cleft. these structures involve the pinnae, external auditory meati, tympanic membranes, middle ear cavities and the ossicles (carlson, 1999; lam mer, 1991; sadler, 1995). as part of level 1 o f the 4-level early communication assessment framework (see figure 1), the results o f the otoscopic examinations, middle ear functioning and measurements of the external auditory meati are displayed in table 4. as indicated in table 4 the otoscopic examinations carried out at the data collection sessions revealed the participant's narrow exter­ nal ear meati, one o f the known symptoms o f frs and described in table 3. the narrow ear canals made visual inspection o f the tympanic membranes impossible and it was only during an examination by a medical doctor at 20 months and using a larger otoscope, that the tym pani were visible for the first time. as further indicated in table 4 the tympanograms indicated normal middle ear functioning most o f the time, but also a tight con­ duction system (type as tympanogram) and possible serous otitis media (type b tympanogram). the failure to obtain a tight seal in the external meati in order to perform tympanometry, could be attributed to the narrow ear canals and their unusual configuration. the ear canal volumes that could be measured also confirmed unusually small ear canals with values under the norm o f 0,5 cc in children. the partici­ pant was referred to an ear, nose and throat (ent) specialist every time abnormal middle ear measurements were obtained, but otitis me­ dia was never diagnosed. structure or system anomalies in the participant craniofacial structures • high forehead • brachycephaly • retrognathic maxilla • eyes: small, epicanthal folds and asymmetri­ cally positioned • hypertelorism • midfacial hypoplasia hearing and vestibular systems • low-set pinnae • ears asymmetrically positioned • dysmorphic and dysplastic ears • atresia o f the external auditory meati • difference in ear canal volumes • only bottom part o f right pinna developed, ab­ sent top part • external rotation o f right pinna • mircrotia o f the left pinna • total absence o f the concha and antihelix o f the left pinna central nervous system • microcephaly other physical features present in participant, but not described in the literature • small stature • fine textured hair • strabismus o f the eyes • upper lip thin, poorly defined philtrum • high arched palate • simian hand crease pattern • tapered fingers • thumbs can rotate 360 degrees • both feet are narrow • clonus o f the right foot s u b -a im # 2: t h e p a rticip a n t's h ea rin g a b ilities an d liste n in g sk ills the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 44 alta kritzinger and lizanne steenkamp t a b le 4: o to sco p ic ex a m in a tio n s, ty m p a n o g r a m s, v o lu m e m ea su re m e n ts o f th e ex te rn a l a u d ito ry m eati, an d a u d io m etric resu lts a t six* d a ta co llectio n sessio n s. type o f measurement age at data collection sessions 6m 12m 20m 45m 74m 84m otoscopic examination: left tympanum not visible** tympanum not visible medical examination: tympanum visible tympanum not visible tympanum visible tympanum visible otoscopic examination: right tympanum not visible tympanum not visible medical examination: tympanum visible tympanum not visible tympanum visible tympanum not visible tympanogram: left type b ear sensitive type b type as type a type a tympanogram: right n o closure ob­ tained no closure obtained type a type b n o closure obtained n o closure obtained volume: left n o results n o results 0.4 cc 0.39 cc 0 .2 cc n o results volume: right 0.5cc 0.15cc hearing test: left calibrated noise makers: normal responses not done n ot done vra*** 25 db hl vra 0 db hl play audiometry 5 db hl hearing test: right calibrated noise makers: normal responses n ot done n ot done vra 30 db hl vra 5 db hl play audiometry 12 db hl a t 29 m onths o f age no hearing m easurem ents w ere carried out on the participant a -typical findings are indicated in shaded cells v r a = v isual r esponse a udiom etry the participant, however, contracted otitis ex­ terna, an inflammatory condition as a result o f a fungal infection (northern & downs, 2002). it is postulated that the structural anomalies o f the participant's ear ca­ nals may cause retention o f moisture, which may have resulted in an inflammatory condition. the audiometric results indicated in table 4 showed normal hearing abilities at 6 months and 74 months of age. elevated thresholds were measured at 45 months in the participant, which could be attributed to the middle ear condition that was evident at that time. at 84 months o f age a minimal hearing loss was diag­ nosed in the high frequencies in the participant's right ear. apart from the fluctuating middle ear conditions that were evident in the tympanograms and audiometric results over the years, the difference in results over the different data collection sessions may also be attributed to the different audiometric procedures that were used. as the participant’s age increased, and conditioned re­ sponses could be elicited from her, visual response audi­ ometry and play audiometry procedures could be used. the latter also yielded ear specific audiometric informa­ tion, as indicated in the results at 84 months. follow-up hearing evaluations were necessary to monitor these results, since hearing abilities were likely to influence the next three levels o f the participant’s functioning (see figure 1). in order to determine the effect o f the middle ear and audiometric results on the listening skills of the client, a basic requirement for language development (level 2 o f the 4level early communication assess­ ment framework), the chrib l isten in g s cale (hugo, louw, kritzinger & smit, 2001) was used. the results are indicated in table 5. s u b -a im #3: c o m m u n ica tio n d ev elo p m en t o f th e p a rticip a n t t a b le 5: l iste n in g sk ills d u r in g h ea rin g testin g an d co m m u n ica tio n a ssessm en ts. 12m 20m 29m 45m 74m listening skills during hearing testing ' conditioning to sound 1 * n o data** no data 2 | 2 localization responses 1 no data n o data 1 ! i 1 consistency o f responses 2 n o data no data 2 j 2 listening behaviour 1 n o data n o data 2 ; 2 distractibility 2 n o data n o data 2 2 listening skills during communication assessment environmental noise 1 1 1 1 ' 2 . non-speech sounds 1 1 1 3 2 whispered speech 2 1 1 3 1 speech 1 1 1 2 2 k ey: 1= good; 2= inadequate; 3 = poor n o h earin g testing w as done at 20 and 2 9 m onths, se e t able 4 ~)ie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) communication development o f a young child with foetal retinoid syndrome: a seven-year follow-up study 45 as indicated in table 5 it appears that the participant's listening skills were the poorest at 45 months, when abnormal middle ear measurements were obtained (see table 4). at 74 months her listening skills were still not adequate, despite normal middle ear measurements (see table 4). at 84 months when the mild hearing loss was diagnosed (see table 4), un­ fortunately no listening skill evaluation was carried out. the parental report and remarks from the teacher, however, con­ firmed that the participant was distractible. further components of the participant's communica­ tion development included those skills measured by the r o s ­ setti in fan t-t oddler l anguage s cale (rossetti, 1990) until she reached a three year developmental level, which is the age limit of the scale (see figure 2). r o s s e t t i i n f a n t t o d d l e r l a n g u a g e scal e 6m 12m 20m 29m par tic ip ant 's a ge at a s s e s s m e n t s ^ a tta c h m e n t ■ play □ p ra g m a tic s ® receptive a expressive f igu re 2: p a rtic ip a n t's p ro g ress fr o m 6 -2 9 m o n th s on th e rossetti infant-toddler language scale (r o ssetti, 1990). according to figure 2 the participant displayed de­ layed development in attachment to her primary caregiver, play skills related to language development, pragmatics, as well as receptive and expressive language skills during her first year of life. from 20 months it appeared that the partici­ pant showed a gradual increase in developmental levels and displayed catch-up development at 29 months for most com­ ponents o f communication development. the participant dis­ played a pattern of communication development which there­ fore changed gradually from abnormal to normal develop­ ment where an increase in skills was observed, although still below her chronological age, untilj a pattern of catch-up devel­ opment was observed for most components of communication development at 29 months (rossetti, 2001). according to figure 2 a minor delay in expressive lan­ guage development was still present at 29 months a delay that could still be detected at 84 months. the bus s to ry test (renfrew, 1997), a test of narrative speech, indicated short­ term memory difficulties in the participant. the short-term memory problems were also confirmed by the pendulum test. a transcription of the participant's language sample re­ vealed a decreased type-token ratio (shipley & mcafee, 1998), indicating a decreased variety of words in her expres­ sive vocabulary. the participant's type-token ratio was 0.395 and the norm for children of her age is between 0.45 to 0.50 (shipley & mcafee, 1998). at the age of 84 months the par­ ticipant was no longer receiving any speech-language therapy and the difficulties she was experiencing indicated a need for intervention in order to accommodate the academic demands of the school environment. , descriptive observations of the participant's phonetic develop­ ment displayed a gradual increase in her vowel and consonant reper­ toire over the seven serial assessments. at 29 months, cluster reduction, omission of consonants and phoneme specific nasality on [p], [t] and [s] were recorded. at 45 months the phoneme specific nasality was only noticed on one consonant, by 74 months distortion but not nasality was noticed on the [s] and [r] was omitted or substituted with [1], but at 84 months the participant had neither articulation errors nor phonological processes. the cause of phoneme specific nasality could never be estab­ lished, except that it could be related to a mild hearing loss and con­ comitant affected listening skills that the participant experienced (see tables 4 & 5). further components of the participant's communication develop­ ment included a description of behaviour regulation, social interaction, shared attention, conversational structure, means of communication and non-verbal aspects of communication, based on wetherby and prizant (1989). see table 6 for a summary of the new communication functions that developed and were added to her existing repertoire at each data collection session. t a b le 6: p a rtic ip a n t's co m m u n ica tio n d ev elo p m en t b a sed o n w eth e rb y a n d p riza n t (1989). communication feature 6m 12m 20m 29m 45m regulation of another's behaviour p ro te st -> r equest object and action -> social interaction r equest attention and routine g reet c all -» show o f f -> im itate -> a cknow ledge -> r equest perm ission shared attention n ot observed -> c om m ent r equest inform ation -> r equest clarification conversational structure respond m ostly -> initiate m ore -> means of communication e ye contact v ocalisation g esture -> verbal p osture facial expressions table 6 indicates that the participant showed a gradual increase in the variety of communication functions between 6 and 12 months, with a marked increase since 20 months, until she was communicating ac­ tively at the age of 45 months. the pattern of delayed communication development in the first two years of life corresponded with the devel­ opmental pattern identified in the results of the r o ssetti in fan t-t oddler l angu age s cale (rossetti, 1990). since caregiver-infant communication interaction provides the basis of communication development (billeaud, 1998), it was neces­ sary to analyse the quality of the participant's interaction with her adoptive mother. see table 7 for the results of two scales that were used to measure the quality of the mother-child communication inter­ action. t a b le 7: q u a lity o f m o th er-ch ild co m m u n ica tio n in te ra c tio n . communication interaction scale 6m 12m 20m 29m 45m 74m mother-infant communication scale (r aack, 1989) 5-point scale (1 = poor; 5 = excellent) 4 5 5 5 5 5 observation o f communication interaction (k lein & b riggs, 1987) 4-point scale (1 = poor; 4 = excellent) 3 4 4 4 4 3 the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 46 alta kritzinger and lizanne steenkamp according to table 7 it is clear that the participant was consistently exposed to favourable mother-child communica­ tion interactions, which could have contributed to the catch-up pattern of communication development observed in the previ­ ous results. according to vig et al. (2005) young children in foster care are at risk for attachment disruptions and may have complex medical, mental health and developmental needs. as a result of placement stability and permanence in the participant’s life from a very early age, the adoptive mother could establish optimal patterns of communication interaction with the partici­ pant, which could have enhanced her language development. the last component related to level 2 skills of the as­ sessment framework indicates the participant’s development in feeding skills. see table 8. table 8: development o f the participant’s feeding skills according to the oral-motor/feeding rating scale (jelm, 1990). manner of feeding 6m 12m 20m 29m bottle feeding lip and cheek movements tongue movements jaw movements 5* 5 5 4 4 2 spoon feeding lip and cheek movements tongue movements jaw movements 5 5 5 3 4 4 3 4 4 cup drinking lip and cheek movements tongue movements jaw movements 5 5 5 3 4 4 0 0 0 chewing lip and cheek movements tongue movements jaw movements 2 2 2 0 0 0 straw drinking lip and cheek movements tongue movements jaw movements 0 0 0 * 5-point scale: 0 = norm al functioning; 5 = m ore than 75% a-typical functioning as depicted in table 8 the participant showed serious feeding difficulties until 12 months, with a gradual improve­ ment in feeding skills until she displayed no problems at 29 months. the feeding difficulties displayed a similar pattern as the delayed communication development during the first two years of the participant's life. in conclusion, the participant's functioning on general developmental skills over six data collection sessions indicated her skills on level 3 of the 4-level early communication as­ sessment framework (see figure 1). table 9 displays her de­ velopment as measured on the development activities screen­ ing inventory ii dasi-ii (fewell & langley, 1984), a stan­ dardised test of cognitive and fine motor skills. according to table 9 the participant’s cognitive devel­ opment showed the same developmental pattern as communi­ cation development. the initial developmental delay during infancy was replaced by age appropriate development by 29 months of age. at 74 months, however, there appeared to be a flattening in the developmental pattern, and her functioning was no longer age appropriate. table 9. the participant’s general developmental progress ac­ cording to the dasi-ii (fewell & langley, 1984). measurement 6m 12m 20m 29m 45m 74m developmental age in months 2 6 14 29 46 58 developmental quotient 30 50 69 97 1 0 2 78 interpretation of measurements poor poor b elow average average average below average the results of the participant’s general development corresponded with the difficulties she experienced with language skills at the same age. discussion and conclusion the study highlighted the long-term effects that prenatal ex­ posure to isotretinoin may have on the communication development of a young child and her environment. due to reasons not known, she was abandoned by her biological mother at birth. within a rela­ tively short period of two months, she was placed in the foster care of her prospective adoptive family, where mother-child attachment and interaction, as well as integration within the family were suc­ cessful. supportive daycare and educational environments, early communication intervention and occupational therapy, as well as the participant’s good health, added to the advantageous reciprocal rela­ tionship between the participant and her environment over the years of the study. positive environmental factors are known to enhance a child’s development (wemer, 2000), and appeared to have provided the participant with resiliency in her early development. the participant, already diagnosed with frs at the beginning of the longitudinal study, displayed numerous observable anomalies. the anomalies were markedly expressed in her pinnae and external auditory meati, which explained the occurrence of otitis externa. the involvement of the first two pharyngeal arches and first pharyngeal cleft during embryogenesis were evident. the minimal high fre­ quency hearing loss of 12 db hl and concomitant distractibility de­ tected at seven years of age (84 months), may suggest additional in­ ternal ear anomalies that could not be observed during the assess­ ment sessions. the participant displayed a gradual pattern of catch-up devel­ opment in communication skills over seven years, but still demon­ strated a minor expressive language delay at seven years. her origi­ nal articulation and phonological difficulties were resolved, but the remaining expressive language delay may be related to the inade­ quate listening skills and minimal hearing loss. the remainder of the communication developmental delay in the participant may be the cause of ongoing learning difficulties at school. although her com­ munication skills have developed, the prognosis for her cognitive academic language development may be poorer. although the results of a single case study cannot be general­ ized, the study provides an example of a holistic description of the long-term effects of a rare genetic syndrome on a child’s early de­ velopment information often missing in databases on genetic syn­ dromes. descriptions of syndromes often only^focus on genetic analysis of the syndrome and its corresponding' morphological fea­ tures, and omit data on the affected children’s development. de­ scriptions of developmental outcomes of children with genetic syn­ dromes provide important information for clinicians involved in in­ tervention services and vital knowledge to the families of these children. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) communication development o f a young child with foetal retinoid syndrome: a seven-year follow-up study 47 the study also emphasised the importance of research on the development o f young children with rare syndromes. it is the r e s p o n s i b i l i t y o f clinicians involved in early intervention to carry out this kind o f research, so that knowledge can be accumulated to increase evidence-based interventions and provide parents with valid and reliable information to make informed decisions on the future development and education of their children. research re­ sults may therefore be used as a means to enhance family centered practice in early intervention. lastly, the use of the 4-level early communication assess­ ment framework in the study represented an effort to make sense o f the complexities of frs and the resulting trajectory o f early biological events on a young child’s morphological features and communication development. rossetti (2001) has identified the reliable and accurate assessment o f a young child and family as the most challenging clinical activity in early intervention. the holistic assessment of communication skills implies detailed inter­ disciplinary observations o f the dynamic, interactive and interde­ pendent systems involved in early communication development. early communication assessment is both a challenge, and an in­ evitable goal in order to determine the child’s level of communi­ cative functioning, to facilitate treatment planning and to evaluate the intervention efforts (coggins & timler, 2000). clinicians owe it to our clients and the professional discipline o f early communi­ cation intervention to do the best we can. acknowledgements the article is partly based on the undergraduate research project by lizanne steenkamp (nee haumann), 2003. die kommunikasieontwikkeling van ‘n kind met fetale retino'iede sindroom vanaf ses maande tot sewe jarige ouderdom. unpub­ lished undergraduate research, department o f communication pathology, university o f pretoria. references adams, j. 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(1995). longman’s medical embryology. (7th ed.). balti­ more: williams & wilkins. shipley, k. g., & m cafee, j. g. (1998). assessment in speech language pathology: a resource manual (2nd ed.). san diego: singular publishing group, inc. shprintzen, r. j. (1997). genetics, syndromes, and communication disorders. san d iego, ca: singular thomson learning. vig, s., chinitz, s., & shulman, l. (2005). young children in foster care. multiple vulnerabilities and complex service needs. infants and young children, 18(2), 147-160. wetherby, a. m., & prizant, b. m. (1989). the expression o f communi­ cative intent: assessment guidelines. seminars in speech and language, 10(1), 77-91. werner, e. e. (2000). protective factors and individual resilience. in j. p. shonkoff, & s. j. m eisels, handbook o f early childhood inter­ vention (2nd ed.). london: cambridge university press. webster, w. s., johnston, m. c., lammer, e. j., & sulik, k. k. (1986). isotretinoin embryopathy and the cranial neural crest: an in vivo and in vitro study. journal o f craniofacial genetics and develop­ mental biology, 6 , 211-222. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 2· editorial. / it is nearly two years since our first s.a.l.s. journal was published in march, 19^7. we now present vol.1, no.. 2 with the hope that its contents will prove stimulating and thought provoking to our readers. the society has "been far from static during this long period, our chairwoman's report given at our last annual general meeting ably covers the activities of our society during this period. the editorial committee sincerely hopes that this journal will become an annual publication from now on. our society is small and this is only possible with the co-operation of each and every member. our profession is still young in this country and it is surely the duty of every one of us to share our knowledge and experience with each other, if speech therapy is to progress, both in theory and practice, along scientific lines, in south africa. a journal should provide an excellent outlet for the exchange of ideas, discussion and criticism, together with reports on research studies and so on. it may also play a very valuable part in our fight for recognition and help to establish our profession on a.far sounder footing. in the past there has been a very noticeable lack of enthusiasm amongst members to take an active part in the, administrative affairs of our society a deplorable state of affairs i wish to appeal to every member to take an active interest in the future of our journal and make it their responsibility to provide some material suitable for publication each year. the need for circulars and-reminders should not exist. we look forward, with your help, to a profitable and stimulating future through our forthcoming editions of this journal. j diana m. whiting. editorial committee.. editor: miss diana'whiting. secretary: mrs pat samuels. committee members: mrs myra carel, mrs elaine clemons, miss tibby dison. all correspondence to be addressed to:the secretary, 16, raynor c ourt, claim street, hillbrow, johannesburg. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) about the author(s) nandel gouws department of speech-language pathology and audiology, university of pretoria, south africa de wet swanepoel department of speech-language pathology and audiology, university of pretoria, south africa leigh biagio de jager department of speech-language pathology and audiology, university of pretoria, south africa citation gouws, n., swanepoel, d.w., & biagio de jager, l. (2018). erratum: wideband acoustic immittance for assessing middle ear functioning for preterm neonates in the neonatal intensive care unit. south african journal of communication disorders, 65(1), a595. https://doi.org/10.4102/sajcd.v65i1.595 note: doi of original article: https://doi.org/10.4102/sajcd.v64i1.182 erratum erratum: wideband acoustic immittance for assessing middle ear functioning for preterm neonates in the neonatal intensive care unit nandel gouws, de wet swanepoel, leigh biagio de jager published: 14 june 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. in the version of this article initially published, the ‘how to cite’ indicated leigh biagio de jager’s last name as ‘de jager’ but it should be ‘biagio de jager’. the errors have been corrected in the pdf version of the article. the publisher apologises for any inconvenience that this omission may have caused. abstract introduction methods ethical considerations results discussion conclusion acknowledgements references about the author(s) delicia appana department of health, durban, south africa lavanithum joseph discipline of audiology, university of kwazulu-natal, south africa jessica paken discipline of audiology, university of kwazulu-natal, south africa citation appana, d., joseph, l., & paken, j. (2016). an audiological profile of patients infected with multi-drug resistant tuberculosis at a district hospital in kwazulu-natal. south african journal of communication disorders, 63(1), a154. http://dx.doi.org/10.4102/sajcd.v63i1.154 research project no.: be253/010 original research an audiological profile of patients infected with multi-drug resistant tuberculosis at a district hospital in kwazulu-natal delicia appana, lavanithum joseph, jessica paken received: 16 feb. 2016; accepted: 07 aug. 2016; published: 25 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the increased incidence of multi-drug-resistant tuberculosis (mdr-tb) and the consequent use of aminoglycosides with their ototoxic potential necessitate a better understanding of the audiological pattern of infected patients. objective: to describe the occurrence and nature of hearing loss in patients with mdr-tb receiving aminoglycosides over a period of 6 months. methods: baseline and five consecutive monthly audiological assessments were conducted on 52 adults at a hospital in kwazulu-natal. a longitudinal descriptive study was implemented. a conventional audiological test battery, extended high frequency audiometry and otoacoustic emission testing were conducted. data were analysed using spss version 19 statistical software package. results: decreased hearing was the most common audiological symptom experienced. bilateral sensorineural hearing loss was predominant. ototoxic hearing loss was noted in 27 participants (52%) in 1 month post-treatment. hearing loss progressed from mild to moderate at post-treatment one, to moderate to severe at post-treatment three and severe to profound at post-treatment five. changes in hearing function were noted in 52 participants (100%) by post-treatment five. high and ultra-high frequencies were most affected. speech discrimination scores deteriorated over time. the number of patients with absent distortion product otoacoustic emissions increased over treatment duration. conclusion: the greatest effects were observed in the high frequencies before manifesting in the lower frequencies. this highlights the importance of inclusion of high frequency audiometry in the early detection of ototoxicity which can go undiagnosed with traditional audiometry. the high prevalence of hearing loss has implications for the provision of audiological service to this patient population. introduction south africa is in the midst of a tuberculosis (tb) epidemic and is ranked fourth out of the 22 high-burden countries identified worldwide in terms of tb by the world health organization (who) (2008). according to the 2011 statistics of the estimated 10 819 139 people living in kwazulu-natal, the prevalence of tb was 400 per 100 000, with an incidence of 490 per 100 000 population (who, 2011). whilst these statistics are high, the actual burden of tuberculosis may yet be underestimated in this region (mitnick, appelton & shin, 2008). with the increase in the number of tb patients entering the health care system, it is crucial for health care professionals to be aware of this disease. the high incidence and prevalence of tb infection can be partially attributed to the easy spread of the disease. further, the emergence of multi-drug-resistant tuberculosis (mdr-tb) associated with antibiotic resistance poses a barrier to the ongoing struggle of global tb control and is subsequently a major challenge to health care needs within south africa (zager & mcnerney, 2008). mdr-tb refers to the strains of tb resistant to the two main anti-tb drugs, namely isoniazid and rifampicin (zager & mcnerney, 2008). as part of the who recommended guidelines for the effective treatment of mdr-tb, infected patients receive prolonged treatment with category iv treatment regimens that include the use of second-line aminoglycosides such as kanamycin, amikacin, capreomycin, streptomycin and viomycin (who, 2008). however, the foremost disadvantage of aminoglycoside use is the resultant adverse effects on an individual’s auditory, vestibular and renal function (peloquin et al., 2004). therefore, the development of mdr-tb has direct implications for audiological assessment and management of infected patients, creating a need to develop monitoring protocols and document the audiological effects of medication in patients infected with mdr-tb. hence, it is important for audiologists to be actively involved in the multi-disciplinary team management of such patients. the occurrence and nature of hearing loss in patients infected with mdr-tb is not well documented. patients receiving aminoglycosides for the treatment of mdr-tb experience disruption of cochlear activity, which results in ‘aminoglycoside-induced ototoxicity’ (guthrie, 2008, p. 91). hearing loss sustained owing to ototoxicity may be influenced by patient susceptibility as well as factors related to accumulative effects of the drug over time. incidence of hearing loss associated with aminoglycosides is reported to be timeand dose-dependent, related to drug half-life and concentrations in the inner ear (schact, talaska & rybak, 2012). the effects of ototoxicity are initially seen in the outer hair cells at the basal end of the cochlea, with the reception of high frequency sounds therefore being affected first (duggal & sarkar, 2007; guthrie, 2008; li & steyger, 2009). thereafter, there is progressive damage towards the apical end of the cochlea, resulting in the reception of low-frequency sounds being affected. from this, it is understood that with time hearing of the entire speech frequency range will deteriorate (jacob, aguiar, tomiasi, tschoeke & de bitencourt, 2006). this, in turn, may directly impact on the patient’s communication and quality of life. therefore, even at the onset of ototoxicity when the reception of ultra-high frequencies (10.0 khz and 12.5 khz) is affected, monitoring hearing loss becomes important. considering the highly infectious nature of tb and the ongoing challenge of mdr-tb, it is crucial for health care professionals, including audiologists, to be involved in the management of the patient infected with mdr-tb. early identification of hearing loss in such patients is a vital responsibility of the audiologist in order to reduce the negative impact of the hearing loss. it may be that treatment regimens are altered from conventional multiple daily doses to a once daily dose in order to reduce the ototoxic effects of aminoglycosides (barclay, kirkpatrick & begg, 1999; duggal & sakar, 2007). this then will result in enhanced efforts to slow down the progression towards permanent hearing loss, before those frequencies responsible for speech are affected (stavroulaki et al., 1999) and the hearing loss influences the individual’s quality of life. the sense of hearing can greatly influence an individual’s quality of life. hearing loss in adults may reduce communication ability with spoken language, and participation in social and vocational activities, which subsequently impacts on the quality of life of the hearing impaired individual (boothroyd, 2007). an important goal of the audiologist is to improve a patient’s quality of life by enhancing communication abilities (american academy of audiology [aaa], 2009). quality of life is a global imperative, regardless of whether the patient has a life-threatening disease or not. in an effort to reduce the negative impacts of hearing loss, audiologists play an important role in the care of patients infected with tb (khoza-shangase, mupawose & mlangeni, 2009). thus, it is necessary for audiologists to better understand the audiological patterns of patients on tb treatment regimens. thus, the study aimed to describe the audiological profiles of patients on medication for mdr-tb, over a 6 month period, corresponding to the initial intensive phase of mdr-tb treatment. methods objective the objective of this study was to describe the occurrence and nature of hearing loss in terms of type and degree of hearing loss in patients with mdr-tb receiving aminoglycoside treatment over a period of 6 months study design a quantitative longitudinal research design was used. a panel study was used as an investigation was conducted on the same set of participants over the study duration to obtain accurate data changes over time (rubin & babbie, 2009). research context the study was conducted at a district hospital in kwazulu-natal which receives referrals from eight satellite clinics in this area. it has an mdr-tb unit which caters for 60 in-patients receiving direct observation treatment. the hospital was purposefully selected because of to its large referral base. participants sampling technique a purposive sampling technique was used to recruit all participants commencing the 6-month intensive mdr-tb treatment phase during the study period. the following participant selection criteria were adhered to: all participants older than age 18 were included irrespective of risk factors for hearing loss owing to the benefit of repeated measures used in the study. furthermore, children were excluded owing to the sensitivities around informed consent for this population as well as improved reliability during subjective assessments. none of the participants fell into the range for presbycusis. participants had to be admitted as in-patients at the hospital with a positive mdr-tb diagnosis. description of participants the study sample consisted of 52 patients, of which 27 (52%) were males and 25 (48%) were females. the age range of participants was 18–56 years, with a mean age of 34 years. all participants were black south africans with 42 (81%) isizulu first language speakers. educational level ranged from grade 7 to grade 12. none of the 52 participants had previous history of aminoglycoside treatment. forty-nine participants (94%) were hiv-positive, whereas seven participants (14%) had previous occupational noise exposure. in addition, one participant had previous surgery to the head or neck and another participant had a family history of hearing loss. all participants (100%) were receiving kanamycin for the treatment of mdr-tb. thirty-two participants (61%) were only receiving kanamycin whilst 11 (21%) were receiving both kanamycin and antiretroviral medication. further information on other co-existing conditions is reflected in figure 1. figure 1: treatment of other co-morbidities. data collection baseline audiological assessments were conducted on each patient within 24 hours of receiving mdr-tb treatment. all procedures were conducted by the research audiologist, who had basic and clinical isizulu conversational skills developed at university foundation level. the following audiological test battery was used: case history information otoscopic examination immittance audiometry, including tympanometry and ipsilateral acoustic reflex threshold testing at 0.5, 1, 2 and 4 khz pure tone audiometry, including high frequencies of 10 khz and 12.5 khz speech audiometry, including speech reception threshold and speech discrimination threshold testing using monitored live voice testing and isizulu word lists commonly used in hospitals in kwazulu-natal distortion product otoacoustic emissions (dpoae). audiological equipment used included the heine mini 2000 handheld otoscope, gsi 38 auto-tymp immittance meter, bio-logic audx diagnostic otoacoustic emission machine, madsen orbiter 922 twin channel clinical audiometer (version 2) with tdh-39 headphones and a single suite sound proof audiological testing booth. participants were required to undergo the same tests as the baseline audiological assessment, on a monthly basis for the next 5 months, prior to their next dose of medication. the study broadly used the 1994 asha guidelines (aaa, 2009) in terms of the audiological test procedures, except for the sensitivity range of ototoxicity for threshold determination in order to meet the study objective of describing a detailed audiological profile of patients. the timelines for audiological monitoring assessments were in keeping with the current practice at the study site owing to resource, time and personnel constraints. additional data from follow-up case history interviews and review of medical records served to supplement audiological information. data analysis data were analysed using descriptive and inferential statistics. information from the initial and follow-up case history questionnaire, medical history review and otoscopic examination checklist were coded and entered onto the spss version 19 statistical software package (ibm corp, 2010). detailed responses to open-ended questions were analysed using thematic analysis (neuman, 1997). results were described with reference to percentiles and medians as data obtained were not normally distributed (leedy & ormrod, 2005). data from all test procedures were analysed using the cross-check principle and described in table 1. table 1: audiological assessment and statistical procedures for analysis. changes in hearing function from baseline to monitoring sessions were determined using asha (1994) criteria for clinically significant hearing change for early detection and monitoring of ototoxicity (fausti, wilmington, helt, helt & konrad-martin, 2005). thus, the criteria used were as follows: (1) >20 db pure tone threshold shift at one frequency, (2) >10 db shift at two consecutive frequencies, and (3) threshold response shifting to ‘no response’ at three consecutive test frequencies. pure tone audiometric results were averaged and grouped into four frequency categories (rademaker-lakhai et al., 2006) as evident in table 2. table 2: averaged low-, mid-, highand ultra-high frequency groups. speech discrimination scores were classified as excellent, good, fair, poor, very poor and extremely poor (hodgson, 1980). ethical considerations ethical clearance was obtained from the university of kwazulu-natal biomedical research and ethics committee (be253/010). permission was obtained from the kwazulu-natal department of health and the medical manager at the study site. all participants were informed of the nature of the study and provided consent to participate in the study. information sheets and consent forms were available in english and isizulu. participants were informed that there will be no names included in the study, thereby maintaining anonymity. in addition, participants were informed that the procedures were not invasive, were commonly used and therefore not harmful and that they were free to withdraw from the study at any point without repercussions for services at the hospital. as per the protocol at the study site, all patients identified with hearing loss received intervention in the form of counselling, hearing aid assessment and fitting following placement on a waiting list for hearing aids, communication strategies training and management for tinnitus. reliability and validity a battery of audiological test procedures and the cross-check principle were used to enhance reliability and validity. normative data used to analyse the audiological test battery came from evidence-based research and were compared with each other. subjective data were compared with objective data during audiological testing. a pilot study was conducted. all equipment was calibrated by a qualified technician prior to data collection and daily biological calibration was conducted by the researcher. results case history information at baseline, 44 participants (85%) reported no audiological problems. however, reports of hearing loss increased with each successive assessment over treatment duration. at baseline, only four participants (8%) reported hearing loss; however, by post-treatment five, 44 participants (85%) reported decreased hearing, as evident in table 3. the most common complaint was difficulty hearing in group situations and during administration of medication. vertigo was reported by a small number (up to 8%) but resolved over time. reports of tinnitus increased (up to 21%) but dropped to 12%. table 3: relevant case history findings over treatment duration. otoscopic examination and immittance audiometry type a tympanograms were most common over treatment duration in 49 participants (94%) with clear ear canals and intact tympanic membranes on otoscopy. two participants (4%) had tympanic membrane perforations, one (2%) bilaterally and one (2%) on the right tympanic membrane. as treatment duration progressed, the number of participants with absent or reduced acoustic reflex thresholds increased, and sensation levels were reduced. pure tone audiometry occurrence of hearing loss all participants (100%) showed changes for one or more of the asha (1994) criteria for clinically significant hearing change from baseline to post-treatment five. at baseline, normal hearing was observed in 23 participants (44%) on the right ear and 21 participants (40%) on the left ear. by post-treatment five, all 52 participants (100%) showed changes for one or more of the asha (1994) criteria for clinically significant hearing change from baseline to post-treatment five bilaterally. changes in hearing function with pure tone audiometry are highlighted in figures 2 and 3. figure 2: pure tone audiometry mean thresholds over treatment duration: right ear. figure 3: pure tone audiometry mean thresholds over treatment duration: left ear. description of hearing loss hearing thresholds from baseline to post-treatment five were described according to four frequency averages highlighted in table 2. low frequencies: the low-frequency median on the left ear was 13.33 (iqr 10.00–17.08) at baseline. this value deteriorated to 25.00 (iqr 20.00–37.08) at post-treatment five. a similar trend was noted on the right ear with low frequencies. the median at baseline was 13.33 (iqr 9.58–17.08) and 23.33 (iqr 21.25–33.33) at post-treatment five. gradual deterioration of low-frequency medians were noted over each consecutive post-treatment assessment; however, the averages remained within normal limits. see figure 4. figure 4: low-frequency threshold changes over treatment duration. mid-frequencies: on the right ear, pure tone mid-frequency medians were 15.00 (iqr 10.00–22.50) at baseline. at post-treatment five, deterioration to 42.50 (iqr 36.88–62.50) was observed. similarly, on the left ear, mid-frequency pure tone medians at baseline were 5.00 (iqr 10.00–22.50) and 42.50 (iqr 36.88–62.50) at post-treatment five. thus, there was an increase in pure tone mid-frequency thresholds from baseline to post-treatment five (see figure 5). figure 5: mid-frequency threshold changes over treatment duration. high frequencies: the high frequency median at baseline was 20.00 for both right (iqr 15.00–33.75) and left (15.00–32.50) ears. at post-treatment five, this value increased to 65.00 (iqr 51.25–85.00) on the right ear and 70.00 (iqr 57.50–85.00) on the left ear. at each consecutive post-treatment assessment, the high frequency medians increased, thereby suggesting gradual deterioration each month (see figure 6). figure 6: high frequency threshold changes over treatment duration. ultra-high frequencies: on the right ear, the ultra-high frequency median was 25.00 (iqr 20.00–35.00) at baseline. at post-treatment five, marked deterioration to 82.50 (iqr 70.00–92.50) was observed. similarly, on the left ear, ultra-high frequency median at baseline was 25.00 (iqr 22.50–38.13) which increased to 87.50 (iqr 63.75–95.00) at post-treatment five. therefore, the ultra-high frequencies were the most affected during pure tone audiometry (see figure 7). figure 7: ultra-high frequency threshold changes over treatment duration. hearing loss was most prominent in the ultra-high frequencies initially. however, over the five post-treatment assessments, high, mid and low frequencies were gradually affected. the degree of hearing loss was initially mild to moderate at post-treatment one and gradually deteriorated to severe to profound by post-treatment five. at post-treatment one, sensorineural hearing loss was most common in 42 participants (81%) on the right ear (figure 8), and 46 participants (89%) on the left ear (figure 9). the occurrence of sensorineural hearing loss continued to be most common on subsequent audiological assessments, as evident in figure 4 and figure 5. figure 8: type of hearing loss over treatment duration (right ear). figure 9: type of hearing loss over treatment duration (left ear). speech audiometry at baseline, 48 participants (92%) presented with good speech discrimination and four (8%) presented with fair speech discrimination. at post-treatment five, speech audiometry was conducted on only 27 participants due to participant reports of fatigue or speech distortion. thus, participants were unable to cope with speech audiometry as treatment duration progressed. of these 27 participants, 6 participants (22%) presented with very poor speech discrimination scores, as reflected in table 4. table 4: speech discrimination results: speech discrimination (better ear). distortion production otoacoustic emissions the number of participants with absent dpoaes increased over treatment duration. at baseline, 27 participants (55%) presented with absent dpoaes on the right ear and 22 participants (45%) on the left ear. by post-treatment five, all 52 participants (100%) presented with absent dpoaes bilaterally as reflected in figure 10. figure 10: distortion product otoacoustic emissions over treatment duration. discussion the auditory symptoms reported by participants in this study are in keeping with symptoms of ototoxicity. case history interviews conducted at baseline and post-treatment assessments revealed increased reports and then a plateau in the number of participants who complained of tinnitus. tinnitus is commonly associated with cochlear hearing loss, associated with aminoglycosides, such as in patients on treatment for mdr-tb. the reports of vertigo could be associated with kanamycin which is reported to have more cochlear than vestibular effects. however, vertigo may have been confused with weakness or fatigue as a result of mdr-tb, as it was not confirmed using any formal vestibular assessments. reports of decreased hearing increased over treatment duration. this concurred with pure tone results showing an increase in hearing thresholds as the duration of the mdr-tb treatment increased. a prominent high frequency hearing loss from aminoglycoside use was evident, the results of which concur with the study conducted by jacob et al. (2006). with each successive post-treatment assessment, an increased number of participants reported perceptions of hearing loss, with the most common complaint being listening in background noise. this is in keeping with the results of ultra-high frequencies being most affected. hearing in noisy situations may be significantly impacted when high frequencies are affected (rademaker-lakhai et al., 2006). therefore, the need for audiological monitoring programmes at regular intervals to detect early onset ototoxic hearing loss beginning in the high frequencies is highlighted. early detection of hearing loss and subsequent management may significantly impact an individual’s communication ability, thereby improving quality of life (fausti et al., 2005). type a tympanograms were most commonly observed, thereby highlighting adequate functioning of the middle ear system (fowler & shanks, 2002) in participants on mdr-tb treatment. whilst absent ipsilateral acoustic reflex thresholds served to confirm the increasing severity of the hearing loss, reduced sensation levels served to confirm the presence of cochlear hearing loss over treatment duration (clark, roeser & mendrygal, 2007). high frequency acoustic reflex thresholds were more affected and supported the results of pure tone audiometry and dpoae testing to confirm sloping high frequency sensorineural hearing loss bilaterally. pure tone results at baseline revealed normal hearing in 23 participants (44%) on the right ear and 21 participants (40%) on the left ear. whilst this initial number of participants with normal hearing appears to be low, participants presented with a number of co-morbidities that may contribute to hearing loss. these co-morbid conditions include diabetes mellitus, hypertension, hiv and the use of antiretroviral medication. the exacerbated effects of hiv and tb and the effect of their individual treatments on the auditory system (harris et al., 2012b) must be considered as 49 (94%) of the patients presented with hiv co-infection. possible changes to the auditory system from use of antiretroviral therapy are an important risk factor to consider; however, such data were not available to the researcher. another risk factor for tb and the development of hearing loss is age. whilst the participants in this study did not fall within the age range for presbycusis, an ageing effect cannot be ruled out as in the case of precocious presbycusis or a response to the medication in older individuals. tb may alter the homeostatic mechanisms of the auditory system in a manner similar to presbycusis, thereby increasing the likelihood of hearing loss in older participants (brits, strauss, eloff, becker & swanepoel, 2012). pre-treatment audiological assessments were therefore used as a baseline to measure hearing function over treatment duration. at baseline, 26 participants (50%) and 28 participants (54%) presented with sensorineural hearing loss on the right and left ears, respectively. as treatment duration increased, so too did the number of participants presenting with sensorineural hearing loss, which increased to 49 (94%) and 50 (96%) participants on the right and left ears, respectively. at post-treatment five. hearing loss was noted from as early as post-treatment one. these results concur with the study by de jager and van altena (2002) who reported the presence of aminoglycoside-induced hearing loss from as early as 5 days. thus, the need for audiological monitoring, especially when treatment exceeds 3 days, such as in those patients on mdr-tb treatment regimens (zembower, nosin, postelnick, nguyen & peterson, 1998), is highlighted. in addition, these results correlate with the available literature suggesting sensorineural nature of hearing loss most common in patients on mdr-tb treatment (duggal & sarkar, 2007; guthrie, 2008; rademaker-lakhai et al., 2006). high and ultra-high frequencies were most affected over treatment duration bilaterally. these frequencies progressed from mild to moderate at post-treatment one to severe to profound at post-treatment five. the literature strongly supports high frequency cochlear hearing loss as a result of ototoxicity (barclay, kirkpatrick & begg, 1999; duggal & sarkar, 2007; fausti, frey, henry, olson & schaffer, 1993; guthrie, 2008; jacob et al., 2006; li & steyger, 2009). likewise, the steady increases in failed dpoae results imply increasing severity of hearing loss and cochlear damage over treatment duration (glattke & robinette, 2007). the progression of cochlear damage in patients on mdr-tb treatment and subsequent increase in pure tone thresholds has direct implications on an individual’s life. according to rademaker-lakhai et al. (2006), low-frequency sounds are responsible for the perception of speech in quiet, whereas higher frequency sounds are responsible for perception of speech in noise. ultra-high frequencies allow for the perception of music as well as appreciation of certain natural sounds (rademaker-lakhai et al., 2006). therefore, patients on treatment for mdr-tb may experience increased difficulty with speech discrimination whereby quality of life may be compromised. this is in keeping with results obtained from speech audiometry. considering the progression of hearing loss over treatment duration, audiological monitoring of patients on mdr-tb treatment is of paramount importance. whilst low-frequency deterioration was noted, thresholds still remained essentially normal. the low frequencies have been reported to be least affected as hearing loss in patients on mdr-tb treatment begins in the high frequencies, and with time progresses to the low frequencies (rademaker-lakhai et al., 2006; selimoglu, 2007). therefore, should the study have been conducted over a longer period, progression of hearing loss affecting the low frequencies is anticipated. progression of hearing loss from mild to profound by post-treatment five reiterates the need for structured audiological monitoring programmes in south africa, where there is increased aminoglycoside use owing to the incidence of mdr-tb. whilst hearing loss is the most common side effect of aminoglycoside use, the prevalence of ototoxicity depends on the method used to define hearing loss (prayle, watson, fortnum & smyth, 2010). considering the progression of cochlear damage begins with the high frequencies and progresses to the lower frequencies, it is necessary that pure tone audiometry include frequencies higher than those assessed in the conventional testing range of 125 hz–8 khz. this highlights the need for appropriate audiological monitoring programmes, including the use of ultra-high frequency audiometry to be implemented in the treatment for mdr-tb. this will allow for early identification of cochlear damage. however, many patients on mdr-tb are too sick or fatigued to cope with the entire test battery; thus, the five-frequency sensitivity range for ototoxicity is recommended (fausti et al., 1993). this was also evident in the current study, where more than half the participants were unable to undergo speech audiometry. decreased speech discrimination may also be attributed to the severity of hearing loss (hodgson, 1980). patients with speech discrimination difficulties experience feelings of frustration, annoyance, depression and inadequacy, and may withdraw from social activity in an attempt to avoid communication (hull, 1997). thus, speech audiometry is a critical component of an audiological monitoring programme. considering half the sample population were unable to cope with speech audiometry over treatment duration, it is essential that monitoring programmes take this into account and include objective tests such as dpoae. the number of overall failed dpoae results increased over the treatment duration. dpoaes may serve as a baseline for early detection of ototoxic hearing loss (glattke & robinette, 2007). thus, the marked increase in the number of participants who failed dpoaes may be attributed to the prolonged exposure to mdr-tb treatment and subsequent hearing loss. in addition, the absence of dpoaes over treatment duration further highlights cochlear hair cell damage or increasing severity of hearing loss in patients on mdr-tb treatment regimens. conclusion the participants in this study were tracked over a period of 6 months to detect changes in audiological status following mdr-tb treatment. all participants manifested changes in hearing associated with ototoxicity, using a test battery approach. changes were noted on pure tone audiometry, speech audiometry, acoustic reflex threshold testing and dpoaes. the case history reports which allowed for participants to voice their perceptions regarding hearing status confirmed changes in hearing levels and noted other effects such as tinnitus and vertigo. hearing loss was progressive over time. deterioration in speech discrimination was an important finding. the study presented a holistic understanding of the effects of ototoxic medication and the need for audiological monitoring and intervention, including counselling, rehabilitation technology and communication intervention. the value of ultra-high frequency audiometry in the detection of ototoxic hearing loss was confirmed. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions d.a. was the project leader, l.j. and j.p. were the supervisors of the project. d.a. performed all aspects of the project, l.j. and j.p. made conceptual contributions. d.a. wrote the manuscript, lj and j.p. critically reviewed and amended the manuscript. all authors approved the final draft. references american academy of audiology. 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(1998). the utility of aminoglycosides in an era of emerging drug resistance. international journal of antimicrobial agents, 10, 95–105. http://dx.doi.org/10.1016/s0924-8579(98)00033-8 prognostic factors in stuttering c . v a n r i p e r western michigan university, kalamazoo, michigan, u.s.a. this paper seeks to review the phasic information in the literature on stuttering which concerns itself with prognosis. we know that many beginning stutterers overcome the problem without professional speech therapy. we also know that cures and improvement have been reported by clinicians using a wide variety of approaches. it is also clear that many stutterers do not improve either through self-help or with the help of speech therapists. a survey of the meager research and the many statements by clinicians concerning prognostic data would seem to have some usefulness at this time, if only to demonstrate the importance of the problem. are there any characteristics of the normal speech shown by stutterers which might have prognostic value? wendahl and cole49 have shown that the apparently normal speech of severe stutterers is characterized by irregularity in time and by more force and strain than that of normal speakers. these features could conceivably be used in prediction, and so too could measures of hesitation phenomena such as that of mahl's31 non-ah ratios. schilling and goeler,39 luchsinger and dubois30 and many others have shown that the pitch range and inflections are more restricted in certain stutterers even when not stuttering and that these features usually indicate a severe problem. hirschberg21 says that a better prognosis is shown when the respiration is not affected. froeschels17 mentions that the amount of air inhaled prior to speaking is a good measure of prognosis, that if it is normal rather than excessive in amount of intake, the prognosis is more favourable. shearer42 states that his recovered stutterers attributed their improvement to speaking more slowly. luper and mulder29 mention good eye-contact with the listener as a favourable sign and the presence of excessive tension as an unfavourable one. robinson3s stresses the importance of speech consciousness and concern about communication as important factors in prognosis. these presumably must have their impact on the normal as well as the abnormal speech of stutterers. other prognostic factors might be the sheer amount of daily talking time, the mean length of normal utterence, the average sound level of the stutterer's normal speech, and even the intelligibility. to our knowledge, no investigator has systematically investigated the incorporation of these leads in devising a prognostic measure. surely the normal speech which the stutterer does possess might provide some important information? are there any overt features of the stuttering behaviour which might yield prognostic clues? there are many statements in the tydskrif van die suid-afrikaanse logopediese vereniging, vol. 15, nr. : des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 c. van riper literature to the effect that when the stuttering behaviour is confined to simple and regular repetitions of syllables, if few in number, the prognosis is more favourable than when avoidance and struggle behaviours are present. glasner and rosenthal20 hold that the more complex the stuttering behaviour, the poorer the prognosis. using three types of behaviours, excessive hesitation, excessive prolongation and excessive repetition, they found that 51% of their stutterers who had only one of these types of behaviours overcame their stuttering whereas only 35% of those having two or three of these patterns recovered. the openness or visibility of the stuttering behaviour has also been mentioned as indicating outcome. freund15, douglass and quarrington14 and others have stated that internalized or hidden stuttering constitutes a much more severe problem therapeutically than stuttering which is plainly overt, an opinion which has more recendy been echoed by danielson10 and quarrington and douglass.36 the variability of the stuttering symptoms. has also been viewed as predictive, schonharl40 stating that when the stuttering behaviours are highly consistent, the prognosis is more favourable than if they fluctuate in form. the characteristic form of the stuttering behaviour has also generated many statements concerning prognosis. froeschels18 mentions the lack of -tonic blockings and also pseudo-tonic (closures without pressure) as indicating less deep-seated problems. he also maintains that if the release from blocking is gradual rather than sudden, the prognosis is better. diamond's research11 showed that predominantly clonic stutterers had a better prognosis than predominantly tonic stutterers. zerneri52 tested the response of 102 stutterers to delayed auditory feedback. those whose stuttering did not improve under d.a.f. he termed organic and did not treat. the remaining 77 became more fluent under d.a.f. and he classified these according to their major behaviours as tonic or clonic. the tonic group did not respond to therapy, but most of the clonic group made rapid progress. where stuttering seems to be associated with a strong cluttering component, the prognosis seems to be worse than when either disorder occurs alone (weiss48), especially when the child is hyperactive or especially nervous. kenyon26 has stressed the point that laryngeal blockings indicate a more severe problem than those where fixations occur in the lips and tongue alone, a conclusion which agrees with our own clinical experience. multiple fixations also give us more concern than singles/ we would also add that when vowels are excessively prolonged with a rise in pitch during the moment of stuttering, the clinical problem has always been very difficult. in general, it appears that in children at least, the more frequent the moments of stuttering and the longer they last, the more likely it is that the prognosis is unfavourable. however, in adults, the converse may be true as voelker47 and others have observed. often the most grossly severe stutterers make the swiftest gains but this seems to depend upon the amount of avoidance behaviour and the overtness of the symptoms. journal of the south african logopedic society, vol. 15, no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) prognostic factors in stuttering 9 a very severe overt stutterer has few word or phonemic fears since all sounds and words give him trouble and he has less to lose by confronting and working with his problem than those who have been able successfully to hide the disorder. in these stutterers, too, progress is more visible. some investigators have sought to investigate the roles of consistency, loci, and adaptation in determining prognosis. lanyon27 found that when the stuttering consistently clustered about certain specific sounds and words, less improvement was shown than when more inconsistency in loci was present. this presumably reflects the intensity of word and phonemic fears. quarringtori35 made the same point—the more consistentlyfeared words or sounds or word position fears shown by the stutterer, the poorer will be the prognosis. johnson, darley and spriestersbach24 also stress the" consistency phenomenon, saying, in general, it may indicate how strongly his stuttering responses are associated with the stimuli or cues to which they have presumably been conditioned. lanyon27 investigated the relationship between initial frequencies of stutterings and also adaptation rate in repeated readings and improvement after therapy, finding that for severe stutterers the adaptation rate might have some prognostic value but that consistency measures or terminal frequencies after adaptation had none. perhaps the most intriguing piece of research on prognosis was performed by stromsta45 who examined the spectrograms of stuttering children who had been examined ten years earlier. he found that all those who showed normal changes in formant transitions and no breaks in air flow during moments of stuttering had recovered completely from stuttering whereas those who had shown abnormal formant transitions and airflow breaks were still stuttering. two other interesting studies with implications for prognosis are those by froeschels and rieber18a who related auditory impercivity to severity, and by ringel and minifie37 who showed that severity was related to protensity (the ability to judge time). what attitudes or covert behaviours have prognostic value? clinicians have often stressed the importance of motivation, anxiety, guilt attitudes, interpersonal relationships and other similar factors in determining prognosis. to review even a portion, of the many statements in the literature bearing upon these would consume far too much space and therefore we confine ourselves primarily to the research findings. andrews and harris1 in their longitudinal study of british children who stuttered found no significant differences in test results or psychiatric interviews between them and their normal-speaking controls. bullwinkle6 treated 23 children who stuttered. those who failed to progress satisfactorily were found to be more sensitive, shy, mother-attached and neurotic. cooper9 reports that those stutterers with strong dependency needs seemed to make more progress in therapy than those who did not have them. shames41 found a slight relationship between test scores indicating 'happy-goluckiness' and prognosis. buscaglia7 suggests that the integration of the self concept should be considered as a factor in prognosis, a finding also. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 15, nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) c. van riper 10 mentioned by clark and murray.8 lanyon,using the mmpi found that ego strength was positively and deviant and repression responses were negatively correlated with improvement in therapy. cooper9 showed that the stutterer's positive affective attitudes toward his clinician were related to progress. sheehan43 failed to find any predictive value in rorschach responses in terms of therapeutic outcome. in their investigation of recovered stutterers sheehan and martyn44 report that of 33 college stutterers who indicated that stuttering had become a part of the selfconcept only three had recovered, whereas of the 31 who had not so defined themselves, 29 had recovered. zelan, sheehan and bugenthal,51 using the w-a-y technique to investigate the self-concepts of 40 stutterers, found results indicating that success in therapy was dependent upon starting therapy with fewer negative self-percepts. naylor and rosenthal33 in a careful study of short term therapy with army stutterers failed to find any reliable or valid predictor of progress from either clinician's ratings or personality test data. if this review of the research appears discouraging, we must point out that it probably reflects the state of behavioral science in general in the prediction of the outcome of treatment. the clinician for the time being must appraise the prognosis of his new patients without the objective tools he will have some day. nevertheless, we are certain that experienced therapists do use the clues provided by the attitudes, emotionality, interpersonal relationships, self concepts and similar phenomena in making reasonably accurate judgments concerning the probable success of their treatment for a given individual. are there developmental factors important in the assessment of prognosis? this question at least seems to yield some unanimity of reply. the younger the stutterer, the better the prognosis! we find this statement almost universally recognized. wulffert50a in bulgaria, andrews and harris1 in england, dozukov13 in czechoslovakia, -kamiyama25 in japan, and arnott2 in australia, are but a few of the many writers who agree in general with glasner and dahl19 in the united states who stated: the evidence today indicates that if the child's stuttering, as defined by the specialist, is not cleared up by the time the child enters school, his condition will more than likely become progressively worse. there is ample evidence, milisen and johnson,32 pollitt,34 bryngelson,5 andrews and harris,1 shearer and williams,12 wingate,50 and sheehan and martyn,14 that a substantial proportion of children who begin to stutter seem to overcome it with or without professional help before adulthood. generally, the opinion seems to be that the longer the stuttering has lasted, the worse the prognosis. some controversy exists concerning the age of onset and prognosis. dostalova12 and wingate50 maintain that the later the onset of stuttering in children, the shorter the duration will be. contrary findings have been reported by jameson22 and others. andrews and harris1 found that four out of five stutterers who began to stutter overcame it before the age of ten years but that only one-fourth of those who were still stuttering at ten ever overcame it. journal oj the south african logopedic society, vol. 15, no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) prognostic factors in stuttering freund10 reviewed the literature on stuttering which began in adulthood and concludes that it is usually of short duration. we have already described the effect of complexity and severity ot stuttering as factors in prognosis. when these are viewed as developmental features of a disorder which usually begins with simple syllabic repetitions and progresses through a series of stages (froeschels,18 bloodstein,4 van riper46) it is apparent that the exacerbation and . growth of the disorder should be taken into account in determining the probable outcome. since this morbid development is usually oscillatory with frequent regressions into an earlier stage and often into periods of complete fluency, the therapist should always view this instability and reversal as favourable signs. once the disorder becomes stabilized in an advanced stage, more difficulty in treatment can be expected. we are certain that the prognosis for an individual stutterer is in large part determined by his basic evaluation of the disorder as a problem and by the positive or negative influences of the significant persons in his present environment and past history. van riper46 has attempted to formulate a tentative equation to include the impact of these factors but we need better models before they can be assessed with any real validity. needless to say, one of the best means for determining a prognosis is the intensive study of the stutterer and his history, and some trial therapy itself. . , in this discussion we have purposely avoided the quagmire of etiology and theory in which the nature of stuttering is presently buried. it seems reasonable to consider the disorder as a syndrome or collection of syndromes with differing components. we suspect that different types of stutterers have had different etiologies and that the differing final behaviours are the result of differential reinforcement. does the cluttererstutterer have a better prognosis than the neurotic stutterer? this and other obvious questions of the same ilk cannot be answered at the present time we can remember, however, that a favourable prognosis depends as much upon the competency of the therapist as it does upon the problem presented by the patient. our successes or failures may help us assess this factor at least. a miserable thought, that! summary this review of the literature on stuttering indicates that clues concerning prognosis can be obtained from the characteristics of the normal speech of stutterers, the overt stuttering behaviour itself, the attitudes, emotionality and interpersonal relationships, and from the developmental history. an appeal is made for more. significant research. opsomming hierdie oorsig oor hakkelliteratuur dui daarop dat leidrade wat betref prognose verkry kan word van die eienskappe van normale spraak, die tydskrif van die suid-afrikaanse logopediese vereniging, vol. 15, nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) i 2 c. van riper merkbare hakkelgedrag self, die houdings, emosionaliteit en interpersoonlike verhoudings, en die ontwikkelingsgeskiedenis van die hakkelaar. daar word 'n pleidooi gelewer vir meer belanghebbende navorsing. references 1. andrews, g. and harris, h. 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(1964): recent work in bulgaria on the treatment of logoneuroses (russian). review of soviet medical sciences, 1, 57-61. 51. zelan, s., sheehan, j., and bugenthal, j. (1954): self perceptions in stuttering. j. clinical psychology, 10, 70-72. λ752. zerneri, l. (1965): tentative d'applicazione delli voci retardata [(daf) terapia delia balbuzie bolletino delia societa italiano di fonetica, fonestria e audiologia, 14, 125, 130. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 15, nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) vol 57 • december 2010 • sajcd 33 young children with fetal alcohol spectrum disorder – communication profiles mari de beer alta kritzinger ursula zsilavecz department of communication pathology, university of pretoria correspondence to: m de beer (mari.debeer@up.ac.za) according to research of the past 10 years, south africa has the highest prevalence of fetal alcohol spectrum disorder (fasd) in the world (viljoen, craig, hymbaugh, boyle & blount, 2001a). fasd has long been identified as the leading cause of preventable mental disability in the usa (antoniadis & daulton, 1992; sparks, 2000). despite the high prevalence of fasd in children and the resulting need for services, appropriate identification and management of genetic and congenital disorders are critically lacking in south africa (ntsabula, 2001). fasd is a lifelong congenital disorder characterised by multiple neurodevelopmental disabilities, including enduring learning, communication and behaviour deficits (carmichael olson, jirikowic, kartin & astley, 2007). the term ‘spectrum’ is currently preferred to ‘syndrome’, since it is more realistic to describe the condition as a range of disorders that vary from mild to severe, than ‘syndrome’ which only refers to a collection of co-occurring symptoms; ‘spectrum’ is therefore more descriptive than ‘syndrome’. services to families and communities with children with fasd are still insufficient. consequently, the high prevalence of children with fasd in south africa provides impetus to health service providers to be competent in the areas of prevention of fasd, early identification, diagnosis, assessment and subsequent intervention. since speech-language therapy forms part of the services that should be provided to families of children with genetic and congenital disorders, and considering the high prevalence of fasd in south africa, it can be expected that the number of children with fasd in the caseload of speech-language therapists (slts) will increase. it appears, however, that only a limited description of the communication development of young children with fasd is available in the relevant literature (sparks, 2000). it is therefore useful to document cases of fasd in order to contribute to the limited knowledge base of the spectrum disorder, to use the information for prevention, early identification and individualised early intervention services, and to facilitate family-to-family contact for support networks. knowledge about fasd is particularly important for slts and audiologists, since limited data exist on the early communication development, feeding and hearing concerns of infants and young children with fasd. studies conducted in the western cape region of south africa indicate that the identification and diagnosis of children with fasd or fetal alcohol effects (fae) (children not complying with the full diagnostic criteria of fasd) occur late, mainly at school entry (viljoen, croxford, gossage, kodituwakku & may, 2001b). an investigation into the early communication development of children diagnosed with fasd may provide additional guidelines for the early detection and appropriate early management of communication disorders in this vulnerable population of young children. early detection may ensure that infants and young children with fasd and their families enjoy the full benefits of early communication intervention (eci) in the form of caregiver training and support. however, for eci to be successful, a comprehensive understanding of fasd and the diagnostic criteria of this condition is essential. the diagnostic criteria as formulated by carmichael olson et al. (2007) for identifying fasd in a child are supplied in table i. the process of diagnosing fasd in a child requires a visual examination of the physical features of the child, obtaining a case history, and conducting a behavioural assessment of the child. the visual examination is conducted by a medical specialist (i.e. dysmorphologist, geneticist or paediatrician), who usually also obtains the case history in order to make the diagnosis. various multidisciplinary team members, including a clinical psychologist, social worker, slt, occupational therapist or physiotherapist, can conduct assessments to arrive at a team diagnosis; however, the tendency is for medical specialists to make the diagnosis (clarren & astley, 1997). once the assessments have been conducted, all four main diagnostic criteria (see table i) must be present in order to diagnose a child with fasd. however, children with fasd may also display more symptoms than those listed in the four main diagnostic criteria. when fewer than four diagnostic criteria are present, children may be diagnosed with fae. fae is found in children who were prenatally exposed to alcohol and ‘are at increased risk of attention impairment and other cognitive difficulties, growth impairment, difficulties in fine and gross motor skills and speech-language problems’ (carmichael olson & burgess, 1997: 114). since children with fae display a subset of the symptoms that are associated with the diagnostic criteria of fasd, the entire abstract the aim of the article is to describe the communication profiles of five young children with fetal alcohol spectrum disorder (fasd) from 4 to 58 months of age. a collective case-study design following a quantitative and descriptive approach was used to describe the communication profiles of the participants. the results are described according to the participants’ case histories and a four-level early communication assessment framework. the significant findings were that all participants were in foster care, and presented with incomplete case histories, general developmental delays and delays regarding all aspects of their communication abilities. an increase in the severity of the spectrum disorder across the participants’ combined communication profiles was also identified. participants presented with complex multiple neurodevelopmental needs that should be viewed within a developmental systems and ecological framework. the importance of early identification, diagnosis and assessment of infants and young children prenatally exposed to alcohol, the identification of precursors to communication impairment at a very early age, and the need for individualised early communication intervention to improve developmental outcomes within a family-centred approach are discussed. suggestions for future research to accumulate knowledge about fasd in the field of early communication intervention are made. keywords: fetal alcohol spectrum disorder, communication profile, early communication intervention 34 sajcd • vol 57 • december 2010 communication profiles in fetal alcohol spectrum disorder population of children who have fasd and fae may therefore display great variability in symptoms on a continuum ranging from mild to severe impairment (carmichael olson & burgess, 1997). according to dittmer and lentz (2004), the fetal pathophysiology brought about by the consumption of alcohol during pregnancy is expressed as follows: alcohol crosses the placenta and rapidly reaches the fetus. unimpeded bidirectional movement of the alcohol between the mother and the fetus takes place. the fetus is dependent on maternal hepatic detoxification, since the activity of alcohol dehydrogenasis in the fetal liver is less than 10% of that in the adult liver. the amniotic fluid acts as a reservoir for alcohol, resulting in prolonged fetal exposure and alteration of fetal development in the following ways: • disruption of cellular differentiation and growth • disruption of dna and protein synthesis • inhibition of neuronal and glial cell migration • deprivation of intra-uterine nutrients, which has a direct effect on fetal growth • causation of a chronic state of fetal hypoxia (hypoxia refers to an oxygen shortage in the tissue). prenatal exposure to alcohol may therefore have pervasive effects on the fetus, and the visible features of these effects can be diagnosed at birth. according to abkarian (1992) the recognisable physical appearance of children with fasd is more pronounced during infancy and may aid in early diagnosis. the process of arriving at a positive diagnosis of fasd, however, does not provide an adequate basis for a prognosis regarding the level of cognitive impairment and the degree of developmental delay in a specific child. a comprehensive individual communication assessment may assist in determining each child’s profile of strengths and weaknesses, as well as protective and risk factors in the family environment, before prognostic predictions can be ventured in the diagnostic process. however, a conclusive diagnosis of fasd cannot always be established in young children (clarren, carmichael olson, clarren & astley, 2000), since manifestation of deficits or impairments in the cognitive and other developmental domains are not as apparent early in life as when the child is older. the accurate prognosis of fasd is further complicated by the variable effects of alcohol in a pregnant woman, the degree of fasd and the effect of intervention on the individual (clarren et al., 2000). appendix a provides additional characteristics of children with fasd and fae to those described in the diagnostic criteria. the summarised information in appendix a emphasises the extensive physical, medical, developmental and behavioural characteristics of children with fasd. the review of the literature, together with appendix a, provides a comprehensive description of known symptoms that may assist slts and other health professionals to identify and assess young children with fasd. the broad spectrum of symptom combinations demonstrates the potential far-reaching effects of prenatal alcohol exposure on fetal development (clarren et al., 2000). different variables may also interact with one another. variables such as dosage of exposure, duration of exposure, gestational timing, genetic characteristics, drinking pattern, type of beverage, individual variation in alcohol metabolism, nutritional status of the mother and the varied susceptibility of the fetus contribute to the severity of symptoms that a child prenatally exposed to alcohol may display (colangelo & jones, 1982). the symptoms are present in a continuum and may range from clearly within the normal range to distinct features of fasd (clarren et al., 2000). as displayed in appendix a and according to steinhaussen, willms, winkler metzke and spohr (2003), children with fasd present with a behavioural phenotype. a behavioural phenotype refers to a biological disorder causing a characteristic pattern of motor, cognitive, linguistic and social deficits that can be consistently associated with fasd. research has shown that many children with fasd display unusual and varied language impairments, but this area has received limited attention among researchers (carmichael olson & burgess, 1997). to facilitate early identification of children with fasd, a comprehensive communication profile outlining the peculiar speech and language impairments of these children would be helpful to clinicians to guide disorder-specific assessment and intervention. since the present study focused on the communication abilities of young children with fasd, an overview of the known communication impairments as described in the literature is provided in appendix b. the literature study of communication impairments of children with fasd served as a basis to compile a comprehensive early communication assessment protocol to be used as data collection material in the empirical study. the literature review covers an asset-based assessment approach, the impact of substance abuse on family interaction patterns, and specifically parent-child interaction, the application of an ecological approach to assessment, and eci for young children with fasd. the current perspective in eci service delivery is to emphasise an asset-based approach. every individual has a profile of strengths and weaknesses, and appropriate eci services can capitalise on the strengths and may ameliorate some of the weaknesses in children with fasd. young children affected by fasd do not display the negative sequelae of prenatal exposure to alcohol only, but may also demonstrate certain positive characteristics, such as being socially engaging, interested in others, talkative – despite numerous expressive language problems – table i. diagnostic criteria diagnostic terminology diagnostic characteristics description 1. fetal alcohol syndrome (fas) • prenatal and/or postnatal growth deficiency • height or weight less than the 10th percentile for (all 4 diagnostic characteristics • central nervous system (cns) impairment gestational age at birth or later in life required for diagnosis) • cluster of craniofacial dysmorphology • evidence of structural, functional or neurological • confirmed prenatal alcohol exposure brain impairment • small palpebral fissures (eye slits), thin upper lip, smooth philtrum • reliable evidence of maternal alcohol consumption. if evidence not obtained, it is not deemed necessary if the cluster of facial features is fully present 2. partial fetal alcohol syndrome (pfas) • growth deficiency (only 3 diagnostic characteristics • cluster of craniofacial dysmorphology required for diagnosis) • cns impairment 3. alcohol-related neurodevelopmental • cns impairment disorder (arnd) (only 2 diagnostic • confirmed prenatal alcohol exposure characteristics required for diagnosis) source: carmichael olson, jirikowic, kartin & astley, 2007. vol 57 • december 2010 • sajcd 35 communication profiles in fetal alcohol spectrum disorder and affectionate (carmichael olson & burgess, 1997). protective factors such as child resilience and foster care placement may be present, but the risks in the social environment, family circumstances and poor attachment with the primary caregiver may be of great concern in children with fasd. often underscored in the literature, poor mother-child attachment adds to communication impairment, since the required developmental stimulation is not provided. appropriate attachment with the primary caregiver is viewed as a foundation for optimal language development, which also forms the basis for cognitive development (sparks & gushurst, 1997). in the case of children with fasd/fae, the personal characteristics of a substance-abusing parent, as well as those of another present or absent parent/caregiver, will influence the family patterns. according to guralnick (1997), family patterns will be influenced by the quality of parent-child transactions, family-orchestrated child experiences and the health care and safety provided by the family to the child. an additional risk factor is the unstable home environments of most children with fasd (vig, chinitz & shulman, 2005). children with fasd are often placed in foster care because of poor social circumstances. vig et al. (2005) report that young children, even those without fasd, who have been removed from their biological families and placed in foster care, are at a significant risk for poor developmental outcomes. the diagnosis of fasd in a child creates additional stressors regarding information needs (regarding what fasd entails and prognostic information), interpersonal and family distress (poor coping skills and maladaptive parenting), resource needs (limited access to appropriate ei services) and confidence threats (feeling inadequate regarding childrearing practices for a child with special needs) (guralnick, 1997). the conceptual model of guralnick (1997), as well as an ecological approach (gabarino & ganzel, 2000), may be used to understand the multitude of factors likely to impinge on the development of the child with fasd/ fae. these theoretical approaches are founded on the understanding that social units such as a family do not act in isolation, but interact both between and within systems. a strong interplay is present between aspects relating to nature and nurture, where interaction takes place between the characteristics of the child with fasd and the environment in which the child is raised (garbarino & ganzel, 2000). therefore, reverberations occur across all the areas of the child’s development. for this reason, eci for children with fasd should focus on caregiver training as well as information giving and support. furthermore the focus should also be on the highest possible degree of development of the children’s stronger abilities in order to compensate for the impairments that are present. empowering affected children and their families with coping strategies which may facilitate improved caregiverchild interaction and child development should also form an integral part of eci focus in this population. viljoen and colleagues (2001) identified specific south african communities with a high incidence of children with fasd (department of health, 2001). this highlights that health professionals should be aware that some communities are more at risk for the prevalence of fasd than others, to be able to provide more appropriate services in those communities. although no national fasd survey has been conducted yet, it appears that specific communities will play an integral role regarding the prevention and identification of fasd, and the facilitation of access to eci services for affected children and their caregivers. the rationale for this study was outlined in the existing need for local data and a communication profile of infants and young children with fasd. the research question that emerged from the rationale was: what are the nature of communication abilities and impairments, as well as the environmental circumstances of a group of infants and young children with fasd in the south african context? method main aim the main aim of the study was to present distinctive communication profiles of a small number of infants and young children diagnosed with fasd. objectives • to describe the developmental histories of the infants and young children with fasd. • to provide a description of their family/caregiving contexts. • to describe the communication functioning of each participant with fasd in order to present individual communication profiles as well as a combined developmental trend of the children. research design a collective case-study design following a quantitative approach was selected (leedy & ormrod, 2005). descriptive statistics were used to describe the communication profiles of the participants who were selected by means of a purposive sampling procedure. owing to the limited number of participants that could be recruited for the study, the participants were too heterogeneous in age to describe as a group. the research design allowed the researcher to study two sets of participants, namely the parents/caregivers, as well as the infants and young children with fasd, as case studies. a cross-sectional observational method was used, as the two groups of participants were only studied once. child participants from different age groups were sampled and compared (leedy & ormrod, 2005) in order to indicate trends in their development. ethical considerations permission to conduct the study was obtained from the research ethics committee of the faculty of humanities, university of pretoria, and the gauteng department of health. confidentiality applies to all studies, but because of the sensitive nature of parental abuse of alcohol and its effect on children, special care was taken to keep participants’ identities confidential. all caregiver participants gave informed consent to participate in the study. full disclosure of assessment results was provided to the caregivers and appropriate early intervention referrals were made. the assessment results were discussed within an asset-based approach with the caregivers, linking the findings to fasd and indicating future implications of the young child’s strengths and weaknesses and how best to address areas of need. research participants the main inclusion selection criteria for the child research participants in the study were as follows: • the child participants had to have a diagnosis of fasd that included a confirmed history of prenatal exposure to alcohol or other drugs, growth retardation, central nervous system dysfunction and fasdspecific dysmorphic features (carmichael olson et al., 2007). • the ages of the participants had to be between 0 and 5 years to comply with the aims of the study, i.e. to investigate a group of infants and young children eligible for eci. • the participants had to be in the greater pretoria area in gauteng. this would make access to participants easier and therefore more timeand cost-effective for the researcher. the selection criteria for the parents/caregivers were: • caregivers/parents of the participants had to provide informed consent (verbal or written) to participate in the research study themselves and for the child participant to participate. • the caregivers/parents’ and children’s first or second language had to be afrikaans or english, since the researcher is proficient in these two languages. despite the high prevalence of fasd in south africa, participant recruitment difficulties were experienced in some of the at-risk communities identified in gauteng, with resistance to research involvement with no perceived benefit for the community. however, 36 sajcd • vol 57 • december 2010 communication profiles in fetal alcohol spectrum disorder free eci services were offered at an eci clinic if the child participants required the services. this free service offer was explained to the community sites before commencement of the research. furthermore it came as a surprise that no biological parents took part in the study, possibly because of the stigmatisation attached to fasd in their communities. description of the foster and adoptive parents, and child participants the seven adult participants in the study were foster parents of the participants (5 mothers and 2 fathers). two fathers participated with their wives. knowledge and information regarding the biological parents were scant or unknown in all the cases and will be presented as part of the results of the study. the participants reported that the social workers did not provide detailed background information on the biological parents to the foster parents. five of the seven foster parents had tertiary education and all the fathers were employed. the composition of the foster families revealed a relatively small number of children (1 3 children). werner (2000) reported that small families appeared more resilient as a result of better stimulation and more attention being provided to the children by the parents. it could therefore be possible that the foster and adoptive families provided the participants with stimulating environments, which can be considered an asset. the caregivers were a data source providing the case history and developmental information regarding each participant. the characteristics of the child participants are summarised in table ii. all the participants had spent various periods in the foster care system. additional characteristics were that gender was not equally divided between participants, but could be regarded as incidental distribution. it is further evident from table ii that the child participants had a wide age range. four of the five participants had only been diagnosed with fasd after being placed in foster care. according to vig et al. (2005), children placed in the foster care system in the usa are usually thoroughly examined by medical specialists and referred to related team members such as therapists, when necessary. this could be a possible explanation of diagnosis only being made after placement in the foster care system in south africa. a lack of attendance to medical or developmental needs in the child’s biological family could have been present because of poverty, lack of accessible services and alcohol abuse in the family (vig et al., 2005). the age of diagnosis in participants 1, 2 and 5 indicated that very early diagnosis of fasd is possible, although not prevalent according to viljoen et al. (2001a). materials the materials used during data collection for the study were: • interview schedule with five categories: general information, prenatal and birth history, medical history, developmental history and parental concerns and needs. • a communication assessment protocol, adapted from kritzinger and louw (2002) to evaluate specific characteristics of fasd. the comprehensive four-level early communication assessment framework (kritzinger & steenkamp, 2006), as used by the clinic for high-risk babies (chrib) assessment team at the university of pretoria, provided a theoretical basis for assessing a child and family affected by fasd. the first level includes screening checklists and procedures to describe the physical appearance of the child that may relate to genetic anomalies, the prenatal and perinatal history, and to ascertain the child’s sensory abilities. the second level focuses on the in-depth assessment of communication functioning and feeding skills of the child. level three involves the screening of general developmental domains, such as cognitive, gross and fine motor development. the function of screening general developmental areas is also to determine the need for referral to specialised assessment by other disciplines such as occupational therapy. the fourth level of the four-level early communication assessment framework of kritzinger and steenkamp (2006) renders a description of all the risk and resilience identified in the child and family (werner, 2000). the research methods utilised were a structured interview with the caregiver, assessment of the child and observation of caregiver-child interaction during the assessment section. procedures validity and reliability the reliability and validity of the study procedures were enhanced by conducting a pilot study on one child with fasd and the family (leedy & ormrod, 2005). the pilot study was deemed successful, because sufficient data were collected on one participant and would therefore be adequate for an in-depth description of the participants of the main study. no changes were required for the structured interview or the assessment protocol. within the assessment protocol the assessment instruments were deemed applicable and the sequential order of assessment procedures was confirmed as appropriate. the different assessment instruments and procedures comprising the early communication assessment protocol have already been used in previous eci research studies and proven to be valid (kritzinger & louw, 2002; kritzinger & steenkamp, 2006). to increase the reliability of data collection and analysis, a second rater was used for the analysis of mother-child interaction. the researcher and second rater analysed the videos independently and discussed points of difference until agreement could be found. the internal validity was addressed through triangulation (de vos, 2002). the researcher’s observations were enhanced by the parental report, video and audio recordings and a second rater for the analysis of mother-child interaction. the content validity was addressed by ensuring that the research materials corresponded with interview schedules, assessment protocols and theoretical frameworks in the field of eci research and in agreement with the aims of the study. face validity was addressed by using a patient/caregiver information leaflet, structuring the interview schedule and assessment protocol in a logical way and using appropriate language and terminology – all of which was tested in a pilot study (leedy & ormrod, 2005). construct validity required that the interview schedule and assessment protocol contain only pertinent questions and assessment tasks that relate to the study’s objectives (leedy & ormrod, 2005). the findings of the study cannot be generalised or transferred to the entire fasd population because of the small, unrepresentative sample utilised in this study (de vos, 2002). data collection procedures and analysis the data were collected during separate interview and assessment sessions for the five participants. a structured interview with the foster parent/s was conducted to obtain a comprehensive case history and developmental overview of the child participant. the assessment session consisted of a play-based assessment and a section for parent-child interaction. the rooms of a private speech-language therapy practice table ii. description of child participants (n=5) characteristic participant 1 participant 2 participant 3 participant 4 participant 5 chronological age 4 months 18 months 35 months 51 months 58 months age when diagnosed with fasd at birth 15 months 28 months 48 months at birth age when placed in foster care system 5 weeks 12 months 26 months 24 months at birth age when adopted n/a n/a n/a n/a during first year of life gender male male female female male vol 57 • december 2010 • sajcd 37 communication profiles in fetal alcohol spectrum disorder and the department of communication pathology at the university were used for the sessions. data were recorded on the assessment forms, developmental levels were determined according to the scoring procedures of the different assessment instruments, and the results were summarised and represented in tables and graphs. results and discussion objectives 1 and 2: to describe the developmental histories of the five participants with fasd and their family/ caregiving contexts according to table iii certain trends emerged from the case histories of the five participants. all participants had a confirmed diagnosis of fasd, indicating that early diagnoses had occurred despite reports by viljoen et al. (2001b) that in south africa children were mostly identified at school entry level. however, the results cannot be generalised as it was a selection criterion to include participants already diagnosed with fasd. four of the five participants were living in foster care, one had already been adopted, and one adoption was in progress. children with fasd in the foster care system in south africa may be more accessible for research than children living with their biological families. placement in foster care resulted in improved circumstances, such as stability, safer environments, and improved access to health care services for the child participants compared with their biological family settings, which were characterised by chaotic lifestyles, posing health and safety risks and exposing the child participants to maltreatment. the foster and adoptive parents displayed a lack of information regarding early intervention services, specifically eci services. the unknown histories of perinatal and postnatal development were characteristic of the participants. the incomplete or lost histories of the period before placement in foster care may be a concern for the participants’ sense of identity as they grow older. furthermore, reliable description of risks such as low birth weight and preterm birth may not be possible. the participants were diagnosed by a single medical professional in a public hospital, without comprehensive team involvement, except for the social worker who was involved in follow-up and foster care placement. the participants displayed problems regarding early self-regulatory behaviour and feeding. recurrent otitis media and tonsillitis suggest that they may have compromised immune systems. the foster and adoptive parents reported that the participants displayed delayed achievement of developmental milestones in different developmental domains, but mostly in listening, speech, language and motor development. the participants were described as talkative and active children by their caregivers. the table iii. summary of the participants’ case histories as reported by the foster and adoptive parents (n=5) categories participant 1 participant 2 participant 3 participant 4 participant 5 age: 4 mo., male age: 18 mo., male age: 35 mo., female age: 53 mo., female age: 58 mo., male 1. biological families parental ages mother: 25 not available mother: 27 not available mother: 35 father: not available father: 28 father: not available parental education not available not available both in special not available not available needs school parental occupations mother: housewife mother: veterinary mother: shop assistant father: gardener assistant father: gardener not available not available socio-economic status (ses) low ses middle class middle class low ses middle class siblings with fasd no no yes yes not available home language sotho english afrikaans afrikaans afrikaans substance abuse alcohol abuse alcohol abuse alcohol abuse alcohol abuse alcohol abuse poly-drug use cigarette use cigarette use 2. foster family home language afrikaans afrikaans & english afrikaans afrikaans & english afrikaans nursery school double-medium at home afrikaans nursery double-medium afrikaans nursery attendance crèche school nursery school school 3. perinatal history full term, nicu not available not available not available full term natural birth bottle fed natural birth breastfed by biological bottle fed mother birth weight 2 400 g not available not available not available 2 805 g 4. early behavioural irritable very active not available very active irritable characteristics inconsolable friendly inconsolable very active very quiet 5. medical history high temperature after chronic middle ear tonsillitis chronic middle-ear one episode of high inoculation infections regular colds & flu infections temperature bronchiolitis grommets grommets tonsillitis eczema chronic tonsillitis chronic tonsillitis regular colds & flu possible lactose gastro-enteritis tonsillectomy intolerance strabismus regular colds & flu, sinusitis gord colic reconstruction of cleft palate 27 m adhd medication 6. history of emesis after birth feeding problems breast-bottle no no feeding difficulties associated no transition problems with cleft palate 7. current feeding status emesis, excessive age appropriate age appropriate age appropriate age appropriate drooling 8. hearing difficulties no yes no no no 9. behavioural sleep difficulties no limited attention limited attention yes difficulties nicu = neonatal intensive care unit ; adhd = attention deficit hyperactivity disorder; gord = gastro-oesophageal reflux disease. 38 sajcd • vol 57 • december 2010 communication profiles in fetal alcohol spectrum disorder characteristics in table iii are also described in the literature as typical of children with fasd (carmichael olson et al., 2007). the trends observed in the case histories of the five participants may serve as guidelines for slts in clinical practice to obtain as comprehensive a case history as possible if a child is suspected of fasd. these observed trends may also be of value in the promotion of effective interdisciplinary team management of young children with fasd. objective 3: communication profiles of participants a classification of severity of delay was implemented to summarise each participant’s results in table format. the severity classification was derived from rossetti (2006) and the arizona revised statutes 15-761 (2010). a mild developmental delay is defined as the child performing 6 months below chronological age expectations in developmental skill mastery, measured against the norms of typically developing children. fig. 2. participant 2: comparison between chronological age and developmental level of functioning. fig. 2. participant 2: comparison between chronological age and developmental level of functioning. fig. 1. participant 1: comparison between chronological age and developmental level of functioning.fig. 1. participant 1: comparison between chronological age and developmental level of functioning. fig. 1. participant 1: comparison between chronological age and developmental level of functioning. fig. 3. participant 3: comparison between chronological age and participant’s level of developmental functioning.fig. 3. participant 3: comparison between chronological age and participant’s level of developmental functioning. fig. 3. participant 3: comparison between chronological age and participant’s level of developmental functioning. fig. 3. participant 3: comparison between chronological age and participant’s level of developmental functioning. fig. 4. participant 4: comparison between chronological age and participant’s level of developmental functioning. fig. 4. participant 4: comparison between chronological age and participant’s level of developmental functioning. fig. 4. participant 4: comparison between chronological age and participant’s level of developmental functioning. fig. 5. participant 5: comparison between chronological age and participant’s level of developmental functioning. fig. 5. participant 5: comparison between chronological age and participant’s level of developmental functioning. fig. 4. participant 4: comparison between chronological age and participant’s level of developmental functioning. vol 57 • december 2010 • sajcd 39 communication profiles in fetal alcohol spectrum disorder the delay is considered moderate when a child is performing more than 6 12 months below chronological age expectations, and severe when a child is performing more than 15 months below chronological age expectations in developmental skill mastery. the individual profiles of each participant obtained in the research study are presented, from the youngest to the oldest participant, in figures 1 to 5. language impairment, communication delay, verbosity and possible processing disorders were present in all the participants. the results correspond with those of kodituwakku, coriale, fiorentino, aragon, kalberg, buckley, gossage, ceccanti and may (2006), who identified language impairments as a primary distinguishing characteristic in a group of children with fasd in an epidemiological study in south africa. research by coggins, timler and olswang (2007) indicated a key deficit among children with fasd – difficulty in using language in sophisticated social contexts. the results of the study also confirmed severe communication impairments as the area of key deficit. the participants also presented with impairment in responding and interacting appropriately in different social contexts such as parentchild interaction, emergent literacy activities and free play. furthermore, to confirm the evidence of language impairments in infants and young children with fasd, voxel-based morphometry data showed anomalies in the temporoparietal cortices in the left hemisphere, which are the critical areas for language processing (kodituwakku et al., 2006). speech-language therapy is therefore most important for children with fasd, as language functioning is a predictor of school success (rossetti, 2001). individual therapy may provide the slt with a unique opportunity to provide safety in a therapeutic relationship and to model effective communication skills to enhance skill building in communication and related aspects in a young child with fasd (henry, sloane & blackpond, 2007). according to henry et al. (2007), language impairments in particular, are likely to contribute to the children’s poor coping strategies that often lead to negative and undesirable behaviour. language impairments will therefore impact on the areas of academic, behavioural and social interactive competence in young children with fasd. the results indicated that the group of participants was not homogeneous, although similarities were found in their profiles. the developmental profile of the youngest participant is indicative of a still emerging spectrum disorder; the full expression of delays may not yet be apparent at 4 months of age. participant 4 presented with multiple impairments and also showed the greatest delay in development. the three similar impairments observed in the participants were difficulties regarding social cognition, language and executive functioning. this triad of impairments is also described by coggins et al. (2007). the developmental profiles of the individual participants were combined to present a collective case study of the results of the five participants. the developmental trend that emerged from the results of the collective case study is depicted in figure 6. it was evident from figure 6 that the delays and impairments present in the participants became more pronounced with an increase in age. this trend corresponds with the findings of henry et al. (2007), indicating that secondary disabilities associated with fasd often become more impaired as the individual ages. there was an increase in the greatest delays and a decrease in the minimal delays, indicating that the severity of delays was increasing. the trend was only visible with the combined profiles of the five participants and does not necessarily indicate greater delays with age for all infants and young children with fasd. none of the participants received any form of eci and therefore the trend could differ for infants and young children with fasd who receive timely eci. a definitive trend can, however, only be determined by means of a longitudinal study (leedy & ormrod, 2005). to minimise the severe impact of fasd on infants and young children with fasd and their families, timely eci is strongly indicated (rogers-adkinson & stuart, 2007). timely eci is important because developmental plasticity is still present to facilitate developmental gains and to minimise the effect of the communication and general developmental impairments (batshaw & conlon, 1997). it is also clear from the results of the collective case study that prenatal alcohol exposure has an impact on core developmental processes such as the neurophysiological growth of the brain and nervous system, psychological development regarding personality formation, and social cognition and communication (henry et al., 2007). because of the effect of fasd on core developmental processes, a wide array of developmental domains are affected in infants and young children with fasd. the detailed profile of the communication development of a small group of infants and young children with fasd affirmed the wide array of developmental domains affected. it is also evident that the participants in the study presented with complex multiple neurodevelopmental needs and key deficits in the domain of communication and related skills, with far-reaching impact on their daily functioning, everyday family life and future academic success. despite their complex needs, strengths that emerged among participants were their socially engaging nature and interest in other people. furthermore, foster care placement and adoption will aid them in attaining more developmental gains as a safer and more nurturing environment facilitates integration into preschool and community settings. conclusion the participants in the study are part of an international increasing clinical population of infants and young children who require eci (coggins et al., 2007; rossetti, 2001). despite the increase, improved services to address the impairments and the social impact of fasd in the south african context are not readily available (viljoen, 1999). therefore multidisciplinary teams have a role to play in prevention of fasd in high-risk populations such as adolescents where alcohol abuse and teenage pregnancy are rife, as well as assessment and treatment of fasd. all slts and audiologists should revisit their caseloads to screen for children with mental disability without definitive aetiologies, to check for the possible presence of fasd. children with fasd are a unique group of clients and present with complex histories and a diversity in cultural backgrounds and clinical profiles (rogers-adkinson & stuart, 2007). slts working in the field of eci in south africa should equip themselves with specialist skills and knowledge to provide contextually relevant services to young children with fasd and their families. undergraduate training at tertiary institutions should aid slts and audiologists to equip them with increased theoretical knowledge about fasd and clinical exposure to cases. as a result of complex needs, families affected by fasd require interdisciplinary support by team members such as the social worker, educational psychologist, slt, occupational therapist, audiologist, dietician, nurse and a variety of medical specialists. because of the permanent nature of fasd, continued services will be required after the eci period through preschool, primary school, adolescence and adulthood (streissguth, barr, kagan & bookstein, 1997). the characteristics of the school-aged population of children with fasd are more widely published (sparks, 2000; thorne, coggins, carmichael olson & astley, 2007) than research regarding the early years of infancy and toddlerhood. further extensive eci research is necessary to enhance appropriate eci service delivery to this population, and to fig. 6. collective developmental trend emerging from the five participants. fig. 6. collective developmental trend emerging from the five participants. 40 sajcd • vol 57 • december 2010 communication profiles in fetal alcohol spectrum disorder contribute to the description of the complex communication profile of infants and young children with fasd. as far as we know, this study was one of the first exploratory studies to describe the developmental histories, family/caregiving contexts and communication functioning of young children with fasd in south africa. the design of the structured interview schedule and the adaptation of the early communication assessment protocol (kritzinger & steenkamp, 2006) provided useful instruments for obtaining information regarding the infant or young child with fasd’s development and family/caregiving context. these instruments were also useful to describe the communication functioning of the participants within a four-level ec framework that included the child’s: (i) physical characteristics, preand perinatal history, sensory integrity; (ii) communication and related skills; (iii) general development; and (iv) risk factors and resilience. although the instruments comprising the four-level ec framework were useful, it can be challenging to assess children of diverse language and cultural backgrounds because of the lack of availability of trained translator services in the health care sector in south africa, and the lack of adequate knowledge regarding communication practices of some indigenous cultures. the study posed some limitations regarding the use of a small sample size restricted to a specific geographical location and only including caregiver and child participants who were proficient in english and afrikaans. to increase the generalisability of results of this type of study, a repeat of this exact study on a larger and more linguistic and culturally representative sample is therefore recommended. acknowledgements the article is based on the postgraduate research project by mari de beer, 2009: ‘communication profiles of a group of young children (0 5 years) with fetal alcohol spectrum disorder’ (unpublished master’s dissertation, department of communication pathology, university of pretoria). the study was financed in part by a postgraduate bursary from the university of pretoria. references abkarian, g. g. (1992). communication effects of prenatal alcohol exposure. journal of communication disorders, 25, 221-240. antoniadis, a., & daulton, d. (1992). meeting the needs of children in pennsylvania who are exposed to alcohol and other drugs. infant-toddler intervention. the transdisciplinary journal, 2(1), 53-62. arizona revised statutes (ars) 15–761, 1–38. (2010). tucson, az: arizona state department legislature. batshaw, m. l., & conlon, c. j. (1997). substance abuse: a preventable threat to development. in m. l. batshaw (ed.), children with disabilities (4th ed.) (pp. 143-162). baltimore, md: paul h. brookes publishing. carmichael olson, h., & burgess, d. m. (1997). early intervention for children prenatally exposed to alcohol and other drugs. in m. j. guralnick (ed.), the effectiveness of early intervention (pp. 109-145). baltimore, md: paul h. brookes publishing. carmichael olson, h., jirikowic, t., kartin, d., & astley, s. (2007). responding to the challenge of early intervention for fetal alcohol spectrum disorders. infants & young children, 20(2), 172-189. clarren, s., & astley, s. (1997). development of the fas diagnostic and prevention network in washington state. in a. streissguth & j. kanter (eds.), the challenge of fetal alcohol syndrome: overcoming secondary disabilities (pp. 40-51). seattle: university of washington press. clarren, s. k., carmichael olson, h., clarren, s. g. b., & astley, s. j. (2000). a child with fetal alcohol syndrome. in m. j. guralnick (ed.), interdisciplinary clinical assessment of young children with developmental disabilities (pp. 307-326). baltimore, md: paul h. brookes publishing. coggins, t. e., timler, g. r., & olswang, l. b. 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(1997). primary and secondary disabilities in fetal alcohol syndrome. in a. streissguth & j. kanter (eds.), the challenge of fetal alcohol syndrome: overcoming secondary disabilities (pp. 25-39). seattle: university of washington press. thorne, j. c., coggins, t. e., carmichael olson, h., & astley, s. j. (2007). exploring the utility of narrative analysis in diagnostic decision making: picture-bound reference, elaboration, and fetal alcohol spectrum disorders. journal of speech, language and hearing disorders, 50, 459-474. vig, s., chinitz, s., & shulman, l. (2005). young children in foster care: multiple vulnerabilities and complex service needs. infants & young children, 18(2), 147-160. viljoen, d. (1999). fetal alcohol syndrome (editorial). south african medical journal, 89, 959-960. viljoen, d., craig, p., hymbaugh, m. p. h., boyle, c., & blount, s. (2001a). fetal alcohol syndrome – south africa, 2001. mmwr, 52, 660-662. retreived from http://www.cdc. gov/mmwr/preview/mmwrhtml/mm5228a2.htm viljoen, d., croxford, j., gossage, j. p., kodituwakku, p. w., & may, p. (2001b). characteristics of mothers of children with fas in the western cape province of south africa: a case control study. journal of studies on alcohol, 62, 962-965. werner, e. e. (2000). protective factors and individual resilience. in j. p. shonkoff & s. j. meisels (eds.), handbook of early childhood intervention (2nd ed.) (pp. 115-132). cambridge: cambridge university press. vol 57 • december 2010 • sajcd 41 communication profiles in fetal alcohol spectrum disorder physical characteristics craniofacial characteristics • cleft lip and/or palate • poor development of dentition • microcephaly • flat midface (hypoplasia) • indistinct philtrum (smooth and/ or long) • thin upper lip and small lips • thinned upper vermillion • small teeth with faulty enamel • prominent lateral palatine ridges in the mouth • epicanthal folds • low nasal bridge • anteverted nostrils • minor ear anomalies, e.g. posterior rotation of the ears, poorly formed concha • short, upturned nose • micrognathia (small mandible) • preor postnatal growth deficiency regarding head circumference • hypoplasia of the maxilla • ptosis (downward displacement of the upper eyelid) • blepharophimosis (reduced space between the eyelids) • strabismus, myopia and clinical micropthalmia other physical characteristics • brachyclinodactyly (shortened 5th finger) • anomalous palmar creases • sacral dimple medical characteristics brain and systemic defects • musculoskeletal defects • genito-urinary defects • immune deficiency • increased risk for seizures • muscular hypotonia • disturbance in brain neurochemistry in the following systems: dopaminergic, noradrenergic, serotonergic, cholinergic, glutamatergic, gabaergic and histaminergic systems organ defects • cardiac (i.e. atrial or ventrical septal defect, occasionally tetralogy of fallot) • liver • kidney • morphological changes in brain structure (especially in the corpus callosum) increased risk of infections • upper respiratory tract infections • otitis media developmental characteristics cognitive impairments • mild to moderate cognitive impairment • attention impairment • memory impairment • complex learning impairment • central processing disorders; slower, less efficient information processing • working memory problems • problems regarding social cognition • deficits in story memory • executive-function deficit in deductive reasoning • inconsistent problem-solving strategies • visual-spatial processing deficits motor impairments • visual-motor integration delay • sensory motor integration problems • psychomotor maturation delay • fine motor dysfunction • gross motor dysfunction sensory impairments • auditory disorders, e.g. increased risk of sensorineural and conductive hearing loss, auditory filtering • vision disorders, e.g. strabismus • sensory-seeking behaviour • sensory processing deficits behavioural difficulties • neonatal irritability • increased non-alert state in infants • sleep disturbances –poor sleep/ wake cycle • social-emotional delay • early onset of adhd of the inattention subtype • hyperactivity • autistic-like behaviours • antisocial • disruptive • hyperkinetic behaviour • slow-to-warm temperament • response inhibition deficit • poor self-regulatory abilities (primary regulatory disorder present from birth) • off-task behaviour • less goal-directed • irritable • impulsive • easily frustrated • poor self-confidence • insecure • anxious • aggressive • difficulty establishing and maintaining relationships with peers • decreased capacity to initiate and organise play appendix a. physical, medical and general developmental characteristics of children with fasd sources: antoniadis & daulton (1992); batshaw & conlon (1997); beirne-smith, ittenbach & patton (2002); carmichael olson (1995); carmichael olson & burgess (1997); carmichael olson et al. (2007); chapman (2000); colangelo & jones (1982); jacobson, jacobson, sokol, martier & ager (1993); kim, sugai & kim (1999); mattson & riley (1997); morrison & villarreal (1993); o’malley & nanson (2002); schoenbrodt & smith (1995); shprintzen (2001); sparks (1993); steinhausen, willms, winkler metzke & spohr (2003) – all cited in de beer m (2009). 42 sajcd • vol 57 • december 2010 communication profiles in fetal alcohol spectrum disorder expressive language developmental stage: infancy 0 24 months • high-pitched cry • decreased vocalisation • delayed onset of first words • limited lexicons • delayed imitations of interactional partner’s language production • frequent use of gestures • phonological skills may be age-appropriate or limited developmental stage: early childhood (24 60 months) • struggles with sequencing during storytelling • difficulty with more complex narrative skills • articulation impaired secondary to neurologically based incoordination • fluency problems • echolalia • short mean length of utterance • word-finding problems • syntactical errors • difficulty with more complex syntax • language expression more affected than language comprehension • increased verbosity • most frequently used word class are nouns receptive language • no descriptions found in the literature • poor comprehension linked to level of cognitive impairment • struggles to follow instructions and directions • semantic errors pragmatics • poor mother-child attachment leading to a negative environment for the development of communication skills • inappropriate use of gestures • limited social interaction • autistic-like behaviours • perseveration on a topic • inappropriate use of language as means of initiating and continuing social discourse • various language function problems (e.g. lack of communication repair) • difficulty taking listener’s perspective into account • autistic-like behaviours (e.g. passive in interaction, not displaying need to communicate • inappropriate answering of questions • poor eye contact • poor turn taking • increased talkativeness (verbosity) oral-motor development • feeding difficulties • difficulty with sucking associated with low muscle tone • weak sucking reflex • long latency to suck: lengthened time to initiate successful sucking • difficulty to regulate the basic feeding cycle • if cleft palate is present, associated feeding difficulties can be expected • delayed achievement of feeding milestones • poor appetite and lack of interest in food • deficiency in one or more of the eight major valves along the vocal tract • poor coordination of articulators, may be a remnant of apraxic behaviour • compensatory articulation patterns secondary to cleft palate or velopharyngeal insufficiency auditory abilities • abnormalities in orientation to auditory stimuli • 93% of infants with fasd present with recurrent otitis media with effusion during the first 6 years of life; this is the highest reported otitis media with effusion rate of any group of children with disabilities in the literature • difficulty regarding speech-sound discrimination • involuntary response to noises due to lack of habituation • increased incidence of sensorineural and conductive hearing loss • prone to otitis media • involuntary response to noises due to lack of habituation • high incidence of sensorineural hearing loss as well as conductive hearing loss • speech discrimination deficits appendix b. characteristics of communication impairments of young children with fasd sources: abkarian (1992); batshaw & conlon (1997); carmichael olson (1995); carmichael olson & burgess (1997); carmichael olson et al. (2007); clarren et al. (2000); coggins, olswang, carmichael olson & timler (2003); crites, fischer, mcneish-stengel & siegel (1992); gerber (1998); kim et al. (1999); lesar (1992); o’malley & nanson (2002); rivers & hedrick (1992); rivers & hedrick (1998); schoenbrodt & smith (1995); sparks (2000) – all cited in de beer m (2009). j o u r n a l o f t h e s o u t h a f r i c a n l o g o p e d c society poliomyelitis ruth millburn. clark, ph.d.* and ruth a. lund, m.a.* introduction: the medical profession agrees that poliomyelitis is caused by a filterable virus whose only known host is man. how this virus spreads how it enters the body, and what happens to it, are still not completely decade ^ g r e a t s t r i d e s h a v e b e e n m a d e i n this'area i n tjie lojt there are three distinct types of polio, spinal polio, bulbar polio and spino-bulbar polio. it is the cranial nerve type of bulbar polio which is of most concern to the speech therapist v implications for the speech therapist. speech involvements in bulbar polio. in the upper cranial nerves the third, iiith, r.xih, seventh a n d eighth nerves suffer involve:.-.cnt. most frequent involvement falls on the :<?nlh nerve: in the minnesota epidemic of i.-lu, 9 0 % of the patients with b u l b a r t y c e ..".owed symptoms indicating the tenth nerve wc:s affected. in the cranial group, symptoms vary from '•-'.lent to patient, affecting most of the prov e s of speech. most frequent conditions nasal.quality, hoarseness, l a r y n g e a l stridor, .".lateral or bilateral w e a k n e s s of the tongue' «:=uctor paralysis of the vocal folds, accumu»:on οι saliva in the oropharynx, difficulty in "''jiiov/mg, paresis of the velum, occasion—y cpnonia, a n d reflex s o a s m of the laryn•c-i musculature. (4). o f ' specific nerve involvement : . following is a breakdown of the results j . e involvement of these cranial nerves..also : : r c . s d l s t h e order cf frequency of o c c u r e n c e to a study of 107 b u l b a r c a s e s ad: ' ' \ o % t n e u n i v e r s i t y of minnesota hospital ^ v a g u s — 10th n e r v e : 95 c a s e s . motor c a r r i e d from this nerve to the larynx, --•(i"' t t v e l u m · ^ ^ posterior root of the •'"^o unilateral paralysis c a u s e s w e a k n e s s s o f t p a ^ t e , pharynx a n d larynx. ~ ^ r f e . 3 m t h e v ° i c e , such a s hoarseness, " ° r progressive w e a k n e s s or difficulty ote d u e t o involvements of the : ' v k ^ ® ' t h e s e a r e o f t e n θ α γ ΐ ^ symptoms bulbar type polio a n d should b e inter" preted a s danger signals pointing to obstruction of the airways. complete bilateral paralysis of the v a g u s nerve is almost always fatal. there is complete paralysis of the pharynx, rendering both vocal cords motionless in a halfway position between^abduction and adduction. the glottis cannot close, the patient can neither speak nor breathe. this, of course, l e a d s to suffocation, unless a tracheotomy is performed. (2) facial—7th nerve : 71 cases. supplies motor fibers to the lips a n d face. paralysis may involve the whole or lower part of the face and accordingly, affect different facial muscles e n g a g e d in speech. the patient cannot whistle or blow out his cheeks. the lack of control of lips and cheeks also prevents him. from correctly producing the sounds, p, b t " d, ch, j, g and possibly others. the vowels will also b e involved. (3) a c c e s s o r y — i i t h n e r v e : 40 cases. a few motor fibers from the 11th n e r v e " b r a r c h ;o tne muscles of the pharynx, velum, and posterior root of the tongue. s o m e of ihe motor aoers^ go to the muscles which a r e used in forced inhalation. (4) h y p o g l o s s a l — 1 2 t h n e r v e : 15 cases. carries motor fibers to some of the extrinsic muscles a n d to the intrinsic muscles of "the tongue. also to certain muscles used in forced exnaiation. unilateral paralysis c a u s e s a deviation of the tongue to the paralyzed side, causing slight impairment in mastication and possibly faulty articulation. bilateral paralysis dr. cicmc is associate professor of speech and director of tne chiicren's speech clinic, university of denver, coicraao, united states of america she was visiting lecturer in lcgopedics, university of the wit_watsrsrcnd,. johannesburg, 1950-1951. *miss lund, m.a., university of denver. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f the south a f r i c a n l o g o p e d i c society ma results in the inability to protrude the tongue at all—affecting " t h " a n d promoting sloppyarticulation. (5) trigeminal—5th n e r v e : 10 c a s e s . carries motor fibers to the muscles of the mandible. paralysis m a y c a u s e disturbances in chewing a n d mastication. a unilateral par-/ alysis of these muscles is rarely seen in polio. (5, 4, 7). (6) the glossopharyngeal—9ih nerve : is sometimes involved. it carries a few motor fibers to the pharynx, velum, a n d to the posterior root of the tongue. paralysis generally occurs, concomitantly with the tenth nerve involvement; it contributes to difficulties in swallowing. (2). b e c a u s e the speech mechanism is so highly· developed and complicated, ii must b e given special consideration in the general re-education program that follows an attack of bulbar polio. frequently, it will b e found that difficulties in swallowing, regurgitation of food, a n d pooling of saliva h a v e c e a s e d but speech has not readjusted itself to its former normal function. it h a s a l s o been observed that while there m a y b e almost complete paralysis of the soft p a l a t e and a s s o c i a t e d inability to move the p a l a t e in speaking, the reflex activities of swallowing, laughing, etc., frequently may b e impaired only partially or not at all. (7). it is regrettable, but none the less true, that s p e e c h deficiencies resulting from this form of polio h a v e received much less attention from the medical personnel than a n y other p h a s e s of this disease. premises for speech therapy : nelson (4) in considering therapy for dysfunctions in speech resulting from bulbar polio, states some general concepts for s p e e c h therapy in this situation. they a r e as follows : 1. the musculature of the speech mechanism, in which is included the muscles which expand a n d contract the rib c a g e , the larynx, pharynx, velum, j a w , tongue a n d lips, is m a d e up of the cross-striated or red muscles, having the s a m e composition a s a n y of the skeletal muscles and hence under the control of the central nervous system. however, a number of differences which distinguish the speech muscles from other skeletal muscles must b e noted.. the a x o n a l endings a r e more complex in the speech musculature, especially in the muscles of the larynx, than in most of the other b i g muscles. the speech organs, for the most part, a r e unpaired mid-line structures. s o m e of the impulses going to the muscles control ling the speech functions a r e under control c the cortex ; in other impulses, partial contrc is exercised ; and in some instances there i little or no volitional control, a s in gaggin or in the sneezing reflex. the task of stimulc; ing inert musculature over which there is lit;: voluntary control is indeed more difficult the: in those muscles which a r e under the contrc of the cortex. 2. the cerebral cortex is so little affected fcthe virus of polio that it may b e a c c e p t e d the the patient can rapidly begin to relearn pc: terns of motor activity which formerly wer· smoothly a n d automatically regulated by ; brain stem without severe lesions. these nev patterns of motor activity which a r e so import ant to recovery.of speech function a r e governs·: b y the cerebral cortex. 3. lesions in the brain stem must reach c certain threshold of severity, varying with th; margin of safety of e a c h center, before dy= function of speech can b e observed. recover;· of function results from two p r o c e s s e s : firs: the regeneration of neurons not d a m a g e : sufficiently to b e destroyed ; second, the rerouting of nerve impulses from interrupte: primary pathways. the first process is usually complete in the first month after the virus invades, but the second process is a long tern relearning activity. 4. where there is muscle atrophy, causec b y denervation, a compensatory muscle aciicr may b e had from muscle fibers v/ith intact innervation. such compensatory muscle acticlikewise is a slow relearning process. 5. nerve cells m a y b e injured to an exten' incompatible v/ith recovery. such injury will account for much of the early paralysis. eu: b e c a u s e of the margin of safety of nerve cell; in the cranial nuclei controlling motor activity in speech, irreversible d a m a g e resulting ir. complete paralysis is not frequent. 6. the impact of polio on the human syste."' is violent physically and psychologically speech is a b a s i c human process, and an interruption of its function is fraught with iru; tration. s p e e c h therapy must treat the whclr person consistent with other administer·?: therapies, and consider ail of the psychological trauma left in the wa k e of the disease· 7. audio-stimulcrtion can well b e utilize·b y the speech therapist. where lesions in inbrain stem must b e b y p a s s e d to restore function, nev/ cerebral a n d motor configuration; must b e set up. audio-stimulation is part this process. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l of t h e s o u t h a f r i c a n l o g o p e d c society ο the d a y to d a y improvement· is slight ..-a is usually not discernible to the patient or those closely a s s o c i a t e d with him. it is im'-riant to the patient to know that he is im-"oving· therefore, the therapist should use '..••• -'ever m e a n s he c a n to h a v e the patient "· ; e r v e his improvement. p e r h a p s the most • radical method is to retain samples of speech * _:::ined at intervals on a wire or tape reader. 9. except for very young children, speech •'.crapy in b u l b a r polio will consist of helping :..c patient to r e l e a s e skills which h a v e b e e n .:.·,!. since most of the patients will h a v e ex: «.-rienced normal communication before their ..inesses, they will appreciate the g o a l s for which the therapist strives. motivation should !.o excellent. 10. many of the techniques used by the pnysical therapist c a n b e a d a p t e d to improve ,;',e speech of bulbar polio patients. for example, the pattern of large muscle movement ~~n be broken down and a n a l y z e d in terms of component parts. intensive work on isoir.'.ed parts of a larger action is often produc:.ν·3 and very frequently n e c e s s a r y . in this .••-̂ pect, nelson quotes from westlake (6) who •..'j.r> made some suggestions concerning cere;:rcl palsied s p e e c h which might well b e applied to the speech of a victim of polio. west:ake points out "that a detailed scrutiny of muscle activity frequently reveals remedial • ieiects which interfere with the speaking a c t . " iio then goes on to say that the s p e e c h act can ••ο fractioned into these abilities : "a. ability to sustain an even exhalation for 10 seconds. b. ability to sustain an even tone for 10 seconds, j c. ability to open a n d close the lips 10 times in 10 seconds. d. ability to open and close the lips 10 times in 10 seconds, while the mandible is stabilized b y keeping the upper and lower teeth together. e. ability to raise tip of tongue to the r u g a e 10 times in 10 seconds,·while the manbible is stabilized b y setting a rubber block, about a quarter of an inch thick, between the teeth. ability to move the tongue tip from one corner of mouth to other 10 times in 10 seconds. 9ability to extend the corners of the lips from the round position 5 times in 10 seconds .when the mandible is stabilized by keeping the teeth together. h. g o o d peristoltic activity of the tongue —ability to propel foods from the front of the mouth to the b a c k of the mouth a n d swallowing them." these rates a r e arbitrary, a n d a r e used only for reference of measurements a n d there are, of course, m a n y other possibilities in which the speech functions c a n b e divided. westlake s a y s this approach h a s four a d v a n t a g e s : " a . it describes the over-all motor a d e q u a c y . b. it isolates foci of particular difficulty. c. it encourages a systematic therapy since it constitutes a map of an important aspect of the speech training." 11. perhaps the most frequent disability of s p e e c h resulting from bulbar polio is hypernasality. the therapist should b e a w a r e of the more recent experimental evidence which indicates that the naso-pharynx port need not b e closed for nasality-free speech. according to mcdonald a n d koepp-baker, (3). "there is a critical point at which a critical b a l a n c e is established between oral and n a s a l resonance. if this critical point is not reached, nasality will occur." to these authors, the determination of the path of the air stream, the action a n d position of the tongue is of much greater significance in cleft p a l a t e speech than the action of the palate. although these men question the efficacy .of blowing exercises for cleft p a l a t e speech, nelson (4), zausmer (7), a n d baker and sokoloff (1) all a g r e e that blowing should provide help for the palatal and p h a r y n g e a l weakness growing out of bulb a r polio. blowing provides exercise against resistance, which kind of exercise has b e e n effective in restoring tonus a n d strength to other muscles of the body. this does not preclude giving attention to direction of the air stream a n d position of the tongue in both cleft p a l a t e e n d bulbar polio c a s e s showing signs of hypernasality. specific therapy in post-bulbar polio s p e e c h : s i n c e the characteristic syndrome of postb u l b a r polio speech resembles that of cleft palate,' the therapy generally attempted is closely allied to the techniques utilized with cleft palate. to strengthen velar action a n d make soft p a l a t e more pliable a n d movable, many types of blowing exercises a r e found helpful. ( 1 , 7 ) candles, pin-wheels, soft balloons, harmonicas, whistles, feathers, ping-pong, bails h a v e all b e e n found useful gadgets. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l of t h e s o u t h a f r i c a n l o g o p e d i c society may other techniques found to b e helpful in stimulating velar activity a r e panting a n d yawning exercises a n d m a s s a g e of the p a l a t e b y a sterile s w a b or finger. the latter therapy tends to e n c o u r a g e a g a g reflex which elevates the p a l a t e . in c a s e s where there a r e residual t r a c e s which show activity in the velum, electrical stimulation of the p a l a t e to increase the movement of this structure m a y b e attempted. (this type of therapy should b e under ihe direction and surveillance or a physician who is a specialist in physical medicine.) (1). ear training is of great importance since all authorities agreethat a major problem with most patients is their inability to tell the difference b e t w e e n n a s a l a n d non-nasal sound. (7). summary. the pathological effects of this d i s e a s e that result in speech disorders a r e generally in the bulbar-cranial type group with many a n d varied types of disorder according to the amount, type a n d extent of involvements of the nerves. nasality seems to b e the most common speech problem. due to the paucity of material, the s p e e c h correctionist must take from other sources a n d work on this disorder much a s she would for nasality for cleft p a l a t e speech. it is important to remember that the "impact of polio on the human system is violent physically a n d psychologically. s p e e c h beinc a b a s i c human process, an interruption of function is fraught with frustration." therefore, we must h a v e a gestalt approach and treat the whole person consistently with the other administered iherapies. (4). a fundamental principle to k e e p in mind is that the organism r e a c t s a s a whole a n d thai anything that affects a part of the organism will have an effect on the whole organism. bibliography. 1. baker, e. e„ jr., & sokoloff, m.a. "therapy ίο; speech deficiencies resulting from acute bulbar •poliomyelitis infection." jomal of speech and hearing disorders. vol. 14:4, 1951. 2. campbell, winona g. "diagnosis of poliomyelitis." arizona medical journal. vol. 8:25-36, 1951. 3. mcdonald, τ. e., & koepp-baker, h.g. "cleft palate speech—an integration of research and clinical observation.' journal of speech and hearing disorders. vol. 16:9, 1951. 4. nelson, roy c. "bulbar poliomyelitis : its sequelcs in the speech processes with some suggestions fcr theraoy." western speech. vol. 16:4 october 1952. 5. neuberger, κ. t. et al. "bulbar poliomyelitis." papers and discussions presented at the firs! international poliomyelitis conference lippericott co. 1943. 6. westlake, harold. "muscle training for cerebral palsied speech cases.' journal oi speech and hecring disorders. vol. 16:103-108. june, 1951. 7. zausrner, elizabeth. "speech defects resulting from bulbar policmvelitis." physical therapy review. vol. 31:7. july] 1951. erratum. the editor wishes to draw attention to the error that a p p e a r e d in the article "the treatment of habitual d y s p h o r i a , " journal of the south african logopedic society, september, 1954, volume 2, number i. the sentence or. p a g e 13 in the first p a r a g r a p h under the.heading postural exercises should r e a d : " . . . a mirror allowing him to s e e heac and shoulders is essential," and not "a mirror allowing him to s e e h e a d cn^ should is e s s e n t i a l . " books on speech defects i and therapy speech correction through story , j selling units. elizabeth mcginley nemoy. price : 35/-. post 1/2 ; aphasia therapeutics j mary c. longerich and jean bordeaux i price:-32/-. post 1/' speech and hearing therapy ruth beckey irwin price:. 44/9. post 1/speech and the deaf child irene r. ewing and a. \v. g ewina. p r i c e : 23/-. post 1/correction of defective consonant sounds (revised edition) nemoy and davis. price : 44/-. post 1/2 improving the child's speech virgil a. anderson p r i c e : 47/-. post 1/1 the child's book of speech sylvia chipman price: 11/6. post 4d. v a n g u a r d b o o k s e l l e r s 23, joubeht street. johannesburg telephone 23-3511 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) subvocal muscle activity during stuttering and fluent speech: a comparison asher bar, joyce singer and robert g . feldman* electromyography has been used in the study of speech (edfeldt,3 hardyck5). hardyck applied this technique to subvocal speech and found that only some of his subjects were aware of their subvocalization. other studies have demonstrated that subvocal speech could appear during reading if the content, typography and grammaticality of the material are complex (davis,kryshova and shteingart,7 shaw,9 sokolov10). electromyography has also been used with stutterers. williams1* reported that stuttered and non-stuttered speech differ in action potential. stuttering and imitated stuttering involved muscular tension both different from, and in excess of normal speech. there have been no studies dealing with stutterers' subvocalizations. in this study, laryngeal muscle activity was recorded in order to investigate: (a) whether or not the subvocalization of stutterers was measurably different from the subvocalization of non-stutterers; (b) whether or not the laryngeal muscle activity was measurably different when a stutterer expected to stutter and when he did not expect to stutter; (c) whether or not the laryngeal muscle activity was measurably different when a non-stutterer expected to have difficulty and when he did not expect to have difficulty. expectancy of stuttering, or preparatory set, has been extensively described. van riper11' explains the preparatory set as a pre-stimulus neuromuscular adjustment which selects, determines and controls the response to the expected stimulus. it is generally agreed that this motor planning or rehearsal behaviour is an important factor just before the act of stuttering. stutterers' ability to predict the occurrence and duration of their stuttering episodes has been verified (johnson, et al.°; van riper and milisen13). in addition, some physiological changes in the individual prior to stuttering have been reported. changes have been noted in breathing, pulse rate, vaso-constriction and muscle * a s h e r bar, chief, speech a n d h e a r i n g center, m o u n t sinai school of medicine, city university of n e w york. joyce singer, massachusetts eye and e a r infirmary. r o b e r t g. f e l d m a n , c h a i r m a n , d e p a r t m e n t of n e u r o l o g y , boston university. tydskrif van die suid-afrikaanse logopediese vereniging, vol.16, r. , des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 asher bar, joyce singer and robert g. feldman tension (fletcher4, robbins8, travis, et al.11). it has been shown already that stuttered speech exhibits a difference in the subvocal laryngeal muscle activity prior to anticipated stuttering; this also should be observable on electromyography. method one clinically diagnosed severe adult stutterer and one non-stutterer were used in the study. both subjects were university students and were matched according to sex, age and education. the same procedure was administered to both of them. stuttering included audible prolongations and repetitions of sounds, syllables and words. a needle electrode was inserted into the cricothyroid muscle. a model 302, mediton electromyograph was used. attached was a stereo tape-recorder. the oscilloscope was built into the unit. channel a recorded muscle activity, and the voice was recorded on channel b. sensitivity was set at 200 microvolts per centimetre for both channels. the tape was played back on an ampex stereo tape-recorder to a model 502 tektronics cathode ray oscilloscope. both beams were photographed at 22.5 mm per second on a 35 mm kymograph camera, with a model c-4 grass oscilloscope. subvocal muscle activity was observable in both subjects, in pre-experimental trials. words were projected by a slide projector, in random order, one at a time. a total of three hundred words was available. one hundred and fifty of the words were uncommon polysyllabic words of at least three syllables, and the rest were monosyllabic, common words. difficult words were included to make the presence of subvocalization more likely, and to elicit expectation of difficulty in the non-stutterer. the subject was able to indicate, nonverbally, whether or not he expected to have difficulty with the word. the words were presented at regular time intervals of twenty seconds. each word was presented on a screen for ten seconds, during which time the subject was instructed to say the word to himself. this period was followed by a blank screen for another ten second interval during which time he was instructed to signal, nonverbally, whether or not he expected to have difficulty. after signalling he said the word aloud. / / the examiner noted one of the following types of response: type 1. the subject indicated he would have difficulty and he did. type 2. the subject indicated he would have difficulty and he did not. type 3. the subject indicated he would not have difficulty and he did not. ' ! type 4. the subject indicated he would not have difficulty and he did. journal of the south african logopedic society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) subvocal muscle activity during stuttering and 11 results and discussions both interand intra-subject comparisons were made. since there were only two subjects, the nonparametric wilcoxon t-test was used to determine the significance of differences. all differences discussed below were significant at the .05 and .01 levels of confidence. the stutterer demonstrated the earliest onset of muscle activity, and the longest time period between onset of muscle activity and onset of voice in a type 1 response (anticipation of stuttering followed by actual stuttering). the short latency period from the presentation of the signal to onset of muscle activity indicated that the stutterer began preparing to say the word much earlier when he anticipated difficulty and had difficulty, than when he anticipated difficulty, and had none (type 2 response), or when he did not anticipate difficulty and had none (type 3 response). the results also indicate that the stutterer began to prepare earlier for a type 2 response than for a type 3 response. since the non-stutterer did not have difficulty in speech and production, there were only type 2 and type 3 responses to compare. the non-stutterer began to prepare earlier when he expected difficulty than when he did not. thus, both the stutterer and the non-stutterer began to prepare to speak earlier when they anticipated difficulty, although when the subjects were compared with each other, the stutterer's preparation began significantly sooner than the non-stutterer's in each instance. this early muscle activity might be one of the physiological parallels of the behaviour referred to as expectation, anticipation, or fear. in addition, this result might suggest that although both stutterers and nonstutterers exhibit muscular reactions when confronted with a difficult task of speaking, the stutterer as a result of his long and severe history of stuttering showed almost instant preparation. the normal speaker, who had no history of stuttering, exhibited slower onset of muscular adjustment. only the stutterer demonstrated earlier onset of muscular activity once the signal had been given to say the word aloud. the nonstutterer had more electromyographic. activity or subvocal speech in the ten second period of preparation prior to the signal to say the word aloud. these findings might appear to be somewhat inconsistent. it is explained, possibly, in the following manner. in an everyday situation, there would be two types of speech: unrehearsed, where little preparation is involved, and situations where it is known that speech will be called for, such as in making a telephone call. the word flashing on the screen, signalling a time to speak, might be compared with unrehearsed speech whereas the ten seconds of preparation in this study might be compared to the second situation. it would appear then, that there are two ways of preparing for speech. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 16, nr. i, des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 asher bar joyce singer and robert g. feldman the results of this study suggest that the stutterer initiates earlier muscle activity of preparation once the signal for speech has been given even though the non-stutterer also makes some preparation at this time. on the other hand, it appears that the non-stutterer uses the ten seconds of preparation for muscular adjustments to a much greater degree than does the stutterer. it seems reasonable to ally fluency or controlled speech with more rehearsal, and stuttering or uncontrolled speech with less rehearsal behaviour. in the case of the stutterer, it seems that the preparatory set and rehearsal behaviours discussed in the literature are confined to that period between the signal (demand) to speak and actual speech, and not to silent speech. the normal speaker seems to use that period of silent speech to establish a preparatory set. this suggests that if the stutterer would begin to prepare his speaking earlier, he might demonstrate more control of his speech. potential therapeutic value may be found in the application of these findings to the training of stutterers to use their preparation period more effectively. such a procedure of training has been suggested already by hardyck5 and basmajian1 who have experimented with muscle activity and electromyography. they demonstrated that when their normal subjects were allowed to view their muscle activity on the oscilloscope and listen to the muscle static through earphones, they were able to exert great control over the muscle in which the electrode was inserted. within about one hour the subjects were able to control the muscles to fire in given rhythms or to render them in a complete state of rest. it would be interesting to note in future studies what effect such a procedure would have on a stutterer's overt speech, if he were trained to use electromyography to control his muscles in similar patterns to those found in normal speakers. the results and suggestions made in this paper are tentative since they are based on a pilot study. however, it appears that the study of the subvocal mechanism of stutterers might explain some of the observable phenomena associated with the moments prior to, and during stuttering. larger populations of subjects are needed before the hypotheses suggested in this study can be confirmed. / acknowledgments / the authors acknowledge the assistance of the staff of the department of neurology, v.a. hospital, boston. , summary electromyography measurements utilizing needle electrodes, were made to compare the laryngeal muscle activity of a stutterer and a journal of the south african logopedi society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) subvocal muscle activity during stuttering and 13 non-stutterer, (a) when they indicated anticipation of either difficulty or no difficulty speaking, (b) when they actually spoke. the stutterer exhibited the earliest and longest laryngeal activity when he anticipated difficulty and actually stuttered. the stutterer exhibited more intense muscle activity before speaking than the non-stutterer. therapeutically, it is suggested that stutterers learn to control the muscle activity prior to the moment of speaking. opsomming daar is gebruik gemaak van elektromiografiese metings (naaldelektrodes is gebruik) om die laringeale spieraktiwiteit van 'n hakkelaar en 'n nie-hakkelaar te vergelyk. spieraktiwiteit is onder die volgende omstandighede bepaal: (a) wanneer hulle verwagting aangedui het van of moeite metof geen moeite met spraak nie. (b) tydens werklike spraak. spieraktiwiteit het vroeer begin en langer aangehou by die hakkelaar wanneer hy verwag het om te hakkel en ook terwyl hy werklik gehakkel het. die hakkelaar het ook meer intense spieraktiwiteit voor die aanvang van spraak getoon as die nie-hakkelaar. terapeutiese leidrade hieruit verkry is dat hakkelaars geleer moet word om die spieraktiwiteit voor die oomblik van hakkel te beheer. references 1. basmajian. j. v. (1963): control and training of individual motor units. science, 14j, 440-441. 2. davis, r. c. (1938): the relationship of muscle action potentials to difficulty and frustration. j o u r n a l of experimental psychology, 23, 141-158. 3. edfeldt, a. w. (1960): silent speech and silent reading. chicago: university of chicago press. 4. fletcher, j. m. (1914): an experimental study of stuttering. journal of applied psychology, 25, 201-249. 5. hardyck, c. d., petrinovitch, l. f. and ellsworth, d. w. (1966): feedback of speech muscle activity during silent reading: rapid extinction. science, 154, 1467-1468. 6. j o h n s o n , w„ knott, j. r. and webster, m. (1937): a quantitative evaluation of expectation of stuttering in relation to the occurrence of stuttering. journal of speech disorders, 2, 101-104. 7. kryshova, n. a. and shteingart, κ. m. (1964): a study of internal speech following a disturbance of the speech motor analyser function. doklady akademii n a v k ussr, 4, 998-1000. 8. robbins, s. d. (1919): a plethysmographic study of shock and stammering. american journal of physiology. 48, 285-330. 9. shaw, w. a. (1940): the relation of muscular action potential to imagined weight lifting. archives of psychology. 35, 5-50. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 16, nr. , des. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 asher bar, joyce singer and r o b e r t g. feldman 10. sokolov. a. n. (1961): studies on the problem of the speech mechanism of thinking. psychological studies in the ussr., 1, 669. 11. travis, l. e., tuttle, w. w. and cowan, d. w. (1936): a study of the heart-rate during stuttering. j o u r n a l of speech and hearing research, 1, 21-26. 12. van riper, c. (1937): the preparatory set in stuttering. j o u r n a l of speech and hearing disorders, 2, 149-154. 13. van riper, c. and milisen. r. l. (1939): a study of the predicted duration of the stutterer's blocks as related to their actual duration. journal of speech disorders, 4, 339-346. 14. williams, d. (1955): masseter muscle action potential in stutterers and non-stutterers. journal of speech and hearing disorders, 20, 242-261. journal of the south african logopedic society, vol. 16, no. 1, dec. 1969 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction method results discussion conclusion acknowledgements references about the author(s) kerry knight department of speech-language pathology and audiology, university of pretoria, south africa simone ducasse department of speech-language pathology and audiology, university of pretoria, south africa ashley coetzee department of speech-language pathology and audiology, university of pretoria, south africa jeannie van der linde department of speech-language pathology and audiology, university of pretoria, south africa anel louw department of speech-language pathology and audiology, university of pretoria, south africa citation knight, k., ducasse, s., coetzee, a., van der linde, j., & louw, a. (2016). the effect of age of cochlear implantation on vocal characteristics in children. south african journal of communication disorders, 63(1), a142. http://dx.doi.org/10.4102/sajcd.v63i1.142 original research the effect of age of cochlear implantation on vocal characteristics in children kerry knight, simone ducasse, ashley coetzee, jeannie van der linde, anel louw received: 29 sept. 2015; accepted: 04 apr. 2016; published: 27 june 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: early cochlear implantation aids auditory feedback and supports better communication and self-monitoring of the voice. the objective of this study was to determine whether the age of cochlear implantation has an impact on vocal development in children implanted before age 4. method and procedures: the study consisted of 19 participants in total. all implant recipients (experimental group) were 3–5 years post-implantation, including four prelingual (0–2 years) and five perilingual (2–4 years) implant recipients. the control group consisted of 10 children whose hearing was within normal limits between the ages 3–6 years and 10 months, which was compared to the experimental group. established paediatric norms were used for additional comparison. a questionnaire was used to gather information from each of the participant’s caregivers to determine whether other personal and contextual factors had an impact on voice production. an acoustic analysis was conducted for each participant using the multi-dimensional voice program of the computerized speech lab. results: when the experimental group and the control group were compared, similar results were yielded for fundamental frequency and short-term perturbation (jitter and shimmer). more variability was noted in long-term frequency and amplitude measures, with significantly higher differences, and therefore further outside the norms, in the prelingual group when compared to the perilingual and control groups. conclusion: in this study, age of implantation did not impact vocal characteristics. further research should include larger sample sizes, with participants that are age and gender matched. introduction an individual’s voice forms the basis of first impressions and is also a means of conveying information effectively (imhof, välikoski, laukkanen & orlob, 2014). vocal characteristics influence how a person is conveyed to others, whether it be likeable, attractive, or intelligent (imhof et al., 2014). voice has a significant influence on the communication partner’s attitude towards the speaker (seifert et al., 2002). literature indicates that certain vocal characteristics in individuals with hearing loss can differ greatly in comparison to those with hearing within the normal range (hocevar-boltezar, vatovec, gros & zargi, 2005) the age of cochlear implantation impacts vocal maturation of children (ertmer, young & nathani, 2007) as it establishes access to sound which is essential in the maturation of voice. control of voice pitch, loudness, laryngeal quality, and resonance are inconsistent in individuals with hearing loss who have not received cochlear implants (lenden & flipsen, 2007). children with implants may have difficulties in controlling the pitch and loudness of their voices during sustained phonation, which may result in perceived variation in pitch and loudness (holler & campisi, 2010). however, the longer a child has been exposed to auditory feedback, the greater control they have over their voice pitch and loudness (holler & campisi, 2010). early cochlear implantation aids auditory feedback and supports better communication as well as the individual’s ability to monitor their own voice (de souza, bevilacqua, brasolotto & coelho, 2012). although it has been reported in the literature, there are few studies which have evaluated the acoustic and perceptual parameters of voice in children who have received cochlear implants (de souza et al., 2012; hocevar-boltezar et al., 2005; holler & campisi, 2010). cochlear implants are neuroprosthetic devices that provide hearing sensitivity to individuals with severe to profound hearing loss (campisi et al., 2005). these devices still have limitations in their transfer of auditory data when compared to normal hearing (uchanski & geers, 2003). the implant does not give the user normal hearing (ertmer et al., 2007), instead it offers essential auditory feedback on the timing, intensity and frequency of sound (campisi et al., 2005). studies have emphasised the importance of auditory feedback for voice production, which is essential for vocal maturation (campisi et al., 2005; seifert et al., 2002). it is therefore expected that children implanted at an earlier age and for a longer duration will produce voice nearer to established norms and control groups (holler & campisi, 2010). cochlear implant users receive enough auditory input and feedback to avoid the additional progress of maladaptive speaking strategies such as excess laryngeal tension and negative intraoral air pressure, as well as unusual speech practices such as audible emissions from the nasal cavity (higgins, mccleary, carney & schulte, 2003). the earlier the child receives a cochlear implant, the greater the auditory experience (holler & campisi, 2010). if a child is deprived of auditory stimulation for a long period of time, there will be a marked reduction in neural plasticity (sharma, dorman & spahr, 2002). therefore, the optimal time for implantation is before auditory deprivation has an impact on the development of the central auditory nervous system, and subsequent speech and language development (sharma et al., 2002). children who receive cochlear implants at an earlier age show more progress over time in attaining intelligible conversational speech than children implanted at a later stage (flipsen, 2008). those implanted before 3 years of age also perform better in both their expressive and receptive language skills (anderson et al., 2004). it is predicted that a similar trend will occur in terms of vocal development in younger cochlear implant recipients. another study has shown that children implanted at an early age have improved neuromuscular control of their articulators (de souza et al., 2012). however, no studies have evaluated the impact of age of implantation on the acoustic and perceptual vocal characteristics in children, using defined age groups of children implanted in the prelingual and the perilingual phases (de souza et al., 2012; holler & campisi, 2010). studies conducted on varying age groups and durations of implantation, that have focused on vocal characteristics of cochlear-implanted children, have shown that prelingually deaf children, who attain a cochlear implant before age 4, have improved control of their pitch and loudness during voice production (hocevar-boltezar et al., 2005). younger cochlear implant users achieved vocal maturation sooner in comparison to those who receive implants at a later stage (ertmer et al., 2007). post-implantation vocal maturation is a process by which prelinguistic children produce increasingly varied and adult-like utterances (ertmer et al., 2007). should a child be implanted at a later age, vocal maturation may be delayed due to the period of auditory deprivation (holler & campisi, 2010). although the sample size of these studies are small, they indicate that the majority of children showed improvements in vocal development post-implantation, and those implanted at a younger age achieved vocal development earlier than children implanted at a later stage of development (ertmer et al., 2007). due to the small sample sizes, unreliable and contradicting results have been reported due to the absence of a standardised methodology in the voice assessment and established norms for paediatric voice data (campisi, tewfik, manoukian & schloss, 2002). studies show that cochlear implantation has many benefits for voice production (coelho, brasolotto & bevilacqua, 2015), including improved perturbation measures and phonation control (campisi et al., 2005; hocevar-boltezar et al., 2005). poor early development of vocal characteristics in hearing-impaired children can be due to the limited auditory feedback they receive (coelho et al., 2015). the earlier a child is implanted, the more likely they are to develop normal vocal characteristics (holler & campisi, 2010) which, in turn, will improve their vocal communication with others. therefore, the purpose of this study is to compare children who received cochlear implants during the prelingual phase to those implanted during the perilingual phase, as well as to compare the cochlear implant participants to children with normal hearing. the comparison will be conducted to determine whether the age of cochlear implantation, during the prelingual versus the perilingual phase, has an effect on children’s vocal characteristics, specifically vocal control of shortand long-term perturbation and fundamental frequency. method a cross-sectional experimental design was implemented, including two experimental groups and a control group. it was hypothesised that the group of children implanted during the prelingual phase would have better vocal characteristics than the group of children implanted during the perilingual phase. participants purposive sampling was used to select the participants who were prelingual at implantation (group 1) and those who were perilingual at implantation (group 2). convenience sampling was used to select the control group (group 3). potential participants for group 1 and group 2 were attained from the university of pretoria cochlear implant unit (upciu). these participants were selected based on the following characteristics: age of implantation and the post-implantation duration. group 1 included participants who received a cochlear implant during the prelingual phase (between the ages 0 and 2 years). participants in group 2 were children who received a cochlear implant during the perilingual phase (between the ages 2 and 4 years). all the experimental participants (in groups 1 and 2) have been implanted for 3–5 years. the following exclusion criteria were applied during the selection of participants for group 1 and group 2: (1) failure to complete the voicing task, typically because of young age and (2) the presence of any additional/multiple disabilities that may have an impact on voice production. these disabilities included auditory neuropathy, chronic sinusitis, neurological disorders or any other disabilities or disorders that impact voice production. no participants were excluded from the study as they were all able to complete the voicing task and were selected based on the absence of any of the above mentioned disabilities. uniand bilaterally implanted children were not separated into two groups due to the small sample size; however, all experimental participants had bilateral amplification (either two implants, or an implant and a hearing aid). as the cochlear implant recipients who complied with the inclusion criteria were scarce, the groups were not stratified according to gender. group 3 consisted of typically developing children with no diagnosed voice disorder. participants were selected based on their age (3–7 years), the same age range as the selected implanted participants. finally, the participants were required to be physically well on the day of the assessment, as throat or sinus infections would affect voice quality. in total, 19 participants were included in the study. the prelingual group consisted of four bilateral implanted participants. the perilingual group had five participants, three with bilateral implants and two with unilateral implants and hearing aids on the non-implanted ears. the control group had 10 participants. of the 19 participants, 6 (32%) had parents who smoke. more female participants (75%, n = 3) were included in the prelingual group, and the mean age of the participants was 4.94 years (sd = 0.98). the perilingual group consisted of only male participants (100%, n = 5), and the mean age of the participants was 6.73 years (sd = 1.01). the control group had an even distribution of gender, female (50%, n = 5) and male (50%, n = 5), with a mean age of 4.28 years (sd = 1.14). material and apparatus a background information questionnaire was completed by the parent or guardian of the participant. questions regarding the participant’s biographical information, health and medical history, as well as any environmental factors that may have an impact on the participant’s voice were included in the questionnaire. the questionnaire consisted of 20 closed-ended and open-ended questions. a published questionnaire (shipley & mcafee 2009) was used as a guide in developing the questionnaire. a voice sample was obtained from each participant. the voice samples were analysed using the multi-dimensional voice program (mdvp) of the computerized speech lab (csl) (model 4500; kaypentax). the mdvp analyses the voice sample and provides acoustic information to determine vocal parameters. table 1 summarises the parameters evaluated. table 1: vocal parameters. procedures ethical clearance was obtained from the research and ethics committee of the department of speech-language pathology and audiology, university of pretoria, and permission was given by the upciu to access their database to identify potential participants to form part of the experimental group. parents or guardians of potential participants were fully informed of the purpose of the study and informed consent was obtained. verbal assent was obtained from the participants. the confidentiality of all participants was ensured throughout the study process. the assessment was conducted at the department of speech-language pathology and audiology at the university of pretoria. first, the questionnaire to gather biographical and background information of the participants was conducted in the form of an interview with the parent or guardian. explanations were provided where necessary to ensure understanding. after the questionnaire was completed the voice recording was made. participants were seated in a soundproof room. a standardised microphone was placed in front of them at an off-axis position of 45° and a constant mouth-to-microphone fixed distance of 10 cm. participants were instructed to produce the vowel /a/ for three seconds using a comfortable pitch and volume. this was repeated three times. the best and most consistently produced sample of the three trials was used for analysis. the phoneme /a/ was chosen because it is a steady-state vowel and is easy for children to reproduce. the voice samples were analysed using the mdvp of the csl (model 4500; kaypentax, lincoln park, new jersey). data analysis all statistical analyses were performed using the commercially available software statistical analysis system (sas®) version 9.3 (sas institute inc., 2011) which was run using microsoft® windows® on a personal computer. the study aimed to determine whether the age of cochlear implantation had an effect on the vocal characteristics in children, implying a comparison between group 1 and group 2, which was the primary objective of the study and the analysis. results obtained from groups 1 and 2 were analysed descriptively because of the small sample size. nevertheless a t-test (gosset, 1908) was performed to compare mean values of vocal parameters in cochlear implant users varying in age of implantation with previously published paediatric norms based on a sample of an american population (campisi et al., 2002). the normative database was made up of 100 control participants (50 boys and 50 girls) between the ages 4 and 18 years (campisi et al., 2002). a comparison was also made between mean values of vocal parameters of the cochlear implant users and the control group of normal hearing participants. normality of the underlying distributions (required for t-tests) could not be verified but could be substantiated. due to the small sample sizes, all the results from the statistical analysis should be interpreted as descriptive or preliminary results and not as conclusive, which may guide future research and clinical practice. results in order to determine whether the age of implantation had an impact on vocal characteristics, specifically vocal control of children with cochlear implants, a number of acoustic measures were evaluated. the mean values of jitter, shimmer, fundamental frequency, fundamental frequency variation or vfo and amplitude variation or vam were compared between the two experimental groups, the control group, as well as the established normative data (campisi et al., 2002). the mean values and standard deviations of vocal parameters between the three groups as well as the paediatric norms are presented in table 2. table 2: acoustic outcomes of cochlear implantation users (prelingual and perilingual), the controls and the paediatric norms for vocal parameters. the perilingual group had a substantially lower fundamental frequency (265.82 hz) when compared to the prelingual group (304.53 hz). when the experimental groups were compared to control group participants of similar ages, all implanted participants had higher long-term frequency (vfo) (prelingual vfo = 6.23, sd = 4.53; perilingual vfo = 4.43. sd = 2.43) and amplitude (vam) (prelingual vam = 36.30, sd = 11.30; perilingual vam = 22.93, sd = 8) perturbation measures than the control group (control vfo = 2.80, sd = 0.83; control vam = 22.37, sd = 7.33). the short-term perturbation scores of three of the four participants in the prelingual group were lower (prelingual jitter = 1.71, sd = 2.13; prelingual shimmer = 3.56, sd = 1.73) than those obtained by the paired similar-aged control group participant (control jitter = 1.23, sd = 0.45; control shimmer = 5.72, sd = 1.93). when comparing the short-term perturbations of the perilingual participants to a paired similar-aged control group participant, three of the five perilingual participants had lower jitter percentages and all five had lower shimmer percentages (perilingual jitter = 1.79, sd = 1.09; perilingual shimmer = 5.10, sd = 2.23). these findings indicate that, in general, implant participants had lower short-term perturbations (jitter and shimmer) and higher long-term frequency (vfo) and amplitude (vam) perturbations than similar-aged control group participants. variances in fundamental frequency were consistent with gender difference. the performance outcomes of the prelingual and the perilingual groups were combined and were compared with the results of the control group for the purpose of comparing children with and without cochlear implantation (ci). when compared, similar results were yielded for fundamental frequency (preand perilingual ci = 283.02 hz; control = 297.74 hz), and short-term perturbation measures including jitter (prelingual and perilingual ci = 1.76%; control = 1.23%) and shimmer (prelingual and perilingual ci = 4.41%; control = 5.72%). the implanted group had slightly higher long-term frequency (prelingual and perilingual ci = 5.23%; control = 2.80%) and long-term amplitude (prelingual and perilingual ci = 28.87%; control = 22.37%) perturbation scores when compared to the control group. the vocal parameters of the various groups are compared in table 3. table 3: differences in vocal parameter outcomes between groups. children implanted prelingually had a significantly higher long-term amplitude perturbation (vam; p = 0.030) in comparison to those implanted perilingually. the children who were prelingual at implantation had significantly higher long-term frequency (vfo; p = 0.028) and long-term amplitude (vam; p = 0.013) perturbation scores when compared to the control group. the long-term amplitude perturbation of the prelingual group was significantly higher (vam; p = 0.033) than the paediatric norms. several parameters were significantly higher in the control group when compared to the paediatric norms, including short-term amplitude perturbation (shimmer; p = 0.004), long-term frequency (vfo; p = 0.003), and long-term amplitude (vam; p = 0.012) perturbation. no statistically significant differences were found between the performance variables of ci (prelingual and perilingual) combined and the control; this, therefore, indicated that the vocal characteristics of children with and without implantation did not differ significantly. discussion the values of fundamental frequency, jitter and shimmer revealed no significant differences between the three groups, except the shimmer of the control group when compared to the paediatric norms (p = 0.004). the short-term variation of frequency (jitter) and amplitude (shimmer) were within the normal range, which according to holler and campisi (2010), is expected when a population does not have a primary laryngeal pathology. interestingly, more variability in long-term frequency and amplitude in vocal productions were noted in the control group when compared to the paediatric norms. however, the age of the control group ranged from 3.00 to 6.83 years (n = 10), whereas the paediatric norm age ranged from 4–18 years (n = 100). therefore, a difference in vocal performance can be expected due to maturation. a previous study established a normative paediatric acoustic database, developing a growth chart for both ageand gender-based vocal maturation (maturo et al., 2012). the study by maturo et al. (2012) included similar norms for fundamental frequency, jitter and shimmer, as well as other acoustic parameters such as noise to harmonic ratio and mean peak airway pressure. however, norms were not established for long-term variation, and therefore, these norms were not used for comparative purposes in this study. the paediatric norms by campisi et al. (2002) used in this study were similar to those published in maturo et al. (2012). thus, comparisons yielded similar results. the perilingual group, of which all the participants were male, had a lower mean fundamental frequency than the prelingual group, although the difference was not significant. these findings are consistent with previous research that indicated that there may be a slight or no difference in fundamental frequency between boys and girls under 12 years (perry, ohde & ashmead, 2001). findings indicated that the prelingual group differed significantly from the perilingual group (p = 0.030), the control group (p = 0.013) as well as the paediatric norms (p = 0.033) with significantly higher long-term amplitude variation (vam). the prelingual group also differed significantly from the control group (p = 0.028) with substantially higher long-term frequency variation (vfo). these findings are similar to the study by campisi et al. (2005) who also stated that long-term variations remain significantly higher in children with cochlear implants. yet the perilingual group performed similarly to the control group without any significant differences in vocal performance. the perilingual participants received their cochlear implants at an older age, and previous research suggests that the earlier a child is implanted the sooner they achieve vocal maturation (ertmer et al., 2007). however, in this study the group implanted perilingually (i.e. an older age) produced vocal productions closer to the control group and paediatric norms when compared to the performance of the group implanted prelingually (i.e. at a younger age). similar results were found between the vocal characteristics of the prelingual and perilingual groups combined when compared to the control group. the long-term variations were slightly higher in the implant group than in the control group of normal-hearing children, however the differences were not significant. therefore, these results, in contradiction to previous studies (ertmer et al., 2007; flipsen, 2008; holler & campisi, 2010; sharma et al., 2002), indicate that the vocal characteristics, more specifically vocal control of shortand long-term perturbation and fundamental frequency, of children with implantation did not differ significantly from normal-hearing children. the results of this study suggest that children, who are implanted at a later stage, before age 4, are not disadvantaged in terms of their vocal development. these findings do not coincide with the initial hypothesis. however, a previous study had similar results, in which children implanted earlier than 4 years of age had better control of their voice at a faster rate and to a larger extent than those who were implanted at a later stage of development (hocevar-boltezar et al., 2005). in south africa, the average age of implantation is around 43 months or three and a half years of age (le roux, swanepoel, louw, vinck & tshifularo, 2015). all but one of the children in the study sample were implanted before the average age of implantation for south african children which implies vocal maturation closer to that of normal-hearing children. the study by hocevar-boltezar et al. (2005) indicated that children implanted before age 4 still achieve positive outcomes in terms of vocal control over time in comparison to children implanted later. this may explain why no significant differences were found between the results for the prelingual and perilingual groups, as the age of implantation did not have an impact on their vocal developmental outcomes. however, due to the small sample size in this study, the results can be seen as descriptive of the specific population. the main limitation of the study was the sample sizes and as a result, only descriptive methods could be used to interpret the data collected. however, the overall size of the implanted population from which prospective participants could be selected is small. in future, researchers should obtain a larger population in order to make use of inferential statistics for more conclusive results. the gender distribution across the groups was not equal; so direct gender comparisons were not made and possible gender differences were not identified. in future research, participants in all groups should be both genderand age-matched. it is recommended that the effect of chronological age on vocal maturation be explored for any possible correlation. the development of more age-specific paediatric norms, by including children from 3 years of age and including long-term perturbation parameters, is recommended to establish a more accurate normative database for comparison. conclusion this study aimed to compare vocal characteristics of children who received cochlear implants during the prelingual phase (0–2 years) and the perilingual phase (2–4 years). implant groups were compared with both the control group and previously established paediatric norms. results showed that when cochlear implant and control participants were compared, similar results were yielded for fundamental frequency and short-term perturbation measures (jitter and shimmer). more variability in the prelingual group was noted in long-term frequency and amplitude perturbation, when the prelingual group was compared with the perilingual and control groups. the age of implantation did not have an effect on vocal control, when the prelingual and perilingual ci groups were compared. vocal control of the implanted children was also similar to children with normal hearing. it therefore appears that, if no other voice problems are present, vocal control may not need to be targeted during intervention for ci recipients. differences found between the paediatric norms and the control group were as a result of the larger age range used in the establishment of the paediatric norms. the development of more age-specific paediatric norms, both worldwide and specifically for the south african population, is recommended in order to have a more accurate normative database for comparison. results were interpreted using descriptive methods due to the small sample size. in future, researchers should obtain a larger population with participants that are both genderand age-matched in order to make more direct comparisons. future researchers should separate the experimental group into uniand bilaterally implanted participants to determine whether a relationship exists between the type of implantation and vocal development. it is recommended that the effect of chronological age on vocal maturation be explored for any possible correlation. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions j.v.d.l and a.l. were responsible for experimental and project design and supervised the project. k.k., s.d. and a.c. conducted the data collection and made conceptual contributions. all the authors contributed in the writing of the manuscript. references anderson, i., weichbold, v., d’haese, p.s.c., szuchnik, j., quevedo, m.s., martin, j., et al. 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(2003). acoustic characteristics of the speech of young cochlear implant users: a comparison with normal-hearing age-mates. ear and hearing, 24(1 suppl), 90s–105s. http://doi.org/10.1097/01.aud.0000051744.24290.c1 15 a preliminary study of biungctalism and stuttering in four jqhmnesburcpschqols. (summary of the original article.) by erica stern, b.a., dip. log. (rand.) 1.·. introduction. tho question as to the relationship between bilingualism and stuttering is still largely a matter of conjecture among logopedical authorities. both mcallister (4) and smiley blanton (1) quote cases of stuttering in which language conflict seems to be the chief etiological factor. from tho statement by frsscliels and jellinek (2) «of "the conflicts which arise within us" during the process of learning a foreign language, it is justifiable to infer that stuttering may result from such language conflicts. burford johnson (3) advises "unilingual development in early years'? to eliminate the confusion that necessarily results from the acquisition of two languages simultaneously. the above authorities offer no statistical data to substantiate their beliefs. the only study offering statistical data bearing on the problem, that has come to the attention of the investigator, is that of travis, johnson ' and shover (5). this investigation was conducted in east chicago, indiana, u.s.a. on 4,827 school children. significantly more stuttering was found among bilingual than among unilingual children, the respective percentages being 2.80 and 1.80. it is the aim of this small, preliminary investigation to ascertain whether or not this tendency is observable in a bilingual country such as south africa which has as its two official languages afrikaans and english. 11. subjects. this investigation was carried out in four johannesburg schools, (two afrikaans and two english medium,) with a total population of 1,861 children, ranging in age from six to sixteen years. the standards in the four schools ranged from grade 1 to std. ¥11, inclusive, plu3 special classes for mentally retarded children. each school contained approximately the same number of boys and girls. 111.' procedure. each school child received a bilingual copy of the questionnaire which was filled in by his/her parents. both children and parents wore kept in ignorance of the real purpose of the questionnaire, viz. to ascertain whether • ™ x copy of questionnaire can be found at the conclusion of article. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16. there is any relation between bilingualism and stuttering. as time did not permit an individual speech examination of every child, only those children considered by their class teachers to be stutterers were interviewed. in a few cases the investigator's diagnosis did not agroe with that of the teacher. the children designated as stutterers in this study then, aro those considered to be stutterers both by their class teacher and by the investigator. the interview was standardised and was conducted in the language corresponding to the medium of the school. the stuttering children were classified according to an arbitary fivepoint severity scale ranging from si (representing a child with only the primary symptons of stuttering)' to s5 (representing so bad a stutterer that for all practical purposes he is unable to communicate with society). each questionnaire was then examined and classed under one of the following classifications: a unilingual, afrikaans speaking only before the age of six years. ε unilingual, english speaking only before the ago of six years. ae bilingual, used both afrikaans and english equally before the age of six years. ae bilingual, but used a great deal more afrikaans than english before the ago of six years. ea bilingual, but used a great deal more english than afrikaans before •the age of bix years. eo bilingual, used both english and another language e.g. french, syrian or jewish equally before the age of six years. iv. results. for the sake of convenience, the two afrikaans medium schools are designated as ax and ay respectively, and the two english medium schools as ex and ey. these four schools had a total population of 1,861 children, but the questionnaire was answered by only 1,035 children. however, there was good reason to assume that the number of questionnaires submitted from each school constituted a fair sampling of that school and the figures that follow are based on that assumption. the following table shows the number and percentage of stutterers in comparison with the general school population in each language group in each of the four schools. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 17. τ abie 1. number and percentage of stutterers in comparison with the general school. population in each language group in each of tho four schools. school language classification number of !pupils. per cent pupils number of stutterers per cent stutterers ax a 572 82.0 2 0.54 ε 6 1.3 0 0 ae 78 16.7 2 2.65 ay a 424 87.8 13 3.07 ε 6 1.3 0 0 ae 20 4.2 0 0 ae 22 4.5 1 4.6 ea 11 2.2 0 0 ex a 32 6.6 0 0 ε 278 57e0 2 0.72 ae 72 14.7 0 0 ae 23 4.8 0 0 ea 69 14.2 4 5.79 eo 13 2.7 1 7.63 ey a 6 1.2 0 0 ξ 340 77.6 7 2.06 ae 24 5,4 0 0 ae 18 4.2 0 0 ea 46 10.5 1 2.16 so 4 1.1 0 0 total 1861 33 1.77 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18. the material of table 1 is presented in summary form in the following table, the children being merely classified as either unilingual or bilingual before the age of six years. table 11. percentages of unilingual and bilingual stutterers. language classifinumber of number of per cent cation pupils stutterers stutterers unilingual 1444 24 1.66 bilingual 417 9 2.16 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) table 111 shows the sex ratio among the stutterers in the two language groups, (unilingual and bilingual,) and their severity ratings. no stutterers were considered to belong to the s5 category; stutterers classified as belonging to'si and s2 groups have been combined and_ regarded as "mild" stutterers, while those stutterers from groups s3 and s4 have been combined to form a group of "severe" stutterers. table 111. sex ratio and severity ratings of the stutterers in the unilingual and bilingual groups. language classification severity rating number of male stutterers number of female stutterers total number of stutterers per cent stutterors si & s2 17 3 20 ' 83.33 unilingual s3 & s4 1 3 4 16.67 si & s2 3 .1 4 44.44 bilingual s3 & s4 5 0 5 55.56 total 26 7 33 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20. v. discussion of results and conclusions. this study contains some obvious weaknesses which must bo borne in mind with respect to any discussion of the results or conclusions presented by the investigator. (1) tho sample is very small and. tendencies noted may quite well be . due to the operation of chance factors. (2) account had to.be made for a number of questionnaires which were not answered, (3) tho questionnaire forms only supply information as to the language classification of the children before the age of six years while the examination of tho children for stuttering refers to the time tho survey was done. of 1,861 school children, 1,444 were classified as being unilingual before the ago of six years, (speaking either afrikaans or english only,) while 4.17 children were classed as being fully or partially bilingual before tho age of six yoars. the languages spoken by the bilingual children included afrikaans and english in varying degrees, french, jewish and syrian. the results seem to indicate that there are more stutterers among bilingual children before the age of six years than among unilingual children, the respective percentages being 2.16 and 1.66. (table 11.) not only does there appear to be a slightly greater percentage of stuttering among bilingual children, but from table 111 it would appear that there is a considerably greater proportion of severe stutterers among bilingual than among the unilingual stutterers. in the unilingual group of twenty-four stutterers, only four or 16.67 per cent wore considered to be severe stutterers; in the bilingual group of nine, on the other hand, five were classed as severe stutterers, giving a percentage of 55.56. table 111 also shows the fact that of the thirty-three stutterers examined, twenty-six wero boys and seven girls, giving a sex ratio of approximately 4:1 in favour of.the boys. the greater incidence of stuttering among boys than among girls is in agreement with all other investigations into the incidence of stuttering. in this survey of four elementary schools in johannesburg! 1.77 per cent of the children were found to be stutterers (table 1,) this figure is in close agreement with previous investigations into the incidence of stuttering among children attending schools in tho transvaal, prof, p, de v, pienaar, university of the witwatersrand, in 1936 conducted an investigation in the schools in the witwatersrand area. ho found 2 por cent of rand school children to bo stutterers. according to tho report of the transvaal commission on education (1939) 1.5 per cent of school children in the transvaal'stutter. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 21. ο the results of this investigation, via. tho slightly greater number of stutterers found among bilingual than among-unilingual children, are in accordance with the results obtained in a similar survey in the u.s.a. by travis, johnson and shovor (5) reported earlier in this study. vi. summary. a preliminary survey was conducted in four johannesburg schools to ascertain the relation between bilingualism and stuttering, if any. £>ut of a total school population of 1,861, 1.77 per cont of the children were found to be stutterers. the findings of this study appear to indicate: 1. more stuttering is found among bilingual than among unilingual children, the respective percentages being 2.16 and 1.66. 2. it would seem that there is a considerably greater proportion of severe stutterers among bilingual than among unilingual stutterers. the results of this study can by no means be taken as conclusive on account of the weaknesses inherent in a preliminary survey of this nature. bibliography. 1. blanton, smiley, a survey of speech defect. journal of educational psychology, vol. 7, 1916, page 581. 2. froschels and jollinek, practice of voice and speech therapy, page 168. boston mass., expression company, 1941. 3. johnson, burford. child psychology, page 223. charles c. thomas, springfield, 111., and baltimore"," maryland, 1932. 4. mcallister, anne, clinical studio in speech therapy. dago 309. london, university press, 1937. 5. travis, johnson and shover, tho rolation of bilingualism to stuttering. journal of speech disorders, september, 1939, vol. 2, page 185. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22. appendix 1. university of the wmtate3sr-^td, johannesburg. investigation into the incidence of stuttering. to the parents of schoolchildren:ladies and gentlemen, for tho purpose of this investigation, wo wish to find out whether your child learnt one language first, and a second after beginning, or learnt two languages together, before going to school. it is of the utmost importance that the following questions be answered accurately. even if you have more than one child at the jne school, please fill out a separate questionnaire for each child. to ensure that the information shall be strictly confidential, it is not necessary for your name to be signed to this questionnaire. age of child years months school sex: male std· femalo list the ages of all the list tho ages of all tho child's brothers:-' child's sisters:1. place a cross next to the language(s) spoken at homg by your child bofore the age of six years. english afrikaans othor lang, (specify) 2. place a cross next to the language most frequently spoken at home by your child before the age of six years. english afrikaans ...... other lang, (specify) 3. state the age at which your child began speaking the following languages:english years months. afrikaans years months. other lang, (specify) years months. 4. place a cross next, to the language,(s) spoken by your child with his/her playmates before the age of six years:english ...... afrikaans other lang, (specify) r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) £5. 5. place a cross next to the language spoken most frequently by your child with his/her playmates before the age of six years. english afrikaans other lang, (specify) 6. to be filled in by the father. place a cross against the language(s) spoken by you at home before your child reached the age of six years. english afrikaans other lang, (specify) 7. place a cross against tho language you spoke most frequently at homo before tho child reached the age of six years. english afrikaans other lang, (specify) 0. to be filled in by the mother. place a cross against the language(s) spokon by you at home before your child reached the age of six years. english afrikaans other lang, (specify) 9. place a cross against the language you spoko most frequently at homo before your child reached tho age of six years. english afrikaans other lang, (specify) 10. does your child stutter (stammer?) universiteit van die witwatersrand, johannesburg. ondersoek insake stotter. aan ouers van skoolkinders:geagte meneer/mevrou, wat ons met die ondersoek beoog is om vas to stel of u kind een taal magtig.was, en »n tweede aangeleer het na hy/sy skool' vir die eerste keer besoek het, of hy/sy reeds vertroud was met beide tale voor hy/sy skool begin besoek het. ons sal dit waardeer as u die volgonde vrao baie noukeurig boantwoord. as u meer as een kind op dieselfdo skool het, vul dan assebliof vir elke kind *n aparte vorm in. daar die inligting wat ons deurhierdie vraelyste inwin streng vertroulik behandel sal word, ag ons dit nio nodig dat u u naam op die vorm token nie. ouderdom van kind skool std jare maande. geslag: manlik . vroulik r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24. ouderdomme van kind se broers. ouderdomme van kind se susters. 1. dui met »n kruisie aan die t-al/'-ale wat deur u kind by die huis gebruik was voor die ouderdo.u van ses jaar. afrikaans engels andertalo (meld) 2. dui mot 'n kruisie aan die taal wat u kind tuis die meeste gebruik het voor die ouderdom van ses jaar. afrikaans engels ander tale (meld) 3. meld die ouderdomme wanneer u kind hom begin bodien het met die volgende tale: afrikaans j'are maande engels jare ......... maande ander tale (meld) .... jare maande 4. dui met *n kruisie aan die taal/tale deur u kind en sy/haar maats gebruik voor die ouderdom van ses jaar. afrikaans engels ander tale (mold) 5. dui met *n kruisie aan die taal wat u kind meeste met sy/haar maats gobruilc hot voor die ouderdom van 3es jaar, afrikaans engels ...... ander tale (mold) 6. • om deur die taper ingevul te word: dui met »n kruisie aan die taal/tale wat u in dio hais gebruik hot voordat u kind die ouderdom .van ses jaar boroik het. afrikaans engels ander tale (meld) 7. dui met »n kruisio aan die taal/tale waarmoo u u die meeste tuis bodien het voordat u kind dio ouderdom van ses jaar boreik hot. afrikaans engels ander tale (meld) 8. om deur die moeder ingsvul te word. dui met »n kruisie aan die teal/tele deur u gebruik in die huis voordat u kind die ouderdom van rts jaar bereik het. afrikaans engels ...... ander tale (mold) 1 9. dui met 'n kruisie aan die taal/tale waarmee u u dio meeste bedien het voordat u kind die ouderdom van ses jaar bereik het. afrikaans ...... engels ander tale (meld) 10. hakkel (stotter) u kind? r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction research method and design research discussion conclusion acknowledgements references appendix 1 about the author(s) coralie van reenen council for scientific and industrial research (csir), south africa catherine karusseit department of architecture, university of pretoria, south africa citation van reenen, c., & karusseit, c. (2017). classroom acoustics as a consideration for inclusive education in south africa. south african journal of communication disorders 64(1), a550. https://doi.org/10.4102/sajcd.v64i1.550 original research classroom acoustics as a consideration for inclusive education in south africa coralie van reenen, catherine karusseit received: 03 feb. 2017; accepted: 12 june 2017; published: 08 sept. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: it can hardly be disputed that a school environment should be conducive or, at the very least, not prohibitive to effective learning. the provision of fair, equal and barrier-free access to education is referred to as inclusive education. south africa supports a policy of inclusive schooling, striving to accommodate all children, including those with disabilities, in mainstream schools. this article sets out to prove that noise control in classrooms is a relevant, yet neglected, aspect of inclusive classroom design in south africa and requires specific attention. objectives: the objectives of this study are to: (1) establish the impact that noise has on learners with sensory, language or learning impairments; (2) establish the preferred listening conditions for these learners by examining prior research and guidelines available in other countries; and (3) outline the current south african regulations pertaining to classroom acoustics and assess them against the preferred listening environment. method: this research was conducted as a systematic review with reference to the south african context. local and international research and guidelines were used as references, providing an overview and evaluation of data concerning noise and learning. results: noise is disadvantageous for learners, particularly those with sensory, language or learning impairments. research and international guidelines show that the ideal ambient level is 30 dba – 35 dba, allowing the achievement of an ideal signal-to-noise ratio (snr) of +15 db, and the ideal reverberation time is 0.4 s – 0.6 s. various south african regulations discussed are inconsistent regarding ambient noise level (ranging from 35 dba – 50 dba) and say little about reverberation time for classrooms. conclusion: south african regulations regarding classroom acoustics require revision to ensure inclusion of all learners with disabilities. the current status does not enforce barrier-free environments in mainstream schools for children with sensory, language or learning impairments. introduction south africa (sa) supports a policy of inclusive schooling, striving to accommodate all children, including those with disabilities, in mainstream schools. to this end, the national department of education promotes the adoption of barrier-free access to schools for all (education white paper 6, 2001). whether a learner attends a special school for learners with impairments or a mainstream school, barriers to learning should be removed and accommodations should be made to ensure that all learners have the best possible access to education (department of education, 2001; world health organization [who], 2011). the provision of fair, equal and barrier-free education is referred to as inclusive education. according to the who (2011), inclusion in this respect means uninhibited access to education for children with special needs, which includes children with disabilities, as well as children who are not necessarily disabled but are disadvantaged in other ways, for example, through race or gender inequality. thus, inclusive education can broadly be interpreted to mean that all children must have access to education in the least restrictive environment possible, whether in a special or mainstream school. the design of inclusive environments is a principle that has been adopted by the department of basic education (dbe) (2012) and is applicable in mainstream schools. this approach to design considers the potential ability of all people. it attempts to include as many people as possible, while simultaneously celebrating diversity by recognising the requirement for design solutions that meet the needs of specific types of impairments. a number of national regulations pertaining to the provision of inclusive schooling exist: the education white paper 6 (2001); the national policy for an equitable provision of an enabling school physical teaching and learning environment (dbe, 2010); the guideline relating to planning for public school infrastructure (dbe, 2012); the regulations relating to minimum norms and standards for public school infrastructure (2013). these recognise the value of quality special-needs schools while promoting inclusiveness in mainstream education in sa. however, the universal design of the physical environment receives little attention. a barrier to learning (dbe, 2015) can be anything preventing learners from performing to their full potential. this article focuses on noise as an environmental barrier for learners with language and learning disorders such as dyslexia, dysphasia, attention deficit hyperactivity disorder (adhd), auditory processing disorder (apd), autism spectrum disorder (asd) or asperger syndrome (as), as well as those with sensory impairments such as visual or hearing impairments. in addition, children being taught in their second or third language (saaled, n.d.) are considered, as a significant number of south african learners fall into this category, and it is postulated that this places them at a disadvantage when listening. in a context of oral teaching and auditory learning, in which 75% of the school day involves listening activities (http://www.asha.org/policy), it is logical that a noisy environment has an impact on learners’ reception of instruction, particularly those with sensory, language or learning disabilities (nelson & blaeser, 2010). this is supported by evidence that emerged from the literature. problem statement despite the policy to eliminate barriers to learning in mainstream schools in sa, environmental barriers are seldom mentioned. where environmental interventions are addressed, it is with reference to providing physical access for learners with physical impairments. insufficient attention is given to other environmental barriers that affect learners with sensory, language or learning impairments. this article specifically investigates the effect of classroom acoustics on these learners. goal and objectives the goal of this study was to determine whether existing sa norms, standards and regulations regarding classroom acoustics in mainstream schools are adequate to ensure a barrier-free learning environment for all, including those with sensory, language or learning impairments. the following objectives were set: to establish the impact that noise has on learners with sensory, language or learning impairments to establish the preferred listening conditions for these learners by examining prior research and guidelines available in other countries to outline the current south african regulations pertaining to classroom acoustics and assess them against the preferred listening environment. significance it is established that sa norms, standards and regulations regarding classroom acoustics are inadequate to ensure a barrier-free learning environment for language and learning impaired learners. the implication is that a large percentage of school learners are currently being disadvantaged, and the policy of inclusive education is not being upheld. children may be performing poorly because of environmental conditions. research method and design this article provides an overview and evaluation of peer-reviewed, published data concerning noise and learning. it is written as a literature review in a narrative style. the method followed is a systematic review with the aim of identifying, critically evaluating and integrating data with an endeavour to detect gaps or trends and make recommendations for further research. in accordance with khan, kunz, kleijnen and antes (2003) the systematic review included the following steps: framing questions for review: background data served to frame the problem statement and established the context for the study. a detailed description of phenomena in question allowed comparisons to be made (shenton, 2004). research questions and objectives were subsequently generated. identifying relevant work: a search was conducted on all topics related to the identified problem from the fields of education, audiology, language development and acoustics. searches on scholarly search engines and academic libraries according to specific keywords and search phrases were conducted. keywords and phrases included: ‘noise in classrooms’, ‘effect of classroom noise’, ‘inclusive classroom’, ‘reverberation and speech perception’, ‘effect of noise on academic performance’ and ‘classroom accommodation’. the literature study was broad, including both local and international sources. assessing the quality of the studies: results were assessed according to specified inclusion and exclusion criteria. where articles were found to reference earlier research, the latter was sought as a primary source. peer-reviewed articles were included and data from reputable institutions such as universities or relevant professional societies. articles from blog sites and sponsored by companies in industries related to acoustic products or equipment were excluded. recent and early literature was considered, with earlier research providing a benchmark for recent research findings. field studies were given preference over reviews or discussion papers in order to accurately identify the impact of noise on subjects. summarising the evidence: once relevant data had been sifted, they were organised according to a matrix (appendix 1). no single paper addressed all the objectives of this discussion at once, thus a meta-analysis of a collection of literature was required. the matrix served to categorise the type of noise, the effect of the noise and the type of learners affected, to identify trends and gaps. national regulations were used to assess the current status of acoustic requirements. international guidelines were examined to establish best practice recommendations. interpreting the findings: findings were interpreted and critically assessed according to the research questions, while objectives and contradictions in the literature were noted. an objective evaluation of the data was further ensured by the addition of the second author. with each author operating out of a different research field, peer scrutiny was guaranteed (shenton, 2004). research the research of literature pertaining to classroom acoustics in the context of inclusive environments was separated according to the three objectives, namely, the impact of noise, ideal listening conditions and the south african regulations. the impact of noise on sensory, language and learning impaired children it is argued that noise presents an environmental barrier to learners with sensory, language and learning impairments, as well as children being taught in their second or third language. the implementation report (department of education, 2015) presents the results of surveys conducted on the number of the aforementioned learners enrolled in mainstream schools in sa 2013. these results support the who’s (2011) statement that close to 20% of learners experience barriers to learning. the effect of noise and acoustics as a barrier to school performance of children has been a topic of research since the mid-20th century (yerges & smith, 1949). however, the effect of noise depends on the variable being measured. when analysing the themes and topics of the literature (appendix 1), three variables emerged and are present either separately or in combination: the effects of different noise conditions on performance the effect of noise on the performance of different types of learners the effect of noise on different measures of performance. to meet the objective of establishing whether or not classroom noise and acoustics have a significant effect on learners, each of the identified variables are discussed in detail below. noise conditions noise can be characterised by its loudness, frequency, fluctuation and meaning. invasive outdoor noise, such as aircraft noise, has been shown to negatively affect learner performance (haines, stansfeld, head & job, 2002; hygge, evans & bullinger, 2002; seabi, cockcroft, goldschagg & greyling, 2012, 2015). studies comparing the performance of children in schools near and distant from airports, and of children in schools near airports before and after decommissioning of the airport bear evidence of this. noise disturbances of 85 dba (hygge et al., 2002) and 95 dba (seabi et al., 2012) and equivalent continuous sound pressure levels of around 69 dba over 24 h characterise the soundscape around these schools and may be considered highly intrusive, periodically interrupting lessons to the extent that teaching needs to be suspended while aircraft pass over. the loudness of the background noise level implies a decrease in the signal-to-noise ratio (snr) in the classroom. the snr is the difference between the sound level of the source sound signal and the ambient (background) sound level (in decibels) and has been shown to be directly proportional to the performance of school children (jamieson, kranjc, yu & hodgetts, 2004). traffic noise has been found to have a similar negative effect on performance, like aircraft noise, as has meaningless irrelevant speech within the class (hygge, boman & enmarker, 2003). because traffic noise and speech are not as loud and invasive as aircraft noise, it appears that there is something else at play. evidently, it is not only the snr in the classroom that produces an effect but rather the characteristic of the noise, in this case, the fluctuation of the noise (hygge et al., 2003). differential performance of school children under different types of background noise supports the notion that both the characteristics of the background noise and the snr are significant (klatte, lachman & meis, 2010; dockrell & shield, 2006). it seems that a significant characteristic of noise that determines the level of disturbance, over and above fluctuation, is the speech content: whether it is present and whether or not it is meaningful. furthermore, the listening environment is also influenced by reverberation time. this refers to the amount of time it takes (in seconds) for a signal sound level to die down by 60 db. the reverberation time is a way of expressing how much a sound reflects or echoes in a room. a long reverberation time has a significant effect on speech intelligibility and perception, especially when in combination with background noise (klatte et al., 2010; ljung & kjellberg, 2009). in a classroom setting, this means that much of what the teacher says in a lesson is not fully comprehended (asha working group on classroom acoustics, 2005). to conclude, the type of noise in a classroom environment is relevant with reference to its fluctuation, its speech content, the reverberation time and the ambient noise level. type of learner while the varying nature of the noise has been shown to have an effect on learners, the type of learner is also a variable that should be considered as they are differentially affected by noise. the most universal differentiating factor is that of age. a comparison of the effects of background noise and reverberation time on speech perception and listening comprehension of children and adults in a classroom-like setting show that children are more impaired by background noise than adults (crandell & smaldino, 1996; jones, moore & amitay, 2015; neuman, wroblewski, hajicek & rubinstein, 2010). children only reach adult-like abilities to perceive speech accurately within noise and reverberation as teenagers (crandell & smaldino, 2000; johnson, 2000). the acoustic conditions of a classroom are particularly important for younger learners. the background noise level (and resultant snr) has a differential effect even within the age range of 5–8 years, with 7to 8-year-olds being able to perform better under noise conditions than 5to 6-year-olds (jamieson et al., 2004). children do not have the phonological maturity to reconstruct degraded speech and lack discipline to remain focused on a task in the presence of distracting noise (edwards & rogers, 2002; klatte et al., 2010). a similar phenomenon can be expected to occur when learners are taught in a language other than their mother tongue. studies indicate that children taught in their second language are at a disadvantage compared to their peers in the academic environment. the effect of classroom noise on attention and speech perception of second-graders learning in their second language compared to those learning in their first language showed that word recognition in both groups was worse under noise conditions but the effect was greater for second language learners (nelson, kohnert, sabur & shaw, 2005). english second language learners require a more favourable snr to ensure good speech perception in the classroom (crandell & smaldino, 1996; peng, 2014). bilingual learners, who show no difference compared to monolingual controls in word recognition under quiet conditions, perform significantly worse under noise with reverberation conditions (rogers, lister, febo & besing, 2006). apart from and in addition to the inherent handicap of age and the possible disadvantage of language, other types of learners experience exaggerated barriers to learning in the presence of noise: learning or sensory impaired learners. learners most vulnerable in poor listening conditions are those with hearing impairments (crandell & smaldino, 2000). because of their low hearing threshold, hearing impaired children require the snr to be at least +10 db but preferably +20 db (finitzo-hieber, 1981). reverberation has a significantly worse effect on speech intelligibility for hearing impaired learners compared to normal-hearing learners (breitsprecher, 2011) and has also been shown to have a worse effect than noise alone. however, the combination of reverberation and background noise has the greatest negative impact on speech clarity (hazrati & loizou, 2012). speech recognition is influenced not only by the clarity of the auditory signal but also the visual signal clarity (grant, walden & seitz, 1998). from this, it may be deduced that that a visually impaired learner would require increased clarity of the auditory signal to function optimally in the classroom. this is further supported by teaching strategies and guidelines for blind and vi learners, such as the document for student well-being from newcastle university (n.d.). a stereotype exists that blind and vi people have ‘super’ senses and can hear better than seeing people (www.dsb.wa.gov). this is not necessarily true. evidence shows that early blind individuals do not have enhanced spatial hearing and their physical hearing ability is not more developed (voss, tabry & zatorre, 2015). what has been confirmed, however, is that some vi people have a heightened perception of sound and that blind subjects can locate sound sources more accurately than sighted and partially sighted subjects (lessard, pare, lepore & lassonde, 1998). rather than being able to hear the teacher better, vi learners are disadvantaged by being unable to follow visual cues and are heavily dependent on auditory communication (newcastle university, n.d.). the effect of classroom noise on auditory processing tasks of learning-disabled children, rather than children in general, has been a topic of interest for several decades. an original study by nober and nober (1975) found that though learning-disabled subjects performed more poorly than the control subjects, both groups performed worse under the noise condition, demonstrating a universal effect of noise. however, other studies have shown a differential effect of noise on children with learning impairments (dockrell & shield, 2006; ljung, israelsson & hygge, 2013). there is evidence that noise has a significant effect on children with low working memory capacity (ljung et al., 2013) while some studies considering the performance of adhd or asd children compared to typically developing controls show little effect of noise. this may indicate that noise does not affect these types of learners; however, in most such studies, the floor effect is raised as a possible reason for this (hygge, 2003; russo, zecker, trommer, chen & kraus, 2009). contrary to these studies, others have shown a positive effect of noise on certain types of learners. children with adhd who listened to music performed better in mathematics than controls and subjects in silence or under speech noise conditions (abikoff, courtney, szeibel & koplewicz, 1996). in another study, learners with attention deficit problems performed better on a memory exercise when exposed to white noise, while controls performed worse under white noise conditions (soderlund, sikstrom, loftesnes & sonuga-barke, 2010). it is thus evident that certain types of learners required different noise conditions to facilitate maximum performance. however, a careful reading of the research reveals that the type of performance being measured is also relevant. types of performance the expected performance of school-going children is measured in different areas of development. it has been found that noise does not necessarily have the same effect on each of these areas of performance. verbal and non-verbal tasks are differentially affected by different noise conditions. verbal tasks, such as reading and spelling, are most negatively affected by background conditions of meaningless irrelevant speech, whereas non-verbal tasks are more affected by a background noise condition of environmental noise combined with meaningless irrelevant speech (dockrell & shield, 2006). when it comes to memory tasks, recall is more affected by noise conditions than recognition (hygge, 2003), demonstrating the differential effect of noise on different performance types. probably, the most obvious cognitive measure to be affected by noise is that of speech perception and auditory processing, as this relies on the ability to hear clearly. tasks that rely on hearing, such as interpreting instructions, are negatively affected by a low snr or long reverberation (crandell & smaldino, 1996; jamieson et al., 2004; nelson et al., 2005). speech perception is more disrupted by general classroom background noise, even under low reverberation, while background noise containing speech affects listening comprehension (klatte et al., 2010). apart from not being able to hear, and thus respond to teaching instruction, other cognitive functions have been shown to be influenced by the presence of environmental noise, such as reading comprehension, attention and memory (hygge et al., 2003; seabi, goldschagg & cockcroft, 2010). children exposed to aircraft noise, road traffic noise and background speech display a poor reading and comprehension ability (hygge et al., 2002; seabi et al., 2012). in some cases where environmental (aircraft) noise was removed, a lag in reading comprehension has been shown to remain (seabi et al., 2015) but in other cases the reading comprehension effect has disappeared (hygge et al., 2002). memory functions have been found to be impaired by noise in the case of aircraft noise, road traffic noise, background speech (hygge et al., 2002), and white noise (soderlund et al., 2010). the preceding review demonstrates noise certainly influences learners and thus poor acoustics proves to be an environmental barrier. the effect of noise is a complex matter because a review of literature has shown that the type of noise, the type of learner and the type of performance being measured are all factors to be considered. no research has been found in which two of these variables have remained constant and only the third tested, e.g. noise condition and type of learner constant with measures of performance tested. however, a meta-analysis of the existing research indicates that all three factors are relevant and should be jointly considered when designing a classroom that is inclusive. preferred listening conditions the above discussion highlights the relevance of acoustics in classrooms. although not all learners are equally affected by noise, it may be concluded that on the whole, classroom environments require a low background noise level and a low reverberation time to ensure good speech perception and learner performance. although adults are able to understand speech at an snr of 0 db, normal-hearing children require an snr of about +10 db (seep, glosemeyer, hulce, linn & aytar, 2000). in the case of children with hearing impairments, evidence shows that the snr level should be at least +15 db (crandell & smaldino, 2000). to achieve favourable snr levels, the background noise levels need to be limited. to this end, most guidelines recommend an ambient level in an unoccupied classroom should be in the region of 30 dba – 35 dba. the american speech-language hearing association (asha) developed thorough guidelines for classroom acoustics for learners with speech-language-hearing disorders, recommending that reverberation time should not exceed 0.4 s, snr should not be less than +15 db, and the ambient noise in an unoccupied classroom should be 30 dba – 35 dba (asha working group on classroom, 2005). it is noteworthy that the specified ambient noise level is for an unoccupied space, as the noise created by occupants is variable and thus does not provide a reliable base for a standard. while classrooms in which hearing impaired learners are to be accommodated should have a reverberation time of close to 0.4 s (crandell & smaldino, 2000), the minimum recommended reverberation time for learners being taught in a second language is 0.6 s (peng, 2014). guidelines for acoustic requirements of classrooms from the united kingdom (uk), the united states of america (usa) and australia are in agreement regarding the ambient noise level and reverberation times as summarised in table 1. these guidelines are also suitable for learners with hearing impairments. table 1: selected international acoustic requirements. apart from the ambient noise levels and the reverberation time, some guidelines also refer to the distance between the speaker and the listener. as sound decays over distance, it follows that the further a listener is from the speaker, the weaker the sound signal will be and thus the snr will be decreased. there is a critical distance beyond which there will be interference between the direct sound field and the reverberant sound (crandell & smaldino, 2000). in an average classroom, this critical distance is approximately 3 m – 4 m from the teacher (crandell & smaldino, 2000). it is recommended that children with learning impairments should be positioned nearest to the teacher (klatte et al., 2010). in summary, to achieve the best listening conditions for all learners, the snr should be +15 db, with an ambient unoccupied noise level of 35 dba, a reverberation time of less than 0.6 s and learners should be within 4 m of the teacher. south african policy, regulations and standards a review of local policies, regulations and standards for acoustic design of classrooms was conducted, which included publications of the dbe and the south african national standards (sans). the national policy for an equitable provision of an enabling school physical teaching and learning environment (dbe, 2010) was developed to ensure parity for learners in an enabling learning environment. recognising that quality education is partly dependent on the learning environment, the policy aims to define and promote an enabling physical teaching and learning environment, including the impact of acoustics on learning outcomes. the policy does not elaborate on design aspects, although it makes provision for the establishment of norms and standards. it is significant that acoustics is recognised as a part of an enabling environment (dbe, 2010, p.27). the dbe published guidelines relating to planning for public school infrastructure in 2012 to ensure inclusive education through set standards for the construction and management of schools, specifying measures for architectural design. it recommends background noise level of 40 dba – 50 dba and a reverberation time of 0.6 to 0.7 s. although the reverberation time recommended is close to that recommended by other international guidelines (table 1), the ambient noise level is significantly higher than international guidelines and would result in a low snr in the classroom. it is also not clear whether the ambient noise level refers to an occupied or unoccupied noise level, although unoccupied should be assumed as the occupied noise level is variable, dependent on occupant activities and thus difficult to standardise and measure. in 2013 the dbe published regulations relating to minimum norms and standards for public school infrastructure. in line with policy, these regulations call for schools to adhere to principles of inclusive design (section 6) and comply with requirements of specialised support programmes for learners with special education needs. however, quantitative norms are not given regarding the inclusive design of the physical environment (section 9). although section 18 requires that as far as reasonably possible, acoustics conditions should not impede clear communication or teaching and learning, no guidelines quantify appropriate acoustic conditions. the sans 10130 (2008) requires that the unoccupied ambient noise level in a classroom be 35 dba. this is in line with international guidelines previously mentioned; however, there are no requirements specified in terms of reverberation time. it is further specified that ‘open space’ teaching areas in secondary schools should have an ambient noise level of 40 dba, while in primary and pre-primary schools it should be 45 dba. this does not correlate with the research findings that younger learners are more affected by noise than older learners (compare with section: ‘type of learner’). sans 10400 (2010), for the application of the national building regulations, does not make provision for acoustic requirements of buildings, explaining in the preface that acoustics is an aspect that only affects comfort or convenience and, being a subjective factor, is difficult to regulate. this is arguable but pertinent to the point that acoustic conditions receive insufficient attention in the design of classrooms. discussion inclusive education policies and guidelines are formulated to ensure that learners with disabilities, especially from previously disadvantaged communities, have access to quality education in both special and mainstream schools. the education white paper 6 (2001) is largely concerned with teaching and learner accommodations, although inclusive education through inclusive design is also promoted. while it is understood that the policy stemmed from a need to redress historical political exclusions, the guidelines and regulations flowing from the policy do not fully acknowledge the wide range of disabilities found among children of school-going age. moreover, a lack of detailed attention is given to the role of acoustics in classroom design. the literature demonstrates the significant impact of classroom acoustics on the performance of learners, particularly those with impairments, who require a lower background noise level and a lower reverberation time to increase speech audibility and clarity. although it seems that the nature of the background noise is significant, there is general consensus that minimal noise, regardless of character, is preferential. the case of certain learners performing better on certain types of tasks under certain types of noise is intriguing but not universal. even within these studies, individual preferences among subjects regarding the noise volume are evident (soderlund et al., 2010), and such requirements may be best met through the use of personal sound systems. it is evident from international guidelines, standards and research that classrooms should not be characterised by ambient noise level alone but that reverberation time and even listening distance are also critical aspects. most international guidelines recommend an ambient noise level of 30 dba – 35 dba for unoccupied classrooms. these levels are adequate to accommodate a diversity of learners. the lowest reverberation time to accommodate the maximum number of learners is 0.4 s. this is a very low level, and the majority of literature agrees that a reverberation time of 0.6 s is suitable for most learners. the recommended ambient noise level of 40 dba – 50 dba given in the dbe guidelines (2012) is not viewed as a satisfactory as it would result in a low snr. although the level required by sans 10103 (2008) of 35 dba is acceptable, the levels for secondary and primary/pre-primary teaching spaces do not reflect evidence found in the literature that younger learners are more negatively affected by background noise than older learners. sans 10103 (2008) does not make any recommendations regarding reverberation time. this is viewed as a shortcoming, as it is clear from the literature that reverberation has a significant impact on the clarity of communication. the recommended reverberation time given in the dbe guidelines (2012) of 0.6 s – 0.7 s is satisfactory for normal learners but according to the data, it is not ideal for hearing impaired learners and thus falls short of creating an inclusive environment. it is important also to note that the reverberation time in a particular room is largely dependent on the absorption and the volume of the room. this infers that the floor area and ceiling height are relevant as well as the material finishes. though the dbe regulations (2013) and guidelines (2012) are clear on the floor area for classrooms, there is a lack of guidance regarding ceiling height or volume and material finishes. when the ambient noise cannot be lowered, a suitable snr can be achieved by amplifying the signal level. this can be done through a frequency modulation (fm) system (disarno, schowalter & grassa, 2002): a radio transmitter system that amplifies the signal sound, either to a device in the listener’s ear (personal fm) or to room speakers (sound-field fm). however, when using sound-field fm, the overall noise level must be carefully considered with regard to hearing damage or fatigue caused by constant high noise levels. in addition, there is a risk of inter-classroom noise disturbance resulting from the amplified signal being overheard from adjacent classrooms. conclusion this study undertook a systematic review of the literature on the effect of noise on learning and the ideal listening conditions with reference to the national policy for inclusive education and existing acoustic guidelines, regulations and standards in sa. it is concluded that sa regulations are inadequate and not on par with international guidelines. noise is indeed bad for children, particularly those with sensory or language and learning impairments. the ideal ambient level is 30 dba – 35 dba, allowing the achievement of an ideal snr of +15 db and the ideal reverberation time is 0.4 s – 0.6 s. these conditions can be achieved by controlling the volume, material finishes and transmission of noise, as well as considering critical distance calculations in classroom design to ensure optimal use of the classroom space for learning. the following recommendations are made for future research: the ambient noise level and reverberation time for classroom design be reviewed and revised in the sa regulations pertaining to classroom acoustics to ensure inclusion of all children with disabilities and to bring them into alignment with each other and with international standards. it is asserted that regulations that accurately describe the ideal listening environment, if diligently applied in practice, will extend the reach of inclusive education. the majority of the research reviewed was not conducted in sa. it is recommended that research be conducted locally to determine the extent to which schools in sa comply with local and international standards. the literature is silent on the impact of classroom noise on visually impaired learners. it is 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(1949). modern schoolroom acoustics. journal of the acoustical society of america, 21(1), 56. https://doi.org/10.1121/1.1917031 appendix 1 table 1-a1: literature review matrix abstract introduction method ethical consideration results discussion conclusion acknowledgements references about the author(s) lucretia petersen division of communication sciences and disorders, department of health and rehabilitation sciences, faculty of health sciences, university of cape town, south africa wayne j. wilson school of health and rehabilitation sciences, faculty of health and behavioural sciences, university of queensland, australia harsha kathard division of communication sciences and disorders, department of health and rehabilitation sciences, faculty of health sciences, university of cape town, south africa citation petersen, l., wilson, w.j., & kathard, h. (2018). towards the preferred stimulus parameters for distortion product otoacoustic emissions in adults: a preliminary study. south african journal of communication disorders, 65(1), a585. https://doi.org/10.4102/sajcd.v65i1.585 original research towards the preferred stimulus parameters for distortion product otoacoustic emissions in adults: a preliminary study lucretia petersen, wayne j. wilson, harsha kathard received: 31 oct. 2017; accepted: 31 mar. 2018; published: 16 july 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: although distortion product otoacoustic emissions (dpoaes) are useful in evaluating cochlear outer hair cell function, determining the optimal stimulus parameters could result in a more reliable, sensitive and specific diagnostic tool across the range of dpoae applications. objectives: to identify which stimulus parameters warrant further investigation for eliciting the largest and most reliable dpoaes in adult humans. method: a single group, repeated measures design involving a convenience sample of 20 normal-hearing participants between 19 and 24 years of age. results: descriptive statistics and mixed model analyses suggested l1/l2 intensity levels of 65/65 db sound pressure level (spl) and 65/55 db spl, and f2/f1 ratios of 1.18, 1.20 and 1.22 elicited larger and more reliable dpoaes in both ears. conclusion: further investigation of the 65/65 db spl and 65/55 db spl intensity levels and the 1.18, 1.20 and 1.22 f2/f1 ratios is warranted to determine the stimulus parameters for eliciting the largest and most reliable dpoaes in adult humans across the range of dpoae applications. introduction distortion product otoacoustic emissions (dpoaes) are sounds emitted from the cochlea in response to two simultaneously presented tonal stimuli. these stimuli have levels designated as l1 and l2 and frequencies designated as f1 and f2. the sensitivity of dpoaes to outer hair cell dysfunction in the cochlea has seen them successfully used in a variety of clinical and research applications, such as newborn hearing screening, diagnostic audiological assessment, ototoxicity monitoring and the study of cochlear mechanics (dhar & hall, 2012; hood & berlin, 2002). the successful use of dpoaes in a range of applications suggests that their optimal stimulus parameters have been determined. this is not the case (petersen, wilson, & kathard, 2017). instead, the dpoae level has been found to depend on varying combinations of stimulus parameters, including f1 and f2 frequencies, f2/f1 ratio, l1 and l2 intensity levels and l1/l2 level separation (prieve & fitzgerald, 2015). furthermore, dpoaes have been elicited using a wide range of stimulus parameters, including f2/f1 ratios from 1.03 to 1.79 and l1/l2 combinations ranging from 30/30 db sound pressure level (spl) to 85/85 db spl (petersen et al., 2017). dreisbach and siegel (2001) added to this complexity by reporting that the optimal f2/f1 ratio varies as a function of f2 frequency, with lower f2/f1 values eliciting higher dpoae levels at higher f2 frequencies and vice versa. recommended stimulus parameters have also varied depending on the application. for diagnostic purposes and/or ototoxicity monitoring, f2/f1 ratios have ranged from 1.20 to 1.22 and l1/l2 combinations from 45/35 db to 65/55 db spl (dhar & hall, 2012; hall, 2000). hall (2000) also reported that for cochlear lesions, decreasing the stimulus levels improved dpoae sensitivity, whereas increasing the stimulus levels improved dpoae specificity. for screening applications, an f2/f1 ratio of 1.20 has often been recommended with l1/l2 combinations of either 65/55 db spl or 65/65 db spl (dhar & hall, 2012; hall, 2000). other recommendations have included an l1/l2 combination of 65/55 db spl for its reported twofold advantage of producing a higher dpoae level with an improved sensitivity to cochlear dysfunction, whereas the use of l1/l2 combinations above 70/70 db spl has been discouraged to avoid possible response artifact that can be mistaken for dpoaes and confusion over the source of the resulting dpoaes (dhar & hall, 2012). the variation in stimulus parameters used to elicit dpoaes highlights the continuing need to determine the optimal dpoae stimulus parameters across all its applications. this search needs to be driven by sound research based on a continuum of evidence that considers two factors: the cyclical nature of knowledge creation and the quality of existing evidence informing clinical practice. the cyclical nature of knowledge creation, especially in the case of clinical practice, refers to the cycle of developing theories that are then tested by research to develop new knowledge. this new knowledge is then applied to clinical settings where it is used to refine existing theories or propose new ones (schmidt & brown, 2015). patient care is improved through the repeating nature of this cycle and its ability to generate ever-changing scientific knowledge. in the case of dpoaes, the quality of existing evidence informing clinical practice refers to the following questions: ‘how rigorous is the research investigating dpoae stimulus parameters?’ and ‘how strong is the evidence for the stimulus parameters currently used in the clinical setting?’ asking such questions seeks to strengthen clinical practice and expand current evidence bases (puddy & wilkins, 2011). in response to the above call, the authors of this study recently began to search for the optimal stimulus parameters for eliciting dpoaes from human adults for clinical applications, especially to assist with early identification of cochlear damage in individuals receiving ototoxic treatment for multi-drug-resistant tuberculosis. this search began with a systematic review (petersen et al., 2017) that first asked: ‘what is an “optimal” dpoae?’ factors such as the clinical value of dpoae level, signal-to-noise ratio (snr), reliability, sensitivity and specificity to cochlear dysfunction were considered, as well as confounds such as the high number of dpoae parameters open to manipulation, the small effect sizes of changing some parameters, the physiological processes represented by dpoaes and the high intersubject variability seen in dpoaes. the review then examined 47 dpoae studies that had met the inclusion criteria for the systematic review. of these, 33 studies met the inclusion criteria to examine the influence of intensity and/or frequency ratio on the dpoae level. most of the studies were found to have small sample sizes (often fewer than 10 participants) and/or to have manipulated only one set of stimulus parameters (18 having manipulated l1/l2 levels at a fixed f2/f1 ratio, or vice versa). of the remaining 15 studies that manipulated both intensity and frequency ratio parameters, 8 studies used 15 participants or fewer. ten of the 15 studies had only used descriptive statistics when reporting their results, leaving open the possibility that any observed differences had occurred by chance alone (interestingly, this limitation was seen in two seminal and highly cited papers on dpoae stimulus parameters by gaskill and brown [1990] and harris, lonsbury-martin, stagner, coats and martin [1989]). petersen et al. (2017) concluded that although some parameters are commonly used to elicit dpoaes, only their effects on dpoae level have been considered in limited detail (with their effect of dpoae snr, reliability and sensitivity and specificity to cochlear dysfunction being largely ignored), and the optimal parameters for eliciting dpoaes in adult humans in clinical applications have yet to be determined (petersen et al., 2017). this study sought to expand on the findings of petersen et al. (2017) towards a final determination of the optimal stimulus parameters for eliciting dpoaes from human adults for clinical diagnostic applications. it considered a wide range of commonly used stimulus parameters from those reported by petersen et al. (2017) but expanded their investigation by systematically manipulating both f2/f1 ratios and l1/l2 levels simultaneously. this study was limited to measuring the effect of stimulus parameters on dpoae level and reliability (and not snr or sensitivity and specificity to cochlear dysfunction) in adult humans with normal hearing, to manage the total number of variables under examination. method research design a single group, repeated measures design was used for this study. this design was deemed appropriate to examine the influence of intensity and frequency ratio stimulus parameters on dpoae levels. participants twenty normal-hearing adult participants (15 female, 5 male, aged 19 to 24 years) were conveniently sampled from the staff and student population of the university of cape town, south africa. these participants had no obvious outer ear or tympanic membrane abnormalities on otoscopy, had hearing thresholds ≤ 15 db hl at octave frequencies from 0.25 to 8 khz on pure tone audiometry (clark, 1981), had middle ear pressure and compliance within normal limits -(grason-stadler, 2001) on tympanometry, had no self-reported history of ear events that could affect dpoae recordings and had passed a dpoae screening assessment. protocol participants were initially screened for inclusion in the study using a live voice interview and a commercially available otoscope, audiometer, tympanometer and dpoae device (gsi audera 2.7, version c). to pass the dpoae screening, the participants had to show 2f1-f2 dpoaes at least 3 db above the noise floor at f2 frequencies 2, 4 and 8 khz to tonal stimuli with an f2/f1 ratio of 1.2 and an l1/l2 setting of 65/55 db spl. all initial testing was conducted in a sound-treated booth meeting south african national standards (2006). distortion product otoacoustic emissions testing was conducted in a quiet room with background noise levels < 55 db a as measured using a brüel & kjær 2238 class 1 handheld sound level meter. the 2f1-f2 dpoae measurements were obtained from each ear of each participant using the following stimulus parameters: f2/f1 ratios – 1.18, 1.20, 1.22, 1.24, 1.26 and 1.28; l1/l2 settings – 65/65 db spl, 65/55 db spl, 60/45 db spl, 60/53 db spl and 55/40 db spl; and f2 frequencies: 2003 hz, 2519 hz, 3178 hz, 3996 hz, 5000 hz, 6996 hz and 8003 hz. to mitigate potential order effects, a single sequence of stimulus parameters was set, and each participant was started at a different point in this sequence. the order of ear testing was reversed for each sequential participant. the 2f1-f2 dpoaes were sampled until at least one of the two stopping rules was met: (1) the noise floor at the distortion product frequency was less than -10 db spl or (2) until 32 s of artifact-free sampling had been averaged (dille et al., 2010). participants were seated in a comfortable chair and were instructed to remain still and quiet during the dpoae test procedure with breaks provided as required. the dpoae test time per participant was approximately 90 min per test occasion. each participant underwent dpoae testing on two occasions 24 h – 48 h apart. data collection the following dpoae data were recorded from each participant for each set of stimulus parameters at each f2 frequency on each test occasion: absolute level of dpoae, absolute level of the noise floor and the dpoae snr, calculated as the absolute level of the dpoae minus the level of the noise floor. data analysis all dpoae data were found to meet parametric assumptions following examination of the histograms of these data, box-and-whisker plots and q–q plots (data not shown). descriptive statistics were calculated for all dpoae measures, and correlation analyses were conducted to determine if the dpoae results for the left and right ears were related. as these analyses showed significant correlations in dpoae results between the ears, all further analyses of the dpoae data were conducted for each ear separately. two sets of linear mixed model analysis were conducted at the 5% significance level on the dpoae data for each f2 value separately. each set of analyses considered dpoae amplitudes as dependent variables, the stimulus level combinations and frequency ratios as fixed effect independent variables and the participants as a random effect independent variable. the first set of analyses sought to identify the presence of any main effects of level settings (l1/l2 in db spl) for all f2/f1 settings combined, and any main effects of frequency ratio settings (f2/f1) for all l1/l2 settings combined. the second set of analyses sought to identify the presence of any main effects of the combined level (l1/l2 in db spl) and frequency ratio (f2/f1) settings. finally, two-way mixed model intraclass correlation coefficient (icc) analyses for absolute agreement were conducted at the 5% significance level on the dpoae data for each f2 value separately to determine the level of agreement (reliability) of the absolute levels of the dpoae recordings from the first to the second assessment occasions for each combined level (l1/l2 in db spl) and frequency ratio (f2/f1) setting separately. all statistical analyses were conducted using ibm spss statistics versions 23 and 24 (64-bit edition). ethical consideration unconditional ethical clearance was granted to conduct the study by the faculty of health sciences human research ethics committee (hrec/ref: 512/2013). results figure 1 shows the dpoae mean absolute levels for all combinations of f2/f1 and l1/l2 at each f2 frequency for the participants at the first assessment occasion. this figure also presents the numbers of ears showing dpoaes at each of these stimulus combinations. these results showed this study’s participants were more likely to show dpoaes of higher intensity at lower f2 frequencies. figure 1: mean distortion product otoacoustic emission absolute levels per intensity and frequency ratio combinations for each frequency (f2): (a) right ear at 2003 hz, (b) left ear at 2003 hz, (c) right ear at 2519 hz, (d) left ear at 2519 hz, (e) right ear at 3175 hz, (f) left ear at 3175 hz, (g) right ear at 3996 hz, (h) left ear at 3996 hz, (i) right ear 5000 hz, (j) left ear at 5000 hz, (k) right ear at 6996 hz, (l) left ear at 6996 hz, (m) right ear at 8003hz and (n) left ear at 8003hz. hz, hertz. figure 1 (continues…): mean distortion product otoacoustic emission absolute levels per intensity and frequency ratio combinations for each frequency (f2): (a) right ear at 2003 hz, (b) left ear at 2003 hz, (c) right ear at 2519 hz, (d) left ear at 2519 hz, (e) right ear at 3175 hz, (f) left ear at 3175 hz, (g) right ear at 3996 hz, (h) left ear at 3996 hz, (i) right ear 5000 hz, (j) left ear at 5000 hz, (k) right ear at 6996 hz, (l) left ear at 6996 hz, (m) right ear at 8003hz and (n) left ear at 8003hz. hz, hertz. figure 1 (continues…): mean distortion product otoacoustic emission absolute levels per intensity and frequency ratio combinations for each frequency (f2): (a) right ear at 2003 hz, (b) left ear at 2003 hz, (c) right ear at 2519 hz, (d) left ear at 2519 hz, (e) right ear at 3175 hz, (f) left ear at 3175 hz, (g) right ear at 3996 hz, (h) left ear at 3996 hz, (i) right ear 5000 hz, (j) left ear at 5000 hz, (k) right ear at 6996 hz, (l) left ear at 6996 hz, (m) right ear at 8003hz and (n) left ear at 8003hz. hz, hertz. figure 1 (continues…): mean distortion product otoacoustic emission absolute levels per intensity and frequency ratio combinations for each frequency (f2): (a) right ear at 2003 hz, (b) left ear at 2003 hz, (c) right ear at 2519 hz, (d) left ear at 2519 hz, (e) right ear at 3175 hz, (f) left ear at 3175 hz, (g) right ear at 3996 hz, (h) left ear at 3996 hz, (i) right ear 5000 hz, (j) left ear at 5000 hz, (k) right ear at 6996 hz, (l) left ear at 6996 hz, (m) right ear at 8003hz and (n) left ear at 8003hz. hz, hertz. table 1 shows the results of the linear mixed model analyses for main effects of level (l1/l2 in db spl) and frequency (f2/f1) settings. for all f2 values and in both ears, these analyses showed that the 65/55 and 65/65 level settings consistently resulted in higher dpoae levels across all f2/f1 settings, and the 1.18, 1.20 and 1.22 f2/f1 settings regularly resulted in higher dpoae levels across all l1/l2 settings. table 1: results of the mixed model analyses for main effects (p < 0.05) of level (l1/l2 in db spl) and frequency (f2/f1) settings. table 2 shows the results of the mixed model analyses of all level and frequency settings combined. for all f2 values and in both ears, these analyses showed that the level (db spl) and frequency ratio settings of 65/65 and 1.20, 65/55 and 1.22, 65/55 and 1.20, and 65/55 and 1.18 regularly resulted in higher dpoae levels compared to other level and frequency ratio combinations. table 2: results of the mixed model analyses of all level and frequency settings combined. the results of the icc analysis of dpoae results obtained for each f2 value, for right and left ears, and for every l1/l2 (db spl) and f2/f1 stimulus combination are not shown in this article (because of the very high number of these analyses conducted). instead, table 3 shows for each f2 value, for right and left ears, the lowest and highest icc absolute agreement (single) coefficients with their 95% confidence intervals from all l1/l2 and f2/f1 stimulus combinations returning significant (p < 0.05) icc values. table 3 also shows for each f2 value, for right and left ears, the l1/l2 (db spl) and f2/f1 stimulus combinations that returned insignificant icc values. no obvious patterns emerged regarding l1/l2 (db spl) and f2/f1 stimulus combinations that were more or less likely to return better or worse icc results for each f2. it was noted, however, that more l1/l2 (db spl) and f2/f1 stimulus combinations returned insignificant icc values for f2 = 8003 hz, meaning that results at this frequency were more likely to be unreliable, regardless of the l1/l2 (db spl) and f2/f1 stimulus combinations used. table 3: results of the intraclass correlation coefficient absolute agreement (single) analyses of distortion product otoacoustic emissions results obtained at each f2 value for each stimulus level (l1/l2 in db spl) and frequency (f2/f1) setting. discussion overall, the l1/l2 combinations and f2/f1 ratios used in this study elicited dpoaes of varying amplitude and reliability. an l1/l2 combination of 65/55 db spl appeared to elicit the largest dpoaes at most f2 values, followed by an l1/l2 combination of 65/65. this finding supports similar findings regarding the l1/l2 combinations more likely to elicit larger dpoaes from human adults (beattie & jones, 1998; vento, durrant, sabo, & boston, 2004). direct comparisons between this study’s findings and similar studies in the literature were difficult, however, with many studies in the literature having used higher l1/l2 levels than this study (beattie, kenworthy, & neal-johnson, 2004; hauser & probst, 1991; meinke et al., 2013; whitehead, mccoy, lonsbury-martin, & martin, 1995). these higher l1/l2 levels were avoided in this study because of their higher likelihood of eliciting false-negative results and artefacts (dhar & hall, 2012). the f2/f1 ratios of 1.18, 1.20 and 1.22 appeared to elicit the largest dpoaes at most f2 values. this finding supports similar findings regarding the f2/f1 ratios that are more likely to elicit larger dpoaes from human adults (abdala, 1996; dreisbach & siegel, 2001; gaskill & brown, 1990) as well as supporting previous reports that the best f2/f1 ratio appears to decrease as f2 increases and vice versa (abdala, 1996; dreisbach & siegel, 2001). stimulus parameters using an l1/l2 of 65/65 with an f2/f1 ratio of 1.20 or an l1/l2 of 65/55 with f2/f1 ratios of 1.18, 1.20 or 1.22 appeared to elicit the largest dpoaes at most f2 values. this result supports similar findings regarding the l1/l2 and f2/f1 ratio parameter settings that are more likely to elicit larger dpoaes from human adults (beattie & jones, 1998; vento et al., 2004). this study’s results do not explain why the largest dpoaes were elicited using stimulus parameters using l1/l2 combinations of 65/65 db spl or 65/55 db spl and f2/f1 ratios of 1.18, 1.20 or 1.22. regarding l1/l2 combinations, the larger dpoaes elicited by stimuli with primaries of 65 (i.e. the 65/65 db spl and 65/55 db spl level stimuli) could be related to the function of the cochlear amplifier (harris et al., 1989) as stimuli, with lower level primaries (l1/l2 levels of 60/53 db spl, 60/45 db spl and 55/40 db spl) yielding lower level dpoaes. such a possibility would be generally consistent with brown and gaskill (1990) who reported dpoae amplitude to depend more on the level of l1 than l2. regarding f2/f1 ratios, the larger dpoaes elicited by f2/f1 ratios of 1.18, 1.20 or 1.22 could reflect the cochlea’s frequency selectivity and bandpass filter function or properties (allen & fahey, 1993). such a possibility would be generally consistent with gaskill and brown (1990) and harris et al. (1989) who found that dpoae levels peaked at f2/f1 ratios of 1.22 and 1.25, respectively, with a decline with higher or lower f2/f1 ratios. stover, neely, and gorga (1999) suggested that these declines at higher f2/f1 ratios could result from greater separation of the primaries that lessen the interaction of their travelling waves on the basilar membrane, whereas the declines at lower f2/f1 ratios could result from less separation of the primaries and greater cancellation of their travelling waves on the basilar membrane. although some l1/l2 combinations and f2/f1 ratios clearly elicited larger dpoaes, no l1/l2 combinations and f2/f1 ratios clearly elicited more reliable dpoaes. this was consistent with previous reports that commonly used sets of stimulus parameters to elicit dpoaes of similarly varying reliability (stuart, passmore, culbertson, & jones, 2009; wagner, heppelmann, vonthein, & zenner, 2008) but inconsistent with reports finding higher l1/l2 combinations to elicit more reliable dpoaes (franklin, mccoy, martin, & lonsbury-martin, 1992; keppler et al., 2010; roede, harris, probst, & xu, 1993). it must be noted that dpoaes for f2 = 8003 hz in this study were most likely to be unreliable. this finding could indicate that any dpoae recorded at such high f2 frequencies is likely to be unreliable; however, such a conclusion should be interpreted with caution as varying the location of the probe microphone has been shown to affect the calibration of the sound source at these frequencies (siegel, 2002). conclusion the study concluded that further, targeted investigation of the 65/65 db spl, 65/55 db spl and 60/53 db spl intensity levels and the 1.18, 1.20, 1.22 f2/f1 ratios is warranted to determine the best stimulus parameters for eliciting the largest and most reliable dpoaes in adult humans. in addition, these stimulus parameters should be investigated in individuals with hearing loss of cochlear origin to select the parameters most sensitive to cochlear damage. acknowledgements this research was funded in part by the national research foundation thuthuka grant ttk14052267763. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions l.p. was the project leader, conducted the research, analysed the data and wrote the manuscript. w.j.w. assisted with conceptualising and writing the manuscript, as well as data analysis. h. k. assisted with conceptualising and writing the manuscript. references abdala, c. 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(2004). development of f2/f1 ratio functions in humans. the journal of the acoustical society of america, 115(5 pt 1), 2138–2147. https://doi.org/10.1121/1.1675819 wagner, w., heppelmann, g., vonthein, r., & zenner, h. p. (2008). test-retest repeatability of distortion product otoacoustic emissions. ear and hearing, 29(3), 378–391. https://doi.org/10.1097/aud.0b013e31816906e7 whitehead, m., mccoy, m., lonsbury-martin, b., & martin, g. (1995). dependence of distortion-product otoacoustic emissions on primary levels in normal and impaired ears. i. effects of decreasing l 2 below l 1. the journal of the acoustical society of america, 97(4), 2346–2358. https://doi.org/10.1121/1.411959 journal of the south african logopedic society november new aspects of voice physiology vocal fold vibrations without air-stream in a living human being by g. h. breckwoldt, ph. d. johannes mtiller (1801-1858) had shown the medical world that there were certain laws of voice-production which could be demonstrated in experiments with the larynges of corpses. in these experiments he showed that (1) the pitch of the tone thus artificially produced depended on the tension of the vocal folds. in other words, if the air-stream remained constant and the tension of the folds of the same larynx was increased, the pitch of the tone went up. he found that (2) with an increasing intensity of the air-stream the volume of the tone increased and the pitch went up. if, however, (3) the pitch of the tone was to remain constant but its volume to increase, the air-stream must be increased but the tension of the vocal folds must be decreased. mtjller regulated the tension of the folds with weights. the air pressure was produced by means of bellows (cf. h. gutzmann, "sprachheilkunde" berlin, 1924, p.14 seq.) ' scientists who held against muller's experiment the fact that he had gained his results from experiments with the heads of bodies and not with living individuals, were directed to experiments demonstrating subglottal pressure "in vivo" i.e. in patients who, after tracheotomy had to wear a cannula. these experiments were supposed to show, similar to muller's findings, that voice pitch depends upon the interaction of vocal fold tension and air-pressure, (cf. cagniard de la tour 1857). the general idea was that the breath-stream activated, i.e. vibrated the otherwise passive vocal folds. as early as 1898 ewald and after him nagel, in 1906-07, criticised the theory that the vocal cords vibrate through the air-stream only; they thought that the air-stream caused the muscles within the folds to vibrate on their own. (cf. g. panconcelli-calzia, "die stinmatnung" leipzig, 1956 p.64). calzia says that their criticism was justified, but that their explanation was wrong. before r. husson began his experiments in voice physiology there were no experiments in this field of any importance, (for the following: cf. r. husson: "physiology of the vibrations of the vocal folds," logopaedie en phoniatrie, rotterdam, october 1956, and husson's numerous publications). up to husson's researches we find the conventional idea that the larynx can be compared with various musical instruments, such as a horn, a cushion-whistle or organ-pipe, etc. f i g . l . c u s h i o n w h i s t l e by w e t h l o . <g. p a n c o n c e l l i c a l z i a : d i e e x p e b i m e n t e l l e p h o n e t i k , berlin 1924, p.39). in order to put an end to this state of affairs, since 1950 experimental investigations have been undertaken by the "laboratoire de physiologie" of the sorbonne in co-operation with the directors of a great number of paris hospitals. the action potentials of the n. recurrens in phonation the action potentials of the n. recurrens, which should determine the voice production have been obtained by experiments "in vivo" (in cases which had to undergo laryngectomy) in the hopital boulincourt, paris, by andre moulonguet (1953). after a year's work, in 1956, moulonguet was successful in making photographs and sound recordings. these recordings show that a congruity exists between the rhythm of the action potentials of the n. recurrens and the rhythm of the contractions of the motor units in the musculus vocalis. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society electromyography of the vocal folds electromyography of the vocal folds was also performed on human beings "in vivo." the subjects had undergone either an extirpation of the root of the tongue or a hemilaryngectomy. the vocal folds λνβγβ visible and directly approachable at several points. in june and december, 1954, electromyographs were made without voice. herefrom one can conclude: 1. that the vocal folds are the seat of a strong electrical activity, which is minimal during inspiration and maximal in expiration. 2. that the contraction periods of a motor unit of the vocal folds are extremely short, from 0.0008"—0.0009". this is the quickest movement that has been found up to date in the musculature of man. in may, 1955, an exceptionally important finding was made. a patient managed with only his larynx — there was no connection with the bucco-pharyngeal cavity — to produce small scales of 6-7 tones. one could then make a myograph during the voice utterance, and film and sound-recordings were made. it appeared that . . . 1. during the utterance the motor unit of the vocal folds synchronised itself with the fundamental f i g . 2. recording of the action potentials of the recurrent nerve in a human being and " i n v i v o . " final stage in m o u l o n g u e t ' s experiment (paris, 1953). the electrodes are placed on the recurrent nerve of the locally anaesthetised patient, and the microphone is put in front of the patient's mouth. the surgeon closes the opening of the tracheal cannula with his finger and asks the patient to utter any one sound and hold it for some time. (a. m o u l o n g u e t , p. l a g e t , r. h u s s o n : . "demonstration chez l'homme, de l'existence . . . . " . bulletin de l'acad6mie nationale de medicine, p.475). tone, i.e. with the frequency of the impulses imparted on the folds by the n. recurrens. 2. every crest in the electromyograph is formed by the simultaneous contraction of the group of motor units that are nearest to the electrode. precautions were taken so that no microphonic distortion was possible. direct stimulation of the n. recurrens direct electrical stimulation of the n. recurrens was first performed on a dog, in 1951-1952, under general anaesthetic. experiments were carried out in the physiological laboratories of the sorbonne by paul laget. the stimulation took place with frequencies varying from 100-700hz. no air passed through the glottis. observation with the stroboscope showed that . . . 1. between 100-500 hz the vocal folds vibrated with slight amplitude but with the same frequency as the stimulation. the vibration is maximal between 150 and 200 hz: from 300 hz onwards it is very small, but it increases with the intensity of the stimulation. 2. about 500 hz the vibration only appears at minimal stimulation. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 2 journal of the south african logopedic society november on another occasion the n. recurrens was stimulated with frequencies of 100-700 hz. the electrical activity of the vocal folds was homorhythmical in every instant. vocal fold vibrations without air-stream in a living human being until february, 1956, the experiments by laget on dogs, which were described just now, were the only ones in which vocal fold vibrations were experimentally created in which there was no occurrence of air stream through the glottis. this effect was achieved by motor recurrens impulses which went out to the larynx muscles. on the 1st february, 1956, jean piquet, g. delacroix and c. libersa, succeeded in filming vocal cord vibrations of a living human being, through whose glottis there passed no air-stream. the n. recurrens was not electrically stimulated, but it was the patient himself who produced the vibrations. in the following i am giving a brief report of this experiment as it is recorded in the publication of the academie des sciences of paris, dated 27th february, 1956. whenever possible, experimental control is used on a human being during an operation. this idea, which leriche had, we have applied in order to examine the role of the subglottal pressure in the creating of vocal fold vibrations in the case of a horizontal supraglottal laryngectomy. thanks to this method, one gets an excellent view of the glottis through the pharyngeal opening. one vocal fold is completely mobile, the other is fixed in a paramedian position. one lets the patient utter a sound (vowel [a:]) ; one studies frequency and intensity, one films the event with an ultra-rapid camera in colour. later on one opens the trachea and introduces a small probe through the opening. this probe is fitted with a tiny rubber balloon which prevents air escape and is joined to a water-manometer. one lets the patient produce the vowel ia:l, while one measures frequency and intensity. one records the pressure as given by the manometer, and the sound is recorded by means of a magnetophone. this has been done on various occasions. the vibrations of the vocal folds have been recorded on a film with a rapid camera. one can then state the following facts: 1. the intensity of a sound stands in direct relationship to the subglottal pressure. 2. the subglottal pressure for a rather loud sound is comparatively small. for a sound of 70 phon pressure is 24 cm. water. for a sound of 77 phon pressure is 30 cm. water. it does not satisfy us any more to say that the vocal folds function like a "reed instrument." we can determine that during a sustained tone no change in subglottal pressure takes place. the reclosure of the vocal folds is a muscular effect and not the result of sub-atmospheric pressure. at another experiment the larynx was instrumentally completely closed off from the tracheal pulmonary system. the patient was also asked to utter [a;] and the following was found: 1. a normal adduction movement of the vocal folds. 2. one vibration lasted a fraction of a second, but no tone was observed except a short rattle. films were made of this as well. the vibrations were recorded and corresponded precisely to the previous recording. we can thus prove that the vocal folds can vibrate without air-stream during a certain length of time (our recording was limited to one second). we can also state the following: 1. a vocal fold, immovably fixed in paramedian position, can vibrate. 2. the vibrations of the vocal folds are not immediately maximal but are increasing in amplitude (the latter phenomenon being known under the name of "kaiser effect"). the above experiments were conducted in order to show that the subglottal pressure is not necessary to ensure vibration of the vocal folds, but that the subglottal pressure plays a decisive role for the intensity of a sound and not at all for the pitch. in a sequel to this article i will discuss . . . 1. the chronaxy measurement of the n. recurrens and its applications. 2. a new method to classify singing voices. 3. a correlation between hand dominance and disturbances in recurrent chronaxy in cases of phonasthenia. 4. i will give a critical discussion of the old and new ideas about voice physiology. 5. there will be a bibliography. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) studies on child grammar jeanette bloom, b . a . l o g . (rand) the general hypothesis on which work in the field is based, is that child speech is a systematic reduction of adult speech, largely accomplished by omitting 'function' words that carry little information. from this corpus of reduced sentences, the child induces general rules which govern the construction of new utterances. as a child becomes capable, through maturation and the consolidation of frequently occurring sequences, of registering more of the detail of adult speech, his original rules will -be revised and supplemented. as the generative grammar grows more complicated and more like adult grammar, the child's speech will become capable of expressing a greater variety of meanings. brown and bellugi2 suggested that the model sentence is processed by the child as a total construction rather than as a list of words. in their study, the child's imitations preserved the word order of the model sentences. there is a constraint, a limitation on the length of utterance the child is able to program or plan. constraint on length compels the imitating child to omit some words or morphemes from the model sentences. differential stress was felt to be a possible cause of the child's differential retention. brown and fraser4 list the morphemes likely to be retained in the child's speech. ervin9 having studied children's imitations systematically to see if they are grammatically different from free utterances, concluded that, we cannot look to overt imitation as a source for the rapid progress children make in grammatical skill in thess early years. certain utterances in a child's language are bound to be imitations of adult sentences. however all children are able to understand and construct sentences they have never heard. these sentences are well-formed in terms of general rules implicit in the sentences the child has heard. the child processes the speech to which he is exposed. he induces the latent structure. braine,1 brown and bellugi,2 brown and fraser4 and miller and ervin14 have been concerned with devising a set of rules which would, account for the material presented in their studies, as well as to predict -new sentences —a generative grammar. braine's study will be mentioned here, since on his findings is based the model of analysis used in the present study. by examining the word combinations and privileges of occurrence in his samples, he derives two main word classes. these he labels 'pivots' and 'x-words'. pivots are few in number, occur in several word combinations and each is associated with a particular position, either initial or final. x-words form a large, open class, containing all the rest of the child's vocabulary. the child's singlejournal of the south african logopedic society, vol. , no. : december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) studies on child grammar 37 word utterances are drawn from the x-class. the class of pivot words px is broken down into pi (initial position) and p2 (those which occur in final position). thus on the basis of privileges of occurrence, it is possible to construct a set of parts of speech and also a syntax which governs the ordering of these parts of speech. syntactic rules which summarize most of the speech here are: utterance = p i + x or x + p2. glass pi and class χ can occur together, and class px always precedes class x. class p2 and χ can occur together, and p2 always follows x. this is a simple generative grammar. brown and fraser4 used this approach to develop a developmental syntax. laura lee,10 also used this as a basis for her model of analysis (table 1), while paula menyuk11-13 studied children's use of transformations. in the present study, the development of syntax from the 'pivot-open class' construction to the formation of kernel sentences at the phrase structure level of grammar, is considered. a comparison of the syntactic structures of a normal and an articulation-defective three-year-old this' study is concerned with the child's acquisition of syntax. it is not concerned with the cognitive aspects of language, with conceptualization, or with receptive-expressive phenomena. it deals entirely with the speech output of the child; and with its systematization of that output into hypothetical stages, from the appearance of single-word utterances, to the formation of adult, grammatically acceptable sentences. before describing the development of a child's grammar, it is necessary to specify the properties of natural languages as used by adults, since this is the model presented to the child and the eventual outcome of his development. from a structural point of view, every natural language is constructed from a small number of distinctive elements, namely vowels and consonants, levels of pitch, pauses and stresses. these make up the phonemes of a language.3 all natural languages have a finite number of phonemes and each sentence can be represented as a finite sequence of these phonemes, though there are infinite sentences.7 every natural language is a system. from knowledge of one part of the language, it is possible to anticipate correctly many other parts. the system of language may be divided into sub-systems. descriptions of language are achieved by dealing with each sub-system as a separate level of representation. 1. phonological level. on this level, the phonemes of a language and the permitted patterns of the combinations of phonemes are enumerated. one language never includes all the conceivable patterns of combinations. in english, for example, one may not combine phonemes / rj / and / k / to produce / 13k / at the beginning of a syllable, while at the end of a syllable this is permitted. the phonological system may be described in tydskrif van die siiid-afrikaans e logopediese vereniging, vol. 15, nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 j. bloom •xs k έ 1 μ st er eo ty pe d ph ra se : d o n 't c ry i du n n o st er eo ty pe d co ns tr . g o ro un d an d ro un d l is te n t o ti ck t oc k re ac h th e to p 2 w or d f ra gm en ts ph ra se s tr uc tu re 2w or d l oc at or : up t he re pr ep , ph ra se : to o ffi ce tr an sf or m at io n: n eg at iv e: n ot ca r c on ju nc ti on : an d ca r (p hr as e st ru ct ur e fr ag m en ts in co rp or at ed in to co ns tr uc ti on .) 2w or d v er ba l ve rb + n ou n: se e ca r pu sh i t ve rb + p ar ti cl e: go u p fa ll d ow n n ou n + v er b: i se e m om m y d o ve rb p hr as e co ns tr . v + ( pa rt ) + ( n p pp lo c a dv .) pu t aw ay t he c ar ri de i n a c ar pu t ca r u p th er e ta ke c ar a ga in 2w or d p re di ca ti ve a d je ct iv e: ca r br ok en li gh t of f lo ca to r: ca r th er e, ca r he re pr ed . c on st r. n .p . + ( ad j. pp lo ca to r n .p .) th at c ar i n g ar ag e th e ca r br ok en th e ca r th er e d av id a g oo d b o y 2w or d d es ig na ti ve lo ca to r: th er e ca r, h er e ca r d em on st ra to r: th is c ar , th at c ar id en ti fi er : it c ar it sa c ar ' sa c ar 's c ar d es ig na ti ve c on st r. (l oc at or de m on st ra to r id en ti fi er ) + n .p . t h er e th e b ig c ar th at m y c ar it a c ar it sa b ig c ar 2w or d n .p . a rt ic le : a ca r, t he c ar po ss es si ve : d ad d y ca r, m y c ar q ua nt if ie r: m or e ca r, t w o ca r a dj ec ti ve : b ig c ar , di rt y ca r (a rt ic le p os si bl e) + ( qu an t. ) + (a dj .) + ν m y bi g ca r no m or e ca r th e ot he r b ig c ar (n .p . in co rp or at ed in to co ns tr uc ti on (c on st r. )) \ \ le ve l i. 2w or d c om bi na ti on s le ve l ii . n ou n p hr as e le ve l ii i. c on st ru ct io ns journal o the south african logopedic society, vol. , no. : december 196 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) studies on child grammar 39 b > h ω υ ζ ω h· ζ ίβ ο ζ < ι-ι η < η 2w or d (s te re ot yp ed co ns tr . in co rp or at ed in to s en te nc es ) (t ra n sf or m at io n fr ag m en ts in co rp or at ed in to t ra n sfo rm at io ns ) 2w or d f ra gm en ts 2w or d v er ba l | a ct or -a ct io n se nt en ce n .p . + v .p . i se e a c ar m e ri de i n c ar m o m m y p u t c ar th er e m e ta ke c ar ag ai n d o + n eg at iv e i d on 't s ee t he ca r in fi ni ti va l co m pl em en t i w an na t ak e a ca r 2w or d p re di ca ti ve pr ed . se nt en ce n .p . + ( is ) + ( ad j. p. p. lo ca to r n .p .) th e ca r is b ro ke n t h at c ar 's i n ga ra ge m y ca r' s th er e d av id i s a go od b oy n eg at iv e th e ca r is n ot br ok en co nj un ct io n th e ca r an d th e tr uc k ar e br ok en 2w or d d es ig na ti ve d es . s en te nc e (l oc at or d em on st + ( is ) + n .p . ra to r id en ti fi er ) t h er e' s th e ca r th is i s a b ig c ar it i s a c ar it sa b ig c ar in te rr og at iv e is t ha t a c ar "u h " qu es ti on w he re i s th e ca r 2w or d n .p . le ve l iv . k er n el se nt en ce s (s im p le a ct iv ed ec la ra ti ve ) su cc es si ve le ve ls . e m er gi n g t ra n sf or m at io n tydskrif van die sid-afrikaanse logopediese vereniging, vol. 5, nr. : des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4° j. bloom terms of the different privileges of occurrences of features or sets of features called phonemes.14 2. morphological level. on this level, the morphemes of a language and their rules for combination are enumerated. morphemes are the smallest individually meaningful elements in the utterances of a language. allomorphs, the sound representations of morphemes, obey certain rules of distribution, i.e. they are phonologically conditioned. one allomorph occurs in a particular phonetic environment in which the others do not. 3. syntactic level. on this level, the construction of sentences by the combination of words into various permitted patterns is described. on all three levels, the patterning of elements into certain permitted combinations, i.e. the patterned structure of language, is evident. the present study is concerned with how a child acquires the patterns of english. how does the child's grammar converge on the norm of the community in which he lives? operant conditioning and reinforcement by the responses of others, together with adult correction of errors, is one source of change. however this does not take account of the fact that a child may say things no-one has taught him.9 similarly, it is unlikely that a child masters a language on the basis of imitation alone. the presence of grammatical errors yields evidence that the child makes sentences he is not likely to have heard.4 an understanding of how the child acquires language brings us into the field of generative grammar. generative grammar. the generative grammar model, as described by chomsky® considers grammar as having a tripartite structure: (a) a phrase-structure level. (b) a transformation level. (c) a morphological level. each of these three levels has a sequence of rules which generate the form of sentences within the level. at the phrase-structure level, the parts of speech combine to form simple-active-declarative sentences of the type, ί play'. these are called terminal strings or kernel sentences and form the basis for all other sentences. at the transformation level, rules will change the order of the symbols in the kernel sentence, or will allow symbols to be deleted or added. thus, from the kernel sentences of english, one could generate the sentence, ί play.' transformational rules would then operate to turn/this into the negative ί do not play' or interrogative 'why do i play?'/ at the morphological level of grammar, there is a sequence of inflectional rules which formulate, for example, the third person, present tense, singular of the verb. the present study is concerned with the development of sentences from the level of single-word utterances to the, formation of kernel sentences at the phrase-structure level of grammar. the speech output of both a normal and an articulation-defective child are analyzed in this way. journal of the south african logopedic society, vol. 15, no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) studies on child grammar methodology of the present study 1. rationale. from a structural point of view, language is described by linguists in terms of three inter-related systems: phonological, morphological and syntactic. inadequate learning of the phonological system, resulting in the disorder to which speech pathologists refer as 'general, dyslalia' would suggest a corresponding inadequacy of either or both of the two remaining systems. considering it from a generative grammar point of view, language is regarded by noam chomsky6 as a set of sentences constructed out of a finite set of elements or phonemes. from this statement, arises the suggestion that a defect involving the elements or phonemes of a language, would affect sentence construction. clinical observation of children who appear to have delayed speech, frequently reveals the presence of numerous articulation errors in conjunction with immature sentence construction, implying a possible relationship between articulation and syntactic abilities. these suggestions invite exploration of such a relationship in an experimental fashion, the information so derived being of value to a speech pathologist concerned with the improvement of a child's linguistic skills. the writer has therefore attempted an investigation of the syntactic structures of a previously diagnosed 'general-dyslalic' child, in relation to that of a child whose speech is characterized by absence of articulation errors. the study is carried out with the hypothesis that the general-dyslalic child will have syntactic structures which deviate from those of the normal child, as revealed by the model of analysis used. the writer has adopted a generative grammar model of analysis, viz: developmental sentence types as devised by laura lee.10 this type of analysis was chosen in preference to those of traditional grammar and the mccarthy-templin-davis approach, because the former approach was considered to be based on an unscientific systematization of language; the latter to be more useful when dealing with normative data or quantitative results, rather than qualitative information required for therapy. the chosen approach was expected to give valuable quantitative information regarding phase and type of syntactic deviation; and served to utilize the field of psycholinguistics in the investigation of a problem pertaining to speech therapy. hypothesis. the general-dyslalic child under investigation will have syntactic structures which differ from those of a normal child of the same age, sex, socio-economic status and intelligence. p r o c e d u r e subjects. two female subjects each aged three years were used. gillian, the general-dyslalic child, was three years five months at the time of investigation. debbie, the normal child, was three years three months. gillian was selected because her speech included numerous articulation errors which could not be attributed to any organic cause. she showed no tydskrif vn die sid-afrikaanse logopediese vereniging, vol. 15, nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 j. bloom evidence of brain injury, mental retardation, hearing defect or emotional disturbance. her articulation errors included: tl/g d3/d si s φ tl/d g/d j/sw t/s tl/t d/z j/sm k/p tr/e dfo ι/θ t/k i/ts omissions: j\j initially and medially, /h/ initially and medially, /n/ initially, /m/ initially, /s/ initially and finally, /r/ initially, medially and finally, /s/ initially, /g/ initially, /d/ medially and finally. distortions: vowels were distorted so that i a/ approximated /λ/ /a/ approximated /ae/ general trends appear to be a substitution of [tf] and [j] for stops and fricatives, omission of initial consonants and distortion of vowels. errors were very inconsistent however, and a sound which frequently substituted for another, might be omitted on some occasions. words were telescoped e.g. 'cigarette' was pronounced 'iaette' in the sample. furthermore, the child was receiving therapy at the time the sample was taken, and had recently started to show ability to make sounds correctly, upon stimulation. the child had only recently begun to talk, but was using sentences at the time of investigation. she attended the university of the witwatersrand speech, voice and hearing clinic. her case history revealed that her parents came from an upper middle-class income group, as indicated by residential address and paternal occupation. she was judged by her therapist to be of normal intelligence, although this was not formally tested. she was the. youngest child and was exposed to english only, at home. debbie was selected from the nursery school attached to the nursery school teachers' training college, in johannesburg. she was a member of the junior class, the three to five year age group. she was chosen among all others in the group because her background most closely resembled that of gillian. she was the eldest child of a monolingual family. she was exposed to english only at home. she came from a neighbourhood very near to that of gillian, being of the upper middleclass income group. she had been attending nursery school for three months and was judged by her" teacher to be of normal intelligence although this was not formally tested. journal of the south african logopedic society, vol. 15, no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) studies on child grammar 43 debbie appeared to have no history of delayed speech, as indicated by the nursery school records, and her speech was characterized by absence of all articulation errors at the time the sample was taken. 2. materials. stimulus material consisted of a set of pictures obtained from a child's story book: gagg, μ. e. 'the party' a ladybird learning to read book series 563, wills and hepworth ltd., loughborough, england, i960. a set of ten brightly coloured, realistic pictures, each 4" χ η" was removed from the book and pasted on to a large cardboard, in sequence, so that the subject could follow the story told by the investigator. 3. method. subjects were tested individually, in familiar surroundings. gillian was tested during her therapy session, in the presence of her therapist. both therapist and investigator participated in eliciting the responses. the testing situation was not unlike the child's usual therapy sessions. debbie was tested at nursery school with a few friends present. she was tested in a familiar room during the play hour when it is quite usual for a group of children to gather round one of the student teachers, to look at pictures and talk. the investigator spent ten minutes playing with the children before the sample of utterances was tape-recorded. this gave the subject the opportunity of overcoming shyness, which would have influenced the sample. the investigator then offered to tell a story about the pictures to each child. the story was told to each in exactly the same way using the same wording. the sentences of the story were constructed so as to represent all types of constructions used in the model of analysis. sentences were above the level of the simple, declarative type the level iv kernel sentences represented in the model. many transformations were introduced to make the stimulus more like that of adult speech to which the child is normally exposed. language was kept simple, and the vocabulary limited to the type most children have experienced by three years of age. the story pertained to a birthday party, selected because this subject-matter is within the range of most children's experience. the investigator told the story in an interesting voice, tracing the development of the story with her finger, on the pictures, pointing out each item with her finger in order to maintain interest and make sure the child understood her. the child was then asked to tell the investigator the story. this required a little prompting and encouragement, in the case of both children. the picture-story was introduced as a control in the experiment, so that the stimulus conditions would be the same for each child and responses would differ only in the syntactic structures used, vocabulary and language content remaining constant. the presence of the pictures was designed to eliminate the variable of memory. the samples of utterances (corpora) so obtained, were tape-recorded, then written out in traditional orthography and analyzed. a corpus of fifty utterances was derived for each child, because the tydskrif van die sid-afrikaanse logopediese vereniging, vol. 15, nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 j. bloom literature8 suggests that this number of utterances is satisfactory for obtaining a reliable measure of language structural complexity. this was discovered however to be a grave methodological flaw regarding the nature of analysis used in this study. the number of sentences is insufficient to reflect a child's linguistic competence. chomsky5 points out the inadequacy of attempting to derive a child's grammar on the basis of a corpus of utterances however large. one cannot say that the child lacks a particular construction, because he has not used it in the corpus especially when the corpus consists of only fifty utterances. a comparison therefore, was made between the syntactic structures used by the two children in this particular situation and no inferences regarding linguistic competence were made. 4. analysis. the model of analysis used was that developed by laura lee10 termed developmental sentence types. a reproduction of the table of this model appears in table 1. an explanation of the table is included here, since this is the analysis used by the writer, in an unmodified version. the child has been speaking up to this stage, in single word utterances. at level 1 he now combines two words into a pivot-open class construction, as discussed above. the two-word combinations are classified according to the type of pivot used. where the pivot is an article, possessive pronoun, quantifier or adjective, it combines with a noun to form a twoword noun phrase. where the pivot is a locator 'here', 'there', demonstrator 'this', 'that' or identifier 'it', 'it's a' its combination with a noun is termed a 2-word designative construction. designators are words which accompany or replace a gesture. where the pivot describes the item of attention, therefore predicating information about it, its combination with a noun becomes a two-word predicative construction. where a two-word combination consists of a noun and a verb, a verb and a noun or a verb and a particle, the construction so formed is termed a two-word verbal. the child may say two-word utterances which are more imitative of adult grammar, some of which are the forerunners of transformations and some of which will be incorporated at the phrase-structure level. these are 'fragments', they do not themselves expand into sentences, but must be incorporated into other constructions, e.g.: 'up there', 'to office'. there are two-word'combinations which are mere imitations of adult stereotyped phrases, e.g.: 'be careful'. this varies from one child to another depending on the adult speech to which he is exposed. they are termed stereotyped phrases. level i: here we observe the emergence of miniature adult syntactic forms. subsequent levels of developmental sentence types demonstrate the expansions and rearrangements of these basic two-word combinations. level ii—the noun phrase: here, certain pivot words become differentiated by privilege of occurrence into articles, possessive nouns and pronouns, numbers or adjectives. two or more former pivots may be used, each with its special location in the string. conventional sequences and combinations are learned very gradually. once developed, the entire noun phrase may be moved from one position to another in a longer string, or may be lifted out entirely and replaced by a pronoun. journal of the south african logopedic society, vol. 15, no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) studies on child grammar 45 level iii—constructions: designative constructions. a locator, identifier or demonstrator is added to a noun phrase. thus at level i, the twoword designative construction 'there car', becomes expanded at level iii to 'there the big car'. addition of an adjective, prepositional phrase, locator after the noun phrase or second noun phrase, to a noun phrase, makes a predicative construction. a predicative construction names the item of attention and then 'predicates' something further about it. this additional information may take many forms: adjective, locator etc. this must not be confused with the designative construction where the noun phrase comes last in the string. addition of a noun phrase, prepositional phrase, locator and adverb, together with an optional particle, to a verb, forms a verb phrase construction. the verb phrase may be further extended by combining more of these components, e.g.: 'put on the hat again' (verb + particle+ noun phrase + adverb). stereotyped constructions are included to account for a few often-repeated phrases which children pick up without understanding the component words as individual semantic units. level iv—sentences: designative sentences are formed by the addition of 'is' between the designative word (locator, demonstrator, identifier) and the noun phrase. similarly a predicative sentence is formed by adding 'is' between a noun phrase and an adjective, prepositional phrase, locator or second noun phrase. actor-action sentences are formed by adding a verb phrase to a noun phrase. this is the development of two-word combinations into kernel sentences of the simple, active, declarative type—sentences at the phrase-structure level. this model was chosen because it was expected to yield differences in terms of level of development between the syntactic structures used by the two children. it was expected that a knowledge of the type of construction as well as of the level of development of that construction, on which the child 'fell down' would be of value in constructing a therapy program. results and discussions the analyses of the two corpora will not be presented in this article, but rather a brief comparison of the two corpora will be given. for a more detailed account the reader is referred to the original thesis a comparison of the syntactic structures of a normal and an articulation defective three year old. j. bloom (1967). single word utterances. although the bulk of these were not included in the sample, because of their mode of elicitation and because they would weigh the sample heavily, they were listed and considered for comparison purposes. gillian answered many questions with single-word replies, where more complete responses were possible. debbie used far less one-word sentences. of the single-word utterances included in the samples, both children used the same number and kind. level 1: two-word combinations. both children used the same number of two-word noun-phrases. gillian used no articles in her corpus tydskrif van die sid-afrikaanse logopediese vereniging, vol. 15, nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 j. bloom while debbie used both 'the' and 'a' correcdy. gillian used many twoword verbals. this construction was quite evident in her corpus, but often atypical e.g. 'is walking' meaning 'susan is walking'. according to brown and bellugi2 it is the stressed morphemes which should be reproduced rather than the unstressed ones. both children showed lack of designative constructions, and both showed emerging transformations at this level. lee10 feels that these constructions are too inconsistent and immature to be called transformations at this stage. level π: noun phrases. debbie used no noun phrases. she appeared to have passed beyond this level, for she incorporated noun phrases into her sentences. gillian used noun phrases, and showed another type of atypical construction, i.e. reversed word order, e.g. 'cake happy birthday' in imitation of 'happy birthday cake'. level πι: constructions. gillian, who did not have the designative construction at level i, still showed no examples of this construction at level iii. for gillian, designators had not yet appeared in her vocabulary, therefore could not be incorporated into constructions; debbie used no designative constructions either, but might be said to have passed beyond this level, since designators appear in sentences at level iv. verb phrase constructions appeared to be the most popular for both children. this would follow from the fact that two-word verbals were the most evident at level i. this is in keeping with a developmental theory. level iv: sentences. debbie used a large number of sentences in her speech. the bulk of her corpus was at this level. she also used a variety of transformations and many items appeared to be beyond the phrase-structure level, as compared with the transformational sentences listed by menyuk. gillian used a number of level iv sentences, though not as many as debbie, and these were not syntactically correct. 'is to party' is an unusual construction in that the verb 'to be' and the preposition is included, while the usually stressed forms, 'john (susan)' and 'going' are omitted; the model sentence being john and susan are going to a party.' similarly 'has a work it' which appears to have meant, 'he's working'. from the two corpora examined, limited as they are, certain trends are apparent. (a) the technique was expected to show up developmental trends. where two-word verbals were used at level i, actor-action sentences were predominant at level iv. where designators were few or nonexistent at an earlier stage, they did not appear at successive stages. other structures appear to have developed ahead of designative and predicative constructions. (b) though the children used roughly the same proportion of various constructions to the whole corpus, they differed in the kind of structures used. this was fairly marked and may not have been revealed using, the mccarthy approach. journal, of the south african logopedic society, vol. 15, no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) studies on child grammar 47 (c) while a morphological analysis of the corpora was not done. gillian showed the same irregularity in her morphemic constructions, e.g. attaching the verbal suffix to the noun rather than the verb: 'mommys feed him'. (d) one cannot say, on the basis of the sample obtained, that debbie, for instance, has no predicative constructions in her grammar. to arrive at such a conclusion, one would have to ask her to repeat certain sentences involving predicative constructions, or answer questions in such a way that predicators must emerge in the responses. one can say, however, that she has not used any in the corpus, and that she does not appear to have developed this type of construction. only by testing for the presence or absence of constructions by using nonsense syllables for instance, can a statement regarding the linguistic competence of the subject be made. the writer has not arrived at a grammar for gillian or debbie, but has demonstrated that on comparison of their syntactic structures, the generaldyslalic child differed qualitatively from the normal three-year-old. conclusion every therapist is familiar with the disorder known as general dyslalia. she is familiar with techniques for analysis of articulation errors, and has at her disposal literature on therapeutic techniques for the teaching of phonemic contrasts the child has failed to make. but what of sentence construction? is she familiar with techniques for analysis of sentences? is there literature available on the methodic, systematic building-up of sentences in children who have failed to do so spontaneously? would she recognize that the child has syntactic deviations in the first place? how would she know that they were deviant? with what would she compare them? in fact, has she knowledge of the normal development of syntax? such a knowledge becomes necessary when dealing with languagedefective cases. if we are to be experts on communication and its disorders, we must know exactly how we come to use the sentences we do; for this, after all, is the way in which we communicate. we give 'general language stimulation' at the one-word level, to our speech-delayed children. we build up a basic vocabulary of nouns and verbs. we may take them through to the two-word stage, by using twoword sentences ourselves, probably unwittingly exploiting the principles of generative grammar. but what of the child who is beyond the two word-level, whose language may be by no means adequate? what of the dysaudic and aphasic? if, in the latter case, we are to build up those constructions which have broken down because of a disturbance of the linguistic processes owing to brain injury, we must have knowledge of the type of syntactic deviations revealed and how these can be systematically and methodically built up. in the case of the dysaudic, it is essential to be systematic in the type of syntax one presents to the patient, since he must imitate and induce a latent structure from sentences presented to him tydskrif van die sid-afrikaanse logopediese vereniging, vol. , nr. : des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 j bloom under reduced auditory cues. he must be taken systematically through the stages of the normal development of syntax. for these reasons, the therapist must have knowledge of the normal development of syntax. models such as the one described above, are of great value, but these have not yet been validated. she looks to the field of psycholinguistics, to provide her with the information she needs, for the future. summary a corpus of utterances was derived from a normal and an articulationdefective three-year-old female child, and was analyzed syntactically using a model of analysis based on a generative grammar approach. the speech output of the articulation-defective child was found to be qualitatively different from that of the normal child. while the small number of subjects, and the size of samples used invalidate the study, the approach was found to yield valuable information regarding the diagnosis and treatment of language-defective cases. opsomming spraakvoorbeelde is verkry van twee drie-jarige dogters; een normaalsprekend en die ander met artikulasieafwykings. die voorbeelde is sintakties geanaliseer deur gebruik te maak van 'n analise—skaal gebasseer op 'n generatief—grammatiese benadering. daar is gevind dat die spraakproduksie van die kind met artikulasieafwykings kwalitatief verskil van die van die normaalsprekende kind. as gevolg van die feit dat net twee proef-persone gebruik is en die grootte van die spraakmonsters nie verteenwoordigend was nie, is die ondersoek nie geldig nie. nogtans is waardevolle inligting aangaande die diagnose en behandeling van taalafwykende gevalle verkry. r e f e r e n c e s 1. braine, m. d. s. (1963): the ontogeny of english phrase structure. language, 39, 1-13. 2. brown, r. and bellugi, u. (1964): three processes in the child's acquisition of syntax. harvard educational review. 34, 133-151. 3. brown, r. and berko, j.: psycholinguistic research methods,'' in handbook of research methods in child development. chapter 13 ,(ed.). mussen, p. 4. brown, r. and fraser, c. (1964): the acquisition of syntax. monagraphs of the society for research in child development, 29, 1, 43-79· 5. chomsky, n. (1964): formal discussion. monographs of the society for research in child development, 29, 1, 35-39. 6. chomsky, n. (1957): syntactic structures. mouton, the hague. 7. chomsky, n. the independence of, grammar in psycholinguistics: a 'book of readings, (ed.) saporta. 8. darley, f. l. and moll, k. l. (i960): reliability of language measures and size of language sample. j. speech1 hearing research, 3, 166-173. 9. ervin, s. m.: imitation and structural change in children's language in new directions in the study of language, (ed.). lenneberg, f. h. journal of the south african logopedic society, vol. , no. 1: december 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) studies on child grammar 49 10. lee, laura (1966): developmental sentence types: a method for comparing normal and deviant syntactic development. j. speech hearing disorders, 31, 4, 311-331. 11. menyuk, p. (1963): syntactic structures in the language of children. journal of child development, 34, 407-422. 12. menyuk, p. (1964): syntactic rules used by children from pre-school. through first grade. child development, 35, 533-546. 13. menyuk, p. (1964): comparison of grammar of children with functionally deviant and normal speech. j. speech hearing research, 7, 109-121. 14. miller, w. and ervin, s. (1964): the development of grammar in child\ language. monographs for the society for research in child development, 29, 1, 9-34tydskrif van die sid-afrikaanse logopediese vereniging, vol. 15, nr. 1: des. 1968 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) e d i t o r i a l the delay in publication of the 1964 issue of the journal of the south african logopedic society has been unavoidable, but we sincerely hope that our readers will reap the benefits in the future from-the re-organisation that has taken place. in this issue we have presented five articles on topics that are of interest and importance to all workers in speech therapy and related fields. all but one contribution to this journal are from south africa, the exception being an informative article on tonal responses of mentally retarded brain injured children by betty hunt bradley of the columbus state school in ohio. most therapists are now aware of the value of the bobath technique in the handling of cerebral palsied children: dr. w.m. guldenpfennig has written an interestingpaper on this subject. inhis article on factors causing severe deafness in childhood dr. w. hatchuel has analysed the records at st. vincent school tor the deaf in'johannesburg and contributed both an interesting and informative paper. a survey on speech therapy in the coloured schools is a valuable contribution by dorothy cornelius. we obtain some appreciation of the problems in coloured schools. from cape town diana whiting presentsher findings in treating a total glossectomy thus adding to our limited knowledge about cases of this nature. in presenting these detailed discussions we hope that the wide variety of subjects covered by our contributors will provide something of interest to every reader. 3 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) r e d a k s i o n e e l weens onvermydelike omstandighede is die 1964 uitgawe van die tydskrif van die s.a. spraakheelkundige vereniging vertraag, maar ons hoop dat ons lesers in die toekoms die vrugte sal pluk van die reorganisasie wat plaasgevind in hierdie uitgawe plaas ons 5 artikels oor onderwerpe wat op die gebied van die spraakheelkunde en verwante gebiede van belang is. alle bydraes, behalwe een, is uit suid-afrika afkomstig. die artikel oor "tonal responses of mentally retarded brain injured children" is geskryf deur betty hunt bradley van die columbus state school in ohio. die meeste terapeute is reeds bewus van die waarde van die bobath-tegniek die hantering van serebraalverlamde kinders: dr. w.m. guldenpfennig het 'n interessante bydrae op die gebied gelewer. in die artikel oor faktore wat emstige doofheid by kinders veroorsaak het, het dr. w. hatchuel verslae van die st. vincent's skool vir dowes in johannesburg ontleed en sodoende 'n interessante en leersame bydrae gemaak. 'n opname van spraakterapie in kleurlingskole is 'n waardevolle bydrae deur dorothy cornelius. hieruit kry ons insig in die bestaande probleme, veral vir die spraakterapeut in die kleurlinggemeenskap en -skole. uit kaapstad het diana whiting bevindings in verband met die behandeling van 'n totale glossektomie, wat bydrae tot ons beperkte kennis op hierdie gebied. deur die aanbieding van hierdie volledige besprekings hoop ons dat die groot verskeidenheid van onderwerpe wat deur die medewerkers aangebied word in die smaak van al ons lesers sal val. 4 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) general and differential therapy in the field of logopedics and phoniatries f. trojan* & h. w e i h s * speech and voice disturbances, however manifold they may be, concern man's natural disposition as a whole. this is anatomically and physiologically homogeneous but varies genotypically according to race and biological constitution or phenotypically due to environmental influences particularly those of speech and culture. through the common factor a general therapy can be developed for all speech and voice defects, in which emphasis may be given to various parts according to the specific problem. on the other hand a differentiated therapy may be compiled on the basis of constitutional and environmental influences as well as pathological variations from the norm. actually both treatments combine to form an inseparable whole. the first part of this paper deals with the general, while the second outlines the differentiated logopedic and phoniatric therapy. 1. outline of the general logopedic and phoniatric therapy (trojan). general therapy may be divided into two, each relating to physiological structures of different evolutional age. one covers a group of antagonists i.e. a between-two-poles-movingmechanism such as the vegetativum (vegetative nervous system), respiration and register mechanism (the regulation of the falsetto, chest voice and so-called voix mixte). these are all innervated first and foremost by the sub-cortex. the other is characterised by a basically different technique, using distinct oppositions of typically cortical nature, even if, (as assumed by penfield and roberts) the integration of such functions is on a sub-cortical level in * felix trojan: ph.d. 1919, univ. vienna, dozent (phonetics) 1947, prof. 1955. leader of the s p e e c h and v o i c e department, e.n.t. clinic, univ. vienna. v i c e president intern. association logopedics and phoniatries, honor. m e m b e r societa itaiiana di fonetica ecc. and s o c i e d a d espanola d e hipnosis clinica y experimental. corresp. m e m b e r n e w york s o c i e t y for s p e e c h and v o i c e therapy, inc. m e m b e r of the permanent council for international congresses of phonetic sciences, editor " f o l i a phoniatrica" and " p h o n e t i c a " &c. * h e r t a w e i h s , ph.d. leader of the s p e e c h and voice department g e n e r a l hospital st. polten. lower austria, and ass. s p e e c h and voice department e.n.t. univ. clinic, vienna. speech. this sphere includes the oppositions: phoneme, word symbol, grammar, syntax and logical stress. although these oppositions vary from speech community to speech community, all languages have certain invariable characteristics, which justifies their grouping in a general logopedic treatment. a. the antagonists here, only the following will be discussed: vegetativum, respiration, abduction and adduction of the vocal cords and the register mechanism. the first three antagonists are of importance in the treatment of stammering, cluttering and their combination, whereas the latter three are more prominent in the treatment of vocal disorders. the vegetative rhythm plays a limited part in the treatment of vocal disorders, (i) vegetativum one must clearly differentiate between thalamencephalic innervation and the sympathetic and parasympathetic parts of the vegetative or autonomic nervous system. the former is characterised by a behaviour pattern of the organism as a whole which can be described both by its function and its symptoms. to this part the terms "trophotropic-endophylatic" and "ergotropic" functional tendencies belong. (w. r. hess). the terms "sympathetic" and "parasympathetic" refer however to peripheral anatomic structures, whose functions are not easily differentiated. it suffices for us here to differentiate between the trophotropic and ergotropic functions. basically the trophotropic functions are to assimilate the food brought into the body and to use it either for growth or to form an energy reserve for emergencies. (w. b. cannon). furthermore the trophotropic functions include sex and reproduction and as a further development along the line of individual trophotropy we have the social emotions (developed from the food-source relationship with the mother) and under certain conditions productive art may develop on the whole trophotropic basis. on the other hand we have the, ergotropic functions (through secretion into the blood of adrenalin and glycogen) which result in an injournal of the south african logopedic society june, 1962 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) crease in muscular performance and thus act as a protection against environmental dangers. on a higher level we have the constant achievements of the will and under special conditions the technical regulation of nature. of course both trophotropic and ergotropic functions which lie on the higher level involve more cortical activity. proof that both parts of the vegetativum also influence the voice in various ways was presented in "the experimental study of the connections between vocal expression and the vegetative nervous system". (1952). "soft" voice is linked with the trophotropic function and "potent" voice with the ergotropic. "soft" voice is characterized by smooth onset, gliding volume change, quiet breathing, dominance of the vocal elements and legato; whereas the "potent" voice shows harsh onset, abrupt breathing, dominance of consonants and general staccato. the natural transition of the vegetativum from peacefulness, contemplation and introspection on the one hand to the fight for life, on the other, is frequently threatened by the demands of society and our technical age. every society demands certain norms of behaviour which inhibit instincts (particularly agression (ergotropic) and sex (trophotropic)). through the mechanisation of our age and our "tempomania" (love of speed) (w. birkmayer) as well as the increased work demand the vegetative equilibrium frequently swings to the sympathicatonic pole. speech and voice therapists encounter disturbances of the vegetativum in the stammering field where, apart from medical and psychotherapy, direct speech therapy is required. for this purpose a "phonic training" aids the restoration of the natural vegetative equilibrium. through the correct speaking of verse in which calmness has received artistic expression the trophotropic tendency can be activated. with regular practice of this and the vocalised expression of courage (ergotropic) the anticipatory fear of the speech situation may be reduced, (ii) respiration. the respiratory mechanism, like the vegetative equilibrium to which it is closely linked, may be disturbed by the influence of society, as in the wearing of tight clothing which inhibits the work of the diaphragm. it is important therefore, that the therapist sees that all cases achieve correct breathing. the patient should also be taught the conscious control of the antagonistic movements of inspiration and expiration. as far as the inspiration is concerned an " inspiratory tension" can be achieved which reduces the subglottic pressure on the larynx. this is of benefit not only for cases of vocal defect but also for stammering. the "inspiratory tension" is achieved by merely imagining that one is breathing in while actually breathing out (speaking). it has been shown by μ. h. draper, p. ladefoged and d. whitteridge in their electromyographic studies that, during the speaking of longer phrases the active expiratory muscles function either right from the onset of speech or after a short period during which the natural relaxation of the inspirators occurs. it can therefore be assumed that through the use of inspiratory tension, this process of active expiration becomes more intense and sets in earlier, as the air pressure required for phonation is absent. in the use of the "soft" voice and therefore of a minimal use of the active expirators, the above control of the respiratory antagonists has proved to be of great value to the therapist. the rib-reserve breathing method is based on a similar principle, the expiratory movements being divided. (iii) the vocal cords. the smooth onset typical of the "soft" voice requires a co-ordinated movement of the antagonistic adand abductors of the vocal cords (lateral and posterior cricoarytenoid muscles). the "messa di voice" which characterizes the "soft" voice, and even more, the singing voice depends on the fine co-ordination of the respiratory and laryngeal muscles. it is an important task of logopedics and phoniatrics to cultivate this sensory-controlled mechanism. the importance of a smooth onset, particularly in the treatment of stammering, has been known for a long time. (iv) the register mechanism. the importance of the physiologically correct use of the various resonators through the employment of the extralaryngeal muscles, was not recognised for a long time. it is well known that the cricothyroid muscle plays an important part in the production of the falsetto voice (or the falsetto part of the voix mixte). w. & a. zenker, however, showed that the cricopharyngeal part of the .laryngopharyngeal muscle may possibly contract if the sternothyroid muscle is tensed and this causes the vocal cords to relax (lowering the larynx) and the chest voice mechanism to function. 1 journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) therapeutically the antagonistic action of these muscles can be produced by firstly phonating a high pitched e e and then going on to a back or middle vowel in low pitch. a light tapping in the area of the sternum during this phonation, brings the vibrations of the thoracic cavity out more clearly and more intense contraction of the sternothyroid muscle is achieved. suitable phrases can be used for this work. b. the oppositions speech, which is more or less a cortical activity, rises above the antagonists, without however becoming completely independent of them. the word symbols and their basis, the sounds and the mediums of grammar and syntax relate to each other in the manner of oppositions. the following premises are necessary for a speech symbol to be formed. firstly, a part must be picked out from the afferent whole. the relationship of the selected part and its background thus becomes as a to non-a i.e. in contradiction —everything which is not a is non-a. if such an isolated afferent is linked with an articulatory form (only possible with use of a sensory-motor arc) this link must be regarded as the basis of the word symbol. every word symbol is made up from a meaning and a specific form (articulation or writing). the meaning refers to the sensory, and the articulation to the motor side of the arc. when for similar things, similar symbols are used we speak of concept formation. just as the attachment of meaning to a speech symbol must remain constant, so the specific forms remain in fixed opposition. accordingly, in the case of dyslalia the therapist must help the patient to learn to form and use sounds conforming to a strict norm. this task will not be equally difficult for all sounds. r. jakobson has shown that there are earlier and later evolved sounds and that the later sounds are most likely to be difficult for speech-retarded children. it has also been shown (by the present author) that the earlier sounds are those produced during vocalized chewing. from such and similar arguments it may be concluded that articulation is a "secondary function" of vocalized chewing, (cf. e. froeschels). of course, the speech sounds themselves, are the products of muscular antagonists. proof of this is shown by a well tested treatment for sigmatism, in which a double antagonist is used. first, the pointed tongue is protruded through the co-ordination of the genio-glossus and the transverse tongue muscle. the tongue then is drawn back into the mouth and made as wide as possible (achieved by the contraction of the hyoglossus and the stylo-glossus as well as the longitudinal tongue muscles). this sharp contrast of movement (antagonistic in nature) results in an extreme widening of the tongue. it should be associated with saying "ee" and feeling the tongue touch or almost protrude on both sides of the upper and lower premolar teeth. this position of the tongue leads to the formation of the proper groove needed for the production of a correct "s". if a perfect symmetry of both halves of the tongue is attained it is seen that the relationship of the tongue tip to the teeth does not inhibit the free passage of air and a correctly produced sound may be speedily achieved. ii. outline of the differentiated phoniatric-logopedic therapy (weihs). whereas the "general" therapy focuses — according to trojan's explanation — on normal functions, the "differentiated" therapy aims at reorientating the disturbed functional conditions into natural channels within the individual's psychosomatic pattern. the aims of treatment vary according to the etiology and nature of speech and voice disorders. therefore, a detailed case history and an exact clinical examination is necessary to obtain (1) a differential diagnosis between primary organic and functional disorders of speech and voice; (2) an adequate phoniatriclogopedic diagnosis, based upon the study of the particular pathologic symptoms and their etiology and the participation of the total personality in the disease process. the psychologic approach in the diagnosis and the treatment is important in view of, (1) the multicausality of functional speech and voice disorders; and (2) the complexity of methods in which the afflicted personality is to be influenced therapeutically as well as (3) the close interdependence of speech, voice and personality. a. aspects of the differentiated phoniatric-logopedic diagnosis. according to our clinical and experimental experiences the following aspects are to be taken into consideration for the purpose of a more detailed diagnosis: 1. age. a. maturity b. differentiated disposition for disease (cf. gerfeldt). summarizing the possibilities 10 journal of the south african logopedic society june, 1962 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) which cannot be exactly differentiated into age groups, we have: in infancy and childhood brain injury; encephalopathia; toxic infections (occuring before, during and after birth and leading either to chewing difficulties; different degrees of receptive and impressive dysphasias; deafness; mental, motor and sensory disturbances; ataxia; and abnormal behaviour patterns); attacks of ear, nose and throat infections; disturbances of nutrition and of skeletal development; postural defects; psychogenic disturbances; schizoid psychopathia. the disposition for glottal and respiratory spasms is given with familiar neuropathic constitution, hypocalcemia, spasmophilia at birth, and with abnormal psychic reaction tendencies, (e.g. stubborness and aggression). voice disorders, chronic hoarseness, mild laryngitis and nodes may arise out of frequent crying in infancy; prolonged and violent coughing spells; allergy e.g. a tendency towards infiltration of the tissue (cf. sedlackova); constant shouting; vocal strain experienced in school, (cf. greene.) this also continues during the period of rapid growth, such as in adolescence we find disposition for upper respiratory tract infections; toxic infection (focal infection such as diseases of the teeth and chronic tonsillitis may also influence voice disorders in adulthood); constitutionally determined faults of posture and breathing; allergy and bronchial asthma, vegetative and vasomotor lability; functional psychic and motor disturbances. prolonged puberphonia beyond the normal age may be due to hormonal deficiency or organic disorders e.g. multiple papillomata in the larynx, asymmetry of the upper thyroid notch (cf. weiss) or to psychological disturbances, neurosis (arising from faulty education or pronounced feminine personality component in the male). t in early adulthood diseases of the respiratory organs, the teeth and the throat aind neck region (cf. stolze); the latter appears to be conditioned by a disposition toward neurotic manifestations in this age group; in women: metabolism diseases; in men the healing process is generally delayed (cf. gerfeldt.) in middle age we have in addition a disposition towards diseases of the circulatory and digestive systems; the onset of immobility in the thorax; in diseases of the throat and neck region (associated with e.g. globus, disturbed mobility of the vocal cords and vasomotor lability). pathogenetic factors are: arthritic deformities of the cervical and upper thoracic vertebrae as well as the increased disposition for psychoneurotic and mental disturbances, which in women are conditioned by hormonal metamorphosis; in men there is a disposition towards carcinoma of the larynx and cerebral insults. in old age involution processes of the larynx and the total organism; increasing immobility of the thorax; disposition for carcinoma of the larynx and cerebral insult; personality regression. ii. physique: 1. the special anatomic characteristics of the physique, 2. the condition and adaptability of the vegetative and endocrine system 3. the disposition of various diseases 4. the momentary vegetative reaction tendency 5. reaction to stress 6. fatiguability. iii. temperament: 1. personality (according to trojan: on the basis of the trophotropic, ergotropic and the cortical functions as well as from the corresponding forms of vocal expression of affects). 2. pathologic personality patterns (e.g. hysteria, psychosis, schizoid psychopathy, depressive or obsessional states). iv. individual history: 1. physical development 2. heredity: (e.g. familia neuropathy, schizophrenia, epilepsy, psychopathy, imbecility, familia central speech imbalance (cf. weihs). constitutional delayed speaking, motor and language. 3. environment: the emotional familiar atmosphere is responsible for the pathologic functioning of the child's voice and speech; disturbances may become fixed in childhood and persist as early established behaviour patterns in the adult; we consider also the actual vocational and familiar situation and the ability to relate. v. spccial etiological factors: 1. psychic disturbances 1 journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 2. endocrinological disorders 3. allergy (tendency to infiltration of the tissue) and asthma 4. postural defects (e.g. hyperlordosis of the lumbar and cervical spine), 5. organic defects of the vertebrae, 6. deficiencies of the breathing mechanism leading to respiratory insufficiencies: e.g. a) thoracic underdevelopment b) thoracic immobility c) thoracic deformity d) underdevelopment or lack of training of the respiratory muscles e) paradox diaphragmatic movements vi. further local organic defects: 1. structural abnormalities: e.g. a) congenital deformity of the larynx, epiglottis. b) anomalies of the upper respiratory tract (cleft palate, short soft palate, asymmetry of the atlas vertebrae) c) obstruction of the nasal airway d) articulatory abnormalities. 2. congenital deafness, partial or complete, 3. multiple papillomata of the larynx, 4. external trauma of the larynx, 5. partial palsy following thyroidectomy. b. the experimental diagnostic method for diagnostic purposes, the clinical examination —internal, neurologic, x-ray, laboratory, audiometric and phoniatric-logopedic—is supplemented by experimental investigations (cf. weihs). the following techniques appear useful for objective diagnosis as well as for assessing the influences upon speech, voice and breathing exerted by phoniatric-logopedic treatment. 1. electroacoustic analysis, to assess sound quality, volume, resonance and carrying power of the 1. speaking and singing voice before and after treatment 2. oesophageal speech 3. speech and voice of the deaf (hard of hearing) adults after training with hearing aid 4. postoperative cleft palate specch (after spcech therapy) the technique is supported by intelligibility tests (providing an objective measure) e.g. telephone nonsense-syllable test with laryngectomized patients (cf. weihs). ii. radiographic techniques. 1. lateral cine x-ray examinations of the larynx 2. frontal tomograms and posterior-anterior "hartstrahl" x-rays. 3. x-ray examination of a) the whole spine b) the wrist c) the diaphragmatic movements. iii. electromyographic examinations (to be carried out in voice disorders, cluttering and neuropathic and psychopathic stuttering) (cf. bente et al . . . trojan-weihs). iv. electromyographic t e c h n i q u e with sychronus sound (which is to be compared with the vowel spectrum) to assess the activity of the muscles of the neck, sternocleido-mastoid (before and after treatment; to be carried out also with laryngectomised patients; with superficial electrodes). v. spirographic investigations 1. spirometric measuring of the lung capacity, the pulmonary volumes and the pulmonary ventilation (to be carried out also in laryngectomized patients). 2. spirographic registrations during phonation and speech, to assess the use of breath and oxygen for phonation (to be carried out with stutterers and clutterers also). vi. electrovibration-test: to observe the changes of muscle tone as a reflex response to mechanic stimulation. vii. automatic reactometer test, (developed by hauswirth and kraemer), to determine the functional predisposition of the autonomic nervous system (following imre). v i n . psychological assessment. 1. projective tests: tat, cat (murray); drawing tests: tree-test (koch), drawing the human figure (mancover), drawing the family (minkowsky and parot), etc. bibliographies and stories compiled by the patient which enable the personality to be assessed in depth through the overall organisation of the expressive activity in combination with j 2. the emotional resonance test (g.r.t.) (trojan) and the personality-diagnosis from the speaking voice (trojan-teirich) to disclose the structure of the personality 1 journal of the south african logopedic society june, 1962 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) in terms of the two .vegetative dispositions and the range of the cortex (as described previously) and from the corresponding forms of vocal expression of affects. apart from personality tests, stress is laid upon conversations in a relaxed atmosphere, from person to person. such a personal contact enables the phoniatrician to observe the pattern of the actual overall speech of the patient, his general attitude, his behaviour pattern, his reaction to his disability as well as the condition of general muscular and nervous tension as seen in posture, gesture, body movement and the ability to relate towards people. a special battery of tests is used to investigate the level of intelligence, motor, speech and language development; comprehension of speech, auditory and visual memory; visuo-motor and constructive activity; the type of ideation (the individual prevailing tendency toward motorkinesthetic, visual or acoustic imagery); speech classification. the items are taken from the oseretzky-gollnitz scale, merrill-palmer and terman-merrill scale, wechsler bellevue (cf. reference in arnold, luchsinger). we test also the musical gifts, the feeling and sense of rhythm and sound. c. therapy it is here only possible to give a general outline of differentiated therapy in accordance with the various problems mentioned above. 1. the severe central defects such as receptive and impressive dysphasias, central dyslalia (seeman) and dysarthria, combined with classical neurological disorders; the delayed speech development with the syndrome of extrapyramidal voice and speech disorders, speech disorders in general motor retardation and in grave psychic asthenia, aphasias in adults and acoustic agnosia (cf. seeman) require a neurologic treatment and in many cases a phoniatriclogopedic therapy which may help to improve the disturbed functional conditions. the same is true of the stammering with the "sensory" or "motor" component of cluttering (abnormal eeg) (cf. | trojan-weihs and the references listed there).] ' 2. the simpler cases of receptive and expressive dysphasias in cases of delayed speech and language; "junctional" dyslalia—arising from motor or sensory disorders, ataxia and low intelligence; "organic" dyslalia due to peripheralreceptive defects (such as audiogenic dyslalias and dysglossias etc.) (cf. arnold, luchsinger). the logopedic treatment helps the patient not only in the areas in which he has the greatest difficulties, but contributes to the further central speech development, peripheral-expressive speaking ability and cerebral integration. therefore, therapy has to begin as early as the age of 4 or 5, or earlier in cases of deafness. 3. functional speech and voice disorders, psychoneurotic speech disorders, the neuro-and psychopathic stuttering as well as the manifold forms of "functional" voice disorders and of nasal dysphonias necessitate a phoniatric-logopedic therapy, which is in accordance with the total personality pattern, focussing on rehabilitation of the defects and on psychotherapy. therapeutic measures one of the first aims of differential therapy is to correct the postural and breathing faults with the help of a "passive" and "active breathing therapy". by "passive breathing therapy" is meant the technique which allows the patient to utilize his respiratory mechanism to the full. electro-vibration which is carried out over, the lumbar-sacral-pelvic region, along the spine, on the neck and the mastoids, is expected to lead to a vagus controlled condition, (cf. bischoff, mozer, schmitt). "active breathing therapy" helps the patient to get the feeling of and learn rhythmic breathing and the conscious control of fine co-ordinated breathing and phonation (respectively the uninhibited flowing out of breath, controlled by support of the respiratory apparatus which gives the voice emission the utmost expanding ability) as well as the natural posture and movement which are needed for speech. in cases of paradox diaphragmatic movements and organic defects of the vertebrae an additional breathing-orthopedic treatment is necessitated (cf. schmitt). in voice disorders we achieve full breathing and full amplification of the tone as well as an optimal base of articulation by elongating the whole spine, especially by diminishing the lumbar and cervical lordosis and poising the head in relation to the spine (which is helped by exercises with a neck-extension-cushion) and by relaxing the mandible and moving the tongue towards the hard palate. in electromyographic registrations there is an harmonious interaction of the muscles of the neck which keep the head correctly balanced on the shoulders during respiration, (the sterno-cleido-mastoid muscles and the respiratory muscles as well as the infra-and suprahyoid muscle groups). this harmonic in1 journal of the south african logopedic society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) teraction (preparatory to the onset of voice) helps the diaphragm and the larynx to descend on inspiration and the musculature of the tongue to relax, thus facilitating the balance of registerfunctions and the process of articulation. lateral x-ray pictures show the whole supraglottic portion of the larynx and the pharynx enlarged. the changes in the reciprocal position of the hyoid bone and the bony larynx together with the epiglottic-laryngeal fat-body-mechanism (zenker) interfere in improving the abduction, the vibration form and the adduction of the vocal cords. primarily hypokinetic voice disorders due to vegetative and muscular hypotension, the different degrees of internal tensor weakness and the paresis of the recurrent nerve require a combination of the above described electro-vibration and the harmonious vibration of the larynx and the sternum during phonation on the same pitch, with an electrophysical treatment in the form of a selective muscle stimulation by exponential current—(cf. trojan-weihs). in hyperkinetic voice disorders however, which arise from ergotropic tension, psychogenic disturbances, spasmic tendencies, vocal abuse etc., in dysphonia plicae ventricularis and rheumatic laryngeal arthritis it appears useful to combine the electro vibration with the special harmonious vibration of the larynx and sternum. the phoniatric treatment of hyper-or hypokinetic voice disorders begins only when all inflammations and infections are removed. in the case of organic defects of the verterbrae and of paradox diaphragmatic movements a special breathing-orthopedic treatment is necessary. conclusion (trojan); the polarity between general and differentiated therapy presented in this paper can be. used by every logopedic and phoniatric therapist to determine which trend his therapy follows. the more generally orientated therapist aims at normality and thinks teleologically. he will sometimes expect better results from his treatment than is possible but he will not be discouraged by the facts of heredity and pathological environmental influencies, whose importance he may underestimate. conversely, the differential therapist will tend to concentrate on the causal connections between the pathological symptoms, heredity and environmental influences. he may show less optimism with regard to therapeutic prognosis and it may be difficult for him to rise above the viewpoint of determinism. the true aim of the logopedic and phoniatric therapist should be to find his own medium between the two lines of treatment we have shown. ad i (trojan) μ. h. draper, p. ladefoged and d. whitteridge: e. froeschels: w. r. hess: r. jacobson: f. trojan. f. trojan et al: w. zenker und a. zenker: bibliography respiratory muscles in speech, j. of speech & hearing research. 2. pp. 16-27 (1959.) medizinsche beitrage zu einer theorie der entstehung der sprachbewegungen ( d e r artikulierten sprache). arch. neerl. phonetiquc experimentale 15-81. (1939.) die funktionelle organisation des vegetativen nerven-systems, basel 1948. kindersprache, aphasie und allgcmeine dautgesetze. uppsala univ. aarsskrifter, 1942, 9, p. 1. der ausdruck der sprechstimme. 2nd ed. vienna 1948. zeichen, silbe und laut in entwicklungsgeschichtlichcr sicht, phonetica 1, 63-81. (1957). experimentelle untersuchungen iiber den zusammenhang zeichen dem stimmlichen ausdruck und dem vegetativen nervensystem. folia phoniatrica, 4, 65-92. 1952. uber die regelung der stimmlippenspanning durch von auben angreifende mechanismen. folia phoniatrica, 12, 1-36, (1960.) ad ii (weihs). arnold, g. und lehrbuch der stimm-und sprachluchsinger, r. heilkunde, 2. aufl. (springer, wien 1959). bente, d: eeg begunde bei stotterern und schonharl, e. ihre bedeutung fur die medikamenund krunip, j. tose terapie. arch. ohr.-nas.-kehlkheilk. u.s.w. 169: 513-519. (1960). bischos, k. die winklerkur, zeitspiegel des atems (kuppe), p. 92-96 (schwabe, bad homburg 1960). buch, j. n. the htp technique. j. clin. psychol. (1948), (1949). gcrfcldt, e. differenzierte krankheitsanfalligkeit und lebensalter. vita humana 1: 19-42, (1958). goiinitz, g. die bedeitung der fruhkinglichcn hirnschadigung fur die kinderpsychiatrie (thieme, leipzig 1954). greene, m. diagnosis and treatment of late speech and language development in children. folia phoniat. 12: 101-107. (1960). linre, v. sprachstorung und vegetative konstitution. folio phoniat. 12: 273-281. (1960.) 1 journal of the south african logopedic society june, 1962 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kocj, κ. der baumtest. (huber, bern. 1954). minkovska, f. l'enfant et le dessin. pediatrie und porot, m. (1952). mozer h. brennpunkte der krankheiten, 2, aufl. (haug, ulm. 1954). murray, h. a. exploration on personality. (oxford univ. press. new york 1938). oseretzky, h. j. psychomotrik. beih. ζ. z. angew. psychol. (1931). schmitt, j. l. atemheilkunst, 3. aufl. (miiller/ humata, miinchen/berlin und bern/ salzburg 1957). sedlackova, e. les dysphonies hyperkinetiques des enfants, causees par surmenge vocal. folia phoniat. 12: 48-60. (1960). seeman, m. sprachstorungen bei kindern (marhold, halle/ saale 1956). stolze, h. das obere kreuz (lehmann, miinchen 1953). tierich und die stimme des arztes in der ordination. trojan f. akturelle probleme der phoniatrie u. logopedie. 2, karger. basel. 1961. trojan f. und zur behandlung einseitiger recurweihs h. renspareses. arch. ohren-uns. heik.u. z.hals-usw.heik. 169 233-235. (1956); studien zur stotterbehandlung. folia phoniat. 14: (1962). weihs h. die beeinflussung der vegetativen tonuslage durch komplexe akustische reize. folia phoniat. 6: 19-34. (1954) stimmstorungen und personlichkeitsstoruktur. folia phoniat. 9: 101-155. (1957); der einflub benachbarter bewegungssteme auf die hervorbringung der oesophagussprache. arch. ohrenusw. heilk une z.hals-usw. heilk. 173: 529-533. (1858); beitrage pur kenntnis und behandlung von stimmstorungen. folia phoniat. 13: 13-55 (1961); funktionsstorungen der stimme und psychische hygiene. akt. probl. phoniat. logop. 2:140-166. (kargar, basel/new york 1961); fatigue and psychic caturation in sing and speaking. k. modern education. (boktor, cairo 1954). weiss, d. a. the pubertal change of human voice. folia phoniat. 2: 126-159 (1950); cluttering (central speech imbalance). folia phoniat. 3: 111-132 (1951). zenker, w. anatomische probleme zum spannmechanismus der stimmlippen. wien.klin.wxchr. 70 801-802. (1958); uber bindegewebsstrukturen des kehlkopfes und seines aufhangesystems und deren funktionelle bedeutung fur den kehlkopfraum. mschr. ohrenheilk. 92: 269-307: 349-383. (1958). 1 journal of the south african logopedic society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract contextual background: vulnerable children in south africa method ethical consideration findings discussion and conclusion acknowledgements references about the author(s) faadhilah tayob department of speech pathology and audiology, thelle mogoerane regional hospital, south africa sharon moonsamy department of speech pathology and audiology, university of the witwatersrand, south africa citation tayob, f. & moonsamy, s. (2018). caregivers’ reading practices to promote literacy in a south african children’s home: experiences and perceptions. south african journal of communication disorders, 65(1), a559. https://doi.org/10.4102/sajcd.v65i1.559 original research caregivers’ reading practices to promote literacy in a south african children’s home: experiences and perceptions faadhilah tayob, sharon moonsamy received: 03 apr. 2017; accepted: 31 mar. 2018; published: 28 june 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: exposure to social trauma influences the psychosocial experiences of vulnerable children. this affects their positive development, consequentially resulting in poor scholastic progress. south africa’s history of inequality and injustice has compounded the current social, educational and economic situation, highlighting the need for research on children in care. a paucity of published studies exists on caregiver facilitation of literacy skills among vulnerable populations in south african children’s homes. the purpose of this paper is to describe the reading practices that caregivers in one children’s home (orphanage) used to promote literacy development. method: an exploratory, descriptive contextual design was implemented, using inductive and interpretative approaches. semi-structured interviews and focus group discussion were conducted. ten caregivers, who supervised children aged 9–10 years at the home, consented to be participants. applied content thematic analysis was used to interpret the data obtained. findings: the caregivers at the children’s home were implementing some reading strategies, but they did not engage sufficiently in self-reflection on the reading processes. the caregivers used relevant reading strategies, such as asking questions to develop understanding and memory recall. they encouraged dialogue through characterisation, where the children acted out the roles of the main characters. these reading strategies demonstrate the quality of the mediation. conclusions: speech–language therapists have a role in prevention and promotion programmes in children’s homes. they should advocate for, collaborate on and support caregivers’ facilitation of early literacy skills in these homes, as the link between literacy and language cannot be ignored. providing guidelines and sharing knowledge on reading instruction for the children are essential in improving the literacy rates in vulnerable populations. language and literacy interventions are only effective and meaningful if the social and cultural contexts are considered. such interventions would add value and constitute a step towards redressing past inequalities in south africa. these results contribute to our understanding of context when developing literacy programmes. the sample size was a limitation. however, the aim was not about generalisation but to gain an insight into caregiver reading practices so that literacy programmes are built on these strengths. contextual background: vulnerable children in south africa some south african families, specifically mothers and their children, infected and/or affected by hiv and/or aids, are provided with safe living environments. several of these children have been orphaned and live in care after the death of their parents (unicef, 2012). an estimated 3.7 million orphans live in south africa, with only a percentage of them residing in children homes, while others may be living with relatives or running child-headed households (unicef, 2012). the plight of orphans and abandoned children is an ever-increasing phenomenon, globally. a study conducted by morantz and heymann (2010) revealed that orphaned children experience a sense of isolation that limits effective coping and grief recovery. the psychosocial experiences of these vulnerable children influence their educational and future achievements. vulnerable children need safe environments, but given south africa’s past, it is often not the case. from its apartheid past, south africa has inherited a legacy of inequality and social displacement, resulting in high levels of poverty, violence, neglect and substance as well as sexual abuse (graven, 2013; unicef, 2012). theron and theron (2014) argue that children growing up in such contexts experience social trauma that affects their positive development and consequentially results in poor scholastic progress. international declarations, including the millennium goals and education for all, aim to prioritise education of vulnerable children (escueta, whetten, ostermann, & o’donnell, 2014). south africa’s history of inequality and injustice has compounded the current social, educational and economic situations, highlighting the need for research on children in care. studies have been conducted internationally and locally on topics related to education or literacy particularly, as well as on the contexts of children’s homes (orphanages) (escueta et al., 2014). nevertheless, a paucity of published research exists on caregiver facilitation of literacy skills among vulnerable populations in south african children’s homes. we argue that creating an enabling environment with quality mediation will improve the culture of literacy in children’s homes. therefore, the purpose of this paper is to examine the reading practices of caregivers that promote literacy in a children’s home. findings from the study will contribute to promoting collaborations between speech–language therapists (slts) and caregivers, as well as designing language and literacy interventions relevant to the context. the word ‘children’s home’, as used in this paper, is synonymous with the global term ‘orphanage’. the theoretical framework and key concepts that underpin this paper are discussed, next. reading acquisition and development the importance of both reading and writing is well documented in the literature; however, for the purpose of this paper, an argument is made for reading acquisition and development. schools provide formal reading instruction, but the home environment needs to support reading development, so that reading skills are consolidated (centre for education, 2017; mather, bos, & babur, 2001). additionally, home environments provide the source that enhances language skills, which are foundational for reading acquisition (sènèchal, lefevre, thomas, & daley, 1998). parents and caregivers from different social classes have different perspectives concerning the importance of literacy development and facilitation, as literacy is socially bound (mckenzie, 2015). high levels of illiteracy among a large section of the south african population are mainly because of the country’s historical inequalities and social injustices (graven, 2013). hence, huge disparities in knowledge around reading exist. these views strongly influence parental and caregiver roles in facilitating quality mediation in literacy development. thus, some parents and caregivers might be unable to facilitate effective reading within their homes. collaborative support by professionals can only be provided if the current reading practices in children’s homes are identified. reading strategies that promote literacy development studies on reading have examined different methods of interaction between caregivers and children that influence emergent and existing literacy skills. these methods of communication between caregivers and children include verbal interaction (vernon-feagaans & bratsch-hines, 2013), utilising environmental print (neumann, 2014), exposure to writing (welsch, sullivan, & justice, 2003) and using gestures during early word learning (bennet, weigel, & martin, 2002). specific reading strategies, such as shared book reading, dialogic reading and print referencing, also facilitate and encourage literacy development (graves, 2006; owens, 2014). furthermore, environmental print can foster print awareness, print knowledge and sound knowledge. neumann (2014) indicates that environmental print is one avenue to overcome a lack of resources and has had effective results, especially in younger children. environmental print may be beneficial in the context of children’s homes, as it is functional and cost-effective and can be implemented by all caregivers during routine activities of play, bath and meal times. the shared book reading strategy fosters social and affective aspects of literacy, which expands the child’s understanding of language structures such as narratives, vocabulary, syntax, story structure and basic print concepts (owens, 2014). shared book reading allows children to form a connection between oral languages and print (roth, 2009). dialogic reading is a form of shared book reading, which is known to be a one-on-one interactive picture book reading approach. graves (2006) states that the dialogic reading strategy promotes language development in children through the practices of using language to talk about language (metalinguistic skills), providing feedback on language and scaffolding interactions between the adult and the child. print referencing is another strategy that highlights verbal and non-verbal cues used by adults to focus children’s attention on important aspects of the text. children are encouraged to track print and pointing to the print and pictures. lane and wright (2010) state that print referencing aims to increase the metalinguistic focus of reading aloud and as a result increases print interest. the use of print referencing further develops children’s knowledge of print concepts, concept of letters and words and alphabet knowledge. finally, decoding strategies and discussion of the text will benefit emerging and novel readers, improving their comprehension of the text. mature readers develop a knowledge base of narrative and expository text structure, which aids their future reading comprehension (gajria, jitendra, sood, & sacks, 2007; harris & rothstein, 2014). when parents and caregivers have some awareness of such strategies, they can promote reading. however, this is not always evident, as certain factors facilitate reading acquisition and development, while others may limit its trajectory. thus, parent/caregiver support might be interrupted as a result of certain proximal factors. factors affecting reading acquisition and development various proximal factors, including the home environment, parent education, social and economic disparities, affect a child’s reading acquisition (brittnacher, 2014). according to neumann (2014), language and literacy skills of children from socially disadvantaged communities (sdc) are lacking, as they may have less opportunity to access quality mediation and resources. poor facilitation of language and literacy development will influence children’s learning and subsequently their academic performance (mcdowell, lonigan, & goldstein, 2007). academic failure begins early and might persist throughout a child’s schooling career. we argue that the need to promote quality caregiver–child interactions is foundational for language and literacy development. a longitudinal study by juel (1988, cited in colvin, 2007) found that children who lack decoding and comprehension skills at the end of grade 1 are likely to lack these skills as they progress to higher grades, falling behind their peers. lyon et al. (2001, cited in colvin, 2007) state that reading difficulties may persist into adulthood, unless suitable intervention is provided. therefore, early and appropriate learning opportunities ought to be endorsed, in addition to the quality of mediation from significant adults or peers. mediational theory that underpins the interaction between adult and child is discussed next. mediation for reading to understand a mediated experience, vygotsky’s theory on the zone of proximal development (zpd) (kozulin, 2015), as well as feuerstein’s mediated learning experience (mle) (tzuriel, 2013; tzuriel & caspi, 2017), are introduced. mle is defined as the quality of the interaction between an individual and their environment (feuerstein, feuerstein, falik, & rand, 2006). mle is a dynamic and intentional process conducted by a more knowledgeable other within the zpd. literacy development can therefore be facilitated through mle, as caregivers interact with the children. vygotsky and feuerstein’s theories, as indicated in research (scanlon, anderson, & sweeney, 2011), support the argument that the quality of the learning experiences that children are exposed to is the main contributing factor to effective learning and scholastic progress. reese and cox’s study (1999) confirmed that the quality of adult book reading in the home environment had an effect on children’s literacy skills. children’s responses to parents’ and caregivers’ interactions depend on the quality of these experiences, hence the focus on the caregivers’ reading practices within the orphanage. thus, by examining the reading practices of the caregivers, an insight into the quality of the mediation will be achieved. however, the quality of mediation needs to be established with further research. home and social contexts the interaction of parents and caregivers with their children is frequently dependent, as indicated earlier, on proximal factors such as parent educational levels, employment status and social circumstances. these proximal factors may marginalise children in sdc, placing them at higher risk for reduced language and literacy acquisition. limited exposure to literary environments (e.g. books, comics, written puzzles and games) is a significant contributor to low literacy levels (graven, 2013). a preschooler with fewer opportunities for acquiring knowledge and skills, and limited access to books and reading, is more susceptible to presenting with reading difficulties than a preschooler from a rich literacy environment (snow, burns, & griffin, 1998). all children, regardless of their socio-economic background, ought to benefit from rich literacy environments, as it encourages their language and literacy skill development and ultimately influences their scholastic achievements. it is the quality and not just the quantity of stimulation or their socio-economic background that makes a difference to their literacy development (bennet et al., 2002; mcdowell et al., 2007). we maintain that children, despite their adversities, are resilient and will achieve success given the support, opportunities and the environment to discover learning, particularly in literacy. hence, the caregivers in children’s homes play a fundamental role in creating an environment that stimulates literacy development. their practices in encouraging reading need to be explored, so that strengths are acknowledged and the interventions requested are relevant. as the home environment is the context in which literacy is first encountered (bennet et al., 2002; niklas & schneider, 2013), examining the children’s home context, especially in south africa, is important. furthermore, it is fundamental to establish what caregivers do to promote rich language and literacy development and to determine how they consider the children’s diverse strengths and weaknesses when learning. the information obtained through addressing the study’s aims will foster an asset-based approach, so that literacy programmes that enhance current caregiver practices are the focus. identifying issues of facilitation and resources are critical considerations when discussing literacy acquisition and development in the context of children’s homes, as interruptions in stimulation may occur frequently when these children are placed in foster care and/or returned to their relatives. caregivers have indicated a need for up-skilling with regard to promoting language and literacy among the children. this will redress the issues of social injustice and financial constraints experienced in children’s homes. various low-cost solutions to resources can be applied, but the critical skills of mediation (that is, the quality of the interaction) and reading strategies that emphasise how to read more effectively are foundational. caregiver understanding of the importance of literacy plays a role in what they actually do to facilitate and promote literacy. therefore, the aim of the study examined the caregivers’ reading practices that promoted literacy in a children’s home in gauteng. the following objectives operationalised the main aim: to determine the caregivers’ perceptions of reading as a strategy to promote literacy to establish how reading was encouraged by the caregivers to determine the reading strategies caregivers use during shared book-reading experiences to establish the resources available in the children’s home that promote literacy. method research design an exploratory, descriptive contextual design was implemented, using a quantitative and qualitative approach. focus groups and semi-structured interviews provided triangulation of methods to ensure validation of data collected and to capture a more complete and contextual representation of the study. participants a purposive, non-probability sampling strategy was applied. the sample consisted of 10 caregivers in the age range of 20–50 years old, who supervised children between 0 and 9 years of age. they were selected according to the inclusionary and exclusionary criterion. the participants had to be resident at the selected children’s home and had to interact daily with the children they supervised. either one or two caregivers supervised each age group. in the case of two caregivers, both the caregivers were included, if they agreed to participate. furthermore, the caregivers were not excluded based on their level of english linguistic competence, as interpretation services were available when needed. procedure an additional caregiver who had met the inclusion criteria was interviewed for the pilot study but was not included in the main study. feedback from the pilot study included modifying and clarifying questions. for the main study, each participant was interviewed individually and thereafter one caregiver supervising each age group was randomly selected to join the focus group. face-to-face semi-structured interviews of approximately 15–20 min were conducted at the children’s home. the interview schedule examined the participants’ demographic information, their knowledge of reading strategies, reading resources and how the caregivers facilitated reading. the questionnaire further explored the caregivers’ thoughts on reading in english, versus other indigenous languages, types of text structures and the influence reading had on caregivers’ knowledge and skills. an interpreter was included in one of the 10 interviews conducted, once consent was obtained from the interviewee. a 45-min focus-group discussion was also conducted at the home, 2 weeks after the individual interviews. the focus group schedule was based on the themes obtained from the interview data. data analyses the data was analysed using content thematic analyses. themes were formulated from the data. three phases were included in the thematic analysis: coding, which aims to organise the data; categorising, to distinguish between the various ideas of the data collected; and identification of themes (creswell, 2009). trustworthiness and credibility credibility was established through a pilot study, as well as triangulation of methods. face-to-face interviews and formulating a focus group, reduced intrinsic bias, which results from single method studies. the participants reviewed their interview transcripts (member checking) to ensure clarity of the data collected. honesty of response was encouraged to establish creditability. transferability and dependability were achieved by providing detailed information on the methodology and the background of the study, as well as through audio recording. ethical consideration all ethical parameters were maintained. the participants provided informed consent and the institute’s committee on human research approved the study’s protocol (protocol #h15/02/32). findings the study examined the caregivers’ reading practices that promote literacy in a children’s home in gauteng. the findings are presented and discussed according to the themes that emerged, in line with the objectives. caregivers’ perception of reading the majority of the caregivers felt that reading was important, as it allowed the children to improve their english language skills, increased their knowledge base on different topics and promoted their education and future job opportunities. ‘i think that because in class they are being taught in english, so they understand better what the teacher is explaining in the class by reading and they get to learn more.’ [p9, female, caregiver] the caregivers’ perception of english as a strategic avenue to educational success was evident. from their explanations, reading was linked to the enhancement of english as a language, rather than being perceived as an avenue to developing the children’s phoneme–grapheme awareness, encoding, decoding and print awareness. some of the caregivers, however, highlighted the importance of reading in relation to literacy development, as indicated in p8’s and p6’s statements: ‘i think it’s [reading] very important because it helps you, really mostly in speaking; you can speak very well if you read (mostly, eh) those novels or magazines. it helps you to know things that are happening outside and the spelling; also if you like to read, i don’t think you can have a problem with spelling.’ [p8, female, caregiver] ‘it will help them because if you are able to read words, word by word, your spelling will be good because you went through the words while we were reading and you know the word while we’re doing the spelling.’ [p6, female, caregiver] these caregivers saw a relationship between speaking, reading and spelling, as well as building world knowledge. additionally, oral narration and reading of text structure were indicated as important. the caregivers suggested oral narration as important, consolidating the oral culture of africa. they indicated that old traditional tales were not often found in books, as these are stories told over generations that impart life lessons. ‘yes, because you get more of a vocabulary and you learn a lot of things when you are reading, like the feelings and actions of people. like what happened before – the history.’ [p7, female, caregiver] these findings indicate that both reading and oral narration are important for literary knowledge, even though their structures are different (dickinson, n.d.). the caregivers described books that portrayed historical facts and mentioned oral stories as a medium for transferring cultural practices; both modes seemed to engage the different generations in discussions. the importance of text structure when reading was nevertheless not ignored among the caregivers. they reported that text structure enables children to spell words and to understand grammar. ‘they read it so nice and loudly. they take the book and sometimes call a friend, “did you know this and this?”, and you can see he is really trying to share the information that he/she is picking up from the book.’ [p2, female, caregiver] unbeknown to the caregivers, they were exposing the children to different narrative and expository text structures, which would influence the children’s reading comprehension, as indicated in the studies by gajria et al. (2007) and harris and rothstein (2014). reading empowers caregivers the caregivers described reading as benefitting their roles as caregivers. they stated that reading developed their interpersonal communication skills. they were better able to interact with others, especially those with whom they worked. they also experienced increased confidence, where they were able to transmit their knowledge when responding to the children’s questions: ‘for me, before i came here i never used to read much, but with english, it improves the language and helps you understand better. i mean, we help the children with their homework, and how are we going to help them if we don’t read? so reading is helping me get better in english for myself and as a caregiver.’ [p5, female, caregiver] the caregivers said that they could apply the knowledge gained from reading to scenarios that they may experience within the home context. additionally, they learnt how to nurture and care for the children, understanding their behaviour. ‘as an individual it helps me with my english, you know; it helps me understand not only myself but also how to interact with other people that i work with and my teamwork in general. as a caseworker it helps me because most of the time with the kids it is not only the information i learned before but sometimes you really need to read and go back to the materials that you had so that you can understand what to apply when those scenarios happen.’ [p2, female, caregiver] caregivers’ encouragement of children’s reading caregivers emphasised the importance of reading to the children. they practised various methods, including bedtime stories, setting up a mini-library within each cottage where books were available and within reach, and setting up a reading time. caregivers felt that reading should be encouraged through the methods that most motivated the children. in the focus group, they stated that having pictures together with text improved the child’s comprehension of the text. ‘yes, putting up written words with a picture to explain so that the child understands. remember, if it’s a picture, it is more attractive to the child than just having straight words. so putting a picture and a few sentences under to explain the picture i think will also encourage them, especially the younger ages.’ [p2, female, caregiver] the caregivers indicated that pictures were attractive and engaging, which motivated the children to read. the children discussed the pictures in shared book reading, aiding in their understanding of the text. moreover, the older children were encouraged to assist with the younger children during reading time. hence, they read occasionally to the younger children, and this often inspired the younger children to want to read. ‘there is normally paired reading. so normally, when they ask the careworkers and it is too much workload then they usually take the older kids to help them to read to the younger kids.’ [p2, female, caregiver] ‘when the elders are helping them with spelling, they respond. they like to be taught to read today and then the following day they want to read themselves; they don’t want anyone to help them.’ [p10, female, caregiver] the caregivers believed that the younger children enjoyed learning from the older children; consequentially they attempted to read independently. young children also learnt related literacy skills from older children, including spelling strategies. however, the caregivers recognised that younger children respond positively or negatively, depending on whether they like or dislike the person reading to them. the caregivers said that setting an example of their own reading behaviours was important. eight caregivers mentioned that the type of reading materials being read by the adults and caregivers around the home influenced the children’s perceptions of the importance of reading, while two caregivers indicated that the reading materials they read did not influence the children. ‘well, what i can say is that if they saw me reading a magazine or something, they are only interested in the pictures not the information.’ [p1, female, caregiver] ‘i think that whatever you are reading is important because you obviously want to know what it is about and you want to have information. and you want to understand the book that you are reading, the stories and everything. (if they perceive reading as important it will always be important to them.)’ [p6, female, caregiver] during the focus group discussion, the caregivers confirmed that they often encountered learning experiences when reading and interacting with the children. they indicated that it was important to share these learning experiences with the children through praise and acknowledgment, as this was motivational for them. ‘i just praise them and say “wow i didn’t know it is like that” and then they will say “really but you are so old” and then i will say “yes i am old but i didn’t know” and then they will be surprised because they have taught me something that i didn’t know and i have informed them that i learnt from them. they will feel proud of themselves.’ [p8, female, caregiver] these comments indicate that the caregivers understood the importance of acknowledging and connecting with the children, which builds a sense of belonging for vulnerable children. the findings revealed that the caregivers had access to a variety of reading materials, and the children were often aware that their caregivers enjoyed reading. the children residing at the home allowed the caregivers space and time to read, and they were often curious and enquired about what the caregivers were reading. the caregivers’ reading behaviours confirmed that leading by example is an important teaching tool; they were seen demonstrating the reading behaviours that they were promoting. moreover, the caregivers’ encouragement reflects the humanity they demonstrated through the process of reading, thus creating a nurturing and mediated environment. caregivers’ beliefs on the frequency of reading the results showed that all caregivers read to children during the evening, mostly before the children went to bed. however, reading did not occur on a daily basis and varied among caregivers. the following findings, recorded in figure 1, indicate the frequency of reading times within the caregivers’ respective cottages. figure 1: frequency of reading to the children. figure 1 indicates that a greater number of caregivers (40%) found reading to the children three times a week to be beneficial, whereas one caregiver believed that reading should occur more often. according to li, zhang, chin and khalid bin bari (2013), an increased frequency of reading activities leads to positive reading outcomes. the focus-group interview confirmed that reading to children three times a week was sufficient, as the children engaged in additional activities during the remaining time. the caregivers suggested that in addition to reading, children should socialise with others, play, share their feelings, role-play and colour pictures. this, they stated, ought to keep the children motivated to read. the caregivers stated that children do learn skills of understanding other individuals’ feelings and perceptions and sharing when engaging in the activities mentioned; hence they promote a balance between reading times and additional activities. reading strategies applied by caregivers four caregivers acknowledged the term ‘reading strategies’, while approximately 60% (n = 6/10) had never heard the term before. one caregiver stated that she was unsure of whether or not she had heard the term ‘reading strategies’ before. the four caregivers who indicated their awareness of reading strategies described it as a method of teaching a child how to read based on their age, identification of the type of books being read and a method of learning. they said that reading strategies enabled the child to give meaning to and explain what was being read. the caregivers, within the focus group, further explained that they were aware of reading strategies such as picture reading, group reading, storytelling and the use of age-appropriate books. the six caregivers who had no previous recall of the term stated that reading strategies might be defined as the way in which one reads, reading in groups and using a dictionary to identify and understand unfamiliar words and explain what is being read. these responses indicate that the caregivers have some understanding that strategies are techniques to aid the child’s reading. however, their own level of metalinguistic skills and their english linguistic proficiency might have limited their explanations. the most common reading strategies that the caregivers reported on were dialogic reading and shared book reading. from the discussion, it was found that the caregivers used the terms (dialogic reading and shared book reading) as per the interview questions and they presented their understanding of these strategies based on a literal interpretation of the name of the strategy. therefore, dialogic reading was often described as the use of dialogue imitation while reading; and shared booked reading was described as the sharing of books among one another. this confirms that the caregivers did not have an understanding of these specific strategies. however, their engagement with the children during book reading and discussion reflected their shared book reading strategies. a number of additional reported strategies implemented by the caregivers are listed in figure 2. figure 2: reading strategies implemented by the caregivers. it was concluded that the best strategy they applied with the children who they supervised was print referencing, which involves reinforcing the child by encouraging them to continue reading and picture reading. implementation of reading strategies, especially referring to pictures, was deemed important by the caregivers, as this strategy enabled the child to understand the text being read: ‘it is more interesting for the kids if the book has pictures so that they can see what the story is talking about’ [p1, female, caregiver]. p1 reported that the child becomes familiar with the image, then formulates and maintains a mental image while reading. furthermore, the child has a wider view of what is being read when pictures are used in comparison to text only. this discussion of reading strategies confirms the caregivers’ positive perceptions of the reading. when these strategies are examined, it is clearly evident that even though the caregivers might not have the language competency to define strategies used, they are applying many useful cues to aid reading. they used questions and explanations to build comprehension of the text. they created opportunities to recall the text being read, which develops memory and expressive skills. further, they encouraged the children to use a dictionary to build their understanding of words. they might also not have been aware that the act of reading together promotes fluency in reading, nor that interest and motivation are built when assigning the child a choice of character. the findings also showed that the caregivers thought that using reading strategies promoted self-confidence in reading and increased interaction with others. they stated that children became aware of dialogue, learnt from what they read and were encouraged to ask questions. increased self-confidence encourages children to read by themselves, promoting a love for reading. furthermore, individual reading assists in literacy development, as it allows the child to understand that they can gain knowledge through reading and can read for pleasure. engagement in individual and group reading sessions varied among caregivers. reading materials and literacy resources the participants reported that they had access to a variety of reading materials available in the library at the home. figure 3 indicates the types of materials available at the children’s home. figure 3: caregivers’ awareness of the types of literacy resources. the majority of the materials at the home are only available in english. two caregivers reported that there were some materials in isizulu, while another caregiver reported that sesotho, isixhosa and afrikaans materials were available, though limited. hence, the caregivers did not read to the children in languages other than english. the caregivers felt that reading materials in their indigenous languages ought to be available to the children, as many of them had difficulty with understanding english. the caregivers stated that many of the children residing in the home were from zulu and sotho backgrounds, and english was not their mother tongue. materials in their home languages would thus promote the preservation of indigenous languages and cultural practices, in addition to english. one caregiver said: ‘… it is important for these children to have access to their home languages, as it builds on their cultural knowledge, as the children may one day return to their communities.’ [p2, female, caregiver] another caregiver noted: ‘yes, it’s good, because remember, our kids are – it’s not like they are here forever; definitely one day they have to go back to the society and the society they come from is not an english-speaking society; it can be a zulu or a sotho, or isixhosa [sic].’ [p4, female, caregiver] furthermore, it was found that isizulu was one of the languages being taught at school. the caregivers said that the children only had access to isizulu word lists but not to reading materials, resulting in limitations of learning and applying the language adequately. however, one caregiver felt that having the reading materials in english only was beneficial; she believed that english was a priority as it was the language of learning and teaching (lolt) at school. moreover, she said that english would be beneficial for the children’s future, in tertiary education and job opportunities. the majority of the caregivers expressed the importance of materials in both the children’s mother tongue and english, reflecting equal value of all languages. the single caregiver who indicated only english reading materials might be unaware of mother tongue attrition and its impact on cognitive and linguistic skills. hence, collaboration between caregivers and slts is important, where slts can share their understanding of first and additional languages in language and literacy development (jordaan, 2015). discussion and conclusion the reading practices of the caregivers provided an insight into how they promoted reading in this children’s home. this offers a lens into formulating appropriate collaborative support structures for the slt and the caregivers. the caregivers’ reading practices were evident and did promote literacy development across the age groups. reading interventions built on a strength-based approach will empower caregivers and enhance the literacy skills of the children. the quality of the caregivers’ mediation is foundational to the success of literacy development in children’s homes, as these children are vulnerable and require nurturing environments (feuerstein et al., 2006; morantz & heymann, 2010). the findings in this study confirmed that the caregivers had created an enabling environment, and this had promoted literacy development for their resident children. the caregivers’ perceptions of reading reflected fundamental phases that would create stable and consistent stimulation, encouraging reading. important distinctions, such as oral narration versus text reading, showed that the caregivers were responsive to their context. this was further indicated when the caregivers discussed the need for access to more resources in the children’s mother tongue, as languages and cultures have to be retained, even though english was the children’s lolt at school. such insights are assets to encouraging reading skills as part of social development (dickinson, n.d.; mckenzie, 2015). caregivers are role models, setting an example by scheduling reading times for both children and adults. it was our perception that the caregivers expressed great personal gains from reading, which fostered their confidence, translating into information sharing with the children. moreover, the children in this home seemed to be secure in asking questions related to the readings, indicating an environment of ease around reading time. creation of a library facility within the home environment further cemented the importance and value of reading. the caregivers’ responses showed that they had created an environment that supported literacy development. li et al. (2013) supports the call for an enabling home literacy environment and encourages parents and teachers in singapore to have this realisation. in addition, a responsive environment that provides structure and a positive climate facilitates language and literacy development (roberts, jurgens, & burchinal, 2005). these facilitating behaviours of the caregivers in the current study represent a quality interaction, which is foundational for language, literacy and scholastic success. scanlon et al. (2011) support the argument that the quality of interaction between adult and child influences scholastic success. the caregivers used relevant reading strategies, such as asking questions to develop understanding and memory recall. they encouraged dialogue through characterisation, where the children acted out the roles of the main characters. these reading strategies achieved the aim of developing literacy skills through quality mediation. the main aim was thus met, as the study described the reading practices that caregivers applied in the children’s home to facilitate reading instruction. the findings also revealed that the caregivers implemented specific reading strategies, even though they seemed unaware that they were in fact doing so. despite the facilitation of these reading strategies being devoted for the most part to improving the understanding of the english language, caregivers were meeting the needs of the children, regarding their learning and wanting to read. the caregivers’ absent knowledge of text labels, including print awareness, print knowledge, sound awareness, phoneme–grapheme awareness and syntax, might be construed as a poor knowledge base and thus reduced mediation, but we disagree. it is therefore important to identify strengths in a context prior to formulating intervention plans. thus, we concluded that slts have a role in prevention and promotion programmes in children’s homes. they can work in collaboration with the caregivers, to further literacy practices. slts need to apply an asset-based approach to build on the potential of the caregivers. slts have a knowledge base of the relationships between language, cognition and literacy, and the theories of learning. moreover, they have a solid background in promoting and maintaining the importance of the mother tongue in young children, as the first language scaffolds the development of additional languages (jordaan, 2015). the caregivers had a wealth of knowledge on the context, the resources and the children. thus, through collaboration, sharing and developing skills, indicate dual benefits. slts would empower caregivers’ facilitation of literacy skills, influencing the children’s scholastic performance. moreover, slts would develop their own skills in formulating relevant programmes and being responsive to the context (moonsamy & kathard, 2015). language and literacy intervention will only be effective and meaningful if the social and cultural milieus are considered. such interventions would add value and would constitute a step towards redressing past inequalities in south africa. a language barrier was a limitation in one interview, but an interpreter was included to manage the interaction. the results of the study may not be generalised, as they relate to one context. nevertheless, the findings contribute to understanding the context of children’s homes and caregiver reading practices that promote literacy. future studies may look at caregiver and parent perceptions on reading strategies, following literacy interventions. acknowledgements the authors thank the caregivers at the children’s home who were willing to be participants in this study. competing interests the authors declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article. authors’ contributions both authors, f.t. and s.m., equally contributed to the writing of this article. references bennet, k. k., weigel, d. j., & martin, s. s. 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(2003). that’s my letter! what pre-schoolers’ name writing representations tell us about emergent literacy knowledge. journal of literacy research, 35(2), 757–776. https://doi.org/10.1207/s15548430jlr3502_4 7 is your boy's voice "changing"?. m' e. thayer curry. associate professor of speech, university of illirlols. if your boy's voice is changing, he is undergoing a transition which is experienced by nearly every adolescent boy.1 for some boys this change results in but few problems. other adolescents are confronted by speech and psychological difficulties which seem insurmountable to them.at the moment. parents would be better able to understand and guide their boys during this period if they were familiar with recent scientific information about the nature of voice change. probably the individual most concerned with this matter of voice change is the teen-ager himself. parents and teachers may be asked to help the boy whose voice is "breaking". curious as it may seem, growing interest in this characteristic peculiar to adolescence has been shown by research workers in the fields of medicine, psychology, anthropology, music and speech. there are at least three specific questions which vex parents and teachers about this phenomenon, we will make it the purpose of this brief article to point out what has been learned by the investigators with regard to these three questions: first. how do we recognize voice change? second. when can we expect this, change to commence? third. what are the reasons for this change?. then for the parent who would be prepared to meet this problem wisely, we will suggest very briefly how this change may be handled psychologically. how do we recognize voice change?. the onset of voice change is evident to parents and teachers (particularly instructors of speech and music) because of the wide deviations from the normal voice pattern. these deviations have been categorized and analyzed by investigators in speech and music. most of these observers were impressed first by the loss of vocal control, and second, by the general instability of the voice undergoing change. note. some small number of boys will have achieved voice change before adolescence. a few others do not have change of voice until after maturity. in fact, some voices never do achieve this change. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8. jerome, an investigator using both acoustic and anthropometric techniques, gives us a very picturesque and accurate description of these deviations: "change of voice may be technically described as a normal loss of control of voice, occupying an undetermined length of time in the preadolescent stage or during some period of adolescence. the loss of control is usually evidenced by instantaneous, unpredicted, and involuntary changes of pitch, the reasons for which are not readily apparent. occasional concomitants of this loss of control of the voice are double resonance, restricted range of pitch, and the appearance of a tremolo".2 other speech authorities have reported further that during 'this time the voice may become raucous, hoarse and tend to "break into falsetto notes higher than those which were > normal before the change of voice commenced. professor grant fairbanks at the university of southern california has been responsible for extensive studies in the determination of vocal pitch. he and his graduate studentl have learned many fascinating things about the voice of the adolescent male dr c.p. „pedrey has also contributed university? h i s s t u d i e b a t louisiana state h^+ffif1?10 a ^ t i c a l technleuee developed and utilized sl η investigators have contributed much to our present ftjds™nrse+hf v o i c t c h a n s e . one of the most indicia p ™ ^ } ? ? v l t h e s e s t u d i e s h a s *een that when voice change is be?se ?hpths v ° i c e b e a b o u t a n o c t a v e than ? wis el°! ^change. many investigators have verified this extent of lowering of the voice level. thatt?^2· t h ® s e characteristics of voice change we can say that the voice is husky before change, unstable during change is likely to take place with our teen-ager we would like to know when this change can be expected to occur? when may ̂ this change to common*?. bllewfl«i?st+r2portvd· w o r k generally recognized on this proreported ihai 5y-hp a u lse n' g e r m a n > ^ 1887. paulsen at age 11 φ^ ° t 0 y s t e g a n t 0 experience voice change that fifti of +1 m ? r e ? e c e n t w o r k o f pedrey has indicated change ί ^ ϊ ? ? ± n + h i * b t ^ a t 13 had begun the nge. in addition to the views of paulsen and pedrey, 2. quas;^ 1 ? 0 1 1 k·-, °5a5ge o f v o i c e i n m a l e adolescents, '"saarterjj^^r^ of speech. xxiii: 648-653, 1937. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 9. many other investigators have reported a wide range of ages when the voice change may be expected to commence. these wide differences are perhaps due to the deviations in standards among different workers used in defining exactly what is meant by voice change. the anthropometrists have long utilized an objective technique for very accurate measures of the skeletal age of an individual. such skeletal age, determined by the bone structure of typical parts of the body, more nearly measures the actual development of a child than does the child's chronological age. one recent study related time of voice change to the skeletal age of the adolescent boy. even this work has indicated that this relatively restricted anthropometric measure gives a rather wide range for the time of onset of voice change. all of these objective studies indicate that there is no narrow range of age during which the voice change can be expected to commence. the very large range in chronological age is probably due to the variation in skeletal age for a group of a given chronological age. our best information would indicate that the average time for change is near or slightly less than 14 years of chronological age. what are the reasons for this change?. rapid growth changes in the larynx at about the time of voice change most likely explain the sudden change of voice level. this rapid growth, approximately at the time of puberty, represents the culmination of a long period of development in the organ of voice. before puberty, the voices of boys and girls are rather similar. the larynx has grown rapidly in both sexes until the age of six. at this age growth of the larynx nearly stops and the vocal bands neither lengthen nor thicken appreciably until the time of change of voice about eight years later. near puberty the vocal bands enlarge in mass and increase in length. investigations indicate that the vocal bands in the "boy double their length; those of the girl meanwhile increase about kcfi in length. all the growth apparently takes place in a limited period of time. this sudden enlargement in the larynx usually means that for a period the boy is unable to consciously manipulate the more massive voice muscles upon which his control of pitch depends. the result is, therefore, that while the voice is being lowered an octave in pitch level pitch control is greatly lessened. the "voice break", so characteristic" of this period, has been defined by one writer as a "sudden and uncontrollable rise or fall from the characteristic pitch of the individual a rise or fall which is definite enough to be heard by a r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10. 3 listener". the voice "break typically one octave in extent is usually a "break down from the pre-adolescent pitch level'to the level which the voice will assume after the period of change is completed. somewhat less frequent a r e the breaks from the post-change level u£ to the preadolescent _pitch. thi s "break is a completely uncontrollable variation in the vocal pitch. jql of these investigations have indicated that voice change is related to: (l) pubic development in the male, (2) a general physical growth pattern indicated by skeletal measurements and (3) specific growth patterns within the larynx itself. prom our present knowledge we are apparently justified in summarizing these investigations as follows: first. perceptually, voice change is characterized by: (1) loss of vocal control. (2) vocal instability. (3) voice 'breaks', which are one octave in extent. (4) certain symptoms, including huskiness, which precede the actual change. second. the average age for these changes is approximately 14 years on a chronological age scale. third. certain skeletal and muscular enlargements take place within the larynx near the time of change of voice. fourth. scientific investigations have related change of voice to pubic development and certain anthropometric skeletal measures. now a further word to the parent. how is this problem to be met psychologically? what should be the parent's attitude toward these obvious changes? what may we tell the boy to help him as best we can?. the research which has been done to discover the extent and magnitude of the boy's embarrassment over this change of voice has indicated that perhaps writers and teachers have tended to overestimate the actual psychological problem which this change in itself causes. perhaps any real problems 3 pedrey, charles p. a study of voice change in boys between the ages of 11 and 16. speech monographs. xii: 30-36, 1945. ' r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) at this age come from the whole pattern of rapid growth and rapid change of the whole personality rather than the change of his voice alone. at any rate the study of pedrey on this phase of the problem has indicated that the embarrassment experienced is strictly limited.4 the knowing parent will be able to prepare the adolescent beforehand about the change which will one day arrive. he can explain that the boy might reasonably expect some*sign of the change as early as twelve years but that most likelv it will not occur until slightly before the age of fourteen this change will last for an indefinite period perhaps six months to a year. during this time of change the voice will probably show considerable instability. voice control will not always be predictable. however the boy may be assured with certainty that this is simply a natural normal change which he is experiencing and that in a short while his voice will be significantly lower in pitch. even after the voice has assumed the lower pitch level and the change has apparently been completed some brief recurrences of the instability and breaks may occasionally evidence themselves. it can be further explained that most of these changes are die to the rapid growth changes taking place within the§lary^ itlelf. pedrey, charles p. op. cit., page 35. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a neurological approach to speech therapy for the cerebral palsied by ruth jacobs. b.a.log.(rancl) this new approach, which has revolutionised speech therapy for the cerebral palsied child, is based on neurophysiology. unlike lesions of the lower motor neuron which cause paralysis, the brain damage resulting in cerebral palsy will lead to abnormalities of muscle tone which can produce incoordination of muscles, so that the patient is unable to control his muscle function in the normal way. it is because of the abnormalities in muscle tone, as welluas the dominance of primitive reflexes, and the absence of higher postural reflexes that normal posture and therefore, normal movements are impossible for these children. the peripheral nervous system is intact and the power in the muscles necessary for performing movements is there, but the child is unable to direct or grade the impulses in order to obtain smooth and separate movements. it is not possible for the child to contract or relax individual muscle groups, nor to move parts of the body independently. the disorder of motor function is often associated with defects of speech and hearing. the treatment is based on inhibition of abnormal reflexes and normalising of muscle tone. these are the pre-requisites for normal movement patterns. it is this which allows the maintenance of posture against gravity and also for easy, smooth and purposeful movements. the speech therapist's aim is to give the child the normal sensations of speech, so that she will have to break down and prevent any abnormal reactions associated with the act of articulation. in order to do this the child must be positioned so that the normal speech developmental sequences can be followed. it must be remembered that as the speech musculature obeys the same laws as the skeleton muscles, the child must be treated as a whole. it is because of the abnormal and fluctuating muscle tone and lack of grading of movements that the athetoid has involuntary movements. this is seen in the twitching lips and snake-like movements of the tongue. the muscle tone must be steady before one can expect the smooth movements required for speech. in the floppy athetoid one might have to increase tone, being careful not to get spasms — this is done by grading of stimuli. in the spastic, the problem is often one of hypertonicity, and here one must reduce muscle tone by inhibiting the action of the agonists, and where there is co-contraction, of the antagonists as well. when speaking of reducing muscle tone we refer to that of the whole body. next, any primitive, pathological reflexes, affecting the speech mechanism must be inhibited and at the same time higher reflex activity must be introduced, for example: if the child has the bite reflex, and bites whenever the inside of the mouth is stimulated, desensitise this area and then encourage chewing movements. speech must function as an activity, independent from the rest of the body. this means that the child must be able to talk without associated reactions occuring or spasms being initiated. it is true that movement and speech go together, but here the grading is important. stimuli must be carefully graded so that the child is neither under· nor over-stimulated. when encouraging a child to talk, see that the situation is interesting and if you want a certain word, instead of demanding this, talk to and question the child in order to get him to say the required word. in order to develop speech we must give the child the normal sensation of speaking as χ he learns through sensory intake. it is unrealistic to expect a child to be able to produce sounds unless he has experienced the feeling kinaesthetically, so that no amount of visual or auditory aids will be of assistance unless the child is given the opportunity to acquire these normal sensations. thereafter, one can use these different avenues to re-inforce what has been facilitated. 2 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) let us now examine the pre-requisites for speech. firstly, one must ascertain that the child's hearing is adequate for speech. a hearing assessment is, therefore, one of our initial tasks, and must be carried out as early as possible. here one must ascertain that the baby is at a maturation level in keeping with his age, allowing for the usual lee-way in maturing found in all children. when carrying out these hearing tests, be sure that the child cannot only hear, but can localise the sound source. as there is often a high-frequency loss associated with athetosis, these children should be very carefully assessed and the possibility of a hearing aid discussed. the testing of these children, particularly those under the age of five, presents many added difficulties, for often their physical handicap prevents a response. in such cases, one must observe the child and use any reaction he can produce. example: some babies respond by blinking, others by stilling; the older child may only be able to protrude his tongue and this response must then be conditioned so that testing can be carried out. as speech is superimposed on the basic functions, feeding must precede speech, so that a knowledge of the gesell norms is required. here again the therapist must remember that these developmental stages are subject to individual variation, and that this variation will depend on the severity of the physical handicaps. at 8-12 weeks when tongue-tip movement should have developed, this will often only occur during a spasm. at 16 weeks, when biting occurs, the cerebral palsied child is often not yet able to bite or presents the biting reflex and will bite whenever the inside of the mouth, and especially the molar area, is stimulated, so that chewing is prevented. to inhibit this reflex, hold the jaw open and stimulate the inside of the mouth by rubbing with your finger, or a wooden spatula or spoon if the reflex is very strong. at 28 weeks the baby is chewing and eating semi-solids which it can take from a spoon; it [will be found that many cerebral palsied children cannot yet chew at this stage, nor can they purse their lips in order to take food from a spoon. at 40 weeks the baby can hold his own bottle and here again we find that many cerebral palsied babies have not iyet reached this stage as they cannot bring their fingers to their mouth, nor their hands to the mid-position. at this stage the child is able to keep his mouth closed and dribbling ceases, but this is long delayed in a cerebral palsied child. another stage which is delayed is drinking from a cup, which the 48 week old child does, although still spilling. here, the difficulty in mouth closure will mean that liquid escapes down the corner of the mouth. at the end of the first year, the normal child has learned that in order to drain his cup, his head must tilt back. often flexor spasm prevents the cerebral palsied child from so doing. should the child have extensor spasms swallowing will be difficult. so through all the remaining stages, leading to self-feeding of a full diet, we will see a delay in most cerebral palsied children. the feeding patterns must be carefully assessed so that, by positioning the head, neck, trunk and limbs we can inhibit the pathological reflexes and prevent spasms, and so progress to a later stage in our developmental sequence. in the same way as we compare the feeding stage at which the child is, so too must we watch the sucking and see at what stage of development the child is. at 16 weeks the normal child, when presented with food, opens his mouth, waits for the teat and closes its mouth around it. during the sucking movement the posterior part of the tongue is elevated. if solids are introduced at this stage, the baby will make chewing movements with his tongue, as he would for sucking. poor sucking movements are usually associated with the following:— (a) the tongue cleaving to the roof of the mouth; (b) imperfect approximation of the lips; (c) drawing in of the lower lip; (d) inability to release the teat as the child cannot part his lips; and (e) choking and swallowing air as breathing and swallowing are not synchronised. as voice is dependent on breathing we must examine the breathing pattern exhibited by the child and note any existing abnormalities. note any blocking on inspiration or expiration. often it will be seen that the athetoid will breathe in, then block and with great effort get out one word and then the breath supply is finished. breathing must be automatic, and once a rhythmic pattern is obtained, speech can be superimposed. begin with vocalisation and aid this by vibrating on the chest wall, larynx, abdomen and spine. it must be borne in mind that movements of the head and neck influence breathing, so that reflex inhibiting postures (r.i.p's) must december, 1962 journal of the south african l o o p e d i c society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) be used and head control facilitated. these reflex inhibiting postures are positions which favour more normal muscle tone and which break up primitive reflex postural patterns and. therefore, reduce spasm and spasticity. in the case of the athetoid and the ataxic, r.i.p's give stability and are used preventatively. our emphasis is on expiration, for once this occurs adequately, inspiration must follow. the voice of the child will supply information as to the breathing. if blocking is noted, the therapist must find where and in what position this occurs. the manner in which one vibrates alters the rhythm of breathing as well as the loudness of the sound, while a change in the position of the head will alter the pitch. aim at a sustained sound, so that the child will not only get the feeling of breathing out, but will hear his own voice. once voluntary vocalisation can be obtained, without great effort, babbling can be facilitated. here the vowels are aimed at first, and as choice is important, it is wise to remember the following: "ah" is an extensor sound and is said with an open mouth. because of this, it would not be our choice with a child whose pattern was predominantly one of extension as this would re-inforce and not break down the pattern. it is often easier to facilitate the "ah" sound when the child is in a prone or a sitting position as this will break down the extensor spasm. as "au" is also an extensor sound the above holds true. the "oo" sound is a flexion one and the prone position can be favoured. the "ou" sound, while a flexion one, is more difficult to produce as it requires pursing of the lips. the "er", which is a neutral sound, is a good starting point, when vowels can be produced, consonants are facilitated by touching the lips and under the chin. the position of the therapist's finger under the chin will raise or lower the tongue in the required position, e.g. place your finger under the chin for "t, d, 1" or "n", so pushing the tongue forward and up. push further back, so moving the tongue up and back for "k, g" and "ng". facilitate for "p" and "b" by holding the lips together and then releasing them. often releasing the lips is very difficult for the child. production of plosives usually increases spasm and this must be watched. when consonants can also be produced, vowel and consonant combinations are worked on. remember always, that what has been achieved in one position can and must be achieved in other positions. the sensory motorpattern must be laid down for each sound, and the child must progress to as many different positions as possible, the idea being that eventually the child will be able to talk and move without setting up spasms in any part of the body. the criteria for good articulation is a spasm-free trunk and head. with poor head control there can be but little speech. this is seen in a normal child, where, once head control is established, babbling will begin — at about 6 months of age. one cannot have a selective activity without fixation, and as speech is our most selective activity, one cannot expect the intricate speech mechanism to function when the head is all over the place. dribbling and swallowing are also dependent on head control. children dribble because they have not established the skill of obtaining mouth closure, and thus cannot swallow their saliva. one may start working on obtaining mouth closure and facilitating the swallowing reflexfwhile the child is in supine or side-lying positions. however, when the, child progresses to sitting the difficulty in sustaining mouth closure will reoccur where there is poor head-neck and trunk control. if head control can be established in all positions, dribbling will cease. to dissociate breathing and speech from the posture and movement of the rest of the body we work in r.i.p's initially. in these postures, once the initial struggle has died down, muscle tone.becomes normalised temporarily. before attempting speech we must be able to place the child in at least one or two r.i.p's. this is because, once muscle tone becomes normalised, proprioceptive sensations can also become normal, so that the speech organs will not only look normal, but will feel normal to the child. in a younger child this position will often induce babbling, or even single words. in older children, where speech has already set up abnormal reactions, r.i.p's will reduce spasticity and normalise muscle tone so that speech will improve. here, one must facilitate sustained vocalisation and babbling with one's hands, so that the patient makes! no effort. often these areas which are facilitated must first be desensitised, so that the patient can tolerate the handling. these areas are usually the i journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) neck, chest, gums and under the chin. let us now turn to the assessment of the cerebral palsied child. this is the most important item in treatment and should consist of a complete physical assessment, carried out in consultation with a physiotherapist. it is from this assessment that abnormalities will be noted and the therapist will be able to plan her programme accordingly. reassessment is equally important, for in this way progress can be noted. from the assessment, both abnormal and normal reactions will have been seen and the therapist must decide which are pathological and which primitive, depending on the age of the child. the pathological reactions must be inhibited and then the normal ones encouraged, advancing to higher patterns of co-ordination as the more primitive patterns are replaced. from the assessment the therapist will also see what the child can perform voluntarily and which movements are involuntary, as well as those which can be performed under emotional stress only; e.g. when examining breathing, see if a child can voluntarily hold his breath; can he bite voluntarily or does he only exhibit the bite reflex. it is important to note whether the abnormal, reactions of the child are due to tonic reflex activity, to voluntary compensation, or, in many cases, to both. during the assessment watch the child carefully and observe what he can and cannot do, and the manner in which, skills are performed. note the reactions which certain movements will , have on other parts of the body. if the child can speak, listen carefully and assess it generally. as a detailed assessment does not fall within the scope of this paper, suffice it to say that a full assessment of the following must be carefully made:— (a) sucking. (b) swallowing. (c) chewing. (d) biting. <e) jaw and tongue movements. (f) head control. (g) developmental history, both social and motor. (h) breathing.· as observation of all the above, with the possible exception of breathing, will be familiar to the reader, let us turn to the neurophysiological approach to breathing.breathing is the background on which speech is built. the crying of the infant develops tone generally and with this, breathing and voice increase and can be sustained. it is important to note whether any abnormalities are present. to prevent these we use the following positions:— 1. supine, with flexed legs arms at the sides. vibrate under the dorsal spine, on the sternum and if necessary on the larynx. later on vibrate on the lower ribs and . abdomen. 2. in side-lying vibrate on the upper side of the ribs, the abdomen and sternum. 3. in^ prone vibrate on the spine and lower back. 4. heel-sitting, with the spine extended and arms forward. vibrate on the spine, back, abdomen and sides. remember that vibration is movement, that there is a connection between movement and sound and that movement without spasm encourages sound. when the child moves it vocalises and consequently movement can be used to stimulate sound. it is easier to do this from a sitting position. when examining the breathing pattern it should be borne in mind that breathing difficulties lead, not only to speech difficulties, but also to difficulties in feeding, as in order to swallow, breathing and swallowing must be synchronised to avoid choking and the swallowing of air with food, which would cause wind and indigestion. the breathing pattern of the athetoid will usually present abnormalities. at best the breathing is shallow and of short duration, so that there is not enough volume of breath to initiate speech. the important considerations as regards all breathing patterns are (1) rate, (2) vital capacity and (3) control. they naturally all depend upon adequate functioning of the muscles of respiration. once we can improve motor function, breathing should become normalised. in athetoids who have weak flexor muscles in the neck and shoulders, and in those spastics whose pattern is predominantly one of flexion, excessive belly-breathing occurs. when the child is in this flexed position the chest is cramped and squashed together, so that the muscles of respiration cannot function normally. coupled with this, the fluctuating muscle tone of the athetoid december, 1962'' journal of the south african lo&opedic society 31 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) prevents a rhythmic pattern of breathing. such a child would, therefore, be treated by breaking up the flexion and introducing extension in the trunk neck and limbs, depending on the existing flexor pattern. the child would be maintained in a controlled r.i.p. so that the tone does not become markedly extensor, but remains as near normal as possible. total r.i.p's must never be used because of the danger of shunting spasticity. often a spastic is unable to inhale without a backward movement of the head as well as other signs of extension throughout the body. here the child can be placed in a sitting position, with the therapist behind, so that she can hold his head and help to superimpose rhythmic breathing by moving the head backwards and forwards so that the neck extends with inspiration and flexes with expiration. to improve breathing function we must aim at better head control so that the chest is maintained in the desired position. with a child who has a predominantly extensor pattern it is possible that blocking on expiration will occur because the child is in a position of inspiration, and cannot exhale. by placing the child into a position which favours flexion one will facilitate expiration and therefore, normal breathing will follow. it can thus be seen that the chest must be in a position which favours normal breathing and which is neither markedly flexor nor extensor, but where muscle tone will be normalised. usually from the speech therapist's point of view, better results are gained in a flexed child if we can improve extensor tone first, so that the flexed position can be overcome. flexor spasms are associated with difficulties in inspiration. when the sitting balance is poor, in a flexed child who lacks extensor tone, the child will sit in a hunched-up position with the result that the chest cannot expand. once sitting is improved the upper chest movement will often show a similar improvement. in supine, positioning can facilitate use of the muscles of inhalation because they will be in a position which favours inspiration. here a rolled-up towel placed along the vertebral column, between the scapuli so that the shoulders are pressed down and touch the plinth, will help increase inspiration. the upper chest and anterior neck muscles, which serve inhalation are now in a favourable position so that upper thoracic activity should increase. care must be taken not to elicit a stretch reflex by using a position which is too extreme. to encourage the thoracic expansion of diaphragmatic breathers, it helps to shift the emphasis from the diaphragm to the thorax. here the palms are placed on the anterior thoracic wall, with the fingers fanned out to control movements and encourage use of the whole chest. one must establish balance between the intercostals and the diaphragm for normal breathing and in order to prevent deformities. in my experience, cerebral palsied children who present speech difficulties due to improper breathing, have usually shown predominantly flexor patterns. adequate breath support for speech requires voluntary control of both inhalation and exhalation, with sufficient air intake for sustained phonation. furthermore, length of expiration must be adequate for a series of words to be spoken between breaths. the breathing rate of babies varies from twenty to forty per minute and by 2 years of age, should be in the low twenties. athetoids, due to fluctuations in muscle tone have rates which vary and therefore it is necessary to take several counts and then to average them. diaphragmatic breathing can be regarded as normal till 2 years of age; after this, there should be a visible lifting of the upper chest when breathing in. when the upper chest is depressed during inspiration, we get reversed breathing, which in a normal infant disappears within the first few months. if this reversed breathing pattern persists, the rib-cage will be reduced in size and it follows that the volume of air inhaled will be similarly reduced. where there is difficulty with expiration the prone position is most favourably used, as the chest is then in a position of expiration. watch for any spasm which will disrupt the expulsion of air. it is not sufficent to watch passive breathing patterns, one must see whether activity in other areas will trigger off involuntary activity in the muscles of respiration. to see whether this does in fact occur, let the child move his y arms or head while breathing and note the reaction. once breathing abnormalities are noted the best positions for facilitation must be found. these positions are never used statically. by using rotation as well as positioning, better breathing movements will be obtained. if there is spasm in the vocal cords, phonation will be interfered with. vocal cord ad2 journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) duction seems to be associated with extensor patterns and the child may extend the trunk and neck to assist adduction of cords if there is hypotonicity. in the athetoid, where there is fluctuation in the laryngeal muscle-tone, fluctuation in voice will result. one must ascertain that these fluctuations are due to the above, and not to poor breath support. to facilitate vocalisation vibrate on the fixed area, which may be the spine, chest, diaphragm or the larynx. once there is a rhythmic, co-ordinated breathing pattern, attention should be paid to encouraging sound production, depending on the abnormal patterns which exist, as has been discussed and remembering that, for a child whose pattern is predominantly one of extension, extensor sounds would not be facilitated and similarly with the predominantly flexed child, flexor sounds would not be the first to be facilitated. from this discussion it will be seen that success in treatment will depend on the linkup between the physiotherapist, occupational therapist and speech therapist. the cerebral palsied child presents a problem of control and development in all fields. the speech therapist must take into account both language and articulation. the language ability of the child is the concern of the speech therapist, and here she will guide the physiotherapist as well as the educationalist. when discussing this neuro-physiological approach, it must be remembered that the problem of aphasia is excluded. articulation is, of course, the concern of both the physiotherapist and the speech therapist. in dysarthrics, the disturbance of sensation around the oral area leads to lack of speech or, at best, indistinct articulation with great effort. often a difficulty in voluntarily closing the eyelids is seen in the dysarthrics, and is linked with bulbar palsy. i the isolated small movements of the face must relate to the isolated movements of the lips for speech, while any activity of the muscles pf the face will be related to the muscles bf the whole body. any spasm can change the position of the tongue or the jaw; this is seen in the subluxated jaw of the athetoid, 'or the retracted mandible of the spastic. spasm will naturally also involve the diaphragm and muscles of respiration, as well as the larynx. change in muscle tone affects movement and thus the articulation and voice of the patient. this is demonstrated in the athetoid, whose fluctuating muscle tone has such an effect on his speech, as well as the loudness and speed at which he can speak. for this reason it is better, at the beginning, to use single sounds. grading of stimuli, in this case the increase of speed of the speech required, will make speaking more difficult. speech is a complicated pattern of co-ordination between the body musculature and the fine co-ordination of the tongue. that is why we find good speech in children with head and neck control, and where the upper part of the body is least affected. as the muscles which control head and neck and shoulder girdle control the arms, it will be found that a child with no speech will often be unable to use his hands adequately. from this discussion of the difficulties relating to speech, breathing, the basic functions and hearing, will emerge the fact that the speech therapist now treats the child as a whole. this means that an even closer relationship must exist between the occupational therapist, physiotherapist and speech therapist because our work depends on the stage the child has reached in its physical developmental sequence. because the therapists have problems which affect them mutually, much can be gained from this close co-operation. it can also be seen that while the aims in speech therapy may not have changed over the past few years, this neuro-physiological approach to cerebral palsy, as advocated by the bobaths, has radically altered the attitude to the speech problems which arise. our ultimate goal is to develop speech as a means of communication, so that our aim will be the achievement of intelligible speech within the limits of each child's potential. we are realising more and more clearly that there are some cerebral palsied children, who, due to a bulbar involvement, will never speak. here we concentrate on increasing understanding of the spoken and written word, so that the child will be able to gain as much pleasure as possible through the use of these avenues. the importance of early diagnosis and treatment cannot be over emphasised and it is this which must be brought to the attention of medical practitioners throughout the december, 1962 journal of the south african l o o p e d i c society 3 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) country. once incorrect patterns have been established it is extremely difficult to break them down. it is for us to see that this is accomplished if the cerebral palsied child is to derive the maximum benefits which treatment can offer. summary the brain damage resulting in cerebral palsy leads to abnormalities in muscle tone. because of this abnormality and the dominance of abnormal reflexes, as well as the absence of higher postural reflexes, normal movements are impossible. the child cannot contract or relax individual muscle groups, nor can he move parts of the body independently. the approach discussed is a neurophysiological one, as advocated by dr. and mrs. bobath, and around which other techniques can be adapted. the aims of treatment are:— (1) to normalise muscle tone. (2) to inhibit the abnormal and primitive patterns in order to achieve the more normal sensations of speech, on a background of more normal muscle tone. (3) to establish head control as the fine and selective movements of the tongue, lips and larynx cannot occur unless there is fixation. (4) to correct any abnormalities in breathing as breathing is a prerequisite for speech. a rhythmic, co-ordinated breathing pattern must therefore be established. (5) to inhibit the bite reflex by holding the jaw open, and stimulating the inside of the mouth. (6) to mobilise the jaw of the spastic. in the athetoid the grading of jaw positions is important as they cannot achieve mid-positions. (7) to stimulate the teeth for chewing. (8) to inhibit the sucking reflex. (9) when the above has been achieved, facilitate speech sounds in the following order:— (a) vowels, (b) consonants and (c) combinations of vowels and consonants, which will facilitate babbling. (10) now guide and direct the tongue from under the chin, e.g. push the tongue forward and up to facilitate t,d,l, or n. push further back, directing the tongue up and back for k,g,ng. (11) watch for and correct any compensating movements the child might have. (12) study the feeding patterns and compare the stage at which the child is, with the feeding "norms". a careful assessment of the patient must be made, in consultation with a physiotherapist. from this assessment abnormalities will be noted, as well as the stage of development the child has reached. the therapist will also notice the pathological reactions which must be inhibited, as well as the normal ones which will be encouraged. early assessment is important because the earlier treatment is introduced, the more favourable will be the prognosis. once incorrect patterns have been established they are difficult to break down. the child must be treated as a whole and therefore close co-operation must exist between the occupational therapist, physiotherapist and speech therapist. opsomming die breinbesering wat serebrale verlamming veroorsaak, lei tot abnormaliteite in spiertonus. as gevolg van hierdie abnormaliteit en die oorheersing van abnormale reflekse, asook die afwesigheid van hoer houdingsreflekse, is normale bewegings onmoontlik. die kind kan nie afsonderlike spiergroepe saamtrek of verslap nie; hy kan nie liggaamsdele onafhanklik van mekaar beweeg nie. die benadering hier bespreek, is neurofisiologies van aard, soos voorgestaan deur dr. en mev. bobath, en ander tegnieke kan hierby aangepas word. die doele van behandeling is:— (1) om spiertonus terug te bring na die normale. (2) om die abnormale en primitiewe patrone te verhinder, en sodoende die meer normale reaksies van spraak te bereik, teen 'n agtergrond van meer normale spiertonus. (3) om beheer oor die kop te verkry en dit stil te hou, want die ifynere en selektiewe bewegings van die tong, lippe en strottehoof kan nie andersinds teweeggebring word nie. (4) om enige asemhalirigsabnormaliteite reg te stel, omdat asemhaling 'n voorvereiste is vir spraak. 'n ritmiese, gekoordineerde asemhalingspatroon moet dus verkry word. journal of the south african l o o p e d i c society 1 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) (5) om die bytrefleks te verhinder deur die kakebeen oop te hou en die binnekant van die mond te prikkel. (6) om die kakebeen van 'n spastiese pasient te mobiliseer. by die atetotiese pasient is die gradering van kakebeenposisies belangrik, aangesien geen tussenposisies verkry kan word nie. (7) stimuleer die tande vir koubewegings. (8) verhinder die suigrefleks. (9) nadat die bogenoemde bereik is, kan met die aanmoediging van spraakklanke in die volgende volgorde begin word:— (a) klinkers (b) medeklinkers (c) kombinasies van (a) en (b) wat brabbeltaal sal aanhelp. (10) lei en beweeg die tong nou van onder die ken af bv. stoot die tong vorentoe en op vir t, d, 1, of n. stoot verder terug en beweeg die tong op en terug vir k, g, ng. (11) let op na, en verbeter enige kompensasie bewegings wat die pasient mag openbaar. (12) bestudeer die voedingspatrone en vergelyk die stadium waarop die pasient is, met die voedings-,norme'. 'n noukeurige opsomming moet van die pasient gemaak word in samewerking met 'n fisioterapeut. hiervolgens kan abnormaliteite onderskei word, asook die stadium van ontwikkeling waarin die pasient hom bevind. die terapeut moet ook die patologiese reaksies wat verhinder moet word, merk, asook die normales wat aangemoedig sal word. vroegtydige diagnose is belangrik, want hoe vroeer met behandeling begin kan word, hoe beter die prognose. as verkeerde patrone eers gestabiliseer is, is dit moeilik om hulle af te breek. die pasient moet ook as 'n geheel behandel word en dus is noue samewerking tussen die beroepsterapeut, fisioterapeut en spraakterapeut noodsaaklik. bibliography 1. bobath, k. and b., "personal communication". london. 1962. 2. bobath, k. and b., "spastic paralysis, treatment by use of reflex inhibition." british journal of physical medicine, vol. 13, june 1950. 3. bobath, k. and b., "a treatment of cerebral palsy based on the analysis of the patient's motor behaviour." british journal of physical medicine, vol. 25, may 1952. 4. bobath, b. "the treatment of motor disorders of pyramidal and extra-pyramidal origin by reflex inhibition and facilitation of movement." physiotherapy, may 1952. 5. bobath, b., "control of postures and movement in the treatment of cerebral palsy." physiotherapy, 1953. 6. bobath, k. and b., notes from a post-graduate lecture course. 7. illingworth, r. s., "recent advances in cerebral palsy." london. j. & h. churchill ltd., 1958. 8. wright, samson. "applied physiology." oxford university press. 1952. 9. gesell, α., "the first five years of life." new york. harper bros. 1950. 10. gesell, a. and armatruda. "developmental diagnosis." new york. paul b. hober inc.. 1947. 11. jacobson, e., "progressive relaxation" chicago. university press. 1938. december, 1962 journal of the south african l o o p e d i c society 3 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) concept formation in the speaking autistic child m x r l e n e n o a c h , b . a . , s p . & h . t h . ( r a n d ) department of speech pathology and audiology, university of the witwatersrand, johannesburg examination of the case histories of speaking austistic children reveals instances of compulsive concreteness in thought and action. their global intellectual functioning, their perception and their language in particular, seem to reflect a disturbance in the capacity for concept formation. they are known for their "islets of intelligence" against a background "of serious retardation.2 kanner9 has indicated that their "striking physiognomies" relate to their excellent rote memory for poems and names, and the precise recollection of complex patterns and sequences. these activities are essentially concrete and are used in a stereotyped and compulsive manner. goldstein and scheerer4 have shown that this type of behaviour is indicative of an impairment in abstract attitude.* • the abnormal perceptual experience of autistic children—their, characteristic "visual and auditory avoidance"16 further supports speculation regarding a disturbance in concept formation, which occupies a higher level than perception in the hierarchies of experience. . many aspects of their language further support this postulation, such as the lack of spontaneous utterances and their echolalia. the latter may well be interpreted as "stereotyped attempts to assimilate experience successfully" as proposed by myklebust.11 their echolalia may be regarded as a mechanism used for coping with their inability to assimilate language in-its symbolic meaning. kanner6 has spokenof the "literalness" characteristically present in their language. some apt examples should illustrate this: one child learned to sav "yes" when his father told him that he would put him on his shoulders if he said "ves". this word then came to mean and express only the desire to be put on his father's shoulders.6 john f. corrected his father's statement about pictures on the wall"—the pictures were "near the wall".10 it is apparent that meaning can only be used with reference to the original acquired connotation. this is again displayed in their "metaphorical expressions"—an apparent discrepant characteristic in the •abstract attitude implies the conscious and volitional activity of abstracting common from particular properties and synthesizing these. the individual thing represents a concept or category. tydskrif van die suid-afrikaanse vereniging vir spraak en gehoorheelkunde, vol 18, desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 40 marlene n o a c h clinical picture. kanner7 was able to trace these "irrelevant phrases" to their original sources and to learn that these peculiar expressions, out of place in ordinary conversation, assume definite meaning. from the following evidence, one may infer that concepts are well within the autistic child's scope: gary t. at five years, designated a bread basket as "home bakery". he did not stop there. after this, every basket to him became a "home bakery".7 their conceptual ability, however, becomes questionable when one considers the case of "idiot savant", whose case history is similar in a number of aspects to that of children with early childhood autism. scheerer, rothmann and goldstein13 proposed that this child produced abstract words in the "situational sense of his concrete realism", rather than in their abstract meaning. this would appear to be the more logical interpretation of the irrelevant and metaphorical utterances of the autistic children, so that it could be speculated that they are in fact functioning at an extremely concrete level. rutter1 2 has reported a number of experiments carried out by hermelin and o'connor in which they examined the coding and immediate recall in autistic subjects. these children did not use concepts or association in memorizing words as did the normal subjects. in addition, it w^s found that autistic children were more likely to remember nonsense phrases than normal children, so that it was concluded that their verbal recall was independent of meaning. since no studies known to the writer have been conducted to experimentally investigate the concept formation in autistic children, it was felt that such a study could yield useful information which could have important implications for a wide range of behaviour. method the aim of this investigation was to determine the structure of concept formation on different levels of its development in speaking autistic children. the data will be discussed in relation to that of a group of normal children selected to form a basis for comparison. the test used was modelled on a test suggested by hanfmann and kasanin5, who are ardent followers of vygotsky. they modified and standardized the methods used by vygotsky in his many valuable studies, of concept formation. subjects the experimental group consisted of four female, speaking autistic children of different ages. these subjects were selected in terms of the following criteria: ' (a) diagnosis of autism by a psychiatrist. subjects who developed autism as a result of any disease process were not included in this study. journal of the south african speech and hearing association, vol. 18, december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) concept f o r m a t i o n in speaking autistic child 41 (b) the presence of speech, regardless of peculiarities. (c) case histories indicating one of kanner's two premises for a diagnosis of early childhood autism. these have been universally accepted as the two cardinal features of autism— (i) an inability to relate to people in an ordinary way; (ii) insistence on the preservation of sameness and sustained resistance to change. the comparative group of normal children was matched in pairs as closely as possible for chronological age, sex, socio-economic status, and language medium. the subjects were not matched for intelligence and the writer is aware of the severe limitation this poses to an accurate comparison of the two groups. however, i.q. scores could not be taken into account as those available for the autistic children were particularly noted for their unreliability. the age range was 8 years 9 months to 14 years 4 months. (table 1.) materials ' the materials consisted of 22 cardboard blocks varying in a. number of aspects, viz. colour, shape, height and size. (figure 1.) figure 1. organization of blocks to illustrate their different attributes one of four, nonsense syllables (lag, mur, bik, cev) was written on the underside of each block which was not visible to the subject. regardless of colour, "lag" was written on all large, tall blocks, "bik" on all large, flat blocks, "mur" on all small, tall blocks and "cev" on the small, flat ones. it is thus apparent that the materials provided the perceptual experience necessary for the abstraction of traits, as well as the word, which the soviet psychologists believe to be essential in aiding the process of concept formation. the aim of the test was for the subjects to classify the blocks according to height and size, ignoring the other aspects. at the beginning of the test, all the blocks, well-distributed as to colour and size, were arranged on the circular area of a square board, the remainder of which was divided into four spaces. (figure 2.) tydskrif van die suid-afrikaanse vereniging vir spraak-en gehoorheelkunde, vol. , desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 42 marlene n o a c h the subject was told that there were four different kinds of blocks and that each kind had a name. each kind was to be sorted into a separate corner space. the experimenter turned up one of the blocks, exposed its name to the subject and suggested that he select those blocks which he thought might belong to the same kind. after he had done so, the experimenter exposed one of the incorrectly selected blocks, stated that it was a block of a different kind and that it had a different name and s u g g e s t e d further attempts at the task. the correction process was repeated after each new attempt, until either the principle of figure 2. presentation of blocks at the beginning of the test. classification was discovered, or the blocks were classified through all having been turned up by the experimenter. it is thus evident that in the task, word-meaning developed. the word which was originally a nonsense wcjrd came to represent certain characteristics in the blocks, i.e. the w o r d ; " represented the desired concept. this test was felt to be particularly suitable for use with autistic children since it allowed a freedom of procedure on the part of the s u b j e c t s . ..furthermore, its, value lies in a detailed qualitative analysis of their performance. many examiners who have attempted to investigate the behavioural" and cognitive aspects of autistic children have terminated their investigations with the bland statement; "this child is untestable". this has been particularly the case with tests scored according to a pass/fail dichotomy. this test does not rely on quantitative measures. procedures administration of the test • / the test was administered individually to each subject in "the appropriate language medium. a number of additional techniques were used in testing the autistic children,, for example, "techniques of structure" or "adaptive teaching techniques". these have been recommended by an american investigator, davis,3 who used them for an appraisal of the language and learning behaviour of autistic children. the technique involves the controlling of stimulus modalities by blocking others that might interfere, e.g. subject's eyes are covered while the experimenter journal of the south african speech'and hearing association, vol, 18, december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) concept formation in speaking autistic child 43 talks directly into her ear, or the experimenter cups her hands on the sides of the child's face, blocking the peripheral vision, so that the child can look only where directed. in view of the autistic child's preference for the proximal senses, they were encouraged to hold and feel the blocks so as to facilitate better identification. testing was often lengthy but no breaks were given during, testing. sweets were used for motivation. a tape recording was made of the entire testing procedure. an independent observer made detailed records of the corrections made by the experimenter and the selections made by the subjects. the tape recordings and written record were then combined for purposes of analysis. ranking of the subjects before the data was analysed, the autistic children were ranked in order of the severity of their autism from 1, the clinically most severely affected child, to 4, the clinically most normal child. this ranking procedure was adopted in order to compare the severity of autism with the level of conceptual attainment. a nalysis the independent records of each child were analysed qualitatively according to vygotsky's15 developmental stages in the ascent to concept formation. these range from syncretic thinking, through complex thinking with its various levels of complex formation, to true conceptual thinking. bruner and olver's2 "multiple grouping complex" was applied to the test performance of subject al. (table 1.) results and discussion due to the length of the records of subjects, a schematic representation of each subject's performance will be provided. (table 1.) the subjects are presented in order of the ranking of the autistic subjects. it may be seen that the autistic group is uniformly inferior to the normal. (i). each autistic subject was at a more primitive stage in the .development of conceptual ability than the normal subject. (ii) the entire group of autistic subjects displayed syncretic thinking at one stage or another, whereas there was an absence of the formation of a syncretic image in· the normal group. syncretic thinking, is displayed in the experimental task when the subject places a number of unrelated blocks randomly in one group· or by virtue of their spatial position on the board.1 5 tydskrif van. die suid-afrikaanse vereniging vir spraak.-.en gehoorheelkunde, vol. 18, desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 marlene n o a c h (iii) at no stage during the experiment did the autistic children adopt a conceptual procedure. the entire group cf normal children showed a capacity for conceptual thinking. it is further evident that both groups used complex thinking at one stage or another. complex thinking is a more objective type of thinking than syncretic. it is objective in that bonds are observed in the experimental material, but it is differentiated from the conceptual approach by the fact that these bonds are concrete and factual rather than abstract and logical.15 autistic normal a.l age: 11.8 1. syncretism 2. multiple grouping complex 3. associative complex 4. multiple grouping complex n.l age: 11.6 1. genuine concept 2. collection complex 3. collection complex based on mixed principles 4. potential concept 5. genuine concept a.2 . age: 9.0 1. syncretism 2. syncretism combined with associative complex 3. syncretism n.2 age: 9.0 1. potential concept 2. diffuse complex 3. pseudo concept 4. diffuse complex 5. potential concept a. 3 age: 14.4 1. syncretism 2. collection complex 3. collection based on mixed principles 4. collection complex n.3 age: 14.4 1. genuine concept a.4 age: 8.9 1. syncretism 2. chain complex 3. associative complex 4. collection complex based on mixed principles 5. collection complex n.4 age: 8.9 1. potential concept 2. genuine concept table 1: developmental sequence of forms of thinking employed by the subjects in the experimental task obvious differences in the usage of complex thinking do exist. in the autistic group, this was the highest phase of development, whereas in the normal group complex thinking preceded the conceptual approach. on the basis of this, it may be concluded that the difference between the two groups is not that the normal group will never/use a more primitive procedure, but that they can use a conceptual one. the hypothesis of a general·disturbance in concept formation may therefore be accepted. concerning the nature of the disturbance, the possibility of a developmental delay appears to be negated by the fact that the same phase of concept formation was reached. by the subjects regardless of the age differences. regression to more primitive stages has been proposed, on the basis of the data, to be related to the severity of the autism journal of the south african speech and hearing association, vol. 18, december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) concept f o r m a t i o n in speaking autistic child 45 since progressively more complicated forms of complex formation were used by the clinically more normal children. it seems, therefore, that the nature of the disturbance is an impairment. this may further be substantiated by the fact that vygotsky14 found schizophrenic adults to be incapable of conceptual thinking and to exist at the complex thinking phase of development. if we go along with the early theories that autism may be classified in the psychiatric nosology as the "earliest stage in the development of schizophrenia",8 then it appears that since both groups exist at the same level of conceptual attainment, that there may be a general impairment of concept formation in the psychiatric disorder. it was interesting to note and, in fact, this appears to substantiate the findings analysed according to vygotsky's theory, that the autistic subjects showed the characteristics of "lack of shifting" or "rigidity" in their approach to the task, as well as the characteristic of "extreme susceptibility to stimuli". these characteristics are well-known in braininjured patients. goldstein and scheerer4 have actually stated that they are a direct result of a concrete attitude. conclusions and implications on the basis of the data obtained from this investigation, it may be concluded that the autistic children showed an impairment in concept formation, existing at a lower developmental level than the comparative normal group. findings apply legitimately only to the subjects used in this study due to limitations inherent in the experimental methods. despite limitations it is felt that the results do give an indication of the problems involved in the development of conceptual skills in speaking autistic children. it would seem essential in therapy to devise a programme to develop their conceptual abilities. there is a tendency in therapy to teach concepts by the mere association of the word with the object. by viewing conceptualization as the highest point on a continuum, from perception, through abstraction and generalization to conceptualization, it would be illogical to begin with conceptualization. therapy should first be directed at improving their perceptual abilities. the children should then be given basic training in the processes of abstraction and generalization. they may be taught to compare objects in terms of their differing attributes, then to sort and classify the common abstracted elements. in an attempt to make their thought processes less rigid, generalizations to new situations should be taught. by applying this therapy programme, concept formation will be effected by an "active intellectual process"15 guided by the role of language, rather than by the association of verbal symbols and objects which vygotsky has shown to be insufficient for true concept formation. a similar study with a more representative sample and a number of subjects at each age level, together with the use of a battery of concept tydskrif van die suid-afrikaanse vereniging vir spraak-en gehoorheelkunde, vol. 18, desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 marlene noach / formation tests, could yield more conclusive evidence of the findings of this study. should the findings be substantiated, a further aetiological consideration could be put forward to support an organic theory of early childhood autism. by a study of this kind, we may be given better insight into the cardinal features of autism. deprived of the organizing role of concepts to give .order to their sensations, they cope by withdrawing "to seek comfort in solitude"8 rather than to exist in a chaotic world of a multitude of^stimuli. conceptualization permits a manipulation of the "hypothetical world". possessing an impairment in this function of prediction and manipulation of experience, they cope by insisting on the preservation of sameness, resisting change with every effort so as to provide a degree of stability in the face of ever-changing environmental demands. a further investigation comparing the concept formation of speaking and mute autistic children could provide an indication into, the possible existing differences between these two groups in terms of their concept formation. as language has been noted to be an important factor indicating prognosis, so ability for concept formation may possibly be regarded as a further prognostic indicator. summary the aim of this investigation was to determine the structure of concept formation on different levels of its development in speaking autistic children. a modified form of the hanfmann-kasanin test of concept formation was administered to four female speaking autistic children. a control group was selected for; comparative purposes. it was established by a qualitative analysis according to vygotsky's theory that the autistic group was uniformly inferior to the normal group in their capacity for concept formation. it was concluded that these children showed an impairment in concept formation. opsomming die doel van hierdie ondersoek was om die struktuur van konsepvorming op verskillende vlakke van ontwikkeling in outistiese kinders, wat die vermoe besit om te praat, vas te stel. die hanfmann-kasanintoets vir konsepvorming is gewysig en toegepas op vier vroulike, pratende outistiese kinders. 'n kontrolegroep is geselekteer vir vergelykende doeleindes. daar is deur middel van 'n kwalitatiewe analise volgens vygotsky se teorie vasgestel dat die outistiese groep as geheel minderwaardig is in hul vermoe tot konsepvorming in vergelyking met die'normale groep. die afleiding is dus gemaak dat hierdie kinders 'n defek toon in konsepvorming. references 1 bruner j. s. and olver, r. r. (1965): development of equivalence transformation in children. in readings in the psychology of cognition ed. anderson, r. c. and ausabel, d. p. holt, rinehart and winston, inc., new york! journal of the south african speech and hearing association, vol. 18, december 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) concept f o r m a t i o n in speaking autistic child 47 2. creak, ε. m. (1963): childhood psychosis: a review of one hundred cases. british journal of psychiatry, 109. 3. davis, b. j. (1967): a clinical method of the appraisal of language and learning behaviour of young autistic children. journal of communication disorders, 1, 277-296. 4. goldstein, k. and scheerer, m. (1941): abstract and concrete behaviour. an experimental study with special tests. psychological monographs, 53:2, 1-149. 5. hanfmann, e. and kasanin, j. (1937): a method for the study of concept formation. journal of psychology, 3, 521-540. 6. kanner, l. (1944): early infantile autism. journal of paediatrics, 25:2, 211-217. 7. kanner, l. (1946): irrelevant and metaphorical language in early infantile autism. american journal of psychiatry, 103, 242-246. 8. kanner, l. (1949): problems of nosology and psychodynamics of early infantile autism. american journal of orthopsychiatry, 19, 416-426. 9. kanner, l. (1957): child psychiatry. chapter 49. charles c. thomas, publisher, springfield, illinois. third edition. 10. kanner, l. and lesser, l. i. (1958): early infantile autism. paediatric clinics of north america, 5:3, 711-729. 11. myklebust, h. r. (1957): babbling and echolalia in language theory. journal of speech and hearing disorders, 22, 356-360. 12. rutter, m. (1968): concepts of autism: a review of research. journal of child psychology and psychiatry, 9:1, 1-25. 13. scheerer, m., rothmann, e. and goldstein, k. (1945): a case of "idiot savant": an experimental study of personality organization. psychological monographs, 58:4, 1-61. 14. vygotsky, l. s. (1934): thought in schizophrenia. translated bv j. kasanin. archives of neurology and psychiatry, 31:5, 1063-1077. 15. vygotsky, l. s. (1962): thought and language. the m.i.t. press. 16. wing, j. k. (1966): diagnosis, epidemiology, aetiology. chapter 1 in early childhood autism : clinical, educational and social aspects. ed. wing, j. k. pergamon press, london. tydskrif van die suid-afrikaanse vereniging vir spraak-en gehoorheelkunde, vol. 18, desember 1971 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction background methodology results and discussion conclusion acknowledgements references appendix 1 footnotes about the author(s) anna wium centre for medical ethics and law, university of stellenbosch, south africa berna gerber centre for medical ethics and law, university of stellenbosch, south africa citation wium, a., & gerber, b. (2016). ototoxicity management: an investigation into doctors’ knowledge and practices, and the roles of audiologists in a tertiary hospital. south african journal of communication disorders, 63(1), a174. http://dx.doi.org/10.4102/sajcd.v63i1.174 research project no.: s14/04/082 original research ototoxicity management: an investigation into doctors’ knowledge and practices, and the roles of audiologists in a tertiary hospital anna wium, berna gerber received: 25 july 2016; accepted: 22 sept. 2016; published: 01 dec. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: a significant number of medications that are prescribed by doctors to treat cancers, tuberculosis and infections are ototoxic. disclosure of ototoxic risks is ethical practice as patients have the right to be properly informed about and involved in decisions about their health care. often, doctors fail to disclose such information. aim: this research investigated whether a group of doctors working in a south african academic hospital inform their patients about the ototoxic risks associated with specific medications, and if not, explore the reasons for it. it was determined what the participants’ knowledge levels of ototoxicity were as knowledge is seen as a precursor to disclosing information to their patients. a further aim of the research was to determine whether audiologists should expand their role by sharing information with patients and other professionals in the management of ototoxicity and in the hospital. method: there were 90 participants included in the study through convenience sampling, which represented interns, medical officers, registrars and consultants in the neonatal intensive care unit, intensive care unit, ear–nose–throat, and internal and family medicine departments. the research made use of a descriptive survey design that collected mainly quantitative data and a limited amount of qualitative data through questionnaires. the data were descriptively analysed, and the qualitative data were listed and quantified. results: the research firstly determined the participants’ knowledge and understanding of ototoxicity, and it was found that there was room for improvement. with reference to the current practices of doctors in the prescription of ototoxic medicines, it was found that disclosure of ototoxic risks was limited, mostly because of a lack of time and insufficient knowledge. in comparing knowledge and practices between levels of employment, it was found that particular post levels performed better than others. the participants regarded the role of the audiologist as team member important, although very few referred their patients for audiological monitoring when they prescribe ototoxic medication. conclusion: a need for additional support to doctors was identified, which indicates that audiologists should expand their role to include the provision of continued professional development activities and to renew their efforts to advocate their role in the hospital so that doctors are made aware of the importance to refer their patients for ototoxic screening and monitoring. introduction much progress has been made in terms of clients’ rights within the health care environment. such changes place the actions of health care professionals under an ethical magnifying glass and require revisiting the concept of professionalism. medicine is regarded as a profession, and it implies ‘… a commitment to serving the public so that patients1 receive the benefit of health’ (moodley, 2013b, p. 4). when considering the fiduciary relationship that exists between health care professionals and patients, professionalism can be seen as ‘… acting out the values and beliefs in individuals who serve those whose well-being is entrusted to them by putting the client’s interests first’ (kirk, 2007, p. 13). it is important that each individual within a health care team acts responsibly and in the patient’s best interest, and see to it that their colleagues also do so (moodley, 2013a). health care professionals’ duties towards their patients include providing patients with the necessary information, in a manner that the patients can understand, so that patients can exercise their right to autonomous decision-making about the health care they receive (beauchamp & childress, 2013). this research investigates informed consent and disclosure of important information in the management of ototoxicity. it aims to determine what doctors’ knowledge of ototoxic medication is, and whether doctors as a rule disclose ototoxic risks to their patients and, if not, to find the reasons for their not doing so. knowledge is seen as a precursor to disclosing such information to their patients. should it be determined that the participants had insufficient knowledge of ototoxicity to adequately inform their patients about the risks, the aim of the research was to determine whether audiologists, as part of the health care team and in a supportive role, should expand their role in the management of ototoxicity to do so. the research, therefore, falls within the field of descriptive ethics as it investigates the moral behaviour of a group of doctors working in a tertiary hospital. a significant number of medications that are prescribed by doctors to treat cancers, tuberculosis (tb) and infections cause damage to the inner ear, and therefore are ototoxic (schellack & naude, 2013). population groups at risk for ototoxic treatments include patients suffering from infections, those in oncology units, patients with renal failure and newborn babies in neonatal intensive care units (nicu) (engler, schellack & naude, 2013). in most cases, patients who are admitted to hospital wards are extremely sick and are desperate to have their conditions treated. this desperation for better health places them in a vulnerable position where they often unconditionally accept the doctor’s advice regarding how their condition should be treated. they trust that their doctors know and will do what is best for them (moodley, 2013b) and do not necessarily question the risks attached to their treatment. as a rule, doctors should select the most cost-effective and least toxic medication necessary to effectively treat their patients. doctors have an ethical and professional duty to disclose the potential harm of medication (including ototoxic medication) that they prescribe and to obtain informed consent from patients prior to treatment. should doctors not disclose information (such as adverse effects of medicines), it can be considered as unethical practice. the problem of insufficient patient involvement in decision-making can be exacerbated in contexts such as south africa, where linguistic and cultural divides between health care professionals and patients are common. furthermore, patients with low levels of education and literacy are vulnerable to have their right to autonomous decision-making compromised. sadly, there are many such patients who make use of the public health care service in south africa. background with the focus of this study on ototoxicity and informed consent, it is necessary to address some key concepts, namely the nature of ototoxicity and ototoxic medication as well as the management of ototoxicity from an ethical perspective. this includes a discussion on the role of the audiologist in the management of ototoxicity. ototoxicity patients at risk of the effects of ototoxicity (dobie, black, pezsnecker & stallings, 2006) typically include those receiving treatment for tb, those in oncology units or those who are suffering from renal failure. newborn and/or premature babies who are put on such medication in nicu may also be at risk. patients most likely to develop ototoxicity-related adverse effects appear to have a genetic tendency because of a mutation in the mitochondrial rna in cells of the organ of corti (banotai, 2004). roland and rutka (2004) described ototoxicity as the tendency of certain substances, which are administered either in a systemic or topical manner, to cause functional impairment and cellular damage to the tissue of the inner ear, especially to the end organs of the cochlear and vestibular divisions of the eighth cranial nerve. ototoxic drugs (aminoglycosides and antineoplastic drugs) can create damage to the basal region of the cochlea, which will affect the perception of high-frequency sounds and later can also affect the apex of the cochlea where the perception of low-frequency sounds originate from (schellack & naude, 2013). such medication could cause permanent sensorineural hearing loss, tinnitus and/or disequilibrium, as well as difficulty to understand speech in background noise. the damage can present as either cochlear toxicity (damage to the cochlea) or vestibular toxicity (damage to the vestibular system) or both (selimoglu, 2013). cochlear toxicity can result in sensory neural hearing loss with permanent tinnitus and hyperacusis. patients may find it difficult to discriminate voice from background noise. when the vestibular system is damaged, patients present with disequilibrium, ataxia, nystagmus, oscillopsia and vertigo (selimoglu, 2013). although sources differ, it is estimated that aminoglycosides affect approximately 33% of patients (cheng, huth & ricci, 2011), and chemotherapy drugs (e.g. cisplatin or carboplatin) affect 22%–70% of patients (banotai, 2004; yansey et al., 2012). ototoxic drugs include antibiotics (e.g. gentamicin, tobramycin and amikacin), loop diuretics (e.g. furosemide) and platinum-based chemotherapy agents, such as cisplatin (hellberg et al., 2009). other ototoxic medication includes macrolide antibiotics, quinine derivatives and also nonsteroidal anti-inflammatory drugs, which could cause temporary hearing loss that is reversible (professional board for speech language and hearing professions, 2015). the probability of ototoxicity can be decreased if the administration of aminoglycosides is monitored using pharmacokinetic principles (banotai, 2004). aminoglycoside-related ototoxicity, as well as that caused by platinum-based chemotherapy agents, is irreversible (selimoglu, 2013). the ototoxic effect of loop diuretics (e.g. furosemide and ethacrynic acid), macrolide antibiotics (e.g. clarithromycin and erythromycin) and antimalarial drugs (e.g. chloroquine and quinine) is temporary and/or reversible. it is, however, possible that a pre-existing hearing condition was present before taking the ototoxic drugs, which may then cause an additional high-frequency hearing loss or exacerbate an existing high-frequency hearing loss. adequate hearing from birth onwards is essential for language development and later literacy development (paul & norbury, 2012). the impact of hearing loss on the quality of life is detrimental (konrad-martin et al., 2005) and, therefore, should be prevented as far as possible through careful monitoring and management of ototoxic medication. management of ototoxicity from an ethical perspective ethical behaviour is expected from health care professionals, at least since the time of ancient greek physician hippocrates, who advocated the principle of primum non nocere (moodley, 2013a, p. 5). finally, the emphasis in healthcare ethics is on patients’ rights, as well as teamwork (naude & bornman, 2014). patients have the right to be informed about their health care options, particularly if there is a risk of serious side effects such as hearing impairment or potential deafness. a decision in favour of ototoxic treatment based on the net benefit of treatment fits in well with the principlism approach to bioethics, which emphasises the four ethical principles of respect for autonomy, beneficence, non-maleficence and justice. within the principlism approach (van niekerk, 2013), these principles are not viewed as absolute but rather as prima facie, meaning that they need not and cannot be followed without exception. in deciding which course of action to follow in a specific situation, the relevant principles and the rules stemming from them should be weighed and balanced, and the principle(s) that carry the most weight (from a moral standpoint) in the particular circumstances should be adhered to. when discussing ototoxicity from an ethical perspective, the focus is particularly on the principles of respect for autonomy, beneficence and non-maleficence. respect for patient autonomy the bioethical principle of respect for patient autonomy creates four obligations for health care professionals, namely informed consent, confidentiality, truth telling and communication (moodley, 2013c). informed consent includes the process of providing the necessary information to patients about their health care options, particularly when there are risks involved (such as hearing impairment or potential deafness), so that they can make informed choices about the course of action to follow. it is the right of the patient to receive a sufficient explanation of his or her condition, the possible treatment options, the risks and benefits associated with each of these options, and the prognosis without treatment. the process of informed consent also requires engagement with the patient before a treatment decision is reached. informed choices are dependent on the nature and quality of the information provided. according to south african law, such choices should be exercised by adults (> 18 years), and whenever children or adolescents (< 18 years) are involved the parent or guardian must be informed about the risks of treatment (south african government gazette, 2005). children >12 years can provide consent to their own medical care, provided they have the mental capacity to understand the risks, benefits and other implications of the treatment (south african government gazette, 2005). beauchamp and childress (2013) described the elements of informed consent: informed consent to an intervention can be provided only when one is competent to act and has received a thorough disclosure of core information and comprehend such a disclosure. once the information has been provided, it is necessary to assess the patient’s understanding thereof. accompanying the disclosure should be a recommendation of a plan of action (including alternatives), which can then be accepted or rejected by the patient. patient’s consent to the intervention should be voluntarily. beneficence and non-maleficence beneficence refers to actively promoting and seeking what is in the patient’s best interest and considers the patient’s pain, and the risk of disability and death (emanuel et al., 2008). closely related to the principle of beneficence, non-maleficence refers to the obligation to ‘do no harm’. in the case of ototoxicity, the risk of hearing impairment can be seen as a harm that is outweighed by the greater harm of the risk of death or serious disease. the benefits (avoidance of death and possible recovery) outweigh the potential harm of treatment (e.g. hearing and/or vestibular impairment). doctors’ ethical reasoning is often heavily influenced by deontology and utilitarianism, which both consider the question: ‘what is the right thing to do?’. when doctors prescribe ototoxic medication, their decisions mostly are based on a consequentialist view where the morality of the decision stems from the expected outcome or result (healing and avoidance of death) (van niekerk, 2013). in the case of ototoxicity, the one extreme can be seen as a matter of ‘death versus deaf’. such an approach aims to be impartial and does not consider aspects such as attachment in special relationships or concern for those towards whom one has a specific social role as important in ethical reasoning and decision-making. there is no room for special circumstances and relationships in such rule-based decision-making processes. a theory which values the role of relationships, emotions and special circumstances in making decisions is the ethics of care (eoc), which will be discussed in the following section. the ethics of care gilligan (1982) was of the opinion that the emotions and certain character traits, including the capacity for sympathy, form an important part of ethical decision-making, a perspective that is referred to as the eoc. the eoc is suitable for the clinical health care context because the health care professional (e.g. the doctor and the audiologist) should be responsive to the patients’ and their caregivers’ needs, and show concern for them. it is well suited to deal with decision-making and difficult discussions within health care, such as disclosures, which typically involves participation of the patient’s family with the health care team in a supportive role (gerber, 2013). the roles of the audiologist (health professions council of south africa, 2005) resonate well with such a perspective. the eoc perspective developed from virtue ethics and is the moral perspective most closely identified with modern feminist philosophy (van niekerk, 2013). the contention is not that the rule-based traditional moral theories are erroneous, but rather that they account for only a part of the whole moral world. prominence is given to care within personal relationships and specific circumstances. patients who are very sick, are prescribed ototoxic medication and are at risk for hearing loss find themselves in a vulnerable position and are in need of emotional and informational support. from an eoc perspective, the management of such a patient turns the focus from what one should do (the right action) to how the action should be performed (emphasis on the relationships and the role of the emotions in morality). there is, thus, a difference in emphasis rather than a difference in primary values. the eoc perspective thus supplements rather than replace the traditional theories. the significance of care within the audiologist–patient or audiologist–client relationship that stems from their professional roles empowers audiologists to not only treat the disorder (scientifically) but also attend to the psychosocial aspects of the patient’s situation (naude & bornman, 2014). such an approach favours both the audiologist and the patient. audiologists and ototoxicity professional ethics call for a commitment to patients and to other health care professionals. audiologists are bound by their professional code of ethics, which relies on the four principles of common morality (van niekerk, 2013): respect for autonomy, beneficence, non-maleficence and justice. the roles of audiologists (stach, 2010) include the prevention, identification, assessment, diagnosis, rehabilitation, counselling, advocacy or consultation, as well as education, research and administration related to hearing and balance disorders. such roles are nurtured throughout their professional training with the main focus on the development of professionalism. in terms of ototoxicity management, a much narrower role has been described for the audiologist by the professional board for speech language and hearing professions (2015), which specify assessment of baseline hearing sensitivity prior to treatment, the monitoring of hearing at regular intervals, management of hearing impairment, as well as vestibular assessment and management (professional board for speech language and hearing professions, 2015). although these roles are essential in the management of ototoxicity, they may need to be revisited to accommodate more of a supportive role in addition to their existing roles. although audiologists are bound by the four principles of bioethics (van niekerk, 2013), the nature of their work enables them to develop partnerships with their clients. an eoc view on morality is, therefore, also suitable when managing ototoxicity and hearing loss. ototoxicity can impact negatively on communication, coping skills and quality of life. it is, therefore, of crucial importance that the ototoxic effect of medication be determined as soon as possible (konrad-martin et al., 2005). audiologists have an important role in monitoring ototoxicity that affects cochlear and vestibular function (e.g. aminoglycoside or cisplatin ototoxicity) (professional board for speech language and hearing professions, 2015). monitoring of ototoxicity is performed through a series of hearing tests, which include basic audiometry, high-frequency audiometry, oto-acoustic emissions, automated auditory brainstem responses, vestibulotoxicity monitoring and the dizziness handicap inventory (hall, 2000). such monitoring should continue even after patients have stopped taking the ototoxic medication. from bedside tests, they can determine adverse effects that affect the hearing and balance and notify the doctor immediately. any changes in the cochlear function of the patient are likely to be first detected by the audiologist and should be reported to the patient, his or her family and the other members of the health care team (katz, medwetsky, burkard & hood, 2009). early identification of hearing loss allows for timely counselling of the patient and his or her significant others (professional board for speech language and hearing professions, 2015). counselling of patients with hearing loss as a result of ototoxic medication implies that audiologists provide patients and their families with information on the symptoms of ototoxicity, side effects of certain medicines, otoprotective strategies and management of hearing loss (which may include fitting the client with a hearing aid) in order to help the patient make informed decisions about the treatment options should he or she present with hearing loss. patients have a right to be informed of the possible side effects of their prescribed medicine and the management of ototoxicity. audiologists also have an educational role to play towards other members of the health care team in terms of providing information and training on relevant topics (e.g. hearing loss and ototoxicity). ototoxicity and informed consent patients have a right to make informed decisions regarding their health and treatment. some prescribed medications present an ototoxic risk to patients. although it is expected that professionals will act responsibly and to the benefit of their patients, doctors may not necessarily inform their patients about the potential risks of certain medicines. in the case of ototoxicity, ethical practice requires that patients be made aware of the name of the drug, the dosage and administration and how it is absorbed and excreted, the kidney and liver function and the potential risks for ototoxicity. not all hospitals have such protocols and services in place. in addition, doctors may tend to focus more on treating the primary pathology than the patient holistically (de andrade, hajat & khoza-shangase, 2009). this then brings one to the question as to what the role of the audiologist should be in this instance. considering the roles of audiologists (health professions council of south africa, 2005), the management of ototoxicity falls within their scope of practice (stach, 2010). should audiologists not take it upon themselves to provide more patient-centred care to patients and disclose information on ototoxicity? during their training, audiologists are encouraged to provide patient-centred services which entail aspects of respect, provision of emotional support and physical comfort, disseminating information through effective communication (that also includes the involvement of family and carers), care coordination and access to care (gerteis, edgman, levitan, daley & delbanco, 1993). methodology aim and objectives of the research the aim of this research was to determine what doctors’ practices were with regard to the prescription of ototoxic medications and what their perceptions were regarding the role (and potential role) of audiologists in the management of ototoxicity at a tertiary institution in a semi-rural context. the objectives of the research were as follows: to determine participants’ knowledge and understanding of ototoxicity (including knowledge of side effects and ototoxic compensatory strategies). to explore the current practices of doctors when prescribing ototoxic medication, which addresses participants (non-participants) or disclosure of side effects of ototoxic medicines and the reasons for not disclosing, referral of patients to audiologists for ototoxicity monitoring, and the use of resources on ototoxic medicines. to determine how the participants regard the role of the audiologist in terms of ototoxicity management in the hospital. the context of the research was a tertiary hospital in a township context, which is in a previously disadvantaged context in south africa where unemployment is high, and poverty with associated medical conditions (e.g. aids and tb) are endemic. patients often have low education and literacy levels. in this hospital, doctors from all levels of employment have large workloads and have to deal with challenges inherent to the public health system. a purposive and convenience sampling method was used as all doctors who were present at the academic or departmental meeting of specific departments on a given day were included. the research sample (table 1) included 90 participants consisting of interns (n = 14); medical officers (mos) (n = 14); registrars (reg) (n = 38) and consultants (n = 24) within the departments of internal medicine (internal meds), intensive care unit (icu), ear–nose–throat (ent) surgery, nicu, paediatrics (paeds) and family medicine (fam med). table 1: description of the research sample. the study made use of a survey design, which collected mainly quantitative data. questionnaires (appendix a) consisting of both closed-ended and open-ended questions were used to collect the data from doctors in these specific units or departments. the self-constructed questionnaire consisted mainly of closed-ended questions, checklists and questions with likert-type scale answers. only a limited number of open-ended questions were included. the questionnaires were designed to be user-friendly and to allow for quick and easy completion. the questions were reviewed by two experts in questionnaire design (of which one was also an expert in pharmacology). the questionnaires were approved for use by a research and ethics committee (s14/04/082). permission to conduct the research and ethical clearance was obtained from a research and ethics committee, as well as the management of the specific hospital. a pilot study was conducted where three doctors, who were not participants, acted as critical readers and completed the questionnaires to report on the clarity of the questions, the length of the questionnaire and the time required for completion prior to use. based on the results of the pilot study, changes were made to the layout of the questionnaire and numbering, as well as the question format of one question. the various department heads were informed of the study, who in turn arranged for the researcher to address the staff during an academic or routine morning meeting in their respective departments. the participants were verbally informed about the nature of the study, and informed consent was obtained prior to distributing the questionnaires (appendix a). questionnaires were completed anonymously and afterwards the participants were offered muffins as a gesture of goodwill to thank them for their time. the participants placed the completed questionnaires in a box at the door of the venue when they left, and these were collected by hand afterwards. completed questionnaires were scored according to model answers that were obtained from the literature. qualitative data for each open-ended question were listed in excel format and coded. all codes were listed and grouped into categories. the demographic information was correlated with the results obtained from the other sections (e.g. relationships were obtained between the participants’ performance on knowledge-related questions and the resources they accessed). qualitative data were also quantified by being scored on a binary scale (creswell, 2008). all the data were analysed descriptively by calculating averages and percentages in excel. data obtained from both quantitative and qualitative data were triangulated through corroboration to deduct conclusions. results were presented as graphs and tables. an effort was made to adhere to all ethical principles when conducting the research. by obtaining informed consent and emphasising that participation was voluntarily, the researchers based the research on the ethical principle of autonomy. the data were collected anonymously and participants’ information was treated with confidentiality adhering to the principle of respect. results and discussion the results are presented and discussed in accordance with the research objectives. the research firstly addressed the participants’ knowledge of ototoxicity, particularly on the various side effects, and otoprotective strategies. secondly, the research determined their current practices in ototoxicity management, for example, disclosing side effects, otoprotective strategies, as well as resources consulted in this regard. lastly, the role of the audiologists with regard to ototoxicity management in the hospital as regarded by the participants is also explored (e.g. whether they consider them as members of the ototoxicity management team, ototoxicity monitoring, disclosing of ototoxicity risks and support to patients who develop hearing loss as a result of ototoxicity). objective 1: participants knowledge of ototoxicity in determining the participants’ knowledge of ototoxicity, the research focussed on whether the medicines were ototoxic or vestibulotoxic, the risk factors as well as the most suitable otoprotective strategies to be used in the management of ototoxicity. participants’ knowledge of side effects the participants were required to indicate from a list of medicines which medicines were either cochleotoxic or vestibulotoxic, and to indicate the risk factors for ototoxicity. the results obtained from questions on all these aspects were analysed and are presented in table 2. table 2: participants’ knowledge of ototoxic medicines and their side effects. table 2 shows that the majority of the participants (53%, n = 48) achieved a score of ≥80%, which implies them to have adequate knowledge of ototoxic medicines and that 47% will benefit from additional information and increased knowledge to various degrees. when the participants’ knowledge of ototoxicity was further explored and was compared across various departments (table 3), it can be seen that there is a difference. it is acknowledged that such a comparison should be viewed with caution as the sample size does not allow for conclusions based on statistical significance. however, such results suggest that knowledge of ototoxicity could be context specific, as some departments scored higher than others. the variance in these results indicates that additional support (e.g. continued professional development (cpd) activities) with regard to ototoxicity should be provided to specific departments. table 3: knowledge of side effects of ototoxic medicines compared across various departments. the participants had varying opinions with regard to otoprotective strategies2 (table 4), from which deductions can be made with regard to their knowledge in this matter. table 4: participants’ opinions of otoprotective strategies (quantitative data). the results presented in table 4 show that there was 89% of the participants who agreed that they needed more information on otoprotective strategies, which indicates that these participants did not feel confident in terms of their knowledge on this matter. from table 4, it is also evident that 86% of the participants agreed that they support the use of otoprotective strategies. it thus seems that they knew what the right thing was to do but were unable to do so in practice. it can be assumed that a person will be hesitant to disclose information on otoprotective strategies if they do not feel confident about his or her knowledge in this regard. in summary, when the results of all questions which determined knowledge of ototoxicity were analysed for the group, it showed a peak at 60%–70% (figure 1). figure 1: comparison of participants’ knowledge of ototoxicity as measured by all questions (for the entire group of participants). a similar analysis was performed across the various levels of appointment on responses to all questions that explored knowledge of ototoxicity and compared performance across levels of appointment (figure 2). figure 2: comparison of participants’ knowledge of ototoxicity as depicted from all questions across positions. the results (figure 2) show that 50% of all mos obtained scores of 60%, and 35% of the entire group scored around 60% for the knowledge section in the questionnaire. the consultants show a dual peak, whereas the others typically have lower scores than consultants. see also the ‘bottle graph’ phenomenon, which shows a slightly higher score for consultants than others, and some growth opportunities for the interns, which can probably be ascribed to more experience and higher levels of education within the rest of the participant group. educational background and/or years of experience probably have an influence on their performance. consultants with more experience and higher levels of educational credentials are instrumental in the training of junior doctors and can, therefore, be expected to be more knowledgeable. they also play an important quality control role in the hospital. when the knowledge of ototoxicity of the consultants was investigated across departments (figure 3), it shows that the paediatrics department presents with dual peaks. insufficient data are available to explain this fact, but it is postulated that consultants in some departments were more knowledgeable with regard to ototoxicity than those in others. it seems as if knowledge of this specific topic is context (department) specific. the findings obtained in terms of knowledge revealed that doctors do not necessarily have adequate knowledge of ototoxicity symptoms or treatment, which is consistent with results reported by khoza-shangase (2013) and de andrade et al. (2009). in essence, those participants with lesser knowledge could benefit from cpd activities that focus on the management of ototoxicity. cpd activities can, thus, be tailor-made to meet the needs of for specific departments. figure 3: comparison of consultants’ overall knowledge of ototoxicity across departments. figure 4 shows the knowledge of all the participants across the various positions. figure 4: knowledge of ototoxicity per position. with reference to figure 4, there is not much difference in knowledge of the participants overall, although consultants score highest and interns lowest. this probably relates to years of experience and knowledge accrued over time, as well as their credentials. it is clear that there is room for improvement of knowledge on ototoxicity across all levels of appointment, and additional information should be provided to them. by corroborating the quantitative and qualitative results on the participants’ knowledge of ototoxicity, it can be concluded that the participants need additional training in ototoxicity (e.g. the types of medicines that are ototoxic, what the side effects are, as well as otoprotective strategies). objective 2: current practices of doctors when prescribing ototoxic medicines the participants’ current practices when prescribing ototoxic medicines focussed on whether they disclose the side effects thereof to their patients and whether they refer their patients to audiologists for screening. participants’ practices with regard to disclosure of ototoxicity figure 5 shows the percentage of doctors (n = 90) who reportedly have disclosed information on the side effects of the various medicines to their patients. the quantitative results show that only a minority (16%) of the participants routinely disclosed ototoxic risks to their patients, whereas 28% of the participants never disclosed such risks to their patients. the 54% who only ‘sometimes’ disclosed such information did so selectively. figure 5: participants’ practices with regard to disclosure of ototoxicity. the reasons for non-disclosure of side effects were obtained from open-ended questions that were qualitatively analysed. these results were categorised and are listed in table 5. table 5: reasons for non-disclosure and disclosure of side effects of ototoxic medication (qualitative data). some participants (24%) indicated that they only provide such information for a select group of medications, which could be because they did not know all the medicines that could be ototoxic. this finding was also confirmed by the following statement: ‘only if patient is on streptomycin, this other ototoxic drugs are not known by me.’ [p12; medical officer] such results confirm those shown before in table 5 where there were at least 31% (14% + 17%) of the participants who admitted that they did not have time to discuss otoprotective strategies with their patients. obtaining informed consent in the proper manner before administering ototoxic medication can be time consuming as it requires engagement with the patient to explain what the treatment will entail, what the risks are and what the alternatives would be (moodley, 2013c). what makes it even more time consuming is that the doctor has to make sure the client understands his diagnosis and treatment options and then also present the patient with a management plan. the patients must then make an informed choice of whether he or she accepts or declines the doctor’s decision (moodley, 2013c). doctors with a heavy caseload and limited time may find it a challenge to spend so much time on one patient. audiologists, who are in a supportive role to doctors in the ototoxicity management team, may want to take in upon themselves to disclose the ototoxic risks of certain medicines and obtain informed consent. considering their patient-centred approach to health care, which is closely related to an eoc perspective, audiologists are likely to regard communication with the patient as an important aspect of health care. they probably have good communication skills because of their professional focus on the management of communication disorders. although the majority of the participants (62%) considered otoprotective strategies to be effective, it must be kept in mind that the occurrence of disclosure by doctors may also be context specific. those doctors working in icu may have patients who are too sick for discussions about side effects, or they may not be conscious. in the paediatric wards in this particular context, the parents may not be available to discuss the risks. participants’ referral to audiologists the management of ototoxicity ideally should be based on a team approach, which includes several team members, including an audiologist (schellack, wium, ehlert, van aswegen & gous, 2015). effective monitoring requires that patients who are on ototoxic medicines be referred to the audiologist for baseline measurements and follow-up monitoring. figure 6 shows the participants’ reported frequency of referring a patient to the audiology department for screening and monitoring of ototoxicity. figure 6: frequency of referral to audiologists in the management of ototoxicity. from figure 6, it can be derived that in this specific hospital it is not common practice to refer patients to an audiologist as only 18% of the participants routinely referred their patients. these findings are consistent with the existing body of knowledge (wall in banotai, 2004), which indicates that audiologists are underutilised in hospital settings across the globe. this situation appears to be similar in other contexts in south africa (de andrade et al., 2009; khoza-shangase, 2013). examples of some of the reasons provided by the participants for not referring patients are as follows: ‘due to large amount of patients……. and time constraints.’ [p23; consultant] ‘there is usually not time to explain’ [p18; registrar] the majority of participants reported that they were either too busy or they did not know about the potential ototoxicity of medications and/or the possibility of referral to an audiologist and pharmacist. the lack of referral affects the quality of care and also has serious implications for patients who might develop hearing loss (professional board for speech language and hearing professions, 2015). participants’ practices in obtaining information on ototoxic medicines in terms of the participants’ knowledge of ototoxicity, the research sought answers as to where the participants obtained their information on medicines (table 6). the south african medical formulator (samf), google and medication insert pamphlets were the information sources most commonly used by all participants across departments or wards. micromedex (an online compendium of drug information) was least commonly used. table 6: sources consulted by participants to obtain information on medicines. to investigate whether those with higher scores in knowledge consult specific sources of information, a more detailed assessment was carried out to determine the relationship between scores in knowledge and sources consulted (figure 7). these results show that the average scores of participants were not significantly affected by particular sources of information. figure 7: relationship between scores in knowledge and information sources consulted. despite access to such an array of sources, the results indicate that there is room for improvement with regard to their knowledge of ototoxicity. it is possible that because of their heavy workloads, they do not have time to read about ototoxicity and the side effects of certain medication. in the case of serious illness, doctors may not necessarily prioritise the side effects of medicines that are intended to save lives. should this be the case, it emphasises the need for support for doctors who work with patient groups at risk for ototoxic treatments through cpd activities, which is in line with earlier recommendations by the world health organization (1994) to prevent hearing impairment as a result of exposure to ototoxic medication. objective 3: participants’ opinions on the role of audiologists in the hospital because of their inadequate knowledge of ototoxicity, it is possible that the participants were not fully aware of the role of the audiologist. figure 8 indicates that the participants showed high levels of agreement (81%) towards audiologists having to inform patients of the risks of ototoxic medications. traditionally, it has been expected of the doctor to disclose the side effects of ototoxic medication prior to starting a patient on such a treatment regimen. such disclosure is an important element in the process of obtaining informed consent (moodley, 2013c) and is necessary for ethical practice and effective service delivery. it can be questioned whether audiologists, in a supportive role to the doctor, be the one who can take on the role of disclosing the ototoxicity? should doctors refer to them timeously before they start treatment, it will be possible to monitor the effect of the medicine on hearing. however, audiologists are mostly consulted only after the patient has been started on the ototoxic medication, which is too late and can be considered a challenge in this context. it may be necessary for audiologists to pertinently promote their role in monitoring ototoxicity so that they get referrals timeously. figure 8: participants’ perceptions of the role of the audiologist in the hospital. the participants strongly agreed (93%) that the audiologist should be part of the ototoxicity management team when patients are prescribed ototoxic medication and that they should monitor hearing ability (88%). although such findings are in accordance with evidence-based practice, particularly when patients are prescribed platinum chemotherapy agents and aminoglycoside therapy (banotai, 2004; professional board for speech language and hearing professions, 2015), there are significant differences in the implementation or existence of ototoxicity monitoring protocols across the world (steffens et al., 2014). in south africa, khoza-shangase (2013) and de andrade et al. (2009) reported that in none of hospitals included in their studies, were there any audiologists included in the management teams for patients who were on ototoxicity medicines. careful monitoring will facilitate early identification of ototoxic-induced changes in hearing sensitivity, which will alert doctors and pharmacists to investigate the possibilities for altering the dosage of the prescription, or alternatively changing to a less ototoxic medicine. the majority of participants (93%) indicated that should patients develop hearing loss, the audiologist should support them. the monitoring by an ototoxicity management team includes audiometry as performed by an audiologist and surveillance of the dose and duration of the treatment by a pharmacist (schellack et al., 2015; world health organization, 1994). should it be necessary that the current medication be continued, and hearing loss do develop, the patient and/or the family can be counselled and supported (konrad-martin et al., 2005). most of the participants (94%) regarded the audiologist as being responsible for the supply of hearing aids and aural rehabilitation. such results show that doctors consider audiologists as important members of the management team. despite such positive perceptions regarding the audiologists’ role in the hospital, the results also highlight the poor routine referral practices to audiologists, which confirm previous findings by khoza-shangase (2013) that reported poor referral to audiologists, and that they were not necessarily known to be part of the team in the treatment of tb. such poor referral practices could be related to factors such as limited knowledge of ototoxicity and, to a lesser degree, to time restrictions because of high workloads. should this be the case, then the audiologist has an obligation to actively promote their role in detecting and managing ototoxicity and to consider an increasing supportive role by providing in-service training or cpd activities for doctors in this regard. critical review of the findings to limit potential bias, the questionnaire was formulated in such a manner as to answer the specific research questions. to increase the face validity of the questionnaire, the questions were presented neatly and in an organised manner. internal validity was enhanced by including questions that were related to the research objectives and by pilot testing the questionnaire for clarity. content validity was increased when the questions in the questionnaire were checked by two experts (one audiologist and one pharmacist) in the field of ototoxicity. a possible threat to the internal validity was the sampling method and the sample size of the study because only doctors who were present at the routine morning meeting on a specific day were included in the research. it is possible that different results would have been obtained if all doctors working in these wards or departments were included. in terms of the threat to external validity, convenience sampling limits the interpretation of results to the specific context and, therefore, the results cannot be generalised to other contexts (leedy & ormrod, 2010). although the analysis of the qualitative data was not confirmed by an independent rater, and thus could have affected quality, this was in part compensated for by triangulating the results. the qualitative data were limited in comparison to the quantitative data and were used to confirm or explain the quantitative results. bias was controlled by adhering to ethical guidelines (offering confidentiality in the completion of the questionnaires), and the data collection procedure that allowed the participants to anonymously put their completed questionnaires in a box. conclusion patients have a right to make informed decisions about the health care they receive, and doctors have an obligation to inform their patients of adverse effects of the medicines they prescribe. disclosure of such information is part of ethical practice that has to be integrated in the curricula and professional training of doctors. failure for participants in this study to disclose such information could be because they were not aware of such risks, and also because south africa is a multilingual and multicultural context, which has implications on interactions between health professionals and clients, often resulting in ethical dilemmas. in terms of the main aim of the research, the results showed that doctors in this study need to refresh their knowledge on ototoxicity and could benefit from workshops or cpd activities. with regard to the second objective of this study, it is encouraging to note that the doctors who participated in this study acknowledged these elements of the audiologist’s role, which provides a good foundation for interventions aimed at improving practice with regard to informed decision-making and proper management of ototoxic treatments. the results from this research emphasised the importance of cpd to make doctors more aware of ethical practices (e.g. such as disclosure of adverse effects of ototoxic medications). the development and presentation of cpd activities that address ethics and ototoxicity should be a collaborative team effort including various disciplines (banotai, 2004). it is important for doctors to work in a team with other health care professionals (e.g. the audiologists, nurses and pharmacists) to identify early signs of hearing loss and to search for an alternative treatment approach that may cause less harm to hearing. whenever there is no other choice than to prescribe ototoxic medication as to save a patient’s life (which often has a high probability of irreversible hearing loss), there are two augmentative ethical perspectives at play. the doctors’ decisions often are based on the principle of causing the least harm and optimum benefit to the patient, which is to save the patient’s life. audiologists, whose ethical perspective reflects an eoc, strive to be responsive to the patient and the family’s needs and, therefore, play a supportive role. an eoc perspective may require spending more time with the patient and the family and to talk to them about their concerns, which is an expansion of the current roles that were identified by the south african speech-language hearing association (saslha) task team on ototoxicity. such support entails the provision of information and the development of a jointly agreed upon intervention plan and possibly fitting of hearing aids to address the hearing problem. the results of this study emphasise the multiple roles required from audiologists in a hospital with regard to the management of ototoxicity. not only do they have to participate in cpd activities for other health care professionals, but they also should make patients aware of potential risks prior to treatment, monitor the ototoxicity during and after treatment, and support those who do develop hearing loss as a result thereof (schellack & naude, 2013). this may be a more extensive role description for audiologists than was originally specified by the health professions council of south africa (hpcsa). the results of this study emphasise a need for audiologists to expand their roles in the health sector. it is recommended that audiologists in hospital contexts actively advocate their role in the management of ototoxicity to encourage doctors to routinely refer such patients for screening. future research should investigate how the roles of audiologists in ototoxicity management in south africa would compare with those internationally. acknowledgements research reported in this publication was supported by the fogarty international center and office of aids research, od and national institute of allergy and infectious diseases and the national institute of mental health of the national institutes of health under award number r25 tw 008981 to the aresa project. competing interests the authors declare that they have no 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(2014). the current state of ototoxicity monitoring in new zealand. the new zealand medical journal, 127(1398), 85–97. van niekerk, a.a. (2013). ethics theories and the principlist approach in bioethics. in k. moodley (ed.), medical ethics, law and human rights: a south african perspective (3rd edn.). pretoria: van schaik. world health organization. (1994). report of an informal consultation on strategies for prevention of hearing impairment from ototoxic drugs. geneva: world health organization. yansey, a., harris, m.s., egbelakin, a., gilbert, j., pisone, d.b., & renbarger, j. (2012). risk factors for cisplatin associated ototoxicity in paediatric oncology patients. pediatric blood cancer, 59(1), 144–148. http://dx.doi.org/10.1002/pbc.24138 appendix 1 footnotes 1. the terms ‘patient’ and ‘client’ are used interchangeably in this document. the assumption is that patients are those who are sick and admitted to hospital, and clients are not necessarily sick but may suffer from a condition such as hearing or balance problems. 2. otoprotective strategies: pharmacokinetics and/or nutrition management to reduce the negative effect of ototoxic medicines on hearing and balance. abstract introduction research design materials procedures ethical considerations results and discussion discussion conclusion limitations and recommendations for future research acknowledgements references appendix 1 about the author(s) maria le roux department of speech-language pathology and audiology, university of pretoria, south africa salome geertsema department of speech-language pathology and audiology, university of pretoria, south africa heila jordaan department of speech pathology and audiology, university of the witwatersrand, south africa danie prinsloo department of african languages, university of pretoria, south africa citation le roux, m., geertsema, s., jordaan, h., & prinsloo, d. (2017). phonemic awareness of english second language learners. south african journal of communication disorders 64(1), a164. https://doi.org/10.4102/sajcd.v64i1.164 research project no.: nrf. 92701 original research phonemic awareness of english second language learners maria le roux, salome geertsema, heila jordaan, danie prinsloo received: 07 june 2016; accepted: 11 sept. 2016; published: 30 jan. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the pa skills of phonological blending and segmentation and auditory word discrimination relate directly to literacy and may be weak in english second language (el2) learners. in south africa, literacy skills have been found to be poor in especially el2 learners. objectives: the purpose of this paper is to determine the effects of vowel perception and production intervention on phonemic awareness (pa) and literacy skills of setswana first language (l1) learners. these learners are english second language (el2) learners in grade 3. method: the present study employed a quasi-experimental, pre-test–post-test design. results: the findings of low–literacy skill levels concurred with previous investigations. however, post-test results of intervention in pa seemed to improve the literacy skills of el2 learners. conclusion: pa skills should be a crucial part of the literacy curriculum in south africa. introduction phonemic awareness (pa), as a specific sub-skill of phonological awareness, is the refined ability to segment words into constituting sounds and blend these sounds to form new words (yeong & rickard liow, 2012). this type of awareness is the more ‘sophisticated’ of pa skills according to stewart (2004, p. 32), requiring recognition of the phoneme as the smallest unit of language that can bring about a difference in meaning. pa skills develop during the pre-school years and during the beginning stages of learning to read (adams, 1990). children in grades rr, r and 1 should understand that words are constructed by blending phonemes together, for example, ‘cat’ is formed by blending /k/, /æ/ and /t/. simultaneously, the word ‘cat’ can be segmented into /k/, /æ/ and /t/. learners should also be able to recognise that a difference in meaning occurs when the /k/ in ‘cat’ is replaced with /m/ and a new word, ‘mat’, is formed. when a child learns that a phoneme contributes to distinguishing meaning in words, pa is triggered. well-developed pa skills enable the child to manipulate phonemes by blending, segmenting or replacing individual phonemes in words to generate new words (cisero & royer, 1995). these skills will assist in mastering phonic skills such as phoneme–grapheme coupling required for reading and spelling. when considering the english language of learning and teaching (elolt) context in south africa, the question as to how el2 learners develop pa skills (and phonological awareness skills in general) arises. research posits that those pa skills already developed in the acquisition of the first language (l1), including knowledge of the phonological system of the l1, will be transferred to the second language (l2) (anderson, 2004). the success with which a child is able to make such transfers depends not only on the level of pa skills but also on the linguistic characteristics of the two languages in question. pa skills development seems to be parallel when comparing most of the alphabetic languages, while the rate of development and level of aptitude vary (anthony & francis, 2005; ziegler & goswami, 2005). yeong and rickard liow (2012) posited that this variation is because of the dissimilarities in the characteristics of the children’s oral language. the less complicated the phonological structure of the language, the less sensitive to pa the child seems to be (mcbride-chang et al., 2008; melhuish et al., 2008; yeong & rickard liow, 2012). this variation of pa skills development could apply to setswana l1 learners in the elolt environment. setswana, in contrast to english, has a smaller vowel system, consisting of seven basic vowels, four raised vowels and no diphthongs (cole, 1955). in contrast, english distinguishes 19 vowel sounds (bekker, 2009). additionally, while english distinguishes long monophthongs, setswana does not. therefore, setswana l1 learners often do not distinguish the long english monophthongs. this means that the setswana l1 learner has developed less advanced pa skills to discriminate between the vowels and the diphthongs of elolt (seeff-gabriel, 2003). lack of sufficiently developed pa skills is concerning as these skills are regarded as the best predictor for reading ability during the early school years (cockcroft & alloway, 2012; phillips, clancey-menchetti & lonigan, 2008). of these, segmentation and blending are the most important ‘sub-skills’ required when a child starts to read (yeong & rickard liow, 2012). a sufficient level of these skills will enable the young learner to decode words during the initial stages of literacy (koda, 2007). research on the transition to elolt in grade 4 in south africa indicated that the pa skills of el2 learners were extremely low (pretorius, 2014). this has a negative influence on the literacy skills and academic performance of these young learners as decoding skills predict reading comprehension, accuracy and fluency in the beginning stages of reading in both the l1 and l2 (van staden, 2011). the results of the pre-progress in international reading literacy study 2011 (prepirls) indicated that grade 4 el2 learners scored 80 points lower than their el1 peers (howie, van staden, tshele, dowse & zimmerman, 2012). the difference in scores becomes meaningful when howie et al. (2012) explain that a difference of 80 points relates to a difference of about 2 years less schooling for the el2 group. in addition to the prepirls2011 (2012) results, the annual national assessment indicated that in 2014 only 52% of grade 3 learners passed the literacy assessment (department of basic education, 2015). with research indicating that learners with low levels of literacy often do not have sufficient pa skills, the aim of this study was to assess the effects of vowel perception and production intervention on pa and literacy skills of el2 (setswana l1 speaking) learners in grade 3. research design a quasi-experimental design was employed. we aimed to rule out the possible effects of non-intervention variables. the variables controlled for are testing (pre-test–post-test design), maturation [period between pre-test and post-test was minimised to eliminate biological changes (12 weeks)] (armstrong & van mechelen, 2008), instrumentation (standardised tests were used for assessment), regression (the mean of results of participants were used; not individual scores), mortality and/or attrition (intervention was made stimulating through the use of feedback in the form of real-time spectrograms and intermittent positive reinforcement – verbal and tangible – by the student therapists . this was done to prevent drop-out) and selection (participants in groups were as similar as possible). simultaneously, the study used a comparative design. participants english second language (esl) speaking participants were randomly assigned to the el2 and control group (cg) groups. participants of the el1 group were also randomly selected. el1 group twelve 8to 10-year-old south african english l1 speakers, attending an english medium school in pretoria, were selected for the comparative preand post-tests. bekker (2009) stated that this variety of english can be seen as standard south african english. this group was seen as the ‘norm’ and did not receive intervention. el2 group fifteen 8to 10-year-old el2 (setswana l1 speaking) learners, attending two english medium primary schools in the moot (pretoria), were selected for comparative preand post-tests. these participants received additional input concerning the english vowel system by final-year el1 speech-language therapy (slt) students. control group fifteen 8–10-year-old el2 (setswana l1 speaking) learners were selected. these participants did not receive intervention. they were selected from the same schools as participants in the el2 group. participant characteristics age participants were in grade 3 and aged between 8 and 10 years old. these learners were exposed to elolt for 3–4 years, and basic literacy skills should have been established at this stage. gender participants were male and female learners. at least 15 setswana l1-speaking learners were needed in each group; however, there were insufficient male-only or female-only learners available for selection at the primary schools that were willing to participate. socio-economic and geographical status participants attended former model-c primary schools. the el1 group school is in a higher socio-economic area. although the el2 and cg groups’ schools are in lower socio-economic areas, these participants were not necessarily from lower socio-economic households. school records showed many parents find it logistically easier to enrol the children in those particular schools. speech and hearing abilities participants displayed normal speech and hearing abilities as screened by the student slts and teachers. materials all materials are standardised, but not necessarily for the south african esl population. as such, these tests are interpreted as only an indication of the level of el2 functioning. the test of auditory processing skills test of auditory processing skills, third edition (taps-3) (martin & brownell, 2005), was employed to investigate the auditory processing of the participants. the first three sub-tests (phonological processing) were the focus of the research. the sub-tests evaluate word discrimination, phonological segmentation, and phonological blending. not only does this test assess the phonemic skills of blending and segmentation but also it focuses on the discrimination of phonological similarities and differences in word pairs. as word discrimination plays an important role in especially the l2 class room, it was necessary to determine the participants’ skills on this sub-test. the one-minute reading test the one-minute reading test (transvaal education department, 1987) was used to assess the reading accuracy skills. this test consists of monosyllabic words and the reading is assessed against time to produce a chronological reading age. the uct spelling test the uct spelling test (university of cape town, 1985) was used to assess the spelling skills. this test is a standardised south african spelling test containing stimulus words of increasing complexity. procedures procedure for data collection assessment protocol participants were assessed in a venue at the schools by female english l1-speaking slt students who were trained to conduct the tests. the order of the tests was randomised to counterbalance the effects of fatigue on the last administered test. testing took approximately 60 min per participant. the results were calculated and captured in microsoft excel (2010). after 12 weeks of intervention with the el2 group, the participants were re-assessed using the same protocol. intervention protocol for the vowel perception and production intervention, the researchers combined the traditional articulation approach (van riper & emerick, 1984) and cycles phonological remediation approach (hodson, 2006) (appendix). aspects from the traditional articulation approach followed a specific course beginning with sensory-perceptual training (ear training – identification, isolation, stimulation, and discrimination of vowel contrasts). production training followed in which the target vowel sound was established or acquired and then stabilised (creaghead, newman & secord, 1989). to stabilise the sounds, participants practiced the production of the vowel sounds in isolation, nonsense syllables and words. adapted aspects of the cycles phonological remediation approach were also used to guide intervention. the nonsense syllable within each repetition of this section of the session was repeated with increasing complexity. this pattern formed part of the cycle as in the adapted shorter version of the cycles approach of hodson (2006). an example is nana [nænæ] – nanu [nænʊ] in a single session; revision of these stimuli in the following session and addition of another vowel and or syllable, such as nana [nænæ] – nanu [nænʊ] – nani [nænʊ] or nana [nænæ] – nananu [nænænʊ]. because intervention was only given once a week, revision was offered to be in line with educational approaches. target sounds were reviewed with production practice of words from the previous session. a listening activity and production practice followed. the sessions incorporated segmentation and blending activities because research indicates that this is the way in which pa skills should be taught to enable reading and spelling ability (moats, 2007). these activities emulate the approach that teachers (may) use to teach literacy skills, which could enhance the benefits of the intervention. the words for reading and spelling practice were selected using age-appropriate reading lists as suggested by the curriculum assessment policy statement (department of basic education, 2011). ten words for spelling and reading were randomly selected for each vowel where possible. the words presented in the sessions were not contained in the uct spelling test or the one-minute reading test used for assessing the participants. the researchers targeted each of the 19 south african english (bekker, 2009) vowel sounds with a maximum of two vowel sounds covered per session. twelve weekly intervention sessions were conducted. during every second intervention session, a single vowel sound was targeted. the intervention session concluded with revision of the vowels previously addressed. when no revision was conducted, two vowel sounds were targeted. each session lasted 45 min. sessions were conducted in a group setting with three participants in each session and one student slt. when two vowel sounds were targeted the student slts would introduce the first vowel sound and perform the discrimination, production and reading task. the second vowel sound would be introduced and targeted. the vowel sounds were then targeted concurrently for the spelling task. the intervention programme followed a set structure for each session. during sessions, the student slts gave augmented verbal feedback about the different auditory and articulatory characteristics of the relevant vowel(s). procedure for data analysis results on the sub-tests of taps-3 were compared preand post-intervention and are presented in tables and bar graphs. the data on the reading and spelling assessments were also analysed and compared preand post-intervention. data were analysed using stata 12.1 (stata corporation, college station, tx, usa). descriptive statistics were calculated for all variables, viz. mean and standard deviation. additionally, the median and interquartile ranges were determined for the highly skewed pre-test scores for spelling and phonological blending. student’s paired t-tests were used to test for significant differences between the preand post-test results of normally distributed variables within each of the participating groups. likewise, the wilcoxon signed-rank test was used in the analysis of non-normal variables. one-way and kruskal–wallis analysis of variance (anova) identified differences between the means of each variable, across all groups. where a significant difference in mean scores was observed, further post hoc analyses were carried out to determine in which groups the differences occurred. differences with p < 0.05 were deemed statistically significant. ethical considerations permission for the study was obtained from the university of pretoria, the gauteng department of education, and the participating schools. parental consent and participant assent were obtained. during assessments and intervention, care was taken to minimise any discomfort that the participants might have experienced. participants were praised for their diligence and willingness to participate. none of the participants withdrew from the project. the cg group did not receive intervention. however, the researchers offered the option of intervention after completion of the present research to the parents and participants of this group. results and discussion performance on the word discrimination sub-test of the taps-3 the average scores on the word discrimination sub-test are illustrated in figure 1. figure 1: average scaled scores of word discrimination of all participants across all groups. in tables 1 and 2, the results of the t-tests for significant differences within and between groups on the word discrimination sub-test are provided. table 1: results of t-tests for significant differences in preand post-intervention word discrimination scores within groups. table 2: results of t-tests for significant differences between groups on word discrimination scores. the paired t-test confirmed a significant difference on the word discrimination sub-test between preand post-intervention results in the el2 (p = 0.01) and cg (p = 0.002) groups. these groups improved from an average of 5.67 to 9.2 and 6.2 to 8.53, respectively. the el2 group showed an improvement of 62.4% compared to the 37.6% of the cg, indicating that the intervention was effective in improving word discrimination skills. the cg group also showed a significant difference in their preand post-intervention scores, although it was not enough to bring them to the level of the el1 group. these results provide further support for the positive influence of the intervention; that is, maturation alone is not enough to close the gap between these two groups. the difference between the el2 and cg groups was not significant pre-intervention (p = 0.62) but both the el2 (p < 0.001) and cg groups (p = 0.002) scored significantly below the el1 group. although the cg improved significantly from preto post-intervention (table 2), its mean score remained significantly different from the el1 group (p = 0.01) after intervention, unlike the el2 group, who no longer scored significantly below the el1 group (p = 0.12). these results would indicate that the el2 group improved significantly on this measure (5.67–9.20 post-intervention), further confirming the effectiveness of the intervention. performance on the phonological segmentation sub-test of the taps-3 the average scores on the phonological segmentation sub-test of the taps-3 are illustrated in figure 2. figure 2: average scaled scores on phonological segmentation across all groups. statistically significant differences between the group means were evident in the pre-intervention scores (p = 0.04) but not in the post-intervention (p = 0.08) scores. the statistical within-group comparison between preand post-intervention scores is provided in table 3. table 3: results of t-tests for significant differences in preand post-intervention scores on phonological segmentation scores within groups. the paired t-test confirmed significant improvements from preto post-intervention phonological segmentation skills in all three groups (el1 p = 0.04, el2 p = 0.002, cg p = 0.01). table 4 portrays the results of t-tests for significant differences between groups. table 4: results of t-tests for significant differences between groups on phonological segmentation scores. post-intervention scores in the el1 and el2 groups were not significantly different. this would indicate that the el2 group improved significantly in this measurement, to the extent that no statistically significant difference between them and the el1 group could be observed. this improvement in el1 group post-intervention scores suggests that the intervention was effective. performance on the phonological blending sub-test of the taps-3 the average scores on the phonological blending sub-test of the taps-3 are illustrated in figure 3. figure 3: average scaled scores of phonological blending of all participants across all groups. the statistical within-group comparisons between preand post-intervention scores are provided in table 5. table 5: results of t-tests for significant differences in preand post-intervention phonological blending scores within groups. wilcoxon signed-rank tests confirmed that there was no significant improvement between the preand post-intervention scores within any of three groups, including the el2 group. therefore, the intervention did not have an effect on phonological blending skills. table 6 portrays the results of t-tests for significant differences between groups. table 6: results of t-tests for significant differences in phonological blending scores between groups. differences between the pre-intervention scores of the el1 and el2 groups (p = 0.05) and the el1 and the cg (p = 0.12) were not significant, implying that the groups had similar levels of phonological blending ability at the start of the study. post-intervention results indicate that significant differences exist between the el2 and el1 groups (p = 0.004) as well as between the cg and el1 groups (p = 0.02). these differences may be because of an improvement in the el1 group scores from 11.17 to 11.75 (figure 3). performance on the reading skills scores the average scores for reading skills are illustrated in figure 4. the withinand between-group comparisons follow directly thereafter. figure 4: average scaled scores of reading accuracy of all participants across all groups. the statistical comparison between preand post-intervention scores on the reading assessment within all three groups is provided in table 7. table 7: results of t-tests for significant differences in preand post-intervention scores on reading accuracy assessment within groups. the paired t-test confirmed significant differences between the preand post-intervention reading results in all three groups. all three groups’ reading skills could be seen to have improved. however, the el2 group improved the most, with 35.8% compared to the 29.1% improvement of the cg and 14.1% improvement of the el1 group. the el2 group thus showed significant improvement in reading abilities (38.73–52.6 post-intervention), which could be attributed to the intervention received. table 8 portrays the between-group comparisons. table 8: results of t-tests for significant differences in reading scores between groups. table 9: results of t-tests for significant differences in preand post-intervention scores on spelling within groups. both the el2 and cg groups performed significantly below the el1 group in the preand post-intervention assessments. no significant difference between cg and el2 reading accuracy scores were observed. performance on the spelling skills scores the average scores for spelling skills are illustrated in figure 5. the withinand between-group comparisons follow directly thereafter. figure 5: average scaled preand post-intervention scores of all groups on the uct spelling test. wilcoxon signed-rank tests confirmed a significant difference in preversus post-intervention results for all three groups. all three groups’ reading skills could be seen to have improved. however, when analysing the spelling scores, the el2 group once again shows a significant improvement of 31.5% compared to the 22.6% improvement of the cg and 13.9% improvement of the el1. note that this improvement within the el1 group was also significant. however, even after the intervention, the spelling skills of the el2 group, as measured by the uct spelling test, are still 44% lower than those of the el1 group. table 10 displays the significant differences in spelling scores between groups. table 10: results for significant differences in spelling scores between groups. significant differences between groups were observed between the preand post-intervention spelling scores of el1, el2 and cg groups. these findings underline the similarity of the el2 and cg to each other, and the significant difference in their results compared to the results of the el1 group. the results were to be expected as the el2 and cg comprised el2 learners, while the el1 group consisted of el1 learners. discussion the word discrimination sub-test determined whether the participants could recognise phonological differences and similarities within word pairs (martin & brownell, 2005). the participants had to indicate whether the members of the word pairs were the same or different (e.g. in the word pair ‘miss: mess’). eleven of the 20 word pairs consisted of words in which the vowels differ. because it has been established that l2 speakers find it difficult to distinguish all the vowels and diphthongs of english (seeff-gabriel, 2003), the low word discrimination scores of the l2 learners could be attributed to this. another possible reason for the discrepancy in scores between the el1 and el2 groups is proposed by phillips et al. (2008): word discrimination skills are related to word meaning. therefore, it is possible that the el2 participants struggled to recognise the meaning of the words presented and could not discriminate between the words because of meaning loss that occurred. therefore, increasing vocabulary knowledge as part of oral skills is of utmost importance in the elolt environment (phillips et al., 2008). lonigan (2007) explained that the more enriched the vocabulary of a learner becomes, the more minimal pairs with distinctive sounds will form part of the lexicon of the learner. such an increase will enhance phonological and pa abilities. the significant increase in post-intervention scores of the el2 group indicated that additional input such as that described in the intervention plan may improve the ability of the el2 learner to discriminate between sounds in minimal word pairs. these increased scores also suggest that the el2 group became more aware of the different vowels of english because more than 50% of the word pairs differed in the vowel. the phonological segmentation tasks of the taps-3 not only focus on syllable deletion but also on the deletion of phonemes in various positions. it is a sophisticated skill that develops from, or at least concurrently with, print experiences during the beginning reading phase (cisero & royer, 1995). young learners struggle to realise that words are constructed by different phonemes when they do not have adequate print experience (melhuish et al., 2008). in south africa, many el2 learners are from a print-deprived environment (howie et al., 2012). this could be cited as a reason for the fact that the el1 participants achieved significantly higher pre-intervention scores than their el2 peers. the increase in post-intervention scores of the el2 group indicates that the input received by this group improved their segmentation skills considerably. the intervention seems to have increased the awareness of the sounds of english in the el2 group, not only of the vowels but also of the consonants. the phonological blending sub-test requires the participant to blend the phonemes produced in isolation to form the required word. blending tasks are deemed easier than segmentation tasks (phillips et al., 2008) and the overall high scores of all three groups (compared to those of the segmentation tasks) confirmed this assumption. this test is the only sub-test of the taps-3 in which the el2 group did not improve their scores post-intervention. a disturbing occurrence is that, although there was no significant difference between the scores of the el1 and the el2 groups before intervention, a significant difference between these groups was noted after intervention because of improvement of the phonological blending skills of the el1 learners. because phonological blending is considered to be easier than phonological segmentation, the gap developing between the el1 and el2 groups is a cause for concern. the results obtained from the two literacy skills assessments confirm the direct impact of pa on these skills. the literacy skills of the el2 participants measured below the level of their el1 peers. although an improvement in the abilities of the el2 group can be noted after intervention, the skills levels were still low. an improvement was not sufficient for the el2 group to ‘catch up’ with the el1 group. this may be because of the fact that intervention took place only once a week for 45 min, instead of additional input being given throughout the day, as suggested by researchers like trehearne, healy, cantalini-williams and moore (2004). the age at which the l2 learner receives additional input to enhance his and/or her phonological awareness skills and phonological knowledge of the lolt may play an important role in the poor el2 literacy skills as well. while in this study the intervention was given in grade 3, the ideal time for structured literacy instruction is considered to be pre-school (lessing & de witt, 2005). because improvement in the literacy skills of the el2 group can be noted, it is suggested that much more input concerning pa skills as well as oral language skills should be given to el2 learners in grade r already. conclusion sufficiently developed pa skills, especially segmentation and blending, are seen as the best predictor for successful literacy acquisition during early school years (cockcroft & alloway, 2012; moats, 2007). pa seems to be most at risk for el2 learners because of differences in the phonetic repertoire of the respective languages. children who have a first language with a less complicated phonological structure, such as that of setswana, may have less sensitive pa skills (mcbride-chang et al., 2008; yeong & liow, 2012). the results of the present investigation also support this theoretical hypothesis. our el2 participants displayed significant challenges not only in the pa domains, particularly in word discrimination and phoneme segmentation, but also in phonological blending. these challenges have a negative impact on their decoding (reading) skills and encoding (spelling) skills. not only is there limited time available to address literacy instruction (department of basic education, 2011) but also it seems from our study that the even more important building blocks of these literacy skills, and the additional challenges posed by second language learning, may also be lacking and prohibiting these children from effectively attaining literacy. therapists and educationalists should take note of the possible lack of sufficient pa skills in especially el2 learners. therefore, intensive pa training should be introduced into the curriculum as early as possible. this should enable the el2 learner to become familiar with the phonological system of english, which in turn may lead to more successful literacy acquisition. limitations and recommendations for future research a few limitations should be noted. the south african spelling and reading tests used are relatively dated. only two small peer-matched el2 groups of participants were available for this study. these two groups came from middle-class former model-c schools. additional comparisons should be drawn between different socio-economic groups, provinces and other languages to direct educators towards an intervention program. another recommendation for future research is to explore the underlying assumption that phonological awareness of consonants should be less problematic for setswana el2 learners. this is because the largest difference in phoneme inventories between these two languages occurs on the level of vowel systems. in addition, testing for language difference versus language disorder would be advisable. such testing would be useful to compare the semantic knowledge of the groups because vocabulary contributes to pa and literacy skills as well. investigations into the association of socio-economic status with limited early literacy experiences and vocabulary in el2, for example, should be conducted. a final recommendation would be to utilise inter-rater reliability measures to compare the student slts assessment and intervention sessions. acknowledgements this work is based on the research supported in part by the national research foundation of south africa (unique grant no: 92701). competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions m.l.r. was the project leader and responsible for project design and supervision of data collection. m.l.r. was responsible for the analysis and discussion of the results, with s.g. being co-responsible. d.p. and h.j. made valuable conceptual contributions. references adams, m.j. 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(2005). reading acquisition, developmental dyslexia and skilled reading across languages. psychological bulletin, 131, 3–29. http://dx.doi.org/10.1037/0033-2909.131.1.3 appendix 1 table 1-a1: intervention hierarchy. abstract introduction method research personnel community entry classification of hearing loss reliability and validity data analysis results discussion conclusions acknowledgements references appendix 1 appendix 2 about the author(s) lebogang ramma division of communication sciences & disorders, university of cape town, south africa ben sebothoma clinical educator, division of communication sciences & disorders, university of cape town, south africa citation ramma, l., & sebothoma, b. (2016). the prevalence of hearing impairment within the cape town metropolitan area. south african journal of communication disorders 63(1), a105. http://dx.doi.org/10.4102/sajcd.v63i1.105 original research the prevalence of hearing impairment within the cape town metropolitan area lebogang ramma, ben sebothoma received: 28 sep. 2014; accepted: 20 mar. 2015; published: 08 apr. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: there is a lack of data on the prevalence of hearing impairment in south africa. current data is unreliable as it is based on national census information which tends to underestimate the prevalence of hearing impairment. aim: the aim of this study was to estimate the prevalence of hearing impairment in the cape town metropolitan area and to determine factors associated with hearing impairment. method: a cross-sectional household survey involving 2494 partcipants from 718 households was conducted between the months of february and october 2013. random cluster sampling was used to select four health sub-districts from eight health sub-districts in the cape town metropolitan area using a method of probability proportional to size (pps). the survey was conducted according to the world health organization (who) ear and hearing disorders survey protocol and the classifcation of hearing impairment matched the who’s criteria for the grading of hearing impairment. results: the overall prevalence of hearing impairment in the population of this study was 12.35% (95% ci: 11.06% – 13.64%) and prevalence of disabling hearing impairment was 4.57% (95% ci: 3.75% – 5.39%) amongst individuals ≥ 4 years old. the following factors were found to be associated with hearing impairment; male gender, age, hypertension, a history of head and neck trauma and a family history of hearing impairment. conclusion: based on the data from communities surveyed during this study, hearing impairment is more prevalent than previously estimated based on national population census information. interventions for the prevention of hearing impairment in these communities should focus on individuals with associated risk factors. introduction hearing is one of the essential senses for human communication. hearing impairment at any stage of life can compromise the communication process and influence an individual’s quality of life (gondim et al., 2012). hearing impairment in childhood can cause delays in the development of speech, language, and cognition which may later lead to educational disadvantage, social isolation and ultimately economic disadvantage (finitzo, albright & o’neal, 1998; stevens et al., 2011; yoshinaga-itano, 2003). in adults, untreated hearing impairment has been linked to depression, anxiety and other psychological disorders (kochkin & rogin, 2000), as well as an increased risk of dementia (lin et al., 2011a). hearing impairment is a highly prevalent societal problem and it is one of the biggest contributors to the burden of disabilities in the world (agrawal, platz & niparko, 2008). hearing impairment was ranked first in the category of health conditions associated with disability and among the leading causes of the global burden of disability in the world disability report of 2011 (world health organization [who], 2011). the who estimates that approximately 360 million persons live with disabling hearing impairment worldwide and that the majority of these people live in developing countries, specifically south asia, asia pacific and sub-saharan africa (who, 2012). various risk factors, also linked to specific stages of life, are associated with hearing impairment. in children, risk factors for hearing impairment include, but are not restricted to: low birth weight, craniofacial anomalies, neonatal infections such as cytomegalovirus, herpes hyperbilirubinemia requiring exchange transfusion, respiratory distress, prolonged mechanical ventilation, meningitis, a family history of hearing loss and low apgar score (saunders et al., 2007; todd, 1994). for adults, the main risk factors for hearing impairment are advanced age and prolonged exposure to excessive noise (isaacson & vora, 2003). research also links some non-communicable diseases, e.g. cardiovascular disease and/or diabetes, and lifestyle factors such as smoking with increased risk of developing hearing impairment during adulthood (fransen et al., 2008). finally, exposure to ototoxic medications during the treatment of some health conditions such as cancer and drug-resistant tuberculosis have been shown to increase the risk of acquiring hearing impairment amongst both children and adults (harris et al., 2011; saunders et al., 2007; whitehorn et al., 2014). population-based surveys that estimate the magnitude of hearing impairment are generally few, despite the fact that hearing impairment is considered to be a leading contributor to the burden of disability (stevens et al., 2011). the lack of good estimates of the magnitude of hearing impairment makes it difficult to plan adequately for interventions and services aimed at individuals with hearing impairment. currently, information on the prevalence of hearing impairment in south africa is based primarily on data from the national population census (statistics south africa, 2003). prevalence of hearing impairment estimates based on census data is typically based on self-report (or proxies’ report) of hearing impairment by individuals interviewed, and this tends to underestimate the magnitude of the problem (nondahl et al., 1998; sindhusake et al., 2001). this study therefore aims to estimate the prevalence of hearing impairment in the cape town metropolitan area using a survey protocol that includes actual assessment of hearing status. method aim the aim of this study was to estimate the prevalence of hearing impairment in the cape town metropolitan area as well as to investigate the factors associated with hearing impairment in the population of this study. research design the study design made use of a cross-sectional population survey using the who’s ear and hearing disorders survey protocol (who, 1999). the survey was conducted between the months of february and october 2013 in the cape town metropolitan area. context the cape town metropolitan area is one of the six health districts in the western cape. this health district is further divided into eight (health) sub-districts. the most recent national population census data of 2011 indicated that this metropolitan area has a population of 3 740 025 people evenly spread across these eight health sub-districts (statistics south africa, 2012). participants participants in this survey included all individuals in the selected households who gave consent or assent to take part in this study. minors (children younger than 12 years old) were only included in the study if their parents or legal guardians gave consent. for older children (≥ 12 years old) parental consent and assent from the child were obtained prior to being included in this study. individuals were excluded from the study if they refused to give consent, were not at home after a second visit, were unable to understand either written or verbal instructions, or had cognitive impairment or communication difficulties. sampling strategy random cluster sampling was used to select four sub-districts (cluster) from the eight health sub-districts within the cape town metropolitan area through a method of probability proportional to size (pps). an aerial map of each of the health sub-districts to be surveyed was used to aid in selecting the households to be sampled. the distribution of types of residences for each sub-district was obtained from the national census database to determine the proportion of each residence type within the health sub-district (statistics south africa, 2012). the sample was further stratified according to the type of residence (i.e. free standing house, block of flats and shacks). in residences which contained several households (e.g. main house and a backyard shelter), only one of the households per residence was surveyed. in the case of a block of flats, one floor per block of flats was surveyed and each unit/flat was treated as a household. for each residence type strata, a total of eight streets were randomly selected. fifteen residences were identified in each street using the map, starting from the first residence to the right of the street corner and then including every second residence from this point until 15 households were visited for each of the eight selected streets. sample size the sample size for this study was determined using the who ear and hearing disorders survey protocol (who, 1999). according to this protocol, assuming a prevalence of hearing impairment in the population of about 10%, with a precision of 1.08% and a design effect factor of 2, the required sample size for a simple random design (ci:95%) should be 5924 persons (who, 1999). at least 1693 households were required to be visited to obtain the required sample size using an average household size of 3.50 persons in the cape town metropolitan area (statistics south africa, 2012). research personnel the research personnel comprised four teams of two senior audiology students of the university of cape town per team, and two qualified audiologists with a total of 18 years of clinical experience between them. all of the students were senior audiology students and therefore had adequate clinical skills required for the assessments required in this study. furthermore, all the students were given additional training specific to the testing protocol used in this study to ensure consistency in assessment procedures and in the reporting of results. ethical considerations this study adhered to the ethical principles as outlined in the declaration of helsinki (world medical association declaration of helsinki, 2008). informed consent was requested from potential participants prior to participation in this study and they were informed that their participation was voluntary. all efforts were made to safeguard the confidentiality of participants’ information and no specific identifying information was obtained for use in study reports. participants were assured that they have the right to withdraw from this study at any time without negative consequences to themselves. ethical approval to conduct the study was given by the faculty of health sciences human research ethics committee, university of cape town (hrec ref 603/2012). community entry key stakeholders in the communities selected for this study were approached by the researchers after ethical approval to conduct the study was granted. this served to inform the stakeholders about the study and to request their support in encouraging community members to participate in this study. key stakeholders included: managers of health facilities, representatives of community forums as well as representatives of community health forums in the selected sub-districts. community members were additionally informed about the study through posters placed at various points in the community and through flyers placed in mail boxes. pilot study a pilot study was conducted in one of the four health sub-districts selected for this to test the study protocols. the outcome of the pilot study revealed that the assessment protocol proposed for this study was feasible in the communities being surveyed. furthermore, the pilot study yielded information that optimised the efficient collection of data such as best test sequence when assessing participants’ hearing status and the best days of the weeks and times of the day to conduct the survey. procedures research teams (in groups of two) approached selected households; explained the purpose of the study and procedures to be followed to the members of selected household with an invitation to participate. the research team entered the household and followed the following protocol, in households where the members (i.e. head of household or a guardian over the age of 18 years old) agreed and consented to be part of this study. obtain consent: the research team requested consent from each member of the household eligible to participate in this study. for young children (< 12 years old), the parent or legal guardian was asked to give consent on behalf of the child to participate in the study. for older children (≥ 12 years old, but ≤18 years old), assent and consent was obtained from the child before being tested. participants were asked to sign a consent form (or assent form where applicable) to indicate their willingness to participate in the study. assessment: audiometric assessments proceeded in the following sequence: measurement of ambient noise levels in the room, obtaining pertinent background history information (refer to the ear form, appendix 1), audiometric assessment, feedback and referral to the nearest health facility (where applicable). participants ≥ 4 years were assessed using the following tests/procedures: otoscopic examination, tymapnometry and pure tone audiometry while partcipants aged 0–3 years were assessed using otoscopic examination, tymapnometry and distortion product otoacoustic emissions (dpoae) (refer to appendix 2 for the detailed description of the assessment procedures). classification of hearing loss hearing impairment was classified according to the who grading of hearing impairment (refer to table 1-a2, appendix 2) criteria. disabling hearing impairment was defined as a permanent unaided hearing threshold level in the better ear of ≥ 41 db hl (for adults) and permanent unaided threshold level in the better ear of ≥31 db or (children younger than 15 years old) (who, 2014). hearing impairment was further classified according to the type (conductive, mixed or sensorineural hearing loss) for all participants ≥ 4 years old. reliability and validity to ensure consistency and reliability of data collected, all members of the research team were trained on the study protocol and procedures prior to commencement of the study. furthermore, the data collected was verified by re-visiting 10.7% of the selected households to confirm the following information: head of the household (or the person who allowed the participants to enter the household), whether otoscopy, tympanometry and audiometry were done. the verification process showed good agreement (kappa = 98%) between data collected by different research teams and therefore the data was considered was reliable. finally, all decisions regarding the diagnosis of hearing loss were made by a qualified audiologist and all decisions involving a diagnosis of hearing loss were forwarded to the second qualified audiologist for cross-checking. there was also good agreement between the two audiologists (kappa = 0.96). all of the equipment used in this study were calibrated prior to the start of this study and also underwent a daily biological calibration check prior to data collection sessions. test procedures used in this study were routine audiological tests with established validity. data was captured on the hard copy version of the who/pdh ear and hearing disorders examination form (version 7.1a), then transferred into an excel spread sheet by four research assistants. to ensure consistency when entering the data into an excel spread sheet, at least 10% of the data entered by each one of the research assistants was double checked by a different person to ensure accurate capturing of the data. data analysis data analysis was performed using the stata data analysis and statistical software package (stata corp lp, 2014) and both descriptive and inferential statistical methods were used. tables and histograms were used to summarise and describe the results of the study. an independent t-test (p = 0.05) was used to compare hearing thresholds obtained under different ambient noise levels, whilst binomial logistic regression was used to model the relationship between hearing impairment and several explanatory variables; age, gender, level of education, a family history of hearing impairment, a history of stroke, a self-reported history of hypertension, a self-reported history of diabetes, smoking, a history of respiratory difficulties and a history of head and neck trauma. binomial logistic regression was also done to estimate the probability (odds) of occurrence of hearing as a function of these explanatory variables. results demographic profile a total of 791 households were approached and invited to take part in this study; 73 households either refused to participate (21 households) or no one was home on a second visit (52 households). it was not possible to find out the number of household members for 49 of the 73 households that were eligible but did not participate in this study. however, for the remaining 24 households in which household members were not assessed, the number of individuals per household ranged from 3 to 7. the number of non-respondent households was distributed evenly across all the health districts surveyed (i.e. there was no district with a markedly high number of non-respondent households). ultimately 718 households participated in this study and 2494 individuals (42% of the original study sample) from those households had their hearing screened; women comprised the majority of the participants (60.9%) and individuals in the 10–19 years old age category constituted 22.9% of the sample, whilst individuals 60+ years old constituted 7.6% of the sample (refer to figure 1 for age and gender profile of participants in the study). figure 1: age and gender profile of the participants (n = 2494). ambient noise levels the average level of ambient noise during testing was 52.6±3.4 dba. a t-test for independent samples (p = 0.05) showed no statistically significant relationship between the level of ambient noise during testing and the different categories of hearing impairment in this study (p = 0.163). prevalence of hearing impairment of the total number of participants to this study, 12.35% (95% ci: 11.06% – 13.64%) had some degree of hearing impairment. see table 1 for a detailed presentation of hearing impairment according to different age categories. table 1: percentage (%) of participants by degree of hearing impairment and age category. table 2: proportion of persons with disabling hearing (%) loss by gender and age categories. disabling hearing impairment the prevalence of disabling hearing impairment amongst individuals who participated in this study was 4.57% (95% ci: 3.75% – 5.39%). as a group, males and participants older than 60 years old had a higher proportion of individuals with disabling hearing impairment than other groups of participants. unilateral hearing loss the prevalence of unilateral hearing impairment in this study was 2.3% (95% ci: 1.71% – 2.89%). tympanometry assessment also showed that participants in the 0–3 and 4–9 year old age categories had higher rates of abnormal tympanometry findings than other age categories. refer to table 3 for laterality of hearing impairment and tympanometry findings. table 3: laterality of hearing loss & tympanometry. association between hearing impairment and the following factors was investigated; age, gender, level of education, a family history of hearing impairment, prior episode of stroke (cva), a self-reported history of hypertension, a self-reported history of diabetes, a prior history of respiratory difficulties, whether participant smokes or not, and a prior history of head and neck trauma. the results of this study showed that increased age, male gender, a family history of hearing impairment, a self-reported history of hypertension, and a prior history of head and neck trauma were associated with hearing impairment (p < 0.05) (refer to table 4 below for more detailed information, including odds ration [or]). table 4: factors associated with hearing loss. discussion the primary aim of this study was to estimate the prevalence of hearing impairment in selected health sub-districts within the cape town metropolitan area. using the who grading of hearing impairment classification (who, 2014), it was estimated that overall prevalence of hearing impairment in this study was 12.35% (95% ci: 11.06% – 13.64%). age, gender, a family history of hearing impairment, a self-reported history of hypertension, and a history of prior head and neck trauma were main factors associated with hearing impairment. while the estimates of the prevalence of hearing impairment in this study were consistent with that of stevens et al., (2011), it was noted that it was slightly lower than prevalence rates reported in previous studies which used the who ear and hearing disorders survey protocol (who, 1999). for instance, a study conducted in brazil (béria et al., 2007) reported prevalence rates of 26.1% (overall hearing impairment) and 6.8% (disabling hearing impairment). an egyptian study by abdel-hamid, khatib, aly, morad, and kamel (2007) reported prevalence rates of 16.0% (overall hearing impairment) and 2.9% for disabling hearing impairment, whilst a study by westerberg et al. (2008) done in uganda also reported much higher prevalence rates for disabling hearing impairment than reported in the current study: 11.7% in adults and 10.2% in children respectively. it is generally difficult to compare prevalence estimates across different studies even when using similar protocols and definitions of hearing impairment. the difficulty in such comparisons stems from differences in demographic characteristics of participant cohorts and study contexts (lin, thorpe, gordon-salant and ferrucci (2011b). therefore, it was expected that prevalence estimates in this study would be somewhat different from those of other studies. however, part of the reasons for differences in the prevalence rates reported in previous studies and the current study may also have to do with the criteria used to ascertain the degree of hearing impairment in children younger than four years old. it was not clear how some of these studies confirmed the degree and type of hearing impairment in children. for instance, the brazilian study only used pure tone audiometry (and did not use tympanometry) and therefore would have had difficulties in confirming hearing impairment in participants in this age category. the egyptian study (abdel-hamid et al., 2007) on the other hand, deviated from the recommended who ear and hearing disorders protocol and used only otoacoustic emission and tympanometry to assess hearing impairment, which makes it extremely difficult to ascertain degree and type of hearing impairment across all age categories. consistent with the findings of previous studies (lin et al., 2011b; mcmahon, kifley, rochtchina, newall & mitchell, 2008; saunders et al., 2007), this study found that increasing age was associated with hearing impairment. in one american study, lin et al., (2011b) reported that about two thirds of adults aged 70 years and older had some degree of hearing impairment. regarding association between gender and hearing impairment, previous research studies (caban, lee, gómez-marín, lam & zheng, 2005; smeeth et al., 2002) have reported a higher prevalence of hearing impairment in males than females, and the same trend was also observed in this study. it is worth noting though that gender differences in the prevalence of hearing impairment has been reported even in populations with no evidence of noise-induced hearing loss (pearson et al., 1995) therefore this difference cannot simply be attributed the fact that men generally tend to be exposed to noisy activities. a family history of hearing impairment and a history of head and neck trauma were other factors that were found to be associated with hearing impairment in this study, which is also consistent with the findings of previous studies (fitzgerald, 1996; mcmahon et al., 2008; ottaviano et al., 2009). in an australian study involving 2669 individuals aged 50 years and older, mcmahon et al., (2008) reported that a family history of hearing impairment (especially a maternal family history of hearing impairment) was strongly associated with moderate to severe age-related hearing impairment. with respect to a history of head and neck trauma, hearing loss following trauma to the head and neck areas has been documented in literature (fitzgerald, 1996; ottaviano et al., 2009). results indicate that participants who reported a history of hypertension, in this study, were twice as likely to have hearing impairment as participants who did not report hypertension. this finding was consistent with those of previous studies (chang et al., 2011; chao, 2004; fransen et al., 2008; kakarlapudi, sawyer & staecker 2003). an unexpected finding in this study was the lack of statistically significant association between a history of diabetes and hearing impairment. this is in spite of the fact that there are now several studies that have reported a plausible association between diabetes and hearing impairment (jáuregui-renaud, sánchez, ibarra olmos & gonzález-barcena, 2009; pemmaiah & srinivas, 2011; thimmasettaiah & shankar, 2012) possible reasons for the apparent lack of association between diabetes and hearing impairment may have to do with the small number of participants who reported a history of diabetes in this study. some of the participants may not have been aware that they are diabetic or may have simply chosen not to disclose their diabetes status. the findings of this study must be interpreted with caution given its methodological limitations. these included unfavourable testing environments as audiological assessment done outside of audiometric booths is bound to be challenging. specific to this study, the fact that the test environment varied from one household to the next, introduced a further challenge to this study. however, the study protocol was very stringent regarding ambient noise levels that were considered acceptable for a hearing assessment to be conducted. for instance, if the environment was found to be too noisy (i.e. ambient noise >55 db) then a hearing assessment was not done at all or was terminated. furthermore, an analysis of the results also revealed that there was no association between a participant being diagnosed with hearing impairment or having a particular degree of hearing impairment and the level of noise in the room. another limitation of this study was the small sample size which compromised the representativeness of the study sample. the calculated sample for this study was 5924 participants. however, only 42% (2494 participants) of this sample was achieved during this study. data collection for this study had to be terminated prematurely before achieving the required sample size due to a flare-up of gang-related violence in the areas selected for this survey. this may have led to the resultant study sample being biased in favour of female participants and participants under the age of 20 years old, and this may have potentially introduced a bias that could have led to an underestimation of the prevalence of hearing impairment in this study. however, despite a possibly biased sample, the trends revealed by the data in this study were consistent with those reported in previous studies, i.e. more hearing impairment in males than females, as well as an association between hearing impairment and advanced age. conclusions this study showed that the prevalence of hearing impairment in the communities surveyed is much higher than current estimates obtained through national census. main factors associated with hearing impairment were also identified. therefore, in spite of its limitations, this study represents one of the few population-based surveys of hearing impairment done in south africa. the findings of this study could therefore be useful in planning for prevention and interventions services for hearing impairment, especially in the cape town metropolitan area. it is also hoped that the findings of this study will stimulate interest among the south african research community to conduct similar research studies in other parts of the country (especially in rural areas) to obtain a more complete picture of the magnitude of hearing impairment on a national scale. this will yield information that could be used to lobby for resources that are required for prevention and intervention services for hearing impairment. acknowledgements the authors would like to acknowledge and thank all the individuals who took time to participate in this study. also a special thanks to the following individuals who dedicated their time and energy to ensure that this study became a reality: sithembile ndlela, vuyisani sholo, fatima ally, rhofiwa netsifhire, sivuyile jange & siphesihle mcetywa, muneebah benjamin, maserame masemola, jareth andreas, bongile langa, kerry-ann youngman, zenzo chakara, chárnae pieterse and jane le roux. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions l.r. (university of cape town) was the project leader. he conceptualised the project, participated in the collection of data for the study and wrote the initial draft of the manuscript. b.s. (university of cape town) was the data collection manager. he coordinated data collection activities and reviewed and gave input in drafts of this manuscript. references abdel-hamid, o., khatib, o.m.n., aly, a., morad, m., & kamel, s. (2007). prevalence and patterns of hearing impairment in egypt: a national household survey. eastern mediterranean health journal, 13(5), 1170–1180. agrawal, y., platz, f.a., & niparko, j.k. (2008). prevalence of hearing loss and differences by demographic characteristics among us adults: data from the national health and nutrition examination survey, 1999–2004. archives of internal medicine, 168(14), 1522–1530. http://dx.doi.org/10.1001/archinte.168.14.1522 béria, j.u., raymann, b.c.w., gigante, l.p., figueredo, a.c.l., jotz, g., roithman, r. et al. 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(2003). from screening to early identification and intervention: discovering predictors to successful outcomes for children with significant hearing loss, journal of deaf studies and deaf education, 8(1), 11–30. http://dx.doi.org/10.1093/deafed/8.1.11 appendix 1 appendix 2 instrumentation & assessment procedures instrumentation otoscope heinne s700 mini gsi 39 tympanometer screener gsi 17 screening audiometer gsi audioscreener+ kuduwave 5000 audiometer bruel & kjær 2239 type ii integrating sound level meter (denmark) who/pdh ear and hearing disorders examination form (version 7.1a) assessment procedures measurement of noise levels measurement of ambient noise level in the room was measured using bruel & kjær 2239 type ii integrating sound level meter (bruel & kjær, denmark) prior to the start of assessment. if noise levels were deemed suitable for pure tone hearing screening (≤50 dba ±5dba) then the researcher proceeded to interview participants to get background information about their hearing/auditory status (i.e. case history information) followed by audiometric assessment. audiometric assessment all audiometric equipment used in this study were calibrated prior to the commencement of this study and were used exclusively in this study for the duration of the survey. furthermore, biological calibration of each piece of equipment was performed every morning before the equipment was used. audiometric assessment were conducted by trained research assitants (all senior audiology students) under close supervision of a qualified audiologist. audiometric testing was only done when the ambient noise in the room was deemed suitable for a hearing assessment. the following assessment procedures were followed: individials ≥ 4 years old; otoscopic examination was conducted using heinne s700 mini otoscope (heinne optotechnic, germany) to view and assess the external ear canal and tympanic membrane status. otoscopic examination was followed by tympanometry screening using grason-stadler (gsi 39 screening tympanometer (gsi, minnesota, united states of america) to check mobility of the tympanic membrane and assess middle ear statusand pure tone audiometry screening. hearing status was screened using gsi 17 portable audiometer (gsi, minnesota, united states of america) with standard tdh 39 headphones fittted with amplivox audiocups (amplivox limited, united kindom). a screening level of 30 db hl (with a 60 db hl 1 khz as the first tone presented) at the following frequencies; 0.5, 1, 2 & 4 khz was used and audiometric test started on the ear that the participant considered their best ear. participants were asked to raise their hands everytime they hear the test tone. partcipant was considerd to have “passed” the hearing screening (i.e. no hearing impairment) if they responded to at least 3 out of the 4 test frequencies in each ear and a “refer” result (i.e. hearing impairment suspected) was when the participants failed to repond to at least 2 of the test frequencies in at least one ear. individuals who obtained “refer” results underwant further assessment (diagnostic) using a kuduwave 5000 audiometer (geoaxon, pretoria, south africa) to confirm the degree and type of hearing impairment. this audiometer was selected because it is capable of live monitoring of environmental noise and it also has enhanced noise attenuation capability through the use of a combination of insert earphone and circumaural earphone which has implications for accuracy of test results (swanepoel, mngemane, molemong, mkhwanazi & tushini, 2010b). furthermore, it has been shown to yield test results that a comparable to those that are obtained in a standard sound treated environment (maclennan-smith, swanepoel de & hall, 2013; swanepoel, koekermoer & clark, 2010a). for children ≤ 3 years old; the following assessment procedures were followed; otoscopic examination (heinne s700 mini otoscope), tympanometry screening (gsi 39 screening tympanometer [gsi, minnesota, united states of america]). distortion product otoacoustic emissions (dpoae) screening using gsi audioscreener+ (gsi, minnesota, united states of america) was used instead of pure tone audiometry. a child was considered to have “passed” the hearing screening if a dpoae response was obtained to at least 2 of the 3 screening frequencies (1, 2 & 3 khz) plus a type a tympnogram in both ears. a “refer” results was no response to at least 2 of the screening frequencies with or without an abnormal tympanometry results in at least one ear. all groups of partcipants (i.e ≤ 3 years old or ≥4 years old), with abnormal audiometric test results following the hearing screening and or diagnostic assessment were referred to the nearest primary health care facility to initiate the process of getting appropriate services for their hearing impairment. all assessment information was recorded on the relevant sections of the who/pdh ear and hearing disorders examination form (version 7.1a) (who, 1999). classification of hearing loss disabling hearing impairment in this study was defined as a permanent unaided threshold level in the better ear of ≥ 41 db hl (for adults) and permanent unaided threshold level in the better ear of ≥31 db or (children younger than 15 years old) (refer to table 1b below). table 1-a2: who criteria for grading of hearing loss. j o u r n a l of t h e s o u t h a f r i c a n l o g o p e d c society inleiding van ontspanning tot η terapeutiese program vir moeders van met spraak-gebreke i deur f . t. lubinsky, b.a. log. (rand). groepkinders δ an die b e g i n van 1954 het die moedersnroep w a t d e u r die s p r a a k , stemen g e hoorhiniek v a n die universiteit in die l e w e :°roep w a s , b e s t a a n uit 8 m o e d e r s v a n kinders vat die kliniek b y g e w o o n het. hierdie g e t a l ipt redelik konstant g e b l y d w a r s d e u r die j a a r hhoewel d i e individuele lede soms deur huisiv'e o m s t a n d i g h e d e g e n o o d s a a k w a s om atr e s i a te w e e s en n u w e iede byge/.om het. v/eeklikse v e r g a d e r i n g s v a n 'n uur w a s gehou. die doelstellings vcm die groep volgens baurnan (1) w a s a s v c i g : (1) help d i e m o e d e r s om hulself te help. (2) om onkundigheid te bestry en onderlinge v e r s t a n d h o u d i n g s te ontwi.uel. (3) om g e l e e n t h e d e d a a r te stel vir g r o e p b e s p r e k i n g s , lesings en d e b a i t e . (4) om 'n meer tevrede ouer-kind verhouding te bewerkstellig. (5) hervestiging v a n o u e r w a a r d e s , standa a r d e e n ,'moontlik ook persoonii.chede. (6) om g e v o e l e n s van skuld en s k a a m t e te verminderj en die ouers η groter insig m hul p r o b l e m e te g e e . (7) om a a n 4 dui dat p r o b l e m e a i g e m e e n ' i s ; a n d e r p e r s o n e se p r o b l e m e te b e g r y p e n sodoeride ook p r o b e e r om individuele problemei op te los. (8) om d i e l e d e a a n te m c e d i g om hulle e i e ' status te erken en s o d o e n d e m e e r s e l f vertroue te kry. (9) koestering v a n g r o e p e e n h e i d , stabiliteit, e n standvastigheid. (10) moedig s a m e w e r k i n g en g o e d g e s i n d h e i d a a n . gedurende die eerste helfte vcm die j a a r v/as die r a a d g e e i s t e r g r o t e n d e e l s die middelpunt van d i e groep. lesings w a s deur die raadgeeister g e g e e om in die b e h o e i t e s van die moederste voorsien. in elke lesing het die r a a d g e e i s t e r die b e s p r e k i n g s ingeiei en die m o e d e r s a a n g e m o e d i g om v r a e te stel en huile e i e ondervindings te b e s p r e e k . algeι m e n e en spesiiieke kinder-probleme, ouer-kmd verhoudings, probleme in v e r b a n d met s p r a a x t e r a p i e en verhoudings tussen ouers w a s b e spreek. die l a a s t e lesing v a n hierdie termyn w a s are children affected b y implied attitudes." hierdie lesing het η l e w e n d i g e bespreicing uitgelok en αί die moeders w a s dit e e n s dat a s hulle die d a g a r i k k e l b a a r w a s hulle kinders in 'n soortgelyke g e m o e d s t o e s t a n d w a s . die t e e n o o r g e s t e l d e v/as ook w a a r , a s die moeders in 'n kalm en ontspande houding was, het hulle kinders soos „klein e n g e l t j i e s , " g e r e a g e e r . ^die b e s p r e k i n g s het a a n g e d u i dat die m e e s t e m o e d e r s g e s p a n n e en p r i k k e l b a a r tuis w a s . die r a a d a e e f s t e r het d e r h a l w e besluit om moeders 'n kursus in ontspanningsterapie te l a a t o n d e r g a a n . g e d u r e n d e die tv/eede helfte v a n die j a a r het d i e spil grootliks om die g r o e p l e d e g e draai. twintig minute van ontspanningstei-apie w a s deur die r a a d g e e i s t e r a a n die m o e d e r s g e g e e , en in d i e oorblywende 40 minute het die ouers lesings g e g e e . ^lke moeder is deur die r a a d g e e i s t e r t w e e w e i e voor die tyd g e h e l p a a n literatuur en die lesings het dan gewoonlik g e g a a n oor spesiiieke persoonlike probleme en d a a r n a is v r a e g e s t e l en b e a n t w o o r d . ontspanningsterapie: t w e e inleidende lesings w a s g e i e w e r w a t die vraarde v a n ontspanning u i t g e b e e l d het. b e s c r e k i n g s w a s g e h o u oor die m o d e m e g e j a a g d e en g e s p a n n e l e w e n s w y s e . die v o l g e n d e moontlike oplossing _was a a n g e b i e d :—it remains to e n q u i r e whether h a b i t s altered t h r o u g h ' r e l a x a t i o n m a y not permit us to e n j o y modern civilization without burning the c a n d l e a ? both e n d s . " (2). 'n g e v a l s g e s k i e d e n i s het onder bespreking g e k o m w a a r i n die dokter s e d i a g n o s e a s volg w a s : „u w e n d u e n e r g i e in verskeie· verk e e r d e ' rigtings a a n , om hierdie r e d e k l a u r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) j o u r n a l o f 1 t h b ^ s o l £ i r > ! ^ a f r l ^ a n — l o g o p e d i c s o c i e t y ^ may om t e ontspan. (2). s p i e r o n t s p a n n i n g is a s volg u i t g e b e e l d die a i w e s i g h e i d v a n a l l e spierspanning» dit ? d u s t i s i e i o n m o o n t l i k om in e m g e deel van die l j g a a m s e n u w e e a g t i g te w e e s , a s ,y g e h e e l e n a l in d i e deel ontspan het. g e l e i d e l i k e ontspcnming (2) w a s os volg ged o e n : (1) die verskil tussen s p a n n i n g en ontspan( " ning w a s g e d e m o n s t r e e r en elke moeder w a s t o e g e l a a t om die t w e e s e n s a s i e s te ondervind. v (2) hulle w a s versoek om die spiere van a i e 1 * l i n k e r a m te span en te ontspan. a a n • hulle w a s v e r d u i d e l i k d a t hulle moet ' a a n h o u ontspan verby die punt w a a r d i e spiere h e e l t e m a l o n t s p a n voel dit w a s h e r h a a l d e h k g e d o e n tot-dat al die m o e d e r s d a a r i n g e s l a a g het. (3) dieselfde prosedure w a s gevolg met die ( j o s e r d e l e v a n d i e l i g g a a m m d i e v o l g e n d e o r d e : ( a ) r e g t e r a m ; (b) linkerbeen ; (c) r e g t e r b e e n ; (d) m a a g s p i e r e ; (e) b o r s ; (i) nek (9) v o o r k o p ; (h) o e ; (i) mond ; . (j) alle g e s i g s p i e r e . geleidelik is m e e r en meer spiere v a n d i e l i g g a a m t o e g e l a a t om te ontspan. i a) tussen die ontspanning v a n elke d e e l l ) wps hulle versoek om diep asern te n a a l . (5) hierdie oefening m o e s vir η haliuur e k e d a g tuis voortgesit word. (6) ν a d i e kursus vir η m a a n d a a n die ' g £ i g was, en die m o e d e r s heeltemal b e s y p het w a t v a n hulle v e r w a g word, s s ritmiese d r o m s l a e en s a g t e klayier z u l l s l g e b r u i k , o m η k a l m e a t m o s t e e r te ffip s u g g e s t i e is ook gebruik om klam a a n g e n a m e p s i g i e s e b e e l d e voor t e stel. . (7) deur η g e b r e i k a a n a k k o m o d a s i e kon , ( 7 ) o n t s p a n n i n g s o e ' e n i n g e alleenuk in η ^ t t e n d e posisie g e d o e n word. moeders w s s e f f r versoek om o e i e n m g e m η horisontale posisie tuis voort te sit. h a l f j a a r l i k s e uitslae v a n o n t s p a n n m g s t e r a p i e : l e d e v a n die g r o e p het die ontspanmngs i d e j met groot geesdrii ontvang, a l h o e w e l ν ϊ ι ' d i e m o e d e r s s e l f b e w u s w a s om in die ^ p e n b a a r te ontspan. die e i e n s k a p p e v a n die ontspanning het egter g e blyk om tot groot hulp vir hulle te w e e s . die meeste v a n hulle het gerapporteer dc: huue en hulle families minder g e s c c m n e is en dat die huislike milieu gelukkiger ten slotte kon d a a r o p g e w y s word dat dis m o e d e r s van h a k k e l a a r s a s η resultaat b o a e n o e m d e terapie m e e r ontspanne w a s « huue kinders s a a m met hulle g e s e l s net, geϊ ο ghk " o n die kinders makliker o m s p a n . a l g e m e n e g e v o l g t r e k k i n g s : d i e beleid v a n d i e g r o e p s i t u a s i e h e r e o n m o e d e r s d i e g e l e e n t h e i d v e r s k a i o j ^ j j in*ia in hulle p r o b l e m e te vind hu le h e , ^ s i 'n meer inskikliker houdmg m g e s l a c n . f s i e s e ontspanning het g e b l y k η metode le w e e s om met d a a g l i k s e probleme te en dus vir hulle η geleentheid te g e e tot fc..e. a a n p a s s i n g . bibliografie. , c baumon "an organismic approach t o j h e 1. b. daui-ΐυ-;. tvrrfdy gs g γι£-ιγ:~theory and practice ^ t h , ! c : r . dial technique in speecn i n e . c p y . 1954. witv/atersrcmd universe*/. 2. e. lacobson. edition. 1945. "you must relax." pockel eook 'the latest miracle of modern science' truly a product of the new electronic age. the c i 500 hours' life from a carbon fen cell; t h e operating cost—a m e r e 2/6a. a year (8-hour day)! the tr.3 is the smallest all-transistor aid in the world—the size of a packet of book matches—yet robust and strong. weight—a m e r e 3 ozs.! crystal clear, true tone, simple to use, easy to conceal, comfortable and convenient. * don't delay in hearing for yourself how much this con me*, to you. there « no obligation-just phone or wr.ee . » . africa (pty.) ltd. automutua! house. 57 de villiers street •>.0. box 4127 johannesburg telephone r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction methodology ethical consideration results and discussion conclusion acknowledgements references about the author(s) ntsako p. maluleke department of speech pathology and audiology, school of health care sciences, sefako makgatho health sciences university, south africa katijah khoza-shangase department of speech pathology and audiology, school of human and community development, university of the witwatersrand, south africa amisha kanji department of speech pathology and audiology, school of human and community development, university of the witwatersrand, south africa citation maluleke, n.p., khoza-shangase, k., & kanji, a. (2019). communication and school readiness abilities of children with hearing impairment in south africa: a retrospective review of early intervention preschool records. south african journal of communication disorders, 66(1), a604. https://doi.org/10.4102/sajcd.v66i1.604 original research communication and school readiness abilities of children with hearing impairment in south africa: a retrospective review of early intervention preschool records ntsako p. maluleke, katijah khoza-shangase, amisha kanji received: 13 june 2018; accepted: 28 oct. 2018; published: 28 feb. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the national prevalence of hearing impairment in south africa is estimated to be four to six in every 1000 live births in the public health care sector. an undetected hearing impairment in childhood can lead to delayed speech and language development as well as put the child at risk of not achieving the necessary school readiness abilities that will enable them to achieve academic success. however, through early hearing detection and intervention services, children with hearing impairment can develop communication and school readiness abilities on par with children with normal hearing. objective: the aim of the study was to describe communication and school readiness abilities of children who were identified with hearing impairment and enrolled in early intervention (ei) preschools in gauteng. methods: within a descriptive research study design, a retrospective record review was conducted on files of eight children, ranging in age from 9 years and 7 months to 12 years and 7 months, identified with a hearing impairment and enrolled in ei preschools in gauteng, south africa. descriptive statistics were used to analyse the data, using frequency distribution and measures of central tendency. results: current findings revealed that children with hearing impairment who were enrolled in ei preschools in gauteng were identified late. this consequently led to delayed ages at initiation of ei services when compared to international benchmarks and the health professions council of south africa’s (hpcsa) guidelines of 2018. consequently, participants presented with below average communication and school readiness abilities, which are characteristic of hearing impairment that is identified late. conclusions: transference of current contextually relevant research findings into practice by both the department of health and the department of basic education forms part of future directions from this study. this conversion of research findings into service delivery must be conducted in a systematic manner at all levels in these two sectors to facilitate achievement of early hearing detection and intervention (ehdi), resulting in better communication and school readiness outcomes. introduction in south africa, it is estimated nationally that the prevalence of hearing impairment is four to six in every 1000 live births in the public health care sector (swanepoel, storbeck & friedland, 2009). more recently, studies specifically related to prevalence of hearing impairment in the cape town metropolitan area and urban schools in pretoria found that 11.4% of 174 children aged 0–3 years and 4.3% of 430 children aged 4–9 years presented with hearing impairment (ramma & sebothoma, 2016). other findings from an urban south african context indicated that the youngest age group (<7 years of age) had a higher prevalence of hearing impairment (6.2%) when compared to the older age groups, which presented with a prevalence of 1.7% and 1.3% (mohamed-asmail, swanepoel, & eikelboom, 2016). these findings highlight the importance of the identification of hearing impairment as early as possible. evidence exists that has established a relationship between an undetected hearing impairment in childhood and delayed speech and language development, as well as social and emotional problems (sininger, grimes, & christensen, 2010; van dyk, swanepoel, & hall, 2015). these difficulties may result in lower educational and employment levels during adulthood (joint committee on infant hearing [jcih], 2007). by its very nature, hearing impairment provides incomplete access to spoken language, leading to negative effects on the understanding and development of use of spoken language (wang & engler, 2011). researchers have reported that as these children are at risk of not achieving the necessary skills to prepare them for school, this will have a negative impact on education and academic success, which will ultimately impact their ability to find employment later in their lives (harrington, desjardin, & shea, 2009; marschark, 2007). these difficulties may be further exacerbated by the realities of the south african context. a report from a 2013 meeting between the department of basic education (dbe), department of public service and administration (dpsa) and the deputy minister of women, children and persons with disability indicated that the majority of deaf children did not have early access to early childhood development programmes for stimulation and development of sign language; the majority of deaf children were born to hearing parents, and without the necessary sign language development. in addition, approximately 80% of teachers in schools for the deaf were unable to use sign language. few deaf learners were reported to have progressed beyond grade 12, with only a few schools having audiology equipment and audiologists (parliamentary monitoring group, 2013). research has produced evidence that indicates that the speech and language abilities of children with hearing impairment can equal that of their hearing peers if the hearing impairment is identified early and intervention commenced timeously (meyer, swanepoel, & le roux, 2014; swanepoel et al., 2009). according to the health professions council of south africa (health professions council of south africa [hpcsa], 2018) and the jcih (2007), diagnostic audiological assessment should be conducted by 3–4 months of age with the commencement of early intervention (ei) services before 6 months of age. through timeous initiation of ei services, children with hearing impairment can develop age-appropriate communication and school readiness abilities (desjardin et al., 2014; harrington, desjardin, & shea, 2010). early intervention is used broadly to refer to intervention practices with children from birth to 5 years of age (khoza-shangase, barrat, & jonosky, 2010) who are identified as having, or being at risk of developing, a developmental delay (ackah & appiah, 2011). early intervention is grounded in the conviction that during the first 3–5 years of life there is a unique opportunity to prevent or reverse children’s developmental delays (fulcher, nivelles, purcell, baker, & munro, 2015). success in communication and school readiness abilities provides the foundation for children with hearing impairment to have similar educational opportunities to their normal hearing peers (harrington et al., 2010; le roux, swanepoel, louw, vinck, & tshifularo, 2015). school readiness abilities equip a child to participate successfully on entering school (de jager, 2014; du plooy, 2003) and enable them to learn easily, effectively and without emotional disturbance (du plooy, 2003). although there is no clear statement of what factors constitute school readiness, most researchers in early childhood education agree that in addition to early communication abilities, a solid foundation in early literacy, attention skills and mathematical concepts supports later academic achievement in children (harrington et al., 2009; mukari, ling, & ghani, 2007). over the last decade, there has been a growing recognition of human rights for children with disabilities (storbeck & moodley, 2011). access to education is one of a range of social citizenship rights that are intended to afford these children an opportunity to share in a basic level of social, economic, and cultural well-being and to mitigate inequalities (storbeck & moodley, 2011). thus, there is a need for laying a solid foundation in early childhood to ensure adequate development and growth for children with hearing impairment (storbeck & moodley, 2011). the children’s act no. 38 of 2005 (as enacted in april 2010) makes provision for the delivery of early childhood development services that promote the development of children from birth to school-going age, and for programmes that provide developmentally appropriate learning and support (the united nations international children’s emergency fund [unicef], 2015). through ei services children with hearing impairment can be well prepared as they enter formal education (harrington et al., 2009; kanji & khoza-shangase, 2016). thus, the current study aimed to describe the communication and school readiness abilities of children with hearing impairment who were enrolled in ei preschools in the gauteng province, south africa. methodology the research study set out to describe the communication and school readiness abilities of children with hearing impairment who were enrolled in ei preschools in gauteng, south africa. the following objectives were formulated: to determine the ages at identification of the hearing impairment and ages at initiation of ei services for children with a hearing impairment who were enrolled in ei preschools; to describe the communication abilities of children with a hearing impairment who were enrolled in ei preschools; to describe the school readiness abilities of children with a hearing impairment who were enrolled in ei preschools. research design a descriptive, retrospective record review design was adopted in the current study. a review of written and printed material of preschool files was undertaken to gather the relevant information for analysis, as outlined in the ‘materials’ section. participants the primary population included eight hearing impaired children who had graduated from ei preschools. this sample had four males and four females with an age range of 9.7 years–12.7 years (median = 11.1 years) at the time of data collection. upon enrolment at the ei preschools, participants’ ages ranged from 2 years to 5.8 years with a median of 2.4 years. six of the participants were white people and two were people of mixed race (table 1). four of the participants had been enrolled at ei centre a, and the other four had been enrolled at ei centre b. early intervention centre a is situated in johannesburg and offers a specialised preschool programme for children with hearing impairments and/or language delay, while ei centre b is situated in pretoria and offers habilitation services for children with hearing impairments in a preschool setting (maluleke, khoza-shangase, & kanji, 2018). table 1: demographic information of participants. participants had to meet the following criteria in order to be included in the study: participants had to present with a diagnosis of a bilateral, moderate hearing impairment or greater, unaided. participants had to be fitted with amplification devices, such as hearing aids and/or cochlear implants, in order to compensate for the hearing impairment. participants who presented with co-morbidities such as a cognitive impairment in addition to the hearing impairment were excluded from the study. participants came from the upper middle-class to upper class socio-economic backgrounds. procedure in order to identify potential participants for the current study, the researchers obtained written consent from two ei preschools, allowing them access to the preschool files. subsequently, the researchers compiled a list of caregivers’ contact details for all possible participants using purposive, non-probability sampling. primary caregivers of all possible participants were contacted by telephone, and permission was requested to review their child’s preschool records. consent forms were then emailed to primary caregivers after they indicated their willingness to allow the researchers to review their child’s preschool records. material data obtained from the preschool records included participants’ demographic information, audiology reports, age at commencement of ei services, communication abilities and school readiness abilities. the communication abilities recorded for the purpose of this research study were the last available speech-language assessment results recorded prior to the participants’ graduation from the ei preschool. participants’ communication abilities were assessed in english using standardised language assessment tools. school readiness abilities were extracted from the participants’ preschool reports issued upon graduation from the ei centre. to determine the ages at initiation of ei services, the researchers obtained results pertaining to both age at provision of amplification devices and age at provision of habilitation services. data collection the researchers (dually qualified speech-language therapists and audiologists) were not permitted to remove the files from the ei preschools, thus the desired data were recorded at the preschools on an excel (2009) spreadsheet in such a way that the participants could not be identified by using participant reference numbers. reliability and validity the researchers ensured reliability by conducting the main study in the same manner as the pilot study which was used to ensure that the findings of the current study were reliable (van der riet & durrheim, 2006). validity was ensured through alterations that were made to the data collection tool on the basis of the results of the pilot study. data analysis data analysis followed descriptive statistics where measures of dispersion and central tendency were utilised, as the study was descriptive in nature (creswell, 2009). these included the mean, mode and range. ethical consideration this study adhered to the ethical principles as outlined in the revised helsinki declaration of 1975 (world medical association, 2008), with ethical clearance obtained from the university’s medical human research ethics committee (protocol number: m130240). results and discussion ages at identification of the hearing impairment and initiation of early intervention services because all participants were identified late, ages at initiation of ei services were also consequently delayed (table 2) (maluleke et al., 2018). none of the participants received newborn hearing screening services, thus participants in the current study were identified late following maternal suspicion of the hearing impairment. ages at identification of the hearing impairment ranged from 7 months to 4 years and 1 month, with a mean age at identification of 2 years and 3 months, and the median age was 2 years (maluleke et al., 2018). current findings are inconsistent with the recommendations by the hpcsa (2018) which suggests earlier targets for identification of hearing impairment. table 2: ages at identification, amplification and initiation of early intervention services (n = 8). the results of this study simulate those of other studies. khoza-shangase and michal (2014) examined the current audiological management protocols for children with hearing impairment in the public hospitals of gauteng, south africa. in their results, khoza-shangase and michal (2014) reported a mean age at identification of 1 year and 11 months, which is similar to findings in the current study. it is widely reported that children identified with a hearing impairment after 6 months of age may demonstrate a significant delay in milestones as compared to peers who are identified early on, which may result in delayed speech and language abilities throughout childhood (abdala & visser-dumont, 2001). hence, this finding pertaining to age at identification raises the necessity to develop effective and feasible universal newborn hearing screening (unhs) throughout the diverse south african hospitals (khoza-shangase & harbinson, 2015) and clinic settings (petersen & ramma, 2015) so that hearing impairment may be identified timeously (before parental suspicion), allowing for the commencement of ei soon after diagnosis. the fact that delayed ages at identification of hearing impairment were found in the current study, it was to be expected that delayed age at provision of amplification devices would be found (swanepoel, johl, & pienaar, 2013). ages at provision of amplification devices ranged between 1 year and 6 months and 4 years and 4 months, with the median age at provision of amplification devices being 2 years and 8 months and the mode, 2 years and 6 months (table 2). reasons for delays in provision of amplification devices were not investigated as part of the current study and are implications for future research, but may be influenced by the limited number of audiologists in the public health care sector and long waiting lists as a result of constrained budgets. similar suboptimal provision of amplification devices in the south african context has been reported. in a national survey of paediatric audiology services conducted by meyer et al. (2014), suboptimal provision of amplification devices at ages older than 2 years was reported. these findings demonstrate poor adherence to the hpcsa (2018) guidelines for best practice, which recommend provision of amplification devices within 1 month of identification of the hearing impairment. in addition to mandated unhs, necessary budget provisions are required to ensure that children identified with a hearing impairment in south africa are promptly provided with amplification devices. evidence also suggests that provision of amplification devices as soon as possible after a child has been identified with the hearing impairment is of crucial importance as lack of auditory stimulation has an effect on the development of the child’s speech and language skills (olusanya, okolo, & adeosum, 2004). in addition to suboptimal provision of amplification devices, the current study found that commencement of ei services was late. ages at initiation of ei services in the form of habilitation services ranged between 1 year and 5 months and 4 years and 2 months, with a mean age at initiation of services of 2 years and 5 months, and a median age of 2 years. these findings do not adhere to the hpcsa’s (2018) recommendation of infants with a confirmed hearing impairment receiving intervention services before 6 months and no later than 8 months of age. research evidence shows that an infant with a hearing impairment who receives habilitation services within the first 6 months of life is likely to have linguistic, speech and cognitive development comparable to normal hearing peers, in contrast to persistent delays for those who are identified late. this benefit is attributed to the principle of ‘critical developmental period’, which allows for optimal cognitive, language and speech development early in the child’s life (hpcsa, 2007). the findings of the current study, coupled with a lack of reports of studies conducted in the south african context investigating commencement of habilitation services for children with a hearing impairment, is of great concern. owing to the financial constraints experienced by the south african health care system, implementation of early hearing detection and intervention (ehdi) services required adjustments from the developed context model in order to ensure that these programmes were contextually relevant and achievable (south african speech-learning-hearing association [saslha], 2007). thus, studies in the south african context have mainly focused on validation of early hearing detection services and the development of contextually feasible models of service delivery (de kock, swanepoel, & hall, 2016). consequently, little information is available for studies that demonstrate the mediumto long-term benefits of the entire ehdi process from hearing screening to ei (pillay, moonsamy, & khoza-shangase, 2010). communication abilities communication abilities are reported in terms of receptive and expressive language compared to chronological age (figure 1). one participant presented with above average communication abilities as measured by the test of auditory comprehension of language, 3rd edition (tacl-3) and expressive one-word picture vocabulary test (eowpvt). two participants’ communication abilities approximated age-appropriate norms as measured by the developmental assessment scale (das), while five participants presented with delayed receptive and expressive language abilities as measured by the das, tacl-3, eowpvt and the preschool language scale, 4th edition (pls-4). owing to the dearth of research in this area, there was a lack of results in the south african context to compare with the findings of the current study. however, the delayed communication abilities demonstrated by some of the participants were expected, on account of the late identification of the hearing impairment and subsequent late commencement of ei services reported in the current study (maluleke et al., 2018). figure 1: participants’ communication abilities versus chronological age. in their study, fulcher et al. (2015) investigated whether children with a hearing impairment who were identified early with no co-morbid conditions would outperform similar children who were identified late. results of the study demonstrated that children identified early significantly outperformed the children who were identified late at all ages. children identified before the age of 12 months achieved age-appropriate scores for speech as well as receptive and expressive language abilities. however, late identification and intervention, as demonstrated in the current study, misses the crucial 2 years of the language development period that will enable these children to develop age-appropriate language abilities (storbeck & young, 2016). this finding once again highlights the need for comprehensive ehdi infrastructure. through such ehdi programmes, children with a hearing impairment can experience the optimal benefits from the earliest possible hearing identification and intervention (meyer et al., 2014). it is possible for children with a hearing impairment to achieve age-appropriate speech and language outcomes (fulcher, purcell, baker, & munro, 2012). school readiness abilities participants’ school readiness abilities are reported based on attention/listening skills, communication abilities, mathematical concept knowledge and early literacy skills. a ‘yes’ indicates that the participant presented with age-appropriate skills for the area, while a ‘no’ indicates that the participant’s abilities for that area were not age-appropriate (table 3). table 3: participants’ school readiness abilities. only three participants attained age-appropriate school readiness abilities; however, the remaining five participants did not attain age-appropriate school readiness abilities as demonstrated by poor attention, communication abilities, concept knowledge and early literacy skills. the participants who had attained age-appropriate school readiness abilities also presented with communication abilities that were age-appropriate or approximated age-appropriate norms. this finding is consistent with harrington et al.’s (2009) study, which reported that children who were identified with hearing impairment and received ei at a later date demonstrated lower language scores, which were related to lower school readiness scores. this finding supports the belief that communication abilities are crucial in the development of age-appropriate school readiness abilities (zaidman-zait & young, 2008). presumably, children who have a solid foundation in communication abilities have the ability to apply their linguistic knowledge to concepts such as alphabet knowledge, colour recognition, number identification and time and sequence, which are all considered as skills necessary for school readiness (harrington et al., 2009). the findings of the current study further illustrate that without ehdi programmes, infant and childhood hearing impairment are identified after critical language development periods have passed, resulting in limited opportunities to develop age-appropriate communication and school readiness abilities. hence the need for comprehensive ehdi programmes which will meet the unique needs of children with hearing impairments and their families (albino & berry, 2013). according to albino and berry (2013), to forgo greater investment in ecd interventions means compromising the well-being of south africa’s communities, perpetuating cycles of poverty, poor educational attainment, inequality and socio-economic challenges. conclusion children with hearing impairment who were enrolled in ei preschools in gauteng were identified late. this late identification consequently led to delayed ages at initiation of ei services. these delays were significantly beyond those stipulated in international benchmarks and hpcsa (2018) guidelines, where the ages preclude optimal development (maluleke et al., 2018). consequently, participants presented with below average communication and school readiness abilities, which are characteristic of hearing impairment that is identified late. these findings raise implications for systematic planning and implementation of international level gold standards at various levels of service delivery, in both the department of health and the department of basic education. the consequences of this would be earlier identification of infant and childhood hearing impairment. through early identification of hearing impairment and initiation of ei services, better communication and school readiness outcomes may be achieved. this will enable children with hearing impairment to perform on par with their normal hearing peers. furthermore, urgent implementation of widespread ei services would serve as a concrete step to equalise opportunities for vocational and societal contexts for children with a hearing impairment. strengths and limitations this study may possibly be the first to look at communication in relation to school readiness abilities for ei preschool graduates in the south african context for children with hearing impairment. available literature investigates these factors in isolation. therefore, it addresses the dearth of research in this area. the findings of the current study are reported and interpreted within identified limitations. a small sample size of eight participants from similar upper middle-class to upper class socio-economic backgrounds was used for the current study. although not representative of the demographic profile of the country, it was representative of the context in which the study was conducted. using a larger sample size with participants from varied backgrounds would have allowed for generalisability of the findings to the general population. moreover, participants of the current study were all from the gauteng province. extending the research study to the rest of the eight provinces would have allowed the researchers to establish ehdi outcomes in south africa as a whole, and hence raises an implication for future research. acknowledgements the authors would like to thank the participants. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contribution n.p.m. was the researcher. k.k.s. was the supervisor and a.k. was the co-supervisor. all three authors were involved in the write-up of the article. references abdala, c., & visser-dumont, l. 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(2008). parental involvement in the habilitation process following children’s cochlear implantation: an action theory perspective. journal of deaf studies and deaf education, 13, 193–214. https://doi.org/10.1093/deafed/enm051 abstract introduction research method and design procedure results ethical considerations discussion conclusion acknowledgements references about the author(s) vedika bagwandin discipline of audiology, university of kwazulu-natal, south africa lavanithum joseph discipline of audiology, university of kwazulu-natal, south africa citation bagwandin, v., & joseph, l. (2017). a survey exploring awareness and experience of tinnitus in young adults. south african journal of communication disorders 64(1), a545. https://doi.org/10.4102/sajcd.v64i1.545 original research a survey exploring awareness and experience of tinnitus in young adults vedika bagwandin, lavanithum joseph received: 15 jan. 2017; accepted: 31 july 2017; published: 17 nov. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: hearing loss among young adults is on the increase largely because of greater exposure to recreational noise. one of the effects of a sensorineural hearing loss is tinnitus. despite efforts to raise awareness of hearing loss and tinnitus, young adults continue to expose themselves to the potential risks. the reasons for this are unclear; neither is the extent to which tinnitus is experienced in this population. objectives: the study aimed to describe the awareness and experience of tinnitus among young adults, with regard to its existence, causes, effects and management. methods: a descriptive study design was employed using an electronic survey that targeted students within a selected school at a university in kwazulu-natal. there were 75 participants between 18 years and 30 years. data were analysed using descriptive statistics. to raise awareness about tinnitus, on completion of the questionnaire, all participants were given access to an information document about tinnitus, its causes and management. results: the majority of participants (69.86%) were not aware of the existence of tinnitus. thus, most of the participants did not know about the causes or effects of tinnitus. tinnitus was experienced by 13.51% of participants themselves and 12.16% knew someone who suffered from it. conclusions: the general lack of awareness of what tinnitus was, its causes and effects, has implications for audiologists who are involved in hearing health care across the age span. hearing health promotion programmes targeted at young adults should include information on hearing loss as well as tinnitus and its management. introduction tinnitus is defined as a sound perceived in the ears and/or head without an external sound source (alam et al., 2012). its intrusive nature can interfere with the lifestyle of the affected individual, irrespective of age, gender, race and socio-economic status (henry, dennis & schechter, 2005). traditionally, studies on tinnitus have focused predominantly on older adults. however, recent studies have shown that approximately 18% of young adults between the ages of 18 and 25 experience tinnitus (degeest, corthals, vinck & keppler, 2014). the causes of tinnitus can include illness, certain medication, head and neck injury, surgery and exposure to excessive noise experienced at places such as nightclubs, raves and concerts (nondahl et al., 2010). some studies have found that chronic noise exposure has been reported as the main cause of tinnitus in young adults because of exposure to excessively loud noise from personal listening devices (plds), recreational activities or attending nightclubs (gilles, van hal, de ridder, wouters & van de heyning, 2013; salvago et al., 2012). however, it is important to note that there may be other confounding variables with regard to the population group in the current study when compared to the same population group of other studies. the burden of diseases including tuberculosis and ototoxicity associated with tinnitus, low socio-economic status and lifestyle influencing access to plds and nightclubs may be different in the south african young adult population. it is evident though that young adults expose themselves to loud noise while participating in leisure activities (degeest et al., 2014). it is believed that these young adults may listen to excessively loud music for reasons associated with social norms and expectations (levey, fligor, ginocchi & kagimbi, 2012). thus, these individuals are at risk of acquiring tinnitus during recreational activities and by using plds and other sources of loud music (vogel, looij-jansen, mieloo, burdof & de waart, 2014). therefore, it has been suggested that young adults should be educated about the harmful effects of excessive noise exposure in nightclubs, raves and concerts and about the advantages of using hearing protection devices (hpds) (gilles et al., 2013). however, it appears that despite the increasing prevalence of tinnitus and hearing loss in the young–adult population (chung, roches, catherine, meunier & eavey, 2005), there is still a lack of knowledge about the impact of excessive noise on the ears and use of hpds. generally, hearing loss is associated with the elderly; therefore, it is unlikely that young adults may pursue the use of hpds. thus, it may be beneficial to strive to change the attitudes of young adults (gilles et al., 2013). as in older adults, young adults may also experience the negative effects of tinnitus in their daily lives. some of the most common effects of tinnitus reported in young adults include difficulty falling asleep, feeling depressed, irritability, interference in social activities, hearing difficulty, feeling confused and experience of disruption of daily activities and jobs (zeman, koller, langguth & landgrebe, 2014). in fact, these unwanted effects may be more detrimental to the young adult in that they may affect their academic studies. it is assumed that these negative effects of tinnitus may cause an increase in the failure and dropout rates at learning institutions and also prevent them from obtaining employment. according to the world health organization, health is described as total mental and physical fitness which allows an individual to participate in daily life (who, 2007). if young adults experience the unwanted effects of tinnitus such as trouble falling asleep, concentration difficulties and psychological complications, this may negatively impact on their daily life including social interactions and academic and vocational progression. some studies have suggested that there may be a relationship between tinnitus, anxiety, depression and suicide in young adults who suffer with tinnitus (cho, chi, song, lee & kim, 2013). researchers revealed that 10% of 973 young adults from a dutch inner-city senior-secondary vocational school, who participated in their study, reported depression and suicidal thoughts after experiencing tinnitus and hearing loss and thus sought help (vogel et al., 2014). although there are various methods of managing tinnitus, such as the use of hearing aids, counselling, acoustic therapy, relaxation techniques, pharmacological and surgical approaches (sweeto, 2013), young adults may not always be aware that there are management strategies for tinnitus and as a result may not seek help. it is also suggested that because young adults do not consider tinnitus as an important health problem, as there is no associated pain, they may not seek any help for it (roberts, hal martin & bosnyak, 2011). it is clear that more awareness on what tinnitus is, its causes and effects has to be provided to young adults. however, it may be more beneficial to inform all young adults about the effects of tinnitus on their lives specifically rather than focus on how hearing loss and tinnitus occur generally (roberts et al., 2011). if young adults are aware of how this affects them personally, they may be more likely to take precautions. this point of view is also promoted by other researchers who state that young adults are likely to perceive and understand risks involved with exposing themselves to detrimental situations only if it emerges from their own personal experiences (landälv, malmström & widen, 2013). tinnitus can manifest in various ways because of the underlying cause; and thus management would also differ depending on the reason for the tinnitus. while many tinnitus management strategies exist, young adults, in general, may not seek help because of their lack of knowledge regarding tinnitus management. this highlights the need for young adults to be better informed about tinnitus. it is also important that audiologists who provide services to tinnitus sufferers have knowledge about the extent to which this condition exists and manifests in young adults. therefore, the aim of this study was to describe young adults’ awareness and experience of tinnitus. research method and design aim the aim of the study was to describe the awareness and experience of young adults regarding tinnitus. this led to the following objectives: to describe awareness regarding the causes of tinnitus and its effects to describe experience and management of tinnitus. design a quantitative descriptive survey design was used as it aims to report on a large population and also serves as a means of describing attitudes, beliefs and opinions of individuals (leedy & ormrod, 2013). the data were obtained by means of a self-administered questionnaire that was distributed electronically. an electronic survey was chosen as it was a cost-effective way to obtain responses. it also facilitated data collection by allowing the researcher to obtain several responses in a short time (hunter, corcoran, leeder & phelps, 2013). it was also considered a viable method to communicate with this sample population as university students are expected to use electronic communication, including online learning at this university with access to computer laboratories. sampling method a non-probability purposive sampling method was used. participants were selected according to their age range and the specific school in which they were registered at the university (levey & lemeshow, 2013). the participants were selected because they were easily accessible to the researcher (leedy & ormrod, 2013) while meeting the age criteria of young adults. the sample of participants comprised all undergraduate and postgraduate students in 2013, who met the inclusion criteria, from one non-health sciences school at the university of kwazulu-natal. this school had the most students while allowing for a level of homogeneity in the sample. participants because this study focused only on young adults, the age group 18 years – 30 years was chosen. some other studies, which focused on young adults at universities, also used participants within this age group as it best represented a young adult group (agrawal, platz & niparko, 2008; mostafapour, lahargoue & gates, 2009). the researcher chose university students specifically, as they would fit this age group easily. selection criteria participants had to be between the ages of 18 years and 30 years and currently registered as students in the selected school. the participants needed to be undergraduate or postgraduate students in 2013. the researcher included the postgraduate students for two reasons. firstly, the study required young adults from 18 years to 30 years and it is challenging to obtain participants from the 30-year age group who are undergraduate students. secondly, there are many students who may have chosen to do postgraduate studies shortly after completing an undergraduate degree. these students would have been below the 30-year age group. description of participants only 103 participants of a potential 4179 students responded to the survey. however, 75 completed the questionnaires. only 74 (98.6%) participants confirmed their gender, of which 24 (32.43%) were males and 50 (67.57%) were females. data collection instrument the data collection instrument was developed by the researcher based on previous literature. the questionnaire used in the current study was a structured, self-administered questionnaire. the questionnaire comprised 32 questions with a range of closed-ended, open-ended, single-response and likert-scale questions which probed various areas relating to the participants’ awareness of what tinnitus was, the causes and effects, as well as their experience of tinnitus. closed-ended questions gave participants a choice to explain responses categorised as ‘other’. the questions provided an opportunity to express their experience of tinnitus in an easy, yet comprehensive, manner and also provided the researcher with information to achieve the aim and objectives of the study (refer to table 1 for a description of the questionnaire developed by the researcher). the questionnaire was adapted for online format for survey monkey software. table 1: description of the questionnaire. refer to the online appendix 1 for the questionnaire used in the study. procedure reliability and validity a pilot study was conducted to ensure that the questionnaire was clear and that participants had understood all questions. the pilot study was conducted on students in the same age group who were registered in another school at the university. it provided feedback clarity on the reliability of the electronic survey and assisted in determining whether the questions were appropriate, unbiased and provided an idea of possible analysis of the results. the questionnaire used simple and unambiguous language so that participants provided answers which focused on the response intended and related to the aim and objectives of the study in terms of face and content validity (leedy & ormrod, 2013). clear instructions were provided to make it easier for participants to answer the questions. data analysis data were analysed by inputting the results on the spss program, version 21 (ibm core). descriptive statistical procedures such as frequency and percentages were used based on the type of questions being addressed. results for awareness and knowledge, experience of tinnitus and noise exposure were analysed by using frequency counts and percentages. mean average scores were used to analyse the average number of responses for the causes of tinnitus. results the awareness of the existence of tinnitus the results showed the majority of the participants in this study were not aware of what tinnitus was, as 51 (69.86%) stated that they had not heard of the condition. when participants were asked about their source of information on tinnitus, only 25 participants chose to answer that question. thirty-two per cent of these 25 participants knew about the condition from friends and family who experienced it and from the internet. only one respondent reported being aware of the condition from their own experience. these results show that tinnitus is not commonly known and experienced and therefore participants were not likely to actively search for information on it. awareness of the effects of tinnitus only two out of 74 participants who answered this question (2.79%) were aware about the effects of tinnitus. from these two participants, one reported that individuals might have ringing in the ears and decreased hearing for environmental sounds as effects of the tinnitus. the second participant did not specify what they believed to be the effects of tinnitus. awareness of the causes of tinnitus participants were given a set of choices for the possible causes of tinnitus, each on a five-point likert-scale, ranging from strongly disagree to strongly agree. most of the participants (64.39%) agreed that plds cause tinnitus and another 61.81% agreed that ear-related problems cause tinnitus (refer to table 2 for awareness of the causes of tinnitus). interestingly, it was also noted that participants viewed plds as a bigger cause of tinnitus than attending nightclubs, raves and concerts. table 2: views about the causes of tinnitus. awareness and use of hearing protection devices the majority of 65 (91.78%) participants who answered this question were aware of hpds. most of the participants (49.71%) heard about hpds from their family, while 44.71% had learned about hpds from the internet. although the majority, 73.6%, agreed that hpds should be used when exposed to excessively loud levels of noise, 95.95% stated that they do not wear hpds when exposed to excessively loud noise (refer to figure 1 for participant’s awareness and use of hearing protection devices). only a small percentage (4.17%) stated that they wore hpds during excessive noise such as those at nightclubs, raves and concerts. it must be noted that participants were not given any explanation what excessive noise meant. however, as the previous question alluded to the fact that attendance at nightclubs, raves and concerts may cause tinnitus, participants may have understood that to be the meaning of excessive noise in this study. figure 1: need of hpds during exposure to high levels of noise (n = 73). experience of tinnitus the results indicated that out of the 74 participants who answered this question, 10 (13.51%) participants had experienced tinnitus themselves and 9 (12.16%) knew of a family member or friend who experienced tinnitus (refer to figure 2 for participant’s experience of tinnitus). however, it is clear that the majority had no experience with tinnitus. from the nine participants who indicated that they knew someone who experienced tinnitus, five participants indicated that it was a close family member who had tinnitus, that is, mother, grandmother and grandfather. it was also evident that the tinnitus presented differently to each participant. figure 2: experience of tinnitus from family and friends and personal experience (n = 74). description of tinnitus experienced all participants described noticing a ringing in their ears at some point in their lives. of the 10 (13.51%) participants who personally experienced tinnitus, 40% experienced the sound in both ears, while a small percentage (10%) were unsure of the location of the sound. it was observed that 50% of participants stated a gradual onset of the sound and 50% stated a sudden onset. all the participants (100%) stated that the sound occurred sometimes, which is intermittently. the results also revealed that 50% of participants described the sound as ringing, while one participant described a pulsating sound. according to the results obtained, 90% of participants described the sound as annoying. approximately a third (30%) said that they found the sound extremely annoying. however, it is not certain whether these participants who found the sound annoying knew what tinnitus actually was. effect of tinnitus on daily life only eight of the 10 participants who experienced tinnitus provided information regarding the impact of the tinnitus in their life. of these, 62.50% complained of concentration difficulties because of the tinnitus. one participant complained of sleeping problems and one participant complained of social problems. however, it must be noted that although only a few participants chose to answer this question, the other participants in this study who did not answer this question or young adults in general with tinnitus may also experience similar effects of tinnitus (refer to figure 3 for effect of tinnitus on daily life). figure 3: effects of tinnitus on daily life (n = 8). management, self-treatment and relief of experienced tinnitus from the 10 participants who indicated that they had tinnitus, none of them sought any help from a health professional, even those who found the tinnitus bothersome. it is unknown from the survey why they did not seek any help as this question was not included in the questionnaire. also, none of the participants who had tinnitus experienced any relief with regard to the severity and intrusiveness of the sound. from the 10 participants who reported having tinnitus, 30% said that they had been treating the tinnitus themselves by reducing the levels of noise they are exposed to. it was not clear whether these levels of noise were within the environment or from pld. the results of this study also revealed that 70% of the 10 participants were doing nothing about their tinnitus. however, only 22% of those three participants who reduced the noise levels were satisfied with the methods they were using to alleviate the tinnitus. request for information on tinnitus the results of this research indicated that 62% of the participants requested more information about tinnitus. of these 62% of participants, 58.69% indicated that they would like to know more about the causes and where to seek help for it. it was found that although some of the participants did not know about tinnitus, they still did not request any further information about it. ethical considerations ethical clearance was obtained from the human and social sciences research and ethics committee of the university of kwazulu-natal to conduct the study (hss/0497/013m). once permission was granted by the registrar of the university to access students, a link to the survey monkey website was placed on the university’s online notice system, for all students registered in the selected school. this was done with the assistance of the information technology department at the university. participants could access the information document, consent form, questionnaire and information document via this link. participants were able to complete a consent form online prior to completing the questionnaire. only those participants who provided informed consent were able to access the questionnaire. potential participants had to confirm that they were between 18 years and 30 years and currently registered in the selected school. the consent forms and questionnaires were returned to the researcher electronically once they were completed via survey monkey. a reminder was sent to students after 2 weeks to improve the response rate. data were coded and then analysed with the assistance of a statistician. discussion the awareness of the existence of tinnitus as in the current study, low levels of awareness have also been observed in other studies (mostafapour et al., 2009). chung et al. (2005) reported that young adults seemed more concerned about what they perceived as more life-threatening health conditions and as they did not consider complications of the ears as life-threatening, the young adults in their study did not have much concern about tinnitus and hearing loss. however, in this study, it is evident that the majority of participants did not know what the condition was, and therefore, one cannot make an assumption that they may have not considered it life-threatening. recent studies have indicate that health promotion programmes regarding tinnitus should be presented to young adults in various ways so that they may be more likely to take advice (dell & holmes, 2012; henderson, testa & hartnick, 2010). also, from a study by henderson et al. (2010), it was felt to be more beneficial if the source of awareness came from a health professional rather than the internet. however, it seems that the results from the current study were different. when participants were asked about where they had heard of the condition, a few reported that they knew someone in their family who experienced it and a few came across it while surfing the internet. awareness of the effects of tinnitus literature indicates that the severity of tinnitus is not necessarily a true reflection of the actual impact it has on the individual’s life (alam et al., 2012). sometimes, a person can have tinnitus that is mild but may still feel that it has a significant impact on daily life. also, someone who may have extremely severe tinnitus may feel that it does not impact daily life (mccombe et al., 2001). it is concerning that most participants in this study complained of concentration difficulties. these participants were university students and thus required to concentrate on their studies in order to succeed. these negative effects can drastically prevent young adults from participating in their social contexts and affect their progress academically, socially and vocationally (who, 2007). the other negative effects such as reduced social interactions and sleeping difficulties were also reported in this study. these results were similar to those found in a few other studies (alam et al., 2012; cho et al., 2013). concentration difficulty can impact negatively academic performance and it is therefore important to identify this problem earlier in the acquisition of tinnitus. because the majority of participants in this study indicated that they did not know about the condition, it is even more apparent that education programmes be provided to young adults, highlighting the negative effects of tinnitus. with an increase in awareness of this condition, young adults will be able to recognise it and seek appropriate management, thereby increasing their chances of success in their career and social interactions. awareness of the causes of tinnitus a study by gilliver, beach and williams (2013) found that there was an urgent need for young adults to be aware of prolonged use of plds at high sound levels. their study concurs with results from other similar studies which found that young adults were not well educated about the causes of tinnitus and as a result, exposed themselves to high levels of noise either from plds or from attending nightclubs, concerts and/or raves and recreational activities (gilles et al., 2013; dell & holmes, 2012). however, even after being made aware of the risks, they may still choose to use plds because of social reasons (levey et al., 2012). perhaps, young adults may only limit the use of plds if they have tinnitus or any other ear-related problems after prolonged use. in this study, all the participants who experienced tinnitus stated that it may have been because of noise exposure that was attributed mostly to plds. it can be assumed in this study that, perhaps, exposure to noise may have been a contributing cause to the tinnitus. awareness and use of hearing protection devices the few participants who obtained knowledge about hpds from family and friends who have used it, as well as the internet, may, in fact, be knowledgeable about the importance of the use of hpds. however, they may not be putting this knowledge into practice because of, perhaps, peer pressure and conforming to trends that have been set by their peers. studies have stated that young adults are likely to behave in a certain way because they want to ‘fit into’ society, that is, in a similar way as their peers (gilles et al., 2013). it may also be that the participants do not have easy access to hpds or may not be aware of where to access them; hence, they do not use them. it is unknown whether the participants did, in fact, frequent areas or activities with excessive noise such as nightclubs, concerts, raves and shooting ranges. although participants may be exposed to places with loud noise such as pubs and malls, it may not warrant the use of hpds as there is an unlikely chance of acquiring permanent bothersome tinnitus in these noise environments. mostly, tinnitus can be prevented and understood better if one is aware of its causes. if there are ways in which young adults can protect themselves from acquiring tinnitus, then they need to be aware of those ways. previous studies have shown that young adults are not aware of hpds (gilles et al., 2013; gilliver et al., 2013). in this study, it became evident that young adults seemed to know about hpds; however, most of them did not make use of hearing protection when exposed to loud noise. there is no definite reason that can be identified as to why this is so as this question was not included in the survey. taking precautions when visiting a nightclub or limiting the use of a pld may be seen as deviating from the social norms and not conforming. experience of tinnitus tinnitus may not always be experienced by the individual person but can be experienced via family and friends who may be associated with that person. therefore, it may be assumed that young adults may be likely to indirectly be exposed to the causes, effects and characteristics of tinnitus from close family and friends who experience it. with regard to the participants themselves having tinnitus, research has shown that young adults are at risk of acquiring tinnitus (chung et al., 2005). other recent research by gilles et al. (2013) also found that tinnitus has increased in the last 20 years in the young population group. one such study found that 89.5% of young adults had transient tinnitus after exposure to excessive noise (gilles et al., 2013). however, from the results found in this study, one would notice that these results are different from what previous researchers have found. perhaps, a possible reason could be that this study did not have as many participants as the others. therefore, these results need to be interpreted with caution. description of tinnitus experienced according to literature, tinnitus with a gradual onset is generally associated with pathologies such as sensorineural hearing loss and tumours, whereas tinnitus with a sudden onset can result from ear trauma which can be physical or through sudden loud noise exposure (tyler, 2000). in this study, a few participants felt that noise exposure had caused their tinnitus. previous studies have also indicated that the onset of tinnitus may be linked to the exposure of excessive noise (degeest et al., 2014; landälv et al., 2013). all the participants (100%) who experienced tinnitus stated that it occurs ‘sometimes’. however, it was not requested from the participants in the survey to elaborate on what they meant by ‘sometimes’. therefore, it is difficult to make further assumptions in this regard. it has been suggested that intermittent tinnitus is related to excessive noise exposure (gilles et al., 2013). therefore, it can only be assumed that the participants who complained of hearing tinnitus ‘sometimes’ may have acquired it from exposure to excessive noise. however, if these participants experienced the tinnitus only ‘sometimes’, then the tinnitus may not be as intrusive as it would have been if it were present all the time. this is particularly important for young adults who are most likely involved in academic studies, as permanent tinnitus may negatively affect their studies. although one must revert to the early results where participants stated that the tinnitus was extremely annoying. this reiterates the fact about the link between the subjective report of tinnitus and the actual objective severity of it. the results also show that 50% of participants felt that the tinnitus sounds like it is ringing. ringing tinnitus is usually associated with exposure to loud noise (holmes & padgham, 2011), which may allude to the fact that excessive noise exposure may have been the primary cause of tinnitus in those participants who complained of a ringing sound. it must be noted, however, that one participant (10%) complained of pulsating tinnitus. according to the literature, pulsatile tinnitus may be indicative of a possible vascular problem (british tinnitus association, 2014). it was not known whether any of the participants suffered from a vascular problem, as there was no specific question in the questionnaire to confirm this information. management, self-treatment and relief of experienced tinnitus there are various methods that may relieve tinnitus, ranging from counselling to masking and possibly surgery (canadian academy of audiology, 2014). however, none of the participants in this study obtained help from a health professional. it may be assumed that because there was a lack of knowledge with regard to tinnitus, these participants did not know where to go for assistance. also, as some participants experienced the tinnitus only ‘sometimes’, they may have not felt the urgent need of seeking treatment for it. because only very few participants (30%) had indicated that they reduced the volume of their music in order to alleviate the problem, this result cannot be generalised to the wider population. one also cannot be sure as to what may have been the actual cause of their tinnitus, which may not have necessarily been excessively loud noise. conclusion studies on tinnitus have focused predominantly on the older adult population. however, various studies have established that there is an increase of reported tinnitus in young adults, which motivated the researcher to conduct this study. the study confirmed that a few young adults from this study experienced tinnitus. it must be known that these results cannot be generalised to the wider young adult population because of the small sample size obtained. it is important that young adults are aware of tinnitus so that they can protect themselves from exposure to its causes and know where to seek help if they experience tinnitus. it needs to be considered that although the internet is a good online tool to use for health promotion, it may not be accessible to all young adults especially those from a lower socio-economic group. other studies as those mentioned in the literature above also allude to the fact that a health professional may also be a preferred person to conduct health promotion and awareness on tinnitus. it was evident that the majority of young adults in this study did not know about tinnitus nor its causes. health promotion programmes on tinnitus are important as it will ensure that young adults limit their exposure to tinnitus, which may in the long run inadvertently decrease the existence of tinnitus and its negative effects in young adults. also, by providing knowledge and awareness on the appropriate management for tinnitus, young adults who have tinnitus will know where to go to seek help. this will have a positive effect on their career and overall quality of life. limitations of the study although this study has revealed pertinent information regarding tinnitus in young adults, some limitations were identified: the expected sample size was not achieved. the sample size was not large enough to make a generalisation to the entire young adult population. detailed questions regarding the participant’s actual exposure to tinnitus, such as attending nightclubs, exposure to illnesses and injury were not included in the questionnaire. an internal consistency measure which would have enhanced the reliability of the questionnaire was lacking. the use and limitations of electronic surveys in this study were apparent with regard to the low response rate obtained. implications from the results obtained in this study, the following clinical and theoretical implications are postulated: the provision of tinnitus management by health professionals responsible should be more accessible to young adults with tinnitus with regard to their awareness of strategies available and who they can seek help from. audiologists, other health care professionals, young adults and the general public should be more aware about the need for early intervention of tinnitus in young adults to assist with the negative effects of tinnitus. increased awareness of the existence, causes and management of tinnitus may be provided via accessible sources such as the internet, health talks in the media and health clinics. it is important to propose educational programmes at tertiary institutions about hearing loss and associated tinnitus as this is an environment where young adults can be readily accessed. there needs to be greater awareness created among young people about the damaging effects of listening to high levels of sound. recommendations for future research from the study, the following recommendations are suggested: a paper-based questionnaire should be used to probe issues like knowledge about tinnitus in young adults. a paper-based questionnaire may provide a better response rate. the levels and length of time of noise exposure causing tinnitus in young adults should be further explored. more studies need to be conducted on young adults who have tinnitus. these studies should ideally be qualitative studies that focus on the experience of tinnitus, access to management and psychological effects. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them 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(2014). which tinnitus-related aspects are relevant for quality of life and depression: results from a large international multicentre sample. biomed central, 12(7), 1–10. https://doi.org/10.1186/1477-7525-12-7 14 sajcd • vol 57 • december 2010 speech-language therapists supporting foundation-phase teachers with literacy and numeracy in a rural and township context anna-marie wium brenda louw university of pretoria irma eloff faculty of education, university of pretoria correspondence to: a wium (awium@ul.ac.za) introduction background benchmark studies (the timms & pirls international study centre, 2007) pointed out that foundation-phase learners in the south african education system have not developed the basic reading skills required for learning and that learners who study in an indigenous language lack the necessary language skills for numeracy. this implies that the majority of learners in south africa are not receiving quality education, which can be considered a violation of their constitutional rights. to improve learners’ performance in literacy and numeracy, educators in the foundation phase would benefit from the support of speechlanguage therapists (slts) to facilitate these aforementioned skills. effective support requires the slt to collaborate with district facilitators, as well as educators and their schools. such collaboration contributes to meeting the special educational needs of learners (paradice, baileywood & davies, 2007). slts with their specialised knowledge of communication and language are particularly equipped to support educators to facilitate listening, speaking, reading and writing. slts working in education contexts therefore have a dual focus – to support learners, but also educators. within a collaborative and consultative approach, this study developed a multicomponent continued professional development (cpd) programme for foundation-phase educators to facilitate listening and language skills, particularly the language skills required for numeracy. the research determined the value and benefits of such a programme for the participants. the reasons for developing such a cpd programme include issues related to language use, a new national curriculum statement (ncs), and the specific training needs of educators, as well as the need for early childhood development programmes to enhance school readiness of learners. language-related issues many young learners in south africa struggle to develop ageappropriate language skills because of an inherent pathology (e.g. a specific language disorder or a language delay) and/or barriers in their learning environment. receptive and expressive language skills (spoken and written) are the basis for learning and the entire curriculum (paradice et al., 2007). a delay in language development during the early years causes learners to fall behind and eventually drop out. this is a particular problem in south africa, a country where scientific and technological expertise and skills are needed (department of education, gauteng, 2007). an escalating number of learners learn in a language other than their home language (l1). in gauteng, 33% of the learners receive instruction in their second or third language (department of education chief directorate: quality assurance, 2002). also, in many classrooms the l1 of the educator is not the same as the l1 of the learners. with only home support of their mother tongue, these learners lag behind in the acquisition of literacy (o’connor & geiger, 2009). owing to the diversity of language and culture in the south african context, the language of learning and teaching (lolt) in classrooms is a contentious issue with no straight answers. since the new dispensation has come into power, there has been a shift in the demographic, cultural and linguistic composition of classrooms, which complicates the choice of the lolt. educators find such complexity in terms of language use difficult to deal with and often opt for a middle ground by using english as the lolt. often educators have a different l1 than the lolt. considering that slts have expertise in language and phonetics, they can make a significant contribution to the acquisition of literacy skills (e.g. reading, speaking, writing and listening). slts working within a consultative and collaborative model of support are required to provide educators with workshops to facilitate languageand literacy-related skills (moodley, chetty & pahl, 2005). new national curriculum statement alongside the above challenges, educators currently have to adapt to a new national curriculum statement (ncs) that is based on an outcomes-based education (obe) approach. many educators, especially those in previously disadvantaged areas, find it difficult to implement the ncs as they are not necessarily equipped to deal with these changes from the ‘old’ system (gouws & dicker, 2006). as a result there is a abstract language is required for learning, but educators often find it difficult to facilitate listening and language skills while they have to adapt to a new national curriculum with an outcomes-based approach for which they have not necessarily been adequately trained. a multifaceted support programme was developed for foundation-phase educators to facilitate listening and language for literacy and numeracy, with a particular focus on language for numeracy. the aim of the research was to determine the value of this particular support programme for foundation-phase educators in two different contexts (a semi-rural and a township context). a mixed methods approach with a concurrent, equal status triangulation design was used, where qualitative data were transformed to quantitative data in order to be compared in a matrix. the results show that the participants benefited to varying degrees from the programme. the combination of workshops, practical and mentoring components proved to be an effective means of support. the results indicate a need for pre-training selection procedures as more effective support can be provided to homogeneous groups. keywords: educator support, language competence, speech-language therapists vol 57 • december 2010 • sajcd 15 speech-language therapists supporting teachers need for high-quality staff development and training. currently, many educators are still struggling to deal with the challenges brought about by the legacy of apartheid, for example teaching large classes, being undertrained and underqualified, as well as coping with insufficient facilities and resources. these challenges affect educators’ morale. as the general attitude of educators may have a significant impact on learners’ performance, it is important to counteract low morale by providing additional support (killen, 2007). training needs of educators international research (girolametto, weitzman, lefebvre & greenberg, 2007) indicates that many educators have little or no special training to effectively teach learners who experience (or who are at risk of developing) barriers to learning. earlier reports (badroodien, gewer, roberts & sedibe, 2002) estimated that 86 000 educators in south african public schools were underqualified, and more recently it was reported (davids, 2009) that almost a third of the educators lack appropriate qualifications. many of those educators who are unqualified teach grade r, which is a very important stage for young learners as they are being prepared for grade 1. consequently, cpd of educators, particularly in the foundation phase, has become a national priority to increase performance in the literacy and numeracy learning areas (creecy, 2009). slts working in the education environment can make a significant contribution to this end because of their expertise in the acquisition of language for learning. school readiness and the need for early childhood development in south africa, 40% of all children come from extremely impoverished backgrounds where low literacy levels prevail (botha, maree & de witt, 2005) and learners have limited access to learner-support materials. such learners may not enjoy the stimulation and learning experiences that promote school readiness. therefore, learners from low socioeconomic schools (sess) need to be supported to overcome their potential developmental delays, particularly in the foundation phase, so as to prevent future learning problems. although several studies were identified that focused on literacy and language, and particularly the vocabulary required for numeracy (botha et al., 2005; pluddemann, mati & mahlalela-thusi, 1998; reed, davis & nyabanyaba, 2003; setati, 1999), limited research was available that was pertinent to the support of foundation-phase educators in facilitating such skills. one of the reasons for developing this particular cpd programme was to support foundation-phase educators to facilitate improvement in their abilities to teach literacy and numeracy. previous studies were mainly descriptive in nature, and made use of quantitative data. mixed methods research, such as was used in this particular study, is extremely suitable for use in educational contexts (mcmillan & schumacher, 2006). the cpd programme developed by this study this study developed the framework for a continued support process for foundation-phase educators, as well as the training material to support this. framework for a support programme the proposed programme consisted of training, practical and mentoring components to support educators in facilitating listening and language skills for literacy, and with a particular focus on the language of numeracy. these three components (illustrated in figure 1) were designed to augment each other in empowering foundation-phase educators to facilitate listening and language skills in learners. the support provided by the training component was aimed at the acquisition of foundational competence. it consisted of three full-day workshops that focused on subject knowledge of facilitating listening and language, as well as the language for numeracy as stipulated in the ncs. a practical and a mentoring component were also included, as limited benefit can be expected from one-day workshops (massel & goertz, in roberts, 2002). research (sowden, 2007) has shown that elements of reflection, as well as opportunities to gain first-hand experience (‘knowledge in practice’) (adler, slonimsky & reed, 2003), enhance learning. the training component the training component consisted of the development of the training material and design of three full-day workshops per annum. the three workshops integrated the principles of adult learning, learning preferences and obe. in the semi-rural context the workshops were conducted on saturdays; in the urban context on a school holiday and public holidays. the workshops provided participants with strategies and activities to facilitate listening and language skills, which were firstly demonstrated. strategies included the use of a theme with supporting stories, songs, rhymes and crafts, which in many instances were selfconstructed. such strategies were used to facilitate the four language systems required by the ncs (reading, speaking, listening and writing). participants had the opportunity to practise these strategies in role play in the workshop before applying them in their classrooms. based on the whole-language approach (goodman, 1986), the use of a theme created several language-rich experiences and allowed the learners to develop the vocabulary related to a specific topic, and integrate skills across the curriculum. the facilitator of these workshops was a qualified slt with experience in the field of educator support and adult learning. the training material developed for the workshops included basic theoretical background for educators to understand the importance of listening and language skills with regard to the ncs. the three workshop topics and the rationale for their selection were as follows: • ‘listening for learning’. learners need to learn the art of listening actively, attentively and analytically in order to learn. as listening and language are interrelated, the facilitation of auditory processing skills needs to be included as part of an integrated approach in the classroom (bellis, 2003). such an integrated intervention approach also includes phonological awareness and phonemic processing (richards, 2004). • ‘language for learning’. emergent literacy involves both written language awareness and phonological awareness (justice & ezell, 2001), which are both based on normal oral language (particularly vocabulary development). age-appropriate oral language development is required for the development of reading competence, and therefore oral language proficiency is regarded as predictive of reading achievements as well as other written language achievements at a later stage (catts, fey, zhang & tomblin, 2002). this specific programme supported a ‘balanced approach’ as current best practice for the facilitation of literacy (justice & kaderavek, 2004). such an approach firstly creates opportunities to develop an understanding of the language and then uses this understanding as the basis to teach discrete skills within a phonics-oriented, code-based approach (justice, skibbe & ezell, 2006). • ‘language for numeracy’. the aim of the workshop ‘language for numeracy’ was to alert educators to the importance of language use 1 the three-pronged approach to teacher support training component (workshops) mentoring component: training support materials (manual & video) group support feedback on portfolio assignments practical component (experience) lesson planning and implementation in classroom compilation of portfolio assignments foundational competence practical competence reflective competence what? language for learning listening for learning language in numeracy how? strategies to be used in the classroom why? literacy numeracy fig. 1. a model of the cpd programme for foundation-phase educators. fig. 1. a model of the cpd programme for foundation-phase educators. 16 sajcd • vol 57 • december 2010 speech-language therapists supporting teachers in numeracy and to empower them to facilitate the acquisition of the vocabulary required for numeracy development (gawned, 1993). towards the end of the grade r year learners should have acquired an understanding of the language of measurement, position in space, selection criteria for sorting, exploring, building, and matching with shapes. when considering that numeracy is: ‘… the language or system of thought’ (bullock, 1994), and mathematics is ‘… abstract and platonic and based on absolute truths about relations among ideal objects’ (steen, 2001), then the importance of the vocabulary that develops from this emergent phase of numeracy becomes evident as it provides a basis for mathematics. the practical component the practical component required participants to implement strategies in the classroom and then to complete portfolio assignments. the implementation of listening and language strategies was directed at skills acquisition to develop the educators’ practical competence at applying the skills learnt. the participants were required to prepare their lesson plans within a theme for 3 weeks following training, to implement the strategies learnt in the workshops, and to monitor the participation of at least three learners in the class (a competent learner, an average learner and a weak learner) on a weekly basis by completing a scaled checklist that was provided by the course facilitator. the mentoring component throughout the process of engagement the educators were supported by a mentoring component that was aimed at developing their reflective competence. their portfolios with lesson plans and teaching materials were assessed and each participant received individualised feedback. the four participants from each school included in the programme also supported each other by planning their lessons as a group, and by a weekly peer review when implementing the strategies in class. furthermore, ongoing support provided by the district facilitators at school level enhanced the effect of the training. the evaluation of a programme is an important phase of its development. this article specifically focuses on the gains made by the participants from attending this multifaceted programme. research methods this article focuses on the gains made by the participants in knowledge, skills and attitude as these demonstrate the effect of the multifaceted support provided (training, mentoring and opportunities for application in the classroom). ethical clearance was obtained from the university of pretoria research proposal and ethics committee, and approval from the gauteng provincial department of education was sought to conduct the research in schools. a concurrent, equal status triangulation design was used where qualitative data were transformed into quantitative data. the research was conducted in two previously disadvantaged settings (semi-rural and township schools) for one year each consecutively. the participants the participants were selected by using convenience sampling (leedy & ormrod, 2005) as the provincial department of education prioritised specific schools in these regions in an effort to redress previous imbalances in investments in schools. although participants volunteered to participate in the research, one educator from each grade level in the foundation phase (grades r 3) from 12 schools in each context was selected per annum (n=96). three schools in the township context did not have any grade r classes in the school, in which case the grade r classes from the feeder schools were included. data collection and analysis all interested educators were invited to attend the briefing meeting at a central venue at a school, and those who wanted to participate were required to give informed consent. quantitative data were collected by means of questionnaires (at the briefing meeting, as well as before and after workshops), portfolio assignments and attendance registers. the questionnaires, however, were self-constructed, which in itself posed a threat to reliability and validity. to increase the validity of the questionnaires, the questions were first reviewed by a language editor. the content of the questions were scrutinised by two experts in the field, and the clarity of questions and ease of use was evaluated by three potential participants who were not included in the study. a statistician reviewed the questions and layout prior to use to ensure ease of use and accurate data capturing. a pilot study (with 12 participants) developed the questions and the data collection procedure. the reliability was increased through repetitive use (six times) over a prolonged period of 2 years within two different contexts. the reliability was compromised by factors related to timing, the use of english and low literacy levels of some of the participants. descriptive statistics, regression and factor analysis were employed to analyse the data. the quantitative data were statistically analysed and displayed as graphs and figures. eight focus groups (using a nested design) (leech & onwuegbuzie, 2005), a research journal consisting of diary entries made by the researcher following each significant event, testimonials, and various correspondence provided qualitative data that were transcribed and coded, and categorised within themes. the support programme was evaluated using a logic model approach (w. k. kellogg foundation, 2004) consisting of input, process, output, and outcomes. information was coded and categorised by using atlas-ti software. the research questions were placed within the logic model framework and codes which answered these questions were categorised accordingly. these codes and categories (with their accompanying phrases/keywords) were listed and entered in an excel spreadsheet and grouped within the theme structure provided by the logic model (w. k. kellogg foundation, 2004). once both quantitative and qualitative data had been analysed, the data in the qualitative strand were translated to quantitative data using a binary scale (creswell & plano clark, 2007). the value of 1 was assigned to items that confirmed or positively described or supported the codes categorised under specific themes to answer the research question, and the value of 2 was assigned to all items that refuted or contrasted the items categorised under a specific theme. results and discussion owing to the nature of the research design, the qualitative inferences are discussed first, followed by a discussion of the results obtained from the quantitative strand. next, the results from both strands are converged in a matrix. the results of the ‘entire group’ who attended each workshop and the ‘core group’ are provided. the latter refers to those participants who signed informed consent at the onset of the programme, and who attended all the workshops and completed the portfolio assignments. the ‘entire group’ refers to all the participants who attended one or more of the workshops and compiled one or more portfolios. although the workshops were well attended, there was a high level of attrition (35%) from the original group over the course of the programme. participants from the original group who could not attend workshops sent replacements, who did not provide informed consent, and therefore the data obtained from these individuals could not be included in the research. the data from the ‘entire group’ were nevertheless used for comparison with the results from the ‘core group’ to emphasise a particular point when deemed necessary (mcmillan & schumacher, 2006). qualitative assessment of knowledge and skills gains by participants the results with regard to the acquisition of knowledge and skills in the qualitative strand of the research are discussed according to the levels of knowledge and skills acquisition described by miller and watts (1990) and presented in table i. the specific codes used in the qualitative analysis are in italics and parenthesised. vol 57 • december 2010 • sajcd 17 speech-language therapists supporting teachers although the participants gained in knowledge and skills, they did not gain equally. the results indicate that a relatively small number of items were coded as confirmative for the more advanced levels of knowledge as described by bloom (anderson & krathwohl, 2001) and skills acquisition described by miller and watts (1990). a much higher number of items were coded for the more basic levels of knowledge. the implication is that although knowledge and skills were acquired, learning occurred more towards the ‘shallow’ end of the knowledge and skills continuum (and therefore less ‘deep learning’ was acquired within the group). table i. qualitative inferences re gains made in knowledge and skills by the participants level of knowledge and skills acquisition gains made level 1 the acquisition of new terminology was confirmed by 90% of items coded as ‘terminology’ (n=83 the use of terminology the use of new terminology was, however, not generalised during the training as became evident when 64% (n=14) of the items were coded as ‘inability to recall the information’. the participants’ inability to recall the terminology also may have been related to their limited language proficiency in english as is evident from the following example: participant: ‘i am talking about, i forgot the thing that you showed us. the … the – when you taught the kids the heavy, heavier …. trainer: the scale?’ participant: the scale. yeah!’ when participants could not recall the correct terminology, they described the concepts in their own words. knowledge acquisition, however, was on the ‘awareness level’, which, according to bloom’s taxonomy of the knowledge domain (anderson & krathwohl, 2001), is the lowest level of acquiring new knowledge and is related to ‘shallow learning’. such knowledge is not sufficient for participants to apply in their classrooms (miller & watts, 1990). level 2 participants gained in ‘understanding’ of the concepts taught in the workshop as confirmed by 93% understanding of concepts (n=43) of the items categorised in this regard. participants gained a new understanding of concepts (e.g. some of the participants admitted that they had never addressed the concept of ‘estimation’ or ‘three-dimensionality’ in their numeracy lessons prior to training, because they did not understand the concept or how to teach it). the participants’ language proficiency in english was closely related to their understanding of the concepts. the participants had different levels of prior knowledge before the workshops. this is because not all the participants had similar qualifications, or were on similar levels of competence when they entered the programme, and therefore they differed in their understanding of the material as can be seen from the following example: ‘t: if i just think of the lady, who just thinks of ‘adjectives’, but they are ‘prepositions’. educators can only teach what they understand themselves. level 3 once the concepts were explained in the workshops and the material was understood, the particiimplementation of strategies pants were able to ‘implement’ the strategies in their classrooms. of the coded items 88% (n=377) were positive. the participants were convinced that these new skills would help them to improve their teaching and that their learners would benefit. there was also evidence of a ‘change in teaching practice’, which was confirmed by 91% of the 44 items coded as such. the participants felt (87% of the 45 items coded) that the training helped them to become more ‘competent’ as they had learnt to integrate various assessment standards and learning objectives in one activity, which some said they could not do previously. such an integrated approach to teaching is inherent to obe and the ncs (gauteng department of education, 1997). there was also evidence that some of the participants found it easier to do their ‘lesson planning’ (80% of the 25 items coded), as illustrated by the following quote: ‘most of our educators had problems with planning our lessons. or creating lo’s. i am so perfect now. i can now use the one lo and apply it to another – we kill two los. it also help us to be creative.’ (lo = learning outcomes) the training helped some participants to become more independent of commercial programmes purchased by their schools. those participants who managed to develop their own lesson plans gained in confidence, which in turn could result in improved learner achievement (killen, 2007). however, the portfolio assessments revealed that in several instances the lesson plans were incomplete and did not take the needs of individual learners into account. regardless of the educator’s level of expertise, thoughtful lesson planning is necessary to make the learning experience in the classroom purposeful, effective, and efficient. incomplete and insufficient lesson planning may lead to ineffective teaching and learning. a few participants experienced themselves as becoming more ‘creative and innovative’ (89% of 9 items coded) as they had acquired new ‘strategies’, while others reported to have gained new ideas to implement in class (n=28). in one school the participants collected polystyrene from the refuse dump to cut out three-dimensional shapes. this particular group of participants testified that the workshop facilitated their understanding of three-dimensionality, which simultaneously reflects on poor content knowledge prior to the training. there was also evidence that some of the participants experienced the workshops as being helpful in dealing with ‘diversity and multilevel teaching’ (79% of the 14 items coded). the participants derived satisfaction from including all learners in the activities, as they had felt guilty about not supporting some learners in a more efficient manner. the completion of the portfolio assignments allowed some participants to identify the ‘slow learners’ who required more time to master the new strategies. although the participants applied the strategies in their classrooms, it does not imply that they have become fully competent as ‘implementation’ represents only the third of five levels of acquiring competence (miller & watts, 1990). the portfolio assignments bore evidence that many of those who implemented the strategies still required some level of support. level 4 a few participants were empowered to such an extent that they were able to ‘help or train the teaching of others colleagues’ (n=21) (e.g. one participant took a small group of her learners from class to class to demonstrate the strategies). this signifies the fifth and final level of knowledge acquisition described by miller and watts (1990), where a few participants were able to successfully apply their newly acquired knowledge and skills, and to train others in the application thereof. 18 sajcd • vol 57 • december 2010 speech-language therapists supporting teachers quantitative assessment of knowledge gains the quantitative strand employed preand post-training questionnaires to assess how many participants had acquired new knowledge, and portfolio assessments to assess the application of this knowledge in practice. knowledge gains assessed by questionnaires when considering the core group’s results (figure 2) from questionnaires across the three workshops, 61% of the participants made gains in knowledge. closer scrutiny of the results indicates that for the first workshop 66% of the participants in both contexts showed an increase in knowledge. it should be noted that there was an absence of data for the second workshop (ws2) in the rural context because the reliability of questionnaire use in this particular context was questioned at that time. in consultation with the statistical advisor the use of questionnaires was resumed shortly thereafter. the results show that 42% of the participants in the urban context made gains in knowledge. the data for workshop 3 (ws3) show a discrepancy in knowledge gains between the semi-rural and urban context. the participants in the semi-rural area came from a much lower base than those in the urban context, and therefore made more gains. such a discrepancy suggests that the level of prior knowledge (obtained through either formal qualifications and/or previous support provided) affected the outcomes. when considering that the participants from the two contexts were similarly qualified, it can be deducted that the participants in the semi-rural context received less prior support than those in the urban context. the data obtained from post-training questionnaires of how participants themselves perceived their knowledge gains differ considerably, as shown in figure 3. these results show that in both contexts >92% of the participants believed that they had gained in knowledge, which is much higher than what questionnaire data on actual gains had shown. this was attributed to the fact that all the participants were introduced to new ideas and observed practical demonstrations of strategies to use in class, which made them feel enthusiastic and confident. the possibility that they were trying to please the researchers should also not be excluded. all the participants did not necessarily understand the information or know how to apply it. in addition, the use of questionnaires in these contexts was questioned. it was necessary to determine whether the knowledge gains measured by the questionnaires were related to knowledge applied in practice. knowledge gains assessed by portfolio assessment the portfolios assessed knowledge applied in practice. an understanding of performance could be obtained by analysing the scores to show the spread of achievement. table ii depicts the ratio of participants who achieved scores above specific indicated levels. the performance of the different categories of participants differed minimally and the general achievement was centred on 47% for both the core and ‘entire’ (non-core) group. average scores higher than 60% were achieved when there were more participants in the core group (27% versus 19% in the ‘entire’ group), which indicates a better performance of participants who attended all workshops. each workshop provided a scaffold for new knowledge to be added in the next workshop, which emphasises the importance of good attendance in support programmes. every effort should therefore be made to limit attrition in support programmes. when the portfolios were scrutinised for explanations for the low scores achieved by the participants, it became evident that poor achievement could be attributed to inefficiency or a slow rate of implementation. the rubric used in the assessment of the portfolios assigned scores for each week of implementation (which required a new lesson plan to be prepared within the theme of the week, accompanied with a story, song and rhyme and activities to facilitate phonological awareness skills). when the same lesson plan was used for the entire period of implementation, the portfolio was scored much lower than when a new lesson plan was developed for each of the 3 weeks. the educators in both these contexts were subjected to many challenges (e.g. language use, limited infrastructure and resources, inappropriate and/or lack of qualifications, as well as learners who were not ready for school) and therefore many of them experienced difficulty in completing the portfolio assignments according to the specifications. such results therefore made them appear ineffective. the results shown in table iii concur that the participants have gained in knowledge and skills. the two measuring instruments (questionnaires and portfolio assignments) assessed different aspects of knowledge, namely factual knowledge and applied knowledge (adler et al., 2003). the results obtained with both these methods show that a relatively large number of participants performed satisfactorily and gained in knowledge and 2                                            fig. 2. knowledge gains in workshops. fig. 2. knowledge gains in workshops. 3 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% semi-rural: pre n=57 semi-rural: post n=57 urban: pre n=57 urban: post n=57 perceptions of gains benefit not sure no benefit fig. 3. perceptions of knowledge and skill gains. fig. 3. perceptions of knowledge and skill gains. table ii. ratio of participants with scores above the indicated average scores group entire group core group indicated average score all semi-rural urban all semi-rural urban >40% 69% 69% 69% 67% 68% 65% >50% 44% 47% 41% 49% 52% 45% >60% 19% 22% 16% 27% 32% 20% >70% 13% 14% 13% 18% 20% 15% >80% 6% 3% 9% 7% 4% 10% average 47.2% 47.1% 47.2% 47.9% 48.5% 47.2% vol 57 • december 2010 • sajcd 19 speech-language therapists supporting teachers skills. it is, however, not possible to draw conclusions from average scores as some participants gained less than others. attitude changes qualitative strand: confidence an increasing sense of professional confidence is important for learning (graven, 2002, in adler et al., 2003). evidence of increased ‘confidence’ was noted in 88% of items coded, although the sample size was relatively small (n=16). a statement such as ‘i have learnt so much’ from several participants in the focus groups was therefore regarded as a positive indication of increased confidence. confidence was also inherently included in items coded in the category ‘value to the educator’ as items ‘value of training’ (n=34) and ‘value of training to the educator’ (n =38). several participants reported in the focus groups that they had acquired more confidence by compiling the portfolio, as this required them to develop lesson plans and activities that they were unable to do before. the acquisition of self-confidence enabled some of the participants to train their colleagues. the code ‘empowerment’ could also be related to the development of confidence (n=17). the implementation of strategies in class may have increased the participants’ confidence, because they perceived themselves as being successful. quantitative strand: confidence the participants rated their confidence in a self-evaluation section in the questionnaires. the results depicted in figure 4 show that participants rated their own competence as high, but this did not correlate with their actual performance in the portfolio assessments. as mentioned previously the participants who completed the selfevaluation in general judged their own competence as being high (>70%), which indicated high levels of self-confidence in implementing the strategies learnt in the workshop. the discrepancy between confidence levels and portfolio performance may be attributed to participants’ limited insight. it was taken into account that not all the participants opted to complete the self-evaluation section in the portfolio assignments, probably because they were unable to reflect on their practices or did not feel confident of their competence to implement the strategies. reflection is an inherent part of obe (killen, 2007), and an inability to reflect on one’s own practices could imply a need for support in this aspect. it is possible that the portfolio scores were not a true reflection of competence in the classroom as the scores were affected by several factors (e.g. class sizes, the participants’ language proficiency, prior support, factors related to timing, intrinsic motivation/attitude, school culture and school management support), which made it difficult to accurately determine the actual levels of competence. convergence of results: confidence the results regarding the confidence of the participants are converged in table iv. these results indicate high levels of confidence in both strands of the research regarding the implementation of strategies following training. the evaluation of confidence was subjective as it was based on the participants’ own perceptions of their gains in confidence. in confirmation of the gains made in attitude, testimonials obtained from a group of educator support educators who unofficially attended the workshops verified the positive attitudes noted in participant feedback. because of prolonged engagement and multiple observations across contexts (leedy & ormrod, 2005), the credibility of the inferences regarding attitudinal gains was high. limitations of the research the following limitations were identified in the research: • the data collection instruments were self-constructed and although all attempts were made to ensure validity, it is possible that these were subject to the trainer/researcher’s subjectivity. • all the focus groups were conducted, transcribed, coded and analysed by the trainer/researcher, and therefore the interpretations made could have been subjective. • the high level of non-response with questionnaires and portfolio assignments was caused by several factors (language use in the cpd programme, education and literacy levels of the participants, factors related to timing and logistics). • attrition posed a threat to inference quality because it resulted in a reduced sample size (and therefore decreased the generalisability of the findings). an attempt was made to limit attrition by offering a certificate at completion, but this did not have the desired result. • neither the quantitative nor the qualitative samples in this study were randomly selected, which limited the inference quality and transferability of the findings. conclusions knowledge gains were made that could improve teaching practices. however, the participants did not make equal gains, and in several instances the gains were minimal. the participants came from diverse backgrounds and not all of them benefited from the support programme to the same extent. although there was sufficient evidence that the participants could recall some of the terminology, there were also those who could only describe the concepts in their own words. knowledge acquisition therefore was on the ‘awareness level’, which, according to bloom’s taxonomy (anderson & krathwohl, 2001) of the knowledge domain, is the lowest level of acquiring new knowledge. knowledge on the awareness level is not sufficient for participants to apply such knowledge in their classrooms (miller & watts, 1990). such low-level knowledge, together with participants’ limited insight in judging their own competence, indicates a continued need for support. a stratified approach with selection criteria in terms of the educators’ qualifications may result in more effective support to different groups. table iii. corroboration of results re knowledge gains theme category qualitative quantitative competency ‘knowledge’ 85% 61% gains ‘skills’ (knowledge in practice) 88% 47% 4 0 1 2 3 4 5 6 7 8 9 10 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 participant comparison between allocated and self scores average self eval listening self eval numeracy fig. 4. comparison of assignment scores with self-evaluation of competence. fig. 4. comparison of assignment scores with self-evaluation of competence. table iv. convergence of results with regard to confidence aspect assessed qualitative quantitative overall confidence (total) 88% (n=147) >70% (n=31) confidence 89% (n=15) empowerment 100% (n=17 ) implementing 86% (n=102) help/train colleagues 85% (n=13) 20 sajcd • vol 57 • december 2010 speech-language therapists supporting teachers language use in the cpd programme affected the level of understanding of concepts as english was not the l1, but an additional language for all the participants. educators can only teach what they understand themselves. the fact that the ncs is in english may therefore present a challenge to many educators. a specific outcome of this programme was that some of the participants became inspired to improve their teaching practices, which could only benefit the learners. evidence of increased creativity (although limited), noted when a group of educators from a specific school went to the refuse dump for polystyrene to cut out threedimensional shapes, confirmed that educators can overcome contextual challenges if they are internally motivated and have the support of their management and school-based support teams. educator confidence is directly related to educator competence, and clear links exist between educators’ confidence and their ability to facilitate learning (killen, 2007). high levels of confidence are therefore a positive attribute of this training programme as it can be expected that learners may also benefit. in general, the gains made in knowledge, skills and confidence with this cpd programme contributed to the professional growth of the participants. this particular three-pronged approach to educator support shows potential to yield positive results in two previously disadvantaged contexts. cpd and support of educators, however, cannot be viewed ‘… as a form of educator education that produces quick fixes for complex and enduring problems in schooling’ (zeichner & wray, 2001). educator support should rather be seen as a continual and lifelong learning process that could motivate and empower educators to facilitate learning. successful education reform depends on the identification and implementation of effective practices that are based on the connection between research and practice. it is therefore important that intervention programmes be evaluated 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(2002). national report on systemic evaluation (2001) (mainstream) gr. 3. pretoria: department of education. department of education gauteng. (2007). annual performance plan – 2007/08 to 2009/10. [cited 2 january]. retrieved from <http://www.education.gpg.gov.za/publications/ annual%20perfomance%20outcome.pdf> gauteng department of education. (1997). curriculum 2005: guidelines for learning programmes for the foundation phase grade one (+first term). johannesburg: gauteng department of education. gawned, s. (1993). an emerging model of the language of mathematics. in j. bickmore-brand (ed.), the language of mathematics (pp. 27-41). portsmouth, nh: heinekenn. author: heinemann? girolametto, l., weitzman, e., lefebvre, p., & greenberg, j. (2007). the effects of in-service education to promote emergent literacy in child care centres: a feasibility study. language, speech, and hearing services in schools, 38, 72-83. goodman, k. (1986). what’s whole in whole language? a parent/teacher guide to children’s learning. portsmouth, nh: heinemann educational books. gouws, e., & dicker, a. m. (2006). onderwysers se belewing van indiensopleiding met betrekking tot die hersiene nasionale kurrikulumverklaring: ‘n gevallestudie. tydskrif vir geesteswetenskappe, 46(4), 416-427. justice, l. m., & ezell, h. k. (2001). written language awareness in preschool children from low income households: a descriptive analysis. communication disorders quarterly, 22, 123-134. justice, l. m., & kaderavek, j. n. (2004). embedded-explicit emergent literacy intervention: background and description of approach. language, speech, and hearing services in schools, 35, 201-212. justice, l. m., skibbe, l., & ezell, h. (2006). using print referencing to promote written language awareness. in t. a. ukrainetz (ed.), contextualized language intervention: scaffolding pre k-12 literacy achievement (389-428). eau claire, wi: thinking publications. killen, r. (2007). teaching strategies for outcomes-based education (2nd ed.). cape town: juta. leech, n. l., & onwuegbuzie, a. j. (2005). a typology of mixed methods research designs. annual meeting of the american educational research association, montreal, canada. leedy, p. d., & ormrod, j. e. (2005). practical research: planning and design (5th ed.). upper saddle river, nj: pearson education. mcmillan, j. h., & schumacher, s. (2006). research in education. boston, ma: allyn & bacon. miller, a., & watts, p. (1990). planning and managing effective professional development. moodley, s., chetty, s., & pahl, j. (2005). the school-based speech-language therapist: choosing multicultural texts. die suid afrikaanse tydskrif vir kommunikasieafwykings, 52, 40-50. o’connor, j., & geiger, m. (2009). challenges facing primary school educators of english second (or other) language learners in the western cape. south african journal of education, 29, 253-269. paradice, r., bailey-wood, n., & davies, k. 2007. developing successful collaborative working practices for children with speech and language difficulties: a pilot study. child language teaching and therapy, 23(2), 223-236. pluddemann, p., mati, x., & mahlalela-thusi, b. (1998). problems and possibilities in multilingual classrooms in the eastern cape. in n. taylor & p. vinjevold (eds.), getting learning right: report of the president’s education initiative research project (p. 317-319). johannesburg: joint education trust/department of education. reed, y., davis, h., & nyabanyaba, t. (2003). teachers’ take-up of reflective practices in under-resourced multilingual contexts. in j. adler & y. reed (eds.), challenges of teacher development: an investigation of take-up in south africa (p. 113). pretoria: van schaik. richards, g. (2004). redefining auditory processing disorder: a speech-language pathologist’s perspective. asha leader, 9(6), 7-21. roberts, j. (2002). district development: the new hope for educational reform. johannesburg: joint education trust. setati, m. (1999). innovative language practices in multilingual mathematics classrooms. in n. taylor & p. vinjevold (eds.), getting learning right: report of the president’s education initiative research project. johannesburg: joint education trust/department of education. sowden, p. (2007). culture and the good teacher in the english language classroom. elt journal, 61(4), 304-310. steen, l. a. (2001). mathematics and numeracy: two literacies, one language. the mathematics educator, 6 (1), 7. the timms & pirls international study centre. (2007). pirls 2006 international press release. boston, ma: boston college in association with international association for the evaluation of educational achievement. w. k. kellogg foundation. (2004). logic model development guide. [cited 30 december 2008]. retrieved from http://www.uwex.edu/ces/pdande/evaluation/pub3669.pdf. zeichner, k., & wray, s. (2001). the teaching portfolio in us teacher education programs: what we know and what we need to know. teaching and teacher education, 17(5), 613621. vol 57 • december 2010 • sajcd 21 speech-language therapists supporting teachers 5 knowledge comprehension application analysis synthesis eval knowledge comprehension application analysis synthesis eval remember understand apply analyze evaluate create remember understand apply analyze evaluate create old version new version fig. 5. bloom’s taxonomy of learning in the knowledge domain. fig. 5. bloom’s taxonomy of learning in the knowledge domain. appendix a bloom’s taxonomy is a classification system of learning objectives within education, which has been revised by anderson & krathwohl (2001) (figure 5). knowledge acquisition in the cognitive domain of bloom’s taxonomy focuses mainly on knowledge, comprehension, and critical thinking of a particular topic. knowledge is acquired sequentially in a hierarchical format, where the lower levels serve as scaffolding for the higher levels. when learning occurs on the lowest level (‘knowledge’/’remember’), the learner is able to recall facts, terms, basic concepts and answers. on the second level (‘comprehension’) the learner is able to demonstrate understanding of the material by organising, comparing, translating, interpreting, giving descriptions, and stating main ideas. the third level in the taxonomy refers to ‘application’ of knowledge when the learner is able to apply his/ her knowledge by solving problems in new situations. on the ‘analysis’ level the learner is able to make inferences and to find evidence to support generalisations. the fifth level of the taxonomy refers to the learner’s ability to synthesise the information. the learner is able to compile the information through the combination of elements in a new pattern or through proposing alternative solutions to a problem. the highest level represents the ability to evaluate the knowledge. the learner is able to defend opinions by making judgments about information. the acquisition of knowledge on this level allows the learner to validate ideas or quality of work according to specific criteria. the electrical activity of the brain in some disorders related to communication g . k. nelson chief research officer and head of the division of neuropsychology at the national institute for personnel research, a consliluenl of the south african council for scientific and industrial research, johannesburg few developments in the field of medicine and particularly of psychiatry have been attended with more initial enthusiasm than the discovery of the electrical activity of the brain. although caton's revelation in 1870 that it was possible to record electrical impulses from the brain received little attention, the painstaking research of berger4 provided the impetus for the sudden and rapid development of electroencephalography from the early thirties. berger was a psychiatrist and his profession had very high hopes of the electroencephalogram (eeg) especially when it was finally accepted as a genuine phenomenon. yet it is neurology and neurosurgery that received the more spectacular benefits of the technique which revolutionized the practical and theoretical problems of epilepsy and greatly facilitated the detection of cranial neoplasms and the assessment of head injuries. meanwhile the specific problems of psychiatry were only partly clarified by ths e e g which has shown itself to be of value mainly in the differential diagnosis of organic, epileptic and socalled functional disorders such as schizophrenia. nevertheless certain findings in the psychoses do hold promise of ultimately assisting in the understanding of these conditions. while this field is beyond the scope of the present paper, it is important to take note of the application of the e e g in the related field of psychology, in both clinical appraisal and basic research on the determinants of behaviour. t h e purpose of this paper is to review briefly the general significance of the e e g and to evaluate its specific contribution in the field of disorders of communication. general significance of the eeg t h e normal e e g comprises complex signals of approximately sinewave form, these waves being recorded at the scalp (fig. 1) at frequencies up to about 30 c / s e c and voltages of a few microvolts. e e g characteristics are defined in terms of frequency, amplitude, wave-form, location, persistence and responsiveness. t h e r e are 4 main r h y t h m s : tydskrif van die suid-afrikaanse logopediese vereniging, vol. 13, nr. : mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) g. κ. nelson ι. alpha. a rhythm at 8-13 c/sec from the parieto-occipital regions of normal adults (fig. 2). it is present only when the person is awake, is maximal during relaxation and disappears when the eyes are opened. this is known as the blocking response of the alpha rhythm and implies an important role of the functions reflected by this activity in the processes of visual perception and imagery, since alpha blocking may also be seen during visual imagery. while other perceptual modalities such as hearing may also show such changes in the alpha rhythm, the blocking response is most consistent in association with visual processes, providing the basis for the hypothesis that this electrical oscillation represents a scanning system in the visual projection area of the cerebral cortex, which is employed in the integration and coding of information received from the eyes. t h e frequency of the alpha rhythm varies from person to person, and there is some evidence that individual mean frequency is a measure of central nervous speed reflected in temperament, such that relatively rapid reaction, impulsiveness, a wide span of attention and distractibility are associated with higher alpha frequencies, while individuals with lower mean alpha frequencies tend to be cautious, methodical and systematic (mundy-castle4 3). amplitude of the alpha rhvthm is related to level of arousal in a curvilinear manner, being maximal during relaxed wakefulness and minimal at the two extremes of sleep and hyperexcitation. characteristic imagery mode is reflected in the index or percent-time of alpha rhythm, i.e. the number of seconds in a ioo-second sample of e e g during which alpha rhythms are apparent. while most--persons have indices of 30-90, low indices are associated with predominantly visual imagery, while high indices, and even alpha rhythms that do not block at all, are found in persons who make use mostly of verbal, kinesthetic or other types of non-verbal imagery. more recently positive correlations of alpha frequency with intelligence test performance have been reported by mundy-castle4 4 and mundycastle and nelson.4 5 2. beta. these are rhythms of 14-30 c/sec, generally of lower amplitude than alpha and not specifically characteristic of any part of the brain. fig. 1. placement of e e g electrodes: electrode positions a n d names are in accordance with t h e recommendations of t h e i n t e r n a tional federation of societies for e l e c t r o e n c e p h a l o g r a p h y a n d clinical neurophysiology. recordings may be bipolar (connecting electrodes in serial chains, e.g. f p 1 f 3 , f 3 c 3 ) c 3 p 3 ) p 3 o i , etc.) or unipolar, referring each cortical electrode t o a " n e u t r a l " or reference electrode. unless otherwise stated, all e e g figures in this paper show bipolar recordings. a1 c 4 o j o a ; journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) cerebral electrical activity and communication disorders 7 beta rhythms are associated with cortical activation, but are also found in light sleep. when more prominent than alpha activity, beta rhythms are regarded as a non-specific e e g abnormality. 3· theta. theta activity, at 4-7 c/sec is predominant in the e e g ' s of young children, and in sleep in persons of all ages. in a waking adult diffuse theta rhythms are abnormal and suggestive of epilepsy, organic brain disease or severe immaturity of the cortex. focal theta rhythms are found in head injury and focal epilepsy and may indicate sub-cortical disturbance. 4. delta. delta activity comprises any potential fluctuation of c/sec or slower. it is abnormal except in very young children and in deep sleep at all ages. otherwise focal or diffuse delta activity is generally an accompaniment of organic pathology. in addition to these main rhythms, other e e g features are of great clinical significance. these include such abnormal features as spikes, sharp waves, and the distinctive wave-and-spike pattern. in general such phenomena are linked with the epilepsies, but are also sometimes found in behaviour disorders. abnormalities in the e e g are seen in the e e g ' s of 5 to 15 % of the normal population. t h e rough classification of e e g abnormalities and their clinical correlates shown in t a b h 1 is a convenient although very inadequate summary. table i : e e g abnormalities and t h e i r m a i n c l i n i c a l correlates type/location diffuse or generalized localized or focal episodic or pacentrencephalic epilepsy focal epilepsy roxysmal non-episodic or organic pathology organic lesions non-paroxysmal epilepsy epilepsy immaturity maturation defects developmental aspects. t h e e e g appears to be the result of largely hereditary factors as shown by the similarity in general pattern in identical twins. nevertheless the brain rhythm record is a highly individual trait, as unique as the fingerprints. environmental factors may however bring about temporary or permanent alterations. temporary changes are produced, by drugs such as alcohol, and by mild head injury, while severe head injury, disease, malnutrition and toxic agents such as lead may cause permanent changes. apart from the effects of such hazards, the record remains relatively stable from early adulthood to old age. rhythmic activity is first seen in the infant at the age of about 2 months at a frequency of 2 to 3 c/sec. this frequency increases with age (fig. 3) until the adult (usually alpha-dominant) pattern becomes established at between 18 and 25 years of age. it is known that this tydskrif van die suid-afrikaanse logopediese vereniging, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) g. κ. nelson development can be adversely affected by such disorders as protein deficiency (nelson1 0). activation methods. routine clinical e e g examination includes a comprehensive recording of the brain waves in the resting state. in order to reveal possible latent abnormalities two activation methods are generally used to supplement this recording: (a) photic stimulation (by means of a special stroboscope directed at the closed eyes); (b) hyperventilation (deep breathing for three minutes). these techniques are described in full elsewhere (nelson4 7). main areas of the brain concerned with communication vision and hearing are the two primary sensory modalities involved in the development of ordinary human communication. disturbances of a sensory and motor kind related to these functions form the main theme of this account of the significance of the e e g . a brief consideration of the representation of these functions in the brain is a necessary preliminary to the survey of e e g findings. for reasons of brevity, almost exclusive attention is given to cerebral cortical representation. 1. vision. reference has already been made to the apparent role in visual perception of a cerebral neural process giving rise to the alpha rhythm of the e e g . t h e alpha rhythm originates in or near to the calcarine cortex of area 17 at the occipital pole, but may also arise from the more anterior visual association regions in areas 18 and 19 of the parietal lobe. lesions in the more posterior regions tend to produce complete blindness if they are bilateral, or hemianopsia if unilateral. more anterior regions are implicated in binocular vision, while there is evidence that" both frontal and temporal areas are involved in visuo-motor co-ordination. a full account of the neuro-anatomical relations is given by humphries.2 4 2. hearing. t h e area of cortex primarily concerned with the reception of auditory signals lies in the temporal lobe, in area 41 on the upper surface of this lobe which forms the lower bank of the sylvian fissure. auditory perception is mediated by the surrounding area 42, covering most of the middle part of the upper surface of the temporal lobe. 3. speech. broca's area (brodmann's area) is often considered to be of utmost importance in speech, but jefferson2" considers it to be a highly overrated localized functional area since excision of it in man leads to only transient aphasia, while stimulation of the region results in movements of the larynx and crude vocalization without words. penfield and jasper4 9 point out that vocalization has representation of equal value in the dominant and non-dominant hemispheres and that either of the two areas may be removed without interference with speech. on the other hand these authors emphasize that stimulation of a speech area produces aphasia, and that such speech areas are in the left hemisphere in right-handed persons, while in left-handed persons they may be in either hemisphere. when the left hemisphere is severely injured in a right-handed child, speech may be lost for a period of months and is eventually re-established in the cortex journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) cerebral electrical activity and communication disorders 9 of the right hemisphere. otherwise the "speech" areas of the non-dominant hemisphere are functionally "silent". four speech areas in the dominant hemisphere were described by penfield and jasper4 9 and penfield and roberts,5 0 in the frontal, parietal and temporal regions. kriegf describes area 40 as a semantic area, because obstruction of this region results in loss of "the highest level of speech". area 22 is a syntactic area where injury may result in interference with the understanding of speech, or merely the distortion of sounds. a lesion in area 39 produces nominal aphasia, the inability to assign names to common objects. fulton 1 5 found that unilateral lesions of the 3rd left frontal convolution in monkeys and chimpanzees led to no apparent impairment of their capacity to vocalize. on the other hand, bilateral lesions in these cortical areas led to confusion and inability to carry out complex motor manouevres, a defect comparable to apraxia in right-handed. humans with lesions in broca's area. electrical stimulation of the cingular gyrus in monkeys produces vocalization responses identical to those that the animal might be expected to make under normal conditions (smith5 0). yet penfield and jasper4 9 found that stimulation of a cortical speech area in humans produces aphasia. these observations should not be allowed to obscure the role of subcortical mechanisms in speech; for example the subtle effects of stimulation of some areas around the 3rd ventricle were described by sem-jacobsen.54 t h e present paper is nevertheless primarily concerned with cortical manifestations as detected by the e e g . the contribution of the eeg in communication disorders this brief report of e e g findings is based on data obtained from t h e ' following samples (table 2). most of these cases were referred to the n.i.p.r. for clinical e e g examination but a number were tested in the course of unrelated research projects. t a b l e 2 disorder no. of cases visual 15 auditory 2 delayed speech 21 aphasia 10 dyslexia 3 stuttering 5 total: 56 each defect will be considered separately in the light of concomitant clinical syndromes, with evaluation of the e e g findings. t h e nature of many of these cases necessitates a detailed individual description. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ιο g. κ. nelson s e n s o r y d e f e c t s vision. t h e question is often asked: i n view of the apparently intricate involvement of the alpha rhythm in the process of visual perception, what are the e e g findings in blind persons? one of the earlier studies was carried out on helen keller (still57). as most people know, helen keller became blind and deaf after a sudden brief illness at the age of 19 months. an e e g recorded when she was 64 showed relatively low-amplitude occipital alpha rhythms, while "alpha" activity was prominent in the more anterior areas. this, it was suggested reflected changes in the functional organization of the cortex corresponding to the emphasis on the sense of touch or tactile discrimination which she developed. t h e e e g findings in six cases of left occipital lobectomy were described by masland et al.4" sharp waves and beta activity were seen, in the temporal, central and frontal areas, and "overactivity" of the left temporal lobe was striking—alpha-like waves and high-voltage "sleep waves" were prominent in this region. t h e e e g in amblyopia was studied by parsons-smith4 8 who found abnormal records in 31 out of 50 cases, beta activity being particularly common. bergman's7 account of unilateral loss of alpha rhythms in hemianopia was criticized by cobb 9 who believed that in bergman's cases the lesion responsible for hemianopia almost certainly extended beyond the primary visual system. in 30 blind and partially blind 8 to 9 year old children with retrolental fibroplasia, metcalf41 found a 9 0 % incidence of e e g abnormality which was not related to intellectual or other characteristics, but was characterized by the unusual prominence of focal disturbances, generally maximal in the occipital regions. in five cases of retinitis pigmentosa associated with juvenile cerebral lipoidosis (spielmeyer-vogt disease) uniformly abnormal records with diffuse paroxysmal disturbances and runs at 2.5 to 4 c / s e c as well as wavesand-spikes and occasional variable interhemispheric asynchrony are -described by ellingson and schain.1 1 other recent studies include that of subirana and oller-daurella5 9 who obtained e e g ' s from two anophthalmic children, whose parents were first cousins. t h e records showed a badly organized background with diffuse fast activity. both cases also showed occipital spikes and waveand-spike activity. it was suggested that this reflected neurological lesions a n d / o r "functional" focal activity in the cortical visual areas. jeannerod and courjon 2 5 describe similar abnormalities ' in five blind children, proposing that occipital spikes in this context represent neural degeneration of the cortex. lairy et al.3i studied partially sighted and blind children of school-going age, finding occipital spike foci on the left side in 2 5 % and on the right side in 4 % . it was concluded that cases of dyspraxia with sight occipital spikes are more or less reversible with re-education of the psycho-motor difficulty. eeg findings in the present series. results from 15 cases of visual defect are given in table 3. t w o of the three cases with a clinical diagjournal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) cerebral electrical activity and communication disorders nosis of brain damage ( i , 2, 3) had abnormal e e g ' s , raising the possibility of post-traumatic epilepsy in both cases. cases 4, 5, 6 and 7 had a clinical diagnosis of athetosis, quadriplegia and hemiplegia. all but one had abnormal e e g ' s suggestive of localized cerebral abnormalities, in each case involving the parietal area (fig. 4). case 7 had a normal record. t h e following three patients, cases 8, 9 and 10 were epileptics and all had abnormal e e g ' s ; although the record of case 8 did not show any e e g sign of the t u m o u r , the e e g revealed localized epileptogenic abnormalities in both case 9 and case 10 (fig. 5). t h e remaining five miscellaneous disorders with accompanying visual defects are of interest: while it is not surprising that the patient with riley's disease had a normal e e g (this is a transient disorder of childhood) the findings were of positive value in the r e m a i n d e r : case 12, diagnosis unknown, had a remarkable e e g in that occipital beta r h y t h m s seemed to have supplanted alpha activity; the record of case 13 pointed to clear brain damage with post-operative epilepsy appearing as a disorder of concentration and memory; in case 14 the e e g confirmed the presence of an organic abnormality in the right parietal area; case 15 provided an opportunity for the application of another electrophysiological technique, namely electroretinography ( e r g ) , the measurement of the electrical activity of the retina (fig. 6). t h e e e g , including the response to photic stimulation, was normal, but the e r g , although showing a normal waveform on both sides, had an amplitude reduction of 50 p : r cent on the right. evoked responses in the cerebral cortex showed a corresponding inequality when the eyes were independently stimulated by a flashing light, but both occipital lobes appeared capable of responses of equal amplitude. it was therefore concluded that the disturbance was peripheral and not central, but that the right eye was not totally inactive. comment. t h e incidence of e e g abnormality in these 15 cases was extremely high, 11 cases having abnormal records ( 7 3 % ) , but this should be viewed in the light of the major clinical features, especially brain damage and epilepsy. f r o m the point of view of visual perception, useful diagnostic information was nevertheless supplied by the e e g in 7 instances, viz.: cases 2, 9 and 10, in whom visual disturbances were shown to be of epileptic origin or at least related to epilepsy*; cases 4, 13 and 14 in whom a localized brain disturbance was demonstrated; case 15, in whom the combination of e e g and e r g resolved the problem of central or peripheral locus of a disturbance resulting in a visual defect. t h u s the e e g was of positive value in 4 7 % of these cases. hearing. t h e e e g has been held to be of value in the investigation of hearing disorders related to speech difficulties. abnormal e e g ' s were found *a case described by strauss 5 8 is called to mind here—an 11-year-old boy suffered attacks of complete blindness, with preservation of consciousness, lasting from 2 to 3 minutes; the e e g showed almost continuous high-voltage 1.5-3 c/sec occipital, temporal and more rarely parietal wave-and-spikes; although neurological examination revealed no abnormality, the interpretation was of a centrencephalic disturbance with maximal effect in the occipital regions; the e e g abnormalities and clinical phenomena were promptly controlled by anticonvulsant drugs. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) g. κ. nelson in 19 of 53 children with severe hearing loss (marcus3 9). disturbances had a predilection for the temporal lobes. marcus held that the e e g arousal response (desynchronization of alpha activity) was an adequate index of hearing. t h e use of " e e g audiometry" (to be described in relation to case 17) is considered by fisch1 2 and gordon and taylor 1 9 to be of great assistance in differentiating between peripheral and central deafness. t h e findings of marcus and of gottlieb et al.20 support the hypothesis that the cerebral mechanisms relevant to speech acquisition are simplified, facilitated and less prone to interference when control of speech, hand and eye is localized primarily in one hemisphere of the brain. generally speaking the alpha rhythm shows a reduced amplitude in the dominant hemisphere, so that the consistency a n d / o r degree of inter hemispheric difference in amplitude of the alpha rhythms might well form a profitable basis for a systematic study of communicative disorders. eeg findings in the present series. t w o cases of hearing defects are detailed in table 2. t h e first of these (case 16) was reported by the speech therapist to have a fluctuating ability to speak. t h e patient was intelligent and it was felt that deafness was not the whole trouble. t h e e e g was suggestive of a localized organic abnormality. t h e second patient, case 17, who was apparently deaf, had an e e g suggestive of epilepsy associated with a brain abnormality in the left frontal area. t w o months later he was given a "hearing e e g " , signals at a variety of frequencies and intensities being applied to each ear independently in an attempt to assess cortical responsiveness. on this occasion averaging techniques were not used, but an apparent attenuation or augmentation of spontaneous electrical activity was seen in response to 81 of the 142 stimuli presented. t h e range of frequencies covered by these 81 stimuli suggested that, if the cortical responses were genuine, there was little if any hearing loss in this case. although the findings are similar to those of lesny and odvarkova3 5 in normal children and adults, the results of such simple tests are to be treated with considerable reserve owing to the variability of the spontaneous e e g pattern, especially in children. a series of studies utilizing automatic averaging and integrating techniques has been planned to determine more precisely the contribution to be expected from the e e g in this area. preliminary experiments by appleby et al} have yielded promising results. comment. in only one of these patients with suspected hearing defects was an electrical abnormality demonstrated in an area approximating the auditory reception region in the superior portion of the temporal lobe. this was case 16, where a left parieto-temporal abnormality was-'detected. however, it must be stressed that such focal e e g signs should not lightly be invested with specificity, since they may occur in a variety of syndromes such as epilepsy, psychopathy and delinquency, and their aetiology may be found in head injury, malnutrition (nelson4 6) or genetic factors (mundycastle45). nevertheless gervasio and, marenzi's studies17 have shown the value of the e e g in differentiating defects in structures and functions up to and including the cochlea from those more centrally located. in a series journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) cerebral electrical activity and communication disorders 13 of 165 deaf-mute children e e g abnormalities were found in 7 4 % ; the results suggested that spreading or localized e e g disturbances indicated deafness consequent on brain injury caused by infective, toxic or traumatic factors; excessive, beta activity was suggestive of congenital deafness (hereditary or otherwise) or inflammatory ear disease. furthermore, independently of the nature of the injury, deafness due to cochlear lesions was characterized by a high incidence of normal or mildly abnormal eeg's, while interruption of the auditory fibres at the post-cochlear or cortical levels was associated with irritative abnormalities in the form of "slow spikes" or bursts of beta, theta or delta activity. t h e possible relationship of hearing difficulties to epileptic disorders should not be overlooked, particularly if there is any apparent fluctuation in auditory efficiency. gowers2 1 described auditory loss before seizures in 6 patients, in one of whom there was concomitant temporary loss of vision. more specifically the frequent association of apparent hearing defects with more general behavioural problems deserves attention in view of the functions of the temporal lobe, which, besides containing the primary receptive area for auditory sensation, also plays a profound role in the behavioural and emotional life of the individual (chatfield8). this very brief survey of e e g findings in visual and auditory anomalies should serve as a cautionary introduction to a consideration of the e e g in communicative disorders proper. only if the excessive optimism associated with the initial enthusiasm that generally surrounds the application of a technique such as the e e g in such a highly specialised field is first dispelled are the actual electro-clinical correlations likely to emerge. t h e following is a brief survey of some types of communicative disorder, representing the more common syndromes of, delayed speech, aphasia and stuttering in relation to the electrical activity of the brain. d e l a y e d s p e e c h speech usually develops between the ages of 1 year and 18 months, otherwise deafness is usually suspected. if this cannot be demonstrated the possibility of a mental defect is raised, or failing this, in the words of adams1, "some psychic disturbance or special neurological defect", but he goes on to point out that there is often no evidence of brain injury. in a group of 41 children with severe speech retardation webb and lawson114 found that 13 had generalized and 11 focal e e g abnormalities. a high incidence of e e g abnormality was also reported by berges et al." in 45 children including cases of delayed speech, stuttering and difficulties in articulation: nearly 50% showed an inter-hemispheric asynchrony, with or without a spike focus, while an equivalent proportion had paroxysmal e e g disturbances during hyperventilation and photic stimulation. most of these signs were found to disappear with the normalization of speech. an interesting interference was that a normal e e g in a child with delayed speech connoted an unfavourable prognosis, a view reminiscent of that of hill2 2 in relation to psychopathy. tydskri van die suid-afrikaanse logopediese vereniging, vol. , nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) g. κ. nelson eeg findings in the present series. e e g ' s were obtained from 21 patients aged 20 months to 10 years (table 4). t h e overall incidence of abnormality was 17 out of 21 (81%), the e e g being severely abnormal in one case (spastic quadriplegia), moderately, abnormal in 11, mildly abnormal in one and doubtful in the remaining four. t h e four patients with normal e e g ' s comprised: behaviour problem, aged 7; mental defect, aged 5 years 11 months; post meningitis, aged 2 years 8 months; an otherwise normal child aged 6 years 9 months t h e most common abnormality w.as excessive parieto-occipital or diffuse slow activity, suggestive of cortical immaturity, found in 5 patients. focal disturbances were seen in 8 patients, in the right parietal area in 3, and in the right post-temporal, right fronto-centro-temporal, left frontal, left temporal and left parieto-temporo-occipital regions in one patient each. t w o children had marked inter-hemispheric asynchronies in their eeg's. it is perhaps not surprising that five of these patients showed e e g evidence of delayed cortical development. in such cases little of prognostic value can be gained from the e e g without repeated studies at intervals of 3 to 6 months. t h e focal disturbances had no consistent location, either in a lobe or hemisphere. while some of these perhaps reflected localized maturation defects, three were of the type usually associated with epilepsy ( f i g · 7)· only one of these (case 28) had any history of a disorder related to epilepsy, yet all three showed types of e e g abnormality usually associated with epilepsy. in this connection adams1 observed that if external electrical stimulation of the cortex is followed by inability to speak, it is logical to assume that spontaneous electrical dysrhythmia may be responsible for delayed speech in children. another two cases were brother and sister. although the e e g abnormality was posterior in case 19 and anterior in case 20, the right temporal lobe was implicated in each, and the possibility is raised of a genetic contribution to a localized maturation defect in these two children. comment. although the incidence of e e g abnormality in these patients with delayed speech must also be viewed against the background of their more general disorders, the e e g provided valuable information in almost all cases, either confirming dysfunction of the brain or differentiating between possible brain lesions and immaturity. a p h a s i a it is accepted that aphasia is often a manifestation of a localized dysfunction of the brain, although evidence for this may be absent in many cases. t h e r e is also reason to suspect that aphasia may at least be triggered by psychogenic factors in some cases. from the neurophysiological standpoint, adams1 showed that electrical stimulation of a speech area of the cortex was accompanied by aphasia for the duration of the stimulus. t h e role of epileptic discharges in the brain was. considered by volterra63 who concluded that there are critical and "paracritical" speech changes of a definitely epileptic nature, but also journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) cerebral electrical activity and communication disorders 15 "non-critical" disturbances with no manifest epileptic, other neurological, intellectual or sensory defect, although the e e g shows a "grave irritative epileptic dysrhythmia", generally localized in the brain regions concerned with speech. kreindler et al:'j found marked interhemispheric asymmetries in the blocking response of the alpha rhythm in 19 of 25 aphasic patients. it was inferred that the absence of alpha rhythm blocking in the dominant hemisphere might be attributed to a unilateral alteration of reticulo-cortical interrelations. nevertheless severe aphasia of various types is commonly associated with " a normal e e g (gibbs and gibbs 1 8 ), but where the record is abnormal, these authors claim a frequent association with mid-temporal slow wave foci. e e g ' s were obtained by liberson"' from 18 aphasic patients, 13 of whom had abnormal records. of these 10 showed depression or suppression of evoked potentials in the affected hemisphere (all 10 suffering from middle cerebral artery thrombosis), while 3 had bilaterally abnormal eeg's. these findings revealed a high degree of concordance with the evaluation of the speech therapist. eeg findings in the present series. e e g ' s were obtained from 10 patients with aphasia, aged 3 to 37 years. there was a history of epilepsy in two cases, while the remainder comprised one case each of spastic quadriplegia, surgical anoxia, head injury, behaviour disorder, mental retardation, "bad home environment", uncomplicated speech and spatial difficulty, and febrile illness. t h e e e g was normal in only two of these patients: an 8 i year old child with a bad home environment and a 3 year old child with a history of convulsions. t h e incidence of e e g abnormality was thus 8 0 % in this small sample, the record being severely abnormal in three cases (quadriplegia, behaviour disorder and surgical anoxia), moderately abnormal in three (speech and spatial difficulty, febrile illness and mental retardation), and doubtful in two (head injury, epilepsy). t h e types of abnormality were, as in the group with delayed speech, varied: excessive non-paroxysmal slow activity was seen occipitally in the case of speech and spatial difficulty, in the left temporal area in surgical anoxia, and in the right hemisphere in head injury. focal bursts at various frequencies a n d / o r spikes a n d / o r waves-and-spikes were seen in spastic quadriplegia (right-frontal), febrile illness (temporal and generalized), behaviour disturbance (right hemisphere), and mental retardation (left frontal and fronto-temporal). although there was again no consistent pattern of abnormality, the e e g was of positive value in 8 of these 10 cases: case 39: an 8-year-old right-handed boy had speech and spatial difficulty, with no other symptom. t h e e e g suggested a severe cortical maturation defect, or organic pathology, involving the left occipital area in particular (fig. 8), case 40: a 3-year-old boy with spastic quadriplegia and aphasia had no epileptic manifestation but his e e g showed numerous runs of high-voltage delta tydskrif van die suid-afrikaanse logopediese vereniging, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) g . κ. nelson activity and waves-and-spikes, sometimes generalized but with a focus in the right frontal area. case 41: an 81-year-old boy with expressive aphasia had a bad home environment. since he had tried to formulate words his defect was regarded as probably not psychogenic. however, his e e g showed no evidence of either organic pathology or delayed maturation. case 42: a 4-year-old boy had had' a febrile illness months previously, after which he stopped talking and walking. an organic brain lesion was suspected but the e e g showed generalized wave-and-spike outbursts indicative of epilepsy, with no sign of a focal disturbance (fig. 9). case 43: a 30-year-old woman had a heart operation 3 years prior to her e e g . d u r i n g the operation she suffered a cerebral haemorrhage with consequent total right paralysis and inability to speak, read or write. speech therapy had been successful to a limited d e g r e e : while she was able to speak slowly b u t with some echolalia, her e e g (fig. 10) showed a clear focus of delta, theta and alphoid r h y t h m s in the left temporal area. h a d it been possible to carry out repeat e e g ' s the patient's progress might have been more precisely charted and even predicted. case 44: a 23-month-old child had fallen off a table at the age of 17 m o n t h s and ceased to speak, although he was able to convey information by signs. his behaviour deteriorated and he was reported to be losing his memory. t h e e e g was doubtful due to a persistent slight asymmetry between the hemispheres, delta activity arising chiefly from the right temporal area. t h i s could reflect a maturation defect or an organic lesion. a repeat e e g at the age of 31 m o n t h s resolved the problem. t h i s record was normal, suggesting that the previous record had reflected maturation processes. h e had meanwhile recovered the ability to speak. case 45: a 7-year-old boy was referred because of a speech defect which had appeared at an early age and resisted therapy. h e was an illegitimate child, illtreatedby his mother and admitted to an orphanage. t h e first e e g was doubtful showing various disturbances of quite obscure significance. t h e second e e g , 3 weeks later, was similar, b u t raised the question of a left-sided cerebral abnormality. t h e third e e g , after a further 6 i m o n t h s was unequivocally abnormal, showing r u n s and bursts of theta activity, chiefly of temporal origin, with bursts of delta waves often confined to the left temporal area. his speech had improved b u t his general behaviour had shown marked deterioration. t h e e e g abnormalities were interpreted as reflecting a severe maturation defect underlying the behavioural deviation. case 46: a 3-2-year-old boy gave the impression of being retarded and aphasic. a neurological examination led to the provisional diagnosis of anterior cerebral abnormality. t h i s was confirmed by the e e g which showed a clear left frontotemporal focus of spikes and sharp waves. c o m m e n t . g o w e r s 2 1 a n d p e n f i e l d a n d j a s p e r 4 9 d e s c r i b e d a p h a s i a i n e p i l e p t i c s , o f t e n f o r m i n g t h e m o s t i m p o r t a n t s i g n of t h e s e i z u r e , b u t a l w a y s a s s o c i a t e d w i t h a n a b n o r m a l d i s c h a r g e i n t h e d o m i n a n t h e m i s p h e r e . t h e l a t t e r a u t h o r s s t r e s s t h a t w h i l e a n e p i l e p t i c d i s c h a r g e p r o d u c e s a c t i v a t i o n a n d i n t e r f e r e n c e , t h e effect o n s p e e c h is c o n f i n e d t o i n t e r f e r e n c e . t h e y q u o t e a c a s e i n w h i c h t h e e e g c o n t a i n e d s p i k e s f r o m t h e left i n f e r i o r t e m p o r a l l o b e . a s a d a m s 1 p u t s it, " e p i l e p s y i n a s p e e c h c e n t r e " d o e s n o t p r o d u c e a " p o u r i n g o u t of w o r d s " d u r i n g t h e a t t a c k , b u t i n s t e a d t h e r e is a n i n a b i l i t y t o s p e a k ; i n s p i t e of t h e fact t h a t s t i m u l a t i o n of a c o r t i c a l s p e e c h a r e a c a u s e s m o v e m e n t of t h e p e r i p h e r a l s p e e c h a p o a r a t u s , t h e r e is n o e x t e r n a l v o c a l i z a t i o n . t y p i c a l of s u c h a n effect is a c a s e d e s c r i b e d b y journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) cerebral electrical activity and communication disorders 17 gastaut ei al."' of a man with seizures accompanied by rhythmic left temporal and post-temporal spikes, during which he had expressive aphasia. t h e potential contribution of the e e g in cases where a psychogenic factor is in question is well exemplified by a case cited by bagchi et al*: a highly intelligent girl with no personal or familial history of epilepsy developed sibling rivalry and stopped talking. t h e r e were no other behavioural changes. t h e e e g showed severe abnormality in the form of generalized wave-and-spike discharges. n o follow-up data are available, but such a record is strongly suggestive of epilepsy and would provide a strong basis for therapy based on anticonvulsants even though overt epileptic symptoms are absent. d y s l e x i a t h e concept of cerebral dominance has received much attention in the literature relating to reading difficulties, but hughes et alp and kennard and rabinovitch" found no correlation between e e g abnormalities and either reading difficulty or cerebral dominance. t h e study of webb and lawson" previously cited was undertaken because of the frequent observation that degree of efficiency in reading in a given child often varies from day to day or even from hour to hour, "as though the deficit were intermittent or paroxysmal." t h e y describe a case of a 13-year-old child with severe dyslexia whose e e g was abnormal due to left temporal spikes. an identical twin had a similar e e g but no other defect. in the opinion of these authors this suggests the possibility of an organic defect underlying dyslexia in the one twin which was demonstrable by the e e g alone. a recent investigation by knott et av of 50 children with reading disabilities revealed abnormal e e g ' s in 31 (84%), of whom 15 had 14 and 6 per sec positive spikes in their sleeping eeg's. three groups were distinguished : (a) normal e e g ' s ; (b) abnormal e e g ' s with no spikes; (c) abnormal e e g ' s with spikes. there was however no significant difference in reading disability or any other characteristic between these groups. of the 31 abnormal records 41% contained positive spikes while 50% showed posterior slow dysrhythmia. t h r e e patients were studied. from the first of these only one e e g was obtained, but the other 2 were intensively investigated. case 47: a 21-year-old male mill-hand was stated to have congenital alexia. h e could understand written and spoken speech very well but was unable to read or write. t h e r e were no clinical abnormalities and he gave the impression of having a good i.q. h e was right-eyed and right-footed. t h e e e g was normal but very unusual in that alpha rhythms at 9-10 c/sec were more prominent frontally than parieto-occipitally, amplitudes being 20 and 15 microvolt respectively (fig. 11). phase relationships showed that the anterior rhythms were identical with those of more orthodox location, and were thus not independent alphoid rhythms. case 48: a 12-year-old boy was referred because of dyslexia. his first e e g was moderately abnormal due to a number of medium-high voltage 2 c/sec runs tydskri van die suid-arikaanse logopediese vereniging, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) g. κ. nelson from the left parieto-occipital area, and some asynchrony of the alpha rhythms. at this stage the interpretation was of a maturation defect or organic abnormality in the left parieto-occipital area. a second e e g 5 ϊ months later showed a reduction of slow activity which was now more prominent on the right side, although still of parieto-occipital origin. a third e e g after a further 8 i months showed little change, except that parieto-occipital slow activity appeared independently on both left and right sides, giving some evidence of sub-cortical involvement. t h e final interpretation can only be made with confidence after further e e g ' s have been' obtained. t h e r e has been little change in the dyslexia. case 49: a 3-year-old boy with a fluctuating behaviour pattern and mild right hemiplegia following surgery for a left cerebral haemorrhage caused by a fall at the age of i o months. his e e g showed several focal paroxysmal 1-2 per second wave-and-spike discharges from the right parieto-temporal region, being suggestive of an epileptogenic abnormality in this area (fig. 12). his second e e g a year later was more abnormal due to an increase in number and voltage of the focal disturbances which had spread to the fronto-central areas as well. after another year the e e g was improved in that wave-and-spike disturbances were less prominent and confined to the right parietal area. a fourth e e g after another i o months, at the age of 5 years 8 months, was still abnormal but showed further improvement due to reduced amplitude of abnormalities and dissociation of spikes and slow waves. j and this time dyslexia became apparent. t h e r e was some improvement in this respect, followed by a relapse prior to the fifth e e g at the age of 7 years. t h e record had changed, containing numerous isolated spikes and larval waves-andspikes, especially from the left frontal area. after a further one and a half months isolated spikes were seen in the left temporal, fronto-temporal and parietal areas, with some slow activity in the homologous regions of the right hemisphere. reading difficulties continue. a t n o s t a g e h a s t h i s p a t i e n t g i v e n a n y sign of e p i l e p s y , yet t h e e e g a b n o r m a l i t i e s a r e t h o s e m o s t c o m m o n l y a s s o c i a t e d w i t h e p i l e p s y . w h e t h e r o r n o t t h i s is a c a s e of l a t e n t e p i l e p s y , it is s t r i k i n g t h a t t h e e e g a n o m a l i e s a p p e a r t o a r i s e i n t h e r e g i o n s of t h e d o m i n a n t h e m i s p h e r e c o n c e r n e d w i t h r e a d i n g . i t is h o w e v e r i m p o r t a n t t o n o t e t h e fluctuating n a t u r e of his d i s o r d e r , c h a r a c t e r i z e d b y i n t e r m i t t e n t d i s t r a c t i b i l i t y a n d r e d u c e d s t a m i n a . c o m m e n t . t h e s e t h r e e cases i l l u s t r a t e o n c e m o r e t h e v a r i e t y of e e g a b n o r m a l i t i e s a s s o c i a t e d w i t h d i s o r d e r s of t h e a p h a s i c v a r i e t y . t h e y a l s o s e r v e t o u n d e r l i n e t h e i m p o r t a n c e of serial s t u d i e s t o t a k e a c c o u n t of c h a n g e s d u e t o m a t u r a t i o n . s t u t t e r i n g a n e a r l y p a p e r b y t r a v i s a n d k n o t t 6 0 r e p o r t e d n o difference i n e e g f r e q u e n c y b e t w e e n n o r m a l s p e a k e r s a n d s t u t t e r e r s , b u t in t w o s t u t t e r e r s t o n i c s p a s m s w i t h o u t v o c a l i z a t i o n w e r e a c c o m p a n i e d b y h i g h v o l t a g e s p i k e s i n t h e e e g , s u g g e s t i v e of e p i l e p t i c i n v o l v e m e n t . i n 1 9 3 7 a f u r t h e r r e p o r t b y t r a v i s a n d m a l a m u d 6 2 a g a i n i n d i c a t e d n o difference i n e e g f r e q u e n c y b e t w e e n s t u t t e r e r s a n d c o n t r o l s , a n d a t h i r d p a p e r ( t r a v i s a n d k n o t t 6 1 ) s u p p o r t e d t h e s e r e s u l t s . a s u b s e q u e n t i n v e s t i g a t i o n ( l i n d s l e y 3 7 ) d i d h o w e v e r r e v e a l i n t e r h e m i s p h e r i c differences in b r a i n p o t e n t i a l s i n s t u t t e r e r s , a n d f r e e s t o n e 1 3 · 1 4 f o u n d t h a t s t u t t e r e r s h a d a h i g h e r a l p h a a n d b e t a a m p l i t u d e t h a n n o r m a l journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) cerebral electrical activity and communication disorders 19 speakers and that this increased further during stuttering. in addition there was relatively little amplitude difference between the hemispheres in stutterers, who also showed less alpha blocking with speech. these features would suggest a diminished focus of attention in stutterers, but freestone's view was not that the neurological differences suggested by the e e g results were the cause of stuttering but that they acted "as potential subsoils in which stuttering may arise". in 1943 douglass1 0 reported that, in silence, normal speakers showed more alpha blocking in the right hemisphere, stutterers in the left. during speech this difference did not appear. his sample of 20 stutterers showed more bilateral alpha blocking during speech than in silence and he concluded that speech has a greater attention value for stutterers. in the same year knott and tjossen'1 published data supporting the view of douglass and interpreted these as favouring the lateral dominance theory of stuttering. in 1954 knott and correll2 8 in a study of the e e g ' s of 14 stutterers found "no very striking difference" between these and the records of nonstutterers, although the former had a slightly higher alpha amplitude. although rheinberger et al:'' were also unable to find any significant difference in the e e g ' s of 10 stutterers and 10 non-stutterers, and scarborough's5 3 study accorded with this, pierce and lipcon 5 1 found abnormal records in 2 2 % of stutterers and only 8% of a control group. other differences relating to clinical history and psychological assessment led pierce and lipcon to the conclusion that stuttering as a habit is attributable to interrelated psychic, social and organic factors. in line with this hypothesis is the recent report by berges et al.6 already cited in connection with delayed speech. morin 4 2 investigated 30 young stutterers before and after speech therapy which was successful in 9 cases, produced an improvement in 14 and failed in the remaining 7. morin claims that the e e g has a prognostic value since all 7 failures had normal e e g ' s while most of the others had abnormal records with "slow paroxysmal discharges". where the e e g was most abnormal success was spectacular and rapid. in addition to these implications concerning the relationship between brain function and stuttering, there is no doubt that some cases of stuttering are associated with frank but unusual epileptic patterns. t w o such cases are described by anastopoulos et al.2 furthermore, assessments of capillary blood oxygen saturation in stutterers during stress resemble those of paranoid and epileptic patients rather than those of neurotics (levett doust3 8). eeg findings in the present series. e e g ' s were obtained from five male stutterers aged 8 to 29. in four patients the e e g was abnormal, and the remaining case had an unusual record: case 50: an 8-year-old boy was classified as brain damaged because of marked difficulty in conceptualization, mirror-writing and a history of seizures. his mother had resented her pregnancy and he was born after a five-day labour. h e started to stutter not long before the e e g which was grossly abnormal due to tydskri van die suid-afrikaanse logopediese vereniging, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) g. κ. nelson a focus of slow activity in the left parietal region suggestive of an organic disturbance. a repeat e e g i o months later showed little change. case 51: a 13-year-old boy was referred because of stuttering and a tic. n o history was available. his e e g was of doubtful normality owing to excessive theta activity, raising the question of cortical immaturity. case 52: a 19-year-old army recruit was normal except for a marked stutter. his e e g was severely abnormal due to an almost continuous focus of slow activity in the right post-temporal area, and severe slowing with hyperventilation (fig. 13). case s3 a 19-year-old toolmaker had a history of sudden onset of stuttering at the age of 8 years, following the divorce of his parents and subsequent remarriage of his father. his e e g was moderately abnormal due to excessive sometimes paroxysmal theta and beta activity from the right post-temporal region. when asked to read aloud, verbal blocking was accompanied by brief bursts of temporooccipital 6-7 c / s e c activity. case 54: a 29-year-old man, normal in all respects except for his stutter, had a normal but unusual e e g . during reading there was marked lambda variant activity at 5-7 c/sec. at halts due to stuttering the following phenomena were seen : (a) brief bursts of occipital 12-14 c / s e c activity (fig. 14). (b) suppression of lambda variant activity. (3) traces of irregular occipital beta rhythms. t h e first of these (12-14 c / s e c bursts) preceded the halts slightly, while suppression of lambda activity generally followed them. lambda activity is often seen during successful reading and has been reported to disappear during stuttering. t h e clear augmentation of alpha activity during stuttering is suggestive of fluctuating attention. comment. in these five cases the only abnormality of any apparent consistency is the temporal or post-temporal disturbance in three patients. all were right-handed, yet the focus was in the left, or presumably dominant, hemisphere in only one case. t h e significance of such localized abnormalities and of e e g changes accompanying stuttering will be dealt with in a subsequent report of an experimental study of stutterers. conclusions t h e data presented here provide little reason for optimism on the part of those seeking straightforward correlations between communicative disorders generally and the electrical activity of the brain. in spite of the high incidence of e e g abnormality in these patients, this would appear to relate more directly to an underlying clinical syndrome such as epilepsy which need not necessarily be accompanied by any disorder of a sensory or motor kind concerned with communication. although some of these cases, particularly those with aphasia and stuttering, demonstrate focal abnormalities, such abnormalities may occur in the dominant or sub-dominant hemispheres, although the main speech centres are to be found in the dominant hemisphere. such cases merely serve to support what is known of the significance of speech and other centres in the dominant hemisphere. on the other hand an actively abnormal discharge in the sub-dominant hemisphere can disturb the operation journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) cerebral electrical activity and communication disorders 21 of the crucial centres in the dominant half of the brain. such an abnormal discharge could have its origin in an injured portion of brain tissue, in an epileptogenic focus or even in a region which has failed to mature at the same rate as the remainder of the brain. research in this field must however constantly take account of the recent warning of stern5 5 that the assumption that the brain is a "master organ" controlling other physiological systems, can not exclude the effect of these other systems on the activity of the central nervous system. in the following paper the question is raised of the relative contribution of brain dysfunction (as reflected in the e e g ) to stuttering, and the effect of stuttering oh concomitant brain activity. it is the detection and localization of sites of abnormal brain function giving rise to a variety of clinical symptoms amongst which may be a disorder of communication, that the main practical benefit is to be derived from e e g examination at the present time. concomitantly the common problem of the relative contribution .of organic and psychogenic factors to the development of a communication disorder can often be resolved with the assistance of an eeg. it remains to be discovered whether refinements of the basic approach to the e e g , such as the study of evoked responses and the analytical techniques of autoand cross-correlation, will throw more light on the precise role of the electrical activity of the brain in the determination of the efficiency of man's communication with his world. summary a general introduction to electroencephalography (eeg) is given, followed by a brief outline of the main brain areas concerned with vision, hearing and speech. previous e e g findings in sensory defects, delayed speech, aphasia, dyslexia and stuttering are considered and discussed in the light of e e g ' s from representative cases. finally the value of the e e g in the diagnosis and study of communication disorders is appraised. opsomming 'n algemene inleiding tot elektroenkefalografie (eeg) word aangebied. daarop volg 'n kort oorsig van die vernaamste breingebiede wat by gesig, gehoor en spraak betrokke is. vorige eeg-bevindings by waarnemingsgebreke, vertraagde spraakontwikkeling, afasia, disleksia en gehakkel word beskryf en in die lig van e e g ' s van verteenwoordigende gevalle bespreek. laastens word die waarde van die e e g in die diagnose en studie van kommunikasiesteurings oorweeg. t h e assistance and co-operation of the following is greatly appreciated: forest t o w n school for spasties, johannesburg; miss .ina van wyk and miss barbara pethnick, of the division of neuropsychology, national institute for personnel research, johannesburg. tydskrif van die suid-afrikaanse logopediese vereniging, vol. , nr. : mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) g. κ. nelson references ι . adams, j. 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(1957): fundamentals of clinical neurophysiology. springfield, 111., charles c. t h o m a s . 9. cobb, w. a. (1963): the eeg of lesions in general, in: electroencephalography. e d s : hill, j. d. n . a n d parr, g., 2nd edition, macdonald and co. l t d . , l o n d o n . 10. douglass, l . c. (1943): a study of • bilaterally recorded electroencephalograms of adult stutterers. j. exp. psychol., 32, 247. 11. ellingson, r. j. and schain, r. j. (1965): eeg's in juvenile cerebral lipoidosis (spielmeyer-vogt disease). electroenceph. clin. neurophysiol., 18, 513. 12. fisch, l . (1965): neurological mechanisms of hearing and speech. nature, 206, 541. 13. freestone, n . w. (1942): electroencephalographic study on moment of stuttering. speech monog., 9, 28-60. 14. freestone, n . w. (1942): brain-wave interpretation of stuttering. quart. j. speech, 28, 446-468. 15. f u l t o n , j. f. (1949): physiology of the nervous system. 3rd ed., n.y.. oxford university press. 16. gastaut, h., n a q u e t , r., dongier, s. and lanoir, j. (1962): subintrant aphasic attacks in a temporal lobe epileptic: an electroclinical study. electroenceph. clin. neurophysiol., 14, 788. 17. gervasio, l . and marenzi, m . l . (1963): comparative study of eeg, aetiopathogenetic and audiometric data in 165 cases of deafness in children. electroenceph. clin. neurophysiol., 15, 918. 18. g i b b s , f. a. and g i b b s , e. l . (1964): atlas of electroencephalography. addison-wesley publ. co., inc., reading, mass. 19. g o r d o n , n . and taylor, i. g. (1964): the assessment of children with difficulties of communication. brain, 87, 121-140. 20. gottlieb, g., doran, c. and whitley, s. (1964): cerebral dominance and speech acquisition in deaf children. j. abn. soc. psychol., 69, 182-189. 21. gowers, w . r. (1885): epilepsy and other chronic convulsive diseases: their causes, symptoms and treatment. l o n d o n , wood. 22. hill, d. (1963): the eeg in psychiatry. in: electroencephalography, hill, j. d. n . and p a r r , g., eds., 2nd edition, l o n d o n , m a c d o n a l d . 23. hughes. j., leander, r. and k e t c h u m . g. (1949): electroencephalographs studies in specific reading disabilities. electroenceph. clin. neurophysiol., 1, 377-378. / 24. h u m p h r i e s , d. (196s): the relation of binocular vision' 'to psychological . rigidity. p h . d . thesis, university of the witwatersrand. 25. jeannerod, m . and courjon, j. (1965): occipital spikes during sleep in the amblyopic child. electroeceph. clin. neurophysiol., 18, 722-723. 26. jefferson, g . (1950): localization of function in the cerebral cortex. brit, med. bull., 6, 333-340. 27. k e n n a r d , μ . α., rabinovitch, r. and wexler, d. (19s2): the significance of amplitude asymmetry in the eeg as related to reading disability in children. canad. med. assoc. j., 67, 330. 28. k n o t t , j. r. and correll, r. .e. (1954): photic driving in stutterers. electroenceph. clin. neurophysiol., 6, 158. journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) cerebral electrical activity and communication disorders 23 29. knott, j. r., correll, r. e. and shepperd, j. n . (1959): frequency analysis of electroencephalograms of stutterers and non-stutterers. j. speech hearing res., 2, 74-80. 30. knott, j.· r., muehl, s. and benton, a. l . (1965): electroencephalograms in children with reading disabilities. electroenceph. clin. neurophysiol., 18, 513. 31. knott, j. r. and tjossem, t . d. (1943): bilateral electroencephalograms from normal speakers and stutterers. j. exp. psychol., 32, 357. 32. kreindler, α., crighel, e., poilici, i. and rzeznicka, s. (1962) : eeg and vasomotor reactivity in aphasia. electroenceph. clin. neurophysiol., 14, 567. 33. krieg, w. j. s. (1957): brain mechanisms in diachrome, 2nd edition, evanston, 111., brain books. 34. lairy, g. c., harrison, a. and leger, ε. m . (1965): asynchronous bi-occipital eeg foci of spikes in partially sighted and blind children of school age. electroenceph. clin. neurophysiol., 18, 723. 35. lesny, i. and odvarkova, j. (1959): the influence of sonic stimulation of a constant tone of different frequencies on human electroencephalogram especially in children. electroenceph. clin. neurophysiol., 11, 178. 36. liberson, w. t . (1965): the study of evoked potentials in aphasics. electroenceph. clin. neurophysiol., 18, 515. 37. lindsley, d. b. (1940): bilateral differences in brain potentials from two cerebral hemispheres in relation to laterality and stuttering. j. exp. psychol., 26, 211-225. 38. lovett doust, j. w. (1956): stress and psychopathology in stutterers. canad. j. psycol., 10, 31-37. 39. marcus, r. e. (1951): hearing and speech problems in children. observations and use of electroencephalography. arch. otolaryng., 53, 134-146. 40. masland, r. l., austin, g. and grant, f. c. ( i 9 4 9 ) : the electroencephalogram following occipital lobectomy. electroenceph. clin. neurophysiol., 1, 273282. 41. metcalf, d. r. (1959·): electroencephalographic findings in ex-premature infants with partial and complete blindness due to retrolental fibroplasia. electroenceph. clin. neurophysiol., 11, 182. 42. morin, s. (1965): eeg correlates of stuttering. electroenceph. clin. neurophysiol., 18, 425. 43. mundy-castle, a. c. (1955): the relationship between primary-secondary function and the alpha rhythm of the electroencephalogram. j. nat. inst. personnel res., 6, 95-102. 44. mundy-castle, a. c. (1958): electrophysiological correlates of intelligence. j. personality, 26, 184-199. 45. mundy-castle, a. c. and nelson, g. k. c1962): a neuropsychological study of the knysna forest workers. psychol. afr., 9, 240 : 272. 46. nelson, g. k. (1959): the electroencephalogram in kwashiorkor. electroenceph. clin. neurophysiol., 11, 73-84. 47. nelson, g. k. ( i 9 6 0 ) : the measurement and significance of brain rhythms. trans. s. afr. inst. elect. eng., 51, 2-17. 48. parsons-smith, g. (1953): activity of the cerebral cortex in amblyopia. brit. j. ophth., 37, 359. 49. penfield, w. and jasper, η. h. ( i 9 5 4 ) : epilepsy and the functional anatomy of the human brain. boston, little. 50. penfield, w. and roberts, l. (1959): speech and brain mechanisms. princeton, n.j., princeton univ. press. 51. pierce, c. m . and lipcon. η. h . (1959·): stuttering: clinical and .electroencephalographic findings. mil. med., 124, 511-519. 52. rheinberger, μ . b., karlin, i. w. and bertram, a. b. (i943~>: electroencephalographic and laterality studies of stuttering and non-stuttering children. nervous child, 2, 117-133. 53. scarbrough, η. e. (1943): quantitative and qualitative analysis of eeg's of stutterers and non-stutterers. j. exp. psychol., 32, 156-167. 54. sem-jacobsen, c. w. (1962): electrical stimulation-effects on speech in some areas around the third ventricle. electroenceph. clin. neurophvsiol., 14. 956. 55. stern, j. a. (1965): relationship between the eeg and other physiological measures in man. in: applications of electroencephalography in psychiatry. wilson, w. p. (ed.), durham, n. c., duke univ. press. 56. smith, w. k. (1q45): the functional significance of the rastral cin^ular cortex as revealed by its responses to electrical excitation. j. neurophysiol., 8. 241-255. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) g . κ. nelson 57. still, w . c. (1947): an electroencephalographic study of helen keller. arch. neurol. psychiat., 57, 629-632. 58. strauss, h . (1963): paroxysmal blindness. electroenceph. clin. neuro-physiol., 15, 921. 59. s u b i r a n a , a. a n d oller-daurella, l . (1965): eeg study of two cases of anophthalmia. electroenceph. clin neurophysiol., 18, 723. 60. travis, l . e. and k n o t t , j. r . (1936): brain potentials from normal speakers and stutterers. j. psychol., 2, 239. 61. t r a v i s , l . e. and k n o t t , j. r. (1937): bilaterally recorded brain potentials from normal speakers and stutterers. j. speech. dis., 2, 239. 62. t r a v i s , l . e. and m a l a m u d , w . (1937): brain potentials from normal subjects, stutterers and schizophrenic patients. amer. j. psychiat., 93, 929. 63. volterra, v. (1961): speech disturbances as an expression of critical or. latent epilepsy. clinical and eeg aspects. electroenceph. clin. neurophysiol., 13. 13564. w e b b , ε. m . a n d l a w s o n , l . (1956): the eeg in severe speech and reading disabilities of childhood. electroenceph. clin. neurophysiol., 7, 168. appendix c 4 . p 4 taoa ffl-fi -01 τtoo \uv eyes t openeft e y w t ^ ' ' " λ γ close» ^ fig. 2. n o r m a l adult e e g : alpha r h y t h m s , most p r o m i n e n t in t h e parieto-occipital leads, disappear or block w i t h eye-opening. t h e large deflections in channels f p 2 f 4 a n d f p 1 f 3 are artifacts d u e t o eye-movement. voltage calibration is in microvolts as in succeeding figures. ' journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) cerebral electrical activity and communication disorders 25 / s/85/c c3-p3 „ y . 1 co«. θ fp2-f4 zzozc cj -λι τ ίοσ © fig. 3. normal e e g from a child aged 9 years: dominant activity is at 7 • 5 8 c/sec. large deflections in channels f p 2 f p 4 and f p 1 f 3 are due to eye-movements. fig. 4. e e g in unilateral blindness: case 6: girl, 9 years old, almost blind right eye (table 3): focal sharp waves in the left parietal area (channels c 3 p 3 and p3-o1). tydskrif van die suid-afrikaanse logopediese vereniging, vol. 13, nr. : mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) g. κ. nelson λ, p4-oz fp! f=3 r erg l ena ^ y y w w «>2 £4 c4-oz a 01 photic stimulation *t 4 -1 l k k ί i i i i i 1 ' • > » i ι » l· © / fig. 5. e e g in epilepsy with visual defect: case 9: boy, 7 years (table 3): focus of slow waves and spikes in the right frontal area (channels f p 2 c 4 and c4-o2), suggestive of a localized epileptogenic abnormality. fig. 6. e e g and e r g in unilateral visual defect: case 15 (see table 3 and text): boy aged 14 years. record shows approximately equal amplitude of cortical response to photic stimulation at 9 flashes per second, but marked reduction of e r g on right side. irregular trace above photic stimulation registration is automatic frequency analyzer write-out, showing dominant activity at 4 c/sec. in r e r g . journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) cerebral electrical activity and communication disorders 27 4-34 c \ v c4· pari oz fp! fi fz-cs i ioc λ» p3ol fig. 7. e e g in delayed speech: case 22: girl, 7 j years (table 4). excessive slow activity with occasional high-voltage 4-5 c/sec. bursts. fig. 8. e e g in aphasia: case 39 (see text): focus of delta activity i n ' left occipital region, spreading to right side. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 3, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) g. κ. nelson fp! c3 photic 57 mult)7ton ne 78 c. ( j v a a a a a / ' ^ ' — — . 1 stc . i too 1 < · " 1 / / " < co*. © . λ 1.1 — 1233 fp2 7 4 t4--02 c+-t4· fp / 73 οι v fig. 9. e e g in aphasia: case 42 (see text). photic stimulation at 9 flashes per second evokes high-voltage theta and delta burst with spikes. fig. 10. e e g in aphasia: case 43 (see text): clear left temporal delta and theta focus. automatic frequency analyzer shows that dominant activity in channel t3-.o1 is at 1 · 5 6 c/sec. journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) cerebral electrical activity and communication disorders 29 4-os ffi c4 c4--oz c4-t4fpt c3 c3-t3 τ loo 1 μ" , t i*£t ^ com. fpz-f+ . .. 1806 c. φ f* c.4c+ p4fpt-fi eyes λα'· i ioo , ' fig. i i . e e g in dyslexia: case 47 (see text): alpha rhythms more prominent anteriorly than posteriorly (anterior rhythms underlined). fig. 12. e e g in dyslexia: case 49 (see text): focal 3-4 c/sec. wave-andspike activity in the right parietal area on eye-opening. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) g. κ. nelson 2749 tt 02 t3 ts 60m. n/to ieconh qftlr sr**t or hv/v <ven?/ler«>/v λ/νλ/ν i sec i 5» -«mr— fi£. 13. e e g in stuttering: case 52 (see text): upper sample: right post-temporal delta and theta focus in resting record; lower sample: severe slowing with hyperventilation. journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) cerebral electrical activity and communication disorders 31 iis3 c4-oz 5-6 v>rv 12. ιλλί^αν, · 1 sec © fig. 14. e e g in stuttering: case 54 (see text): eyes open: burst of 12 c/sec. alpha activity at start of a block during reading. f r e quency analyzer trace shows wide range of e e g frequencies (channels c 4 o 2 analyzed). tydskrif van die suid-afrikaanse logopediese vereniging, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) g . κ . n elson — χ: 73 . ' υ ~ ν rt ί ε α ω ω 3 οο ο λ 0> — . •δ 2 8-8 ω '' ω 3 οο 73 .i ω ~ ν λ ~ ε •j ο ί c ηχ ι α 0j — . •δ 2 8 a 3 οο α c ο . ω „ ω tc ο — ι a ^ ή ο ϊ o a ^ υ a cfl > "b ο 512 s g>-si « oo a ™ u u x ! u* 3 i •3 rt to w o> a £5. ε u .» o <" u ι >-. c*3 ι ι (h s a s ° (ji h ul c -s ·« β υ c 's-g-g-s «i s " --r 8 a .δ .a .5:2 ο s fi.sfs " « ι" a s 5 ΐ ω sp s -a tj s ω ο c b ω 3 y c/3 u i i 2 .g ts n fο q . i i v-1 « ο ΰ ο a •/l 3 t-1 .... •3x 1 « λ & h s_ 3 „ > e l » s ο " a τ » i 0> > μ « ^ s <υ ο β o -'s) •μ η μ > <*> rt '<*> ,. <l> υ «β .y ,> υ > '< λ ΰ αϊ υ <υ ο υ χ τΐ « c λ λ ο — < » _ <λ ο λ <υ α υ ν ο " χ i λ υ ^ ι ο g f ο π χ ! μ < 'δ — "β « b a ο ε > c υ > ω ΐ'ΐ, a "· ό 3 t-l 2 u e s s s 2 ta «ts c 2 jj • · w i •2-5 « e ε ε y * ο (λ fl 8 2 ·*•« ε ϊ» r un μ ω ι „ — ' u !?·">> k, u £? £ 2 υ 2 is u 5 u (λ o -μ ~ r t λ rt vo ε " 9 f ι y ^ ο si 2 7 3 rε β o x rt χι a.s « a £ s » b « » 5 μ r t u ·-< η ^ w5 λ <υ ο s ε " u .2 •α v~t oj 4 ε t3 λ _ν 'ο, "λ • ση »-. cj u (λ u c i! ° « s ω g ω ι» δι « 2 c3 w3 ^ ο υ u 71 λ) μ -ι" rt bfl ε.δ 2 ο s o c « > xi < ε' ο 3 ρη μ ™ ϋ μ u 2 c — ο π jj ε ΐ l-l j2 *c c 3 o . j3 bp 'c c oj [ζ ih rt υ c3 13 * 5λ u 0 a 1 0 0 0 μ ο a ε ε ο μ 1 ο c c xi υ < ν q b ο ε <u co 3 ε 03 g tj ω ο a u 5 _ 3 rt ^ »> a" •«•3 s . ft w ο «ι. nq < • < υ' d «υ i> § si υ w3 qi λ ο χ ! ΰ bj3 rt τ3 c ο u ε υ xi ω •α c 7 3 ο η ο « " « •2 a ο 3 ε χ: ω "α ε ο • h a χι ο rt nj tu u ω ΰ 2 .8 a £ 3.0 s σ · λ τ3 " 1 ·ε rj ^ c 3 "5 1) ·"· u bopq 3 ε & d λ 3 bfi λ ε α τ3 c •2 « & 3 'c j e.e e ε s o ό r rfi rt rt ph κ κ rt μ — '3 x3 t3 .s 3 λ m 3 ϋ 2 x3 " s s w t o [1 aj rt •a" ο 6 0 f-l υ χΐ — < 2 2 's ™ s 3 2 2 r; rt ω t a h • t! oo xi x; ε υ xi .g ω ω c 3 _ ο ι; 2 "u iis β •fi s. c <3: ω m m £ xi ο . ut3 c : 03 £ a l· 1 •s " , ce « ο ο f ^ > o< % ts g ω 3 .2 ·" ω " 3 a jiu " ο ω t; "a u '> xi ω ti £ °-als "·β··3 s s3 2.ξ § s p 2 | ε 2 ^ γ &h η <d p . a c 73 c ω a, . 3 w §· a λ λ . 73 c •j3 ^ 5λ h g a 5λ γ73 « λ υ β w ft ο jc ·2 c a is «2-3 u to λ s s λ λ s λ cm q 00 on on journ al of the south a frican l ogopedic society, v ol. 13, n o. 1: m ay 1966 reproduced by sabinet gateway under licence granted by the publisher (dated 2012) c ereb ral e lectrical a ctivity and c om m u n ication d isord ers 33 ο ζ ο ζ £ ο ω ω < η — 3 c -0j3.u a c υ ^ u — (j r f ™ s a l t m ο ο.— κ-· e al2 a ° i ό — u 43 u '3-3 2 « 2 60 ·"> ·ϊ ο .t! ω ο 3 ^ ^ n y tif ln u 'h s ^ h s ri " " t m u 's o o b h a » h ,5 a u ® u cs> α ο s-α go-g a s-g -s g ϋ μ 3 cl, (κ i.s ο ο. >"• c a «s.s ω α ω (j (j ^ h ω ί s —< to ο ο η 'is-si 00 υ μ ο c < cfl β u ο -a c " , t3 ra e.s ' ".δι (λ (j ι ω υ ; s ? is 2 ο a ~ g μ jj j3 ω ο s λ oj _ ^ cfl ω ο .3 » s ^ o ω a c ο . u a ti.no.> a u rt w fcj trnc •s -o s ji „ c x — ti ra u cfl ; η < · j ω ω ι § '§ • ? a e -3 s b on ο c λ < m 3-3 δ j s· < oj c : ί fi) £ b-) u w ο ω be c 2 'g ~ cfl ο u > .3 .3 " •3 c •c u ·· -δ bd g o ojh 3 <c a • s i s s 1> js " co a, ο 3 e < 2 s ρ c ο 7 3 £ α> 3 y u « •h u (j β ο u •α •α ji .s ξ •α s a ο .β ω ο ί ρ a a < "α ε ο .2 ο ω 3 c 3 « ελ ω τ3 c3 « £ β» η •8 " ή v -2 ° & g jc ^ ο sos 3 j -α 3 cfl ιη ιη § c 2 υ ε ϋ ε § υ 2 8 •g& h β. ύ -0 1 ρη β ω τ3 τ3 ω s s ^ cfl ra on λ g .5? § a ° tj 2 ii « ι <tj 2 c 3 £ c 2 ι-ι ο υ £ w ν> τι κ γη ^ ό λ ο (4-1 ° m s jc.s u u π ω j5 3 — 3 s u ο -r a (u •s -s qq υ 3 tn ω "s ε a rv ·°·3 ο υ cfl ~ oj μ ω υ λ > ρ. ν ω u to λ λ λ to <3 t ydskrif van die suid-a frikaan se l ogopediese v eren igin g, v ol. 13, n r. 1: m ei 1966 reproduced by sabinet gateway under licence granted by the publisher (dated 2012) g . κ . n elson ο til 2 u cfl 4-1 rt « m ο ι-» q , rr* ™ a a (u u — . β . • a js > o .sp 4-» 4-» 'j ^ ο η s 3 £ ώ ° s ε ^ α 9 & > <υ ο ά ο » 1?? 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eh w u c ν u η υ „ » ι g rt .. ο .. ^ * * .a μ η μ h 6 ·"· 6 g e a ε a ο a ο c c j3 j3 < < "α ε ο •α rt ° «ί c q j ί-ι * λ tn a s 'fi ω ·α c rt •s 3 55 cr 4j crt c/j rt o a chc/3 s ο α c β i υ ω ti <υ « υ a ο rt ι " a σ· ω υ . •5 ω a rt.2 a u « 4-1 v) ' a οο 3 σ· • b rt λ ss ie g d s 05 bp α o 2^ •c -io. t ydskrif van die suid-a frikaan se l ogopediese v eren igin g, v ol. 13, n r. 1: m ei 1966 reproduced by sabinet gateway under licence granted by the publisher (dated 2012) abstract introduction materials and methods results discussion conclusion acknowledgements references about the author(s) lebogang ramma department of health and rehabilitation sciences, university of cape town, south africa primrose t. nhokwara department of health and rehabilitation sciences, division of communications sciences and disorder, university of cape town, south africa christine rogers department of health and rehabilitation sciences, division of communication sciences and disorders, university of cape town, south africa citation ramma, l., nhokwara, p.t., & rogers, c. (2019). statistical factors associated with utilisation of ototoxicity monitoring services for multi-drug-resistant tuberculosis patients in the western cape. south african journal of communication disorders, 66(1), a596. https://doi.org/10.4102/sajcd.v66i1.596 original research statistical factors associated with utilisation of ototoxicity monitoring services for multi-drug-resistant tuberculosis patients in the western cape lebogang ramma, primrose t. nhokwara, christine rogers received: 31 mar. 2018; accepted: 09 oct. 2018; published: 30 jan. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: south africa is a high-burden multi-drug-resistant tuberculosis (mdr-tb) country. previously, standard mdr-tb treatment regimen in south africa included kanamycin, an aminoglycoside, which can cause permanent hearing loss in patients. south african national tuberculosis control programme’s guidelines for the management of patients with mdr-tb were revised in 2011 to support outpatient-based models. this, in turn, required reorganisation of ototoxicity monitoring services to support these new models of service delivery. objectives: the aim of this study was to determine factors associated with the utilisation of ototoxicity monitoring services for patients with mdr-tb who accessed treatment as outpatients. method: a retrospective review of medical records of patients who attended ototoxicity monitoring clinic at a central tb hospital in cape town during 2012–2013 was conducted. a total of 801 medical folders were reviewed: 415 (51.8%) males and 386 (48.2%) females, median age 37 (range 7–85) years. results: ten per cent of patients attended all the recommended six-monthly appointments. patients who presented with hearing loss at baseline or developed hearing loss after treatment initiation were more likely to attend their appointments. patients were also more likely to attend their appointments if a baseline audiometric assessment was conducted within 1 month of mdr-tb treatment initiation. conclusion: this study revealed that outpatient-based ototoxicity monitoring services were largely underutilised by patients. development of hearing loss and prompt determination of a baseline audiogram were associated with a higher likelihood of attendance of ototoxicity monitoring appointments. therefore, utilisation of outpatient-based ototoxicity monitoring services is likely to be improved by identifying patients early and monitoring them closely. introduction south africa is ranked third among the 22 high-burden tuberculosis (tb) countries. the latest (2017) world health organisation (who) report estimated that tb incidence in south africa is approximately 781 (95% ci, 543–1060) or more cases per 100 000 people, thus making it a country with one of the highest incidence rates of tb in the world (who, 2017). south africa also has the second highest number of patients diagnosed with either mdr-tb or rifampicin-resistant tuberculosis (rr-tb) globally (churchyard et al., 2014). the who estimated that the annual rr-tb or mdr-tb incidence rate in south africa is about 34 (95% ci, 22–45) per 100 000 people or 3.4% (95% ci, 2.5% – 4.3%) and 7.1% (95% ci, 4.8% – 9.5%) among new and retreatment tb cases, respectively. latest data showed at least 19 073 laboratory confirmed cases of rr-tb or mdr-tb during 2016 (who, 2017). the who’s recommended second-line drugs to be used for treating mdr-tb still include amikacin and kanamycin, both aminoglycoside antibiotics (who, 2016). until 2018, the south african mdr-tb treatment regimen also included kanamycin, an aminoglycoside antibiotic with many significant side effects (department of health [doh], 2013; duggal & sarkar, 2007). one of the most common adverse effects resulting from treatment with kanamycin is permanent sensorineural hearing loss (snhl). incidence of permanent snhl has been reported to be up to 57% in a group of south african mdr-tb patients and may vary in severity from slight to profound (harris, peer, & fagan, 2012; ramma & ibekwe, 2012). hearing loss, if it affects frequencies that are important for speech perception, is associated with marked communication difficulties (arlinger, 2003). if left untreated, these communication difficulties may result in social isolation, feelings of exclusion, reduction in social activity, depression, anxiety and negatively impact on the socio-emotional well-being of those affected (manrique-huarte et al., 2016). in recognition of this high risk of developing hearing loss, and to avoid potentially negative consequences that could result from mdr-tb treatment-induced hearing loss, south african treatment guidelines for mdr-tb require that patients’ hearing thresholds be monitored (i.e. ototoxicity monitoring) when they are treated with a regimen that includes kanamycin (department of health, 2013). the health professions council of south africa’s (hpcsa) guidelines on the management of patients who are treated with drugs that include ototoxic medications also recommend ototoxicity monitoring for patients treated with drugs such as kanamycin (hpcsa, 2018). ototoxicity monitoring involves scheduled, repeated audiometric assessment of patients’ hearing thresholds over time. changes in hearing status allow review of drug regimens and management of any hearing loss that may result because of treatment (dinnes, hewison, altman, & deeks, 2012; hpcsa, 2018). prior to 2011, national policy guidelines in south africa on the management of mdr-tb mandated that all mdr-tb patients be initiated on treatment only after they had been admitted to the country’s few specialised tb hospitals (department of health, 2013). it was relatively easy to provide ototoxicity monitoring services for these patients, as they were institutionalised and, therefore, available. however, in 2011, policy guidelines for the management of patients with drug-resistant tb were revised to support outpatient-based mdr-tb treatment services (including ototoxicity monitoring). outpatient-based mdr-tb treatment meant that patients could now access services as outpatients in a facility nearest to them, instead of centralised tb hospitals. decentralisation was expected to lead to better access to ototoxicity monitoring by patients because of close proximity of services to those who need them. proximity to facilities has been reported elsewhere to be an important factor in increasing health seeking and utilisation of services (al-mandhari et al., 2008; lavella et al., 2004). some studies have reported on other factors besides geographical proximity that can influence utilisation of service. for instance, vaidya et al. (2012) reported on the influence of sex and likelihood of utilising health care services; women generally tend to have higher service utilisation rates when compared with men. this study therefore aimed to describe utilisation patterns and determine factors associated with the utilisation of ototoxicity monitoring services when provided as outpatient services. materials and methods this was a descriptive, retrospective review of medical records of all patients who accessed outpatient-based ototoxicity monitoring services during january 2012 to march 2013 at brooklyn chest tb hospital (bch) in cape town. at the time of this study (2012–2013), patients in the western cape were already receiving their daily mdr-tb treatment (directly observed treatment [dot]) at their nearest primary health care clinics. patients who lived closer to bch were usually referred by their facilities to the hospital for ototoxicity monitoring. in addition, some patients were required to come to bch once a month for a follow-up appointment with a specialist mdr-tb doctor who was based there. hospital protocol required audiometric assessment (ototoxicity monitoring) at the start of patients’ mdr-tb treatment and during their monthly follow-up appointments with the doctor. ototoxicity monitoring protocol at the hospital was as follows: identification of patients by the medical and nursing staff during mdr-tb treatment initiation and referral to audiology for baseline audiogram. baseline audiometric assessments included otoscopic examination, tympanometry and pure tone audiometry (air conduction [ac]: 250 hz – 8000 hz and bone conduction [bc]: 250 hz – 4000 hz). patients were monitored once a month (over a 6-month period) at a time when they came for their monthly follow-up appointment with the doctor. monthly audiometric monitoring tests included otoscopic examination and pure tone ac from 250 hz to 8000 hz. patients who showed a significant hearing threshold shift (sts) following treatment initiation underwent a comprehensive audiometric evaluation (tests administered at baseline) and were referred back to the doctor for medical management. monitoring intensity in patients who showed a significant sts increased to biweekly instead of monthly. patients who developed a disabling hearing loss were managed according to the hospital’s aural rehabilitation protocol (amplification, communication repair strategies and auditory training as indicated). an sts posttreatment initiation was defined according to the american speech and hearing association’s (asha) 1994 criteria; the presence or absence of hearing loss was defined according to margolis and saly (2007) classification (i.e. pure tone average [pta]: 0.5 khz, 1 khz and 2 khz] ≤25 db hl = no hearing loss, pta: 0.5 khz, 1 khz and 2 khz ≥26 db hl = hearing loss) and disabling hearing loss was defined as a hearing loss >40 db hl (pta: 0.5 khz, 1 khz, 2 khz and 4 khz) in the better ear (adults) (who, 2014). descriptive statistics (means and medians) were used to describe central tendencies in the data. log-binomial regression (generalised linear modelling) (p < 0.05) was used to determine variables associated with the likelihood of attending a scheduled appointment for ototoxicity monitoring. data were analysed using the statistical programme stata (release 13) (stata corp, 2013). ethical consideration ethical clearance was sought and obtained from the university of cape town’s faculty of health sciences health research ethics committee prior to the commencement of data collection (hrec ref: 604/2012). permission was granted from the provincial department of health and the management of the hospital facility before conducting the study. only records of patients who had a confirmed diagnosis of mdr-tb, and attended ototoxicity monitoring services at least once during the review period, were included for review. patients’ records with missing information (e.g. drug regimen) and records of xdr-tb patients were excluded. relevant data from patients’ medical folders, demographics, mdr-tb treatment and audiometric data were recorded into a password-protected excel spreadsheet for analysis at a later stage. results patients’ description a total of 801 patient medical folders were accessed for review in this study. there was an equal proportion of males and females; most of the patients were from within the cape town metropolitan area; the majority were treated with kanamycin (as the only aminoglycoside) (table 1). table 1: summary of patient description (n = 801). an analysis of the pattern of attendance of scheduled appointments was also conducted, and it was found that only 10% of the patients attended all of the recommended six appointments for ototoxicity monitoring that they were scheduled to attend (figure 1). figure 1: pattern of attendance of scheduled ototoxicity monitoring appointments. relative risk estimation by log-binomial regression (p < 0.05) was used to investigate the association between different variables and likelihood of attending a scheduled appointment for ototoxicity monitoring. it was found that the longer the time taken to conduct baseline audiometry assessment after treatment initiation, the less likely the patients were to utilise the services. in terms of hearing thresholds, compared to those with a hearing loss at the time of initial hearing assessment, those with normal hearing were 30% less likely to attend (rr 0.7 [95% ci, 0.6–0.9], p = 0.02) a scheduled visit. those who developed hearing loss during the course of treatment were 60% more likely to attend when compared with those who did not develop hearing loss (rr 1.6 [95% ci, 1.3–2.2], p = 0.0). patients with a disabling hearing loss were 120% times more likely to attend their scheduled appointment for ototoxicity monitoring than those without a disabling hearing loss (rr 2.2 [95% ci, 1.7–2.8], p = 0.0). age, sex, treatment regimen and proximity of referral area to the facility where services were accessed were not associated with whether the patient will attend their appointment or not (see table 2). table 2: variables associated with regular attendance of scheduled ototoxicity monitoring appointments (i.e. 4–6 visits). discussion this study showed that an overwhelming majority (90%) of patients did not attend the recommended number of ototoxicity monitoring visits when services were provided on an outpatient basis. patients were more likely to utilise the services if a baseline audiometric assessment was conducted within a month of initiating treatment, they had a pre-existing hearing loss (pta0.5–2 khz ≥26 db hl) at baseline or they developed hearing loss during the course of treatment. interestingly, a close proximity between the patient’s area of residence and the facility was not associated with a higher likelihood of attending scheduled appointments. only about 10% (9.6%) of the patients whose medical folders were reviewed attended all of the recommended six ototoxicity monitoring appointments as per protocol at the facility where services were provided. at the time of this study, patients on mdr-tb treatment were at the highest risk of ototoxicity-induced hearing loss during the first 4–6 months (intensive phase) of their treatment when they were undergoing daily kanamycin injections (tb alliance, 2015; who, 2017). therefore, a protocol at the facility required that these patients undergo monthly audiometric assessment during the first 6 months of treatment to monitor their hearing thresholds. duggal and sarkar (2007) recommended that these patients should ideally be monitored throughout the course of treatment and then for up to 6 months posttreatment with ototoxic aminoglycoside because of the propensity for ototoxic hearing loss to continue to progress even after the use of these drugs has been withdrawn or discontinued. it is apparent that an opportunity has been missed to actively manage patients with possible ototoxic hearing loss. patients were more likely to attend their scheduled ototoxicity monitoring visits if a baseline audiometric assessment was conducted before, or shortly after they initiated mdr-tb treatment. the recently published hpcsa ototoxicity monitoring guidelines recommend that a baseline assessment be conducted before or within 72 hours of treatment with ototoxic aminoglycoside such as kanamycin (hpcsa, 2018). baseline assessments assist in defining any pre-existing hearing loss, which is a risk factor for further deterioration of hearing thresholds as a result of aminoglycoside exposure. a baseline assessment also enables comparison with subsequent tests to evaluate whether ototoxicity has occurred (durrant et al., 2009). therefore, it is important to identify patients early, conduct baseline assessments and provide them with information that will empower them to use ototoxicity monitoring services. it was also found that patients who presented with hearing loss (i.e. pta0.5–2 khz ≥26 db hl) at baseline; patients who developed hearing loss during treatment and those with disabling hearing loss were more likely to use ototoxicity monitoring services when compared to patients with normal hearing thresholds. this was consistent with reports from previous studies, which reported that patients who perceive themselves to have a hearing loss are likely to seek intervention for their problem (meyer & hickson, 2012; ramma & sebothoma, 2017). garstecki and erler (1998) also reported that individuals who had a severe degree of hearing loss were likely to adhere to ototoxicity monitoring services, thus supporting the notion that hearing loss, especially when severe, is a motivating factor for adherence to recommended ototoxicity monitoring services. a study by vaidya et al. (2012) suggested that there is a difference between males and females when it comes to health care service utilisation, with a higher uptake in women. however, there was no significant difference in the patterns of utilisation of the services between men and women in the current study. differences in service utilisation could be because of the fact that for some types of health care services, women have higher utilisation rates than men (gerritsen & devillé, 2009). ototoxicity monitoring, therefore, could be an example of the type of services where there is no significant difference in service utilisation between sexes. an unexpected finding in this study was the lack of association between a close proximity of patients’ place of residence (based on area of referral) to the health facility and the likelihood of using outpatient-based ototoxicity monitoring services. close proximity facilitates utilisation of health care services (al-mandhari et al., 2008; lavella et al., 2004), while conversely distance may act as a barrier when services are remote from where the individuals reside (fujita et al., 2017; nteta et al., 2010). it was, therefore, expected that patients who lived closer to health care facility (i.e. better geographical access) would show higher utilisation rates for ototoxicity monitoring services. however, in this study it was found that proximity to health facility was not necessarily associated with a higher utilisation of ototoxicity monitoring services. these findings seem to suggest that simply making services available closer to patients may not be sufficient to ensure high uptake of services. other interventions such as active campaigns to inform patients (zamawe, banda, & dube, 2016) about the value of ototoxicity monitoring services and improving the quality (audo, ferguson, & njoroge, 2005) of these services may be required to increase patients’ utilisation. thus, quality of the service, comprehensive follow-up and patient empowerment are important considerations for future roll-out of outpatient-based ototoxicity audiology services. this was one of the first studies conducted in south africa to systematically evaluate the utilisation of outpatient-based ototoxicity monitoring for mdr-tb patients. therefore, it gave insights that can inform future decentralised service delivery models for audiology services in general. however, the study also had several limitations related to its design. firstly, the nature of the study was a retrospective record review. secondly, because it was a descriptive quantitative study, the reasons for underutilisation could not be ascertained from the records. thirdly, the study was conducted during the early phases of decentralisation of mdr-tb treatment, and the health system was still undergoing a series of modifications to enable this new model of service provision (i.e. outpatient mdr-tb treatment). however, positive developments have occurred in the past 5 years to improve access to ototoxicity monitoring at primary care facilities. these include employing more audiologists dedicated to the provision of ototoxicity monitoring for mdr-tb patients, a national roll-out of a portable audiometry programme to enable audiometric assessments at primary health care facilities as well as involvement of non-audiology personnel (e.g. mdr-tb nursing sisters) in audiometric assessment for ototoxicity monitoring (mngemane, ndjeka, & ramma, 2017). more importantly, a recent (2018) announcement to introduce a kanamycin-free treatment regimen for mdr-tb (medecins sans frontieres, 2018) by the south african national department of health will change how ototoxicity monitoring occurs (if any) in these patients. it is, therefore, highly likely that these interventions have significantly changed utilisation patterns for ototoxicity monitoring services under a decentralised model of mdr-tb treatment model. conclusion the findings of this study showed that centrally located outpatient-based ototoxicity monitoring services for mdr-tb patients were significantly underutilised by patients. the services also lacked responsiveness, as shown by most of the patients in this study getting their baseline audiological assessment more than a month after they initiated treatment. the duration between treatment initiation and baseline audiometry assessment, pre-existing hearing loss at baseline audiological assessment, development of ototoxic hearing loss during treatment and the development of disabling hearing loss were all associated with a higher likelihood of adhering to the recommended ototoxicity monitoring plan. proximity to services (or facility) was not necessarily associated with higher likelihood of utilisation of services. it is, therefore, recommended that interventions aimed at improving uptake of outpatient-based ototoxicity monitoring services must aim to conduct a baseline assessment before or within the recommended 72-h posttreatment initiation. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contribution l.r. was responsible for conceptualisation of the project and wrote the original and final draft of the manuscript. p.n. collected and analysed the data and reviewed all manuscript drafts. c.r. supervised the project and reviewed and edited all manuscript drafts. references al-mandhari, a., al-adawi, s., al-zakwani, i., al-shafaee, m., & eloul, l. 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(2015). the effect of mass media campaign on men’s participation in maternal health: a cross-sectional study in malawi. reproductive health, 12, 31. https://doi.org/10.1186/s12978-015-0020-0 abstract introduction background demystifying mixed-methods research critical appraisal of mixed-methods research the mixed-methods research procedure critical review of mixed-methods research conclusion acknowledgements references about the author(s) anna-marie wium discipline speech-language pathology and audiology, sefako makgatho health sciences university, south africa brenda louw department of audiology and speech-language pathology, college of clinical and rehabilitative health sciences, east tennessee state university, united states citation wium, a-m. & louw, b. (2018). mixed-methods research: a tutorial for speech-language therapists and audiologists in south africa. south african journal of communication disorders, 65(1), a573. https://doi.org/10.4102/sajcd.v65i1.573 original research mixed-methods research: a tutorial for speech-language therapists and audiologists in south africa anna-marie wium, brenda louw received: 14 aug. 2017; accepted: 08 may 2018; published: 12 july 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: mixed-methods research (mmr) offers much to healthcare professions on clinical and research levels. speech-language therapists and audiologists work in both educational and health settings where they deal with real-world problems. through the nature of their work, they are confronted with multifaceted questions arising from their efforts to provide evidence-based services to individuals of all ages with communication disorders. mmr methods research is eminently suited to addressing such questions. objective: the aim of this tutorial is to increase awareness of the value of mmr, especially for readers less familiar with this research approach. method: a literature review was conducted to provide an overview of the key issues in mmr. the tutorial discusses the various issues to be considered in the critical appraisal of mmr, followed by an explanation of the process of conducting mmr. a critical review describes the strengths and challenges in mmr. results: mmr is less commonly used or published in the fields of speech-language therapy and audiology. conclusion: researchers working in teams can draw on the strengths of different disciples and their research approaches. such collaborative enterprises will contribute to capacity building. researchers, slts and audiologists are encouraged to make use of mmr to address the complex research issues in the multicultural, multifaceted south african context. mmr makes an important contribution to the understanding of individuals with communication disorders, and in turn, researchers in the two disciplinary fields of speech-language therapy and audiology can contribute to the development of this research approach. mmr is well suited to the complexity of south african contexts and its populations, as it can provide multiple perspectives of a topic. introduction traditionally, the emphasis in research in the fields of speech-language therapy and audiology has been on quantitative research, in large part as a result of the medical model that dominated the field for many years. the qualitative research paradigm started to gain popularity in the late 1980s shifting to a more biopsychosocial approach as propagated by the world health organization (2001). this shift was brought about by research becoming more person-centred, as well as by the impact of qualitative research in fields such as education, social sciences and psychology. mixed-methods research (mmr) is a more recent development in the research arena and can make an important contribution to the understanding of individuals with communication disorders. research in the disciplines of speech-language therapy and audiology continues to evolve as methodological developments occur, which impact researchers and clinicians alike. johnson, onwuegbuzie and turner (2007) discuss many definitions for mmr, but for the purpose of this discussion the explanation by creswell and plano clark (2011) was deemed to be the most explanatory. mixed-methods research is a research approach or methodology focusing on: research questions that call for real-life contextual understanding, multilevel perspectives and cultural influences employs rigorous quantitative research assessing the magnitude and frequency of constructs and rigorous qualitative research exploring the meaning and understanding of constructs utilises multiple methods (e.g. intervention trials and in-depth interviews) intentionally integrates or combines these methods to draw on the strengths of each and framing the investigation within philosophical and theoretical positions. yin (2006) described high-quality mmr as studies where the mixing occurs from formulating the research questions right through to the interpretation of findings. not all mmr is reported as such as many studies may include only a small component from one of the methods (e.g. a few open-ended questions in a mainly closed-ended questionnaire to enhance the findings). the assumption in mmr is that the use of quantitative and qualitative approaches in combination provides a better understanding of research problems than either approach alone (creswell & plano clark, 2007). mixed-methods research collects and analyses data, integrates the findings and draws inferences using both qualitative and quantitative approaches in a single study or programme of inquiry (creswell, klassen, plano clark, & clegg smith, 2011). mixed-methods research is a relatively new approach in the fields of speech-language therapy and audiology and has been under-represented in these disciplines as compared, to mono-method approaches. suleman and hopper (2014) reported that less than 1.2% of studies published in the four most prominent speech-language therapy and audiology journals in the united states and canada during the period 2007–2011, used an mmr approach. an electronic search of the term mixed-method or quantitative and qualitative through the aosis search engine in the south african journal of communication disorders over the past 10 years showed that 12 articles have been published from mmr studies, of which eight articles reported on both quantitative and qualitative findings, and four articles reported findings from single methods, but stated that it was part of a larger mmr project and/or study through findings from an electronic search may not be as exact as a paper search, it does give an indication of a scarcity of such research in the field. there appears to be some uncertainty as to what can be considered as mmr and what such studies entail. many studies that incorporate both quantitative and qualitative methods for data collection do not include the term mmr in the title of the research (refer to table 1). it is also noted that when such a term is included in the title, and both quantitative and qualitative methods are included in the research, the researchers rarely explain how the two methods have been integrated (hashemi & babaii, 2013), or where in the research process the mixing did occur (azul, arnold, & neushaefer-rube, 2018). table 1: mixed-methods research articles published in the south african journal of communication disorders (2008–2018). researchers also tend to report results obtained from mmr as a single method (refer to table 1), as if two separate studies were conducted within one topic. the reason to do this may be attributed to the length of such studies that makes it difficult to keep to word count restrictions stipulated by most journals. another reason for confusion is that studies are referred to as mmr when questionnaires are used with mainly closed-ended questions but with a single open-ended question included at the end (bryman, becker, & sempik, 2008). considering these aforementioned reasons for confusion, some clarification is required for researchers and clinicians in terms of mmr concepts and methods. the aim of this tutorial is to provide researchers, speech-language therapists and audiologists with an overview of mmr to serve as alternative to the traditional quantitative and qualitative research approaches in their pursuit of evidence-based practice (ebp). based on a comprehensive and in-depth literature review, the tutorial firstly provides a background that explains mmr in terms of the philosophy and its relationship to ebp. next, the definition and clarification of concepts, as well as the characteristics of mmr are explained. the article discusses the various issues to be considered in the critical appraisal of mmr, followed by a description of the process of conducting mmr. a critical review of mmr describes the advantages, as well as the controversies and challenges in mmr. lastly, a conclusion highlights the importance of mmr for the disciplines of speech-language therapy and audiology. background as a methodology, mmr involves philosophical assumptions that guide the direction of the collection and analysis of data and the mixture of qualitative and quantitative data in a single study or series of studies. philosophical underpinnings of mixed-methods research new methodologies evolved that combine and integrate quantitative and qualitative research approaches, which open up more possibilities in answering specific research questions (glogowska, 2011). in studies where specific health issues of a population need to be assessed, it calls for counting and measuring or comparing, which rely on quantitative inquiries. qualitative approaches are in turn more suitable whenever explanations for certain phenomena are called for (e.g. when clients’ understanding of their problems needs to be determined, their perceptions of treatments are sought or the determination of how services have been delivered). when considering the nature of the research, there are definite differences between quantitative, qualitative and mmr approaches (creswell & plano clark, 2007; tashakkori & teddlie, 2010). in terms of the nature of reasoning (ontology), quantitative research is deductive, whereas qualitative research is adductive. between these two ontologies, mmr is inductive. when considering the nature of reality (axiology), quantitative research has a single reality view, as opposed to qualitative research where multiple views of reality exist. mixed-methods research draws from both these realities as it includes both single and multiple realities. in terms of the epistemology, the nature of knowing in quantitative research is objective, as opposed to qualitative research, where the nature of knowing is subjective. once again mmr takes the middle ground as the nature of knowing is intersubjective. the role of values in the interpretation of results also differs, as quantitative researchers strive to be unbiased and take precautions to avoid bias, which is different from qualitative research where the researchers are integrally part of the research and, therefore, are fundamentally biased. in mmr, the interpretation of findings is both biased and unbiased as both quantitative and qualitative methods are used. however, in mmr, care is taken to limit bias by putting specific measures in place. in the interpretation of results, quantitative results can be generalised because of the sample size and selection methods being used, which is not the case in qualitative research where smaller samples are typically used which makes the findings more context specific. in mmr, the findings are transferrable to similar contexts and population groups because thick descriptions are used in the qualitative strand and also because a sufficient sample size is being used in the quantitative strand. the three research approaches also differ in terms of causality: in quantitative research the cause results in effect, whereas in qualitative research the cause cannot be isolated from the effect. in mmr, causality cannot be determined. it can, therefore, be concluded that because both the quantitative and qualitative approaches are included in mmr, it has a unique underlying philosophy that is based in the common ground between these two methodologies. in the case of mmr, the claim of knowledge (philosophical assumption) often is pragmatic because the rigid interpretations of methodologies have begun to fade (onwuegbuzie & dickinson, 2007). christ (2013) shows the relevance of a critical realist stance and how these two approaches are very similar in practical terms. mertens (2011) provides insights into a more transformative paradigm for whenever researchers show concern for priority on social justice and the furtherance of human rights. other alternatives include the dialectical position (johnson et al., 2007) or the critical interpretive view (denzin & lincoln, 2005). these philosophical positions need not be compared as it is evident that the mixing of methods could contribute to a better understanding of the research question (hashemi & babaii, 2013). in short, mixed research acknowledges a meta-paradigmatic existence. research in speech-language therapy and audiology aims to not only accumulate knowledge concerning communication and its disorders but also consider the therapeutic issues that could improve the quality of life of individuals with communication disorders. such knowledge should inform practice. evidence-based practice emerged as an important principle in the delivery of speech-language therapy and audiology services in the past decade (american speech-language-hearing association, 2005). evidence-based practice and implementation science evidence-based practice involves the integration of best current research evidence, clinical expertise and the needs, abilities, values, preferences and interests of clients and their families in making clinical decisions to provide high-quality services and, therefore, ebp is central to the disciplines of speech-language therapy and audiology (american speech-language-hearing-association, 2005). the trilateral principles forming the basis for ebp (american speech-language-hearing association, 2005) are illustrated in figure 1, with emphasis on the research evidence. figure 1: evidence-based practice. however, a gap often exists in the application of knowledge to practice, which opens up the field of implementation science (olswang & prelock, 2015), which focuses on research methods that facilitate the systematic application of research to practice in both the health and education sectors. such research identifies, defines and evaluates the strategies used in the treatment of communication disorders and requires the use of both quantitative and qualitative data (olswang & prelock, 2015). implementation science and ebp have led to an increased need for applied clinical research in the speech-language therapy and audiology disciplines to answer multiple questions that are related to the ‘what?’, ‘why?’ and ‘how?’ of assessment and intervention, for which a variety of quantitative and qualitative data or both are required. systematic reviews were developed to support ebp and can be performed on mmr by analysing both quantitative and qualitative research evidence. in this case, it is necessary for data analyses to be carried out separately in order to ensure the integrity of the research. mixed-method systematic reviews are suitable to understand the barriers and facilitators to the implementation of certain interventions, to assess cost-effectiveness and to address the core competencies of practitioners. these systematic reviews add important value to traditional systematic reviews as the inclusion of qualitative studies provides a greater understanding of the appropriateness of an intervention beyond documentation of its effectiveness (orlikoff, schiavetti, & metz, 2015). mixed-methods research provides the opportunity to seek answers to complex clinical questions and to explore evidence from both quantitative and qualitative perspectives in the pursuit of improving outcomes. it is important for speech-language therapists and audiologists to be cognisant of the mmr approach and how it can be applied in ebp. demystifying mixed-methods research mixed-methods research is often criticised for a lack of a common definition, confusing terminology and limited guidelines for when it is suitable to select mmr methods (creswell, 2013). the question arises as to when to select a mmr approach? when is mixed-methods research suitable? the most probable answers to this question are when either the quantitative or the qualitative methods by itself appear to be inadequate to create a complete understanding of the research problem, or to develop multiple perspectives of a phenomenon, for example, when quantitative outcome measures are enhanced or explained by using qualitative data. on the other hand, a qualitative exploration, for example, a focus group discussion prior to the development of an instrument or measurement tool, may inform the contents and approach thereof. creswell and plano clark (2011) identified further reasons for using mmr, such as when information needs to be contextualised and it may be necessary to obtain a macro picture of a system (e.g. a school or hospital). it could be that the researcher might want to develop a complementary picture; to compare, validate or triangulate results; to provide an illustration of context and trends; or to examine process or experiences along with outcomes. mixed-methods research may also be useful when one database needs to be built on another, or when one method is failing and the second method can be used to rescue the study. according to glogowska (2011), mmr is a good option when conducting research on marginalised groups as it provides them with a voice when research is conducted concerning them, which in effect is empowering them. novice researchers need to understand the terms and concepts, as well as the characteristics and notations used in mmr before applying the approach. clarification of terms and concepts in mixed-methods research several terms are used to describe the nature and extent of mixing methods (e.g. mixing, combining and integrating), and these are often used interchangeably (creswell, plano clark, gutmann, & hanson, 2003; teddlie & tashakkori, 2003). for clarity, such multiple method designs can be described as either mixed-methods designs or multimethod research. these two concepts should not be confused. in multimethod research, the research question is answered by using two data collection procedures or methods, each from the same quantitative and qualitative traditions and is known as either a multimethod qualitative study or a multimethod quantitative study. mixed-method designs can either be mmr or mixed-model research. for instance: mixed-methods research is where the mixing occurs in the methods stage of the study and it can be on a continuum from simple to complex (onwuegbuzie & johnson, 2006). the qualitative and quantitative data collection and analysis are performed in either parallel or sequential phases. the term combining methods refers to a situation where one method paves the way for the other, or follows the first method in an effort to help or assist towards the planned outcomes or intention of the research. in this case, the two approaches are not weighted equally. integrating methods is used when the methods are kept separate at the paradigm level, but are interlinked with each other as it looks at the same phenomenon from two different perspectives to create a more comprehensive view of the phenomenon (woolley, 2009). the integration can occur any time from the very beginning or towards the end when the results are written up (glogowska, 2011). it may be that sampling and data collection are carried out separately, but that the integration occurs during data analysis, interpretation or theory generation. the study by abdoola, flack and karrim (2017) that facilitated pragmatic skills through role-play in learners with language-learning disability kept the two sets of data separate and only integrated them at the reporting level through a weaving approach. mixed-model research is where the mixing occurs in all stages of the study (the research question, methods, data collection and analysis and inference processes). mixed-methods research: characteristics and notations there are definite differences that distinguish mmr from mono-method designs (garuth, 2013). in mmr, the researchers should offer a rationale for using both quantitative and qualitative methods in the research and also clearly state that both quantitative and qualitative data have been collected. there needs to be a clear statement that indicates which method carries more weight and what the sequence of data collection procedures is (i.e. sequential or concurrent). the analysis of data is related to a specific design type (e.g. convergent, explanatory, exploratory or embedded design), although not limited to these. in mmr, a diagram is provided that shows the procedures used in the study (creswell and plano clarke 2011), morse (1991) provided mixed-methods notations that are useful for representing the different designs which are referred to in the literature. the use of upper case refers to emphasis (i.e. the primary or dominant method), whereas the use of lower case refers to lower emphasis, priority or dominance: quan or quan refers to quantitative data qual or qual refers to qualitative data mm refers to mixed-methods → data collected sequentially + data collected simultaneously = converged data collection ( ) one method embedded in the other. knowledge of the notation system used in mmr makes it easier to read and to critically appraise such studies. critical appraisal of mixed-methods research speech-language therapists and audiologists are required to critically appraise research before selecting the findings for making ebp decisions. many research studies include both quantitative and qualitative data collection and analysis methods. the quality of research depends on how well the accepted form for both qualitative and quantitative research designs is followed (garuth, 2013). the following steps and guidelines are proposed for readers when conducting a critical appraisal of mmr. initial identification it is recommended that the process be initiated by performing a general screening procedure that involves scanning the abstract and methodology sections of an article to determine where in the research process the mixing occurred (e.g. at the research questions stage, the sampling stage, the data collection or analyses). it is important to search for key words that refer to terms, for example, mixedor multimethods, or qualitative, quantitative, triangulation, integrating methods, and combining methods. once the initial scanning process has been completed it is necessary to conduct a rigorous content analysis to look for rich descriptions of the content, particularly on how the mixing and/or combining was performed. at this stage of the appraisal, it is necessary to identify the design of the study, the type of sampling and the data collection and analysis. next, one has to consider issues of validity and whether there are any signs of using meta-inferences that could indicate inference quality (tashakkori & teddlie, 2010). identification of the mixed-methods research designs the second step in the critical appraisal of mmr is to identify the research design and to ensure that a pattern is used throughout the research. the specific mixed-methods design is determined by two main factors (tashakkori & teddlie, 1998; creswell, 2003; onwuegbuzie & dickinson, 2007): (1) priority of weight, where equal weight can be allocated to both quantitative and qualitative aspects, or alternatively, different weights can be given; (2) order of data collection, which refers to the order in which qualitative and quantitative data can be collected. creswell et al. (2011) classified mmr designs as not only concurrent or sequential, but also transformative. concurrent designs: are when quantitative and qualitative data are collected at the same time. such designs are referred to as simultaneous, concurrent, convergent, or parallel designs (irwin, pannbacker, & lass, 2014). the two subtypes are: concurrent triangulation designs: concurrent (convergent) procedures are used to converge quantitative and qualitative data in order to provide a comprehensive analysis of the problem. in this case, the qualitative and quantitative data are collected simultaneously. the results are then integrated in the final interpretation. merging of quan and qual results occurs during the analysis or interpretation to provide an integrated conclusion and involves comparing, contrasting and synthesising the two strands (creswell & plano clark, 2011). for example, overby, carrell and bernthal (2007) investigated second-grade teachers’ perceptions of the academic, social and behavioural competence of second-grade students with speech-sound disorders (ssds) by converging quantitative results with qualitative detail using a concurrent mmr design. concurrent designs may also comprise data being collected by using both open-ended and close-ended questions with a survey instrument (creswell & plano clark, 2011), such as was employed by teixeira and joubert (2014) in their descriptive, cross-sectional survey to describe the availability of clinical audiological equipment and protocols used in gauteng. bedwinek, kummer, rice and grames (2010) explored preschool and school-based speech-language therapists’ assessment and treatment practices of children with cleft lip and palate to determine continuing education needs in this area. quantitative data were collected through a survey using likert-type scales and responses analysed descriptively. the qualitative data were collected concurrently using open-ended questions that were designed to be complementary to quantitative questions. thematic analyses were used to examine and interpret the responses to the open-ended questions. a similar example can be found in a study that described the poor consistency in evaluating south african adults with neurogenic dysphagia, where the small qualitative component collected concurrently in a mainly closed-ended questionnaire was subjected to textual analyses and themes were coded into numerical values (andrews & pillay, 2017). concurrent embedded design: in concurrent (convergent) designs, one form of data collection is often nested within another (larger) data collection procedure to analyse different questions or levels of units creswell et al. (2011) for example: qual + quan; quan + qual. the primary purpose is to enhance the traditional qual or quan design (creswell, 2013). in this case, the two components have unequal weighting and the timing could be either concurrent or sequential. these designs can be configured as either that the quan is emphasised and the qual is supplemental, or vice versa. embedded designs have two research questions, which should be answered separately. the supplemental data set should answer the second research question. danzak (2011a), for example, first reported the quan component of her research, which was on writing samples from english language learners that were analysed for linguistic complexity to establish a difference between english and spanish. in the second article based on the qualitative component, the author reported on the analyses of english language learners’ journal entries to determine the impact of literacy experiences as bilingual writers (danzak, 2011b). similarly, wium (2010) developed a support programme for foundation-phase teachers to facilitate literacy and numeracy skills, which was evaluated using a variety of quantitative and qualitative methods. quan data were collected with questionnaires from 96 participants to determine how the programme was implemented in two different contexts, together with portfolio assessments. in an embedded design, qualitative data were collected from six focus groups (qual) consisting of six participants each who were selected from the larger group, as well as journal entries to determine how the participants experienced the programme. as the primary and secondary data in these designs addressed distinct questions, the results were collected separately and were reported on separately, which were different but related. the integration occurred when qualitative data were transformed to be compared with quantitative data in table format to answer the specific research questions (wium, louw, & eloff, 2010). the quantification of qualitative data for comparison with quantitative data has been described by creswell (2003) and is considered as an acceptable method of data integration in mmr, although this practice may be considered as controversial by some qualitative researchers. sequential designs: these types of designs lend themselves to studies where the quan and qual components are not equal in weight and data are collected sequentially in phases, where the first phase informs the second phase. these designs provide a summary of both sets of results with a discussion on how the second phase confirmed or expanded on the first phase (creswell & plano clark, 2011). the mixing occurs in the interpretation. the two types of sequential designs are the following: sequential explanatory design: an alternative is the explanatory design (quan → qual), where one would start off with a quantitative method to test theories or concepts, and then to follow up with qualitative methods with a small group of participants to explore the issues further (creswell & plano clark, 2011). an example would be where participants with hearing loss are asked to rate their conversational abilities before and after an aural rehabilitation programme (quan). some of these participants will then be interviewed individually afterwards to discuss the reasons for their ratings (qual) (suleman & hopper, 2014). sequential exploratory design: the qualitative strand helps to develop or inform the quantitative strand and to connect the data between the two phases (e.g. in instrument design, theory building or testing). the emphasis usually is on qual, but can be quan, or it can be equal. the mixing occurs in the interpretation of the results – (qual → quan). the qual part of the study will provide information to uncover variables of interest. the second phase would be where the quan phase is used to develop the tool from the results obtained in the first phase. a focus group in a school could explore how teachers determine perceived barriers to receive speech-language services at their schools (qual), and then these ideas will be used to conduct a large-scale survey in a district by asking the participants to rate the impact of predetermined barriers (quan) (suleman & hopper, 2014). another example could be found in a study by langevin, packman and onslow (2009), where the researchers determined whether specific characteristics of participants’ stuttering patterns elicited negative peer responses by firstly transcribing play sessions (qual) and then went on to analyse stuttering behaviours, durations of stutters and judgements of the meaningfulness of peer-directed stuttered utterances (qual → quan). research sampling the third step in the critical appraisal of mmr is to review the sampling process. collins, onwuegbuzie and sutton (2006) described a model for mmr sampling, which categorise sampling designs according to the time orientation of the components and the relationship of the qualitative and quantitative samples. in terms of the time orientation, the sampling can be carried out either concurrently or sequentially. the relationship between these two types of samples can be one of the following: identical sampling is where the qualitative and quantitative samples include the same participants. parallel sampling design is where different qualitative and quantitative samples are drawn from the same population. there is parallel use for probability and purposive strategies, either concurrently or sequentially. examples are where one set may be a subset of the other, or where both studies use the same total sample. nested sampling design is where the participants from one component of the investigation represent a subset of those who were included in another phase of the study. multilevel sampling makes use of sample sets from different populations at different levels of the study. in this case, probability and purposive sampling techniques are used at different levels of analysis (e.g. therapists and clients). data collection the fourth step in the critical appraisal of mmr is to evaluate the data collection. data are collected simultaneously (concurrently) or sequentially (creswell & plano clark, 2011). an example of a concurrent design in speech-language therapy was provided by bedwinek et al. (2010), who performed a national survey using mmr to determine the training needs of preschool and school-based speech-language therapists regarding children with cleft lip or cleft palate. these authors (ibid) collected quantitative data using a likert-type scale and concurrently also collected qualitative data from open-ended questions that were complementary to the quantitative questions in the same questionnaire. in a sequential study, overby et al. (2007) collected quantitative data to determine the extent of differences between teachers’ perceptions of students with ssds and those with typically developing speech by means of audiotaped sentences as stimuli that had to be rated. this phase was followed by collecting qualitative data through open-ended questions to discover insights into the characteristics of any similarities or differences. another example of a sequential study is that of langevin et al. (2009) who explored the social impact of stuttering of preschoolers in free-play by investigating peer responses to stuttered utterances. four free-play sessions were audioand videotaped and participants’ intelligible utterances were transcribed. inter-observer reliability was obtained from independent research assistants who were speech-language therapists by randomly selecting different subsets of data for each reliability measure to confirm the integrity of the research. in a nested mmr design, bryman et al. (2008; bryman, 2006) investigated social policy researchers in the united kingdom. they made use of an e-survey to investigate views regarding quality. in a nested mmr design, the researchers used semi-structured interviews (per telephone) with a small number of participants from the original sample. the use of open-ended questions allowed the participants to express opinions that could not be covered with the closed-ended questions in the e-survey. the qualitative component allowed several issues to be explored in greater depth, which enhanced the survey findings. data analysis and integration it is essential that one evaluates or assesses which data analyses were employed when critically appraising mmr. various data analyses methods can be used in mmr. quantitative data analysis is either descriptive and/or inferential, whereas qualitative data analysis is carried out descriptively and through thematic analyses of text or image. overby et al. (2007) made use of descriptive statistics to show differences in the means of all dependent variables, as well as multiple analyses of variance to disclose statistical differences between intelligibility levels. the study by bryman et al. (2008) used descriptive statistics with frequencies from the e-survey with contingency table analysis of specific quality criteria. the qualitative data from telephone interviews were recorded, transcribed and analysed thematically. in the langevin et al. (2009) study, the quantitative and qualitative results were used to answer different components of the research. data were analysed separately for each research question. peer responses to stuttered utterances were recorded. the duration of stuttering behaviours was measured in utterances that elicited negative responses from peers by the use of, ‘the stuttering severity instrument for children and adults 3rd edition’ (riley, 1994). in addition, responses were coded as either neutral or positive (no adverse attention by peer) or negative, which in turn was behaviourally described and labelled. the meaningfulness of all peer-directed stuttered utterances was coded and inter-coder reliability was obtained. in all these aforementioned studies, the quantitative and qualitative analyses were carried out separately. none of the aforementioned studies or researchers provided a clear explanation of how the qualitative and quantitative methods were integrated. once the initial quantitative and qualitative data analyses have been completed, the mmr analysis should be carried out. creswell (2003) described four strategies for data analysis in mmr, which include data transformation, exploration of articles, instrument development and examination on multiple levels, although operational definitions that describe objectively measurable indicators for such an analysis are not specifically described. tashakkori and teddlie (2010) in turn described integrative efficacy as how well the inferences made in each strand of the mmr can be integrated into a theoretically consistent meta-inference (tashakkori & teddlie, 2010). these authors (ibid) proposed three methods for integrating multiple forms of data: merging data: qualitative data (texts or images) can be combined with quantitative data (numeric information). when merging data, the process of integration occurs when qualitative and quantitative data are merged to obtain the results. merging involves equal emphasis on both strands of the research as the results are compared, contrasted or synthesised (suleman & hopper, 2014). the method of merging is to report qualitative and quantitative results together in a discussion section, for example, where the quantitative statistical results are reported first, followed by quotes or themes that either support or refute the quantitative results. merging can also be obtained by transforming one data set (e.g. counting the themes in a qualitative data set) in order to compare with the other data set (quantitative data set). finally, the quantitative and qualitative results can be displayed and compared in tables or figures. connecting data: sequential designs require that one data set is collected, analysed and interpreted before the next phase where the process is being repeated, which is when data are connected. such information is used to inform subsequent data collection – for example, when the qualitative data (e.g. focus group) are used to develop the questionnaire to collect quantitative data, which in turn are calculated to obtain the results. embedding data: this process refers to when one data set of secondary priority is embedded within a larger primary design. examples of embedding data is when data are collected through questionnaires from a large group of participants, but from that group a smaller group is selected to participate in a focus group to provide answers to the research question. qualitative data may precede an experimental trial to inform development of procedures. alternatively, qualitative data may follow an experimental trial to help explain the results of the trial. in embedded designs, the data are being reported independently (creswell et al., 2011). from the integration process, several outcomes are possible in mmr (brannen, 2016). there can be corroboration of the same results from both methods; elaboration where the qualitative data findings explain the quantitative findings; complementary outcomes where the results from the two strands may differ but when used together they provide new insights. in the case where there is a contradiction in the outcomes, such as is the case in conflicting results, several strategies can be applied to explain (moffatt, white, mackintosh, & howell, 2006). the researchers should either treat the methods as fundamentally different or explain the methodological rigour of each component. the data set can also be explored or additional data can be collected for comparative purposes. one can also explore whether the intervention worked or explore whether the outcomes of the quantitative and qualitative components match. legitimising the research the process of legitimising the research (which is the mixed-methods nomenclature for validity, reliability and trustworthiness) determines quality (onwuegbuzie & johnson, 2006) (refer to figure 2). when critically appraising mmr, the legitimising process is a crucial step. legitimising the research is the most important aspect of the research as findings that lack validity are considered of no use. firstly, researchers should critically review the findings from both the qualitative and quantitative strands of the research (garuth, 2013) and then proceed to assess how these findings have been integrated. in the discussion, the researcher should point out how the inferences relate to the objectives of the research. figure 2: aspects related to legitimising the research three processes determine the value of mmr, namely methodological rigour, interpretive rigour and inference transferability (refer to figure 2). the methodological rigour (also known as design quality) is concerned with the application of method and provides the standards for the assessment of mmr. dellinger and leech (2006) propose a validation framework consisting of concepts outside the more common terms. these terms include, for example, foundational elements (referring to prior knowledge of a construct or phenomenon under study that can influence the manner in which data are interpreted) and inferential consistency that depends on what is known from prior understandings, past research and theory, in addition to the study design, measurement and analyses. the criteria for determining quality of the quantitative research are firstly to ascertain validity, which is to determine whether a measure actually measures what it is supposed to. validity should be assured for each aspect of the research design, and only once validity has been established in both the quantitative and qualitative research, can the researchers consider this matter in mmr. secondly, research has to show reliability, which is to measure and produce similar results across time and measures. thirdly, it has to be generalisable, where findings should be applied across the wider population. as a result of issues in meeting these stringent criteria, additional measures have to be introduced to ensure quality in qualitative research (bryman, 2006). these include credibility, which ensures that findings makes sense and can be trusted. secondly, the research findings must be dependable, which implies that they should be the same when repeated in a similar context. thirdly, the research must also be transparent and findings must be confirmed. lastly, the criterion of transferability should be met in that findings become relevant in other contexts. bryman (2006) discusses issues of convergent criteria (which is when the same criteria are being used for both the quantitative and qualitative components in different elements in the research), as well as bespoke criteria, where new criteria are instituted for mixed methods. when working within a pragmatic approach, one has to consider the purpose of the methods used, for example, in the case where qualitative methods are used to develop a questionnaire, it may be better to use convergent criteria (validity and reliability) rather than separate or bespoke criteria. alternatively, when a qualitative project is preceded by a phase that collects quantitative data (e.g. demographic information), convergent criteria that support the trustworthiness of the research may be more suitable. creswell and plano clark (2011) highlight additional potential validity issues that require attention: inference quality, which refers to validity within a mixed-methods context, that allows the researcher to draw meaningful and accurate conclusions. consequential validity, which is steered by the pragmatist approach as it guides the triangulation design which results in an overarching validity when researchers draw evidence from different sets of data that provide better results than any of the two data sets can do alone. in mmr, it is important that each method is complete and meets the criteria for rigour as if it would when standing alone (woolley, 2009; irwin et al., 2014). an advantage of this standard is that each component can be published independently, particularly in sequential triangulation where projects are spanning over an extended period of time. the blending and merging of data is only conducted when results are fitted in a cohesive outcome or theory, or by confirming or revising existing theory. the critical appraisal of the research is considered an integral step in the mmr procedure. the mixed-methods research procedure in mmr, researchers firstly have to determine whether a mixed-methods study is practical and what the justification for the mixing of methods is. this is followed by formulating the research questions and collecting and analysing the data. lastly, the report has to be written (creswell & plano clark, 2011). several models for the development of mmr have been proposed (leech & onwuegbuzie, 2005; mcmillan & schumacher, 2006; yin, 2006; onwuegbuzie & dickinson, 2007). for the purpose of this tutorial, the framework developed by collins et al. (2006) consisting of four phases with 13 steps is considered as a practical guideline. although several of the steps in this framework may at a glance resemble those used in mono-method studies, the elements within these steps are specific to mmr. researchers need to be cognisant of both the strengths or advantages and the challenges or controversies related to mmr that need to be considered. critical review of mixed-methods research advantages and strengths of mixed-methods research mixed-methods research maximises the strengths and reduces the limitations of single methods (polit & beck, 2010). when qualitative methods are used in combination with quantitative research, it provides a deeper insight into the context or the process and why treatment options are effective (stewart & richardson, 2004). validity is increased when standard clinical measures are augmented through gathering the views of clients concerning treatment effectiveness (kovarsky, 2008). the use of mmr can identify what to be mindful of in data collection or can identify the factors that impact on programme outcomes. when quantitative and qualitative methods are used together, they both contribute to a common understanding of the research phenomenon (o’cathain, murphy, & nicholl, 2008). the findings from one method can aid in the development of another, for example, findings from a focus group can determine the construction of a questionnaire. mixed-methods research designs can include words, photos and narratives to supplement meaning to numbers, while numbers can add exactness to words, photos and narratives. a definite advantage of mmr is that it can be used to provide a voice to marginalised groups (e.g. when participants are not literate and need to be interviewed to obtain their views on a specific matter) (teddlie & tashakkori, 2003; glogowska, 2011). mixed-methods research findings are transferable, which is not the case when qualitative designs are used on their own. qualitative research tends to be context specific because of the smaller sample size. despite these advantages of using mmr, there are several controversies and unresolved issues that researchers need to be cognisant of before embarking on such a venture. it is necessary to identify the potential threats or challenges that could have occurred during data collection and analysis, as it could impact on the validity of the findings. in order to enhance the quality of the mmr, the researchers should also indicate how such threats were countered by them (venkatesh et al., 2013). controversies and challenges in mixed-methods research controversies and challenges may occur in the conceptualisation stage of research (in providing a rationale for the mixing of methods), the operationalisation stage (how the methods will be used) or the synthesis stage where the findings of various methods used are interpreted. teddlie and tashakkori (2003) pointed to the following controversies which have also been experienced by some south african studies: (1) the nomenclature and basic definitions used in mmr remain to be disputed, (2) the use of mmr, (3) paradigms underpinning mmr, (4) issues related to the design of mmr (schütte, 2016), (5) inferences derived from mmr (wium, 2010) and (6) logistics when conducting mmr (wium & louw, 2011). table 2: the mixed-methods research process. these aforementioned controversies were later encapsulated in four challenges described by onwuegbuzie and dickinson (2007). sampling issues: are inherent to both quantitative and qualitative research. in quantitative research, a significant threat to validity is the use of an inadequate or inappropriate sample (schmidt, 1996). lundie, erasmus, zsilavecz and van der linde (2014) experienced a limitation in the sample size of their study that developed a checklist of differential diagnosis of neurogenic stuttering. the use of non-random samples limits generalisation to other populations, as was noted in the study by wium and gerber (2016) that explored doctors’ knowledge of ototoxicity. the problem with adequacy should be countered by calculating the sample statistically. in qualitative research, threats related to adequacy of the sample are dealt with through data saturation. the challenge of representation (denzin & lincoln, 2005) that is often encountered by qualitative researchers also becomes an issue in mmr when researchers experience challenges in capturing the lived experiences using words and numbers. it may require representation of the total population (irwin et al., 2014). another threat is appropriateness of the sample (onwuegbuzie, jiao, & bostick, 2004), which can be countered by representation of the phenomena under study (e.g. how well the participants can articulate their experiences) (irwin et al., 2014). another sampling challenge is the merging of quantitative and qualitative research in sequential designs as researchers have to decide which results from the initial phase should be used in the follow-up phase. it may be challenging to select adequate sample sizes for both phases because of the unequal weighting thereof. legitimation: it is more difficult to obtain legitimation in mmr than in either of the mono-method approaches. in quantitative research, the challenges experienced are in obtaining validity (e.g. construct validity, criterion validity and content validity) (american educational research association, 1999). in qualitative research, researchers strive for credibility (internal validity), dependability (reliability), transferability (external validity) and confirmability (objectivity) of their findings (denzin & lincoln, 2005, p. 17). in mmr, it is expected of researchers to obtain credible, trustworthy, dependable, transferable and/or confirmable findings (onwuegbuzie & johnson, 2006). integration: the third contentious issue in mmr relates to integration of quantitative and qualitative findings (onwuegbuzie & teddlie, 2003; creswell et al., 2011; glogowska, 2011). the unequal weighting of the two data sets may create a challenge in terms of validity (irwin et al., 2014). it is about triangulating, expanding, comparing or consolidating findings obtained from data stemming from large, random samples in quantitative research with data obtained from the qualitative component that stems from small purposive samples. another issue related to the integration of findings is when a decision has to be made in terms of integration during sequential designs. it may not be clear which results from the first phase will be the primary data in the second phase. in addition, researchers often make superficial claims to the use of mmr. very often, questionnaires are mainly quantitative in nature (e.g. they not only consist mainly of closed-ended questions or checklists but also include a few open-ended questions), which cannot be regarded as true integration of methods. such issues can be dealt with by rigorously defending the methodological choices. researchers should also explicitly document methodological congruence. fourthly, there is a challenge concerning politics, based on the tensions that exist between researchers when combining quantitative and qualitative approaches. methodological purists maintain that mixing is not possible from a paradigmatic perspective (onwuegbuzie & teddlie, 2003; creswell et al., 2011; glogowska, 2011). it may also be a challenge to convince stakeholders to value the findings from both the quantitative and qualitative components of the study (irwin et al., 2014). other challenges may be encountered when conducting mmr (morse, 1991; creswell et al., 2011; glogowska, 2011). when the quantitative and qualitative results do not confirm each other, it is best to report both sets of findings to emphasise the complexity of the phenomenon or intervention, which is often the case in health and education contexts. in such a case, the use of mmr is particularly useful, as by doing so one can demonstrate how mixed methods can tell a more comprehensive and realistic story, for example, about what works under which circumstances and with whom. many mmr projects end up being published separately as mono-method research. reasons for this may be that the authors expect readers to have an interest in one specific aspect of the study or because of the strict page and word limitations in some journals. mixed-methods research is longer than mono-methods research, and researchers may find such limitations challenging to get their work published. in sequential studies, the timing of the various components of the research may also be the cause for not publishing mixed-methods studies as researchers may feel pressured to publish results obtained from earlier phases first. there may also be logistical challenges, which are related to availability of resources (onwuegbuzie & teddlie, 2003; creswell et al., 2011; glogowska, 2011), as mmr is more costly as a result of more than one type of data collection procedure being used. research training may be required as the researchers need to be tri-skilled in quantitative, qualitative and mmr (irwin et al., 2014). mixed-methods research requires greater effort than single-method designs and can pose a challenge to a single researcher, especially in the case of concurrent designs. in the case of sequential designs, it may be more time consuming. it may be best to work in a team (creswell et al., 2011). researchers should, however, not be discouraged by these challenges but should familiarise themselves with the mmr literature and explore the exciting possibilities that mixed-methods designs can offer. the challenges can, however, be turned into advantages as it requires researchers to be versatile and to work in teams and across disciplines. interprofessional collaborative practice in both health care and education settings is supported across the globe (garuth, 2013). the mixed-methods approach is ideally suited for research in inter-profesional collaborations to improve outcomes for individuals with communication disorders and their families and to deliver the highest quality of care across settings. conclusion the mmr approach offers an exciting avenue for exploring multidimensional and complex questions in the disciplines of speech-language therapy and audiology. speech-language therapists and audiologists serve clients with complex conditions such as speech, language, hearing, balance and swallowing problems. these clients are affected by the physical, social and attitudinal environments in which they live (world health organization, 2001). speech-language therapists and audiologists are required to provide ebp services, which are multifaceted to meet the needs of these individuals and their significant others. the therapeutic process itself can be viewed as a mmr process, as assessment procedures consist of quantitative data that are complemented by qualitative data obtained from interviews with the clients and their families. a dearth of knowledge continues to exist regarding the most efficacious intervention approaches for clients with a variety of communication disorders. interprofessional research is becoming increasingly popular and lends itself to mmr. researchers working in teams can draw on the strengths of different disciples and their research approaches. such collaborative enterprises will contribute to capacity building. researchers, speech-language therapists and audiologists are encouraged to make use of mmr to address the complex research issues in the multicultural, multifaceted south african context. mixed-methods research makes an important contribution to the understanding of individuals with communication disorders, and in turn, researchers in the two disciplinary fields of speech-language therapy and audiology can contribute to the development of this research approach. mixed-methods research is well suited to the complexity of south african contexts and its populations, as it can provide multiple perspectives on a topic. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions a-m.w. was the project leader and prepared the conceptual draft and edited the article. b.l. gave conceptual input and edited the article. references abdoola, f., flack, p.s., & karrim, s.b. 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(2011). teacher support – and exploration of how foundation-phase teachers facilitate language skills. south african journal of communication disorders, 58(december 2011), 86–94. https://doi.org/10.4102/sajcd.v58i2.30 wium, a.m., louw, b., & eloff, i. (2010). speech-language therapists supporting foundation phase teachers with literacy and numeracy in a rural and township context. south african journal of communication disorders, 57(1), 14–22. https://doi.org/10.4102/sajcd.v57i1.45 woolley, c.m. (2009). meeting the mixed methods challenge of integration in a sociological study of structure and agency. journal of mixed methods research, 3(1), 7–25. https://doi.org/10.1177/1558689808325774 world health organization. (2001). international classification of functioning, disability and health. geneva: world health organization. yin, r.k. (2006). mixed methods research: are the methods genuinely integrated or merely parallel? research in the schools, 13(1), 41–47. retrieved from http://connection.ebscohost.com/c/articles/22225172/mixed-methods-research-are-methods-genuinely-integrated-merely-parallel 76 sajcd • vol 57 • december 2010 comparison of postmenopausal voice changes across professional and non-professional users of the voice pallavi sovani institute for psychological health, thane and hiranandani hospital, thane, maharashtra, india geetha mukundan ali yavar jung national institute for the hearing handicapped, mumbai, india correspondence to: p sovani (pallavi_mail2003@yahoo.co.in) voice production requires an intact vocal mechanism comprising laryngeal tissues, cartilage and muscles, and the elastic and pliable vocal folds. the laryngeal mechanism is extremely vulnerable to a large number of factors such as vocal abuse or misuse, drugs, allergies, infection, alcohol or smoking, and also several non-pathological factors such as the proportion of various hormones in the body. according to boone (1997), the larynx is heavily influenced by hormonal changes within the individual, especially during puberty, and during and after menopause. menopause is defined as the time when there have been no menstrual periods for 12 consecutive months and no other biological or physiological cause can be identified (conrad-stoppler, 1999). age of onset of menopause varies according to race, climate and dietary habits. research on menopause is even more important in the indian scenario, as the mean age for menopause in indian women is lower than the mean age worldwide (syamala & sivakami, 2007). early research on menopause involved singers with amenorrhoea, and showed that common vocal complaints among these singers included a crack in the voice, breathiness/weakness, an inability to phonate on certain pitches, and an inability to adequately support tones (sataloff, 1998). other studies on menopause and the singing voice include those of emerich, hoover and sataloff (1996), and abitbol, abitbol and abitbol (1999). abitbol et al.’s study listed loss of power, vocal fatigue, decreased range and a loss of high notes among the changes associated with menopause. boulet and oddens (1996) studied female voice changes around and after menopause. their subjects comprised 48 female and 24 male professional singers aged 40 74 years. a questionnaire was used to determine whether women’s and men’s voice changes were different, and to indicate whether menopause had an impact on the female voice. both men and women were of the opinion that the voice generally underwent changes at around age 50, but the female singers placed greater emphasis on problems affecting the high registers and voice control than the men. both sexes reported huskiness, but the women seemed to have more frequent problems with voice emission, voice control and reaching their highest registers. meurer, wender, corleta and capp (2003) studied phono-articulatory variations in women of reproductive age (30 40 years) and postmenopausal women. results showed a greater variability in vocal sustenance, less variation in formants, and verbal variations in diadochokinesis in postmenopausal women. these studies indicate that although changes in voice may occur as a result of ageing in men and women, the female voice does undergo specific changes around the time of menopause. the impact that a change in voice may have on an individual’s life may depend on many factors, one factor being the extent of voice use (yiu, 2002; zeine & waltar, 2002). koufman and isaacson (1991) suggested a ‘vocal usage’ classification system. this is a comprehensive classification encompassing a wide range of vocal use, and has been alluded to in earlier research studies (timmermans, de bodt, wuyts, boudewijins, clement, peeters, et al., 2002). a recent study by cheng and woo (2010) utilised another method of classification in the form of a rating scale from 0 (low use) to 5 (elite use). however, the koufman and isaacson classification appears to be a more specific, well-defined system, comprising four levels: level i: the elite vocal performer – including professional singers and actors, for whom even slight vocal difficulty may cause serious consequences. level ii: the professional voice user – including clergy, public speakers, lecturers, telephone operators, for whom moderate vocal difficulty would prevent adequate job performance. level iii: the non-vocal professional – comprising doctors, lawyers, business persons, sales persons, etc. who cannot perform their work properly if suffering from severe dysphonia. level iv: includes factory workers, labourers, clerks, who would not be prevented from doing their work if suffering from vocal difficulties. stemple, glaze and gerdeman (1995) define professional voice users as the group of individuals who, by the very nature of their occupation, are directly dependent on vocal communication for their livelihood. their voice problems can be labelled occupational voice disorders since the symptoms they suffer from are likely to be caused by the type of work. early studies on professional voice users involved mainly actors (novak, dlouha, capkova & vohradnik, 1991) and singers (sheela, abstract menopause effects a permanent change in certain body functions, including voice. if the voice is used continually as part of one’s occupation, this may further impact on postmenopausal voice changes. the present study investigated individual and combined effects of menopause and professional voice use on voice. ninety-two women were classified into reproductive (52) and postmenopausal (40) groups. each group was divided into level ii (teachers) and level iv (clerks) of koufman and isaacson’s (1991) classification. voice samples were recorded and analysed using the visipitch iii software. aerodynamic parameters were manually calculated. the voice handicap index (vhi) was included to improve face validity of the study. results suggest that fundamental frequency (fo), speaking fundamental frequency (sfo) and maximum phonation time (mpt) decrease after menopause while noise-to-harmonic ratio and voice turbulence index increase. being a professional voice user seems to affect the nature of postmenopausal voice changes, since an interaction effect was observed for some voice parameters. vhi scores reflect that teachers are aware of voice problems caused by vocal abuse, though relatively unaware of postmenopausal voice changes. the study has implications for improving the working conditions of teachers in india, developing norms for menopausal changes and modifying allowable limits for voice recognition systems in future. keywords: acoustic, aerodynamic, menopause, voice, voice handicap index vol 57 • december 2010 • sajcd 77 menopause and professional voice use 1974; ragini, 1986), i.e. the ‘artistic’ professional voice users. these studies established that elite vocal performers have to stretch their voice beyond average limits, a finding reaffirmed by sataloff (1991). level ii professionals, however, were given relatively less importance. this was in spite of the fact that among professional voice users, teachers form the biggest group and are at maximum risk for developing voice disorders (buekers, bierens, kingma & marres, 1995; simberg, sala & ronnemaa, 2004). factors such as number of students, classroom design, ergonomics (resulting in faulty posture), dusty environment (especially chalk dust), background noise and teachers’ additional duties also act against vocal hygiene. voice abuse in teachers was investigated by rantala, vilkman and bloigu (2002), who found an increase in fundamental frequency (fo) during the working day. soderstein, granqvist, hammarberg and szabo (2002) who studied preschool teachers found that on average, the teachers spoke 9.1 db louder and with a higher mean fo at work than the baseline for fo during other speech tasks. simberg et al. (2004) compared the prevalence of vocal symptoms among students studying to be teachers and other university students. the student teachers reported a greater number and frequency of vocal symptoms. in a study on respiratory and laryngeal function of teachers with and without voice disorders, lowell, barkmeier-kraemer, hoit and story (2008) used the voice activity and participation profile (vapp) (ma & yiu, 2001), a tool that evaluates subjects’ perception of impact of the voice problem on various areas of their lives. vapp scores for the voice-disordered group were significantly greater than those for the control group. the four studies discussed above have two important implications: firstly, that teaching is a vocally demanding profession, and secondly, the use of self-assessment questionnaires brings forth the degree to which teachers are aware of their vocal discomfort, and the degree to which they are affected by it. in professional voice users, the voice disorder not only causes vocal symptoms but also carries with it a high level of emotional strain and anxiety as a result of the inability to perform their job (stemple et al., 1995). quality of life (qol) measures provide a better insight into these difficulties and recognise the centrality of the patient’s point of view. one such subjective measure is the voice handicap index (vhi) (jacobson, johnson, grywalsky, silbergleit, jacobson, benniger, et al., 1997), a standardised self-assessment ordinal scale to subjectively assess the amount of difficulty a voice disorder is causing. it consists of 30 questions representing different problems in speaking situations, with the person required to rate the frequency of the problem on a 5-point scale (from 0 to 4). each question tests one of three aspects, resulting in three subscale scores – functional, physical and emotional (maximum possible for each subscale = 40) – and a total score (maximum possible score = 120). the vhi has been widely used for research purposes (rosen, murry, zinn, zullo & sonbolian, 2000; wheeler, collins & sapienza, 2006). it has also been translated into and validated in other languages such as portuguese (guimaraes & abberton, 2004) and hebrew (amir, ashkenazi, leibovitzh, michael, tavor & wolf, 2006). qol measures have been used with objective measures by various researchers, leading to the conclusion that these subjective assessment tools are affected by factors other than voice quality (murry, medrado, hogikyan & jonathan, 2004); that they effectively measure functional therapeutic outcomes (rosen et al., 2000); and that objective and subjective measures give independent information in practice (wheeler et al., 2006). these studies suggest that assessment using a subjective tool is necessary for gauging the impact of vocal difficulties experienced by subjects. female teachers are likely to experience vocal difficulties when they undergo menopause. the extent of voice use in their profession would also affect their voice. in fact, the two factors might interact. russell, oates and greenwood (1998) found that female teachers are twice as likely as male teachers to report voice problems, a finding that suggests the influence of factors other than occupational voice use. the researchers stressed the need for further investigation of the causes of vocal dysfunction in teachers. however, studies on menopause and the professional voice have generally focused on level i professionals (actors, singers). although the scope of voice therapy is rapidly widening in order to cater to the special population of ‘professional voice users’, including level ii professionals, few studies have attempted to document voice changes due to menopause, or their interaction with occupational voice use, in this population. no norms have been cited in literature to account for voice changes due to menopause. in spite of the earlier age for menopause in indian women, not enough efforts are being made to conduct research and forewarn women about postmenopausal voice changes so as to reduce their potential psychosocial impact. hence the present study was aimed at investigating the changes in acoustic and aerodynamic voice parameters of women who are professional voice users versus those who are non-professional voice users, following menopause. it also aimed at probing the relevance of these findings to the population concerned using a subjective assessment tool, since subjective measures greatly add to the face validity of the study (in that they help reflect upon the actual problems faced by the subjects) and in turn, the value of the study. method the data were collected on visits to schools and offices across mumbai and interacting with teachers and clerks/accountants respectively, after seeking permission from their employers. a ‘brief voice history’ questionnaire (colton & casper, 1990) was administered to potential subjects. this was to elicit information on various general and systemic variables such as illnesses, allergies, medications, surgery, nature and amount of voice use at work, etc. two questions – pertaining to ‘marital status’ and ‘time elapsed post menopause (if menopause had occurred)’ – were added to the questionnaire. based on responses to the questionnaire, the subjects were screened for all the inclusion criteria and could be assigned to an appropriate group (table i). in this way, a purposive sample of 92 subjects was included in the study. a 2 * 2 quasiexperimental research design was used, and subjects were classified according to two independent variables – menopause (reproductive age and postmenopausal) and professional voice use (level ii of koufman and isaacson’s classification represented by teachers and level iv represented by clerks). the group distribution is shown in table i. inclusion criteria for women of reproductive age: 1. age range: 30 35 years 2. regular menstrual cycles 3. at least a week elapsed since the onset of the previous menstrual cycle 4. the next menstrual cycle has not yet commenced 5. marital status: married. for postmenopausal women: 1. minimum age limit: 45 years 2. marital status: married 3. 1 5 years elapsed since cessation of menstruation 4. marital status was a criterion because the vocal demands and stressors in the life of married and unmarried women can be expected to be different (ravichandran & rajendran, 2007), and controlling this variable could increase the internal validity of the study. exclusion criteria 1. use of oral or injectable contraceptives, hormonal medication or hormonal therapy table i. distribution of subjects into groups level ii (teachers) level iv (clerks) reproductive age 32 20 postmenopausal 20 20 78 sajcd • vol 57 • december 2010 menopause and professional voice use 2. subjects with upper respiratory tract infection, especially during recording 3. subjects with a history of smoking, chronic alcoholism, asthma, or vocal cord pathologies. procedure validation of the digital voice recorder a pilot study was conducted with 20 young normal healthy adults as subjects (10 male, 10 female) and acoustic parameters obtained from online analysis and analysis of recordings using a sony icd-p620 digital voice recorder were compared using student’s t-test. no significant difference between the two sets of values was obtained for any of the parameters. shimmer for the recorded sample was slightly higher, but the difference was not significant. administration of the voice handicap index the vhi (jacobson et al., 1997) was the most readily available tool used regularly as part of the clinical voice evaluation at ali yavar jung national institute for the hearing handicapped (ayjnihh), mumbai, i.e. the place of research. the subjects were given the vhi to investigate their perceptions of changes in voice, if any. they were given the following instructions: ‘answer the questions by marking the appropriate option according to the frequency of the problems stated (an example was given using the first question). rate the frequency of the problem on a 5-point scale, where 0 = never; 1 = almost never; 2 = sometimes; 3 = almost always; 4 = always.’ obtaining voice samples the voice samples were obtained, with informed consent, using a sony icd-p620 digital voice recorder. the subject was asked to sit comfortably in a quiet room. the microphone was held by the researcher at a mouthto-microphone distance of 15 cm, at an angle of 45 degrees. the subject was asked to perform three tasks: • to phonate /a/, /i/ and /u/ sounds at comfortable pitch and loudness. • to read the first three lines of fairbanks’ ‘rainbow passage’ (fairbanks, 1960) out of which the second line was chosen for analysis, to avoid any special effects associated with initial and final sentences and yet provide tolerable accuracy (baken & orlikoff, 2000). • to introduce herself when asked the question ‘what is your name?’ the acoustic voice parameters were then obtained using the multidimensional voice profile (mdvp) program of the visipitch iii software at ayjnihh, mumbai. aerodynamic measures the subjects were asked to prolong an /a/ sound for as long as they could. the better of two trials was taken as the maximum phonation time (mpt), measured using a stopwatch. the subjects were asked to prolong an /s/ sound for as long as they could. they were then asked to try to produce a /z/. for subjects who could manage to produce a /z/ sound the s/z ratio was calculated (65 of them could not produce a /z/, since the sound does not belong to the phonology of many indian languages). statistical analysis two-way anova (analysis of variance) was used to find out if a significant difference exists across menopause, profession, and whether any interaction effect was present. an additional analysis was done using ancova (analysis of covariance), to see whether the significant difference in voice parameters due to menopause persisted after covarying out the effects of age. results acoustic parameters fundamental frequency (fo) the overall trend seen in the findings was that the fo appeared to decrease after menopause, as shown in table ii. on statistical analysis using two-way anova, the fo of postmenopausal women was significantly lower for /a/ [f(1,88)=21.43, p<0.001], /i/ [f(1,88)=11.04, p<0.001] and /u/ [f(1.88)=11.15, p<0.001] than women of reproductive age. for all three vowels, there was no significant difference in fo across the two levels of voice use, i.e. between teachers (level ii) and clerks (level iv). however, an interaction effect was seen between professional voice use and menopause. to further investigate this interaction, an independent-samples t-test was first conducted between level ii and level iv professionals within the reproductive group. the test was then repeated within the postmenopausal group. in the reproductive group, the fo of the teachers was found to be significantly lower. however, the difference between fo of level ii and level iv professionals was not significant in the postmenopausal group. this meant that the fo reduction after menopause in teachers was less than that of the clerical population. relative average perturbation (rap) (%) there were no specific trends seen in the data for rap values. statistical analysis using two-way anova revealed no significant differences either across profession or across menopause, for any of the vowels tested. no significant interaction was seen between profession and menopause. table ii. means and sds of fo values (in hz) for sustained phonation across the different groups of level ii and level iv professionals /a/ /i/ /u/ category level ii level iv level ii level iv level ii level iv reproductive age mean 207.21 222.99 207.01 228.05 213.99 226.88 sd 19.55 20.27 20.95 19.39 19.07 20.51 postmenopausal mean 194.24 193.68 201.93 198.27 206.86 199.10 sd 14.54 29.74 18.78 32.44 16.52 34.92 sd = standard deviation; fo = fundamental frequency. table iii. means and sds of nhr values for sustained phonation of /a/, /i/ and /u/ across the different groups studied /a/ /i/ /u/ category level ii level iv level ii level iv level ii level iv reproductive age mean 0.17 0.14 0.22 0.22 0.18 0.19 sd 0.07 0.03 0.09 0.12 0.10 0.10 postmenopausal mean 0.18 0.17 0.27 0.26 0.27 0.15 sd 0.07 0.06 0.11 0.19 0.14 0.04 sd = standard deviation; nhr = noise-to-harmonic ratio. vol 57 • december 2010 • sajcd 79 menopause and professional voice use shimmer (db) like rap, overall there were no specific trends seen for shimmer. when two-way anova was used, there was no significant difference in shimmer across menopause, or across profession. noise-to-harmonic ratio (nhr) overall, the nhr values appeared to increase after menopause. also, nhr values for professional voice users appeared to be higher than those for non-vocal professionals. however, these differences were not statistically significant, and there was no interaction effect. the means and standard deviations (sds) are displayed in table iii. a common trend seen between nhr and perturbation measures was that the values for /i/ and /u/ were greater than those of /a/. voice turbulence index (vti) a significant increase was found in the vti after menopause when teachers and clerks were considered as one group. however, when a t-test was done separately on the clerical population, there was no significant difference in the vti values of clerks after menopause. this implies that the significant increase in vti after menopause for all the women taken together was due to the increase in vti values of teachers after menopause. the attributes of menopause and professional voice use were therefore seen to interact here, a finding confirmed by an interaction effect on the two-way anova. the vti values for /i/ were the greatest among the three vowels tested. means and sds are given in table iv. speaking fundamental frequency (sfo) the mean sfo value for the reproductive age group in the present study was 223.26 hz. sfo, like fo for phonation, tended to decrease after menopause. this was true for both clerks and teachers, for both the types of stimuli used. the means and sds are displayed in table v. when the data were subjected to analysis using two-way anova, a significant difference was seen in the sfo values between women of reproductive age and postmenopausal women for both reading [f(1.88)=20.09, p<0.001] and spontaneous speech [f(1.88)=20.79, p<0.001] samples. no significant difference was obtained between the sfo values of the two professional groups. being a professional voice user seemed to affect postmenopausal changes in sfo in that changes in teachers were smaller than those in clerks. however, the interaction effect was not statistically significant. an incidental finding was that there was no significant difference in sfo obtained for both the tasks when verified using an independent-samples t-test. aerodynamic parameters maximum phonation time (mpt) (seconds) the data showed that there was a slight reduction in mpt after menopause. also, the mpt values for teachers were lower than those of clerks. however, both these differences were not statistically significant. no interaction effect was seen. mean and sd values are displayed in table vi. s/z ratio there were no particular trends observed in the s/z ratio for either professional or non-professional voice users, probably because of the limited data. two-way anova revealed no effects of menopause or profession, and no interaction effect, on the s/z ratio. voice handicap index (vhi) one extremely apparent trend was that vhi (jacobson et al., 1997) scores (total as well as subscale) were much greater in level ii professionals than in level iv professionals. another interesting finding was that for both teachers and clerks, the vhi scores were greater in the reproductive age group, and lower in the postmenopausal group, although the difference was not statistically significant. two-way anova revealed a highly significant difference across the two levels of voice use, i.e. across clerks and teachers, for the total vhi score [f(1.88)=17.53, p<0.001] as well as for the functional [f(1,88)=6.20, p<0.01], physical [f(1.88)=26.02, p<0.001] and emotional [f(1.88)= 9.89, p<0.002] subscale scores. no significant interaction effect was observed. the results are displayed in table vii. discussion acoustic parameters the mean fo of all the women (teachers and clerks) in the reproductive age group for vowel /a/ was 213.28 hz. when compared with the mean fo obtained in a study by till, jafari, crumley and law-till (1992), precisely 221.2 hz, the mean in the present study appears to be lower. this could be because the population in till et al.’s (1992) study table iv. means and sds of vti values for sustained phonation of /a/, /i/ and /u/ across the different groups studied /a/ /i/ /u/ category level ii level iv level ii level iv level ii level iv reproductive age mean 0.04 0.03 0.08 0.07 0.02 0.02 sd 0.01 0.01 0.03 0.07 0.01 0.01 postmenopausal mean 0.05 0.04 0.16 0.06 0.05 0.02 sd 0.02 0.01 0.09 0.03 0.03 0.01 sd = standard deviation; vti = voice turbulence index. table v. means and sds of sfo values (in hz) for reading and spontaneous speech tasks across the different groups studied reading (rainbow passage) spontaneous speech category level ii level iv level ii level iv reproductive age mean 220.15 226.37 220.86 228.49 sd 20.11 21.56 20.98 21.83 postmenopausal mean 206.92 201.70 205.30 203.89 sd 15.19 21.70 16.59 22.60 sd = standard deviation; sfo = speaking fundamental frequency. table vi. means and sds of mpt values (in seconds) across the different groups studied category level ii level iv reproductive age mean 11.87 13.45 sd 4.98 4.47 postmenopausal mean 11.05 12.80 sd 3.47 5.20 sd = standard deviation; mpt = mean phonation time. 80 sajcd • vol 57 • december 2010 menopause and professional voice use included a random selection of young normal healthy females with no voice complaints or strain on the voice. the two mean values would be in closer agreement if the mean of only the clerical group (level iv) in the present study is considered (222.9 hz). this is because the clerks in the reproductive age group make up a group of young normal healthy females similar to the sample chosen for till et al.’s study. this suggests that teachers (level ii) in the present study have a lower fo which reduces the overall mean fo of the reproductive age group. this low value of the fo in teachers of reproductive age is probably due to constant professional voice use (all other factors being constant). there is a reduction in fo for both professionals after menopause, a finding that agrees with fawcus (1991), boone (1997) and sataloff (1998). the explanation for this reduction may be a rapid reduction in oestrogen (titze, 1994) and an increase in androgen (boone, 1997). the difference in fo before and after menopause was less in clerks, however. the smaller change in fo in teachers could either be because the fo was already lowered in the reproductive age group, or because the changes were forestalled as a result of regular voice use, or both. although these hypotheses need further investigation, the above observations do suggest that prolonged use of the voice seems to affect the rate at which the fundamental frequency reduces after menopause. nhr, which was higher in teachers, appears to correlate well with selfreported voice problems (as was evident on the vhi), a finding similar to that of wolfe, long, youngblood, henry and olson (2002). professional voice use does not seem to affect postmenopausal changes in nhr. brown, morris and hicks (1993) reported that the professional voice, unlike the untrained, is unaffected by the ageing process. although their study pertained to singers (level i), the present study suggests that similar trends may be seen even in level ii professionals, as the decrease in sfo (and fo) of teachers was smaller compared with clerks. however, since teachers in india are neither trained adequately at voice projection nor follow a good vocal hygiene programme, the factor resisting sfo change in teachers may not be training, but could definitely be vocal use experience. the incidental finding that there was no significant difference in sfo obtained for reading and speaking tasks has clinical relevance. it implies that certain standardised stimuli could be used to elicit narration samples from those who cannot read, who make up a large subgroup of the indian population. aerodynamic parameters a probable explanation for the fact that teachers have a lower mpt could be excessive voice use at work. short-term changes (rantala et al., 2002; mehta, 2005), if not reversed, may therefore progress to become long-term changes in mpt. voice handicap index vhi (jacobson et al., 1997) results yield much information in the light of the results obtained in relation to acoustic and aerodynamic parameters. it may be recalled that teachers are at an advantage compared with clerks in that they have a relatively smaller reduction in fo and sfo after menopause. also there were no significant differences as compared to the clerical group in perturbation measures, s/z ratio or sfo. in spite of this, teachers reported greater vocal difficulty on the vhi. this underlines the importance of voice to their profession and also highlights how objective voice assessments coupled with a qol measure would tremendously increase the face validity of our assessment. the lower vhi scores of postmenopausal women could be a cohort effect. an important observation that is apparent in table vii was that the sds of all the vhi scores were almost equal to or even greater than the means, unlike the small sd values of objective parameters such as fo, sfo, mpt, etc. this demonstrates the large degree of variation that can be present in individual scores in spite of similar objective findings, and reaffirms the need to use a qol measure to obtain client-specific information. an interesting insight into menopausal voice changes was obtained when the findings were re-analysed using ancova. on co-varying out the effects of age, the significant difference across menopause either decreased (vti) or disappeared (fo). this gives statistical support to the statements by samuel (1973) and sataloff (1998) that ageing changes and menopausal changes are inseparable. however, it does not challenge the presence of menopausal changes. the presence of ‘laryngopathia premenstrualis’, the role that hormonal replacement therapy plays in counteracting menopausal changes, and the fact that corresponding changes are not seen in men around the age of 45 50 (baken & orlikoff, 2000), place enough emphasis on the existence of postmenopausal changes. a peculiar result was obtained on ancova for mpt. where the difference in mpt of teachers and clerks was not statistically significant on two-way anova, it became significant after co-varying out the variable of age. age might therefore have been a factor, which earlier confounded the difference in mpt across profession. hence the authors recommend that future cross-sectional studies on menopause should essentially consider using ancova for statistical testing. additional information obtained from the screening questionnaire since the brief voice history questionnaire also had questions about nature and amount of voice use, a lot of incidental information could be obtained which would be of value for future research. the teachers reported having to use a loud voice for around 3 5 hours a day. vocal misuse in the form of shouting amounted to a total of around 30 minutes a day. some of them had been pursuing singing as a hobby but had to discontinue it because of deterioration of their voices as a result of continual use. they also reported various skin and throat allergies to chalk dust, which they were regularly exposed to despite attempts to avoid it. all the schools visited had large classrooms, with capacity for about 60 students, again a condition detrimental to the voice. teachers seem to be aware of the voice abuse and their poor environmental working conditions, and yet no efforts have been made to ameliorate these conditions. conclusion menopausal changes in voice, as a part of age-related changes, appear in all women, irrespective of their profession. however, the severity and rate of these changes are slightly different if the woman uses her voice regularly as part of her profession. menopausal changes in some parameters of voice are accelerated while in others they are decelerated in teachers compared with clerks. teachers are aware of their voice problems. however, lack of initiatives taken to make necessary changes, and lack of adequate knowledge of vocal hygiene, voice projection techniques, etc., increase their risk of developing vocal pathology. these findings could be put to practical use in the following ways: 1. the findings of this study could be used as norms pertaining to the range of variation in voice parameters of postmenopausal women. these norms in turn could serve to determine allowable limits of variation in voice parameters during voice assessment of this subpopulation of women. 2. the findings could aid research on voice changes in women using or not using hormonal replacement therapy, and also voice changes in table vii. means and sds of vhi total and subscale scores across the different groups studied reproductive age postmenopausal level ii level iv level ii level iv vhi scores mean 14.96 4.6 10.90 3.65 sd 14.12 3.8 9.34 4.99 functional mean 5.15 2.65 3.35 1.65 (f) score sd 5.52 2.18 3.37 2.62 physical mean 6.62 1.45 5.40 1.50 (p) score sd 5.69 1.63 4.72 1.70 emotional mean 3.18 0.50 2.15 0.50 (e) score sd 4.70 1.05 3.08 1.35 sd = standard deviation; vhi = voice handicap index. vol 57 • december 2010 • sajcd 81 menopause and professional voice use women who have undergone natural menopause versus those who have undergone hysterectomy. 3. studies on effects of training in efficient voice use, vocal hygiene and voice therapy on postmenopausal voice changes could stem from the information obtained in the present study. 4. the findings also bring to light the need to improve working conditions for teachers and have provisions similar to those given for other occupational disorders. 5. in future, research documenting effects of factors such as occupational voice use and menopause on voice, would be required to account for voice changes even in non-professional voice users, with the advent of speech recognition systems for day-to-day transactions. 6. the study also highlights the use of qol measures as a means to make assessment and intervention a more meaningful and efficient process. references abitbol, j., abitbol, p., & abitbol, b. 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(1992). effects of initial consonant, pneumotachographic mask, and oral pressure tube on vocal perturbation, harmonics-tonoise, and intensity measurements. journal of voice, 6, 217-223. timmermans, b., de bodt, m. s., wuyts, f. l., boudewijins, a., clement, g., peeters, a., et al. (2002). poor voice quality in future elite vocal performers and professional voice users. journal of voice, 16(3), 372-382. titze, i. r. (1994). principles of voice production. new jersey: prentice hall. wheeler, k. m., collins, s. p., & sapienza, c. m. (2006). the relationship between vhi scores and specific acoustic measures of mildly disordered voice population. journal of voice, 20(2), 308-317. wolfe, v., long, j., youngblood, h. c., henry, w., & olson, m. s. (2002). vocal parameters of aerobic instructors with and without voice problems. journal of voice, 16(1), 52-60. yiu, e. m-l. 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(2002). the voice and its care: survey findings from actors’ perspectives. journal of voice, 16(2), 229-243. 25. vir die t0ek0m3tige gehooraeparaat-verbhuiker. deur w. van der sandt. dikwels ontvang ons briewe van hardhorende persone, waarin hulle ons om raad versoek in hulle moeilikheid. hiervolg »n tipiese geval: «die afgelope paar jaar het my doofhoid gewcldig toegeneem en 'η x gehoortoestel was van nul en generwaarde. my vrou moet of teen my skreeu, 6f moet alles uitskrywe, wat natuurlik uitloop op 'n geweldige inspanning vir albei van ons, ek sal onoindig daarby kan bant as ok die geleentheid kan kry om lippetaal te lees, maar ongolukkig is ok op die platteland woonagtig en kan ek nie klasse by woon nie. daarom wens ek u raad intewin, of u reken dat ek besoek moet bring aan 'n professionele onderwyser in liplees, of met behulp van »n handboek en hulp van 'n buitestander, (in hierdie geval my vrou) die kuns aan te loer wat so broodnodig vir dio hardhorende is, persone neem soms sommer aan dat bloot deur ander se lippe dop te hou, behoort »n mens maklik die vaardigheid om lippe te lees sonder sposialg opleiding meester raak maar dit is nie so in my geval nie. tj raad sal ton seerste gewaardeer word." problemo van die onaangepasto hardhorende volwassene word in hierdie brief pragtig saamgevat. die skrywer het waarskynlik «η gehoorapparaat blindweg uitgesoek, sonder om te weet of dit vir sy spesifieke geval geskik is. sonder om enige baat daarby te vind met verloop van tyd, probeer hy homself nou rehabiliteer deur liplees aan te leer. hy het ook, net soos soveel ander hardhorende persone die verkeerde rigting van die staanspoor af ingeslaan, * verondorstol u het 'n bepaalde hoeveelhoid gehoor kwyt geraak. by die begin-fase van u gebrek het u geaarsel om u vriende dit te laat agterkom. hoe lank reken u dat dit weggesteek kan word sonder dat iemand daarvan op een of ander tyd bewus word? by een of ander geloentheid sal u nie hoor wat gesq word nie en sal min of meer 'n ernstige situasie ontstaan. soms na slaaplose nagte, nadat die situasie oor en oor betrag is, sal u besluit om iets in verband met die saak aan te vang, maar wat? u sal waarskynlik »n oorspesialiteit raadpleeg. tj moet voordat u verder gaan u onderwerp aan 'n mediese ondersoek en 'n diagnose probeer inwin oor wat verantwoordelik daarvoor is dat u gehoor aangetas is. die gehoorverlies mag altemit toegeskrywo word bloot aan 'n opstruksie wat veroorsaak is deur »n opeenhoping van was in die buiteoor-kanaal, of aan vergrote mangels of adenoide of aan hoe bloeddruk. as hierdie oorsake uit die weg geruim word, sal u gehoor waarskynlik woer normaal of ampor normaal word. maar as u geval toe te skrywe is aan progressiewe doofheid moet daar ander stappe geneem word. moet dus geen gehoorapparaat aanskaf alvorens die " oorsaak van u verlles behoorlik gediagnoseer is nie. die volgende stap sal dan wees om 'n algehele mediese ondersoek te r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26. ο ondergaan om u fisiese goskiktheid vastestol» u dieet mag aandag nodig ho, baie hardhorende individue vind baat by dieet therapie, wat help om vermoeienis te v6rwyder. met die verbetering van u algemene gesondheid, mag u gehoor outomatios ook verbeter. die normalo menslike oor beskik oor gewoldigo moontlikhede wat betrof gehoorsgovoeligheid, om die telefoontermo te gebruik dit staan gelykaan 120 decibels, dio decibels, vernoem na alexander graham bell, die ontworper van die telofoon, is 'n eenheid wat gebruik word om klank-intensiteit to meet. die vraag ontstaan nou hoeveel van hierdie: decibols 'n mens kan verloor sonder dat jyself of iemand anders daarvan bewus word? outoriteito boweer dat dit van individu op individu varieer. in sommige gevalle sal u fn gehoorsgevoelikheid agteruitgang bespeur met fn verlies van 18 tot 20 decibels, maar in ander gevalle weer sal die hoedanigheid om outomaties te hoor voortduur selfs mot 'n verlies van 30 decibels, sodra u verlies 30 decibels oorskrei, sal u vind dat die gesproke woord nie meer verstaanbaar is nie tensy u 'n meganies.o of olektriese versterkingsapparaat gebruik. die individu word nou in die fhardhorende' katorgorie. geplaas. in sommige gevalle sal die gehoor steeds agteruitgaan, en die pogins om te hoor met 'n apparaat sal meer en meer inspanning verg.' so'n toestand word gewoonlik na verwys as 'doofheid', alhoewel daar soms restantegehoor oorskiot wat sluimerend en ongebruik bly. hierdie restantegehoor staan bekend as die gohoor-residium. as u u gehoor audiometries laat ondersook deur 'n oor-spesialiteit, wat waarskynlik oor 'n audiometer sal beskik, kan. die verlies in decibels bepaal word, dio algemene karakteristieke van u verlies kan vasgestel word. die toets sal ook toon of u beter met luggeloiding of met beengeleiding sal kan hoor in eersgenoemde geval word die oorstuk in die oorkanaal geplaas, en in laasgenoemde geval word die been-ossilator op die mastoide been agter die oor geplaas. die toets sal ook toon of u aan konduktiewe of perseptiewe doofheid ly. die patroon van u gehoorkurwe sal toon hooveel baat u van 'n gehoorapparaat kan verwag. as die verlies tussen 20 en 40 decibels strok, kan u veel baat van fn gehoorapparaat verwag na die nodige verstellings gedoen is. as die vorlies tussen 40 en 60 decibels le kan u nog baie van die instrument verwag dio beste wat verkry kan word. as die verlies van 60 tot 80 decibels strek, sal dit in die meeste gevalle nodig wees dat die gehoor-rosidium weer to moet opvoed om gehele en ongesteurde spraak optevang. dit hang bloot van dio individu af, en hoelank die gehoor in onbruik geweos het. as die verlies tusson 80 on 100 decibels 1©, dan kan alleenlik met intensiewe oefening van die gehoor-residium en met behulp van liplees dit moontlik gemaak word om spraak van een persoon in 'n stil omgewing te "tfolg. as u 'n liefhebber van musiek is, sal u dit nog oor die radio of oor 'n grammofoon kan geniet. u sal moet gewoon raak aan 'n sekere hoeveelheid r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 27 agtergrond geraas, en leer om dit te ignoreer, want alhoewel die ontwikkcling van elektriese gehoorapparate ver gevorder en 'n hoe peil bereik het, is daar nog bykomende interne geluide, in sommigo apparate meer, ander minder wat steurend kan wees. sommigs gevalle van gehoorverlies maak die gebruik van ·η gehoortoestel onmoontlik. klank wat hom deur die apparaat bereik, mag so ab'normaal wees (veral· deur die goedkopor apparate) dat dit die oor baie irritecr en die luisteraar nie die geluid kan verduur nie. in so'n geval is al genade vir die akoestiesegesteurde om die ander sintuie in tc span en gebruik te maak van liplees, asook ·η betor verstaanbaarheid te ontwikkel deur wakkerheid on oplettendheid. as. u dus *n apparaat probeer, dring aan op 'n verstaanbaarheids en diskriminasie. toots. as so'n woordelys nie verkrybaar is nie, laat iemand dan vir u ·η paar sinnotjies voorlees en herhaal dit sonder om na die spreker se lippe of gesig to kyk. as dio apparaat wat u besig is om te toots u goeie diens gesorg, behoort u ·η telling van 70$ te behaal, on as dit die instrument is wat dio besto beantwoord aan u vereisto behoort u enigiets van 90 tot ·η 100$ te behaal. u telling sal natuurlik grootliks saamhang mot die tipe on graad van u verlios. as u nie kan besluit of die apparaat u die nodiga hulp verleen nie, neem dit na u huislike of kantooromgewing vir 'n week en toets dit daar aan dio alledaagso vereistes. moet dit nooit nalaat om lippe te leer leos nie al is u verlies hoe gering. deur u gehoor van die godurige spanning to vorlig, help dit al baie om die verlies nie te vergroot nie, oo, ore en vorstand sal geredelik saamwerk, solfs al gebruik u ·η gehoorapparaat. die klank wat in meeste van die gevalle vir u onverstaanbaar vir die oor voorkom, sal dikwels deur die oog onderskei word. as u in ·η stad woonagtig is waar daar fasiliteite vir liplees bostaan, •n skool of ander inrigting, moet u dadelik daarby aan.sluit sodra u seker daarvan is dat geen mediese of snykundige bohandeling u kan baat nie. maar moet dit ook nooit nalaat om die gghoor-residium to stimuleer nie. die voordeel wat die meeste van die hardhorendes dour hierdie akoestiese oefeniug sal baat, kan allsenlilc gesmaak word deur »n persoon wat dit gebruilc. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sajcd 87 speech-language therapy for adolescents with written-language difficulties: the south african context d erasmus, b communication pathology; l schutte, b communication pathology; m van der merwe, b communication pathology; s geertsema, m communication pathology department of communication pathology, university of pretoria, gauteng, south africa corresponding author: s geertsema (salome.geertsema@up.ac.za) objective. to investigate whether privately practising speech-language therapists in south africa are fulfilling their role of identification, assessment and intervention for adolescents with written-language and reading difficulties. further needs concerning training with regard to this population group were also determined. method. a survey study was conducted, using a self-administered questionnaire. twenty-two currently practising speech-language therapists who are registered members of the south african speech-language-hearing association (saslha) participated in the study. results. the respondents indicated that they are aware of their role regarding adolescents with written-language difficulties. however, they feel that south-african speech-language therapists are not fulfilling this role. existing assessment tools and interventions for written-language difficulties are described as inadequate, and culturally and age inappropriate. yet, the majority of the respondents feel that they are adequately equipped to work with adolescents with written-language difficulties, based on their own experience, self-study and secondary training. the respondents feel that training regarding effective collaboration with teachers is necessary to establish specific roles, and to promote speech-language therapy for adolescents among teachers. conclusion. further research is needed in developing appropriate assessment and intervention tools as well as improvement of training at an undergraduate level. keywords: speech-language therapist, adolescents, written difficulties, current practice, perceptions, needs, training, south african context s afr j cd 2013;60:50-58 doi:10.7196/sajcd.87 appendix a is available with the online pdf of this article at http://dx.doi.org/10.7196/sajcd.87 the international reading association’s commission on adolescent literacy (moore, bean, birdyshaw & rycik, 1999) states that 21st century adolescents will be required to read and write more when entering the adult world. future literacy needs of adolescents are complex and demanding; therefore serious and continuing attention is needed in the development of their reading, writing and language skills (kathard et al., 2011). with age, literacy difficulties increasingly affect adolescents, which can lead to reduced competence and confidence in adulthood. this compromises their life and work trajectories (harreveld, baker & isdale, 2008). a common concern is that adolescents do not develop the adequate writing skills needed for academic and vocational success and success in their personal lives (kathard et al., 2011). the effect that reading and writing disabilities have on students’ transition into adult life is seldom addressed (sitlington, 2008). most adolescents who have learning disabilities not only present with reading deficits, but also with deficits in other academic areas such as writing (geertsema, hyman & van deventer, 2011; shumaker & deshler, 2003). owens (2010) further categorises written-language difficulties into dyslexia (a disorder of reading characterised by poor reading comprehension or word-recognition abilities), and dysgraphia (difficulty in writing including spelling errors, punctuation, word omissions, agrammatical sentences, substitution and lack of organisation). dyslexia and dysgraphia are distinguished from non-specific reading disorders, on the grounds of their characteristic problems with decoding and encoding (jantzen, 2010; stark, 2010). these decoding and encoding problems can be described in terms of dyslexia, discalculia (a mathematical learning problem), and gertsmann syndrome (poor spatial orientation) (stark, 2010). non-specific reading difficulties are differentially distinguished from dyslexia on the basis of possible low intelligence, poor motivation, perceptual and sensory problems, emotional problems, social-cultural factors, educational deprivation, attention deficit disorder (add), attention deficit hyperactivity disorder (adhd), or a second-language learning barrier (stark, 2010). factors leading to non-specific writing difficulties may range from difficulties with the execution and regulation of the processes that underlie proficient composing to motivational factors (stark, 2010). children experiencing these difficulties display shorter written texts, are more prone to grammatical or spelling errors, and have poor organisational skills (owens, 2010). literacy skills are essential for people to achieve maximum functional participation throughout their foundation-phase school years into adulthood, and are prerequisites for employment as well as quality of life (asha, 2001). many children and adolescents, growing up in deprived socioeconomic environments, are at risk of poor oral language and general communication skills (kathard et al., 2011). spoken and written language are strongly linked in terms of the physiology of the reading (decoding) and writing (encoding) processes (stark, 2010). phonetic decoding abilities (word attack strategies) as well as eidetic deciphering (look-and-say strategies) rely strongly on an individual’s vocabulary. this poses a risk in terms of second-language learning barriers, and cognitive academic language proficiency in general. these risks are aggravated by the current socioeconomic and educational situation in south africa (kathard et al., 2011; jordaan, 2011). south africa has one of the most diverse multilingual and multicultural populations in the world (seeff-gabriel, 2003). the language of learning and teaching (lolt) in schools differs in many cases from home languages spoken and understood by learners. the term ‘additional language’ as opposed to ‘second language’ is preferred, as many south african children are exposed to more than one language in the home and community (jordaan, 2011). many studies in south africa have shown english additional language (eal) learners to display poorer phonological awareness skills than those of their english first language (efl) peers (seeff-gabriel, 2003). these poor phonological awareness skills impact on learners’ basic cognitive academic skills. the result is poorer pronunciation, and negative influences on their reading and spelling skills in the class context, where the lolt is english (pijper, 2003). additional-language learning barriers can also mask the differential diagnosis of dyslexia and non-specific reading and writing problems, because of the many additional factors at play (stark, 2010). the education system in south africa also poses certain challenges. the discontinued outcomes-based education system (obe) is said to have contributed to the high school failure rate. naki (2010) stated that school pass rates have dropped from a 60% average to about 40% average in rural areas, since the onset of the obe system. literacy and numeracy skills have been rated as some of the weakest in the world, as a result of underqualified educators as well as a lack of learning resources (naki, 2010). however, these are not the only factors contributing to the academic situation. the role of language in education, peer-interaction as a social construct during language learning, and contentand language-integrated learning are often overlooked. jordaan (2011) summarises these challenges as limited language awareness, inadequate teaching methods, the essentially positivist nature of obe and weak integrated learning contexts. in addressing some of the challenges, the newly introduced curriculum and assessment policy statements (caps) mark ‘an important step to a basic education sector that is more unified, accountable, better informed about itself and more focused on workable solutions’ (soobrayan cited in department of basic education; notice 752 of 2010, p.4). the caps action plan to 2014 acknowledges the need for improvement of all learning outcomes and proposes to introduce quality early childhood development, improve quality of teaching and learning, undertake regular assessments to track progress, and ensure an outcomes-focused planning and accountability system. more compulsory time spent on english in the foundation-phase classroom of the eal learner, constant numeracy and literacy progress tracking, attainment of minimum language and mathematics competencies in grades 6 and 9, and eventually increasing the number of grade 12 learners eligible for a university bachelor’s programme, are among the 13 proposed goals looking at learning outcomes and coverage (department of basic education, 2010). for a learner to access education, the ability to participate in active and interactive communication with peers as well as with adults in the classroom is necessary. speech-language therapists play a critical role in the development of literacy when a child or adolescent displays communication difficulties. this role is implemented in collaboration with other experts in the field of the development of written language (asha, 2001). the written-language component of literacy is not explored by many speech-language therapists in the secondary school context. a study by ehren and ehren (2001) indicated that many speech-language therapists do not think that the assessment and intervention of written language is their role at the secondary school level. speech-language therapists may be reluctant to assume roles regarding reading and writing for a variety of reasons such as their own perceptions, fear of change, and lack of training (ehren & ehren, 2001). in addition to this, standardised tests with adequate validity and norms are not always available for adolescents (adams, 2002). in a more recent study wellman (2006) of the university of cincinnati (usa) suggested that educator collaboration with speech-language therapists exists in supporting secondary school learners with reading problems, but many educators still hold a more traditional view of speech-language therapists as working only with speech sound production. wellman (2006) suggested that educators and speech-language therapists are not in agreement regarding the roles of the school-based speech-language therapist pertaining to literacy, as put forth by asha (2001). in south africa, very few tests are available to cater for the 11 official languages, and even if assessment material such as the african receptive-expressive tests compiled in the south african language assessments manual (bortz, 1997) are administered, the examiner should preferably be a first-language speaker of the test being administered. only when assisted by a first-language speaker, may an afrikaans or english speaker administer the test (bortz, 1997). specific diagnostic tests for dyslexia are also much needed, and only recently has an afrikaans dyslexia test entered our system (stark, 2010). although many locally relevant studies indicate a willingness to collaborate, support and provide services to primary schools (kathard et al., 2011; moodley, chetty, & pahl, 2005), there is a dearth of knowledge regarding the south african adolescent population. to be a role player in the department of basic education’s immediate ‘action plan to 2014’ (department of basic education, 2010), the speech-language therapist in south africa has to answer a few questions regarding expected competencies and our role in the enhancement of language, learning and literacy in basic education. issues to consider are the type of service delivery models, support in the development of all languages (including english as an additional language), and leadership and participation roles in social innovation (kathard et al., 2011). therapy that addresses the underlying language problems in adolescents should be the primary role of the speech-language therapist at secondary school level. if language disabilities persist beyond the age of 8 10 years, it is no longer perceived to be the educator’s responsibility to address the residual effects (owens, 2010). recent studies indicate that many such residual and persistent effects can occur into adolescence (rescorla, 2008). according to geertsema et al. (2011) written-language challenges, such as sms (short message system) language occurring in the adolescent age group, are usually addressed by the educators themselves. however, the educators in their study perceived the role of the speech-language therapist to be one of assessment of and intervention in spelling errors, and sentence length and complexity. learners should also be supported in the application of specific skills in order to construct meaning from spoken and written language (staskowski & creaghead, 2001). a greater focus on, and understanding of, the needs of adolescents as they progress through their secondary school education is needed for this support (bercow, 2008). there is currently an internationally increased focus on the constant development of the language and communication skills of adolescents throughout their secondary school education (vance & clegg, 2010). if an educator notices a learner who shows signs of poor academic performance due to a possible learning difficulty, referral to a speech-language therapist should be made (asha, 2001). however, wellman (2006) suggested that there is no significant relationship between the educators’ perceived roles of the speech-language therapist working in usa schools and their referral practices. geertsema et al. (2011) found that educators in the south african secondary school system perceive the role of the speech-language therapist to be one of addressing written-language difficulties in the adolescent age group. this perception is in agreement with the roles and responsibilities as set forth by asha (2001) and sashla (2013). furthermore, these educators represent the main source of referral within a system of collaboration in the secondary schools (kathard et al., 2011). evidence-based practice within a population that is often neglected is warranted (geertsema et al., 2011; kathard et al., 2011; rescorla, 2008). as school-based speech-language therapists in south africa are generally employed in schools for learners with special educational needs (lsen), and these populations exclude learners with average to above-average iqs such as learners with dyslexia, the current study focused on services provided to learners in mainstream secondary schools by private-practising speech-language therapists. furthermore, the presence of many eal learners in the historical model c schools in the middle-class socio-economic group has increased the caseload of these learners among private practices in suburban areas. methods objectives the main aim of this study was to describe the services provided to adolescents with written-language disabilities by private-practising speech-language therapists in south africa. the three objectives were to describe: • current practices of speech-language therapists in south africa regarding the assessment of and intervention in written-language skills of adolescents • perceptions of speech-language therapists in south africa regarding their role in assessment and intervention for written-language difficulties in adolescents • the nature of speech-language therapists’ needs in future training, andspecific training skills needed for assessment and intervention for this population. research design this was a survey study which aimed to develop hypotheses in such a manner that more accurate investigation may occur at a later time. within the exploratory research design, a self-administered questionnaire was utilised to research a larger population and more extended geographical region, ensuring a high degree of freedom and anonymity (leedy & ormrod, 2005). participants the target population was speech-language therapists in south africa in private practice. a stratified, purposive probability sampling technique was used. this study only included those speech-language therapists currently in private practice, and the group of respondents was further divided into specific areas of practice. respondents needed to meet the criterion of being actively in private practice – therefore registered with the health professions council of south africa (hpcsa) – before being eligible for inclusion in the sample. the sashla 2009 membership list was used to obtain the names and contact details of all the currently private-practising speech-language therapists in south africa. each member on this list was invited to participate in the study. biographical profile of respondents ten of the respondents (45%) indicated that they graduated from the university of pretoria, 23% from the university of cape town, and 18% from the university of the witwatersrand. one respondent graduated from the university of stellenbosch, one from the university of kwazulu-natal, and one from a university not situated in south africa. of the 22 respondents, 14 indicated that their highest qualification is an undergraduate degree in speech-language therapy and they represented 64% of the sample. thirty-six per cent of the respondents indicated that their highest qualification is a master’s degree in speech-language therapy. twelve of the respondents (55%) have more than 15 years experience in the field, and another 18% have between 10 and 15 years of clinical experience. this indicated that all the respondents have sufficient knowledge and exposure in working with speech and language difficulties. eighteen of the respondents’ caseloads are comprised of less than 25%, 3 of the respondents’ caseloads are comprised of 25 50%, and only 1 respondent’s caseloads are comprised of 50 75% of adolescents with written-language difficulties. ethics the study abided by principles of research ethics by obtaining informed consent, adhering to anonymity and beneficence in terms of the research design, and ensuring the competency of the researchers. informed consent was granted through submission of the questionnaire. each questionnaire was numbered and no names were requested. ethical clearance was obtained from the faculty of humanities, university of pretoria, south africa. procedure a self-administered questionnaire (appendix a) was chosen as the method of data collection. a pilot study was conducted prior to the data collection. based on the feedback received from the respondents who participated in the pilot study, refinements to the questionnaire were made. a covering letter explaining the nature, content and aim of the research study was attached to the questionnaire. respondents were informed that they were consenting to participate in the research study by completing the questionnaire, and that participation was voluntary. a total of 100 questionnaires were distributed to all speech-language therapists on the 2009 saslha membership list via email. the saslha membership list is the most comprehensive database available of private-practising speech-language therapists in south africa. however, it is recognised that not all private-practising speech-language therapists are sashla members, and therefore some amount of respondent bias could have occurred. twenty-two questionnaires were returned via email. a response rate of 20 30% is seen as acceptable (salkind, 2006). the monitoring of returns via email was carefully recorded by utilising a return rate graph, and follow-up mailings to non-respondents was an additional encouragement to participate (irwin, pannbacker, & lass, 2005). analysis data were analysed quantitatively as well as qualitatively. the study objectives were used to guide the analysis, and data were presented in tabular and graphical format using the computer spreadsheet program microsoft excel. a descriptive statistical analysis was used to synthesise and describe quantitative data (irwin et al., 2005). qualitative data were analysed by means of a content analysis. this process involved the categorising of responses obtained and placing these in a specific context. a descriptive statistical analysis was used to synthesise and describe quantitative data (irwin et al., 2005). the objectives were used to determine which topics to include or exclude during the analysis. the number of responses associated with each theme was analysed statistically by determining the frequency patterns for each theme. validity and reliability the goals of the research project were clearly specified in the cover letter. an in-depth literature study was conducted consulting recent and relevant research on assessment and intervention of isolated written-language difficulties in adolescents as well as long-term outcomes when disabilities are not addressed. previous research questionnaires were reviewed and compared with the questionnaire used in this study, in order to ensure criterion validity. a range of questions were included in the questionnaire, e.g. openand closed-ended questions, to ensure construct validity of a well-planned questionnaire (irwin et al., 2005). results and discussion current practice of speech-language therapists in south africa regarding the assessment and intervention of adolescent written-language skills practice regarding assessment most of the respondents (95%) felt that existing assessment tools for assessment of written-language difficulties are insufficient. furthermore, the respondents use more informal assessment tools (64%) than formal tools (36%), confirming this inadequacy. examples of formal assessment tools used by the respondents are the test of word reading efficiency (towre) (torgesen, wagner, & rashotte, 1999), test of written language-2 (towl-2) (hammill & larsen, 1988), wechsler objective language dimensions (wold) (wechsler, 1996), and the test of adolescent language (toal-4) (hammill, brown, larson, & wederholt, 2007). informal assessment tools were mainly indicated as informal written tasks, making use of the adolescents’ school books and written class work and ability to formulate and write down answers. a few of the respondents were of the opinion that the existing assessment tools are not age appropriate (8%) and many felt that they are culturally inappropriate (44%). a need exists for culturally valid and reliable developmental assessment tools for children with written-language difficulties that are able to accommodate multiple languages (bornman, sevcik, romski, & pae, 2010). in south africa the work of authors such as bortz (1997) and stark (2010) is a step in the right direction, but considerable work still needs to be done. furthermore, linguistic bias by the therapist who administers the test, and bias toward life experience and social practices (laing & kamhi, 2003) should be considered in a developing country which requires innovative initiatives grounded in knowledge of the challenges that characterise it. practice regarding intervention respondents mostly base their intervention on experience and not on previous research (figure 1). this indicates that relevant literature and research on intervention with adolescents of diverse linguistic and cultural backgrounds are limited. examples of the different programmes and techniques used by a number of the respondents during intervention are indicated in table 1. fig. 1. respondents’ (n=22)intervention bases. successful intervention the respondents described the following factors as necessary for successful intervention: • the child’s motivation and the parent’s support. many respondents felt that the adolescent’s will to succeed plays the biggest role in successful intervention. when the adolescent has a positive attitude and is willing to work with the therapist, improvement is more likely to occur. it is also important that parents provide support and understand the long-term advantages of speech-language therapists’ services. • appropriate and consistent therapy programmes. respondents commented that consistent intervention, that is relevant to the adolescent’s curriculum, is important. a client-based programme, which specifically meets the needs of the individual, must be designed. one respondent commented that activities need to be fun, and that computer-based activities seem to interest adolescents. another respondent commented that it is important for adolescents to see visible signs of their own progress in order to increase motivation. • improved understanding of written-language deficits. it is important that speech-language therapists understand and identify underlying deficits of written-language disabilities. one respondent mentioned that written-language difficulties, which may not have been identified early, do not necessarily resolve and therefore require the resumption of therapy in the adolescent years when language demands increase. research on neural plasticity and central auditory processing has emerged, and the speech-language therapist has to be knowledgeable in these areas in order to make a correct diagnosis and treat written-language difficulties effectively. challenges the respondents described the following challenges faced by the south african speech-language therapist: • lack of awareness of the speech-language therapist’s role. a lack of public awareness results in reduced referrals from teachers and other professionals, as well as reduced collaboration between professionals. a lack of knowledge among teachers and parents exists in terms of how speech-language therapy can help with adolescent language. • correct identification and diagnosis. respondents felt that written-language difficulties are often identified at a late stage. some respondents are of the opinion that adolescents with written-language difficulties are often labelled as having poor cognitive abilities, and are then referred for remedial education. other respondents feel that written-language difficulties are still diagnosed as a learning problem and referred to remedial programmes where the focus is on grammar and spelling, and not on the language used in writing. • limited appropriate material. this is not only a challenge during assessment, but also during intervention. most of the respondents (95%) were of the opinion that the available treatment tools are culturally inappropriate. some respondents (82%) also felt that they have inadequate training and exposure in the use of available tools for intervention. respondents mentioned an insufficient number of effective programmes and a lack of intervention tools incorporating aspects of the school curriculum. the ever-present additional-language challenge impacting on effective treatment was highlighted. • adolescents themselves. motivation on the side of the client may be the most apparent barrier. clients’ lack of interest and lack of self-confidence poses a problem during intervention. the respondents identified numerous constraints, such as adolescents having limited time to attend and follow through with the intervention programmes, as well as limited financial resources. the greatest challenge identified by the respondents regarding intervention for this population was the lack of sufficient assessment and intervention tools. the fact that speech-language therapists are not adequately trained at undergraduate level in this area was also mentioned. the respondents considered the client’s motivation and parent support to be the most important additional contributor to successful intervention. this correlates with the self-determination theory which suggests that students’ motivation for academic tasks varies in both strength and quality, and both strength and quality predict learning, achievement, and continuation to tertiary education (hardré & reeve, 2003). perceptions of speech-language therapists in south africa regarding their role in assessment and intervention of adolescent written-language difficulties a majority of the respondents (86%) indicated that they felt that speech-language therapists are not adequately involved when it comes to the identification, assessment and intervention of written-language difficulties in adolescents. however, they do feel they have a role to play in these processes. speech-language therapists may be reluctant to assume roles regarding reading and writing for a variety of reasons such as: their own perceptions, fear of change and lack of training (ehren & ehren, 2001). according to our findings, south african private-practising speech-language therapists are aware that identification, assessment and intervention of adolescents with written-language difficulties are within the scope of practice of the speech-language therapist. perception regarding assessment a majority of the respondents (86%) felt that speech-language therapists in south africa are insufficiently active and involved in the assessment of adolescents with written-language difficulties. fourteen respondents (64%) indicated that they feel responsible for identification of adolescents with written-language difficulties together with other professionals. these professionals include: teachers, occupational therapists, remedial teachers, neuro-psychologists, educational psychologists and clinical psychologists. perception regarding intervention a majority of the respondents (82%) reported that speech-language therapists in south africa are insufficiently active in providing treatment to adolescents with written-language difficulties. only 18% of the respondents indicated that they feel solely responsible. twelve (55%) indicated they are responsible as part of a multiprofessional team. six respondents (27%) felt that they had no role to play during intervention in written-language difficulties in this population. needs in future training regarding assessment and intervention for adolescent written-language difficulties ten (45%) respondents felt adequately equipped to provide intervention to adoles­cents with written-language difficulties. some indicated they felt this way because of experience, self-study and secondary training. on the other hand, 8 respondents (36%) stated that they felt poorly equipped to provide intervention to this population. ten (45%) respondents also felt that training in intervention of written-language difficulties in adolescents should be taking place at an undergraduate level. the respondents specifically stated that training with regard to collaboration with teachers is needed, as well as training in the provision of information to educators in order for them to make appropriate referrals and accommodations in the classroom. there is increasing awareness of the need for collaboration between speech-language therapists and professionals in the secondary educational setting (vance & clegg, 2010). most respondents also felt that the greatest need in providing intervention to adolescents with written-language difficulties lay in the area of assessment. training needs at different levels of education can be summarised as follows: undergraduate of the 22 respondents, 14 (64%) indicated that their highest qualification is an undergraduate degree in speech-language therapy. one of these indicated that s/he did not feel equipped to provide intervention, and another indicated that s/he is well equipped. half indicated that they feel adequately equipped to provide intervention; however, 36% indicated that they feel poorly equipped to do so. masters eight (36%) respondents indicated that their highest qualification is a master’s degree in speech-language therapy. equal numbers of these respondents felt sufficiently and insufficiently equipped to provide intervention for written-language difficulties. some of the respondents who indicated feeling adequately equipped did not feel equipped through primary training, but as a result of experience, self-study and secondary training in the field of remedial education. figure 2 indicates the respondents’ perceptions regarding the expected level of training necessary for assessment and intervention for adolescents with written-language difficulties. fig. 2. respondents’ (n=22) perceptions regarding necessary level of training. in summary, most respondents (86%) indicated that they felt the greatest overall need in written-language difficulties in adolescents lay in the area of assessment by speech-language therapists. the south african context, the need for standardised tools in the various languages, and the need for culturally and linguistically valid tools, as well as more affordable tools, were stressed throughout. the need for specific guidelines when working with adolescents with written-language difficulties was mentioned, as well as a need for information on the curriculum of secondary school students, and what is expected of them academically. a previous study reported that classroom teachers are the team members who are most familiar with the educational curriculum and are most responsible for ensuring that it is presented (geertsema et al., 2011). on the other hand, speech-language therapists are also key role players in the modification, adaptation, and individualisation of this curriculum (elksnin & capilouto, 1994). it is therefore essential that confidence and trust be established among educators and speech-language therapists when educating children in the classroom (ferguson, 1992). the need for information on the influence of language impairment on written language was additionally identified as a possible contributory factor to the uncertainty surrounding the assessment and treatment of the adolescent population. summary and conclusion according to asha (2001) and sashla (2013), assessment of and intervention for adolescents with written-language difficulties fall within the role of the speech-language therapist. educators agree that this population is the responsibility of speech-language therapists (geertsema et al., 2011). the findings of the study indicate that the respondents are aware that this is their role, and that they should be actively involved in the identification of, assessment of and intervention for adolescents with written-language difficulties; however, they feel that speech-language therapists in general are not actively involved in identification, assessment and intervention in this population. the majority of the respondents feel that they are adequately equipped to work with adolescents with written-language difficulties; however, this is based on own experience, self-study and secondary training. training regarding assessment of and intervention with adolescents with written-language difficulties needs to take place at an undergraduate level. there is also a need for training regarding effective collaboration with teachers, including the provision of information to teachers in the secondary educational setting – which is a depicted role of the speech-language therapist (owens, 2010). the current practice of speech-language therapists involves mostly assessment with informal assessment tools, indicating that current assessment tools are not sufficient, age-appropriate or culturally sensitive. the current situation in south africa is that school pass rates have dropped from a 60% average to about a 40% average in rural areas (naki, 2010). this highlights the importance of our role as speech-language therapists in a collaborative relationship with educators (geertsema et al., 2011). further research is needed in developing appropriate assessment and intervention tools, as well as improvement of training at an undergraduate level. implications the current study yielded a small sample size and focused only on speech-language therapists in private practice in south africa. however, the preliminary results could have long-term implications for undergraduate and postgraduate degree studies, continuous professional development programmes, and similar studies on a larger scale in south africa. should an additional training programme be developed, the data obtained could be used to address the perceptions and needs of speech-language therapists regarding assessment and intervention of adolescents with written-language difficulties, e.g. the development of linguistically and culturally valid assessment material, broadening the theoretical knowledge base on the adolescent population in general, and collaborative practices within the educational system. the adolescent population in the current south african education system has been identified as having extensive literacy problems within a system that seems to have failed them (naki, 2010). optimal intervention should therefore be provided by the south african speech-language therapist as part of a team of professionals. speech-language therapists should be optimally equipped to provide intervention for adolescents with written-language difficulties. recommendations for further research the involvement and role of other professionals working with adolescents with written-language difficulties could be researched in the future. the effectiveness of collaboration between different professionals during assessment of and intervention with adolescents with written-language difficulties should also be evaluated. in-depth research focusing on the assessment and intervention materials currently used by speech-language therapists should be conducted. specific assessment tools and programmes should be evaluated regarding their appropriateness for the south african context. there is currently a lack of research regarding adolescents and adults with written-language difficulties and how they cope in the educational and vocational settings. this is a topic for future research. references adams, c. (2002). practitioner review: the assessment of language pragmatics. j child psychol psychiatry, 43, 973-988. doi:10.1111/1469.0026 american speech-language-hearing association. (2001). roles and responsibilities of speech-language pathologists with respect to reading and writing in children and adolescents (position statement). retrieved 18 august 2013 from www.asha.org/policy. bercow, j. (2008). the bercow report: a review of services for children and young people (0-19) with speech-language and communication needs. nottingham: dcsf publications. bornman, j., sevcik, r. a., romski, m., & pae, h. (2010). successfully translating language and culture when adapting assessment. journal of policy and practice in intellectual disabilities, 7(2), 111-118. doi:10.1111/j.1741-1130.00254.x bortz, m. (1997). south african language assessments manual. northumberland: stass publications. davies, a. (1987). thrass: teaching handwriting, reading and spelling skills. london, collins educational. department of basic education. (2010, p. 4). notice 752 of 2010. pretoria: department of basic education. ehren, b. j., & ehren, t. c. (2001). new or expanded literacy roles for speech-language pathologists: making it happen in the schools. semin speech lang, 22(3), 233-244. doi:10.1055/1-2001-16146 elksnin, l., & capilouto, g. (1994). speech-language pathologists’ perceptions of integrated service delivery in school settings. language, speech, and hearing services in schools, 25, 258-267. ferguson, m. (1992). implementing collaborative consultation: an introduction. language, speech, and hearing services in schools, 23, 361-362. geertsema, s., hyman, c., & van deventer, c. (2011). sms language and written language problems: educators’ perspectives. south african journal of education, 31(4), 475-487. hammill, d. d., brown, v. l., larson, s. c., & wederholt, j. l. (2007). test of adolescent language (4th ed). east moline, il: linguisystems. hammill, d. d., & larsen, s. c. (1988). test of written language (2nd ed.), austin, tx: pro-ed. hardre, l., & reeve, j. (2003). a motivational model of rural students’ intentions to persist in versus drop out of high school. journal of educational psychology, 95(2), 347. doi:10.1037/0022-0663.95.2.347 harreveld, b., baker, k., & isdale, l. (2008). teachers’ work in reading literacy across the curriculum in the senior phase of learning. curriculum journal, 19(2), 105-118. doi:10.1080/09585170802079538 irwin, d. l., pannbacker, m., & lass, n. j. (2005). clinical research methods in speech-language pathology and audiology (1st ed.). san diego: plural publishing. jantzen, c. (2010). dyslexia: learning disorder or creative gift? (2nd ed.). chippenham, wiltshire: cpi antony rowe. jordaan, h. l. (2011). language teaching is no panacea: a theoretical perspective and critical evaluation of language in education within the south african context. south african journal of communication disorders, 58(2),79-85. kathard, h., ramma, l., pascoe, m., jordaan, h. l., moonsamy, s., wium, a-m., du plessis, s., pottas, l., khan n. b. (2011) how can speech-language therapists and audiologists enhance language and literacy outcomes in south africa? (and why we urgently need to). south african speech-language-hearing association, 2011-12. south african journal of communication disorders, 58(2), 59-71. laing, s. p., & kamhi, a. (2003). alternative assessment of language and literacy in culturally and linguistically diverse populations. language, speech, and hearing services in schools (34)44-55. doi:10.1044/0161-1461(2003/005) moodley, s., chetty, s., & pahl, j. (2005). the school-based speech-language therapist: choosing multicultural texts. south african journal of communication disorders, 52, 40-50. moore, d. w., bean, t. w., birdyshaw, d., & rycik, j. a. (1999). adolescent literacy: a position statement for the commission on adolescent literacy of the international reading association. retrieved 18 august 2013 from www.reading.org/downloads/positions/ps1036_adolescent.pdf naki, e. (2010, july 06). south african pupils to learn in first language. retrieved 22 august 2010 from apnews.excite.com/article/20100706/d9gpn3cg2.html. owens, r. e. (2010). language disorders: a functional approach to assessment and intervention (5th ed.). boston: pearson. pijper, n. c. (2003). the phonological awareness, written spelling and oral reading of learners in an inclusive english-medium education setting. unpublished master’s dissertation. university of pretoria. rescorla, l. (2008). age 13 language and reading outcomes in late-talking toddlers. j speech lang hear res, 48, 459-472. doi:10.1044/1092-4399 (2005/031) salkind, n. j. (2006). exploring research. upper saddle river, nj: pearson education. sashla. (2013). south african speech-language-hearing association position statement. retrieved 18 august 2013 from www.sashla.org. schumaker, j. b., & deshler, d. d. (2003). can students with ld become competent writers? learning disability quarterly, 26(2), 129-141. doi:10/2307/1593595 seeff-gabriel, b. (2003). phonological processing: a platform for assisting second-language learners with english spelling. unpublished master’s dissertation: university of pretoria. sitlington, p. l. (2008). students with reading and writing challenges: using an informal assessment to assist in planning for the transition to adult life. reading &writing quarterly, 24(1), 77-100. stark, s. (2010). disleksie. vereeniging: prestige art press. staskowski, m. & creaghead, n. a. (2001). reading comprehension: language intervention target from early childhood through adolescents. semin speech lang, 22(3), 185-196. doi:10.1055/s-2001-16198 torgesen, j., wagner, r. & rashotte, c. (1999). test of word reading efficiency (towre). torrance, ca: western psychological services. vance, m., & clegg, j. (2010). editorial note: research and practice in the language and communication needs of adolescents in secondary education. child language teaching and therapy, 26(2), 101-102. doi:10.1177/0265659010366503 wechsler, d. (1996). wechsler objective language dimensions. upper saddle river, nj: pearson education. wellman, l. (2006). teachers’ and speech-language pathologists’ definition of reading and perceived roles of school-based speech-language pathologists: relationships to teacher referral practices. (dissertation). retrieved from https://etd.ohiolink.edu/ vol 57 • december 2010 • sajcd 3 editorial communicating openly: sajcd is now an open-access journal the internet has revolutionised publishing, and journal articles are now primarily accessed electronically. in 2005 european online sales in scientific, technical and medical publishing surpassed print sales for the first time (mort, 2006). in 2009 nearly 10% of all scientific, technical and medical journals were published using an open-access model (pollock, 2009). open-access literature is online, available to all, free of charge and free of most copyright and licensing restrictions. it is made possible through the internet and the consent of the author/s (suber, 2004). this issue of the south african journal of communication disorders is our first openaccess edition, available to all online at http://www.sajcd.org.za/index. php/sajcd – an important milestone for the journal, which has come a long way since its inception in 1948. looking back sajcd was first published as the journal of logopedics in march 1948. the editor, rhona gorvy, gives a fascinating insight into the professions at that time. focusing mainly on ‘speech therapy’ rather than audiology, she exhorts colleagues to engage with the papers therein and notes that: while much has changed in the profession since that time – not least the disappearance of terminology that now makes us shudder (e.g. clients referred to as ‘speech deviates’ or ‘hearing deviates’) – there is much in this first volume that is still pertinent today: a call for closer co-operation between education and health; awareness and promotion of cpd events; and a call to provide services to all the ‘different racial groups’ through mobile clinics in rural districts. this latter point is especially poignant since 1948 is the year in which apartheid was introduced as an official policy in south africa following the general election. in 1954 the journal became known as the journal of the south african logopedic society, and a further name change occurred in 1971, to the journal of the south african speech and hearing association. the annual subscription fee at this time was r1.50. in 1977 the journal became the south african journal of communication disorders, and the subscription was upped to r2.50. professor brenda louw, editor of the sajcd in 1994 – another milestone year – outlined some of the challenges of editing the journal (louw, 1994), the ultimate one being whether a scientific publication in the fields of speech-language pathology and audiology is at all relevant to the south african situation. the alternative to scientific publication is informal dissemination of clinical information, e.g. through newsletters and study groups. she concluded that such a publication is indeed important: ‘the time and effort invested in the publication process by the author, reviewers and editors is justified to help create an important body of knowledge in the field. this is specifically true of the south african situation in which a dearth of knowledge still exists regarding communication disorders and service delivery in the local context.’ (p. 106). the question raised by louw (1994) has been raised often since then. claire penn (2007) described a crisis in the professions due to a widening chasm between clinical practice and scientific research. she noted that ‘without the discipline of science, we will simply remain a group of practicing clinicians and we will never achieve mastery or acknowledgement. we can “practice” doing science but what is needed is for science to be done with authority, with an audience, with peer review, with argumentation and with energy.’ (p. 15). looking forwards open-access publishing is entirely compatible with peer review, one of the aspects mentioned by penn (2007). all of the major open-access initiatives for scholarly literature insist on the importance of the peer review process in promoting and maintaining the highest standards of scientific research. sajcd has always relied on peer review, but this process itself is not without challenges: the pool of appropriately qualified and available reviewers is small, and the time-consuming task of review is uncompensated and voluntary. many of the authors of journal papers are drawn from this same pool. please consider signing up as a peer reviewer if you are able, and developing your research and writing skills. clinicians can engage in research and are often in the best position to do so! our new cpd section (see back of journal) encourages engagement with the journal and application of findings to one’s own practice. we hope that you will find this a useful avenue for obtaining cpd points. contrary to popular belief, open-access literature is not free or cheap to produce, although it is less expensive to produce than conventionally published literature. advocates of online publishing ask whether there are better ways to pay the bills than by charging readers and creating access barriers. looking forwards we will have to consider the costeffectiveness of sajcd, and whether a printed copy is necessary. in general, the success of online, open-access publications has assuaged concerns about the permanency and impact of online-only articles. please let us know whether you would be happy to no longer receive a printed journal, and perhaps save a few trees in the process. we believe strongly that the journal has a critical role to play in the professions in south africa. we aim to advocate and endorse a full range of research methods, strive for excellence, and ask for help when it is required. but we are aware that the existence of the journal is not something to be taken for granted, and its future is not necessarily secure. it relies on those who contribute to it – as authors, reviewers, editors and readers – and we may need to fight for its survival, if we, like louw and penn, wish the professions in south africa to achieve mastery through research. we encourage our readers and authors to contact the journal (michelle. pascoe@uct.ac.za) with suggestions for what more we can offer the professions of speech-language pathology and audiology, as we usher in the latest phase of the evolution of sajcd (http://www.sajcd.org.za/ index.php/sajcd). michelle pascoe editor-in-chief references gorvy, r. (1948). editorial. journal of logopedics, 1, 1. louw, b. (1994). editing a scientific journal on communication disorders in south africa: a unique challenge. south african journal of communication disorders, 41, 103-107. mort, d. (2006). online passes print in stm publishing. research information. http://www. researchinformation.info/riaugsep06analysis.html penn, c. (2007). ‘don’t give me the theory, just tell me what to do in therapy!’: the slippery slope challenge for the south african professions of speech-language pathology and audiology. south african journal of communication disorders, 54, 13-17. pollock, d. (2009). an open access primer – market size and trends. outsell inc. http:// www.outsellinc.com/store/products/873 suber, p. (2004). a very brief introduction to open access. http://www.earlham.edu/~peters/ fos/brief.htm abstract introduction methodology ethical considerations results discussion conclusion acknowledgements references about the author(s) musa makhoba discipline of audiology, university of kwazulu-natal, south africa neethie joseph discipline of audiology, university of kwazulu-natal, south africa citation makhoba, m., & joseph, n. (2016). practices and views of audiologists regarding aural rehabilitation services for adults with acquired hearing loss. south african journal of communication disorders, 63(1), a155. http://dx.doi.org/10.4102/sajcd.v63i1.155 research project no.: hss/0027/013m original research practices and views of audiologists regarding aural rehabilitation services for adults with acquired hearing loss musa makhoba, neethie joseph received: 03 mar. 2016; accepted: 31 july 2016; published: 29 sept. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: hearing loss in adults is one of the leading disabilities globally. it is managed through aural rehabilitation for which there is a paucity of literature in south africa. this raises the question of interest, the integrity of holistic service provision amongst audiologists and whether interest and challenges affect current practices. objectives: to describe audiologists’ practices and views on aural rehabilitation services for adults, including interest and challenges experienced. method: a descriptive online survey was completed by 45 of 1440 invited practicing audiologists who were members of the two national professional associations in south africa. each association emailed the questionnaire link to all its members. data were analysed using the statistical package for the social sciences version 21, and included the paired samples t-test and chi-squared tests. results: the most provided services were hearing aids (81.4%), communication strategies training (69.8%) and informational counselling (79.8%). a strong interest was reported by most for each service. challenges included limited client compliance, unaffordability of services, limited undergraduate training, language barriers, unrealistic expectations and individual differences. statistically significant differences between service provision, interest and challenges indicated that these are influential but not individually significant to service provision. conclusion: imbalanced service provision, high interest and many more challenges are experienced. these factors contribute but are not solely markedly influential in service provision. introduction background hearing loss in adults is one of the most common disabilities globally (world health organization [who], 2011), especially in countries in sub-saharan africa (adoga, nimkur & silas, 2010). it was reportedly the third most prevalent disability in 2007 in south africa (statistic south africa [stats sa], 2007). adult south africans are exposed to many possible causes of hearing loss such as excessive noise, ototoxic medication and diseases such as hiv-aids that lead to hair cell damage (khoza & ross, 2002). these adults are at risk of experiencing hearing-related communication difficulties such as poor speech discrimination and reduced access to environmental sounds (heine & browning, 2002), emotional withdrawal (pronk et al., 2011) and poor quality of life (joore, potjewijd, timmerman & anteunis, 2002). such difficulties may be effectively managed through aural rehabilitation provided by audiologists (tye-murray, 2009). aural rehabilitation may help reduce participation limitation and facilitate better personal and environmental strategies to reduce the disabling effects of hearing loss (who, 2001). aural rehabilitation is defined as ‘any device, procedure, information, interaction, or therapy which lessens the communicative and psychosocial consequences of a hearing loss’ (ross, cited in bally & bakke, 2007, p. 125). in accordance with this definition, the current study adapted a list of services from the study conducted by prendergast and kelly (2002), who investigated the provision of various aspects of aural rehabilitation services by audiologists. these services were organised into three main components of a comprehensive aural rehabilitation programme, including sensory management, communication training and counselling (figure 1) (boothroyd, 2007). however, interest in these services for adult clients has been reported to be on a decline since the 1970s (schow, balsara, smedley & whitcomb, 1993). limited and imbalanced aural rehabilitation service provision and limited locally relevant literature in south africa seems to be a concern to the profession of audiology as there is more focus on life-threatening conditions, which is typical in developing countries (olusanya, 2004). intervention with hearing aids seems to be the most preferred service by most audiologists, who tend to focus less on comprehensive aural rehabilitation provision (naidoo, 2006; sweetow & palmer, 2005). reasons for this trend are unknown, but it is likely owing to the fact that hearing aids are typically the starting point to enhance hearing prior to providing further intervention (sweetow & sabes, 2005). figure 1: aural rehabilitation components and services. sensory management includes personal devices that enhance access to auditory stimulation. communication training involves helping one learn to effectively communicate after acquiring a hearing loss. counselling involves providing information while supporting the client psychologically and emotionally to effectively deal with changes experienced because of changed hearing. aural rehabilitation counselling the relationship between communication limitations and psychological or emotional well-being in adults with acquired hearing loss necessitates psychosocial adjustment counselling to optimise the client’s emotional well-being and therapeutic progress (ciorba, bianchini, pelucchi & pastore, 2012; pronk et al., 2011). informational counselling entails sharing information that would improve the client’s knowledge about the rehabilitative process and its importance (hartley, 2005; kochkin, 2009; schneider et al., 2010 as cited in meyer & hickson, 2012). this counselling includes information about hearing, the effects of hearing loss and the importance of intervention (tye-murray, 2009). it also helps the client formulate realistic expectations of the intervention (tye-murray, 2009). informational counselling may be used to address issues of cultural and stereotypical beliefs that could lead to limited compliance with the aural rehabilitation programme, which is very important in south africa where there is strong cultural diversity (de andrade & ross, 2005; mackenzie, 1999). thus, audiologists in south africa should be trained to provide culturally and contextually relevant aural rehabilitation, including counselling (national department of health, 2012). sensory management sensory management specifically through hearing aids is usually a first step in the intervention process. cochlear implants on the contrary are less widely fitted, more costly, need extra training for audiologists and involve other medical professionals, making them less feasible in south africa. frequency modulation (fm) systems are also an effective treatment of peripheral hearing and processing difficulties (sykes, 2010). however, there is limited literature on its use in south africa. it was thus imperative that the current study investigates the provision of each sensory management service and the possible reasons for the limited provision of some of these services. communication intervention communication intervention helps improve communication skills, satisfaction, benefit and reduce dissatisfaction from using personal sensory management devices, leading to less retuned sensory devices from unsatisfied users (hawkins, 2005; pienaar, stearn, & swanepoel, 2010; stecker, bowman, yund, herron & roup, 2006; sweetow & palmer, 2005). knudsen, oberg, nielsen, naylor and kramer (2010) reported a non-use rate of up to 40% of hearing aids fitted in australia, the united kingdom and other countries outside africa. storm (2007, as cited in sweetow & sabes, 2010) reports a return rate of 17% of hearing aids for refund if fitting was without further intervention. it appears that audiologists do not provide sufficient communication intervention or mostly only offer specific services that are less time consuming within this category. this could possibly be because of lack of time and being understaffed, besides other challenges. auditory training involves helping the client learn to effectively listen during conversation while communication strategies training involves training to improve expressive communication skills (tye-murray, 2009). speechreading training involves training to effectively use audio-visual skills to improve communication (bishop & miller, 2011; tye-muray, 2009). however, research has constantly indicated limited provision of speechreading training in comparison to other services, even in south africa over the years (millington, 2000; naidoo, 2006; prendergast & kelly, 2002; schow et al., 1993). frequent communication partner training involves training communication partners to effectively communicate with the person who has a hearing loss (laplante-l`evesque, hickson & worrall, 2010). such training seems to be provided insufficiently in south africa (naidoo, 2006). reasons behind this are unknown, but it could be because of limited training even though the scope of practice and undergraduate training should include family-orientated approaches to rehabilitation (national department of health, 2014). aural rehabilitation technology use of computer-based interventions could optimise service provision in south africa. for instance, computer-assisted aural rehabilitation programmes reportedly save time and improve the organisation of the data on each client (sweetow & sabes, 2007). however, there seems to be limited literature regarding use of such technology locally. four common programmes discussed by sweetow and sabes (2007) are recognised in the current study, namely the computer-assisted speech-perception testing and training at the sentence level (caspersent), the computer-assisted tracking simulation (cats), the computer-assisted speech training (cast) and the listening and communication enhancement (lace) programme. little is known about the use of these programmes in south africa. further, it also seems that practical training using these programmes is limited, if at all it takes place in local training institutions. tele-audiology is another technological development to make audiology services more accessible, especially in remote rural areas (lawrence, 2012; nemes, 2010; swanepoel, 2012). however, it seems to remain unused by many audiologists in south africa and there is limited literature on its use as a means to provide aural rehabilitation services. hence, there is limited information on its effects on addressing some of the challenges experienced in providing aural rehabilitation (sweetow & sabes, 2007). this lack of use could be because of such technology being relatively new in south africa. thus, more could be known about it in future, including its possible use in the provision of aural rehabilitation. challenges with aural rehabilitation services lack of resources to provide aural rehabilitation such as time, tools and audiology staff is a global challenge (swanepoel et al., 2010). south africa is no exception, and this may have contributed negatively to audiology service provision as many audiologists rather provide what they can and not what they should (fagan & jacobs, 2012; swanepoel, 2006). binzer (2002) mentioned the lack of adequate reimbursement for providing aural rehabilitation services as one of the reasons that many audiologists do not provide those services. non-compliance of clients with therapy also affects the provision of aural rehabilitation services (sweetow & sabes, 2010). in south africa, socio-economic factors may also impact on service delivery with issues such as unaffordability of transport costs, which could affect attendance to aural rehabilitation sessions for low-income clients. this may have implications for client compliance and benefit from intervention. lack of audiologists’ interest in aural rehabilitation was another challenge reported in the study by prendergast and kelly (2002). little is known about challenges of aural rehabilitation specific to the south african context owing to limited relevant literature. thus, the current study would provide information about the current status of aural rehabilitation service provision, challenges, interest and related factors as reported by audiologists in current practice. methodology study design and context this non-experimental, descriptive study was conducted using a self-administered online survey questionnaire developed by the researcher to best investigate audiologists’ views and practices of aural rehabilitation in south africa. aim and objectives the study’s aim was to describe audiologists’ practice and views on the provision of aural rehabilitation services to adults with acquired hearing loss. objectives were: to describe aural rehabilitation services provided by audiologists to adults with acquired hearing loss; to describe interest in aural rehabilitation and challenges experienced by audiologists in providing aural rehabilitation services to adult clients. participants the link to the questionnaire was sent to a total of 1440 potential participants, of which 1080 were members of the south african speech-language-hearing association (saslha) and 360 were members of the south african association of audiology (saaa). this was in keeping with previous studies that surveyed aural rehabilitation services provided by audiologists who were members of associations (prendergast & kelly, 2002; schow et al., 1993; whitcomb, 1982, as cited in millington, 2000). all participants had to be registered with at least one of the two south african associations and the health professionals council of south africa, and be currently working in south africa as an audiologist and speech therapist and/or audiologist. a total of 45 returned questionnaires were usable. twenty-three participants (51.11%) were speech therapist and audiologists, and 22 (45.89%) were audiologists. twenty-three (51.11%) of the participants worked in private practice, and 12 (26.67%) worked in public hospitals. five (11.11%) participants worked in universities and five worked in other settings. most participants had 6–10 years of work experience. the majority were 30 years or younger, and female. materials the questionnaire was developed using a google form from the google drive system (google, 2013). it was chosen as it was freely accessible and user friendly for the researcher. it consisted of 28 items including short, open-ended, multiple-choice, likert-scale contingent questions, and checkboxes. the questionnaire allowed for different levels of probing within the predominantly close-ended questions, as a large sample size was anticipated. the questionnaire comprised five sections relating to demographics, detailed aspects of service provision, interest and challenges, and training and technological advancements in aural rehabilitation. ethical considerations ethical clearance (hss/0027/013m) was obtained from the humanities and social sciences ethics committee of the university of kwazulu-natal. participants remained anonymous as their email addresses were known only to the professional associations who distributed the questionnaire. participants received an information sheet explaining the nature of the study and their rights as participants, and provided consent before gaining access to the questionnaire. reliability and validity the questionnaire was piloted on five conveniently selected audiologists working at a university to test for any need for improvements (leedy & ormrod, 2013). the pilot questionnaires were initially distributed via post together with a short suggestion form for participants to suggest necessary improvements in the structure, understandability and length. participants’ feedback from the pilot helped to ensure a good face and content validity. the high relevance of the construct to the participants ensured that the construct validity was not compromised. the use of a subjective questionnaire carries the risk of compromising reliability, thus the researcher relied on the participants being open and honest. however, there were responses through which internal consistency was checked amongst different questions probing the same service. the pilot study resulted in structural changes to the questionnaire and the use of an online questionnaire to further simplify the data collection process. research procedure saslha and saaa were requested to email the link to the questionnaire to all their members. participants submitted the completed questionnaires anonymously directly to the researcher’s email by clicking the submit button. completed questionnaires were available in the google form for analysis. the professional associations were asked to send a reminder to all their members after a 2-week period. after 5 weeks from the date of questionnaire distribution, data were transferred to the statistical package for social sciences (version 22) for analysis. data analysis descriptive and inferential statistics were used to analyse the data. the paired samples t-test was used to assess for significance of a difference between two services for one variable such as audiologists’ interest in hearing aids compared with auditory training. the chi-squared (x2) test was used to compare variables of the same service for statistical significance of difference. for instance, a comparison between service provision, interest and challenges for hearing aids was made. the same was done for other services as well. for both the chi-squared and the paired samples t-test, the statistical significance level (p-value) was set at p ≤ 0.05. therefore, a p-value of more than 0.05 would be an indication that there is no significant difference between variables being compared. thus, there would be a high chance of a relationship between the variables being compared. a statistician advised on the selection of statistical tests suitable for the number of responses and sample size to ensure good quality of data analysis. results description of participants while the sample size was relatively small, which could be attributed to limited practice or interest in the topic of aural rehabilitation, results provided an insight into current practices and views. the small sample size and unequal participant numbers precluded analysis such as the difference in practice between public and private audiologists. aural rehabilitation service provision all services were predominantly provided through individual-based sessions. of the 20 provided reasons, 18 (90%) were for individual-based sessions, including personal preference by them or their clients, lack of client compliance, poor feasibility, time, space and financial constraints. reasons for two (10%) participants using group sessions included it being beneficial to family and friends of the client. hearing aids, communication strategies training and informational counselling were provided by more participants in comparison with other aural rehabilitation services (figure 2). figure 2: specific aural rehabilitation services provided. hearing aids were the most provided sensory management service by 81.4% of the 43 participants. most (83.7%) of the 43 participants reported not providing cochlear implant intervention. the majority (79.1%) of the 43 participants reported providing informational counselling services which was significantly greater (p = 0.000) compared with the 52.5% that reported providing psychosocial adjustment counselling. significantly more (p = 0.001) participants provided communication strategies training compared with auditory training. there was a significant difference (p = 0.000) between communication strategies training and frequent communication partner training as more participants provided the former. even more (75.6%) of the 41 participants did not provide speechreading training which was provided by significantly less participants (p = 0.033; p = 0.018) in comparison with frequent communication partner training and auditory training, respectively. five of the 11 participants provided reasons for not providing aural rehabilitation to adults. for instance, two (18.18%) only worked with paediatric clients, one (9.09%) only supervised other audiologists, one (9.09%) participant reported not being trained for cochlear implant mapping and one other (9.09%) participant reported language barriers, time and staff shortage. limited use of technology to aid aural rehabilitation service provision was reported. use of computer-aided programmes seems limited in south africa as none of the participants reported using the cats, caspersent or cast programmes. the lace was used by eight (27.6%) of the 29 participants that responded to the question. eleven (37.9%) participants used other programmes such as cochlear implant programmes, earena, hearing aid programmes, internet-based resources and questionnaires such as the cosi. five participants provided reasons for not using computer-aided programmes, including lack of resources, lack of awareness, and one participant reported using hearing aid software programmes instead, which she thought served the same purpose. four (13.3%) of the 30 participants that responded to the question on tele-audiology reported using it, amongst which one did not use it for aural rehabilitation and the others did not specify. twenty-one participants provided reasons for not using tele-audiology. six (28.57%) did not see a need; eight (38, 09%) reported lack of resources; and six (28.57%) reported lack of knowledge, skills or training on its use. one (4.76%) participant reported that she never thought tele-audiology could be used for aural rehabilitation services. audiologists’ views on their interest in aural rehabilitation contrary to limited service provision, a strong interest was reported. for each aural rehabilitation service, the majority of the participants that did not already provide it reported being keen or very keen on providing it. participants already providing aural rehabilitation were asked if they found each service interesting. most found each service interesting or strongly interesting (table 1). table 1: interest in specific aural rehabilitation services provided. overall, most participants reported finding all services strongly interesting except speechreading training and fm systems which the majority of participants found a little interesting. audiologists’ views on challenges in aural rehabilitation services challenges were experienced with all services as there were more participants that reported experiencing challenges with most services than those that did not (figure 3). figure 3: challenges in aural rehabilitation services currently provided. significantly more (p = 0.023) participants experienced challenges with auditory training than with speechreading training. a significant difference (p = 0.006) between communication strategies training and speechreading was indicated, with more participants experiencing challenges with the former. this was expected as more participants reported challenges with the service that was provided by markedly more participants. twenty-one participants specified challenges experienced. of these, six (28.57%) reported client compliance and five (23.8%) reported lack of skills, knowledge or training in the field of aural rehabilitation. four participants (19.04%) reported a language barrier, two (9.52%) reported unrealistic expectations from their clients, while another two (9.52%) reported individual differences amongst their clients. another two (9.52%) participants reported the cost to their clients as the main challenge. other challenges reported included affordability, limited time, finances and resources, language barrier, limited skills and knowledge in the field of aural rehabilitation, lack of motivation and poor compliance from clients. training for service provision as a challenge was further explored. responses are seen in table 2. table 2: undergraduate training for specific ar services. overall, most participants felt poorly trained for most aural rehabilitation services. the majority reported being sufficiently trained to provide hearing aids, communication strategies training and informational counselling. however, the majority also reported poor undergraduate training for the provision of fm systems, auditory training, psychosocial adjustment counselling, frequent communication partner training and speechreading training. twenty-two (59.5%) of the 37 participants that responded reported that they were never trained for the provision of cochlear implants at all. relationship between service provision, interest and challenges in aural rehabilitation a relationship between service provision and interest as well as service provision and challenges experienced were explored to determine if, and the extent to which, these influence service provision (table 3). table 3: relationship of service provision, interest and challenges in each ar service. overall, there was a significant difference between service provision, interest and challenges experienced by the participants with most services. no statistically significant difference was found between interest and service provision for auditory training and informational counselling, possibly indicating an influential relationship between these variables for each service. thus, it is likely there was high numbers of audiologists providing these services owing to their interest in them. similarly, there was no significant difference between interest and challenges for informational counselling and communication strategies training, indicating a possibility of interest being influenced by challenges or vice versa. thus, it was likely that challenges had an impact on how interesting each service is found to be. discussion the study results provided insight into aural rehabilitation even though only 45 participants responded which limited the generalisability of the study. a possible reason for a poor response rate included the questionnaire being accessible only online meaning that some audiologists had to use their own internet and computers without any incentive. it is also likely that the topic was only of interest to those that responded. however, results provided a starting point from which more research can build on. aural rehabilitation service provision there was unequal service provision overall with hearing aids, communication strategies training and informational counselling being the most commonly provided services. amongst sensory management devices, intervention through hearing aids is, and has been, the most provided service traditionally, even in south africa (carmen, 2003; hull, 2013; naidoo, 2006; ross, 2001). cochlear implants were the least provided sensory management service possibly because of the need for additional training for south african audiologists to practice in this area. the reason for most audiologists not obtaining such training is to be investigated further. another south african study (naidoo, 2006) that investigated audiology service provision in the country also indicated that 91.67% of audiologists reported not providing cochlear implant services since nearly a decade ago. thus, there could be very limited progress and expansion of cochlear implant services in the country as there are still very limited providers of this service. likewise, fm systems are still provided by only a few audiologists. although specific reasons for limited provision of fm systems need to be explored, it is suspected that it could be linked to limited provision of auditory processing assessments conducted prior to recommending an fm system (naidoo, 2006). many medical aids in south africa do not cover the cost of fm systems, further limiting accessibility even in private practice. in comparison, provision of fm systems was and could still be at a much higher rate in the united states as the study conducted by kelly and prendergast (2002) indicated that 84% of participants provided assistive listening devices which include fm systems in the united states. most participants had reported being sufficiently trained for communication strategies training, which is consistent with it being the most provided amongst all communication training intervention services. auditory training seems to be provided by fewer audiologists over time in south africa as only 44.2% of the participants in the current study in comparison with the 90% of government audiologists and 70% of private audiologists in the study by naidoo (2006) provided it. reasons for such a trend are not clear. however, the differences of sample sizes between the two studies could also have contributed to the findings. it is also likely that improved hearing aid technology could make auditory training less relevant as some participants in the study reported. speechreading training seems to be consistently amongst the least provided services, both abroad and in south africa (bally & bakke, 2007; naidoo, 2006; prendergast & kelly, 2002; schow et al., 1993). wemmer (2007) reported that many (26.28%) audiologists are only somewhat clinically prepared to provide speechreading services. in the current study, the majority (40.5%) reported poor undergraduate training and time constraints as reasons for not providing speechreading training. again, the relevance of speechreading in the current times with better hearing aid technology is also in question. in practice, speechreading training takes much more time and effort in comparison with other communication training services, which could also explain its limited provision locally as audiologists are very limited. the provision of frequent communication partner training is still not optimal as more than 50% of the audiologists do not provide it, possibly because of limited undergraduate training. likewise, limited training has possibly led to limited psychosocial adjustment counselling in comparison to informational counselling which is provided by significantly more audiologists. this is consistent with literature which indicated that informational counselling is the most provided counselling compared with other types of counselling (millington, 2000; prendergast & kelly, 2002; ratanjee, 2014). with regard to other technologies used in aural rehabilitation, tele-audiology and computer-aided aural rehabilitation programmes seem to be used to a limited extent locally as suggested by the current study results. it could be that knowledge and resources necessary to use such a technology are limited in the south african context. only the lace programme was reportedly used by less than 30% of participants that responded. none of the participants in the current study used the cats, caspersent and cast programmes. most of these programmes were developed outside africa and as such may not be seen as contextually relevant (khoza, ramma, mphosho & moroka, 2008; pascoe & norman, 2011). however, their use would be better than not, until locally relevant material is available. most participants did not use tele-audiology because they did not see a need for it and lacked knowledge or the necessary skills to use it. other factors that influence the choice of material or technology to use when providing aural rehabilitation services are not known yet, especially in the south african context. interest and challenges in aural rehabilitation a strong interest in aural rehabilitation was generally reported. thus, it is highly likely that most audiologists are interested in aural rehabilitation. however, this interest has not directly translated into increased service provision across all services, possibly because of limited undergraduate training for most services and other factors posing a challenge. none of the aural rehabilitation services are without challenges with linguistic barriers highlighted. language barrier and cultural diversity in south africa are examples of a need to develop contextually relevant resources as research has indicated that the accuracy of a clinical tool could be maintained when made linguistically and culturally relevant (pascoe et al., 2010; rogers et al., 2011). in addition, challenges such as limited training, time, resource and financial constraints reported are expected to have negative effects on aural rehabilitation service provision. however, challenges and interest in isolation do not themselves have a significant effect in the provision of aural rehabilitation. thus, a group of factors significantly affect service provision, and these factors need to be investigated further. the overall findings of this study indicated that although the audiology as a profession has come a long way in the development and provision of particular audiology services, there is still a great need for further development, particularly in training for, developing and providing aural rehabilitation services suitable for the south african context. conclusion aural rehabilitation services are not provided optimally locally, with some services provided much less than others. this has implications for holistic and comprehensive aural rehabilitation. challenges are likely experienced by most audiologists but challenges in isolation may not be sufficient to limit service provision. further, local audiologists most likely have not started using technological developments to their full potential to improve efficiency of service provision. high interest in aural rehabilitation with limited service provision indicates a need to review various aspects of each service and its relevance to the current times and needs of clients with hearing loss. the study highlights a strong need for improvement in training and service provision for aural rehabilitation to fully benefit adults with hearing loss in south africa. limitations the study had limited participants and was conducted via a survey where not all participants may have had easy access to the electronic questionnaire, limiting the generalisability of results. limited numbers of participants limited the use of inferential statistics where inferences had to be made with caution. acknowledgements the authors would like to thank the research supervisor, researchers in the area of aural rehabilitation and related services contributed immensely to this project. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions m.m. is the main researcher who conducted the study for a master’s degree in audiology. l.j. is the research supervisor, who supervised the project from beginning to end. m.m. wrote the manuscript. l.j. critically reviewed the manuscript. m.m. and l.j. amended the manuscript. both authors approved the final draft. references adoga, a, nimkur, t., & silas, o. 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(2001). international classification of functioning, disability and health. retrieved on december 20, 2014 from http://apps.who.int/iris/bitstream/10665/42407/7/9241545429_tha%2beng.pdf world health organization. (2011). world report on disability: 2011. geneva: world health organization. retrieved november 12, 2011, from http://www.who.int/gho/publications abstract introduction research method and design materials and methodology used for data gathering results ethical considerations discussion conclusion acknowledgements references about the author(s) nandel gouws department of speech-language pathology and audiology, university of pretoria, south africa de wet swanepoel department of speech-language pathology and audiology, university of pretoria, south africa leigh biagio de jager department of speech-language pathology and audiology, university of pretoria, south africa citation gouws, n., swanepoel, d.w., & de jager, l.b. (2017). wideband acoustic immittance for assessing middle ear functioning for preterm neonates in the neonatal intensive care unit. south african journal of communication disorders 64(1), a182. https://doi.org/10.4102/sajcd.v64i1.182 original research wideband acoustic immittance for assessing middle ear functioning for preterm neonates in the neonatal intensive care unit nandel gouws, de wet swanepoel, leigh biagio de jager received: 30 aug. 2016; accepted: 11 feb. 2017; published: 28 june 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the primary aim of newborn hearing screening is to detect permanent hearing loss. because otoacoustic emissions (oaes) and automated auditory brainstem response (aabr) are sensitive to hearing loss, they are often used as screening tools. on the other hand, false-positive results are most often because of transient outerand middle ear conditions. wideband acoustic immittance (wai), which includes physical measures known as reflectance and absorbance, has shown potential for accurate assessment of middle ear function in young infants. objective: the main objective of this study was to determine the feasibility of wai as a diagnostic tool for assessing middle ear functioning in preterm neonates in the neonatal intensive care unit (nicu) designed for premature and ill neonates. a further objective was to indicate the difference between the reflectance values of tones and click stimuli. method: fifty-six at-risk neonates (30 male and 26 female), with a mean age at testing of 35.6 weeks (range: 32–37 weeks) and a standard deviation of 1.6 from three private hospitals, who passed both the distortion product otoacoustic emission (dpoae) and aabr tests, were evaluated prior to discharge from the nicu. neonates who presented with abnormal dpoae and aabr results were excluded from the study. wai was measured by using chirp and tone stimuli. in addition to reflectance, the reflectance area index (rai) values were calculated. results: both tone and chirp stimuli indicated high-power reflectance values below a frequency of 1.5 khz. median reflectance reached a minimum of 0.67 at 1 khz – 2 khz but increased to 0.7 below 1 khz and 0.72 above 2 khz for the tone stimuli. for chirp stimuli, the median reflectance reached a minimum of 0.51 at 1 khz – 2 khz but increased to 0.68 below 1 khz and decreased to 0.5 above 2 khz. a comparison between the present study and previous studies on wai indicated a substantial variability across all frequency ranges. conclusion: these wai measurements conducted on at-risk preterm nicu neonates (mean age at testing: 35.6 weeks, range: 32–37 weeks) identified wai patterns not previously reported in the literature. high reflective values were obtained across all frequency ranges. the age of the neonates when tested might have influenced the results. the neonates included in the present study were very young preterm neonates compared to the ages of neonates in previous studies. wai measured in at-risk preterm neonates in the nicu was variable with environmental and internal noise influences. transient conditions affecting the sound-conduction pathway might have influenced the results. additional research is required to investigate wai testing in ears with and without middle ear dysfunction. the findings of the current study imply that in preterm neonates it was not possible to determine the feasibility of wai as a diagnostic tool to differentiate between ears with and without middle ear pathology. introduction background congenital hearing loss has been described as the most common sensory birth defect and is estimated to affect one to six in every 1000 newborns (wrightson, 2007). universal newborn hearing screening (unhs) is a way to detect permanent hearing loss in newborns whether they present with known risk factors or not (hunter, feeney, miller, jeng & bohning, 2010). a known risk factor for the congenital hearing loss is a premature birth which necessitates a stay in the neonatal intensive care unit (nicu) (wrightson, 2007). currently, automated auditory brainstem response (aabr) and otoacoustic emission (oae) hearing screening methods are used to identify possible hearing loss in well-babies as well as at-risk premature neonates. both these screening procedures may be influenced by middle ear conditions. oaes in particular are affected by middle ear pathology (hunter, prieve, kei & sanford, 2013). while aabr appears to be less affected, air conduction thresholds for diagnostic auditory brainstem response (abr) may be elevated in the presence of middle ear effusion (mee) (hunter et al., 2013). because of the high prevalence of mee in neonates (boudewyns, declau & van den ende, 2011), effective and efficient diagnostic tools that can be used in combination with hearing screening technologies, such as oae and aabr are necessary to help detect middle ear dysfunction. wideband acoustic immittance (wai) is a method of middle ear analysis that may provide diagnostic capability in diagnosing middle ear conditions in neonates (hunter, tubaugh, jackson & propes, 2008). while tympanometry uses a single frequency stimulus, wai measures function across a range of frequencies (hunter et al., 2008). wai includes measures, such as wideband reflectance and wideband absorbance. keefe, folsom and gorga (2000) found that the addition of a wai test improved the prediction of hearing status when 2638 newborns were tested with distortion product otoacoustic emissions (dpoaes), transient evoked otoacoustic emissions (teoaes) and aabr. information on middle ear status was thus shown to improve the ability to predict hearing status (hunter et al., 2008). wai tests have also demonstrated better identification of middle ear pathology in neonates than either 226 or 1 khz probe tone tympanometry (hunter et al., 2008); wai is, therefore, a tool that may offer an accurate and non-invasive diagnosis of middle ear function and could be used to differentiate between a ‘refer’ on neonatal hearing screening because of outer and middle ear pathology, and a ‘refer’ because of permanent congenital or early onset hearing loss (pchl) in at-risk neonates residing in the nicu. literature review hearing loss in early childhood and infancy often goes undetected because it exhibits no obvious indication and symptoms. the primary aim of newborn hearing screening is to detect permanent hearing loss, a condition to which oae and aabr are sensitive (hunter, feeney, lapsley miller, jeng & bohning, 2010). these screening tests can be affected by transient outer ear and middle ear conditions that are often present at birth (hall, smith & popelka, 2004). this may lead to false-positive results. neonates in nicu typically represent 10% of the newborn population and the prevalence for pchl is higher than any other condition screened for in the newborn period [joint committee on infant hearing (jcih), 2007]. an admission for a period of longer than 2 days in the nicu is associated with a higher incidence of pchl (jcih, 2007). accurate early identification of pchl is especially problematic in the neonatal population because of the high prevalence of otitis media with effusion (hunter et al., 2008). distinguishing middle ear conditions from sensorineural hearing loss is important to improve hearing screening programme efficacy and for appropriate referrals (boudewyns et al., 2011). in addition, vartiainen (2000) reported delayed diagnosis in infants with pchl because of coexistent transient middle ear pathology. measures of middle ear dysfunction are therefore essential for audiological diagnosis of pchl (jcih, 2007) and should be routinely incorporated in hearing screening protocols (hunter et al., 2013). assessing conductive disorders in young infants (aged 0–6 months) is a challenge (kei & zhao, 2012). conventional 226-hz tympanometry is effective in evaluating middle ear functioning accurately in children older than 7 months, but its efficacy in infants aged 6 months and younger is limited because of the immaturity of infant outer and middle ears (holte, margolis & cavanaugh, 1991; hunter & morgolis, 1992). during the development of the infant ear, several anatomic changes take place that influence the mechanical properties of the ear canal and middle ear (shahnaz, cai & qi, 2014). immittance testing by using a higher probe tone frequency (1 khz) is recommended for diagnostic testing in infants younger than 4 months because it is more sensitive to middle ear dysfunction than conventional 226-hz tympanometry (hunter et al., 2010). in addition to high probe tone immittance testing, wai has been recommended as a test of middle ear function for young infants (aithal, kei, driscoll & khan, 2013). wai measurements of the middle ear can provide information about how well the middle ear functions across the traditional audiometric frequency range, instead of at a single frequency, as is the case with tympanometry (feeney et al., 2014). the technique uses a broad range of frequencies from 62 hz to 13 000 hz and includes a measure of power reflectance as well as admittance and impedance quantities. according to hunter et al. (2008), wai provides more detailed information on the status of the middle ear than tympanometry and does not require pressurisation of the ear canal that might cause discomfort to the infant, making it less difficult to obtain results (keefe et al., 1993; keefe & levi, 1996). power reflectance is the ratio of reflected energy to incident energy (voss & allen, 1994) and ranges from zero (representing complete transfer of sound into the middle ear) up to one (representing no sound transferred into the middle ear). power reflectance is highest at frequencies below 1000 hz and above 4000 hz (hunter et al., 2010), which corresponds to the middle ear transfer function with the most compliant frequencies in the mid-frequency range. wai has the potential to increase the accuracy of diagnosing middle ear pathologies in infants failing newborn hearing screening (keefe et al., 2003). keefe et al. (2003) demonstrated that inclusion of the wai test in unhs programmes decreased the false-positive rates from 5% to 1%. this finding suggests that information on middle ear status improves the ability to correctly refer neonates for diagnostic hearing assessments and improves the ability to predict hearing status. wai is, therefore, recommended as an adjunct tool within newborn hearing screening programmes. the effect of anatomic differences on wai patterns in healthy infants has been investigated by several researchers. keefe et al. (1993) measured wai patterns in 78 healthy infants aged 1–24 months. they reported that infants have lower middle ear compliance and higher resistance compared to adults, which was attributed to ear canal wall movement at lower frequencies. this results in a clear separation in energy reflectance values between 1-month-old infants and adults for responses of less than 0.7 khz, with infants having lower energy reflectance values than adults. keefe et al. (2000) measured energy reflectance in 4031 ears of nicu neonates, healthy neonates and healthy neonates with one or more risk factors for hearing loss. shahnaz et al. (2014) stated that maturation of the middle ear occurs after birth and continues as infants become older. results showed that power reflectance values increased (closer to 1) at low frequencies (<400 hz) and decreased (closer to 0) at high frequencies (>2000 hz) as a function of age. hunter et al. (2010) demonstrated an increase in energy reflectance at 2 khz and greater when middle ear dysfunction was suspected in newborns. hunter et al. (2010) used dpoaes to predict middle ear status at birth and at 4 days thereafter. a few days after birth, when these newborns passed dpoae screening, reflectance values improved (decreased) with normalisation of middle ear function in frequency ranges involving 2 khz and greater. the dpoae test is, therefore, often used as the reference standard to determine normal middle ear function in infants. however, the dpoae alone may not accurately identify minor or sub-clinical middle ear pathologies (kemp, 2002) and hence may not serve as an ideal reference standard (hunter et al., 2010; sanford, keefe & liu 2009). according to aithal, kei, driscoll, khan and swanston (2015) combining dpoae with high-frequency tympanometry, teoae and aabr may provide more stringent control for middle ear pathology in the neonatal population. wai patterns were measured by shahnaz (2008) in 31 nicu neonates that passed both aabr and teoae screening protocols and compared these to wai measurements of 56 adults with normal hearing. results showed a clear separation in reflectance between nicu neonates and adults for responses of less than 0.727 khz. nicu neonates had lower reflectance values than adults at the low frequencies (shahnaz, 2008). shahnaz (2008) reported a mean gestation age of 37.8 weeks of the neonates tested. it is unclear, however, whether this was the gestation age at birth or the gestation age at time of testing. newborn hearing screening routinely takes place prior to discharge from nicu, which may mean that preterm neonates undergo hearing screening at a younger age than that of the infants tested by shahnaz (2008). the current study, therefore, aimed to determine the feasibility of using wai for assessing middle ear functioning of preterm neonates in the nicu. research method and design a cross-sectional exploratory design yielding quantitative data was used for the study. at-risk preterm neonates with a gestation age of 32–37 weeks (mean age at testing: 35.6 weeks, s.d. = 1.6) admitted to the nicu who passed hearing screening by means of both dpoae and aabr were evaluated by using wai prior to discharge. neonates who presented with abnormal dpoae and aabr results were excluded from the study. the study coincided with a routine hearing screening service offered at these hospitals by a private audiology practice. participant selection criteria a purposive sampling technique was used (etikan, musa & alkassim, 2016). the carers for preterm neonates with a gestation age of 32–37 weeks who were admitted to the nicu were given the opportunity to participate in the study. all neonates had to be considered medically stable by nicu personnel and had to have passed both dpoae and aabr screenings before they were included in the study. aabr and dpoae testing was performed for selection of participants and not for data gathering. male and female neonates were accepted as participants in the study. in total, the carers for 56 preterm neonates (106 ears) who passed both dpoae and aabr hearing screening in one or both ears provided written informed consent for participation. six ears were referred for further testing from either dpoae or aabr, or both, and were excluded from the study. wai measurements could be obtained in 75 ears by using a chirp stimulus, in 82 ears by applying a tone-stimulus and in 59 ears by using both chirp and tone stimuli. mean gestational age at the time of testing was 35.6 weeks (range: 32–37 weeks, s.d. = 1.6) with a mean birth weight of 2.1 kg (range: 1.1 kg – 3.45 kg, s.d. = 0.5). fifty infants (89.3%) were asleep during testing, four (7.2%) were awake but quiet and two (3.6%) were awake and restless. twenty-six neonates were female and 30 neonates were male. materials and methodology used for data gathering wai by using either a tone or a chirp stimulus, or both, was performed on the neonates who passed their hearing screens and for whom informed consent was obtained. automated auditory brainstem response aabr was conducted by using the natus algo 3i aabr newborn hearing screening system. this system screens both ears simultaneously at an intensity of 35 dbnhl and 37 clicks per second. it is fully automated with objective ‘pass/refer’ results that require no interpretation (natus algo 3i user manual, 2013). distortion product otoacoustic emissions the automated biologic (audx) oae screener was used to conduct the dpoae measurements. dpoaes were measured in response to pairs of primary tones, with f2 set at 2 khz, 3 khz, 4 khz and 5 khz. the f2/f1 ratio was 1.2 for each primary pair. the stimulus level of f1 was 65 db sound pressure level (spl), and the stimulus level of f2 was 55-db spl. for an overall ‘pass’ result of the dpoae test, three of the four test frequencies had to meet the response conditions defined for a ‘pass’. a ‘pass’ at each f2 frequency is implemented in the default set-up parameters of the audx with reference to absolute dpoae amplitude and the difference between dpoae amplitude and noise floor (audx service and user’s manual, 2002). wideband acoustic immittance power reflectance which is part of wai is the square of pressure reflectance and the ratio of reflected power over incident power (shahnaz et al., 2014). therefore, a power reflectance value of one will indicate that 100% of the energy has been reflected, whereas a power reflectance value of zero will indicate that 100% of the energy has been absorbed and transmitted through the middle ear. power reflectance values greater than one will indicate that more energy has been received than was used as stimulus, which might be attributed to a noisy test environment and/or restless neonate. hunter et al. (2010) proposed the use of a reflectance area index (rai), wherein, instead of individual reflectance values, the reflectance values are averaged over a specified frequency range (e.g. 1 khz – 2 khz, 1 khz – 4 khz and 2 khz – 6 khz). rai can be applied to both the continuous chirp stimulus reflectance function and the discrete tone-stimulus function. the rai has the same unit (percentage) as reflectance (hunter et al., 2010). the commercial hearid system model 3.5.0.5 (mimosa acoustics, inc.) was used for the wai (module 4.5.0.0). the system consists of a laptop-hosted pc-card, connected to an er-10c probe (etymotic research, elk grove village, il) with a probe adaptor cable and a calibration cavity set of four cavities. probe tubes were covered with a silicone rubber tip size er10c-03 (4.3 mm). the same rubber tip size was used for all the neonates tested. this specific probe tip was used because of its easy and stable insertion in the ear canal. the silicone rubber tips were relatively incompressible in the neonate’s ear, but still provided a better fit than the foam tips which are more suitable for larger ear canals. the rubber tips were considered more appropriate in size for the neonate ear (hunter et al., 2010). the probe was calibrated daily (every 24 h) in a quiet room with hearid before testing commenced in the nicu. the mimosa acoustics calibration cavity set (voss & allen, 1994) was used during probe calibration. each test session for all the neonates tested consisted of two wai measurements in each ear one for each stimulus type, namely chirp and tone stimuli. the wideband chirp stimulus was presented at a volume of 60-db spl repeatedly for an average of 1 s. the chirp stimulus data consisted of a frequency range from 0.21 khz to 6 khz with 248 measurements within this range. the 9-tone series (250 hz, 500 hz, 750 hz, 1000 hz, 1500 hz, 2000 hz, 3000 hz, 4000 hz and 6000 hz) was presented simultaneously at a volume of 60-db spl the grouping of frequencies, which were averaged to determine the rai, was determined by using the software for each individual measurement completed in accordance to similar reflectance values at adjacent frequencies (e.g. 250 hz and 300 hz and 400 hz–800 hz) for each of the neonates. the same method was described and followed by hunter et al. (2010). procedure testing was conducted in the nicu. the same audiologist conducted all the procedures. neonates were first tested by dpoae and aabr. to test the reliability of the results from the dpoae and the aabr tests, a rescreen was conducted once if a ‘refer’ result was obtained during the dpoae test, and the same principle was applied for the aabr test. these tests were performed as the initial hearing screening (stage 1) as part of a unhs programme. the relevant protocol specifies that testing should consist of no more than two attempts by using the same screening technique on each ear (jcih, 2007). the aabr and dpoae testing was carried out for the selection of subjects and not for the purpose of data gathering. wai was conducted once the neonate passed both the dpoae and the aabr screening. for wai measurements at least two measurements were completed per ear, one for each channel in the probe (chirp and tone stimuli). the ear that was most accessible was tested first. test time for each neonate varied between 20 and 45 min to assess both ears by using dpoae, aabr and wai. test time depended on various factors, including the neonate’s wakefulness and fussiness, as well as difficulties maintaining probe insertion and noisy environments. in certain cases, the probe had to be refitted between measurements because of noisy conditions and inaccurate probe placement. because nicu ambient noise levels are typically high, a major difficulty during the testing was to keep the noise levels low. it was important to make sure that the neonate was as quiet as possible and in a restful state before testing commenced. to achieve this, neonates were tested after feeding, while in natural sleep or in an awake and quiet state. pacifiers were used if needed to sooth the neonates as well as swaddling. the hearid system made it possible to repeat tests. this was carried out if it was possible to settle down the neonate sufficiently. data screening, cleaning and reduction an expected challenge was to keep noise levels as low as possible while conducting the tests. the aim of data screening was to find one wai measurement, by using either a chirp stimulus or a tone-stimulus or both per ear and one dpoae and aabr measurement in the same test session (hunter et al., 2010). in the current study, the best chirp stimulus and tone-stimulus measurements were automatically selected within a test session by using a default algorithm in the software. this algorithm is described by hunter et al. (2010) as follows: (1) the signal-to-noise ratio at frequencies lower than 1 khz had to be >10 db for over half the tested frequencies, (2) reflectance for each channel within measurements could not be separated by >5 percentage points for frequencies >1 khz and (3) for measurements meeting these criteria, the measurement with the highest signal-to-noise ratio between 1 khz and 6 khz was chosen. the software that was used during the screening process did not provide warnings to the tester as to whether noise levels were unacceptable. to remove high noise and off-target stimulus levels, therefore, the data were post hoc screened. this screening process consisted of identifying measured data with a reflectance value greater than 100% and adjusting the value to 100% (hunter et al., 2010). table 1 presents the number of times that out of range reflectance values of greater than 100% had to be adjusted to 100%. from 961 hz to 2016 hz there are a total number of 1665 samples, and 322 of these samples were corrected to a reflectance value of a 100 – therefore, 19.3% of the data in this range was corrected. table 1: number of corrected wideband reflectance samples by using chirp and tone stimuli. results after data correction was applied, percentiles were calculated at individual frequencies for both chirp and tone stimuli. rai values were subsequently calculated for the frequency ranges as indicated in tables 2 and 3. this process involved evaluation of individual frequencies between 0.25 khz and 8 khz (aithal et al., 2013). as stated by aithal et al. (2013) and hunter et al. (2010), an alternative method would be to evaluate the rais obtained, by grouping adjacent frequencies with similar reflectance. the rai estimation would involve fewer variables and facilitate accurate interpretation of the results. table 2: mean reflectance and rai values for 0.26 khz – 6 khz for nicu neonates by using tone stimuli (n = 82 ears). table 3: mean reflectance and rai values for 0.26 khz – 6 khz nicu neonates by using chirp stimuli (n = 75 ears). figure 1: reflectance data for tone stimuli at individual frequencies (n = 82 ears). figure 2: reflectance data for chirp stimulus at individual frequencies (n = 75 ears). wai measurements were recorded across the wideband reflective spectrum for both tone and chirp stimuli and for integrated frequency ranges in 106 ears. in some cases the neonate was restless and only one of the stimuli could be applied. individual tests were absent for various reasons, such as distress or non-performance on the part of the neonate and inadequate signal level for dpoae testing. for the neonates in the present study, tables 2 and 3 present the reflectance values for the 0, 5th, 10th, 50th, 90th, 95th and 100th percentiles at the individual frequencies and rai frequency ranges for tone stimuli and chirp stimuli, respectively. as shown in table 2 the high reflectance values are evident from the 75th percentile onwards. a similar trend can be seen from the chirp stimuli data displayed in table 3. reflectance values of 56% are already evident at the 10th percentile for a frequency range between 210 hz and 400 hz. when the rai values are compared for the 0th to 75th percentiles, it is apparent that the low-frequency range below 1 khz has the highest reflectance values. for the 90th to 100th percentiles reflectance values of 100% were obtained across the complete frequency band. figure 1 shows the reflectance data for tone stimuli at individual frequencies. the 90th percentile shows a reflectance value of 1 throughout the frequency range. for the 50th percentile higher reflectance values are visible in the low-frequency range compared to the reflectance values of the midand high-frequency ranges. higher reflectance values are also visible in the low-frequency ranges for the 10th percentile, compared to the reflectance values of the midand high-frequency ranges. the 10th and 50th percentile reflectance values decrease between 0.2 khz and 1.5 khz after which the reflectance value data remain relatively constant. the 90th percentile reflectance values for tone and chirp stimuli remained 1 throughout the frequency range. the median reflectance reached a minimum of 0.67 at 1 khz – 2 khz, but increased to 0.7 below 1 khz and 0, 72 above 2 khz for tone stimuli. for chirp stimuli the median reflectance reached a minimum of 0.51 at 1 khz – 2 khz, but increased to 0.68 below 1 khz and decreased to 0.5 above 2 khz. ethical considerations the study was approved by the institutional review board before data collection commenced with ethical clearance reference number: 10433920. neonates enrolled in the study were born at any one of the three specified private hospitals and were admitted to the nicu after birth. parents of nicu neonates were informed of the study and given the opportunity to participate. written parental consent was obtained prior to data collection. it was communicated to the parents that there are no risks involved for the participants of this study as the screening tests are non-intrusive and not harmful to the neonate. discussion wai measures, by using chirp and tone stimuli, were obtained for individual frequencies from 0.26 khz to 6 khz as well as rais that were averaged over different frequency regions (tables 2 and 3). high reflectance values were obtained below 1.5 khz for both tone and chirp stimuli (range of reflectance values: 0.26 khz – 6 khz) compared to the frequency range above 1.5 khz when considering the 0th to 75th percentiles. the high reflectance values measured in the current study below 1.5 khz are in agreement with several other studies that also showed that, for infants, reflectance is the highest at frequencies below 1 khz and above 4 khz, and lowest in the frequency region between 1 khz and 4 khz (aithal et al., 2013; hunter, tubaugh, jackson & propes, 2008). in comparison with previous research on wai in infants (aithal et al. 2013; hunter et al. 2010; shahnaz et al., 2014), the reflectance values measured in the current study were lower at 1.25 khz – 2 khz, and between 3 khz and 4 khz. the 50th percentile was higher in the current study than in the study of aithal et al. (2013). the wai results of the present study are compared to those from the study of aithal et al. (2013) and shown in figure 3. if the median reflectance values of the two studies are compared, similar reflectance values are present in the mid-frequency range of 3 khz – 4 khz. in the study of aithal et al. (2013), the reflectance values obtained at 3 khz are similar to those obtained at 3 khz in the present study. in the low-frequency ranges below 3 khz and in the high-frequency range above 4 khz, however, the present study shows much higher reflectance values if compared to those of aithal et al. (2013). the difference between the wai results of the current study and those of aithal et al. (2013) may be because of the fact that the current study was conducted on nicu neonates, while that of aithal et al. (2013) was conducted on full-term infants. figure 3: a comparison of the reflectance values measured in the present study. table 4 presents rai obtained from neonates in the present study compared to those reported by aithal et al. (2013). when comparing the rai values obtained by aithal et al. (2013), with those of the present study, the rai values for the mid-frequency range (2 khz – 4 khz) at the 10th percentile are found to be comparable, but for the 90th percentile much higher rai values were obtained. considering the complete frequency range (0.2 khz – 6 khz), the difference in rai values between the present study and that of aithal et al. (2013) at the 10th and 90th percentiles were 23.4% and 41.7%, respectively. similarly, the mean difference in rai values across the frequency range of 1 khz – 6 khz at the 10th and 90th percentiles were 4.1% and 44.8%, respectively. for the lower percentile values, it seems as if the difference is lower for the higher-frequency range (1 khz – 6 khz), indicating that the low-frequency values, less than 1 khz, contribute to the relatively high rai values. reflectance values for both studies tend to increase at a frequency less than 1.5 khz and between 2 khz and 4 khz. rai values reported by hunter et al. (2010) in a study on healthy full-term infants demonstrated similar wai values to those reported by aithal et al. (2013). however, the 90th and 100th percentile wai values measured by hunter et al. (2010) were higher than those presented by aithal et al. (2013). in the study by hunter et al. (2010) reflectance values were defined over various frequency regions for both tone and chirp stimuli, which was also carried out in the present study. the results obtained by hunter et al. (2010) indicated that tone and chirp stimuli reflectance values were essentially indistinguishable. in the present study, both tone and chirp stimuli indicate high-power reflectance values below a frequency of 1.5 khz. median reflectance reached a minimum of 0.67 at 1 khz – 2 khz but increased to 0.7 below 1 khz and 0.72 above 2 khz for the tone stimuli. for chirp stimuli the median reflectance reached a minimum of 0.51 at 1 khz – 2 khz, but increased to 0.68 below 1 khz and decreased to 0.5 above 2 khz. table 4: reflectance area indices of infants in the present study (n = 75) compared to those reported by aithal et al. (2013) (n = 66). according to the report of shahnaz et al. (2014), the wai results for newborns tested at 1-month intervals up to 6 months of age show that power reflectance values increased at low frequencies (<400 hz) and decreased at high frequencies (>2000 hz) as a function of age. if the results of the present study are compared to the results from shahnaz et al. (2014), power reflectance decreases at high frequencies (>2000 hz) for the 50th and 10th percentiles. in the present study, high reflectance values were obtained at low frequencies (<800 hz) at the 50th percentile, but values decreased at the 25th and 10th percentiles. methodological differences between the studies of hunter et al. (2010), aithal et al. (2013) shahnaz et al. (2014) and the present study could be contributing to the differences in reflectance measures reported. differences between the studies include reference standard used, age of infant sample, mass element control of the middle ear, instrumentation used and probe fit. firstly, the reference standard used to determine middle ear status was different. the present study used dpoae measurements to confirm the absence of outer and middle ear pathology, whereas previous studies by aithal et al. (2013), hunter et al. (2010) and shahnaz et al. (2014) used a combination of dpoae, teoae and lowand high-frequency tympanometry as a reference standard. middle ear pathology may have been overlooked by using dpoae only. although a ‘pass’ on a test battery which includes dpoae provides some assurance of an unobstructed conductive pathway, it should not be regarded as a gold standard for detecting ears with a satisfactory conductive condition in view of the limitations of the test battery when used with young infants (aithal, kei & driscoll 2014). it is possible, therefore, that conductive pathology may have been overlooked because of the protocol that was used in the current study compared to other studies, such as those by aithal et al. (2014), hunter et al. (2010) and shahnaz et al. (2014) who included additional measures to ensure normal outer and middle ear function. the second possible reason for the discrepancy in wai measures between the current and previous wai studies is the age of the infant sample. aithal et al. (2013) conducted their research on full-term neonates with a mean gestational age of 38.7 weeks (s.d. = 5.01, range: 36–42 weeks). shahnaz (2008) also conducted research on nicu neonates as did the present study, but with a mean gestational age of 37.8 weeks (range: 32–51 weeks) and not earlier than 3 weeks before discharge, compared to the premature neonates tested in the present study (mean age at testing 35.6 weeks, range: 32–37 weeks), who were younger. according to a study by keefe and levi (1996), 1-month-old infants have smaller energy reflectance values than nicu infants at lower frequencies. the present study indicated high reflectance values in the low-frequency range. shahnaz et al. (2014) stated that if the overall mass of the middle ear is higher for nicu infants than for 1-month-old infants, more incident energy will be reflected and less will be absorbed at higher frequencies. although the presence of amniotic fluid in the ear canal and middle ear is not unique to premature neonates, it is possible that the amount of mesenchyme in the middle ear is greater in premature than in full-term neonates because of the normal middle ear developmental changes that take place towards the end of the third trimester. this may be the reason why the reflectance value data obtained in the premature neonates of the current study were higher than those recorded in previous studies. aithal et al. (2014) reported that a developmental trend was evident in the normal development of the infant ear canal and middle ear. reflectance results obtained from 0and 6-month-old infants differed significantly from those of other age groups in the study. wai results exhibited a multipeaked pattern for infants aged 0–2 months, while a single broad-peaked pattern was observed for 4and 6-month-old infants, indicating that developmental effects of wai were evident for infants during the first 6 months of life. participants in the study by hunter et al. (2010) were healthy full-term neonates and tests were conducted between three and 102 h after birth. the mean age at time of testing was 29 h after birth. hunter et al. (2010) reported that with normalisation of middle ear function, reflectance values decreased during the first 4 days after birth and proposed that high reflectance values in neonates are indicative of conductive pathology. infants were included in the current study if they passed dpoae screening, which implies an absence of significant conductive pathology. however, it is possible that neonates may have passed dpoae testing while presenting with minimal conductive pathology (baldwin, 2006). minimal outer and middle ear pathology may, therefore, have played a role in the higher reflectance values reported in the present study. it is for this reason that aithal et al. (2014) and shahnaz et al. (2014) added more stringent measures of middle ear function, namely 1 khz tympanometry and teoae. hunter et al. (2010) attributed high reflectance values at regions involving 2 khz to middle ear pathology. shahnaz (2008) reported mass element control conduction of the high-frequency response of the middle ear. therefore, if the mass of the middle ear is higher for neonates than for 1-month-old infants, more incident energy will be reflected and less will be absorbed at high frequencies (shahnaz, 2008). the overall maturation of the middle ear might result in an increase in mass at birth, which gradually decreases as infants become older. if the middle ear is mass dominated in early infancy and in preterm neonates, it can affect the conduction of higher frequencies to the cochlea. the impedance of the neonatal middle ear is dominated more by mass than by stiffness (holte et al., 1991). it is possible that the mass dominated middle ear systems of the preterm neonates in the current study resulted in higher reflectance values compared to full-term infants tested by hunter et al. (2010) from birth to 4 months. thirdly, the instruments used in the various studies differed. both the equipment and calibration procedures for the wai measurements in the present study differed from that used by aithal et al. (2013). aithal et al. (2013) used reflwin developed by interacoustics a/s in denmark. however, the mimosa wai system used in the present study was also used by hunter et al. (2010) and by shahnaz (2008). equipment choice is, therefore, unlikely to have played a contributing role in the difference in wai results. calibration methods and different ear tips used for the two systems could have contributed to the observed differences between the studies (merchant et al., 2010). a tight probe fit should be ensured for accuracy of wai measurements. the reflectance response is sensitive to the quality of probe fit, which, in turn, affects the energy being reflected or absorbed (aithal et al., 2012). keefe et al. (2000) used negative equivalent volume to verify the seal only during the recording of results. this method reported that 13% of neonates had a poor acoustic seal. a hermetic seal was often difficult to obtain because of the small size of the ear canal opening. keefe et al. (2000) and feeney and sanford (2005) noted that a poor probe tip seal allows for loss of energy in the low-frequency portion of the stimulus and decreases reflectance measured in the ear canal (hunter et al., 2008). this is in contrast to the present study, because very high reflectance values were present at frequencies below 1 khz. this suggests that poor probe fit was not the cause of high reflectance values at low frequencies. nevertheless, probe fit should be checked during data acquisition by using either visual display of results or equivalent volume to determine adequate seal. finally, concerning inherent background noise in the nicus, it is possible that the noise levels influenced wai test results, as was reported by shahnaz (2008). the overall a-weighted noise level in the nicu was measured as 65-db spl by shahnaz (2008). wai values below 450 hz were therefore excluded from their study. the present study did not measure noise levels in the nicus, which can be regarded as a shortcoming of the study. it is, therefore, possible that external noise levels present during wai testing might have resulted in the elevated reflectance values. however, this is only likely to have been the case for the low-frequency reflectance values measured in the current study and does not account for the high reflectance levels between 0.5 khz and 3 khz and above 4 khz. wai results obtained from the present study are similar to results from participants reported as possibly presenting with conductive pathology in a study by sanford et al. (2009). this may indicate that wai measurements in preterm neonates cannot be used to effectively differentiate between ears with conductive pathology and those without. wai measurements may provide data to suggest that many newborn hearing screening referrals are a consequence of transient conditions affecting the sound-conduction pathway. however, further research on preterm neonates with confirmed conductive pathology is required. conclusion the data from the current study identified wai patterns that had not previously been reported in the literature. high reflective values were obtained across all frequency ranges especially in the low-frequency ranges below 3 khz and in the high-frequency range above 4 khz. the age of the neonates when tested might have influenced the results. the neonates of the present study were very young preterm neonates compared to the ages of neonates in previous studies. wai measurements on at-risk preterm neonates in the nicu were variable with environmental and internal noise influences. transient and or maturational conditions affecting the sound-conduction pathway may have influenced the results. additional research is required to investigate wai testing in ears with and without confirmed outer and/or middle ear dysfunction. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions n.g. was the main author and responsible for conducting all data collection and analyses, as well as compiling the final report. dw.s. was the main supervisor during the study, providing guidance in conducting the research and deciding on the research protocol to be used. lb.d.j. was co-supervisor and provided valuable insight into the final compilation of the study. references aithal, s., kei, j., & driscoll, c. 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(2007). universal newborn hearing screening. american family physician, 75(9), 1349–1352. journal of the south african logopedic society word deafness katrina de hirsch, l.c.s.t. and the term "word deafness" has been used in the literature with reference to both children and adults; the present discussion is confined to word deafness in children. the word-deaf child is entirely or partially unable to comprehend spoken language. in some of the milder cases all that can be observed is a time lag between reception and interpretation of the verbal, stimulus. there may or may not be difficulty in attaching meaning to sounds other than language such as the ring of the telephone or the bark of a dog. occasionally there is trouble with localization of sounds. however, the disturbance is essentially on the verbal symbolic level and these children are often good at interpreting the inflection of the speaker's voice or his facial and bodily expression. the degree of expressive language impairment varies. language may be non-existent, limited in quantity or poor in quality; jargon may be substituted for meaningful speech. the diagnosis of word-deafness is appropriate only when significant peripheral auditory loss, mental retardation and psychopathology are ruled out as major contributory factors. differential diagnosis is by no means always easy (particularly in the case of young children) and can be arrived at only by a process of elimination. it was kussmaul(8) in 1877 who first coined the term "word-deafness" when referring to patients who had difficulty with comprehension of speech. allen( 1 ) in 1951 divided the historical development of the concept into four phases. during the first phase from 1828 to 1868 the tendency was (with only a few exceptions) to regard word-deaf children as idiots. during phase two (from about 1868 to 1900) the expressive aspects of the disorder were emphasised, and hale-white, golding-bird, bastian and others described children who had a language all their own. during phase three, lasting through world war i, there; was a shift back to the receptive field. during the fourth phase the study of traumatic aphasias resulting from the first world war gave new impetus! to these investigations. wallin in 1927 first suggested that the disorder might be more widespread than was generally recognized. worster-drought's(13) description of the syndrome is basic to present understanding of the disorder. he said that these children's speech, once it develops, is monotonous, indistinct and often complicated by what he calls verbal aphasia. he feels that the disturbance is probably the result of a biological variation in the nature of an agenesis. froeschels(5) focusses interest mainly on the audijeanette jefferson jansky tory inattention of word-deaf children and recommends therapy directed towards this aspect of the syndrome. in 1937 orton ( 1 1 ) drew attention to the hyperactivity of word-deaf children, also to their delay in developing a master hand. he was particularly interested in what he calls "developmental" word deafness — cases which did not show a reliable history of brain-injury but in whose family background there was ample evidence of various forms of language disability. ewing's(4) study in 1940 showed that of 10 children who had been diagnosed as word-deaf six had high frequency losses, thus pointing up the necessity for careful hearing evaluation. nance ( 1 0 ) , in 1946, described intelligence evaluation of word-deaf children by means of tests not requiring comprehension and use of language. in a report in 1950 goldenberg((1) (stimulated by bangs' study done in 1948) did an exploratory investigation on 14 children said to be word-deaf, by comparing their performance with that of 10 "normal" youngsters and found that intellectual retardation, brain injury and regional hearing loss accounted for "numerous" cases diagnosed as being word-deaf. carrell and bangs( 2 ) in 1951 asserted that trouble with language comprehension was but one aspect of a more widespread syndrome and suggested that disturbed visuo-motor function, poor abstract performance, inferior figurebackground discrimination are worth while investigating. in a paper in 1952 de hirsch( 3 ) took up some problems in differential diagnosis and drew attention to the fact that profound auditory inattention, tendency to echolalia and paucity of language are features found both in word-deaf and in autistic children and that only prolonged clinical observation of the child's total behaviour enables the clinician to discriminate between the two. she emphasized the fact that while not all word-deaf children show a positive electro-encephalogram or gross neurological signs, observation of their performance reveals perseveration, stimulus-bound behaviour, severe hyperkinesis and difficulty with control. in a later publication(3) she stresses these children's basic gestalt difficulties. myklebust(9) inhis book published in 1954, throws light on behavioural symptoms of word-deaf children. he feels that their disturbance on the cortical level makes for difficulty with integration in most areas of functioning. strauss(12) in his very important contribution to the problem views word-deaf children as brain-damaged. brain injury, he says, results in poor development of basic sensory-motor schemata and thus leads to difficulty with language reception and expression. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society november the latest (as yet unpublished) study in the field by jansky(7), who with de hirsch investigated in detail 12 word-deaf children, points in the same direction. diagnosis of word-deafness in this investigation was arrived at after other possible etiology had been ruled out. the audiograms of some of the children studied showed some inconsistency.. however, careful testing (including the psycho-galvanic skin resistance test) proved absence of a significant peripheral hearing loss in every single case, though some patients manifested marked delay in response to verbal stimuli. all of the 12 children were carefully evaluated as to intellectual potential. in addition to a quantitative analysis (the children's i.q. ranged from dull normal to superior), they were analysed qualitativelyso as to assess functioning in areas other than language. all 12 cases were studied by signs of withdrawal or other psychopathology and only if it was possible to really reach the child was the diagnosis of autism ruled out. jansky closely investigated the receptive aspect of language by testing the children's interpretation of both words and sentences. inability to attend to verbal material, need for frequent repetition of linguistic stimuli, excessively short auditory memory span were all found to be of interest. the categories articulation, intelligibility, quantity of verbal output, pitch and rate were evaluated so as to assess the children's competence in terms of the expressive aspect of language. the children's body image, their perpetual, their motor and their visuo-motor performance were studied, as well as figure-ground discrimination. in addition, other "soft" neurological signs: evidence of disorganization, impulsiveness, distractibility, rigidity and perseveration, were noted. laterality was evaluated in the framework of the child's ability to deal with spatial relationships. the results of jansky's study showed that in word-deaf children language deviations are accompanied by disturbances in other areas of functioning and suggest that their performance is similar to that found in youngsters with verifiable brain-injury. severe word-deafness is not a frequent syndrome. when it occurs there is often a history of anoxia, birth injury, haemorrhage, convulsions, or erhyroblastosis fetalis due to the rh factor. in cases where neurological and encephalographic tests are negative it has been usually inferred that one deals with what is generally called "developmental" worddeafness. however, strauss' findings indicate that diffuse organicity can be inferred from severe motor area as well as from behavioural and language symptoms in the absence of a positive electroencephalogram and gross (as opposed to soft) deviations in the percepetual-motor and visuoneurological signs. one therefore feels inclined to assume that many of the cases diagnosed as "developmental" actually do present diffuse, nonfocal and probably mild organic signs on a central level. the writers agree with strauss that word-deaf children have trouble with fundamental sensorymotor-schemata. they feel that these youngsters' inability to respond to the highly complex patterns as they are presented in spoken speech is but one aspect of their difficulty with perceptual-motor and visuo-motor configurations. they have trouble structuring the perceptual field and experience speech in a diffuse, undifferentiated manner. the figure — be it the spoken word or the sentence — does not stand out from the vast number of unorganised stimuli constantly impinging on the organism. thus, words fail to have meaning. the word-deaf child's attempts at speech—monotonous, indistinct, formless and slurred, reflect equal difficulty in organization and differentiation. from these theoretical assumptions certain conclusions can be drawn for therapy: 1. while word-deafness in severe form is a rare occurrence, it is probably insufficiently recognized that a relatively large number of children referred for dyslalia suffer from mild, receptive language disturbances — even where there is no significant peripheral hearing loss. failure to recognize that the resulting paucity of language, the paragrammatism and the poor motor speech patterns have a receptive basis, results in wasteful and ineffective therapeutic efforts. 2. inconsistent audiograms are fairly typical for word-deaf children. 3. a time lag in response to auditory stimuli is not always due to a hearing deficit, nor is it necessarily an indication of mental retardation. it might occur as part of the word-deaf syndrome and represent difficulty with differentiation and integration of the essential feature" of an auditory experience. 4. since the latest studies have shown that hyperkinesis and distractibility are important features of the syndrome (many of these children are explosive and disorganized) it would follow that they need help with structuralization of their environment. the number of stimuli has to be reduced, and a relatively simple frame of reference has to be set up before language training can be undertaken. 5. since it is assumed that these children's difficulty is primarily one of organization of complex auditory configurations, the cutting down of these configurations into shorter units is thus a prerequisite of treatment. speech must also be slowed up, dramatized in actual life situations. constant repetition of verbal stimuli is needed to facilitate the integration of the material of experience with the linguistic symbols representing' them. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society bibliography (11 allen i. " t h e history of congenital auditory imper( ception:·' the new zealand medical journal, 51: 239274; june 1952. m carrel james and bangs, jack. " d i s o r d e r s of speech u ) comprehension associated with idiopathic language r e t a r d a t i o n . " t h e nervous child, 9: 64-76, 1957. (3) de hirsch, katrina. "developmental w o r d deafness and sdeech t h e r a p y . " bulletin of the orton society, 3 11-20april 1953 " g e s t a l t psychology as applied to language disturbances." journal of nervous and mental diseases, vol. 120, nos. 3: 4, 1954. (4) ewing, alex. differential diagnosis of aphasia in children, london oxford university pifess, 1940. (5) froeschels, emil. " p u r e w o r d deafness in a child (auditory verbal agnosia nielsen) " t h e quarterly journal of child behaviour, 1: 228-240; april 1949. (6) goldenberg, samuel. " a n exploratory study of some aspects of idiopathic language retardation. ' the journal of speech and hearing disorders, 15: 221 m i , september 19t>0. (7) jansky, jeanette. " w o r d deafness viewed as one aspect of an inclusive s y n d r o m e . " paper written for city college, n e w york, m a y 1955. (8 kussmaul. " d i e sterungen der sprache," ziemssen's handbuch der speziellen pathologie und therapie 1877. (9) myklebust, helmer. auditory disorders in children, n e w y o r k : grune and stratton, 1954, 380p. (10) nance lorna. "differential diagnosis of aphasia in children." the journal of speech disorders, 2: 219223: september 1946. (11) orton, samuel. reading, w r i t i n g and speech p r o b lems in children. n e w y o r k : w . w . norton and c o m pany, incorporated, 1957 , 215p. (12) strauss, alfred. " a p h a s i a in children." american journal of physical medicine, 32, 93-99, 1954. strauss, alfred and kephast, newell. psychopathology and education of the brain-injured child. (volume i i ) n e w y o r k : grune and stratton, 1955, 267p. strauss, alfred and lehtinen, laura. psychopatholosy and education of the brain-injured child... n e w y o r k : grune and stratton, 1950, 220p. (13) worster-drought, c. "congenital auditory i m p e r ception (congenital w o r d deafness) and its relation to idioglossia and allied speech defects." t h e medical press and circular, 210, 411-417. book reviews the riddle of stuttering, c. s. bluemel, m.d., danville, illinois: the interstate publishing company, pp. 142, $3.50. dr. bluemel has added significantly to the literature on stuttering by his latest book the riddle of stuttering. after many years of thinking and writing on the subject, (dr. bluemel's first book. stammering and cognate defects of speech, was published in 1913), he approaches the subject in a mature, yet new and stimulating' manner. he seeks the answer to the riddle in the field of psychiatry. unlike many of the writers in the field he says that stuttering results from a combination of many, at least three, different causes. this means that the riddle is not a simple speech disorder, but a complex disturbance which must be studied in its many aspects of both speech and personality. the three factors or causes which, according to the author, produce stammering are: the personality of the stammerer, the non-organization of the original speech, and dis-organization of the speech by stress before it becomes securely established. he says stammerers have a predisposition to their speech difficulty, as they are poorly organized in their neuromuscular reactions, and their inco-ordinatio'ns include the function of speech. under stress the poorly organized speech readily becomes dis-organized. this latter is nonorganized speech, or speech in the un-making, and occurs when the psycho-physiological pattern has not been safely and securely organised. the chapter on "the organization of speech" is excellent and is particularly good for the nonmedical person. the chapter on the "disorganization of speech" is equally good and, as far as this reviewer knows, is an entirely new approach in the speech pathology literature. dr. bluemel's therapy is directed toward reorganizing the basic speech of the stammerer. while ear training is one of the most popular and valuable techniques in working with an articulation speech problem, his concept of sensory stimulation, i.e. ear training, as a therapeutic device to use with stammerers is new and thought provoking. he says: ear training is employed to establish a good mental pattern of speech. attention is then directed to the thinking process in speech, which is more important in the therapy than the talking process. in this concept of therapy, talking is thinking out loud. the mind broadcasts to the mouth; the words say themselves. the importance of mental hygiene in the programme of stammerers is not overlooked. for the personality re-education it is suggested that psychotherapy be used. the book ends on an optimistic note with the feeling that the riddle will soon be solved. there are many new and scientific ideas in the book, and it should be read and absorbed by everyone interested in speech problems. rutii m. clark, ph.d., professor speech pathology, university of denver, denver 10, colorado. "the voice and its disorders," by margaret c. l. greene, l.c.s.t. london, pitman, 1957, pp. 224. in the preface of this book there are a few items worth discussing: 1. the author says, p.v, "no comprehensive (sic!) study of normal and disordered voice existed to serve as a single source of reference for those interested in vocal rehabilitation." she r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction contextual complexity decision-making frameworks and training in adult dysphagia need for mentorship potential solutions conclusion acknowledgements references about the author(s) kim a. coutts department of speech pathology, university of the witwatersrand, johannesburg, south africa citation coutts, k.a. (2019). community service speech language therapists practising in adult dysphagia: is the healthcare system failing them?. south african journal of communication disorders, 66(1), a615. https://doi.org/10.4102/sajcd.v66i1.615 opinion paper community service speech language therapists practising in adult dysphagia: is the healthcare system failing them? kim a. coutts received: 01 nov. 2018; accepted: 20 may 2019; published: 18 july 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract performing community service is a necessity prior to practising speech language therapy in south africa. this system allows for improved access to these specialised services in the more rural areas. the current challenges of practising in complex settings with little access to mentorship can result in these community service therapists feeling underprepared to assess and manage patients presenting with adult dysphagia (swallowing disorders). this paper explores this topic through the theoretical lens of decision-making, from both clinical and academic perspectives. it aims to pose potential solutions on how to better transform the current practices to be contextually responsive to these challenges. keywords: speech pathology; community service; decision-making; dysphagia; mentoring. introduction south africa’s healthcare system is under considerable stress, as 15% of the healthcare workers need to service 68% of the population within a resource-limited public healthcare setting (coovardia, jewkes, barron, sanders, & mcintyre, 2009). the role that community service speech language therapists (slts) play to bridge this gap for the benefit of the population they serve is of significance; however, i want to pose the question, is the healthcare system failing them? through the lens of decision-making, this article will highlight the various challenges but also pose potential solutions that can provide development for junior slts, with a focus on their practices around adult dysphagia (swallowing disorders). contextual complexity the south african public healthcare setting is complex. healthcare institutions range from larger academic or tertiary hospitals with a focus on providing specialised services in the more urban areas and a progressively filter down to primary health care (phc) clinics that have a focus on more outreach, prevention and basic healthcare services. these institutions are required to function on less than optimal funding to service a large majority of the population, as seen with the lack of funding for permanent posts as reported by wranz (2011). the current slt to patient ratio in south africa can be calculated as 1:18 000 (health professions council of south africa [hpcsa], 2018). this is a challenging setting for even experienced slts. compulsory community service for slts in south africa was initiated in 2003, the intention being to provide better access to specialised rehabilitation services for underserved areas of the population (reid, 2001). it is generally acknowledged that community service is useful for newly qualified therapists, including slts for a number of reasons, including that it provides valuable work experience and a unique opportunity to learn and improve their skills and gain knowledge (wranz, 2011). it also enables them to make a difference in the communities that they serve (van stormbroek, 2014). the challenge is that community service therapists are often placed in rural areas where they are faced with these complex contextual challenges, as well as transitioning into their new role as independent practitioners (van stormbroek, 2014). the hpcsa has guidelines for universities that require new slts to be able to practise independently (hpcsa, 2012), yet are not able to register as independent practitioners until the completion of their compulsory community service year. when referring again to adult dysphagia, lack of appropriate clinical expertise can have a serious impact not only for the clinical development of the slt but for the patient as well, who may receive less than optimal treatment (singh et al., 2015). pillay and andrews (2017) noted that the contextual challenges of limited resources, both human and physical, were a challenge and resulted in long waiting times for the patient and inadequate clinical management of dysphagia cases. this is a daunting task for a junior slt who is required to practise independently, considering the medical consequences of dysphagia. also, south african slts students often have limited exposure to dysphagia cases and little experience with objective measures such as videofluroscopy and fibreoptic endoscopic evaluation of swallowing (vfss and fees) due to the restricted access to these services within the various training sites, that is, public-sector hospitals and clinics. this can result in community service slts feeling somewhat underprepared to practise independently in this area immediately after graduation (singh, et al. 2015; yiannopoulos, 2016). when focusing on dysphagia practices, wranz (2011) explored the readiness, reality and readjustment of community service therapists in south africa. she noted that while community service slts were perceived to have adequate knowledge in the field, they felt inadequate in terms of their skills. singh et al. (2015) stated that less than half of the sample of community service slts felt competent to practise in dysphagia as they lacked confidence, which resulted in feelings of underpreparedness. based on the information above, to assist community service slts they need to develop praxis and build their clinical confidence. the need for mentorship becomes apparent. decision-making frameworks and training in adult dysphagia decision-making is a complex process, especially in healthcare. simplistically, at an undergraduate level, students gain different types of knowledge: theoretical (patel & kaufman, 2002) and methodological (wainwright & mcginnis, 2009). theoretically, there are limited frameworks that are available to assist in the decision-making processes. there are static one-dimensional models such as those by yoder and kent (1980) and singh (2016). these models are based solely on the clinical signs and symptoms of the patient and lack the impact of a complex contextual setting, as well as the influence of the slt themselves. the dual processing model suggested by humbert (2015) is more complex as it involves the metacognitive processes of the slt but then also lacks the influence of the contextual factors. these models are summarised in table 1. table 1: description of the decision-making models and the challenges. methodologically, slts gain clinical experience and start to integrate the theory with the practical component, called praxis (whitehead, 2002), which starts at university level but should progress throughout their career. students in nursing (banning, 2007), occupational (reich & eastwood, 1998) and physiotherapy (smith & higgs, 2008) learn clinical decision-making skills through a combination of praxis that is honed through contextual experience and mentorship. these findings corroborate the conclusions from my phd, which explored the decision-making processes of slts assessing dysphagia at the bedside (coutts, 2017). this study highlighted that the process of praxis is a highly individual one and stems various micro(intrapersonal) and macro(external) factors, including their previous clinical experience and exposure during student training. therefore, limited exposure to dysphagia cases and experience in the more specialised instrumental assessments are critical, often due to lack of availability at various training sites. the importance of having access to appropriate mentorship was also found to be key in this developmental process. the concept of mentorship will be explored in detail in the article. another factor that can further impact the decision-making of community service slts is the inconsistency of teaching around dysphagia practices in south african universities. andrews and pillay (2017) identified the absence of standardised adult dysphagia teaching methods across institutions, which was noted in the different bedside assessment protocols used in clinical practices. these findings were supported by yiannopoulos (2016), who suggested that south african universities need to standardise their dysphagia curricula to address the new graduates’ feelings of underpreparedness. it is hard to establish sound clinical reasoning and decision-making skills amongst these different practice patterns without appropriate mentorship and senior clinical experience from which to gain knowledge and skills. in summary, the lack of decision-making models and inconsistency in teachings, coupled with the complexity of practising in the south african healthcare context, highlight the needs for these challenges to be addressed. need for mentorship there are multiple definitions of mentorship, which describes various roles of what a mentor should encompass. for the purposes of this article, the definition of mentorship in terms of practice, education and research to ensure growth and future of the profession will be the main focus (gandy, 1993). in south africa, schwertdle, morphet and hall (2017) mention that due to the complexities of the healthcare system, continuing development is often under-prioritised. if training does occur, the focus is often on senior staff members. this training also takes place in urban areas and is often too expensive to attend, thus making it impractical for many community service slts. this needs to change. the transition from student to a practising clinician is a complex one (van stormbroek, 2014). the process starts with enthusiasm and excitement but quickly dissipates when various challenges of the context are realised. the study on south african community service occupational therapists learning a specialised skill (van stormbroek, 2014) revealed interesting results that may also be generalised to slts. it showed that the reality of practice was responded to with a process of adaptation, where the therapists learn to respond to the realities of the context (van stormbroek, 2014). in south africa, community service therapists start to shift their perception from their ability and skill set as theoretical, to needing to meet the needs of patients more clinically (i.e. praxis). some therapists also struggle with developing their clinical reasoning skills (i.e. decision-making abilities) and adopting a client-centered approach due to the various contextual challenges (van stormbroek, 2014). this lack of confidence that the therapists experienced was in direct correlation to their lack of support and led to other feelings of anxiety, frustration and inadequacy (van stormbroek, 2014). a key finding from van stormbroek (2014) was that the biggest advantage in assisting with the transition to independent clinician was that the students received the support that they needed. all participants in her study felt that they needed access to senior staff for mentorship, which may be expected to be the case with slts. wranz (2011) showed that although community service slts felt generally underprepared, their overall clinical skills did improve over the course of their community service year, which is encouraging. however, dysphagia was one of the main areas in which all slts still do not feel confident to practise independently due to the medical risks, which include aspiration, dehydration, malnutrition and possible death (bax, macfarlane, & green, 2014). the slt participants stated that they felt more alone during their community service year, as there was either no or very limited access to the necessary supervision or support, even from peers. wranz (2011) also noted that the true development of knowledge and skills is greatly improved when newly qualified slts receive adequate mentoring under appropriate supervision, and that the absence of mentors in the south african context was a grave concern. this was reported in the findings from the participants in her study. in the studies mentioned above, there appeared to be little access to appropriate supervision, either because there were no other slts available, or the colleagues were also inexperienced. this stems from the broader challenge of the lack of funds for posts in the public healthcare sector. although being in a working environment will inevitably result in skill development, the slts are unlikely to learn as much as if they were under mentorship. this is particularly pertinent for dysphagia, where serious adverse consequences can arise due to a lack of knowledge and skills. there are significant benefits to mentorship as noted from a variety of healthcare professions. these benefits include: (1) under appropriate mentorship, they had the freedom and support to make mistakes and to then learn from them (van stormbroek, 2014); (2) naidoo (2006) stated that in physiotherapy, it creates dialogue about practice, promotes development, stimulates reflection, yielded productivity and refined leadership skills; (3) henry-noel, bishop, gwede, petkova and szumacher (2018) noted that mentorship is an essential process to academic medicine and promotes professional satisfaction; (4) in speech therapy, pamploma, ysunza, sarre, morales and sterling (2015) stated that mentorship aided in self-confidence and overall performance; (5) wranz (2011) said it well when the first few years of a career are vital for developing good habits, favourable attitudes and proper work ethics, which can only come from adequate mentorship. all of these skills are important contributors to positively impacting on the overall decision-making processes of slts in adult dysphagia in the complex public healthcare context. potential solutions there has been a recent cry for the transformation of practices from the south african student bodies, and these potential solutions can assist in starting this process. in new zealand, the united states and ireland, new graduates are supervised for a certain period of time (iaslt, 2015) prior to their registration as independent practitioners. this is also the case as seen with the medical doctors who completed 2 years of internship prior to entering their community service year. potentially, an internship model could be proposed for slts prior to expecting community service slts to practise independently in such challenging circumstances. five studies (coutts, 2017; pillay & andrews, 2017; singh et al., 2015; van stormbroek, 2014; wranz, 2011) suggested that the development of knowledge and skills in adult dysphagia can continue with the attendance of continuing professional development courses, even in the absence of supervision. attending courses allow junior slts to engage with the latest clinical information and to learn from senior colleagues, but it is not a long-term solution. these continuing professional development (cpd) courses also need to be accessible and affordable for community service slts from all settings. there needs to be a creative collaboration between the department of health and the department of higher education that focuses on junior colleagues being able to access mentors in the profession from both clinical and research perspectives. university staff members can create platforms using a blended learning approach (i.e. skype) to assist slts in continuing professional growth and support from all contexts. this is important to combat the limited number of available staff in the department of health who cannot take on the active role of mentorship, considering their case load and often inaccessibility. future research is required in establishing how a mentorship programme from both within and external to the department of health can be established and potentially benefit the skills and development of junior slts in adult dysphagia specifically. conclusion both locally and abroad, having novice slts practising in under-resourced settings is inevitable, and it is of vital importance that they are adequately prepared for this year (van stormbroek, 2014). in the context of the lack of adequate mentorship and complex contextual challenges, making decisions in adult dysphagia independently can be daunting for many slts, which can have serious clinical consequences. there are potential solutions in which higher education institutions need to ensure that they are able to provide the support that bridges this gap by providing mentorship and access to other learning opportunities. the solution will require creative collaboration by the department of health and department of higher education. these solutions can further assist in starting to answer the call for transformation of our practices within the profession. acknowledgements the author thanks ms carrin martin (ukzn – editor) for her contributions to this article. competing interests the author declares that he has no financial or personal relationships which may have inappropriately influenced him in writing this article. author’s contributions k.a.c. is the sole author of this article. funding this research received no specific grant from any funding agency in the public, commercial, or 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(1988). decision-making in speech-language pathology. decker: toronto. sajcd 62_1 book files.indb reviewer acknowledgement open accesshttp://www.sajcd.org.za page 1 of 1 the editorial team of the south african journal of communication disorders recognises the value and importance of peer reviewers in the overall publication process – not only in shaping individual manuscripts, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank the following reviewers who participated in shaping this issue of the south african journal of communication disorders: alexandra m. stipinovich alida ellis alta kritzinger anita edwards anita van der merwe anna-mari olivier brian watermeyer caitlin v.k. longman carianne vermeulen claire penn harsha kathard heila l. jordaan jenny pahl joanne neille karin joubert karyn casey lebogang ramma linda cupples lucretia petersen melissa bortz mershen pillay michelle pascoe priya rajaram rajeev ranjan rene hornby sarah james stephanie wainwright tarryn m. reddy we appreciate the time taken to perform your review successfully. in an effort to facilitate the selection of appropriate peer reviewers for the south african journal of communication disorders, we ask that you take a moment to update your electronic portfolio on www.sajcd.org.za for our files, allowing us better access to your areas of interest and expertise, in order to match reviewers with submitted manuscripts. if you would like to become a reviewer, please visit the journal website and register as a reviewer. to access your details on the website, you will need to follow these steps: 1. log into the online journal at http://www. sajcd.org.za 2. in your ‘user home’ [http://www.sajcd.org. za/index.php/sajcd/user] select ‘edit my profile’ under the heading ‘my account’ and insert all relevant details, bio statement and reviewing interest. 3. it is good practice as a reviewer to update your personal details regularly to ensure contact with you throughout your professional term as reviewer to the south african journal of communication disorders. please do not hesitate to contact us if you require assistance in performing this task. publisher: publishing@aosis.co.za tel: +27 21 975 2602 fax: +27 21 975 4635 south african journal of communication disorders sajcd abstract introduction methods results discussion acknowledgements references appendix a: consonant inventory of isixhosa appendix b: isixhosa wordlist and recording sheet. appendix c: list of minimal pairs used in abx task. appendix d: administration sheet (for repetition and auditory discrimination). about the author(s) michelle pascoe communication sciences and disorders, department of health and rehabilitation sciences, university of cape town, south africa kate rossouw communication sciences and disorders, department of health and rehabilitation sciences, university of cape town, south africa laura fish communication sciences and disorders, department of health and rehabilitation sciences, university of cape town, south africa charne jansen communication sciences and disorders, department of health and rehabilitation sciences, university of cape town, south africa natalie manley communication sciences and disorders, department of health and rehabilitation sciences, university of cape town, south africa michelle powell communication sciences and disorders, department of health and rehabilitation sciences, university of cape town, south africa loren rosen communication sciences and disorders, department of health and rehabilitation sciences, university of cape town, south africa citation pascoe, m., rossouw, k., fish, l., jansen, c. et al. (2016) speech processing and production in two-year-old children acquiring isixhosa: a tale of two children. south african journal of communication disorders, 63(2), a134. http://dx.doi.org/10.4102/sajcd.v63i2.134 original research speech processing and production in two-year-old children acquiring isixhosa: a tale of two children michelle pascoe, kate rossouw, laura fish, charne jansen, natalie manley, michelle powell, loren rosen received: 23 july 2015; accepted: 16 feb. 2016; published: 20 may 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract we investigated the speech processing and production of 2-year-old children acquiring isixhosa in south africa. two children (2 years, 5 months; 2 years, 8 months) are presented as single cases. speech input processing, stored phonological knowledge and speech output are described, based on data from auditory discrimination, naming, and repetition tasks. both children were approximating adult levels of accuracy in their speech output, although naming was constrained by vocabulary. performance across tasks was variable: one child showed a relative strength with repetition, and experienced most difficulties with auditory discrimination. the other performed equally well in naming and repetition, and obtained 100% for her auditory task. there is limited data regarding typical development of isixhosa, and the focus has mainly been on speech production. this exploratory study describes typical development of isixhosa using a variety of tasks understood within a psycholinguistic framework. we describe some ways in which speech and language therapists can devise and carry out assessment with children in situations where few formal assessments exist, and also detail the challenges of such work. introduction speech processing and production tasks such as auditory discrimination, naming, and realand non-word repetition have been widely used in research into the typical and atypical development of speech in children (dispaldro, leonard & deevy, 2013; graf estes, evans, & else-quest, 2007; coady & evans, 2008; roy & chiat, 2004; newton, chiat & hald, 2008). such tasks elucidate children’s speech development and show how intervention for children with speech difficulties can best respond to their specific needs. the models map a proposed information-processing pathway for particular tasks so that if difficulties occur, they can be viewed as a breakdown at one or more levels of the system (baker, croot, mcleod & paul, 2001; stackhouse & wells, 1997). the psycholinguistic framework of stackhouse and wells (1997; 2001) has been applied to children’s speech development and difficulties (constable, stackhouse & wells, 1997; ebbels, 2000; pascoe, stackhouse & wells, 2004). the key components of the framework can be summarised in a simple speech-processing model (figure 1) and include processing of speech input, storage of word knowledge or lexical representations, and the output or production of words. the model can also be used to explain what underlying components of the system, assessment, or therapy tasks tap. auditory discrimination is an input task, which may optionally involve access of stored lexical knowledge. naming is an output task involving access of stored lexical knowledge and production. repetition tasks involve all components of the system: auditory processing, access of word knowledge (if the word is known), and production of the word. figure 1: simple speech processing model with processing routes indicated for three tasks. the simple model derives from a ‘box-and-arrow’ model (figure 2) which provides a detailed description of the different levels of processing, and subsequent routes underlying all speech processing and production tasks: auditory discrimination tasks would involve auditory processing, phonetic discrimination, and phonological recognition of words. naming involves semantic and phonological representations as well as access of motor programmes for words and their physical production. repetition involves the entire system: if the word repeated is a known word, the participant may tap into their phonological and semantic representation of the word. figure 2: information processing model showing processing pathways for three tasks. constable et al. (1997) described michael, a 7-year-old boy with severe word-finding difficulties. tasks such as word association, semantic knowledge, auditory discrimination, auditory lexical decision, naming, and real-/non-word repetition were administered. results revealed significant differences between michael’s performance and that of control children. although he showed no apparent semantic deficit, he did show pervasive deficits in phonological processing. ebbels (2000) and pascoe, randall-pieterse and geiger (2013) pinpointed specific difficulties with speech processing in deaf children whose speech and language levels were below those predicted from their hearing losses. comparison of performance on different tasks such as naming and repetition enabled the authors to detail specific areas of difficulty that could be targeted in therapy. there is a large body of research that has investigated the phonological development of english-speaking 2-year-olds (e.g. bland-stewart, 2003; dodd & mcintosh, 2010; roy & chiat, 2004), and to a lesser extent, 2-year-old speakers of other languages (e.g. goldstein & cintron, 2001; saaristo-helin, kunnari & savinainen-makkonen, 2011; teixeira & davis, 2002). most of these studies have focused on speech output only, either through analysis of spontaneous speech, naming or repetition. roy and chiat (2004) used word and non-word repetition tasks to collect data from 2-year old english-speaking children. stokes and klee (2009) examined factors that influence vocabulary development in 2-year-old children, and found that non-word repetition was one of the significant unique predictors of vocabulary. we contend that using three tasks such as auditory discrimination, naming, and repetition allows one to tap into the speech processing and production system as a whole. there is thus a need for studies which look beyond speech output to input speech processing and storage of lexical items. although much of the research using the stackhouse and wells (2001) psycholinguistic framework has focused on pre-school or school-aged children, there is less research using this approach that has looked at children as young as two years of age. the challenges involved in working with such young children are well documented (roy & chiat, 2004; tuomi, gxilishe & matomela, 2001) and include difficulties eliciting speech using unfamiliar tasks, vocabulary constraints, and reliability of responses. adapted forms of tasks may be required, e.g. the abx format is a simplified auditory discrimination task for 2-year olds, as it does not require the participants to understand the concepts of ‘same’ and ‘different’ as many tests of auditory discrimination require, e.g. wepman and reynolds (1987). the task requires hearing two closelyrelated words (e.g. ‘hat’ [a] and ‘cat’ [b]), retaining these in memory, and on presentation of the third stimulus (‘hat’ [x], which could be either a or b), a judgement must be made about which word was heard. this task identifies the accuracy of the participant’s phonological representation of a word without requiring production of the word. puppets are used, with one saying the first word: and second puppet naming the second word, and the child then asked to indicate who said the third word. isixhosa isixhosa is a southern bantu language belonging to the nguni family. it has a simple five vowel system and at least 38 consonants including 16 clicks resulting from the variation of the three basic clicks: dental (/ǀ/), lateral (/ǁ/), and palatal (/!/) (mowrer & burger, 1991; gxilishe, 2004). there are certain unusual features associated with isixhosa phonology (e.g. ejective and aspirated plosives, mowrer & burger, 1991), but there are also many consonants which are common to isixhosa and other languages. appendix a details the consonant and vowel inventory of the language. as with most bantu languages, isixhosa syllable structure is characterised by open syllables (e.g. /i.li.so/eye) (demuth, 2003; mowrer & burger, 1991). many of the bantu languages have a cvcv word structure, and many words contain five or six syllables, often because of the agglutinative structure of the language, which means that a variety of affixes are used to alter the basic meaning of a root word. despite the fact that isixhosa is a ‘majority’ language in terms of its number of speakers in south africa – it is the second most spoken language in south africa it is a ‘minority’ language in terms of available resources and what is known about its development (demuth, 2003; pascoe & smouse, 2012). research into this language has focused on development of children aged 3–5 years and suggests that by these ages typically developing children will have almost completely mastered the complexities of the isixhosa speech and language system (gxilishe, 2004; mowrer & burger, 1991). less focus has been placed on the typical development of speech and language in younger (0 to 2 years old) isixhosa-speaking children. tuomi et al. (2001), in one of the few studies, which looked at younger children, found that vowels are developed by 1.6 years. gxilishe (2004), focusing on the same age, but looking only at clicks, found that these are some of the latest acquired phonemes of the language, typically only by 2.7 to 3.0 years. conradie, jeggo, purchase, rosewall and winfield (2011) conducted a single case study of a young isixhosa-speaking child and found the participant’s vowel inventory was complete and she had acquired many consonants, including some clicks by the age of 1.7 years. most of these studies have focused on children’s observable speech behaviour (output). to our knowledge there are no studies focusing on young isixhosa children’s speech processing abilities or their knowledge of phonological forms, which underpin the output abilities. the purpose of this exploratory study was to investigate 2-year olds’ speech processing and production abilities in isixhosa and ultimately contribute to the body of knowledge about 2-year-olds’ abilities to carry out basic speech processing and production tasks, and ways in which speech and language therapists might assess these. methods aims to describe the speech input, stored phonological representations, and speech output of isixhosa-speaking 2-year old children. design this exploratory study was carried out to trial ways of assessing the speech processing and production of young children. we used a single subject design with two children treated as separate cases. the research team comprised speech and language therapists, none of whom had isixhosa as a first language. driven by clinical need, the study followed an action research process (sagor, 2000) because it followed a disciplined process of inquiry conducted by and for those taking the action. participants two girls, aged 2.5 and 2.8, participated in the study. to ensure that appropriate milestones had been reached, a case history form was sent to the children’s parents or legal guardians. hearing screening and an informal oral-motor examination were also conducted. both typically developing girls attend the same crèche for 5 days of the week in nyanga, cape town, where isixhosa is used, as well as being the main language spoken in their homes. the children are exposed to some english through the crèche environment, television, and their families, but this was judged to be minimal in relation to the isixhosa approximately 1–2 hours per day at the most. procedures following approval from the university ethics committee, information letters and consent forms were sent to the crèche, and the parents/legal guardians of the participants. in this section we describe the tasks that were used, their administration, and analysis. task 1: naming participants were presented with 50 pictures from the masincokoleni speech assessment (maphalala, pascoe & smouse, 2014). the wordlist and pictures in this assessment were devised in order to assess the speech production (phonology) of children aged 3.0–5.11 years (appendix b). the words were selected on the basis of, (1) semantic and conceptual appropriateness for preschool children; (2) inclusion of all isixhosa consonants, vowels, and word shapes; and (3) ability to be pictorially represented. most of the items in the test are nouns and approximately 25% are predicates. maphalala et al. (2014) carried out preliminary validation of the wordlist using an isixhosa-speaking panel of experts. although this assessment was designed for children older than those participating in our study, it is one of few assessments designed specifically for isixhosa-speaking children and as such it formed the basis of our assessment. selected words in this test were also used for the other two tasks. the advantage of having the same words across different tasks is that it allows for a more comprehensive understanding of a specific lexical item within the individual’s speech system (stackhouse & wells, 2001). following the assessment guidelines, responses were elicited using two phrases: ntoni le? [what is this?] and wenza ntoni? [what is happening?]. naming requires access of the semantic representation and knowledge about how to produce the word (motor programme) as well as all the subsequent motor components required for the physical production of speech (vance, stackhouse & wells, 2005). for the purposes of this study we distinguished between three categories of responses: category a were words which children did not know, i.e. they could not access the appropriate semantic label category b were words for which children were able to access appropriate semantic labels, but had difficulties producing accurately category c words were where children were able to access appropriate semantic labels and could produce these accurately with no speech errors. in determining whether a speech production was correct or not, we used the adult standard as the model, allowing for typical adult speech processes such as assimilation. task 2: repetition the repetition task required participants to repeat real words that were produced by an adult – either from the research team or staff at the crèche. a repetition task was included in the assessment for two main reasons, (1) repetition involves different underlying processes to naming and should thus be part of a comprehensive speech processing assessment and (2) repetition may be a clinically useful way to assess the auditory processing and speech production abilities of young children. vance et al. (2005) suggest that speech accuracy is likely to be similar across naming and repetition tasks for children who are typically developing, but this may be different for children with speech difficulties suggesting that comparison of the two tasks might be useful diagnostically. repetition tasks are fairly straightforward to administer and do not require many resources. if a word is unfamiliar, the child would need to listen to the word, map the input they process (phonological representation) onto output (i.e. devise a motor programme), and articulate it. if a word is known the child may access the stored information they already have of the word. because of the different way in which known words and new ones are processed, we used a combination of different words from the naming task. for each child we composed a list of 18 words: 6 words which the children did not know (category a words from the naming task), 6 words which they had in their vocabulary but could not produce yet with adult-like accuracy (category b words), and 6 words which they could produce with adult-like accuracy (category c words). for typically developing children, speech accuracy in naming and repetition are usually similar when equivalent tasks are used (vance et al., 2005) although this may not be the case for children with speech difficulties. task 3: auditory discrimination the auditory discrimination task required a list of real-word minimal pairs based on the items used in the naming task as well as corresponding non-word minimal pairs. words were considered minimal pairs if they differed by one phoneme. in some cases real-word minimal pairs were unable to be developed and so closely-related words were used instead (e.g. ibhola [ball] paired with ibhodi [board]). from the 50 words in the naming task, the research team developed 29 real-word minimal pairs and corresponding non-word minimal pairs, 8 closely-related words with corresponding non-words, 4 closely-related words without non-words, and 5 words with only a non-word pair (appendix c). for each child a set of 12 items (based on the naming task) was created to ensure that a mix of words was used in the task. six of the participants’ own correctly produced responses from the naming task were used (category c words), plus a combination of six incorrect (category b) and/or not elicited (category a) responses from that task. the same target words as used in the repetition task could not always be used, as the words had to have either realor non-word minimal pairs. these words were randomly selected and then half of the stimuli were paired with real-words and half with the non-words. because this task was unfamiliar to the children, they were first trained using practice words. these words were not minimal pairs as the aim of the training was to ensure that the participant understood the concept of the task. the abx format was used for this task, which was conducted using two toys (teddy bear and dog). one researcher would hold the dog and say a word (a), e.g. ibhola [ball], while the other would hold the teddy bear and say a different, similar-sounding word (b), e.g. ibhodi [board]. these words would be repeated numerous times to ensure that if the participant could discern the difference, they were clear about which toy was saying each word. a third researcher would then ask the participant to point to the toy that was ‘saying’ the target word (x). the eliciting phrases inja uthi[dog says-], iteddy uthi[teddy says -], and khomba– [point to -] were used. administration the tasks were presented in the following order, (1) naming, (2) repetition and (3) auditory discrimination. this allowed the research team to select appropriate stimuli for the second and third tasks for each participant based on their speech samples produced in the first task. data was collected at the crèche over a total of 10 sessions for each child. the average duration of each session was 1–2 h and plenty of play breaks took place during this time to ensure that the children did not become distracted or irritable. detailed transcriptions and comments were captured live on administration sheets (appendices a and d). audio and video recordings were taken using a panasonic sdr-h855 recorder. for the naming task children were shown one picture at a time and asked to name the item if they were able to. we followed the instructions for task administration by maphalala et al. (2014). on completion of this assessment, we divided the child’s responses into categories a, b, and c as described above. the 18 items for the repetition task were then selected based on the child’s responses in the naming task. we chose the first 6 items from the naming task that met the category criteria. these items were then randomly ordered and presented to the children by members of the research team who had sufficient isixhosa to be able to produce them accurately or by crèche staff. for the auditory discrimination task, the abx task was used where each child was presented with minimal pairs and asked to discern differences between them using a game format. data analysis results for each of the tasks were first analysed separately for each child. the percentage of items correct was calculated using a binary format, i.e. either correct or incorrect. patterns were then detailed for each child, focusing specifically on lexical items, which had been used in all three tasks. validity and reliability two researchers independently transcribed the data. they then retranscribed the words to determine intra-rater reliability. researchers 1 and 2 had intra-rater reliabilities of 91% and 80% respectively. the two researchers discussed their transcriptions and reached consensus for each differing item. an experienced isixhosa linguist then transcribed 25% of the words in the data, blind to the transcription of the research team. there was an 86% agreement between the words transcribed by the linguist and the words transcribed by the research team. the 14% difference in transcriptions was then discussed until consensus was reached. results child a (2.8 years) child a was able to name 26 of the 50 pictures with the appropriate semantic label, and of these 26 she named 17 (65%) with adult-like speech accuracy. she was given 18 words to repeat (a combination of words that she had produced accurately [category c], words with which she had speech production difficulties [category b], and words that she did not know [category a]). the child was unable to complete the task, so only 17 items were reliably administered. she was able to accurately repeat 15/17 (88%) items. in the auditory discrimination task she was able to correctly discriminate between 7/12 (58%) closely-related word pairs. results are shown in table 1 together with examples of her performance with some specific items that were used in all three tasks. table 1: summary of child a’s performance across the three tasks. child a was able to name many of the pictures with an adult-like accuracy. these included four-syllable words and words containing clicks. she produced all the isixhosa vowels, as well as some non-isixhosa vowels used in loan words. she was not yet producing all the isixhosa consonants in her production of single words. on some occasions she distorted vowels (e.g. /ɛndʒʌ/ for inja [dog]), and the production of her affricates was not yet always accurate. the repetition task posed few difficulties for her. she was able to repeat many of the words given to her, including four-syllable words. she was able to accurately produce the affricate /tʃ’/ in iwotshi which she had not been able to do in the naming task. when naming, she substituted it with a slightly lateralised close approximation of the phoneme. she has a semantic representation of the word as she attempted to produce the word in the naming task; however, as she was unable to produce the word accurately, she may have an inaccurate stored phonological representation of the word or articulatory difficulties in producing /tʃ’/. her ability to repeat the word accurately suggests that she must have adequate articulatory skills to physically produce it and therefore it is more likely to be a phonological difficulty. figure 3 indicates the possible areas of difficulty for this word. in the auditory discrimination task child a was presented with the closely-related word pair (iwotshi vs. idotshi). she was not able to distinguish accurately between these items, which supports the notion that she may have an inaccurate phonological representation stored for this word. figure 3: possible areas of difficulty for the word iwotshi [watch] (child a). another example of a word that was more accurately produced in repetition than in naming is qhuba. in the naming task child a produced a one syllable word /!ʰub/ but in the repetition task she benefitted from having an adult model to copy and produced qhuba accurately. the word ibhola [ball], a high frequency word for most young children, was used in all three tasks. she was able to accurately name it and repeat it, suggesting that she has accurate semantic and phonological representations, as well as accurate motor programming skills to physically produce the word. however, in the auditory task, when asked to discriminate between /l/ and /d/ in the words ibhola [ball] and ibhodi [board] respectively, she was unable to do this. similarly, she had difficulty discriminating between other minimal pairs involving /d/. the pattern for amagxa [shoulders] is the same, with accurate naming and repetition but difficulty in the discrimination task involving that word. she was only able to correctly discriminate between 7 of the 12 pairs of words. some of the difficulties noted in this task, with particular sound contrasts, were not predicted based on her performance on the other two tasks, suggesting that it may have been the nature of the task that was hard for her. however, there were lexical items with which child a experienced no difficulties in any of the tasks. for example, she was able to accurately name the word imali [money] in the naming task, as well as accurately repeat it in the repetition task. this suggests that she has accurate semantic and phonological representations, and accurate motor programming skills to physically produce the word. in the auditory discrimination task, she was able to discriminate between /m/ and /b/ in the words imali [money] and the non-word ibali. overall she has accurate knowledge of this word. having the same lexical items across three tasks is helpful for making comparisons. although this was not always possible in this study, where it did occur, it allowed for more strong conclusions to be drawn. in some cases, it was impossible to develop suitable minimal word pairs for the abx task, e.g. in the case of inja [dog]. her attempt at naming the picture suggests she has a semantic representation, but her inaccurate production may suggest difficulties with phonological representation of the word. there is evidence that she can articulate this vowel through her accurate production of words such as iti [tea]. she was able to accurately repeat inja in the second task. this suggests that she has the ability to develop and produce an accurate motor programme of this word when given a model. her difficulty with spontaneous naming may suggest an outdated/inaccurate phonological representation. for this word, again, an auditory discrimination task administered using the word inja [dog] versus /ɛndʒʌ/ would have provided information regarding her ability to phonetically discriminate these words. child b (2.5 years) child b was able to name 16 of the 50 pictures with the appropriate semantic label. of these 16, she named 9 (56%) with adult-like speech accuracy. she was given 18 words to repeat in the repetition task. as for child a these comprised a mix of words which had and had not been correctly produced. two items were excluded from the task as her responses were not reliable. she was able to accurately complete this task with 9/16 (56%) items. in the auditory discrimination task she was able to correctly discriminate between 12/12 (100%) closely-related word pairs. the results for child b are shown in table 2. table 2: summary of child b’s performance across the three tasks. child b was not yet able to produce all the isixhosa consonants or vowels in her production of single words. she only produced threeand not yet four-syllable words. phonological processes were mainly noted in her production of consonants, and most predominant was deaffrication. despite her developing speech, she experienced no difficulties with the auditory task; child b got all items correct in the abx task. here it was noted that she would spontaneously repeat the target words in order to help her decision-making. this is a useful strategy that children and adults often use to help them with such tasks, and ensures that one does not have to rely on one instance of input alone. in one case, she was heard to change a non-word in the minimal pair (pheda) to a realword (pheka [cook]), and she repeated both words as pheka. stackhouse and wells (1997) describe this process of nominalisation as a typical way in which young children process non-words. despite nominalisations such as this one she still made the appropriate judgements, suggesting that on an input level she could discern the differences. in other minimal pairs she repeated real-words inaccurately, for example ihagu [pig] was repeated as /ilagu/. this suggests that she had the phonetic discrimination skills to carry out the task successfully, but was not able to accurately map from what she heard into her own output. in this repetition task it is unclear whether the breakdown occurs in her mapping from phonological representation to a motor programme, or the physical production of the word. this fits with her overall performance across tasks as repetition was found to pose some challenges for her. the word pheka [cook] was present in all three tasks. child b was able to name it and repeat it accurately, as well as discriminate between the phonemes /k/ and /d/ in the word pheka [cook] and non-word pheda. this suggests that she has a strong and accurate lexical representation of this word. the pattern for imali [money] is the same, with accurate naming, repetition, and auditory discrimination skills. a different pattern emerged with the word ikati [cat]. in the naming task, child b produced this word correctly, suggesting that she has semantic knowledge, accurate phonological knowledge, and accurate motor programming skills to produce the word. when required to repeat the word in the second task she produced /kats/ on the first attempt but was able to correctly produce the word ikati when prompted again on the second try. this may suggest difficulties in her phonological representation of the word, which may have been attributable to the poor acoustic environment of the crèche. a second possibility may be because of the assimilation of the final vowel causing prolongation of the phoneme /t/ resulting in the phoneme sounding like /ts/. it would be beneficial to administer the auditory discrimination task using the word ikati [cat] paired with /ikats/. this would confirm whether inaccurate production in the repetition task was because of difficulties with auditory discrimination or if it is related to the assimilation process used. in the naming task, child b produced the word iwotshi [watch] as /iwɔtsi/ changing the /tʃ/ phoneme to a /ts/. her attempt at naming this picture suggests that she has semantic knowledge of this word but may have inaccurate stored phonological knowledge about it. when required to repeat the word in the repetition task, she produced /iwɔʃi/, which is a closer approximation to the target phoneme. this indicates that she could recognise this word and was able to distinguish it from her own inaccurate production. however, her difficulty producing it accurately suggests difficulty with either her phonological representation of the word or her motor programming skills to produce it. when given the adult model in the repetition task she was more accurate and appeared to be using the model to create/map a new and a more accurate motor programme, but clearly this needs further refinement. figure 4 indicates the possible areas of difficulty for this word. figure 4: possible areas of difficulty for iwotshi [watch] (child b). the words ipapa [porridge] and ilanga [sun] were produced accurately in the repetition task. child b was able to discriminate between the /p/ in ipapa [porridge] and the /k/ in ikapa [cape town] in the auditory discrimination task. she was also able to discriminate between the /l/ in ilanga [sun] and the /pl/ in iplanga [plank]. this suggests she has accurate phonological representations and motor programming skills to produce these words accurately. naming was not attempted for these items and so further comparison across tasks is not possible. child b was able to accurately name the words lala [sleep] and ibhola [ball] in the first task, as well as accurately repeat them in the second task. this suggests that she has accurate semantic representations, accurate phonological representations, and accurate motor programming skills to physically produce the words. for further comprehensive analysis it would be beneficial to administer the auditory discrimination task using the words lala and ibhola paired with appropriate minimal pairs. the word ukutya [eat] was elicited in both the naming and repetition tasks. both were inaccurate as she produced /ukuta/ for both tasks. her attempt at naming this picture suggests that she has semantic representation of this word. however, her incorrect production of the phoneme /c’/ in the word in naming suggests that she has inaccurate phonological representation and/or does not have the appropriate motor programming skills to physically produce the word. her inaccurate production when repeating suggests that she may have a difficulty with her phonological recognition skills and/or does not have the appropriate motor programming skills to physically produce the word. she was, however, able to better map out the three syllables when given the adult model. for further comprehensive analysis of the /c’/ phoneme in the word ukutya [eat], it would be beneficial to administer the auditory discrimination task using the word ukutya [eat] paired with a minimal pair contrasting /c’/ with /t/. this would confirm whether her inaccurate production in the repetition task was because of difficulties with auditory discrimination of the word or developing abilities to produce the word. in general, repetition seemed to improve on naming, a conclusion based on a small set of lexical items common to the two tasks, e.g. iwotshi [watch] and ikati [cat]. although in some cases she presented with similar phonological processes affecting consonants in both tasks. child b was able to complete the auditory discrimination task, obtaining 100% when discriminating between the 12 pairs of words. she used an interesting strategy that appeared to support her in carrying out this task; she repeated items out loud, and this gave the researchers further insights into her repetition skills. discussion naming is the most widely used method of assessing a child’s speech-production abilities, but it has considerable cognitive and linguistic demands. in order to successfully carry out the task, children need to have semantic knowledge of the word (i.e. it must be in their vocabulary), they must have stored the lexical item accurately in their phonology, and they must have the ability to articulate it. as a starting point for our assessments with 2-year children, we were able to adapt an existing naming assessment. both children were only able to spontaneously name small subsets of the pictures given the limitations of their vocabularies. of the words that were spontaneously named, both children showed ability to appropriately articulate consonants and vowels in the words. this fits with what has been noted previously by researchers about the development of phonology in isixhosa. for example, tuomi et al. (2001) and gxilishe (2004) suggested that much isixhosa speech development would have taken place by the time a child turns 2. the findings of this study confirm this and show that both children had acquired all of the vowels of their language and many of the consonants. however, there were some vowels and consonants that were still challenging for the children. child a distorted vowels on occasion (e.g. /ɛndʒʌ/ for inja [dog]). affricates were noted to not yet be acquired by both children: child a was unable to accurately produce /tʃ’/ in iwotshi in the naming task, but could do it when given the model in the repetition task. child b used deaffrication as a main process and when naming, she substituted some affricates with a slightly lateralised close approximation of the phoneme. child b was not able to produce the /c’/ in ukutya [eat] and instead produced/ukuta/. these findings fit with the small body of research that has focused on acquisition of vowels and consonants in isixhosa. maphalala et al. (2014) suggested that isixhosa may be characterised by late acquired affricates. this study however, aimed to move beyond naming tasks and consider speech processing tasks that tap input and the entire speech processing system more systematically. speech accuracy has been shown to be similar when comparing equivalent naming and repetition tasks for typically developing children (vance et al., 2005). for children with speech and/or language difficulties, repetition may be easier than naming because the cognitive load required to access semantic information is omitted, or at least not necessitated. however, for other children with difficulties, repetition can pose additional challenges: they need to be able to accurately perceive the target word, remember it, and then have the articulatory abilities to execute it. child a achieved her highest score (88%) for repetition, which was a considerable improvement from naming (65%). given that her auditory perception performance was 58%, one might conclude that her auditory input processing abilities are a relative weakness. however, if this was the case, her repetition would be poorer than her naming because repetition is heavily dependent on accurate auditory processing. it may have been the nature of the abx task that was a challenge for the child, although it cannot be attributed to memory difficulties alone because, again repetition tasks draw heavily on memory. the notion of a talking teddy bear (as was used in this study) may be unfamiliar to children from some cultures where parents will not routinely hold up toys and ‘pretend’ they are talking – as occurs typically in some other cultures. this could be an explanation for some of the challenges experienced by this child with the abx task. a further contributing factor may be the nature of the minimal pair words themselves. in drawing up the minimal pair lists many challenges were faced and many compromises made. further studies will be needed to refine both the stimuli and their administration. we might have expected that child b’s performance would be similar to child a given that the girls were very similar in terms of age, language exposure, and the crèche that they attended. however, this was not the case despite the similar procedures used. child b performed at the same level for naming and repetition (56%), and obtained 100% items correct for the abx task. many of her speech errors were common across naming and repetition, and other errors balanced out with some inaccuracies noted for naming (and not repetition) and then vice versa. when presented with her own errors paired with target productions in the abx task she experienced no difficulties, although her strategy for making the distinctions was interesting in that she did not appear to want to rely on input processing alone and automatically produced her own productions of the words. it may be that the abx task used in this project was cognitively demanding for 2-year-old children, and other more suitable ways of assessing the auditory abilities of such young children will need to be found. newton et al. (2008) used a different technique for assessing auditory discrimination in young children; the duration and direction of their gaze in response to computer presented visual and auditory stimuli. although their research did not focus on 2-year-olds, they suggest that the use of such an approach is a viable alternative to the methods currently used with children aged 4–7 years. given the challenges faced with isixhosa – there are currently very few isixhosa-speaking clinicians in southern africa, despite this being the second most spoken language in the region – it might be helpful to have a computerised assessment that could then include recordings of isixhosa words as well as automatic measures of eye gaze parameters. limitations the naming task that was used as the basis for the assessment battery was developed for use with older children aged 3–6 years. because of this, the young children could name only a small subset of the pictures presented. only words that were known and named were included in the analysis. however, in order to set up the abx task in advance there were some items in this component of the assessment that included words that were unfamiliar to the children. when a word was included in all three tasks, it enabled more interpretation of the child’s ability to process that item. future studies should ensure that the vocabulary used in naming tasks is tailor-made for the children of a particular age, and that where possible the same lexical items are used across tasks to enable more fruitful comparison. a study with only two participants cannot be generalised to the wider population, but given the limited nature of this type of study with 2-year-old isixhosa speakers, it may serve as a starting point for larger studies of this kind. it would also have been helpful to track the children’s development on these tasks over time using a longitudinal design. unfortunately this was not possible for these children, but longitudinal work should be considered in future studies. clinical implications the two children presented in this paper obtained very similar scores for the naming task. however, moving beyond the speech accuracy of their naming, two very different patterns of performance were revealed. child a performed better with repetition, and more poorly with auditory discrimination. child b maintained the same level of performance for repetition, and then exceeded this with her auditory performance. these are typically developing children who most likely will not require speech and language therapy. however, if this variable pattern of performance occurs for all children, and naming is really just one window into a bigger picture of speech processing and production, then it would be helpful for clinicians to know the nature of an individual child’s strengths and weaknesses to ensure that therapy is appropriately targeted. this is not a novel idea and much of stackhouse and wells’ work has suggested the same. however, the data presented here for very young children acquiring an under-researched language is new and supports that argument. next steps in this action research cycle would be to create an adapted version of the masincokoleni speech assessment that would be appropriate for 2-year-olds (shorter and bearing in mind their lexical abilities), and age-appropriate repetition and auditory discrimination tasks. the repetition task could be administered as an alternative to the naming task, or in addition to it, and would allow for comparisons to be made between performance on the two tasks. vance et al. (2005) suggest that speech accuracy is likely to be similar across naming and repetition tasks for children who are typically developing, but this may be different for children with speech difficulties and thus hold potential for diagnosing children with speech difficulties. acknowledgements thank you to our colleagues sean bowerman, nazneen gangji, zinhle maphalala, and somikazi deyi at the university of cape town for assisting with this research. we are grateful to barbara stemmert, jo mcclellan, ruth mandisa matyane, and namhla sithetho from ikamva labantu for their practical support. steve porter provided assistance with technical aspects of the data collection process. jenny pahl (university of kwazulu-natal), joy stackhouse, and bill wells (university of sheffield) are gratefully acknowledged for sharing their knowledge and providing advice about the research process. michelle pascoe was funded by the national research foundation. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions m.p. was the supervisor of this honours project carried out by a group of six final-year speech language pathology students at the university of cape town. m.p. was the project leader who conceptualised the project and oversaw the work. the students undertook data collection and analysis. the article was jointly authored by k.r., l.f., c.j., n.m, m.p. and l.r. who all contributed equally to the writing of this article. references baker, e., croot, k., mcleod, s., & paul, r. 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(2nd edn.). los angeles, ca: western psychological services. appendix a: consonant inventory of isixhosa appendix b: isixhosa wordlist and recording sheet. appendix c: list of minimal pairs used in abx task. appendix d: administration sheet (for repetition and auditory discrimination). task 2: repetition task task 3: auditory discrimination current management for word finding difficulties by speech-language therapists in south african remedial schools 59 current management for word finding difficulties by speech-language therapists in south african remedial schools ingrid de rauville, sandhya chetty and jenny pahl university o f kwazulu-natal a b s t r a c t word finding difficulties frequently found in learners with language learning difficulties (casby, 1992) are an integral part o f speech language therapists’ management role when working with learning disabled children. this study investigated current management for word finding difficulties by 70 speech-language therapists in south african remedial schools. a descriptive survey design using a quantitative and qualitative approach was used. a questionnaire and follow-up focus group discussion were used to collect data. results highlighted the use o f the renfrew word finding scale (renfrew, 1972, 1995) as the most frequently used formal assessment tool. lan­ guage sample analysis and discourse analysis were the most frequently used informal assessment procedures. formal intervention pro­ grammes were generally not used. phonetic, phonemic or phonological cueing were the most frequently used therapeutic strategies. the authors note strengths and raise concerns about current management for word finding difficulties in south african remedial schools, par­ ticularly in terms o f bilingualism. opportunities are highlighted regarding the development o f assessment and intervention measures rele­ vant to the diverse learning disabled population in south africa. key words: word finding difficulties, learning disabled children, assessment, intervention. introduction learners with language learning disabilities frequently ex­ perience word finding difficulties (casby, 1992; german, 1998) as cited by german, 2005) word finding difficulties (wfds) are an integral aspect o f the speech-language therapist’s management practices when working with a learner who has a language learning disability (lld). using the royal college o f speech therapists’ definition o f practice (1998), hereinafter, management refers to the assessment, formulating and implementing intervention pro­ grammes and decision making about discharge from therapy. many factors impact on the complex management o f developmen­ tal wfds by south african speech-language therapists (slts), including: controversies about the nature and impact o f wfds; the training o f slts in wfds; the role o f the slt in managing wfds; the context in which services are provided; the model o f service delivery in use; policy issues including inclusive educa­ tion; outcomes based education and language issues. furthermore, speech-language therapists (slts) have experienced frustration with the outcome o f therapy for wfds (haynes, 1993). “learning disability is a general term that refers to a hetero­ geneous group o f disorders manifested by significant difficulties in the acquisition and use o f listening, speaking, reading, writing, reasoning or mathematical abilities” (national joint committee on learning disabilities (1991, as cited by owens, 2004). south afri­ can learners with learning disabilities exhibit discrepancies be­ tween their intellectual potential (usually average to above aver­ age) and expected academic performance and are typically admit­ ted to remedial schools (s, mohamed, personal communication, august, 24* 2004).speech-language therapy services for learners with lld and wfds in the south african context are frequently provided in the context o f remedial education. within the current educational system in south africa, learners with lld (and possi­ ble wfds) are educated at long and short-term remedial schools or within mainstream schools. slts’ practice in different educational settings is shaped and influenced by current and changing educa­ tional policies such as outcomes^ based education (department o f education, 2001). another policy influencing the practice o f slts is inclusive education where the focus is on overcoming barriers in the system that prevent meeting learning needs by adapting the support systems in the classroom (department o f education, 2001). policies like this impact on service delivery models for learners with lld and possible wfds viz. individual versus group therapy, traditional pull-out system or classroom-based therapy. wfds in children with ld, who meet the criteria for ad­ mission into a remedial school, are pervasive in nature, and impact on their communicative and academic performance (faust, dimi trovsky & shacht, 2003; lemer, 2000). this takes the form o f dif­ ficulties with confrontation naming, reading, and conversational discourse. secondary behaviours such as hesitations, repetitions and re-formulations occur (dockrell, messer, george & wilson, 1998) and may result in inaccurate messages being conveyed (faust et al., 2003). it is therefore important for wfds to be sys­ tematically identified, assessed and treated as early as possible in the learner’s educational career (faust et al., 2003). speech language therapy interventions for wfds have been reported to be ineffective (dockrell et al., 1998), and have thus not enabled the learner to achieve the academic and communicative competence required for progress in education. the causes of word finding difficulties there is no unequivocal explanation for the presence of wfds (casby, 1992). within a psycholinguistic framework, lim­ ited processing resources, inadequate or ill-defined semantic repre­ sentations, inadequate phonological specifications and naming speed deficits are possible contributing causes o f wfds (dockrell et al., 1998). within the processing view, the two inter-related compo­ nents o f the initial learning, organisation and storage o f informa­ tion that impacts on the learning o f vocabulary (easton, sheach & easton, 1997), and the ability to retrieve words (macgregor & leonard, 1989, cited in easton et al., 1997) may impact on wfds. thus storage strength (i.e. how well a word is learned) and re­ trieval strength (i.e. how easily a word is retrieved) are important. a debate exists about the types o f word-knowledge viz. semantic the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 60 ingrid de rauville, sandhya chetty and jenny pahl and phonological features of a word and the link between them in relation to storage and retrieval strength (easton et al., 1997). an additional view of the cause of wfds is that of inade­ quate semantic specification (easton et al., 1997). semantic defi­ cits result in simple semantic networks, with limited options for associations for stimulus words, which may result in oral and writ­ ten wfds (casby, 1992). a further causal view is that wfds are attributable to an inadequate phonological representation (easton et al., 1997). in­ adequate phonological representation could, according to a proc­ essing model used by chiat and hunt (1993), indicate difficulty at an input (phonological representation) or output (phonological ac­ cess) level. naming difficulties may suggest difficulties in phono­ logical storage (webster, 1994). deficits in phonological access may present as difficulties in the naming of familiar words such as colours, digits, letters or objects (clark, 1988 as cited by webster, 1994). however while it is not always easy to determine what the underlying cause of the child’s wfd is (easton et al., 1997), it is important to assume an interaction between the two processes of semantic representation and phonological specification. assessment for wfds according to german (1989a), a comprehensive assessment for wfds should incorporate naming tasks, a comprehension task and the identification of word finding characteristics. a thorough assessment of wfds is needed for bilingual learners (german, 1989a), which is of particular importance in the south african context. learners acquiring english as a second language, particu­ larly in the school setting, should have their abilities assessed us­ ing tools sensitive to their cultural and linguistic backgrounds (cheng, 1994; montgomery, 1999 as cited by apel, 2001). the strategies for assessing wfds may be formal and in­ formal (wiig & semel, 1984). spontaneous language sample analysis is an informal tool suggested by wiig and semel (1984). a number of formal or standardised assessment procedures of brit­ ish and american origin used by slts to assess word finding are highlighted in available literature, but may be of limited applica­ tion to the south african learner. wiig and semel’s (1984) guide­ lines for selection of procedures for assessing wfds highlights the need to have a range of assessment contexts and procedures to diagnose or to determine the nature, severity and impact o f a wfd. to provide an in-depth assessment of word finding abilities and difficulties, one has to select multiple procedures with a num­ ber of tasks which require naming in a variety of contexts (wiig & semel, 1984), such as: • rapid naming upon confrontation of visual stimuli (such as the renfrew word finding scale'renfrew, 1972, 1995). • rapid naming of automatic sequential series (such as the fa­ miliar sequences criterion referenced sub-test of the clinical evaluation of language fundamentals-four, semel, wiig & secord, 2003). • rapid automatised naming (such as the rapid automatic nam­ ing task of the clinical evaluation of language fundamen­ tals-four, semel, wiig and secord, 2003). • rapid naming of words in free or controlled association tasks. 't h e r w fs as a standardised test nam e is used to rep resen t both the old version o f the test (r enfrew , 1972) and the new version o f the test (r enfrew , 1995), w hich has altered its nam e to the w ord finding v ocabulary t est (w fv t). t his differentiation w as not m ade on the questionnaire. german and simon (1991), also highlight the importance of as­ sessing children’s wfds in discourse. while a battery of reliable and valid measures, which allow for the profiling of wfds, is important, the limitations o f formal assessment tools applied to the south african context need to be acknowledged. furthermore, a shift from standardised testing to criterion-referenced and educator-produced tests is recommended (department of education directorate: inclusive education, 2002) intervention word finding intervention is complex with no single treat­ ment approach available that is known to address all wfds. for storage difficulties, therapy should identify and elaborate semantic features of words. for retrieval difficulties, therapy should aim at semantic categorisation or visual imagery (wiig & becker-caplan, 1984 as cited in german, 1992). when working with storage, one should aim to increase vocabulary, targeting common, frequent and meaningful words and those with concrete referents. the words should be taught in an orderly way, such as by using themes, and should highlight categorical and associative relation­ ships (nippold, 1992). aims of intervention for wfds (nippold, 1992) include hierarchically enhancing naming accuracy, improving retrieval strength and increasing the use of strategies by increasing meta cognitive and meta-linguistic awareness of factors that affect word finding ability, such as looking at meaning changes across contexts (nippold, 1992). the focus of intervention differs if a learner presents with wfds in spontaneous language or discourse. therapy should fo­ cus on increasing accuracy and fluency rate. a number of retrieval strategies, such as phonological, visual and semantic categories in discourse, need to be used and taught (german, 1992). response to particular types of intervention also informs us of the nature of the learner’s problem in relation to reading difficulties. learners with single phonological core deficits respond well to phonologically based therapy, which aims to increase phonemic awareness. learners with single processing speed deficits or a double-deficit (a deficit in both areas) are typically only partially served by such intervention. they would require emphasis on building fluency in reading and building automaticity in lower level processes serving these skills (wolf & segal, 1992). from the above it is evident that working with learners with lld and wfds is a complex area, impacted on by factors such as changing educational policy. it is also an area where slts have experienced frustration with the outcome of therapy (haynes, 1993). since wfds are frequently found in learners with lld (casby, 1992) and are an integral part of the slts’ management when working with lld, the purpose of this study was to deter­ mine current management for wfds in learners with lld within the context of south african remedial schools, an undocumented area of investigation. such investigation may highlight current strengths and difficulties in managing learners with wfds and serve to guide slts toward the required shift in management within the south african educational setting. slts’ opinions on the management of learners with lld and wfds'currently used in the various remedial educational institutions were important to as­ certain how these management practices meet the current needs of therapists and learners. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) current management for word finding difficulties by speech-language therapists in south african remedial schools 61 methodolgy aim the aim of the study was to determine slts’ current as­ s e s s m e n t and intervention practice for word finding difficulties in the language learning disabled population in south african reme­ dial schools. critical questions needed to be asked in order to meet the aim of the study. these included: 1. what is the current practice in terms of assessment proce­ dures used for learners with word finding difficulties? 2. what is the current practice in terms of intervention pro­ cedures used for learners with word finding difficulties? research design the nature of this research study was descriptive. the de­ sign employed could be further described as a descriptive survey as it allowed the researcher to describe characteristics of a sample at a particular point (leedy, 1997). as it is important to collect data for qualitative research using a skilled individual rather than a single instrument, (leedy, 1997), a questionnaire (quantitative) and a focus group discussion (qualitative) were used (mcmillan & schumacher, 2000). slts employed at remedial schools were par­ ticipants and it was their responses to the questionnaires that formed a significant basis of the research study. participant selection criteria participants needed to be slts working in south african government remedial schools. furthermore, they needed to be reg­ istered with the health professions council of south africa and the south african council of educators. participants needed to be willing to participate and learners with lld and wfds had to be part of their caseloads. figure 1 summarises the process of obtaining approval to conduct research and of participant selection. profile of participants a summary about the slt participants is provided in table 1. table 1: participant selection criteria letters of approval to conduct research sent to provincial superintendent generals of education r approval from gauteng kwazulu natal western cape free state province not applicable (no speech therapists) northern cape north west province criteria p articipants needed to be slt s w orking in south a frican govern­ m ent, rem edial schools. p articip an ts had to be reg istered with the h ealth p ro fessio n s c ouncil of south a frica and the south a frican c ouncil o f e ducators. l earners with lld and w fd s had to be part o f their caseloads. p articipants needed to be w illing to participate. reasons t he focus o f the study w as the m an­ agem ent o f w f d s by s l t s in this p articu lar context and s l t s w ere to be th e participants. this was to ensure that the partici­ pant slt s had the necessary qualifi­ cations and registrations to work in this area. t his population was the focus o f the resea rch study. t his is an im portant ethical consid­ eration. data collection methods the data collection procedure involved two phases: ad­ ministration of the questionnaire (survey method) and follow-up focus group discussion. the focus group discussion is a strategy to obtain a better understanding of information obtained in the re­ search procedure (mcmillan & schumacher, 2000). focus groups are unstructured interactions in a small group. interactions are with group members and the group leader or researcher (bowling, 1997). the questionnaire was administered following completion o f a pilot study using four qualified slts with relevant experience who were not part of the study sample. data collection instruments description o f the questionnaire all questions were developed using the critical questions as a guide and were developed using relevant theory. a total of 23 questions were developed (refer to appendix a). these questions were divided into three sections focussing on demographics, prac­ tice of wfds and efficacy o f intervention for wfds. nineteen of approval from principles gauteng: 8 from 9 kwazulu natal: 11 from 12 western cape: 5 from 5 questionnaires sent gauteng 62 questionnaires sent kwazulu natal 22 not applicable (no speech therapists) free state questionnaires sent western cape 16 no response eastern cape limpopo i figure 1: process for participant selection the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 62 ingrid de rauville, sandhya chetty and jenny pahl the questions were close-ended questions. the questions fol­ lowed a likert scale format (bailey, 1991). a statistical pro­ gramme, statistical package for the social sciences (spss) (spss inc., 1995), was used to explore patterns identified using frequency counts and percentages. four open-ended questions were included in the questionnaire allowing for richer data to be obtained: the responses to the open-ended questions were quali­ tatively analysed. all questionnaires were coded using letters and numbers on questionnaires to ensure anonymity and confi­ dentiality. focus group discussion schedule information obtained from the questionnaire needed to be explored further to improve the quality and richness o f the infor­ mation obtained (mcmillan & schumacher, 2000). this was achieved by developing a focus group discussion schedule which documented the open-ended questions to be investigated in an unstructured way (mcmillan & schumacher, 2000) using questions to probe further information where necessary. participants in the focus group discussion were from kwa-zulu natal which allowed ease o f access. eight partici­ pants attended the single focus group discussion at which the researcher and a scribe were present. data analysis data analysis for this research embodied both quantita­ tive and qualitative analysis as the research tools used for data collection characterised both types o f research. according to vithal and jansen (1997) data analysis includes three steps, sum­ marised as ( 1) scanning and cleaning the data, (2) organizing the data and (3) representing the data. these steps and how they were applied to this study are presented in table 2. table 2: description of the 70 participant slts the research procedure involved a number of pivotal phases. each phase was dependant on the completion o f the previous phase. a summary o f the research procedure, high­ lighting the phases is presented in figure 2. p h a s e 1 • a list o f rem edial schools in sa w as obtained from sa u v se . • p erm ission from regional s u p erin ten d en t g enerals to p erform the research w as obtained. p h a s e 2 • r em edial schools w ere co n tacted to determ in e i f s lts w ere em ployed there. • p erm issio n from school prin c ip als to perform the research w as obtained. p h a s e 3 • p ilo t study • a lterations to the q u estio n n aire w ere m ade. p h a s e 4 • l etters w ere d istrib u ted to p otential p articipants inform ing th e m o f th e researc h aim. • l etters o f co n sen t to particip ate w ere s e n t to participants. • t h e revised q uestionnaire w as ad m inistered to s lts in rem edial schools. • p articip a n ts w ere rem in d ed th a t questio n n aires w ere due for subm ission. p h a s e s • q u estionnaires w ere scanned to determ in e i f they m e t the criteria fo r d ata analysis. • s tatistical d ata analysis w as com pleted. p h a s e 6 • r esponses on q u estionnaires w ere u sed to id e ntify trends to develop th e interview schedule. • a focus group discu ssio n w as held in a selected region. p h a s e 7 • r esearch and research findings w ere w ritten up. • f eed b a ck to ed u c atio n auth o rities and p articipants reg ard in g the research findings w as com pleted. figure 2: summary of research phases ethical considerations using guidelines outlined by leedy (1997) certain ethical issues were considered for this research study. potential partici­ pants were informed in writing about the research study. informa­ tion included an ethical clearance number (03140a), who was un­ dertaking the research, why it was being undertaken and who fi­ nanced it. a letter to possible participants included a consent form, (informed consent) indicating willingness to participate! in the re­ search. letters to participants highlighted that they could withdraw from the study at any time, or refuse to participate without any pen­ alty. confidentiality in terms o f the participants, both slts and remedial schools, was guaranteed. all the information recorded in this research document was coded in order to uphold this. further­ more, the participants were assured that once the study was com­ pleted, audiocassettes used for the recording o f the focus group discussions would be destroyed. results o f this study were pro­ vided to the participants. a summary o f the findings and the impli­ cations thereof, were posted, faxed or e-mailed to the individuals, institutions, superintendent generals o f the provinces and all the relevant school principals that participated. reliability and validity for the purpose o f this study, a pilot study was conducted to parameter summarised description years o f experience 60% o f slts: 10 years or less experience 17% o f slts: 11-20 years experience 23% o f slts: 21 years + experience number of years working with wfds mean number o f years: 7,24 years university attended more than 80 % o f slts attended the former udw ,w its or pretoria language of therapy slts are guided by the language medium o f the school. the majority o f slts at dual medium schools provide therapy in english and afrikaans. slts at single medium schools provide therapy in the language o f the school procedure die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) c urren t management for word finding difficulties by speech-language therapists in south african remedial schools 63 refine the questionnaire, with the aim of increasing reliability. ecological validity was evaluated by the extent to which find jngs could be generalised beyond the find­ ings of the present study (mcmillan & schumacher, 2000). strategies used to in­ crease validity in the context of this re­ search included varied data collection strategies (mcmillan & schumacher, 2000) (for this study, a questionnaire and focus group discussion). this resulted in the tri­ angulation of data across techniques, where consistency of findings by different data collection methods was checked (bailey, 1991). it was important to be aware of the hawthorne effect, where participants may have acted differently since they were par­ ticipants in a research project (mcmillan & schumacher, 2000). furthermore, acknowl­ edging bias, particularly in descriptive re­ search, was important since it is inevitable (leedy, 1997). disciplined subjectivity and inter-personal subjectivity assisted in ac­ k n o w led g in g b ia s (m c m illa n & schumacher, 2000). therefore, a daily field log was kept, a field journal written and ethical decisions recorded. finally, it is im­ portant to highlight that what was being researched was “reported practice”, i.e., what clinician’s said they did was not nec­ essarily what they may do in actual prac­ tice. results results from the questionnaire, com­ pleted by 70 slts in south african reme­ dial schools, and from the focus group dis­ cussion, involving slts in the greater dur­ ban area in kwazulu natal follow. the re­ sults are presented and discussed in two main sections: assessment and intervention practice. current assessment practice, especially procedures used for wfds assessment procedures results indicated that participant slts usually used both standardised and informal assessment procedures when as­ sessing for wfds (question 13). “other” assessment procedures used by only 8% of participants, included subjective measures, speaking to parents and other members of staff and observation. a summary o f re­ sults obtained is presented in figure 3. standardised assessments participants were asked to indicate which standardised assessment tools they used in assessing wfds in learners with lld (question 14). it was found that the renfrew word finding scale (renfrew, 1972, 1995) was by far the most fre­ quently used test to assess wfds. eighty three percent of the partici­ pants who answered this question used either the renfrew word finding scale (rwfs) only or used it together with some other test(s). the results are summa­ rized in figure 4. the use o f the rwfs as a tool for assessing wfds was further explored in the focus group discussion to determine participants’ views o f this tool for identi­ fying wfds. participants at the focus group discussion offered views including that the rwfs depended on an intact vo­ cabulary, identified only severe wfds, needed to be used with another tool and did not effectively test for wfds, as indi­ cated by the following excerpt: “. . . i d o n ’t b eliev e i t ’s m ore effective than ju s t even a spon taneous language sa m p le ch arting the w f d .... ” informal measures used in the assess­ ment o f learners with lld and wfds on the questionnaire, participants were asked to indicate which informal measures were used to identify wfds (question 15). language sample analysis (lsa) or discourse analysis (da) was the most frequently used informal measure to identify wfds. thus 77 % of the partici­ pants in the sample who answered the question used either lsa or da only or together with some other measure(s). these results are summarised in figure 5. slts view o f assessment procedures fo r wfds the results showed that 45 % of participant slts in the sample disagreed that assessment procedures were relevant to the south african population but 58 % agreed that the procedures assisted in identifying wfds. thirty four percent disagreed and 31 % remained neutral re­ garding assessment procedures providing sufficient detail to provide treatment goals. the results suggest that almost fifty percent of the participants working with wfds in lld were aware that the formal tools used were not relevant to the south african population. 3 0 i 25 20 15 10 5-/ / / / / / / / fz a h h h 0never sometimes usually aiways mean2) □ number using standardized tests °i 12 26 22 2.17 □ number using informal measures °l 19 19 16 1.94 □number using othem) °l 2 2 2 figure 3: assessment procedures used by participant slts for learners with lld and wfds (n=60) ; 1. t he m easures listed under “other” include subjective m easures, speaking to parents and other m em bers o f staff, observation and a com bination o f standardised tests and inform al m easures. 2. t he calculation o f the m ean is based on allocating 0 fo r a “never” response, 1 fo r a “som e tim es” re­ sponse, 2 fo r a “ usually” resp o n se and 3 for an “ alw ays” response. figure 4: standardised tests used for identification of wfds (told-3 t est o f l anguage d evelopm ent 3, n o specific sub-test). the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 64 ingrid de rauville, sandhya chetty and jenny pahl figure 5: informal measures used for assessment o f wfds (key: l sa = language sa m p le analysis. d a = discourse analysis) figure 6: formal programmes used in intervention (key: l s= l ingui system s) figure 7: therapeutic strategies used by participant slts in intervention for wfds figure 8: number of participant slts who reported providing both individual and group therapy (n=59) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 current intervention practice, espe­ cially procedures used for learners with wfds the second area of focus was cur­ rent management practice in terms of in­ tervention procedures used for learners with lld and wfds (question 16). more than 60% of the participants in the sample did not use any formal interven­ tion programme. of those who did use a formal programme, a variety of pro­ grammes were given, with no particular one being used by the majority of schools in the sample. the results obtained are summarized in figure 6. the findings suggested that pho­ netic cueing combined with some “other” strategy was the informal therapeutic strategy most used in working with lld children with wfds (question 17). ninety one percent of the participants who answered the question used either phonetic cueing only or together with some other strategy or strategies. other informal strategies included for example: categorizing, associations, mind map­ ping, cloze tasks and visual cueing. a summary of the results indicating the therapeutic strategies used in interven­ tion, is presented in figure 7. administering therapy participants provided either group, individual or both individual and group therapy to learners with llds and wfds (question 10). a summary of results is presented in figure 8. using the chi square test of association, no significant differences between the provision of individual ver­ sus group therapy were noted.'however, qualitatively, some differences were identified. this issue was explored dur­ ing the focus group discussion and re­ vealed the following about intervention for learners with wfds. three i variables were identified as influencing' whether slts provided intervention for wfds individually or in a group. these vari­ ables were the slt’s caseload, the popu­ lation of learners at the school, and deci­ sions of school management. participants in the focus group discussion indicated that the greater the caseload, the more likely group intervention was provided. further, the more severe,a learner’s diffi­ culty the less likely they were to receive group therapy. in terms o f caseload, two thirds of the participants in the sample saw 10 or--less learners with lld and wfds per week. these results are sum­ marized in figure 9. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) current management for word finding difficulties by speech-language therapists in south african remedial schools 65 21 -iper vseek 13% 1 -5pervsfcek 50% total number of responses = 60 figure 9: number of learners with learning disabilities as well as with wfds seen per week slts’ views on intervention procedures used fo r wfds an equal number of participants in the sample (36 %) agreed or were neutral in terms of intervention procedures being relevant to the south african population of learners with wfds and llds (question 21). sixty one percent of the participants agreed that intervention pro­ cedures were useful in addressing wfds. continuing professional development in the area o f wfds there was an overwhelming re­ sponse (100%) where all participant slts in the sample wanted wfds to be covered in continuing professional development programmes. due to this overwhelming response, continuing professional develop­ ment as an issue was further explored dur­ ing the focus group discussion. the results are discussed in the discussion of current practice in terms of intervention proce­ dures. discussion i current assessment practice for wfds in learners with lld an in-depth and thorough assess­ ment for wfds in learners with lld with multiple procedures and a number of tasks in a variety of contexts is recommended (wiig & semel 1984, wolf & segal 1992, german, 1989a). despite this, the rwfs as a single tool was by far the most fre­ quently used standardised assessment tool for identifying wfds. a number of possi­ bilities for this assessment practice exist. these include training in wfds, knowl­ edge bases, available resources and poli­ cies. knowledge from undergraduate training may be related to limited choice of assessment procedures for wfds since two-thirds of participant slts responded that word finding was not an area covered in training. on the other hand, the avail­ ability of resources in the south african context could impact on the choice of assessment tools used. slts may be re­ stricted in purchasing standardised proce­ dures specifically for wfds like the test of word-finding (twf) (german, 1989b) due to availability, high costs or other practical reasons. standardised assess­ ment tools are generally expensive. the rwfs is relatively cost effective. it is also quick to administer (renfrew, 1995), making it functional for slts in the re­ medial school environment with large caseloads (stockman, 2000). in assessment, the literature stresses the importance of identifying the type and possible cause of the wfd. this influences the intervention selected. while some participant slts described wfds according to semantic deficits, retrieval deficits and general characteris­ tics of wfds, the descriptions did not seem to match their assessment practices. these focussed mainly on assessing ex­ pressive vocabulary using the rwfs. the purpose of the rwfs is to identify if a child is able to name a word (renfrew, 1995), not to assess word finding specifi­ cally. the use of the rwfs could there­ fore impact on service delivery, since it provides limited information about wfds. in comparison german’s test of word finding (1989b), assesses accuracy of word finding, word comprehension, speed of naming, use of gestures and extra verbalizations. augmenting assessment with qualitative observation of how the learner responds (as recommended by renfrew, 1995), provides additional, valuable but partial information about wfds. furthermore, renfrew (1995), when commenting on studies informing revisions to the rwfs test, notes that its use with a south african population is problematic (pahl & kara, 1992). using tests not standardised on the population with which you work impacts on the va­ lidity of findings (apel, 1999). slts in south african remedial schools need to be aware of this limitation regarding the in­ terpretation of formal test findings when assessing wfds. using vocabulary tests, such as the rwfs, with multicultural populations often provides a negatively biased view of linguistic competence (stockman, 2000). using standardised tests not normed for our population highlights ethnocentricity. with the shift in south african educa­ tional policies, criterion-referenced and educator-produced tests are recommended by the department of education (department of education directorate: inclusive education, 2002). consistent with the department of education’s rec­ ommendation for criterion-referenced tests, terrell and terrell (1993) suggest the use of criterion-referenced assess­ ments with individuals from diverse cul­ tural backgrounds. slts assessing wfds should consider devising criterionrefer­ enced and educator-produced tests for use in the context of south african remedial schooling. the most frequently used informal assessment procedures for identifying wfds in learners with lld were lan­ guage sample analysis (lsa) or discourse analysis. the use of lsa as an informal assessment procedure to determine how wfds create difficulties for the learner with a lld is recommended by wiig and semel (1984). using lsa with the learner with lld is particularly relevant when formal tests are not relevant to the popula­ tion with whom we work (pahl & kara, 1992). however, it is important to bear in mind whether the lsa is in the learner’s first language. apel (1999) suggests that slts use contextbased assessment methods such as assessing communication skills in the classroom. such an approach would be consistent with a more consulta­ tive or collaborative role (schoeman, 2003). current intervention practice, espe­ cially procedures used for wfds in learners with lld the findings of the study revealed that most participant slts in the sample did not use formal programmes for inter­ vention. this is consistent with the lim­ ited availability of specific programmes the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 66 ingrid de rauville, sandhya chetty and jenny pahl for wfds (german, 1992). possible reasons for predominant use o f informal programmes are similar to those discussed under as­ sessment for wfds namely: knowledge o f available pro­ grammes, limited training, and limited resources. it is possible that even if resources were not limited, intervention programmes developed in other countries using unfamiliar stimulus material would be inappropriate to south african learners with wfds. using informal programmes may be an advantage in that slts can plan and develop appropriate interventions for the south af­ rican context. most participant slts agreed that the formal intervention procedures they used for wfds in learners with lld were use­ ful. although participant slts found the programmes useful, the programmes were not specifically developed for targeting wfds. therefore, a very specific aspect o f wfds, which may not be the learner’s area of difficulty in word finding, may be addressed, raising questions about the effectiveness o f intervention. the most frequently used informal therapy strategy for wfds was phonetic, phonemic or phonological cueing. these findings are supported by literature recommending these strate­ gies for intervention with wfds (wiig & semel, 1984). how­ ever, slts need to be aware that response to a specific type o f intervention informs us o f the nature o f the learner’s problem. for example, if the response to phonological based therapy is good, the difficulty is phonologically based (w olf & bowers, 2000). adopting such an approach to treatment implies that diag­ nostic therapy is relevant for wfds. intervention strategies would need to change if the child does not respond to selected strategies. slts in remedial education in south africa should also incorporate into intervention for wfds a number o f other skills. these include: phonological segmentation and imagery (wing, 1990), self-cueing, semantic intervention and phonologi­ cal awareness intervention (wittmann, 1996), combined semantic and phonological treatment approaches (easton et al., 1997) and discourse based intervention (stiegler & hoffman, 2001). how­ ever, since there is little evidence to support the efficacy o f treat­ ment approaches for learners with wfds (casby, 1992), slts need to monitor the effects o f their treatment (wittmann, 1996). this will assist in determining the most appropriate treatment for the learner with lld and wfds. the predominant languages in which intervention for wfds was p ro v id ed were english and afrikaans. a concern arises for learners who speak other official languages of south africa and for whom the language o f instruction is english or afrikaans. when working with learners who use more than one language, a differential diagnosis is necessary. the aim is to de­ termine if the difficulties are related to a first language learning problem, a problem with acquiring a second language or if the learner is in a normal process o f learning an additional language (miller, 1984). slts should question which the optimal lan­ guage to provide therapy for wfds in, is (miller, 1984). consistent with the findings o f haynes (1993), participant slts in south african remedial schools seem to be providing strategies for wfds but it did not appear that consideration was given to the general aims o f intervention outlined by german (1992). since therapy for wfds is complex and there is no single intervention approach that addresses all wfds, the general aims o f intervention as outlined by german (1992) can be used to guide such intervention. these aims are to enhance naming accu­ racy, improve retrieval strength and develop meta-cognitive and meta-linguistic strategies to improve wfds and to increase accu­ racy and fluency in spontaneous language. consistent with the findings o f haynes (1993), slts in south african remedial schools need to extend their understanding o f language process­ ing so that therapy for wfds can be addressed in a broader man­ ner. the issues raised by participants about institutions’ demands and experience for example, become secondary to providing the most effective and accountable service (baum, 1998), for learn­ ers in remedial schools. caseloads of slts for learners with lld with wfds it is difficult to account for the low caseload o f learners with lld and wfds reported by the participants. compared to the prevalence figure of 49 % of all grade four and five learners with ld having wfds (german, 1998 cited by german, 2005), this low caseload o f less than ten learners with lld and wfds is of concern. as wfds are the domain of the slt, this may imply that the wfds of some learners are not being identified. if the wfds o f learners in remedial schools which focus on reducing barriers to learning (schoeman, 2003), and aim to return learners to mainstream schools, are not being identified and treated, these learners are possibly not receiving the help that they need. other possible reasons for this low caseload o f learners with wfds receiving intervention from slts may be low priori­ tisation given to wfds in comparison to other difficulties experi­ enced by learners in remedial schools. furthermore, limited availability o f procedures appropriate to the south african con­ text may be another reason for small caseloads o f learners with wfds for slts in remedial schools. limitations of the study a number of limitations in both the implementation and results o f this study are noted. since the sample was limited to slts in south african remedial schools, the results obtained provide information specific to this population. this means that the findings cannot be generalised to other populations of slts. the focus group discussion was only completed in kzn for logistical reasons. if these focus group discussions had been extended to other regions, the results may have provided a valu­ able comparison o f findings. some responses on the focus group discussion differed from the findings o f the questionnaire, possi­ bly because participants were given more opportunity to explain or expand on certain issues. the questionnaire used a predominantly close-ended ques­ tion format with slts ticking the appropriate response. such a format was selected to facilitate quick completion of; the ques­ tionnaire (bailey, 1991). however, in selecting such a', question­ naire format, more detailed responses were limited to i questions posed in the focus group discussion. this may have had an im­ pact on the quality o f the information obtained. it is recommended that biased or leading questions be avoided (leedy, 1997). although this was a criterion used for developing the questionnaire for this study, examples o f tests were provided for specific questions. generally the responses to those specific questions used the examples provided. richer in­ formation may have been obtained with open-ended questions. conclusion from this study, the following conclusions can be drawn. in terms o f assessment of wfds in south african remedial schools, there were concerns, strengths and opportunities for change. it seems that the vast majority o f participant slts in south african remedial schools who typically assess wfds use die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) c u r r en t management for word finding difficulties by speech-language therapists in south african remedial schools 67 standardised tests. this is despite the tests b e in g b ia sed against our population and limited in their application for comprehensive a ssessm en t of wfds in learners with llds. reasons for this concerning assessment practice may include limited training in wfds and limited resources. it is however encouraging that some participant slts in remedial schools were incorporating informal assessment measures into their standard test battery. us­ ing informal strategies reduces test bias but the manner of o b ta in ­ ing the language sample and the mother tongue of the learner are crucial considerations. using lsa, for example, is a useful strat­ e g y to observe wfds in discourse, but lsa used with another tool such as the rwfs is not enough. furthermore, slts need to include teachers in the assessment of wfds. teachers can pro­ vide information about the impact of wfds on classroom per­ formance. as slts follow policy changes in education and shift from standardised testing to criterion-referenced and educator produced tests (department of education directorate: inclusive education, 2002), assessment practices for wfds will become more applicable to our context. in terms of intervention for wfds by slts in south afri­ can remedial schools, there were also concerns, strengths and op­ portunities for change. o f concern was the finding that, consis­ tent with haynes (1993), some participant slts were only pro­ viding strategies for wfds. while this is an important interven­ tion principle, it is not sufficient (german, 1989a, german, 1992, wiig & semel, 1984, wolf & bowers, 2000). it seems that cur­ rent service delivery models typify a “pull out” model with lim­ ited collaboration with teachers. this is problematic in that it is not in line with changes in educational policy. other concerns include small caseloads for wfds in learners with lld and the language of instruction differing from the mother tongue of the learner receiving intervention. the predominant use of informal programmes in intervention for wfds may be an advantage in that slts can plan and develop appropriate interventions for the south african context. again, in the context of changing educa­ tional policy, an opportunity exists for reviewing and extending current intervention practices for wfds. with the changing education system for learners in reme­ dial schooling, slts face many challenges. one of these is to re­ visit the management of wfds in learners with lld. slts in remedial education should embrace the challenges by reviewing and improving existing management practices. they should be encouraged to build on existing j strengths to serve the learners with lld whom they serve. j acknowledgements i this article embodies the culmination of a thesis submit­ ted to the university of kwazulu-2natal by the first author, in partial fulfilment of the requirements for the degree, master of communication pathology (speech-language pathology), under supervision of the second and third authors. references apel, k. (2001). d eveloping evidence based practices and research col­ laborations in school settings. language speech and hearing services in schools, 32, 149-152 (prologue). apel, k. (1999). checks and balances: keeping the science in our pro­ fession. language speech and hearing services in schools, 30, 98-107. 2 the u niversity o f d urban-w estville and the u niversity o f n atal m erged in 2004 to becom e t h e u niversity o f k w az ulu-n atal bailey, d.m. (1991). research fo r the health professional: a practical guide (2 nd ed.). philadelphia: f. a. davis company. baum, h.m. (1998). overview, definitions, and goals for a sha’s treat­ ment outcomes and clinical trials activities. (what difference do outcome data make to you?). language speech and hearing ser­ vices in schools, 29, 246-249. bowling, a. (1997). research methods in health: investigating health and health services. buckingham: open university press. casby, m.w. 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(2000). the new peabody picture vocabulary test-1 11: an illusion o f unbiased assessment? language, speech, and hearing services in schools, 31, 340-353. terrell, s., & terrell, f. (1993). african american cultures. in d. battle. communication disorders in multicultural populations (chapter one). boston: andover medical publishers. vithal, r., & jansen, j. (1997). designing yo u r fir s t research proposal. kenwyn, south africa: juta & co. webster, p.e. (1994). linguistic factors in reading disability: a model for assessing children who are without overt language impair­ ment. child language teaching and therapy, 10 (1), 259-281. w iig, e., & semel, e. (1984). language assessment and intervention fo r the language learning disabled. (2nd ed.). columbus: charles e. merrill publishing company. wing, c.s. (1990). a preliminary investigation o f generalisation to un­ trained words follow ing two treatments o f children’s word finding problems. language speech and hearing services in schools, (21) 151-156. wittmann, s. (1996). a case study in word finding. child language teaching and therapy, 12 (3), 300-311. w olf, m., & bowers, p.g., (2000). naming speed processes and devel­ opmental reading disabilities. an introduction to the special issue o f the double deficit hypothesis. journal o f learning disabili­ ties, 33 (4), 322-324. w o lf, m., & segal, d. (!992). word finding and reading in the develop­ mental dyslexias. topics in language disorders, 51-23. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) current management for word finding difficulties by speech-language therapists in south african remedial schools 69 appendix a q u estion n aire fo r s p eech -l an gu age t h erap ists (s l t s) to in vestigate p ra ctice w ith w ord f in d in g d ifficu lties in c h ild ren w ith l a n g u a g e l ea rn in g d isab ilities. dear colleagues, i would appreciate your time in completing the follow ing questionnaire to investigate practice in dealing with children with word finding difficulties. i would like to assure you that you are fr e e to withdraw from this research programme at any time and that all information will remain anonymous. should you have a query about the language o f the questionnaire, please contact the researcher. thanks fo r yo u r time. section a tick the appropriate box. 1. how many years is it since you graduated as a slt 1 1-5 years 2 6 1 0 years 3 11-15 years 4 16-20 years 5 2 1 + years 2. which university did you attend? 1 university o f *durban-westville 2 university o f the witwatersrand 3 university o f pretoria 4 university o f cape town 5 university o f stellenbosch 6 other * t he u niversity o f d urban-w estville a n d the u n iv ersity o f n atal m erged in 2004 to becom e t he u niversity o f k w az ulu-n atal i if other, please specify: _________________________________________________________________________________ 3. how many years have you been in practice as a slt? 1 i 1-5 years 2 6-10 years 3 11-15 years 4 16-20 years 5 21+ years 4. what is (are) the language (s) of instruction at your school? 7 xitsonga 8 isishangaan 9 isindebele 10 sepedi 11 siswati 12 other 1 english 2 afrikaans 3 isizulu 4 isixhosa 5 setswana 6 tshivenda i f other, please specify: the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 5. during your training did you specifically cover word-finding difficulties as a topic in your course on learning disabilities? 7 0 ingrid de rauville, sandhya chetty and jenny pahl yes no 6. how many years have you worked specifically with language learning disabled children with word finding difficulties? 1 never 2 1-5 years 3 6 1 0 years 4 11-15 years 5 16-20 years 6 21 + years 7. if you responded never for question 6, please give a reason 1 lack o f skill in the area o f word finding therapy 2 lack o f awareness o f the presence o f word finding difficulties 3 limited assessment tools for the identification o f word finding difficulties 4 limited therapy programmes for word finding therapy 5 low prioritisation in terms o f intervention for word finding difficulties 6 other if other, please specify: ______________________________________ 8. what language (s) do you provide therapy for word finding difficulties in? 7 xitsonga 8 isishangaan 9 isindebele 10 sepedi 11 siswati 12 other 1 english 2 afrikaans 3 isizulu 4 isixhosa 5 setswana 6 tshivenda if other, please specify: section b 1 i the following section need only be completed if you presently manage word-finding difficulties in children with language learning disabilities. tick the appropriate box(es) 9. who refers language learning disabled children to you? most referrals some few none 1 psychologists 2 slts / 3 occupational therapists 4 remedial teachers 5 other if other, please specify: ___________________ d ie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) c u rren t management for word finding difficulties by speech-language therapists in south african remedial schools 10. h ow do you adm inister therapy to language learning disabled children w ith word finding difficulties? 71 always usually sometimes never 1 individual therapy only 2 group therapy 3 both 11. how many language learning disabled children with word finding problems do you see per week? 1 none per week 2 1-5 years 3 6-10 years 4 11-15 years 5 16-20 years 6 2 1+ years 12. how many children are there in your caseload for whom the language of instruction is different to their mother tongue? 1 none 2 1-5 years 3 6-10 years 4 11-15 years 5 16-20 years 6 2 1+ years 13. what assessment measures do you use? always usually sometimes n ever 1 standardised tests 2 informalj 3 other if other, please specify: i 14. please list the standardised tests you use to identify word finding difficulties in language learning disabled children. please list in order of frequency o f use e.g. 3. renfrew word finding scale. most frequently used name o f standardised test used 1 2 3 4 ' 5 6 the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 72 ingrid de rauville, sandhya chetty and jenny pahl 15. please list the informal measures you use to identify word finding difficulties in language learning disabled children. please list in order o f frequency o f use, e.g. 1. language sample analysis. most frequently used informal measure used 1 2 3 4 5 6 16. what formal programmes/ and or activities do you use in your work with word finding difficulties in language learning disabled children. please list in order o f frequency o f use e.g. 4. lingui systems auditory association activity booklet. most frequently used name o f programme or activities used 1 2 3 4 5 6 17. what therapeutic strategies do you use in your work in language learning disabled children with word finding difficulties? e.g. 5. phonetic cueing. please list in order o f frequency. most frequently used name of therapeutic strategy used 1 2 3 4 5 6 18. what role do other team members play in your management of word finding difficulties in the language learning disabled children that you treat? j always mostly some­ times hardly ever never 1 teachers are involved in the management process by observing slt classroom based therapy to gain insight into strategies used. 2 teachers are involved in the management process by providing strategies for word finding difficulties in the classroom 3 occupational therapists are involved in the management process by providing strategies for word finding difficulties in their interac­ tions during their therapy sessions / 4 psychologists are involved in the manage­ ment process by providing strategies for word finding difficulties in their interactions during their therapy sessions 5 staff are aware o f the impact o f wfd on their assessment. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) current management for word finding difficulties by speech-language therapists in south african remedial schools 73 section c tick the appropriate box. 19. do you feel that your therapy for word finding difficulties in language learning disabled children is effective? always usually sometimes never 20. how do you measure the effectiveness of your therapy? strongly agree agree neutral dis­ agree strongly disagree i feel my therapy for word finding difficulties in children with language learning disabilities is effective i feel the effectiveness o f m y therapy is based on m y theoreti­ cal knowledge related to word finding difficulties in language learning disabled children there is a strong degree o f carry-over o f skills developed during therapy for word finding difficulties in children with language learning disabilities in terms o f accuracy, fluency and word retrieval there is a strong degree o f carry-over o f skills developed during therapy for word finding difficulties in children with language learning disabilities in terms o f an increase in read­ ing fluency i feel the effectiveness o f m y therapy is based on the assess­ ment measures i use to identify word finding difficulties in children with language learning disabilities i use assessments or re-assessments to measure therapy out­ comes for word finding difficulties in children with language learning disabilities i use teacher checklists to measure the effectiveness o f my therapy for word finding difficulties in children with lan­ guage learning disabilities i use parent checklists to measure the effectiveness o f my therapy for word finding difficulties in children with lan­ guage learning disabilities 21. what is your opinion on the management procedures used for word finding difficulties in children with language learning disabilities? 1 strongly agree agree neutral disagree strongl y dis­ agree assessment procedures are relevant to the south african context assessment procedures are useful in identifying such difficulties assessment procedures provide sufficient detail to facili­ tate the formulation o f treatment goals intervention procedures are relevant to the south african context intervention procedures are useful in addressing word finding difficulties therapy outcome measures are useful in identifying the benefit o f therapy the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) ingrid de rauville, sandhya chetty and jenny pahl 22. did your training prepare you to adequately manage language learning disabled children with word finding difficulties? strongly agree a gree n eutral d isagree strongl y dis­ agree my training in word finding difficulties in language learning disabled children was indepth and relevant m y training in word finding difficulties in language learning disabled children was limited m y training in word finding difficulties in language learning disabled children focused on theory m y training in word finding difficulties in language learning disabled children focused on clinical experi­ ence m y training in word finding difficulties in language learning disabled children was a balance o f theory and clinical experience m y training in word finding difficulties in language learning disabled children adequately prepared me for practice in this area 23. is word finding an area that you would like to be addressed for continuing professional development? yes no die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) c u rre n t management for word finding difficulties by speech-language therapists in south african remedial schools 75 appendix b focus group discussion interview schedule thank you for participating today. my role is as facilitator to discuss some o f the responses to the questionnaires on practice for wfds. the discussion is informal. based on the responses obtained, i would like to explore a few issues. it is important for me to briefly discuss some o f the reasons why i selected wfds as a topic to research: • it has always been a significant part of my caseload within a remedial school environment • i have not always been sure which assessments, interventions, strategies or therapy outcome measures to use when dealing with wfds and have sometimes experienced frustration at the benefit o f intervention • with the proposed changes for service delivery in education, i have queries about how practice for wfds will be af­ fected 100 questionnaires were sent to remedial schools in south africa. 73 were returned and 69 were used for analysis. (four were not analysed as the therapists did not work with wfds or had no experience in the area). 1. i would like to start by asking how you define wfds? (depending on responses, use this as adjusted probe ques­ tion: do you for example consider it to be a processing deficit or a storage deficit? 2. in terms o f caseload, it was found that all o f you provide therapy for wfds in english. some of the children with wfds in your caseloads speak english as a second language. what impact does this have on your assess­ ment and intervention. what patterns do you encounter, if any? 3. in terms o f formal assessments, the rwfs was by far the most frequently used tool for identifying wfds. how do you feel about the use of the rwfs? what do you feel about its “fit” to your definition of wfds? how do you feel about its appropriacy and effectiveness in the assessment of wfds? 4. differences were noted in terms o f practice specifically regarding individual versus group therapy. based on your experience in schools, what information can you provide about this pattern? 5. do you find intervention needs change from year to year? can you explain this? 6 . within a school, the various slts differed as to whether they used standardised versus informal assessment pro­ cedures and in' their assessment and treatment approaches. can you provide possible reasons for this? 7. participants frequently responded that their undergraduate training in wfds was inadequate but generally thera­ pists said wf therapy is sometimes or usually effective. why do you think this is? 8. every participant said “yes” to wf being a topic of interest for cpd. why is this? what other solutions for in­ creasing knowledge in this area do you have? who would you like to see doing a wfd workshop and how do you think it could be done to be o f most value to you? i 9. many therapists seemed to have a small caseload for wfds and some gave it low priority in terms of interven­ tion. how significant do you think the impact o f wfds is on academic performance? 10. how do you see wf therapy fitting into the proposed changes in education such as an increased role for the therapist as consultant and less role in providing intervention to children? 11. are there any other issues you would like to raise? the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) information for contributors nature of publication the south african jo u rn a l o f com m unication disorders publishes reports and papers concerned with research, and critically evalua­ tive theoretical and philosophical conceptual issues dealing with aspects o f human com m unication and its disorders, dysphagia, service provision, training and policy. the journal will accept the following three types of articles: • research articles defined as reports based on qualitative or quantitative research. • original general articles which are reports of work usually, but not exclusively, theoretical in nature and regarded as provid­ ing a significant, critically evaluative 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30, unless specifi­ cally warranted. examples locke, j.l. (1983). clinical psychology: the explanation and treat­ m ent of speech sound disorders. j. speech h ear disord., 48 339 341. penrod, j.p. (1985). speech discrim ination testing. in j. katz (ed.), h andbook o f clinical audiology (3rd ed.). baltimore: williams & wilkins. davis, g. & w ilcox, m.j. 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(2020). post-stroke dysphagia: an exploration of initial identification and management performed by nurses and doctors. south african journal of communication disorders, 67(1), a625. https://doi.org/10.4102/sajcd.v67i1.625 original research post-stroke dysphagia: an exploration of initial identification and management performed by nurses and doctors maggie pierpoint, mershen pillay received: 23 jan. 2019; accepted: 20 mar. 2020; published: 28 may 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: south african speech-language therapists are the only health professionals charged with dysphagia rehabilitation. however, registered nurses and doctors are often initial healthcare contact points for post-stroke dysphagia. notwithstanding service concerns, they do indeed identify and manage post-stroke dysphagia. however, little is known about specifically what they do during these initial clinical encounters. objective: to explore how doctors and registered nurses, on initial clinical contact, identify and manage post-stroke dysphagia. method: a quantitative descriptive survey design, with non-probability, purposive sampling, was used. twenty-one registered nurses and four doctors at a private south african hospital self-administered a questionnaire. univariate analyses were completed by calculating frequency distributions of nurses’ and doctors’ identification and management practices. results: most (86%) did not use a formal screening tool. indicators screened informally included: presence of drooling (84%) or gag reflex (76%), level of alertness (80%) and spontaneous saliva swallow (80%). participants neglected important indicators like voluntary cough and vocal quality. management provided included head of bed elevation (96%), speech-language therapist referrals (92%), nasogastric tube insertions (88%), intravenous fluids (84%) and positional adjustments (76%). alternative management included total parenteral nutrition (52%), syringe feeding (48%), swallow muscle strengthening exercises (56%) and swallow manoeuvres (52%). conclusion: results indicated that doctors and registered nurses under-utilised important dysphagia indicators and used potentially harmful management practices like syringe feeding. management practices further included out-of-scope methods like dysphagia rehabilitation exercises or manoeuvres. recommendations include peer dysphagia screening training using formal tools and basic dysphagia management methods to better equip doctors and registered nurses when they clinically engage post-stroke patients. keywords: stroke; dysphagia management; early identification; dysphagia intervention; doctors and registered nurses. introduction globally ~590 million people (8% of the world population) experience dysphagia (cichero et al., 2017). in south africa (sa), blackwell and littlejohns (2010) reported a prevalence of dysphagia in 56% of stroke cases, but indicated that this number may have been exaggerated because of the use of subjective and conservative swallowing assessment methods. patients with dysphagia (post-stroke) are more at risk of developing pneumonia (22.9%), which is most likely aspiration-related than those without dysphagia (1.1%). therefore, they have an increased risk of mortality, and early identification and management is essential to manage aspiration risks (arnold et al., 2016). it is important to disclaim that we refer to a bespoke south african reality about dysphagia practice in sa as reviewed by andrews and pillay (2017). they referred to a practice reality that, prior to a speech-language therapist (slt) assessment or diagnosis, it is highly likely that post-stroke dysphagics will be identified and managed by other healthcare professionals, usually nurses and medical doctors. in this light, the terms ‘identification’ and ‘management’ take on the uncommon usage of referring to what occurs before the more specialised slt-led screening and management. identification (or screening) of dysphagia refers to that which occurs through formal or informal methods (american speech-language-hearing association [asha], 2009; donovan et al., 2013; hinchey et al., 2005). informal screening refers to focussed observation of clinical signs and symptoms and generally does not include the use of a formal screening tool (asha, 2009; bryer et al., 2010). formal screening refers to the use of a systematic method (e.g. checklist) with specified pass or fail criteria (donovan et al., 2013) to identify the presence or absence of dysphagia requiring further in-depth assessment by an slt (bray et al., 2016; horiguchi & suzuki, 2011). management of dysphagia, usually within an slts’ scope of practice, may include diet textural modifications, compensatory postures and therapeutic exercises to name but a few methods to improve the safety of the swallow (rogus-pulia & robbins, 2013). intervention is that which is performed to maintain or improve the patient’s current health status and to prevent complications associated with the patient’s dysphagia (groher & crary, 2010). the incidence of pneumonia may increase by 1% per day when identification is delayed (bray et al., 2016). south african stroke guidelines recommended that all stroke survivors should have a swallowing assessment before oral intake. to guide this process, a list of items is provided to assist an observational (informal) screening with recommendation that if these signs are present, then the patient should remain nil per mouth until formally assessed by an slt. it is not clearly indicated who should perform the initial screening (bryer et al., 2010). perhaps, this is because doctors and registered nurses are the first point of contact (andrews & pillay, 2017). these professionals then refer to slts for dysphagia assessment, differential diagnosis and treatment (asha, 2015; blackwell & littlejohns, 2010). in sa, there are insufficient slts to manage the demand (pillay, tiwari, kathard, & chikte, in press). while slts manage dysphagia, only a small percentage actually provide comprehensive dysphagia services in sa, as evidenced by the number of respondents in a dysphagia practice survey (andrew & pillay, 2017). the implication of this workforce shortage is that persons with post-stroke dysphagia may experience unnecessary disruptions in nutrition, hydration and medication that can adversely affect their general health (blackwell & littlejohns, 2010; bryer et al., 2010; donovan et al., 2013). to bridge the gap between the shortage of slts in sa and the need for timely dysphagia identification and intervention, task shifting and role sharing is recommended (world health organization [who], 2008) especially for tasks that require basic training such as screening or identification. indeed, several countries (e.g. the united kingdom, the united states and canada) have programme for swallowing screening to be conducted by other trained professionals with the use of a validated screening tool, for example, the modified mann assessment of swallowing ability (mmasa) (for doctors) or the toronto bedside swallowing screening (tor-bsst) for doctors and registered nurses (antonios et al., 2010; hebert et al., 2016; intercollegiate stroke working party, 2016; martino et al., 2009; winstein et al., 2016). doctors and registered nurses may be trained to perform the initial swallowing screening, as they are the first healthcare practitioners that post-stroke patients encounter and are more readily available than slts (antonios et al., 2010; pillay & kathard, 2018; titsworth et al., 2013). this not only has the potential to reduce the time to screening but can also reduce pneumonia rates and hospital length of stay, especially when coupled with appropriate early intervention (palli et al., 2017). alongside most health workers in sa, 78% slts work in the private sector (pillay et al, in press), continuing an established tradition of over-servicing a minority of south africans who can afford and access their services (pillay & kathard, 2018). in the section on methodology, the study site is described and a motivation provided for why it was selected. suffice to note here that this private sector was deemed an interesting, fertile context to study how nurses and doctors who theoretically should be more aware of, and have access to, slt services practise with post-stroke dysphagia. specifically, we aimed to describe how doctors and registered nurses: (1) identify and (2) manage persons with post-stroke dysphagia. research methods and design design a cross-sectional, descriptive survey (babbie & mouton, 2014; eds. franklin & walker, 2010) was performed at a single, private acute care hospital in sa to gather first-hand information in a timely and cost-effective manner about the dysphagia practices of doctors and registered nurses. the study location was a private hospital because it is purposively aligned to the study question, reflected the dominant practice site for slt in sa (notwithstanding underservicing in the public sector) and was a convenient practice work site for the primary researcher. this article is part of a larger study conducted for a master’s degree and only the main objectives and results are discussed here. the reader is referred to pierpoint (2016). data collection method and tool a paper-based questionnaire (appendix 1) was compiled by the first author and self-administered. the questionnaire was in english – the hospital’s official language of business. participants the study population, selected by non-probability purposive sampling, consisted of doctors and registered nurses (74) who practice within this hospital. doctors were included based on their specialty (those who are typically involved in stroke cases) and registered nurses based on the wards in which stroke patients are treated. they consisted of 11 medical doctors (three physicians, three specialist physicians, one neurologist and four neurosurgeons) and 63 registered nurses (23 from the intensive care unit, 18 from high care and 22 from the cardiothoracic and medical wards). twenty-one registered nurses and four doctors agreed to complete the dmq, resulting in a response rate of 33.3% for the former and 36.4% for the latter. the overall study response rate was 33.78%. pilot study the dmq was developed for this study, which necessitated a pilot study. the dmq was based on dysphagia risk factors, signs, symptoms, screening and intervention and derived from studies by blackwell and littlejohns (2010), baroni, fábio and dantas (2012), carnaby, hankey and pizzi (2006), horiguchi and suzuki (2011), rogus-pulia and robbins (2013), smith hammond and goldstein (2006) as well as via and mechanick (2013). an overview of the questionnaire is presented in table 1 according to the study objectives. the aim of this pilot study was to pre-test the questionnaire to determine whether the questions and instructions were stated clearly enough and were understood correctly by the participants. the dmq included items specific to the scope of practice of dysphagia practitioners like slts. it is recognised that these rehabilitation methods, for example, airway protection manoeuvres, require training and competence and were included to establish this very fact as well as to provide a wide as possible map of practice activities. notably, these items, including the dysphagia rehabilitation items, were reviewed and are the product of the pilot study. table 1: objectives and methods of development of the dysphagia management questionnaire. pilot study participants included three doctors and six registered nurses from a different private subacute care rehabilitation hospital who matched the target, main study population. a pre-testing technique, namely, concurrent cognitive interviews, was used for the pilot study (caspar & peytcheva, 2011). this technique required the participants to individually complete the dmq and comment on the questions or ask for clarification in case of ambiguity (caspar & peytcheva, 2011). the results and suggestions were used to alter the questionnaire, to ensure optimal validity and reliability of the research instrument (babbie & mouton, 2014). data collection process the questionnaires were delivered to the relevant doctors and registered nurses, followed by a postal reminder of the collection date. completed consent forms and questionnaires were collected and sorted by an independent entity to ensure anonymity. data analysis and management after data collection and editing, a custom-designed data import utility, with a user interface identical to the dmq, was used to capture the raw data and convert it into a microsoft excel spreadsheet with numerical data. data validation was coded into the data import utility to prevent user error when capturing the data. univariate analysis of the numerical data was performed to describe the single variables in the study objectives: (1) identification of dysphagia and (2) management of dysphagia. the numerical data were analysed using descriptive statistics, and frequency distributions were calculated by the statistician with the use of microsoft excel and presented in tables for the interpretation of the results. ethical consideration ethical approval was obtained from the university of kwazulu-natal’s biomedical research ethics committee (be280/15). gatekeeper permission was obtained from the hospital management, and participants were asked to sign an informed consent document before completing the dysphagia management questionnaire (dmq), which was designed for this study. results the results are described according to how doctors and registered nurses: (1) identify and (2) manage dysphagia. all 25 participants were experienced in working with stroke patients, most (72%) indicated that they had experience working in the intensive care unit, their years of experience ranged from five to 20+ years, and 96% indicated that they were experienced in identifying dysphagia. dysphagia identification seventy-five per cent (3 of 4) of the doctors and 89% (16 of 18) of the registered nurses identified dysphagia through informal screening methods. see table 2 for a full list of the items screened, which included the presence of drooling, level of alertness and ability to swallow their saliva reflexively. the ‘other’ items that participants reported were ‘bell’s palsy’ and ‘turning the head to the side when swallowing’. table 2: items screened to determine the presence of dysphagia. most participants (19 of 22, 86%) did not use a specific formal screening tool when identifying dysphagia. the use of two formal screening tools was, however, reported: ‘a water swallow test’ and an item referred to as ‘post-operative anterior cervical fusion checklist b for swelling, dysphagia and dyspnoea’. data regarding the timing of screening were not obtained. dysphagia management the intervention methods were divided into five subcategories, as presented in table 3: enteral feeding, parenteral feeding, compensations, rehabilitation and referral. table 3: dysphagia intervention. intervention was predominantly provided through compensations, such as elevating the head of the bed, and referral to an slt. aside from this, almost half of the participants reported using syringe feeding as an alternative and just over half of the participants reported recommending total parenteral nutrition (tpn). discussion the results are discussed in relation to other research, where appropriate, and presented according to the study objectives, namely, dysphagia identification and management. dysphagia identification dysphagia screening should be valid, reliable and repeatable, and therefore, the use of a formal screening test has been recommended as best practice in the united kingdom, the united states and canada stroke guidelines (donovan et al., 2013; hebert et al., 2016; intercollegiate stroke working party, 2016; winstein et al., 2016). in the current study, most of the doctors and registered nurses did not use a formal screening test; this may be because of a lack of awareness of the available screening tests and their benefits, as none have been mentioned in the south african stroke guidelines (bryer et al., 2010; kiyani & butt, 2014; mubeen & butt, 2014). the available formal screening tests for doctors and registered nurses were, however, all developed internationally, which may be why they are not mentioned in the south african stroke guidelines (antonios et al., 2010; bryer et al., 2010; martino et al., 2009; ostrofsky & seedat, 2016). doctors and registered nurses who are aware of these tests may also find that they are not suitable to the context in which they work and may choose not to use them (ostrofsky & seedat, 2016). as an alternative to formal screening tests, the south african stroke guidelines indicate that wet voice, abnormal voluntary cough, abnormal phonatory quality, reduced level of consciousness and reduced laryngeal elevation or swallow should be screened before a formal swallowing assessment is performed (bryer et al., 2010). the participants in the current study used various appropriate informal screening methods and indicators such as the presence of drooling, level of alertness and the ability to swallow saliva reflexively or spontaneously to determine the presence of dysphagia (baroni et al., 2012; horiguchi & suzuki, 2011; smith hammond & goldstein, 2006). important signs that the participants infrequently screened for were the sound of a patient’s voice and their ability to cough voluntarily. vocal cord paralysis, which could occur in stroke patients, results in poor closure of the glottis and leads to dysphonia, reduced protection of the airway and therefore a higher risk for aspiration (bhattacharyya, kotz, & shapiro, 2002). it is thus important to screen the sound of a patient’s voice to determine what their glottal closure and airway protection is like and to establish a baseline for comparison after the swallow. changes in vocal quality may not be directly related to aspiration; however, the observation of a clear voice after the swallow indicates that aspiration is likely absent (waito, bailey, molfenter, zoratto, & steele, 2011). coughing and swallowing share neuroanatomical substrates and thus an impaired voluntary cough after a stroke may also indicate impaired swallowing (watts, tabor, & plowman, 2016). a weak voluntary cough indicates poor protection of the airway and reduced ability to expel aspirated material and has been correlated with dysphagia and aspiration (smith hammond & goldstein, 2006; watts et al., 2016; ward et al., 2010). therefore, it is important to screen a patient’s ability to cough voluntarily as an indication of the neuroanatomical integrity of the swallow and competence of airway protection. in contrast to the above-mentioned important signs that were infrequently screened, the majority of the participants relied on the gag reflex as a determinant of the condition. as a single clinical feature, it has low sensitivity and specificity for identifying dysphagia and does not correlate to the results of a water or paste swallowing test (bours, speyer, lemmers, limburg, & de wit, 2009; henrique dias marques, lúcia zuma de rosso, & andré, 2008). nakajima et al. (2010) found that 31% of the stroke patients in their non-oral group had an intact gag reflex. on the contrary, many healthy subjects may have an absent or suppressed gag reflex (lim, hew, lau, lim, & tan, 2009). doctors and registered nurses therefore should not over-rely on the gag reflex as a key item when identifying dysphagia. the participants’ informal screening methods are possibly lacking because of insufficient knowledge of dysphagia and may lead to under-identification of dysphagia indicators. first-line contact medical practitioners would therefore benefit from using formal screening tools that are supported by evidence to guide their practice to accurately identify patients with dysphagia (gandolfi et al., 2014). dysphagia management enteral feeds both the doctors and registered nurses recommended enteral feeding via nasogastric (ng) tube as well as percutaneous endoscopic gastroscopy (peg) tube. most of the participants, however, recommended ng tube feeding. this is supported by kenny and singh (2015), who reported that peg tubes should not be placed too soon after a stroke, as it poses a risk for mortality because of the underlying condition of a stroke. nasogastric tubes are thus better for short-term enteral feeding, although it should not be in situ for longer than 4–8 weeks, as it could cause complications of its own such as nasal ulceration, increased reflux and increased risk of aspiration pneumonia if misplaced (kenny & singh, 2015). if patients cannot safely return to oral intake after a few weeks, peg placement should be considered, as it provides better long-term nutritional support (bouziana & tziomalos, 2011). parenteral feeds total parenteral feeding (tpn) was recommended by more than half of the participants. while meeting nutritional goals, tpn can be potentially harmful, as it is associated with hepatic injury, thrombosis, hyperglycaemia and higher infection rates (via & mechanick, 2013). it should therefore only be advised in patients with severe malnutrition and concomitant gastrointestinal tract impairment (via & mechanick, 2013). compensations the participants made use of various compensation methods that were in line with the literature (table 3) (bryer et al., 2010; hines et al., 2011; metheny, davis-jackson, & stewart, 2010). however, the participants also indicated the use of the potentially dangerous practice of syringe feeding. although there has been limited research on the topic, syringe feeding is not recommended, nor appropriate, for stroke patients with dysphagia (lazarus & kulpa, 1996). syringe feeding could lead to premature spillage of the bolus into the pharynx and subsequent aspiration, if the bolus size is not carefully controlled and strategically placed on the floor of the mouth (lazarus & kulpa, 1996; wakasugi et al., 2008). the fact that almost half of the participants use this as a management method indicates that they are not aware of the potential risks associated with syringe feeding. rehabilitation rehabilitation is aimed at improving the function of the swallowing mechanism to advance recovery (rogus-pulia & robbins, 2013; vose, nonnenmacher, singer, & gonzález-fernández, 2014). in the current study, more than half of the participants indicated that they would recommend rehabilitation exercises such as muscle strengthening exercises (e.g. for the tongue) and swallowing manoeuvres (for functional training, e.g. mendelsohn). researchers have indicated that other healthcare professionals such as registered nurses could perform rehabilitation exercises after a full swallowing assessment has been performed by an slt, if they have had the necessary specialised training to do so (hines et al., 2011; perry, hamilton, williams, & jones, 2013). doctors and registered nurses should, however, caution against prescribing therapeutic interventions such as rehabilitation exercises, as this does not fall within their scope of practice but is solely the slt’s role (asha, 2015; perry et al., 2013). referral dysphagia is best managed in a multidisciplinary team; therefore, appropriate and timely referral is very important (gandolfi et al., 2014). as dysphagia could lead to malnutrition, it is essential for a dietitian to manage nutritional intake (blackwell & littlejohns, 2010). occupational therapists also provide valuable interventions like the adaptation of feeding utensils and exercises to improve self-feeding, which may reduce the risk of pneumonia (bryer et al., 2010; langmore, skarupski, park, & fries, 2002; rogus-pulia & robbins, 2013). most of the participants referred patients with dysphagia to an slt. participants appear not to be aware of the role of other members of the multidisciplinary team, specifically occupational therapists and dietitians as they inadequately referred to them. in summary, the doctors and registered nurses used various appropriate management methods such as elevating the head of the bed, referring to an slt, recommending an ng tube or positioning adjustments and placing an intravenous drip (bryer et al., 2010; carnaby et al., 2006; hines et al., 2011; kenny & singh, 2015; metheny et al., 2010; perry et al., 2013; seedat & penn, 2016). however, they also reported recommending rehabilitation exercises and manoeuvres, which is not within their scope of practice, and using potentially harmful methods such as parenteral and syringe feeding (lazarus & kulpa, 1996; via & mechanick, 2013; wakasugi et al., 2008). this testifies that doctors and registered nurses may have insufficient knowledge of dysphagia to intervene optimally and may not be sure of their role and scope of practice within dysphagia management. significance and limitations doctors and registered nurses identify and manage dysphagia to the best of their knowledge, but risk under-identifying patients or harming them, because their knowledge of dysphagia may be insufficient. if doctors and registered nurses are expected to share the task of dysphagia identification and management, they should receive tertiary and in-service training to improve their knowledge, which could improve their practice and reduce the use of dangerous and inappropriate practices for the safety of the patients. dysphagia practices could also be improved through standardisation and the use of formal screening tools such as the south african dysphagia screening tool (sads) (ostrofsky & seedat, 2016). the data from this study are useful but with limited generalisability because of poor external validity as a result of non-probability sampling and a poor response rate. notably, the data are of only a single hospital site. the survey design was furthermore limited to self-reported data of dysphagia identification and management practices, which could be influenced by social desirability bias and therefore may not reflect what is truly performed in practice (grimm, 2010). it is acknowledged that there may be concerns regarding the wording of the tool and the use of the same questionnaire for registered nurses and doctors who have different scopes of practice. the design of the tool was, however, informed by the pilot study conducted. we also recognise that the viability of the recommendation for doctors and registered nurses to conduct the initial dysphagia screening needs to be explored, as it may over-burden these professionals who face staff shortages of their own. recommendations the following recommendations for future research bear relevance: given the high prevalence (56%) of dysphagia in stroke patients in sa, this study should be repeated and comparisons drawn among private and public hospitals across sa (blackwell & littlejohns, 2010). this study should also be conducted with a larger study population to enable random sampling, which will allow generalisation of the results and improve external validity. studies are needed to investigate the effect of: (1) in-service training; (2) the use of a formal screening tool; and (3) discontinuing inappropriate practices, on doctors and registered nurses’ dysphagia practices, as well as on pneumonia and mortality rates associated with dysphagia. there is a need to develop a south african dysphagia screening tool (e.g. ostrofsky and seedat’s south african dysphagia screening, 2016), which can also be used by doctors and registered nurses. summary and conclusion doctors and registered nurses mainly used informal screening methods to identify dysphagia, and neglected important indicators, such as voluntary cough and vocal quality, which could lead to the under-identification of dysphagia. management methods such as parenteral nutrition and syringe feeding, which can potentially lead to higher infection rates and aspiration, respectively, were also used (lazarus & kulpa, 1996; via & mechanick, 2013; wakasugi et al., 2008). the participants furthermore took it upon themselves to recommend rehabilitation exercises and manoeuvres, which is beyond their scope of practice (asha, 2015; perry et al., 2013). doctors and registered nurses could benefit from dysphagia training during and after their undergraduate programmes, including the use of formal screening tools. as primary practitioners in dysphagia management, slts will need to facilitate tertiary as well as in-service training for doctors and registered nurses, with a focus on their particular role within the multidisciplinary dysphagia management team. this may result in more timely and appropriate referrals and reduce the use of potentially harmful management practices, which, in turn, could reduce the occurrence of complications such as pneumonia and mortality. acknowledgements a word of appreciation goes to dr danie venter for the statistical analysis and carrin martin for editing the thesis. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions m. pierpoint (corresponding author and the primary researcher) was responsible for the conception and design, acquisition of data, interpretation of the results and the final write-up of the manuscript. m. pillay supervised the first author’s masters’ research project and reviewed the manuscript for publication. funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability statement data sharing is not applicable to this article. disclaimer the views and opinions expressed in this article are the authors’ own and not an official position of the institution. references american speech-language-hearing association (asha). 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(2008). task shifting: rational redistribution of tasks among health workforce teams: global recommendations and guidelines. retrieved from http://www.who.int/healthsystems/ttr-taskshifting.pdf appendix 1 dysphagia management questionnaire the management of hospitalised adults with neurogenic dysphagia: a descriptive study dysphagia refers to any swallowing difficulties and/or disorders. dysphagia is a common complication after a stroke. instructions: please complete the questionnaire on your own and do not share your answers with others please complete all of the applicable questions please tick (✓) the appropriate box(es) section 1: identification of dysphagia refers to the formal screening and/or informal observation of dysphagia signs and symptoms. 1.1 have you ever identified dysphagia in stroke patients? □ yes     □ no if no to question 1.1, please proceed to section 3 1.2 do you use a specific screening test or checklist to assess the presence or absence of dysphagia? (choose one answer) □ yes     □ no if yes, please specify the name of the screening test or checklist_______________________ 1.3 what do you assess or observe (formally or informally) to determine whether or not the patient has dysphagia? (please tick all the relevant boxes) □ level of alertness □ presence of a gag reflex □ sound of their voice, for example, hoarse, aphonic (no voice) □ difficulties speaking □ ability to perform mouth movements (e.g. tongue and lip movement) □ ability to cough reflexively or spontaneously □ ability to cough on instruction □ presence of drooling □ weight changes □ ability to swallow their saliva reflexively or spontaneously □ ability to swallow their saliva on instruction □ ability to pass a water swallow test (without coughing) □ appetite □ oxygen desaturation □ other, please specify ______________________ 1.4 which of the following would you say are signs or symptoms of dysphagia? (please tick all the relevant boxes) □ eating fast □ food or liquid falling out of the mouth or coming through the nose □ coughing or throat clearing before, during or after swallowing □ loss of appetite and/or reduced intake □ nausea and/or vomiting □ difficulty getting the food or medication down □ food left over in the mouth after swallowing □ voice changes after swallowing □ respiratory problems □ eating too much □ other, please specify ______________________ 1.5 what other factors may put stroke patients at an increased risk for dysphagia? (please tick all the relevant boxes) □ reduced level of consciousness □ older than 60 years □ over weight □ lung disease or pneumonia □ comprehension difficulties □ needs oxygen □ stroke in the left hemisphere (right-sided weakness) □ a brainstem stroke □ a weak cough □ needs oral-pharyngeal suctioning □ slurred speech or difficulties speaking □ small mouth □ has had more than one stroke □ has another muscular or neurological disease, for example, parkinson’s disease, alzheimer’s disease, dementia and so on. section 2: intervention in dysphagia refers to the techniques used to maintain or improve the safety of the patient’s current intake. the aim is to prevent complications, for example, aspiration pneumonia, dehydration or malnutrition. 2.1 what do you do once you have identified that a patient has dysphagia? (please tick all the relevant boxes) enteral feeds □ recommend a nasogastric (ng) tube □ recommend a percutaneous endoscopic gastroscopy (peg) □ recommend orogastric feeding □ recommend a percutaneous endoscopic jejunostomy (pej) □ other, please specify ________________________ parenteral feeds □ recommend partial parenteral nutrition (ppn) □ recommend total parenteral nutrition (tpn) □ other, please specify ________________________ compensations □ use a commercial thickener to thicken liquids or foods, for example, nutilis/thick & easy □ use a syringe to give the patient food or liquid orally □ ensure adequate fluid intake by putting up an intravenous drip □ elevate the head of the bed to a 30° – 45° incline to prevent aspiration of secretions □ improve oral hygiene □ recommend a different (dysphagia) diet, for example, soft food, sloppy or puree food □ recommend positioning adjustments, for example, the patient must be seated upright during meals □ maintain the patient upright for at least half an hour after a meal to prevent aspiration of refluxed material □ recommend head posture adjustments, for example, chin tuck, head rotation □ recommend eating strategies, for example, taking small bites or sips □ other, please specify ________________________ rehabilitation □ recommend swallow manoeuvres for functional training of the swallow, for example, mendelsohn, effortful swallow □ recommend exercises to strengthen the muscles of the swallowing mechanism, for example, tongue exercises □ other, please specify ________________________ referral □ to a doctor □ to a nurse □ to a clinical dietitian □ to a physiotherapist □ to an occupational therapist □ to a speech therapist □ other healthcare professional, please specify___________________________ 2.2 when a patient is tube fed (e.g. peg/ng) because of a swallowing difficulty, how do you decide if they can eat orally again? (please tick all the relevant boxes) □ do a swallowing screening □ refer the patient to a speech therapist □ give the patient an oral feeding trial, for example, food or water □ i do not do or decide this section 3: training and experience 3.1 in which ward(s) have you worked? □ icu □ high care □ cardiothoracic ward (e ward) □ medical ward (f ward) □ all of the above 3.2 where did you receive your qualification? □ college. please specify_________________________________ □ university. please specify_______________________________ □ other. please specify___________________________________ 3.2.1 did you receive any information on dysphagia during your studies? □ yes     □ no 3.2.2 if yes to question 3.2.1, do you feel that the information was sufficient? □ yes     □ no 3.3 did you learn about dysphagia anywhere else? □ yes     □ no 3.3.1 if yes to question 3.3, where did you learn about dysphagia? (please tick all the relevant boxes) informal method □ peer, for example, colleague □ mentor or manager, for example, unit manager or clinical lead □ self-study, for example, journal article or book □ other, please specify___________________________ formal method □ continuing professional development (cpd) activity, please specify ____________ □ other, please specify___________________________ 3.4 how many years of work experience do you have? □ <5 years □ 5–9 years □ 10–19 years □ 20+ years abstract introduction and background research method and design results discussion conclusion acknowledgements references about the author(s) dhanashree pillay department of speech and hearing therapy, school of human and community development, university of the witwatersrand, south africa sharon moonsamy department of speech and hearing therapy, school of human and community development, university of the witwatersrand, south africa citation pillay, d. & moonsamy, s. (2018). a pilot study: considering spirituality in an inclusive model of practice in clinical audiology. south african journal of communication disorders 65(1), a552. https://doi.org/10.4102/sajcd.v65i1.552 original research a pilot study: considering spirituality in an inclusive model of practice in clinical audiology dhanashree pillay, sharon moonsamy received: 23 feb. 2017; accepted: 20 july 2017; published: 21 june 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: a patient-orientated approach in medical clinical practice is emerging where patients and practitioners are considering and including the spiritual, emotional and psychosocial aspects of the individual. this practice is an important change in health care, specifically in the field of audiology as a holistic view of the patient now alters the perspective on the management of individuals with hearing impairments. objectives: this article explored the experiences of a participant who reported supernatural healing of his sensorineural hearing loss (snhl). hence, this study focuses on the consideration of spirituality in the inclusive model of care. method: an exploratory, qualitative narrative inquiry was used to obtain data from a single pilot case study of a 27-year-old man who reported healing of his permanent profound hearing loss. results: four themes were identified within the narrative obtained: prayer and faith, deaf culture, identity and purpose. the participant stated that he believed that he was partially healed to fulfil his purpose in life. the partial healing allowed him to belong to the deaf community and the hearing world simultaneously. conclusion: south africans live in a diverse society where most people accept spirituality as part of their search for meaning in life. health care for individuals should therefore consider the person as a holistic being more than a medical entity. the exploration of narratives of individuals who report supernatural healing of a snhl will assist health care practitioners and audiologists in managing individuals in an inclusive manner. this pilot study thus has implications for policy and practice in health care contexts. introduction and background recent research is deliberating the various approaches to health care, including alternative medicine, conventional medicine, integrative approaches and integral approaches (pan & zhou, 2013; ross, 2009). it can therefore be assumed that a transformation in medical clinical practice is beginning to emerge. in spite of the shift from conventional medical practice to a more holistic vision, better integration of these approaches is essential, so that best practice models are achieved for the individual (pan & zhou, 2013). different approaches to health care are discussed in the literature (pan & zhou, 2013; ross, 2009). according to ross (2009), integral medicine is the way forward from integrative medicine as it incorporates not just conventional and alternative medicine, but all dimensions of healing; from physical to psychosocial and cultural to spiritual. pan and zhou (2013), however, discuss integrative approaches in further depth. there are several organisations such as hospice and hi hopes (home intervention hearing and language opportunities parent education services) which promote holistic and integral health care, showing a better quality of life for the individual. the integral and integrative models therefore build optimal healing environments rather than focusing on a disease-centred approach and are inclusive of all systems that influence the patient. the integral model of practice spans the distance between religion, spirituality, culture, social interaction and family interaction (ross, 2009). the basic tenet that a change in the medical clinical paradigm encourages is that even though medical practitioners may not be adept at allied health care professionals’ practices, they should nevertheless be aware of the patient’s psychological and spiritual issues and their implications when it comes to healing and health. limited published research into inclusive medical practices continues to keep us bound to the tried and tested gold standard of ‘double-blind randomised controlled trial’ medical practices. furthermore, discussions on models of practice pertain mainly to medicine, with little to no research in the allied medical professions, specifically in the field of audiology. hearing loss – the hidden disability – is regarded as the number one malady in the world (cohen, labadie & haynes, 2005); thus, a significant proportion of the world’s population is affected directly or indirectly by this communication disorder. there are three major types of hearing loss: conductive (which may result from pathologies of the outer and middle ear), sensorineural (caused by damage to the sensitive structures of the inner ear) and mixed (resulting from the combination of conductive and sensorineural pathologies) (gelfand, 2001). whatever the cause of a hearing loss, the most drastic effects in communication are seen in sensorineural hearing loss (snhl). permanent cochlear damage resulting in a snhl may be associated with presbycusis, ototoxicity, injury, trauma, diseases and congenital aspects (møller, 2006), with irreversible damage to the hair cells in the cochlear structure. ‘when there is irreversible loss of hearing sensitivity, it is called a permanent threshold shift (pts)’ (tanner, 2007). the person diagnosed with a snhl may experience mental health issues such as depression and anxiety because ‘there is no cure’ (eddy, 2013). spirituality, faith and belief systems might be foundational structures of support when experiencing such mental health issues. when considering changes in health care in relation to audiology, the impact of mental health issues should be included. the current study does not directly focus on mental health issues; however, they are included in the biopsychosocial–spiritual model adopted. there is very little international research relating to alternative methods to manage a hearing loss. the individual’s approach to health care is shaped by their religious and cultural practices. culture plays a significant role in the way disability is viewed by an individual (salas-provance, erickson & reed, 2003) and most cultures have been influenced by science and the medical assessment and management of illnesses and disease. in the audiological context, however, there is a unique culture that has developed through the medical diagnosis of a hearing impairment. deaf culture is a collective group of deaf individuals who identify themselves as having a common language and an understanding of each other (siple, 2003). the notion of ‘hearing loss’ is changing as holistic management aims to be inclusive of all areas that are central to the patient. the question that has sparked this change is: what can be lost that was never there in the first place? the ‘representation of the self’ (baumeister & vohs, 2003) is the most common way of developing an identity. individuals group themselves based on morals, spiritual values, religion, profession, tribes and family names amongst others. deaf culture is nevertheless the only medically defined culture as it is based solely on the premise of a hearing impairment. parents are the biggest role-players when determining if a child will develop a specific form of communication modality. even though signing is the major method used by individuals who belong to the deaf culture (ladd, 2003), most parents opt for some method of medical management to improve the hearing ability of their child. international research focuses on hearing aids and implant technology as a priority for the audiologist and an aim of successful audiological intervention. rehabilitation, according to medical sciences, is said to be the only option to improve hearing and communication for individuals with a permanent snhl. according to the authors of this article, however, this view seems narrow in the context of rapidly changing perspectives in world health care. as there is little published research in audiology, the significance of the current study will contribute to the literature, not just in a south african context but to medical practice globally. integrative models of practice are complex and require a mental shift from a straightforward administration of a medical perspective in audiology to a mindfulness of the person and the systems in which that person operates. the theories of person and environment, as well as biopsychosocial models are recommended rather than merely a medical model perspective. despite the changes and influences from the world, each individual has personal standards, morals and spiritual values and these serve as internal regulators for reshaping ideas and actions based on the circumstance (bandura, 1991). social theoretical models have agents that intentionally influence the individual’s life. these agents could be a direct personal agency, proxy agency or a group agency (bandura, 2002). spiritual and religious leaders, therapists, doctors and family members act as proxies and they play a major role in the well-being of the individual concerned. the actions of others in contributing to decisions taken are important as these actions or decisions form supportive bases in the spheres of healing and rehabilitation. through the social learning system, new patterns of behaviour are acquired by direct experiences of healing or through observation of healing in other individuals (bandura, 1977). by understanding the human psychosocial relationship, the audiologist can aim to provide a more inclusive service delivery to all patients regardless of race, religion, spiritual beliefs and background. the key to the inclusive approach selected is that the patient is involved and is an active part of the decision-making process, and thus active in their healing. this article argues that the conventional medical model used in medical practices, specifically in audiology, should change to embrace a more inclusive model that is patient-centred, encompassing mind, body and spirit. this inclusive model of practice in audiology should focus on the potential for mental, emotional, social, behavioural and spiritual processes that affect a patient’s health, personal growth and quality of life. this article thus examines an inclusive model of intervention to patients with a hearing loss who report on spiritual healing, as documented narratives of patients are lacking in the literature. the diversity of cultures and spiritual beliefs within south africa encourages the need for such research so that the experiences of these individuals can be documented. the diverse south african population seeks advice from traditional healers, pastors, rabbis, hakeems and gurus as a source of healing and these alternative healers should form part of the holistic management programme. audiology should not merely be defined by the practice of assessment and management of a hearing loss. hearing loss affects a person’s life, including (where they exist) their religious beliefs and practices, and a person’s faith. these contribute to the biggest influences in that individual’s reactions to life events, including illness and disease. spirituality is one of the key strengths in personal well-being (ellison & levin, 1998) and should be taken into account in the audiological intervention process. research method and design aims of the study the main aim of this study was to explore and document the narratives of south african individuals who reported a supernatural healing of a snhl. the following sub-aims operationalise the main aim: documenting the ‘turning point’ event or events that caused the reported healing to occur documenting the participant’s perceptions of the mechanism of the healing describing the participant’s perceptions of the reactions of other people to the reported healing documenting the social influences of spirituality and beliefs on the healing process in audiology. sample the sample for the main study consists of between 8 and 10 participants, using purposive and snowball sampling. narrative researchers can select a small sample size to achieve adequate information from in-depth interviews that answers the research questions (jones, brown & holloway, 2012). the researchers aimed to balance the distribution of participants from the major religious and racial groups in south africa. participants who had been diagnosed by an audiologist with any degree of snhl, either unilaterally or bilaterally, were included in the study. this article reports on the pilot study of this main study. a 27-year-old man narrated his story. design and instrumentation an exploratory, qualitative research design was used. this study was exploratory in nature as supernatural intervention has had limited theoretical analysis and is an area of undocumented occurrences (sim & wright, 2000) in south african medical practice, particularly within the context of audiology. a narrative inquiry interview was used to obtain data. the narrative inquiry included records, stories and ideas that provide information about the experiences of the individual (mitchell & egudo, 2003). a sound understanding of human behaviour and the rationale for such behaviour becomes evident in a qualitative study (wisker, 2007) and the current study aimed to document individuals’ experiences of supernatural healing shaped by a belief system, a behaviour pattern and by society as a whole. an interpretive approach was adopted as the participants’ experiences are being studied within their respective contexts taking into consideration the subjective meaning to the context (willis, 2008). procedure a semistructured interview was used (connelly & clandinin, 1990) to obtain narrative data from individuals who reported having experienced supernatural healing. the interview began with an open-ended question that allowed the participant to narrate his or her experiences of the healing process. additional questions were asked when necessary. the interview session was recorded to ensure that the information was captured accurately, thereby increasing the credibility and trustworthiness of the data. the rapport between the researcher and the participant was maintained throughout the interview process (immy, 2005). analysis the data were transcribed by the researcher and thematic content analysis was conducted on the transcribed information. thematic content analysis is a significant area of analysis within narrative analysis, where common themes of the individuals’ experiences and perceptions are extracted regarding (in this instance) the supernatural intervention and healing process (symon & cassell, 2012). the narratives were initially deconstructed from qualitative raw data transcriptions into words or sentences that were coded. according to kim (2015), the codes were grouped into familiar categories and within each category, themes were identified. this study met all the required ethical parameters as set by the university of the witwatersrand’s human ethics committee (protocol number h15/02/07). results a single pilot case study was conducted with a 27-year-old south african man, who reported experiencing supernatural healing of the hearing in one ear at the age of 7. the participant was diagnosed with a profound bilateral snhl at birth and attended a school for deaf children. the participant stated that he was diagnosed and fitted with bilateral hearing aids; however, he did not use the one hearing aid post-healing. the focus of this study was to document the participant’s experiences of the ‘healing’ in relation to the hearing loss. the study did not aim to prove that the hearing loss was ‘cured’; therefore, a new audiogram was not required as proof of the recovery of hearing. the participant is of the christian faith and he reported that the hearing in his left ear was healed, and his healing, he believed, was an answer to the prayers of his family: ‘i was six years old or seven years old … i started to hear on the right, no on the left ear (pointing to the left ear). so far i’m happy, i’m christian, and i know god always helps me to hear. maybe later on he (god) will heal me 100%, because now i’m growing up now i know sign language and i’m english speaking. and i believe god helped me to speak and to hear. even though i cannot hear in right ear, nothing in the right ear, only the left ear. i can speak, show the people how i talk, how i prove how i feel god’s presence.’ [p1, male, 27 years] ‘so i understand different situations, i’m happy with god, i always pray. my family they (are) christians, my uncle and my cousin are pastors. i have another uncle that is a pastor too. there are so many people who are christian in my family. and i realised that they were praying for me, god answered their prayers to improve my life and i received lots…’ [p1, male, 27 years] from this narrative, the importance of identity with the deaf is evident. this participant holds a strong deaf identity, as he relates, communicates and identifies with the deaf culture; however, he also continues to see himself as a hard-of-hearing individual. he stated that he feels: ‘god helped me to hear partially because there’s so many deaf people who don’t know god and so god was giving me purpose, to communicate with deaf people and hearing people, that’s what i feel. so i share the word of god, about god with the people whose hearing and deaf. so far i’m happy that i still stayed hard-of-hearing because i can communicate with this side and this side (meaning with the hearing and the hearing impaired). if, imagine if god healed me 100% full i wouldn’t have talked with deaf people about god, cos they don’t know. i feel god’s purpose for me to be hard-of-hearing and i’m happy with who i am. so i’m happy that i’m hard-of-hearing and i can hear a little bit and i know deaf culture, deaf feelings, how the people feel if they don’t hear and how the people who hear, how they feel. so i understand different situations, i’m happy with god, i always pray.’ [p1, male, 27 years] this participant’s identity is driven by his ability to define this healing event as a purpose-driven event in his life. human interaction and relationship-building dictate that it is inevitable that there will be questions surrounding such claims of healing. this participant had a friend of a different faith, who questioned his healing and the mechanisms behind it as the friend was curious about the reasons for the healing. ‘my one friend is muslim, he don’t believe in god, how i believe, how i, he asked where my hearing comes from. maybe spirit, coming from god? people they can’t see god, the spirit, the relationship, the feeling, even hearing from god is a must. but must get the information in the heart, in my mind when you read the bible, when you ask something to god and you are rushing to get the answer, one day when i was reading the bible, that’s the answer (pointing to the page in a book). then i see the bible is the truth and now many people don’t believe the bible, (they ask) who wrote the bible, how he gets the words from? and i try to explain, people who wrote because they get their message from god, through hearing, dreams…’ [p1, male, 27 years] from the results of the participant in the pilot study, several themes have emerged that confirm or support findings discussed in the literature. the following four themes are discussed below: prayer and faith, deaf culture, identity and purpose. discussion prayer and faith christians believe in god – the father, the son and the holy spirit. when individuals proclaim jesus as their lord and saviour, then the believer is ‘filled’ with the holy spirit of god (ware, 2005). christianity reveals that the holy spirit is the agent for healing and testimonies are used to support the belief that the healing is a godly intervention at work (broadman & holman, 1998). faith healings are believed to occur through prayer and the laying on of hands (christensen & kockrow, 2013). christians believe that disease and illness are not from god and believers practice the physical laying on of their hands on the sick person, while praying for the power of god to move through them and heal the individual (porterfield, 2005). this participant stated that he believes that god healed him as an answer to the prayers of his family members. this indicates that an action was required to elicit a response from god, and the active spiritual belief, faith and prayers of others led to the supernatural healing. the narrative in this study can motivate the audiologist to self-reflect on the following questions: should audiologists be conversant with the spiritual beliefs of their patients? should audiologists include questions in the case history session that would direct the patient into divulging information pertaining to their spiritual beliefs and non-medical practices? the information obtained by the audiologist can be shared with the ear, nose and throat (ent) specialist within the multidisciplinary team. the ent can use the information obtained by the audiologist to benefit his or her own assessment and management practices. if we believe that the medical clinical model is failing the patient (as the medical clinical model appears to focus more on the disease than the person), then we need a shift in mind-set. this shift means that audiologists need to be moving towards a goal of including questions relating to faith and spiritual beliefs from the initial consultation with the patient. deaf culture, identity and purpose deaf culture, identity and purpose are themes that conjure up further questions for us as audiologists. are we defined by the illness or disease? who are we and why are we experiencing these situations in life? are we designed to teach others about perseverance as part of the process of overcoming difficult situations? the purpose of life is an ongoing enigma for every individual. people tend to rationalise good and bad events so that it allows them the ability to accept the situation at hand and move on. the 27-year-old participant in this study referred to his deafness as a positive factor in his life as he stated that he believes that he can communicate with the deaf, and impact them by sharing information about god. his purpose was defined as the provider of life-changing information to the deaf. the participant stated that he was bilingual as he is proficient in both sign and oral language. furthermore, he sees himself as a bridge between the deaf and hearing worlds. he reiterates that there is a reason for his partial hearing as he now belongs to a ‘bicultural’ world, straddling the hearing and deaf communities allowing him to share his knowledge about god. cultural and linguistic factors are therefore important considerations in medical clinical management. similar to the participant in the current study, research has indicated that long-term breast cancer survivors reported a deeper spiritual experience following their diagnosis (sabado & tanjasiri, 2010). the findings from the current pilot study indicated that the person as a whole matters more than simply his or her disease or disability. conclusion change is required from a medical clinical model to a more inclusive model of intervention within health care and this has been recommended in the literature. increased reports of more ‘personal experience evidence’, is, however, now available to support transformation in intervention approaches. this study therefore argues for an inclusive approach to intervention in audiology. we live in a spiritual society and most people accept a spiritual aspect in their lives as they seek to obtain a meaning of life (bandura, 2003). the medical model dictates the service delivery within the health care sector, excluding the psychosocial and spiritual aspects of the patient’s life. when health care provision negates the holistic and phenomenological perspectives, it is antithetical in its approach to understanding the patient as a whole. therefore, health care for individuals should be inclusive of the whole person and to not only be seen as a medical entity. the history of patient care indicates that the majority of patients are assessed and managed under a medical model which focuses on the doctor or therapist’s education and knowledge when assisting the patient. an inclusive perspective of audiological management should therefore shift the focus from the disease to the person. the medical model has led to the person being seen as a specimen and despite the advances in cracking the genetic code, the understanding of the human as a whole has stagnated (sulmasy, 2002). as far back as 1988, researchers such as mcleroy, bibeau, steckler and glanz began to discuss the notion of an ecological model of patient care. a holistic model that focuses on the community, public policy, social and individual influencers is required. how should audiologists then respond to the patient in a holistic manner? the audiologist can work holistically with a patient by obtaining the support of a multidisciplinary team, consisting of counsellors, psychologists, religious leaders or community leaders. psychosocial–spiritual factors of influence will dictate the compliance of patients to hearing screening, hearing aid assessments and management. the impact of a hearing loss stretches far beyond the borders of the home environment. management and care of the patient should thus also traverse beyond the borders of the hospital. sulmasy (2002) supports the holistic biopsychosocial–spiritual model of care, as patients stated that they would like their spiritual needs to be considered when they are being managed by a health professional. a holistic model of patient care should include significant role-players in the patient’s spiritual community. mcleroy, bibeau, steckler and glanz (1988) define ‘community’ in three ways, namely as a mediating structure to which the individual belongs, the relationships amongst groups in a defined area and as a geographical term. the mediating structure of community is vital as the community is a source of social resource and social identity (mcleroy et al., 1988) that is required by the hard-of-hearing or deaf individual. griffin (2013) stated that integrated models of support and care will shape the patient’s future as well as the future of country as a whole. the following questions are relevant and should be reflected on to create the shift in health care practice: how do we transition from the old to the new inclusive health care process? are audiologists equipped and ready to change the way we assess and manage our patients? audiologists are making progress and the evidence must be documented in further studies within the areas of supernatural healing and medicine. this study should therefore contribute further to understanding the changes needed in medical clinical practice. acknowledgements we thank the participant for his contribution in the pilot study. competing interests the authors declare that they have no significant competing financial, personal or professional interests that might have influenced the writing of this article. authors’ contributions the article is partially based on a current phd study being undertaken by d.p. at the university of the witwatersrand. s.m. is the research supervisor. references bandura, a. 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(2007). the postgraduate research handbook: succeed with your ma, mphil, ed d and phd. hampshire, new york: palgrave macmillan. abstract introduction methods results and discussion limitations of the study conclusion acknowledgements references about the author(s) amisha kanji department of speech pathology and audiology, university of the witwatersrand, south africa kirsten krabbenhoft department of speech pathology and audiology, university of the witwatersrand, south africa citation kanji, a., & krabbenhoft, k. (2018). audiological follow-up in a risk-based newborn hearing screening programme: an exploratory study of the influencing factors. south african journal of communication disorders 65(1), a587. https://doi.org/10.4102/sajcd.v65i1.587 original research audiological follow-up in a risk-based newborn hearing screening programme: an exploratory study of the influencing factors amisha kanji, kirsten krabbenhoft received: 10 nov. 2017; accepted: 26 aug. 2018; published: 25 oct. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: follow-up return rate in early hearing detection and intervention (ehdi) programmes is of specific importance as it ensures that benchmarks are met and that no child with suspected hearing loss is left unidentified. objectives: the aim of this study was to determine the factors influencing audiological follow-up of high-risk infants in a risk-based newborn hearing screening programme. method: a non-experimental, exploratory, qualitative research design was employed. purposive sampling was used. the study was conducted at a secondary level hospital in the public health care sector in south africa. participants comprised 10 caregivers (age range 26–40 years) of infants who had been enrolled in a risk-based newborn hearing screening programme, and returned for follow-up appointments. data were collected using semi-structured interviews. responses were recorded by the researcher and a colleague to ensure rigour and trustworthiness of findings. data were analysed using thematic analysis for open-ended questions and descriptive statistics for the closed-ended questions. results: the most common positive contributors that facilitated participants’ attendance at follow-up appointments were: having friendly audiologists; a clear line of communication between caregiver and audiologist and a reminder of the appointment. the most significant perceived challenge that participants described in returning for the follow-up appointment was living in far proximity from the hospital. conclusion: findings of the study revealed that influencing factors on follow-up return rate are demographic, socio-economic, and interpersonal in nature and further suggested the need for an all-inclusive appointment day. it may be of importance to not only look at what is being done to improve the follow-up return rate but also how it should be done in terms of professional-to-patient communication and interactions. introduction the ability of a developing child to hear is of great importance. the age at identification of hearing loss and intervention is vital in ensuring early diagnosis and intervention, as this leads to positive developmental outcomes (yoshinaga-itano, 2003). early detection of hearing loss can be addressed through universal newborn hearing screening (unhs) programmes as recommended by the joint committee on infant hearing (jcih, 2007) and the health professions council of south africa (hpcsa, 2007). because of the fact that early hearing detection and intervention (ehdi) is not yet fully implemented within the south african context, risk-based newborn hearing screening (screening of newborns and infants with risk factors for hearing impairment) has been recommended as the interim solution where unhs is not immediately feasible (hpcsa, 2007; kanji & khoza-shangase, 2016). it has been reported that one of the main challenges for ehdi systems globally is poor follow-up return rate (hpcsa, 2007). developing countries experience a significantly lower follow-up return rate than developed countries. this is displayed by comparing findings from a developing context to that of a developed context. a study conducted in the united states of america (usa) (developed country) revealed a follow-up return rate of 58% and 100% at two different hospitals (todd, 2006), whilst studies conducted in lagos, nigeria and south africa (developing countries) revealed return rates of 16% and 31.4%, respectively (kanji, khoza-shangase, & ballot, 2010; olusanya, wirz, & luxon, 2008). it is understandable that in developing contexts such as south africa, follow-up return rates are worse than in developed contexts, possibly because of socio-economic factors; an increasing burden of disease; and under-resourced and exhausted public health care services. however, the problem of poor follow-up return rates is still prominent in both developing and developed contexts and has consequences for the appropriate and timely diagnosis of and intervention for hearing impairment. follow-up return rates contribute towards the efficacy of ehdi programmes, as follow-up is necessary in order for audiologists to diagnostically assess and confirm the presence of a hearing loss, to evaluate candidacy for various amplification devices and/or assistive technology, and to ensure prompt referral to early intervention services (hpcsa, 2018). follow-up return rates of 70% or higher are considered ideal (hpcsa, 2018). to improve such efficacy and success of ehdi programmes, various research studies have been conducted that explore the reasons for loss to follow-up. reasons for loss to follow-up in developing countries, such as malaysia, include factors, such as lack of communication between parents and screening personnel regarding the need for a follow-up, weakness in the protocol for provision of follow-up appointments, lack of public awareness of childhood hearing loss and the importance of early intervention, accessibility to services, and not having the screening as an integral part of the childcare system (mukari, tan, & abdullah, 2006). factors related to communication are particularly important within the south african context as it is a multilingual and multicultural context, whereby language differences and mismatches between the audiologist and the caregiver may play a role (watermeyer, kanji, & cohen, 2012). other studies in nigeria have revealed cultural beliefs, stigma and place of birth and/or delivery as the possible key determinants of poor compliance to follow-up after discharge (olusanya, 2009; olusanya & akinyemi, 2009). results from a recent south african study revealed that the most frequent reasons for follow-up default were most commonly related to costs, lack of caregiver knowledge of newborn hearing screening (nhs), caregivers forgetting to bring their infant for the follow-up appointment, lack of caregiver knowledge of results from the initial hearing screening and caregivers being unaware of the recommended follow-up rescreen (scheepers, swanepoel, & le roux, 2014). it was concluded that reminders and increased communication with caregivers are required to decrease follow-up default (scheepers et al., 2014). the current study aimed to describe factors influencing caregivers returning for follow-up audiological services in a risk-based nhs programme. adequate follow-up needs to be ensured for newborns and infants at risk for hearing impairment, as it may not necessarily be detected immediately after birth and the early identification of late or progressive hearing impairment needs to be considered. the current study differs from most studies on follow-up return rates in hearing screening programmes within a developing context that appear to focus on reasons for loss to follow-up, instead of the positive factors that have influenced attendance at follow-up appointments. conducting research into both the positive factors and perceived challenges may result in a more balanced perspective on follow-up return rate in nhs programmes in south africa. the current study, therefore, served to investigate the influencing factors of caregivers returning for follow-up audiological services and aimed to focus not only on the perceived challenges, but also the positive influencing factors in an effort to determine if there are factors that may be built on and strengthened. methods objectives the main aim of this study was to describe the factors influencing audiological follow-up of high-risk infants in a risk-based nhs programme. specific sub-aims were to: describe the reasons for attending audiological follow-up appointments within a risk-based nhs programme; determine the perceived challenges faced by caregivers when returning for audiological follow-up within a risk-based hearing screening programme. research design this study adopted a non-experimental, exploratory, qualitative research design. research context the study was conducted at a secondary level hospital. at the time of the study, nhs was being conducted on a referral basis from paediatricians and neonatologists and was not routinely conducted. a unhs feasibility study was also conducted by a paediatrician at this hospital, the results of which indicated that unhs was not feasible at this site. sampling a non-probability, purposive sampling method was used. participants participants consisted of 10 caregivers of high-risk infants who had undergone two hearing screenings and had been booked for a diagnostic audiological follow-up. the first hearing screening was performed during hospital stay (before discharge) and follow-up appointments were scheduled on days coinciding with the neonatal follow-up clinic with paediatricians (usually 4–6 weeks post discharge). because of the unavailability of diagnostic audiological equipment at the hospital during the time of the study, diagnostic follow-up was conducted at the nearest university (approximately 6 km – 8 km from the hospital). the caregivers were of infants who underwent hearing screening (within a risk-based nhs programme) at a secondary level hospital in the public health care sector. participants had to be caregivers of infants who had been enrolled in a risk-based nhs programme and needed to be able to speak and understand english, as either their first or subsequent language, as the researcher did not have access to a trained interpreter at the time. participants who attended were all above the age of 20 years. the mean age of participants was 30.5 years (range: 26–40 years; s.d.: 4.79). in terms of the level of education of the participants, all but two participants had a secondary level education. the home languages of participants varied. two participants’ home language was sesotho, two participants had isizulu as the home language, three had english, one had sepedi, one had seswati and one had amharic as the home language. data collection procedures data were collected in the form of semi-structured interviews with caregivers who had returned for the follow-up audiological assessment of their infant. reasons for non-attendance were explored in another larger study (kanji & khoza-shangase, 2018). the interview included both open and closed-ended questions. both these types of questions were aimed at enquiring about the positive factors, as well as perceived challenges in order to facilitate trustworthiness and rigour. the questions were related to: (1) the reasons why caregivers attended follow-up audiological assessments, (2) the challenges that caregivers faced in attending the follow-up appointment and (3) the changes that caregivers would make to the hearing screening programme or process to reduce the challenges that they faced. the interviews in this study were to be audio recorded but the research site did not permit this, for reasons not specified. therefore, the researcher scribed and transcribed each interview with a colleague, and these transcriptions were then compared to ensure trustworthiness. a pilot study was conducted prior to the commencement of the current study to ensure the appropriateness of interview questions. findings from the pilot study indicated the need to simplify the language used which was then implemented. data analysis data obtained were analysed using thematic analysis for the open-ended questions and descriptive statistics (measures of frequency) for the closed-ended questions. thematic analysis allows for themes or topics to be extracted from the data set that is later used as a method of summarising raw data, comparing the frequency of relative themes and looking for co-occurring themes (namey, guest, thairu, & johnson, 2008). ethical consideration ethical clearance was granted by the university’s human research medical ethics committee (approved protocol number: m150147). permission to collect data in the form of interviews was obtained from the head of the audiology department and the chief executive officer (ceo) of the hospital where the research was conducted. written informed consent was obtained from the participants who were interviewed. the participants were reminded of their right to withdraw from the study at any time. confidentiality and anonymity of data were maintained by using participant codes instead of names. results and discussion findings of this study will be presented and discussed in accordance with the sub-aims of the study. results pertaining to the related closed-ended questions will be discussed first, followed by the themes emerging from the open-ended questions. the first sub-aim of this study was to obtain information regarding the reasons caregivers attended audiological follow-up appointments. results from the closed-ended questions related to this sub-aim revealed that the most common positive contributors that facilitated participant’s attendance at follow-up appointments were the following: having friendly audiologists (n = 10), a clear line of communication between caregiver and audiologist (n = 10) and a reminder from the audiologist or having set one’s own reminder (n = 10) (figure 1). figure 1: positive factors influencing follow-up. of the 10 participants, 7 reported that the time and day of the appointment made it easier to return for the follow-up appointments and five said that not having other children made it easier. the appointments were generally in the morning, at a time and on a day that was suitable for caregivers. participants, who had other children to look after, reported the morning time as the best time for the appointment as the other children were at school. the other five caregivers, with a primiparous child, stated that it did not matter what time of the day the appointment was, as long as it was not late in the afternoon where they would be likely to get stuck in traffic on the way home. these findings are supported by a study on follow-up return rates, which revealed that failure to follow-up or a delay in follow-up was significant in families with more than two children at home (asha, 2008). thus, highlighting the importance of consideration of the family context. four of the 10 caregivers reported that living close to the hospital and having the time because of unemployment or maternity leave were positive influencing factors for them to return for the follow-up appointment. geographical distance from the hospital and busy work schedules have been shown to be contributing factors to caregivers failing to return for follow-up appointments in nhs programmes (kanji et al., 2010; mukari et al., 2006). therefore, caregivers who do not face these challenges appear to be more likely to return for follow-up hearing screenings. three out of 10 caregivers felt that knowing someone with a hearing loss and availability of transport were positive influencing factors for returning for follow-up (figure 1). exposure to individuals with hearing loss may facilitate awareness of hearing loss and the effects it has on the person, which may understandably increase the likeliness of caregivers returning for follow-up audiological assessments. these findings are supported by literature that has indicated that a lack of caregiver knowledge about nhs and hearing loss was attributed to failure to return for follow-up screenings (scheepers et al., 2014). with regard to the availability of transport, caregivers interviewed in the current study had all been discharged from hospital and required transport to attend the follow-up appointment at the stipulated facility. literature has indicated that the need for transport to return for second stage hearing screening, once mother and baby have been discharged from the hospital of birth may contribute to the failure to follow-up (shulman et al., 2010). the current study’s findings are in support of this literature as it highlights the influence of socio-demographic and contextual factors. these findings are further supported by literature that suggests that factors such as maternal age, ethnicity, maternal education, distance from health care facilities and parity play a role in the uptake of health care services in developing countries (babalola & fatusi, 2009; say & raineb, 2007; tsawe et al., 2015) and suggests the need to view follow-up return rate within a broader context. theme 1: the earlier the better participants were asked about what facilitated their decision to attend the follow-up appointment. responses to this open-ended question suggested themes of the earlier, the better and child comes first. one participant said that the reason she returned for the follow-up appointment was because she wanted: ‘to know about the growing up and hearing [of her child]’. (participant 2, 37 years, female) another caregiver said: ‘… because i want to see my child healthy and everything in her body must be functioning one hundred percent. (participant 7, 27 years, female) two of the participants also remarked that: ‘… if there is a problem, she must get help early’ (participant 7, 27 years, female) ‘… if there is something wrong they will pick it up earlier, better safe than sorry’. (participant 8, 28 years, female) a study by meintjes and van belkum (2013) revealed knowledge deficits amongst caregivers with all developmental categories, with the highest deficit in the domains of speech-language development. this was despite the majority of caregivers indicating that developmental problems should be treated early, as per the awareness demonstrated by participants in the current study. similarly, scheepers et al. (2014) in their study reported that one of the most common reasons that caregivers reported not returning for follow-up audiological assessment was associated with a lack of caregiver knowledge in the domain of hearing. contrary to the current study’s findings, their study found that the majority of caregivers believed that nhs was unnecessary (scheepers et al., 2014). a study by swanepoel and almec (2008) on the other hand revealed that 99% of mothers expressed the desire to have their infant’s hearing screened after birth (swanepoel & almec, 2008). theme 2: child comes first one participant reported that they returned for the follow-up appointment: ‘… because it’s very important and i know she comes first.’ (participant 3, 26 years, female) another caregiver said: ‘… nothing actually helped me, i knew i needed to be here to make sure everything is fine with her.’ (participant 4, 31 years, female) this finding appears to illustrate an instinctual sense of responsibility and accountability of the caregiver towards the child’s health care needs. a child’s development is influenced by the caregiver’s competency to provide care (meintjes & van belkum, 2013). health care professionals rely on caregivers’ knowledge about the health and development of their children in order to facilitate decision-making, intervention and necessary referrals. programmes designed to improve the health, development and well-being of children depend on involvement from caregivers (meintjes & van belkum, 2013). apart from the importance and concern for their child’s development, findings may also be suggestive of a level of commitment from caregivers. cavalcanti and guerra (2012) believe that follow-up return rates for screening or diagnostic assessment depict parental commitment more accurately than the initial screening in hospital which only requires maternal consent. the second sub-aim of the current study was to determine the perceived challenges faced by caregivers when returning for audiological follow-up within a risk-based nhs programme. responses from the closed-ended questions revealed that the most significant challenge that participants described in returning for the follow-up appointment was living in far proximity from the hospital (n = 5). half the participants felt that lack of availability of transport was a perceived challenge to returning for follow-up appointments. three out of 10 participants felt that lack of time because of employment commitments, having other children to look after and lack of funds for transport were perceived challenges. the least significant challenge that the participants faced was that time and/or day of appointment was inconvenient (n = 2) (figure 2). figure 2: perceived challenges influencing caregiver’s follow-up. theme 3: lost when asked an open-ended question about the perceived challenges that they faced, the theme of being ‘lost’ was evident. participants 2 and 5 stated that ‘not knowing the place’ was a challenge because: ‘… directions and even with directions, it was easy to get lost because taxi’s don’t always drop one at the gate of the place that one needs to be.’ (participant 2, 37 years, female). in addition, it is a further challenge to try and navigate around an unfamiliar place by foot. another participant said that: ‘i took the taxi early, but i was still late here.’ (participant 8, 28 years, female) when asked what changes they would make to the process of hearing screening, one participant stated she would prefer if everything took place there, as: ‘… the hospital is the nearest place.’ (participant 7, 40 years, female) another participant said: ‘… only if you could visit the local clinics because they are nearby.’ (participant 6, 29 years, female) this finding illustrates feelings of uncertainty and feeling lost as a result of the proximity to and unfamiliarity with the facility. a study conducted in the usa, revealed that families who were compliant with follow-up revealed that a further traveling distance could be a barrier to follow-up (macneil, liu, stone, & farrell, 2007). another study conducted in brazil, a developing context, revealed through analysis of socio-economic and demographic factors that mothers who did not return to complete the hearing screening generally came from lower-income families who lived in rural areas outside of the city where the nhs services were not being provided (griz, merces, menezes, & lima, 2009). in exploration of failure to return for follow-up, a study in malaysia revealed that geographical distance was one of the reasons that caregivers defaulted in returning for second stage hearing screening (mukari et al., 2006). these studies outline the fact that in both a developing and a developed context, proximity to resources appears to be a challenge for follow-up. it has been shown that proximity to health care is an important factor affecting various health outcomes (tanser, gijsbertsen, & herbst, 2006). thus, improving geographical access to primary health care could have a direct impact on the improvement of health outcomes such as hearing loss (tanser et al., 2006). a retrospective record review study, conducted in south africa, to determine the follow-up rate for a hearing screening programme implemented as part of a very low birth weight project revealed that efforts to improve the return rate should be concentrated on and strengthened (kanji et al., 2010). recommendations to improve return rate included the suggestion that follow-up screening should take place at immunisation clinics that are more accessible to patients (kanji et al., 2010). this strengthens the theme of proximity and familiarity with a health care facility being a challenge and allows a solution to the challenges of proximity to health care resources, as well as lack of availability of transport, and lack of funds for transport. having hearing screening take place at immunisation clinics suggests the need for a ‘medical home’ which was also derived from interviews in this study. theme 4: need for a medical home another theme that emerged was the need for a medical home. two participants stated that if they were to make any changes to the process of hearing screening programmes, they would have ‘… it all in one place’ to avoid having to travel further. it was also reported that, ‘… if everything for the child took place at a hospital nearby’, then the participant could walk to get there. this finding illustrates the need for all child health care services to be provided at the same health care facility and for this facility to be in close proximity for the caregivers. these services include hearing screening at immunisation clinics and/or neonatal follow-up (nnfu) clinics at the hospital of birth. if all of these services could be provided at primary health care clinics (equipped with necessary screening equipment), which are more frequently situated in most areas, this would essentially solve the problems of lack of availability of transport and lack of funds for transport contributing to default to follow-up in hearing screening programmes. primary health care clinics have been proposed as a platform for nhs with the rationale that it provides an opportunity to reach the entire population resulting in increased coverage of screened infants and improved follow-up return rates (hpcsa, 2007; swanepoel, hugo, & louw, 2006). a systematic community-based nhs programme initiated at eight phc clinics in the western cape was evaluated against the guidelines in the hpcsa (2007) position statement. although follow-up return rates varied amongst clinics, they were considered to be good (friderichs, swanepoel, & hall, 2012). these findings highlight the advantage of provision of services at the primary health care level, which would facilitate easier accessibility to services by caregivers. theme 5: all at once the theme of ‘all at once’ also emanated when participants asked what they would change to facilitate the perceived challenges. one participant stated that: ‘i would prefer if the six -month visit was here on the same day as neonatal follow-up.’ (participant 7, 40 years, female) another stated that she would prefer if the screening could take place: ‘… on my appointment day’. (participant 5, 33 years, female) this finding illustrates the challenge of trying to schedule appointments when caregivers have limited time because of employment commitments, and/or duties involving taking care of several children. these are challenges that caregivers reported to have faced when returning for follow-up audiological screening. two different studies have shown that difficulties in scheduling appointments for follow-up hearing screenings have created barriers for families in terms of completing neonatal/infant hearing screening programmes (harrison, roush, & wallace, 2003; macneil et al., 2007). it has been recommended that follow-up hearing screening takes place on the same day as nnfu clinics to improve follow-up return rates (kanji et al., 2010). this strengthens the results from the current study that revealed that participants would like an ‘all-inclusive’ appointment day where their child will be able to receive more than one health care service. therefore, having multiple appointments on the same day could potentially eliminate the challenges mentioned above and increase follow-up return rates in ehdi programmes. these findings are supported by ng, hui, lam, goh and yeung (2004), who suggest that scheduling of appointments on a single day may also be less costly for caregivers. a summary of themes and supportive quotes is presented in table 1. table 1: summary of themes from qualitative analysis. limitations of the study this study was exploratory in nature and consisted of a small sample of participants who returned for follow-up. in addition, the sample was only obtained from one site. the influence of cultural beliefs on follow-up return was not explored in the current study. conclusion findings of this study revealed that the perceived challenges related to follow-up return rate are demographic and socio-economic in nature. the most pertinent results from this study have suggested that positive influencing factors are more interpersonal in nature. it may be of importance to not only look at what is being done to improve the follow-up return rate but also how it should be done in terms of professional-to-patient communication and interactions. acknowledgements the authors would like to thank the caregivers who participated in this study. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contribution a.k. conceptualised the study. k.k. collected and analysed the data and wrote up the study results under the supervision of a.k. a.k. and k.k. wrote the first draft of the manuscript. a.k. revised the manuscript. references asha. 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(2003). from screening to early identification and intervention: discovering predictors to successful outcomes for children with significant hearing loss. journal of deaf studies and deaf education, 8(1), 11–30. https://doi.org/10.1093/deafed/8.1.11 . my experience of laryngectomies and oesophageal speech alison osborne. l.c.s.t. the first laryngectomy case i saw treated for oesophageal speech was a wcman of some seventy odd years, and perhaps she was not a very fortunate subject for my first introduction both her age and sex were against her. her age because 70 is rather late in life to be forced to learn new habits, and her sex because i have since learned that women are more difficult cases than men. they do not take to it kindly. they are more sensitive. their fashions are against them the trachyotomy tube and the opening in the trachea is so conveniently camouflaged by man's collar and tie. the type of "voice" used in oesophageal speech is gruff and inclined to be harsh, which, though almost unnoticeable in a. man, and at worst sounds like a very bad cold, in a woman is not attractive or natural-sounding and is rather 'disgusting', as my lady kept saying. she had unfortunately discovered that the air in the buccal cavity could be used to her advantage before she came for speech therapy, and that by "spitting" out noiseless words and syllabus at people she could make herself understood. having resorted to this exaggerated use of the articulating organs it was all the harder for her to learn oesophageal speech. and particularly hard because she thought it all so 'disgusting'. she would sit and listen to the therapist doing her level best, then she would shake her head and say "its disgusting", (two words that she could 'spit' out with very effective forcei) but it was not nearly so disgusting as all the wheezing, coughing and spluttering noises, she continually made through her tube. great efforts were made to interest her in the subject; to prove ;that it wasn't disgusting but really rather marvellous. to entourage her, former successful oesophageal speakers were called; upon to come and help. there were quite a few cases of which her therapist was proud to boast, the most creditable of these being a young lawyer in his thirties. as a result of intrinsic carcinoma his larynx had to be removed. in a few weeks he had mastered oesophageal speech and within a few months, his health being quite recovered, he was back at the bar where he is still carrying on most successfully. few would suspect he was talking his way out of things without a "sound box": he is perfectly intelligible, and not only does he speak well but r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) . he has adjusted well to the situation and copes extremely competently and extremely politely with the inconvenience of his trachyotomy tube. the lady of whom we were speaking gave up coming to the clinic. she was not well and was not happy. 'she preferred to go on m her old way writing it down when she couldn't make herself· understood. she lived alone, so had little need to talk. this was a big point without the incentive to practise little is done, and without practise particularly with this oesophageal speech little is achieved. ti!ilt0 e x o n e r a t ® h ® r from any blame, let it be sai'd here that there appear to be three types of laryngectomy cases. ' 1. those that grasp the idea of oesophageal speech right away by going back to 5th form standards, and master.it quickly. 2. those that learn it slowly and surely but master it latterly. 3. those that simply can not do it. it is interesting to watch the various cases from the beginning. immediately after the operation all they can do when visited i n. ^ a r d s i s gesticulate some shrug and frown, others grin and cock a thumb, according to their mood. ten days alter the operation they learn to belch to order. and from then on to articulate on the belch. starting with syllables, working up to words and sentences and on to conversation, ihe length of time it takes to master this and develop it into a fine art, with improved tone to the stage where they neither run out of air before they run out of words, nor do they run out of words before they've used all their air depends on the ability of the individual. ' most of the work to acquire oesophageal speech should be done ? the patient on his own. as much practise as possible should be done each day to achieve and better the sound. alter practising the patient should come to the clinic for guidance, correction and further suggestions for more practise, regular, fairly frequent visits are desirable to keep the patient up to the mark and to provide incentive for practise, ihe patient s health has to be watched as well. it is not always advisable to press the speech training, as it frequently causes dreadful flatulence and for this reason patients must be warned not to practise one hour before or after a meal. secondary growths are known to appear, and particularly if radium was the mode of treatment (rather than operation), the r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) wound is found to break down. another two very interesting cases i saw were a farmer and an ex-"boxer. the farmer was the younger of the two, "being in his thirties, also, perhaps, a "better class of person. he was a north countryman and had a farm in yorkshire. he seemed shy and a little reserved. the ex-boxer was a very jovial individual in his fifties. he was very pleased with himself and, indeed, had something to be pleased about. he was a great talker and told us all aloout it. both these men had had total laryngectomies performed, followed by speech therapy. the ex-boxer had only had speech therapy over a period of weeks (6-9). the yorkshireman had had speech therapy for a corresponding period of months, yet of the two the boxer was the better speaker. there are probably several reasons for this, but it is partly accounted for by personality. he was a hearty type, not at all' shy of making a fool of himself or of appearing conspicuous. the farmer was shy and more retiring, and more refined, which, interestingly enough, would appear to be a drawback maybe in the long run he will benefit from it by having a more polished performance but at the time it appeared that he was tenser, less free to experiment and therefore his efforts were inhibited. a point greatly in the boxer's favour was that he lived in town and could conveniently attend therapy. whereas the farmer, living in yorkshire, had only visited london, i believe, three times for speech therapy, after the initial first week of treatment. in this, however, he served as a perfect example of results which may be obtained from practise. these two; men came especially one day to illustrate a talk on' oesophageal speech. it was a great ordeal for them to appear on the stage before a hall packed with people, but in spite of the conditions and any 'nerves' they might have had, they spoke very well; and could be heard and understood at the back of the hall without the aid of any microphone.. i was most impressed with the ex-boxer and the way he kept stressing, how fit and well he was. he was very happy and pleased with life and told us of all the exercise he took in a day even to a light bit of sparring. this was interesting, as without a larynx it is impossible to take a break and close the glottis, holding the thoracic eavity braced, as we all do when effort is required of us. the farmer too carried on his normal work without his larynx. his life was not much affected. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 23. one last case you might like to hear of, is a man of about 60. he is a grocer and owns a shop. another very proud and cheerful person. he had had speech therapy "before i saw him and could now manage on his own. he had "been taught by a different method, his tone was harsher and thinner than ethers i had seen treated, and he appeared to gulp air only as far as the pharynx instead of right into the stomach. he was perfectly intelligible and assured us he had no difficulty in serving his customers and making himself understood. he had not mastered a smooth flow of conversation, however, but spoke in gusts. healso gulped air in rather noisily. there is a great tendency for all laryngectomies to make such a business of swallowing the air, and they wheeze, tense and strain, filling their lungs to capacity at the same time. it is hard for them to realise that any air taken in at the mouth must go into the stomach via the oesophagus, as there is nowhere else for it to go. the action of swallowing air is entirely independent of the action of breathing. now there is no connection between their nose and mouth and their lungs. it is important that they should not try too hard and should have perpetual encouragement. and it is amazing what can be achieved. the only sound that remains impossible for them is the h, for which they substitute g (as in gaan). for those cases that cannot master oesophageal speech the laryngeal reed or artificial larynx is better than being inarticulate. but it is conspicuous, costly and requires careful handling lest air-blocks arise. ! \ r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) hoe frekwensie-timpanometrie izak s hay (dphil)(pret) departement spraakwetenskap, spraakheelkunde en oudiologie, universiteit van pretoria opsomming t o w z ? ™ ^t,!6ste\0fh0^ek»e™e (600hz) timpanometrie van meerdiagnostiese waarde as laefrekwens,e (220hz) tmpanornetne ,s. as kontrolegroep is 96 normale ore gebruik. as eksperimentele groep is 70 ore met n venkzenheulvan mddeloorpatologieegebruik. die resultate dui daarop dat hoe frekwensie-timpanometrie slegs vazeerdznotize waarde is, wanneer daar sprake van 'n hiper-beweeglike middeloorstelsel is soos bv. by dislokasie van die zzs die voorktrl· vantjmpanogranune met negatiewe piekwaardes by hoe frekwensie-timpanometrie blyk van grvot waardttezs^eox skeiding van η dtslokaste en 'n slap oordrom. die rigting van drukverandering hetgeen lgnostiesewltexnnt abstract the purpose of the study was to determine whether high frequency (660hz) tympanometry had more diagnostic value than low uzstot* 9 6 n°™1 — 70 with a variety of middle ear pathologies were subb ed'otol whent z l z q m n c y t p a t e t r y fesults l n d i c a t € t h a t frequency tympanometry is only of more diagtostcvaz nel ? τ 7 s y t l s h f e r m o b i l e « i s t h e c a s e ™th ™ ossicle dislocation. the presence of negative zzogmm timpanometrie het die afgelope dekade 'n integrale deel geword van oudiologiese diagnostiek. die relatief lae koste van die apparaat sowel as die eenvoud van die metode, het timpanometrie binne die vermoe van die meeste klinici geplaas. die feit dat dit 'n objektiewe metode is, het dit moontlik gemaak om die integriteit van die middelore van baie jong kinders sowel as άίέ wat nie wil of kan saamwerk nie te bepaal.2· 3 · 7 · 8 die meetfrekwensie wat tydens timpanometrie gebruik word sal 'n effek he op die vorm van die timpanogram.4 die gebruik van 'n frekwensie hoer as die gebruiklike 220hz word deur sommige navorsers6· 11 as van diagnostiese waarde beskou terwyl ander1 die diagnostiese waarde van hoe frekwensie-timpanometrie verwerp. by beskouing van die teorie van die middeloor as akoestiesemeganiese stelsel'·13 word dit duidelik dat die impedansie by 'n lae frekwensie soos 220hz deur styfheid oorheers word terwyl dit by hoer frekwensies soos byvoorbeeld by 660hz die massa van die stelsel is, wat 'n groter rol begin speel. die reaktansie-komponent van die impedansie is dan ook negatief by lae frekwensies en positief by hoe frekwensies. die skeiding tussen 'n positiewe en negatiewe reaktansie is die resonansfrekwensie van die stelsel.9 © sasha 1983 die effek van patologie in die middeloor is om die resonansfrekwensie van die middeloor te wysig. die resonansfrekwensie word verhoog deur 'n toename in styfheid (otosklerose) en dit word verlaag deur 'n afname in styfheid (dislokasie van die ossikels). hierdie feite kan diagnostiese waarde he deurdat die teken van die timpanogrampiek 'n aanduiding kan gee of die middeloorstelsel deur styfheid of deur massa beheer word. colletti4 het die vorm van die timpanogram met meettone van 200 tot 2000hz bepaal. hy het gevind dat daar drie fases bestaan: die eerste fase kom voor by frekwensies laer as die resonansfrekwensie en het 'n v-vorm; die tweede fase kom voor in die omgewing van die resonansfrekwensie en die timpanogram het drie pieke; die derde fase kom voor by frekwensies bo die resonansfrekwensie en het 'n omgekeerde v-vorm (kyk tabel 1) die tweede fase het volgens colletti4 verander met middeloorpatologie. dit het by laer frekwensies voorgekom in die geval van 'n dislokasie van die ossikels en by hoer frekwensies in die geval van otosklerose. van camp, vanpeperstraete, dreten en van huyse,15 wat die admittansie (= i m p e d a n s i e ) tydens timpanometrie gemeet het, the south african journal of communication disorders, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) hoe frekwensie-timpanometrie tabel 1 die voorkoms van verskillende timpanogramvorms by sekere frekwensiegebiede in die geval van normales, otosklerose en dislokasie frekwensiegebiede waar verskillende timpanogramvorms voorkom (colletti4) timpanogramvorm normaal ostosklerose dislokasie w 200-1000hz 200-1100hz 200-500hz λ λ 1100-1300hz 1300-1490hz 580-800hz 1400-1900hz 1550-1900hz 900-1400hz 2,0 1,5 1,0 0,5 0 -0,5 -1,0 (a) -100 -50 0 50 100 mm waterdruk 2,0 ε 1,5 u *« β 1,0 a 1,0 υ <λ 0,5 <λ 0,5 00 0 -0,5 ι , ο (b) -100 -50 0 50 100 mm waterdruk figuur 1 die verloop van die susseptansie-timpanogram in die geval van 'n hiperbeweeglike oordrom (a) en van dislokasie disl te ° p ) n e q a t i e v e w a a r d e v a n d i e p i e k in die geval van 11 het gevind dat die timpanogram negatiewe waardes aangeneem het sodra die meettoon hoer as die resonansfrekwensie was. so 'n toestand kom voor wanneer die middeloor deur massa beheer word soos in die geval van 'n dislokasie van die ossikels. (kyk fig. 1) dit was die doel van hierdie studie om vas te stel of hoe frekwensie-timpanometrie van meer diagnostiese waarde is as die gebruik van die gebruiklike 220hz meettoon. eksperimentele prosedure ten einde die waarde van hoe frekwensie-timpanometrie te ondersoek, is proefpersone met normale ore (kontrole groep) en proefpersone met bevestigde middeloorpatologiee (ekspenmentele groep) onderwerp aan lae (220hz) en hoe (660hz) frekwensie timpanometriese toetse. proefpersone as kontrole groep het 49 (96 ore) normaalhorende studente en personeellede van die departement spraakwetenskap, spraakheelkunde en oudiologie van die universiteit van pretoria opgetree. die ore wat gebruik is, is deur 'n otoloog as normaal verklaar en die gehoordrempelpeile het nie 15db iso oorskrei nie. die ouderdomme van die proefpersone in hierdie groep het gewissel tussen 18 en 33 jaar met 'n gemiddelde ouderdom van 20 / 1 2 jaar. die ouderdom van die persone in die kontrole groep is so gekies dat die faktor van presbiakusie uitgeskakel sou word. (kyk tabel 2 vir besonderhede) die eksperimentele groepe het bestaan uit 70 ore van 70 proefpersone met 'n verskeidenheid patologiee. die vereiste dat 'n lug-been gaping van ten minste lodb moet bestaan, is gestel die proefpersone in die eksperimentele groepe is verkry van die oor-, neusen keel hospitaal, pretoria en van privaat oor-, neusen keelartse in pretoria. alle proefpersone is deur gekwalifiseerde oor-, neusen keelartse gediagnoseer. geen vereiste ten opsigte van ouderdom is vir die eksperimentele groepe gestel nie aangesien die patologiee by alle ouderdomme voorkom en ook omdat nerbonne, bliss en s c h o w 1 3 gevind het dat die impedansie van die middeloor nie betekenisvol verskil by verskillende ouderdomme nie. tabe. 2 oudjometriese en persoonlike besonderhede van die kontrole en eksperimentele groepe kontrole eksperimentele groepe aantal manlik (m) vroulik (v) ouderdom (jaar) normaal 96v 2 0 % otosklerose 7m 14v 41 v a sereuse otitis media 13 μ 12v 203/l2 akute otitis media 4m 3v 15v]2 timpanoplastiek 6v w/]2 post-stapedektomie 3m 4v 37"/,2 dislokasie 2m 2v 31>/,2 gemiddelde luggeleidingsgemiddelde lug-been ,5k arempels (db) ik 2k 4khz ,5k gapings (db) ik 2k 4khz 3,6 4,7 1,5 ,5 ,5 ,15 0 0 49 49 43 52 31 31 18 18 31 30 29 36 17 17 14 13 27 24 16 26 18 16 10 13 40 40 38 43 32 28 23 22 34 33 38 56 13 14 10 17 51 48 44 53 39 40 25 33 d , e s»'d-afnkaanse tydskrif vir kommunikasieafwykings, vol. 30. 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 wat geslag betref is 41 ore van vroue en 29 van mans in die eksperimentele groepe gebruik. (kyk tabel ii vir besonderhede) apparaat vir die bepaling van die timpanogramme is daar van 'n grason stadler oto-admittansmeter model 1720 gebruik gemaak. die apparaat is ge-yk volgens die vervaardigers se voorskrifte. die apparaat is in 'n onbehandelde kantoor van die universiteit van pretoria, of die oor-, neusen keel hospitaal, pretoria geplaas. die omgewingslawaai het geen noemenswaardige invloed op die metings gemaak nie. metode die proefjpersone het op 'n gemaklike stoel plaasgeneem en is onderwerp aan beide 220hz en 660hz timpanometriese toetse. die rigting van die drukverandering is van positief na negatief en van negatief na positief aangebied ten einde die effek van rigting van drukverandering vas te stel. hoewel beide die konduktansieen susseptansieveranderinge opgeteken is, word hier slegs verslag gelewer oor laasgenoemde. die vorm van timpanogramme is beoordeel volgens jerger5 en liden, harford en hallen10 se klassifikasie: die volgende timpanogramtipes is gebruik: tipe a d hoogte dubbel did van tipe a tipe a normale timpanogram tipe a s hoogte helfte as die van tipe a tipe β plat timpanogram tipe c piek by negatiewe drukwaarde tipe d meer as een skerp piek tipe ε meer as een geronde piek resultate tabel 3 gee 'n opsomming van die klassifikasie van die timpanogramme van elke groep soos bepaal met 220 en 660hz. die resultate van die normale groep dui daarop dat behalwe in tipe b, alle tipes by beide 220 en 660hz voorkom. dit is egter duidelik dat by 220hz 'n baie groter persentasie izak s. hay timpanogramme as tipe a geklassifiseer is as by 660hz. by 660hz het 'n groot persentasie (25,5%) tipe d timpanogramme voorgekom wat as 'n valse diagnose beskou kan word aangesien die proefpersone in hierdie groep almal normale gehoor gehad het. dit blyk dus dat 220hz meer betroubare resultate oplewer by die bepaling van normaliteit van die middeloor. wat die otosklerose-groep betref, het tipe a s vir beide 220 en 660hz meer dikwels voorgekom (61,9 en 57,1% respektiewelik). volgens jerger5 is dit die korrekte klassifikasie vir otosklerose en dus kan 220hz en 660hz as ewe suksesvol beskou word in die diagnose van hierdie patologie. die voorkoms van 'n groot aantal tipe a timpanogramme in beide 220 en 660hz kan gesien word in die lig van die feit dat baie beweeglike middelore en middelore met otosklerose normale timpanogramme kan lewer. wat die groep sereuse otitis media betref kom byna gelyke getalle tipe β timpanogramme vir beide 220 en 660hz voor (64 en 60% respektiewelik). ook hier kan beide frekwensies akkurate diagnoses moontlik maak. akute otitis media lewer volgens jerger5 tipe c timpanogramme op. dit was ook die bevinding in hierdie studie waar 85,7% van die gevalle met akute otitis media tipe c timpanogramme opgelewer het in beide 220 en 660hz. die groepe timpanoplastiek, post-stapedektomie en dislokasie het almal 'n beduidende verskil in klassifikasie van die timpanogramme vir 220 en 660hz, getoon. vir die groep timpanoplastiek is vir 220hz, 66,7% as tipe a geklassifiseer en vir 660hz is 66,7% as tipe ε geklassifiseer. vir die groep poststapedektomie is vir 220hz, 64,3% as tipe a geklassifiseer terwyl vir 660hz, 42,9 % as tipe a en 42,9 % as tipe d geklassifiseer is. vir die groep dislokasie is vir 220hz, 100% as tipe a d en vir 660hz is 100% as tipe d geklassifiseer. dit wil dus voorkom of die hoer frekwensie timpanogramme van addisionele diagnostiese waarde is, waar daar sprake van 'n meer beweeglike middeloorstelsel is soos in die geval van timpanoplastiek en dislokasie vermoed word. die voorkoms tabel 3 persentasies van die klassifikasie c d vorms van die timpanogramme vir elke groep vir 220 en 660hz normaal ν n=96 220 660 6,8 0,5 70,8 41,1 10,9 13,0 0 0 3,6 2,6 7,3 25,5 0,5 6,8 otosklerose ο n = 2 1 220 660 0 2,4 38,1 35,7 61,9 57,1 0 0 0 0 0 4,8 0 0 sereuse otitis media som ν =25 220 660 4,0 8,0 4,0 16,0 12,0 64,0 60,0 4,0 4,0 0 8,0 4,0 12,0 akute otitis media aom ν =7 220 660 14,3 14,3 85,7 85,7 timpanoplastiek tp n=6 220 660 66,7 16,7 16,7 16,7 0 16,7 0 66,7 pbst-stapedektomie ps ν =7 220 660 28,5 0 64,3 42,9 7,1 0 0/ 0 0 42,9 0 14,2 dislokasie d ν=4 220 660 100 0 0 0 0 0 0 0 0 0 0 100 0 0 the south african journal of communication disorders, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) hoe frekwensie-timpanometrie van 100% tipe a d timpanogramme vir 220hz vir die groep dislokasie dui op die feit dat die laer frekwensie net so goed in dislokasie diagnoseer as die hoer frekwensie. in die geval van die groep post-stapedektomie is daar vir die 660hz ewe veel (42,9 %) as tipe a en tipe d geklassifiseer vir 220hz is dit oorwegend tipe a timpanogramme wat voorgekom het. (64,3%) e tbneinde die bevinding van van camp et al.15 te kontroleer is timpanogramme van die verskillende groepe nagegaan om te bepaal hoeveel timpanogramme negatiewe susseptansiewaardes bereik het. timpanogramme met tipe d en tipe ε vorms is nagegaan. tabel 4 gee 'n opsomming van die resultate van hierdie ondersoek. hieruit is dit duidelik dat die negatabel 4 die persentasie voorkoms van negatiewe susseptansie timpanogramwaardes eksperimentele groepe: % timpanogramme: 220hz 660hz normaal otosklerose sereuse otitis media akute otitis media timpanoplastiek post-stapedektomie dislokasie van ossikels 0 3 0 0 0 0 0 0 0 16 0 30 ° * tiewe susseptansie-waardes slegs by 660hz voorkom vender kan daar gesien word dat vir die groep dislokasie die negatiewe waardes in 75% van die gevalle voorgekom het, vir die groep dislokasie in 16% en vir die groep post stapedektomie in 30% van die gevalle. in die geval van die normale groep het daar 3% gevalle voorgekom met timpanogramme met negatiewe susseptansie-waardes. ten slotte moet daar verwys word na die bestudering van die v a n d l e n 8 t i n i v^n die drukverandering op die vorm van die timpanogramme. dit is bevind dat bogenoemde aspek geen effek op die vorm van die timpanogramme by 220 of 660hz vir enige van die eksperimentele groepe gehad het. gevolgtrekkings die gebruik van hoe frekwensie timpanogramme het slegs addisionele diagnostiesej waarde wanneer daar sprake is van 'n middeloorstelsel wat deur massa oorheers word. in hierdie 13 studie is dit bevestig dat in die groepe waar styfheid vanwee die patologie 'n minder belangrike rol speel, die hoe frekwen sie timpanogramme inligting verskaf wat of die lae frekwensie bevinding bevestig of meer akkurate inligting verskaf die pa tologiee waarna hier verwys word, is timpanoplastiek poststapedektomie en dislokasie. verwysings 1. alberti, p. w. en jerger, j. f. (1974): probe tone frequency and the diagnostic value of tympanometry arch otolaryngol., 99, 206-210. 2. brooks, d. n. (1968): an objective method of detecting fluid in the middle ear. int. audiology, vii 3 280-286 3. brooks, d. n. (1969): the use of electro-acoustic impedance bridge in the assessment of middle ear function int audiology, viii, 4, 563-569. 4. colletti, v. (1976): tympanometry from 200 to 200hz probe tone. audiology, 15, 106-119. 5. jerger, j. (1970): clinical experience with impedance audiometry. arch. otolaryngol., 92, 311-324. 6. jerger, j. (1980): persoonlike komm'unikasie. 7. keith, r. w. (1973): impedance audiometry with neonates. arch. otolaryngol., 97, 465-467. 8. keith, r. w. (1975): middle ear function in neonates arch. otolaryngol., 101, 376-379. 9. kinsler, l. e. en frey, a. r. (1959): fundamentals of acoustics, john wiley and son. 10. liden, g., harford, e. en hallen, o. (1974): automatic tympanometry in clinical practice. audioloev 13 2 126-139. ' 11. liden, g. en petersen, j. l. (1970): tympanometry, arch otolaryngol. 92, 248-256. 12. moller, a. r. (1961): network model of the middle ear j.a.s.a., 33, 168-176. 13. nerbonne, μ. α.; bliss, a. t. en schow, r. l. (1978): acoustic impedance values in the elderly, j.asa 4 2 57-59. · · . , , , 14. newman, β. t. en fanger, d. m. (1973). oto-admittance handbook i and 2. grason-stadler co., massachusets. 15. van camp, κ. h.; vanpeperstraete, p. m.; dreten, w l en van huyse, v. j. (1975): on irregular acoustic reflex patterns. scand. audiol., 4, 4, 227-232. d afrikaanse tydskrif vir kommunikasieafwykings, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) unique design, unrivalled technology and exceptional sound quality the 123 series is a completely new generation of small hearing aids combining an anatomically correct design w i t h the latest in technology. the 123 series offers the advantages of: modern, attractive design comfortable behind-the-ear fit convenient controls excellent sound quality and low distortion high degree of reliability gain unaffected by changes in battery voltage d o w n to 1 volt very low battery consumption d a η a v o x acoustimed hearing services 3 r d f l o o r bosman b u i l d i n g e l o f f street j o h a n n e s b u r g t e l . : 337-2977 the south african journal of communication disorders, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction method results ethical consideration discussion acknowledgements references about the author(s) tessa l. rausch department of speech-language pathology and audiology, university of pretoria, south africa diane l. kendall department of speech-language pathology and audiology, university of pretoria, south africa department of speech and hearing sciences, university of washington, united states sara t. kover department of speech and hearing sciences, university of washington, united states elizabeth m. louw department of statistics, university of pretoria, south africa ursula l. zsilavecz department of speech-language pathology and audiology, university of pretoria, south africa anita van der merwe department of speech-language pathology and audiology, university of pretoria, south africa citation rausch, t.l., kendall, d.l., kover, s.t., & louw, e.m. et al. (2017). the effect of methylphenidate-oros® on the narrative ability of children with attention-deficit hyperactivity disorder. south african journal of communication disorders 64(1), a180. https://doi.org/10.4102/sajcd.v64i1.180 original research the effect of methylphenidate-oros® on the narrative ability of children with attention-deficit hyperactivity disorder tessa l. rausch, diane l. kendall, sara t. kover, elizabeth m. louw, ursula l. zsilavecz, anita van der merwe received: 20 aug. 2016; accepted: 20 nov. 2016; published: 27 feb. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background and objective: children with attention-deficit hyperactivity disorder (adhd) experience difficulty with expressive language, including form (e.g. grammatical construction) and content (e.g. coherence). the current study aimed to investigate the effect of methylphenidate-osmotic release oral system® (mph-oros®) on the narrative ability of children with adhd and language impairment, through the analysis of microstructure and macrostructure narrative elements. method: in a single group off–on medication test design, narratives were obtained from 12 children with adhd, aged 7–13 years, using wordless picture books. for microstructure, number of words, type–token ratio and mean length of utterance were derived from narrative samples using systematic analysis of language transcripts conventions. for macrostructure, the narratives were coded according to the narrative scoring scheme, which includes seven narrative characteristics, as well as a composite score reflecting the child’s overall narrative ability. results: the administration of mph-oros® resulted in a significant difference in certain aspects of language macrostructure: cohesion and overall narrative ability. little effect was noted in microstructure elements. conclusion: we observed a positive effect of stimulant medication on the macrostructure, but not on the microstructure, of narrative production. although stimulant medication improves attention and concentration, it does not improve all aspects of language abilities in children with adhd. language difficulties associated with adhd related to language content and use may be more responsive to stimulant medication than language form, which is likely to be affected by cascading effects of inattention, hyperactivity and impulsivity beginning very early in life and to progress over a more protracted period. therefore, a combination of treatments is advocated to ensure that children with adhd are successful in reaching their full potential. introduction attention-deficit hyperactivity disorder (adhd) is a frequently occurring psychiatric condition in school-aged children with estimates of prevalence ranging from 3% to 5% (national institutes of health [nih] consensus development panel, 2000; westby & watson, 2004). as outlined in the diagnostic and statistical manual of mental disorders, 5th edition (dsm-5; american psychiatric association, 2013), adhd refers to a heterogeneous group of individuals who display a persistent pattern of inattention, with or without hyperactivity and impulsivity, that disrupts functioning or development. based on the presentation of these difficulties, individuals may be considered to belong to one of three subtypes: adhd primarily inattentive (adhd-pi), adhd primarily hyperactive or impulsive (adhd-ph) or adhd combined type (adhd-c). the symptoms of adhd are pervasive and negatively impact performance across a variety of settings throughout the individual’s life. although widespread agreement exists regarding the validity of adhd as a diagnosis, there is not a single neurological or physiological test to objectively diagnose the disorder. furthermore, no definite neurological, genetic or biological aetiology exists (furman, 2005; nih consensus development panel, 2000). theories regarding the aetiology of adhd implicate neuroanatomical, neurochemical and neurophysiological mechanisms. in particular, dopaminergic neurotransmitters, for example, catecholamines (i.e. hormones produced by the adrenal glands which include dopamine, norepinephrine and epinephrine; dugdale, 2013), have been shown to regulate cognitive behaviours such as attention, inhibition and motivation (ballard et al., 1997). though the exact effect of the catecholamines on behaviour remains unresolved, support for their involvement can be found by improved performance of children with adhd across a range of behavioural measures and cognitive tasks, including those of attention and memory, following stimulant medication (berridge & waterhouse, 2003; pelham et al., 1990a; schachar et al., 2008). in addition to impaired attention and inhibition, children with adhd frequently present with speech or language difficulties. although most estimates range between 20% and 60% (oram, fine, okamoto & tannock, 1999), reports on the rate of speech or language impairment in children with adhd vary depending on whether the samples were clinically referred or enlisted from the community (engelhardt, ferreira & nigg, 2011). children with adhd demonstrate impairments in language processes that have been noted in verbal production (oram et al., 1999; purvis & tannock, 1997), comprehension (mcinnes, humphries, hogg-johnson & tannock, 2003) and reading (baker & cantwell, 1992). prior work documenting disorders in language processing in this population has focused almost entirely on the modality of expressive language, documenting impaired sentence formulation and organisation, coherence and self-monitoring (francis, fine & tannock, 2001; purvis & tannock, 1997), poor topic maintenance (tannock, 2004/2005; westby & watson, 2004) and increased grammatical errors and dysfluency because of false starts, repetitions and hesitations (tannock, 2004/2005). furthermore, children with adhd are prone to speak for longer stretches (excessive talk) with many short pauses during speech production (breznitz, 2003). these characteristics are likely because of verbal retrieval problems resulting in increased use of non-specific terms (tannock, 2004/2005). taken together, children with adhd are at risk of having expressive language abilities that are characterised by weaknesses in both form (e.g. grammatical construction) and content (e.g. coherence). the weaknesses in expressive language associated with adhd are particularly apparent in the context of narrative production. for example, the narrative production of children with adhd is characterised by errors in the sequencing of story events, which research has attributed to a breakdown in the global organisation of language (purvis & tannock, 1997). the literature also reports an inability to acknowledge the needs of the communication partner and a failure to achieve and monitor cohesion at a sentence level (purvis & tannock, 1997). tannock (2000) discusses the fact that poor implementation of pragmatic rules negatively impacts this population’s spoken language, with many studies reporting difficulty in the application of basic pragmatic rules essential for successful and cohesive narrative production, including turn taking, introduction and topic maintenance (oram et al., 1999; purvis & tannock, 1997; väisänen, loukusa, moilanen & yliherva, 2014). furthermore, children with adhd are prone to producing ambiguous statements during narrative production because of the unclear use of referents and a lack of cohesive devices, as well as providing far less information during narration than their normally developing peers (miniscalco, hagberg, kadesjö, westerlund & gillberg, 2007; purvis & tannock, 1997; rumpf, kamp-becker, becker & kauschke, 2012). in addition, van lambalgen, van kruistum and parigger (2008) reported that children with adhd use complexity-reducing strategies during narrative production. these strategies include more tenseless utterances by avoiding direct speech, a greater number of tense shifts leading to incoherence and a limited use of temporal adverbials. according to luo and timler (2008), children with adhd and language impairment produce less organised narratives than their typically developing peers, with particular difficulty noted with story units, with goal–attempt–outcome structure. although luo and timler found no significant difference between the narratives produced by children with adhd and their typically developing peers during a picture sequence task, they found that the children with adhd and language impairment produced significantly fewer complete goal–attempt–outcome units than their peers when narrating a single picture. as such, narrative tasks may most effectively illustrate the language difficulties, as well as the potential for improved performance because of treatment, in children with adhd. theoretical accounts for the association between adhd and language impairment the co-occurrence of attention disorders and language impairment is not arbitrary; however, there continues to be dispute regarding the specific cognitive-linguistic mechanisms responsible for language impairments in this population. theories ranging from general developmental delays to executive function impairments to attention deficits have been proposed. one explanation for the documented concomitance between these deficits is that both are rooted in general developmental delays, as indicated by studies that have focused on the relationship between the development of attention, cognition and language (redmond, 2004). for example, tallal, dukette and curtiss (1989) found high correlations between language, attention and motor functioning, suggesting that attention deficits identified in children with language disorders may be related to neurodevelopmental delays in perceptual and motor functioning. boucher (2000, p. 13) suggested that developmental disorders associated with language difficulties, such as adhd, may reflect a disruption in the development of underlying ‘time parsing mechanisms’ (referring to a continuum of perceptual and cognitive processes implicated in the segmentation and analysis of information, including linguistic material). the continuum of perceptual and cognitive processes described by boucher (2000) could allow for the variation observed in attentional, cognitive and linguistic symptoms associated with adhd. alternatively, the notion that language acquisition may be hampered by existing deficits in attention has been proposed (camarata & gibson, 1999; sameroff & chandler, 1975). camarata and gibson (1999) discussed the effects of adhd on language acquisition through the transactional model of mother–child interaction, which focuses on the interaction between child and adult behaviour responsible for the development of a child’s language (sameroff & chandler, 1975; yoder & warren, 1993). based on this model, the authors suggest that inattention, hyperactivity and impulsivity negatively influence a child’s ability to engage in language-learning opportunities, upsetting these interactions and therefore disrupting the process of language-learning. although these disruptions occur early in life, they presumably continue through childhood, with cascading effects on more advanced language forms and uses. in addition to general developmental delays and attention deficits, executive dysfunction, which refers to those cognitive, self-regulatory behaviours necessary for the selection and maintenance of actions, guiding one’s behaviour within a rule-governed context, is also observed in this population (barkley, 1997; westby & watson, 2004). some propose that deficits in executive function are responsible for core behavioural symptoms of adhd as well as language difficulties (tannock & schachar, 1996) and diminished working memory (barkley, 1997). furthermore, tannock and schachar (1996) suggested that this executive dysfunction may create a profile of language difficulties unique to children with adhd. support for this theory can be found in the work of tannock (2004/2005) and westby and watson (2004), which showed that language characteristics of children with adhd include a lack in ability to initiate or plan an intended message. this results in difficulty shifting between, and organisation of, their thoughts, while maintaining the necessary sequence of behaviours or events. the presence of these deficits could contribute to weaknesses in narration in children with adhd, as these are the skills required to generate a rich and cohesive narrative (moonsamy, jordaan & greenop, 2009). narrative production in children with adhd given the symptoms of adhd and the underlying mechanisms thereof, the cognitive profiles associated with adhd can be mapped onto the requisite skills of narration, which include sustained attention and topic maintenance, as well as complex syntax and an organisational structure based on temporal and causal chains (owens, 2001). given this overlap, it is evident that narrative production, in particular, would be informative to study with respect to the effects of medication on children with adhd. the importance of investigating narratives has been highlighted in the literature for a number of reasons, perhaps foremost, because of the close correlation between narrative performance and academic success in children with language impairment. research has indicated that preschool children with poorly developed narrative abilities are at risk for later academic and language difficulties (paul & smith, 1993). in addition, narrative skills are fundamental to social communication. oral narratives enable individuals to develop social relationships through the sharing of experiences, allowing one to engage emotionally with others (coupland & jaworski, 2003). furthermore, because of the decontextualised nature of narratives, individuals are able to share events that are removed from the here-and-now (peterson, jesso & mccabe, 1999). that is, the core behavioural difficulties and language impairments associated with adhd could impact narrative production ability, with implications for academic and social outcomes. the idea that medication could positively influence language production in narratives in children with adhd has been documented in only a few studies. one such study is that by francis et al. (2001), in which 50 children with adhd, aged 7–12 years, listened to an audiotaped story accompanied by a wordless picture book during a randomised, placebo-controlled crossover trial with both 10 mg and 20 mg doses of standard-release methylphenidate (mph). mph is a stimulant medication used in the treatment of the behavioural symptoms of adhd through its effect on neurotransmitter levels within the brain (ballard et al., 1997; poulton, 2006). participants were required to retell the story as well as answer comprehension questions. the narratives were analysed in terms of their story grammar (critical narrative elements), length of retell and errors produced. results indicated that mph increased the participants’ recognition of the character’s internal responses and attempts (i.e. aspects of narrative macrostructure) but showed no effect on retelling errors, story length or story comprehension. based on the design of the study, however, it is evident that participants’ understanding of the narrative was influenced by their comprehension of the audiotaped story prior to their narrative retell. indeed, the way in which a narrative task is elicited (e.g. visual vs. audio + visual) can impact performance (gazella & stockman, 2003; schneider & dube, 2005). as difficulties in comprehension of the presented story may have influenced the participants’ ability to subsequently retell the narrative, results obtained would be a reflection of the effect of mph on the summation of receptive and expressive language abilities. in a similar study to that of francis et al. (2001), derefinko, bailey, milich, lorch and riley (2009) investigated the effects of stimulant medication on the narrative production of 17 children with adhd, aged 9–13 years, using an online story narration task. online narration allows for the investigation of narratives and story processing, while decreasing demands on memory and receptive language abilities. in this case, narrative elicitation involved telling a story from a wordless picture book, without first listening to a recording of the story or previewing the picture book ahead of time. derefinko et al. compared the narrative abilities on and off-medication for children with adhd who were taking a variety of stimulant medications, rather than a single stimulant across all participants. narratives were evaluated with a focus on goal-based attempts and outcomes (i.e. goal-based story events), using story grammar categories that included overall goal, subsequent subgoal, attempts and outcomes as well as resolution of the overall goal. furthermore, within-clause, whole-clause and repetition errors were noted. for children with adhd, results indicated that stimulant medication did not improve goal-based story production skills. although children on medication included more clauses in their narratives (increased length of narratives), no other significant effects were evident. thus, in contrast to francis et al., derefinko et al. identified an effect of medication on microstructure (i.e. on productivity in terms of narrative length) – but not macrostructure – of narrative production in children with adhd. the discrepancy between the findings of these two studies may have been a result of methodological differences in elicitation of narratives or the particular outcome measures examined. the purpose of the current study was to extend prior work on the effects of a single medication, namely mph-osmotic release oral system (mph-oros®), on language production processes in children with adhd. in the current study, so as to circumvent the effect of comprehension skills on narrative production, an elicitation procedure was utilised that was less likely to result in performance that varies on the basis of memory or receptive language ability. narrative elicitation did not involve listening to the story in advance, but rather previewing the wordless picture book prior to narrative production, allowing the processing of the entire story before planning and organising story components into a cohesive narrative. the current study sought to comprehensively measure microstructure and macrostructure elements of narration, employing a sensitive and specific scale of narrative production that rates the degree of development of story grammar elements rather than the mere presence or absence thereof (narrative scoring scheme; nss; miller, adriacchi & nockerts, 2011). to that end, in a group of 12 children with a diagnosis of adhd and developmental language impairment, the following two questions were addressed: (1) is there an effect of mph-oros® medication on microstructure language production elements during story narration, as measured by productivity, grammatical complexity and lexical diversity? (2) is there an effect of mph-oros® medication on macrostructure language production elements (introduction, character development, conflict resolution, mental state, referencing, cohesion and coherence) during story narration, as measured by nss? method participants in the context of a single group off–on medication test design, 12 first-language english-speaking children with adhd (3 girls and 9 boys), aged 7 and 13 years (mean age of 11.23 with a standard deviation of 2.28) with average or above average intelligence (mean of 96.42 with a standard deviation of 10.05), were selected from a private remedial school. see table 1 for a summary of participant characteristics. only those children with adhd were included in the study as the primary aim of the current study is to investigate the effects of mph-oros® on a heterogeneous group of individuals with adhd. written consent was obtained from parents prior to commencement of the study, and verbal assent was obtained from the children prior to each data gathering session. a university-based ethics committee granted permission for the study to be performed. table 1: demographics of study participants. inclusion only those children who had been diagnosed with adhd by a qualified child neurologist or child psychiatrist, using the diagnostic and statistical manual of mental disorders-iv (dsm-iv), were included in this study. in addition, participants held a current prescription for mph-oros® for a minimum of 3 months prior to the commencement of the study with consent from parents to administer medication at school. participants had a diagnosis of language impairment, as defined by at least one standard deviation below the mean for standard scores on any of the following test batteries: clinical evaluation of language fundamentals (celf-4) (semel et al., 2003), test of auditory processing skills (taps-3) (martin & brownell, 2005), peabody picture vocabulary test (ppvt-4) (dunn & dunn, 2007) and test for auditory comprehension of language (tacl) (carrow-woolfolk, 1998). see table 1 for performance data on these tests. finally, study participants were currently receiving intervention for language difficulties by a speech-language therapist, during the course of the school day. figure 1: boxplots representing the median and interquartile ranges for microstructure elements, off and on medication for (a) productivity (number of words), (b) grammatical complexity (mean length of utterance) and (c) lexical diversity (type–token ratio). figure 2: boxplots indicating median and interquartile ranges for macrostructure elements, off and on medication. exclusion individuals were excluded if they demonstrated below average intelligence based on the senior south african individual scale – revised (ssais-r) (van eeden, 1997) and also if they spoke english as a second language. children receiving additional chronic medications were not permitted to take part in the study, as this may have clouded the results obtained. procedure two examiners, the first author and one other speech-language therapist, carried out data collection in a quiet environment. to assess the behaviour without the influence of medication, all participants were assessed after a 2-day ‘drug holiday’. the assumption for this time period is that after 24 hours, normal blood level baselines would be reached (liu, muniz, minami & silva, 2005). participants were assessed twice on a single day: once prior to receiving their daily dose of medication and again 4 hours later (after the medication had taken effect). the decision to schedule the post-medication assessment 4 hours after medication had been administered was made in consultation with a representative from the relevant pharmaceutical company, as this is when maximum level of mph-oros® is reached. narrative task and outcome measures narrative stimuli the research questions were answered by the administration and subsequent scoring of language production elicited by narrative production procedures. the wordless picture books frog, where are you? (mayer, 1969) and one frog too many (mayer & mayer, 1975) were used to elicit narratives, based on evidence of their comparability (john, lui & tannock, 2003). order of presentation of the books was randomised between preand post-medication sessions. frog goes to dinner (mayer, 1974) was used for warm up, prior to the pre-medication session, and the narrative obtained was recorded but discarded without analysis. these stories are similar with regard to theme, structural complexity, number of main characters and length (john et al., 2003; petersen, gillam & gillam, 2008; strong, 1998), and they have been used extensively to assess children’s narrative abilities (berman & slobin, 1994) with both typical and atypical populations (losh & capps, 2003). narrative production procedure the book was placed on the table in front of the child. the instructions given to the participants were pre-formulated in order to avoid any additional influence on their performance: here is a picture book that tells a story. this book has no words. i want you to look through the book from start to finish. then we will go through the book together and i want you to tell me the story for each picture. if the child was quiet for prolonged periods of time, the prompt ‘tell me more’ was used once. no further prompts to produce language were given. the examiner gave no feedback regarding performance but provided occasional social continuants such as head nods and ‘uh-huh’. participant language samples, and all prompts from the examiner, were digitally recorded in a quiet environment using an olympus vn-713pc dictaphone to allow for later playback and analysis. transcription and outcome measure scoring the first author orthographically transcribed the audio recordings into c-units using the systematic analysis of language transcripts (salt) guidelines and software (miller et al., 2011). for microstructure elements, the number of words, type–token ratio and mean length of utterance (mlu) in words, of complete and intelligible utterances, were determined using salt standard measures. for the analysis of macrostructure, the transcripts were coded according to the nss (miller et al., 2011). the nss includes instructions on how to code story grammar and cohesion according to a 0to 5-point likert-type scale. the nss focuses on the following aspects of narratives, each described further below: introduction, character development, mental states, referencing, conflict resolution, cohesion and conclusion. each category is assigned a score ranging from 5 (proficient), 3 (emerging) and 1 (minimal or immature). scores of 2 and 4 were assigned if performance fell somewhere between the major anchors (bajaj, 2007). a score of 0 is assigned when performance cannot be judged because of a variety of child errors including unintelligibility, task abandonment or refusal to complete the task at hand, conversing with the examiner and narration of the incorrect story (miller et al., 2011). the scores from the seven categories were then combined to provide a composite score reflecting the child’s overall narrative ability as described by miller et al. outcome measure description: microstructure and macrostructure language elements were quantified. microstructure was defined as productivity (number of words produced), lexical diversity (type–token ratio) and grammatical complexity (mlu). macrostructure was defined using the nss as introduction (provides the setting for the story and introduces main characters), character development (ability to use metalinguistic verbs, differentiate between characters and talk in first person to depict story characters), mental states (ability to use metacognitive verbs to describe thoughts and feelings), referencing (referential cohesion through the use of pronouns and antecedents), conflict resolution (highlights major conflicts and resolutions), cohesion (refers to lexical and conjunctive aspects which include ordering, emphasis and transition between story events) and conclusion (story is wrapped up using concluding statements) (miller et al., 2011). transcription agreement and nss scoring reliability: intraand inter-rater agreement and reliability procedures were performed by the first author and an unbiased speech-language pathologist, who was blinded as to whether recordings were preor post-medication and who had no personal interest in the study. these procedures were carried out on all microstructure and macrostructure elements on 20% of the data. narratives from 5 of the 12 participants were randomly selected, from which one of the narratives (either pre-medication or post-medication) was randomly chosen for agreement and reliability scoring. narratives were re-transcribed in salt and re-analysed using nss both by the original transcriber as well as by the second transcriber. inter(intra)-rater agreements for the salt microstructure transcript elements were determined using pearson’s correlations. the results showed the following correlation coefficients: 1.00 (1.00) for number of words, 0.997 (1.00) for length of t-unit and 0.987 (0.996) for type–token ratio. krippendorff’s alpha values were calculated with ordinal scaling to determine inter-rater reliability of the nss scores using 0.67 (acceptable) and 0.80 (adequate) benchmarks (hayes & krippendorff, 2007). this reliability metric was chosen because it has been used extensively with nss scoring (finestack, palmer & abbeduto, 2012; heilmann, miller & nockerts, 2010). the resultant alpha values for each nss component are represented in table 2. table 2: krippendorff’s alpha values obtained for nss scoring reliability. results based on the small sample size and the skewed distribution of the differences between the onand off-medication measurements, non-parametric tests were used. inferential statistics were employed to determine the significance of results at a 5% level of significance. the wilcoxon paired signed ranks test, a non-parametric equivalent of the paired t-test, was selected to determine the effectiveness of mph-oros® on improving microstructure and macrostructure elements during narration. multiple testing was done to evaluate the effect of medication on each of the independent microstructure and macrostructure language production elements separately. see table 3 for descriptive and test results. the median (me) and interquartile range (iqr), the difference between the third quartile and the first quartile, have been reported because of the skewed distribution of the data. these descriptive measures are more robust than averages and standard deviations as they are not influenced by outliers. table 3: effects of mph-oros® on the narrative production of children with attention-deficit hyperactivity disorder. the nss categories, in accordance with previous literature, were divided into three groups. introduction, conflict resolution and conclusion were grouped together as these nss components refer to the key components of story grammar. referencing and cohesion form the second group and represent the overall coherence of the narrative. character development and mental states are concerned with the use of a literate style (rollins, 2014). we used the holm (1979) sequentially rejective multiple comparisons procedure for each of these three families to control alpha (i.e. compared the lowest p-value with 0.05/3 = 0.0167 for the families with three variables and the lowest p-value with 0.05/2 = 0.025 for the families with two variables). because of the non-parametric analysis of results, and the comparison of medians, effect sizes were calculated using r-values (cohen, 1988). results for the first research question (effect of medication on microstructure language production elements during narrative production) were not significant (all p-values in the table were not less than the level of significance of 5%). the second research question asked was whether there was an effect of medication on macrostructure language production elements (introduction, character development, conflict resolution, mental state, referencing, cohesion, coherence and total) during narrative production as measured by nss. the p-value of 0.008, which is less than 0.05, indicates that mph-oros® elicited a statistically significant effect on the overall narrative performance (nss total score). using the holm procedure for multiple comparisons, results showed that the medication has a significant influence on one of the seven independent macrostructure language production elements: cohesion. the p-value for cohesion was 0.020, indicating that mph-oros® elicited a significant effect on this component. note that the improvement for conflict resolution failed to reach significance after the family-wise correction for multiple comparisons, p = 0.026; however, the effect size for this difference was -0.454, indicating a medium-to-large correlation (cohen, 1988). the remaining five story grammar variables independently showed that the medication has no significant influence on them. ethical consideration prior to the onset of data gathering, a detailed outline of the study and data gathering procedures, including the administration of medication, was presented to the appropriate committees for ethical consideration. approval by the department of speech-language pathology and audiology research committee was obtained, following which ethical clearance was given by the faculty of humanities research proposal and ethics committee at the university of pretoria. discussion the purpose of this study was to investigate the effect of mph-oros® on microstructure and macrostructure elements of language in children with adhd and concomitant language impairment. overall, independent results indicate that mph-oros® positively impacts aspects of language macrostructure, namely cohesion and the overall narrative, although little effect (not significant) was noted in microstructure elements. details regarding each of the questions will be discussed below. microstructure the first research question addressed the effect of medication on microstructure language production elements during story narration as measured by productivity, grammatical complexity and lexical diversity. results indicated that mph-oros® did not impact microstructure elements. these findings are in line with the results obtained by francis et al. (2001) but contrary to derefinko et al. (2009). these results may be attributed to the notions that: (1) the group participants included those with various adhd subtypes and (2) linguistic impairments persist despite improved attention during a circumscribed narrative production task. in the current study, measures of productivity did not improve as a result of mph-oros®; however, derefinko et al. (2009) showed that stimulant medication increased productivity (number of clauses produced). based on tannock’s (2004/2005) summary of fine’s (2005) ‘linguistic manifestation of adhd symptoms’, excessive language output can be attributed to the hyperactive component of adhd. therefore, children’s specific adhd presentations, namely the presence or absence of the hyperactive component, might impact the language production of children, particularly with regard to productivity. research has shown that performance on language tasks differs between individuals from different adhd subtypes (engelhardt et al., 2011; engelhardt, veld & nigg, 2012). one notable feature of the performance in the current sample was the wide variability among individuals; however, we lacked the statistical power to differentiate between adhd subtypes. future research will be necessary to establish whether this variability might be accounted for by adhd subtype and whether effects of medication differ across adhd subtypes for the measures examined. it is hypothesised that medication may impact narrative microstructure differently for those with adhd-pi and adhd-c, such that improved attention may slow down narrative performance and increase productivity in former case and may result in more focused and therefore shorter narratives in the latter case. grammatical complexity and lexical diversity did not improve with the administration of mph-oros®. these results could provide support for the idea that, despite improved attention, linguistic impairment persists. camarata and gibson’s (1999) discussion of language acquisition in children with adhd is congruent with this line of thinking. through their review of adhd and its impact on pragmatic skills, based on the transactional model of mother–child interactions (sameroff & chandler, 1975; yoder & warren, 1993), they suggest that it is this aspect of language that is particularly vulnerable to disruption because of inattentive, hyperactive and impulsive behavioural characteristics. they attribute linguistic deficits to pragmatic difficulties during early interactions between mother and infant. these negatively influence the child’s ability to engage in language-learning opportunities and may lead to cascading impairments in language ability in childhood and adolescence. even with improved attention because of the administration of mph-oros®, children with adhd may not have the requisite language skills to produce a more mature narrative. macrostructure the second research question addressed the effect of medication on macrostructure language production elements during story narration as measured by nss. an overall improvement in nss total score was observed following mph-oros®. various categories of the nss were differentially affected. one specific macrostructure element was improved (i.e. cohesion) while five were not (i.e. introduction, character development, mental states, referencing and conclusion). the improvement noted in cohesion may be indicative of the effect of mph-oros® on executive functions as this element may be more deeply rooted in one’s present ability to relate and organise events in relation to one another and perhaps less reliant on the modelling of story structure during previous language-learning opportunities. as predicted, mph-oros® showed a positive effect on the cohesion of narratives, supporting the theory that the language characteristics of individuals with adhd can be attributed to executive dysfunction (tannock & schachar, 1996). the improvements may be indicative of the documented effect of stimulant medications on some tasks of executive functions (aman, roberts & pennington, 1998), thus allowing participants to better plan and organise their narratives, improved sequencing and smoother transitions between story events. although conflict resolution did not significantly improve, it is an aspect of narrative ability that is worth future investigation as evidenced by the effect size. although speculative, one possibility for the potential improvement in conflict resolution may be that mph-oros® decreases impulsive behaviour, slowing the thought process and allowing one to tap into executive functions. participants would therefore be able to select information, monitor the outcome of story events and redirect responses where necessary. the results of the current study indicated improvement in aspects of narrative ability that were not identified by derefinko et al. (2009), which may be due to differences in the method of elicitation. derefinko et al. (2009) made use of online story narration, whereas the current study provided participants with the opportunity to preview the storybook prior to narrative production. as a result, participants were given the chance to plan and organise their story components in relation to one another, as well as to tell the story with the end goal in mind. the elicitation protocol in the current study may have increased the chance that participants, given their increased focus and attention because of the administration of mph-oros®, would include causal chains and make comments regarding goal-directed behaviour and initiating events. in addition to cohesion, the administration of mph-oros® significantly impacted the nss total score, indicating meaningful improvement in the overall impression and efficacy of a narrative. therefore, results suggest that some children with adhd, who are treated with mph-oros®, may be better able to express their thoughts and experiences through more effective, richer narratives. the fact that mental states did not improve in this study is contradictory to the results obtained by francis et al. (2001). in that study, mph improved the recognition and verbal expression of internal responses. internal responses refer to the emotional responses, thoughts and desires of characters (referred to in the current study as mental states). francis et al. (2001) attributed this improvement to an increase in sensitivity to emotional information and the actions of others. the fact that mph-oros® did not improve performance on all aspects of narrative production is consistent with previous work focusing on the effects of stimulant medication on higher-order skills in children with adhd, both on language and non-language tasks. bailey, derefinko, milich, lorch and metze (2011) investigated the effect of mph on free recall of story events in children with adhd. results indicated that although stimulant medication improved the percentage of story events that were recalled, there was no improvement in the recall of events that were central to the story. abikoff et al. (2009) investigated the effect of stimulant medication on organisational skills, planning and time management and found that although aspects improved, medication did not eliminate difficulties altogether. similarly, pelham et al. (1990b) found that although stimulant medication improved immediate attention during baseball games, it did not improve their overall performance. these studies, along with the results for those of derefinko et al. (2009), francis et al. (2001) and the current study, suggest that although stimulant medication improves attention and concentration, it cannot make up for the loss of structural and pragmatic language abilities that may be associated with – or downstream effects of – the primary symptoms of adhd. therefore, although stimulant medication improves performance of individuals with adhd in some domains, it is not a sufficient intervention to improve higher-order metacognitive and linguistic skills. a combination of treatments is therefore necessary to ensure that individuals with adhd are able to reach their full potential. these interventions could include, but may not be limited to, medication, behaviour modification therapy, speech-language therapy, occupational therapy and remedial education. limitations the strict selection criteria and resultant small sample size of the current study did not allow for the differentiation between presentation subtypes of adhd (i.e. adhd-pi vs. adhd-ph vs. adhd-c). differentiation between adhd subtypes would prove valuable as the effect of mph-oros® on narrative ability may be influenced by the presence or absence of the hyperactive component. in addition, obtaining multiple narrative samples per participant would allow for a more accurate representation of an individual’s abilities as results would be less affected by external and internal factors. however, because of the nature of this study, it was necessary that material be similar with regard to theme, structural complexity, number of main characters and length so as to not exert an influence on the narratives produced. with limited material available to meet these criteria, it was only possible to obtain a single onand off-medication narrative sample. further, the repeated elicitation of narratives from the participants may have resulted in training effects and could be circumvented in future studies by making use of a crossover design or adjusting the period the period of time between onand off-medication sampling. developmental differences in narrative production, because of the wide age range of the study participants, may have impacted upon their narrative ability and could have subsequently influenced the results. although reliability appeared low for the introduction component on the nss, it is important to note that raw scores never differed by more than a single point (e.g. 2 [intermediate between immature and emergent] vs. 3 [emergent]). scores within one point are considered consistent, given that the scale was constructed with clear anchors of 1, 3 and 5 (with intermediate scores of 2 and 4). in addition, the low scores can in part be attributed to the very small number of reliability transcripts. rescoring 20% of the data translated into only five language samples, leaving little margin for error. with regard to the difference in points between scorers, no trends could be noted between transcriptions with regard to participant characteristics for the two transcripts with a scoring discrepancy. transcripts were both 100% intelligible, and the book used to elicit the narratives differed between transcripts as did the presence or absence of medication. reliability for conflict resolution was also low; however, again, scores never differed by more than a single point and scores were identical for four of five transcripts. one possible reason for differences between scorers may be based on the scorers’ interpretation of the descriptions of the criteria. for example, an emergent score (3 points) under the introduction category requires (1) setting: ‘states general setting but provides no detail’, ‘descriptions or elements of setting are given intermittently through story’ and ‘may provide description of specific element of setting (e.g. the frog is in the jar)’ and (2) characters: ‘characters of story are mentioned with no detail/description’. the immature (1 point) requires that the speaker ‘launches into the story with no attempt to provide setting’ (miller et al., 2011). it is therefore clear whether or not to assign a score of 1, but far more challenging to determine whether the performance meets all the descriptors to warrant a score of 3. for example, the interpretation of descriptions given ‘intermittently’ throughout the story may differ between scorers. should a scorer’s best judgment be that not all descriptions were met; a score of 2 should be awarded instead. similar discrepancies were reported in petersen et al.’s (2008) summary and evaluation of measures of narration, which included the nss, noting particular discrepancies with the coding of mental states and cohesion (petersen et al., 2008). future directions although the current study focused on the effect of medication on the narrative ability of children with adhd using a within group comparison, future research should be carried using a peer control group comprising typically developing children. this would provide further clarity regarding the narrative difficulties experienced by this population as well as insights into the degree to which medication normalises the narrative performance of children with adhd. the current study should be replicated using a larger sample size. this would allow for the differentiation between adhd subtypes, namely adhd-pi, adhd-ph and adhd-c, as recent studies have noted differences in language production between these groups (engelhardt et al., 2011, 2012), and would make generalisation of the findings possible. this may provide further insights into the relationship between adhd and language impairment as well as the effect of mph-oros® on language production. further studies should also be carried out to determine whether the effects of stimulant medication on narrative ability are mediated by attention or memory by directly assessing attention, memory and executive function. future studies in this line of research would benefit from the comparison of language samples elicited in different language sampling contexts (e.g. conversation, expository samples and persuasion), which may be maximally informative in terms of the effects of stimulant medication on the spontaneous expressive language of children with adhd. to support research in this area, additional elicitation materials should be developed to allow multiple narrative samples – or multiple samples from other contexts – to be obtained over time from a wider age range of participants. for example, a series of standardised narrative elicitation materials would allow for repeated measurements without the reliability of narrative production being affected by additional factors such as story length, number of characters and subject matter. although there are six wordless picture books available by mercer meyer, the literature suggests that these books may not all be sufficiently comparable for the elicitation of multiple narratives over time. john et al. (2003) examined children’s retelling of narratives using the strong narrative assessment procedure (snap) (strong, 1998). the snap contains the wordless picture books frog, where are you?, a boy, a dog and a frog (mayer, 1967) and one frog too many, as well as frog goes to dinner, which is included as practice material. through the exploration of the equivalency of the stories, john et al. found that a boy, a dog and a frog was retold with greater ease, resulting in inflated scores for story grammar components and inferential comprehension when compared with other two stories. based on these results, it was recommended that clinicians only administer frog, where are you? or one frog too many – the two books utilised in the present study – when assessing progress in narrative production. as a result, one’s ability to obtain multiple samples over time is limited. if researchers are able to limit the age range of participants more narrowly, some available tools may prove beneficial in furthering our understanding of the effect of stimulant medication on narratives in children with adhd. this includes the multilingual assessment instrument for narratives (main) (gagarina et al., 2012), which can be used for children aged 3–10. normed protocols that may prove useful include the test for narrative language (tnl) (gillam & pearson, 2004), although this only contains two story sequences and will therefore not allow for multiple data gathering sessions over time, and the edmonton narrative norms instrument (enni) (schneider, dubé & hayward, 2005), which can be used with participants aged 4–9. clinical significance the findings of this study have potential implications, both academically and socially. children with adhd are at risk for academic underachievement because of the primary symptoms associated with adhd (loe & feldman, 2007). in addition, the documented narrative impairment may further hamper academic success in this population (moonsamy et al., 2009). narrative ability is critical to classroom performance and forms part of common daily activities (kaderavek & sulzby, 2000). individuals with poor narrative ability are often negatively perceived by others (hemphill & siperstein, 1990). furthermore, narrative ability fosters social communication, allowing one to engage with their peers (coupland & jaworski, 2003), thus supporting socio-emotional development. therefore, because of the large role that narratives play in academic and social settings, it is evident that narrative inability in children with adhd cannot be ignored by those professionals working with this population. the findings that mph-oros® improves aspects of narrative ability in children with adhd could be valuable information for clinicians and speech-language pathologists as this, if replicated, might prove beneficial when guiding parents in decision-making processes regarding medication as well as the ongoing necessity of speech-language therapy in children with adhd. acknowledgements the authors wish to thank the participants and their families for participating in this study. they thank kate bellew for her assistance in scoring for reliability measures, and andries masenge, department of statistics, university of pretoria, for his statistical contributions. this research was supported, in part, by a tuition bursary from the university of pretoria. competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions the research was conducted by t.l.r. to complete her master’s degree in speech-language pathology at the university of pretoria. she was responsible for developing the research project, conducting the literature review, collecting primary data in the form of narrative samples, as well as compiling and reporting upon the results obtained. dr kendall was responsible for the mentorship of the first author during the conceptualisation of the research questions, methodology, data collection and data analysis. dr kover edited drafts of the manuscript, provided relevant literature and contributed to the selection and execution of analyses. dr louw provided assistance in statistical analysis, interpretation and visual representation of the results. mrs zsilavecz acted as project co-supervisor for the completion of this work as the first author’s master’s degree. supervision included early conceptualisation of the study, administrative support and editing of drafts. prof. van der merwe acted as supervisor for the master’s study and was involved in planning of the research design as well as acted as the project supervisor, and a co-author. references abikoff, h., nissley-tsiopinis, j., gallagher, r., zambenedetti, m., seyffert, m., boorady, r., et al. 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(1993). can developmentally delayed children’s language development be enhanced through prelinguistic intervention? in a.p. kaiser & d.b. gray (eds.), enhancing children’s communication: research foundations for intervention (pp. 35–63). baltimore, md: brookes. article information authors: katerina ehlert1 alida m. naude1 affiliation: 1faculty of health sciences, university of limpopo medunsa campus, south africa correspondence to: katerina ehlert postal address: po box 22129, lyttelton 0140, south africa dates: received: 25 feb. 2014 accepted: 21 june 2014 published: 11 nov. 2014 how to cite this article: ehlert, k., & naude, a.m. (2014). infection prevention and control measures currently applied in south african audiology. south african journal of communication disorders, 61 (1), art. #55, 10 pages. http://dx.doi.org/10.4102/ sajcd.v61i1.55 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. infection prevention and control measures currently applied in south african audiology in this original research... open access • abstract • introduction • method    • aims    • participants       • inclusion criteria       • sample    • research method and design       • data collection       • ethical considerations       • reliability, validity and bias       • data analysis • results and discussion    • infection control measures applied in audiology practices • conclusion and recommendations • acknowledgements    • competing interests    • authors’ contributions • references • appendix abstract top ↑ background: to counter the global increase in infection-related deaths, infection control has recently developed into an active area of research. many diseases can be prevented by infection control. in the confines of the audiology clinic, cross-contamination by micro-organisms associated with opportunistic infections remains a real concern.objective: the primary aim of the study was to ascertain the methods that audiologists in south africa use to prevent and control the spread of infections during and after consultation with clients. method: a survey study was conducted, using a self-administered questionnaire. fifty currently practising audiologists participated in the study. results: the majority (84%; n = 42) of respondents acknowledged the importance of hand hygiene for the purpose of infection control, with 76% (n = 38) making use of no-rinse hand sanitisers. approximately a third of audiologists wear gloves during procedures such as otoscopy and immittance, and while handling hearing aids. disinfecting audiological equipment seem to be the preferred choice of infection control, with only 60% (n = 30) of respondents sterilising audiological equipment after each individual patient consultation. less than half of the respondents disinfected touch surfaces and toys in the reception area. conclusions: based on the results, further education and training should focus on measures implemented in infection control, awareness of possible risk factors at work settings, and vaccination as an effective means of infection control. introduction top ↑ the second leading cause of death worldwide, after heart disease, is infectious diseases, many of which are spread by contact with unclean hands (world health organization [who], 2008). infectious diseases also lead to compromised health and disability. in response to the increase of infection-related deaths, there has recently been a special focus on infection control globally. in the south african context, infection control is of significant concern to audiologists and their clients in all clinical settings (south african speech-language-hearing association [saslha], 2011). the aim of infection control is to eliminate and reduce the spread of infectious diseases (kemp & bankaitis, 2000b).over the last 20 years, change in the scope of practice in audiology has improved significantly to include immittance, vestibular procedures, hearing aid technology, the clinical application of evoked potentials and cerumen management. the services provided by audiologists are sought by a diverse population of clients in terms of age, socio-economic position, pre-existing disease, history of pharmaceutical interventions, and other aspects that can affect the integrity of individuals’ immune systems and their ability to fend off potentially infectious micro-organisms, subsequently resulting in heightened susceptibility to contracting infection (clark, kemp & bankaitis, 2003). in the confines of the audiology clinic, cross-contamination with micro-organisms associated with opportunistic infections remains a realistic concern. opportunistic infections result from ever-present organisms residing in abundance throughout the environment that can cause threatening conditions in patients who are immune compromised (bankaitis, 2002). as shown by bankaitis (2002), light to heavy amounts of bacterial and/or fungal growth have been recovered from hearing aid surfaces. audiologists handling hearing instruments without applying the necessary infection control procedures, inherently increase the potential for disease transmission. reinsertion of contaminated hearing instruments into the patient’s ear canal provides micro-organisms with an easy entry portal into the body. under the right conditions, such contaminated objects can lead to opportunistic infection that can manifest at the level of the ear canal or gain access into the body, causing a systemic disease. other objects that may be contaminated and come into direct or indirect contact with patients include headphones, emission probe tips, electrodes, otoscope, specula, oto-lights, earmould impression syringes, probe tubes for real-ear measurements, earmoulds and hearing aids (clark et al., 2003, saslha, 2011). accordingly, it is essential that audiologists are made aware of infectious organisms that could be hazardous to them and their patients. table 1 summarises the infections relevant to the area of audiology. table 1: infectious diseases important to audiology. there are standard precautionary measures that should be incorporated to control infection in audiology practice (kemp & bankaitis, 2000a). the responsibility of the audiologist includes preventing and controlling disease transmission by means of cleaning, disinfecting and sterilising items and surfaces that are re-used, using protective barriers such as gloves, immunisation to protect themselves against disease, and effective waste management (saslha, 2011). contact transmission remains the most common means of cross-contamination and potential disease transmission (kemp & bankaitis, 2000b). contact transmission may occur when the audiologist or the client touches another individual or object, which may encourage unintentional cross-infection via contact transmission. for this reason, proper hand washing is the most effective way to prevent the spread of infections (kemp & bankaitis, 2000a). hands should be washed before and after contact with a client. in addition, gloves should be worn when there is a risk of exposure to any bodily fluid. audiological equipment should be cleaned, disinfected and sterilised at regular intervals (centers for disease control and prevention, 2002; saslha, 2011). since the turn of the century, the topic of infection control has received special attention by various audiology organisations. the american academy of audiology (aaa) issued practice guidelines to its members, addressing the importance and the need for implementing infection control procedures in clinical practice (clark et al., 2003). the american speech-language-hearing association (asha), as well as the south african speech-language-hearing association (saslha), subsequently published similar policy documents. the increased focus on infection control resulted in several studies related to audiology and infection control specifically related to bacterial growth on hearing aids and audiological equipment as well as current infection control trends. the studies indicated the presence of normal flora of the ear as well as isolated pathogens detected on hearing aids, earmoulds and audiological equipment (ahmad, etheridge, farrington & baguley, 2007; bankaitis, 2002; bankaitis, 2005; burco, 2007; clark et al., 2003; mehdinejad, khosravi & mahmoudabadi, 2010; powell, perry & meikle, 2003; sturgulewski, bankaitis, klodd & haberkamp, 2006). despite such increased interest in the topic, a survey study on the implementation of infection control guidelines concluded that audiologists were unaware of the potential sources of cross-infection (kemp & bankaitis, 2000a). the majority of surveyed audiologists also indicated that they were unaware of the potential cross-infection by way of virulent pathogens located on standard audiology equipment such as headphones, otoscope specula inserted in the ear canal during ear canal inspection, and probe tips inserted in the ear to assess tympanic membrane mobility. an environment of increased risk of spreading infections and diseases is created by this lack of knowledge, or if knowledge is not implemented adequately. the extent to which audiologists appreciate the need for infection control, or the importance of integrating infection control principles in the clinical environment in africa, remains unknown. developing countries in africa have the highest infection rate in the world, with south africa identified as having the highest co-infection rate (national intelligence council, 2000). the high co-infection rate is related to most clinics being in rural areas that face challenges such as a lack of resources, including water and disinfectant materials. with research (sarma & ahmed, 2010) showing that healthcare-associated infections in developing countries (such as south africa) can exceed 25%, compared with developed countries, it is clear that infection control is an issue of considerable importance that highlights the significance of a study on infection control at the present time, to curb the ever-increasing rate of cross-contamination in south africa. therefore the research question arises: what is the application of infection control measures in audiology practice in south africa? method top ↑ aims the main aim of the study was to determine how specific infection control measures were applied in audiology clinical settings in south africa. secondary objectives were to determine (1) which infection control measures are applied in audiology practices; (2) how frequently specific infection control measures are applied in audiology practices; (3) current compliance with infection control measures in accordance with measures required by the south african department of health; (4) possible needs for further continued professional development in the area of infection control; and (5) guidelines for the development of future programmes focused on infection control. participants inclusion criteria the criteria for subject selection were that respondents had to be practising at the time of the study, registered with the health professions council of south africa (hpcsa), and literate in english. sample purposive sampling was used because this method is based on the judgment of researchers regarding the characteristics of a representative sample (leedy & ormrod, 2010). fifty practising audiologists participated in the study, comprising 15 african women, 33 caucasian women and 2 caucasian men. the participants represented all nine provinces, namely northern cape (n = 5), eastern cape (n = 7), free state (n = 2), western cape (n = 9), limpopo (n = 10), north west (n = 2), kwazulu-natal (n = 5), mpumalanga (n = 5) and gauteng (n = 5). fifty-two percent (n = 26) of this sample represented service delivery in rural areas. the mean age of the audiologists was 37 years. the audiologists are referred to as the respondents. research method and design a quantitative research approach was employed for the purpose of this study, and a survey (questionnaire) was used to conduct the descriptive study. data collection the questionnaire consisted of the following sections: biographic information; infection control measures in audiology; transmission of infectious diseases; knowledge regarding infection control; application measures in infection control; and personal views. both openand closed-ended questions were included. during closed-ended questions, respondents were requested to select one of the provided answers, while respondents had to formulate their own answers to open-ended questions (czaja & blair, 2005). answers to the closed-ended questions were easily comparable, coded statistically and analysed. questionnaires and consent letters were emailed and delivered by hand to the respondents. questionnaires were returned by email or delivered by hand. from the 200 questionnaires distributed to audiologists practising in south africa, 50 respondents (25%) participated in the study, which is an acceptable return rate for questionnaires (champion & sear, 1999). ethical considerations approval was obtained from the medunsa research ethics committee (mrec). for the purposes of the current study, confidentiality and anonymity of respondents was maintained by ensuring that no names appeared on the completed questionnaires. reliability, validity and bias to ensure validity of the measurements, the researchers considered the face validity of the questionnaire (leedy & ormrod, 2010). during the pilot study, two audiologists recognised for their expertise in infection control measures were asked to complete the questionnaire and evaluate if the instrument measures matched the outcomes of the study, if the questions were phrased appropriately, and if the options for responding seemed appropriate. this information was important as incorrect wording of questions can lead to survey bias. as bias can result from unreliable and/or invalid questions, the experts were asked to identify questions that were subject to various interpretations, or invalid questions that could push the respondent toward a certain type of answer, thus creating bias in predictable ways (penwarden, 2013). assessment of the wording of questions, the type of questions used, the design of the questionnaire, and the survey structure was essential to minimise response bias. the two expert audiologists were asked to highlight loaded terms, compound questions, and excessively long phrases. the questionnaire questions were comprehensive to address the objectives, but were limited to closed-ended questions, and each question included instructions on how to answer the question. close-ended questions greatly simplify coding and analysis later on (penwarden, 2013). the two experts were also asked to evaluate the content validity of the questionnaire with reference to the known components involved in infection control measures for audiologists. suggested changes were effected before the questionnaires were distributed. the researchers also considered criterion validity by comparing the questionnaire with other measures of infection control in the literature (leedy & ormrod, 2010). reliability of the study was established by describing the methodology in detail to ensure that similar results would be found, should the study be repeated. the other aspect of reliability that was considered was consistency among the questions (penwarden, 2013). the respondents’ answers were checked to ensure that they were fairly consistent and correlated with other questions in other categories of the questionnaire. bias was further minimised by addressing over-generalisation, over-comparison and unfounded conclusions based on the research data collected during the study, and that the researchers interpreted the respondent ideas appropriately by writing down only a summary of the answers with the consultation of the statistician (leedy & ormrod, 2010). data analysis descriptive statistics formed the basis of the data analysis procedure. the data collected from the questionnaires were encoded and then tabulated and analysed using the south african statistics (sas) software, version 9.1.3 for windows®. averages, means and statistical significances were used to analyse the data. results and discussion top ↑ infection control measures applied in audiology practices hand hygiene represents the single most important procedure for effectively limiting the spread of infectious diseases, and is seen as a minimum requirement for performing tasks in audiology (kemp & bankaitis, 2000a; saslha, 2011). it is one of the most critical components of a basic infection control programme and is therefore addressed first in terms of reporting results related to the specific outcomes of this study. the results of the study are presented in table 2. table 2: hand washing practices of respondents in clinical settings. the results showed that most (84%; n = 42) respondents acknowledged the importance of hand hygiene for the purpose of infection control. these respondents indicated that they wash their hands after contact with a patient, which is in line with the 82% reported in the study conducted by burco (2007). this finding is also in line with the international focus on education in the area of infection control and saslha guidelines. it is interesting, however, that although not statistically significant according to the t-test (p > 0.05), only 62% (n = 32) of respondents washed their hands before a patient session. the results regarding hand washing after bathroom use is of great concern. only 78% (n = 36) of respondents reported that they always wash their hands after using the bathroom. the implication is that respondents expose themselves and their patients to infections, as bathrooms are associated with various infections. it is also interesting that, although 2% (n = 1) of respondents did not report hand hygiene to be important, some infection control guidelines were still followed on occasion. since hand washing is regarded as the most effective method for reducing the spread of diseases, especially in healthcare practices, hands should be washed with hospital antibacterial soap and water before and after each patient (kemp & bankaitis, 2000a). the fact that more respondents preferred to wash their hands after seeing a patient than before, suggests that respondents have the perception that they can only contract diseases from their patients but not vice versa. respondents are not following effective hand hygiene in accordance with the guidelines for effective control measures provided by saslha and kemp and bankaitis (2000a), and this could result in cross-infection from audiologist to patient and vice versa. only 2% (n=1) of respondents did not consider hand hygiene effective for infection control. although this is a low number, it may have an influence on the application of infection control. hand hygiene is receiving a great deal of attention globally and is an effective way of reducing the spread of diseases, as mentioned previously. the use of hand sanitisers has been approved as effective for hand hygiene and reduces the number of bacteria more effectively than washing soap and even antibacterial soap (bankaitis & kemp, 2000; hand hygiene resource center, 2002). sanitisers can be used with ease and convenience compared with soap and water. during the study, it was determined that most respondents (76%; n = 38), have access to a no-rinse hand sanitiser in their clinical setting, which is higher than the reported 50% by almani (1999). this is seen as a positive response, as no-rinse hand sanitisers can be easily and effortlessly applied before and after seeing each patient (bankaitis & kemp, 2000). the results, however, indicate that 14% (n = 7) of respondents did not have access to a no-rinse hand sanitiser, possibly owing to the cost involved or easy access to water. however, since most respondents practise in rural areas where they face challenges such as a lack of running water, this can increase the chances of cross-infection. where there is no running water and respondents also do not have access to no-rinse hand sanitisers, respondents cannot practise proper infection control measures. in addition to hand washing and hand sanitisers, gloves are a well-known means of infection control and effective in preventing audiologists from handling used equipment with bare hands, which could increase cross-infections (saslha, 2011). the results showed that less than half of the respondents used gloves when performing the audiological procedures mentioned in table 3. this could be because there is no potential risk of cross-infection and that gloves are only used when there is a potential risk of cross-infection. only 30% of the respondents indicated that they always wore gloves. it is concerning that 36% of the respondents did not see the significance of wearing gloves when performing otoscopy. the number of respondents that indicated that they never wore gloves during otoacoustic emissions (oae) testing, immittance testing and hearing aid fitting is also of great concern as these procedures increase the risk of cross-infection from patient to patient, and patient to audiologist, and the other way round (kemp & bankaitis, 2000b). when comparing the results on impression taking with the results of burco (2007), less than 9% of the respondents used latex gloves during earmould impression procedures in both studies. this is a matter of concern as the earmould impressions removed from the ear canal can be contaminated with cerumen and other micro-organisms that may reside in the ear canal (bankaitis & kemp, 2002). these respondents increase the potential risk of cross-infection and spread of diseases which can occur when handling earmould impressions with bare hands. the results showed a decrease in the application of gloves when handling hearing aids from 39% in the burco (2007) study compared with 16% (n = 8) in this study. this decrease could possibly be attributed to respondents in this study not seeing hearing aids as potential carriers of infection. table 3: application of latex gloves. effective implementation of infection control measures also includes sterilisation of equipment and apparatus used during audiological practice. sterilisation is an effective measure of infection control as it kills 100% of the vegetative micro-organisms and endospores (bankaitis & kemp, 2005; saslha, 2011). the results showed that more than 60% (n = 30) of the respondents preferred to sterilise audiological equipment after each individual patient consultation. it is alarming that 34% (n = 17) of the respondents only sterilised equipment once a week. regardless of the reasons for irregular sterilisation of equipment, it remains in conflict with ethical and infection control guidelines which focus on putting patients first and practising in their best interest (saslha, 2011). implementation of effective infection control measures is crucial for any health profession, requiring professionals to adhere to the guidelines stipulated by saslha (2011). this study investigated and reported methods of minimising the spread of infections and infectious diseases in audiology practice; the results are presented in figure 2. figure 1: frequency of sterilising audiology equipment. figure 2: methods of minimising infectious disease in audiology practices. the majority (90%; n = 45) of respondents disinfected headphones in audiology clinical settings and cleaned the audiometer top. however, a few respondents did not see the significance of cleaning an audiometer. although cleaning removes gross contamination from an object or surface, it does not kill germs, but it is a precursor for sterilising and disinfecting (saslha, 2011). the results showed that 10% (n = 5) of the respondents did not disinfect headphones, and 64% (n = 32) did not dispose of insert earphones. this practice is hazardous to patients because it increases the chances of cross-infection from patient to patient. unfortunately, the question did not allow respondents to elaborate on the reason why they did not dispose of insert earphones or whether they re-used them or not. when insert earphones are used from patient to patient, it puts the patient at risk of contracting infections as micro-organisms may grow on the earphones, causing cross-infections. it is a well-known fact that some audiologists wash insert earphones with soap and water or products such as milton. this practice is not recommended, as the effectiveness of these products is reduced by blood and bodily fluids (bankaitis & kemp, 2005). disinfection is acceptable for items that are in contact with blood and infectious substances; such items should be disinfected before handling and immediately after use (bankaitis & kemp, 2005). the results for applied methods of minimising the spread of infections and infectious diseases specifically in components of mechanical instruments used in audiology practice are presented in figure 3. figure 3: method of minimising infectious disease. mechanical instruments in audiology usually comprise the equipment used during cerumen management, such as curettes and forceps. just over half of the respondents (54%; n=27) disinfected mechanical equipment. it is of great concern that 34% (n = 17) of respondents did not disinfect their mechanical equipment, which puts their patients at risk of cross-transmission of infectious diseases, as mentioned previously. there is a decrease from 45% (n = 32) to 32% (n=16) in the results when compared with the burco (2007) study. apart from audiological equipment, it is also important to disinfect objects such as office toys as they are often the cause of transferring infections (kemp & bankaitis, 2000a). the present study investigated the frequency of disinfecting objects and toys in audiology practices; the results are presented in figure 4. figure 4: frequency of disinfection of objects and toys in audiology practices. the results show that less than half of respondents disinfected touch surfaces and toys, and then only when there was visible contamination. although this figure is higher than that reported by burco (2007), it is not acceptable according to professional infection control guidelines (saslha, 2011). reception toys should be disinfected daily because children may put them in their mouth, and saliva is a fertile source of bacteria. other touch surfaces such as desks, magazine tables, chairs and door handles need to be disinfected regularly (kemp & bankaitis, 2000a). the responses from respondents in this study as well as that of burco (2007) indicate the need to also revise the professional code of ethics. professionals commit themselves to principles such as non-maleficence, trust and social responsibility; these should be considered key elements in audiology practice. conclusion and recommendations top ↑ although no previous findings related to south africa were available on audiology-specific infection control that could be used to compare the results, the present study assessed the current application of infection control measures in audiology practices in south africa. the results from this study also provided individual opinions of the infection control application measures, identified areas of concern and whether audiologists are in danger of cross-infection or causing cross-infection, and brought awareness to audiologists about the importance of applying measures to prevent infections. specific areas of infection control for future research were also identified.if audiologists are not alert regarding possible communicable diseases in their clinical settings, infection control measures will be compromised. in assisting such audiologists to effectively practice infection control, the following steps should be taken: (1) annual training and review of infection control, (2) cpd workshops on the topic of infection control, (3) adequate education and training during undergraduate studies, (4) every audiology clinical setting should have infection control guidelines, (5) audiologists should receive training on how to apply infection control measures to specific diseases such as tb and the h1n1 virus, (6) training on handling an exposure incidence, and (7) disposing of waste materials. as the practice of audiology and speech-language pathology involves and requires a notable degree of patient contact, patients and clinicians are exposed to an environment in which a variety of contaminated objects may come into direct or indirect contact with numerous patients. in the delivery of any health-related service, it is the health professional’s responsibility to ensure the safety of their patients. it is imperative that audiologists provide patients with diagnostic and treatment environments that are designed to minimise or eliminate potential transmission of disease. audiologists must be professionally and socially responsible by being diligent in their efforts to control the spread of infectious disease within the context of the entire clinical setting. indications for future research include repeating the study on a larger population so as to generalise the data to the entire field, to obtain statistical data on infection control practices in the field as a whole. it would also be of value to develop a training programme and evaluate its effect on audiologists. a study testing for micro-organisms on different audiological equipment could also be of value to increase audiologists’ awareness of the importance of infection control. acknowledgements top ↑ portia mpudi, solly ngwanathi, alfa nkuna and liepollo ntlhakana are thanked for their valuable contribution to the original study. competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions k.n. 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(2010). infection control with limited resources: why and how to make it possible. indian j med microbiol, 28 (1), 11–16. http://dx.doi.org/10.4103/0255-0857.58721 south african speech-language-hearing association (saslha). (2011). guidelines infection control: guidelines for speech-language therapists and audiologists regarding infection control. retrieved june 06, 2012, from http://www.saslha.co.za sturgulewski, s.k., bankaitis, a.u., klodd, d.a., & haberkamp, t. (2006). what’s still growing of your patients’ hearing aids? hearing journal, 59 , 45–48. http://dx.doi.org/10.1097/01.hj.0000285827.98823.87 world health organization (who). (2008). the global burden of disease: 2004 update. retrieved 02, november 2012, from http://www.who.int/evidence/bod/18%20july%202012 appendix top ↑ questionnaire part 1 questionnaire part 2 questionnaire part 3 abstract introduction materials and methods results discussion conclusion limitations and recommendations acknowledgements references appendix 1 about the author(s) nasim b. khan discipline of audiology, school of health sciences, university of kwazulu-natal, durban, south africa chenay r. charles discipline of audiology, school of health sciences, university of kwazulu-natal, durban, south africa naedene naidoo discipline of audiology, school of health sciences, university of kwazulu-natal, durban, south africa amanda nokubonga discipline of audiology, school of health sciences, university of kwazulu-natal, durban, south africa ndabenhle a. mkhwanazi discipline of audiology, school of health sciences, university of kwazulu-natal, durban, south africa hella m.t.e. moustache discipline of audiology, school of health sciences, university of kwazulu-natal, durban, south africa citation khan, n.b., charles, c.r., naidoo, n., nokubonga, a., mkhwanazi, n.a., & moustache, h.m.t.e. (2019). infection prevention and control measures in audiology practice within public healthcare facilities in kwazulu-natal province, south africa. south african journal of communication disorders, 66(1), a636. https://doi.org/10.4102/sajcd.v66i1.636 original research infection prevention and control measures in audiology practice within public healthcare facilities in kwazulu-natal province, south africa nasim b. khan, chenay r. charles, naedene naidoo, amanda nokubonga, ndabenhle a. mkhwanazi, hella m.t.e. moustache received: 09 apr. 2019; accepted: 08 oct. 2019; published: 02 dec. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: audiologists have a clinical and ethical responsibility to create a working environment, designed to reduce the potential for cross-contamination or transmission of infections. objectives: to describe the infection prevention and control (ipc) measures utilised and the opinions of audiologists and speech therapists, and audiologists (a/stas) towards ipc in public healthcare facilities in kwazulu-natal province, south africa. method: a quantitative, descriptive survey was utilised and entailed completing an online questionnaire. the cronbach’s alpha (0.82) indicated good internal consistency of the tool. forty-nine a/stas from 29 public healthcare facilities responded. results: most participants (82%) followed a generic department of health policy on ipc, while 67% alluded to a discipline-specific policy. participants had received training in infection control but indicated that further instruction was required for audiology-specific infection control procedures. only 57% indicated that they ‘sometimes’ wore gloves with every patient during direct clinical contact. an association between the healthcare facility level and the wearing of gloves was found to be statistically significant (p = 0.025). participants at regional and tertiary levels contended that gloves should be worn during most procedures versus those at district levels of care. while 96% washed their hands after each patient, only 76% washed their hands before each patient. twenty-nine per cent indicated that they only ‘sometimes’ wore masks when in contact with patients with communicable diseases. approximately one-third disinfected touch surfaces and toys, based on the clinician’s discretion. the majority (86%) of participants, however, always followed the correct protocol for medical waste disposal. despite training and the availability of policies, some practitioners displayed poor ipc practices in terms of universal precautions, personal protective equipment, handwashing and sterilisation. conclusion: further education, training and awareness related to appropriate ipc measures are recommended for audiologists. it is envisaged that this will lead to more effective ipc measures in audiology practice thereby reducing the risk of infection transmission. keywords: infection prevention; infection control; handwashing; universal precautions; personal protective equipment; waste management. introduction infection prevention and control (ipc) measures are defined as eliminating or minimising the potential spread of disease by consciously managing the clinical environment (bankaitis, 2005a). according to the world health organization (who), infectious diseases are the second leading cause of death, after heart diseases, worldwide (who, 2008). nosocomial infections or hospital acquired infections (hais) can result in prolonged hospital stays, increased mortality and morbidity, and an increased financial burden for the health sector (mahomed, mahomed, sturm, knight, & moodley, 2017). despite the limited literature and lack of intervention and impact studies, the clinical environment in patient care has widely been recognised as crucial for patient safety through proper ipc measures (peters et al., 2018). the scope of audiology has expanded over the years to include vestibular and balance testing, intraoperative monitoring and cerumen management; therefore, infection control is an area that has become increasingly important (burco, 2007). audiologists provide rehabilitative and diagnostic services that are required by patients who differ in various factors, including underlying disease, age and socio-economic status (ehlert & naude, 2014). healthy patients have a general resistance to infection, whereas neonatal intensive care unit (nicu) infants and the elderly, who also require audiology services, have lower resistance and may be more susceptible to infections. immunocompromised individuals with underlying diseases, that is, tuberculosis (tb), human immunodeficiency virus (hiv) and acquired immunodeficiency syndrome (aids), may present with a hearing loss because of the nature of the virus and exposure to antiretroviral treatment (burco, 2007). audiologists in clinical practice have a great degree of indirect and direct contact with patients during procedures to assess the auditory system (health professionals council of south africa [hpcsa], 2012). although the risk of hiv and aids transmission is remote, by conducting various procedures, including but not limited to, vestibular testing and intraoperative monitoring, audiologists may be exposed to bodily fluids and blood, thus increasing the risk of infection (burco, 2007). the majority of hais occur via the transmission of pathogens, especially by healthcare practitioners (hcps) who do not wash their hands after treating a patient or properly complying with hospital ipc measures (adegboye, zakari, ahmed, & olufemi, 2018). the hands of hcps are thus responsible for up to 50% – 70% of all hais and are the main vectors for spreading diseases (peters et al., 2018). according to the who, there were approximately 558 000 cases of multidrug-resistant (mdr) tb worldwide in 2017 (who, 2018). south africa has one of the world’s highest tb epidemics, which is driven by hiv (claassens et al., 2013; peters et al., 2018) and the second highest number of identified mdr tb cases after india (churchyard et al., 2014). its treatment includes a group of antibiotics termed aminoglycosides, which are ototoxic and target the cochlea vestibular system. managing individuals with tb requires the inclusion of the appropriate hcps, including audiologists, who are essential in monitoring the effects of ototoxic medication on hearing (khoza-shangase, 2013). a south african study by khoza-shangase and van rie (2017) conducted with 96 participants from an hiv and aids research unit indicated that, of those diagnosed with hiv and aids, 14% reported co-occurring vestibular symptoms and 69% reported experiencing co-occurring audiological symptoms. therefore, audiologists and speech therapists, and audiologists (a/stas) in a south african context have numerous contacts with patients with communicable diseases and should implement effective ipc practices when in contact with all patients (khoza-shangase & van rie, 2017), thus embracing universal precautions. in a study by alp, leblebicioglu, doganay and voss (2011) regarding infection control practices in countries with limited resources, a comparison was made between two countries, turkey and the netherlands, of different socio-economic statuses. the results indicated that the attitude of hcps in hospitals that were not well equipped affected the infection rate. alp et al.’s study findings correlated with peters et al.’s (2018) study that low salaries, inadequate facilities and limited infrastructure caused hcps to lose enthusiasm for their profession and thus do the bare minimum. therefore, this may have resulted in the incorrect implementation of ipc measures (alp et al., 2011; sahiledengle, gebresilassie, getahun, & hiko, 2018). the hpcsa recommends that general universal infection control measures need to be followed by all hcps, regarding hygiene and cleanliness (hpcsa, 2002). these routine precautions include: (1) washing hands before and after every patient; (2) wearing gloves when conducting an oral peripheral examination; (3) washing, wiping or soaking any non-disposable equipment, including toys, with sterilising solution, whenever used; and (4) the correct disposal of waste in appropriate waste disposal bags directly after use (hpcsa, 2002). this is reiterated by the south african speech-language hearing association (saslha) (2011) that indicates that hand hygiene, handwashing, the use of personal protective equipment (ppe) and cleaning or sterilising and disinfecting are essential procedures in audiology-specific infection control for minimising the spread of infectious diseases (saslha, 2011). similarities were noted in ehlert and naude’s (2014) and burco’s (2007) studies, which indicated that 84% of respondents from burco’s study and 82% from ehlert and naude’s study recognised the significance of handwashing. results from a study by archanalakshmi, stanly and paul (2015) revealed that when individuals worked for 30 h – 40 h, only 62% indicated that they would wash hands. however, only 22% of individuals who worked for 40 h – 50 h would wash hands. this indicates that when hcps work for longer hours, the chances of washing hands decrease (archanalakshmi et al., 2015). gloves can be used to reduce hand contamination from blood and other infectious agents, but cannot prevent injury from sharp objects or instruments. the risk of cross-contamination increases if gloves are not changed between patients or if they are contaminated with bodily fluids. their use is not a substitute for handwashing, therefore necessitating that hands be washed after the removal of gloves (who, 2001, 2004). according to the canadian association of speech, language pathologists and audiologists (caslpa, 2010), audiologists use and reuse clinical equipment across a wide range of patients. these consist of otoscope speculae, probes and headphones, which can be reused, but should be cleaned, disinfected and/or sterilised after each patient. cleaning eliminates gross contamination but does not remove germs from the objects or surfaces and should therefore be a precursor to disinfection and sterilisation (caslpa, 2010). results from ehlert and naude’s study indicated that 60% of respondents sterilised their audiological equipment after seeing each patient. less than 50% of respondents disinfected toys and touch surfaces, compared to burco’s study where approximately 40% disinfected, and would only do so if there was visible contamination, with the latter disinfection dictated by the audiologists’ discretion (burco, 2007; ehlert & naude, 2014). toys that are situated in the waiting area should also be disinfected daily, as children could insert them into their mouths, resulting in saliva on the toy, which is a source of bacteria (burco, 2007; ehlert & naude, 2014). thus, the significance of infection control regarding toys, audiological equipment and touch surfaces before and after patients should be emphasised, as this reduces the transmission of diseases and cross-contamination of microorganisms. correct waste disposal is a strategy used to prevent and minimise infections among hcps and community members, which is an essential infection control intervention (haifete, justus, & iita, 2016). if medical waste is not disposed of correctly, it can become an agent to increase the spread of diseases such as hiv and aids, hepatitis b and other communicable diseases, which may result in hcps, patients and even the community being affected (haifete et al., 2016). limited studies have been conducted in south africa in this area, despite the emerging burden of communicable or infectious diseases and the expanding scope of practice in audiology. in addition, audiologists working within the public sector face various resource limitations, which could have an impact on the ipc measures available. information obtained from the study will be used to make contextually appropriate recommendations for infection control measures and practices. materials and methods the main aim of the study was to determine the ipc measures utilised by a/stas in public healthcare facilities in kwazulu-natal (kzn). a secondary aim was to describe the opinions of a/stas towards ipc in public healthcare facilities in kzn province, south africa. the objectives of the study were to describe the ipc policies used, to describe the opinions of a/stas regarding the training received and training needed, to describe the a/stas’ handwashing practices, to determine the personal protective measures available and used by a/stas for ipc and to determine the opinions of a/stas regarding equipment management and waste disposal in public healthcare facilities in kzn, south africa. a quantitative, non-experimental, descriptive survey research design was used to obtain information from the 83 a/stas conveniently sampled from 39 public healthcare facilities in the 11 districts within kzn during 2017. a pilot study was conducted on 9 of the 83 a/stas, with the remaining 74 a/stas being the target group for the main study. responses were obtained from 59% (n = 49 people), this being from 29 out of 39 of the targeted public healthcare facilities. a questionnaire (appendix 1) was developed from the three studies conducted by amlani (1999), burco (2007) and ehlert and naude (2014) consisting of five sections (a–e) with 40 questions. the questionnaire included multiple-choice, closed, open-ended and contingency questions (leedy & ormrod, 2015). the a/stas were emailed the link to the google forms survey where an informed consent letter provided information about the research study, assurance of confidentiality and instructions for completing the questionnaire. after 10 working days, the researchers contacted the a/stas’ department at the various healthcare facilities to remind them to complete the questionnaire. one week later, an email reminder via google forms was sent to the a/stas’ departments, with a total of three reminders being sent to encourage them to complete the questionnaire in an effort to improve the response rate. the participants were given approximately 3 weeks to complete the questionnaire. prior to analysis of the data using the statistical package for social sciences (spss version 24), the researchers coded the results onto a microsoft excel spreadsheet for easy analysis. once all the data were collected, the results were transferred from excel to spss for analysis. descriptive statistics and inferential statistics (pearson’s chi-square test) were used. information obtained from the open-ended questions was used to report on the participants’ subjective data specifically regarding the implementation of ipc practices within public healthcare facilities in kzn. to ensure reliability and test the internal consistency of the study, the cronbach’s alpha was utilised, and revealed a score of 0.821, indicating good internal consistency of the tool (sirakaya-turk, uysal, hammitt, & vaske, 2017). the data collection tool was developed based on the findings of previous studies, and an extensive review of the literature was conducted to ensure its reliability and validity (amlani, 1999; burco, 2007; ehlert & naude, 2014). the content validity of the questionnaire was addressed through the pilot study with six qualified a/stas. they completed the forms online to test the process. in addition, they had to complete a pilot feedback form indicating the ease of administration, whether the questions were ambiguous, or whether the questions needed to be changed in any way to avoid misunderstanding that could lead participants in a particular direction, thereby creating bias. the changes suggested were implemented in the questionnaire prior to the main study. ethical considerations ethical approval was obtained from the humanities and social sciences research ethics committee at ukzn (ethical clearance number: hss/0377/017u). once approval had been obtained from the kzn provincial department of health and health district managers, the hospital and medical managers were contacted with a request for permission to conduct the study at the healthcare facilities. anonymity and confidentiality were maintained, as no names were recorded and the data collected were only available to the researchers, supervisor and statistician. participation in the study was voluntary and the participants were informed that they could withdraw from the study at any time. results demographic details participant demographics are summarised in table 1, with most being between the ages of 21–30 years, female, having a bachelor degree, with < 6 years’ experience. table 1: demographic information (n = 49). the results are presented according to the key objectives of the study as follows: to describe the infection prevention and control policies utilised by audiologists and speech therapists, and audiologists sixty-three per cent (n = 31) of participants had an audiology-specific ipc policy in place and the majority 82% (n = 40) stated that there was a department of health (doh) policy available. only 25 participants stipulated the type of policy with most 68% (n = 17), utilising the national doh’s ipc policy. table 2 provides information regarding the participants’ ipc policies used. table 2: summary of the infection prevention and control policies used by the participants. to describe the opinions of audiologists and speech therapists, and audiologists regarding the training received and training needed only 41% (n = 20) of participants received audiology-specific ipc training, with most rating their training as good or satisfactory. in an open-ended response, participants indicated that they would like more information regarding audiology-specific infection control, sterilisation and disinfection of instruments to be included in infection control training. participants also mentioned that they would like annual education and training sessions (such as workshops, short courses and literature) regarding audiology-specific infection control and that public healthcare facilities should have improved resources for proper implementation of ipc measures. table 3 provides information regarding training a/stas received and additional training needs. table 3: summary of the training the audiologists and speech therapists, and audiologists had received and additional training needs. to describe the handwashing practices of audiologists and speech therapists, and audiologists all of the participants reported that adequate hand hygiene is an essential part of infection control. the results indicated that 98% (n = 48) had access to alcohol-based hand rub, and 71% (n = 35) had a sink with running water, with the sink being < 50 m from their consultation area. participants washed their hands with water and soap (33%), hibitane solution (33%) or liquid hand wash (30%). table 4 illustrates the handwashing practices followed by participants within their working environment. interestingly, only 76% (n = 37) washed their hands prior to managing patients, while the majority 96% (n = 47) washed their hands after each patient. only 67% (n = 33) washed their hands after the removal of gloves. table 4: participants’ handwashing practices. to determine the personal protective measures available and used by the audiologists and speech therapists, and audiologists for infection prevention and control eighty-six per cent (n = 42) believed that their workplace had a high exposure to communicable diseases, while only 22% (n = 11) believed that their workplace had adequate ventilation for individuals with communicable diseases such as tb. seventy-one per cent (n = 35) indicated that masks should always be worn with patients with communicable diseases, while 29% (n = 14) felt that this was only necessary sometimes. more than half (57%, n = 28) reported wearing gloves sometimes with every patient, while 43% (n = 21) always wore them with every patient. an association between the level of the healthcare facility and the wearing of gloves was found to be statistically significant (p = 0.025) with more participants at regional and tertiary levels being of the opinion that gloves should be worn during most procedures versus those at district levels of care. table 5 indicates how often participants wore gloves during various audiological procedures. participants responded to a three-point likert scale (with options always, sometimes and never). table 5: use of gloves during audiological procedures. to determine the opinions of audiologists and speech therapists, and audiologists regarding equipment management and waste disposal in public healthcare facilities in kwazulu-natal, south africa all the participants (n = 49) contended that the otoscope specula should be disinfected and/or sterilised on a daily basis, while 94% (n = 46) and 98% (n = 48) indicated that immittance probe tips and headphones should be disinfected and/or sterilised on a daily basis. a few (14%, n = 7) believed that earmoulds used during hearing aid fittings should not be disinfected and/or sterilised. the majority of participants contended that otoscope specula, immittance probes, otoacoustic emission (oae) probes, headphones and insert earphones could expose them to infectious diseases, while 32% (n = 16) felt that this was not possible through distraction toys. only 6% (n = 3) believed that touch surfaces, such as countertops, armchair rests or counselling table surfaces, should be disinfected after each appointment. only 40% (n = 19) and 27% (n = 13) believed that touch surfaces and paediatric toys, respectively, should be disinfected as needed, based on the discretion of the clinician. figure 1 illustrates the frequency of participants’ responses in relation to the disinfection of paediatric toys and touch surfaces. figure 1: frequency of disinfecting paediatric toys and touch surfaces (n = 49). all the participants believed that medical waste should not be put in the same bin as general waste, and 80% (n = 39) indicated that hearing aid batteries should be disposed of separately from other waste. the majority (98%, n = 48) indicated that they had red medical waste disposal bins available (for infectious substances such as gloves and alcohol swabs) and 57% (n = 28) had the yellow medical waste disposal bins available (for sharps such as needles and syringes), while only 31% (n = 15) had the green medical waste disposal bins (for pharmaceuticals, i.e. expired medication) at their workplace (see figure 2). figure 2: medical waste disposal bins available at participants’ workplace (n = 49). discussion implementing effective infection control measures is essential for any hcp, with adherence to ipc guidelines being stipulated by employing bodies, regulatory bodies (hpcsa, 2002) and professional associations, such as saslha (saslha, 2011). it was encouraging to note that 67% of the participants had a discipline-specific infection control policy in their workplace, which correlated with results obtained from the study by burco (2007), who indicated that 61% of respondents had audiology-specific infection control plans in place. research findings from burco’s (2007) study indicated that nearly 60% of respondents received audiology-specific infection control training prior to employment, while results from the current research study indicated a lower percentage. it was of concern that some participants were unaware of discipline-specific policies in their workplace. results from the current study indicated that only 49% believed that paediatric toys should be disinfected after each appointment, while 27% indicated that they would disinfect ‘at the clinician’s discretion’. this correlated with results from ehlert and naude’s (2014) study, which indicated that less than half of the respondents disinfected touch surfaces and toys, and would only do so if there was visible contamination. therefore, participants may have been unwittingly transmitting disease, causing microbes from patient to patient by not adhering to proper infection control guidelines. education and training for hcps is essential on a regular basis to increase awareness about infection control policies and guidelines, and it results in improved adherence to these practices and measures, changes negative attitudes and promotes a safer environment (ojulong, mitonga, & iipinge, 2013; schellack, ismail, & babarinde, 2016). addis ababa and india are similar to other developing countries, such as south africa, where there are minimal efforts to prevent and control hais (sahiledengle et al., 2018). hand hygiene is the most effective, least costly and simplest method of decreasing the incidence of hais (mathur, 2011) but it is not recognised as such or appreciated by healthcare workers (ojulong et al., 2013). in healthcare, hands are another extremely mobile surface that are frequently contaminated and seldom disinfected (peters et al., 2018). all of the participants reported that adequate hand hygiene was an essential part of infection control. the most common handwashing method was washing hands with soap and water and using hibitane, with 33% of participants choosing either method. according to ehlert and naude (2014), hand sanitisers are an approved and effective method for hand hygiene, reported to be more effective than washing hands with soap and water. however, according to the who’s guidelines on hand hygiene in healthcare (who, 2006), based on evidence from several studies, antiseptic alcohol-based hand rubs demonstrated maximum efficacy in removing pathogens from the hands of healthcare workers. these may not be available in all contexts, given costs and cultural beliefs (for example, the islamic religious beliefs are against the use of alcohol for any purpose). it is thus recommended that currently utilised, commercially available hand rub and liquid soaps meet acceptable standards, as outlined in the guideline for ipc (who, 2006). almost a quarter of the participants indicated that they did not wash their hands before each patient, which was also a concern raised by ehlert and naude (2014); perhaps they believed that they cannot transmit infection to their patients. approximately one-third of the participants reported not washing hands after removing gloves. although only 67% of participants believed that it was necessary to wash hands after cerumen management, 88% of participants reported that they washed their hands after cerumen management. however, this is still concerning, as cerumen can be considered an infectious substance and may lead to opportunistic infections, such as methicillin-resistant staphylococcus aureus (mrsa) (kemp & bankaitis, 2000; patel, engelbrecht, mcdonald, morris, & smythe, 2016). universal precautions are the most effective and simple way of preventing infection in healthcare settings (who, 2001). these guidelines include using appropriate ppe or prophylactic measures, such as gloves, n-95 masks (respiratory hygiene), cough etiquette, hand hygiene, environmental cleanliness and waste management (fayaz et al., 2014; who, 2001). it was concerning that more than half of the participants only sometimes wore gloves with every patient, as a 2012 south african survey estimated 12.2% of the population to be living with hiv and aids (shisana et al., 2014). encouragingly, the majority (78%) of participants were of the opinion that gloves should be worn during routine procedures, such as otoscopy and immittance. one-third felt that gloves should be worn during earmould impression taking and hearing aid fitting, which correlated with results from the study by ehlert and naude (2014). these results are concerning as research by ahmad et al. (2007) indicated that earmoulds may harbour pathogenic microorganisms that can result in the development of chronic otitis externa such as staphylococci, bacteria and fungi (ahmad, etheridge, farrington, & baguley, 2007; bankaitis, 2005b). half the participants contended that hearing aids could not expose them to infectious diseases, these concerning findings being similar to bankaitis’s (2002) study, which reported staphylococcus bacterium on the surface of hearing aids, this being implicated in hais (bankaitis, 2002). this was supported in a study by sturgulewski, bankaitis, klodd and haberkamp (2006), where fungi, bacteria and even faecal matter were found on the surface of hearing aids. thus, hearing aids have been implicated as a source of microbial transmission and should be treated as a vector (sturgulewski et al., 2006). results from bankaitis (2005b) indicate that as alcohol does not kill bacteria or fungi, given the extent of reported microbial growth on hearing aid and earmould surfaces. audiologists and speech therapists, and audiologists should be made aware that the use of ppes is essential while handling hearing aids and all related accessories, as disinfection may be insufficient (bankaitis, 2005b). bankaitis and kemp (2010) suggest that ipc is not an arbitrary process and should be based on established guidelines and compliance thereof. it was concerning that almost half the participants (47%) indicated that they would only sometimes wear gloves during evoked potentials and vestibular testing; however, it was encouraging that an equal number indicated that they would always wear gloves. it was important to note that about a quarter of the participants from khoza-shangase and van rie’s study (2017) reported that they had diminished hearing sensitivity since being diagnosed with hiv and aids. this is further supported by the literature from heinze, swanepoel and hofmeyer (2011), in which reports of auditory and vestibular manifestations were identified in patients with hiv and aids (heinze et al., 2011), necessitating audiological services. results from the khoza-shangase and van rie study (2017) also found that patients with hiv and aids are prone to middle ear infections and otorrhoea, which are symptoms indicative of middle ear pathology, also present with co-occurring vestibular and audiologic symptoms. as the a/stas’ scope of practice has increased to include vestibular testing, a/stas need to be cognisant that some patients who have possible ear infections are likely to be immunocompromised, and that proper use of gloves and other ppes need to be used during all procedures to prevent the spread of opportunistic infections (khoza-shangase & van rie, 2017). many opportunistic infections can be prevented through correct implementation and compliance to evidence-based ipc measures. although researchers have highlighted the importance of universal precautions, few studies have examined audiologists’ infection control practices, despite the many challenges these hcps face in resource-limited settings (russell et al., 2018). the results from the current study indicated that 25% of the participants believed that masks should only be worn when they are in contact with an individual with a communicable disease. sahiledengle et al.’s (2018) study revealed that more than half (57.9%) of the hcps wore masks when in contact with a patient suspected of, or confirmed with having tb, with the results being slightly higher than a study previously conducted in the same city, which revealed that only 50.2% wore masks. however, microorganisms that cause communicable diseases cannot be seen with the naked eye and hcps would be unaware of the patients’ medical diagnosis (claassens et al., 2013), leaving them at risk for acquiring a communicable disease. the majority of the participants (86%) reported that their workplace had a high exposure to communicable diseases, which has nearly doubled from burco’s (2007) and amlani’s (1999) studies being 48% and 20%, respectively. seventy-eight per cent of the participants reported that their workplace did not have adequate ventilation, this being important for audiologists whose patients present with tb for ototoxic monitoring (claassens et al., 2013). encouragingly, results from the current research study indicated that all participants believed that otoscope speculae should be sterilised on a daily basis, which is an improvement from burco’s (2007) study, where 42% of respondents indicated that they sterilised and/or disinfected otoscope. research indicates that the practices of sterilisation and disinfection of audiological equipment have steadily improved over the years. in the current study, the participants did not believe that hearing aids or acrylic moulds could expose them or their patients to infectious disease, warranting further education and training (saslha, 2011). according to bankaitis and kemp (2002), whether attempting to obtain an earmould impression, using the earmould when doing a hearing aid fitting or removing the earmoulds from the patients ear (e.g. making adjustments to the hearing aid), it must be cleaned and handled with gloves. the earmould makes contact with the patient’s ear canal and can be contaminated with substances lining the ear canal with blood, cerumen or ear infection. it is therefore important to use a disinfectant spray on the hearing aid and earmould to minimise the risk of cross-infection. implementing effective ipc practices in the audiological environment also provides an opportunity for a/stas to educate their patients about proper hearing instrument hygiene, care and maintenance (bankaitis, 2002). equipment and surfaces that may be frequently touched are thought to provide the greatest risk for patients (dancer, 2009). in burco’s study, one-third of the participants did not believe that distraction toys could expose them to infectious disease (burco, 2007). the results regarding disinfecting at the clinician’s discretion correlated with burco’s (2007) findings, which indicated that 40% would only disinfect when there was visible contamination. paediatric toys and touch surfaces should be sterilised according to professional infection control guidelines and after each patient appointment to prevent cross-contamination (dancer, 2009). research regarding audiology-specific waste disposal methods is minimal, and according to universal precautions and infection control guidelines, infectious waste should be disposed of appropriately (saslha, 2011). it was encouraging to note that all the participants believed that medical and other waste should be disposed of separately, as medical waste can cause the possible spread of disease if it is not disposed of properly. fourteen per cent of the participants believed they should only ‘sometimes’ follow the correct medical waste disposal methods, which may have been because of their not having the correct medical waste disposal bins available. this correlated with results from the current study, which indicated that 35% of the participants did not have the yellow and 55% did not have the green medical waste disposal bins in their workplace. conclusion the study aimed to determine the ipc measures and opinions of a/stas in public healthcare facilities in the kzn province, south africa. the self-reported findings suggest variable practices and mixed opinions about ipc practices. despite training and the availability of policies, some participants displayed poor adherence to standard ipc practices, while others indicated the non-availability of policies and/or discipline-specific training. this suggests that audiology clinics need to be equipped with adequate discipline-specific policies, and that a/stas be trained on ipc issues relevant to their practice. hand hygiene is a cost-effective intervention that should be practiced before and after patients, even if gloves were worn. poor compliance to ipc measures may stem from a deficit in the knowledge and/or attitudes, including perceived barriers such as lack of time, patient and hcp discomfort, lack of resources (ppe) and the sense that protective equipment interferes with work performance. an effective infection control programme depends largely on the personnel responsible for its implementation, there has to be a mechanism in place for monitoring. information, education, training, guidelines and effective practices are essential to break the cycle of inadequate infection control. ultimately, it is the audiologist’s responsibility to ensure that effective ipc measures are routinely adhered to in clinical practice. limitations and recommendations a small sample size limited the generalisability of the study to hcps, as it was only conducted in public healthcare facilities in kzn. information bias may have occurred as participants may not have taken time to consider each question, but may rather have completed the questionnaires quickly. the compliance with ipc was based on reported practices of audiologists and not those directly observed by the researchers, which could have resulted in them providing answers that they thought more appropriate, thus introducing social desirability bias. the researchers could have probed more about the barriers to ipc practices that would have been useful when suggesting further clinical and research implications. increasing the awareness of the importance of ipc within healthcare facilities will help motivate hcps to implement adequate measures throughout their clinical practice and ensure compliance. healthcare practitioners could also counsel their patients about the proper cleaning and disinfecting of their hearing instruments. future research could venture into a more in-depth investigation and consideration of the real environment of audiological practice in public hospitals for more meaningful recommendations to be made. the effectiveness of ipc measures in audiology needs further investigation. the profession needs to advocate for ipc resources to decrease the risk of infections and cross-contamination in healthcare facilities. acknowledgements the authors would like to thank the participants of the study for their contributions. competing interests the authors declare that there is no conflict of interest regarding the publication of this article. authors’ contributions n.b.k., c.r.c. and n.n. contributed equally to the write-up of the article. c.r.c., a.n., n.a.m., h.m.t.e.m. and n.n. contributed to the undergraduate research proposal development, data collection and research project. n.b.k. did the supervision. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references adegboye, m.b., zakari, s., ahmed, b.a., & olufem, g.h. 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(2018). global tuberculosis report 2018. retrieved from https://www.who.int/tb/publications/global_report/en/.france appendix 1 questionnaire section a: demographical information (please circle or tick the option(s) that fit best) section b: infection prevention and control policies and training if you answered yes to the above question, please answer the question below. section c: handwashing (if you answered yes to the above question, please answer the question below) section d: personal protective measures (please tick the option[s] that fit best) (if you answered ‘yes’ to the above question, please answer the question below) section e: management of equipment and waste disposal (please tick the option[s] that fit best) thank you for your time and participation. 28. case study 0? dyslexia. by theima stoer. extract from thesis presented for the degree of master of arts in logopedics to the university of the witwatersrand. reading in itself is a complex activity requiring a number of interlinked skills. briefly, according to buckhardt, bond and bond,and colo, these consist of: 1. a vocabulary ability in which the individual must be able to acquire an increasing vocabulary by understanding the meanings of words and to unlock or work out long and incomprehensible appearing words. 11. perception, or visual acuity in reading. tho minimum requirement being a sharp and accurate discrimination of the differences between the shapes and configuration of the visual symbols of letters,words and phrases. 111. comprehension, or conception of what .is being read. this factor is a very necessary adjunct,for the mere mechanics of reading are of no use whatsoever if there is no understanding. not infrequently, the speech therapist comes across dyslexic, or reading disability cases.· quite often they show ono or several characteristics upon examination. briefly, these may be: 1. psychological, such as hyperemotionality, poor attention, too high a level of attainment, rivalry with siblings, etc. 11. educational factors which seem to be the main causes of the difficulty and are mainly due to failures to acquire the right techniques that might have been acquired had the right guidance been given at the time. 111. neurological characteristics in which,according to orton and dearborn, there is a confusion or conflict in cerebral dominance, and is more, likely to appear when people are neither definitely left nor right handed. finally there may also be physical factors such as poor auditory conditions, such as hard of hearing, and/or definite weakness of auditory discrimination. defects of vision and/or lack of visual acuity may also be another characteristic. an interesting case which was recently treated by the writer showed several of these characteristics, the details and treatment of which, are as follows: female. age 15 years. duration of therapy: 12 months. history of difficulty: ' this case was referred as being in need of treatment, because, although ' she managed to keep up to grade in all her work, she was a complete nonreader with a phenomenal auditory memory. she was able to repeat accurately word for word, lengthy material which had been read out to her, and by this means was able to do all hey learning work, and to hide her disability for r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 29. such a long time. even her essays, which were excellent, were dictated. • condition prior to therapy: i. psychological picture; this case was emotionally unstable. according to her mother she had had a "nervous breakdown" at tho age of two years due to some obscure reason. she was very restless, complaining that she couldn't sleep at night duo to terrifying nightmares. her great lack of concentration was very apparent during the interview and in the test situations. ii. educational' picture: arithmetic and mathematical ability, spelling and composition were excellent. writing was untidy and at times incomprehensible. examination of reading ability factors: a. reading attainments: word recognition was entirely nil. case had not the slightest idea of the visual appearance of the words, but made wild guesses. she burst into tears during the attempt. silent reading was" non existent, and the oral reading consisted of making up the story. this was highly imaginative, but had nothing to do with the context. b. comprehension: nil. c. technique of word attack. nil. d. perceptual orientation. this was very interesting. there were 'no eyo movements, as the girl did not even attempt to look at the reading material. she fixated on one part of the paper, and stared through a haze of tears. e. visual perception. there was not the slightest response to this test, even the names, capitals, and lower case letters were not known, f. audit oryperception. she could respond accuratoly to any auditory cue. thus the cue of "b" r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30. sounded out led to her response of "boy",""baby". spelling was excellent and words spelled out to her were recognised as a gestalt. she could repeat a full page of material five minutes after it had been read to her. it was interesting to note that she was word perfect. 111. neurological: there had always been left handed tendencies with an inability to use the right hand correctly. 17. former method of teaching: apparently this had been mainly the "look and say" method to begin with, and the teachers * complete repetoire of teaching methods was attempted with hopeless results. conclusions: this girl was definitely an audile typo, tho auditory cue being tho sole lead for tho learning and memory processes. thi3 explained the good spelling and recognition of spelt words and the excellent dictated essays. although her sight was normal there was no visual discrimination or perceptual ability whatsoever, and it seemed possible that this was compensated for to some 'extent by her amazing auditory memory. probably her lack of reading ability was closely related to her extreme emotionality, as she seemed to be outstanding in other school subjects. it is possible that some of the tests which she would not attempt, frightened her. principles and techniques of therapy: the child's amazing auditory memory would probably be a handicap to her in developing visual cues and this one factor would be very important to bear in mind. it seemed impractical to devise any therapy based on a visual approach, so a kineasthetic method was used. visual recognition: the visual symbols were always correctly written in a word but as she found it impossible to recognise that word afterwards, a variation of the fernald-keller method was tried. first certain signs were presented, and she was asked to trace over them with her finger several times until she had learned the "feel" of them. when this was achieved after a number of weeks, the signs were presented in duplicate, and she was asked to match them, drawing over them again if she was not sure. then this was done with the individual letters, carefully going through the whole alphabet, until the girl had learnt to match them accurately. next this was done without tracing. this seemed at first impossible to achieve, but finally after many failures, she was able to call out the sounds and names of the letters presented. slowly the various phonograms were worked r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 31. through in this way, until eventually simple words were introduced. in order to consolidate what she had learnt up to now, word matching games vaere used. lists of many words were compiled, and she had to choose certain words in a list and find their counterparts either in the same list, or elsewhero. at first it took her an hour and a half to match twenty words correctly, always tracing,'when she was doubtful, but she improved to such an extent until she could match a hundred words in fifteen minutes. formal heading and 'comprehension. in this way, a fairly good sight vocabulary was obtained, and her emô tional roaponse to this situation became moro stable. it was therefore possible to begin formal reading, with the use of tho gates-hubor reading work books. these consist of simplo instructions in cutting out, colouring and exercises; sho enjoyed thorn immensely, and worked through the several in a few weeks, thus bringing her reading to a higher grade. as she evinced a desire to read some fairy tales, and brought a book of these along with her, questions concerning these were given for home assignments which sho completed. technique of word attack. as there was difficulty in word attack, several techniques were taught with little success. these were word recognition, (from the look and say method), phonetic blending,which strangely enough proved futile, and tracing, which although fairly useful, was not always successful. finally it was decided to let her spell the words out, first orally, and then, if there was any improvement, silently. this was in instantaneous success, especially when used in conjunction with other methods, and reading seemed to progress rapidly. it was surprising to see how quickly she could attack a word byspelling, and often the pauses in the oral reading were very slight. when sho came across new words which were not included in her vocabulary, she attempted to work them out by a process of tracing and sounding, and met with a very fair measure of success. with the improvement in oral reading, speed in silent reading was now aimed at, with special reference to accuracy of comprehension. this was slow at first but soon she was able to read any story or book, results of therapy. although the progress was so very slow, it was definite, and good reading habits wore established. at first tho early attompts at reading showed reversals and poor eye movements, which however wore remedied by the use of tho slit card. another difficulty was that she recognised individual words and wove a story around these, ignoring the context completely. this was deceptive to the listener who was not aware of tho contents of tho story, and she burst into tears when this tendency was pointed out to her. it ceased whon r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32. word, perception improved. re-examination of reading ability factors. reading attainments: word, sentence and paragraph recognition was good. oral reading was satisfactory, and to a lesser extent, silent reading. this probably indicates that the auditory cue was still highly influential. comprehension: when the reading was of an oral type this was excellent, but mediocre during silent reading. techniques of word attack: three techniques which were useful when used in combination with each other were used. visual recognition in which tho shape and configuration of the words were studied, was first attempted, if this failed the word was spelled, and finally, if there was still no success, tracing and blending followed. at this point it is interesting to observe that she used lip movements during the study of a word. this was not corrected as it appeared to assist in the working out of a word. visual perception: ο this had definitely developed as seen by the process made here. it had often to be assisted by the kineasthetic method even after the case had learned to read fairly well. words however could bo satisfactorily broken into component elements. this case was one of the most difficult problems that the writer had over tackled. progress was slow and many times disheartening, and it was only duo to continual motivation that she persevered. there was no doubt that tho auditory cue was so dominant that it interfered with the development of the other cues necessary for learning. references: 1. buckhardt, k.h. ' "an analysis of reading ability" 2. bond & bond,g.l.&e. teaching the child to read 3. cole, l, ι 4. dearborn, w.f. 5. orton, s.t. the improvement of reading with reference to remedial instruction. "ocular & manual dominance in dyslexia", reading, writing, and speech problems in children journal of educational research. feb. 1945, macmillan. 1943, farrar & rinehart, 1941, psychological bulletin. xxviii. november, 1931. w.w. norton co. 1936, r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 66 sajcd • vol 57 • december 2010 children with speech difficulties: an exploratory survey of clinical practice in the western cape michelle pascoe zinhle maphalala aeysha ebrahim daneil hime bathobile mdladla nerosha mohamed mandy skinner division of communication sciences and disorders, faculty of health sciences, university of cape town correspondence to: m pascoe (michelle.pascoe@uct.ac.za) children with speech difficulties typically constitute a large proportion of speech language therapists’ (slts’) caseloads. while the prevalence of speech difficulties in south africa is not yet known, prevalence estimates from the usa show that approximately 7.5% of children between 3 and 11 years of age experience speech difficulties that are clinically significant (ruscello, 2008). in the uk, approximately 48 000 children are referred with speech difficulties each year (broomfield & dodd, 2004); these speech difficulties are described as being of a primary nature, not secondary to a known aetiology such as hearing impairment or cleft palate. the term ‘speech difficulties’ refers to any difficulty that affects the speech processing system and results in reduced intelligibility (pascoe, stackhouse & wells, 2006). the population of children with speech difficulties is a heterogeneous one. some children experience peripheral speech problems, e.g. articulation or structural-based difficulties; some have difficulties with auditory input processing (e.g. auditory discrimination), and others with stored phonological representations or a combination of these (stackhouse & wells, 1997). in addition to the nature of the difficulties, the degree of difficulty may vary from mild, affecting a small subset of speech sounds, to more widespread involvement of the phonological/linguistic system (dodd, 2005). in the present study, the term ‘speech difficulties’ is used to include all difficulties of speech processing and production of a primary nature (following dodd, 2005; stackhouse & wells, 1997). a range of perspectives are adopted by slts to deal with the variation of the population: psycholinguistic, linguistic and medical approaches. the psycholinguistic approach attempts to understand a child’s difficulties by examining their strengths and weaknesses, as well as pinpointing the underlying breakdown (stackhouse & wells, 1997). for example, stackhouse, pascoe and gardner (2006) investigated a child’s speech and literacy development by focusing on speech input, output and phonological representations. these underlying speech processing skills are necessary not only for speech development but also for phonological awareness, the bridge that links speech and literacy development in hearing populations. a breakdown at any one of these levels will not only result in spoken language difficulties but may also lead to written language difficulties (stackhouse & wells, 1997). the linguistic approach categorises children in terms of their observed speech behaviours, e.g. children with phonological processes may be observed to use ‘fronting’ and ‘stopping’ irrespective of the reason causing the process or particular features affected (grunwell, 1985). the linguistic approach can be useful as it may give detailed information regarding the child’s phonological system and speech output that should be targeted to achieve more intelligible speech. dodd (2005) describes a differential diagnostic approach to understanding speech sound difficulties whereby all children are classified into one of five categories based on the observed nature of their difficulties: phonological disorder (inconsistent); phonological disorder (consistent); phonological delay; articulation difficulty; or childhood apraxia of speech (cas). in contrast, the medical approach to speech difficulties centres around specific medical diagnoses and the typically observed cluster of signs associated with particular disorders (stackhouse & wells, 1997). this approach does not focus on the individual strengths and weaknesses of a child, or on the observed patterns of speech and language use, but rather aims to group children who present with similar and fairly broadly defined difficulties (e.g. inconsistent speech, prosodic difficulties, general clumsiness) under one label. the advantage of the medical approach is that diagnostic labelling facilitates communication between professionals and can be helpful in managing causal factors, e.g. hearing loss (stackhouse & wells, 1997). however, being able to fit a child into a specific group does not always equate to a ready-made therapy plan and children diagnosed with similar speech difficulties (e.g. cas) are very likely to require different therapy approaches. the literature shows that children with similar speech difficulties can have different underlying problems, and it can therefore be a challenge for slts to select an appropriate approach based on available evidence. clearly the frameworks that a therapist uses to understand speech difficulties will be reflected in his/her choice of assessment and therapy methods. abstract this study investigated the methods of assessment and intervention used by speech-language therapists (slts) in the western cape when working with children with speech difficulties. children with speech difficulties are likely to form a considerable part of slt caseloads in south africa, but assessment choice may not be clear-cut given the linguistic diversity of the region and that few assessments have been developed specifically for the sa population. selection of intervention approaches may also pose difficulties, linked to the lack of assessments and the limited evidence base in our context. a questionnaire was sent to slts working with preand/ or primary-school-aged children. twenty-nine clinicians responded (18.7% response rate). the majority (89%) use informal assessment in combination with formal assessment. when using formal assessments, more than 50% of slts surveyed make procedural or linguistic modifications. participants used a variety of interventions such as auditory discrimination and phonological awareness, often in combination, and based on a child’s profile of difficulties. forty-six per cent of slts felt unsure about the selection of assessments and intervention for bi/multilingual children. clinical implications arising from this preliminary investigation are discussed together with some suggestions for developing knowledge of children’s speech difficulties in south africa. keywords: articulation, assessment, clinical practice, intervention, phonology, speech difficulties vol 57 • december 2010 • sajcd 67 children with speech difficulties the identification and management of speech difficulties in children is important because such difficulties can result in communication problems for the child. in addition, speech difficulties may place children at increased risk of experiencing psychosocial difficulties such as being ignored by peers or bullied (nash, stengelhofen & brown, 2002). a large body of evidence suggests that speech disorders may affect preliteracy and literacy skills (reilly, douglas & oates, 2004). bird, bishop and freeman (1995) conducted a study which indicated that children with speech problems had difficulty with phonological awareness and experienced significant literacy problems, most notably with spelling, when compared with typically developing children of the same chronological age without any speech difficulties. children who have not been treated by the time they begin formal schooling, roughly at a chronological age of 6 years, can be at greater risk of developing literacy difficulties which can in turn result in poor academic achievement. the type of speech difficulties that have been linked to such negative outcomes are thought to be phonologically based difficulties rather than articulation difficulties. joffe and pring (2008) carried out a survey of 98 slts working with children with phonological difficulties in the uk. while the title of the study describes ‘phonological problems’, their questionnaire included questions about both articulation and phonology as well as cas. joffe and pring aimed to move beyond anecdotal evidence about how slts manage such children and describe the assessments and interventions carried out in that context. british slts favoured the south tyneside assessment of phonology (stap) (armstrong & ainley, 1988), an easily administered screening tool to assess children’s speech, but faced difficulties in distinguishing between phonological disorder and cas. most slts used a combination of interventions, with minimal-pair therapy, auditory discrimination and phonological awareness therapy being particularly popular (joffe & pring, 2008). the literature on children’s speech difficulties strongly suggests that children with speech disorders benefit from appropriately administered intervention (bowen, 2009; reilly et al., 2004), and there are a range of effective treatment methods available for facilitating a change in children’s sound systems (see williams, mcleod & mccauley, 2010 for a review). in terms of phonology, these include minimal-pair approaches (e.g. gierut, 1990; weiner, 1981); core vocabulary (e.g. dodd, 2005) and phonological awareness approaches (e.g. gillon, 2000), which have been shown to be effective. therapy aimed at addressing articulation difficulties is also purported to have positive outcomes (bowen, 2009), while interventions for motor-speech difficulties such as cas and dysarthria have had more variable outcomes (see williams et al., 2010). the great majority of intervention studies focusing on children’s speech have been carried out in developed nations; to date there is a paucity of information about the effectiveness of intervention for children with speech difficulties in the south african context. speech difficulties in south african children south africa is a country rich in linguistic diversity, with eleven official languages. in the western cape, the main languages spoken are afrikaans, isixhosa and english. relatively little is known about the acquisition of south african english or afrikaans phonology, and even less about isixhosa. while there is a substantial amount of research surrounding children’s speech sound acquisition in english (e.g. grunwell, 1985; dodd, 2005), most of this has been conducted with children in europe, north america or australia. gxilishe (2004) conducted a study in the western cape, looking at the acquisition of clicks by xhosa-speaking children. he found that at the onset of speech (approximately 1 year of age) xhosa-speaking children begin using three basic clicks. such studies are important in advancing our knowledge of speech and language development in the local context; however, further research is needed. in south africa monolingualism is rare. most children presenting with speech difficulties will be bilingual or multilingual. this results in significant challenges in the provision of assessment and intervention services, especially as the vast majority of south african slts are currently english or afrikaans-speaking. goldstein and fabiano (2006) state that the difficulty in treating these children is caused by the lack of understanding of theories of bilingual phonological representation and the lack of knowledge of current best practices related to the assessment of and intervention for biand multilingual children. children with speech difficulties are likely to form a considerable part of slt caseloads in south africa – if prevalence estimates from other countries are anything to go by (broomfield & dodd, 2004; ruscello, 2008) – but the choice of assessments may not be straightforward, given the linguistic diversity of the region and the fact that few assessments have been developed specifically for the sa population. carter, lees, murira, gona, neville and newton (2004) emphasise the need to develop culturally appropriate materials because of cultural variation and potential cultural bias. in their kenyan-based study they found that very few clinicians assess or treat children from a culture different to their own. the vast majority of slts working in south africa today are englishor afrikaans-speaking whites, and as a result speakers of the indigenous languages (e.g. isixhosa and isizulu) have typically been under-served. this study reports an exploratory survey of slts in the western cape working with children with speech difficulties. current knowledge of clinical practice in the western cape, (as in the uk, joffe & pring, 2008) is largely anecdotal and therefore the study aimed to find more reliable evidence about the assessment and therapies currently being used. slts’ current experiences of working with children with speech difficulties were investigated with a view to using this information as a starting point to understanding the needs of clinicians in the region in terms of the knowledge needed, and assessment and intervention materials required. methodology aim the aim was to investigate the clinical practice of slts in the western cape working with children with speech difficulties. objectives 1. to contextualise the general nature of the clinical practice of slts in the western cape working with children with speech difficulties. 2. to describe the assessment methods used by slts in the western cape working with children with speech difficulties. 3. to describe the intervention approaches used by slts in the western cape working with children with speech difficulties. research design a descriptive, questionnaire-based survey design was used. a questionnaire was sent to slts working with preand/or primary-schoolaged children to investigate their experiences of working with children with speech difficulties. survey research is commonly used as a means of collecting information about certain characteristics and practices in order to use it for descriptive purposes and has been widely used to study professional and clinical issues in the field of communication disorders (maxwell & satake, 2006). the study was exploratory: it was used as a starting point to investigate issues relating to speech development and difficulties in a multilingual context. exploratory research is typically used when research is in a preliminary stage and definitive conclusions arising from it are rare (maxwell & satake, 2006). participants selection criteria participants were slts registered with the health professions council of south africa (hpcsa). these slts had to be currently working in the western cape with preand/or primary-school-aged children. the total population was estimated at 155. researchers attempted to gather data from the entire population. those who responded to the questionnaire formed the sample for this study. such convenience sampling targets individuals who are readily available to form a participant group and is often used for exploratory research (maxwell & satake, 2006). 68 sajcd • vol 57 • december 2010 children with speech difficulties description of materials the questionnaire used (appendix a) was based on that of joffe and pring (2008), but adapted for the purpose of this study in two ways: (i) the conceptualisation of speech difficulties followed the psycholinguistic perspective of stackhouse and wells (1997) rather than being limited only to phonological difficulties; and (ii) the developing nature of the south african context and the linguistic diversity of the region was explored as it relates to children with speech difficulties. the questionnaire consisted of: (i) open-ended questions, where the participants were encouraged to provide their own responses; and (ii) closed questions, where the participants were required to choose an option. the three objectives covered included: (i) general questions about clinical practice; (ii) questions related to the methods of assessment; and (iii) questions related to the methods of intervention used by slts in the western cape. in section a participants were asked about their clinical experience and work setting, their own languages and those of their clients. in section b they were asked about the assessments used, including languages of assessment, challenges associated with assessment and theoretical frameworks that may help identify, assess and diagnose speech difficulties. section c focused firstly on intervention for children with speech difficulties, and then, following joffe and pring (2008), listed questions about specific therapies for speech difficulties that have been documented in the literature. questions were also included in this section regarding knowledge of the evidence base related to intervention for speech difficulties, and challenges in the south african context. pilot the questionnaire was given to one slt for completion, prior to the final mailing. although a larger pilot sample would have been preferable, one pilot participant was all that was practical in a short time frame and from a relatively small population in this preliminary study. this slt was asked to provide feedback on the covering letter, length of time taken to complete the questionnaire and the clarity of the questions. a few questions were reworded for improved clarity. the length of the questionnaire was acceptable and was therefore not adjusted. procedures slts currently registered with the hpcsa and practising in the western cape were identified via mailing lists and databases from special interest groups, the south african speech language and hearing association (saslha), private practice organisations and through personal contacts. the questionnaire was sent to all slts via electronic mail and by post on request. one hundred and fifty-five questionnaires were sent out to slts in the western cape. participants were given 2 months to respond to the questionnaire and electronic reminders were sent 3 weeks after the mailing of the first questionnaire. ethical considerations the study received ethical approval from the university of cape town research ethics committee. a covering letter containing information about the purpose of the study was included with the questionnaire. all slts who read the letter and sent back the completed questionnaire within the given timeframe were assumed to have given informed consent to participate in the study. analysis when completed questionnaires were received, identifying information was removed and a numerical code was assigned in order to ensure anonymity. data were entered into a microsoft excel spreadsheet. the first step of analysis was calculating the response rate, carried out as suggested by maxwell and satake (2006). the data were then quantitatively analysed using descriptive statistical analysis, and qualitatively analysed by summarising key themes/trends. results one hundred and fifty-five questionnaires were sent out to slts in the western cape. twenty-nine completed questionnaires (18.7%) were returned. this is a low response rate, and the results should be interpreted with caution because respondents may be fundamentally different (i.e. more interested in research, more willing to engage with issues of linguistic diversity) from non-respondents. the low response rate may also suggest that many of the slts in the region are not in fact working directly with the population of children with speech difficulties; the nature of slt work in a developing context may mean that speech difficulties are not regarded as a priority. nevertheless, despite the low response rate, the data were considered important given the exploratory nature of the study. of the 29 questionnaires received, 28 were included (96.5%). one participant did not meet the criteria as s/he did not work with children. general nature of clinical practice participants were divided into three groups: inexperienced therapists (from 1 to 3 years’ working experience; n=6; 22%), experienced therapists (4 10 years’ working experience; n=9; 32%), and very experienced therapists (more than 10 years’ working experience; n=13; 46%). participants practise in a variety of settings: 8 (29%) work in independent practice, 5 (18%) work in government hospitals, 4 (14%) work in government schools and 1 works in an independent school. the remainder of the participants (n=10; 36%) work in a combination of these settings, as well as universities, private hospitals and nongovernmental organisations. the majority of participants (n=19, 68%) speak english and afrikaans; 5 participants (18%) speak english only; 2 participants (7%) speak english, afrikaans and german; 1 participant (4%) speaks english, afrikaans and isixhosa; and 1 participant (4%) speaks english and german. figure 1 summarises these language data. the majority (54%, n=15) work with multilingual children who speak english, afrikaans and isixhosa; 21% (n=6) work with english-speaking children only and 18% (n=5) work with children who speak english and afrikaans. twenty-eight per cent of participants (n=9) reported that they would always assess and give therapy using a child’s home language, but many of these slts who emphasised home language were therapists who were either only working with monolingual children, or were bilingual english/afrikaans speakers themselves who would then offer treatment in either language, depending on the home language of the child. focusing on the 15 respondents who work with multilingual (english, afrikaans and isixhosa) children, only 6 (40%) said that they would always assess and treat in the child’s home language – whether it was english, afrikaans or isixhosa. one of these slts was able to speak isixhosa, and the other 5 mentioned that they would work through interpreters, parents or colleagues. the majority (60%, n=9) of those slts working with multilingual children will assess and manage those children in english (or in some cases english or afrikaans) only. for the majority of the participants (36%; n=10) between 40% and 70% of the children they see have speech difficulties, a substantial proportion of their caseloads. 1 fig. 1. languages spoken by participants. fig. 1. languages spoken by participants. vol 57 • december 2010 • sajcd 69 children with speech difficulties twenty-five per cent (n=7) of the participants rated themselves very confident or confident about selection of assessments and providing therapy to a child who speaks another language to their own; 29% (n=8) rated themselves as neutral in this regard; 46% (n=13) rated themselves as not confident/not confident at all. figure 2 shows these data. among the participants who rated themselves confident or very confident, no specific pattern was identified in relation to their level of experience. however, it was found that of the 13 participants that rated themselves not very confident or not confident at all, 10 were very experienced (having practised for more than 10 years). assessment ten different formal assessments are used to assess children’s speech. the goldman-fristoe articulation test (gfta) (goldman & fristoe, 1986) was the most popular with 32% (n=9) using it. other assessments that were commonly used include: the assessment component of the nuffield centre dyspraxia programme (williams & stephens, 2004) used by 14% (n=4) of the therapists, and the edinburgh articulation test (anthony, bogle, ingram, & mcisaac, 1971) used by 10% (n=3) of the therapists. other assessments mentioned included the phonological awareness test (robertson & salter, 1995) and the test of auditory perceptual skills (gardner, 1996). these results are shown in figure 3. all of the assessments have been standardised on, or have been developed for use with, english-speaking monolingual populations, mainly in the uk and north america. eighty-nine per cent (n=25) use informal assessment tools in addition to the formal assessments described. more than 50% of slts (n=14) indicated that they make adaptations to formal tests to better suit the south african population, e.g. translating the assessment into another language and using more culturally appropriate material (e.g. pictures and objects). for example, one slt reported that ‘i have included “taxi” in my … assessment – more culturally appropriate than “underground”.’ it was also noted that slts often change the administration method of tests; they often repeat instructions to encourage the child to respond: ‘i explain the test differently or leave out sections.’ many of the standardised tests were being used as a set of picture stimuli to elicit speech, which was then qualitatively analysed and interpreted rather than following the prescribed scoring and analysis procedures. the same set of pictures was sometimes used to elicit words in a variety of languages. many of the slts (n=10; 36%) elicit connected speech by story-telling and have made their own assessments. typically these were described as sets of pictures that contain all the consonants of a given language, mostly for english and afrikaans, although in a small number of cases (n=2) participants mentioned a set of screening pictures for eliciting some isixhosa speech sounds. one of the participants gave some detail of the materials used in her own test: ‘… 63 flash cards, targeting speech sounds [of english ]... pictures are stickers of real items in colour and are of objects and items they should be familiar with.’ another participant stated ‘i use picture cards, objects, play, history from parents, etc.’ one of the participants attached a speech assessment s/he developed while an undergraduate student. the assessment contained pictures that could be used to elicit all the speech sounds of the english language and with pictures specifically selected for the south african context. the therapists who indicated that they had made their own speech tests all speak more than one language and treat children who speak more than one language themselves, but materials were developed mostly for english and afrikaans speakers, and very few for isixhosa speakers. participants were asked whether they would find an assessment useful if it could be used in all three predominant languages of the region. the majority of the participants, (72%, n=20) agreed that they would find it helpful. the remaining participants (29%, n 8) said they would not find such an assessment useful for various reasons (their caseloads only comprised english-speaking children or they only felt confident in assessing and treating children in english). participants were asked to specify which additional materials they would find helpful when assessing a child’s speech. these included accepted variations of speech sound production in the western cape and south africa as well as standard norms, clinical judgement frameworks to assist in the judgement of disordered or delayed profiles, modern colourful pictures, pictures and objects for special populations, photograph-based tests with matching objects and a list of phonological processes in more languages. the slts were asked about their frameworks or approaches to understanding children with speech difficulties. the majority (68%; n=19) use developmental approaches together with a diagnostic approach to understanding children with speech difficulties, e.g. ‘… show the parent the chart of norms for sound development … i.e. a developmentally based target selection’; ‘[group in terms of ] ... articulation or phonological delay. sometimes say dyspraxia when oral motor planning difficulties are evident’; ‘[differentiate between] … phonological errors, stutter, and articulation errors’. one participant explained further, ‘i generally try to categorise errors as being delayed or disordered based on the developmental norms, consistency vs. variability is nb in deciding if it’s a phonological problem or a motor sequencing dyspraxia problem.’ the comments made by participants indicate that they are using a range of widely recognised frameworks, even though they did not always explicitly label them. intervention eight participants (29%) indicated that they have a ‘core’ therapy approach that they routinely use for children with speech difficulties. the remainder of the participants indicated that they do not have one specific approach. some reasons given for not using a specific core approach were: ‘don’t know of anything appropriate in afrikaans’; ‘i design treatment to suit each individual child’; ‘children present with 2 fig. 2. confidence levels of therapists when selecting assessments and providing therapy to bi/multilingual children with speech difficulties. fig. 2. confidence levels of therapists when selecting assessments and providing therapy to bi/multilingual children with speech difficulties. 3 fig. 3. formal assessments of children’s speech used by participants.fig. 3. formal assessments of children’s speech used by participants. 70 sajcd • vol 57 • december 2010 children with speech difficulties individual speech production errors. approach will thus depend on child’s profile.’ this illustrates that therapies are often combined and used in an eclectic manner, as slts consider an individual child and his/her presenting difficulties. table i shows how often different approaches are used by slts in their practice. the table divides these therapies into three categories (by collapsing responses to three levels), namely ‘rarely/never’, ‘sometimes’ and ‘always/often’. it further divides therapies into two categories, namely popular therapies (those used always/often by more than 50% of participants) and less popular therapies (those used always/often by less than 50%). this part of the analysis follows the joffe and pring (2008) paper. auditory discrimination, phonological awareness, parent-based programmes, articulation work/motor-skills training and core vocabulary are popular (used always/often by more than 50%). meaningful minimal-contrast pairs, cued articulation and the wholelanguage approach are among the popular therapies used overall by the participants in this survey; however they fell at the lower end of the popular category. participants were asked what factors influence their choice of approach. in most cases participants mentioned general criteria such as child’s age (n=10; 36%), frequency of therapy that can be offered (n=10; 36%), and parent involvement (n=8; 29%). more specific criteria related to the speech difficulty were also given, e.g. whether the child’s errors are consistent or inconsistent (n=8; 29%) and whether the child has delayed or disordered speech (n=6; 22%). many participants (n=12; 43%) also commented on the importance of having family support. the participants were asked to identify the factors that presented the greatest challenge when assessing and providing therapy to children with speech difficulties. the majority of participants commented that language presented a challenge when managing bilingual children, with one participant commenting on challenges related to bilingualism, saying ‘[difficult to make] differentiation between language delays versus bilingualism issues’. other challenges included limited resources or lack of standardised tests, and participants commented: ‘[difficult to decide] which children to refer to speech therapy’, ‘inappropriate material’ and ‘inconsistent attendance due to social situations of family’, ‘lack of accountability of the department of education in providing support in schools for these children’. participants were asked about their awareness of the evidence base for intervention for children with speech disorders. most of the participants strongly agreed/agreed that there is sufficient evidence to show that intervention for children with speech disorders is effective (85%, n=24). the remaining participants either reported that they did not know (4%, n=1), disagreed (4%, n=1) or did not respond (7%, n=2). none of the participants referred to the evidence base when justifying their selection of therapy methods. discussion children with speech difficulties comprise a substantial proportion (40 70%) of the caseloads of the majority of slt participants in this study. in south africa, most children presenting with speech difficulties will be bilingual or multilingual. the survey found that the majority of the slt participants working with children with speech difficulties in the western cape see children who are multilingual speakers of the main languages, afrikaans, isixhosa and english. however, children who speak isixhosa and have speech difficulties are at a considerable disadvantage because there are few therapists in the region who can speak isixhosa (n=1; 4% in the present study). furthermore, of the slts available to work with isixhosa children in the region, only 40% are able to make use of interpreters or problem solve in creative ways so that these children can be assessed and managed in their first language. it is important to note that results from this survey show that a considerable proportion of slts are only able to offer therapy in english (or afrikaans) – even when working with children who have these as a second or third language. there is a fundamental challenge here: ethical guidelines suggest a child should not be denied intervention because of a language mismatch with the clinician, but slts may not be competent to offer therapy in all languages. a study by jordaan and yelland (2003) attempted to determine how south african slts provide language intervention for multilingual language-impaired children. similar to the present study, the results indicated that the majority of slts are providing language therapy to multilingual children in the child’s second language only – typically english. jordaan and yelland (2003) attributed this to parental insistence and a lack of another common language between the slt and child. this finding confirms that there is a lack of african-language-practising slts in south africa, and many children are therefore not being treated for speech and/or language disorders in their mother tongue. there are few assessments, therapy materials and a lack of published literature available that deal with languages other than english, and the challenges facing slts are considerable. it is not surprising that most participants do not feel confident in selecting assessment and therapy approaches when managing children with speech difficulties, especially when the children are multilingual. many of the participants who rated themselves as not very confident/not confident at all were very experienced (having worked for more than 10 years). this may be related to differences in training of slts, where the training of those who graduated before 1994 was focused mainly on treating children in english or afrikaans. newly graduated slts are now exposed to different teaching methods to overcome language as a barrier to assessment and intervention. slts should be constantly improving their language skills so that they can practise cross-linguistically, and should make every attempt to problem solve around such issues. table i. percentage of participants (n=28) using individual therapies category rarely/never sometimes always/often popular therapies auditory discrimination 0 11 89 phonological awareness (gillon, 2000) 0 21 79 parent-based programmes 7 19 74 articulation work/motor-skills training (van riper & emerick, 1984) 14 25 61 core vocabulary (dodd, 2005) 26 18.5 55.5 meaningful minimal-contrast pairs (weiner, 1981) 7 43 50 cued articulation (passey, 1990) 37 19 44 whole language approach (hoffman et al., 1990) 22 36 42 less popular therapies metaphon (howell & dean, 1991) 68 24 8 suck, swallow, breathe synchrony (oetter et al., 1993) 57 25 18 maximal contrast therapy (gierut, 1990) 59 26 15 non-speech oro-motor work (lancaster & pope, 1989) 54 29 18 nuffield centre dyspraxia programme (williams & stephens, 2004) 58 19 23 cycles (hodson & paden, 1991) 58 31 11 auditory bombardment (hodson & paden, 1991) 46 32 22 vol 57 • december 2010 • sajcd 71 children with speech difficulties assessment of the slts surveyed, it was found that 89% (n=25) use informal assessment tools in addition to formal assessments. this differs from the findings by joffe and pring (2008) from their study of uk-based therapists, and shows the contextual differences between the two settings. in the western cape the main languages are afrikaans, isixhosa and (south african) english and there are few, if any, assessments that have been specifically developed and validated for these populations. western cape slts therefore rely largely on informal assessments when evaluating children’s speech. they make adaptations to formal assessments, as well as using other informal assessments of their own design. more than 50% of therapists indicated that they make adaptations to formal tests to better suit the population, e.g. translating the assessment and using more contextually relevant pictures. these slts will often omit items or sections of formal assessments that are not appropriate for their clients, and will administer tests in non-standardised ways, e.g. repeating instructions or test items. few slts specified how the results from such assessments are interpreted, but presumably the norms are then used as guidelines only, and the focus is on a qualitative description. this thoughtful engagement with assessment issues is to be commended, but raises two important issues. firstly, since there are clearly many slts who have created/adapted assessments, it may be valuable to share these resources through a common forum which could advance the development of such assessments in a systematic manner and ensure that new slts or those setting up services would not have to ‘reinvent the wheel’. secondly, there is clearly a need for speech assessments that have been properly validated and normed on local populations, so that all clients can be accurately and reliably assessed. this is a need that must be addressed if slts are to appropriately serve all clients requiring services. in the current situation, many clients are not having their speech difficulties managed because they do not speak english as their first language. those who are assessed will, for the most part, not be assessed using valid and reliable tools; this in turn creates difficulties in planning and evaluating intervention. in terms of formal tests, the gfta (1986) was the most popular assessment used. this is surprising for a number of reasons. like many of the other tools used by south african slts it has been developed overseas and standardised on a different population. the gfta elicits phonemes in only one specific phonetic context within a preselected word. it provides information about the child’s phonetic inventory but does not involve phonological analysis or detail whether sound errors are developmentally appropriate. like many other speech assessments it focuses primarily on single words and not connected speech. research suggests that the discrepancy between single-word and connected speech phonology may be considerable, and is an important factor to take into account in intervention planning (pascoe et al., 2006). the way in which the gfta was used was not always fully detailed by respondents, but there were slts in this study who use the gfta pictures as a starting point for eliciting single words, before going on to elicit a connected speech sample, and then using their own system of analysis to interpret the results. the informal assessment tools used by slts in the western cape reflect the way in which slts think about speech disorders. the psycholinguistic approach was often implicitly followed. for example, sets of pictures were devised by participants or taken from formal assessments and used in confrontation naming tasks to access lexical representations. there was however a bias in both assessment and intervention towards output aspects of speech processing (naming, repetition) rather than tasks which focused primarily on auditory input or mispronunciation detection. joffe and pring (2008) found that slts had little enthusiasm for frameworks in which a more detailed assessment could be carried out, with many slts reporting their ‘fear’ of the psycholinguistic approach. however, in this study, this was not the case, as most of the slts make use of certain aspects of the psycholinguistic approach. stackhouse and wells (1997) note that all materials can be used psycholinguistically and that it is an approach carried in the head of the user rather than in a specific box of equipment. in recent years there has been an increase in awareness around cultural appropriateness of assessment tools in south africa and many of the slts surveyed are making necessary adaptations to overcome related issues; however, more information in this regard is needed in order to make the assessment of speech difficulties in children more effective. most respondents noted that a speech assessment that enabled them to assess all three of the main western cape languages would be useful. they envisaged a test with modern, colourful pictures appropriate for all children living in the region. in addition it would be valuable to know more about accepted variations of speech sound production in the western cape, have norms for speech development in the region, e.g. a list of phonological processes in each of the languages, and have clinical judgement frameworks to assist in decision making regarding disordered or delayed profiles. while the importance of formal assessment is emphasised here, slts should also be cautious not to rely solely on such tools. clearly a thorough assessment will entail integration of formal and informal assessment tasks, clinical judgement and input from the child and significant others. intervention a wide range of approaches and techniques are available for managing speech difficulties in children. however, there is limited literature addressing the issue of how to choose between the treatments options (dodd, 2005) and the evidence base regarding the effectiveness of the approaches is still in its infancy. like those in the study by joffe and pring (2008), slts surveyed in our sample use a wide variety of therapies, often in an eclectic way. few therapists adhere to one core approach when treating children with speech difficulties. this seems entirely appropriate, as authors such as bowen (2009) note that management of speech difficulties should be adjusted to suit the diversity of each client, and therapy should consist of a combination of approaches most suitably tailored for each individual. evidence-based practice is about choosing the most appropriate intervention for a particular client, based on best available evidence as well as therapist experience and client needs. in the study by joffe and pring (2008) the most popular therapies used were auditory discrimination, phonological awareness and parent involvement. the results of the present study follow closely in that 89% of participants used auditory discrimination, 79% used phonological awareness and 74% used parent involvement. the popularity of auditory work in both studies warrants further investigation. children with speech difficulties may have strong auditory processing skills even in the context of severe output difficulties, therefore joffe and pring (2008) concluded that in these cases, work on auditory discrimination may be unnecessary. however, input-based therapy may be a useful way of accessing the phonological system of children with persisting speech difficulties who are unwilling to produce speech, perhaps as a result of years of therapy focused on their speech output (pascoe et al., 2006). in our questionnaire ‘auditory discrimination’ was included as a general approach to therapy, rather than referring to a specific programme of therapy. however, auditory discrimination activities could be carried out at a variety of levels (e.g. single sounds, words, sentences) and in a variety of ways (e.g. as preparation for a minimal-pair approach to therapy that focuses on output, or as the main intervention in its own right). the questionnaire did not allow slts to indicate how they incorporate auditory activities into their interventions. another more specific auditory-based approach, that of auditory bombardment (hodson & paden, 1991), proved considerably less popular. phonological awareness approaches were popular in both studies. in our study (as for the joffe and pring (2008) paper) we included phonological awareness approaches such as those described by gillon (2000) which focus on using phonological awareness activities as a way to access and improve phonological representations. there is evidence that such approaches are effective in bringing about change in children’s speech, phonological awareness and early literacy (bowen, 2009; gillon, 2000). again, the way in which therapists in our study carry out 72 sajcd • vol 57 • december 2010 children with speech difficulties phonological awareness activities was not explored, and the focus of the interventions (and rationale underpinning them) may in fact vary widely, e.g. phonological awareness may include aspects of input and/ or output processing at a variety of levels. parent involvement has long been described as key to effective intervention (bowen, 2009) but might be facilitated in a variety of ways. in some cases ‘home programmes’ are used as the sole form of intervention; in other instances parents play a key role in therapy (e.g. the pact approach (bowen & cupples, 2006) and in core vocabulary approaches (dodd, 2005). in some instances parents are involved to a lesser extent, often as a result of resource constraints. in this study most of the slts adopt a parent-based approach to therapy which follows the joffe and pring study where 76.5% of slts included parental involvement in their intervention programmes, but again this does not mean that all slts involve parents in the same way. the effectiveness of many of the approaches used by the slts in our study has been demonstrated, although often in small-scale or inconsistent ways (williams et al., 2010). in describing the decision-making process, slts referred to multiple factors such as a client’s age, the nature of their speech difficulties and family support, but did not mention the available evidence base as a guiding factor in their selection. joffe and pring (2008) describe this as a gap between research and practice. in the present study, slts were asked about their awareness of the evidence base in the area of children’s speech difficulties and the majority (85%) agreed that there is sufficient evidence to show that intervention for children with speech disorders is effective. however, none of the participants referred to the evidence base when justifying their selection of therapy methods, suggesting that they are either not familiar with the recent evidence or that evidence-based practice may be a concept that slts find hard to apply to their own work – the research/practice gap that joffe and pring describe. as for the assessment section of the questionnaire, most of the respondents described challenges in terms of intervention that focused on working with bi/multilingual children and a lack of resources. slts also mentioned the social/financial difficulties that may make it hard for clients to attend appointments. this raises a bigger issue for the profession as a whole regarding service delivery that is relevant and not ‘hard to reach’ (lees, 2002). given that there are no slts currently employed in ordinary mainstream schools in the western cape, there are further challenges in accessing children who need intervention. limitations of the study the study reports results from a small sample of local slts. the response rate was below the desirable response rate described in the literature (maxwell & satake, 2006) and therefore findings cannot be generalised to the greater population. furthermore the findings may be biased because the slts who did respond are more likely to have been interested in research, and interested in issues of linguistic diversity than those who had engaged less with the topic. however, findings do provide insight into the methods of assessment and intervention used by some slts in this region, and may serve as a start in exploring clinical practice of this group. the use of questionnaires presents difficulties in the collection of data. in this study this included the low response rate, issues of validity and difficulties with some of the questions. for example, question 16 posed difficulties for many respondents as it consisted of two questions in one: ‘are you aware of or do you use any frameworks for categorising children with speech difficulties? which features would help you to identify a child with a phonological delay; phonological disorder or dyspraxia?’ many of the participants only answered the second part of the question, thus making it difficult to draw conclusions about slt’s awareness of frameworks. a more comprehensive piloting of the questionnaire would have been helpful in detecting some of these difficulties, and increasing the validity of the instrument. carrying out face-to-face interviews may have increased the sample size and yielded more in-depth information; however, it may have been difficult because of slts’ time constraints. another possible alternative would be to conduct a similar study with a larger sample size (i.e. including slts in south africa as a whole). the information obtained from a national survey may be more valuable than merely looking at the local context and would not require significantly more resources since most of the questionnaires were sent via electronic mail. clinical implications almost all the survey respondents described similar challenges in managing children with speech difficulties, linked mainly to a lack of appropriate resources and compounded by the fact that there is often a mismatch between clinician and client’s languages. clinicians in the western cape, and in south africa as a whole, can constructively address these issues by sharing multi-language resources they may have developed with other clinicians and offering critique and support in the ongoing development of such materials to ensure that quality service delivery is maintained. it is exciting to know that there are isixhosa screening tools in use, and it would be helpful to share these and develop them further. where therapists are adapting assessments, they should think critically about the nature of these adaptations: what is really being assessed? is this fair and appropriate given the client’s language/s? how do the data collected inform therapy planning? ongoing engagement with the literature on speech difficulties and bilingual speech and language development will ensure that a gap between research and practice does not develop. clinicians should be mindful of the current state of the evidence base in this area. there is strong and clear evidence about which approaches work best with which children, but clinicians working in the south african context are well positioned to add to this evidence base and grow the knowledge in a local context. the calls made by slts in this study for lists of phonological processes in more languages and accepted variations of speech sounds produced in particular regions are basic tools that are urgently needed. further research in south africa there is a great need to develop new and appropriate assessment tools in languages other than english. further, knowledge regarding the development of speech in the different languages is needed for slts as this could be used as a guideline for both assessment and intervention for children with speech difficulties in these languages. slts will not be able to achieve this in isolation. we should collaborate with each other at a national level, look internationally for lessons and guidelines in materials development and translation, and link with our academic colleagues working in disciplines such as linguistics and psychology. more evidence about speech difficulties in languages such as afrikaans and isixhosa is needed as most of the studies have been done with english-speaking children. there is also a need for intervention studies on the south african population in order to build an evidence base for the different approaches used. conclusion this study found that the majority of slts working in the western cape assess and manage children with speech difficulties as a substantial part of their caseloads. informal assessments and adapted versions of published tests are widely used. the slts surveyed draw on a wide range of intervention approaches and use them most often in combination. most of the participants do not feel confident in selecting assessment and therapy approaches when managing children with speech difficulties, specifically when managing multilingual children. this was associated with challenges related to the language diversity of the children in this region, the lack of resources and the lack of assessments standardised on this population. there is a need for further research into typical speech development in the south african context, as well as development of resources tailored to the population. acknowledgements thanks to all the clinicians who participated in the study, and to jenny pahl for her helpful comments on an earlier draft. this research was funded by the national research foundation (south africa). vol 57 • december 2010 • sajcd 73 children with speech difficulties references anthony, a., bogle, d., ingram, t., & mcisaac, w. (1971). the edinburgh articulation test. edinburgh: livingstone. armstrong, s., & ainley, m. (1988). the south tyneside assessment of phonology. northumberland: stass. bird, j, bishop, d. v. m., & freeman, n. h. (1995). phonological awareness and literacy development in children with expressive phonological impairments. journal of speech and hearing research 38, 446-462. bowen, c. (2009). children’s speech sound disorders. oxford: wiley-blackwell. bowen, c., & cupples, l. (2006). pact: parents and children together in phonological therapy. advances in speech-language pathology, 8, 282-292. broomfield, j., & dodd, b. (2004). children with speech and language disability: caseload characteristics. international journal of language and communication disorders, 39, 303324. carter, j., lees, j., murira, g., gona, j., neville, b., & newton, c. (2004). issues in the development of cross-cultural assessments in speech and language for children. international journal of language and communication disorders, 4, 385-401. dodd, b. (ed.). (2005). differential diagnosis and treatment of children with speech disorder (2nd ed.). london: whurr publishers. gardner, m. f. (1996). test of auditory perceptual skills: revised. burlingame, ca: psychological and educational publications. gierut, j. (1990). differential learning of phonological oppositions. journal of speech and hearing research, 33, 540-549. gillon, g. t. (2000). the efficacy of phonological awareness intervention for children with spoken language impairment. language, speech and hearing services in schools, 31, 126141. goldman, r., & fristoe, m. (1986). goldman-fristoe test of articulation. circle pines, mn: ags. goldstein, b. a., & fabiano, l. (2006). assessment and intervention of children with phonological difficulties. early intervention in depth. rockville, md: the american speech and hearing association. grunwell, p. (1985). phonological assessment of child speech. nfer-nelson: windsor. gxilishe, s. (2004). the acquisition of clicks by xhosa speaking children. per linguam, 2, 1-12. hodson, b., & paden, e. (1991). targetting intelligible speech: a phonological approach to remediation. san diego, ca: college hill press. hoffman, p., norris, j., & monjure, j. (1990). comparison of process targeting and whole language treatments for phonologically delayed preschool children. language, speech and hearing services in schools, 21, 102-109. howell, j., & dean, e. (1991). treating phonological disorders in children: metaphon – theory to practice. london: whurr publishers. joffe, v., & pring, t. (2008). children with phonological problems: a survey of clinical practice. international journal of language & communication disorders, 43, 154-165. jordaan, h., & yelland, a. (2003). intervention with multilingual language impaired children by south african slts. journal of multilingual communication disorders, 1, 13-33. lancaster, g., & pope, l. (1989). working with children’s phonology. bicester: winslow. lees, j. (2002) crossing the cultural divide. bulletin of the royal college of speech and language therapists, october, 11-12. maxwell, d. l., & satake, e. (2006). research and statistical methods in communication sciences & disorders (1st ed.). boston: thomson delmar learning. nash, p., stengelhofen, j., & brown, j. (2002). improving children’s communication: managing persistent communication difficulties. chichester: wiley. oetter, p., richter, e., & frick, s. (1993). more: integrating the mouth with sensory and postural functions. hugo, mn: pdp. pascoe, m., stackhouse, j., & wells, b. (2006). persisting speech difficulties in children: children’s speech and literacy difficulties 3. chichester: wiley. passey, j. (1990). cued articulation. melbourne: acer. reilly, s., douglas, j., & oates, j. (2004). evidence-based practice in speech pathology. london: whurr publishers. robertson, c., & salter, w. (1995). the phonological awareness kit. east moline, il: linguisystems. ruscello, d. m. (2008). treating articulation & phonology disorders in children. st louis: mosby elsevier. stackhouse, j., & wells, b. (1997). children’s speech and literacy difficulties: a psycholinguistic framework. london: whurr publishers. stackhouse, j., pascoe, m., & gardner, h. (2006) intervention for a child with persisting speech and literacy difficulties: a psycholinguistic approach. international journal of speech-language pathology, 3, 231-244. van riper, r., & emerick, l. (1984). speech correction: an introduction to speech pathology and audiology. englewood cliffs, nj: prentice-hall. weiner, f. (1981). treatment of phonological disability using the method of meaningful minimal contrast: two case studies. journal of speech and hearing disorders, 46, 97-103. williams, a. l., mcleod, s., & mccauley, r. (2010). interventions for speech sound disorders in children. baltimore, md: paul brookes. williams, p., & stephens, h. (eds.). (2004). nuffield centre dyspraxia programme. windsor, uk: the miracle factory. questionnaire a. general questions: 1. do you work with children? (please circle) yes / no (if no, please proceed to question 22) 2. how long have you been a speech-language therapist? (please circle) less than 1 year / between 1 and 3 years / between 4 and 6 years / between 7 and 10 years / more than 10 years 3. in which setting/settings do you work? (please circle) private practice / state hospital / private hospital / state school / private school / university / non-governmental organisation (ngo) / other (please specify) _________________________________________________________________________________________________________ 4. what language/s do you speak? (please circle) english / afrikaans / xhosa / other (please specify) _______________________________________________________________________________ 5. please describe the main client group that comprise your individual case load. (please complete using the following example) example: 10% children with phonological problems 30% children with fluency difficulties 50% feeding difficulties 10% autistic speech 6. what percentage of your current (individual) caseload is taken up with clients with speech difficulties? (note: by speech difficulties we mean children who have difficulties in producing clear, fluent, well-articulated or intelligible speech) (please circle) less than 10% / between 10% and 39% / between 40% and 70% / greater than 70% 7. please indicate whether you work with children that speak the following languages: (please circle) english / afrikaans / xhosa / other (please specify) _______________________________________________________________________________ 8. focusing on children’s main language (l1), how many children that are part of your caseload have speech difficulties in the different languages? english l1_________% / afrikaans l1_________% / xhosa l1_________ % / other l1_________ % appendix a 74 sajcd • vol 57 • december 2010 children with speech difficulties 9. how confident do you feel assessing and providing therapy to a child that speaks another language to your own? (please circle most appropriate response) very confident / confident / neutral / not very confident / not confident at all 10. what language(s) do you use when assessing and providing therapy? (please circle) english / afrikaans / xhosa / the child’s home language b. assessment: the following questions are based on your assessment methods for evaluating a child’s speech. (i.e. focusing primarily on articulation and phonology) standardised assessments 11. do you use any standardised assessments? (please select, by circling an appropriate answer) if no, why not? ____________________________________________________________________________________________________ if yes, what assessments do you use? (please list) 12. do you make any adaptations to these standardised assessments? if yes, please explain why and how (please provide an example if possible): ____________________________________________________ ___________________________________________________________________________________________________________________________ informal assessments 13. do you use informal assessments? please describe in further detail (and see questions below). _________________________________________________________________ ___________________________________________________________________________________________________________________________ test items: 13a. do you use: (please circle) pictures / objects / both / none 13b. please describe your test items: pictures: colour or black and white big or small line drawings or 2-dimensional single picture presentation or multiple picture presentation ________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________ objects big or small single object presentation or multiple object presentation if you are able to include sample words from the informal assessment please do so. _____________________________________________________ ________________________________________________________________________________________________________________________ 14. would an assessment used in all three predominantly used languages (english, afrikaans, and xhosa) be helpful to you in your current practice? please specify yes/ no and comment as appropriate. _________________________________________________________________________________ ____________________________________________________________________________________________________________________________ 15. what additional materials would you find helpful in assessing a child’s speech? _________________________________________________________ _______________________________________________________________________________________________________________________________ 16. are you aware of or do you use any frameworks for categorizing / diagnosing/ describing children with speech difficulties? which features would help you to identify a child with a phonological delay; phonological disorder or dyspraxia? ________________________________________________ ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ c. intervention/therapy: 17. do you have a core treatment approach or package that you routinely use for children with speech difficulties? yes – which one and why? ______________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ no – why? __________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ yes / no yes / no yes / no vol 57 • december 2010 • sajcd 75 children with speech difficulties 18. below is a list of common treatment approaches used to treat speech disorders. by circling, please rate how frequently you use each approach in your therapy using the scale below: 5 always / 4 often / 3 sometimes / 2 rarely / 1 never auditory discrimination 5 4 3 2 1 meaningful minimal contrast therapy (weiner, 1981) 5 4 3 2 1 maximal contrast therapy (gierut, 1990) 5 4 3 2 1 articulation work/motor skills training (van riper & emerick, 1984) 5 4 3 2 1 suck-swallow-breathe synchrony (oetter, richter & frick, 1993) 5 4 3 2 1 non-speech oro-motor work (lancaster & pope, 1989) 5 4 3 2 1 nuffield centre dyspraxia programme (williams & stephens, 2004) 5 4 3 2 1 core vocabulary (dodd, 2005) 5 4 3 2 1 whole-language approach (hoffman, norris & monjure, 1990) 5 4 3 2 1 auditory bombardment (hodson & paden, 1991) 5 4 3 2 1 metaphon (howell & dean, 1991) 5 4 3 2 1 phonological awareness (gillon, 2000) 5 4 3 2 1 cued articulation (passey, 1990) 5 4 3 2 1 cycles approach (hodson & paden, 1991) 5 4 3 2 1 parent-based work 5 4 3 2 1 other: ______________________________________________________________________________________________________________________ 19. of these approaches, which do you find to be most effective? ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ 20. do you incorporate home programmes (please circle)? always / often / sometimes / rarely / never 21. what factors do you consider when deciding on an appropriate treatment programme in the remediation of speech difficulties? ____________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________ 22. being in a south african context, what are your greatest challenges faced with regard to assessment and therapy with children with speech difficulties? language culture resources lack of standardised tests other, elaborate: ______________________________________________________________________________________________________________ 23. please state whether you agree or disagree with this statement: ‘i feel there is sufficient evidence to show that intervention for children with speech disorder is effective’ strongly agree / agree / neither agree nor disagree / disagree / strongly disagree abstract introduction method results discussion conclusion acknowledgements references appendix 1 about the author(s) omphile mogole department of clinical pharmacy, school of pharmacy, sefako makgatho health sciences university, pretoria, south africa natalie schellack department of clinical pharmacy, school of pharmacy, sefako makgatho health sciences university, pretoria, south africa cara hollander department of speech pathology and audiology, university of the witwatersrand, johannesburg, south africa lebogang ramma department of health and rehabilitation sciences, university of cape town, cape town, south africa citation mogole, o., schellack, n., hollander, c., & ramma, l. (2019). knowledge of final year medicine, pharmacy, audiology and nursing students in south africa on drug-induced ototoxicity: a pilot study. south african journal of communication disorders, 66(1), a606. https://doi.org/10.4102/sajcd.v66i1.606 original research knowledge of final year medicine, pharmacy, audiology and nursing students in south africa on drug-induced ototoxicity: a pilot study omphile mogole, natalie schellack, cara hollander, lebogang ramma received: 30 july 2018; accepted: 11 aug. 2019; published: 14 nov. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: there is a high prevalence of human immunodeficiency virus (hiv), tuberculosis (tb), cancer and malaria in south africa, and the drugs used to treat these conditions can be ototoxic. it is therefore important that healthcare professionals are able to identify and understand these drugs and their effects to ensure effective care of the patient. objective: this study aimed to assess the knowledge regarding pharmacotherapy-induced ototoxicity amongst final year, medicine, pharmacy, audiology and nursing students across south african universities. methods: a descriptive cross-sectional study design was used, and data were collected via a self-administered online questionnaire. non-probability purposive sampling was used to identify the participants at the universities which train audiologists, pharmacists, medical and nursing students. results: an overall response rate of 41% (n = 720) was obtained. sixty-four per cent (n = 461) of respondents were women (median age: 23 years). the majority of the respondents (95%) knew what pharmacotherapy-induced ototoxicity was, but a few (39%) knew the general signs and symptoms of ototoxicity. furthermore, just less than half of the sample (48%) could identify the specific ototoxic medicines and the type of damage caused by this medication. conclusion: to manage pharmacotherapy-induced ototoxicity effectively, a multidisciplinary healthcare team must have sufficient knowledge about ototoxicity. therefore, efforts should be made to introduce extensively concepts of pharmacotherapy-induced ototoxicity into the undergraduate curricula of pharmacy, medical, nursing and audiology programmes. keywords: multidisciplinary; ototoxicity; training; pharmacotherapy; students. introduction according to schellack, wium, ehlert, van aswegen and gous (2015), pharmacotherapy-induced ototoxicity is a growing issue, especially in developing countries such as south africa. the prevalence of tuberculosis (tb), human immunodeficiency virus (hiv) and malaria in south africa predisposes these patients to hearing loss which is induced by agents used to treat these conditions (schellack et al., 2015). while there are no real statistics regarding the incidence of hearing loss because of hiv and malaria, petersen and rogers (2015) estimate that up to 90% of patients with tb, specifically drug-resistant tb, may experience hearing loss. neonates, particularly those born prematurely, are more prone to infections because of their immunocompromised nature. furthermore, the antibiotics, for example, amikacin, that are used to treat these infections have been shown to be ototoxic in approximately 59% of these babies (engler, schellack, naude, & gous, 2013). furthermore, schellack et al. (2015) state that pharmacists along with medical professionals and nurses play an integral role in identifying and monitoring ototoxic agents, while audiologists often get involved only after the patients have completed therapy and start experiencing hearing loss. early identification of hearing loss and balance problems (ototoxicity monitoring) is of paramount importance to prevent or minimise permanent impairment and therefore improve the quality of life post-treatment (saindane, 2016). thus, audiologists need to be involved at the initial stages of patient care and part of the multidisciplinary team. to assist this multidisciplinary care, interprofessional education (ipe) is needed. according to treadwell and havenga (2013), ipe refers to the learning from and between the disciplines of various health science students in order to improve collaboration and the quality of patient care. interprofessional education is an important approach to develop health science students, as trained students are more likely to become collaborative interprofessional team members who show respect and positive attitudes towards each other and work towards improving patient outcomes (bridges, davidson, odegard, maki, & tomkowiak, 2011). however, medicine, pharmacy, nursing and other health professions are supposed to work together in a clinical environment, which requires effective teamwork and communication skills. the majority of university-based health professional education currently delivers a discipline-specific model of teaching (lapkin, levett-jones, & gilligan, 2013). furthermore, a relationship between the physician (as the prescribers) and nurses (as the care takers) needs to be established. this relationship should be supported by education regarding the importance and benefits of drug monitoring and as well as the evaluation of possible adverse effects, which should be discussed with the patients (konrad-martin, wilmington, gordon, reavis, & fausti, 2005). according to vasquez and mattucci (2003), many physicians do not understand the importance of otolaryngologists and audiologists in pre-treatment counselling and evaluation and the need for follow-up assessments of the patient’s auditory function. a multidisciplinary team approach, particularly between physicians, pharmacists, audiologists and nurses, is integral to collaborative patient education programmes regarding ototoxic medication, its effects and management. this is considering that most primary care clinicians and clinical pharmacists, particularly in developing countries such as south africa, have seen patients who have suffered from ototoxicity at some point in their careers (schellack et al., 2015). hearing loss, especially when occurring during childhood, can negatively impact communication development, scholastic performance and quality of life (phanguphangu & ramma, 2018). therefore, identification and understanding of the drugs and their impacts can improve patient care and outcomes. however, literature pertaining to the core curriculum or knowledge and perceptions of these healthcare workers in training is limited, especially in the south african context. method study design, setting and population a descriptive cross-sectional survey design was used. the target population for this study included all final year pharmacy, medical, audiology and nursing students across south african universities (see table 1). non-probability purposive sampling was used to select the participants, as this type of purposive sampling is able to produce a sample considered as ‘representative’ of the population (battaglia, 2008). table 1: universities offering pharmacy, medical, audiology and nursing degrees. data collection instruments and procedures a randomised, self-developed questionnaire (appendix 1) was the primary data collection tool in this study. the questionnaire was developed and compiled using information from an article by schellack and naude (2013) regarding pharmacotherapy-induced ototoxicity. the questionnaire explored the following themes of knowledge in relation to pharmacotherapy-induced ototoxicity: general knowledge, prevention, ototoxicity monitoring and the prescription of ototoxic drugs. data collection was conducted over a period of 24 weeks. a link to the questionnaire was sent to a designated staff member, who was either the head of department or someone chosen by the head of department. this person was the one who sent out the link of the study to the students in the department and was responsible for disseminating the link to the final year students in their respective departments. implied consent was used. reminder emails pertaining to the online questionnaire were sent to these designated staff members at the university departments or schools on a weekly basis throughout the data collection period. the aim of this communication was for the designated staff members to remind students to complete and submit the questionnaire on the online platform. data analysis data were entered into microsoft excel® spreadsheets and exported to ibm statistical analysis software® (sas) for analysis. prior to analysis, universities were de-identified and recoded as ‘a’, ‘b’, ‘c’, ‘d’, ‘e’, ‘f’, ‘g’, ‘h’, ‘i’, ‘j’, ‘k’, ‘l’ and ‘m’. frequencies and percentages were calculated for all variables, including knowledge in relation to pharmacotherapy-induced ototoxicity. this encompassed general knowledge, prevention, ototoxicity monitoring and the prescription of ototoxic drugs. fisher’s exact test was used to test for differences in response and the chi-square test was used to test for associations in responses between the different universities. statistical significance was set at p ≤ 0.05. ethical consideration ethical approval was sought from the university research ethics committees before commencement of data collection (smurec/h/246/2016: pg). permission for the study was obtained from the head of each department and research ethics committees at the different universities. implied consent was used for the purposes of the study and has been stated as part of the data collection instrument. the completion of the questionnaire implied consent to participate in the study. participation was voluntary, and the responses were anonymous. results response rate questionnaires were sent to all universities that train medicine, pharmacy, nursing and audiology students; therefore, an estimated 1760 potential participants were expected to take part in this study. seven hundred and twenty final year students from all courses across south african universities participated in the study. this figure represents an average response rate of only 41% (25% – 86% across the different universities and courses). the response rates by institution and course are shown in table 2. table 2: response rate by university and course. demographics overall, 64.03% of the respondents were women. over two-thirds (68.19%) of the students were between the ages of 22–25 years; 6.94% were younger than 22 years and 24.72% were over the age of 25 years. general knowledge of pharmacotherapy-induced ototoxicity respondents’ general knowledge of pharmacotherapy-induced ototoxicity is summarised in table 3. a vast majority of the respondents (95%) demonstrated knowledge about ototoxicity; however, only a small proportion of respondents (28%) identified the signs of ototoxicity (p < 0.001), and 21% of the respondents knew the risk factors of pharmacotherapy-induced ototoxicity (p < 0.001). table 3: general knowledge of final year pharmacy, medical, nursing and audiology students regarding pharmacotherapy-induced ototoxicity. drugs causing ototoxicity respondents’ knowledge regarding drugs causing ototoxicity is summarised in table 4. forty-eight per cent of participants identified ototoxic drugs, with pharmacy students performing slightly better than the other groups. only 36% of the respondents knew how non-steroidal anti-inflammatory drugs (nsaid)-induced ototoxicity occurred (p < 0.001) and 43% of the respondents accurately reported that hearing loss caused by aminoglycosides was irreversible, with significant differences between knowledge of students in the different disciplines (p < 0.001). close to one-fifth of the respondents (19%) identified ototoxic anti-hypertensive medication (p < 0.001). forty-three per cent were able to identify ototoxic anti-tb medication, with significant difference in responses between the different courses (p < 0.001). table 4: final year pharmacy, medical, nursing and audiology students’ knowledge about drugs that cause ototoxicity (percentage of students who answered correctly). type of damage caused respondents’ knowledge regarding the type of damage caused by ototoxic drugs is summarised in table 5. a quarter of the respondents (25%) knew the ototoxic side effects caused by aspirin (p < 0.001). just over 50% of the medical students (52%) identified the most ototoxic medicine from a list of ototoxic medications (p < 0.001). pharmacy students showed poor knowledge regarding the signs of damage to the cochlea and vestibular system. pharmacy (42%) and audiology students (43%) showed a fair knowledge of the type of hearing loss caused by cisplatin and vancomycin, with both pharmacy (13%) and audiology (27%) also showing insufficient knowledge regarding the cause of sensorineural hearing loss (p < 0.001). table 5: final year pharmacy, medical, nursing and audiology students’ knowledge about the type of damage caused by ototoxic medicine (percentage of students who answered correctly). discipline-specific questions discipline-specific questions were aimed at assessing what the students needed to know regarding pharmacotherapy-induced ototoxicity within their specific disciplines, namely, pharmacy, medical, nursing and audiology. respondent’s discipline-specific knowledge is summarised in table 6. less than half of the respondents (45%) knew the steps which needed to be taken when a patient starts experiencing ototoxic side effects. just over half of the pharmacy students (54%) knew the otoprotective anti-oxidant properties of n-acetylcysteine (p < 0.001), while 23% knew the strategies required to minimise drug-induced ototoxicity. the majority of both pharmacy (61%) and audiology (75%) students understood what otoacoustic emissions were. fourteen per cent of pharmacy students and 29% of audiology students knew what pure tone audiometry tests are used for in determining hearing loss. both pharmacy (36%) and audiology (39%) students showed slight knowledge regarding when baseline audiometric tests should be performed for patients taking ototoxic medication. pharmacy students seemed to have a better knowledge regarding when audiometric monitoring should be initiated (46%) than audiology students did (30%). just over half of the medical students (54%) reported that a patient should not receive more than one ototoxic medicine at a time, with only 31% of them being able to identify what to do in the event of ototoxicity. table 6: discipline-specific knowledge of final year pharmacy, medical, nursing and audiology students regarding pharmacotherapy-induced ototoxicity. just over 60% of medical students indicated that the risk-to-benefit ratio should also be considered when prescribing ototoxic medication, with significant differences between the individual universities (p < 0.001). just over half of the medical students (52%) indicated that patients who experience ototoxic effects should be referred for audiological monitoring only once the therapy has been completed (p < 0.001). a few of the medical students (35%) reported that patients should be counselled before treatment about the possible ototoxic side effects of the medicine and 59% reported that most ototoxic medicine will not cause hearing loss when given at therapeutic doses. only 33% of pharmacy students indicated that patients with a past history of hearing loss should not take ototoxic drugs, and 60% of medical students agreed with them (p < 0.001). discussion this study evaluated final year pharmacy, medical, nursing and audiology students’ knowledge regarding pharmacotherapy-induced ototoxicity. to the best of our knowledge, this study is the first to assess these aspects amongst pharmacy, medical, nursing and audiology students across south african universities. this study attempted to assess all south african universities; however, not all chose to participate in the study. the results indicated that the majority of the students across different universities and professional fields of studies may not have adequate basic knowledge regarding pharmacotherapy-induced ototoxicity, as determined by the questionnaire in this study. across all universities, the students were able only to define ototoxicity, but could not identify the signs of ototoxicity and risk factors involved. the results are also in agreement with those reported by khoza-shangase and jina (2013), a study which revealed that doctors do not have adequate knowledge of ototoxicity symptoms and treatment. pharmacy students, however, scored much better (97%) than students from other courses in terms of general knowledge regarding pharmacotherapy-induced ototoxicity, which may be attributed to the fact that they have more extensive pharmacology training at undergraduate level than the other courses. however, as they should take an active role in the identification of ototoxic drugs, and the potential management, a greater knowledge is still required. furthermore, most of the respondents could not adequately identify drugs that cause ototoxicity. audiology students scored the lowest for this question (32%), which can be explained by the fact that they do not have pharmacology training at undergraduate level. this supported a study conducted by naidoo (2006) in which the majority of the audiologists were of the opinion that their undergraduate clinical training had left them unprepared to implement pharmacotherapy-induced ototoxicity monitoring services. this could indicate that perhaps the curriculum needs to be adapted to include pharmacology for audiologists. the respondents’ knowledge regarding the type of damage caused by ototoxic medicine was shown to be poor. respondents could not adequately identify whether certain medicines caused reversible or irreversible hearing loss. also, the respondents could not determine the signs that arise because of damage to a specific structure of the ear (cochlear and vestibular system) as well as which drugs cause damage to which structure. with respect to discipline-specific questions, pharmacy and medical students performed relatively well in terms of identifying the steps to follow if a patient starts experiencing ototoxicity and preventative measures that can be taken, including the pre-treatment that can be used when a patient is receiving ototoxic medicine, as compared to the other disciplines such as nursing and audiology. this is in line with an article by lapkin et al. (2013), who described a report by the world health organization (who, 2016) which suggested that a large percentage of hearing impairment was attributed to ototoxic medication as a result of inappropriate use by healthcare providers, most especially from those prescribing. knowledge was inadequate regarding when audiological monitoring should be initiated, and also regarding prevention and pre-treatment of pharmacotherapy-induced ototoxicity. nursing students showed poor knowledge in terms of steps to be taken when a patient starts experiencing ototoxic side effects. audiology students scored acceptably with regard to the steps that need to be followed when patients start experiencing ototoxic side effects and showed slight knowledge regarding when audiological monitoring should be initiated, as the majority of them indicated that audiological monitoring can be done only once a patient has completed treatment. a strength of the study was that it was conducted amongst final year undergraduate students at a point when they had completed most of their formal academic curriculum to ensure that their knowledge would be assessed close to completion of their degrees. the study also had some limitations; use of an online survey might have reduced the response rate and difficulty permission from some universities. also, not all universities that train these professionals participated in the study. the reasons for the lack of participation was either because the relevant head of department or dean did not respond to the numerous emails that were sent out or declined to participate in the study. conclusion the study demonstrated that final year pharmacy, medical, nursing and audiology students across south african universities lack sufficient knowledge regarding pharmacotherapy-induced ototoxicity. the gaps in knowledge regarding the topic indicate that there may be insufficient undergraduate training pertaining to ototoxicity. the results suggest that pharmacy, medical, nursing and audiology students should be adequately trained at undergraduate level to handle cases of pharmacotherapy-induced ototoxicity once they get into the professional multidisciplinary healthcare environment to ensure patient safety. this would include the identification of potentially ototoxic medication, counselling of patients, and further ongoing monitoring and management of the drug and hearing loss. schellack and naude (2013) highlighted the importance of a coordinated and cooperative healthcare team in the early detection of cochleotoxicity, which holds especially true for a country such as south africa that has a high disease burden, which often includes treatment by potentially ototoxic medication. acknowledgements competing interests the authors have declared that no competing interests exist. authors’ contributions all authors contributed equally to the article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references battaglia, m. 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(2016). ototoxicity prevention by early identification. retrieved from http://hearingcaredoctors.ca/2016/02/03/ototoxicity-prevention-by-early-identification. schellack, n., & naude, a. (2013). an overview of pharmacotherapy-induced ototoxicity. south african family practice, 55(4), 357–365. https://doi.org/10.1080/20786204.2013.10874377 schellack, n., wium, a.m., ehlert, k., van aswegen, y., & gous, a. (2015). establishing a pharmacotherapy induced ototoxicity programme within a service-learning approach. south african journal of communication disorders, 62(1), 1–7. https://doi.org/10.4102/sajcd.v62i1.96 treadwell, i., & havenga, h.s. (2013). ten key elements for implementing interprofessional learning in clinical simulations. african journal of health professions education, 5(2), 80–83. https://doi.org/10.7196/ajhpe.233 vasquez, r., & mattucci, k.f. (2003). a proposed protocol for monitoring ototoxicity in patients who take cochleo-or vestibulotoxic drugs. ear, nose & throat journal, 82(3), 181. https://doi.org/10.1177/014556130308200310 world health organization (who). (2016). global tuberculosis report 2016. retrieved from http://apps.who.int/iris/bitstream/handle/10665/250441/9789241565394-eng.pdf;jsessionid=95c32a85aa1edf1a759fe721ab3d5df1?sequence=1. appendix 1 questionnaire on pharmacotherapy-induced ototoxicity. dear candidate, please choose the sections applicable to you. section a: demographics section b: general knowledge regarding pharmacotherapy-induced ototoxicity (to be completed by everyone) ototoxicity is a side effect of medicine resulting in auditory and/or vestibular dysfunction resulting in hearing loss and disequilibrium a toxic reaction resulting from an interaction between two or more drugs renal impairment because of medicine overdose a side effect of medicine resulting in severe skin rash i don’t know signs of ototoxicity include: hearing loss disequilibrium renal impairment a and b a, b and c i don’t know which of the following drugs does not cause ototoxicity? vancomycin cisplatin penicillin i don’t know which patients are at risk of developing ototoxicity? patients with renal impairment mdr-tb patients heart failure patients all of the above i don’t know aminoglycosides-induced ototoxicity is reversible. true false i don’t know nsaid-induced ototoxicity may occurs when patients use the medication for a prolonged period double the normal dose is administered patients take a normal dose for a few days all of the above i don’t know aspirin causes the following ototoxic effects: hearing loss tinnitus disequilibrium earache all of the above i don’t know which medicine used for tb is likely to cause hearing loss? rifampicin ethambutol amikacin isoniazid none of the above i don’t know hypertensive patients are at risk of ototoxicity when using high doses of which anti-hypertensive hydrochlorothiazide enalapril lorsatan furosemide i don’t know as a nurse, when you suspect that a patient may be showing some ototoxic signs/symptoms, you must: observe the patient for a while before referring them refer to an audiologist for confirmation inform the treating physician wait until the end of the treatment before referring the patient i don’t know section c: prevention of pharmacotherapy-induced ototoxicity (to be answered by pharmacy students) n-acetylcysteine (acc-200®) can be used as a protective agent in patients treated with ototoxic drugs true false i don’t know which of the following is the most correct preventative measure for patients receiving ototoxic medicine? change medication counsel patient change dosage all of the above i don’t know the protective anti-oxidant effects of which drug is related to its action as a free radical scavenger? paracetamol n-acetycsteine sodium chloride adrenaline none of the above i don’t know patients can receive more than one ototoxic drug as long as the doses are not too high. true false i don’t know damage to the vestibular organ results in which side effects? tinnitus hearing loss dizziness loss of balance (disequilibrium) a and b c and d i don’t know patients with a past history of hearing loss should not take any ototoxic medicine. true false i don’t know which of the following patients are at a higher risk of aminoglycoside ototoxicity? those taking therapy for more than 5 days those taking higher doses elderly patients with renal insufficiency all of the above i don’t know drugs that cause reversible hearing loss (erythromycin) do not have to be monitored for ototoxic effects. true false i don’t know strategies to minimise ototoxicity include: keep patients hydrated dosage instructions should be strictly followed noisy environments should be avoided for at least 6 months after treatment a and b a, b and c i don’t know section d: monitoring of pharmacotherapy-induced ototoxicity (to be completed by audiology and pharmacy students) otoacoustic emissions are sounds generated by the cochlea’s sensory hair cells in response to auditory stimulation. true false i don’t know pharmacotherapy-induced hearing loss affects lower frequencies first and then progresses to the higher frequencies higher frequencies first and then progresses to the lower frequencies both lower and higher frequencies at the same time i don’t know otoacoustic emissions are used to monitor effects of treatment treat ototoxicity before it progresses determine which medicine caused the ototoxicity change the sound generated by the cochlea i don’t know damage to the cochlea results in which side effects? tinnitus hearing loss dizziness loss of balance (disequilibrium) a and b c and d i don’t know which hair cells are more susceptible to ototoxic damage? inner hair cells outer hair cells middle hair cells all of the above i don’t know cisplatin and vancomycin causes which type of hearing loss? reversible irreversible i don’t know high-frequency sensorineural hearing loss is caused by damage to the cochlea vestibular organ tympanic membrane ear drum i don’t know baseline testing should be performed _________ treatment has started 2 h before 24 h before 2 h after 24 h after i don’t know pure tone audiometry tests determine absence or presence of hearing loss extent of hearing loss the cause of hearing loss all of the above i don’t know monitoring of ototoxicity can be done only once the patient starts experiencing ototoxic effects (e.g. tinnitus). true false i don’t know section e: prescribing of ototoxic medicine (to be completed by medicine students) a patient can receive more than two ototoxic medicines as long as the doses are not high. true false i don’t know if a patient starts experiencing ototoxic effects, the following should be done: change the medicine to less toxic ones counsel the patient change the dose of the medicine all of the above i don’t know when prescribing ototoxic drugs, the risk-to-benefit ratio should always be taken into consideration. true false i don’t know patients experiencing ototoxic effects should be referred for audiological monitoring only after the treatment has finished. true false i don’t know which of the following drugs can be used concurrently with ototoxic medicine to try to minimise the ototoxic effects? adrenaline n-acetycysteine sodium chloride paracetamol none of the above i don’t know audiological monitoring should be initiated before treatment, during treatment and after treatment only before treatment to assess hearing only after treatment to assess effect of treatment only during course of treatment none of the above i don’t know patients receiving ototoxic drugs should not be counselled about the possible effects as this will prevent treatment compliance. true false i don’t know most ototoxic drugs do not cause hearing loss when given at therapeutic doses. true false i don’t know which of the following drugs are the most ototoxic? furosemide erythromycin vancomycin aspirin i don’t know patients with a past history of hearing loss should not take any ototoxic medicine. true false i don’t know abstract introduction methods results discussion conclusion acknowledgement references about the author(s) vuyelwa z. peter discipline of audiology, school of health sciences, college of health sciences, university of kwazulu-natal, durban, south africa jessica paken discipline of audiology, school of health sciences, college of health sciences, university of kwazulu-natal, durban, south africa lavanithum joseph discipline of audiology, school of health sciences, college of health sciences, university of kwazulu-natal, durban, south africa citation peter, v.z., paken, j., & joseph, l. (2020). an audiological profile of a cohort of school-aged children with hiv and aids attending an antiretroviral clinic in south africa. south african journal of communication disorders, 67(1), a651. https://doi.org/10.4102/sajcd.v67i1.651 original research an audiological profile of a cohort of school-aged children with hiv and aids attending an antiretroviral clinic in south africa vuyelwa z. peter, jessica paken, lavanithum joseph received: 26 jul. 2019; accepted: 10 nov. 2019; published: 20 apr. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: recent estimates reveal that there are approximately 280 000 children between the ages of birth and 14 years who are living with the human immunodeficiency virus (hiv) and acquired immunodeficiency syndrome (aids) in south africa. these children are living with a compromised immune system, are vulnerable to opportunistic infections and subsequent hearing loss. however, there is limited research on the nature and extent of this sensory impairment amongst school-aged children. objective: this study aimed to determine an audiological profile of a cohort of school-aged children attending an antiretroviral (arv) clinic, describing the occurrence of hearing loss and nature in terms of degree, type, configuration and symmetry. methods: a non-experimental descriptive exploratory study was conducted, where 30 children aged between 6 and 12 years underwent diagnostic audiological assessments. audiological procedures included case history, medical record review, otoscopic examination, immittance audiometry, pure-tone audiometry, speech audiometry, distortion product otoacoustic emissions (dpoaes) and neurological auditory brainstem response (abr) testing. the results were analysed descriptively using spss version 22 software. results: the results indicated abnormal otoscopic findings in half the participants, and consequently type c tympanograms were the most common. of the 28 participants who could be assessed with pure-tone audiometry, 15 (54%) showed a hearing loss. a bilateral rising mild, conductive hearing loss was predominant. thirteen (43%) of the participants could not be tested using dpoae because of outer and middle-ear pathology. neurological abr testing revealed an abnormality in 18 (60%) of the participants suggesting the sensitivity of the abr to detect subtle neurological changes. conclusion: half the children in this study showed hearing loss, which has serious implications for the holistic management of the children within the health and educational contexts. therefore, there is a need for audiological monitoring of children with hiv and aids. keywords: audiological profile; hiv; aids; hearing loss; school children. introduction the joint united nations programme on human immunodeficiency virus (hiv) and acquired immunodeficiency syndrome (aids) estimated that approximately 280 000 children in south africa were infected with hiv in 2016 (united nations acquired immuno-deficiency syndrome [unaids], 2016). furthermore, they reported that 55% of children living with hiv in south africa are on antiretroviral (arv) treatment. the global use of arv is reported to have cut the number of deaths in half amongst children (aged 0–14 years) between 2010 and 2016, the major reason being increased access to paediatric arv therapy, especially in eastern and southern africa (unaids, 2017). thus, the disease and its treatment are of major interest worldwide. literature suggests that the hiv virus does not only attack the immune system but may also affect the function of different organs of the body, including the auditory system, which can result in hearing loss. the reported cause of hearing loss in these children can be attributed to otologic infections (gurney & murr, 2003), which may give rise to a conductive (chl), mixed (mxhl) or sensorineural hearing loss (snhl), as well as central auditory deficits, which could affect language development (abrams, moon, robinson, & van dyke, 2006; lasis, 2005). the hearing loss can thus manifest in young children through failure to attain language developmental milestones on par with other children (makar, dhara, sinha, chatterjee, & dutta, 2012). language is essential for thinking, communication learning, and hearing loss may interfere with successful learning (donald, walker, riordan, govender, & wilmshurst, 2012). this may result in poor educational outcomes and future prospects of employment (feagans, kipp, & blood, 1994), with a life-long effect on the quality of life. a study by shapiro and novelli (1998) on children hiv infection indicated that 32 (44.4%) of the participants presented with one or more episodes of middle-ear pathology, which was otitis media. whilst the results of a pathogen type of immunocompetent children were similar to the general population of children not infected with hiv, the results suggested that the severity of immunosuppression was associated with a higher incidence of middle-ear pathology. another study by matas, leite, leite-magliaro and gonçalves (2006) revealed that children with aids had more abnormal results than their counterparts. the authors suggested that aids be recommended as a risk factor for peripheral and/or auditory brainstem disorders. it also highlighted the need for regular follow up and monitoring of the peripheral and brainsterm pathways. this is further supported by palacios et al. (2008) who recommended that children with hiv and aids should undergo audiological evaluation at an earlier stage for immediate intervention to minimise the psychosocial impact of hearing loss on their development. matas, dos santos filho, de juan, pinto and gonçlaves (2010) further added that because of the growing incidence of hearing loss in hiv-positive people, audiological as well as electrophysiological investigations of hearing should be conducted to detect the alterations of the peripheral and central auditory pathways as the stages of hiv infection progress to aids stage. thus, it becomes vitally important to conduct hearing assessments on children who appear to be at high risk for hearing loss because of their hiv status. in-depth hearing assessment would shed light on the auditory manifestation of the disease as studies conducted on the adult population report a notable prevalence of sensorineural hearing loss (khoza & ross, 2002; khoza-shangase, 2010; makar et al., 2012; north-matthiassen & singh, 2006; paken, 2007). ototoxic medication in response to treating infections may also contribute to hearing loss; however, such studies are limited in the paediatric population (khoza-shangase, 2010; makar et al., 2012). whilst studies have highlighted the need for audiological assessment in the paediatric population, the actual prevalence and nature of hearing loss in this population is still not known, especially in south africa, as most published research relating to hiv and aids and hearing research is focussed on the adult population (khoza-shangase, 2010). there are limited published findings in south africa that report on the auditory status of hiv-infected children, and there is a need for such research to be published (moragan et al., 2002). this study, therefore, posed the question, what is the audiological profile of children with hiv and aids in south africa? therefore, this study aimed to determine the audiological profile of a cohort of school-aged children with hiv and aids during their medical monitoring at an urban public sector arv clinic in kwazulu-natal (kzn) south africa. methods study aim to determine an audiological profile of a cohort of school-aged children with hiv and aids at an arv clinic in kzn. study objective to describe the occurrence and nature of hearing loss in terms of type, degree, symmetry and configuration. study design a descriptive exploratory study design with non-probability convenience sampling was used. convenience sampling was used for the site selection as the primary investigator was employed at the study site during the data collection phase. participants were recruited and assessed once using a non-probability consecutive sampling technique (cresswell, 2009). the study was conducted at an arv clinic in an urban public hospital in durban, which is a metropolitan hub of kzn. description of study participants thirty children were recruited for this study, with 17 (60%) males and 13 (40%) females, and an age range of 6–12 years. participant’s grades ranged from grade r to grade 7. the mean age of the children was 4.3 years. there were 17 children in the foundation phase and 13 participants in the senior phase. twenty-nine participants (97%) were on arv treatment and one participant (3%) was arv naive at the time of testing, as his viral load was below detectable levels. twenty-three (79%) participants had been on arv for longer than 5 years, and six (20%) participants have been on arv for less than 5 years. twenty-one (72%) of the participants were on regimen two (consisting of zidovudine [azt] + epivir [3tc] + efavirenz [efv]) whilst eight (27%) participants were on regimen one (abacavir [abc] + 3tc + efv) treatment. twenty-eight (93%) of the participants had cluster of differentiation -4 (cd4) cell count category results reordered in their medical during the data collection phase of the study, and it ranged from 1 to 3 as reflected in table 1. majority of the participants (89%) were in the moderate category with cd4 cell of between 200 mm3 and 500mm3. table 1: cluster of differentiation 4 (cd4) percentage and cd4 count for children according to word health organization 2015 guidelines. data collection procedure the audiological evaluation followed the standard practice for children with a test battery approach and cross-check principle to ensure that results correlate (jacobson & jacobson, 2004) using the following seven tests, materials and equipment: a case history questionnaire was developed for this study. the questions were developed based on literature recommendations regarding the development of case history questionnaire. the questionnaire consisted of 26 questions, of which 10 were closed-ended and 16 were open-ended questions. this addressed the concern on content validity; the questions were translated into isizulu and back translated into english. the primary investigator is a first language isizulu speaker, and there was no need for an interpreter. the caregiver (parents or close relatives) who accompanied the child to the assessment provided the case history details. a medical record form was developed for the purpose of this study. it consisted of three sections that used a checklist to capture the required information. information on the following pertinent areas was included: cd4 cell measures within a 6-month period; viral load measures within 6 months; arv regimen was recorded for those who had commenced arv; other prescribed drugs for other medically related conditions; audiological interventions including audiological tests administered; and results and management strategies employed to manage the presenting audiological conditions. an otoscopic examination was conducted using a wall-mounted welch allyn diagnostic otoscope. the purpose was the identification of any outer ear abnormalities (gelfand, 2001). immittance audiometry, including tympanometry and acoustic reflex threshold testing, conducted using the interacoustic az 26 middle-ear analyser with a frequency tone of 226 hz (gelfand, 2001). distortion product otoacoustic emissions (dpoaes) were conducted using the gsi audera dpoae. pure-tone audiometry, including both air and bone conduction testing, was carried out using the madsen otometrics itera ii audiometer. air conduction pure-tone audiometry was conducted at every octave frequency from 250 hz to 8000 hz, with bone conduction audiometry ranging from 250 hz to 4000 hz. normal hearing was defined to be thresholds of less than 15 db across all the frequencies (gelfand, 2001). speech audiometry testing included speech reception thresholds (srt) obtained through live speech testing in a soundproof booth using a digit list by ramkisson (2002). the digit word list was used for isizulu-speaking participants, as there was no validated word list during the time of this study. this was to address construct validity concerns. speech discrimination testing (sd) to obtain word recognition scores was conducted using the isizulu discrimination word list developed by balkisoon (2001) for isizulu-speaking children in kzn. the list factored in cultural, linguistic and age appropriateness, using evidence-based principles accounting for reliability and validity concerns. no validated word lists developed for children were available during the time of the study. auditory brainstem response (abr) testing used a click. click stimuli with a rarefaction polarity at an intensity of 80dbhl, duration of 0.1 ms and speed of presentation of 11.1 ms stimulation per second were used. values of absolute latencies for waves i, iii and v and interpeak latencies i–iii, iii–v and i–v were identified. the abr was obtained using the gsi audera auditory evoked potentials (aep) in a sound-treated room. testing was conducted on the same day. testing was conducted in a soundproof booth and sound-treated rooms to ensure reliable results (gelfand, 2001). the participants were provided with comfort breaks between the tests to improve the concentration and reliability of the results (babbie, 2008). each participant underwent testing for 2 hours. the order of testing assessment followed this sequence: a case history, medical review, otoscopic examination, immittance, pure tone, speech audiometry, dpoae and abr with natural sleep. feedback on the test results was provided in the language of the client and if referrals to other health care professionals were required, an appointment was secured and referral letter issued on the same day. all equipment had undergone calibration to ensure reliable results. participants were recruited from the arv clinic at the selected hospital with the assistance of the clinic nurse during the data collection period. results were classified as either normal or abnormal using audiological normative data such as normal otoscopic examination findings, type a tympanogram, and ipsilateral and contralateral acoustic reflex thresholds between 70 db and 100 db spl. pure-tone audiometry across all frequencies of less than 15db and srt and pure-tone average agreement between 0 db and 5 db. the results were descriptively analysed and classified as either normal or abnormal. data were analysed using spss version 22 software with the assistance of a statistician. descriptive results were conducted using percentages, and frequency. ethical and legal considerations were in line with the world medical association’s 2008 helsinki declaration, which included informed caregiver consent and child assent. the participants’ identities were kept confidential as they were assigned numbers for identification purposes. a pilot study was conducted on five participants to establish whether the case history questionnaire questions were clear and to identify ambiguity. the pilot study aimed to assess the rate, ease of recruiting participants and the time to conduct a full audiological test on each participant (babbie, 2008; gravett & foronzo, 2009). the recommendations from the participants of the pilot study were used to guide the data collection process (shi, 2008). the participants in the pilot study were not included in the main study. the pilot study assisted to address concerns on process issues such as participant recruitment and legible criteria. in addition, it addressed resource concerns such as time for testing, equipment reliability, referral pathways and if the testing procedure resulted in the correct identification of hearing loss (thabane et al., 2010). construct validity was accounted for by a pilot study, and the use of valid audiological and calibrated equipment. reliability was ensured by providing short breaks between tests, and abr result interpretation was confirmed by an expert in the field and by adhering to a data collection schedule (creswell, 2009). children identified to have a hearing loss and other medical conditions were referred to the relevant health care professionals within the facility. ethical consideration ethical approval was obtained from the university of kwazulu-natal biomedical research and ethics committee (ethical clearance no. be051/13), the provincial kwazulu-natal department of health research office and the chief executive officer at the study site. written informed consent was obtained from the caregiver, and written assent was obtained from each child participant in the study (greig, taylor, & mackay, 2007). results case history interview results half (15; 50%) of the participants reported delays in speech-language developmental milestones, and 14 (46%) participants had other coexisting medical conditions that included tuberculosis, epilepsy and encephalopathy. thirteen (43%) participants were suspected of hearing loss by the caregivers, and 24 (80%) participants had never had an audiological assessment although they had reported ear pathology to other health care professionals. concerning educational history, 14 (47%) of the participants had repeated a grade whilst 15 (50%) reported not being able to cope academically in the current grade. audiological results are presented below in terms of right and left ears. otoscopic examination results observations revealed the presence of occlusive impacted wax (eight right and six left ears), discharge (two left and two right ears) and perforated tympanic membranes (four right and five left ears). immittance audiometry type a tympanogram, suggesting normal middle-ear function, was evident in the right ear of 17 participants (68%) and the left ear of 18 participants (75%), as indicated in table 2. as to be expected, results of ipsilateral and contralateral reflexes were significantly influenced by the status of the middle ear. five participants could not be tested because of the presence of discharge. abnormal results included no responses and elevated thresholds. thus, 12 (40%) of the participants had abnormal immittance results. table 2: immittance audiometry results. pure-tone audiometry pure-tone audiometry was conducted on 28 participants (n = 28), as two children could not be conditioned for testing. of the 28 participants assessed, hearing loss was observed in the right ear of 15 (54%) and left ear of 13 (46%) participants. of the 16 (57%) participants who presented with a hearing loss in either one or both ears, four (25%) presented with a unilateral hearing loss, whilst the majority 12 (75%) had bilateral hearing loss, with six (38%) having symmetrical hearing loss. only 12 (43%) of those tested presented with hearing within normal limits. normal hearing was classified with thresholds better than 15 db across all the frequencies (gelfand, 2001). mild hearing loss was the most common degree of hearing loss observed in 12 (42%) participants, as depicted in figure 1. conductive hearing loss was the predominant type of hearing loss observed in eight (29%) participants, as depicted in figure 2. figure 1: hearing loss degree. figure 2: types of hearing loss. the most common configuration was a rising pattern, which is commonly associated with conductive hearing loss. speech audiometry results speech audiometry results are reflected in table 3. the majority of participants obtained good srt-pta correlation, indicating good pure-tone test reliability. good correlation was considered when the srt-pta correlation was less than 5 db, fair correlation between 6 db and 9 db and poor correlation greater than 10 db (gelfand, 2001). ninety-six per cent of the participants obtained 90% – 100% speech discrimination, which is in keeping with the pure-tone audiometry results and conductive hearing loss. word recognition scores of more than 88% are considered good (gelfand, 2001). table 3: result of speech audiometry testing (n = 28). electrophysiology twelve (40%) of the participants were not assessed using dpoae because the presence of outerand middle-ear pathology. majority the sample (83%) had a pass result for the right ear, with 12 (70%) having a pass in the left ear. half of the sample (15; 50%) had abnormal absolute latency for the right ear and 10 (33%) for the left ear (tables 4 and 5). table 4: distortion product otoacoustic emission distortion product otoacoustic emissions results. table 5: neurological auditory brainstem response abr results. discussion almost half the children in this study had some degree of hearing loss. these findings are higher than the prevalence of 32% for the age group of 7–12 years reported by matas et al. (2010). ensink & kupper (2017), in their review of studies on hearing loss in people infected with hiv, reported a prevalence range of 22% – 13% in children. whilst this finding may be attributed to the small sample size in the current study, it is in line with reports that south africa has a high prevalence of children with hiv and aids globally. however, the occurrence of hearing loss in this population has not been adequately reported in spite of the high hiv and aids prevalence (unicef, 2012). one can conclude that there are varying prevalence rates globally related to hearing loss associated with the hiv and aids population. therefore, regular audiological monitoring is warranted, and the researchers concur with the view of palacios et al. (2008) supporting this. regular monitoring and documentation will assist in understanding the audiological manifestations of hearing loss in children infected with hiv, as there are limited studies that have reported on the prevalence of hearing loss in this population. in this present study, the degree of hearing loss varied across the participants, with the majority of the participants having mild hearing loss, that is, eight (29%) of right ears and 13 (46%) of left ears. these results agree with the findings of de lange (2007) and khoza and ross (2002) who found mild hearing loss to be the predominant degree of hearing impairment in the adult population with hiv and aids. however, in children, a mild hearing loss is usually not detected easily, and one of the symptoms is auditory fatigue in school because of the extra effort required to listen (paluski & kaderavek, 2002). early-onset of any hearing loss could result in reduced processing at the lower brainstem and cortical levels in subsequent years (maruthy & mannarukrishniah, 2008). auditory processing deficits may manifest as poor concentration, auditory recall, auditory analysis and synthesis. these aspects are, however, essential for reading and writing abilities (feagans et al., 1994). therefore, language and auditory processing deficits, resulting from a hearing loss, can interfere with the successful acquisition of literacy skills (carney & moeller, 1998). children with reading fluency problems associated with hearing loss also present with difficulties in reading comprehension (chandrasekhar et al., 2000). it is, therefore, imperative that early identification of hearing loss be established to improve the academic performance and vocational potential of each child (paluski & kaderavek, 2002). the significance is that educators and other health care professionals need to be alerted that auditory fatigue could be a sign of mild hearing loss, including in children with hiv and aids. in this study, we found conductive hearing loss to be the predominant type of hearing loss, in line with the findings by shapiro and novelli (1998), matas et al. (2006) and palacios et al. (2008). khoza (2002) and de lange (2007) found different results, where sensorineural hearing loss was dominant. however, both studies were conducted in the adult population. robbert et al. (2017) found that conductive hearing loss was predominant in children with hiv. meuller and pizzo (1997) attributed the high prevalence of hearing loss in children with hiv to an immature immune system, resulting in a high susceptibility to otologic infections and hearing loss, thus amplifying the need for early identification and management. children with severe immunosuppression are likely to have otologic conditions that will affect their hearing (feagans et al., 1994). palacios et al. (2008) reported that audiological abnormalities were more frequent in patients with more prolonged hiv-1 infections, higher viral loads or lower absolute cd4+ cell counts. this phenomenon was not part of the study scope, as the focus was on determining the audiological profile. however, in the south african context, khoza-shangase (2010) and de lange (2007) had different results, where sensorineural hearing loss was dominant. in this study, it was observed that conductive hearing loss was the most predominant type of hearing loss, and a rising audiometric configuration was predominant, which is in line with conductive hearing loss that could be associated with otitis media (most & tsach, 2010). miziara, webber, cuhna, filho and neto (2007) conducted a study where they assessed the prevalence of otitis media associated with the use of highly active antiretroviral therapy (haart) in hiv-positive children. the results revealed that otitis media had a prevalence of 31% and, therefore, the use of haart resulted in a lower prevalence of otitis media. the age group studied in miziara et al. (2007) is similar to the current study echoing similar findings. palacios et al. (2008) correlated a lower cd4 cell count to auditory pathology and concluded that immunocompromised children are susceptible to otologic infections including otitis media. besides, the researcher speculates that conductive hearing loss could also be related to the time of data collection, during the month of june, when it is winter in south africa, a season associated with a higher prevalence of upper respiratory tract infections associated with otitis media (khoza-shangase, 2011). of the 16 (57%) participants with a hearing loss, four (25%) participants presented with unilateral hearing loss whilst 12 (75%) participants presented with bilateral hearing loss. caregivers suspected hearing loss in 13 (43%) participants, and 24 (80%) participants had never had an audiological assessment even though they had reported ear pathology to other health professionals, indicating a need for caregiver reports of ear-related concerns to be addressed through audiological assessments (carney & moeller, 1998; north-matthiassen & singh, 2006; olyer, oyler, & matkin, 1988; paluski & kaderavek, 2002). the caregivers in this study reported hearing-related concerns and suspicions of hearing loss to other health professionals but no audiological referrals were made for further investigations. olusanya, okolo and ijaduol (2000) reported that the lack of understanding of the impact of hearing loss on academic potential was a contributing factor to such a high incidence of unreported hearing loss in africa. the lack of the necessary audiological referrals raises a concern regarding the prioritisation of hearing loss in the public health care system, especially to children who are vulnerable to hearing loss (taha et al., 2010). furthermore, in this study, half of the participants reported that their children had repeated a grade, indicating that the presence of a hearing loss had possibly negatively affected scholastic performance. therefore, there appears to be a possible link in children between immunocompromise and susceptibility to hearing difficulties that negatively impact on academic performance (most & tsach, 2010). there are other neurological factors such as the neurotrophic nature of the virus that needs to be considered in the population of children infected with hiv (gross, wolf, elidan, & eliashar, 2007). the human immunodeficiency virus is reported to affect the inner ear, as the virus has been reported to be neurotropic and can present with neurological symptoms (lasis, 2005). viral agents have been reported to attack the spiral ganglion and acoustic section of the eighth cranial nerve, resulting in the sudden onset of a permanent hearing loss (gross et al., 2007). in this study, it was observed that participants who have epilepsy and hiv encephalopathy showed abnormal abr results (govender, eley, walker, petersen and wilmshurst, 2014). in addition, it was initially believed that the virus affects only the immune cells of the body, and further research has indicated that the virus attacks and destroys the central nervous system (cns), with an estimated 10% – 30% of people infected with hiv displaying neurological abnormalities (khoza-shangase, 2010; makar et al., 2012; harris, et al., 2012). paken (2007) confirmed that there are neurological changes in normal-hearing adults with hiv and aids; however, similar findings in children need further investigation. hence, a neurological abr was recommended for inclusion in the test battery for this study to assess neural integrity. the neurological abnormalities can also be associated with hearing-related problems, with reports of auditory processing deficits, central hearing loss and auditory brainstem disorders, which negatively affect language development and communication (makar et al., 2012). this study supports the principle that abr is sensitive to detect neurological subtleties, which might not be detected with other tests (gross et al., 2007). therefore, immunocompromised children could require audiological assessments, including neurological abr, for earlier detection of the subtle neurological changes that can affect hearing. conclusion whilst the present study findings cannot be generalised to the entire south african population because of the small sample size, it has identified that incidence of hearing loss in children with hiv and aids appears to be higher than observed internationally. however, this finding is interpreted with caution because of study limitations. this study supports khoza-shangase’s (2011b) the assertion that there is a role for the audiologist in the assessment and management of hearing in children with hiv and aids. furthermore, it was observed that audiological referrals were not facilitated in spite of caregiver reports of hearing concerns by health professionals managing the children. audiologists need to prioritise health promotion in health facilities, including the arv clinics. therefore, children with hiv and aids, in this study, as a result of compromised immunity, are prone to hearing loss that needs identification, even if they are asymptomatic, to give them a fair opportunity to succeed in life. studies on larger sample sizes across various sites need to be conducted to track hearing issues in children with hiv and aids. in addition, further studies to investigate neurological changes and hearing status could be explored. the pervasive nature of hiv and its effect on a child’s developmental trajectory must be borne in mind by all health care professionals. acknowledgement the authors would like to thank the discipline of audiology at university of kwazulu-natal for the equipment and support. a special acknowledgment to hospital staff for their assistance with the research, the participants for their willingness to be part of this study and the statistician ms f. nkwanyana for the support in the analysis of the results. competing interests the authors have declared that no competing interests exist. authors’ contributions v.z.p. is the primary investigator, and she performed all the aspects of this research and wrote the manuscript. j.p. supervised this research, made conceptual contributions to this study and critically reviewed and amended the manuscript. dr l.j. supervised this study, made conceptual contributions, and critically reviewed and amended this manuscript. funding information this project received funding from the college of health science research funding grant from the university of kwazulu-natal, durban, south africa. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency or the authors. references abrams, e., moon, r.y., robinson, l.g., & van dyke, r.b. 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(2017). unaids data 2017. geneva: united nations aids (unaids). retrieved from https://www.unaids.org/sites/default/files/media_asset/20170720_data_book_2017_en.pdf unicef. (2012). global hiv/aids response: epidemic update and health sector progress towards universal access. progress report 2011. retrieved from http://www.wpro.who.int/hiv/pub/progress_report2011/en/ 33. rhythmic distraction techniques in a dysphemic therapy. a general discussion. by m.l. rosendorff. (b.a. dip. log.) distraction has been defined as "an occupation that relieves excessive concentration", and this may well be applied to any procedure that draws attention away from the speech defect of stuttering. according to this definition then, one may consider imposed rhythms, including the three general types, bodily rhythms, speech rhythms, and rhythmic sensory stimulation, as "distractions". all these may be successful in reducing tho frequency of stuttering, usually for a limited period, and in homo cases to a zero degree. this seems to "offer conclusive evidence that stuttering is not basically a phonetic difficulty"» that distractions may bo of use in the therapy of stuttering cannot, be denied. ' first of all as tho above definition points out, distractions do "relievo the excess concentration" with which the stutterer regards his speech. two simultaneous occupations usually mean a division of concentration, and when the stutterer has to divide his attention between speech and another occupation, lie is likely to be less conscious of the former. this moans that ho .has 1 ess opportunity and. time to be emotional about his talking, and with the psychological factor reduced, the stuttering decreases. • the stutterer himself, however, does not realise at the time, or in any case, during the first few times, of using the distraction, that it is in reality a division of attention, or a "relieving of concentration", that is helping him in his speech, and imagines either that he is improving, or that there is some magical charm in what he is doing. this point can be made use of at the commencement of α therapy. often when a stutterer comes to a speech therapist ho has already become convinced that he is an abnormal person because he cannot speak like other people, and has given up all hope of ever attaining a normal speech flow. if, during the first few lessons, he is given an opportunity by means of these distractions to find that he can bo as successful as any other talker, (for example, when reading with a metronome,) it may lay an important foundation for the building up of confidence, not only· for his own future improvement,' but confidence in his clinician as well. secondly, as has been pointed out, it proves to him that he is not a stutterer because of incurable organic conditions, but that he is a normal speaker who has been subjected to abnormal stimuli. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 54. distractions as an aid in therapy, need not necessarily be discarded after the first few sessions, but may be used to advantage right through tho treatment, combined with other techniques. it must be remembered that in this discussion of distractions, we are considering more specifically, the three general typos of imposed rhythm; speech, bodily and rhythmic sensory stimulation. stuttering has as one of its manifestations a lack of rhythm. using an imposed rhythm,in speech, a patient can bo mado to talk in.time with tho ̂ rhythmic auditory stimulation furnished by the metronome — beginning during tho first few loss'ons, at a very low imposed speed, and gradually increasing this, till later in tho therapy the beat is almost similar to a normal speaking rate. the case should then try to get the same feoling of imposed rhythm without using the metronome, but by imagining that he hears the beat. the same of course can be done with bodily rhythms, such as foot-tapping and armswinging, or it can be utilised by beginning first of all with tho metronome, then going on to arm-swinging, then to foot-tapping, then finger-tapping,_and finally to an imagined rhythmical stimulation, coming down the scale, as it were, in descending order of gross actions, these becoming less and less noticeable. choral speaking may be considered as another example of imposed rhythmical stimulation, and this may be very well adapted to a group therapy. there are however, disadvantages in a distraction technique, which cannot be overlooked, and almost overcome the advantages. when he first begins to use a distraction to help overcome the stuttering spasm, the distraction is at a highly conscious level. but with constant use one finds that the stutterer tends to become negatively adapted to the distraction, and it later becomes automatic and canalised and the stutter reappears. often he still uses, but quite unconsciously now, the former distraction, and adds a new one to help him over his difficulties. this may later become canalised too,, so that one may find a stutterer, who clicks his fingers and taps hi3 feet, all this appearing quite unconscious. it is thus unwise to uso distractions as "tricks" to overcome the spasms, because they are so apt to become automatic. secondly one must' consider that distractions aro ways of concealing the repetitions and blocks, characteristic of a stutterer's speech, from others in the social environment, but that however good the camouflage may be, the clumsy hesitant speech remains all the while, and the stutterer is terrified that the guise might be penetrated. distraction techniques do not allow for the stutterer to become "toughened up" towards his defect, nor does it allow him to bo properly adjusted to it. by concealing the stutter, speech may sound far better to those in the audience, but the stutterer feels no improvement, because of the strain it imposes upon him. a third disadvantage of distraction techniques, is that it in itself does not include the important psychological factors of tho individual's life such r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 35. as his homo or worlc environment, his personality make-up, and his social attitudes and evaluations. it makes no provision for these in its therapy, and they are too important to he overlooked. tho investigation of a stutterer's general background is as important as an improvement in his speech pattern. but as virginia barber says "a real understanding of the mechanism of distraction, would probably load to the basic nature of stuttering itself, for if we could isolate and understand the operation of the factors which alleviate tho difficulty, it is at least highly probable that most revealing clues to the fundamental etiology of the disturbance would follow." invitation to the hard-of-hearing. new comfort and ease with s o n o t o n e . better hearing is more than putting on a hearing aid.' every case is different, and the very first step is to find out what the problem is. when you place yourself under the personal guidance and care of sonotone trained technicians, your hearing loss is scientifically estimated through an audiometer and chart. without cost or obligation, a sonotone technician will chart your hearing loss, which is vital to every person with-a hearing impairment. phone or mail this coupon for an appointment at your convenience.' the magic key doubles hearing comfort: advanced design brings you the convenience of all-in-one design, without dangling cord or outside batteries as well, or the economy combination with long-life batteries for those requiring plus power. sonotone laboratories, protea electro-medical ltd. p.o. box 7993 johannesburg phone 22.0511. (office's throughout the union). name: address: date appointment is preferred: r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) acknowledgements references about the author(s) katijah khoza-shangase department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa nomfundo f moroe department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa anita edwards south african journal of communication disorders, durban, south africa citation khoza-shangase, k., moroe, n.f., & edwards, a. (2020). occupational hearing loss in africa: an interdisciplinary view of the current status. south african journal of communication disorders, 67(2), a700. https://doi.org/10.4102/sajcd.v67i2.700 note: special collection: occupational hearing loss in africa. editorial occupational hearing loss in africa: an interdisciplinary view of the current status katijah khoza-shangase, nomfundo f moroe, anita edwards received: 03 feb. 2020; accepted: 04 feb. 2020; published: 03 mar. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. keywords: africa; current; context; hearing loss; interdisciplinary; occupational. noise-induced hearing loss is 100% preventable if the collaborative stakeholders in the prevention process are fully committed to the process and implement effective measures timely. audiologists have within their scope of practice the prevention of hearing loss and this needs to be at the forefront of all advocacy campaigns to prevent occupational hearing loss (ohl). in a systematic review by moroe, khoza-shangase, kanji and ntlhakana (2018), where literature into the exposure to occupational noise in developing countries suggested that the prevalence of occupational noise-induced hearing loss (onihl) is still high, significant gaps in locally relevant and responsive evidence were identified. there is also evidence that the mining industry is aware of this epidemic; however, the efforts to curb onihl are currently unsuccessful. these authors explored and documented current evidence reflecting trends in the management of onihl in the mining industry in africa from 1994 to 2016 through the use of the preferred reporting items for systematic reviews and meta-analysis. findings from this systematic review indicated that there is a dearth of research on the management of onihl in africa. the limited research on the management of onihl focuses on some aspects of the hearing conservation programme pillars and not on all the pillars as suggested by some scholars in the field. furthermore, they found that published studies had small sample sizes, thereby minimising their generalisation. this systematic review’s findings highlighted a need for more studies on the management of onihl in the mining sector, as evidence suggests that this condition in african countries is still on the rise; hence, there is the importance of this special issue, based on south africa. the south african mine health and safety council (mhsc, 2016) clearly articulates its goal as ‘every mine worker returning from work unharmed everyday: striving for zero harm’. moroe et al. (2018) argue that as far as ear and hearing health is concerned, this goal has not been realised despite the concerted efforts from the mhsc and the chamber of mines in south africa. these authors present evidence that reveals the reality that approximately 73.2% of miners in south africa are exposed to excessive noise surpassing the legislated occupational exposure limit of 85 decibel (db), despite hearing conservation programmes (hcps) implemented in the mining sector (edwards, dekker, franz, van dyk, & banyini, 2011; strauss, swanepoel, becker, eloff, & hall, 2014). this is over and above exposure to other toxins including burden of diseases such as tuberculosis, which exacerbate the problem (khoza-shangase, 2019). evidence from numerous studies, which have been conducted to evaluate the effectiveness and efficacy of management of ohl within the south african mining industry, have yielded unfavourable findings, which indicate that significant efforts are still required to successfully manage ohl (dekker, edwards, franz, & banyini, 2011; edwards & kritzinger, 2012; edwards, milanzi, khoza, letsoalo, & zungu, 2015). well-integrated and comprehensive hcps are those that acknowledge the multi-component nature of the interventions, comprising seven pillars: periodic noise exposure monitoring, engineering controls, administrative controls, personal hearing protection, audiometric evaluations, employee and management education, and training and record keeping (hong, kerr, poling, & dhar, 2013). moroe (2018) argues for these interventions to be viewed as a form of complex interventions in order to be realistic about implementation. against this backdrop, the guest editors, prof. katijah khoza-shangase and dr nomfundo moroe, who are both from department of speech pathology and audiology at the university of the witwatersrand, embarked on this special issue entitled ‘occupational hearing loss in africa: an interdisciplinary view of the current status’ by inviting research papers from academics and researchers, specifically in the mining sector in africa. this special issue presents current contextually relevant and responsive evidence that fills the gap in occupational audiology, while responding to the call for evidence to be afrocentric. the goal of the special issue is to provide a comprehensive current status overview of ohl within the african context in order to contribute towards the industry’s ability to meet the elimination of hearing loss targets. this special issue therefore looks at challenges as well as possible solutions for the african context. papers presented include original research and review papers. the papers address any of the following sub-themes in the field of ohl that are either directly or indirectly related to the main theme: (1) recent advances in the management of occupational noise, (2) barriers and/or facilitators to hearing conservation, (3) contextual factors influencing implementation of hcps, (4) monitoring and evaluation factors in occupational noise, (5) other toxins contributing to ohl and (6) policy and legislation in the management of occupational noise. published evidence indicates that the prevalence of ohl is high in lowand middle-income (lami) countries, such as south africa. this is a serious indictment as hearing loss is known to represent a heavier burden in lami countries than in high-income regions of the world because of the challenges faced by lami countries when compared with their developed counterparts. this is particularly concerning in a country of significant socio-economic inequity such as south africa, where ohl can present a limitation on the kind of employment suitable for a person with a hearing impairment (reid et al., 2006). establishing the status of ohl and its management in lami countries is important if strategic planning about this occupational health challenge has to be systematic and successful. this challenge is applicable to other african countries covered in this special issue, such as tanzania and zimbabwe. the article ‘risk vs. benefit: who assesses this in the context of occupational noise-induced hearing loss in the mining industry?’ starts off by highlighting important strategic indicators as well as important variables that the occupational health and audiology community needs to consider in order to plan more effective hcps to prevent onihl. although this paper is contextualised within the south african mining context, it is generalisable to most lami countries. the authors highlight the importance of regulatory authorities to hold the employers accountable for the elimination of onihl, and the important role that audiologists should play in conducting best risk–benefit evaluation of hcps during the development and monitoring process. the role of regulatory authorities is explored comprehensively in the article entitled ‘a critical analysis of current south african occupation health law and hearing loss’. the authors provide a comprehensive review of current south african occupational health law in relation to hearing loss. one of the important gaps in the law identified by the authors is the highly divided legal framework of occupational health and safety (ohs) in south africa, which, according to the authors, perpetuates a monological ‘excessive noise-hearing loss’ paradigm that has serious implication for the rights of all workers to equal protections and benefits specifically with respect to occupational audiology healthcare. these authors assert that there is a need to harmonise ohs law and expand the scope of hearing protection legislation to include the full range of established and present ototoxic hazards to ensure that all workers receive equal protection and benefits from the law. findings presented in the paper ‘chemicals, noise and occupational hearing health in south africa: a mapping study’ support the aforementioned view. this paper answers the question, ‘what is the nature of knowledge about occupational ototoxic chemicals and/or noise exposure in south africa?’, with findings clearly indicating that chemical exposures are only just beginning to be recognised as ototoxic in south africa; therefore, regulations need to consider this as an important aspect of hcps. the articles ‘burden of disease: a scoping review of hiv/aids and tb in occupational noise-induced hearing loss’ and ‘middle ear pathologies in adults within the mining industry: a systematic review’ argue that over and above chemical exposure as a compounding factor in ohl, considerations of burden of disease in otology and audiology should be viewed as critical as certain diseases can cause hearing impairment as a primary effect, as a secondary or opportunistic effect, or as a side effect of treatment options for that disease. when an employee is suffering from any such diseases, concomitant exposure to hazardous noise levels can present an even bigger challenge to successful hcps, if the complex interactions are not taken into consideration in the conception, implementation and monitoring of hcps. furthermore, the article ‘occupational noise and age: a longitudinal study of hearing sensitivity’ reminds the readers of the impact of age as an influencing factor, over and above the aforementioned factors, also in ohl. the focus on the employees is further seen in the article ‘does occupational noise matter among manufacturing sme workers? empirical evidence from magaba, mbare’, where the authors explore how occupational noise impacts attitudes towards occupational noise exposure, susceptibility to hearing loss and job performance. the article ‘occupational noise-induced hearing loss in the mining sector in south africa: perspectives from occupational health practitioners on how mineworkers are trained’ places the employees in the hands of occupational health personnel (ohps) by exploring these stakeholders’ perspectives regarding education and training of mineworkers on onihl and its impact on mineworkers’ health. important contextual factors, such as linguistic and cultural diversity considerations, are suggested as critical if efficient training programmes for employees of hcps are to succeed within the african context. the role of the ohps, with a special focus on the audiologist, is centralised in hcps in the articles ‘secondary data review of a south african platinum mine: estimating miners’ risk for occupational noise-induced hearing loss’, ‘classification of audiograms in the prevention of noise-induced hearing loss’ and ‘feedback-based noise management matrix in action’. accurate, comprehensive and efficient data capturing, management and use is key to any successful programme implementation and monitoring. such data management relies on the use of accredited sensitive and valid measures as well as classification and criteria – with the data allowing matrix and models to be utilised in a complex intervention manner to plan, execute and monitor primary preventive programmes such as hcps. for example, the article ‘feedback-based noise management matrix in action’ demonstrates a basic static feedback model with its practical applications, such as estimating, monitoring and providing quantitative information to aid miners, mining administrators and policymakers in decision-making around hcps. the articles entitled ‘recent advances in hcps: a systematic review’ and ‘engineering noise control for mines: lessons from the world’ offer critical review and analysis of advances that require serious deliberation and consideration because they could be of benefit to lami contexts such as africa, with a goal to learn from developed contexts in order to meet the noise elimination targets. the authors of these papers provide this evidence while interrogating the practicability and implementation possibilities within the south african or african mining industry. these advances are presented with careful consideration of the african context, allowing the readers to apply these in a contextually responsive manner. the article ‘south african hearing conservation programmes in the context of tele-audiology: a scoping review’ takes the importance of contextual relevance to conclusion in this special issue by offering strong recommendations about the application of tele-audiology as a service delivery model because of its particular relevance in resource-constrained settings, such as africa. because of the significant capacity:demand challenges in lami countries and the need for scaling up audiology professions’ management of hcps as they fall under their scope of practice, the authors of this manuscript suggest careful consideration of tele-audiology as a platform to deliver services in these contexts. tele-hcps have been explored as one of the leading recommendations for increasing access to services within lami contexts. the above papers have comprehensively addressed issues of policy and law, context, assessment, management, monitoring, as well as challenges and solutions in this first special issue on ohl within the african context in the history of the south african audiology profession. overall, these papers highlight the following key issues: (1) the importance of translation of knowledge, laws and regulations into practice; (2) the value of collaborative work of all stakeholders for hcps to be successfully implemented within complex interventions, with audiologists centrally placed; (3) the need to keep abreast with recent advances and their implementation where relevant and responsive contextually; (4) the importance of context analysis in programme implementation; and (5) the complex nature of ohl as well as the importance of managing this within a complex intervention framework. the guest editors are deeply grateful to the national institute for the humanities and social sciences and the consortium for advanced research training in africa for the financial support in producing this special edition. acknowledgements the authors would like to thank the academics and researchers who contributed their valuable work to this important special issue. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions k.k.-s. and n.f.m. co-conceptualised the idea for the special issue. all three authors contributed to this editorial, with k.k.-s. being the lead author in the writing up of the manuscript for publication. all three authors read and approved the final version of the manuscript. funding information the authors thank the national institute for the humanities and social sciences (nihss) and the consortium for advanced research training in africa (carta) for providing financial assistance for the publication of this editorial, as well as for the articles published within this special issue. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references dekker, j.j., edwards, a.l., franz, r.m., & banyini, a. (2011). meeting the milestones are south african smallto medium-scale mines up to the task. south african institute of mining and metallurgy, 111(5), 309–313. edwards, a., & kritzinger, d. (2012). noise-induced hearing loss milestones: past and future. south african institute of mining and metallurgy, 112(10), 865–869. edwards, a., milanzi, l.a., khoza, n.n., letsoalo, m.s., & zungu, l.i. (2015). evaluation of the current practices of noise-induced hearing loss (nihl) awareness training in the south african mining industry. occupational health southern africa, 21(1), 11–17. edwards, a.l., dekker, j.j., franz, r.m., van dyk, t., & banyini, a. (2011). profiles of noise exposure levels in south african mining. the journal of the southern african institute of mining and metallurgy, 111(5), 315–322. hong, o., kerr, m.j., poling, g.l., & dhar, s. (2013). understanding and preventing noise-induced hearing loss. disease-a-month, 59(4), 110–118. https://doi.org/10.1016/j.disamonth.2013.01.002 khoza-shangase, k. (2019). hearing function of gold miners with and without a history of tuberculosis: treatment: a retrospective data review. brazilian journal of otorhinolaryngology (in press), pii: s1808-8694(18)30189-7. https://doi.org/10.1016/j.bjorl.2018.12.003 mine health and safety council. (2016). vision, mission, values. retrieved n.d., from http://www.mhsc.org.za/ moroe, n.f. (2018). occupational noise-induced hearing loss in south african large-scale mines: exploring hearing conservation programmes as complex interventions embedded in a realist approach. international journal of occupational safety and ergonomics, 2018, 1–9. https://doi.org/10.1080/10803548.2018.1498183 moroe, n.f., khoza-shangase, k., kanji, a., & ntlhakana, l. (2018). the management of occupational noise-induced hearing loss in the mining sector in africa: a systematic review – 1994 to 2016. noise and vibration worldwide, 49(5), 181–191. https://doi.org/10.1177/0957456518781860 reid, n., thorne, p., ameratunga, s., williams, w., purdy, s., & dodd, g. (2006). best practice in noise-induced hearing loss management and prevention: a review of literature, practices and policies for the new zealand context. retrieved november 01, 2019 from https://dspace.nal.gov.au/xmlui/bitstream/handle/123456789/481/best%20practice%20in%20noise%20-%20induced%20hearing%20loss%20management%20and%20prevention.pdf?sequence=1&isallowed=y strauss, s., swanepoel, d.w., becker, p., eloff, z., & hall, j.w., iii. (2014). noise and age-related hearing loss: a study of 40 123 gold miners in south africa. international journal of audiology, 53(2), s66–s75. https://doi.org/10.3109/14992027.2013.865846 clinical implications of a neuropsychological approach to aphasia aura kagan ma (speech pathology) (witwatersrand),* michael saling phd (witwatersrand),t margaret marks wahlhaus ma (witwatersrand)* * department of speech pathology and audiology, university of the witwatersrand, johannesburg, t department of psychology, university of the witwatersrand, johannesburg. abstract this paper deals with the clinical implications arising out of a study designed to evaluate luria's approach to the cerebral organisation of higher mental functions such as language. the research took the form of four in-depth case studies of aphasic patients and involved a comparison of neuropsychological predictions as to the site-of-lesion with radiological findings (cranial computerised tomographic scanning). correspondence was felt to be good in most instances, indicating that luria's theory provides a valid framework within which to relate clinical symptomatology andfocal brain damage. the fact that luria places clinical practice on a firm theoretical foundation is seen as being advantageous and is discussed in relation to assessment and therapy. opsomming in hierdie studie word luria se benadering tot die organisasie van hoer-verstandelike funksies soos onder andere, taal, evalueer. die kliniese implikasies van die studie kom veral onder die soeklig. die navorsing het uit vier gevalle studies van afatiese patiente bestaan. 'n vergelyking is tussen die neuropsigologiese simptome as voorspelling van die lokus van die letsel, en radiologiese bewysings, getref. die ooreenkoms tussen die neuropsigologiese voorspelling en die lokus van die letsel was in meeste gevalle goed. dit dui dus aan dat luria se teorie 'n geldige raamwerk verskaf waarbinne kliniese simptomatologie enfokale breinskade gekoppel kan word. die kliniese praktyk wat luria op so 'n vaste teoretiese grondslag bou, word met betrekking tot diagnose en behandeling bespreek. the speech clinician involved in the assessment and remediation of aphasia is confronted by a bewildering array of approaches to this complex disorder. this paper focuses on some clinical implications arising out of a study** designed to evaluate, within the context of speech pathology, the neuropsychological approach developed by luria, who has been described as "this century's leading soviet figure in aphasiology".8 according to hatfield,8 luria is one of the few leading aphasiologists who has combined clinical practice with theory. this is seen as a major advantage, but it does imply that an understanding of the general neuropsychological principles upon which luria based his work is essential for the clinician who wishes to use this approach. a brief resume of theoretical aspects relevant to this paper follows. luria viewed his work on the organisation of higher mental functions in the brain as incorporating the positive aspects of two opposed approaches to the subject. he felt that neither the mechanistic narrow view, given its major impetus by the work of broca,1 nor the integral or noetic view, supported by authorities such as goldstein,5 successfully accounted for the cerebral organisation of higher mental function. both views in luria's opinion contributed to misunderstandings of this complex subject. **this study formed part of the first author's ma dissertation entitled "a © sasha 1983 in a re-examination of concepts such as function, localisation and symptom, luria retained and integrated parts of both the extreme views mentioned above, while successfully avoiding the less desirable aspects, namely, the idea that complex mental processes can be located in a single focal area of the brain on the one hand, and that such activities involve the whole brain in an undifferentiated fashion on the other. according to luria,12 13 one should conceptualise the higher mental functions as functional systems with an extremely complex composition. the performance of iany such mental activity necessarily involves the co-operation of many different parts of the brain. luria divides the brain into three main functional units. these units and their further subdivision into hierarchically arranged cortical zones, are described in detail in his works'2 13 and are represented schematically in figure 1. speech and language are thus viewed as complex functional systems to which many different cortical areas contribute (see table 1). luria13 refers to these cortical areas as "links" within the functional system. damage to any one of these areas affects its ability to function optimally and it thus becomes a weak or broken link within the chain of the functional system. although any damaged link :hological approach to assessment in aphasia". the south african journal of communication disorders, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) clinical implications of a neuropsychological approach to aphasia 57 units i ii iii (regulation of (reception, analysis programming, tone, waking and storage of regulation and mental information) and verifistate) cation of activity zones 1. primary: receives impulses from or sends them to the periphery 2. secondary: processes incoming information or prepares programmes for action 3. tertiary: responsible for the integrative participation of many areas figure 1 schematic view of luria's division of the brain into units and zones. will affect the functional system, the effects will vary depending upon the particular link involved. the interference with the normal function of a specified cortical area results in a primary or fundamental problem. the secondary or systemic effect of this primary problem is the breakdown in the functional systems to which the area normally contributes. two points should be noted at this stage. first, what appears to be the same symptom complex, may actually be related to one of several primary problems. for example, the common aphasic symptom of word-finding difficulty may be caused by a breakdown in phonemic hearing, problems with simultaneous synthesis,' or difficulties at the articulatory level. second, because the function of a specific cortical area may be a link in several functional systems, a focal lesion might result in a group of symptoms which are seemingly unrelated. however, appropriate neuropsychological analysis reveals that the symptom complex (consists of "externally heterogeneous but, in fact, internally' interconnected symptoms".13 for example, a lesion of the overlapping tertiary zone in unit ii results in a specific primary problem, namely, difficulty with simultaneous synthesis. however secondary or systemic effects include a problem with logical-grammatical relationships as well as acalculia. rather than attempting to localise complex functional systems such as receptive or expressive language, an attempt should be made to identify the various focal areas of the brain which make a specific contribution to the system as a whole. the clinician who is able to localise the lesion and who understands how the resultant primary problem may affect the functional system under consideration, is then in a position to plan appropriate treatment. thus within luria's framework, a classifactory label attached to an aphasic patient is not merely descriptive but is rather an indication of the primary problem underlying the presenting symptom cluster (see table 2). luria14 himself recognised the need to evaluate his work in terms of some objective criterion and it was with this in mind that the present research evolved. the study was designed to assess luria's views on the manner in which symptomatology relates to brain damage. more specifically, the aim was to compare the site-of-lesion in aphasic patients as ascertained by luria's neuropsychological tests, with the results of radiological findings based on cranial computerised tomography (c.t.) scanning. the study itself will be described very briefly and will be followed by a discussion of clinical implications. method this research took the form of four in-depth case-studies. subjects all subjects were diagnosed as aphasic by a speech therapist and a neurologist. etiology was required to be a cva resulting in a focal lesion that could be observed on a cranial ct scan. the upper age-limit was set at 55 years and hearing was required to be within normal limits. a minimum period of three months had to have elapsed since the onset of the cva to allow for spontaneous recovery in accordance with the, study by demeurisse, demol, derouck, debeuckelaer, coekaerts and capon.4 see table 3 for a description of the subjects. procedure subjects were scanned (cranial ct scanning) in order to establish the presence of a focal lesion. as this was a blind table 1 an illustration of some aspects of the roles played by different cortical units and zones in the functional system of speech and language (with respect to left/dominant hemisphere function) unit i maintains the optimal level of cortical tone necessary for the functioning of the systems of speech and language unit π auditory analyser visual analyser tactile-kinaesthetic analyser zone 1 receives auditory impulses receives visual impulses receives sensory impulses zone 2 recognition and processing of speech sounds or phonemes visual gnostic functions ibctile-kinaesthetic gnostic functions zone 3 integration of successive input unit πι zone 1 outlet channel for movement 1 zone 2 planning of movement zone 3 regulation and verification of complex behaviour d t e suid-afrikaanse tydskrif vir kommunikasieafwykings, vbl. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) aura kagan, michael saling and margaret marks wahlhaus table 2 luria's classification of aphasia as related to primary problems and areas of cortical damage type of aphasia primary problem cortical area efferent motor afferent motor dynamic sensory acoustico-mnestic semantic skilled sequential movements motor kinesthetic afferentation speech drive phonemic hearing audio-verbal memory simultaneous synthesis affecting quasi-spatial operations pre-central post-central frontal lobes superior, posterior temporal lobe middle temporal lobe posterior inferoparietal lobe (tertiary, overlapping zone) table 3 description of subjects subjects ο ρ v d age at time of testing 49 years 50 years 44 years 23 years sex male male female male time elapsed since onset 9 months 5 months 1} years almost 2 years immediate effects of the cva including progress in first 3 weeks could not speak for first 3 days. recovered slowly could not speak for first 3 days. recovered slowly. paralysis of right upper limb recovered completely could not speak. dense right hemiplegia. coma for 2£ weeks. right-sided hemiplegia. speech therapy immediately after stroke for 4 months immediately after stroke. discontinued after 1 year immediately after stroke until the present time pre-morbid conditions heart condition (3 previous heart attacks). high blood pressure. diabetes diagnosed at age 35 years — post-morbid complications in addition to aphasia athetoid movements of right hand. hemianopia — severe hemiplegia residual hemiplegia and hemiparesis. jacksonian epilepsy pre-morbid handedness drags taken at the time of testing right right right left pre-morbid handedness drags taken at the time of testing aldomet, isoptin, syndol persanton, librium epinutin epinutin, persanton, aspirin, tegretol home language afrikaans english afrikaans english pre-morbid occupation lawyer sheet-metal worker secretary university student present occupation same housewife stores issues clerk pre-morbid educational level 1i university degree standard five matriculation. secretarial diploma university student study, the researcher did not have access to the scans at this stage, and thus had no knowledge of the extent or localisation of the lesion. luria's neuropsychological investigation (lni)2·3 was then administered and analysed. the details of the neuropsychological process of analysis have been described in kagan.» once a neuropsychological decision as to the site-of-lesion for each subject had been reached, this was handed to a person uninvolved in the study. the cranial ct scans were then made available and were interpreted by a radiologist. a conclusion as to the correspondence between the neuropsychological and radiological findings was reached. results the results of the study are summarised in table 4 which compares neuropsychological predictions as to the site-of-lesion with radiological findings (cranial ct scans). bearing in mind normal individual variation in the cerebral organisation of higher mental functions, as well as subject characteristics encountered in this study (for example, one left-handed subject and one with a premorbidly low level of intellectual function), the correspondence between the neuropsychological and radiological findings is felt to be good. however, mention must be made of instances of non-agreement. in certain cases, the south african journal of communication disorders, l. 30 19 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) clinical implications of a neuropsychological approach to aphasia table 4 summary of results comparing neuropsychological and radiological findings for all four subjects site-of-lesion subject ο subject ρ subject v subject d hemisphere right 1 • · • · 0 1 1 left • · • · 1 • · • · 1 • · • · 1 • · • · 1 cortical areas sensorimotor • · • · 0 • · • · 1 • · • · 1 • · • · 1 tertiary parietal • · • · 1 • · • · 0 • · • · 1 • · • · 1 prefrontal 1 • · • · 1 • · • · 1 • · • · 1 superior, posterior temporal 1 1 0 0 middle temporal • · • · 1 1 • · • · 1 0 occipital • · • · 1 1 1 1 radiological confirmation of neuropsychological findings 1 confirmed 0 not confirmed done by hardyck.7 however, it is more difficult to account for the same situation arising in subject v, who is a righthander. the fact that damage to wernicke's area did not result in the expected symptomatology, despite good correspondence in other areas, leads one to consider the possibility of a premorbid bilateral representation of language in this subject. despite the above instances of non-agreement the fact that the principles of luria's neuropsychological analysis were useful in arriving at the site-of-lesion in most cases, indicates that his theory of functional localisation, in which the concept of the primary problem plays such a central role, is a valid means of relating observed symptomatology to focal brain damage. discussion this result has clinical implications for the speech clinician dealing with aphasia as luria's views on diagnosis and therapy are logically related to his theory. first, as regards classification, luria's approach12·13 differs from many traditional approaches e g 16. neuropsychological findings • · · • · · indication of damage contra-indication of damage there was no evidence of structural damage to support clinical symptomatology. in this instance, it is possible that there is damage that has not been picked up on the scans. it should be borne in mind that the scanning techniques used here provide a static representation of extant neuropathology. it is our belief that neuroradiological procedures which can detect physiological or functional change such as blood-flow, for example, might correlate better with neuropsychological dysfunction, than the static structural damage observed on the scans used in this study. it is felt to be more important to account for the cases in which r e i s 3 definite indication of damage on the scan but no evidence of the clinical symptoms one would expect from such amage. in both subjects κ and d, for example, there was little 0 r no clinical manifestation of observed damage to the ^penor posterior temperal lobe (wernicke's area). in subject 0 w a s premorbidly left-handed, there is a strong possibility of bilateral representation in the premorbid erebral organisation of language, lending support to work d e suid-afrikaanse tydskrif vir kommunikasieafwykings, vl. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 60 while accurate classification is stressed, this does not, as mentioned previously, merely involve the attaching of descriptive labels. rather, classification gives an indication of the real (primary) problem or problems underlying the often confusing picture presented by the patient. as can be seen from table 5, although the types of aphasia represented range from the highly specific, such as afferent motor aphasia, to those of a broader nature, such as dynamic and semantic aphasia, they all relate to underlying brain damage in the same fashion, namely, focal brain damage results in specific primary problems which are manifested in the symptoms we observe. aura kagan, michael saling and margaret marks wahlhaus one of the advantages of luria's approach is that it enables one to be specific. for example, the commonly used term 'global aphasia' indicates that there are gross expressive and receptive language defects related to an extensive lesion probably involving both anterior and posterior parts of the brain.10·15 it might be for more useful clinically to have more detail about the exact extent of the lesion and the primary problems which need to be tackled. in other words, global aphasia should be viewed as a complex combination of several primary problems rather than as an undifferentiated whole. similarly it would be more useful theoretically and clinically to classify complex tbble 5 classification of subjects according to the primary problem and types of aphasia subject primary problem "type of aphasia in terms of luria's classification ο visual agnosia for letters spatial and quasi-spatial difficulties mild audio-verbal memory difficulties semantic aphasic mild acoustico-mnestic aphasia ρ some quasi-spatial problems mild semantic aphasia v efferent and afferent organization of movement and speech quasi-spatial difficulties audio-verbal memory regulation of movements and actions efferent motor aphasia semantic aphasia acoustico-mnestic aphasia possibility of dynamic aphasia efferent and afferent organization of movement and speech quasi-spatial difficulties efferent aphasia afferent aphasia semantic aphasia "fable 6 primary problems and effects relevant for therapy (subject v) primary problem effects on speech and language other major effects of relevance to the speech clinician efferent and afferent organization of movement and speech severe articulation problems absence of narrative speech hemiplegia simultaneous synthesis (quasi-spatial problems) quasi-spatial functions, for example, difficulty in understanding logical-grammatical speech note: some difficulties, such as naming and comprehension audio-verbal difficulties difficulty with series of verbal stimuli regulation of movements and actions possibility of problems with internal speech problems of,motivation, attention, perseveration, attention to irrelevant stimuli, inhibition of actions, etc. diff.cu.ties may be due to a c o m b w o 7 s o m ^ ~ * * * p r o b l e m i n « * » * * « • table 7 primary problems and effects relevant for therapy (subject o) primary problem simultaneous synthesis (quasi-spatial problems) agnosia for letters mild audio-verbal difficulties visual field defect effects on speech and language word-finding difficulty some difficulty with confrontation naming mild problems with logicalgrammatical structures severe alexia difficulty with the retention of series of auditory material in the absence of semantic cues / other mqjor effects of relevance to the speech clinician hemianopia the south african journal of communication disorders, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) clinical implications of a neuropsychological approach to aphasia 61 cases of aphasia, such as broca's, in terms of the primary problems involved (see table 5) instead of grouping them together in a broad symptomatological category often inaccurately related to an isolated focal area of the cortex. second, in order to plan therapy appropriately, it is necessary to relate the primary problem to speech and language. other effects of the primary problem while not directly related to speech and language, must also be taken into account. the following charts (see tables 6 and 7) have been drawn up as an illustration of one way in which the speech clinician can relate the primary problem to the overall symptom complex. subjects v and ο have been chosen as examples because they represent different levels of severity and complexity. in the former case (v), brain-damage was extensive and the clinical picture highly complex, making it difficult to identify the underlying primary problems. in the latter case (o), the primary problems were relatively easy to identify. these therapy charts need to be individually tailored for each patient. being able to isolate the primary problem does not mean that the entire symptom profile can be predicted, although symptoms should be able to be explained in terms of the primary problem. the neuropsychological examination, in addition to giving information about the site-of-lesion, enables the clinician to be fairly specific about the functional effects of this damage in the individual being examined. for example in subject v, there was evidence of both efferent and afferent motor aphasia. however, the latter predominated and would therefore require more attention initially. it was observed, that if this subject was able to circumvent kinaesthesis by compensating with her strong visual abilities or a combination of audio-visual stimulation for example, she was able to articulate reasonably well. this fact should be used in constructing an appropriately graded therapy programme. in addition, the major effects of prefrontal damage in the case of subject v would definitely affect therapy adversely and would make for a far less favourable prognosis. examples of the symptoms being referred to are problems of motivation, attention to irrelevant stimuli, and inhibition of actions, among other things. the clinician must therefore be aware of which problems are of major importance and require most attention. it must be understood that 'important' in this case refers to the fact that the particular problem is having a major effect on the patient's ability to communicate. for example, in the case of subject ο (see table 7), the mild audio-verbal difficulties noted did not affect communication significantly. conclusion the implications of the findings of the study reported here have been discussed in relation to classification and therapy. although these have been discussed separately, it is hoped that the logical and cohesive nature of luria's neuropsychological othe7 ' s c v i d e n t i n t h e w a y i n w h i c h t h e s e topics relate to each the fact that luria places clinical practice on a firm eoretical foundation is seen as being advantageous to the speech clinician, who, with her theoretical background and t j c c e s s t 0 c l i nical material, has in turn a significant contribu°n to make to the neuropsychological study of aphasia. furd e suid-afrikaanse tydskrif vir kommunikasieafwykings, vl. 30, 1983 ther research in the field would be usefully augmented by clinical studies evaluating, in particular, luria's approach to assessment and remediation in aphasia. feedback from such studies could for example be used to remodel aspects of luria's classification of aphasia which do not seem to tie in with clinical reality. on a more practical level, luria's work should be made available in a format especially designed for use by the speech clinician involved in the field of aphasia. although a considerable investment of time and energy is required of the speech clinician interested in applying luria's approach, the effort is felt to be worthwhile "for practicalminded field speech pathologists, who are willing and flexible enough to try to understand the underlying philosophy".8 acknowledgements financial assistance from the medical research council and the george elkin bequest is gratefully acknowledged as are a senior bursary and freda lawenski scholarship fund grant administered by the university of the witwatersrand, johannesburg. references 1. broca, p. remarques sur le siige de la faculty du langage articuli, suivies d'une observation d'aphimie (perte de la parole). bulletins de la societe anatomique de paris, 1861, 6, 330-357. 2. christensen, a. l. luria's neuropsychological investigation: text, copenhagen: munksgaard, 1974. 3. christensen, a. l. luria's neuropsychological investigation: manual, copenhagen: munksgaard, 1975. 4. demeurisse, g., demol, o., derouck, m., debeuckelaer, r., coekaerts, m. j. & capon, a. quantitative study of the rate of recovery from aphasia due to ischemic stroke. stroke, 1980, 11, 455-458. 5. goldstein, k. language and language disturbances. new york: grune & stratton, 1948. 6. goodglass, h. & kaplan, e. the assessment of aphasia and related disorders. philadelphia: lea & febiger 1972. 7. hardyck, c. a model of individual differences in hemispheric functioning. in h. whitaker & h. a. whitaker (eds.) studies in neurolinguistics, vol. 3, new york: academic press, inc., 1977. 8. hatfield, f. m. analysis and remediation of aphasia in the u.s.s.r.: the contribution of a. r. luria. j speech hear dis, 1981, 46, 338-347. 9. kagan, a.a neuropsychological approach to assessment in aphasia. unpublished dissertation submitted to the department of speech pathology and audiology, university of the witwatersrand, johannesburg, south africa, 1982. 10. kertesz, a. aphasia and associated disorders: taxonomy, localization and recovery. new york: grune & stratton, inc., 1979. 11. luria, a. r. traumatic aphasia: its syndromes, psychology and treatment. the hague: mouton, 1970. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 62 12. luria, a. r. the working brain: an introduction to neuropsychology. harmondsworth, middlesex: penguin books ltd., 1973. 13. luria, a. r. higher cortical functions in man. 2nd ed. new york: basic books, inc., 1980. 14. luria, a. r. & majovski, l. v. basic approaches used in american and soviet clinical neuropsychology. am psychol, 1977, 32, 959-968. aura kagan, michael saling and margaret marks wahlhaus 15. naeser, m. a. and hay ward, r. w. lesion localisation in aphasia with cranial computed tomography and the boston diagnostic aphasia exam. neurology, 1978, 28 545-551. 16. schuell, h., jenkins, j. j. & jimenez-pabon, e. aphasia in adults. new york: harper & row, 1964. the south african journal of communication disorders, vol. 30. 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) article information authors: natalie schellack2 anna m. wium1 katerina ehlert1 yolande van aswegen2 andries gous2 affiliations: 1discipline of speech-language pathology and audiology, sefako makgatho health sciences university, south africa 2department of pharmacy, sefako makgatho health sciences university, south africa correspondence to: natalie schellack email: natalie.schellack@ul.ac.za postal address: po box 195, medunsa 0204, south africa dates: received: 26 june 2014 accepted: 04 apr. 2015 published: 17 june 2015 how to cite this article: schellack, n., wium, a.m., ehlert, k., van aswegen, y., & gous, a. (2015). establishing a pharmacotherapy induced ototoxicity programme within a service-learning approach. south african journal of communication disorders 62(1), art. #96, 7 pages. http://dx.doi.org/10.4102/sajcd.v62i1.96 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. establishing a pharmacotherapy induced ototoxicity programme within a service-learning approach in this original research... open access • abstract • introduction • ototoxicity: the need for monitoring • what is ototoxicity? • establishing an ototoxicity clinic as service-learning context • challenges and strengths       • experiences of the stakeholders       • content taught • role of the facilitators • attendance, and learning and teaching opportunities • logistics • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ pharmacotherapy-induced ototoxicity is growing, especially in developing countries such as south africa. this highlights the importance of ototoxicity monitoring and management of hearing loss. this article focuses on the establishment of an ototoxicity clinic as a site for the implementation of a service-learning module in the audiology programme. the clinic offers a unique opportunity of collaboration between pharmacists and an audiologist where pharmacotherapy-induced ototoxicity is uniquely monitored. the sefako makgatho health sciences university (smu) provides training to both the disciplines audiology and pharmacy. the main aim of this article is to describe how ototoxicity monitoring is implemented in the curriculum within such an academic service-learning approach. through service learning students develop a deeper understanding of course content, acquire new knowledge and engage in civic activity. it simultaneously provides a unique opportunity for interdisciplinary collaboration between the disciplines of audiology and pharmacy. the objectives for this programme are therefore to facilitate learning and to provide a service to the local community by identifying, preventing and monitoring medicine-induced hearing loss in in-hospital and out-patients; as well as to establish inter-disciplinary collaboration between the disciplines and stakeholders for more effective service delivery. the constant interdisciplinary teamwork between the audiologist, pharmacist, physician and nursing staff in the wards results in best practice and management of patients with ototoxic damage. introduction top ↑ the creation of competent and caring professionals who contribute to the welfare of the country is the ultimate aim of higher education institutions (stevens, 2009). traditionally students were taught professionalism through their clinical training (scudder, 2006). it is important that students not only obtain their clinical competence through the training of splinter skills that are based on theoretical knowledge, but that they learn by applying their knowledge, and to further become competent in analysing, synthesising, and evaluating what they have learnt in the classroom (stevens, 2009). the past decade has seen several changes in teaching and learning practices. one of the paths to facilitating professional competence of audiologists is though service-learning experiences. academic service-learning (asl) is a ‘valued pedagogy for engaged campuses’ (bringle & hatcher, 2009, p. 37) and is a methodology for teaching and learning that facilitates the application of knowledge and reflecting on it, while simultaneously addressing community needs. through asl, students develop a deeper understanding of course content, acquire new knowledge and engage in civic activity (colby, ehrlich, beaumont & stephens, 2003). this article focuses on a newly established ototoxicity clinic in a semi-rural context where students obtain hands-on learning experiences in ototoxicity monitoring by simultaneously providing a service to the community. the main aim of this article is to describe the collaboration between two disciplines (smu – department of pharmacy and the discipline of speech-language pathology and audiology) in the initiation of a pharmacotherapy induced ototoxicity clinic within a service-learning approach. ototoxicity: the need for monitoring top ↑ south africa is faced with a major challenge in terms of tuberculosis (tb), human immunodeficiency virus (hiv) (achkar, kasprowicz & wilson, 2011) and malaria (department of health, 2014). in all three of these conditions, hearing loss can be induced by the treating agents. dr george mukhari academic hospital (dgmah) specifically encounters the challenges in treating tb and hiv. one of the challenges posed by these statistics lies in the fact that multi-drug resistant tb (mdr-tb) requires the use of an aminoglycoside for an extended period of time (department of health, 2014). aminoglycoside-related ototoxicity has been well described in literature and is known to be irreversible (cheng, huth & ricci, 2011). therefore the tb burden in sa also accounts for an additional burden on the health care system of pharmacotherapy-induced ototoxicity and the resulting hearing loss in patients with tb. specific attention should further be paid to patients who are treated with ototoxic medications, as they are at risk for hearing loss. patients suffering from multi-drug resistant tuberculosis, renal failure (schacht, talaska & xie, 2011), oncology patients (handelsman, 2011), and neonates with severe infections or sepsis who are treated in the neonatal intensive care unit (cheng et al., 2011) can be classified as high-risk patient populations for possible ototoxicity. according to bratt et al., (2005) the best way to detect ototoxicity is by assessing auditory and vestibular function directly. early detection of ototoxic damage can improve the treatment outcome through minimising hearing loss progression and by counselling and rehabilitation of the patient. it also provides the physicians the opportunity to adjust the therapeutic regimen to the benefit of the patient. an effective ototoxicity monitoring programme should consist of various aspects, including specific criteria to identify ototoxicity, timely identification of the at-risk population, pre-treatment counselling regarding the potential ototoxic effect of the drug treatment, valid baseline measurements and on-going monitoring during and after the completion of the drug treatment (asha, 1994). what is ototoxicity? top ↑ ototoxicity can broadly be defined as the tendency of certain substances, either systemic or topical, to cause functional impairment and cellular damage to the tissues of the inner ear and especially to the end organs of the cochlear and vestibular divisions of the eight cranial nerves (roland & rutka, 2004). medications that may lead to ototoxicity can either cause cochleotoxicity or vestibulotoxicity, depending on their mechanism of action in terms of the ototoxicity. certain medications, e.g. aminoglycosides, have the tendency to cause both (selimoglu, 2007). cochleotoxicity may present as reversible or irreversible hearing loss, tinnitus, hyperacusis, as well as the difficulty in system may present as disequilibrium, unsteadiness when walking or ataxia, oscillopsia, nystagmus and/or vertigo (selimoglu, 2007). blockman and sinxadi (2009) consider a drug to be ototoxic if it has any toxic effects on the structures of the inner ear, such as the cochlea, vestibule, semi-circular canals and the otoliths. hearing problems can start within minutes to several days after the administration of an ototoxic drug, or it is possible that it can only start presenting several years after treatment with ototoxic medicine (de andrade, hajat & khoza-shangase, 2009). depending on the type of medicine being used as part of the patient’s specific treatment regimen, hearing loss may be reversible or permanent (irreversible). examples of drugs causing irreversible hearing loss are aminoglycosides, platinum compounds and quinine. reversible hearing loss can occur as a result of loop diuretics, salicylates and non-steroidal anti-inflammatories (blockman & sinxadi, 2009). considering that most primary care clinicians and clinical pharmacists have seen patients who have suffered from ototoxicity at some point in their career, it makes sense that audiologists should be more involved in a collaborative patient education effort with physicians, nurses and pharmacists concerning ototoxic medications (banotai, 2004). pharmacists can play an active role in identifying and monitoring ototoxicity agents, and can subsequently, where applicable, perform therapeutic drug monitoring to reduce ototoxicity (schellack & naude, 2013). audiologists often only become involved in ototoxicity-related problems after the patients stop taking medication or leave the hospital and experience hearing or vestibular problems. establishing an ototoxicity clinic as service-learning context top ↑ the establishment of the pharmacotherapy-induced ototoxicity programme ensures that there is a team approach from the clinical pharmacist, audiologist, nurse and physician in managing the patient. this service to the local community (i.e. the hospital) created a platform for an academic service-learning approach (asl), which is a form of experiential learning. a service-learning approach places equal emphasis on student learning and service to the community (bringle & hatcher, 2009). simultaneously, it aims to facilitate social responsibility. it is a process through which students develop knowledge, skills and values from direct experiences outside a traditional academic setting. well-planned supervised and assessed service-learning programmes promotes interdisciplinary learning, facilitates social responsibility, career development, cultural awareness, leadership and other professional and intellectual skills. smu provides training to both the disciplines audiology and pharmacy, and is attached to the dr george mukhari academic hospital (dgmah), which is adjacent to the campus. previously, there were no accepted clinical protocols or criteria for ototoxic change using objective measures of ototoxicity at dgmah. to this effect, two academic departments at smu (department of pharmacy and the discipline of speech-language pathology and audiology) and one clinical department (speech-language and audiology department of dr george mukhari academic hospital) initiated an ototoxicity clinic. the establishment of a programme with medicinal and audiological monitoring for ototoxicity provided the basis for developing objective protocols for monitoring ototoxic damage. the aim of the collaboration was to engage in service-learning at the dr george mukhari academic hospital by establishing a clinic to monitor pharmacotherapy-induced ototoxicity. through such a clinic a service could be provided to the patients at dgmah by identifying, preventing and monitoring medicine-induced hearing loss to in-hospital and out-patients. the objectives for this project were aligned with the criteria for asl (stacey, rice & langer, 2001) as follows: the service provided is relevant and meaningful to the hospital community, the students and the academic staff. ototoxic monitoring services have not been available to this hospital prior to the establishment of the ototoxicity clinic, and have now become an integral and necessary part of more effective service delivery. during regular staff-student meetings in the clinic, the nurses and doctors in the various units value the contribution of the students and consider their role as necessary. effective service delivery requires effective inter-disciplinary collaboration between the disciplines and stakeholders in order to provide more effective service delivery in health care. literature states that audiologists should collaborate with doctors, nursing staff and other health care professionals when monitoring a patient presenting with ototoxicity, but in current practises and existing programmes audiologists work on their own and only provide results and reports to other professionals in an inter-disciplinary approach. (dille et al., 2011). the experience enhances academic learning as it strengthens the accomplishment of module outcomes. the objectives related to patients are considered service-learning (s-l) outcomes in the curriculum. this experience facilitates interdisciplinary learning between students in the disciplines audiology and pharmacology, to obtain competence (knowledge and skills) in managing pharmacotherapy induced ototoxicity. this allows audiology students the opportunity to apply their knowledge regarding ototoxicity monitoring and to reflect on it (bender, daniels, lazarus, naude & sattar, 2006). the rotation in the ototoxicity clinic fosters students’ social responsibility as the knowledge, skills and values obtained prepare students for active involvement in future communities (bender et al., 2006) the students engage in structured reflection by completing their reflection journals to think critically about what happened at the service site and their experiences at the end of each day. they need to do this in order to plan for the next session. through this reflection they examine their own feelings, attitudes and beliefs. they further relate their learning to the module outcomes and apply their prior knowledge to conduct a more effective service in future. at the conclusion of the rotation block they complete a course evaluation sheet to evaluate the entire experience. considering the health professions act 56 of 1974 for clinical training of students in audiology, it was necessary to include aspects of prevention and identification; assessment; and management of ototoxicity. this early detection of ototoxicity will make it possible to prevent the progression of hearing loss to lower frequencies where speech perception can be greatly impaired. the department of pharmacy provides a service of evaluation and possible identification of medicines that has the potential of causing ototoxicity; with subsequent monitoring of the medicine in terms of dose, duration, levels (peak and trough) where indicated, and renal function. where appropriate, dosage adjustments are made and medicines are stopped or changed for less toxic agents. the department also developed a short course that is available on line to promote education in the monitoring of ototoxicity. pharmacy postgraduate students are also enrolled to investigate pharmacotherapy-induced ototoxicity. to this effect they collaborate with the discipline of speech-language pathology and audiology for audiological monitoring with possible identification of hearing loss. educational activities need to be evaluated to ensure that trainees will professionally benefit from them. monitoring is achieved through interdisciplinary team meetings and patient feedback. reflective journals kept by students facilitate higher level learning as they are expected to analyse and synthesise the information learnt within ototoxicity as well as prior knowledge needed from other audiological modules. the criterion for judging programmes is the extent to which it can be used to make decisions that improve the programme, which implies that the findings are valued and credible. students engage in the service-learning activity in a rotation format and the process consists of several phases: preparation, acting (service), reflecting, and lastly evaluating whether the learning outcomes and service goals were met (bender et al., 2006). the latter contributes to the effectiveness of the service provided. students are initially orientated for their asl experience firstly in the classroom by the pharmacists on the topics of pharmacotherapy and ototoxicity. secondly they are prepared by their supervisors at the clinic to become familiarised with learning outcomes and the assessment procedures. several aspects had to be considered in the establishment of such a clinic as a service-learning context (ginsberg, 2007): firstly, the learning goals in the curriculum from which students could benefit from hands-on learning experience had to be considered. these included those goals where direct interaction with clients was concerned. secondly, the specific context where these goals could be realised had to be identified. in this case, an academic hospital in a rural context that was within easy access for students appeared to be the most suitable choice. as no ototoxicity monitoring services have previously been available in this context, the patients in specific wards (nicu, paediatrics, renal, tb and oncology) could certainly benefit from such an incentive. in establishing this clinic as a vehicle for service-learning, it was further necessary to consider the types of activities that the students had to perform. with regards to ototoxicity, these include identification of the medicines prescribed and the basic mechanisms through which certain medicines can cause ototoxicity, case history, employing an audiology protocol to assess hearing abilities with regards to baseline testing and serial monitoring, designing and implementing a management plan, report writing, ethical decision-making, counselling appropriate to a variety of audiences with different levels of knowledge and collaboration with the pharmacist, physician and nurse. knowledge from other audiology modules within the audiology curriculum is needed to achieve the outcomes in ototoxicity monitoring. the critical cross-field outcomes within the curriculum need to be applied and integrated. these include: identifying and solving problems through responsible decision-making and creative, critical thinking. working effectively with others as a member of a team, group, organisation and community. organising and managing oneself and one’s activities responsibly and effectively collecting, analysing, organising and critically evaluating information. communicating effectively using visual, mathematical and/or language skills in the modes of oral and/or written persuasion. demonstrating and understanding of the world as a set of related systems by recognising that problem-solving contexts do not exist in isolation (inter-disciplinary collaboration). using science and technology effectively and critically, showing responsibility toward the environment and health of others. developing entrepreneurial opportunities. contributing to the full personal development of each learner and the social and economic development of the society at large, by making it the underlying intention of any programme of learning to make an individual aware of the importance of: reflecting on and exploring a variety of strategies to learn more effectively participating as responsible citizens in the life of local, national and global communities being culturally and aesthetically sensitive across a range of social contexts. looking into a variety of educational and professional opportunities. these activities could not only provide a service to the wards in the hospital, the patients and their significant others, but also provide students with an opportunity to learn (altosino & armstrong, 2014). the process of establishing the ototoxicity clinic required the following: human resources: staff from both the pharmacy and speech-language pathology and audiology departments are involved in the clinical training. one supervisor from the discipline of speech-language pathology and audiology manages the clinic on a weekly basis. whenever the students are not available (e.g. during examination periods and recess), this role is taken over by the staff from the dgmah speech therapy and audiology department. site and physical space: the clinic is situated in the skills-lab at medunsa campus and testing is conducted in the paediatric oncology and renal wards at dgmah. the clinic is situated in an ideal quiet environment for audiology testing procedures. challenges are experienced when hearing screening takes place in the wards due to noise levels. air-conditioning is available in the clinic, which improves infection control, as infections spread quicker in a heated environment (hicpac, 2003). technology and protocol: baseline and serial monitoring of pure-tone hearing thresholds (with a frequency range of 250 to 8000 hz) using serial audiograms are the most effective indicators of hearing loss, especially when ultra-high frequency testing is included (bratt et al., 2005). extended high-frequency (ehf) and otoacoustic emissions (oaes) are audiologic tests that are sensitive to primary ototoxic damage. ehf and oaes can detect any changes in the auditory function before ototoxicity affects the hearing at such frequencies where speech recognition can be affected (kraemer, knight, neuwelt & winter, 2007). oaes evaluate the cochlear outer hair cell system. early changes in oae may reflect on cochlear damage that could progress to further hearing loss if the ototoxic medication is continued. the audiological services available at the clinic provide baseline and serial monitoring of pure-tone thresholds (with a frequency range of 250 to 8000 hz) in a soundproof booth, tympanometry, as well as distortion product (dpoae) and transient evoked oto-acoustic emissions (teoae). unfortunately, ehf audiometry is not available due to a lack of appropriate equipment in the clinic which is due to a lack of funding. when testing is done in the wards at dgmah, only oae testing and tympanometry is done, as equipment used for baseline and serial monitoring of pure-tone hearing thresholds is not mobile. often, hospital treatment protocols have specific time points for performing audiological assessments. these times points are based on several factors, such as diagnosis, treatment plan, patient age and ototoxicity risk (bass, white & jones, 2013). at the smu clinic the patients are evaluated at any time during or after therapy if a noticeable change in hearing occurs. bass et al. (2013) is of the opinion that patients diagnosed with severe or fluctuating hearing loss should be followed up more frequently than the ototoxicity protocol indicates, at least until hearing loss stabilises. in the medunsa clinic ototoxicity monitoring is not concluded at the end of therapy, as delayed onset and progressive hearing loss has been documented in patients treated with ototoxic medication (bass et al., 2013). to date no accepted clinical techniques for vestibulotoxicity exist despite reported cases of possible effects thereof (jones, 2008). patients that display symptoms such as dizziness and unsteady gate associated with ototoxic therapy are referred for a complete vestibular evaluation at smu vestibular clinic. needs of stakeholders: funding is a major need for the clinic, as no funds were available at the onset of the programme. up to the present, existing equipment from the discipline of speech-language pathology and audiology had to be utilised. this aspect poses occasional challenges, as the equipment is also needed at several other student training sites. although ehf audiometry is a vital test to be administered in an ototoxicity monitoring programme (kraemer et al., 2007), this equipment is not available at present. challenges and strengths top ↑ oaes are successfully used for evaluating cochlear outer hair cell function (kraemer et al., 2007). many adults with normal hearing present with low-level oaes. therefore, in ototoxicity, the ability to detect low-level oaes and small oae changes over time is required. achieving valid and reliable measurements of low-level oaes pushes the limits of standard oae equipment, which invariably has been designed with infant screening in mind, as infants with normal hearing usually present with large oaes and are easy to elicit. eliciting low-level oaes are also more affected by environmental noise or noise generated from a restless patient. despite these challenges, oaes can be successfully used in ototoxicity programmes (marshall & miller, 2007). another challenge is that some patients (e.g. the paediatric oncology patients) are too ill and immunocompromised to attend the clinic. this results in only oaes being conducted, as baseline and serial measures are not possible in the wards due to immobile equipment and noise levels. therefore, pure-tone thresholds, which is considered as the most effective measure of hearing loss is not possible. oaes are conducted at the patient’s bedside or in a section of the ward. the acoustic climate of the wards is noisy, which makes is difficult to obtain reliable results on a repeated basis. nursing staff also do not always realise the importance of a quiet environment during oae testing. the collaborations allows for the following strengths and weaknesses: in terms of the former, a definite strength of this ototoxicity programme is the constant interdisciplinary teamwork between the audiologist, pharmacist, physician and nursing staff in the wards. effective teamwork based on evidence based practices may enhance better practices and management of patients with ototoxic and vestibulotoxic damage. in addition, there is a close proximity by providing easy and frequent access to the ototoxicity clinic; there is a clear communication and trust between the two disciplines; the patient sees both disciplines at once, which proved to be more effective than seeing the patient one after the other, and this increases the communication between the disciplines and the patient. the patient receives more effective treatment because the concerns are addressed immediately and ototoxic effects can be minimised and/or prevented if possible. state of the art equipment that is frequently calibrated is available to increase reliability. student training is also taking place within a service-learning context. the hospital staff is also involved, which ensures the continuation of the ototoxicity clinic services when the university is closed for recess. in terms of weaknesses, the student schedule causes the clinic to run according to the university calendar, which causes an increased workload for the hospital staff. testing often occurs in the wards due to the patients being immunocompromised. the noise levels in the wards are high, which makes the testing challenging and often creates unreliable results. there is a lack of equipment for high-frequency audiometry at present, which ideally should be part of the protocol. experiences of the stakeholders at present there is no formal evidence of the experiences of the stakeholders, as this matter currently is being researched. the staff from the hospital departments expressed appreciation for the service and continues to send patients for screening. the clinical pharmacists have established working relationships with the physicians and audiologists and have become familiar with the type of hearing impairment caused by the different drugs. the audiologists performing the monitoring find the wards to be too noisy at times and struggle to obtain reliable oae results. although a quiet environment is the ideal for efficient testing, this is not necessarily the case. in reality the noise levels are high, which often cause the results to be unreliable and patients have to be re-assessed. in addition, the procedure takes much longer than it usually should. patients who are not too ill are transported to the ototoxicity clinic where the environment is more conducive to testing. student training has been successful, as students perform well in conducting the assessment procedures. students attend on a rotation basis and block review reports and reflective journals have shown a positive result in terms of student self-review of competencies. content taught the ototoxicity clinic at smu provides a platform for student teaching and learning within a service-learning approach. audiology students have the opportunity to work within an interdisciplinary team with pharmacists, nurses and physicians, and to interact with a diverse group of patients. the department of pharmacy provides the students with the background information on pharmacology and drugs that cause ototoxicity in the classroom prior to the onset of their rotation. on clinic days the students provide ototoxicity-monitoring services, including counselling to adult and paediatric patients affected by ototoxic and vestibulotoxic medications. students are also required to develop a management plan for patients identified with ototoxic and vestibulotoxic damage. these plans are also submitted for assessment. report writing is a collaborative effort between the clinical pharmacist and the audiologist. reports are based on a discussion of results and planning of the way forward for each patient. while providing a vital service to the community, students are able to meet their learning outcomes related to ototoxicity monitoring within a hospital setting. summative and formative assessment procedures are applied throughout the clinical block. at the end of the module, the students are able to conduct an age and case-appropriate interview through the selection of appropriate questions from a case history form, display well-developed information retrieval skills together with the ability to critically analyse and synthesise information obtained from the assessment. students are also expected to conduct and apply ageand case-appropriate protocols during the conduction of the basic audiometric test battery, critically analyse and synthesise information and interpret accurately. additionally, students are able to conduct and apply age and case-appropriate procedures during the determination of diagnostic oaes displaying logical and critical thinking; as well as demonstrate engaged participation during discussion of results. students are expected to summarise audiometric results and explain it in a well-structured comprehensible manner during feedback and in the diagnostic report to the client, the parents, caregivers and/or significant others. reflective journals allow analysis and synthesis of information learnt. when working with nurses, doctors, pharmacists and patients in the clinic, the students are exposed to multidisciplinary teamwork. role of the facilitators top ↑ one staff member from the pharmacy and audiology department, assisted by a masters student, provides consultations with regard to the ototoxic medication. they also brief the students in speech-language pathology and audiology regarding ototoxicity, pharmacotherapy and the clinic protocol. demonstrations in the use of the equipment for students training in audiology are offered and supervision is provided, whilst students gain hands-on testing experience. the entire process of learning and serving is monitored through structured assessment instruments by the facilitators. attendance, and learning and teaching opportunities top ↑ from the initiation of the clinic in february 2013 up until april 2014, a total of 52 patients with 102 patient visits (an average of 1.9 visits per patient) attended the clinic. some patients visited the clinic more than once depending on the recommendations by the team. all of these patients had a regimen containing either one or two medicines that may cause ototoxicity. to date 48 students have been trained in the clinic, and from their course evaluations and reflections on the module it appears as if they consider their training as good or excellent. logistics top ↑ the clinic is conducted on friday mornings between 08h00 and 12h00. currently patients are referred by the paediatric oncology unit, nicu, renal and internal medicine wards. the clinical pharmacist identifies patients from other unit’s e.g. internal medicine. the programme intends to extend to other departments, e.g. adult oncology. patients with pharmacotherapy that may cause ototoxicity are either identified by the clinical pharmacist or referred to the service department (which is the hospital department of pharmacy or speech-language and audiology). the clinical pharmacist then provides a description of the type of toxicity to be expected (i.e. vestibular/cochleotoxic and reversible/irreversible toxicity). the audiologist then assesses the patient and a full report is written from both disciplines with recommendations for alteration of therapy to the treating physician. the current regimen of prescription contains either one or two medicines that may cause ototoxicity. the medicines mostly implicated include amikacin, gentamicin, cisplatin and furosemide (at high dosages and used orally for extended periods of time in patients within the renal unit). these medicines might have been used alone or in combination. additional details on the type of ototoxicity seen with these agents will be included as part of a master’s degree study currently being conducted at the clinic. conclusion top ↑ through a service-learning approach, it is possible to form partnerships with the hospital staff and other stakeholders in order to meet the hospital community’s needs, but also to meet the specific learning outcomes, of which inter-professional collaboration and teamwork is but one. through asl a reciprocal relationship is established in which both parties benefit. the establishment of this service-learning programme has created a unique opportunity for interdisciplinary collaboration between audiologists and pharmacists. such collaboration provides an opportunity for early identification of medicines that may cause hearing impairment in vulnerable patients. early identification affords early intervention for both the clinical pharmacist and the audiologist. future research should further explore the nature and extent of hearing loss caused by the various agents and the experiences of stakeholders. a service-learning approach seems to contribute to the quality of their training. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions n.s. (sefako makgatho health sciences university) conceptualisation and drafting of manuscript; a.m.w. (sefako makgatho health sciences university) – conceptualisation and drafting of manuscript; k.e. (sefako makgatho health sciences university) – conceptualisation and drafting of manuscript; y.v.a. (sefako makgatho health sciences university) conceptualisation and clinical implementation; a.g. (sefako makgatho health sciences university) review of final document. references top ↑ achkar, j.m., kasprowicz, v.o., & wilson, d. (2011). the tuberculosis and hiv epidemic in south africa and the kwazulu-natal research institute for tuberculosis and hiv. the journal of infectious diseases, 204, 1099–1101. http://dx.doi.org/10.1093/infdis/jir414 altosino, a., & armstrong, j.l. (2014). the effects of a service learning workshop on the intellectual life of graduate students in communication disorders. http://dx.doi.org/10.1044/aihe17.1.27 american speech-language-hearing association (asha). 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(2009). journey to professional competency in speech-language patholgy. the scholarship of teaching and learning at emu, 1, article 4. retrieved october 06, 2014, from http://commons.emich.edu/sotl/vol1/iss1/4 abstract introduction literature review research questions and hypotheses ethical considerations research method and design results discussion conclusion acknowledgements references appendix a appendix b footnotes about the author(s) carien wilsenach department of linguistics, university of south africa, south africa citation wilsenach, c. (2016) ‘identifying phonological processing deficits in northern sotho-speaking children: the use of non-word repetition as a language assessment tool in the south african context’, south african journal of communication disorders, 63(2), a145. http://dx.doi.org/10.4102/sajcd.v63i2.145 original research identifying phonological processing deficits in northern sotho-speaking children: the use of non-word repetition as a language assessment tool in the south african context carien wilsenach received: 18 nov. 2015; accepted: 29 feb. 2016; published: 20 may 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract diagnostic testing of speech/language skills in the african languages spoken in south africa is a challenging task, as standardised language tests in the official languages of south africa barely exist. commercially available language tests are in english, and have been standardised in other parts of the world. such tests are often translated into african languages, a practice that speech language therapists deem linguistically and culturally inappropriate. in response to the need for developing clinical language assessment instruments that could be used in south africa, this article reports on data collected with a northern sotho non-word repetition task (nrt). non-word repetition measures various aspects of phonological processing, including phonological working memory (pwm), and is used widely by speech language therapists, linguists, and educational psychologists in the western world. the design of a novel northern sotho nrt is described, and it is argued that the task could be used successfully in the south african context to discriminate between children with weak and strong northern sotho phonological processing ability, regardless of the language of learning and teaching. the nrt was piloted with 120 third graders, and showed moderate to strong correlations with other measures of pwm, such as digit span and english non-word repetition. furthermore, the task was positively associated with both word and fluent reading in northern sotho, and it reliably predicted reading outcomes in the tested population. suggestions are made for improving the current version of the northern sotho nrt, whereafter it should be suitable to test learners from various age groups. introduction language assessment in south african languages the provision of effective services to patients from diverse linguistic backgrounds is a big challenge within the south african healthcare system (mosdell, balchin & ameen, 2010; pascoe & norman, 2011; van dulm & southwood, 2014). almost 20 years after becoming an officially multilingual country, the provision of speech-language therapist (slt) services to a linguistically diverse population remains problematic. the majority of slt professionals speak english or afrikaans (or both) and have little or no knowledge of the official african languages (bornman, sevcik, romski & pae, 2010; gerber, 2009; van dulm & southwood, 2014). this is a particularly grave concern, given the fact that in slt services ‘language’ is not only used as a means of communication, but is the reason why a person is seeking help. formal assessment of a patient’s linguistic profile and linguistic problems provide a baseline for intervention, but is compromised if a patient is assessed in a language that is not his or her first language. this is especially true for children. in south africa, the majority of child language assessment measures used are in english and have been standardised in the united kingdom or the united states of america. as a result, (ad hoc) translators or translations are often used by south african slts in clinical encounters. in a national survey conducted by van dulm and southwood (2014), which investigated child language assessment and intervention practices in south africa, less than half of slts who participated felt that commercially available or translated language assessment instruments are linguistically appropriate for the south african context. only about one-third of the slts thought that the instruments they use are culturally appropriate. thus, slts are aware that their lack of knowledge of the native languages of their patients, combined with the lack of standardised language tests in african languages, in fact jeopardise language assessment and intervention results. barrett, khoza-shangase and msimang (2012) note that ‘this awareness should range from case history taking to the actual assessment to the test material used in the assessment, and therefore more emphasis should to be placed on development of assessment and intervention materials in all languages’. in response to the need for assessment materials in south african languages, the current study explored the usefulness of developing a non-word repetition task (nrt) in northern sotho (one of the official languages of south africa). internationally, the nrt is used widely to access both normal and impaired language acquisition. the nrt is particularly associated with diagnosing children with speech-language disorders such as specific language impairment (sli) and dyslexia, but has become a widely used tool in the field of speech-language pathology (also in the population at large); the reason being that non-word repetition closely matches the phonological component of word learning and is associated with phonological working memory (pwm), a construct which is crucially important in the attainment of language and literacy skills (dollaghan & campbell, 1998; gathercole, willis, baddeley & emslie, 1994). in this study, data gathered with a northern sotho nrt (ns nrt) will be presented. despite the routine use of the nrt as a clinical assessment instrument in other parts of the world, such tasks have not yet been standardised for any of the african languages spoken in south africa. the aim of this study was to determine the effectiveness of a nrt in determining different levels of phonological processing in northern sotho-speaking children, and to investigate whether performance on a ns nrt reliably predicts reading performance in northern sotho children. given the high occurrence of reading failure in south african schools, developing tests which measure linguistic skills associated with reading is critically important. literature review phonological processing the broad construct phonological processing consists of ‘three separate but interrelated phonological abilities, namely phonological awareness, phonetic coding in working memory, and phonological recoding in lexical access’ (claessen, leitão, kane & williams, 2013, p. 472). in its broadest sense, phonological processing has been defined as the ability to encode, store, retrieve, and reproduce sounds (de bree, 2007). more specifically, phonological processing involves the encoding of auditory (linguistic) signals, the temporary storage of these signals, the retrieval of stored signals, and the planning involved in reproducing these signals (chiat, 2001; snowling, nation, moxham, gallagher & frith, 1997). the focus of this article is on pwm and therefore ‘phonological awareness’ and ‘phonological recoding’ will not be discussed further. pwm is a basic cognitive skill that underlies all successful auditory language processing. specifically, it underlies the online cognitive processing that allows the segmentation of the incoming speech stream and the subsequent development of accurate phonological representations of sounds, and (later on) words. in infants and young children, the pwm has to store strings of sounds representing words that are unfamiliar sound sequences when the child hears them for the first time. the quality of a child’s pwm is thought to affect the accuracy and efficiency with which the phonological representations of words are converted from short-term to long-term memory. thus, pwm is very closely related to vocabulary acquisition, whereas other measures of working memory may be more related to language comprehension and syntactic processing (gathercole, 2006). the best-known model of working memory has been proposed by baddeley (1999, 2003). in this model, pwm is depicted as a subcomponent, i.e. the ‘phonological loop’, of working memory. the other subcomponents of working memory include the visuospatial sketchpad, the central executive, and the episodic buffer. the phonological loop consists of a phonological store (that retains all verbal information that has to be processed or produced for a short period) and an articulatory loop (that rehearses and invigorates the verbal information in the phonological store to ensure that it does not fade away before being processed accurately) (baddeley, 1999). the phonological loop is active in the acquisition of new vocabulary, in general problem-solving, numerical problem solving, and in remembering instructions. the central executive incorporates information from the phonological loop, the visuospatial sketchpad, and the episodic buffer; and guides the conversion of information from the phonological loop to long-term memory. the central executive is further implicated in multitasking, selective attention, suppression of irrelevant information, and temporary activation of long-term memory. pwm is generally assessed with tasks that tap into the phonological loop and the central executive, such as the digit span forward and backward task and the nrt. pwm is believed to also affect the acquisition and processing of written language (catts & kamhi, 1999; geva & siegel, 2000; nithart et al., 2011), because the ability to decode a word (or syllable) into phonemes (which is necessary for learning to read) requires the pwm system to store the entire phonological representation of a word while the constituent phonemes of that word are first disjointed and then sequenced back into the correct order by the learner. poor pwm may lead to unstable phoneme representations in a person’s long term memory, which in turn may affect the acquisition of the phoneme-grapheme correspondences of a language negatively. numerous studies suggest that deficits in pwm play a causal role in the phonological processing limitations that manifest in diverse clinical populations. pwm deficits have been documented in developmental genetic language disorders, such as sli (claessen, et al., 2013; conti-ramsden & durkin, 2007; gathercole, 2006), dyslexia (laasonen, lehtinen, leppamaki & tani, 2010; ramus, 2003; spironelli, penolazzi, vio & angrilli, 2006) and in other genetic syndromes such as down’s syndrome (jarrold & baddeley, 2001; numminen, service, ahonen & ruoppila, 2001). the cause(s) for a pwm deficit itself is the topic of much neurobiological research. genetic-molecular studies using non-word repetition ‘have reported linkage to regions of interest on chromosomes 16 and 19 for children with language impairment’ (shriberg, et al., 2009). other genetic regions of interest are chromosome 3 and chromosome 6. so far, one gene, namely robo1 (situated on chromosome 3), has been linked specifically to the functioning of the phonological loop of the pwm system (bates, et al., 2011). non-word repetition tasks two decades ago gathercole et al. (1994) observed that children who experience learning difficulties and who fail to progress in a formal schooling environment, often have difficulties in remembering spoken language even for short periods of time. this limitation manifests itself as the apparent inability of a child to attend to and carry out simple instructions. in an attempt to discover the precise role of phonological memory in children’s language development, gathercole et al. (1994) developed the children’s test of non-word repetition (cnrep). in their initial study, the cnrep was administered to more than 600 children, and the test developers found that the correlations between non-word repetition and language skills were consistently stronger than those between auditory digit span (which also contains a significant pwm component) and language skills. in a nrt, a person has to repeat ‘pseudo’ words. pseudo words are word forms that could have been lexical items in a particular language, in that they follow the morphophonological rules of that language, but which do not exist. non-word repetition is more closely associated with linguistic abilities such as vocabulary knowledge, understanding of spoken language, reading ability, and later school performance than the digit span task (gathercole, 2006; gathercole & baddeley, 1996; gathercole et al., 1994). because a nrt consists of novel items, which no child would have encountered prior to testing, it does not disadvantage children who received impoverished linguistic input (and thus have smaller vocabularies). even though nrts are often said to measure pwm, such tasks measure a different aspect of phonological memory than digit or word span tasks. nrt is believed to entail the phonological analysis and temporary storage of novel phonological representations, with an individual being asked to recall a representation that at best mimics existing words (nithart et al., 2011). digit and word span, on the other hand, entail the processing of representations that already have a stored form in long-term memory – this stored information assists an individual in the analysis and temporary storage of phonological information. thus, non-word repetition is thought to represent a clearer view of an individual’s phonological processing capacity in real time, and is more likely to detect inefficiencies in the phonological loop of pwm than digit or word span tasks. nrts are typically designed to contain both simple and complex words. the complexity of non-words is determined by two factors: the phonotactic structure of the word (e.g. a word containing consonant clusters is more complex than a word containing no consonant clusters) the length (e.g. a four syllable word is more complex than a two syllable word). clinical populations, such as dyslexics, children with sli, people living with down’s syndrome, and cochlear implant patients have all been found to be impaired on nrts. these groups score significantly lower on non-word repetition than their age/language-matched normally developing peers. on the basis of this, and seeing that reading-disabled people also experience phonological awareness and phonological recoding impairments, the phonological deficit hypothesis (ramus, 2001; snowling, 2001; vellutino, fletcher, snowling, & scanlon, 2004) became one of the most influential theories in explaining reading disability in clinical populations. generally speaking, non-word repetition deficits appear to remain present in reading-disabled individuals, even into adolescence and adulthood (de bree, 2007). this is less true for digit span and word span tasks, which confirms that, although these tasks are related, they tap into different aspects of phonological processing. there is no agreement as to whether the nrt can be used to predict reading ability in the population at large. bishop, adams and norbury (2004, p. 96) are adamant that non-word repetition does not predict reading outcome in the general population at large. according to these scholars: a prediction…is that a sample of children with reading disability recruited by general population screening would not be expected to contain many cases with poor non-word repetition. however, …we would expect to see poor nrt scores in dyslexic samples who were selected for genetic linkage studies… bishop et al. (2004) are of the opinion that reading difficulties in non-clinical groups are caused by environmental factors such as poverty, inadequate education, and social factors such as the age and education of a child’s mother and the child’s position in the family. although all of these environmental factors probably contribute to the low literacy levels of south african learners, the causal role of underdeveloped phonological processing skills and vocabulary skills (see wilsenach, 2015), which are strongly associated with non-word repetition, remains unclear in the south african context. studies on the use of the nrt in african languages are very limited. veii and everatt (2005) investigated predictors of word reading among grade 2–5 herero-english bilingual children. they included herero and english phoneme recognition, pwm, a herero and english nrt, herero and english rapid naming, and herero and english word reading as measures. phonological skills in herero and english (such as phoneme awareness and non-word repetition) reliably predicted reading ability in both languages. alcock, ngorosho, deus and jukes (2010) studied the relationship between phonological awareness and literacy in swahili-speaking children. they investigated implicit and explicit phonological awareness skills and literacy in tanzanian school-going and non-school-going children between the ages of 7 and 10. alcock et al. (2010) found that children who could not read had poorer phonological awareness skills than those who could, except in counting syllables, counting sounds, and in nrt (however, there might have been a ceiling effect in the nrt). wilsenach (2013) assessed phonological processing (including syllable awareness, non-word repetition, and digit span) in two groups of northern sotho-speaking third graders. one group received their schooling in their home language (northern sotho) from grade 1–3, whereas the other group received their schooling in english from the beginning of grade 1. contrary to bishop et al.’s (2004) prediction, northern sotho non-word repetition reliably discriminated between the two groups of normally developing northern sotho-speaking children. however, wilsenach (2013) acknowledged that the study was limited – primarily because of the small sample (50 overall), and recommended that a larger sample needs to be tested. the present study set out to measure phonological processing, specifically non-word repetition, memory for digits and reading in 120 northern-sotho third graders. in order to evaluate the effect of the language of learning and teaching (lolt) on the learners’ ability to process sounds in their mother tongue, half of the learners received their schooling in northern sotho, and the other half received their schooling in english. research questions and hypotheses the following research questions were addressed in this study: does the ns nrt used here discriminate between northern sotho-speaking children with good and poor pwm skills? does the lolt affect the performance of northern sotho-speaking children on a ns nrt and on an english nrt? does the ns nrt used here correlate with other measures that tap into pwm, such as digit span and english nrt? does the ns nrt used here predict word reading and fluent reading in northern sotho-speaking children? on the basis of wilsenach (2013), it is hypothesised that learners who received instruction in northern sotho will fare better in the ns nrt. furthermore, it is hypothesised that, in the sample as a whole, the ns nrt will correlate with digit span, with english non-word repetition, and with northern sotho reading ability. finally, it is predicted that learners who received instruction in english will display enhanced phonological processing abilities in english, resulting in higher scores on the english nrt. ethical considerations the learners who participated in this project were recruited on a voluntary basis. ethical clearance was obtained from the relevant educational authorities, and learners participated only if their caregivers signed an informed consent form (which was provided in both northern sotho and english) and if they themselves agreed to participate before the start of the testing session. learners’ identities were kept confidential, and data obtained from this project were not disclosed to any third party. there were no physical risks involved in taking part in the research. psychological risks were minimised by discontinuing any assessment that proved too difficult for a particular learner. research method and design research setting the current study was conducted in two primary schools located in a high-poverty suburb of pretoria (one of the capital cities of south africa). northern sotho is the most common home language in this suburb, but several other african languages occur in the research area. some schools within the area use northern sotho as lolt from grade r until the end of grade 3, after which the curriculum is delivered via english. in the present study, northern sotho was used as lolt in one of the schools; the other school followed a straight for english language policy. participants one hundred and twenty grade-3 learners1 were selected to participate in the study, using a purposive and convenience sampling technique. in order to participate in the study, learners had to speak northern sotho as their home language. the participants were made up of two groups: group 1 (n = 60; mean age 8.8) was instructed in english (with northern sotho being taught as an additional language), whereas group 2 (n = 60; mean age 8.8) was instructed in northern sotho (with english being taught as an additional language). there was no significant difference between the groups in terms of age (t = -0.04; p = 0.96). generally speaking, learners from both groups came from poor households, as evidenced by the fact that both schools have feeding schemes for learners (the children in group 1 attended a quantile 2 school, whereas the children in group 2 attended a quantile 1 school).2 group 1 contained 35 girls; group 2 contained 29 girls. research design and materials the research was conducted as a cross-sectional quantitative study. the participants were tested individually during a single session. various phonological skills (not all reported on here) and reading were tested. the research was conducted during a 5-week period in the second term of the school year. all the tasks were presented to the learners using a computer and headphones – this ensured that the auditory presentation happened accurately, and with consistent rate and consistent intonation. performance was scored online, but a digital recording of each test session was made in order to be able to check a learner’s responses. pwm were measured with a ns nrt, an english nrt, and an english digit span task.3 the ns nrt was similar to the task reported on in wilsenach (2013). it was designed following most of the criteria set out by dollaghan and campbell (1998), including: neither the non-words nor their constituent syllables corresponded to lexical items the non-words included phonemes and syllable types that are acquired early in development the non-words were phonotactically possible in northern sotho. the ns nrt consisted of 20 test items, ranging from four syllables (e.g. sepokari) to seven syllables (e.g. nasibhekarabile) in length. the test comprised five items at each syllable length. the non-words were pre-recorded by a native speaker of northern sotho and were presented in the same order to each of the participants. the 20 test items are included in appendix a. english nrt was measured with subtest 5 of the comprehensive test of phonological processing (ctopp) (wagner, torgesen & rashotte, 1999). this nrt proceeded from 1-syllable non-words to 10-syllable non-words. pwm was further assessed with subtest four (memory for digits) from the ctopp. the participants had to recall strings of digits in english, as presented on the ctopp cd. the memory for digits test started with strings of two digits, and progressed to strings with nine digits. the english nrt and the memory for digits test were discontinued after three consecutive incorrect responses. the rationale for including the english nrt and the memory for digits task here is that the scores obtained on the ns nrt should correlate with these measures, if the ns nrt indeed taps into phonological processing/pwm abilities. word reading in northern sotho was tested with a tailor made word reading task, consisting of 30 items (in order of increasing length and difficulty; see appendix b). northern sotho text reading was assessed by measuring the amount of words that learners could read accurately in one minute, using a grade appropriate reader. word reading in english was assessed with the diagnostic test of word reading processes (frll, institute of education, 2012), which consists of three subsections (non-word reading, exception word reading, and regular word reading). only regular word reading will be reported on here, as this subsection of the test best compared with the northern sotho word reading test. english text reading was assessed by measuring the amount of words that learners could read accurately in one minute, using a grade appropriate reader. data analysis and statistical procedures raw scores were calculated for every participant on each of the measures. the raw scores on the ns nrt and on the northern sotho word reading test were transformed into percentages, and based on these scores a mean raw score and mean percentage were calculated for the sample as a whole, as well as for the two groups. the raw scores on the english nrt and on the memory for digits test were converted to standard scores (sss), using the age norms in wagner et al. (1999). the raw scores on the english word reading test were used in the statistical analyses, as the gl assessment manual only provides ss for the composite word reading raw score (consisting of all three subsections of the test). raw scores for northern sotho text reading and english text reading were calculated by counting the number of words that a child read aloud in 1 min, and subtracting the number of incorrectly read words from this total. the distribution of the test scores on the ns nrt was tested with the shapiro–wilk test, and was further analysed via a visual inspection of the data. seeing that the ns nrt is not a standardised test, it was important to confirm that the test scores were distributed normally. the effect of lolt on northern sotho phonological processing ability, as well as between-group differences (in terms of ns nrt, english nrt, and pwm, and reading) were tested using a multivariate analysis of variance (manova) (glm option multivariate). group was entered as an independent variable in the model, whereas ns nrt, english nrt, digit span, ns word reading, ns text reading, english word reading, and english text reading were entered as dependent variables. pearson correlations were conducted in order to determine the relationship between ns non-word repetition and related phonological constructs, such as memory for digits and english non-word repetition. hierarchical multiple regressions (method enter) were conducted to determine the contribution of ns non-word repetition to ns reading. results distribution of northern sotho non-word repetition task scores the descriptive statistics for the ns nrt are given in table 1. table 1: descriptive statistics for northern sotho non-word repetition task. a shapiro–wilk test, performed on the collapsed data, yielded a non-significant result, indicating that the ns nrt test scores were distributed normally (w(120) = 0.98, p = 0.058). both skewness (-0.31; se = 0.22) and kurtosis (-0.36; se = 0.49) were negative, suggesting a build-up of high scores, but the associated z-scores for both skewness and kurtosis (calculated by dividing these values by their standard errors) were smaller than 1.96, indicating no significant problems with either skew or kurtosis. further support for the claim that the ns nrt test scores were distributed normally is derived from the normal quantile-quantile (q-q) plot (figure 1), in which the plotted quantiles fall very closely to the diagonal line (which represents a perfect normal distribution). figure 1: normal q-q plot of ns nrt scores. the histogram in figure 2 confirms a (relatively) flat and light-tailed distribution of the ns nrt scores, but also indicates a slight build-up of higher scores; with a peak at raw score 13 (i.e. 65% correct responses to the test). the visual inspection of the data seems to suggest that a peak at 11 or 12 would fit the normal distribution curve better. figure 2: distribution of ns nrt scores in the tested sample. nevertheless, for the purposes of this study, the non-significant result of the shapiro–wilk test was seen as sufficient evidence that the scores obtained in the ns nrt were normally distributed, and hence the rest of the statistical analyses were conducted using parametric tests. main effects and between group differences the glm model (option multivariate) established a significant main effect for group (f[3,116] = 9.67, p = 0.000). following this significant effect, tests of between-subjects effect were conducted, which showed that group had a significant effect on english nrt (f = 14.13, p = 0.000), but no effect on digit span or ns nrt. pairwise comparisons (tukey–bonferroni post hoc tests) confirmed that there were no significant differences between the groups in terms of digit span or ns nrt, but that group 1 significantly outperformed group 2 in the english nrt. furthermore, group 1 performed significantly better on both english reading measures, whereas group 2 performed significantly better on both the northern sotho reading measures. the mean scores and test statistics for the measures digit span, ns nrt, english nrt, northern sotho word reading, northern sotho text reading, english word reading, and english text reading are presented in table 2. table 2: mean raw score and ss for digit span, mean percentage for northern sotho non-word repetition task (ns nrt), mean raw score and ss score for english nrt, means for word reading and raw score for fluent reading. correlations and multiple regressions pearson correlations (two-tailed) indicated that ns nrt was significantly correlated with digit span, english nrt, ns word reading, ns text reading and english word reading. english nrt was significantly correlated with both english reading measures, but showed no correlation with the ns reading measures. digit span was significantly associated with all the reading measures in both languages. the r-values of these correlations are given in table 3 (significant correlations are flagged with an asterisk). table 3: correlations between nrt, pwr and reading. multiple hierarchical regression models with ns word reading and ns text reading as dependent variables and ns non-word repetition and digit span as predictors, showed that performance on the ns nrt reliably predicted the outcome of ns reading ability (non-word repetition was entered at step 1 of the model and digit span was entered at step 2). the ability of the ns nrt to predict english reading skills was not of primary interest here, and the correlations mentioned in table 3 suggest that there is no, or a very weak relationship between the ns nrt and english reading. thus, no regression with english reading as dependent variable is reported here. the constant values, betas, standard errors, standardised betas, and r2 values for each of these regression analyses are provided in table 4. table 4: hierarchical regression analyses with ns word reading and, ns text reading as dependent variables and ns nrt and digit span as predictors. discussion in south africa, where many school-aged learners display below average language and literacy skills (department of basic education, 2014; howie, et al., 2008; wilsenach, 2015), the dilemma of failing learners probably remains the most serious and most common problem that teachers, educational psychologists, and slts encounter. in this context, the accurate assessment of processing problems, particularly those related to language and literacy achievement is crucial. the current study set out to investigate the usefulness of using a nrt to detect phonological processing problems, indicative of reading failure, in the northern sotho-speaking population. four research questions were posed, which will be discussed in this section. the first and second research questions (repeated below) will be discussed first, followed by a discussion of the third and fourth research questions: does the ns nrt used in this study discriminate between northern sotho-speaking children with good and poor pwm skills? does the lolt affect the performance of northern sotho-speaking children on a ns nrt and on an english nrt? the ns nrt developed and tested here clearly shows potential as a northern sotho language assessment instrument. the test scores obtained from a sample of 120 third graders were distributed normally, with scores ranging between 1 and 19 (0 being the lowest possible and 20 being the highest possible score). a visual inspection of the data confirmed a relatively flat and light-tailed distribution of scores, indicating that the test most certainly discriminated between learners with very weak and very strong ns phonological processing abilities. both the shapiro–wilk test and the q-q plot suggested that the test scores were normally distributed, but a visual inspection of the data did suggest a slight build-up of higher scores (peaking around 65% correct responses). the ability of the test to discriminate between learners with ‘low average’, ‘high average’, and ‘moderately high’ phonological processing ability (if one is to assume a generic normal distribution curve) could most probably be improved on. the longest non-words in the current version of the ns nrt consist of seven syllables, and all of the non-words follow the characteristic cvcv structure of northern sotho. increasing the pwm load could be achieved by adding non-words of up to 10 syllables (which is the length of the longest english non-words in the ctopp). it is, however, useful to consider other nrt design features in any revision of the current version of the ns nrt, as length is not the only complexity factor that can be introduced. archibald and gathercole (2006) compared performance on two english nrts, namely the cnrep (gathercole & baddeley, 1996) and the nrt (dollaghan & campbell, 1998). half of the non-words in the cnrep contain consonant clusters whereas the remainder have only single consonants. many of the non-words in the cnrep include lexical components and morphemes, e.g. ‘pen’ in ‘pennel’/pεnᴉ/, and ‘ball’ in ‘ballop’/balǝp/. the cnrep non-words are presented with a typical english prosodic pattern. the non-words in the dollaghan & campbell task, on the other hand, contain a limited set of acoustically salient and early acquired phonemes (11 consonants and 9 vowels). the nrt non-words follow a cv structure, and none of the syllables correspond to english lexical items. because of the absence of weak syllables, the prosody of these non-words is unlike the typical english prosodic structure. summarising the features of the two tasks, one could say that the cnrep contains items that sound more like english words (and are higher in ‘wordlikeness’, because of the inclusion of lexical components and morphemes), but have greater articulatory complexity, whereas the nrt non-words sound less like english words, but are simpler in terms of articulation. (it should be noted that neither test contains lengthy non-words – the longest items in the cnrep are five syllables long, whereas the longest items on the nrt are four syllables long). memory for non-words is enhanced via existing knowledge of the lexical and phonotactic structure of a particular language (roodenrys & hinton, 2002; vitevitch & luce, 2005). existing phonological representations of novel sound sequences can be activated via sublexical processing, which would support the processing of novel words (martin & gupta, 2004). according to the original pwm account of non-word repetition, proposed by gathercole et al. (1994), children with impaired pwm are disadvantaged in repeating non-words as a result of the absence of lexical support. thus, if a pwm deficit alone causes a non-word repetition deficit, children should be more disadvantaged on the nrt than on the cnrep, because of the greater presence of lexical and phonotactic knowledge-based support in the cnrep. however, archibald and gathercole (2006) found that children with sli obtained lower scores on the cnrep, which they explained on the basis that children with limited vocabulary knowledge may be at a disadvantage in non-word repetition, not only because of impaired pwm, but also because they cannot support the temporary representations of non-words in their pwm with lexical and sublexical knowledge. furthermore, the sli children performed poorer in articulatory more complex non-words (i.e. non-word that contain consonant clusters). possibly, these children have less robust phonological representations for relatively uncommon phoneme combinations. alternatively, they may be less capable of producing stable rhythmic speech-motor movements, which may affect their ability to repeat consonant clusters. this explanation is supported by klein, watkins, zatorre and milner (2006), who found that distinct cortico cerebellar systems (associated with motor learning, and thus with the acquisition of the articulatory patterns of a language) are more active in the non-word repetition of english-french bilinguals when these individuals are asked to repeat complex words in their l2. klein et al.’s findings suggest that increased articulatory demands imposed when producing novel sequences activate a cerebellar network, which requires more complex motor control for speech production. it seems likely then that there are multiple origins to a deficit in non-word repetition, including pwm, lexical knowledge, and speech-motor processes, among others. an ideal nrt should include stimuli that address as many of these components as possible. it would therefore be advisable to not only add longer non-words to the current ns nrt, but to also carefully control the number and nature of articulatory more complex non-words, and to consider the use of items that can be categorised as ‘more wordlike’ and ‘less wordlike’. in the current version of the ns nrt, the non-words both sound like northern sotho words (i.e. are quite high in wordlikeness) and are fairly simple in terms of articulation. increasing both length and articulation complexity should help to improve the power of the test to reliably distinguish between children who fall somewhere between a ‘low-average’ and ‘moderately-high’ profile in terms of northern sotho phonological processing ability. the results of this study further suggest that northern sotho children, who receive their schooling in english, do not perform significantly differently on a ns nrt, compared to children who receive instruction in northern sotho. group 2 scored higher on the ns nrt, but not significantly so, and thus the processing of phonological input in the l1 does not seem to be altered greatly in northern sotho children who receive their schooling in english. the first hypothesis of this study thus turns out to be incorrect. the two groups were also not different in terms of their ability to recall digits, suggesting that, at a very basic level, the groups’ cognitive functioning and pwm were alike. however, the lolt did affect english phonological processing skills – learners who received their schooling in english from grade 1 performed significantly better on the english nrt task. the poorer performance of the northern sotho lolt group on the english nrt provides further support for the idea that performance on nrts is not independent of language skill; the learners in group 2 would have received far less linguistic input in english, and would probably have known significantly fewer english words. thus, poor non-word repetition skills in bilingual populations is perhaps, like in clinical populations, the result of a poorly differentiated representational system arising from less effective lexical mediation. the third and fourth research questions (repeated below) will be discussed next: does the ns nrt used here correlate with other measures that tap into pwm, such as digit span and english nrt? does the ns nrt used here predict word reading and fluent reading in northern sotho speaking children? pearson correlations on the collapsed data set established that performance on the ns nrt was significantly and positively associated with digit span (r = 0.34), with the english nrt (r = 0.41) and with both measures of northern sotho reading (r = 0.44 for word reading and r = 0.31 for text reading). the association between ns nrt and memory for digits was moderately weak. memory for digits showed a moderately strong correlation with the english nrt. the association between the two nrts was moderate, indicating that the tasks probably assessed the same underlying cognitive skill. ideally, one would like to see stronger associations before reaching firm conclusions, but it is argued here that the ns nrt seems to be associated with both aspects conventionally associated with the pwm construct, namely the processing of information in the short term memory that have stored representations in long term memory and the processing of novel phonological representations which only simulate existing phonological structures. although this study aimed to test the ability of a ns nrt to identify phonological processing deficits in the northern sotho-speaking population at large (i.e. not taking into account the lolt of a child), it is interesting to note that cross-linguistic pwm correlations were much stronger in the l1 instruction group than in the l2 instruction group. in the northern sotho instruction group, the nrts showed a strong correlation with one another (r = 0.64), and with digit span (r = 0.51 for ns nrt and r = 0.59 for english nrt). in the english instruction group, the nrts showed a weak correlation with one another (r = 0.28) and a weak correlation with digit span (r = 0.25 for ns nrt and r = 0.28 for english nrt). the ns nrt was moderately associated with northern sotho word reading, and weakly associated with northern sotho text reading and english word reading. this outcome echoes existing research, suggesting that non-word repetition is particularly associated with word reading (botting & conti-ramsden, 2001; baird, slonims, simonoff & dworzynski, 2011). interestingly, there were no significant correlations between english non-word repetition and northern sotho reading in the current study, which suggests a different cross-linguistic correlational pattern to the one reported in veii and everatt (2005), who found that l2 non-word repetition skills predicted more variance in l1 and l2 literacy than l1 non-word repetition. overall, the correlational pattern seems to suggest that phonological processing ability in bilingual children does not necessarily or automatically transfer across languages (i.e. high performance on a pwm measure in one’s l1 does not guarantee high performance on the same (or another) pwm measure in one’s l2. this notion is further supported by the absence of any meaningful associations between the english nrt and northern sotho reading, and between the ns nrt and english reading. the observed differences between the two groups with regards to the strength of cross-linguistic correlations seem to indicate that the lolt affects the likelihood of transfer of certain aspects of linguistic knowledge. northern sotho learners who received their first years of schooling in their home language seem more likely to transfer phonological processing skills from their l1 to their l2, whereas northern sotho learners who received their schooling in english might not automatically transfer phonological processing skills acquired in english to northern sotho. however, a more systematic analysis of the data is required in order to disentangle the nature of transfer of linguistic knowledge in these groups of learners, and this was not the primary focus here. in line with the initial finding of wilsenach (2013), performance on the ns nrt reliably predicted word reading and fluent text reading in northern sotho in this study. reading performance was clearly influenced by the lolt, with group 1 displaying stronger english reading skills, and group 2 showing stronger northern sotho reading skills. ns nrt accounted for 19.5% of the variance in ns word reading, but only for 9% of the variance in fluent reading in the population at large. memory for digits, which was entered as predictor of word reading and text reading in the second step of the regression model, made no independent contribution to performance in northern sotho reading, suggesting that the ns nrt tested here is a better indicator of reading performance than a digit span task. as a stand-alone assessment instrument, nrt is probably not powerful enough to detect problems in fluent reading in the population at large. even so, 48 of the learners (40%) obtained 50% or less on the test, indicating that, unlike bishop et al.’s (2014) claim, a substantial number of northern sotho children in the population at large seems to have compromised phonological processing abilities. the results presented here clearly show that non-word repetition distinguishes between learners with weak and strong pwm skills, and that the task is associated with reading performance on various levels. thus, a nrt should form part of a test battery that measures northern sotho phonological processing. other measures in a comprehensive test would include measures of phonological awareness, such as syllable and phoneme awareness as well as measures of phonological recoding, such as rapid naming. conclusion in the south african basic education context, where many learners fail to acquire literacy skills at an accepted standard, it is crucially important to be able to test phonological processing skills, in a child’s first language and in the lolt. this article demonstrates that the developed ns nrt is a useful instrument, in that it reliably identifies children with poor pwm (and hence poor phonological processing) skills – such children are, by default, at risk of reading failure. the current version of the ns nrt can be improved on, specifically by adding longer and articulatory more complex non-words. once this has been done, it would be worthwhile to standardise the test. nrts can be developed in all the african languages spoken in south africa, and would, if designed properly, detect children with impaired phonological memory more reliably than other pwm such as digit and word span. the task is easy to administer and economical in terms of assessment time. developing nrts as stand-alone tests, or preferably as subtests in comprehensive phonological processing tests should thus receive more attention in the south african slt, psycholinguistic, and educational psychology environment. acknowledgements the author wishes to thank the research directorate of the university of south africa for their financial support, which made this project possible. competing interests the author declares that she has no financial or personal relationships which may have inappropriately influenced her in writing this article. references alcock, k.j., ngorosho, d., deus, c., & jukes, m.c.h. 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(2015). receptive vocabulary and early literacy skills in emergent bilingual northern sotho-english children. reading & writing, 6(1), art. #77, 11 p. http://dx.doi.org/10.4102/rw.v6i1.77 appendix a northern sotho non-word repetition task sêlumaka mofugatsadi balobadikwe basetswegokoela kuratshifodiri nthufobila katôngwaloshane batêraphôtwana hlôdikilêswagoba neratomkibangwane sepokari ntombuweka makepodiri nôrakulêswibisi bosithirangwe nasibhêkarabilê nesodiwako mogisiroletha hlatoyana narulongwakhubasi appendix b northern sotho word reading test nna ema tee moo eng bona yena dira kudu fase batho mahlo leina phela swara ngwana mathomo meetse bolela morena gopola bošego mantšu kgopela batswadi hlodimela monotlwana phaphamala tshesepere gosenaselo footnotes 1. the rationale for including grade 3 learners was that the researcher wanted to test reading fluency in both northern sotho and english, which is often not possible before grade 3 in this kind of research setting. furthermore, the learners were assessed on a range of phonological skills (not reported on here) which were deemed too challenging for younger learners. 2. in order to determine the allocation of financial resources, south african public schools are categorised into five groups (quintiles). quintile one schools are the ‘poorest’, while quintile five schools are the ‘least poor’. the poverty of the community surrounding the school and various infrastructural factors determine the ranking of a school. 3. the researcher opted to use only an english digit span task, as the participants in group 1 might not have had much exposure to the northern sotho equivalents of the digits 1–10. the participants in group 2, on the other hand, would have had ample exposure to these digits in english. http://www.sajcd.co.za open access page 1 of 1 reviewer acknowledgement read online: scan this qr code with your smart phone or mobile device to read online. 00 acknowledgement to reviewers in an effort to facilitate the 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us if you require assistance in performing this task. publisher: publishing@aosis.co.za tel: +27 21 975 2602 tel: 086 1000 381 the editorial team of the south african journal of communication disorders recognises the value and importance of the peer reviewer in the overall publication process – not only in shaping the individual manuscript, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank all reviewers who participated in shaping this volume of the south african journal of communication disorders. we appreciate the time taken to perform your review(s) successfully. anel botha anita edwards anna-mari olivier anniah mupawose bea staley candice randall cherilee rutherford christine rogers dhanashree pillay fareeaa abdoola heila jordaan helena oosthuizen husmita ratanjee-vanmali jackie clark jane herbert jenny pahl jenny perold joanne neille katerina ehlert lauren fouche lucretia petersen mershen pillay michelle pascoe monique visser mukovhe phanguphangu musa makhoba neethie joseph nikki keeton nola chambers nomfundo moroe nondumiso mthiyane nondumiso gina olebeng mahura penelope flack samantha govender shabnam abdoola sumitrajit dhar talita le roux tracey-lee cloete victor de andrade zandile blose http://www.sajesbm.co.za https://sajcd.org.za https://sajcd.org.za https://sajcd.org.za https://sajcd.org.za/index.php/sajcd/user https://sajcd.org.za/index.php/sajcd/user mailto:publishing@aosis.co.za abstract introduction methods results and discussion conclusion acknowledgements references about the author(s) nomfundo f. moroe department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa katijah khoza-shangase department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation moroe, n.f., & khoza-shangase, k. (2020). recent advances in hearing conservation programmes: a systematic review. south african journal of communication disorders, 67(2), a675. https://doi.org/10.4102/sajcd.v67i2.675 note: special collection: occupational hearing loss in africa. original research recent advances in hearing conservation programmes: a systematic review nomfundo f. moroe, katijah khoza-shangase received: 19 aug. 2019; accepted: 30 jan. 2020; published: 03 mar. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: current evidence from lowand middle-income (lami) countries, such as south africa, indicates that occupational noise-induced hearing loss (onihl) continues to be a health and safety challenge for the mining industry. there is also evidence of hearing conservation programmes (hcps) being implemented with limited success. objectives: the aim of this study was to explore and document current evidence reflecting recent advances in hcps in order to identify gaps within the south african hcps. method: a systematic literature review was conducted in line with the preferred reporting items for systematic reviews and meta-analysis. electronic databases including sage, science direct, pubmed, scopus medline, proquest and google scholar were searched for potential studies published in english between 2010 and 2019 reporting on recent advances in hcps within the mining industry. results: the study findings revealed a number of important recent advances internationally, which require deliberation for possible implementation within the south african hcps context. these advances have been presented under seven themes: (1) the use of metrics, (2) pharmacological interventions and hair cell regeneration, (3) artificial neural network, (4) audiology assessment measures, (5) noise monitoring advances, (6) conceptual approaches to hcps and (7) buying quiet. conclusion: the study findings raise important advances that may have significant implications for hcps in lami countries where onihl remains a highly prevalent occupational health challenge. establishing feasibility and efficacy of these advances in these contexts to ensure contextual relevance and responsiveness is one of the recommendations to facilitate the success of hcps targets. keywords: advances; hearing conservation programmes; industry; innovation; management; occupational; policies; recent. introduction a recent systematic review on the management of occupational noise-induced hearing loss (onihl) in the mining sector in africa between 1994 and 2016 revealed that there is a dearth of research on its management (moroe, khoza-shangase, kanji, & ntlhakana, 2018). findings from this study revealed limited research, often conducted with small sample sizes, limiting the generalisation of findings – research that limited its focus on some aspects of hearing conservation programme (hcp) pillars instead of comprehensive review of these programmes within the african context. these authors argue that the limited research and the nature of the research in this field in africa is a contributing factor towards the documented failure of hcps in this context as evidenced by the onihl in african countries, which is still on the rise. consequently, these authors raise an implication for future studies in hcps to facilitate implementation of successful programmes within the mining sector. an hcp is required when any person in the workplace is exposed to excessive noise. excessive noise is defined as an equivalent sound pressure level of 85 decibels (averaged) (db [a]) or more over an 8-h workday (workplace safety and health council, 2010). the objectives of an hcp are to protect exposed employees from the adverse effects of noise and to minimise the risks associated with workplace noise exposure, thereby preventing onihl (workplace safety and health council, 2010). occupational noise-induced hearing loss is an occupational medical condition (lie, skogstad, johnsen, engdahl, & tambs, 2015) characterised by a permanent sensorineural hearing loss because of excessive exposure to high levels of noise in the workplace (nelson, nelson, concha-barrientos, & fingerhut, 2005; thorne, 2006). globally, it is said to be the number one work-related disability and the second most common form of acquired hearing loss (mostaghaci et al., 2013; ritzel & mccrary-quarles, 2008). while hearing loss is not considered a life-threatening condition (campo, morata, & hong, 2013; hong, kerr, poling, & dhar, 2013; le, straatman, lea, & westerberg, 2017), if left unmanaged, it can significantly lead to adverse consequences on the health, safety and economic outlook of the affected individuals, their families, societies and the state as well (moroe, 2018b). furthermore, in lowand middle-income (lami) countries such as south africa, the effects of onihl should not be underestimated as south africa is currently faced with a quadruple burden of disease, increased unemployment rates, and political and economic instability (gray & vawda, 2016; leboea, 2017; lehohla, 2017); hence, there is the importance of successful hcps. in south africa, hcps were first officially implemented in 1994, following the leon commission of enquiry into health and safety. in 2003, the south african mine health and safety council (mhsc), comprising state, labour and employer representatives, in consultation with various mine houses, implemented the mhsc 2003 onihl milestones (phillips, heyns, & nelson, 2007; strauss, swanepoel, becker, eloff, & hall, 2014) as an improvement to the hcp implemented in 1994. these improved milestones were further refined in 2014 (moroe, 2018). moroe (2018) argues that the refinement of hcps alludes to the complex nature of hcps within the south african context. furthermore, these refinements could be driven by the rapid advances in technology over the years, which may have a significant influence on hcps. hearing conservation programmes are complex in that all seven pillars comprising hcps, which include periodic noise exposure monitoring, engineering controls, administrative controls, personal hearing protection, audiometric evaluations, employee and/or management education, and training and record keeping (hong et al., 2013; moroe et al., 2018), must be implemented in order to yield the expected outputs. inherent to an hcp is the influence of different stakeholders who have a key role in the implementation of these programmes. furthermore, keeping up with research into advances in technology seems to influence the implementation of hcps. in fact, according to brauch (2017): we live in an era of unprecedented technological advancement that impacts every aspect of our lives, from the way we shop and travel to the way we communicate with friends and family. these trends are resulting in new methods and tools that change the way safety professionals and industrial hygienists prevent hearing loss. (p. 1) brauch (2017) asserts that advances in technology with regard to hcps are evidenced by the use of smartphones, low-cost sensors and the growing interest by government agencies in promoting and implementing hcps to ensure worker safety and health outcomes. brauch (2017) argues that, for instance, ‘buying quiet’ as an engineering control strategy is not always feasible or cost-effective, and traditional noisy machining systems can easily be replaced by more versatile and affordable low noise printers. medical advancements are also a consideration for hcps, particularly in the otoprotective agents, which might greatly assist in preventing the impact of noise on the ear. there is sufficient evidence to show that the development of drugs that prevent or treat hearing loss is an increasing business. this rapid growth has been attributed to advancements in drug delivery to the inner ear (henderson & tanaka, 2009). tieu and campbell (2013) provide a comprehensive review of pharmacologic otoprotective agents in or approaching clinical trials, and how these elucidate mechanisms of noise-induced hearing loss (nihl), where both prophylactic and rescue agents are included. these authors reviewed classes of agents including antioxidants, vasodilators and glucocorticoids, and concluded that although no pharmacologic agent is yet approved by the food and drug administration (fda) for clinical use to prevent or treat nihl during the time of their review, they expect that this situation would change within a decade or so to allow for at least one of these agents to be available for clinical use – another reason for the importance of the current systematic review study. there is therefore a need to review evidence on recent advances in hcps and onihl in order to update occupational audiologists and relevant stakeholders for successful target outcomes within this sector – particularly within the lami contexts where limited resources and strict healthcare priorities call for primary prevention measures to be successfully implemented. this systematic review and focus on onihl is also timely as it aligns well with the world health assembly’s (2017) focus, which is deliberately highlighting the prevention of deafness and nihl, particularly in lami countries such as south africa – as 90% of the population with hearing loss resides in these countries. within the south african context, as early as 2013, the minerals council south africa, formerly known as the chamber of mines of south africa, called for innovative and comprehensive ways of managing onihl in the mining sector (booyens, 2013) – hence the relevance of the current study. the main objective of the current study is to explore and document recent advances in hcps through a systematic review methodology. methods data sources and literature search in identifying studies on the recent advances in hcps, a systematic literature review was conducted following the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines. therefore, electronic bibliographic databases including science direct, pubmed, scopus medline, proquest and google scholar were searched for potential studies. the following search terms (pubmed mesh terms) were included: ‘recent’ or ‘advances’ and ‘ management’ and ‘hearing conservation programmes’, or ‘policies’ or ‘industry’, ‘occupational’, ‘innovative’. inclusion and exclusion criteria articles between the 2010 and 2019 time frame were selected for inclusion in the study if they were original pieces of scientific work or reports published in peer-reviewed scientific journals, with a focus on recent advances on hcps or the management of onihl, and were published in english. articles that did not meet these inclusion criteria were excluded from the study. data extraction and synthesis articles selected for inclusion were independently identified by the researchers (n.f.m. and k.k.-s.). in instances where there were disagreements on papers selected for inclusion, these were resolved through discussion and consensus of both authors. where consensus was not reached, n.m. as the primary investigator made the final decision. after agreeing on articles to be included, the researchers then proceeded to provide a narrative synthesis of the findings from the studies meeting the inclusion criteria. the synthesis included the study objectives, study design, study setting and reported strategy which is regarded as an advancement for the purposes of this manuscript. a total of 4688 studies were identified for a potential analysis in this study. of the studies, 3784 records were identified through the aforementioned database search, while the remaining 904 studies were identified through manual searches of references of the identified studies. in the process of collating and organising the studies, 4115 studies were removed as these were duplicates; thus, only 573 studies were considered. of the 573 remaining studies, 519 were excluded based on the titles and/or abstracts deemed not in line with the focus of the study. hence, 54 studies were assessed for eligibility and from this 28 were excluded as they did not meet the inclusion criteria of the current study, meaning that these studies were either conducted before the stipulated time frame or the focus was not contributing towards recent advances in the management of onihl. finally, 26 studies were included for analysis in the current study (see figure 1). figure 1: the preferred reporting items for systematic reviews and meta-analyses flow diagram describing the process of study selection. ethical considerations this article followed all ethical standards for a research without direct contact with human or animal subjects. results and discussion findings of the current systematic review indicated recent advances towards assessment and management of onihl. in total, 26 studies were reviewed, of which 16 were from high-income countries and the remaining 10 were from the lami regions (see table 1). of the remaining 10, only two were from africa. qualitative analysis revealed the emergence of seven themes under which the recent advances can be captured. the fact that glaringly limited research conducted on hcps in africa was noted is a significant drawback to the collation of contextually relevant evidence that can be used to implement effective hcps, as cautioned by moroe et al. (2018), and the fact that most of this evidence was from south africa alone is an even bigger concern. these themes include advances in the use of metrics, pharmacological interventions and hair cell regeneration, artificial neural networks (anns), audiology assessment measures, noise monitoring advances, conceptual approaches to hcps, and buying quiet. table 1: details of study characteristics of each included study. table 1(continues...): details of study characteristics of each included study. table 1(continues...): details of study characteristics of each included study. the use of metrics metrics can be loosely defined as a set of quantitative tools that can be used to assess, monitor, improve or evaluate compliance and success of programmes in order to set and track goals of the implemented programme (sullivan, mcdaniel, mcdaniel limbart, siegel, & services, 2004). in this review, three studies by moroe et al. (2019) and al-dayyeni, sun and qin (2018) focused on the use of metrics as a recent advancement in hcps. davis et al. (2012) examined the value of using the statistical metric, kurtosis, along with an energy metric to determine the hazard to hearing from high-level industrial noise environments, while moroe et al. (2019) proposed the use of a basic static feedback-based noise monitoring model as a tool for monitoring and managing occupational noise in the workplace. both these studies used the international organization for standardization (iso-1999:1990) model to estimate and predict the noise-induced permanent threshold shift in people exposed to noise in the workplace. while davis et al. (2012) used epidemiological data obtained on actual participants, moroe et al. (2019) used fictitious data; therefore, this model still needs to be validated with actual data. al-dayyeni et al. (2018), on the other hand, proposed two noise hazard metrics based on two excitation patterns to evaluate hazardous noise levels caused by different types of noise. in this study, gaussian noise and single-tone noise are simulated to evaluate performances of the proposed excitation patterns (eps) and the noise metrics. these metrics were validated on two auditory filters: the dual resonance nonlinear filter and the rounded exponential filter. the use of metrics as an advancement in the management of onihl adds value towards the implementation of hcps in that, if these models are accurately designed and implemented, they may yield the desired effects of enhancing success of hcps. metrics have been included in studies concerned with risk management in occupations with excessive nose exposure (army regulation, 2016; australian government, 2009; li, huang, & zhang, 2018; moroe et al., 2019). in these studies, excessive noise exposure is viewed as a risk that needs to be managed. metrics are versatile in that they can augment any pillar of the hcp. for instance, models can be used in assessing and monitoring the risk of exposure (periodic noise exposure) (army regulation, 2016), in measuring and attenuating noise emissions from the machinery (engineering controls) (nanda, 2012), in improving and evaluating compliance in the implementation of administrative processes and policies designed to mitigate the excessive exposure to the employees (administrative controls), in conducting audiogram baselines and annual checks (audiometric evaluations), in the use of hearing protection devices (personal hearing protection), in how workers are trained on the effects of excessive noise exposure (education and training) as well as in evaluating compliance and success of programmes in order to set and track goals of the implemented programme (monitoring and record keeping) (moroe et al., 2019). based on the discussion above, the use of metrics can be considered a valuable advancement in the management of onihl. closely linked to the use of metrics is the use of artificial intelligence in hcps, another advancement covered in this systematic review. pharmacological interventions and hair cell regeneration pharmacological interventions are defined as approaches developed for the prevention or treatment of nihl using antioxidant drugs to restore the balance between antioxidant defence and the formation of free radicals in the cochlea (choi & choi, 2015; choi, du, floyd, & kopke, 2014). the current review on recent advances in this area shows that there are pharmacological interventions that have a focus on preventing the problem – nihl – and those that focus on reversing or treating the effects of the problem. as far as the pharmacological interventions that are aimed at preventing the problem are concerned, this systematic review included seven studies (choi & choi, 2015; choi et al., 2014; mukherjea et al., 2011; oishi & schacht, 2011; santaolalla et al., 2013; tieu & campbell, 2013; zheng & zuo, 2017). a study by choi and choi (2015) reviewed structural and functional changes and basic mechanisms triggered by noise exposure in the cochlear and the brain as well as the therapeutic effects of an assortment of antioxidant drugs for the treatment of nihl. this study demonstrated a strong synergistic effect of pharmacological interventions when each antioxidant is used in combination with other antioxidants, depending on optimal timing and the duration of treatment, which is strongly associated with the time window of free radical formation induced by noise exposure. the authors, however, cautioned on the need for further research in this area as the clear relationship between free radical formation and the optimal timing of antioxidant treatment is not yet established. similarly, mukherjea et al. (2011) discussed what they term future strategies into the prevention of hearing loss because of excessive noise exposure. according to these authors, novel delivery systems will provide ways to pharmacological interventions to the desired areas in the inner ear, thereby circumventing problems associated with therapeutic interference agents to minimise the side effects. as far as the pharmacological interventions concerned with reversing or treating the effects of exposure to excessive noise are concerned, three studies were included in this review. zheng and zuo (2017) conducted a study to explore the use of drugs to reverse hair cell loss and to promote hair cell regeneration to enable effective hair cells regeneration in vivo, while oishi and schacht (2011) in a systematic review discussed the pathophysiology of nihl, the underlying molecular mechanisms of damage and the basis for therapeutic approaches to improve the loss of auditory function. likewise, santaolalla et al. (2013) also conducted a literature review and clinical application of inner ear hair cell regeneration. the findings of these authors caution that while drugs can enable effective hair cell regeneration in vivo, it is not currently understood how reagents can be delivered effectively to the mature organ of corti in vivo or how drugs pass through the blood-labyrinth barrier in the inner ear fluids – all implications for future studies. artificial neural networks artificial neural networks are defined as analytical techniques modelled on the learning processes of human cognitive system and the neurological functions of the brain (deng, chen, & pei, 2008). deng et al. (2008) state that anns work by processing information like biological neurons in the brain and consist of small processing units known as artificial neurons, which can be trained to perform complex calculations. in the current review, five studies (aliabadi, farhadian, & darvishi, 2015; aliabadi, golmohammadi, mansoorizadeh, khotanlou, & ohadi hamadani, 2013; badri, 2010; rehman, nawi, & ghazali, 2012; sabanciet et al., 2017) were included on the use of artificial intelligence as a recent advancement in the management of excessive noise exposure in the workplace. aliabadi et al. (2013) and badri (2010) described the development of neural network models for noise reduction, while aliabadi et al. (2013) additionally presented an empirical technique for predicting the noise levels. rehman et al. (2012) focused on using age, work duration, and maximum and minimum noise exposure as the main factors involved in the hearing loss. aliabadi et al. (2015) used artificial intelligence as a new approach to predict hearing loss thresholds amongst noise-exposed workers, while sabanci et al. (2017) estimated the dominant noise source in a workshop using ann. artificial neural networks are considered as one of the most important artificial intelligence techniques because of their ability to store and apply empirical data (aliabadi et al., 2013), and they have been successfully applied in fields such as mathematics, engineering, medicine, economics, meteorology, psychology, neurology (kalogirou, 2006) and now in hcps. the benefits of anns, which can also be successfully applied in designing hcps, include the following: (1) ann models may be used as an alternative method in engineering analysis and prediction; (2) they have the ability to handle large and complex systems with many inter-related parameters; (3) they potentially offer better, quicker and more practical predictions than any of the traditional methods; (4) they provide innovative ways of solving design issues instantaneously, with expert opinion on demand; and (5) they are fault tolerant, robust and noise immune (kalogirou, 2006). with the fourth industrial revolution upon us, with contextual challenges around demand and considering the capacity of audiology and general healthcare manpower in lami countries, anns seem a valuable recent advance to explore. audiology assessment measures bakay, anderson, garcia-lazaro, mcalpine and schaette (2018), lobarinas, spankovich and le prell (2017), plack, barker and prendergast (2014) and plack et al. (2016) have turned to the use of audiological assessment measures as an advanced strategy to diagnose cochlear neuropathology in people exposed to excessive noise. the strength of this strategy lies in its potential to detect early stages of hearing loss in people, who, without further audiological testing, may be mismanaged because of presenting with an audiogram indicating hearing within normal limits. all the above-mentioned authors have, to varying degrees and contexts, explored the relationship amongst noise exposures that produced large temporary threshold shift, significant auditory brain response wave-i reduction and hearing-in-noise deficits in rats. the findings of these studies showed reduced auditory brainstem response (abr) wave-i amplitudes and a low signal-to-noise ratio in hearing-in-noise performance. although these studies have only been conducted on rats and there are acknowledged limitations, the strength of the strategy lies in its early detection of cochlear hidden hearing loss in people exposed to hazardous noise. literature indicates that onihl is gradual (nandi & dhatrak, 2008) and it can take about 10–15 years before the full impact of excessive noise is fully realised. by that time, the damage is done and cannot be reversed. in adopting this strategy in hcps, particularly in audiometric evaluations, monitoring standard threshold shifts, as is the current practice in the south african mining industry (mine health and safety council, 2016), adding abr and monitoring wave-i may be beneficial in monitoring the worker’s hearing status before the ‘measurable’ threshold shift occurs, which is the goal of a successful preventive audiology programme. noise monitoring advances in keeping up with the advances in the use of devices in the management of excessive exposure, researchers such as michael, tougaw and wilkinson (2011), mctague et al. (2013), williams and rabinowitz (2012), michael (2016), rabinowitz et al. (2011) and bayley, woo and wong (2013) have focused on the noise exposure pillar of the hcp to eliminate noise in the workplace. bayley et al. (2013) and michael (2016) in particular have patented devices that can be used for continues noise monitoring in the workplace. bayley et al. (2013) invented a wireless headset noise exposure dosimeter. this dosimeter has a wireless communications transceiver, a speaker, a non-volatile memory storage, a criterion sound level, threshold sound level, a recorded noise dose measurement, an exchange rate and a processor. michael (2016), on the other hand, invented a hearing protection device with two microphones to calculate the exposure dosage of periods when the device is worn (primary microphone) and when the device is not worn (secondary microphone). this device provides an accurate measurement of the exposure dosage when worn accurately. mctague et al. (2013) conducted a study where participants were fitted with a noise monitoring device consisting of a dosimeter carried in a pocket or worn on a belt or helmet. this device was connected by wires to a small microphone to record noise exposure under hearing protective devices. rabinowitz et al. (2011) and williams and rabinowitz (2012) used a hearing protection device fitted with a dosimeter attached to a microphone for measuring noise exposures inside the hearing protection device. the benefits of monitoring noise exposure, if an overexposure is identified, are that the safety representative can intervene appropriately and timely. according to michael, tougaw and wilkinson (2011, p. 197), ‘intervention can take the form of a warning, such as wear the hearing protection devices (hpds) more effectively tomorrow….’ additionally, these devices can eliminate the human element in the reporting and thereby minimise reliance on self-correction by the employee. the use of these gadgets is in line with the sentiments by brauch (2017) who attested that smart hpds are capable of providing effective motivators, empowering noise-exposed individuals to take control of their hearing health outcomes. as such, the national institute for occupational safety and health (niosh) has developed alternative fit checking systems that can be used with virtually any type of earplug regardless of the manufacturer (brauch, 2017). therefore, the contribution towards effective hpds in the management of excessive noise exposure in the workplace cannot be underestimated. conceptual approaches to hearing conservation programmes for the purpose of this systematic review, conceptual approaches are defined as researchers’ synthesis of available evidence used to explain the phenomenon of occupational noise and hcps, with the goal of mapping out actions required to eliminate excessive exposure to noise in the workplace. in this review, only one study (moroe, 2018) was included as a recent advance in the management of occupational noise. moroe (2018) successfully argued for a change in the conceptual framework framing our approach to hcps where she recommends that hcps should be viewed as a complex intervention. complex interventions are defined as interventions built from multiple interacting components, which may act both independently and interdependently (medical research council, 2000; moore et al., 2015). complex interventions are generally conducted to improve health, at the individual, organisational, policy or population level, in different fields such as public health research, medical research (moore et al., 2015) and any public services dealing with complex social interventions such as performance measures, regulations and inspection of funding reforms (pawson et al., 2005). seeing hcps as complex interventions allows for conducting realist reviews, which are concerned with ‘understanding and unpacking the mechanisms by which an intervention works (or fails to work)’ (rycroft-malone et al., 2012, p. 1). realist approaches focus on theory development while taking into consideration the context when methodically and transparently synthesising results (pawson, 2006; pawson et al., 2005; rycroft-malone, mccormack, decorby, & hutchinson, 2010). there are four benefits of conducting realist reviews. firstly, these provide stakeholders and policymakers with enlightenment and empirical evidence on the nature of the programme or intervention implemented in a given setting (pawson et al., 2005). secondly, realist reviews assist policymakers to interpret and clearly understand why a programme worked better in one context than in another context, for example, international versus local context. thirdly, realist reviews provide policymakers with a justification for taking one course of action over another. lastly, realist reviews alert policymakers about potential problems and specific measures that can be applied to mitigate such problems. moreover, realist reviews provide explanations rather than judgements around interventions (pawson et al., 2005). as a recent advance, this conceptual framework ensures holistic and comprehensive, as well as contextually relevant and responsive, implementation of all relevant pillars of hcps in any given context. buying quiet buying quiet is an initiative focused on adopting and promoting the use of quieter machines as a strategy for controlling noise at its source. brereton and patel (2016) advocate for designing and manufacturing power tools and equipment as a strategy for reducing the risk of onihl. the current authors propose that while buying quiet as a strategy in hcps is not a recent advance, the suggested partnership between manufacturers and consumers encouraging companies to seek out and demand quieter equipment effectively driving the market to design and create quieter products while demonstrating the cost benefits of doing buying quiet is a recent advance. according to brereton and patel (2016), investment in noise controls should in the long run be more common as the market demands quieter products. exploration of such partnerships will be beneficial to hcps. conclusion hearing conservation programmes are mandated when employees are exposed to excessive noise in the workplace. this review study identified 26 papers that met the predefined inclusion criteria for this systematic review. these papers were further grouped under various themes. the studies that were selected were heterogeneous; therefore, attempts were not made to conduct a quantitative synthesis or meta-analysis; however, the qualitative analysis yielded clear trends indicating advances in seven themed areas, including advances in the use of metrics, pharmacological interventions and hair cell regeneration, artificial intelligence, audiology assessment measures, noise monitoring strategies, conceptual approaches to hcps and buying quiet. these advances raise important implications for hcps globally, but particularly so in lami countries where onihl remains a significant challenge. as evident by the studies included in this review, only two studies were conducted in lami countries. this indicates that as far as advances in the management of occupational noise are concerned, local studies have focused on the use of metrics and conceptual approaches. these advances are yet to be carried out practically in order to measure their contribution to recent advances in developing countries. therefore, there are implications for research aimed at establishing contextually relevant and appropriate hcps based on the recent advances, which have also been raised by the current findings. increased efforts for collation of evidence from the african context are needed if africa is to keep up with recent advances in hcps. evidence from these studies may raise implications for training as well as policy formulation within these contexts. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. author’s contributions both authors co-conceptualised the idea for the research as well as the design and methodology adopted. n.f.m. was the lead author in writing up of the manuscript for publication with input from k.k.-s. both authors read and approved the final manuscript. funding information the authors thank the national institute for the humanities and social sciences (nihss) and the consortium for advanced research training in africa (carta) for providing financial assistance for the publication of this manuscript. data availability statement the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references al-dayyeni, w., sun, p., & qin, j. 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( rand.) . the cardinal principal in speech acquisition is the desire to express thought or reaction notivated when pantomime or allied grunts and groans are to the child no longer an adequate medium. for so long as a child has no need or reason to implement gestures and sounds with properly constructed words, there is no incentive to acquire normal and progressive speech, and thus the lack of such incentive may well develop into a case of delayed speech. in addition to the psychological causes of alalia prolongata there are numerous other causes which either alone or together with a disturbed psychological history must be considered. illnesses affecting the brain, injuries to the speech centre, and/or speech organs or to the nerves innervating them, congenital factors and mental deficiency are examples by no means comprehensive. to be considered also is the effect of total or severe hearing loss. alalia may be a resultant of severe shock a functional hysterical reaction. an imagined or real inability to obtain satisfaction through oral expression may cause the subject to sever contact with his environment and to lapse into silent despair or sullen resentment. generally the naturad inability of an infant to express emotional disturbances may give rise to a reluctance to develop speech with a refuge being later taken in planned silence. a neglected child will often persist in baby speech, a common condition where the adults do not trouble to conduct normal speech with the child. similarly with a spoilt child whose defective speech is considered quaint and amusing, or one to whom things are given or help rendered at a mere gesture or sound. twins, as between themselves, may establish a rudimentary vocabulary of their own invention, sufficient for their purpeses. these illustrations serve to demonstrate the effect of a lack of incentive leading to articulative laziness and maladjust-ment . where there is delayed speech inxa subject of under 6 years, the speech correctionist will as a prime cause look for lack r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 25 j?.ihe ? s e n c e o f necessity and without realising the utility of speech, a child will frequently not learn to talk. the general principal here is the o^practisl'11110'1011 ^ i s l 0 s t ° γ ^ ^ o p e d tss^ss^i1?11 m u s t b e g i v e n t o over-protection and solici-tude which in many cases can not only delay, but often prevent speech acquisition entirely. ofmotivation i s closely linked with poor speech standards in the home. f emotional conflict often causes delayed speech or speech tn^h^v, 1 i c t 7 a r l e s fr°m an unhappy home life to too high a standard set for the child., the wide practise his°s?l? isf t 0 r e c i t e o t h e ™ i s e vertom against ejl ζh j o e o n a confession, and other pert d ® m a n d s o n t h e may result in a refusal to talk which becomes chronic. the therapist is well aware of the numerous factors to be considered. what may effect one child, in a similar situation may well have no reaction on another. the wide range of emotions and degrees of frustration tolerance level in each child present vast fields of study r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction methodology data analysis results discussion conclusion acknowledgements references about the author(s) jenni-mari potgieter department of speech-language pathology and audiology, university of pretoria, south africa de wet swanepoel department of speech-language pathology and audiology, university of pretoria, south africa ear sciences centre, school of surgery, university of western australia, ear science institute australia, australia cas smits department of otolaryngology, head and neck surgery, section ear and hearing, the netherlands amsterdam public health research institute, vu university medical center, the netherlands citation potgieter, j-m., swanepoel, d.w., & smits c. (2018). evaluating a smartphone digits-in-noise test as part of the audiometric test battery. south african journal of communication disorders, 65(1), a574. https://doi.org/10.4102/sajcd.v65i1.574 original research evaluating a smartphone digits-in-noise test as part of the audiometric test battery jenni-mari potgieter, de wet swanepoel, cas smits received: 27 aug. 2017; accepted: 06 mar. 2018; published: 21 may 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: speech-in-noise tests have become a valuable part of the audiometric test battery providing an indication of a listener’s ability to function in background noise. a simple digits-in-noise (din) test could be valuable to support diagnostic hearing assessments, hearing aid fittings and counselling for both paediatric and adult populations. objective: the objective of this study was to evaluate the south african english smartphone din test’s performance as part of the audiometric test battery. design: this descriptive study evaluated 109 adult subjects (43 male and 66 female subjects) with and without sensorineural hearing loss by comparing pure-tone air conduction thresholds, speech recognition monaural performance scores (srs db) and the din speech reception threshold (srt). an additional nine adult hearing aid users (four male and five female subjects) were included in a subset to determine aided and unaided din srts. results: the din srt is strongly associated with the best ear 4 frequency pure-tone average (4fpta) (rs = 0.81) and maximum srs db (r = 0.72). the din test had high sensitivity and specificity to identify abnormal pure-tone (0.88 and 0.88, respectively) and srs db (0.76 and 0.88, respectively) results. there was a mean signal-to-noise ratio (snr) improvement in the aided condition that demonstrated an overall benefit of 0.84 snr db. conclusion: the din srt was significantly correlated with the best ear 4fpta and maximum srs db. the din srt provides a useful measure of speech recognition in noise that can evaluate hearing aid fittings, manage counselling and hearing expectations. introduction background one of the major problems persons with hearing loss experience is communication in the presence of background noise (taylor, 2003). amplification options such as hearing aids, cochlear implants and assistive listening devices could improve hearing abilities, but most hearing-impaired listeners still find it difficult to understand conversation in background noise (smits, goverts, & festen, 2013). speech-in-noise tests have become an important asset to the diagnostic audiometric test battery as pure-tone air conduction testing and speech recognition scores are not able to determine or mimic the everyday challenge of listening to speech-in-noise (taylor, 2003). by the late 1970s, speech-in-noise tests became popular as a result of the pioneering work by plomp and mimpen (1979) with the development of the standard dutch speech-in-noise test. the standard dutch speech-in-noise test was able to reliably determine the speech reception threshold (srt) for sentences. many variations of the standard dutch speech-in-noise test were developed in several languages because of the test’s strong validity, reliability, sensitivity and specificity (plomp & mimpen, 1979; theunissen, swanepoel, & hanekom, 2009). examples of such tests include the hint (hearing in noise test), mhint (mandarin hearing in noise test) and the german sentence test (kollmeier & wesselkamp, 1997; nilsson, soli & sullivan, 1994; wong, soli, liu, han, & huang, 2007). today speech-in-noise tests are primarily used in the clinical setting to determine a person’s ability to function in a general communication environment by evaluating the speech understanding handicap caused by the hearing loss (smits et al., 2013). speech-in-noise tests possess additional clinical value because information on speech understanding in noise can support adjustment and monitoring of hearing aid and cochlear implant fitting parameters (smits et al., 2013). speech-in-noise tests have also played an important role in counselling hearing aid or cochlear implant users to understand their hearing disability, manage expectations and implement intervention approaches (kaandorp, smits, merkus, goverts, & festen, 2015; smits et al., 2013). most speech-in-noise tests use meaningful sentences as speech material because sentences are representative of daily conversation. even though speech-in-noise sentence tests are able to determine hearing loss for speech, the appropriateness of such a test may be limited (smits et al., 2013; theunissen et al., 2009). to administer a speech-in-noise sentence test, the listener must be able to understand a whole sentence correctly at a comfortable signal-to-noise ratio (snr). most listeners with a hearing loss perform poorly on speech recognition tasks as a result of the severity of the hearing loss or language competence, especially in additional language listeners (potgieter, swanepoel, myburg, & smits, 2017; smits et al., 2013). therefore, listeners with poor additional language competence, cochlear implant users, children and people with severe hearing losses are not able to undertake a speech-in-noise sentence test (potgieter et al., 2017; smits et al., 2013). more recently the digits-in-noise test (din) was developed for diagnostic and clinical purposes (smits et al., 2013). this test, using digit-triplet (i.e. 1-6-5) material, was demonstrated to be suitable as speech material in a diagnostic din by comparing it to the gold standard dutch sentence test developed by plomp and mimpen (1979). this study concluded that the digit-triplets test demonstrated no learning effect and an accurate srt could be determined (smits et al., 2013). the din also had high criterion validity, and the steepness of the slope for the speech recognition function compared positively to the dutch sentence test (smits et al., 2013). additionally, the din test could be conducted from normal to profound hearing losses. the simplicity of the din test even allows children to conduct the test (smits et al., 2013). because of the successful development of the din, the south african smartphone-based din hearing test was developed in 2016 (potgieter, swanepoel, myburgh, hopper, & smits, 2016; smits et al., 2013). following a similar development and validation procedure as the dutch din test (potgieter et al., 2016; smits et al., 2013), the south african din was developed using south african english digits (0–9) as speech material. the noise level was fixed for negative snrs, whereas the speech was fixed for positive snrs. an adaptive test procedure was followed where a triplet was presented 2 db higher (correct response) or 2 db lower (incorrect response) based on the subject’s response. the srt was calculated as the average snr of the triplets presented. a cut-off value was determined at -9.55 db to indicate ‘pass’ or ‘refer’ for hearing loss in native english speakers or non-native speakers with a high level of self-reported english-speaking competence (potgieter et al., 2017; smits et al., 2013). potgieter et al. (2017) demonstrated that the south african din could accommodate non-native listeners by adjusting the ‘pass’ or ‘refer’ criteria based on self-reported english-speaking competency. the south african din, therefore, ensures an accurate test result across native and non-native south african english listeners (potgieter et al., 2017). additionally, the increased use of smartphones in south africa allows the din to be available to increasing numbers of south africans living in rural and urban areas (potgieter et al., 2016, 2017). based on the successful implementation of the south african din as a screening test [available on a smartphone application (app)], its suitability for clinical use in an audiology clinic required investigation. smits et al. (2013) reported that the diagnostic din test could be an important asset to the audiometric test battery for the following two reasons: firstly, in south africa, no standardised or validated recorded speech materials for spondee or phonetically balanced word lists exists. a diagnostic version of the south african din can provide additional information on a listener’s hearing impairment for speech recognition in noise. the din is validated and consists of recorded speech material with low linguistic demands suitable to test normal hearing to profound hearing losses (potgieter et al., 2016; smits et al., 2013). secondly, the test could assist in counselling and management of a listener’s hearing aid expectation as well as assessing hearing aid benefit (smits et al., 2013). objective given the potential benefit of a diagnostic version of the south african din, this study aimed to compare the din alongside standard diagnostic audiology tests in clinical practice. a comparison was conducted between pure-tone audiometry, speech recognition monaural performance scores (srs db) and the din srt. the din was also used in a subset of participants to explore the potential benefit for use with hearing aid listeners by determining aided and unaided din srts. methodology the institutional review board of the university of pretoria approved the research study before data collection commenced. subjects a comparative and correlational descriptive research design was followed. various audiometric practices in the gauteng region assisted with data collection. each audiologist was supplied with a smartphone to conduct the south african english smartphone-based din on subjects in their own private practice or at the public health hospital audiology clinic. a convenience non-probability sampling procedure was followed with selected subjects as they were available and willing to volunteer to take part in the research study at clinical data collection sites. the subjects were assessed with a comprehensive audiometric test battery and the smartphone din in a single test session lasting approximately 1 h. methods and materials an otoscopic evaluation was performed to allow observation of any obstruction in the external auditory meatus. any ear canal obstructions were removed by a qualified audiologist or healthcare provider before testing commenced. a variety of clinical audiometers were used to conduct pure-tone air conduction, bone conduction and speech recognition testing. air conduction and speech audiometry were done in a soundproof booth using supra-aural or insert earphones. a bone oscillator was used to conduct bone conduction audiometry. air conduction thresholds across octave frequencies from 250 to 8000 hz were determined, while bone conduction thresholds were determined from 500 to 4000 hz. the modified hughson–westlake method was used to seek pure-tone air and bone conduction thresholds (hughson & westlake, 1944). the pure-tone average (500, 1000, 2000 and 4000 hz) was calculated to categorise the severity and configuration of the hearing impairment according to the jerger criteria (jerger & jerger, 1980). normal-hearing was categorised as normal if the best ear 4 frequency pure-tone average (4fpta) was ≤25 db hl. a mixed hearing loss was determined by calculating the pure-tone and bone conduction averages (500, 1000, 2000 and 4000 hz) for both ears. the hearing loss was categorised as conductive or mixed when the average threshold difference was >15 db hl (margolis & saly, 2007). speech recognition testing was presented with live voice in afrikaans or english. speech recognition monaural performance scores were obtained across intensities by administering the afrikaanse foneties gebalanseerde woordelys (a phonetically balanced word list) to afrikaans-speaking subjects (laubscher & tesner, 1966). the university of pretoria, english phonetically balanced word list was used to obtain srs db in first-language english speakers. a list of 25 phonetically balanced words was presented 30 db hl above the 4fpta at three different intensities (maximum intensity 90 db). english additional language speakers could choose whether they would like speech recognition testing to be presented in afrikaans or english. normal maximum srs db was classified as a 100% word discrimination score at intensities ≤40 db hl. the best ear maximum srs db was used in the analysis. the 50% srs db was not available for all subjects. various sites were involved in data collection, thereby not using the same methods for determining srs db scores. the south african smartphone din app instructed the subject to enter his or her gender, date of birth, initials and surname. the subject placed the smartphone earphone set into the ears and listened to digits being repeated. a scroll bar allowed the subject to adjust the volume of the digits being repeated to a comfortable listening intensity. a ‘start test’ button presented the test. the subject entered the digit responses on the smartphone keypad. once the din hearing screening test started, the test operates by varying the noise intensity level while having a fixed speech level when triplets with negative snrs are presented. when triplets with positive snrs are presented, the speech level becomes fixed and the noise level varies. the noise starts 500 ms before triplet presentation and stops 500 ms after triplet presentation. the digits were pronounced by a female speaker with natural intonation, for example, 6–9–0, spoken as six–nine–zero. the first digit-triplet set was presented at the subject’s comfortable listening intensity. the subject responded to the triplet set by entering the digit-triplet set on a pop-up keypad. the next digit is presented 2 db higher (incorrect response) or 2 db lower (correct response) based on the subject’s response. a subgroup of nine hearing aid users were asked to perform an additional din using their hearing aids. the din was presented using free-field speakers in a soundproof booth. the smartphone were connected to the free-field speakers. the subjects were seated 1 m from the speaker facing the speaker at 0°. the din was operated using the smartphone app and the subjects entered their response using the smartphone app. data analysis a spearman correlation coefficient was determined to assess the relationship between the best ear 4fpta, maximum srs db and the din srt (1% significance level used). the performance of the south african english smartphone din was determined by comparing the srt to the best ear 4fpta and maximum srs db. descriptive statistics, frequencies and proportions were determined for these variables. the sensitivity and specificity, positive predictive value (ppv) and negative predictive value (npv) were calculated as an indication of the accuracy of the method for determining a hearing loss. additionally, the area under the curve (auroc) from a receiver operation characteristic curve (roc) analysis was determined to provide a further indication of the accuracy between the variables. descriptive statistics for aided and unaided hearing aid din srts were determined for a subset of nine subjects. results a total of 109 adult subjects (43 male and 66 female subjects) participated in this study. the mean age was 55 years (20 sd) with a range of 16–89 years. the sample included 50 normal-hearing subjects and 59 subjects with a hearing loss. an additional subset of nine adult subjects (4 male and 5 female subjects) with an average age of 72 years (7.2 sd; 63–84 years range) participated in this sub-study. comparing digits-in-noise speech reception threshold, pure-tone audiometry and maximum speech recognition monaural performance score intensity significant correlations (figure 1a) were evident between the best ear 4fpta and maximum srs db (r = 0.87; n = 111; p < 0.001), and the best ear 4fpta and din srt (figure 1b) (rs = 0.81; n = 120; p < 0.001) and the maximum srs db and din srt (figure 1c) (r = 0.72; n = 111; p < 0.001). the strongest correlation was between the best ear 4fpta and maximum srs db and the weakest correlation was between the maximum srs db and the din srt. a comparison between the best ear 4fpta (28.8 mean; 17.9 sd) and srs db (53.6 mean; 18.9 sd) showed a significant difference between the two variables. figure 1: (a) scatterplot indicating the correlation between the best ear 4 frequency pure-tone average and maximum speech recognition monaural performance scores; (b) scatterplot indicating the correlation between the best ear 4 frequency pure-tone average and digits-in-noise signal-to-noise ratio; (c) scatterplot indicating the correlation between the best ear maximum speech recognition monaural performance scores and digits-in-noise signal-to-noise ratio. high sensitivity and specificity were obtained when comparing the din srt to the maximum srs db hl (table 1). the ppv of the din srt was 91.5% and npv was 66% to identify subjects with and without an abnormal maximum srs db result (≤100% word discrimination score at ≥40 db hl). table 1: performance of digits-in-noise speech reception threshold and maximum speech recognition monaural performance scores to predict normal and abnormal best ear 4 frequency pure-tone average (snr cut-off = −9.5 db snr). the din srt had a high sensitivity and specificity to identify subjects with an abnormal 4fpta result (table 1). the ppv of the din srt was 89.8% and npv was 86% to identify subjects with and without an abnormal 4fpta result. the best ear maximum srs db predicted normal and abnormal best ear 4fpta, with a high sensitivity and specificity (table 1). the ppv of the maximum srs db hl was 98.3% and the npv was 75.5% to identify subjects with and without an abnormal 4fpta result. a comparison between aided hearing aid din srts (−7.2 mean; 2.1 sd; −3.2 to −9.4 range) and unaided hearing aid din srts (−6.4 mean; 2.6 sd; −2 to −9.4 range) showed a small increase in srt with hearing aids (0.8 mean; 1.5 sd). there was significant individual variability between subjects in the aided condition (−3.2 to −9.4 range) and unaided condition (−2 to −9.4 range) (table 2). table 2: descriptive statistics for aided and unaided hearing aid digits-in-noise speech reception thresholds (n = 9). discussion an english smartphone din was successfully developed in 2016 to provide widespread hearing screening in south africa (potgieter et al., 2016). smits et al. (2013) implemented a diagnostic version of the din to support the diagnostic audiometric test battery in determining the speech recognition impairment in noise for listeners (smits et al., 2013). in order to determine the south african english din hearing test’s applicability as a diagnostic tool, the din srt was compared to the audiometric 4fpta (best ear) and maximum srs db (best ear) in the current study. the smartphone din srt and the best ear 4fpta was significantly correlated (rs = 0.81) in line with previous results reported for the dutch (r = 0.72), french (r = 0.77) and american english (r = 0.74) landline telephone din hearing screening tests (jansen, luts, wagener, frachet, & wouters, 2010; smits, kapteyn, & houtgast, 2004; watson, kidd, miller, smits, & humes, 2012). a good relationship between the din srt and maximum srs db was demonstrated (rs = 0.72) and corresponded to previous results comparing the northwestern university auditory test no. 6 in quiet to the words-in-noise test (rs = 0.61) (wilson, 2011). the auroc for the din srt and best ear 4fpta comparison (0.941) in this study compared well to the auroc for the dutch (0.974) landline din (smits et al., 2004). the sensitivity and specificity of the din provides an indication of the din srt’s ability to correctly identify listeners with or without a hearing loss. the sensitivity and specificity of the din srt compared to the best ear 4fpta (0.88 and 0.88, respectively) related well to the dutch (0.91 and 0.93, respectively) and american english (0.80 and 0.83, respectively) landline dins (smits et al., 2004; watson et al., 2012). a high sensitivity (0.76) and specificity (0.87) were also found when comparing the din srt to the maximum srs db. the poorest correlation was between the din srt and maximum srs db. unsurprisingly, these tests are very different in what they measure with the srs db being a supra-threshold speech test in quiet while the din is a threshold test in noise (lucks mendel, 2008; taylor, 2003; wilson, 2011). the tests therefore complement each other within a clinical test battery. the srs db would always remain a fundamental part of the audiometric test battery as it is a method to crosscheck the pure-tone threshold and provides information on speech processing, sensitivity to speech stimuli and understanding speech at supra-threshold levels in quiet (lucks mendel, 2008). the din reflects a person’s speech recognition ability in noise and provides an indication of loss for speech-in-noise ability (smits et al., 2013; taylor, 2003; wilson, 2011). the din can therefore inform counselling and hearing aid expectation management (smits et al., 2013; taylor, 2003; wilson, 2011). pure-tone threshold testing forms an essential part of the audiometric test battery as the measurement provides information regarding a listener’s degree, type and configuration of hearing loss (kramer, kapteyn, festen, & tobi, 1996). pure-tone thresholds, however, are unable to provide insight into speech recognition abilities in background noise (kramer et al., 1996; smits et al., 2004). speech-in-noise tests (i.e. the din) are most valuable in diagnosing a listener’s speech recognition impairment in noise (smits et al., 2013; taylor, 2003). the results from the comparison between the din srt and best ear 4fpta show a strong relationship between these measures. the din srt is therefore strongly associated with the 4fpta but provides complementary information on speech recognition impairment in noise. additionally, the din can be an applicable asset to the diagnostic audiometric test battery for the following reasons. firstly, the din is easy to administer and takes a few minutes to conduct (potgieter et al., 2016). secondly, simple speech material is used requiring low linguistic demands (potgieter et al., 2016; smits et al., 2004). thirdly, the din can be conducted from normal-hearing to profound hearing losses. fourthly, the test is user friendly and can be used to test children (smits et al., 2013). finally, non-native english listeners with poor english language–speaking competence are able to conduct the din (potgieter et al., 2017). a small sample (n = 9) of hearing aid users were evaluated with the din with and without hearing aid amplification. the mean snr improved in the aided condition and demonstrated an overall benefit of 0.84 snr db. there was significant individual variability between subjects in the aided condition (−3.2 to −9.4 snr db) and unaided condition (−2 to −9.4 snr db). the din can be valuable in a clinical audiology setting to provide individualised performance measures for hearing aid users in background noise (smits et al., 2013; taylor, 2003). a measure of speech-in-noise ability is a valuable clinical addition for counselling and demonstrating hearing aid benefit in the presence of background noise (smits et al., 2013; taylor, 2003). counselling informed by the din srt could assist hearing aid users to understand their hearing impairment and provide important information regarding the communication difficulties that may persist (smits et al., 2013; taylor, 2003). the hearing aid could also be adjusted according to the hearing aid user’s needs as reflected on the din srt (taylor, 2003). the limitation of this study included the small sample of hearing aid users evaluated with and without hearing aid amplification using the din and the lack of data for 50% srs db scores. conclusion the din srt is strongly associated with the best ear 4fpta and maximum srs db and could therefore provide complementary information on speech recognition impairment in noise. the din had high sensitivity and specificity to identify abnormal pure-tone and srs db results. the din srt and best ear 4fpta were significantly correlated with previously developed landline telephone dins. the din srt can also demonstrate benefit for hearing aid fittings. the test is quick to administer, inexpensive, readily available and provides information on the snr loss. the din srt could therefore be used as a counselling tool to evaluate hearing aid fittings, manage counselling and hearing expectations. acknowledgements this research was funded by the national research foundation under grant number 88803. competing interests the university of pretoria has assigned the ip of the hearza din smartphone test for commercialisation. authors’ contributions j.p. was the main author and responsible for data collection, analysis and compiling the final report. d.w.s. was the main supervisor and provided guidance for the research protocol, analysis and compiling the final report. c.s. was the co-supervisor and provided guidance in compiling the final report. references hughson, w., & westlake, h. 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(2013). the digits-in-noise test: assessing auditory speech recognition abilities in noise. journal of the acoustical society of america, 133(3), 1693–1706. https://doi.org/10.1121/1.4789933 smits, c., kapteyn, t.s., & houtgast, t. (2004). development and validation of an automatic speech-in-noise screening test by telephone. international journal of audiology, 43, 15–28. https://doi.org/10.1080/14992020400050004 taylor, b. (2003). speech-in-noise tests: how and why to include them in your basic test-battery. the hearing journal, 56(1), 40–43. https://doi.org/10.1097/01.hj.0000293000.76300.ff theunissen, m., swanepoel, d.w., & hanekom, j. (2009). sentence recognition in noise: variables in compilation and interpretation of tests. international journal of audiology, 48(11), 743–757. https://doi.org/10.3109/14992020903082088 watson, c.s., kidd, g.r., miller, j.d., smits, c., & humes, l.e. (2012). telephone screening tests for functionally impaired hearing: current use in seven countries and development of a us version. journal of the american academy of audiology, 23(10), 757–767. https://doi.org/10.3766/jaaa.23.10.2 wilson, r.h. (2011). clinical experience with the words-in-noise test on 3430 veterans: comparisons with pure-tone thresholds and word recognition in quiet. journal of the american academy of audiology, 22, 405–423. https://doi.org/10.3766/jaaa.22.7.3 wong, l.l.d., soli, s.d., liu, s., han, n., & huang, m.w. (2007). development of the mandarin hearing in noise test (mhint). ear and hearing, 28(2), 70s–74s. https://doi.org/10.1097/aud.0b013e31803154d0 reviewer acknowledgement open accesshttp://www.sajcd.org.za page 1 of 1 the editorial team of the south african journal of communication disorders recognises the value and importance of peer reviewers in the overall publication process – not only in shaping individual manuscripts, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank the following reviewers who participated in shaping this issue of the south african journal of communication disorders: andrea fourie annelie lloyd-jones candice randall cara l. hollander coralie van reenen daleen klop erika bostock esedra kruger fareeaa abdoola fatemah camroodien-surve frenette southwood hanlie degenaar helen l. barrett helena oosthuizen husmita ratanjee-vanmali inge burger ingrid willenberg jackie clark jenny pahl jenny perold joanne neille judy george karin joubert karyn casey katerina ehlert khomotjo s. kgare leanie engelbrecht liepollo ntlhakana luanet smit-white maggi soer mari m. viviers meera rijhumal melissa a. bortz monique visser neethie joseph nikki l. keeton nola chambers nomfundo f. moroe pallavi kelkar pinki singh shajila singh sharon moonsamy tarryn reddy vivienne norman in an effort to facilitate the selection of appropriate peer reviewers for the south african journal of communication disorders, we ask that you take a moment to update your electronic portfolio on http://www.sajcd.org.za for our files, allowing us better access to your areas of interest and expertise, in order to 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http://www.sajcd.org.za http://www.sajcd.org.za http://www.sajcd.org.za/index.php/sajcd/user http://www.sajcd.org.za/index.php/sajcd/user mailto:publishing@aosis.co.za the aphasic child* diana m . whiting b.a. log (rand) l . c . s . t . speech therapist, groote schuur hospital, cape town aphasia in children is of two main types, acquired aphasia and congenital or developmental aphasia. i n acquired aphasia, in a child whose language function has developed normally for his age, the disturbance may result from acute illnesses such as cerebral infections of encephalitis or meningitis; from cerebral tumour or cerebral abscess, or it may be due to a head injury. t h e resulting language disturbance may be transitory and recovery is often good, residual deficit depending on the extent of the cerebral damage and the age of the child. it is this type of aphasia which we meet more frequently in our clinical experience at groote schuur hospital. my clinical experience with the child with congenital or developmental aphasia is far more limited. looking back i feel certain that misdiagnosis and failure to recognise the syndrome has played its part. for the purpose of this paper, i use the term congenital aphasia to imply a specific language disability of probable organic origin, a failure to develop symbolic language due to minimal diffuse neurological deficit, or at least some neurophysiological immaturity or a "developmental lag" as some writers prefer to think of it (de hirsch, bender, ingram, morley et al.). most writers seem to agree that this special entity of the impairment of the acquisition of language function does exist. aphasia is the term, controversial though it may be, most generally used to denote it. some writers, however, restrict the term aphasia to refer to linguistic impairment of oral and aural .communications, whereas others extend it to embrace the continuum of the more complex language functions of reading, writing, spelling and composition (arnold, de hirsch et al.). some feel the symptoms of aphasia in children are limited to language as expressed orally and perceived aurally whereas others feel elements of the syndrome are to be found outside of the behaviour of speaking and listening. t h i s seems reasonable to me as perception gives meaning to sensation and evidence of deficits of neurophysiological ^phenomena underlying linguistic behaviour should aid diagnosis and guide therapy planning. t h e child's ability to form concepts of size, shape, form, colour, number, time, space and so on is an integral part of learning to use functional language. some writers feel that the diagnosis of aphasia is onlv plausible when the linguistic disturbance stems from a definite demonstrable organic * this paper was read on 14 october 1965 at the cape education department's conference for teachers of speech defective and hard of hearing children. journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the aphasic child 37 o r i g i n , w h e r e a s o t h e r s feel t h a t t h e r e is a g r o u p i n w h i c h a l a r g e familial c o n s t i t u t i o n a l factor is i m p o r t a n t , a n d yet o t h e r s feel t h a t t h e l a n g u a g e s y m p t o m s t h e m s e l v e s a r e sufficient t o classify t h e d i s o r d e r as a p h a s i a . t h e s e d i v e r s i t i e s of o p i n i o n are, of c o u r s e , a n i n d i c a t i o n of t h e c o m p l e x i t y of t h i s specific l a n g u a g e d i s a b i l i t y . d e f i n i t i o n s eisenson defines aphasia in children as "an impairment of the ability to express and comprehend verbal symbols." west defines it as "an impairment of language function, receptive or expressive, resulting from maldevelopment or injury to the central nervous system pre-, paraor post-natally." mycklebust defines is as "a language disorder which derives from organic impairment, i.e. a symbolic disorder due to neurological involvement." mcginnis and kleffner define it as "an inability to express a n d / o r understand language symbols as a result of a deficit in the central nervous system rather than as the result of a deficit in the peripheral speech mechanism, ear or auditory nerve, a defect of intelligence or severe emotional disturbance." language development in children f u n c t i o n a l l a n g u a g e d e v e l o p m e n t m a y b e d i v i d e d i n t o 3 t y p e s : 1. inner language: the language we use for inner life and thought. 2. receptive language: the language we use to understand others. 3. expressive language: the language we use to express thoughts and ideas to others. inner language d u r i n g t h e first m o n t h s of life t h e infant r e c e i v e s m u l t i p l e s e n s a t i o n s of m a n y t y p e s . t h r o u g h g r a d u a l i n t e g r a t i o n h e d e v e l o p s a b a s i c i n n e r a n d f u n d a m e n t a l l a n g u a g e , i.e. a n a w a r e n e s s of s e n s a t i o n a n d r e c o g n i t i o n . a t 8 9 m o n t h s h e b e g i n s t o c o m p r e h e n d s p o k e n l a n g u a g e a n d at + 1 y e a r h e b e g i n s t o u s e e x p r e s s i v e l a n g u a g e . a c c o r d i n g t o k a r l i n , t h e d e v e l o p m e n t of r e c e p t i v e a n d e x p r e s s i v e l a n g u a g e f u n c t i o n s follow a n o r d e r of i n c r e a s e d c o r t i c a l c o m p l e x i t y . r e c e p t i v e l e v e l s first level: t h e awareness of sensation, or the arrival platform as orton calls it. second level: recognition, i.e. the ability to recognize objects and symbols and build u p memory constellations capable of recall. third level: symbolic formulation where concepts are formed and language is elaborated. m o t o r l e v e l s first level: ability to contract striated muscles voluntarily. second level: ability to prform purposeful movements. third level: ability to express meaningful language. a disturbance and disorder of function at any of these levels will result in : receptive motor 1. cortical blindness/deafness dysarthria 2. visual/auditory agnosia dyspraxia 3. receptive aphasia expressive aphasia. tydskrif van die suid-afrikaanse logopediese veren'ging, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 diana μ. whiting assessment in the absence of valid and reliable assessment techniques the diagnosis of developmental aphasia becomes one of elimination as is implied by mcginnis and k l e i n e r ' s definition. t h e aphasic child must be differentiated from the deaf child, the mentally retarded child, the autistic child and the severely emotionally disturbed child for failure to acquire language and respond to speech is common to all these groups. diagnosis should therefore be a multi-disciplinary process and should include: (a) a detailed developmental, medical and social history. (b) neurological examination. (c) psychiatric evaluation. (d) psychometric testing. (e) audiological investigation. (f) an assessment of inner, receptive and expressive language functions. (g) observations of behaviour and neuro-physiological phenomna underlying linguistic behaviour. history. a careful developmental, medical and social history of the child must be taken. t h i s should include a family history of speech, reading, writing, laterality and neurological deficits. it is important to note the presence or absence of vocal play in infancy, and responses to sounds and speech. such comments as "he doesn't listen," "he's disobedient," "sometimes he seems to hear sounds," "he keeps on saying ' w h a t ' " may prove to be significant, as may be reports of clumsiness, hyperactivity, falling, etc. goldstein, landau and kleffner believe that the etiological background contributes to differentiation. they believe t h a t : (a) meningitis, infantile infections and family history of deafness support the classification of deafness. (b) jaundice from rh incompatibility, anoxia at birth, convulsive disorders, congenital brain abnormalities and a family history of speech and neurological disorders support the classification of aphasia. many asphasic children respond normally to social training in a broad sense and are then capable of fairly normal behaviour, whereas the autistic child and the severely emotionally disturbed child will present a different picture and is more likely not to respond to social training. extreme "aloneness," failure to make contact and persistant bizarre behaviour may hallmark the autistic child. neurological investigation. many aphasic children show/no obvious neurological deficit. sub-clinical diffuse organic involvement may only be picked up when the child fails to acquire the complex activities of speaking and reading. some show no deviations on classical neurological examination and electroencephalography. yet performance on more subtle neurological tests may infer minimal neurological deficit. focal abnormalities on electroencephalography are more common among aphasic than deaf children as is "obst'ruseness" during neurological testjournal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the aphasic child 39 ing as evidenced by an inability to grasp a perceptual non-language task (goldstein, landau and kleffner). psychiatric evaluation. receptive and expressive language functions are frequently disturbed in severely emotionally disturbed and autistic children. t h e bizarre behaviour and failure to make contact exhibited by the autistic child may be readily distinguishable to those familiar with the disorder. but the partially autistic child and the emotionally disturbed child may not be so readily recognized without the help of a child psychiatrist. psychometric testing. testing the intelligence of the non-communicating child presents the psychologist with many problems. testing procedures which require no language in their administration and response may be required. t h e performance and verbal scales of the wechsler intelligence scale for children seem to be the most commonly used here in assessing children with brain damage or suspected neurological deficit. in this test it appears that there are also certain items which enable the tester to distinguish the neurologically involved child with a language deficit. memory for temporal and spacial patterning appears to be markedly weak in aphasic children, and therefore memory test items may be diagnostically significant. however, it must be remembered that ultimately it is the information derived from the analysis of the test results rather than the score that is of importance and significance in planning treatment and education. visuo-motor organization. in this sphere the bender gestalt t e s t is useful. responses in the aphasic child seem to be developmental^ immature or to show poor spacial organization (de hirsch). goodenough draw-a-man test, de hirsch finds the responses of a child with a specific language disability may be two years behind his mental and chronological age, indicating disturbances of body schema. figure ground organization.. differentiation between figure and ground is essential for both speech and reading, i.e. in both auditory and spacial areas. spacial organization. t h i s must be observed within the age limits of the child. ambilaterality is related to difficulties with temporal and spacial sequences. t h e child who says "ricecrispsy" for "rice crispy," "hostipal" for "hospital" and the one who reads " w o n " for " n o w " and " t a p " for " p a t " has the same difficulty but in different modalities. confusion of temporal and spacial organization, according to de hirsch, may be related to familial factors but is also indicative of central nervous system immaturity or deficit. audiological investigation. children who do not respond to sound or speech are not necessarily deaf, nor can they all be educated by methods conventionally used with the deaf. one of the most striking features of the aphasic child's behaviour is his inconsistency of response. this inconsistency of response to all types tydskrif van die suid-afrikaanse logopediese verening, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 0 diana μ. whiting of hearing tests makes assessment of his hearing-potential extremely, difficult. it may be some time before a reliable audiogram is obtained, for at times the child seems to be hard of hearing, and at other times not. attention span is generally poor, so it is wise to test for quiet sounds first. he may alert to faint sounds such as the rustling of tissue paper or a quiet " s h " and fail to respond at all to loud sounds and speech. he may show a normal response to one or two sounds only. he may alert to everyday sounds or unusual sounds, but fail to alert to speech. if no startle response is elicited it may be necessary to use psychogalvanic or electroencephalographic audiometry to establish the presence or absence of hearing. gordon and taylor have reported some interesting .work with electroencephalographic audiometry in manchester with children with severe communication disorders. t h e y have recorded responses at 30 db in children who have failed to respond at all to conventional pure tone and speech audiometry. such results are significant diagnostically in that peripheral hearing is intact, and so cortical deafness and auditory agnosia are implied. goldstein, landau and kleffner reported half the aphasic group at the central institute for the deaf to have some degree of peripheral hearing loss but this was not considered to be the major factor contributing to their failure to use language. t h e y n o t e d : (a) normal hearing or moderate loss on all frequencies was characteristic of the aphasic group. (b) sloping audiograms with severe loss was characteristic of the deaf group. (c) sloping audiograms with moderate to severe loss were found in both groups. (d) normal vestibular responses were characteristic of the deaf group, except in meningitis when there was no response. (e) depressed vestibular responses were characteristic of the aphasic group. assessment of language function: (a) inner language. this may be observed by presenting the child with toy objects and family figures related to his environment and watching his play for association of objects, concreteness and abstractness. it is likely that the aphasic child's play is less imaginative than the deaf child's. (b) receptive language. observations must include auditory memory and auditory discrimination as well as auditory recognition and comprehension of language of increasing complexity. predominantly receptive aphasia. t h e basic characteristics a r e : i. an inability to understand and use language. ii. a poor memory for learning it. other clinical manifestations are variable. t h e following are typical: i. intelligence within normal limits. / ii. normal or slightly impaired hearing. iii. inability to associate names with objects. iv. inability to name objects. v. inability to imitate names of objects. vi. poor recall of names he has repeated. vii. inability to interpret and use environmental language. according to mcginnis the speech behaviour of these children manifests itself in 4 different ways: i. silence or rare vocalization. ii. t h e use of jargon with inflections indicative of adequate hearing. journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the aphasic child 41 iii. jargon speech interspersed with intelligible words or phrases. iv. echolalia, where the child can repeat words and phrases without any association of meaning. r e c e p t i v e a p h a s i a is f r e q u e n t l y a c c o m p a n i e d b y o t h e r c o n d i t i o n s a n d it m a y b e difficult t o d e c i d e w h i c h is t h e p r e d o m i n a n t factor i n t h e failure t o l e a r n s p e e c h a n d l a n g u a g e . (c) expressive language. a s s e s s m e n t of e x p r e s s i v e l a n g u a g e a b i l i t y m u s t b e g u i d e d b y t h e stage of l a n g u a g e d e v e l o p m e n t , if a n y , t h a t ' t h e c h i l d h a s r e a c h e d . i t is i m p o r t a n t t o n o t e h i s a b i l i t y t o u s e vocal p l a y a n d h i s a b i l i t y t o n a m e o b j e c t s , r e p e a t n a m e s or s o u n d s , u s e o n e w o r d s e n t e n c e s , p h r a s e s , e t c . predominantly expressive aphasia. t h e b a s i c c h a r a c t e r i s t i c s a r e : i. intelligence within normal limits. ii. adequate hearing and understanding of speech. iii. i n general behaviour symptoms of perseveration, disinhibition, hyperactivity and distractibility are in evidence. iv. echolalia, where the child can repeat words and phrases without any associawardness, poor balance, a tendency to fall and confused laterality. s p e e c h b e h a v i o u r m a n i f e s t s itself i n t h e following m a n n e r : i. vocalization may be limited to staccato vowels and occasional consonants. ii. t h e r e is usually some evidence of a constant chatter of perseverative patterns in no way resembling words these children attempt to say. iii. a limited ability to imitate words. iv. a limited ability to initiate speech sounds. v. a delay in onset of speech until the age of four years or later. vi. a pronounced difficulty in memory for sequences of sounds. w h e n a s s e s s i n g older" c h i l d r e n w i t h s p e e c h a n d / o r r e a d i n g d i s a b i l i t i e s w h o h a v e h i s t o r i e s of late a c q u i s i t i o n of s p e e c h , t h e following c h a r a c t e r istics m a y b e i n d i c a t i v e of r e s i d u a l specific l a n g u a g e d i s a b i l i t y a n d s h o u l d t h u s b e fully i n v e s t i g a t e d : i. poor memory for word sequences in sentences, e.g. question and negation forms such as " h e r come here?" " m e no can do." ii. difficulty in discriminating like sounds. iii. confusion of the beginnings and ends of words. iv. word-finding difficulties. v. many sound substitutions and the omission of final consonants. vi. pronounced developmental lag in the language area. vii. grammatical confusions, e.g.: omission of prepositions and articles. omission of forms of the verb "to be," e.g. "billy going school." objective use of pronouns, e.g. " m e do it," "her want it." infinitive form of verbs for every person. exclusive use of the present tense. viii. striking monotony with distortions of rhythm and rate. ix. motor immaturity such as turning the head when flexing the tongue. x. difficulties with conceptualization related to time and space. xi. at about twelve years or m o r e : trouble with formulating ideas. poor ability to put a story together. difficulty in functioning on a high abstract verbal level. difficulty with literal and figurative meanings of words. difficulty with metaphors. a marked concreteness, e.g. an ability to do better with pictorial rather than verbal absurdities. e a r l y d i a g n o s i s a n d t r e a t m e n t for t h e a p h a s i c c h i l d is a d v o c a t e d b y all w r i t e r s . p r o g n o s i s is infinitely b e t t e r , p a r t i c u l a r l y for s e v e r e cases w h e n tydskrif van die suid-afrikaanse logopediese verening, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 4 2 diana μ. whiting the problem is recognized early and adequate treatment is provided in the pre-school years. treatment there appear to be two main approaches to the treatment of young aphasic children: 1. the association method. t h i s was devised and used at the c e n t r j l institute for the deaf by mcginnis. it is an elemental approach in which the child is taught t o : (a) articulate a number of speech sounds correctly. (b) produce several individual sounds in a set sequence. (c) read and write these sounds. t h i s is all taught before the sequence is identified as a word and associated with an object or picture representing it. · a multi-sensory approach is emphasized to reinforce the auditory channel and when a number of words have been acquired, sentence building is begun. cursive writing, never printing, is used from the start. 2. synthetic approach. t h i s approach starts with a word as a unit of language in order to let the child develop the concept of the word as a symbol. eisenson advocates a uni-sensory approach initially until some basic symbolic communication is established, whether this be gesture, reading or speech, before reinforcement and further learning through a multi-sensory approach is begun. both methods emphasize the need to speak slowly and clearly to the child at all times. according to authorities such as mcginnis, eisenson and others; children with aphasia uncomplicated by other disorders, diagnosed correctly and treated from an early age may be ready to take their place in the ordinary classroom from the age of 9 or ι ο years. those with less severe disturbances may be ready to take their place in the ordinary school system from the start, but may require special help with speech and the complex language functions of reading, writing, spelling and composition. t h e problem of childhood aphasia is a complex andfascinating one requiring a multi-disciplinary approach. there is an increasing awareness in this country of the need for an expert team of specialists and educators to investigate this problem, develop reliable diagnostic techniques and to provide suitable treatment and education for this type of child. opsomming 'n kort opsomming van die algemene gedagte in verband met die verloop van aangebore of ontwikkelde afasie dien as 'n verwys van die ingewikkeldheid van hierdie spesifieke taalgebrek. die identifisering van hierdie taalgebrek is afhanklik van 'n multidisiplinere benadering tesame met neurologiese, psigiatriese, psigometriese en oudiologiese ondersoek en beraming van innerlike reseptiewe en ekspressiewe taalvermoe. journal of the south african logopedic society, vol. 13, no. 1: may 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the aphasic child 43 die twee vernaamste behandelingsmetodes is reeds genoem en die belangrikheid van vroee volledige diagnose en behandeling is benadruk. references 1. arnold, g. e. 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(1962): childhood aphasia in proceedings of the institute on childhood aphasia, stanford university school of medicine. california: stanford univ. press. tydskrif van die suid-afrikaanse logopediese verenging, vol. 13, nr. 1: mei 1966 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sajcd 248 clinical signs and symptoms of tinnitus in temporomandibular joint disorders: a pilot study comparing patients and non-patients a kanji, ba speech and hearing theory, ma (audiology); k khoza-shangase, ba speech and hearing theory, phd (audiology) department of speech pathology and audiology, university of the witwatersrand, johannesburg, south africa corresponding author: a kanji (amisha.kanji@wits.ac.za) background. tinnitus is one of the otologic symptoms commonly reported to be associated with temporomandibular disorder (tmd), and questions regarding its nature and cause continue to plague the clinical and research community. objectives. the current pilot study aimed to investigate the clinical signs and symptoms of presenting tinnitus in a group of individuals with tmd (group a), and compare them with a group with tinnitus but without tmd (group b). twenty participants were included in the study, 10 from each group. methods. all participants underwent basic audiological as well as ear, nose and throat (ent) evaluations to establish group a and group b. for tinnitus assessment, all participants completed a tinnitus survey questionnaire, and their tinnitus was evaluated using tinnitus matching procedures. results. findings revealed clinically relevant differences in attributes of tinnitus in patients with and without tmd. most of the participants in group a matched their tinnitus to a 6 000 hz tone or noise, at lower intensity levels than participants in group b, although these results were not statistically significant. participants in group a associated their tinnitus with a single sound whereas some participants in group b associated it with more than one sound. more participants in group b reported the duration of their tinnitus as constant. conclusions. tinnitus may occur in patients with tmd, and be of high frequency. this highlights the importance of thorough assessment for patients with tinnitus as this might have implications for diagnosis and management. keywords: matching, pitch, tinnitus retraining therapy, temporomandibular disorder s afr j cd 2013;60:16-20. doi:10.7196/sajcd.248 appendix a is available with the online pdf of this article at http://dx.doi.org/10.7196/sajcd.248 although tinnitus has been described for centuries, theories about its origin, assessment and treatment continue to evolve (viirre, 2007). tinnitus is a common otological disorder that is characterised by the perception of sound in the absence of an external sound source. its many possible causes, generation and various management strategies are topics of continued scientific enquiry and much controversy (salvinelli, casale, paparo, persico & zini, 2003; ariizumi, hatanaka & kitamura, 2010; vielsmeier et al., 2011). a review of the current literature indicates a continued need for research into tinnitus in pursuit of appropriate treatment strategies to enhance the quality of life of the tinnitus sufferer, hence the current study. successful management of tinnitus continues to be challenging, arguably owing to the fact that a number of possible causes of tinnitus exist, with the most understood being those of objective tinnitus (hall & haynes, 2001). subjective tinnitus is however more common. among the causes of objective types of tinnitus are extra-auditory disorders, namely, temporomandibular disorders (tmds) (crummer & hassan, 2004) vascular disorders, neurological disorders and eustachian tube disorders (crummer & hassan, 2004). in audiological practice, tinnitus often presents as a concomitant symptom of hearing loss, which commonly resolves when hearing loss is managed (ariizumi et al., 2010). other studies have reported tinnitus in individuals with ‘hidden hearing loss’ as indicated by a normal audiogram but reduced wave i amplitude on auditory brainstem response testing (schaette & mcalpine, 2011). in cases where hearing loss is not part of the presenting symptomatology, careful assessment and characterisation of the presenting tinnitus can guide diagnosis of other conditions and/or guide the tinnitus treatment plan. tmd is well documented as being frequently associated with tinnitus (vielsmeier et al., 2011). tmd is a collective term that describes various related disorders affecting the temporomandibular joint (tmj), and muscles of mastication, as well as associated structures, with common symptoms such as pain and restricted jaw opening (dimitroulis, 1998; sobhy et al. 2004). these signs and symptoms may manifest in areas of the face and neck, the temporal, occipital and frontal areas of the head, as well as the preauricular and auricular areas. a number of patients with tmj disorder may also present with aural symptoms, of which the most commonly reported is tinnitus (vielsmeier et al., 2011). although tinnitus in tmd is a documented common symptom, it does not occur as frequently nor is it as specific a symptom as the most common clinical features that include orofacial pain, joint noise and limited jaw function (dimitroulis, 1998). the association between tinnitus and tmd has been confirmed by numerous other studies, some reporting an increased prevalence of tinnitus in tmd (chole & parker, 1992; wright & bifano, 1997; vielsmeier et al., 2011). there is agreement that individuals with tmd may present with tinnitus as a primary or as a secondary complaint (chole & parker, 1992), thus highlighting the importance of careful assessment and management, including appropriate referral for the tinnitus sufferer. although tinnitus in tmd has been documented to be objective in nature (crummer & hassan, 2004), evidence exists that it can also be subjective. according to salvinelli et al. (2003) tmd results in subjective rather than objective tinnitus. subjective tinnitus refers to an auditory sensation that is not related to the perception of external, acoustic stimulation of the cochlea. the causes of subjective tinnitus include otologic diseases or hearing loss, ototoxicity, and metabolic and psychogenic disorders (crummer & hassan, 2004). viirre (2007) makes specific reference to salicylate toxicity, noise exposure, and endolymphatic hydrops as noteworthy causes of acute forms of tinnitus, thus highlighting the importance of establishing the clinical signs and symptoms in this population. the prevalence of tinnitus in tmd patients has received much review, and the difference in findings and reports encourages one to be critical in interpreting the results. for example, tuz, onder and kisnisci (2005) suggested a significantly higher prevalence of tinnitus and vertigo in their symptomatic tmd group than in the asymptomatic control group. in contrast, bernhardt et al. (2004) investigated whether signs of tmd are more frequently displayed in patients with tinnitus than in those without tinnitus. findings indicated that the tinnitus group reported more pain on the palpation of the masticatory muscles in comparison with the control group. additional evidence for tmj-tinnitus association is provided by morgan (1992) who examined 20 patients who were not known to have tmd but presented with a chief complaint of tinnitus. findings indicated that 19 of the 20 presented with one or more clinical indications of jaw joint disorder, and that an examination of the tmj should be performed when an otological examination is unable to determine the cause of the tinnitus (morgan, 1992). most recently, vielsmeier et al. (2011) concluded that classic risk factors for tinnitus such as older age, male gender and hearing loss are less relevant in tinnitus sufferers with tmd. these authors assert that their findings suggest a causal role of tmd in the generation as well as the maintenance of tinnitus. this causal relationship has implications for the tinnitus treatment strategy adopted by the clinician. early studies showed that tmd treatment can alleviate tinnitus. therefore, knowledge of the accurate diagnosis of the cause of tinnitus and its presentation, as well as audiological attributes, can significantly add value to the management of this patient population. as early as 1964, investigations by kelly and goodfellow indicated an elimination and/or improvement of tinnitus following tmd therapy in a significant number of the participants in their study. wright and bifano (1997) documented that 56% of their participants reported that their tinnitus had been resolved and 30% reported significant improvement following tmd therapy. sobhy et al. (2004) reported improved cochlear functioning, as evidenced by the objective increase in distortion product levels on otoacoustic emissions at most frequency bands, and subjective improvement in tinnitus on self-assessment questionnaires. all these studies provide evidence for an influence of the somatosensory system on tinnitus perception. vielsmeier et al. (2011) report that approximately two-thirds of tinnitus sufferers can change the loudness and pitch of their tinnitus by employing somatic manoeuvres such as jaw clenching or tensing their neck muscles. these findings show that clinicians should be aware of the fact that tinnitus can be a sign and symptom of tmd and that a careful case history can result in an appropriate referral to a tmd clinic. alleviation of tinnitus through appropriate tmd therapy avoids inappropriate and ineffective treatment options in the tmd population such as the use of sound generators. audiologists can play a crucial role in the correct diagnosis and treatment of tinnitus in the tmd population, and the subsequent improvement in quality of life (ariizumi et al., 2010). evidence exists for the importance of appropriate assessment and management of the tinnitus sufferer as a way of ensuring positive quality of life. for example, a study performed by erlandsson, rubenstein, axelson and carlsson (1991), regarding the psychological dimensions in patients with disabling tinnitus and craniomandibular disorders, indicated that patients with persistent tinnitus experience distress similar to that in patients with chronic pain. in addition, increased levels of depression have been reported in patients with tinnitus (camparis, formigoni, teixeira & de siqueira, 2005). it is therefore also crucial that psychological observations of the patient complaining of tinnitus be considered in order to achieve successful management. these observations may be made through the use of a self-report questionnaire to determine the extent of interference that the tinnitus causes in an individual’s work, social and mental activities. in order to provide appropriate tinnitus treatment guidelines, and to determine the efficacy of the treatment, accurate measurement of the presenting tinnitus is important. in addition to a physical examination by an otolaryngologist, and basic audiometric testing by an audiologist, henry, zaugg and schechter (2005) argue that it is also essential for each patient with presenting tinnitus to be evaluated audiologically to determine the pitch and the loudness of the tinnitus. a paucity of data exists on these tinnitus characteristics in tmd. existing evidence points to the controversy about tmd resulting in either subjective or objective tinnitus, although felicio, faria, da silva, de aquino and junqueira (2004) did report that tinnitus with tmd is usually of high frequency and moderate intensity, and episodic in nature, which differentiates it from most types of tinnitus commonly associated with otoneurological signs. however, these authors did not specify the tinnitus frequency and intensity ranges which may be of benefit during tinnitus masking procedures and during tinnitus retraining therapy. therefore, the purpose of the current pilot study was to investigate and compare the clinical signs and symptoms of tinnitus in patients with and without tmd. method objectives the primary aim of the current pilot study was to establish clinical signs and symptoms of tinnitus in patients with tmd, with the following specific objectives: • to gather and compare descriptions of subjective tinnitus in groups of tinnitus sufferers with and without tmd through data collected via a questionnaire. • to gather and compare descriptions of the clinical signs of tinnitus in groups of tinnitus sufferers with and without tmd through data obtained via tinnitus matching procedures. participants participants for the current pilot study were recruited by means of a non-probability quota sampling strategy. a purposive convenience sampling technique was adopted as the sample was selected from a location convenient to the researchers at a local academic tmd clinic and ear, nose and throat (ent) clinic in johannesburg. the study included two groups of participants (n=20). group a consisted of 10 patients diagnosed as having tinnitus with tmd, and group b consisted of 10 patients diagnosed as having tinnitus of other aetiologies excluding tmd. for the participants with tmd, the diagnosis of tmd was determined by a clinical, stomatognathic examination of tmd (dimitroulis, 1998), conducted by a specialist dentist. patients had to present with the signs and symptoms typically associated with tmd, with tinnitus being one of the complaints. an important inclusion criterion for participants with tinnitus and tmd was that they had to present with hearing within normal limits from pure tone audiometry testing. participants were also assessed by an ent specialist to rule out any other conditions associated with tinnitus. although age and gender are reported to be risk factors (vielsmeier et al., 2011), their effect is inconsistent (davis & el refaie, 2000). these were therefore not controlled for in the current pilot study, an acknowledged limitation which is an identified implication for future studies. the profile of the participants is depicted in table 1. research design this study made use of an exploratory non-experimental between-subjects research design, as the performances of separate groups of participants were measured, and comparisons were made between the groups. comparisons between group a (patients with tmd) and group b (non-tmd patients) were made with regard to their performance on certain criterion variables (devlin, 2006). materials and procedures permission to conduct the study was obtained from the medical human research ethics committee (protocol number: m060105) and approval was obtained from all relevant authorities and departments at the research site. research conduct adhered to and was guided by the ethical principles and practices advocated by the south african medical research council (2003). the following test protocol was adopted for all participants: all participants were requested to complete a questionnaire (appendix a) pertaining to the perception of their tinnitus with regard to onset, duration, location, pitch, intensity and treatment, as well as the effect that the tinnitus has on their lifestyle. this questionnaire was adapted from the carolina ear and hearing clinic (2005) tinnitus questionnaire, as well as the health questionnaire of the tmd clinic. all participants underwent a tmd examination. the examination included detailed case history, palpation of head and neck areas for evaluation of tenderness, mouth opening, examination of the masticatory musculature, lateral and protrusive excursion measurements, palpation of the joint and muscles of mastication, endfeel (the nature of resistance felt by the examiner just prior to the border for a passive joint movement), jointplay (measurement of joint surface roughness), dynamic pain test (this test requires only a slight resistance to the patient’s mandible during active movements in all directions), static pain test (this requires heavy manual resistance executed by the examiner) and joint sounds (clicking and crepitation) (dimitroulis, 1998). all participants were referred for an ent evaluation. a comprehensive audiometric test battery was conducted on all participants. for patients with tmd, normal hearing function was required for inclusion in the study. lastly, all participants underwent a tinnitus matching procedure. specifically, the following audiological measures and procedures were adopted in the current study: 1. otoscopy: an otoscopic evaluation of participants’ ears for the presence of impacted wax, otitis externa, possible otitis media, perforated tympanic membranes, collapsed ear canals, presence of any growths and any other ear disorders was conducted. abnormal otoscopic findings such as cerumen or other obstruction may contribute to audible tinnitus (crummer & hassan, 2004). 2. impedance audiometry in the form of tympanometry (through the use of inter-acoustic az26 tympanometer) was utilised to assess the status and integrity of middle-ear functioning. standard single frequency tympanometry using an 85 db spl tone set at 226 hz was done. the primary purpose of impedance audiometry was to determine the status of the tympanic membrane and middle ear via tympanometry. tympanometry for the participants with tmd was performed to ensure normal middle ear status and normal eustachian tube functioning. the presence of middle ear pathology such as otitis media and otosclerosis has been reported to cause audible tinnitus (tyler, 2000). 3. pure tone audiometry: conventional (250 8 000 hz) pure tone air and bone conduction audiometry (with pulsed stimuli) was performed on all participants (using the bracketing method) through the use of inter-acoustic ac 40 diagnostic audiometer. the criteria used to define normal hearing were those of pure tone thresholds of 25 dbhl or lower across all frequencies, with the absence of an air-bone gap. where pure tone air conduction and tympanometry were abnormal at any test frequencies for the participants with tmd, these participants were excluded from the study, and were referred to ent specialists for assessment, management and appropriate audiological rehabilitation. 4. speech audiometry was conducted using monitored live voice to validate the audiogram and to determine the presence of conductive, cochlear or retrocochlear pathology. monitored live voice was used as it was convenient, allowed for flexibility and reduced test time (thibodeau, 2007). speech reception threshold was performed using the cidw1 spondee word list and speech discrimination testing was conducted using the nal word list. 5. psychoacoustical measurements of tinnitus were performed through headphones using the ac40 audiometer. these consisted of tinnitus pitchand loudness-matching procedures as these measures aid in documenting the nature and severity of the tinnitus, as well as facilitating appropriate use of acoustical therapy and evaluation of treatment effects (henry et al., 2005). firstly, a noise band centred at the frequency of 1 khz and a tone at 1 khz was presented in an alternating fashion, at 20 db sl (bauer & brozoski, 2006). thereafter, if the individual matched their tinnitus to a tone, a comparison of two tones of different frequencies was performed, with f1 being of lower frequency than f2 (2afc procedure) (bauer & brozoski, 2006). the tone was presented at the following comparative frequencies, 1 khz v. 2 khz, 2 khz v. 3 khz, 3 khz v. 4 khz, 4 khz v. 6 khz and 6 khz v. 8 khz. if 1 khz was selected, the 2afc procedure proceeded downward in frequency. if the individual matched their tinnitus to a noise band, comparative noise bands were presented, beginning at 2 khz. this 2afc procedure was continued until there was a frequency reversal (henry et al., 2005). the final frequency selected was confirmed by an octave confusion test, whereby the selected tone was compared with a tone one octave higher. following tinnitus pitch matching, tinnitus loudness matching was performed at the frequency of the selected tone or noise band, beginning at 20 dbsl. the intensity was presented in 1 db increments or decrements, depending on whether the individual reported their tinnitus as being louder or softer than the presented tone or noise band. data analysis the differences in clinical symptoms of tinnitus between the two groups were descriptively analysed, which involved describing and comparing the set of data obtained from the questionnaires administered to each group. quantitative analysis of the clinical signs of tinnitus was performed using the two-independent t-test of unequal variance (devlin, 2006). reliability and validity test reliability was controlled and maintained at a high level by standardising test administration, ensuring proper equipment calibration, and controlling patient variables. for all audiological assessments precautionary measures advocated by bess and humes (1990) were followed in terms of proper maintenance and calibration of the equipment, optimising testing environment, and correct earphone and bone vibrator placement. all testing was conducted in a soundproof booth with equipment that was calibrated on an annual basis, with biological calibration conducted before every test session. all participants were tested by the same researcher using the same audiological test procedures. furthermore, all patients were tested in the mornings to reduce the effect that fatigue can have on patients’ responses to behavioural audiometry testing. similar protocols existed for ent and dental assessments where appropriate. however, threats to validity in the current study were present. this included the fact that the study was not double-blind, as the researcher was aware of which participants were in the each group, and there was no random selection of participants to reduce bias in the sample. finally, because of the sample size and the fact that the data were collected in one hospital in gauteng, south africa, the researcher’s ability to generalise the results from the sample studied to the total population of patients with tmd is limited. results and discussion the demographic profile of the participants as depicted in table 1 closely resembled the documented profiles of tinnitus sufferers in both groups with regard to age and gender. evidence suggests that tinnitus in non-tmd tends to occur in the older age group and in more males than females – a similar trend noted in the current study. furthermore, although the effect of gender on the prevalence of tinnitus is inconsistent (davis & el refaie, 2000) tmd is generally considered to be more prevalent among females with 4 females being affected to every 1 male (vernon, griest & press, 1992; dimitroulis, 1998), a trend also identified in the current sample. it is therefore felt that the study sample is a fair representation of the populations studied. subjective tinnitus descriptions (questionnaire) an analysis of data from the questionnaire revealed the following: consistency of tinnitus: relevant differences between the two groups were noted as far as consistency of tinnitus presentation was concerned. a large majority of participants (8 of the 10) in the non-tmd group as opposed to only 3 of the 10 participants in the tmd group reported the frequency and duration of their tinnitus to be constant. these findings are consistent with reports by felicio et al. (2004) which indicate that tinnitus in tmd is of high frequency, moderate in intensity and episodic in nature, thus differentiating it from most types of tinnitus commonly associated with otoneurological pathologies. nature of tinnitus: with regard to participants’ perception of their tinnitus, all participants in the tmd group indicated their tinnitus to be of a single sound, whereas three participants in the non-tmd group associated their tinnitus with more than one sound. the most common types of sound experienced by participants in group a were ringing and whistling. ringing and buzzing were the most commonly experienced sounds reported by participants in group b. the results from the non-tmd group are consistent with findings by baguley (2002), who reported the most common descriptors of tinnitus to be hissing, sizzling and buzzing. in terms of loudness perception, there was no difference between the two groups as more than half of participants in both groups reported their tinnitus to be of intermediate intensity. these differences are inconsistent with findings reported by vernon et al. (1992) who investigated tinnitus attributes that are likely to be predictable of tmd origin. although a difference was noted in the duration and frequency of the tinnitus, there was not much difference noted between the two groups with regard to the amount of interference the tinnitus causes for daily activities. tinnitus was reported to cause no interference for 6 of the participants in group a, in comparison with 5 participants in group b. tinnitus matching procedures from basic audiometry testing results, all participants in group a had hearing within normal limits with mean air conduction thresholds across all frequencies ranging from 6.67 db hl to 23.33 db hl in the right ear, and 2.5 db hl to 20.8 db hl in the left ear. all participants presented with type a tympanograms bilaterally with speech audiometry scores with a mean pb max of 99% in the right and 90% in the left ear. the presence of normal audiological results did not require the application of statistical tests for analysis, but were important in ensuring that the tinnitus in group a participants was not confounded by the presence of a hearing loss. data from the tinnitus matching procedures revealed that 8 of the participants in the tmd group matched their tinnitus to a 6 000 hz sound, with 6 of these 8 participants having matched it to a tone and 2 to a narrow band noise (fig. 1). although this may be indicative of a specific attribute of tinnitus with tmd, there are a number of other pathologies with tinnitus occurrence within the 6 000 hz frequency region. in general, pitch matches for noise-induced hearing loss and presbyacusis have been reported to be between 2 000 and 8 000 hz. tinnitus pitch has been noted to occur in the frequency region of maximum hearing loss (tyler, 2000). however, in the present study, these confounding variables of noise-induced hearing loss and presbyacusis were eliminated in the tmd group as they were all confirmed to have hearing within normal limits, and had undergone ent evaluation to ensure no other otologic origin of the tinnitus. in comparison, participants in the non-tmd group matched their tinnitus across a wider range of frequencies, with half having matched their tinnitus to an 8 000 hz tone, 3 to a 1 000 hz tone, 1 to a 3 000 hz tone and 1 to a 250 hz noise (fig. 2). despite the seemingly clear clinical differences between the two groups, statistical analysis of the tinnitus pitch using the two independent t-test of unequal variance revealed no statistically significant differences between the two groups (t(10)=2.22, p=0.272, p>0.05). however, the lack of statistically significant differences can be attributed to the small sample size in the current study. despite the lack of statistically significant results, the pitch matching results are consistent with reports by felicio et al. (2004) who reported tinnitus with tmd was normally of high frequency. the pitch matching results are very useful in counselling a tinnitus sufferer. pitch match is also useful for the selection and fitting of tinnitus maskers (henry et al., 2005). hence, tinnitus pitch characteristics in patients with tmd may need to be investigated further, using a larger sample of participants, with the use of extended high-frequency testing. furthermore, reports and/or clinical findings of high-pitched tinnitus may signal a need for referral to a tmd clinic for assessment and management as tmd therapy has been documented to alleviate tinnitus symptoms (wright & bifano, 1997). with regard to tinnitus loudness, again there was no statistically significant difference between the two groups (t(11)=2.20, p=0.098, p>0.05). however, generally, the tmd group participants matched their tinnitus to a lower intensity, with a mean intensity of 25.4 db hl (fig. 3), in comparison with participants in the non-tmd group, who matched their tinnitus to a mean intensity level of 33.5 db hl (fig. 4). the fact that the tmd group (group a) presented with normal hearing sensitivity could be an influencing factor in the perception of tinnitus loudness. published evidence indicates that the loudness of tinnitus is usually found to be only a few decibels above a person’s threshold for the frequency being tested (henry & meikle, 2000); hence lower levels are noted for the group with better hearing thresholds. a recent study by martines et al. (2010) reported tinnitus loudness levels between 0 and 15 db above threshold in individuals with varying degrees of sensorineural hearing loss. hence, results obtained from tinnitus loudness matching are consistent with these findings. fig. 1. tinnitus pitch matching for group a (tmd group). fig. 2. tinnitus pitch matching for group b (non-tmd group). fig. 3. tinnitus loudness matching for group a. fig. 4. tinnitus loudness matching for group b. conclusions the attributes of tinnitus in patients with tmd were found to differ from those experienced by non-tmd patients. although most participants in group a matched their tinnitus to a 6 000 hz tone or noise, at lower intensity levels than participants in group b, results were not statistically significant. results obtained from the study highlight the fact that tinnitus is a presenting problem in patients with tmd. this implies the need for improved awareness and understanding of the relationship between tmd and the ear in terms of tinnitus as a symptom, as well as a multidisciplinary approach to tinnitus assessment and management which includes dental professionals. future research should be conducted on matched groups with regard to age and gender. in addition, further investigation regarding the attributes of tinnitus in tmd patients should include extended high-frequency testing because it is a useful indicator of tinnitus pitch. the current study should also be conducted on a larger scale with a bigger sample size to overcome the statistical significance limitations of the current study. acknowledgements. the authors wish to acknowledge dr vesna karic and prof rashid essop from the tmd clinic for their significant and much appreciated input during the current study. references ariizumi, y., hatanaka, a. & kitamura, k. 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(2005). prevalence of otologic complaints in patients with temporomanibular disorder. am j orthod dentofacial orthop, 123(6), 620-623. doi:10.1016/s0889-5406(03)00153-7 tyler, r.s. (2000). the psychoacoustical measurment of tinnitus. in r. s. tyler (ed.), tinnitus handbook (pp. 149-181). san diego: singular thomson learning. vernon, j., griest, s. & press, l. (1992). attributes of tinnitus that may predict temporomandibular joint dysfunction. journal of craniomandibular practice, 10 (4), 282-287. vielsmeier, v., kleinjung, t., strutz, j., burgers, r., kreuzer, p. m. & langguth, b. (2011). tinnitus with temporomandibular joint disorders: a specific entity of tinnitus patients? otolaryngol-head neck surg, 145(5), 748-752. doi:10.1177/0194599811413376 viirre, e. (2007). cognitive neuroscience in tinnitus research: a current review. int tinnitus j, 13(2), 110-117. wright, e. f. & bifano, s. l. (1997). tinnitus improvement through tmd therapy. j am dent assoc, 128, 1424-1432. journal of the south african logopedic society page n e d i t o r i a l volume 2, number 1 of the journal of the south african logopedic society marks an important step forward in the history of t i e south african logopedic society, for this is the first time that the journal has been printed. the committee would like to put forward the suggestion that the society publishes four journals a year. this would prove of advantage to members and advertisers. in order to produce more journals we must have far more co-operation from members in the form of articles, case histories, book reviews, etc. we must not regress, but must publish more journals per annum. we need your help, please do not fail us. sheila g. develing. ¥ ¥ ¥ editorial committee chairman vice-chairman secretary treasurer committee member miss s. develing. mrs. c. leibowitz. mrs. r. jacobs. miss b. ogus. miss f. kleiman. all correspondence to: the secretary, editorial committee, department of phonetics and logopedics, witwatersrand university, milner park, ' johannesburg. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction research methods and design results discussion conclusion acknowledgements references about the author(s) katerina ehlert department of speech-language pathology and audiology, faculty of healthcare sciences, sefako makgatho health sciences university, pretoria, south africa celeste coetzer department of speech-language pathology and audiology, faculty of healthcare sciences, sefako makgatho health sciences university, pretoria, south africa archer & mann audiologists inc., pretoria, south africa citation ehlert, k., & coetzer, c. (2020). maternal knowledge and views regarding early hearing detection and intervention in children aged 0–5 years at a semi-urban primary care clinic in south africa. south african journal of communication disorders, 67(1), a681. https://doi.org/10.4102/sajcd.v67i1.681 original research maternal knowledge and views regarding early hearing detection and intervention in children aged 0–5 years at a semi-urban primary care clinic in south africa katerina ehlert, celeste coetzer received: 01 oct. 2019; accepted: 09 may 2020; published: 21 july 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: south africans have an increasing burden of hearing loss, especially in low-income rural areas. limited information is available regarding caregivers’ knowledge and views regarding infant hearing loss, which is essential for the successful implementation of early hearing detection and intervention (ehdi) programmes. objectives: the main aim of the study was to describe the knowledge and views of mothers with children aged between 0 and 5 years old regarding hearing screening, risk factors, symptoms of hearing loss, and intervention options for hearing loss. method: a survey was employed at a primary care clinic to gain insight into the maternal views on hearing loss and early intervention services for children aged 0–5 years old. results: the majority (83.2%) of the mothers believed that hearing can be tested at birth, 90.7% believed in the biomedical model of intervention which is based on cure, prevention, and pathology as opposed to traditional or alternative medicinal beliefs, and 95.3% indicated that they would seek medical attention if they noticed symptoms of hearing loss. consequences of hearing loss, such as academic, communication and social problems, were indicated by 65.4% of mothers. conclusion: the findings demonstrated that although cultural beliefs regarding superstitious causes of hearing loss and use of traditional medicine exist, satisfactory maternal knowledge regarding detection and intervention for hearing loss is present. maternal views are favourable and a general willingness to participate in ehdi programmes was present. this study advocates for the implementation of ehdi programmes at all primary healthcare clinics across south africa. keywords: early hearing detection and intervention; maternal knowledge; maternal views; primary care clinic; hearing loss; developing country. introduction roughly 141 million live births occurred in the world in 2012, approximately 127 million of which occurred in developing countries (olusanya, 2012). the estimated prevalence of permanent congenital or early onset hearing impairment in developing countries in 2012 was six cases per 1000 live births. this prevalence is three times higher than in developed countries (olusanya, 2012). the national prevalence of hearing impairment in south africa is estimated to be four to six in every 1000 live births in the public health care sector (maluleke, khoza-shangase, & kanji, 2019). primary prevention of hearing impairment, especially in developing countries, is crucial. secondary and tertiary prevention via early detection and intervention of hearing impairment, especially in infants and young children, are still compulsory and should be actively applied (olusanya, neumann & saunders, 2014). early hearing detection and intervention (ehdi) services are the foundation for achieving optimal outcomes in infants with hearing loss. generally, these services are not widely available or accessible in south africa. the main goal of ehdi programmes is to promote the early identification and intervention of infants with hearing loss and to identify late onset or progressive hearing loss in children with risk factors who have passed infant hearing screening (pynnonen et al., 2016). the aim is to ensure optimal and cost-effective solutions that enable effective communication (health professions council of south africa, 2018). guidelines for ehdi programmes have been developed in south africa to ensure optimal outcomes for infants with hearing loss, their families, and society at large (health professions council of south africa, 2018). the ideal age of identification is 3 months, however in south africa, the estimated age of identification is between 23 and 31 months (swanepoel & almec, 2008; van der spuy & pottas, 2008). the south african public healthcare sector, which serves 85% of the population, only offers ehdi programmes in 7.5% of the hospitals. these statistics differ slightly for the private healthcare sector, with 14% of the hospitals offering ehdi programmes (casoojee, 2012), and one private hospital group now offering newborn hearing screening as part of their birthing care package (netcare limited, 2019). based on these statistics, less than 10% of south african infants are likely to undergo infant hearing screening. infant hearing loss is regarded as one of the most prevalent congenital sensory disabilities affecting double the number of neonates when compared to other screenable disorders impacting the linguistic, educational, socio-emotional and vocational domain (swanepoel & almec, 2008). the long-term effects of childhood hearing loss include delayed speech and language development, delayed development of cognitive skills resulting in slow learning and poor academic performance (peer, 2015), as well as long-term societal costs (swanepoel & almec, 2008; swanepoel, scheepers, & le roux, 2014). later in life, those with disabling hearing loss experience problems with employment and societal integration (peer, 2015). the minorities that have jobs are likely to work in lower grades of employment (world health organization, 2015). this has a substantial financial implication for south africa, as the disability grants and unemployment rates increase as a result of late identification and intervention of hearing loss (mayosi & benatar, 2014). attitudes toward hearing loss are critical to the audiologist’s work; the attitudes of the client, their family, and their community toward the causes, effects and intervention of the hearing loss can be crucial in the rehabilitative process. in many healthcare settings, especially urban locations, the audiologist’s service population is multicultural (bebout & arthur, 1992). attitudes toward disorders are likely to be culture-bound (bebout & arthur, 1992). parental beliefs and perceptions related to disability may influence their knowledge on causes of infant hearing loss and their decisions regarding healthcare and rehabilitation. parents who believe in the biomedical model (a model of illness that includes biological factors to understand medical illness whilst excluding psychological and social factors) are more likely to consult medical practitioners; and those who believe in traditional/spiritual causes are more likely to seek the services of traditional practitioners (danseco, 1997). the biomedical model is based on three concepts, namely, cure, prevention and pathology, therefore health education is based on providing information about diseases, as well as how to cure and prevent them (carvalho, dantas & rauma, 2007). the main idea is to get informed about diseases based primarily on medical research and to persuade individuals to avoid or change unhealthy habits in order to prevent such diseases. in the 20th century, the notion of health promotion emerged, and proposed a more holistic perspective where a person is seen as a bio-psycho-social unit in permanent interaction within himor herself and his or her environment, including other human beings. the health promotion model considers the biomedical model as only a small part of a larger whole when it comes to the cause of illnesses (carvalho et al., 2007). the biomedical model views illnesses as a medical entity, whilst the health promotion model views illnesses as an interaction between the individual’s social, psychological and biological environment. both these models disregard spirituality as a possible cause and/or cure for illnesses. on the other hand, traditional medicine is defined as diverse health practices, approaches, knowledge and beliefs (peltzer, 2009). it incorporates plant-, animaland/or mineral-based medicines, spiritual therapies, manual techniques and exercises. these can be applied singularly or in combination to maintain well-being, as well as to treat, diagnose or prevent illnesses. a study by astin (1998) revealed that in the united states the majority of alternative medicine users state that they opt for alternative measures because they find these healthcare alternatives to be more congruent with their own values, beliefs and philosophical orientations toward health and life. in developing countries, public awareness and attitudes towards childhood disabilities such as hearing loss, have been influenced by often irrational customs and beliefs (de andrade & ross, 2005; olusanya, 2000; stephens, stephens & eisenhart-rothe, 2000). the decisions made by caregivers for infants with hearing loss in relation to ehdi influence the outcomes (swanepoel, storbeck & friedland, 2009). limited studies regarding mothers’ knowledge and attitudes regarding infant hearing loss in south africa exist, or they are outdated and specific to a context. more such studies in rural and semi-urban areas, and in a variety of communities, are necessary to gain a nationally representative point of view (swanepoel & almec, 2008). inadequate maternal knowledge of hearing loss is one of the contributing factors to the high number of undetected hearing loss and late implementation of intervention in infants and young children (swanepoel, ebrahim, joseph & friedland, 2007). for ehdi to succeed, it is essential to obtain the views of parents regarding infant hearing loss in a variety of contexts in order to identify what practical steps would be required to facilitate its acceptance. this study therefore sought to investigate the maternal views regarding hearing loss in children aged 0–5 years at a primary care clinic in south africa to gain insights into the prevailing knowledge and attitudes towards ehdi. research methods and design aims the main aim of the study was to describe the knowledge and views of mothers with children aged between 0 and 5 years old regarding hearing screening, risk factors, symptoms of hearing loss, and intervention options for hearing loss. secondary objectives were to determine: (1) if the mothers are aware that hearing could be tested and/or screened at birth, (2) what mothers do when they first suspect that their children have a hearing loss, (3) maternal knowledge regarding the consequences and recognition of unidentified and untreated hearing loss, and (4) whether mothers believe in the biomedical model or traditional medicine regarding intervention for hearing loss. participants inclusion criteria inclusion criteria were mothers with children aged 0–5 years, who who were either english, setswana, isizulu and xitsonga proficient, and who were 18 years and older. exclusion criteria were mothers who had children older than 5 years, who were not literate (unable to read or write), who did not understand english, setswana, isizulu and xitsonga, and who were younger than 18 years of age. sample purposive sampling was used because this method is based on the judgement of researchers regarding the characteristics of a representative sample (leedy & ormrod, 2015). all mothers who met the inclusion criteria and attended the clinic for antenatal care and immunisations for their children were given an equal opportunity to participate. research method and design a quantitative research approach was employed for the purpose of this study, and a survey (structured questionnaire) was used to conduct the descriptive study. research site the study was conducted at a primary healthcare clinic in the north of pretoria, south africa, that provides ehdi services. the clinic services a large population in the north of pretoria and provides all primary healthcare services. although selection of a single clinic may influence the generalisation of results, this clinic services populations from various african backgrounds, as described in figure 1, which is expected to be similar at other primary care clinics in south africa. selection of this site was based on convenience and proximity to researchers. figure 1: languages or cultures of participants. speech-language pathology and audiology students have community outreach programmes at the clinic where they educate mothers about the cause, prevention and treatment of hearing loss. there are also audiology services provided at the clinic and the audiologist does biweekly home visits in the community. questionnaire a structured questionnaire with openand closed-ended questions was used. the questionnaire was adapted from focus group questions used in a study in india (narayansamy, ramkumar & nagarajan, 2014). the questionnaire was adapted to ensure that it was contextualised for the south african population, by adding questions appropriate to the south african context. additionally, options were added to choose from, resulting in more closed-ended questions with an option of providing additional information. the questionnaire consisted of the following sections: demographic data, ear care, causes and prevention of hearing loss in children, hearing assessment, effects and/or signs of hearing loss, and hearing rehabilitation. a pilot study improved the reliability and validity of the questionnaire. data collection researchers approached potential participants at the clinic when they attend the clinic for immunisations or antenatal care. questionnaires were provided to those who met the required inclusion criteria and provided consent. the questionnaires were collected directly after completion. for participants who were unable to read and/or write in english, assistance was provided by the researchers, and verbal translation was provided in their home language. data analysis descriptive statistics formed the basis of the data analysis procedure. answers to the closed-ended questions were easily comparable, coded and analysed. the data collected from the questionnaires were encoded and then tabulated and analysed using excel for windows version 10. averages and means were used to analyse the data. thematic analysis was used for open-ended questions. thematic analysis is an innovative research method that combines both a qualitative and quantitative dimension in the study (meier, boivin & meier, 2008). the researchers closely examined the data to identify common themes – topics, ideas and patterns of meaning that came up repeatedly. ethical consideration approval was obtained from the sefako makgatho health sciences research and ethics committee (smurec: smurec/h/96/2017/ug). consent was obtained from the gauteng department of health, as well as from the clinic manager before commencement of data collection. for the purpose of the current study, confidentiality and anonymity of respondents were maintained by ensuring that no names appeared on the completed questionnaires. results the self-administered survey was completed by 107 mothers attending a semi-urban primary healthcare clinic in tshwane. the minimum age of the mothers in years was 18, and the maximum age was 47. most mothers (n = 102, 95.3%) lived in soshanguve, 1 (0.9%) came from hammanskraal and 3.7% (n = 4) did not provide a home address. figure 1 describes the demographic information for the participants which indicates a multicultural sample including 10 of the 11 languages/cultures represented in south africa. sepedi (26%), xitsonga (20%) and setswana (16%) were the most prevalent languages and cultures of the participants. figure 2 illustrates the main results from the study. figure 2: results according to the objectives of the study: (a) participants’ beliefs regarding at what age hearing can be tested; (b) participants’ opinions regarding consequences of hearing loss; (c) participants’ knowledge of specialists or professionals involved in ears and hearing; (d) participants’ health beliefs model. the majority (83.2%) of the mothers reported that hearing can be tested between the ages of 0 and 5 years, whilst 9.3% reported that hearing can be tested at any age. when mothers were asked what they would do if they suspected that their child has a hearing loss, the overwhelming majority of the participants (95.3%, n = 102) would take their child to the clinic, doctor or audiologist. a limited number of participants (1.9%, n = 2) indicated that their child should be taken to the traditional healer and 2.8% (n = 3) did not give a response, which could indicate a lack of knowledge or uncertainty in understanding the question even though literacy was an inclusion criterion for this study. the knowledge of mothers regarding the consequences and recognition of unidentified and untreated hearing loss revealed that the majority of the mothers (62.6%, n = 67) indicated that, should a child have normal hearing, the child will look at you when spoken to and 23.4% (n = 25) mentioned that the child will startle when hearing a loud sound. results revealed that most (69.2%, n = 74) mothers believed that children will not respond to speech if they have a sign of hearing loss. a few reported that blood or discharge coming out of the ear could indicate hearing loss. a large number of participants (65.4%, n = 70) reported that hearing loss can cause communication, academic and social problems and 13.1% (n = 14) stated that hearing loss could lead to emotional problems. only 2.8% (n = 3) of the participants indicated that hearing loss can be identified by doing a hearing test. the reported preand post-natal risk factors were prematurity (n = 2, 1.9%), infant jaundice and oxygen after birth [n = 2, 1.9%] and maternal high blood pressure (n = 3, 2.8%). only five participants (n = 5, 4.7%) indicated complications during pregnancy such as bleeding, anaemia, fibroids, placenta praevia and thrombocytopoenia. the remainder of the participants (n = 95, 89%) indicated no pre-, perior post-natal risk factors or problems. more than half of the participants (65.4%, n = 70) indicated that hearing loss can result from ear malformations or infections, 15.9% (n = 17) indicated that it could result from loud noise. eight (7.5%) of the participants indicated that hearing loss may be a result of punishment from gods or a curse (22.4%, n = 24). furthermore, 2.8% (n = 3) indicated both ear malformations or infections and noise as a possible cause of hearing loss. a few (0.9%, n = 1) indicated a blocked ear, 0.9% (n = 1) indicated putting objects in the ear, and 6.5% (n = 7) didn’t respond, which could indicate a lack of knowledge or understanding of the question. when asked if they believe that hearing loss can be a curse, most (64.5%, n = 69) indicated no, 22.4% (n = 24) indicated yes and 8.4% (n = 9) were unsure and indicated maybe; 4.7% (n = 5) indicated that they did not know. almost all participants (90.7%, n = 97) indicated that children can be taken to the doctor if they have hearing loss. this supports the notion that most mothers believe in the biomedical model of health as opposed to traditional medicine. with regard to treatment of hearing loss, most of the participants (72%, n = 77) were of the opinion that hearing aids would be an effective treatment option. the second most common treatment option (9.3% (n = 10) was aural rehabilitation. the least common treatment option was the use of herbs from a traditional healer (0.9%, n = 1). a single participant (0.9%) indicated that all three treatment options could be consulted. thirteen of the participants (12.1%) indicated that they didn’t know of any treatment options. most parents (67.3%, n = 72) indicated that special schools would be the educational option for a hearing-impaired child. eighteen participants (16.8%) indicated inclusive schools and 11.2% (n = 12) indicated mainstream schools. in terms of the prevention of hearing loss, the results obtained indicated that the majority (74.8%, n = 80) of the mothers indicated that they would regularly visit a doctor or audiologist, followed by avoiding noise exposure (10.3%, n = 8), however, it is significant from the results that some (7.5%, n = 8) mothers believe that hearing loss can be avoided by praying or giving an offering to the gods and/or ancestors. discussion the brics countries(brazil, russia, india, china and south africa) exhibit substantial and often similar challenges when it comes to the healthcare system and attaining universal health coverage (marten et al., 2014). this includes, but is not limited to, the inability to provide equal access to the effective healthcare needed, as well as the barriers that exist in accessing healthcare. there is also a shortage and uneven distribution of healthcare workers in these countries (johl & pienaar, 2013). the most pressing issues for these five countries when it comes to providing healthcare to its population are: meeting the demands for more human resources; managing changing demographics and disease burdens; and addressing the social determinants of health (marten et al., 2014). because of the similarities in the healthcare systems of the brics countries, comparisons to the other countries in this group are feasible. furthermore, the adapted questionnaire was originally used in a study conducted in india, which experiences similar challenges when implementing effective ehdi services. for developing countries, poor parental compliance as a result of cultural biases to disabilities has been reported (swanepoel & almec, 2008). the support and informed choices from parents involved result in a successful ehdi programme. the current study makes an important contribution by revealing parental knowledge and views at a clinic where ehdi services have been provided. the results of this study indicated that the majority of the parents believed that their children’s hearing can be tested between the ages of 0 and 5 years. similarly, swanepoel and almec (2008) noted that 68% of mothers indicate that hearing loss can be detected soon after birth. the possible explanation for the high percentage in this current study could be that speech-language pathology and audiology students have community outreach programmes at the clinic, where they educate mothers about the cause, prevention and treatment of hearing loss. there are also audiology services provided at the clinic and the audiologist makes home visits twice a week in the community. an overwhelming majority of the study participants will take their child to the clinic, doctor or audiologist if they suspect a hearing loss. govender and khan (2017) also supported this, but stated that more than 70% of the participants did not know that audiologists are the ones responsible for hearing aid prescription and fitting, as well as aural rehabilitation services. only 45% of participants were aware that an audiologist is responsible for screening, assessing, diagnosing and managing hearing loss in both children and adults. the audiological services available in this study have promoted the audiology profession, creating awareness amongst the mothers regarding the audiologist’s role. regarding the effects of hearing loss on an infant’s development, the results correlate with the study by narayansamy et al. (2014), where mothers mentioned that the child responds to their name if called when they have normal hearing. however, in their study none of the mothers directly reported the achievement of normal speech milestones as being related to normal hearing, whilst in this current study, mothers mentioned that hearing loss will cause delayed speech and language development. this again could be attributed to the audiological services provided at the clinic and in the community. in this current study, a large number of participants reported that hearing loss can cause communication, academic and social-emotional problems. similarly, a study in india also reported that most mothers identified lack of learning, difficulty understanding verbal instructions, and inability to lead an independent life as the most frequent effects of hearing loss. a few mothers reported low confidence levels and frustration (narayansamy et al., 2014). the reported preand post-natal risk factors were prematurity, infant jaundice, oxygen after birth, and maternal high blood pressure. olusanya, luxon and wirz (2006) showed similar results, with good maternal knowledge of the risks related to measles, otitis media, birth asphyxia, and jaundice. it is crucial to educate mothers on various risk factors and management of hearing loss so as to reduce its consequences (dudda et al.,2017). in south africa, implementing risk-based hearing screening programmes, which involves screening of newborns with known risk factors for hearing loss, is a more reasonable interim approach to follow in order to ensure early identification of children with hearing loss on the various levels of service delivery contexts within the south african healthcare system (kanji, 2016). in developing countries, the use of traditional methods as an alternative measure is rapidly increasing, with africa having up to 80% of the population using traditional methods to prevent, diagnose and treat illnesses (peltzer, 2009). a similar study in south africa by de andrade and ross (2005) confirms that eight out of 10 black south africans consult traditional healers. traditional healers in south africa have reported to have been consulted for a variety of audiological and otological problems, and the reason for becoming ill was often sought in a supernatural realm. most (64.5%) of the participants indicated that hearing loss is not a curse, however some did believe that hearing loss may be a curse. almost all participants indicated that children can be taken to the doctor if they have a hearing loss, again emphasising the belief in the biomedical model. a study by govender and khan (2017), performed in urban kwazulu-natal, durban central region, yielded different results with regard to cultural beliefs. angry ancestors were noted by 60.8% of the participants and curses by 55.9% as being causes of hearing loss in their infants. the discrepancy in the current study may be related to the audiological services provided in the community used in the current study. a study by swanepoel and almec (2008), conducted in the city of tshwane (urban area), gauteng, indicated that 44% of mothers have at least one cultural belief (blood impurities) regarding a possible cause of hearing loss. most parents (82.2%) preferred medical treatment options such as hearing aid fitting and aural rehabilitation, as was found in this study. only one mother indicated that she would seek alternative options, such as herbs from a traditional healer or prayer. the results, however, also indicated that some mothers prefer using both traditional medicine and biomedical options. de andrade and ross (2005) mentioned that treatments for hearing problems used by traditional healers in south africa may not be effective and may in fact be harmful to patients (e.g. using the insides of the millipede, and sewing machine oil). the majority of mothers believe in the biomedical model of prevention and treatment of hearing loss. this could be because of the outreach programme that is conducted by students, which educates mothers about hearing loss, causes and treatment options that are available, as well as the audiological services provided at the clinic. avoiding noise exposure was also reported as a prevention method, however it is significant from the results that some mothers believe that hearing loss can be avoided by praying or giving offerings to the gods and/or ancestors. the proposed explanation is that there is better health awareness in the urban and semi-urban cities. health awareness is essential in health prevention and improvement, since childhood disabilities could be aggravated as a result of poor public awareness (de andrade & ross, 2005; olusanya, 2001; olusanya et al., 2006; swanepoel & almec, 2008). the impact on and/or influence of a family’s cultural background should also be considered during assessment and intervention service provision. barriers regarding cultural competence at each stage of service delivery (during diagnoses, amplification discussions, language assessments, and interventions) have been identified (grandpierre et al., 2019). potential linguistic and cultural barriers to interacting with families must be identified and a plan developed to address these needs. this helps to ensure effective communication and follow-up. culturallyand linguistically-appropriate modes of communication, which may include the use of interpreters or translators, should be used during assessment and management (geron, 2002). families should have an active involvement in the assessment and intervention process so that they understand the complex nature of audiologic service delivery. the family’s rights (including informed consent and confidentiality issues), reasonable expectations, reasonable needs and preferences are paramount, and must be considered throughout the provision of services. additionally, ehdi systems must honour the racial, ethnic, cultural, and socioeconomic diversity of families (american speech-language-hearing association, 2008). parental decisions regarding ehdi have dire consequences for the hearing-impaired child. these decisions are often based on parental knowledge and views towards available options regarding infant hearing loss, and are often aggravated by unfavourable superstitious beliefs and customs (gupta, sharma & singh, 2010; olusanya & newton, 2007). this situation may delay the promotion of ehdi if it is not addressed appropriately. the favourable views reported for the communities in this study indicate a general readiness amongst primary caregivers for the improvement of current ehdi programmes and show promising support and cooperation from parents in the primary healthcare context. limitations the time constraints for the research project contribute to the small sample size. the small sample size was also influenced by the availability of mothers who were willing and qualified to participate in the study. information pertaining to the educational level of the participants was not included. this could have been beneficial as it could possibly explain why some responses were inappropriate or not completed at all. furthermore, literacy levels of mothers differed as some mothers (approximately 12%) required assistance when completing the questionnaire, even though they reported being literate. assistance with completion of the questionnaire could introduce social desirability bias (the desire of respondents to present themselves in the best possible light), however, some research has reported no differences between interviewer versus self-completion modes and type of response (bowling, 2005). the wide age range of the participants could also have affected the participants’ responses, because older mothers may have more experience and young mothers may have better literacy skills than the older participants. this research study was also context specific and cannot be generalised to the wider population in south africa. however, 10 languages and/or cultures were represented in this sample, making it representative of the multicultural samples to be expected across primary healthcare clinics in south africa. furthermore, the different levels of healthcare in south africa offer similar services at the primary healthcare level, and this study can serve as a pilot study for investigation of the readiness of mothers to receive ehdi services at other primary healthcare clinics across the province and the country. recommendations for further research this study was representative of a semi-urban population and results from rural and/or urban populations may be different. further research is required to determine the readiness of mothers to receive ehdi services in urban, semi-urban and rural primary healthcare clinics across south africa. conclusion this study was conducted to gain insight into the knowledge and views of mothers regarding hearing loss, as mothers play a very important role in the health of their children. the results indicated that the majority of the mothers believed that hearing can be tested at birth. an overwhelming number of mothers indicated that they would seek medical attention if they noticed symptoms of hearing loss in their children. a large number of mothers indicated academic, communication and social problems as possible consequences of hearing loss. most mothers believed in the biomedical model. these results indicate that the mothers have appropriate awareness regarding hearing loss and its management. this could be attributed to the active audiological services in the community regarding prevention, diagnosis, and intervention of hearing loss. in order for the mothers to make correct and appropriate health decisions for their children, they need to have knowledge about health disorders in their childhood years. hearing loss is one of the childhood disorders that both mothers and caregivers need to be aware of in light of the high prevalence rates. the current study demonstrated that although cultural beliefs regarding superstitious causes of hearing loss and use of traditional medicine exist, satisfactory maternal knowledge regarding detection and intervention for hearing loss is present. maternal views are favourable and a general willingness to participate in ehdi programmes was present. this study advocates for the implementation of ehdi programmes at all primary healthcare clinics across south africa. acknowledgements the authors would like to thank a. khambule, m. mathoma & n. mathebula for assistance with data collection. competing interests the authors have declared that no competing interest exist. authors’ contributions k.e. was the supervisor of the research with c.c. as research co-supervisor. both contributed to writing article. funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views expressed in the submitted article are the views of the authors and not an official position of the institution or funder. references american speech-language-hearing association (asha). 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(2015). mortality and burden of diseases. retrieved from http://www.who.int/countries/zaf/en/ abstract death and (hearing) disability as collateral damage for workers chemicals with or without noise poison peoples’ ears why should south african hearing health professionals care? aim and objectives methodology data sources sampling search strategy inclusion and exclusion criteria for articles data collection and analysis results and discussion current knowledge focal research topics knowledge gaps and research opportunities conclusion acknowledgements references appendix 1: ototoxic medications by type of effect (hearing loss, tinnitus, vertigo) footnote about the author(s) mershen pillay discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa citation pillay, m. (2020). chemicals, noise and occupational hearing health in south africa: a mapping study. south african journal of communication disorders, 67(2), a693. https://doi.org/10.4102/sajcd.v67i2.693 note: special collections: occupational hearing loss in africa. original research chemicals, noise and occupational hearing health in south africa: a mapping study mershen pillay received: 11 nov. 2019; accepted: 02 feb. 2020; published: 10 mar. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: chemical exposure leading to ototoxicity is a fresh challenge for occupational healthcare in south africa. objectives: the critical question is: ‘what is known about occupational ototoxic chemicals with or without noise exposure in south africa?’ method: this qualitative, mapping study was completed with published (peer-reviewed) and grey literature from 1979-2019. data was analysed using the preferred reporting items for systematic reviews and meta-analyses: extension for scoping reviews and the nursing and allied health resources section subcommittee on mapping the literature of nursing and allied health (adapted). numerical analysis of article type was completed, but the primary focus was on capturing patterns/trends using thematic analysis and ideology critique. results: the african journal of disability, african journal of primary health care and family medicine, south african medical journal, the south african journal of communication disorders [sajcd] and health sa gesondheid) were included with the sajcd containing one relevant item and seventeen other items were analysed. research focusses on the mining sector (gold) in gauteng, and ototoxic medication (tuberculosis and/or human immunodeficiency virus) take precedence. in kwazulu-natal, the focus is on commerce and industry across formal and informal sectors. there are no governmental policies that refer to chemical ototoxicity. occupational hearing loss is configured exclusively on the meme that noise exposure is the only toxin. conclusion: chemical exposures are only just beginning to be recognised as ototoxic in south africa. hearing conservation programmes should always serve the workers’ interests and never bow down to the econometric interests of employers. keywords: chemical; ototoxicity; occupational health; audiology; hearing loss; lowand middle-income countries; mapping study; south africa. death and (hearing) disability as collateral damage for workers every day, 6000 women and men die because of occupational fatalities. of those who survive, 160 million live with disabling injuries or illnesses (international labour organisation, 2019). amongst this workforce, hearing loss is the main contributor to disability-adjusted life years for approximately one in five workers (who, 2018). this highly preventable disability is a global concern. occupational noise exposure is a major cause of hearing loss (basner, 2019). the general perception is that occupational hearing loss is greater in industrialised (minority world) countries like in australia, new zealand, north america and other european countries. however, in less industrialised (majority world) regions, ~21% of workers (vs. ~16% in the minority world) experience disabling hearing loss (basner et al., 2014; nelson, nelson, concha-barrientos, & fingerhut, 2005). in, sub-saharan africa, the world bank recently (2016–2017) commissioned a study on occupational health in the mining sector (osewe & nkrumah, 2018). according to this report, hearing loss accounted for 18% of the burden of injury among ex-mine workers in lesotho, mozambique, south africa and swaziland. historically, this is not unusual given how migrant workers across the world were (and continue) to work in 3d (dirty, dangerous and difficult) jobs (pillay, 2013). osewe and nkrumah also presented a novel model of worker-centred hearing healthcare across hearing screening, audiological management and aural rehabilitation. significantly, from an early identification perspective, they stated that during hearing screening (osewe & nkrumah, 2018): if the candidates pass this screening, they would still be eligible for a re-screening every six months to monitor their hearing as part of their being a high-risk group with a history of noise (and/or ototoxic chemical) exposures in the workplace. (p. 173) this is one of the most significant items in this world bank’s discussion paper. why? for hearing healthcare in southern africa, the world bank’s recommendation represents a shift from relying on a ‘noise-only’ discourse to explaining occupational hearing loss. critically, osewe and nkrumah have sounded alarm bells about workplace chemicals as contributing to hearing loss too. this positioning of chemical ototoxicity is a fresh challenge for occupational healthcare in less industrialised world regions such as sub-saharan africa. chemicals with or without noise poison peoples’ ears among occupational healthcare professionals, it is widely known that chemicals affect hearing. it is well established that medications (chemicals) are ototoxic as many illnesses, and diseases in the world are treated using medications with innate ototoxic properties, for example, aspirin (johnson & morata, 2010). globally, over 600 categories of medications are identified as potentially ototoxic and include aminoglycoside antibiotics, platinum-based chemotherapeutic agents, loop diuretics, macrolide antibiotics and antimalarials (ganesan, 2018). for example, aminoglycosides (like kanamycin) used to treat tuberculosis (tb) (khoza-shangase & stirk, 2016), highly active anti-retroviral therapy (haart) for human immunodeficiency virus/acquired immunodeficiency syndrome (khoza-shangase, 2009) and cisplatin for cancer (paken, govender, pillay & sewram, 2016; whitehorn et al., 2014) are all associated with hearing loss. notably, these medications also have an impact on the vestibular system, resulting in vertigo or dizziness (khoza-shangase, 2018). while there is some appreciation of the ototoxic effects of relevant medications (wium & gerber, 2016), chemicals are rarely recognised as ototoxic agents in south african occupational settings and are not identified as contributing to occupational hearing loss (manning & pillay, 2020). johnson and morata (2010) reported impact on cochlear and central auditory processing structures owing to ototoxic properties from several solvents, for example, styrene, toluene, xylene, ethylbenzene, trichloroethylene, n-hexane, jet fuel, white spirit and other solvent mixtures. worker-based research studies have focussed mainly on styrene, toluene, lead, mercury, carbon disulphide and carbon monoxide (johnson & morata, 2010; nakhooda, sartorius, & govender, 2019). table 1 shows a review of chemicals (and workplaces) that are potentially ototoxic. table 1: lists of chemical exposures and workplaces that are potentially ototoxic. animal experimental studies (johnson & morata, 2010) revealed the synergistic effects of noise and solvents (chen, chi, kostyniak, & henderson, 2007), and demonstrated loss of hair cells hypothesised to be caused by the formation of free radicals, namely, reactive oxygen species (le prell et al., 2007). johnson and morata (2010) reported other animal studies where chemicals (metals and pesticides) have damaged the cochlea and central auditory pathways. these animal studies are corroborated by studies of workplace chemicals on the human auditory mechanism (see appendix 1). ototoxic chemicals may damage the cochlea, vestibular mechanism and/or the auditory neurological pathways, leading to hearing loss, tinnitus and vertigo. the need for evidence regarding noise exposures in combination with workplace chemical exposure has been promoted since the 1990s (morata & dunn, 1995). for workers exposed to chemicals and noise, this combined exposure has power to, synergistically, potentiate noise-induced hearing loss (lewkowski et al., 2019) even when exposures for each agent alone are measured at acceptable levels (morata, 2007). in summary, exposure to chemicals in the workplace may be ototoxic. if combined exposures to chemicals and noise occur, then the risk for hearing loss is exacerbated, for example, noise and multiple solvent exposures (nakhooda et al., 2019) or tb medications use/exposure (khoza-shangase, 2018).however, while this is a known global concern, in south africa, exposure to chemicals in the workplace is barely/hardly documented. why should south african hearing health professionals care? south africa’s apartheid government continued british and other european colonial missions to subjugate black south africans (pillay & kathard, 2018). mainly white south african employers and international businesses turned a blind eye to the health and safety of their mainly black south african workers (gumede, 2015). as a south african audiologist having worked under apartheid and presently working in a post-1994 south africa, i have observed the continuation of the substandard management of workers’ health. notably, this occurs under a government born from a coalition with worker unions, a constitution that enshrines worker rights replete with worker-oriented policies, protocols and guidelines. table 2: included journals with identified data items. in inchanga (kwazulu-natal [kzn]) in the early 1990s, i worked with communities maimed by the british company, thor chemicals. this company is a case in point of how big business and government, enabled by a historicised geopolitical license, value the dollar over death and disability. in the 1970s, they started exporting toxic chemical waste (mainly mercury) to cato ridge (kzn) after disallowed to continue operations in england (carnie, 2019). so, from margate in england to margate in kzn (and beyond), british toxic waste flowed into the mgweni river and its tributaries, and found its way into the bodies of workers and local residents. residents 30–40 km away from the city of durban/ethekwini washed in these rivers, and drank and irrigated food crops with thor chemicals’ mercury. many died, and those residents and workers who survived live as persons with disabilities in contemporary south africa (makhaya & mkhize, 2019) with even more worker exposures documented in october 2019 (carnie, 2019). corporations with social responsibility on their minds and old and new democracies are bedfellows with the ‘unholy trinity’: the international monetary fund, world bank and the world trade organisation (peet, 2009). big business makes or uses, stores and/or spills chemicals into water, land and air, resulting in death or disability as the outcome for workers. as workplace chemicals are neurotoxic (some predominantly ototoxic), south african audiologists are obliged to get to know not just what these chemicals are but also where/which occupational settings are likely to be considered ‘high-risk’. such data would inform the management of workers who are vulnerable, key populations at risk of hearing loss, especially when exposed to chemicals with/without noise. hence, the critical question for this study is: ‘what is known about occupational ototoxic chemicals with/without noise exposure in south africa?’ aim and objectives the aim of this study was to identify the coverage of the current body of knowledge of workers’ hearing when exposed to ototoxic chemicals with/without noise in literature focussed on south africa. topics that have attracted hearing healthcare researchers, and gaps or opportunities for further research will be identified. methodology the selected design is a qualitative, literature mapping study because it is best suited to answer a research question that is about ‘what is happening’ in a particular subject or field of inquiry. mapping studies, as a genre of evidence synthesis methods, have been used since the early 1990s by health science researchers. perryman (2016) reviewed mapping studies relative to other similar methodologies for (1) comprehensiveness, (2) transparency in methodology and (3) rigour. she declared that generic/narrative-type literature reviews are at the one end of a scale, with systematic reviews and meta-analyses on the other end of the scale owing to the nature of their protocols (data retrieval, categorisation, statistical synthesis) and their narrow focus area/topic. depending on the protocol, mapping studies may – like scoping reviews – also categorise literature through content analysis. dissimilar to other reviews, mapping studies generally do not involve critical content evaluation or statistical synthesis of findings. indeed, mapping reviews are often misunderstood as scoping reviews and vice versa. however, instead of analysing results, mapping studies identify the relationship between ideas (perryman, 2016). such studies may occur in one of two formats: firstly, they may be formatted vis-à-vis a visualisation of ideas, not unlike mind or concept maps, for example, see an excellent ototoxicity concept map by watts (2019). secondly, and not mutually exclusive, studies are characterised by varying levels of systematic mapping of, for example, where an activity occurred, research funding sources, journal site or mode/medium of presentation. this second format, selected for my study, may include either published, peer-reviewed literature or other media like books, newspapers, policy documents and internet/electronic data (cooper, 2016). data sources two broad data sets were used: (1) published, peer-reviewed articles – obtained via two search strategies, detailed below, and (2) grey literature (including print/paper data) tagged by the type or authenticity of the data, see below. databases used were limited to google scholar, pubmed/medline and sciencedirect/scopus for a 40-year period (1979–2019) – selected for accessibility of electronic and print data. sampling theoretical or operational construct sampling was used because this form of purposive sampling is suited for the selection of data that represent important constructs about the phenomenon of interest (suri, 2011). operational definitions were developed for the following constructs: chemical ototoxicity with/without noise exposures and occupational hearing loss. a data richness scale was developed (simplified after ames, glenton, & lewin, 2019) to rate the amount of data (as per analytical categories, detailed below) in the selected item (e.g. ‘1’ = little/fair data, ‘5’ = large/rich data), and a strategy of sampling for (match of) study scope (cf. inclusion criteria) was used to guide data items selected for mapping. search strategy as the design is a mapping study but with principles adapted from other evidence synthesis methods like scoping and systematic literature reviews, two search strategies were used; the initial search (discussed in detail below) was performed by a research assistant. firstly, we identified highly ranked journals via the international scopus1 scimago journal and country rank that were likely to publish articles regarding occupational hearing loss owing to chemical ototoxicity with/without noise, focussed on south africa. there are inherent limitations to this method, discussed later. however, words (or synonyms) in the journal titles had to be related to ‘occupation’ and/or ‘health’, ‘hearing’, ‘disability’, ‘communication’, ‘noise’, ‘pharmaceutical’, ‘chemical’ and/or ‘toxicology’. ‘african’ and/or ‘south(ern) africa’ and synonyms were the terms selected to identify and include relevant journals. secondly, a search strategy was adapted from the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr) (tricco et al., 2018). within this strategy, and given that the scopus (2018) scimago journal and country rank is limiting by geopolitical intellectual space, i was concerned about a bias/risk of missing unindexed publications from/about south africa. this then made it necessary to locate articles that were published but not necessarily peer-reviewed, namely, grey literature like items in paper (vs. electronic) versions, for example, unpublished university student dissertations. across peer-reviewed published and grey literature items, i ensured that all were about south african workers, chemical (with/without) noise exposures and occupational hearing loss. therefore, keywords searches were completed using medical subject headings (mesh) or boolean searches (as per database) for ‘chemicals’, ‘solvents’, ‘hearing loss’, ‘ototoxicity’, ‘audiologist’, ‘audiology’, ‘hearing healthcare’, ‘south africa’, ‘africa’, ‘industry’ and ‘occupational health and safety’. inclusion and exclusion criteria for articles to develop boundaries, specific inclusion and exclusion criteria were created to facilitate the selection of primary studies for synthesis. the inclusion criteria were that the article content had to focus on: (1) chemical exposures with/without noise in the workplace and that (2) the south african workforce were considered for the time period stipulated above (1979–2019). data collection and analysis a structured data collection schedule was developed and included the following items: a determination of the number of citations and classification of the literature format types by: books government documents internet source miscellaneous. database sorting of format type, cited year (selected as 1979 onwards) and tagged as: ‘pre-’ if prior to the year range ‘in-press’ for unpublished work in 2019 ‘unknown’ for undated items. when journals changed their titles/names, articles were listed under the most recent title of the journal. development of the data collection tool and process: a data collection schedule was adapted from the protocols of the nursing and allied health resources section (nahrs) subcommittee on mapping the literature of nursing and allied health (delwiche, schloman, & allen, 2010). nursing and allied health resources section protocols are premised on bradford’s law of scattering (cooper, 2016). this law prescribes reviewing journals over 3 years (not followed here) to establish bibliographic coverage and zoning as to how ‘scattered’ the topic is across specific journals. this has the potential to influence database producers because it characterises and zones data by accessibility. therefore, in this study, bradford’s law of scattering is applied in principle towards establishing/zoning coverage of the knowledge scatter and not towards quantitative calculations. initially, a research assistant and i completed the selection of whole journals by title and specific journal articles were selected by title and abstract. this was a blind review in an attempt to increase inter-rater consistency. we resolved conflicts via discussion and in defence of our application of the inclusion/exclusion criteria, removed duplicates and finalised a single list of journals and articles to review. notably, where duplicates occurred between published and grey literature, for example, brits (2011) (an unpublished master’s thesis) and brits, strauss, eloff, becker and swanepoel (2012) (a published, peer-reviewed item), the latter was selected as superior. the same principle applied within grey literature items like, for example, edwards (2009) (a conference paper) and edwards (2012) (a conference poster), the former was selected over the poster version. once the initial search was completed, i conducted all further article searches (by title and abstracts) in each journal, searched for grey literature and finally conducted an analysis of all selected data items. analysis and interpretation of data: the emergent-focussed mapping review and synthesis method (aveyard & bradbury-jones, 2019) was considered to examine broader epistemological contexts of the knowledge scatter in chemical ototoxicity. notably, titles and abstracts were also analysed in this adaption of the prisma-scr as per guidelines by schultz et al. (2018). therefore, all selected items were read in full and data were extracted as per the data analysis schedule, adapted from nahrs (described above). this implies that abstracts constituted full data items and were not up for exclusion but analysed for their content. numerical analysis of the number of data items by type was computed. the primary focus for this analysis was on capturing patterns and trends in the literature. to do this, data were analysed using braun and clarke’s (2006) method beginning with: (1) data familiarisation; (2) initial coding; (3) theme identification; (4) theme clustering; (5) theme definition towards a conceptual topography/map; (6) defining/naming themes towards overall patterns; and (7) report of empirical data for analysis. i also performed an ideological critique based on an interrogative framework by guba and lincoln (1994), adapted by pillay (2003) and pillay and kathard (2018), and supported with exemplary textual extracts from included articles to demonstrate claims made. no computer software was used in the analysis of the data. neither were any critical quality appraisals of methodology completed as the purpose was to profile what is happening in the field rather than to draw conclusions from the included studies’ findings. several methods were used during the data collection and analysis phases to ensure credible, trustworthy data such as establishing the authenticity of data sources via ranked journals. triangulation of multiple data sources and multiple data collection methods was used to increase trustworthiness of the overall study. in this way, triangulation assisted in a comprehensive understanding of chemicals and hearing loss in the workplace by ‘testing’ validity through data convergence from different sources (grey, published). the initial blind review for the selection of primary data assisted with data credibility too. data dependability was checked via a detailed track record of the data collection process. as generalisability is not the goal of this type of qualitative research, transferability was what guided evaluations of the usefulness of data for other contexts or setting conducted via designing reflexive categories of analysis. ethical considerations this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. results and discussion in relation to stated aims and objectives, south african workers’ exposure to chemicals with/without noise is discussed under the following topics: current knowledge focal research topics knowledge gaps and research opportunities. current knowledge the following journals were identified using the international scopus (2018) scimago journal and country rank for south africa only, and by the following subject areas: ‘health professions’, ‘medicine’, multidisciplinary’, ‘neuroscience’ and ‘pharmacology, toxicology and pharmaceutics’: african journal of disability african journal of primary health care and family medicine south african medical journal the south african journal of communication disorders [die suid-afrikaanse tydskrif vir kommunikasieafwykings] health sa gesondheid journal contents’ pages were reviewed (40-year period as per electronic and print media accessibility) for a focus on chemical exposures with/without noise regarding south african workers. notably, there were no occupational health-related journals ranked by the scimago journal and country rank, in spite of the occupational health southern africa journal being accredited by the department of higher education and training in south africa. across all the journals, only one item per journal was included, which was the same as that identified in the data base searches (nakhooda et al., 2019). preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews guidelines were used to electronically identify the initial data set of 2010 items. inclusion criteria were applied – see the prisma-scr flow chart (figure 1), adapted from the prisma scoping review guidelines for this mapping study. figure 1: preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews flow chart for the mapping review of knowledge about workers’ hearing when exposed to ototoxic chemicals with/without noise in literature focussed on south africa. table 3 contains the final included set of 17 items classified by nahrs categories. besides six published articles, items included in the data set consist of grey literature items, namely, a professional association (saslha) conference programme, a conference paper (full, unpublished) and abstracts of conference presentations. a global discussion paper, published by the world bank with expert peer input but not peer reviewed, was also included. table 3: data items classified by type. table 4 shows an overview of each item including an evaluation of data richness and sample matching as per inclusion criteria. notably, three items (nakhooda, 2016; nakhooda et al., 2019; niranjan 2015) are the most suitable for analysis. it may be noted that authors, where possible, were identified as mainly audiologists and/or from community health studies (niranjan). most study sites referred to the mining sector, specifically gold mines in gauteng and environs. other sites, when stated, included the paint and shoe industries, rubber industries and the informal sector, namely, street market traders that encompassed both urban environmental exposures and other toxins. table 4: item classification by type, data richness and sampling match. focal research topics most items were focussed on the topic of noise as the point of entry towards understanding chemical ototoxicity in the workplace. all items explicitly refer to combined exposures to chemicals in the workplace. some make minor references to chemical exposures in their theoretical framework like edwards (2009). she theorised a ‘…synergistic effect of chemicals and noise on the inner ear’ (p. 2) in her study focussed on multiple risk factors within a synergistic framework, namely, noise, heat and exercise. significantly, brits et al. (2012) and khoza-shangase (2018) both researched medication-induced ototoxicity (tb) and its ability to potentiate hearing loss by noise in gold mines. nakhooda (2016) and nakhooda et al. (2019) are two items emanating from the same study with the latter a systematic review and meta-analysis of the literature. while generated in south africa and a precursor to the main study (nakhooda, 2016), this literature review decontextualised south african occupational contexts in favour of analysing combined exposures (noise and solvents) as a phenomenon across global literature bases. niranjan (2015) completed a study in 2014 on combined exposures in rubber factories that produced components for motor, shoe and plumbing industries in the metropolitan area of durban. nakhooda’s main study overlaps with niranjan’s study as she focussed on workers in the paint and shoe industry. these are the only two south african studies that focussed on noise-chemical exposures and both are based in kzn. my ongoing practice/clinical service project (called aweh – advancing workers’ engagement with hearing) (see item by pillay & kathard, 2018) is also based in kzn. this service, alongside the research generated from/about occupational hearing loss, places kzn as the province that promotes audiologists, hearing healthcare of workers and research in occupational ototoxicity. my coauthors (booi, kinnear and kathard) and i have presented conference papers, posters and a publication, with a specific angle on chemical occupational ototoxicity. this work initially focussed on the rubber industry (pillay, 2002), with a current focus on workers in the informal sector, namely, street market traders and the complexity of exposures to car fumes, solvents, related ototoxic medications, smoking, alcohol and music and noise exposures in ethekwini’s warwick junction markets (see items 11–16). in summary, research in chemicals and noise exposures in the workplace focus on the mining sector in gauteng with the interaction of workers on ototoxic medication (for tb and/or hiv) taking precedence. in kzn there appears to be a clearer focus on commerce and industry – both in the formal and informal sectors. kwazulu-natal research and services are developed especially for workers exposed to solvents in combination with noise and other risk factors like ototoxic medication. knowledge gaps and research opportunities the most critical gap noted is that there are no governmental policies that link chemical ototoxicity in any south african policy on occupational hearing loss, noise or otherwise. occupational hearing loss is configured exclusively on the meme that noise exposure is the only toxin. for a more detailed analysis of this bias and/or omission in the law, see manning and pillay (2020). furthermore, hearing healthcare professional education programmes must consider the informal sector and workers’ exposure to a plethora of toxins. the notion of occupational hearing loss owing to ototoxicity must find its way onto the agendas of public and occupational health researchers and practitioners alike. chemical exposures are only just being recognised as ototoxic in the mining (osewe & nkrumah, 2018) and other commercial sectors, but this recognition is missing for how workers in the informal sector are managed. while not even noise is managed in the informal occupational sector as yet (pillay & kathard, 2018), south africa’s recognition of chemical ototoxicity in the occupational sector must include informal workers too as we teach, research and develop policies in occupational hearing healthcare. conclusion in response to the question, ‘what is known about occupational ototoxic chemicals with/without noise exposure in south africa?’, this study has mapped the knowledge we are developing in this field in south africa. however, it does indicate the need for a more systematic evaluation of the nature of studies, their methodological quality and a deeper evaluation of the contribution hearing healthcare researchers make in transforming how employers configure their employers’ healthcare. in a study, entitled ‘hearing conservation programmes: for employers/workers?’, south african formulae for calculating workers’ compensation were evaluated for how one accounted for complexities like chemical ototoxic occupational hearing loss (pillay, 2002). what was critiqued almost 20 years ago remains true even today: south african businesses, like mining companies, maintain a strong interest in commercial gain over healthcare. notions like corporate social responsibility lie uncomfortably when placed next to workers who are econometric instruments in a business. as healthcare professionals, we need to recognise the inherent conflict with hearing conservation activities when considering >85 db and solvents; african language speakers and speech audiometry – or the measurement of occupational hearing impairment versus hearing disability. our hearing conservation programmes, especially when confounded by chemical exposures, noise and other factors, should always serve the workers’ interests and never bow down to the econometric interests of employers. acknowledgements wendy memela (national research foundation/department of science and technology research intern at the university of kwazulu-natal, discipline of speech-language pathology) assisted in the initial data collection phase of this study. competing interests the author declares that he has no financial or personal relationships that may have inappropriately influenced him in writing this article. author’s contributions m.p. conceptualised the study and collated and analysed data. m.p. was also solely responsible for the writing of this article. funding information the author thanks the national institute for the humanities and social sciences (nihss) and the consortium for advanced research training in africa (carta) for providing financial assistance for the publication of this manuscript. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any affiliated agency of the author. references ames, h., glenton, c., & lewin, s. 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(2018). addressing the rising prevalence of hearing loss. geneva: who appendix 1: ototoxic medications by type of effect (hearing loss, tinnitus, vertigo) the tables below document ototoxic medications by type of effect (hearing loss, tinnitus and vertigo). table 1-a1: drugs causing hearing loss as a side effect. table 2-a1: drugs causing tinnitus as a side effect. table 3-a1: drugs causing vertigo or dizziness as a side effect. footnote 1. see https://www.scimagojr.com/. abstract introduction research method and design results ethical considerations discussion study limitations conclusion acknowledgements references about the author(s) ulrike schütte department of speech and language pedagogy and therapy, leibniz university of hannover, germany citation schütte, u. (2016). culturally sensitive adaptation of the concept of relational communication therapy as a support to language development: an exploratory study in collaboration with a tanzanian orphanage. south african journal of communication disorders, 63(1), a166. http://dx.doi.org/10.4102/sajcd.v63i1.166 original research culturally sensitive adaptation of the concept of relational communication therapy as a support to language development: an exploratory study in collaboration with a tanzanian orphanage ulrike schütte received: 09 june 2016; accepted: 16 aug. 2016; published: 07 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: orphans and other vulnerable children (ovc) who grow up in institutional care often show communication and language problems. the caregivers lack training, and there are few language didactics programmes aimed at supporting communication and language development in ovc in institutional care in tanzania. objectives: the purpose of the study was to adapt the german concept of relational communication therapy (rct) as a support to language development in a tanzanian early childhood education context in a culturally sensitive way. following the adaptation of the concept, a training programme for tanzanian caregiver students was developed to compare their competencies in language didactics before and after training. methods: a convergent mixed methods design was used to examine changes following training in 12 participating caregiver students in a tanzanian orphanage. the competencies in relational language didactics were assessed by a self-developed test and video recordings before and after intervention. based on the results, we drew conclusions regarding necessary modifications to the training modules and to the concept of rct. results: the relational didactics competencies of the caregiver students improved significantly following their training. a detailed analysis of the four training modules showed that the improvement in relational didactics competencies varied depending on the topic and the teacher. conclusion: the results provide essential hints for the professionalisation of caregivers and for using the concept of rct for ovc in institutional care in tanzania. training programmes and concepts should not just be transferred across different cultures, disciplines and settings; they must be adapted to the specific cultural setting. introduction according to current figures, there are an estimated 3 million – and counting – orphans living in tanzania (unicef, 2013). as a result, extended families and community-based care programmes are overburdened (subbarao & coury, 2004), and orphanages and other institutional care facilities are catering for many orphans and other vulnerable children (ovc). international studies have provided documentary evidence that children who grow up in institutional care show developmental disorders – especially if the children are placed in institutional care at a very young age (hermenau, hecker, elbert & ruf-leuschner, 2014; smyke, zeanah, fox, nelson & guthrie, 2010). children who have been institutionalised often show delayed physical and cognitive development (dobrova-krol, ijzendoorn, bakermans-kranenburg & juffer, 2010; merz & mccall, 2010) and suffer from social, behavioural and psychological problems (hermenau et al., 2011; oliveira et al., 2012). furthermore, ovc are at risk of delayed speech and language development (glennen, 2002; levin & haines, 2007; st. petersburg usa orphanage research team, 2008). the reasons are manifold: on the one hand, caregivers lack training in areas such as child-rearing – especially in relation to children who have developmental problems (muhamedrahimov, palmov, nikiforova, groark & mccall, 2004; naqshbandi, mudasir, rashmi & hassan, 2012). instead, the caregivers focus on medical care and routine daily caring. on the other hand, there is a lack of language didactics concepts for encouraging communication and language development in ovc (hermenau et al., 2014). this is the point of departure for the present study. using a culturally adapted version of the concept of relational communication therapy (rct) as a support to language development (lüdtke, 2012b) in a tanzanian early childhood education context, a training programme for the caregiver students at a tanzanian orphanage was developed, implemented and evaluated in a cooperative venture between sebastian kolowa memorial university in tanzania and leibniz university hannover in germany (schütte et al., 2016). by capturing the theoretical relational competencies (trc), the methodological relational competencies (mrc) and the dialogical relational competencies (drc) (lüdtke, 2010) of the caregiver students, i was able to reach certain conclusions about the influence of the training and as a consequence about the concept and the culturally sensitive way it was adapted. the changes in the children were not assessed. research with and ‘on’ orphans is a highly sensitive topic. carrying out this type of research in one of germany’s former colonies and in a church-run institution implies the need for a culturally sensitive approach. cultural sensitivity covers everything from the establishment of a mutually satisfactory relationship of trust between the parties (westby & hwa-froelich, 2003) to a commitment to the results benefiting all research participants. numerous studies throughout the world showing a preference for research with rather than on people support this approach (davis & reid, 1999; koch, selim & kralik, 2002). following the same line of thinking, it is also argued that speech therapy models and training concepts cannot be transferred between different cultural contexts and countries without culturally sensitive adaptation (barrett & marshall, 2013). therefore, the concept and resulting training programme was developed, implemented and evaluated on the principles of the participatory action research approach (reason & bradbury, 2009). culturally sensitive adaptation of the concept of relational communication therapy as a support to language development for vulnerable children in early institutional care in this study, cultural sensitivity and participatory action research (par) were closely interdependent (reason & bradbury, 2009). par implies a form of research that is carried out with the involvement of all protagonists, addresses actual problems, discusses and reflects on the results and also models follow-up actions in discussion with all concerned parties. as such, par is described as a cycle in which reflexive and active parts mutually influence and enforce one another (reason & bradbury, 2009). in particular, the emphasis on an openness towards intersubjective dialogue is of great importance. par implies the shaping of community relations between protagonists and the opening of new areas of communication in which dialogue and development may progress (reason & bradbury, 2009). dialogical relationships and intersubjective construction of meaning therefore serve as key theoretical concepts at the different levels described in this article: (1) the innate intersubjectivity theory (trevarthen & aitken, 2001) with regard to the caregiver–child dialogue, (2) in the relational theory of communication and language acquisition (lüdtke, 2012a), (3) in approaches to foster children who have developmental communication and language disorders (frank & lüdtke, 2012) as well as in (4) the didactical orientation of the video interaction guidance (vig) approach (kennedy, landor & todd, 2011). in particular, the ethical dimension as well as the tacit power differences in international development cooperation require an obligatory focus on the global common good (walker & early, 2010). this shows that the principles of par are fundamentally bound up with culturally sensitive work. within the framework of this study, the concept of rct plays a fundamental role and was adapted in a culturally sensitive manner to the early childhood education context with regard to working with ovc in tanzania. it is not the aim of this article to describe the concept of rct, which originally focused on mother–child interactions, in both the german and tanzanian contexts. instead, i simply discuss the adapted tanzanian model with the modifications made for this special cultural context. these modifications are marked in the text and in figure 1 with the word ‘here’. the derived competencies and modules of the concept in particular have been adapted to be culturally sensitive to the tanzanian orphanage setting (see figure 1 and table 1) and influence one another (see figure 2). figure 1: adapted, culturally sensitive relational language didactics triangle. figure 2: interacting theoretical levels. table 1: adapted, culturally sensitive training modules. the focus of the present study was on delayed communication and language development in ovc. levin and haines (2007) show that every child in the orphanage they studied in south africa had speech and language difficulties. one of the contributory reasons for this is a lack of response from the caregivers. they speak rarely or not at all to the children. interactions usually happen in a directive and not a child-oriented manner. furthermore, caregivers do not establish eye contact and do not respond to the communicative attempts of the children (levin & haines). the concept of rct adapted in a culturally sensitive manner addresses the root of this problem. ‘language didactics’ is defined as the professional organisation of specific communication and language teaching and learning processes (lüdtke & stitzinger, 2015). as such, the intuitive behaviour of parents interacting with their children (papoušek & papoušek, 1983) is taken up by professionals and didactically presented to the participating caregiver students. the concept is based on the following three elements. innate intersubjectivity theory even newborn babies have an intrinsic motive to make contact with somebody meaningful. this is understood to be a precondition for an individual’s ‘cultural learning’. trevarthen and aitken (2001) describe this as ‘innate intersubjectivity’. the need for an intersubjective exchange of emotions is seen as the basis of social learning and brain development and the closely related cognitive learning progress (lüdtke, 2012b). even newborn babies can mirror emotions (trevarthen & aitken, 2001) and undertake or even initiate emotional interaction (nagy & molnar, 2004). relational theory of communication and language acquisition the relational theory of communication and language acquisition, which refers to innate intersubjectivity theory, sees communication and language development as a co-constructing process in which meaning is developed in intersubjective and emotionally meaningful situations (lüdtke, 2012b). the learning child (here: ovc) needs an emotionally responsive communicating other (here: caregiver student) for successful language development. relational emotions and their reciprocal mirroring are crucial for communication and language development (lüdtke, 2010). relational language didactics relational language didactics is based on the principles of the relational theory of language acquisition and constructivist pedagogy and didactics (lüdtke, 2012a). constructivist pedagogy and didactics assumes that learning cannot be reduced to the reproduction of existing knowledge but needs to be understood as interplay between internal construction and instruction from the outside (reich, 2004). in this sense language-learning is an active acquisition process in which the person teaching (here: caregiver student) plays an important role (reich, 2004). relational language didactics integrates the two elements referred to above to describe the development of severe communication and language disorders. methodologically, this implies that professionals need to account for the function of emotions in communication and language development (lüdtke, 2010). that in turn means that, for example, a child (here: ovc) needs an emotionally meaningful communicating other (here: caregiver student) if he or she is to develop an awareness of the meaning of signs in interactions and to use these emotionally meaningful interactions as motivation for further learning. based on the culturally adapted concept, the project team operationalised competencies in relational language didactics for a training programme for tanzanian caregiver students. relational language didactics competencies as adapted in a culturally sensitive manner ‘competency’ is a wide-ranging term and can be understood from different perspectives and in a different way depending on the academic discipline. in our particular language didactics context, i refer to the relational language didactics model proposed by lüdtke (2014, 2012a) (see figure 1). it assumes an interdependent triangular set of referentials in the language didactics teaching and/or learning process (lüdtke, 2010): the person with communication and/or language disorders (here: ovc with communication and language development disorders) the person teaching (here: caregiver student) and communication and language and their impairments (here: developmental language disorders). the aim of the training is for the caregiver student to acquire the competencies to successfully combine two of the components in the relational language didactics triangle (lüdtke, 2010): the trc covers profound interdisciplinary knowledge of how therapeutic didactic decisions connect to the emotive linguistic specifics of the intersubjective language-learning process (here: knowledge about the intersubjective language-learning process between the caregiver student and ovc) (e.g. knowledge about the communicative abilities of a newborn child). the mrc covers the ability to apply acquired techniques in the given language-learning contexts to the person with communication and language disorders (here: ovc with disorders in communication and language development). this includes the design of a suitable environment for the developmental stage of the child’s communication abilities (e.g. establish eye contact). the drc covers the ability of the person teaching (here: caregiver student) to make and to maintain an appropriate dialogical connection to the client (here: ovc) (e.g. to recognise and respond positively emotionally to the communicative attempts of the ovc). taking the culturally sensitive adaptation of rct as a basis, four modules suggest themselves, reflecting the content-related and methodological specifics of the tanzanian orphanage setting (see table 1). the levels described above overlap, complement and influence one another (see figure 2). this also accounts for possible changes in the concept of rct that may occur as a result of the training in relational language didactics competencies. research method and design setting the empirical study was conducted in an orphanage in rural tanzania, affiliated to the evangelical-lutheran church. the institution was under missionary influence for many years but is now becoming an increasingly inclusive institution with a focus on preventive thinking. at the time of the study, the orphanage had 2 managers, 8 permanent employees, 25 apprentices and 32 children ranging from newborn babies to 3-year-olds. the orphanage obtained its funding through donations and the sale of agricultural produce. participants twelve caregiver students at this tanzanian orphanage took part in the study (mean age = 22 years; age range = 21–28 years; all female). they belonged to five different ethnic groups (ndembwike, 2006) – as a result, 10 out of the 12 participants grew up speaking multiple languages. all of them were in their second and final year of apprenticeship. the caregiver students received only limited training with regard to childcare. the emphasis of their apprenticeship was generally on agriculture, housekeeping and business matters. the caregiver students had no final secondary-school qualification, which significantly complicated their vocational integration. therefore the training was specifically designed in an easy-access way using non-academic swahili instructions. research questions the aim of this study was to adapt the concept of rct to a culturally sensitive training programme for caregiver students in a tanzanian orphanage. changes in communicative and language behaviour between the caregiver students and the children were captured using a pre-post design. pre-post design is based on the principle that pedagogical–therapeutic competencies are not fixed but evolve progressively and change through internal or external aspects (kaufhold, 2006). as a result, the two main research questions were the following: (1) to what extent do the theoretical, methodological and dialogical relational competencies (trc, mrc and drc) of the caregiver students change as a result of training? (2) which module-specific differences in the theoretical, methodological and dialogical relational competencies (trc, mrc and drc) can be found in the caregiver students after taking part in training? both research questions are discussed here with regard to the trc and mrc perspectives of the adapted, culturally sensitive, relational language didactics triangle. the description of the changes in drc can be found in future publications. research design the culturally sensitive design (see figure 3) was carried out according to the standards of focused ethnography. this implies shorter field research, focusing on situations in which communicative activities as well as specific forms of personal interaction could be studied (tuma, schnettler & knoblauch, 2013). the culturally sensitive design was characterised by an intensive and equal collaboration between all german and tanzanian scientists and students as well as the orphanage and the church. the collaborative relationship strengthened over the course of the project. figure 3 illustrates these aspects through culturally sensitive feedback loops: at the preliminary considerations stage, we organised joint study design workshops. we planned to capture the effects of the training with a quantitative control and intervention group design (punch, 2014). this phase was followed by the exploration phase to understand the needs of the study participants. as a first step, the management of the orphanage was involved in setting the thematic framework of the training programme and discussing the local situation. participant observation was used at this stage to deepen understanding of cultural specifics from the inside (friebertshäuser, 2010). during conversations with the orphanage management, it became clear that the biggest need was to gain theoretical and practical knowledge in the field of communication and language promotion, with a focus on establishing an emotionally responsive dialogue between caregiver students and children. cross-cultural research into the literature relating to the training topics rounded off this phase of exploration. as a result of the exploration process, we had to abandon the planned control and intervention group design due to specific local circumstances (e.g. the high turnover of caregiver students and cohabitation in the orphanage). this example also illustrates the constant movement and development of the methodology as it evolved as part of a mutual process that included all those involved. during the pilot phase, the german and tanzanian project partners worked together with tanzanian students from sebastian kolowa memorial university on defining the topics for the training programme. firstly, the students were familiarised with the theoretical content of the four modules and reflected on the adaptability of the content to the tanzanian cultural and institutional context. after that, the detailed goal descriptions for trc, mrc and drc were operationalised as concrete competencies (see table 2). in addition, the caregiver students recorded the first videos of their interaction with the children. based on this, they received their first video feedback via vig (kennedy et al., 2011). following this, implementation and evaluation of the training took place. the caregiver students participated in a 4-week training programme (four modules with three teaching units) on the topics of innate intersubjectivity, child language development, respectful caretaking and communicative musicality and play (see table 1). the tanzanian students gave the training in swahili to ensure cultural and linguistic proximity among caregiver students. the german team took a supervisory role. over the course of the study, both caregiver students and tanzanian students were recorded during interactions with the children or during instructions. both groups received feedback and supervision using vig. the training was rounded off with preand post-testing, which consisted of two components. firstly, a self-developed informal competence test was administered in swahili to capture trc and mrc. the second component consisted of video recordings, which were used to capture drc before and after the training. because the capturing of drc requires direct interaction with an emotional meaningful other, it was thus not part of the questionnaire. four months after the training, long-term data were collected in the follow-up. it consisted of the informal competency test to capture trc and mrc as well as video recordings to capture drc. the follow-up served as a control measure with regard to the sustainability of the training and the effects of learning. the results of the follow-up are described and discussed as part of the dissertation project of my tanzanian colleague j. semkiwa (work in progress). figure 3: culturally sensitive study design. table 2: extract from detailed goal descriptions and subsequent questions from the informal competency test for modules 1 and 2. instruments the present study is based on the requirements of summative evaluation (westermann, 2002). it assessed the competencies of the participating caregiver students both before and after training. it was analysed so as to reveal if, and to what extent, the trc, mrc and drc of the caregiver students changed after training. because of the lack of a control group and the small sample size, it cannot be demonstrated reliably that there is a causal connection between the changes in the competencies and the training. for that reason, the data before and after training can be assessed but not necessarily causally linked. moreover, the results can be related to the examined group only and cannot be used to make generalisations. mixed methods design the complete study consisted of three substudies and is based on a convergent design (see figure 4). it involved the separate collection and analysis of (1) quantitative and (2) qualitative data with the intention of (3) merging the results of both strands at the end of the research to obtain meta-inferences (creswell, 2015). figure 4: detailed schema of the convergent design. this procedure was used for both the preand the post-test. the meta-inferences of both points of data collection can then be correlated. i will concentrate here on the (1) quantitative inferences of the preand post-test (see figure 4 left strand). the (2) qualitative results and the (3) merging of the results will be discussed in future publications. informal competency test the informal competency test was developed at the request of the orphanage managers to capture trc and mrc before and after training. it consisted of 27 questions (with multiple possible answers) focusing on the four topics included in the training (see table 1). these questions captured either trc or mrc. each detailed goal description was operationalised in one question (see table 2). completing the test took approximately 30 min. the informal competency test fulfilled the main psychometric criteria (bühner, 2006) as mentioned below. objectivity the test was completed by each caregiver student independently at the same time. additionally, the test contained only closed-ended multiple-choice questions, with the result that the interpretation was unambiguous due to the objectivity. reliability the reliability of the test was analysed and checked using spss statistical analysis software. items that did not correlate well with the total scale were removed from the test. this led to a total of 27 questions instead of the original 38. consequently, the informal competency test showed acceptable internal consistency (cronbach’s alpha α = 0.75) (field, 2009). validity in order to increase the validity of the test, the phrasing of the questions followed a simple yet precise format to keep questions strictly related to the subject in hand and to guarantee that the instrument measured the intended topic. a swahili native speaker from the research team translated the questions from english into swahili, using easy non-academic language where possible. a second member of the team approved the phrasing. data analysis the results of the tests were generated using spss to obtain descriptive statistics and spearman correlations, as well as to check statistical significance from the first time of measurement to the second one (t1 to t2) by the non-parametric wilcoxon signed-rank test. because the questions were operationalised to show either trc or mrc transfer, i was able to draw conclusions about each caregiver student’s competency in both areas. in this way i was also able to assess, for example, whether a caregiver student had comprehensive knowledge about innate intersubjectivity but had not yet put it into practice in methodological procedures. results to answer the first research question (q1) concerning the shift of trc and mrc post-training, an overview of the overall development of the 12 caregiver students as well as the shift in trc and mrc preand post-test follows. trc was not significantly related to mrc (rs = 0.11, p = 0.735), and thus these areas are analysed separately. ten out of the twelve caregiver students increased the number of correctly answered questions in the informal competency post-test (see figure 5). in the case of one student (c10), the number of correctly answered questions decreased, whereas one student showed no difference before and after training (c12). figure 5: overview of shift in competencies (trc and mrc) of the 12 caregiver students (c1–c12). because of the small sample size, the appropriate measure of central tendency was the median, and the appropriate statistical test was the wilcoxon signed-rank test. table 3 shows that the median of the post-test (t2) was higher than that of the pre-test (t1) (in all three examined units). the interquartile range (iqr) describes the mean distribution and is used for the present study as an appropriate statistical dispersion. in all of the three examined units the iqr decreased – therefore the dispersion decreased (see table 3). table 3: results in total and by competency. table 4 illustrates a significant difference between preand post-test for both the total results and the results of trc and mrc. the effect size r is ≥ 0.7 for all three examined units. this signifies a strong effect (field, 2009). table 4: results of the wilcoxon signed-rank test: theoretical relational competency and methodological relational competency of all modules in total and of each module separately. as a second step i sketch the module-specific differences in trc and mrc in the caregiver students following the training in order to answer research question q2. the spearman correlation analysis draws the following picture: innate intersubjectivity trc and mrc (rs = 0.06, p = 0.853), child language development trc and mrc (rs = 0.45, p = 0.139), respectful caretaking trc and mrc (rs = 0.50, p = 0.097) and communicative musicality and play trc and mrc (rs = 0.38, p = 0.220). there are no relevant correlations, so all areas will be analysed separately. the module-specific analysis showed that the median increased from preto post-test for the topics of innate intersubjectivity, child language development, and communicative musicality and play in trc and mrc. for the topic of respectful caretaking, the median decreased in trc but increased in mrc. the iqr decreased for all examined units – therefore the dispersion decreased. only for the topic of child language development did the iqr increase in mrc (see table 5). table 5: results of the module-specific analysis of the training topics. the differences between preand post-test were examined by means of inferential statistics (see table 4). it is evident that trc in the innate intersubjectivity module differed significantly before and after the training. the effect size r = 0.81 indicates that it was a strong effect (field, 2009). mrc showed no significant difference. in the child language development module neither trc nor mrc showed a significant difference between preand post-test. for the respectful caretaking topic it can be concluded that trc showed no significant difference between preand post-test. by contrast, mrc showed a significant difference before and after the training. the effect size r = 0.63 illustrates that it was a strong effect (field, 2009). in the communicative musicality and play module, trc and mrc indicated a significant difference between preand post-test. the effect size r = 0.65/0.59 shows that it was a strong effect (field, 2009) (see table 4). ethical considerations the study was conducted in an ethically responsible manner and with the clear consent and acceptance of those involved. participants had the right to withdraw their written informed consent at any time during the research process. the ethics committee at leibniz university of hannover inspected the application in-depth and approved it. the tanzanian team obtained research clearance through the tanzanian commission for science and technology ethics committee. in addition, the head of the church and the managers of the orphanage consented to the study in writing and were involved in all stages of the research. discussion owing to the lack of language didactics concepts for ovc in institutional care in tanzania, the current study focused on a culturally sensitive adaptation of the german concept of rct. based on the adapted model, a training programme for the caregiver students at a tanzanian orphanage was developed, implemented and evaluated. the first research question (q1) addressed the shift in trc and mrc after training as illustrated by the overall development of the 12 caregiver students using preand post-test data. as a second step, i sketched the module-specific differences in trc and mrc in the caregiver students after the training in order to answer research question q2. the increase in the median from preto post-test underlines the shift in competencies in the caregiver students. the decrease in the iqr and therefore the decrease in dispersion indicates that the group became more homogeneous with regard to their trc and mrc. analysis of the results shows a significant increase in competencies after training in both trc and mrc. one caregiver student (c10) showed a decrease in competencies post-training; however, she had already scored very highly in the pre-test compared with the rest of the group (97/108 points). also in the post-test, this student ranked among the best in the group (91 points). the same applied to another caregiver student (c12), who obtained the same number of points (85 points) before and after the training. it can be assumed that the inclusion of the orphanage’s management level from the beginning played an important role in the high levels of competency increase achieved. this reality is also confirmed by taneja et al. (2002) as well as groark and mccall (2011). moreover, group training programmes have a huge peer-learning effect when directly implemented in a social setting, for example in an orphanage. they also allow the caregivers to implement the lessons learned immediately. this is consistent with other findings (groark & mccall, 2011). the intrinsic motivation should also not be underestimated. proof of the intrinsic motivation of the participating caregiver students could be seen in their ongoing commitment over the course of training and in their multiple oral assurances highlighting the importance of the training. the module-specific analysis of trc and mrc indicates that the shift in competencies depended on the topic. for instance, in the innate intersubjectivity module, the caregiver students increased their knowledge significantly in trc but not in mrc. contrary to this, in the respectful caretaking module, mrc increased significantly but not trc. in the child language development module there was no significant difference between the before and after training data. finally, in the communicative musicality and play module, caregiver students showed a significant increase in both trc and mrc. the difference in competency shifts may be the result of the different trainers in the different modules. the four thematic blocks were taught by different groups of students and consequently by different lecturers. their impact on the mediation of the content plays a crucial role. this agrees with the findings of taneja et al. (2002), who also emphasise the role of the lecturer in the success of training programmes. in the current case, some of the topics were taught using a more theoretical approach (e.g. innate intersubjectivity) than others (e.g. respectful caretaking). as result of the training, it was possible to record changes in early childhood education standards at the orphanage: caregiver students showed greater knowledge about the communicative abilities of babies and how to interact with them at the time of the post-test (see table 1, innate intersubjectivity module, topics a and b). moreover, mrc had increased with regard to the importance of an emotionally meaningful relationship for speech and language development as well as with regard to building an emotionally meaningful relationship (see table 1, respectful caretaking module, topics a and b). in addition, their mrc concerning different types of songs for regulating a child’s emotions increased, as well as their knowledge about different ways of expressing emotions (see table 1, communicative musicality and play module, topics a and b). these results are consistent with existing evidence on interventions. a study by groark et al. (2005) elicited the impact of two interventions on promoting a social–emotional relationship and attachment between caregivers and children in orphanages in st. petersburg, russia. firstly, they trained the caregivers to promote responsive caregiving. secondly, they changed staffing and structures to support relationship building. the authors suggest that training the staff and implementing structural changes are effective measures that can increase socially responsive caregiving (groark et al., 2005). the present study also shows the preand post-test behavioural changes in caregiver and child interaction. however, we refrained from implementing structural changes, as this could have been perceived as coercive interference in tanzanian orphanage culture. in addition, a study by sparling et al. (2005) also proved the impact of educational interventions on the developmental progress of romanian orphans. sparling and others argue that educational intervention programmes should start as early as possible in a child’s life – preferably from birth. this idea was also integrated into the present study. thus, the training focused on children from birth to 3 years old and particularly during the first few months of life. study limitations being designed as an empirical study, the sample size in particular as well as the absence of a control group and the related robustness in the results need to be critically assessed. other studies that have also operated in orphanages indicate similar limitations (mccall et al., 2010; wright et al., 2014). the present study shows the first stages of a culturally sensitive and participative intervention in the field of early communication and language development in tanzania. this is in line with chevalier and buckles (2013), who state that science has reached a junction where each researcher has to decide between: (1) reinforcing the ivory tower by advocating vague institutional interests (i.e. trying to ‘measure’ the institutional reality despite the complexity of real practice, whereby each attempt at quantitative survey already changes the social reality), and (2) including in academic practice an obligatory focus on the needs of society by adding a qualitative element. i now share the opinion that only the latter approach is compatible with special-needs education, for which reason this study was complemented and added to by qualitative data such as the video recordings. here the constant movement and development of the methodology becomes apparent once again. the results have to be seen as provisional and representative only of the specific local context. another limitation to the scope of the results lies in the lack of a control group. because of this, i cannot attribute with absolute certainty the behavioural changes in the caregiver students to participation in the training programme. however, the complementary qualitative video analysis does support the line of argument of the quantitative data presented (see future publications). in general, the exploratory character of the study should be stressed again; the results should serve as a starting point for further work in the field. a more in-depth methodological review with regard to participative research is essential and crucial. babylab hannover (frank & trevarthen, 2015) is currently working on the intersubjective and intercultural (inclusive) in vivo research (iii-r) approach. this approach explicitly connects the developmental psychological concept of innate intersubjectivity with the demands of inclusive work in an intercultural context. as part of the process, participative methods will be developed collaboratively with all involved participants (frank & trevarthen, 2015). conclusion in addition to identifying the shift in trc and mrc in the language-learning interactions of caregiver students preand post-training (q1), this sub-study also presented an analysis of module-specific differences in the acquisition of competencies (q2). the intervention training was modelled around the culturally sensitive adaptation of the concept of rct as a support to language development. the competencies acquired by caregiver students were then assessed using a mixture of quantitative and qualitative data whereby only the quantitative part was presented here. the results indicate some special requirements for and attributes of didactical and methodological language concepts for the further professionalisation of educators in early education and especially those working with ovc. the implications for training concepts in ovc institutional care include the following. culturally sensitive feedback loops advanced training in early education, and especially in early relational communication as a support to language development for ovc, should address real problems in the field and allow individual designs to account for local specificities. therefore, it is highly advisable to design the training and evaluation of the intervention in a participative way, taking into account the perspectives of all participants. this is in accordance with the findings of wright et al. (2014). the training programme presented in this article is one example of how to proceed with the training of staff working in early education using the concept of rct. as such, it can only account for the specific local context described. transferring the concept to another setting would require yet another culturally sensitive adaptation of the concept. the transfer of theory into practice in addition to the culturally sensitive feedback loops, it is crucial to establish a connection between theoretical input and the practical context encountered by early childhood professionals. this guarantees not only that theoretical knowledge (trc) is accumulated, but also that the caregiver has the opportunity to apply the lessons learned in practice (mrc and drc). furthermore, the training needs to connect the working context of the individual caregiver with the institution’s management level (nentwig-gesemann, fröhlich-gildhoff, harms & richter, 2011). the management level has to be constantly involved in the training (groark & mccall, 2011) to work successfully with the early education staff. because this approach can turn out to be very resource-intensive, handouts for the management level proved useful in our context. moreover, group training scores highly when it comes to transferring theory into practice (nentwig-gesemann et al., 2011). additionally, the use of a video feedback system for supervision is very valuable (digel, olleck, hartz & schrader, 2010; groark & mccall, 2011). however, at this point these factors cannot be considered to be proven because of the exploratory nature of the study. instead, more in-depth research is needed in the future. future research will capture the training’s impact on the children concerned; for example in which areas does the training bring about changes in the children’s communication and language development, and to what extent? where is it not effective? data in this field should be used to modify and revise the training modules in both content and didactics. furthermore, this could be followed by a longitudinal study, which would capture the long-term effects on the children (ou, 2005). in addition, follow-up studies concerning the lasting effects of the training will be of great interest, for instance to what extent the learned topics are still meaningful for caregiver–child interaction 1 year after the training. taneja et al. (2005) illustrate problems regarding sustainability in their study. due to the high turnover of caregiver students in the orphanages, it is very difficult to firmly implant training knowledge in the institution. this underlines the need for a reliable, locally based professional who can take up the role of maintaining standards with regard to child–caregiver interaction. this study can be considered as a first step towards the professionalisation of tanzanian caregiver students using the adapted, culturally sensitive concept of rct as a support to language development. an increase in the number of vulnerable children is to be expected due to the current stream of refugees to europe (bamf, 2016) and globally (unhcr, 2016). for this reason, methodological considerations about culturally adapted concepts in language didactics for early childhood contexts will be of increasing importance. sharpening the awareness of this topic was one of the main concerns of this article, as it may serve as a foundation and guide for further culturally sensitive adaptations. acknowledgements the author wish to thank all participants for their contributions to this study: the tanzanian and german students, my colleagues a. vuliva, j. semkiwa, b. frank, c. polzin and u. lüdtke, the head of the diocese j. mwinuka, all caregiver students, the children of the orphanage and especially the management of the orphanage, e. mdemu and m. mrisho. competing interests the author declares that she has no financial or personal relationships that may have inappropriately influenced her in writing this article. references barrett, h., & marshall, j. 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(2014). from maid to mother: transforming facilities, staff training, and caregiver dignitiy in an institutional facility for young children in nepal. infant mental health journal, 35(2), 132–143. http://dx.doi.org/10.1002/imhj.21429 abstract introduction methodology ethical consideration results discussion conclusion acknowledgements references about the author(s) dhanashree pillay department of speech and hearing therapy, school of human and community development, university of the witwatersrand, south africa shaaista dada department of speech and hearing therapy, school of human and community development, university of the witwatersrand, south africa citation pillay, d. & dada, s. (2018). skydiving: the audiological perspective. south african journal of communication disorders 65(1), a553. https://doi.org/10.4102/sajcd.v65i1.553 original research skydiving: the audiological perspective dhanashree pillay, shaaista dada received: 25 feb. 2017; accepted: 20 july 2017; published: 28 may 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: skydiving is a popular recreational sport for the young and old. there is minimal research pertaining to skydiving and its relation to the audiological system. the risks of skydiving in relation to the auditory system should be explored further. aims: the main aim of this study was to explore the relationship between skydiving and audiology in south africa. the sub-aims of the study focused on determining if skydivers were provided with safety precautions before they commenced with the dive, determining the middle ear pressure before and after the skydive and identifying the audiological symptoms that were present post-dive. this study also aimed at scrutinising the south african sports and recreation policy. method: a mixed-method descriptive research design was utilised. qualitative information pertaining to audiology was identified and recorded from the scrutiny of south africa (sa) policy and the dropzone consent forms at two skydiving schools. thirty-one skydivers were purposefully recruited to undergo a preand post-dive tympanometric assessment. results: there is no information within the clearance forms that pertain to the audiological risks related to skydiving. there was a lack of information related to the risks of skydiving in the clearance forms at both dive schools. a statistically significant pressure change was noted in regular skydivers, regardless of the ability to equalise effectively during the skydive. conclusion: this study identified the gaps in policy and clearance forms, highlighting the need for the inclusion of safety measures and risks in the documentation and legislation that governs the sport. audiologists, sportspeople and medical advisors should be cognisant of the negative consequences that may be evident within the auditory system of skydivers. introduction risk-taking behaviours are usually considered to be socially unacceptable and reckless with negative consequences. however, high-risk sports are regarded as socially acceptable because of the thrill and excitement of the sport (castainer, le scanff & woodman, 2013). participants of high-risk sports are usually sensation seekers who thrive on the increased stimulation (zuckerman, 1990). examples of high-risk extreme sports include rock climbing, skydiving, skiing, scuba diving, white water rafting and bungee jumping. serious consequences of extreme sports may include skull fractures, vertebrae fractures, loss of consciousness, barotrauma or even death (burke, 2013; gutovitz, weber, colern, papa & giordano, 2008). barotrauma occurs because of the lack of pressure equalisation, and it is the most common medical complication arising from diving and aviation (bentz & hughes, 2012; du plessis, fothergill, gertner, hughes & schwaller, 2008). barotrauma to the ear may affect the middle or inner ear with symptoms and signs such as tinnitus, vertigo, otalgia, hearing loss or rupture of the tympanic membrane (bentz & hughes, 2012). alternobaric vertigo may be a consequence of skydiving as this phenomenon is caused by the difference in pressure between the middle ear space and inner ear which consequently causes vertigo (bentz & hughes, 2012). therefore, skydiving is an extreme sport that may negatively affect the hearing mechanism of the participant. the risks involved in participating in a sport should be highlighted in the consent forms that are signed by the participant. this will ensure that the participant is fully aware of the negative consequences that may occur. sports and recreational legislation should aim to protect the participant in a sport; therefore, safety aspects should be included in the documentation. the safety at sports and recreational events act of 2010 does not include any information that is related to the safety of sports participants (republic of south africa, 2010), and the safety section within the legislation pertains to the attendance of a sporting event. the sporting associations in south africa (sa) are responsible for the safety of their participants. skydiving in sa is governed by the parachute association of south africa, using a manual of procedures as approved by the south african civil aviation authority. this manual was last updated in july 2012 and suggests that a sport skydiver should provide his or her chief instructor with a medical certificate which states that he or she is medically fit to skydive (parachute association of south africa [pasa], 2012). the south african boxing act of 2001 mandates that the boxing association of south africa (bsa) must ensure that the safety of boxers and the relationships between boxers, managers, promoters, trainers and officials and bsa are effectively and efficiently administered and governed in the best interests of boxing and its stakeholders as a whole (republic of south africa, 2017). recreational scuba divers in sa undergo a medical examination that includes a hearing assessment (pillay & jardine, 2010), in light of the failure to adequately equalise ear pressure that may result in a ruptured tympanic membrane and subsequent pain (strauss & aksenov, 2004). scuba diving and skydiving are popular in sa (visser, 2004) despite the risks of barotraumas being evident in both sports. recreational skydivers may obtain a license from the parachute association of south africa; however, it is not obligatory (pasa, 2012). the participant is not mandated to have follow-up medicals to determine the effects of frequent jumps on the auditory system. furthermore, in skydiving, untrained participants are able to strap themselves to a qualified tandem master and experience the sport without a licensing requirement. a study in florida, usa, found that the average pre-jump middle ear pressure was −23.5 dapa, the average post-jump pressure was −70.5 dapa and the participants experienced aural fullness, otalgia, vertigo, or a sensation of a loss in hearing abilities (gutovitz et al., 2008). based on these symptoms, the long-term consequences of frequent participation in the sport may lead to permanent auditory damage. the higher the altitude of the jump and a longer time of freefall during the jump are factors that may negatively impact the middle ear system of a frequent jumper. this highlights the need for better regulation and awareness among participants about the symptoms. internationally and in the south african context, there is a scarcity of research conducted with the participants of the ever popular sport of skydiving. the knowledge gaps pertaining to the relationship between skydiving and audiology are evident in the dearth of literature available. however, the growth in popularity necessitates that further investigations are conducted to ascertain the audiological consequences of participation in the sport. this study was conducted to add to the body of knowledge in sa that relates to the effect of skydiving, specifically on the middle ear system. the popularity of skydiving in sa necessitates the exploration of clearance forms to ensure that the skydiver is aware of the risks. the effects of skydiving on the auditory system need to be documented to inform the skydiving population of the potential risk of the sport. methodology aims and sub-aims the main aim of this study was to explore the relationship between skydiving and audiology in south africa. the sub-aims of the study are as follows: to review the dropzone pre-jump consent forms at the skydiving schools and document any information related to audiology to determine what policies govern skydiving in sa and document any hearing-related risks and precautions to assess the difference in middle ear pressure preand post-skydive to determine the audiological symptoms experienced post-skydive to document the skydivers’ perceptions about the possible ear-related risks when skydiving. research design a mixed-method descriptive research design was employed in this study. qualitative information was obtained from reviewing of policies, clearance forms and open-ended questions on a questionnaire. the information extracted from the clearance forms and from the scrutiny of the policies that govern the sport in sa was transcribed onto a recording form. a tympanometry assessment was conducted at 5 min before flight for the jump and immediately after landing post-jump. the quantitative information was obtained from the tympanometry results, specifically the changes in the middle ear pressure, because of the altitudes experienced during skydiving. sample thirty-one participants (21 males and 10 females) were recruited using a purposive sampling design. the group was divided into regular (more than five jumps) skydivers (n = 13) and first time skydivers (n = 18). inclusion criteria for participants were as follows: 18 years or older as seen in table 1 either first time skydiver or an experienced skydiver. exclusion criteria were as follows: participants that have had a previous audiological problems such as: previous middle ear surgery grommets recurrent middle ear infections otitis externa occluding cerumen a pre-dive tympanogram that indicated a possible middle ear abnormality. table 1: age range of participants. the above-mentioned exclusion criteria were included as these factors have an impact on the results obtained in tympanometry. a middle ear infection yields negative pressure, whereas grommets increase the volume of the ear canal volume (gutovitz et al., 2008). data collection procedure data analysis the pressure changes during a skydive were the focal aspect of the assessments, and hence, the pressure measured in dapa was documented and analysed using stata statistical software. preand post-tympanometry results were analysed with a paired t-test to determine if they were statistically different (p < 0.05). qualitative data from the questionnaire were thematically analysed according to the common themes that emerged. ethical consideration ethical clearance was initially obtained from the medical ethics committee; thereafter, two skydiving schools in sa provided the research with permission to access the skydivers. consent forms were completed by all participants. south african policy documents from the south african parachute association (sapa) were scrutinised. the sapa is the officiating body that oversees the health and safety aspects with the sport. clearance forms from the two skydiving schools were obtained, and the audiologically relevant information from the clearance form was recorded on a record form. the second phase included the use of questionnaires to 31 skydivers, and the third phase included a middle ear assessment via tympanometry, preand post-skydives. results clearance forms and policies the information in the clearance forms pertaining to the audiological risks such as barotrauma to the middle or inner ear was non-existent. the clearance forms used are not standardised but self-developed by the skydiving school; therefore, findings cannot be generalised. there was no evidence of any medical clearance requirement for a tandem passenger, which places the first time jumper at risk. preand post-skydive tympanometry there was no statistically significant difference between the left and right ears. when assessing the regular and non-regular skydivers, the preto post-jump pressures are statistically significant at the 5% level, and hence both groups reveal a statistically significant difference (table 2). table 2: average ear pressure changes. audiological symptoms experienced post-skydive nine participants reported having experienced tinnitus after the skydive (figure 1). the majority of participants in the study reported a sense of aural fullness which was either unilateral or bilateral. there were four participants who reported a temporary threshold shift after the skydive. the researcher did not measure the time taken for the temporary symptom to subside. figure 1: audiological symptoms experienced by participants. skydivers’ perceptions about the possible ear-related risks when skydiving twenty-two participants reported having an understanding about tympanic membrane rupture and its causes. it was noted that of the 22 participants that understood this phenomenon, 12 of them had a previous tympanic membrane rupture from the sport. participants highlighted that loud noises may pose a risk to hearing, and one participant noted that ear infections and ‘eardrum’ bursts may be a cause of hearing loss. only 13 participants reported that they read the dropzone pre-jump consent form before signing it. fifteen participants did not foresee any health or audiological risks related to skydiving. it was further noted that five participants saw death as a more likely consequence. another five participants noted an awareness of possible physical injury as a result of the skydive. four participants noted an awareness of a possible decrease in hearing over a sustained period of skydiving. discussion participants are at risk of ear trauma as there is a lack of information provided to the prospective new skydiver at both skydiving schools. the lack of precautions on the clearance forms places the sportspeople in a vulnerable and dangerous position, as a tympanic membrane perforation can occur at the first jump creating a middle ear pathology and a conductive hearing loss (bentz & hughes, 2012). south african sport and recreation policies focus on the safety at sports events, whilst specific sporting associations are responsible for the safety of participants. the parachute association of south africa, the governing body that is responsible for the safety measures that are implemented in the sport (pasa, 2012), needs to include more detailed information pertaining to the different options of skydiving and the related risk to the hearing system to ensure that all participants are making informed decisions. the findings of this study indicate that the dropzone consent forms were developed at the discretion of the owners at each school. the lack of an official consent form, with the inclusion of safety rights, is evidence for the development of a standardised form that is endorsed by the pasa. the number of participants in this study who read the consent forms concurred with participants who partake in other extreme sports in sa, as a study regarding recreational scuba diving (pillay & jardine, 2010) ascertained that only 45% of the participants in their study had signed the consent form without being fully aware of the details in these forms. the symptom of tinnitus can be attributed to the rapid middle ear pressure change (gutovitz et al., 2008) during the dive or the loud noise experienced from the aircraft during flight pre-dive. the aural fullness experienced is as a direct result of the pressure change that is experienced during the skydive. the findings indicate the need for awareness about the audiological consequences that may result from extreme sports such as skydiving. this study illustrates the need for a larger study that considers how different sports have an effect on the auditory system. conclusion skydiving has become a popular sport; however, research regarding the sport and its audiological consequences is minimal. as a result, participants have little to no knowledge of the effect that skydiving has on the auditory system. it was noted that individuals who only participated in the sport once were not educated about the manner and time at which to equalise during the skydive. the results from this study clearly depict a pressure change – which poses a hazard of tympanic membrane perforation and middle ear barotrauma. although the study provides useful information, there are some limitations that must be considered. it must first be noted that the research only took place at two skydiving schools, and therefore, the generalisability of the results is limited. however, the study draws attention to the risks associated with skydiving. audiologists, sportspeople and medical advisors should be cognisant of the negative consequences that may be evident within the auditory system of skydivers. acknowledgements the authors would like to thank the individuals and the skydiving school owners for their participation in the study. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions the article was written by the supervisor d.p. at the university of the witwatersrand, with s.d., a fourth year research student. references bentz, b., & hughes, a. 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(2004). the developmental impacts of backpacker tourism in south africa. geojournal, 60, 283–299. https://doi.org/10.1023/b:gejo.0000034735.26184.ae zuckerman, m. (1990). the psychophysiology of sensation seeking. journal of personality, 58, 313–345. https://doi.org/10.1111/j.1467-6494.1990.tb00918.x abstract introduction method results ethical consideration discussion conclusion acknowledgements references footnotes about the author(s) mary e. weidner department of communication disorders, marshall university, united states kenneth o. st. louis department of communication sciences and disorders, west virginia university, united states egemen nakisci private practice, turkey ramazan s. ozdemir department of speech and language therapy, istanbul medipol university, turkey citation weidner, m.e., st. louis, k.o., nakisci, e., & ozdemir, r.s. (2017). a comparison of attitudes towards stuttering of non-stuttering preschoolers in the united states and turkey. south african journal of communication disorders 64(1), a178. https://doi.org/10.4102/sajcd.v64i1.178 original research a comparison of attitudes towards stuttering of non-stuttering preschoolers in the united states and turkey mary e. weidner, kenneth o. st. louis, egemen nakisci, ramazan s. ozdemir received: 11 aug. 2016; accepted: 15 jan. 2017; published: 21 apr. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background and objectives: extensive research documents ubiquitous negative attitudes towards stuttering, but when and how they develop is unclear. this non-experimental, comparative study examined us and turkish preschoolers to explore the origin of stuttering attitudes cross-culturally. method: the authors compared stuttering attitudes of 28 us and 31 turkish non-stuttering preschoolers on english and turkish versions of experimental prototypes of the newly developed public opinion survey on human attributes–stuttering/child (posha–s/child). children first watched a short video of two stuttering avatar characters and then answered oral questions about stuttering. parents completed a demographic questionnaire. differences in the us and turkish posha–s/child means were calculated using the mann–whitney u test. results: attitudes of the us and turkish children were remarkably similar. children rated most of the items negatively but also rated some items as neutral or positive. they held relatively more negative attitudes towards traits and personalities of children who stutter yet relatively more positive attitudes towards stuttering children’s potential. conclusion: stuttering attitudes in children appear to be partly independent of culture. introduction stuttering attitudes include how people think and feel about stuttering and people who stutter, as well as what they indicate their actions would be towards these persons. an expansive literature (e.g. abdalla & st. louis, 2012; crowe & walton, 1981; hughes, 2015; hughes, gabel, roseman & daniels, 2015; ruscello, lass, schmitt & pannbacker, 1994) has documented pervasive negative or uninformed stuttering attitudes among non-stuttering adults across widely variable populations and cultures. for example, the general public often has misconceptions about the causes of the disorder and may subsequently perceive stutterers as being anxious, shy, nervous, unintelligent and incompetent (woods & williams, 1976). many predictor variables and correlates have been examined in order to explain the observed variability of stuttering attitudes (st. louis, 2015). among the many variables examined [e.g. sex, socio-economic status (ses), profession], one’s culture and early development are suspected to have a particularly important influence on stuttering attitudes. although stuttering attitudes among adults from different countries have been reported to share a number of similarities, there remains important cultural trends as well as cross-cultural distinctions (st. louis, 2015). cross-cultural research has been used widely to isolate subtle cultural influences and nuances of stuttering attitudes (e.g. al-khaledi, lincoln, mccabe, packman & alshatti, 2009; de britto pereia, rossi & van borsel, 2008; st. louis, et al., 2016; van borsel, verniers & bouvry, 1999; xing ming, jing, yi wen & van borsel, 2001). on a standard measure, public stuttering attitudes have been examined in 42 countries (st. louis, 2015). importantly, turkey is one country that is quite disparate culturally from the united states but for which robust stuttering attitude research exists. for example, using a probability sampling technique in one moderate-sized city, özdemir, st. louis and topbaş (2011b) compared stuttering attitudes of sixth-grade turkish children with attitudes of their parents, their grandparents or other adult relatives, and their neighbours. this child versus adult attitude comparison, which has not been carried out in another country, revealed four important findings. firstly, stuttering attitudes of the schoolchildren, their parents, grandparents or adult relatives were remarkably similar. such unanimity of beliefs and reactions to stuttering suggested a ‘top-down’ influence on stuttering attitudes on children, that is, that adult family attitudes are passed on to their children. secondly, the attitudes between individual family units and their neighbours were more similar than those from different family or neighbour units. thirdly, the attitudes of these children and adults were less positive in many ways than were previous convenience samples of adults in turkey using the same survey instrument (aydın, 2008; özdemir, st. louis & topbaş, 2011a; st. louis, andrade, georgieva & troudt, 2005; st. louis et al., 2011). fourthly, despite differences because of the apparent sampling of different populations, stuttering attitudes of turks were less positive than for most other samples of adults from north america (st. louis, 2015). specific differences seen in turkish adults, compared to ‘average’ samples around the world, included a greater likelihood of attributing the cause of stuttering to ‘an act of god (allah)’, of making a joke about stuttering or filling in a person’s words but at the same time being less concerned if one’s doctor or neighbour stuttered, and being more optimistic about the potential of a person who stutters. a comparison of the stuttering attitudes of the study by özdemir et al. (2011b) on 420 turkish adults (i.e. the parents, grandparents, adult relatives, and neighbours) with 378 american adults (st. louis, weidner & mancini, 2016) confirmed that respondents’ nationality predicted stuttering attitudes [i.e. beliefs and self-reactions] to a significant level. other ses variables, including respondents’ years of education and relative income1 were also examined between the groups, revealing a significant effect of education on stuttering attitudes, but not of relative income. taken together, these studies can be interpreted to suggest a strong cultural influence on stuttering attitudes, especially within the probability sample (özdemir et al., 2011b). cultural differences, however, provide only one explanation for stuttering attitudes in adults. new and growing efforts are seeking to investigate other variables that may explain stuttering attitudes, with specific interest in stuttering attitude development in young children (e.g. langevin, packman & onslow, 2009; weidner, st. louis, burgess & lemasters, 2015). weidner, st. louis, et al. (2015) compared the stuttering attitudes of 27 non-stuttering preschool-aged and 24 kindergarten children from a mid-atlantic state in the united states using a prototype of a newly developed stuttering attitude instrument for children, the public opinion survey on human attributes–stuttering/child (posha–s/child; weidner & st. louis, 2014), which is described below. unexpectedly, means for the preschoolers were significantly worse than means for kindergarteners. in both groups, children expressed little knowledge about stuttering and how to appropriately respond to a stuttering peer. most children noted they would say, ‘slow down’ and would finish the words of a peer who stuttered, responses that have been shown to be generally undesired among both adults and children who stutter (rodriguez et al., 2015; weidner, coleman, et al., 2015). both preschool and kindergarten respondents held more negative attitudes towards the attribute of stuttering itself compared to the stuttering person. on one hand, children reported that stuttering is an undesirable attribute, and they would be worried if they or their family or friends stuttered. on the other hand, they noted that stuttering children have the potential to make friends, make good choices and can do the same things as others. that stuttering is perceived as an undesirable attribute was further supported by ezrati-vinacour, platzky and yairi (2001), who showed that some non-stuttering 4-year-olds described the speech of stuttering children unfavourably. what accounts for the origin of stuttering attitudes in young children, remains unclear. however, research on the emergence of race and gender stereotyping has suggested that children’s negative appraisal of others depends on their cognitive ability to identify differences in others and socially categorise persons based on those salient features (bigler & liben, 2006; mulvey, hitti & killen, 2010). developmentally, children’s ability to do so typically emerges during the preschool years (rochat, 2003). during that period, their cognitive ability to think flexibly and dynamically about another’s attributes and differences is generally immature; therefore, they form social categories in which to classify persons with similar characteristic features (killen & rutland, 2011). by categorising people based on an attribute, children may construct their own expectations of the way those persons might behave. for example, if children categorise persons by sex, they might expect boys to play with trucks, but not girls (e.g. gelman, collman & maccoby, 1986). although awareness and categorisation based on attributes is far from prejudicial behaviour, rigid social categories may cause children to show favourable bias towards those similar to themselves. as a consequence, they may demonstrate fear or exclusion of those who exhibit different traits or attributes (levy & killen, 2008). derman-sparks (1989) defined this initial distancing among children towards others with differences as pre-prejudice. applying this conceptualisation to stuttering, weidner, st. louis, et al. (2015) suggested that preschool-aged non-stuttering children (i.e. 3–5 year olds) may have shown pre-prejudicial attitudes towards children who stutter. although favouritism for one’s own ‘fluency group’ (i.e. typically fluent or stuttering) has not yet been unambiguously confirmed, some studies are suggestive that fluent children may demonstrate such tendencies. for example, griffin and leahy (2007) conducted a mixed-methods study in which they measured the stuttering attitudes of 3to 5-year-old non-stuttering children. results showed that 78% of the children ‘noticed the stutter and acknowledged that disfluent speech was not the “norm”’ (p. 221). to a statistically significant level, children perceived a non-stuttering speaker more favourably than a stuttering speaker. in a related study, hartford and leahy (2007) showed that 81% of non-stuttering 11to 13-year-old children (n = 26) reported preference for a fluent friend as opposed to a stuttering friend. langevin et al. (2009) showed that preschool-aged children who stutter are at risk for being viewed unfavourably by their fluent peers. thus, they may be at a disadvantage for experiencing normal communication opportunities. while no known longitudinal studies have investigated the long-term ramifications of negative attitudes towards preschool children, evidence suggests that negative attitudes towards stuttering children persist through the elementary school–aged years and adolescence. samples of children who stutter from the united states, canada, ireland and england have been shown to be at a risk for teasing and bullying (blood & blood, 2004; langevin 2015; langevin, bortnick, hammer & wiebe, 1998; mooney & smith, 1995; yaruss, murphy, quesal & reardon, 2004) and social exclusion (davis, howell & cooke, 2002; gertner & rice, 1994; hartford & leahy, 2007). although the nature and management of experiences among children who stutter are highly variable, it is clear that negative attitudes among non-stuttering peers have the potential to disrupt the social-emotional growth and development of stuttering children. given that these behaviours may begin as early as preschool, it is important to further substantiate the preliminary research on young children’s stuttering attitudes. doing so will help speech-language pathologists, teachers and parents to understand the social challenges faced by young stuttering children and to promote positive social interactions between children who do and do not stutter. based on the aforementioned literature, one’s culture of origin, as well as early development during the preschool years, appears to impact the stuttering attitudes. to date, however, no known research has empirically investigated the relationship between those variables. the purpose of this study, therefore, was to compare stuttering attitudes of preschool children cross-culturally. turkey and united states were of particular interest, given the extensive stuttering attitude research in both countries as well as the distinct cultural differences between them. we used the original english experimental version of the posha–s/child and a parallel experimental version translated to turkish. method measure of children’s stuttering attitudes this non-experimental, comparative study used a standard instrument, the posha–s/child, to compare the attitudes of american and turkish children. the posha–s/child was introduced by weidner and st. louis (2014) and is intended to be used with children 3–10 years of age. it is an extension of the adult version the posha–s (st. louis, 2011), which has been used in epidemiological investigations extending across 39 countries (including turkey) with over 10 000 respondents (st. louis, 2015). numerous studies provide evidence of its validity and reliability (see st. louis, 2015 for a review). items in the child version parallel as closely as possible those of the adult version. for example, in the adult version, respondents are asked whether or not they would ‘make a joke about stuttering’ when talking to a person who stutters; in the child version, that item was adapted to whether or not respondents would ‘laugh [at a child who stutters] because of their stuttering’. selected psychometric properties of the english posha–s/child was examined in a recent study in which 378 adults completed online versions of both the adult and child versions of the posha–s, in counterbalanced order (st. louis, weidner, et al., 2016). the study was carried out with adults because preschool children would be unable to complete the standard adult posha–s. the subscore and the overall stuttering score (oss) means on the two versions were quite similar. posha–s means were: obesity and/or mental illness = -28, beliefs = 48, self-reactions = 11 and oss = 30. posha–s/child means were: obesity and/or wheelchair = -29, beliefs = 39, self-reactions = 22 and oss = 31. these similarities constitute preliminary evidence of concurrent and construct validity of the posha–s/child. the posha–s/child begins with a printed demographic section completed by a parent, requesting information about the family’s ses, the child’s educational history, and the child’s health and abilities. parents also report their child’s personal experience with and exposure to people who stutter, are obese, or are confined to a wheelchair. these are combined into an experience score for each of the three attributes, results of which provide a perspective for better understanding children’s stuttering attitudes in the broader context of other human conditions (cf. st. louis, 2011). as to not influence or prime their child’s responses, parents do not see the survey materials presented to the children. the remainder of the posha–s/child is administered orally to the child separate from the parents. it begins with a video played on a tablet featuring two stuttering avatars, one girl and one boy, whose mouths move as they talk. the avatars were purposefully designed to be culturally neutral (i.e. skin colour, clothing, etc.). the characters’ speech consists of obvious prolongations, blocks and initial sound and syllable repetitions, which was judged by two stuttering experts as ‘severe’. the administrator labels the character’s speech as ‘stuttering’ and provides a standard definition and examples of stuttering. following the video, the administrator verbally asks a series of ‘yes’ and ‘no’ questions relating to the child’s beliefs about and reactions towards children who stutter assuring the child that there were ‘no right or wrong answers’. the examiner presents each of the items and records each child’s responses on a paper copy of the survey. if a child fails to answer, the question is repeated. a second failure to respond or a response of ‘i do not know’ is recorded as ‘unsure’. parallel to the parents’ written responses, the final section examines children’s preference for stuttering as compared to being obese or in a wheelchair. the selection of obesity and wheelchair is based on evidence identifying them as attributes that are highly recognisable by young children (e.g. bell & morgan, 2000; vilchinsky, werner & findler, 2010). children are shown a line drawing of the avatar of the stuttering child featured in the stimulus video (of their sex) and line drawings of similar avatars depicting a child who is obese or is in a wheelchair. the drawings are presented in pairs (e.g. stuttering versus obese), and the child is asked, ‘which one would you rather be?’ responses are averaged into a preference score for each of the three attributes. as with the posha–s (st. louis, 2011), children’s responses to stuttering attitude items are assigned a value, wherein ‘no’ = 1, ‘unsure’ or ‘i do not know’ = 2, and ‘yes’ = 3. scores are then converted to a -100 to +100 continuum, where neutral = 0. more accurate (based on the research) or sensitive attitudes correspond to higher values and less informed or more insensitive attitudes correspond to lower values. this procedure has been justified in several reports (e.g. st. louis, 2012), and in one case involved extensive consultation with a statistician (abdalla & st. louis, 2014). ratings on some items are inverted so that, uniformly, higher mean ratings reflect more accurate and sensitive responses, and vice versa. means of stuttering items are clustered into seven components, and the means of components are clustered into three sub-scores. two sub-scores relate to stuttering, that is, self-reactions and beliefs, and an oss is derived from the means of these sub-scores. the beliefs sub-score components include traits and/or personality (e.g. children who stutter are nervous), who should help (e.g. a doctor), causes (e.g. germs) and potential (e.g. children who stutter can make friends). the self-reactions components include accommodating and/or helping (e.g. i would say ‘slow down’), social distance and/or sympathy (e.g. i would be patient) and experience with stuttering per child and parent report (e.g. do you or your child stutter). a third sub-score, wheelchair and/or obesity, relates to children’s experience with, exposure to and preferences for these attributes. for the purposes of this investigation, the posha–s/child prototype was translated from english into turkish by the third and fourth authors, and then back-translated into english by a person unfamiliar with the study and speech-language pathology. the video was also translated into turkish, with the stuttering events having the same number of repetition units, as well as the same length of blocks and prolongations. like the english version, the stuttering severity is ‘severe’. the original english version of the posha–s/child and the video was carefully written to ensure ease and accuracy of translatability (i.e. the text did not include slang, figurative language or other culturally specific references). using these procedures, st. louis and roberts (2010) demonstrated satisfactory posha–s translatability, and the same protocol has been successfully employed in translations into 26 different languages circa december, 2016. participants a total of 58 preschool-aged children from the united states (n = 27) and turkey (n = 31) participated in this study. the us sample consisted entirely of the preschool sample compared to a kindergarten sample in weidner, st. louis, et al. (2015). according to parent and teacher reports in both united states and turkish samples, none of the children stuttered. the united states preschoolers attended school for 2.5 h five times per week in a north-central west virginia university city of approximately 60 000 inhabitants. the turkish preschoolers attended school 8 h per day, 5 days per week in ankara, turkey, a city of 4 million inhabitants. procedure after obtaining appropriate human subject consent in the united states (from west virginia university) and in turkey (from anadolu university), the first and third authors, who are speech-language pathologists, carried out the convenience sampling procedures in the two countries, respectively. in order to ensure consistency of the video adaptation and administration procedures of the posha–s/child in turkish, the us authors travelled to turkey to consult with and train their turkish colleagues. the investigators in each country met with the parents of the children face-to-face to complete consent procedures. (assent procedures were not required, as all the participants were under 7 years of age.) at that time, parents also completed the written demographic portion of the posha–s/child. participants met individually with each examiner in a quiet room at their respective preschool. as judged by the two examiners, all the children in both countries were able to respond to yes–no questions and to possess receptive and receptive language skills adequate to comprehend the survey items. data analysis the means for each item, component, sub-score, and oss were calculated for the total sample and each country group. because of the non-normal distribution of the ratings, non-parametric mann–whitney u tests were carried out to determine the significance of differences between the two groups on demographic and stuttering attitudes variables (field, 2013). a bonferroni-corrected alpha level of p ≤ 0.00414 (0.05/12), used widely in adult studies (st. louis, 2012), was employed to reduce the likelihood of type i errors, but at the same time providing a balance for not making type ii errors (grimm & yarnold, 1995). effect sizes for significant differences, r, were calculated based on the z value divided by the square root of the sample size (rosenthal, 1991). results demographics the mean age of the us children was 4.5 years (sd = 0.61) and of the turkish children, 4.3 (sd = 0.75). the combined sample’s mean age was 4.4 years (sd = 0.68). female versus male percentages in the us sample were 67% (n = 18) and 33% (n = 9) compared with 48% (n = 15) and 52% (n = 16) in the turkish sample. it should be noted that being male or female participant did not have a significant impact on the oss within groups or in the combined sample. the us children’s parents reported an average education of 17.1 years for the parent spending the most time with the child compared to 12.9 years for the turkish parents. these differences were statistically significant [u = 114.00, r = 0.64 (‘medium-large’)]. the us relative family income score of 281 was also significantly greater than the -8 value for the turkish income [u = 150.0, r = 0.51 (‘medium’)]. the posha–s database sample median of 1 is virtually near the middle of the −100 to +100 scale. interestingly, means for parental report of children’s health and abilities were also significantly different, with the us children being rated higher on their health and abilities than the turkish children. respective us and turkish values for physical health were 91 and 11 [u = 28.50, r = 0.86 (‘large’)]; for mental health, 89 and 15 [u = 49.50, r = 0.79 (‘large’)]; for ability to learn 89 and 16 [u = 43.50, r = 0.81 (‘large’)]; for speaking ability, 74 and 10 [u = 92.00, r = 0.71 (‘large’)]; and the composite for all four, 86 and 13 [u = 12.0, r = 0.84 (‘large’)]. (as interpreted below, we regard these differences as cultural tendencies in parental reports rather than large differences in the children’s health and abilities.) further, although means were low in both groups, us children reportedly had more exposure to and experience with stuttering, obesity and wheelchair use than the turkish children. the composite parental ratings for obesity and wheelchair experience were -64 for the us group versus 10 for turkey [u = 201.00, r = 0.49 (‘moderate’)]. parental ratings for stuttering experience were -97 for the us group versus -99 for the turkey group. united states and turkey group differences table 1 outlines the group means for all of the posha–s/child ratings. as with the posha–s (st. louis, 2011), the self-reactions sub-score for these respondents on the posha–s/child was quite low in both groups (united states = -21; turkey = -28), whereas the beliefs sub-score was higher (united states = 8; turkey = 14). the oss (the average of these two sub-scores) was -7 for both groups, revealing generally negative stuttering attitudes among both us and turkish non-stuttering children. table 1: public opinion survey on human attributes–stuttering/child (posha–s/child) mean stuttering attitude ratings and standard deviations in parentheses for american and turkish samples and both samples combined. of the 49 attitude group comparisons related to stuttering, only one significant difference (2%) emerged, that is, rejecting the etiological statement that ‘[stuttering] comes from god (allah)’ [united states = -33, turkey = 61; u = 211.00; r = 0.49 (‘moderate’)].2 comparing the magnitude of all the mean stuttering ratings, one sample was not consistently more positive than the other; slightly worse attitudes characterised the us sample for 22 items (45%) and the turkey sample for 27 items (55%). when arranged from least to most positive, the rank-order of the seven stuttering components was identical for the us and turkish children, that is, experience (united states = -82; turkey = -94) > traits/personality (united states = -35; turkey = -24) > causes (united states = -19; turkey = -4), > accommodating/helping (united states = 7; turkey = -1) > social distance/sympathy (united states = 11; turkey = 9) > who should help (united states = 24; turkey = 27) > potential (united states = 61; turkey = 68). regarding experience with stuttering (the lowest rated component), only two us preschoolers and none of the turkish preschoolers reportedly had prior personal contact with a person who stutters, and none of the participants in either group stuttered. the overall similarities of the two samples are shown in figure 1. figure 1: comparison of mean values for posha–s/child components, sub-scores, and overall stuttering scores for the united states and turkish groups. mean ratings on various posha–s/child items were noteworthy. respondents rated children who stutter as ‘different’ (united states = -78; turkey = -58) and ‘shy’ (united states = -22; turkey = -13). they also gave low ratings for stuttering children being ‘able to talk well’ (united states = -48; turkey = -26). although children indicated that they would generally not laugh at a child who stuttered (united states = 48; turkey = 65), they noted they would be somewhat to quite likely to finish their words (united states = -11; turkey = -29) and tell them to ‘slow down’ (united states = -85; turkey = -74). relative to beliefs about causes for stuttering, most respondents indicated stuttering was learned (united states = -67; turkey = -71) or resulted from something bad that happened (united states = -16; turkey = -15). as noted, the belief that stuttering came from god/allah was significantly different between groups, with the us children being more likely to indicate agreement (-33) with the statement than the turkish children (61) [u = 211.00, r = 0.49 (‘moderate’)]. respondents noted that children who stutter can make friends (united states = 85; turkey = 74), make good choices (united states = 78; turkey = 55) and do the same things as others (united states = 29; turkey = 52). as noted, after responding to all stuttering items, the children were asked to compare the attribute of stuttering to that of being obese and being wheelchair-bound. these, combined with parental reports of whether the children knew anyone with the three attributes (and the child’s report for stuttering only), generated mean ratings for preference of and experience with the attributes. in both samples, children had the same rank-ordered experience with the three attributes. although limited in both samples, they had the most experience with obesity (united states = -45; turkey = -85), the second-most experience with wheelchair use (united states = -84 and turkey = -92) and the least experience with stuttering (united states = -97; turkey = -99). preschoolers in both samples indicated highest preference for being a child who stutters (united states = 43; turkey = 52) compared to being obese (united states = -33; turkey = 23) or in a wheelchair (united states = -4; turkey = -74). us children’s second choice for an undesired trait was wheelchair use, followed by obesity, whereas the turkish children’s second-place choice was obesity, followed by wheelchair use. the between-group preferences were significantly different for both obesity [u = 211.00, r =0.39 (‘small to moderate’)] and wheelchair use [u = 169.00, r = 0.51 (‘medium’)]. comparisons for experience were significantly different for obesity [united states = -45; turkey = -85; u = 199.00, r = 0.52 (‘medium’)] but not for wheelchair use (united states = -84; turkey = -92). predictor analyses a multiple regression was conducted to compare the effect of socio-economic variables on oss, controlling for a country. results indicated that there was no significant interaction between composite income and education relative to the stuttering attitudes between the turkish and us samples [f (3, 50) = 0.326, p = 0.807]. furthermore, despite large differences between them, none of the children’s health and ability ratings (i.e. physical health, mental health, ability to learn, and ability to speak) as reported by their parents was significantly correlated to either their self-reactions or beliefs sub-scores. pearson product–moment correlations for the eight comparisons were very low, ranging from -0.054 (p = 0.689) to 0.186 (p = 0.163). ethical consideration human subject study consent was obtained from west virginia university and anadolu university. discussion this study extends preliminary findings of negative stuttering attitudes of young, us non-stuttering children (weidner, st. louis, et al., 2015) to turkish children. measured attitudes towards stuttering were very similar between the two samples of children. how can these findings be explained? cultural influences together with previous investigations, one of the most important findings of this study is that the cross-cultural similarities in young children’s stuttering-related attitudes were much greater than the similarities observed in cross-cultural comparisons of adults (e.g. st. louis, 2015). based on substantial differences observed for stuttering attitudes in the united states for preschool versus kindergarten children, the finding of no significant differences for 48 of the 49 mean stuttering ratings between the turkish versus us children (table 1) was unexpected. the similarity was further buttressed by identical osss in the us and turkish children, that is, -7, as well as the same rank-order of the seven component scores in the two samples. by contrast, although limited to only four posha–s/child item ratings (combined into two components and one sub-score), five of seven ratings for obesity and mental illness (71%) were significantly different. the reader will recall that these were included to evaluate how stuttering is viewed within the context of other negative attributes. it has been consistently shown that while similarities in adult stuttering attitudes exist across different cultures (st. louis, 2015), important and occasionally large differences between regions, samples, professions and other variables have emerged (e.g. abdalla & st. louis, 2012; ip, st. louis, myers & an xue, 2012; özdemir et al., 2011a; st. louis, 2012; st. louis, sønderstreud, et al., 2016). if the current preschool sample reflected a similar cultural influence as seen between us and turkish adults, we would have expected turkish children to view some traits/personality items of a person who stutters more negatively than the us children, such as being more ‘nervous’. results revealed that they actually held slightly better attitudes for the traits/personality component, although group differences did not reach statistical significance. similarly, we also expected the turkish children would have more negative attitudes relative to the causes of stuttering, such that it comes from ‘germs’. their mean for this component was also slightly, but not significantly, more positive than that for the us group. one might think that in order for the children to hold such similar stuttering attitudes, their environmental conditions must be comparable. that was clearly not the case. significant group differences distinguished the families’ ses. the turkish parents reported significantly lower relative income scores and years of education than the us parents. st. louis and rogers (2011) reported that these ses variables played a limited but measurable role in the attitudes of several thousand adult respondents in the posha–s database, with higher education and higher income predicting more positive stuttering attitudes. more relevant, özdemir et al. (2011a) compared two adult samples from a single city in turkey, one sample with a much higher education and income level than the other. the authors attributed observed differences in their stuttering attitudes primarily to these ses discrepancies. by contrast, this study showed that family ses influences were either extremely limited. in the companion study from the united states (weidner, st. louis, et al., 2015), the lower ses kindergarteners had better attitudes than the higher ses preschoolers, which was the opposite of what would be expected if ses played a major role. in that study, the authors hypothesised that ses factors were masked by a stronger effect of age. turkish parents reported the health and abilities of their children to be greatly and significantly worse than parents of us children; yet, these differences, too, were not associated with differences in stuttering attitudes. we submit that this puzzling disparity very likely was not truly reflective of the children’s actual abilities, but rather a demographic difference, that is, a reflection of cultural differences in the social acceptability of affirming one’s (or one’s child’s) ‘excellence’. much lower than average ratings by adults of their health and abilities have also been reported in poland (przepiórka, błachnio, st. louis & wozniak, 2013), portugal (valente, jesus, leahy & st. louis, 2014), korea (lee & st. louis, 2014) and hong kong or mainland china (ip et al., 2012). attitudes in korea and china were strikingly more negative than average, while attitudes in poland and portugal were close to average. thus, it cannot be asserted that low ratings of health and abilities are consistent with exceptionally negative stuttering attitudes in adults. instead, these findings have been interpreted to indicate that respondents from some cultures find ‘bragging’ to be inappropriate and, therefore, demonstrate more ‘reticence’ to rate themselves favourably on their health and abilities, including their own intelligence. we draw attention to the only significant difference for stuttering-related ratings between the groups, that is, ‘stuttering came from god/allah’. the us children, who were drawn from a predominantly christian society, were more inclined to report that stuttering came from their deity than were the turkish children, who were drawn from a predominantly muslim society. this is counter to several studies wherein adult muslim respondents from the middle east were much more likely to attribute the cause of stuttering to an act of allah than western respondents to an act of god (e.g. st. louis, abdalla, burgess & kuhn, 2015; st. louis, lemasters & poormohammad, 2015). the only study to date that has explored religion within a country showed that, although similar, respondents from a primarily muslim region in bosnia-herzegovina held slightly better stuttering attitudes than respondents from either a primarily christian orthodox or a catholic region, even though the primarily muslim respondents were slightly more likely to attribute cause to one’s deity (st. louis, sønsterud, et al., 2016). as with these adult data, we cannot explain the significant differences relative to children’s attribution of the cause of stuttering to religion. it would be interesting, however, to examine how children from different religious upbringings conceptualise the role of one’s deity to justify human attributes and differences. developmental and experiential influences as noted, both us and turkish samples had very limited experience with stuttering: none of the participants stuttered, and only two children from the united states and no children in the turkish group (according to both children and parents) had some prior exposure to stuttering. the children’s stuttering experience was rated by their parents lower than for obesity and wheelchair use. their only serious exposure to stuttering consisted of seeing and hearing the short interaction between avatar characters who stuttered in the posha–s/child video. this virtually equal lack of stuttering experiences and yet the nearly equal measured attitudes between the turkish and us children cannot be overlooked. a majority of the non-stuttering preschoolers reported that children who stutter are ‘different from others’, ‘shy’ and ‘[un]able to talk well’. in these results, we submit that the short exposure to stuttering avatars in the video appears to exert a powerful effect on the beginning of negative stuttering attitudes in young children even though the simple play interaction depicted gave no hints or information about stuttering or ways to interact appropriately with stuttering peers. aside from providing empirical evidence that a stuttering stereotype may begin at a very young age, the fact that the children responded negatively to some traits/personality and other items in this study is consistent with previous research that documented awareness of stuttering is present in typically fluent children who viewed videos of stuttering puppets (ambrose & yairi, 1994; ezrati-vinacour et al., 2001; griffin & leahy, 2007). our findings suggest, therefore, that awareness of and attitudes towards stuttering may not be mutually exclusive processes; brief exposure to stuttering led to an immediate and measurable negative attitude of the disorder. our study cannot offer a definitive answer to why the stuttering attitudes of children from culturally diverse samples were remarkably similar. however, we speculate that cognitive development and experience with stuttering is the most likely factor, among others, to account for the attitudinal correspondence. killen and rutland (2011) asserted that young children’s bias towards others relies on their cognitive ability to categorise people into certain groups, which allows across them to generate impressions of people who possess attributes unlike their own. one example of this in our study was children’s tendency classify children who stutter as being ‘different’. although not indicative of a negative behaviour in and of itself, mulvey et al. (2010) explained that children’s categorisation of others may be a ‘precursor’ to subsequent stereotyping. because their research was related to race and gender, much work would need to be done to confirm or unconfirm that children’s stuttering attitudes are a product of categorising others based on their fluency. relatedly, the seminal of work of psychologist frances aboud (1988) on ethnic prejudice has suggested that an affective process drives the development of prejudice among preschool children. that the preschool children in our study demonstrated reactions such as ‘worry’ if they or anyone close to them stuttered not only supports aboud’s position but also extends its applicability beyond ethnicity-related prejudice. aboud further suggested that slightly older children (i.e. around age 7) use cognitive processes on which to base their impressions of others. she explained that the shift in the underlying process accounting for prejudicial behaviour (i.e. affective versus cognitive) may cause older children to demonstrate a decrease in prejudice and also a greater likelihood for their attitudes to be influenced by those of their parents. weidner, st. louis, et al. (2015) posited a similar explanation for kindergarten children’s stuttering attitudes being somewhat more positive than those of preschoolers. reduction in prejudice in older children is consistent with the findings by özdemir et al. (2011b) that turkish sixth-grade children’s attitudes were virtually the same as those of their parents, grandparents and adult neighbours. attitudes and social ramifications the question then arises, ‘would nonstuttering children’s negative perceptions of stuttering be likely to result in undesired or negative social consequences toward children who stutter?’ here we distinguish between children’s reports of how they would respond to children’s stuttering events (i.e. dealing stuttering as a behaviour) and how they would engage with stuttering children in social interactions (i.e. dealing with the person who stutters). to the former, the children presumably had little knowledge of how to respond appropriately to children’s stuttering behaviour. they indicated they would finish the words of a stuttering child and say ‘slow down’. regarding social interactions, however, this study did not provide strong suggestive evidence of the social exclusion of stuttering children. the non-stuttering children in both countries indicated that stuttering children are fun to play with, can make friends and can do the same things as others. both us and turkish children indicated that they would not laugh at their stuttering peers and would be patient with them. weidner, st. louis, et al. (2015) identified this phenomenon in preschool and kindergarten children, claiming that their attitudes towards ‘stuttering’ are more negative than their attitudes towards the ‘stutterer’. we suspect that the differences in children’s perceptions of stuttering as a behaviour and of stuttering children themselves is in part because of their fluid formation of constructs regarding others’ differences, as well as their initial tendency to evaluate such differences negatively. derman-sparks (1989) referred to this as pre-prejudice. weidner, st. louis, et al. (2015) adopted the term to explain the disparity between children’s ratings of the attribute of stuttering and their ratings of the actual stutterer. the current study echoes those claims. we acknowledge, however, that there may be discordance with preschoolers’ responses to an avatar-based stuttering encounter versus one that is ‘real’. langevin et al. (2009) employed an observational methodology to directly examine the actual reactions of typically fluent preschoolers towards their stuttering peers. that study showed that children who stutter experienced some negative social consequences as a result of their stuttering. it is possible that non-stuttering children’s restraint or expression of negative social behaviours towards their stuttering peers may be impacted by the personality and emotions of both the child who stutters as well as that of the peers (langevin et al., 2009). research with older children has shown that peers’ stuttering severity might also play an important role in social interactions between non-stuttering and stuttering children (evans, healey, kawai & rowland, 2008; vanryckeghem, hylebos, brutten & peleman, 2001). until substantially more research is conducted to elucidate these and related variables, we cannot claim confidently an absence or presence of negative social consequences for all stuttering preschoolers. however, our data strongly suggest that negative and uninformed attitudes relative to the attribute of stuttering and the traits of children who stutter may emerge during the preschool years and can do so very quickly, even with no experience with in vivo or ‘real’ stuttering. other research suggests that these attitudes may eventually evolve into overt, negative social behaviours during the school-age years and adolescence (blood & blood, 2004; davis et al., 2002; hartford & leahy, 2007; langevin et al., 1998; mooney & smith, 1995). conclusion the following limitations and cautions must be kept in mind as the reader interprets this study. firstly, the sample sizes were modest. secondly, it employed the posha–s/child, an instrument currently under development. its psychometric qualities, although promising, have been partly but incompletely established. results from this and the weidner, st. louis, et al. (2015) study provide preliminary evidence of the instrument’s construct validity. thirdly, the convenience samples used in the study cannot be assumed to be representative of preschool children in either the united states or turkey. fourthly, without corroborating evidence, it is possible – though not likely based on the research to date – that the attitudes reported might have been somehow influenced by the instrument we used to measure them. future studies should further evaluate to further identify potential differences among samples of children. for example, other studies could include replications of this investigation with larger and representative samples of children in the preschool (3–4 years) age group, the kindergarten age group (5–6 years) and early elementary (7–8 years) age group. this was the first study to have used a translated version of the posha–s/child. as with the posha–s database (st. louis, 2011) which contains samples obtained in 26 different languages (circa june, 2016), further translations and use of the posha–s/child with numerous samples involving children across various cultures and languages would be useful to provide comparative data that can document the robustness of findings from any given sample. once sufficient respondents have been run to carry out item analyses of a finalised instrument, further studies of reliability and validity should be undertaken before the posha–s/child is advanced as a standard measure of children’s stuttering attitudes. future studies that compare the attitudes of preschoolers with others (e.g. parents, older children and the public) will inform our understanding of how stuttering attitudes emerge and change over the lifespan. in addition, a detailed understanding of children’s attitudes towards other human attributes, such as obesity and wheelchair use, may further anchor and contextualise our interpretation of their attitudes towards stuttering. this and future studies will play an important role in identifying the aetiology of stuttering attitudes, factors that influence those attitudes and informing educational programmes aimed to mitigate children’s stuttering attitudes. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions m.e.w. and k.o.s.l. developed the instrument used in this study, carried out the data collection for the american children and wrote the manuscript. e.n. and r.s.o. translated the instrument into turkish and carried out the data collection for the turkish children. references abdalla, f.a., & st. louis, k.o. 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(2004). bullying and teasing: helping children who stutter. new york: national stuttering association. footnotes 1. the relative income score is the derived and converted mean of respondents’ 1–5 rating of their own income compared to that of their ‘family and friends’ and ‘all the people in their country’. it is converted to a -100 to +100 scale, where 0 is neutral. 2. in the weidner et al. (2015) study, the alpha level was .05. if we used that alpha level here, only one more item would be statistically significant. hearing aids and "deaf" education. by d.k. rycroft. b.a.rand. up till a few decades ago little discrimination was made between mentally abnormal children and the totally or partially deaf. with the wider application of scientific testing methods however, it is today possible to differentiate and segregate the two main groups at an early age so that specialised education may be better organised accordingly. the advisability of treating together the totally and partially deaf has only in recent years come up for questioning, the appoarance, during the war years, of efficient and wearable vacuum-tube hearing aids bringing tho new question mark, bezold, who tested children at a school for the deaf towards the end of the last century, using tuning forks, concluded that only about 20$ could be classified as totally deaf. hugiison, with more recent testing methods, estimates 95$ of children at the pennsylvania school for the deaf as having sufficient hearing to respond to strong sound stimuli. in theory, purely visual and kinaesthetic education for such children is analogous to treating children with defective eyesight as though they were totally blind,, in practice it is of course much simpler and less costly to fit the latter group with spectacles than the former with hearing aids, but to continue treating together the totally and the partially deaf, means branding these partially deaf children roughly 95$ if we accept hughson's findings with typical "deaf speech", with its monotony of tone and clumsy articulation. cordia bunch, in his work "clinical audiometry", cites the case of a young american from a large deaf institute who passed into adult life "to all intents and purposes totally deaf,, his speach stunted and lipreading inadequate. he was found however to have enough hearing to benefit from a hearing aid, but, being obliged to earn a living, he was unable to spare time or money for a lengthy re-education in sound discrimination," this boy, with a great deal of residual hearing, faces a life of deafness and of social and occupational maladjustment which could have been prevented had his. residual hearing been used in his educational program. it is obviously the duty of those in charge of the education, of children thought to be deaf ̂ to determine at the earliest possible moment the presence and extent of any existing usable residual hearing, and, in the child's educational programme, to have this residual hearing and its possible utilization constantly in mind. the first two of the accompanying audiograms*are those of persons recently fitted with hearing aids in johannesburg, mr. v. of fig. 1., developed normal speech habits and attended a normal school before his disability set in at the age of twelve. his schooling was completed with tho aid of naturally acquired lip-reading while his hearing became progressively worse. today, fitted with a powerful hearing aid, his speech is normal·',, he enjoys the cinema and radio, and earns enough to support a mother £ind two * see f>.31. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 37. sisters. miss d. of fig. 2., has "deaf.speech" and is socially and occupationally handicapped. although showing more residual hearing than mr. v. her sound discrimination has not been developed, and, using a hearing aid with extra high-frequency amplification, the odds are still against her ever becoming as well adapted to her environment as tho former case. what can be and is being done to prevent the recurrence of this state of affairs? tests were performed on young children at the salford war nurseries in england during the recent war by dr. and mrs. ewing of manchester university. it was found that, up to the age of three months, percussive sounds wero moro effective than tho human voice, usually producing reflex responses such as blinking or starting in children not totally deaf. after the third month the voice, associated with such events as feeding and comforting gained response. between 7 and 12 months skill appeared to develop "in differentiating sounds and locating their source. from one to two years simple words and sentences were generally understood, and those with normal hearing responded to soft speech at a distance of six to nine feet. after the second year pitch-pipes could be used to detect impairment in different frequency ranges. reliable audiometer testing was not found to be feasible below the age of five years, and even at this age much depended upon the. degree of co-operation which could be elicited. they stress that, even with children who respond only to intense sounds, as much auditory stimulation as possible should be given thechild by means of speaking and singing close to the ear before ho begins to walk, and thereby discovering new and brighter interests. at the stage where speech develops in normal children, they advise that the partially deaf child be given lip-reading training hand in hand with tho aural, so that he has a link with the outer world. for the development of good speech habits 'the aural stimuli, however, are the more important. even if expense,, and the necessary care in the handling of hearing aids, precludes the use of a hearing aid in early childhood, tho help of auditory stimulation in-developing good speech habits is, i think, sufficient reason for its application. in england, the education act of 1944 allows the admission of children as young as 2 years to schools for the deaf. in a south african school of my acquaintance children of 2 and a half are accepted. at the latter school much time is spent in interesting young partially deaf children in loud percussive and musical sounds such a3 bells, drums and clappers and in training them to discriminate between the respective sounds. group hearing aids are extensively used to develop a speech-sound sense. even if a child is unable to perceive all sounds used in speech, as happens with high-frequency loss cases, a well developed sense of rhythm can do much toward better speoch development. there is necessarily a limit to the dogrco of impairment to which a hearing aid can bring sufficient sound for the understanding of speech. fig, 3 shows the "probable minimum" of residual hearing required, as put forward by a group of leading american scientists. one sorvicoable ear is sufficient for speech perception, but if both ears fall much below this limit such a r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38. high degree of amplification is necessary, to present speech to the ear, that intense external sounds, such as the slamming of a door, will be amplified to an intensity painful and possibly detrimental to the inner ear mechanism. the correct fitting of a hearing aid, to give tho best type of compensation for the individual case,' is a skilled operation and somewhat akin to the fitting of spectacles. speech therapists who deal with partially deaf children and overseas schools, for the deaf, are attaching increasingly greater importance to early auditory stimulation and the skilled fitting of individual hearing aids wherever possible. a slow but steady revolution appears, to be taking place in the adapting of hearing-handicapped persons to their environment with the help of the modern hearing aid. references j bunch clinical audiometry. ewing and ewing "the ascertainment of deafness in infancy and early childhood" j.e. laryngology & otology, vol. 59 no. 9 september 1944. 7 ^ * "what now?" writing advertising copy becomes difficult when one gets to subjects like logopedics. to save us the trouble of having to invent bright slogans and sparkling catchphrases, why not come in or write for a list of our comprehensive'stocks? v a n g u a r d b o o k s e l l e r s (eft.) ltd. 28, joubert street, johannesburg.. telephone 22-7937." r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 59, pi£. mr. v. age 5 23 figmiss do age s 19 a •h ω w ο ti ο •h ω μ ο 0 10 20 30 40 50 60 70 8c 90 100 110 120 0 10. 20 30 40 50 60 70 80 90 100 110 120' x. 512 1024 frequency in cycles/sec 204f 409^ ηγ92 **γ x , ::± — 1-28 256 5t2" 1024 " 2048"*" frequency in cycles/sec. ~409β bl92 fig. 3 probable minimum of residual hearing which can benefit from a hearing aid. a •h 0 10 20 30 40 50 60 3 70 5 80 90 100 110 120 128" —>< i, ι f: -i.... j 1 ψ—f 256 " 51t "1024 ' 2048 4096 8192 frequency in cycles/sec. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) reviewer acknowledgement open accesshttp://www.sajcd.org.za page 1 of 1 the editorial team of the south african journal of communication disorders recognises the value and importance of peer reviewers in the overall publication process – not only in shaping individual manuscripts, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank the following reviewers who participated in shaping this issue of the south african journal of communication disorders: alida ellis amisha kanji anita l. edwards anna m. wium aurellia g. bion candice r. randall daleen klop fatemah camroodien-surve heila l. jordaan jane e. herbert jeannie van der linde jenny pahl jenny perold katijah khoza-shangase kim a. coutts lebogang ramma lidia pottas lucretia petersen manne bylund meera rijhumal melissa a. bortz mershen pillay neil s. hockley nikki l. keeton olebeng o. mahura prawin kumar sharon moonsamy tracey-lee cloete ursula l. zsilavecz victor de andrade vivienne norman in an effort to facilitate the selection of appropriate peer reviewers for the south african journal of communication disorders, we ask that you take a moment to update your electronic portfolio on www.sajcd.org.za for our files, allowing us better access to your areas of interest and expertise, in order to match reviewers with submitted manuscripts. if you would like to become a reviewer, please visit the journal website and register as a reviewer. to access your details on the website, you will need to follow these steps: 1. log into the online journal at http://www. sajcd.org.za 2. in your ‘user home’ [http://www.sajcd.org. za/index.php/sajcd/user] select ‘edit my profile’ under the heading ‘my account’ and insert all relevant details, bio statement and reviewing interest. 3. it is good practice as a reviewer to update your personal details regularly to ensure contact with you throughout your professional term as reviewer to the south african journal of communication disorders. please do not hesitate to contact us if you require assistance in performing this task. publisher: publishing@aosis.co.za tel: +27 21 975 2602 fax: +27 21 975 4635 south african journal of communication disorders sajcd we appreciate the time taken to perform your review successfully. http://www.sajcd.org.za www.sajcd.org.za http://www.sajcd.org.za http://www.sajcd.org.za http://www.sajcd.org.za/index.php/sajcd/user http://www.sajcd.org.za/index.php/sajcd/user mailto:publishing@aosis.co.za tempaqplacement tempaqplacement _enref_15 _enref_21 _enref_38 _enref_43 _enref_95 _enref_101 _enref_133 _enref_142 _enref_147 _enref_158 _enref_162 _enref_163 _enref_165 _enref_173 _enref_178 _enref_192 _enref_196 _enref_202 _enref_205 _enref_219 _enref_220 _enref_263 _enref_273 _enref_274 _enref_278 _enref_283 _enref_289 _enref_298 _enref_307 _enref_323 _enref_1 _enref_2 _enref_3 _enref_4 _enref_5 _enref_6 _enref_7 _enref_8 _enref_9 _enref_10 _enref_11 _enref_12 _enref_13 _enref_14 _enref_15 _enref_16 _enref_17 _enref_18 _enref_19 _enref_20 _enref_21 _enref_22 _enref_23 _enref_24 _enref_25 _enref_26 _enref_27 _enref_28 _enref_29 _enref_30 _enref_31 _enref_32 _enref_1 _enref_2 _enref_3 _enref_4 _enref_5 _enref_6 _enref_8 _enref_9 _enref_10 _enref_11 _enref_12 _enref_13 _enref_15 _enref_16 _enref_17 _enref_18 _enref_19 _enref_20 _enref_21 _enref_22 _enref_23 _enref_24 _enref_25 _enref_26 _enref_27 _enref_28 _enref_29 _enref_30 _enref_31 _enref_32 _enref_33 _enref_34 _enref_35 abstract introduction dysphagia and covid-19: a brief overview the argument acknowledgements references about the author(s) kim a. coutts department of speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation coutts, k.a. (2020). dysphagia services in the era of covid-19: are speech-language therapists essential? south african journal of communication disorders, 67(1), a709. https://doi.org/10.4102/sajcd.v67i1.709 opinion paper dysphagia services in the era of covid-19: are speech-language therapists essential? kim a. coutts received: 08 apr. 2020; accepted: 27 june 2020; published: 29 july 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract in the era of coronavirus disease 2019 (covid-19), many healthcare professionals are being faced with the question of what is considered to be an essential service. this opinion paper has attempted to answer this complex question by understanding the potential relationship between dysphagia and covid-19 and how speech-language therapists (slts) in south africa should tackle this. it also aims to answer the question through the lens of a risk–benefit discussion based around practices and decision-making. important gaps in the field relating to how slt practices need to move forward during this challenging time have also been highlighted. reflective questions that can assist slts when seeing dysphagia cases have been provided. keywords: dysphagia; covid-19; essential services; speech language therapy; swallowing. introduction this challenging and somewhat scary era, during which we are facing the threat of the coronavirus disease 2019 (covid-19) on a daily basis, is constantly evolving. as healthcare workers, we need to respond to this by also evolving in both our thinking and practices. this pandemic is resulting in severely limited resources in all healthcare settings globally, and as a result, the roles and scopes of many professionals are being redefined. this is a complex topic with many aspects that still need to be discussed. there are also a number of critical questions that are being asked, especially amongst rehabilitation professions. this article will attempt to address one question: should dysphagia services by speech-language therapists (slts) be considered essential in this covid-19 era in the south african (sa) context? dysphagia and covid-19: a brief overview covid-19 is a novel coronavirus that impacts the functioning of the respiratory system (world health organization [who], 2020). it also appears to be severely affecting the more at-risk populations, who are considered to be the elderly (people over the age of 60 years), people with pre-existing lung conditions as well as individuals with already underlying medical conditions that have resulted in a weakened immune system (who, 2020). because covid-19 affects the respiratory system primarily, this is significant for speech-language therapists (slts), as these are patients who are at risk for also developing a dysphagia. this link will be explored below. dysphagia can lead to some significant medical consequences, including but not limited to dehydration, malnutrition, aspiration and aspiration pneumonia (abu-ghanem, chen, & milan, 2020). these factors alone can lead patients to a longer hospital stay, which has resource implications for the healthcare facility as well as an impact on the patient in terms of their well-being (martino et al., 2005). the relationship between covid-19 and dysphagia is still a new area, but there is enough understanding in the field to create links between the two. as the respiratory system is closely coordinated with the normal swallowing pattern, if a patient were to present with significant respiratory complications, the patient could be at risk of developing a dysphagia, which can result in aspiration (matsuo & palmer, 2009). if the normal breathing pattern is disrupted, the airway is potentially exposed as a result of this uncoordinated period of apnoea, which may result in inadequate airway closure (nishino, 2012). this phenomenon can be seen with the high prevalence of dysphagia in individuals with chronic obstructive pulmonary disease (copd) (scelza, greco, lopes, & de melo, 2015), for example. it is also known that patients with covid-19 often require extended periods of ventilation – for longer than 72 h – and this alone can lead to an increase in post-extubation dysphagia (ped), which is already prevalent (bhatraju et al., 2020) in these now-overcrowded intensive care units (icus). prevalent post-extubation dysphagia, if unidentified, can lead to further complications such as aspiration and aspiration pneumonia, and these will increase the patient’s length of stay in the icu as well as lead to a higher mortality rate (patel et al., 2018; perren, zürcher, & schefold, 2019). luis riquelme made a fair assumption when he stated that covid-19-positive patients with an impaired respiratory system who then present with a ped may not present typically, as this is a new disease (the role of the slp during covid 19 – youtube, 2020). these new and unknown factors are something that slts need to be aware of when assessing and managing these patients. the role of slts in identifying and managing these cases is therefore also vital. there is also evidence emerging that covid-19 patients can present with neurological deficits (mannan baig, khaleeq, ali, & syeda, 2020). the extent of these deficits is still being determined, but it is probably not a far reach to assume that a potential consequence of these neurological fallouts could be dysphagia, depending on where the site of the lesion is. the description of these neurological deficits in covid-19 patients still requires extensive investigation in all settings. in the sa population, where a vast portion of the population presents with various communicable and non-communicable diseases that impair the immune system, how covid-19 will manifest is also yet to be fully determined. these covid-19 manifestations, together with the already known diseases in the sa population, can have a further significant impact on who slts may need to treat and for what intervention in the already overcrowded, underserviced public healthcare system. in terms of dysphagia in covid-19 patients, the main consideration needs to be that the most severe consequence is an aspiration pneumonia. a patient presenting with covid-19 who either has or subsequently develops an aspiration pneumonia would then become severely ill, therefore further complicating the respiratory effects of the virus and affecting the overall recovery time. this situation needs to be prevented at all costs, especially in the sa context where access to scarce resources such as icu beds is a challenge. the argument in an attempt to shed light on the question at hand, we need to examine it from the perspective of a risk–benefit discussion. this simple framework attempts to weigh the clinical benefits of a dysphagia intervention against the possible side effects or implications that can arise from this type of contact. it can also be expected that the answer to this question would be slightly different depending on the context in which the slt is employed, for example, acute care versus long-term care or a rehabilitation setting. the benefits there are some significant medical complications associated with an untreated dysphagia (abu-ghanem et al., 2020), and the goal of early rehabilitation (including the need for an slt) in an acute setting is to decrease the potential medical complications that can arise from the dysphagia itself or as a consequence of being in these settings, such as ped. it is also to decrease the length of stay of a patient in a healthcare facility (taito et al., 2018). in the covid-19 era, when lack of availability of resources such as icu beds, ventilators and personal protective equipment (ppe) further exacerbates an existing challenge (naidoo, singh, & lalloo, 2013), this practice of early rehabilitation initiation is paramount. this article argues that slts need to be in the forefront of this pandemic in order to reduce the complications that can arise from being in an icu setting together with other rehabilitation professionals (hu, hsu, yip, jeng, & wang, 2010). in the more long-term and rehabilitation settings, the intended outcome of slt intervention still would be to prevent the serious medical sequelae of dysphagia. this intervention should still be prioritised in these settings, as the main population there are considered to be the most at risk (often elderly people with underlying medical conditions) for developing the serious sequelae of covid-19. by preventing these medical consequences of dysphagia whilst patients are still in old-age homes or rehabilitation settings, slts are preventing these patients from being admitted into hospitals, the epicentres of treatment for covid-19 patients. by identifying these patients early, these consequences and hospital visits can be avoided. however, this begs the question, does this mean that every person needs a dysphagia screening or assessment by an slt, considering that we are now in the era of social distancing and ppe scarcity? perhaps a patient risk profile needs to be developed in order to identify patients in order of priority and severity risk? the new south african speech-language-hearing association (saslha) dysphagia guidelines for covid-19 (2020) appear to also focus on this type of approach of triaging and risk identification. the need for screening and assessing all patients in this era could lead to some significant risks for both patients and slts. the risks let’s start with a broad statement about slt services generally. all slt services place the clinician at risk for airborne diseases, as our work involves functions of both the upper and lower respiratory tract – talking, breathing and swallowing. this alone is something that we as slts need to be cognisant of. that said, let us focus on dysphagia. this could arguably be the most high-risk area that an slt could be involved in, specifically in this covid-19 era. the assessment and management of dysphagia cases would involve aerosolization within close contact. the recent saslha dysphagia guidelines for covid-19 patients (2020) state specifically that oral care, cough reflex testing, implementation of videofluoroscopic swallow studies (vfss) or flexible endoscopic evaluation of swallowing (fees), interventions with tracheostomy and ventilator dependency and laryngectomy are considered risky procedures. these are potential aerosol-generating procedures (agps), and slts need to be careful when conducting them. these close-contact procedures can place both the clinician as well as the patient at risk for transmission of the virus. aerosol-generating procedures are risky for the clinician, but an slt seeing multiple patients for these agps can place the patient at risk for potential cross-contamination (rodriguez, 2020). it is best practice at this point to assume that everyone is considered positive, and all necessary precautions should be taken to avoid transmission during sessions and to avoid cross-contamination between patients who are being seen by the slt. in order to do this, the appropriate ppe needs to be used in all cases (rodriguez, 2020). herein lies one of the key conundrums that is facing all healthcare workers globally but can become a significant challenge for slts in sa. as a result of the ever-increasing number of cases that are being admitted into hospitals, there is a significant shortage of ppe in all healthcare facilities. social distancing is also now a necessity in order to avoid transmission. considering the importance of social distancing and the lack of ppe, we loop back to the question of whether slts should be changing the types of patients who are being regularly referred for dysphagia assessments in this era by implementing a triaging approach to referrals. should slts be assessing all patients for dysphagia, or do certain patients need to be prioritized based on their medical risk factors and case history? an older study by langmore et al. (1998) analysed various clinical criteria that could be used as predictive factors for patients who were at risk of developing aspiration (langmore et al., 1998). this study implies that using medical histories, more at-risk patients can be identified successfully. there have been various online discussion forums (covid era and slp dysphagia practice on apple podcasts, 2020) from the united states (us) that also suggest that certain ‘at-risk patient’ protocols are already in place at some healthcare institutions. the concept implies that prioritizing certain patients who are potentially more at risk of developing a dysphagia reduces exposure and potential transmission and requires less ppe. a suggestion for this type of criteria, as mentioned in the same online discussion forum, was that more medically unstable patients who have been referred specifically by a physician for signs and symptoms of a dysphagia, need to be prioritized. also, patients with a particular condition that is known to cause a dysphagia or patients with a history of dysphagia require more frequent monitoring. when investigating this topic, a gap emerges. there appears to be more literature around what tools are appropriate for the screening and assessment of dysphagic patients (audag, goubau, toussaint, & reychler, 2019; sassi, medeiros, zilberstein, jayanthi, & andrade, 2017) compared to what criteria can be used to identify these patients by other professionals prior to a screening or assessment by an slt. perhaps, this is an area that needs to be developed. for many slts in sa, this may require physicians to be trained more specifically on dysphagia so that they are also being more cognisant of who is considered to be at risk and therefore should be referred. because of the newness of this pandemic, data on the prevalence and description of dysphagia in covid-19 patients specifically in the sa context would be valuable here for future research trajectories. this is important to inform improved context-specific practices and policies. this question regarding the role of dysphagia assessments also becomes significant in light of the fact that ear, nose and throat (ent) doctors have essentially stopped all non-emergent (i.e. everything other than emergent airway cases) endoscopic procedures because of the high risk of transmitting covid-19 with these procedures (ent united kingdom [uk] guidelines for changes in ent during covid-19 pandemic, 2020). so, in that case, what does it indicate about the need for and access to instrumental measures for dysphagia assessments if the use of endoscopic evaluations (i.e. fees) becomes severely limited? how would this change slt assessment protocols and guidelines? another factor to consider is the use of videofluoroscopy for assessments, as the need to disinfect the equipment and the room and the risk of exposing a larger team of people for one assessment become a challenge. the saslha guidelines (2020) recommend that such assessments only be conducted when emergent and essential. again, the need for a set of criteria to identify emergent and essential patients is clear. this shift in focus regarding how and when assessments should be conducted is interesting considering that slts are functioning in a technologically driven world, where instrumental measures have become the norm and are the gold standard assessment tools (costa, 2010). this covid-19 era has once again levelled the playing field amongst slts from different parts of the world by limiting all slts’ access to instrumental measures. this has left the humble and often-overlooked clinical swallow evaluation (cse) as the primary first-line diagnostic tool. there is a significant body of research from within the dysphagia field that has firmly placed the cse predominantly as a screening tool because of its lower sensitivity and specificity (kertscher, speyer, & palmieri, 2014; lim et al., 2001; tohara, saitoh, mays, kuhlemeier, & palmer, 2003) as a result of its lack of visual input on the actual swallow anatomy and physiology. that said, this era in which slts find themselves now requires a significant shift in thinking from all slts regarding what information can actually be obtained from a cse and how slts can use it diagnostically in this acute phase to achieve assessment goals. the study by langmore et al. (1998) is a good start, as it highlights how slts can focus on other clinical data sets of the dysphagia assessment battery when needing to make acute diagnostic decisions at the bedside. adding other measures such as pulse oximetry and cervical auscultation as an adjunct to the cse could also assist this decision-making process at the bedside (bergström, svensson, & hartelius, 2014; zhou, salle, daviet, stuit, & nguyen, 2011). there is research advocating for a focus on critical thinking and how slts make decisions at the bedside with the physiological information that is readily available. what makes slts clinicians rather than merely technicians is this ability to critically evaluate and make immediate diagnostic decisions at the bedside. this process is multifaceted and based on a variety of factors such as patient and environmental factors, clinical experience and exposure, and theoretical understanding (croskerry, 2009; plowman & humbert, 2018; vose, kesneck, sunday, plowman, & humbert, 2018). this is another suggested area of focus for sa slts, especially now that we are in this era of limited access to instrumental measures. the role of the multidisciplinary team related to the need to reduce the number of contacts with patients and to limit the use of ppe is how slts can possibly draw upon other members of a multidisciplinary team to assist in the assessment and management of dysphagia cases. in sa, a multidisciplinary model appears to be the primary model used in acute care settings. this model involves each member working together as a team to achieve a goal, but generally they function independently (magnus & turkington, 2006). however, in this covid-19 era perhaps a more transdisciplinary model needs to be adopted? a transdisciplinary model involves the integration of multiple perspectives to achieve and solve complex challenges (van bewer, 2017). this is a more fluid process as to how professionals interact with the patient and each other, with certain team members picking up the responsibilities of others. perhaps slts need to draw on the assistance of nursing or physiotherapy staff in the initial phases of dysphagia assessments? there are potentially significant ethical and scope-of-practice challenges that would need to be overcome before this option would be viable, but it is something that could be considered and further researched. there have been some studies that have highlighted that a multidisciplinary team approach is possible in dysphagia care, but it requires constant monitoring and open communication (farneti & consolmagno, 2007; logemann, 1994). there is a paucity of evidence that focuses on how specifically a transdisciplinary model for dysphagia assessment and management might work, especially in settings such as the icu, but there is evidence to justify the need for early joint rehabilitation (taito et al., 2018). so, in short, yes, dysphagia services from slts are and should always be prioritized as essential services. however, it is a complex answer, as there are some significant risks associated with practising in dysphagia in this era of covid-19, and it requires some changes in thinking and practices alike. there are also significant benefits for both the patient and healthcare system from this type of intervention. in summary, slts should be doing dysphagia practices but not be practising as business as usual. the gaps and more questions thinking about how slts perform dysphagia practices in the covid-19 era and after having a basic risk–benefit discussion, there are some significant gaps that need highlighting: there is currently little dysphagia prevalence or epidemiological data available for south africa. if we are to justify why dysphagia services are essential, the necessary statistics are required to assist in this argument. this data was severely limited prior to covid-19 and is now needed even more. the sa context is unique because of its under-resourced healthcare system that serves a significant portion of the population (pre-covid19) (coovadia, jewkes, barron, sanders, & mcintyre, 2009). this pandemic can potentially only complicate this situation and place more strain on the system. the role slts can play in potentially alleviating certain pressures specifically through early rehabilitation is yet to be determined and needs to be researched. the role of the slt within the healthcare team needs to explored, and how each member can potentially change or assist in dysphagia assessments to offset these very real risks also needs to be investigated. the notion of potentially using a transdisciplinary approach is one example. considering the quadruple burden of disease that impacts on the sa patient population, the future remains unclear as to the full impact that covid19 will have on the population. speech-language therapists need to keep abreast with the latest developments and be considered as frontline healthcare workers to provide this crucial information. this data needs to be recorded for future guidelines and considerations. there is a paucity of global data that reflects what dysphagia practices are occurring in different facilities worldwide. there is some data suggesting that dysphagia practice patterns are varied (andrews & pillay, 2017; pettigrew & o’toole, 2007), which is already problematic. if slts were to change practices to suit the demands of the covid-19 era, there is currently little to no existing baseline data that we can use as a comparison to support our changes in practices. baseline efficacy studies are therefore one of the types of studies that are needed going forward. practically, during this era, slts need to advocate for their roles in high care settings and with patients who have recently required ventilation. there is currently enough data to support this argument when looking at the importance of early rehabilitation in icus and ped. speech-language therapists also need to advocate for the importance of identifying dysphagia early (in all settings) so as to avoid unnecessary hospital visits or longer hospital stays. the types of patients who potentially need to be prioritised and who screens these patients are questions that still need answering. speech-language therapists need to develop criteria-based tools to identify those patients who are most at risk. perhaps training of other professionals is also important for this. the role of telerehabilitation specifically for dysphagia management needs to be investigated. this is important as it may offset some of the risks that have been identified. the limitation of access in the sa context does need to be considered, but this does not necessarily rule it out as an option entirely. the current decision-making processes of slts during this covid-19 era and how this links to the evidence-based practice (ebp) model needs to be investigated. the ebp model includes three arms: clinical knowledge, data from the field and patient/contextual factors (asha, 2012). there is a need to explore how slts are using their clinical expertise, together with existing dysphagia data and with the current tools at their disposal, to negotiate and conduct dysphagia services in this challenging time across different settings in sa specifically. the point raised earlier on the critical use of the cse and the decision-making process around this, specifically in the sa context, is something that needs to be potentially relooked at and engaged with. in light of the discussion brought forward, here are some reflective questions that a slt could use during the covid-19 era: what are my institutional guidelines and policies currently in place regarding essential services? what is my current clinical expertise in response to my patients’ needs and contextual circumstances? is my intervention medically warranted for this patient at this stage (risk versus benefit)? in conclusion, this is an evolving situation, both in terms of the virus itself, how the patient population is presenting and slt needs and practices. there are currently more questions than answers, but the hope is that this article has started a much-needed conversation and some thinking about how we as a profession can start to address these ever-emerging gaps and questions during this pandemic. acknowledgements competing interests the authors have declared that no competing interest exist. author’s contributions i declare that i am the sole author of this research article. ethical consideration the author confirmed that no ethical clearance was required for the writing of this article. funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references abu-ghanem, s., chen, s., & milan, i. 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(2018). a survey of clinician decision making when identifying swallowing impairments and determining treatment. journal of speech, language, and hearing research, 61(11), 2735–2756. https://doi.org/10.1044/2018_jslhr-s-17-0212 who. (2020). coronavirus. retrieved from https://www.who.int/health-topics/coronavirus#tab=tab_1 zhou, z., salle, j.-y., daviet, j.-c., stuit, a., & nguyen, c. (2011). combined approach in bedside assessment of aspiration risk post stroke: pass. european journal of physical and rehabilitation medicine, 47(3), 441–446. article information authors: selvarani moodley1 claudine storbeck1 affiliations: 1centre for deaf studies, university of the witwatersrand, south africa correspondence to: selvarani moodley email: selvarani.moodley@wits.ac.za postal address: private bag x3, wits 2050, south africa dates: received: 23 mar. 2015 accepted: 26 sept. 2015 published: 27 nov. 2015 how to cite this article: moodley, s., & storbeck, c. (2015). narrative review of ehdi in south africa. south african journal of communication disorders, 62(1), art. #126, 10 pages. http://dx.doi.org/10.4102/sajcd.v62i1.126 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. narrative review of ehdi in south africa in this original research... open access • abstract • introduction • research methodology    • research design    • data collection    • data analysis       • results • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references • appendix abstract top ↑ background: with 17 babies born with hearing loss every day in south africa, there is a pressing need for systematic early hearing detection and intervention (ehdi) services. progress is being made in offering newborn hearing screening and studies have been conducted to document these processes within south africa. however, due to the lack of a national and holistic overview of ehdi services to date, an accurate picture of the current status of ehdi within the south african context is required. objective: to document and profile what has been published within the field of ehdi in south africa over the last two decades (jan 1995–sept 2014) in order to gain a comprehensive overview of the current status and practice of screening and diagnosis in the field of paediatric hearing loss. method: a narrative review of peer-reviewed articles related to ehdi in south africa was conducted by searching the ebscohost, scopus and jstor databases for the period january 1995 to september 2014. results: results indicate that over the last two decades research and publications in the field of ehdi have increased considerably. these publications have revealed extensive knowledge related to paediatric hearing screening and intervention services in south africa; however, this knowledge seems to be limited primarily to the provinces of gauteng and the western cape. furthermore, studies pertaining to diagnosis have revealed that, although much has been written on the scientific aspects on tools for diagnosis of hearing loss, there is a lack of comprehensive information on diagnostic protocols and procedures. conclusion: despite the clear progress being made in south africa in the field of early hearing detection and intervention, there is a need for comprehensive studies on protocols and procedures in diagnosing paediatric hearing loss. finally, the narrative review revealed a clear need to ensure that development and growth in the field of ehdi is a national priority and extends beyond the two provinces currently showing growth. introduction top ↑ south africa is estimated to have 16–17 babies with hearing loss born daily (swanepoel, 2008) and despite having no legislation in place, awareness of the importance of early detection of hearing loss, followed by appropriate intervention, is growing. early hearing detection and intervention (ehdi) describes the pathway from infant screening for hearing loss to the subsequent process of diagnosis and intervention. in response to the international drive for effective and early ehdi programmes, the health professions council of south africa (hpcsa) published a position statement in 2007. this statement describes internationally benchmarked indicators of screening at birth, amplification by three months and enrolment in early intervention by six months of age (as published in joint committee on infant hearing [jcih], 2007) and then provides the south african benchmarks of screening by four months, appropriate amplification by six months and enrolment in an early intervention programme by no later than eight months of age (health professions council of south africa [hpcsa], 2007). universal newborn hearing screening and the subsequent early diagnosis of infant hearing loss is a new practice in south africa when compared to international progress. in the usa as early as 1965, health, education and welfare departments recommended universal evaluation of hearing loss on a national level. hearing screening has since become universal in the usa (every newborn is offered the option of having a hearing screening), with only 5% of newborns not having their hearing screened (eiserman et al., 2008). although there is a system in place to ensure newborn hearing screening in the usa, the system is complex. screening occurs at the birth hospital, rescreening at a different outpatient facility, referral to an otorhinolaryngologist for amplification and referral to early intervention services (russ, hanna, desgeorges & forsman, 2010). quality management, which includes record keeping and reporting to ensure a seamless transition from screening to diagnosis to intervention, is ensured through a good data management system (finitzo & grosse, 2003). in the united kingdom (uk), hearing screening forms part of their general screening regimen and is preceded by screening procedures for medical disorders such as haemoglobin disorders, metabolic disorders and neurogenetic disorders. by 2004, as part of the universal newborn hearing screening programme in england, between 90% and 94% of mothers had been offered hearing screening for their newborn (bamford, uus & davis, 2005). prior to implementation of universal hearing screening in the uk, studies were conducted on the likely impact of screening on paediatric audiology services. the readiness of paediatric audiology services to deal with referrals from newborn hearing screening and the proficiency of audiologists in the accurate diagnosis of and intervention for paediatric hearing loss were determined (uus, bamford, young & mccracken, 2005). these studies informed the feasibility of the screening programmes as well as the training needs of audiologists involved in paediatric audiology screening and diagnosis. it also informed the development of guidelines for screening and diagnosis. the implementation of effective hearing screening programmes as outlined in developed countries requires numerous resources and financial investment a number of conceptual and research articles have recognised the impracticalities inherent in attempting to implement developed world models of hearing screening in a developing country (swanepoel, delport & swart, 2004; swanepoel, hugo & louw, 2005a), and recommendations highlighted the need for further research in the areas of using alternative screening forums (swanepoel, hugo & louw, 2005b, 2006) for effective implementation of universal newborn hearing screening (unhs) in south africa. although numerous screening programmes have been implemented in hospitals and local south african communities, research to report on the outcomes are isolated and broader studies describing a collated overview of the general knowledge base and status of ehdi in south africa are missing. furthermore, areas in which there are gaps in knowledge have not been systematically presented nor has there been an outlining of strengths and weaknesses of ehdi systems and identification of areas where additional research is necessary. a review of published studies on ehdi in south africa was therefore needed to gain a comprehensive understanding of the current practice and status of newborn screening and diagnosis of paediatric hearing loss. research methodology top ↑ research design this study, whilst sharing much in common with the systematic review in terms of an academic database search with clear parameters (liberati et al., 2009), is descriptive rather than evaluative and therefore a narrative review. the overall aim of a narrative review is to ‘tell the story’ and thus provide an overall description of the current knowledge base and national activity within the field of ehdi as evidenced in the published research. in telling the story about the publications, the aims of this narrative review are: to detail the number of peer-reviewed papers on ehdi in south africa from january 1995 to september 2014 and to classify the articles according to type of publication: a conceptual or research article or a letter to the editor. to describe the main and secondary focus of each paper in order to get an overview of the work that has been done in the field within this time-frame. to outline the chronological progress within the field of early hearing detection and intervention over the period of twenty years, january 1995 to september 2014. data collection an electronic academic-database search of ebscohost, scopus and jstor databases was conducted using a combination of search terms related to the general ehdi topics of screening and diagnosis of paediatric hearing loss in south africa. the two search parameters required that all the articles had to be peer-reviewed – thereby excluding theses and dissertations – and published between january 1995 and september 2014 (table 1). table 1: description of the search results identifying articles for the narrative review. of the 759 articles identified using the search terms across the three databases as noted above, 83 were identified as duplicates. the remaining 676 articles were examined for relevance and 635 were omitted as being irrelevant. an additional six were omitted as they were published before 1995. the 35 remaining articles were studied and reference lists were reviewed in order to identify any additional relevant articles, from which eight were identified. a final total of 43 peer-reviewed articles were included in the narrative review. masters and phd dissertations, as well as the hpcsa position statement were excluded from the review, as they are not peer-reviewed academic articles. data analysis articles were classified according to: (1) type of publication, whether it was conceptual, editorial or a research paper; (2) year of publication in order to determine chronological progression of ehdi in south africa; and (3) primary and secondary focus of the publication. if the majority of the article related to a specific area, it was classed as the primary focus. if some reference was made to a specific area, but was not the main topic, it was classed as the secondary focus. results 43 peer-reviewed articles were identified in the field of ehdi in south africa for the period january 1995 to september 2014. these included 15 conceptual articles, 26 research articles and two letters to journal editors. in classifying the papers by their primary and secondary areas of focus, the following four categories arose: (1) screening, which includes the process and forum for identification of hearing loss; (2) diagnosis, which involves the comprehensive testing and classification of the hearing loss; (3) intervention, which refers to the fitting of amplification and referral to early intervention services and (4) data management, which includes reference to the follow-up and referral network. a summary of the 43 papers can be found in appendix a. the analysis revealed that almost 60% (n = 24) of the papers focused on screening as their primary focus and just under 30% (n = 11) focused on diagnosis, whilst the remaining six focused on intervention (n = 5) and data management respectively (n = 1). two articles (swanepoel, 2006; swanepoel & störbeck, 2008) could not be classified into one of the four areas, as one was an article describing the profession of audiology and the other was an overview article describing ehdi knowledge (table 2). table 2: area of focus for articles included in narrative review. when considering the chronological pattern that emerged over the 20 years of publications, the research increased considerably over time (see figure 1), with the first 8 years (1995 – 2002) showing no empirical research, the second eight-year period (2004 – 2011) showing a growth in conceptual papers and research papers with the largest growth in research occurring in the last 3 years (2012 – 2014). figure 1: the chronological pattern. note: article type (n=43) the period of 1995–2002 showed minimal focus on the area of ehdi, with just two publications: one being a letter to the journal editor discussing the feasibility of introducing universal newborn hearing screening in south africa (1995) and the other being a conceptual article discussing the auditory steady state response (assr) as a tool for diagnosis of paediatric hearing loss. more conceptual than research articles were published between 2004 and 2007. the focus of these articles was mainly on hearing screening forums and the importance of early identification and intervention for paediatric hearing loss. in 2008 a number of research articles dedicated to the proceedings of the first ehdi in africa conference (held in 2007) was published in a special edition of the international journal of audiology. between 2009 and 2010 the focus of the articles then shifted to a summary of the current status of edhi services in south africa and the introduction of a pilot screening programme implemented in one province of south africa. the 2011–2014 period focused on alternative screening forums as well as retrospective reviews of audiology records to determine current practice. discussion top ↑ the 43 articles included in the narrative review will be discussed chronologically, with reference to specific themes within each time period. it is only in the new millennium (2000 onwards) that research in the field of ehdi has shown considerable growth in south africa with studies in the specific areas of screening and early intervention. in 1993, the us national institute of health (nih) conference addressed the issue of late identification of hearing loss and made the recommendation of universal newborn hearing screening (nih consensus statement, 1993). this led to a meeting at the departments of otolaryngology, logopaedics and neonatal paediatrics at the university of cape town in south africa. the conclusion of this meeting was that unhs in south africa was not feasible due to the lack of proof of effectiveness of hearing screening and the workload impracticality (prescott, 1995). further research in this area then showed a decline until 2002, when general scientific research to determine the effectiveness of the assr in diagnosis of hearing loss in infants was conducted by south african authors (swanepoel, schmulian & hugo, 2002). the year 2004 also saw the importance of early identification and intervention for paediatric hearing loss being well recognised, with five conceptual articles (swanepoel, 2006; swanepoel, delport & swart, 2007; swanepoel, delport et al., 2004; swanepoel, louw & hugo, 2007; swanepoel et al., 2005a) and seven research articles relating to this topic published between 2004 and 2007. research during this period focused mainly on the use of immunisation and maternal health clinics as forums for screening of hearing loss in infants (olusanya & okolo, 2006; swanepoel, 2006; swanepoel, hugo & louw, 2004; swanepoel et al., 2005b, 2006; swanepoel, louw et al., 2007), screening uptake at a private healthcare clinic (swanepoel, ebrahim, joseph & friedland, 2007) and one article focusing on the generic topic of the assr being a reliable measure of threshold estimation for children with severe to profound hearing loss (swanepoel et al., 2002). initial research in the field of ehdi from 2002 to 2007 focused mainly on an alternative screening forum that could be used in public health and the uptake of the offer for newborn hearing screening in private health. the use of screening methods, diagnostic data specific to south african practice and data management were gap areas in the research. the areas of research and south african specific knowledge in the field of ehdi were highlighted when the first ehdi africa conference was held in south africa in 2007. a special supplement of the international journal of audiology (ija) was dedicated to the publishing of proceedings from conference presentations. the introductory editorial article (swanepoel & störbeck, 2008) highlighted the increased concern and advocacy on the topic of paediatric hearing loss and ehdi on the african continent. important findings from research in this special ija supplement in terms of audiology included the lack of resources and personnel, as well as the need for resources and training in implementation of screening in the public health sector (theunissen & swanepoel, 2008), and in the fitting of paediatric amplification (strauss & van dijk, 2008). the importance of the parents in the ehdi process and the role of the audiologist in providing on-going support and guidance (swanepoel & almec, 2008; van der spuy & pottas, 2008), as well as the need to focus beyond screening and consider the importance of cultural, linguistic and accessibility factors in intervention (störbeck & pittman, 2008), was also addressed. additional articles during this period focused on the scientific aspects of using the assr in the diagnosis of hearing loss (swanepoel & ebrahim, 2009; swanepoel, ebrahim, friedland, swanepoel & pottas, 2008) and were not based on issues related specifically to the south african context. this period of research showed an expansion of earlier research in that there was a consideration of contextual factors related to staffing in the public health sector, the role of the audiologist in fitting of amplification as well as providing support. this included the importance of culture, linguistics and access to services in early intervention. however, there was still a lack of a focus on screening methods and effectiveness, south african specific diagnostic practice and data management. the period of 2009–2010 produced a number of conceptual/review articles relating to the implementation of newborn hearing screening, early intervention and the importance of a follow-up referral network (copley & friderichs, 2010; pillay, moonsamy & khoza-shangase, 2010; swanepoel, 2009; swanepoel, störbeck & friedland, 2009). research topics during this period focused on targeted screening and follow-up (kanji, khoza-shangase & ballot, 2010) and audiological management following meningitis (khoza-shangase & rifkind, 2010). the need for screening and diagnostic protocols for children with a high risk of acquired hearing loss due to illnesses such as meningitis is unique to the african situation. conclusions included the need for improved knowledge of hearing screening and early intervention among professionals as well as parents (kanji et al., 2010; khoza-shangase, barratt & jonosky, 2010). this highlights the importance of focused studies taking into account all aspects of the situation in africa, including the professional knowledge of all specialists involved in the ehdi process, as well as the impact of ear infections and illnesses such as meningitis on acquired hearing loss. data management and cross-disciplinary diagnostic data are clearly lacking in south african studies within the time period of the review. studies up until the 2009–2010 period focused mainly on the public healthcare sector, and thus provided little indication of ehdi services available to the 15% of the population that use private healthcare services. in 2011 and 2012 a survey of hearing screening practice in the private healthcare sector was conducted on a national level (meyer & swanepoel, 2011; meyer, swanepoel, le roux & van der linde, 2012). the inadequacy of hearing screening services in the private healthcare sector, the need to improve knowledge of hearing screening among professionals, as well as the need for a centralised data management and follow-up system was highlighted. in the public sector, a pilot screening programme using nurses as screening personnel in clinics in a single province of south africa, the western cape, was implemented (friderichs, swanepoel & hall, 2012). conclusions from this programme were that follow-up is improved if there is a dedicated ehdi coordinator, and that screening coverage rates could be improved if screening was implemented at midwife obstetric units. the conceptual article outlining the many roles nurses can play in the ehdi process (moodley & störbeck, 2012) was contradicted by the pilot screening programme findings that for successful implementation of unhs there needs to be dedicated ehdi personnel (friderichs et al., 2012). this was further corroborated by a study in another province (gauteng), where it was found that nurses do not adhere to documenting and recording screening protocols as proposed by the national department of health (joubert & casoojee, 2013). whilst these studies acknowledge data management and follow-up as important factors, there is limited focus on the use of data management systems within the south african context. the use of midwife obstetric units (mous) as alternative screening forums is advancement on the studies earlier in the decade relating to the use of alternative screening forums. however, screening methods and the effectiveness related to this is an area that has still not been extensively studied. until this period, south african specific diagnostic data and practice has not been researched. more recent research activities (from 2012) have focused on retrospective and, less commonly, prospective review of audiology records. the prospective studies focused on using audiology records to determine the impact of risk factors for hearing loss in low birth-weight babies (kanji & khoza-shangase, 2012) and a study of children with serous otitis media in one province (tiedt et al., 2013). findings from these studies correlated with previous findings of the late identification of hearing loss, audiology staff shortage, as well as that south african context specific risk factors should be developed if targeted screening is to be used for early identification of hearing loss. for targeted screening to be successful it is important for parents and healthcare professionals to recognise risk factors and that these children have access to hearing screening. following findings that parent knowledge of hearing loss is poor, research conducted indicated that a contributing factor is the poor quality and readability of information pamphlets (joubert & githinji, 2014) and that parents refuse screening due to costs, as well as a lack of knowledge of the importance of hearing screening (swanepoel, scheepers & le roux, 2014). whilst the focus of studies has moved on to investigate parent knowledge of hearing loss and screening and factors related to this, the main focus remains on screening of hearing loss. even within the review of audiology records, there is a lack of comprehensive information on the process of diagnosing paediatric hearing loss in south africa. studies following from screening to diagnosis, and the outlining of research related to diagnostic procedures and protocols, have only recently been conducted internationally (larsen, munoz, desgeorges, nelson & kennedy, 2012; munoz, nelson, goldgewicht & odell, 2011). south african specific information related to diagnosis within the 2013/2014 period included two studies of retrospective audiology record analysis (khoza-shangase & michal, 2014; swanepoel, johl & pienaar, 2013). whilst both these studies provide important initial information on diagnostic procedures, swanepoel et al. (2013) focused on types of hearing loss related to risk factors and the diagnosis of auditory neuropathy spectrum disorder in a university clinic, whilst khoza-shangase and michal (2014) focused on types of hearing loss, age of identification, amplification, intervention and a brief summary of diagnostic audiological evaluation in south african state hospitals. neither of these studies provided an understanding of the process followed in diagnosis of type and level of paediatric hearing loss so as to allow for the progression to the next steps of ehdi, namely early intervention services and amplification. previous south african studies related to diagnosis have focused on using the abr and assr for the diagnosis of severe to profound hearing loss (swanepoel & ebrahim, 2009; swanepoel, hugo & roode, 2004; swanepoel et al., 2002), age of diagnosis of hearing loss in south africa (butler et al., 2013; van der spuy & pottas, 2008), reports on diagnosis of hearing loss in state hospitals (swanepoel, 2008) and protocols for audiological management following meningitis (khoza-shangase & rifkind, 2010). a study on audiology equipment and protocols used for paediatric assessment and hearing aid fitting highlighted the lack of both equipment as well as evidence-based guidelines for assessment in south africa (teixeira & joubert, 2014). developed countries have focused on putting policies and procedures in place to ensure early detection of childhood hearing loss and prompt initiation of early intervention services. screening has become a standard of care, with studies on diagnosis being conducted to improve the diagnostic process. there is agreement on the need for standardisation and improvement of diagnostic services across developed countries. the south african journey of research into ehdi services from 1995–2014 highlights the progress made in outlining the implementation of paediatric hearing screening services in a developing world context. the need for education of parents and professionals on the importance of early screening, the practical aspects of implementing screening programmes and the importance of south african specific risk factors being recognised was clearly highlighted. after the period of the review end date (september 2014) a further three articles were published in the field of ehdi in south africa. one article focused on procedures and protocols for hearing screening at immunisation clinics in two south african provinces (petrocchi-bartal & khoza-shangase, 2014) whilst the other two focused on diagnosis and intervention for paediatric hearing loss (le roux, swanepoel, louw, vinck & tshifularo, 2015; stroebel & swanepoel, 2014). one focused on the parental experience of the diagnostic process for children with auditory neuropathy (stroebel & swanepoel, 2014) and the other focused on the risk profile and a summary of diagnostic procedures for children receiving cochlear implants (le roux et al., 2015). comprehensive research and evaluation of paediatric diagnostic audiology services and the procedures to be followed in the diagnosis of paediatric hearing loss in south africa has emerged as a gap in the field. the use of tools such as the assr for diagnosis of paediatric hearing loss is an area of scientific knowledge for south africa. however, comprehensive studies on diagnosis of paediatric hearing loss are lacking. the use of diagnostic tools and how they relate to the use of evidence-based guidelines for diagnosis of paediatric hearing loss, as well as the development of south african specific diagnostic guidelines (as was the case for recognition of the need for south african specific risk factors for screening), are areas for development and expansion. an area of strength in ehdi research in south africa is inclusive information on implementation of screening at different forums within the public and private healthcare sectors. the progress in development of south african specific risk factors with targeted screening as an option, as well as the need for the education of parents and professionals on the importance of hearing screening is clearly laid out. whilst there is an acknowledgement of staff and equipment shortage for implementation of screening in the public health sector, there is not as much comprehensive information on the private health sector. an area that is also lacking is one that focuses on screening methods used and the effectiveness thereof. related to this is what seems to be a lack of prioritisation of data management in the south african context, as few studies related to data management have been conducted limitations of this study include the fact that, as a narrative review, the study did not consider qualitative aspects of the research such as study sample or size, nor did it evaluate the research for possible bias or weakness in the individual studies. additionally, the search, though exhaustive, did not include an independent researcher for verification. conclusion top ↑ south africa has taken many strides in growing the knowledge base of the field of ehdi, and has recognised and tried to overcome challenges in the implementation of ehdi services by researching and identifying alternative forums for screening, parent reasons for refusing screening and the availability of early intervention services. however, studies are mainly conducted in, and related to the context within, the gauteng and western cape provinces of south africa. additionally, a large portion of the research is mainly focused on the screening process, with some studies into the usefulness of assr as a diagnostic tool and record reviews related to diagnostic procedures. the research has shown that south africa lacks a nationally agreed battery of tests and protocols for diagnosing hearing loss for infants and babies, and although a draft document on diagnostic guidelines for the paediatric population has been released for comment by the hpcsa, (swanepoel, 2012), no process has yet been put into place to take it further. in addition, the current practice of audiologists in the diagnosis of paediatric hearing loss has not been fully explored or documented. since accurate diagnosis is necessary for appropriate amplification and intervention and screening has been the primary focus to date, there is a need for studies focusing on the diagnostic process. the development of diagnostic practice guidelines appropriate for use in a developing country context will go a long way towards improving the ehdi process in africa. studies looking at the development of universal screening, diagnosis and intervention across both the public and private healthcare systems will provide much needed information on all aspects of ehdi in a developing world context. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions this article is a write-up of part of s.m.'s (university of the witwatersrand) phd., with c.s. 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(2008). infant hearing loss in south africa: age of intervention and parental needs for support. international journal of audiology, 47(suppl. 1), s30–s35. pmid: 18781511, http://dx.doi.org/10.1080/14992020802286210 appendix top ↑ appendix 1: database and search strategy details appendix 2: summary of articles included in review abstract introduction methods results discussion conclusion and recommendations acknowledgements references about the author(s) liepollo ntlhakana department of speech pathology and audiology, university of the witwatersrand, johannesburg, south africa angie heliopoulos department of speech pathology and audiology, university of the witwatersrand, johannesburg, south africa citation ntlhakana, l., & heliopoulos, a. (2020). the hearing function of sound engineers: a hearing conservation perspective. south african journal of communication disorders, 67(1), a638. https://doi.org/10.4102/sajcd.v67i1.638 original research the hearing function of sound engineers: a hearing conservation perspective liepollo ntlhakana, angie heliopoulos received: 02 may 2019; accepted: 21 jan. 2020; published: 28 apr. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: occupational activities performed by sound engineers are associated with hearing loss. however, there is a dearth of research on the hearing functions and the related hearing loss for sound engineers. objectives: to determine the hearing function and early effects of noise on the hearing ability of sound engineers, and to establish whether there are hearing conservation programmes (hcps) available for sound engineer participants in johannesburg. methods: a quantitative cross-sectional design was used. eight sound engineers from the academy of sound engineering (ase) participated in the study. the following data were collected from the participants: case history data, ear-related symptoms and hearing conservation data. hearing screening followed by full diagnostic audiological assessments was conducted for each participant. descriptive statistics and one-sample t-test were used to analyse the data (confidence interval [ci] = 95%). results: participants reported tinnitus and aural fullness as common complaints. only one participant had a unilateral impacted cerumen. all the participants presented with hearing within normal limits bilaterally, with a percentage loss of hearing (plh) of 1.1% for all the participants. however, five participants presented with a notched configuration that was ≥ 10 decibel (db), in the high frequency region at 3000 hz and 6000 hz bilaterally. one-sample t-test (p = 0.001) inferred that at a mean age of 27.6 years (standard deviation [sd] = 3.85), a notch at 3000 hz and 6000 hz was associated with an early sign of a hearing loss for the study participants. an hcp was not in place at the study site. conclusion: the study indicated a younger age as an associated early sign of noise-induced hearing loss (nihl) for the study participants, and that audiologists’ clinical practice needs to explore hcp strategies specific for the sound engineers in order to prevent hearing loss. keywords: noise-induced hearing loss; hearing conservation programmes; hearing protection devices, sound engineers, decibels. introduction hearing loss because of a prolonged exposure to loud music emulates signs of noise-induced hearing loss (nihl) in the organ of corti (rabinowitz, 2000). noise-induced hearing loss can be defined as hearing loss caused by continuous or intermittent noise exposure, which may develop slowly over several years (kirchner et al., 2012). this type of hearing loss is sensori-neural in nature and is preventable (rabinowitz, 2000; world health organization [who], 2010). on a plotted audiogram, nihl is typically recognised with a ‘notched’ configuration usually seen around 4000 hertz (hz) in the region of 3000 hz – 6000 hz (feuerstein, 2009; rabinowitz, 2000). in south africa, hearing conservation policies exist in order to reduce noise exposure levels to below 85 decibel a (dba) averaged over an 8h period and prevent nihl (south african national standards [sans], 2013). noise-induced hearing loss is an irreversible and a permanent type of hearing loss, which is also associated with tinnitus and aural fullness. because of the nature of nihl, affected individuals are unaware of the deterioration in their hearing acuity and only realise the problem when they have a hearing loss (cruz, 2005). the world health organization has provided a list of professionals at risk of developing nihl, and professionals in the music industry appear in this list as well. sound engineers’ professional work relies strictly on their hearing acuity as they integrate separate sounds to formulate one sound (sokanu, 2018). they are involved in mixing, producing, recording and adjusting sounds together for television (tv) advertisements; they also work with radio station transmissions, musical groups in recording studios and live events. some of the tools that sound engineers work with include microphones, speakers, recorders and amplifiers (hynes, 2007). the work environment and tools used by sound engineers emit high levels of noise, increasing susceptibility to hearing loss (careerexplorer, 2018). early identification and prevention of hearing loss for sound engineers is important (marshall, 2018). therefore, a need to monitor their hearing function within a hearing conservation programme (hcp) is imperative. in a study from 1997 to 2000 conducted by cruz and potthoff (2005), the following audio industry professionals – the audio engineering society, the national sound contractors’ association, the national association of music merchandisers and lighting design international – all reported hearing within limits following hearing screening assessment. although the participants presented with hearing screening results within normal limits as indicated on the pure-tone audiogram, a notch in the 3000 hz – 6000 hz frequency range was evident, which indicated an early sign of nihl (rabinowitz, 2000). thus, the researchers highlighted the importance of continuous hearing screening for the prevention of nihl. for a profession that relies heavily on the use of ears, there is no mention of hcps integrated in the training of sound engineers (academy of sound engineering, 2019). this results in professionals continuously displaying early signs of nihl. furthermore, research on the hearing functions and effects of noise exposure on audio engineering professionals remains scarce (bulla, 2003). in south africa, there are several studies that exist on hearing and the harmful effects of working in a noisy environment (chamber of mines, 2016; de jager, 2017; edwards, dekker, franz, van dyk, & banyini, 2011; edwards, malanzi, khoza, & zungu, 2015). however, the focus has been placed on the regulated mining and construction industries (balfour-kaipa, 2014; chung, 2007). this could be influenced by factors such as contribution to the country’s workforce and the financial contributions made by these industries towards the country’s gross domestic product (gdp). sound engineering does not feature on the gdp list provided by the statistics south africa reports; yet risks related to sound engineers’ occupation need to be monitored and addressed. there are audiological implications for this professional group; therefore, hcps guided by audiologists need to be considered for purposes of early identification and monitoring of nihl together with prevention. methods aim the purpose of this study was to determine the hearing function of sound engineers and to establish if hcps were in place at the sound engineers’ academy in johannesburg, south africa. objectives the objectives of this article were: (1) to determine the sound engineers’ hearing status and (2) to establish an hcp followed by the sound engineers’ academy. research design a quantitative, cross-sectional research design was used for this study. the researchers conducted audiometry assessments and established if the study site had an hcp available in place. quantitative data were obtained from the participants’ audiometry results. in order to address the study’s aim, all the data obtained were analysed quantitatively. study sample a non-probability purposive sampling method was used for the selection of participants. the study sample included eight sound engineering lecturers employed at the academy of sound engineering (ase) in johannesburg. the mean age of the participants was 28 years (standard deviation [sd] = 3.85 years), with only one participant above the age of 30 years. six were white participants and seven were male participants. the recorded years of experience within the sample ranged between 3 and 16 years, with the majority (n = 7) of participants having worked for less than 10 years. the mean duration of noise exposure per day (in hours) was 6 h. table 1 shows the participants’ demographic information. the sample had only one female participant. table 1: demographics of the study participants (n = 8). data collection data collected for case history information were based on a self-developed and administered questionnaire. questions included signs and symptoms of hearing loss, medical and family history, occupational and recreational history. additional data collected included hearing screening and diagnostic audiology assessment results. the audiometric protocol included otoscopic examination, immittance audiometry, pure-tone hearing screening and distortion product oto-acoustic emissions (dpoaes). diagnostic audiometry included additional tests for speech audiometry. hearing screening and diagnostic audiometry were conducted 1 week apart from one another to resolve existing middle ear pathologies. assessment tools were calibrated and calibration certificates were valid at the time of data collection. data collection procedures and tools testing for hearing screening and diagnostic audiometry was performed at the university audiology clinic. results obtained from all assessment tests were interpreted by the researchers in order to confirm the participants’ hearing function. cross-check principle for the audiometric test battery was maintained. the two audiologists cross-checked each other’s audiological findings. all tested frequencies were repeated twice and correlated with other audiological results obtained. hearing screening was conducted initially, followed by diagnostic audiometry (see table 2). table 2: equipment used and procedures followed in the current study. ethical consideration prior to data collection, the researcher obtained permission from the director of the ase to conduct the study. then, individual participants were approached for participation in the study, where verbal consent and written informed consent were obtained from all the participants prior to screening and diagnostic testing. ethical clearance was obtained from the university ethics committee at the university of the witwatersrand (non-medical ethics number: sta_2016_11). the study adhered to all ethical considerations set out by the declaration of helsinki, revised in 2013 (the helsinki declaration of the world medical association [wma] 2014). data analysis data obtained were captured on microsoft excel spreadsheet and were later represented into frequency tables and graphs. one-sample t-test was used to establish the relationship between age and an increased intensity (higher decibels) in the high frequencies. p-value was calculated at 95% for this finding in order to confirm the statistical significance. results responses for this section were obtained from the self-developed and administered case history questionnaire, hearing screening and diagnostic audiology findings. the case history questionnaire provided data on the participants’ reported symptoms associated with hearing loss. figure 1 illustrates the participants’ case history information associated with hearing loss. three participants reported a history of middle ear infections. of those three, two participants reported recurrent middle ear infections during childhood, and one participant reported to have experienced a last time middle ear infection in 2011 which was treated with antibiotics. figure 1: study participants’ symptomatology. three participants reported a continuous high-pitched tinnitus throughout the day and night, especially following a work shift where they were exposed to loud music or sounds. there were five participants who stated they did not experience continuous tinnitus, but rather reported only experiencing tinnitus following a live event, which faded when resting the ears in a quiet environment. three participants reported experiencing a fluctuating aural fullness following a prolonged exposure to loud sounds, but said that aural fullness disappeared the next morning. participants’ previous hearing history five participants reported that they had hearing screening conducted before joining ase. three participants reported that they have never had their ears tested before. the participants (n = 8) reported that they have never undergone diagnostic audiological assessment before. participants’ recreational noise exposure history seven participants reported that they were involved in the types of hobbies as listed in figure 2. six participants stated that they often attended musical events such as live concerts and music festivals during their spare time. one participant reported that he enjoyed extremely loud music. figure 2: recreational noise exposure. participants’ hearing function the results presented in this section were participants’ hearing function that was determined from hearing screening and diagnostic audiometry findings. hearing screening results table 3 illustrates the findings obtained from all eight participants, all presented with hearing within normal limits bilaterally. during otoscopic examination, half (n = 4) of the participants presented with impacted cerumen and a dull tympanic membrane. abnormal middle ear pressure and compliance were obtained from six participants. table 3: hearing screening results (n = 8). a ‘pass’ result in pure-tone hearing screening was obtained for all the participants (roeser, valente, & hosford-dunn, 2007). distortion product oto-acoustic emission results indicated a ‘pass’ result at all the frequencies tested, bilaterally, for all the participants. diagnostic audiometry results table 4 and figure 3 show diagnostic audiometry findings for all the participants. impacted cerumen was observed in one participant, and all the participants presented with normal otoscopic examination results as well as normal middle ear pressure and compliance. three participants presented with absent acoustic reflexes bilaterally. diagnostic audiometry findings from pure-tone audiometry correlated with speech audiometry and indicated hearing within normal limits bilaterally for all the participants. lastly, oto-acoustic emissions were present for all the participants. figure 3: configuration of participants’ audiograms. table 4: results from diagnostic audiological testing (n = 16 ears) figure 3 illustrates pure-tone audiometry findings for all the participants (n = 8). only three participants (p1, p5 and p6) did not present with a notch of ≥10 db, in the region between 3000 hz and 6000 hz frequency. five participants’ audiograms indicated a notched configuration in the high frequencies from 3000 hz (n = 2) and 6000 hz (n = 3), with the greatest decrease in hearing thresholds obtained at 15 db (6000 hz). the percentage loss of hearing (plh) was calculated bilaterally using 500 hz, 1000 hz, 2000 hz, 3000 hz and 4000 hz frequencies. all eight participants obtained 1.1% plh value. for the five participants with increased thresholds at 3000 hz and 6000 hz, a t-value of 17.6 and p-value of 0.001 inferred that at a mean age of 27.6 years (sd = 3.85), there was evidence that at high frequencies of 3000 hz – 6000 hz, an increased intensity (notch) would be obtained 95% of the time for these participants. hearing conservation programme the participants only reported the use of hearing protection devices (hpds) for hearing loss prevention. six participants reported wearing hpds every time they were working at live concerts. the other two participants reported that they avoided wearing earplugs consistently, as this limited their range of hearing music whilst at work. the issue of cost was raised by one participant who indicated that the replacement cost of earplugs was expensive. disposable earplugs were reported as the most common type of hpds used. results from the study indicated that only four participants knew about nihl. they knew about the effects of noise on the auditory system and they had been educated on the use of hpds as a preventative measure for nihl. discussion the south african sound engineering population is small and dominated by white men. our study sample was small but had more white men (n = 6). our sample was also small when compared to the overall sound engineer population in south africa, which is estimated to be about 4000 nationally (payscale, 2019). the sample size was small because of the tight teaching schedule of the participants. with one woman participating in the study, this was representative of the south african sound engineering population, where women constitute 8% of the population (payscale, 2019). the sample had more (76%) mid-career participants, with 3–10 years of experience (payscale, 2019). overall, the demographics of our study sample were similar to that of the south african sound engineers according to information presented in the payscale (2019) website. although the study sample was representative of the sound engineer demographics, the results may not be generalised to the greater south african sound engineering population. tinnitus and aural fullness are common symptoms associated with nihl. only three participants in the current study reported these symptoms. in clinical audiology practice, questions about tinnitus and aural fullness are asked in order to establish their presence and impact on one’s hearing function. in a study by drake-lee (1992) on rock musicians, the author reported that following a heavy metal concert, participants reported symptoms of temporary blockage (aural fullness) and tinnitus which disappeared the next morning. that study’s findings were similar to the current study findings. although this study was conducted a while back, common symptoms, tinnitus and aural fullness were common in this population. tinnitus and aural fullness have been identified as the commonly reported symptoms associated with hearing loss for the sound engineers in our study. recreational noise exposure increases one’s susceptibility to nihl. activities such as attending live concerts, being in a band and shooting reported by the study participants have been found to be associated with an increased risk of nihl (berg, pickett, linneman, wood, & marlenga, 2014; cohen, 2015). data obtained for the current study were subjective because of the lack of actual noise exposure levels, but highlighted confounding factors that increased the participants’ risk to hearing loss. hearing loss has negative implications for sound engineers, as this affects their ability to produce music (einhorn, 2012). therefore, hearing monitoring programmes are imperative for sound engineers in order to prevent any type of hearing loss. ear and hearing health promotion emphasises a normal functioning of outer and middle ear. only one participant had impacted cerumen, and all the participants presented with clear outer ear structures. unilateral absent acoustic reflexes (ipsilateral and contralateral) obtained, without middle ear pathologies noted in some of our participants, raise concerns with regard to the effectiveness of their stapedius muscle’s protective function. specific to the study sample, this could be because of excessive levels of music exposure (wojtczak, beim, & oxenham, 2017). although no studies have reported this finding on the sound engineers, our findings indicated that this (unilateral absence of acoustic reflexes) may be an early sign of hearing loss for this group of participants. hearing within normal limits with a notch in the region of 3000 hz – 6000 hz is an early sign of nihl (rabinowitz, 2000). in a study conducted on sound technicians, the authors (el dib, silva, morais, & trevisani, 2008) reported a high frequency hearing loss in sound technicians, predominantly in the 25–35 years old age group, which was similar to our findings. in another study conducted by jansen, helleman, dreschler and de laat (2009), the authors looked at musicians of symphony orchestras using an extensive audiological test battery and found that most musicians could be classified as hearing within normal limits, but their audiograms revealed notches at 6000 hz. these results correlated with our study findings that indicated that a notch at 6000 hz was an associated early sign of nihl, with a notch evident for musicians. although these studies were conducted more than 5 years apart, their findings were similar and still relevant to our study sample. prevention of nihl requires an effective hcp for sound engineers. the study site did not have an hcp in place, and the participants did not have audiometry records in line with hcp guidelines. within an hcp, there are seven pillars considered: noise measurement, engineering and administrative controls, education and training, use of hpds, risk-based medical examination and finally medical surveillance and audiometry (sans, 2013). none of the pillars existed at our study site. without an hcp in place, concerns are raised with regard to the company’s intention of hearing loss prevention strategy for this study site. professional sound engineers and sound engineering students need to be aware of noise and the consequent effects of noise exposure on hearing, and the importance of hearing loss prevention within the hcp framework (sans, 2013). conclusion and recommendations the main aim of this study was to determine the hearing function of sound engineers and to establish if hcps were in place at the sound engineers’ academy in johannesburg, south africa. in conclusion, all the participants presented with hearing within normal limits bilaterally. however, participants’ results revealed the following early signs of nihl: reported tinnitus and aural fullness, unilateral absent acoustic reflexes (ipsilateral and contralateral), and a notch at 3000 hz and 6000 hz frequencies obtained from pure-tone results (n = 5). without an hcp set at the academy, participants could continue to lose their hearing gradually, leading to nihl. this study raised awareness on the importance of creating a sound engineering-specific hcp that would benefit professionals at the study site. limitations the limitations of this study are the following: a sample size of eight participants was too small for the findings to be generalised. the participants were full-time lecturers and not full-time sound engineers. therefore, their experiences were supposedly different from that of full-time sound engineers. participants were not randomly selected. noise exposure levels were not measured; therefore, there was uncertainty whether levels exceeded 85 dba over 8 hours. acknowledgements the authors would like to express their sincere gratitude to the following people for their assistance: the director of the academy of sound engineering, george hattingh, for granting the permission to conduct the research study, and the participants for providing consent and willingness to participate in the study and for sharing their precious time and contribution towards the questionnaire, screening and diagnostic testing process. this article is based on the undergraduate research study conducted for the completion of a bachelor of arts degree in speech pathology and audiology at the university of the witwatersrand. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions l.n. wrote the article and a.h. assisted with data access used in the results. funding information this research received no specific grant from any funding 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(2017). weak middle-ear-muscle reflex in humans with noise-induced tinnitus and normal hearing may reflect cochlear synaptopathy. eneuro, 4(6), eneuro.0363-0317. https://doi.org/10.1523/eneuro.0363-17.2017 abstract introduction research method and design ethical considerations results discussion strengths, limitations and future research acknowledgements references about the author(s) kristen abrahams department of communication sciences and disorders, university of cape town, south africa michal harty department of communication sciences and disorders, university of cape town, south africa kenneth o. st. louis department of communication sciences and disorders, west virginia university, united states lehana thabane department of clinical epidemiology and biostatistics, mcmaster university, canada harsha kathard department of health sciences education, university of cape town, south africa citation abrahams, k., harty, m., st. louis, k.o., thabane, l., & kathard, h. (2016). primary school teachers’ opinions and attitudes towards stuttering in two south african urban education districts. south african journal of communication disorders 63(1), a157. http://dx.doi.org/10.4102/sajcd.v63i1.157 original research primary school teachers’ opinions and attitudes towards stuttering in two south african urban education districts kristen abrahams, michal harty, kenneth o. st. louis, lehana thabane, harsha kathard received: 15 mar. 2016; accepted: 31 may 2016; published: 27 july 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: as teachers form an important part of the intervention process with children who stutter in primary school, the primary aim was to describe primary school teachers’ attitudes in south africa. the secondary aim was to compare teachers’ attitudes towards stuttering in south africa with those from a pooled group of respondents in the public opinion survey of human attributes–stuttering (posha-s) database from different countries collected in 2009–2014. method: a quantitative, cross-sectional survey research design was used. primary schools in two education districts in western cape, south africa, were sampled. the posha-s, a self-administered questionnaire, was completed by a cluster sample of 469 participants. results: overall positive attitudes towards stuttering were found, specifically related to the potential of people who stutter, although the result should be interpreted with caution as the sample was not homogenously positive. teachers still had misconceptions about personality stereotypes and the cause of stuttering. the attitudes of the south african sample were slightly more positive compared with the samples in the current posha-s database. conclusion: when developing stuttering intervention strategies, there are a number of key considerations to take into account. the study provides a basis for speech-language therapists to think about intervention with teachers and which areas of stuttering to consider. introduction it is well-documented in the literature that people in the child’s environment influence the child’s experiences of their stutter (bennett, 2003; blood & blood, 2004), communicative ability and their progress in therapy (murphy, yaruss & quesal, 2007). for school-aged children who spend a large amount of time at school, there can be little dispute that teachers are figures of authority who can have a significant impact on a child’s early years. if teachers hold unsubstantiated views on stuttering, it can have a negative impact on how they perceive and interact with children who stutter (cws; abdalla & st. louis, 2012). additionally, teachers’ empathy and behaviour as they interact with cws can have an impact on the way these children are viewed and treated by their peers (boberg & calder, 2012; jenkins, 2010). the success of the therapeutic process is highly dependent on understanding the attitudes of significant others (including teachers) in cws’ lives (abdalla & st. louis, 2012). currently, little is known about teachers’ attitudes towards stuttering in south africa. in the management of stuttering, teachers are a central component; therefore, understanding their attitudes will assist in planning and developing appropriate interventions. with limited knowledge and resources for the south african context, this leaves speech-language therapists (slts) with many questions: what do teachers know about stuttering? how do they feel about stuttering? how do they react? how do teachers manage stuttering in the classroom? the present study aims to address these questions in the south african context. international studies have found varying teacher opinions and attitudes towards stuttering. pachigar, stansfield and goldbart (2011) conducted a mixed-method (i.e. quantitative and qualitative) study in mumbai considering 58 indian teachers’ attitudes towards cws. the authors found that many teachers had not been provided with any formal information about stuttering and they reported having limited experience with cws. the questionnaire found broadly positive attitudes towards cws. the interview process also highlighted a positive approach to dealing with cws in the classroom, specifically related to decreasing the pressure placed on the child, and subsequently reducing stress and anxiety. similarly, irani, abdalla and gabel (2012) aimed to determine kuwaiti arab teachers’ attitudes towards people who stutter (pws) and to compare their attitudes with american teachers to determine if cultural differences were present. the results indicated that arab teachers generally showed neutral to positive attitudes towards pws. one-third of arab teachers indicated negative attitudes on questions related to employment and social skills. although both sets of teachers generally had positive attitudes towards stuttering, american teachers were significantly more positive than arab teachers (p ≤ 0.003). due to the different questionnaires used in each study, drawing comparisons between attitudes is difficult. in order to address the lack of a standardised measure, the international project on attitudes toward human attributes initiative developed the public opinion survey of human attributes–stuttering (posha–s) which is designed to measure public opinion on, and attitudes towards, stuttering worldwide (st. louis, 2011). the posha–s considers attitudes in relation to other positive (i.e. intelligence), neutral (i.e. left-handedness) and negative (i.e. obesity, mental illness) human attributes. these attributes were included in the posha–s as ‘attitudes towards stuttering will be more meaningful within the context of attitudes towards other human conditions’ (st. louis & roberts, 2010, p. 362). to assess public opinion, the posha–s groups items together to form components and groups components to form subscores (st. louis, 2012). items related to stuttering are grouped according to two subscores: (1) beliefs about stuttering and (2) self-reactions to stuttering. beliefs about stuttering relate to a participant’s thoughts and impressions about stuttering (not related to them personally), whereas self-reactions to stuttering consider a participant’s self-perceptions of his or her behaviours, reactions and knowledge (przepiorka, blachnio, st. louis & wozniak, 2013). three recent posha–s studies (abdalla & st. louis, 2012; arnold, li & goltl, 2015; li & arnold, 2015) investigated school teachers’ attitudes towards stuttering. abdalla and st. louis (2012) examined school teachers’ knowledge, attitudes and beliefs about stuttering. participants were 262 arabic-speaking residents of kuwait who were in-service public school teachers of grades 1–12 and 209 pre-service school teachers, that is, education students. the results of the study found that teachers were familiar with stuttering, but held misconceptions about the cause of stuttering, personality stereotypes, role entrapment (i.e. cannot do any job they want) and strategies for coping with stuttering (i.e. repetition of word until the child is able to say it, filling in words, etc.; abdalla & st. louis, 2012). abdalla and st. louis (2014) further found that the implementation of an education documentary video depicting factual and emotional aspects of stuttering was found to positively change pre-service teachers’ attitudes (in terms of the subscores, beliefs about stuttering and self-reactions to stuttering) but not those of the in-service teachers. more recently, arnold et al. (2015) used the posha–s beliefs subscore to compare 269 kindergarten to grade 12 teachers with 1388 non-teachers from the posha–s database. linear regression analysis indicated that there were no differences between teachers and non-teachers. nevertheless, irrespective of profession, female participants provided statistically significant (p < 0.001), more accurate beliefs. an increase in age (p < 0.01) and years of education (p < 0.01) were significantly associated with more favourable beliefs. participants who knew at least one person who stuttered were found to have more positive responses (p < 0.0001). li and arnold (2015) further considered the self-reactions subscore. the results indicated no significant difference in any of the components forming the self-reactions subscore except knowledge source. teachers’ generally scored higher than the non-teachers, indicating a larger variety of sources of knowledge. age (p < 0.001) and years of experience (p < 0.001) were also associated with more positive responses. regardless of occupation, it was found that female participants generally scored higher than male participants for the accommodating and/or helping component (p < 0.001). from the existing posha–s studies, it is clear that there are differences in opinions about stuttering worldwide, possibly because of the unique context of each country with regard to religion, culture, language, nationality and ethnicity (abdalla & st. louis, 2012; st. louis, 2005). this highlights the importance of gaining a contextual understanding of stuttering internationally, especially in areas where little is known about the condition. south africa provides a unique context for the provision of health care services. apartheid has greatly shaped south africa, creating social, economic and racial inequalities (engelbrecht, oswald & forlin, 2006). the diversity within the country both linguistically and culturally adds to the complexity of the context. in post-apartheid south africa, policy changes in education led to desegregation of schools and many other changes to the education system and institutions. the teaching profession has had to cope with the movement to a single national system, as well as a change of curriculum, which acknowledges the importance of professional autonomy. teachers were required to gain new knowledge and competencies with drastic changes to the composition of classrooms, demographically, linguistically and culturally (department of education, 2006). in mainstream primary schools, teachers have little or no direct support from slts as the majority of slts employed by the department of education are based at a district level or in ‘special schools’ (kathard et al., 2011). as a result, slts only serve a small minority of learners’, generally working with more severe cases (kathard et al., 2011). along with the well-documented language and literacy difficulties plaguing the education sector (navsaria, pascoe & kathard, 2011), it is unlikely that a condition such as stuttering will be a priority. although international studies provide slts with insight into teachers’ attitudes, no study in south africa has considered teachers and stuttering. therefore, our present knowledge base on teachers’ attitudes towards stuttering is strongly influenced by the developed world. according to kathard and pillay (2013), the developed world’s knowledge base has been labelled as universal, when in fact it has been influenced by culture. therefore, we cannot assume that the developed world’s knowledge will be identical to the knowledge of the developing world. for the south african context, which is so diverse, it is essential that we determine which aspects are universal and which are specific to cultural groups (abdalla & st. louis, 2012). the study forms part of a larger ongoing project considering stuttering in the school context. this study is the first in the western cape to consider teachers’ attitudes; therefore, using the survey, we aimed to gain general insight into teachers’ opinions. as such, the study focused on urban areas in cape town, where the population density is higher. further studies consider a more in-depth understanding through qualitative data. this study presents the findings of the survey considering teachers’ views on stuttering in the western cape in a context where teachers have reported concerns about stuttering (kathard et al., 2014) alongside general communication challenges in the classroom context (i.e. linguistic diversity, lack of development of communication skills). the study also compared south african teachers’ attitudes to the posha–s database, in order to identify patterns of relative strengths and challenges for this group of teachers. research method and design a quantitative, cross-sectional survey design was used in the study. before the administration of the posha-s, a pilot study was conducted to determine the adequacy of the research procedure, the potential response rate, the level of awareness of stuttering and the reliability and validity of the posha–s for the south african context. based on the results of the pilot study, modifications were made to the phrasing of questions and the procedure. participants the present study was conducted in the western cape of south africa, specifically two urban education districts, metro east and metro central within cape town. cluster sampling was used (bruce, pope & stanistreet, 2008) to obtain a sample of teachers working in primary schools in the two education districts. in order to obtain a representative sample, schools were further stratified. schools were stratified according to teaching phase (i.e. foundation [grades 1–3] or intermediate phase [grades 4–7]). schools were also stratified according to quintile [i.e. government funding provided to schools based on resources and poverty scores (motala, 2006; sayed & motala, 2012), i.e. higher (quintile 4 and 5) and lower (quintile 1 and 2)]. it should be noted that this study does not focus on the effect of these variables. in 42 chosen schools, an approximate total of 560 out of 856 teachers (according to the school principals) were invited to participate. figure 1 provides an overview of the schools and teachers sampled. based on the figure, it is clear that there were a number of non-respondents, either because of declining to take part or logistical issues. figure 1: flow chart depicting sampling process, with number of respondents per stage. five hundred and twenty participants agreed to complete the questionnaire with a response rate of ± 92.9% (i.e. 520/560). fifty-two participants were excluded because of incorrect profession or critical information that was not completed. table 1 summarises the demographic information for all participants’ in the sample. there were a total of 469 participants, with a mean age of 45 years with a range of 22–66.6 years. table 1: demographic information for the south african participants of the study (n = 469). the public opinion survey of human attributes-stuttering the posha–s was developed to be translatable into a variety of languages and cultures, efficient, valid, reliable and easy to use (st. louis, 2005). south africa also participated in development of posha–s (st. louis, 2005). the posha–experimental (i.e. previous version) was able to identify slight differences within sample groups such as distinctions between rural versus urban, student versus non-student and lowand/or middle-income versus high-income nations (st. louis, 2005). research has also found that the posha–s has a satisfactory test–retest reliability (st. louis, lubker, yaruss & aliveto, 2009), internal consistency (al-khaledi, lincoln, mccabe, packman & alshatti, 2009) and construct and concurrent validity (st. louis et al., 2009). for a description of the layout of the posha–s, refer to ip, st. louis, myers and xue (2012). to assess public opinion, the posha–s groups items together to form components and groups components to form subscores (st. louis, 2012). the mean scores for test items formed the component scores, and the mean for certain component scores formed the three subscores. the mean of the two stuttering subscores formed the overall stuttering score. all the rating scores were then converted using a scale from −100 to +100 with neutral = 0 (st. louis, 2012). depending on the wording of the questions, the sign (i.e. + or −) was reversed so that the higher the overall score, the more favourable the attitude (st. louis, 2012). for the present study, modifications were made (i.e. changing wording, adding items to questions and adding additional demographic questions) to the posha–s in order to enhance the content validity of the study to better suit the south african context. questions related to teachers’ views on management of stuttering in the classroom were included and were adapted from crowe and walton (1981), yeakle and cooper (1986) and heite (2000). comparisons can be drawn to the median, lowest and highest sample means in the posha–s database so that researchers are able to determine the extent to which their sample is comparable or different from previous research samples (st. louis, 2011). circa august 2014, the database consisted of 10 174 participants representing 36 countries and 22 languages. samples were gathered from many different professions including learners, family members of a pws, and even food and hospitality service workers (st. louis, 2015). the highest overall stuttering score to date was obtained from a sample of stuttering, self-help leaders, suggesting that they held the most favourable attitudes towards stuttering, with the lowest score from a group of mid-socioeconomic status parents in karnataka, india, suggesting they held the least favourable (st. louis, 2015). procedure informed consent was carried out according to guidelines of the health science research ethics committee and the western cape department of education. potential participants were identified by principals of the selected schools who verbally consented to the study, where upon information letters were distributed to the school for all potential participants. after agreeing on times, and locations, the teachers met in a group setting where consent was obtained and questionnaires were handed out for immediate completion. the participants were asked to complete the questionnaires individually. data analysis the distribution of the sample was determined using frequency tables. percentages and bar charts were used to give an overview of the responses of the participants for each section in order to describe the views of all primary school teachers sampled. the data from this study were then compared to the average calculated from all the data from the posha–s database (st. louis, 2012), in order to determine similarities and differences between responses obtained in the present study and previous study samples (st. louis, 2011). in addition, percentile ranks of the mean scores for the items, components, subscores and overall stuttering score were compared to samples in the database. the quartile in which the results fell in were also determined (i.e. first quartile [0%–25%]; interquartile [25%–75%] and fourth quartile [75%–100%]), in order to determine whether south african teachers’ attitudes were more or less positive than the other respondents in the database (özdemir, st. louis & topbas, 2011). a radial graph was used to show the mean ratings for the components and subscores from all of the samples in the posha–s database and the lowest, median and highest mean ratings (przepiorka et al., 2013). ethical considerations the following ethical principles were considered and incorporated into the study (world medical association declaration of helsinki, 2013): autonomy, beneficence and non-maleficence and justice. results the overall key results are presented according to the stuttering subscores, beliefs about stuttering and self-reactions to stuttering. in general, positive results were found, particularly related to pws’s potential and their reactions to stuttering. beliefs about stuttering over 50% of participants indicated that pws were nervous or excitable (56%, n = 248) or shy or fearful (58.2%, n = 256). however, over 80% of participants did not agree with the statement that pws have themselves to blame for their stutter (84.1%, n = 376). participants’ beliefs about the cause of stuttering were diverse. while majority of participants (53.4%, n = 230) indicated that stuttering was caused by genetic inheritance, others believed that it was caused by an act of god (36.3%, n = 153), learning or habits (26.7%, n = 113) or a very frightening event (24.2%, n = 103). participants generally believed that a slt should assist pws (94.1%, n = 416). other participants were divided on their views with 38.7% (n = 163) indicating that people like themselves should assist pws while 43.5% (n = 183) disagreed. over 50% of participants indicated that pws should not be helped by a medical doctor or other pws, with 93.8% (n = 390) indicating that traditional healer would not be an appropriate referral. self-reactions to stuttering the majority of participants indicated that they would do the following: try to act like the person was talking normally (81.5%, n = 347), feel comfortable and relaxed (79.5%, n = 348) and speak calmly and slowly to the person (67.4%, n = 295). many participants indicated that they personally knew someone who stutters (83.7%, n = 379), with 25.6% (n = 116) who currently had someone in their class who stutters. twenty-one (4.7%) participants indicated that they stuttered. while the majority of participants had experience with stuttering, participants’ indicated that they knew the least about stuttering (m = 2.5) and mental illness (m = 2.6) in comparison to the other human attributes (i.e. intelligence [m = 3.6], left-handedness [m = 3.2] and obesity [m = 3]). comparison to public opinion survey of human attributes-stuttering database the data from the present study are compared with the lowest, highest and median samples from the posha-s database to date (circa august 2014). figure 2 is a visual representation of how the responses of the south african sample compares to the database in terms of the components, subscores and overall score on the posha-s. figure 2: summary of posha–s radial graph for the south african sample in comparison to the lowest, median and highest scores in the posha–s database archive (circa august 2014). in order to provide a percentile comparison, mean scores for all of the posha–s ratings (items, components, subscores and overall stuttering score) for the south african sample were compared to the 146 samples in the posha–s database (refer to table 2). table 2: south african participants’ mean ratings for the overall stuttering score, subscores and components followed by percentile values. the south african sample scored higher for all subscores and the overall stuttering score (refer to table 2). the south african sample scored lower than average for (1) traits and/or personality, (2) accommodating and/or helping (3) and the amount known about obesity and mental illness. also within the cause component, specifically the response act of god was much lower than the posha–s database (15 for the south african sample compared to 65 for the posha–s database; not shown in table 2). within the traits and/or personality component, the items which received the lowest score were pws are nervous or excitable (a mean score of -26 for the south african sample compared to three for the database) or shy and fearful (a mean score of -28 vs. -8). within the accommodating and/or helping component, the greatest difference between scores was found for the item, if i were talking with a person who stutters, i would feel comfortable or relaxed (south african sample scored -22 compared to 22 for the database). two stuttering components fell into the fourth quartile, namely potential and knowledge and/or experience. for potential, the items that received the highest score were pws can make friends (score of 91 compared to 93), lead normal lives (94 compared to 87) and can do any job they want (78 compared to 51). for the knowledge and/or experience component, personal experience with stuttering received the highest score (49 for south african sample compared to four for the database). for all 60 standard posha–s ratings, (i.e. all items, components, subscores and overall stuttering score), 5% of the south african means were in the lowest quartile, 62% were in the interquartile range and 33% were in the highest quartile. as the majority of the scores fell within the interquartile range, it can be assumed that the majority of the attitudes of the south african participants in this study were generally aligned with the typical results found in other studies. nevertheless, a considerable percentage of scores were in the highest quartile and few in the lowest quartile, indicating that the south african sample had relatively more positive attitudes than average. supporting this result is the fact that the overall score for the south african sample (i.e. 23) was slightly higher than the median sample mean of 18. discussion it is encouraging that there was a general consensus from primary school teachers that regardless of a person’s stutter, teachers believed that pws had the potential to lead successful lives both socially and economically. teachers were generally familiar with stuttering and would act in a considerate manner when interacting with a cws. however, personality stereotypes were still evident (i.e. pws are shy and/or fearful or nervous and/or excitable). there was also a large diversity of responses for the cause of stuttering ranging from genetic inheritance to an act of god. due to the limited amount of slts in the schooling system, the responsibility for managing stuttering in the classroom largely falls upon the teacher. with primary school teachers reporting a lack of perceived knowledge about stuttering as compared to the other human attributes (i.e. intelligence, left-handedness, mental illness and obesity), there are a number of key findings that can assist in conceptualising and developing interventions targeted at teachers. some teachers (43.5%) did not believe they should be someone who helps pws. this result may also be linked to the fact that teachers do not feel they have the knowledge and skills necessary to adequately assist a cws (berquez, cook, millard & jarvis, 2011). we agree with others that teachers are key figures in the lives of cws as they are one of the communication partners for children in the classroom (gottwald & hall, 2003). therefore, it is important that slts are able to empower teachers with the basic knowledge and skills to manage cws in the classroom. with a general consensus that improved knowledge can lead to improved attitudes (crowe & walton, 1981; hobbs, 2012; yeakle & cooper, 1986), implementation of professional development programmes related to stuttering may therefore improve teachers’ knowledge about stuttering and subsequently their beliefs. also, as a consequence of increased knowledge, teachers may feel more confident in their ability to assist a cws in the classroom. the study by abdalla and st. louis (2014) found that the implementation of an education documentary video positively changed certain aspects of student teachers’ attitudes towards stuttering. the use of such educational material could prove to be a valuable asset when attempting to change attitudes of individuals who hold negative or unfavourable attitudes towards pws. their results provide insight into the potential strategies that could be employed in order to address the unfavourable and reinforce positive attitudes. kathard et al. (2014) found that through collaboration with teachers as intervention partners, negative attitudes peers hold towards cws may be reduced. educating teachers about stuttering and how to manage stuttering in the classroom were essential to the success of the study. this leads to the question: what kind of information do teachers require? participants in this study generally believed that pws could be productive members of society. even with a perceived lack of knowledge about stuttering, it did not affect their opinion about the potential of pws. this result is encouraging for intervention planning because a positive attitude towards the potential of pws is essential for the success of any intervention programme (snyder, 2001). results generally indicated that teachers would be considerate when interacting with a pws. many teachers would try to act like the person was talking normally (81.5%) and speak calmly and slowly to the person (67.4%). teachers also indicated that they would not feel impatient (89.2%) or pity (64.9%). it has been made clear that the environmental context in which a child communicates is important relative to the reactions of teachers and peers, which can affect the child’s fluency (yaruss & reardon, 2002). conture et al. (2006) highlight the importance of ‘pressure-free’ response time for cws within the educational setting. accordingly, the results from our study are encouraging as teachers’ report acting in a way which seems to promote fluency through creating an environment which does not put too much pressure on the cws. the results also highlight some differences in the beliefs and attitudes of south african teachers compared to the individuals in the posha–s database. there were two stuttering scores that were lower than the posha–s database, namely: traits and/or personality component and the item act of god as a cause of stuttering. for the former, the items which contributed to the lower score for the south african sample related to personality stereotypes, that is, shy or fearful (28th percentile) or nervous or excitable (20th percentile). mackinnon, hall and macintyre (2007) theorised that stuttering stereotypes originated from the anchor-adjustment hypothesis, which states that ‘people adopt another person’s perspective by serially adjusting from their own perspective’ (p. 300). their study concluded that the formation of the stuttering stereotype was because of generalisations and adjustments that fluent speakers make, based on their own personal experience of normal dysfluency. teachers may, therefore, believe that pws possess certain personality stereotypes based on their own negative experiences with normal dysfluency. coupled with the fact that the present study found that teachers perceived they had limited knowledge on stuttering and that they generally obtained this knowledge from personal experience, the anchor-adjustment hypothesis may be a viable explanation. in many african cultures, disability and illness are viewed within a spiritual framework (legg & penn, 2013); thus, the belief that stuttering is caused by an act of god (22nd percentile) was expected to be more prevalent than in north america or europe. the result clearly shows that populations may vary in how they view potential causes of stuttering. as a consequence, interventions may be required to be specifically tailored to the targeted community. the results also highlight that slts cannot assume that all communities will respond to stuttering in the same way and this reinforces the importance of gaining a nuanced understanding of the views of the community before the implementation of any professional development programme. the study provided a first-level survey to inform intervention planning. presently, there are further studies exploring teachers’ attitudes in greater depth (hobbs et al., 2016). compared to the findings of abdalla and st. louis (2012), south african teachers provided more positive responses relating to the potential of pws and their reactions towards pws. both groups of participants had misconceptions about the cause of stuttering and who should help a pws. however, misconceptions differed, for example, many arab teachers believed stuttering was caused by a very frightening event compared to few south african teachers. similarly, half of the arab teachers thought that a medical doctor should help a pws compared to very few south african teachers. the comparison highlights the importance of gaining knowledge about teachers’ attitudes within the context in which they work as clearly south african and arab teachers, while similar in some regards, had differing opinions and thoughts about stuttering. the studies by li and arnold (2015) and arnold et al. (2015) further highlight that there are a number of variables, including gender, age, years of experience and familiarity that have an impact on attitudes. teachers’ belief that pws have the potential to be productive members of society provides a positive platform for intervention. intervention should reinforce positive attitudes and/or behaviours such as the considerate classroom management strategies and reactions to stuttering and focus on addressing misconceptions related to personality stereotypes and the causes of stuttering in order to improve teachers’ knowledge and subsequently their belief that they too can help pws. while the overall result indicates a positive attitude of the sample, a closer examination of the findings indicated that the majority of responses for the south african sample fell within the interquartile range (62%) when compared to the database archive. as a result, the findings of the study should be interpreted with caution. the overall result may mask the fact that there is still a substantial percentage of teachers who hold negative attitudes towards stuttering. the sample is not homogeneous, as highlighted by the significant differences reported on certain demographic factors investigated. furthermore, participants who respond to questionnaires are generally more positively inclined (jenkins et al., 2013). teachers who were more positive towards stuttering are more likely to participate in the study than teachers who were not. in all questionnaires, there is a possibility that the participants might provide responses that are more socially acceptable than their true beliefs (i.e. the hawthorne effect; benson, 2004). teachers may have thought that negative attitudes towards pws may be viewed as unacceptable for their profession (irani & gabel, 2008). individuals may be reluctant to overtly state negative attitudes because of the predisposition of society to political correctness (irani & gabel, 2008). it is also important to take into consideration that the non-respondents (those who did not complete the questionnaire) may have held more negative views towards stuttering. as a result, caution should be exercised when generalising the findings of the study to the broader teaching profession. strengths, limitations and future research as this is the only known study to consider south african teachers’ attitudes towards stuttering, it provides a platform for understanding attitudes within the country’s primary school system in the urban area of the western cape and provides clinicians with insight into intervention planning. the large sample size makes the study robust relative to the generalisability of results. however, given the diversity of schools in south africa, the applicability of findings to other geographical areas must be made with caution. the following limitations of the study are acknowledged and were kept in mind during the interpretation of the results: the results for all participants who agreed to participate in the study were utilised in the analysis. on analysis of the results, it was found that there were participants who did not complete the majority of the questionnaire. in future, it is suggested that the quality of the responses be determined in order to decrease the possibility of inaccuracies in the analysis the validity and reliability of the added questions and options were not formally tested and established. however, as the primary aim was to describe teachers’ attitudes, determining the validity and reliability of the additional questions and options was not a main priority. future research may focus on: qualitative analysis of teachers’ attitudes to gain a more in-depth understanding, not only of what attitudes and reactions teachers have towards stuttering but also the important element of why. the attitudes of teachers in rural areas. the present study focused on urban population and previous research (doody, kalinowski, armson & stuart 1993) has shown that attitudes between urban and rural communities may differ. acknowledgements data collection was partially funded by the programme for enhancement of research capacity (perc) grant, university of cape town (uct) and kristen abrahams received a bursary to assist with completion of her research from uct kw johnstone research scholarship. competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions k.a. completed the study as part of her master’s degree and therefore contributed to data collection, analysis and writing up of the manuscript. m.h. assisted with reviewing and editing the document. k.s.l. is the developer of the posha and assisted with data analysis. l.t. assisted with data analysis. h.a. was the project leader. references abdalla, f., & st. louis, k.o. 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(2002). successful communication for children who stutter: finding the balance. seminars in speech and language, 23, 195–204. http://dx.doi.org/10.1055/s-2002-33753 yeakle, m.k., & cooper, e.b. (1986). teacher perceptions of stuttering. journal of fluency disorders, 11(4), 345–359. http://dx.doi.org/10.1016/0094-730x(86)90022-7 article information authors: miriam e. meyer1 de wet swanepoel1,2,3 talita le roux1 affiliations: 1department of speech-language pathology & audiology, university of pretoria, south africa2ear sciences centre, school of surgery, university of western australia, australia 3ear science institute australia, subiaco, australia correspondence to: de wet swanepoel postal address: private bag x20, hatfield 0028, south africa dates: received: 26 feb. 2014 accepted: 28 june 2014 published: 11 nov. 2014 how to cite this article: meyer, m.e., swanepoel, d., & le roux, t. (2014). national survey of paediatric audiological services for diagnosis and intervention in the south african private health care sector. south african journal of communication disorders, 61 (1), art. #62, 8 pages. http://dx.doi.org/10.4102/ sajcd.v61i1.62 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. national survey of paediatric audiological services for diagnosis and intervention in the south african private health care sector in this original research... open access • abstract • introduction • methodology    • objectives    • research design    • ethical clearance    • inclusion criteria    • material    • data analysis • results    • diagnostic audiological protocols    • age at diagnosis    • age at hearing aid fitting    • delay from diagnosis to audiological intervention    • intervention practices • discussion    • diagnostic audiological protocols    • age at diagnosis    • age at hearing aid fitting    • delay from diagnosis to audiological intervention    • intervention practices • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ objective: a national survey of early hearing detection and intervention services was undertaken to describe the current status of diagnostic and intervention services in the south african private health care sector. methods: all private hospitals with obstetric units (n = 166) were surveyed telephonically. the data was integrated with data collected from self-administered questionnaires subsequently distributed nationally to private audiology practices providing hearing screening at the respective hospitals reporting hearing screening services (n = 87). data was analysed descriptively to yield national percentages and frequency distributions. results: average reported age at diagnosis was 11 months. most participants (74%) indicated that less than 20% of infants fitted with hearing aids received amplification before the age of 6 months. most (64%) participants indicated that the average period between confirmed diagnosis and hearing aid fitting was 1 month, on par with international benchmarks. only 16%–23% of participants included all diagnostic procedures recommended by the health professions council of south africa’s 2007 position statement for minimum diagnostic test batteries for infants and young children. conclusions: diagnosis of hearing loss, hearing aid fitting and audiological intervention is delayed significantly in the south african private health care sector. improved services should include integrated systematic hospital-based screening as part of birthing packages with diagnostic referral to specialist paediatric audiologists for accurate assessment and management of patients in a timely manner. introduction top ↑ every day an estimated 17 babies in south africa will be born with or acquire significant permanent bilateral hearing loss within the first few weeks of life (swanepoel, störbeck & friedland, 2009). this is based on an estimated incidence of 6/1000 live births in the public health care sector, which serves 85% of the south african population, and 3/1000 live births in the private health care sector, which serves the remaining 15% of the population (swanepoel et al., 2009). unlike many other congenital or early-onset disabilities, infants with hearing loss could develop speech and language skills on par with normal hearing peers, provided that the loss is identified and intervention initiated early enough (nelson, bougatsos & nygren, 2008; watkin et al., 2007). if these infants were screened shortly after birth, audiological and medical evaluations were conducted before 3 months of age, confirmation of permanent congenital or early-onset hearing loss was no later than 4 months of age and intervention was initiated before 6 months of age, they would have had the potential to develop age-appropriate speech and language skills (boudewyns et al., 2011; health professions council of south africa [hpcsa], 2007; jcih, 2007; yoshinaga-itano & thomson, 2008). however, if these children are not identified early, it could cause developmental delays in speech, language, social, emotional and cognitive development (hpcsa, 2007; korver et al., 2010; olusanya, 2008; olusanya & newton, 2007; yoshinaga-itano & thomson, 2008). the longer the hearing loss goes undetected, the poorer speech, language, literacy and educational outcomes are likely to be for the child, with higher associated long-term costs to the family, society and the country (joint committee on infant hearing [jcih], 2007; korver et al., 2010; morton & nance, 2006; olusanya, 2008; olusanya & newton, 2007; olusanya, ruben & parving, 2006; swanepoel, 2008; swanepoel, 2010; yoshinaga-itano & thomson, 2008). ultimately, infants with hearing loss are often consigned to a life of exclusion and stigmatisation (olusanya et al., 2006; swanepoel, 2008; swanepoel, 2010). in south africa, infant hearing loss is primarily detected passively when parents become concerned about speech and language delays or unusual behaviour, which usually occur after 2 years of age, when the critical age of language development has passed (swanepoel, 2008; swanepoel et al., 2009; swanepoel, 2010; swanepoel, johl & pienaar, 2013; theunissen & swanepoel, 2008). recent studies performed on urban samples from two provinces reported a mean age at hearing loss diagnosis of 23 and 31 months, respectively, and a mean age at initial hearing aid fitting of 28 and 39 months, respectively (van der spuy & pottas, 2008; venter & viljoen, 2008). in these urban samples, it was furthermore reported that the mean age at initial enrolment into an early intervention programme was 31 months and 43 months, respectively (van der spuy & pottas, 2008; venter & viljoen, 2008). in a more recent study at a diagnostic referral clinic, nearly half (47%) of participants were only diagnosed after 36 months of age although 40% of them were suspected of having a hearing loss before 12 months of age (swanepoel et al., 2013). the delayed age at diagnosis could partly be attributed to the poor status of current early hearing detection services in south africa (meyer & swanepoel, 2011; meyer, swanepoel, le roux & van der linde, 2012; swanepoel et al., 2013; theunissen & swanepoel, 2008). in the public sector, only 7.5% of hospitals provide some form of neonatal and infant hearing screening, whilst less than 1% offer universal screening (theunissen & swanepoel, 2008). although screening coverage might have improved since the theunissen and swanepoel (2008) publication, no updated survey on the current status has been published since. in the private sector, universal newborn hearing screening is only offered in 14% of obstetric units (meyer & swanepoel, 2011). other possible reasons for late diagnosis and enrolment into early intervention programmes in the public health care sector are poor follow-up return rates, a lack of awareness amongst parents of the importance of infant hearing screening and the detrimental effects of permanent childhood hearing impairment, and a possible delay in hearing aid procurement (swanepoel, ebrahim, joseph & friedland, 2007; theunissen & swanepoel, 2008). until recently, however, there has been no national survey of early hearing detection and intervention (ehdi) services in the private health care sector (meyer et al., 2012; meyer & swanepoel, 2011; swanepoel et al., 2009). as the private health care sector serves a minority (15%) of the south african population but comprises the majority of national health care expenditure (dambisya, modipa & health systems research group, 2009), it may appear as though more resources are available for ehdi services in this sector as opposed to the public health care sector. however, screening programmes in these private health care institutions are mostly dependent on individual initiatives from audiologists in private practice who may face similar problems with programme implementation as the public health care sector (blecher & harrison, 2006; dambisya et al., 2009; swanepoel et al., 2009). the health professions council of south africa’s (hpcsa) position statement on ehdi programmes in south africa (hpcsa, 2007) specifies recommended diagnostic protocols, practices and targets for ehdi programmes. to date it is unknown whether audiologists in private practice are aware of the hpcsa position statement and its recommended guidelines for best practice or to what extent they adhere to these guidelines. in light of this, the objective of the current study was to describe the audiological diagnostic protocols and intervention practices implemented in the south african private health care sector. the study is part of the first national survey on ehdi services in the south african private health care sector (meyer et al., 2012; meyer & swanepoel, 2011). a review of existing audiological diagnostic and intervention practices in ehdi provides baseline information essential for planning and coordination of improved widespread early hearing detection, diagnosis and intervention services into the future. methodology top ↑ objectives this study had the following objectives with regard to the south african private health care sector:• to describe diagnostic audiological protocols for ehdi • to determine the average age at diagnosis • to determine the average age at hearing aid fitting • to determine the delay from diagnosis to audiological intervention • to describe intervention practices. research design a descriptive survey design was used in this national survey of the south african private health care sector. ethical clearance institutional ethical clearance was obtained from the faculty of humanities at the university of pretoria before data collection was initiated. informed consent was obtained from and confidentiality was ensured to all participating individuals and institutions. inclusion criteria the total population included ward matrons at all private health care hospitals or clinics that offer obstetric services as well as the audiologists in private practice (registered with the hpcsa) who provide infant hearing screening services at these units (figure 1). all private health care institutions that did not provide obstetric services and all audiologists in private practice working at these institutions were excluded from the study. figure 1: flowchart of study populations and survey methods. all private health care (non-government funded) institutions in south africa were contacted telephonically in order to determine whether they provided obstetric services. a total of 304 such institutions, including hospitals, clinics and private practices listed in the national registry (medpages, 2009), were considered for potential inclusion in the population. after removing duplicated listings (6 listings), partially government funded institutions (8 listings) and institutions that no longer existed (4 listings), 286 institutions remained to be considered as eligible private health care sector institutions. of these, 122 institutions did not provide obstetric services, whilst the remaining 166 did (population 1, figure 1). infant hearing screening was conducted at 87 of those institutions. the 87 audiologists that offered infant hearing screening at those institutions (population 2, figure 1) were sent questionnaires to complete. participants who worked at more than one private health care institution were asked to complete one questionnaire per institution to ensure that data was representative for each respective hospital or clinic. material a structured telephonic survey of all private health care institutions that provided obstetric services was used for initial data collection amongst ward matrons in private health care institutions with obstetric units. information obtained in the telephonic survey included the average amount of babies born at their institution per month, whether newborn hearing screening was conducted and who conducted it. subsequently, a self-administered emailed or faxed questionnaire, adapted from the questionnaire used by theunissen and swanepoel (2008), was used for data collection. a pilot study was conducted prior to commencement of the study to improve reliability and validity. the first few sections surveyed biographical information, information on work context and hearing screening practices, data management and quality control. survey questions relating to diagnostic protocols and intervention practices are reported on in this study. data analysis data collected from the telephonic survey with private health care institutions’ obstetric ward matrons (population 1) were linked to data collected from the questionnaires completed by audiologists (population 2) at the respective institutions. the data was analysed to yield frequency distributions across provinces and nationally. in addition, group comparisons were made using the chi-squared and fisher’s exact tests. results top ↑ diagnostic audiological protocols of the newborn hearing screening programmes surveyed, 69% (53/77) provide diagnostic audiological assessment services following their screening services. only responses by participants who provided such diagnostic audiological services were included for the diagnostic protocol results. results indicate that in the 0–6 months category (figure 2), most participants included distortion product oto-acoustic emissions (dpoae) or transient emissions oto-acoustic emissions (teoae) (89%; 47/53), case history and/or parental questionnaire (85%; 45/53), otoscopic examination (66%; 35/53), high-frequency tympanometry (64%; 34/53) and air conduction auditory brainstem response (abr) (58%; 31/53) in their diagnostic audiological test battery. figure 2: inclusion of tests in minimum diagnostic test battery for infants aged 0–6 months and 7–36 months (n = 53). for the 7–36 months category (figure 2), participants generally replaced high-frequency tympanometry with standard tympanometry (89%; 47/53). more participants included behavioural observation, speech detection and speech recognition testing in testing for the older age group. one in four participants (26%; 14/53) that provided diagnostic testing for babies 0–6 months of age did not use auditory evoked potential testing (i.e. abr or auditory steady state response (assr)). this percentage increased to 36% (19/53) in the older age group (7–36 months). five participants (9%) included assr for the 0–6 months age group only and not for the 7–36 months age group. a single participant included assr for the 7–36 months age group only and not for the 0–6 months age group. eighty percent of participants (61/76) were aware of the hpcsa (2007) position statement. on further analysis of the data it was found that a significant association existed between participants’ years of experience and awareness of the hpcsa position statement (chi-squared and fisher’s exact tests; p < 0.05). the more years of experience participating audiologists in private practice had, the less likely they were to be aware of the hpcsa position statement. age at diagnosis participants were asked to report the average number of infants diagnosed with a permanent childhood hearing loss in the previous 12 months (whether or not they conducted the diagnostic testing themselves). the average reported numbers were added together in the two respective age group categories. significantly more infants (64%; 145/227) were diagnosed in the 7–36 months age group than in the 0–6 months age group (36%; 82/227). most participants (64%; 35/55) indicated that they had diagnosed only 1–3 infants with a permanent childhood hearing loss in the previous 12 months.the average reported age at diagnosis amongst the particular participants that conducted diagnostic audiological assessments ranged from 1–36 months (figure 3). if participants did not provide diagnostic audiological testing services, their responses were not included. twenty-seven percent (13/48) of participants indicated that infants were diagnosed on average between 0 and 3 months of age whilst 44% (21/48) indicated an average age at diagnosis of 9 months or older. the total average reported age at diagnosis in the private health care sector was 11 months (minimum age of 1 month; maximum age of 36 months; standard deviation of 9.98). figure 3: reported average age at which diagnosis of a permanent congenital or early-onset hearing loss is confirmed (n = 48). age at hearing aid fitting most (72%; 55/76) participants indicated that they provided hearing aid fitting services to children aged 0–36 months; however, only 84% of these (46/55) also provided diagnostic audiological services. only 34 of these 46 participant responses – those that were completed in full – were considered in relation to age at hearing aid fitting (figure 4). seventy-four percent (25/34) indicated that less than 20% of infants who had been fitted with hearing aids at their respective private health care institutions in the previous 12 months received amplification before the age of 6 months. fifty-nine percent of participants (20/34) reported that less than 20% of hearing aids fitted to young children at their particular institutions in the previous 12 months was fitted between the ages of 1 and 2 years. six participants (18%; n = 34) indicated that an average of 81%–100% of children fitted with hearing aids at their respective institutions were older than 2 years. figure 4: estimated percentage of children in different age groups fitted with hearing aids in the previous 12 months (n = 34). delay from diagnosis to audiological intervention most (64%; 39/61) of the participants indicated that the average period between confirmed diagnosis and hearing aid fitting (irrespective of who conducted the fitting) in their work context was 1 month. thirteen percent (8/61), 16% (10/61), 2% (1/61) and 5% (3/61) indicated that the average waiting period is 2, 3, 5 and 6 months, respectively. the most commonly reported factors contributing to delayed audiological intervention services (figure 5) were the family’s personal funding for amplification (62%; 48/77), approval for funding from medical aids (60%; 46/77) and parents’ delay in returning for follow-up appointments (43%; 33/77). the ‘other’ category (10%; 8/77) included factors such as transport to attend appointments, parental denial, parental resistance to accepting the diagnosis, the process of seeking a second opinion, the waiting period for donated hearing aids for orphans and the lengthy process of cochlear implant candidacy investigations. figure 5: contributing factors that prolong the waiting period between diagnosis and first visit for audiological intervention. intervention practices most (94%; 72/77) of the participants indicated that they provide some form of early intervention services to children aged 0–3 years as part of their intervention practices. eighty percent of participants (58/72) provide parent counselling, 77% (52/77) offer parent guidance, 50% (36/72) provide speech-language intervention, 12% (9/72) offer support group services and 6% (5/72) provide auditory training. those participants who do not provide early intervention services or provide limited services only have to refer children elsewhere for certain intervention options. seventy-one percent of participants (55/77) indicated that they referred children to other private practices, 70% (54/77) to schools or intervention centres, 45% (35/77) to non-governmental organisations such as hi hopes (störbeck & pittman, 2008) and 34% (26/77) to public hospitals when their services or the patient’s funding are insufficient. one participant indicated having to refer children to another province as there are no available services in the vicinity, three participants reported that they refer to a cochlear implant team for intervention in possible candidacy cases, one indicated often referring to the occupational therapist and another two participants refer children and their parents to the local parent support group. none of the participants indicated that it is the parents’ own responsibility to find a suitable facility that offered early intervention services. discussion top ↑ diagnostic audiological protocols only 16% (12/77) and 23% (18/77) of participants included all the procedures recommended by the hpcsa (2007) position statement in their minimum diagnostic test battery for infants younger than 6 months and children 6 months and older, respectively. the most frequently occurring diagnostic procedures in participants’ test batteries for infants 0–6 months included dpoae/teoae, case history and/or parental questionnaire, otoscopic examination, high-frequency tympanometry and air conduction abr. high-frequency tympanometry was replaced by standard tympanometry and air conduction abr by behavioural observation audiometry as the most frequently occurring diagnostic procedures in test batteries for children 7–36 months of age. a similar survey in the public health care sector indicated that acoustic reflex testing was more often included in minimum diagnostic test batteries for all age groups and speech/language assessment for children 7–36 months of age (theunissen & swanepoel, 2008). the public health care sector study reported that abr testing was often omitted from minimum diagnostic test batteries (theunissen & swanepoel, 2008). more frequent use of air conduction abr in the private health care sector might simply be an issue of unavailability and expenses related to abr equipment and consumables in the public health care sector (dambisya et al., 2009; swanepoel, 2009).ten participants (13%) in the present study included all the recommended procedures (hpcsa, 2007) in their minimum diagnostic test batteries for young children (older than 6 months) except the screening of communication and language milestones. although the screening of communication and language milestones is part of both the audiology and speech-language therapy scope of practice, it seems that audiologists in the private health care sector may rather refer to a speech-language therapist for formal assessment of speech and language. often the speech-language therapists referred to already have experience with children with hearing impairment. high-frequency tympanometry was omitted from the diagnostic test battery for the 0–6 months age group by 36% (19/53) of participants. the prevalence of otitis media with effusion in the newborn population has been reported to approximate 1 in 250 (boudewyns et al., 2011). these infants will not be identified or receive appropriate treatment early enough without using high-frequency tympanometry (boudewyns et al., 2011). standard tympanometry was omitted from the diagnostic test battery for the 7–36 months age group by 11% (6/53) of participants. the highest prevalence rates for otitis media are between the ages of 6 and 48 months; more than 50% of children are expected to have at least one episode of otitis media with effusion in the first year of life (boudewyns et al., 2011). this emphasises the importance of including tympanometry in the minimum test battery in order to identify otitis media with effusion promptly (boudewyns et al., 2011). nine percent of participants included assr in their minimum test batteries for the 0–6 months age group but not for the 7–36 months age group. however, the relationship in young infants between behavioural thresholds and assr is not well defined and remains variable throughout the first year of life, especially during the first 3 weeks of life (john, brown, muir & picton, 2004; rance, 2008). participants might have chosen to include assr in the younger group as opposed to the older group as infants become increasingly active and mobile as they get older, which could make assr testing challenging or require conscious sedation during testing. the variations in procedures included in diagnostic protocols amongst participants might be attributed partly to the increased equipment and consumable costs associated with certain tests, such as high-frequency tympanometry, abr or assr (swanepoel, 2009). diagnostic tests utilised are entirely dependent on the devices acquired by audiologists, resulting in significant variability in diagnostic protocols (meyer et al., 2012). comprehensive test batteries in accordance with hpcsa recommended protocols are necessary not only for correct and prompt diagnosis but also for optimal amplification and verification (hpcsa, 2007; strauss & van dijk, 2008). the variations in protocols may furthermore be ascribed in part to a lack of awareness of national and international recommendations, benchmarks and quality indicators of ehdi programmes. this study established that 80% of participants (61/76) were aware of the hpcsa (2007) position statement, a document that specifies recommended protocols, practices and targets for ehdi programmes. however, awareness of the hpcsa position statement does not mean that recommended hpcsa protocols are implemented, as confirmed by this survey. non-compliance of minimum diagnostic audiological test batteries with international benchmarks and quality indicators may result in incorrect or late identification of infants with hearing impairment and subsequent suboptimal amplification (hpcsa, 2007; korver et al., 2010; olusanya, 2008; olusanya & newton, 2007; strauss & van dijk, 2008; yoshinaga-itano & thomson, 2008). this in turn might cause delayed speech, language, cognitive, social and emotional development (hpcsa, 2007; korver et al., 2010; olusanya, 2008; olusanya & newton, 2007; yoshinaga-itano & thomson, 2008). ideally, paediatric diagnostic testing would be conducted at specialised paediatric facilities across the country where all necessary tests are included in the diagnostic test battery and experienced paediatric audiologists are available. age at diagnosis as reported by participants, most infants and children in this private health care sector study were diagnosed with a permanent childhood hearing loss when they were older than 6 months. less than a third (27%; 13/48) of participants indicated that infants were diagnosed with permanent childhood hearing loss at the target age (0–3 months) according to national and international benchmarks (hpcsa, 2007; jcih, 2007; world health organization [who], 2010).the average age at diagnosis reported in this survey was 11 months. although this does not meet the target of earliest possible diagnosis (before 3 months and no later than 4 months of age), it is better than reported in studies conducted on small urban samples in gauteng and the western cape, where the average age at diagnosis was 31 and 24 months, respectively (van der spuy & pottas, 2008; venter & viljoen, 2008). in a recent referral clinic study, the average age at diagnosis was 42 months (swanepoel et al., 2013). the delayed age at diagnosis may be attributed to several factors, including poor follow-up return rates (meyer et al., 2012; russ, dougherty & jagadish, 2010; shulman et al., 2010; who, 2010), late-onset or progressive hearing loss (hpcsa, 2007; murphy & radford, 2006; shulman et al., 2010; swanepoel et al., 2007) and poor data management systems for ensuring that the diagnostic assessment is efficient and has adequate quality control (hpcsa, 2007; meyer et al., 2012; shulman et al., 2010; swanepoel et al., 2007; swanepoel et al., 2013). age at hearing aid fitting most participants (74%; 25/34) reported that less than 20% of infants who were fitted with hearing aids in the previous 12 months received amplification by the target age of 6 months (hpcsa, 2007; jcih, 2007). more than half (59%) reported that most of their hearing aid fittings in the previous 12 months occurred when the children were older than 24 months. similar suboptimal ages at hearing aid fitting were reported in previous south african studies conducted on urban samples in gauteng and the western cape, where the average age at hearing aid fitting were 39 months and 28 months, respectively (swanepoel et al., 2013; van der spuy & pottas, 2008; venter & viljoen, 2008). in a national survey of the south african public health care sector, only 7% of infants who were fitted in the previous 12 months were fitted by the target age of 6 months (theunissen & swanepoel, 2008). with the unsystematic hearing screening programmes and poor follow-up rates experienced in south africa, leading to delayed diagnosis, one expects delays in hearing aid fittings as reported in the current study. delay from diagnosis to audiological intervention the recommended time between confirmed diagnosis and initial hearing aid fitting is 1 month (hpcsa, 2007) and was reportedly attained by most (64%; 39/61) of the participants. the remaining participants (36%) indicated waiting periods of 2–6 months on average. the average period between diagnosis and fitting of amplification in the national public health care sector was 5 months (theunissen & swanepoel, 2008). in the public health care sector, possible factors contributing to delayed audiological intervention, including amplification, were financial, administrative or medical factors (theunissen & swanepoel, 2008). it is clear that similar factors apply to the delays found in the current private health care sector study.the most commonly reported factors contributing to delayed first visit for audiological intervention in the private health care sector were the family’s personal funding for amplification or approval for funding from medical aids (financial) and the parents’ delay in returning for follow-up appointments (administrative). the ‘other’ category in participant responses included factors such as transport to attend appointments (administrative) and the lengthy process of cochlear implant candidacy investigations (medical). a further category that might be added is parental acceptance of hearing impairment. parental denial, parental resistance to accept the diagnosis and the process of seeking a second opinion were listed as significant factors that might contribute to the suboptimal waiting period for initiating intervention services. these factors are not unique to the south african context as similar factors also delay processes of ehdi programmes in the united states of america (nelson et al., 2008; shulman et al., 2010; yoshinaga-itano & thomson, 2008). intervention practices most (94%) of the participants provide some form of early intervention services to children aged 0–3 years following diagnosis of permanent childhood hearing loss. participants who do not provide early intervention services or only provide limited services indicated that they refer children elsewhere for certain intervention options. the present study did not survey the typical period between diagnosis and the commencement of early intervention services. yoshinaga-itano and thomson (2008) reported that the provision of amplification is merely one of the purposes of early identification and that one should not wait to provide intervention services until the hearing aids have been acquired. the majority of participants (71%) indicated that they refer children to other private practices for intervention (auditory training and/or speech-language therapy) – probably to speech-language therapists, as auditory training does not fall solely within the audiologist’s scope of practice (department of health, 2012). in one particular province in south africa, there were no intervention services available and children had to be referred to a neighbouring province for intervention. this emphasises the need for upscaling integrated and comprehensive ehdi service infrastructure to make services accessible to all young children and their families, as well as establishing a national data management system to track young children as they progress through the system (meyer et al., 2012; meyer & swanepoel, 2011; russ et al., 2010; shulman et al., 2010; swanepoel et al., 2009; watkin & baldwin, 2011; who, 2010). conclusion top ↑ this study investigated the current status of diagnostic and audiological intervention services at south african private health care centres. diagnosis of permanent congenital or early-onset hearing loss occurred earlier and delays between diagnosis and hearing aid fitting were shorter in the private health care sector than previously reported for the public health care sector (theunissen & swanepoel, 2008). however, most programmes were found not to adhere to the hpcsa’s (2007) diagnostic protocol recommendations, which could cause delayed or incorrect diagnoses and suboptimal amplification. the upscaling of an integrated, accessible and comprehensive ehdi infrastructure should be prioritised in south africa in order to ensure prompt access to services and subsequent optimal benefits from the earliest possible hearing detection and intervention. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions m.e.m. 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(2011). identifying deafness in early childhood: requirements after the newborn hearing screen. archives of disease in childhood, 96 , 62–66. http://dx.doi.org/10.1136/adc.2010.185819 watkin, p., mccann, d., law, c., mullee, m., petrou, s., stevenson, j., et al. (2007). language ability in children with permanent childhood hearing impairment: the influence of early management and family participation. pediatrics, 120 , e694–e701. http://dx.doi.org/10.1542/peds.2006-2116 world health organization (who). (2010). newborn and infant hearing screening: current issues and guiding principles for action. geneva: who press. yoshinaga-itano, c., & thomson, v. (2008). the work of the village: creating a new world for children with hearing loss and their families. international journal of audiology, 47 (suppl. 1), s14–s22. http://dx.doi.org/10.1080/14992020802286202 . recent research in dyslalias. . μ erica stern. b.a., dip. log.. (rand.v lecturer in speech defects, university of cape town. 1. introduction. in 1937 the cape education department introduced free lessons in speech correction for primary school children, and today there are + 32 speech correction teachers throughout the cape province giving lessons to ± 2000 speech defective school children in eight cities and towns. lessons are given twice.weekly, each of about thirty minutes in duration. this investigation has been based rn the experiences and results obtained by these speech · correction teachers. it is the aim of this investigation to determine whether there is any significant difference in the time taken by . children at different age levels to complete a course in speech correction for functional dyslalia. this study is concerned only with children of normal intelligence who have one sound only defective in their speech, not resulting from any organic lesion, who have received lessons in speech correction over an uninterrupted period. this study also'aims at discovering whether some defective sounds are more quickly corrected than others. 11. subjects. the 350 speech defective children included in this study were all attending primary schools in the oape province, and receiving special lessons in speech correction, each of t 30 minutes in length, at their schools twice weekly. therej were 193 boys and 157 girls ranging in age from 5 to 12] years inclusive, and from sub std. a until std. vi inclusive. this study does not include children from special classes. 111. procedure. the speech correction teachers who co-operated in this investigation were asked to supply the following information as regards each of their pupils:name, sex, defective sound, age on admission to speech correction class, and duration of speech correction lessons. in addition each pupil was interviewed three months or longer after r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) . dismissal to ensure that no relapse had occurred. iv. results and conclusions. table 1. — defective sound number of pupils 5 212 -l or r 71 θ / r 67 it was found that among 350 primary school children having only one defective sound, (functional dyslalia), the sound was defective among 212 children, the sound τ was defective in 71 children, and the sound qj<f was defective in 67 children. margaret hall (2) in her study of "auditory factors in functional articulatory speech defects", has also found these three sounds s to "be among those most frequently mispronounced, ' the follewing table illustrates the results obtained when the subjects were classified according to age. table ]jl. age in years no. of pupils :5 21 ,6 79 17 82 18 68 |9 37 10 3k 11 16 12 13 total 350 these results agree with those obtained by roe and milisen (k) in their investigation on "the effect of maturation upon defective articulation in elementary grades". they found among their subjects in similar schools in indiana, u.s.a., that the mean number of errors decreased between the first and the sixth grades, i.e. between the ages of 6 and 11 years, as the grade level inoreased. the small number, of dyslalic r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28. pupils at the 5 year old level can be explained "by the fact that these children are not all at school yet. similar results have also been obtained by maralyn wight (6) in ypsilanti. michigan. as regards the time taken to complete the lessons in speech correction, it was found that the 350 children took on the average 10 months, (or approximately one school year), from the time they were admitted to speech correction classes, until their dismissal as rehabilitated. table 111 shows the average time taken by the pupils at each age level to complete their speech correction lessons, the difference in the average time taken by the 7 and 11 year old pupils and the critical ratio. table 111. age average time difference critical ratio 5 9.42 months 6 9.91 , ! 7 10.35 " 8 10.69 " 9 9.72 •» 10 9.70 " 11 7.25 " 12 8.81 » 7 & 11 3.10 months 2.97 it would thus seem that the most favourable time for children to learn how to articulate a sound correctly and how to in-' corporate this new and correct sound into their spontaneous speech is at the age of 11 years. taking into account the small number of pupils in the 11 year old group, there is a significant difference at the 1% level (1) in the time taken by the 7 and 11 year old pupils to complete their lessons, in favour of the older pupils. table iv demonstrates the average times taken by the pupils in learning to correct each of the three defective sounds, the differences between the average times taken and the critical ratios. table iv ... r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) . table tv, sound corrected. average time difference critical ratio s -l or r e/<f j and 7-,... £ and a. and <9/if· , \ i 11.014 months 10.183 " 7.1k9 " 0.831 months 3.865 " 3.034 " 0.89 5.95 3.32 thus there is no significant difference in the time taken.to ?? 5 λ t > ( a v e r a g e ^mes taken being, 11.014 and 10.183 months respectively), but the sound θ/w either 'tor ζ 1 ^ 3 ^ i s n l f i c a n t l y more quickly corrected7 than the greater incidence of speech defects among boys than among girls as reported by the white house conference, (5) ib con-firmed by the present investigation. 1. 2. 3. k. v. summary. among 350 primary school children having each only one sound defective in their speech, (functional dyslalia), it was found that there were more boys (193) than girls (157). it was found that in all cases one of the following three sounds was defective , 5 (212) ̂ or 7(71) <9/^(67). the average time taken by all the subjects between the ages ;of 5 and 12 years to complete their speech correction -lessons was 10 months the least time taken being by the 11 year old pupils (7.25 months). it wa;s found that the sound θ β \ ά β significantly more quickly corrected (7.149 months) than either 5 or>l but that there was no significant difference in the time taken to correct s (11.014 months) and (10.183 months). bibliography .. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) . bibliography. 1. edwards, allen, statistical analysis for students in psychology and education. rinehart and company, inc., new york, page 330. 2. hall, margaret, auditory factors in functional articulatory speech defects. 3. pearson, karl, tables for statisticians and biometriclans. u. roe, v. , and milisen, r., the effect of maturation upon defective articulation in elementary grades. journal of speech disorders, vol. 7, no. 1, page 37. 5. white house conference on child health and protection, report of the committee on special classes. d. appletoncentury, co. inc., new york, 1931. 6. wight, maralyn. journal of speech disorders. september, 1947, page 303. ~~ . acknowledgement s. my grateful thanks are due to mrs m. kihn, organiser of classes for speech defective and hard-of-hearing classes, department of public education, cape of good hope, under whose aegis this investigation was conducted, and to mr j. taylor, department of psychology, university of cape town, for help with the statistical analysis. 1 cape education department. it is the ipurpose of this investigation to determine whether there is any significant difference in the time taken by children at different age levels to complete a course in speech correction. this study is concerned only with children of normal intelligence with one simple articulatory defect, (dyslalia,) not resulting from any organic lesion, e.g. cleft palate, hearing loss, who have received lessons in speech correction over an uninterrupted period. this study also aims at discovering whether some defective sounds are more quickly corrected than others. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) . suggestions for filling in the form, sex: speech defect; language: date; standard: dismissal: duration of lessons: check up: teacher: write μ (male) or f (female). this study is concerned only with children who have only one defective sound. the sound which is defective, together with the sound substituted, should "be entered, e.g. substitutes 'v for "r". state whether the speech correction lessons were conducted through the medium of afrikaans or english or "both. (write α. ε or ae.) do not include the names of pupils whose lessons have "been interrupted "by a break of a term or more owing to change of teacher, absence of pupil or any other reason. write down the names of only those children who were in ordinary classes both at time of admission and at time of dismissal. do not include the. names of children from special classes or who were placed in special classes during the course in speech correction. this study is concerned only with those pupil s who have been dismissed as rehabilitated. write in the time in-years and months from the admission date until the dismissal date, i.e. the actual time taken for the course in speech correction. in cases where this.is possible, state whether the child's speech is still satisfactory-, or whether there has been any relapse. write in the name of the teacher who gave the course in speech correction to the pupil concerned. any number of names of pupils can be entered on the same form, but· draw a line right across the page after the name of each pupil. when you have filled in the forms, please return them to:miss e. stern, c/o mrs m. kihn, public school, mowbray„ cape town. thank you for the information. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract the need for early hearing detection and intervention striving towards universal newborn hearing screening considering early hearing detection and intervention within the broader south african health care system recommendations and considerations for south africa acknowledgements references about the author(s) amisha kanji department of speech pathology and audiology, university of the witwatersrand, south africa citation kanji, a. (2018). early hearing detection and intervention: reflections from the south african context. south african journal of communication disorders, 65(1), a581. https://doi.org/10.4102/sajcd.v65i1.581 discussion forum early hearing detection and intervention: reflections from the south african context amisha kanji received: 18 sept. 2017; accepted: 28 feb. 2018; published: 19 apr. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract for researchers and clinicians in developing contexts like south africa, the establishment of universal newborn hearing screening (unhs) programmes is something which we have strived to achieve. however, we need to ask the question as to whether we have attempted to view our ultimate goal of achieving mandated unhs programmes from the perspective of the south african healthcare system as a whole. the current manuscript is aimed at providing an overview of audiological services within a broader context, with reflections from a south african perspective, and a suggestion to consider alternatives to unhs, particularly in the south african public health care sector. the need for early hearing detection and intervention there is a convincing argument, and enough published research evidence, for the need for early detection of hearing loss in newborns and infants, with universal newborn hearing screening (unhs) being the gold standard. undoubtedly, there is enough evidence that proves the positive outcomes and benefits that result from early hearing detection and intervention (ehdi), particularly unhs (fulcher, purcell, baker, & munro, 2012; kennedy et al., 2006; pimperton & kennedy, 2012). this evidence mainly stems from developed contexts where ehdi programmes have been mandated or are established and well run, even with trained screening personnel (mcpherson, 2012; singh, 2015). striving towards universal newborn hearing screening for researchers and clinicians in developing contexts like south africa, the establishment of unhs programmes is something which we have strived to achieve. firstly, this is partly because we tend to use current research from the developed world to justify evidence-based best practice in each of our contexts. secondly, it is because we want to achieve the goals outlined in position documents from our regulatory bodies. whilst these serve as good reasons to aim towards best practice from the developed contexts (which form the benchmark), there is a sense that we are working within our individual departments and in silos within the bigger picture of the health care system in our context. the lack of efficient data management systems for ehdi, which are largely paper based and do not allow for sharing of information with other professionals adds to this complex context (moodley & storbeck, 2017). there have been some attempts at exploring newborn hearing screening (nhs) within the south african context, which have included a single study related to unhs within a private health care hospital in gauteng, and a few studies related to the implementation of unhs at primary health care (phc) clinics and midwife obstetric units in gauteng and the western cape (de kock, swanepoel, & hall, 2016; khoza-shangase & harbinson, 2015; swanepoel, ebrahim, joseph, & friedland, 2007). whilst these studies have informed the implementation of nhs in a contexts, they are limited to a few provinces only, and findings have not in all instances led to the actual implementation of fully fledged national programmes. have we paused and attempted to view our ultimate goal of achieving mandated unhs programmes from the position of the south african healthcare system as a whole? considering early hearing detection and intervention within the broader south african health care system health should be considered within the broader context of links (direct and indirect) between health and wealth (mayosi & benatar, 2014). our current healthcare in south africa consists of a large public health care sector which is funded by the state. the majority (84%) of the population is dependent on this public health care system (naidoo, 2012), which is served by only 30% of health care professionals (doh, 2011; van rensburg, 2014). whilst the distribution of the number of births and the population accessing public versus private health care is similar in some developed countries such as the united kingdom, their health sector had the largest number of employees in 2012, and the number of health care workers within their national health service has grown over the years (jayaweera, 2015). unlike countries such as the united kingdom where health systems function relatively well with less money being spent on health as a percentage of gdp, 40% of all expenditure for health in south africa comes from national treasury, with public health consuming 11% of the total government budget (cylus et al., 2015; jobson, 2015). these figures are higher than the 5% of gdp recommended by the world health organization (who) and reflect the huge burden of disease requiring management within the public health care sector (jobson, 2015). this high level of burden of disease highlights the need for an increase in the number of health care professionals; yet, we need to be mindful that quality of life often directly links to staying alive (mayosi & benatar, 2014; moyakhe, 2014), with little or no focus on impairments such as those related to hearing and communication. with over 1 million births per year in south africa (statistics south africa, 2016), and an estimated 6116 of these babies presenting with congenital, permanent or acquired hearing loss within the first few weeks of life (swanepoel, 2009), there is a clear need for sufficient staffing of audiologists. however, the capacity: demand ratio may be far from ideal with an overall 5216 registered speech pathology and audiology professionals in south africa (hpcsa, 2017). although this figure has increased slightly from 4892 in 2016, there were only 503 registered audiologists and 1510 dually qualified speech pathologists and audiologists (hpcsa, 2016), which poses a serious manpower challenge towards the implementation of unhs services. this is in comparison with other developed countries such as australia and the united states where overall health care workforce may be large (jayaweera, 2015) and/or where nhs services are well established and conducted by other healthcare professionals, audiology technicians or trained volunteers other than audiologists (choo & meinzen-derr, 2010; ferro, tanner, erler, erickson, & dhar, 2007; olusanya, 2011; who, 2010), possibly contributing towards the overall feasibility and success of unhs programmes. in other developing countries, such as lagos, nigeria, the use of non-specialists and community healthcare workers as screeners (at an inner city environment and immunisation clinics, respectively) has been reported to be feasible in effecting nhs services (olusanya, wirz, & luxon, 2008). however, screening by non-specialists would require the ongoing need for staff training provision and maintenance of equipment. furthermore, the health professions council of south africa has regulations governing the provision of health care, and the use of such cadres of screeners would need to be regulated by such a governing body. recommendations and considerations for south africa considering the realities of the south african health care context, and given that ehdi is vital for newborns and infants with hearing loss, we need to seriously consider how nhs services may be adapted to better meet these realities. one option is to seriously consider targeted nhs as a starting point or interim approach to early identification, particularly within a hospital setting (kanji, 2016). the reason being that certain medical case history factors may predispose or place newborns at a greater risk for significant hearing loss. newborns or infants with these medical risk factors may be more likely to be admitted or referred to a hospital setting (mcpherson, 2012). other risk factors such as family history of hearing loss and human immunodeficiency virus (hiv) exposure (hpcsa, 2007) may result in admission to well-baby nurseries within the hospital context, and these newborns and infants should therefore be monitored at their first follow-up visit at the relevant health care context. efforts to achieve sustainable improvements in health in the context of limited resources suggests the need for improvement in healthcare management and extensive shifts in attitude to service to ‘doing better with less’ (mayosi & benatar, 2014, p. 1351). it is this position that has led me to reflect on south africa’s engagement with ehdi, how we have progressed, and if not, whether we are failing to be ‘doing better with less’. having framed ehdi within the broader context of health in south africa, and through my research and clinical engagements in the field, i have asked the following questions: why unhs and why now? why is targeted nhs not considered a sufficient, realistic, interim solution and a good stepping stone to achieving quality audiological services within existing resources, with the aim of perfecting these services whilst striving towards the international gold standard? perhaps we need to consider the following aspects as recommendations in an attempt to answer these questions and approach the issue of ehdi services in south africa: factors contributing towards the reluctance to provide the best of services within our means our agenda as audiologists and what we convey towards achieving successful nhs programmes within the ehdi framework our actual achievements within the ehdi framework the ehdi goals that are truly actionable at this very point in time in our context. to achieve ‘doing better with less’ as a profession in south africa, what should we be advocating as standard care in the quest for the ideal? are we attempting to digest the elephant as a whole instead of piecemeal as a logical step? all programmes need to start somewhere and undergo their infancy stages. hence, perhaps it is time that we reflect and realise that conducting targeted or risk-based nhs is in fact a good foundation for the infancy stages and that doing something well is better than doing nothing at all, particularly in the public health care sector which is under-resourced. we also need to realise that effective and quality healthcare is not only dependent on individual professionals but involves other main stakeholders such as the government and civil organisations (moyakhe, 2014). as health care professionals we need to acknowledge the limitations but not allow it to preclude us from providing quality services within our means. acknowledgements competing interests the author declares no competing interests with regard to the writing of this article. references choo, d., & meinzen-derr, j. 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(2010). newborn and infant hearing screening. retrieved from http://www.who.int/blindness/publications/newborn_and_infant_hearing_screening_report.pdf abstract introduction aim of the study ethical considerations results and discussion conclusion acknowledgements references about the author(s) r. rajasudhakar department of speech-language sciences, all india institute of speech and hearing (aiish), india citation rajasudhakar, r. (2016). effect of voice therapy in sulcus vocalis: a single case study. south african journal of communication disorders 63(1), a146. http://dx.doi.org/10.4102/sajcd.v63i1.146 original research effect of voice therapy in sulcus vocalis: a single case study r. rajasudhakar received: 23 nov. 2015; accepted: 07 aug. 2016; published: 30 nov. 2016 copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: sulcus vocalis is a structural deformity of the vocal ligament. it is the focal invagination of the epithelium deeply attaching to the vocal ligament. there is a dearth of literature on the outcome of voice therapy in sulcus vocalis condition. objective: the primary objective of this study was to document voice characteristics of sulcus vocalis and the secondary objective was to establish the efficacy of voice therapy in a patient with sulcus vocalis. method: a trial of voice therapy was given to the client who was diagnosed as having sulcus vocalis. boon’s facilitation techniques were used in voice therapy along with other techniques such as breath holding and push and pull approach prior to surgery. acoustic, aerodynamic, perceptual, quantitative measures of voice quality and self-rating measurements were performed before and after voice therapy. results: improvement was noticed in 10/10 acoustic, 4/4 aerodynamic, perceptual, dysphonia severity index and voice handicap index scores, which hinted that voice therapy can be an option critically for clients with sulcus vocalis in the initial stage. conclusion: voice therapy showed promising improvement in the study and it must be recommended as the initial treatment option before any surgical management. introduction speech is the most frequent and significant way in which humans use language to communicate. speech contains fluency, articulation and voice as its components. the systems included in the production of voice are phonatory, respiratory and resonatory systems. pitch, loudness and quality are the three parameters of voice. any deviance in these parameters from normality results in voice disorders. abnormal voice is any voice that calls attention to itself, does not meet the occupational or social needs of the speaker, or is inappropriate to the age, gender or situation (aronson & bless, 2010). voice disorders are mainly classified as organic and functional voice disorders. organic voice disorders could lead to structural changes in the voice production system. sulcus vocalis is one of the uncommon clinical conditions caused by structural abnormalities in the vocal folds. it is the focal invagination of the epithelium deeply attaching to the vocal ligament (bouchayer & cornut, 2000). the lack of tissue causes a divot in the vocal fold which gives the disorder its medical name ‘sulcus’, which means ‘cleft’ or ‘furrow’ (in latin). sulcus vocalis is a groove mainly along the edge of superficial lamina propria. in severe cases, the groove can extend up to the intermediate and the deep layer also. there are three types of sulcus vocalis: physiologic sulcus, sulcus vergeture and sulcus vocalis proper (ford, inagi, bless, khidr & gilchrist, 1996). physiologic sulcus (type 1) is a longitudinal depression that extends along the superficial layer of lamina propria without actually moving the vocal ligament. in physiologic sulcus, there is preserved vibratory activity and anatomic layer of lamina propria as reported. sulcus vergeture (type 2) is a more extensive longitudinal indentation that does not extend into the vocal ligament, involving loss of superficial, intermittent and deep layer of lamina propria. sulcus vocalis proper (type 3) is a focal pit which extends beyond the vocal ligament into the thyro-arytenoid muscle (bouchayer & cornut, 2000). incidence and prevalence about 15 patients (1.07%) were diagnosed with sulcus vocalis among 1400 patients with voice disorders in denmark (greison 1984). the prevalence of sulcus vocalis was estimated in excised vocal folds among laryngeal cancer patients in the usa (nakayama, ford, brandenburg & bless, 1994). these authors observed 58 cancer patients and reported 28 (48.3%) had sulcus deformities. bilateral sulcus was found in 7 of 28 (25%) cancer patients and unilateral sulcus was found in 21 of 28 (75%) cancer patients. the authors even compared the presence of sulcus in non-diseased control patients with cancer patients and concluded that sulci were common in cancer group (nakayama et al., 1994). aetiology the cause of this disorder is not widely studied and is poorly understood. the three causes for sulcus vocalis that are reported in the literature are congenital, acquired and unknown causes (postma, blalock & koufman, 1998). the congenital cause includes faulty development of the fourth and sixth branchial arches and rupture of the epidermoid cyst and vocal fold scars are characterised by replacement of the normal micro-architecture by disorganised collagen. acquired causes are associated with vocal abuse, laryngoesophageal reflux, trauma and infections. signs and symptoms all the measures of voice such as perceptual, aerodynamic, physiological and acoustics of voice are affected in patients with sulcus vocalis. the clinical features of the disorder include reduced phonation time (aerodynamic), altered fundamental frequency (acoustical), dysphonia, breathiness, harshness, hoarseness of voice (perceptual), vocal fatigue, incomplete glottal closure, interrupted mucosal wave transmission and ‘spindle-shaped’ glottis (physiology) (boon, mcfarlane, von berly & zraick, 2010; hirano, yoshida, tanaka & hibi, 1990). treatment there are two lines of management: medical (surgical) and non-medical (behavioural modification, counselling and voice therapy) management. surgical management includes vocal fold medialisation which includes intrafold injection and medialisation surgery. intrafold injection includes transoral injection with indirect laryngeal mirror, transoral injection with direct laryngoscopy and transcutaneous injection. the medialisation surgery includes surgical augmentation, medial shift of thyroid cartilage and rotation of arytenoid cartilage (calton & casper, 1990). however, studies report that the impacts of surgeries in sulcus are unpredictable and the goal is usually to reduce the glottic leakage. it may also be possible that the post-operative voice would be even worse than the preoperative voice (giovanni, chanterect & lagier, 2007). voice therapy includes implementing hygienic, symptomatic, psychogenic, physiologic and eclectic approaches. voice therapy has limited success in clients with sulcus vocalis (rubin & yanagisawa, 2006). in general, voice therapy in sulcus vocalis focuses on reducing strain on vocal folds, reducing compensatory voice changes and optimising the voice production subsystems, thereby increasing the vocal efficiency. however, there is a need to systematically document the voice profile of clients with sulcus vocalis in order to understand their voice characteristics and determine the efficacy of voice therapy for such individuals. aim of the study this study aimed at determining the effect of voice therapy in a client with sulcus vocalis. client history a 23-year-old adult male ‘c’ who completed a bachelor of engineering (be) and was working in a private firm as an automobile supervisor reported to the department of clinical services at all india institute of speech and hearing (aiish), mysore, with the complaint of his voice being wrongly perceived as female voice. no pubertal change of voice was reported. difficulty in varying the pitches while speaking was reported. he reported that the amount of voice usage at work settings was about 6 h. also, he complained of vocal tiredness after excessive use of voice. in addition, he reported that the level of noise in the automobile workshop was moderate. no other associated problems were reported. the aim and objective of the study was explained to the client and a written consent was obtained before initiation of the study. voice evaluation a detailed voice assessment was carried out by a team of professionals including an otorhinolaryngologist, a speech-language pathologist and a phonosurgeon. otorhinolaryngologist’s and phonosurgeon’s evaluation: fibre-optic flexible laryngoscopy (ffl) was used to view the vocal tract and glottis. the client was diagnosed to have bilateral sulcus vocalis (figure 1). figure 1: bilateral sulcus vocalis of vocal folds (pointed by the arrow marks). evaluation by speech-language pathologist a detailed evaluation by a speech-language pathologist consisting of acoustic, aerodynamic, perceptual and quantitative measures of voice quality such as dysphonia severity index (dsi) (wuyts et al., 2000) and self-rating measures using voice handicap index (vhi) was carried out. acoustic voice evaluation was carried out by using vaghmi software (vss, bangalore) in a sound-treated room where ‘shure’ sm 48 model microphone was used. aerodynamic measures were performed using a spirometer (helios, 701 model from rms, chandigargh). lingwaves (wavosys, germany) software was employed to measure dsi scores. perceptual evaluation of voice was carried out by using grbas scale (hirano 1981). two experienced speech-language pathologists, who had 10 years of experience in assessing and treating clients with voice disorders, assessed perceptually the phonation as well as spontaneous speech sample of client ‘c’. preand post-therapy phonation and/or speech samples were randomised for perceptual evaluation, where the judges were blindfolded for the purpose. they were asked to rate samples on a four-point rating scale using the grbas scale. the psychosocial impact of dysphonia because of sulcus vocalis was assessed using voice handicap index (vhi) (jacobson et al., 1997) questionnaire (which consisted of 30 questions). it is a self-rating scale that highlights the perceived severity of voice problem by the client. the voice evaluation was performed two consecutive days before the initiation of voice therapy and the results were averaged. the voice evaluation results are presented in table 1. these measures were obtained before the initiation of voice therapy programme (pre-therapy). table 1: comparison of pre-therapy and post-therapy voice parameters. voice therapy programme the secondary focus of this study was to determine the effect of non-medical treatment (i.e. voice therapy) for this pathological condition. boone’s facilitation techniques (boon et al., 2010) including elimination of abuses, relaxation, establishing a new pitch, forward focus and auditory feedback were employed in the voice therapy programme. the aim of the voice therapy plan was: (1) to increase the vocal efficiency by improving the coordination between respiratory and phonatory systems, (2) to improve the quality of voice by forward focus and resonance voice therapy and (3) to eliminate the vocal abusive behaviours through a customised vocal hygiene programme for the client. the client attended voice therapy for 15 sessions, where each session lasted for about 45 min. furthermore, the laryngeal adduction exercises including breath holding technique and pushing and pulling technique were practiced in the therapy sessions. the post-therapy measures on all the domains (acoustic, aerodynamic, perceptual, self-rating and objective voice quality measures) were obtained after 15 sessions of voice therapy, and preand post-therapy measures on all the domains were compared (table 1). ethical considerations ethical clearance was obtained from the ethics committee for bio-behavioural research projects involving human subjects, at all india institute of speech and hearing (aiish). reference number: ecc-res.art/02/2016-17. results and discussion the results are discussed in the following two sections: (1) voice characteristics in client ‘c’ and (2) effect of voice therapy. table 1 shows the comparison of preand post-therapy voice measures. voice characteristics in client ‘c’ in the pre-therapy assessment, from table 1, the average fundamental frequency of the client was 186.6 hz, which was measured for phonation sample. the obtained frequency value is higher than the male frequency range (eguchi & hirsh, 1969). this higher fundamental frequency (f0) led to perceive or recognise the client as female by listeners. the standard deviation (sd) of f0 was 8.79 hz. the jitter and shimmer values were 0.23% and 0.08%, respectively. the extent and speed of fluctuation in f0 and intensity (i0) was higher in the client when compared to the normative value (ideally it must be zero). the normalised noise energy (nne) was -10.38 and the number of harmonics was just two in the pre-therapy voice sample. the forced vital capacity (fvc) and mean air flow rate (mafr) were measured during pre-therapy assessment and the values were 1760 ml and 300 ml/s, respectively. the fvc of the client was less when compared to the normative value of indian adult male values (2500 ml and above). also, maximum phonation duration (mpd) in the client was about 6 s. this indicates poor respiratory support for voice production in the present client of interest. on the other hand, the client had higher mafr value compared to normal value (80 ml/s – 180 ml/s), which indicates glottal incompetence, that is, poor contact or closure of the vocal folds during phonation (baken 1987). the results of the perceptual voice evaluation revealed that judge 1 and judge 2 rated the overall grade of dysphonia as moderate (2) and mild (1), respectively. breathiness was rated as severe (3) and moderate (2) by judges 1 and 2, respectively. the other parameters such as roughness, asthenia and strain were rated similarly by both the judges at the pre-therapy condition. table 2 shows the perceptual ratings of both judges at preand post-therapy conditions. the measured dsi score (objective voice quality measure) was -2.6 during pre-therapy assessment, indicating a poor voice quality. table 2: grbas results before and after voice therapy. the negative impact of the voice disorder or difficulty was assessed by using vhi-30 questionnaire. the vhi questionnaire is a self-rating questionnaire consisting of 30 questions that assesses the functional, physical and emotional aspects of the client because of voice difficulty. effect of voice therapy the client attended 15 sessions of voice therapy, and on the 16th session, post-therapy voice assessment was performed by considering the average performance of three trials. the comparison of preand post-therapy voice assessments on acoustic, aerodynamic, perceptual, objective voice quality and self-rating measures was carried out (see table 1). the average f0 was reduced from 181.6 hz to 138.3 hz after voice therapy which now falls within the normal f0 range of adult males (eguchi & hirsh, 1969). also, there was a reduction noticed in the sd of f0. the reduction in sd f0 value indicates reduced variability of pitch. the jitter and shimmer values (perturbation measures) reduced after voice therapy in the client. this indicates more stable voice with less fluctuation in pitch and loudness parameters. furthermore, the extent and speed of fluctuations in both f0 and i0 was reached relatively within normal limits after voice therapy. the nne value has improved after voice therapy and also the number of harmonics has increased from 2 to 10 in the post-therapy. in general, it is known that there is a correlation between voice quality and the number of harmonics (qi & hillman, 1997). increased number of harmonics after therapy in client ‘c’ can be attributed to improved and better voice quality. forced vital capacity and mpd measurement increased after voice therapy and it needs to be worked upon further to reach the normative range. s/z ratio and mafr reduced prominently after therapy. reduction in mafr indicated that the airflow between the vocal folds (glottis) during phonation is reduced and it could be because of improvement in the adduction of vocal folds during phonation. perceptually, the post-therapy sample has no strain and roughness. judge 2 rated the post-therapy sample as normal (indicated ‘0’ on all the five parameters) in comparison to judge 1 who rated the sample as mild breathy. a prominent reduction was noticed on overall grade, roughness, asthenia and strain by both the judges, which indicated that the client produces voice (both phonation and speech task) with utmost ease without any difficulty or straining himself within the post-test situation. the dsi value predominantly improved after voice therapy. that is, it improved from -2.6 to 4. the improvement in dsi value could be because of increased mpd value and greater control on pitch and loudness of voice. the vhi values were also reduced from 27 to 17 after therapy. the decreased vhi values can be attributed to the improvement in functional, physiological and emotional aspects of the client, which is triggered by voice therapy. outcome studies after behavioural intervention are very few in the case of sulcus vocalis. in this regard, there is a study wherein the efficacy of a trial voice therapy (10 sessions of 40 min duration for 15 days) in a 31-year-old male client with sulcus vocalis was examined (ranjini, ramya, namboothri & gopikishore, 2011). in the above study, the authors found positive changes in the vocal behaviours after voice therapy on objective, perceptual and self-perceptual domains. the authors concluded the behavioural voice management such as respiratory–phonatory control exercises, laryngeal manual therapy and forward focus as effective options for treating individuals with sulcus vocalis. the results of the present study are in consonance with the above research findings. however, sulcus vocalis condition is challenging to treat because of the lesions involving the vocal fold layers. eventually, in general, the physiologic sulcus (type 1) condition responds to voice therapy unlike types 2 and 3. the improvement shown by client ‘c’ leads us to opine that the sulcus vocalis might probably be of type 1 rather than of other types. conclusion this study was aimed at determining the effect of voice therapy on a client with sulcus vocalis. also, the study documented and/or profiled the voice characteristics using some of the acoustic, aerodynamic, perceptual, objective voice quality measure (dsi) and self-rating scale (vhi) parameters. the outcome of the voice therapy was empirically documented in the study by comparing the pre-therapy and post-therapy voice parameters. the study found prominent positive changes in the voice parameters after voice therapy, such as reduction in f0, reduction in perturbation measures (jitter and shimmer), increased number of harmonics, increased mpd, vital capacity and reduced mafr. the vhi scores were also reduced after therapy. perceptually, overall grade and strain in voice reduced during post-therapy condition. the objective voice quality measure (dsi) shifted from negative value towards positive value. these changes can be attributed to the influence of non-medical management, that is, voice therapy. boon’s facilitation techniques, improving the coordination between respiratory and phonatory systems and educating on vocal hygiene, were proved to be beneficial for client ‘c’ with sulcus vocalis. the other contributing factor could be the motivation of the client. the client in this study was greatly motivated and attended all the voice therapy sessions without fail. it is substantial to document systematically the multidomain voice measures for evidence-based clinical practice in voice disorders. limitations of the study are the following: it is a single-subject study; therefore, one must be cautious in generalising the results and post-therapy ffl could not be done for better comparison because of implicit reasons. the voice therapy employed in the study improved client c’s physiology of vocal apparatus and not the anatomy of vocal folds which would have been commented if ffl was done during post-therapy. however, this study documented the immediate effect of voice therapy on multiparametric approach in voice assessment. the long-term effect of the same can be studied in future. more studies are warranted in voice therapy outcome measures with more clients with sulcus vocalis. to conclude from this study, voice therapy can be considered as the initial treatment option before any surgical management, and if it fails, the latter can be recommended consequently for clients with sulcus vocalis. acknowledgements competing interests the author declares that he has no financial or personal relationships which may have inappropriately influenced him in writing this article. references aronson, a.e., & bless, d.m. (2010). clinical voice disorders. (4th edn.). new york: thieme publishers. baken, r.j. (1987). clinical measurement of speech and voice. boston, ma: little, brown. boon, d.r., mcfarlane, s.c., von berly, s.l., & zraick, r.i. (2010). the voice and voice therapy. (8th edn.). boston, ma: pearson publication. bouchayer, m., & cornut, g. (2000). voice disorders of structural orgin. in a.e. aronson & d.m. bless (eds.), clinical voice disorders (2010) (pp. 164–178). new york: thieme publishers. calton, r.h., & casper, j.k. (1990). understanding voice problems. a physiological perspective for diagnosis and treatment. baltimore, md: williams & wilkins, pp. 51–69. eguchi, s., & hirsh. i.j. (1969). fundamental frequency. acta oto-laryngologica, 68(suppl 257), 23–26. http://dx.doi.org/10.3109/00016486909129236 ford, c.n., inagi, k., bless, d., khidr, a., & gilchrist, k.w. (1996). sulcus vocalis: a rational analytical approach to diagnosis and management. annals of otology rhinology laryngology, 105, 189–200. http://dx.doi.org/10.1177/000348949610500304 giovanni, a., chanterect, c., & lagier, a. (2007). sulcus vocalis: a review. european archives of oto-rhino-laryngology, 264, 337–344. http://dx.doi.org/10.1007/s00405-006-0230-8 greison, o. (1984). vocal cord sulcus. journal of laryngology and otology, 98, 293–296. http://dx.doi.org/10.1017/s0022215100146596 hirano, m. (1981). psycho-acoustic evaluation of voice. in g.e. arnold, f. winckel & b.d. wyke (eds.), disorders of human communication, 5, clinical examination of voice (pp. 81–84). new york: springer-verlag. hirano, m., yoshida, t., tanaka, s., & hibi, s. 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(1997). temporal and spectral estimations of harmonics to noise ratio in human voice signals. the journal of acoustical society of america, 102(1), 537–543. http://dx.doi.org/10.1121/1.419726 ranjini, g.c., ramya, h.y., namboothri, k.v., & gopikishore, p. (2011). efficacy of voice therapy in sulcus vocalis: a single case study. in proceedings of the international symposium on frontiers of research on speech & music and computer music modeling and retrieval, 9–12 march 2011, bhubaneswar, pp. 84–88. rubin, j.s., & yanagisawa, e. (2006). benign vocal fold pathology through the eyes of the laryngologist. in j.s. rubin, r.t sataloff, & g.s korovin (eds.), diagnosis and treatment of voice disorders. (3rd edn., pp. 209–221). san diego, ca: plural publishing inc. wuyts, f.l., de bodt, m.s., molenberghs, g., remacle, m., heylen, l., miilet, b., et al., (2000). the dysphonia severity index: an objective measure of vocal quality based on a multi-parameter approach. journal of speech, language and hearing research, 43(3), 796–809. http://dx.doi.org/10.1044/jslhr.4303.796 sajcd63(2).indb reviewer acknowledgement open accesshttp://www.sajcd.org.za page 1 of 1 the editorial team of the south african journal of communication disorders recognises the value and importance of peer reviewers in the overall publication process – not only in shaping individual manuscripts, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank the following reviewers who participated in shaping this issue of the south african journal of communication disorders: gale stam heila jordaan jean-marc colletta maxwell kadenge michelle pascoe olga carpirci ramona kunene nicolas we appreciate the time taken to perform your review successfully. in an effort to facilitate the selection of appropriate peer reviewers for the south african journal of communication disorders, we ask that you take a moment to update your electronic portfolio on www.sajcd.org.za for our files, allowing us better access to your areas of interest and expertise, in order to match reviewers with submitted manuscripts. if you would like to become a reviewer, please visit the journal website and register as a reviewer. to access your details on the website, you will need to follow these steps: 1. log into the online journal at http://www. sajcd.org.za 2. in your ‘user home’ [http://www.sajcd.org. za/index.php/sajcd/user] select ‘edit my profile’ under the heading ‘my account’ and insert all relevant details, bio statement and reviewing interest. 3. it is good practice as a reviewer to update your personal details regularly to ensure contact with you throughout your professional term as reviewer to the south african journal of communication disorders. please do not hesitate to contact us if you require assistance in performing this task. publisher: publishing@aosis.co.za tel: +27 21 975 2602 fax: +27 21 975 4635 south african journal of communication disorders sajcd kortikale komper-oudiometrie „electric response audiometry (era)" i. s. hay departement spraakheelkunde, oudiologie en spraakwetenskap, universiteit van pretoria inleiding alle studente van die vakgebied oudiometrie, is bewus van die noodsaaklikheid van die bestaan van gestandardiseerde, objektiewe oudiometriese metodes. sodanige metodes het as vereistes praktiese uitvoerbaarheid sowel as response sonder die bewuste samewerking van die indiwidu. daar bestaan talle situasies waargeen betroubare response volgens subjektiewe metodes verkry kan word by die ondersoek van 'n persoon se gehoordrumpel nie. hierdie situasie kom voor by bykans alle ouderdomsgroepe, maar dis veral by die baba of jong kind wat dit van kardinale belang is dat 'n redelik betroubare oudiogram verkry kan word. die vroee diagnosering van gehoorverlies by die baba en jong kind kan deurslaggewend wees wat die aanleer van taal en spraak betref asook die algemene opvoedbaarheid van die kind. verskeie objektiewe oudiometriese metodes is in die afgelope drie dekades ontwikkel met mindere of meerdere mate van sukses, maar geeneen van die metodes word vandag as roetinemetodes in die praktyk gebruik nie. bekendste van die.metodes is seker die elektro-dermale metode waar 'n ligte elektriese skokstimulus kondisionerend gebruik word om 'n velweerstandsverandering te bewerkstellig by die aanbieding van 'n klankstimulus. behalwe vir die vrees wat die skok veral. by kinders inboesem, word die metode onaanvaarbaar weens die vele vals positiewe response wat ontstaan by ontvangs van stimuli anders as klankstimuli. hoewel die response objektief genoem kan word, is die interpretasie van resultate, wat baie tyd in beslag neem, beslis subjektief van aard. die elektro-ensefalografie bied 'n ander moontlikheid van objektiewe gehoorondersoek aangesien klankstimuli, soos meeste ander sensoriese stimuli, een of ander uitwerking het op die eeg-patroon wat gelyktydig met die aanvang en bee'indiging van die stimulus plaasvind. hierdie metode word nog in sommige navorsingsinrigtings oorsee gebruik, maar is vanwee die ongeveer drie uur wat benodig word om die resultate te ontleed, nie geskik as 'n roetine oudiometriese metode nie. netsoos by die elektro-dermale metode is die beoordeling van die resultate hier meestal subjektief aangesien die verandering wat in die eeg-patroon plaasvind nie altyd onomstrede is nie. sedert die vroee sestigerjare tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. : des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 8 i. s. h a y is daar gewerk aan 'n gewysigde eeg-metode wat gebruik maak van 'n sommeringsproses wat die klein en twyfelagtige ouditiewe response in die geheue van 'n rekenaar bewaar en met elke opvolgende stimulus sommeer tot 'n positiewe respoas wat as sodanig erken kan word sonder enige twyfel. hierdie nuwe metode wat reeds in baie klinieke oor die aardbol heen met groot welslae gebruik word, word genoem ..cortical evoked response audiometry" of ..cortical average evoked response audiometry". aangesien die engelse terme nie geredelik in afrikaans vertaal kan word nie, het prof. p. de v. pienaar voorgestel dat die metode in afrikaans moet heet: kortikale komperoudiometrie, om daardeur te wys op die feit dat 'n komper (..computer") in die apparaat gebruik word. historiese agtergrond caton (1875) kan beskou word as die eerste wetenskaplike wat resultate van kortikale potensiale gemeet op diere, gepubliseer het. hy het hierdie metings gemaak as reaksies op sensoriese stimuli sowel as spontane breinaktiwiteit. hierna is veel gepubliseer op hierdie gebied, maar dit was hans berger (1929) wat die wetenskaplikes bewus gemaak het van die bestaan van die spontane elektriese breinaktiwiteit by die mens. sedertdien het menige ondersoek berger se bevindinge aangaande die bestaan van breinritmes bevestig. tussen 1930 en 1940 het baie ondersoekers die stadige breingolfritmes beskryf asook die elektriese kortikale response op visuele, ouditiewe en ander sensoriese stimulasies. pogings is ook aangewend om die bron van hierdie kortikale response vas te stel, maar dit was nie baie suksesvol nie. (douchin en lindsley, 1969.) die kortikale response was egter nie by alle indiwidue maklik as sodanig identifiseerbaar nie aangesien veranderinge voortdurend in die eeg-optekeninge plaasgevind het. verder was die response dikwels veel kleiner as die spontane aktiwiteit van die brein. wetenskaplikes het dus besef dat 'n metode gevind moes word waardeur die response op opeenvolgende stimuli bymekaar getel kon word sonder om die spontane breinaktiwiteit te sommeer. die eerste pogings tot so 'n sommeringsproses was die van dawson (meganiese kommutator) en spoor (fotografiese superposisie), maar beide^metodes was as minder geslaagd beskou. dit was eers met die koms van spesiaal ontwerpte rekenaars wat 'n suksesvolle' metode van sommering ontwikkel is. response wat aan die stimuli in tyd gebonde was, kon in die geheue van 'n rekenaar gesommeer word. aangesien die spontane breinaktiwiteit nie in tyd aan die stimulus gebonde is nie, kanselleer dit geleidelik uit terwyl die response geleidelik groei tot 'n duidelik waarneembare positiewe gesommeerde respons. in werklikheid groei die response met n, die aantal response wat gesommeer word, terwyl die spontane aktiwiteit groei met -\/n. die komper wat verantwoordelik is vir hierdie elektroniese „toertjie", word genoem 'n journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kortikale komper-oudiometrie „electric response audiometry (era)" 9 „gemiddelde responskomper", en dit vorm die hart van die kortikale komper-oudiometrie. vir 'n kort tydjie na die stimulus maak die geheue van die komper oop en daar word weggele 'n rekord van die elektriese kortikale respons. daar word 'n ander soortgelyke stimulus aangebied. die komper beskou weer die breinrespons onmiddellik na die stimulus, en voeg hierdie response by die response wat reeds in die geheue vasgele is. die proses van sommering van response word herhaal met die aanbieding van elke stimulus. die gemeenskaplike eienskappe van al die response voeg saam terwyl die spontane breinaktiwiteit neig om uit te kanselleer. die komper verbeter dus die sein-tot-ruisverhouding deur 'n groot aantal tyd-gebonde-response te sommeer. (davis, 1968) die vertekspotensiaal vanghan (1969) het isopotensiaal-kaarte van die skedel opgestel waarop hy die verspreiding van potensiale van response op visuele, ouditiewe en somato-sensoriese stimuli aandui. hieruit blyk dit dat die verteks (die kruispunt van twee reghoekige lyne wat die inion en nasion enersyds, en die twee eksterne oorkanale andersyds oor die skedel verbind) die gunstigste posisie op die skedel is waar response op stimuli van aldrie genoemde modaliteite waargeneem kan word. (douchin en lindsley, 1969.) die verteks het die verdere voordeel dat dit ver genoeg weg is van die gesig vanwaar steurings vanaf spiere tydens oogknipbewegings ontstaan. hierdie steurings kan 'n nadelige uitwerking he op die kortikale potensiale. die vertekspotensiaal word algemeen beskou as 'n diffuse, nie-spesifieke respons wat opgewek kan word deur ouditiewe, visuele en somato-sensoriese stimuli. die golfvorms van response op stimuli van die verskillende modaliteite is in 'n mate verskillend, maar hulle het almal dieselfde algemene vorm. (fig. 1.) die fisiologiese betekenis van hierdie potensiaal is onbekend. dit bevat positiewe en negatiewe pieke wat ons aandui deur no, pi, nl, p2 ens., en met benaderde latensies van n o = 3 0 , p1=50,n1= 100, p2~ 175, n2=300 msek respektiewelik. die mees konstante en kenmerkende paar is n l p2 en ons meet die amplitude van die vertekspotensiaal hier tensy dit anders gespesifiseer word. (davis en zerlin, 1966.) een van die uitstaande kenmerke van die vertekspotensiaal, is sy variabiliteit selfs wanneer dit beskou word as 'n gesommeerde respons. hierdie variabiliteit kan slegs deels gewyt word aan veranderinge in die staat van die geval. sekere fisiese parameters is bepalend wat die grootte van die respons betref, en is van belang by die interpretasie van oudiometriese resultate. die volgende parameters is van die grootste belang: (1) interstimulus-intervalle die response is die grootste wanneer die intervalle tussen stimuli die grootste is. hierdie feit staan heelwaarskynlik in verband met die tydskrif van die suid-afrikaanse logopediese vereniging, vol. , nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 10 i. s. h a y absolute refraktere periode wat benodig word voordat die „stelsel" weer gereed is vir 'n verdere respons netsoos 'n senuvesel 'n periode 100 ms 200 ms 5mv 1 100 ms h fig. 1. voorbeelde van tipiese kortikale responsgolfvorms vir stimuli van verskillende modaiiteite (gehoor, taktiel en visueel). die komponente n1-p2 is die mees stabiele fase en word die „vertekspotensiaal" genoem. • journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kortikale komper-oudiometrie electric response audiometry (era)" van rus benodig voordat dit vir 'n tweede keer kan vuur. lang-intervalle veroorsaak egter 'n lang toetsperiode wat ongewens is wanneer klein kindertjies ondersoek word. tydens 'n oudiometriese ondersoek stel ons belang in die grootste lewering per minute en dit word bereik met 1 of 2 stimuli per sekonde. (davis et al, 1966.) (2) stimulussterkte daar is 'n geleidelike toename in responsgroote met verhoging van stimuluspeil. ongeveer 25 desibel sensasiepeil word benodig vir 'n verdubbeling van die vertekspotensiaal. (davis en zerlin, 1966.) (3) aantal response wat gesommeer word hoe groter die aantal stimuli wat vir sommasie aangebied word, hoe groter die gesommeerde respons. in werklikheid groei die respons lineer met die aantal response. die agtergrond of spontane aktiwiteit groei met die vierkantswortel van die aantal response wat gesommeer word. weereens word 'n beperking op die aantal gele deur die tydsfaktor veral by jong kinders. (4) gereelde vs ongereelde intervalle navorsing het bewys dat ongereelde intervalle 'n geringe voordeel het bo gereelde aanbiedings, maar die voordeel regverdig nie die addisionele koste van die apparaat wat vir ongereelde intervalle benodig word nie. die toestand van die toetsling kan ook 'n iiitwerking he op die kortikale respons. die beste resultate word verkry wanneer die geval of heeltemal wakker is, of in 'n diepe slaap verkeer. 'n toestand van ligte slaap of in 'n oorgangstadium veroorsaak 'n veranderende responspatroon wat die interpretasie van resultate bemoeilik. hieruit kan afgelei word dat bewuste aandag nie noodsaaklik is by die opwekking van response nie, solank die gevalle in die wakkertoestand ontspanne sit en lees. wanneer 'n kind dus in die slaaptoestand ondersoek word, moet daar noukeurig gelet word op die diepte van slaap deur na die onverwerkte eeg-patroon te kyk terwyl die toets aan. die gang is. apparaat basies bestaan die apparaat wat in die algemeen vir kortikale komperoudiometrie gebruik word, uit vier hoofonderdele: 1. oudiometer 'n standaard oudiometer, volgens internasionale standaard ingestel, word gebruik vir die lewering van stimuli deur middel van oorfone,' 'n vibrator, of 'n luidspreker. tydskrif van die suid-afrikaanse logopedieseverenigig, vol. nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 i. s. h a y 2. tydreeling ten einde beheer uit te oefen oor die aantal stimuli wat aangebied word asook die intervalle tussen die stimuli, word 'n teller en tydreelingsapparaat gebruik. die teller word gekoppel aan die geheue van die rekenaar aangesien dit bepaal hoeveel response gesommeer moet word. 3. komper 'n spesiale tipe komper wat die elektriese potensiale vanaf die verteks sommeer en sodoende 'n gesommeerde of gemiddelde respons in die geheue vasle, word gebruik. die golfvorm van die kortikale respons, word netso in die geheue vasgele sodat die gesommeerde respons 'n potensiaal-tyd funksie is waarin die oorspronklike funksie behoue gebly het. die geheue bestaan uit 100 tyd „bins" wat 'n goeie akkuraatheid verseker. 4. eeg-apparaat standaard eeg-toerusting word gebruik vir die versterking en filtrering van die elektriese potensiale wat deur elektrodes op die skedel opgeneem word. na die versterker en filter verdeel die geleiding: een baan gaan direk na 'n skrywer vir die optekening van die onverwerkte eeg-patrone, die tweede baan gaan via die rekenaar na 'n ander skrywer waar die gesommeerde response opgeteken word. kliniese toepassing die kliniese toepassing van die kortikale komper-oudiometriese metode, bestaan daaruit dat response op stimuli gesommeer word en dat die finale gesommeerde respons beskou word om vas te stel of dit as 'n positiewe respons geag kan word. (a) elektrodes drie elektrodes moet aan die kopvel vasgeheg word: die aktiewe elektrode kom op die verteks, die verwysingselektrode op die mastoied en die grondelektrode op die voorkop. die beste tipe elektrode om te gebruik, is die miniatuur beckmanelektrodes wat deur middel van klewerige plastiek aan die skedel vasgeheg word. (b) beheer van die kind die kind wat in 'n gewekte toestand getoets word, moet besig gehou word terwyl hy stil sit. dit verg meestal 'n bekwame persoon wat die vertroue van die kind kan wen en sy aandag kan wegkeer van die oorfone journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kortikale komper-oudiometrie „electric response audiometry (era)" 13 en elektrodes op sy kop. hierdie assistent kan beskou word as 'n baie belangrike lid van die toetsspan. die kind wat in die slaaptoestand ondersoek word, moet gerieflik gemaak word, verkieslik in 'n bababed. , indien 'n luidspreker in plaas van oorfone gebruik word, is dit belangrik om dit te yk vir 'n bepaalde afstand vanaf die luidspreker. dit word dikwels gevind dat 'n kind weier om die oorfone op die kop toe te laat en in so 'n geval is die luidspreker die aangewese klankbron. (c) toetsfrekwensies daar is gewoonlik nie tyd vir toetse by meer as drie frekwensies nie. die kind wat in die gewefcte toestand getoets word kan nie langer as uiters een uur besig gehou word nie. die slapende kind sal ook nie lank genoeg in daardie toestand verkeer nie. derhalwe is dit raadsaam om slegs by 250, 1 000 en 3 000 hz te toets. positiewe resultate by hierdie 3 frekwensies sal 'n baie goeie beeld gee van die kind se gehoorvermoe. (d) intensiteitspeil vanwee die tydsbeperking is die keuse van die aanvangsintensiteit baie belangrik. indien 'n erge verlies vermoed word, moet daar by 'n hoe intensiteit begin word (bv. 90 desibel) en indien 'n geringe verlies vermoed word, sal 50 desibel voldoende wees. aangesien hierdie ondersoek 'n drempelwaarde soek, sal die intensiteitspeil verminder word totdat geen respons meer waargeneem word nie. gewoonlik word daar nie laer as 30 desibel getoets nie aangesien die response te klein word vir identifikasie. 'n redelike respons by 30 desibel word dus beskou as 'n aanduiding van normale gehoor. hoe intensiteitspeile by lae frekwensies (250 en 500 hz) kan moontlik 'n taktiele respons tot gevolg he en die toetsafnemer moet op sy hoede wees by die interpretasie van sodanige toetse. (e) kontrolestimulasie in die geval van atipiese ouditiewe response, is dit nuttig om van stimuli van 'n ander modaliteit gebruik te maak teneiende die sentrale senustelsel te toets. 'n flitsende lig of 125 hz vibrasie op die hand of voet, is goeie voorbeelde van sodanige stimulasie. die kortikale respons van die taktiele vibrasies het feitlik dieselfde vorm as die van die ouditiewe respons en kan gebruik word as voorbeeld van hoe die ouditiewe respons behoort te lyk. (f) identifisering van positiewe response vir die volwasse persoon bestaan daar 'n betreklike normatiewe kortikale respons op ouditiewe stimuli. by so 'n indiwidu verskyn die kenmerkende positiewe en negatiewe pieke van die responsgolfvorm tydskrif van die suid-afrikaanse logopediese vereniging, vol. , nr. 1: des. 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 i. s. h a y altyd op min of meer dieselfde plekke. in sodanige gevalle is dit redelik maklik om tot 'n beslissing te kom of die respons positief is, al dan nie. by die kind en veral die voorskoolse kind, is die respons minder stabiel en wanneer die kind in die slaaptoestand getoets word, kry ons te doen met 'n veranderende golfvorm waarin die kenmerkende vorm glad nie verskyn nie. in so 'n geval kan 'n positiewe respons slegs herken word indien die respons, wat sy vorm ookal, herhaalbaar is. die beoordeling van hierdie herhaalbaarheid, is 'n subjektiewe proses, maar met genoegsame oefening en deur superponering van verskeie resultate kan die positiewe response gei'dentifiseer word. voorts is dit die temporale aspek: van die respons wat die herhaalbaarheid bepaal en nie die amplitude nie. die amplitude van die respons is in die reel baie onstabiel en kan nie sondermeer as norm gebruik word nie. (g) bepaling van 'n gehoordrempel aangesien dit selde gebeur dat 'n positiewe kortikale respons by 'n subjektiewe drempel gevind word, dien dit geen doel om so 'n respons te soek nie. indien 'n positiewe respons by 30 desibel gei'dentifiseer kan word, kan normale gehoor aanvaar word aangesien slegs 'n redelike groot respons identifiseerbaar is te midde van die kortikale agtergrondsaktiwiteit. soos voorheen aangedui, neem die grootte van die respons toe met verhoogde stimulus intensiteitspeil. teoreties sal dit dus moontlik wees om die opgetekende response by verskillende intensiteitspeile te vergelyk en waar te neem hoe die response kleiner word met afnemende intensiteitspeile. in die praktyk is soiets alleen waanieembaar met talle replikasies by dieselfde intensiteitspeile wat natuurlik nie moontlik is nie aangesien tyd 'n faktor is. tydens die toets van 'n jong kind word daar slegs gesoek na die laagste intensiteitspeil waar wel. 'n respons te bespeur is, verkieslik na 'n enkele herhaling by elke intensiteitspeil (fig. 2.) dit is ook toelaatbaar (davis et al, 1967) om te interpoleer of te ekstrapoleer deur die grootte en identifiseerbaarheid van die respons in ag te neem. (h) kortikale response van kinders die response van die kind verskil in vorm van die van die volwasse persoon. op 7 jaar is daar tekens van stabilisasie en begin/die response in vorm te vergelyk met die van die volwassene. die respons van 'n baba van 'n paar dae oud lyk ook heeltemal anders as die van 'n baba van 'n paar maande oud. verder is die variabiliteit van die respons by die kind veel groter as die van die volwasse persoon wie se variabiliteit al klaar groot afmetings aanneem. hierdie feit maak die akkurate toetsing van 'n jong kind baie moeilik. daar is 'n neigin£ by die respons van die kind om die nl-komponent te verloor eh n2 begin dan toeneem in belangrikheid. journal of the south african logopedic society, vol. 17, no. 1: december 7970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kortikale komper-oudiometrie „electric response audiometry (era)" 15 in so 'n geval is dit noodsaaklik dat daar gesoek word na die karakteristieke vorm van die kind se respons eerder as om 'n ideale, eenvoudige, gemiddelde patroon voor te hou. verteks potensiaal gehoorpeil 30 db 2 0 d b μ 500 4 ms fig. 2. die vertekspotensiaal by verskillende gehoorpeile. dit stel voor die respons van 'n volwasse persoon met 'n goed gevormde en konstante response. die n1-p2 fase is duidelik sigbaar by die hoer peile, m a a r verdwyn naby die drempel. (negatief opwaarts). tydskrif van die suid-afrikaanse logopediese vereniging, vol. , nr. 1: des.1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 i. s. h a y (i) gebruik van kalmeermiddels die gebruik van 'n kalmeerof selfs slaapmiddel, word voorgeskryf waar hiperaktiwiteit die kanse op 'n suksesvolle toets onwaarskynlik maak. die baba tussen 6 en 18 maande oud, is moeilik beheerbaar en moet sondermeer 'n slaapmiddel toegedien word. die baba onder 6 maande oud, kan gewoonlik net na voeding getoets word wanneer hy gou aan die slaap raak. die voordeel van 'n slaapmiddel is egter dat die kind vir 'n langer tydperk vir toetsing beskikbaar is. die hiperaktiewe kind se bewegings is in die reel sodanig dat indien die elektrodes nie heeltemal afgetrek word nie, dan werk die spieraksies nadelig in op die kortikale response. hoewel dit altyd beter is om 'n kind in die gewekte toestand te toets in welke toestand 'n meer bekende responsgolfvorm onstaan, moet ons aanvaar dat by die kind wat baie beweeg daar min hoop is op 'n goeie toetsresultaat. die effek van die kalmeerof slaapmiddels varieer van een preparaat tot 'n ander wat hul wysiging van die kortikale respons betref. die hoeveelheid wat toegedien word sal in die reel afhang van die ouderdom en massa van die kind. dis egter die slaaptoestand of diepte van slaap wat 'n groter uitwerking het as die middel self, 'n statiese toestand is ook gunstiger as 'n veranderende een. die middels wat die skrywer as die mees suksesvolle beskou, is secobarbital en chloral-hydrate. eersgenoemde hou die kind langer in 'n slaaptoestand en het die minste uitwerking op die eeg-patroon. opsomming die nuutste objektiewe oudiometriese metode wat vandag wereldwyd aanvaar is, is die kortikale komper-oudiometrie. dit maak gebruik van 'n gespesialiseerde komper wat die elektriese response wat in tyd aan die stimuli gebonde is, sommeer tot 'n identifiseerbare respons. by die volwassene het die gesommeerde vertekspotensiaal 'n golfvorm wat min verskil van een indiwidu tot 'n ander. by die kind onder sewe jaar oud, en veral in die slaaptoestand, is die golfvorm minder konstant. vanwee die steurende effek van spierbewegings op die kortikale respons, is dit verkieslik dat die jong aktiewe kind met kalmeermiddels tot 'n slaaptoestand gebring word. na die sommering van 'n voorafgekose aantal response, word die gesommeerde response uitgeskryf om 'n permanente rekord te vorm. deur superponering kan die resultate by verskillende frekwensies en intensiteite vergelyk word deur hulle oor 'n sterk lig te hou./vergelykbare response word as positief gei'dentifiseer en die drempel geskat volgens die laagste intensiteit waar positiewe response sigbaar is. wanneer 'n standard golfvorm nie verskyn nie,, word gesoek na die kenmerkende golfvorm vir die betrokke'indiwidu. summary the electric response audiometric method is being accepted the world over as a reliable objective method. it utilizes a special purpose journal of the south african logopedic society, vol. 17, no. 1: december 1970 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) kortikale komper-oudiometrie „electric response" audiometry (era)" 17 computer which averages time locked responses in such a way that an identifiable response emerges. the waveform of the averaged cortical responses ,of adults differs little from one individual to another. the averaged response of children under the age of seven, varies greatly especially when they are tested in a state of sleep. because of the interference caused by muscle action while the testing is in progress, it is always desirable to test the active young child after application of a sedative which will put the child to sleep. after averaging a predetermined number of responses, a permanent record is made by writing out the summated response. the results of stimuli of different frequencies and intensities are compared by superimposing the results over a strong light. comparable responses can thus be identified and an estimate made of the thresholds according to the lowest intensity levels which gave positive response. when a standard waveform does not appear, it is suggested that the individual's characteristic waveform be sought. bibliografie 1. douchin, e. en lindsley, d. b. (ed.): average evoked potentials, national aeronautics and space administration, 1969. 2. davis, h . : slow electrical responses of the h u m a n cortex. proc. of amer. philosophical society. vol. 112, 3, 1968. 3. davis, h . en zerlin, s: acoustic relations of the h u m a n vertex potential. journal of acoustic society of america. 39, 1, 109-116, 1966. 4. davis, h., mast, t., yoshie, n . en zerlin, s.: slow response of the h u m a n cortex t o auditory stimuli: recovery process. electroenceph. clin. neurophysiol. 1966, 21: 105-113. 5. davis, h., hirsh, s. k., shelmutt, j. and bowers, c. f u r t h e r validation of evoked response audiometry (era). journal of speech and hearing research. dec. 1967. vol. 10, n o . 4. tydskrif van die suid-afrikaanse logopediese vereniging, vol. 17, nr. 1: des. 1970, r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract background methods ethical consideration results and discussion conclusion acknowledgements references about the author(s) katijah khoza-shangase department of speech pathology and audiology, university of the witwatersrand, johannesburg, south africa katherine gautschi-mills department of speech pathology and audiology, university of the witwatersrand, johannesburg, south africa citation khoza-shangase, k., & gautschi-mills, k. (2019). exploration of factors influencing the preservation of residual hearing following cochlear implantation. south african journal of communication disorders 66(1), a607. https://doi.org/10.4102/sajcd.v66i1.607 original research exploration of factors influencing the preservation of residual hearing following cochlear implantation katijah khoza-shangase, katherine gautschi-mills received: 16 aug. 2018; accepted: 24 jan. 2019; published: 10 apr. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: increasing access to cochlear implants within the resource-constrained south african context calls for careful investigation of all factors that might influence benefit from this technological advancement. objective: the aim of this study was to investigate preservation of hearing following cochlear implant surgery and whether a relationship existed between the post-operative hearing findings and certain factors. methods: within a quantitative paradigm, a retrospective data review design was adopted where a sample consisting of audiological records from 60 observations and surgical records from two cochlear implant units in south africa was investigated. these records were selected using purposive sampling and consisted of records from participants ranging from 6 to 59 years. comparative analysis of unaided audiological test results was preand post-operatively performed, where all paitents were implanted with cochlear devices. factors documented to have a possible influence on post-operative outcomes were examined in an attempt to establish relationships that may exist. findings were analysed by means of both inferential and descriptive statistics. results: the findings indicated 92% success rate in preservation of residual hearing. there was a direct correlation between surgical techniques, as well as cochlear implant type and the successful hearing findings, in the absence of surgical complications. other factors explored did not have any negative effect on the hearing findings. conclusion: the study findings suggest improved surgical outcomes with enhanced surgical techniques and advanced technology, with a clear negative impact of intraoperative complications on the outcomes. keywords: cochlear implant; complications; electrode; intracochlear; preservation; residual hearing. background evidence of improved speech perception because of technological advances in cochlear implantation and improvements in surgical techniques exists (balkany et al., 2006), and this includes patients with residual hearing in low frequencies. historically, patients with residual hearing were excluded from implantation even though they experienced poor speech discrimination when fitted with high-quality digital hearing aids (skarzynski et al., 2002). furthermore, historically, there was a belief that residual hearing was lost during cochlear implantation as a result of trauma caused by the insertion of the electrode array (balkany et al., 2006).this is, however, no longer the held belief as enough evidence has shown preserved residual hearing post-implantation. this residual of hearing post-implantation has facilitated the introduction of bimodal electro-acoustic stimulation (eas), which involves using a combination of cochlear implant and hearing aid use in the same ear (balkany et al., 2006). this evidence highlights the importance of complication minimal surgical techniques. success in conservation of residual hearing after cochlear implantation has benefited patients with high levels of residual low-frequency hearing who were not previously considered for conventional cochlear implantation (skarzynski et al., 2002), hence the importance of exploring possible influencing factors in the success or failure of preserving residual hearing during this process. although some implantees lose their residual hearing post-surgery despite all efforts to preserve it, the rate at which implantees have their residual hearing preserved is reportedly increasing at a steady pace. one of the cited reasons for this is the expanding knowledge and experience of advancements in electrode designs and surgical techniques, resulting in minimal trauma (gstoettner et al., 2009). di nardo et al. (2007) found that it was possible to have minimal trauma to structures in the cochlea, following electrode array insertion during cochlear implant surgery. skarzynski et al. (2002) investigated the preservation of residual hearing using the ‘soft surgery’ technique and atraumatic electrode insertion and found that 62% of implantees retained their residual hearing and 19% experienced a total loss of functional hearing. furthermore, they found that chronological age, gender, aetiology and implant type did not have an influence on the hearing findings – these results are consistent with those by cosetti et al. (2013). such findings highlight the importance of investigating factors that might have a possible influence on the preservation of residual hearing following cochlear implants; hence, the current study was undertaken within the south african context. methods main aim this study formed part of a study titled ‘preservation of residual hearing after cochlear implant surgery: an exploration of residual hearing function in a group of recipients at cochlear implant units’ (gautschi-mills, khoza-shangase, & pillay, 2018). the primary objective was to explore the preservation of residual hearing function in a group of cochlear implant recipients in two cochlear implant units in south africa. the study’s specific secondary aim was to establish whether a relationship exists between the hearing findings and the following factors: degree of preoperative hearing loss aetiologies of hearing loss duration of hearing loss prior to surgery duration between surgery and unaided post-operative hearing testing electrode type electrode array insertion electrode array insertion depth surgical techniques intraoperative complications. research design this study adopted a quantitative design in which a retrospective data review was conducted. existing preand post-operative unaided audiological testing results as well as surgical records of patients who had cochlear implant surgery were reviewed to establish whether there was a relationship between the hearing findings and the various factors. a total of 53 audiological records and 50 surgical records were included in the study. although there were 53 participants, seven of these individuals were bilaterally implanted, yielding a sample size of 60 observations. the majority of the participants (64%) were women, with the mean age being 30.8 years. all participant records had to meet specific inclusion criteria. participation criteria used in south africa include cochlear implant fitting, residual preoperative hearing thresholds, less than 60% for sentence recognition in the ear to be implanted (wagenfeld et al., 2004) and intact auditory nerve functioning (with the absence of auditory neuropathy) (moctezuma & tu, 2011) were adopted. an adapted surgical form, originally devised by one of the units, was completed, using surgical notes from participant files: the researcher collected additional data, which included the following: age, gender, aetiology, duration of hearing loss prior to implantation (in years and months), electrode type, electrode array insertion, electrode array depth, surgical technique and intraoperative complications. data analysis the change in hearing thresholds from preoperative to post-operative hearing threshold levels was classified for each participant, with a change of 0–10 db depicting complete preservation of residual hearing, a change greater than 10 db indicating partial preservation and no response post-surgery indicating complete loss of residual hearing. these findings are published by gautschi-mills et al. (2018), and the readers are referred there for further details. preand post-operative unaided thresholds were presented in order to compare them. for inferential statistics, the 95% confidence level was used throughout. general patterns or trends were examined to determine whether certain relationships existed between the post-operative hearing thresholds and the following: degree of preoperative hearing duration between surgery and unaided post-operative hearing testing electrode type. the x2 test was used to assess the relationships between categorical variables. ethical consideration ethical clearance was obtained prior to the commencement of the study (protocol number: m111037), with permission from all relevant authorities. furthermore, this research adhered to the helsinki declaration of 1975, as revised in 2008. results and discussion hearing thresholds before and after surgery findings from the study of which this current study formed a part, revealed that preoperatively participants in the overall sample presented with severe to profound range of hearing loss, with some degree of low-frequency residual hearing with poorer hearing in the high frequencies (figures 1 and 2) (gautschi-mills et al., 2018). figure 1: preoperative hearing threshold levels overall. figure 2: post-operative hearing threshold levels overall. these findings are consistent with the tonotopicity of the cochlea, where high frequencies are more susceptible to damage than lower frequencies (martin & clark, 2006). post-operatively, the results obtained indicated a high-frequency loss, with some preservation of the low frequencies and slight preservation of the mid-frequencies post-operatively. although the results indicated some preservation of low-frequency and mid-frequency hearing, it was clear that there was some loss in residual hearing, which means that the hearing threshold levels before surgery dropped further after surgery (gautschi-mills et al., 2018). overall, 92% of the implantees experienced hearing preservation post-operatively – either partial or complete hearing preservation. these findings partly supported previous findings by skarzynski et al. (2002) and cosetti et al. (2013) who found hearing preservation post-operatively under similar conditions as in the current study. the relationship between the hearing findings and various factors degree of preoperative hearing loss current findings indicated that the degree of preoperative low-frequency hearing had no effect on the post-operative hearing findings. similarly, cosetti et al. (2013) found that there was no significant relationship between the low-frequency pure-tone average and the post-operative hearing findings. current findings are inconsistent with those by balkany et al. (2006) who found that there was a relationship between the degree of preoperative hearing loss and the hearing findings, in that those patients who had a greater degree of preoperative hearing loss tended to experience a complete loss of residual hearing post-operatively. in the current study, there was no significant correlation between the preoperative hearing threshold levels and the preservation of post-operative residual hearing (p = 0.174). despite the fact that there was a correlation between the degree of preoperative hearing threshold levels and post-operative hearing in balkany et al.’s (2006) study, this was limited to patients who experienced a complete loss of residual hearing post-operatively. in general, there was no significant relationship between the degree of preoperative hearing loss and the unaided post-operative hearing findings. aetiologies of hearing loss as depicted in table 1, the main categories for aetiologies of hearing loss varied, with congenital causes being the most commonly occurring aetiology. congenital causes of hearing impairment were also found in derinsu, serin, akdas and batman’s (2011) study, where the aetiologies of hearing loss indicated a predominance of congenital factors. table 1: aetiologies of hearing loss found in the current study. an analysis of the relationship between the hearing findings and aetiology revealed that the effect of aetiology on change in hearing thresholds was not significant for any of the frequencies. the fact that aetiologies in the present study did not have any effect on the hearing findings is consistent with the findings of skarzynski et al. (2002) who found that aetiologies had no influence on the post-operative hearing findings. duration of hearing loss prior to surgery the mean duration of hearing loss prior to surgery was established to determine the relationship between the duration of the hearing loss before surgery and the post-operative hearing findings. the study findings indicated that the mean duration of hearing loss prior to surgery was 22 years and 9 months (s.d. = ± 3.1) overall. the effect of duration of hearing loss was not significant for any of the frequencies. thus, there was no significant difference in terms of post-operative hearing threshold levels between those implantees who had a longer duration of preoperative hearing loss and those implantees who experienced hearing loss for a shorter period of time. this is contrary to what lenarz et al. (2009) found, that patients with a shorter duration of preoperative hearing loss had better hearing preservation post-operatively than those with a longer duration of loss preoperatively. current findings are consistent with those of cosetti et al. (2013) who found that there was no correlation between the duration of hearing loss and the unaided post-operative hearing threshold findings. duration between surgery and unaided post-operative hearing testing the researcher examined the mean time between surgery and first post-operative hearing test to ascertain whether this had had any influence on the post-operative hearing threshold levels. this was used as a covariate in the analysis of the results in order to prevent the findings being affected by any extraneous variables. the mean time between surgery and first post-operative hearing test was 24.7 months (s.d. = ±9.0) (range 0.5–159 months). findings on the relationship between the hearing findings and the duration between surgery and unaided post-operative hearing testing indicated that this time was not significant. this means that the duration between surgery and unaided post-operative hearing testing did not affect the preservation of residual hearing post-operatively. this is a notable finding from this study where the upper extreme was 13 years and 4 months. these findings seem contrary to previously published research where a number of patients lost their residual hearing at different times post-surgery, with 30% of the sample experiencing a low-frequency threshold drop of more than 30 db over time (gantz et al., 2009). electrode type as shown in table 2, the category ‘other’ (17%) included inter alia the electrode type –nucleus ci24r with contour advance electrode (n = 5). in this study, the electrode type that was used most after the two categories mentioned above (namely, the ci512 and the ci24re) was the ci24r. however, there were only five observations for the ci24r. there were even fewer observations for other electrode types that included ci24m, nucleus ci24(st) and nucleus ci422. statistical analysis could not be performed on these electrode types as there was not sufficient data because the number of observations was too small. table 2: electrode types for participants in the current study (n = 60). the effect of electrode type on change in hearing thresholds was not significant for any of the frequencies, with the exception of 2000 hz: the mean change in hearing thresholds was 5.9 db higher for other versus nucleus freedom (nf). in other words, the electrode type did not have a negative effect on the post-operative hearing threshold levels (or the change in residual hearing), with the exception of that at 2000 hz. given that there was no trend with respect to the other frequencies, this could have been a spurious result. although the discrepancy of 5.9 db between the nf and other was only at one frequency, namely 2000 hz, and the difference was minimal, this was clinically relevant for speech understanding. the current findings are consistent with those of cosetti et al. (2013) who found that electrode type did not have any effect on the hearing findings. in a review paper, brant and ruckenstein (2016) conclude that although there is some evidence that indicates that shorter electrodes may improve hearing preservation, studies that directly examine the effect of implant length on hearing preservation in similar patient populations are required. the large majority (see table 3) of the participants (83% overall) had the contour advance electrode array implanted. other classifications included ‘other’ electrode types (8% overall). table 3: electrode array type and insertion in the current sample (n = 60). the contour advance electrode is the only perimodiolar array in the industry and is pre-curved for complete insertion, with softip that enables atraumatic insertion (roland, shelva, gibson, & treaba, 2005). as only five non-contour advance electrodes were implanted, it would not have been possible to compare the results; thus, the researcher found it to be impractical to perform this analysis which looked at the relationship between the hearing findings and the electrode array type. therefore, the researcher did not perform this analysis as the data obtained would have no relevance to the findings. in skarzynski et al.’s (2002) study, it was found that the electrode type did not have any effect on the hearing findings post-operatively. furthermore, dhanasingh and jolly (2017) did not consider electrode type as one of the key factors that influence hearing performance post-implantation in their overview of cochlear implant electrode array designs. electrode array insertion the findings with regard to the percentages for electrode array insertion techniques at the two centres and overall are presented in table 3. from surgical reports, as this was a retrospective record review, it was evident that the majority of participants had their electrode arrays inserted in the scala tympani during surgery (82% overall). the fact that the current study did not include a review of radiology results for this determination is acknowledged as a limitation and should be taken into consideration when interpreting current findings. the category ‘other’ included inter alia one case involving electrode array insertion via the scala vestibule, possibly because of obstructed scala tympani (kiefer, weber, pfennigdorff, & von ilberg, 2000) and another via the round window. however, given the fact that there was only one patient in each case, a meaningful statistical analysis could not be performed on the results; also no significant effects were anticipated because the electrode is placed via the round window into the scala tympani. the technique used in this study is supported by adunka, pillsbury and kiefer (2006), as 90% of their patients retained their residual hearing post-operatively. in the current study, there was one case where the electrode was inserted in the scala vestibuli. however, review of the surgical notes of this case did not indicate any surgical complications. this was surprising as in previous studies it has been discovered and reported that insertion via the scala vestibuli can result in intracochlear damage (adunka et al., 2006), as well as variable speech perception outcomes (lin, marrinan, waltzman, & roland, 2006). a total of 91% of patients were implanted in the scala tympani and there was a 92% success rate in the preservation of residual hearing (partial and complete) at both centres combined; therefore, it can be inferred that this technique did not negatively influence the hearing findings. o’connell, hunter and wanna (2016) assert about the superior audiologic outcomes for electrode arrays inserted entirely within the scala tympani. electrode array insertion depth in the current study (table 4), the researcher found that the majority of the participants (93%) underwent complete insertion of the electrode array during surgery. table 4: electrode insertion depth and surgical technique in the current sample (n = 60). there was only one case of electrode array insertion depth with partial insertion, possibly because of obstructions within the cochlea, such as cochlear otosclerosis, cochlear anomalies and so on (lee, nadol, & eddington, 2011). the remainder of the data consisted of the electrode array depth being complete insertion. as a result of this, the results were not comparable. thus, the researcher did not perform this analysis as it would not have added any meaningful contribution to the findings. nonetheless, current findings where preservation of residual hearing was achieved with full insertion depth for the majority of the cases are supported by bruce, bates, melling, mawman and green (2011) who emphasised that the insertion depth was critical to the successful conservation of residual hearing. numerous other studies reviewed by miranda, sampaio, lopes, venosa and de oliveira (2014) revealed that limiting the depth of electrode insertion preserved low-frequency hearing, although this did not include maintenance of ability to discriminate for all patients. current findings are inconsistent with what turner, gantz, vidal, behrens and henry (2004) have also reported, where they stated that less damage is caused to intracochlear structures by using short electrode arrays rather than the more invasive long electrode arrays. james et al. (2005) studied 12 patients who had received a long electrode and reported that there was preservation of post-operative residual hearing. contrary to the findings of earlier studies, the post-operative unaided hearing threshold levels in the current study were not affected by the insertion depth. surgical techniques the findings for the surgical techniques are summarised in table 4. two main surgical techniques were used at the two centres: contour advance and the advance off-stylet (aos) techniques. the majority of surgeons (67% overall; 33% at unit a and 94% at unit b) used the aos technique. the majority of surgeons utilised a cochleostomy approach, with the exception of four cases where the round window approach was used. mangus, rivas tsai, haynes and roland (2012) assert that the round window approach has advantages for the conservation of residual hearing over the cochleostomy approach that may result in intracochlear trauma. however, the positive findings in the current study seem to dispute this because the cochleostomy approach achieved success in preserving residual hearing post-operatively. briggs et al. (2006) observed in their study that both approaches successfully avoided trauma to the cochlea during surgery, thus conserving post-operative residual hearing. the examination of the surgical techniques was considered to be relevant in terms of establishing the possible effect or lack of effect on the preservation of residual hearing. by investigating their effects on the hearing findings, the researcher was interested in determining whether certain surgical techniques were more favourable than others in preserving residual hearing. thus, an analysis was carried out to establish whether a relationship existed between the hearing findings and the surgical techniques employed. the effect of surgical technique on change in hearing thresholds was not significant for any of the frequencies, except for 2000 hz, where the mean change in hearing thresholds was 10.1 (10.3) db lower for contour on stylet (contour) versus aos, and the mean change in hearing thresholds was 7.9 (6.8) db higher for other versus aos. as this discrepancy was limited to one frequency (2000 hz), and as the change in hearing threshold levels was minimal, this was not statistically significant. intraoperative complications from the surgical notes of the surgeons, the researcher investigated surgical complications to determine the possible influence on residual hearing and whether they affected the conservation of functional hearing post-surgery. these are reported in the gautschi-mills et al. (2018) study, which included intraoperative complications such as adhesions (3%), drill out of basal turn (3%), gusher (5%) and trauma (10%), with no complications reported in 68% of the participants. according to clark, tong and martin (1981) and balkany et al. (cited in di nardo et al., 2007), surgical complications affect anatomical structures following implantation. a relationship between the surgical complications and hearing threshold levels became apparent in the current study where the researcher found a direct correlation between the surgical complications and the hearing findings. when summarising the relationship between the hearing findings and the various factors listed above, it became evident that the variables investigated had little or no negative effect in general on the preservation of residual hearing, with the exception of surgical complications (gautschi-mills et al., 2018). it was found that the aforementioned complications during cochlear implant surgery had a direct influence on the change in residual hearing in that the surgical complications resulted in loss of residual hearing. conclusion the findings of this study indicated that preservation of residual hearing was successfully achieved at the two centres under consideration. preservation of post-operative residual hearing was achieved in 92% of participants. an exploration of factors that could have an influence on post-operative preservation of hearing thresholds found that the following variables investigated did not affect the post-operative hearing findings: degree of preoperative hearing loss, aetiology, duration of preoperative hearing loss, as well as the duration between surgery and the unaided post-operative hearing testing. in general, the surgeons in the current study used the same electrode array, insertion method, insertion depth and implant manufacturer. therefore, comparative statistics could not be performed. from the positive findings of 92% preservation of residual hearing, it could be inferred that optimal results for conservation could be achieved by using the contour advance electrode from the manufacturer – cochlear, the aos technique and complete insertion of the electrode into the cochlea via the scala tympani – as was performed in the majority of cases in the current study. current findings should be interpreted within the identified methodological limitations. firstly, the retrospective data review nature of this study had its limitations in terms of controlling for possible data collection confounding factors. secondly, the fact that current findings only looked into two sets of results per participant (one pre-surgery and one post-surgery audiogram) means that the current findings show a snapshot at one point in time post-surgery without establishing whether the preserved residual hearing thresholds remained stable over time. thirdly, although the current sample size was deemed large enough, the fact that it was conducted in only two cochlear implant units in south africa limits the generalisability of the findings to the broader population in south africa. despite these limitations, the findings have implications for clinical assessment and management, as well as for surgical management of cochlear implant candidates. preoperative counselling of cochlear implant candidates with residual hearing may benefit from current evidence as candidates may be informed about the possible benefits and risks involved. future cochlear implant candidates with residual hearing and those candidates for eas may therefore benefit from these findings as these may assist them in the decision-making process. the conservation of residual hearing post-surgery has many advantages for future cochlear implant candidates with preoperative residual hearing and for those implantees with preserved post-operative residual hearing. these cochlear implant candidates and recipients could then become candidates for eas, which, in turn, has many hearing benefits, such as improved speech perception in noise and musical acuity. evidence of the negative impact of intraoperative complications on preservation of residual hearing found in the current study raises implications for surgeons involved in cochlear implantation. for replication and generalisation of the current findings, as well as opportunity for diversity in the various variables explored, it is recommended that this study should be conducted on a broader population at a number of different cochlear implant centres across south africa, with larger sample sizes, in order to obtain data that could be generalised to an even broader population in south africa. acknowledgements the authors would like to thank dr dhanashree pillay who served as a co-supervisor in the main study. the authors would also like to acknowledge the national institute for the humanities and social sciences (nihss) for funding towards manuscript publication fees. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contribution both authors co-conceptualised the idea for the research as well as the design and methodology adopted. k.g.-m. 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'η ondersoek na die vokaalduur van die esofagale afrikaanssprekende mariette botha b(log)(pret) transvalla skool vir epileptici, pretoria opsomming — gale sprekers ,e bepaal. vokaalduur van die estfa. summary η — * n e ^ — — φ * . — z j z s s r s s/wca i,,,. although therezagz7jz«z,l^ τ γ ' "k""^ duration and dura,,on of voxels in the p " v o m l ' < * < ^duration and speech skill. tfc voiceless 'consonant enviro^tt as! t z z z o z ^ e t ** «**» ' die duur van 'n klank kan omskryf word as die tyd wat dit neem om die klank te artikuleer.* korrekte vokaalduur is noodsaaklik vir die verstaanbaarheid van die spreker se spraak, omrede dit 'n groot invloed het op die persepsie van linguistiese eienskappe soos byvoorbeeld die herkenning van foneme.3 die rol wat vokaalduur speel in die verstaanbaarheid van 'n spreker se spraak spreek duidelik uit die volgende feite: die voorafgaande vokaalduur het 'n invloed op die waarneming van die daaropvolgende konsonant as stemhebbend of stemloos.3 verder kan die betekenis van die totale woord moontlik bemvloed word wanneer die vokaalduur verander, omrede ons in afrikaans 'n lang en kort uitspraak aantref van dieselfde vokaal, byvoorbeeld [kas/ka:s] vokaalduur en vokaalintensiteitsverhoudings speel albei 'n rol in die beoordeling van aanwesigheid van klem in 'n woord. vokaalduur is egter 'n meer effektiewe en betroubaarder metode om klem aan te1 dui.4 as die vokaalduur dan foutief is, sal klempatrone ook foutief voorkom en die woord of lettergreep sal dan foutief perseptueer word. dit is dus duidelik dat korrekte vokaalduur 'n belangrike aspek van normale spraakproduksie is. ,die esofagale spreker moet leer om sy artikulators op s<5 'n manier te manipuleer dat hy maksimale benutting van sy beperkte lugvoorraad bekoffl om beide vokale en konsonante te produseer wat soortgelyk is aan die produksie van die normaalsprekende.8 die doel van hierdie studie is om vokaalduur by die esofagal' afrikaanssprekende te vergelyk met die vokaalduur van die natuurlik afrikaanssprekende persoon en om te bepaal of daar 'n verband is tussen die vaardigheid van die esofagale spreker en korrekte vokaalduur. © sasha 1983 the south african journal of communication disorders, l. 30, 19 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) ·„ ondersoek na die vokaalduur van die esofagale afrikaanssprekende eksperimentele metode die agt eksperimentele proefpersone se ouderdomme het gewissel vanaf 49 jaar tot 71 jaar en die nege kontrole proefpersone is geselekteer om hierdie ouderdomsomvang te pas, nl. met ouderdomme tussen 51 jaar en 68 jaar. manlike proefpersone is gebruik vir albei groepe. die totale tydperk van terapie en tydperk sedert operasie is nie konstant gehou in die seleksie van die eksperimentele proefpersone nie, aangesien die enigs t e vereiste in hierdie opsig was dat die proefpersoon esofagale spraak gebruik vir kommunikasie. spraakopnames is gedoen op 'n nakamitchi bandopnemer nommer 556 en tdk sa90 kassette is gebruik; vir die meting van vokaalduur in ms. is 'n digitale herhalingslyn model 2a gebruik. elke proefpersoon se gehoor is eers getoets om te bepaal of die persoon voldoen aan die kriteria vir seleksie, nl. gehoor binne normale perke. tydens die eksperiment het die ondersoeker tesame met die proefpersoon stelling ingeneem in 'n klankdigte eenheid vir spraakopnames. die ondersoeker het telkens die inleidende sin en die konsonant-vokaal-konsonantwoorde voorgelees waarna die proefpersoon dit herhaal het. voor elk van die konsonant-vokaal-konsonantwoorde is daar van die volgende inleidende sin gebruik gemaak, nl. "ek se . . . " die volgende a. [kat, kit, ket, kat, kot] b. [gat, git, get, gat, got] c. [pat, pit, pet, pat, pot] d. [bat, bit, bet, bat, bot] slegs kort vokale is gebruik vir die doel van hierdie studie omdat die produksie van kort vokale hoer eise stel aan die vinmg opeenvolgende sluitingsen openingsfunksie van die neoglottis. die rede vir seleksie van die genoemde eksplosiewe konsonante is dat hierdie klanke makliker en duideliker waarneembaar is op die digitale herhalingslyn en dus kan meting meer akkuraat uitgevoer word. om "n tydsmeting van tlie betrokke vokaal te maak, is die digitale herhalingslyn eerstens ingestel sodat die begin van die voval n 3 1 1 ^ 1 6 h n k e r k a n t v a n d i e e e r s t e °ssiloskoop se skerm . die begin van die:vokaal is geneem waar duidelike ossilaes op die skerm 'n patroon begin vorm het en die einde van e vokaal is geneem waar daar 'n skielike afsluiting van die pairoon van ossilasies was. tydens die bepaling van die duur skiel γ h i l l e n d e v o k a l e i s d a a r opiemerk dat daar na die den* f d l g l n g v a n d i e groot amplitudepatroon vormengekom h s 1 c s v a " d i c v o k a l c ' ω ε ί η 6 γ ^p^tude-ossilasies voordie vol· . ° i e p ° s t v o k a a l d u u r i s geneem vanaf die einde van ossilaci s ° 0 s f e e d s b e s k r y f ' t 0 t 3 2 , 1 d i e e i n d e v a n d i e sigbare nie ο ; / / " " i e t 0 t b y d i e b e g i n v a n d i e finale consonant [t] lende uit ^ ^ p o s t v o k a a l o s s i l a s i e s is vir vier verskilin elkp ' " g s [ k 3 t ' g i t ' p u t ' b e t i v a n elk van die proefpersone groep bereken. e s o ? g a k ? n t e s i s g e d ° e n ° m d i e spraakvaardigheid van die luisteraars e r s te b e p a a l g r o e p v a n vyf gesofistikeerde puntskaal h g e k t e e r o m d i e beoordeling te doen. 'n vyfu i t g e d e e l s ^ s t a k n d e " " s c s k a t e g o r i e g i s elke luisteraar b e o o r d e l l g a t h u l l e eers vertroud kan raak met die punte 51 a) algemene verstaanbaarheid van die persoon se woord en sinsuitinge. b) die mate van nie-funksionele steurende stomaen luginnamegeruise wat voorkom gedurende spraak. c) die mate waarin die persoon in staat is om luidheid en toonhoogte effektief aan te wend gedurende spraak, met ander woorde stemgebruik. d) die mate van akkuraatheid van die artikulatoriese bewegings. e) die mate waarin die spraaktempo (spoed van opeenvolging van lettergrepe) en die kontinuiteit (pouses wat voorkom in die spraakstroom) van die esofagale spreker ooreenstem met die van die normaalsprekende. f) die mate van luisteraangenaamheid in die spreker se stem, met ander woorde stemkwaliteit. die totale spraakvaardigheid van elke spreker is soos volg bereken op die vyfpuntskaal: 'n gemiddelde vaardigheidstelling is bereken deur die ses vaardigheidstellings van elk van die vyf luisteraars bymekaar te tel en 'n gemiddeld te bereken vir elke spreker. die volgende syferwaardes vir kategoriale plasing van proefpersone as meeren mindervaardig, is arbitrer gekies nl.: die syfer 1-2,5 verteenwoordig die meervaardige sprekers oor die syfer 2,5-3,5 kan geen besliste uitspraak gelewer word nie, aangesien dit deur die beoordelaars as grensgevalle beoordeel is. die syfer 3,5-5 verteenwoordig die mindervaardige sprekers. om te bepaal of daar 'n verband bestaan tussen vokaalduur en spraakvaardigheid is daar van 'n 95% betroubaarheidsinterval gebruik gemaak wat bereken is vir die normaalsprekende groep se vokaalduuruitings. vir die bepalings van die invloed van stemhebbendheid en stemloosheid van die konsonantomgewing op die duur van die vokaal, is daar vir die eksperimentele groep sowel as die kontrolegroep van profielontledings gebruik gemaak om sodoende vir elkeen van die twee groepe, die vokaalduur in die stemhebbend-stemlose konsonantomgewing te vergelyk met die vokaalduur in die stemloos-stemlose konsonantomgewing van d'e su'd-afriknn tydskrif vir kommunikasieafwykings, vol. 30, resultate resultate van vokaalduurmetings: dit het geblyk dat die [a, e, o] in beide die [k-t] en [g-t]konsonantomgewings met verkorte duur uitgespreek is deur die eksperimentele groep, soos vergelyk met die kontrolegroep. die [i, u] is met verlengde duur uitgespreek deur die eksperimentele groep in beide die [k-t] en [g-t]-konsonantomgewings daar is dus by die esofagale sprekers meer vokale wat met 'n verkorte fonasieduur uitgespreek is, as vokale met 'n verlengde fonasieduur, in vergelyking met die normaalsprekendes daar is gevind dat die [u] in beide die [p-t] en [b-t]-konsonantomgewings deur die groep eksperimentele sprekers verleng is en die [a] in beide die genoemde konsonantomgewings deur die groep eksperimentele sprekers verkort is. resultate van spraakvaardigheidsbeoordelings: die resultate toon dat daar vyf van die agt esofagale sprekers is wat as meervaardig beoordeel is en slegs een spreker is wat as mindervaardig beoordeel is. daar kan geen besliste 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 52 normaalsprekende [bet] λ\ vokaalduur esofagale spreker [bet] postvokaalduur vokaalduur postvokaalduur normaalsprekende [kat] esofagale spreker [kat] vokaalduur figuur 1 vokaalen postvokaalduur in stemlose en stemhebbende konsonant omgewings mariette botha postvokaalduur postvokaalduur van normaal eh esofagale sprekers the south african journal of communication disorders, vol. 30, 198r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) qndersoek na die vokaalduur van die esofagale afrikaanssprekende 53 uitspraak gelewer word oor die vaardigheid van twee van die sprekers nie, as gevolg van gevarieerde tellings tussen meere n mindervaardig. hulle vaardigheidstellings word dan as grenstellings beskou. resultate van die verband tussen spraakvaardigheid en vokaalduur van die esofagale sprekers: daar is ses van die agt esofagale sprekers met gemiddelde voicaalduurtellings wat binne die intervalomvangs val soos daargestel deur die normaalsprekendes. daar is dus slegs twee esofagale sprekers met afwykende vokaalduurtellings wat buite die intervalomvangs val soos daargestel deur die normaalsprekendes. hierdie esofagale sprekers is deur die luisteraars beoordeel as meervaardig. hulle vokaalduurtellings was korter as die tellings wat deur die interval gegee word. by die twee esofagale sprekers waar daar geen besliste uitspraak gelewer kon word oor hulle vaardigheid nie, is daar gevind dat hulle vokaalduurtellings binne die intervalomvangs val. die invloed van stemhebbenden stemloosheid van die konsonantomgewing op vokaalduur: a1 die vokale, [a, ε, i, o, a, u], het 'n verlengde vokaalduur getoon in die stemhebbend-stemlose konsonantomgewing [bt] in vergelyking met die stemloos-stemlose konsonantomgewing [p-t] by die normaalsprekende. daar blyk 'n eweredige vokaalduurverlenging te wees vir al die vokale, wanneer die stemhebbend-stemlose konsonantomgewing beskou word teenoor die stemloos-stemlose konsonantomgewing. by die esofagale sprekers het daar nie sulke eweredige vokaalduurverskille voorgekom soos by die normaalsprekendes nie. daar het by die normaalsprekendes telkens slegs verlenging van die vokaalduur voorgekom in die stemhebbend-stemlose konsonantomgewings in vergelyking met die stemloos-stemlose konsonantomgewings, maar by die esofagale sprekers was daar verlengings en verkortings van vokaalduur in die stemhebbendstemlose konsonantomgewings. daar was groter vokaalduurverskille opmerklik by die normaalsprekendes wanneer die stemhebbend-stemlose' konsonantomgewings vergelyk is met die stemloos-stemlosejkonsonantomgewings, byvoorbeeld by die normaalsprekendes was daar 'n verlenging van die vokaalduur in 'n stemhebbend-stemlose omgewing van 11 ms vir die woord [bot] teenoor die esofagale sprekers waar daar vir dieselfde woord slegs !'n verlenging van 1 ms was. uit die resultate kom dit voor dat die esofagale sprekers net soos die normaalsprekendes die vokaal verleng het wanneer die vokaal voorgekom het in 'n stemhebbend-stemlose konsonantomgewing. die esofagale sprekers vertoon egter 'n mindere mate van verlenging van die vokaal in 'n stemhebbendstemlose konsonantomgewing. daar word dus 'n duideliker onderskeid gemaak tussen stemhebbendheid en stemloosheid van die konsonantomgewing soos gesien in vokaalduurmetings, by die normaalsprekende, as by die esofagale spreker. resultate van postvokaalduurmetings: tydens die meting van die vokaalduur plus postvokaalduur van die esofagale sprekers, sowel as die normaalsprekendes is daar gevind dat die postvokaalduur baie langer was vir die eksperimentele groep, as vir die normaalsprekende groep vir al vier die konsonant-vokaal-konsonant-verbindings. (verwys na tabel i.) wanneer die eksperimentele groep se vokaal plus postvokaalduur vergelyk word met die kontrolegroep se vokaal plus postvokaalduur is daar 'n duidelike verskil in vokaalduur te sien. die eksperimentele groep se vokaal plus postvokaalduur is baie langer as die kontrolegroep se vokaal plus postvokaalduur. resultate van vokaal plus postvokaalduurmetings soos in verband gebring met betroubaarheidsintervalsomvang: wanneer postvokaalduur saam met vokaalduur in ag geneem word, is daar meer esofagale sprekers (vyf uit agt) met 'n afwykende vokaalduur (langer as normaalsprekendes) in vergelyking met vokaalduur sonder postvokaalduur waar net twee uit agt esofagale sprekers afwykende vokaalduur (korter as normaalsprekendes) aantoon. bespreking van resultate die gemiddelde vokaalduur vir die groep esofagale sprekers het in so 'n mate gevarieer dat geen deurlopende patroon opgemerk kon word nie. daar is gevind dat die vokaalduur by die groep esofagale sprekers wisselend (korter of langer) was, maar in gevalle het dit ook ooreengestem met die normaalsprekendes. geen algemene afleiding kan gemaak word ten opsigte van die verskille in vokaalduur tussen die groepe esofagale sprekers en tabel 1 gemiddelde vokaalduurtellings en postvokaalduurtellings vir beide die eksperimentele groepe en kontrolegroepe *proefpersone (e) en (k) kvk-verbinding vokaalduur alleen postvokaalduur alleen vokaal plus postvokaalduur κ ε [kat] 71 ms 78 ms 18 ms 44 ms 89 ms 122 ms κ ε [gitl 96 ms 93 ms 18 ms 43 ms 114 ms 136 ms κ ε [put] 79 ms 83 ms 11 ms 49 ms 91 ms 132 ms κ ε [bet] 124 ms 114 ms 14 ms 28 ms 138 ms 147 ms κ ?kperimemele groep ~ kontrolegroep , e su'd-afrikaanse tydskrif vir kommunikasieafwykings, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) • 54 normaalsprekendes nie..wanneer daar egter gekyk word na afsonderlike vokaalduurtellings by die verskillende individue, is dit duidelik dat sommige van die esofagale sprekers soms afwykende vokaalduuφatrone vertoon. die vraag ontstaan dus nou of individuele afwykende vokaalduurpatrone, soos wat wel voorkom, maar net verskuil is in die groepsresultate by die esofagale spreker 'n invloed het op die verstaanbaarheid van die spreker se uitings. swisher8 het 'n studie gedoen met esofagale engelssprekendes, waann hy gevind het dat die duur van die vokale verleng word deur die esofagale sprekers. hy vind 'n verdubbeling van vokaalduur by sommige van die vokale, soos uitgespreek deur 'n esofagale spreker in vergelyking met 'n normaalsprekende chnstensen en weinberg2 het 'n soortgelyke studie gedoen en soortgelyke resultate gevind. kritiek teen swisher8 se metode van vokaalduurmeting is dat hy nie net die vokaal gemeet het toe hy die "friction period" bygemeet het, en die vokaal geneem het tot waar die finale konsonant begin nie. dit is belangrik om te onthou dat 'n vokaal duidelike formante moet he om as vokaal gedefinieer te word.7 tydens die meting van die vokaalduur is daar wel opgemerk dat daar aan die einde van die vokaal (soos op die ossiloskoop gesien) nog opsigtelike, postvokaal klein amplitudeossilasies voorkom by al die esofagale sprekers en soms ook by die normaalsprekendes. 'n moontlike verklaring vir hierdie verskynsel is dat die aanvang en afsluiting van stemgewing vinnig en doeltreffend beheer kan word deur die beweging van die stemlippe by die normaalsprekende, maar by die esofagale spreker is dit moontlik dat die beweging van die pseudoglottis tydens die sametrekking en ontspanning van die sfinkterspier, nie vinnig en ferm genoeg kan plaasvind nie, wat dan resulteer in voortgaande vibrasiesiklusse (verwys na figuur 1). die onvoldoende werking van die neuromuskulere meganisme veroorsaak dat 'n "geluid" steeds sal voorkom na die produksie van die vokaal. hierdie "geluid" kan nie as deel van die vokaal beskou word nie, as gevolg van geen duidelike patroonvormende ossilasies nie. die vraag wat vooraf in hierdie bespreking ontstaan het oor die moontlike invloed van afwykende vokaalduurpatrone op die verstaanbaarheid van die esofagale spreker se uitings kan moontlik nou beantwoord word. tydens die beoordeling van die esofagale sprekers se spraakvaardigheid op die vyfpuntskaal vir die ses verskillende parameters, was een van die parameters die beoordeling van algemene verstaanbaarheid van woord en sinsuitinge. daar is gevind dat die duur van die vokaal me 'n oorwegende rol speel in die verstaanbaarheid van esofagale spraak nie. dit kan toegeskryf word aan die resultaat dat die esofagale sprekers wat afwykende vokaalduur getoon het nogtans deur die luisteraars as baie goed verstaanbaar beoordeel is. die een spreker wat as baie moeilik verstaanbaar beoordeel is, het 'n gemiddelde vokaalduur getoon wat binne die normale mtervalomvangs geplaas is. binder' maak die opmerkmg dat die akoestiese faktore wat saamval met verhoogde verstaanbaarheidsbeoordelings blyk verbind te wees aan verhoogde pseudoglottiese beheer oor esofagale lugvrylating. die afleiding kan dus gemaak word dat daar baie ander faktore is wat die algemene verstaanbaarheid van esofagale spraak beinvloed byvoorbeeld steurende stomaen luginnamegeruise, swak artikulasie, asook algemene afwykende spraaktempo en kontinuiteitspatrone. mariette botha tydens die ondersoek na die invloed van afwykende vokaal duur op spraakvaardigheid is daar in groepsverband nie 'n on sigtelike verband tussen vokaalduur en spraakvaardigheid ge vind me. daar is egter 'n duideliker verband gevind tussen vokaal plus postvokaalduur en spraakvaardigheid. goeie beheer van vokaalduur kan dus wel 'n bydrae lewer tot goeie spraak vaardigheid. tydens die bepaling van die.invloed van stemhebbendheid en stemloosheid van die konsonantomgewing op die duur van die vokaal, is daar gevind dat by die normaalsprekendes, die vokaalduur langer was waar die vokaal voorafgegaan is deur 'n stemhebbende konsonant en gevolg is deur 'n stemlose konsonant, as waar die inisiele en finale konsonante albei stemloos was in die konsonant-vokaal-konsonant-kombinasie. by die esofagale sprekers was die vokaalduur egter gevarieerd langer en korter gewees waar die vokaal in 'n stemhebbend-stemlose konsonantomgewing geplaas is, en dan vergelyk word met die vokaal in 'n stemloos-stemlose konsonantomgewing die ge middelde verlenging van die vokaalduur was baie minder by die esofagale sprekers as by die normaalsprekendes hier is dus nie duidelike stemhebbend/stemlose onderskeid by die esofagale spreker nie. binder1 haal nichol aan, naamlik "voicing is a vulnerable feature in esophageal speech intelligibility". twee moontlike verklarings vir die toename in vokaalduur in die stemhebbend-stemlose konsonantomgewing kan soos vole gegee word, naamlik: dat verlenging van hierdie vokaal moontlik die rede is waarom die stemlose konsonant wat voorafgegaan word deur die vokaal dan deur die oor as stemhebbend perseptueer word. weismer, dinnsen en elbert9 het in engels gevind dat die vokaalduur langer was waar die vokaal 'n stemhebbende konsonant voorafgegaan het. wanneer die inisiele konsonant wat geproduseer word stemloos is, verkeer die pseudoglottis in 'n ontspanne toestand. moolenaar-bijl6 se dat as die stemlose konsonant direk opgevolg word deur 'n vokaal, dan word die ingepersde esofagale lug gebruik vir die produksie van die vokaal die knko-faringale spier trek saam sodat daar vernouing plaasvind van die pseudoglottis en die vokaal dan geproduseer kan word. indien die finale daaropvolgende konsonant dan weer stemhebbend is, is die pseudoglottis alreeds in 'n geaddukeerde toestand sodat dit maklik is om die stemhebbende konsonant te produseer, maar as die finale opvolgende konsonant stemloos is, dan moet daar vinnige ontspanning van die sfinkterspier plaasvind. dit is dus 'n vinnig opeenvolgende "openings-sluitings-openings'^aksie wat meer bewegingsvaardigheid van die pseudoglottis verg die inligting wat uit die resultate verkry is, is nie genoegsaam om veralgemenings te maak ten opsigte van die rol van korrekte vokaalduur in esofagale spraak nie, maar die vokaalduur "abnormaliteite" wat wel by sommige van die individuele esofagale sprekers voorgekom het, blyk 'n invloed te he op spraakvaardigheidsbeoordelings en verstaanbaarheid. dit is duidelik dat esofagale spraak nie net deur vokaalduurafwykings beinvloed word nie, maar ook deur ander faktore soos steurende stomaen luginnamegeruise asook afwykende latente periodes. the south african journal of communication disorders, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) -η ondersoek na die vokaalduur van die esofagale afrikaan; gevolgtrekkings die gevolgtrekkings wat uit hierdie ondersoek gemaak kan w o r d , is die volgende: dat daar esofagale sprekers is wat soms afwykende vokaalduur vertoon in hulle spraak. die gemiddelde vokaalduur vir die esofagale groep sprekers het in so 'n mate gevarieer dat geen deurlopende patroon opgemerk kon word nie, omdat die esofagale sprekers gevarieerd langer of korter, of soms dieselfde vokaalduur getoon het as die normaalsprekendes. dat daar nie 'n opsigtelike verband bestaan tussen vokaalduur en spraakvaardigheid nie, omdat die luisteraars se beoordelings van die meeren mindervaardige sprekers nie ooreenstem met die spreker se normaleof abnormale vokaalduurtellings nie. daar is 'n duideliker verband tussen vokaal plus postvokaalduur en spraakvaardigheid omrede die luisteraars die meeste van die esofagale sprekers met normale vokaalduur ook geklassifiseer het as meervaardige sprekers, en die esofagale spreker met abnormale vokaalduur geklassifiseer het as mindervaardig. die esofagale sprekers probleme ondervind om effektiewe stemhebbend/stemlose onderskeid te tref van die konsonantomgewing waarin die vokaal voorkom. die mate van onderskeid tussen die stemhebbendheid en stemloosheid van die konsonantomgewing is baie duideliker by die normaalsprekende. uit die resultate wat in hierdie studie verkry is, sien ons dus dat die esofagale spreker 'n groot hoeveelheid van motorieskomplekse aspekte van spraak het om aan te leer, om sodoende as 'n vaardige en verstaanbare spreker beskou te kan word. 55 bedankings my dank aan die volgende persone: mev. a. van der merwe en mnr. η. e. c. tesner, kolonel l. p. c. jansen van die for. wet. laboratorium vir die gebruik van apparaat. verwysings 1. binder, g. (1978): selected acoustic characteristics of emerging esophageal speech: case study. the south african journal of communication disorders vol 25 dd 24-51. ' ' 2. christensen, j. m. en weinberg, b. (1976): vowel duration characteristics of esophageal speech. journal of speech and hearing research, vol. 19, pp. 678-689). 3. denes, p. (1955): effect of duration on the perception of voicing. journal of the acoustical society of america, vol. 27, no. 4, pp. 761-764). 4. fry, d. b. (1955): duration and intensity as physical correlates of linguistic stress. journal of the acoustical society of america, vol. 27, no. 4, pp. 765-768). 5. le roux, τ. h. en pienaar, p. de v. (1927): afrikaanse fonetiek. johannesburg, juta en kie bpk. 6. moolenaar-bijl, a. (1953): connection between consonant articulation and the intake of air in esophageal speech. folia phoniatrica, vol. 5, pp. 212-215). 7. potter, r. k., kopp, g. a. en green, h. c. (1947): visible speech. d. van nostrand company, inc., new york. 8. swisher, w. e. (1980): oral pressures, vowel durations and acceptability ratings of esophageal speakers. journal of communication disorders, vol. 13, pp. 171-181. 9. weismer, g., dinnsen, d. a. en elbert, m. (1979): a clinical study of the voicing distinction and final stop deletion. indiana university linguistics club, lindley hall, indiana. su'd-afiikaanse tydskrif vir kommunikasieafwykings, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction method ethical consideration results discussion clinical implications acknowledgements references appendix 1 footnote about the author(s) kate rossouw division of communication sciences and disorders, department of health and rehabilitation sciences, faculty of health sciences, university of cape town, south africa michelle pascoe division of communication sciences and disorders, department of health and rehabilitation sciences, faculty of health sciences, university of cape town, south africa citation rossouw, k., & pascoe, m. (2018). intervention for bilingual speech sound disorders: a case study of an isixhosa–english-speaking child. south african journal of communication disorders 65(1), a566. https://doi.org/10.4102/sajcd.v65i1.566 note: this article is partially based on the first author’s dissertation of the degree for master for science in speech language pathology at the university of cape town, south africa, with supervisor michelle pascoe and co-supervisor mantoa smouse, submitted august 2015, available here: http://open.uct.ac.za/bitstream/handle/11427/22934/thesis_hsf_2016_rossouw_katherine.pdf?sequence=1 original research intervention for bilingual speech sound disorders: a case study of an isixhosa–english-speaking child kate rossouw, michelle pascoe received: 01 june 2017; accepted: 20 sept. 2017; published: 19 mar. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: bilingualism is common in south africa, with many children acquiring isixhosa as a home language and learning english from a young age in nursery or crèche. isixhosa is a local language, part of the bantu language family, widely spoken in the country. aims: to describe changes in a bilingual child’s speech following intervention based on a theoretically motivated and tailored intervention plan. methods and procedures: this study describes a female isixhosa–english bilingual child, named gcobisa (pseudonym) (chronological age 4 years and 2 months) with a speech sound disorder. gcobisa’s speech was assessed and her difficulties categorised according to dodd’s (2005) diagnostic framework. from this, intervention was planned and the language of intervention was selected. following intervention, gcobisa’s speech was reassessed. outcomes and results: gcobisa’s speech was categorised as a consistent phonological delay as she presented with gliding of/l/in both english and isixhosa, cluster reduction in english and several other age appropriate phonological processes. she was provided with 16 sessions of intervention using a minimal pairs approach, targeting the phonological process of gliding of/l/, which was not considered age appropriate for gcobisa in isixhosa when compared to the small set of normative data regarding monolingual isixhosa development. as a result, the targets and stimuli were in isixhosa while the main language of instruction was english. this reflects the language mismatch often faced by speech language therapists in south africa. gcobisa showed evidence of generalising the target phoneme to english words. conclusions and implications: the data have theoretical implications regarding bilingual development of isixhosa–english, as it highlights the ways bilingual development may differ from the monolingual development of this language pair. it adds to the small set of intervention studies investigating the changes in the speech of bilingual children following intervention. in addition, it contributes to the small amount of data gathered regarding typical bilingual acquisition of this language pair. introduction as throughout the world, multilingualism is typical in south africa owing to a culturally and linguistically diverse population, as well as the mobility of the population and the country’s historical and political background. many people speak two or more languages in their day-to-day life (williams & stroud, 2013). although the country’s constitution states that all 11 official languages should be treated with equal esteem, and that children have the right to receive education in any of the official languages, many parents want their children to be educated in english rather than in their home language owing to the perceived higher status of english (webb, lafon & pare, 2010). this article focuses on difficulties in the bilingual speech sound acquisition of isixhosa and english. isixhosa is one of the 11 official languages of south africa. it is the second most widely spoken language in south africa, with 16% of the population speaking it as a home language (statistics south africa, 2012). isixhosa is a bantu language from the nguni group along with isizulu, siswati and isindebele. it is one of the main languages spoken in the western cape region of the country, along with afrikaans and south african english. previous research into bantu languages has considered various aspects of speech and language acquisition and disorders. for example, demuth (2003) summarises research considering the acquisition of various bantu languages, looking at the acquisition of noun classes, verbal morphology and syntactic structures and phonology. suzman and tshabalala (2000) considered the nature of language impairment in two isizulu-speaking children, analysing their phonology, morphology, syntax and pragmatics. demuth and suzman (1997) also describe the language impairments displayed by an isizulu-speaking child. their findings suggested that the child’s language was qualitatively different from a typically developing isizulu-speaking child’s language, and not just delayed. considering isixhosa, the phonological development in isixhosa-speaking children has been investigated (gxilishe, 2004; lewis & roux, 1996; maphalala, pascoe & smouse, 2014; mowrer & burger, 1991; pascoe et al., 2016; tuomi, gxilishe & matomela, 2001). maphalala et al. (2014) conducted a cross-sectional study, investigating the speech production of 24 isixhosa-speaking children between the ages of 3 and 6 years. an isixhosa speech assessment, masincokoleni isixhosa speech assessment (maphalala, pascoe & smouse, 2012) was developed to more accurately describe the speech skills of the children in the study. results suggested that most consonants are acquired by the age of 3 years, with aspirated plosives, affricates, fricatives and clicks being amongst the later developing phonemes. affricates were also identified as later developing by tuomi et al. (2001) and mowrer and burger (1991). mowrer and burger (1991) also suggested that isixhosa-speaking children acquire most consonants earlier than their english-speaking peers. this was similarly noted in two case studies conducted by pascoe et al. (2016), who found that the two children in their study had acquired all of their vowels and many of their consonants by the ages of 2 years and 5 months, and 2 years and 8 months. clicks, one of the most well-studied aspects of isixhosa phonology, are acquired between the ages of 1 and 3 years (gxilishe, 2004; tuomi et al., 2001). research has also described the typical simplifications used by young isixhosa-speaking children as they acquire clicks (lewis & roux, 1996). isixhosa-speaking children make use of phonological processes for other consonants, most commonly gliding of liquids, stopping, depalatalisation, deaspiration and denasalisation (maphalala et al., 2014). pascoe et al. (2015) considered the acquisition of english phonology by 3-year olds in cape town. their sample included a small number (n = 25) of isixhosa–english bilingual speakers and provides some data regarding the english phonology of isixhosa–english bilingual 3-year olds. findings suggested that the isixhosa bilingual children in their sample had the most complete consonant inventories in english when compared with monolingual english speakers, bilingual english–afrikaans speakers and trilingual english–afrikaans–isixhosa speakers in the study. however, the isixhosa–english children also had the lowest mean percentage of correct vowels. the researchers questioned the validity of this score, suggesting it may have been caused by typical vowel substitutions used by isixhosa–english bilingual speakers, given the complexity of the english vowel system in comparison to the five vowels of isixhosa. the study also determined that the phonological processes of cluster reduction and stopping were more prevalent in the english speech of the isixhosa–english children than in the other groups, as well as the processes of backing and devoicing (pascoe et al., 2015), often considered non-developmental in monolingual english speech (dodd, holm, hua & crosbie, 2003). backing and devoicing may be typical in the development of english by isixhosa–english bilingual children. none of the isixhosa–english bilingual children were identified as having a speech difficulty, although it is important to note that the sample of isixhosa–english children was small (pascoe et al., 2015). it has been hypothesised that if a bilingual child presents with a speech sound disorder, the disorder will fall in the same category in both languages, suggesting that although the child has two phonological systems, a single underlying deficit affects both (holm & dodd, 1999b; holm, dodd, stow & pert, 1999). this seems to align with interactional dual systems theory (paradis, 2001), which suggests a child’s two phonological systems interact in various ways as the child’s phonology develops, resulting in cross-linguistic transfer. this has been documented across a range of language pairs by authors, including holm, dodd, stow and pert (1997), holm and dodd (1999a, 1999b, 2001) and ray (2002). where a child presents with speech errors in only one language, this may be indicative of cross-linguistic transfer rather than a speech sound disorder (mcleod, verdon & international expert panel on multilingual children’s speech, 2017). for example, a child who speaks both english and french may not be able to produce the fricative [θ] in english and substitutes it with the plosive [t], as it is not present in french. if this use of the phonological process of stopping is only present in english, it is not necessarily caused by a speech sound disorder, but rather by cross-linguistic transfer from french to english. this highlights the importance of a speech language therapist (slt) being able to identify whether a bilingual child presents with a speech sound disorder or difference (mcleod et al., 2017). a child acquiring two or more languages may present with differences in their speech that are not true errors but rather are caused by the typical acquisition of two languages or dialects (mcleod, 2012). this, too, must be differentiated from a child who presents with a true phonological disorder or delay (mcleod et al., 2017). in order to do this, knowledge of the typical development of bilingual children acquiring various language pairs is essential. for many language pairs, this information is lacking. although there have been a large number of studies considering bilingual intervention for language disorders, there are fewer that describe intervention for a bilingual child presenting with a speech sound disorder. a literature search identified seven articles that present an intervention study of bilingual or multilingual children with speech sound disorders that clearly describes the participants’ speech sound disorder, the intervention provided and the changes in the child’s speech following intervention (see table 1). the studies presented vary in approach to intervention, as well as language of intervention, and investigated a variety of language pairs. the majority of the studies provided intervention only in english (holm & dodd, 1999a, 2001; holm et al., 1997; ray, 2002), while one provided intervention only in arabic (mamdouh, 2008) – in all of these cases, intervention was provided in the language that was dominant within the community. in contrast, two of the case studies provided intervention in both of the children’s languages, spanish and english (gildersleeve-neumann & goldstein, 2015) and portuguese and english (ramos & mead, 2014). no intervention studies were found that include a language pair that is common amongst bilingual children in south africa or a bantu language. table 1: summary of studies investigating the effect of intervention on the speech sound disorders of multilingual children. the procedures and approaches employed in the studies varied greatly, resulting in difficulty drawing conclusions. however, it is interesting to note the findings of gildersleeve-neumann and goldstein (2015) and ramos and mead (2014) who investigated the effect of providing intervention in both languages. the use of both the child’s languages in intervention is more in line with the recommendations provided by various individuals and organisations (e.g. gildersleeve-neumann & goldstein, 2012; goldstein & fabiano, 2007; international expert panel on multilingual children’s speech, 2012). results indicated an increase in overall accuracy in both languages (gildersleeve-neumann & goldstein, 2015; ramos & mead, 2014). the results recorded by ramos and mead (2014) are worth mentioning, as they compared the results of a period of intervention in one language (english) to those following a period of intervention in two languages (english and portuguese). they concluded that for their participant, even though some improvement of specific phonological processes was noted in portuguese when the processes were targeted in english, there was a much greater improvement when she received bilingual intervention (1 h of english and 1 h of portuguese per week). in addition, although providing english intervention improved her english speech production, bilingual intervention had a greater effect on improving her english production. however, they did note that some phonological processes (e.g. fronting of palatal fricatives) had to be specifically targeted in portuguese, her weaker language, for the child to show indications of eliminating those specific processes from her portuguese speech (ramos & mead, 2014). this study aimed to describe changes occurring in an isixhosa–english bilingual child’s speech following intervention targeted at her speech sound difficulties. we intended to add to the limited research considering intervention for speech sound disorders with bilingual children, as well as considering the challenges of assessing the speech of a bilingual child when little is known about the typical bilingual speech development of the language pair spoken by the child. method the objective of this study was to analyse and describe the isixhosa and english speech of a bilingual isixhosa–english-speaking child before and after providing intervention based on a tailor-made, theoretically motivated intervention plan. it followed an exploratory descriptive design in order to detail the changes that occurred in the child’s speech. a single subject pre-test and post-test design was used: this allowed the participant to be described as an individual case and act as her own control (vance & clegg, 2012), and included assessing the child’s speech before and after the intervention. participant isixhosa–english bilingual children with possible speech sound disorders were referred to the researcher by teachers at local crèches. after consent was obtained from their parents, these children were assessed, and the participant was randomly selected from the smaller pool of children who met the criteria: between the ages of 3 and 6 years, bilingual with isixhosa as their home language and english as an additional language, presented with a speech sound difficulty as their primary difficulty and had not received previous intervention. gcobisa1, an isixhosa–english bilingual girl was 4 years and 2 months at the start of the study. she was referred to the researcher by her teacher owing to concerns regarding her speech development. gcobisa’s mother gave consent for gcobisa to take part in the study. gcobisa’s mother reported that her child had been exposed to both isixhosa and english from a young age, both at home and at school, as well as some southern sotho, another local language, at home. she reported her motor milestones were in the average range, while her speech and language milestones appeared slightly delayed. assessment english speech was assessed using the diagnostic evaluation of articulation and phonology (deap) (dodd, hua, crosbie, holm & ozanne, 2002). this is an assessment tool developed in the united kingdom that assesses a child’s articulation, phonology, inconsistency and oral motor skills in english and allows for clear descriptions and categorisation of speech sound disorders. isixhosa speech was assessed using the masincokoleni isixhosa speech assessment (maphalala et al., 2012), a single-word naming test developed in south africa to evaluate a child’s phonology in isixhosa. receptive language in both english and isixhosa was assessed using the peabody picture vocabulary test (fourth edition) (ppvt-4) (dunn & dunn, 2007), using an isixhosa translation of the ppvt-4 developed by dawes, biersteker and hendricks (2012). these tests assess a child’s understanding of vocabulary (single words) and give an indication of their understanding of each language. as the isixhosa version was a translation, the results were analysed descriptively. all assessment sessions were audio recorded. a portion of the audio recorded data was transcribed both by the researcher, and a linguist familiar with both isixhosa and english. thus, intra-rater and inter-rater reliability were established to ensure data analysis was based on accurate data. the results of these assessments were analysed to place the participant’s speech sound disorder into a functional category as described by dodd (2005). from this, an intervention plan was developed and implemented (see results for further details on how this plan was developed). at each session, a fidelity checklist was completed to ensure the intervention followed the intervention plan in terms of approach of intervention and language of intervention. following intervention, the participant’s english and isixhosa speech were reassessed, using the same assessment tools. ethical consideration the study received ethical clearance from the university of cape town faculty of health science human research ethics committee, hrec ref: 448/2015. results english speech assessment gcobisa’s pre-intervention assessment results are summarised in table 2. table 2: gcobisa’s initial assessment results. gcobisa’s phonetic inventory was age appropriate (see appendix 1, table 1-a1). although the fricatives [θ] and [ð] and the phoneme [ɹ] were missing from her inventory, this is age appropriate in comparison to monolingual norms (dodd et al., 2002). all other english sounds were present in her phonetic inventory. in addition, gcobisa showed evidence of being able to produce all vowels and diphthongs appropriately. gcobisa used many developmental phonological processes and few non-developmental processes (see table 2), but most of them were isolated occurrences (not used consistently on every production of the phoneme), suggesting that she is in the process of eliminating many of them. this made her speech seem unintelligible and occasionally inconsistent, and she had a percentage consonants correct (pcc) of 75% as a result of her errors. however, the results of the inconsistency assessment suggested her speech did not meet the criteria for an inconsistent speech disorder. gcobisa has two consistent phonological processes: gliding and cluster reduction. the process of gliding was still age appropriate as it should be eliminated by the age of 5 years and 11 months according to monolingual english norms (dodd et al., 2002). the process of cluster reduction of two part clusters was of more concern, as a monolingual child acquiring english should be able to produce clusters containing two consonants by the age of 3 years and 11 months (dodd et al., 2002). from this information, it was determined that gcobisa presented with a mild phonological delay in english. isixhosa assessment gcobisa’s isixhosa phonetic inventory was considered age appropriate, although she was not yet producing the phonemes [r] and [kx], which she should be in the process of acquiring (see appendix 1, table 2-a1). she was able to produce all isixhosa vowels accurately with very few errors. her pcc and percentage phonemes correct (ppc), however, were low in comparison to the scores described by maphalala et al. (2014), although they were similar to her english pcc and ppc scores. as with her english speech, she made use of some phonological processes consistently, as well as some on isolated occurrences. this made her speech seem inconsistent, but comparing her productions of the same word, her consistency was judged to be appropriate for her age. two consistent phonological processes were gliding and backing of the palatal plosive. according to the information gathered in the study by maphalala et al. (2014), the process of gliding was found to have been eliminated in the speech of the children by the age of 3 years and 6 months. considering this, gcobisa’s use of the phonological process of gliding could be considered delayed. it was determined gcobisa presented with a mild phonological delay in isixhosa. her receptive language scores suggested her receptive language skills were not yet at an age-appropriate level. however, her understanding of language was judged to be adequate for participation in therapy activities. intervention plan gcobisa had a mild phonological delay in both english and isixhosa. the minimal pairs approach was selected as an appropriate approach for this type of speech difficulty (baker, 2010). intervention aims included: gcobisa will be able to produce [l] accurately: in initial position, for example, in verbs that, when produced as a command, start with consonants such as luma (bite) and medial position, for example, after the prefix of nouns, such as ilanga (sun) in words and in phrases in isixhosa. the language of instruction throughout all intervention sessions was english. this was because of a variety of reasons: gcobisa showed evidence of understanding english to the same degree or more than isixhosa; in addition, as a language mismatch is common between slts and clients in south africa, this reflected the realities of most slts currently providing intervention in south africa. however, the language of the intervention stimuli was considered further. although the process of gliding was present in both english and isixhosa, gliding was still considered to be an age-appropriate process for gcobisa in english. as such, all targets chosen were in isixhosa, as the process of gliding is not age appropriate for gcobisa in isixhosa. intervention gcobisa attended 16 sessions of intervention over 8 weeks, attending sessions lasting 30 min, twice a week. intervention took place in a quiet room at her crèche. she received approximately 8 h of intervention. each session was guided by a fidelity checklist to ensure sessions adhered to the intervention developed for gcobisa’s speech sound disorder. gcobisa was initially shy but soon began participating more in sessions. the following steps, based on those outlined by baker (2010), were followed: familiarise gcobisa with the minimal pair pictures and words train gcobisa to perceive the difference between the minimal pairs imitation of target words production of minimal pairs, highlighting communication breakdown where appropriate generalisation activities. post-intervention english speech assessment following intervention, gcobisa’s speech was reassessed. results are summarised in table 3. table 3: summary of post-intervention english speech assessment results. following intervention, gcobisa’s phonetic inventory was age-appropriate with the fricatives [θ] and [ð] present. gcobisa still used many developmental phonological processes and a few non-developmental processes, but most of them were isolated occurrences, suggesting that she is in the process of eliminating many of these phonological processes. in the phonology subtest, gcobisa’s pcc improved from 75% to 79%. her use of gliding reduced from 13 to five instances and her overall inaccuracies from 34 to 24 instances. gcobisa still made use of the two consistent phonological processes: gliding and cluster reduction. however, gliding of [l] only accounted for two of the five instances of gliding, the remaining three being instances of gliding [ɹ]. the process of gliding is still age-appropriate as it should be eliminated by the age of 5 years and 11 months (dodd et al., 2002). she made use of the phonological process of cluster reduction at a similar level as the initial assessment. her use of cluster reduction continues to be of concern as, considering monolingual english norms, she should have eliminated this phonological process by the age of 3 years and 11 months (dodd et al., 2002). her speech was more consistent, with an inconsistency of only 8% in comparison to 24% in the initial assessment. as gcobisa still made use of the immature process of cluster reduction, she still presented with a mild phonological delay. post-intervention isixhosa speech results gcobisa’s isixhosa reassessment results are summarised in table 4. gcobisa’s inventory increased, with the only immature omission being [r] (maphalala et al., 2014). her ppc, percentage vowels correct (pvc) and ppc all increased and were considered age appropriate in comparison to the small sample of data collected for masincokoleni (maphalala et al., 2014). although she did still make use of some phonological processes, the majority of these were isolated occurrences, and on many occasions she was able to produce the accurate production of the word on the second attempt. gcobisa’s speech was more consistent, with only two instances of inconsistent productions of words, and both of these contrasting an inaccurate production with an accurate production of the word. table 4: summary of post-intervention isixhosa speech assessment results. gcobisa only made use of gliding the trill [r]. although this process should be eliminated by her age, the phoneme [r] is not common in isixhosa. on two occasions, she made use of the process of backing of the palatal plosives. although this is usually considered a non-developmental process, pascoe et al. (2015) suggest that this may be a typical process for isixhosa–english bilingual children in cape town. gcobisa’s use of gliding of [r] suggested that she still had a mild phonological delay. discussion this study considered the changes in a bilingual child’s speech in both languages when provided with intervention targeting her speech sound disorder. the intervention approach of minimal pairs was chosen to target gcobisa’s speech sound disorder (baker, 2010), resulting in a change in gcobisa’s phonological system, as she was able to accurately produce the phoneme [l] in both trained and untrained words and phrases in isixhosa and in words in english. kohnert (2010) highlights three issues that clinicians need to take into account when considering bilingual children regardless of whether they have acquired their languages simultaneously or sequentially: (1) children may present with an uneven distribution of skills in their two languages, so their language skills may be distributed across both languages rather than duplicated from their stronger language to their weaker language; (2) some form of cross-linguistic interaction will take place; and (3) owing to the complex interaction between personal factors evident in all children (e.g. socioeconomic situation and general exposure to language at home) as well as factors specific to bilingual children (e.g. exposure to each language, age of acquisition of each language and opportunity to use each language), bilingual children present as a very heterogeneous group, making it difficult to compare a bilingual child’s development to norms, even when those norms are based on a similar group of bilingual children. this was evident in the case under discussion, and the lack of information regarding typical development in the isixhosa–english population resulted in challenges in interpreting the data in the current study. interpretation was based on monolingual norms, but this is problematic, as bilingual speech development is known to differ from the monolingual development of the languages (holm & dodd, 2006). this results in bilingual children often being under-referred or over-referred for intervention (hambly, wren, mcleod & roulstone, 2013), as demonstrated in the current study. although gcobisa’s teachers were eager to refer her to the researcher and reported concerns regarding intelligibility, detailed analyses of phonological skills were difficult, as little is known about isixhosa–english bilingual acquisition. in addition, her mother did not share the teacher’s concerns. results were compared to monolingual norms, and the effect on gcobisa’s participation in the classroom guided the decision to provide intervention. however, if one considers that gcobisa is acquiring both english and isixhosa, and this acquisition is different to monolingual development of each language, her speech development may be typical for a bilingual child, particularly considering the heterogeneity of the bilingual population. preliminary research into the typical development of south african english has included a small sample of isixhosa–english bilingual children (n = 25) and provided some information regarding their english speech development (pascoe et al., 2015). one of the findings in that study suggested that backing, a phonological process considered non-developmental in english, was prevalent in the english speech of isixhosa–english bilingual participants. gcobisa showed evidence of backing in isixhosa. this adds to the data collected by pascoe et al. (2015), adding to the evidence that backing may be a typical process in bilingual isixhosa–english children. however, unlike pascoe et al. (2015), this study also considered isixhosa speech. backing was evident in gcobisa’s isixhosa speech but was not evident in the monolingual isixhosa sample under consideration by maphalala et al. (2014). this process may be considered typical when evident in one or both languages of isixhosa–english bilingual children, highlighting a difference between monolingual and bilingual speech acquisition of the two languages. however, a larger sample of isixhosa–english children is required to determine whether this is typical of the larger population, as previous research has focused on fairly small samples. another process identified as being more prevalent in isixhosa–english bilinguals than in monolinguals is cluster reduction (pascoe et al., 2015). this may be the result of the effect of one language on the other: isixhosa makes use of very few clusters (maphalala et al., 2014). it is therefore not surprising that children who speak isixhosa as a home language find the production of clusters difficult, often reducing them. this was noted in the english speech of gcobisa. cluster reduction is expected to be eliminated from the speech of monolingual english children by the age of 3 years and 11 months (dodd et al., 2003) and yet this was the most prevalent process in the speech of gcobisa (4 years and 6 months at the end of the study). this suggests that it may be typical for isixhosa–english children to continue to use cluster reduction beyond the age of 4 years. however, again, this would need to be explored further with a larger sample of isixhosa–english bilingual children. south africa’s multilingual environment creates challenges for slts. the current demographic of qualified slts is poorly representative of the south african population, as the majority of slts speak english and/or afrikaans (pascoe & norman, 2011). although this is gradually changing to reflect a more diverse demographic, there is often a language mismatch between slt and client (pascoe & norman, 2011). globally, this is also a common problem as discussed in a tutorial article by mcleod et al. (2017) entitled ‘speech assessment for multilingual children who do not speak the same language(s) as the speech language pathologist’. around the world, slts face further challenges in providing appropriate intervention for children who are multilingual, as there is limited research on the appropriate approach for intervention for this population (goldstein & fabiano, 2007). in the recruitment process, a number of bilingual children were referred to the researcher and assessed. however, after analysing their speech using monolingual norms, very few of these children presented speech sound disorders. in south africa, a preliminary study investigating the speech of 150 3-year-old children acquiring english identified that 6.66% of the children presented with speech sound disorders (pascoe et al., 2015). of the 6.66%, none were isixhosa–english bilingual children. further research into the speech development of bilingual children, particularly those acquiring isixhosa and english, would be useful in order to aid slts in being able to differentiate between a speech disorder and speech differences. many previous studies considering intervention for bilingual children provided intervention in only one of the multilingual child’s languages (holm & dodd, 1999a, 2001; holm et al., 1997; mamdouh, 2008; ray, 2002). ramos and mead (2014), however, provided intervention in both languages of a bilingual child. from their results, they concluded that intervention in both languages was more effective than intervention provided in only one of the child’s languages, even if generalisation takes place (ramos & mead, 2014). considering the case of gcobisa, although the targets chosen were in isixhosa, the main language used within the sessions was english, with some simple isixhosa instructions [e.g. hlala pantsi (sit down); mamela (listen); ewe (yes)]. this was a situation not well-documented in the literature, where the targets were in isixhosa while the instructions and other interactions with the researcher took place in english. this may have had an impact on the generalisation from the treated isixhosa to the untreated english. holm et al. (1997), holm and dodd (2001) and mamdouh (2008) reported situations where generalisation did not occur from the treated to the untreated language. in these cases, the targeted error or phoneme appeared to be specific to the targeted language or uncommon in the untreated language. this would suggest that if a targeted error pattern or phoneme is common to both languages, intervention in one language may result in generalisation of results to the untreated language, as evidenced in gcobisa’s results. gcobisa made use of gliding of [l], producing the liquid as [j] in both english and isixhosa. intervention that used targets from only one language (isixhosa) resulted in generalisation of results to the untreated language (english), as gcobisa showed evidence of eliminating this phonological process from both her isixhosa and her english speech. clinical implications this case study considered the changes in the speech of a bilingual child following intervention. intervention sessions were conducted predominantly in english, while targets and stimuli chosen were in isixhosa. these unique conditions appear to have resulted in change to the phonology of both languages. the language mismatch between the researcher and the child mirrors the situation often experienced by south african slts, who are not always able to speak all of the languages spoken by their clients. although providing intervention in both languages is considered ideal (gildersleeve-neumann & goldstein, 2012; goldstein & fabiano, 2007; international expert panel on multilingual children’s speech, 2012), in situations where this is not possible and translators are not readily available, the use of targets in one language and intervention in the other language may result in change to both languages, although further research is necessary with a larger sample of children to generalise this to the wider population. finally, this article also added to the small body of research considering isixhosa–english typical speech acquisition. the child in the single case study presented with backing and cluster reduction that persisted beyond the typical age of elimination, both processes also noted by pascoe et al. (2015) in the english speech of the isixhosa–english bilingual children included in their study. this adds to the evidence that these processes may be typical in the acquisition of isixhosa–english speech. acknowledgements financial assistance from the national research foundation (nrf) of south africa and the university of cape town (postgraduate publication incentive) is hereby acknowledged. opinions expressed and conclusions arrived at are those of the authors and are not necessarily to be attributed to the nrf. we gratefully acknowledge the support of olebeng mahura and mantoa smouse for this work. both m.p. and k.r. contributed equally to the writing of this article. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions this article stems from a dissertation of k.r. at the university of cape town, supervised by m.p. and co-supervised by dr mantoa smouse. references baker, e. 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(2013). multilingualism in transformative spaces: contact and conviviality. language policy, 12, 289–311. https://doi.org/10.1007/s10993-012-9265-4 appendix 1: gcobisa’s consonant inventories in english and isixhosa table 1-a1: gcobisa’s english consonant inventory. table 2-a1: gcobisa’s isixhosa consonant inventory. table 3-a1: gcobisa’s inventory of clicks. footnote 1. a pseudonym was used to ensure anonymity. abstract introduction method results discussion strengths and limitations implications for practice and further research conclusion acknowledgements references appendix 1 footnotes about the author(s) danél hattingh centre for augmentative and alternative communication, university of pretoria, pretoria, south africa kerstin m. tönsing centre for augmentative and alternative communication, university of pretoria, pretoria, south africa citation hattingh, d., & tönsing, m.k. (2020). the core vocabulary of south african afrikaans-speaking grade r learners without disabilities. south african journal of communication disorders, 67(1), a701. https://doi.org/10.4102/sajcd.v67i1.701 original research the core vocabulary of south african afrikaans-speaking grade r learners without disabilities danél hattingh, kerstin m. tönsing received: 09 feb. 2020; accepted: 28 apr. 2020; published: 20 july 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: augmentative and alternative communication (aac) can enable individuals with little or no functional speech to communicate functionally in a variety of communication contexts. aac systems for individuals who are not (yet) fully literate often require that the vocabulary for the system be preselected. by including the most commonlyand most frequently-used words (core vocabulary) in an aac system, access to novel utterance generation can arguably be facilitated. at present, no afrikaans core vocabulary list based on children’s speech samples exists. objectives: this study aimed to identify the most frequentlyand commonly-used words of south african afrikaans-speaking grade r learners without disabilities. method: spontaneous speech samples were collected from 12 afrikaans-speaking grade r learners during regular preschool activities. samples were transcribed and analysed to determine the number of different words used, the frequency with which each word was used, as well as the commonality of word use across the 12 participants. results: a total of 239 words met the criteria for inclusion in the core vocabulary (words used with a frequency of more than 0.05% in the sample, and used by at least half of the participants). these words accounted for 79.4% of words used in the entire speech sample. conclusion: the established core vocabulary consists of a relatively small set of words that was found to represent a large proportion of speech. aac team members may consider including these words on afrikaans aac systems that are intended to give access to a measure of novel utterance generation. keywords: afrikaans; augmentative and alternative communication (aac); core vocabulary; grade r learners; vocabulary selection. introduction augmentative and alternative communication (aac) systems, such as those representing words and messages with graphic symbols, can support communication for persons with little or no functional speech who are not (yet) fully literate. graphic symbol-based systems require the preselection of vocabulary. the selected vocabulary should enable the person using the system to meet all their communication needs across different contexts and with different partners (fallon, light & paige, 2001), but should be small enough to minimise the cognitive and motor demands in memorising and navigating to the location of the vocabulary. vocabulary selection typically requires people other than the individual who will use the vocabulary to predict the words this person will require in all the communication situations that he or she encounters (dark & balandin, 2007). this is a complex process, often leading to the inclusion of irrelevant and seldom-used words (dark & balandin, 2007). various ways to select the most relevant and appropriate vocabulary have been suggested and researched (thistle & wilkinson, 2015). one such method is the use of core vocabulary lists as a resource for vocabulary selection. previous studies in english and other european languages have indicated that 200–250 spoken words account for approximately 80% of a person’s spoken communication (robillard, mayer-crittenden, minor-corriveau & bélanger, 2014; trembath, balandin, & togher, 2007). spoken language sample analyses in korean, mandarin chinese and isizulu have also indicated that it is possible to isolate a limited number of lexical items (although these may not always be words but may also include morphemes) that are used with a high frequency and are reused continuously in conversations (liu & sloane, 2006; mngomezulu, tönsing, dada & bokaba, 2019; shin & hill, 2016). these frequentlyand commonly-used words/morphemes have been termed ‘core vocabulary’. core vocabulary may be useful for inclusion on aac systems because of its small size but high potential for reusability across contexts and partners (baker & chang, 2006). core vocabularies typically contain a number of structure words – words that have little semantic meaning but perform a grammatical function and therefore contribute to the grammatical correctness of sentences (witkowski & baker, 2012). certain parts of speech, such as conjunctions and prepositions, are typically classified as structure words. content words, such as nouns, verbs and adjectives, on the other hand, do have a semantic meaning. although afrikaans vocabulary frequency lists have been published, these are either derived from written sources or the source of origin is not mentioned (barnes, 1995; malan, 1943). since written language samples have been shown to differ from spoken language samples, these lists may not be completely representative of the spoken core vocabulary used by children (liu & sloane, 2006). similarly, the translation of existing core vocabulary lists derived from samples in languages other than afrikaans is also unlikely to yield an appropriate representative core vocabulary set, because morphological differences between different languages result in (at times substantial) differences in vocabulary lists of specific languages (mngomezulu et al., 2019). these morphological differences would affect especially structure vocabulary. sociocultural and geographic influences have also been noted in the core vocabulary, affecting specifically nouns, slang words and interjections (balandin & iacono, 1999). these differences have been noted even between australian and american english adult-based core vocabulary lists, and can therefore be expected to be found in the lists generated for different languages. language-specific frequency lists that are based on original spoken language samples are therefore required. the main aim of this study was to determine the afrikaans core vocabulary of grade r learners without disabilities. the study had the following objectives: (1) to analyse language samples of afrikaans-speaking grade r learners obtained during regular preschool activities in order to determine the total number of words, the number of different/unique words (ndw), and the most frequentlyand commonly-used words (core vocabulary); and (2) to further describe the core vocabulary by classifying words into content and structure words. method design a quantitative non-experimental descriptive observational design was used in this study (mcmillan & schumacher, 2010). audio recordings were made of participants’ speech and these were analysed to determine the core vocabulary. setting the participants for the study were recruited from five grade r classes from three preschools with afrikaans as the primary language of instruction in a metropolitan area. all three schools were located in a middleto high-income area. classes ranged in size from 15 to 29 children, with an adult:child ratio ranging from 1:12 to 1:15. participants convenience sampling was used to identify five grade r classes where afrikaans was the language of teaching and learning, located within a reasonable travel distance from the researcher’s residence. class teachers were requested to nominate between two and four learners per class (equal numbers of boys and girls per class) for possible inclusion in the study. a total of 12 grade r learners aged 5;2 (years;months) to 6;10 were included. the specific age range was chosen as most children with typical language development of this age use adult-like language structures (owens, 2012). in addition, children had to meet the following selection criteria in order to be included: (1) afrikaans home language; (2) no concerns about language development, and no history of language impairment or delay; (3) no concerns about general development; (4) attendance of the preschool for at least 2 months prior to data collection, and weekly attendance of at least twice a week. questionnaires completed by parents and teachers were used to ensure that children met the selection criteria (hattingh, 2018). data collection participants wore digital audio-recording devices in small zipped pouches around their waist, with lapel microphones attached to the collars of their clothing. the devices, which were fitted and turned on at the beginning of the school day, recorded the participants’ speech during regular preschool activities, such as book reading and free-play. teachers could switch off and/or remove and could refit/turn on the devices again at their own discretion. recordings continued on a daily basis until 3500 words (including unintelligible words and utterances) had been recorded per participant. the time taken to reach this number of words varied from 2 h 16 min to 6 h 50 min, recorded across 1–3 days. data analysis the first 20 min of the recordings were discarded to limit novelty effects. any subsequent utterances referencing to the equipment or data collection process were also excluded from the transcriptions, in order to ensure that the speech samples remained as authentic as possible (trembath et al., 2007). the rest of the recordings were transcribed verbatim by the first author into the systematic analysis of language transcripts software (miller & iglesias, 2012), using relevant transcription rules (hattingh, 2018). additional codes were added to the words in the transcription to ensure that inflectional morphological variations of different parts of speech were traceable to the uninflected root form of the word. a second transcriber transcribed a randomly-selected segment of recording per participant, amounting to 20% of the total recording (ayres & ledford, 2014). the transcription was compared to that of the researcher, and word-by-word agreement was calculated by dividing the number of identically transcribed words by the sum of words transcribed identically, words omitted, words added and words transcribed differently. the percentage of agreement obtained in the study was 80%. although at the lower end of acceptability, this percentage seems common for studies where real-time conversations are recorded (mngomezulu et al., 2019; robillard et al., 2014). the second transcriber also independently coded 20% of the transcriptions, and this coding was compared to the coding done by the researcher. percentage agreement was found to be 82%. the systematic analysis of language transcripts program was used to calculate the total number of words, ndw, as well as the type-token ratio (ttr). unintelligible words were excluded from the analysis. the transcriptions did not make distinctions between words with the same orthographic forms but two or more distinct meanings (homonyms) or functions (polysemes). therefore, core vocabulary needed to be determined in three steps. in step 1, the frequency and commonality criteria were applied, and all words that occurred with a frequency of at least 0.05 per 100 words (i.e., 0.05% or once in every 2000 words) and that were used by at least six or 50% of the participants (i.e., commonality score of 6) were listed. step 2 involved looking up all words in this list in the dictionary (odendal & gouws, 2012), to determine if they had more than one meaning and/or grammatical function. where this was the case, words in the transcripts were given unique codes to separate them by meaning/function, leading to the recalculation of frequency and commonality scores for the respective forms. during step 3, frequency and commonality scores were re-examined to ensure that words that were separated into their respective meanings/functions complied with the set criteria described in step 1. ethical consideration prior to data collection, the study was approved by the research ethics committee of the faculty of humanities of the university of pretoria (protocol number gw20171002hs). permission from the gauteng department of education, and the principals of the relevant preschools were also obtained. furthermore, parents/legal guardians were informed of all aspects of the study via an information letter and their written consent was obtained prior to approaching the children and providing them with verbal information on all aspects of the study using a script in child-friendly language and pictures to support comprehension. only children who assented to participate were included in the study. ongoing verbal assent was obtained every time the participant was fitted with the audio recorder. all ethical principles regarding the involvement of human participants as set out in the belmont report (department of health education and welfare, 1979) were adhered to in the study. results after unintelligible units were excluded, the words collected per participant ranged from 3108 to 3419 words. the composite sample across all 12 participants consisted of 39 645 orthographic words. the ndw obtained from the composite sample amounted to 3304 orthographically distinct words, with an overall ttr of 0.08 or 1:12. a core vocabulary list consisting of 239 words was determined (see appendix 1) by using the three-step process described in the methods section. the average commonality score of the 239 core words was 10. the remaining words made up the fringe vocabulary. core words had a coverage of 79.4% of the entire composite sample. this means that, of the 39 645 orthographic words that made up the composite sample, 79.4% were core words. fringe words therefore covered the remaining 20.6% of the sample. the 239 words identified as core vocabulary were categorised into two broad categories consisting of content words (carrying a semantic meaning) and structure words (words that have little semantic meaning and perform a grammatical function) (van rooy, 2017). of the 239 words in the vocabulary list, 76 were structure words and 163 were content words. the percentage of content versus structure words in the most frequently-used 20, 50, 100, 200 and total number of core words is provided in figure 1. from the figure it can be seen that the percentage of content words increases as the number of words increases. figure 1: percentage of content versus structure words in the top 20, 50, 100, 200 and total core vocabulary words. although there were more content than structure words (in number) in the core vocabulary, content words were used only marginally more often than structure words. whilst the total coverage of the core was 79.4%, 41.0% of words used during conversations were content core words, whilst 38.4% of words were structure core words. the ttr for content words was about 0.01 (or 1:100), whilst the ttr for structure words was about 0.005 (or 1:200). this means that, on average, a content word occurred 100 times in the sample, whilst a structure word occurred 200 times on average. the core vocabulary was categorised into 14 different parts of speech. results are represented in table 1. verbs had the highest ndw (n = 53), followed by adverbs (n = 31) and nouns and pronouns (n = 29 each). the categories miscellaneous words (n = 1), articles (n = 2) and enclitic words (n = 2) had the lowest ndw. regarding frequency of use, the part of speech most frequently used was pronouns, constituting 20.2% of the total sample. this was followed by verbs and adverbs, representing 18.3% and 11.3% of the total sample, respectively. the ndw contained per category does not necessarily predict the frequency of use of that category. for example, 29 pronouns covered 20.2% of the sample, whereas 53 verbs covered 18.3%. the category ‘articles’, on the contrary, contained only two words (’n and die), but accounted for 4.0% of the sample. table 1: core words classified according to parts of speech. discussion the language sample of 39 645 words obtained in this study yielded 3304 unique words (ndw). the core vocabulary established by the three-step process consisted of 239 words, which accounted for 79.4% of the composite sample. the results of the study show vocabulary frequency patterns that are in many ways similar to those found in studies done in other languages, where the total number of words or linguistic units used typically outnumbered the unique number of words or linguistic units by a considerable margin (boenisch, 2014; liu & sloane, 2006). as reported in other studies, a considerable proportion of the total words is represented by a relatively small set of unique words. these results are consistent with those from previous literature, indicating that a small set of linguistic units are repeatedly reused with a high frequency during conversations. the proportion of structure versus content words in the afrikaans core vocabulary (which amounted to 32% and 68% respectively) was found to be identical to that found in the english core vocabulary established by boenisch and soto (2015). these authors found that in the top 300 words used most frequently by native english speakers, 68% were designated as content vocabulary, whereas 32% were designated as structure vocabulary. a similar pattern was also discerned by mngomezulu et al. (2019), who found that 68% of the isizulu core vocabulary established, consisted of content formatives, whereas 29% consisted of structure formatives (with 3% consisting of words classified neither as content nor core). although there were less structure words than content words in the core vocabulary, the coverage of content and structure core words differed only marginally. the ttrs show that, on average, a structure core word occurred twice as often as a content core word in the sample. mngomezulu et al. (2019) also found that there were more content than structure formatives in the isizulu core vocabulary, but that structure formatives occurred with a higher frequency. in their study, structure formatives occurred about 3.3 times as often (on average) as content formatives. similarities were found in terms of the parts of speech making up the core vocabulary. pronouns, verbs and adverbs made up a large proportion of the core vocabulary in this and other studies (boenisch & soto, 2015; mngomezulu et al., 2019). these parts of speech tended to be used with a high frequency; for example, many different verbs were found in the core vocabulary whilst also being used with a high frequency. similarly, pronouns and adverbs featured prominently, both in terms of ndw and in terms of frequency of use. these findings suggest some similarities in the way parts of speech are used across languages. verbs, for example, seem to be central to sentence construction across languages (sutton, soto & blockberger, 2002). strengths and limitations the afrikaans core vocabulary established in this study is based on language samples collected across a variety of preschool activities, resulting in a vocabulary that is not limited to, for example, playtime or snack time. furthermore, excluding the first 20 min of each sample reduced the novelty effect that the recorders might have had on the participants’ speech. this study is one of few where homonyms and polysemes were rigorously separated. the aim thereof was to ensure that the meaning of each word in the core vocabulary list was unambiguous, thus enabling appropriate graphic representation of the words in an aac system. whilst the inflected morphological variations of nouns, verbs, numerals, pronouns and adjectives were counted together under the root form of the word in this study, the codes and tags added to the transcription also allowed for frequency information for each variation to be obtained (hattingh, 2018). this information can assist practitioners to make informed decisions about the necessity of including access to inflected forms on specific aac systems. the relatively small sample size in combination with participants from similar ages across three fairly similar sites, as well as the limited time span taken for data collection, influenced the generalisability of the data. the criteria for determining core vocabulary consisting of frequency and commonality scores have also been criticised as arbitrary (shin & hill, 2016). in the present study, vocabulary was included based on a commonality score of at least six (i.e., at least 50%) and a frequency count of equal to or more than 0.05%. there is no scientific reason why words with a frequency of 0.05% are designated as core vocabulary, whilst words with a frequency count of 0.049% are designated as fringe. the commonality criterion is equally arbitrary. shin and hill (2016) suggest that grouped frequency counts are a more rigorous and defensible way to distinguish between core and fringe words. implications for practice and further research the established afrikaans core vocabulary list (hattingh, 2018) can be used as a vocabulary source for afrikaans-speaking children who require aac. words can be judiciously selected from this list for inclusion on aac systems. the core word list can be particularly helpful to alert team members to the importance of including structure words, since these words provide access to morphology and syntax. however, the provided core list is not intended to be used in isolation, but in combination with a child-specific fringe vocabulary. environmental inventories and informants can assist in determining these fringe words that should reflect the interests, personality, and contexts of the child in need of the system (robillard et al., 2014). an appropriate combination of core and fringe vocabulary should allow children to express themselves appropriately in various communication situations. since this is the first core word list established in afrikaans based on a sample of spoken words, clinicians may also consider referring to it when selecting words for afrikaans individuals of other ages or for use across other settings, as previous research has indicated that core vocabularies are, to some extent, useful across settings and individuals (van tilborg & deckers, 2016). however, this should be done judiciously, as certain words in the core vocabulary list (specifically nouns and verbs such as blok [‘block’] and inkleur [‘to colour’]) are clearly reflective of the preschool context and specific to the population. the vocabulary list may also be useful for purposes outside the realm of aac. representing words that are frequently used by afrikaans-speaking grade r learners, the list could be consulted in the development of formal and informal language and vocabulary assessments. it could also be consulted when developing intervention tasks targeting syntax and morphology, in an effort to choose familiar vocabulary that does not add a linguistic processing burden. however, the small and homogenous participant group has to be kept in mind, and caution should be exercised to avoid overgeneralisation of the results. the current core vocabulary list was generated based on conversational samples from a small and homogenous group of participants. since the way persons use language and vocabulary is intricately related to their age, as well as to the social and physical microand macro-context and the activity settings in which they find themselves, collecting further spoken afrikaans language samples from persons of different age groups, various geographical regions, and during various communication situations could help to establish a more representative core vocabulary list. furthermore, studies are needed to determine if design conventions for core–fringe based aac systems that have been developed for other languages (e.g., english systems such as tobii snap core firsttm,1 the super core grid set for grid 3tm,2 and the pixontm communication boardstm3) are appropriate for afrikaans core-fringe-based systems. research to determine effective methods for introducing the use of such systems to persons in need of aac and their partners is also urgently needed. conclusion this study contributes to the growing body of research aiming to support professionals and other team members with the challenging task of selecting the appropriate vocabulary for not (yet) literate individuals. the identified list of afrikaans vocabulary core words can be used as a source for guiding vocabulary selection for young children in need of an afrikaans aac system. specifically, the variety and proportion of content and structure words, as well as words from different parts of speech found in the core vocabulary, point to the necessity of including such a variety on a system that is intended to encourage novel utterance generation. acknowledgements the authors would like to thank all the participants, teachers, parents and schools for their participating in this study. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions d.h. conducted the study as part of the requirements of her master’s degree, under the supervision of k.m.t. both authors co-wrote this manuscript. funding information the financial assistance for the study was provided by the national research foundation (nrf) in the form of a grant holder linked bursary (#ttk150617119597) towards this research project, is hereby acknowledged. opinions expressed in this report and conclusions arrived at are those of the author and are not necessarily to be attributed to the nrf or the authors’ institution. data availability statement data collected for this study is not available in order to protect the privacy of the participants. disclaimer opinions expressed in this report 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(2012). addressing the content vocabulary with core: theory and practice for nonliterate or emerging literate students. perspectives on augmentative and alternative communication, 21(3), 74–81. https://doi.org/10.1044/aac21.3.74 appendix 1 afrikaans core vocabulary list a [cs] aan af ag agter ah al (adverb) al (numeral) alles almal altyd amper an and [cs] ander as askuus asseblief baie be [cs] begin bietjie blok blou boek bou breek bring bruin by cn come [cs] cool [cs] daai daar dan dankie dat die dié dieselfde ding dink dis dit doen dogter drie een (pronoun) een (numeral) een_twee_drie eers eerste eet ek en gaan (auxiliary verb) gaan (lexical verb) gebruik gee geel go [cs] goed gooi gou groen groot haar hallo hand hei hele help het (auxiliary verb) het (lexical verb) hier hierdie hierso hmm hoe hoekom hom hoog hoor hou huh huh_uh huis hulle hy i [cs] iemand iets i’m [cs] in inkleur is [cs] is it [cs] ja jou juffrou julle jy kan keer ken kies kind klaar klas klein kleur kom kort kos koukie kry kyk laat lekker lelik loop los lyk ma maak maar maat mag mamma man meer mens met mhmh mmh mmm moenie moet mooi my [cs] my myne ’n naam nè nee net nie niemand niks nog nou now [cs] oe of oh om on [cs] ons ook op (adverb) op (preposition) oranje oukei ouma ow pasop pers prent reg regtig rooi ry saam sal se sê seer seun sien sirkel sit slang s’n so soek sommer soos speel staan sulke sussie swart sy (possessive pronoun) sy (personal pronoun) tannie te teken tel the [cs] this [cs] tn to [cs] toe tot twee uit um val van vandag vat vier vinnig vir voel voor waar wag wanneer want wat water watter weer weet weg werk (noun) werk (verb) wie wil wit word wys yay yes [cs] you [cs] cs, code switch; an, adult name; cn, child name; tn, teacher name. note: only the uninflected root forms of nouns, verbs, numerals, pronouns and adjectives are given as all inflected forms were counted under the root form. footnotes 1. tobii snap core is a product of tobii dynavox of pittsburgh, pa, usa, https://www.tobiidynavox.com 2. the grid 3 is a product of sensory software international limited of malvern, england, https://www.sensorysoftware.com 3. pixon is a product of prentke romich company of wooster, oh, usa, https://www.prentrom.com 91 the auditory brainstem response are south mrican ent's missing the point? antonia sahli, shamim ebrahim .and wayne j wilson department of speech pathology and audiology, university of the witwatersrand, south africa abstract the use and misuse of the auditory brainstem response (abr) test by hearing professionals is often related to the extent and nature of the training they have received. this study used a postal survey based questionnaire to investigate the levels of training in, knowledge about, and appropriateness of referral for, abr testing in ear, nose and throat (ent) surgeons and registrars in gauteng, south africa. thirty-seven actively practising ent specialists and registrars were sampled using a convenience sampling technique. overall, a poor level of training and knowledge in abr and its related areas of audiology was identified. this was mirrored by a high demand for further education. considering the prevalence of auditory disorders in south africa, and the push towards primary care and early intervention, this study's results highlight the need for improved training in abr for ent surgeons and registrars. opsomming die gebruik en misbruik van die ouditiewe breinstamrespons (obr) toets deur professionele individue gemoeid met gehoor, hang dikwels af van die aard en omvang van die opleiding wat hulle ontvang het. hierdie studie het deur middel van 'n posvraelys, die vlakke van opleiding, kennis, en toepaslikheid van verwysings vir obr-toetsing deur 'n groep oor-, neusen keelartse (onk) in gauteng, suid-afrika, ondersoek. sewe en dertig praktiserende onk -artse en kliniese assistente is deur middel van 'n gerieflikheidssteekproeftegniek geselekteer. 'n algemene gebrek aan opleiding en'n lae vlak van kennis oor obr en verwante terreine van oudiologie is gei"dentifiseer. terselfdertyd is daar 'n uitgesproke behoefte aan verdere opleiding. in die lig van die hoe voorkoms van gehoorprobleme in suid-afrika en die voorkoming en vroee interuensie, dui die resultate van hierdie studie op 'n besliste behoefte aan verbeterde opleiding oor obr onder oor-, neus-, en keelartse. keywords: auditory brainstem response, ear nose and throat surgeons and registrars, training, knowledge. / / introduction the auditory brainstem r~sponse (abr) has been the mainstay ofthe advanced audiological and ent neuro-otological test battery since its cl~nical introduction in the late 1970's (hall, 1992; ferraro & durrant, 1994). it is a farfield, differentially averaged, electrophysiologically recorded signal that represents the summed and averaged responses to repeated acoustic stimulation, of thousands of nerve fibres in the viiith cranial nerve, and the auditory brainstem, thalamus and thalamocortical radiations (hall, 1992). clinical advantages of abr include the fact that it is relatively easy to record, objective, non-invasive, is independent of state of subject arousal, is generally drug resistant, and provides ear-specific information (hall, 1992; musiek, borenstein, hall & schwaber, 1994). furthermore, abr results provide reproducible, sensitive and quantitative clinical information that can localise lesions within the auditory pathway even when the patient's history and physical examination are normal (chiappa & young, 1985). as a result of its many advantages, the abr is now established as the best audiological and oto-neurological test of the functional integrity of1eighth cranial nerve and auditory brainstem (the so called "site of lesion" or "diagnostic" abr). in this application, the abr has proven to be more sensitive in detecting mass lesions than a computerised tomography scan (but less sensitive than an magnetic resonance imaging scan), and more sensitive than any test in detecting functional lesions of the viiith cn and auditory brainstem (hall, 1992; stanton & cashman, 1997). as the abr is an accepted test of viiith cn and auditory brainstem function, it has also been widely and successfully used as estimator of hearing thresholds (the so called "threshold" abr). in this role the abr is used to estimate hearing thresholds in difficult to test subjects such as high risk newborn infants, the mentally and physically handicapped and psychogenic hearing losses (hall, 1992). the abr is not without significant limitations however. of primary concern is the fact that the abr is not a test of hearing. the perceptual act of hearing requires, at the very least, neural activity to occur in the cortex. as the abr is a test of the viiith cn and auditory brainstem only, it cannot be used to comment on cortical function. the abr cannot, therefore, be seen to reflect the conscious act of hearing (hall, 1992; roush & matkin, 1994). other abr limitations include the need for sufficient peripheral hearing to enable accurate viiith cn and audidie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 92 antonia sahli, shamim ebrahim and wayne j wilson tory brainstem site of lesion evaluation (hall, 1992), and the high frequency emphasis ofthe click stimulus and less than ideal error margin (± 20 db) when using abr to estimate hearing thresholds (eggermont, 1984; bachmann & hall, 1997). v whilst there is no doubt the abr is a powerful component of the advanced audiological and otoneurological test battery, poor knowledge of the abr's advantages and disadvantages have lead to its serious misuse in many clinical settings by both audiologists and medical doctors (ferraro & durrant, 1994). in a retrospective record review study, holland (1996) and downs (1996) showed 13/ 15 southern african hearing impaired children from 15 to 74 months old to have been successfully assessed using behavioural audiometry after being initially assessed using abr. they concluded the initial abr assessment to have been unnecessary and to have delayed the initiation of appropriate aural rehabilitation in all 13 cases. such misuse of abr is often related to the extent and nature of professional training in auditory evoked potentials. as ear, nose and throat (ent) specialists are often the first medical professional to be consulted about an auditory pathology, and the most likely to refer a patient for abr testing, they are the medical professionals in the most need of up-to-date and accurate abr training. in view of the under-utilisation of abr technology in south africa to date, and the fact that a substantial number of ent specialists presently practising in south africa were trained before the peak era of abr technology, there is a likely demand for continued abr education of south african ents. without adequate training, underutilisation and inappropriate utilisation of abr technology will continue (donohoe, 1988). table 1: description of respondents (n=37) demographic factor sample 1. level of training registrar consultant 2. university of graduation cape town medunsa bloemfontein pretoria stellenbosch witwatersrand other 3. years of practice less than 1 year 1-3 years 4-6 years 7-10 years 10 or more years by the year 2000, south africa's population is projected to reach 47 million, the health of whom is expected to be managed within a primary health care framework (african national congress, 1994). in view of the potential of abr for early identification of auditoty pathologies and hearing loss both as a screening tool and a diagnostic tool, and the emphasis in the white paper for the transformation of the health system in south africa (1997) on the appropriate use of health technology, the current knowledge and training of south african ents on abr needs to be evaluated. methods aim this study used a postal survey based questionnaire to investigate ent surgeon's and registrar's levels of training in; knowledge about; and appropriateness of referral for; auditory brains tern response testing specifically, and its place within audiological site of lesion and threshold testing generally, in gauteng, south africa. specifically this study aimed to: 1 determine the extent and nature of training received by ents in, and; 2 explore ents' perceptions regarding the adequacy of their training in; abr testing specifically, and audiological site of lesion and threshold testing generally, and to; 3 evaluate the referral criteria employed by ents for, and; 4 determine ents' views with regard to their need for further training in; abr testing specifically. total percentage 7 19% 30 81% 1 3% , 2 5% i 1 3% i , 10 27% ! ; 2 5% i 20 54% \ 1 3% i 3 8% i 3 8% i 9 24% 7 19% 15 41% 4. place of employment government hospital 27 73% , (n=51)* private practice 16 43% university 8 21% , / / / 5. predominant patient population infants (0-18 months) 34 92% (n=139)* paediatrics (19 months 11 years) 34 92% adolescents (12-17 years) 35 95% adults (18 years+) 36 / 97% * n"# 37 as respondents could reply in more than one category. ' / the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the auditory brainstem response are south african ents missing the point? 93 procedure subject sampling procedure and selection criteria subjects were sampled using a convenience sampling technique from the names of90 ents and ent registrars listed as members of the south african society of otorhinolaryngology, head and neck surgery. in order to be eligible for inclusion in the survey, all subjects were requir~d to be either actively practising as qualified ent specialists or be ent registrars completing their training. due to time and resource restraints, oi1ly subjects practising in gauteng province, south africa, were selected. description of subjects of the 90 subjects who received questionnaires, 37 responded yielding a response rate of 41 %. moser and kalton ' (1971) report that a 20-30% response rate is acceptable as a baseline of replies to mailed questionnaires, and in general, a response rate below 50% is not unusual for postal surveys. a description of the respondents is provided in table 1. questionnaire the questionnaire comprised of20 close ended multiple choice questions divided into five sections: demographic information (five questions); extent, nature and perceived adequacy of training in abr and related audiological/otological tests (six questions); nature of current abr referral practises (seven questions); need and desire for additional information in various areas of abr (two questions); and an additional comments section that allowed for open ended comments to be made. data analysis questionnaire responses were analysed using descriptive statistics. responses to multiple choice questions were assessed for percentages of respondents choosing each response. responses to the open ended comment question were subjectively assessed for themes common across multiple respondents, or on individual comments considered to be of interest. general conclusions were then made. results the results are presented in accordance with the subaims formulated for the study: undergraduate and professional training respondent's training in the field of abr of the 37 respondents, 19 (51%) had received formal training in the abr. for these 19 respondents, 2 (11%) received the training during their undergraduate courses, 16 (84%) during their time as an ent registrar, and 1 (5%) during their time as a qualified ent surgeon. three of the 19 (16%) had their training conducted by an audiologist and ent, whilst the remaining 16 (84%) had their training conducted by an audiologist only. many of the 19 respondents received their abr training in multiple formats with 13 (68%) responses for formal lectures, 6 (31%) for workshops, 4 (21%) for conferences, 5 (26%) for journal clubs, and 10 (53%) for self-reading of the literature. this training was for more than 10 hours in 6 (32%) cases, between 5-10 hours in4 (21 %) cases, between 1-4 hours 8 (42%) cases, and was less than one hour in 1 (5%) case. table 2: numbers and percentages of respondents who had received training in other audiological and/or electrophysiological test~ (n=37). aydiologic/electrophysi~logical test total percentage visual reinforcement audiometry 8 22% , conditioned orienting re~ponse audiometry 3 8% , play audiometry i 7 19% tangible reinforcement' o~erant conditioning audiometry 2 6% pure tone air and bone audiometry 33 92% speech audiometry 28 78% site-of-lesion testing (e.g., bekesy audiometry) 10 28% otoacoustic emissions 11 31% i electrocochleogra phy 6 17% auditory middle latency response 4 11% auditory p300 response 0 0% auditory 40 hz response i 0 0% die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 94 respondent's training in other audiological site of lesion and threshold tests percentages of the 37 respondents who had received training in other audiological and/or electrophysiological tests are shown in table 2. perceived adequacy of training the respondents average perceived adequacy of training in abr anatomy and physiology, clinical applications, clinical limitations, interpretation, and referral criteria is shown in figure 1. their perceived adequacy of training in audiology in general is shown in figure 2 with the five point scale from one-poor to five-excellent showing percentages of responses of 17% for one, 22% for two, 47% for three, 8% for four, and 6% for five. respondent's current level of referral forabr professional to whom respondents refer for abr testing thirty-five (94%) respondents indicated they refer to an audiologist for abr testing. two (3%) indicated they refer to an audiologist and neurologist, whilst 2 (3%) indicated they refer to a medical technologist. reasons for abr referral fourteen (37%) respondents indicated they refer for abr testing for threshold estimation, 9 (26%) for threshold diagnosis (exact threshold identification), and 14 (37%) for site oflesion purposes. confidence in abr results the respondent's average confidence in the accuracy of abr results for site of lesion purposes, for threshold estimation purposes, and for fitting of amplification, is shown in figure 3. .' • anatomy and physiology ii clinical applications iii clinical limitations e interpretation o referral criteria figure i: average responses (o-very poor to 5-very good) for respondent's perceived adequacy of training in abr (n=19). antonia sahli, shamim ebrahim and wayne j wilson access to abr resources the respondent's level of access to abr is shown in figure 4 with the five point scale from one-low to five-high showing percentages of responses of 6% for one, 6% for two, 11 % for three, 25% for four, and 52% for five. l.. .1 (very poor) u12 03 c]4 05 (very good) figure 2: percentage of respondents in each category for perceived adequacy of training in audiology in general (n=37). o 2 3 o for fitting of amplification iii site-of-lesion purposes .threshold purposes 4 figure 3: average responses (o-low to 5-high) for respondent's confidence in abr results (n=37). i i 5(high) / ' figure 4: percentage of respondents in each category (i-low to 5-high) for level of access to abr (n=37). . . the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the auditory brainstem response are south african ents missing the point? 95 referral of paediatric and difficult-to-test patients for abr thresho(d testing prior to other audiological testing twenty-four (64%) respondents said they would refer neonates (0-3 months old), 26 (69%) infants (4-18 months old), 11 (31%) toddlers (19 months 4 years old), 3 (8%) children (5-11 years old), 12 (33%) physically disabled patients, and 29 (78%) mentally retarded clients, prior to any other audiological testing. indication for abr testing of various pathologies, signs and symptoms table 3 shows respondent's responses as to the indication for abr testing of various patholoiies, signs and symptoms. need for additional abr information respondent's perceptions regarding the type of abr information that is required six (16%) of the 37 respondents reported they did not, and 31 (84%) reported they did require further abr training. of the 31 respondents requesting further abr training, 22 (70%) requested training on referral criteria for abr, 28 (90%) on interpretation of abr results, 25 (80%) on the clinical limitations of abr, 30 (97%) on the clinical applications of abr,and 21 (67%) on the anatomy and physiology of abr. twenty-three (73%) of these 31 respondents preferred this information to be presented in a workshop format, 4 (13%) preferred a conference format, and 11 (37%) preferred a lecture format. twenty nine (94%) of these 31 respondents preferred this information to be presented by an audiologist, whilst 1 (3%) preferred a neurologist, and 1 (3%) a medical technologist. additional comments in the final item ofthe questionnaire, respondents were given the opportunity to express any further comments. this question was formulated as an open-ended item. the following are comments that were recorded verbatim: "in all cases i will prefer otoacoustic emission testing prior to abr if available." "unavailability of abr in my region is the main reason for my low referral rate. for screening purposes, oae's seem to be taking over." table 3: respondent's responses (n=37) as to the indication for abr of various pathologies, signs and symptoms (* indicates moderate and ** indicates major literature support for abr use), pathology total percentage otosclerosis 2 6% ossicular discontinuity 1 3% cochlear pathologies * 18 50% presbycusis '" 3 8% , tinnitus, vertigo, hearing loss ** 30' 83% / i /. recruitment * i 16 44% poor speech discriminati6n ** 21 58% i i '!bne decay ** i 20 56% i i intra-axial brainstem le$ion~** 20 56% extra-axial brainstem lesions ** 20 56% demyelinating lesions of the brainstem ** 23 64% cerebral vascular disease in the acute stages 19 53% cerebral vascular disease in the recovery stages 9 25% hydrocephalus * 10 28% comatose patients '" 19 53% intra-operative monitoring of neurological status after brain injury * 16 44% intensive care unit monitoring * 20 56% die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 96 "abr is less important in ent than in general and otoneurology. developments in audiology and radiology are surpassing its diagnostic ability. the high costs of abr will serve to limit its use in battery testing in a managed care environment." "in my opinion, mri scanning has replaced abr for diagnosis of pathology regarding intra-cranial tumours, cv disease, comatose patients, m.s. abr is suitable for threshold testing in small children and malingerers." "depending on costs and logistics a lot more patients could be referred for abr." "education is very necessary for the ent specialist." "i have chosen an audiologist to now train me in abr because i do not know how much information others have onabr." discussion this study used a postal survey based questionnaire to investigate ent surgeon's and registrar's levels of training in, knowledge about, and reasons for referral for, auditory brainstem response testing. specifically the aims of the study were to; determine the extent and nature oftraining received by ents in, and explore ent's perceptions regarding the adequacy of their training in, abr testing specifically and audiological site of lesion and threshold testing generally; and evaluate the referral criteria employed by ent's for, and to determine ent's views with regard to their need for further training in, abr testing specifically. thirty-seven actively practising ent specialists and seven ent registrars from gauteng province, south africa were sampled using a convenience sampling technique. their questionnaire responses will now be discussed in the order of the s.tudy's aims. undergraduate and professional training with only 51% of the respondents having received any formal training in abr, the precedent for poor ent abr knowledge was immediately set. the finding that the majority (84%) of this 51 % received their training during their registrar period was not surprising considering the specialist auditory nature of the abr. the vast majority (87%) of respondents with abr training were trained by an audiologist, whilst the remainder (13%) were trained by an ent and audiologist. this shows that when formal abr training did occur, the professional of choice for abr training, i.e., the audiologist, was involved. on closer examination of the 51% of respondents who had received formal abr training, the quality of this training seems questionable with the lecture (68%) and personal reading of literature (53%) methods being the dominant form of education. audiology curriculum guidelines for otolaryngologists recommend that students need to observe and participate in testing that they are involved in (campbell, 1995). whilst such recommendations promote the workshop method as being the ideal (kimura, 1985; caffarella, 1994), only 31 % of respondents withabr training received it in this format. the fi.nding that only 53% of respondents with abr training reported reading abr literature is also concerning considering the literature review is perceived as the most basic form of continuing education and a primary strategy for developing understanding and skills (moll, 1974). further effecting the quality of ent abr training is antonia sahli, shamim ebrahim and wayne j wilson the finding that only a minority of respondents (32%) received training that extended for a time period of greater than ten hours. because abr testing is continually evolving technologically, continuing education programmes of less than 10 hours are unlikely to have kept the respondents up to date in the field (kimura, 1985). such brief durations of training commonly educate solely in terms of clinical applications, and run the risk of generating false senses of competence (kimura, 1985). whilst abr training was generally poor, overall training in audiology was somewhat improved, but was still far from ideal (table 2). whilst the majority of respondents (as many as 92%) had received training in basic audiological procedures, only a minority of respondents (as few as 0%) had received training in all areas of diagnostic and threshold audiology. this result is concerning considering the well accepted fact that a test battery approach is vital in any assessment of hearing (hecox & jacobson, 1984; asha, 1989). with the increased recognition of abr as an effective screening method for evaluating hearing in young infants, such incomplete knowledge of audiological test procedures also puts ents at risk of inappropriately referring for, or over-utilising, electrophysiological tests in lieu of classic behavioural methods. such a problem would be consistent with literature reports of inappropriate referrals of children aged five to 74 months for immediate abr testing when behavioural audiometry was the preferred first test of choice (widen, 1990; hodgson, 1994; downs, 1996; holland, 1996). a comprehensive knowledge of all audiological tests is required by ents because, in certain clinical applications, these tests surpass abr in terms of their diagnostic and threshold capabilities (cornacchia, viglian & arpipini, 1982; folsom, 1990; hall, 1992). overall, the "extent and nature of abr training received by ents" results suggest that the current education of ent's in terms of abr specifically, and audiology generally, is unsatisfactory and supports the many literature reports of a shortage of clinical training opportunities for those who are no longer attending academic institutions (hall, 1992). perceived adequacy of training whilst the "extent and nature of abr training received by ents" results suggest that the current education ofe~t's in abr is unsatisfactory, on average respondents who had received prior abr training perceived this training to bk of a generally good standard (figure 1). this was particul~rly true in the areas of clinical applications of abr, less s6 in the anatomy and physiology, clinical limitations and referral criteria of abr, and not so for interpretation of abr. such results are useful in further identifying the areas of abr knowledge that the ents themselves perceive as being their most inadequate. whilst those ents who have received formal abr training perceived it to be of a generally high standard, on average, the majority of all ent respondents (86o/~felt their overall adequacy of training in audiology in general was average to very poor (figure 2). this perception/was supported by the low numbers of responses given -(as low as 0%) for actual training received in many ~f the audiological tests listed in table 2. such poor perceived and actual training in audiology does not provide a good platform for training in more advanced audiological procedures such as abr. the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the auditory brainstem response -are south mrican ents missing the point? 97 respondent's current level of referral forabr all respondents indicated that they refer for abr testing, with the overwhelming majority (97%) referring to an audiologist. considering the poor level of knowledge of abr amongst the ents surveyed, the fact that they are all referring for abrs is concerning. the concurrent finding that these referrals ~re to audiologists predominantly is reassuring, however, as it provides a safety net for the filtering of unnecessary referrals. reasons for referring for abr, and confidence in abr results, were less promising with 63% of the respondents stating that they refer for threshold estimation or threshold diagnosis purposes, compared to only 37% for site-oflesion testing. similarly, respondent's confidence in abr results was, on average, higher for threshold assessments than for site of lesion assessments (figure 3). these findings do not comply with the literature that states the abr is at its most sensitive and specific when used as a site of lesion tool in an audiologicallotoneurological test battery, and is less sensitive and specific when used as a threshold estimation tool (hall, 1992; stanton and cashman, 1997) where the abr's subcortical properties and poor accuracy in estimating hearing thresholds prevent it from being a true test of hearing (weber, 1994). the poor confidence, on average, in abr as a useful tool in hearing aid fitting was consistent with the literature (kileny, 1982; gorga, beuchaine & reiland, 1987; seitz & kisiel, 1990). following on from the skewed preference for abr use as a thresholding tool, was the 69% of respondents who indicated that they would immediately refer an infant (418 months) for abr testing without obtaining prior behavioural measurements. this data conflicts with abundant literature on infant paediatric audiological testing which asserts that it is in the neonatal (0-3 months) population that the clinical applications of abr measurements are especially salient (asha, 1989; folsom, 1990; joint committee on infant hearing, 1991; sininger, abdala & conewesson; 1997), whilst behavioural audiometry is preferred for,children who are old enough to be conditioned (generally over four months old) (asha, 1991). the numbers of respondents who would immediately refer toddlers (19 months to 4 years) (31 %), children (5 to 11 years) (8%), and • j the mentally and the physically retarded (78%) for abr assessment were more in lib.e with relevant abr guidelines (silman & silverman, ]991; hall, 1992; hood, 1995), but still demonstrated an oveteagerness for immediate abr referral. ; /' in agreement with the poor abr knowledge levels shown previously was the respondents poor responses to appropriate and non-appropriate indicators for abr referral (table 3), despite the literature coverage of this area being extensive (hall, 1992; musiek et ai., 1994; hood, 1995; stanton & cashman, 1997). the major abr indicators (listed as tinnitus, vertigo and hearing loss) and contraindicators (listed as otoschlerosis, ossicular discontinuity and cerebrovascular disease) were well identified (as high as 83%), but many respondents missed (as low as 8%) other, less obvious, direct and indirectabr indicators (listed as poor speech discrimination, tone decay, intra and extra-axial brainstem lesions, and demylinating lesions of the brainstem, cochlear pathologies, presbyacusis, recruitment, hydrocephalus, comatose patients, intra-operative monitoring after brain injury, and icu monitoring). whilst the respondents showed evidence of poor abr knowledge and training, most (88%) (figure 4) also reported having an average to high access to abr. such accessibility reinforces the need for appropriate education to prevent the underutilisation of, and inappropriate referral for, abr testing. overall, the "respondent's current level of referral for abr" results were consistent with the "extent and nature of abr training received by ents" results and further suggest a need to improve ent knowledge of abr specifically, and audiology generally. need for additional abr information the respondents showed an overwhelming desire (84%) for additional information and gave strong indications of the areas they want covered and the way the information should be presented. according to the majority of ents surveyed in this study, abr education in the ent population needs to be: primarily in the areas of interpretation, clinicallimitations and clinical applications of abr, then in referral criteria, and then the anatomy and physiology underlying the technique. presented in practical workshops rather than conferences and lectures. presented by audiologists. additional comments these verbatim responses indicated that some respondents in the study felt that both oto-acoustic emissions as well as magnetic resonance imaging were transcending abr in terms of their diagnostic abilities in both audiology and otoneurology. however, in direct contrast to this, other respondents also indicated that because of its high cost and inaccessibility, abr is not sufficiently employed. lastly, the need for further training was also highlighted. respond~ ents thus again, appeared willing and motivated to increase their knowledge with regard to abr. this has implications for the provision of future education. conclusions overall, a poor level of training and knowledge in abr and its related areas of audiology, was identified in the surveyed ent specialists and registrars in gauteng. this finding was mirrored by a high demand amongst the respondents for further education in abr technology, preferably in a workshop format run by a qualified audiologist. this demonstrated willingness amongst ents to further their working knowledge of abr places the responsibility for this education back on the south african audiology community. the south african audiology community needs to be more active in its attempts to make a larger contribution to the audiological education of its ent allies, both at undergraduate and postgraduate levels. the abr remains essential to the modern practice of hearing medicine. its proliferation in the last 20 years, and the often limited expertise of its users, has seen the abr become both over and underutilised in the clini~al setting. considering the prevalence of auditory disorders in south africa, it is hoped that this study's results will heighten the need for improved awareness of abr in ent surgeons die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 98 and registrars. an improved awareness will motivate increased training in abr, the enforcement of correct referral guidelines, and further research into abr and related areas. such endeavours are likely to lead to a refined use of abr in south mrica, which in turn should result in improvements in the provision of hearing health care to the population at large. limitations of this study include the relatively small and restricted ent population sampled. these limitations prevent this study's results from being generalised beyond the ent surgeon and registrar population practising in gauteng, south mrica. note: the questionnaire used in this study is available on request from the corresponding author; 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(2nd ed.). london: heinemann. musiek, f.e., borenstein, s.p., hall, j.w & schwaber, m.k. (1994). aud~tory brains~em response: neurodiagnosis and intra-operatlve apphcatlons. in katz, j. (ed.), handbook of clinical audiology (4th ed) .. baltimore: williams and wilkins. roush, r, & matkin, n.d. (1994). infants and toddlers with hearing loss: family centred assessment and intervention. baltimore: york press inc. seitz, m.r & kisiel, d.l. (1990). hearing aid assessment and the auditory brainstem response. in sandlin, r. (ed). hand. ?ook of hearing aid amplification. boston: college hill press. smmger, y.s., abdala, c. & cone-wesson, b. (1997). auditory thresho~d sensit~vity of the human neonate as measured by the auditory bramstem response. hearing research 104 2738. ' , silman, s. & silverman, c.a.(1991). auditory diagnosis: principles and applications. new york: academic press. stanton, s.g. & cashman, m.z. (1997). abr: a comparison of different strategies for detection of cerebellopontine angle tumours. scandinavian audiology, 25, 109-119. , weber, b.a. (1994). auditory brainstem response: threshold estimation and auditory screening. in katz, j (ed.). handbook of clinical audiology (4th ed.). baltimore: williams and wilkins. . white ~aper for the transformation of the health system in south afnca. government gazette no 1108 of 1997. pretoria: 'government printers. ", widen, j.e. (1990). behavioral screening of high-risk infant~ using visual reinforcement audiometry. seminars in hea~ing 11, 343-348. i ' the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) information for contributors 1. nature of publication the south african journal of communication disorders publishes reports and papers concerned with research, and critically evaluative theoretical and philosophical conceptual issues dealing with aspects of human communication and its disorders, service provision, training and policy. the south african journal of communication disorders will not accept material which has been published elsewhere or that is currently under review by other publications. 2. manuscript style and requirements • articles must be accompanied by a covering letter providing the author's address, telephone and fax numbers and email address. • articles must be typed on a4 pages in double spacing and in a font size of 12. • three print-outs of the article must be submitted. • one exact copy of the article on disk must be submitted. filenames must include the first author's initials and a clearly identifiable key word and must be type-written on the last line of the last page of the reference list (for retrieval purposes only). • articles must not exceed 30 pages. • the title page of one must contain: • title of the article. • full names of the author/so • institutional affiliation. • abstract of the article in the language of the article. • the title page of the remaining two copies must not contain the author/s name/s or institutional affiliations. • each article must contain an abstract' of no more than 200 words. • all abstracts must be in english, irrespective of the language in which the article was written each article must provide 5-7 key words for indexing purposes. • all contributions are required to follow strictly, the style specified in the publicati'on manual of the american psy/' chological association (afa pub. man., 1983). ,'. headings are not numbered. the order of importance is indicated as follows: i • main heading in capitals and bold print. • sub-headings in capifuls, bold and italic print. • sub-subheadings in ubper and lower case bold and italic print. ; • sub-sub-sub-heading in upper and lower case bold print. • major headings, where a:pplicable, must be in the order of introduction, method, results, discus· sion, conclusion,acknowledgements, references. • all paragraphs should be indented. • all tables, figures and illustrations must be numbered and provided with titles. • the title of tables, which appear above, and of figures, which appear below, must be concise but explanatory. • allow for·50-75% reduction in printing of tables, figures an illustrations. • each table, figure or illustration must appear on a separate page and be print ready. preferable not printed on colour printers. • do not include more than 10 tables, figures or illustrations. 3. references • references must be cited in the text by surname of the author and the date, e.g., van riper (1971). • where there are more than two authors, after the first occurrence, et al. may be used from the start. , • the names of all authors must appear in the reference list;' which must be listed in strict alphabetical order in triple spacing at the end of the article. • all references must be included in the list, including secondary sources, (apa pub. man. 1983, p. 13.) ,. only acceptable abbreviations of journals may be used, (see dsh abstracts, october; or the world list of sci~ntific periodicals). • the number of references should not exceed much more than 30, ·unless specifically warranted. examples locke, j.l. (1983). clinical psychology: the explanation and treatment of speech sound disorders. j. speech hear. disord., 48 339-341. penrod, j.p. (1985). speech discrimination testing. in j. katz (ed.), handbook of clinical audiology (3"d ed.). baltimore: williams & wilkins. davis, g.a. & wilcox, m.j. (1985). adult aphasia rehabilitation: applied pragmatics. san diego, ca: college-hill. editing • articles must be revised for grammar and style prior to sub'. mission. • the manuscript style of the article must be strictly according to the guidelines provided. o only'articles complying with the above requirements will be j accepted for review. ''', reviewing system o the peer review of refereeing system is employed as a method of quality control of this publication. • peer reviewers are selected by the editor based on their expertise in the field and' each arti~le is sent to two independent reviewers to assess the quality of the manuscript's scientific and technical content. o the blind peer review system is employed during which the names of the author/authors are not disclosed to the reviewers. o the editor retains the final responsibility for decisions regarding revision, acceptance or rejection of the manuscript. deadline for contrmutions: 30'h june each year. queries, correspondence & manuscripts: should be addressed to the editor, south african journal of communication disorders, south mrican speech-language-hearing association, p.o. box 91042, auckland park. 2006. tel. 011/726-5014, fax. 0111726-5013. copyright the copyright of all articles printed in the south mrican journal of communication disorders is reserved by the south mrican speech-language-hearing association (saslha). die suid-afrikaanse tydskrifuir kommunikasieafwykings, vl?i.46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) intelligibility alterations in an oral cancer patient following primary sumerv and two reconstructions: a case study y surgery and marlene carno jacobson ba (sp & η therapy) (witwatersrand) department of speech therapy and audiology, hillbrow hospital, johannesburg abstract intelligibility and perceptual characteristics were examined in η hili„»„„i 7 ι ,vu and mandibulectomy with primary closure and twosubseauent recon^n^-t °sa's^e ^ pat'ent following glossectomy a twelve-month period were instigated, using τζ ύιζζι s adm^ ζ usm^steomyoc^eous flaps. changes across and fiberoptic investigations. hndfngs e m p h ^ l τ ^ ^ ^ ^ γ γ γτ' ^ ™ xe^graphy, bility, relationships between articulators and the positioning ofvocaltrurt ^ ^ t o for preservation of articulator moterious to speech and a more influential rt 'ophic changes deleopsomming sluit. veranderinge in die ν ^ ζ γ ; ^ οζΐζαζ ^ t ^ t ^ ^ ^ ^ ™gestaanbaarheidstoetse (moedertaal luisteraars) latzifz !• w f a l f m a a n d e p™ode ondersoek. daar is van ver"" d<*?omumen,k m„ vemmmgs die tmhus vakal· l » * « % ' <««<·» mikulathe role of the south african speech therapist in the management of the surgically,' treated cancer patient has been almost exclusively limited to the laryngectomee despite the comparable incidence of glossectomy and other shared features such as difficulties with communication. among sowetan blacks, the ratio of larynx to tongue lesions is in the order of ι τ a proportion closely corresponding to that noted in the united states of america.20 the primary objective of oral ablative surgery is curative «ence excision of extensive tumours of the floor of the mouth a i r ? ' " ' ^ b c f ° r c e d t 0 i n c l u d e r e s e c t i ° n of unaffected ξ γ s t m t k s s u c h a s mandible, tonsil and anterior gue as well as associated cervical lymph nodes. without ^mediate^reconstruction, this may result in the typical "andy amdeof c s s ) d e f 0 m i i t y " w h i c h i s λ ε m o s t extreme extifiabl ^ e r e τ " 1 c r i p p l m g " 2 2 s u c h a c a i * is readily idendeelnhh» d s p e e c h ' disordered masticatory and cosmetic η γ a n i s m s ' d r ° 0 l i n 8 ' d e n t a l malocclusion and t̂ n of l n t t i t y ' "thc q u 3 l i t y °f h f e 3 α ε γ succes5ftl1 abla" cure rates. ° f ' ^ h e a d a n d n e c k i s n o t r e f l e c t e d * * m^'inofhead'and'n ° f t h e t u m o u r ' 1 1 « e s within the doadapt form a " d n e c k reconstructive techniques to restore and the t i m i ^ 0 f qr ^ " c t l ° n t 0 o r a l peripheral mechanism, g of oral cavity reconstructive surgery has been cond , e s u i d a f * k ° a n s e t y < l s k r i f v i r k ® sasha 1983 tommumkasieafwykings, vol 30. 1983 troversial, but currently the compelling advantages of immediate rather than delayed reconstruction are being emphasised. the introduction of composite osteomyocutaneous and myocutaneous flaps (pedicled grafts containing a donor blood vessel and the associated skin, underlying muscle and sometimes bone) has stirred a new wave of enthusiasm for reconstructive suigery. for the patient, the quality of life following radical surgery is largely a measure of adequate reconstruction17 "and the only thing that tends to tide the affected individual over the twilight zone is the hope that some day in the not too distant future his somatic deformity will be corrected."3 published studies to date focus on speech following primary surgery only, i.e. without reconstruction.1· » one study explores the effects of a prosthetic tongue on intelligibility and food management.13 at present, the focus of surgical reconstruction appears to highlight the anatomical parameters of tissue survival its form, bulk and contour, with a comparatively diluted emphasis on functional integrity. it seems that the effects of various reconstructive procedures, remain largely unexplored. s y the present study was designed to elucidate the surgicallyinduced changes in articulator mobility, perceptual r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 characteristics and composite speech intelligibility in an oral cancer patient who underwent an initial resection with primary closure, followed by two reconstructions, using osteomyocutaneous flaps. whereas current surgical practice tends to resect and reconstruct within a single lengthy operation, the subject of this study underwent staged management and thereby afforded a unique opportunity for investigation. methodology subject t.n. was a fifty-six year-old black bilingual zulu/xhosaspeaking illiterate male who underwent a suprahyoid block dissection (commando procedure) for a well-differentiated squamous carcinoma of the anterior floor of the mouth, in april, 1981. he was a heavy smoker and took alcohol frequently. the histopathology report described a 5 χ 1 cm lesion of the floor of the mouth anterior to the tongue, involving the base of the tongue and the gingiva. the cortex of the mandible had been invaded but no infiltration of the bone was observed. (a) marlene carno jacobson primary surgery surgical excision included the resection of both mandibular rami from angle to angle, transection of the anterior half of the tongue, and removal of the floor of the mouth. primary closure was achieved by attaching the remnant of the tongue bilaterally and anteriorly to the buccal mucosa. the geniohyoid, mylohyoid, and hyoglossus muscles were divided. the hypoglossal nerve (xii) was preserved, but the mandibular branches of the trigeminal nerve (v) were obligatorily severed, causing a loss of sensation in the lower lip. details of the original lesion and primary surgery are illustrated in figure 1. in september, 1981, the patient was admitted to the hillbrow hospital, johannesburg, for reconstructive surgery. it was at this point that the writer first came into contact with him. secondary surgery at this stage and three subsequent stages, the patient's speech was assessed using the procedures to be discussed shortly. geniohyoid* mylohyoid* figure 1 anatomical details of site-of-lesion and primary surgery (a) lateral view of site and extent of tumour. (b) muscles (*) divided during tumour excision. (c) frontal view of area of excision. (d) lateral view of area of mandibular excision. (d) the south african journal of communication disorders, vbl. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) intelligibility alterations in an oral cancer patient these four stages co-incide with the preand post-reconstruction periods associated with each reconstruction. the first reconstruction, in october, 1981, employed a right pectoralis major (chest) osteomyocutaneous flap and the second, in june, 1982, a spine of scapula-trapezius (shoulder) osteomyocutaneous flap. the reason for the repeated attempt at reconstruction was the fact that resorption of the first graft occurred, leaving only a healthy skin island in the floor of mouth area. throughout the period subsequent to primary surgery (april 1981, to august, 1982), t.n. experienced severe drooling owing to poor oral closure and dysphagia. thus, vegetative functioning was poor at all four stages with only the swallowing of liquids and purged foods being possible. procedures in order to explore and capture the speech changes comprehensively, a battery incorporating both subjective (1) and objective (2 and 3) procedures was utilised. 1. speech intelligibility assessment: to obtain an index of intelligibility, an intelligibility task was constructed for administration to native speakers who were naive listeners 2. xeroradiographic studies: to obtain anatomical and physiological data regarding articulatory mobility and the variability of vocal tract dimensions. xeroradiography provides excellent soft tissue definition; numerous soft tissue densities are presented in a single image, and the components of the speech production mechanism are easily identifiable by speech pathologists without radiographic training.7 3. fiberoptic examination: to examine altered anatomical features. (it should be noted that sound spectrography was used in order to derive an objective acoustic representation of auditory parameters. data yielded by spectrographic measures are the subject of a further paper and will therefore not be discussed at present.) data collection intelligibility data 1· preliminary speech materials at each of the four stages, the subject was required to imitate the model provided by a fluent zulu speaker, of eightytwo ngum words, extracted from an article by lanham'° e c 0 r a l l n f ° ™ i z u 1 u w ° r d l i s t " t h e s e i m i t a t i < ™ were record ° n u u h c r 4 2 0 0 r e p o r t s t e r e ° ic reel-to-reel tape treated en c a r e f t " v u m o n i t o r i n g w * h i n a soun£ treated environment. 2intelligibility test construction f o u r * « » w e r e c o n were selected ΐ " * * ^ ° r i g i n a l e i s h t r t w 0 ^ m s stance of eacj '̂̂ f" t t™ * γ ^ * l e a s t i n " presented in a f p h o n e m e s · ' n 2 3 the word list is of thtsfcdy ^ a t n d l x · 1 0 ^ ^ s p e c t i v e nature been n c o ^ t e d * * p h o n e m e s h a d n o t therefore the fiiwl r " ^ ° r i g i n a l s p e e c h « h * and dick; s c e d c l t ( / " / γ γ ^ ' ™ ^ /nhl/, /ndl) and /id/ a " d / g x / ) ; a n d t h e affricates tional framework o f " 5 o f principles of tradimeworks of articulation such as "the syllable"'6 17 "word initial, medial and final positions"6 was rejected due to the difficult segmentation of multisyllabic words and the common characteristic of vowels in initial and final position in zulu lexical items. therefore taiget phonemes were not localised to specific positions within words. it was also impossible to regulate retrospectively, factors such as word length, semantic complexity or conversational familiarity. 3. tape construction: four tapes were constructed by copying each imitated word three times consecutively from a revox high fidelity reel-to-reel recorder onto a uher 4200 report stereo ic reel-to-reel recorder. no interval was scheduled between the three identical imitations. the interstimulus interval between successive test items was five seconds. the four thirty-item sequences were varied and randomised using random numbers to avoid a "listlearning effect".18 4. judges: three judges were chosen, the selection criteria being that they were native speakers of zulu, had hearing within normal limits, and normal speech discrimination ability at conversational level (55db hl) and 75db hl using c.i.d. w.22 p.b. word lists. they had had no previous contact with the patient, nor knowledge of the nature of his speech pathology. the same judges were employed for all four tapes in order to maintain "listener-level stability" 18 5. playback conditions: testing was conducted individually the judges being seated in a sound-treated room approximately 1,6 metres in the midline from a pair of bang and olaufcen speakers, through which the experimental tapes were presented. the sequence of tape presentation varied for each judge to counteract a possible familiarisation effect which could bias the findings by exaggerating the average intelligibility of the tape played last. after listening to the thrice-presented production of a particular word each judge was required to imitate the subject's production and then to guess the word that he was saying. the judges' responses were recorded on a sony stereo cassette corder tc with vu meter monitoring for later transcription and analysis. anatomical and physiological data: 1. xeroradiography was repeated at each stage with lateral views taken of the articulators in a rest position and during the sustained production of five zulu cardinal vowels. 2. fiberoptic examinations were performed prior to and following the second reconstruction, using a standard olympus vf 4a vocal cords fiberscope with a camera attachment. die suid-afrikaanse ttdskrif • r tydsknf vir kommunikasieafwykings, vol. 30. 1983 data analysis intelligibility test at each of the four stages, the number of words correctly recognised by each of the judges was scored and totalled a mean percentage intelligibility was derived for each tape the number of refusals was also computed. the judges' stimulus imitations were broadly transcribed. vowel and consonant analyses of these were conducted, using broad distinctive features in order to highlight perceptual confusions and basic trends in the data. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 marlene carno jacobson 40 30 20 10 28,9 prerec. i 25,6 postrec. i k.14,4. prerec. ii 23,3 postrec. ii figure 2 percentage of words correctly recognised at each stage. 40 30 20 10 10,0 l prerec. i 28,9 postrec. i prerec. ii postrec. ii figure 3 percentage of words "refused" at each stage. + 1 0 1 0 +2,0 postrec. ii figure 4 percentage of correct words minus percentage of refusals at each stage. anatomical and physiological aspects for each stage, superimposed tracings were done of the vocal tract configurations for the five vowels and the rest position, using the cervical spine as a constant axis. in this way, changes in vocal tract dimensions were illustrated. results a. overall speech intelligibility 1. single word intelligibility was greatest prior to any reconstructive procedure, that is, with contracted primary closure alone. this was a most surprising finding and contrary to expectation, as it suggested that reconstruction was functionally unconstructive and possibly destructive to speech (fig. 2). 2. it may appear that the stage at which speech was almost as intelligible as pre-reconstruction speech was following the first reconstruction. however, notice the large number of refusals at this point (fig. 3). 3. in order to magnify the differences between the various stages, the number of correctly guessed words was balanced with the number of refusals by subtracting the latter from the former. following this operation, it became apparent that the patient was considerably more intelligible prior to any reconstruction (fig. 4). \ 4. following the second reconstruction, speech was more intelligible than following the first, but still markedly inferior in comparison to pre-construction intelligibility (fig. 4). 5. note the deterioration in intelligibility occurring following the first reconstruction and prior to the second when graft resorption occurred (see fig. 4). this feature is further elucidated by the xerographic findings. ' β (physiological aspects) (see fig 5) and c (anatomical aspects) (see fig. 6) 1. if the tracings from each stage are compared, it is evident that prior to the first reconstruction, there was remarkable flexibility in the sizes of the oral and pharyngeal cavities with different vowel productions. (see fig. 5a.) 2. following the first reconstruction and prior to the second reconstruction, the "floor of the mouth" displays an inthe south african journal of communication disorders, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) intelligibility alterations in an oral cancer patient 19 pre-reconstruction i post-reconstruction i pre-reconstruction ii post-reconstruction ii figure 5 tracings of /a/ and /i/ xerographs at four stages. die suid-afrikaans 6 ^^fvir kommunikasieafwykings, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 marlene carno jacobson the south african journal of communication disorders, vl. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) intelligibility alterations in an oral cancer patient variant gently rising convex formation, and the new appearance of a bump in the anterior oropharyngeal area can be observed. this was assumed to be a portion of the osteomyocutaneous flap. (see fig. 6b.) the constancy of the dimensions of the oral and pharyngeal cavities can be observed. (fig. 5b.) 3. prior to the second reconstruction, the relative rigidity of the vocal tract can again be noted from the tracings. (fig 5c.) in particular, there is clearly narrowing of the pharynx compared to pre-reconstruction i. comparison of the /u/ xerographs of post-reconstruction i and prereconstruction ii, reveals slight shrinkage of the pharyngeal "bump" and the reduction in size of the gentle hump anteriorly when the graft had resorbed and atrophied. 4. fiberoptic examination at this point, prior to reconstruction ii, revealed that the pharyngeal "bump" appeared to be the remnant of the tongue which had been sutured posteriorly in the erection of the island flap in the floor of the mouth area. in addition, this resulted in an extremely narrow airway. it would be expected that such a narrow communication between the pharyngeal and oral cavities would seriously affect the radiation of acoustic energy from the pharynx. 5. it was therefore recommended to the suigeons undertaking the second reconstruction that the constriction in the pharynx be reduced and that the tongue remnant be repositioned anteriorly. this was performed unilaterally, as was evident from post-reconstruction ii fiberoptic examination. following this, it seemed that there was greater variability in the anterior floor of mouth height as seen on the tracings (fig. 5d), although this feature is not wellillustrated on the /u/ xerograph following the second reconstruction, as the unilateral change is not captured hence the second reconstruction restored more open communication between the oral and pharyngeal cavities allowing for radiation of sound out of the pharynx anteriorly through the vocal tract. support for the notion of the significance to speech of the pharyngeal constriction and its subsequent reduction, is provided by the word in9 0 80 7 0 60 so 7 4 , 7 7 7 , 4 prerec. postrec. i prerec. ii ' postrec. ii 21 telligibility results, where recognition of the subject's utterances varied in relation to the degree of constriction i e the greater the constriction, the lower the intelligibility while the partially constricted pharynx resulted in improved intelligibility. d. vowel intelligibility the intelligibility of vowels was assessed by extracting the judges' imitations of vowels from their imitations of the stimulus words. hence, vowel intelligibility was not examined in isolation, but, rather, in the context of words. 1. the effect of the first reconstruction was to reduce intelligibility, which deteriorated even further with atrophy of the graft. 2. vowels were most intelligible following the second reconstruction, fractionally better than prior to any reconstruction (see fig. 13). this result further substantiates the view that better radiation of acoustic energy was possible when the pharyngeal constriction was reduced 3. the most intelligible vowel at all four stages was /a/ possibly because the constriction was correctly positioned (i.e. back of the oral cavity) and of appropriate magnitude (see fig. 8.) 4. the back-rounded vowels /u/ and /o/ became more intelligible when the maxilla and replaced mandible were in better alignment, i.e. reconstruction was positive for the intelligibility of these phonemes. (see fig. 8.) 5. following the first reconstruction, /e/ deteriorated dramatically; possibly both the degree and position of constriction were totally inappropriate for its production 1 0 0 9 0 80 7 0 60 5 0 4 0 3 0 20 10 10q· /a/ prerec. i postrec. i prerec. i postrec. ii figure 7 percentage of intelligible vowels at each stage. d l e swd-afrikaanse tydskrif vir kommunikasieafwykings, vol. 30, 1983 figure 8 percentage of individual vowel intelligibility at each stage. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 when the degree of constriction was reduced and sound allowed to radiate out of the phary nx, the previous level of intelligibility was restored. 6. the predominance of /a/ substitutions for the mid-vowels /e/ and /o/, was perhaps due to the position and degree of constriction, and the difficulty with explicit lip-rounding (because of absent sensation in the lower lip and poor maxilla-mandible alignment). 7. it appeared that when anterior constriction with the tongue remnant was possible (i.e. when the oral cavity was contracted, prior to any reconstruction), front vowels /i/ and /e/ were most intelligible while when there was the fixed posterior constriction due to the repositioned tongue remnant, the back vowels, /u/ and /o/, became most intelligible. (see fig. 13.) in other words, vowel intelligibility corresponded closely with the structure of the oral cavity. prior to any reconstruction, it seems that the vocal tract had some flexibility but limited ability to constrict at any point, so that it had the appearance of a single tube resonator, displaying free communication between the pharyngeal and oral cavities. the effect of the first reconstruction was to introduce an extreme constriction, positionally invariant, with marginal communication between the two cavities. the second reconstruction served to maintain an area of constriction even if it was positionally invariant and allowed for sufficient communication between the two cavities for radiation of acoustic energy throughout the vocal tract. these appear to be the critical factors in vowel intelligibility for this patient. marlene carno jacobson e. consonants generally, the trends in consonant perception were consistent throughout all four stages, but perception became more predictable and stereotyped, showing reduced variability during the intermediary two stages, i.e. a limited range of consonants was being perceived. (see table 1.) 1. during the interim two stages, fewer consonants requiring an oral articulation were perceived i.e. most consonants were perceived as / ' / and /h/ (glottal). when viewed in conjunction with the word intelligibility results, inaccuracy of consonants produced in the oral cavity seems preferable to glottal substitutes. 2. the judges attempted to simulate the muffled auditory impression of the voice by velarising, nasalising and pharyngealising i.e. by effecting a thoroughly atypical balance among the resonators, for the phonetics of the language. discussion the present study indicates that speech intelligibility was greatest prior to any reconstructive procedures. this level of intelligibility (28,9%) corresponds fairly closely to the range of partial glossectomy pre-therapy speech intelligibility scores reported by skelly et al., 1 8 which ranged from 6-24%. it is interesting that these authors used a similar test paradigm to that employed in the present study they attempted to sample all the phonemes of the language, selected phonetically balanced word lists as stimulus items and administered pretable 1 patterns of consonant perception class group common percept example plain voiceless /?/ /, t/ /?/ stops other voiceless modification /tv /h/ stops voiced continuant (usually fricative) id/ /z/ anterior features of manner and voicing retained it/ /?/ posterior features of place and voicing retained /k/ ixl fricatives voiceless /h/ /f/ /h/ voiced often correct (? effect of additional feature of voicing) voiceless glottal /hi various; not always correct, possibly because such a common substitute /hi /{/ voiced glottal ifj always correct all substitutes retain features of manner eg. (-(-continuant) best preserved continuants nasals anterior nasals: /m/,/n/ liquids and approximants /m/ /w/ posterior nasal: usually correct articulator contact virtually possible liquids and glides all usually correct or in-class substitions or glide/liquid /l/ /y/ /w/ /y/ africates voiceless ityl m voiced fricative /d3/ /z/ the south african journal of communication disorders, vl. 30, r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) intelligibility alterations in an oral cancer patient recorded stimuli within an open response format. in contrast, other studies;5 "·12 have employed either multiple or forced choice paradigms (closed response formats) or utterances ranging in length and compexity, from nonsense syllables to sentences.11·12·20 the stimulus presentation employed in this study diverges from a representation of real verbal interaction, thereby undermining the patient's "functional intelligibility" because words were produced without any syntactic context and without the complementary visual modality, which allows for an integrated signal.15 nonetheless, for the present purpose, this method was useful in describing the relationship between structure and function. in addition, some words e.g. "cija" did not have an initial vowel to provide acoustic cues in the form of formant transition. it also emerged that approximately five of the test words (asterisked in the word list) were not familiar to all the judges, and hence ought to be altered in future tests. further, being presented in an imperfect form, therefore almost certainly inaccessible to passive vocabulary, these items may be regarded as "dead weight",4 as they are not discriminating items. however a source of useful information to the judges was the fact that nguni languages use tones phonemically. these tonemes are likely to have provided helpful suprasegmental cues to words, evident in the way the judges always reproduced the tone contours of the stimuli correctly. bloomer and hawk1 mention that iii is the least intelligible vowel phoneme for the glossectomee; however, in this case combined glossectomy-mandibulectomy with mandibular retraction and inability to produce lip-rounding, appears to affect back vowels more dramatically, rendering these even less intelligible than anterior vowels. the nature of the maxillamandible relationship is as important to consonants as to vowels. if alignment is accurate and bilabial approximation achieved, the subject could be expected to produce good bilabial consonants ipl, lb/, /m/, /w/, which may enhance intelligibility considerably. it is therefore critical for reconstructive surgery to strive to meet the goal of adequate maxillary-mandibular, occlusion. furthermore, for the glossectomee with an additional mandibulectomy, mandibular replacement would seem to be a crucial procedure to vowel and consonant intelligibility and one that is more than elective".17 ; the distinctive predominance of the glottis as a compensatory articulatory site for a glossectomy-mandibulectomy patient is emphasised in this study, particularly in the case of stops and ncatives. the tendency of the judges to perceive most con' a s , h a v i n 8 a "fricative manner of production", and a glottal place of articulation", best describes the compensatory phenomena associated with this subject. these are not «ea a s compensatory characteristics in the literature although men ion is made of the compensatory use of mandibular, buccal, labial and palatal movements.18 however, the glottis as the site of compensatory articulation t i r e x t 1 8 1 " 8 3 s t h e l a r y n x w a s t h e o n l y po^t along the end r o ^ t r a c t w h e r e c o m p l e t e closure could be effected. apr e s x a ; i 0 n τ , a c h i e v e d * the lingua-velar junction and th" " p intelligibility of the velar stops ik/ and /g/, 23 the trend that glides, liquids and nasals were clearer prior to reconstructive attempts, may have been due to better pre surgical ability to constrict the oral cavity. although the dissected muscles, namely, geniohyoid, mylohyoid and hyoglossus had probably atrophied following anterior tongue transection, the possibility of styloglossus having been intoct is not unlikely. support for this notion is provided by the observation that high-back vowels and velar consonants were generally recognisable prior to any reconstruction the presence of residual tongue stump mobility prior to reconstructive efforts, is implied. la riviere et al." propose that some spontaneous improvement of glossectomee speech occurs with time. this may be true for primary closure but not necessarily for surgical reconstruction using flaps which have the potential to resorb in this case, partial contraction was a reality and altered the vocal tract dimensions considerably, with critical articulatory and auditory effects. the findings of this study underline the need for the speech therapist's involvement in the management of the oral cancer patient. the speech therapist may be active from the very early stages of pre-operative counselling, post-surgical communication and swallowing facilitation. he/she may later imp ement a communication board or gestural system, and could ultimately focus on "communication" (perhaps utilising augmentative methods to supplement the auditory signal) rather than "speech". this is a somewhat predictable conclusion. what this paper demonstrates most powerfully, however, is that speech may be a sensitive and valid criterion of the efficacy of surgical reconstruction. for too long, the role of the speech pathologist in tins area has resided in dealing with a surgical fait accompli and with the use of treatment strategies such as "vocal parameter manipulation"1' and "compensatory physiologic phonetics".18 the present writer suggests that there is a need > tor the speech therapist to enter the treatment arena at a point where he/she can be instrumental in determining and planning the structural springboard" for therapy and assist in the crea tion of optimal prognostic potential. with a sound knowledge of speech anatomy and articulatory phonetics, the speech therapists s intervention may serve as the bridge between anatomical structure and functional integrity. "the management of head and neck cancer presents a unique opportunity for the co-operative efforts of multiple disciplines in order to achieve both maximum cure rates and maximum rehabilitation."21 die suid-afril· jnkoanse tydskrif vir kommunikasieafwykings, vol. 30, 1983 acknowledgements the writer wishes to thank prof. a. traill, associate professor, department of linguistics, university of the witwatersrand, johannesburg, for his assistance, guidance and time in conducting investigative procedures, constructing the intelligibility tapes and interpreting the data. the writer also wishes to thank dr. claire penn, lecturer, department of speech pathology and audiology, university of the witwatersrand, for her helpful comments in the writing of this article. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 references. 1. bloomer, a. h. and hawk, a. m. (1973): speech considerations: speech disorders associated with ablative surgery of the face, mouth and pharynx ablative approaches to learning. in orofacial anomalies: clinical and research implications. a.s.h.a. reports & publication of the american speech and hearing association, washington. 2. bradley, p. j., hoover, l. a. and stell, p. m. (1980): articulation after surgery to the tongue. folia phoniatr. 32 334-341. ' ' 3. crikelair, g. (1967): history of reconstructive surgery in head and neck cancer. in cancer of the head and neck. conley, j. (ed.). butterworthy inc., tennesee. 4. egan, j. p. (1948): articulation testing methods. laryngoscope 58, 955-991. 5. georgian, r. α., logemann, j. a. and fisher, η. b. (1982): compensatory articulation patterns of a surgically treated oral cancer patient. j. speech hear. disord 47, 154-159. 6. hall powers, m. (1971): functional disorders of articulation symptomatology and etiology. chapter 33 in handbook of speech pathology and audiology. travis, l. e. (ed.). prentice-hall, new jersey. 7. holonger, p. h., lutterbeck, e. f. and bulger, r. (1972): xeroradiography of the larynx. arch. otolaryngol 81 806-808. 8. isaacson, c. (1982): pathology of a black african population. springer-verlag, berlin, heidelberg, new york. 9. khumalo, s. j. m. zulu tonology (1981): unpublished dissertation. submitted for the degree of master of arts, university of the witwatersrand, johannesburg. 10. lanham, l. w. (1969): generative phonology and the analysis of nguni consonants. lingua 24, 155-162. 11. la riviere, c., seilo, μ. t. and dimmick, k. c. (1974): the pretherapy speech intelligibility of a glossectomee. j. commun. disord. 7, 357-364. 12. la riviere, c., seilo, μ. t. and dimmick, k. c. (1975): report on the speech intelligibility of a glossectomee folia phoniatr. 27, 201-214. 13. leonard, r. and gillis, r. (1982): effects of a prosthetic tongue on vowel intelligibility and food management in a patient with total glossectomy. j. speech hear. disord 47, 25-30. 14. massengill, r., maxwell, s. and pickrell, k. (1970): an analysis of articulation following partial and total glossectomy. j. speech hear. disord. 35, 170-173 15. mccormick, b. (1979): audio-visual discrimination of speech. clin. otolaryngol. 4, 355-362. 16. mcdonald, ε. t. (1964): articulation testing and treatment: a sensory motor approach. stanwix house pittsburgh. 17. myers, ε. n. (1972): reconstruction of the oral cavity. otolaryngolgic clinics of north america, 5, 413-433. marlene carno jacobson 18. skelly, m., spector, d. j., donaldson, r. c., brodeur, a. and paletta, f. x. (1971): compensatory physiologic phonetics for the glossectomee. j. speech hear. disord 36, 101-114. 19. skelly, m., donaldson, r. c., fust, r. s. and townsend, d. l. (1972): changes in phonatory aspects of glossectomee speech through vocal parameter manipulation. j. speech hear. disord., 379-389. 20. skelly, m. glossectomee speech rehabilitation. (1973): charles c. thomas, springfield, illinois. 21. southwick, h. w. (1973): cancer of the tongue. surgical clinics of north america 53, 147-158. 22. summers, g. w. (1974): physiologic problems following ablative surgery of the head and neck. otolaryngologic clinics of north america 7, 217-250. 23. ziervogel, d., louw, j. a. and taljaard, p. c. (1981): a handbook of the zulu language. third edition. j. l. van schaik, pretoria. appendix nguni speech intelligibility word list 1. umunwe (finger) 2. inqawe (a pipe) 3. ivovo (strainer) 4. ithanga (pumpkin) 5. itiye (tea) 6. incwadi (book) 7. inyoni (bird) 8. uzipho (finger-nail) 9. isichaka (poor fellow, servant) 10. ihashi (horse) 11. idada (duck) 12. ugogo (grandmother) 13. umhume (cave) * 14. isipoliyane (female hysteria or a type of brain disease) 15. kaka (to excrete faeces or to surround) 16. khipha (take) 17. tshela (tell) * 18. ukubhubha (to die) * 19. ububovu (pus) 20. isifo (sickness) 21· rola (to roll or to pay out) j xhosa 22. hlola (inspect) | 23. dlala (play) 24. xhosa (chase away) 25. cija (sharpen) 26. qangqa (explain) 27. inxele (left side) 28. iqhude (a cock) 29. ingcawe (type of assegai) * 30. ingxoko (grain store) *: words not familiar to all three judges. / the south african journal of communication disorders, vl. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) gsi 28 auto tymp the gsi 28 auto tymp provides testing capability for tympanometry, ipsilateral and contralateral acoustic reflex estmg and screening audiometry. selection of test sequence s as simple as pressing a button! the auto tymp is hghtwe.ght and compact so it can be easily moved from one more dortaht? 0 p t i 0 n a , c a r r y i n 9 c a s e i s avai.ase if more portability is required. the needier westdene organisation (pty) limited in association with / in medewerking met hearing and acoustic instruments (pty) ltd lewis's hearing centre (pty) ltd engineered acoustic products noise control e k s s , die suid-afrikaanse tydskhf • „ n j n r kommunikasieafwykings, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction a brief summary of hearing conservation programme pillars overview of engineering noise control methods summarized research on the use of engineering noise control in south africa case studies of engineering noise control methods currently being used across the world recommendations on how south african mines can contextualise the noise control methods used by the rest of the world limitations of the work and conclusion acknowledgements references about the author(s) milka c. madahana school of electrical and information engineering, faculty of engineering, university of the witwatersrand, johannesburg, south africa otis t. nyandoro school of electrical and information engineering, faculty of engineering, university of the witwatersrand, johannesburg, south africa nomfundo f. moroe department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation madahana, m.c., nyandoro, o.t., & moroe, n.f. (2020). engineering noise control for mines: lessons from the world. south african journal of communication disorders, 67(2), a684. https://doi.org/10.4102/sajcd.v67i2.684 note: special collection: occupational hearing loss in africa. original research engineering noise control for mines: lessons from the world milka c. madahana, otis t. nyandoro, nomfundo f. moroe received: 13 oct. 2019; accepted: 01 feb. 2020; published: 31 mar. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract objective: the main objective of this article was to present some of the engineering noise control methods that are currently being used across the world in the mining industry, while at the same time interrogating noise control measures that could be applied to effectively reduce noise emissions from the equipment utilised within south african mines. background: a brief summary of the hearing conservation programmes used in south africa is presented. summarised research on the use of engineering noise control in south africa is also presented, with an overview of the various engineering noise control methods applied across the world in dealing with occupational noise. method: for illustrative purposes, case studies were used to show how engineering noise controls could be used to reduce the noise levels and risks within this context. results: some of the case studies used have cited a reduction in the noise intensity emitted by machinery from a range of 93 dba – 104 dba to a range of 90 dba – 94 dba, demonstrating quite a significant reduction in the noise emission of the equipment. this article further provides recommendations on how south african mines could contextualise these methods. conclusion: one of the key recommendations is encouraging the south african mining industry towards the documenting and publishing of those engineering noise control methodologies that have proven to be effective for shared best practice. a need was identified for extensive research to be conducted and documented evidence to be made available to assist the south african mining industry with locating and assessing current engineering controls available in south africa. machines and processes that require noise control should be identified and, lastly, the current barriers to the use of engineering noise control methodologies should be identified, with the main goals of finding ways to overcome the noise challenges in the mines. keywords: noise; engineering; barriers; isolators; controls. introduction noise may be defined as an undesirable sound lacking musical quality (concha-barrientos, campbell-lendrum, & steenland, 2004). depending on the sources from which it is generated, noise can be classified as intermittent, impact or impulsive noise, repetitive impact noise, continuous narrowband noise and continuous wide band noise (concha-barrientos et al., 2004). these classifications of noise are emitted in the mines at varying frequencies and intensities (basner et al., 2014). excessive occupational noise levels and exposure to such noise have been documented to cause occupational noise-induced hearing loss (onihl), tinnitus, disturbance in speech communication and increased risks of accidents (lie et al., 2016; lopes, otowiz, lopes, lauris, & santos, 2012). occupational noise-induced hearing loss is one of the most prevalent occupational diseases caused by extended exposure to loud noise (nanda, 2012). hearing conservation programmes (hcps) were introduced to the south african mines by the leon commission of enquiry in 1994 (stanton, 2003). this was one of the measures recommended to deal with the noise dilemma in the south african mining industry. a brief summary of hearing conservation programme pillars the seven pillars of hcps as documented by moroe, khoza-shangase, madahana and nyandoro (2019) are shown in figure 1. figure 1: seven pillars of an effective hearing conservation programme. this article mainly focuses on the last pillar shown in figure 1 (i.e. engineering controls), which entails the use of noise controls. the main objective of this article was to present some of the engineering noise control methods that are currently being used across the world in the mining industry and how these noise control measures can be applied effectively to reduce noise emissions from machines in the south african mines. this article is structured as follows: a brief introduction is given, followed by the subsections listed below that show how the main objective will be achieved: a brief summary of hearing conservation programme (hcp) pillars overview of engineering noise control methods summarised research on the use of engineering noise control in south africa for illustrative purposes, case studies of engineering noise control methods currently being used across the world are used to show how engineering noise controls can be used to reduce noise levels in this context. recommendations on how south african mines can contextualize the noise control methods used by the rest of the world. overview of engineering noise control methods the engineering noise control methods can be divided into: control of noise at source, control of noise propagation and receiver control as shown in figure 2. figure 2: an overview of engineering noise controls. summarized research on the use of engineering noise control in south africa gumede, blomerus, coutts and de beer (2014) conducted a study that proposed a strategy to buy quitter equipment, which is one of the engineering noise control methods. it is in the category of the control of noise at source as shown in figure 2. the findings of the research indicated that the mining industry perceives the buying of quitter equipment as a proactive strategy that will aid in the reduction of onihl, thus improving the management of noise from source. burger, von wielligh, de wet, otterman and steyn (2004) developed a low noise blast-hole drilling system whose main goal was to reduce the risks associated with the exposure to excessive noise in the underground mining. the system was tested in an underground mining environment. case studies of engineering noise control methods currently being used across the world identification of machinery that emits the most noise in the mines sensogut (2007) documented the main sources of noise in the mine to be excavators, stage loaders, shearers, compressors, fans, continuous miners, pneumatic drilling machines, vibrating screens, rotating breakers and mills. spencer (2009) also carried out an investigation on equipment operator’s noise exposure in western underground gold and silver mines. the research findings on some of the equipment that emit the loudest noise were consistent with sensogut’s (2007) findings. effective engineering noise controls entail understanding the production of quieter processes by understanding the noise producing mechanism. it is much easier when the implementation is done in the original design. most engineers do not have access to the equipment and can only apply extra features to the machines once they have been purchased. these additional features can sometimes be cumbersome and perceived as an obstruction to progress at work. noise mapping case studies show how engineering noise controls can be used to reduce noise levels in this context. nikola, aleksandar, dinko, vladimir and uros (2018) proposed that in order to have a mine with successful noise management, there is a need for an assessment to be carried out in the initial stages of setting up the mine to establish in advance that the mining activities will have reasonable noise effects. it is further proposed in the paper that the following measures should be taken at the design phase of the mine: noise mapping of the mine should be carried using efficient and accurate computer modelling software (nikola et al., 2018), baseline characterisation should also be performed to understand the characteristics of the area in which the mine is located. noise emission estimation for each machinery should be done using available international standards to estimate and quantify the anticipated noise that will be coming from each unit and the entire mine. the noise emission estimation should be done in conjunction with the manufacturer’s data sheet and the actual measurements (nikola et al., 2018). the research further proposes that noise assessment and control should always be one step ahead of the potential problem. control of noise at source and noise propagation the research by sensogut (2007), using a case example of mines in turkey, indicates that noise controls and administrative actions should always be ranked as the first line of defence when it comes to combating noise dilemma in the mines. the research further suggests that engineering noise control measures to be implemented would include the following: selecting of processes with lower sound pressure level, locating of a mine in noiseless places, enclosing the noise sources and prevention of noise from being transmitted and moving of noisy machines to sections of the mine that are used less (sensogut, 2007). the peterson (2018) proposed that research (peterson, 2018) proposed that engineering controls require physical changes to the workplace, such as redesigning of equipment to eliminate noise sources and constructing barriers that prevent noise from reaching a worker. manwar, mandal and pal (2016) carried out research which was based on using noise mapping as a measure obtained from the european mines to combat the noise dilemma. the findings of the research indicated that prediction of total amount of noise likely to be emitted by a mine can be used as a tool for understanding the type of noise measures to be taken to minimise the effects of noise on the miners and surrounding communities. the research further proposed the use of engineering control methods, for example, using acoustic barriers near machines that emit excessive noise or crushers to attenuate noise propagation. reeves, randolph, yantek and peterson (2009) carried out a research in noise control in underground metal mining. in this work, it is proposed that some of the lessons learnt that could aid in the reduction of noise in underground mines were correct use of sound barriers; for high frequencies, it is recommended that environmental cabs and windshield should be used. plugging gaps in machine panels and wind shields combined with a material that can create an airtight seal that can also be used to create barriers. checking that there are no gaps in barriers because they compromise the effectiveness of noise control and in a situation where enclosures are necessary, a partial enclosure can be provided and can be used. it is further recommended that enclosures should be lined with absorptive materials that are thick enough to absorb the dominant sound frequencies. spencer and reeves (2010) conducted a research on the assessment of engineering noise controls at a talc-processing plant and found a reduction in sound level from a range of 93 dba – 104 dba to a range of 90 dba – 94 dba. the engineering control measures that were used to achieve this reduction were placing of curtains around fans and the crushers. the mill was treated with a ductwork with a sound barrier material. control of noise at source by design peterson, miller and yantek (2014), working with the national institute for occupational safety and health (niosh), visited a collaborating mine and investigated a haul truck underground in a shop area using source path contribution (spc) techniques for noise source identification (nsid) (peterson et al., 2014). further studies were conducted in 2018, using dosimetry and time motion to determine when an operator accumulates the most noise dose (peterson, 2018). the investigations carried out by peterson involved retrofitted noise control package for load haul dumps (lhds) used in underground metal and non-metal mines. the results showed that the reduction in lhd operator exposure was less than that of the haul truck operator. a reduction of 2 db – 9 db was achieved. saleh, woskie and bello (2016) conducted a research on installation of acoustic curtains on fans and crushers for noise reduction and found that there was a noise reduction from a range of 93 db – 104 db to a range of 88 db – 94 db. camargo, azman and alcorn (2016) carried out a research that was targeting the reduction of noise emitted by the long wall shearer cutting drums. several models were built and tested before choosing structural modification to increase the stiffness of the outer vane plates as a suitable method. this method was implemented and a reduction of 3 db was achieved. recommendations on how south african mines can contextualise the noise control methods used by the rest of the world engineering noise controls that have been discussed may be implemented in the south african mines, for example, by enclosing noisy places, using correct sound barriers and using curtains and retrofitted noise control packages. there is limited published evidence from the south african mines that document how engineering noise controls have contributed towards a reduction in noise emission from equipment. mining companies and research centres in south africa should consider partnering with niosh because of their extensive documented research work on onihl in the mines, to extend and contextualise their research to south african mines. the south african mines should thereafter consider conducting research and the documented evidence should be made available to assist with locating and assessing current engineering controls in south african mines. this research work should also include identification of machines and processes that require noise control. current barriers to the use of noise control should be identified with the main goals of finding ways to mitigate them. limitations of the work and conclusion this article is not a systematic review paper; hence, not all engineering noise control methods currently have been applied. the engineering noise control method as a technique to mitigating noise in the mines has been presented. case studies from around the world and how they can be contextualised to the south african mining industry have also been presented. a follow-up to this work would include the documentation of a strategic plan that would encourage the mining industry to publish the noise control interventions that have currently worked for them. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions all authors contributed equally to this work. ethical considerations this article followed all ethical standards for a research without direct contact with human or animal subjects. funding information the authors thank the national institute for the humanities and social sciences (nihss) and the consortium for advanced research training in africa (carta) for providing financial assistance for the publication of this manuscript. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references banach, j.d. 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(2003). report of the commission of inquiry into safety and health in the mining industry. the south african ohs commissions, 1(1), 1–192. 37 story grammar analysis ofpre-schoolers' narratives: an investigation into the influence of task parameters kerstin m, tonsing and herman tesner department of communication pathology university of pretoria abstract this study aimed at examining the influences of the parameters of the narrative task (administered to the pre-schooler) on narrative structure. seventeen pre-school children were selected as subjects. five narrative·tasks were administered to each subject. the narratives were analysed for length and structure. mainly two factors were found to influence the length and structure of the produced narratives; firstly, the presence or absence of a 'model' on which the child could base his / her narrative, and, secondly, the structure inherent in this 'model'. the implications of the study for clinical assessment ofnarrative skills as well as for further research are considered. opsomming in hierdie studie is gepoog om die invloed van die parameters van die narratiewe taak (voorgele aan die voorskoolse kind) op die struktuur van die narratiewe produksie te ondersoek. sewentien voorskoolse kinders is as proefpersone gekies. vyf verskillende take is deur elke kind uitgevoer. elkeen van die take het die vertelling van narratiewe vereis. alle geproduseerde narratiewe is geanaliseer ten opsigte van lengte en struktuur. veral twee faktore het 'n invloed gehad op die lengte en struktuur van die geproduseerde narratiewe; eerstens, die teenwoordigheid of afwesigheid van 'n 'model' waarop 'n kind sy / haar narratief kon baseer, en tweedens, die inherente struktuur van hierdie 'model'. die kliniese implikasies van die bevindinge met betrekking tot die evaluasie van storiegrammatika asook die implikasies vir verdere navorsing word bespreek. key words: story grammar, pre-schoolers, narrative task, story generation, story retelling, personal experience narratives inj'roduction / " since the 1980s researchers in childhood language assessment have increasingly shifted their focus from the evaluation of discrete lin~istic skills on word and sentence i level to a more holistic diagnosis of longer linguistic units, such as discourse (merritt & liles, 1987). amongst other types of discourse assessmknt, the evaluation of narratives has gained popularity as 'a clinical tool. story grammars have been developed by various authors to describe narrative structure (mandler & johnson, 1977; stein & glenn, 1979; roth & spekman, 1986). the assumption underlying all of these grammars is that ideal stories are constructed of episodes, these being well-organised structures which describe goal-based behaviour. story grammar models seek firstly to judge the completeness and well-formedness of an episode, and secondly to describe relations between episodes in multiple-episode narratives. one example 'of such a story grammar model is that described by stein and glenn (1979). it includes a description of story components making up an episode, as well as the relations linking these episodes together. this story grammar model and various adaptations of it have been used to analyse the structure of narratives generated by subjects from the age range of pre-school to adulthood (merritt & liles, 1987; peterson & mccabe, 1983). used as a clinical tool, story grammar analysis provides valuable information, not only on language abilities but also on higher level processing skills. inferences on the cognitive organisational skills of the individual have proved to be valuable sources of information to speech-language pathologists, educators and psychologists. in a pre-school setting, story grammar analysis thus seems an invaluable clinical tool for valid and accountable language screening and evaluation, as potential learning and language-learning problems can be detected at an early stage (hemphill, feldman, camp, griffin, miranda & wolf, 1994). the clinician intending to do such an analysis is faced with an array of choices pertaining to the variables of the task used for sampling story grammar skills. scott (1988) lists and describes some of the parameters of narrative type and context. amongst these are: • source: narratives can be self-generated or retold • experience base: narratives can be based on personal experiences or they can be fictional creations • eliciting stimuli: different types of stimuli, such as pictures or props can be made available to the child. die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 38 regarding the source of the narrative, story retelling is generally believed to be the 'easier' task, as direct input of pre-structured content is given (liles, 1993). literature supports the notion that story generation is a more sensitive indicator of story grammar abilities. roth and spekman (1986), for example, found significant differences between the story grammar abilities oflanguage-learning disabled subjects and subjects with normal language ability as displayed during story generation tasks. research by peterson and mccabe (1983) suggests that narratives based on personal experiences. contain more story structures and.more mature ones than fictional narratives, especially where younger children are concerned. they propose that real events need less mental ordering and may have been reported before, which leaves children to devote their attention to structural organisation of the narrative. however, children exposed to traditions of story telling have been shown to generate well-structured fictional narratives (alant, tesner & taljaard, 1993; kayraining bird & kluppelvetter, 1994). differences between the structural complexity of personal experience narratives as opposed to fictional narratives thus remain to be researched within given populations. . the types of stimuli used in eliciting fictional narratives in pre-schoolers differ with regard to the amount of structure inherent in the stimulus, and its potential effect on the organisation of the story construction. puppets, for example, do not provide the child with any structure while producing a story. a single action picture provides a medium amount of structure as the setting, the potential story characters and an event are given. a sequence of related pictures gives a high degree of structure. research findings on the influence of media input on story retelling varies. in some instances visual stimuli augmenting the audio-input has been shown to aid re e call, (liles, 1993) while others report an opposite effect (schneider, 1996). different effects of the use of props during presentation of the story on the one hand versus recall of the story on the other hand are also issues that have not been fully researched in the pre-school population. insufficient and controversial data thus exists regarding the various methodological issues involved in evaluating story grammar abilities in precschoolers be it the source of the produced narrative (generated versus retold), the experience base ofthe narrative (personal experience versus fiction) and/or the type of stimuli used for each task. this study therefore aims' to address the following questions: • does a story grammar analysis of pre-schoolers' narratives elicited under various sampling conditions indicate structural similarities of productions across task? • are there differences in productions correlated to these. param~ters of sampling that have practical implicationsin tenns of clinical asse,ssment? method aim the aim 9f this study was to investigate how preschoolers' use of story grammar is affected by the following parameters of the narrlltive task: the experience base, the source and the eliciting.stimuli. sub-aims included the description of structural characteristics (length and story kerstin m. tonsing and herman tesner grammar parameters) of narratives elicited under five different sampling conditions, and examining possible correlations and differences between them. design a cross-sectional quasi -experimental design was chosen. children's use of story grammar was measured in five tasks. correlations between the sampling parameters and the structural properties of the pro.duced narratives were then established. subjects a non-random convenience sample of seventeen subjects was drawn from two nursery schools. thirteen children attended the preparatory class of an english nursery school in an affiuent area, while a further four children were nonrandomly selected from the preparatory class of an english-medium nursery school in a less affiuent area of the same town. the latter four children were intentionally chosen on the basis oftheir background; their teacher described them as coming from lower socio-economic backgrounds and disrupted families. although a comparison between the two test populations, was not the aim ofthe study, a varied test population might promote a richer description of the phenomena (peterson, 1994). the age range displayed by the subjects ranged from 4 years, 8 months to 6 years, 4 months, with a mean age of 5 years, 6 months. all subjects had normal vision and hearing and had not received speech/language intervention before. the home language of all the children was english. eleven boys and six girls partici pated. in order to gather infonnation on the subjects' exposure to stories and the story reading practices of their care-givers, a questionnaire was filled in by a care-giver of each of the subjects. from the results it seemed that all subjects were exposed to stories from books and from television. material task 1: personal experience narrati~es . i a 'conversational map' based on mccabe and rosenthal rollins's guidelines (mccabe & rosenthal rol~ins, i994) was devised in order to elicit personal experience narrativesfrom the subjects. the adapted 'conversational inap' consisted of six personal anecdotes followed by variou~ sets . • i of probe questions. each set of questions c,onsisted of one or two closed questions to establish whether a theme w'ould be successful, followed by an open question which in~ited the actual telling of the narrative. task 2: story generation with puppets five cardboard puppets, as well as three cardboard pictures of objects were used. task 3: story generation with a picture / a magazine, picture was chosen as a .stimulus for this story .generation task. it depicted a setting and potential story characters involved in a problem-solving attempt. story retelling~ 'task 4 (puppet condition) and task 5 (picture condition) / the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) story grammar analysis of pre-schoolers' narratives: an investigation into the influ~hce oitask parameters material used for the retelling tasks consisted of two model stories as well as the visual material used for each story. in order to limit variables as much as possible, care was taken to ensure that the model stories corresponded to each other in length, structure and content. the first model story (used in task 4) consisted of251 words and 41 clauses; while the second model story (used in task 5) consisted of 255 words and 41 clauses. the structure of each story was analysed according to stein and glenn's story grammar analysis (stein & glenn, 1979).46 and 47 story components were identified in the two stories respectively. both stories were classified as multiple structure episodes. a set of eight cardboard puppets as well as five c'ardboard pictures of objects were used for the first retelling task (task 4). a sequence of eight hand-drawn and coloured-in pictures was used for the second retelling task (task 5). procedure a pilot study was undertaken in order to determine whether the material used during the narrative tasks was age-appropriate, and whether elicitation procedures and analytical procedures were successful. the procedures for the main study were then adapted based on the results of the pilot study. ,pre-recording procedures: the researcher spent an average of two hours spread over three to four days per week for three consecutive weeks to establish rapport with the children. recording procedures: each child completed all five tasks in one sitting and was tested individually in a quiet venue at the nursery school by a single examiner. generated and retold stories were audio-recorded by means of a tandberg audio tutor tat 771 tape recorder and tdk iec:rtrype 1 d 60 cassettes. the production and retelling tasks were presented in this prder to eliminate the possibility of the model stories influ·'encing the child's generated stories. no time limits were imposed on any of the tasks. task 1: collection of p 1rsonal experience na~a~ives the conversational map was used. the researcher engag:d in conversation +ththe subject and inserted the various personal anecdotes after each of which were inserted. two or more questions/prompts inviting subjects to share their experience. while the subje~t was narrating, merely neutral sub-prompts such as the exact repetition of a portion ofthe child's utterance, vocalisations ('ah!', 'hmm', 'oh') and neutral questions (such as 'and then?') were used. at least five narratives were collected per subject. task 2: story generation with puppet~ subjects were presented with the cardboard pictures and puppets. the following instructions were given: 'use these pictures to make up your own story. use as many of the pictures as you like; you need not use all the pictures:think about your story first, and tell me when you are ready.' while subjects were narrating, once again only neutral subprompts were given. i 39 task 3: story generation with an action picture subjects were presented with ,an action pict~~e. they were given the following instructions: 'look at this picture carefully. make up a story about it. your story need not be only about the picture, you can tell me about what happened before and after as well. think about your story and tell it to me when you are ready.' tasks 4 and 5: story retellings subjects were given the following instructions before both retelling tasks: 'i am going to tell you a story n~w. listen carefully. mter i've finished, i want you to tell the story back to me.' cardboard puppets 'and pictures of objects were presented to the subject as the first model story (puppet condition) was narrated by 'the examiner. following the presentation, the examiner gave the following instructions: 'now you tell me the story.' the cardboard puppets and pictures were given to the subject to use'during hislher retelling. during narration of the second model story (picture condition), the subject was 'presented with a sequence of eight pictures depicting the 'story episodes. the picture~ were presented one by one 'while the examiner narrated the model story. the subject 'was them prompted to retell the story with the same instr'uctions as for task 4. the pictures were not available to the subject during the retelling task.' ' " processing of data , transcription as the researcher was interested in the structural properties of the children's narratives, transcription of the taped narratives focused on the content of the child's utterances. repetitions of words and vocalisations were not transcribed. analysis quantitative and qualitative data w~s obtained and analysed by means of descriptive statistics consisting of means, percentages and relative frequency measrire~"ex­ pressed as percentages (caswell, 1995). for narratives to be included in the analysis they had to consist of ~~ini­ mum of two statements. all included narratives 'were analysed for length as well as for their structural properties. eachnarrative was segmented into statements; defined as main or subordinate clauses. thecriteri&governing the selection of,statements for the analysis are given in appendix 1. a word count was done for each ofthe elicited narratives. the words of all statements that were included in the analysis were counted. no fillers, repetitions or false starts were counted. a statement count was also done for each ofthe elicited narratives. statements were then classified into story components. descriptions of these components can be found in'appendix 2. mter statements were , coded, so-called structural patterns (peterson & mccabe, 1983) were identified, by which narratives were divided into sequences (non-goal-based) or episodes (goalcbased). descriptions ofthese structural patterns can be found in appendix 3. the data analysis consisted of comparing the narratives elicited by each of the five'tasks with respect to the following: • average length of narratives as calculated by wordand statement counts ' die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 40 • average length of structural patterns: basic structural patterns and complete episodes • frequency with which the 11 structural patterns occurred. scoring reliability eighteen (10%) of the elicited narratives were independently rated by ii second examiner, yielding a point-to point agreement of 86% for the assignment of structural patterns to the narratives. point-to-point agreement was 85% for classifying statements into story components. results and discussion length analyses pertained to the average length of narratives as well as to the average length of complete episodes. average length was determined by the mean number of words, the mean number of statements and the mean number of basic structural patterns across all narratives produced for a specific task. the results are summarised in table 1. while stories generated in response to the picture (task 3) were similar in length to story retellings (tasks 4 and 5), personal experience narratives were significantly shorter on average. stories generated in response to puppets were significantly longer on average. the experience base of the narrative clearly influenced length, as can be established when comparing personal experience narratives (task 1) and generated stories (tasks 2 and 3). personal experience narratives, by the nature of the prompts, tended to be accounts focusing on usually one dramatic incidence, with between one and three prominent characters. more than half of these narratives (55,36%) consisted of only one structural pattern. usually no extended recounts of preceding or following events was given. in contrast, the stories generated in response to puppet and picture stimuli were more elaborate narratives, including more detailed descriptions of settings, ini tiating events, attempts etc. orsolini (1990) remarks on the more formal and elaborate style encountered in children's fantasy narratives when compared to their 'real' (personal experience) narratives. he ascribes this difference to the fact that perkerstin m. tonsing and herman tesner sonal experience narratives are aided by shared knowledge between speaker and listener, conversational co-operation and memory of the events narrated. as a result, the process of conveying pieces of verbal information is facilitated, and the speaker is allowed certain 'short-cuts' in his language use. fictional narratives, however, require extension of discourse topic without these scaffolds, necessitating more detail and descriptions and more formal language use (orsolini, 1990). generated stories necessitate a great deal of planning, both of semantic content and of so-called 'macro-' and 'micro-units' (i.e. story grammar and sentence grammar respectively) (orsolini, 1990). however, it seemed that the subjects of this study were not always aware of this demand, and spontaneously launched into all narrative tasks without much pre-consideration to either structure or content. if the narrator was offered some form of structured 'model' (be it a highly structured picture, a personal experience that can be retrieved from memory or a model story) this lack of planning could be compensated for by resorting to the structure inherent in this 'model'. however, if no structured 'model' was available (as was the case for stories generated in response to the puppet stimuli), this lack of planning resulted in long, rambling, unfocussed narratives as were produced for task 2. when considering the two story generation tasks (tasks 2 and 3), the degree of structure inherent in the stimulus influenced length. puppets, being unstructured stimuli, resulted in elaborate, yet somewhat rambling stories. subjects narrated consecutive actions and events, without one main goal or focus within the narrative. the single action picture, in contrast, strongly suggested a central incident for the narrative the retrieval of a kite. only three subjects extended the content oftheit narrative beyond this incident. regarding the retelling tasks, stories retold with the use of puppets (task 4) were found to be longer on average than those retold without visual support material (task 5). these results were in agreement with the research review by liles (1993), who tentatively concludes that children respond favourably to visual support during retelling. story grammar analysis after coding statements into story grammar components, structural patterns were identified, and the relativ;e fretable 1: word and statement counts of narratives produced for tasks 1 5 i task 1: task 2: task 3: i task 4: task 5: personal story story story i story , experience generation: generation: retelling: retelling: narratives puppet~ picture puppets picture sum of narratives produced 112 17 17 17 17 mean number of words per narrative 58.5 232.53 95.76 111.76 90.29 mean number of statements . 'per narrative 9.67 39.53 15.41 19.41 /,14.06 ~ mean no. of basic structural patterns per narrative 1.69 7.42 2.41 4.12. '. 2.65 / relative frequency of narratives consisting of a single basic structural pattern 55.36% 11.76% 29.41% 0.00% 11.76% / the south african journal of communication. disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) story grammar analysis of pre-schoolers' narratives: an investigation into the influence of task parameters quency ofthe 11 types of structural patterns (see appendix 2 for definitions) was calculated for each of the five tasks. hierarchies of structural patterns as a function of task were established. data was then grouped to allow for comparisons of the following parameters: • relative frequency of structures with internal causal links (i.e. all structures except for descriptive and temporal sequences) • relative frequency of complete episodes (i.e. all abbreviated, simple, interactive and complex episodes, as well as episodes with multiple plan application) • relative frequency of complex episodes. tasks were compared by grouping them into hierarchies. results are summarised in table 2. parameters ofthe narrative task clearly influenced the narrative structure as described by these structural patterns. narratives based on personal experiences (task 1) contained more complex episodes than the fictional narratives (tasks 2 and 3). in this regard, the results confirmed peterson and mccabe's (1983) suggestion that narratives about personal experience may be more complex than fictional narratives as the child reports events already ordered. the demand on creativity and imagination is thus less, resulting in more time being devoted to the structuring ofthe narrative (peterson & mccabe, 1983). another factor that might have contributed to the finding that personal experience narratives were better-structured than generated stories, could be the motivation underlying each task. narrating a personal experience is usually a self-initiated attempt to share an important event (heath, 1986). the narrator must structure hislher account well in order to facilitate the comprehension of the listener. in narrating fictional stories, listener comprehension is, of course equally important. however, fictional stories do not emanate from the desire to share an important event pre-schoolers in this study seemed to be less concerned with the listener's comprehension of their fictional narratives, possibly resulting in poorer structure. furthermore, fictional narratives are only indirectly based on the causality of the real world (i.e., the relationship between cause and effect), while personal experience narratives have a direct model which engenders causality promoting a causal structure. generated stories differed in structural complexity aci cording to the stimulus material used. the picture stimulus (task 3) elicited more complex and complete narratives than the puppets (task 2) which could be attributed to the i 41 greater amount of structure inherent in this stimulus (hedberg & stoel-gammon, 1986). the picture portrayed goal-based behaviour, thereby strongly suggesting to the child a single-episode narrative. puppets, on the other hand, have no inherent structure, and thus placed high demands on the narrator with regard to content. from the results'it seemed clear that the pre-schoolers were not yet skilled in structuring narratives under such conditions where demands on content were high (orsolini, 1990). the influence of eliciting stimuli on the retold stories was more difficult to determine retelling tasks differed by more than one variable, namely the type of stimulus used during presentation and availability of visual support material for retelling. both variables or the combination could be responsible for the difference in complexity. stories retold for the picture condition (task 5) showed greater structural complexity than stories retold for the puppet condition (task 4). the use of the puppets during presentation of the model story (task 4) might have given less visual structure to the story than the sequence of eight pictures (task 5). children's encoding of the story structure might thus have been enhanced by the picture sequence more than by the use of puppets, resulting in more complex retellings. however, it is important to note that the children remembered less story information and fewer episodes for task 5, but structured their retellings better. this led to a hypothesis concerning the size of the memory load for each of the retelling tasks. the notion that story grammar abilities directly guide the encoding, remembrance and integrity of recall of a model story is wide-spread in the literature (mandler & johnson, 1977; page & stewart, ,1985; montague, maddux & dereshiwsky; 1990). it is therefore hypothesised, that a recall task with a greater memory load necessitates a greater reliance on story grammar abilities than a task which has a lesser load on memory. the lack of visual stimuli during the activity of retelling the story for the picture condition (task 5) is hypothesised to increase memory load, resulting in a smaller number of episodes being recalled. simultaneously a greater reliance on story grammar due to the greater memory load resulted in better-structured productions. i comparisons regarding the structural complexity of retold versus generated narratives showed a clear tendency towards higher complexity in the retold stories. this result correlated well with research findings on narrative generation and retelling of older children with and without language impairment (merritt & liles, 1989). it seems that a model story serves as a guide-line which facilitates the table 2: hierarchy of tasks regarding relative frequency of structures with internal causal links, complete episodes and complex episodes relative frequency of structures relative frequency of complete relative frequency of complex with internal causal links episodes episodes task 5 80.76% task 3 66.67% task 5 40.74% i task 3 78.79% task 5 62.86% task 4 29.27% task 4 76.47% task 4 51.22% task 1 17.76% task 1 70.75% task 1 50.66% task 3 11.43% task 2 i 58.76% task 2 33.33% task 2 6.31% die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 42 structural organisation of a child's narrative. one reason could be that a retelling task demands less imagination and creativity than a generation task, as the model story presented the retelling task provides the content ofthe story. one might argue that, while narrative retelling reduces the demands on creativity and imagination, it certainly makes demands on memory. however, literature supports the notion that remembering story details and structuring these into a narrative are closely interrelated processes (mandler & johnson, 1977). in the same way as structuring abilities were argued to aid in the encoding and remembrance of past events, structuring abilities should aid in both the process of encoding (and therefor.e remembering) the story, as well as in the process of retelling the story. the same type of relationship does not necessarily exist between creativity (needed to generate a story) and structuring abilities. whereas demands on structuring and creativity therefore seem to be cumulative, competing for cognitive resources, demands on memory and structuring rely on the same cognitive mechanism. conclusion while assessment of narrative abilities has been shown to be a valid method of sampling language and higher-level processing skills, the pragmatic nature of the task makes the narrator's performance susceptible to the influence of ,methodological variables ofthe elicitation task (liles et ai, 1995). in this regard, researchers (such as johnson, 1995; schneider, 1996) alert to the need for in-depth studies of children's narrative discourse, not only across variables such as children's age, cultural, ethnic and socio-economic backgrounds but also across diff~r~nt samj)ling conditions. within limits, this study has aimed to address the latter issue. it is thus proposed that, bearing certain methodological constraints in mind, the results contribute towards a better understanding of the relationship between the narrative task parameters and the narrative produced by children of pre-school age. in particular, the results illuminate the influence of the methodological parameters of the experience base of the narrative, the source of the narrative and the eliciting stimuli used during the task on the length and structure of the product. in so-doing, some clinical guidelines for assessment of pre-schoolers' narrative skills can be proposed. all five story tasks elicited extended discourse, which could be analysed according to a story grammar scheme. several factors, however, might influence the clinician's choice of task in a given situation. narrative length stories generated in response to puppets were found to be longest, while personal experience narratives were rather short on average. while length is an asset when certain linguistic parameters in the realm of semantics or syntax need to be assessed (merritt & liles, 1989), transcription is laborious. structural organisation pre-schoolers' narrative productions benefited (with regard to structural organisation) from highly structured stimuli such as the action picture or the model stories. stimuli with little inherent structure (such as the puppets) resulted in less complex and well-organised productions. kerstin m. tonsing and herman tesner this finding was related to the higher demand on creativity that 'unstructured' stimuli place on the narrator (orsolini, 1990). pre-schoolers with a language impairment, who can be expected to have difficulties with both creativity and structuring of discourse (liles et ai, 1995), are likely to be overtaxed by tasks requiring both skills. however, creativity associated with 'unstructured' stimuli allows for observation of other variables in the children's productions, for example the theme chosen, the character details (quantity of characters, description of these), and the originality ofthe story line. ease of elicitation in the present study, it was found that personal experience narratives were more readily told by the children. the informal, conversational method of eliciting narratives allowed the clinician to establish rapport with the child. however, relating personal experiences to adults is not a common practice in all cultural groups (heath, 1986). children from different cultural backgrounds might therefore not display the same spontaneity as the present subjects when prompted to share personal experiences. relevance of the task fora school-readiness evaluation as narrative abilities are strong indicators of predicted school success (mccabe & rosenthal rollins, 1994), assessment of story grammar abilities should form part of a schoolreadiness evaluation. in selecting a narrative task for such a purpose, the clinician should ensure its predictive validity (n~uman, 1997). th.~ ability to structure: de:conte:xtualise:d discourse is one of the prerequisites for the acquisition of literacy. while the organisational skills required for relating a personal experience are reminiscent of pragmatic conversational competence, story generation and retelling require structuring of m'ore decontextualised discourse. the latter two tasks might thus be more representative of the cognitive academic language demands placed on the child in the school context. apart from clinical implications, results add to the growing body of research data on children's narrative abil'ities and can direct further research. individual differences: and the variability of performance within one individual could be researched by comparing performance of individual children across tasks. the influence of a child's exposure to narratives on his/her story grammar abilities could be' determined with more extensive surveys, field observations and interviews with teachers and care-givers. a subject pool controlled for gender could illustrate the differences between the story grammar abilities of boys versus girls. the validity of the present story grammar model for analysing stories told by members of non-western cultures needs to be determined as a prerequisite for accountable intervention. a longitudinal study could illustrate the relationship between a child's story grammar abilities and his/her consequent school performance. such data is the prerequisite to including the assessment of narrative abilitie13,ih a schoolreadiness evaluation. the study of children's narrative ability is an exciting and expanding field of research, of interest to many professionals such as educators, clinicaland cognitive psychologists, anthropologists, linguists and speech-language pathologists. studies such as the present one can aid in exthe south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) story grammar analysis of pre-schoolers' narratives: an investigation into the influence of task parameters panding the knowledge of narration and narrative development. ultimately, the establishment of a comprehensive set of norms for narration might be achieved, although this task is a formidable one in view of the many contextual influences on narrative ability (johnson, 1995; schneider, 1996). however, even without a comprehensive set of norms, understanding the variables that influence a child's narrative production should enable clinicians to conduct valid and accountable assessments of narrative skills and should direct their efforts in intervention. references alant, e., tesner, h. & taljaard, e. (1993). narrative performance in context: analysis and implications within a south african context. child language teaching and therapy, 8(2), 188-204. caswell, c. (1995). success in statistics. john murray ltd.: london. heath, s. b. (1986). taking a cross-cultural look at narratives. topics in language disorders, 7(1), 84-94. hedberg, n. l. & stoel-gammon, c. (1986). narrative analysis: clinical procedures. topics in language disorders, 7(1), 58-69. hemphill, l., feldman, h. m., camp, l., griffin, t. m., miranda, a. b. & wolf, d. p. (1994). developmental changes in narrative and non-narrative discourse in children with and without brain injury. journal of communication disorders, 27(2), 107-133. johnson, c. j. (1995). expanding norms for narration. language, speech and hearing services in schools, 26(4), 326-343. kay-raining bird, e. & kluppel vetter, d. (1994). story telling in chippewa-cree children. journal of speech and hearing re· search, 37(6), 1354-1368. liles, b. z. (1993). narrative discourse in children with language disorders and children with normal language: a critical review of the literature. journal of speech and hearing research, 36(5), 868-882. liles, b. z., duffy, r. j., merritt, d. d. & purcell, s. l. (1995). measurement of narrative discourse ability in children with language disorders. journal of speech and hearing research, 38(2), 415-425. mandler, j. m. & johnson, n. s. (1977). remembrance of things parsed: story structure and recall. cognitive psychology, 9, 111151. mccabe, a. & rosenthal rollins, p. (1994). assessment of pre-school narrative skills. american journal of speech-language pathology, 3(1), 45-56. merritt, d. d. & liles, b. z. (1987). story grammar ability in chil~ dren with and without language disorder: story generation, story retelling and story comprehension. journal of speech and hearing research, 30(4): 539-552. merritt, d. d. & liles, b. z. (1989). narrative analysis: clinical applications of story genhation and story retelling. journal of speech and hearing dis6rders, 54(3), 438-447. montague, m., maddux, c. b. & dereshiwsky, m. 1. (1990). story grammar and comprehension and production of narrative prose by students with learning disabilities. journal of learning disabilities, 23(3), 190-197.i neuman, w l. (1997). social research methods. qualitative and quantitative approaches. allyn & bacon: boston .. orsolini, m. (1990). episodic structure in children's fantasy narratives: "breakthrough" to decontextualised discourse. language and cognitive processes, 5(1), 53-79. owens, r. e. (1995). language disorders: a functional approach to assessment and intervention. allyn & bacon: massachusetts. page, j. l. & stewart, s. r. (1985). story grammar skills in schoolage children. topics in language disorders, 5(2), 16-30. peterson, c. (1994). narrative skills and social class. canadian journal of education, 19(3), 251-269. peterson, c. & mccabe, a. (1983). developmental psycholinguistics. three ways of looking at a child's narrative. plenum press: new york. roth, f. p. & spekman, n. j. (1986). narrative discourse: spontaneously generated stories of learning-disabled and normally achieving students. journal of speech and hearing disorders, 51(1),8-23. schneider, p. (1996). effects of pictures versus orally presented stories on story retellings by children with language impairment. american journal of speech-language pathology, 5(1), 43 86-95. scott, c. m. (1988). a perspective on the evaluation of school children's narratives. language, speech and hearing services in schools, 19(1),67-82. stein, n. & glenn, c. (1979). an analysis of story comprehension in elementary school children. in r. o. freedle, editor, new directions in discourse processing, ablex: new jersey. appendix 1 scoring procedure: story components the following procedural guidelines were adapted from peterson & mccabe's (1983) story components, which was based on stein & glenn's story grammar categories (stein & glenn, 1979). if a statement met the criteria for more than one component, it was scored as both. a statement was generally not scored as more' than two categories, and maximally in three, which occurred seldom. assigning components to statements proceeded in the same manner for both generated and retold narratives. statements that were retold from the model story were thus assigned a certain component based on the function they served within the retold story, regardless of the component which they had been assigned in the original model story. appendix 2 story grammar components set 1: components of this set were assigned to statements within structural patterns displaying internal causal links. 1. setting: introductions of characters, descriptions of location or time, information on the habitual social, physical, and!or temporal context, as well as habitual actions or states. 2. initiating event: any natural occurrences, actions, internal events and awareness of these (e.g. pain, hunger, etc.) as well as verbalisations having some immediate result or evoking a response, internal response or attempt from a character. 3. internal response: internal states such as affects, cognitions, or goals, that motivated a protagonist and! or were caused by an initiating event. 4. response: all verbal responses of the characters to an initiating event, provided that such responses were not an expression of internal affect, cognition or goals, in which case they fell into the category of internal responses. 5. plan: statements specifying the character's strategy for obtaining a goal. 6. attempt: the character's overt action(s) to obtain a goal. 7. direct consequence: descriptions of the character's success or failure at attaining hislher goal(s), any existing states once all attempts had failed, or any change in the sequence of events resulting from the character's attempts. 8. reaction: how the character felt about the outcome, and verbal responses to this. 9. result: a result was scored when an initiating event and! or an internal response caused a change in the environment which had not been planned or intended by the character(s), and it did not result from a goal-based action from the character(s). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 44 set 2: components of this set were assigned statements within narratives without causal links, or togeneral statements (which neither served a specific function nor provided setting information) occurring within a structural pattern with internal causal links. 1. actions: these described the behaviour ofthe character. included in this category were verbalisations of the character(s), such as 'he said, "happy birthday, lisa!'" 2. external states: this category could be described as roughly an equivalent of the setting-category, as it inchided all statements which described the story environment, such as introductions.and descriptions of the character(s), their physical chafacteristics and states (hunger, pain, tiredness) and information about the location and the temporal aspects. the character's position in space was also incluci~d in this category, for ex. amjlle, .~he stood next to her'.' \. 3. internal states: these described the internal states of the cha~acter(s), that is, affect, likes, dislikes and character traits. 4. occurrences: these described changes in the environment and/or character which neither were character-induced nor fell into the category of internal states. examples are: 'the car crashed' or 'he died'. appendix 3 structural patterns in order of increasing complexity , 1. descriptive sequence: descriptions of character(s), surroundings, and habitual actions without any temporal or causal relationship. ,kerstin m. tonsing and herman tesner 2. temporal sequence (t / s): at least two actions arid/or occurrences that were chronologically rather than causally ordered. 3. 'reactive sequence (r / s): in these sequences, events, changes or conditions automatically caused' other changes, but no planning or goal-based behaviour from character(s) was evident. 4. abbreviated episode (a/e): a goal could be understood though it was inferred rather than explicitly stated. 5. simple episode:an entire goal-based behaviour sequence was described, including a motive for action in the form of an initiating event or an internal response, an overt attempt and a direct consequence. 6. multiple plan application: an elaboration ofthe simple episode where the character met with failure ofhislher attempt to achieve a goal, and consequently engaged in at least one new attempt to reach the same goal. 7. interactive episode: two characters had (usually opposing) goals and influenced each other. when several structures had causal links between them, they formed a complex episode. three types of complex episodes exist: 1. complex episode: embedded reactive sequence: a reac~ tive sequence was causally related to an episode 2. complex episode: embedded episode: two episodes were causally related 3. multiple structure episode: more than two episodes and/ or reactive sequences were causally related incomplete episode (/ e) these episodes lacked a direct consequence. if no consequence could be inferred, yet the character's behaviour was purposive, episodes were scored as incomplete. the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) ,77 use of the nal-ab wordlists as a south african english speech discrimination test wayne j. wilson, beverley jones and peter fridjhon department of speech pathology and audiology, university of the witwatersrand department of statistics and actuarial science, university of the witwatersrand abstract south africa still lacks a south african english specific speech discrimination test. as an alternative, this study investigated the use of the australian english, national acoustic laboratories arthur boothroyd (n al-ab) wordlists to assess the speech discrimination of south african english speakers. thirty south african english speakers were tested at 0, 5, 10,20 and 25 dbhl (audiometer dial reading) and their performance-intensity functions were compared qualitatively to the nal-ab wordlist normative data. results showed three general patterns; similar performance for both groups; poorer performance by the south african english speakers at the low to mid presentation intensities only; and poorer performance by the south african english speakers across most presentation intensities. use of the nal-ab wordlists at threshold levels or for site of lesion assessment was therefore concluded to be unwise. use of these wordlists at supra-threshold levels, however, would provide a valid and reliable option for the speech discrimination assessment of south african english speakers. opsomming daar bestaan tans nie 'n engelse spraakdiskriminasie-toets spesifiek vir die suid-afrikaanse konteks nie. hierdie studie was 'n ondersoek na die bruikbaarkeid van die "national acoustic laboratories arthur boothroyd (nal-ab}"-woordelyste, wat op engelssprekende australianers toegepas word, om die spraakdiskriminasie van engelssprekende suid-afrikaners te toets. dertig proefpersone is by 0, 5, 10, 20, en 25 dbhl (oudiometerlesing) getoets, en hulle diskriminasie-intensiteitsfunksies is kwalitatief met die normatiewe data van die nal-ab vergelyk. daar is drie algemene patrone gevind:geen verskil tussen die twee groepe nie; swakker diskriminasie deur die suid-afrikaanse groep by slegs die lae en middel-intensiteite ; en swakker diskriminasie deur die suid-atrikaanse engelssprekendes by die meeste intensiteite. die nal-ab-woordelyste is egter geskik om die spraakdiskriminasie jan engelssprekende suid-afrikaners bo gehoordrempels te toets. . keywords: speech discrilination, phonemic scoring, nal-ab wordlists, australian english, south african english. i south africa still lacks al pre-recorded speech discrimination test specific to smith african english. with no less than 11 current, official languages, and an unknown number of dialectal variatioris, the development of such a test that is both language and culturally appropriate is a formidable task. of further hindrance is the need for community based definitions of "normal" language and communication (pakendorf & alant, 1997), and for ethnographically based research that defines current "south african english" language and culture (taylor, 1986). solving these prerequisite problems is proving to be both resource and time consuming (as forewarned by jordaan, 1989) and the development of original tests remains, for the moment, a developing area. in the absence of the full development of south african english speech discrimination test, south african audiologists have traditionally used the united states of america's central institute for the deaf (c.ld.)w-22 wordlists, presented using monitored live voice. the use of non-south african speech and speech related tests, both in their orjginal form and in modified forms, has occurred in south africa for many years with varying degrees of success. examples include (amongst others); the wi pi and nu-chips speech discrimination tests (mehl, 1992), the staggered spondaic word test (collie, 1991; stevens, 1991; corke, 1993; modi, 1995), the paediatric speech intelligibility test (ewen, 1993), the willeford battery of central auditory function (kastner, 1994; modi, 1995), and the peabody picture vocabulary test-revised (alant & beukes, 1986; labuschagne 1990; koekemoer, 1994; pakendorf & alant, 1997). whilst the reliability and validity of using these tests on south african speakers has been formally assessed, the use of the c.ld. w-22 on south african english speakers appears to be due mainly to its high and well-documented acceptance in the u.s.a only, and not because of any published data validating its use on the south african population. the use of the c.ld. w-22 in south africa introduces many reliability and validity problems. firstly, there is the effect of familiarity and context (or expectation). familiar words (ostergard, 1983) and phonemes (lehiste & peterson, 1959) can be identified up to 15 db lower than die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 78 those that are unfamiliar (edgerton & danhauer, 1979). secondly, an ideal speech tests should contain an equal phonetic composition representative of everyday speech in the test population (egan, 1948). in applying the c.ld. w-22 to the south african population, any equal phonetic representation is lost. tobias (1964) and campbell (1965) questioned the need for equal phonetic representation, however, by claiming there was overwhelming clinical and experimental evidence that this an interesting, but unnecessary component in speech audiometry testing. even today, experimental evidence is lacking and the issue remains unresolved (mendel & danhauer, 1997)]. finally, a valid speech discrimination test should contain an equal range and average level of difficulty within and between wordlists. although this ideal is rarely achieved in reality (ross & huntington, 1962), large variations will affect test reliability and sensitivity. these factors all strongly influence, and possibly invalidate, the use of the c.ld. w-22 with its american english normative data on the south mrican english speaking population. in response to the problems faced by the c.ld. w-22, many south mrican audiologists make use of monitored live voice (mlv) presentation. whilst mlv provides a partial solution to speakerilistener accent mismatch, it does not reduce the dialectal differences inherent in the test materials themselves. added to this is mlv's wellrecognised poor test-retest reliability (carhart, 1965; brandy, 1966; kreul, bell & nixon, 1969; northern & hattler, 1974), and the problem of comparing mlv test results to standardisation information obtained using recorded versions of the stimuli (mendel & danhauer, 1997). considering the problems already faced in using non-south african english speech material, the significantly greater variability ofmlv could effectively negate any advantages it may offer in overcoming accent differences. if mlv is to be avoided (an opinion not held by all clinicians), this returns the south african audiologist to the option of using the c.ld. w-22 in its pre-recorded form on cassette tape or compact disc. in addition to the previously mentioned problems this introduces, closer inspection of the c.ld. w-22 reveals that it may not be the best option for the south mrican english speaker in the first place. the c.ld. w-22 was designed as an improvement on one of the first pre-recorded speech tests, the psychoacoustic laboratories phonetically-balanced 50-word lists (pal pb-50). it improved phonetic balance (lehiste & peterson, 1959), equality of difficulty between lists (brewer & resnick, 1983) and degree of familiarity (brewer & resnick, 1983; hirsch et ai., 1952). the test consists of 4 lists of 50 monosyllabic words with no repetitions. the words were chosen to be familiar to north american english speakers, and the phonetic composition of each list aims to reflect that of english as a whole (still based, however, on north american english). each word is preceded by a carrier phrase and each list may be .' presented with one of six different word orders. in its recorded form, it is spoken by an adult male with "general north american" accented english and all its normative values are based on north american english speakers (hirsch et ai., 1952). despite the improvements shown by the c.ld. w-22, it still has several faults that will only be worsened when applying the test to the south mrican english speaking wayne j. wilson, beverley jones and peter fridjhon population. brewer and resnick (1983) and ostergard (1983) question the c.ld. w-22's ability to discriminate effectively among the performance of the hearing impaired, claiming that it is too easy. ross and huntington (1962) and studebaker and sherbecoe (1991) disclaim equality of difficulty between lists. mendel and danhauer (1997) have also claimed that the validity and reliability of the test for certain conditions under which it is used, such as in background noise, are poorly documented. finally, users recognised almost immediately the benefits of reducing the test-time (edgerton & danhauer, 1979) by administering 25 word half-lists (martin & forbis, 1978). however, these shorter lists are prone to higher variability and therefore poorer reliability and are no longer phonetically balanced (ostergard, 1983). even considering cakiroglu and danhauer's (1992) claim that listener's and talker's linguistic background has statistical, but not clinical, effects on the performance of non-native english-speaking subjects on the c.ld. w-22 (although they do warn that listener's having less experience with english may not perform as well as native-english speakers), these identified problems warrant a search for a better speech discrimination test for the south mrican english speaker. an alternative which claims to combat many of the problems encountered by whole word tests, such as the c.ld. w-22, is the phonemically scored speech test (edgerton & danhauer, 1979). lehiste and peterson (1959) argued that as the speech signal is not acoustically invariant, it is impossible to achieve phonetic balance in a speech test. therefore intelligibility (discrimination) measures should use materials that are phonemically balanced [although again, the need for phonemic balancing in the first place has been queried (mendel & danhauer, 1997)]. phonemic scoring offers advantages of general and specific significance to a south african english speaking population. generally, factors such as increased reliability, abbreviated test lists, and decreased test time (edgerton & danhauer, 1979) are all beneficial. specifically, factors such as a decrease in the effect ofthe listener's familiarity with the vocabulary used, and the controversial claim that phoneme scoring involves less extrinsic redundan'cy and therefore eliminates the effects of linguisti~ bias (lyregaard, 1987; contested by keith, katbamna, tawfik & smolak, 1987), suggest that use of normative '~alues supplied with a phonemically scored wordlist could ~rovide greater test reliability and validity when used on !south mrican english speakers. \ following the success of the first phonemically scored wordlists developed in the u.s.a. by lehiste and peterson in 1959 (the consonant-nucleus-consonant or cncilists), and tillman, cahart and wilber in 1963 (the northwestern university auditory tests no.4 and no.6), arthur boothroyd of the united kingdom developed the phonemically scored arthur boothroyd (ab) wordlists (boothroyd, 1968). boothroyd's test contains 15 isophonemic lists, each containing 10 words with 30 scorable phonemes. each list contains the same 20 consonants and 10 vowels, in varying combinations (der~ody' & mackie"; 1987). the phonemes chpsen were those found to be most frequent in boothroyd's vocabulary, and the only'limitations placed on the original word lists were that neither first names nor obscenities would be included (boothroyd, 1968). the ab wordlists received criticism, however, with suggestions that boothroyd's northern english accent / the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) use of the nal-ab wordlists as a south african english speech discrimination test 79 impacted on the design of the test's phoneme content, and that the lists did not comprise random samples of phonemes. despite boothroyd's reply that the phonemes are altered by changing their word position, and therefore the phoneme arrangements are essentially random (which would appear to undermine his claim of equality of phonetic representation), the ab wordlists were recorded on at least 2 occasions in the united kingdom using different u.k. accents (evans, 1987). the success of the phonemically scored ab lists in the u.k.led to their use in australia by the national acoustic laboratories (nal) (dermody & mackie, 1987). nal produced a revised version specifically for australian use, with rearranged word orders and several new words to replace those considered to have low familiarity for australian english speakers (travers, 1990). according to bench (1987), australian english is based on that of the united kingdom, but includes north american influences and some uniquely australian expressions, while some words common to both dialects may carry different meanings. the nal-ab wordlists (appendix one) quickly became the most commonly used speech discrimination test in australia (bench, 1987), resulting mainly from advantages such as short administration time, and the availability of a high number oflists allowing multiple testing to occur in the one session without learning effects or fatigue (markides, 1987; mendel & danhauer, 1997). in view of the success of the pre-recordedab wordlists in the u.k. and australia, the possibility that they could offer significant advantages over the present mlv presentation of the c.ld. w-22 wordlists in south mrica becomes apparent. the problem oflinguistic bias remains, however, and despite claims that phonemic scoring decreases the effect of linguistic bias (lyregaard, 1987; contested by keith, katbamna, tawfik & smolak, 1987), and can be used even on clients with limited familiarity with english (evans, 1987), it is vital to consider the validity of using this test in a multilingual population such as south mrica's. : aims the aims of this study were as follows: i 1) to determine if first language south mrican english speakers performed differently to first language, australian english speakers, bn the pre-recorded nal-ab wordlists. i /' 2) to determine if the first ten (of fifteen) pre-recorded nal-ab wordlists were of equal difficulty for first-language, south african english speakers. 3) to investigate the feasibility of using the pre-recorded nal-ab wordlists, with the' nal australian english normative data, to assess the speech discrimination abilities of first-language south mrican english speakers in south africa. methodology exact replication of the nal-ab wordlist normative study proved to be difficult. the normative data on the performance of australian english speakers on the prerecorded nal-ab wordlists is documented in a clinical manual entitled "ab word lists: nal protocols" prepared by anne travers, nal, victoria, august, 1990. this document is supplied with thenal-ab word list compact disk and outlines graphically all normative data for the 15 wordlists separately, and as a total average, and contains full recommended procedures the test's clinical use. on close inspection, however, the document provides little detail as to the exact procedures used to obtain the normative values. details of the nal-ab wordlist study were not published in the literature and the original data has since been removed from nal archives. the only fact that is clearly stated in the travers document is that the data was obtained using 120 normally hearing subjects. with this limited information in mind, the following methodology was used. subjects subject selection criteria subjects were selected using a convenience sampling technique according to the following criteria: (i) subjects should be adults between 17 and 40 years. this controlled for the well-recognised effects of paediatric and geriatric age ranges on performance on speech discrimination tasks (hall, 1983). (ii) subjects should be female. this criterion was included for ease of subject selection, as it was deemed unlikely that a sample balanced for gender could be easily obtained. (iii) subjects should be first-language speakers of south african english. (iv) subjects should be resident in gauteng, south africa as according to fuller (1987), subjects for research in the area of speech audiometry should be native to the local area. (v) as determined by a pretest audiogram, the test ear should have hearing thresholds no greater than 5dbhl at 250, 500, 1000, 2000, 4000 and 8000 hz. (v) as determined by self-report on a pretest questionnaire, subjects should have no significant history, past or present, of: hearing impairment; speech or language impairment; tinnitus; ear infections; noise exposure; speech/articulation disorders; the presence of any disorders of language or; family history of hearing problems. (vi) subjects should have no knowledge or experience with the nal-ab wordlists specifically. (vii) subjects should have little or no knowledge or experience of australian english. subject description an initial sample of 32 female, first language south african english speaking subjects, all resident in the gauteng region was collected. two subjects were excluded when pure tone screening revealed unacceptable hearing thresholds leaving a final 30 subjects ranging in age from 17.5 years to 26.0 years, with a mean age of20.5 years, a standard deviation of 1.8 years, and a median age of21.0 years. education levels included two subjects with secondary level, and 28 with, or receiving, tertiary level education. 26 ofthe 28 tertiary level subjects were studying in the field of speech pathology and audiology. on the basis of selecting the best hearing ear as the test ear, 12 right and 18 left ears were tested. test environment, equipment and recorded material testing took place in a two-room sound treated booth at the university of the witwatersrand hearing clinic in die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 80 johannesburg, gauteng, southmrica. the booth included a one-way mirror to allow the tester to observe the subjects during testing. the nal-ab wordlists were presented via a sanyo compact disc player cdp-41 coupled with a grayson-stadler gsi16 audiometer. presentation was by means oftdh-50 headphones with mxar41 cushions. the nal speech recognition materials (disc 1) compact disc with intensity levels equated using an a-weighted long term equivalent level (leq) procedure provided the speech stimuli. the nal-ab wordlist cd provides 15 pre-recordedab wordlists (appendix one) arranged to be as representative as possible of 'typical' australian english (travers, 1990). lists are spoken by an adult male australian general english speaker. each list contains the same 20 consonants and 10 vowels, arranged into various combinations of 10 cvc monosyllables per list. the lists are ordered according to their reliability as measured on the australian population (dermody, cited in travers, 1990). the order reflects a pairing of those lists with the most similar performance-intensity functions. the last three of the 15 lists demonstrate the most widely variant functions and nal recommends that these be used at the top end of the pi function only. each of the word lists is preceded by a short warning pip, the inter-stimulus interval is 4 seconds which serves as the subject response period (there is no carrier phrase), and each list is recorded on a separate track. measurement procedures and data collection on passing the initial hearing and case history questionnaire screening, subjects were assessed on their speech discrimination performance on the first 10 of the 15 pre-recorded nal-ab wordlists in their better hearing ear. administration of all 15 lists to both ears was considered to be impracticable for 3 reasons: (1) the duration of testing would be increased to unacceptably high levels possibly leading to subject fatigue; (2) the additional repetitions of each list would induce a greater degree of practise/learning effects; and (3) as lists 13-15 were shown to be more variable in the australian sample (dermody, cited in travers, 1990), it was felt that lists 1-10, the most reliable and commonly used lists, were more pertinent to the aims of this study. an identical set of instructions was given to all subjects, via the headphones, as per nal recommendations (travers, 1990, p8). the instructions read as: "you are going to hear some single words. mter each word there will be a pause for you to repeat the word. listen carefully and repeat whatever you hear. some of the words will be very soft and it is important that you have a guess at each word even ifit doesn't make sense or you only hear a part of the word such as 'ee' or 'ch'. just repeat what you hear." once subjects had been instructed, list 11 was presented . at 30dbhl (audiometer dial reading), in order to familiarise subjects with the test procedure. the wordlist presentation was pseudorandomised with the initial ten list order being randomly selected, and then repeated five times. this was done to prevent a particular list from occurring several times in succession, or in close proximity. the intensity presentation was then randomised throughqut all 50 presentations such that each of the ten lists was presented once at five different intensity levels. wayne j. wilson, beverley jones and peter fridjhon the whole process of pseudorandom is at ion was conducted separately for each individual subject. intensity levels of 0, 5, 10, 20 and 25 dbhl (as per the audiometer dial reading) were used, emulating the normative data provided by nal. all subject's responses were recorded and scored. online by a single tester, a student of speech and hearing therapy at the university of the witwatersrand, under the supervision ofa full member of the audiological society of australia, in fulfilment of that society's requirements for use of materials. responses were transcribed using a combination of orthographic and phonetic transcription. each word was then assigned a score of 0%, ifno phonemes were correctly repeated; 3% for 1 correct phoneme; 7% for 2 correct phonemes; or 10% if the response was completely correct; as per the scoring protocols, suggested by nal (travers, 1990). subject responses were considered to be correct only if they were pronounced exactly as per the australian english pronunciation on the nal-ab wordlist cd. it was noted, however, that none of the 15 nal-ab wordlists contained words where a predicted difference in pronunciation between australian english and south african english should occur (for e.g., there were no words such as "dance", which would be pronounced as /dams/ in australian english, but as /dans/ in south african english). in cases where single phonemes or nonsense syllables were given as a response instead ofa whole word, the phonemes were scored based on their acoustic similarity to the relevant australian english phonemes in the stimulus word. in the case of more than one response being given for a single stimulus, the first response was taken irrespective of accuracy. subjects were allowed the opportunity to rest at any stage during the test procedure. data analysis comparison between the south mrican english speaker scores and the nal-ab wordlist australian english normative data was done graphically with all nal normative data values being extrapolated from the graphs provided in travers (1990) for reanalysis. plots lof the extrapolated nal normative data and the south african english speakers data were completed using mi~rosoft excel for windows, version 5.0©. i analysis for differences within the south african english speaker discrimination scores, between p~esen­ tation intensities, was conducted separately fot" each wordlist using kruskal-wallis anova by ranks (~cross all intensities at p<0.05) and mann-whitney u (between adjacent intensities only, at p<o.ol to allow for the multiple comparisons) analyses. non-parametric statistics were used as a result of the non-homogeneity of variances (determined by the f test at the p<o.ol level) and the significant correlation of mean scores to variances present in the data (determined by the pearson's product moment correlation coefficient test at the p<0.05 level). analysis for differences within the south african english speaker discrimination scores, bet~een wordlists, was conducted separately for each presentation intensity using one way, repeated measures anova and tukey honest significant difference ana:lyses (chosen as it is one of the more conservative of the post hoc analysis tests) at the p<0.05 level. analyses for correlations in the south african english / the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) use of the nal·ab wordlists as a south mrican english speech discrimination test 81 speaker discrimination scores between wordlists was conducted separately for each presentation intensity using pearson's product moment correlation co-efficient analyses (at the p<0.05 level). similar analyses for correlations between presentation intensities was also conducted separately for each wordlist. all statistical analysis was conducted using statistica for windows, version 4.5 software from statsoft inc, 1993©. results south african english speakers' versus australian english speakers' results figure 1 shows the south mrican english speakers' speech discrimination results, superimposed on the extrapolated nalaustralian english normative data, for each individual nal-ab word list. overall, the nal australian english speakers' mean scores tended to be better than the south african english speakers' mean scores with greater differences occurring at the lower presentation intensities. extrapolated mean values for the nal australian english normative data generally fell within 1 standard deviation above the south african english speakers' means. only list four at 5 dbhl, list eight at 0 dbhl and list nine at 5 dbhl, showed the nal australian english scores to be greater than one standard deviation above the mean south african english scores on visual inspection. specific comparison between the mean south african english speakers' speech discrimination scores and the extrapolated nal australian english normative data showed three basic (qualitative) categories: 1) similar mean scores across four or more presentation levels (lists one and five). 2) south african english mean scores falling below the nalaustralian english mean scores in the mid and/or low presentation levels only (lists three, four, seven, ei~ht and nine). i 3) south african english mean scores falling below the nal australian english imean scores across four or more presentation levels (~ists two, six and ten). i i comparisons within south african english speakers' results i table 1 shows the mean arid standard deviation speech discrimination scores for the 30 south mrican english speakers on all ten nal-ab wordlists, at all five presentation intensities. table 2 shows kruskall-wallis anova by ranks and mann-whitney u analysis results for differences in the scores between presentation intensities, conducted separately for each wordlist. significant differences (p<o.ol) were shown between all adjacent presentation intensities in each wordlist except between 20 and 25 dbhl for lists 1, 2, 5, and 6. tables 3 and 4 show one-way repeated measures anova and tukey honest significant difference test results for differences in scores between wordlists, conducted separately for each presentation intensity. results showed multiple significant differences between wordlists at all five presentation intensities, but predominantly at the higher intensities. pearson's product moment correlation co-efficient analyses (p<0.05) between scores at each presentation intensity, conducted separately for each wordlist, showed mild (0.4) to strong (0.9) correlations between intensities for all wordlists. a small number (<10% ofthe total number of correlations) of poor «0.4) or non-significant (p>0.05) correlations occurred within the wordlists between low and high presentation intensities only. similar analyses between scores across wordlists, conducted separately for each presentation intensity, showed mild (0.4) to strong (0.9) correlations between scores for all presentation intensities except for 25 dbhl, which showed large numbers (24.4%) of poor «0.4) or non-significant (p>0.05) correlations between wordlists. f test analysis for differences in the variance of the south african english speakers' discrimination scores between the different presentation intensities, conducted separately for each wordlist, showed the variance at 25 dbhl to be significantly different (p<o.01) to the variance at 0, 5 and 10 dbhl in lists 1, 2, 3, 4, 6, 9 and 10; to the variance at 0 and 5 dbhl in list 5; and to the variance at 5 and 10 dbhl in list 8. the variance at 20 dbhl was shown to be significantly different (p<o.01) to the variance at 0 and 5 dbhl in list 3 and to the variance at 0 dbhl in list 5. list 7 showed no significant differences (p<o.ol) in variance at any presentation intensity. discussion the aims of this study were: (i) to determine if first language, south african english speakers performed differently to australian english speakers on the prerecorded nal-ab wordlists, (ii) to determine if the prerecorded nal-ab wordlists were of equal difficulty for first-language, south african english speakers and (iii) table 1: south mrican english speakers'mean and s.d speech discrimination scores on nal·ab wordlists 1·10. dbhl 0 5 10 20 25 list 1 24.8± 18.1 52.5± 22.4 69.1± 18.4 91.0 ± 10.2 95.6 ± 5.7 list 2 23.2 ± 18.1 43.8 ± 19.3 63.0 ± 18.7 85.7 ± 10.6 90.1 ± 5.9 list 3 27.2 ± 24.6 47.1 ± 22.1 65.8 ± 18.3 87.9 ± 8.3 92.2 ± 6.8 list 4 19.9± 15.1 37.6 ± 16.5 60.2 ± 19.1 89.3 ± 10.5 96.3 ± 5.7 list 5 29.5± 22.9 50.2 ± 20.2 69.7± 15.0 90.0 ± 9.0 93.5 ± 6.5 list 6 23.3± 18.2 47.6 ± 20.5 66.9 ± 18.1 84.4 ± 12.4 90.6 ± 7.5 list 7 20.6± 17.2 40.7± 18.6 58.7± 18.0 86.9± 11.0 92.5 ± 9.8 lists 18.2 ± 14.2 42.1 ± 17.4 62.1 ± 17.1 83.1 ± 8.4 89.1 ± 6.5 list 9 23.8± 18.9 47.0 ± 19.0 66.2 ± 18.2 88.8 ± 11.0 94.3 ±7.3 list 10 19.8 ± 16.1 45.4 ± 18.7 57.0 ±19.6 82.8 ± 10.2 88.4 ± 6.4 die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) ~ '" ~ ~ s. ~ "::j> 0;' q ;:! ~ ~ ~ ~ .s;, f? ;3 ;3 ~ ;:! 0;' q "'" 0' ;:! t:::; 1;;' o ~ .;;'l ~ ~ sj"i .... <:0 & list 1 100 ~"~'-<~-r~'«1 .r. j;~"':! 1'" , r 75 50 25 o +i--,-..--....--r-' -5 5 15 25 presentation level (dbhl) list 6 1 00 t'~><'~'"'~ ''''''''''_''!*v ..... "'r..: 1 75'\ 1;'/ ! r "~l 50 -l ~ ! j'l ;~~ 25 i ! 01.l ~ -5 5 15 25 presentation level (dbhl) \ b l!! .. o o ~ -u qi c 0 0 ~ 0 list 2 100 75 50 25 o +-=-.,-....... ~-' -5 5 15 25 presentation level (dbhl) list 7 100 tw"""'~---"",,tm) 75 ... 50· 25 0 -5 5 15 25 presentation level (dbhl) i o o ~ ~ 0 0 ~ list 3 1 00 t"~'~"~'~w~~ 75 -5 5 15 25 presentation level (dbhl) list 8 ': r--":~1 ! so 250 ~'"--''''''''l'''""''''' -5 5 15 25 presentation level (dbhl) 1:3 l!! 8 ~ -u qi .. .. 0 0 ~ list 4 75 o +--,,--,-~ -5 5 15 25 presentation level (dbhl) list 9 75' so 250 -5 5 15 25 presentation level (dbhl) b ~ o o ~ -u qi .. .. 0 0 ~ 100 75 50 25 list 5 .-~--'1iwl 1/".l.j..! (i o . , -5 5 15 25 presentation level (dbhi list 10 100 r-'mm"~m''''''''--l -:t' i!i:' . ,.il 75 -1 t/7.ll , so25' o r--" 't i ~ -5 5 15 25 presentation level (dbh figure 1: plots, of south mrican english speakers' mean scores (diamonds) with error bars (1 s.d.) and nal's australian english speaker mean scores (squares) for nal-ab wordlists 1-10. 00 t\:) ~ ~= t1> ~ ~ .iii o ? t:d t1> < !t t1> '< c.., ~ t1> iii ~ = ~ 'tl t1> .... t1> '1 ~ ... 8: ::r o = r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) use of the nal-ab wordlists as a south mrican english speech discrimination test 83 to investigate the feasibility of using the pre-recorded nalab wordlists, with the nal-australian english normative data, to assess the speech discrimination abilities of firstlanguage south african english speakers in south africa. to achieve these aims, nal-ab wordlist speech discrimination scores were obtained from 30 first language south african english speaking, female adults with normal hearing. these scores were then compared to the nal australian english speaker normative data (as provided by dermody, in travers, 1991). in general, the southmrican scores were lower, with three qualitative patterns being observed; similar performance between the two groups (lists one and five); south african scores occurring below the australian scores at the lower and/or mid presentation levels only (lists three, four, seven, eight and nine); and south african scores occurring below the australian scores across four or all five presentation intensities (lists two, six and ten). comparisons of south mrican scores within and between nal-ab wordlists showed multiple differences and correlations, depending on which lists and presentation intensities were being compared. the qualitative finding that south african scores were generally worse than those of the australians, indicates the direct llse of the pre-recorded nal-ab wordlists with their associated normative values cannot be applied to the south african english speaking population without significant modification. the three differing patterns of south african versus australian results indicates the different nal-ab wordlists were not of equal difficulty for the two populations. the first category of results showing similar mean scores for the two groups, suggests these lists were equally difficult. the second category showing differences at the low and/or mid-presentation intensities only, suggests both groups were able to hear these wordlists equally well at the higher presentation intensities, but the australians were able to extract more information at the lower presentation intensities, due most probably to their table 2: kruskal-wallisanova by ranks and mann-whitney u results for differences in south mrican english speakers' mean scores between presentation intensities, conducted for each nal-ab wordlist separately (*highly significant). nal-ab wordlist kruskal-wallis anova between the five mann-whitney u (n-=60) number presentation intensities for results between adjacent each wordlist presentation levels for worldlist n p level 1,2,3,4,5,6,7,8,9,10 150 <0.005* sig. diff's (p<o.01*) between all adjacent presentation levels except between 20 and 25 dbhl on lists 1, 2, 5, and 6. table 3: repeated measures, one way anovaresults for differences in south african english speakers' mean scores between nal-ab wordlists, conducted for each presentation intensity separately (*-highly significant). j , i presentation intensity (dbhl) i 0,5,10,20,25 1 degrees of freedom (10 nal-ab wordlists) p level 9 <0.001* table 4: results of tukey analysis for differences (p<0.05) in south african english speakers' mean scores between wordlists when p'resented at the same presentation intensity, e.g., lists 8 and 5 showed significantly different scores when presented at 0, at 20, and at 25 dbhl, but not at 5 or at 10 dbhl. nal-ab list no. 1 2 3 4 5 6 7 8 9 10 1 2025 5 2025 51o 2025 10 20 25 2 25 25 3 20 10,20 4 0,5,10 25 10,20,25 10,20,25 5 20 0,10 0,20,25 0,10,20,25 6 10 7 8 20,25 9 10,20,25 j 10 die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 84 familiarity with australian english. the third category showing a poorer south african english speaker performance across four or all five presentation intensities, suggests that even the advantage of increased presentation intensity did not allow the south africans to overcome the difficul ties encountered in listening to australian english. this "three category ranking" of australian versus south african scores places the ten nal-ab wordlists in a "valid" (category one) through to "use with caution" (category three) ranking for south african english speakers. this supports markide's 1987 disagreement with boothroyd's 1968 and keith's 1987 claims that phoneme scored speech discrimination tests generally, and the ab wordlists specifically, can be used accurately with non-english speakers. it also questions evans' 1987 suggestion that subjects with minimal knowledge of english may be tested with ab lists by a clinician whose own experience with the ,test is extensive. evans stated the pi functions are likely to be less steep, approximating those for nonsense syllables, but maximum scores may still reach 100%. this study showed equal or steeper sloped performance intensity functions for the south african english speakers, with the steeper functions seen in category two. the 4:1-australian:south african ratio of sample sizes used in this study prevents any comment on whether there was a true difference in the variance of the speech discrimination scores between the australians and south africans. a notable observation, however, was the significant decrease in the variance of the south african scores as the presentation intensity increased. this finding appears to be similar (on visual inspection only) to the australian plots (travers, 1990), and only partly agrees with ostergard's (1983) findings that variability in speech discrimination scores tend to decrease for extreme scores and increase for midrange scores. difference analyses within the south african scores themselves, further indicated that the nal-ab wordlists were not of equal range and difficulty for the south african english speakers (although a similar conclusion was found for the australian english speakers by nal themselves). overall, the multiple significant differences seen indicate that the performance ofthe south africans was dependent on which wordlist and presentation intensity was being used. interpretation ofthe significant differences must be ,approached with caution, however, as close inspection shows many of these to be more dependent on differences in variance, rather than any true clinical differences in mean scores. even so, the south africans did show a steady improvement in scores on all wordlists with increases in presentation intensity, with evidence ofthe beginning of a ceiling effect at the 25 dbhl level. correlational analyses within the south african scores showed a high number of significant positive correlations between different lists at the different presentation intensities, particularly for the mid-presentation intensities. this indicates a good relationship between .nal-ab wordlists for the south africans in that a high score on one wordlist at one intensity, will generally predict a high score on the same or another wordlist at the same or different intensity (and vice versa). the exception to this was at 25 dbhl where a large number (24.4%) of poor «0.4) or non-significant (p>0.05) correlations occurred between wordlists. this finding supports the earlier suggestion of the beginning of a ceiling at 25 dbhl presentation intensity as scores in a ceiling range should wayne j. wilson, beverley jones and peter fridjhon be more random and therefore have fewer correlations. minor limitations to this study include the all young, adult female composition of the sample, and the lack of control over right versus left ear selection. with no reports, to the authors knowledge, of significant female/male or right/left ear performance differences in the literature for any ofthe monosyllabic word tests, these points were not considered to have had any significant impact on this study's findings. a more significant limitation was the sample's english first language prerequisite, and predominance of tertiary level education, much of which was in the field of speech pathology and audiology. davis (1983) (cited in lutman, 1987) demonstrated a relationship between socio-economic status and type of occupation, and performance in speech audiometry with higher education level implying a certain level of linguistic competence and even sophistication. it might therefore be predicted that a more representative sample ofthe south african english speaking population would not have performed as well as the more educated sample used in this study. finally, it must be noted a significant factor affecting any interpretation of speech discrimination results is the large amount of variability inherent in speech testing. mendel and danhauer (1997) warn that a margin of 1620% should be allowed for erroneous scoring alone, because of errors in the scorer's perception. similarly, thorton and raffin (1978), ostergard (1983) and green (1987) state that a single score obtained for a particular wordlist is only an indicator of a range of scores in which the true score is likely to be. this inherent variability in speech audiometry diminishes its accuracy in all uses generally, and the strength of the descriptive results of this study specifically. conclusions the similarities observed between the australian english and south african english speakers on the prerecorded nal-ab wordlists makes this test a valid option for the speech discrimination assessment of south african english speakers, under certain conditions. the nal-ab wordlists are most su.itable for use at suprathresholdilevels (where the fewest differences were observed) where the advantages of shorter test times, and more available wordlists, can be accessed without critically compro~ising test reliability or validity. use ofthe nal-ab wordli'sts at threshold, or near threshold, levels (where the imost differences were observed) should be approached! with caution, however, and reliance on these wordlists fo'r site , i of lesion purposes should be avoided. general test reliability and validity could be improved by changing the wordlist presentation order to (5, 1), (3, 9), (7,6), (8, 4), (2, 10) (where brackets indicate interchangeable lists) to suit south african english speakers, and by collecting larger south african normative data bases where possible. despite this study's findings, the over-riding need for a south african english specific speech discrimination test remains. whilst the nal-ab wordlists offer/advantages over the c.i.d. w-22 wordlists such as ph~emic s~oring and, based on this study's results, at least 'some idea of how south african english speakers vary from the normative data (information which is not currently published for the c.i.d. w-22 wordlists), the cdntinued use of non-south african tests must be seen ~s an interim measure only. in view of similarities between the performance of south the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) use of the nal·ab wordlists as a south african english speech discrimination test 85 african english and australian english speakers seen in this study, the option of modifying the nal-ab wordlists to suit south african english (as per naus modification of the original u.k. ab wordlists to suit australian english) could provide the starting point needed to develop the long awaited south african english specific speech discrimination test. acknowledgement the authors wish to thank nicci campbell of the department of communication pathology, university of pretoria, for her work in finding many of the south african studies referenced in this paper. references alant, e. & beukes, s.m. (1986). the application of the revised version of the peabody picture vocabulary test (ppvt-r) to non-mainstream children. south african journal of communication disorders, 33: 7-12. bench, j. (1987). speech audiometry in australia. in m. martin (ed.), speech audiometry. london: whurr publishers ltd. boothroyd, a. (1968). developments in speech audiometry. sound, 2: 2-10. brandy, w.t. (1966). reliability of voice tests of speech discrimination. journal of speech and hearing research, 9: 461-465. brewer, c.c. & resnick, d.m. (1983). a review of tests of speech discrimination. seminars in hearing, 4: 205-220. cakiroglu, s. & danhauer, j.l. (1992). effects of listeners' and talkers' linguistic backgrounds on w-22 test perfomance. journal of the american academy of audiology, 3: 186-192. campbell, ra. (1965). discrimination test word difficulty. journal of speech and hearing research, 8: 13-22. carhart, r. 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(1986). treatment of communication disorders in linguistically diuerse populations. boston: college-hill. thorton, ar & raffin, m.j. (1978). speech discrimination scores modelled as a binomial variable. journal of speech and hearing research, 21(3): 507-518. tillman, t.w., cahart, r & wilber, l. (1963). a test for speech discrimination composed of cnc monosyllabic words. northwestern university auditory test no.4. technical documentary report no. sam-tdr-62-135, usaf school of aerospace medicine, brooks airforce base, texas. tobias, j.v. (1964). on phonemic analysis of speech discrimination, journal of speech and hearing research, 7: 98-100. travers, a (1990). ab word lists: nal protocols. australian hearing services, victoria, australia. die suid-afrikaansetydskrifvir kommunikasieafwykings, vol. 45,1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 86 wayne j. wilson, beverley jones and peter fridjhon appendix 1 national acoustics laboratories arthur boothroyd wordlists one to fifteen. list 1 list 2 list 3 list 4 list 5 list 6 list 7 list 8 list 9 list 10 fan fun thug hush jug bath have hug math wish rug will witch gas latch hum wig dish hip dutch ship vat teak thin wick dig buff ban gun jam cheek shape rap fake faith five mice rage ride heath haze wreath vice chime sign ways teeth chief siege laze dice hide jail weave beep reach jays pies veil bike both guess hen jet hem joke poach wet chose rove well comb shows rob rod noose rule cove shoot pet jot choose food dope vote pot den loose web fog move job bomb lose shoes shell shock moth cough soon list 11 list 12 list 13 list 14 list 15 badge fish fib fill kiss hutch duck thatch catch buzz kill path sum thumb hash thighs cheese heel heap thieve wave race wide wise gate reap hive rake rave wife foam bone goes got pole goose wedge shop shown wretch not log vet bed dodge shed tomb june juice moon the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) references about the author(s) heila jordaan faculty of humanities, speech pathology and audiology, university of the witwatersrand, south africa ramona kunene nicolas department of linguistics, university of the witwatersrand, south africa citation jordaan, h., & kunene nicolas, r. (2016). editorial to the south african journal of communication disorders special issue. south african journal of communication disorders, 63(2), a167. http://dx.doi.org/10.4102/sajcd.v63i2.167 editorial editorial to the south african journal of communication disorders special issue heila jordaan, ramona kunene nicolas copyright: © 2016. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the 2014 annual joint lssa/saala/saalt linguistics and applied linguistics conference took place at the university of the witwatersrand from 24 to 27 june, 2014. the theme of the conference was ‘synergies and intersections’, with a focus on an interdisciplinary approach to language theory and practice. featuring over 115 presentations, the conference was primarily held for south african linguists and language practitioners, but it was also well attended by scholars from france, india, new zealand, nigeria, switzerland, the uk and the usa. plenary talks ranged from phonological processing, meaning construction in discourse to turbulent diversities in multilingual encounters, multimodal trans-lingual practices and sociocultural processes. panel sessions focused on reading practices in african languages; the application of corpus linguistics to discourse studies; socio-phonetics in south africa with a focus on south african, young, black, middle-class english speakers, gesture, language acquisition, culture, and the grammatical investigation of the afrikaans verb. postgraduate students and researchers alike enjoyed the interdisciplinary nature of this conference and the enthusiasm around the study of south african languages was infectious. against this backdrop, ramona kunene-nicolas from the wits linguistics department and heila jordaan from the wits speech pathology and audiology department decided to collaborate on one of their research interests: acquisition of south african languages by south africa–based scholars. research on the acquisition of south african languages was vibrant in the 1990s with the pioneering works of scholars like susan suzman, katherine demuth, mowrer and burger, and connelly, to name a few. thereafter, there was a lull for some 18 years before the contemporary research of gxilishe, jordaan, pascoe and smouse, kunene, bortz and tshule (all in the 2000s) showed that there was a renewed, robust interest in the much-needed studies of language acquisition within the south african context. speech-language therapists, who are confronted with a dearth of research in language acquisition for clinical purposes, initiated contemporary research in this domain. jordaan and kunene-nicolas sought to bring together this vibrant and renewed interest by south african scholars in this volume. it is with this special issue that we hope to advertise the important research that is conducted locally and yet within a global framework. this special issue seeks not only to create awareness of the current work but also to highlight the challenges faced by a multilingual south africa. this is the beginning of several special issues that will soon tackle bilingualism and multilingualism in order to improve the literacy levels of young south africans. this special issue also seeks to highlight the need for interdisciplinary work by linguists and language practitioners to find solutions. in this special issue, we showcase some of the most recent research on south african language acquisition. in south africa, many children speak different languages at home than their language of instruction. this affects the development of conceptual and analytical skills, expression of thought and reading and writing. a synergy of psycholinguistic and language practice research is crucial in improving pedagogy and clinical diagnosis. many children with language difficulties or delays often are undiagnosed and this increases their chances of academic failure. policies devised by politicians and education specialists who have no background in linguistics change their strategies regularly, with a negative impact on teaching and learning. this special issue seeks to bring together contemporary research on south african languages, with special emphasis on the bantu language family, afrikaans and south african english, and it specifically focuses on acquisition using both psycholinguistic and clinical approaches. this pioneering interdisciplinary synergy will allow the exposition of local academic research within the local and the international field of language development. from a psycholinguistic and linguistic theory perspective, we have seen the investigation of the noun class prefix and nominal agreement, consonants and clicks, acquisition of word order, relative clauses, morphophonology (for a review on studies of bantu language acquisition, see demuth [2003]; and for contemporary overview of studies on sa bantu language, see gxilishe, 2008; pascoe & smouse, 2012) and for pragmatic development, see kunene-nicolas (2015). it is apparent that linguists need to increase investigations on bilingualism and multilingualism which will feed into both research and language practice. from the speech-language therapist and audiologist’s perspective, there is an acute need to provide assessment and intervention in the languages of their clients. there are many ways in which this can be accomplished, not least of which is the education and training of sa african language-speaking personnel as well as instruction in the african languages for those who are not mother tongue speakers. however, this is simply not enough. deeper knowledge and understanding of the cognitive and linguistic processes inherent in these languages is essential if we are to provide the same level of service as we do in english and afrikaans. this is particularly relevant to the literacy development of young children in the early school years and those who may be at risk for language impairment. to reach this level of understanding it requires synergistic and nuanced research by multidisciplinary teams comprising inter alia linguists, psychologists and speech–language therapists. we believe that the articles contained in this volume illustrate this approach to research and provide excellent generalisable methods and results that can be applied to the study of other african languages and most importantly to the development of resources for assessment and intervention in these languages. the article by michelle pascoe describes speech processing and production of 2-year-old children acquiring isixhosa. speech input processing, stored phonological knowledge and speech output are described based on data from auditory discrimination, naming and repetition tasks within a psycholinguistic framework. this article not only describes typical phonological development in isixhosa but also provides a valuable theoretical framework and method within which future studies can be conducted. the article by nel and southwood on the comprehension and production of quantifiers in isixhosa-speaking grade 1 learners focuses on a specific structure that children need to access and produce narratives and other classroom discourse. little is known about the development, especially the production, of quantifiers, specifically in speakers of an african language. the study records the development of quantifiers in isixhosa first language (l1) learners during grade 1. by including two low socio-economic groups of l1 isixhosa learners with either isixhosa or english as language of learning and teaching (lolt), the research takes the very important variable of context into account. contextual influences of socio-economic status and language in education are critical in the south african context, and as expected this study showed that the isixhosa lolt group comprehended no/none, any and all fully either at the beginning or end of grade 1, and produced all quantifiers at the beginning of the year. the english lolt group had not acquired either the comprehension or the production of quantifiers by the end of grade 1, although they did show some development. the english lolt group performed worse than their peers who were taught in their l1. this article also illustrates the theoretical and methodological sophistication required to do research on african language acquisition. potgieter’s article on lexical and grammatical development in trilingual speakers of isixhosa, english and afrikaans provides much-needed normative data on linguistic development in multilingual children who constitute the largest part of the population who speak the african languages. the article also dispels negative lay opinion on the effect of early multilingualism on language development which ultimately affects home and school language policies. focusing on isixhosa, south african english and afrikaans, the study involved a comparison of 11 four-year-olds developing trilinguals’ acquisition of vocabulary and passive constructions with that of 10 age-matched monolingual speakers of each language. the trilinguals proved to be monolingual-like in their lexical development in the language to which, on average, they had been exposed the most over time, that is, isixhosa. no developmental delay was found in the trilinguals’ acquisition of the passive, regardless of the language of testing. as previously found for bilingual development, a reduced quantity of exposure does not hinder lexical development in the trilinguals’ input dominant language either. the overall lack of delay in their acquisition of the passive is interpreted as possible evidence of cross-linguistic bootstrapping, and support for early multilingual exposure. once again, this article provides theoretical and methodological guidelines on the assessment of languages other than english and also provides evidence for value of raising children with more than one language. this has significant implications for policy and practice in education. wilsenach’s article on identifying phonological processing deficits in northern sotho–speaking children using non-word repetition is in line with current trends in language assessment practices internationally. standardised language tests in the official languages of south africa barely exist. commercially available language tests are in english and have been standardised in other parts of the world. such tests are often translated into african languages, a practice that speech-language therapists deem linguistically and culturally inappropriate. in response to the need for developing clinical language assessment instruments that could be used in south africa, this paper reports on data collected with a northern sotho non-word repetition task. non-word repetition measures various aspects of phonological processing, including phonological working memory, and is used widely by speech-language therapists, linguists and educational psychologists in the western world. the design of a novel northern sotho non-word repetition task is described, and it is argued that the task could be used successfully in the south african context to discriminate between children with weak and strong northern sotho phonological processing skills, regardless of the lolt. the non-word repetition task was piloted with 120 third graders and showed moderate to strong correlations with other measures of phonological working memory, such as digit span and english non-word repetition. furthermore, the task was positively associated with both word and fluent reading in northern sotho, and it reliably predicted reading outcome in the tested population. suggestions are made for improving the current version of the northern sotho non-word repetition task, whereafter it should be suitable to test learners from various age groups. strong evidence is therefore provided for the use of this method as a potential assessment task in other african languages. kunene-nicolas and ahmed write on the lexical development of noun and predicate comprehension and production in isizulu-speaking children aged between 25 and 36 months. it compares lexical comprehension and production in isizulu, using a vocabulary assessment tool developed and validated in italian: the picture naming game developed by bello et al. (2012). this study shows a detailed adaptation process of an assessment tool into the south african context and presents findings based on the direct assessment of the lexical inventory of 36 children. it confirms the universal theory that comprehension precedes language production. it highlights that children’s inventory is largely linked to their linguistic input in the home environment, and linguistic materials have to take this into account when children are introduced to a different language of learning in the formal school environment. we are deeply grateful to the south african speech language and hearing association for the financial support in producing this special edition. we thank the wits sparc fund for supporting the project. references bello, a., giannantoni, p., pettenati, p., stefanini, s., & caselli, m. c. (2012). assessing lexicon: validation and developmental data of the picture naming game (ping), a new picture naming task for toddlers. international journal of language & communication disorders, 47(5), 589–602. demuth, k. (2003). the acquisition of bantu languages. in d. nurse & g. philipson (eds.), the bantu languages, pp. 209–222. surry, uk: curzon press. gxilishe, s. (2008). african languages, linguistics, child speech and speech pathology – the connection. per linguam, 24(2), 75–87. http://dx.doi.org/10.5785/24-2-45 kunene nicolas, r. (2015). zulu oral narrative development from a speech and gesture perspective. per linguam, 31(3), 1–18. http://dx.doi.org/10.5785/31-3-560 pascoe, m., & smouse, m. (2012). masithethe: speech and language development and difficulties in isixhosa. south african medical journal, 102(6), 469–471. abstract introduction methods ethical consideration results discussion conclusion acknowledgements references about the author(s) seema panday discipline of audiology, school of health sciences, university of kwazulu-natal, south africa harsha kathard department of health and rehabilitation sciences, university of cape town, south africa mershen pillay discipline of speech language therapy, school of health sciences, university of kwazulu-natal, south africa wayne wilson school of health and rehabilitation sciences, university of queensland, australia citation panday, s., kathard, h., pillay, m., & wilson, w. (2018). first-language raters’ opinions when validating word recordings for a newly developed speech reception threshold test. south african journal of communication disorders 65(1), a555. https://doi.org/10.4102/sajcd.v65i1.555 original research first-language raters’ opinions when validating word recordings for a newly developed speech reception threshold test seema panday, harsha kathard, mershen pillay, wayne wilson received: 08 mar. 2017; accepted: 05 oct. 2017; published: 29 mar. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the purpose of this study was to consider the value of adding first-language speaker ratings to the process of validating word recordings for use in a new speech reception threshold (srt) test in audiology. previous studies had identified 28 word recordings as being suitable for use in a new srt test. these word recordings had been shown to satisfy the linguistic criteria of familiarity, phonetic dissimilarity and tone, and the psychometric criterion of homogeneity of audibility. objectives: the aim of the study was to consider the value of adding first-language speakers’ ratings when validating word recordings for a new srt test. method: a single observation, cross-sectional design was used to collect and analyse quantitative data in this study. eleven first-language isizulu speakers, purposively selected, were asked to rate each of the word recordings for pitch, clarity, naturalness, speech rate and quality on a 5-point likert scale. the percent agreement and friedman test were used for analysis. results: more than 20% of these 11 participants rated the three-word recordings below ‘strongly agree’ in the category of pitch or tone, and one-word recording below ‘strongly agree’ in the categories of pitch or tone, clarity or articulation and naturalness or dialect. conclusion: the first-language speaker ratings proved to be a valuable addition to the process of selecting word recordings for use in a new srt test. in particular, these ratings identified potentially problematic word recordings in the new srt test that had been missed by the previously and more commonly used linguistic and psychometric selection criteria. introduction speech reception threshold (srt) testing is routinely used as part of the basic audiological assessment of hearing (ramkissoon, proctor, lansing & bilger, 2002). it is typically conducted by presenting a series of words to a listener who must repeat those words as heard. this can be performed, using headphones, or in the free-field, depending on the age and abilities of the listener. the srt score is the presentation level (typically reported in decibels hearing level [db hl]) required for a listener to correctly repeat 50% of a list of presented words. this score is used to quantify the listener’s hearing level for speech and to cross-check the listener’s pure-tone audiometry thresholds (the gold standard test for hearing thresholds) (gelfand, 2001). two factors are commonly considered when selecting the words to be included in an srt test for use in clinical practice: linguistic familiarity and homogeneity of audibility. linguistic familiarity considers the linguistic properties of words in the language of persons for whom the srt test is being developed. it identifies the need to choose words most likely to be familiar to most first-language speakers of that language (kruger & mazor, 1987). homogeneity of audibility refers to the ‘ease at which a word is understood when spoken at a constant level of intensity’ (silman & silverman, 1991, p. 61). it considers several psychoacoustic properties including each word’s psychometric function and prosodic pattern when spoken (nissen, harris, jennings, eggert & buck, 2005). a word’s psychometric function is described as its percentage of correct identification by presentation level (kruger & mazor, 1987; liu & shi, 2013; macpherson & akeroyd, 2014). these functions show that increasing the presentation level of a word increases the probability that a listener will repeat it correctly. the slope of a word’s psychometric function should be steep to provide for more precise estimations of srt (hudgins, hawkins, karlin & stevens, 1947) and greater sensitivity to changes in a listener’s ability to understand speech. a word’s prosodic pattern refers to several features including its length, accent, stress, tone and intonation (fox, 2000). these features carry different meanings in different languages and are often determined by measuring the pitch and energy contours of the word (panday, kathard, pillay & govender, 2009). although linguistic criteria and homogeneity of audibility are clearly important in the development of srt tests in audiology, these factors alone may not be sufficient to ensure that the final srt test adequately represents all facets of the construct it has been designed to measure (maxwell & satake, 2006). in the context of an srt test, this refers to the need to satisfy not only linguistic and psychoacoustic criteria, such as those discussed above but also broader criteria, such as the appropriateness of the word recordings for the communities in which the srt test will be used. this can be done by including expert speakers of the language from the communities in which the test is recorded. these persons can provide immediate and direct feedback as to the appropriateness of the proposed word recordings, being trialled by rating factors such as word intonation, tone and clarity, and representation in terms of dialect. such ratings could contribute to the final srt test’s content and ecological validity (theunissen, swanepoel & hanekom, 2009), where content validity refers to how well the test words represent the content domain the test was designed to measure, and ecological validity refers to how the test words represent everyday word use in the communities in which the test will be used (theunissen et al., 2009). this study reflects on the lessons learnt during the development of a new srt test for use with speakers of isizulu in kwazulu-natal (kzn), south africa (panday, kathard, pillay & govender, 2007, 2009). in particular, it considers the value of adding expert speaker ratings of test word recordings where those expert speakers were drawn from the population in which the test is to be used. methods aim the aim of the study was to consider the value of adding first-language speakers’ ratings when validating word recordings for a new srt test. research design a single observation, cross-sectional design (maxwell & satake, 2006) was used to collect and analyse quantitative data in this study. participants the participants were 11 first-language isizulu speakers (3 men and 8 women, aged 18–60 years with a mean age of 36 years) purposively selected for measuring the suitability of the srt test word recordings. these participants were permanent residents of kzn province in south africa and were self-reported native speakers of isizulu with normal hearing thresholds (≤20 db hl or better at octave frequencies from 125 hz to 8 khz), normal middle ear function [within normal limits on acoustic immittance testing (asha, 1990; roup, wiley, safady & stoppenbach, 1998) and no self-reported history of factors that could affect their hearing ability when listening to the recording of the newly developed word list. they were considered to represent the general population in kzn, with participants coming from the following occupational groups: domestic worker, linguist, student, teacher, technician, librarian, clerk, factory worker and administrator. materials and instrumentation the test word recording the test word recordings used in this study were the 28 disyllabic isizulu low-tone verbs recordings, selected during previous research for the development of an srt test for isizulu speakers in kzn, south africa (panday et al., 2007, 2009). this previous research had shown that these 28 word recordings satisfied the criteria of linguistic familiarity and homogeneity of audibility for the target population of isizulu-speaking adults (panday et al., 2007, 2009). the criterion of linguistic familiarity had been shown by having two zulu speaking language interpreters and two tertiary-level educators identify 131 commonly used zulu words, with 82% of these words subsequently identified as being disyllabic verbs. five linguistic experts then rated 58 of these disyllabic verbs as being sufficiently familiar, phonetically dissimilar and low in tone to be potentially suitable for use in the development of an srt test in isizulu (panday et al., 2007). the criterion of homogeneity of audibility had been shown by recording these previously identified 58 words from a male first-language speaker of isizulu and playing these word recordings at six intensity levels to 30 isizulu first-language speaking adults (aged 18 to 25 years) with hearing within normal limits (panday et al., 2009). logistic regression analysis was used to determine the psychometric function of each of the 58 word recordings, with 28 word recordings meeting the criterion of having a mean slope at 50% intelligibility within 1 sd of the group mean of 5.98%/db. the prosodic features of these 28 word recordings were then analysed and their pitch contours were shown to conform to the prosodic pattern apparent within isizulu linguistic structure (panday et al., 2009). table 1 shows the 28 disyllabic isizulu low-tone verbs used in this study and the psychometric properties of each word reported in previous research (panday et al., 2009). for this study, the levels of each of the 28 word recordings were adjusted (δdb) so that the 50% correct perception scores for each word occurred at the mean pure-tone average (2.8 db hl) of the participants in the previous homogeneity of audibility study (panday et al., 2009). the size of this adjustment for each word is shown by the δdb levels in table 1. figure 1 shows each recorded word’s psychometric function before and after this level adjustment. figure 1: psychometric functions for the 28 recorded isizulu words unadjusted (a) and adjusted (b) for listener hearing thresholds. table 1: psychometric properties of the 28 disyllabic isizulu word recordings used in this study. the rating scale the rating scale used in this study was developed based on previous research (theunissen et al., 2009). it consisted of five questions asking the participant to rate each word on five criteria: pitch or tone, clarity/articulation, naturalness or dialect, speech rate and quality. participants responded to each question on a 5-point likert-like scale where 1 corresponded to strongly agree, 2 to agree, 3 to neutral, 4 to disagree and 5 to strongly disagree. data collection procedure a pilot study was first conducted on three participants who were not part of the main study. the rating scale and test procedure were piloted for accuracy and ambiguity. minor editorial and rephrasing of instructions were made. thereafter, participants for the main study were recruited. each first-language isizulu-speaking participant in the main study was shown the rating scale and instructed on its use. each participant then listened to each of the 28 recorded isizulu word recordings. each word recording was played three times at a comfortable listening level of 60 db hl, before each participant was asked to complete his or her ratings of that word recording. the word recordings were routed from a technics (slpg390) cd player to the external input of a grason stadler model 61 audiometer (calibrated in accordance with ansi s3.6 specifications [ansi, 2004]) and then to the test ear (chosen by flipping a coin) of each participant through a single tdh-49 headphone with mx41/ar cushions. prior to testing each participant, the external inputs to the audiometer were calibrated to 0 vu using the 1000 hz calibration tone on track one of the test cd. data analysis the ratings, obtained from the 11 first-language isizulu-speaking participants about the pitch or tone, clarity/articulation, naturalness or dialect, speech rate and quality of speech for each of the 28 isizulu word recordings, were analysed descriptively and inferentially. agreement amongst the 11 raters was calculated using percentage agreement. as these percentages were exceptionally high, further analysis using kappa statistics was abandoned in favour of friedman analysis of variance (anova) analyses (mchugh, 2012). these friedman anova analyses considered rater as the independent variable and the ratings in each rating category as the dependent variable. a friedman anova analysis was conducted for each rating category separately (pitch or tone, clarity/articulation, etc.). all statistical analyses in this study were carried out using stata version 14 under the guidance of a statistician from the medical research council of south africa (durban). ethical consideration unconditional ethical clearance was obtained from the university of cape town (hrec 652/2012). verbal and written informed consent was obtained from all participants. all participants were given an information document that outlined the details of the study. participants were assured of their anonymity and were free to withdraw from the study at any point. confidentiality was maintained throughout the study. results figure 2 shows ≥80% of the 11 first-language isizulu-speaking participants rated 24 of the 28 isizulu word recordings as ‘strongly agree’ in the categories of pitch or tone, clarity/articulation, naturalness or dialect, speech rate and quality. more than 20% of these 11 participants rated the three-word recordings – ‘kheta’, ‘washa’ and ‘yonga’ – below ‘strongly agree’ in the category of pitch or tone, and one-word recording – ‘cinga’ – below ‘strongly agree’ in the categories of pitch or tone, clarity or articulation and naturalness or dialect. figure 2: percentage of raters strongly agreeing in each rating category for each of the 28 recorded isizulu words. the assessment of rater reliability showed that the chi-square statistic of 18.31 (df = 10) was far greater than the calculated friedman statistic in each rating category (pitch or tone, clarity/articulation, etc.) (table 2). this led to the null hypothesis that there was agreement amongst the 11 participating raters within each of the five categories at a 95% confidence level. table 2: friedman analysis of variance analyses comparing raters within each rating category. discussion the first-language speaker ratings were a valuable addition to the process of validating word recordings for use in a new srt test. this was evident in at least four aspects of the rating scale: (1) by keeping the scale simple, it proved to be easy to develop; (2) by targeting the population for whom the srt test was being developed, the participants proved to be easy to recruit; (3) with points one and two in place, the participants found the scale easy to complete; and (4) the results obtained from the scale were easily integrated with the linguistic and psychometric results already obtained for the srt in its development to date and added evidence for the content validity of this test. the first-language speaker ratings were also a useful addition to the process of validating word recordings for use in a new srt test. this was most evident in all 28 word recordings having been previously accepted on linguistic and psychometric criteria (panday et al., 2007, 2009), but the first-language speakers then identified potential problems with three-word recordings on pitch or tone and with one-word recording on pitch or tone, clarity or articulation and naturalness or dialect. a possible cause for these problems could lie in the manner in which the first-language isizulu speaker spoke these words during the original recording. on reviewing these recordings, this speaker was heard to have provided greater emphasis on the second syllable of these words (an iambic meter). this resulted in a slight change in the pitch and tone of these word recordings, particularly for the word ‘cinga’. it was noted that this iambic meter (greater emphasis on the second syllable) differs from the spondaic meter (equal emphasis on each syllable) present in the disyllabic word recordings used in english language speech reception tests. the value added by including first-language speaker ratings in the development of the isizulu srt test, considered in this study, supports suggestions that commonly used measures of linguistic criteria and homogeneity of audibility alone may not be sufficient to ensure that the final srt test adequately represents all facets of the construct it has been designed to measure (maxwell & satake, 2006; nissen et al., 2005). considering broader criteria such as the appropriateness of the word recordings, as rated by members of the communities in which the srt test will be used, can provide immediate and direct feedback as to the appropriateness of the proposed word recordings being trialled. such ratings will contribute to the content and ecological validity of any final srt test recording. pascoe, rogers and norman (2013) indicate that there is need for researchers in south africa to share the methods used to develop and validate contextually relevant tests. the use of community members or first-language speakers as experts of the language when selecting word recordings for srt tests, is another method to consider when developing contextually relevant materials in south africa. conclusion the first-language speaker ratings proved to be a valuable addition to the process of selecting word recordings for use in a new srt test. in particular, these ratings identified potentially problematic word recordings in the new srt test that had been missed by the previously, and more commonly, used linguistic and psychometric selection criteria. this study has implications for the methods used to determine the reliability and validity of new tests for speech audiometry. it supports the use of multiple methods to systematically accumulate evidence for and against the use of new tests, and the viewing of this evidence in an integrated way to determine the true reliability and validity of new tests in the settings in which they will be used. acknowledgements the authors thank the south african medical research council for biostatistical support, specifically cathy connolly, rebecca shunmugam and yusentha balakrishna. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions s.p., h.k., m.p. and w.w. contributed conceptually to the study. s.p. is the lead investigator of this study and the larger study containing this study. s.p. contributed to the data collection; s.p. and w.w. contributed to the writing, structure and layout; and s.p., h.k., m.p. and w.w. contributed to the editorial aspects of this article. references american national standards institute. 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(2005). psychometrically equivalent trisyllabic words for speech reception threshold testing in mandarin. international journal of audiology, 44, 391–399. https://doi.org/10.1080/14992020500147672 panday, s., kathard, h., pillay, m., & govender, c. (2007). the development of a zulu speech reception threshold test for zulu first language speakers in kwa zulu-natal. south african journal of communication disorders, 54, 111–122. panday, s., kathard, h., pillay, m., & govender, c. (2009). the homogeneity of audibility and prosody of zulu words for speech reception threshold (srt) testing. south african journal of communication disorders, 56, 60–75. pascoe, m., rogers, c., & norman, v. (2013). are we there yet? on a journey towards more contextually relevant resources in speech-language therapy and audiology. south african journal of communication disorders, 60, 2–9. https://doi.org/10.4102/sajcd.v60i1.3 ramkissoon, i., proctor, a., lansing, c., & bilger, r.c. (2002). digit speech recognition threshold (srt) for non-native speakers of english. american journal of audiology, 11, 23–28. https://doi.org/10.1044/1059-0889(2002/005) silman, s., & silverman, c.a. (1991). audiology diagnosis: principles and practice. new york: academic press inc. theunissen, m., swanepoel, d.w., & hanekom, j. (2009). sentence recognition in noise: variables in compilation and interpretation of tests. international journal of audiology, 48(11), 747–757. https://doi.org/10.3109/14992020903082088 roup, c.m., wiley, t.l., safady, s.h., & stoppenbach, d.t. (1998). tympanometric screening norms for adults. american journal of audiology, 7, 1059–1089. https://doi.org/10.1044/1059-0889(1998/014) a t e a m w o r k a p p r o a c h to cleft p a l a t e r e h a b i l i t a t i o n i n south africa m a r g a r e t m a r k s , m . a . assistant supervisor, speech, voice and hearing clinic, university of the witwatersrand "a cleft palate is a fissure located in the palate and completely surrounded by a human being." (1) tion of persons with cleft lip and associated t h e problems which a cleft palate* creates are numerous. t h e condition can affect the function ot eating, the normal production of speech, and the physical appearance of the individual. added to these are the possibilities of allied anatomical and functional disorders which can accompany the inadequate structure, and emotional difficulties which arise from the individual's awareness of his differences. whose then is the cleft palate "baby"? his complex problems must land him, fairly and squarely, in the capacious lap of a team of experts who are co-operating for the best for this particular child. it is the task of the specialists involved to remember that they are working with a hole, surrounded by a palate, surrounding by a child; and not in a vacuum. more and more workers have realised the lack of economy in working as individuals on a problem which demands a co-operative approach. mccue, writing on team relationships in the rehabilitation process discusses the difficulties of the patient having to be "shared" among specialists who are "patient or client focused" and not "other discipline focused". she sees corrective approaches as first, sufficient knowledge of each other's role and contribution and, second, appropriate use of the knowledge. with this knowledge, one can relinquish certain activities to another discipline without loss of face, since the other may at a given time have the principal contribution to offer. knowledge and respect will enable us to communicate with a minimum of time, which is always at a premium. they will allow us to differ and discuss, rather than listen and take orders we disagree with . . . relationships must be horizontal with each other as well as vertical with the patient or client. (2) it is the purpose of this article to consider the possibilities of a team approach to the problem of the cleft palate individual, particularly in a country such as south africa. the aims of an association such as the american association for cleft palate rehabilitation could serve as a guide for a discussion on how a team approach could be directed. " 1. to encourage scientific research in the causes and nature of cleft palate and lip. 2. to promote the science and art of rehabilitathe words "cleft palate" will be used to describe aspects of cleft lip and/or cleft palate. all deformities. 3. to encourage co-operation among and stimulation of those specialists interested in the rehabilitation of cleft palate persons. 4. to stimulate the public interest in, and support of, the rehabilitation of cleft palate persons." (3) team work would take as its basic goal the hadintation and rehabilitation of persons with cieft palates. uur ultimate and most far-reaching aim is one oi service. this can best be achieved by co-operation among interested specialists; by research which would advance knowledge in the held; and by interesting and obtaining the support of the general public in its understanding of the condition and of the individual problems of each person who has a cleft palate. the relative youth of a country such as south africa brings its own special problems when a project such as the one envisaged, is considered. on the one hand it presents certain disadvantages. " we suffer from a paucity of specialists. those that there are, are so involved in the service aspect of their work, that little time can be spent on the more deliberative, philosophical and research aspects. a typical example would be that of speech therapy. until 1960 (when a second department opened) there has been only one university centre in south africa which is regarded by the south african medical and dental council as being qualified to train speech therapists. the graduates produced during the short life of the department, which is less than twenty-five years old, have had to fulfil the first requirements of therapists i.e. to give treatment to those who need it. there are pitifully few therapists to treat those speech, voice, language and hearing defectives whose basic psychosocial tool — communication — is impaired; and the energies of this young profession have perforce been channeled into service. on the other hand we have a distinct advantage in that very few hide-bound traditions exist which could affect the smooth working of a team. conscious, in the best sense, of the relative youth of each speciality, the majority of our professional workers are keen to consider new ideas, to implement new techniques, to learn from other related disciplines. we do not seem to suffer from what mccue calls the "prima donna syndrome". we are fortunate in that our professional journal of the south african logopedic society december r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) growth has paralleled the growdis of the realisation that not only in spite of, but in fact because of, specialisation, an integrated team of specialists is a necessity when the treatment of a person is considered. the composition of a team could include the following specialities as recommended by the new york city department of health in a memorandum which discusses standards of care for cleft palate rehabilitation centres in hospitals: dentistry (general dental care); nursing (hospital and public health); oral surgery; orthodontia; otolaryngology; pediatrics; plastic surgery; prosthodontia; psychiatry; psychology; social service; speech therapy. a co-ordinator is also necessary for the smooth functioning of a team (4). working teams could be constructed made up of smaller units than those mentioned, but it is important to realise that all of these are essential for the total well-being of the case. a specialist not mentioned above is the radiologist. in a unit such as the northwestern university cleft lip and palate institute (where the writer was privileged to observe a team at work) x-rays of the child's face are shown which demonstrate the anatomical structure and physiological possibilities of closure during the articulation of various sounds. although of general interest, these are particularly important for the speech therapist to inform her about the possibilities of closure and to show her if she can work on sounds demanding maximum intra-oral pressure, at the present time. how can a cleft palate team function? sufficient knowledge of each other's role and contribution, and appropriate use of this knowledge were mentioned before as the main objectives of a team approach. by the very nature of the cleft palate problem it is obviously impossible to separate the theoretical and the practical aspects entirely, but projects will be discussed which emphasise either the academic or the service view. academic discussion should precede practical work but it must lead to direct application. if a team is to be set up some sort of "in-service training" must be given, by each specialist putting forward the aims of his work | with a cleft palate individual. it is important, for example, that the surgeon, prosthodontist and orthodontist know how far the speech therapist can go with her programme while there is still an incomplete mechanism; it is important for the prosthodontist and surgeon to know each others' views about the optimum time for surgery and the role of appliances before that time is reached. these and many other aspects of the problem can be discussed. the discussions can take the form of regular seminars, or of conferences. the american association for cleft palate rehabilitation holds an annual meeting which includes a one-day short course and two days of contributed papers. the geography of our country would seem to support both regular seminars and occasional conventions; the former by virtue of the fact that the majority of specialists are centred in a few large cities, and can, with time and other such limitations permitting, convene relatively easily; but nation-wide conventions are also very necessary to supply the needs of the growing numbers of professional workers who are servicing the smaller towns and country areas. the word "academic" was deliberately chosen to carry the implications of student training. whether on an undergraduate, or post-graduate level, student training should be an integral part of a team approach. when qualified, many students will be working in hospitals, universities, or clinics, and they will have acquired knowledge and experience regarding the need for implementation of a team in the rehabilitation of cleft palate cases. a working cleft-palate team with service as its immediate goal, as contrasted with an academic emphasis, could function in one of the following ways: 1. independent examination of the child, and any one member of the team can contact any other who is working on the case, 2. group examination of the child and group discussion, 3. independent examination, and a group discussion among the specialists who have seen the child. each of these has its advantages and disadvantages. the first course is one which has in the main been followed up to now. it has the advantage of an economical use of the valuable commodity, time, but it is necessarily cursory and omits, the handling of many problems which do not fall directly into the areas of the two specialists concerned. group examination, followed by group discussion, presents the opposite side of the coin. the advantage is in the obvious thoroughness of the approach; the disadvantage lies in the time-consuming nature of the examination. this approach could, however, be used to great advantage in the regular recheck of cases who are under treatment. each worker, at a recheck, is familiar with the individual problems of the case; he is not looking at a new mouth, but is looking for something — further growth of tissue, better occlusion, more adequate functioning of the velopharyngeal mechanism, than at the last examination. his recheck examination is much more brief than his original, and it is particularly at the recheck that he needs to have the other workers on hand to discuss what future co-operation can be brought about to benefit the case further. journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) independent examination, and a group discussion of the problems of each case, is the third, and probably most practicable of the possibilities. it is both thorough and economical. using this structure, each member of the team comes to the discussion to present the salient points of his examination, and to plan a continued programme which will fit in with the programmes of the other team members. the academic and service aims of a team bring with them two other major by-products i.e. research and publicity. the need for research need not be stressed; a country such as south africa, with its different cultural groups, and resultant physical and psycho-social differences, provides a rich sub-soil for research at any level. in a field such as the one under discussion, different dietary habits and incidence of cleft palate can be investigated; our rural, particularly african, population can provide many cases with whom no treatment has been carried out and comparison with treated cases can be made at all levels; these are but two of the many research projects which could be carried out. a team working on rehabilitation must also be involved with publicity. probably one of the most important functions of a team is to make known the facilities which exist. to parents, the birth of a newborn cleft palate baby can be traumatic. it is of vital b o o k b i n d i n g „ ! ί ί ] β . korytowski i 1 mvlin court, 24 beit street, doornfontein i telephone 44-9602 ! four reasons why you should have your books, magazines and thesis bound by us: ( 1. modern linen in 30 colours. | leather with beautiful grains i 2. first class craftsmanship | guarantee for unbreakable binding | 3. q u i c k delivery | 4. w e l l k n o w n for r e a s o n a b l e j p r i c e s ] •4importance that these parents are assured that much can be done to help their child, and that, with proper treatment, he can grow into a normal, adequate individual. too often parents are told by those who are ignorant of the available treatment that "he will never talk normally", or "nothing can be done about his hare-lip". it should be incumbent on everyone who delivers a cleft palate baby, to inform the parents that highly specialised plastic surgeons are available to perform the necessary operations; that other workers exist who will help the child to grow into a normal individual who will "look well, eat well, speak well." wherever possible the team should be on hand to explain to the parents what the situation is and what can be done in the future. in this way, with the best facilities open to him and qualified specialists available to treat the infant in the best possible way, the child who is born with a cleft palate should be able to grow into an adequate person, not a handicapped individual; public relations work must also be done to give the public some knowledge of the problem, as well as an awareness of the normality of people who were born with cleft lips and palates, and a realisation that an acceptance of the person is basic to his adjustment. s u m m a r y there is an important need for teamwork in the habilitation and rehabilitation of the cleft palate child, particularly in a country such as south africa. the main sub-goals of a team approach are academic and service; reserch and publicity are seen as by-products of these goals. i should like to express my thanks to professor h. westlake of northwestern university and dr. k. bsoch of northwestern university cleft lip and palate institute, for their instruction, and permission to observe at the institute; and professor j. dreyer, and dr. g. gavron of the oral and dental hospital, university of the witwatersrand, for helpful discussions. references 1 rosen, m. s. and bzoch, k. r. the prosthetic speech appliance in rehabilitation of patients with cleft palate. .journal of american dental association, vol. 57, august 1958, pp. 203-210. 2 mccue, c. team relationships in the rehabilitation process, rehabilitation literature, vol. x x i , 3, march 1960, pp. 96-97. ; 3 american association for cleft palate rehabilitation. historical summary, cleft palate bulletin, membership directory, 1958, p. 3 . 4. new york city health department. standards of care for cleft palate rehabilitation centres in hospitals, bureau for handicapped children, department of health. journal of the south african logopedic society december r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) article information authors: leanne teixeira1 karin joubert2 affiliations: 1chris hani baragwanath hospital, johannesburg, south africa2department of speech pathology and audiology, university of the witwatersrand, south africa correspondence to: karin joubert postal address: po box 420, bromhof 2154, south africa dates: received: 07 apr. 2013 accepted: 02 may 2013 published: 27 aug. 2014 republished: 02 dec. 2014 how to cite this article: teixeira, l., & joubert, k. (2014). availability of audiological equipment and protocols for paediatric assessment and hearing aid fitting in gauteng, south africa. south african journal of communication disorders, 61(1), art. #58, 8 pages. http://dx.doi.org/10.4102/ sajcd.v61i1.58 note: article republished with corrected journal name. copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. availability of audiological equipment and protocols for paediatric assessment and hearing aid fitting in gauteng, south africa in this original research... open access • abstract • introduction • method    • aim    • research design    • participants       • sampling strategy       • participant description    • materials    • procedures       • ethical considerations    • data collection    • reliability and validity       • data analysis • results    • availability of audiological equipment    • departmental protocols for paediatric assessment and ha fitting • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references • appendix 1 abstract top ↑ background: accurate diagnosis and management of hearing loss (hl) is based on valid and accurate ear-specific and frequency-specific information. this is especially relevant as non-optimal hearing amplification as part of early hearing detection and intervention programmes may result in further delays in the speech and language development of children with hl. audiological measures utilised may vary according to the age, cognitive ability and physical ability of the infant or child. it is therefore important to compare and critically evaluate current clinical practice in order to recommend guidelines for paediatric audiology in south africa.objectives: to determine the availability of audiological equipment and clinical protocols used by audiologists in gauteng for paediatric audiological assessment and hearing aid (ha) fitting. method: a descriptive, cross-sectional survey research design was utilised to describe the availability of clinical audiological equipment and protocols used by audiologists in gauteng, south africa for paediatric assessment and ha fitting. eighteen audiology departments, eleven public hospitals and seven private practices were included in the study. results: results revealed the limited availability of departmental protocols within departments for paediatric assessment and ha fitting. although there appeared to be a wide variety of equipment available to audiologists in public sector hospitals and private practice, a lack of high-frequency tympanometers and equipment for real ear measurements was revealed. conclusion: these findings highlight the need for the development and use of current, evidence-based practice guidelines for paediatric audiological assessment and ha fitting in south africa. these guidelines should include a list of essential equipment required for paediatric assessment and ha fitting. current, evidence-based practice guidelines for paediatric ha fitting are important in ensuring that secondary developmental delays associated with a delay in early intervention for children with hl are reduced. introduction top ↑ the transformation of the south african health system has been hindered by insufficient numbers and inequitable distribution of health workers and resources across private and public health care sectors (lloyd, sanders & lehmann, 2010). the inequitable distribution of resources is evident: 55.6% of health finances are utilised in the south african private health care sector (blecher & harrison, 2006). this whilst only 16% of the south african population have access to the private health care system through medical aid schemes, whilst the remaining 84% of the population access public health care (lloyd et al., 2010). public health care funding in south africa has recently focused on funding allocation to primary health care, hiv and aids and related illnesses, infrastructure and emergency medical services (blecher & harrison, 2006). despite this, various other challenges still need to be addressed, including the early identification and appropriate management of paediatric hearing loss (hl).based on birth estimates (statistics south africa [ssa], 2011) and estimated hl incidence for sub-saharan africa (olusanya, 2008), it is estimated that in south africa, 6357 children are born annually with permanent hl or acquire it at an early age. the majority of these children are born in the public health sector. in south africa, children with hl are diagnosed at a later age than international recommended norms (strauss, 2006; van der spuy & pottas, 2008). this may be due to the fact that neonatal hearing screening in south africa is not yet implemented universally. audiological protocols based on evidence-based practice assist in achieving care for patients with proven quality and effectiveness (moodie et al., 2011). there are various international gold standards regarding early detection and intervention for children with hl (baldwin, sutton, gravel & low, 2008; british columbia early hearing programme [bcep], 2008; joint committee on infant hearing [jcih], 2007). these guidelines highlight the importance of using appropriate audiological equipment and age-appropriate measures during early hl detection and intervention (ehdi), to ensure the appropriate diagnosis and management of paediatric hl. in south africa, the health professions council of south africa’s (hpcsa) position statement on ehdi (hpcsa, 2007) describes the age at which intervention should be initiated, as well as what early intervention should involve. the position statement recommends that, in a hospital-based setting, hl should be identified by 3 months of age and intervention provided by 6 months of age, whilst in a clinic-based setting, hl should be identified by 4 months of age and intervention provided by 8 months of age. this guideline, however, only includes limited information on how audiological results should be used for ha fitting. the goal of paediatric audiological assessment is to determine whether permanent hl is present and, if required, to initiate a management plan as directed by the child’s family (bcep, 2008). this process involves the application of a test-battery approach to determine the exact nature of the hl, as well as evaluating the integrity of the auditory pathway (diefendorf, 2009). this ensures that an accurate diagnosis is made, based on valid and accurate ear-specific and frequency-specific hearing information (bcep, 2008). the audiological measures utilised may vary according to the age, cognitive ability and physical ability of the infant or child (diefendorf, 2009). case history and clinical observation are important components of the audiological assessment of children of all ages. both these components provide the clinician with an understanding of a child’s overall development, which will guide audiological procedures used during assessment (diefendorf, 2009). a test battery for audiological assessment of children from birth to 6 months may, in addition, include a family report and observations; high-frequency (1000 hz) tympanometry and acoustic reflexes; oto-acoustic emissions (oaes); auditory brainstem response (abr) (gravel, 2000); cochlear microphonic (cm); and auditory steady-state response (assr) (stevens, sutton, wood & mason, 2007). behavioural testing can usually be included as part of the test battery from 5 to 6 months of age (madell, 2008), as well as using a low-frequency immittance probe tube from 6 months of age (baldwin et al., 2008). research exploring ehdi services in south africa found that only 2% of the hospitals surveyed conducted universal hearing screening (theunissen & swanepoel, 2008). the reasons provided for the lack of universal screening included the lack of staff and equipment. the researchers further reported that only 34% of hospitals had access to screening equipment (such as an oae screener and/or automated abr) (theunissen & swanepoel, 2008). however, there is limited information on the availability of equipment and protocols used for diagnostic paediatric audiological assessment and management in south africa. together with the necessary resources (equipment and staff), a sustainable programme for ehdi should be based on evidence-based protocols. hyde (2010) clearly states the importance of clinical protocols: good protocols are absolutely and unquestionably essential for all major components of a high quality ehdi program. without them, high effectiveness, equity and efficiency of services are virtually impossible to achieve, sustain or improve. (p. 64) despite this, strauss (2006) found that only 35% of individual audiology departments surveyed in south africa reported following a protocol for ehdi. without adequate resources (such as equipment and skilled paediatric audiologists) and evidence-based protocols the implementation of a sustainable ehdi programme will remain a challenge in south africa. it is thus important to compare and critically evaluate current clinical practice in order to recommend guidelines for paediatric audiology in south africa. this is especially relevant as non-optimal ha fitting as part of ehdi may result in further delays in the speech and language development of children with hl (yoshinago-itano, sedey, coulter & mehl, 1998). due to the dearth of information on the current clinical practice, this study addressed the following question: what is the clinical practice of south african audiologists, with specific reference to the availability of audiological equipment and protocols for paediatric audiological assessment? method top ↑ aim the study aimed to:• determine the availability of clinical audiological equipment used by audiologists in gauteng for paediatric audiological assessment and ha fitting • determine the availability of clinical protocols used by audiologists in gauteng for paediatric audiological assessment and ha fitting. research design a non-experimental, descriptive, cross-sectional survey research design was utilised for the purposes of the study. a questionnaire was developed by consulting current evidence-based practice protocols, and refined after a pilot study was completed. the self-developed questionnaire administered through face-to-face interviews assisted in ensuring high response rates and allowed the researchers to describe the current clinical practice of audiologists employed in gauteng. participants sampling strategy a non-probability, purposive sampling strategy was employed to recruit as many participants as possible who met the participant selection criteria (cresswell, 2003). participants in this study were required to be audiologists working in departments that render paediatric audiological services in either the private or public health care sector in gauteng. participant description of the 23 potential audiology departments and practices in gauteng, a total of 18 audiology departments (n = 18) agreed to participate in this study. participants had to be performing paediatric abr or assr testing and/or be fitting hearing aids to children based on such results. a total of 34 interviews were conducted: 27 within the public health sector and 7 within the private health sector. public sector audiology departments comprised 61% of the sample (n1 = 11), whilst private audiology practices comprised the remaining 39% (n2 = 7). more than one participant from each department was interviewed if they were willing to participate in the study. this allowed for comparison of participants’ responses to the same questions. in some cases, more than one participant from public health sector departments were interviewed. this was not the case in private audiology practices, where often only one clinician was employed or available due to smaller departmental staff size. if more than one participant was interviewed per department, between two and four participants were interviewed, depending on their availability and departmental staff size.the majority of participants (82%; n = 28) included in the study were qualified as both speech-language pathologists and audiologists, whilst 18% (n = 6) of participants were qualified as audiologists only. since qualifying, 26% (n = 9) of the dually qualified therapists were now practicing as audiologists only. participants’ years of experience ranged from < 1 year to > 15 years. the majority of participants (68%; n = 23) had 4 or less years’ experience. private practice participants had the most years of experience. fifty-seven percent of the private practice participants had 10 or more years’ experience, whilst only 7% of the public sector participants had 10 or more year’s clinical experience. materials a self-developed structured questionnaire with predomi-nantly close-ended questions was used during the face-to-face interviews. the questionnaire included eight sections, but for the purposes of this article only the sections related to current clinical practice will be reported on. these sections included the availability of audiological equipment and departmental protocols for paediatric assessment and management (see appendix 1). procedures ethical considerations various ethical considerations were implemented throughout the research study. the researcher obtained ethical clearance from the university of the witwatersrand research ethics committee and written permission from the gauteng department of health to conduct this study. all participants in the study were fully informed of the nature of the study and were assured of confidentiality. each participant was required to sign a consent form, providing proof of their willingness to participate in the study. they further had the right to withdraw from the study at any time, without any negative consequences. only participants who signed the consent forms were included in the study. data collection data was collected during november and december 2010. once possible participants were identified, they were contacted telephonically, informed of the nature of the study and invited to participate. appointments were made at times that were convenient for participants. participants received a written information sheet detailing the information discussed telephonically and once participant consent was obtained the self-developed questionnaire was administered via individual personal interviews. data was documented on the measuring instrument. participants were thanked for their participation. reliability and validity various measures were adopted to improve the validity and reliability of this study. content validity was achieved by consulting current literature and experienced professionals in the field whilst developing the questionnaire. in addition, a pilot study was conducted to finalise the measuring instrument and data collection procedures.in an attempt to minimise the hawthorne effect, it was made clear to participants that there were no correct or incorrect answers to the questions. interviews were not electronically recorded, but participants were provided opportunity to discuss or elaborate on their responses to questions. face-to-face interviews assisted in ensuring that participants could not consult one another regarding their responses to questions, improving reliability of responses, as well as allowing for comparison of participants’ responses to the same questions, in order to analyse participants’ awareness of resources such as protocols and equipment. as this study was only conducted in the gauteng province, generalisation of results to clinical practice and availability of resources across the whole of south africa could not be assumed (cresswell, 2003). data analysis data was documented on all relevant measuring instruments and encoded for data analysis. all data was computerised for statistical analysis with microsoft excel and sigmaxl 6.11 software packages. results were analysed utilising descriptive statistics (such as measures of central tendency and variability) that assisted in the summary and organisation of the collected data. results top ↑ availability of audiological equipment participants were provided with a list of audiological equipment and requested to indicate which of these were available in their department or practice. the results are presented in table 1. table 1: equipment available at private and public sector audiology departments (n =18). all departments (n = 18) reported having access to sound-treated booths, otoscopes, diagnostic audiometers and screening oaes. only 44% (n = 8) of departments had access to assr, whilst slightly more departments (61%, n = 11) had access to diagnostic abr equipment. all private sector departments (n2 = 7) reported having access to diagnostic oae equipment, whilst only 18% (n1 = 2) of public sector departments reported having access to such equipment. seventy-two percent (n = 13) of departments had access to noisemakers, of which 82% (n1 = 9) were public sector departments and 57% (n2 = 4) were private sector departments. with regard to other screening equipment, 50% (n = 9) of departments reported having access to both screening abr and screening audiometers. only two audiology departments (11%), which were within the private sector, reported having access to sound level meters (slms). there was limited availability of real ear measure (rem) equipment for verification of ha fitting, as only 39% (n = 7) of departments reported having access to such equipment. this was for both private and public audiology departments. availability of rem equipment was similar for both private (43%, n2 = 3) and public (36%, n1 = 4) sector departments. all departments (n = 18) reported having access to some form of tympanometry. fifty percent (n = 9) of departments reported having access to low-frequency tympanometry, whilst 44% (n = 8) of departments reported having access to high-frequency probe tone tympanometry. the remaining department (6%) was unsure whether their immittance equipment had both high-frequency and low-frequency probe tone options or not. only 57% (n2 = 4) of the 7 private sector departments reported having high-frequency tympanometry, but all reported seeing babies of less than 6 months of age. all but one public sector department (91%, n1 = 10) reported seeing infants from birth to 6 months of age. despite this, only 36.5% (n1 = 4) of the 11 public sector departments interviewed reported having access to high-frequency tympanometry. some public sector departments further reported that certain equipment was not functioning and that their hospital employer had not provided funding for the timely repair of equipment. as seen in table 1, some public health sector participants from the same department gave varied responses regarding the availability of equipment in their department. varied responses regarding the presence of equipment per public sector audiology department were given regarding diagnostic oaes, noisemakers, screening abr and screening audiometers, slms as well as high-frequency and low-frequency probe tone tympanometers. departmental protocols for paediatric assessment and ha fitting it is vital that audiological practice is evidence-based in order to ensure that patients’ audiological needs are appropriately met, whilst being of a high standard, as well as assisting with continuity of care with staff turn-over. the presence of protocols for paediatric assessment (including abr and assr) and ha fitting within departments was probed.results indicate that only 28% of departments (n = 5) reported having a paediatric ha fitting protocol. in some departments, more than one audiologist was interviewed. nine percent (n = 3) of the 34 individual participants in the study were unsure whether their department had a paediatric ha fitting protocol or not. furthermore, although 44% (n = 15) of participants reported having a paediatric ha fitting protocol, when comparing the response to this question across participants at the same department, not all (n = 4) responded with the same answer. seven public sector departments had more than one participant. eleven of the 18 participating departments reported that they perform abr and/or assr testing. only three (27%) of these departments had protocols for paediatric abr and/or assr assessment. at one public sector department (9%), responses regarding the presence of a protocol varied across participants. participants were asked for copies of their abr and/or assr assessment protocol, if available. the protocols reviewed appeared to be mainly procedural with limited direct reference to current evidence-based practice or comprehensive reference lists. discussion top ↑ overall, there appeared to be a wide variety of equipment available to both the private and public sector departments included in this study. however, this equipment was not always adequate in terms of meeting the audiological needs of all paediatric patients. public sector departments were more limited than private sector departments in terms of access to certain types of equipment and experienced particular challenges regarding the timely repair of equipment by hospital management. the lack of functioning, well-maintained audiological equipment may affect a clinician’s ability to undertake appropriate evidence-based audiological practices. the varied responses of some public sector participants regarding the availability of equipment suggest a lack of awareness of resources available. this may be due to high staff turn-over and lack of carry-over, including information regarding availability of equipment. this lack of awareness of available resources results in the underutilisation of equipment as well as delivering services that may not be appropriate or meet a child’s audiological needs.of particular concern is the limited availability of high-frequency probe tone tympanometry. the importance of using an appropriate immittance probe tone to accurately determine the middle-ear status of a child cannot be underestimated. recommended practice stipulates the use of a 1000-hz rather than a 226-hz probe tone for immittance assessment of infants less than 6 months corrected age (baldwin et al., 2008). appropriate evaluation of middle-ear status is of particular importance in south africa, where hiv and aids are major health challenges prioritised in the public health care sector (open society foundation for south africa, 2007). children with hiv or aids may have recurrent bacterial infections, neurologic disease or developmental problems (muma, lyons, borucki & pollard, 1997). due to recurrent infections, these children may require more frequent monitoring of their middle-ear status and hearing. it is therefore important to accurately undertake tympanometry measures utilising the appropriate probe tone. according to valente and valente (2009, p. 858), ‘[t]he most reliable and efficient method for assessing the performance provided by amplification is real ear measures’. despite this, the majority of participants indicated that rems are not routinely conducted to verify paediatric ha fittings. the majority of participants reported lack of equipment as the main reason. other reasons provided included malfunctioning equipment; unfamiliarity with the equipment; infrequent fittings not justifying the cost of the equipment; and rems being too time consuming or unreliable. in addition, it was reported that rems were only completed if the child was making insufficient progress, or if they were older than 6 years. some participants also reported that they rely on other measures such as aided testing, parental report and checklists. this feedback is disconcerting as objective verification ensures that target gain, compression ratio and threshold as well as output levels are met, resulting in optimal ha fitting (beauchaine, 2001). the use of current, evidence-based practice for paediatric ha fitting is important in ensuring that secondary developmental delays associated with a delay in early intervention for children with hl are reduced. however, the current study established that departments have limited protocols for paediatric assessment and ha fitting. the lack of departmental protocols is concerning, as it makes meeting the needs of patients and families, development of services, consistent clinical practice, as well as adherence to current, evidence-based practice challenging. the approach to paediatric ha fitting is unique and differs from adult ha fitting due to various factors, such as smaller ear canals and different listening needs. as an infant’s ear canal is smaller, higher sound pressure levels (spls) will be produced in the ear canal than in an adult’s (bcep, 2008). the listening needs of a child also differ from those of an adult. for children, the goal of amplification is to promote oral speech and language development. for adults, however, acquired hl is usually post-lingual. language, cognitive and world knowledge can thus be utilised to facilitate understanding of acoustic information (stelmachowicz & hoover, 2009). for equivalent speech recognition ability, young children require greater spls than adults (stelmachowicz, hoover, lewis, kortekaas & pittman, 2000). protocols should be utilised within all areas of paediatric audiology, including abr and assr assessment and ha fitting. it is vital to ensure that protocols are as focused as possible and encompass all relevant areas to ensure that clinical practice is evidence-based. an evidence-based approach assists in putting research into clinical practice, improves patient care and promotes standardisation of care (moodie et al., 2011). conclusion top ↑ despite the fact that this study was limited to the gauteng province, which restricted the generalisability of the results, it is representative of the typical distribution of audiology departments and private practices in gauteng. the study provides specific information regarding the availability of clinical audiological equipment and protocols currently used by audiologists in gauteng. the findings from this study suggest several recommendations for paediatric audiology in south africa that would promote development of this area in this country.firstly, it is recommended that national, evidence-based guidelines or standards that include levels of service delivery and the minimum equipment required are developed for both paediatric assessment and ha fitting. in recent years, draft national guidelines have been in circulation for review and development, but these guidelines have yet to be finalised. once final guidelines have been released, departments should develop their own internal guidelines by referring to national guidelines and provide clinic-specific procedures, if appropriate. this will assist with standardisation of care and sustainability of services. in the interim, it is recommended that departments develop their own guidelines based on evidence-based practice. secondly, it is imperative that clinicians have access to well-maintained audiological equipment that is relevant for use in the paediatric population. adequate funding for the procurement and maintenance of equipment should be a priority, as without fully functioning equipment, audiologists cannot effectively meet the needs of children with hl as outlined in the hpcsa (2007) position statement on ehdi. for universal newborn hearing screening to be a viable project, it should be supported by the national department of health, with dedicated funding for human and equipment resources. given the dearth of information regarding the south african audiological clinical practice, this study provided the groundwork for future, more in-depth, research. this may include refinement and expansion of the current study in various ways that would allow for generalisation of results beyond this specific population. it may be useful to replicate the study once appropriate equipment has been procured and protocols have been implemented in order to monitor changes in clinical practice. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions l.t. (chris hani baragwanath hospital) acted as researcher and k.j. (university of the witwatersrand) as research supervisor; both contributed equally to writing the manuscript. references top ↑ baldwin, m., sutton, g., gravel, j., & low, r. (2008). tympanometry in babies under 6 months. a recommended test protocol version 2.0. newborn hearing screening programme (england). retrieved october 13, 2011, from http://hearing.screening.nhs.uk/audiologyprotocolsbeauchaine, k.l. (2001). an amplification protocol for infants. in r.c. seewald & j.s. gravel (eds.), a sound foundation through early amplification (pp. 105–112). warrenville, il: phonak hearing systems. blecher, m., & harrison, s. 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(1998). language of earlyand later-identified children with hearing loss. pediatrics, 102(5), 1161–1171. http://dx.doi.org/10.1542/peds.102.5.1161 appendix 1 top ↑ abstract introduction literature review methodology ethical considerations results and discussion conclusion acknowledgements references about the author(s) marguerite de jongh discipline of speech-language pathology and audiology, sefako makgatho health sciences university, ga-rankuwa, pretoria, south africa anna-marie wium discipline of speech-language pathology and audiology, sefako makgatho health sciences university, ga-rankuwa, pretoria, south africa wilna basson department of psychology, sefako makgatho health sciences university, ga-rankuwa, pretoria, south africa citation de jongh, m., wium, a-m., & basson, w. (2019). the piloting of a specific support programme for grade r teachers on attention deficit hyperactivity disorder: the process of development. south african journal of communication disorders, 66(1), a600. https://doi.org/10.4102/sajcd.v66i1.600 original research the piloting of a specific support programme for grade r teachers on attention deficit hyperactivity disorder: the process of development marguerite de jongh, anna-marie wium, wilna basson received: 24 may 2018; accepted: 15 jan. 2019; published: 26 mar. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: attention deficit hyperactivity disorder (adhd) is one of the most common psychiatric disorders in children and is generally identified and diagnosed during the preschool years. preschool learners with adhd are at risk of developing emergent literacy difficulties, crucial for the development of reading and writing. many teachers have insufficient training to identify and address barriers to learning, such as adhd. aim: the aim of this article was to report on the process followed in the development of a specific support programme for grade r teachers on adhd and on the piloting of the programme. method: an adapted version of the intervention research model provided the structure and phases for the development, implementation and evaluation of the support programme. current literature on adhd training programmes, adult learning principles and bronfenbrenners’ ecosystemic framework was explored to develop the programme, training material, manual and method of presentation (phase 1). workshops were presented to 65 grade r teachers working in an urban and semi-rural context (phase 2). participants were made aware of the symptoms of adhd, and early identification and management of specific barriers to learning, such as adhd, in order to reduce the risk of educational complications. participants provided feedback (phase 3) on the training, training material and manner of presentation following the workshops. results: the results obtained in phases 1 and 2 of the adapted intervention research model included the compilation of the information presented in the workshops and the training manual, as well as the instructional phase and piloting of the programme. the results obtained for phase 3 include a summary of the feedback provided by the grade r teachers on how they experienced the training. participants’ feedback confirmed that the programme was valued and that their training expectations were met. conclusion: the intervention research model provided a valuable structure for the development and piloting of a specific support programme. this study can be replicated, and may pave the way for future support programmes for teachers. capacity building of teachers is of the utmost importance in raising education standards in south africa. keywords: attention deficit hyperactivity disorder; adhd; emergent literacy; grade r teachers; support programme; intervention research model; bronfenbrenner. introduction attention deficit hyperactivity disorder (adhd) is defined by the american psychiatric association (apa) in the fifth edition of diagnostic and statistical manual of mental disorders (dsm-5) as: ‘a persistent pattern of inattention and/or hyperactivity [which] interferes with development, has symptoms presenting in two or more settings (e.g. at home, school, or work), and negatively impacts directly on social, academic or occupational functioning’ (apa, 2013). according to amod, vorster and lazarus (2013), these patterns of inattention and/or hyperactivity consequently impact on an individual’s well-being. this disorder is one of the most common psychiatric disorders in children, with symptoms being recognised mainly during the preschool years (suvarna & kamath, 2009). preschool children with adhd are at risk of developing emergent literacy problems (sims & lonigan, 2013; walcott, scheemaker & bielski, 2010), which can result in academic under-achievement (sims & lonigan, 2013; wessels, 2011). attention deficit hyperactivity disorder should therefore be managed early in the preschool years in order to support these learners to attain future academic success. the effective management of adhd is imperative in the preschool years as it affects the development of emergent literacy, specifically phonological awareness, which is a prerequisite for the development of reading and writing (wessels, 2011). many preschool teachers have insufficient training to identify and address barriers to learning (wium, 2010). disorders such as adhd may be a challenge to many teachers, and they often do not recognise the link that exists between adhd and emergent literacy problems (sims & lonigan, 2013; spangler & slate, 2012). therefore, a specific support programme was developed and piloted for grade r teachers to recognise the signs and symptoms of adhd and to manage the associated emergent literacy problems. this article consequently aims to contribute to the field of programme development as it describes the process of how this particular programme was developed. literature review skills shortages and gaps in the knowledge of adhd (lawrence, 2012; lopes, 2009; perold, louw, & kleynhans, 2010) and associated co-morbidities (amod et al., 2013; murray, 2009) among foundation phase teachers may compromise the effective educational management of adhd (lawrence, 2012; perold et al., 2010). internationally, researchers such as procaccini (2013) and spangler and slate (2012) have identified the need for training protocols to improve teachers’ knowledge on the management of adhd. south african inclusive education policies, such as the white paper 6 on special needs (department of education [doe], 2001) and the revised national curriculum statement (rncs) grades r-9 (doe, 2001), require that a diverse population of learners be accommodated in the classroom context. teachers are therefore expected to meet the needs of all learners in this environment (perold et al., 2010). in line with national policies, all learners should be able to learn and therefore be supported and provided with suitable resources to obtain academic success (mahlo, 2011; wium & louw, 2015). primary schools in south africa are phasing in the grade r (reception year) as part of the foundation phase. considering that the majority of grade r teachers were trained when tertiary training was still racially and ethnically divided, the training may have been inadequate, the necessary qualifications never obtained and additional training not presented (wium & louw, 2013). thus, grade r teachers may not be well prepared for the present-day demands in the south african educational domain (wium & louw, 2011). therefore, teaching grade r learners who experience barriers to learning (wium & louw, 2013), such as adhd and concomitant emergent literacy difficulties – which mostly become noticeable in the preschool or reception year (wessels, 2011) – may be challenging for grade r teachers, especially if they have no background in managing such challenges. the doe recognised a need for training to amend previous inequities, which include retraining and supporting teachers as indicated by the minister of basic education as far back as 2011 (gumede, 2017). support for teachers will minimise the gaps in teachers’ knowledge as improved knowledge affects the management of learners with barriers to learning and consequently learner performance (wium & louw, 2013). subsequently, the doe and the department of basic education implemented national education policies such as, among others, the white paper 6 in 2001, the new national curriculum statement (ncs) and the rncs in 2001, as well as the curriculum assessment policy statements (caps) in 2010. these were employed to assist teachers in addressing barriers to learning. however, many teachers, especially those in previously disadvantaged areas, find it difficult to implement these policies because they may not be equipped to do so (wium & louw, 2015). the retraining of teachers and teacher support is therefore fundamental to the successful implementation of these policy documents (wium & louw, 2015). recent policy changes aim to bring about change from supporting the child with barriers, to learning to support the teacher (wium & louw, 2013). research conducted by sims and lonigan (2013), as well as by spangler and slate (2012), emphasises the fact that training programmes need to address gaps in teachers’ overall knowledge of adhd and emergent literacy, including awareness, skills, motivation, values, accountability and attitudes (wium, 2010). the training of teachers will consequently affect learners, helping them to succeed both socially and academically (murray, 2009; perold et al., 2010; procaccini, 2013). internationally, training programmes with a focus solely on adhd have been conducted by researchers such as jones and chronis-tuscano (2008), syed and hussein (2010) and procaccini (2013). although previous studies in the south african context described teachers’ knowledge of adhd (perold et al., 2010), none reported on teachers’ ability to identify and manage barriers to learning, such as adhd and co-morbid conditions. two local programmes aimed at foundation phase teachers only addressed either adhd (wessels, 2011) or emergent literacy (wium, 2010). several local researchers pointed out that quality support programmes and guidelines should be developed for teachers in the south african context (amod et al., 2013; olivier, anthonissen & southwood, 2010; perold et al., 2010; wium, 2010), as there is a paucity of research on the development of support programmes for preschool teachers in the identification and management of adhd and co-morbid conditions such as emergent literacy. findings by girolametto, weitzman, lefebvre and greenberg (2007), as well as lessing and de wit (2008), indicate that teachers in the local context do not adequately assist learners when co-morbidities of adhd arise. a need was identified for the development of a support programme for grade r teachers in the identification and management of learners with barriers to learning, including adhd, to prevent delays in the acquisition of pre-literacy skills. the main aim of the article is to share with the readers how a proposed support programme for grade r teachers to facilitate knowledge on adhd was developed and how it was perceived. this article specifically reports on the process followed to develop such a support programme for grade r teachers, as well as to report on the piloting of the training. the programme consisted of workshops and a corresponding training manual. the feedback provided by the participants on the training material and manner of presentation following the workshops (phase 3) is briefly presented as the scope of the article is mainly on the development process. a detailed discussion on the feedback provided by the participants and the analysis will be outlined and presented in a follow-up article. this article therefore mainly focuses on phase 1 of the process (table 1), consisting of the development process; design; development of the training content and manual; manner of presentation; and the piloting of the programme (phase 2) as presented in the methodology. table 1: research process: phases of the research. methodology programme development process (phase 1) the structure for the research, including the design, implementation and piloting of the support programme, was provided by the various phases described by the intervention research model. in 1994, thomas and rothman included six phases in their intervention research model. these are the problem analysis and project planning, information gathering and synthesis, design, early development and pilot testing, evaluation and advanced development, and dissemination of information (de vos, delport, fouché & strydom, 2011). the phases of this model were adapted and consequently renamed for the purposes of this research and provided the structure for the study. a summary of the structure for the research is presented in table 1. theoretical framework for the training: ecosystemic model the support programme was based on bronfenbrenner’s (1979, 2005) ecosystemic model and was developed by a speech-language therapist, with a special interest and experience in adhd, in collaboration with a psychologist, focusing on different role players in the ecosystemic framework. according to the bio-ecological model, speech-language therapists and psychologists form part of the exosystem, which also includes district facilitators, remedial and learning support teachers, and therapists and educational psychologists, among others (mahlo, 2011). these role players, including speech-language therapists, collaborate with teachers and implement teacher support programmes. they also assist teachers with the assessment and management of learners with barriers to learning (mahlo, 2011), as their role in the educational context includes programme design and prevention (wium & louw, 2013). bronfenbrenner (2005) states that children, in this case learners, should be viewed holistically within different social contexts. these contexts highlight the role of mutually dependent relationships between individuals and the systems that they are exposed to, as well as the structures in the environment that shape the development of a human being (mahlo, 2011). learners therefore do not exist in isolation, but are part of different systems. these systems should effectively work together to the advantage of all learners in schools, including those who experience barriers to learning. this study placed emphasis on the relationship between grade r teachers and learners with barriers to learning and how grade r teachers could support learners with behavioural difficulties and co-morbid conditions within an inclusive environment (denis, 2012; lewthwaite, 2011). in addition, the interdependency between adhd and associated educational problems within a broader social ecological model was also highlighted (lopes, 2009). the training stressed the relationship and responsibilities of different role players within the educational context. these role players in the educational management of adhd include teachers, parents and peers, school governing bodies, the department of basic education, school districts and so on. these role players are considered representatives of bronfenbrenner’s (1979, 2005) ‘meso-’ and ‘exosystems’ working together in implementing policies and ensuring that all learners with adhd receive adequate support (lewthwaite, 2011). process of content development a literature review (including a google scholar search between 2008 and 2015) that focused on previous training programmes for teachers (both internationally and in the south african context) on adhd and the consequent development of early literacy, as well as recommendations offered by these researchers in the field of adhd, provided guidelines for the development of the support programme (amod et al., 2013; jones & chronis-tuscano, 2008; perold et al., 2010; procaccini, 2013; syed & hussein, 2010; wessels, 2011; wium, 2010). these recommendations obtained from the literature search indicated that the following need to be addressed throughout the training; that is, general knowledge on adhd; the early identification of behaviour associated with adhd and the management of adhd. the basic outline of the support programme, as a result of the literature review, is presented in figure 1. this specific support programme is, however, unique as it focuses on the early identification and management of barriers to learning, including both adhd and emergent literacy, and is likely the first of its kind to be implemented for grade r teachers in the south african context. figure 1: components of the support programme on attention deficit hyperactivity disorder and emergent literacy. training content as a result of the process followed, two main themes were identified for the training, which included adhd and emergent literacy. the adhd theme included different topics such as defining adhd; the features, prevalence and aetiology; the symptoms and risk factors associated with adhd; the co-morbid conditions related to adhd; the risk factors aggravating the condition; the identification and diagnosis of adhd; and coping strategies for teachers managing adhd, as well as the multimodal treatment of adhd including pharmacological and non-pharmacological interventions. the emergent literacy topics comprised the impact of adhd on emergent literacy and reducing the risk of educational complications such as emergent literacy. an improved knowledge on the above will affect teachers’ management and support of learners with adhd and co-morbid barriers to learning. additionally, the content of the support programme is sequenced in such a way that the simple or less complicated information is presented before the more complex information, as implied in figure 1. the components such as the facilitation of general knowledge on adhd is presented first, after which the identification and management of this barrier to learning is offered. finally, the figure emphasises the interdependency between adhd and co-morbidities, which infers that the risk of further educational complications might be reduced should teachers’ knowledge on early identification and referral improve. training manual a training manual was developed as a resource guide and corresponds with the training content and the information provided in the workshops. the manual comprised the rationale for the training, newspaper clippings, case scenarios and powerpoint slides as well as material to be used in the classroom context. information on the identification and management of specific barriers to learning, including adhd and emergent literacy problems, as well as the training process and training content presented in figure 1 and table 3, was similarly included in this resource manual. a directory of services available, such as the relevant role players for the identification, diagnosis and management of adhd, was also incorporated into the manual. the manual was handed to the grade r teachers during the training. design of the training component and manner of delivery the workshops comprised training, as well as interactive components that had opportunities for further practice in the classroom context in order to support the grade r teachers. these included the initial identification and, as a result, the management of specific barriers to learning, such as adhd and emergent literacy problems. the identification of barriers to learning is recognised as one of the seven roles of educators (rossouw, 2009). consequently, the use of handouts, newspaper clippings, powerpoint slides and icebreakers; the presentation of case studies and real-life scenarios; small group discussions; group work; problem-solving activities; and roleplay, among others, were included in the training. considering that teachers are adult learners, the training was additionally designed in accordance with adult learning principles, as suggested by the adult learning theories such as andragogy, originally proposed by knowles (1975, 1984). consequently, additional theories of adult learning (such as experiential learning, self-directed learning, transformative learning as well as the principles underlying these theories), the factors that may influence adult learning, and the way all these aspects influence learning were explored and integrated to provide the underlying basis of the support provided (conlan, grabowski & smith, 2012; freire, 2004; killen, 2012; kolb & kolb, 2005; wessels, 2011). the underlying principles also recognise that adults are internally motivated and that their self-concept changes from being dependent learners to being self-directed learners. furthermore, as adult learners accumulate experience, these experiences become resources for obtaining added knowledge, which can then be incorporated and applied to work-related tasks and problem-solving (knowles, 1984). additionally, these principles also suggest that training is most effective when groups are smaller; training is applied for shorter periods and, where possible, is preventative in nature. recommendations provided by researchers such as wium (2010) and wessels (2011) also suggest that training should be interactive and collaborative, that the needs of the teachers should be addressed and that the support and knowledge of the teachers should be integrated and transferred into the school context. the stated theories, principles and recommendations provided guidelines for the development of and the manner in which the workshops were delivered. the training was therefore designed around and based on various adult learning theories and in accordance with the adult learning principles, and not ‘the way … [they] … were [initially] taught’ (zoller & harrison, 2007, p. 1). as a result, the training was interactive and the grade r teachers were dynamic participants and in control of their own learning (killen, 2012; wessels, 2011). these principles, as integrated into the teaching and learning strategies, are reflected in table 2. the learning strategies included hands-on tasks performed by the grade r teachers, such as completing checklists related to simulated cases. an outline of the support programme, the sub-aims, specific outcomes, assessment criteria and activities, including the teaching and learning strategies, as well as the different topics offered, is presented in table 2. additionally, table 2 provides a summary of the workshop content and procedures presented to the teachers to facilitate their understanding of adhd and emergent literacy. an improved understanding of adhd will support the grade r teachers’ identification of adhd as they utilise identification procedures such as rating scales and checklists in the classroom context. in addition, the accurate identification of adhd will enable the grade r teachers to manage the disorder fittingly. the management may include parental discussions and referrals to relevant allied health and medical professionals for further investigation of grade r learners’ behaviour and attention. the outline of the programme, the different sessions and the themes and topics presented is shown in table 3. table 3 aligns with the information presented in table 2 as well as with the information provided in the training manual. after the development of the programme content and the manual, the programme was piloted (phase 2), as shown in table 1. piloting of the programme (phase 2) the programme was presented as two workshops to 65 grade r teachers. these teachers represented 57 schools in a specific district of tshwane. two groups of participants were identified; that is, one group with grade r teachers from urban schools and another group with grade r teachers from a semi-rural context. two district facilitators, representing the department of basic education from the specific district, also attended the training and assisted in the facilitation of the training. the training consisted of two half-day workshops for the urban school participants and one full-day workshop for the participants from a semi-rural context. the outline of the programme and topics presented are indicated in tables 2 and 3, as discussed in the section ‘design of the training component’. the aim of the training was to make participants aware of the symptoms of adhd and the importance of early identification and management of specific barriers to learning such as adhd in order to reduce the risk of educational complications. following the implementation of the training (phase 2), the participants provided feedback on the training (phase 3), as shown in table 1. table 2: outline of the support programme: aims, outcomes, assessment criteria, activities, teaching and learning strategies, and assessment strategies. table 3: outline of the sessions, themes and topics of the workshop. participants’ feedback (phase 3) qualitative data were obtained from questionnaires and two focus group discussions. these provided information on how the participants perceived the training and the content that was provided, the training material and the manner of presentation following the workshops. participants had to complete the open-ended questions as presented in the last section of the post-training questionnaire. two focus group discussions were held, one for the urban and one for the semi-rural context. the responses to the open-ended questions and information obtained in the focus group discussions were grouped; themes were identified and then analysed. the researcher made use of inductive analysis (creswell, 2009) by organising the data into increasingly more abstract units of information in order to ascertain how the participants experienced the training. ethical considerations ethical clearance to perform the research was obtained from the sefako makgatho health sciences university research and ethics committee (mrec/m/336/2014:pg). permission was obtained from the department of basic education to conduct research in a specific district and the grade r participants provided consent to participate in the study. results and discussion the results are presented in accordance with the different phases (phases 1, 2 and 3) of the intervention research model. phases 1 and 2 the structure, development and implementation of the programme formed part of the results for phases 1 and 2. the outcomes of phases 1 and 2, consisting of the instructional design, process of development, training content, training manual, manner of delivery and implementation of the programme at the workshops, are presented as part of the methodology section and are considered the results for phase 1 (programme development) and phase 2 (programme implementation and data collection). these results for phases 1 and 2 are also presented in tables 1, 2 and 3. phase 3 the results obtained in phase 3 are related to the participants’ perceptions of the programme content and feedback on how they experienced the training. the feedback included grade r teachers’ opinions on the workshops, training material and manner of presentation, as well as suggestions on how to advance the programme for future implementation. in this article, only a summary of the open-ended feedback in the post-training questionnaire and the feedback regarding the teachers’ experiences and opinions, as obtained from two focus group discussions, are presented as results for phase 3. the qualitative feedback from the participants in the questionnaire indicated that they were grateful for and positive about the training. similar themes were identified from the focus group discussions. the two main themes included ‘value of the programme’ and ‘participants’ suggestions and recommendations’. the focus group participants likewise indicated that they were appreciative of and were more confident in identifying and managing adhd after the training. they also stated that the training was both beneficial and effective, delivered results efficiently and generally met their expectations. the feedback included comments such as: ‘it was fantastic … [it] held my attention … the presentation was fun so i felt i could participate … i wasn’t bored at all [because] you used a lot of … examples.’ (female, grade r teacher, urban context) ‘you took our needs into consideration.’ (female, grade r teacher, urban context) ‘we really have those kinds of children but no idea how to deal with them … it opened up a new world.’ (female, grade r teacher, semi-rural context) these comments echoed the importance of integrating adult learning principles in the execution of such programmes. the feedback from the participants also emphasised that their awareness improved regarding the role of mutually dependent relationships between individuals and the systems that they are exposed to (bronfenbrenner, 1979, 2005). they stressed the interaction between different role players, such as parents and teachers who should be equally responsible in improving the academic outcomes of learners with adhd. comments including the following: ‘i really had a positive experience … i can contribute more … and positively … influence the parents’. (female, grade r teacher, urban context) and providing evidence in this regard: ‘… if you engage the parent, you will see the parent also giving the child support at home.’ (female, grade r teacher, semi-rural context) the participants furthermore revealed that an additional advantage of the support was that the training material; that is, manual, was valuable and should also be used in follow-up training. one of the participants stated: ‘i have something to show … and it was nice for me to make copies from the manual’. (female, grade r teacher, urban context) another participant added: ‘i can add the checklist … as part of the report’. (female, grade r teacher, urban context) they reflected that the manual could be utilised as a resource guide for teachers in the identification and management of specific barriers to learning, such as adhd. the feedback also yielded suggestions for the enhancement of knowledge concerning adhd. these included the need for additional training, not only for grade r teachers but for all foundation phase teachers and other stakeholders involved. furthermore, they requested that the department of basic education be involved in the follow-up training on adhd. topkin, roman and mwaba (2015) suggest that training should not be once-off but continuous in order for teachers to improve their knowledge by solving actual problems that arise in the classroom context. additional feedback from the participants indicated that the information conveyed about the misconceptions of adhd as well as the information on psycho-stimulant medication was particularly useful and should be included in future training. they restated the importance of an integrated approach, including the different role players in the management of adhd and emergent literacy, and the significance of this information in training. the feedback and recommendations from the participants also provided information on how to further develop the programme for future implementation, as suggested by patton in 2008. participants reiterated that interactive components such as demonstrations, role-play and problem-solving activities should be expanded in future training. the restricted amount of interactive components as perceived by the participants can be regarded as a limitation of the programme. furthermore, the fact that only teachers from one district participated in the study can also be considered a limitation as participants expressed the need for additional training. it is therefore recommended that this support programme be repeated in more districts and may need to be adjusted as contexts may differ significantly. conclusion the complex nature of adhd, the intricacies of the condition in the south african context and skills shortages, as well as the lack of training for teachers provided the rationale for this research. spaull (2013) affirmed that the support of teachers should be seen as a lifelong investment in their skills in order to assist in the development of learners who exhibit barriers to learning. the implementation of such support programmes for teachers – to build capacity and raise education standards – is of the utmost importance in the current south african context. the study stressed the usefulness of the intervention research model as a framework for the development and imple-mentation of the support programme for grade r teachers. the positive feedback obtained from the grade r participants provided evidence that the training was valued and that teachers needed such information on adhd. thus, the intervention research model was suitable for the development of support programmes and can therefore be replicated for the purpose of developing similar support programmes. it will most possibly ‘serve the needs of education and its components within a broader systemic approach’ (wium, 2010:4-3). acknowledgements the authors would like to thank the sefako makgatho health sciences university for the support and the infrastructure provided to complete the research. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contribution m.d.j. was responsible for the conceptualisation, planning, design, drafting, data collection, analysis and editing. w.b. was responsible for the conceptualisation, planning and editing, and was the supervisor of the original research. a.-m.w. was responsible for the conceptualisation, planning and editing, and was the co-supervisor of the original research. references american psychological association (apa). 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(2007). sierra training associates: we can teach the way we were taught, or we can teach the way people learn. retrieved from https://www.sierra-training.com/pdf/adultlearning.pdf abstract introduction methods results and discussion conclusions acknowledgements references about the author(s) nomfundo f. moroe department of speech-language pathology and audiology, faculty of humanities, school of human and community development, university of the witwatersrand, johannesburg, south africa citation moroe, n.f. (2020). occupational noise-induced hearing loss in the mining sector of south africa: perspectives of occupational health practitioners on how mineworkers are trained. south african journal of communication disorders, 67(2), a676. https://doi.org/10.4102/sajcd.v67i2.676 note: special collection: occupational hearing loss in africa. original research occupational noise-induced hearing loss in the mining sector of south africa: perspectives of occupational health practitioners on how mineworkers are trained nomfundo f. moroe received: 05 sept. 2019; accepted: 05 feb. 2020; published: 30 mar. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: historically, occupational health concerns associated with mining, particularly occupational noise-induced hearing loss (onihl), were ignored by the mining sector, policy-makers and academic researchers. as such, there is a dearth of literature related to onihl, especially in lowand middle-income countries such as south africa. consequently, mineworkers were not aware of the latent effects of excessive exposure to hazardous noise and the resultant hearing loss thereof. objectives: the aim of this study was to explore the perspectives of occupational health practitioners (ohps) regarding education and training of mineworkers on occupational noise-induced hearing loss (onihl) and its impact on mineworkers’ health. method: qualitative, in-depth telephonic and face-to-face interviews were conducted with 16 ohps. purposive and snowball sampling methods were utilised to recruit participants. data were analysed using inductive thematic analysis. results: three themes emerged from the data: ‘seeing is believing’, ‘not my department!’ and ‘barriers and facilitators to raising awareness’ with two subthemes: ‘blame it on the language and level of education’ and ‘compensation pay-outs’. superficially, ohps believe that mineworkers are aware of the impact of noise on health; however, the ohps are not aware on how the mineworkers are educated on onihl and its latent consequences. furthermore, language, low levels of education and literacy, as well as financial constraints, are the factors found to affect education and training of the mineworkers about the risks of onihl. conclusion: if the mining industry is committed in eliminating onihl, they should prioritise health literacy, and mines need to have an effective awareness-raising plan in place to eliminate onihl from every mine. this plan must consider diversity of workforce, including linguistic, as well as educational level diversity. keywords: awareness; education; hearing loss; mineworkers; occupational health; health literacy. introduction historically, occupational health concerns associated with mining, particularly occupational noise-induced hearing loss (onihl), were ignored by the mining sector, policy-makers and academic researchers (national institute for occupational safety and health [niosh], 1996). as such, there is a dearth of literature related to onihl, especially in lowand middle-income countries such as south africa. consequently, mineworkers were not aware of the latent effects of excessive exposure to hazardous noise and the resultant hearing loss thereof (kahan & ross,1994). a literature search into onihl in the mining sector in south africa prior to 1994 revealed only one study by hessel and sluis-cremer (1987), which was conducted on white mineworkers, with the exclusion of black workers who formed the majority of the mines’ workforce. it was only in 1994, at the apartheid-democracy twilight, that a study was conducted on black mineworkers. kahan and ross (1994) explored knowledge and attitudes of black mineworkers regarding onihl and the use of hearing protection devices (hpds). findings in this study revealed that firstly, mineworkers were not aware that noise was a health hazard. secondly, their knowledge was based on personal experiences and observations, rather than on formal educational input. thirdly, mineworkers were self-motivated to protect themselves from acquiring a hearing loss and to learn more about the effects of noise. lastly, mineworkers complained about discomfort, feelings of insecurity because of inadequate communication and inability to hear when using hpds. findings of this study are consistent with simon’s (1960) assertions that black workers were not given instructions on occupational health and safety issues as they were seen as incapable to learn. two decades later, in 2015, ntlhakana, kanji, and khoza-shangase explored the use of hpds amongst mineworkers. similar to kahan and ross (1994), findings revealed that mineworkers still complain about comfort, design and difficulties with work-related communication because of hpds. contrary to kahan and ross (1994), participants in this study were reportedly knowledgeable about noise exposure levels, onihl and appropriate use of hpds. in the same year (2015), edwards, milanzi, khoza, letsoalo and zungu conducted a descriptive survey to evaluate onihl awareness training programmes in six mines in south africa. their findings suggested that, firstly, there is a lack of prioritisation of commitment to awareness training by management. secondly, a large majority of mines lacked a solid and consolidated theoretical basis for their awareness training programmes. lastly, there were challenges with the language used during awareness training. in 2018, moroe and khoza-shangase (2018) conducted a study on the management of onihl in the mining sector. findings revealed awareness training of mineworkers as one of the successes realised by the mining sector. additionally, implementation of the revised 2014 mine health and safety council milestones on the elimination of onihl in the mining sector facilitated a change in the culture of the organisation as the mining industry increased focus on awareness training and education on onihl and its effects. currently, efforts on raising awareness of onihl may be overshadowed by the increased burden of disease, particularly human immunodeficiency virus (hiv) and acquired immune deficiency syndrome (aids) and tuberculosis (tb), which are the most prevalent diseases in the south african mining industry (stuckler, basu, mckee, & lurie, 2011; stuckler, steele, lurie, & basu, 2013). relying on anecdotal evidence and findings presented by edwards et al. (2015), it appears that mineworkers are not well informed about the effects of onihl. moreover, the mining industry’s efforts in targeting education of mineworkers do not seem to be successful yet. therefore, there is a need to conduct studies to establish how mineworkers are educated on onihl and its consequences. this study, therefore, sought to explore the perspectives of occupational health practitioners (ohps) responsible for implementing the training programme within the south african mining industry. methods this study is nested on a phd study titled ‘occupational noise-induced hearing loss in south african mines: from policy formulation to implementation and monitoring’. this article aims to explore perspectives of ohps on awareness and training of mineworkers on onihl and its impact on their health. a qualitative design, which used a naturalistic approach in seeking to understand the phenomena in context-specific settings, without the influence of the researcher, thereby eliminating the manipulation of and allowing the phenomena of interest to unfold naturally, was employed in this study (golafshani, 2003; patton, 2005). purposive snowball sampling was utilised to recruit possible participants (valerio et al., 2016) identified from websites of companies affiliated with the south african mining industry. participants were contacted via emails and telephonically. furthermore, participants were requested to identify and request other appropriate participants, meeting the study inclusion criteria, on behalf of the researcher to participate in the study. therefore, snowball sampling, as discussed by penrod, preston, cain and starks (2003), was necessary in this study because of the challenges experienced by the researcher in identifying and recruiting participants. for inclusion in the study, participants needed to be involved in the management of onihl in the south african mining industry. they needed to have been employed for a minimum of 6 months to ensure that they were familiar with the hearing conservation programmes (hcps) implemented at the mines. ultimately, 16 participants were selected and interviewed. participants comprised six representatives from the mine health and safety council of south africa, seven audiologists, two ventilation and occupational health engineers and one occupational hygienist – all herein referred to as ohps. data were collected through in-depth face-to-face and telephonic interviews. telephonic interviews were conducted with participants who had time constraints and/or who were far from johannesburg. both telephonic and face-to-face interviews were conducted in the same manner to ensure uniformity in how data were collected. the interview structure followed the recommendations by rubin and babbie (2005), where the interviewer possesses a plan of inquiry as well as a set of questions. all the interviews were conducted in english and were audio-recorded for analysis. research questions focused on the ohps’ perspectives on awareness and training of mineworkers on onihl and its effects. reflexivity and bracketing were applied during the transcription and analysis of data as well as during the report writing process. this was carried out to guard against any bias from the researcher. after transcribing the interviews, the researcher conducted member or participant checks to ‘learn from the interviewee how well the researcher’s interpretations reflect the interviewee’s meaning’ (morrow, 2005, p. 17). inductive thematic analysis was used to code the data that allowed the themes to emerge from the data (braun & clark, 2006). data were analysed using six steps recommended by braun and clark (2006), which include familiarisation with the data, generation of initial codes, searching for themes, reviewing themes, defining themes and writing up. representative verbatim quotations were used in the write-up of the study to provide examples of the themes that emerged from the data. ethical considerations ethical clearance was obtained from the university’s human research ethics committee (medical) (protocol number: m160264). results and discussion the following three themes emerged from the data, which are discussed in the subsequent sections: ‘seeing is believing’, ‘not my department!’, and ‘barriers and facilitators to raising awareness’ with two subthemes: ‘blame it on the language and level of education’ and ‘compensation pay-outs’. theme 1: seeing is believing participants were asked to share their perspectives on whether mineworkers are aware of the impact of onihl and its latent consequences on their hearing. the majority indicated that the workers are superficially aware of the impact of noise. participant 11 felt that, although the miners are aware of the impact, they only fully appreciate the impact when they develop a hearing loss: ‘i think so. yes. but i don’t think the fact that it is permanent (hearing loss), cannot be cured. i don’t think that people realize that. i think at the back of their minds they think when they go away from the mines, back home, their hearing will get better again. i think they have this perception that while i’m in the noise, it’s damaged but once i go home and i’m not working in the mines anymore my hearing will improve.’ (p11, female, no date) participant 1 believes that as hearing is insidious and is an abstract concept to grasp, some workers do not actually understand the implications of acquiring a hearing loss: ‘but i think what we need to remember is that the ear is a very abstract thing for them (workers). when we tell people there is a hole in your eardrum, it’s like what are you talking about! they don’t see it. that’s the problem. our workers are people who want to see something. you know, when i break my arm and the bone is sticking out, i can see it you know. so next time, i’m gonna [going to] (sic) be careful doing that job because my colleague was injured and i saw the blood. i think hearing loss, because it is an invisible thing to them, i think it is a difficult thing to comprehend….’ (p1, female, no date) from the results presented above, ohps believe that mineworkers have limited and superficial knowledge regarding noise exposure and its effects on them. the perception is that mineworkers do not fully grasp that onihl is irreversible. according to kurmis and apps (2007), workers may not be aware of the harmful nature of excessive noise exposure because of its latency and painless nature. mostaghaci et al. (2013) and tye-murray (2009) argue that onihl is irreversible and permanent and that once acquired, there are no guaranteed benefits from rehabilitation. therefore, it is important that workers are made aware of this lasting negative impact of hearing loss on their quality of life. as shown in this study, although workers may be informed about onihl, it was observed that the medical information presented at the time of diagnosis could be misunderstood or easily forgotten (kessels, 2003; reese & hnath-chisolm, 2005), which may be the case with the mineworkers. written or spoken information presented at induction is essential; however, it may not be sufficient to empower mineworkers in such a way that they actively practice good occupational health. the fact that hearing loss is an abstract concept calls for reinforcing of health literacy in the mining sector. health literacy is ‘the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions’ (national academies of sciences and medicine, 2016). education and motivation are a priority in minimising hearing loss in the mines as they create opportunities for both management and employees to discuss and agree on commitments, communication lines and cooperation (byrne, 2005). training serves to explain various and pertinent topics, such as the effects of noise on hearing and the purpose and value of wearing hpds. during training, advantages and disadvantages of the hearing protectors being offered could be discussed in detail, with an opportunity for highlighting miners’ and operators’ responsibilities in maintaining noise controls (byrne, 2005). if individuals understand the reasons and the benefits of an hcp, they are more likely to participate, especially if training addresses the specific needs of individuals exposed to excessive noise. furthermore, training may be more effective when conducted continually and around the annual hearing tests and in small groups (byrne, 2005). there is, therefore, a need to aggressively promote education within the mining sector in order to combat onihl. theme 2: not my department! participants were asked to elaborate on how workers are educated on the impact of onihl on their hearing. responses highlighted that participants are not knowledgeable on how workers are trained. it should be noted that these participants are ohps and they should either be involved in the education or be informed on whose role it is to inform workers regarding the effects of onihl: ‘i don’t know how it’s done. it’s in the law that the worker must be trained, how to clean and use his protection but it’s also done at the safety department. also nothing to do with the medical department (sic). so it’s definitely in the law but i don’t know which programmes or how many hours or you know, exactly how it’s done.’ (p11, female, no date) participant 7 stated the following: ‘i don’t know. i’m not 100% sure. i’m sure that they get information on that. for example, at xxx mine there was a big… like a waiting area. and there is a tv that shows all these videos and information. i know there, they have something. but i’m not 100% sure.’ (p7, female, no date) participant 1 admitted the following: ‘to be honest, we haven’t done a campaign solely on noise and i think this year, depending on funding we will look into such a campaign.’ (p1, female, no date) it is of concern that ohps are not informed regarding mineworkers’ education and training on onihl; however, they claim that mineworkers are aware of the effects of noise on their health. byrne (2005) asserts that before implementing hcps, mines should address administrative issues, where company regulations as well as individuals’ responsibilities and roles are identified and enforced. from the responses above, it is not clear that ohps are not clear about who is responsible for educating mineworkers on onihl. in south africa, evidence indicates that there are a few audiologists employed in the mining sector as mines prefer services of audiometrists who are considered more cost-effective (moroe & khoza-shangase, 2018). edwards et al. (2015) commented that mines have a lack of qualified professionals who possess knowledge and skills on how to teach adults to achieve health promotion and behavioural change. therefore, these findings highlight the important role of audiologists in actively participating in educating and training mineworkers regarding the impact of onihl on their health. in the united states, audiologists may firstly provide programmes tailored to the needs of the audience such as hcp team members, employee work groups, supervisors and upper management. secondly, they may develop or recommend appropriate educational materials. thirdly, they may instruct in-house staff in effective methods of motivating and educating workers. fourthly, audiologists contribute to management education by preparing articles for publication or speaking before trade and management groups. lastly, they maintain up-to-date knowledge of pertinent local, state and federal regulations in order to provide management with accurate information concerning these matters (american speech-language-hearing association, 2004). hence, there is a need in the south african mining industry for audiologists to play an active role in providing direction on the material and strategies in teaching mineworkers and management on onihl and its effects on individuals exposed to excessive noise. theme 3: barriers and facilitators to raising awareness two subthemes were identified regarding the theme: ‘barriers and facilitators to raising awareness’. the first subtheme (‘blame it on the language and level of education’) was on the part of ohps, whilst the second subtheme (‘compensation pay-outs’) was in relation to mineworkers. these barriers were also cited as facilitators, in that, if they are overcome, they can enable a conducive environment and positively contribute towards promoting awareness and education amongst mineworkers. subtheme 3.1: blame it on the language and level of education participants were asked to share possible barriers to teaching mineworkers about onihl and its effects. language and levels of education were highlighted as the biggest barriers. participant 8 admitted that language differences contribute to the difficulty in teaching: ‘obviously, i know that i’m lacking in my communication with my patients. i always feel that it is important to have good communication with all my patients that i see. most of them can’t even speak english or afrikaans. so that is a struggle for me. i really try my best.’ (p8, female, no date) participant 5 shared a similar experience: ‘they do understand the basics because they have been getting screened for a very long time. but getting to the details… that is a struggle for me because i’m not able to communicate with them in a language that they understand.’ (p5, female, no date) participant 14 mentioned the levels of education as barrier as well: ‘it’s difficult; you know your skills levels, your education levels generally in the mining industry is not that high for your average worker. most of them do not have proper education and you know, so i think it’s a very difficult thing.’ (p14, female, no date) nelson mandela, the late former president of south africa accurately captures the importance of language when engaging with people: ‘if you talk to a man in a language he understands, that goes to his head. if you talk to him in his language that goes to his heart’ (laka, 2014, n.p.). this quote rings true in this context where language seems to be a barrier in achieving the desired results in the training of workers. a study conducted by edward et al (2015) indicated that 30% of the training on onihl in the mines was conducted in english only, 30% in zulu and english and the remaining 40% in the employee’s language of choice. this is not an ideal situation if one considers the racial and linguistic profile of mineworkers in south african mines, which mainly comprised of black african language speakers. moreover, south africa is a multilingual country with 12 official languages. using english as a chosen mode of communication still excludes workers who may not be proficient in the english or zulu languages. the 2011 census indicated that isizulu is the most spoken language with english ranking at number four (south african statistics, 2016). this raises a challenge in the training of workers on the dangers of noise. furthermore, as africa is a developing continent and south africa, because of its infrastructure, continues to be viewed as the richest developing country in africa, this has led to people from neighbouring countries migrating to south africa to seek better job opportunities in the mining industry (van averbeke, 2003). this has resulted in a culturally and linguistically rich and diverse environment. occupational health practitioners, therefore, need to take language and culture into account when planning worker-training initiatives within the mining sector. in addition to the language barrier, challenges with literacy levels of mineworkers were also reported as a barrier in this study. the report of literacy levels being a barrier is contradictory to the report that literacy levels have improved amongst mineworkers in the past few years, especially with the advent of millennials in the mining sector (smit & mji, 2012). edwards et al. (2015) indicated that the content of training materials used to train workers was the same as that used for managers and other levels of workers. these findings shed light on some of the reasons that mineworkers are reported to have superficial knowledge on onihl and its impact. therefore, to overcome the literacy and language barriers, information should be matched to the worker’s levels of understanding by utilising a range of modalities such as verbal, visual and printed material to enhance learning and improve awareness whilst observing literacy, cultural and linguistic relevance. in this way, even complex concepts could be understood if appropriate communication skills are applied (zuhlke & engel, 2013). it is known that physicians’ explanations and the level of patients’ understanding significantly affect treatment adherence, treatment outcome and patients’ satisfaction (clayton, 2010). the same argument applies to ohps. if trainers explain concepts at the level of mineworker’s understanding, workers could have deeper knowledge and understanding of the consequences of excessive exposure to noise at the workplace, and they are more likely to adopt and practice preventive change in behaviour at the workplace. subtheme 3.2: compensation pay-outs participants were asked why mineworkers still present with a high incidence of onihl if they are aware of onihl and its effects. responses indicated that socioeconomic factors may be at play: ‘i definitely think that compensation plays a very big role. i definitely think that it plays a very big role because unfortunately we see a lot of people who pretend to have a hearing loss because they want compensation. it is something that in a very sad way motivates them not to look after their ears because they think they gonna (sic) get money.’ (p7) participant 6 confirmed financial gain as a major contributor: ‘…you know because there are production bonuses in the industry. sometimes people feel… people then sacrifice health and safety because they are chasing production bonuses.’ (p6) participant 2 also shared her concern about the observed practice: ‘…[w]hen we intervene, then the exposed individual says ‘i can hear’ because there are incentives for high production and you know so and so is strong. that same individual will go back to drilling because he knows that his team depends on him. so there are those dynamics.’ (p2) participant 2 further elaborated: ‘so then the discussion shifted to should there not be indicators of health and safety that are included in the bonus. so… you know, sort of be remunerated or rewarded for high production but also at the same time keeping or maintaining health and safety.’ (p2) workers may be aware of onihl and its effects; nevertheless, socioeconomic difficulties may play a role in health practices of mineworkers. south africa as a whole is faced with high levels of unemployment, high burden of disease as well as increased cost of living. historically, mineworkers were unskilled and uneducated and were refused skill training to improve their skills and salaries (kane-berman, 2017). the potential of a financial incentive for compensation for loss of hearing is understandably a possible way of addressing their financial needs and therefore not taking heed of any training that they may have received or knowledge of the consequences that a mineworker may have regarding excessive exposure to hazardous noise levels. although current findings are based on ohps’ speculations, they, nevertheless, highlight the plight faced by workers in meeting their financial obligations. it is of concern that some miners may resort to exposing themselves to excessive noise for financial gains. however, it is also positive that the mining industry is aware of this predicament; hence, the attempt is to balance high production with maintaining health and safety as alluded to by participant 2. conclusions one of the most important components of an effective hcp is the education and motivation of workers and management (american speech-language-hearing association, 2004). success of programmes relies on the involvement of all stakeholders to ensure that objectives and outcomes are identified and achievable (leonard, 2010). additionally, stakeholders are likely to support initiatives if they are involved in the decision-making process (consultative forum on mining and the environment, 2002), as without their support, initiatives may be ignored, criticised, resisted or even sabotaged (us department of health and human services, 2011). mineworkers are primary stakeholders in the management of onihl, and if the mining industry is committed to eliminating onihl, they should involve mineworkers in decision-making processes to ensure active participation, empowerment and support for the programme. furthermore, audiologists also need to take an active role in educating and training mineworkers and other professionals on the impact of excessive noise at the workplace. current findings are important as they raise issues that audiologists must take into consideration for their role in hcps as far as awareness training is concerned. however, these findings should be interpreted with careful consideration of the identified limitations of the methodology. the study is based on the perspectives of ohps; 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(2003). an overview of south africa’s primary industrial mineral imports and exports, 2003. r42/2003. pretoria, south africa: mineralia centre, department of minerals and energy. retrieved from http://www.dmr.gov.za/linkclick.aspx?fileticket=rmbizxshvjw%3d&portalid=0 zuhlke, l.j., & engel, m.e. (2013). the importance of awareness and education in prevention and control of rhd. global heart, 8(3), 235–239. https://doi.org/10.1016/j.gheart.2013.08.009 abstract introduction method results discussion conclusions and recommendations acknowledgements references about the author(s) firdaus dawood discipline of audiology, university of kwazulu-natal, durban, south africa nasim b. khan discipline of audiology, university of kwazulu-natal, durban, south africa vedika bagwandin discipline of audiology, university of kwazulu-natal, durban, south africa citation dawood, f., khan, n.b., & bagwandin, v. (2019). management of adult patients with tinnitus: preparedness, perspectives and practices of audiologists. south african journal of communication disorders, 66(1), a621. https://doi.org/10.4102/sajcd.v66i1.621 original research management of adult patients with tinnitus: preparedness, perspectives and practices of audiologists firdaus dawood, nasim b. khan, vedika bagwandin received: 18 nov. 2018; accepted: 11 aug. 2019; published: 19 nov. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: audiologists, globally, are generally challenged when assessing and creating intervention plans to help patients suffering from tinnitus. tinnitus is very common among individuals and may significantly affect one’s quality of life, especially if not addressed by health care professionals. in south africa, there seems to be limited published studies regarding the current practices of tinnitus management by audiologists. this is mainly because of limited training and a lack of guidelines and strategies for the management of tinnitus. in particular, some participants reported being unfamiliar on how to approach the identification of tinnitus and difficulty is also encountered when counselling tinnitus patients. aim: the aim of this study was to describe the preparedness, perspectives and practices of audiologists who manage adult patients with tinnitus. method: two hundred and forty-three registered health professions council of south africa (hpcsa) participants were involved in the study by responding to an electronic questionnaire survey. data were collected online from survey monkey and were exported to statistical packages for the social sciences (spss) (version 23) for statistical analysis. data were analysed using descriptive and inferential statistics. closed-ended questions were analysed within a quantitative framework and thematic analysis for open-ended questions that were descriptively quantified. results: the results of the study are presented according to the objectives. approximately 44% of participants (44.3%) disagreed that the undergraduate university training had sufficiently prepared them to manage adult patients with tinnitus. very few (12.3%) had the opportunity to attend specialist training on how to assess patients with tinnitus. similarly, only 11.6% received any specialist training with regard to tinnitus intervention. with regard to its overall management, 49.4% felt adequately informed in the assessment of patients with tinnitus, while a further 39.2% rated their experience as being limited with regard to tinnitus intervention. there is no statistical significance relationship between participants’ years of experience and tinnitus intervention (p = 0.075). most participants did not follow any standard guidelines for its management. some participants (26.8%) reported that further education and training are required in the overall management of patients with tinnitus, while a further 17.7% required training in all areas of tinnitus. conclusion: the feedback relating to the study suggests that overall management of tinnitus seems to be a challenge among south african audiologists, irrespective of their years of experience. audiologists in the study perceived that tinnitus services are limited mainly because of a lack of or limited knowledge, training and guidelines, these being affected by contextual restraints. keywords: audiologists; speech therapist and audiologists; sta’s; tinnitus; intervention; management. introduction tinnitus is commonly understood as the sensation or perception of sound that a person experiences mainly in the absence of external auditory stimuli (langguth, kreuzer, kleinjung, & de ridder, 2013). there are reports of underlying clinical causes associated with tinnitus that include middle ear and cardiovascular diseases, nasal allergies, autoimmunity, diabetes, degenerative neural disorders and socio-demographic and environmental factors (heller, 2003; hoffman & reed, 2004; sindhusake et al., 2003; vernon & meikle, 1998 all as cited in manche, madhavi, meganadh, & jyothy, 2016). the aetiology of tinnitus is not yet known or fully understood, and can arise from pathological changes within the auditory system (langguth et al., 2013), its pathophysiology being considered a controversial area in the field of medical science (swain, nayak, ravan, & sahu, 2016). there are variations in the prevalence of tinnitus among epidemiological studies globally (henry & wilson, 2001). approximately 10% – 15% of adults experience tinnitus, of whom approximately 20% require clinical intervention (davis & refaie, 2000; hoffman & reed, 2004; jastreboff & hazell, 2004 all as cited in henry, zaugg, myers, & schechter, 2008). there is a strong association between hearing loss and tinnitus, which has resulted in many audiological associations and regulatory bodies noting tinnitus as a significant component of audiological practice (moller, langguth, de ridder, & kleinjung, 2011). approximately 20% of individuals experience tinnitus to the extent that their quality of life, well-being and productivity are diminished (jastreboff & hazell, 2004; sullivan et al., 1988). numerous studies have reported on the adverse effects of tinnitus, which include insomnia, depression, impaired concentration and impaired quality of life (moroe & khoza-shangase, 2014; sourgen & ross, 1998). audiologists providing tinnitus services should, therefore, have knowledge on the extent to which patients are affected by tinnitus (bagwandin & joseph, 2017), highlighting the need for the overall management of tinnitus as patients require interventions to address this condition. audiologists are considered an essential part of the team to assist patients with tinnitus because of their extensive professional training and experiences (henry, schechter et al., 2005). audiologists are trained regarding auditory disorders and functioning, acoustics and psychoacoustics, which are important for the overall management of tinnitus. however, there are variations in the audiology training programmes that are intended to prepare them for this role (henry, schechter et al., 2005). an audiological evaluation of tinnitus is essential, and includes facilitating the following measures: an otoscopic examination, tympanometry, pure tone threshold evaluation including high frequencies and interoctaves and speech tests (henry, schechter et al., 2005; tunkel et al., 2014). a detailed case history is the key to measuring the disability or handicap that is associated with tinnitus (sweetow et al., 2000). after an audiologic assessment, the basic evaluation of tinnitus should include but not be limited to the following measures: a comprehensive case history, psychoacoustic testing that includes most comfortable levels, loudness discomfort levels, tinnitus pitch matching with octave confusion, loudness matching minimum masking levels and residual inhibition as well as the use of subjective questionnaires (sweetow et al., 2000). the type of management implemented for tinnitus patients is determined by the experience of clinicians (hall, szczepek, kennedy, & haider, 2015). emphasis is placed on the audiologists’ familiarity with hearing aids and their ability to reduce the effects of tinnitus by using auditory stimulation (sheldrake & jastreboff, 2004, as cited in henry & zaugg et al., 2005). furthermore, audiologists have counselling skills that are necessary to manage patients’ symptoms, facilitate a better understanding of their condition and help patients achieve a form of acceptance to cope (hall & ruth, 1999). the belief and attitude of patients towards tinnitus may play a significant role in their rehabilitation process (erlandsson et al., 1992 as cited in sourgen & ross, 1998), with patients needing to be given the necessary information to live with or overcome the condition (tyler & babin, 1993 as cited in sourgen & ross, 1998). to date, there are no international standards to manage tinnitus, with research being the best avenue to ensure that better practices are available for good management (tyler, 1999). tinnitus management strategies are diverse among patients, being based on their various aetiologies and characteristics (powers & ramirez, 2014). tinnitus retraining therapy and cognitive behavioural therapy are the most documented methods of management to assist patients with tinnitus (langguth et al., 2013), and more research in this area would ensure for better practice as there is no international standard being implemented for the overall management of tinnitus. it has been reported that in the united states, for example, the practice of tinnitus management challenges health care professionals as graduate programmes differ with regard to the degree and type of training provided (henry, dennis et al., 2005). a local study highlighted the need for audiologists to be adequately trained to assist patients with tinnitus and for a more uniform approach to be in place (moroe & khoza-shangase, 2014). as a result, audiologists may not be adequately trained on how to manage it, which adds to the challenges they face in advising their patients. audiologists therefore need to be proactive by keeping updated with the latest literature in this field and attending continuous professional development workshops on tinnitus. this may help them keep informed and be open to new procedures to effectively implement suitable strategies to meet the needs of their patients. a study in south africa conducted by naidoo (2006) reported an absence of published data regarding implemented tinnitus management approaches and interventions. it was further recommended that the development of guidelines on the management of tinnitus in south africa should address the diverse practices of tinnitus management among audiologists. this may also encourage health care professionals with limited undergraduate training to practise confidently in this area (naidoo, 2006). the availability of practice guidelines will assist in reducing the variations in clinical care (tunkel et al., 2014), and will ensure that effective tinnitus services are provided, specifically in south africa, where no standards are currently in place. a study conducted in south africa revealed that limited tinnitus services were provided to adult patients because of minimal and varied training of audiologists in the area (naidoo, 2006). the main reason for audiologists not practising tinnitus management in both the public (46.15%, n = 12) and private sector (41.17%, n = 7) were because of insufficient training among health care professionals. however, the necessity for tinnitus management was recognised in the study, and the management of tinnitus was practised routinely more in the private (23.29%) than public (12.5%) sectors (naidoo, 2006). in the united kingdom, it was reported that limited time is a factor when interacting with tinnitus patients (hoare, gander, collins, smith, & hall, 2010). schechter and henry (2002) have acknowledged that because of the fast-pace nature of audiology clinics, longer time slots for tinnitus care may not be possible at all institutes; however, this may work in the private sector. another patient perspective study revealed that 21 (78%) of 27 participants reported that coping strategies were not provided to them, while nine (33%) implemented their own behavioural coping strategies (moroe & khoza-shangase, 2014). the study findings may be interpreted with caution as a smaller sample size was used with an unequal gender distribution, which limited the generalisability to the general tinnitus-suffering population (moroe & khoza-shangase, 2014). a study by rau (2004 as cited in moroe & khoza-shangase, 2014) concluded that audiologists in private practice did not feel adequately trained and were not familiar with techniques to treat tinnitus because of insufficient training in this area. in view of the complex nature of tinnitus, its assessment is a challenge as patients often receive different levels of service from audiologists, its management generally not being part of all audiological training programmes (schechter & henry, 2002). the use of questionnaires can be beneficial to determine the impact of tinnitus (meikle et al., 2012) and to develop intervention plans that are patient specific (mccombe et al., 2008). the tinnitus handicap inventory, tinnitus handicap questionnaire, tinnitus reactions questionnaire and the tinnitus questionnaire have been selected unanimously by professionals with experience in tinnitus to use when determining the severity of tinnitus in patients (hall et al., 2015). however, meikle et al. (2012) discuss the tinnitus functional index, which documents the validity of determining the impact of the severity of the tinnitus. in terms of intervention, studies have documented efficacy with the following techniques: sound, habituation, tinnitus retraining and cognitive behavioural therapy (de barros suzuki, suzuki, yonamine, onishi, & penido, 2016; hobson, chisholm, & el refaie, 2012; falkenberg & wie, 2012; andersson, 2002). audiologists may have counselling skills that are necessary to manage the symptoms, which may facilitate a better understanding of tinnitus by the patient and learn strategies to cope with tinnitus (hall & ruth, 1999). counselling by audiologists can help the patient to understand the impact of their tinnitus, while education and management options may reduce any fear or anxiety experienced by the patient and alleviate the severity of their condition (keaton, 2014). limited studies relating to tinnitus have been conducted in south africa, some of which noted the need for appropriate tinnitus services to enable patients to lead a better quality of life (moroe & khoza-shangase, 2014; naidoo, 2006, sourgen & ross, 1998). however, the measures taken by audiologists to manage patients with tinnitus remain unclear (naidoo, 2006). the limited provision of services and poor management strategies may be because of a number of reasons, the most apparent being the absence of established standards to support audiologists and inadequate training, which results in a lack of knowledge and confidence. furthermore, studies have primarily focused on the impact that tinnitus has on the daily activities in the adult population (moroe & khoza-shangase, 2014; sourgen & ross, 1998), and there seems to be a lack of literature relating to the services provided by audiologists to patients with tinnitus. method objectives the study had the following objectives: to describe audiologists’ preparedness regarding the overall management of tinnitus in adult patients to describe audiologists’ perspectives and practices relating to assessing and providing interventions for adult patients with tinnitus to obtain insight regarding the challenges and limitations hindering the overall management of adult patients with tinnitus and make recommendations for the improvement thereof. research design a non-experimental survey research design was used to obtain quantitative data from a questionnaire survey completed by speech therapists and audiologists that was completed online. in 2016, 1822 audiologists and speech therapists and audiologists were registered with the health professions council of south africa (hpcsa, 2016) were contacted to participate in the study. of these, 243 (13 %) participated in the online survey, with nine incomplete questionnaires being excluded, their details being provided in table 1. table 1: biographical details (n = 243). research procedure prior to data collection, the hpcsa was informed about the research aims and procedures, and permission to access the postal addresses of the registered audiologists was obtained. all registered professionals were invited to participate in the study through an online portal, survey monkey. participants were informed about the purpose of the study, the ethical considerations that would apply and were required to confirm their willingness to participate. audiologists registered with the hpcsa and have worked with adult patients with tinnitus were part of the inclusion criteria. the information letter, consent form and questionnaire were uploaded onto survey monkey. the devised questionnaire was based upon studies by hoare et al. (2010) and hoare, broomhead, stockdale and kennedy (2015), which was used as a guide and adapted to suit the south african context. the questionnaire was divided into four sections and consisted of 33 tick box and two open-ended questions, which took 10–15 min to complete. the sections were biographical details, preparedness to manage tinnitus, views and practices of audiologists regarding assessment and interventions, challenges experienced and recommendations. an extensive literature review was done, and the current survey devised for this study was based upon research studies by hoare et al. (2010) and (2015) and ensured it was suitable to the context of practising audiologist and/or speeach therapist and audiologist. in addition, a qualified audiologist with expertise in the area of tinnitus reviewed and validated the research tool. five participants took part in the pilot study, with minor modifications being made. the electronic medium of collating responses via survey monkey was effective and maintained confidentiality, with no software issues. data were collected online from survey monkey and exported to spss (version 23) for statistical analysis. a descriptive statistical analysis of the data was initially conducted prior to conducting inferential analysis to assess associations between any categorical variables. ethical consideration all ethical principles that govern research were maintained throughout the study. the university of kwazulu-natal’s humanities and social research ethics committee provided ethical clearance (hss/0609/016m). results the results are presented with respect to the three objectives, with the demographic details being provided in table 1. the majority of participants (n = 209, 86%) were female, with less than 5 years’ experience and were based in urban areas. approximately 85% had an undergraduate degree, with 14.8% of participants having a postgraduate degree, and worked in either a public or a private sector hospital or clinic. the majority were from gauteng and kwazulu-natal provinces, which are the two most populous provinces in the country (statistics south africa, 2011). to describe the preparedness of participants for the overall management of tinnitus in adult patients some participants disagreed (n = 103, 42%) that they were sufficiently prepared for the overall management of tinnitus (n = 104, 43%) and reported being unsure regarding the availability of courses for tinnitus management in south africa. very few had undertaken specialist training to assess (n = 29, 12.3%) and intervene (n = 27, 11.6%) with patients with tinnitus. however, despite these participants indicating perceived lack of undergraduate training, only approximately one-quarter reported the need for further education and training in the overall management of tinnitus (n=139, 26.8%), while less than nine (1.7%) felt comfortable managing these patients. this may be because of participants not practising in the area of tinnitus and, therefore, did not see the need for further education and training in tinnitus (table 2). descriptive statistics analysed frequency responses and percentage calculations obtained from the closed-ended questions for this study. table 2: further education and training of tinnitus. to describe the perspectives and practices of participants relating to the assessment and intervention of adult patients with tinnitus the results indicated that half (n = 116, 49.4%) felt adequately informed to assess tinnitus in adult patients, while 100 (42.5%) felt poorly or very poorly informed, and only 19 (8.1%) were confident in their ability. participants with less than a year of working experience indicated their knowledge of assessment was mostly adequate (n = 21), poorly informed (n = 7) and very poorly informed (n = 3) (table 3). participants with more than 10 years of working experience also indicated that they are adequately (n = 8) and poorly informed (n = 5), with some participants in this category also feeling very poorly informed (n = 2). based on the results, there was no statistically significant relationship between the two variables (p = 0.394). table 3: years of experience and extent of being informed about assessment. risk factors for tinnitus that were most familiar by participants included noise exposure (n = 145, 34.6%), infections (n = 92, 21.9%) and head or neck injuries (n = 52, 12.4%), suggesting familiarity of factors that warrant further management. other risk factors included hearing loss (presbycusis and otosclerosis), ototoxic medication (tb and hiv and aids), stress, anxiety, impacted cerumen, headaches and dizziness. case history (n = 232, 22.1%), otoscopy (n = 210, 20%) and routine audiological testing (n = 215, 20.5%) were largely undertaken as part of the tinnitus assessment along with the use of tinnitus questionnaires (n = 140, 13.3%) (table 4). table 4: test battery used to assess tinnitus. participants rated their professional experience as limited (n = 91, 39.2%) and adequate (n = 87, 37.5%) for the intervention of tinnitus in adult patients. with regard to the level of satisfaction experienced by participants when providing tinnitus services, it is observed that 78 (33.6%) participants felt neither satisfied nor dissatisfied. more participants leaned towards a negative response feeling dissatisfied (n = 73, 31.5%), while fewer participants felt satisfied (n = 57, 24.6%) with the provision of services offered. participants with varied years of experiences reported their experience of working with tinnitus patients as limited (n = 11) and very limited (n = 10), respectively. the majority of participants with greater periods of working experience (i.e. >10 years) indicated their experience as limited (n = 13). there does not seem to be a statistically significant relationship between participants’ years of experience and tinnitus intervention (p = 0.075) (table 5). table 5: years of experience and intervention of tinnitus. most participants did not follow any standard procedures nor standard guidelines or policies to assess adult patients with tinnitus (n = 113, 48.1%) (n = 147, 59.5%), respectively. this question was targeted to determine whether there has been a change in this regard and in comparison to earlier studies. participants responded positively (n = 142, 61.2% – strongly agree; n = 62, 26.7% – agree) for the development of guidelines to manage tinnitus. the most common guidelines used by participants for the assessment and intervention of tinnitus are presented in table 6. table 6: use of guidelines or policies for the assessment and intervention of tinnitus. participants mostly implemented counselling techniques as part of the intervention process, followed by sound generators or tinnitus maskers, trt and providing educational support or awareness. the data also indicated a combination of the above to aid in the provision of effective intervention services (table 7). table 7: techniques used by participants as part of their intervention with tinnitus patients. participants in private practice (n = 39, 24%) seemed to create and implement more intervention plans for tinnitus in contrast than those in public health sector (n = 27, 10%). most participants expressed an interest in developing a tinnitus management programme at their institute (n = 162, 69.8%), while 6.5% (n = 15) responded that this was not possible because of time constraints, understaffing issues and lack of interest in the area of tinnitus. with regard to referrals, ear, nose and throat specialists (ents) (n = 199, 36.3%) received most referrals from audiologists for further management of tinnitus patients. to understand the challenges and limitations hindering the overall management of adult patients with tinnitus and make recommendations for its improvements two open-ended questions were included for participants to highlight their challenges and provide recommendations to address these concerns. these responses were quantified, with the following key elements emerging (tables 8 and 9). participants reported a number of factors that challenged their ability to effectively assist in the overall management of tinnitus. table 8: challenges regarding managing adult patients with tinnitus (n = 89). table 9: recommendations to improve the tinnitus management in adult patients (n = 100). most reported that they had limited ability to assess or provide intervention services (n = 47, 53%). this was mainly because of limited knowledge and a lack of standard protocols or guidelines (n = 13, 15%) to assist them with this process. other factors that limited the overall management of tinnitus included limited resources or funding (n = 28, 31.4%), language barriers (n = 30, 33.7%) and time constraints. most participants reported that further training in the overall management of tinnitus (n = 39, 39%), standard guidelines (n = 32, 32%), further research and continuous professional development workshops to support audiologists to effectively assist their patients would be beneficial. discussion this study revealed that participants lack confidence in the overall management of adult patients with tinnitus, citing limited preparedness, training, guidelines and resources as possible factors contributing to their limited service provision. with regard to training, capacity and preparedness, the results of the current study are similar to a local study conducted by naidoo (2006). in that study, it was revealed that limited tinnitus services were provided because of limited training and its management was practised more routinely in the private than public health care sectors (naidoo, 2006). most participants also reported not attending specialised training for tinnitus, with only five participants attending courses that were facilitated in denmark and the united kingdom. similar findings have also been observed in a study by hoare et al. (2010), where 15% of audiologists specialised in tinnitus in the united kingdom, with fewer clinicians undertaking training for counselling. in the current study, most participants had not undertaken any further specialised training and it is evident that extra courses for tinnitus are necessary for the overall management of tinnitus. the feedback relating to the views and practices for the assessment of tinnitus indicated a variation in practices and a lack of standardised tinnitus practice among audiologists. in terms of intervention, participants also seem to lack confidence in this regard as their feedback bears similarity to their responses in relation to the assessment of tinnitus. these results are similar to a uk-based study in which it was noted that tinnitus practices are not standardised and this results in fragmented care with cost implications (hoare et al., 2010). the serious impact of tinnitus and its lack of management could possibly lead to limited service provision (holmes & padgham, 2011). in this study, most participants did not refer to any standard procedures for the assessment of tinnitus, while fewer participants sometimes followed standard procedures. the creation of guidelines specific to the needs of the community would serve as a guide to assist clinicians to manage tinnitus patients. although there are currently no established guidelines in south africa, it would be useful for audiologists to review international standards and make adaptations and recommendations as this would serve as a baseline for patient progress while empowering clinicians to create management plans for their patients. the majority of participants also responded positively for the development of tinnitus guidelines and also expressed an interest to develop a tinnitus management programme at their respective places of employment to assist with the overall management of tinnitus and offer services required by patients. noise exposure, infections, and head and neck injuries are considered major risk factors of tinnitus that may require other health care professionals to intervene and assist patients where necessary (baguley, mcferran, & hall, 2013). in this study, it is evident that participants were familiar with the suggested risk factors associated with tinnitus and have also reported other conditions that included the intake of ototoxic medication for tb, hiv and aids and medication for depressed and anxious patients, in which tinnitus is likely to result as a side effect (gülbay et al., 2006; pillay-van wyk et al., 2013). it is noted that participants made referrals mainly to ent specialists, psychologists, dentists and neurologists. referrals were also made to experienced audiologists with further training and who have a special interest in tinnitus. regrettably, participants reported that referrals are not made to fellow health care professional as no staff are employed within the hospital or in closer surrounding areas. collaboration with allied health care workers are essential to ensure that tinnitus patients are obtaining the appropriate medical services. with regard to the assessment of tinnitus, participants included at least one of the options listed in the survey and these included case history, otoscopy and routine audiological testing. a lower response was attained for the inclusion of questionnaires. similar results were obtained by hoare et al. (2010) in which 91% of participants conducted audiological assessments with the inclusion of otoacoustic emission testing and acoustic reflexes as part of their assessment, with fewer participants conducting structured interviews. audiologists also used unstructured interviews to determine the impact of tinnitus. the tinnitus handicap inventory was the most commonly used questionnaire by participants, and the similar was noted in the united kingdom in which the most prevalent measure of tinnitus severity was the use of questionnaires (67%) followed by the tinnitus handicap inventory (45%) and the use of the tinnitus functional index (tfi) at 18% (hoare et al., 2010, 2015). participants conducted some form of tinnitus intervention by primarily providing counselling services, tinnitus retraining therapy and cognitive behavioural therapy. in a study by hoare et al. (2010), similar feedback was obtained in which participants provided some form of management strategies that included hearing aids with directive counselling, sound generators, habituation therapies, stress management and psychological support, which included relaxation, acceptance and commitment therapy. there was no published data with regard to the most common practices used by audiologists to manage tinnitus patients and clinicians greatly relied on their clinical experiences (naidoo, 2006). tinnitus care is highly variable and the level of care differs among clinicians and countries (hoare et al., 2015), and this is certainly noted in the current study. the most significant challenge identified by participants is their inability to confidently assess and intervene adult patients with tinnitus. there seems to be much variation in tinnitus practice among audiologists in south africa, with minimum to no standardisation for the overall management of tinnitus. other international studies have also noted variations in tinnitus services between audiology departments among countries in the united kingdom (hoare et al., 2015). most participants reported they do not refer to any guides in particular during the overall management of tinnitus and also displayed a lack of awareness or familiarity of resources that are used in other countries. this is important for the standardisation of practice, platform for sharing methods and success stories to assist those who may not be as confident when managing adults with tinnitus. participants reported interest for a guide in place for the overall management of tinnitus as this would serve as a baseline for health care professionals. although most participants provided some form of counselling to patients, they felt that their knowledge in this area is limited with fewer audiologists undertaking specialised training to counsel tinnitus patients. participants reported it as being challenging to counsel patients after being seen by medical professionals who disregard tinnitus, indicating that nothing can be done about it (moroe & khoza-shangase, 2014; sourgen & ross, 1998). it is necessary that this misconception changes towards a positive approach. this can only be achieved once audiologists become informed and begin to create awareness of the role to assist patients lead a better quality of life and help them effectively manage their symptoms (hoare & hall, 2010). regrettably, from the data it was identified that some institutions do not have any equipment or resources for the assessment of tinnitus. some rural areas do not have ent specialists employed and referrals for further medical review are not possible, placing patients at risk of not being treated for other life-threatening conditions that are associated with tinnitus. it is unfortunate that because of the invisible nature of tinnitus, resources are not often a priority and the sparse availability of resources in south africa may affect the provision of tinnitus services (moroe & khoza-shangase, 2014). participants reported that the lack of funding within the public health sector places a strain on the efficient functioning of the audiology departments. because of budget constraints allocated for audiology, the main aim is to ensure that hearing aids are obtained as this is more crucial as opposed to purchasing expensive technology linked specifically to tinnitus maskers. it is imperative that audiologists continue to urge relevant levels of managements at their respective institutions to consider and support funding for much required resources, training and care. participants have noted that time constraints play a major role in the overall management of tinnitus. because of a lack of staff in very busy hospitals, audiologists are limited in integrating much needed services into their clinical environments. the unequal distribution of audiologists in the public and private sectors has challenged the provision of audiological services to the greater population in south africa (swanepoel, 2006). because of the fast pace nature of audiology clinics, longer time slots for tinnitus may work in the private health care sector (schechter & henry, 2002). although english is a primary language in south africa, isizulu is the home language to 22.7% of the population (statistics south africa, 2011). from the data it was noted that 33.7% of participants have reported language barriers being an area of great concern. there are currently no tinnitus questionnaires translated into isizulu and the language used in that particular context to suit the needs of patients whose first language is not english, thus impacting on the patient’s ability to understand and clearly express themselves through this process. not all patients view tinnitus as a medical condition, with feedback from some participants reporting tinnitus being a spiritual condition. in the unique multicultural society that we reside in, it is important to understand and respect the beliefs of patients as many south africans prefer consulting with traditional healers along with modern health care medicine for health-related issues (ross, 2008). participants have expressed the need for workshops to be held for both newly qualified clinicians and experienced audiologists who have an interest in the area of tinnitus. it was suggested that intensive training in the form of annual courses and educational workshops be implemented to keep updated regarding the current trends in tinnitus management. participants requested to be trained on the relevant practical aspects of tinnitus, which include the assessment and management that would be useful within the clinical environment. conclusions and recommendations in south africa, tinnitus services offered by audiologists seem to be limited. there are various contextual, linguistic and cultural factors that may influence the overall management of tinnitus in a clinical environment. a step forward would be to determine the measures taken by the clinician for the overall management of tinnitus and build on this to ensure that appropriate tinnitus services are being provided to patients. this may be partly accomplished through continual professional development workshops, adequate guidelines and resources for the overall assessment and intervention of tinnitus and advocacy with the aim of improving the quality of life of patients with tinnitus. the teaching curriculum at universities should be reviewed so that students confidently enter the workforce being more prepared and knowledgeable on how to assess and manage patients with tinnitus. feedback from participants recommended that more clinical case studies be included, and to ensure familiarity of tinnitus the course content should be provided earlier in the degree. according to hoare et al. (2010), participants reported that patient empowerment and a positive attitude towards tinnitus make up a successful tinnitus management plan. from the current study, it is evident that audiologists have acknowledged the gaps in their professional capacity to assist tinnitus patients and indicated their need to be trained further. participants also accepted that being informed would enable them to confidently manage patients with tinnitus. the majority of participants strongly recommended the need for a guide or protocol to aid audiologists with the overall management of tinnitus patients. it was emphasised that these guides should be developed specifically to suit the context of south african patients in which cultural and linguistic aspects should be considered. it is recommended that experienced audiologists collaborate to create a task force dedicated to tinnitus. although it would be extremely beneficial for a guide to be in place, it is important that audiologists are mindful that the overall management of each tinnitus patient may differ. some participants felt that there is a lack of awareness among health care professionals regarding the role of audiologists towards patients with tinnitus and it is vital that awareness is created to efficiently assist patients. furthermore, a lack of research or information regarding tinnitus and its overall management within the south african context was reported. as a result, the creation of a local website dedicated to tinnitus was recommended by participants in which an online forum would serve as a platform for audiologists, where health care professionals may share knowledge and resources that are easily accessible. consideration to develop a website to support patients would also be useful for those who do not have direct access to tinnitus services at their hospitals and this would also be advantageous to patients within the south african context as some patients may easily access wi-fi. research implications and limitations future research on a larger scale should be considered and incorporating a mixed-method design over a longer period with the aim of creating evidence-based practices that is relevant to the needs of patients with tinnitus in south africa. this could additionally consider the cultural and linguistic factors when managing tinnitus patients. some patients do not consider tinnitus as a medical condition, but rather a result of spiritual causes. more research in this area can be used to advise practitioners accordingly. the results obtained were based on a small sample size and may lack generalisability. results should, therefore, be interpreted with caution. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions this article is based on a master’s study by f.d., who was supervised by n.b.k. and co-supervised by v.b. the article was drafted by f.d. and the supervisors contributed substantially to all subsequent drafts and the final article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references andersson, g. 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(1999). the use of science to find successful tinnitus treatments. in proceedings of the sixth international tinnitus seminar. london: the tinnitus and hyperacusis centre. article information authors: diane kendall1,2 lisa edmonds3 anine van zyl4 inge odendaal4 molly stein4 anita van der merwe4 affiliations: 1va rr & d puget sound dva medical center, speech and hearing sciences, university of washington, united states of america 2fulbright, university of pretoria, pretoria, south africa 3department of biobehavioral sciences, speech language pathology, teachers college, columbia university, united states of america 4speech-language pathology and audiology, university of pretoria, south africa correspondence to: diane kendall email: dkendall@uw.edu postal address: box 35875, 1417 ne 42nd street, seattle, washington 98105, united states dates: received: 21 nov. 2014 accepted: 25 apr. 2015 published: 26 june 2015 how to cite this article: kendall, d., edmonds, l., van zyl, a., odendaal, i., stein, m., & van der merwe, a. (2015). what can speech production errors tell us about cross-linguistic processing in bilingual aphasia? evidence from four english/afrikaans bilingual individuals with aphasia. south african journal of communication disorders, 62(1), art. #111, 10 pages. http://dx.doi.org/10.4102/sajcd.v62i1.111 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. what can speech production errors tell us about cross-linguistic processing in bilingual aphasia? evidence from four english/afrikaans bilingual individuals with aphasia in this original research... open access • abstract • introduction • methods    • participants       • ethical considerations    • stimuli    • overlapping cognate analysis    • data collection procedures    • outcome measure analysis    • error coding procedures    • data analysis • results    • reliability of outcome measure scoring    • overall accuracy    • error type    • cognate effect • discussion    • accuracy    • errors    • cognate effect    • limitations and future directions • conclusions • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ introduction: the aim of this study is contribute to clinical practice of bilinguals around the globe, as well as to add to our understanding of bilingual aphasia processing, by analysing confrontation naming data from four afrikaans/english bilingual individuals with acquired aphasia due to a left hemisphere stroke. methods: this is a case series analysis of four afrikaans/english bilingual aphasic individuals following a left cerebrovascular accident. error analysis of confrontation naming data in both languages was performed. research questions were directed toward the between language differences in lexical retrieval abilities, types of errors produced and degree of cognate overlap. results: three of the four participants showed significantly higher naming accuracy in first acquired language (l1) relative to the second acquired language (l2) and the largest proportion of error type for those three participants in both l1 and l2 was omission. one of the four participants (linguistically balanced) showed no between language accuracy difference. regarding cognate overlap, there was a trend for higher accuracy for higher cognate words (compared to low). discussion: this study showed that naming performance in these four individuals was reflective of their relative language proficiency and use patterns prior to their stroke. these findings are consistent with the hierarchical model, in normal bilingual speakers and with persons with bilingual aphasia. introduction top ↑ aphasia is a chronic, pervasive and often debilitating impairment of language that is most often a consequence of stroke in the left cerebral hemisphere. speech-language pathologists strive to provide effective clinical rehabilitative services to remediate language impairments in persons with aphasia (pwa); with increasing prevalence of bilingualism in the world, special consideration to bilingual aphasia is imperative. bilingual aphasia is a complex topic largely because of the heterogeneity within and across bilingual speakers due to varying manners of acquisition, patterns of use and relative abilities across languages (grosjean, 1998). thus, speech-language clinicians need to not only be cognisant of the potential variability of language backgrounds of people with aphasia but also knowledgeable regarding the mechanisms of lexical representation and processing in bilingual aphasia so that effective diagnostic and rehabilitative strategies can be employed. understanding the psycholinguistic mechanisms involved in bilingual word production can be viewed similarly to the activation and selection mechanisms in monolingual word production. dell’s (1986) interactive activation theory of word processing (dell, schwartz, martin, saffran & gagnon, 1997) states that word retrieval processes are a result of three layers of activity: semantic, lemma and phoneme. connections between the layers allow bidirectional spread of activation (e.g. semantics ↔ lemma ↔ phonemes). for example, during confrontation naming of the word cat, visual analysis allows for identification of the picture with activation to corresponding semantic units or features, with bidirectional spread of information to lemma and phonological layers. this cascading process also occurs in reverse during comprehension with bottom-up activated phonological nodes spreading connections to lemma nodes, then to corresponding semantic nodes. similar to dell’s interactive model, models of bilingual language representation and processing also account for a conceptual or semantic layer (shared between languages for most concepts), a lexical layer (with distinct lexical representations for each of the languages) (kroll & stewart, 1994) and a phoneme layer (with a certain degree of overlap between the phonological systems of the languages depending upon how closely the languages are sublexically related) (costa, 2005). essentially, in bilingual word processing, activation of the semantic system that is shared between languages spreads to both lexicons. this flow of activation is target language nonspecific regardless of the language in which the task is being performed (costa, 2005; edmonds & kiran, 2006). for example, in a bilingual afrikaans and english speaker, activation of the concept of ‘the piece of furniture in the dining room used to eat upon’ results in simultaneous activation of ‘tafel’ and ‘table’. regardless of target-language output, this conceptual or semantic activation spreads to two distinct lexicons, then on to phonologic encoding of each of the language-specific words. factors known to influence the extent of interconnectivity and production abilities of the two languages in bilingual speakers include the linguistic task itself (e.g. narrative vs naming) and typological characteristics of each language (e.g. tone vs nontonal). further, characteristics inherent to bilingual speakers that can influence production are related to patterns and relative use across languages (e.g. kroll & stewart, 1994). according to the hierarchical model, which we present as our working model for bilingualism, the strength of connections between the semantic system and each lexicon is dependent on use and proficiency, which are largely related to each other. with respect to lexical retrieval, a person’s more proficient language corresponds to that which is used more. as a result, the connections between the semantic system and the lexicon of the more proficient language are stronger, facilitating faster retrieval and a larger lexicon. further, connections between the two lexicons (i.e. translation of words, e.g. ‘hond’ to ‘dog’) are also dependent on relative proficiency across languages, as translation from the less proficient language to the more proficient language is faster and more accurate than the reverse; these patterns are thought to correspond to relative strength of connections (mixed model, de groot, 1992) (see figure 1). figure 1: model of bilingual language. cognate status (words with the same meaning that have some degree of overlapping phonology or orthography) is a structural element of language that has also been shown to impact word processing in bilinguals (e.g. costa, caramazza & sebastian-galles, 2000; costa, santesteban & caño, 2005; gollan & acenas, 2004). that is, the extent to which phonological and orthographic similarities exist between two languages can influence the speed to which the words are processed and produced. for example, hart (afrikaans) and heart (english) sharing the same number of syllables and initial consonants (high cognate overlap), whilst stoel (afrikaans) and chair (english) share only the same number of syllables without vowel or consonant overlap (low cognate overlap). costa et al. (2000) investigated cognate status on the speed of processing and found that during a picture naming task, naming latencies were faster for pictures of cognates than for pictures with noncognate names. the results were interpreted in the context of spread of activation such that words with overlapping cognates share semantic and phonological activation from two sources (target and nontarget language representations), whilst words without overlapping cognates only receive activation from a single language, rendering slower and less efficient production. in a later article, costa et al. (2005) posited and provided further evidence from the literature for the assumption that cognate translations in the nontarget language receive activation from the semantic system, along with the corresponding phonology, and that phonological segments send back activation to the lexical segments in both languages that they are connected to. however, different language combinations have differing degrees of cognates depending on phonological overlap, contact and borrowed words. although there is evidence of general facilitation effect of cognates, bilinguals’ relative proficiency across languages impacts that effect. in typical bilingual adults, it appears that the benefits of cognates is observed in the second acquired language (l2) of persons with relatively balanced abilities across languages (e.g. gollan, fennema-notestine, montoya & jernigan, 2007; roberts & deslauriers, 1999), whereas there is no effect of cognate status in persons with a more proficient language. in other words, relatively balanced bilinguals exhibit similar accuracy across first acquired language (l1) and l2 in general, although they are more accurate with cognates in l2. in bilinguals with a more proficient language, their accuracy is lower in l2 in general, with no cognate effect. less is known about cognate production in persons with bilingual aphasia. roberts and deslauriers (1999) report that persons with bilingual aphasia reported higher accuracy for naming pictures with cognate words than non-cognate words in the language learned second in a group of french/english participants who reported high use and proficiency in both languages, which were learned before age 10. other studies directly examining cognate effects in multilingual aphasia are more difficult to interpret because they were single case studies, involved polyglots (rather than bilinguals) and provided limited information on the cognates used in their studies (ferrand & humphreys, 1996; stadie, springer, de bleser & burk, 1995). because confrontation naming is an integral component of aphasia testing, and often an outcome measure for treatment, more information is needed regarding the relationship between cognate status of items and proficiency and use patterns in persons with bilingual aphasia. most individuals living in south africa speak more than one language (statistics south africa, 2012). dutch and english were the first official languages of south africa from 1909–1925. between 1984 and 1994 the two official languages of south africa were english and afrikaans (thompson, 2001). since 1994, south africa has had 11 official languages, nine of which are african bantu languages, whilst two, english and afrikaans, are germanic languages. because english and afrikaans are west germanic languages, their linguistic characteristics overlap considerably. both languages are considered more analytic than synthetic; that is, they make use of relatively few bound morphemes (barber, 1999). english and afrikaans are also inflectional languages, implying that their bound morphemes are not invariable and each morpheme may indicate more than one characteristic, in contrast to agglutinative languages (such as finnish and isizulu) or isolating languages (such as chinese and vietnamese), whose bound morphemes are invariable and only indicate one characteristic (barber, 1999). although both english and afrikaans make use of intonation to distinguish sentence or utterance types, neither uses syllabic tone to indicate differences in word meaning (that is, tone is not phonemic in either english or afrikaans) (kuiper & scott allan, 1996; odendaal, 1989). the high incidence of bilingual english/afrikaans speakers in south africa as well as the amount of overlap of these two germanic languages presents a unique challenge to clinicians working with individuals with aphasia in that region. furthermore, in addition to informing clinical practice of bilinguals around the globe, as well as adding to our understanding of bilingual aphasia processing, we have analysed confrontation naming data from four afrikaans/english bilingual individuals with acquired aphasia due to a left hemisphere stroke. in a retrospective case series analysis, we examined the differential performance in lexical retrieval abilities between l1 and l2, types of errors produced and, finally, if performance was influenced by degree of cognate overlap. we also considered relative premorbid language use as reported by participants to contextualise our findings. the following research questions were posed: is there a significant difference in confrontation naming abilities between l1 and l2 as measured by accuracy? is there a difference between l1 and l2 in the types of errors produced as measured by raw number and proportion of errors? is there a difference in spoken word accuracy between l1 and l2 for high and low overlapping cognates? methods top ↑ participants ethical considerations ethical clearance was obtained from the local university in south africa. individuals were recruited by solicitation from clinical speech-language pathologists (slps) who work in pretoria hospitals, clinics and rehabilitation centres. data were collected by two speech pathology students (third and fourth authors). inclusion criteria included the presence of a left hemisphere stroke, the presence of aphasia determined by a clinical slp, bilingual speaker of english/afrikaans with one language indicated by the participant as the predominant language and adequate hearing thresholds to conduct all tasks. the participants had to be capable of using full sentences or phrases in l1 during communication to ensure adequate verbal ability to perform the task. exclusion criteria included severe aphasia, severely compromised receptive language ability, psychiatric illness, degenerative neurological disease, chronic medical illness, severe impairment in vision or hearing and knowledge or use of a third language. the four participants were on average 73 years of age (sd 11.7) and ranged between four years and two months post stroke onset. there were two men and two women, all were right-handed and were bilingual in afrikaans and english (see table 1). table 1: participant demographics participant 1 (p1), male, age 72 was three months post stroke onset, had a university education and worked premorbidly as a university lecturer. he stated that he was fully bilingual since an early age, with acquisition of afrikaans first (l1) and english later (l2) at the age of three. he was exposed to english through family and school and predominately spoke english in his occupational setting. participant 2 (p2), female, age 84 was two months post stroke onset, completed grade 12 and worked as a homemaker. she stated that she learned english first in the home (l1) and was exposed to afrikaans from the age of four years (l2). she indicated that she was exposed to both english and afrikaans in both the community and school and reported to have mastered both languages equally. for approximately 20 years pre-onset she was mainly exposed to english (l1) and used only english at home. participant 3 (p3), male, age 57 was three months post stroke onset, had a four-year university degree and worked as an engineer. he stated that his first language was afrikaans (l1) and that his second language, english (l2), was acquired at approximately eight years, predominately through formal classes in school and by watching the television. he regarded himself as quite proficient in both languages, using english and afrikaans interchangeably at work. participant 4 (p4), female, age 76 was three years and five months post stroke onset, had a grade 12 education and worked as a homemaker. she stated that her first and most used language was afrikaans (l1) and that she was exposed to english (l2) at age eight from formal lessons at school. she stated that she had a good english vocabulary prior to her stroke; however, she did not use english as much as afrikaans in her daily life. stimuli in order to elicit confrontation naming, colour pictures corresponding to 40 one-syllable, two-syllable, and three-syllable nouns were selected in english and afrikaans. high and low frequency words were selected from http://www.wordcount.org (see table 2). word pairs (in these two languages) had the same number of syllables. to determine name agreement, each picture was presented on a 14 cm by 22 cm card to five healthy afrikaans/english bilingual adults who named the pictures with 100% accuracy and 100% agreement. table 2: stimuli used in experiment with degree of cognate overlap. overlapping cognate analysis a 10-point scale to quantify the degree of phonological overlap between translation word pairs was employed (see kohnert, windsor & miller, 2004 for details regarding development of scale). this cognate scale indexes four different features: initial sound, number of syllables, percentage of overlapping consonants and percentage of overlapping vowels. a specific rating scale is employed to further describe each of the four features. initial sound is scored between 0 and 3 points (3 = same consonant, 2 = same vowel, 1 = similar sound, 0 = complete mismatch). number of syllables was scored between 0 and 2 points (2 = same number of syllables, 1 = different by only one syllable, 0 = different by more than one syllable). consonants were scored between 0 and 3 points (3 = >70% consonant overlap, 2 = 50%–70% overlap, 1 = <50% overlap, 0 = no overlap). finally, vowels were scored between 0 and 2 points (2 = >80% overlap, 1 = 50%–80% overlap, 0 = no overlap). all scores for each word were tallied. for the purposes of this study, we deemed that a word was judged to have high overlap if it was between 8 and 10, medium overlap between 5 and 7, low overlap between 1 and 4 and no overlap if 0. see table 2 for results of cognate scores. data collection procedures participants were seated in a quiet room and stimulus cards were randomised and presented one at a time without any cues. the participants were requested to first name all objects in the set of 40 pictures in l1. after completion of the set of pictures in l1 they were again presented with the pictures, which were again randomised, and asked to name the pictures in l2. l1 was consistently probed first to control the possible influence of uncertainty or higher demands in l2. instructions were provided in both languages (english for the english naming and afrikaans for the afrikaans naming). participant responses were not constrained with a time limit. participant responses were audio recorded and later scored for overall accuracy, total number of phonemes correctly produced and error type by three members from the motor speech laboratory at the university of pretoria (first, fifth and sixth authors). outcome measure analysis the first research question addressed confrontation picture naming whole word accuracy. the second question addressed total number of phonemes correct and types of errors made. the final question looked at naming accuracy as a function of high, medium and low overlapping cognate status. methods and procedures for each of these outcome measures are described below. error coding procedures digital recordings of participant responses were scored, by consensus, by three trained slps (first and last two authors), two of whom are proficient afrikaans/english bilingual speakers. the english speaking only slp scored just the english responses. only the participants’ first responses were coded. correct response included the correct lexical item only. fillers such as ‘um’ and ‘i don't know’ were not counted. incorrect responses were coded for error type using five categories: phonologic (p) – substitutions, additions, transpositions, omissions. semantic (s) – related within language (sr-w: ‘child’ for ‘girl’), unrelated within language (su–w: ‘grape’ for ‘house’), related across language (sr-a: english ‘colt’ for afrikaans ‘perd’, which means horse), unrelated across language (su-a: english ‘horse’ for afrikaans ‘stoel’, which means chair). mixed (m) – real words with a phonologic relationship to the target. omission (o) – includes circumlocutions and non-responses. neologism (n) – nonwords that were not phonologically related to the target. direct translations were coded (t), as well as translations with phonologic errors (tp). data analysis to answer research question 1, paired-samples unequal variance t tests comparing confrontation naming accuracy between l1 and l2 were performed. for the error analysis questions, paired-samples t tests compared l1 and l2 for raw number of each error type and error type proportions (proportion of each error type relative to total numbers of errors made). for the cognate question, percentage accuracy was documented for high, medium and low overlap cognate words and paired-samples t tests were used to compare l1 and l2 differences. results top ↑ reliability of outcome measure scoring consensus reliability on 25% of the corpus resulted in 98% point-to-point reliability on accuracy scores and 83% reliability on error type coding. overall accuracy the first research question asked if there was a significant difference in confrontation naming abilities between l1 and l2 as measured by accuracy. results for p1 showed 75% (l1) and 83% (l2) accuracy, resulting in no difference (p = 0.209). results for p2 were 58% (l1) and 28% (l2), showing a significant between language difference (p = 0.038). results for p3 were 38% (l1) and 20% (l2) accurate, showing statistical significance (p = 0.047). finally, results for p4 were 23% (l1) and 2.5% (l2) accurate, which was significantly different (p = 0.047) (see figure 2). figure 2: confrontation naming accuracy for four bilingual – afrikaans (af) and english (eng) – persons with aphasia (research question #1). error type the second research question asked if there was a significant difference for each participant between l1 and l2 in the number and types of errors produced as measured by raw number and proportion of errors. results for each participant, for l1 and l2, are described and are shown in figure 3. figure 3: p1, p2, p3 and p4: proportion of error types for l1 versus l2 (research question #2) p1 (l1) had 10 raw errors (out of 40 words). nine errors were semantic and one mixed. the l1 semantic errors were further subdivided into eight within language-related errors and one within language-unrelated error. proportion of errors were 0.90 semantic and 0.10 mixed. in l2, he had seven total errors (out of 40 words). four errors were semantic, two phonologic and one omission. the l2 semantic errors were further subdivided into three within language-related errors and one within language-unrelated error. proportion of errors was 0.29 phonologic, 0.57 semantic and 0.14 omission. p2 (l1) had 17 raw errors (out of 40 words). seven errors were semantic, 1 phonologic, 7 omission, 1 translation and 1 neologism. the l1 semantic errors were further subdivided into 5 within language-related, 1 within language-unrelated and 1 across language-related error categories. proportion of errors was 0.41 semantic, 0.06 mixed, 0.06 translation and 0.06 neologism. in l2, she had 29 errors (out of 40 words). ten errors were semantic, 18 omission and 1 translation. the l2 semantic errors were further subdivided into 7 within language related, 2 within language unrelated and 1 across language related categories. proportion of errors was 0.34 semantic, 0.62 omission and 0.03 translation. p3 (l1) had 25 raw errors (out of 40 words). eight errors were semantic, two phonologic, 10 omission, two translation and three neologism. the l1 semantic errors were further subdivided into two across language-unrelated, three within language-unrelated, one across language-related and two within language-related categories. proportion of errors were 0.08 phonologic, 0.32 semantic, 0.40 omission, 0.08 translation and 0.12 neologism. in l2, he had 32 errors (out of 40 words). ten errors were semantic, one phonologic, one mixed, 14 omission, three translation and three neologism. the l2 semantic errors were further subdivided into two across language-unrelated, four within language-related, one across language-related and one within language-related categories. proportion of errors was 0.31 semantic, 0.03 phonologic, 0.03 mixed, 0.43 omission, 0.09 translation and 0.09 neologism. p4 (l1) had 31 raw errors (out of 40 words). two errors were semantic, six phonologic, two mixed, 16 omission and five neologism. the l1 semantic errors were further subdivided into one within language-unrelated and one within language-related categories. proportion of errors was 0.19 phonologic, 0.06 semantic, 0.07 mixed, 0.48 omission and 0.16 neologism. in l2, she had 39 errors (out of 40 words). four errors were semantic, two phonologic, 14 omission, 17 translation and two neologism. the l2 semantic errors were further subdivided into one within language-unrelated and three across language-related categories. proportion of errors was 0.14 semantic, 0.07 phonologic, 0.48 omission, 0.59 translation and 0.07 neologism. cognate effect the third research question asked if any differences were observed in spoken word accuracy between l1 and l2 for high, medium and low overlapping cognates. as a reminder, out of 40 words there were 17 with high overlap, 9 with medium overlap and 14 low-overlapping cognate words. data are displayed in table 3 (percentage accuracy for high-overlap, medium-overlap and low-overlap cognate words) and figure 4 (scatterplot illustrating individual performance on words according to the cognate scale 1 to 10). whilst all l1 versus l2 comparisons for high, medium and low cognate words were non-significant, the following interesting trends were found. table 3: percentage correct for l1 and l2 performance for high, medium and low overlapping cognates (research question #3) figure 4: individual scatterplots for participants 1–4. l1 and l2 naming accuracy (y-axis) x cognate categories. in regard to naming accuracy for the high overlap words, p1 showed similar performance between l1 (71%) and l2 (88%) (p = 0.22). p2 was higher in l1 (65%) than l2 (35%) (p = 0.09). p3 was slightly higher in l1 (47%) than l2 (33%) (p = 0.30). p4 was more accurate in l1 (47%) than in l2 (29%) (p = 0.30). naming accuracy for the medium overlap words for p1 showed equivocal performance between l1 (89%) and l2 (89%) (p = 1.0). p2 was higher in l1 (67%) than l2 (33%) (p = 0.18). p3 performed slightly higher in l1 (33%) than l2 (0%) (p = 0.08). p4 was slightly more accurate in l1 (33%) than in l2 (0%) (p = 0.08). naming accuracy for the low overlap words for p1 showed similar performance for l1 (71%) and l2 (71%) (p = 1.0). p2 was higher in l1 (43%) than l2 (14%) (p = 0.10). p3 performed higher in l1 (29%) than l2 (21%) (p = 0.68). p4 was slightly more accurate in l1 (29%) than in l2 (21%) (p = 0.68). discussion top ↑ the purpose of this retrospective study was to investigate lexical retrieval abilities from four bilingual (afrikaans/english) individuals with aphasia with the goal of elucidating psycholinguistic mechanisms involved in bilingual word production. overall, this study showed that whilst all participants had a diagnosis of aphasia, their naming impairments were reflective of their reported relative use patterns prior to their stroke. these findings are consistent with the hierarchical model (kroll & stewart, 1994), which states that connectivity between semantic and lexical representations of the more proficient language is stronger (relative to the less proficient language), resulting in higher accuracy of naming performance post stroke. similar patterns have also been reported in normal bilingual speakers (e.g. edmonds & donovan, 2014; gollan et al., 2007) and with persons with bilingual aphasia (e.g. edmonds & kiran, 2006). accuracy the first research question explored differences in accuracy of confrontation naming between l1 and l2. only one participant (p1) appeared to be relatively balanced in use and proficiency in both languages and he is the only participant who did not show significant differences in accuracy across languages. on the other hand, although p2, p3 and p4 acquired both languages relatively young (≤10 years old) and demonstrated the most severe naming impairments of the group, they showed significant differences in accuracy between l1 and l2. the lower performance of these three participants, then, could be interpreted from the perspective of premorbid use patterns (and potentially proficiency levels) as opposed to severity of aphasia. although the amount of detail we have regarding the participants’ premorbid language use is limited, our findings are consistent with pitre’s (1895, cited in lebrun, 1995) law, which posits that premorbid use and proficiency influence relative impairment across languages post-stroke. the premorbid proficiency and use patterns of p2, p3 and p4 assume weaker connections between the shared l1/l2 semantic system and independent (or language-specific) l2 lexical representations (see figure 1). conversely, p1, who was relatively balanced, appeared to show equal connectivity between shared l1/l2 semantics and shared l1/l2 lexical representations, resulting in a lack of significance between language differences. errors the second research question explored if there were any differences in the types of errors produced in l1 versus l2. the results revealed that the proportion of semantic, phonological and mixed, omission, cross-linguistic and neologistic errors was essentially the same, regardless if the words were being spoken in l1 or in l2 (excepting p1’s semantic errors and p4’s cross-linguistic errors). from the perspective of bilingual word processing, the linguistic system is shared between languages and, as such, a linguistic impairment would evidence similarly in both languages. so, if there is a decrease in activation of the semantic system, the spread of activation is target language nonspecific, resulting in similar errors in both languages (costa, 2005; edmonds & kiran, 2006). thus, the level of linguistic impairment would not necessarily be different across languages, which appears to be the case in our participants. however, we did observe some impact of relative proficiency, which interacted with aphasia severity, on error types. p1 had more semantic substitutions in l2 relative to l1 (and also relative to the other three participants) that is likely attributed to his milder form of anomia. the presence of semantic errors indicates residual (albeit impaired) lexical or semantic activation and has been labelled ‘smart errors’ (dell et al., 1997). in dell’s (1986) model, semantic errors are said to occur due to a competing node receiving levels of activation greater than the target node. therefore, semantically related substitutions (e.g. apple à pear) occur during lexical access when a semantically related lexeme activation level is higher than that of the target. omission errors, on the other hand, may occur when semantic nodes do not reach an adequate level of threshold necessary for spread of activation. omission errors were evidenced by p2, p3 and p4, who exhibited a more severe form of anomia. the higher proportion of omission errors (relative to other error types as well as relative to milder p1) could be attributed to the combined effect of lower proficiency or usage and an overall decrease of lexical or semantic activation. finally, p4 showed more cross-linguistic errors in l2 versus l1 (and relative to all other participants). a cross-linguistic error is not a true omission (lack of activation in both languages); rather, it may evidence that she was relying on l1 when she was unable to produce a word in l2. with respect to the phonological errors, p1, the only participant to show more phonological errors in l2, had the highest accuracy overall and was closer to the target in general across all attempts. further, his phonological errors occurred in the low overlap items, suggesting that these words might be most sensitive in l2, even for relatively balanced bilinguals. p4 showed more phonologic errors in l1 (six), compared to l2 (two) which may indicate that since a phonologic error is a ‘smart’ error, it would occur in l1 and not l2 (which is the less accurate or proficient language). cognate effect the third research question explored l1 and l2 differences as a function of cognate status. this issue was important, as degree of phonological and orthographic overlap between languages has been shown to impact word processing in bilinguals (costa et al., 2000). that is, the more overlap, the faster and more accurately words are processed due to the redundant top-down and bottom-up processes. overall, whilst our findings were statistically insignificant, the trend in the accuracy data supported the notion that regardless of severity of the participants, and for all participants except p1 who was balanced, there was a trend of higher accuracy for high cognate words compared to low overlap words. it is important to note that items were not controlled for other psycholinguistic variables. that said, there were no differences in syllable length between the high and low cognate word lists. p1 showed a slightly higher score for cognates in l2 (88% accuracy) compared to l1 (71%). although not statistically significant, this trend is consistent with roberts and deslauriers (1999), who showed higher accuracy for cognates in the l2 of highly balanced english/french bilingual speakers with aphasia, a pattern also observed in normal bilingual speakers (gollan et al., 2007; roberts & deslauriers, 1999). interestingly, p1 showed equal accuracy in medium and low overlap words, indicating that high overlap words (compared to medium and low overlap) facilitate processing due to the shared semantic and phonological activation. the participants with a higher performance in one language did not show the same effect of cognates as p1, though an effect was seen. in these participants, picture naming in their l1 was slightly higher than l2 in high, medium and low phonological overlap words, suggesting that cognates helped retrieval in both languages, but with a consistent trend of higher naming in l1. this is consistent with the multilingual participant described by stadie et al. (1995). also, the higher performance seen by the three participants in their more proficient language indicates that words with overlapping cognates share semantic and phonological activation from two sources (target and nontarget language representations), thereby facilitating production. the converse is true as well. a trend of lower accuracy observed with the low overlap words spoken with the least proficient language supports this notion as well. finally, phonological overlap may indeed be a good way to characterise words for bilinguals in addition to more conventional, psycholinguistic terms, such as frequency (edmonds & donovan, 2012, 2014). from a clinical standpoint, training items with high cognate status may indeed be an efficient approach, since this would activate direct connections between semantics and phonology within languages and bidirectionally activate phonology as well. such a manipulation may result in more cross-linguistic generalisation for the trained words regardless of whether the more or less proficient language is trained (kohnert, 2004) (as compared to training words without phonological overlap, e.g. edmonds & kiran, 2006; but, see kurland & falcon, 2011), which would be particularly beneficial when a clinician does not share the second language with the patient. however, it should be noted that generalisation to untrained (noncognate) words may still require direct training in both languages (e.g. edmonds & kiran, 2006; kohnert, 2004) and many languages do not have a high incidence of cognates (kohnert, 2009). limitations and future directions there are several limitations that are important to note. firstly, the sample size was small. there were only four participants and additional persons who are afrikaans/english speaking with aphasia need to be tested to replicate these findings. secondly, there is limited language use information known on these individuals other than their brief report. thirdly, the stimulus items employed in this study were not selected for the cognate analysis. fourthly, because there are no available standardised aphasia testing measures for english/afrikaans, overall language severity of this particular sample is unknown. in the future, items should be selected based on specific psycholinguistic variables of interest. also, since the connections between the languages of bilingual persons are fluid and may indeed change depending on use, issues pertaining to the impact of the language in which therapy is provided as well as the impact of language usage post-stroke (e.g. individuals unable to return to work who are thus no longer exposed as much to one of the languages) on patterns of recovery should be addressed in future research studies. finally, it is important to note that parallels to other african languages are limited as the results will be person-specific and may depend on the classification of the languages that are compared. both languages in the current study were germanic languages. the clinical implications for this study are that the clinician needs to gather necessary information during the assessment period on level of proficiency and use. also, if possible, the clinician should evaluate the word retrieval impairment across languages to provide additional information regarding severity. conclusions top ↑ characterising phonological word equivalents across languages in word evaluations (i.e. translations) in evaluations of lexical retrieval in aphasia may provide additional insight into the interactions between premorbid proficiency and use, level of impairment and degree of phonological overlap across languages. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions d.k. 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(1987). t heory and science in com m unication disorders. j o u rn a l o f s p eech a n d h ea rin g d isorders, 52, 99-104. s im m ons-m ackie, n ., & d am ico, j. (2003). c ontributions o f qualitative research to the know ledge base o f norm al com m unication. a m erica n jo u rn a l o f speech l a n g u a g e pathology, 12, 144-154. w alsh, d., & d ow ne, s. (2006). a p praising the q uality o f q u alitative research. m idw ifery, 22, 108-119. w ertz, r. (1987). l anguage treatm ent for aphasia is efficacious, bu t for w hom ? topics in l a n g u a g e d isorders, 8, 1-10. w ertz, r ., w eiss, d., a ten, j., b rookshire, r ., g arcia-b unuel, l., h olland, a ., et al. (1986). c o m p ariso n o f clinic, hom e, and deferred language treatm ent for aphasia: v eterans a dm inistration cooperative study. a rch ives o f n eurology, 43, 653-658. a p la ce f o r m ixed methodologies? response to: the relevance o f speech-language pathology and audiology research and practice challenges f o r the professions the authors are to be commended for raising pertinent issues relating to the ways in which the professions conduct research and the relevance for accountable practice, especially at this point in our professions’ and nation’s history. given our past and current realities the challenge is to advance research and professional practice responsibly and responsively. in the new spirit o f redressing previous inequities, and increasing the access o f the majority o f south africans to professional ser­ vices, there has arisen an urgent need for research that guides ethical service delivery in the context o f cultural and linguistic diversity, poverty, and the ravages o f pandemics such as tu­ berculosis and hiv/aids. posing solutions to the questions raised by the authors might sug­ gest that there are ready answers which is, manifestly not the case. hence this treatise considers some o f the issues relating to the production o f knowledge and the challenge of making it respon­ sive to professional practice. how do we produce knowledge? the ways in which knowledge is produced reflects particular worldviews which have changed over time. critics (such as habermas, 1972; and lincoln & guba, 1985) o f the modem posi­ tivist approach which espouses that the natural causal laws govthe south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 18 h. k athard, e. n aude, m. p illay and e. ross eming the real world can best be understood by objectively ana­ lyzing the components using experimental methods, assuming linearity, absolute truth and rationality, suggest that it is no longer useful in knowledge production. a deconstructive post­ modern alternative posits that knowledge is relative as it is sub­ jectively constructed by unique individuals arising out o f their lived experiences within a particular culture and social structure (usher & bryant, 1989); while the critical paradigm recognizes the relationship between researchers involved in knowledge making and the institutionalized political and cultural power that favours the privileged (calas & smircich, 1999). action research, according to reason and bradbury (2001), is “concerned with the development o f democratic forms o f knowledge” (p.6) and is conceived o f being possible only “with, for, and by persons and communities, ideally involving all stakeholders both in the questioning and sense-making that in­ forms the research and in the action which is its focus” (p.2), with the ultimate purpose o f research being “human flourish­ ing” (p. 10). the participatory worldview promotes inquiry into what “flourishing” is and incorporates elements o f both positiv­ ism (i.e. “there is a ‘real’ reality”) and deconstructive postmod­ ernism (“any a c co u n t... o f the cosmos ... is culturally framed”), hence facilitating use o f positivist techniques and knowledge (where appropriate) and framing “these within a human con­ text” (p. 7). how do we best take advantage o f these different ways o f knowledge production? the choice o f research method sig­ nals a particular worldview and also ought to reflect deep con­ sideration of the complexities of the issues facing the profes­ sion. it could be argued that the participative framework has potential for addressing issues o f concern in the practice of our professions, where we draw on the knowledge gained from the positivist research and work with our patients/clients towards improved interventions. what methodologies promote research that is responsive to professional practice? a challenge lies in seeking out methods for research that are acceptable to the communities being researched and which yield data that advances the interests o f their members. action re­ search would suggest involvement of the community in democ­ ratically making this determination by reviewing and discussing options. certain research questions may best be answered by one or other approach. quantitative methodologies for example, may be suited to inquiries relating to: determination o f inci­ dence and prevalence o f disorders; establishment o f develop­ mental norms in a variety o f languages and cultures; and evi­ dence based practice. other research questions, such as the impact o f hearing loss on the quality o f life, may be more suited to a qualitative approach. re/habilitation involves prolonged contact with indi­ viduals, their families and even their communities. failure to consider the context and the participants’ lived experiences may render the research based interventions irrelevant. for example, in recommending home discharge with a fine bore nasogastric tube to decrease discomfort, one could seriously compromise the health and nutrition o f the patient if there is no access to electricity or a food processor, and tea ends up being poured into the tube. qualitative methodologies may be more reflec­ tive o f the prevailing dynamics and thus ultimately lead to inter­ ventions that are responsive to patients. further, in the production o f knowledge, one might sug­ gest that mixed methodologies have relevance. both quantita­ d ie suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 tive and qualitative modes o f research are umbrellas that accom­ modate a range o f research methodologies within their ambit, it could be recommended that judicious selection from among these broad research schools could enhance knowledge produc­ tion as well as practice, e.g. prevalence of children with late identification o f hearing loss, and its impact on their lives. how­ ever, giddings (2006) cautions against mixed methods being seen as a “quick fix” in the face of economic and social pres­ sures and they must be considered against the need for sophisti­ cated designs that address the complexities challenging speech language pathologists and audiologists nationally and interna­ tionally. the research agenda determination o f the research agenda is frequently driven by academic researchers’ interests and experiences, in a climate where research and publication are a requirement of the job. researchers are in a powerful position to determine the issues that will receive attention as well as the scope and nature o f the research. however, researcher interests may not match the re­ search needs o f the community in which the research will be conducted. further, the definitions and values espoused in such enquiries may reflect researcher perspectives rather than those of the participants. without consideration o f the communities and research participants’ context, realities and needs, the respon­ siveness o f the research to the germane issues may be chal­ lenged, and the consequent relevance for practice may be ques­ tionable. so the question that arises is: is it possible to conduct research without engaging communities in a participatory man­ ner? organizations such as the world health organization and the united nations typically have global perspectives on health research needs, and research funding agencies such as the na­ tional research foundation and the medical research council may be more responsive to the broader needs o f the country and attempt to guide research by determining research directions and providing funding to conduct research within these parameters. some o f the health research trends tend to derive from national burden o f disease data which are based on mortality statistics. however professions such as speech-language pathology and audiology are concerned primarily with re/habilitation, and re­ search directions may be better informed by information on dis­ ability in general and communication disability in particular, of which there is a paucity nationally. where research is funded by international agencies, the benefits to the local communities (and indeed to researchers) need to be addressed. is there and should there be room for collaboration across these spheres o f interests? over-researched communities in communities with a high prevalence o f a particular health phenomenon o f interest, there may be many research projects within the community with the same individuals being asked to participate in several studies. a consideration that arises is one of distributive justice whereby these individuals have to bear more o f the burdens relative to the fruits o f research. research­ ers may want to consider establishing community advisory pan­ els to negotiate entry into the community, determine research needs, and explore options for methodologies that are acceptable to the community, as well as yielding data that is meaningful criteria for selecting members o f the advisory panels warrant consideration to enhance representation of the community. fur­ ther, their independence of the researchers, and empowerment of the advisory panels are important to ensure their credibility. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) im proving the r elevance o f speech-l anguage pathology and a udiology r esearch and practice 19 the nature of the knowledge to be produced should research endeavours be ultimately geared to promoting human flourishing? from a participatory research perspective, all research should be for the betterment o f mankind. what are the ethical considerations when a limited resource, such as na­ tional researchers in our profession, is expended on research that adds to our knowledge and understanding o f the basic sci­ ences but may not have immediate or apparent application for practice? what is the impact of constraining academic freedom by eschewing research based on anything other than national needs? will potential innovations be lost by prescribing the nature o f knowledge to be produced? who are the researchers? the current demographic profile o f the profession and its re­ searchers are predominantly o f white and indian descent with relatively fewer indigenous african and coloured researchers reflecting the historical legacy o f inequitable access to tertiary education in the country. such a situation results in a cultural and linguistic mis-match between the majority o f the research­ ers and the populations to be researched. there continues to be an imperative to redress the inequities in access to training in these professions. however, given the urgent need for profes­ sion specific research in south africa, it may not be as impor­ tant to match the culture and language o f the researcher and participant, as it is for the researcher to demonstrate awareness o f and sensitivity towards the pertinent characteristics o f par­ ticipants and their communities. in other professions, such as medicine, clinicians are frequently researchers, but this is not necessarily reflective of our professions. the question that arises is: should cohorts o f clinicians be prompted to be researchers as well? why should this be a consideration and what would clinicians gain? n a­ tionally, research in our professions has been conducted by academics, and postand under-graduate students at universi­ ties, who constitute a limited pool o f researchers. further, it is the clinician who faces the challenge o f providing meaningful professional services to the diversity that constitutes the south african public. clinician researchers are the “bridgers” be­ tween the research and practice communities, and are best suited to develop clinically relevant research, (yanos & zie donis, 2006), to develop innovations for therapy (charlton, 1997), and to disseminate the research findings into clinical practice (yanos & ziedonis, 2006). what is the feasibility of developing a culture of clinicians as researchers? perhaps re­ search partnerships could be established between academics and clinicians which could result in research being responsive as well as clinically relevant? in conclusion, it should be noted that a particularly im­ portant issue in our professions is who speaks for those who cannot? should empowerment o f all vulnerable groups be a goal o f research and o f practice? it could be argued that re­ search in our professions should ensure that we hear our clients and that we create opportunities for them to develop their own voices in order to be heard. charlton, b.g . (1997). n atu ral kinds, n atural history and the clinician researcher. qjm, 90(11), 707-709. h aberm as, j. (1972). k n o w led g e a n d hum an interests; theory a n d p ra c tic e; c om m unication a n d th e evolution o f so c iety (j.j. shapiro, t rans.). london: h einem ann. g iddings, l.s. (2006). m ixed-m ethods research: p ositivism dressed in drag? j o u rn a l o f r esea rch in n ursing, 11(3), 195-2003. l incoln, y .s., & g uba, e.g. (1985). n a tu ra listic inquiry. b everley h ills, ca: sage publications. r eason, p., & b radbury, h. (2001). introduction: inquiry and p articip atio n in search o f w orld w orthy o f h um an aspiration. in p. r eason, & h. b radbury (eds.), h a n d b o o k o f action research: p a rticip a tive inquiry a n d p ra c tic e (pp. 1-14). london: sage. y anos, p.t., & z eidonis, d.m . (2006). t he patient-oriented clinicianresearcher: a dvantages and challenges o f being a double agent. p sych ia t­ ric services, 57, 249-253. the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) abstract introduction methodology results and discussion conclusion acknowledgements references appendix 1 about the author(s) warren g. manning discipline of audiology, school of health sciences, university of kwazulu-natal, durban, south africa mershen pillay discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa citation manning, w.g., & pillay, m. (2020). a critical analysis of the current south african occupational health law and hearing loss. south african journal of communication disorders, 67(2), a694. https://doi.org/10.4102/sajcd.v67i2.694 note: special collection: occupational hearing loss in africa. original research a critical analysis of the current south african occupational health law and hearing loss warren g. manning, mershen pillay received: 19 nov. 2019; accepted: 01 feb. 2020; published: 24 mar. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: occupational health laws must recognise the constitutional requirement of substantive equality, and its role in ‘the progressive realisation’ of the rights provided by section 27. objectives: our main aim is to review current south african occupational health law (vis-à-vis workers’ constitutional rights) in relation to hearing loss. we focus on gaps in the law regarding occupational hearing loss in south africa. method: our review of legal texts relies on experience as a methodological device augmented by the use of a critical science. guided by literature or evidence synthesis methodologies, south african primary and secondary laws were reviewed along with unpublished (non-peer-reviewed) grey literature. an established six-step framework guided our thematic analysis. a semantic approach aided the critical interpretation of data using the bill of rights as a core analytical framework. results: four themes are discussed: (1) separate and unequal regulatory frameworks; (2) monologic foregrounding of noise; (3) minimisation of vestibular disorders; and (4) dilution of ototoxic agents. the highly divided legal framework of occupational health and safety in south africa perpetuates a monologic ‘excessive noise-hearing loss’ paradigm that has implications for the rights of all workers to equal protections and benefits. there is a need to harmonise occupational health and safety law, and expand the scope of hearing-protection legislation to include the full range of established ototoxic hazards. conclusion: occupational audiology is dominated by efforts to address noise-induced hearing loss. a ‘noise’ despite the reality of workers’ exposures to a range of ototoxic stressors that act synergistically on the ear, resulting in audio-vestibular disorders. keywords: chemical; ototoxicity; occupational health; occupational health and safety law; audiology; hearing loss. introduction in this review, we present an understanding of occupational hearing loss (ohl) in relation to south african health law. traditionally, a review of any health condition would consist of an epidemiological description augmented with statistics like the size of the affected populations, incidence and prevalence rates, morbidity and mortality rates, and estimated economic burdens and other costs. however, the literature on ohl is characterised by a lack of data. this notch in epidemiological healthcare literature is an artefact of audiology’s history as a healthcare practice, particularly in south africa (osewe & nkrumah, 2018). our raison d’être is entwined with the constitution in chapter two of the south african bill of rights, which outlined standards for equality and the provision of healthcare services that all subordinate law, policy and administrative actions must meet. section 9 mandates the state to provide equal protection and benefit to all and disallows unfair direct and indirect discrimination. further, section 27 mandates the state to progressively realise healthcare rights (south african government, 1996). in order to understand the functional nature of law, it is first necessary to appreciate the general structure of south african legislation as was illustrated by collier-reed and lehman (2013) (figure 1): figure 1: branches of south african law. occupational healthcare is implicit in public law via regulatory laws and explicit in private law in the employment law sub-branch via the occupational health and safety laws. there are at least 11 laws, within public law (administrative law) and private law (commercial law) branches, requiring occupational healthcare services. in addition, there are regulations, guidelines and codes of practice that expand the number of legally binding requirements. the structure of south african law can therefore be overlaid by laws relevant to our focus, as demonstrated in figure 2. figure 2: structure of south african law. there exists a complex legal framework (see appendix 1) that spans general occupational sectors and specific mining, maritime, aviation, railway, transport and nuclear or energy sectors. the regulations and codes of practice associated with these sectors may refer to workers’ balance and/or hearing functions. notably, chemicals in the workplaces may be ototoxic (nakhooda, 2016) or, when combined with noise, exacerbate hearing loss (moroe & khoza-shangase, 2018). therefore, acts and codes for hazardous substances also bear relevance to ohl. furthermore, south africa has two worker compensation acts, namely, compensation for occupational injuries and diseases act (coida) and the occupational diseases in mines and works act (odmwa). these acts differ in the administration and benefits provided – and indication of these legal and worker compensation frameworks encode or reflect theoretical understandings of what constitutes a hearing loss in the workplace, what etiological factors are responsible for ohl as well as how to measure and manage workers’ hearing. indeed, and has been previously argued (pillay, 2001, 2011a; pillay & kathard, 2018), such understandings are usually unclear, hidden and not well-understood by audiologists outside of a few basic references to south african national standard (sans) guidelines or coida. significantly, this has an impact on worker rights when we consider that these are laws that mandate occupational hearing protections. the question this raises is: how adequately, in this legal quagmire of acts and regulations, is the state realising south african worker rights as per sections 9 and 27 of the bill of rights? therefore, the main aim of this article is to review current south african occupational health law (vis-à-vis workers’ constitutional rights) in relation to hearing loss. this review focusses on the identification of gaps in the law regarding ohl in south africa. the intention is to highlight the nature of work, the challenges and opportunities that hearing healthcare professionals – and specifically audiologists – need to pay attention to in post-1994 south africa. methodology this review is based on our combined experience of over 50 years in occupational health and audiology. experience used as a methodological device (daher, carré, jaramillo, olivares, & tomicic, 2017) is not a thoughtless method lacking theory. instead, we rooted experience within an old (but relevant) framework proposed by pillay, kathard and samuel (1997) who argued for south african audiologists’ use of a critical science to re-look at inequities. as such, we reflexively reviewed laws with social, political, cultural, gendered, historical and allied contexts related to how knowledge of workers’ hearing has been produced. methodologically, this facilitated constructing, deconstructing (cf decolonising: pillay & kathard, 2015, 2018) and re-constructing new meaning across occupational law. we relied on the inherently subjective (gonzález rey & mitjáns martínez, 2019:21) and useful method of dialogue or critical conversations (pillay, 2011b). finally, we read these laws within a political framework (kathard & pillay, 2013) to interpret worker rights. while not designed as a literature review study, per se, we were influenced by evidence synthesis methodologies to review south african primary and secondary law. the first author, an occupational health and safety expert, identified relevant acts, regulations and codes of practice. selected for their current relevance in south african law, these laws refer to various occupational sectors, and they contain references to noise, hearing, vestibular disorder, dizziness, vertigo, giddiness, nystagmus, ménière’s disease, radiation, pressure and barotrauma. notably, we excluded laws applicable to the south african national defence force and the south african police services because of their unique legislation and compensation laws. we identified a lot of grey literature (unpublished or non-peer-reviewed legal documents) to enrich our analysis. we made sense of what we read using braun and clarke’s (2006) six-step framework. we familiarised ourselves with the data, followed by a system of coding of selected text towards identifying themes that were then clustered for the development of a conceptual map. we further identified thematic patterns and identified textual extracts. a semantic approach was followed in order to describe the content of current legal data. we then critically interpreted possible implications to the rights of all persons for equal protection and benefit from the law – cross referencing the bill of rights as a core analytical framework. ethical considerations the authors confirm that ethical clearance was not needed or required for this study. results and discussion we identified the following major themes: separate and unequal regulatory frameworks monologic foregrounding of noise minimisation of vestibular disorders dilution of ototoxic agents. separate and unequal regulatory frameworks occupational health and safety (ohs) law is fragmented based on scopes and types that mandate employee’s medical monitoring. firstly, the division in scope spans three occupational fields: general, mining and shipping – with shipping being further divided, wherein cargo handlers (e.g. stevedores) are covered under the occupational health and safety act (osha) (republic of south africa, 1993b) and all other personnel on the ship are covered under the maritime shipping act (msa) (republic of south africa 1951). therefore, different legislative requirements apply to each group. it must be noted that the msa dates from the 1950s and lacks an analogous structure and purpose as compared to the ohsa and the mine health and safety act (mhsa). the msa mainly has a regulatory purpose to manage, for example, licensing and labour relations. a second division between the types of law resulted in the separation of regulatory and employment law. the three ohs laws fall within the employment law division, but the laws creating the specific regulator bodies, for example, the civil aviation authority (caa) falls under regulatory law. while occupational health and safety law is focussed on the creation of safe and healthy work environments, regulatory law is focussed primarily on liability management, and it can be argued that these laws address occupational illness from a tort law perspective where illness is characterised as a result of ‘human error’ (hutchings, 2017), a risk that must be managed. in this regulatory and employment division, the following characteristics are critical: (1) codes of practice under ohsa and msa have a different status compared to the codes of practice under mhsa and (2) the use of exposure limits from other jurisdictions, for example, from the united kingdom occur – as in the case of the maritime sector (2007). there are several other characteristics that make the set of relevant legal frameworks unequal, namely: a variety of nomenclature to designate and empower medical practitioners, not all of whom are defined as occupational medical practitioners, for example, designated aviation medical practitioner (republic of south africa, 2001; south african civil aviation authority, 2011) and occupational health practitioner (republic of south africa, 2000a). reporting mechanisms differ; for example, in msa, as per s5(e), the ‘employer’ alone reports cases (1996), or in shipping, a case is entered into the ships’ official log-book and, as per s185 of msa, the master delivers this log-book to the ‘proper officer’ when the ship returns to port (1996). regulatory bodies focus on liability management while the impact of working conditions appears to be minimised. different and uncomplimentary organisational cultures persist; for example, in aviation (sa-cats, 2011: caa, schedule 28: obstetrics and gynaecology), this includes ‘menstrual disturbances’ and ‘medical requirements following confinement or termination of pregnancy’ (2011). the use of an irregular term (menstrual disturbance) and the inclusion of outdated traditional practices (confinement) are both remnants of a past paternalistic culture. medical standards exist with highly detailed protocols (e.g. aviation) or as accepted standards (maritime, railways) that manage ‘human factors’ as risk sources or, as dictated by organisational culture, used interchangeably with human error (hutchings, 2017), giving no cognisance to ill health from occupational stressors. critically, these medical standards do not provide instructions on rehabilitation protocols. hazardous biological agents regulations (2001), hazardous chemical substances regulations (hcsr) (1995) and the lead regulations (2001) contain medical surveillance standards but exclude reference to ototoxicity in spite of known ototoxic agents, for example, infectious agents, solvents and lead. national road traffic regulations (republic of south africa, 2000a) and construction (2014) require medical certification without any medical fitness standards. both work environments contain known ototoxic agents like carbon monoxide and solvents. medical surveillance and medical incapacity management protocols are unequal; for example, mhsa is unmatched for its promulgation of standards for exposure, fitness, medical surveillance implementation and management of rehabilitation and return to work. sector disparities exist with workers in noisy workplaces benefitting from legislation (e.g. the noise-induced hearing loss regulations [nihlr]) to manage this specific ototoxic agent without similar benefits for those exposed to ototoxic agents, such as chemicals, excessive pressure changes or radiation. in summary, south african ohs law is highly fragmented and has been so for over the last 40 years, as commented on by ncube and kanda (2018). they explained that these fragmentations have been resulting in duplication of law enforcement roles; a costly waste of scarce resources; and inconsistencies and lack of uniformity in the implementation of enforcement functions. the main outcome is a hampering of progress at safeguarding workers’ health. our analysis is aligned with ncube and kanda’s conclusions that there are four departments (labour, mining, transport and health) creating legislation and five regulatory bodies (aviation, rail, road, nuclear, maritime) creating specific management protocols. the shipping sector does not have any pure occupational health and safety enabling legislation equivalent to the ohsa and mhsa. overall, it is therefore not surprising that systemic inconsistencies exist for the provision of occupational audiology protections and services in south africa. the next three sections, summarised in table 1, focus on more specific issues: table 1: summary of the core themes emerging from an analysis of south african general, mining and shipping acts and regulations of occupational hearing loss. monologic foregrounding of noise the current legal doctrine mandating occupational audiology protection is essentially monologic, as its theoretical rationality is centred on ‘excessive noise’ as the only ototoxic stressor and ‘hearing loss’ as the only negative health outcome. for example, nihl regulation 3 includes exposure to noise and sets the noise exposure limit at 85 dba (republic of south africa, 2003); regulation 8 sets the requirements for a system of environmental monitoring and medical surveillance of ‘noise zones’ (republic of south africa, 2003). similarly, the title of sans 10083 (south african bureau of standards, 2013) is clear about its focus, namely, ‘the measurement and assessment of occupational noise for hearing conservation purposes’ as is the compensation commissioner’s circular instruction no. 171, entitled ‘determination of permanent disablement resulting from noise-induced hearing loss and trauma’. similarly, the diving regulation codes of practice (south african department of labour, 2001) cite ‘noise’ approximately eight times and ‘hearing’ or ‘hearing loss’ four times in its text. chemical and pressure hazards are noted but inconsistently referenced to audio-vestibular disorder risks. in mining, noise-induced hearing loss is prioritised by standards for pollutants, heat and noise (regulation 9, 1996) – specific guidelines for noise exposure management (department of mineral resources, 2003b) and hearing conservation (standard threshold shift) (department of mineral resources, 2016a). the fitness standard uses a pure tone audiometric assessment protocol (fitness standards) (department of mineral resources, 2003a). this monologic rationality is echoed in shipping with the msa and south african maritime safety authority act (samsa) (republic of south africa, 1998a) whose regulations and codes of practice emphasise the role of noise and the importance of noise control by focussing on an insistence by portnet (1994) that one ‘must check the noise level’ alongside the use of ear protection and noise exposure (maritime and coastguard agency [mca], 2018) or the reduction of noise levels and soundproofing of workstations (mca, 2018). the coida, by its presumption in section 66, recognises that disease conditions listed in schedule 3 are because of an occupational overexposure for which this insurance regime considers compensation. however, ‘hearing loss caused by excessive noise’ is the only specific audio-vestibular disability or disease that is listed. in summary, the dominant narrative is one of the need to control ‘noise’ exposure to prevent ‘hearing-loss’. it is well-established that chemicals, for example, complicatedly affect workers hearing in the presence of noise (watts, 2019). other stressors (pressure, heat, vibration, etc.) also complicate hearing loss (lie et al., 2016). however, even if noise is the single stressor, then auditory effects are not the only outcome. suicide, depression, anti-social behaviours – other psychological, social and even associated physiological (non-auditory) effects have disabling, if not fatal, outcomes on workers’ (and their families or social) lives (basner et al., 2014). thus, the monologic rationality that dominates the legal discourse results in a violation of worker rights by being selectively protective. this means that these laws indirectly discriminate worker rights. indirect discrimination is the violation of one’s rights to equal protection because the existing policy disfavours a particular group, without justification. the analysis of the current legal doctrine normalises noise-induced hearing-loss as the standard occupational disability that must be prevented by the measures prescribed by the nihlr as an example. the minimisation of vestibular disorders none of the three legal frameworks address vestibular disorder in any substantial manner, save its inclusion in specific medical testing regimes. aviation (south african civil aviation authority, 2011), maritime (south african maritime safety authority, 2016) and railway management specification (southern african railway association [sara], 2011) include requirements and protocols for the assessment of vestibular disorder – with a frequent reference to ‘meniere’s disease’, which minimises the recognition of occupational ototoxic agents. in mining, for example, in mhsa regulations 11 3 c (viii), broad statements exist like: ‘…(o)occupational diseases, past or present, including severity’ (republic of south africa, 1996) without specific reference to vestibular disorders. mining regulations prescribe exclusive use of pure-tone audiometry, which is not suitable for detecting vestibular disorder. similarly, diving documentation, such as the code of practice for off-shore diving (department of labour, 2017), includes statements like ‘…other systems of the body’ and ‘(s)pecific diving injuries and diseases’, which may beinterpreted as including audio-vestibular disorders. in reference to water pressure in the external ear canal, outcomes are noted as ‘…splinting the tympanic membrane, etc.,…’,where vestibular disorders may be included in the ‘etc.’. for coida, schedule 3 (republic of south africa, 1993c) lists the wider range of audio-vestibular disorder within broader statements such as ‘…any disease or pathological manifestations…’ caused by the given list of chemical agents, ‘…dysbarism, including decompression sickness, baro-trauma or osteonecrosis,…’ and ‘…(a)ny disease caused by ionising radiation’. the term ‘ototoxic agent’ is not included. in summary, vestibular disorders are rarely and barely recognised as occupational stressors, which results in selective medical testing, compromising worker rights – as discussed in the implications section. dilution of ototoxic agents dilution of ototoxic agents refers to the grouping of agents together into a general hazard group. only the sara (2011) noted the ‘…(d)elayed effects such as nervous system toxicity, cancer of the lungs or chemically-induced hearing loss…’. the dominant doctrine places known ototoxic agents into a common basket of hazards, for example: the hazardous biological agents regulations (republic of south africa, 2001), hcsr (republic of south africa, 1995) and the lead regulations (republic of south africa, 2002a) contain medical surveillance standards but do not include any reference to ototoxic outcomes even though these regulations are aimed at known ototoxic agents, for example, infectious agents, solvents and lead. the hcsr require safety data sheets to be prepared in a form described in annexure 8 (republic of south africa, 1995); it is not a requirement for known ototoxic chemicals to be labelled as such. similarly, in the mining sector, the mhsa (republic of south africa, 1996) notes that there are ‘…significant hazards or risks the employee was exposed to, such as dust, noise, radiation, chemical or other’. in the shipping sector ‘…gasses, fumes, dust, radiation, excessive noise…’ are clustered together (portnet, 1994). chemicals are noted as ‘harmful to face and eyes’ and can ‘cause skin damage’ (mca, 2018). the diving regulations codes of practice (department of labour, 2017) that refer to ‘…health hazards’ include ‘physical hazards’ and these include ‘radiation hazards, noise, temperature extremes and pressure (causing barotrauma, decompression sickness)’. chemicals are highly referenced in the codes, and it is noted that ‘…(s)kin exposure may cause local effects (e.g. chemical burns) or may cause systemic effects due to absorption of the chemical’ (p. 13), but these references do not highlight their ototoxic potential. barotrauma appears twice (2); once as ‘pulmonary barotrauma’ but aural or otic barotrauma is never indicated. in summary, diluting ototoxic agents into a homogenous etiological ‘phenomenon’ disguises the specific nature of ototoxic agents. this clustering of aetiological factors has implications for what and how workers are compensated. the compensation procedure (stipulated by ci 171) and the absence of any specific reference to other forms of audio-vestibular disorder in schedule 3 of the coida places persons with these disease conditions at a disadvantage. in addition, as none of the regulatory agencies’ medical examination protocols explicitly refer to the legal obligation of sections 24 and 25 of the ohsa, cases may go unreported to the compensation commission. this is, in fact, the committing of an offense in terms of the ohsa. the insistence of a medically simplistic meme of ‘one stressor-one outcome’, rooted to its monologic rationality, is an artefact of biomedical, empirical science that simplifies the complexities of workers’ lived realities. the implications of this are discussed next. implications of the ‘one-stressor, one-outcome’ paradigm and worker rights three aspects of the current paradigm require evaluation for (1) the provision of reasonable protection in the workplace; (2) how medical surveillance testing occurs; and (3) the compensation for occupational disease. from our analysis above, it becomes apparent that workers are (1) selectively protected; (2) offered selective medical testing; and (3) selectively compensated across occupations for their ohl or disability in south africa. as noted above, when noise is – legally – the prime ototoxic agent, regulations violate worker rights by being selectively protective. facilitated by a monologic rationality, the full range of occupational audio-vestibular disorder is othered outside of noise-induced hearing loss. the lack of reform of the regulation, for example, nihlr to include other known ototoxic agents is contrary to the mandate to progressively extend protection to all employees including those in non-noisy but oto-traumatic occupations. medical testing is then cast as selective. consider (employment equity act [section 7] [republic of south africa, 1998b]): (1) medical testing of an employee is prohibited, unless … it is justifiable in the light of medical facts, employment conditions, social policy, the fair distribution of employee benefits or the inherent requirements of a job. (n.p.) medical surveillance and fitness testing that exclude protocols to determine non-noise audio-vestibular disorders or disabilities are prohibitive. they do not recognise established medical facts regarding the polylogical aetiologies of occupational audio-vestibular disorder. selective medical testing is a healthcare mechanism that prohibits the fair distribution of employee benefits and does not acknowledge the inherent requirements of a job. such medical testing implies that workers are selectively compensated, indicating a form of worker discrimination. under the promotion of equality and preventi on of unfair discrimination act (republic of south africa, 2000b), discrimination is defined as: [a]ny act or omission, including a policy, law, rule, practice, condition or situation which directly or indirectly imposes burdens, obligations or disadvantage on; or withholds benefits, opportunities or advantages from any person on one or more of the prohibited grounds… (n.p.) in section 14, the ‘determination of fairness or unfairness’test includes a consideration of the social position of the affected persons and the systemic nature of the discrimination, its nature and purpose. a legal framework, as we have demonstrated, which inadvertently disadvantages or withholds benefits, such as insurance products, from reaching workers for scientifically unjustifiable reasons because of the manner in which the system of occupational health and safety operates will face a serious challenge to be accepted as ‘fair’. summary and recommendations in summary: south african workers are exposed to a range of oto-traumatic agents, for example, noise, pressure, radiation in addition to background exposure to a growing list of chemical pollutants (e.g. matatiele et al., 2019; niranjan, 2015). exposure to these agents (singularly or in combination) may likely lead to a range of audio-vestibular diseases not limited to auditory effects or loss of hearing acuity, per se. the loss of audio-vestibular function may lead to dismissal on grounds of medical incapacity. current compensation laws will not necessarily acknowledge claims of non-noise-induced hearing losses. the exclusion of established hearing assessment protocols from the mandatory medical surveillance examinations is irrational and discriminatory. we recommend: a critical review of all laws relevant to hearing healthcare (specifically, occupational audiology) intended to broaden the definition of ohl rationalisation and harmonisation of the ohs law into one system specific inclusion of audio-vestibular disorders under coida identification of gaps in ohl research such as epidemiological data development of adjusted standards for: exposure limits including realistic combinations of ototoxic agents environmental monitoring, for example, codes of practice for noise measurement in under-water and deep mining contexts guidelines for the transportation of mine workers in deep-level mining. conclusion in 2016, revelations of a systemic cover-up of occupational disease in the silicosis trial (nkala and others v harmony gold mining company limited 2016) resurrected the spectre of gross human rights abuse in the workplace. the south african human rights commission (2016) conducted a national hearing on unfair discrimination in the workplace. the report on these hearings made the following findings: significant advances and gains made in labour practices since 1994, but unfair discrimination still pervades the workplace there is a lack of understanding by key role-players as to the meaning and complexity of unfair discrimination in its entirety there is a lack of awareness and/or sufficient attention paid to other forms of systemic discrimination taking place in the workplace many instances and specific manifestations of unfair discrimination continue to occur inconspicuously and remain largely unreported one of the biggest driving factors of unfair discrimination is a lack of awareness and information. while this report deals with disability in the workplace, it overlooks: (1) impairments of occupational cause; (2) the fairness of medical fitness assessments; and (3) the need for a review of the ohs law, with special attention to broadening the definitions of occupational disease and the need to establish valid medical surveillance standards. like all forms of cultural blindness, ours is deep and effort is required to address the gaps and weakness in our ohs law in order to ensure equality to all. this work is urgent noting what ackermann stated in the constitutional court ruling in the national coalition for gay and lesbian equality and others v minister of home affairs and others (cct10/99) (1999) case for same sex rights ‘like justice, equality delayed is equality denied’. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions w.g.m. is the main author who conceptualised, collated and analysed all data and prepared all drafts of the article. m.p. served as a critical reader and reviewed legal references to the theoretical context of audiology practice, education and research in south africa . funding information the authors acknowledge the national institute for the humanities and social sciences (nihss) and the consortium for advanced research training in africa (carta) for providing financial assistance during publication of this manuscript. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references basner, m., babisch, w., davis, a., brink, m., clark, c., janssen, s., & stansfeld, s. 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(2019). ototoxicity: visualised in concept maps. seminars in hearing, 40(2), 177–187. https://doi.org/10.1055/s-0039-1684046 appendix 1 box a1: selected legal frameworks (acts, regulations and codes) of south african occupational sectors for worker hearing. table a1: summary of hearing protection laws. table a2: summary of results in regulatory law. page two journal of the south afrian logopedic society stuttering: an interpretation of research findings. wendell johnson, ph.d. university of iowa experimental research in stuttering has been carried on continuously at the university of iowa since 1924. the first studies were concerned with the possible hypothesis that stuttering might be due to some sort of physical fault, but relatively thoroughgoing investigation over a period of several years failed to substantiate the hypothesis. gradually, then, particularly after'the. early thirties, the iowa researchers turned their atten-' tion more and more toward other approaches to the problem, four in particular:! 1. the inter-relationship between stuttering and : personality manifestitations. λ 2. the conditions associated with onset and early development of stuttering ins children. • 3. modes of therapy and their effects. 4. conditions associated with variations in amount or severity of stuttering. ι the personality studies have indicated that stutterers are essentially like non-stutterers. ^insofar as they differ from non-stutterers id their personal and social adjustments, they are a little! more socially withdrawing and a little more inclined toward discouragement. it is a difference on the average of about the proper magnitude to indicate that stutterers react to the frustration and humiliation of stuttering with essentially normal affect. if they were more like non-stutterers than they are in these respects, it might be suspected that they were bland to an abnormal! degree. what there is to add to this generalization is jthe observation that, while stutterers are like other people in having various reasons for developing maladjustments, the stuttering itself undoubtedly serves in many cases as a source of more or less significant emotional unrest and demoralization. this is not to say that stuttering is, or leads to, or is a symptom of psychoneurosis. it does not mean that stutterers cannot have psychoneuroses of the types other people have. nor does it mean that psychoneurotic mechanisms cannot in some instances manifest themselves in stutter-like reactions. what it does mean primarily is that, while stutterers by and large appear to be essentially normal as personalities, they like other people, can and do have adjustment problems, and some of their adjustment difficulties seem to stem from the fact that they stutter. in general, the studies so far made of the onset of stuttering have yielded substantial indications that the children who develop stuttering are essentially normal, and that in cases in which the problem can be traced back to its first days, or hours, or even minutes,, the patient turns out to have more than two legs, so to speak. what is meant is that there is always the mother or father, occasionally a teacher, or some other responsible adult listener, or even several such listeners, in the picture along with the child. at first, indeed, there appears to be serious question whether the child is doing anything at all that can be properly judged to be of clinical significance. what the parent, or other adult listener, is doing, however, appears to be of very considerable importance. the parent, or other listener, in such a case is found to be making and acting upon a judgement — a judgment to the effect that the child's speech is not as it should be, a judgment that becomes overt in postures, frowns, jor even actual statements that the child interprets as disapproval. and so it is the listener's judgment rather than the youngster's speech that appears (to have the kind of consequences that need to be counteracted. speech samples obtained, from approximately 200 pre-school age children have been analyzed. these have been essentially unselected children, except that they were attending the university of iowa preschools. instances of repetition in trie speech of these children have been counted. the repetitions fall into three main categories: (1) those involving repeated sounds or syllables sususuch as this; (2) those involving repeated words such such such as this; and (3) those involving repeated phrases such as this such as this such as this. all children observed have exhibited repetitions; the range is roughly from 5 to 100 instances of repetition per 1,000 words, and the average is approximately 45 instances per 1,000 words. the repetitions are essentially effortless and apparently "unconscious." whenever young stutterers have been observed soon enough after the alleged onset, the phenomena indicated by their parents as those which they have "diagnosed" as stuttering are found to be quite like these normal speech repetitions. on the other hand histories taken very long after onset tend strongly to be obscured and apparently fashioned largely by presupposition. the basic fact appears to be that the parents, in the usual case, regard the child's normal non-fluencies as "abnormal""df "defective" or as "stuttering", or "stammering" and then react to the child accordingly with more or less disapproval and concern, which they make more or less manifest to the child. what it comes to, so far as the present writer can determine, is that the speaker (the child) responds to what the listener (the adult) does. and what the listener does seems to be more or less unnerving to the speaker, so that, while the responses and effects appear r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society page three to be quite subtle and slow-working in most cases, the speaker's reactions to the listener's evident evaluations come in time to be marked by noticeable hesitation and tension. and as this development leads to more evident concern and disapproval on the part of the listener, so this more evident concern and disapproval are reacted to by the child with speech attempts that are correspondingly more unsure and strained. it is a vicious cycle, and, as such, it tends to expand. the problem of stuttering, then, would seem to start, not in the speaker's mouth, but in the listener's ear, and at the very first it is the parent, or other authoritative listener, rather than the child, who is the patient, or at least the major part of the "composite patient." but the problem, starting in this essential fashion, does not arise in a social, psychological, and physiological vacuum. things happen to these parents and these children just as they do to other parents and other children, and some of these things are more conducive than are others to the sorts of parental evaluations and child reactions, and the sorts of basic parent-child relationships, that tend to eventuate in the behavior we recognize in speech clinics as stuttering. research on therapy per se has proved to be very difficult from a technical point of view. experience with it to date has served to persuade the writer that during the exploratory phases of research of this type the most fruitful approach is likely to be the fairly simple one of doing the 'best one can to treat stuttering effectively case by case, keeping reasonably detailed records of what is done in each case, and observing and measuring by any and all means that one can devise the various kinds of change that take place. elaborately designed experiments, with two or more types of therapy, matched control groups, and other refinements, do not appear to this writer to be feasible at the present stage of our theoretical and clinical development and in any clinical situations known to him. it is to be hoped that the advances necessary to make them practical and worthwhile will be achieved. in the meantime, not. only is there promise of important finding from the conservative type of project sketched above, but also there would seem to be significant implications for therapy in the data from much of the laboratory research on stuttering, particularly that concerned with determination of the conditions under which stuttering increases and decreases. indeed, in recent tyears the variations in amount or severity of stuttering] have been drawn into sharper and sharper focus by investigators of the problem. in 1933 in the quarterly journal of speech the present writer presented the notion that the stuttering problem might be approached fruitfully by concentrating on the moment of stuttering — that is to say, by dealing with the problem of stuttering as a series of stutterings, by regarding it crucially not as a more or less constant condition, but as intermittent responses. this concept of the moment of stuttering suggested the feasibility of measuring amount of stuttering and variations in it by the obvious means of counting the moments of stuttering in systematically obtained samples of speech. from studies involving the counting of moments of stuttering three basic findings emerged. these were (a) the adaptation effect — the decrease in frequency of stuttering that occurs with repeated readings of a passage or, to a lesser degree, with continued reading of non-repeated material; (b) the consistency effect — the tendency for stuttering to occur consistently in response to the same cues or stimuli; and (c) the recovery of the strength of the stuttering response, as measured by reference to its frequency or severity, subsequent to a sufficient interval of time following adaptation. the adaptation of the stuttering response was found to amount on the average to about a fifty per cent, reduction in its frequency from the first to the fifth consecutive reading of a passage. the decrease with continued reading of constantly changing material is less but still substantial. one may look upon the adaptation effect as a kind of laboratory model of the improvement process, and as such it can readily be observed as affected by any specified condition. in this way the conditions associated with increase in improvement, as well as those associated with its retardation, or even its reversal, can be ascertained and appraised. research of this sort tends, therefore, to yield findings that are of value not only in a theoretical but also in a most practical therapeutic sense, since anything one might mean by therapy for stuttering must necessarily involve the fostering of those conditions under which stuttering decreases in amount or severity. in like manner the spontaneous recovery of the stuttering response following adaptation is of both theoretical and practical interest. the jones* study showed that within twenty-four hours after adaptation, achieved by five consecutive readings of a passage, the frequency of the stuttering response had returned to the approximate level observed before adaptation. the jamison study indicated that roughly full recovery might be achieved within as short a period as four and one-half hours. this effect may be looked upon as a laboratory model, so to speak, of the process that is recognized clinically as a relapse. like the adaptation effect, it can be investigated under controlled conditions with a view to identifying and evaluating the factors associated with increase and decrease in its rate and extent. the findings from such research would seem to have clinical implications of a very practical kind. the consistency effect is significant particularly for what it implies relative to the essential nature of stuttering behaviour. the fundamental implication is that stuttering, rather than behaving like a "disorder," or "spasm," or "incoordination," or random "dyssynchronization" of the neuro-muscular mechanism involved in speech, behaves like a response made to r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) page four journal of the south african logopedic society identifiable stimuli or cues with a very considerable degree of consistency or predictability. in the original study dealing with the consistency effect, professor knott and the writer reported that of the words stuttered in the second reading of a passage roughly twothirds had been among those stuttered in the first reading. in general, this holds for any reading in relation to the proceeding reading of any passage that is read several times in succession. this degree of consistency of the specific words eliciting the stuttering response suggests some mechanism akin to conditioning, if it is not in fact a variety of conditioning. this suggestion is heavily underscored by brown's 1945 findings which may be highly abstracted in the statement that ninety-five per cent, of the stutterings in his investigation could be accounted for by reference to just four features of the stuttered words: initial sound, position in the sentence, length (number of letters), and grammatical function. ninety-five per cent, of the stuttered words possessed one or" more of the following characteristics: initial sound a consonant (except for the consonants -th (h), (w), (m), and (t), length greater than the median (five letters or more), one of first three words of a sentence, and grammatical function of adjective, adverb, noun, or verb. such findings, set in the general context of presentday knowledge about stuttering, and about behaviour generally, serve to emphasize impressively that neither of the traditional theories of stuttering — that one which attributed it to a physical fault and the other which viewed it as a symptom of an unstable or turbulent personality — was based on sufficient information about the ways in which stuttering behavior behaves. if they explained stuttering, they did not account for the stutterer's non-stuttered speech, and they did not explain the variations in stuttering frequency or severity in response to the particular cues and conditions now known to be associated with these variations. the kinds of data here referred to prompt one to regard stuttering as learned behaviour, and to investigate it, theorize about it, and treat it clinically, as such. at the present stage of our total stuttering research program a relatively rough theory may be attempted. the writer, acknowledging his debt to all his instructors, students and colleagues in this area of research and clinical work, would prefer to state it in this general way: stuttering appears to be an anxiety-motivated avoidant response that becomes "conditioned" to the cues or stimuli associated with its occurrences. like other anxiety-motivated avoidant responses, stuttering is anticipatory. that is, stuttering comes to be expected. the expectation of stuttering is apprehensive, characterized by anxiety in some degree, ranging from near panic to the very mild sort of affective reaction which the stutterer expresses by saying simply that he would rather not stutter — an affective condition or state which the present writer has called "rather-not-ness." this anxious or apprehensive expectation comes to be associated with and to be elicited by the sounds, words, listeners and other cues or features of situations in relation to which stuttering has been experienced in the past. such cues, then, function as reminders, and so as "storm signals," warning of "danger ahead." the "danger ahead" is evaluated with degrees of anxiety from mild to severe, depending on a number of factors among which are to be included quite definitely (a) the severity and discomfort of past stuttering, (b) the penalties consequent to past stuttering, (c) the stutterer's insight into the nature of his stuttering, behavior and the factors or conditions that affect it, (d) the stutterer's familiarity with ways of modifying his stuttering responses so as to decrease the tension, discomfort, and feelings of helplessness and lack of control involved in them, and (e) the stutterer's general sense of personal security, his feeling of "being able to afford to stutter," and his basic personal and social adjustment. so long as the "danger ahead" is anticipated with any degree of anxiety, the stutterer's reaction to it is avoidant. that is, he does various things in an attempt to avoid the "danger ahead," the expected stuttering. now, these things he does to keep the expected stuttering from occurring, these avoidant responses — these are the stuttering. stuttering, then, is what the speaker does to keep from stuttering. the more intense the speaker's anxiety or concern over the anticipated "stuttering," the more cues it is likely to become associated with, so that the avoidant responses will occur more frequently, and the more intense or elaborate or prolonged or severe the avoidant responses will be on the average. as the anxiety about stuttering is weakened, therefore, both the frequency and severity of the avoidant reactions — of the stuttering, that is — are reduced. improvement is a function, then, of anxiety deconfirmation. this theory implies that therapy is to be properly designed to deconfirm the speaker's anxiety or concern about his stuttering, by means of any and all relevant procedures from counseling in its various forms, through various techniques of modifying the avoidant responses, to systematically and judiciously increased speaking experiences and total speaking time. this rough outline of a theory of stuttering is presented tentatively. it is the fruit, acceptable or not as it may be to specific readers, of experimenting and thinking by many workers over a period of many years. it is to be expected that it will be influenced by further data and by further evaluating of both old and new data. its main value at this stage is undoubtedly to be found in the further experimentation and theorizing that it may stimulate. • t h i s article was s u b m i t t e d a t the request of t h e e d i t o r i a l c o m m i t t e e of the s o u t h african l o g o p e d i c society. w h e n t h e r e q u e s t was received t h e writer h a d j u s t c o m p l e t e d a s u m m i n g u p of s o m e t h i r t y years of s t u t t e r i n g r e s e a r c h at t h e university of i o w a , a n d it s e e m e d t h a t he could best serve t h e i n t e r e s t s of t h e r e a d e r s of t h e journal by s h a r i n g with t h e m t h e m a i n c o n c l u s i o n s of this research. t h e m a t e r i a l c o n t a i n e d in this p a p e r therefore, is d r a w n a n d a d a p t e d , by p e r m i s s i o n of t h e p u b l i s h e r f r o m stuttering in children and adults! a partial report of thirty years of research at the university of iowa, edited by t h e writer with t h e a f 1 s , o ? i e u ° f ? a l p l ; i e u t e n e g g e r a n d scheduled for p u b l i c a t i o n in the fall of 1954 by t h e u n i v e r s i t y of m i n n e s o t a press, m i n n e a p o l i s , m i n n e s o t a , u . s . a . , u n d e r a g r a n t f r o m t h e l o u i s w . a n d m a u d hill f a m i l y f o u n d a t i o n t h e a u t h o r is c h a i r m a n of t h e u n i v e r s i t y of i o w a c o u n c i l on speech pathology and audiology. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) journal of the south african logopedic society page ie b i b l i o g r a p h i c a l n o t e t h e s t a t e m e n t s m a d e in this p a p e r a r e based o n d a t a a n d t h e o r e t i c a l discussions of d a t a t h a t a r e to be found in a c o n s i d e r a b l e n u m b e r of articles, m o n o g r a p h s , a n d b o o k s . a t t h e u n i v e r s i t y of i o w a a l o n e a p p r o x i m a t e l y 150 m . a . a n d p h . d . investigative d i s s e r t i o n s o n s t u t t e r i n g h a v e been c o m p l e t e d since 1924, and s o m e 250 r e s e a r c h r e p o r t s a n d clinical a n d theoritical p u b l i c a t i o n s dealing with t h e p r o b l e m h a v e been p r o d u c e d a t this r e s e a r c h c e n t r e . a few selected references, including all these specifically cited in this article, a r e h e r e listed for t h e benefit of interested r e a d e r s . 1. b r o w n , s p e n c e r f . " t h e l o c i of s t u t t e r i n g s in t h e s p e e c h s e q u e n c e , " journal of speech disorders. 10:181-192 (1945). 2. d a r l e y , f r e d e r i c l . " t h e r e l a t i o n s h i p of p a r e n t a l a t t i t u d e s a n d a d j u s t m e n t s to t h e d e v e l o p m e n t of s t u t t e r i n g , " stuttering in children and adults, j o h n s o n , w . e d . , l e u t e n e g g e r , r . , a s s t . e d . , m i n n e a p o l i s : university of m i n n e s o t a p r e s s , scheduled for p u b l i c a t i o n , fall, 1954. 3 d a v i s , d o r o t h y m . " t h e r e l a t i o n of r e p e t i t i o n s in t h e speech of y o u n g c h i l d r e n to c e r t a i n m e a s u r e s of l a n g u a g e m a t u r i t y a n d situat i o n a l f a c t o r s , p a r t i , " journal of speech disorders, 4:303-318 (1939). 4 . d a v i s . d o r o t h y m . " t h e r e l a t i o n of r e p e t i t i o n s in the s p e e c h of y o u n g c h i l d r e n t o c e r t a i n m e a s u r e s of l a n g u a g e m a t u r i t y a n d s i t u a t i o n a l f a c t o r s , p a r t i i , " journal of speech disorders, 5:235-246 (1940). 5. j a m i s o n , d o r o t h y j a n e . ' " s p o n t a n e o u s r e c o v e r y of t h e s t u t t e r i n g r e s p o n s e as a f u n c t i o n of t i m e f o l l o w i n g a d a p t a t i o n , " stattering in children and adults, j o h n s o n , w . e d . , l e u t e n e g g e r , r . , a s s t . e d . , m i n n e a p o l i s : u n i v e r s i t y of m i n n e s o t a press, scheduled for p u b l i c a t i o n , fall, 1954. 6 j o h n s o n , w e n d e l l . " a n i n t e r p r e t a t i o n of s t u t t e r i n g , " qnarterly journal of speech, 19:70-77 (1933). 7 j o h n s o n w e n d e l l . people in quandaries: the semantics of personal adjustment. n e w y o r k : h a r p e r & b r o s . , 1946, p p . 532. c h a p t e r 17, ' t h e i n d i a n s h a v e n o w o r d for i t : t h e p r o b l e m of s t u t t e r i n g . " 8. j o h n s o n , w e n d e l l a n d b r o w n , s p e n c e r f . " s t u t t e r i n g in r e l a t i o n t o v a r i o u s s p e e c h s o u n d s , " quarterly journal of speech, 21:481-496 (1935). 9 j o h n s o n , w e n d e l l a n d k n o t t , j o h n r . " t h e m o m e n t of s t u t t e r i n g , " journal of genetic p s y c h o l o g y , 48:475-479 (1936). 10. j o h n s o n , w e n d e l l a n d k n o t t , j o h n r . " s t u d i e s in t h e psychology of s t u t t e r i n g : i . t h e d i s t r i b u t i o n of m o m e n t s of s t u t t e r i n g in successive r e a d i n g s of t h e s a m e m a t e r i a l , " journal of speech disorders, 2:17-19 (1937). 1 11. j o h n s o n , w e n d e l l a n d i n n e s s , m a r j o r i e . " s t u d i e s in t h e p s y c h o l o g y of s t u t t e r i n g : x i i i . a statistical a n a l y s i s of t h e a d a p t a t i o n a n d c o n s i s t e n c y effects in r e l a t i o n to s t u t t e r i n g , " joudnal of speech disorders, 4:79-86 (1939). 12. j o h n s o n , w e n d e l l a n d king, a r t h u r . " h a n d u s a g e a n d a n g l e b o a r d d e x t r a l i t y q u o t i e n t s of a d u l t s t u t t e r e r s a n d n o n s t u t t e r e r s , " journal of experimental psychology, 31:293-311 (1942). a b s t r a c t in psychological bulletin, 37:424 (1940). 13. j o h n s o n , w . , b r o w n , s . f . , c u r t i s ; j . f „ e d n e y , c . e . , a n d k e a s t e r , j . speech handicapped school children. new y o r k : h a r p e r & b r o s . , 1948. c h a p t e r 5, " s t u t t e r i n g , " p p . 179-257, a n d a p p e n d i x , p p . 409411, 439-451. 14. j o h n s o n , w e n d e l l . " a s t u d y of t h e o n s e t a n d d e v e l o p m e n t of s t u t t e r i n g , " stuttering in children and adults, j o h n s o n , w . e d . , l e u t e n e g g e r , r . , asst. e d . , m i n n e a p o l i s : university of m i n n e s o t a press, scheduled for p u b l i c a t i o n , fall, 1954. 15. j o n e s , e . l e r o i . " e x p l o r a t i o n s of e x p e r i m e n t a l e x t i n c t i o n a n d spont a n e o u s r e c o v e r y in s t u t t e r i n g , " stuttering in children and adults, j o h n s o n , w . e d . , l e u t e n e g g e r , r . , a s s t . e d . , m i n n e a p o l i s : university of m i n n e s o t a press, scheduled for p u b l i c a t i o n , fall, 1954. 16. l o v e , w i l l i a m r o b e r t . " t h e effect of p e n t o b a r b i t a l s o d i u m ( n e m b u t a l ) a n d a m p h e t a m i n e s u l p h a t e ( b e n z e d r i n e ) o n the severity of s t u t t e r i n g , " stuttering in children and adults, j o h n s o n , w . e d . , l e u t e n e g g e r , r . , asst. e d . , m i n n e a p o l i s : university of m i n n e s o t a press, s c h e d u l e d for p u b l i c a t i o n , fall, 1954. 17. schuell, h i l d r e d m . " s e x differences in r e l a t i o n to s t u t t e r i n g : p a r t i , " journal of speech disorders, 11:277-298 (1946). 18. schuell. h i l d r e d m . " s e x differences in r e l a t i o n to s t u t t e r i n g . p a r t 11," journal of speech disorders, 12:23-38 (1947). 19. travis, l e e e d w a r d . speech p a t h o l o g y . new y o r k : a p p l e t o n c e n t u r y , 1931. 20. t u t h i l l , c u r t i s . " a q u a n t i t a t i v e s t u d y of e x t e n t i o n a l m e a n i n g with special reference to s t u t t e r i n g , " speech monographs, 13:81-98 (1946). a b s t r a c t e d in papers of american congress of general semantics, 2:200-204 (1943) a n d journal of speech disorders, 5:189-191 (1940). 21. v a n r i p e r , c h a r l e s a n d h u l l , c a t h e r i n e j . " t h e q u a n t i t a t i v e m e a s u r e m e n t of t h e effect of c e r t a i n s i t u a t i o n s o n s t u t t e r i n g , " stuttering in children and adults, j o h n s o n , w . , e d . , l e u t e n e g g e r , r . , asst. e d . , m i n n e a p o l i s : university of m i n n e s o t a press, scheduled for p u b l i c a t i o n , fall, 1954. 22. w i s c h n e r , g e o r g e . " s t u t t e r i n g b e h a v i o u r a n d l e a r n i n g : a p r e l i m i n a r y t h e o r e t i c a l f o r m u l a t i o n , " journal of speech and hearing disorders, 15:324-335 (1950). r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction methodology review findings implications and recommendations conclusion acknowledgements references appendix 1 appendix 2 about the author(s) elanie van schalkwyk division of speech-language and hearing therapy, faculty of medicine and health sciences, stellenbosch university, cape town, south africa samantha gay division of speech-language and hearing therapy, faculty of medicine and health sciences, stellenbosch university, cape town, south africa julia miller division of speech-language and hearing therapy, faculty of medicine and health sciences, stellenbosch university, cape town, south africa elani matthee division of speech-language and hearing therapy, faculty of medicine and health sciences, stellenbosch university, cape town, south africa berna gerber division of speech-language and hearing therapy, faculty of medicine and health sciences, stellenbosch university, cape town, south africa citation van schalkwyk, e., gay, s., miller, j., matthee, e., & gerber, b. (2020). perceptions of mothers with preterm infants about early communication development: a scoping review. south african journal of communication disorders, 67(1), a640. https://doi.org/10.4102/sajcd.v67i1.640 original research perceptions of mothers with preterm infants about early communication development: a scoping review elanie van schalkwyk, samantha gay, julia miller, elani matthee, berna gerber received: 29 may 2019; accepted: 24 oct. 2019; published: 29 jan. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: preterm infants are at risk of communication disorders or delays, and their mothers experience various difficult emotions and realities. these communication difficulties could be effectively prevented or addressed through the provision of appropriate maternal support. maternal perceptions regarding early communication–interaction and development in preterm population should thus be well understood by health professionals. previous studies have focussed on parents’ and patients’ perceptions of medical information received from health professionals. limited research, however, has been undertaken on maternal perceptions of early communication development in preterm infants, specifically in the south african context. objectives: the study aims to summarise the range and the nature of available research in the fields of early communication development and intervention in preterm infants, specifically maternal perceptions thereof. method: a scoping review methodology comprising five phases was used. data were extracted from the final selection of 12 articles and analysed through quantitative and thematic techniques. results: the results of the scoping review indicate that the defined research field is in a developing phase. mothers mainly experience negative emotions and have limited knowledge regarding communication interaction with preterm infants. furthermore, hospitalisation has been experienced as a barrier to natural communication–interaction between mother and infant. conclusion: based on these results, it is recommended that primary research be conducted with the mothers of preterm infants to establish the most effective strategies for communication–interaction training with this vulnerable population. a further recommendation would be to increase awareness of early communication development and intervention in the preterm population amongst both parents and health professionals. keywords: mother; perception; preterm infant; early communication development; communication; interaction. introduction an estimated 15 million babies are born prematurely every year (world health organization [who], 2018). preterm birth is defined as the birth before 37 weeks of pregnancy (who, 2018). approximately 84,000 of these births occur in south africa, and 10% of the preterm infants born in south africa do not survive in spite of the fact that the majority of preterm births occurs at healthcare facilities (who, 2018). many caregivers in developing countries are exposed to a myriad of factors that may increase the risk of preterm birth and challenge caretaking following preterm birth (who, 2018). the majority of south africans live in low socioeconomic conditions (statistics south africa, 2017), and this could be viewed as a serious threat to childhood outcomes (dawes, biersteker, & irvine, 2008). poor living environments, dangerous working environments and limited social networks and support for mothers are common amongst populations with low socioeconomic status. these factors increase the risk of preterm births and complicate the task of taking care of preterm infants. the mothers of preterm infants have a different communication–interaction experience with their infants than the mothers of full-term infants. preterm infants are born whilst they are still neurologically, physiologically and anatomically unprepared for life outside the mother’s womb (crisp, 2006). therefore, they are less alert and responsive than full-term infants (pascoe, bissessur, & mayers, 2016) and display limited interaction with their environment. communication development unfolds in the context of an infant’s social environment. the nature of mother–infant interactions plays a critical role in supporting and shaping communication development. the factors that influence the quality of mother–child interactions must thus be well understood to provide effective early communication intervention for preterm infants (loi et al., 2017). feeding skills of preterm infants are also often compromised, thereby hindering breastfeeding and bonding between the mother and infant dyad (flacking, ewald, nyqvist, & starrin, 2006). preterm infants generally require intervention from a team of health professionals and may undergo frequent and/or prolonged hospitalisation. hospitalisation includes in-patient services such as admission to neonatal intensive care unit (nicu) and other relevant wards, as well as out-patient services such as high-risk follow-up clinics and other relevant therapeutic interventions. the hospital setting, specifically the nicu, is a novel environment for most mothers and is often experienced as challenging or intimidating (swift & scholten, 2010). a broad range of personal and contextual factors (who, 2018) therefore contributes to inhibit prolonged periods of communication–interaction between the mother and infant dyad. this often leads to the formation of negative maternal perceptions regarding their preterm infant’s, as well as their own capabilities. a mother’s negative perceptions regarding her preterm infant and parenting abilities may inhibit the development of normal communication–interaction. rapid communication development takes place during the first 2 years of infant’s life (beuker, rommelse, donders, & buitelaar, 2013). it is during this period that crucial skills and opportunities – such as joint attention and engagement with the environment – are developed and provided to lay a sound foundation for the social, emotional and academic development of the child (crisp, 2006). studies have shown that infants who experience positive interactions with their mothers display improved cognitive and linguistic development (nicolaou, rosewell, marlow, & glazebrook, 2009). negative maternal perceptions often lead to reduction in interaction with the preterm infant and thus limit the preterm infant’s experience of successful communication. contact between the mother and the healthcare professional during in-patient (e.g. nicu admissions) or out-patient (e.g. high-risk follow-up clinics) services provide a window of opportunity to support mother–infant interaction and bonding, thereby preventing or mitigating negative maternal perceptions. early identification of communication disorders/delays in preterm infants is critical to ensure optimal communication development, as this provides us with an opportunity to implement both preventative and therapeutic intervention services (rossetti, 2001). preventative intervention includes health promotion programmes focussed on mothers and infants such as the mom. connect or first 1000 days initiatives of the national department of health (2018) and western cape government (2018). the rationale for this scoping review was that an enhanced understanding of existing evidence regarding maternal perceptions may lead to improved early intervention service delivery to the mother–infant pair. this creates the potential to improve interaction–attachment and bonding, and thus communication outcomes, for both mother and the preterm infant. the following research question was therefore articulated: what is the nature of the research literature on the perceptions of mothers of preterm infants regarding the early communication development of their babies? the aims of our study were twofold. firstly, to map the literature in terms of time (year of publication), setting (location and context in which it was created) and types of research methodology employed. secondly, to describe this body of research in terms of its results that pertain to maternal perceptions regarding early communication development and intervention in preterm infants. this study therefore aims to serve as a foundation for further primary research and recommendations for clinical practice with the goal of improving early intervention service delivery to preterm infants and their mothers. methodology the scoping review method is defined as a form of knowledge synthesis that addresses an exploratory research question. key concepts, types of evidence and gaps in a defined research field are mapped through systematically searching, selecting and synthesising existing knowledge (colquhoun et al., 2014). this scoping review comprised five phases as outlined by arksey and o’malley (2005) and summarised in figure 1. figure 1: summary of methodology. the four key concepts that are to be addressed in a relevant manner for inclusion of a research paper in the scoping study are listed in table 1. these concepts and related terminologies were identified during a literature search within the defined research field. table 1: summary of key concepts and related terminology. the inclusion criteria were established after considering the research question and the aims of the study, as described in the introduction as well as the definitions of key concepts. table 2 provides the inclusion criteria and the accompanying motivations (levac, colquhoun, & o’brien, 2010). table 2: inclusion criteria. the prisma diagram (figure 2) provides the nine databases that were searched as well as the number of articles found in each database. the most recent search was performed on 12 february 2018, and studies from all dates were included as a result of the limited number of research in the defined field. figure 2: prisma diagram representing the number of articles found in each database. an example of the search string used to search the database cinahl is as follows: … (knowledge or perception or understanding) and (*mother or caregiver) and (preterm infants or premature infants or low birth weight) and (early communication development or prelinguistic or early development) the first four researchers of this article reviewed the titles, abstracts, followed by the full text of articles identified to increase consistency (tricco et al., 2018). all disagreements were resolved through discussion until a consensus was reached. the initial search yielded 104 articles, of which 18 articles were eliminated because of duplication. twenty-one articles were excluded during the full-text review because they did not adhere to the four key concepts and the key words in a relevant manner. during the data extraction phase, another four articles were excluded. after charting the data from these articles, the researchers reached a consensus that the information did not sufficiently address the research question. therefore, 12 articles were included in this scoping review, as displayed in appendix 1. this study followed a descriptive–analytical charting approach, which involved applying an identical analytical framework to all 12 articles included in the scoping review and collecting standard information from each article. the extraction of data involved a technique called charting, known as synthesising and interpreting qualitative data by sifting through and sorting material according to key concepts and themes (arksey & o’malley, 2005). applying a consistent approach allowed the researchers to make comparisons and identify contradictions, gaps and ‘new frontiers’ amongst the included studies. the extracted data were entered into a microsoft excel spreadsheet. appendix 2 demonstrates the information extracted from each article. the goal of the final phase of this scoping review was to present an overview of all the material reviewed to answer the outlined research question, namely: ‘what is the nature of the research literature on the perceptions of mothers of preterm infants regarding the early communication development of their babies?’ in keeping with the scoping review methodology (arksey & o’malley, 2005), this was done without assessing the quality of the reviewed evidence or determining whether this evidence could be generalised. the year of publication, study setting (location and context) and type of study were analysed numerically to summarise the extent and nature of studies included in this review (arksey & o’malley, 2005) and to fulfil the first aim, namely: ‘to map the literature in terms of time (year of publication), setting (location and context in which it was created) and types of research methodology employed’. this method of analysis allowed the researchers to obtain an overview of the general information of the selected studies as well as to identify the most frequently occurring study types, settings and procedures of data collection and analysis. in order to fulfil the second aim, namely: ‘o describe this body of research in terms of its results that pertains to maternal perceptions regarding early communication development and intervention in preterm infants’, the results of the studies were analysed using content-based analysis to provide an overview of the ideas that emerged from the results of the reviewed literature and the frequency of these ideas amongst the analysed articles. through this method, we aimed to retain clarity of the reporting strategy so that potential bias in reporting or recommendations could be determined by the reader (arksey & o’malley, 2005). review findings numerical analysis results the year of study of publications ranged from 2002 to 2016, with an even spread of approximately one publication per year across the period. figure 3 illustrates the types of studies as well as the frequency of each study type amongst the set of reviewed studies. figure 3: bar graph representing the types of studies included in the scoping review. it is important to note that some listed studies used more than one descriptor to describe their research approach. half of the studies (i.e. six) included in the scoping review were qualitative studies. this type of research is well suited to the research topic, as the sensitive nature of the topic lends itself to smaller number of participants with results that cannot and should not be generalised too widely. within our defined research field, only one review article was available in the form of a ‘generic’ literature review (grant & booth, 2009, p. 94). the majority of studies (i.e. seven) were conducted in south africa and in particular within nicu settings in public hospitals. the local research community should thus be commended for being relatively active in this research field. it is important to note that the context and culture of research participants greatly affects their perceptions and knowledge, and therefore the results of this scoping review should not be taken to represent the perspectives of all mothers globally. the high number of south african studies may be ascribed to the large number of risk factors for premature birth found in south africa. these risk factors include high levels of poverty, limited formal maternal education and maternal hiv and/or aids (mcinroy & kritzinger, 2005). this finding supports our claim that speech–language pathologists, and specifically those working in the south african context, should aim to increase their knowledge and skill in delivery of service to neonatal population. thematic analysis results seven themes emerged from the results of the included studies (the frequency of each theme is illustrated in figure 4). these themes highlight the existing maternal perceptions regarding communication with their preterm infants. factors that mothers perceived as barriers to communication with their preterm infants constitute the majority of the identified themes. figure 4: bar graph representing the codes of relevant results from the data. kmc, kangaroo mother care. mothers experience negative emotions, such as guilt, anxiety and uncertainty, relating to their preterm infant (flacking et al., 2006; leonard & mayers, 2008; mcinroy & kritzinger, 2005; nicolaou et al., 2009; swift & scholten, 2010; tanner, 2012): these emotions could be assigned to a variety of factors such as maternal insecurity, limited communicative and feeding capabilities of infant as well as the child’s physical appearance (crisp, 2006). maternal insecurity (flacking et al., 2006; kritzinger & louw, 2003; leonard & mayers, 2008; nicolaou et al., 2009; swift & scholten, 2010): a significant number of reviewed literature identified that mothers lacked confidence in their ability to take care of a medically compromised infant. this, ironically, pertained more to communication–interaction and independently performing daily caretaking routines, such as bathing or dressing, than complicated medical procedures or monitoring (flacking et al., 2006). a possible reason that was suggested for this phenomenon was that information received from healthcare professionals focussed almost exclusively on medical aspects, with little attention on how to interact with and take care of a preterm infant (swift & scholten, 2010). type of care and/or information received (crisp, 2006; nicolaou et al., 2009; swift & scholten, 2010): the medical and physical needs of infants are often prioritised above communication–interaction when information or care is provided to mothers. feeding difficulties lead to minimised interaction with infants (swift & scholten, 2010): feeding difficulties experienced by preterm infants, such as problems with breastfeeding, lead to compromised bonding between mothers and infants as well as maternal feelings of guilt. the task of feeding is complicated owing to the reduced feeding ability of infant as well as increased maternal anxiety and shifting of focus from pleasurable interaction to task completion (flacking et al., 2006). maternal perceptions of a sleepy or unresponsive infant (kritzinger & louw, 2003; nicolaou et al., 2009; pascoe et al., 2016; tanner, 2012): these reported perceptions lead to a feeling of one-sided interaction and uncertainty on the mother’s part (pascoe et al., 2016). hospitalisation poses a barrier to natural communication–interaction (crisp, 2006; flacking et al., 2006; kritzinger & louw, 2003; leonard & mayers, 2008; mcinroy & kritzinger, 2005; nicolaou et al., 2009; swift & scholten, 2010): the nicu is a novel environment for most mothers, leading to a unique and challenging experience (swift & scholten, 2010). incubators, feeding tubes, respiration tubes and a variety of monitors attached to small preterm infants create both physical and emotional barriers. strict rules and policies regarding physical handling, visiting hours and feeding schedules further limit the naturalness of interaction. the constant presence of healthcare professionals, such as nurses and doctors, are often seen as an invasion of privacy between the infant and the mother and their opportunity to freely interact with each other. this leads to the maternal perception of being redundant and a passive onlooker of the process. the attitude of healthcare professionals, especially the nurses who perform daily caretaking routines normally performed by infant’s mother, is perceived as an enabler of or barrier to interaction. nurses who actively include the mother in this process stimulate bonding and interaction between the mother and infant dyad. nurses who perform these routines independently create maternal perceptions of incompetency and hindered bonding and interaction. culture and language differences between mothers and healthcare professionals are perceived as further potential barriers to communication–interaction between mothers and their infants in hospital settings. this could be ascribed to communication breakdown occurring when health professionals attempt to explain concepts related to facilitating communication–interaction in the presence of language differences. thus, mothers may not understand health professionals’ advice on how to facilitate the communication–interaction with their infant and may also be reluctant to implement behaviours that deviate from their cultural beliefs and practices. this perception is of special relevance when viewed in light of a multilingual and multicultural country, such as south africa, where the culture and language of mothers and the health professionals are likely to differ (penn & watermeyer, 2018), and the values and practices of the profession largely reflect those of western societies (verdon, blake, hopf, pham, & mcleod, 2016). kangaroo mother care (kmc) improves maternal perceptions of their preterm babies’ early communication capabilities (feldman, eidelman, sirota, & weller, 2002; flacking et al., 2006; green & phipps, 2015; kritzinger & louw, 2003; kritzinger & van rooyen, 2014; mcinroy & kritzinger, 2005; pascoe et al., 2016): a significant number (i.e. seven) of the included studies indicated that mothers who practiced kmc demonstrated a strong awareness of their role in early communication and the development thereof. interaction between mother and infant for prolonged periods increases the mother’s ability to perceive and infer the meaning behind her infant’s behavioural signals, and to respond to them promptly and appropriately. in a comparison study, kritzinger and van rooyen (2014) conclude that practicing kmc led to the formation of more realistic and positive maternal perceptions regarding early communication and interaction with their preterm infant. mothers who practise kmc thus had a better understanding of their children and respond in a more natural manner during interactions with their infants than mothers who did not practice kmc. thus, during kmc programmes, it may be beneficial to provide specific information to mothers on how to interact and take care of their preterm infants. this could decrease maternal insecurities and therefore increase positive perceptions (pascoe et al., 2016), abilities and wellbeing. implications and recommendations the implications and recommendations derived from our scoping review facilitate the design and delivery of family-centred early intervention services that empower the mothers of preterm infants by making them active participants in the intervention process. the results of this scoping review indicate that the mothers of preterm infants mostly perceive the nicu and other hospital settings as a rule-bound and strict medical context where they become passive onlookers of their infants’ care. these perceptions worsen mothers’ existing negative emotions such as anxiety, insecurity and self-doubt. it seems that the guiding principle of family-centred early intervention (american speech-language-hearing association [asha], 2008) is not optimally implemented in this highly medical and technology-dominant environment. with regard to future research, it is thus recommended that in-depth primary research be conducted with perceptions of the mothers of preterm infants’ being the main source of data. a more specific recommendation would be to have focus groups or individual interviews with this vulnerable population to determine their information and support needs as well as the preferred method and agent of transfer of information. this specific research may guide the design and delivery of neonatal intervention programmes (mcinroy & kritzinger, 2005) that address the unique needs of this vulnerable population. with regard to clinical practice, the following practical strategies are recommended to reduce negative maternal perceptions and overcome the various barriers that hospitalisation poses to natural interaction between the mother and infant dyad: firstly, it is advised that health professionals establish open and safe communication pathways with the mothers of preterm infants. this may empower mothers to actively seek the information and support they require. secondly, health professionals could provide more information on general caregiving activities such as bathing or dressing of a preterm infant alongside more complex medical information. this would reduce maternal insecurities regarding the performance of activities of daily living. health professionals could also encourage mothers’ participation during these activities to prevent their feelings of passive onlookers during their infants’ care and to build their confidence. thirdly, it is recommended that health professionals encourage maternal participation and engagement during the feeding period. this recommendation is valid for all feeding methods, and is of special importance when infants are not able to breastfeed. the last recommendation is that special care must be taken to ensure that sufficient opportunities exist for interaction and bonding between the mother and infant dyad. the implementation of structured kmc programmes could facilitate mother–infant bonding and attachment, and aid in reducing negative maternal perceptions relating to their infant. conclusion this scoping review aimed to map and describe the time, setting, research methodology and results of the available literature in the field of early communication development and intervention in the preterm population, specifically maternal perceptions thereof. firstly, it became evident that the defined research field is limited and does not provide sufficient insight into the maternal perceptions of early communication development and intervention. secondly, it became clear that mothers of preterm infants experience various difficult emotions and realities whilst being hospitalised and taking care of their infants. the ecology of the nicu and other hospital settings is furthermore perceived as a barrier to natural interaction between the mother and infant dyad. it is thus recommended that in-depth research is conducted with this vulnerable population to determine their unique information and support needs as well as the preferred method and agent of transfer. practical suggestions for clinical practice that aim to reduce negative maternal perceptions and overcome the perceived barriers that hospitalisation poses are further advised. this scoping review therefore strives to facilitate the design and delivery of family-centred early intervention services that empower the mothers of preterm infants by making them active participants in the intervention process. acknowledgements experts in the field were consulted for recommendations and contributions to the study. competing interests the authors have declared that no competing interest exist. authors’ contributions the five authors of this article together conceptualised the study. the first four authors performed the scoping review and the last author acted as their research supervisor. reviewing and writing tasks were divided equally amongst the first four authors. the first author orchestrated and compiled the manuscript, whilst the last author reviewed the manuscript and provided suggestions and contributions. ethical consideration this article followed all ethical standards for carrying out research. funding information the views and opinions expressed in this article are those of the authors and not an official position of stellenbosch university. data availability statement sharing is not applicable to this article as no new data were created or analysed in this study disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any 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(2018). preterm birth. retrieved from http://www.who.int/mediacentre/factsheets/fs363/en/ appendix 1 table 1-a1: references of 12 studies included in scoping review. appendix 2 table 1-a2: the format used to chart 12 articles. a n o n s y s t e m a t i c r e v i e w o f e v i d e n c e b a s e d p r a c t i c e w i t h i n s p e e c h p a t h o l o g y i n a u s t r a l i a s h a ry n n e m c l e o d c harles s tu rt u niversity, a ustralia f a bstract in this n o n -s y s te m a tic review , e v id e n c e -b a s e d p ra c tic e (ebp) in a u stralia n speech p a th o lo g y research a n d p ra c tic e is ex­ a m in e d . m a n y a u stralia n resea rc h e rs a r e c o n tr ib u tin g to th e th e o re tic a le v id e n c e th ro u g h s y s te m a tic r e v ie w s , ra n d o m is e d c o n tro lle d trials, a n d o th e r clinical research. a d d itio n a lly , a ustralian researchers are in te g ra tin g in te rn a tio n a l th e o re tic a l e v id e n c e via speechbite ™ and o th e r in itia tives. a ustralian s peech p a th o lo g is ts 'c lin ic a l e x p e rtis e is s u p p o rte d via s p eech p a t h o lo g y a u s tr a lia a n d a n e x a m p le o fth e im p le m e n ta tio n o f ebp in clinical co n te x ts is th e n sw ebp n e tw o rk . w ith in aus­ tralia, research a tte n tio n also has b e e n d ire c te d to w a rd s th e c lie n t's c h o ic e a n d th e c lie n t's v o ic e .t h is p a p e ra c k n o w le d g e s lim ita tio n s o f im p le m e n tin g ebp in a ustralia: s u g g e s tin g t h a t inclu sion o f th e client's vo ice c o u ld b e fo rm a lis e d a n d th a t a d d itio n a l research n e e d s to b e u n d e rta k e n to a d d re s s practical d iffe re n c e s in service d e liv e ry m o d e ls b e tw e e n a ustralian an d in te rn a tio n a l contexts. k e y w o rd s : e v id e n c e -b a s e d p ractice, a ustralia, profession al p ractice, s p e e c h -la n g u a g e p a th o lo g y , icf. evidence-based practice ( e b p ) is increasingly encour­aged within the health and medical professions as a method to underpin clinical decision making. based on the definition o f sackett, rosenberg, gray, hayes, and richardson (1 9 9 6 ), e b p is considered to have three com ­ ponents: theoretical evidence, clinical expertise and client’s choice. in this paper, these three components will be con­ sidered by drawing on examples o f research and practice un­ dertaken within the field o f speech pathology in australia w h ile the author has aimed to represent a broad overview o f e b p in australia, it is acknowledged that this paper does not present a systematic review. to contextualise this paper, australia is a country o f over 2 0 million people and is one o f the most multicultural coun­ tries in the world (hugo, 2 0 02). i t is primarily populated along the coasts with the largest population centres being sydney, brisbane and melbourne on the east coast, whereas inland australia is sparsely populated. distance and remote­ ness bring challenges to the provision o f health care within australia. healthcare in australia is freely available for all through government funding and there is also opportunity for privately funded healthcare. speech pathology is pro­ vided through the health, education and disability sectors by the australian government as well as through private prac­ tices; however, this non-centralised approach coupled with geographical barriers can mean that some people do not have access to the amount o f speech pathology services they require (e.g., m cl eo d & m ck innon, 2 0 0 7 ; o ’callaghan, m callister & w ilson, 2005a). the traditions o f speech pa­ thology practice in australia were originally influenced by britain; however, over the years the australian speech pa­ thology profession has been acknowledged for drawing on, synthesising and enhancing perspectives from throughout the world. currently, there are eight universities that pro­ vide professional preparation programs for speech patholo­ gists and speech pathology australia (www.speechpathologyaustralia.org.au) is the peak professional body for speech pathologists. theoretical evidence the first component o f e b p mentioned by sackett et al. (1996) is theoretical evidence. according to australia’s n a­ tional h ealth and m edical research council (n h m r c ) (2 000, p. 7 -8 ) the highest level o f evidence for “assessing clin­ ical and public health interventions” is “a systematic review o f all relevant randomised controlled trials”. the next high­ est is “evidence obtained from at least one properly designed randomised controlled trial”. key australian speech pathol­ ogy researchers have been at the cutting edge in undertak­ ing systematic research regarding interventions for people with communication disorders. for example, an australian, angela m organ has co-authored a cochrane systematic review on the topic o f intervention for developmental apraxia o f speech (morgan & vogel, 2 0 06). the australian stuttering research centre (a s r c ) has conducted ran­ domised controlled trials to demonstrate the effectiveness o f the lidcom be program for preschool children who stutter (e.g., jones et al., 2 0 0 5 ; jones et a l , in press). randomised controlled trials also have been conducted in australia re­ garding interventions for chronic cough (vertigan, theod­ oras, gibson, & w inkw orth, 2 0 0 6 ), the training o f com ­ munication partners o f people with traumatic brain injury (togher, m cd onald, code, & grant, 20 0 4 ) and the train­ ing o f volunteers to assist people who have aphasia (w or rall & y iu, 2 0 0 0 ). additionally, there is much research be­ ing undertaken within australia that would be categorised ______________________________________ / author contact: sharynne mcleod, phd school o f teacher education, charles sturt university panorama ave, bathurst, nsw, 2795, australia tel: +61-2-63384463 fax: +61-2-63384417 e-mail: smcleod@csu.edu.au 16 | die su id -afr ika an setydsk r if vir k o m m u n ik a s ie -a fw y k in g s , vo l. 5 5, 2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:smcleod@csu.edu.au ebp in a u s t r a l ia by n h m r c as providing “lower” levels o f evidence, yet is important for understanding the effectiveness and efficien­ cy o f intervention for people with communication disorders (code, 2 0 00). australian researchers have also been involved in synthe­ sizing available international evidence for speech pathology practice. notably, a group o f australian speech pathology ac­ ademics primarily from latrobe university have compiled and analysed evidence in their book e viden ce basedpractice in speech pathology (reilly, douglas & o ates, 2 0 0 4 ). this book critiques theoretical evidence for working with clinical pop­ ulations including people who have aphasia, acquired brain injury, stuttering, voice disorders, dysphagia, developmen­ tal language disorders, motor speech disorders, articulation and phonological disorders and those who use augmentative and alternative communication. recently, speech patholo­ gy australia, in association with the university o f sydney has launched sp eechb it e ™ (www.speechbite.com) “[t]o enable speech pathology clinicians and researchers to effi­ ciently access the best available evidence to inform speech pathology practice and research”. the free online database catalogues systematic reviews, randomised controlled tri­ als (r c t s), non-randomised controlled trials (n on -r c t s), case series and single case experimental designs (s c e d s) that are relevant to speech pathology practice. to enable clinicians to more easily interpret the scientific quality o f the research, r c t s, n o n -r c t s and s c e d studies are giv­ en a methodological rating and papers are listed according to their methodological quality. sp eech b it e ™ is the most recently launched o f four databases which have been devel­ oped in australia to facilitate the use o f e b p in clinical de­ cision making. the others include p e d ro for physiotherapy (www.pedro.fhs.usyd.edu.au), o t seeker for occupational therapy (www.otseeker.com) and p sy cb it e ™ for people working in the field o f acquired brain impairment (www. psycbite.com). 1 o ne o f the difficulties that australians face with employ­ ing theoretical evidence generated in some international speech pathology studies, is that the recommended dosage o f intervention is not possible within the australian health, education and disability sectors; frequently due to limited funding for services'. for example, many international stud­ ies recommend provision o f intervention twice a week to children; a service cielivery model that is rare within aus­ tralia. w ith in the united kingdom, glogowska, roulstone, enderby, and peters (2000) demonstrated in a pragmatic randomised controlled trial that i f children do not receive a high enough dosage o f intervention, then speech pathol­ ogy outcomes may be negligible. furthermore, speech pa­ thologists are not employed by the government education system o f the largest state within australia (new south wales [n s w ]), so evidence-based interventions that have been designed for school settings are rarely able to be im ­ plemented. in addition to the importance o f considering the theo­ retical evidence, there are two other components to e b p as espoused by sackett et al. (1 996, p. 71): “evidence based medicine is not “cookbook” medicine. because it requires a bottom up approach that integrates the best external evidence with individual clinical expertise and patients’ choice, it cannot result in slavish, cookbook approaches to individual patient care. external clinical evidence can inform, but can never replace, individual clinical expertise.” clinical expertise speech pathology graduates from australian universi­ ties are conversant with evidence-based practice guidelines. each o f these university courses are accredited by speech pathology australia and each graduate has met com peten­ cy-based occupational standards (c b o s ) (speech pathol­ ogy australia, 2 0 0 1 ) demonstrating their clinical expertise. for example, in order to plan clinical intervention, entry lev­ el speech pathologists must demonstrate that they can “... give a rationale for decisions made with reference to: the client’s communication/swallowing history, the critical ap­ praisal o f evidence in current literature and research, clinical reasoning.” (speech pathology australia, 2 0 0 1 , p. 9). speech pathology australia supports the ongoing devel­ opment o f clinical expertise through evidence-based prac­ tice in many ways. i t publishes both an academic journal (in tern ation al jo u r n a l o f speech-language pathology, previ­ ously called advances in speech-language pathology) and a clinical journal (acq uiring know ledge in speech, language a n d h earin g) that has a regular column titled “w h a t’s the evidence fo r...?” the association organises an annual sci­ entific conference that is attended by hundreds o f speech pathologists (including both national and international del­ egates). additionally, it organises regular professional de­ velopment courses in each state that are presented by key researchers and clinicians. speech pathology australia also provides a professional self regulation (p s r ) program to support and recognise continuing professional development o f australian speech pathologists. those who are involved in the p s r program are able to use the postnominals, c p s p (certified practicing speech pathologist). around australia speech pathologists are encouraged to apply evidence-based practice to their management o f peo­ ple with communication disorders. the n s w speech pa­ thology e b p network (2008) is possibly the most formal­ ized method where this takes place. this e b p network was established in 2 0 0 2 so that speech pathologists could col laboratively examine evidence to enhance their practice and is currently organised around the following clinical groups: augmentative and alternative communication, tracheostomy and critical care, paediatric language, paediatric phonology, paediatric feeding, adult swallowing, adult speech, adult lan­ guage, cleft palate. each clinical group has their own terms o f reference and presents critically appraised papers and topics (caps and cats) on the website and at their annual conference. additionally, a number o f australian researchers are in­ volved in translation o f research to clinical practice to sup­ port the development o f clinical expertise. onslow, jones, o ’brian, and m enzies (in press) have recently written a tu­ torial paper to facilitate consum ers’understanding and inter­ pretation o f clinical trials o f stuttering treatments. a special issue o f advances in speech-language pathology (m cleod, 20 0 6 ) provided readers with ten different perspectives from international experts on intervention approaches for jarrod, a seven-year-old with unintelligible speech. the special issue th e s o u t h a f r ic a n j o u r n a l of c o m m u n ic a t io n d iso rd er s, vo l . 55 2 0 0 8 | 17 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.speechbite.com http://www.pedro.fhs.usyd.edu.au http://www.otseeker.com s h a r y n n e m c l e o d was accompanied by online video files to enable clinicians to develop their clinical expertise by reflecting on their clinical decision making for jarrod. shelton (1993, p. 175) indicated that “clinicians need to make skillful use o f a tremendous store o f in form ation ...” australian researchers have conducted research into speech pathologists’ professional practice. for example, m cleod and baker (2004) examined australian speech pathologists’ clinical practice for children with speech impairment and w atts pappas, m cl eod , m callister and m ck innon (2008) studied australian speech pathologists’ practices for work­ ing with families. client’s choice m any australian researchers have a commitment to ex­ ploration o f the client’s choice and the client perspective. for example, australian speech pathology researchers have talked with people who have aphasia (cruice, worrall 8c hickson, 2 0 06), adolescents who stutter (herane, packman, onslow 8c quine, in press), stakeholders involved with peo­ ple who had a traumatic brain injury (larkins, worrall 8c hickson, 2 0 0 4 ), parents o f children who have undergone newborn infant hearing screening (mazlan, hickson, 8c driscoll, 20 0 6 ) and siblings o f children with speech impair­ ment (barr, m cl eod 8c daniel, 2008). australian research has also considered clients’ opinions on the barriers o f ac­ cessing speech pathology services when they are in rural and remote locations (o ’callaghan et a l , 2005b). kovarsky (2008, p. 4 7) indicated that “the current version o f e b p needs to be reformulated to include subjective voices from the life-worlds o f clients as a form o f evidence.” although not considered on the n h m r c levels o f evidence, explo­ ration and consideration o f the client’s voice is important within the australian research context. summary m any australian speech pathologists have incorporated e b p within their clinical decision-making, strongly sup­ ported by speech pathology australia. along with many others throughout the world, australian researchers have embraced and contributed to understanding the three dis­ creet and interconnected aspects o f e b p : theoretical evi­ dence, clinical expertise and client’s choice. in this paper it is suggested that formalised e b p categories could expand to further acknowledge client’s voices. ray kent, in his role as vice president for research and technology o f the am er­ ican speech-language-hearing association (a sh a ) de­ scribed the application o f e b p to the speech pathology and audiology professions in the u s a as follows “evidence based practice (e b p ) is a challenging but attainable goal for audiology and speech-language pathology. o ur profes­ sions have made rapid progress in developing the founda­ tions for ebp. to be sure, a great deal o f work remains to be done, but we have learned from the experiences o f other professions and have built our own systems to support e b p ” (kent, 2 0 0 6 , p. 268). his words can be echoed in the aus­ tralian context. references code, c. (2000). the problem with rcts. rcslt bulletin, 1415. march. cruice, m . n , worrall, l. e. 8c hickson, l. m. h. (2006). per­ spectives on quality of life by people with aphasia and their family: suggestions for successful living. topics in stroke reha­ bilitation, 1 3 ,14-24. glogowska, m , roulstone, s , enderby, r, 8c peters, t. j. (2000). randomised controlled trial of community based speech and language therapy in preschool children. british medical journal, 3 2 1 ,1-5.14 october. hearne, a , packman, a , quine, s , 8c onslow, m. (2008). stut­ tering and its treatment in adolescence: the perceptions of peo­ ple who stutter.journal offluency disorders. 3 3 ,2, 81-98. hugo, g. (2002). year book australia: centenary article—a centu ry o f population change in australia. retrieved december 12, 2003 from http://www.abs.gov.au/ausstats/abs@.nsf/lookup/ 0b82c2f2654c3694ca2569de002139d9. jones, m , hearne, a , onslow, m , packman, a , ormond, t., williams, s , schwarz, i , 8c o ’brian, s. (2008). extended fol­ low up of a randomised controlled trial of the lidcombe pro­ gram of early stuttering intervention. international journal o f language and communication disorders. doi: 10.1080/136828 20801895599. jones, m , onslow, m , packman, a , williams, s , ormond, t., schwarz, i , et al. (2005). randomised controlled trial of the lidcombe program for early stuttering intervention. british medical journal, 331, 7518,659-663. kent, r. d. (2006). evidence-based practice in communication disorders: progress not perfection. language, speech, and hear­ ing services in schools, 3 7 ,4,268-270. kovarsky, d. (2008). representing voices from the life-world in evidence-based practice. international journal o f language and communication disorders, 43(1 supp 1), 4757. larkins, b. m , worrall, l. e. 8c hickson, l. m. h. (2004). stakeholder opinion of functional communication activities following traumatic brain injury. brain injury, 1 8 ,691-706. mazlan, r , hickson, l. m. h. 8c driscoll, c. (2006). measuring parent satisfaction with a neonatal hearing screening program. journal o f the american academy o f audiology, 1 7, 4,253-264. mcleod, s. (2006). editorial: perspectives on a child with unintelligible speech. advances in speech-language pathology, 8,! 3,153-155. mcleod, s , 8c baker, e. (2004). current clinical practice for children with speech impairment. in b. e. murdoch, j. goozee, b. m. whelan 8c k. docking (eds.), proceedings o f the 26th world congress o f the international association o f logopedics and phoniatrics. brisbane: university of queensland. morgan, a , 8c vogel, a. (2006). intervention for developmen­ tal apraxia of speech. cochrane database o f systematic reviews issue 4. art. no.: c d 006278, doi: 10.1002/14651858. cd14006278. national health and medical research council (nhmrc) (2000). how to use the evidence: assessment and application o f sci­ entific evidence. canberra: commonwealth of australia. nsw speech pathology ebp network (2008). nswspeech pathol­ ogy evidence based practice. retrieved june 16,2008 from http:// www.ciap.health.nsw.gov.au/specialties/ebp_sp_path/index. html. o’callaghan, a. m , mcallister, l , 8c wilson, l. (2005a). barriers to accessing rural paediatric speech pathology services: health care consumers’ perspectives. australian journal o f rural health, 1 3 ,3 ,162-171. 18 | die su id -afr ika an se ty dsk r if vir k o m m u n ik a s ie -a fw y k in g s , vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.abs.gov.au/ausstats/abs@.nsf/lookup/ http://www.ciap.health.nsw.gov.au/specialties/ebp_sp_path/index eb p in a u s t r a l ia o ’callaghan, a. m., mcallister, l., 8c wilson, l. (2005b). c o n s u m e r s ’ proposed solutions to barriers to access of rural and remote speech pathology services .advances in speech-language pathology, 7,2,58-64. onslow, m., jones, m ., o ’brian, s., 8c menzies, r. (in press). de­ fining, identifying, and evaluating clinical trials of stuttering treatments: a tutorial .american journal ofspeech-language pa­ thology. reilly, s., douglas, j., 8c oates, j. (2004). evidence based practice in speech pathology. whurr publishers: london. sackett, d. l., rosenberg, w. m. c., gray, j. a. m ., hayes, r. b., 8c richardson, w. s. (1996). evidence-based medicine: what it is and what is isn’t. british medical journal, 3 1 2 ,71-72. speech pathology australia (2001). competency-based occupational standards (cbos) fo r entry level. melbourne: the speech pa­ thology association of australia. speechbite™ (2008). speechbite™ speech pathology database fo r best interventions and treatment efficacy. retrieved june 16,2008 from http://www.speechbite.com. togher, l„ mcdonald, s., code, c., 8c grant, s. (2004). training communication partners of people with traumatic brain injury. a randomised controlled trial, aphasiology, 1 8 ,4 ,313-335. vertigan, a. e.,theodores, d. g., gibson, p. g., winkworth, a. l. (2006). efficacy of speech pathology management for chronic cough: a randomised placebo controlled trial of treatment ef­ ficacy. thorax, 6 1 ,12,1065-1069. watts pappas, n., mcleod, s., mcallister, l ., 8c mckinnon, d. h. (2008). parental involvement in speech intervention: a national survey. clinical linguistics and phonetics, 2 2 ,4 ,335-344. worra]l l., 8c yiu e. (2000). effectiveness of functional communication therapy by volunteers for people with aphasia following stroke. aphasiology, 1 4 ,9, 911-924. th e s o u t h a fr ic a n j o u r n a l of c o m m u n ic a t io n disord er s, v o l 5 5 2 0 0 8 19 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.speechbite.com die gebruik van die akoestiese refleks vir bepaling van die gehoorapparaat winsinstelling marina basson, β log (pretoria) departement spraakwetenskap, spraakheelkunde en oudiologie, universiteit van pretoria opsomm1ng wt^f 7 " va" ^fsehoorapparoatdraers met sensories-neurale gehoorveruese verkry. die toetsstimuli was afnkaanse eenlettergrepige woorde wat in die teenwoordigheid van agtergrondsgeraas van aaneenlo^nd^r^k mtt sein-tot-ruis verhoudmg van +10db aangebied is. spraakdiskriminasietellinglis by vier winsinstelling. ztzett h m m i n s t e l l i n g w m d i e a k ° e s t l e s e refleksdrempel vir spraakgtraas ontlok in die oor z z l z t tot z oor met ώβ gehoorapparaat; twee winsinstellings by ± 10db relatieftot die refleks drempel winsinstelling; en » w^ltelz aoneenlopende spraak teen 50db gehoorpeil vir die pasient mees gemaklik klink. die hoogste gemjdelde svrmskrimf nasietellings is by die refleksdrempel winsinstelling verkry. gemiaaeiae spraakdisknmiabstract aideci speech discrimination scores were obtained for twelve subjects with sensori-neuml hearing loss the test stimuli were afrikaans monosyllabic words with a competing message of connected discourse at a slgnll-to noise zttizb threshold μ' ^ , ** ^ c o n t r a l a t e r a l t o t h e ^ed ear; two gain settings at + 10db relative to the rez ^ ι ά ι ζ ' μ ι t n h 7 i n 8 a t w h l c h t h e s u b j € c t e m l u a t e d c o n n e c t e d s p e e c h a t 5 0 d b h l u^ut sou^ed tst comfortable for him. mean speech discrimination scores were highest at the reflex threshold gain setting. dit is 'n bekende feit dat gehoorapparaatseleksieprosedures gebruik maak van die subjektiewe beoordelings van die pasient, en sluit gewoonlik suiwertoon, lugen beengeleidingstoetse, spraakoudiometrie en die bepaling van die pasient se mees gemaklike luidheid (mgl) en verdrabare peil (vp) in.12 in die geval van jong kinders en moeilik toetsbare pasiente is bogenoemde prosedures ontoereikend, aangesien sodanige pasiente nie in staat is om betroubaar op 'n ouditiewe sein te reageer nie. die gevolg is dat gehoorapparaatseleksie op grond van onvolledige en onbetroubare oudiometriese inligting uitgevoer moet word.9 om bogenoemde redes is daar in άίέ navorsing begin om die akoestiese refleks (ar) te gebruik as 'n hulpmiddel tydens meer objektiewe gehoorapparaatseleksie. die pasient maak dan nie enige subjektiewe beoordelings nie. in 'n studie wat uitgevoer is deur rappaport en tait," gebruik hulle die akoestiese refleksdrempel (ard)-meting om die wins van die gehoorapparaat in te stel. sodoende het hulle die verhouding tussen die ard en maksimum spraakdiskriminasie by gehoorapparaatdraers ondersoek. hulle vind dat die hoogste gemiddelde spraakdiskriminasietellings by die ard-winsinstel ling verkry is in vergelyking met 'n mgl-winsinstelling, en winsinstellings lodb bo en onder die ard-instelling. uit hulle navorsing wil dit dus voorkom asof die oudioloog die wins van die gehoorapparaat moet instel by 'n intensiteitspeil wat die ard ontlok. hierdie studie is 'n poging om bogenoemde bevindings te bevestig. metode i proefpersone 'n eksperimentele groep van 12 volwasse afrikaanssprekende gehoorgestremde persone is geselekteer. die pasient het reeds gehoorapparate ontvang by die oor-, neusen keelhospitaal in pretoria. alle proef]persone moes 'n geriiige of 'n gemiddelde sensories-neurale gehoorverlies vertoon (gemiddelde suiwertoondrempel van die beter oor tussen 27db en 55db).10 sodra die gehoorverlies bo did kriteria toeneem, of konduktief van aard is, word die moontlikheid minder dat die ar geregistreer kan word.7 laasgenoemde was dan 'n vereiste vir die uitvoering van die eksperiment. elke proefpersoon het sy gehoorapparaat reeds vir 'n tydperk van ses maande tot 'n jaar gedra. stimuli gepulseerde spraakgeraas teen 50db gehoorpeil (gp), vanaf 'n gsi 10 oudiometer, is gebruik om die ard-winsinstelling te bepaal. dit is gepulseer (een sekonde aantyd, en drie sekondes aftyd), om refleksadaptasie te verhoed." 'n kassetopname van aaneenlopende spraak teen 50db gp is gebruik vir die bepaling van die mgl-winsinstelling. © sasha 1983 the south african journal of communication disorders, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die gebruik van die akoestiese refleks spraakdiskriminasietellings is bepaal met behulp van die eerste vier afrikaanse foneties gebalanseerde woordlyste. elke woordlys bestaan uit 25 eenlettergrepige woorde met hul inleidende frases. die woordlyste is opgeneem op 'n hoe kwaliteit kassetband in die teenwoordigheid van 'n kompeterende geraas van aaneenlopende spraak.6 die sein-tot-ruis verhouding was + 10db. die kompeterende geraas is ingesluit, omdat geraas dikwels aanwesig is u i » " " 1 σ . υ in u i c kommunikasieomgewing.1 dit gee dus 'n beter beeld van die diskriminasievermoe van 'n persoon in alledaagse kommunikasiesituasies. eksperimentele prosedure elke proef]persoon is in 'n klankdigte kamer, op 'n stoel, 1,5 meter vanaf die oudiometer se luidspreker geplaas, en het direk na die luidspreker gekyk." daarna is die volgende prosedure by elkeen gevolg: bepaling van die mgl-winsinstelling terwyl die proef]persoon na 'n kassetopname van aaneenlopende spraak teen 50db gp (verteenwoordigend van die intensiteit van alledaagse gesprek1) oor die luidspreker geluister het, het hy/sy die winskontrole van die gehoorapparaat verstel, totdatdie spraak "mees gemaklik" geklink het. hierdie instelling is op die winskontrole gemerk en winsinstelling a genoem. bepaling van die ard-winsinstelling die meetprop van die elektro-akoestiese impedansbrug is in die kontralaterale oor geplaas. terwyl die proefpersoon na die gepulseerde spraakgeraas oor die luidspreker teen 50db gp geluister het, het die ondersoeker die winskontrole van die gehoorapparaat verstel, totdat die punt gevind is waar die kleinste waarneembare defleksie van die balansmeternaald, kenmerkend van die ard, waargeneem is.4·» hierdie posisie op die winskontrole is gemerk, en winsinstelling β genoem. bepaling van die winsinstellings: lodb bo en lodb onder die ard-winsinstelling die gehoorapparaat is vervolgens in 'n fonix fp 20 gehoorapparaat analiseerder geplaas wat die uitset van die gehoorapparaat by die ard-winsinstelling weergegee het. hierdie kdpwaarde het gedien as 'n verwysingspunt waarvandaan die winskontrole verstel is na 'n winsinstelling van lodb bo en lodb onder die ard-winsinstelling. di<s winsinstellings is op die kontrole gemerk, en winsinstellings c en d genoem. boge~ η · r n s i n s t e l l i n g s i s m g e s l u i t ' t e n einde vas te stel of der h ? m i n a s i e t e l l i n g s v a n gehoorapparaatdraers verantot dk arb i r t e n s i t e i t s ° m v a n g v a n ~ 1 0 d b e n + 1 0 d b ' relatief die 27 spraakdiskriminasietoetsing 'n spraakdiskriminasietoets is vervolgens by elk van die vier winsinstellings uitgevoer. die kasset-opname van die woordlyste, in die teenwoordigheid van die kompeterende geraas, is oor die luidspreker aangebied. die woordlyste is teen 50db gp, en die kompeterende geraas teen 40db gp aangebied die persentasie spraakdiskriminasie is by elke winsinstelling bereken. resultate die gemiddelde en omvang van spraakdiskriminasietellings(%) van die 12 proef]persone, by die vier winsinstellings is bereken. dit word in tabel i, hieronder, weergegee. dit blyk dat daar groot individuele verskille asook oorvleueling van spraakdiskriminasietellings by die vier winsinstellings is. die hoogste gemiddelde spraakdiskriminasietellings is egter verkry by winsinstelling β (ard-winsinstelling). toepassing van die metode van meervoudige vergelyking,3 toon egter dat bogenoemde spraakdiskriminasiestellings nie betekenisvol hoer is as die van die spraakdiskriminasiestellings wat by winsinstelling a (mgl-winsinstelling) verkry is nie. met betrekking tot verdere onderlinge verskille tussen die spraakdiskriminasietellings by die vier winsinstellings, is die volgende gevind tydens uitvoering van friedman se rangsomtoets:13 spraakdiskriminasietellings by winsinstelling β is betekenisvol hoer as did verkry by winsinstelling c. spraakdiskriminasietellings by winsinstelling β is betekenisvol hoer as di£ verkry by winsinstelling d. daar is nie 'n beduidende verskil tussen die spraakdiskriminasietellings by winsinstellings c en d nie. bespreking die feit dat die hoogste gemiddelde spraakdiskriminasietellings (in geraas) by winsinstelling β verkry is, bevestig die reeds genoemde bevindinge van rappaport & tail." moontlike verklarings vir diέ bevinding kan onttrek word uit studies gedoen deur onder andere borg2 en liden, nordlund en hawkins.5 borg2 vind dat die sametrekking van die stapediusspier by die ard, lae frekwensie energie (onder 100hz) meer attenueer as die van hoe frekwensie. volgens lid<sn et al.s is bogenoemde eienskap van die ar van waarde vir die persoon wat na spraak in die teenwoordigheid van lae frekwensie agtergrondgeraas ^ j ^ g e m i d d e l d e e n o m v a n g van spraakdiskriminasietellings (%) van die 12 proefpersone, by die vier winsinstellings winsinstelling gemiddelde spraakdiskriminasie (%)· ν = 12 omvang van spraakdiskriminasietellings (%) r ; λ , ^ γ w i n s m s t e l l i n g d: lodbonder ^ r n ^ 1 1 1 " 8 die suld ac-:-ι 54,3% 56,3% 38% 47% 28 -72% 40-80% 16-56% 16-64% r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 luister. die ar stel die persoon dus in staat om die spraakfrekwensies bo 1000hz (wat meer inligting bevat as die frekwensies onder 1000hz) beter te hoor. die bevinding dat daar nie 'n betekenisvolle verskil bestaan tussen die spraakdiskriminasietellings by winsinstellings a en β nie, kan moontlik toegeskryf word aan die feit dat die proefpersone reeds ondervinding van die dra van 'n gehoorapparaat het. hulle het moontlik al geleer om die wins van die apparaat self in te stel by 'n vlak wat vir hulle maksimum spraakdiskriminasie gee.14 niemeyer8 gee 'n moontlike verklaring vir die bevinding dat die spraakdiskriminasietellings by winsinstelling β betekenisvol hoer is as did verkry by winsinstelling c. hy meen dat spraakdiskriminasie afheem by intensiteitsvlakke bo die ard, weens sensoriese oorlading. dit lei tot distorsie van spraak, en gevolglike afname in die spraakverstaanbaarheid. die feit dat spraakdiskriminasietellings verkry by winsinstelling β ook betekenisvol hoer is as did by winsinstelling d, word deur rappaport en tait" verklaar. hulle is van mening dat die spraaksein by 'n intensiteitsvlak onder die ard, nog nie hard genoeg is om maksimum verstaanbaarheid m'ee te bring nie. die kompeterende boodskap in die agteigrond mag ook dele van die stimuluswoorde maskeer. uit bogenoemde bespreking word afgelei dat spraakdiskriminasietellings in geraas, met 'n gehoorapparaat, betekenisvol toeneem met intensiteitstoename, totdat die ard bereik word. met 'n verdere toename in intensiteit neem die spraakdiskriminasie tellings weer betekenisvol af. addisionele inligting wat op grand van subjektiewe beoordelings van die proefpersone verkry is, is dat die ard-winsinstelling by 'n intensiteitspeil voorkom wat naby of by die peil is wat vir die persoon mees gemaklik klink, eerder as by 'n peil wat die persoon se verdrabare peil aandui. gevolgtrekkings hierdie studie dui op 'n positiewe verband tussen maksimum spraakdiskriminasie in geraas, met 'n gehoorapparaat, en die ard-winsinstelling. hierdie verband het kliniese toepassingsmoontlikhede in die sin dat die oudioloog die ardmeting kan gebruik as 'n objektiewe meting vir die bepaling van die winsinstelling van die gehoorapparaat. dit is veral in die geval van pediatriese en moeilik toetsbare pasiente wat did objektiewe meting vir die bepaling van die gehoorapparaatwinsinstelling van nut is. aangesien die rol van die akoestiese refleks in gehoorapparaatseleksieprosedures nog in sy ontwikkelingstadium is, word verdere navorsing in did rigting verwelkom, met die oog op die verbetering van bestaande prosedures. navorsers kan in die rigting aangespoor word deur die woorde van horning ;i975) wat deur northern9 aangehaal word: in increasing number of mild and moderate hearing-impaired youngsters who previously would have been unaidable, ...are marina basson successfully wearing and benefiting from aids selected on the basis of acoustic reflex measurement.9 bedank1ngs die outeur spreek haar dank uit teenoor prof. i. s. hay en mev s. meyer van die departement spraakwetenskap, spraakheelkunde en oudiologie van die universiteit van pretoria, onder wie se leiding hierdie studie uitgevoer is, asook teenoor mev g. de villiers, van die departement statistiek, vir die statistiese verwerking van die data. verwysings 1. alpiner, j. g. (1975): hearing aid selection for adults. in: m. c. pollack (ed.) amplification for the hearingimpaired. new york: grune & stratton. 2. borg, e. (1969): a quantitative study of the effect of the acoustic stapedius reflex on sound transmission through the middle ear of man. acta oto-laryngologica, 66, 461-472. 3. gibbons, j. d. (1976): nonparametric methods for quantitative analysis. new york: holt rinehart & winston. 4. jerger, s. & j. jerger. (1977): diagnostic value of crossed vs uncrossed acoustic reflexes. archives of otolaryngology, 103, 445-453. 5. lid£n, g., b. nordlund & j. e. hawkins, jr. (1963): significance of the stapedius reflex for the understanding of speech. acta oto-laryngologica, supplement 188 275-279. 6. martin, f. n. (1975): introduction to audiology. englewood cliffs, n. j.: prentice-hall, inc. 7. mc candless, g. a. & r. w. keith. (1980): the use of impedance measures in hearing aid fitting. in: j. jerger (ed.) clinical impedance audiometry. (second edition). n. j.: american electromedics corp. 8. niemeyer, w. (1971): relations between the discomfort level and the reflex threshold of the middle ear muscles. audiology, 10, 172-176.' 9. northern, j. l. (1978): hearing aids and acoustic impedance measurements. monographs in contemporary audiology, 1:2, 5-23. 10. quigley, s. p. (1978): effects of early hearing-impairment on normal language development. in: f. n. martin (red.) pediatric audiology. englewood cliffs, n. j.: prentice-hall, inc. ! 11. rappaport, β. z. & c. a. tait. (1976):! acoustic reflex threshold measurements in hearing aid selection. archives of oto-laryngology, 102, 129-132. 12. shapiro, i. (1976): hearing aid fitting by prescription audiology, 15:2, 163-173. 13. steyn, a. g. w., c. f. smith & s. h. c. du toit. (1982): moderne statistiek in die praktyk. (tweede uitgawe) pre-" toria: j. l. van schaik. 14. yantis, p. α., j. p. millin & i. shapiro. (1966): speech discrimination in sensori-neural·hearing loss: two experiments on the role of intensity. journal of speech and hearing research, 9:2, 187-193. the south african journal of communication disorders, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 732 medical city eloff cor. jeppe street . 111 w \ \ \ \ 1 i i i johannesburg, transvaal r e p u b l i c ® ' ' j j l j l j iii i iii i telephone 29-6359 h e a r i n g a l n ' ' i ^ 5 m m i r a l s c o u n c o n s u l t a n t s ι ρ τ ϊ γ τ ϊ ξ ''π 3 1 t ^ i t t avenue l t d · ' rosebank, transvaal telephone 442-8691 r m ? e d a t e a m n e . e ^ n u a l s ^ ™ 9 a n d c l i n i c a l a ~ e r s and viennatone computerised micro-processor clinical audiometer ^ u r wn°^dpmen° u please oonta^us^or besfprics"terms or leasing we manufacture soundproof booths and soundproof rooms industrial noise consultants hearing aids we specialise in e t s h p e ecta%r a n d ™ η 9 ^ a i d s <°r f a r i n g losses, nerve deafness recruitment bone conduction cases i crc)ss aids: cros bicros multicros, etc. b ° | b y v l e n n a t o n e ) 0 n * * b ° d y ' ^ masses (speciality moulds: soft, hard, skeleton, vented, occluded, etc. r e prepra®: a " ^ s u p p " ' e d w i t h 3 s c i e n t i f i c performance report after tinnitus maskers and tinnitus instruments special prices for dealers and institutions. ^ ^ o r s ^ n ^ ^ a n d l n f r a r e d t e a c h . n g e q u . p m e n t die suid-afrikoanse 7 w t w • r y n f w r kommunikasieafwykings, vol. 30, 1983 j r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction methods results discussion conclusion acknowledgements references appendix 1 about the author(s) alison millar department of speech pathology and audiology, university of the witwatersrand, johannesburg, south africa karin joubert department of speech pathology and audiology, university of the witwatersrand, johannesburg, south africa ndlovu wits audiology clinic and outreach programme, dennilton, south africa alida naude centre for augmentative and alternative communication, faculty of humanities, university of pretoria, pretoria, south africa citation millar, a., joubert, k., & naude, a. (2020). prevalence of hearing loss and tinnitus in a group of adults with human immunodeficiency virus. south african journal of communication disorders, 67(1), a631. https://doi.org/10.4102/sajcd.v67i1.631 original research prevalence of hearing loss and tinnitus in a group of adults with human immunodeficiency virus alison millar, karin joubert, alida naude received: 04 mar. 2019; accepted: 06 aug. 2019; published: 04 feb. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the human immunodeficiency virus (hiv) has become a global pandemic. with the improvement of antiretroviral (arv) treatment regimens, life-expectancy of hiv-positive individuals has increased. hiv literature suggests that head and neck manifestations may be the first indication of supressed immunity. therefore, research regarding the effects of hiv and new treatment regimens on auditory function remains a priority. objectives: to describe the audiological characteristics and determine the prevalence of hearing loss and tinnitus in a group of hiv-positive individuals on arv treatment residing in a rural province. methods: the study employed a cross-sectional descriptive research design. participants were recruited from the clinic and pharmacy waiting areas of a medical centre in a rural area of limpopo province, south africa. two participant groups, an hiv-positive group (n1 = 60) and an hiv-negative group (n2 = 32) were included in the study. the test battery comprised a comprehensive case history and a routine audiological test battery, which included otoscopy, tympanometry and pure tone audiometry (250 hz to 8000 hz). results: no statistically significant difference was found regarding the prevalence of hearing loss in the two participant groups (p = 0.709). however, the prevalence of tinnitus was significantly higher in the hiv-positive group (p = 0.05). conclusion: the insignificant difference in the audiological test battery results found between the two participant groups may be due to improved arv treatment regimens and management strategies employed at the medical centre. however, the increased prevalence of tinnitus in the hiv-positive group may also be attributed to the arv regimen and/or the result of subtle damage to the auditory system, which was not identified by the current audiological test battery. more insight may be obtained about the effects of hiv on hearing by employing a longitudinal research design and inclusion of a more ototoxicity sensitive test battery. keywords: human immunodeficiency virus; acquired immunodeficiency syndrome; antiretroviral; hearing loss; tinnitus; audiology; rural. introduction the human immunodeficiency virus (hiv) is one of the most significant pandemics of modern times (piot & quinn, 2013). although hiv is a global problem, 33.5% of people living with hiv can be found in sub-saharan africa, of which 19.4 million reside in the eastern and southern regions (unaids, 2017). in 2002, hiv prevalence in south africa was estimated to be 4.25 million, increasing to 7.52 million in 2018. however, when considering population growth, there has been an overall decline in incidence rate from 1.88% in 2002 to 1.21% in 2018 (statistics south africa, 2018). the highest hiv burden in south africa is reported in rural areas (gaede & versteeg, 2011). limpopo, one of south africa’s most rural provinces, has a reported prevalence of 17.2% (human sciences research council, 2017). high hiv prevalence in rural areas may be attributed to, amongst other factors, poor socioeconomic conditions, high unemployment rates and limited access to healthcare services and resources. these challenges adversely affect healthcare provision, which ultimately result in poorer healthcare outcomes for residents in these areas (gaede & versteeg, 2011). hiv disease has, since the use of antiretrovirals (arvs), changed from life-threatening to a manageable condition (heinze, swanepoel, & hofmeyr, 2011). hiv targets the immune system by reducing cluster of differentiation 4 cells (cd4+) or t-lymphocytes (t-cells) (world health organization (who), 2015). an hiv-positive individual may transition through various stages of infection (categories 1 to 3 and a, b and c) based on the cd4+ count and presence of comorbid conditions. the most advanced stage of infection is known as acquired immunodeficiency syndrome (aids) (centres for disease control and prevention (cdc), 1992). in the absence of arv treatment, immune function remains supressed and hiv-positive individuals become more susceptible to the development of certain cancers and opportunistic infections (who, 2015). clinical manifestations involving the head and neck region have been reported as among the first indications of suppressed immunity (lacovou, vlastarakos, papacharalampous, kampessis, & nikolopoulos, 2012). the reported prevalence of complications in the auditory system range from 14% to 75% (chandrasekhar et al., 2000; khoza & ross, 2002; prasad, bhojwani, shenoy, & prasad, 2006; van der westhuizen, swanepoel, heinze, & hofmeyr, 2013; zuniga, 1999). symptoms indicating involvement of the auditory system may include hearing loss, tinnitus, sensation of aural fullness, otalgia, otorrhoea, headaches, oscilliopsia, nausea and a variety of balance disturbances presenting as vertigo, dizziness, gait instability or disequilibrium (khoza-shangase & van rie, 2016; zingler et al., 2007). these symptoms may be the result of direct damage to certain portions of the auditory and/or vestibular pathway or secondary damage resulting from opportunistic infections or use of ototoxic treatment regimens (stearn & swanepoel, 2010). various changes have been made to the hiv treatment guidelines since it was first published by the who in 2002. the most notable changes include earlier treatment initiation, the use of safer and less toxic arv drugs and the inclusion of a single, fixed-dose combination tablet taken only once-daily (od), which may improve treatment adherence (who, 2013, 2015). a variety of studies have suggested that arvs may be ototoxic (kakuda, 2000; khoza-shangase, 2011; marra et al., 1997; mata, yebra, tutor de ureta, villarreal, & garcía, 2000). however, establishing the ototoxic relationship between arvs and auditory function is intricate due to a range of confounding variables affecting auditory function (khoza-shangase, 2011). these variables may include age (very young or aged >60 years); genetic susceptibility; duration of treatment; dosage; simultaneous use of diuretic therapy; co-treatment with other ototoxic drugs; previous history of receiving ototoxic medications or any sensitivity to these medications; impaired renal or hepatic function; pre-existing hearing loss; and history of noise exposure (bauman, 2003). contrary to the studies suggesting ototoxicity, a longitudinal prospective study conducted by schouten and colleagues (2006) suggested that arvs had no damaging effect on hearing. these authors further suggested that auditory function may be affected by hiv itself; however; hearing may be improved once immune function is strengthened with the use of arv treatment. a therapeutic role of arvs has also been suggested by cohen and colleagues (2012), who reported that these agents had no negative effect on vestibular function. direct comparison of the results from various ototoxic studies is however difficult, as different test batteries were employed, and thus different portions of the auditory system were evaluated. as a result of improved arv protocols and access to treatment, the life expectancy of hiv-positive individuals has increased (swanepoel & louw, 2010). therefore, research regarding the effects of hiv and new treatment regimens on the auditory and vestibular system remains crucial. objectives the objectives of this study were to describe the audiological characteristics and determine the prevalence of hearing loss and tinnitus in hiv-positive individuals treated with arvs residing in a rural community. methods a cross-sectional, descriptive research design was used to describe the audiological characteristics and determine the prevalence of hearing loss and tinnitus. participants were recruited from the ndlovu medical centre (nmc) situated in elandsdoorn, a rural settlement in the elias motsoaledi local municipality of the sekhukhune district (limpopo province, south africa). this non-governmental organisation has provided free integrated primary health care to hiv-positive individuals since 1994 (ndlovu care group, 2015). participants the first group comprised hiv-positive individuals (n1 = 60) and the control group, hiv-negative individuals (n2 = 32) (table 1). participants were aged between 18 and 50 years. the age limit was set at 50 years to eliminate the possible impact of the natural ageing process on the auditory system (huang & tang, 2010). all participants in the study were black africans and the majority were sepedi first language speakers. most of participants resided in the sekhukhune district and were from a disadvantaged socioeconomic background. table 1: participants’ description. the 1992 revised cdc classification system was used to determine the progressive stage of infection of participants in the hiv-positive group (appendix 1). most participants in the hiv-positive group (58%; n1 = 35) were in category a, with a further 18% (n1 = 11) in category b, and the remainder (23%; n1 = 14) in category c. participants were on a wide variety of arv protocols, with 88% (n1 = 53) on first-line arv regimens. of these, 50% (n1 = 30) were on a first-line fixed-dose combination treatment consisting of efavirenz, emtricitabine and tenofovir disoproxil fumarate. data collection protocol participants were recruited from the clinic and pharmacy waiting areas of the nmc using a purposive sampling strategy. only participants who gave written consent were included in the study. data collection protocol comprised a review of hiv-positive participants’ medical records (cd4 count, presence of comorbid conditions, arv protocol and treatment duration) to guide the classification of hiv-positive participants according to the cdc category. for the two participant groups, a comprehensive case history (medical and audiological) and routine audiological examination were conducted. the audiological test battery was conducted on site at the ndlovu wits audiology clinic. all equipment was calibrated prior to the commencement of the study (sabs 0154-1; 0154-2). the test battery included otoscopy (heine mini 3000 otoscope), tympanometry using a 226 hz frequency probe tone (interacoustics titan tympanometer) and standard pure tone audiometry (interacoustics diagnostic audiometer: ad629). a normal type a tympanogram was classified according to the following criteria: ear canal volume: 0.8 to 2.0 ml; static compliance: 0.3 to 1.8 ml; middle ear pressure: -100 dapa to +50 dapa (jerger, 1970). air conduction thresholds were obtained via headphones (250 hz to 8000 hz) for both ears. the air conduction thresholds obtained at 500 hz, 1 khz and 2 khz were used to calculate the pure tone average (pta). bone conduction testing was conducted when air conduction thresholds exceeded 25 db hl at any frequency between and including 250 hz and 4000 hz. these thresholds were obtained by placing the bone vibrator on one mastoid at a time, in the case of a bilateral impairment, or one side only in the case of a unilateral impairment. pure tone audiometry results were classified as within normal limits based on a pta of ≤ 25 db hl. therefore, a pta of > 25 db hl was considered a hearing loss. the hearing loss was categorised as conductive, sensorineural, mixed or a hearing loss at only a specific frequency (e.g. abnormal threshold of > 25 db hl at 8 khz). data analysis the data analysis was performed using sas release 9.4 (sas institute inc., carey, nc, usa). descriptive statistics were used to describe measures of central tendencies (mean value) as well as measures of variability (i.e. range and standard deviation [sd]). the fisher’s exact test was used to establish significance of percentages between the two participant groups. this test was also used to establish whether prevalence of tinnitus between the various cdc categories (1–3) was significant. for probability tests, p ≤ 0.05 was considered statistically significant. ethical consideration data collection commenced once ethical clearance was obtained from the human research ethics committee (medical) of the university of the witwatersrand (protocol number: m160150) and permission was granted by the limpopo department of health and social development. results audiological characteristics self-reported auditory symptoms (such as hearing loss, otalgia and a blocked-ear sensation) were reported in 33% (n1 = 20) of hiv-positive participants and 25% (n2 = 8) of the control group. difference in the prevalence of these symptoms between the two groups was not statistically significant (p = 0.481; fisher’s exact test). a majority of participants in both groups presented with normal otoscopy, tympanometry (figure 1) and pure tone results with hearing < 30 db hl bilaterally. pure tone results were symmetrical in 83% (n1 = 50) of hiv-positive participants and 91% (n2 = 29) of the control group. a summary of the presence and nature of hearing loss in participants of the current study are presented in table 2. figure 1: most prevalent audiological characteristics in the two participant groups (hiv-positive participants [n1 = 60] and hiv-negative participants [n2 = 32]). table 2: presence and nature of hearing loss. the prevalence of abnormal otoscopy between the two groups was not statistically significant (p = 0.177; fisher’s exact test), and neither was abnormal middle ear function, as suggested by tympanometry (p = 1.000; fisher’s exact test). prevalence of hearing loss the mean pta (db hl) was similar in both groups. the hiv-positive group obtained a mean pta of 12.6 db hl and 12.3 db hl in the left and right ears respectively. in the control group, the pta was 11.4 db hl in the left ear and 13.7 db hl in the right. the prevalence of hearing loss was 10% (n1 = 6) in the hiv-positive group and 6% (n2 = 2) in the hiv-negative control group. this difference was not significant (p = 0.709; fisher’s exact test). prevalence of tinnitus tinnitus was reported by participants of both groups (figure 1). bilateral high frequency, intermittent tinnitus was most frequently reported in both groups. bilateral tinnitus was reported by 48% of hiv-positive participants (n1 = 29) and unilateral tinnitus was reported by only 8% (n1 = 5). the overall prevalence of tinnitus in the hiv-positive group was 57% (n1 = 34) and in the control group, 34% (n2 = 11). tinnitus reported in the control group was bilateral in nature. this difference was statistically significant (p = 0.05; fisher’s exact test). the prevalence of tinnitus between different cdc categories increased at more progressive stages of infection (cdc category 1 (50%); cdc category 2 (65%) and cdc category 3 (53.9%). however, based on the statistical analysis, this increase was not significant (p = 0.633; fisher’s exact test). discussion prevalence of hearing loss the 10% hearing loss (>25 db hl) in hiv-positive individuals and 6% in the control group is lower than the 19.88% hearing loss prevalence in the general population as reported for the elias motsoaledi municipality (joubert & botha, 2019). the findings of the current study do not suggest a high prevalence of hearing loss in hiv-positive individuals (table 3) and are similar to the findings reported by van der westhuizen et al. (2013). the difference in findings may be attributed to the cdc category of participants, the test battery employed as well as the criteria used to classify hearing loss. table 3: prevalence of hearing loss and tinnitus in the current study in comparison to previous studies. most of the participants in the current study (58%; n1 = 53) were classified as cdc category a, suggesting that they were asymptomatic and did not present with any secondary conditions. contrary to this, in the study conducted by chandrasekhar and colleagues (2000), the majority of participants were in cdc categories b (38%) and c (44%), whilst the minority were classified as cdc category a participants (18%). similarly, khoza and ross (2002) also reported that the majority (91%) of hiv-positive participants in their study presented with secondary conditions. the prevalence of significantly higher hearing loss reported by these studies (table 3) may be attributed to the higher prevalence of secondary conditions and medications used to treat these conditions. the comparable hearing thresholds between the two participant groups in the current study may pertain to the arv regimen used. the majority of participants were on a first-line arv regimen, which has been associated with less toxicity (who, 2013) and improved treatment adherence due to its once-daily dosing (who, 2016). furthermore, all participants were treated according to new arv guidelines where treatment is initiated much earlier, irrespective of cd4+ count or progressive stage of infection. in addition, the nmc, where the study was conducted, employs strict monitoring protocols involving regular blood tests as well as counselling sessions. therefore, as more emphasis is placed on the follow-up care, treatment adherence levels may have been more optimal, ultimately contributing to reduced auditory damage. the prevalence of slightly higher hearing loss reported by an earlier study (14%; n = 28; van der westhuizen et al., 2013) may have been attributed to the fact that only participants in cdc category c were receiving arvs. thus, the therapeutic effect of arvs may have limited the destructive effects of hiv on the auditory system in the current study. these findings have also previously been suggested (cohen et al., 2012; schouten et al., 2006). the audiological test batteries used in previous studies included additional measures such as auditory brainstem response audiometry (khoza & ross, 2002) or otoacoustic emissions (oaes) (van der westhuizen et al., 2013). these measures may have been more sensitive at detecting auditory damage. the prevalence of reduced hearing loss in the current study may also be related to the criteria used to classify hearing loss. for example, a previous study (khoza & ross, 2002) classified hearing loss as any frequency with a threshold of >25 db hl, whilst the current study based the criteria on the pta. however, if frequency-specific criteria were used in the current study, the prevalence of hearing loss would be higher (22%; n1 = 13). furthermore, the reduced prevalence of snhl in the current study may be explained by the fact that hearing loss which only affected specific higher frequencies (e.g. 8 khz) was not classified as sensorineural in nature. this type of configuration was classified in a separate category, whilst other studies may have described such configuration as snhl. prevalence of tinnitus the most significant finding of the current study was the increased prevalence of tinnitus in the hiv-positive group. this prevalence was also significantly higher than reported in previous studies (table 3). the high prevalence in the current study may be attributed to the inclusion of more detailed tinnitus categories. therefore, participants may have been more likely to report tinnitus even if it was only experienced intermittently or in a different pitch than the more common ‘high frequency ringing’. it may however be possible that the increased prevalence of tinnitus may be a result of subtle damage to the auditory pathway, which was not detectable with conventional audiometry. similar to the findings reported by van der westhuizen et al. (2013), the prevalence of tinnitus was higher in cdc categories 2 and 3 compared to cdc category 1. although this increase was not statistically significant, this finding may represent progressive damage caused by hiv during more advanced stages of infection (van der westhuizen et al., 2013). as tinnitus may present as a symptom of hearing loss, it would be expected that self-reported hearing loss would also be more prevalent in the hiv-positive group. the finding that hearing loss was not reported as frequently as tinnitus, may be attributed to tinnitus being related to non-auditory pathologies, or if the tinnitus is related to hearing loss, the nature or configuration may be more discreet and not always recognised or reported by the individual (khoza-shangase & van rie, 2016). although high-frequency tinnitus was reported by 50% (n1 = 4) of hiv-positive participants with high-frequency hearing loss, this type of tinnitus was also reported by hiv-positive participants with hearing that was within normal limits. as the pitch of tinnitus may represent the hearing frequency most affected (castillo & roland, 2007), the inclusion of high-frequency audiometry (>8 khz) may have identified more participants presenting with hearing loss. conclusion comparable audiological results were found in the two participant groups. however, the prevalence of tinnitus was more significant in the hiv-positive group. results from the current study warrant the need for longitudinal research to obtain insight regarding the causal relationship between hiv, its treatment regimen and audiological characteristics. these studies, especially if conducted in rural settings, may consider the use of mhealth technologies such as smartphone-automated pure-tone audiometry. these tests may prove to be more time-efficient when used for regular audiological monitoring purposes, ultimately allowing more individuals to be tested in a shorter amount of time (brittz, heinze, mahomed-asmail, swanepoel, & stoltz, 2018). to increase the generalisability of results, future studies should include participant groups with similar sample sizes, which are ageand gender-matched. the inclusion of an ototoxicity sensitive test battery (e.g. otoacoustic emissions test or high-frequency audiometry of >8 khz) may also be valuable to evaluate the effects of new arv regimens, treatment adherence levels and effective follow-up care on hearing status. as tinnitus was a prevalent finding in the hiv-positive group, research should place more emphasis on this area. acknowledgements the authors thank ndlovu medical centre for allowing the use of their audio-clinic and facility to retrieve participants. this article is based on the dissertation submitted by a.m. to the university of the witwatersrand, johannesburg, south africa. competing interests the authors declare that no financial interests or personal relationships are involved that may have inappropriately influenced the writing of this article. authors’ contributions a.m. was the principal investigator, co-conceptualised and designed the study and drafted the manuscript. k.j and a.n. co-conceptualised and designed the study, supervised the project and reviewed the manuscript. all three authors read and approved the final version of the manuscript and have approved its submission for publication. funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability statement the data that support the findings of this article are openly available from http://wiredspace.wits.ac.za/handle/10539/26552. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references bauman, n.g. 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(1999). communication disorders and hiv disease. journal of the international association of physicians in aids care, 5(4), 16–23. appendix 1 table 1-a1: cdc classification system for hiv-infected adults and adolescents. table 2-a1: cdc classification system for hiv-infected adults and adolescents. about the author(s) lauren c. fouché department of speech-language pathology and audiology, university of pretoria, south africa alta kritzinger department of speech-language pathology and audiology, university of pretoria, south africa talita le roux department of speech-language pathology and audiology, university of pretoria, south africa citation fouché, l.c., kritzinger, a., & le roux, t. (2019). corrigendum: gestational age and birth weight variations in young children with language impairment at an early communication intervention clinic. south african journal of communication disorders 66(1), a622. https://doi.org/10.4102/sajcd.v66i1.622 note: doi of original article: https://doi.org/10.4102/sajcd.v65i1.584 corrigendum corrigendum: gestational age and birth weight variations in young children with language impairment at an early communication intervention clinic lauren c. fouché, alta kritzinger, talita le roux published: 12 sept. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. in the initial published version of this article, the competing interest statement was omitted and the acknowledgment statement was incorrect. the statement is hereby provided and updated as follows: ‘the authors declare no potential conflicts of interest with respect to the research, authorship and/or publication of this article.’ the acknowledgments paragraph is hereby updated as follows: ‘l.c.f. thanks prof. a. kritzinger and dr t. le roux for their continued support, guidance and valuable input into this article. she also thanks her family and friends, who stood by her through the writing process, lending an ear to listen as she phrased and rephrased sections. she also appreciates all the support she had during her journey.’ these corrections do not alter the study’s findings of significance or overall interpretation of the study results. the author apologises for any inconvenience caused. abstract introduction and literature review research method and design results implications and recommendations conclusion acknowledgements references appendix 1 about the author(s) samantha m. govender department of speech-language pathology & audiology, school of health sciences, sefako makgatho health sciences university, pretoria, south africa marguerite de jongh department of speech-language pathology & audiology, school of health sciences, sefako makgatho health sciences university, pretoria, south africa citation govender, s.m., & de jongh, m. (2021). identifying hearing impairment and the associated impact on the quality of life among the elderly residing in retirement homes in pretoria, south africa. south african journal of communication disorders, 68(1), a788. https://doi.org/10.4102/sajcd.v68i1.788 original research identifying hearing impairment and the associated impact on the quality of life among the elderly residing in retirement homes in pretoria, south africa samantha m. govender, marguerite de jongh received: 02 july 2020; accepted: 09 jan. 2021; published: 01 mar. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: age-related hearing loss (arhl) is the most widespread sensory disorder in the elderly. poor audiological support within retirement homes is one of the fundamental issues impacting the quality of life (qol). objectives: the objectives of this study were to: (1) identify the presence of hearing impairment through a hearing screening test battery in a sample of elderly participants residing in three retirement homes. (2) determine the psychological, communication-related and social impact of the hearing impairment on the qol in a sample of elderly participants residing in retirement homes. method: a prospective cross-sectional research design with quantitative methods of data analysis was used to obtain data from 70 elderly participants (mean age = 79 years, 79% were female). ten of them used hearing aids. hearing screening was conducted using otoscopy, tympanometry and air conduction screening (500 hz–4 khz). the world health organization quality of life (whoqol) questionnaire was adapted and utilised for the present study. results: findings revealed that 77% of the sample obtained a refer result from the hearing screening protocol indicating a high presence of hearing impairment. twenty-nine per cent (n = 16) of the participants felt depressed, worried and anxious because of their hearing loss and 20% of participants felt unaccepted by their significant others as a result of their hearing impairment. hearing difficulties were significantly associated with a reduced qol (p = 0.045). eight of the 10 participants who wore hearing aids reported an overall improvement in qol since receiving and utilising their hearing aids and 20% (n = 2) of hearing aid users reported challenges with maintaining their hearing aids. conclusion: the findings of this study emphasised the need for an increased role for audiological services provided by audiologists within retirement homes, thereby contributing to an improved qol. keywords: hearing impairment; retirement homes; presbycusis; pure tone audiometry (pta); distortion product otoacoustic emissions (dpoaes); quality of life. introduction and literature review hearing impairment, the most wide-spread sensory disorder in the elderly, is of growing concern (mulwafu, kuper & ensink, 2016; quaranta et al., 2015). globally; it is estimated that 25% of the geriatric population aged between 65 and 75 years, and 70%–80% over 75 years present with age-related hearing loss (arhl) with an overall prevalence of approximately 44% in adults 65 years and older in sub-saharan africa (guthrie et al., 2018; homans et al., 2017; world health organization [who], 2004). age-related hearing loss, also known as presbycusis is a multifactorial disorder that is associated with a shift in hearing sensitivity because of a degenerating auditory system (d’haese, van rompaey, de bodt, & van de heyning, 2019), environmental factors (lee, 2013) and/or medical conditions (quaranta et al., 2015). because of this shift in hearing sensitivity, the elderly experience difficulties in communication and understanding speech in the presence of background noise as well as with social engagements which are important aspects of everyday life and are associated with psychological well-being (ciorba, bianchini, pelucchi, & pastore, 2012; moser, luxenberger, & freidl, 2017; quaranta et al., 2015). the effects of arhl hearing loss may result in reduced quality of life (qol) that is considered a multidimensional concept (moser et al., 2017) with the elderly experiencing feelings of depression, anxiety, worry, anger and embarrassment and may also be associated with cognitive decline (ciorba et al., 2012; d’haese et al., 2019; sogebi, olusanya-peters, & oluwapeluni, 2013). the world health organisation (1994) describes qol as individuals’ perception of how their health, wellness, culture, living conditions and environment affect the psychological or emotional state, social relationships, independence, communication and personal beliefs. for the purposes of this paper, qol will specifically refer to the psychological or emotional impact of hearing impairment on life as well as its impact on social relationships. studies indicate that elderly individuals residing in retirement homes (both within a state and within the private context) have a greater prevalence of hearing loss and an associated reduction in qol (chalise, 2019; mccreedy, weinstein, chodosh, & blustein, 2018; mirwan et al., 2016; moroe & vazzana, 2019). salonen and colleagues (2013) have identified three fundamental reasons for this. firstly, poor audiological care for this population is a concern as audiology services are not routinely conducted within retirement homes. secondly, elderly patients who have been tested and diagnosed with hearing impairment within these homes are inappropriately managed as they are provided with hearing aids but not provided with associated support because of either poor access to healthcare or because of financial limitations. finally, those who have been fitted with hearing aids do not comply with using and maintaining them because of poor follow-up as a consequence of a negative attitude towards hearing instruments; negative perceptions related to the appearance of hearing instruments on the ear; internal and external stigma and denial of the hearing impairment. additional factors contributing to reduced qol in this population relate to social isolation because of stigma around hearing loss and hearing aid use; lack of support including audiologists monitoring of qol issues during consultations and follow-up visits and lack of family or spousal assistance (bainbridge & ramachandran, 2014; govender & paken, 2015; hickson, worral, wilson, tilse, & sedderfund, 2005; homans et al., 2017; moroe & vazzana, 2019; patel & mckinnon, 2018). the above perusal of literature confirms four important aspects. firstly, there is a high prevalence of arhl; secondly, this hearing impairment can lead to a reduced qol, especially if there is poor hearing aid support. the role of the audiologist in improving qol for the elderly with arhl is understated in literature. finally, literature also affirms that there is a paucity of studies within the south african context relating to hearing loss and associated qol issues amongst the elderly. it is therefore worth investigating these issues within the sa context so that findings emerging from such studies may be assimilated into designing contextually relevant hearing screening programmes and evidence-based intervention for the elderly residing in retirement homes. the purpose of the study was therefore, to determine the presence of hearing impairment and its impact on qol for the elderly residing within retirement home facilities. research method and design aims and objectives the objectives of the study were to: (1) identify the presence of hearing impairment through a hearing screening test battery in a sample of elderly participants residing in three retirement homes. (2) determine the psychological, communication and social impact of the hearing impairment on the qol in a sample of elderly participants residing in retirement homes. study design the study employed a cross-sectional research design that aimed to investigate both the presence of hearing impairment through a hearing screening test battery as well as to determine the impact of hearing impairment on qol through a questionnaire at one point in time in a sample of elderly participants residing in retirement homes. study sites several sites in pretoria, including both government and private retirement homes, were invited to participate; however, the majority of participants were from private retirement homes with only one state retirement home providing permission. study sample a total of five retirement homes, four classified as private retirement homes and one as a state facility, consented to participate, with a total population of 500 elderly individuals within these retirement homes. the minimum recommended sample size for the study was calculated to be 218 by applying a 5% margin of error, 95% confidence level and 50% response distribution. because of time constraints, participant refusal and cognitive disorders, only 30% (n = 70) of the estimated sample size was obtained. sampling method participants were conveniently sampled, based on their availability and willingness to participate in the study. participant description the participants’ ages ranged from 65 to 98 years, with a mean age of 79 years. seventy-nine per cent of the participants were female. data-collection tools for the hearing screening component of the study, an otoscope, pure-tone audiometer screener (gsi 18), titan middle ear analyser and dpoae screener and rs pro rs-95 sound level meter were calibrated and used for data collection. a questionnaire was utilised to understand the perceived impact of hearing loss on qol the world health organization quality of life (whoqol) disability questionnaire consists of four domains: namely physical, psychological, social and environmental. the questions relating to social and psychological factors and communication were adapted from the whoqol disability questionnaire (who, 1998). additional questions relating to communication challenges and hearing aid use were added. the formulation of the additional questions was guided by perusing literature (ciorba et al., 2012; salonen et al., 2013) (see appendix 1). data-collection procedure a hearing screening test battery and administration of the questionnaire was conducted on 60 participants and 10 additional participants only completed the qol questionnaire as they were already diagnosed with hearing impairment and wore a hearing aid. screening process hearing screening was conducted on all participants (n = 60) without hearing aids. otoscopy, pure tone audiometry (pta), tympanometry and otoacoustic missions (oaes) screening were conducted. pure tone audiometry was conducted over the range of 500 hz–4 khz according to the protocol. the intensity level was set at 25 dbhl (asha, 2018). otoacoustic emissions were included because of their sensitivity in detecting cochlear dysfunction, which is associated with ageing. the screening protocol, pass or refer criteria (asha, 2018), as well as the referral pathway, are illustrated in figure 1. all participants received an informational pamphlet regarding ear care at the end of the screening process. participants who obtained a ‘refer result’ (failed two or more frequencies) were appropriately referred to the relevant professionals such as general practitioners for cerumen management and audiologists for diagnostic testing. figure 1: asha (2018) screening protocol and pass or refer criteria. questionnaire administration participants who underwent hearing screening (n = 60) as well as those already fitted with hearing aids (n = 10) completed the adapted whoqol questionnaire. because of dexterity and visual problems, the researchers and nursing staff assisted participants in completing the questionnaire by reading out the questions. the researchers conversed in english and tswana, and for participants that spoke afrikaans only, the nursing staff were available to translate the questions. the questionnaire comprised simple and easy to follow questions. all of the questions were either yes or no or multiple-choice questions. participants who used or were fitted with hearing aids previously (n = 10) were required to complete an additional section of the questionnaire (section c), that explored hearing aid use. this section required the participants to mainly respond to yes or no questions and to state their primary challenges with hearing aid use if applicable. data analysis the data were analysed descriptively through percentage counts and mean averages, and then displayed on graphs and/or pie charts. the chi-square test was used to determine the significance between the relationships of variables (presence of hearing impairment and qol). reliability, validity and bias the reliability and content validity of the questionnaire utilised in this study was ensured by using questions from a valid and reliable standardised questionnaire (whoqol questionnaire, 1998) as well as formulating questions from peer-reviewed articles (bainbridge & ramachuandran, 2014; ciorba et al., 2012). content validity was additionally ensured as two qualified audiologists scrutinised and evaluated the clarity and relevance of the questions and that the questions met with the objectives of the study. the recommendations made by these audiologists were implemented. a pilot study was conducted on five participants at one retirement home that was not included in the main study. these five participants were not included in the final analysis of data. three of these participants were hearing-aid users. the purpose of the pilot study was twofold: (1) to evaluate the reliability of the hearing screening test battery, (2) to test the reliability of the questionnaire. the researchers ensured that the hearing screening equipment was calibrated and therefore, reliable results were obtained. the screening test battery was conducted by researchers in an environment with low ambient noise to improve reliability. the participants were able to respond appropriately to the tonal stimuli, indicating that they understood the instructions. feedback was given to the participants, referring the participants who failed the screening and obtained a refer result to an audiologist for a diagnostic assessment. noise levels were noted to be a problem during the pilot study and impacted on the screening test. for the main study, a quiet room was identified, and noise level measurements were routinely taken to monitor noise levels. the participants needed to verbally respond ‘yes’ or ‘no’ to questions relating to the ease of use of the questionnaire. the questions related to the number of questions, language simplicity and ease of understanding (comprehension). all five participants reported no problems filling in the questionnaire; therefore, no changes were made to the questionnaire. bias was likewise avoided through careful design of the data-collection tool; addressing the participants regarding the purpose of the study; the use of simple and accessible language; avoiding of double-barreled questions and testing data-collection tools through a pilot study (bless, higson-smith, & sithole, 2013). furthermore, the researchers did not influence any of the responses provided by the participants and analysis bias was avoided by ensuring that the collection and interpretation of the questions were solely completed by writing down the exact participant responses (word-for-word) and selecting a statistician for the data analysis with no ties to the current research study. ethical consideration ethical approval to conduct the study was obtained from the school of health care sciences (smurec/h/121/2016:u). furthermore, no participants were harmed or exposed to any risk and confidentiality was assured. participants willingly provided informed consent and were free to withdraw at any stage. participants with cognitive challenges were excluded from participation. confidentiality and anonymity were maintained throughout the study as information derived from this study was not disclosed, and research codes replaced names. questionnaires and hearing screening results were additionally stored in a locked cabinet and access to the research data was available only to the researchers, research supervisor and the statistician. all participants who obtained a refer result were appropriately referred. researchers also used calibrated equipment and maintained measures to control infection at all times. regarding beneficence, all participants received a pamphlet on ear care; participants screened or who required hearing aid support, were appropriately referred. results the results are discussed in accordance with the objectives of the study. presence of hearing impairment a total of 60 participants underwent a hearing screening test. seventy-nine per cent of the participants were female. the racial distribution of the sample size consisted of blacks and whites, with the latter group comprising the largest percentage 91% (n = 64). the results obtained from the hearing screening test battery revealed that 23% (n = 14) of participants passed the screening and 77% (n = 46) of participants obtained a refer result. of those participants that obtained a ‘refer’ result, 15% (n = 7) failed the otoscopic examination because of impacted cerumen, 13% (n = 6) of participants failed pure tone audiometry (pta) screening across two or more frequencies and 72% (n = 33) failed both pta and distortion product oaes screening. sixty-five per cent of participants (n = 39) were referred for diagnostic audiometry. fifteen per cent (n = 7) were referred to the general practitioner for cerumen management. impact of hearing impairment on the quality of life the 60 participants who underwent hearing screening were asked if they perceived themselves as having a hearing problem and of these 51% (n = 31) provided an affirmative response. of the total sample, both those with and without hearing aids (n = 70), 74% (n = 36) reported that the hearing problem negatively affects their lives. results revealed that 29% (n = 16) of the participants felt depressed, worried and anxious as a result of their hearing difficulties. this was followed by a total of 11% (n = 8) of the participants who reported feeling angry about their hearing difficulties. a total of 10% (n = 7) felt a sense of grief because of their loss of hearing. twenty per cent of participants felt unaccepted by their significant others as a result of their hearing impairment. regarding social interaction, a total of 78% (n = 55) of participants stated yes to the question relating to social participation in that they continue to partake in social gatherings and meetings held at homes and religious gatherings. however, 29% of participants (n = 20) reported that their communication partners do get angry and frustrated with them as a result of the hearing problem. in terms of localisation, 66% (n = 46) reported that they were able to identify where sounds originated from in the environment, and 33% (n = 36) reported challenges with speech discrimination over the phone. a chi square test was conducted to determine the relationship between the screening result (n = 60) and qol responses. hearing difficulties were significantly associated with a reduced qol (p = 0.045, p < ?). of the 60 participants who were screened, 63% (n = 38) stated that they had not heard of an audiologist before. hearing aid use and quality of life all 10 participants who wore hearing aids were fitted with digital hearing aids. eight of the 10 (80%) participants reported that they used their hearing aids daily with two out of the 10 (20%) saying that they use them infrequently. all participants (n = 10) cited challenges with dexterity issues, acoustic feedback and discomfort as reasons for disuse of the hearing aid. ninety per cent (n = 9) of the participants said that since using their hearing aids, their communication abilities improved in terms of sound localisation and listening abilities in the presence of background noise. six (60%) of the participants mentioned an improvement in localisation to sound since receiving their hearing aids. eight of the 10 participants further reported an overall improvement in qol since receiving and utilising their hearing aids, and two of the 10 participants reported challenges with maintaining their hearing aids in terms of changing the batteries and with cleaning their device. implications and recommendations the results of this study identified possible hearing impairment in more than half of the study sample, requiring further evaluation towards diagnosis and intervention. the study findings correlated with other published studies, relating to the presence of hearing impairment in the elderly (homans et al, 2017; mccreedy et al., 2018). another salient finding of the present study was that 15% of participants failed the otoscopic examination because of cerumen impaction. this finding was consistent with other studies (aremu, alabi, segun-busari, & ogah, 2010; sugiura et al., 2014). reasons cited for the increased presence of impacted cerumen amongst the elderly include thinning of the surface epithelium, atrophy of the subcutaneous tissue, less production of oil and sweat by the ceruminous and sebaceous glands and lengthening of the hair in the ear canal all associated with the ageing of the skin in the ear canal (sogebi et al., 2013). a large percentage of participants also failed the oae screening, implying that the cochlear outer hair cells (ohcs) have been affected. this is consistent with the disease progression of arhl (fischer, johnson chacko, glueckert, & schrott-fischer, 2020). the current study findings illustrated a statistically significant relationship between the presence of possible hearing impairment (through a screening test battery) and self-reported reduction in qol. joore and colleagues (2002) demonstrated that new hearing aid users experienced less anxiety and depression following hearing aid use. mulrow et al. (1990) also reported a reduction in depression among hearing aid users, as measured by a geriatric depression scale. participants expressed feelings of anger, grief, frustration and sadness as a result of their difficulties with hearing. in addition, the sample that were fitted with hearing aids, reported improved social and communication interaction because of hearing aid use. however, the hearing aid fitted participants reported problems with managing their devices. these findings are in agreement with the existing body of literature (ciorba et al., 2012; nordvik et al., 2018). chew and yeak (2010) emphasise that untreated or poorly managed hearing loss can result in significant reduction in qol in the elderly. the majority of the study sample were either not diagnosed or not adequately managed for hearing impairment and this decline in hearing was associated with their feelings of anger, sadness, worry and depression. ciorba et al. (2012) hence emphasise the importance of routine evaluation of qol status during routine audiological management. ciorba and colleagues (2012) as well as tognola, mainardi, vincenti and cuda (2019) found that hearing aid fittings and continued follow-up improve qol in the elderly. the present study findings aligned to the above assertion in that the participants who used hearing aids reported improved social interaction and communication. a small proportion of the sample of hearing aid users did report challenges in maintaining their hearing aid. it is plausible that the lack of adequate audiological support within the context could be the attributable cause; however, this would require a scientific inquiry to support this assumption. hearing aid support would improve qol for the elderly as said (2017) states that such support for the elderly can result in improved psychosocial and cognitive functioning. overall, the results of the present study corroborate with those of salonen and colleagues (2013), where the three fundamental problems of poor audiological care, poor continuity of care for those diagnosed with hearing loss and poor hearing aid maintenance, were identified as the salient issues relating to audiological care in old age homes. geriatric hearing screening programmes within retirement facilities and at the community level need to be developed (solheim, shiryaeva, & kvaerner, 2016). however, there is a dearth of such promotion and prevention programmes in the south african context, despite its relevance within the primary healthcare approach. the findings of this study, therefore, place impetus on the development and initiation of hearing screening and (re) habilitative programmes and support within retirement homes and for the elderly in general so that adequate intervention may be provided which could, therefore, mitigate the impact of auditory problems on the qol. thus it becomes important that audiology intervention programmes consider the multifaceted nature of arhl and address not only the hearing difficulties but the associated impact on social, communication and psychological well-being. conclusion a high prevalence of undiagnosed and poorly managed hearing impairment in the elderly residing in retirement homes is a significant problem. hearing impairment has an impact on the social, psychological and communication aspects thereby reducing qol. audiologists need to solidify their roles and responsibilities for the management of arhl and ensure that the vulnerable ageing population is adequately provided with the knowledge, resources and services to effectively manage their hearing disorders to reduce the negative impact that arhl can have on qol. future research is required on the development and feasibility of geriatric hearing screening programmes, particularly for use within retirement home facilities. these programmes should ideally be multidisciplinary, offering evaluation and monitoring of qol, practical coping mechanisms and psychosocial support, alongside audiological management in order to remediate the progression of the disorder and subsequently impact on the qol of the elderly in these facilities. further research into the outcomes of a collaborative approach of different professionals in the management of hearing loss in retirement homes would be warranted. this is important as the progression of presbycusis cannot be prevented, therefore, early identification and subsequent management of the hearing impairment is essential (ciobra, 2012). limitations of the study included the small sample size that hindered the generalisation of findings. furthermore, a comparison of services and qol outcomes within the private and state homes could not be conducted for this study because of the uneven distribution between both contexts. in addition, more qualitative studies looking into experiences of the current population involving hearing and their qol as well as interviewing professionals to also assess reasons behind poor or neglectful care, including lack of follow-up, is required. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this research article. authors’ contributions s.m.g. and m.d.j. contributed equally to this research article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed during this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references american speech-language-hearing association (asha). 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(2004). global burden of diseases. health statistics and information systems. retrieved 07 october 2016, from http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/ appendix 1 questionnaire research questionnaire: hearing aids users identifying auditory pathology and associated factors amongst the elderly in retirement homes in pretoria north. 11 signs of the times: deaf language and culture in south africa* claire penn head: department of speech pathology and audiology university of the witwatersrand introduction of all human behaviours, language is probably the one which has been most studied through the ages. it has provided seemingly endless fascination to many disciplines, offering at once both the means and the focus of interdisciplinary dialogue. language is the tool of thought, of poetry of narrative, of persuasion, history, tradition and religion. it is the means by which human relationships are started, maintained and terminated. language portrays sentiment, love, anger, hope, belief. from whatever perspective we examine it scientific, philosophical, neurological, anthropological even archaeological, the study of language continues to perplex and intrigue us. language is not a neutral topic. as a repository of cultural knowledge and a symbol of social identity, it has been and continues to be a charged and embattled area linked closely to social, political and educational issues. "a language can serve as a cohesive defining source of pride and positive identification and simultaneously as a focus for stigma and ridicule from members of the majority culture." (meadow, 1975:17.) this is a situation we know all too well in our own country, in which many of the issues in politics and education have been centred both in the past and at present in linguistic and cultural issues. the topic of sign language reflects just such debate and controversy particularly in the south african context. i will propose that the study of sign language and the issues which surround it, provide insight into many of the broader issues of history, language identity, culture, education and language planning in this country. i will also demonstrate that the study of sign language helps shed light on some issues of general concern to those studying language, such as the biological basis of language and the relationship between language and thought. sign language is the language of eyes and hands, of movement and of space. sign language is the natural language of the deaf community. * this article is an inaugural address delivered on 17th february 1993, university of the witwatersrand. a few definitions seem worthwhile here. the term "deaf" is traditionally defined in relation to the audiogram. a person with a mild to moderate degree of hearing loss is still able to hear a number of speech sounds and is capable, with some extra help, of benefiting from the amplification provided by a hearing aid, and of learning language in the way that hearing children do, that is in the oral-aural mode. even a person with a severe degree of hearing loss is capable, with adequate intervention, of acquiring spoken language. the term "deaf" should probably therefore be reserved for those individuals with very little residual hearing that is those with a severe to profound degree of hearing loss who will not benefit from amplification. in fact this term again, is far from a neutral one. as a medical description measured in decibels or degree of infirmity, deafness is viewed as a pathology requiring treatment a problem which can be fixed. the overall goal of both medicine and education has been to normalise the situation and to make the individual as normal or as hearing as possible. both historically and currently, however, there is overwhelming evidence to suggest that neither medical nor traditional educational interventions produce very successful goals in this direction with the profoundly deaf child. however, an alternate perspective of deafness exists which is emerging as an equal if not more powerful and compelling one than the traditional view . the term deaf has become a descriptor for a distinct group with its own cultural identity and language. padden and humphries, two deaf americans write: "the traditional way of writing about deafness is to focus on the fact of their condition that they do not hear and to interpret all other aspects of their lives as consequences of this fact in contrast to the long history of writings which treat them as medical cases or as people with disabilities who "compensate" for their deafness by using sign language, we want to portray the lives they live, their art and their performances, their everyday lives, their shared myths and the lessons they teach one another. we have always felt that the attention given to the physical condition of not hearing has obscured far more interesting facets of deaf peoples lives." (padden & humphries, 1988:1.) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 12 claire penn the cultural cohesion of such a group thus overrides similarities or differences on the audiogram and reflects a far more complex and dynamic state of affairs. there is limited correlation between the audiogram and the descriptor. those who share a common language and culture are considered deaf with a capital d. such a distinction explains nancy reflects's (1985; p.53) account of her own deafness: "when i was born, my hearing was fine. at age 2,1 became deaf. at age 16, i became deaf'. age of onset is a crucial factor to be considered within this definition: the cultural term "dear is used primarily for those with congenital deafness or who acquire deafness at a very early age. those individuals who tragically become profoundly deaf later on in life but who have had an opportunity to acquire spoken language are rarely considered to be part of the deaf culture unless of course they become fluent signers. similarly those who are labelled as "hard of hearing" (that is with some amount of residual hearing, who wear a hearing aid) and who have a substantial amount of oral language) are often excluded from the deaf cultural group. residual hearing, far from becoming a desirable asset, thus becomes a type of handicap which excludes certain individuals from the deaf group. this is the force which causes deaf adolescents to remove their hearing aids and to abandon attempts at oral communication. one of the chief things which distinguishes the deaf culture then is language. the nature of sign language a number of myths have surrounded sign language for centuries. with the advent of the videorecorder which has enabled detailed study of this rich fleeting language, the past three decades has seen many of these myths dispelled. william stokoe a linguist from gallaudet university who must be considered the foremost researcher in this regard has suggested: "interestingly as sign language is as a system, tantalizingly like other languages and fascinatingly different, the real value to be found in the study of sign language is a human and not abstract scientific value. all language is unique, but the study of sign language reveals that language is both abstract, independent of speech and of gestural expression, and biologically concrete because of its expression. language depends on the human brain, not on the naked or electronically assisted human ear." (stokoe, 1976,p.13.) what are some of the misconceptions which the research of stokoe and others have dispelled? . sign language is not gesture. it is not a primitive form of language and is not equivalent to or derived from the codes used by american indians and aboriginal people, chimpanzees, and silent orders, or on a local level, the signs of the bushmen. it is not more concrete, and it is not less grammatical than spoken language. it is not pantomime. it is not universala popular misconceptionand one which has particular relevance in the south african context. as a result of linguistic change and because of independent creation in different parts of the world, no single sign language exists. as figure 1 suggests,sign languages are often mutually unintelligible, even within countries that use the same spoken languages (as happens for example between british and american sign language). signs are arbitrary and not iconic. the grammar of sign is not derived from the spoken language of the hearing community. signing does not interfere in any way with the acquisition of spoken language or of speech. on the contrary like any first language, it provides a cognitive framework for the learning of later second languages. most important the deaf are not dumba commonly used but hugely derogatory term which reflects many of the historical biases and misconceptions held about their language. american sign language danish sign language chinese sign language1 figure 1: seven language symbols that represent the same object. in short sign language is a real language, equivalent in status to any other language deaf persons can sign about any topic, concrete or abstract as economically, as effectively , as rapidly and as grammatically as hearing people can. sign language is influenced by entirely equivalent historical social and psychological factors as spoken language there are rules for attention-getting, turn-taking, story telling, there are jokes, puns and taboo signs, there are generational effects observed in sign language, metaphors and " slips of the hand." in short as stokoe observes: "language is not mouth stuff, it's brain stuff." let us examine some of the evidence accumulated with reference where possible to our own south african research base to highlight some of the properties of sign language as well as its biological basis. sign language has a unique spatial syntax which is complex and multilayered. what is sequential, linear and temporal in speech, additionally becomes multidimensional and simultaneous in signin other words "language in four dimensions." the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) signs of the times: deaf language and culture in south africa 13 signer addressee addressee (a) fixed framework (b) shifting reference figure 2: examples of fixed framework and shifting reference. individual signs differ from each other in terms of a system of distinctive features known as cheremes, which include hand shape, orientation, movement and location in space. in addition a complex system of nonmanual features exists involving eye gaze, posture and facial expression. description of these features includes both the syntax , that is the way that individual signs are organised into larger units such as clauses and sentences, and also the rich morphology that is the regular ways in which the signs can be modified to express specific grammatical functions such as number and aspect. a few specific examples will illustrate these points: in sign language nominals (people or other referents) are introduced into signed discourse by initially assigning spatially distinct loci. injspoken conversation, speakers may point to a specific location to indicate a person or object. for example, two speakers may be talking about (and point to) a cat| who occupies a particular chair. here a real location is used. in sign languages a combination of real as well |as relative and conventionalised locations is used. in relative locations a signer uses points in space to produce an image of some or other location. any subsequent reference to that locus either by pointing, gazing or shifting the body or by verb agreement refers back to the previously established nominal even when other signs have intervened. in figure 2 for example we see how the subjects of the conversation and the space they occupy remain established throughout the stretch of discourse. conventionalised locations may be illustrated in relation to the system of pronouns where indexing in relation to the speaker indicates a range of particular pronouns. (see figure 3.) such conventional location may also be found in the system of verb inflections. in certain verbs the movement is mutable and marks the grammatical relationships among sentence constituents. for example, the difference between the sentences i ask you and you ask me relate to the differences in movement of the hand (and orientation) towards and away form the body, asa μλ h · · • • a-b a-c c-e d-b-c first person singular second person singular third person singular fourth person singular inclusive 'we' exclusive 'we* third person plural second person plural etc. figure 3. example of conventionalised locations pronouns. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 14 i-give-you you-give-me figure 4: example of conventionalised locations : verb inflections. signing both the subject and the object of the sentence. (see figure 4.) additional cohesion in signed discourse is achieved through the use of "performatives" equivalent to role playing in which there is modification to facial expression, body posture and style of signing as the signer adopts a particular character role in a story or everyday conversation. the marking of the time and aspect in sign language is also of interest. two main mechanisms may be identified.one of the ways is adverbial modification (using separate signs for concepts such as yesterday, recently, etc). some writers make reference to the putative time line in which these adverbials as well as particular verbs are marked in a location in space to represent time illustrated in figure 5. thus the past is viewed as located over the right shoulder and the future in front of the body. other ways of marking tense include the use of signs such as finish which imply completiveness. a time line in front of the body will represent continuousnessdifferentiating for instance between past tense "i posted the letter" and continuous tense "i am posting the letter". in addition the verbs themselves can undergo complex modulation providing information about manner, location and direction differentiating for example between the uninflected form of the meaning "be sick" and other meanings: prone to be sick, get sick easily, sick for a long time, never stops being sick, often sick, very sick, sort of sick, became sick, through morphological changes to the basic sign in terms of reduplication, repetition and duration. claire penn another important area of sign language structure is nonmanual behaviour. just as tone of voice can serve to alter meaning in spoken language, so various aspects of facial expression and posture can modify meaning in sign language._it can be used to mark sentence boundaries. it can be used to mark a grammatical function for instance in serving to mark the difference between statement and questions (illustrated in figure 6) and statefigure 6a: examples of nonmanual behaviour. figure 6b: examples of nonmanual behaviour. the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) signs of the times: deaf language and culture in south africa 15 figure 6c: examples of nonmanual behaviour. ments and negatives. nonmanual behaviour is also used in an adverbial way to illustrate concepts such as ease, effort, enjoyment, intensity, etc. (see figure 6.) what i have dealt with here is only a brief look into the some aspects of sign language linguistics. it has, however, i hope illustrated the complexity of the process as well as the rule based nature of this unique language. having dealt with the behavioural perspective, it seems timely to move to the biological perspective of sign language. two areas of research shed light on this aspect and these are the areas of acquisition and dissolution: | how do deaf children acquire sign language and how does sign language become impaired after brain damage? are there parallels betw.een the acquisition and dissolution of spoken and sign language and what are the implications of such parallels? i acquisition and dissolution'of sign language the best context in which to observe the acquisition of sign language is by observing the sign language development of a deaf child born to deaf parents. it has been demonstrated that such babies acquire sign language at approximately the same rate and in the same sequence as hearing children acquire spoken language. deaf babies "babble" with their hands,in the same repetitive rhythmic patterns as hearing babies babble with their voices. the first signed word occurs at around nine months often before the first spoken word of hearing babies for reasons suggested to be related to motoric and neurodevelopmental aspects. subsequent development takes place in leaps and bounds, with characteristic childhood errors (such as incorrect use of some of the more complex spatialised syntax) but within a short period of time, the deaf child achieves full signing competence . thus when the language learning environment is compatible with the needs of the deaf child and is presented in the visual mode, language can be acquired easily and at the same pace as language presented in the aural mode. the question remains as to where sign language is stored in the human brain. cerebral asymmetries in person with normal hearing and specialisation of the left hemisphere for spoken language have long been documented. though research in the area of deafness in this regard is more sparse, sign language is similarly located (poizner, klima and bellugi, 1989). this is in spite of the fact that sign as we have seen has a large spatial component a function widely recognised to be subserved by the right hemisphere. one of the ways in which hemispheric specialization has been studied is by examining the effect of brain lesions on the language of an individual. in spoken aphasia, which has been documented for well over a century, characteristic patterns of language deficit emerge correlating with specific areas of brain damage. for example, in broca's aphasia or agrammatic aphasia which is caused by a lesion in the left inferior frontal lobe, there is an impairment of expressive syntax in the presence of relatively well retained receptive abilities. in cases of sign aphasia, that is when for example a fluent deaf signer suffers a stroke in the same area, an equivalent pattern of syntactic and morphological deficit emerges in relation to the sign. an examination of some of data supports this claim. figure 7 illustrates three cases of deaf adults who were previously fluent in sign language and who have as a result of a stroke shown a dissolution in their language abilities. sign aphasia key: + relatively relatively preserved impaired patient a expressive receptive visuo grammatical sign sign perceptual facial syntax syntax abilities recognition + + + patient β + + + patient c + + figure 7: performance of 3 deaf persons with brain lesions on linguistic and neuropsychological batteries. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 16 the first two cases demonstrate a left hemisphere lesion and the third, a right hemisphere lesion.their performance on a battery of neuropsychological and linguistic tests is summarised on the right hand side of the figure. case one demonstrates a lesion in what is traditionally known as broca's area of the brain . her sign language is agrammatic consisting of uninflected and sparse nouns and verbs. she shows none of the grammatical apparatus previously described no verb agreements or inflections and no use of spatialized syntax. in contrast, her reception of sign is relatively well retained she is able to follow sign instructions and to understand a sign conversation. her visuo spatial and constructional abilities, as measured on a range of adapted neuropsychological tests, remain intact, as does her ability to recognize and comprehend some of the grammatical nonmanual features (such as changes in facial expression) which have been discussed already. this profile therefore shows some interesting parallels with the neurolinguistic profiles of a left hemisphere damaged hearing patients. interestingly in this case (as in the only other cases of documented cases of this nature) shows damage not only to broca's area but also to the cortical immediately above it that dealing with the handand this suggests that the area above the left motor area may be an important component of sign aphasia specifically. case 2 with a left parietal lesion though fluent in expressive sign language has severe difficulties in the comprehension of certain grammatical forms. this receptive difficulty does not appear to parallel in severity the comprehension of a speaking aphasic patient with a lesion in this area and suggests perhaps that because of the spatial aspects to sign language, a left parietal lesion is of more impact. this patient, however, like case i shows competence in visuospatial ability (a function served by the right hemisphere) but cannot accurately recognise the grammatical distinction between certain facial behaviours a finding which tends to suggest a dissociation between different spatial aspects in the brain (those with and without linguistic overlay). finally case 3 who has a lesion in the right capsula interna region shows poor performance as one would expect in a hearing patient with a similar lesion on a battery of visuospatial and visuoconstructional tasks such as block design. however, signing competence is spared both expressively and receptively except, interestingly, in the domain of nonmanual features . this patient appears to lack an ability to recognise some of the grammatical and adverbial marker marked by facial expression such as has been shown. the impact of a right hemisphere lesion therefore may be greater for the deaf person than for the hearing person. . this type of data while broadly confirming that sign language has an equivalent biological basis to spoken language, is thus highlighting certain interesting differences. such lines of evidence are also accumulating from psycholinguistic experiments with neurologically normal deaf and hearing individuals. for example, researchers at the salk institute have shown that deaf children are superior to hearing children in being able to draw accurately the shape of a claire pennl moving light pattern travelling in space. similarly deaf adults seem to be better than hearing adults at generating and manipulating mental images, e.g. telling whether one object is the same as another but rotated in space. the question arises as to whether the mode of language learning thus influences the brain's ability to perform certain tasks and takes us back to the sapirwhorf hypothesis which suggests that how we talk determines the way we think. many questions still need addressing but to recap so far, i have argued that the structure and the biological basis of sign language demonstrates its full status as a l a n g u a g e . "sign l a n g u a g e is b i o l o g i c a l l y and unsilenceably the voice of the d e a r (sacks, 1989 :123). such research has done more than anything in the past three decades to consolidate the notion of deaf culture. cultural and historical aspects of deafness the growing acceptance of sign language as a real language has done a great deal to strengthen the notion of deafness as a cultural entity. the past few years have seen the emergence of a ^ strong and powerful deaf culture in many countries. there is deaf art, poetry, theatre, sport, many deaf clubs, and congregations. films such as children of a lesser god and tv series like reasonable doubts have helped to show the hearing world the pride and unique status of deaf culture. additional indices of such cultural cohesion include a shared set of behavioural norms among deaf as groups and a largely endogamous marital pattern. regardless of parental hearing status over 90 % of deaf people marry other deaf people. a shared history is another such index of cultural strength and a glimpse into the history of the deaf of their language and culture and the attitudes of hearing persons to deafness provides an intriguing window on prevailing attitudes and thought about cultural minorities. there is some reference made to the deaf and their language in greek times. for example in plato there is a dialogue between socrates and hermogenes on; the relation between word and idea and socrates asks: "if we had neither the voice nor tongue and wished to explain things to others, could we not try like the deaf to convey our meaning by using our hands, heads and other parts of our bodies?" hippocrates, however, suggested that deafness was due to a defect in the tongue since the deaf were not able to speak. during the renaissance several mentions were made of methods of teaching the deaf language and leonardo da vinci suggested that lip reading was a very valuable lesson for the painter. most modern accounts of deaf education and language, however, begin in the 18th century. the father of modern sign language was probably the abbe 1 epee who founded the first school for deaf children in france in about 1765. observing closely the natural language of two deaf girls he met in a paris slum, he decided to dedicate himself to the education of the deaf. he learnt their signs as a medium of teaching and imposed on them a formal grammar and method of instruction (based on rules of spoken french). his disthe south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) signs of the times: deaf language and culture in south africa 17 ciple and successor abbe sicard continued in his footsteps but gradually the use of methodical signing was viewed as unwieldy and cumbersome and the natural syntax of sign was adopted. among the foremost proponents of this was a deaf frenchman laurent clerc who was invited by rev thomas gallaudet to america and who with gallaudet founded the first school for deaf children in america in 1817 . the french signs were formally integrated with some of the sign language used by local deaf groups and what became known as american sign language (asl) was formally adopted in the deaf schools in america. in 1867 there were 26 institutions for the education for the deaf in america and asl was the language of instruction in all. deaf persons had moved into positions of esteem and success and were working as teachers in all the schools. by 1907 there were 139 schools and asl was allowed in none. a similar state of affairs had happened in france and in other european countries. what happened is that at a meeting of hearing educators in 1880 held in milan it was agreed that oral instruction only could restore deaf people to society. thus towards the ends of the last century hearing teachers took control of schools for deaf children and banished sign from the classrooms as well as all the deaf teachers. despite considerable deaf protest manual language thus became oppressed. the first president of the national association of the deaf said at the turn of the century: "what heinous crime have the deaf been guilty of that their language should be proscribed?" (quoted in lane, 1984:xvii). harlan lane, an eminent psychologist who has written two powerful b o o k s on deaf culture and history (1984,1992) has suggested that: milan was the single most critical event in driving the languages of the deaf communities beneath the surface; i believe it is the single most important cause of the limited educational achievements of modern deaf men and women (19|84:25). there is every indication according to lane,that the deaf were better off in the 19th j century. not until very recently have things been rectified (at least in countries such as the united states). lane believes that attitude and treatment of the deaf during the first part of this century can be viewed within a framework of stigma and paternalism. for example, alexander graham bell inventor of the telephone and son of a deaf mother as well as married to a deaf woman, not only suggested that sign language and deaf teachers should be banished but as committee member of the breeders association, wrote a great deal about eugenics, and the danger of marriage between immigrants, and also between deaf people. presupposing that familial deafness was something to be avoided, he urged deaf students not to " hand your affliction down to your children" and to "enter into an ideal marriage with a hearing person". the unfortunate mrs mabel bell not surprisingly wrote near the end of her life " i shrink from any reference to my disability... i have striven in every way to have my deafness forgotten ... i would have no friends among them." the development of psychometrics and iq tests also had a negative import for this model of disability. such tests were grievously misapplied to deaf children and adults -deaf people performing up to 30 points below hearing people on such tests standardised and administered in oral language. this was taken as evidence for the "dumbness" of deaf people and provided reason for diversion into non-academic subjects. on the psychological track, a series of publications emerged describing the personality characteristics of the deaf. lane (1992) likens the historical attitude towards deafness to the forces of colonization particularly in africa. drawing on colonial literature on the one hand, and descriptions of deafness in the past twenty years from the educational and psychological literature on the other, he demonstrates vividly the frightening parallels in description and terminology. he expands the argument by drawing parallels in attitude between the oppressors in both cases. as an explanation lane cites the ideas of french historian and philosopher foucault (1977) who proposes that power in modern society is disseminated into small structures. through a system of norms and exclusion, those members of society who are different (such as the criminal, the insane , the sick, and of course, the deaf) are given a set of rules and restrictions which highlight t h e i r differences and d i s e m p o w e r t h e m further. what is also interesting is the interdependence between physicians, educators and decision makers on the one hand and the oppressed sick (or deaf) people slipping into roles of subservience and non-achievement. what is probably the most important milestone in the history of deaf culture this century is the series of events which took place during a week in early march 1988 at gallaudet university for the deaf in washington. this university had hearing presidents since its founding in 1864. the appointment of a new hearing president dr elizabeth zinser lead to a strong accelerating protest among students and staff at gallaudet. during the week of protest which included a march to the white house, the shutting of the university and the barricading of campus, the activities touched the hearts and imagination of the hearing world and highlighted the power of the deaf culture. eventually this action resulted in the resignation of dr zinser and the appointment of a deaf president dr irving king jordan whose words "deaf people can do anything but hear" have become a slogan for deaf empowerment. jesse jackson said of this event: your determination , strength and unity achieved a historic victory at gallaudet ... your victory was a victory for all of us ... it was a victory for all people who ever felt the pain of being stereotyped, devalued and unrepresented. after a century of oppression things had at last changed. if such attitudes towards disability have prevailed throughout the world how much more can we expect them to be entrenched in a country like our own which has formally legislated against certain groups for so long? die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 18 claire penn moving to a history of the south african deaf we see some uncomfortably close parallels and some similar shifts in attitudes. history of south african deaf the main milestones in the history of the deaf in south africa are portrayed in table 1. table 1: milestones in the history of signing in south africa 1863 irish sisters involved in training programmes for the deaf 1874 grimley institute for deaf and dumb opened in cape town 1877 german (dominican) sisters started school for the deaf in king williams town 1881 de la bat school started by drc in worcester 1920 oralism formally adopted in deaf schools 1934 schools divided into "european" and "noneuropean" st vincent's school for the deaf opened in jhb 1941 first school for the black deaf established paget gorman coding system introduced 1980 publication of "talking to the deaf' adopted by det 1984 medium of education changed from vernacular to english in det schools there is little history formally documented and what i have had to rely on is press cuttings, records and newsletters of the south african national council for the deaf founded in 1929 and interviews with deaf adults. in 1863, five sisters from the dominican convent, cabra, dublin ireland founded a school for the deaf in cape town, later known as the grimley institute for the deaf. at approximately the same time, the dominican sisters started a school for the deaf in king william's town. in 1881 the de la bat school for the deaf was started by the dutch reformed church in worcester . official educational policy changed in south africa changed, and in accordance with recommendations made at the milan congress, oralism was formally adopted in deaf schools in 1920. with pride the schools advertised themselves as "purely oral" and advocated the "the modern method of speech and lip reading." dr van schalkwyk, superintendent of social welfare and probation in 1938 said, "a deaf mute child given the opportunity to learn lip reading will learn it as naturally and easily as a normal child learning to speak." a deaf informant in cape town, born to deaf parents tells of how a principal of a local deaf school agreed to admit her on one condition only : that the parents (both of whom had sign language as their first language) would never use their hands in front of her. the belief of the time was that with amplification and early intervention , including lip reading "the deaf will hear and the dumb will speak" to quote an early cape newspaper. unfortunately with hindsight, such goals were hideously misdirected. i have already discussed the complete proficiency with which deaf children acquire language from their deaf parents. the language outcome for deaf children born to hearing parents and placed in a purely oral environment is, however, considerably less effective. in most cases the deafness is not detected until the child is a few months old, and in south africa it is quite common for this to be much later. research suggest overwhelmingly that in the case of profound congenital hearing loss that even with concentrated and intensive early intervention, there are often considerable delays in the acquisition of spoken language and subsequently literacy. over sixty percent of the deaf adult's speech remains unintelligible to the average listener. the average reading age of the deaf school leaver is that of an eight year old. in short, the deliberate exclusion of sign language from the learning of such children sometimes has had a disastrous effect on overall scholastic and vocational goals for the deaf in south africa. this lack of a mutual communication system during a critical language learning phase leads to poor language development: " there is an especial peril that threatens human development, both intellectual and emotional, if the healthy acquisition of language fails to occur" (sacks, 1989:60). in the press cuttings i have seen, recording the history of dominican schools for the deaf in cape town from 1932 to 1965 the only reference to sign language that i found was: "we don't teach it officially but they pick it up from older children and pass it on in their turn." (sister amata dominican school, 1962.) thus sign language continued to be used informally in the playgrounds and in deaf clubs and congregations. in some of our own findings surveying adult deaf in south africa about when and from whom sign language was learned, this was confirmed, well over half our respondents learning sign from contexts other thanihome and formal school settings. (figures 8.), j in 1934, the same year that st vincent school for the deaf was founded in johannesburg,schools were diyided into european and non-european . ι in the spirit of the times dr cawston of the juvenile affairs board, writing in the silent messenger 1936 said: attention would not seem to have been paid to the fact that south african natives are very seldom hard of hearing except in old age. this may be partly due to the fact that they have such spacious nostrils and air space. it is hoped that provision will shortly be made for those who are both deaf and dumb, for primitive peoples cannot be expected to look after them adequately in their own homes. the first school for the black deaf was opened in 1941 increasing fragmentation of educational policy was entrenched by the coming to power of the nationalist governments in 1948. ironically in contrast to so many other the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) signs of the times: deaf language and culture in south africa 19 percent distribution of sign users by period of acquisition of sign language oo 60 55 50 45 40 % 3 5 30 25 20 15 10 5 η oo 60 55 50 45 40 % 3 5 30 25 20 15 10 5 η oo 60 55 50 45 40 % 3 5 30 25 20 15 10 5 η oo 60 55 50 45 40 % 3 5 30 25 20 15 10 5 η oo 60 55 50 45 40 % 3 5 30 25 20 15 10 5 η oo 60 55 50 45 40 % 3 5 30 25 20 15 10 5 η oo 60 55 50 45 40 % 3 5 30 25 20 15 10 5 η oo 60 55 50 45 40 % 3 5 30 25 20 15 10 5 η oo 60 55 50 45 40 % 3 5 30 25 20 15 10 5 η oo 60 55 50 45 40 % 3 5 30 25 20 15 10 5 η oo 60 55 50 45 40 % 3 5 30 25 20 15 10 5 η oo 60 55 50 45 40 % 3 5 30 25 20 15 10 5 η oo 60 55 50 45 40 % 3 5 30 25 20 15 10 5 η "0-3 3-5 6-12 13-18 18+ years figure 8a: age during which sign language was learnt. β friends •family eoteachers •friends & family •teachers & family bleachers & friends figure 8b: primary educators of sign language. areas of education the situation for the black deaf child with the advent of the group areas act and the separate education bill, became educationally superior to that of the white deaf child for part of the educational policy was to introduce manual communication into the schools. the system used was not sign language per se but a manual code known as the paget gorman system which enabled a facility in communication and established a very strong deaf culture among the children and graduates of the black deaf schools. one assumes at the time that this was out of a sense of sheer desperation as hearing aids were not available to black deaf children and no effective communication system was available, but it was a happy choice, leading to the first attempt by norman nieder heitmann, principal of a school for the deaf near rustenburg to produce a dictionary of signs for use by the deaf in south africa. this text, called talking to the deafi 1980) was formally adopted as a teaching manual in the det schools where medium of instruction was changed to english in 1984. i unfortunately subsequent educational policy has denied the right of such children to achieve their potential. it is no longer possible for black deaf children to move beyond standard six in academic subjects and the focus of their education has been limited to highly technical aspects. such attitudes, although not legislated in the white schools for the deaf, some of which still offer an academic matriculation, have tended nevertheless to be entrenched: for example, rev de la bat after whom the school for the deaf in worcester was named, in justifying training programmes for deaf girls (1935) said: my personal view is that normal intelligent educated and well trained deaf girls make excellent wives and homemakers.the general desire today of girls for social entertainment, for excitement, for economic independence and freedom from domestic trammels does not affect the deaf girl so much. this is due to her handicap of deafness..these trends in modern girls are not in themselves faults and constitute essential factors in the woman wage earner but i am old fashioned enough to hold the view that these trends are detrimental to homemaking... the married woman because of her deafness naturally finds her interests and activities curtailed and consequently confines herself more to the sphere of her home.... i would suggest therefore that training be given to deaf girls in sewing, pattern making, costume designing, dress-making, cooking,invalid cooking, dietetics, upholstery, housewifery, home nursing, household decoration, washing and ironing, rug making, woolwork, knitting, millinery,marketing, toy making, basketry, lamp shade making, eiderdown quilt making and last but not least, gardening and agriculture. even this vocational advice is not as misdirected as that of the misguided dr cawston who suggested: secretarial work is difficult for those who fail to hear what is being said at committee meetings... but broadcast stations should provide a serviceable outlet of public speakers who are defective in hearing or suffer from other inefficiencies which make it difficult for them to speak from a public platform. in 1987 a national research project jointly funded by the south african national council for the deaf and the human sciences research council was established which had as its aim a characterisation of the diversity of sign languages in the country as well as of the sign syntax found among deaf groups. the first volume of the dictionary of southern african signs was published at the end of last year (penn, 1992). as we had predicted because of the widely diverse education systems, a number of sign variations were found to exist as illustrated in figure 8 . no one had, however, predicted the extent of this variation with the finding of an average of six variations per word. only two percent of the words had common signs a reflection of the effects of the legacy of apartheid and the attempts by hearing educationalists to divide , transplant and fragment deaf people (see also penn and reagan, 1990; penn, reagan & ogilvy, 1992). happily, however, and a point on which to build future educational policy die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 20 claire penn insect grammatical category : noun. level : preschool. theme : insect general. translations : gogga (a)/ intythwane (z)/ kokonyana (s). example of usage : flies, bees, grasshoppers, and beetles are insects. 'n insek het hom op die wang gesteek. * r* 7'f variation 1: one-handed sign in which 5-hand (clawed), palm down, hand away moves away in wriggling motion. used by det. variation 2: one-handed sign in which finger and thumb of α-hand, palm away, hand left, pinch corner of mouth. used by 2. variation 6: eenhandteken. g-hand, palm na onder, hand na links, wys na kant van mond en word vinnig na regs beweeg. used by 8, 9. variation 5: two-handed sign in which dominant 5-(clawed) hand, palm down, hand left, makes crawling movement along back of subordinate b-hand, palm down, hand right. used by 5, 7. variation 3: two-handed sign in which index finger of dominant g-hand, palm down, hand away, wriggles away along palm of subordinate b-hand, palm up, hand away. used by 1, 3, 6. variation 4: double-handed version of det. (variation 1). used by 4. key: 1/n tvl tswana. 2/soweto sotho. 3/zulu natal. 4/tvl indian. 5/natal english. 6/cape english. 7/tvl english. 8/cape afrik. 9/tvl afrik. det/sign taught in dept education and training. figure 9: excerpt: dictionary of south african signs (penn, 1992). the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) signs of the times: deaf language and culture in south africa 21 is the finding that which lexical variety exists there is a strong common shared syntax which will surely become the basis of formal language teaching for the deaf in the future. before i pass on to future directions, mention should be made of two deaf south africans whose rise to fame serve as an inspiration to all those who have struggled with an inequitable system: the first is deaf artist tommy motswai born in 1963 a pupil of kutlwa:nong school for the deaf near rustenburg, who has become a well known figure in south african art his work has been hung in local and international galleries and has won awards including most recently the standard bank young artists award. his delightful work portrayed in figure 10 captures the essence of south african societyits diversity, colour and its humour and reveals a sparkling wit and observation. figure 10: children play love by tommy motswai (reprinted from: standard bank young a r t i s t award 1992. p h o t o g r a p h y : michael hall). j the second famous deaf south african is david wright a poet of considerable influence having edited several anthologies and the penguin book of modern verse. wright was born in johannesburg in 1920 and became totally deaf from scarlet fever at the age of 7. he received some schooling here , then went to northampton school for the deaf and then to oriel college, oxford. he felt unsettled, lost and alienated at the deaf school, not having learnt the sign of his peers, but at university he also felt a stranger in a hearing world (wright 1969). in his verse he shows a cynical perception of life's paradoxes and injustices. the last verse of his poem "monologue of a deaf man" is particularly poignant: "thus i too must praise out of a quiet ear the great creation to which i owe i am my grief and my love. oh hear me if i cry among the din of birds deaf to their acclaim involved like them in the not unhearing air" in the last lines of his own funeral oration which he wrote at the age of 30, he makes reference to his south african origins: "born in a dominion in which he hoped not to go back since predisposed to imagine white possibly black his life, like his times, was appalling; his conduct odd he hoped to write one good line; died believing in god" alas many of our talented deaf (like the hearing) are leaving south africa like wright because of lack of opportunities and frustration with the authorities." having dealt with the history of the topic, a look at the present state of affairs is relevant. the current situation in south africa in south africa, in sign language , as of course in many other things, things are in a state of transition. the ripples of the gallaudet revolution have been felt worldwide and changes may be seen in many aspects relating to the deaf in this country. sign language courses are being taught by deaf persons, the first deaf chairman has been appointed to sancd , there is sign language interpreting in theatres and the deaf in johannesburg organised a march through the streets two years ago to highlight their situation. the situation in certain schools is slowly changing and although not formally legislated, the use of sign language is becoming more and more accepted sometimes as a last resort when all else fails. deaf teaching assistants are sometimes employed informally to assist their hearing counterparts. such informal change is i believe a reaction to the manifest failure of prescribed educational methods with the deaf and a frustration with the authorities: at official levels, however, change is much less rapid. "none so deaf as those that do not hear." there remains fragmentation and a lack of cohesive educational policy towards the deaf. as yet there are no proper courses for training teachers of the deaf and no possibility of deaf persons becoming registered teachers for the deaf in this country. some schools continue to actively punish the use of hands even of natural gesture and the children are reduced to "closet signing" in the playground, running the risk of developing fully neither oral nor sign language in the early years a recipe for disastrous cognitive, social and vocational outcome. attitudes towards deafness and handicap in general remain locked in a pathology/infirmity model which appears to be adhered to with vigour by far too many education and special education departments throughout the country. there is a huge lack of available resources and personnel and often some misguided decisions about even these limited resources. provision of expensive technology in the form of audiometers and hearing aids cannot substitute for the adequate training of specialised teachers. until such time as there is an infrastructure throughout the country which can not only provide, but also service and use such technology, programmes which have as their very dubious goal the expensive equipping of deaf individuals and deaf schools throughout the country will have limited impact. the goal of education should surely be the development of language skills in all, not speech in the few who will benefit from amplification. once again one is reminded of the position put fordie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 22 claire penn ward by lane and that is in medicalizing deafness, the majority "audist" culture stands to be considerably economically advantaged. many deaf individuals derive little or no benefit from extremely costly hearing aids. this is a fine example of "biopower" which foucault (1977) has referred to as being characteristic of medical advances in this century. this argument has to be even more valid for cochlear implantation particularly in this country. hailed as the "greatest advance in the treatment of deafness" briefly cochlear implantation involves a surgical procedure lasting about 3 and a half hours , and costing over r60 000 in which a multichannel electrode is implanted into the skull of the patient, so that acoustic energy can be converted into a type of mechanical energy which stimulates the auditory nerve. with intensive training, such individuals are able to detect and recognise distinct sounds and hopefully ultimately speech sounds. it was first approved by the federal drug administration in 1985 for use with adults, and in 1989 for use with children over two years old. several adults have been implanted with multichannel electrodes in south africa and the first child was implanted in johannesburg in october 1992. while the benefits of cochlear implantation in the postlingually deafened adult have been well demonstrated, cochlear implantation for the young congenially deaf child is much more controversial. not only is there relatively little research on their long term success but it calls to mind the whole ethical issue of child rights. there has been a very strong voice among deaf groups internationally against such early and drastic intervention.in a sense to implant a child is to commit oneself to oralism, and hence a rejection of deaf culture and language. further, it is a commitment to a great deal of intervention and money for relatively few individuals which is a highly questionable goal in a country like ours with scarce therapeutic resources. cochlear implantation is for life. the adolescent or adult is not able to discard the device as he is a hearing aid. we may be creating a " culturally homeless" child who fits neither into a deaf or hearing world. while not denying of course the need for such research we need to weigh up very carefully at the present time the distribution of relatively scarce resources. hopes for the future the issue of cochlear implantation like many others i have discussed this evening is far from resolved and presents a lively, often emotional battlefield for differing opinions on language and culture. i believe that the topic of sign language and the issues which surround it, is in a sense a microcosm of many of the issues that face south africa today, in that it reflects a history of debate, oppression,linguistic, cultural and educational schisms. there is a great need to be objective and to proceed with properly conducted research. some of the questions which have up to now been ignored for reasons of cultural prejudice, are now ready for study. under the large file i have called "reasons for staying in south africa" which alas all too often is disregarded by the cream of our profession, i must include the wonderful, relevant, exciting prospects in the area of sign language research which exist in this country. the relationship of hearing society to the deaf community has up to now been largely paternalistic, prescriptive and medicalizing. we need to "depathologize" deafness as woodward (1982 )suggests and begin to understand and appreciate an alternate view to deafness. i sincerely hope that this will happen in my own department. in conclusion, i would like to use this platform to indulge myself in stating publicly some of my hopes for my department and my profession and for the future of the deaf in south africa. deafness in its cultural and linguistic manifestations is an area of concern for a number of disciplines in this country. it is not only a medical problem, it is not only an educational challenge. it is a veritable banquet for practitioners and researchers, for historians, language planners, sociologists and philosophers, a reason perhaps, that i continue to regard the arts faculty as the happy home of our department. facts about deaf language and culture should be taught formally at all levels and i hope that this university will continue to be a forerunner in this regard supporting the sign language classes that have started here, the mooted development of courses for sign language interpreters within the department of translation, the acceptance of deaf students into academic programmes and the provision of interpreters for them within lectures. particularly i hope that this university will move in the direction of promotion of deaf teacher training and registration. this is not a new idea. indeed in 1803 abbe sicard suggested: "as a foreigner is not fit to teach a frenchman french, so the speaking man has no business to meddle with the invention of signs, giving them abstract values." (kyle and woll, 1985.) i believe that the time is ripe in the country for the deaf to become fully involved in their own affairs. there are many positive indications that there is a groundswell among teachers of the deaf and the deaf themselves which will hopefully affect policy in the near future. i hope to see a name change from the current national council for the deaf to national council of the deaf. we are seeing here an increasingly empowered group who hopefully using the developing research base as justification can begin to be involved in their own future, in guiding educational policy, in informing, the hearing public about deaf culture and language, in decision making and in research. ι i _ "what matters deafness of the ear when the mind hears... the one true deafness, the incurable deafness is that of the mind." victor hugo (1845) during the course of history, health practitioners, scientists and educationalists have labelled various groups biologically inferior: these include women, blacks, gays and deaf people. south africa i hope is at last moving away from some of its institutionalised legislation in this regard. it is my ardent hope that the future of the deaf in this country should reflect such changes of perspective . acknowledgements / it remains for me to thank those who have shaped my ideas through the years and who have assisted in the conception and the production of this lecture : the south african journal of communication disorders, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) signs of the times: deaf language and culture in south africa being aware of the somewhat controversial nature of my topic, i must assume full responsibility for what i have said but gratefully acknowledge the input and inspiration of many others: prof myrtle aron former head of the department of speech patholgy & audiology for her guidance and vision through the years and the fine example she set for me. her dedication to embedding the profession within the changing needs of south africa were an inspiration to me and all those she has taught. prof tony traill form the dept linguistics whose outstanding teaching when i was an undergraduate student provided me with a sustained fascination in language and its usage and whose keen research mind as well as supportive friendship i have valued highly throughout the years. my thanks go too to professor len lanham, now of rhodes university and professor david crystal from university college of north wales whose teaching and encouragement during the development of my career have been highly valued. prof timothy reagan of university of connecticut has been a wonderful friend and colleague during recent years and a buttress during some of the sign language sorties which i have had to engage in in this country. the ideas and attitudes of the late carol prutting my dear friend and mentor from the university of california,santa barbara influenced me in more ways than can be imagined and to her goes a special tribute. to the sign language research team of the human sciences research council, i owe much gratitude, particularly to dale ogilvy foreman for her constant support and friendship. t h a n k s are also due to dr peggy marks wahlhaus.ruth wakefield, and debra nails for their continued support. finally and most important i would like to thank my deaf friends and colleagues who have in the past few years allowed me some glimpses and insight into their language and culture and who have radically changed my attitudes towards disability and my visions for the profession in this country. i the fact that the large group of deaf people who cooperated in the dictionary project and coming from widely differing geographic, racial, religious, educa23 tional and linguistic backgrounds could within a few hours even minutes, link so successfully and communicate so well is a tribute to the power of their language and the limitless flexibility in a difficult world. the salience of deaf identity overshadows differences of ethnicity, age, class and gander which are so prominent in hearing society. it is my ardent hope that all south africans will take up such a common cause and move towards better communication in the future. references becker, n. (1985) being deaf and surprised. in alan j. brightman (ed) ordinary moments: the disabled experience. syracuse: human policy press. foucault, m. (1977) discipline and punish : the birth of the prison new york: pantheon books. kyle, j. & woll, b. (1985) sign language : the study of deaf people and their culture. cambridge: cambridge university press. lane, h. (1984) when the mind hears. new york: random house. lane, h. (1992) the mask of benevolence. new york: alfred j knopf. meadow, k. (1975) the deaf subculture. hearing and speech action 43:17. / nieder-heitmann, n. (1980) talking to the deaf i praat met die dowes. pretoria: government printer. padden, c. & humphries, t. (1988) deaf in america: voices from a culture. cambridge ma: harvard university press. penn, c. (1992) dictionary of southern african signs. pretoria: hsrc press. penn, c. & reagan, t. (1990) how do you sign "apartheid"? the politics of south african sign language.language problems and language planning 14, 2: 91-103. penn, c. & reagan, t. (1991) towards a national policy for deaf education. s a j communication disorders 38, 1924. penn, c., reagan, t. & ogilvy, d. (1991) "on that day the deaf shall hear": deaf-hearing interchange in south africa. sign language studies 71: 131-142. poizner, h., klima, e. s. & bellugi, u. (1989) what the hands reveal about the brain. cambridge ma:mit press. sacks, o. (1989) seeing voices: a journey into the world of the deaf berkely: university of california press. stokoe, w. c. (1976) the study and use of sign language. sign language studies 10:1-36 woodward, j. (1982) how you gonna get to heaven if you can't talk with jesus? on depathologizing deafness: silver spring, md: t. j. publishers. wright, d. (1969) deafness: a personal account. new york: stein and day. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 40, 1993 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 24 ο ed play and schoolroom ο ed shop 6l the rosebank mews 173 oxford road rosebank jhb. phone 788-1304 fax: 880-1341 tests, programmes, books, teaching aids, journals and resources for child development speech & language learning disabilities special needs adult rehabilitation social activities po box 52137 saxonwolid 2132 the south african journal of communication disorders, vol. 40, 199 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sajcd 121 continued professional development of teachers to facilitate language used in numeracy and mathematics a-m wium, b louw   department speech-language pathology and audiology, university of limpopo anna-marie wium department communication pathology , university of pretoria brenda louw corresponding author: a wium (anna-marie1.wium@ul.ac.za ) learners in south african schools have been found to perform poorly in mathematics because they do not understand the language used in solving mathematical problems. in order to improve academic performance teachers need to be made aware of the importance of language in the development of numeracy. a continued professional development (cpd) programme addressed this need. the purpose of the research was to understand how the participants implemented the strategies developed during the programme and how they perceived the support provided by the programme. the research was conducted over 2 years in semi-rural and urban contexts. as part of a more comprehensive mixed method study, the qualitative data referred to in this article were obtained through open-ended questions in questionnaires, focus groups, reflections in portfolios, and a research diary. results showed that numeracy terminology was often used by learners that differed from standard terminology prescribed by the curriculum. the participants themselves did not necessarily understand the numeracy terminology and thus found it a challenge to implement curriculum outcomes. issues related to language use of the participants in teaching numeracy were associated with the lack of resources available in the language of learning and teaching (lolt). some of the participants taught numeracy in english, rather than lolt. the results indicated low teacher expectations of the learners. the cpd programme was considered valuable and effective. slps in schools need to be expand their role to provide cpd opportunities for teachers. keywords: teacher support, numeracy, collaboration, language, foundation phase, speech-language pathologist s afr j cd 2012;59(1):8-15. doi:10.7196/sajcd.121 background and contextualisation of the study it is widely acknowledged that learners in south africa have performed poorly in numeracy benchmark tests, which was partly ascribed to inadequate language capabilities as many learners did not understand what was expected of them when they were assessed (department of basic education, 2011). such findings indicate a need to raise the level of learner achievement. however, raising learners’ performance levels in the current context is complex as few learners from low socio-economic schools (ses) receive any preschool education, which impacts on their school readiness when they enter formal education (botha, maree & de witt, 2005). furthermore, many of the teachers currently in the system received their training under a previous dispensation when education was fragmented and inequitable, resulting in inadequate professional training (thusi, 2006). in addition, the new democracy brought about positive sociopolitical change, including a new national education curriculum. however, the implementation of a new curriculum requires additional support of teachers, which could be provided with continued professional development (cpd) activities. this paper continues the reporting of the results of a body of research on the development of a cpd programme for foundation-phase teachers to facilitate the development of literacy skills, as well as the language used for the teaching of numeracy in the classroom (wium, louw, & eloff, 2010). based on the premise that language is the key to all learning, this article focuses on how foundation-phase teachers can be supported to facilitate learners’ language for numeracy and mathematics. the aim of the study was to develop a support programme for foundation-phase teachers to facilitate language for numeracy skills by using a three-pronged approach (appendix a, table a1), consisting of a training component (workshop), a practical component (classroom implementation of strategies), and a mentoring component (feedback by facilitator on lesson planning and portfolio assignments). the research objectives reported on in this article are firstly to determine how the participants implemented strategies that were acquired in a cpd programme to facilitate the language for numeracy in their classrooms, and secondly, to determine their perceptions of the support provided by the cpd programme. numeracy, mathematics and language numeracy is the ability to understand and reason with number, to act wisely in daily living activities, and to participate in civic life. it also allows one to use mathematics in order to solve problems. learners therefore need both numeracy and mathematics for mathematical learning. the current south african curriculum includes numeracy in the foundation phase as basis for mathematics, which is presented in gr 4 and onwards. it is therefore imperative that all children should acquire numeracy skills from early on. according to schleppegrell (2007: 140) ‘learning the language of a new discipline is part of learning the new discipline; in fact, the language and learning cannot be separated.’ the language of mathematics needs to be acquired, since the teaching of mathematics occurs through discourses; students’ work is assessed through oral and written communication, and learners process their ideas to develop understanding of numeracy and mathematics through language (raiker, 2002). there are contrasting viewpoints on the relationship between language acquisition and the acquisition of numerical concepts. one group of researchers contends that there is a causal relationship between language acquisition and the acquisition of numerical concepts, while another viewpoint holds that by learning a conventional spoken language for number, children learn to reason numerically (arvedson, 2002). although the exact relationship remains complex and controversial, language competency plays an important role in the development of numeracy and mathematical skills. language, mathematics and numerical cognition are all closely interrelated. the role of language and social interaction in the learning of mathematical concepts is based on interactions between the teacher and learners, as well as within peer groups (barwell, leungh, morgan & street, 2005). teachers, as mediators and facilitators of learning, play a significant role in guiding discourses in the classroom, and also provide the necessary scaffolding through instruction, modelling and group-based activities in the use of language for reasoning (mercer & sams, 2006). learning theory in relation to the development of numeracy skills the developmentally appropriate practice (dap) that was grounded in piaget’s stage-based theory on child development has now been replaced by a neo-vygotskian sociocultural perspective. the sociocultural theory, together with the closely related ‘activity theory’, account for learning and development as mediated processes (mercer & sams, 2006). the latter view considers social involvement in problem-solving activities as a crucial factor for individual development. social experiences with more ‘knowledgeable others’ (e.g. parent or teacher) enable the child to develop understanding that facilitates further learning. language is considered as both a psychological and cultural tool. learning first appears on a social plane (between people), and then on a psychological plane, which is within the child (also referred to as ‘internalisation’). early literacy and numeracy do not simply happen, but evolve through a social process that is based on children’s relationships with significant others in their environment (e.g. parents, siblings, grandparents, teachers, extended family, etc.). based on sociocultural theories, there is a close relationship between symbolic thinking and early literacy and numeracy. communication and cognitive learning take place through informal socialisation, and without direct instruction. learners with age-appropriate language proficiency acquire the language of mathematics as one component of a complex symbolic communication function. young children acquire mathematical concepts during play, and at the onset of gr r typically developing children have acquired the emergent numeracy concepts (torbeyns, van den noortgate, & ghesquirer, 2002), as well as language of measurement and position in space, the selection criteria for sorting, exploring, building, and matching with shapes. the vocabulary that develops from this emergent phase of numeracy is of particular importance. a summary of emergent numeracy skills and the associated vocabulary are summarised in table 1. table 1. emergent numeracy skills with required matching vocabulary (based on torbeyns et al ., 2002) concept vocabulary concept of comparison: ability to compare objects in terms of quantitative and qualitative properties   same/different more than/less than number words: one, two, three, four, etc. opposites: smallest/biggest; longest/shortest, tallest/shortest, lots, many/few; most/least; the same (equal) classification: the prerequisite is that learners must be able to sort comparative words, e.g. same/different; long/short; more/less; too many/not enough; none one-to-one correspondence also includes comparative words, e.g. same/different; long/short; more/less; too many/not enough; none; degrees of comparison (e.g. short, shorter, shortest) general understanding of numbers counting, plus all of the above approaches to teaching of language for numeracy and mathematics the issue of how vocabulary for numeracy should be taught is debated from opposing perspectives. vacca and vacca (1996) conclude that the vocabulary of mathematics instruction should be taught directly. in contrast, thompson and rubenstein (2000) propose an enculturation with the language of mathematics, especially at the preschool level, which concurs with views on literacy development. elkind (2001), however, states that neither the direct nor the indirect manner of instruction provides an answer, and suggests that children should learn mathematical vocabulary in both a formal and informal manner. this debate highlights the focus on the role of language and social interaction in the learning of numeracy and mathematics. discourses used in classrooms the discourses used in classrooms are a determining factor in the acquisition of numeracy and mathematics. figure 1 illustrates that the language for numeracy and mathematics requires competence on four different levels (gawned, 1993). the developed cpd programme specifically addressed levels 3 and 4 of the numeracy discourses as these were more specific in terms of vocabulary and terminology used in the numeracy curriculum (refer to table c1 in appendix c). fig. 1. the numeracy discourses used in classrooms (gawned, 1993) (bics = basic interactive communicative skills; calp = cognitive academic language proficiency). language required for numeracy: level 3 with reference to level 3 in figure 1, four different numeracy discourses need to be considered, namely the language of reasoning (problem solving), the language of the numeracy or mathematics curriculum, the language of activities, and the language of mathematics literacy (gawned, 1993). these domains of language use relate to the cognitive academic language proficiency (calp) required in the numeracy skill area, which can only develop once competence in basic interactive communicative skills (bics) have been achieved. learners have to acquire the terminology and vocabulary included in the subject material because it will allow them to communicate their thinking and will increase their confidence (monroe & omre, 2002). studies by reeves and long (1998) conducted in the western cape and by setati (1999) with gr 4 learners in mamelodi, gauteng, reported that incorrect use of mathematical language in classrooms had a negative effect on learning. teachers need to be aware that the language they use to teach and to discuss numeracy also warrants careful consideration. formal language in itself consists of procedural, calculative, and conceptual language that provides the reasons for proceeding or calculating in particular ways (refer to appendix b, table b1). setati (1999) found lessons to be dominated by procedural discourse and that conceptual discourse was limited. before teachers can affect any changes in practice they need to be cognisant of their own use of language and, if necessary, make purposeful modifications. gawned’s (1993) description of the discourses used in mathematics classrooms remains relevant today and is also applicable to the language used in foundation-phase classrooms where a numeracy curriculum is followed (e.g. in the current context). the language used in mathematics builds on the language used in the numeracy curriculum and such learning therefore occurs on a continuum. the role of speech-language pathologists (slps) in supporting numeracy children with early speech and language impairments are at risk for literacy and numeracy problems (arvedson, 2002; harrison, mcleod, berthelsen & walker, 2009). traditionally slps have provided direct services to children with speech and language impairment who experience literacy difficulties in schools. however, the role of the slp in south africa has recently evolved and expanded to provide support to teachers in literacy development of all learners (kathard et al., 2011) because of challenges such as children having a different first language (l1) to the language of learning and teaching (lolt), large classes, lack of resources and limited teacher training (wium et al., 2010). unfortunately teachers may be unaware of the important role that language plays in numeracy and mathematics and as a result may not realise that slps can collaborate and support them in the teaching of early numeracy and mathematics. slps are well equipped to support teachers as they have knowledge of collaborative practice, current theories and developmental sequences of language development and use, as well as literacy and cognitive development, which includes numerical cognition. slps therefore need to become involved in the support of language for the development of numeracy, which calls for specific approaches to teaching and learning. in addition, slps are also required to take up leadership roles, such as providing professional development opportunities (asha, 2010). although the role of the slp in numeracy and mathematics is recognised (brennan, 2008; harrison et al., 2009; samuelson, 2008), limited research has been conducted on speech-language interventions targeting mathematical skills with children with speech and language impairment (koponen, mononen, rasanen & ahonen, 2006). there is also a dearth of research on the role and involvement of slps in providing teacher support to facilitate the development of numeracy and mathematical skills in all learners. the aim of this article is to report on a cpd programme that focuses on teacher support regarding the language required for numeracy. the objectives were to determine how the participants implemented the strategies to facilitate the language for numeracy in their classrooms, and how they perceived the cpd programme. methodology the qualitative research reported in this article is part of a more comprehensive mixed methods study (wium et al., 2010), and the workshop and data focused on in this article were part of a larger data set. participants selection criteria all participants included in this study were required to meet the following criteria: • be appointed in teaching positions in the foundation phase (gr r, 1, 2 and 3) at schools in the targeted schools of the two contexts. the gauteng department of education (gde) specified two particular districts and specific schools for this cpd programme and therefore only teachers from the assigned schools could be included. • be proficient in english as the training and procedures were developed in english. • participate voluntarily and not as a result of coercion by their superiors. selection procedure the gde assigned 24 low socio-economic schools (ses) in the tshwane region to this project over a period of 2 consecutive years. there were 12 schools included from a semi-rural area, and 12 schools from an urban/densely populated area (including township schools and schools from informal settlements). through a process of stratified sampling each school was required to allocate one teacher from each grade in the foundation phase, provided their participation was voluntary. with 48 teachers participating per annum the entire sample consisted of 96 teachers, which was considered sufficient to serve the purpose of this specific study. the sample was fairly homogeneous in terms of contexts, grade levels represented, and the teachers’ experience in teaching (but not in terms of qualification), and therefore is considered to be a realistic cross-section of the population. all the participants in the semi-rural context were female, whereas two of the urban participants were male. a focus group consisting of 12 participants was conducted in each of the two contexts. with a total of 24 participants in the focus groups the sample was considered as representative (25%) of the entire group that was trained, and allowed for attrition. the research made use of the entire sample (n=96) to complete the open-ended questionnaires, but also used a nested sample design for the selection of the participants in the focus group. the participants who volunteered to participate in the focus groups (n=24) originated from the entire sample and therefore were similar to those in the rest of the study. data collection methods and instruments a specific workshop on the topic ‘language in numeracy’ was conducted in each context (refer to appendix a, table a1 for an outline of the workshop as described in the ‘training component’). in order to meet the specific objectives of this study qualitative data were collected through open-ended questions in questionnaires, narrative data obtained from a focus group with field notes and reflections in portfolios, as well as reflections of the researcher in a research diary. the participants reported on their perceived value of the cpd, while the researchers made conclusive inferences by reflecting on the entire process of support provided. the two open-ended questions included in the questionnaires were related to the participants’ perceptions of the workshop and their recommendations for change. questionnaires were completed prior to and directly after training, and were placed in a box when participants exited the training venue for a tea break or at the end of the day. a focus group discussion was conducted 3 4 weeks after the workshop in each of the two contexts. in the semi-rural context the focus group was conducted in a teachers’ training centre, and in the urban context it was conducted in a conference room at the department communication pathology, university of pretoria because it was half-way between the townships. each focus group was conducted in english, but participants were encouraged to respond in their language of preference should they feel the need. the district facilitators served as interpreters and/or translators for those who chose to use an indigenous language. questions often had to be rephrased and repeated to accommodate participants with limited english language proficiency. the session was concluded with a summary of the meeting being read to the participants for approval (‘member checking’). the content and construct validity of the focus group schedule were increased by following literature guidelines and having the questions reviewed by two experts in the field prior to use. during the period of classroom implementation following the workshop, the participants were required to compile a portfolio consisting of their lesson planning for each week of the 3-week implementation period, their reflections on the strategies used, and some artefacts used in their teaching. the researcher continually reflected on the process of teacher support in a research diary. entries to the research diary were made within hours of an event or contact with the participants and these reflections were shared with experts and colleagues, which elicited meta-reflection. credibility credibility was determined by randomly selecting 10% of the primary documents in the larger study for coding by an external rater. this sample was compared with the codes assigned by the researcher. there was an 80% level of agreement in the coding of the text by the two raters. the focus groups were conducted in both contexts, and contributed similar information without any new revelations, which was considered as data saturation. at the conclusion of each focus group, member-checking was done by presenting a summary of each focus group to the participants for their approval immediately following the session. this measure deviated from conventional member checking (which is usually done at the conclusion of a study), to limit costs and time required by an additional contact session. field notes by the researcher further supplemented the summary and transcription of the audio-recording. at the completion of the workshop the researcher compared notes with the assistant moderator (who was one of the district facilitators) and reflected on the procedure, the participation, as well as the outcomes of the session. the researcher further reflected on the focus group shortly afterwards. the transcriptions were done according to literature guidelines. in order to protect the identity of the participants numbers were assigned to each, and they were referred to as t1, t2, etc. credibility was increased by including verbatim quotations that were provided as data and an audit trial. data analyses in this qualitative research content analyses were used as they provided clear descriptions of how the participants implemented the strategies in their classrooms and also documented their experiences. the qualitative data were analysed with atlas-ti (thomas muir scientific software development, 2003-2004) (qualitative descriptive analysis), which allowed for enumeration. the counting of the codes enabled the researcher to determine the prominence of the various categories. tabulations were used to interpret the data as they reflected how the strategies were implemented, and how the support was perceived. to further explore the significance of the findings the qualitative data (codes) were converted to quantitative data by reducing them to numerical information in three dichotomous categories (0 – neutral/nonspecific, 1 – negative, or 2 – positive). the quantified qualitative data were summarised and presented on theme level, category level, and in specific cases also on a code level. final conclusions were drawn once a validation process confirmed the interpretation of the inferences. results and discussion implementation of the strategies in the classroom based on the responses to the questionnaires, reflections and focus groups, the following information was obtained on the participants’ implementation of strategies to facilitate numeracy. use of terminology the results showed that of the items coded, 53% (n=15) confirmed the acquisition of new terminology after the workshop. some participants demonstrated better recall than others, which may be the result of more prior knowledge, which became evident from the following quote: t: i’m thinking about the one-to-one correspondence, and the seriation, classification. that is what they are doing. so when they come to gr 1 we expect them to know those things. the use of new terminology was, however, not generalised during the training as became evident when 64% (n=14) of the items were coded as ‘inability to recall the information’. the inability to recall the terminology may have been related to some participants having limited language proficiency in english as is evident from the following example: t: i am talking about … i forgot the thing that you showed us. the … the … when you taught the kids the heavy, heavier? a.m: the scale? t: the scale. yeah! when participants could not recall the correct terminology, they described the concepts in their own words. this relates to the ‘awareness level’ of knowledge acquisition, which is one level higher than the entry level in knowledge acquisition (miller & watts, 1990). in this case the participants were aware of the information, but in several instances their knowledge was not applied in their classrooms. it is possible that some of the participants could not recall the terminology because they had not completed their portfolio assignments. the participants reported that although the learners understood the language used in the classroom (e.g. when money was referred to as ‘five-bob’), they became confused when standard terminology was used (‘five rand’) on their worksheets, which were mostly in english. one participant described the situation as follows: primary document (pd) 5, line 76, focus group 2, in 2005: ‘they know the money when we talk [in]formally but when write(sic),…. oh chaos!’ it may be confusing for a learner when the teacher states a problem in one way while the text presents the same problem in a different manner with different vocabulary and terminology. learners from disadvantaged communities may not have had access to books or experiences that would allow them to develop appropriate concepts and terminology for numeracy. the use of incorrect terminology may cause learners to experience difficulty in standardised assessment procedures (e.g. the gde’s annual numeracy challenge, or the third international mathematics and science study (timss)), as the formal terminology may be unfamiliar to them. it is important that teachers consistently provide accurate examples of numeracy terminology and vocabulary (thompson & rubinstein, 2000), and participants therefore need to be alerted to the consequences of not doing so. prior knowledge of teachers the conceptual knowledge for teaching numeracy is as much about pedagogy as it is about content. some of the participants reported that they had never before addressed specific numeracy concepts in class (e.g. the concepts of estimation or three-dimensionality), because they themselves had a limited understanding of the concepts. diary entry 15 on pilot workshop 3: in one focus group it was determined that the participants had never before addressed the term ‘estimate’ (which is required by the ncs), because the term was unfamiliar to them. this is attributed to the fact that not all the participants had similar qualifications or displayed similar levels of competence when they entered the programme, and therefore they differed in their understanding of the material during the programme. the inability to explain certain terminology may be ascribed to limited prior knowledge and/or inadequate english language proficiency. the national curriculum statement (ncs) is available in english, however, the vocabulary used and concepts referred to were not understood by all the participants. limited conceptual knowledge of teachers causes poor performance of learners, and therefore indicates a need for continued teacher support. expectations of learners reflective notes of the researcher after marking the portfolio assignments indicated that some participants applied inappropriate activities that appeared to be more suitable for lower grades than for the specific grade levels that they were teaching. line 28, reflection of the trainer: from the assignments, it is clear that in many cases the teachers provided numeracy activities which seemed more suitable for lower grades than for the specific grade level (do they have low expectations?)) in addition, it was found that the teaching materials used often did not meet the level of learning required, which is consistent with results obtained by thusi (2006). such materials are unlikely to develop higher order thinking skills in their learners. the results show that some of the participants underestimated the learners’ abilities, or had too-low expectations. it is also possible that the learners were too far behind in the curriculum to meet the standards set for specific grade levels. low teacher expectations of learners’ achievement in low-income communities are well documented. the reeves study (1998) of teaching and learning gr 4 mathematics, as well as recent reports from the khanyisa project (khoza, 2007), found that teachers had fairly low expectations of their learners as a whole as tasks were not cognitively demanding, which may have been the case in this context. in addition, it is also known that learners from poor ses mostly have limited or no preschool experience, which places them at risk of failing (botha et al., 2005:697). it is therefore possible that these learners required more time to catch up. language issues resources in the lolt pluddemann, mati and mahlalela-thusi (1998) reported that teachers favoured the use of english materials, which was also confirmed by this study. many of the participants made use of worksheets which they copied from english workbooks. because of a lack of suitable resources in the lolt, many teachers bought a numeracy workbook written in english from the local news agency, and photocopied the worksheets for their learners. english worksheets were used despite the school’s policy on the lolt, because the teachers had no other resources available. english is an additional language for all the learners in these particular schools and this practice could have affected their acquisition of the numeracy concepts taught in the classrooms. when considering that cognitive academic language takes 5 7 years to develop (cummins, 2000), the use of english workbooks could have implications for the quality of education in this context. ideally, basic concepts should first be acquired in the mother tongue, and even though workbooks were available in northern sotho (e.g. oxford university press), schools in these specific contexts did not have access to them or the funds to buy them. in addition, it was noted by the researcher that: line 8, reflection of the trainer: even though workbooks could be provided in the lolt, it would not necessarily meet the diverse needs of all learners. such practices indicate a need for teacher support in implementing the numeracy curriculum. language use in the classroom despite their schools policy in terms of the lolt, some of the participants were also confused as to whether they should not rather use english when teaching numeracy because it was much easier for them to use the english terminology and to have access to english worksheets. the use of english terminology and vocabulary in these contexts was not uncommon, which makes it imperative to use code switching to an african language when introducing new concepts in numeracy (du plessis, 2005). the importance of code switching therefore needs to be emphasised in future cpd programmes. some of the participants discovered the importance of l1 to develop ‘numeracy’ skills as illustrated in the following comment: line 49, focus group on workshop (ws) 3: t1: ‘he must understand the language first.’ they also learnt how to facilitate numeracy skills in a constructive manner (by making use of real objects and live experiences, and using the correct numeracy vocabulary and terminology), as was confirmed by 89% of items coded (n=35). importance of play and culture in learning the participants’ portfolios contained evidence that the language of numeracy was facilitated by use of indigenous games (e.g. ‘morabaraba’, a board game usually played with stones, which requires counting), stories, songs, and teaching resources. according to arvedson (2002) children learn the conventional count words of their culture and use these words to manipulate larger and larger sets of objects and events. a child’s count range is evidence of the child’s opportunities to experience and manipulate the conventional count words of that child’s culture (arvedson, 2002). the use of indigenous games by the participants provided a natural experience for the facilitation of the learners’ numeracy development. the importance of culture in teaching and learning became evident in the following quote from the researcher’s field notes: line 97, reflection on focus group 1, semi-rural context: one of the participants expressed sadness because her own son attended a school with english as lolt, which caused him to lose his language and culture. the value of the cpd programme to the participants there was convincing evidence that the cpd programme was valued by the participants. impact on creativity a few participants experienced themselves as becoming more ‘creative and innovative’ (89%, n=9) as they had acquired new ‘strategies’ and generated new ideas to implement in class (n=28). pd11, line 101, focus group 3: t2: but at the course, we got those ideas. i got the polystyrene. then the shapes, when i drew this, it were one dimension. the moment i had it on polystyrene it was three dimensions! so the hod and i, we went to the rubbish heap, and got that polystyrene. the participants testified that the workshop facilitated their understanding of three-dimensionality, which confirms on poor content knowledge prior to the training. sufficient content knowledge enables teachers to employ inventive and creative opportunities for learning (van der sandt & nieuwoudt, 2005). such creativity was described by spady (2001: 34) as one of the common threads of quality learning because ‘…learning is not just absorbing content from printed material; it’s an inherent part of living simply because living is a continuously unfolding array of new input and experiences.’ impact on functioning several participants (who previously relied heavily on ‘commercial programmes’ to teach) reported that the training helped them to become more independent from using such programmes and also more confident in creating their own materials and activities. line 235, pilot focus group 1: in gr r ... and another thing the workshop also help us a lot to be creative. they thought in our language we can only teach one, two, three. now we can create our own stories, our own riddles, and our own songs. the ability to develop their own lesson plans increased the participants’ confidence, which in turn can be related to improved learner achievement. the benefit of this workshop to the participants was further confirmed by an external evaluation of a group of learning support teachers (lse) from the gde, who unofficially attended the workshop in the urban context. they viewed the information taught in the workshop as having the potential to change the manner in which teachers teach numeracy and thought it would be valuable in their own support of teachers and learners who experience challenges in numeracy. line 24, testimonials from teacher support teachers: the teachers’ approach is going to be different especially with numeracy. line 12, testimonials from teacher support teachers: i have developed competence and skill in teaching numeracy in the foundation phase because i have no teaching experience of this phase. and will be able to address the problem of lolt at english medium schools. some of the participants were not specifically qualified to teach the foundation phase and were grateful for the opportunity to learn practical skills for supporting young learners with numeracy. they may not have been fully equipped to deal with the demands of foundation-phase teaching and its specific curriculum, which in itself may also be a factor to be considered in providing additional support of teachers. limitations of the study several challenges were experienced during the research. the data showed a level of non-response in the open-ended questions in the questionnaires, as well as in the critical reflections in the portfolio assessments. this could be attributed to the participants not being familiar with reflective practices, but also to the use of language, literacy levels, and aspects related to timing, as well as logistics of the programme. the threat of subjectivity is acknowledged as the first author was involved with these communities over a prolonged period of time, and personally conducted all aspects of the research. subjectivity is considered as one of the weaknesses of qualitative research but by paying close attention to credibility and using a reflection diary, personal bias was limited. conclusions and implications based on the findings of the literature review it is clear that the slp has a crucial role to play in the support of teachers regarding numeracy. this cpd programme proved to be an effective method to make teachers aware of the importance of language in the acquisition of numeracy skills and how to facilitate the process. the programme was valued by the participants as it allowed them to address specific assessment standards that they were not able to do prior to training and to gain confidence. within a collaborative approach to teacher support, slps need to provide workshops where teachers can see how numeracy concepts are being demonstrated by using the correct use of language. such workshops would also allow teachers to practise strategies in role play, which is non-threatening. in turn, teachers, as mediators of learning, need to create multiple opportunities for learners to practise the correct use of numeracy language (e.g. through general as well as small-group discussions). it cannot be taken for granted that teachers themselves understand the vocabulary in the curriculum, which implies that slps need to include explanations and demonstrations of the concepts in a support programme. such support should not be restricted to classroom teachers only, but needs to include the learning support teachers who are responsible for learners at risk of failure, as well as the district facilitators. in cases where teachers use english as lolt, the use of code switching should be emphasised when explaining numeracy concepts. slps working in schools with limited resources should support teachers in the translation of english worksheets to the lolt. although the department of education is currently committed to supplying the necessary resources, school leadership should be encouraged to plan ahead and order their supplies in time. from the results obtained from the larger study, it was determined that cpd activities are required on an ongoing basis because of diversity of teachers (e.g. qualifications, language proficiency). workshops will be more effective if conducted with smaller groups as opposed to large-group workshops. ideally, teachers from a particular cluster or school will learn best by sitting around a table for shorter topic-specific sessions, which are offered over a prolonged period of time. the present study provides evidence that the support of teachers through a cpd programme was effective and was perceived as being positive by the participants. slps working in the school system who expand their role to support teachers through cpd programmes, can contribute to ensuring educational relevance in teaching and learning and to the implementation of the curriculum, which in turn fulfils some of the critical roles of slps working in school contexts. acknowledgements. the research was funded by a grant from the shuttleworth foundation.   references arvedson, p. j. 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(2010). speech-language therapists supporting foundation phase teachers with literacy and numeracy in a rural and township context. south african journal of communication disorders, 57(1), 14-22.   appendix a. cpd: supporting teachers with a three-pronged approach the continued professional programme (cpd) consisted of a three-pronged approach (wium et al., 2010): table a1. a three-pronged approach used in the cpd programme component procedure training component (workshop) ‘language in numeracy’ workshops have been identified as important ‘confidence boosters’ (baxen & green, 1999: 264). considering that confidence is an important component of competence, this cpd programme offered a full-day workshop in two contexts (semi-rural and urban), the aims of this workshop were to alert teachers to the importance of language use in numeracy, and to empower them to facilitate the acquisition of the language required for numeracy development. the workshop was conducted as follows: • the workshop firstly emphasised the importance of language in numeracy and explained the various discourses in the classroom, using powerpoint (ppt) and whole-class discussion. • the workshop facilitator demonstrated to the delegates how to explain various concepts with accompanying instructional vocabulary, by using real objects/activities and items to manipulate (e.g. containers with water to demonstrate volume, a scale for weighing and to demonstrate mass, bottle caps for sorting, counting, etc). • four participants were grouped in grade levels and were each handed four different written problems cut from numeracy worksheets (which were obtained from grade level numeracy workbooks) (e.g. oxford books). • the groups were required to use a role play scenario to explain and clarify the specific vocabulary that typically occurs in the curriculum. • the groups presented their scenarios to the entire class, which was a fun manner to learn from each other. the role play activities provided the participants with the opportunity to first observe the strategies before they were required to apply the strategies over a period of time and to reflect on the process. practical component following the workshops the participants were required to apply their knowledge in their classrooms for a period of 3 4 weeks, which was documented in a portfolio. mentoring component the mentoring component consisted of collaborative peer learning and feedback on portfolio assignments (wium et al., 2010). the portfolio consisted of lesson plans for each week of the implementation period, monitoring sheets which were completed to monitor the participation of three learners from varying performance levels, self-reflection sheets, and artefacts used in their lessons. the workshop facilitator provided feedback on the lesson plans and the portfolios. continued professional development of teachers appendix b. vocabulary items in the foundation-phase curriculum table b1. vocabulary items in the foundation-phase curriculum for english first language (department of education, 2002) gr r and gr 1 add arrange build choose circle colour compare complete copy count cross double estimate fill in find finish fold halve join link match subtract tick trace use work out gr 2 and 3 above/up add, addition after all capacity (l, ml, kl) measurement (cm, mm, 10 mm = 1 cm) all shapes (circle, square, triangle) all weights (kg, f, etc) apart ascending order before below, down beside between bigger complete complete the equation decrease descending order difference different discuss divide division double empty equal to estimate evaluate far, near first, second, third, etc. full greater (more) than/less than group halve higher/lower how many? increase less than long time   appendix c. discourses used in the classroom table c1. levels 3 and 4 of discourses used in the classroom (gawned, 1993) level 3: the language required for numeracy methods of facilitation language of reasoning (problem solving) the language of reasoning is used by teachers and learners in problem-solving contexts and includes complex sentences used for inferences, justifications, comparisons and predictions. this type of language is determined by the discourse used for description, comparison, and reflection.     teachers need to: • use discussion to clarify meaning and help learners to absorb terminology and understand the concepts (department of education, 2002). • create opportunities for talking about learners’ ideas in relation to their experiences. • create an awareness of thought, e.g. to encourage, predict, and hypothesise, as well as to create opportunities in terms of questions and situations for the use of ‘if/then’, ‘what if?’, ‘why?’, ‘what would happen?’, ‘what did happen?’ and ‘how did you know?’ (reeves, 1993: 91). language of the numeracy curriculum • language of the numeracy curriculum (refer to appendix b, table b1) includes terminology which has to be explicitly taught and learnt (botha et al., 2005), as it is essential for developing higher level thinking skills such as analysis, discussion, problem solving and design in relation to the subject matter. • learning of the terminology of the mathematics curriculum requires that learners firstly develop an understanding of the underlying concepts through their own experiences, problem-solving solutions, and strategies (du toit, froneman & maree, 2002). • firstly make use of manipulates, shapes, and collections of objects in play activities (botha et al., 2005). • when translation of mathematical terms to an african language is not possible, an english word can be used, but should also be described in the african language. be aware of possible ambiguity in word meaning, and actively clarify and teach unfamiliar terms. • avoid using english workbooks in classes where the lolt is an indigenous language because the grammatical and morphological structures differ. • start teaching of terminology and vocabulary for numeracy when the learner is being taught the vocabulary necessary to start reading. language of activities classroom activities require both descriptive language and procedural language (gawned, 1993). • descriptive language: allows the user to participate in an activity (e.g. labels, attribute terms and noun phrase constructions to discuss relationships between numbers, concepts, etc.), • procedural language: used to explain how procedures need to be conducted and provide reasons for classifying or grouping items in a particular manner. learners need to be encouraged to talk about procedures when working in groups and to engage actively with real objects in a constructive manner to develop an understanding of the concepts. language of mathematics literacy the language of mathematics literacy: • develops once learners start with the mathematics curriculum (not applicable to the numeracy curriculum in the foundation phase). • refers to the representation and recording of mathematics (e.g. graph construction, diagramming, mapping, writing the digits accurately, etc.) (gawned, 1993) • brennan (2008) distinguishes between ‘ordinary english (oe), math english (me) and specialised meanings (sm)’. • oe refers to the same word that has the same meaning, • me has only a primary meaning in mathematics, and is taught by the teacher (e.g. ‘numerator’). it becomes a language in its own right. • sm: the same word has different meanings (e.g. ‘average’, ‘range’, ‘equal’, ‘divide’, etc.), which may or may not necessarily be taught by the teacher. •   teachers should use clear syntax in order to allow learners to understand what is required of them in completing the computation. • brennan (2008) suggests avoidance of long, dense noun phrases, and complex meanings should be unpacked. • numerical comparisons should be practised (e.g. ‘write a sentence that gives the same information as the information in the diagram’). • teachers need to match the sentence structures used for writing mathematical problems (e.g. in word sums) with the learners’ levels of comprehension. accordingly, learners’ written language needs to be practised in the classroom. level 4: construction of meaning (gawned, 1993) methods of facilitation teachers need to ensure that learners acquire the necessary vocabulary and language competence to enable them to understand the mathematical concepts being taught.   learners with a well-developed vocabulary can devote all their attention to the new concepts and the next step and do not experience difficulties in understanding the meaning of the words used. pay attention to conceptual confusion when everyday metaphors are used in the classroom. teachers should be aware of cause for confusion, e.g. • pronoun ambiguity: (e.g. clarify who does ‘we’ refer to when explaining calculations e.g. “we take 10 from the 10s column”). • when teachers make the shift from ‘i’ to ‘you’ it implies generalisation. • the use of passive voice (e.g. ‘the answer is written below the line’) where agency becomes suppressed and changing from human agency to disciplinary agency. allow more opportunity for dialogue about these concepts and processes and encourage learners to apply them to their lives in small groups. the south african journal o f communication disorders, vol. 54, 2007 lead article improving the relevance of speech-language pathology & audiology research and practice kathard, h., naude, e., pillay, m & ross, e. editorial board: south african journal o f communication disorders h o w d o th e p r o fe s s io n s o f s p e e c h -l a n g u a g e p a th o lo g y a n d a u d io lo g y p r a c tic e ? h o w do th e y p r o d u c e th e ir k n o w le d g e ? the focus o f this article is on the nature o f research within the joint professions o f speech-language pathology (slp) and audiology. specifically, we foreground the issue o f relevance within professional research for professional practice. in doing so, we not only seek to promote a certain symbiosis between researchers and practitioners but also to promote greater compe­ tence toward improving the lives o f people living with commu­ nication and/or swallowing disorders which direct its research and practice foci. essentially, slp and audiology’s project is really about accessing the lived experience o f people with com­ munication/swallowing disorders. as lives are deeply related to the professions’ foci, then it is reasonable to assume that its re­ search and practice ought to engage what is o f relevance to peo­ ple and their lives. gender, race, socio-economic status, culture, political determinants and such like are interpenetrating factors that determine one’s experiences of, for example, living with an acquired language disorder. predominantly, how has slp and audiology researched its foci? mainly, we have researched the pathology by sanitizing peoples’ social, political and cultural influences o f their lives. historically, research for and within the professions have relied on good empirical, scientific methods to situate communi­ cation disorders. for example,, in perusing publications associ­ ated with the beginnings (early 19th century) o f slp and audiol­ ogy research in the western world it is not unusual to encounter articles with titles such as: j o observations on the history ,̂ use, and construction o f obtu­ rators, or what have hitherto been called in this country artificial palates (snell, 1824) ® clinical report on robert b ates’ cure fo r stammering (meigs, 1852) i ® mutilation o f stutterers. surgical operations which have been performed fo r the cure o f defects o f speech (werner, 1881) ® the possibility o f obtaining m arked improvement in the treatment o f deafness and supposed deaf-mutism by acous­ tic gymnastics; a system o f vocal training o f the auditory nerve as advocated by urbantschitsch, o f vienna (goldstein, 1895) writing styles aside, these titles reflect the way slp and audio­ logy have developed their knowledge with the use o f an empiri­ cal, positivist scientific frame which positions: • reality as apprehensible, driven by natural laws and mecha­ nisms (deterministic) and therefore reducible to parts which may be manipulated in an objective fashion. • truth as existing outside o f the researcher, and accessible via various objective techniques, and • uses methods which emphasise experiments, the predictabil­ ity o f phenomena, allows for the testing o f hypotheses and controls for confounding conditions. empiricism is preferred and valued as a research and practice orientation by slp and audiology practitioners and is used to focus the body as the site of prime interest. in referring to communication via this biological metaphor o f the body; ‘assessment’, ‘treatment’, ‘diagnoses’ and ‘prognoses’ are now well established slp and audiology clinical frameworks. as such, good professional research is regarded as that which not only promotes the use o f logical rationality, objectivity, cause effect relationships, and experimental verification amongst a plethora o f similar axioms; but also one understands people with communication disorders from a biological, medically orientated perspective. at its core,' across practice sites in edu­ cation or health care, the professions engage a medical gaze (foucault, 1976) to research and practice. the use o f highly valued empirical research methodolo­ gies has functioned to develop our professional interests. for slp and audiology, as it is with other caring professions, re­ search meets several key professional development functions. in the first instance, doing research fulfils practitioners’ ethical obligations to contribute to their professions’ knowledge base. research is the dominant, usual method o f sharing knowledge amongst professionals. furthermore, this latter function is related to the understanding that professional research and practice ought to nurture and inform each other. while sensi­ ble, the reciprocal nature o f the practice-research relationship does, however, require optimizing. indeed, kamhi (1999) ex­ horted researchers and clinicians to work together, not only to improve clinical practice through research, but also to make researchers more responsive to the needs o f practitioners. it is a widely held expectation that research itself once disseminated, shared and applied can enhance the effective­ ness o f practice. currently, this sharing o f research is placed in bare tension with the trend toward evidence based practice (ebp). strenuous demands are placed on practitioners to test and evaluate what was previously recognised as ‘best prac­ tice’. practitioners have to follow clinical research literature in order to evaluate the relevance o f the findings and make in­ formed decisions to the benefit o f the families and communi­ ties they serve (bothe, 2004). according to kamhi (1999) practitioners are well qualified to evaluate the effectiveness of new approaches suggested by research findings. in fact, prac­ titioners are becoming ever more critical of activities not grounded in research-proven evidence. therefore, the rela­ tionship between research and practice which is implicit in ebp also guides relevant research and accountable clinical practice for practitioners in south africa (sa) and elsewhere. the methodological shape of ebp is inextricably intertwined with the professions’ adoption o f empirical research method­ ologies. the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 6 h. k athard, e. n aude, m. pillay and e. r0ss it may be said that, thus far, empirical research has been an excellent vehicle without which slp and audiology may not have developed their current status as valid professions working with speech, language, voice, hearing and swallowing disorders. however, as we use empirically orientated frame­ works such as ebp, professional research and practice must consider not only that evidence is necessary to develop prac­ tice; but also how practitioners’ use evidence in ways that bear relevance to the lives o f people they encounter in their clinical practice. as such, the utility value o f our research, our profes­ sional knowledge base is brought into question. for slp and audiology most professional knowledge is based on research with mainly male, urban, middle-class, judeo -christian, european language speakers (taylor, 1986; pillay, 1997; marshall, goldbart & evans, 2004). the adequacy (and relevance) o f our research for all aspects o f our professional work becomes dubious when we consider slp and audiology across the world’s social, cultural, economic and political reali­ ties. for the majority world populations, most who live in pov­ erty, it may be said that our research inadequately supports the needs o f people in societal "black holes" (soludo, 2001). such people refer to those living in indigenous australian communi­ ties, american ghettos, indian slums, emirates’ labour camps and south african informal settlements. post-apartheid sa has, as it is with other world democracies like india, brazil and america; provided us with an opportunity to re-assess how, especially residents o f societal black holes, may benefit from grand notions o f democracy, equality, and anti-discrimination. these political ideologies affect everything we do, including our professional research and clinical practices. to structure the implementation o f democratic ideolo­ gies international organizations have developed several strate­ gies to generate practices that address our world’s social, politi­ cal and cultural realities. for example, as health care practitio­ ners, we are urged to pursue the collective wishes o f the world as stated within the united nation’s (un) millennium devel­ opment goals (un, 2005). slp research and practice ought to be configured in relation to the eight millennium development goals which range from the eradication o f extreme poverty and hunger to the development o f global partnerships for develop­ ment. therefore we should be guided by these priorities to help create a more equitable world. and as we do this, we should direct ourselves toward re-positioning our dominant medical understanding o f disability within a social model that empha­ sizes human functioning as promoted by the international clas­ sification o f functioning (who, 2001). betwixt and between these world directives are issues o f deep social and political concerns. what slp and audiology practitioners need to ask is: should we be involved in addressing such social and politi­ cal issues? should we not just stay out o f politics? perhaps we need to clearly demarcate issues o f professional. science from political issues. indeed, it may be argued that sexism, racism, homophobia, poverty and such issues are really outside the professions’ domain o f practice. almost thirty years ago, a similar argument was pre­ sented at an american speech and hearing association's (asha) convention in 1968. orlando taylor, a pre-eminent slp in multicultural practice, explicitly linked his professional development to the greater political events o f the time, i.e. a time when america was experiencing "...severe national dis­ cord over the vietnam war and civil unrest by blacks in nu­ merous urban centers" (taylor, 1986, p.2). taylor argued that: “ ...professional organizations should articulate a point o f view on the important social and political issues o f the day, making it possible for the corpodie suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 rate body to influence decisions...i urge the ameri­ can speech and hearing association to provide ag­ gressive leadership for moral, ethical, and judicial behavior in areas o f significant social signifi­ cance...” (taylor, 1986, p.2) taylor presented the above argument to john michel . (university o f kansas, usa) who responded with the follow­ ing: “it is unwise to jeopardize the purely professional nature of asha and the harmony among our mem­ bers by introducing current issues outside the realm o f speech and hearing. it is both healthy and admira­ ble that individual members are sensitive to social issues and have the courage to organize opinion against unsatisfactoiy aspects o f our society.” (taylor, 1986, p. 2) in essence, michel argued that, while being sensitive, profes­ sionals should not be involved in engaging social, political, and cultural issues. o f course, slp and audiology has always fo­ cused on cultural, social, political, gender and related issues. it is just that this focus is largely untheorised as politically situ­ ated even though it has produced knowledge predominantly rooted in, and beneficial to, politically dominant populations of the world. however, as citizens o f a world populated by a di­ versity o f classes, genders, races, cultures and so on; slp and audiology practitioners must necessarily concern themselves with the everyday, lived experiences o f most o f the world’s peoples. when considering the nature o f the relationship be­ tween practice and research (or between practitioner and re­ searcher) a basic premise ought to be considered, viz.: the coin­ cidence o f researchers’ and practitioners’ realities with the re­ alities o f majority world populations. researchers and practitio­ ners alike must ask: is evidence fro m professional research that is dominantly based on minority world populations such as caucasian, middle-class, monolingual, english-speakers rele­ vant fo r practice with majority world populations? locally, for sa, what would it mean to practice slp and audiology in rela­ tion to issues ofpoverty? what o f slp and audiology research when we consider the burden o f diseases such as tuberculosis, aid s/h iv or malaria? indeed, the kind o f engagement required involves more than relocating services to community clinics or re-focusing an empirical research lens to, for example, black african lan­ guages. all this may serve to do is re-produce the same kind of restrictive ways o f knowing, the same level o f knowledge util­ ity. here, the question raised is really not about ‘culture’ or ‘race’ or ‘politics’ and suchlike. rather, it is about the science we use to engage the issues. as a cultural artifact in itself em­ pirical science must be considered for its usefulness to move the profession into the millennium. perhaps, the time has come to listen to taylor and consider ways in which we research and practice. while, michel’s sentiment may remain within profes­ sional ideologies and practices, the profession may still need to explore its response relative to “ ...moral, ethical, a n d judicial behavior in areas o f significant social significance...” the question now is: can we rely on an empirical science to enable us to adequately engage what are issues o f social justice? in sa, policy changes have provided a fertile conceptual resource for the profession to consider issues o f social justice. equality and anti-discrimination, ubuntu/human dignity an respect, democracy, equity, transparency and a cco u n ta b ility are all excellent signposts for the professions’ researchers and/or practitioners to consider when thinking about social justice. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) im proving the r elevance o f speech-l anguage pathology and a udiology r esearch and p ractice 7 while our local focus is on how we live with the contradictions o f 'colour' (an ideological issue) we are really engaged in a broader project o f humanity. ours is a political-social experiment that focuses how we relate to each other because o f our social condi­ tioning and o f our political condition. the world has a pointed interest in sa for how we develop our human relationships, our humanity. our policies, our political project is actually a world project because south african policies have largely been imag­ ined around how we exist as people. furthermore, although slp and audiology practices vary internationally and are shaped by local contextual realities, the core historical-cultural medical pro­ fessional practices remain entrenched (pillay, 1997). in this way, as slp and audiology researchers/practitioners we may comforta­ bly and ably dialogue with colleagues in other countries who share similar aspirations through international organizations that espouse liberal, democratic ideologies such as the world bank, the united nations (un), and the world health organisation (who). in the last few decades, several shifts in professional prac­ tice have occurred that may (retrospectively) be understood rela­ tive to democratic ideologies engendered within global develop­ ment maps like the millennium development goals and the inter­ national classification o f functioning. consider the focus on mul­ ticultural/multilingual practice which has challenged the domi­ nant theoretical frames that did not consider the implications of non-white, non-english, and non-middle class values. an associ­ ated trend has been the development of ecological frameworks o f practice such as whole language (norris, 1990) and ecological audiology (borg, 1998). similarly, socially-orientated services such as community based rehabilitation (cbr) and/or or primary health care (phc) within slp and audiology has promoted ser­ vices to people with communication disorders in their homes and/ or via community structures (jager, 1994; wirz, 1995). signifi­ cantly, qualitative methods have been explored for practice within slp and audiology (eastwood, 1988; hetu, riverin, lalande, getty, & st-cyr, 1998). qualitative methods have gained meas­ ured success with the recognition o f strategies such criterion refer­ encing (westby, stevensdominguez & oetter, 1996) and research (kearns, 1999). finally, narrative methods o f practice have slowly been gaining credence since at least the late 1990's within, for example, the field o f aphasia (parr, byng, gilpin & ireland, 1997). j _ these shifts link to sources 'outside' o f the professions’ own peculiar foci. for example, they draw on inspirations from the social sciences, education] social anthropology, philosophy and suchlike. they also serve as a challenge to the professional knowledge base by presenting concepts that must actively account for a range of contextual factors such as culture, race, social and economic factors. if suitable, how may we use qualitative re­ search to effect changes in practice? what about the use o f ran­ domized control trials when working with the multidimensional complexities o f people that inherently defy controlling? are all research questions suited to ethnographic studies, life histories and similar phenomenological approaches? what about the rele­ vance o f research that uses good empirical science that enables us to manage people with swallowing disorders? ca!n hearing disor­ ders benefit from ecological audiology? what lies beyond electro physiological assessments o f hearing? how do slps and audiolo­ gists work with ‘normal’ people to prevent disorders? how do we research non-curative, preventative ways of working? what re­ mains is for slp and audiology to develop ways o f guiding rele­ vant research for relevant practice. in the next few responses, leading researchers and/or practitioners highlight their thoughts in relation to these questions. they contribute solutions to the dilem­ mas and theoretical-practical issues raised throughout this article. borg, e. (1998). a udiology in an e cological perspective d evelopm ent o f a c onceptual fram ew ork. s candinavian a udiology, 27, supplem ent no. 49, 132-139. b othe, a .k . (2004). e vid en ce-b a sed treatm ent o f stu tterin g — em p irica l bases a n d clin ica l applications. m ahw ah, n j: l aw rence e rlbaum a ssociates. e astw ood, j. (1988). q ualitative research: a n additional research m ethodology for speech p athology? b ritish j o u rn a l o f c om m unication d isorders, 23, 171-184. f oucault, m. (1976). the b irth o f the clinic: a n a rch a eo lo g y o f m ed ica l p er­ ception. t avistock: london. g oldstein, m . (1895). t he possibility o f obtain in g m arked im provem ent in the treatm ent o f deafness and supposed deaf-m utism by acoustic gym nastics; a system o f vocal t raining o f th e a uditory n erv e as a dvocated by ur b antschitsch, o f v ienna. a rchives o f o tolaryngology, x x iv . hetu, r ., r iverin, l., lalande, n ., g etty, l. & st-c yr, c. (1998). q ualitative analysis o f the handicap associated w ith occupational hearing loss. british jo u rn a l o f a udiology, 22, 251-264. jager, g .w . (1994). c om m unity based education in speech p athology and a ud io lo g y at th e u niversity o f d urban-w estville in an un d erserv ed com ­ m unity. south a frica n jo u rn a l o f c om m unication d isorders, 41, 93-103. k am hi, a .g . (1999). to use or n o t to use: factors th at influence the selection o f new treatm en t approaches. language, speech, a n d h ea rin g services in schools, 30(1), 92-98. k earns, k .p. (1999). q ualitative research m ethods in a phasia: a w elcom e addition. a p hasiology, (13), 9-11, 649-650. m arshall, j., g oldbart, j. & e vans, r. (2004). international students o f speech andl anguage t herapy in the uk: d o w e m eet their needs? in ternational j o u rn a l o f l a n g u a g e & c om m unication d isorders, 39 (2), 269-284. m eigs, j. (1852). c linical r eport on r o b e rt b a te s ’ cure f o r stam m ering. p hila­ delphia, pa : clinic o f jefferson m edical c ollege: s urgeon g en eral’s o ffice library. n orris, j. a. (1990). clinical forum , language, speech, a n d h e a rin g services in schools, 21, 205. parr, s., b yng, s., g ilpin, s., & ireland, c. (1997). t alking ab o u t a phasia. open u niversity press: uk. p illay, m. (1997). s p eech-l anguage therapy a n d a udiology: p ractice w ith a b la c k a frica n f ir st l a n g u a g e c lientele. u npublished m asters dissertation. u niversity o f d urban-w estville: south a frica. snell, j. (1824) o bservations on the h istory, use, a n d c onstruction o f o btura­ tors, o r w hat h a ve h itherto b een c a lled in this c ountry a rtificia l palates. c ollins & c ollins: london. soludo, c.c . (2001). d isputing c astellian g lobalisation for a frica. in j. m ul­ ler, n . c loete, & s. b adat (eds), c hallenges o f g lobalisation: south a fri­ can d ebates w ith castells. m askew m iller longm an: c ape town. t aylor, o.l. (ed.) (1986). n a tu re o f c om m unication d isorders in c ulturally a n d l in g u istica lly d iverse populations, c ollege-h ill, san diego. u nited n atio n s d epartm ent o f e conom ic & social a ffairs and the u nited n a ­ tions d epartm ent o f p ublic inform ation (2005). m illennium d evelopm ent goals: p ro g ress chart. u nited n ations: g en ev a [septem ber 2005]. w erner, e.s. (1881). m utilation o f stutterers. surgical operations w hich have been p erfo rm ed for the cure o f defects o f speech. the voice, 3 (9), 127-128. w estby, c., stevensd om inguez, m ., & o etter, p. (1996). a perform ance/ com petence m odel o f observational assessm ent. language, speech a n d h ea rin g services in schools, 27, 144-156. w irz, s. (1995). o pportunities and responsibilities tow ards people w ith com m u­ n ication disorders in less developed c ountries. c aring to c om m uni­ cate: p ro ceed in g s o f the g olden j u b ile e conference, r oyal c ollege o f speech a n d l a n g u a g e therapists, london: u .k , 459-465. w orld h ealth o rganisation (2001). in tern a tio n a l c lassification o f f unctioning, d isa b ility a n d h ealth. w h o : geneva. the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) abstract introduction methods results discussion conclusion acknowledgements references about the author(s) ben sebothoma department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa khetsiwe masuku department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa nomfundo moroe department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation sebothoma, b., masuku, k., & moroe, n. (2021). factors influencing speech language pathologists’ and audiologists’ decision to pursue postgraduate studies in south africa. south african journal of communication disorders, 68(1), a796. https://doi.org/10.4102/sajcd.v68i1.796 original research factors influencing speech language pathologists’ and audiologists’ decision to pursue postgraduate studies in south africa ben sebothoma, khetsiwe masuku, nomfundo moroe received: 05 oct. 2020; accepted: 26 mar. 2021; published: 18 may 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: factors that influence various professionals to pursue postgraduate studies have been investigated. however, there is a dearth of evidence of factors that influence south african speech language pathologists (slps) and audiologists (as) to pursue their postgraduate studies. objective: therefore, this study aimed to determine factors that influence the decision of south african slps and as to pursue postgraduate studies and potential barriers to this pursuit. method: a quantitative survey research methodology with a cross-sectional research design was adopted, where a 21-item web-based survey was used to survey 127 speech therapists, as and speech therapists and as from across the country. all participants were qualified and registered with the health professionals council of south africa (hpcsa). ethical clearance and permission from relevant stakeholders were obtained. data were analysed descriptively. results: the findings suggested that over half of the participants pursued their postgraduate studies to fulfil a personal goal and improve their knowledge, whilst others did it to develop expertise and for job opportunities. participants highlighted that a lack of time and funding, heavy workloads and bad experiences during their undergraduate studies were the main barriers to pursuing postgraduate studies. whilst community service was not a barrier per se, participants felt that it delayed them from beginning their postgraduate studies immediately. conclusion: the findings of this study highlighted the urgent need for institutions of higher learning, government and other stakeholders to provide the necessary support for slps and as in south africa to pursue postgraduate studies. keywords: speech language pathologist; audiologist; influencing factors; postgraduate studies; postgraduate degree; south africa. introduction speech language pathologists (slps) and audiologists (as) are health professionals that deal with the assessment and treatment of patients with communication difficulties (including hearing loss) and swallowing disorders (gillam & gillam, 2011). literature suggests that people who pursue a career in speech language pathology or audiology (slp or a) are often motivated by the desire to help people. for example, du plessis (2018) and stone and pellowski (2016) found that 74% and 70%, respectively, of slp and a students chose their profession because of this desire. whilst the reasons for the pursuit of slp and a as a profession are clear in the literature, the reasons for the pursuit of postgraduate studies in slp and a, especially in a south african context, are not clear. therefore, this study aimed to explore factors that influence students’ and clinicians’ decision to pursue postgraduate studies in slp and a. postgraduate education is increasingly becoming important in many countries worldwide. as a result, institutions of higher learning are encouraged to develop strategies to increase the number of their postgraduate students (mccallin & nayar, 2012; national development plan [ndp], 2012). in lowand middle-income countries, such as south africa, postgraduate education is recognised as one way of enhancing economic growth (ndp, 2012) and challenging the colonial epistemology through the production of contextually relevant knowledge (khoza-shangase & mophosho, 2018; mdlalo, flack, & joubert, 2019; pascoe & norman, 2011; pillay & kathard, 2015). this is particularly important for the slp and a profession, which has always been governed by first world knowledge (khoza-shangase & mophosho, 2018). consequently, south africa, through the ndp, intends to produce as many as 100 doctoral graduates per one million per year by the end of 2030 (ndp, 2012). whilst obtaining a postgraduate degree is important because of its prospective transformational and economic benefits, postgraduate students continue to face a myriad of challenges that may threaten the achievement of initiatives, which address socioeconomic factors (albertyn, kapp, & bitzer, 2008). for example, postgraduate students often experience financial difficulties or a lack of family time, whilst others struggle with writing skills (abdullah & evans, 2012; govender et al., 2018; yasmin et al., 2018). despite these known challenges, literature suggests that there are students who persistently pursue their postgraduate studies (cobbing et al., 2017). the aim of the study was therefore to investigate the potential facilitators and barriers to the pursuit of postgraduate studies. it is hoped that the results of this study may be of benefit to policymakers in south african universities and health service providers and to slp, audiologist and speech pathologists, audiologist and slps and audiologist. the motivation to pursue postgraduate studies may not necessarily be in line with national programmes and vision. literature suggests that people pursue postgraduate studies for different reasons. for example, jasińska-stroschein, kurczewska and orszulak-michalak (2017) in a polish study conducted with 414 pharmacy students found that pharmacy students pursued their postgraduate studies to acquire a promotion at work. a total of 425 physiotherapy students in south africa and 1632 nursing students in australia indicated that they pursued postgraduate studies because they wanted to develop their clinical expertise, fulfil personal goals and improve patient care (cobbing et al., 2017; ng, eley & tuckett, 2016). a study conducted with non-medical science students in korea by jung and lee (2019) indicated that students enrolled into postgraduate studies if they were satisfied with their undergraduate education. in the profession of slp and a, motivations to pursue postgraduate studies were found to be different from other professions. internationally, a postgraduate degree such as a clinical doctorate in audiology (e.g. aud) or master’s degree in slp is a required minimum qualification to become a licensed clinician (martin & clark, 2015). the american speech hearing association (asha) specifically stipulates that slps require a minimum of a master’s degree, whilst audiologists require a clinical doctorate to be certified as clinically competent (ccc-slp/a) (asha, 2007). in australia, a postgraduate degree (i.e. master of clinical audiology) is regarded as an entry level to practice as an audiologist (audiology australia, 2013). therefore, the motivation and decision to pursue postgraduate studies in slp and a in countries such as the united states of america and australia are predicated on the career trajectory to become a licensed clinician. however, in a south african context, where an undergraduate 4-year degree (e.g. ba, bsc) in slp and a is a sufficient qualification to practice as a clinician in any clinical setting (health professions council of south africa [hpcsa], 2011; south african speech language hearing association [saslha] ethics and standards, 2010), factors that influence a graduate’s decision to pursue postgraduate studies are not well studied. hence, there is a need for this study. methods aim the aim of this study was to determine the factors that influence the decision of south african slps and as to pursue postgraduate studies and potential barriers to this pursuit. research design in this study, we employed a quantitative survey research methodology with a cross-sectional research design (creswell, 2013). a quantitative approach was adopted because the study sought to quantify the number of students who return for postgraduate studies. in this study, a web-based survey research was utilised as it allowed the researchers to gather data from speech and hearing professionals across south africa (khoza-shangase & masondo, 2020). this method has previously been used successfully in a south african context with both slps and as (khoza-shangase & masondo, 2020; khoza-shangase, sebothoma, & seedat, 2019; makhoba & joseph, 2016; seedat, khoza-shangase, & sebothoma, 2018), because it enabled the researchers to gain access to individuals in distant locations (wright, 2005). participants a non-probability purposive sampling strategy was used to recruit potential participants where specific inclusion and exclusion were adopted (leedy & ormrod, 2013). participants in this study had to be registered with the hpcsa and salsha and/or south african association of audiology (saaa). the saslha and the saaa were contacted to gain access to their members’ contact details in order to distribute the survey link to their members. a total of 127 participants (28 as, 43 slps and 56 slps and as) who were registered with the hpcsa and working in different settings completed the survey. descriptive statistics were used to analyse the data (ali & bhaskar, 2016). percentages and graphs were used to summarise and describe all the sections of the questionnaire. data collection and instrument the research questionnaire used in this study was developed according to the aims and objectives of the study. the questionnaire was developed based on previous research (cobbing et al., 2017; hammond et al., 2017; jasińska-stroschein et al., 2017; jung & lee, 2019), and items were generated to suit the context of this study. the items on the questionnaire were predominantly closed-ended questions, with multiple choice answers. the questionnaire comprised of 21 questions and three sections, namely the demographic characteristics of the participants, postgraduate status and factors influencing the decision to pursue postgraduate studies. the survey questionnaire was piloted with two professionals, one slp and one a using the same methodology used in the main study. the purpose of the pilot study was to determine the content and face validity of the questionnaire (leedy & ormrod, 2015). the two professionals (slp and a) were asked to comment on the content and to determine whether the content of the questionnaire is in line with the objective of the study. in addition, the two professionals were asked to comment whether at face value, the questionnaire has captured what is being investigated. the pilot study showed that the questionnaire was appropriate and could be completed in approximately 10 min. the final questionnaire was uploaded on survey monkeytm, which was used to create the survey. the participants received an email from their associations (saslha and saaa) containing the link of questionnaire. a 3-month cut-off time was set for participants to respond to the survey. procedure permission to conduct the study was obtained from the professional associations (saaa and saslha). once permissions and ethical clearance had been obtained from the relevant authorities, a survey questionnaire was distributed to south african slps who are registered members of saaa and saslha, using surveymonkey®. the survey questionnaire was accompanied by an information sheet, which detailed the purpose and nature of the study. all participants provided informed consent by completing the survey. results description of participants a total of 127 participants responded to the survey, with the majority of the participants (n = 75; 59%) working in urban areas (figure 1). majority of the participants (57%) were white practitioners, whilst 23% of the participants were black african practitioners. participants varied in terms of how many years they had been in clinical practice (figure 2). almost half of the participants (44%) were dually qualified (slp and a), whilst the rest were either slps or as. the majority of the participants (n = 72; 57%) indicated an undergraduate degree (e.g. ba or bsc) in slp and/or audiology as the highest level of qualification obtained with the rest possessing a postgraduate degree. figure 1: type of practice setting. figure 2: number of years spent in clinical practice. the pursuit of postgraduate studies only a minority of participants (37%) were currently pursuing postgraduate studies. of those, 36% were pursuing a master’s in research, 23% a research doctorate (e.g. phd), 9% coursework masters, 1% clinical doctorate (aud) and 31% indicated ‘other’. a significant number of participants (30%) were pursuing postgraduate studies in other professions such as psychology (e.g. honours) or business (e.g. business administration). of the participants who had completed or were currently pursuing their postgraduate studies, almost half of them (46%) had waited between 1 and 5 years before registering for their postgraduate studies (figure 3). there are various reasons why participants waited for that specific period, including personal, a lack of funding, being impeded by community service year, feeling uncertain about the research topic, not seeing the value of postgraduate studies or wanting to take a break. even though the majority of participants stated their reasons for waiting for a certain period before pursuing their postgraduate studies, 44% of the participants responded ‘other’ to why they waited for a specific period. figure 3: number of years before the pursuit of postgraduate studies. factors influencing students’ decision to pursue postgraduate studies participants were asked to indicate the factors that influenced their decision to pursue postgraduate studies. the primary factors were fulfilment of a personal goal (55%) and improving their knowledge (53%). almost half of the participants indicated that the need for the development of expertise (47%) and improving job opportunities (46%) also influenced their decision to take up postgraduate studies. very few participants indicated that they were influenced by other factors, as depicted (figure 4). the majority of the participants (69%) indicated that their community service experience did not influence their decision to pursue postgraduate studies; instead, some highlighted that it had delayed them from enrolling immediately after completing their undergraduate studies. figure 4: factors influencing speech language pathologists’ and audiologists’ decision to pursue postgraduate studies. barriers to pursuing postgraduate studies participants were asked to outline barriers that impeded them from pursuing postgraduate studies. the primary barriers indicated were a lack of time because of family commitments, heavy workloads and a lack of funding: ‘single mom needed to work to support my children and had neither the finances nor the time to further my studies.’ (participant 1, slta, female) ‘the biggest issue is the time commitment. i’m interested in research, but i am also very busy and involved in other professional and other activities. i am often too tired in the evenings to do anything academic. i also have financial and other insecurity; my husband is unemployed and my salary must cover the expenses for him, my son and his girlfriend, who are not yet financially independent. if i could do it at my own pace i would be more inclined to register for post-graduate studies, because the risk of having to deregister because of time constraints would no longer be there.’ (participant 2, slta, female) ‘time and finances – i worry about having enough time to maintain my current workload and income yet still be able to give enough time to completing a postgraduate degree and making it worthwhile.’ (participant 3, slta, female) furthermore, participants indicated that they were not pursuing postgraduate studies because there were no financial and/or clinical benefits of doing so in south africa. these participants believed that attending seminars or continuing professional development (cpd) activities was equally beneficial. some participants highlighted that their ‘bad experiences’ during their undergraduate years at university made them unwilling to return and pursue their postgraduate studies: ‘i believe in obtaining a variety of skills that are often not included in postgraduate programmes. i would rather attend workshops and seminars that interest me.’ (participant 4, slta, female) ‘i have been working for 26 years and have specialised in the paediatric scholastic population. i feel that with regular cpd activities i am able to maintain my knowledge without having to do a postgraduate degree. my undergraduate studies were so stressful that i vowed never to study again, and to date i have not had the desire to go back to university. my life is also very busy with three children and i do not think i have sufficient time at the moment.’ (participant 5, slta, female) some of the participants reported that they were not pursuing postgraduate studies, particularly in their community service year because they prohibited by ‘a policy’: ‘[w]anted to wait 1 year, to rest after 4 years of studies, and focus on my community service year.’(participant 6, slta, female). ‘i had to complete my community service first because i was told i couldn’t do my masters in my community service because it is against the hpcsa the policy.’ (participant 7, slta, female) lastly, low marks obtained during undergraduate (i.e. research report marks) also made slps and as reluctant to pursue postgraduate studies. discussion the purpose of this study was to determine factors that influence south african slps’ and as’ decision to pursue postgraduate studies, and potential barriers to this pursuit. findings from this study suggest that there are various factors that influence south african slps’ and as’ decision to pursue postgraduate studies. south african slps and as and sltas indicated that they pursued their postgraduate studies to fulfil their personal goals and to improve their knowledge. the findings of this study corroborate the findings of hoffman and julie (2012) who found that 57.8% of the students in the faculty of community health science who worked in the areas of nursing, public health, social work, physiotherapy, human ecology, psychology, occupational therapy, sports and recreational science and human ecology and natural medicine pursued their postgraduate studies because of the need to improve their knowledge in the field. whilst south african slps and as primarily pursued their postgraduate studies to improve their knowledge and opportunities, approximately half (47%) of the slps and as indicated that they pursue postgraduate studies to develop their expertise in a specific area and improve their job opportunities. these findings were consistent with findings from a study by cobbing et al. (2017), who also found that some south african physiotherapists pursued postgraduate studies to develop their expertise in a specific area. these findings suggest that slp and as see value and relevance of postgraduate studies in clinical practice. therefore, these findings raise important curriculum implication. institutions of higher learning may need to also establish postgraduate programmes that placed greater emphasis on developing or improving specific expertise. cobbings et al. (2017) also reported that physiotherapists were likely to pursue postgraduate studies that placed an emphasis on acquisition of clinical skills. it was assuring to find that participants constantly received information on postgraduate studies. participants indicated that information on postgraduate opportunities was being disseminated by professional associations such as saaa and sashla, and some participants had personally been contacted by academics to pursue their postgraduate studies. current authors encourage further and wider distribution of information on postgraduate studies, which include transparent information on available funding opportunities. given that not all spl and as are affiliated with saaa and/or saslha, there must be an effort to reach those who are not affiliated with these associations and those who do not have access to internet. for example, professional associations such as saaa and/or saslha can collaborate with institutions of higher learning through their alumni programmes to reach wider audience. the biggest barriers to pursuing postgraduate studies reported in this study were lack of time, funding opportunity and family commitment. cobbing et al. (2017) and havenga and sengane (2018), also found that participants described lack of time, funding and family commitments as the main barriers to pursuing postgraduate studies. mutula (2011) suggested that funding opportunities for postgraduate students remain a problem across the african continent. cleary et al. (2011) believed that the high attrition rates of postgraduate students are because of financial difficulties. these findings raise implications for resource distribution and allocations. institutions of higher learning should create awareness on available funding opportunities for postgraduate studies. given that postgraduate studies provide an opportunity to improve knowledge and skills, thus contributing towards the quality service offered to patients, it would benefit the health facilities such as hospitals to create time and support for clinicians who want to pursue postgraduate studies, if financial support is available. some participants in this study highlighted ‘bad experiences’ during their undergraduate years as one of the reasons they are not pursuing postgraduate studies. in a study conducted by jung and lee (2019), satisfaction with undergraduate study had a positive effect on enrolment in postgraduate studies. in this study, participants did not specify what constituted and contributed to their ‘bad experience’. it is not known whether the individual factors described in studies conducted by seabi, seedat, khoza-shangase and sullivan (2012) and tanga and maphosa (2018) or combination of these factors contributed to the ‘bad experiences’. therefore, there is a need for further studies to explore specific factors that contribute to ‘bad experiences’ of students during their undergraduate year. these findings raise implications for support of students during their undergraduate studies. undergraduate programmes must create a conducive environment, provide adequate support and positive experience for undergraduate students so that they are most likely to consider returning for postgraduate studies. an interesting finding in this study was that some slp and as participants stated that an hpcsa policy impeded them from studying during their community service year. current authors searched for the policy on the hpcsa website but could not find such document. despite the lack of available policy, most participants (69%) indicated that their community service experience did not influence their decision to pursue postgraduate studies. in fact, some participants highlighted that their community service year has delayed their commencement of their postgraduate studies. burman et al. (2019) argued that community service in south africa, which focusses primarily on clinical exposure for new graduates, makes it difficult for professionals to maintain a research interest. firstly, the authors of this study propose that a policy on community services and studies be transparent and easily accessible. if such policy exists and it impedes graduates from pursuing postgraduate, based on current findings, this policy requires a review. hanson, paulsen and pascarella (2016) argued that in order to increase the number of postgraduate students, policy makers must understand what motivates students to pursue their postgraduate studies. therefore, as burman et al. (2019) showed, these findings suggest the need for restructuring community service in order to increase research interest in graduates. finally, obtaining low research report scores during an undergraduate year was also reported as a potential barrier to pursuing postgraduate studies. given that there is no strong association between undergraduate performance and postgraduate success (woloschuk, mclauglin, & wright, 2010), these findings suggest that institutions of higher learning need to reconsider their entry requirement for postgraduate studies. secondly, institutions of higher learning should consider pre-masters and pre-doctoral programs, particularly to support and accommodate potential postgraduate students who may not necessarily meet their entry requirement. study limitations and recommendations the recruitment method used in this study permitted access only to participants registered with saaa and saslha. therefore, slp and as who were not affiliated with these associations could not participate in the study. future studies need to use recruitment methods that allow for wider reach of participants, including those who are not affiliated with these associations. in addition, participants without access to internet could not participate in this study. as a result of the limitations of the recruitment method used, it was not possible to accurately calculate the response rate. as some participants were affiliated with both associations, it was not possible to tease out which of the participants were affiliated with one or both associations. previous studies that used similar method could not calculate the response rate (khoza-shangase et al., 2020; makhoba & joseph, 2016; seedat et al., 2018). future studies should include a question that requires participants to indicate their affiliations. future studies should also consider employing a qualitative research, which will explore the results further and provide an in-depth information (cobbing et al., 2017). conclusion these findings highlighted the need for support of slps and as who intend to pursue their postgraduate studies. various stakeholders need to provide the necessary support to enable clinicians to pursue their postgraduate studies. this support is crucial and urgent given that postgraduate study in countries such as south africa is linked with the transformation and decolonisation of the two professions. for example, in south africa, there is an extreme shortage of black academics and the content of the curriculum is still based on euro-western epistemology (khoza-shangase & mophosho, 2018). increasing the number of postgraduate students in slp and a may result in an increased number of black people in academia. however, institutions of higher learning need to create a supportive environment that will motivate students to pursue their postgraduate studies. these findings also highlighted the need for policy review on community service for both slp and a. acknowledgements the authors would like to thank the south african association of audiology and south african speech language hearing association for distributing the electronic survey to their members. we would also like to thank participants who took part in the study. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. author’s contributions b.s., k.m. and n.m. all contributed equally to the writing of this article. ethical consideration all procedures in this study adhered to the world medical association (wma) declaration of helsinki (2013) ethical guidelines. ethical clearance was obtained from the human research ethics committee of the university of the witwatersrand (non-medical) (protocol number: h19/09/48). funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data sets used and/or analysed during this study are available from the corresponding author on reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references abdullah, m.n.l.y., & evans, t. 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(2018). challenges faced by postgraduate students: a case study of a private university in pakistan. journal of education and human development, 7(1), 109–116. abstract introduction method ethical consideration results and discussion conclusion acknowledgements references about the author(s) shabnam s. abdoola department of speech-language pathology and audiology, university of pretoria, pretoria, south africa renata mosca department of speech-language pathology and audiology, university of pretoria, pretoria, south africa bhavani s. pillay department of speech-language pathology and audiology, university of pretoria, pretoria, south africa citation abdoola, s.s., mosca, r., & pillay, b.s. (2019). responsive communication coaching for early childhood practitioners in underserved south african contexts: clinical perspectives. south african journal of communication disorders, 66(1), a608. https://doi.org/10.4102/sajcd.v66i1.608 clinical perspective responsive communication coaching for early childhood practitioners in underserved south african contexts: clinical perspectives shabnam s. abdoola, renata mosca, bhavani s. pillay received: 07 sept. 2018; accepted: 09 apr. 2019; published: 03 june 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract children spend longer hours with early childhood development (ecd) practitioners who are well-placed to facilitate critical early language development. ecd classrooms include a growing number of children at risk for communication delays. greater collaboration between speech-language therapists (slts) and ecd practitioners is needed. research highlights that responsivity coaching improves communication development. therefore, responsive communication coaching was identified as a possible approach to early communication development within the classroom. this clinical perspective serves as a reflection on the programme by examining ecd practitioners’ perceptions thereof. responsive communication coaching was identified as a means to improve practitioner–student collaboration within classrooms. this reflection aimed to describe ecd practitioners’ perceptions of responsive communication coaching implemented by student slts. early childhood development practitioners were recruited from three sites in low to middle socio-economic settings, where most children were english additional language learners. coaching was presented to 15 practitioners via 16 sessions conducted by student slts under supervision. practitioners completed a custom-designed survey regarding their skill development and experiences of the coaching. all practitioners expressed benefit from coaching. half of the practitioners (50%) rated coaching as very helpful, while 37% perceived it as helpful. the remaining practitioners (13%), based at the special needs preschool, perceived coaching as quite helpful. thematic analysis identified the following benefits: enhanced interaction, improvements in children’s communication and the use of responsive communication strategies. speech-language therapists need to collaborate with and support ecd practitioners in novel ways. the exploratory findings suggest that ecd practitioners benefit from slt student-led responsive communication coaching sessions. keywords: early childhood development; responsive communication coaching; inter-professional collaboration; participation; teamwork. introduction undergraduate speech-language therapy (slt) students at the university of pretoria provide services in numerous early childhood development (ecd) settings as part of their clinical training. a traditional ‘pull-out’ approach to therapy was followed with minimal collaboration with ecd practitioners. children showed benefits from the condition-centred intervention approach used; however, generalisation was limited because of poor ecd practitioner–student collaboration, and university examinations and holidays resulted in service delivery disruptions. consequently, clinical supervisors recognised that the slt services were inadequately aligned to the international classification of functioning and disability – children and youth (icf-cy) guidelines (world health organization [who], 2007), which encourage a holistic view of children within their environments. the clinical supervisors wanted to explore a service delivery method that would enable ecd practitioners and slt students to shift their focus towards common child-centred goals, to optimise resources and facilitate early communication development within the classroom (sheridan, edwards, marvin, & knoche, 2009). considering situational challenges and recent literature (archibald, 2017; glover, mccormack, & smith-tamaray, 2015), responsive communication coaching was identified as a possible new approach to early communication development. early communication skills lie at the core of ecd and later academic success (rezzonico et al., 2015). the importance of ecd is well-recognised in literature and educational and health policies (south african department of education, 2008; human sciences research council, 2012). as many countries have made reception year (grade r) compulsory, there is a greater focus on stimulation of foundational skills prior to formal schooling (department of education [doe], 2001). as a result, families and communities have sought out ecd centres for their young children. early childhood abilities are strong predictors of academic and social outcomes, and children who attend quality ecd programmes are more prepared for formal schooling (duncan et al., 2007). however, children from low socio-economic settings (ses) are less likely to access ecd programmes than children from higher socio-economic contexts. additionally, children in impoverished settings are more at risk for developmental delay, because of environmental and biological factors (walker et al., 2011), and require greater support during early development (samuels, slemming, & balton, 2012). globally, there is a disparity between learning settings available to young children, predominantly related to families’ socio-economic statuses (alderman, 2011). three hundred and eighty-five million children worldwide live in extreme poverty (newhouse, suarez-becerra, & evans, 2016). nearly two-thirds of south african families experience stresses including reduced family resources and negative patterns of interactions, such as separation from caregivers because of migrant labour, which influence child development (hall, richter, mokomane, & lake, 2018; hsrc, 2012). stressors can impact development over generations, maintaining the cycle of poverty and disability (hsrc, 2012). children from low ses develop communication and academic skills slower than children from higher ses (hirsh-pasek et al., 2015; morgan, farkas, hillemeier, & maczuga, 2009). early intervention and early education programmes should focus on the communication and future academic potential of children to secure the upliftment of vulnerable populations. early childhood development classrooms increasingly include typically developing children and a growing number of children at risk for communication delays (rezzonico et al., 2015) as the number of stay-at-home parents is decreasing (phillips & adams, 2001). children are spending longer hours in the care of ecd practitioners who, with support from health professionals like slts, are well placed to facilitate critical early communication development (hsrc, 2012; mashburn et al., 2008). extensive literature shows that early intervention services are most effective when strategies are implemented by children’s primary caregivers (britto et al., 2017). coaching children’s primary caregivers rather than providing intervention directly better aligns with the (icf-cy) guidelines (who, 2007) as children receive stimulation more frequently and within their functional daily activities. therefore, because of increased ecd attendance and the role that ecd practitioners play in children’s lives; slts should seek out collaborative partnerships with ecd practitioners. the need for interprofessional collaboration is further highlighted when considering the limited number of slts available to treat individuals requiring services (mayosi & benatar, 2014). ecd practitioners and slts need to reconsider their roles and rather work together to meet the needs of the young, vulnerable population. interprofessional collaboration is central to the role of slts working in early intervention (asha, 2008; south african speech-language and hearing association, 2017). a suitable approach to respond to the identified needs within the classroom could be responsive communication coaching (archibald, 2017; glover et al., 2015; girolametto, weitzman & greenberg, 2006 & friedman, 2015). responsive communication is described as consistent and contingent reactions of communication partners, including practitioners, to children’s verbal and non-verbal communication attempts (flippin & watson, 2015). coaching offers a means of customising information for individuals to implement specific strategies within a particular setting (milburn, girolametto, weitzman, & greenberg, 2014). recent research has highlighted the benefits of practitioners’ responsivity coaching for communication development (glover et al., 2015). coaching improves practitioners’ use of communication facilitation strategies and assists practitioners to embed responsive communication strategies during interactions with young children (friedman & woods, 2015; girolametto et al., 2006), such as identifying and commenting on children’s interests in order to encourage more conversation turns. responsive communication coaching is predominately applied within the functional setting of the classroom. collaboration with educators is one of the roles and responsibilities of slts working in school-based settings (asha, 2010). classroom-based intervention is outlined as a favourable and viable approach to meeting the needs of young south african learners (moonsamy & kathard, 2015) with and who are at risk for communication disorders. however, research on responsive communication coaching and collaboration between ecd practitioners and slts in lowto middle-income countries (lmic), like south africa, is lacking. currently, there are few programmes that guide ecd practitioner–slt collaboration. these include learning language and loving it (llli) – the hanen program for early childhood educators/teachers (weitzman & greenberg, 2002), maximizing academic growth by improving communication (magic), language-in-classroom (lic) and vocabulary enrichment program (vep) (archibald, 2017). although interprofessional collaboration between ecd practitioners and slts is identified as advisable, the optimal approach is not yet known (cirrin et al., 2010). therefore, reviews of the existing literature currently do not recommend one programme but recommend reason-based practice to guide service delivery (archibald, 2017; cirrin et al., 2010; mcginty & justice, 2006). further research into interprofessional collaboration between ecd practitioners and slts is necessary. subsequent to the implementation of interprofessional-based responsive communication coaching, there was a need to reflect on the perceived benefits of the programme. ecd practitioners are one of the primary caregivers in young children’s lives, and therefore, their perceptions of the coaching programme were reviewed. method aim and research design this study aimed to reflect on ecd practitioners’ perceptions of responsive communication coaching conducted by student slts in underserved south african contexts. an explorative research design was implemented. settings students were already involved in service delivery at three ecd centres as part of their clinical training and convenience sampling was thus applied. sites included a preschool in a low socio-economic suburb, a preschool in a small informal community, characterised by poverty, and a preschool catering for children with developmental and special needs. all three preschools required support from non-governmental organisations. the children, most of whom were english additional language learners, either had or were at risk of communication delays due to environmental and biological factors including, limited maternal education, poverty, hiv and aids and cerebral palsy (table 1). children attending the special needs preschool presented with communication impairments associated with developmental conditions including autism spectrum disorder, cerebral palsy and down syndrome. table 1: overview of settings. the number of children per site differed significantly. at the special needs preschool, there were five children in each of the four classrooms. the preschool located in the informal settlement included 35 children in one large classroom. the preschool has subsequently expanded, and there are now more classes available and thus smaller class sizes, averaging at about 10 children per class. the suburban preschool classes contained approximately 15 children each in two classes. participants fifteen ecd practitioners that the students interacted with at varying sites provided consent to participate in the study. three participants were educators at the suburban preschool, seven participants were from the preschool for children with special needs and five participants were from the preschool in the informal settlement. there were two ecd practitioners in each classroom, except for one classroom at the suburban preschool where there was only one practitioner. participants were all female and aged between 20 and 50 years. although, english was the medium of language for learning and teaching at all three preschools, it was not the first language for most practitioners, which is a common finding in south africa (sibomana, 2017). this diversity is a characteristic of south africa where the majority of the population are multilingual (samuels et al., 2012). the educational level and role of the practitioners differed substantially between sites. the range in levels of education, and the fact that most participants (n = 9) were not qualified, may be because of previous legislation in south africa that did not require ecd centres to employ qualified practitioners (hsrc, 2012). of the nine ecd practitioners with no training (figure 1), four participants were from the special needs preschool and five were from the preschool in the informal community. however, three of the six practitioners with formal ecd qualifications were completing additional training through tertiary institutions. two of these practitioners were from the suburban preschool and one was from the preschool for children with special needs. none of the practitioners received responsive communication coaching prior to the sessions with the student slts. figure 1: level of practitioner training across settings. procedure the principals and ecd practitioners at all three sites provided consent to participate. the 16-week coaching programme ran from march to august 2016. the student slts clinical rotations lasted 6 weeks with four to five senior students in each block and one supervisor per site. students received seminars regarding interprofessional collaboration and responsive communication coaching. structured handover occurred between student rotations to ensure treatment fidelity. at the beginning of the academic year, practitioners completed a checklist identifying their needs, adapted from the teacher input checklist (tennessee department of education, 2009). the checklist was originally designed to help determine how language problems affect educational performance. additionally, data were collected by students over two sessions through unstructured classroom observations of spontaneous interactions between practitioners and children during classroom routines such as group time, arts and crafts and snack time. coaching was presented to 15 practitioners via 16 sessions conducted by student slts under the guidance of their supervisors. the student slts, ecd practitioners and children were divided into small groups in the classroom. the duration (45 minutes) of coaching sessions remained constant; however, the regularity of the site visits differed between settings. the preschool for children with disabilities was visited most frequently, with two coaching sessions provided per week. the preschool in the suburban setting received one session a week, while the site in the informal settlement only received coaching once every second week. responsive communication strategies were selected from llli (weitzman & greenberg, 2002) based on the needs identified by the checklist and classroom observations. this programme was selected as it is most widely used in literature (bouchard et al., 2010; cabell et al., 2011; eadie, tayler, & stark, 2017; girolametto et al., 2006; glover et al., 2015). llli does not require specific classroom materials and can be easily incorporated into any existing preschool curriculum (cabell et al., 2011). the programme focuses on the promotion of responsive language and overall communication development naturally throughout daily activities and routines in the classroom setting (weitzman & greenberg, 2002), such as feeding times, group time and craft activities. increased conversational turns have been shown to activate language-related areas in the brain, which results in improved language abilities. reciprocal communication experiences have a greater impact on language development than the quantity of words children are exposed to by their caregivers (romeo et al., 2018). reciprocal communication coaching sessions incorporated components of adult learning such as explaining the relevance of strategies (friedman, woods, & salisbury, 2012), offering descriptions and demonstrations of strategy use, guiding the practitioner through practice, and offering feedback and opportunities for reflections (dunst & trivette, 2009). practitioners were coached to provide responsive language input on children’s topics of interest using child-oriented strategies including ‘observe, wait & listen’ (owl), ‘face-to-face’ and ‘join in and play’ (weitzman & greenberg, 2002). topics included communication and language development, fostering interaction between children and ecd practitioners, and responsive communication strategies to promote active engagement of children in the communication interaction. coaching sessions began with a review of previous strategies and practitioners’ application thereof to classroom settings. thereafter, the next strategies were discussed and jointly implemented by students and practitioners during classroom routines. as outlined in friedman and woods (2015), student slts then gave practitioners feedback or suggestions on how to use a strategy (e.g. ‘when he takes the block out of the container, you can copy him and say ‘out’. the meaning of what you say is then very clear to him with the action accompanied by the word’.) or about the child’s response (‘when you paused before giving him another block, he looked at you and made a sound. that gave you a turn and gave him a chance to respond to you’.). practitioners were encouraged to form an action plan for the incorporation of strategies into the classroom (friedman & woods, 2015; milburn et al., 2014). supervisors were available during the sessions to assist both slt students and ecd practitioners. after 16 weeks of coaching, practitioners completed a self-constructed survey regarding their skill development and experiences of the coaching programme. the survey comprised of four open-ended questions and a likert scale, ranging from one (not helpful) to five (very helpful), rating the benefit they experienced. the survey evaluated perceived changes in communication and interaction abilities of practitioners, the quality of coaching, overall experience of the coaching process and future needs. both quantitative and qualitative data were gathered from the survey. descriptive statistics and thematic content analysis were used to qualitatively analyse the data obtained from the checklist, classroom observations and the survey. ethical consideration ethical clearance was obtained from the research committee of the department of speech-language pathology and audiology, university of pretoria. results and discussion in the initial checklist, practitioners identified class size, practitioner–child interaction and diverse needs within the classroom as the main challenges to successful teaching and learning. from a clinical perspective, the student slts reported that the unstructured classroom observations of spontaneous interactions revealed a traditional lecture style (schwerdt & wuppermann, 2011) of teaching with limited responsive interaction between the practitioners and children. students also observed busy classroom schedules and practitioner frustration. the identified challenges resonate with recent research (glover et al., 2015). the custom-designed survey identified that half of the practitioners (50%) found the coaching very helpful, while 37% perceived it as helpful. the remaining practitioners (13%), based at the special needs preschool, perceived coaching as quite helpful. all practitioners thus expressed benefit from the programme. research indicates that practitioners perceive a range of benefits from coaching programmes (friedman & woods, 2015). the participants from the preschool for children with special needs may have only found the coaching ‘quite helpful’ because most of the practitioners at that site were not qualified (n = 4). there is some evidence that certain thresholds of knowledge need to be in place prior to the implementation of coaching programmes (eadie et al., 2017). the fact that most of the practitioners (n = 14) worked in pairs in their classrooms may have helped them implement the targeted strategies. however, the one practitioner that had a preschool class alone reported that she was excited to ask her colleagues to support her when implementing the strategies with the children. ecd practitioners benefit from the support of other practitioners when applying the strategies covered during responsive communication coaching programmes (eadie et al., 2017). responses from the open-ended survey questions were coded thematically. three main themes were identified including increased interaction, improved communication abilities and helpful strategies. these themes were contrasted against the initial challenges identified during the needs analysis checklist completed by the ecd practitioners and the unstructured classroom observations by students (table 2). survey results indicated that ecd practitioners felt the coaching facilitated reciprocal interaction. facilitating more effective communication between children and their primary caregivers leads to language development (romeo et al., 2018) through a more functional icf-cy (who, 2007) approach. the themes are further explained below. table 2: initial challenges and coaching programme outcomes. increased interaction practitioners (60%) reported improved shared attention during interaction. twenty-five per cent of practitioners perceived improvements in children’s understanding of classroom routines, and 25% felt that they could facilitate improved communication through play. these developments work towards alleviating the limited responsive interaction identified during classroom observations. classroom-based coaching thus assists ecd practitioners in enhancing children’s communication within daily routines (friedman & woods, 2015) as recommended by icf-cy (who, 2007). children’s improved communication half of the practitioners perceived improvements in their ability to understand children’s communication attempts. twenty per cent of practitioners noted improved anticipation of routines, and 20% reported improved communication during daily routines such as mealtimes. these developments were perceived to reduce the stress of large classroom sizes and busy schedules across the sites. over time, these changes could contribute to improved overall communication within classrooms. thus, facilitating the development of communication as practitioners engage children more often in responsive, language-rich interactions (burchinal, roberts, zeisel, hennon, & hooper, 2006; vernon-feagans, bratsch-hines, & family life project key investigators, 2013). helpful strategies to initiate conversations the practitioners reported using more responsive communication strategies after the coaching programme. the most useful strategies were identified as ‘observe, wait and listen (owl)’ (67%), using visual supports to augment verbal communication (33%), providing choices (30%), and using gestures (38%) and face-to-face communication (65%) (weitzman & greenberg, 2002). these strategies can promote children’s participation in communication exchanges and increase practitioners’ abilities to respond to children’s diverse communication needs. conversations centred on children’s interests are processed more easily thereby freeing up cognitive resources for learning (girolametto et al., 2006). future coaching needs practitioners expressed various needs for further coaching including skills to facilitate play and peer-interaction, and to extend the duration of communication exchanges. results highlight practitioners’ increased awareness of their role in nurturing children’s functional communication abilities. practitioners at the special needs preschool requested additional training in augmentative and alternative communication strategies. this indicates that the coaching programme needs to be tailored for the diverse populations at each site. consistent with previous research, results from this study suggest that practitioners have a need for context-based practical strategies for use in the classroom (glover et al., 2015). coaching requires a paradigm shift, from traditional approaches to responsive interaction, by all parties involved and time is needed to adjust to new roles and perspectives (rezzonico et al., 2015). continued coaching is required and will be provided, to aid generalisation of strategies to all classroom activities. generalisation and transdisciplinary teamwork are central to the success of coaching programmes (friedman & woods, 2015; glover et al., 2015). a positive outcome from the study was that role extension, enrichment and expansion were achieved, although not the focus of the coaching programme. role exchange and release, therefore, require increased focus in future coaching programmes. limitations and suggestions for future research the implementation of the coaching programme may have been disrupted by student rotations and the variation in frequency of coaching sessions across sites. the number of children in the classrooms at different sites also varied. it should be recognised that it can be extremely challenging to implement new approaches in a large class of 35 children or in a small class of 5 children, where the children have complex developmental challenges and needs. the size of the classrooms may have influenced the application of the responsive communication coaching programme. the study did not evaluate the outcomes of the coaching programme in relation to practitioners’ respective levels of experience, and a control group of practitioners that did not receive coaching was not included. it would have been insightful to assess children’s communication abilities preand post-intervention. however, there was a multitude of potential contributing factors such as additional private, individual slt. the maintenance of strategies beyond immediate coaching was not formally monitored but collaborative service delivery continued. additionally, a future consideration is to compare the effect of coaching with in-service workshops to classroom coaching alone. preliminary results of this study indicate that further research on responsive communication coaching for ecd in lmic practitioners is warranted. conclusion ecd practitioners reported that in-classroom coaching sessions led to an increased use of responsive communication strategies and improved interaction and communication with children. upon reflection of the newly implemented approach, the clinical supervisors were encouraged to continue implementing responsive communication coaching sessions during student’s preschool-based clinical visits. growing recognition of the link between early language abilities and later academic success emphasises the need for icf-cy responsive (who, 2007) interprofessional collaboration between slts and ecd practitioners (rezzonico et al., 2015). speech-language therapists and educators present with diverse yet complimentary skills and knowledge sets, which could be beneficial for collaboration and improved ecd (archibald, 2017). speech-language therapists need to respond by supporting ecd practitioners in novel ways. the exploratory findings suggest that ecd practitioners benefit from slt student-led responsive communication coaching sessions. acknowledgements the authors would like to thank the participating ecd centres and practitioners for participating in this study. data availability statement data will be stored at the university of pretoria for 15 years as per the university policy. competing interests the authors declare that there are no competing interests in this study. the views expressed in this article are the authors’ own and not an official position of their institution. author’s contributions r.m. and b.s.p. supervised the student’s practical. all authors contributed equally to the drafting of the manuscript. references alderman, h. 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(2007). international classification of functioning, disability and health – children and youth version (icf-cy). geneva: who. abstract introduction method materials and instrumentation application development procedures vocabulary measures e-book intervention postand follow-up testing data coding and analysis ethical consideration results discussion limitations clinical implications conclusion acknowledgements references appendix 1 footnote about the author(s) daleen klop division of speech-language and hearing therapy, stellenbosch university, south africa laurette marais human language technology research group, meraka institute, council for scientific and industrial research (csir), pretoria, south africa amanda msindwana division of speech-language and hearing therapy, stellenbosch university, south africa febe de wet human language technology research group, meraka institute, council for scientific and industrial research (csir), pretoria, south africa citation klop, d., marais, l., msindwana, a., & de wet, f. (2018). learning new words from an interactive electronic storybook intervention. south african journal of communication disorders 65(1), a601. https://doi.org/10.4102/sajcd.v65i1.601 original research learning new words from an interactive electronic storybook intervention daleen klop, laurette marais, amanda msindwana, febe de wet received: 28 may 2018; accepted: 29 july 2018; published: 13 sept. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: children who enter school with limited vocabulary knowledge are at risk for reading failure. this study investigated the efficacy of an interactive e-book, implemented as a mobile application, to facilitate vocabulary learning in grade 1 isixhosa-speaking children (n = 65). objective: the purpose was to measure if an e-book intervention, specifically developed for use in the south african context, could facilitate the acquisition and retention of new words at different levels of lexical representation. method: a randomised pre-test and/or post-test between-subject design was used where an experimental group that received the e-book intervention was compared to a control group before the control group received a delayed intervention. follow-up testing was performed to measure retention of the new vocabulary after eight weeks. mixed-model repeated-measure analysis of variance (anovas) were used to determine differences between the participants in the experimental and control groups. results: the short-term e-book intervention not only facilitated fast-mapping of new words but enabled participants to develop more robust lexical representations of the newly acquired words. follow-up assessment showed that they retained their newly acquired word knowledge. conclusion: multimedia technology can be used to provide explicit and embedded vocabulary training to young children at risk for academic failure. these findings are particularly relevant for south african environments where there is limited parental support and lack of educational resources to promote vocabulary learning in young children. introduction south africa is faced with an ongoing crisis in literacy and reading, as our children perform poorly when compared to international standards. many south african children are at risk for scholastic failure because of the pervasive and persistent inequalities in educational resources, risk factors associated with poverty and limited parental support, and inadequate instruction in overcrowded classrooms. the 2016 progress in international reading literacy study (pirls) showed that of the 12 810 grade 4 children who were assessed in 293 schools across south africa, 78% did not reach the low international benchmark for reading. they could not perform basic reading skills such as reading for meaning, locating and retrieving explicitly stated information or make inferences about events or provide reasons for actions (howie et al., 2017). vocabulary, the knowledge of word meanings, is a powerful predictor of reading comprehension. children with a limited vocabulary struggle with reading comprehension because they lack sufficient depth of word knowledge to process the meaning of more complex words or words in different morphosyntactic forms. they have less efficient lexical processing skills, are less likely to learn new words from incidental or embedded exposure to words and need repeated and explicit instruction to acquire deeper word knowledge (coyne et al., 2009). in south africa, wilsenach (2015) found that receptive vocabulary size in emergent bilingual northern sotho–english children predicted the development of their early literacy skills. children with a limited vocabulary not only lag behind their peers at school entry, but the gap widens as they progress through school. pretorius and stoffelsma (2017) found that a group english first additional language learners in the eastern cape only knew 27% of the most frequent words in their textbooks by the end of grade 3. research has shown that children at risk for literacy failure need not only code-based reading instruction but also interventions to improve language and vocabulary skills (biemiller & boote, 2006; coyne et al., 2009). according to nation (2013) the most effective ways to maximise vocabulary learning are to ensure that children do large amounts of reading, using graded material at the appropriate developmental level, repeated exposure to targeted vocabulary and deliberate learning through linked activities such as reading with exercises and computer-based activities. there is therefore a growing focus on the development of programmes and procedures to improve and even accelerate vocabulary growth in children at risk for literacy failure. one such option is the development of multimedia interventions to support the language and literacy learning skills of children growing up in lower socio-economic status (ses) home and school environments. in this article we report the results of using an interactive electronic book (e-book) to facilitate vocabulary learning in children from disadvantaged backgrounds. the use of technology is a promising solution to support the development of literacy and to compensate for the language gap between linguistically advantaged and disadvantaged children (bus & neuman, 2009). one of the recommendations in response to the 2016 pirls results was that effective and sustainable access to information and communications technology (ict) in south african primary schools should be increased (howie et al., 2017). for our study we developed an original interactive e-book, implemented as a mobile application. the purpose of our study was to measure the efficacy of an e-book, specifically developed for use in the south african context, to facilitate the learning of new words in children at risk for scholastic failure. the results of an earlier study reported in de wet, pretorius and klop (2015) showed that afrikaans-speaking grade 1 participants (n = 28) from disadvantaged backgrounds acquired and retained new words after short-term exposure to an e-book intervention. this follow-up study was conducted to determine if similar changes would emerge in a different test population, namely isixhosa-speaking children in a lower ses rural environment in the eastern cape. the study was guided by the following research question: what is the effect of an interactive e-book intervention on vocabulary learning of a group of isixhosa-speaking mainstream grade 1 children? the specific research questions were as follows: what are the differences between the participants’ knowledge of 15 target words before and after the intervention in terms of the following levels of word learning: receptive or partial knowledge? contextual or deeper knowledge? in-depth or full knowledge? will they retain their knowledge of new words at the different levels of learning? the hypothesis, based on the results of de wet et al. (2015), was that participants would acquire and retain new words from their exposure to the e-book intervention. method study design a randomised pre-test and/or post-test between-subject design was used, where an experimental group that received the intervention was compared to a control group before the control group received a delayed intervention. participants participants were recruited from grade 1 classes in two isixhosa-medium schools in the district of ntsika yethu-cofimvaba, in the eastern cape. the community comprise mainly subsistence farmers, and many children are cared for by grandparents while their parents are migrant workers in urban areas. both schools had only one grade 1 class. as a result, the classrooms were overcrowded, with 51 children in one class and 91 children in the other class. the quality of teaching and learning in both schools was further compromised by a lack of learning resources available in the classrooms and children’s poor school attendance. for inclusion in the study, children had to pass otoscopic examinations, pure tone hearing and optometric screening tests to ensure that all participants had normal hearing and vision. children were assessed individually by two researchers who were fluent isixhosa speakers, in a quiet room in the school. their non-verbal skills were assessed by means of the test of nonverbal intelligence, fourth edition (toni-4) (brown, sherbenou & johnsen, 2010), a language-free measure of cognitive ability. the purpose of this measure was to enable comparisons between participant groups in terms of their cognitive ability. participants’ toni-4 index scores ranged from 77 to 106 (scores below 90 indicate below-average performance). there are no standardised language tests available for isixhosa-speaking children and participants’ language skills could therefore not be assessed formally. inclusion criteria stipulated that the children had to be isixhosa first-language speakers, aged between 6 and 8 years. children older than 8 years, and children who failed the hearing and visual screening tests, were excluded from the study. after matching for gender, participants who complied with the selection criteria were randomly assigned to the experimental and control groups. because of poor school attendance in general, many children were absent during the assessment and intervention period. only 65 of the 140 children who consented to participation fulfilled all the selection criteria and completed all the phases of the study. the experimental group (n = 33) comprised 16 boys and 17 girls, and the control group (n = 32) comprised 13 boys and 19 girls; their average age was 6 years and 7 months. the groups were comparable in terms of age and non-verbal intelligence. one-way analysis of variance (anova) showed no differences between the groups for toni-4 index scores, f(1, 63) = 3.1670, p = 0.08. materials and instrumentation storybook an original story with learning activities was created by the first author for the study reported in de wet et al. (2015). it was translated from afrikaans to isixhosa by the third author, a first-language isixhosa speaker who is fluent in afrikaans. a professional artist illustrated the story under the guidance of the first author to ensure that each picture portrayed the target words and storyline. adjustments to the story and pictorial content were made to the afrikaans story to accommodate the linguistic differences between afrikaans and isixhosa. for instance, for the isixhosa version the illustrator altered the rabbit’s tail to depict the target word fukufuku (a word to describe the texture of a dandelion seed) more accurately. figure 1 presents a screenshot from the e-book. figure 1: screenshot of story on tablet. vocabulary content the e-book contained 15 target words (5 nouns, 4 verbs, 1 adverb and 5 adjectives) that were embedded in the story context (see box 1). the 15 words were selected to represented tier 2 words, that is, words that are used frequently by adults and in books but are unlikely to be familiar to young children, although they would be able to understand them in context (beck & mckeown, 2007). figure 2 illustrates an interactive activity. box 1: fifteen target words figure 2: example of an interactive activity. application development the application included three subcomponents, namely the home page with activity choices, such as activities of interaction with the e-book content and thirdly multichoice-style quizzes with questions that were answered by clicking on or dragging an object to the correct answer. the home page of the application provided buttons for accessing six different activities. the activities included reading through the e-book content and interacting with it, as well as multichoice-style activities for answering questions about the e-book content. the e-book was implemented as a mobile application, specifically for android tablets. it used a text-to-speech (tts) engine to generate the audio version of the text displayed on the screen. the application used the qfrency1 tts3 isixhosa voice to convert tts. qfrency tts is a speech synthesis system that was developed specifically for south africa’s official languages. technical details on application implementation are provided in de wet et al. (2015). children first listened to the story read by a voice while observing the pictures on the tablet. the interactive activities, based on the story content, were added to facilitate participants’ active engagement with the target words through manipulation and discrimination tasks. the aim was to provide more opportunities to interact with the target words to consolidate and reinforce comprehension and to enable deeper word learning. the frequency of the target words was controlled for the number of times each word occurred in the story text and the learning activities to make comparisons between words possible. procedures pre-testing measurement tasks were developed by the researchers to test participants’ knowledge of the 15 target words at three task levels prior to the e-book intervention. the assessments were based on the protocol that was piloted in the de wet et al. (2015) study and were deemed valid by the researchers to assess the three levels of vocabulary learning. training items were provided to make sure that the children understood the tasks and instructions. the assessment protocol is shown in appendix 1. the study timeline is shown in figure 3. figure 3: assessment and intervention schedule. vocabulary measures receptive vocabulary knowledge task (partial knowledge) this task entailed matching a word with its pictorial referent out of three distractors, for example, ‘show me woven (ephothiweyo)’. this activity required only partial knowledge of a word, and a correct response did not necessarily indicate full understanding of the word. each correct answer received one point. sentence completion task (contextual and/or deeper knowledge) this measure assessed expressive knowledge of the target words within the context of a sentence, for example, ‘the rabbit’s tail is … ? (fluffy)’. the cue sentences were novel sentences and not taken verbatim from the story or interactive activities to prevent responses that were just repetition from memory. each correct answer received one point. word definition task (in-depth and/or full knowledge) this measure assessed how well children understood the target words and whether they were able to express their understanding in a meaningful explanation, for example, ‘what do you think woven means?’ no explicit definitions or word explanations were provided in the story or interactive activities. participants’ responses were coded on a four-point scale: 0 points for no or incorrect responses, one point for a response that used the word appropriately but without an explanation or elaboration, for example, ‘the nest is woven’, two points for a response that indicated attempts to explain or elaborate, for example, ‘woven is like the bird’s nest’, three points for a definition or description that indicated full understanding of the word, for example, ‘woven means the bird used grass to make his nest’. e-book intervention the experimental group (n = 33) received the e-book intervention in groups of 3–4 children, three times per week in 20-min sessions, for a period of 2 weeks, that is, 6 sessions (2 h) in total. two weeks after the programme was completed, the vocabulary assessment battery was repeated on both groups. the control group (n = 32) then received the e-book intervention programme in the same way as the experimental group. the intervention sessions were supervised and directed by one of the researchers, who helped the children to become familiar with the tablet and to access the interactive e-book. children listened to the e-book through headphones to maximise the sound quality of the application and to avoid distractions. they engaged independently with the story and activities, following the verbal instructions that were part of the e-book. all the children had previous exposure to tablets and were familiar with interacting with educational material on tablets. postand follow-up testing to minimise memory effects, post-tests to assess and compare both groups’ knowledge of the target words took place two weeks after the experimental group completed the intervention. after a period of 8 weeks, the assessments were repeated on the experimental group to determine their retention of the newly acquired words. the control group’s post-tests took place 2 weeks after they completed the intervention to assess their word learning. the control group was not assessed again for retention, as it was felt that a fourth assessment with the same battery could have elicited training effects. to minimise training effects between the tasks, participants were always tested first with the definition task, then with the sentence completion task and lastly with the receptive task. data coding and analysis the results of the screening and the preand post-intervention assessments were manually coded and analysed by the third author. to ensure inter-rater scoring reliability, the word definition task was scored independently by another person who was an isixhosa first-language speaker and unaware of participants’ group assignment. point-by-point agreement, calculated by comparing the total number of agreements with the agreements plus disagreements, was 98%. a software package, statistica 12, was used for the statistical analyses. to examine the differences between the participants in the experimental and control groups, mixed-model repeated-measure anovas were used. a 5% significance level (p < 0.05) was used as the guideline for determining significant effect. ethical consideration the study formed part of a project approved by the council for scientific and industrial research (csir) ethics committee (62/2013). formal written consent was obtained from the school principals, parents or caregivers and verbal assent from the participants prior to the study. results the main aim of the study was to determine the efficacy of an interactive e-book to facilitate vocabulary learning. as shown in table 1, both groups had similar pre-test scores, but the experimental group performed significantly better than the control group when assessed after the intervention. the control group’s post-test scores showed that their scores improved in a similar way following the intervention. the experimental group’s follow-up results, 8 weeks after completion of the intervention programmes, indicated that they had retained these gains. table 1: means (and standard deviation) for receptive vocabulary, sentence completion and word definition scores for participants in the experimental (n = 33) and control (n = 32) groups for the pre-, postand follow-up assessments. receptive vocabulary a significant interaction between group and time was found, f(2, 126) = 26.29, p < 0.05. as shown in figure 4, most of the participants demonstrated at least partial word learning of most of the 15 target words as a result of their exposure to the words in the e-book intervention. figure 4: receptive vocabulary: mean scores of participant groups for pre-, postand follow-up assessment. sentence completion a significant interaction between group and time was found, f (2, 126) = 23.79, p < 0.05. as shown in figure 5, few of the participants could use any of the 15 target words to complete the cue sentence prior to the intervention. this result was expected, as only the target word was accepted as correct, even if another word was used appropriately to complete the sentence. results of the postand follow-up tests demonstrated that modest gains in expressive word learning took place and that most participants could use some target words in a meaningful sentence context. figure 5: expressive vocabulary: mean scores of participant groups for pre-, postand follow-up assessment of the sentence completion task. word definitions this subtest assessed the children’s ability to provide definitions of the 15 target words and to assess the depth of their word learning. as shown in figure 6, significant interaction between group and time was found, f(2, 126) = 10.83, p < 0.05. the postand follow-up tests demonstrated therefore that most participants could provide some form of expressive explanation or interpretation of the target words, indicating that they acquired not only partial knowledge of word meanings but also deeper and more complete understanding of the target words. figure 6: mean scores of participant groups for pre-, postand follow-up assessment of the word definition task. discussion our intervention aimed not only to facilitate fast-mapping of new words but to enable participants to develop more robust lexical representations of the newly acquired words. the results showed that all the participants acquired new tier 2 level words at different levels of semantic representation. moreover, in contrast with the findings of other studies (e.g. coyne et al., 2009), their word learning over time was robust and they retained not only their gains in partial word knowledge but also at deeper levels of word understanding and lexical representation. this is particularly significant for such a short-term intervention; children were only exposed to the 15 target words for 2 h in total over a period of 2 weeks. it should be acknowledged that learning effects could have occurred during the post-intervention assessments, but the stability of vocabulary scores even after 8 weeks is encouraging. limitations this study only used one e-book that was created specifically for the project. it can, therefore, not be inferred that similar learning effects would be observed for all e-books. most commercially available e-books are created for entertainment purposes and may be less effective in facilitating word learning than an e-book that was created with vocabulary intervention goals in mind. further research to investigate differences in learning effects for e-books, with and without additional training activities, could inform developers and consumers about the most effective ways to use e-books for word learning. clinical implications one of the main benefits of e-book interventions is that children can engage with the content and activities independently with limited adult mediation. in an environment where there is little parental support at home and too many children in school classrooms, opportunities for shared storybook reading are often inadequate. e-books can, therefore, fill an important gap by enabling children from these environments to direct their own learning experiences and benefit from regular exposure to stories. e-books, in contrast with conventional shared reading, can also offer additional learning opportunities through interactive activities to reinforce and consolidate learning of new words. conclusion the short-term e-book intervention facilitated the acquisition of new words in a group of isixhosa-speaking grade 1 children at risk for scholastic failure. the results confirmed the findings of the earlier study in an afrikaans-speaking population (de wet et al., 2015). it can therefore be concluded that this e-book intervention is an effective tool to facilitate vocabulary learning, even across linguistic populations. acknowledgements we are grateful to the children, teachers, schools and the eastern cape education department, who with their participation and assistance made this project possible. this collaborative project between meraka institute and stellenbosch university was funded by the csir. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. the views expressed in this article are the authors’ own and not an official position of their institutions. authors’ contributions d.k. was responsible for conceptualising the project, the literacy content and the experimental and project design. l.m. made conceptual contributions and was responsible for development of the application. a.m. translated and adjusted the content and performed data collection and analysis. f.d.w. was involved in conceptualising the project and acted as project leader. references beck, i. l., & mckeown, m. g. (2007). increasing young low-income children’s oral vocabulary repertoires through rich and focused instruction. the elementary school journal, 107(3), 251–271. https://doi.org/10.1086/511706 biemiller, a., & boote, c. (2006). an effective method for building meaning vocabulary in primary grades. journal of educational psychology, 98(1), 44–62. https://doi.org/10.1037/0022-0663.98.1.44 brown, r., sherbenou, r. j., & johnsen, s. k. (2010). test of nonverbal intelligence (4th edn.). los angeles, ca: western psychological services. bus, a. g., & neuman, s. b. (2009). introduction. in a. g. bus & s. b. neuman (eds.), multimedia and literacy development (pp. 1–12). new york: routledge. coyne, m. d., mccoach, d. b., loftus, s., zipoli, r., & kapp, s. (2009). direct vocabulary instruction in kindergarten: teaching for breadth, versus depth. the elementary school journal, 110(1), 1–48. https://doi.org/10.1086/598840 de wet, f., pretorius, l., & klop, d. (2015). text-to-speech enhanced ebooks for emerging literacy development. in s. seidl, a. batliner, & o. jokisch (eds.), slate 2015 – workshop on speech and language technology in education: proceedings of an international conference held in leipzig, germany, 4–5 september 2015 (pp. 173–177), viewed 09 august 2018, from https://www.slate2015.org/files/slate2015-proceedings.pdf howie, s. j., combrinck, c., roux, k., tshele, m., mokoena, g. m., & mcleod palane, n. (2017). pirls literacy 2016: south african highlights report. pretoria: centre for evaluation and assessment. nation, p. (2013). designing reading tasks to maximize vocabulary learning. applied research on english language, 3(1), 1–8. pretorius, e. j., & stoffelsma, l., (2017). how is their word knowledge growing? exploring grade 3 vocabulary in south african township schools. south african journal of childhood education, 7(1), a553. https://doi.org/10.4102/sajce.v7i1.553 wilsenach, c. (2015). receptive vocabulary and early literacy skills in emergent bilingual northern sotho-english children. reading & writing, 6(1), art. #77, 11 pages. https://doi.org/10.4102/rw.v6i1.77 appendix 1 assessment protocol icandelo a: isigama esichazwayo itafile 1-a1: inkcazo yamagama isivakalasi esitshiwo kuqala: uthetha/ithetha ntoni … ? itafile 2-a1: izivakalisi ezingaphelelanga icandelo b: isivakalasi esitshiwo kuqala: khomba (yolatha) ngomnwe wakho… itafile 3-a1: isigama esiqondwayo isivakalasi esitshiwo kuqala: khomba (yolatha) ngomnwe wakho… footnote 1. http://www.qfrency.com/ abstract introduction research method and design ethical consideration results discussion conclusion acknowledgements references about the author(s) samantha m. govender department of telehealth, university of kwazulu-natal, south africa maurice mars department of telehealth, university of kwazulu-natal, south africa citation govender, s.m., & mars, m. (2018). assessing the efficacy of asynchronous telehealth-based hearing screening and diagnostic services using automated audiometry in a rural south african school. south african journal of communication disorders, 65(1), a582. https://doi.org/10.4102/sajcd.v65i1.582 original research assessing the efficacy of asynchronous telehealth-based hearing screening and diagnostic services using automated audiometry in a rural south african school samantha m. govender, maurice mars received: 16 oct. 2017; accepted: 06 mar. 2018; published: 05 july 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: asynchronous automated telehealth-based hearing screening and diagnostic testing can be used within the rural school context to identify and confirm hearing loss. objective: the aims of the study were to evaluate the efficacy of an asynchronous telehealth-based service delivery model using automated technology for screening and diagnostic testing as well as to describe the prevalence, type and degree of hearing loss. method: a comparative within-subject design was used. frequency distributions, sensitivity, specificity scores as well as the positive and negative predictive values were calculated. testing was conducted in a non-sound-treated classroom within a school environment on 73 participants (146 ears). the sensitivity and specificity rates were 65.2% and 100%, respectively. diagnostic accuracy was 91.7% and the negative predictive values (npv) and positive predictive values (ppv) were 93.8% and 100%, respectively. results: results revealed that 23 ears of 20 participants (16%) presented with hearing loss. twelve per cent of ears presented with unilateral hearing impairment and 4% with bilateral hearing loss. mild hearing loss was identified as most prevalent (8% of ears). eight ears obtained false-negative results and presented with mild lowto mid-frequency hearing loss. the sensitivity rate for the study was low and was attributed to plausible reasons relating to test accuracy, child-related variables and mild low-frequency sensory-neural hearing loss. conclusion: the study demonstrates that asynchronous telehealth-based automated hearing testing within the school context can be used to facilitate early identification of hearing loss; however, further research and development into protocol formulation, ongoing device monitoring and facilitator training is required to improve test sensitivity and ensure accuracy of results. introduction children comprise 32 million of the 360 million people globally presenting with disabling hearing loss, and it is estimated that almost 9% of hearing-impaired children are 15 years and younger (world health organization [who], 2017). according to butler (2012), by using a conservative prevalence of 1% for the combined group, it can be estimated that 1.5 million children under the age of 15 years in south africa present with some type of hearing impairment. late diagnosis of childhood hearing loss is associated with lack of early detection and intervention programmes, late identification of hearing loss and prioritisation of life-threatening health conditions over hearing loss (olusanya, okolo, & adeosun, 2004). developing regions including sub-saharan africa, asia pacific and south asia share the greatest burden of hearing impairment (gell et al., 1992). otitis media, wax impaction and hearing loss, particularly mild and unilateral in nature, are the most common auditory pathologies noted in school-aged children (sarafraz & ahmadi, 2009). permanent disabling hearing loss of varying degrees (mild to profound) is also a concern in this population (yamamah, mabrouk, ghorab, ahmady, & abdulsalam, 2012). a disabling hearing loss is defined as the pure-tone average (500 hz, 1000 hz and 2000 hz) of 30 dbhl or more in the better ear (who, 2012). irrespective of the time of onset, cause or severity, undiagnosed or late-diagnosed hearing loss in children can negatively impact on academic performance, social and emotional development as well as vocational opportunities (janardhana, muralidhar, naidu, & raghevendra, 2015). the emphasis on educating children holistically has drawn focus to the multiple dimensions that influence learning and academic progress (kochhar-bryant & heishman, 2010). it has long been recognised that early identification and timely management of auditory pathology in children translates into positive outcomes (yoshinaga-itano, sedey, coulter, & mehl, 1998). however, although school hearing screening programmes are a reality in most developed countries, developing countries still lack such services as a result of resource constraints (monica et al., 2016). developing countries such as india, kenya, nigeria and south africa have attempted to develop and implement school-based healthcare services that include hearing screening (balarajan, selvaraj, & subramanian, 2011; department of basic education [dobe], 2012; oyinlade, ogunkunle, & olanrewaju, 2014). the inclusion of hearing screening is within the healthcare package offered as part of the integrated school health programme (dobe, 2012) to south african schools, an initiative of the south african government. however, several challenges relating to implementing and sustaining hearing screening services within the school context have been highlighted. these challenges include lack of diagnostic follow-up and continuation of care (govender, latiff, asmail, ramsaroop, & mbhele, 2016; jin, sklar, oh, & li, 2008), lack of efficient transport systems, financial difficulties, long travel distances and negotiating long waiting queues in public sector hospitals. furthermore, parents face challenges in obtaining leave of absence from work, thereby adding to the poor follow-up process (jones, sherman, & varga, 2005). failure of the referral system defeats the primary purpose of hearing screening which is to identify children with hearing loss and enable diagnosis and timely management (mahomed-asmail, swanepoel, & eikelboom, 2016a; skarżyński & piotrowska, 2012). furthermore, high-noise levels when conducting conventional screening at schools also posed challenges to the screening programme as this can result in high false-positive rates and associated unnecessary referrals (lo & mcpherson, 2013). introducing diagnostic hearing testing within the school environment could remedy some of these challenges, such as poor follow-up of recommendations made, as well as unnecessary referrals. however, conventional diagnostic testing in schools requires infrastructure and special considerations including sound-treated facilities and diagnostic audiometers. there are also too few audiologists globally, including in south africa, to ensure that these services can be adequately and equitably delivered to all children (swanepoel et al., 2010). the use of automated telehealth applications in audiology within schools may alleviate some of these challenges. telehealth-based audiology services allow for service delivery to remote and rural areas as such testing can be done outside a sound-treated environment. noise cancellation headphones allow for testing to be conducted outside the sound-treated room within a noise-controlled environment (swanepoel, maclennan-smith, & hall, 2013). such headphones provide an opportunity for both screening and diagnostic services to be delivered at schools, thereby possibly closing the gap between identification and intervention. automation of audiology equipment allows for standardisation of test procedures and protocols, improvement in diagnostic accuracy by reducing clinician variability, and efficient electronic record keeping (brennan-jones, eikelboom, & swanepoel, 2017; mahomed, swanepoel, eikelboom, & soer, 2013; margolis & morgan, 2008; mars, 2013; storey, munoz, nelson, larsen, & white, 2014). applying an asynchronous, store and forward model for both screening and diagnostic assessment allows testing to be performed by a trained assistant with the results subsequently evaluated by an audiologist at a different location and time (swanepoel et al., 2010). therefore, a store and forward model provides an opportunity for testing to be done at any time by a trained facilitator, and the results can be stored in a password-protected computer and subsequently sent to a qualified audiologist anywhere in the world for interpretation and analysis. screening coupled with an asynchronous telehealth diagnostic service delivery model may be beneficial in rural areas in south africa and other developing countries where access to services is limited. such a service delivery model optimises human resource distribution in resource-constrained settings. existing studies confirm that diagnostic automated testing can yield reliable results (brennan-jones et al., 2017; mahomed-asmail, eikelboom, myburgh, & hall, 2016b). however, only a few diagnostic studies using automated audiometry have been conducted in schools. in addition, available studies primarily focus on validation as well as comparing conventional results to automated findings. based on current evidence, asynchronous tele-audiology services using automated technology may be used as an effective service delivery model in schools; however, more empirical evidence is required to assess the efficacy of this model. a review of the literature shows that telehealth services can be used to deliver audiology services within the school context; however, not all these studies used automated technology. in addition, only a few studies conducted both screening and diagnostic assessments. remote hearing screening via telehealth using manual audiometry was conducted at a rural elementary school in utah in the united states on 32 grade 3 children (lancaster, krumm, ribera, & klich, 2008). each participant received one screening on site and another through telehealth procedures. no statistically significant differences were found between results obtained through remote pure-tone screening and on-site screening. the researchers did find five participants who performed differently during the telehealth method and suggested that more studies were required to understand the reasons for false responses. diagnostic pure-tone audiometry within two urban school contexts without a sound-treated environment was evaluated (swanepoel et al., 2013). a total of 149 children were evaluated asynchronously both within a soundproof booth with conventional audiometry and with a computerised device, the kuduwave 5000. the participants were purposively selected and none presented with significant hearing loss. in addition, any participants presenting with middle ear pathologies during the middle ear assessments were also excluded from the final sample. both air and bone conduction testing were performed, and no statistically significant differences were found between thresholds recorded under both conditions. monica et al. (2016) conducted a synchronous tele-hearing screening service in a school. remote computing software was used so that the audiologist could remotely operate the audiometer whilst the facilitator set up and instructed the participant at another school. teamviewer was used to provide videoconferencing and synchronous services between both sites for screening to be conducted. thirty-one children participated in the study. all participants were screened using telehealth and conventional methods of screening with no statistically significant differences between methods. in the studies conducted by both swanepoel et al. and saleth et al., only manual audiometry was utilised which is different from the context of the present study, which aims to evaluate the use of automated audiometry within the natural school environment. a telehealth model using synchronous audiometry was used to conduct hearing screening on 143 children in a study by skarżyński et al. (2016). hearing impairment was identified in 34 participants (23.7%). the study supported the use of a telemedicine model to assess hearing status in children within the school context. this study also used a manual protocol for assessment. mahomed-asmail et al. (2016b) investigated the validity of automated diagnostic air and bone conduction audiometry for children in a natural school environment following a hearing screening test. no significant differences were found between manual and automated air and bone conduction audiometry. this study conducted screening with smartphone technology and only used the kuduwave 5000 for diagnostic testing. the study highlighted some limitations, including that testing was only conducted down to 15 dbhl as that was considered the cut-off for normal hearing, and the authors recommended that future studies conduct testing lower to 0 dbhl. the study also recommended that testing should be done in more natural school environments with adverse acoustic conditions. the purpose of the present study was to build on the work conducted in automated audiometry by evaluating the efficacy of an asynchronous model using automated audiometry to conduct screening and diagnostic testing. this was considered necessary because most of the studies reviewed have either conducted synchronous testing or used manual audiometry as opposed to automated audiometry. research method and design aims the aims of the study were to evaluate the efficacy of an asynchronous telehealth-based service delivery model using automated technology for screening and diagnostic testing in a rural school in south africa as well as to describe the prevalence, type and degree of hearing loss found in the study sample. study design a comparative within-subject design was used. a within-subject design ensures that every participant receives the test that is under investigation and serves as his or her own control. this reduces the amount of error that may arise when comparing variables between participants (charness, gneezy, & kuhn, 2012). the disadvantage of this design is related to the ‘carry-over effects’, where a participant’s performance in one test may influence his or her performance with the other test and therefore needs careful consideration. study site the study was undertaken at a rural primary school in the bojanala district of the north-west province in south africa. sampling method the entire population of learners at the school (n = 300) was invited to participate and were given invitation letters, along with consent forms, information documents and letters of assent to take home to their parents. only those learners who returned a signed consent form were included in the study. participant description participants were from grades 1 to 7 and ranged in age from 6 to 12 years with a mean age of 8.9 (sd = 1.99). both genders were adequately represented in the study sample with 60% girls and 40% boys. equipment the otoscopic examination was conducted using a de500 firefly digital video otoscope and various sizes of specula. screening and diagnostic automated audiometry was conducted using the kuduwave 5000 type 2 clinical audiometer (emoyodotnet, johannesburg, south africa). the kuduwave 5000 was connected to an hp probook laptop with a windows 10 operating system. the kuduwave provides ‘ambidome’ technology, which has built-in soundproofing, replacing the soundproof booth (kuduwave user manual, 2013). it uses a combination of sound dampening and real-time monitoring of ambient noise. the device connects to circumaural earphones that attenuate ambient noise through two microphones positioned on the headphones that monitor the noise levels. deeply inserted foam ear tips, connected to two detachable sound tubes, connected to the kuduwave were placed into the ear canal of the participant with the circumaural headphones placed over both ears. a b71 bone oscillator was used for bone conduction testing and was kept in position on the head by a screw-on headband. the bone oscillator was placed on the forehead. the patient was given a response button connected to the kuduwave, allowing automated recording of the responses. the kuduwave was a new device and was calibrated by emoyo.net a month before use. the gsi 33 middle ear analyser was used to conduct tympanometry testing. classification of tympanograms was made according to the shape, middle ear pressure, ear canal volume and static compliance in accordance with the study by jerger (1970). facilitator training the facilitator was recruited through a local doctor in the bojanala district who was familiar with some of the community volunteers. she could speak english as well as the local language (setswana) and was computer literate. the facilitator was trained by the primary investigator (sg) who had been trained by a kuduwave representative. facilitator training took place over 2 days. day one consisted of an overview of the hearing screening protocol and orientation to the kuduwave and the digital firefly otoscope. aspects including proper handling and setting up of the equipment, patient set-up, patient information entry and troubleshooting were addressed. day two comprised a practical component where the assistant was required to conduct screening of 10 children under the observation of the primary investigator. the primary investigator was also present for the first day of screening to ensure that no problems were experienced by the facilitator. the assistant was also given a copy of the kuduwave manual (2013:revision 3) for reference. test environment testing was conducted in the school library, which was approximately 20 m away from the playground and classrooms. during testing, no children were allowed access to the library. testing was interrupted during break time as a result of increased noise levels. noise level measurements were taken intermittently (an average of three readings per day) to ensure that the noise levels were kept below 50 dbspl. there were only a few occasions when the noise levels reached an average of 60 dba after the three readings and testing was interrupted during these times. participant preparation participants were conditioned for both screening and diagnostic testing before the assessment began. they had the opportunity to ask questions, to listen to practice tones and were orientated to the response button. instructions were given in a simple manner in the first language of the participant. data collection procedure screening phase the screening protocol as outlined by saslha (2011) was adhered to (figure 1). an asynchronous telehealth model was applied. a trained facilitator conducted the screening, and the results were asynchronously evaluated later by a qualified audiologist. participants first underwent an otoscopic examination performed by the facilitator using a de500 firefly digital otoscope, which is a laptop-based video otoscope programme. video recordings of the participants’ external auditory canal and tympanic membrane were saved in a password-protected folder on the computer. these recordings were studied asynchronously by the audiologist daily after the participants were screened. a healthy outer ear and external auditory canal and presence of a light reflex from the tympanic membrane were landmarks for normal otoscopic findings. participants presenting with pathologies on otoscopy such as impacted cerumen, perforated tympanic membranes or fluid around the tympanic membrane were referred to general practitioners in the area for further evaluation, including cerumen removal, and were thereafter rescreened. rescreening took place within 2 weeks of the referral for management. figure 1: clinical protocol. each child was screened bilaterally with the left ear tested first, using automated screening methods at frequencies from 500 hz to 4000 hz. the pass criterion was set at 25 dbhl (american academy of audiology, 2011). other similar studies using automated technology used similar or higher pass criteria (kam et al., 2014; mahomed-asmail et al., 2016b). during peak noise level, testing was interrupted until the noise levels reached below 50 dba, again in accordance with the american speech and hearing association (1997) and american academy of audiology (2011). if a child failed to respond to the required intensity level at one or more frequencies, he or she was rescreened. the rescreen followed the same process as the initial screen. the rescreen was conducted after a rest period was given. all screening results were saved to a password-protected folder and emailed to the audiologist for later review, as well as to ensure proper record keeping of screening results. diagnostic phase the qualified audiologist conducted on-site diagnostic measures using automated audiometry. to test concordance, the agreement between screening and diagnostic tests, all participants underwent a diagnostic audiology assessment, irrespective of whether they passed the otoscopic examination and screening. diagnostic testing was performed on-site by an audiologist (sg) after the participant was set up and instructed by the facilitator. automated audiometry was used to conduct the diagnostic phase of testing. all participants were given a rest period of an hour or longer between screening and diagnostic testing. six grades of hearing loss, from slight to profound, were classified according to clark (1981). the clinical protocol utilised for both screening and diagnostic testing is presented in figure 1. all data were saved to a password-protected folder with only the researchers having access. data were entered and verified by both researchers. all forms and audiograms were stored in a locked cabinet after data entry was complete. data analysis frequency distributions were calculated for all screening and diagnostic tests. sensitivity (%) and specificity (%) scores as well as the positive and negative predictive values (ppv/npv) were calculated using two-by-two contingency tables. sensitivity reflects the probability of the automated test being positive when the hearing loss is truly present. specificity indicated the probability of the automated test being negative when the hearing loss was truly absent. ppv represents the percentage of participants with a positive result who actually have hearing loss, whilst npv reflects the percentage of participants with a negative test outcome who truly do not present with hearing loss. ethical consideration ethics approval was obtained from the biomedical research and ethics committee of the university of kwazulu-natal (certification number: be288/15). ethics approval was also obtained from the department of basic education within the north west province. participants received information letters, consent forms and letters of assent. participants were informed of their right to withdraw at any stage of the study. participants who required management were appropriately referred, and all participants received a copy of their results to take home to their parents. data were entered onto a password-protected computer, and names were replaced with research numbers to ensure anonymity and confidentiality. results a total of 146 ears were assessed. for those participants who were rescreened at one or more frequencies, only the rescreen results were used for analysis. otoscopic examination based on otoscopic findings, four ears (3%) required referral for cerumen management, three for partial impaction of wax and one for complete occlusion. they were referred for cerumen removal then rescreened. these participants also underwent diagnostic audiometric testing. automated screening and diagnostic outcomes in all, 15 ears (10.3%) of 13 participants failed the automated screening test. a total of 16 participants were rescreened after obtaining a fail result on the initial screen and 13 participants obtained a fail result on the rescreen, whilst 3 participants passed the rescreen and were given an overall pass result. for diagnostic testing, 23 ears (15.7%) of 20 children were identified as having a hearing deficit. eight ears that passed the screening test result failed the diagnostic test. therefore, there were eight false-negative screening tests but no false-positive tests. the sensitivity, specificity, ppv, npv and diagnostic accuracy of the automated test are shown in table 1. the sensitivity was low (65.2%) indicating that a total of eight ears that passed the screening test failed the diagnostic assessment. the specificity was high (100%), which implied that all participants who truly did not have hearing loss were correctly identified by the automated hearing assessment. table 1: outcome of screening and diagnostic tests. all hearing losses identified were sensory-neural in nature. mild hearing loss was identified in 11 ears (8%), moderate in 7 (5%), severe in 3 (2%) and profound in 2 ears (1%). seventeen ears (12%) presented with unilateral hearing impairment and six ears of three participants (4%) had bilateral hearing impairment. the eight false-negative screening test results were further analysed (table 2). three ears showed low-frequency sensory-neural hearing loss, whilst five ears showed a lowto mid-frequency hearing loss, which ranged from mild to moderate. table 2: thresholds across frequency ranges for diagnostic (d) and screening (s) tests for eight false-negative screening tests. discussion this study showed the results of a combination of asynchronous telehealth and automated testing methods to deliver both screening and diagnostic hearing services in a rural school context. diagnostic testing performed at the school overcomes the risk of loss to follow-up for diagnostic testing that occurs in conventional screening services. the present study had a high specificity (100%) but a lower sensitivity (65.2%). this is similar to the findings of cardoso et al. (2014) where the sensitivity and specificity of a portable hearing screening device were determined. they felt that modification of screening level criteria may be necessary when working with different population groups. when using a new device, especially automated devices, audiologists should carefully evaluate the protocols proposed for the device and if necessary conduct trial studies that specifically evaluate modifications to the test protocols. the kuduwave, for example, suggests a response time of 1500 m/s. this time may be too short for children to respond and as a result this may be recorded as a no response. such protocol issues can be adjusted through future studies investigating response time and its impact on test performance. it is understood no screening measure is likely to identify all true positives and true negatives (stein, 1999), because of the nature of hearing screening measures where pass and fail criteria are based on a predetermined intensity level. however, it is important that the screening outcomes reflect a low false-positive rate (high specificity), and more importantly a low false-negative rate (high sensitivity) (clemens & davis, 2001). fletcher, fletcher and wagner (1996) emphasised that screening tests are most useful to the clinician if they have a high sensitivity rate. an evidence-based literature review of eight studies for pure-tone screening tests for children reported sensitivities of 0.12% – 97% and specificities of 0.5% – 99%. definitions of hearing loss, response criteria and technologies used varied between the eight studies reported (prieve, schooling, venediktov, & franceschini, 2015). the false-negative tests in this study are of concern. whilst the authors could not find a definitive explanation, possible reasons for the false-negative tests could relate to the device, the testing procedure or child-related variables. distractibility of some of the participants during diagnostic testing was a concern, especially the younger ones (6-year olds). because of this, they may have not been focused during diagnostic testing, therefore failing the test. the diagnostic and screening tests used the same device, so tone generation and volume should have been consistent. the kuduwave device has been validated for diagnostic testing in several studies (brennan-jones et al., 2017; visagie, swanepoel, & eikelboom, 2015). what may have differed in the two test situations might have been the depth of insertion of the foam ear tips. the facilitator inserted them for both screening and diagnostic testing, and it is speculated that they might not have been inserted as deeply for diagnostic testing as they were during screening. ambient noise has been cited as a reason for failure to diagnose low-frequency hearing loss (lfhl). the same noise attenuation methods and headphones were used in all tests, both screening and diagnostic. diagnostic testing took place an hour after screening and the noise levels may have risen and exceeded the noise-dampening capacity of the ambidome headphones and insert earphones. when the ambient noise level was routinely checked, it was mostly lower than 50 dbspl during testing. based on the environmental noise control measures undertaken, which is slight as well as on the noise control features of the device, it is unlikely that noise could have significantly impacted on the test result. another possible reason could be related to the lack of counterbalanced testing for this study. the same order of testing was used for all children and this may have resulted in a learning effect for listening. three of the false-negative screening tests in this study presented with an lfhl and five of the eight false-negative tests failed to identify hearing loss at 1000 hz. low-frequency hearing loss is prevalent in this age group and is consistent with other studies (olusanya, neuman, & saunders, 2014; rao, subramanyam, nair, & rajashekhar, 2002), which report a prevalence of mild hearing loss in school-aged children of around 11.3%, which is slightly higher than the prevalence of 8% found in the present study. mild hearing loss is not easily identified and as a result is most often underestimated in terms of its impact on academic development (dodd-murphy, murphy, & bess, 2014). hyde (2016) mentions that no screening programme could achieve perfect sensitivity and that ‘real-world’ screening tests are likely to miss some patients. this point may inevitably outline the benefits of using telehealth-based audiology service delivery models in schools, as screening and subsequent diagnostic testing could be conducted immediately after screening. other studies using automated audiology technology such as automated auditory brainstem response testing and otoacoustic emissions yielded a small percentage (<20%) of false-negative results (hyde, riko, & malizia, 2006; schmidt, sataloff, newman, spiegel, & myers, 2001) and protocol revisions, noise control measures and equipment calibration were some measures mentioned applied to improve test sensitivity. however, it is important to note that the above mentioned tests are objective measures, therefore not requiring a response from the patient. it is plausible to assume that with subjective measures such as in the case of pure-tone audiometry, human-related variables such as distractibility and fatigue could also add to reduced test sensitivity rates. careful protocol consideration is imperative when conducting a hearing evaluation programme. although not investigated in the study, the extension of the response time on the automated software provided more time for the learner to respond. this is especially necessary when evaluating children because of their uncertainty and fluctuating attention levels. screening protocols should also carefully consider their criteria in terms of screening intensity levels. the majority of the screening protocols recommend that screening be conducted at 20 dbhl (saslha, 2011); however because of the high-noise environments, screening intensity levels have often been raised to 25 dbhl, or even to 30 dbhl, in order to avoid false-positive referrals (mahomed-asmail et al., 2016a, 2016b). an intensity level of 25 dbhl was used to sensitise the test battery to identify mild hearing losses (dodd-murphy et al., 2014). several studies highlight the concern of mild hearing loss among participants (olusanya et al., 2014; samelli, rabelo, & vespasiano, 2011). the protocol was also successful in identifying unilateral hearing loss and this was most prevalent in the present study. unilateral hearing loss is a concern in the school-aged population and can result in challenges with localisation and speech perception in background noise (lieu, 2013). the study found that children presented with primarily unilateral mild hearing impairment. this finding was consistent with other studies, which indicate that this type of hearing loss is prevalent in the school-aged population (butler, 2012; govender et al., 2016). based on diagnostic testing, children were referred for management, including further diagnostic testing that included speech audiometry, as well as for a hearing aid evaluation. this study confirmed that a facilitator can be trained to perform video-otoscopy and pure-tone screening using an automated audiometric device in a school during teaching hours. the results can be transmitted to an audiologist for review at a later time. diagnostic testing can also be performed in the school using the same device. for this study diagnostic testing was undertaken by an audiologist on site, but it can also be performed remotely by an audiologist with the facilitator setting up the patient and being supervised in real-time over the internet. automated audiometry because of its predetermined protocol also allows for an adequately trained facilitator to execute the test under the remote observation of the audiologist. the results could then be forwarded to an audiologist for later review and management decisions. for the developing world, task shifting and enabling a facilitator to perform both screening and diagnostic testing on site in a school would be the most efficient use of scarce resources. other similar studies also document successful outcomes when using a trained facilitator in an underserved context (biagio, swanepoel, adeyemo, hall, & vinck, 2013). future studies should focus on obtaining facilitator feedback regarding the process so that improvements can be made. conclusion the study investigated the outcomes of a telehealth-based audiology service model using automated audiometric testing to screen hearing and confirm hearing loss in children at a rural south african school. the findings revealed that automated audiometry used within an asynchronous model can identify hearing loss in school-aged children; however, the issue of the false-negative rate obtained in this study was of concern. it is therefore recommended that ongoing evaluation occurs for automated devices to improve their reliability and validity particularly in relation to child-related factors. when testing children, it is important to ensure that they are attentive and alert to avoid effects of distractibility on test results. counterbalancing testing order especially with children is important so as to avoid a learning effect for listening, and this was a limitation of the study probably contributing to the high false-negative rate. these factors support the increasing need for practice guidelines to be developed for tele-audiology to ensure standardised practice. future research should focus on developing other automated audiology tests and implementing these within the school context so that a comprehensive test battery of automated audiology tests can be provided within a telehealth model. acknowledgements competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions s.m.g., the main author, contributed in the literature review, data collection, writing and compilation of manuscript. m.m., the co-author, conceptualised and contributed to the conceptualisation, literature, design, reviewing, editing and finalisation of the manuscript. references american academy of audiology. 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(1998). language of early-and later-identified children with hearing loss. pediatrics, 102(5), 1161–1171. https://doi.org/10.1542/peds.102.5.1161 abstract background number in jordanian arabic methods results discussion conclusion acknowledgements references about the author(s) bassil mashaqba department of english language and literature, faculty of arts, the hashemite university, zarqa, jordan haneen abu sa’aleek department of english language and literature, faculty of arts, the hashemite university, zarqa, jordan anas huneety department of english language and literature, faculty of arts, the hashemite university, zarqa, jordan sabri al-shboul department of english language and literature, faculty of arts, the hashemite university, zarqa, jordan citation mashaqba, b., abu sa’aleek, h., huneety, a., & al-shboul, s. (2020). grammatical number inflection in arabic-speaking children and young adults with down syndrome. south african journal of communication disorders, 67(1), a702. https://doi.org/10.4102/sajcd.v67i1.702 original research grammatical number inflection in arabic-speaking children and young adults with down syndrome bassil mashaqba, haneen abu sa’aleek, anas huneety, sabri al-shboul received: 21 feb. 2020; accepted: 16 aug. 2020; published: 05 nov. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: individuals with down syndrome (ds) have more difficulties with the structural aspects of language, including morphology (concatenation and non-concatenation) and syntax (word order and grammatical/concord rules), than with other language components (e.g. vocabulary, phonetics and pragmatics). objectives: this study investigates the accuracy of grammatical number inflection produced by jordanian arabic-speaking children and young adults with ds. the work also examines the correlation between age and the correct production of singular, dual and plural numbers. methods: the study involved 60 monolingual arabic children and young adults with ds, 30 males and 30 females, enrolled at the nazik al hariri welfare centre for special education, amman. the participants were divided into three groups: kg2 (7.1–12.5 years old), school (13.10–17.6) and vocational training (18.3–27.3). the participants’ data were collected from a picture elicitation task and free speech, and the answers were recorded using a smartphone. tokens were classified into correctly used, incorrectly used or not recognised. proficiency percentage in using the correct number in correlation with age was calculated adopting jia’s (2003) composite score of proficiency. the one-way analysis of variance was used to trace the impact of age on the correct performance of number. post hoc comparisons (guided by the scheffe test) were calculated for the cumulative results of the scale as a whole to examine the difference in the arithmetic mean between the three groups. results: the singular form was the most used by all age groups (83.3%), followed by the plural (27%); the most delayed was dual (10.3%). intriguingly, the dual form is the most difficult plural pattern because it was the least frequently used pattern in everyday language. results were in line with other research on morphological markers in individuals with ds (e.g. penke, 2018). the cumulative results statistically prove the influence of age on the correct use of grammatical number, in favour of the older two groups (total f = 29.865, at the level of significance p = 0.000), with a higher arithmetic mean of all categories (am: kg2 = 9.00, school = 15.10, vt = 16.25). hence, sensitivity to the correct number option increases with age although children and young adults with ds do not reach adult-like performance. the non-recognition cases of the proper number category significantly mark language delay in participants with ds. conclusion: the study concluded that inflection for grammatical number is evidently delayed in individuals with ds. linguistic teaching and training of children with ds (involving families, caregivers and educators) should start from childhood and continue to adulthood to improve their use of dual and plural numbers. keywords: down syndrome; dual; grammatical number; inflection; jordanian arabic; morphology; plural; singular. background down syndrome (ds), also known as trisomy 21, is the most commonly identified genetic disorder, and the most frequent chromosomal defect in live-birth infants as a consequence of non-disjunction, an error in cell division. this error produces an extra copy of chromosome 21, resulting in 47 chromosomes instead of the normal 46. this extra copy of chromosome 21 is the generator of abnormalities and structural and functional anomalies in the body’s systems (wajuihian, 2016, p. 1). down syndrome has three types: trisomy 21 (found in 95% of people with ds), translocation (4%) and mosaic (1% – 2%). only the translocation type is inherited (wajuihian, 2016, p. 6). language is one of the common developmental disabilities in individuals with ds. it is referred to as delayed instead of deficient ability as people with ds produce their first utterances or words later than their peers. such delay in language production is also reflected in the more predominant use of gestures by ds children than typically developing children (tdc) (kim & ko, 2002). people with ds follow the same developmental stages of language acquisition, although these are rarely complete (rondal, 2009, p. 138). this incompleteness of language development results from cognitive impairment in the brain that is linked to intellectual disability (rondal, 2009, p. 138). despite the fact that individuals with ds vary in cognitive abilities, they exhibit the same linguistic profile of communication strengths and difficulties (martin, klusek, estigarribia, & roberts, 2009). morphology and syntax are the most problematic aspects in ds children, although this improves with age. the major morphological difficulties lie in: ‘producing the proper inflections for nominal number concord as well as the markings for person, number, and tense or aspect on verbs’ (rondal, 2010, p. 11). in addition, verb patterns and auxiliaries are learnt at a later stage and tend to remain unstable in individuals with ds. a good deal of literature concentrates on morphological and grammatical acquisition in children with ds, as one of the impaired cognitive domains in ds. the studies conclude that children with ds acquire these patterns at a later stage than typically developing individuals (e.g. penke, 2018). language delay is also accompanied by inconsistency and atypical asynchrony in using free morphemes, grammatical morphemes, verb inflections (for person, number and gender), nominal inflection and word use (within noun as well as verb phrases); individual and age differences are also evident (fabbretti, pizzuto, vicari, & volterra, 1997; rondal, 2010). children with ds struggle with functional patterns across languages. english-speaking children with ds tend to delete function words (e.g. pronouns, prepositions, copula and auxiliaries) and bound morphemes (arias-trejo & barrón-martínez, 2017; chapman, seung, schwartz, & bird, 1998); spanish-speaking children use gender, number and tense agreement inconsistently (lázaro, garayzabal, & moraleda, 2014), and german-speaking children omit verbal agreement marking (penke, 2018). whilst several studies have been conducted on children with ds in several languages, no single work has considered the use of grammatical number by individuals with ds in arabic. number differs amongst different language systems. for example, english is a concatenative language, whereas arabic, which belongs to the semitic family, is non-concatenative. for instance, the number system does not follow a linear process (suffixation) to an extent and irregular plural patterns must usually be experienced and memorised (lexicalised) (for details on the plural system, refer to the next section: ‘number in jordanian arabic’). this complexity may create more language difficulties in arabic-speaking individuals with ds. following the recommendation of galeote, soto, sebastián, checa and sánchez-palacios (2014), more experiments should be carried out in other languages, to examine the role of different language aspects in setting up specific developmental profiles. arabic is one of the languages that lack research examining the linguistic profile of children and young adults with ds. this study aims to fill in a gap in literature by addressing grammatical number in arabic, as produced by children and young adults with ds in jordan. it also identifies differences in this morphological aspect occurring as a result of variables such as age, as a warning sign to conduct continuous language training. a set of clinical and pedagogical implications are suggested to be considered by teachers and therapists for better improvement of individuals with ds. such implications can be pedagogical because number is not targeted adequately in the process of teaching, especially as arabic has a complex number morphology which may cause misunderstanding(s). hence, creative teaching methods should be refined to help individuals with ds express their needs and thoughts. the linguistic behaviour of individuals with ds is highly inconsistent and unclear and characterised by severe delayed use. this study contributes to building, with other studies from different languages, a comprehensive linguistic profile for individuals with ds. the contribution of this work is of paramount importance because no validated and standardised tool currently exists to measure the progress of individuals with ds in jordanian arabic (ja). thus, this work stands in support of recommendations for building such a tool and identifies a set of pedagogical implications that help to find comprehensive intervention. number in jordanian arabic grammatical number in jordanian arabic (ja) is trifold: singular, dual and plural. the singular number is unmarked and represents the word root/stem. the dual number is marked by using the suffix – (t)e:n to express all cases, with phonological modification of the suffix from a:n/ajn or using the plural form (see table 1). plural number is divided into two categories: (regular) sound plural (sp) and (irregular) broken plural (bp). sound plural involves linear by adding suffixes to the singular base without any internal change: stem + -i:n for masculine sound plural (msp; table 1, data in a) and stem + -a:t for feminine sound plural (fsp; table 1, data in b). broken plural is formed via non-linear processes, which involve stem re-modification and/or internal vowel change (table 1, data in c; mashaqba, 2015; mashaqba, al-khawaldeh, ghweri, & alodwan, 2020; mashaqba & huneety, 2017). table 1: simplified number system in jordanian arabic. in terms of number acquisition in arabic by typically developing children, the singular form is mastered first, followed by dual number and then the plural (e.g. aljenaie, abdalla, & farghal, 2011; moawad, 2006). as bp does not follow linear formation rules, it can only be acquired through lexicalisation and learning. it is therefore expected to be mastered after sp (abdalla, aljenaie, & mahfoudhi, 2012). age and the type of plural category significantly affect the progress of acquiring the plural system in ja. sensitivity to the non-concatenative option increases with age and conforms to the three-phase representation of the plural development: ‘pre-morphology, proto-morphology and morphology proper’ (albirini, 2015, p. 754). the pre-morphological phase is manifested predominantly in 3-year-olds who apply uninflected singular stems and produce some inflected plural forms. this is because the plural system may not be adequately developed. at this stage, no dominant default pattern has yet been formed. this is revealed by equal performance of different plural categories. the proto-morphological stage probably begins at the 4-year stage, where children accurately employ singular uninflected stems accompanied by the excessive use the fsp –a:t to any other stems. at the age of 5 and 6 years, children clearly develop their plural system, internalising and increasing the pluralisation through a variety of morphemes. however, the msp and bp forms remain susceptible to be used mistakenly because of incomplete knowledge of these forms; children still make mistakes as they are selectively asked to apply human and non-human nouns. the morphology proper stage, starting when children are 7 and 8 years old, implies increasing ability in using plural forms. at this stage, children approximate adult-like usage and show better performance of fsp, msp and bp. this stage involves the over-regularisation strategy that occurs throughout language development (albirini, 2015). methods participants the sample of this study was 60 monolingual ja-speaking individuals diagnosed with ds: 10 males and 10 females in each of the three groups. all participants had trisomy 21 type, and they were seen at nazik al hariri welfare centre for special education in amman. data were taken from three age groups: the kg2 group had a chronological age (ca) of 7.1 to 12.5 years (m = 9.7, sd = 1.86), a mental age (ma) of 3.3 to 5.9 years (m = 4.5, sd = 0.98) and a mean average iq = 49.1; the school group’s ca was from 13.10 to 17.6 years (m = 15.25, sd = 1.38), their ma was 7.2–10.8 years (m = 7.95, sd = 1.3), and mean average iq was 55.8; and the vocational training group’s (vt) ca was from 18.3 to 27.3 years (m = 22.6, sd = 3.94), ma 9.1–16.9 (m = 12.7, sd = 3.36), and mean average iq was 56.6. age was examined because it impacts the use of grammatical number by individuals with ds. iq scores were determined using the stanford–binet iq test. all participants lived with their families. based on their clinical records, they had no history of hearing or vision problems, additional medical or behavioural conditions (such as anxiety disorder, psychosis and epilepsy). all participants in this research commonly produced more than two-word utterances in spontaneous speech. this information was confirmed by a speech pathologist and his or her teachers. data collection to date, research on individuals with ds in ja has no validated and standardised measurement tool. data were elicited via a picture naming task where each participant was shown 10 pictures on microsoft powerpoint 2016, with each picture shown separately for 20 s. all tasks took place in the familiar setting of a comfortable room and involved one participant and the examiner (the second author) in each session. the powerpoint show involved 10 common items under examination where the order of presentation was the same for all participants and all items. each task was preceded by a familiarisation practice with two pictures of common objects, which are not part of the 10 items on the ppt; the examiner asked the participant to describe what she or he saw in the picture. in this phase, the examiner gave positive feedback plus the target sentence naʕam saḥi:ḥ ʃaṭṭu:r ‘yes you are right, excellent!’, whereas in the experiment itself, no positive feedback was provided. the examiner just said xalli:-na n-ʃu:f iṣ-ṣu:ra illi baʕd-ha ‘let’s see the next picture’, and the examiner asked the participant to describe what she or he saw in the picture. every item was presented in the three cases of the grammatical category of number in arabic: singular, dual and plural. for the plural number, only the fsp and bps were tested because they are the default plural patterns. stating that bp is a (minor) default pattern does not contradict the notion that it is one of the most complex plural forms in arabic. considering the lexicon as a whole, bp is non-exceptional (al-shboul, huneety, mashaqba, zuraiq, & al-omari, 2020; mashaqba, 2015; mashaqba et al., 2020; mccarthy & prince, 1990). corpus studies on pluralisation system in arabic confirm that bp is frequent and, to an extent, predictable by native arabic-speaking adults (boudelaa & gaskell, 2002). although fsp is the default plural, it is concatenated to a limited set of nominal stems; by way of contrast, bp is more frequently used than sp by native arabic-speaking adults. to elicit the required data, the examiner asked in arabic: ʃu: ʃa:jif biṣ-ṣu:ra ‘what do you see in the picture?’. the first two authors recorded monologues (free speech) uttered by the participants, and conversations between the participants themselves and between them and their teachers. the researchers did not depend on free speech as a method of collecting data from the participants. however, there was a persistent need to make some free conversations with some participants to encourage them (especially the youngest group/kg2) to speak freely as some of them were shy and silent and to notice their production of plural structures naturally when speaking freely. the results of the free speech were not calculated in the statistical analysis. only the data generated from elicited pictures were counted. all picture naming tasks, monologues and conversations were recorded using a smartphone and transcribed using the acceptable phonetic symbols for arabic (http://jss.oxfordjournals.org/). to achieve reliable testing and avoid researcher bias, the transcription was double-checked by co-authors and a language therapist, and any case of pronunciation disagreement was excluded. elicited data were transferred to an excel sheet. procedure of data analysis all recorded responses were evaluated for each individual; all analysable tokens for number category were extracted and then classified into correctly used, incorrectly used or not recognised by any age group. when the participant did not say anything, the answer was put in a special pattern called non-recognition. the tokens were calculated and given scores. every correct pattern was given one point and every wrong or not recognised pattern zero. jia’s (2003) composite score of proficiency (abdalla et al., 2012, p. 153) was adopted to find out proficiency percentage in using the correct patterns in correlation with age for each pattern: the correct answers are the forms produced by every native ja-speaking adult as reported in literature. in this work, the researchers and one language therapist, who are native speakers of ja, identified the correct forms. the one-way analysis of variance (anova) statistical test was used to trace the impact of age on the correct performance of number. for more accurate validity, post hoc comparisons (guided by the scheffe test) were calculated for the cumulative results of the scale as a whole and its correlation with age variables to statistically examine the difference in the arithmetic mean between the three groups. ethical consideration a consent form was prepared, and ethical clearance was obtained from scientific research and research ethical approval committee of the hashemite university (number: 1/2019/2020) and permission was granted by department of english language & literature on 22 september 2019. the consent form was signed by parents or caregivers after they were shown the objectives of the study and assured that all ethical issues would be taken seriously. confidentiality was ensured as the collected data remained private with identification through code names, and the researchers guaranteed that they would delete all the results from their desktops and/or smart phones after conducting the study if the centre and the participants so wished. results participants were divided into three age groups to test the influence of age differences and progress in individuals with ds on the production of grammatical number. table 2 summarises the frequency of patterns produced. table 2: frequencies of number patterns performed by down syndrome participants.‡ applying jia’s (2003) composite score of proficiency, the three ds groups showed different proficiency scores regarding the three categories of number: singular, dual and plural (see eqn 1). considering the singular number, the school group was the most proficient in the correct singular form (94%), followed by the vt group (82%), and the kg2 group (74%). in terms of dual number, more progress was reported for the school and vt groups. the vt group produced the (default) dual and acceptable plural in 35% of cases. next, and very close, the school group scored the second highest correct use (34%). the kg2 group statistically suffered a weak performance using the correct dual inflection (0% for the dual pattern and 9% for the acceptable plural form). the kg2 group had used the plural forms, with only 7% correct responses, as opposed to 27% for the school group and 47% for the vt participants. the finding that some participants did not use any pattern is of interest. across all number patterns, the non-recognition cases constituted 16% of the cases of the three numbers; the highest percentage was scored by the kg2 group (33%), followed by the school group (9%) and the vt group (6%). the arithmetic mean (am) of the three age groups revealed statistically significant differences in accuracy amongst the groups (table 3). the vt group scored the highest accuracy mean, followed by the school group and the last kg2 group. therefore, age has an influence on generating differences in producing grammatical number. table 3: arithmetic mean and standard deviation in the grammatical number as produced by the three down syndrome age groups. one-way anova confirmed significant statistical differences between the three age groups in the responses of the participants by age (table 4). table 4: correlation between age and accuracy of grammatical number production. the results in table 4 confirm the existence of statistically significant differences at the significance level (a = 0.05) because of the effect of age on number, where the value of (f) on this category registers f = 29.865, respectively, at the level of significance (p = 0.000). the cumulative results prove a statistical significance of the influence of age on grammatical number (total f = 29.865). over the cumulative results of the scale as a whole and its correlation with age variables, the post hoc comparisons (guided by the scheffe test) presented statistically significant differences in the arithmetic mean between the kg2 group and the school group and between the members of the kg2 group and the members of the vt group (table 5). the differences are in favour of the school group and the vt group over the kg2 group with a higher arithmetic mean of all categories on the total scale. table 5: post hoc comparisons of age variable in grammatical number. discussion one major finding of this study is that participants with ds have difficulties and limited knowledge of the proper number inflection. the incorrect patterns used by the three groups reflect the presence of a mental disorder area in people with ds that causes the linguistic behaviour of the incorrect production of linguistic items in contexts other than their obligatory ones, in addition to usage inconsistency of grammatical morphemes (cf. fabbretti et al., 1997). all ds groups scored high rates of proficiency in producing the correct singular number. this could be ascribed to the fact that singular number is the default category and the easiest pattern to acquire first (albirini, 2015; mashaqba et al., 2020; mashaqbeh, 2009). all ds groups produced singular as the most frequent incorrect pattern to express dual and plural, which implies a cognitive delay in using the proper dual/plural form. typically developing arabic-speaking children master the dual number at the age of 10 years (moawad, 2006). hence, reliance on the (default) singular to express the other inflected numbers denotes that children and young adults with ds are still in the pre-morphological phase, corresponding to that of 3-year typical children (albirini, 2015). this phase reveals language delay in producing the dual and plural numbers by jordanian children and young adults with ds compared with typically developing children. the kg2 group represents a significant linguistic behaviour in producing the grammatical number. the abundance in the number of incorrectly produced patterns (such as phonological fragments, verb patterns and word reduplication) probably refers to linguistic instability and inconsistency in this younger group, which confirms the persistent need to expose individuals with ds to linguistic intervention at early ages. this result is in line with christodoulou (2015) who found articulation problems and morpho-phonological delayed associations related to ds. consequently, the phonological difficulties influence the morphological abilities, making it difficult for researchers to distinguish words’ phonological boundaries and thus whether the answers are correct or not correct. utilising verbs and verbal nouns instead of the target words implies that: (1) the acquisition of the verb form is in progress at this age (chapman et al., 1998). the participants showed limited performance in verbs in their mandatory contexts, and this pattern reveals inconsistency in using grammatical forms in ds (fabbretti et al., 1997), especially when describing verbs. (2) it is an apparent sign of the influence of the surrounding environment on young individuals with ds, educational centres in particular. the researchers set out with this belief when observing that children pronounce words such as kita:ba ‘writing’ in its standard form, which means they have learned it in a formal way. on the other hand, this pattern indicates immature linguistic ability in this young group as a result of cognitive problems and appears in the wrong context in which the pattern is used. (3) by using word reduplication, the participants resemble the children recorded by mashaqbeh (2009) in the 3–4 year age group who use it only to describe the dual form. using word reduplication indicates that the kg2 participants probably understand the multiple characteristics of things but have problems in acquaintance with the morphological form. the participants in the school group were more competent in using the singular number than the younger kg2 group and the older vt group. this linguistic competence in relation to the groups’ age was also found by fabbretti et al. (1997). in comparison with the vt group, this may correspond to individual abilities found amongst the participants. on the other hand, this finding is incompatible with chapman et al. (1998) and rondal and comblain (2002), who proposed that linguistic change from adolescence into late adulthood is not attested. remember that the school group outperformed the vt group in other aspects in this study (our data reported instances where the school group is outperformed by the vt group). in sum, it can be claimed that there are signs of language decline in individuals with ds that starts in young adulthood. down syndrome groups endure a kind of inability to produce the dual number. excluding the acceptable plural number, the typical dual form is altered to be the weakest number in ds. this signifies that the dual number is a secondary number category. also, the deficient use of the real dual number form by the ds participants contradicts the linguistic behaviour of the tdc children who master and better perform the dual number prior to the plural number because it has one single form. instead, ds children and young adults rely more on their environmental language input, for the plural number form is more used in ja than the dual number form. hence, the dual number is acquired after the plural in ds, unlike in the typical children reported in moawad (2006) and aljenaie et al. (2011), reflecting the sensitivity to the surrounding environment by individuals with ds. thus, children and young adults with ds perform a considerable amount of dependency in using more social language (martin et al., 2009). in this sense, but different from chapman et al. (1998) and rondal and comblain (2002), it should be noted that the use of the real dual form becomes better amongst the older groups, associated with less reliance on the plural form, which implies an acquisition-in-progress process for this pattern (see table 2). unlike the findings of chapman et al. (1998) and rondal and comblain (2002), the three age groups show a distinguishable gap in improving proficiency of plural inflection (kg2 = 7%, school = 27%, and vt = 47%), which may be attributed to the significant role of age (albirini, 2015; mashaqba et al., 2020). the findings extracted from the one-way anova test reveal a significant statistical variance as well as transcendence in favour of the vt group preponderantly (see tables 2–4). both school and vt groups exhibit large-scale variance from the kg2 group. the two groups do not score an extended variance, although the vt group is better. the plural form is, however, considered as a weakness area in ds; it is the second most commonly and correctly used number after the default singular, as it is used to denote the dual number more than the typical dual form and the canonical plural form. this is the opposite of acquisition behaviour in typically developing children (aljenaie et al., 2011). in addition, it is at variance with the argument that children with ds acquire the linguistic patterns at a similar phase to tdc children. as age has a significant role on linguistic performance, linguistic training must be available from childhood and continue to adulthood. families should pay attention to linguistic input for its role on the linguistic performance in individuals with ds. they also need early teaching to recognise the things around them and how to name these things appropriately. the study recommends more concentrated teaching and training given regarding the dual form in the first place and the plural number in the second place, because they contain a variety of inflection constructions and patterns, which pose a difficulty to many individuals with ds. lastly, older individuals with ds must be given more training because there is the possibility of language decline with age. the non-recognition pattern involves cases in which the participants kept silent, referred to names of other items, or pointed at different items found in the class (with their fingers or eyes) where the test is conducted. both silence and body language are attributed to the fact that children with ds rely heavily on non-verbal modes of communication when they are in formal or unfamiliar situations, bearing in mind that they are not accustomed to the researchers (cf. martin et al., 2009). the high frequency of this pattern reveals the instability and language deficiency in ds. instability clearly appears in the vt group’s responses, as the participants are not performing to their ideal age competence. the members of the kg2 group register the highest percentage of this pattern where they do not use the items under examination. the non-recognition cases observed along the examination process stress the need for integrating individuals with ds in different societies and new circumstances to learn about the things around them. the settings of the test conducted in this study reveal how acquaintance and familiarity strongly impact language comprehension and production and the psychological status in individuals with ds, especially young groups. conclusion this work starts from the belief that arabic is one of the languages that lacks scientific research on language aspects (particularly morphology) of people with ds. in this account, we believe that the study findings sustain and encourage evolution of the educational curriculum concerning the language-learning phase in arabic-speaking society. the findings conclude that jordanian children and young adults with ds have problems in producing numbers (singular, dual and plural). the singular number is the most accurately used because it is the unmarked pattern, followed by the plural number. the kg2 group (the youngest group) is distinguishable from the other two groups as it produces patterns that are not used by other groups to describe the singular category, despite its simplicity. the participants show weaknesses in using the real dual pattern, but more reliance on the plural pattern. the non-recognition cases are important signs indicating language delay in ds and how individuals with ds are concerned and responsive to the surrounding circumstances. finally, age has a significant influence on language behaviour in ds. as a whole, there is a language improvement in the production of number as age increases. therefore, children with ds need an early language intervention that must continue into adulthood. based on these conclusions, we recommend further investigations of derivational aspects such as verbal derivatives, denominals and denominatives. furthermore, because arabic lacks this kind of study, we suggest more research into other linguistic levels, especially morpho-phonological levels, which are clearly delayed in ds and significantly affect communication with other people. such investigations might also consider the impact of gender on the language of individuals with ds. acknowledgements competing interests the authors have declared that no competing interests exist. authors’ contributions all authors contributed equally to this work. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references abdalla, f., aljenaie, k., & mahfoudhi, a. 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(2016). down syndrome: an overview. african vision and eye health, 75(1), 1–6. https://doi.org/10.4102/aveh.v75i1.346 abstract introduction and aim material and methods results ethical consideration discussion conclusion acknowledgements references about the author(s) christine van der merwe centre for augmentative and alternative communication, university of pretoria, south africa juan bornman centre for augmentative and alternative communication, university of pretoria, south africa dana donohue centre for augmentative and alternative communication, university of pretoria, south africa department of psychological sciences, northern arizona university, united states michal harty centre for augmentative and alternative communication, university of pretoria, south africa division of communication sciences and disorders, department of health and rehab sciences, university of cape town, south africa citation van der merwe, c., bornman, j., dana donohue, d., & harty, m., 2017 ‘the attitudes of typically developing adolescents towards their sibling with autism spectrum disorder’, south african journal of communication disorders 64(1), a184. https://doi.org/10.4102/sajcd.v64i1.184 original research the attitudes of typically developing adolescents towards their sibling with autism spectrum disorder christine van der merwe, juan bornman, dana donohue, michal harty received: 13 sept. 2016; accepted: 04 mar. 2017; published: 26 apr. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: understanding how the cognitive, emotional and behavioural components of sibling attitudes interact with one another at various stages of a sibling’s lifespan will allow clinicians to provide better support to children with autism spectrum disorder (asd) and their families. however, no research exists which focusses on describing the attitudes of adolescent siblings of children with asd within the south african context towards their sibling with an asd. the primary aim of this study was to investigate how typically developing adolescents recall their past attitudes and describe their present attitudes towards their sibling with an asd. methods: thirty typically developing adolescents who have siblings with asd were selected to complete the survey instrument, the lifespan sibling relationship scale, using a cross-sectional design. results: results indicate that the measure has internal consistency within this sample. wilcoxon signed-ranks tests were used to test for significant differences between the mean values for the two self-reported time periods. friedman analysis of variances (anovas) was used to test for significant differences in the three components of attitudes, namely affect, behaviour and cognition. results indicate that participants held more positive attitudes towards their siblings with asd as adolescents compared with when they were younger and that adolescents rated their current emotions towards and beliefs about their sibling with asd to be more positive than their current interaction experiences. conclusion: as siblings’ attitudes appear to change over time, clinicians should use a lifespan approach to sibling attitudes when designing and implementing supports for siblings of children with asd. introduction and aim similar to international trends, the prevalence of autism spectrum disorder (asd) in south africa appears to be increasing (bateman, 2013). a recent south african study which investigated asd rates between 1996 and 2005 reported an 8.2% increase in the number of children with features of asd at a clinic in the western cape during this period (springer, van toorn, laughton & kidd, 2013). asd is characterised by persistent deficits in the areas of social interaction, language and communication, behaviour and thinking, and sensory processing (american psychiatric association, 2013). these difficulties impact the way that individuals with asd develop, understand and maintain social relationships with others. characteristics of asd that make social interaction difficult include the lack of joint attention and turn-taking (prelock & nelson, 2012), limited use of gesture (ellawadi & ellis weismer, 2014) and limited age-appropriate spoken language (ellis weismer, lord & esler, 2010). the early social attention difficulties associated with asd often lead to cascading effects on children’s learning and social relationships (adamson, romski & barton-hulsey, 2014). sibling interactions often provide children with asd with their first socialisation experiences (meadan, stoner & angell, 2010). during childhood, children will spend more time with their siblings than with any other individual (orsmond & seltzer, 2007). therefore, it is not surprising that the role of siblings (especially older ones) on speech, language and communication development has been considered in the literature (marshall, goldbart & phillips, 2007). the aforementioned core characteristics of autism (vis á vis difficulty with social communication, maintaining eye contact, the presence of restrictive and repetitive behaviours, and sensory processing difficulties) make it more challenging for typically developing children to interact with their sibling with asd (ferraioli, hansford & harris, 2012). the increase in prevalence of asd means that more children have siblings with asd (diener, anderson, wright & dunn, 2014), and thus, it is important to understand the siblings’ psychosocial adjustment when their sister or brother has asd. the results of research regarding the impact of asd on siblings’ psychosocial adjustment have been mixed (see meadan et al., 2010 for a review), with some studies reporting negative influences of having a sibling with asd (bitsika, sharpley & mailli, 2015; macks & reeve, 2007; meyer, ingersoll & hambrick, 2011) and other studies reporting positive influences (kaminsky & dewey, 2001). interestingly, there are also studies in which individuals acknowledge the presence of mixed emotions or emotional ambivalence towards their sibling with asd (angell, meadan & stoner, 2012; petalas, hastings, nash, lloyd & dowey, 2009). angell et al. (2012) report that typically developing siblings related examples of typical sibling experiences, as well as negative experiences of embarrassment related to the challenging behaviour demonstrated by their sibling with asd. petalas et al. (2009) suggest that, at least for some siblings, a tension exists between accepting their sibling with asd while still wanting aspects of the asd to be alleviated. they (petalas et al., 2009) state: it is not clear whether the children actively held these tensions between acceptance and change, or whether these often contradictory views were evidence of ongoing cognitive processing and appraisal. (p. 389) notwithstanding this lack of consensus in the literature, it is clear that typically developing siblings of children with asd hold varying degrees of positivity towards their relationship with their sibling with asd. on the contrary, a recent systematic review that investigated the effectiveness of sibling support for children with intellectual disabilities indicates that not all siblings are likely to be in need of support (tudor & lerner, 2015). tudor and lerner (2015) indicate that factors such as demographic status and degree of challenging behaviour exhibited by the sibling with intellectual disability, as well as gender and birth order of siblings, may influence sibling adjustment. although not specific to asd, this systematic review highlights the need for more data to be collected, which will assist in determining which subgroup of siblings may benefit from more intensive sibling support. in addition to the demographic and familial differences that impact on the need for sibling support, siblings’ attitudes towards, and understanding of, the disorder is known to change over time. they have been linked to the cognitive skills a sibling can employ when assigning meaning to the experiences they share with the child with asd (glasberg, 2000; riggio, 2000). consequently, understanding how the cognitive, emotional and behavioural components of sibling attitudes interact with one another at various stages of a sibling’s lifespan will allow clinicians to provide better support for children with asd and their families. to capture the changes in the sibling relationship over time, riggio (2000) developed the lifespan sibling relationship scale (lsrs). this scale measures three dimensions of the sibling relationship in both childhood and adulthood, namely positivity of behaviour, beliefs about the relationship and affect towards the sibling. this self-report scale differs from other scales that measure sibling relationships, in that it measures past and present attitudes towards the sibling with asd. the development of the scale was based on the conceptualisation that attitudes comprise three different components, namely cognitive, behavioural and affective components. oppenheim (2000) explains how these three components are interrelated and states that beliefs (the cognitive component) often elicit very strong feelings (affective component). together, these result in specific actions being taken (behavioural component) (oppenheim, 2000). it is, therefore, evident that the sibling relationship between typically developing siblings and children with intellectual disabilities, including autism, has received substantial attention in international literature. however, there are only a handful of south african studies that explore issues relating to siblings of children with developmental disorders or disabilities. the authors are aware of two studies that have been conducted that explore the attitudes of siblings of children with severe speech and language difficulties (hansen, harty & bornman, 2016), and the attitudes of siblings of children with severe disabilities (opperman & alant, 2003). hansen et al. (2016) indicated that older siblings were most positive towards completing household tasks and playing with their younger sibling with speech and language difficulties, less positive about their ability to communicate with their younger siblings and the least positive about the effect that having a younger sibling has on their own ability to build and maintain relationships with family members, such as parents. opperman and alant (2003) found that typically developing siblings felt inadequately supported and excluded from the intervention process, which resulted in atypical family participation and interaction patterns. together, the results of these studies suggest that while typically developing siblings enjoy interacting with their sibling with a disability, they require additional information and support to navigate the more challenging aspects of the sibling relationship. to date, however, no research exists which focusses on describing the attitudes of adolescent siblings of children with asd within the south african context towards their sibling with asd. this study, therefore, sought to describe and compare participants’ self-reported past and present attitudes towards their sibling with asd, as well as to explore the association between the components of attitudes and the two life stages under examination, namely childhood and adolescence. material and methods design and measures this study uses a cross-sectional survey design. given that both of these attitudes (past and present) were assessed at a single point in time, it is partially a retrospective design. the lsrs (riggio, 2000) was used to collect the data for this study. this tool is a self-report survey and differs from other attitudinal scales as it captures self-reported attitudes of adults as well as their memory of attitudes they held as children. the scale has been developed to measure three dimensions of the sibling relationship (affect, behaviour and cognition), and captures these dimensions in childhood and adulthood (riggio, 2000). the scale comprises 48 items divided into six subscales. child affect (caff) and adult affect (aaff) measure emotions towards the sibling. child cognition (ccog) and adult cognition (acog) assess beliefs about their sibling and their sibling relationship in the respective developmental phases. the measurement of how positive behavioural interactions were, or are, comprises child behaviour (cbeh) and adult behaviour (abeh). the scale is, thus, unique in that it captures current views as well as requests the participant to recall earlier views they held as a child. the items are answered on a five-point likert scale, with ‘1’ indicating strong disagreement with the statement and ‘5’ indicating strong agreement. as the participants in this study were adolescents, the ‘a’ in the scale names will refer to adolescent instead of adult as in the original scale, while the ‘c’ for child remains unchanged, that is, child and adolescent affect (caff and aaff), child and adolescent behaviours (cbeh and abeh) and child and adolescent cognition (ccog and acog). the psychometric properties of the lsrs have been established with a sample of 711 undergraduate and graduate students (62% female and 38% male). the lsrs (riggio, 2000) has been validated and demonstrated high internal consistency for all six subscales (with a range from α = 0.84 to α = 0.91) and the instrument as a whole (α = 0.96). there is also evidence of a coherent factor structure and stability of responses over time (riggio, 2000). for the purposes of this study, we made a minor modification to the wording of the scale. in the questions on the three subscales dealing with attitudes held as children, the phrase ‘as a child’ was replaced with ‘when we were younger’, as the siblings were adolescents, not adults. sample questions from each subscale and the original subscale α-values can be viewed in table 1. key biographical information was also collected using a questionnaire, specifically designed to capture information relating to participants age and gender, number of siblings in the house, and the age and gender of siblings. this questionnaire was completed at the same time as the lsrs. table 1: sample items from the lifespan sibling relationship scale modified for completion by the adolescents. procedure permission to conduct this study was obtained from the relevant ethics authorities. data were collected at two special schools for children with asd, one in cape town and the other in pretoria, as part of a ‘sibling support day’. the aim of the day was to provide information to siblings about asd, as well as to create an opportunity for them to discuss issues of concern in a safe environment. content covered included the children’s understanding of what asd was, the different expectations parents may have of the adolescents, compared with their sibling with asd, the siblings’ experience of having a sibling with asd (both the positive and negative aspects) and what their hopes and fears were regarding the sibling at that point in time as well as in the future. the lsrs was completed prior to the commencement of the activities for the sibling support day, to ensure that the planned activities did not influence the adolescents’ responses. both of the sibling support days were facilitated by the first author. a flyer was distributed through the networks of autism western cape and autism sa. letters were also sent to schools specialising in the education of children with asd in both cape town and pretoria. parents received a flyer containing information about the study, which they were encouraged to share with the participants. written consent was obtained from the parents of the sibling. before data were collected, the adolescents themselves also provided written assent. there were a number of families who indicated a willingness to participate but were unable to attend either of the sibling support days for a variety of reasons. a copy of the survey was sent to these typically developing siblings either through email or through the school, depending on their personal preference. they completed the survey at home and returned it to the researcher either through email or through the school. participants thirty typically developing siblings completed and returned the questionnaire. the demographics of the participants and their families were collected using a biographical questionnaire developed specifically for this study. thirteen participants completed the questionnaire during one of the two sibling support days, whereas seventeen (who wanted to complete the questionnaires but who could not attend the sibling support days) completed the questionnaires at home. a fischer’s exact test indicated that there was no significant difference between the group who completed their questionnaire at the sibling support day and those who completed the questionnaire at home, in terms of gender (p = 0.9999) and number of siblings in the household (p = 0.2608). since the two groups were functionally equivalent on these characteristics, the data from both groups were analysed together as one data set (n = 30). the majority of the adolescents were living in the same house as their sibling at the time of data collection (90%, n = 27). ninety per cent (n = 27) of the parents were married at the time of data collection. twelve participants came from families with two children, 13 participants had three children in the family and five participants had four or more children in the family. the ages of the adolescent siblings ranged from 13 to 20 years (m = 15 years; sd = 1.69). an equal number of male participants (n = 15) and female participants (n = 15) completed the survey. the majority of the typically developing adolescents (n = 27) were older than their sibling with an asd. the age of the siblings with asd ranged from 7 to 21 years (m = 10 years; sd = 3.50). ninety per cent (n = 27) of the children with asd were male and all had received a formal diagnosis of asd, which would have been confirmed at the time in which they enrolled for formal schooling (using the diagnostic and statistical manual of mental disorders, 4th edition (dsm iv) criteria). the children all attended a special school for children with asd (either in cape town or pretoria) and had access to the necessary therapeutic support through the school. data analysis data were analysed using the statistical package for the social sciences 24 (spss). firstly, data were checked for accuracy, normality and outliers. the shapiro–wilk test for normality suggested that each of the subscales exhibited normality (aaff: p = 0.08, abeh: p = 0.72, acog: p = 0.44, caff: p = 0.11, cbeh: p = 0.26, with the exception of ccog: p = 0.02). because subscale ccog violated the assumption of normality, non-parametric analyses were used to test for significant differences between the mean values for the two self-reported time periods (‘now’ and ‘when we were younger’). friedman two-way analysis of variance (anova) was used to test for significant differences in the components (affect, behaviour and cognition) of attitudes between the two self-reported time periods. internal consistency reliability in this study in order to test whether the lsrs (riggio, 2000) retained its internal consistency with the modifications which were made for the purposes of the study (the cognition subscale was reduced from eight items to seven items in this data set due to missing data on the last ccog item). cronbach’s alpha values were obtained for each of the six subscales. the cronbach’s alpha values for each subscale ranged from 0.71 to 0.97 (total scale α = 0.83), which indicated a satisfactory level of internal consistency. these values can be viewed in table 2. table 2: means, standard deviations and cronbach’s alpha values for the three subscales and wilcoxon rank mean difference and z-scores comparing attitudinal differences in childhood and adolescence (n = 30). results comparison of the attitude according to life stage in order to compare the components of present attitudes towards siblings with asd to past attitudes, wilcoxon signed-rank tests were run on the data, which are also presented in table 2. the first analyses were conducted to compare participants’ scores between child and adolescent affect. the results showed a statistically significant increase from caff (mean rank = 17.85) to aaff (mean rank = 6.40), z = -4.87, p < 0.01, r = 0.63, where participants rated their aaff scores significantly higher than their caff scores. the second analyses compared participants’ scores for behaviour, cbeh (mean rank = 14.18) and abeh (mean rank = 13.70), which indicated no significant difference z = -1.25, p > 0.05. the final analyses determined whether or not there were differences in participants’ scores on cognition and compared ccog with acog. the results showed a statistically significant increase from ccog (mean rank = 16.56) to acog (mean rank = 10.20), z = -3.74, p < 0.01, r = 0.48, where participants’ acog scores were significantly higher than their ccog scores. comparison of attitude components within each life stage in order to gain a better understanding of the three components of attitudes, a friedman anova was conducted to explore how the components of attitudes (affect, behaviour and cognition) differed within each life stage. the first anova showed that there were significant differences within child attitudes, χ2 (2, n = 30) = 47.41, p < 0.01. to identify which attitudes differed, a series of wilcoxon ranked sum tests with bonferroni corrections were run (p < 0.016). the results showed a statistically significant decrease from caff (mean rank = 2.88) to cbeh (mean rank = 1.71), z = -4.50, p < 0.01, r = 0.58; a statistically significant decrease from caff (mean rank = 2.88) to ccog (mean rank = 1.41), z = -4.68, p < 0.01, r = 0.60; and a non-significant decrease from cbeh (mean rank = 1.71) to ccog (mean rank = 1.41), z = -1.80, p = 0.07. the second anova showed that there were significant differences within adolescent attitudes, χ2 (2, n = 29) = 35.81, p < 0.01. the results showed a statistically significant decrease from aaff (mean rank = 3.00) to abeh (mean rank = 1.32), z = -4.79, p < 0.01, r = 0.62; a statistically significant decrease from aaff (mean rank = 3.00) to acog (mean rank = 1.68), z = -4.87, p < 0.01, r = 0.63; and a significant decrease from acog (mean rank = 1.68) to abeh (mean rank = 1.32), z = -2.42, p = 0.015, r = 0.31. ethical consideration all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional or national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. informed voluntary consent was obtained from all individual participants included in the study. discussion the purpose of this study was to examine and compare adolescents’ past and present attitudes towards their siblings with asd. attitudinal scores were calculated in the areas of affect, behaviour and cognition. there are two main findings from the study. the first is that the results of the analyses indicated that the adolescents who participated in this study experienced their relationships with their siblings with asd more positively as they grew older. the second point to discuss is the significant differences found within the attitudinal components within each of the two life stage periods (childhood and adolescence). a possible explanation as to why the adolescents in this study reported that their relationships became more positive as they grew older is that over time the adolescents’ abilities to understand and cope with their siblings with asd may have increased. research suggests that, compared with younger children, adolescents are more able to engage with material explaining autism and its effects (bloch & weinstein, 2009; petalas et al., 2009). these participants may thus have developed the cognitive ability to better understand the characteristics of asd and become more empathetic with their siblings. accordingly, our findings are in agreement with the work of glasberg (2000), who suggests that adolescents between the ages of 11 and 17 years are able to reason logically about the past as well as present events and that they are able to use past and present experiences to project the implications of their sibling’s disability on their sibling’s life, as well as their own. thus, the higher level of cognitive thinking aligned with adolescence allows adolescents to develop more positive attitudes towards their siblings as they get older. moreover, they may also have developed more appropriate coping strategies as they grew into adolescence. a significant difference was found between the scores of the participants’ affect and behaviour components when compared with their cognition scores during adolescence. in other words, adolescents rated their present emotions towards their sibling with asd (affect component) and their present beliefs about their relationship with their sibling with asd (cognition component) higher than their present positive interactions with their sibling with asd (behaviour component). this may be due to the fact that, no matter how positive their feelings towards their sibling are and how well they understand asd, they still need to manage their own behaviour in relation to the obstacles that their sibling with asd is likely to have in social relationships (rivers & stoneman, 2003). larson (1998) refers to a similar concept, defined as the ‘paradox of disability’. on the one hand, the typically developing sibling loves the sibling with asd as he or she is, while also wanting to erase the disability. if typically developing siblings could be taught to embrace the paradox of disability, they could attempt to create a positive bias that could fuel their optimism in the sibling relationship. participants were also asked to recall their past attitudes about their sibling with asd when they were both younger. within the child life stage, a significant difference was found between their higher affect scores when compared with their lower behaviour and cognition scores. thus, when participants recalled their relationship with their sibling with asd when they were younger, they reported that they felt more positive emotion towards their sibling with asd (affect component) compared with their feelings about interactions with their sibling with asd (behaviour component) and beliefs about their relationship (cognition component). perhaps this is their own reflection of their limited awareness of how to navigate atypical interactions when they were younger. these data corroborate results from bitsika et al. (2015), which suggests that sibling interventions may need to focus on some attitudinal areas more than others in order to foster the sibling relationship. as suggested by bitsika et al. (2015), teaching siblings of children with asd to control their emotions and so change their behavioural responses towards their sibling with an asd can be an important intervention topic for support or sibling intervention to encourage positive social interactions between them. however, a recent systematic review indicated that clinicians should be cautious in applying a one-size-fits-all approach to sibling support. tudor and lerner (2015) suggest: in addition to psychological and behavioural functioning and sibling impairments, familial psychopathology, problematic family functioning, amount of attention given toward siblings, and sibling social skills impairments could all be of import in identifying at-risk youth and selecting appropriate services. (p. 18) acknowledging this caution, we nevertheless believe that these data provide some implications for how clinicians develop and provide support for siblings of children with asd. when talking about their present attitudes, data indicate that the behaviour component of their attitude was most impacted by the presence of asd, whereas when they were younger, it was the cognition component of attitudes that appeared most problematic. in other words, findings from this study indicate that support provided to young children should focus on providing an understanding of the disability and its potential impact on sibling relationships, as suggested by glasberg (2000); while during adolescence, siblings may benefit most from support that focusses on improving their ability to modify their own behaviours during their interaction with their sibling with asd. research has also demonstrated that siblings can have direct effects on one another’s development when they serve as social partners and role models as well as indirect influences through their impact on larger family dynamics – such as family structure, favouritism or diluting family resources (mchale, updegraff & whiteman, 2012). therefore, speech-language therapists should capitalise on both these direct and indirect effects, for example, by supporting siblings in their communication partner role, as this has lifelong implications. this focus on siblings is also in line with american speech-language-hearing association (asha) guidelines on family-centred practice which underscores the role of siblings in speech-language intervention for contextualising intervention that reflects the family system and preferences, for paying attention to family priorities and concerns, for developing meaningful learning opportunities and teaching interaction skills to support and manage behaviour and the development of communication and language, and for recognising the transactional nature of a communication disorder (such as asd) when evaluating family interactions and relationships (asha, 2017). certain methodological issues must be considered before generalising the findings too broadly. the first issue was the relatively small sample size that was recruited. future research should endeavour to obtain a sample that is more representative of the sibling population within the south african context at large. the second issue was the self-report nature of the questionnaire, as participants may have provided responses that they thought were appropriate rather than truthful, thereby creating a hawthorne effect. self-report methodology is, however, the typical method of collecting data for attitudinal research, as no one can better report on their attitudes than the participants being surveyed. the third issue was the retrospective way that past attitudinal data were collected. despite the fact that the lsrs (riggio, 2000) has well-established reliability and validity in measuring the past and present state of sibling relationships, it was designed to be a recall measure. therefore, a more accurate way to study changes in attitudes over time would be to use a longitudinal design. using a longitudinal design would potentially provide a more accurate description of participants’ attitudes at different periods in time, as it does not rely on memories of experiences. this type of longitudinal design has its own disadvantages, particularly as far as participant attrition is concerned. conclusion the results of this study add to the empirical data documenting sibling relationships where one sibling has asd. findings indicate that the sibling attitudes change depending on whether the participant is thinking about their attitudes at the present moment, or when they recall their attitudes when they were younger. as a result, supports for siblings should be differentiated to account for the differences in the components of attitudes as reported in these data. data suggest that sibling support interventions should acknowledge the developmental life stage of the sibling and focus on teaching strategies to bolster the component of attitude which is reported as being the least positive at that life stage. in conclusion, when designing and implementing supports for siblings of children with asd, clinicians should use a lifespan approach to sibling attitudes to ensure that supports to bolster the cognition, affect and behaviour components which influence attitudes to the sibling relationship. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions j.b. was the project leader. c.v.d.m. collected the data. j.b, c.v.d.m, m.h. and d.d. analysed the data. m.h., j.b., c.v.d.m. and d.d. prepared the manuscript. references adamson, l.b., romski, m.a., & barton-hulsey, a. 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(2015). intervention and support for siblings of youth with developmental disabilities: a systematic review. clinical child and family psychology review, 18(1), 1–23. https://doi.org/10.1007/s10567-014-0175-1 abstract introduction method results discussion summary and conclusion acknowledgements references about the author(s) khalid g. al-shdifat department of rehabilitation sciences, faculty of applied medical sciences, jordan university of science and technology, jordan jawdat sarsak amman center for speech-language and swallowing, amman, jordan fatoon a. ghareeb amman center for speech-language and swallowing, amman, jordan citation al-shdifat, k.g., sarsak, j., & ghareeb, f.a. (2018). exploring the efficacy of melodic intonation therapy with broca’s aphasia in arabic. south african journal of communication disorders, 65(1), a567. https://doi.org/10.4102/sajcd.v65i1.567 original research exploring the efficacy of melodic intonation therapy with broca’s aphasia in arabic khalid g. al-shdifat, jawdat sarsak, fatoon a. ghareeb received: 06 june 2017; accepted: 07 mar. 2018; published: 31 may 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: even though the efficacy of melodic intonation therapy (mit) with persons with aphasia (pwa) has been explored in different languages, the efficacy of mit with arabic-speaking pwa has never been explored. aims: to explore the efficacy of mit, adapted to arabic, in promoting the expressive abilities of a 70-year-old jordanian arabic-speaking male subject with severe broca’s aphasia 3 months post-onset. methods: an 8-week mit therapy programme with tapping (1.5 h daily, 6 days a week) was used in a multiple baseline design across two types of trained phrases (i.e. automatic and self-generated phrases). outcome measures included accuracy of production of trained (at the end of each session) and untrained phrases (at the end of each week). preand post-treatment measures used, were the bilingual aphasia test, the american speech-language hearing association functional assessment of communicative skills, the communicative effectiveness index and the american speech and hearing association quality of communication life scale. accuracy of production for the trained and untrained phrases was also measured 2 weeks and 4 weeks after the treatment programme was finished. results: the patient, (mk), improved his expressive productions post-treatment in automatic and self-generated phrases. automatic phrases exceeded the established 75% accuracy criterion, whereas the self-generated phrases reached criterion and remained constant at follow-up. moreover, mk gradually started improving on the generalisation stimuli, once the treatment on the self-generated phrases started and maintained the gains 2 weeks and 4 weeks post-treatment. conclusion: mit appears to be a viable treatment option for jordanian arabic-speaking persons with broca’s aphasia. however, more research is needed with larger groups of jordanian arabic-speaking persons with broca’s aphasia to provide more support to the present findings. moreover, future studies might focus on the efficacy of mit with persons with broca’s aphasia from different arab countries and from countries where arabic is part of the multicultural structure like south africa and other countries on the african continent. introduction the global burden of aphasia estimates are 25.7 million individuals (feigin et al., 2015). it is worth noting that between 22.7 and 250 per 100 000 people have a stroke every year, while survival rates are becoming higher, the prevalence rate falls between 508 and 777 per 100 000 people (el-hajj et al., 2016). this high prevalence rate underscores the importance of research studies in general and intervention studies to try to alleviate the burden placed on stroke survivors and their families. nonetheless, studies related to aphasia in arabic have previously looked at the nature of the speech of arabic-speaking persons with aphasia (pwa), for example, albustanji, milman, fox and bourgeois (2013) looked at the nature of morphosyntax of jordanian arabic-speaking pwa. adam (2014) compared the noun to verb production abilities in the speech of palestinian arabic-speaking pwa. in addition, freidmann (2006) examined the speech of two palestinian arabic speakers and a group of hebrew-speaking persons with broca’s aphasia. she compared their accuracy of producing ‘yes/no’ questions to wh-questions in spontaneous speech and in an elicitation task. hence, it seems that none of the previous studies has examined the effect of any intervention programme on improving the speech and language abilities of arabic-speaking pwa. therefore, using an intervention programme like melodic intonation therapy (mit) with arabic-speaking pwa might help them regain functional speech and might provide more support to the efficacy of mit in general. moreover, most studies that examined the effectiveness of mit have used it with patients in the chronic phase. thus, examining the effectiveness of mit in the subacute phase is of importance (hurkmans et al., 2012). for many years, clinicians have reported that broca’s aphasic subjects are good at singing some words where they are articulated at a slow rate, but they cannot produce them at a normal rate (brust, 2003; schlaug, marchina & norton, 2008; schlaug, norton, marchina, zipse, & wan, 2010). because the right hemisphere is oriented to music and prosody, this led to the development of mit to utilise the right hemisphere’s ability for melody and music in the treatment of severely non-fluent aphasic patients to recover speech (albert, sparks, & helm, 1973; norton, zipse, marchina, & schlaug, 2009; ozdemir, norton, & schlaug, 2006; racette, bard, & peretz, 2006; schlaug et al., 2008; sparks, helm, & albert, 1974; sparks & holland, 1976; wan, rüber, hohmann, & schlaug, 2010; wilson, parsons, & reutens, 2006). however, recent research suggests different mechanisms that might come to function when using mit (i.e. brain neuroplasticity in utilising the right hemisphere for language, utilisation of the mirror neuron system to improve motor speech production, shared processing pathways of music and language and the pleasurably engaging way singing can help pwa express themselves) with pwa (merrett, peretz, & wilson, 2014). although mit is recommended for subjects with severe non-fluent aphasia to restore their verbal communicative abilities (ferguson et al., 1994; norton et al., 2009; sparks et al., 1974; sparks & holland, 1976), it has been used with milder forms of non-fluent aphasia (hough, 2010; vines, norton, & schlaug, 2011). mit mainly focuses on utilising the exaggerated prosody of speech to help non-fluent aphasic subjects improve speech production (vines et al., 2011). this therapy makes alterations to normal prosody giving higher pitch to stressed syllables on words while keeping the original variation of pitch differences found in the sentence (sparks & holland, 1976). sparks and holland (1976) were the first to describe mit which is unlike singing, as it uses a limited range of musical notes by manipulating elements of prosody (i.e. slow tempo, precise rhythm and distinct stress) to help aphasic patients regain speech (sparks & holland, 1976). in addition, intensive therapy using mit is recommended in the treatment of patients with broca’s aphasia (ferguson et al., 1994; schlaug et al., 2008; wan et al., 2010) which might help patients reach generalisation to untreated stimuli. when non-intensive therapy (e.g. three sessions per week [hough, 2010]) is used, generalisation to untreated items might not be reached. when compared to other types of treatment, such as rehearsed and unrehearsed phrase production, combining melody to phrase production in mit had longer term effects on the production of phrases (wilson et al., 2006). moreover, such gains in the production of phrases using mit were found in other studies (hough, 2010; schlaug et al., 2008). longer term gains are key outcome in the choice of intervention programmes for pwa. the best candidates who might benefit from an mit programme are broca’s aphasics who demonstrate better auditory comprehension than verbal abilities, good attention span, motivation and emotional stability (norton et al., 2009). the effectiveness of mit was explored in the treatment of patients with broca’s aphasia in other languages, such as english (albert et al., 1973; hough, 2010; schlaug et al., 2008; schlaug et al., 2010; sparks et al., 1974; wilson et al., 2006), french (zumbansen, peretz, & hébert, 2014) and italian (cortese, riganello, arcuri, pignataro, & buglione 2015). these studies reported improvements in the speech of their subjects to varying degrees. even though mit was explored in these languages, this type of treatment with arabic broca’s aphasic patients was never explored. before discussing an intervention using mit with arabic-speaking pwa, it is important to explain the prosody of the arabic language. intonation intonation is usually used for the purposes of manipulating discourse, expressing intents, modifying the sentence grammar and controlling speech register (bonakdarpour, eftekharzadeh, & ashayeri, 2003). intonation in arabic is similar to english in using low intonation levels with declaratives in general. however, it seems that arabic differs from english in its use of low–high intonation contours at the end of interrogative sentences, whereas english uses high-rising intonation contours at the end of questions (de jong & zawaydeh, 1999). stress arabic has three basic types of syllables, which are light, heavy and superheavy, and stress usually falls on the heavy or superheavy syllables in arabic (watson, 2011). moreover these three basic syllables have six-syllable structure types. the first syllable is the light syllable and is always made up of a consonant and a short vowel (cv). the second is the heavy syllable and is usually made up of two-syllable structure types, which are a consonant and a long vowel or a diphthong (cvv), or a consonant followed by a short vowel followed by a consonant (cvc). a superheavy syllable is usually made up of three-syllable structure types, namely a consonant followed by a long vowel or a diphthong and a consonant (cvvc), or a consonant followed by a long vowel and two consonants (cvvcc), or a consonant followed by a vowel and two consonants (cvcc) (halpern, 2009). in jordanian arabic, when a word contains a heavy syllable next to the last syllable in a word, stress usually falls on the heavy syllable regardless of the number of syllables in the word. if there is no heavy syllable next to the last syllable in the word or the word does not contain a heavy syllable, the stress usually falls on the syllable that comes next to the last syllable in the word. in addition, if the last syllable in a word contains a long vowel or ends with a consonant cluster, then the stress is placed on that syllable in the word (de jong & zawaydeh, 1999). rhythm: arabic is stress-timed similar to english (nespor, shukla, & mehler, 2011). however, arabic does not strictly produce syllable stress at the same phases within phrases like english. in addition, the fundamental frequency (f1) for low vowels in stressed syllables in arabic is between 10 and 40 hz, compared to 50 and 100 hz in english (tajima, zawaydeh, & kitabara, 1999). based on the aforementioned characteristics of arabic prosody, mit was determined to be used with a jordanian arabic-speaking patient (i.e. mk) with broca’s aphasia taking into account differences from english language. stressed syllables were produced with a higher pitch, keeping the same stress patterns found in normal spoken arabic. this study followed hough (2010) procedures with some modifications, such as intensity of therapy, which was increased, and explicitly signalling the patient to wait to promote inner rehearsal. thus, the purpose of the current study was to investigate the effectiveness of an mit programme with a jordanian monolingual arabic-speaking patient with broca’s aphasia, which is to our knowledge the first study to examine an effectiveness of a treatment programme for aphasia with an arabic-speaking patient. method participant the participant (mk) in this study was a 70-year-old jordanian male subject who is a monolingual arabic speaker with an education level of high school. he is married and self-employed. moreover, mk and his family gave consent for him to participate in the current study, and he signed consent in the presence of his son to participate in the study. mk was right-handed prior to his illness and was enrolled in the mit programme 3 months post-onset where he had conventional speech therapy (i.e. picture naming), prior to enrolment in the mit programme. magnetic resonance imaging (mri) and magnetic resonance angiography reports confirmed occlusion of the left internal carotid artery, which affected the middle communicating and the anterior cerebral arteries, resulting in severe broca’s aphasia. he could only produce few intelligible words, such as yes and no. he also presented with a moderate form of apraxia of speech. perseveration was also noticed in his attempts to communicate and his speech was markedly laboured. he could follow simple one-step verbal commands and his auditory comprehension was relatively intact as can be seen from the aphasia test results (table 1). in addition, mk was aware of his communicative problem as he attempted to correct his mis-productions most of the time with repeated trials. he demonstrated many errors when he was asked to write words and phrases. table 1: preand post-treatment scores on the bilingual aphasia test – the jordanian arabic version. because mk was highly motivated for therapy, emotionally stable and had relatively good auditory comprehension, these factors were indicators that mk was a good candidate for the mit programme. materials the jordanian arabic version of the bilingual aphasia test (bat) (paradis & libben, 1987) was used to measure the linguistic abilities of mk. the bat consists of three parts: part one is related to bilingualism, part two assesses language skills in arabic and part three assesses translation skills. part two of the bat (the language assessment) is formed of 427 items that allow a thorough assessment of language skills and was used with mk in the present study. in addition, the american speech-language hearing association functional assessment of communicative skills (asha-facs) (frattali, thompson, holland, wohl, & ferketic, 1995) was used to assess mk’s performance across four domains: (1) social communication; (2) communication of basic needs; (3) reading, writing and number concepts; and (4) daily planning. the asha-facs consists of 43 items that are completed by the clinician after at least three meetings with the patient. it uses a 7-point likert scale starting with 1 meaning total absence of a skill, even with assistance provided, and 7 meaning total presence of a skill which is performed independently with no prompting to communicate and/or assistance. moreover, the asha-facs pre-treatment ratings were not made available to the rater in the post-treatment ratings. the communicative effectiveness index (ceti) (lomas et al., 1989) was used to measure the change in mk’s functional communication ability, as perceived by his close family (i.e. son). mk’s son was asked to complete the ceti in order to get a clear picture of the change in mk’s functional communication ability, based on his son’s observation as his son spent most of the time with him at work and at home. the american speech and hearing association quality of communication life scale (asha-qcl) (paul et al., 2004) provides information on the effect of aphasia on the affected individual’s social life, self-confidence like confidence in one’s ability to communicate and roles (e.g. family roles). it is a self-report measure and each item consists of a five-point vertical visual analogue scale. mk’s self-rating and the change in scores on the asha-qcl preand post-treatment scores are recorded in table 4. to avoid bias, a clinician who was blind to the study was asked to administer the assessments preand post-treatment. stimuli: in all, 55 phrases were selected as treatment stimuli to be used with mk in the present study. the stimuli were divided into 20 automatic phrases, 20 self-generated phrases and 15 (self-generated) generalisation stimuli. to ensure functionality of the phrases selected for therapy, mk’s son and spouse were asked to write down the most important phrases he used at home, work, etc. that were important for his daily communicative needs. the family wrote approximately 100 phrases, which were then classified into automatic or self-generated phrases. the three researchers and a clinician (four raters) completed this process. the phrases that received the same classification by the four raters were used in the intervention programme, whereas the phrases that were in disagreement were not included. a total of 95 phrases received the same classification by three out of four to four out of four raters. then 70 phrases were included in the study, which had the same rating by the four raters. of the 70 phrases, 45 phrases were classified as self-generated, while 25 were classified as automatic phrases. after that, we asked mk’s son and wife to select 35 out of the 45 self-generated phrases that they considered most important to mk’s daily communicative needs and to select 20 of the 25 automatic phrases. the researchers used such selection criteria to ensure functionality of the phrases chosen for therapy to help mk make use of family-centred care and to restore daily communication routines. examples of stimuli used in the present study: automatic phrases:  good night تصبح على خير  good job يعطيك العافيه  no problem بسيطه  forgive me سامحني self-generated phrases:  going out for prayer طالع اصلي  i want to take a shower داخل اتحمم  leaving to work طالع على الشغل  get my car ready جهز سيارتي procedure: a multiple baseline design across the two types of phrases (i.e. automatic and self-generated phrases) was used. because mk had speech and writing difficulties, his son and spouse wrote down the phrases and these were read to mk by one of the researchers for agreement. he agreed with his wife and son on all the phrases. then, the researchers classified the phrases as automatic or self-generated phrases. self-generated phrases were defined as phrases used to communicate thought involving semantic processing, while automatic phrases were defined as overlearned forms, involving phonological processing, following definition of propositional (self-generated) and non-propositional (automatic) phrases proposed by lum and ellis (1994). nonetheless, all the phrases used were relevant to the patient’s daily communicative needs, which emphasise the functionality of the phrases (hough, 2010; sparks & holland, 1976). a condensed eight-step continuum (rosenbek, 1985) of the four-level model described by sparks and holland (1976) was used in the current study. the reason for choosing this eight-step continuum is because we wanted mk to use both types of phrases in his everyday communication. the model described by sparks and holland (1976) uses short phrases in the first two levels to familiarise a non-fluent aphasic person to intoned speech. in the first step of the adopted eight-step continuum, the client was required to tap the hummed and then intoned utterance with his left hand while he just listened to the clinician humming and intoning each phrase. the clinician waited 5 s after each time he hummed and intoned the phrase and then repeated the procedure as he signalled the client to wait. this allowed for establishing inner rehearsal (norton et al., 2009) and to control mk’s verbal perseverations. mk’s perseverations were noticeable and we believed that controlling them would help him focus on the targeted stimuli. stark (2011) defines perseveration as the inappropriate repetition of a previously produced stimulus. the reason why people with broca’s aphasia perseverate on verbal production might be that they can notice their errors and thus try to correct them (stark, 2011). in step two, the client was required to intone the utterance in unison with the clinician while he tapped the rhythm with his left hand. if the client had difficulty tapping along, the clinician tapped the rhythm. in step three, the clinician started the production of the phrase along with the client and then faded out from unison production, keeping the visual cues allowing the client to complete the intoned phrase by himself. if the client could not produce the phrase at a certain step, the phrase was recycled using the previous step. in step four, the clinician modelled each intoned phrase and waited 5 s and at the same time signalled the client to wait; and then he asked the client to imitate the intoned phrase. in step five, the client produced each phrase in unison with the clinician using exaggerated inflection and gradually approximating normal speech prosody. in step six, the clinician kept the visual cues while withdrawing from unison production. in step seven, the clinician produced each phrase using normal prosody and then waited 5 s and then asked the client to repeat the phrase using normal prosody. in step eight, the client was required to produce the phrase in response to the clinician’s question. all of the 20 phrases were targeted during each session at each step of the treatment. the dependent variable was accuracy of phrase production. thus, if each word in the phrase was produced accurately and was intelligible, the phrase production was marked accurate. whether the client produced the phrase with normal prosody or with exaggerated inflection, the phrase was considered accurate. the intervention started with the automatic phrases, deeming these phrases easier for the client to produce. in addition, they were targeted first to examine if he would generalise to the self-generated phrases and to the untreated probes (generalisation stimuli). baseline data were taken daily for the self-generated phrases as the intervention programme proceeded with the treatment of the automatic phrases. once the criterion for the automatic phrases was reached, treatment of the self-generated phrases was started and maintenance checking for the automatic phrases was done daily. probing the generalisation of untreated stimuli was continued at the end of each week. because our intervention programme was 8 weeks long, we adopted hough’s (2010) criteria of 75% accuracy so we could move from the automatic to the self-generated phrases within the time frame for the study. analysis: the data were analysed using the welch’s two-samples t-test to compare the automatic phrase scores to the maintenance and follow-up phrase scores. it was also used to compare the self-generated phrase scores on baseline to the follow-up. this test was used as a result of the skewed nature of the data and because the data were expected to be of unequal variances. in addition, the durbin–watson test was utilised to check that the data points had no autocorrelation. results the results seem to indicate that mk has benefitted from mit. mk’s post-treatment bat scores have improved compared to his pre-treatment bat scores (table 1). mk’s rating on the asha-facs has improved as well (table 2); his score prior to intervention was three and rose to six post-intervention. the ceti preand post-treatment ratings of mk by his son show that his son believed his father improved post-treatment compared to pre-treatment. the difference between the preand post-treatment rating was +47.9 (table 3). table 2: preand post-treatment ratings on the american speech-language hearing association functional assessment of communicative skills. table 3: communicative effectiveness index pre-treatment and post-treatment ratings of mk by his son and difference scores. mk’s quality of life score measured using the asha-qcl scale reveals an increase post-treatment of +25.9 compared to his score pre-treatment (table 4). there was a gradual improvement of mk’s verbal productions as treatment progressed (figure 1). he exceeded the criterion (i.e. 75%) for the automatic phrases and kept the gains even during the maintenance and follow-up phases. during training on the automatic phrases and even when the baseline extended for more than 2 weeks for the self-generated phrases, there was no noticeable improvement on the production of this type of phrases (figure 1). however, mk reached criterion, that is, 75% accuracy for the self-generated phrases after treatment was initiated for those phrases. figure 1: percentages of accuracy for the automatic, self-generated and generalisation phrases used in the current study: (a) presents treatment of the automatic phrases; (b) presents treatment of the self-generated phrases measured daily and the generalisation stimuli measured at the end of every week. table 4: mk’s scores preand post-treatment scores† on the american speech-language hearing association quality of communication life scale. welch’s t-test was used to check if the differences between baselines and post-treatments were significant for the two types of phrases targeted in therapy. the welch’s t-test for the automatic phrases revealed a significant difference comparing mk’s scores in the baseline to the maintenance and post-treatment scores (t = 38.118; df = 18.825; p = 0.000). in addition, there was a significant difference for the self-generated phrases when the baseline performance was compared to post-treatment (t = 83.329; df = 6.324; p = 0.000). the data were also examined for autocorrelation using the durbin–watson test; the durbin–watson test showed that there was no autocorrelation between data points for the automatic and self-generated phrases. the durbin–watson score for the automatic phrases was 1.95 and 1.72 for the self-generated phrases. discussion the purpose of the current investigation was to examine the efficacy of mit with a jordanian arabic-speaking pwa. the results of the study show that mit seems a viable treatment option for jordanian arabic aphasic patients. indeed, the benefit of rhythm and pitch elicited the strongest generalisation effect, both to non-trained stimuli and connected speech, compared to normally spoken and to rhythmic therapy alone (zumbansen et al., 2014). mk’s verbal ability seems to have improved when treatment using mit was initiated. this improvement was evident from the score change that can be seen on the bat. nonetheless, one administration of the bat would not allow for a solid conclusion, so future studies might consider multiple administrations of the instrument prior to and during therapy. mk’s production accuracy improved on the automatic and self-generated phrases; the improvement was gradual. mk’s accuracy producing the self-generated phrases did not start to improve until they were targeted in therapy. moreover, his accuracy on the generalisation stimuli started to improve gradually when therapy started targeting the self-generated phrases but not when the automatic phrases were targeted in therapy. this might be as a result of the nature of automatic phrases, as they are considered overlearned forms. this is consistent with stahl, henseler, turner, geyer and kotz (2013) where they found that their subjects did not generalise beyond formulaic phrases when singing and rhythmic therapy were used. because mit utilises rhythm and pitch, improvement on phrase production was observed in the current study. there are some reasons that might explain why mk improved in therapy using mit in arabic. firstly, his improvement might be because he had better auditory comprehension than verbal abilities; he had good attention span; he was motivated to be enrolled in therapy; and he was emotionally stable (helm, nicholas, & morgan, 1989). secondly, the intensity of therapy might have resulted in mk’s improvement and his reaching the set accuracy level for both types of phrases. he received six sessions per week and each session was 1.5 h long. such intensive therapy using mit is recommended for pwa (schlaug et al., 2008; wan et al., 2010). hough (2010) reported that while her aphasic patient reached criterion level for the automatic phrases, he did not reach criterion for the self-generated phrases. her patient might have reached criterion for the automatic phrases because these types of phrases are overlearned forms and do not need much effort. on the other hand, her patient did not reach criterion for the self-generated phrases because these phrases carry thought, and unlike automatic phrases, they are not overlearned (lum & ellis, 1994). reaching criteria for the two types of phrases might also be attributed to the functionality of communication of the two types of phrases (hough, 2010; sparks & holland, 1976) by asking mk’s son and spouse to write the most important phrases for the patient in his daily interactions to ensure functionality of the targeted phrases in therapy. another reason that might account for mk’s improvement and his attainment of accuracy criteria for the two types of phrases is the nature of arabic language. arabic language speakers might employ intonation in some aspects of their speech more than english language speakers. intonation can vary meanings of the same utterance (o’connor, 1980; halliday, 1970). speakers of colloquial arabic or everyday arabic tend to employ intonation in their speech most of the time to convey different communicative purposes. for instance, speakers of colloquial arabic do not use a question word to form ‘yes/no’ questions; they use intonation instead. this might explain why mk reached criterion and maintained the gain at follow-up. however, this is speculative because there are no functional mri studies on arabic speakers to corroborate this assumption. support for this notion might come from friedman’s (2006) finding in that ‘yes/no’ questions were highly accurate in spontaneous speech and in an elicitation task, compared to wh-questions in two palestinian arabic-speaking aphasic patients. the homologous areas of speech-motor and language in the right part of the brain might be equipped with the ability to take over the speech and language tasks of the damaged areas in the left hemisphere (rosen et al., 2006; schlaug et al., 2008). the design of the mit programme may have promoted improvement in mk’s speech; our study targeted automatic phrases as mk did not show improvement on the self-generated phrases until mit targeted those phrases. limitations and future directions the current study was limited to only one jordanian arabic speaker with aphasia in one arabic-speaking country, which is jordan. the study was limited to the use of one variation of mit, which limited the scope of comparing the efficacy of other variations of mit (e.g. use of mit with transcranial direct current stimulation). future intervention studies using mit with arabic pwa might consider enrolling larger numbers of patients. they might also consider implementing intervention studies in different arabic-speaking countries to check the efficacy of these interventions with speakers of different arabic dialects. furthermore, future studies with arabic-speaking pwa might want to consider using different variations of mit programmes to check their efficacy in arabic. they might also want to consider the variation of changing treatment stimuli to ‘yes/no’ interrogative questions and gradually changing them to declarative statements as accuracy of their production increases. summary and conclusion this is the first intervention study to test the efficacy of a treatment programme for arabic-speaking pwa. an mit programme was used with a jordanian arabic-speaking patient with severe broca’s aphasia. the subject in the current study benefitted from mit and his accuracy improved on three types of phrases, namely automatic phrases, self-generated phrases and generalisation phrases (untreated phrases). because no research has explored the effectiveness of aphasia treatments with arabic pwa, the results of the current study using 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using automated audiometry in a rural south african school samantha m. govender, maurice mars south african journal of communication disorders | vol 65, no 1 | a582 | 05 july 2018 original research language and culture in speech-language and hearing professions in south africa: the dangers of a single story katijah khoza-shangase, munyane mophosho south african journal of communication disorders | vol 65, no 1 | a594 | 09 july 2018 original research mixed-methods research: a tutorial for speech-language therapists and audiologists in south africa anna-marie wium, brenda louw south african journal of communication disorders | vol 65, no 1 | a573 | 12 july 2018 original research a comparison between video otoscopy and standard tympanometry findings in adults living with human immunodeficiency virus (hiv) in south africa ben sebothoma, katijah khoza-shangase south african journal of communication disorders | vol 65, no 1 | a591 | 16 july 2018 original research towards the preferred stimulus parameters for distortion product otoacoustic emissions in adults: a preliminary study lucretia petersen, wayne j. wilson, harsha kathard south african journal of communication disorders | vol 65, no 1 | a585 | 16 july 2018 original research a pilot study to determine the feasibility of a cluster randomised controlled trial of an intervention to change peer attitudes towards children who stutter rizwana b. mallick, lehana thabane, a.s.m. borhan, harsha kathard south african journal of communication disorders | vol 65, no 1 | a583 | 18 july 2018 62 70 79 88 95 108 115 125 page i of ii table of contents i original research adapting and translating the mullen scales of early learning for the south african context juan bornman, maryann romski, kerstin tonsing, rose sevcik, robyn white, andrea barton-hulsey, refilwe morwane south african journal of communication disorders | vol 65, no 1 | a571 | 08 march 2018 original research intervention for bilingual speech sound disorders: a case study of an isixhosa–english-speaking child kate rossouw, michelle pascoe south african journal of communication disorders | vol 65, no 1 | a566 | 19 march 2018 original research first-language raters’ opinions when validating word recordings for a newly developed speech reception threshold test seema panday, harsha kathard, mershen pillay, wayne wilson south african journal of communication disorders | vol 65, no 1 | a555 | 29 march 2018 discussion forum early hearing detection and intervention: reflections from the south african context amisha kanji south african journal of communication disorders | vol 65, no 1 | a581 | 19 april 2018 original research male students’ perceptions about gender imbalances in a speech-language pathology and audiology training programme of a south african institution of higher education sandra du plessis south african journal of communication disorders | vol 65, no 1 | a570 | 16 may 2018 original research evaluating a smartphone digits-in-noise test as part of the audiometric test battery jenni-mari potgieter, de wet swanepoel, cas smits south african journal of communication disorders | vol 65, no 1 | a574 | 21 may 2018 original research skydiving: the audiological perspective dhanashree pillay, shaaista dada south african journal of communication disorders | vol 65, no 1 | a553 | 28 may 2018 original research exploring the efficacy of melodic intonation therapy with broca’s aphasia in arabic khalid g. al-shdifat, jawdat sarsak, fatoon a. ghareeb south african journal of communication disorders | vol 65, no 1 | a567 | 31 may 2018 original research a pilot study: considering spirituality in an inclusive model of practice in clinical audiology dhanashree pillay, sharon moonsamy south african journal of communication disorders | vol 65, no 1 | a552 | 21 june 2018 10 20 26 29 38 44 56 vol 65, no 1 (2018) issn: 0379-8046 (print) | issn: 2225-4765 (online)south african journal of communication disorders 1 48 http://www.sajcd.org.za open access table of contents ii original research learning new words from an interactive electronic storybook intervention daleen klop, laurette marais, amanda msindwana, febe de wet south african journal of communication disorders | vol 65, no 1 | a601 | 13 september 2018 original research gestational age and birth weight variations in young children with language impairment at an early communication intervention clinic lauren c. fouché, alta kritzinger, talita le roux south african journal of communication disorders | vol 65, no 1 | a584 | 17 september 2018 original research audiological follow-up in a risk-based newborn hearing screening programme: an exploratory study of the influencing factors amisha kanji, kirsten krabbenhoft south african journal of communication disorders | vol 65, no 1 | a587 | 25 october 2018 141 150 correction erratum: wideband acoustic immittance for assessing middle ear functioning for preterm neonates in the neonatal intensive care unit nandel gouws, de wet swanepoel, leigh biagio de jager south african journal of communication disorders | vol 65, no 1 | a595 | 14 june 2018 reviewer acknowledgement south african journal of communication disorders | vol 65, no 1 | a616 | 26 november 2018 157 158 page ii of ii 133 abstract introduction methods ethical consideration results discussion conclusion acknowledgements references appendix 1 about the author(s) seema panday discipline of audiology, school of health sciences, university of kwazulu-natal, south africa harsha kathard department of health and rehabilitation sciences, university of cape town, south africa mershen pillay discipline of audiology, school of health sciences, university of kwazulu-natal, south africa wayne wilson school of health and rehabilitation sciences, the university of queensland, australia citation panday, p., kathard, h., pillay, m., & wilson, w. (2018). the internal and external consistency of a speech reception threshold test for isizulu speakers with normal hearing sensitivity. south african journal of communication disorders 65(1), a556. https://doi.org/10.4102/sajcd.v65i1.556 original research the internal and external consistency of a speech reception threshold test for isizulu speakers with normal hearing sensitivity seema panday, harsha kathard, mershen pillay, wayne wilson received: 10 mar. 2017; accepted: 06 mar. 2018; published: 25 june 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background and objectives: this study investigated reliability, particularly the internal and external consistency, of a new isizulu speech reception threshold (srt) test. methods: to examine internal consistency, 21 adult isizulu speakers with normal hearing sensitivity completed the srt test using the first and second halves of the srt wordlist in the same test session. to examine external consistency, a separate 23 adult isizulu speakers with normal hearing sensitivity completed the srt test, using the whole word list on two occasions 4 weeks apart. consistency of srt test scores in these test conditions was measured using intraclass correlation coefficient analyses (a measure of the consistency or reproducibility of different observations of the same quantity) and bland and altman analyses of agreement (a comparison of measurement error with the expected variation amongst subjects). results: intraclass correlation coefficient values ranged from 0.69 to 0.79, showing the isizulu test scores were highly consistent between the test and retest conditions used in this study. bland and altman analyses showed that isizulu speakers with normal hearing sensitivity can be expected to return isizulu srt test scores that differ by no more than 7.5 db hl – 8.7 db hl between original and repeat assessments. conclusion: the isizulu srt test was reliable, showing high internal and external consistency, when used to assess first-language speakers of isizulu with normal hearing sensitivity. these findings warrant continued development of the isizulu srt test for eventual clinical use. this development should include validating this test on first-language speakers of isizulu with and without hearing loss. introduction since its introduction in the 1950s, speech reception threshold (srt) testing has maintained its place in the basic audiological test battery (ramkissoon, proctor, lansing, & bilger, 2002). srt tests typically consist of a list of words presented to a listener who must repeat each word as heard. the level of the words is then altered until the listener correctly repeats 50% of a group of words. this level is considered to be the listener’s srt, which is used to quantify the listener’s hearing level for speech, cross-check the listener’s pure-tone average threshold from pure-tone audiometry testing and provide diagnostic and prognostic value for medical, surgical and/or rehabilitative management of hearing loss (gelfand, 2001). despite its widely reported clinical value, srt testing still faces several significant threats to its reliability and validity as a measure of speech reception. harris et al. (2007) summarised these threats to include the number, type and homogeneity of the words in the test; the accent or dialect of the speaker; and the method and level of stimulus presentation. panday, kathard, pillay and govender (2007, 2009) provided a description of how these threats may be addressed when developing srt tests. another important threat to the reliability and validity of srt testing is the listener’s familiarity with the test word stimuli (lyregaard, 1997; nissen, harris, jennings, eggett, & buck, 2005). such familiarity in srt testing is best achieved by using words from the first language (or mother tongue) of the target population (nissen et al., 2005). in this regard, craig (1997) warned the use of unfamiliar test words on groups of first and second language speakers of a language will result in the second language speakers being less able or unable to hear subtle sound segments and prosodic nuances of the word stimuli. similarly, takayanagi, dirks and moshfegh (2002) found second language english speakers both with and without hearing impairment required higher intensity for equal recognition of english test words. such findings suggest that words having a higher frequency of occurrence in the target population, that is, familiar words, are more easily recognised by persons in that population than are words with lower frequencies of occurrence. it also suggests that listeners rely on their higher order cognitive resources such as prosodic, semantic, lexical knowledge of the language and context in order for them to recognise and understand test word stimuli (lyregaard, 1997; medwedsky, 2002). the majority of srt tests used in audiology have been developed in english using american english spondee words, where a spondee word is a bisyllabic word pronounced with equal stress on each syllable (ballachanda, 2001; ramkissoon et al., 2002). the use of these srt tests on non-english (and even non-american english) speaking populations can be inappropriate both culturally and linguistically (ramkissoon et al., 2002). such inappropriate application can adversely affect the interpretation of srt test results, with non-american english speakers performing poorly on these tests not because they have a true speech reception deficit, but because they are simply unfamiliar (or at least less familiar) with american english (aleksandrovsky, mccullough, & wilson, 1998; harris, kim, & egget, 2003; harris, nielson, mcpherson, skarzynski, & egget, 2004; martin & hart, 1978; ramkissoon et al., 2002). the potential risks of using culturally and linguistically inappropriate srt tests are particularly relevant in south africa with its diverse multicultural and multilingual population that has experienced major, recent socio-political change. such risks have seen calls to develop contextually relevant tests in south africa not only for items such as srt tests in audiology, but also for resources across the full spectrum of health and rehabilitation sciences. one such call for audiology and speech pathology was from pascoe (2011) who defined contextually relevant resources as: … any tools (assessments, intervention programmes, guidelines and norms) that are available for speech-language therapists and audiologists to use with a specific population in a specific setting, and that have been developed with that population and setting in mind. (pp. 2–5) importantly, pascoe also acknowledged efforts in south africa to not only develop test materials in indigenous local languages, but also to encourage collaborations amongst researchers, clinicians and the local populations to develop knowledge of the process of these developments. attempts to address the need for culturally and linguistically appropriate srt and other speech audiometry tests in south africa have generally focused on two areas: the potential for using non-south african language speech audiometry tests and developing new south african language speech audiometry tests. on the potential for using non-south african language speech audiometry tests on south african populations, research has suggested that first-language speakers of south african english with normal hearing thresholds perform well on non-south african english speech recognition tests at suprathreshold levels but perform poorly at threshold levels. this was seen in studies using the national acoustic laboratories arthur boothroyd (nal-ab) wordlists in australian english (wilson, jones, & fridjhon, 1998) and the central institute of the deaf wordlist 22 (cid w22) in american english (wilson & moodley, 2000). while not addressing srt testing directly, these studies argue against using or adapting non-south african language speech audiometry tests for south african populations. on the development of new south african language speech audiometry tests, recent research has shown significant promise. this includes the ongoing development of the south african spondaic (sas) wordlists in south african english (hanekom, soer, & pottas, 2015) and a non-standardised tswana wordlist (khoza, ramma, mophosho, & moroka, 2008). both of these tests are intended for srt testing with south african populations with normal hearing thresholds performing better or equivalently on these tests compared to equivalent tests in non-south african languages. it also includes the ongoing development of a speech-in-noise test in afrikaans (theunissen, swanepoel, & hanekom, 2009). the hanekom et al. (2015) and khoza et al. (2008) studies in particular support the need for ongoing efforts to develop culturally and linguistically appropriate srt tests for south african populations. while most south african people are multilingual, the most spoken language is isizulu, with approximately 23% of south africa’s 53 million people reporting isizulu as the primary language they speak at home (census, 2011). isizulu is a nguni language. at least two of its differences to the germanic language of english are of particular relevance to srt testing. first, isizulu is a tonal language (rycroft & ncgobo, 1979) where variations in pitch influence word meaning (other examples of tonal languages include mandarin and cantonese). second, isizulu does not have spondee words, the word type most commonly used for srt testing in english. instead, isizulu favours trochee words where prominence is placed on the second syllable of a bisyllabic word. this prominence is often achieved by shortening the duration of the second syllable (cope, 1982), for example, the low tone verb hamba (meaning ‘to go’) would typically be pronounced with a shortened ‘ba’. the authors refer the readers to van der merwe and le roux (2014) for a review of isizulu lexical tone and syllable structure. to address the need of culturally and linguistically appropriate srt tests for south african speakers of isizulu, panday et al. (2007, 2009) developed an isizulu srt test and panday, kathard, pillay and wilson (2018) have begun to systematically validate this isizulu srt test that considers the linguistic structure of isizulu. the current version of this isizulu srt test consists of a cd recording of 28 common, bisyllabic low-tone isizulu verb imperatives (spoken by a male first-language speaker of isizulu). to date, the development of the cd recording of the isizulu srt test has concentrated on its content validity, that is, how well the test represents the content domain it is being designed to measure. to begin, two isizulu-speaking language interpreters and two tertiary level educators identified 131 commonly used isizulu words for possible use in an isizulu srt test, with 124 of these words subsequently identified as being bisyllabic verbs. five linguists (each holding a master’s degree in the linguistics of african languages) then rated 58 of these bisyllabic verbs as being sufficiently familiar, phonetically dissimilar and low in tone to be potentially suitable for use in the development of an srt test in isizulu (panday et al., 2007). recorded versions of these 58 bisyllabic words (spoken by an adult male, first-language speaker of isizulu) were then tested for homogeneity of audibility by playing the words at six intensity levels to 30 isizulu first-language-speaking adults (aged 18–25 years) with normal hearing (panday et al., 2009). homogeneity of audibility was determined by examining the psychometric functions (also known as the performance intensity functions or curves) of each of the 58 word recordings. these functions illustrate how well a speech sample or test item is correctly identified as a function of intensity level. twenty-eight of the recorded words met the criterion of having a mean slope at 50% intelligibility within 1 sd of the group mean of 5.98%/db. finally, an analysis of the prosodic features and pitch contours of these 28 word recordings showed these word recordings conformed to the prosodic pattern apparent within the linguistic structure of isizulu (panday et al., 2009). the present study continues the development and validation of panday et al.’s (2007, 2009) isizulu srt test by determining its reliability when applied to first-language isizulu speakers with normal hearing. methods research design this study proceeded in two parts. part 1 was designed to assess the internal consistency and part 2 was designed to assess the external consistency of the new isizulu srt test. both parts of this study used an observational, repeated measures design. participants part 1 of this study conveniently sampled 21 persons (5 males and 16 females; aged 17–51 years, median = 35 years, first quartile = 24 years and third quartile = 44 years), and part 2 conveniently sampled 23 persons (4 males and 19 females; aged 21–58 years, median = 36 years, first quartile = 24.5 years and third quartile = 43 years), from the adult, first-language isizulu-speaking population of kwazulu-natal, south africa. all participants in this study were first-language speakers of isizulu (self-reported) and permanent residents of kwazulu-natal, south africa (as shown on their south african identity documents). they had responded to advertisements in posters and flyers distributed by the researchers in their communities. after three rounds of advertisement, participants were also recruited through family members of enrolled participants and the university of kwazulu-natal community. all participants had unremarkable medical and hearing histories (self-reported), hearing thresholds ≤ 25 db hl at octave frequencies from 250 hz to 8000 hz, and normal middle ear pressure and compliance (asha, 1988; roup, wiley, safady, & stoppenbach 1998). the isizulu speech reception threshold wordlist the ongoing development of the isizulu srt wordlist (see appendix 1) used in this study has been reported by panday (2006), panday et al. (2007, 2009) and panday et al. (2018). its current recording (panday et al., 2018) consists of 28 bisyllabic isizulu low tone verbs shown to satisfy criteria of linguistic familiarity and homogeneity of audibility for isizulu-speaking adults. these verbs are (in order as per the current recording): banga, gxeka, cinga, faka, thela, linda, khaba, kheta, thatha, donsa, washa, chela, xola, yonga, yona, veza, wina, khanya, shada, geza, khipa, thola, jeza, qonda, thenga, loya, minya and yeka. each recorded isizulu word had been adjusted in level (panday et al., 2018) to ensure its 50% correct perception score occurs at the mean pure-tone average (2.8 db hl) of the 30 normally hearing isizulu first-language-speaking adults (mean age 21.5 years) who participated in panday et al. (2009). procedure prior to completing the srt assessments, all participants filled out a case history questionnaire and underwent pure-tone audiometry assessment at octave frequencies from 250 hz to 8000 hz using a grayson-stradler gsi 61 twin-channel clinical audiometer with tdh-49 telephonic earphones and mx41-ar cushions, and a tympanometric assessment using a gsi tympstar clinical middle ear analyser. this testing was completed in an isolated industrial acoustics company twin audiometric soundproof booth of double wall construction meeting ansi (1977) standards. all srt testing was conducted using the isizulu srt test cd, a technics (slpg390) cd player and the audiometer and booth described above. this testing was conducted by an isizulu first-language-speaking audiologist with 6 years of clinical experience who had been trained by the present study’s first author (s.p.). each srt test began with the audiologist showing the participant a printed copy of the words (in a randomised order) contained in the isizulu srt test as it was being presented on that occasion. the audiologist and the participant then read aloud each word with the participant being given the opportunity to clarify any words with which he or she was unfamiliar (as recommended by asha, 1988). the audiologist then placed headphones on the participant and played the isizulu srt test instructions from the cd at 30 db sl. to measure each participant’s srt, the audiologist followed a modified version of the chaiklin and ventry (1964) descending method cited in gelfand (2001) for srt testing. this method was modified by changing the starting level from 25 db sl relative to a two-frequency pure-tone average to 10 db sl relative to the three-frequency (0.5 khz, 1 khz and 2 khz) pure-tone average. this was performed to reduce test time in expectation of the participants having normal pure-tone thresholds. to complete part one of this study investigating the internal consistency of the isizulu srt test, the isizulu srt word list was split such that the first 14 words formed test a (banga, cinga, thela, khaba, thatha, washa, xola, yona, khanya, geza, thola, qonda, thenga and minya) and the last 14 words formed test b (gxeka, faka, linda, kheta, donsa, chela, yonga, veza, wina, shada, khipa, jeza, loya and yeka). the srt for each participant was then determined for test a and test b. these srt measures were conducted sequentially within each participant and for right and left ear stimulation separately. the order of testing (test a then test b or vice versa) and ears tested (right then left or vice versa) was counterbalanced amongst participants. to complete part two of this study investigating the external consistency of the isizulu srt test, the srt for each participant was determined using all 28 words of the isizulu srt test on two occasions, 4 weeks apart. these srt values were determined for right ear stimulation only. data analysis descriptive statistics were calculated for each participant’s srt score for each variation of the srt assessment. these scores were confirmed as meeting parametric assumptions by inspecting their histograms, box-and-whisker plots and q-q plots. for both parts one and two of this study, the consistency of the srt scores obtained, were assessed using two methods. the first method was intraclass correlation coefficients (iccs) using a two-way random model (2, 1) and the 95% confidence intervals (ci) for these iccs. the second method was the bland and altman method for assessing agreement. this includes calculations of the mean difference between measures (), the 95% ci for , the standard deviation of the differences (sddiff), the 95% limits of agreement and a reliability coefficient. the measures of intraclass correlation were completed according to the shrout and fleiss (1979), rankin and stokes (1998) and bartlett and frost (2008). the strength of reliability indicated by the icc values was determined using the general (although arbitrary) guidelines reported by landis and koch (1977) of values <0 indicating poor agreement, 0.01–0.20 indicating slight agreement, 0.21–0.40 indicating fair agreement, 0.41–0.60 indicating moderate agreement, 0.61–0.80 indicating substantial agreement and 0.81–1.00 indicating almost perfect agreement. the bland and altman method of assessing agreement was conducted according to altman (1991), bland (1987) and bland and altman (1986). the strength of reliability based on this assessment was determined by considering the argument that the reliability of a measure should reflect the true variability of that measure in the target population (riddle, finucane, rothstein, & walker, 1989; streiner & norman, 1995). this argument suggests that reliability is relative and should reflect how well a measurement can differentiate individuals in the target population. in this regard, reliability (or measurement error) should be contrasted with the expected variation amongst the subjects being tested (streiner & norman, 1995). a brief, narrative review of the literature on srt testing, using words, suggested that a variability of ± 5 db would be a clinically acceptable variation in measured srt values within subjects (ansi, 2004; asha, 1988; caswell, 2013; hallgren, larsby, & arlinger, 2006; neuman, baumann, sick, euler, & weigerber, 2012). as a result, any differences of ± 5 db in the mean difference () scores in any of the srt assessments conducted in the present study (in the split-half or test-retest analyses) were considered to indicate that the srt score was reliable as the difference () score was no greater than the expected variation within subjects. ethical consideration unconditional ethical clearance was granted by the faculty of health sciences human research ethics committee of the university of cape town to conduct the study (clearance number: hrec 652/2012). results table 1 shows the srt measurements and table 2 shows the iccs (2, 1) and bland and altman test results for parts one and two of the study. figure 1 shows the bland and altman plots for parts one and two of the study. all icc (2, 1) values were in the range of 0.69–0.79 indicating substantial agreement (landis & koch, 1977). the bland and altman test results showed no evidence of systematic variability in any srt difference scores. slight negative trends in the difference values were noted although these trends were not considered to be significant relative to the magnitude of the measurement. the observed difference scores ranging from +5 db hl to -5 db hl would not be considered as important in clinical measurement of srt (ansi 2004; asha, 1988; caswell, 2013; hallgren et al., 2006; neuman et al., 2012). the coefficient of repeatability ranged from 7.5 to 8.7 for the srt measures in both parts of the study. these coefficients indicate that the differences between two measurements of an srt value obtained using any one of the three variations of srt measurement used in the present study can be expected to differ by no more than 7.5 db hl – 8.7 db hl on 95% of occasions. figure 1: bland and altman plots to examine the consistency of the isizulu srt test results. internal consistency was considered by comparing scores between test halves a and test b for the right ear ([plot] a) and left ear ([plot] b). external consistency was considered by comparing whole test scores between test times 1 and 2 for the right ear ([plot] c). table 1: speech reception threshold measurements for parts one (internal consistency) and two (external consistency) of the study. table 2: intraclass correlation coefficients (2,1) and bland and altman tests for parts 1 (internal consistency) and 2 (external consistency) of the study. discussion the isizulu srt test was reliable, showing high internal and external consistency, when used to assess first-language speakers of isizulu with normal hearing sensitivity. the high internal consistency was shown by the split-half analysis results showing substantial absolute agreement on icc (2, 1) analyses, and the range of difference () scores being within the ±5 db variation in srt scores expected within subjects in a clinical setting on the bland altman analyses, for both right and left ear stimulation. these results show that both the first and second halves of the isizulu srt test wordlist contributed equally to the measurement of srt in the present study’s isizulu-speaking subjects with normal hearing sensitivity. while not recommended, these results also suggests that the isizulu srt test could be used in half-list form (i.e. only half of the words in the list to be used during an assessment) should such a need arise in a clinical setting. the high external consistency was shown by test-retest analysis results showing substantial agreement on icc (2, 1) analysis, and the range of difference () scores on the bland altman analyses being within the ±5 db variation in srt scores expected within subjects in a clinical setting, for the right ear stimulation used in this part of the study. these results show that test scores on the isizulu srt test can be expected to remain stable in isizulu-speaking subjects with normal hearing sensitivity who experience no changes in their hearing over a 4-week period. such a finding should prove useful in clinical settings where serial monitoring of srts is needed up to a monthly basis. at least four limitations are noted in the present study that should be considered before generalising the results to the wider isizulu-speaking population. first, the two parts of the study sampled 21 and 23 participants, respectively, with both samples being non-random in nature. second, the method of obtaining the srt scores was modified from that described by chaiklin and ventry (1964) cited in gelfand (2001), which may not immediately generalise to srt scores obtained using other methods. third, the split-half analysis of the isizulu srt test was conducted by splitting its wordlist into half by word order (a simple split of the first 12 and the last 12 words in the whole srt wordlist). other methods such as splitting the words by odd and even positions could have obtained different results. finally, the bland and altman results were deemed to support the consistency of the srt test results on the basis that variability of ±5 db in srt score would be clinically acceptable. a requirement for less variability would change the interpretation of these bland and altman test results. the high reliability, both for internal and external consistency, of the new isizulu srt test showed in first-language speakers of isizulu with normal hearing sensitivity warrants the continued development of this test for eventual clinical use. the 28 isizulu wordlist recording is not yet available for clinical use as further research is needed to validate its use on first-language speakers of isizulu with and without hearing loss. as many of the previous studies conducted locally in south africa focused on the development aspect of speech audiometry tests, the future validity testing of this isizulu test will contribute to local literature both in terms of methods followed and clinical application of the test for hearing and hearing impaired individuals. conclusion the isizulu srt test was reliable, showing high internal and external consistency, when used to assess first-language speakers of isizulu with normal hearing sensitivity. acknowledgements the authors acknowledge yusentha balakrishna from the south african medical research council, durban, south africa, and dr asad khan from the school of health and rehabilitation sciences, the university of queensland, australia, for assistance with statistical analyses. they also acknowledge zandile blose who assisted as a test administrator during the data collection for this study. competing interests the authors report no conflicts of interest with regard to the writing of this article. authors’ 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(2000). use of the cid w22 as a south african english speech discrimination test. south african journal of communication disorders, 47, 57–62. appendix 1 the 28 bisyllabic isizulu low tone verbs in the isizulu srt wordlist used in the present study: banga gxeka cinga faka thela linda khaba kheta thatha donsa washa chela xola yonga yona veza wina khanya shada geza khipa thola jeza qonda thenga loya minya yeka abstract introduction methods results and discussion conclusions acknowledgements references about the author(s) katijah khoza-shangase department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa; citation khoza-shangase, k. (2020). burden of disease: a scoping review of hiv/aids and tb in occupational noise-induced hearing loss. south african journal of communication disorders, 67(2), a669. https://doi.org/10.4102/sajcd.v67i2.669 note: special collection: occupational hearing loss in africa. original research burden of disease: a scoping review of hiv/aids and tb in occupational noise-induced hearing loss katijah khoza-shangase received: 18 aug. 2019; accepted: 06 feb. 2020; published: 03 mar. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: occupational noise-induced hearing loss (onihl) does not occur in isolation from other influencing factors such as health conditions and illnesses like human immunodeficiency virus and acquired immunodeficiency syndrome (hiv and aids), as well as tuberculosis (tb). how the burden of disease influences the occurrence and/or management of onihl becomes a key if the goal of hearing conservation programmes (hcps) is to be achieved within these contexts. objectives: the purpose of this scoping review was to conduct an investigation on how the burden of disease’s influence on onihl is reported in literature, with a specific focus on the most prevalent diseases in south african mines – hiv and aids and tb. method: a scoping review was conducted using the arksey and o’malley’s framework. a search was conducted in five electronic bibliographic databases and the grey literature. results: the search procured 10 publications, with two specific to onihl within the south african context. in addition to the two publications specific to tb and onihl, findings revealed a serious gap in the evidence around the scoping review question globally. this obvious lack of investigations into the influence of these two conditions in the south african mining context raises serious implications about the responsiveness, and proactive nature of hcps within this population. conclusion: considering the burden of diseases on otology and audiology is critical as certain diseases cause hearing impairment either as a primary effect, as a secondary/opportunistic effect or as a side effect of treatment options for that disease. an employee suffering from any such disease with concomitant exposure to hazardous noise levels presents an even bigger challenge to hcps if such is not taken into consideration in the conception, implementation and monitoring of hcps. keywords: africa; conservation; disease; hiv and aids; health; hearing; noise; occupational; burden; tuberculosis. introduction evidence indicates that south africa remains one of the lowand middle-income (lami) countries with poor health outcomes and high mortality rates linked to the unique quadruple burden of disease (institute for health metrics and evaluation [ihme], 2018; pillay-van wyk et al., 2016; rohde et al., 2008). occupational health conditions in this context occur within this unique quadruple burden of diseases; hence, they cannot be seen and managed in a manner that is dissociated from this burden of disease. this is particularly true in occupational noise-induced hearing loss (onihl), which has numerous influences linked to the quadruple burden of disease (khoza-shangase 2019a). freeman (n.d.) argues that it is necessary to prioritise health conditions in south africa because of the reality that there are limited resources, including financial and human resources, to address all health challenges. this author asserts that it is therefore crucial to focus energies and resources, otherwise nothing could be carried out properly to address healthcare challenges in the country. putting additional resources into priorities and getting the systems and processes in place for a limited number of conditions could make a difference than trying to do everything at once, and this is the position adopted in the current scoping review where within the context of onihl, human immunodeficiency virus (hiv)/acquired immunodeficiency syndrome (aids) and tuberculosis (tb) have been prioritised as key diseases in the quadruple burden of diseases relevant within the context of south african mining industry. adams, ehrlich, ismail, quail, and jeebhay (2018) support this position when they state that healthcare workers in the south african workforce are at risk of the rising tb because of their occupational activity and exposure to as members of communities with a high hiv and tb burden, with an increasing risk of multidrug-resistant tb. occupational noise-induced hearing loss is a globally prevalent condition, classified as the number one work-related disability, second only to presbycusis as a form of acquired hearing loss (krishnamurti, 2009; mostaghaci et al., 2013). this disability is characterised by a sensorineural partial or complete loss of hearing that develops gradually over a period of several years because of exposure to continuous or intermittent high levels of noise or hazardous levels greater than 85 dba during an 8-h shift at workplace (patel et al., 2010; rappaport & provencal, 2001; ritzel & mccrary-quarles, 2008). evidence indicates that the influence of exposure to high levels of noise during their work life extends past their period of employment, as older people with presbycutic hearing loss have been found to suffer even more severe consequences if they have been exposed to high levels of noise during their working life (mostaghaci et al., 2013; ritzel & mccrary-quarles, 2008). this is particularly established in developing countries (chadambuka, mususa, & muteti, 2013; miah, rubya, & kabir, 2014; nandi & dhatrak, 2008) where additional burden of disease complicates the presentation (khoza-shangase, 2019a). global estimates of the prevalence of onihl have indicated rapidly increasing numbers. nelson, nelson, concha-barrientos, and fingerhut (2005) provided global estimates ranging between 7% and 21%, with feder and colleagues (2017) recently revising these to be between 16% and 24%. this increase in prevalence of onihl has been reported to be greater in lami countries (chadambuka et al., 2013; feder et al., 2017; strauss, swanepoel, becker, eloff, & hall, 2014). specific to south african mines, the only evidence available confirms this conclusion, with edwards, dekker, franz van dyk, and banyini (2011) reporting that approximately 73.2% of the workforce was exposed to noise levels above the legislated occupational exposure level of 85 dba, and chamber of mines, as cited by strauss et al. (2014), reporting that 3.1 out of every 1000 workers have onihl. strauss and colleagues (2014) argue that over and above occupational noise exposure, within the south african context, these figures could be influenced by biological factors as well. these factors include smoking (fabry et al., 2010), age, gender (daniel, 2007), genetics (lavinsky et al., 2016), ototoxic drugs and illnesses such as tb (assuiti, lanzoni, dos santos, erdmann, & meirelles, 2013; khoza-shangase, 2019a). recently, khoza-shangase (2019a) has found that goldminers with a history of tb treatment have worse hearing thresholds in high frequencies when compared to those without having tb history. thus, this author highlights the importance of strategic hearing conservation programmes (hcps), including ototoxicity monitoring in miners with a history of tb and hiv/aids, and the possible use of oto-protective/chemo-protective agents in the south african mining population (khoza-shangase, 2010a, 2010b, 2011, 2017). stuckler and colleagues (2011, 2013) argue that south africa is amongst the countries with the highest incidence of hiv/aids and tb, with the highest prevalence of these diseases in the mining industry. this is because of the fact that tb within the south african context has been shown to grow dramatically, and has been correlated with the increased prevalence of hiv (chaisson & martinson, 2008). a report by reddy and swanepoel (2006) has stated that in the south african mining sector, approximately one-third of mineworkers acquired hiv within 18 months of being employed at the mines. another report by anglogold ashanti (2012) west wits mining district provided estimates of approximately 85% of their employees with a diagnosis of tb and hiv. owing to the documented evidence of the compounding impact of synergistic effects of concomitant exposure to ototoxic medications used to treat hiv/aids and/or tb and noise (khoza-shangase, 2019a; valente, hosford-dunn, & roeser, 2008), the implications of the coexistence of these burden of diseases within a chronic noise exposure environment require investigation, quantification and deliberation within hcps. despite the significant progress made through various programmes, such as roll out of antiretroviral therapy (art), to reduce deaths related to hiv and improve life expectancy (gueler et al., 2017; joint united nations programme on hiv/aids [unaids], 2018), hiv continues to increase, particularly in lami countries with increasing evidences of new infections (world health organisation [who], 2018). in south africa, the prevalence of hiv almost doubled from 4.25 million in 2002 to 7.52 million in 2018 (statistics south africa, 2018). hence, south africa has become an epicentre of hiv/aids with a combined high rate of tb co-infection, with links having been established between treatments of these conditions and ototoxicity (khoza-shangase, 2019b). owing to high numbers of patients currently on long-term treatment of tb, it is said that south africa is ‘…potentially facing the risk of a significant proportion of the population acquiring aminoglycoside-induced permanent hearing loss’ (bardien, schaaf, fagan, & petersen, 2009). in 2017, a news24 article by singh (2017) reported that 123 tb patients in kwazulu-natal (kzn) had gone deaf following tb treatment. in this article, the reason cited for the patients going deaf was negligence by the department of health: ‘… as their tb treatment was not properly monitored causing a complete loss of hearing’. as part of hcps, it is important that monitoring and management of ototoxicity in hiv/aids and tb is added as an important aspect of hearing conservation strategy. the need for audiometric testing to identify early changes in hearing thresholds resulting from drug therapy is felt by this population, giving careful cognisance to the concomitant exposure to excessive occupational noise. within hcps, if ototoxicity monitoring does not form part of the treatment, employees’ hearing outcomes could be far worse (khoza-shangase, 2019a) as they would not be benefitted from various treatment options, including alternative drugs, reduced dosages or altered treatment regimens, although ototoxicity is detected early during the treatment period (lonsbury-martin & martin, 2001). furthermore, removal of employee from noisy areas during ototoxic treatment to avoid the synergistic impact of noise and medications on the ear is not carried out, thus exposing the worker to higher risks. methods adhering to the methodology advocated by levac, colquhoun, and o’brien (2010), the research team comprising two researchers working in the field of preventive audiology, which includes onihl and hcps, agreed on a broad research question to be addressed by scoping review and overall study protocol, including specification of search terms/keywords/phrases as well as selection of databases to be searched. the framework adopted was that of arksey and o’malley (2005), and it specifies five key phases: (1) identifying the research question, (2) identifying relevant publications, (3) study selection, (4) charting the data and (5) collating, summarising and reporting the results. research question the broad question that directed the current review was, ‘does onihl research consider the burden of hiv/aids and tb as a potential influence in hcps, and what has been documented in the literature on this?’ this question was guided by the high prevalence of hiv/aids and tb in south africa and particularly in the mining sector of south africa. the researcher aimed to perform this review to integrate and map available evidences for identification of existing lacunae that could be influencing the success or lack thereof of hcps within the south african mining industry. furthermore, influenced by daudt, van mossel, and scott (2013) on the value of scoping reviews, the current review also revealed the types and sources of evidence available on the above-mentioned question; all of these reviews would have implications for academic and clinical training, clinical practice, policymaking as well as future research. data sources and search strategy the initial search was carried out on 18 april 2019 in the following five electronic databases: science direct, pubmed, scopus medline, proquest and google scholar. the databases were selected to be comprehensive and to cover publications considering the influence of the burden of disease (hiv/aids and tb) in onihl and hcps. the selected studies were restricted to the studies published in english, with a focus on these two major burdens of diseases in this population. the search consisted of the following terms: africa, conservation, disease, hiv/aids, health, noise-induced hearing loss, occupational, burden, impact, effects, developing countries, mines and tuberculosis. applying the same search process/string that was used in science direct, pubmed, scopus medline and proquest, a web search was conducted in google scholar to identify grey literature. then a priori decision was made to screen only the first 10 hits (as sorted by relevance by google scholar) after considering the time required to screen each hit and because it was believed that further screening was unlikely to yield more relevant articles (stevinson & lawlor 2004). the following websites were also searched manually: the mine health and safety council; minerals council south africa and department of mineral resources. the following citations, as shown in table 1, were eventually included: adams et al. (2018); barwise, lind, bennett, and martins (2013); brits, strauss, eloff, becker, and de swanepoel (2012); edwards (2009); eisler (2003); elgstrand and vingård (2013); khoza-shangase (2019a); kistnasamy et al. (2018); minerals council of south africa (2018) and sibanye gold (2018). snowball sampling was adopted where citations, meeting the inclusion criteria, within articles were searched. another search of the above-mentioned bibliographic databases and grey literature was conducted in august 2019 to ascertain if there were any additional publications post the initial search. no new hits were identified. table 1: studies reflecting burden of disease in occupational noise-induced hearing loss and its management. citation management all citations were imported into the web-based bibliographic manager endnote. duplicate citations were removed manually. further duplicate citations if found were removed during title and abstract relevance screening and data characterisation of full articles. eligibility criteria the researchers adopted a two-stage screening process to evaluate the applicability of publications identified in the search. the first stage involved the inclusion of publications containing keywords and phrases and those broadly describing the influence/inclusion of hiv/aids and/or tb (burden of disease) in onihl and/or hcps to determine and characterise the existing evidence base on the impact of the burden of disease in onihl. the second stage involved excluding from analysis the publications that described hiv/aids and/or tb and hearing loss in areas other than onihl; however, reference lists from these publications were reviewed to identify additional relevant publications. owing to limited resources for translation, only english publications were included. title and abstract relevance screening for efficient time management and as recommended by arksey and o’malley (2005), the first level of inspection of the evidences involved reviewing only the titles of the manuscripts. the second level included reviewing the abstracts only. finally, entire articles were reviewed (refer to figure 1). this ensured that resources were not wasted for procurement of articles that did not meet the minimum inclusion criteria of this review. the researchers used the research team’s previously developed and pretested abstract relevance screening spreadsheet, which was found to have a reviewer agreement (overall kappa) greater than 0.8 – which is considered to represent a high level of agreement (viera & garret, 2005). the titles, abstracts and entire articles were independently screened by both researchers. for titles where abstracts were not available, the researchers included them for subsequent review of full article during data characterisation phase. the researchers met regularly during entire process to ensure that conflicts were resolved, with author making the final decision where disagreements were found. a high level of agreement was found with the overall kappa of 0.81. figure 1: preferred reporting items for systematic reviews and meta-analysis (prisma) flow diagram for included publications. data characterisation all relevant citations for the current scoping review on hiv/aids and/or tb in onihl and hcps after title and abstract inspection were obtained for later review of full publications. a spreadsheet was developed by the author where relevance of the publication was confirmed and where details of the publication, such as type of publication, author and publication year, title, focus and aims, methodology, context, results/recommendations and reported challenges, gaps and limitations, were mentioned. the characteristics of each publication were extracted by both researchers. further publications were excluded at this phase if they did not meet the minimum eligibility criteria. in adherence with levac et al.’s (2010) framework, the researchers met to resolve any conflicts and ensure consistency between them as well to make sure that the publications were consistent with the set research question and purpose following their independent reviews. data summary and synthesis the data were compiled in a single spreadsheet and imported into microsoft excel 2016 (microsoft corporation, redmond, wa, usa) for descriptive analysis. ethical consideration this article followed all ethical standards for a research without direct contact with human or animal subjects. results and discussion current findings highlight a significant need for research in this area as indicated by paucity of evidence on highly prevalent burden of disease conditions relating to onihl and hcps within the context of africa and the world. this is despite the available evidence on the influence of hiv/aids and tb on hearing function within and outside the context of noise exposure (brits et al., 2012; cox, reuter, furin, & seddon, 2017; khoza & ross, 2002; khoza-shangase, 2010a, 2019a; matas, angrisani, magliaro, & segurado, 2014; wilson, tucci, merson, & o’donoghue, 2017). the paucity was found in spite of all evidences pointing towards the synergistic relationship between noise exposure and ototoxic medications (behar, 2018; european agency for safety and health at work [eu-osha], 2009; li & steyger, 2009). of the publications deemed potentially relevant for this scoping review, only two south african studies were found that specifically investigated the possible influence of tb treatment on onihl in goldminers (brits et al. 2012; khoza-shangase 2019a). apart from the two south african studies, nuanced analysis of publications revealed that research in occupational health has not addressed onihl as a complex condition that occurs in this context – a condition that does not occur in isolation, and particularly a condition that can be exacerbated by pharmacological treatments that miners receive for occupational health conditions such as tb. this conclusion is drawn from reviewed studies that address health and/or diseases in miners without linking these to each other and to occupational health prevention strategies (such as hcps for onihl). these studies, as shown in table 1, investigated the following aspects, which the current author believes have implications for the burden of disease influence on hcps: studies on intensifying action to address hiv and tb in the mining sector; reviews on health risks amongst goldminers; investigations on challenges of occupational health facing the department of health – protecting employees against tb and caring for former mineworkers with occupational health disease; occupational safety and health in mining anthology on situations in 16 mining countries; and studies looking at whether 85 dba as a regulation point is protective enough to prevent onihl in south african miners. all these publications, although speaking on the burden of disease directly and/or indirectly, are silent on focussing the influence of these on onihl. barwise et al. (2013), driven by their knowledge of the high burden of hiv/aids and tb in lami countries, conducted a study in mozambique, where they analysed the importance of recent policy developments, both regional and national, aimed at intensifying action to address hiv and tb in mozambique’s mining sector. these authors recommend that the country’s declaration regarding occupational health be operationalised and enforced. they further report research conducted from 2011 to 2012 on health-related attitudes and behaviours of mozambican mine workers and their families, and present an estimate of the financial burden of the disease related to migrant mine work for mozambique’s public services and migrant-sending communities. furthermore, these authors suggested that practical measures, including training of health workers in migrants’ right to health; user-friendly health information in portuguese and local languages; building the advocacy capacity of mine workers’ representatives; and giving more attention to social, cultural, and economic factors that affect migrant mine workers’ health, including better access to health information and services be put in place. these recommendations are seem to be applicable in the context of south african as well, as evidenced in kistnasamy et al.’s (2018) study, where they explored recent developments and ongoing challenges to tackle injustices of occupational lung diseases acquired in south african mines. in their assessment of developments over the last 5 years in providing compensation, quantifying shortfalls and exploring underlying challenges with tb management in south african mines, these authors found that by the end of 2017, 111 166 miners had received compensation, of which 55 864 were for permanent lung impairment, and another 52 473 for tb. this shows significant burden on south african mining sector because of these conditions, and hence a consequent need for practical measures in onihl similar to those described in barwise et al.’s (2013) study. the inferred implications of these studies for possible hearing loss-related compensation linked to noise exposure with concomitant ototoxicity are significant, with inferences for appropriate hcps. as far as reviews on health risks of goldminers are concerned, eisler (2003) simply documents health problems of goldminers in australia, north america, south america and africa. eisler (2003) identified noise-induced hearing loss amongst conditions such as decreased life expectancy; increased frequency of cancer of the trachea, bronchus, lung, stomach and liver; increased frequency of pulmonary tuberculosis (ptb), silicosis and pleural diseases; increased frequency of insect-borne diseases such as malaria and dengue fever; increased prevalence of certain bacterial and viral diseases; and diseases of the blood, skin and musculoskeletal system. relationships between these health problems and their possible influence on others are not considered in this review. this is problematic as far as the question for this scoping review is concerned, and highlights the failure of mining industry to, for example, consider the affect of ototoxicity arising from treatments for most of these listed health conditions, including cancer (landier, 2016), tb (brits et al., 2012; khoza-shangase, 2019a) and bacterial and viral diseases, such as hiv/aids (khoza-shangase, 2010a, 2017, 2019b). vulnerability of the inner ear during treatments for the mentioned diseased conditions with concomitant exposure to excessive noise has been documented to worsen presenting onihl (brits et al., 2012; khoza-shangase, 2019a; li & steyger, 2009). exploration of hcps and health and safety regulations in the mining industry clearly indicate a gap in clinical practice and decision-making concerning management of relevant pillars of hcps. of all the pillars for successful implementation of hcps, which include periodic noise exposure measurement/monitoring; engineering controls; administrative controls; personal hearing protection; employee/management education, motivation, and training; risk-based medical examination; medical surveillance; and audiometric evaluations as well as record-keeping (amedofu, 2007; hong, kerr, poling, & dhar, 2013), careful deliberation of employees presenting with health problems, as well as the treatment they are taking to manage these problems, is critical. key to these ‘at risk’ employees’ hcp could be stricter administrative control, which includes reducing shifts in noisy areas; individualised or more-directed employee motivation and training programmes, including ototoxicity education and monitoring; more frequent and more comprehensive medical surveillance and audiometric evaluations. all this would require the use of a proactive data management system for record-keeping (jantti & cater-steel, 2017) to be able to proactively track these ‘at risk’ miners and efficiently monitor key factors, including ototoxicity monitoring and intervention, and provide preventive and intervention measures where required. adams et al. (2018), in their investigations on occupational health challenges faced by the department of health in south africa, recommend protection of employees against tb and caring for former mineworkers with occupational health diseases, surprisingly without any mention of the benefits of this recommendation on hcps and miners’ hearing preservation. this publication does not mention onihl, and is another example of missed alignment of occupational health disease management. these authors, however, highlight department of health’s shortcomings in fulfilling its legal mandate of providing statutory medical examinations over and above the treatment of tb and hiv-related disease in all public healthcare facilities. the current author suggests audiological monitoring and intervention as one of these healthcare facilities. most importantly, adams et al. (2018) conclude their findings by sounding a crucial requirement for reform (legal, financial and managerial) of the occupational diseases in mines and works act (odmwa). on the contrary, elgstrand and vingård (2013), in their study on occupational safety and health in mining anthology on situations in 16 mining countries, discussed onihl in isolation from the burden of diseases. this lack of viewing employees’ health conditions in a comprehensive holistic manner that acknowledges the possible influence that one condition might have on another (specifically in this case hiv/aids and tb’s influence on onihl) is also seen in specific industry annual reports of minerals council south africa (2018) and sibanye gold (2018). these reports clearly show intensive efforts to improve the employees’ hiv/aids and tb status through testing, counselling, treatment and efficient reporting. none of the reports, however, deliberate on and/or mention the possible impact that these conditions have on onihl in their employees. nuanced analysis of the reporting provided in these reports shows that the data management system used by minerals council south africa (2018), minerals council health information management system, is such that it shows the employees having ‘risk factors’ for onihl as far as these two burdens of diseases are concerned, and therefore shows the employees in need of close monitoring in their hcps. however, this could successfully happen only if all mines are compliant with utilising this data management tool, and the current report raises non-compliance of registered companies as one of the challenges, alongside data system quality assurance and the system’s functionality limitations. the closest study arguing for consideration of onihl as a complex condition that is influenced by other factors such as chemical exposure, heat and exercise (workload), is the one conducted by edwards (2009). it questioned whether the occupational exposure limit (oel) of 85 dba as a regulation point is protective enough to prevent onihl in south african miners. this study, however, found statistically significant differences between pre-exposure and post-exposure otoacoustic measurements for noise as a stressor when using 85 dba, but not for other health stressors. these did not appear to accentuate effect on the cochlea. edwards (2009) concludes by recommending further investigations of 85 dba oel. the current author recommends inclusion of the burden of diseased conditions that are the focus of this scoping review in such future studies. this recommendation is bolstered by the only two studies found which specifically examined the possible influence of tb on onihl in the context of south africa. brits et al. (2012), in their study on hearing profile of goldminers with and without tb in south africa, where they compared hearing of goldminers with and without tb to determine the effect of tb and its associated risk profile on hearing, have found that hearing thresholds for tb groups were significantly (p < 0.01) elevated compared to the control group, and that hearing thresholds over time also deteriorated significantly (p < 0.01) more in workers with tb (single and multiple treatment) than in workers without tb. these findings were recently supported by khoza-shangase (2019a) in a retrospective data review study, which also investigated hearing function of goldminers with and without a history of tb treatment. this recent study also investigated possible influence of age and hiv in these two groups. findings from this study suggest that goldminers with a history of tb treatment have worse hearing thresholds in high frequencies when compared with those without this history, with evidence of a noise-induced hearing loss notch at 6000 hz in both groups. furthermore, findings of this study have indicated a weak positive (negative) correlation between hiv and hearing loss as well as between hearing loss and age in this population. khoza-shangase (2019a) uses findings from this study to highlight the importance of strategic hcps, including ototoxicity monitoring, and the possible use of oto-protective/chemo-protective agents in this population. conclusions human immunodeficiency virus, tb and cancer are three of south africa’s greatest burdens of disease (olu et al., 2015). the current scope review revealed paucity of evidence and engagement with the possible influence of hiv/aids and tb on onihl and hcps. this is a significant worry considering that mining remains an important industrial sector in many parts of the world, and one of the key sectors in south africa where hiv/aids and tb are significant burdens of disease. globally, evidence suggests that progress has been made in terms of control and management of occupational health hazards; however, significant room exists for further improvement, especially in lami countries, and as far as occupational diseases are concerned for managing onihl. significant room exists for reducing occupational health risks as well as managing and compensating for occupational health conditions. occupational noise-induced hearing loss risk reduction and management requires carefully conceived and efficiently implemented and monitored hcps. these hcps need to be contextually sensitive, responsive and relevant. such contextualised hcps for south africa call for awareness and acknowledgement of the burdens of disease in the form of hiv/aids and tb in the presentation of onihl. this awareness could only increase the likelihood of success of hcps that have shown to be less than optimal in achieving the goals of eliminating onihl within this context. occupational noise-induced hearing loss is a complex condition influenced by a number of factors, with ototoxicity being one of the key factors. although limited research has been conducted in the synergistic effects of noise and ototoxic medications in the mining industry, sufficient evidence exists for the audiology community to increase their focus on this population and deliberate on how to ensure successful preventive measures are in place to maintain miners’ quality of life. hearing conservation programmes naïve of the burden of disease implications fail to ensure closer monitoring of employees, individualised administrative controls for involved miners and exploration of other protective measures for employees on ototoxic treatments such as oto-protective agents; hence, implications for policy and practice reviews in hcps are important. acknowledgements the author wishes to thank dr n. moroe, research team member, for contributing towards the title and abstract relevance screening of the scoping review. competing interests the author declares that she has no financial or personal relationships that may have inappropriately influenced her in writing this article. author’s contributions k.k-s. is the sole author of this research article. funding information financial assistance was provided by the national institute for the humanities and social sciences and the consortium for advanced research training in africa. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any affiliated agency of the author. references adams, s., ehrlich, r., ismail, n., quail, z., & jeebhay, m. 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(2018). addressing the rising prevalence of hearing loss. retrieved from https://apps.who.int/iris/bitstream/handle/10665/260336/9789241550260-eng.pdf;jsessionid=13ffe7ccec3fe3335fd451fa5132cbd4?sequence=1 45 narrative discourse productions in older language impaired learning disabled children: employing stricter reliability measures luanne henshilwood and dale ogilvy department of logopaedics university of cape town abstract this study aimed to describe narrative discourse productions of older language impaired learning disabled (lrld) children, using stringent reliability measures. coherence and cohesion were the measures of analysis employed. content and clarity ratings provided a subjective analysis of narrative productions. interrater and intrarater reliability measures were calculated and testing for stability of scores across three testing sessions were undertaken. the results indicated subtle differences in the coherence and cohesion of narrative productions in the lild compared with controls. the findings ofthis study support past literature, which calls for greater research in this area using stricter reliability measures. opsomming daar is in hierdie navorsing gepoog om narratiewe diskoersproduksie van leergestremde persone met 'n taalafwyking te beskryf, met die gebruik van streng betroubaarheidsmaatreels. koherensie en kohesie is die maatreels van analise wat gebruik is. interbeskouer en intrabeskouerbetroubaarheidsmetings is verwerk en toetsing vir stabiliteit van punte oor drie toetsessies onderneem. subjektiewe analise van narratiewe produksies is deur inhoudsberekeninge voorsien. die resultate het subtiele verskille in die koherensie en kohesie van diskoers in die leergestremde persone met 'n taalafwyking , in vergelyking met die kontrolegroep, aangedui. die bevindinge van hierdie navorsing ondersteun vroeer literatuurstudies, naamlik dat verdere navorsing in hierdie area meer doeltreffende betroubaarheidsmaatreels sal moet gebruik. key words: narrative discourse, older language impaired learning disabled children, reliability measures in discourse. introduction / if narrative is an org'aniser of human experience, what better and more relevhnt mode of expression can we use to probe the abilities land disorders that shape human communication? (bruper, 1990, pg 286) assessment of discojrse in older children and adolescents allows a clinician tb exa,mine a child's ability to manage larger units of discourse as well as to examine their ability to process coherent oral and written texts (nelson, 1993). learning disabled children have been found to present with problems in discourse forms, which either supersede linguistic deficits or occur in the absence ofstructurallinguistic problems (roth and spekman, 1986). according to klein (1991) learning disabled children may find it difficult to communicate in a free flowing, creative and interesting manner. children who present with expressive difficulties may produce circumlocutions and confabulations while searching for the correct word, while others may talk endlessly but their language is empty and repetitive (klein, 1991). the popularity of obtaining and analysing samples of children's discourse in combination with traditional language assessment procedures has increased over the past two decades (gallagher, 1983; stickler, 1987; owens, 1995 in hux, sanger, ried & maschka, 1997). the popularity can be attributed to the limitations of standardised tests and the limited information these tests provide a clinician ( hux, sanger, ried & maschka, 1997). narrative discourse tasks have been found to be good instruments to assess higher level language and cognitive skills (paul & smith, 1993). past research on narrative abilities in learning disabled children has presented with many contradictory results. roth and spekman (1986) and ripich and griffith (1988) found that learning disabled students perform poorer than normal peers in some aspects of narrative productions, but in other aspects perform equally well. other studies have stated that learning disabled children produce less cohesive narratives than non-learning disabled persons with the main difference being attributed to the use of pronouns as referents and conjunctions as tie elements (strong & shaver, 1991; liles, duffy, merritt & purcell, 1995). on the other hand, some studies have found that in many aspects learning disabled children were not found to proc duce narratives that are significantly different to those of normal children. ripich and griffith (1988) found that children with learning disabilities are able to organise their stories according to an appropriate story grammar. liles et al. (1995) support these findings as they state that learning disabled children appear to be using, or attempt to use die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 46 information typical of a normally developing child regarding production of narrative discourse. in addition, past studies have shown that the differences between the language impaired learning disabled and control groups are small and insignificant or none at all (ripich & griffith, 1988). this indicates there are often more similarities between the groups than differences (roth & spekman, 1986). strong and shaver (1991) attribute the conflicting results to the unreliability of scores given the analysed elements of the discourse. with all the attention being placed on the method of sampling language, there is still little agreement as to the most reliable and valid procedure (morris-friehe & sanger, 1992). in more recent studies validity and reliability have become increasingly important aspects to language sampling and analysis of discourse productions (strong & shaver, 1991~ morris-friehe & sanger, 1992). hux et al. (1997) highlight many methodological issues that can contribute to the reduced reliability in such research. the variability oflanguage across context and tasks, the diverse nature of lan.guage, little normative data on older children and the heterogeneous nature of clients all contribute to the controversy in this area of research (morrisfriehe & sanger, 1992; nelson, 1993; hux et ai., 1997). reliability becomes an important concern when discourse analysis highlights the pragmatic nature oflanguage resulting in analysis that sometimes offers vague descriptions (hux et ai., 1997). in order for results to be interpreted with confidence, researchers have collected data across a number of different testing times spaced at brief intervals to determine whether the scores do not fluctuate greatly across testing sessions (strong & shaver, 1991; morris~friehe & sanger, 1992). strong and shaver (1991) further recommended the use of important reliability measures such as intra-coder agreement; internal consistency of responses and stability of scores across testing sessions before 'the researcher can generalise any results to the general population. in summary, from a review of the literature, conflicting findings show a clear need for further research in the production of discourse in the language impaired learning disabled popula,tion. furthermore, strict reliability measures are required. this study has two aims. firstly to assess and describe the narrative abilities of older language impaired learni~g disabled children and secondly to employ strict reliability measures. method aims primary aims the primary aims of this study are: 1) to describe the narrative discourse productions of older language impaired learning disabled children; 2) to employ stringent measures of reliability. . ' m,;;re sp'(/ci/ically the specific aims of this study are: 1) to analyse the language impaired learning disabled narrative discourse productions on a macro'structure·level, using the measures of coherence' and 'cohesion; 2) to determine inter and intracoder agreement and stability of scores across testing sessions. . luanne henshilwood and dale ogilvy research design a parallel case study design was employed in this study as it was considered the most appropriate method of research in the learning disabled population due to the heterogeneity of this population. the heterogeneous nature of the learning disabled population has been recognised for many years (wiig & semel, 1986; morris-friehe & sanger, , 1992; nelson, 1993). subjects sample size three language impaired learning disabled children (lild 1, lild 2 and lild 3) between the ages of 11-13 years, were assessed in this study. three non-learning disabled persons with no history oflearning disabilities or any other neurological or behavioural disorders were included in this study as control subjects (c1, c2 and c3). these control subjects were matched for age and sex. the control subjects were not required to match for grade as the lild children have repeated grades at school. the inclusion of these non-learning disabled subjects allows for the validation of the tasks and the obtained results. subject selection criteria a number of criteria were applied in the process of selecting the three subjects. the subjects were required to have: 1) been diagnosed as language impaired learning disabled by a speech and language pathologist and other professionals ;2) to be attending a school for the learning disabled ;3) to be impaired in either the receptive and/or expre'ssive areas oflanguage ; 4) been diagnosed as learning disabled not attributed to cultural differences; 5) have an average or above average non-verbal i.q., ranging from 85 onwards, as determined by a formal intellectual ability test; 6) the subjects were required to be in the 11.0 to 13.0 year range. this choice of age group was influence by developmental aspects of narrative discourse. applebee (1978) stated that children over the age of six years are able to produce an ideal or adult like narrative structure, although development continues over the age of ten years; 7) tb be first language english speaking. subject description the biographical and clinical information of the three lild subjects is presented in table 1. data collection and instrumentation the researcher met with each subject and control subject three times. in each session one story was elicited. a total of18 ~arrative samples were collected, three from e'ach subject. the procedure of collecting a narrative sample three times was undertaken for the following reasons: firstly, to examine the stability of narrative productions' across a number of testing sessions. secondly, to determine whether more than one sample of the child's narrative yielded more reliable results when analysing the appropriate elements. thirdly and finally, three narrative samples were collected to increase the length of the narratives by combining the length of all three stories. cole, mills and dale (1989) / the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) / narrative discourse productions in older language impaired learning disabled children: 47 employing stricter reliability measures stated that multiple samples taken over a short period of time were more useful than one sample taken at a single point in time and presented with more lexical information than one sample. furthermore, liles (1993) stated that a story of substantial length ensures the narrative is representative of the child's narrative ability. stimulus material the narrative samples were elicited using three wordless picture books: story a: "moonlight" by jan ormerod; story b: "the snowman" by ramond briggs and story c: "the angel and the soldier boy" by peter collington. narrative language sample a story-retelling task was employed in this study for the following reasons: past research has shown that story retelling is much easier than story generation or creation (ripich & griffith, 1988). story generation requires a person to formulate a story without a model, which can lead to problems in the lild where their ability to organise events on their own and construct cohesive narrative language may be reduced (ripich & griffith, 1988). story retelling also provides information regarding the more salient features of narrative such as memory for structure and cohesive devices (ripich & griffith, 1988). an advantage of story retelling is that it allows the child to tell a story that is more complete and has sufficient length (strong & shaver, 1991). merritt and liles (1989) state that story retelling was found to be more useful as the stories contained more grammatical components and more complete episodes for both lild and normal language subjects. they also found that story retelling allowed for easiertran~ scription and were more reliably scored than story gimeration. listener familiarity in this study the naive listener condition was adopted. research has found that when the listener adopts a naive listen~r role the narrator will produce a higher numb~r of cohesive devices especially personal references (liles, 1993). in addition, purcell and liles (1992) state that the naive listener condition also results in longer narratives and more coherent productions than a non-naive listener condition. treatment of data transcription of the narrative sample the researcher transcribed the videotaped discourse samples. t.he transcribed data was prepared for analysis table 1: biological and clinical information of the llld subjects. lildi lild2 lild3 chronological age 12.8 years 11.0 years 12.9 years , sex male male female grade 6 5 4 no. of years at school 4 3 5 / no. of yr. in therapy >5 >6 >5 / . medication i ritalin ritalin no medication i i i.q i above average above average above average , current therapy i speech, twice weekly speech, twice weekly speech, twice weekly i l"t language : english english english speech therapy reports • limited expressive • limited expressive • poor receptive and language ability language 'expressive language • limited auditory • limited auditory abilities perceptual abilities perceptual abilities • limited auditory percep• vocabulary age • word finding difficulty iual abilities . appropriate • vocabulary below • vocabulary below av;rage average general education reports • poor written • poor written • poor written language skills language skills language skills ., • received remedial • received remedial • poor arithmetic lessons lessons • poor arithmetic • received occupational therapy for visuali motor integration die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 48 by bracketing all false starts, repetitions and unintelligible utterances. the bracketed words were not included in the final word count but counted as a separate unit. rules for counting the number of words were adopted from strong and shaver's (1991) rules for counting words. the transcribed data was segmented according to an "event". for the purpose ofthis study an event was defined as a change in place, character or action. methods of analysis the narrative samples obtained in this study were analysed according to macrolinguistic organisation. coherence and cohesion were taken as the measures of suprasentential (macrolinguistic) organisation (glosser & deser, 1990; ulatowska, freedman -stern, doyel, macaluso-haynes & north ,1983). coherence the narrative samples obtained in this study were analysed according to labov's (1977) narrative structure elements that constitute a well-formed narrative: • abstract: this refers to the one or two clauses summarising the whole story. • orientation: at the beginning ofthe narrative the time, place, persons and their activity or the situation is defined. • complicating action: this is the sequence of events, which is presented chronologically. • evaluation: various elements are used to express the narrator's feelings about the characters or events. • resolution: these are one or more statement, which reflect the final events or end the experience. • coda: these are the free clauses that indicate the narrative is finished. evaluation evaluation functions in order to specify why the narrative is being told and what the point of the narrative is (labov, 197'i} this is achieved through the narrator's comments. evaluation is also a means by which the narrator can attribute emotion to any character or event (liles, 1993). labov (1977) proposed that evaluation consists offour major categories: intensifiers, comparators, correlatives and explication. each category consists of a number of subtypes. see labov(1977) for full description of subtypes. cohesion according to halliday and hasan (1976) cohesion refers to the relations of meaning that exits within the text and define it as a text. cohesion is expressed through grammar and vocabulary, waich is referred to as grammatical cohesion and lexical cohesion, respectively. grammatical cohesion consists of different types ofties namely: reference ties, substitution ties and ellipsis ties, while conjunction ties are mainly grammatical but contain a lexical component. lexical ties are another important tie in cohesion (halliday and hasan, 1976). cohesive ties this refers to the percentages of reference ties, substitution ties, ellipsis ties and conjunction ties and lexical ties luanne henshilwood and dale ogilvy used in the text (halliday & hasan, 1976).the percentage of each tie was calculated for each narrative sample and statistically analysed. the types of cohesive ties analysed in this' study (as described by halliday and hasan, 1976) were as follows: . • anaphoric reference. this is defined as pronouns that refer to previously identified nouns. for example: ... suzie was at home playing with her dolls. • demonstrative reference: this refers to the use of terms 'this, that, here and there'. for example: ... there was a girl and her mother and her father. • ellipsis: this allows the speaker to reduce redundancy in a message by only encoding the essential elements. for example: ... she went back. • substitution: this refers to items other than personal pronouns thatreplace previously identified elements. for example: .. she likes big boats because the little one was small. • conjunctions: these serve a cohesive function as they relate successive utterances to each other. for example: they were quite happy because it was quite big. • lexical ties: a lexical item refers back to another lexical item, and is related by having a common referent. for example: ... he steals some fruit for the nose and some berries for the eyes. the items fruit and berries are a lexical tie as well as nose and eyes. cohesive adequacy cohesive adequacy refers to the percentages of complete, incomplete, and erroneous ties (liles, 1985). the definitions adopted for this study for complete, incomplete and erroneous ties were as follows (liles et al., 1995): • complete tie: a complete tie is determined when the cohesive item that the tie refers to is easily identifiable and can be defined with no ambiguity. • incomplete tie: a tie is incomplete ifthe item referred to by the cohesive marker is not given in the text. • erroneous tie: a tie is erroneous if the cohesive marker refers to an ambiguous or erroneous item. content and clarity ratings to supplement the objective analysis ofthis study, a rating system was devised to evaluate the "content" and "clarity" ratings of the subjects' narrative discourse sampl~s. this rating system also allows the researcher to compa~e the objective analysis with the subjective evaluation ofthe listener (ulatowska et al. 1983). ulatowska et al. (1983) suggested that "content" could be referred to as a rough measure of coherence, and "clarity" as a rough estimate of cohesion. the rating system used in this study was adapted from ogilvy (1995) and ulatowska et al. (1983). , three raters rated the content ofthe narrative, using a threepoint scale and answeririg specific questions. five questions were used in this section. examples include "do. you know what is happening in this story?" and "'does the sequence. of events make sense?" the clarity ofthe narrative was also rated using a threepoint scale. three questions were used in this section. an example ofa question, "is it clear to whom the narrator is referring to throughout the story?" the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) narrative discourse productions in older language impaired learning disabled children: 49 employing'stricter reliability measures results and discussion the findings ofthis study involve two parts. firstly the results of the reliability measure,s and the implications thereof, will be presented. this will be followed by a discussion of the results. of the analyses of the lild and control subjects' discourse productions. measures of reliability three raters, who are qualified speech and language pathologists, were involved in this study. each rater received training regarding tile methods of analysis. the subjective content and clarity ratings were rated buy adults who were not qualified speech and language pathologists as formal training was not required. interrater reliability in this study, inter-observer agreement was determined. this served to assess the extent to which different observers or raters agree that they 'see' the same phenomena (hux et ai., 1997). according to hux et ai. (1997) inter-observer agreement consists of a number of assumptions. firstly, the raters must share an understanding of what trait is being rated. secondly, the raters must be able to determine the occurrence or nonoccurrence of what is being measured. finally, the raters must have a common means of recording the occurrence of the targeted behaviour or trait. pearson product -moment correlation coefficients were calculated to determine transcription and score reliability. transcription reliability transcription accuracy was determined by a word-byword reliability. this kind of transcription agreement is most commonly used in speech pathology research using transcriptions as a means of analysing data. the transcription agreemenundices ai'e generally calculated by a word by word agreement procedure. 20% of each sample was ran/domly selected by two trahscribers who independently transcribed each selected slample of narrative productions (strong & shaver, 1991). ford-by-word agreement resulted in percentage agreement ranging from 95% to 98%. correlation coefficients for intdrrater transcriptions were greater than .99 for all additionhl transcriptions, indicating high transcription reliability. ! i coder reliability an additional coder was trained to analyse a randomly selected 20% of each narrative sample (strong & shaver, 1991). the coder randomly selected the samples. the coder was required to analyse coherence and cohesion. this allowed the researcher to determine whether the method of analysis used was consistent across all narrative samples. the coder was trained for approximately 4 to 6 hours before interrater coding began. the coder randomly selected 20% of each sample and coded each transcription independently. point -by -point agreement was calculated and an agreement percentage of 95% to 98% for intercoder reliability was obtained. a correlation coefficient of .99 was obtained indicating high intercoder reliability. intrarater reliability transcription reliability 15% of each narrative sample was randomly selected for transcribing a second time by the researcher. word -by -word reliability measures resulted in intrarater reliability for transcription averaging at 97%. a correlation coefficient of .996, was obtained for intrarater transcription reliability. coder reliability 15% of each narrative sample was randomly selected and scored a second time by the researcher. word-by-word,reliability measures resulted in an intrarater reliability for coding averaging at 98%. the correlation coefficient for intracoder reliability was .96, indicating a high reliability. stability coefficients the main fundionofthe reliability measures presented in this research was to determine the relationship among scores obtained across the three testing times, i.e., to determine whether the measurement was consistent over the testing sessions. according to hux et ai. (1997) and strong and shaver (1991) calculating correlation coefficients is a conimon way of assessing the reliability of scores in discourse analysis. for the purpose ofthis study pearson product -moment correlation coefficients and an analysis of variance (anova) were computed to 'examine the reliability of the obtained scores. an alpha level of .05 was used for all statistical levels'. correlation coefficients were computed across the three stories to establish the stability of scores of evaluation, cohesive ties and cohesive adequacy across the testing sessions. as the stories were administered with identical instructions, they were considered suitable to be used as parallel forms for the calculation of the coefficients of stability. stability coefficients for evaluation analysis of variance (anova) was computed for each subcategory of evaluation. these results are presented in table 2. no significant scores were obtained indicating there was no fluctuation of these scores across the three testing sessions. therefore, it can be stated that there wasstability across all testing sessions for evaluative elements. stability coefficients for cohesion cohesive ties pearson product-moment correlation coefficients were computed to determine the stability of cohesive ties and cohesive adequacy across the three testing sessions. tne results are presented in table 3. the results indicate that' the values for demonstrative reference, substitution, conjunction and lexical ties were not significantly different and therefore were stabie across the three testing sessions. values for anaphoric reference and ellipsis were significant and therefore were not found to be stable across' testing sessions. cohesive adequacy statistical analysis of cohesive adequacy revealed significant correlation for most of the ana phoric reference and lexical ties. this shows that these scores were not stable die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 52 substitution was the least used category, and was only used by c2, c3 and lildl. ellipsis and substitution were used less frequently than the other categories such as reference and conjunctions. this finding supports research documented by rumble and malan (1990). cohesive adequacy no marked differences were noted amongst the lild subjects and the control subjects regarding the cohesive adequacy of their narrative productions. in addition, as noted previously, measures of reliability indicated that these scores were unstable across testing sessions and need to be considered with caution. however, it was of interest that the results from the analysis of the narrative productions revealed erroneous use of anaphoric referencing of lild2, ellipsis by lild1 and the lexical ties by lild3. these erroneous perceptions may account for the lower clarity ratings obtained by the' lild subjects. this is discussed in more detail below. content and clarity rating content and clarity ratings were developed to compare the results of the objective analysis with a subjective analysis regarding the content and elarity of each subjects' narrative sample of story b. in order to determine the interrater reliability for the content and clarity ratings, pearson product-moment correlation coefficients were computed. a significant value was found between rater 1 and rater 2 and between rater 2 and 3 for cohesion. therefore these raters presented with high correlation values and these ratings can be considered as being reliable. most of the subjects received mixed ratings for content except for c 1, who received "high" ratings. this could be explained as c1 produced the most accurate narrative according to the model, including all or most of the appropriate information. the other subjects were· reported by the raters, to omit or include infol")1lation, which was not part of the model story. the lild subjects received lower ratings for clarity than the control group. this means that the raters judged the lild group to produce narratives without the appropriate use of language, referencing and conjunctions. objective analysis of the lild narratives regarding cohesion concurs with the clarity ratings as the lild group tended to use a higher number of incomplete and e,rroneous cohesive ties. lild2 was shown to use the least percentage of complete anaphoric ties, and was judged to have the lowest rating of cohesion in his narrative of story b. lild3 produced the least amount of complete lexical ties in story b. this could explain why lild3 received a lower rating of cohesion than lild1 and the control group. summary of the findings a summary ofthe findings of the subjective and objective analysis are presented below: • amount of information: no difference was noted between the lild and control subjects. • length of the narrative discourse productions: no variations noted regarding length of narratives produced. • temporal sequence:_ali subjects showed general preservation of temporal sequence. • coherence: according to the objective and subjective luanne henshilwood and dale ogilvy analysis of coherence the lild and control subjects generally used the necessary items needed for a well-formed narrative. • evaluation: all subjects used necessary elements of evaluation although subtle variations were noted between the lild and control subjects. furthermore, the lild subjects tended to use less complex elements and increased ritual utterances and intensifiers than the control subjects. • cohesion: no marked differences were noted amongst the subjects for cohesive ties. analysis of cohesive adequacy indicated that there could be difficulties with anaphoric referencing and lexical ties in the lild subjects' narrative productions. these subtle deficits noted across all the lild subjects in the objective analysis were supported by the lower subject ratings received by all three lild subjects on the clarity ratings. conclusion and implications the use of reliable measures in the analysis of narrative discourse productions, in this study, allowed for findings'to be adopted with greater confidence. stability coefficients enable the researcher to know that the scores are representative of the samples produced by the subjects. results that are not stable across testing sessions need to be considered with caution until further investigation can clarify the reliability of the scores being analysed. one of the most important clinical findings of this study was that the lild subjects were able to tell stories. this supports previous research, which states that lild children contain the basic ability to produce stories (roth & spekman, 1986, morrls-friehe & sanger, 1992). these findings further support liles et al. (1995) as they state that lild children appear to be using, or· attempting to use information typical of a normal developing child regarding the production of narrative discourse. at times, objective analysis of the coherence and cohesion of all the subjects' narrative productions did not present with marked differences but rather indicated subtle differences. these findings support past studies which have shown that differences between lild subjects and control subjects are small and insignificant or none at au (ripich & griffith,1988). : furthermore, the heterogeneous nature of the learning disabled population has often been highlighted in past literature. the variations found within learning disabled!children often overlap with the variations found within the nonlearning disabled population (morris-friehe & sanger, 1992, nelson, 1993). ' possible factors thought to have contributed to the findings presented in this study include the nature and complexity of the task employed. the material used in this study could have been too simple, with too few events or lacking the appropriate complexity to tap any existing ling\listic deficits. it is believed that other additional discourse tasks and perhaps more complex tasks are required in or~er to tap the more subtle language deficits found in older language impaired learning disabled children. / another variable that could have influenced the findings in this study is the amount of speech and language therapy the subjects received prior to the study. ulatowska, hill, thompson ,parsons and wertz (1998) stated that this could play ~m important role in this area of narrative discourse research. /' the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) narrative discourse productions in older language impaired learning disabled children: 53 employing stricter reliability measures finally, the amount of variation in the normal controls needs to be highlighted. the results presented in this study not only illustrated the subtle differences in the lild subjects but also quite noticeably highlighted the individual variations found within the control subjects. the differences amongst the lild and control subjects were not always marked and sometimes the differences related merely to a matter of degree. sonnenberg and penn (1998) state that there is a wide variability across discourse measures that illustrate the features of normal subjects' discourse that are found to overlap with those of the clinical subjects. sonnenberg and penn (1998) provided a quote that captures the morality and issues involved in the research of narrative discourse: whose culture, experience, and value system are we to follow in making judgements of propriety? on what basis are we to say that a narration is too much or too little? one person's embellishment is another person's ingenuity. one person's digression is another person's interesting trip. (davis, 1993 in sonnenberg & penn, 1998) future research implications numerous future research implications have emerged from this study: a need to continue to establish valid and reliable indices of measurement for narrative ability has been highlighted. in addition, further research regarding the normal variation in narrative discourse productions in the nonlearning disabled population is needed. without this, interpretation of the analysis of the narrative discourse productions oflanguage impaired populations is limited and the· diagnosis oflanguage impairments from the analysis of narrative discourse remains questionable. as stated previously, language impairments in the learning disabled, become increasingly subtle and harder to identify with age. at present little information is available on narrative discourse in older language impaired children. hence, further investigation in this population would enhance the treatment and rehabilitation of such a disorder. ./ other aspects, which could be considered for further in/vestigation are the compairison of spoken and written discourse samples in the lild population and the measurement of discourse across 8.ifferent elicitation tasks. measi urement of discourse ability across various levels of complexity could yield intere~ting findings and may even provide a means to. tap the more subtle deficits noted in older lild children's narratives. references applebee (1978). the child's concept of story: ages ttuo to seven· teen. the university chicago press, chicago. briggs, r (1978). the snowman. penguin group, london. bruner, j. (1990). acts of meaning. cambridge: harvard university. culatta, b., page, j. & ellis, j. (1983). story retelling as a communicative performance screening tool. language, speech and hearing services in schools, 14,66-74. cole, k, mills, p. & dale, p. (1989). examination of test-retest and split-half reliability measures derived from language samples of young handicapped children. language, speech and hear· ing .services in schools, 20, 259-268. collington, p. (1987). the angel and the soldier boy. methuesen children, london. glosser, g. and deser, t. (1990). patterns of discourse production among neurological patients with fluent language disorders. brain and language, 40, 67-88. halliday, m. and hasan, r (1976). cohesion in english. longman group ltd., london. hux, k., sanger, d., ried, r & maschka, a (1997). discourse analysis procedures: reliability issues. journal of communicative disorders, 30,133-150. isaki, e. and plante, e. (1997). short-term and working memory differences in language/learning disabled and normal adults. journal of communication disorders, 30,427-437. klein, h. (1991). children with specific learning difficulties: the role of the speech therapist. in snow ling, m.(ed.) children's written language difficulties. nfernelson publishing company ltd., oxford. . labov, w. (1977). language in the inner city: studies in the black english vernacular. basil blackwell, oxford. liles, b. (1985).cohesion in the narratives of normal and language -disordered children. journal of speech and hearing research, 28,123-133. liles, b. (1993). narrative discourse in children with language disorders and children with normal language : a critical review of the literature. journal of speech and hearing research, 36, 868-882. . liles, b., duffy, r, merritt, d. & purcell, s. 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(1982). moonlight. penguin group, london. paul, r and smith, r(1993). narrative skills in 4-year·olds with normal, impaired and late-developing language. journal of speech and hearing research, 36,592-598. purcell,s. and liles, b. (1992). cohesion repairs in the narratives of normal-language and language -disordered school-age children. journal of speech and hearing research, 3, 354-362. ripich, d. and griffith, p. (1988). narrative abilities of children with learning disabilities and non-disabled children: story structure, cohesion and propositions~journal of learning disabili· ties, 21(3),165-173. roth, f. and spekman, n. (1986). narrative discourse: spontaneously generate stories oflearning -disabled and normally achieving students. journal of speech and hearing disorders, 51, 8 -23. rumble, s. and malan, k. (1990). the development of a framework for assessing developing conversational skills. the south african journal of communication disorders, 37,21-26. strong, c. and shaver, j. 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(1998). what is abnormal discourse? some cautions for the aphasia therapist. poster presentation at the 8'h international aphasia rehabilitation conference, kwa maritane, pilanesberg national park, south africa. ulatowska, h., freedman -stern, r ,doyel, a, macaluso-haynes, s. & north, a (1983). production of narrative discourse in aphasia, brain and language, 19, 317-334. ulatowska, h., hill, c. ,thompson, j., parsons, s. & wertz, r (1998). discourse productions in african ·americans with apha· sia. presentation at the 8th international aphasia rehabilitation conference, kwa maritane, pilanesberg national park, south africa. wiig, e. and semel, e. (1986). language disabilities in children and adolescents. charles e. merrill publishing company, ohio. die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 54 /' the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) abstract introduction methods questionnaire design selection of participants distribution data analysis results discussion survey distribution sample academic education educational needs and strategy conclusion acknowledgements references about the author(s) emad ghabrial department of orthodontics, faculty of health sciences, university of pretoria, pretoria, south africa kurt w. bütow division of dentistry, faculty of health sciences, university of kwazulu-natal, durban, south africa steve a.s. olorunju biostatistics unit south african medical research council, pretoria, south africa citation ghabrial, e., bütow, k.w., & olorunju, s.a.s. (2020). south african speech-language therapists’ opinion of their training in cleft lip and palate and craniofacial deformities. south african journal of communication disorders, 67(1), a695. https://doi.org/10.4102/sajcd.v67i1.695 original research south african speech-language therapists’ opinion of their training in cleft lip and palate and craniofacial deformities emad ghabrial, kurt w. bütow, steve a.s. olorunju received: 17 nov. 2019; accepted: 09 may 2020; published: 30 july 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: speech care of cleft lip and/or palate (clp) and craniofacial deformities (cfd) is complex and lengthy and requires collaboration amongst different disciplines. consequently, it is important to provide academic educational models that include didactics, online learning and clinical exposure in clp and cfd treatment, and participation in established cleft palate multidisciplinary team management. objectives: to obtain information regarding: (1) the perceived adequacy of clp and cfd academic education of speech-language therapists (slts); (2) the professional services that slts offer to clp and cfd patients; and (3) the educational needs of slts in this field. method: a 54-item online survey to collect quantitative data was conducted by telephone and email using a randomised sample of slts in different areas of south africa. results: the questionnaire was completed by 123 slts, 70% of whom had more than 10 years of professional experience. of the respondents, 81% acknowledged their limited clinical exposure during their academic education. only 42% of the professionals offer treatment for clp and cfd patients. of the respondents, 96% agreed on the need to improve clp and cfd academic education, and the majority recommended certified courses, continued-education workshops and online resources. conclusion: the findings indicate that slts academic training is perceived to be significantly limited in the cleft palate and craniofacial fields. thus, there is a strong need at the undergraduate level for clinical training and exposure to multidisciplinary management. at post-graduate level there is a need to establish an educational strategy to meet the needs of slts providing clp and cfd care. participants suggested that programmes for continuing professional education, degree courses and online resources be designed to provide practising clinicians with updated information and guidance in management of clp and cfd patients. keywords: speech-language therapist; cleft palate; cleft lip; multidisciplinary; education; professional development; medical survey; craniofacial disorder. introduction speech therapy is considered a core service in the management of cleft lip and/or palate (clp) and craniofacial deformities (cfd), since young children with clp are at considerable risk of suffering from delayed or disordered communication development (american cleft palate-craniofacial association, 2016; hammond & stassen, 1999). the role of the speech-language therapist (slt) dealing with children with clp and/or cfd is essential, not only to achieve the maximum communication potential but also in the management of swallowing and feeding (evens & louw, 2015; fair & louw, 1998; peterson-falzone,trost-cardamone, karnell & hardin-jones, 2016). for many years, researchers and practitioners have understood the need to enhance academic education and clinical experience regarding clp and cfd in order to provide quality management and to improve access to care for all patients and their families (dabed & cauvi, 1998; gadbury-amyot, simmer-beck, mccunniff & williams, 2006). one of the earliest attempts to evaluate academic education in the clp field was made by lass, gasperini, overberger and connolly (1973), to assess the exposure of academic students to clp treatment by means of a questionnaire. the main finding was that there was a lack of clinical exposure and basic theoretic education. this was the same as the findings of vallino, lass, pannbacker, klaiman and miller (1992) on the effects of limited academic training in clp management; they advise that a clinician with limited training should not manage individuals with clp. clp patient care relies on the teaching and exposure that the student received at university and the knowledge gained throughout the practitioner’s career (mcdonald, adamidis, eaton, seeholzer & sieminska-piekarczyk, 2000; wium & louw, 2013). therefore, continuous evaluation of the academic education and services provided for clp and cfd is necessary to provide a foundation for the improvement of educational resources. it becomes necessary to obtain information regarding the current knowledge of slts in the clp field and also to determine the educational needs of those providing services to clp and cfd (cameron & widmer, 2013). methods ethical permission was obtained from the humanities and social sciences research ethics committee of the university of kwazulu-natal. a quantitative research method using a 54-item structured questionnaire was developed. qualtrics research suite survey software (qualtrics, 2017) was used to capture and analyse the data. the questionnaire was designed to collect quantitative data using a likert-type scale, which was introduced to each practitioner by means of a telephone call. consent for participation was obtained from each respondent prior to completing the questionnaire. the data was collected either online or in a telephone interview, according to the preference of the participants. questionnaire design the questionnaire consisted of four sections: the first determined whether the participants were acceptable for inclusion in the study. the second section collected the level of knowledge, experience and services provided by the participants. in the third section, their educational needs and preferences regarding further education were determined. the last section collected demographic data, which included title, gender, age, degree(s) and location by region. selection of participants a random sample of slts was obtained from the medpages database registry for practising healthcare professionals (manana et al., 2018). regarding sample size, the author used the literature information (modi & ross, 2000; thandeka, penelope & robin, 2016) as a guidance for the response rate. this was reviewed upward to 19% of medpages’ practising slts to account for a possible sampling error of 15%. distribution the researcher approached the south african speech-language-hearing association to distribute the survey by email. before distribution, the questionnaire was piloted by selected practitioners. they were invited to complete the questionnaire, which was subsequently revised based on the responses, in order to ensure the appropriate capturing of data. initially, the questionnaires were to be distributed by the qualtrics online survey platform twice during the first week, then weekly afterwards. this was ultimately not necessary, as the targeted participant number was achieved by randomly contacting 123 slts on the medpages database. data analysis the data were captured using excel 2013. this was later converted into stata 15 s (string) format. the analysis undertaken was descriptive summary statistics presenting frequencies and associated percentages. no further analytical tools were used because no hypothesis was being tested. ethical consideration this article followed all ethical standards for carrying out research with ethical clearance obtained from university of kwazulu-natal, school of health sciences. results the questionnaire was completed by 123 slts, representing most of south africa’s provinces (figure 1). of these practitioners, 70% had more than 10 years of professional experience (figure 2). figure 1: respondents’ distribution according to province. figure 2: respondents’ distribution according to clinical experience. regarding the basic knowledge questions, 39% of the respondents were uncertain of the correct answers. these questions were: q8. the most common craniofacial facial deformity in humans is cleft lip/palate. true/false/do not know. q9. the incidence of cleft lip/palate is higher in black populations than in white population. true/false/do not know. when asked about their educational experience, only 9% stated that they had clinical exposure during their undergraduate education and 13% during postgraduate education. only 8% at undergraduate level and 13% at postgraduate level participated in multidisciplinary meetings during their academic education. regarding didactic exposure, only 10% of the undergraduates and 59% of the postgraduates had some exposure (figure 3). just 44% of the respondents offered services for both clp and cfd patients and 41% of them participated in multidisciplinary teams. regarding the services provided according to patients’ age groups, only 10 of the participants offer assessment and intervention to infants. the rest offer services to children from the age of 4 years to adult. when the respondents were asked about the facility where clp patients were consulted and treated, the following emerged: private practice 47%, private hospitals 24% and academic and/or government hospitals 25%. only three of the respondents offered their services at special schools and government clinics. figure 3: undergraduate and postgraduate academic education in cleft lip/palate/craniofacial deformities patient management. the 53 respondents who stated that they offer assessment, as well as treatment were asked about the complexity of clp/cfd patients. they acknowledged that it is exceptionally difficult to treat these patients and that it requires special training. when asked why there is a need for special training, they indicated that it is due to the multidisciplinary approach needed (35%), the lengthy treatment (34%), and patients’ socio-economic situation (25%). in the open-ended questions, a few respondents cited the emotional state of the family and patients as being additional complicating factors. when the non-treating respondents were asked to highlight the factors preventing them from treating clp and cfd patients, 44% stated that it was related to limited training and experience, 23% admitted lack of interest, 19% stated that it was because of low referrals and 13% highlighted the duration of the treatment (figure 4). figure 4: what prevents speech-language therapists from treating cleft lip/palate/craniofacial deformities patients? almost all of the respondents agreed on the need to improve the academic education offered to clp and cfd treatment providers, and 97% of the respondents recommended dedicated academic training programmes in that field. of the respondents, 62% would like to further their knowledge of clp and cfd management. when participants were asked about the preferred method of education: the majority 74% recommended short courses and workshops. 21% recommended part-time certificate courses. 3% recommended full-time studies; and only 2% recommended digital learning (figure 5). figure 5: programme for cleft lip/palate/craniofacial deformities format. participants identified interest, passion and the prospect of joining an interdisciplinary team as the most significant reasons for enrolment in clp and cfd-dedicated courses. when asked about a certificate course, the participants suggested that the focus should be on assessment, treatment planning, clinical skills, and an interdisciplinary approach. keeping a logbook of the hours spent in clinical training, as well as participating in examinations, were generally recommended as effective evaluation methods for certificate courses (figure 6). figure 6: what form of evaluation would you suggest? discussion as indicated by callahan and hazelwood (2004), as the speech-language therapy field widens the less-frequently seen clp and cfd patients present a challenge for academic training and practitioners because of less emphasis on academic education and changes in the scope of practice in some countries. in this survey, the majority of the respondents received an academic education that included mandatory course work. this is in line with the findings of vallino, lass, bunnell and pannbacker (2008). despite this, respondents expressed the need for further training and clinical exposure to make them competent to provide services to clp and cfd patients. survey distribution some previous slt surveys, e.g. pannbacker, lass, scheuerle and english (1992), used email or postal questionnaires. others used incentives to improve the response rate (bedwinek, kummer, rice & grames, 2010). this study used a mixed method of data collection: telephone interviews and email provided wide distribution not limited by email access, in line with recommendations by flanigan, mcfarlane and cook (2008). by targeting a number of responses to obtain a statistically valid number, it was possible to reach the required number with less concern about a low response rate than that experienced by asch, jedrziewski and christakis (1997). sample in similar studies, pannbacker et al. (1992) surveyed slts who were members of the american cleft palate association. the sample in the study by bedwinek et al. (2010) comprised slts from selected schools. these surveys provided valuable information but did not include any other types of slt. in this study, attention has been given to including information obtained from slts with varied years of experience, from different locations and places of employment, in order to overcome limitations and to obtain general opinions from all clinicians. academic education this study found a limited emphasis on general knowledge and clinical exposure during academic graduate programmes. this is in line with the findings of callahan and hazelwood (2004) and kuehn, kummer, d’antonio and karnell (2006) that graduate students may leave with limited education in the clp fields. this study found similar data on academic education with limited clinical and multidisciplinary exposure. the findings are in line with those of pannbacker, lass and starr (1979), demonstrating that practitioners who are legally qualified to provide treatment really know very little about these deformities. educational needs and strategy this investigation revealed a strong desire amongst slts for professional development and dedicated educational programmes in the areas of assessment and intervention with children born with clp and cfd, in line with the findings of vallino et al. (2008). most respondents preferred practical information and multidisciplinary exposure related to clp and cfd patients. of the respondents, 73% ranked continued professional development as a preferred way of obtaining information, and 32% recommended a certification programme of 12–24 months. this contrasts with the finding of bedwinek et al. (2010) that web-based education and conferences are the preferred method of continuing education. conclusion as the slt field widens, it leads to less education in uncommon problems such as clp and cfd. speech-language therapists may be confronted with the need to provide services that are not covered by their training and experience. it is essential for slts to know how to assist the patient and communicate with the appropriately-trained professionals. this study shows that there is a demand from slt practitioners for continued education and certificate courses in the clp field. consequently, academic institutions need to adopt educational strategies and provide resources for underand postgraduate students and practitioners. nevertheless, knowledge exchange through online communities will benefit a wider range of slts (karnell, bailey, johnson, dragan & canady, 2005). limitations this survey represents the opinions of those slts who were selected randomly and who were willing to respond to the survey. it is possible that those slts who received the survey and did not respond, did not feel that additional training in this area was a need or concern. another limitation is the lack of verification of the actual training in clp and cfd by the universities, to justify whether the perceptions are valid or not, which could raise a whole new set of questions. acknowledgements the authors would like to thank the gerald gavron research fund of the south african society of orthodontics for financial support, dr esedra krüger department of speech-language pathology and audiology, university of pretoria for her valuable input and effort regarding the project and prof. f.a. de wet, prof. emeritus for proofreading the manuscript. competing interests the authors have declared that no competing interest exist. authors’ contributions the main author, e.g., contributed 60%, with k.w.b. and s.a.s.o. both contributed 20% each. funding information the phd project was funded by the sa society of orthodontics gerald gavron fund. the funding sources were not involved in the design of the study, data collection analysis, interpretation of results, or writing the manuscript. data availability statement the dataset supporting the conclusions of this article is not currently available, as it is part of the researcher’s phd thesis. the questionnaire used to collect the data is available from the corresponding author on request. disclaimer this article is based on a study done by the researcher in partial fulfillment of his phd thesis. the authors declare no conflict of interest. references asch, d.a., jedrziewski, m.k., & christakis, n.a. 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(2013). revisiting the roles and responsibilities of speech-language therapists in south african schools. south african journal of communication disorders, 60(1), 31–37. https://doi.org/10.4102/sajcd.v60i1.8 abstract introduction research method and design results discussion conclusion acknowledgements references about the author(s) jessica paken discipline of audiology, school of health sciences, university of kwazulu-natal, durban, south africa cyril d. govender discipline of audiology, school of health sciences, university of kwazulu-natal, durban, south africa mershen pillay discipline of audiology, school of health sciences, university of kwazulu-natal, durban, south africa vikash sewram african cancer institute, department of global health, faculty of medicine and health sciences, stellenbosch university, cape town, south africa citation paken, j., govender, c.d., pillay, m., & sewram, v. (2020). perspectives and practices of ototoxicity monitoring. south african journal of communication disorders, 67(1), a685. https://doi.org/10.4102/sajcd.v67i1.685 original research perspectives and practices of ototoxicity monitoring jessica paken, cyril d. govender, mershen pillay, vikash sewram received: 14 oct. 2019; accepted: 23 feb. 2020; published: 19 may 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: treatment of cancer with cisplatin can result in hearing loss. given the increasing burden of cancer in africa, appropriate and timely identification, intervention and management of hearing loss in affected patients is of paramount importance. objectives: this study describes the perspectives and practices of healthcare professionals in relation to cisplatin-associated ototoxicity at an institution treating patients diagnosed with cancer. method: a concurrent triangulation study design was used to collect quantitative data from seven oncologists, nine nurses and 13 pharmacists using self-administered questionnaires, and qualitative data from four audiologists through semi-structured interviews for this hospital-based study, conducted in south africa. results: levels of awareness of cisplatin-associated ototoxicity varied with only 33% of the nursing personnel being aware in comparison to the oncologists and pharmacists. oncologists were identified as the main custodians for providing information to patients. whilst 82% of the participants considered the audiologist to be part of the oncology team, there was no provision for ototoxicity monitoring in the chemotherapy protocols, nor any ototoxicity-monitoring programme in place. there was no evidence that knowledge of cisplatin-associated ototoxicity translated into an appropriate management strategy for such patients. conclusion: healthcare personnel overseeing the care and management of cancer patients need to improve their awareness of ototoxicity and refer timeously for audiological evaluation. audiologists require greater awareness of monitoring programmes to appropriately implement and manage such programmes within a cancer platform and be part of a multidisciplinary team. keywords: awareness; cisplatin; south africa; ototoxicity; cervical cancer; healthcare personnel. introduction south africa is experiencing an increase in the overall burden of disease attributable to cancer, with the number of new cancer cases predicted to increase by 46% by 2030 (ferlay et al., 2013). in light of the country’s quadruple burden of disease, this poses a challenge to the medical fraternity, as many human immunodeficiency virus (hiv), tuberculosis (tb) and cancer therapeutics are ototoxic, causing hearing loss from temporary or permanent inner ear dysfunction owing to treatment with such agents (yorgason, fayad, & kalinec, 2006). furthermore, hiv and tb often occur together, in addition to many acquired immunodeficiency syndrome–related malignancies, such as cervical cancer, kaposi’s sarcoma and so on, thus compounding the impact of ototoxicity as a result of the combined regimens that are prescribed. therefore, it is crucial that hearing assessments form part of the holistic management of patients diagnosed with these conditions. however, the public health importance of ototoxicity is often unheeded, to the detriment of affected patients. this negatively affects their communication ability, often resulting in educational and economic shortcomings, and social isolation (paken, govender, pillay, & sewram, 2016). in limited resource environments, such outcomes are often intensified because of the lack of rehabilitation and social services. whilst local statistics are highly underrepresented, the world health organization’s (who) global estimate for disabling hearing impairment, defined as more than 40 db hl impairment in adults and more than 30 db hearing threshold in children, has more than doubled from 120 million people in 1995 to at least 278 million in 2005. of these individuals, approximately 80% of the affected population are living in developing countries (olusanya & newton, 2007). the challenge in addressing this burden lies not only in early identification of high-risk groups but also in the provision of early interventions. increasing global estimates for disabling hearing impairment result not only from more people living longer but also external factors such as recreational and occupational noise exposure as well as increased use of ototoxic medications. the ototoxic effects of cisplatin, such as bilateral high-frequency sensorineural hearing loss and tinnitus (daldal, odabasi, & serbetcioglu, 2007), are compounded in cases where the affected individuals diagnosed with cancer are also hiv-positive and undergoing antiretroviral therapy (art). they face a double-barrelled effect of ototoxicity due to the ototoxic effects of cisplatin and arts (bisht & bist, 2011). cisplatin-associated ototoxicity has been reported by numerous researchers over the years, and it is therefore critical that healthcare professionals understand the impact of this ‘invisible condition’ (tye-murray, 2014), as ototoxicity further impacts on the patient’s quality of life. therefore, to mitigate further deterioration of quality of life, operational processes need to be in place so that impairments that may subsequently arise, including ototoxicity, can be addressed through appropriate and immediate management measures. hence, one has to ensure operational processes that will minimise the resulting comorbidities from the use of such drug regimens (paken et al., 2016). with regard to ototoxicity, an ototoxicity-monitoring programme can avert, to a large extent, the impact of hearing loss. it enables patients undergoing treatment with known ototoxic drugs to be identified early, counselled, monitored and managed through appropriate interventions in a logical, systematic and coherent manner. such a programme can involve a healthcare team, using evidence-based practices (schellack, wium, ehlert, van aswegen, & gous, 2015), to ensure effective sustainability of such a programme, if implemented, with the patient being the central focus. the team should consist of the oncology nurse, oncologist, audiologist and pharmacist. apart from hearing loss, tinnitus and vestibular dysfunction are also by-products of ototoxicity; therefore, sensitivity to a patient’s comorbidity and a resultant comprehensive team approach is crucial to improving the patient’s overall quality of life. awareness of the adverse effects of cisplatin amongst healthcare personnel involved in the management of affected individuals is of paramount importance to ensure appropriate counselling of the patient and provision of appropriate professional referrals for holistic management. a team approach is possible only if the team members are knowledgeable of the ototoxic effects of medication, its related symptoms as well as the responsibilities of each of the members within an ototoxicity-monitoring programme. key responsibilities of the multidisciplinary team involved in ototoxicity monitoring are highlighted in table 1. table 1: key responsibilities of the healthcare personnel involved in ototoxicity monitoring of patients receiving cancer chemotherapy. whilst there is one international study (steffens et al., 2014) and three south african studies that have focussed on the knowledge and/or practices regarding ototoxicity (de andrade, khoza-shangase, & hajat, 2009; khoza-shangase & jina, 2013; wium & gerber, 2016), all four studies have focussed on the oncologists and general practitioners. unfortunately, there are no studies reporting on the variation in practise and awareness of other healthcare professionals such as the nurses, audiologists and pharmacists in relation to cisplatin-associated ototoxicity within a single facility treating cancer patients. it is important to assess awareness and management practices within such a facility, as it provides scope as an ideal environment, if required, for the implementation of an ototoxicity-monitoring programme. this can maximise patient outcomes within the confines of facility-specific infrastructure and resources. it is therefore essential to determine the awareness of healthcare personnel regarding cisplatin-associated ototoxicity and to determine if this awareness, or lack thereof, influences their practice. even though the ototoxic side effect of cisplatin in the literature, most oncologists do not anticipate or look for ototoxicity in patients receiving cisplatin (malhotra, 2009). therefore, the aim of this concurrent mixed methods study was to describe the healthcare professionals’ perspectives of, and current practices for, monitoring ototoxicity in cancer patients receiving cisplatin chemotherapy. the definition of ‘perspectives’ used consistently in the current study refers to participants’ reported knowledge of a situation or fact, whilst ‘practice’ refers to their current management of the affected patient. a greater understanding of the current management practices of affected patients will form a basis for the formulation of a more robust and successful implementation of an ototoxicity-monitoring programme relevant to the south african public health sector. research method and design study design the study utilised a concurrent triangulation approach, as both quantitative and qualitative data were collected simultaneously from different data sources, and the two databases were used to describe the healthcare professionals’ perspectives of, and current practices for, monitoring ototoxicity in cancer patients receiving cisplatin chemotherapy (cresswell, 2009). therefore, whilst the quantitative and qualitative data were collected concurrently and analysed separately, mixing of the data occurred in the results and discussion of this article. setting the study was conducted at a tertiary hospital in kwazulu-natal, south africa, which is one of the treatment centres for patients with cancer in the province. study population and sampling strategy maximal variation sampling was used in the study, as the researcher purposefully sampled individuals who differed on some characteristic, that is, profession (cresswell, 2012). healthcare personnel directly involved in the management of patients with cancer, that is, oncologists, oncology nurses and pharmacists as well as audiologists were invited to participate. physicians, pulmonologists and general nurses were not invited to participate as the study was confined to the oncology unit or clinic, as this was the setting where the greatest influence in terms of appropriate management and referrals of patients with cancer was envisaged to be made. data collection qualitative data were collected from individual face-to-face interviews conducted for approximately 30 minutes and audio recorded with the resident audiologists, using inductive inquiry and a semi-structured interview schedule (with predetermined themes), the questions of which are reflected in table 2. quantitative data were collected from consenting oncologists, nurses and pharmacists on completion of a 10-minute questionnaire specific to their role in ototoxicity monitoring, as indicated in tables 3 and 4. the questionnaire for the oncology clinic personnel was adapted from that of de andrade et al. (2009). table 2: questions in the semi-structured interview schedule. table 3: clinic personnel responses to the questionnaire. table 4: pharmacist’s responses to the questionnaire. the questionnaires and interviews aimed to solicit information on perceived awareness of chemotherapy-associated ototoxicity, patient-reported symptoms and perceived roles and responsibilities of the different healthcare professionals within an ototoxicity-monitoring programme as well as their current practices in the identification and management of patients at risk for cisplatin-associated ototoxicity. interviews were conducted with the audiologists to enable the acquisition of in-depth information, as audiologists are considered the key role players in setting up and implementing an ototoxicity-monitoring programme. data analysis following verbatim transcription of the interviews, the transcripts were uploaded for analysis using qsr international’s nvivo 12 software, and analysed using thematic analysis (richards, 1999). the main themes were predetermined, whilst the subthemes emerged during analysis of the transcriptions. descriptive analysis of the quantitative data included percentage counts. the fisher’s exact test was used to statistically compare the responses between the oncologists and oncology nurses, and reported where significant differences were observed. the point-biserial correlation analysis was used to determine the relationship between the months of clinical experience of the clinical personnel and awareness that certain chemotherapy drugs can cause hearing loss, as well as enquiries with respect of patient history. a p-value of <0.05 was considered statistically significant. the qualitative and quantitative data were then triangulated, as there is evidence from different individuals, different types of data as well as different methods of data collection (cresswell, 2012). this afforded the researchers the opportunity to ensure that the responses were concordant. reliability and validity a pilot study was conducted with one oncologist, one nurse and one pharmacist who were not included in the main study, prior to data collection. the purpose of the pilot study was to assess any potential problems with the questionnaires and to ensure reliability of the study. no changes were made to the questionnaires based on the results of the pilot study. a pilot study was not conducted with the audiologists because of the limited number of audiologists at the study site. member checking with the audiologists was used to verify accurate transcription of interviews. ethical consideration the study was approved by the university research and ethics committee, the department of health and the hospital management ([brec], ref. no.: be064/13). all participants were briefed about the nature of the study, the study procedures, their right to withdraw at any time and procedures to maintain confidentiality. they were also informed that their participation was voluntary. written informed consent was obtained from all participants. results thirty-three healthcare personnel, including seven oncologists, nine nurses and 13 pharmacists, all of whom are involved in the management and care of cancer patients, as well as four audiologists (a, b, c and d), participated in the study. all oncologists had more than 1 year of experience managing patients with cancer. the oncologists included registrars and oncologists, with four (57%) having more than 4 years of experience. five nurses (56%) had less than 1 year of experience managing patients with cancer, whilst two (22%) had more than 4 years of experience. a comprehensive list of the responses by oncologists and nurses is provided in table 3, whilst that of pharmacists is provided in table 4. during the interviews, the five major themes included awareness of chemotherapy-associated ototoxicity, patient-reported symptoms and the perceived roles and responsibilities of the different healthcare professionals within an ototoxicity-monitoring programme as well as their current practices in the identification and management of patients at risk for cisplatin-associated ototoxicity. the themes and subthemes are reflected in figure 1. figure 1: hierarchy of themes arising from transcripts. awareness of chemotherapy-associated ototoxicity all the oncologists and pharmacists indicated that they were aware that certain cancer chemotherapy drugs may cause hearing loss in comparison to 33% of the nursing staff (p = 0.010). identification of common ototoxic medication whilst all audiologists were aware that certain cancer chemotherapy drugs may cause hearing loss, their knowledge regarding other drug classes that may be ototoxic appeared to be limited. this was demonstrated by them correctly identifying medication for tb, that is, aminoglycosides to be ototoxic but not being able to name the drugs. audiologist b reported: ‘all your mycin drugs, what you call that i forgot the name but it’s that class of drugs, then obviously the cancer chemo drugs and more recently we finding renal patients so it’s your loop diuretics and those kind of things.’ (audiologist b, male, 7 years experience) furthermore, audiologists a and b correctly identified loop diuretics as being ototoxic, whilst audiologists a, b and c did not indicate arts to be ototoxic, and audiologist d indicated her uncertainty about arts being ototoxic: ‘i’m not sure if the arvs also cause hearing loss but i also don’t know their names.’ (audiologist d, female, 18 years experience) patient-reported symptoms reduced hearing sensitivity reduced hearing sensitivity and pain in the ears were two of the most common auditory symptoms reported to oncologists and nurses by cancer patients, whilst noises in the ear and hypersensitivity to sounds were seldom or not reported at all. all audiologists indicated that patients on cancer chemotherapy would generally complain of reduced hearing sensitivity and speech discrimination problems. the hearing loss was described to be permanent and progressive, with audiologist c reporting: ‘once they’ve presented with a hearing problem after about the second round of chemo, it does get worse by the end of the treatment.’ (audiologist c, female, 3 years experience) audiologist c indicated that the hearing loss generally appears after approximately 6 weeks. audiologists a and b indicated that the progression of the hearing loss was dose-dependent: ‘i think depending on the dosage and how long they have been on it.’ (audiologist a, male, 8 years experience) tinnitus in addition, audiologists b, c and d also indicated tinnitus, which is permanent; however, audiologist c reported: ‘they generally describe it as a roaring noise and that’s their major issue.’ (audiologist c, female, 3years experience). however, audiologist d described the tinnitus as: ‘… usually high frequency.’ (audiologist d, female, 18 years experience) audiologist b also reported dizziness because of vestibulo-toxicity being a side effect of cancer chemotherapy. awareness of the responsibilities of healthcare personnel team approach in ototoxicity monitoring seven oncologists (100%), seven nurses (78%) and nine pharmacists (69%) considered the audiologist to be part of the team managing a patient with cancer. all audiologists indicated that the hospital did not currently have a team approach for managing adult patients on cancer chemotherapy, with one noting: ‘i don’t think that we are a part of the team if there even is a team.’ (audiologist, a, male, 8 years experience) while audiologist d reported: ‘no there isn’t a team at the hospital with oncology and for cancer patients.’ (audiologist d, female, 18 years experience) furthermore, the audiologists only receive referrals from the oncology department when the patient complains of reduced hearing sensitivity, with audiologist c, indicating: ‘it usually is whatever the patient reports, then they will refer to that professional as needed.’ (audiologist c, female, 3 years experience) pretreatment counselling (information giving) two oncologists (29%) and two nurses (22%) indicated that it was the nurse’s responsibility to provide information to patients about the ototoxic effects of medication, whilst all clinic personnel (100%) felt that it was the oncologist’s responsibility to do so. furthermore, one oncologist (14%) and two nurses (22%) felt that it was the pharmacist’s responsibility to provide patients with information about the possible ototoxic effect of medication, whilst one oncologist (6%) indicated that it was the audiologist’s responsibility to do so. the majority of the pharmacists indicated that it was either their responsibility (85%) or that of the oncologists (92%) to provide patients with information about the possible ototoxic effects of medication, whilst a lesser number indicated that such a role should be delegated to either the nurse (38%) or the audiologist (38%) (table 4). audiologist a reported that it was both the oncologist’s and the audiologist’s responsibility to inform patients about the possible ototoxic effects of chemotherapy: ‘i think the doctors initially do tell them, yes that there is a chance of this happening because they are prescribing the medication because they are responsible for that. and then you need the audiologist to reinforce that.’ (audiologist a, male, 8 years experience) however, audiologist c indicated that it is the oncologist’s responsibility to inform the patients about the ototoxic effects of chemotherapy, ‘i think that it is the doctor because it’s not just audiology that’s involved.’ (audiologist c, female, 3 years experience) another also indicated that the audiologist is responsible for setting up the ototoxicity-monitoring programme: ‘…you know any audiology programme needs to be set up by a key player or audiologist.’ (audiologist b, male, 7 years experience) referrals to ototoxicity-monitoring programme with regard to assuming responsibility for the referral of patients at risk for hearing loss to the ototoxicity-monitoring programme, all pharmacists (100%) felt that it was the oncologists’ responsibility to do so. in addition, two pharmacists (15%) reported that it was the nurse’s responsibility to do so, whilst three pharmacists (23%) indicated that it was their responsibility and one pharmacist (8%) indicated that it was the audiologist’s responsibility to do so. audiologist b indicated: ‘ideally hopefully the doctor would know that they need to come for hearing….’ (audiologist b, male, 7 years experience) whilst another stated that all patients on cisplatin chemotherapy should be sent for audiological assessments: ‘i think that they all should be sent, as long as they are on the drugs.’ (audiologist a, male, 8 years experience) ototoxicity-monitoring programme awareness of ototoxicity-monitoring programme at the hospital five oncologists (71%) and one nurse (11%) indicated that their facility does not have an ototoxicity-monitoring programme, whilst two oncologists (29%) and eight nurses (89%) were not sure if one existed. the fisher’s exact test revealed a significant difference (p = 0.021) between the oncologists and oncology nurses’ responses about the ototoxicity-monitoring programme at the hospital. in addition, most of the oncologists indicated that there was no protocol for monitoring patients’ hearing (57%) or was unsure if one existed (43%). similarly, nurses were unsure if such a protocol existed (78%). all audiologists indicated that there is no ototoxicity-monitoring programme at the hospital, with audiologist b further stating: ‘no, we don’t have a programme but it’s not to say that we won’t have it.’ (audiologist b, male, 7 years experience) elements of an ototoxicity-monitoring programme whilst none of the audiologists were able to correctly state all the key elements of an ototoxicity-monitoring programme, they did indicate baseline testing prior to treatment, monitoring tests to enable the earliest detection of the hearing loss and follow-up tests to determine post-treatment hearing status, but were unable to correctly indicate the intervals for these assessments. audiologists a and b identified pretreatment counselling as an essential element of an ototoxicity-monitoring programme; however, audiologist c indicated: ‘i think it’s important before they go onto chemotherapy that it’s explained the different side effects the treatment could have for them from the doctor’s point of view.’ (audiologist c, female, 3 years experience) with regard to the baseline assessment, audiologists b and c correctly indicated the audiological tests to be conducted. in addition, audiologist b indicated that it is the audiologist who should set up and be in charge of such a programme: ‘…[b]ut the audiologist should be in charge of a programme like that but we don’t have anyone yet.’ (audiologist b, male, 7 years experience) with no ototoxicity-monitoring programme in place, it was not surprising to note that none of the audiologists reported on establishing criteria for determining ototoxicity as an element of the ototoxicity-monitoring programme. current practices in the identification and management of cancer patients at risk for hearing loss at the hospital identification of at-risk patients all pharmacists reported that they were consulted less than 10 times in the previous month about drug interactions. two pharmacists (15%) indicated that the hospital has a system that allows patients at risk for hearing loss to be identified; however, only one pharmacist indicated alerting the clinical staff to patients at risk for an ototoxic hearing loss. when reduced hearing sensitivity is reported by a patient, nurses indicated that such patients were referred to the ear-nose-throat (ent) specialist (89%); however, the oncologists either referred to the ent specialist (43%) or the audiologist (86%). the majority of the oncologists (86%) and nurses (78%) indicated that they provided information to patients on the possible ototoxic effects of medication prior to commencing chemotherapy. with regard to enquiries about a patient’s medical history and exposure to drugs used to treat specific conditions, all the oncologists enquired about the existence of comorbidities such as tb and hiv. majority of the nurses (56%), however, only enquired about hiv infection. referrals to audiology all audiologists reported that the oncology department does not make many referrals, indicating: ‘i can’t say that oncology has been really a referral base for us.’ (audiologist d, female, 18 years experience) ‘the oncology department does refer to us sometimes so we do a baseline audio and monitoring as they see fit.’ (audiologist c, female, 3 years experience) audiologist’s role all audiologists indicated that their current role involved conducting audiological assessments. audiologist b indicated that a baseline is conducted followed by monitoring evaluations at 1 and 6 months post-treatment, respectively. furthermore, audiologist b indicated that a full diagnostic audiological assessment is undertaken: ‘it’s a full diagnostic audio, so air, bone, reflexes, well your full immittance and speech [pause] discrimination.’ (audiologist b, male, 7 years experience) however, audiologist a indicated that baseline audiological assessments do not commonly occur: ‘i don’t think much baselines happen.’ (audiologist a, male, 8 years experience) in addition, audiologist c indicated that audiological monitoring occurs only after treatment, and the patient is then referred to the base hospital for ongoing monitoring, and further elaborated: ‘obviously it wouldn’t make sense for the patient to travel on 2 days and come to this hospital when they have one close by.’ (audiologist c, female, 3 years experience) audiologists a and b reported that doctors are informed of the changes in hearing, and patients are subsequently referred to the base hospitals in their area of residence should they present with an ototoxic hearing loss, and/or are fitted with hearing aids. audiologists a and c also reported that they counsel the affected patients. discussion with the increasing incidence of cancer in south africa, affected patients would expect healthcare professionals to be aware of all side effects of the medication prescribed. results of this study have revealed that all oncologists, pharmacists and audiologists are aware that certain chemotherapy drugs used in cancer treatment may cause hearing loss. this finding adds to the body of published evidence in a similar respect (de andrade et al., 2009; wium & gerber, 2016). however, an area of development has been identified to improve the awareness of nursing staff to the ototoxic nature of some chemotherapy drugs. knowledge and awareness of this drug attribute is fundamental for informing the patient during pretreatment counselling and/or subsequent visits to ensure the early identification of ototoxicity. such information serves to give the patient a sense of greater control over their well-being (pillay, 2002) at a time when their emotional state may be most negatively affected. in spite of the kwazulu-natal province recording the highest hiv infection rate in south africa, only one audiologist mentioned that antiretroviral (arv) drugs or art may be ototoxic. as patients being treated for cancer may also be hiv-positive and on art regimens, this dual comorbidity can present unique challenges to affected patients. hence, ensuring an adequate enquiry with respect to medical history and knowledge of ototoxic drugs can ensure timeous identification of hearing loss within at-risk populations. as ototoxic hearing loss is often only detected when a communication problem becomes evident (fausti, wilmington, helt, helt, & konrad-martin, 2005), patients need to be informed of the early symptoms of ototoxicity to ensure its early identification and management. whilst all audiologists were aware of the symptoms of ototoxicity, majority of the oncologists and nurses reported that patients do not complain of the ‘subtle’ symptoms of cisplatin ototoxicity, such as tinnitus. given that tinnitus is a very early predictor of ototoxicity, patients ought to become aware of such symptoms to ensure timely notification to healthcare personnel to prevent delayed management of the hearing loss (de andrade et al., 2009). there is thus a clear role for the audiologist to be involved in the pretreatment counselling of cancer patients receiving chemotherapy. however, not all participant audiologists were aware that pretreatment counselling fell within their domain. in addition, the participants were not clear as to their roles and responsibilities within an ototoxicity-monitoring programme. information about the ototoxic effects of medication should be provided by the oncologist, nurses and audiologist, with the audiologist providing more details on the signs and symptoms (american speech and hearing association 1994); however, in the current study, pharmacists have also been identified by healthcare personnel as being responsible for providing patients with such information. furthermore, recommendations regarding hearing conservation should be provided to the patient by the audiologist (dabrowski & hussain-said, 2010); however, findings of this study revealed that this is not the case. whilst doctors have an ethical obligation to inform patients about the side effects of prescribed medication to permit patients to make informed decisions, a recent south african study revealed that a minority of the study participants, that is, doctors, routinely disclosed ototoxic risks to their patients (wium & gerber, 2016). this failure to disclose information to patients was attributed to a possible lack of awareness of such risks as well as possible language barriers affecting healthcare professional–patient interaction (wium & gerber, 2016). lack of information to patients provides a barrier for patient care and intervention if and when required (de andrade et al., 2009). whilst majority of the healthcare personnel correctly identified the oncologist as the main custodian for providing patient information on the ototoxic effects of medication, the audiologist was not identified as a key role player in such processes, even by some of the audiologists themselves. this indicates that audiologists may not have viewed themselves as custodians for the provision of such information and to be a part of the larger team. if the audiologists do not see themselves as part of the process, then other healthcare professionals are unlikely to do as well in the collective management of affected patients. therefore, wium and gerber (2016) emphasised that audiologists in south african hospitals should advocate their role in ototoxicity monitoring so as to promote referral of affected patients to an ototoxicity-monitoring programme. whilst the pharmacists have identified the oncologists as being responsible for referring patients at risk of hearing loss, they have not clarified their own roles within an ototoxicity-monitoring programme either, namely, alerting oncology staff and audiologists to patients at risk for a hearing loss. it is likely that the awareness of chemotherapy-associated ototoxicity, its related symptoms and the roles and responsibilities of each of the healthcare personnel within such a programme needs to be delineated and conveyed to ensure a cohesive and effective programme. whilst majority of the oncologists revealed that there is no protocol or programme for monitoring the patient’s hearing status, majority of the nurses were not sure if one existed. this has highlighted the need for further internal communication and knowledge in complex environments. the study further indicates that information on and awareness of ototoxicity will only serve to enhance early detection and timely management of patients, thus highlighting an additional role for audiologists in the establishment of, and participation in, continuing professional development activities on ototoxicity monitoring to raise awareness and grow the knowledge base for other healthcare professionals (wium & gerber, 2016). such activities have the potential to enhance involvement of personnel from the different relevant specialities and ensure that a successful and robust programme with the following key elements is implemented: (1) utilising specific audiometric criteria for cochleotoxicity, (2) identification of patients, (3) pretreatment counselling regarding the potential effects of the treatment on the auditory system, (4) baseline testing prior to treatment, (5) monitoring tests at intervals suitable to enable the earliest detection of the hearing loss and (6) follow-up tests at intervals suitable to determine post-treatment hearing status (american speech and hearing association 1994). access to resources such as the comprehensive programme for the monitoring of cochleotoxicity by the american speech and hearing association (1994), as well as the recently released ototoxicity-monitoring guidelines by the health professions council of south africa (2018) coupled with suitable discussion forums can assist the audiologist in setting up an ototoxicity-monitoring programme, employing a multidisciplinary team approach. this team approach would not be successful without effective communication and cooperation between audiologists, oncologists, nurses and hospital pharmacists. the findings of this study highlight that the pharmacists at the study site are not fully utilised, as they are consulted less than 10 times a month about drug interactions. a robust hospital system for identifying patients at risk for hearing loss would be an important development through the use of an automated database, which would allow the audiologist to identify those individuals receiving cochleotoxic treatment and to target these patients via automated referral generation (american academy of audiology, 2009). this referral system can involve the expertise of pharmacists who have access to the patient’s list of medication. it was evident that whilst the oncologists enquired about common illnesses such as tb, hiv, pain and fever, there was limited awareness around the ototoxic effects of quinine with only one oncologist enquiring about it. this can be attributed to the numerous reports of medication used in the treatment of tb, hiv, malaria, and pain and fever being ototoxic (campbell, 2000). furthermore, majority of the nurses did not enquire about these conditions and as such, patients who contract these illnesses during the course of chemotherapy may not report them, as they are generally not seen by the oncologist during each cycle of chemotherapy but rather by the nurses. oncologists and nurses also did not display awareness of patients being genetically susceptible to hearing loss as only one oncologist and three nurses reported enquiring about family history of hearing loss. it is likely that the nurses do not enquire about family history of hearing loss, as well as previous medical history as they assume that this has been addressed by the oncologists and that there is no change since the last enquiry. patients complaining of reduced hearing sensitivity were more likely to be referred by the nurse to the ent specialist, as opposed to the audiologist, whilst majority of the oncologists reported referring the patient to the audiologist. the findings of this study do not concur with the literature where it was reported that the participant oncologists had superficial knowledge of the role of the audiologist (de andrade et al., 2009). in our study, majority of the oncologists indicated referring patients complaining of reduced hearing sensitivity to the audiologist. this is in keeping with the reports of the audiologists who indicated that patients are only referred to them once there are complaints of reduced hearing sensitivity; hence, conducting baseline assessments is not common practice. all audiologists displayed awareness of their role of conducting audiological assessments in an ototoxicity-monitoring programme; however, this awareness does not translate to practice, as there was disparity in their responses regarding the time frames and tests currently being adhered to at the hospital, with one audiologist reporting that ‘audiological monitoring occurs only once, after the chemotherapy treatment’. furthermore, not all audiologists displayed awareness of their role in managing hearing loss, as only two audiologists reported informing doctors of the change in the hearing, counselling and fitting the patient with hearing aids. whilst the reasons for not practising ototoxicity monitoring were not explored in the current study, the researchers are of the view that the lack of a standardised comprehensive national ototoxicity-monitoring protocol at the time of data collection may have been a contributing factor in addition to limited human resources (coovadia, jewkes, barron, sanders, & mcintyre, 2009). south africa has a low audiologist to population ratio with 1:100 000 compared to 4:100 000 in the united kingdom (fagan & jacobs, 2009). this may result in audiologists not fully engaging with ototoxicity monitoring. similarly, the nursing staff capacity may also impact their levels of patient engagement. pillay (2002) indicated that nurses in the south african public health sector were highly dissatisfied with their pay, workload and the resources available to them and the further recommendation of an ototoxicity-monitoring programme can be impacted by such factors. whilst this study was conducted at a single institution and a larger multisite study to assess awareness and practice within the broader south african context will be extremely valuable, the results do highlight areas for improvement in the practice and care of affected patients. similar resource-limited environments may experience similar variation with respect to ototoxicity knowledge, hence influencing the care of affected patients. conclusion it is evident that there is awareness amongst healthcare personnel that certain chemotherapy drugs, such as cisplatin, can cause hearing loss. however, awareness of the roles and responsibilities of healthcare personnel as well as the success of a monitoring programme all dwell upon an effective and cohesive multidisciplinary team where the roles and responsibilities are delineated for proper referral, counselling, identification and appropriate management. there is also room for improvement with respect to increasing awareness amongst audiologists around the elements of ototoxicity monitoring. acknowledgements the authors are grateful to the participants of this research project for giving their time in answering the questionnaires and the hospital management for allowing this study to be undertaken at the institution. the authors are also grateful to saira banu karim for her expertise in the verification of the qualitative data analysis. competing interests the authors declare that no competing interests exist. authors’ contributions j.p. contributed to the conception and design of the study, collected and analysed data, and drafted the initial manuscript. v.s. contributed to the conceptualisation of the study, analysed data and critically revised the manuscript. c.d.g. contributed to the conceptualisation of the study and reviewed the manuscript providing important intellectual content. m.p. contributed to study design, interpretation of data and reviewed the manuscript providing important intellectual content. all authors approved the final manuscript as submitted. funding information this work was supported by the oticon research foundation under grant number 15-3622, the south african medical research council under the national health scholarship programme and the university of kwazulu-natal under competitive research grant. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and not an official position of the institution or the funder. references american academy of audiology. 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(2006). understanding drug ototoxicity: molecular insights for prevention and clinical management. expert opinion on drug safety, 5(3), 383–399. https://doi.org/10.1517/14740338.5.3.383 abstract background methods ethical consideration results discussion conclusion acknowledgements references about the author(s) ben sebothoma department of speech pathology and audiology, school of human and community development, university of the witwatersrand, south africa katijah khoza-shangase department of speech pathology and audiology, school of human and community development, university of the witwatersrand, south africa citation sebothoma, b., & khoza-shangase, k. (2018). a comparison between video otoscopy and standard tympanometry findings in adults living with human immunodeficiency virus (hiv) in south africa. south african journal of communication disorders 65(1), a591. https://doi.org/10.4102/sajcd.v65i1.591 original research a comparison between video otoscopy and standard tympanometry findings in adults living with human immunodeficiency virus (hiv) in south africa ben sebothoma, katijah khoza-shangase received: 30 jan. 2018; accepted: 12 may 2018; published: 16 july 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: literature suggests that there is a correlation between video otoscopy and standard tympanometry findings. however, there is limited evidence on whether these two measures are comparable in the identification of middle ear pathologies in adults living with human immunodeficiency virus (hiv). objective: this study aimed to determine the correlation between video otoscopy and standard tympanometry with 226 hz probe tone in the identification of middle ear pathologies in adults living with hiv in limpopo, south africa. method: a prospective, non-experimental, comparative design was employed on hiv-positive adults aged 18 years and older. all participants underwent basic audiological assessment including case history interviews, video otoscopy, tympanometry with a 226 hz probe tone and pure tone audiometry. two ear, nose and throat (ent) specialists independently analysed video otoscopic images and provided their reports to the researcher, and these were compared to the tympanometry results. the ibm spss v.24 was used for data analysis, including the use of cohen’s kappa to determine the agreement between the two procedures. pearson’s correlation coefficient was used to determine the strength of the correlation between tympanometry and video otoscopy. results: a total of 87 adults (n = 161 ears) took part in the study. middle ear pathology was observed in 8% (n = 13) of the sample when tympanometry was used, and this increased to 10.6% (n = 17) when video otoscopy was utilised. kappa statistics found a good agreement (k = 0.7) between the diagnoses made by two ents. however, there was poor agreement (k = 0.2) between the diagnoses by video otoscopy and tympanometry. pearson’s correlation coefficient indicated weak correlation between video otoscopy and tympanometry (r = 0.195). conclusion: findings from this study suggest that video otoscopy may be more accurate in the identification of middle ear pathologies in adults living with hiv when compared to tympanometry. these findings have training implications in the use of video otoscopy to ensure accuracy and reliability. clinical implications of current findings include the use of both video otoscopy and tympanometry in a complementary manner for more sensitive identification of middle ear pathologies in this population. lastly, tele-audiologic implications of the use of video otoscopy to increase access in resource-constrained contexts are raised. background the number of people living with human immunodeficiency virus (hiv) continues to increase, especially in sub-saharan african countries (joint united nations programme on hiv and/or acquired immunodeficiency syndrome (aids) [unaids], 2016). in south africa, the number of people living with hiv in the general population has almost doubled from 10.6% – 19.2% in the past few years (unaids, 2016). this increase occurs despite the concerted efforts to prevent the spread of hiv through various methods (slutkin et al., 2006; williams et al., 2006). evidence exists that indicates that hiv increases the risk of middle ear pathologies by causing the cd4 cell count to decline in the body and thus incapacitating the immune system (vajpayee, negi, & kurapati, 2013), allowing viruses and bacteria to enter the middle ear system, and causing middle ear pathologies and transient conductive hearing loss (chl) (chandrasekar et al., 2000; khoza & ross, 2002; khoza-shangase, 2011; obasineke, amdi, ibekwe, ezeanolue, & ogisi, 2014; van der westhuizen, swanepoel, heinze, & hofmeyer, 2013). given this established link between hiv and middle ear pathologies, early identification and management of these pathologies is necessary. middle ear pathologies often manifest themselves on the tympanic membrane (jaisinghani, paparella, schachern, & le, 1999). the tympanic membrane undergoes colour, structural and mobility changes as a result of middle ear pathologies. these changes are also reported in adults living with hiv (van der westhuizen et al., 2013), regardless of whether they are on treatment or not (fokouo et al., 2015). some studies have reported that middle ear pathologies persist in this population despite the efficacy of antiretroviral therapy (fokouo et al., 2015; morsheimer, dramowski, rabbie, & cotton, 2014; tshifularo, govender, & monama, 2013). this occurrence of middle ear pathologies in this population highlights the importance of using sensitive measures during assessments in order to accurately identify and manage them. studies have shown that any measure that is limited in terms of detecting tympanic membrane colour, structural and mobility changes may leave middle ear pathologies undetected (kaf, 2011). although transient chl is the immediate consequence of middle ear pathologies, if left untreated, further complications may occur, and these need to be prevented through early identification. studies have shown that prolonged middle ear pathologies may cause permanent hearing loss and life-threatening conditions such as meningitis (kolo, salisu, yaro, & nwaorgu, 2012; sharma, jaiswal, banerjee, & garg, 2015). hearing loss alone can affect individuals’ ability to communicate with others, especially in the presence of background noise. furthermore, hearing loss can affect their psychosocial well-being, as well as their overall quality of life (anderson, parkerbery-clark, white-schwoch, drehobl, & kraus, 2013; barker, leighton, & ferguson, 2017; glyde, cameron, dillon, hickson, & seeto, 2013; phanguphangu, 2017; pittman, vincent, & carter, 2009). the presence of these conditions can complicate an already challenged quality of life in people living with hiv (khoza-shangase, 2017; mutabazi-mwesigire, seeley, martin, & katamba, 2014). several studies have indicated that people living with hiv face stigma and discrimination (myezwa, stewart, musenge, & nesara, 2009; opara, soni, arinze, & chiazor, 2013), which may affect their employment opportunities (sprague, simon, & sprague, 2011). therefore, accurately identifying middle ear pathologies may improve treatment and reduce the long-term impacts associated with these pathologies the world health organization (who) emphasises the prevention of the impact of middle ear pathologies through early and accurate identification of these pathologies (who, 2011). tympanometry with a single probe tone such as the 226 hz remains the gold standard to evaluate middle ear function (british society of audiology [bsa], 2013). testing typically involves the use of a soft nub placed into the external auditory meatus (eam) and bouncing sound off the tympanic membrane under various amounts of pressure. the test provides immediate graphical representation of the results that indicate the presence or absence of middle ear pathologies (martin & clark, 2015). several studies have shown that tympanometry with 226 hz has a sensitivity ranging from 80% – 100% and specificity ranging from 70% – 100% (anwar, khan, rehman, javaid, & shahabi, 2016; harris, hutchinson, & moravec, 2005; ozturk, gode, ogut, bigen, & kirazli, 2011). although tympanometry is the gold standard for evaluating middle ear pathologies and has high sensitivity and specificity, it has been reported to be insufficient in accurately identifying all middle ear pathologies (hunter et al., 2017; kaf, 2011; shahnaz & polka, 1997), hence the importance of investigating other measures such as video otoscopy. video otoscopy holds promise as an alternative measure of middle ear function. video otoscopy is based on the notion that middle ear pathologies can be diagnosed by analysing the colour and structural changes of the tympanic membrane (jaisinghani et al., 1999). myburgh, van zijl, swanepoel, helström, & laurent (2016) also demonstrated that middle ear pathologies can be diagnosed automatically using tympanic membrane images. ting, huang and tzeng (2016) indicated that video otoscopy produces clearer images of the tympanic membrane, which are crucial for the analysis and diagnosis of middle ear pathologies. the measure is easy and quick to use and can effectively be operated by non-health professionals with sufficient training (biagio, swanepoel, adeyemo, hall, & vinck, 2013). studies have shown that middle ear pathologies can be identified through the use of video otoscopy (biagio, swanepoel, laurent, & lundberg, 2014). a recent study by ting et al. (2016) revealed a high correlation between the diagnoses made through video otoscopy and tympanograms. give the high prevalence of hiv (unaids, 2016) with its consequent impact on middle ear function, investigations into simple, accessible, sensitive, accurate and affordable measures to accurately identify middle ear pathologies in this population are required. early identification often leads to early intervention, preventing the consequent cost implications on medical, surgical and rehabilitation interventions for chronic ear disease. although video otoscopic examination seems to correlate with the standard 226 hz tone (ting et al., 2016), there is currently limited information comparing video otoscopic findings with tympanometry in identifying middle ear pathologies in adults living with hiv, hence the importance of this study within the south african context where hiv and/or aids remains a significant public health challenge. methods aim the aim of this study was to describe middle ear function in a group of adults living with hiv and compare the findings obtained from video otoscopy with those from standard tympanometry. research design a prospective, non-experimental comparative design was employed. a non-experimental design was used because all variables were included and described without manipulation (irwin, pannbacker, & lass, 2014), with findings obtained from two measures (video otoscopy and standard tympanometry) compared to each other (leedy & ormrod, 2013). research context the study was conducted at ndlovu medical centre (nmc) in elias motsoaledi local municipality (emlm), sekhukhune district, limpopo province, south africa. the emlm comprises a number of rural villages with an estimated population of 249 363. the prevalence of hiv in sekhukhune district is reported to be 17.1% (south african national aids council [sanac], 2017). because of this high prevalence, the nmc has set up an extensive hiv-oriented research consortium with wits reproductive health and hiv institute (university of witwatersrand, johannesburg) and the department of infectious diseases, immunology, clinical epidemiology and public health (utrecht university, the netherlands) (vos et al., 2017). participants’ selection criteria participants were selected through non-probability purposive sampling. only participants who were diagnosed with hiv and currently taking antiretroviral treatment at nmc were invited to participate. the inclusion that criteria were the participant must be 18 years and older, diagnosed with hiv and residing in emlm. the exclusion criterion was individuals with discharging ears. description of participants a total of 87 adults diagnosed with hiv were recruited from nmc. all participants were attending nmc as part of their routine medical check-up and for collection of their medications. participants were recruited using word of mouth and posters placed on the walls within the nmc. data collection a self-developed abstraction sheet was used to collect pertinent case history data from all participants. video otoscopy examination using otocam of the amtronix connected to an acer laptop was used to capture the tympanic membrane images. tympanometry with 226 hz probe tone titan, 3.3 version of the interacoustics was used to evaluate the mobility of the tympanic membrane. pure tone thresholds were obtained using the ad629 diagnostic audiometer of the interacoustics, with sennheiser ha200 supra-aural headphones and radio ear b-71 bone conductor. a sound-treated audiometric two-room suite was used to conduct all the tests (martin & clark, 2015). participants were interviewed to obtain pertinent information about symptoms of middle ear pathologies, as well as all other significant medical history. the researcher conducted a basic audiological test battery, tympanometry, as well as video otoscopy on all participants. video otoscopic images were saved under a special folder on the computer using codes. these images were sent to two ent specialists using asynchronous telemedicine (save and forward) (biagio et al., 2013). the ent specialists were requested to independently analyse the video otoscopic images and indicate the presence or absence of middle ear pathology. the two ent specialists had a total of over 20 years of clinical experience and were registered with the health professional council of south africa (hpcsa). reliability and validity test–retest reliability was achieved by conducting a pilot study prior to the main study (satake, 2015). this pilot study was conducted on five adults who met the same inclusion criteria of the main study. no changes were required in the design and tools of the study following pilot study findings. all measures were calibrated according to american national standards institute (ansi). daily biological calibration was also conducted before testing participants on each day (wilber & burkard, 2015). data analysis raw data were first captured on a microsoft excel spreadsheet. the ibm statistical package for social sciences (spss) version 24 was used to analyse the data. descriptive statistics including frequency calculations and percentages were used to summarise the results and describe the characteristics of the sample (irwin et al., 2014). kappa statistics were used to determine the agreement between the diagnoses of the two ent specialists, and between the ent diagnosis and the tympanometry (viera & garreth, 2005). a pearson’s correlation coefficient was used to determine the strength of the correlation between video otoscopy and tympanometry data. correlation coefficients are expressed as values between +1 and -1, with +1 indicating a perfect positive correlation, while 0 indicates no correlation. values between 0 and 0.3 (0 and -0.3) indicate a weak positive (negative) correlation, while values between 0.3 and 0.7 (-0.3 and -0.7) indicate a moderate positive (negative) correlation. values between 0.7 and 1 (-0.7 and -1) indicate a strong positive (negative) correlation (mukaka, 2012). ethical consideration the authors assert that all procedures contributing to this work comply with the ethical standard of the relevant national and institutional guidelines on human experimentation (the university of the witwatersrand medical ethics committee) and with the declaration of helsinki, 2013. the study adhered to the ethical principles outlined in the declaration of helsinki (world medical association declaration of helsinki, 2013). ethics approval was obtained from the human research ethics committee (hrec) (medical) of the university of the witwatersrand, johannesburg (m160663). results participant demographics includes age, gender, ethnicity and treatment information: type of regimen and duration of treatment. description of the participants the study was comprised of 99 (198 ears) adults diagnosed with hiv. the sample, as depicted in table 1, included 28% males and 72% females, with a mean age of 46 years (25–72 years); 99% of the participants were taking antiretroviral therapy as part of their treatment regimen, with only 1% treatment naïve. the names of the treatments per specific patient were not documented; however, the arv treatment offered at the nmc is in line with the adult antiretroviral therapy guidelines (meintjies et al., 2017). because of poor visualisation quality of some of the video otoscopic images, analysis and diagnosis could not be made in 25 ears (13%), and therefore, these ears were excluded from the study. a total of 173 ears were, therefore, included for further analysis. table 1: summary of results. middle ear assessment findings occurrence of middle ear pathologies the occurrences of middle ear pathologies in this study were based on the agreement of the diagnoses of the total sample (161 ears). video otoscopy indicated an occurrence of middle ear pathologies in 11.5% of the sample, with the rest presenting with normal middle ear function. however, tympanometry revealed an occurrence of middle ear pathologies in 8% of the sample, as depicted in table 1. of the 8% with middle ear pathologies through tympanometry, type ad tympanogram was the majority (70%). the types of middle ear pathologies found included otitis media with effusion (n = 5), retracted tympanic membrane (n = 4), tympanic membrane perforations (n = 3), chronic suppurative otitis media (n = 2), tympanosclerosis (n = 1), tympanic membrane scarring (n = 1) and otitis externa (n = 1). inferential statistics the video otoscopic findings and the standard tympanometry findings were compared. of the 173 ears, the two ent specialists did not agree on the diagnoses of 12 ears (16%). cohen’s kappa (k = 0.7) revealed a substantial agreement between the diagnoses made by the two ent specialists using video otoscopic images. the 12 ears that ents could not agree on their diagnoses were not included when comparing the video otoscopy and tympanometry. therefore, a total of 161 ears were used to compare the two measures. when comparing the diagnoses made through the video otoscopy and tympanometry, cohen’s kappa (k = 0.2) indicated poor agreement between the two measures. of the middle ear pathologies identified by both measures, the two measures only agreed on four diagnoses. a pearson’s correlation analysis revealed a weak correlation of 0.19 (n = 161; p = 0.13) between the two measures. discussion the aim of this study was to describe middle ear function in a group of adults living with hiv and also compare their video otoscopic findings with standard tympanometry findings. this study found that middle ear pathology was present in this sample. the occurrence rate increased from 8% of the sample when tympanometry was used to 11% when video otoscopy was utilised. the most commonly found middle ear pathologies were otitis media with effusion and retracted tympanic membrane. although kappa statistics indicated good agreement between the diagnoses made by two ents, there was poor agreement between the diagnoses by video otoscopy and tympanometry. pearson’s correlation coefficient indicated weak correlation between video otoscopy and tympanometry. current findings add to the existing scientific evidence on middle ear pathologies in adults living with hiv. although the sample of this study was small when compared to previous studies on adults living with hiv (khoza-shangase, 2018; van der westhuizen et al., 2013), the age and gender distribution of the sample can be considered a fair representation of the south african population living with hiv, with the majority being women living with hiv (statistics south africa [ssa], 2017). the occurrence of middle ear pathologies in individuals living with hiv in this study was evident from both the video otoscopic findings and tympanometry findings. in this study, the occurrence of middle ear pathologies ranged between 8% and 11%, with video otoscopy identifying more pathologies (11%, n = 17) than tympanometry (8%, n = 13). the occurrence of middle ear pathologies in this study is consistent with published literature indicating that middle ear pathologies are common in individuals living with hiv (chandrasekar et al., 2000; obasineke et al., 2014; tshifularo et al., 2013; van der westhuizen et al., 2013). although the occurrence of middle ear pathologies is evident in this study, it is noted that these occurrences are slightly lower when compared with the previous studies (tshifularo et al., 2013; van der westhuizen et al., 2013). the low occurrence in this study may be attributed to difference in sample sizes and methodological approaches adopted. despite the differences in occurrence of the middle ear pathologies, current findings confirm that middle ear pathologies exist in individuals living with hiv, despite the known efficacy of antiretroviral therapy (art) – which almost all participants in this study were on (morsheimer et al., 2014). when comparing the occurrence of middle ear pathologies based on the measures used, current findings indicated that the results obtained from the two ent specialists were comparable with a kappa statistics of 0.7, indicating substantial agreement (mchugh, 2012). these findings are supported by evidence which indicates that there is good inter-tester agreement between ents when using video otoscopy (biagio et al., 2013; lundberg, westman, hellstrom, & sandstrom, 2008). in this study, both ent specialists excluded 13% of the ears from analysis because of poor visualisation quality. good tester agreement with this measure has important implications for widespread use of video otoscopy where tester and test–retest reliability are important. this is particularly important in resource-constrained contexts such as south africa, where non-professionals might need to be trained to take these images with analysis conducted remotely via tele-practice. furthermore, the small percentage of poor visualisation quality images (13%) in this study is a further encouraging positive finding for video otoscopy as a measure and is consistent with results by mbao, eikelboom, atlas and gallop (2003) who found that the total number of poor quality images that could not be analysed was less than 16%. current findings on the number of acceptable video otoscopic images for analysis were also similar to those reported by biagio et al. (2013). although ting et al. (2016) reported a high correlation between the video otoscopic findings and tympanometry with 226 hz, current findings revealed a weak correlation between the diagnoses made using video otoscopic images and tympanometry (r = 0.19). video otoscopy yielded a higher occurrence of middle ear pathologies (11%, n = 17) than tympanometry with 226 hz (8%, n = 13). the higher occurrence obtained through video otoscopy suggests that middle ear pathologies may affect the structures and colour of the tympanic membrane before (or without) affecting its mobility (hunter et al., 2017), aspects of middle ear function that are not always measurable by tympanometry. several studies that have compared tympanometry with 226 hz and other middle ear measures have also indicated that tympanometry may miss middle ear pathologies that have not yet affected the mobility of the tympanic membrane by up to 63% (kaf, 2011; shahnaz & polka, 1997). this is problematic where early identification is a goal as mobility might be impacted long after the initial onset of the middle ear pathology. current findings suggest that tympanometry alone cannot provide accurate information about middle ear functioning in adults living with hiv, particularly if mobility disorder is not a key or initial feature of the middle ear pathology. these findings seem to suggest that audiologists and other hearing health professionals need to use measures that provide sufficient information about the characteristics of the tympanic membrane, which include structure, colour and mobility in order to achieve the goal of early identification of middle ear pathologies in this population. although pneumatic otoscopy provides such sensitivity and specificity in terms of middle ear assessment (ponka & baddar, 2013), it is not a measure that is useful in a resource-constrained context as it requires specialised skills from trained physicians (abbott, rosenkranz, hu, gunasekera, & reath, 2014). because of the documented shortage of physicians in developing countries (fagan & jacobs, 2009; mulwafu, ensink, kuper & fagan, 2017), pneumatic otoscopy may not be a feasible measure for this purpose within the south african context. current findings have important clinical implications. good prognosis has been documented where middle ear pathologies are identified and treated early. consequences of untreated middle ear pathologies are significant for both patient and the state, and this has been reported by phanguphangu (2017). it is evident from this study that the use of tympanometry alone may leave other middle ear pathologies unidentified, especially pathologies that have not yet affected the mobility of the tympanic membrane. given that individuals living with hiv present with a number of middle ear pathologies, varying in degree and severity (obasineke et al., 2014; tshifularo et al., 2013), an accurate measure of middle ear function that can identify early signs of these pathologies is warranted, hence the implications of current findings on the use of video otoscopy as part of the test battery. although the findings of this study are significant for assessment and management of middle ear function of individuals living with hiv, the results should be interpreted with caution because of the identified methodological limitations. these limitations include the small sample size and the fact that participants were sampled from only one province in south africa. conclusion middle ear pathologies in individuals living with hiv exist despite the efficacy of highly active antiretroviral treatment, albeit in small numbers when compared to treatment naïve individuals. if these pathologies are not detected and treated early, they may contribute significantly to the burden of hearing loss which already exists in developing countries. tympanometry may not always accurately identify middle ear pathologies in individuals living with hiv. the use of video otoscopy in a complementary manner with tympanometry with 226 hz may contribute to early and accurate identification of middle ear pathologies in this population. moreover, the use of video otoscopy can contribute significantly in the accurate identification of middle ear pathologies, with the tele-practice capabilities presenting significant possibilities for access in resource-constrained contexts. therefore, hearing health professionals need to consider using both video otoscopy and tympanometry with 226 hz probe tone in order to get an accurate indication of middle ear function of not only individuals living with hiv but the general population as well. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions b.s. conceptualised the study, collected and analysed the data, and wrote the manuscript. k.k-s. co-conceptualised the study and contributed towards the writing of the manuscript. references abbott, p., rosenkranz, s., hu, w., gunasekera, h., & reath, j. 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(2013). world medical association declaration of helsinki: ethical principles for medical research involving human subjects. retrieved from http://www.health.uct.ac.za/sites/default/file/images/116/helsinki%202013.pdf abstract introduction methods results discussion conclusion acknowledgements references about the author(s) liepollo ntlhakana department of speech pathology and audiology, faculty of humanities, school of human and community development, university of the witwatersrand, johannesburg, south africa gill nelson occupational health division, school of public health, faculty of health sciences, university of the witwatersrand, johannesburg, south africa institute for global health, university college london, london, the united kingdom katijah khoza-shangase department of speech pathology and audiology, faculty of humanities, school of human and community development, university of the witwatersrand, johannesburg, south africa citation ntlhakana, l., nelson, g., & khoza-shangase, k. (2020). estimating miners at risk for occupational noise-induced hearing loss: a review of data from a south african platinum mine. south african journal of communication disorders, 67(2), a677. https://doi.org/10.4102/sajcd.v67i2.677 note: special collection: occupational hearing loss in africa. original research estimating miners at risk for occupational noise-induced hearing loss: a review of data from a south african platinum mine liepollo ntlhakana, gill nelson, katijah khoza-shangase received: 18 sept. 2019; accepted: 06 feb. 2020; published: 26 mar. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: occupational noise-induced hearing loss (onihl) is a complex, but preventable, health problem for south african miners. meticulously collected data should be made use of to design interventions to address this health issue. objectives: a single mine’s electronic data were reviewed in a secondary data review to determine, from the records, factors that hearing conservation practitioners deemed useful for identifying ‘at risk’ miners and to establish factors that would pave the way for the integration of the 2014 hearing conservation programme (hcp) milestones into the mine’s current proactive data management system (pdms). the objectives of this article were to establish how miners with published risk factors associated with onihl were managed by the mine’s hearing conservation practitioners as part of the hcp; to determine if the mine’s hearing conservation practitioners could estimate miners’ risk of onihl using baseline percentage loss of hearing (plh) as a hearing conservation measure; and to estimate the contribution of noise exposure to onihl risk. method: in a secondary data review design, records in a platinum mine’s two electronic data sets were reviewed: the first contained diagnostic audiometry records (n = 1938) and the second comprised a subset of miners diagnosed with onihl (n = 73). data were available for the period 2014–2017 and included demographic, occupational, audiometry and onihl diagnosis data. miners’ risk factors associated with onihl were identified using the functional risk management structure. a logistic regression model was used for the baseline plh margins of 0% – 40% (in 5% increments) to estimate the adjusted predictions for miners at risk of developing onihl. the contribution of noise exposure as a risk for onihl was estimated using a two-way sample proportion test. results: the mean age of the miners (all male candidates) was 47 ± 8.5 years; more than 80% had worked for longer than 10 years. valid baseline audiometry records were available for only 34% (n = 669) of the miners. miners with a 0% baseline plh had a 20% predicted risk of onihl, and a 45% predicted risk if they had a 40% baseline plh – these employees were referred. the noise exposure risk rankings revealed that 64.9% (n = 1250) of the miners were exposed to 91 dba – 105 dba noise exposure levels and that 59 (80.8%) diagnosed with onihl were exposed to noise levels of up to 104 dba. conclusion: these findings indicate significant gaps in the mine’s pdms, requiring attention. nonetheless, the mine’s current data capturing may be used to identify miners at risk of developing onihl. the plh referral cut-off point (≥2.5%) used by the mine’s hearing conservation practitioners, when used in conjunction with baseline plh shifts, was the major factor in early identification of onihl in miners exposed to ≥85 dba noise. an inclusive integrative data management programme that includes the medical surveillance data set of the miners’ noise exposure levels, occupations, ages and medical treatments for tuberculosis and human immunodeficiency syndrome is recommended, as these are important risk indicators for developing onihl, particularly within the south african context. keywords: occupational exposures; risk factors; electronic data; hearing conservation programme; hearing loss; miners. introduction the world health organization (who) reported a 16% prevalence of occupational noise-induced hearing loss (onihl) in 2010 (who, 2010). in south africa, onihl is the third most commonly reported occupational disease affecting miners (balfour-kaipa, 2014). individuals with onihl are susceptible to sleep disturbances, psychological stress associated with the frustration of losing hearing function, fatigue and cardiovascular problems (malatji & stewart, 2013). workers’ susceptibility to onihl is exacerbated by ageing, sex (khoza-shangase, 2019; strauss, swanepoel, becker, eloff, & hall, 2012), a history of otalgia and middle ear infections (edwards, 2008), previous diagnosis of sensory neural hearing loss, cigarette smoking, hypertension and type 2 diabetes (hong, lee, park, & kim, 2014). the risk of developing onihl is increased for workers currently on treatment for tuberculosis (tb), human immunodeficiency syndrome (hiv) and/or cancer (khoza-shangase, 2019). the increased risk of onihl is because of the synergistic effect of high noise levels and the other ototoxic factors mentioned above (campo, morata, & hong, 2013; hong et al., 2014; khoza-shangase, 2019). the symptoms of onihl include a sense of fullness in both ears, tinnitus, balance problems, difficulty following conversations and hearing warning signals, and progressive hearing loss in one or both ears (feuerstein & chasin, 2009). in the diagnosis and management of onihl, it is important to include tracking and monitoring all the aforementioned risk factors to ensure efficient implementation of any hearing conservation programme (hcp). occupational diseases in the mining industry, including pulmonary tuberculosis and silicosis, for example, have been well documented (hermanus, 2007; who, 2010); however, little evidence exists on how these diseases are treated within hcps, although synergistic effects of these diseases and their treatments with noise exposure on the auditory system have been raised (khoza-shangase, 2019). the authors of this article concur with hermanus (2007) in arguing that such evidence is important, as it can assist in developing disease control policies for the mines and health service planning, including hcp planning, implementation and monitoring. the aforementioned comorbid health conditions have not been considered in hcps (nelson, nelson, concha-barrientos, & fingerhut, 2005). in countries like south africa, where the prevalence of onihl is high, it can be argued that the failure to meet onihl elimination targets is influenced by the lack of contextual responsiveness to the burden of disease. consequently, hcps have been deemed ineffective in preventing onihl in south africa (edwards & kritzinger, 2012; moroe et al., 2018; ntlhakana, kanji, & khoza-shangase, 2015), in spite of being introduced in south african large-scale mines as early as 1988 (franz & phillips, 2001). a number of studies on hcps in south african mines have reported factors associated with the failure of hcps to prevent onihl. these include excessive noise levels emitted by equipment (higher than the legislated level of 85 dba), unsatisfactory uptake on the use of hearing protection devices (hpds) by miners (hansia & dickinson, 2010; ntlhakana et al., 2015) and evidence of high prevalence rates of onihl because of a combination of occupational and non-occupational factors (e.g. age, race and sex) (strauss, swanepoel, becker, eloff, & hall, 2014). weaknesses in hcps, including poor risk management techniques and flawed audiometric database analysis (adba) (franz & phillips, 2001), have been proposed as some of the priorities requiring attention by the mining authorities and the audiology community in south africa (moroe & khoza-shangase, 2018). the adba procedures were developed by the american national standards institute working group (ansi s12/wgs12) (ansi, 1991), with the goal of assessing the effectiveness of hcps. the adba procedures can be utilised to ensure the success of hcps by identifying potential problem areas and challenges in the hcp prior to employees developing significant hearing loss (adera, gullickson, helfer, wang, & gardner, 1995), hence highlighting the need for careful longitudinal tracking and monitoring of employees’ hearing function in relation to their noise exposure levels and other key risk factors. such methods require comprehensive and consistent data collection to allow for an accurate and systematic assessment of the effectiveness of hcps, which is a complex challenge with any well-meaning, data-reliant management system. the fact that there is more than one adba method that can be used introduces another challenge when it comes to comparative analysis of findings within and between organisations. the use of the adba for evaluating the effectiveness of hcps, for example, was found lacking in adera et al.’s (1995) paper, where ratings of hcps were found to be inconsistent from year to year, and from procedure to procedure used. use of such a procedure therefore is bound to present significant challenges, if all important and often contextually relevant factors (including the burden of disease specific to the region) do not form part of the data capturing and analysis processes. as illustrated in figure 1, the technique includes recording the miners’ audiometry data from baseline to exit. figure 1: functional structure of a risk management system for occupational noise. this technique requires the use of a data management system to ‘identify occupations, workplaces and activities where hearing loss is progressing most, particularly in the case of a large workforce…..’ (franz & phillips, 2001, p. 209). within the south african context, evidence suggests that although the adba is used, its effectiveness is questionable (begley, 2006), possibly because of the factors listed above. begley (2006) described how south african large-scale mines designed various versions of the adba, and how this inhibited the successful tracking of miners’ audiological status and the monitoring of those diagnosed with onihl. an hcp has seven pillars that include noise control engineering, noise measurement, administrative noise control measures, education–training–motivation, hpd usage, risk-based medical surveillance and audiometry. the technique described by franz and phillips focusses on three pillars, namely: (1) noise control engineering, (2) administrative noise control measures and (3) use of personal protection, as a proactive risk management tool for early identification and prevention of onihl; the said technique was reportedly adopted by the mine where the current study’s data were located. this technique is rather outdated, and there are more recent and more comprehensive hcp structures that cover all pillars of hcps, such as complex interventions (moroe, 2018); nonetheless, this was the technique that was followed for the secondary data analysed in the current study. this method reportedly allowed the mine to send onihl cases to their insurance company according to instruction 171. we analysed data from the mine’s medical surveillance and audiometry records to describe the mine’s onihl prevention efforts (figure 1). a proactive data management system (pdms), as a single point of contact for organisations, has been used for many years to understand complex organisational trends. the pdms follows best practice principles, allows for efficient monitoring of key factors identified by the company and provides intervention measures where required (jantti & cater-steel, 2017). in south africa, large-scale mines have attempted to use the adba technique that draws data from the mine’s medical surveillance and audiometry records, as a pdms for the management of miners exposed to hazardous noise emitted by their equipment, to build the miners’ audiometry database and to prevent onihl. however, the adba’s failure is demonstrated by high noise levels and the continued reporting of miners with onihl (balfour-kaipa, 2014; chamber of mines, 2016). thus, south african mines have not been successful at designing pdmss to prevent onihl. previously reported high incidences of onihl in the south african mining industry indicate the miners’ hearing loss as a function of percentage loss of hearing (plh) at 10% or greater since 2001 when the compensation for occupational injuries and diseases act, 1993 (act no. 130 of 1993) (coida) gazetted circular instruction 171 was instituted (department of labour, 2001). however, the fact that plh calculations included only 500 hertz (hz), 1000 hz, 2000 hz, 3000 hz and 4000 hz meant that higher frequencies known to be affected early by excessive noise exposure (as in onihl) were excluded. hence, studies that reported on miners’ hearing function associated with onihl included low and high frequencies (500 hz – 8000 hz) (khoza-shangase, 2019; moepeng, soer, & vinck, 2017; strauss et al., 2012) in order to provide the miners a broader hearing function spectrum. however, for onihl compensation claim processing, which is still practised by the compensation commissioner, the miners’ audiometry records had to reflect the plh score, indicating the miners’ hearing loss in spite of the noted weaknesses of using such scores. this led to the review of hcp milestones by the minerals council south africa, focussing on the mining equipment noise emissions and the tracking of the miners’ hearing thresholds (high-frequency standard thresholds) (inspectorate, 2017). the new milestones set out in 2014 by the mining industry stakeholders stated that no individual miner’s standard hearing threshold shift (sts) should exceed 25 db from baseline, in both ears, and that the total operational or process noise emitted by any equipment must not exceed 107 dba, by the year 2024 (mine health and safety council – mhsc, 2015). the use of the sts as a sensitive measure for early detection of hearing loss was deemed a proactive practice of managing miners at risk for onihl. this initiative prompted the mines to integrate the miners’ newly recorded standard thresholds and threshold shifts (2014–2016) into their current reporting systems in order to improve their efficiency in identifying miners ‘at risk’ of developing onihl and to be in line with who targets for onihl (who, 2010). we reviewed the data recorded by the mine in order to determine, from the records, factors that hearing conservation practitioners deemed useful for identifying ‘at risk’ miners and to establish factors that would pave the way for the integration of the 2014 hcp milestones into the current pdms of the mine. the objectives of this article were to establish how miners with published risk factors associated with onihl were managed by the mine’s hearing conservation practitioners as part of the hcp; to determine if the mine’s hearing conservation practitioners could estimate miners’ risk of onihl using baseline plh as a hearing conservation measure; and to estimate the contribution of noise exposure to onihl risk. methods research design this was a secondary data review of miners’ electronic records from a platinum mine in limpopo province, south africa. secondary data are called as such for various reasons, including the fact that the data were obtained by somebody else; the data had already undergone one layer of analysis prior to the secondary analysis; and that the data were collected for a focus or objective different to the one these are currently used for (sorensen, sabroe, & olsen, 1996). this is an identified limitation of the current design; however, the limitation was in itself a key aspect of the study’s objective of assessing how the mine utilises its data management system as it is for its hcp. study population we reviewed all miners’ electronic medical surveillance and audiometry records at the research site. this comprised records including miners’ age, sex, years of experience, occupations, noise exposure levels, medical surveillance and audiometric test results. data collection and data management the records reviewed in this secondary data review were stored in two databases, and comprised data from 2014 to 2017. the main database contained 1963 medical surveillance and diagnostic audiometry records of miners, all of which had a baseline plh shift of ≥2.5% (value set by the mine to refer miners for diagnostic audiometry), and had been referred to an occupational medical practitioner for further intervention, and to an audiologist for diagnostic audiometry. the second data set was a subset of records of 73 miners who had calculated plh shifts of ≥10% from baseline. following the diagnostic audiometry assessment, a diagnosis of onihl was confirmed by the audiologist, and some miners had been presented to the rand mutual assurance company for onihl compensation. these two sets of data were handled separately. all data underwent data cleaning processes that included the removal of duplicate records (n = 25), after which 1938 unique records remained in the main database. the audiometric records contained demographic, occupational and audiometry data (screening and diagnostic), and onihl diagnosis information. careful scrutiny and recording of the process followed for miners in both data sets in relation to risk factors was performed for analysis. it should be noted that because this is a secondary data review, plh values were what was recorded and therefore reviewed, but it is acknowledged that the south african mines had started moving towards the new hcp milestones (2014) of using sts. data analysis extracted data were captured into microsoft excel, after which they were imported into and analysed using stata (version 15.1). the variables, such as age, baseline plh, diagnostic audiometry plh, years of noise exposure, noise exposure levels and recorded risk factors, were analysed using descriptive statistical analysis, logistic regression analysis, and a two-way sample proportions test (z-test). to establish how the mine’s hearing conservation practitioners managed miners presenting with risk factors associated with onihl, risk factors stated in the functional risk management structure (figure 1) (franz & phillips, 2001) were used. to determine if the mine’s hearing conservation practitioners could estimate miners’ risk of onihl at baseline, plh margins from 0% to 40% (5% increments) were used to estimate and interpret adjusted predictions, using logistic regression analysis. finally, the contribution of noise exposure to the risk for onihl was estimated using a two-way sample proportion test (z-test), with the significance level set at 95%. ethical considerations ethical clearance to conduct the study was obtained from the university of the witwatersrand’s human ethics committee (m180273) on 11 april 2018, and permission to access the records was obtained from the management team of the mining company. the study adhered to the declaration of helsinki 1975, as revised in 2008, as far as ethical considerations were concerned. results to establish how miners with risk factors associated with occupational noise-induced hearing loss were managed within a hearing conservation programme the workforce comprised only male mine workers. tables 1 and 2 illustrate the miners’ ages and years of working in the mine, with a mean age of 47 (± 8.5) years (44–55 years) and a working experience of 10 (± 3.5) years (8–13 years). no records of all risk factors, particularly medical conditions important for hearing monitoring such as tb and hiv (ototoxicity), were recorded in the audiology records. audiology data captured in the mine’s adba system only included pure-tone audiometry. table 1: demographic characteristics of the miners in the main subset (n = 1938). table 2: demographic characteristics of the miners (n = 73). the data seem to indicate that hearing conservation factors included in the mine’s pdms to manage noise exposure and miners at risk for onihl were plh scores for screening and diagnostic audiometry, with categorised referral points for the miners, as ≤2.5%, 5%, 7% and ≥10%, to monitor those miners at risk for onihl and for compensation purposes. risk rankings for noise exposure levels were not available, from lowest to highest (1–4), for all the miners. furthermore, only 34% of the miners (n = 669) had baseline audiometry records; periodic audiometry records were available for review but there were no monitoring audiometry records; and the diagnostic audiometry records included only pure-tone air-conduction results with no speech audiometry data. to determine if the mine’s hearing conservation practitioners could estimate miners’ risk of occupational noise-induced hearing loss at baseline the miners’ estimated risk for onihl was based on the baseline plh shift of 2.5% used by the mine. baseline plh is core to tracking miner’s hearing deterioration and is required for the calculation of the plh shift for compensation; to determine a plh shift of >10%. figure 2 illustrates baseline plh margins that were generated through logistics regression, from 0% to 40%, used to distinguish (in increments of 5%) between miners at high and low risk of onihl. at 0% plh at baseline, the risk of onihl was predicted to be 20%. a 20% plh at baseline corresponded to a risk level for onihl of about 30%; and a risk of onihl was predicted to be around 45% when a miner had a baseline plh of 40%. the baseline plh shift of 2.5% used by the mine’s hearing conservation practitioners is a proactive measure used for the miners’ hearing preservation. baseline plh scores and plh scores at onihl diagnosis included in the model for the second data subset (n = 73) were used to estimate the predicted risk for onihl. figure 2: baseline percentage loss of hearing adjusted predictions with 95% confidence intervals for occupational noise-induced hearing loss. to estimate the contribution of noise exposure to occupational noise-induced hearing loss risk as a proactive measure the miners’ noise exposure levels were recorded as continuous data and were aligned with their occupations. table 3 shows the mine’s noise exposure risk rating categories that we formulated to classify miners at risk of onihl. more than 80% of the miners (n = 1578) were exposed to noise exposure levels that were higher than the legislated occupational exposure limit (oel) of 85 dba, with 64% of the miners falling into the two highest risk rating categories. table 3: noise exposure risk rating categories of exposed miners (n = 1963). fifty-nine (80.8%) of the 73 miners diagnosed with onihl were exposed to noise levels of 85 dba – 104 dba; 14 (19.2%) were exposed to noise levels of <85 dba. although both groups (those exposed to <85 dba and those exposed to ≥85 dba) were exposed to high noise levels, the results indicated that the risk for onihl increased with the noise exposure category. the z-test showed a mean difference of 62% in noise exposure levels (p = 0.001) between miners exposed to ≥85 dba and those exposed to <85 dba. discussion our study was guided by franz and phillips’ (2001) risk management tool, which was introduced in the early 2000s. analysis of the miners’ records revealed that the mine was using a siloed approach for risk assessment of noise hazards and identification of miners at risk of onihl. the miners’ baseline plh scores could estimate miners’ risk for onihl, although the 2.5% plh used by the mine’s hearing conservation practitioners to refer miners for further intervention delayed the process of identifying miners at risk of onih and that the oel for noise, of ≥85 dba, is not low enough to prevent onihl. with regard to establishing how the mine’s hearing conservation practitioners proactively managed miners presenting with risk factors associated with onihl findings showed that miners older than 40 years and those who had worked in mining for longer than 6 years were at higher risk of developing onihl. the fact that they were referred for diagnostic audiometry with a screening audiometry plh score of ≥2.5% meant they were suspected of being at risk of developing onihl. in other studies, conducted in south african mines (khoza-shangase, 2019; strauss et al., 2012), age was identified as a risk factor for onihl, and our findings support this. miners’ increasing age is already considered by the mines’ hearing conservation practitioners as a risk factor for onihl; increasing work duration could be similarly considered as a risk factor. the adba technique used by the mines requires more sensitive measures to identify miners at risk of onihl. the south african mines consider annual and diagnostic audiometry procedures as sensitive measures for identification of hearing loss; hence, both audiometry procedures were conducted on miners working in areas identified as high risk for onihl. although franz and phillips (2001) recommended the use of the adba technique, based on the findings from royster and royster’s (1986) study, the large-scale mines designed mine-specific adba techniques, guided by the noise induced hearing loss regulation 171 (2001) and the sans 10083:2013. according to both the regulation and sans 10083:2013, two diagnostic audiogram results should be used to confirm the onihl diagnosis. our review of the mine’s electronic records revealed that none of the miners had two diagnostic audiometry records, deeming these results incomplete and inconclusive for the diagnosis of onihl (franz & phillips, 2001). although duplicate diagnostic audiometry records were not in the mine’s reviewed records, they could have been available and kept with other miners’ records. this undermined the adba effort to provide a full picture of the miners’ onihl diagnostic results. in a review of gold miners’ hearing results, researchers argued for the importance of adding an objective diagnostic tool – the distortion-product otoacoustic emissions (dpoaes) tool – for early detection of onihl (moepeng et al., 2017). in addition, evidence from research on dpoaes has provided insight into other causes that lead to occupational hearing loss, such as age, ototoxic drugs, chemical exposure, tuberculosis and hiv (campo et al., 2013; khoza-shangase, 2019; strauss et al., 2014). however, at the time of data collection for our study, the miners’ diagnostic audiometry data did not include information about tb and hiv treatment, as well as types of chemicals to which the miners were exposed at work. the 2014 hcp milestones recommended inclusion of the sts as a measure of the miners’ hearing function, with the aim of improving hearing loss identification for these populations, for which the mining industry needs to be commended. the contextual implications for tb and hiv as contributory factors towards miners’ hearing loss cannot be ignored. our review of the records showed that these data were not included in the miners’ hearing conservation data, in spite of several studies in the south african mining industry indicating that tb and hiv are associated with hearing loss (hermanus, 2007; khoza-shangase, 2019). previous research has argued for the inclusion of these conditions in the medical surveillance records of miners (franz & phillips, 2001; khoza-shangase, 2019; mhsc, 2015), as well as the audiometry records, for audiological monitoring. this should be performed as a proactive way of managing all risks associated with hearing loss. in a recent record review of hearing function among gold miners, khoza-shangase (2019) found that miners with a history of tb treatment presented with worse high-frequency hearing loss than those without a history of tb treatment. the study also highlighted confounding factors that affect the auditory system in this population, namely, the use of ototoxic medications, age and noise exposure. khoza-shangase (2019) raised the importance of audiological monitoring for these miners to be integrated into the mines’ tb and hiv medical surveillance programmes in order to monitor hearing loss holistically. this recommendation was also made by franz and phillips (2001). our findings indicated that baseline audiometry referral scores used by the mines’ hearing conservation practitioners delay the early identification process and intervention of miners at risk of onihl. even at 0% baseline plh, the miners were at a 20% risk of developing onihl. in addition, the plh scores provide low-frequency thresholds at baseline for the miners. the 2.5% plh referral used by the mine was seen as proactive when compared to the legislated referral of 3.2% (sans, 2013), and the method also provides hearing threshold information that could be used in conjunction with the sts to identify miners’ risk of developing onihl at baseline. there is a dearth of literature on the use of baseline plh as part of hcps in south african industries where noise is a problem. the only other study that reviewed baseline plh scores was conducted by bronkorst and schutte (2013) who reviewed audiometry records of workers in various occupational settings in the western cape province to highlight the importance of using the employees’ more sensitive baseline (b-baseline) audiometry results for hearing conservation purposes. the method recommended by bronkorst and schutte (2013) showed the value of baseline plh and the potential use thereof without the need to recreate new baselines for the south african miners. the miners who were exposed to excessive noise levels (≥85 dba) had a greater chance of being diagnosed with onihl. of the 73 miners diagnosed with onihl, 14 (19.1%) were exposed to noise levels <85 dba. this implies that the oel of ≥85 dba used by the mines did not protect miners from developing onihl, or that there could be other risk factors that led to the miners’ onihl diagnosis. our findings and those of edwards et al. (2011) are in agreement as far as noise exposure levels in south african mines are concerned. however, we questioned the association of other risk factors with onihl, specific to miners exposed to <85 dba noise levels. thus, a recommendation is made for the hearing conservation practitioners in the mining industry to review the legislated oel (≥85 dba), and to consider comorbid factors associated with occupational hearing loss, in order to prevent onihl. the fact that the participating mine did not record noise exposure risk rankings is problematic, and it limits efforts for the prevention of onihl. it is important for the mines to provide accurate noise exposure rankings in the miners’ audiometry records, specific to tasks and occupations, in order to correctly identify miners at risk of onihl. in addition, the noise measurement technologies and recording techniques used by the mines’ occupational health practitioners should be effective towards the prevention of onihl. although the duration of exposure was not recorded in the current study, we acknowledge the importance of this aspect in onihl, over and above other personal factors such as genetic predisposition. although significant, the findings should be interpreted carefully, taking cognisance of methodological limitations. the data that we reviewed were exclusively drawn from one large-scale mine, from the miners’ diagnostic audiometry records, and revealed three critical limitations. firstly, the shortcoming associated with the use of secondary data is that some interpretations of our findings are based on assumptions. secondly, the occupational hygienist’s data were not included in the records that we reviewed; thus, additional exposures and duration thereof were not included in the data that we reviewed. our results therefore reflect only a narrow view of the diagnostic audiometry data set. thirdly, the miners’ medical surveillance records regarding tb and hiv status could not be accessed. this compromised our review, as we could not comment on the broader spectrum of the hearing health risks associated with the miners’ onihl. this exclusion of data from the medical surveillance database indicates that the mine did not necessarily view tb, hiv and their medications as risk factors for hearing loss and therefore did not consider them in their hcp strategies. finally, the non-classification of noise exposure levels according to risk rankings (franz & phillips, 2001) implies that the mine may be applying a blanket intervention for miners exposed to noise levels of ≥85 dba. conclusion our findings, guided by the adba technique, which was recommended by franz and phillips in 2000, indicated that the mine was using an adaptation of a technique that was recommended more than 15 years ago. this resulted in the mine’s hearing conservation practitioners considering noise exposure as the sole occupational hazard for onihl. other occupational exposures associated with onihl were excluded. nonetheless, the effort towards keeping records for the miners at risk of developing onihl was commendable. a lower baseline referral plh score should be used to identify miners at risk of onihl early, also allowing for early intervention to be instituted. the mining company is encouraged to add the miner’s data on burden of diseases such as tb and hiv as part of the miners’ audiometry monitoring programmes. this would facilitate proactive management of miners at risk of developing any type of hearing loss, including onihl. the current data management system used by the mine has the potential to be integrated into, and used together with, the new 2014 hcp milestones, to monitor the miners’ hearing function across all frequencies. it is probable that the mines are not achieving the desired outcomes of tracking miners’ hearing loss accurately, because they are using the plh levels to report miners at risk for onihl, rather than sts. we recommend that the mines implement the new milestones (use of sts) across all stages of hcp reporting, to ensure that all new baselines are based on sts levels. this will ensure early identification of onihl instead of focussing on plh, which is concerned with compensation after a disability has occurred. acknowledgements the authors are grateful to dr innocent maposa for assistance with biostatistical analysis in this study. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions l.n. conceptualised the idea for the research, as well as the design and methodology adopted, with assistance from g.n. and k.k.-s. l.n. collected the data for the study and analysed these with supervision from g.n. and k.k.-s. l.n. was the lead author of the manuscript, which was critically reviewed by g.n. and k.k.-s. all three authors read and approved the final manuscript. funding information the authors wish to thank the national institute for the humanities and social sciences (nihss) and the consortium for advanced research training in africa (carta) for financial assistance towards the publication of this manuscript. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references adera, t., gullickson, g.m., helfer, t., wang, l., & gardner, j.w. 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(2010). burden of disease from environmental noise. copenhagen. retrieved from https://www.who.int/quantifying_ehimpacts/publications/e94888.pdf?ua=1 abstract introduction methods results discussion conclusion acknowledgements references about the author(s) khalid a. alshehri college of medicine, king abdulaziz university, jeddah, saudi arabia waleed m. alqulayti college of medicine, king abdulaziz university, jeddah, saudi arabia bassam e. yaghmoor college of medicine, king abdulaziz university, jeddah, saudi arabia hisham alem department of otorhinolaryngology, college of medicine, king abdulaziz university, jeddah, saudi arabia citation alshehri, k.a., alqulayti, w.m., yaghmoor, b.e., & alem, h. (2019). public awareness of ear health and hearing loss in jeddah, saudi arabia. south african journal of communication disorders, 66(1), a633. https://doi.org/10.4102/sajcd.v66i1.633 original research public awareness of ear health and hearing loss in jeddah, saudi arabia khalid a. alshehri, waleed m. alqulayti, bassam e. yaghmoor, hisham alem received: 06 mar. 2019; accepted: 27 june 2019; published: 26 aug. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: knowledge of ear health and hearing loss is essential for early intervention and treatment, but the state of public knowledge of such in jeddah, saudi arabia, remains unknown. objectives: to measure public knowledge of ear health and hearing loss. method: this cross-sectional study was conducted during august 2018 in jeddah, saudi arabia. an electronic survey questionnaire was distributed to 2372 residents of various districts in jeddah. the survey was created in 2013 by adopting previously published world health organization material, designed to assess knowledge and perception of ear health. all males and females aged 10 years or older living in jeddah had the chance to participate in this study. a total of 2372 people participated. percentages mean ± standard deviation, one-way analysis of variance (anovas) and independent t-tests were applied to determine the significant difference. p-values of 0.05 or less were considered significant. results: the overall mean number of correct responses on the survey’s true/false questionnaire was 10.66 ± 1.92 out of 14. female participants gave a higher mean number of correct answers than did male participants (10.73 ± 2.03 vs. 10.54 ± 2.03, respectively). participants with a family history of hearing loss gave a higher mean number of correct answers compared with participants who reported a negative family history (10.89 ± 1.82 vs. 10.53 ± 1.97, respectively). conclusion: overall awareness of ear health and hearing loss management is fair. however, the results indicate a need for more integrated educational materials to be made available both to the general population as well as to hearing loss individuals and their families. keywords: public awareness; ear health; hearing loss; audiology; saudi arabia. introduction hearing loss limits one’s ability to distinguish between sounds correctly, making it challenging to understand basic conversations. furthermore, hearing loss in early life can significantly impair both development and educational achievement, thus negatively impacting both emotional and social quality of life (agrawal, platz, & niparko, 2009; world health organization [who], 2012). many factors throughout all stages of life can cause hearing loss. in particular, chronic ear infection, which can be prevented and managed with medical and surgical interventions, remains one of the leading causes of hearing loss (who, 2012). other causes include exposure to loud noises, use of ototoxic medication and diseases such as meningitis, measles, mumps and rubella (who, 2012). the who estimates that there are 466 million individuals worldwide with moderate to profound bilateral hearing loss, two-thirds of whom live in developing countries and suffer from preventable forms of hearing loss (who, 2012, 2017). the highest prevalence of disabling hearing loss in both children and adults can be found in south asia, asia-pacific and sub-saharan africa (who, 2012). this geographical distribution represents a widespread healthcare problem in that many individuals with impaired hearing are not able to access the facilities they require. these difficulties arise from a variety of issues, including limited resources, a paucity of specialised healthcare professionals, poor professional and public awareness, and natural and geographical barriers (swanepoel et al., 2010). these problems are not only limited to isolated rural regions or developing countries but also exist in urban communities (swanepoel et al., 2010). as public knowledge about hearing loss and ear health is essential for prevention and early treatment, several studies have been conducted to estimate public awareness of ear diseases and their management. for example, a study conducted in italy found that female participants have significantly more knowledge about non-verbal individuals with severe hearing loss and about using a cotton bud for cleaning than male (di berardino et al., 2013). another study conducted in greece concluded that suitable educational programmes could enhance the ability of nurses to communicate with deaf people (velonaki et al., 2015). in a striking example of the importance of education efforts, a study published in india found that parents who were unfamiliar with the topic of hearing loss were less likely to know that late response to speech and late speech development could be associated with hearing loss (merugumala, pothula, & cooper, 2017). finally, a south african study concluded that lack of public awareness regarding audiologists and their profession could affect both hearing health and hearing-related medical care (joubert, sebothoma, & kgare, 2017). many patients who are in danger of hearing loss can be effectively treated if intervention takes place early enough. to the best of our knowledge, there are limited data on the general public’s awareness of ear health and hearing loss in saudi arabia. this study aimed to measure such awareness among the population of jeddah, saudi arabia, in 2018. methods study design and objective a quantitative cross-sectional study aimed to measure such awareness among the population of jeddah, saudi arabia, in 2018. study setting and participants this study was conducted in the urban city of jeddah, saudi arabia, during august 2018. jeddah is one of the largest cities in saudi arabia, located in the western region, on the coast of the red sea. an electronic questionnaire was distributed by trainee data collectors to residents of different districts of the city. children under the age of 10 years have been excluded from the study because of their inability to read and write, yielding a realistic sample of the population of jeddah. participants were recruited by stratified sampling for each administrative area, which were considered as independent strata. the distribution of the sample size between strata was matched to the percentage of each administrate area to the whole population. instruction on the purpose of the study and written informed consent were required before filling out the questionnaire. the participants were able to access the survey link through their phones. questionnaire the self-administered electronic survey consisted of two parts. the first part comprised questions about demographic and clinical characteristics of the participants, including gender, age, nationality, previous diagnosis of hearing loss, family history of hearing loss, self-reported exposure to noise (listening to loud music, working in factories with loud noise or using headphones loudly) and smoking. the second part of the survey was designed to assess the knowledge and perception of ear health and hearing management. this questionnaire was created in 2013 by adopting previously published who material (di berardino et al., 2013) and consists of 14 items divided into four domains (knowledge of infant hearing loss, management of ears including cleaning and treating, effects of overexposure to noise and underestimated ear symptoms leading to diagnostic delay) (table 1). the participants were instructed to evaluate each sentence from the questionnaire as either true or false. the original english questionnaire was translated into arabic by two independent native arabic doctors with high proficiency in english. the arabic version was then translated back into english by two independent native english doctors with high proficiency in arabic, and the authors compared the back-translated version with the original english version and reconciled all differences. table 1: questionnaire to evaluate public awareness of ear and hearing management. data collection and analysis data were collected in an electronic google form and then transformed to the statistical package for social sciences (spss) software version 22 (ibm corp., armonk, ny), which was used to code and analyse all the data. all identifying information from the participants was removed to ensure privacy and confidentiality, and only the authors had access to the data. categorical variables are presented as percentages, while continuous variables are presented as mean ± standard deviation. one-way analysis of variance (anovas) and independent t-tests were used to assess the significant difference between the results of the questionnaire and the demographic and clinical characteristics. for all statistical tests, p-values of 0.05 or less were considered significant. ethical consideration this study was approved by the institutional review board (irb) of king abdulaziz university hospital. all identifying information from the participants was removed to ensure privacy and confidentiality, and only the authors had access to the data. ethical clearance number is 510-18. results out of 5648, 2372 people agreed to participate in our study, reflecting a response rate of 42%. of these, 64.7% were women and 35.3% were men. the mean age was 31.31 ± 11.85 years. a total of 45.1% of participants fell within the age range of 19–29 years. most of the members of our sample were saudi (90.1%). the percentage of participants who reported that they had been previously diagnosed with hearing loss and had a positive family history of hearing loss was 5.5% and 37.5%, respectively. additionally, 35.6% of the respondents stated that they had been exposed to potentially harmful noise. demographic characteristics of the sample are presented in table 2. table 2: demographic characteristics of the sample (n = 2372). there were 14 questions on the true/false questionnaire, and the mean number of correct responses was 10.66 ± 1.92. the eighth question ‘hearing aids need to fit accurately to provide the maximum benefit’ had the highest rate of correct answers (93%), while the 10th question: ‘listening to music for more than 3 h a day using earphones may cause permanent hearing loss’ had the lowest rate of correct answers (53.4%). the prevalence of correct answers for all questions is shown in table 3. table 3: the percentage of correct responses to the true or false questionnaire among the sample (n = 2372). we compared the mean number of correct answers between various age groups and found that the respondents younger than 18 years had the lowest mean number of correct answers (9.93 ± 2.13), while those aged 40 or older had the highest mean number of correct responses (10.85 ± 1.76). female participants had a higher mean number of correct answers compared to male participants (10.73 ± 2.03 vs. 10.54 ± 2.03, respectively). furthermore, saudi participants had a significantly higher mean number of correct answers compared to non-saudi participants (p = 0.005). importantly, participants with a family history of hearing loss had a considerably higher mean number of correct answers compared to those who reported no family history (10.89 ± 1.82 vs. 10.53 ± 1.97, respectively). regarding exposure to noise, people who considered themselves as being regularly exposed to loud noise had a lower mean number of correct answers compared to those who did not (10.59 ± 2.01 vs. 10.71 ± 1.87). details of the mean number of correct responses within our sample are presented in table 4. table 4: the mean of correct responses to the true or false questionnaire among the sample (n = 2372). multivariate regression analysis revealed that age, nationality, family history of hearing loss and smoking were significantly associated with the true/false questionnaire score. values are presented in table 5. table 5: results of the true or false questionnaire score, based on multivariate analyses. discussion in this study, we administered a questionnaire on general knowledge of ear health and hearing management and received answers from 2372 residents of jeddah, saudi arabia. our results show that most answers to each question were correct. the highest correct-answer rate (93%) was for a question about the need for hearing aids to fit correctly to provide maximum benefit, while the lowest correct-answer rate (53.4%) was for a question about whether listening to music for 3 h a day leads to permanent hearing loss, followed by a question about whether vocal cord injury causes deaf–mute persons to be unable to speak (55%). regarding the questionnaire’s four domains, the percentages of correct answers for each domain varied between 68.26% and 85.5%. in the current study, we found a strong association between age and level of awareness: participants who were aged 40 years or older were the most likely to answer the questions correctly, while those aged 18 years or younger were the least likely to answer questions correctly. to the best of our knowledge, this observation has not been reported previously. it could be theorised that this association is because of older participants having had more exposure to and interactions with deaf individuals. there are only a few studies that have assessed awareness of hearing loss in an integrated manner that includes causes, effects and preventive and management measures (di berardino et al., 2013; lass, woodford, lundeen, lundeen, & everly-myers, 1986). interestingly, the question about the need for hearing aids to fit correctly had the lowest correct-answer rate in the previous study (35.8%) but the highest correct-answer rate in our study. however, an older study (lass et al., 1986) that included 71 high-schoolers reported a similarly high percentage of correct answers to this question (82.6%). this might be explained by relatively older age in the former study (di berardino et al., 2013) (mean age, 51.83 ± 16.57 years vs. 31.31 ± 11.85 years in our study and high-schoolers in the other study [lass et al., 1986]) as hearing aids have been widely developed and used more lately in the 20th century (mills, 2011). similarly, according to the results in the work of di berardino et al. (2013) women were more likely to answer correctly to questions related to specific items regarding infant hearing loss, hygiene and treatment; the cause of deaf-mutism; cotton bud safety and the importance of properly fitted hearing aids. this difference was attributed to females being more likely responsible for the care of the health of other family members (di berardino et al., 2013). the relationship between family history and awareness was also significant in their results; however, the relationship was reversed (people with affected relatives were less likely to know that ear drops were insufficient to treat earache). moreover, di berardino et al. reported that exposure to noise was not significantly correlated with a lack of awareness. in contrast, we observed that participants who reported being exposed to noise were more likely to correctly answer questions related to physical agents and overexposure (the effects of kisses and slaps and the recommended duration of noise exposure). the findings in our study can be explained by that having a family history and exposure to noise provides a better background of knowledge and experience, while the lack of knowledge in this group in their study (di berardino et al., 2013) may be explained by the advanced age, reducing the awareness of the condition of younger affected relatives and exposure to noise. nevertheless, these factors need to be further assessed considering the age, which is an important factor in hearing loss and the awareness of it. although our study shows a fair overall awareness of factors related to hearing loss and ear health, with an average score of 10.66 out of 14, the lack of knowledge in 20% – 50% of the population on some points could possibly have a negative effect on the care and well-being of deaf people, as well as on hearing loss prevention efforts in the general population. for example, a lack of knowledge about the association between deaf-mutism and early hearing loss could delay the diagnosis and treatment. indeed, a qualitative study on healthcare staff and parents of affected children in india reported that parents were less likely to recognise delayed speech and delayed response to speech in their children if they did not possess specific knowledge regarding the matter, even if they were highly educated in other fields (merugumala et al., 2017). moreover, a lack of knowledge about the association between hearing loss and performance in school may prevent hearing-impaired children from gaining access to proper care and education. similarly, a lack of awareness about the association between hearing loss and behaviour in elderly people can precipitate social problems for both affected individuals and their families, hinder the role of elderly people in society and prevent the diagnosis and treatment of hearing loss in this population. many studies have shown associations between elderly deafness, especially if untreated, and diminished physical ability and activity (chen, genther, betz, & lin, 2014; solheim, kværner, & falkenberg, 2011), life satisfaction (solheim et al., 2011), quality of life( mulrow et al., 1990; kelly, & atcherson, 2011) and mortality (karpa et al., 2010). lack of public knowledge about the effects of extended listening to music via earphones, the harms of cotton buds, the risk of fungal infections in swimming pools and the recommended duration of noise exposure all lead to poor attitudes regarding prevention of hearing loss. the heterogeneity in awareness found in the present study indicates the need for integrated and comprehensive educational materials to be presented to the public. indeed, chung, des roches, meunier and eavey (2005) reported that individuals in their sample showed a willingness to follow proper precautions after receiving recommendations from a doctor and information about the risks of hearing loss. education on the possible causal role of genetics is also an important goal to help parents decide whether to receive genetic testing, which could contribute to early detection of hearing problems (palmer, lueddeke, & zhou, 2009). therefore, broad national screening programme to preschool children besides awareness is recommended to detect this problem early. our study had several limitations. firstly, we did not account for the education level of the respondents, although there is some evidence that education affects awareness level (merugumala et al., 2017).7 studying the influence of education level would also have implications for estimating awareness in small towns and rural areas. furthermore, the age distribution of the sample was skewed towards younger participants by the method, requiring an electronic form, and because literacy levels are low among the elderly in jeddah. this could affect the accuracy of our estimations of awareness. moreover, this study included residents of jeddah. a future nation-wide survey would better assess awareness of ear health and hearing loss management in the entire saudi population, including those living in the rural areas. finally, we did not include healthcare staff or a representative number of deaf individuals. studies that include healthcare staff and a more representative number of deaf individuals and their families need to be carried out to accurately assess the effect of awareness on the incidence of hearing loss, as well as to assess the psychosocial well-being, access to healthcare and quality of education and work in the deaf population of saudi arabia. conclusion the overall awareness of ear health and hearing loss management in jeddah is adequate, although our results indicate the need for more integrated educational materials for both the general population and hearing-impaired individuals and their families. furthermore, the development of a broad national screening programme can significantly contribute to early detection and management of hearing loss. acknowledgements the authors are grateful to dalia ahmad alshaer, mohammad nasser almatrafi, raad hassan baabdullah, reham ahmed dahmash, shahad ali aleiidi, ahmed habib alshaikh, ohoud muqbil almutairi, sultan sameer alrabghi and meshal ldhubabian for participation as data collectors in the research. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. author’s contributions k.a.a. was responsible for conceptualisation, methodology and formal analysis. h.a. did the validation. w.m.a., k.a.a. and b.e.y. made the investigation. writing or original draft preparation was done by w.m.a., k.a.a. and b.e.y. h.a. performed writing, review and editing of the article. h.a. did the supervision. funding this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references agrawal, y., platz, e. a., & niparko, j. k. (2009). risk factors for hearing loss in us adults: data from the national health and nutrition examination survey, 1999 to 2002. otology & neurotology, 30(2), 139–145. https://doi.org/10.1097/mao.0b013e318192483c chen, d. s., genther, d. j., betz, j., & lin, f. r. (2014). association between hearing impairment and self-reported difficulty in physical functioning. journal of the american geriatrics society, 62(5), 850–856. https://doi.org/10.1111/jgs.12800 chung, j. h., des roches, c. m., meunier, j., & eavey, r. d. (2005). evaluation of noise-induced hearing loss in young people using a web-based survey technique. pediatrics, 115(4), 861–867. https://doi.org/10.1542/peds.2004-0173 di berardino, f., forti, s., iacona, e., orlandi, g. p., ambrosetti, u., & cesarani, a. (2013). public awareness of ear and hearing management as measured using a specific questionnaire. european archives of oto-rhino-laryngology, 270(2), 449–453. https://doi.org/10.1007/s00405-012-1961-3 joubert, k., sebothoma, b., & kgare, k. s. (2017). public awareness of audiology, hearing and hearing health in the limpopo province, south africa. south african journal of communication disorders, 64(1), 1–9. https://doi.org/10.4102%2fsajcd.v64i1.557 karpa, m. j., gopinath, b., beath, k., rochtchina, e., cumming, r. g., wang, j. j., & mitchell, p. (2010). associations between hearing impairment and mortality risk in older persons: the blue mountains hearing study. annals of epidemiology, 20(6), 452–459. https://doi.org/10.1016/j.annepidem.2010.03.011 kelly, r. j., & atcherson, s. r. (2011). quality of life for individuals with hearing impairment who have not consulted for services and their significant others: same-and different-sex couples. journal of communication disorders, 44(3), 336–344. https://doi.org/10.1016/j.jcomdis.2011.01.004 lass, n. j., woodford, c. m., lundeen, c., lundeen, d. j., & everly-myers, d. s. (1986). the prevention of noise-induced hearing loss in the school-aged population: a school educational hearing conservation program. the journal of auditory research, 26(4), 247–254. merugumala, s. v., pothula, v., & cooper, m. (2017). barriers to timely diagnosis and treatment for children with hearing impairment in a southern indian city: a qualitative study of parents and clinic staff. international journal of audiology, 56(10), 733–739. https://doi.org/10.1080/14992027.2017.1340678 mills, m. (2011). hearing aids and the history of electronics miniaturization. ieee annals of the history of computing, 33(2), 24–45. https://doi.org/10.1109/mahc.2011.43 mulrow, c. d., aguilar, c., endicott, j. e., tuley, m. r., velez, r., charlip, w. s., … denino, l. a. (1990). quality-of-life changes and hearing impairment: a randomized trial. annals of internal medicine, 113(3), 188–194. https://doi.org/10.7326/0003-4819-113-3-188 palmer, c. g., lueddeke, j. t., & zhou, j. (2009). factors influencing parental decision about genetics evaluation for their deaf or hard-of-hearing child. genetics in medicine, 11(4), 248. https://doi.org/10.1097%2fgim.0b013e318195aad9 solheim, j., kværner, k. j., & falkenberg, e. s. (2011). daily life consequences of hearing loss in the elderly. disability and rehabilitation, 33(22–23), 2179–2185. https://doi.org/10.3109/09638288.2011.563815 swanepoel, d. w., clark, j. l., koekemoer, d., hall iii, j. w., krumm, m., ferrari, d. v., … barajas, j. j. (2010). telehealth in audiology: the need and potential to reach underserved communities. international journal of audiology, 49(3), 195–202. https://doi.org/10.3109/14992020903470783 velonaki, v. s., kampouroglou, g., velonaki, m., dimakopoulou, k., sourtzi, p., & kalokerinou, a. (2015). nurses’ knowledge, attitudes and behavior toward deaf patients. disability and health journal, 8(1), 109–117. https://doi.org/10.1016/j.dhjo.2014.08.005 world health organization (who). (2012). who global estimates on prevalence of hearing loss. in world health organization (ed.). geneva: who press. retrieved from https://www.who.int/pbd/deafness/who_ge_hl.pdf world health organization (who). (2017). who programme for prevention of deafness and hearing loss. in world health organization (ed.). geneva: who press. retrieved from https://euracoustics.org/news/eaa-newsletter/2018/february/who-programme_for_prevention_of_deafness_and_hearing_loss-activity_report_2017.pdf. pdf file http://www.sajcd.org.za open access page 1 of 1 reviewer acknowledgement acknowledgement to reviewers in an effort to facilitate the selection of appropriate peer reviewers for the south african journal of communication disorders, we ask that you take a moment to update your electronic portfolio on https://sajcd.org.za for our files, allowing us better access to your areas of interest and expertise, in order to match reviewers with submitted manuscripts. if you would like to become a reviewer, please visit the journal website and register as a reviewer. to access your details on the website, you will need to follow these steps: 1. log into the online journal at https://sajcd. org.za 2. in your ‘user home’ [https://sajcd.org.za/ index.php/sajcd/user] select ‘edit my profile’ under the heading ‘my account’ and insert all relevant details, bio statement and reviewing interest(s). 3. it is good practice as a reviewer to update your personal details regularly to ensure contact with you throughout your professional term as reviewer to the south african journal of communication disorders. please do not hesitate to contact us if you require assistance in performing this task. publisher: publishing@aosis.co.za tel: +27 21 975 2602 tel: 086 1000 381 the editorial team of the south african journal of communication disorders recognises the value and importance of the peer reviewer in the overall publication process – not only in shaping the individual manuscript, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank all reviewers who participated in shaping this volume of the south african journal of communication disorders. we appreciate the time taken to perform your review(s) successfully. alida ellis alida naude andrea barton-hulsey anna-lisa sutt anniah mupawose bea staley ben sebothoma bradley mcpherson caitlin wakefield cara hollander celeste sameuls claudine storbeck coralie van reenen dhanashree pillay elanor ross erika bostock fatemah camroodien-surve hanlie degenaar husmita ratanjee-vanmali jackie clark jenny pahl julie durando karin joubert katerina ehlert kim coutts leanie engelbrecht lida muller lidia pottas lucretia petersen maggi soer marguerite de jongh mari viviers melissa bortz michelle pascoe mukovhe phanguphangu nceba gqaleni nomfundo moroe ondene van dulm penelope alison samantha govender shabnam abdoola sharon moonsamy tarryn reddy victor de andrade vishakha rawool vivienne norman zenzo chakara http://www.sajcd.org.za� https://sajcd.org.za https://sajcd.org.za https://sajcd.org.za https://sajcd.org.za/index.php/sajcd/user https://sajcd.org.za/index.php/sajcd/user mailto:publishing@aosis.co.za abstract introduction theoretical framework literature review research methodology results discussion conclusion strengths of the study limitations of the study recommendations for future research acknowledgements references about the author(s) lauraine giacovazzi department of speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa sharon moonsamy department of speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa munyane mophosho department of speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation giacovazzi, l., moonsamy, s., & mophosho, m. (2021). promoting emergent literacy in under-served preschools using environmental print. south african journal of communication disorders, 68(1), a809. https://doi.org/10.4102/sajcd.v68i1.809 research project registration: project number: r14/49 original research promoting emergent literacy in under-served preschools using environmental print lauraine giacovazzi, sharon moonsamy, munyane mophosho received: 23 dec. 2020; accepted: 31 mar. 2021; published: 17 may 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: children from under-served communities are at risk for delayed spoken language and literacy development. under-served preschools frequently contend with lack of resources, especially with regard to access to age-appropriate storybooks and/or print resources. environmental print is a cost-effective material that can be used to stimulate emergent literacy skills. in the context of under-served communities, a collaborative approach and mentorship between preschool teachers and speech-language therapists (slts) promote language and literacy development. objectives: this article’s purpose is two-fold; firstly, to discuss the use of environmental print as a stimulus material to promote emergent literacy in preschoolers in under-served preschools. secondly, to promote the slt’s involvement in such education initiatives. method: a mixed-method, comparative intervention research design, was reported in this article. a preand post-test design was employed, with data collected before and after a teacher-based intervention. results: participants in the intervention group displayed increased scores on the concepts about print (cap) assessment, participants in the comparison group showed no change in scores using the same assessment over the same time period. conclusion: a short-term, teacher-based intervention using environmental print with slt mentoring and collaboration promoted preschool children’s emergent literacy skills. implications include the value of using environmental print as a teaching material and the positive impact of collaboration between slts and teachers to promote emergent literacy in preschool children. keywords: collaboration; emergent literacy; environmental print; under-served preschools; slt. introduction this article aims to highlight a section of the authors’ larger study to demonstrate the benefits of using environmental print as a cost-effective and successful stimulus material to teach print concepts and emergent literacy skills to children in under-served preschools. the article also promotes the collaboration of professionals such as speech-language therapists (slts) with preschool teachers in under-served communities, further highlighting the need for explicit teaching practices that would benefit young children’s emergent literacy development. the concepts of environmental print and under-served preschools will be explored further in more detail. environmental print is the print that is found in public spaces (e.g. road signs, billboards), shopping areas (e.g. brand labels, restaurant signs, logos) and can extend into the school or work areas (e.g. posters) (neuman & celano, 2001; neumann, hood, & ford, 2013; vera, 2007). environmental print can be a particularly valuable tool for use as a stimulus, encouraging the development of certain language skills and emergent literacy in young children. environmental print is cost-effective, easily accessible and has frequent occurrences outside the classroom. its availability outside the classroom allows parents to continue stimulating what their child had learned at school, consolidating their learning. cost-effectiveness becomes a pivotal aspect when considering interventions to address teaching of emergent literacy skills in the south african context, as socioeconomic disparities are evident in our society. continuing inequalities in socioeconomic status, lack of access to a variety of resources for language and literacy learning in the classroom and even limited access to learning in one’s first language exist across south african communities (graven, 2013). such inequalities leave many children in south africa at risk for spoken language and literacy developmental delays, which hinder their progress in education, placing them at risk (fernald, marchman, & wiesleder, 2013; hoff, 2006). furthermore, the aftermath of apartheid and its effects that the majority of south africans continue to face implies that socioeconomic status is multi-dimensional. thus, describing the middle socioeconomic class can become complex, as it depends on the perspective and interpretation of the reader (burger, steenekamp, zoch, & van der berg, 2014; schotte, zizzamia, & leibbrandt, 2017; schutte, 2018). perspective taking, often makes it challenging to determine the potential influence of socioeconomic status on spoken language and literacy development in the south african context. nonetheless, it is well-documented in research internationally that socioeconomic status influences children’s development (fernald et al., 2013; hoff, 2006). therefore, persistent inequalities in the south african context will negatively impact language and literacy skills, unless explicit collaborative interventions are applied to break the cycle (graven, 2013). children from lower socioeconomic and under-served communities are, therefore, frequently placed in a disadvantaged position, academically and socially when compared to the same aged peers from middle to upper socioeconomic communities (walton, bekker, & thompson, 2015). the term under-served applies particularly to schools or communities that are not provided with the same facilities, resources or services that are typically found in middle to upper income communities and/or schools. children in under-served preschools repeatedly contend with lack of resources in their classrooms, especially with regard to access to age-appropriate storybooks and/or print resources as well as access to support services from slts (neuman & celano, 2001). limited access to resources is often largely related to cost. in the case of south africa’s under-served preschools, they often cannot afford to purchase such resources, as they are not funded sufficiently by the government (relying on fees from parents to fund their schools). hence, environmental print becomes a viable, cost-effective resource for teaching emergent literacy skills in these contexts. there is a continuing and urgent need for supporting learners in language and emergent literacy development in the early years in south africa (graven, 2013). methods of teaching that support language and literacy development in at-risk south african children require in-depth research from all stakeholders. similarly, reasons for and ways to address language and literacy delays require more research in the south african context. environmental print is a resource that could be used for teaching print concepts within the preschool setting with potentially positive outcomes for promoting children’s emergent literacy development. collaborative support from slts for preschool teachers is an additional measure that would promote emergent literacy development in children, attending under-served preschools. theoretical framework for this study’s purpose, vygtosky’s socio-cultural theory was selected as it underpins the language-learning approach adopted in the intervention employed. socio-cultural theory focuses on three main areas: social interaction, the more knowledgeable partner (e.g. the adult in teacher-child interactions) and the zone of proximal development (zpd) (keenan & evans, 2009). the emphasis vygotsky placed on cultural and social interactions is apt for the hugely multi-cultural south african environment (wieten & hassim, 2016). vygotsky’s theory advocates that the child plays an active role in his or her cognitive development together with the impact of social interactions with parents, teachers and older children who can provide invaluable guidance (wieten & hassim, 2016). the zpd is defined as the distance between what children can do by themselves and the concepts and skills they can learn with the assistance from adults (levey, 2014). adult individuals aside from parents also include teachers, who play an important role in child development in the early years, within the school environment. literature review emergent literacy varied international and local literature supports the topics of language development, emergent literacy, literacy practices, parentand teacher-based interventions and the effect of socioeconomic status on variation in these areas (atmore, 2013; de witt, 2009; fernald et al., 2013; heugh, 2009; jordaan, 2011; kathard et al., 2011; wium & louw, 2013). literacy encompasses the skills of spelling, reading and writing (wium, 2015) and can be viewed as a social practice influenced by the individual, home culture and school (mckenzie, 2015). emergent literacy, a practice that begins before the formal instruction of literacy, involves both written language awareness and phonological awareness (recognising and working with the sounds used in spoken language), which are both based on typically developing oral language (giess, 2010; wium, 2015). print concepts are part of emergent literacy development and according to clay (2000), it includes if a child understands the following variables: print has meaning. print can be used for different purposes. there is a relationship between print and spoken language. there is a difference between letters and words. words are separated by spaces. there is a difference between words and sentences. there are punctuation marks that signal the end of a sentence. books have parts (front and back cover, title, page and spine). stories have a beginning, middle and end. text is read from left to right and top to bottom. the print concepts listed above are included in clay’s (2000) assessment tool, concepts about print (cap). this particular assessment tool was used in this study at pre-testing and post-testing. beginning readers first develop early or emergent literacy skills and continue to develop these along a continuum until they have established these skills and become independent readers. both literacy and language skills are dependent on a foundation of listening and language competence (wium, 2015). the main research indicates that the earlier literacy practices are introduced into children’s typical interactions with their parents or significant others, it is more likely that children will reap positive gains for their later literacy development (e.g. dodici, draper, & peterson 2003; griffin, hemphill, camp, & wolf, 2004; ntuli & pretorius, 2005). early exposure and or intervention hence become critical not only in home practices but also in educational settings like preschools. this would be especially crucial for at-risk children, which include children from under-served preschools. oral language skills play an essential role in literacy development as do concepts surrounding the print itself. neumann (2016) found that australian parents from more advantaged backgrounds seemed to teach their children more about print (teaching them specifically about letters and words) when compared to parents from lower socioeconomic backgrounds. results like these further emphasise the potential differences that exist between children from varying socioeconomic backgrounds. neumann’s (2016) results also suggested that a specific focus on explicit teaching of print concepts in home literacy practices should not be neglected. print concept knowledge and explicitly teaching these concepts to young children aid in furthering emergent literacy both at home and at school. previous research in the field of emergent literacy has, therefore, proven that early exposure to literacy skills and explicit instruction are keys to building developmental foundations that promote long-term success in literacy progress (griffin et al., 2004; reutzel et al., 2003). for the purpose of this article, a focus on the south african context, given its history of inequalities, will give a clear view of the importance and need for support in language and literacy learning in the early years. likewise, it is important to examine how slts can support learners and collaborate with teachers to further learner’s language and literacy development. the south african context and involvement of speech-language therapists in education there is an unrelenting need for interventions, aimed at promoting language and literacy development in preschool south african children (kathard et al., 2011; wium & louw, 2013). in fact, an urgent need to address literacy across age ranges exists in south africa (gustafsson, van der berg, sheperd, & burger, 2009). many south africans experienced disadvantages across contexts as the result of apartheid, including access to quality education, thus affecting literacy acquisition (moonsamy, mupawose, seedat, & mophosho, 2017). apartheid was a policy of segregation based on race, violating the human rights and dignity of the majority, its black populations (constitution of south africa, 1996). the south african government has acknowledged that there are ‘unquestionable reasons’ for investing specifically in early childhood development (ecd) (republic of south africa, 2010, p. 13). these reasons include children’s rights, human development, equity and the economy (republic of south africa, 2010). there has been an increase in children aged 0 to 4 years attending ecd centres (preschools) from 7% in 2002 to 30% in 2009 (republic of south africa, 2010). in 2016, 53% of children aged 0–6 years attended ecd centres across the country; however, disparities exist between urban and rural access (statistics of south africa, 2016). the government acknowledged that ‘much more is required to improve the quality of education provided’ (republic of south africa, 2010, p. 10). literacy levels in particular go on to affect employment opportunities placing a person who may be illiterate or presenting with below average literacy skills at further economic disadvantage (gustafsson et al., 2009). literacy is, therefore, in a prominent position for evaluation and monitoring, locally and internationally. progress in international reading study (pirls) collects data to provide insight into reading achievements in the fourth, fifth and sixth grade across the globe (mullis, martin, foy, & hooper, 2017). south africa’s performance in pirls assessments has placed the country’s literacy achievement below the international benchmark (mullis, martin, foy, & drucker, 2012; mullis et al., 2017). these statistics imply that south africa is not progressing in its reading achievement at the rate expected. some of the factors identified as potentials for increased achievement in reading via the research gathered from pirls are summarised (box 1). box 1: factors related to increased achievement in reading. box 1 presents factors that relate to reading achievement and are important to the south african context. additionally, mophosho, khoza-shangase and sebole (2019, p. 62) listed the following as contributing factors to the development of reading: how much time is devoted to reading in schools, class organisation (numbers of learners and interactions between them and the teacher), methods used for reading as well as assessing progress, language spoken at home as well as exposure to the language of learning and teaching. south african schools within middle to upper class communities tend to be resourced with materials, social resources, well-trained teachers and parents who are sufficiently affluent to support optimum conditions for language and literacy development. such schools also have access to various therapists, including slts, occupational therapists, physiotherapists and psychologists. however, schools within under-served communities do not have these same advantages (e.g. townships, rural areas and some less wealthy urban areas) (kathard et al., 2011; walton et al., 2015). foundational to the concept of improving the quality of language and literacy teaching practices in schools is a focus on early interventions in ecd (preschools) rather than later in formal primary schooling. this early intervention is fundamental to young children’s developmental potential (vally, 2012) during the critical development period (owens, 2014). further improving the quality of south african schooling requires increased access, better value education and an understanding of the multilingual context of south africa as well as how children could benefit from it (mophosho et al., 2019). the language of learning and teaching gives children access to navigating the curriculum effectively. in the context of preschool, this means access to developing essential language and emergent literacy skills, as prerequisites for later scholastic success. slts have the potential to contribute to this particular aspect of south african schooling, via teacher collaborations and mentoring (moonsamy & carolus, 2019). slts are trained in understanding and providing interventions for language and literacy delays and disorders across age ranges. understanding that the slt has a vital role in collaboration with the education system is essential in providing relevant intervention and services within school contexts in south africa (kathard et al., 2011; wium & louw, 2013). locally, there is a call for an increase in the involvement of slts in education to enhance language and literacy outcomes in south africa (moonsamy et al., 2017). before the end of apartheid in 1994, slts were employed in schools for only white learners and in special schools for children with disabilities, regardless of race (moonsamy et al., 2017). post-1994, slts were not considered for inclusion in employment within the school system apart from special schools (constituting 3% of south african schools) (moonsamy et al., 2017). this leaves the majority of learners, especially within the public school system without direct access to slt services. notwithstanding the challenges of offering slt services in schools, there is a call within the profession itself for slts to increase their involvement in the south african school system. kathard et al. (2011) stated the following: [t]he lens of the profession must expand from the traditional impairment-driven frame to a broader and more inclusive framework which considers not only those who have language and literacy learning impairments, but also considers those who are at risk for literacy development and hence educational failure as a result of disabling systemic conditions. (p. 61) wium and louw (2013) expanded on the necessity for south african slts to take on a similar reform as was stated by the american speech-language association (asha) in 2010 regarding four fundamental areas: critical roles, range of responsibilities, collaboration and leadership. slts have a key role to play in the education system and contribute to ‘education and preparing citizens of the future’ (wium & louw, 2013, p. 36). children who face formal education without intact listening skills, spoken language skills and metalinguistic skills become at risk for academic failure. this, in turn, places them at risk for ‘low self-esteem, social maladjustment and ultimately vocational problems’ (kathard et al., 2011; wium & louw, 2013, p. 33). however, slt’s contributions towards supporting learners do not have to be limited to directly working with learners but could contribute to supporting teachers. slts have the opportunity to not only work with teachers in terms of language-literacy teaching and learning but also to promote resourcefulness in selecting cost-effective materials, like environmental print. environmental print environmental print is a valuable resource that can be used in a learning environment where children may be learning in their second language. this has been demonstrated in both vera (2007) as well as bhuvaneswari and pradakannaya (2017) studies with learners speaking english as their second language but attending english medium schools. with south africa’s multilingual nature, tools that are flexible for learning in multiple languages are prized. in education, one important component contributing to children’s literacy development is a classroom environment rich in written language. there have been limited published studies in south africa which investigate the possible changes an environmental print intervention could make in children’s literacy skills from under-served communities. this study, therefore, aimed to address this knowledge gap. specifically, neumann et al. (2013) and vera’s (2007) studies were explored as an adapted model of intervention for the current study. both of these studies prove valuable in confirming the potential of environmental print in teaching print concepts as a part of emergent literacy development. environmental print has several advantages including cost-effectiveness, accessibility and has frequent occurrence outside the classroom. neumann et al. (2013) findings suggested that environmental print might be more effective than standard print when teaching print concepts, enhancing print motivation and increasing some aspects of emergent literacy because of its contextual nature. participants who were learning english as the second language in vera’s (2007) study furthermore expanded their alphabet knowledge in the context of english and this promotes the value of using environmental print in multilingual contexts (such as south african preschools). the current study aimed to improve emergent literacy skills of south african preschoolers through an environmental print intervention. research methodology research question what is the effect of a teacher-based, slt-supported, environmental print intervention on the emergent literacy skills of children in an under-served preschool? the study investigated if any changes occurred in preschool children’s spoken language and emergent literacy skills, following a short-term teacher-based intervention using environmental print. this article focusses specifically on changes shown by individual children in the intervention group in terms of their emergent literacy print concepts at pre-testing and post-testing. research design a mixed methods comparative intervention research design was utilised, with a preand post-test design applied to measure print concepts. the cap assessment was used pre and post the intervention phase. the researcher, (an slt) and the ecd teacher dynamically created the intervention content weekly. in the results section, the intervention is described (table 4). using a mixed methods approach allows the researcher to use multiple tools to gather more comprehensive data that cover a topic broadly (creswell, 2009; hunter & brewer, 2015). quantitative and qualitative data were collected. an overview of the data collection tools and data analysis is given (table 1). table 1: research methodology. whilst an overview of the tools, assessments, interviews and observation methods used for the study as a whole is given (table 1), this article only focuses on print concepts as it relates to emergent literacy. the cap assessment tool is explained further for this purpose. measures: concepts about print cap assessment tool is based on marie clay’s (2000) research, as a means to ‘observe what children notice about written language in their environments’ (as cited in johnson, 2015, p. 54). the cap assessment is used to assess various print concepts (listed on p. 6.) this tool is efficient in its administration and has been researched and utilised in several different studies (including johnson, 2015; neumann et al., 2013; tafa, 2009; vera, 2007). tafa (2009) found that the cap assessment was highly reliable when used in greek, demonstrating the adaptability of this tool into a different culture and language. this suggests a potential value for the south african context and proved effective within the current study. cap comprises a checklist-style scoring sheet. raw scores were tallied with the use of the assessment checklist. the checklist was used with an ageand culturally appropriate storybook. children were probed with questions or instructions regarding specific concepts surrounding print. two different storybooks were used: one at pre-test and one at post-test data collection. the books used were: ‘wake up, mummy!’ by stephanie moss and ‘who’s in my family? all about our families’ by robie h. harris. the books were selected based on how the print would relate to the cap assessment tool, together with the needs of the narrative sample (mentioned in table 1). the cap assessment has been found to be flexible as a tool used in various contexts, cultures and languages. the context of the current study’s participants is detailed below. participants’ context a purposive sampling strategy was used to strategically create a sample that would be relevant to the research questions (creswell, 2009). the department of social development (dsd) assisted the researcher in sourcing two schools appropriate for the study. both schools were located in the same area near the randburg central business district (cbd), johannesburg, south africa. the schools were randomly assigned as either the intervention group or the comparison group before meeting with the teachers and principals in order to reduce potential researcher bias. all included participants gave informed consent in writing. two teachers agreed to participate in the study. both the intervention group and comparison group teachers had a further education and training certificate: ecd (nqf level 4) qualification. the teachers’ first language was isizulu, but the medium of instruction in both classes was english (their second language). both groups of children spoke a variety of different languages as their first languages, including languages from other african countries (e.g. french, chichewa, shona, yoruba, thumbuka – refer to figure 1). further background information of the 32 children and their parents across both groups was gathered via the consent forms. information specific to the children’s developmental profiles is demonstrated (table 2) and (figure 1), as the contextual information was important when creating the intervention sessions. figure 1: reported first languages of learners. table 2: children’s reported background information. data collection data collection took place across five phases as described (figure 2). figure 2: data collection procedures. pre-test and post-test cap assessment scores were collected in phases two and four, respectively, as shown (figure 2). the data were analysed using descriptive statistics (figure 3) and inferential statistics (table 4). figure 3: concepts about print (cap) preand post-test results (both groups). ethical considerations this research was cleared by the human research ethics committee (non-medical) at the university of the witwatersrand, reference number: h17/07/06. results for the purpose of this article, results presented relate specifically to the intervention sessions and the preand post-test data on the cap assessment. results from preand post-testing demonstrated statistically significant increases in scores on the cap assessment in the intervention group compared with the comparison group. the comparison group did not display statistically significant increases in cap scores over the same period of time. an outline of the 12 intervention sessions in terms of activities and materials used is provided (table 3). table 3: intervention sessions. the intervention sessions planned weekly, with the teacher were presented (table 3). each session utilised environmental print materials as well as explicit instruction of the concepts taught in each session. the preand post-testing scores for cap across both groups of children (with children 1 to 19 representing the intervention group and children 21 to 32 representing the comparison group) are displayed (figure 3). gains at post-testing appeared more frequently amongst the intervention group when compared with the comparison group children as shown (figure 3). this was confirmed via the paired sample t-tests; the p values for the null hypotheses are demonstrated (table 4). table 4: concepts about print t-test p values (intervention and comparison groups). for the intervention group children, the null hypothesis was that the mean cap scores at preand post-testing were equal. the alternative hypothesis was that the mean cap score at post-testing was higher than the mean cap score at pre-testing (one-tailed test). using the data, the null hypothesis was rejected at even a 1% level of significance (0.000077 < 0.01) as shown (table 4). from the data, it can be concluded that the mean cap score at post-testing was greater than the mean cap score at pre-testing amongst the intervention group children. a paired two-sample t-test was used to test whether the mean cap score at post-testing is higher than the mean cap score at pre-testing amongst the comparison group children. the null hypothesis was that the mean cap scores at preand post-testing were equal. the alternative hypothesis was that the mean cap score at post-testing was higher than the mean cap score at pre-testing (one-tailed test). using the data, the null hypothesis could not be rejected at even a 10% level of significance (0.4195 > 0.1) as shown (table 4). there was, therefore, insufficient evidence to suggest that the mean cap score at post-testing was greater than the mean cap score at pre-testing amongst the comparison group children. the comparison group children did not make similar gains in cap scores within the same time frame as the intervention group children. again, one can deduce that the increases that the intervention group children presented with on the cap assessment at post-testing may be attributed to the intervention. both the classrooms of the intervention and comparison groups displayed some environmental print in the form of posters, often hand-made ones. according to reutzel et al. (2003), it is not enough to simply display environmental print in the classroom; rather one needs to explicitly teach children to apply word study, decoding skills and phoneme-grapheme knowledge using the environmental print as a material. explicit instruction using environmental print was included in the intervention (table 3). this particular interpretation, along with other salient topics is included in the discussion section. discussion using environmental print was an effective means to sourcing cost-effective materials to teach pivotal print concepts (refer to table 3 for intervention details). the environmental print that was used within the intervention comprised of materials that the teachers and learners collected or was readily available in the classroom (e.g. posters). the teacher and the researcher were able to maintain a cost-effective approach by becoming resourceful with what was available to the intervention at no financial cost (vally, 2012). environmental print is cost-effective because one can source materials by recycling packaging goods (e.g. cans, cereal boxes, bottles amongst others) or view it at no cost in the form of public signs. environmental print allows children to learn the variables of print concepts (listed on p. 2) with a similar efficacy to traditional print resources (e.g. storybooks) (neuman et al., 2013). it is already known that children in under-served preschools often face lack of resources in their classrooms (e.g. age-appropriate storybooks and/or print resources) (neuman & celano, 2001). both schools had few print resources in the form of printed and hand-made posters; however, the teachers were not maximising the print materials’ inclusion at pre-intervention. the researcher through collaboration had the opportunity to foster resourcefulness in collecting the environmental print material for teaching language and emergent literacy skills. teachers and learners collected materials by recycling empty packages, boxes, cans or similar materials from their homes and schools (refer to table 3 and figure 4 for examples). figure 4: photos of environmental print materials and recycled (‘new’) materials: (a), (b), and (c) are examples of the materials collected; (d), (e) and (f) are examples of how the materials were reused. using environmental print created a viable opportunity to use print that the children would likely encounter again outside of the intervention, lending to the high impact on recognition that environmental print offers (neumann et al., 2013; vera, 2007). carryover of some of the lesson content to the home environment was observed when parents began reporting to the intervention teacher that their children were asking questions, drawing attention to and making statements about print they saw at home and in shopping areas particularly (e.g. brand labels, shopping lists, print found on bank notes or coins). consequently, the intervention teacher was presented with the opportunity to talk to parents about what materials she was using in the classroom, as the children had initiated conversations and interactions outside the classroom with their parents about their lesson content. teacher and parent partnership holds an important influence over a child’s learning as well as the teacher and school as a whole (henderson & berla, 1994). gonzalez-dehass, willems and doan holbeim (2005) noted that significant interactions between parents and teachers positively influence a child’s efforts, concentration and school attendance. hence, the increased interaction of the intervention teacher with parents should be seen as a positive gain. it is important to reiterate that it was not merely the presence of the environmental print that made the children’s gains possible but the teacher’s purposeful and explicit use of the material and teaching technique. instruction, therefore, needs to be explicit and intentional. the intervention group children experienced an intervention where their teacher used more explicit instruction on skills relating to concepts about how print works and phonological awareness skills as opposed to the comparison group children within this particular time frame (see table 4). moonsamy and carolus (2019) found, similarly, an increase in cap scores at post-testing following a literacy intervention programme with south african ecd or preschool teachers. in this particular study, the researcher collaborated with teachers to promote explicit instruction on print concepts through varied reading strategies. hence, moonsamy and carolus (2019) further promoted not only the need for explicit instruction but also the benefits of slts and teacher collaboration. moonsamy and carolus (2019) used storybooks as the resource for explicit instruction whilst neumann et al. (2013) and vera (2007) found that cap scores amongst their participants also increased at post-testing following environmental print interventions, specifically. these examples of explicit instruction and purposeful interaction with environmental print materials support the argument of the current study that collaborating with the teacher on environmental print creates opportunities for children to promote their emergent literacy skills. environmental print materials as an educational tool have shown the possibilities of a resource that is cost-effective, flexible in its use for multiple activities and relevant to the group of children who collect the materials from their own direct environments. increases at post-testing in cap scores amongst the intervention children were statistically significant and likely attributed to the intervention as a similar trend was not observed amongst the comparison group children. these improvements demonstrated that the children were able to generalise the print concepts they had acquired via the environmental print materials to book materials (used with the cap pre-test and post-test). a similar finding was also presented by neumann et al. (2013) and vera (2007). this finding reinforces the theory of the interaction within the zpd between the teachers and the children in their classroom whilst learning print concepts. the findings also supported the theory that environmental print can be used as an effective resource for teaching preschool children print concepts successfully. conclusion the study has revealed that collaboration between slts and teachers can make a positive impact on promoting language and emergent literacy skills in preschool children. the slt’s specific knowledge and skill combined with mentoring and collaborating with teachers can contribute towards the current urgent needs surrounding maximising cognitive potential in south african preschoolers. short-term interventions continue to show their value in stimulating literacy and language skills, as well as, promoting slts involvement in education. short-term interventions create multiple opportunities for slts to make a positive impact with regard to promoting language and emergent literacy teaching and potentially to increase the skills in preschoolers. environmental print offered itself as a valuable resource for teaching language and emergent literacy skills amongst the children who participated in the study. the implication of using environmental print as a teaching material should motivate professionals working in education (especially in the preschool context) to be resourceful in the face of limited traditional resources. the high impact that environmental print offers within the classroom cannot be under-estimated. the principles of language and emergent literacy teaching continue to be at the forefront of discussion, as we address the need to maximise south african children’s cognitive potential (especially within under-served communities). the theoretical principles of the zpd were demonstrated within the current study between the teachers and their preschool learners. furthermore, the theory that environmental print is effective in teaching print concepts to preschool children was reinforced. this particular finding is pivotal for under-served populations that lack resources to teach print concepts (such as story books or other print resources that may be costly). strengths of the study the statistically significant results of the cap that triangulated with qualitative data were a valuable strength to this study. having a student research assistant assist in collecting preand post-test data also offset potential researcher bias. in addition, the researcher (and assistants) had no previous relationship to the schools, which reduced further bias. the dsd assisting with the selection also helped to match the schools, teachers and learners as closely as possible. the researcher working closely with the dsd supports the concept of collaboration between government departments, schools and researchers, so that evidence-based practice can emerge. furthermore, the two schools participating within the study meant that the researcher could use an intervention and comparison group design. comparing results in this manner added validity to outcomes, as the researcher was able to infer that changes observed were likely linked to the intervention. limitations of the study whilst every effort was made to strengthen the research design, limitations did exist and should be acknowledged when considering the study’s results and interpretation. having a smaller sample size means that results cannot necessarily be generalised to all groups of children; however, the information gained contributes to the clinical and theoretical implications. the researcher and the student research assistant were not fluent in other south african languages and this could also be seen as a limitation. however, there were multiple languages that were spoken by the children, attending this school, as they hailed from various countries in africa. even though the results of the current study are not generalisable to other contexts, the findings have powerful contributions to the value of environmental print as a teaching material. furthermore, the outcomes of the study advocate mentorship and collaboration between slts and teachers in ecd centres to promote preschool children’s language and emergent literacy skills. furthermore, it contributes to advancing early intervention practices and promoting the slt’s role in education. recommendations for future research further research in this field could benefit the professions of both slts and preschool educators. projects using environmental print, mentorship and collaboration performed with larger groups of participants could assist with the validity of the results. application of multiple south african languages in shortor long-term environmental print interventions would also be valuable. in this manner, one would be able to ascertain the gains that could be made in children and teachers when they are placed in a position of advantage with their first languages. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions l.g. conceptualised the topic and design, collected the data and wrote the first draft. s.m. and m.m. supervised this research project, contributed from the beginning to the end of the study, including critical input on data analysis, interpretation, revisions and editorial aspects. all authors have given final approval of the manuscript version to be published. funding information this researcher received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability all data generated and analysed during this study are available from the corresponding author, l.g., upon request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references atmore, e. 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(2013). revisiting the roles and responsibilities of speech-language therapists in south african schools. south african journal of communication disorders, 60(1), 31–37. https://doi.org/10.4102/sajcd.v60i1.8 90 liani van der w esthuizen and c atherine van dijk die ervarings van jong volwassenes met kogleere inplantings aangaande bimodale versterking liani van der westhuizen & dr. catherine van dijk departement van kommunikasiepatologie, universiteit van pretoria abstract the main function o f a cochlear implant is to optimise the auditory and communicative abilities o f individuals with hearing loss. the use o f a hearing aid in the non-implanted ear further optimises binaural hearing, which leads to improved sound localization, speech discrimination in noise and quiet surroundings, and refined sound quality. the goal o f the study was to determine the ex­ periences o f young adults with cochlear implants regarding bimodal amplification. considering that all age groups are implanted with cochlear implants and that binaural amplification is beneficial to all age groups, it is important that information on young adults also be included. this study addressed bimodal amplification in terms o f auditory, communicative, and cosmetic aspects, and handling and care o f apparatus. a qualitative, descriptive research design was employed, and questionnaires were completed by fiv e clients who are part o f the pretoria cochlear implant program. three o f the participants took part in the focus group dis­ cussion in support o f the results taken fro m the completed questionnaires. the results o f the study indicate that the participants experience bimodal amplification positively, especially in terms o f auditory and everyday communicative functioning. the partici­ pants largely perceived cosmetic aspects, handling and care o f apparatus negatively. the outcomes o f the study can be used by audiologists in order to adequately inform and counsel candidates regarding bimodal amplification. potential barriers can also be addressed appropriately. key w ords: cochlear implants, bimodal amplification, experiences, auditory functioning, communicative functioning, cosmetics, handling and care. inleid in g die kogleere inplanting is die mees resente en innoverende vordering in die habilitasie en rehabilitasie van kinders wat gehoorverlies het, aangesien dit bruikbare gehoor en verbeterde kommunikasie verskaf (katz, 2002). die inplanting omseil die beskadigde dele van die ouditiewe sisteem en stimuleer die gehoorsenuwee direk, wat die individu met erge of totale gehoorverlies in staat stel om klank te ontvang. die apparaat verskaf die moontlikheid van gedeeltelike herstel van die ouditiewe fimksie en lei tot beter ouditiewe-verbale verbinding in spraak. verbeterde spraakdiskriminasie word dus verkry, wat as die vemaamste voordeel van die kogleere inplanting beklemtoon word (katz, 2002). die gebruik van ‘n unilaterale kogleere inplanting hou egter potensiele probleme in. die gebruik van monourale gehoor veroorsaak dat spraakdiskriminasie in agtergrondsgeraas, sowel as lokalisasie van klank, moeiliker plaasvind (ching, incerti & hill, 2004). lokalisasie is belangrik vir die vermyding van bronne van gevaar, asook wanneer aandag gegee word aan die gekose spreker in kompetisie met ander sprekers. spraakpersepsie in geraas is belangrik vir effektiewe kommunikasie (tyler; gantz, rubinstein, wilson, parkinson, wolaver, preece, witt, & lowder, 2002). die gebruik van ‘n unilaterale kogleere inplanting kan dus daartoe lei dat hierdie vaardighede ingeboet word. navorsingsliteratuur het egter aangedui dat bilaterale kogleere inplantings bogenoemde beperkings verminder. oor die algemeen word aangedui dat bilaterale kogleere inplantering die vofgende voordele inhou: • verbeterde gehoor in geraas waartydens spraakbegrip met 16% verbeter. • verbeterde gehoor in 'n stil omgewing ('n verbetering van ongeveer 19% is waargeneem). • die herstel van ruimtelike gehoor en klanklokalisasie. • hoer kwaliteit klank. (tyler et.al, 2002; van hoesel, tong, hollow & clark, 1993; flynn & schmidtke, 2004). bilaterale kogleere inplantings kom dus toenemend meer algemeen voor vir persone wat dit kan bekostig, selfs binne die suid-afrikaanse konteks (c.van dijk, persoonlike kommunikasie, november 2006). die beperkte finansiele voorsiening vanaf mediese fondse het egter tot gevolg dat sommige persone voel dat hulle goed genoeg oor die weg kom met slegs ‘n unilaterale kogleere inplanting. dit is egter van groot belang dat die oudioloog besef wat die voordele van bimodale versterking is. sodoende kan ‘n altem atief bepaal word vir die stimulering van die teenoorgestelde oor in gevalle waar persone nie ‘n bilaterale inplanting kan bekostig of gereed is vir ‘n tweede inplanting nie (www.cochlear.com). finansiele faktore binne die suid-afrikaanse konteks maak dit moeilik om ‘n persoon bilateraal te inplanteer en daarom moet ‘n altematiewe oplossing gevind word waar die persoon met die gehoorverlies steeds optimale binourale voordele kan ontvang en wat op die individu se behoeftes sal fokus. daar kan dus voorgestel word dat kogleere implanting gebruikers ‘n gehoorapparaat in die teenoorgestelde oor as 'n altem atief kan benut en sodoende steeds bimodale voordeel verkry (ching, psarros, hill, dillon & incerti, 2001). > navorsing deur ching et.al. (2001) op volwassenes met ‘n kogleere inplanting en ‘n gehoorapparaat in die teenoorgestelde oor, het die voordele verbonde aan die gebruik van bimodale versterking bewys. daar is wel gevind dat die gehoorapparaat se versterkingsvereistes ten opsigte van die frekwensierespons toepaslik is volgens die nal-rp voorskrif, maar sekere fyner instellings is steeds nodig. indien die gehoorapparaat aangepas word by die kogleere inplanting, is daar beduidende voordele vir spraakpersepsie, lokalisasie en ourale/orale fimksionering in sosiale situasies. die spraakpersepsie resultate van hierdie studie het bewys dat bimodale versterking beter spraakpersepsie in geraas tot gevolg het. 'n verm indering in lokalisasiefoute is ook in hierdie studie bewys. die persone het aangedui dat hulle binourale voordele in regte lewensituasies ervaar. hulle is in staat om beter t e ' funksioneer in ‘n verskeidenheid van die suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.cochlear.com qie ervarings van jong v olw assenes m et k ogleere lnplantings aangaande b im odale versterking 91 kommunikatiewe situasies, kan musiek meer geniet en hulle ervaar groter selfversekering in hulle daaglikse lewe. kogleere jnplanting-gebruikers het aangedui dat die dra van ‘n h o o r a p p a r a a t bydra tot ‘n meer natuurlike ervaring van klank. s ek ere bimodale gebruikers het aangedui dat hulle eie stemkwaliteit verbeter het en sodoende is hul “voile kommunikasie potensiaal” beskikbaar (armstrong, pegg, james & blarney, 1997; ching, incerti & hill, 2004). die gebruik van die gehoorapparaat komplementeer dus die kogleere inplanting deur aan die gebruiker beter balans tussen die ore te verskaf (ching et al.,2004). aangesien die seleksiekriteria vir kogleere inplantings nie persone uitsluit weens hulle ouderdomme nie, word persone van alle ouderdomme geinplanteer en is binourale versterking vir alle ouderdomme van belang. ‘n groot groep van die kogleere inplanting-gebruikers is jong volwassenes. die jong volwasse ouderdomsgroep is in ‘n belangrike oorgangsfase: die oorgang van tiener na volwassene. tydens hierdie periode ondergaan die individu se lewe vinnige en beduidende veranderinge en hy o f sy het meer onafhanklikheid, meer verantwoordelikhede en meer status (mussen, conger, kagan & geiwitz, 1979). jong volwassenes met kogleere inplantings ervaar waarskynlik dieselfde veranderinge en om die unieke uitdagings verbonde aan hierdie spesifieke ouderdomsgroep aan te spreek, moet daar aandag gegee word aan hulle ervarings, veral ten opsigte van die gebruik van bimodale versterking. daar moet bepaal word wat hulle verwagtinge en motiveringselemente is ten opsigte van bimodale versterking. deur te kyk na hoe hulle die gebruik van bimodale versterking ervaar, kan positiewe en negatiewe aspekte aangaande die tipe versterking gei'dentifiseer word. die doel van die studie is dus om die vooren nadele verbonde aan die gebruik van bimodale versterking, soos ervaar deur jong volwassenes met kogleere inplantings, te bepaal. hulle ervarings en persepsies ten opsigte van hulle ouditiewe en kommunikasie funksionering, die hantering en versorging van versterkingsapparate, sowel as kosmetiese aspekte moet ondersoek word. die potensiele voordele en nadele ten opsigte van bogenoemde areas wat gei'dentifiseer is tydens die studie, sal aangewend kan word om kliente en oudioloe beter in te lig en meer toepaslike dienslewjering te ontwikkel vir bimodale kandidate. dit sal ook implikasies vir die oudioloog inhou in terme van berading, opleidingl en inligtingverskaffing. ! metodologie !i hoofen subdoelstellings die hoofdoel van die studie was om die ervarings van jong volwassenes met kogleere inplantings aangaande bimodale versterking te bepaal. ten einde die hoofdoelwit te bereik, is die volgende subdoelstellings geformuleer: • om jong volwassenes se ervarings aangaande bimodale versterking in terme van ouditiewe aspekte te bepaal. • om jong volwassenes se ervarings aangaande bimodale versterking in terme van kommunikasie aspekte te bepaal. • om jong volwassenes se ervarings aangaande kosmetiese aspekte van bimodale versterking te bepaal. • om jong volwassenes se ervarings aangaande die hantering en versorging van bimodale versterking te bepaal. navorsingsontwerp die navorsingsontwerp was ‘n kwalitatiewe paradigma wat beskrywend van aard was (leedy & ormrod, 2005). triangulasie, oftewel die gebruik van veelvuldige metodes vir data insameling met die doel om die betroubaarheid van die obser vasie te verhoog (de vos, strydom, fouche & delport, 2002; leedy & ormrod, 2005), is tydens hierdie navorsingstudie aangewend om sodoende ‘n betekenisvolle en gedetailleerde beeld van die ervarings van jong volwassenes met kogleere inplantings aangaande die gebruik van bimodale versterking te verkry. eerstens is daar gebruik gemaak van self geadministreerde vraelyste as die data-versamelingstegniek waardeur die deelnemers se ervarings aangaande die gebruik van bimodale versterking bepaal kon word. die deelnemers se persoonlike ervarings is uiters belangrik vir hierdie studie en aangesien vraelyste nie die respondente se spontane antwoorde en nie-verbale inligting deurgee nie, is daar verder gebruik gemaak van fokusgroepe. inligting wat tydens fokusgroepbesprekings ingewin is, kon ook dien om inligting uit die vraelyste te bevestig o f te bevraagteken. seleksie en beskrywing van proefpersone die prosedures vir seleksie en die beskrywing van die proefper­ sone word vervolgens bespreek. steekproefgrootte die jong volwassenes met ‘n kogleere inplanting wat gebruik maak van bimodale versterking beslaan ‘n klein persentasie van die totale kogleere inplanting populasie. slegs ses jong volwassenes wat van bimodale versterking gebruik m aak, is v erbonde aan die p re to ria k ogleere inplantingsprogram. al ses die jong volwassenes verbonde aan die pretoria kogleere inplantingsprogram is genader ten einde deelname aan die studie te verkry. v yf van die preofpersone het die vraelyste voltooi. slegs drie van die proefpersone het egter aan die fokusgroep bespreking deelgeneem. die twee proefpersone wat nie aan die bespreking deelgeneem het nie, was afwesig as gevolg van logistieke redes. indien ‘n steekproef populasie op sigself relatief klein is, is dit belangrik dat die steekproefgrootte uit ‘n redelike groot persentasie van die populasie moet bestaan (de vos et.al, 2002). aangesien 83 % van die totale populasie van die plaaslike kogleere inplantinggebruikers wat gebruik maak van bimodale versterking aan die studie deelgeneem het, kan die klein steekproefgrootte verantwoord word. seleksiekriteria die seleksiekriteria vir die kies van die proefpersone is uiteengesit in tabel 1. proefpersoon seleksieprosedure ‘n betekenisvolle steekproeftegniek is gebruik tydens die seleksieprosedure van proeipersone. betekenisvolle steekproefseleksie behels ‘n steekproef wat saamgestel is uit elemente wat die meeste eienskappe, verteenwoordigende of tipiese bydraes van die ouderdomsgroep, bevat (strydom & delport, 2002). alle jong volwassenes met kogleere inplantings verbonde aan die pretoria kogleere inplantingsprogram en wat voldoen aan die kriteria, is as potensiele deelnemers gei'dentifiseer. slegs ses jong volwassenes het aan die seleksiekriteria voldoen. daar is van die hoof van die pretoria kogleere inplantingsprogram toestemming verkry om die deelnemers te nader om as proefpersone vir hierdie spesifieke navorsingstudie deel te neem. ingeligte toestemming vanaf die deelnemers is hiema verkry deurdat ingeligte toestemmings briewe voltooi is. the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t abel 1: seleksiekriteria vir die bepaling van proefpersone 92 liani van der w esthuizen and c atherine van dijk kriteria motivering proefpersone m oet deel w ees van die pretoria k ogleere in­ plantingsprogram by die u niversiteit van pretoria. om te verseker d a t d a a r eenvorm igheid is o n d er proefpersone en om te verse­ ker d a t die inligting beskikbaar en bekom baar vir d ie navorser is. proefpersone m oet reeds gei'nplanteer w ees m et ‘n kogleere inplanting (“n ucleus c ochlear" apparaat) vir ten m inste 'n pe riode van 6 maande. die persoon m oet reeds gew oond w ees aan die dra van die apparaat en aangepas w ees by die gebruik daarvan. proefpersone m oet reeds gepas w ees m et ‘n g e hoorapparaat vir ten m inste agt w eke in die teenoorgestelde oor. die persoon m oet reeds gew oond w ees aan die dra van die apparaat en aangepas w ees by die gebruik daarvan. proefpersone se gehoo ra p p ara a t m oet reeds aangepas w ees to t die kogleere inplanting. om te ve rse ke r d a t die g e h oorapparaat korrek aangepas is volgens die kogleere inplanting en te verseker d a t die bim odale sisteem optim aal benut word. proefpersone m oet tussen die ouderdom van 21 en 30 ja a r wees. die studie w ord uitgevoer om die ervaring van jo n g volw assenes (18 to t 30 jarige ouderdom ) te bepaal en deelnem ers m oet dus binne hierdie ouderdom sgroep val. d aar is e g te r besluit om persone sp esifiek bo 21 ja a r oud in te sluit sodat deelnem ers s e lf ingeligte toestem m ing kan gee. proefpersone m oet engels o f a frikaans m agtig w ees. persone m oet in staat w ees om die vraelys te kan lees en in te vul, so w el as om deel te neem aan die fokusgroep. die navorser is slegs hierdie tw ee tale magtig. beskrywing van deelnemers die profiel van die deelnemers is saamgevat onder die afdeling “bespreking van resultate”. hierdie inligting is verkry vanuit die biografiese afdeling en afdeling a van die vraelys (sien bylaag a). data insamelingsinstrumente en apparaat kwalitatiewe navorsing fokus inherent op die gebruik van multi -metodes, wat poog om te verseker dat in-diepte begrip van die verskynsel wat ondersoek word, bewerkstellig word (denzin & l in c o ln , 2 0 0 5 ). d a ar is dus v an d rie d ata insamelingsinstrumente gebruik gemaak nl. ‘n lys van die kogleere inplantingsprogram, ‘n vraelys en fokusgroep onderhoude. lys van die pretoria kogleere inplantingsprogram ‘n lys van kliente verbonde aan die kogleere inplantingsprogram is gebruik om die moontlike deelnemers te identifiseer wat aan die seleksiekriteria van die studie voldoen. vraelys kwalitatiewe navorsing bestudeer sosiale situasies om die betekenis van die proefpersone se lewens volgens hulle eie persepsies te verstaan en daar is gebruik gemaak van ‘n vraelys as ‘n data insamelingsinstrument. die vrae in die vraelys is kwalitatief benader deur persoonlike verslag oor die ervarings van die jong volwassenes wat gebruik maak van bimodale versterking, te ontlok (denzin & lincoln, 2000). die volgende voordele is aan hierdie tipe data-insamelingstegniek verbonde (neuman, 1997; delport, 2002): ® dit is ‘n koste-effektiewe, sowel as tydbesparende data jnsamelingstegniek, wat deur ‘n enkele navorser uitgevoer kan word. • die respondent kan die vraelys voltooi wanneer dit gerieflik is en persoonlike rekords kan nagegaan word om akkuraatheid te verseker. ® indien die respondent enige probleme met die vraelys ervaar, kan dit verduidelik word met die veldwerker se terugkeer. • die responstempo is baie hoer as gevolg van die persoonlike kontak tussen die respondent en die veldwerker. die hoof nadeel van self-geadministreerde vraelyste is egter dat ‘n kleiner geografiese area per geleentheid gedek kan word, aangesien die veldwerker moet terugkeer om die vraelys te gaan haal. die vraelys is ook ontoepaslik waar spontane antwoorde en nie-verbale inligting benodig word en die respondent se ervarings en sieninge belangrik is. sekere strategies is egter aangewend om die bogenoemde nadele so ver as moontlik te beperk. daar is slegs ‘n beperkte aantal jong volwassenes met kogleere inplantings wat gebruik maak van bimodale versterking. die deelnemers wat tydens die seleksiek­ riteria gei'dentifiseer is, was meestal bereikbaar in pretoria en hierdie vraelyste is per hand afgelewer. daar is ook gebruik gemaak van faksen posverspreiding van die vraelyste aan twee deelnemers. die verkryging van spontane antwoorde en nie-verbale inligting is ingewin tydens die fokusgroep onder­ houde. die vraelys het bestaan uit 66 vrae wat in 6 onderafdelings verdeel is en saamgevat is in 8 bladsye. die meeste vrae is aangebied as geslote vrae, hoewel daar gebruik gemaak is van enkele oop-einde vrae. die vraelys is onderver deel in die volgende afdelings: biografiese inligting, inligting aangaande die apparate, ouditiewe funksionering, kommuni­ kasie funksionering, kosmetiese aspekte en hantering ;en ver­ sorging. die vraelys is beskikbaar as bylaag a. 1 fokusgroep onderhoude 1 fokusgroep metodologie is ‘n wyse waarop kwalita­ tiewe data ingesamel word deur ‘n informele groepbespreking oor sekere temas te fasiliteer (silverman, 2006). die gebruik van fokusgroep onderhoude vorm deel van ‘n multi-metode studie en is as data-insamelingstegniek gekies vir die volgende redes (leedy & ormrod, 2005): • die interaksie tussen deelnemers is meer insiggewend as individuele onderhoude. / ® die inligting verkry vanuit die vraelys kan meer kwalitatief gei'nterpreteer word, o meer komplekse gedrag en opinies kan uitgelig word en sodoende ondersoek word. duidelike en deurdagte vrae is die fondament van hoe kwaliteit fokusgroep navorsing (greeff, 2002) en die vraelys is gebruik vir die beplanning van die vrae en die samestelling van die fokusgroep onderhoudskedule. die fokusgroep bespreking het die suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) qie ervarings van jong v olw assenes m et k ogleere inplantings aangaande b im odale versterking 93 b e sta a n uit nege onderwerpe en onder elkeen het die navorser vrae gevra aangaande die spesifieke onderwerpe ten einde die data in te samel. die eerste agt temas is gefasiliteer deurdat elke twee opeenvolgende temas dieselfde subdoelstelling ondersoek. daar is telkens onderskeidelik na bimodale v e r s t e r k i n g teenoor unilaterale kogleere inplantinggebruik gekyk. o u d io k a s s e to p n a m e s is gemaak van d ie fokusgroep onderhoud om sodoende geskrewe transkripsies te verskaf en addisionele veldnotas is deur die navorser aangeteken (greeff, 2 002 ). g eld ig h e id e n b e tr o u b a a rh e id om geldige en betroubare data vanuit 'n vraelys te verkry, moet daar voor die implementering van die studie v e r s e k e r w o rd dat die m e tin g s p ro s e d u re s en metingsinstrumente wat gebruik word aan aanvaarbare vlakke van betroubaarheid en geldigheid voldoen (delport 2002). ten einde die geldigheid en betroubaarheid van die vraelys te verseker, is ‘n voorafstudie uitgevoer. die doel van die voorafstudie was om die vraelys wat ontwerp is krities te evalueer om sodoende die nodige aanpassings te maak om die effektiwiteit en bruikbaarheid van die data wat daardeur versamel gaan word, te verbeter. aangesien die hoeveelheid deelnemers aan hierdie studie so beperk was, is die vraelys se voorafstudie uitgevoer deur twee van die pretoria kogleere inplantingsprogram se oudioloe. die oudioloe werk daagliks met hierdie ouderdomsgroep en ken die terminologie van hier­ die veld asook die behoeftes en vermoens van die deelnemers. die logiese verloop en lengte van die vraelyste is oorweeg en die taalgebruik se toepaslikheid is geevalueer. die nodige ve­ randeringe is aangebring. data-insamelingsprosedures ‘n lys wat verkry is vanaf die pretoria kogleere inplantingsprogram met die name van al die kliente wat ‘n kogleere inplanting ontvang het, is gebruik om moontlike proefpersone volgens die seleksiekriteria te identifiseer. die jong volwassenes wat beide ‘n kogleere inplanting en ‘n gehoorapparaat gebruik, is gei'dentifiseer met behulp van die oudioloe v erb o n d e aan die p re to ria k o g lee re inplantingsprogram. die deelnemers is telefonies gekontak om die aard, doel, inhoud en j implikasies van die studie te verduidelik. hiertydens is daar bepaal wie bereid is om aan die studie deel te neem en persoonlike toestemming is verkry. ‘n geskrewe brief van ingeligte toestemming is saam met die vraelys aan die deelnemer j per hand afgelewer, gepos of gefaks, volgens spesifieke voorkeur. ‘n ondersoek is uitgevoer waarby ses deelnemers wat aan die seleksiekriteria voldoen het, betrokke was. die reelings vir die fokusgroep sessie is na die ontvangs van die vraelyste getref. die navorser het sekere onderwerpe uitgelig en dit is in die klein groepie gefasiliteer. wat elke deelnemer in die groep se tydens die bespreking, het bygedra tot die essentiele data verkry vanuit die fokusgroep (morgan & krueger, 1998). data-optekening en analise die inligting verkry vanuit die vraelyste is ontleed saam met die data wat tydens die fokusgroep ingesamel is. die vraelys is ontleed en verwerk in samewerking met ‘n statistikus en die fokusgroep temas is gebruik om hierdie bevindinge te ondersteun. as gevolg van die klein steekproef wat gebruik is, is daar besluit om die ordinale skale te verminder na slegs drie afdeling in plaas van vyf. die spearman korrelasie koeffisient is gebruik, aangesien die studie ‘n ordinale kwalitatiewe studie is (anderson, sweeney & williams, 2003). tipiese gebruike is ondersoek deur die gebruik van data verkry vanaf die vraelyste en vanuit die fokusgroepe. die transkripsies is met behulp van ‘n oudio kassetopnemer gemaak en die data is getranskribeer. die fokusgroep data is deur middel van etnografiese analise metodes ontleed, met die doel om gedetailleerde interpretasies van die spesifieke ervarings van die jong volwassenes te maak. data is aangebied deur die ervarings soos deur die proefpersone aangedui, weer te gee en beskrywende aanhalings van die fokusgroep bespreking te beklemtoon (silverman, 2006). data is op verskeie maniere aangebied bv. die gebruik van besprekings, tabelle en grafieke. etiese aspekte navorsingsetiek is ‘n stel wyd aanvaarde morele beginsels wat reels en gedragsverwagtinge daarstel. die navorser is hierdeur gelei tot die mees korrekte optrede teenoor die navorsingsdeelnemers en ander navorsers (de vos et al., 2002). etiese sake rakende navorsing word hoofsaaklik ingedeel in vier kategoriee nl. beskerming teen skade, ingeligte toestemming, reg tot privaatheid en eerlikheid met professionele kollegas (babbie, 2005). hierdie etiese aspekte is belangrik geag tydens die uitvoering van hierdie studie. etiese klaring is verkry vanaf die navorsingskomitee van die departement kommunikasiepatologie, wat toestemming verleen het vir die uitvoering van die voorgraadse navorsingsprojek. ‘n brief van ingeligte toestemming is gebruik om alle moontlike o f toepaslike inligting aangaande die doel van die ondersoek, die moontlike voordele, nadele en gevare verbonde aan die studie, sowel as die kredietwaardigheid van die navorser, oor te dra aan die deelnemers (strydom, 2002). in die brief is daar aangedui dat deelname vrywillig is en getermineer kan word op enige stadium van die studie. ‘n waarborg dat alle response vertroulik en die deelnemer se inligting anoniem gehou sal word, is ingesluit. etiese riglyne het dus die hoek steen van hierdie navorsingsprojek gevorm. resultate en bespreking die resultate wat beskryf en bespreek word in die onder staande gedeelte is gebaseer op die inligting en response ver­ kry vanaf vyf jong volwassenes wat gebruik maak van ‘n kogleere inplanting en ‘n gehoorapparaat. beskrywing van deelnemers demografiese inligting in tabel 2 word alle relevante biografiese en bykomende inligting met betrekking tot die deelnemers saamgevat om sodoende ‘n vollediger beeld van die persone wat aan die studie deelgeneem het, te verskaf. afdeling a van die vraelys is gebruik om hierdie inligting in te samel. al die deelnemers het nucleus 24 apparate ontvang. vier van die v y f deelnemers gebruik die nucleus 24 contour apparaat. al die deelnemers maak gebruik van die esprit 3g spraakprosesseerder, wat die oorvlak-tipe is en wat kosmeties meer aanvaarbaar is as die saktipe. die ace spraakkoderingstrategie maak gebruik van tussengelaagde en spektrale piek stimulasie, wat tot 22 plekke op die elektrode reeks stimuleer (katz, 2002). hierdie voordelige en nuutste spraakkoderingstrategie word deur al die deelnemers gebruik. the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 94 liani van der w esthuizen and c atherine van dijk bimodale gebruik in die bepaling van faktore wat bydra tot die uitkomste vir elke spesifieke individu, het die duur van gehoorapparaat gebruik die grootste verskil aangedui (iwaki, matsushiro, mah, sato, yasuoka, yamamoto & kubo, 2004). langtermyn gebruik van die gehoorapparaat, selfs in ore van persone met emstige afwykende gehoor, resulteer in goeie aanpassing vir binourale gehoor (iwaki et.al., 2004). al die deelnemers is gepas met gehoorapparate voordat die kogleere inplanting ontvang is. die gehoorapparate is dus vir ‘n langer periode as die inplanting gebruik. die deelnemers is aangemoedig om die gehoorapparaat te gebruik saam met die kogleere inplanting ten einde die aanpassingstyd van die kogleere inplanting te optimaliseer. deelnemer 1 het tydens die fokusgroep bespreking aangedui dat dit die rede was hoekom hy die gehoorapparaat gebruik het, maar wel aangedui dat hy daarmee gestaak het. dit is soos volg gestel: “...die gewone (gehoor)apparate het nie veel vir my gedoen nie. e k dink as dit vir my gehelp het, kon ek dalk anders daaroor gevoel het. ” deelnemer 3 het ook aangedui dat sy nie tans die gehoorapparaat gebruik nie aangesien die kogleere inplanting voldoende versterking verskaf. sy het wel tydens die fokusgroep onderhoud aangedui dat sy moontlik weer die gehoorapparaat sal gebruik ten einde haar residuele gehoor in die nie ge'inplanteerde oor te stimuleer. vanuit die tabel is dit duidelik dat die meeste deelnemers die gekombineerde stel sel gebruik vir die grootste gedeelte van die dag. ervaring van bimodale versterking in terme van oudi tiewe aspekte die vermoe van ‘n luisteraar om suksesvol te kommunikeer en te luister in alledaagse omgewings hang grootliks a f van sy/haar sensitiwiteit vir binourale inligting wat in hierdie situasies beskikbaar is (clark, 2003). die resultate met betrekking tot hierdie subdoelstel ling is saamgestel uit vrae 1-8 uit afdeling b van die vrae lys en word saamgevat in figuur la en lb. klanklokalisasie volgens die data wat ingesamel is, het vier uit die vyf deelnemers aangedui dat hulle vermoe om klank te lokaliseer verbeter is tydens die gebruik van ‘n gekombineerde stelsel. deelnemer 1, wat nie tans van bimodale versterking gebruik maak nie, het daarteenoor aangedui dat hy nie kan lokaliseer nie.die literatuur bevestig dat die gebruik van ‘n gehoorapparaat o f kogleere inplanting in isolasie nie resulteer in die vermoe om bogemiddeld te lokaliseer nie (clark, 2003). die gebruik van ‘n gekombineerde stelsel verskaf meer balans, wat die persoon in staat stel om te bepaal waar die klank vandaan kom. deelnemer 2 het tydens die fokusgroep die vol gende gese, wat lokalisasie bevestig: “you can p ick up where sound comes from. ” binourale gehoor, deur middel van bimo­ dale versterking, dra dus by tot beter lokalisasie van die klank bron (ching et.al. 2004). figuur la : deelnem ers se ervarings aangaande die gebruik van slegs die kogleere inplanting in term e van ouditiew e fiinksionering. f iguur lb : d eelnem ers se ervarings aangaande bim odale versterking in term e van ouditiew e fiinksionering. ouditiewe aspekte: gebruik van bimodale versteiking □ beter □ onseker □ nie beter nie vr a e 1 8 t abel 2: d em ografiese inligting van die deelnem ers deel­ nemer ©esiag gwtwtfoin tipe kogleere in­ planting tipe spraak akkodering-strategie tipe gehoor­ apparaat gehoorterapieofrtvang dwirtnp* bmftvw beideapparate hoeveelheid ure per dag: beide apparate 01 m anlik 21 n ucleus c ontour 24 esprit 3g ace phonak nee 10 m aande + 7 (voorheen) 0 (tans) 02 vroulik 25 n ucleus 24 esprit 3g ace phonak ja, bietjie 5 ja a r ± 15 03 vroulik 21 n ucleus c ontour advance 24 esprit 3g ac e o ticon ja, bietjie 4 m aande ± 15 04 vroulik 24 n ucleus c ontour 24 esprit 3g -a c e phonak nee 3 ja a r ± 18 05 m anlik 25 n ucleus c ontour 24 esprit 3g ace phonak nee 2 ja a r 9 maande +15 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) p ie ervarings van jong v olw assenes m et k ogleere inplantings aangaande b im odale versterking 95 klankpersepsie vrae 2, 3, 7 en 8 is gebruik om data te versamel aangaande die deelnemers se klankpersepsie. om klankpersepsie te bepaal is daar eerstens verwys na die natuurlikheid van klank wat ervaar word. die verbetering in die natuurlikheid van die klank deur die gebruik van die bimodale stelsel, is nie as beduidend beskryf nie. drie van die v y f deelnemers het aangedui dat die gebruik van die kogleere inplanting alleen teenoor die gebruik van die bimodale stelsel nie werklik verskil ten opsigte van die natuurlikheid van klank wat gehoor word nie, terwyl die ander twee onseker was. die gehoorapparaat dra by tot die in druk dat klank in beide ore gehoor word eerder as eksklusief deur die inplanting (armstrong, pegg, james & blarney, 1997). die volgende opmerking rakende hierdie aspek is tydens die fokusgroep onderhoud gemaak: “it is more balanced". daar kan dus afgelei word dat dit bygedra het tot meer natuurlike klank­ persepsie by die meeste van die deelnemers, maar daar bestaan nie ‘n beduidende verskil tussen die gebruik van bimodale ver­ sterking en die kogleere inplanting nie. die kwaliteit van klank wat gehoor word, is beter met die gebruik van die gekombineerde stelsel en dit is aangedui deur al vyf die deelnemers. meer spraak-tipe klankkwaliteit word verkry deur die bimodale stelsel (clark, 2003). een van die deelnemers het met die volgende woorde bevestig dat die ge­ kombineerde stelsel met die 3g spraakprosesseerder bydra tot beter en helderder klankkwaliteit: “the new esprit 3g is so much better. it makes a huge difference. ’’ die resultate in terme van die ervaring van om gewingklanke het gevind dat drie deelnemers voel dat daar nie ‘n beduidende verskil is in die hoor van omgewingsklanke met betrekking tot onderskeidelik die gekombineerde stelsel en die kogleere inplanting alleen nie. die hoeveelheid klankinligting verkry deur ‘n bimodale stelsel is egter positief ervaar deur vier van die deelnemers en dui op die verkryging van groter hoeveel­ heid klankinligting. spraakpersepsie in stilte en geraas om die belang van bimodale versterking te bepaal, is dit belangrik om spraakpersepsie te ondersoek, wat insluit spraakdiskriminasie en spraakbegrip. vraag 4 van die vraelys het aangedui dat drie van die deelnemers spraakdiskriminasie positief ervaar met beide die kogleere inplanting alleen en in kombinasie met die gehoorapparaat. slegs een deelnemer het meer voordeel aangedui met diej gebruik van die bimodale stelsel as met die kogleere inplanting: alleen. tydens die fokusgroep bespreking is daar aangedui dat die gebruik van ‘n gekom­ bineerde stelsel die staatmaking1 op liplees verminder, aangesien die gehoorapparaat en kogleere inplanting optimale ouditiewe inligting verskaf, ongeag die luistersituasie. dit word bevestig deur navorsing uitgevoer deur madell, sislian en hoffman (2004), wat aandui dat ‘n gekombineerde stelsel spraakbegrip verbeter. vraag 5 en 6 is gebruik om data te versamel aangaande spraakpersepsie in stilte en geraas. spraakpersepsie in stilte is oor die algemeen baie positief ervaar deur al vyf die deelnemers: drie het aangedui dat hulle die monourale stelsel en bimodale stelsel dieselfde ervaar en twee het die bimodale stelsel beter ervaar. hierteenoor het slegs een deelnemer beter spraakpersepsie in geraas ervaar met bimodale versterking, maar twee ander deelnemers het ook positiewe spraakpersepsie aangedui, hoewel daar geen verskil was tussen die bimodale stelsel en die kogleere inplanting alleen nie. die volgende stel ling vanuit die fokusgroep het spraakpersepsie goed saamgevat: if there is not much background noise, it is very easy to talk to people and follow what is going on. ” ter opsomming van die ervarings van jong volwassenes wat gebruik maak van bimodale versterking aangaande ouditiewe funksionering, is daar gevind dat daar voordeel ervaar word in terme van spraakpersepsie, klanklokalisasie en spraakdiskriminasie. ervaring van bimodale versterking in terme van kommuni­ kasie aspekte die verstaan van ander mense in agtergrondsgeraas en die bepaling van waar ‘n persoon praat, is probleme wat meer ervaar word met monourale gehoor as met binourale gehoor (ching et.al., 2004), en wat kommunikasie bemoeilik. dit is dus van belang om te bepaal hoe jong volwassenes die bimodale stelsel ervaar ter ondersteuning van binourale gehoor. vanuit die resultate (afdeling c) soos voorgestel in bogenoemde figure blyk dit dat spraakverstaanbaarheid met behulp van bimodale versterking baie positief ervaar word. twee van die deelnemers het aangedui dat beide apparate meer spraakverstaanbaarheid verskaf, terwyl twee van die deelnemers se ervaring was dat ongeag o f die kogleere inplanting alleen o f beide apparate gebruik word, spraakverstaanbaarheid verbeter. die lite ra tu u r b e v e stig dat bim o d ale stim u lasie spraakverstaanbaarheid verbeter (flynn & schmidtke, 2004). vraag 2 en 3 is gebruik om die deelnemers se ervaring ten opsigte van stemkwaliteit te bepaal. twee het aangedui dat hulle eie stemkwaliteit verbeter het deur die gebruik van bimodale versterking. slegs een deelnemer het ervaar dat die bimodale versterking haar stemkwaliteit soos waargeneem deur ander persone, verbeter het. die oorblywende vier deelnemers het drie verskillende ervarings van hierdie aspek van kommunikasie gehad. die natuurlikheid van die stem kan egter nie objektief bepaal word nie, maar word gereflekteer deur dit waaraan ‘n persoon gewoond is (tyler, witt & dunn, 2004). die resultate kan dus deur die mate van subjektiwiteit verklaar word. woordherkenning en gesprekvoering in geraasom standighede is meestal positief ervaar, ongeag die gebruik van die kogleere inplanting alleen o f met die gekombineerde stelsel. slegs een deelnemer het aangedui dat gesprekvoering in geraas beter ervaar word deur die gebruik van slegs die kogleere in­ planting alleen. inligting verkry by twee van die deelnemers tydens die fokusgroep bespreking, het bevestig dat agtergronds­ geraas verminder word deur die gebruik van ‘n gekombineerde stelsel aangesien die gehoorapparaat baie van die agtergronds­ geraas uitskakel. kommunikasie funksionering: gebruik van slegs die kogleere inplanting □ g oe d □ o n s e te r □ nie goed nie & mae 1 5 figuur 2a: r esponse van deelnem ers aangaande die gebruik van slegs die kogleere inplanting in term e van kom m unikasie funksionering. the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 96 liani van der w esthuizen and c atherine van dijk kommunikasie funk sion ering: gebruik van bimodale versterking □goed gonseker □ nie goed nie & j ror j*r cjx vrae 1 5 figuur 2b: r esponse van deelnem ers aangaande die gebruik van bim odale versterking in term e van kom m unikasie fiinksionering. dit is dus duidelik dat die jong volwassenes oor die algemeen ‘n positiewe ervaring aangaande bimodale versterk­ ing vertoon in terme van kommunikasie fiinksionering. die jong volwassene se voile kommunikasie potensiaal word dus beskikbaar gestel deur die gebruik van bimodale versterking (armstrong et.al, 1997). ervaring van bimodale versterking in terme van kosmeti ese aspekte daar word wyd aanvaar dat die meeste gehoorapparaat en kogleere inplantinggebruikers besorgd is oor hulle voorkoms en die sigbaarheid van die apparate (tyler, witt & dunn, 2004). om te bepaal wat die jong volwassenes wat gebruik maak van bimodale versterking, se ervaring aangaande kosmetiek was, is daar aan elkeen vrae gerig oor hulle voorkoms by die werk en by sosiale geleenthede, sowel as hul ervarings ten opsigte van opsigtelikheid. afdeling d van die vraelys is gebruik om die benodigde inligting in te samel. jong volwassenes se ervaring rakende hulle voorkoms by die werk en tydens sosiale geleenthede is aangedui as negatief (drie van die deelnemers het dit so deurgegee). een deelnemer was neutraal teenoor die kosmetiese aspekte, waar die oorblywende deelnemer positief gevoel het oor die gebruik kosmetiese aspekte: gebruik van slegs 'n kogleere inplanting £ 4 □ positief □ onseker □ negatief voorkoms:werk voorkoms:sosiaal vrae 1 3 opsigtelikheid figuur 3a: d eelnem ers se ervarings aangaande die gebruik van slegs die koglesre inplanting in term e van kosm etiese aspekte. kosmetiese aspekte: gebruik van bimodale versterking vrae 1 3 f iguur 3b: d eelnem ers se ervarings aangaande bim odale versterking in term e van kosm etiese aspekte. van die gekombineerde stelsel. hierdie ervaring van die jong volwassenes word verklaar, as daar in ag geneem word dat daar dikwels in vandag se samelewing staat gemaak word op die persoon se voorkoms om sodoende te bepaal o f hy/sy aanvaar word (tyler et.al, 2004). deelnemer 2 se antwoord op die oop vraag, o f mense jou anders hanteer as hulle besef dat jy ‘n gehoorgestremdheid het, was die volgende: “they think y o u ’re stupid. you ’re not hearing impaired. you ’re stupid! ” die meerderheid van die deelnemers (drie) het aangedui dat hulle meer opsigtelik voel tydens die gebruik van ‘n gekombineerde stelsel. daar kan dus afgelei word dat die kosmetiese aspekte aangaande die gebruik van ‘n bimodale stelsel negatief ervaar word. ervaring van bimodale versterking in terme van bantering en versorging volgens dillon (2002) het die gebruik van bilaterale passings nadele aangesien dit meer kos asook moeiliker is om te bestuur. in die geval van die gebruik van bimodale versterking is daar die volgende bevind. die verantwoordelikheid aangaande die identifisering van apparaatprobleme is slegs deur twee deelnemers as negatief ervaar. die ander deelnemers was of onseker o f het geen probleme daarmee gehad nie. die versorging van die apparate in terme van tyd en las het egter meer negatiwiteit aangedui. die skoonmaak en hantering van die bimodale stelsel is ook deur slegs twee deelnemers negatief en spanningsvol ervaar. die ander drie het geen beswaar hieroor gehad nie. ; navorsing het gevind dat die persone wat unilaterale versterking kies ‘n wye verskeidenheid redes aanhang soos vir gemak, gerieflikheid en kosmetiese besorgdhede (gianopoulos & stephens, 2002). die literatuur beskryf egter nie die bimodale versterking gebruikers se ervarings aangaande die fmansiele implikasies nie. die rede hieragter is aangesien eerste wereld lande se publieke gesondheidstelsel sekere. ekonomiese strategies aanwend om oudiologiese versorging te finansier (kobler, rosenhall & hansson, 2001). hierdie is egter nie die geval in suid-afrika nie en juis daarom is dit belangrik om die jong volwassenes se ervarings xin terme van fmansiele implikasies te bepaal. een deelnemer het ‘n negatiewe ervaring, twee deelnemers was onseker en twee deelnemers het ‘n positiewe ervaring getoon wat aandui dat dit nie vir hullle ‘n beduidende probleem is nie. tydens die fokusgroep bespreking die suid-afrikaans e tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) die ervarings van jong v olw assenes m et k ogleere inplantings aangaande b im odale versterking 97 f ig u u r 4a: deelnemers se ervarings aangaande die gebruik van slegs die kogleere inplanting in terme van hantering en versorging. figuur 4b: deelnemers se ervarings aangaande die gebruik van bimodale versterking in terme van hantering en versorging. het deelnemer 3 egter die finansiele sy verbonde aan bimodale versterking soos volg beskryf j: “it is more expensive... but i don’t m ind.” finansiele implikasies sluit in die ervaring ten opsigte van battery verbruik, waartydens daar bepaal is dat dit die grootste negatiewe ervaring is aangaande hantering en ver­ sorging. dit is duidelik dat die hantering en versorging van ‘n gekombineerde stelsel wel sekere negatiewe implikasies gehad het, maar dat die binourale voordele daaraan verbonde hierdie nadele oorskadu. j gevolgtrekkings en implikasies opsomming van resultate die uiteindelike doel van die verskaffing van bimodale gehoor is om die unilaterale kogleere inplantingsgebruiker in staat te stel om voordeel te trek vanuit binourale gehoor in alledaagse situasies (ching et.al., 2004). die resultate van die studie het die voordele en nadele verbonde aan bimodale versterking soos ervaar deur die jong volwassenes, bepaal en die volgende gevolgtrekkings kan gemaak word. die studie het aangedui dat die deelnemers se ervarings in terme van ouditiewe aspekte oor die algemeen positief is. dit het duidelik na vore gekom dat hulle klank lokalisasievermoens met gebruik van bimodale versterking beter is as deur slegs die gebruik van ‘n unilaterale kogleere mplanting. hulle ervaring ten opsigte van klankpersepsie blyk ook positief te wees. die klankkwaliteit en die hoeveelheid klankinligting wat deur die bimodale stelsel ontvang word, is deur byna al die deelnemers as ‘n baie positiewe aspek van ouditiewe funksionering aangedui. alhoewel die natuurlikheid van klank en die waameming van omgewingsklanke deur die meerderheid van die deelnemers as positief ervaar is, was dit duidelik dat daar nie ‘n beduidende verskil is in die klankpersepsie met bimodale versterking teenoor die monourale kogleere inplanting nie. spraakpersepsie in stilte en geraas is ook as positief ervaar, hoewel persepsie van spraak in stilte as meer voordelig ervaar word as persepsie van spraak in geraas. die ervarings is egter subjektief en mag verskil van oudiologiese resultate. spraak diskiriminasie is ervaar as positief, maar vir beide die gebruik van die bimodale stelsel en met die kogleere inplanting alleen. deelnemers het aangedui dat hulle kommunikasie fiink sionering oor die algemeen ‘n sterkpunt is as gevolg van die ge­ bruik van ‘n bimodale stelsel. spraakverstaanbaarheid, woord herkenning en gesprekvoering tydens die gebruik van die bimo­ dale stelsel is as beter ervaar, hoewel die gebruik van ‘n unilater­ ale kogleere inplanting ook as voordelig aangedui is. die subjek tiewe menings van die deelnemers ten opsigte van hulle eie stemkwaliteit en die persepsie van ander ten opsigte van hulle stemkwaliteit was baie verskillend. die minderheid van die deel­ nemers het hul eie stemkwaliteit as positief ervaar en die meerder­ heid was onseker oor hoe ander persone hul stemkwaliteit waam eem. bimodale versterking bei'nvloed dus hulle algemene oudi­ tiewe, kommunikasie en alledaagse funksionering positief. die ervaring aangaande kosmetiese aspekte is hoofsaaklik negatief. die meerderheid van die deelnemers het ervaar dat hulle meer selfbewus en opsigtelik voel met die gebruik van ‘n gekom­ bineerde stelsel. hulle ervaring aangaande die hantering en ver­ sorging van ‘n bimodale stelsel is ook negatief. die versorging van die apparate en die battery-gebruik is hoofsaaklik as die grootste las aangedui, maar die finansiele implikasie van hierdie bimodale stelsel is ook negatief ervaar. die voordele in daaglikse kommunikasie situasies oortref egter die bogenoemde nadele (byrne, 1981). die oorhoofse gevolgtrekking wat gemaak kan word, is dat bimodale versterking grootliks as positief en voordelig ervaar word in terme van ouditiewe, kommunikasie, kosmetiese aspekte asook in terme van hantering en versorging. hierdie ervarings stem ooreen met bevindinge in die literatuur (ching et.al., 2004). oudioloe kan dus hierdie uitkomste gebruik om bimodale kandi date met groter insig te benader en potensiele struikelblokke aan te spreek. kliniese implikasie en evaluasie kliniese implikasies van hierdie studie hou verband met die belangrikheid van inligtingverskaffing, berading en opleiding wat aan jong volwasse kogleere inplantingsgebruikers verskaf moet word. die inligting wat tydens die studie ingewin is, kan voome mende bimodale versterking kandidate in staat stel om ingeligte besluite te neem, asook om realistiese verwagtinge van hierdie tipe stelsel te he. die oudioloog betrokke by die kogleere inplant­ ingsgebruiker speel 'n belangrike rol in pre-operatiewe berading en inligtingverskaffing ten opsigte van potensiele binourale voor­ dele. die voordele aangaande ouditiewe funksionering moet aan die pasiente meegedeel. beter lokalisasie, klankpersepsie en spra­ akpersepsie in stilte en geraas kan beklemtoon word, 'n belan­ grike motivering vir die gebruik van 'n bimodale stelsel is die effektiwiteit daarvan vir goeie kommunikasie funksionering. kan­ didate kan ingelig word aangaande verbeterde gesprekvoering, woordherkenning en spraakverstaanbaarheid ter ondersteuning van hierdie stelsel. the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 98 liani van der w esthuizen and c atherine van dijk om die hoeveelheid bimodale versterking nie-gebruikers te verminder, is dit nodig om meer klem te plaas op berading aangaande die voordele van die bimodale stelsel (chung & stephens, 1986). berading in verband met kosmetiese aspekte en die hantering en ver­ sorging moet aan die potensiele kandidaat verskaf word, ten einde real istiese doelwitte te stel en om hulle voor te berei vir die implikasies van 'n bimodale stelsel. 'n duidelike leemte bestaan ook in die ver skaffing van rehabilitasieprogramme en opleiding ten opsigte van bi­ modale versterking. slegs twee deelnemers in hierdie studie het aangedui dat hulle "’n bietjie" ouditiewe opleiding met hul bimodale stelsel ontvang het. gianopoulus en stephens (2002) het aangedui dat een van die faktore wat volgehoue gebruik van binourale gehoorappa rate bei'nvloed, die aanbieding van rehabilitasie is. gehoorrehabilita sieprogramme moet dus deur die oudioloog verskaf word ten einde beter binourale voordele te verseker. hierdie rehabilitasieprogram moet ook optimale passing en instelling van die gehoorapparaat tot die kogleere inplanting bewerkstellig. ching et.al. (2004) se navorsing het bevestig dat binourale voordele vergroot word deur die gehoorapparaat aan te pas by die kogleere inplanting. deur middel van berading, inlig­ tingverskaffing en opleiding sal die oudioloog sy o f haar etiese verant woordelikheid nakom, deurdat alle voordele en nadele geassosieer met bimodale versterking aan die klient oorgedra word en beste praktyk sodoende verseker word. die navorsingstudie is krities geevalueer en soos by enige navorsingstudie het daar sekere leemtes na vore gekom. om meer geldigheid en betroubaarheid van die resultate te verseker, sou ‘n gro ter steekproefgrootte van waarde gewees het. dit was egter nie moont lik in hierdie studie nie en kan beskryf word as ‘n tekortkoming in die studie. as gevolg van die beperkte hoeveelheid jong volwassenes, is die oudioloe verbonde aan die pretoria kogleere inplantingsprogram genader om die voorafstudie uit te voer. daar is egter tydens die analis ering van die data opgemerk dat sekere vrae van die vraelys problem­ atics gevind is. die gebruik van bimodale versterking gebruikers as proefpersone tydens ‘n voorafstudie is dus noodsaaklik om die toe paslikheid van die vraelys te verseker. die samestelling van die vraelys het tot die besluit gelei om skale van vyf opsies te gebruik. die data analise is hierdeur bemoeilik en die opsies moes verminder word. die gepaardgaande komplikasie kon egter van die begin af verhoed word deur die gebruik van drie opsieskale. hierdie was egter 'n geringe te­ kortkoming en die studie het as ’n geheel waardevolle en bruikbare inligting vir die kogleere inplantingsprogram opgelewer. aanbevelings vir verdere navorsing die volgende areas vir verdere navorsing word aanbeveel: • die jong volwassenes se ouditiewe vaardighede moet objektief geassesseer word in twee omstandighede, naamlik: 1. kogleere inplanting alleen 2. kogleere inplanting in kombinasie met die gehoorap­ paraat sodoende kan die objektief geassesseerde vooren nadele geinter preteer word saam met die gebruiker se ervarings daarvan. • die jong volwasse kogleere inplanting gebruiker se behoeftes ten opsigte van die komponente wat ingesluit moet word in ‘n rehabili­ tasie program na inplantering, moet bepaal word. erkenning hierdie artikel is gebaseer op ‘n voorgraadse studie met die titel: “die ervarings van jong volwassenes met kogleere inplantings aangaande bimodale versterking” geskryf deur die eerste outeur ter gedeeltelike vervulling vir die graad bkommunikasiepatologie aan die universiteit van pretoria. spesiale dank en waardering word uitgespreek aan prof. j.g. swart en die pretoria kogleere inplantingsprogram vir die beskik baarstelling van hul kliente en ondersteuning. die suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 verwysings a nderson, d.r., sw eeney, d.j. & w illiam s, t.a. 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(1993). p sy ch o ­ physical and speech p erception studies: a case report on a binaural coch lear im plant subject. journal o f the acoustical society o f america, v ol. 94(6): 3178-3189. the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.cochlear.com a ppendix 100 liani van der w esthuizen and c atherine van dijk vraelys: die ervarings van jong volwassenes met kogleere inplantings aangaande die gebruik van bimodale versterking. persoonlike inligting: (inligting sal streng vertroulik hanteer word) naam : van: geboortedatum : o u d e r d o m :____ d a tu m :________ kontaknom m er: selnom m er: .(h) vi 1 -2 afdeling a: inligting aangaande die apparate m e r k a s s e b l ie f d e u r 'n k r u is ie (x) in d ie to e p a s lik e b lo k k ie te tr e k w a a r n odig. inligting aangaande iou k ogleere inplanting: datum van inplantering:______________________________ tipe kogleere inplanting: datum van die aanskakeling van jou inplanting: tipe spraakprosesseerder: tipe spraakkoderingstrategie: c l 24 re n u cleu s 24 c on to u r a dvance n ucleus 24 c ontour n ucleus 24k n ucleus 24 d ouble a rray n ucleus 24 spec tr a sprint e sprit 3g cis spea k a c e is daar tans enige probleme wat jy met die kogleere inplanting ondervind? is daar enige addisionele inligting wat jy wil byvoeg? die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) p ie ervarings van jong v olw assenes m et k ogleere lnplantings aangaande b im odale versterking 101 is d a a r ta n s e n ig e p ro b le m e w a t j y m e t d ie k o g le e r e in p la n tin g o n d e rv in d ? is daar enige addisionele inligting wat jy wil byvoeg? inligting aangaande die gehoorapparaat: watter tipe gehoorapparaat gebruik jy tan s?____________________________ het jy enige gehoorterapie ontvang nadat jy met die gehoorapparaat gepas is? ja, bietjie ja, gem iddeld ja, voldoende n ee hoe lank het jy die kogleere inplanting alleen gebruik? ________________________________ hoe gereeld dra jy die gehoorapparaat?______________________________________________ inligting aangaande die kogleere inplanting en gehoorapparaat: hoe lank dra jy al 'n kogleere inplanting en 'n gehoorapparaat tesame?_____________________ hoe gereeld dra jy beide die apparate?_____________________________________ure per dag. voltooi assebl1efdie onderstaande vraelys so noukerig moontlik deur 'nkruisie (x) in d ie toepaslikeblokkie te trek a fd elin g b : o u d it ie w e f u n k s io n e r in g merk die mees toepaslike blokkie af. w an n e er ek slegs die kogleere in p lanting g e b r u ik ... ' stem beslis saam stem saam on seker stem nie saam stem beslis nie saam 1. k an ek die rigting van k la n k m akliker identifiseer. v2 2. h oor ek klanke m eer natuurlik. v3 3. h oor ek beter kw aliteit klanke. v 4 4. is ek in staat o m b eter tu ssen verskillende klanke te onderskei. v5 5. is ek in staat om m eeste k lanke te h o o r in 'n stil om gew ing. v6 6. is ek in staat o m klank b eter te h o o r in die teenw oordigheid van agtergrondgeraas. v7 7. is e k in staat om m eer om gew ingsklanke te hoor. v8 ^.o ntvang ek m eer hoeveelheid klankinligting. v9 10 the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 102 liani van der w esthuizen and c atherine van dijk w an n eer ek b eide die kogleere inplantings en g e h o o ra p p a ra a t g e b ru ik ... stem beslis saam stem saam on seker stem nie saam stem beslis nie saam 1. k an ek die rig tin g van klank m akliker identifiseer. v10 11 2. h o o r ek klanke m eer natuurlik. vll 1 12 3. h oor ek b eter k w aliteit klanke. v12 ] '3 4. is ek in staat om b eter tussen verskillende k lanke te onderskei. v13 □ 14 5. is ek in staat om m eeste klanke te h o o r in 'n stil om gew ing. v14 15 6. is ek in staat om klank b eter te h o o r in die teenw oordigheid van agtergrondgeraas. v15 1 16 7. is ek in staat om m eer om gew ingsklanke te hoor. v16 17 s.ontvang ek m eer hoeveelheid klankinligting. v17 ] is a fd e lin e c: k o m m u n ik a s ie f u n k s io n e r in g merk die mees toepaslike blokkie af. w an n eer ek slegs die kogleere inplanting g e b ru ik ....... stem beslis saam stem saam on seker stem nie saam stem beslis nie saam 1. k an ek spraak verstaan al is d it baie sag. v18 | 1 19 2. k link m y stem v ir m y se lf m eer natuurlik. v19 | | 20 3. se an d er m y stem k link m eer natuurlik. v 20 | 1 21 4. is ek in staat to t b eter w oordherkenning. v21 | ” ] 22 : 5. vind ek d it m akliker om na ’n gesprek te luister in agtergrondgeraas. v22 | 1 23 : ■ w an n eer ek beide die kogleere inplantings en g e h o o ra p p a ra a t g e b ru ik ... stem beslis saam stem saam on seker stem nie saam stem beslis nie saam 1. k an ek spraak verstaan al is d it baie sag. v23 | 1 24 2. k link m y stem v ir m y se lf m eer natuurlik. v24 | 1 2 5 ' 3. se an d er m y stem k link m eer natuurlik. v25 | 1 / 2 6 4. is ek in staat to t b eter w oordherkenning. v 26 | | 27 5. vind ek d it m akliker om na ’n gesprek te lu ister in agtergrondgeraas. v 27 | | 28 d ie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) qie ervarings van jong v olw assenes m et k ogleere inplantings aangaande b im odale versterking 103 a fd elin g d : k o s m e t ie s e a s p e k t e merk die mees toepaslike blokkie af. vvanneer ek slegs die kogleere in p lanting g e b r u ik ... stem beslis saam stem saam o nseker stem nie saam stem beslis nie saam 1 voel ek m eer gem aklik o o r m y voorkom s by die werk. v28 29 2. voel ek m eer gem aklik o o r m y voorkom s in sosiale situasies soos bv. by 'n braai. v29 30 3. voel ek o f ek m eer uitstaan as ander persone. v30 ] 31 w anneer ek beide die kogleere in p lanting en g e h o o rap p a raa t g e b ru ik ... stem beslis saam stem saam o nseker stem nie saam stem beslis nie saam 1. voel ek m eer gem aklik o o r m y voorkom s by die werk. v31 | | 32 2. voel ek m eer gem aklik o o r m y voorkom s in sosiale situasies soos bv. by 'n braai. v 32 | | 33 3. voel ek o f ek m eer uitstaan as ander persone. v33 | | 34 ervaar jy die gelyktydige gebruik van 'n kogleere inplanting en 'n gehoorapparaat positief o f negatief in terme van die kosmetiese aspekte daaraan verbonde? motiveer asb. a fd elin g e: h a n t e r in g e n v e r s o r g in g merk die mees toepaslike blokkie a f w an n eer e k slegs die kogleere inplanting g e b r u ik ... stem beslis saam stem saam o nseker stem nie saam stem beslis nie saam 1. is daar m eer verantw oordelikhede aangaande die identifisering van apparaatproblem e. > v34 35 2. voel ek d at die versorging daarvan m eer tyd in beslag neem . v35 36 3. voel ek die versorging daarvan vir m y 'n groter las is. v36 37 4. v ereis d ie skoonm aak d aarvan m eer tyd van my. v37 38 5. v eroorsaak d ie hantering daarvan v ir m y m eer o n g e rie f o f spanning. v38 39 6. h et die herstel groter finansiele im plikasies. v39 40 7. is die battery-verbruik m eer. v40 41 the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 104 l iani van der w esthuizen and catherine van dijk w an n e er ek beide die kogleere inplanting en g e h o o ra p p a ra a t g e b r u ik ... stem beslis saam stem saam o nseker stem nie saam stem beslis nie saam 1. is daar m eer verantw oordelikhede aangaande die identifisering van apparaatproblem e. v 34 | ~| 35 2. v oel ek dat die versorging daarvan m eer tyd in beslag neem . v35 | | 36 3. v oel ek die verso rg in g daarvan vir m y 'n g roter las is. v 36 | | 37 4. v ereis die sk o o n m aak daarvan m eer tyd van my. v 37 | i 38 5. v ero o rsaak die han terin g daarvan vir my m eer ongerief o f spanning. v 38 | | 39 6. h et die herstel groter fm ansiele im plikasies. v 39 | | 40 7. is die battery -v erb ru ik meer. v 40 | | 41 ervaar jy die gelyktydige gebruik van die kogleere inplanting en die gehoorapparaat positief o f negatief in terme van die hantering en versorging daarvan. motiveer asb. baie dankie vir u tyd en m o eite om hierdie vraelys te voltooi! d ie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) abstract introduction methods results discussion conclusion acknowledgements references about the author(s) lebogang ramma department of health and rehabilitation sciences, faculty of health sciences, university of cape town, cape town, south africa citation ramma, l. (2021). patterns of noise exposure and prevalence of hearing loss amongst cape town minstrel carnival musicians. south african journal of communication disorders, 68(1), a789. https://doi.org/10.4102/sajcd.v68i1.789 original research patterns of noise exposure and prevalence of hearing loss amongst cape town minstrel carnival musicians lebogang ramma received: 03 july 2020; accepted: 05 mar. 2021; published: 31 may 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: cape town minstrel carnival is one of the oldest and most authentic indigenous new year’s customs in south africa. musicians who perform at this carnival are exposed to excessively loud music and therefore at a risk of acquiring noise-induced hearing loss (nihl). objectives: this study aimed to determine patterns of exposure to loud music and prevalence of hearing loss amongst cape town minstrel carnival musicians. method: a descriptive, observational exploratory survey design was used and 43 participants (21 males and 22 females; mean age, 21 ± 9 years) took part in this study. sound level measurements were conducted to assess musicians’ sound exposure during rehearsals and performances. all participants underwent the following audiological test battery at least 2 h before music exposure: case history, otoscopic examination, tympanometry, pure tone audiometry and distortion products otoacoustic emission (dpoae). results: average noise levels recorded were 86 dba during rehearsals and 98.7 dba at performances and average durations of exposure were 240 and 10 min at rehearsals and performances, respectively. one out of 43 (1/43) participants presented with sensorineural hearing loss. audiometric results of the remaining participants were normal and did not show a pattern suggestive of nihl. a high proportion of participants (21/43) reported experiencing tinnitus. conclusion: despite being exposed to high levels of noise, there was a low prevalence of hearing loss amongst these musicians. however, a high proportion of them reported tinnitus, which could be an indication that they were at a high risk of nihl from the music that they played. keywords: noise-induced hearing loss (nihl); musicians; minstrel carnival; noise exposure; prevalence. introduction the cape town minstrel carnival is one of the oldest and most authentic indigenous new year’s customs in south africa (martin, 2007). at the beginning of every year, scores of minstrel troupes, locally known as kaapse klopse [clubs of the cape] partake in the carnival, which include christmas bands and malay choirs (oliphant, 2013). the first and second of january of every year usually represent the apex of the carnival, with performances from early in the morning until the early hours of the next days. however, performances continue every weekend throughout the month of january and beyond (bruinders, 2007). troupes typically consist of a few hundred members, mostly non-professional musicians who perform at the carnival as a pastime, with some members assigned as captains and into respective committee roles (martin, 1999). people of various age groups form part of the troupes, ranging from young toddlers to elderly over 70 years, with the bulk of the troupe members consisting of teenagers and young adults. members perform various roles, including singing, dancing and playing instruments. the music played by the troupes typically includes light western, pop and jazz music; folk songs; and their own compositions (martin, 1999). instruments often include string instruments, like guitars and banjos, drums, tambourines and brass instruments (martin, 1999). each troupe has a brass band that consists of 20–30 musicians, with more vocalists and dancers than musicians. members of the troupes usually practice up to three times per week for several months per year and rehearsal venues vary from garages, back yards, community halls and houses across the suburbs of cape town (baxter, 2001). during brass band rehearsals, music exposure is non-continuous and many silent breaks are granted. at competitions, the duration of performances typically range from 10 to 20 min per performance. there is a growing body of evidence that suggests that exposure to loud music and recreational noise for extended periods of time poses a risk of temporary or permanent noise-induced hearing loss (nihl) (le clercq, van ingen, ruytjens, & van der schroeff, 2016; le prell, et al. 2012; neitzel & fligor, 2019) and tinnitus (guest, munro, prendergast, howe, & plack, 2017; zhao, manchaiah, french, & price, 2010) to those exposed. events such as the cape town minstrel festival generate high levels of noise and therefore pose the risk of nihl to those who participate, especially performers. noise-induced hearing loss can have a negative impact on many aspects of an individual’s life, social and educational development and their ability to work (world health organization, 2015), and therefore should be prevented at all costs. noise-induced hearing loss resulting from music exposure, especially amongst professional musicians, has been documented in several studies (halevi-katz, yaakobi, & putter-katz, 2015; pawlaczyk-łuszczyńska, dudarewicz, zamojska, & śliwinska-kowalska, 2011; pouryaghoub, mehrdad, & pourhosein, 2017; schink et al., 2014). some of these studies have reported a high prevalence of nihl amongst professional musicians (emmerich, rudel, & richter, 2008; phillips, henrich, & mace, 2010; pouryaghoub et al., 2017; schink et al., 2014). relatively fewer studies have investigated the prevalence of nihl amongst non-professional musicians. few studies that investigated nihl amongst non-professional musicians have reported almost no nihl amongst these musicians although they were also exposed to noise levels that could lead to nihl (schmuziger, patscheke, & probst, 2006; virmond, perroca, & moura, 2007). there is some evidence that the content of the sound and the listener’s subjective perception of sound exposure may affect the risk of a temporary threshold shift (tts) (strasser, irle, & scholz, 1999). this was further shown in a study by strasser and colleagues in which it was demonstrated that the amount of tts varied according to the type of sound one is exposed to (strasser, irle, & legler, 2003). for instance, it was shown in the same study that exposure to loud classical music led to substantially less tts than industrial noise of the same duration and intensity (strasser et al., 2003). this has subsequently led to some researchers (virmond et al., 2007) questioning whether exposure to music can cause nihl amongst non-professional musicians. virmond and colleagues posited that there is a possible existing association between the perception of music as a pleasant sound and some psychophysiological protective effect (virmond et al., 2007). that is, a positive attitude from musicians towards their music may explain why non-desirable sound of similar intensity levels and duration may lead to a more damaging effect on hearing than their own music does (virmond et al., 2007). in addition, music and industrial noise are different in terms of their spectral composition and this may also explain the differences in their overall risk to human hearing (kähäri, axelsson, hellstrom, & zachau, 2001; virmond et al., 2007). however, ivory, kane and diaz (2014) reported that music, even when used recreationally, can cause damage to the auditory system, which seems to contradict views of virmond et al. (2007) on this issue. whilst the duration and intensity of the sound are usually used as key indicators to judge the risk of nihl, it is important to bear in mind that these variables (intensity and duration) interact with other factors in influencing an individual’s susceptibility to hearing loss. amongst others, factors such as age, gender, previous non-music-related noise exposure, type of instruments played and accumulated music exposure can also increase a person’s susceptibility to developing hearing loss (agrawal, platz, & niparko, 2009; daniel, 2007). although there are occupational regulations and standards developed to protect individuals who work in excessively noisy environments from acquiring nihl, musicians are often overlooked when it comes to occupational safety and health practices (national institute for occupational safety and health [niosh], 2015). this is especially true for non-professional musicians who may not even consider themselves to be at risk of nihl. for instance, pouryaghoub et al. (2017) reported that most musicians do not have adequate knowledge about hearing conservation and therefore, most of them never use protective devices to prevent nihl. also, despite musicians being at risk of many auditory disorders because of exposure to loud music, most of them are less concerned about these issues and therefore do not use hearing protection (dinakaran, deborah, & thadathil, 2018; santucci, 2010). musicians in the minstrel troupes, especially those who play brass instruments, are exposed to high-intensity music levels for extended periods during rehearsals and performances. therefore, these musicians are at risk of developing nihl from prolonged exposure to high levels of noise. the aim of this study was to determine the patterns of noise exposure and the prevalence of hearing loss amongst cape town minstrel carnival musicians. methods study design, participants and setting a descriptive, observational exploratory survey design was used in this study. participants were members of the minstrel troupes in the cape town metropolitan area and were sampled via convenience sampling. to be included in this study, participants had to be between 5 and 49 years old to minimise the impact of age-related hearing loss (de sousa, júnior, larsson, & ching, 2009). participants who reported history of work-related noise exposure, prior treatment with ototoxic medications, middle ear pathologies and history of ear surgery were excluded from the study. data collection instruments and procedures the study proposal was first submitted to the university of cape town, faculty of health sciences human research ethics committee (hrec) for ethics review and approval. after obtaining ethics approval, minstrel troupes were contacted and invited to take part in the study. appointments for data collection were arranged with the groups that agreed to participate. on the arranged date of data collection, the researchers met members of the troupe, explained the purpose of the study and what participation would entail. participants were asked to indicate their willingness to take part in this study by signing an informed consent form (assent was obtained from participants younger than 18 years old). audiometric assessment took place in carefully selected quiet rooms (ambient noise levels < 50 db spl), using noise-attenuating headphones at each of the rehearsal venues. audiometric assessment was conducted at least 2 h prior to the start of rehearsal sessions. audiological assessment included the following: case history interview (with emphasis on prior history of noise exposure), otoscopy, tympanometry (gsi 39) (gradson-stadler, united states of america), pure tone audiometry (2 khz – 8 khz) (kuduwave 5000 audiometer) (geoaxon, south africa) and distortion products otoacoustic emissions (dpoaes) (gsi audera v2.7) (gradson-stadler, united states of america). parameters for dpoae are set as follows: l1 = 65 db and l2 = 55 db, with an intensity ratio of l1–l2 = 10 db, and frequency range: 2098, 2402, 2754, 3152, 3621, 4184, 4816, 5496, 6340 and 7277 hz. for a dpoae response to be considered normal at a given frequency, it would have to be 3 db or more above noise floor and absolute distortion product (dp) amplitude had to be greater than -10 db (hall & swanepoel, 2010). participants who showed abnormal audiometric findings were counselled about their test results and were referred to the nearest public healthcare facility for further management. sound level measurements were carried out using a brüel & kjær (b&k) (bremen, germany) type 2236 sound level meter (slm). the slm was calibrated before and after each measurement using the manufacturer’s provided calibrator and then compared against a sound source with known intensity level. sound level meter was also fitted with a manufacturer supplied windscreen to minimise impact of wind noise, which could introduce errors in the recorded sound levels. consideration for the impact of wind in sound measurements was especially important when conducting measurements during performances because those were performed outdoors. the slm is set as follows: a-scale frequency weighting, a slow time weighting and a range of 70 db – 140 db. measurements were conducted during the troupe’s rehearsals and at performances during many of the minstrel activities, including the final competition at the athlone stadium in cape town. during rehearsals, sound levels were measured from different points across the room to obtain sound level samples from musicians sitting in the front, middle and back of the room. the slm was placed on a tripod stand, set at least 1.2 m above the floor and at least 1.5 m away from large reflecting surfaces (e.g. the walls). the measurements were recorded at 5 min intervals (i.e. at least 5 min for each interval of recording). during performances, measurements were recorded from between the two rows of musicians as they marched, also ensuring to obtain noise samples from the back, middle and front of the row. the slm was held at an arms length from the individual doing the recording, at about ear level (whilst standing) of the musicians. several samples of sound level measurements were recorded and only peak and equivalent continuous average (laeq) sound levels were recorded and reported for each sound measurement session. data analysis data were analysed using both descriptive statistics (mean, standard deviations, range) and inferential statistics. for inferential statistics, the mann-whitney u test was used to assess whether there was a statistically significant difference (p = 0.05) between the means of different categories of participants. data were analysed using stata 11.1 statistical software package (statacorp, united states of america). ethical considerations ethical approval for this study was granted by the university of cape town, faculty of health sciences hrec (no. 556/2011). ethical conduct during this study was in accordance with and guided by the declaration of helsinki as amended by the 64th world medical association, fortaleza, brazil, in 2013. results a total of 43 participants took part in this study. participants were divided into two categories in accordance with their primary roles in the troupe: instrument players (instrumentalists) or singers (vocalists). there were more instrumentalists than vocalists; however, vocalists were generally older and had more musical experience (me) than instrument players. all participants reported that they had never used hearing protection devices to prevent potential nihl from the music they played (table 1). table 1: participants’ description (n = 43). these musicians were exposed to loud musical sounds for longer durations during rehearsals and to excessively loud sound levels (but for shorter durations) during musical performances at many of the minstrel festivities (table 2). table 2: sound levels that (dba) musicians were exposed to during rehearsals and performances. two participants in the vocalist group (2/12) displayed abnormal results for both pure tone audiometry and dpoae assessment. however, one of these two participants also had an abnormal (type b) tympanogram, which was consistent with a middle ear pathology. the hearing test results of the participant with type b tympanogram were not included in further analysis of results. all the participants in the instrumentalist group passed pure tone screening and dpoae assessment. furthermore, the average hearing thresholds (4 khz – 8 khz) of the participants were all within normal limits and did not show any pattern consistent with exposure to excessive noise (see table 3). table 3: mean hearing thresholds of instrument players only (n = 31) at 4.6 khz and 8 khz. distortion products otoacoustic emission results showed that responses of participants in the instrumentalist group had higher signal-to-noise ratio (snr) when compared with those in the vocalist group. however, the response of both groups showed a similar trend (more robust in the mid frequencies and weaker in the higher frequencies) (see figure 1). figure 1: distortion products otoacoustic emission signal to noise ratio for instrumentalists and vocalists (left ear). mann–whitney u test (p < 0.05) revealed no statistically significant difference in dpoae amplitudes between the following: instrumentalists versus vocalists (p = 0.90), trumpet players versus other instrument players (p = 0.84), weekly noise exposure (< 4 h/week vs. > 4 h/week) (p = 0.63) and me (< 20 vs. > 20) (p = 0.84). finally, there was also no statistically significant difference between the average dpoae amplitudes of vocalists and that of instrumentalists at any of the tested frequencies. discussion this study set out to investigate the patterns of exposure to loud music by musicians who perform in the annual cape town minstrel carnival and to determine the prevalence of hearing loss amongst these musicians. overall findings of the study showed that cape town minstrel carnival performers are exposed to excessively loud sounds during both rehearsal sessions (> 85 dba) and performances (> 98 dba). a high proportion of them reported experiencing tinnitus; however, there was a very low prevalence of hearing loss amongst these musicians. in terms of the patterns of noise exposure, it was observed that these musicians are exposed to loud music for a much longer duration during rehearsal sessions (on average, 4 h per session three times per week, during intensive preparation period) than during performances. exposure to high levels of sound during performances was surprisingly very brief (on average, 10 min per session). however, musicians will typically warm up (10–15 min) before going on stage for performances. noise levels that these musicians were exposed to at both rehearsals and performances exceeded the niosh’s recommended exposure level (rel) for musicians (niosh, 2015), which means that they are at risk of developing nihl. patterns of noise exposure and noise levels that musicians in this study were routinely exposed to were consistent with those reported in previous studies involving musicians who play similar types of instruments (i.e. brass instruments) (emmerich et al., 2008; schmidt et al., 2011). similar noise exposure patterns were also reported by mcllvaine and colleagues, that is, noise levels exceeding niosh recommended noise levels, with higher noise intensities recorded during performances than rehearsals (mcilvaine, stewart, & anderson, 2012). given the high noise levels that these musicians were routinely exposed to, it was surprising to find that only one of the 43 participants in this study presented with a hearing loss (mild high frequency sensory-neural hearing loss). for the remainder of the participants, average pure tone hearing thresholds test results were not consistent with what would be expected in a population that is regularly exposed to these noise levels. some researchers have cautioned about the risk of pure tone audiometry underestimating noise-induced hidden hearing loss because it is often not accompanied by a shift in pure tone hearing thresholds (shi et al., 2016). it was for this reason that dpoae was included as part of the test battery. however, average dpoae amplitudes were also found to be within the normal range at all the frequencies tested, regardless of the role or the musical instrument that the musicians played in the troupe. the fact that there were fewer musicians in this study who presented with hearing loss was an unexpected finding, especially when considering that all the participants reported that they had never used hearing protection devices during rehearsals or performances. however, this was consistent with the findings of previous studies that investigated prevalence of hearing loss amongst non-professional pop musicians, which also reported no hearing loss amongst this group of musicians (schmuziger et al., 2006; virmond et al., 2007). one of the explanations given for the absence of hearing loss amongst these musicians was because musicians generally perceive music as pleasant and this is thought to have a psychological protective effect that reduces the risk of nihl amongst them (virmond et al., 2007). specific to this study, it was observed that whilst these musicians were exposed to loud music for longer durations during rehearsals, there were often many breaks in the music that they were exposed to. for instance, during the practice of a new song, there were frequent breaks in the music to allow other players to master the song to be performed. these frequent pauses are said to be protective when compared with a continuous noise, such as industrial noise, which tends to lead to more hearing loss (virmond et al., 2007). furthermore, cape town minstrel musicians do not play any amplified music. amplified music has been shown to present a much higher risk of nihl than unamplified music (halevi-katz et al., 2015). it was also observed that musicians who participated in this study, especially those who played instruments, were generally young (average age of 16 years) and most of them have been involved in this kind of activity for a short period of time (< 5 years). this could potentially explain why there was such a low prevalence of hearing loss in this group. it was noticed that a high proportion of participants in this study reported experiencing tinnitus: 14/31 (instrumentalists) and 5/12 (vocalists). tinnitus is known to be closely associated with music exposure and indicates a high risk of an individual developing nihl as a result of music exposure (zhao et al., 2010). however, because of the limited number of questions related to tinnitus, it was not possible to further probe participants who reported tinnitus to ascertain whether they were reporting transient tinnitus or tinnitus that interfered with their daily functioning. the fact that most participants in this study reported not using hearing protection when exposed to loud music was expected, especially when considering the informal nature of their musical activities. musicians generally lack awareness about hearing conservation to prevent nihl (pouryaghob et al., 2017; dinakaran et al., 2018) and therefore do not usually follow proper hearing conservation practices (santucci, 2010). the findings of this study should be interpreted whilst taking into account its methodological limitations; this study did not assess noise dose of individual musicians during both rehearsals and performances, which could have given a more detailed nihl risk analysis of individual musicians. instead, noise levels and exposure patterns were assessed over a period of 6 months to obtain a better understanding of how these musicians interact with noise. furthermore, this study involved a small sample size and participants were not randomised when enrolled to the study, which limited generalisability of this study. however, despite its methodological shortcomings, this study is one of the first studies to investigate the prevalence of hearing loss and the risk of nihl in this group of musicians. this study has objectively shown that these musicians are indeed at risk of developing nihl as a result of their music exposure. conclusion cape town minstrel musicians are often exposed to sound levels that are above the niosh rel during both rehearsals and performances. despite this and not using any form of hearing protection, this study found a very low prevalence of hearing loss in this group of musicians. both audiometric and dpoae test results did not indicate any pattern consistent with nihl. however, a high proportion of these musicians reported tinnitus, which may be an indication of increased risk of nihl amongst them. it is therefore very important that these musicians, who are central to this carnival, are made aware of the potential risk the music they play impose to their hearing status and are educated about viable and sustainable strategies such as the use of personal hearing protection devices to prevent potential nihl from their musical activities. acknowledgements the author would like to thank wandile mashego, knowledge mnguni, anine hugo and nonkululeko mtolo. competing interests the author declares that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. author’s contribution l.r. is the sole author of this article. funding information this research was made possible by a grant from the university of cape town’s research committee. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any affiliated agency of the author. references agrawal, y., platz, e., & niparko, j. 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(2010). music exposure and hearing disorders: an overview. international journal of audiology, 49(1), 54–64. https://doi.org/10.3109/14992020903202520 8 h. k athard, e. n aude, m. pillay and e. r 0ss response: sally hartley professor of communication and health, university o f east anglia, norwich, uk. an interactionist way fo rw a rd f o r im proving the relevance o f speech -l an gu age therapy and a udiology research an d practice. i warmly welcome the opportunity to respond to the article by kathard et al., which raises so many very important issues. i intend to build on what has been presented and lay out some options for consideration and discussion. these options involve a paradigm shift in the conceptualisation o f our practice and related research and offer a way forward. this re­ conceptualisation is just as pertinent to people in more and less developed areas o f the world. it can apply to both the profes­ sions o f audiology and speech and language pathology (slp) 1 and relates to all professions involved in rehabilitation.2 my comments revolve around five main areas: 1. the global context. 2. the concepts underpinning our professional practice and research. 3. how we communicate these concepts. 4. what impact 2 and 3 have on our research and practice. 5. how these relate to emerging rehabilitation research and practice. 1. the global context research indicates that around 2-3 % o f a population are likely to have problems with talking and communicating. this esti­ mate appears to be similar in income rich and income poor countries o f the world (cf. enderby & pickstone, 2005 and hartley, 1998, 2001). slp and audiology are two o f the major professions that offer support to this client group. however, sell et al. (2001) estimate that slp services, for instance, are only available in 20% of the world. this leaves 80% o f the world without these essential services. to date slp research has concentrated on evidence in phase 1-3 of the mrc phases for developing evidence for the efficacy o f complex health in­ terventions, (mrc, 2000). this includes, theory exploration, intervention and outcome measurement tool development and piloting. so even in income rich areas o f the world, the evi­ dence for the efficacy o f our professional interventions is still embryonic. for audiology, evidence has a closer fit with the hierarchy of evidence relating to efficacy o f interventions (ocen 2001). 2. the concepts underpinning our practice and research as the authors note, these two professions have evolved from the medical paradigm, generating a positivist/experimental ap­ proach to collecting evidence to underpin their practice. conse­ quently practice very often reflects a ‘disorder/cure’ based fo­ cus. this is most certainly appropriate for some aspects of our work. for example, in audiology practice we are charged with detailed assessment o f hearing levels (comparing individual levels o f hearing with the ‘normal’ levels expected) and pre­ scribing and fitting hearing aids (to bring the hearing levels 1. f o r the purposes o f this disc u ssio n p ap er n o distinction is m ade betw een speech and l anguage p athology (slp) and speech and l anguage t herapy (slt). the term s are considered to be m utually inclusive. 2. d efined as m axim ising functional status and prom oting participation. nearer to ‘normal’). or in the assessment o f cleft palate func­ tioning (comparing it to normal functioning) in relation to (normal/accepted) sound production. as the authors point out this approach has served us well in the development of some of our core skills and professional identities, and may still be seen as necessary for our survival. however, as speech and language therapy practice has developed, the strong link with a ‘disorder’ based approach is often problematic and limiting. this is par­ ticularly so when seeking to improve or maximise communica­ tion related to ‘living with’ these (disorder and contextually related) limitations. it is also problematic when diagnoses do not have a secure evidence base linking them with a pathology, such as stammering and delayed language development. when linking the diagnosis to subsequent treatment, a conceptual incompatibility between ‘disorder’ and ‘disability’ emerges. in practice, for example, this may result in interven­ tions (services) that focus on the ‘disorder’, leaving the other dimensions o f disability receiving less priority and recognition. using icf (who, 2001) terminology, this might be expressed as concentrating therapy on, improving body function (e.g. swallowing,) with less attention to improving activity limita­ tions (eating, talking), participation restrictions (socialising/ communicating through alternative means o f communication) and environmental factors (community and family understand­ ing). when the therapy process addresses only one dimension of disability, the level o f disablement may remain relatively unaf­ fected and the intervention may be deemed ineffective. this dilemma remains the same when therapists tackle one of the ‘non disorder’ dimensions of disablement such as contextual factors (to use the icf terms), by increasing family understand­ ing and coping capacity. it is likely that all dimensions need attention if our interventions are to be effective. tackling con­ textual factors also carries the additional problem of limited available evaluation tools. so the effectiveness or otherwise of the interventions often remains unproven. given that the aim o f slps is to improve communication by whatever means are required, the ‘disorder/cure’ focus ap­ pears to limit and confuse their practice and associated research activity. a ‘disability’ approach incorporating all the dimen­ sions highlighted in the icf (who, 2001), could promote a balanced assessment o f all contributing dimensions (including the disorder). practitioners would be able to frame and defend their interventions in these terms. it’s worth noting that the icf has been adopted by 191 countries as a tool for promoting a more universal response to people who have activ­ ity limitations and participatory restrictions. it provides a com­ mon language and offers the opportunity for all groups involved to communicate more effectively. audiological practice, which possibly has a closer link with pathology, could also benefit from this broader approach if it is to be effective, for example, in supporting better utilisation of hearing aid equipment. the factors that affect such utilization are often ‘non disorder based’ and may relate to c o n f i d e n c e , negative attitudes or vanity about appearances. these social determinants o f the problem of underutilization also need to be assessed, addressed and evaluated as part of good a u d i o l o g i c a l practice. die suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) im proving the r elevance o f s peech-l anguage pathology and a udiology r esearch and practice 9 3. how we communicate these concepts although our practice may be beginning to change (e.g. conver­ sation partners for people with aphasia (an environmental inter­ vention) (parr and byng, 1998); research into hearing aid usage (pothier & bredenkamp, 2006)). our existing professional lan­ guage sends out conflicting and confusing messages. for exam­ ple, ‘the south african journal o f communication ‘disorders’ and the ‘international journal o f language and communication ‘disorders’, re-enforce a narrow focus which is not compatible with these new approaches. also the continued use of ‘speech’ and ‘pathology’ in our titles e.g. speech and language patholo­ gist, (south africa and the us). such language only serves to re -enforce the perception that our practice is ‘speech’ and ‘disorder’ focussed. this does nothing to promote a public and professional understanding o f our role in promoting communi­ cation and participation by the best possible method (which may not, and often is not, speech, e.g. aac, makaton etc.) 4. what impact 2 and 3 have on our research and practice for slps we find ourselves trying to defend our practice in terms of ‘curing’ ‘speech and language’ problems and this is often how we are judged by our clients and by our professional colleagues.... how well can we teach people to speak again? this may be irrelevant to many o f our client groups such as stroke patients or children with learning difficulties. neverthe­ less the cure aspect influences the thrust of our research activity, and it is these aspects which are rewarded and understood. the communication, interactive and therapeutic side o f our practice remains less visible. maximising functional status and promot­ ing participation as positive outcomes are not well understood or defended. 5. emerging rehabilitation practice and research like kathard et al., the physiotherapy literature also reveals discussions about why much of the research that is conducted in physical therapy is not relevant to clinicians (colins, 2005). colins agrees that a reductionist approach cannot provide evi­ dence to support all aspects o f physical therapy, because it is complex and dynamic. he suggests that dynamic systems theo­ ries (thelen et al., 1994) help to conceptualise the multiple fac­ tors that contribute to the complexities of clinical situations. he advocates making use of, rather than eliminating, sources of variation. a canadian team, j the ontario rehabilitation re­ search network (orrn) o f multi-professionals have generated a useful position paper (bartlett e f a l., 2006) utilising this ap­ proach and suggest an ‘interactionist perspective’ to guide re­ search questions, design and subsequent good practice. they believe that client outcomes are generally influenced by interde­ pendence (i.e. interaction) o f factors, rather than by a single factor (last, 2001) and that a comprehensive approach is needed for research to become meaningful (bartlett & lucy, 2004). they argue that these perceptions can provide a unifying direction for rehabilitation research. they too suggest that the icf provides the starting point, which can guide the specifica­ tion o f the research question and subsequent design. this de­ mands that the question takes precedence and research designs are then chosen from an extensive repertoire. these methods are used to examine the disability experience over the life time and address multifaceted interventions, low incidence conditions and the development of new interventions. this reflects the mrc phases for evaluating complex health interventions, (mrc, 2000) but additional emphasis is placed on the necessity for inclusion o f clients and families and all stakeholders in planning research and treatment. this is the mechanism for establishing the validity of research by linking it to practice and lived experiences, i.e. through an interactionist approach. this resonates well with kathard et al. who ask us to ‘engage with what is relevant’ to ‘enhance the effectiveness o f practice’. conclusions and suggestions some ways o f addressing the dilemmas outlined in the kathard et al.’s paper would be to: 1. work towards recognising all the dimensions of disable­ ment in assessments and interventions and defend them through using a theoretical base such as the icf. 2. be clearer about the aims o f our practice. 3. consider changing the names o f our professions and jour­ nals to reflect and communicate a more accurate picture of what we aim to do in our practice. 4. reflect these aims in our research practice. 5. join with other rehabilitation practitioners to develop and contribute to a research philosophy that can be defended in terms o f validity and fit for purpose rather than accepting/ adopting other approaches that are not always appropriate to our practice. b artlett, d. & lucy, s.d. (2004). c om prehensive approach to outcom es re ­ search. p h ysio th era p y can, 56, 237-247. b artlett, d ., m acnab, j., m acarthur, c., m andich, a ., m agill-evans, j., y oung, n ., b eal, d ., c onti-b ecker, a. & p latajko, h. (2006). d isa b ility a n d r e h a ­ b ilitation, 28(19), 1169-1176. c ollins, s.m . (2005). c om plex system s approaches: c ould they enhance the relevance o f clinical research? p h y sic a l therapy, 86 (5), 763-764. e nderby, p. & p ickstone, c. (2005). h ow m any people h ave com m unication disorders and w hy does it m atter? a d va n ces in s p eech a n d l a n g u a g e p athology, 7(1), 8-13. h artley, s. (1998). c hildren w ith v erb al com m unication difficulties in e astern u ganda: a social survey. a frica n j o u r n a l o f s p ecia l n eeds e d ucation, 3 ( 1), 11-2 0 . h artley, s. & w irz, s. (2002). d evelopm ent o f a com m unication disability m odel and its im plications on service deliv ery in low -incom e countries. s o cia l scien ce a n d m edicine, 54(10), 1543-1557. last, j.m . (2001). a dictio n a ry o f epidem iology. (4th e dition). o xford: o xford u niversity press. m r c (2000). a fram ew ork for the developm ent and evaluation o f r c ts for com plex h ealth interventions to im prove health. o xford c entre for e vidence based m edicine, (o c e m ) (2001). l evels o f ev i­ dence. r etrieved from the w orld w ide w eb on 2007/09/10 http:// w w w .cebm .net/index.aspx?o= 1025 parr, s. & b yng, s. (1998). b reaking new ground in fam iliar territory. sup­ ported conversation for adults w ith aphasia. aphasiology, 12(9), 847-850. p othier, d .d . & b redenkam p, c. (2006). h earin g aid insertion: correlation betw een p a tie n ts’ confidence and ability. j o u r n a l o f l a ryn g o lo g y a n d otology, 120, 378-380. sell, d ., m ars, m ., h abel, a., w irz, s., w ickenden, m. & h artley, s. (2001) c ranio-facial s ociety m eeting g reat britain. ireland: d ublin.. t helen, e. & sm ith, l.b . (1994). a dyn a m ic system s approach to the d evelo p ­ m en t o f cognition a n d action. c am bridge, m a .: m it press. w h o (2001). international classification o f f u n ctio n in g and d isability (ic f). g eneva: w h o . the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.cebm.net/index.aspx?o= i n a p p r o p r i a t e s exual b e h a v io u rs e x p e rie n c e d by s p e e c h -l a n g u a g e p a th o lo g ists and a u d io lo g is ts in s o u th a frica 5 inappropriate sexual behaviours experienced by speech-language pathologists and audiologists in south africa k a ren levin and l o ren t ra u b s peech p ath o lo g y and a u d io lo g y u n iv ersity o f the w itw ate rsra n d a b s t r a c t the exp erien c e o f in a p p ro p ria te s e x u a l b eh a vio u rs (isb) b y h ea lth ca re p ro fe s s io n a ls has b een id e n tifie d in te rn a tio n a lly as a se rio u s is­ sue. this s tu d y in v estig a ted the ex te n t o f is b d ire c te d to w a rd s s p e ec h -la n g u a g e p a th o lo g ists a n d /o r a u d io lo g ists (slp /a s) in s o u th a f­ rica. as w ell as th e so u rces a n d th e effects o f isb, th e re sp o n ses o f th e sl p /a s, a n d th e p e r c e p tio n s o f th e s l p /a s with r e g a rd to th eir a b ilitv to m a n a g e is b experiences. f ifty -six q u a lifie d s l p /a s a n d 62 stu d e n t s l p /a s c o m p le te d a q u estio n n a ire b a se d on sim ila r stu d ies co n d u c te d in c anada a n d n ew zealand. m o st o f the resp o n d en ts h a d e x p e r ie n c e d isb, m o stly o f a m ild to m o d era te nature, at s o m e p o in t in th eir careers, a n d so m e h a d ex p e rie n c e d se v e re is b in the w orkplace. is b o c c u rre d in a va riety o f w o r k contexts. the so u rc es o f is b in c lu d ed clients a n d /o r th eir fa m ily m em bers, as w ell as c o llea g u e s a n d em ployers. a ra n g e o fp e r s o n a l a n d w o r k -re la te d effects re su lte d a n d th e re sp o n d en ts to o k the le a st a sse rtiv e strategy' in th e m a n a g em en t o f th e ir is b exp erien ces. the re su lts re fle c te d that s l p /a s in s outh a fric a are p o o r ly in fo rm e d w ith re g a rd to th e ir leg a l rights a n d resp o n sib ilities, as w ell as stra teg ie s to d ea l w ith u n w a n ted se x u ­ a lly re la te d experiences. is b o u g h t to b e r e co g n ise d as a se rio u s issue in c lin ic a l p r a c tic e in south a frica by slp/as, p r o fe ss io n a l bodies as w ell as tra in in g institutions. the results a re in line with p re v io u s resea rch on is b exp erien ces b y s l p /a s a n d o th e r h ea lth ca re p r o fe s ­ sionals. key w ords: sexual h arassm en t; sp eech p ath o lo g y and au d io lo g y ; p ro fe ssio n a l-p atie n t relatio n sh ip s in t r o d u c t io n s exual h ara ssm e n t is a u b iq u ito u s p h en o m en o n th at p e r­ vades all lev els o f society. n o tw ith stan d in g w id e ran g in g deb ates on sexual harassm en t, the d efin itio n is b ro ad and co n tro v ersial b ecau se the ex p erien ce is p erso n al and in d iv id u alised . t he s outh a frican l ab o u r r elatio n s a ct o f 1995, section 2 03(2) o f the d e­ p artm en t o f l ab o u r (1 9 9 5 ) d efin es sexual h ara ssm e n t as u n ­ w anted co n d u ct o f a sexual nature w hich is p ersisten t (alth o u g h a single in cid en t o f h arassm en t can c o n stitu te sexual h arassm en t). a cco rd in g to the a ct, the b eh a v io u r can only be d ee m e d as h a r­ assm ent i f the recip ien t has m ade it clear th at the b e h a v io u r is co n sid ered offensive. in ad d itio n , cen tral to the a ct is the co n d i­ tion th at the p eip etrato r should have kn o w n th at th e b eh a v io u r is regarded as un accep tab le. in co n trast, the u n ite d s tates e qual e m ploym ent o p p o rtu n ity c o m m issio n (1980) w ith in the civil rights a ct o f 1964 (e e o c ) reco g n ises that the p erp e tra to r m ay be co m p letely u n aw are th a t his o r h er b eh a v io u r is o ffen siv e or co n stitu tes sexual h ara ssm e n t or m ay be co m p letely u n aw a re that his or h er actio n s co u ld be u n law fu l, and fu rth erm o re, the e e o c reco g n ises th a t it m ay not be p o ssib le for the rec ip ien t to express in an y w ay that the b eh a v io u rs are unw elcom e. a s w ell as the d ifficu lties inherent in fo rm alised d e fin i­ tions o f sexual harassm en t, b lu rrin g o f b o u n d arie s o ccurs in p e r­ sonal exp erien ce and p erc ep tio n s in th at u n w an ted sexual b eh a v ­ iours are n o t alw ays co n stru ed by the recip ien t as being o f a h a r­ assin g nature (w illiam s, de s eriere & b o d in g to n , 1999). in re c ­ og n itio n o f the alien atin g and ju d g e m e n ta l im p licatio n s o f the term ‘h a ra ss m e n t’, m cc o m as, h erb ert, g iaco m in , k aplan & d ul berg (1 9 9 3 ) used the term ‘in ap p ro p ria te p atien t sexual b e h a v ­ io u rs’ in th e ir in v estig atio n o f the ex p erien ce o f in ap p ro p riate sexual b eh av io u rs (is b ) b y p h y sio th erap ists in c anada. t heir findings, as w ell as th o se o f w illiam s et al. (1 9 9 9 ) in n e w z ea­ land w ho id e n tified the ex p e rien c e o f isb b y sp e ec h -la n g u ag e p ath o lo g ists, co n firm e d th at reh a b ilita tio n th e rap ists do not a l­ w ays c o n stru e the exp erien ce o f isb as sexual harassm en t. t he ab sen ce o f a un iv ersal d efin itio n is ev id en t in the vast literatu re th at d eb ates te rm in o lo g y an d sem an tics in sexual h arassm en t and also in in tern atio n al legal texts and d ep o sitio n s w hich lack c o n ­ sisten cy an d agreem ent. in the ab sen ce o f a u n iv ersal d efin itio n , m o d els o f sexual h ara ssm e n t can help to clarify the b o u n d aries b etw e en w hat is ac ce p ta b le and w h at is u n ac ce p ta b le, w hich h elp s to d eterm in e p erc ep tio n s o f h arassm en t (m cc o m as et al., 1993). o n e o f the m o st c o m m o n ly u sed m odels d ifferen tiates ‘q u id pro quo h ara ss­ m e n t’ from ‘h o stile en v iro n m en t h a ra ss m e n t’. q uid pro quo h a r­ assm en t in v o lv es a p erso n in a su p erio r p o sitio n u sin g sexual h ara ssm e n t as an ex p ressio n o f p o w er to achieve his or h er aims. in co n trast, h o stile e n v iro n m en t h arassm en t o ccurs w hen an equal p eer en g ag es in sexual b eh a v io u rs th at create a h o stile en v iro n ­ ment. t his d iffe ren tia tio n is reflected in the d efin itio n s p ro v id ed b y the s o u th a frican l ab o u r r elatio n s a ct (d e p artm e n t o f l a­ bour, 1995), th e e e o c (1980), as w ell as the c o m m o n w ealth sexual d isc rim in atio n a ct (1 9 8 4 ) w hich co n stitu tes fed eral law in a ustralia. m cc o m as et al. (1 9 9 3 ) m ade use o f a sim ilar m odel in th e ir stu d y in c an ad a w hich ex am ined the ex ten t and n atu re o f isb d irec ted at p h y sio th erap ists. t h ey co n clu d ed th at m o st isb w'as d irec ted b y equal peers, or n o n -su p erio rs, and thus fell into th e categ o ry o f h o stile e n v iro n m en t harassm en t. h ow ever, th eir resp o n d en ts d id no t identifyth e ir ex p e rien c es o f isb as h ara ss­ m ent. t h e ex p erien ce o f b o th q u id p ro quo h arassm en t as w ell as h o stile en v iro n m en t h arassm en t has been reported w id ely by h ealth care p ro fe ssio n a ls in tern atio n ally , such as nurses (h en d erso n , 2003; m adison & m in ich ie llo , 2001; t ang, y ik, c h eu n g , c h o i & a u, 1996); p h y sio th erap ists (m cc o m as et al., 1993; o ’s ullivan & w eerak o o n , 1999); p h arm acists (b ro ed el z augg, s haffer, m aw er & sullivan, 1999); and m edical doctors (r ecu p ero , h eru, price, & a lves, 2004; v u k o v ich , 1996). r e­ search ers estim ate that alm o st one in every tw o w o m en ex p e ri­ the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 6 karen levin and loren traub ence isb at some point in their working lives (fitzgerald, 1993; gutek, 1985). a study conducted by the institute o f directors in 1992 estim ated that 76% o f south african women experience isb in the workplace (vetten, 2001). therefore the professions o speech pathology and audiology, which are predom inantly ema e professions in south africa, cannot ignore isb as a professiona issue because the experience o f isb poses a serious n s k to both the emotional and physical w ell-being o f a person (schneider swann & fitzgerald, 1997). however, despite the fem in.sation o f some professions such as speech pathology and audiology roth stein (1993) in his com m entary on m ccomas et al. s (1993) study argued that isb should be viewed as a professional issue, and cited b ruckner (1993) who argued that isb is n ot prim arily a w om en’s issue. the experience o f isb is a serious professional issue b e­ cause o f the extent o f the harm that it can cause (m ccom as et al., 1993). some theorists, particularly w ithin the psychological as opposed to the legal paradigm , argue that the consequences, rather than the intentions, are the determ ining factors in the defi­ nition o f harassm ent (fitzgerald, 1993; g utek & koss, 1993; m adison & m inichiello, 2001). the consequences o f the experi­ ence o f isb, whether the person defines the experience as harass­ ment or not, include a range o f negative effects in the workplace, such as decreased m orale, increased absenteeism , decreased job satisfaction, jo b loss, and deteriorating relationships with co­ workers (schneider et al., 1997). furthermore, the experience o f isb often has a serious effect on peo p le’s physical and emotional health and the more severe the isb the m ore severe the reactions (g utek & k oss, 1993; schneider et al., 1997). the reactions re­ ported by both m en and wom en who have been the recipients o f isb include anxiety, depression, sleep disturbance, w eight loss or gain, loss o f appetite, headaches, feelings o f frustration, fear, an­ ger, em barrassm ent, shock, alienation, and loss o f self-esteem (m ccom as et al., 1993; schneider et al., 1997). a ccording to schneider et al. (1997), isb m ay lead to sym ptom s o f post traumatic stress disorder. they wrote that people who experience sexual harassment exhibit sim ilar psychological effects as victims o f trauma. furtherm ore, people who have experienced isb in the workplace are likely to experience it on an on-going basis rather than as an isolated incident. r othstein’s (1993) view o f isb as a professional issue provided a lens through w hich the m anagem ent o f the experience o f isb m ay be viewed. the healthcare practitioner’s experience o f isb results from m ultifaceted interactions o f a com plex array o f factors including personal, environm ental, and societal influ­ ences, underscored by their role as professionals. this role begins in education and a num ber o f studies have show n that student health care professionals are at risk for experiencing high levels o f isb (m ccom as et al., 1993; recupero et al., 2004; vukovich, 1996; w illiam s et al., 1999). isb that is experienced in the w ork­ place o f the healthcare professional m ay be influenced by the setting, the nature o f the work, as well as the clients. the settings in w hich healthcare professionals’ w ork place them at risk for the experience o f isb, are places such as consulting rooms, quiet audiology booths, and hospital wards. close physical contact is necessary in m any aspects o f healthcare. healthcare workers m ay provide-a sym pathetic ear to clients and/or their caregivers and fam ily members, and transference is a w ell-docum ented phe­ nom enon in healthcare provision. sexual control problem s may be experienced b y the clients served by healthcare professionals, such as patients with brain injury (bezeau, bogod & mateer, 2004; lawrie & jillings, 2004; philips & schneider, 1993), and severe learning disabilities (m urphy, 2003). recently, m odels for effective m anagem ent o f isb with people who have sexual behav­ iour control issues have been described in the literature (b ezeau et al., 2004; lawrie & jillings, 2004). isb was identified as a serious professional issue in speech-language pathology by w illiam s et al. (1999) who investi­ gated the experiences o f isb by mem bers o f the n ew zealand speech-language t herapists’ a ssociation as well as third and fourth year students studying speech-language pathology. w il­ liam s et al. did not include audiologists in their study. m ore than tw o-thirds o f the students and alm ost 85% o f the qualified speech language pathologists reported at least one experience o f isb. the current study was designed to determine the experiences o f isb directed to slp/as in south a frica because variables that impinge on professional practice m ay differ in different geo-political con­ texts. m eth o d o lo g y aim s the prim ary aim o f this study was to investigate the extent and nature o f the experience o f isb b y qualified speech-language pathologists and audiologists (slp/a) as well as students studying speech-language pathology and/or audiology in south africa. the study aim ed to determ ine (a) the extent o f slp/as experience with isb; (b) the type o f is b encountered; (c) the sources o f isb in their w orkplace (d) slp/as perceptions o f the consequences o f their isb experiences, (e) the strategies em ployed by slp/as to m anage their isb experiences, and (f) slp/as perceptions with regard to their preparedness to deal with isb in the professional setting. research design this study took the form o f a postal survey research design because the aim was to partially replicate the study conducted by w illiam s et a l.( l999) in n ew zealand who adapted a question­ naire developed b y m com as et al. (1993). a survey design was appropriate for this study because it allowed the researchers to access a large sample. the anonym ity assured by the design gave the respondents m ore opportunity to answer honestly questions w hich related to very personal inform ation on a sensitive topic (babbie, 1995). one o f the disadvantages o f survey research is that the answers m ay be unreliable as a result o f m isunderstanding o f the question o r the irrelevance o f the question to the respon­ dents. furtherm ore, the researcher has little control over when and w here the questionnaire is answered. the respondents m ay leave questions unanswered, not understand questions or not answ er the questionnaire in privacy. however, the survey had been used successfully by m ccom as et al. (1993) as well as w illiam s et al. (1999). e thical considerations the researchers were granted perm ission to conduct this research by the ethics com m ittee (humanities) o f the u niversity o f the w itwatersrand. b ecause o f the sensitive nature o f some o f the questions that could evoke difficulties for the respondents, a list o f available counselling services was attached to the question­ naire. included in the inform ation letter that was attached to each questionnaire was an assurance o f confidentiality and anonym ity o f the participants. the participants were inform ed that participa­ tion in this study was voluntary and that their com pletion o f the d ie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) inappropriate sexual behaviours experienced by speech-language pathologists and audiologists in south africa 7 questionnaire was interpreted as their consent to participate in the study. they were asked to avoid including any identifying infor­ m ation in the questionnaire, and were asked to mail the responses in a sealed envelope directly to the researchers. participants participant selection criteria participants were required to be slp/as w orking in south a frica or slp/a students at south african universities. the students were required to be in their third or fourth year o f study because they w ould have had contact w ith clinical w ork by this level o f study. sam pling q ualified slp/as. a m ailing list o f all registered slp/as was obtained through the south a frican speech language and hearing a ssociation (saslha). systematic sam pling was used to gain a representative sample from the larger population. this requires less time, and is cheaper and more practical than simple random sampling. h owever, it is not as accurate as simple ran­ dom sam pling and it m ay result in a cyclical order o f sampling, which m ay result in a biased sam ple (babbie, 1995). a lthough this m ethod o f sam pling results in a sample o f convenience, the researchers were intent on surveying slp/as nationally. the questionnaire was m ailed to 78 qualified slp/as. student slp/as. the questionnaire was distributed to 262 students in the third and fourth year o f study at all south african universities that train slp/as. r esponse rate q ualified slp/as. according to babbie (1995), a 50% response rate for postal surveys allows for adequate analysis and provides an accurate representation o f the subjects. fifty-six questionnaires were returned by qualified slp/as, w hich yielded a response rate o f 71.7%. this high response rate implies that the respondents had an interest in this topic and alludes to the im por­ tance o f the experience o f isb in clinical practice in south africa. a ll o f the responses received were from female slp/as. it is po s­ sible that no male slp/as received a questionnaire as a result o f the sam pling procedure w hich did n ot take into account the few male slp/as in south africa. the lack o f inform ation with re ­ gard to the experiences o f male slp/as in south a frica is an im portant lim itation o f this study, given the num ber o f studies that have dem onstrated that male health care workers experience isb (broedel-zaugg et al., 1999; m adison & m inichiello, 2001; m ccom as et al., 1993). ; student slp/as. sixty-two questionnaires were returned by student slp/as w hich yields a response rate o f 23.6 %. all the universities that were included in the survey were represented in the sample. the low return rate renders the data unrepresenta­ tive o f the student population and therefore leads to difficulties in the interpretation o f the results. it is possible that the students had not been exposed to any o f the behaviours targeted in this study. alternatively, perhaps the poor response rate was due to the fact that the survey was conducted at a particular time o f year in the university tim etable which included exam inations followed b y a vacation period. the researchers acknowledge that this poor return rate is a lim itation o f the study, and that the generalisability o f the results to the general student population is restricted. as w ith the qualified slp/as all the respondents were female and thus the results can only be generalised to the female population o f student slp/as. i d escription o f participants fifty-six qualified slp/as and 62 student slp/as partici­ pated in the study. the dem ographic data o f the qualified slp/as are sum m arised in table 1. the qualified slp/as ranged in age from 20-65 years, and in experience from new graduates to clini­ cians with more than 20 years experience. the participants w orked in a variety o f settings. the sam pling m ethod m ight have been inappropriate to some extent in that w ork contexts were n ot necessarily represented fairly. for example, only one respondent worked in a university setting. fifty-seven o f the student slp/as ranged in age from 20-24 years and five were betw een 26 and 30 years o f age. sixteen students were in third year and 46 students w ere in fourth year. table 1: dem ographic d ata o f q ualified slp/as a ge in years n 2 0 -2 5 5 26-30 27 3 1 5 0 19 50+ 5 y ears in practice n 0-5 18 6 1 0 12 1 1 -2 0 11 2 0 + 15 place o f w ork n university 5 school 18 hospital 16 private practice 2 0 rehabilitation unit 5 procedure q uestionnaire design w illiam s et al. (1999) adapted a questionnaire developed by m ccom as et al. (1993) who investigated isb directed at physiotherapists in canada. n either m ccomas et al. nor w illiams et al. published their questionnaires, and thus the present re­ searchers developed a questionnaire based on the reports o f w il­ liams et al. and m ccom as et al. w orkplace settings w ere defined as they exist in south a frica as well as to accom m odate audiolo­ gists who were not surveyed by w illiam s et al. additionally, the participants were asked to indicate whether they perceived the behaviour to be sym ptom atic o f the clien t’s condition. hence, the current study was a partial replication o f w illiam s et al. the re­ searchers acknow ledge the lim itations im plied by a lack o f pilot­ ing the questionnaire w hich was the result o f time pressure to com plete the study. although the researchers w ere aware that english is not the home language o f all slp/as in the country, the questionnaire was produced in english only and home language was n ot a con­ sideration in the participant selection criteria. the reasons for this lim itation were the time and financial constraints im posed by the study. h owever, m ost o f the professional literature that is con­ sulted by slp/as is in english, and therefore slp/as are pre­ sum ed to have a fairly good reading com prehension level o f e ng­ lish. o f note is that five com pleted questionnaires had comments written in afrikaans in the open-ended sections. the researchers the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 8 karen levin and loren traub acknowledge that the language o f the questionnaire m ight have lim ited the num ber and/or quality o f the responses. the inform ation letter that was attached to the question­ naire em phasised that the questionnaire pertained to the experi­ ence o f isb in the workplace only. the questionnaire was pre­ sented with the topic o f the research as ‘the experience o f inap­ propriate sexual b ehaviour in the w orkplace’, which served to rem ind the respondents that the survey was focussed on the workplace. the questionnaire consisted o f a total o f five sections, w hich included both open and closed type questions. n on exhaustive categories were added to ensure that all possible re­ sponses were catered for (babbie, 1995). this took the form o f “other” and “add any com m ents” . the first section consisted o f a set o f questions to deter­ m ine the biographical data o f the respondents. the information that was sought included gender, age, years o f experience or year o f study (for students) and place o f work. no inform ation was sought with regard to variables such as hom e language, cultural background, gender identity, race, or ethnicity because o f the scope o f the study. h owever, this information m ight have con­ tributed to the depth o f the analyses and the inform ation that was obtained. the second section consisted o f a set o f questions to determ ine the types o f isb experienced by the participants. these took the form o f yes/no questions. this section was based on the questions published by w illiam s et al. (1999), w hich de­ scribed and classified isb as mild, moderate, o r severe. the third section consisted o f a set o f questions to determ ine from whom the isb was experienced as well as in w hich contexts it was ex­ perienced. the fourth section consisted o f a set o f open-ended questions to determ ine the effects on the participants as a result o f the experience o f isb. the final section consisted o f a set o f closed-ended and open-ended questions to determ ine the various ways in which isb was m anaged and what the respondents felt about training at an undergraduate level. one closed-ended ques­ tion asked respondents w hether they had know ledge about the law in south a frica regarding isb. respondents were invited to add any extra comments. (see appendix for copy o f the question­ naire). d istribution o f q uestionnaire q ualified slp/as. m ost o f the questionnaires were sent by mail. tw enty questionnaires were hand delivered to the par­ ticipants to reduce the postage costs. to ensure the participants’ confidentiality, the com pleted questionnaires were n ot personally collected by the researchers but were returned by mail. a ll ques­ tionnaires included a stamped, addressed return envelope. student slp/as. questionnaires, along with the covering letters, were distributed to the slp/a students at the u niversity o f the w itw atersrand in their private m ailing boxes at the univer­ sity by the researchers. the students were asked in the inform a­ tion letter that was attached to the questionnaire to place their sealed and com pleted questionnaires in a box allocated for this purpose. to ensure anonymity, they were asked to place the com pleted questionnaire in the envelope with which they had been provided and to seal it. for the students at the other univer­ sities, each head o f departm ent was m ailed a batch o f question­ naires, with a letter requesting that the questionnaires be distrib­ uted to all third and fourth year students. the inform ation letter to all students requested that the questionnaires should be m ailed directly to the researchers in the stam ped return envelope which was attached to the questionnaire. the questionnaire was analysed using descriptive statistics to summarise, organise and describe the data. frequency counts were com pleted for each section o f the questionnaire, resulting in descriptive data that accounted for the frequency o f occurrence o f isb, the effects o f the isb, the contexts in which isb was experi­ enced as well as the m anagem ent strategies that were employed. a broad thematic analysis was com pleted on the open-ended re­ sponses in line with the aims o f the study and the themes that were identified, as well as personal stories, were analysed to com ple­ m ent the quantitative data (pidgeon & henwood, 1996). m ccom as et al. (1993) categorised the severity o f isb which resulted in their division o f the questions that they posed to their respondents into mild, m oderate and severe categories. because the questions that were em ployed in the current study were almost identical to those used by m ccom as et al., severity o f the isb was analysed as per their categories. the results o f the qualified slp/as and student slp/as were analysed separately because o f their possible differ­ ences with regard to age as well as clinical experience. reliability and validity in order to control for the threat o f researcher bias and to enhance the reliability o f the analyses, a. second rater was em ­ ployed to analyse the responses (babbie, 1995). the rater, a quali­ fied slp/a, was fam iliar with the research topic, as well as the w illiam s et al. (1999) study. the rater was given access to the raw data first and subsequently read the researchers’ analyses o f the data. m ost o f the data was analysed quantitatively and was there­ fore indisputable. h ow ever the qualitative data, generated by the open-ended questions and com m ents that were m ade by the re­ spondents, were open to interpreter bias (babbie, 1995). further­ more, the qualitative data w ere used to support the interpretation o f the quantitative data. in order to control for researcher bias the rater and the researchers discussed how best to represent the re­ sults and w rite up the findings (pidgeon & henwood, 1996). results the results are presented in five sections as per the aim s o f the study. < i severity and frequency o f the experience o f isb i the experiences o f isb were categorised as mild, m oderate or severe as per m ccom as et al. (1993). the data revealed that 55% o f the qualified slp/as and 45% o f the student slp/as had experienced isb at least once in their professional lives. tlie types and severity o f isb experiences are reflected in table 2. m ild isb was experienced by 55% o f the qualified slp/as and 42% o f the student slp/as. w illiam s et al. (1999) reported that m ild isbs were underreported because the slps did not con­ sider m ild behaviours to be offensive. it is possible that under­ reporting occurred in the present study. m oderate isb was experi­ enced by 41% o f the qualified slp/as and 16% o f the student slp/as. severe isb was reported by 26% o f the qualified slp/as and 8% o f the student slp/as. the classification o f severity is an arbitrary one and in a w ay minimises the experiences in the m ild category and draws attention to those in the severe category. the questionnaire did not ask the respondents to rate the severity; perhaps this is a lim itation o f the categorisation strategy em ployed by m ccom as et al. a nalysis o f data die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) inappropriate sexual behaviours experienced by speech-language pathologists and audiologists in south africa table 2: r espondents’ r eports o f isb e xperiences (in %) q uestion q ualified student m ild isb have suggestive stories ever been told to you? has an offensive jo k e ever been told to you? have flattering rem arks about your appearance that m ade you uncom fortable ever been made? have you been stared at in a w ay that made you uncom fortable? h ave you ever been asked for a date? has anyone suggested that you ‘get together’ for a drink? m oderate isb have crude sexual rem arks been m ade to you? have any attem pts been m ade to draw you into a discussion about your private sexual matters? have you ever been propositioned (e.g. asked you to have sex with him or her)? have you ever been deliberately touched (laid a hand on your bare arm or put an arm around your shoul­ ders) in a w ay that m ade you feel uncom fortable? severe isb have you had genitals exposed to you? have you had breasts exposed to you? has anyone ever attem pted to fondle you (stroked your leg or neck, touched your breasts)? has anyone ever made forceful attempts to touch you? h as anyone ever made forceful attempts to fondle you? has anyone ever made forceful attempts to kiss you? has anyone ever m ade forceful attempts to grab you? has anyone ever m ade attem pts to have sexual intercourse with you? has anyone ever used force to have intercourse with you? 7.1 8.9 12.5 14.2 14.2 3.5 7.1 5.3 1.7 16 5.3 0 5.3 1.7 1.7 3.5 3.5 3.5 1.7 12.9 29 32.2 17.7 6.6 0 3.2 6.4 0 11.2 1.6 3.2 3.2 3.2 0 3.2 1.6 3.2 3.2 the effects o f isb the respondents experienced a variety o f physical and em o­ tional reactions to their experiences o f isb as well as consequences in the work-setting. m ost o f the consequences that were reported were psychological, although the respondents experienced physical sym p­ toms as well. some o f the consequences that were reported to have affected w ork perform ance were' serious, such as the resignation o f four slp/as from their jobs. the; study did n ot determ ine whether the effects were long-lasting or not. i the frequency and nature o f these effects are presented in table 3. j sources o f isb the findings show ed that 35% o f the qualified slp/a s and 30% o f the student slp/as reported that isb was predom inantly di­ rected by clients, and o f these respondents, 28% o f the qualified slp/ a s and 30% o f the student slp/as perceived that the perpetrators m ight be expected to have sexual control difficulties due to their un­ derlying pathology. o ther sources o f isb included the parents, spouses, and children o f the clients. p atient’s caregivers were reported to be the perpetrators o f isb by 4.8% o f the student slp/as. isb was reported to have been perpetrated by em ployers and colleagues in senior positions by 8.9% o f the qualified slp/as, and 5.3% o f the qualified slp/as had experiences o f severe isb directed at them by hospital porters. n one o f the student slp/as reported having experi­ enced isb from faculty w orkers or supervisors. table 3: r espondents reported effects o f the experience o f isb effects o f isb qualified slp/as student slp/as w ork perform ance d istraction 8.9 12.9 d ecreased m otivation 5.4 3 resignation 7.1 physical stress 7.1 1insom nia fatigue 3.6 1 e m otional stress nervousness 17.9 17.7 . doubt 7.1 1.6 g uilt 10.7 3.2 em barrassm ent 0 14.5 s e lf consciousness 10.7 3.2 a voidance 8.9 19.4 loss o f confidence 1.7 1.6 feeling uncom fortable 14.3 22.6 feeling anxious 7.1 3.2 the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 10 karen levin and loren traub i<?r was e x p e r i e n c e d by the respondents in a variety o f i«j t t i n e s isb was e x p e r i e n c e d by 0.8% o f the student slp/ a s t n d 20% o f the q u a l i f i e d slp/as in hospital settings. sim i­ larly isb was e x p e r i e n c e d by 3.2% o f the qualified slp/as and 3 6% o f the student slp/as in rehabilitation centres. isb was e x p e r i e n c e d in nursing homes by 4.8% o f the qualified slp/as and 5.3% o f the student slp/as. isb experience was reported in school settings by 8.1% o f the qualified slp/as and 1.7% o f the student slp/a, all o f whom experienced isb from their colleagues. u nfortunately, the questionnaire did n ot determ ine whether the perpetrators were superiors in the w ork-setting, although two o f the respondents who described their experiences in the open section o f the ques­ tionnaire reported that their isb experiences were directed by their school principals. isb was experienced in private practice by 16.1% o f the qualified slp/as and b y 1.6% o f the qualified slp/as in the industrial audiology setting, and was experienced in speech language and/or hearing clinics attached to universities by 40% o f the qualified slp/a s and 17% o f the student slp/as. isb was experienced in rural settings by 4.8% o f the student slp/as. the managem ent o f isb m ethods o f dealing with isb the experience o f isb was ignored b y 30.3% o f the qualified slp/s and 38.7% o f the student slp/as. one o f the strategies that were em ployed by 19.6% o f the qualified slp/as was to discuss the isb w ith their clients, and 14.2% discussed the experience o f isb with their supervisors. similarly, 11.2% o f the student slp/as chose to talk to their clinical tutors about the isb, and 6.4% o f the student slp/as spoke to the clients. call­ ing on co-professionals to manage isb within the team o f health­ care professionals was em ployed by 3.6% o f the qualified slp/ as. term ination o f intervention with a client as a result o f isb was reported by 1.7% o f the qualified slp/as. these findings are similar to those o f w illiam s et al. (1999). perceptions with regard to preparedness to deal with isb in the p ro fessio n a l settin g . a lthough 37% o f the qualified slp/as and 37% o f the student slp/as felt that they had handled the situation effec­ tively, 82% o f the qualified slp/as and 58% o f the student slp/ as believed that specific training in the m anagem ent o f isb w ould be beneficial. m oreover, 64% o f the qualified slp/as and 34% o f the student slp/as indicated that they had not re­ ceived any training at any point in their careers with reference to the m anagem ent o f isb in clinical practice. this finding was also evident in w illiam s et al. (1999) and m ccom as et al. (1993), who found sim ilar trends with regard to slps and physiotherapists. the respondents identified specific topics that they felt w ould be beneficial to include in a training programme. q uali­ fied slp/as and student slp/as suggested similar topics such as assertiveness training, how to define isb, deal with isb, respond effectively to isb, as well as procedures to report isb. in addi­ tion, 85% o f the qualified slp/as and 58% o f the student slp/ as indicated that they were not familiar with the south african laws pertaining to isb, and suggested that this aspect be in­ cluded in training courses. w ork settings in which isb was ex p erien ced the results o f this study show ed that slp/as in south af­ rica are vulnerable to the experience o f isb in their w ork settings. the high response rate, as well as the results o f the study, con­ firms that the experience o f isb in the workplace is a serious pro­ fessional issue. at least h a lf o f the respondents reported having experienced isb at least once, and although the m ajority o f these experiences were mild, m any o f the respondents had had to deal with the experience o f severe isb. the findings are sim ilar to those established by w illiam s et al. (1999) although qualified slp/as in south a frica reported more experiences with severe isb. m ccom as et al. (1993) reported that h a lf o f their qualified physiotherapy respondents and a third o f their students had ex­ perienced severe isb. despite the difficulties with explaining why the experience o f severe isb by the respondents was common, the results o f the current study reveal that slp/as in south a frica are vulnerable to severe personal harm, the m ost serious o f which com prised violent encounters with co-workers, but also extended to experiences o f isb that the respondents did not know how to resolve and w hich led to rem arkable life changes such as chang­ ing career direction and interest. the value o f exam ining the experience o f isb as a profes­ sional issue is warranted by the finding that the m ajority o f isb was directed b y clients, their caregivers, or fam ily members. m any theorists have attem pted to provide a classification or a typology o f the person who directs isb. for example, m adison & m inichiello (2001) described harassers in terms such as ‘the con­ fidante’, ‘one-of-the-gang’, and ‘the b u lly ’ am ong m any others, w hich describe the wide variety o f behaviours as w ell as inten­ tions that characterise harassers. however, clients and their care­ givers cannot be viewed as m em bers o f the typical w orkplace and therefore the typology o f harassers does not necessarily translate into healthcare settings; indeed, the healthcare context is not nec­ essarily com parable to com m ercial w ork environm ents, nor is there a set o f features that defines healthcare contexts. however, clients who present with com m unication disorders and/or their caregivers can be viewed, in m any cases, as vulnerable and fragile m em bers within the healthcare context. w hile transference is a well recognised notion in the psychology o f healthcare (hall, 2001) the behaviours that result from transference and counter transference have not traditionally been labelled as harassm ent although they fit the definitions o f harassment provided by the south african labour relations act (departm ent o f labour, 1995) as well as that o f the eeo c (1980). in m ost cases, the ex­ perience o f isb by the client is blam ed on the healthcare profes­ sio n al’s breach o f the fiduciary relationship (hall, 2001). simi­ larly, the person with a com m unication disorder who finds the slp to be em pathic and sensitive to his o r her em otional needs m ight not be cognisant o f the need, or have the skills, to maintain and lim it their relationship boundaries such as role, space, lan­ guage or physical contact (hall, 2001). in a sim ilar vein, it is well recognised that people who have sustained head injuries have problem s with inhibition and the control over their sexual behav­ iours (bezeau, et al., 2004). in line with this, isb was identified as a symptom o f the clien t’s condition by most o f the respondents in the current study. the south a frican a ct (d epartm ent o f labour, 1995) specifies that the perpetrator is aware o f his or her behav­ iour and knows that it could be unacceptable, but there is ample evidence that clients who have sustained head injuries have im­ paired executive function and reduced awareness and are thus not able to judge the appropriacy o f their behaviours (lawrie and jillings, 2004). it is unfortunate that the questionnaire did not dediscussio n die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) inappropriate sexual behaviours experienced by speech-language pathologists and audiologists in south africa 11 termine the type and severity o f the disorders with which the cli­ ents presented. the m ajority o f respondents in the current study did not perceive the behaviours o f clients and/or their caregivers as unac­ ceptable or as harassing, although at least 10% o f respondents classified their client’s behaviours as harassment. this finding mirrors those o f m ccom as et al. (1993) and w illiam s et al. (1999). w illiam s et al. posited that to label isb as harassm ent implies that the healthcare professional has to apportion blam e on the perpetrator, but victims o f harassm ent prefer to apportion blame to them selves or to circumstances. in the present study, the consequences did n ot necessarily determine whether the respondents perceived isb to be harass­ ment. one o f the respondents resigned from her jo b because she could not cope with isb directed by clients in a nursing home, but she did not perceive the isb to be harassment. rothstein (1993) suggested that healthcare professionals m ight be desensitised to the brutality o f sexual harassm ent b y the extent o f violence and related sexual behaviours which are prevalent in m odem society, and that the abuse m ight begin in student years. he wrote, “perhaps shock gives w ay to coping in a perversion o f the right o f passage into professionalism ” (p. 739). rothstein did not take into account the nature o f people who elect to enter the profession o f slp/a, nor the behaviours that are taught to slp/as as they de­ velop into clinicians. although the literature is very sparse in the field o f education o f slp/as, there is some evidence that suggests that slp/as are taught to be accepting, unconditional, and em pathic (goldberg, 1997) but these attributes, i f not moderated, could result in slp/as being susceptible to abuse. further re ­ search m ay help to explain w hy slp/as did not view isb directed by clients to be harassm ent even i f the consequences were severe. n ot unlike the participants in the study conducted by w il­ liams et al. (1999), respondents in the current study reported the experience o f isb directed by co-workers and colleagues. w il­ liams et al. reported that m ore severe isb was directed by clients but the current study did not concur. the m ost serious report in the current study was a violent encounter o f a qualified slp/a with a hospital porter who hurt the; respondent physically although actual sexual penetration did not occur. n one o f the student s l p /^ s reported having experienced isb from faculty workers or supervisors which was som ewhat unexpected, given the figures that' have dem onstrated that isb in educational settings rem ains a significant problem on campuses across the globe (recupero et al!, 2004). it is possible that the poor response rate o f the student slp/as had an effect on the re­ sults. o n the other hand, it is possible that in a predom inantly female profession taught predom inantly by women, that the chances o f isb are greatly reduced. in contrast, isb was experienced by the respondents in this study in m ost w ork settings. kam el and h ajjar (2004) described the intense burden for nursing home staff created by isb, which was true for the slp/as in the current study. the hospital envi­ ronm ent is a significantly risky environm ent as dem onstrated by the results o f the current study which is supported by the large body o f research on isb that is experienced by healthcare profes­ sionals in hospital settings (phillips and schneider, 1993; r ecu­ pero et al., 2004). in private practice, slp/as m ay w ork alone or with a lim ited num ber o f other slp/as which leaves them rela­ tively pow erless and an easy target for an isb experience. addi­ tionally, slp/as m ay meet with a client’s parent or caregiver in the early m ornings or evening, times which once again provide an opportunity for isb to take place. | slp/as also w ork often behind closed doors, a situation that creates vulnerability for them. the experience o f isb in rural settings is an important finding when considering the fairly recently introduced period o f community service for new ly qualified south african slp/as, m any o f w hom are placed in rural settings. in the main, new graduates are young, inexperienced in the w ork place, are in the earliest stages o f independence and their dissociation from their clinical super­ visors in the university setting. these variables place the new graduate at risk for isb. finally, the silence and isolation o f audi­ ology test environm ents places audiologists at risk for isb. m ost o f the respondents adopted the least assertive strate­ gies to m anage the experience o f isb, which was sim ilar to the findings o f w illiam s et al. (1999) and by researchers in allied healthcare professions (schneider et al., 1997). for example, sandberg, m cn iel and b inder (2002) found that although nurses experience very high levels o f quid pro quo sexual and hostile environm ent harassm ent, very few cases had been reported by the nurses that they studied. m ccom as et al. (1993) discussed re ­ search that has indicated that healthcare practitioners m ay not be prepared for the experience o f isb which then contributes to its reoccurrence. ferns (2006) related her findings with regard to the actions taken by nurses to manage isb to their gender, their ex­ posure to violence in society, the status o f their profession, as well as beaurocratic structures. the slp/as in the current study chose to ignore isb m uch o f the time, but also chose to confront their clients and/or caregivers, or their colleagues. in line with the findings b y w illiam s et al. (1999), m ost o f the respondents per­ ceived their actions to have been successful although most o f them indicated that in-service training as well as training at the undergraduate levels w ould be beneficial. students reacted in sim ilar ways to qualified slp/as although they reported that they avoided confrontation with the perpetrator o f the isb. the experience o f isb is a serious issue, and yet not one respondent was aw are o f the laws in south a frica pertaining to sexual harassm ent. south a frica is one o f few countries to pro­ hibit sexual harassm ent directly through legislation. the labour relations a ct o f 1995, section 203 (1) includes the ‘code o f g ood practice on the h andling o f sexual harassm ent c ases’ (d epartm ent o f labour, 1995). it is incum bent on slp/as who are employers, m anagers, or employees, to be cognizant o f the requirem ents o f the act. f o r example, the a ct specifies that m anagers are responsible for ensuring that the workplace is free o f sexual discrimination; that policy statements on sexual harass­ m ent should be com m unicated effectively to all employees; that employers should develop clear procedures to deal with sexual harassm ent; and that em ployers and em ployer organisations should include the issue o f sexual harassm ent in their orientation, education and training program m es o f employees. conclusio n this study o f south african slp/as revealed that more than h a lf o f the respondents had some degree o f experience with isb directed b y their clients or their caregivers, and colleagues in their professional lives. m ost experiences were m ild to moderate, although severe experiences were reported, and the consequences o f the isb experiences ranged from feeling mild anxiety to re­ signing from the job. isb was experienced in a num ber o f work settings including schools, hospitals, private practices and univer­ sities. in general, the respondents adopted the m ost non confrontational and least assertive strategies to manage their ex­ periences o f isb. m ost o f the time, the respondents did not per­ ceive isb to be o f a harassing nature, even those experiences that resulted in significant consequences. the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 12 karen levin and loren traub the experience of isb is an infringem ent o f hum an rights, no matter if the recipient perceives the isb not to be harassing. m ore than h a lf o f the respondents in the current study reported that they had experienced isb, and although most of them did not label the experiences as harassm ent, they reported a range of con­ sequences w hich could be classified as hostile environm ent h a r­ assm ent and to a lesser extent, quid pro quo harassm ent. if the ex­ perience o f isb is acknowledged to be a professional issue, then it warrants a num ber o f questions to be researched and debated. slp/as need to exam ine the im plications of the high incidence o f isb, the perceptions of acceptability o f isb, and the m anagem ent strategies that are used. for example, rothstein (1993) asked whether professionals are in fact doing their clients an injustice by allow ing their clients to behave inappropriately. r othstein’s ques­ tion is ju st one o f the questions that challenge professional m ores in slp/a. t his is not a case of apportioning blam e because isb is an extrem ely com plex phenom enon, but could rather be viewed as responsible appraisal o f th e values and the nature o f the healthcare professions and its professionals to determ ine w hether existing practices either encourage or do little to discourage isb. the p ro ­ fessionals m ight question whether they com m unicate effectively and explicitly to their clients and their caregivers as well as col­ leagues apropos the boundaries that they wish to maintain. t he professions m ight need to determ ine w hether clinical interven­ tions recognise and m anage adequately transference and counter­ transference, and furtherm ore, whether isb is prom oted by pro­ fessional behaviours that are considered by healthcare profession­ als to be appropriate and integral to optim al program m e efficacy. the professionals may investigate the personality traits of those attracted to the professions and might determ ine at which point these traits and/or behaviours become abused. r esearch m ight address issues surrounding intim acy in the professions. for exam ­ ple, slp/as engage with em otional intim acy by virtue of their involvem ent with communication. in addition, slp/as connect intim ately on a physical basis such as in their m anagem ent o f cli­ ents in acute care settings, in areas such as dysphagia, and in vari­ ous aspects of audiology w here the audiologist is required to be in close physical proxim ity to the client. a ssertiveness is one o f the traits that deter harassm ent. slp/as m ight reflect on whether they assert them selves as a profession and as professionals. the successful m anagem ent of isb is dependent on the cooperation o f stakeholders at a num ber of levels when consider­ ing that sexual harassm ent is an individual hum an rights issue, a professional issue, as well as a societal issue (rothstein, 1993). t he current study showed that 80% o f th e respondents agreed that slp/as in south a frica should receive training in the m anage­ m ent o f isb at the undergraduate level. the results of this study, not unlike those o f w illiam et al. (1999), suggest that, for various reasons, slp/as who participated in this study m ay have allowed isb to occur. t hey w ere not necessarily passive recipients of isb in that m any o f them did take action and most o f them expressed that they would recom m end both under-graduate preparation for and post-graduate training in m anaging isb. furtherm ore, the study revealed that slp/as did not perceive isb in the clinical setting to be harassm ent although the consequences were often harmful. the results of the study highlighted that the experience o f isb by slp/as is com m on in south africa and that know ledge and skills are lacking with regard to the prevention of isb as well as the recognition and m anagem ent o f isb. hence, the responsi­ bility of training institutions, as well as em ploying bodies, is inar guable; however, individuals have to take responsibility for their own safety and w ell-being and have to be proactive in seeking inform ation including their legal rights and responsibilities. t he vast literature on sexual harassm ent in the workplace has shown the com plexity and pervasiveness of this world-wide phenom enon. sexual harassm ent results from interactions be­ tween gender, race, and class on the power dynamics at the organ­ isational, socio-cultural, interpersonal or individual levels. the current study did not collect race data and only women were sur­ veyed. in addition, lim ited inform ation was obtained with regard to the organisational structure of the work settings, the socio­ cultural status o f the respondents, and their location in organisa­ tional hierarchies. however, the results of this study showed clearly the high frequency o f isb experiences by slp/as in south a frica which calls for further research. it is recom m ended that further studies investigate isb experiences within a broader fram ew ork taking cognisance particularly o f the convolutions of south african history in w hich discrim ination and power laid the foundations for current socially constructed systems. as in other geo-political contexts, social interactions, including isb, have been carefully bred within race-gender constructions in south af­ rica. future research which will inform professionals with regard to the prevention, recognition and m anagem ent o f isb m ight ad­ dress how the socially constructed systems within w hich slp/as function are organized around characteristics such as race, gender, class, ethnicity, and sexuality, and how these identity systems in ­ teract and m utually shape and reinforce each other. in addition, research might exam ine the nature of pow er in the workplace o f the slp/a and its role in m aintaining structures of inequality that affect individual and group identities and experiences. as professions develop and change, so they need to exam ­ ine their professional and ethical foundations. t he study revealed that isb is a common experience o f slp/as in south africa. it is therefore incum bent on educational institutions, professional bod­ ies, and individuals to recognise that the experience of isb is a significant issue in professional practice in south africa, and to put into place m echanism s for research and analysis, reflections on professional practice, and advocacy and protection of slp/as in the workplace. r eferences i babbie, e. 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(1999). inappropriate sexual behaviour experienced by speech-language therapists. in­ ternational journal o f language and communication disorders, 34, 99-111. the south african journal of. communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 14 karen levin and loren traub appendix (adapted from m ccom as et al., 1993 and w illiam s et al., 1999) d em ographic inform ation g e n d e r_________________________________________________________________ age __________________ years that you have been practicing as a slp/a ____________________________ for students, year o f s tu d y _________________________________________________ place where you w ork (hospital, university, private practice, other: please specify) questionnaire: the experience of inappropriate sexual behaviour in the workplace please indicate by m eans o f an asterisk * if you feel that this behaviour is a sym ptom o f the clien t’s condition (e.g. brain injury, m ental illness etc.) has this behav­ iour been experi­ enced by you? (please circle) do you feel that this behaviour is harassment? (please circle) have suggestive stories ever been told to you? y es/no y es/no has an offensive jo k e ever been told to you? yes/no y es/no have flattering rem arks about your appearance that m ade you uncom fortable been made? y es/no yes/no have you been stared at in a w ay that m ade you uncom fortable? yes/no y es/no have you ever been asked for a date? yes/no yes/no h as anyone ever suggested that you ‘get together’ for a drink? y es/no y es/no have crude rem arks been m ade to you? yes/no y es/no h ave any attem pts been m ade to draw you into a discussion about your private sexual matters? yes/no yes/no have you ever been propositioned (e.g. asked you to have sex with him or her)? yes/no yes/no h ave you ever been deliberately touched (e.g. laid a hand on your bare arm or put an arm around your shoulders) in a w ay that made you feel uncom fortable? yes/no yes/no h ave you had genitals exposed to you? yes/no yes/no h ave you had breasts exposed to you? yes/no yes/no h as anyone attem pted to fondle you (e.g. stroked your leg or neck, or touched your breasts)? yes/no yes/no has anyone ever made forceful attempts to fondle you? yes/no yes/no h as anyone ever made forceful attempts to kiss you? yes/no yes/no has anyone ever made forceful attempts to grab you? y es/no y e$/n o h as anyone ever made attem pts to have sexual intercourse with you? yes/no yes/no has anyone ever used force to have intercourse with you? y es/no yes/no from which individuals have you experienced inappropriate sexual behaviour? (please tick) client c lient’s caregiver c lient’s spouse c lien t's parent boss or employer o ther (please specify) in which w ork contexts have you experienced inappropriate sexual behaviour? (please tick) school u niversity h ospital private practice n ursing home other (please specify) d ie suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) inappropriate sexual behaviours experienced by speech-language pathologists and audiologists in south africa 15 please describe the effects that the experience o f inappropriate sexual behaviour had on you. did it affect your w ork perform ­ ance, decrease your w ork productivity, m otivation , time off, requests to change w ork placem ent etc.? did it increase your physical stress (e.g. insom nia, headaches, w eight gain, fatigue, pains and digestive problems)? did it increase your em otional stress (e.g. guilt, depression, nervousness)? o ther effects? please describe how you responded to the inappropriate sexual behaviour (please tick). d id you: ignore the behaviour tell your supervisor discuss it with your client provide an ultim atum o ther (please specify) ________________________________________________________________ do you feel that you handled the situation effectively? do you feel that you w ere adequately trained during your undergraduate degree on how to handle such behaviours? do you feel that it w ould benefit future therapists if training was provided by the university at the undergraduate level? ________________ i_____________________________________________________________________ i i f so, w h at topics do you feel should be discussed? do you know the south african laws regarding inappropriate sexual b eh a v io u r? ___________________________________ please try to estim ate how many experiences o f inappropriate sexual behaviours you have had in your professional life please provide any comments thank y o u f o r p a rticipatin g in the study. your involvem ent is appreciated. i the south african journal o f communication disorders, vol. 53, 2006 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) iscan; yes, i can now the power is in your hands. introducing isc.an scan. view. send. right from your office. it w ill change the wav vou work, in no tim e at all. w ith iscan, the first in-office im pression scanner, you can scan im pressions rig ht at yo ur desk. view 3-d im ages onscreen. and o rd er o nline w ith just a click. in fact, total integration w ith o ur o nline ordering system lets you com plete a fu lly validated order in m inutes. a ll w ith unparalleled d ig ita l accuracy. n ow y o u 'll have more flexibility. more p roductivity. and m ore satisfied patients. iscan. it s im p ly changes everything. siemens for details and availability, call (011) 886 6734 w w w .hearin g-siem ens.com /i-scan r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.hearing-siemens.com/i-scan abstract background methods results discussion conclusion acknowledgements references appendix 1 about the author(s) tasneem f. karani department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa anniah mupawose department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation karani, t.f., & mupawose, a. (2020). a descriptive analysis of assessment measures on the effectiveness of a comprehensive stuttering intervention approach: a single case study. south african journal of communication disorders, 67(1), a648. https://doi.org/10.4102/sajcd.v67i1.648 original research a descriptive analysis of assessment measures on the effectiveness of a comprehensive stuttering intervention approach: a single case study tasneem f. karani, anniah mupawose received: 15 july 2019; accepted: 24 feb. 2020; published: 29 apr. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: for effective client outcomes, stuttering assessment and intervention approaches need to be aligned. this encompasses using assessment and intervention approaches that address the three multidimensional constructs of stuttering, namely core behaviours, secondary behaviours and negative feelings and attitudes. objective: the study aimed to explore whether multiple assessment measures could be used to describe the effectiveness of a comprehensive stuttering intervention approach, undergirded by the international classification of functioning, disability and health (icf) framework. method: a single-subject case design was employed with one male adult who stutters. data was collected by administering the stuttering severity instrument-fourth edition (ssi-4) and overall assessment of the speaker’s experience of stuttering-adults (oases-a) at three testing periods (pre-intervention, immediately post-intervention and 7 months post-intervention), and a semi-structured interview schedule immediately post-intervention. descriptive statistics was used to analyse the ssi-4 and oases-a, and thematic analysis was conducted to evaluate the participant’s interview schedule responses. results: the participant’s total scores, impact scores and severity ratings of both the ssi-4 and oases decreased across the three testing periods. the main theme of effectiveness of the comprehensive stuttering intervention to reduce aspects of disability emerged from the participant’s responses. conclusion: evaluation of the results from the assessment measures revealed that the comprehensive stuttering intervention approach was effective in reducing the participant’s core behaviours, secondary behaviours and negative feelings and attitudes. assessment and management of fluency disorders should promote a client-specific multidimensional approach that extends beyond the core behaviours and secondary behaviours, by addressing the underlying social and emotional facets of fluency disorders. keywords: stuttering intervention; person who stutters; case study; icf; comprehensive approach; ssi-4; oases; speech-language pathologist; south africa. background the purpose of this article was to demonstrate the effectiveness of a comprehensive stuttering intervention approach on an adult male participant who stutters based on multiple assessment measures. according to bleek et al. (2012), stuttering is a multidimensional construct characterised by: (1) overt core behaviours, such as involuntary repetitions of syllables and words, prolongations of the sound(s) during the flow of speech and blocks of airflow, and (2) covert behaviours, a variety of behavioural, physiological, cognitive and emotional reactions to the speech disruptions. in essence, stuttering can be reduced to consisting of three components: (1) core speech behaviours, (2) secondary behaviours and (3) negative feelings and attitudes (guitar, 2013). the interaction of these three components of stuttering often leads to debilitating effects. a person who stutters (pws) may experience a variety of emotional challenges, which include sadness, shame, guilt, anger, resentment and fear (yaruss, 2010; yaruss & quesal, 2006). this often leads to feelings of negative self-regard, such as self-blame and an overall sense of negative self-worth. these attitudes may cause further negative behavioural challenges such as avoidance of stuttering instances through secondary behaviours and avoidance of participation in activities that entail any communicative interactions (yaruss, 2010; bleek et al., 2012). there are numerous studies that have explored the efficacy of using comprehensive intervention approaches that are intensive and based on the immersion principle (blomgren, 2007; kroll, 2010). the immersion principle is constructed on the premise that learning occurs when it is ‘intense’ and for shorter periods (i.e. ‘immersive’) (blomgren, 2010). however, additional information is required to determine the success of non-intensive, traditional-based therapy that occurs over longer periods of time (i.e. weeks or months). thus, this study set out to determine the efficacy of using a ‘whole-person’ stuttering approach on a south african multilingual male adult who stutters. the whole-person approach and comprehensive stuttering approach will be used interchangeably in this article. the effectiveness of this approach was determined using assessment measures that evaluate the three multidimensional constructs of stuttering. the low incidence of fluency disorders recorded results in the collection of evidence-based outcomes being limited. in addition, individuals who stutter tend to also be heterogeneous because of their varied lived experiences. thus, assessment measures and intervention approaches need to be adaptable to address the specific needs of a pws. to that end, a single case study design was utilised in this study because it is known to be most appropriate to describe the effects of intervention. moreover, single case designs consider the individual’s responses to a specific approach and are best suited to determine treatment efficacy as they closely resemble clinical practice (millard, nicholas, & cook, 2008; byun, hitchcock, & ferron, 2017). as clinicians, it is vital to begin documenting the value of intervention approaches used to manage stuttering. documenting stuttering interventions lends credence to what clinicians do and informs clinical practice. additionally, the services provided need to subscribe to the principles of evidence-based practice as it is consistent with clinicians’ oath to client welfare (hpcsa, 2019). we argue that the effectiveness of stuttering interventions should be determined based on the assessment measure(s) that can evaluate the three multidimensional constructs of stuttering, namely core behaviours, secondary behaviours and negative feelings and attitudes. indeed there has been a long-standing practice among clinicians to utilise assessment measures that assess stuttering frequency to determine the effectiveness of stuttering intervention (yaruss, 2010). however, stuttering frequency is only a measure of one construct of stuttering (i.e. core behaviours). if comprehensive intervention approaches are implemented, then it follows that the assessment measures should evaluate the multidimensional nature of stuttering and also measure the generalisability of therapy techniques post-intervention (blumgart, tran, yaruss, & craig, 2012). arguably, south africans have even a greater responsibility to provide services that redress the injustices of apartheid. an example of such an injustice was the inequitable access of speech-language pathology services to the majority of the black south african population who presented with communication disorders (moonsamy, mupawose, seedat, mophosho, & pillay, 2017). thus, as south african clinicians, it would behove us to continue to transform and use social justice as a value base for providing services that are attuned to the needs of the variety of populations that we service (kathard & pillay, 2013). since south africa consists of a rich diversity of people, languages and cultures, it is necessary for south african clinicians to be knowledgeable about and be willing to provide culturally and linguistically appropriate services (mdlalo, flack, & joubert, 2016, 2019). with regards to using stuttering intervention that is comprehensive or involves the whole-person approach, it allows clinicians to be responsive to the heterogeneity (race, culture and language, among other factors) of the individuals who stutter that we serve. the comprehensive stuttering approach addresses all three components of stuttering – core speech behaviours, secondary behaviours and negative feelings and attitudes. it utilises a combination of the fluency shaping (fs) and stuttering modification (sm) strategies and addresses the feelings and attitudes associated with stuttering. fluency shaping is a behaviour modification approach that includes techniques such as easy onset, prolongations or stretching, and light articulatory contacts. fluency shaping mainly targets changing the client’s overall speech pattern to obtain stutter-free speech, with little emphasis placed on the associated feelings and attitudes towards the stutter (logan, 2015). conversely, sm consists of four levels, namely identification, desensitisation, modification and stabilisation (shapiro, 2011). stuttering modification does not demand a pws to obtain stutter-free speech. rather, sm seeks to assist a pws to learn to control or modify his or her stuttering and is coupled with addressing negative attitudes and feelings via cognitive restructuring or reframing to further improve fluency (blomgren, 2010). given the differences in the goals of the fs and sm approaches, along with the individual experiences of each pws, the comprehensive or whole-person stuttering approach affords clinicians and the pws greater flexibility to achieve success. in addition, such an approach is designed to increase the pws’ feelings of confidence, subsequently improving his or her chances for effective participation in society (shapiro, 2011). the assessment measures and therapeutic outcomes of this intervention study were undergirded by the tenets of the international classification of functioning, disability and health (icf), more commonly referred to as the icf framework, as proposed by the world health organisation (who, 2001). the icf provides a multidimensional framework through which a disorder such as stuttering can be described and evaluated to determine its impact on activity limitation and participation restriction (who, 2001; yaruss & quesal, 2006). according to the icf, stuttering can be considered disabling due to its impairment on the body structures and functions (speech and respiratory musculature), its limitation on daily activities in relation to communication, and its restriction on participation in various contexts (logan, 2015; who, 2001). the use of the icf terminology provides clinician with a common language for clinical assessment and intervention of stuttering (logan, 2015). the notion of assessing and evaluating intervention outcomes is being highlighted increasingly in the management of fluency disorders (blomgren, 2010; blumgart et al., 2012; shapiro, 2011). methods objectives to describe the scores obtained on the stuttering severity instrument-fourth edition (ssi-4) with regards to its influence on core behaviours and secondary behaviours (impairments in body structures and functions), pre-intervention, immediately post-intervention and 7 months post-intervention. to describe the scores obtained on the overall assessment of the speaker’s experience of stuttering-adults (oases-a) with regards to its influence on activity limitations, participation restrictions and contextual factors (personal and environmental), pre-intervention, immediately post-intervention and 7 months post-intervention. to describe the participant’s perspective on the influence of the comprehensive stuttering intervention on core behaviours, secondary behaviours and activity and participation in various contexts, immediately post-intervention. research design the study utilised a single-subject case design that included an intervention phase and an assessment phase, at three time periods (pre-intervention, immediately post-intervention and 7 months post-intervention) (figure 1). figure 1: four phases involved in data collection. participant description the pws was a client at the university of witwatersrand speech and hearing clinic. he was a 48-year-old, married, black male with two children. he worked as a steward for a well-established company. the pws reported that the onset of his stutter was at 4 years old. he had previously received speech therapy during his primary school years, however, he reported receiving no benefit. data collection the instruments utilised at the three testing periods included the ssi-4 and the oases-a. the ssi-4 provides a rating of the severity of the stuttering. this tool contains three sections: frequency (speaking and/or reading), duration and physical concomitants. the value of each section is matched to a task or scale score. to obtain the total score of the ssi-4 and the percentile ranking for the stuttering severity, the three sections need to be tallied up (riley, 2009). the oases-a assesses the impact of stuttering on an individual’s life. the oases includes four sections – section i: general information; section ii: your reactions to stuttering; section iii: communication in daily situations; and section iv: quality of life. for each section, an impact score is calculated and an impact rating is assigned. thereafter, the impact scores of all four sections are tallied up to provide a total impact score (yaruss & quesal, 2006). in phase 3, following the administration of the ssi-4 and oases-a, a semi-structured interview schedule was conducted. it was used to obtain a broader description of the participant’s experience of stuttering and the comprehensive stuttering intervention approach, and to supplement information obtained from the ssi-4 and the oases. questions were generated based on the literature review and the oases. a section of the interview schedule explored the effects of the stuttering approach on the participant’s core behaviours, secondary behaviours and feelings and attitudes (appendix 1). study procedure phase 2: comprehensive stuttering intervention therapy was conducted at the university speech and hearing clinic by a student clinician. the student clinician completed a course in fluency disorders. individual therapy sessions occurred once a week for a duration of an hour for 7 months (february–may and july–september). therapy was terminated at the end of the academic year. the student was supervised for at least 15 min per session by a speech-language pathologist (slp) registered with the health professions council of south africa. the expected outcomes of the therapeutic process were aligned with the domains of the icf framework to minimise the debilitating effects of stuttering by addressing the impairments of body structures and functions, activity limitations and participation restrictions (who, 2001). table 1 depicts the expected outcomes associated with the components of the icf framework. table 1: expected outcomes associated with components of the international classification of functioning, disability and health (icf) framework. a typical session of the comprehensive stuttering approach included fs techniques, sm principles and activities to address the feelings and attitudes associated with stuttering, in order to limit activity limitations and participation restrictions (guitar, 2013; shapiro, 2011). the sessions included the following: the therapist began the session by obtaining a 100-word conversational speech sample, which was recorded with the participant’s permission. the conversational sample was recorded at the beginning of each session in order to measure the percentage of syllables stuttered (ss) to allow for monitoring of therapeutic outcomes. the conversational sample was elicited by the client providing a recap of what was targeted in the previous session and how it was experienced by the client. therapy would then proceed as per the icf outcomes. therapy session always targeted the three components of stuttering: core behaviours, secondary behaviours and negative feelings and attitude, depending on client’s progress and requests. focusing on the client’s acceptance of stuttering. data analysis responses obtained from the ssi-4 and oases were analysed using descriptive statistics, namely total scores, impact scores and severity ratings. thematic analysis was utilised to analyse the participant’s responses from the semi-structured interview schedule. ethical consideration ethical clearance certificate (sta-2016-40) was obtained from the non-medical research ethics committee of the university of the witwatersrand, johannesburg. results results will be presented according to the three objectives of the study. objective 1: core behaviours and secondary behaviours (body structures and functions) the severity of the participant’s stutter will be presented according to the total score of the frequency, duration and physical concomitants (secondary behaviours) at three testing periods (figure 2). figure 2: total scores of the stuttering severity instrument-fourth edition: frequency, duration, physical concomitants and severity rating at three testing periods. figure 2 reveals that the participant’s total scores of frequency decreased across the three testing periods. the severity rating also reduced from pre-intervention to post-intervention and then stabilised by third assessment interval. however, the duration (average severity of three longest stuttering events) (0.5 s–0.9 s) remained the same over the three testing periods. objective 2: activity limitations, participation restrictions and contextual factors the results of the oases (total impact scores and severity) is presented in figure 3. figure 3: participant’s overall assessment of the speaker’s experience of stuttering results (total impact scores and severity ratings) at three testing periods. the impact scores show a trend of scores decreasing, suggesting an improvement, from moderate/severe (mod/sev) to moderate (mod) across the three testing periods. for section i (general information), the participant demonstrated improved knowledge regarding the speech processes which occur when he stutters (from not at all, to very when assessed immediately post-intervention, to extremely by the third testing). in section ii (your reactions), the participant reported that he does not express himself as he pleases and uses filler words often, and this frequency was stated in all three testing periods. in addition, over the three testing periods, the feelings associated with stuttering (e.g. helpless, frustrated and anxious) reduced from feeling it often to sometimes. for section iii (communications in daily situations), the participant expressed that pre-intervention, he found it extremely difficult to participate in social events. however, immediately post-intervention and 7 months post-intervention, he rated it as not very difficult-somewhat difficult. for section iv (quality of life), the participant changed his perspective of how much stuttering interfered with his educational opportunities from a lot to a little, to not at all, pre-intervention, immediately post-intervention and 7 months post-intervention respectively. with regards to negative attitudes and feelings, the participant rated his self-acceptance on the therapist’s self-designed scale. he rated his self-acceptance from 1.5/5 to 4/5 over the course of the 7 months of intervention. his scores in the first half of therapy were variable depending on his communication experiences. however, scores started stabilising as therapy continued. objective 3: participant’s perspective on the influence of the comprehensive stuttering intervention approach on core behaviours, secondary behaviours and activity and participation in various contexts the participant’s perspective on the influence of the intervention implemented is depicted in table 2. table 2: themes with their respective quotes from the participant on the influence of the comprehensive stuttering approach. discussion the discussion will elaborate on the three objectives of the study and their respective findings. core behaviours and secondary behaviours (body structures and functions) the results revealed that the total scores and severity ratings of the ssi-4 decreased with the comprehensive stuttering approach over the three testing periods. as the ssi-4 assesses the core and secondary behaviours, the scores suggest that using a combination of fs and sm techniques improved the client’s ability to speak fluently. similar findings of improved speech fluency were reported by euler, lange, schroeder and neumann (2014). in their study, the 88 participants reported that fs, sm or a combination of fs and sm was more effective than other stuttering interventions that targeted core and/or secondary behaviours. this could be because fs and sm techniques are both effective at addressing the physiological and structural (impairment of the oral and respiratory musculature) aspects of stuttering that either predispose, precipitate or perpetuate the stutter (shapiro, 2011). however, it has been documented that there is a tendency for a pws to default or relapse to old habits that facilitated the stuttering moments in the long-term, if no booster individual or group therapy is provided (blomgren, 2010; logan, 2015). this is due to the lack of contingencies placed on behaviour modification techniques (i.e. fs) used to increase speech fluency (baxter et al., 2016). activity limitations, participation restrictions and contextual factors the results of the oases showed a reduction in impact scores and severity ratings across the three testing periods. this demonstrated reduced activity limitations and increased communication participation. similar findings were noted by koedoot, bouwmans, franken and stolk (2011), who compared the oases scores of two groups of individuals who stutter. the groups included individuals who received stuttering therapy and those who did not receive stuttering therapy. there was a marked reduction in the impact scores and severity ratings of the individuals who received stuttering therapy. the oases is seen as a good indicator of therapy outcomes more than that of stuttering severity related to frequency (yaruss, 2010). stuttering severity is more subject to variability as a pws may use various strategies depending on the speaking situation and how the pws has experienced the day or week (constantino, leslie, quesal, & yaruss, 2016). at times, there is a difference between how a pws performs in the therapy room with a fluent-inducing stimuli (i.e. slp), versus how they perform in other contexts such as work, social and home settings (constantino et al., 2016). with regard to attitudes and feelings, the results of the oases indicated that the participant’s feelings and attitudes and overall participation improved. this was because of his improved overall psychological well-being, as depicted in figure 3, by his oases total impact scores and severity ratings across the three testing periods. these results are similar to those found by klompas and ross (2004) and blumgart et al. (2012), which indicated from participants’ self-reports how stuttering intervention had improved their overall sense of well-being. participant’s perspective effectiveness of the comprehensive stuttering intervention approach the participant stated that the comprehensive stuttering approach positively influenced his life by addressing the ‘whole person’. approaches that address the three facets of stuttering, core behaviours, secondary behaviours and feelings and attitudes, generally have good outcomes (blomgren, 2010; blomgren et al., 2005; guitar, 2013; logan, 2015). core behaviours and secondary behaviours (body structures and functions) the participant stated that the comprehensive intervention approach assisted in ‘improving his speech’. however, despite the improvement in the core behaviours and secondary behaviours noted in this study and in the literature, there is still an issue of relapse (plexico, manning, & dilollo, 2005). thus, it is important to evaluate therapeutic outcomes following the completion of therapy. the participant showed no relapse in therapy outcomes 7 months post-intervention. however, in the interview he brought to light the need for ongoing therapy to maintain the gains attained. literature suggests that following the termination of therapy, booster individual and group therapy should be conducted to reduce the chances of relapse (blomgren, 2010; logan, 2015). a pws may present with relapse following therapy termination (i.e. increase in speech dysfluencies), because ‘speaking normally’ may be too effortful of an outcome to achieve long-term (logan, 2015). hence, it is important to ascertain the goals of therapy with the pws. activity limitations, participation restrictions and personal factors the participant reported the positive influence of the comprehensive intervention approach on his feelings and attitudes and overall participation. he expressed: ‘knowledge of stuttering has help[ed] me to accept myself and have confidence that i can face the future without fear’. the fact that the participant mentioned that he learnt to accept himself with the stutter is important to note as it indicates that he started acknowledging that stuttering does not define him as a person. it is not uncommon for a pws to state that stuttering intervention was successful, even if there was minimal reduction in speech function (blomgren, 2010, logan, 2015). for some individuals who stutter, reducing activity limitations and participation restrictions can be achieved by improved self-acceptance. if a pws has self-acceptance and self-confidence, they are willing to take on risks and engage in activities that they would never have otherwise. conclusion this study highlighted the importance of using a variety of assessment measures in evaluating and monitoring all three components of stuttering (i.e. core behaviours, secondary behaviours and feelings and attitudes) (craig, blumgart & tran, 2009; yaruss, 2010). the ssi-4 and oases-a provided the quantitative measures, and the interview schedule showcased the individual qualitative gains. this allowed the client-specific nature of stuttering disorders to be highlighted and addressed. furthermore, the comprehensive stuttering approach employed was effective in addressing all three components of stuttering. this was depicted by the reduced percentage of ss post-intervention, reduced impact scores on the oases and the improved self-acceptance ratings. assessment and management of fluency disorders should practice a comprehensive or integrated approach that addresses the multidimensional nature of stuttering. speech-language pathologists should draw on the theoretical framework of the icf to provide therapy that extend beyond the core and secondary behaviours, and targets the underlying social and emotional facets of fluency disorders. the icf framework provides clinicians and researchers with a more comprehensive perspective of the stuttering experience by considering aspects of ‘activity’ and ‘participation’ in therapy, while remediating the overt behaviours and improving covert behaviours (who, 2001). current findings should be interpreted within the identified methodological limitations. firstly, as this study employed a single case study design with a participant with a mild stutter, generalisability of the results to the wider population of individuals who stutter and those with greater severity ratings may be limited. however, despite the afore stated limitation, single case designs are more advantageous for use in the efficacy of interventions in clinical practice. secondly, in critically transcribing the interview schedule, the identified theme and sub-themes may have been influenced by the researchers’ interpretations of the participant’s responses. however, the researcher utilised member checks. this was used to ensure clarity of the participant’s responses (lodico, spaulding, & voegtle, 2010). despite these stated limitations, the findings have significant implications on the practice of speech-language pathology, by affording clinicians with a more holistic view of a pws, drawing on the icf framework. in addition, this study provides clinicians with an overview of the structure and outcomes of the comprehensive intervention approach that can be utilised in the management of individuals who stutter. it is recommended that further research expands on this study by increasing the sample size to include more individuals who stutter from various ethnic groups and ages. further research should investigate the effectiveness of other approaches, being cognisant of intended areas of change and potential barriers to achieving long-term outcomes (baxter et al., 2016). it is recommended that future studies include communication partners of individuals who stutter to obtain a broader perspective on the influence of stuttering and the efficacy of the comprehensive stuttering intervention approach on the core behaviours, secondary behaviours and feelings and attitudes, and overall participation of the pws. acknowledgements the authors would like to thank the participant of this study for sacrificing his time and for sharing his story. competing interests the authors have declared that no competing interest exists. authors’ contributions t.f.k. and a.m. co-conceptualised the idea of the research design and methodology. t.f.k. collected data for the study and analysed the data with assistance from a.m. both authors contributed equally to the drafting of the manuscript. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data will be made available upon request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references baxter, s., johnson, m., blank, l., cantrell, a., brumfitt, s., enderby, p., … goyder, e. (2016). non-pharmacological treatments for stuttering in children and adults: a systematic review and evaluation of clinical effectiveness, and exploration of barriers to successful outcomes. health technology assessment, 20(2), 1–302. bleek, b., reuter, m., yaruss, j.s., cook, s., faber, j., & montag, c. (2012). relationships between personality characteristics of people who stutter and the impact of stuttering on everyday life. journal of fluency disorders, 37(4), 325–333. https://doi.org/10.1016/j.jfludis.2012.07.003 blomgren, m. (2007). stuttering treatment outcomes measurement: assessing above and below the surface. perspectives on fluency and fluency disorders, 17(3), 19–23. https://doi.org/10.1044/ffd17.3.19 blomgren, m., roy, n., callister, t., & merrill, r.m. (2005). intensive stuttering modification therapy. journal of speech, language, and hearing research, 48(3), 509–23. blomgren, m. (2010). stuttering treatment for adults: an update on contemporary approaches. in j.s. yaruss (ed.), semin speech lang (vol. 31, no. 4, pp. 272–282). new york, ny: thieme medical publishers, inc. blumgart, e., tran, y., yaruss, j.s., & craig, a. (2012). australian normative data for the overall assessment of the speaker’s experience of stuttering. journal of fluency disorders, 37(2), 83–90. https://doi.org/10.1016/j.jfludis.2011.12.002 byun, t.m., hitchcock, e.r., & ferron, j. (2017). masked visual analysis: minimizing type i error in visually guided single-case design for communication disorders. journal of speech, language, and hearing research, 60(6), 1455–1466. https://doi.org/10.1044/2017_jslhr-s-16-0344 constantino, c.d., leslie, p., quesal, r.w., & yaruss, j.s. (2016). a preliminary investigation of daily variability of stuttering in adults. journal of communication disorders, 60, 39–50. https://doi.org/10.1016/j.jcomdis.2016.02.001 craig, a., blumgart, e., & tran, y. (2009). the impact of stuttering on the quality of life in adults who stutter. journal of fluency disorders, 34(2), 61–71. euler, h.a., lange, b.p., schroeder, s., & neumann, k. (2014). the effectiveness of stuttering treatments in germany. journal of fluency disorders, 39, 1–11. https://doi.org/10.1016/j.jfludis.2014.01.002 guitar, b. (2013). stuttering. an integrated approach to its nature and treatment (3rd edn.). philadelphia, pa: lippincott williams & wilkins. health professions council of south africa (hpcsa). (2019). guidelines for practice in a culturally and linguistically diverse south africa. retrieved august 7, 2017 from https://www.hpcsa.co.za/uploads/slh/guidelines%20for%20practice%20in%20a%20culturally%20and%20linguistically%20divers---.pdf kathard, h., & pillay, m. (2013). promoting change through political consciousness: a south african speech-language pathology response to the world report on disability. international journal of speech-language pathology, 15(1), 84–89. https://doi.org/10.3109/17549507.2012.757803 klompas, m., & ross, e. (2004). life experiences of people who stutter, and the perceived impact of stuttering on quality of life: personal accounts of south african individuals. journal of fluency disorders, 29(4), 275–305. https://doi.org/10.1016/j.jfludis.2004.10.001 koedoot, c., bouwmans, c., franken, m., & stolk, e. (2011). quality of life in adults who stutter. journal of communication disorders, 44(4), 429–443. https://doi.org/10.1016/j.jcomdis.2011.02.002 kroll, r. (2010). the fluency plus program: an integration of fluency shaping and cognitive restructuring procedures for adolescents and adults who stutter. in b. guitar & r.j. mccauley (eds.), treatment of stuttering: established and emerging interventions (pp. 277–311). baltimore, md: lippincott williams & wilkins. lodico, m.g., spaulding, d.t., & voegtle, k.h. (2010). methods in educational research from theory to practice. san francisco, ca: jossey-bass. logan, k.j. (2015). fluency disorders. san diego, ca: plural publishing. mdlalo, t., flack, p., & joubert, r. (2016). are south african speech-language therapists adequately equipped to assess english additional language (eal) speakers who are from an indigenous linguistic and cultural background? a profile and exploration of the current situation. south african journal of communication disorders, 63(1), 1–5. https://doi.org/10.4102/sajcd.v63i1.130 mdlalo, t., flack, p.s., & joubert, r.w. (2019). the cat on a hot tin roof? critical considerations in multilingual language assessments. the south african journal of communication disorders, 66(1), 610. millard, s.k., nicholas, a., & cook, f. (2008). is parent-child interaction therapy effective in reducing stuttering? journal of speech, language and hearing research, 51(3), 636–650. https://doi.org/10.1044/1092-4388(2008/046) moonsamy, s., mupawose, a., seedat, j., mophosho, m., & pillay, d. (2017). speech-language pathology and audiology in south africa: reflections on transformation in professional training and practice since the end of apartheid. perspectives of the asha special interest groups, 2(17), 30–41. https://doi.org/10.1044/persp2.sig17.30 plexico, l., manning, w.h., & dilollo, a. (2005). a phenomenological understanding of successful stuttering management. journal of fluency disorders, 30(1), 1–22. https://doi.org/10.1016/j.jfludis.2004.12.001 riley, g.d. (2009). ssi-4: stuttering severity instrument. austin, tx: pro-ed. shapiro, d. (2011). stuttering intervention. austin, tx: pro-ed. world health organization (who). (2001). the international classification of functioning, disability & health. geneva: world health organization. yaruss, j.s. (2010). assessing quality of life in stuttering treatment outcomes research. journal of fluency disorders, 35(3), 190–202. https://doi.org/10.1016/j.jfludis.2010.05.010 yaruss, j.s., & quesal, r.w. (2006). overall assessment of the speaker’s experience of stuttering (oases): documenting multiple outcomes in stuttering treatment. journal of fluency disorders, 31(2), 90–115. https://doi.org/10.1016/j.jfludis.2006.02.002 appendix 1 interview schedule (participant [pws]) demographic information: age: gender: ethnic group: marital status: educational level: age of onset of stutter: 1. activities and participation 1.1. education: describe your schooling experience. has stuttering affected your schooling experience? prompts: impact of stuttering, if applicable: schooling attendance, performance and overall academic success relationships and reactions: teachers, peers and classmates university or further studies: career choices, performance 1.2. social life (friends and community): describe your social life. has stuttering had any influence on your communication and social life? prompts: impact of stuttering, if applicable reactions: friends and community community and culture: view of stuttering and its causes interactions, participation and functioning in society (e.g. engaging in social activities-neighbours, church, making small talk at parties, telling jokes) 1.3. family: describe your relationship with your family members, spouse and children. was it affected by your stutter? prompts: family history of stuttering family relationship: parents, grandparents, siblings and extended family marriage: decision to marry, courtship before marriage partner relationship: partner power dynamics, children and your ability to discipline your children 1.4. employment: describe your employment experiences. has stuttering had any influence on it? prompts: current employment: job description, performance, satisfaction and promotions work relationships: employer and co-workers 2. feelings and attitudes 2.1 describe your feelings and attitude growing up with a stutter 2.2 after receiving stuttering therapy, have these feelings and attitude about your stutter remained the same or changed, and in what way? 3. speech therapy: 3.1 tell me about your journey of speech therapy over the years and in particular the current speech therapy prompts: previous speech therapy: when, duration, approach used, view on the approach current speech therapy: approach used and view on it. has therapy affected you in any way? if so, how? discuss its influence, if any, on stuttering behaviours, feelings and attitudes, and overall participation in everyday activities and life roles. some comments on aspects of the methodology for the measurement of stuttering lesley caplan ba(sp & htherapy) ma (clin psych) (witwatersrand) tara, the h. moross centre, private bag x7 randburg, 2125 abstract the measurement of stuttering in a conversational context presents certain problems that are difficult to resolve despite a vast iteraure on the appeal of stuttering behaviour. this view stems from problems encountered in a study designed toguagte effects of conflict generated in a family context, on the stuttering behaviour of the child. conflict was defined as a social process and was induced for the purpose of this study, by a standardised communication conflict sitltion. theresults ofthes^ywee :°j t t z ' h™ever-!t. n o t c 0 n d u d e d t h a t bering and conflict are not related. rather, there are difficulties in aspeclsof^hemethodn^ f γ ^ ™ ^s paper is concerned irfft some aspects of the methodology for the measurement of stuttering that seem inadequate for research that has as its data conversational interaction in a family context. some alternative strategies are suggested. opsomming die diagnose van hakkelin η gespreksituasie lewer baie probleme op alhoewel daar baie literatuur oor die diagnose van hakt £ ? \ ! e m ^ " v°re 8 e k ° m ί η 'n ^ w a t 0 n t w e r ? i s 0 m d i e ** ™ konflik in die gesins-konteks op die hakkelgedrag van die kind te evalueer. konflik is as η sosiale proses gedefinieer en is toegepas by wyse van η standard kommunikatiewe konfliksituasie. die resultate van die studie was nie betekenisvol nie, maar daar kan nye^elei word zhzel en konflik nie verwant is me. daar is eerder struikelblokke om die verwantskap te evalueer. een so η struikelblok is dat die meting van hakkelgedrag problematies is. hierdie artikel lig metingsmetodes vir navorsing uit wat onvanpas is vir die verwerking van data verkry uit gespreksinteraksie in η gesinskonteks. alternatiewe metodes geniet aandag. the quality of most research on stuttering behaviour is disappointing and despite attempts to enhance the standard of inquiry and a plea for greater empirical sufficiency,22 many deficiencies are apparent. little, if any, attention has been given in recent years to measurement conventions such as severity ratings and frequency counts, which constitute the bedrock of assessment of stuttering, or to the nature and size of the speech sample for this procedure.20 in the main, reading passages and short samples of self-formulated speech have been the data for appraisal. it seems that certain assumptions that were made in the early years to permit "an operationally meaningful appraisal of stuttering"5 have been accepted and utilised with little questioning of their 'truth'. in the light of this, the measurement of stuttering in a conversational context presents certain problems that are difficult to resolve despite a vast literature on the methodology for the assessment of stuttering. it may well be that the measurement strategies that have been developed, mask information about stuttering, particularly when applied to conversational data. this view stems from difficulties encountered in a study on the relationship between conflict in the family and stuttering jehaviour. \ brief synopsis of the study follows. methodology the experimental sample consisted of 20 families, each comprising biological mother and father and their stuttering child. the stuttering children were considered to qualify as track 1 stutterers,21 were all boys ranging in age from 8 to 12 years, coping adequately at school and from middle class, englishspeaking south african backgrounds. j the standardised communication conflict situation devised by blakar3 was used to generate conflict and to elicit the stuttering behaviour of the child in the family context. briefly, the task comprises a map of a complex network of streets through a city centre, a copy of which is given to each of two (or more) participants. one of the participants has two routes marked on the map; a short simple route and a longer more complicated one. the other participant/s has/have a map on which no routes are marked. the object of the exercise is for the participant/s with the routes to explain to the other/s how to get through the city to certain endpoints via the predetermined routes. the short simple route permits a baseline measure of behaviour, in this instance stuttering, while the longer route, by virtue of a small discrepancy between the maps is impossible to complete successfully, so generating conflictual interaction. s> sasha 1983 the south african journal of communication disorders, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the measurement of stuttering the design accommodates a parent-child constellation (a triad) and permits the ascribing of roles to the participants as either 'explainers' or 'followers'. whatever the role assigned however, the standardised communication conflict situation constitutes a complex linguistic task demanding flexibility and ensuring a high degree of communicative responsibility for all the participants. it is intrinsically a highly propositional task, which means that language is being used intentionally and intellectually to convey meaning and information.5·8 such a task demands precise accurate verbal communication. this limits the ability of the participants to circumlocute, and so in the case of the stuttering child avoid those words that could precipitate dysfluency. the influence of conflict in the context of the family, on stuttering behaviour of the children, was examined by rating the severity of stuttering and by frequency counts of all dysfluencies as well as frequency of repetitions and prolongations the so-called "core features" of stuttering.21 a 7-point rating scale was used for the severity of stuttering, while frequency was determined by making verbatim transcripts of the data, analysing the dysfluencies using the iowa categories of dysfluency11·12 and computing ratios in relation to the total verbal output. as the standardised communication conflict situation generates conversational interaction, the data for the measurement of stuttering of the child in each family triad comprises a sample of discourse of variable length. there is limited experimentation directed towards ascertaining what constitutes an adequate speech sample representative of the stutterer's speech, and clearly contextual or situational aspects deserve consideration as well as the length of the sample for assessment. the tradition in research on stuttering has been to use oral reading material as the data, but with the recognition that this is not representative of the communication behaviour of the stutterer, various 'spontaneous speech' tasks have been introduced.12 these however, tend to elicit monologues rather than conversational discourse. in general a 3-minute sample of such speech has been considered adequate. however, the preferred method has remained the use of reading material, dictated by the experimental control afforded over certain linguistic parameters considered relevant to stuttering. the paucity of work on so-called spontaneous speech and even less so on speech in a conversational context, is not surprising in the face of difficulties in holding constant, not only the relevant dimensions of the speech output,16·17 but in determining which of a gamut of factors both incidental and manipulated may be operating. for the purpose of the present study, the conversational data was segmented into observational periods of 5 minutes and for each family two, and in some instances, three such samples were used for the analysis of stuttering behaviour in the face conflict in the family. for the baseline measures of stuttermg the entire interaction on the short simple route of the task was used.;> the design of the study was therefore, of the pretest-posttest typeanalyses of covariance were performed to determine the statistical significance of the findings. >esuid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 30, 1983 31 results the results of the study were not significant, however, it was not concluded that conflict and stuttering are not related. rather there are difficulties in establishing this relationship. one of the difficulties concerns the definition and measurement of stuttering. the complexities of the definitional problem will not be considered here. while the current study followed accepted conventions for appraisal, what does differ fundamentally from 'standard' procedures is the manner in which the speech sample was elicited. it seems that the somewhat global measures used in this study, and most often in research on stuttering, may be inadequate for assessing dysfluency in a verbal interchange in a family context. a more detailed consideration of these issues follows. discussion clearly the conversational discourse elicited by the standardised communication conflict situation is a far cry from the reading material and 'monologues' of self-formulated speech traditionally used in clinical and research settings with stutterers. conversational discourse involves an individual's ability to use language not only in terms of its grammatical structure, but also as regards its appropriateness in relation to a variety of different contexts.10 conversation taxes capacities to integrate "linguistic, cognitive and social rules",14 so that communication is realized, not only through the verbal repertoire, but through an awareness of a "complex matrix of referential codes",18 some linguistic and paralinguistic, and some of which are socioculturally determined. with this in mind, it is clear that conversational speech in a communication context is a network of multiple factors, individual and social, and any analysis of such discourse must take cognisance of them. a parameter of discourse that can be used to illustrate the complexity of such an approach concerns features like the postponements, hesitations and retrials that often accompany attempts to formulate and transmit meaningful information. the absence of criteria to define fluency remains a stumbling block in any consideration of dysfluency7 and given conversational discourse as the data for an investigation of stuttering behaviour, even the apparently simple procedure of counting the number of words that constitute the total verbal output of an individual poses a major problem. decisions have to be made as to whether words form an integral part of the meaningful context12 or not and this is not a clear cut task, given the revisions and changes that characterise conversational speech. in considering the measurement of stuttering once again, it could be argued that frequency counts, while constituting a substantial component of the degree of stuttering, are not sufficient.2 other factors, such as the duration of stuttering moments and the tension and struggle behaviour accompanying speech, also contribute to assessment. these features do manifest in the overall tempo of speech and a consideration of the rate of utterance is important in a comprehensive appraisal of stuttering behaviour. as regards the rate of utterance dalton & hardcastle7 recommend a measure of the number of syllables uttered in each second in a sequence of speech for the rate of utterance. there are, of course, difficulties in measuring such short segments accurately with a stop watch. specr ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 trographically, this may be possible, but a certain expertise and skill is required in using the equipment and analysing the results. more specifically with reference to the present study it becomes difficult to find uninterrupted sequences of speech of sufficient duration in a conversational interchange to permit accurate timing without expensive electronic aids. in summary, stuttering is clearly a variable disorder, and the moment of stuttering is a non-unitary combination of a variety of behaviours.6 that some undefined incident evaluated as stuttering has been considered to occur, remains the hallmark of measurement in clinical and experimental work in the field.6 the problems in definition and the inextricably related difficulties in delineating operations to measure stuttering as well as the reliability of these measures are not insubstantial in the light of such complexity and the absence of clearlydefined parameters, recourse to 'consistency' has been the only option in the measurement of stuttering. certain rules are specified to ensure this consistency and so permit some modicum of control.12 it is the present writer's contention however, that these measures are not necessarily capturing the problem behaviour and that given the intrinsic fluctuant, almost mercurial nature of stuttering, frequency counts and severity ratings are too global. it seems that a single rating of severity on a 3-minute sample of speech, or frequency counts of moments of stuttering expressed as a ratio of the total verbal output yield measures of 'mean' stuttering. little can be said on the basis of these and most of the contemporary measurement conventions, about change in stuttering behaviour. in the light of the variability of stuttering, a phenomenon repeatedly noted but subjected to surprisingly little systematic research,1 attention to the 'extremities' of stuttering behaviour and attempts to track changes moment by moment could represent a more refined way of measuring stuttering than the averaging out of stuttering behaviour as a function of the measurement procedures. it may be the very imposition of consistency on the essential variability of stuttering behaviour that may be masking our knowledge of the disorder. having presented a critique of some aspects of the methodology of the measurement of stuttering, it remains to propose some alternative strategies and some rudimentary ideas. it seems that the criticism of research on stuttering for "an insufficiency of empiricism"22 has in fact been perceived and the plea for a more rigorous methodology has been headed by some investigators. a consideration of some of this work follows. there seems to be a need not only for meticulous research into the phenomenology21 or overt manifestations of stuttering behaviour,15 but as already suggested, to track stuttering and relate it, moment by moment, to both language use and its social context.24 the conceptual framework for the study of communication by blakar4 and his associates, and the model for and understanding of stuttering by wertheim,23 seem to provide some guidelines for this endeavour. an attempt will be made to integrate some recent research in stuttering with these views. lesley caplan the writings of kaasin and bjerkan13 reveal both a recognition of the subtle interplay between the individual and the multiplicity of situational and social variants in the act of communication4 and some attempt to encompass these aspects in research. they point out that two issues have been the concern of research on situational variability and stuttering. these are first, the actual situations in which speech takes place, and second, the locus of stuttering in the speech sequence with actual words being attributed with properties that could precipitate the moment of stuttering. berkjan13 coined the concept "critical word" to characterise "the relationship between a word and a situation" so that it is not the word itself that carries the complex of precipitating factors but the word "with reference to the dialogue". similarly, the work of wertheim23·24·25 has relevance. her exposition of the learning of word-meaning and its importance in interpersonal relationships, particularly in the context of the family, not only complements the concept of critical words,13 but extends this to permit a definition of critical situations or "sensitive 'stutterogenic' areas for a given individual".24 given this, recourse to the work of blakar4 and his associates reveals an approach to the analysis of verbal interaction on an utterance level and a categorisation system anchored in communication theory and social-developmental psychology that would seem to facilitate the kind of research mentioned above concepts such as attribution from social psychology or egocentncism, one of the contributions to developmental psychology for which piaget is renowned, have been productively used in research on psychopathology and deviant behaviour. issues such as who attributes the difficulty in what way, to what aspect of the situation, or to whom and how the other responds, are all considered.4 using the standardised communication conflict situation already described and the conversational data elicited by the task, an utterance-byutterance analysis of the interaction thus generated becomes possible. every instance "of an explicit attempt at attributing the experienced communication difficulty"9 can be identified and categorised in terms, for example, of who, what, how, and the response evoked. this could be accompanied by a concurrent and linking analysis of each moment of stuttering the compatibility of this with the work of kaasin and bjerkan13 is evident. conclusion it seems that there are deficits in stuttering research that have become "perennials"19 and despite pleas for greater empiricism22 and an unified effort to enhance the quality of stuttering research,2» little progress has been made. it is clear that despite stuttering being deemed "an impediment in social living"21 the model underlying research efforts seems to have been that of individual psychology. as blakar4 puts it "this model is well suited to understanding the individual as language-user in various aspects. but the model is totally inadequate with regard to the social and situational aspects of communication and even hinders questions to be posed" given the subtle interplay between the individual and the multiplicity of situational and social variants in the act of communication, it seems that a single rating of severity of stuttering on a 5-minute sample of conversation or frequency counts of moments of stuttering expressed as a ratio of the total verbal the south african journal of communication disorders, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the measurement of stuttering output are too global and inclusive. the result is a measure of 'mean' stuttering. in the light of the variability of stuttering it seems that much of the essence of stuttering is being lost' it is clear that the present paper has merely touched on the issues involved. research designs remain simplistic subject populations are usually small and comprise college and university students with little attention to children additional ly, the controversy as to whether suttering frequency data constitute interval data or not2" and the assumptions of linearity of regression and homogeneity of variance, particularly in the case of self-formulated speech, deserve consideration " much remains to be done in research and in synthesising the wealth of data on stuttering. only with this effort and improvements in the quality of research in stuttering can some contribution to the elusive solution to the "riddle" of stuttering2' be made. acknowledgements sincere thanks are expressed to prof. g. straker, head of the applied division of the school of psychology, universky of the witwatersrand, johannesbuig, for her su^rvision ο "the study from which this paper is drawn. references 1. andrews g„ & harvey, r. 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' ' o f a ^ · ' ' s ' & b l a k a r ' r · m · ^ 8 0 ) : ftttems h l t n t a v h ° f ? 0 m m u n i c a t i 0 n d i f f i c u l t i e s i n couples " g 3 schizophrenic', a 'borderline' or ' 'normal' off33 spring in studies of familial communication and psychopathology: a social-developmental approach to deviant behaviour. blakar, r. m. (ed.τ unive sitetsforlaget, oslo. e r 10hymes, d η (1972): on communicative competence in soaolmguistics: selected readings. pride, j b & h o l i e s , i (eds.) penguin education, london. ' ϊ ζ τ ' γ ( 1 9 6 1 ) : m e a s u r e m e n t s oral reading and speaking rate and disfluency of adult male and femde stutterers and non-stutterers. journal of speech az hearing disorders monograph 7 1-20 ^ α ΐ ϊ γ π w ' d a r l f j ' r l · ' & spriestersbach, d. c. t z , z ™ t h o d s in s p e e c h pathol°sy· 13. kaasin, k. & bjerkan, b. (1982): critical words and the ^ c u s of stuttering i n speech. journal of fluez disorders, 7, 433-446 riuency 14kagan, a. (1977): aspects of cohesion and tense in the discourse of the older child. unpublished undergraduate research project, university of the wk watersrand, johannesburg 15. marks wahlhaus, m. (1979): judges agreement on auditory and visual aspects of stuttering the south afrcan journal of communication disorders, 26 3-18 16. minify f. d. & cooker, h. s. (1964): a disfluen^ n ' m'-lll ° f a n d h e a r m g borders! 29, 17. moore, w. e. (1954): relations of stuttering in spon^ i e o u s speech to speech content and adaptation. zrnal of speech and hearing disorders, 19, 208-216 18. muma, j. r. (1975): the communication game· dump and play. j o u m a l o f s p e e c h ^ ^ ^ j ^ p 1 9 ' w " η ? u o c k ' j · ( 1 9 7 ? ) : t h e h'stoncal roots of the theory and therapy of stuttering. journal of communication disorders, 10 3-24 20. sommers, r. k. bobkoff-leventhal, k„ applegate j a & square, p. a. (1979): a critical review of a decade 0 f s p r i n g research. journal of fluency disor^l, 21. van riper, c . (1971): the nature of stuttering. prenticehall, englewood cliffs, new jersey 22. webster r l. (1977): concept and theory in stuttering· 2 3 ' t r t ^ b r i t i \ τ ' ' b i ° " a d a p t i v e t h c 0 t y stutter283-295 ° f m e d l c a l oology, 45, 24. wertheim e. s. (1972): a new approach to the classification and measurement of stuttering. joujlof speech and hearing disorders, 37, 242-251 z t t ' h s i 1 9 7 2 ) : a word? british journal of medical psychology, 45, 35-43. e ^frikaanse tydskrif vir kommunikasieafwykings, vol. 30, r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) pdf file the psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners 77 the psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners " tamar wedcliffe and eleanor ross department of speech pathology and audiology, university of the witwatersrand abstract this study explored the psychosocial impact of traumatic brain injury on the perceived quality of life of a pu1:pos'efully selected group of 14 spouses/partners of head injured persons by means of a self-administered questiom;lqire. analysis of responses revealed that spouses/partners' altered communication patterns were perceived to have affected interpersonal relationships and quality of life extensively, indicating the need for speech-language therapy. decreased income was noted due to the low incidence of return to work. participants reported changes in family relationships, particularly between the injured person and their children as well as deterioration in marital relationships; suggesting the necessity for family therapy and marital counselling. various emotional reactions were documented in response to injury. yet most respondents expressed acceptance of their new roles and responsibilities despite the difficulties entailed. since injured persons were dependent on their spouses/partners to a large' extent, most of the latter reported feeling tied down. loneliness predominated as a social consequence despite the support of pre-injury friendships. in terms of coping resources, friends, family, religion and support groups were perceived to be most effective. results are discussed in tenns of their clinical implications for psychosocial rehabilitation and spouselpartner counselling. opsomming' hierdie studie het die psigososiale impak van traumatiese breinbesering op die lewenskwaliteit van' 'n spesijiek geselekteerde groep vem 14 eggenotel gesellel maats van breinbesserde persone ondersoek deur middel van 'n 'selftoegepaste vraelys. 'n analise van die uitslae het getoon dat die eggenote / geselle / maats se ervaring van die veranderde i ' kommunikasiepatrone 'n groot invloed op interpersoonlike verhoudinge en lewenskwaliteit gehad het, wat aandui dat spraak-taalterapie nodig is. venninderde iizkomste is opgemerk, as gevolg van die lae hoeveelheid terugkeer werk ide. deelnemers het veranderinge in familieverhoudinge gerapporteer, veral tussen die beseerde persone e~ hul kinders, sowel i , as 'n verswakking in huweliksverhoudinge, wat aandui dat gesinsterapie en huweliksberading nodig is. verskeie emosionele reaksies is beskryf teen~or die besering. tog het die meeste respondente aanvaarding van hulle nuwe roile 'en verantwoordelikhede uitge(jruk, ten spyte van die probleme wat ondervind is. aangesien die beseerde persone in "n 'groot mate van hulle eggenote v geselle / maats ajhanklik is, het die meeste deelnemers beskryf :dat hulle vdsgevang voel. eensaamheid was die oo~egende sosiale gevolg, ten spyte van die ondersteuning van vriendskappe 'voor diebesehng.' in tenne van bekampingsbrorine, i~vriende, familie, godsdiens en ondersteuningsgroepe as die mees effektief beskou. resultate is bespreek in terme van kliniese implikasies vir psigososiale reh~bilitasie en eggenoot /geselle-berading. ' key words: traumatic brain injury, spouses, partners, quality of life introduction in south africa, the incidence of traumatic brain injury (tbi), which includes both penetrating injuries from sharp objects as well as closed head injuries from blunt objects is regarded as very high, namely 316 per 100 000 persons (nell & brown, 1990). furthermore, improved medical care has made it increasingly likely that persons with severe head injuries will survive. unfortunately, a considerable number are likely to remain disabled, placingi a burden on their families (mckinlay, brooks, bond, martinage, & marshall, 1981). relatively good physical recovery has been found die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 to occur with most «losed head injured patients. however, a significant number remain with psychosocial deficits and/or cognitive impairment (ponsford, 1995a). after traumatic brain injury, many patients who appear to be functioning normally may have subtle communicative and social problems (penn, jones, schmaman, vyncke, watt, & fridjhon, 1998). since these cognitive and behavioural problems may not be immediately visible (tate, lulham, broe, strettles, & pfaff, 1989), professionals may be quick to gloss over them, underestimating their impact on the patient's functioning within the family environment. r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) as early as 1978, lezak (1988) documented specific reactions experienced by relatives living with chronically disabled brain injured individuals, which included feeling trapped, socially isolated, abandoned by extended family and abused by the patient. indeed, more than two-thirds of relatives in a study by mckinlay, et al. (1981) felt moderately to severely burdened by mental and behavioural changes in their family member one year after injury. since then, studies have shown that traumatic brain injury creates an enormous burden on family life which increases rather than decreases over time (brooks, mckinlay, symington, beattie, & campsie, 1987). when spouse and parent caregiver responses were compared, spouses consistently reported a greater number of behavioural problems which were perceived to have increased in severity over time (hall, karzmark, stevens, englander, o'hare, & wright, 1994). interestingly, panting and merry (1972), and later, thomsen (1984), asserted that marital relationships appeared to be less resilient to the effects of strain than parent-child relationships. oddy, humphrey and uttley (1978) found that marital relationships and family life appeared to withstand the changes resulting from brain injury that had occurred six months before. nonetheless, there is extensive evidence of deterioration or dissolution of marital relationships following traumatic brain injury (thomsen, 1984). the frequently reported marital, social, financial and emotional difficulties may have a considerable impact on the quality of life of the spouse/partner of a brain-injured individual. much emphasis has been placed on the issue of improving quality of life as a realistic goal iii rehabilitation (pain, dunn, anderson, darrah, & kratochvil, 1998). according to the world health organization (1993), quality of life may be defined as the perception of individuals of their positions in life in the culture and value system in which they live, relative to their goals, expectations, standards and concerns. it is . said to be a broad ranging concept affected in a complex way by individuals' physical health, psychological state, level of independence, social relationships and their relationships to salient features in their environment (who, 1993). this definition encompasses the propositions of those who view quality of life as the impact of a perceived health state on the ability to live a fulfilling life; the affective response to a role situation and the discrepancy between an individual's desired and actual circumstances (bowling, 1995). however, a shortcoming of this definition is the fact that no mention is made of the link between communication and quality of life. many studies have focused on the quality of life and psychosocial functioning of head injured persons (for example: klonoff, costa, & snow, 1986; tate et ai., 1989). researchers have also investigated aspects of the psychosocial functioning of the relatives of persons who have sustained traumatic brain injury (for example: thomsen, 1984; livingston, brooks, & bond, 1985; brooks et ai., 1987). many of the studies assessing the latter have used mood rating or stress rating scales. indeed, the use of a single measure of burden was evident in a study by brooks and mckinlay (1983), who found that personality changes following brain injury were associated with high subjective burden in relatives. tamar wedclitte & eleanor ross 78 single ratings of burden or stress may be criticized as being superficial and having limited clinical value since they fail to describe the manifestations of strain which require intervention. more detailed studies are necessary to gain knowledge regarding the specific parameters affecting psychosocial adjustment in order to design effective rehabilitation programmes for patients and their families. one such study by livingston, et al. (1985) investigated the burden of relatives in a more detailed manner, considering aspects of psychiatric and social functioning. similarly, in their study exploring predictors of burden on caregivers, brooks, et al. (1987) described parameters such as language and physical dependence. however, although detailed, these studies neglected many factors affecting quality of life such as financial issues, family dynamics and strategies to alleviate burden. in addition, the relatives and caregivers in these studies were not necessarily the spouses / partners of the injured person. a recently published south african study compared the changes in emotion and daily function experienced by a group of partners of brain injured individuals with a group whose partners had experienced spinal cord injuries (levor & jansen, 1999). the study explored the stress levels and restrictions of social and sexual life of partners in order to identify the needs and available support for each subgroup. however, as in previous studies, detailed information regarding issues such as financial concerns, family relationships and most importantly, communication was not obtained. since quality of life has been defined and operationalized in so many different ways, the present study endeavoured to address weaknesses identified in earlier studies and provide a broader perspective on quality of life of spouses/partners by combining domains such as changes in communication patterns, financial variables, physical, social, emotional and psychological functioning and coping strategies. quality of life was operationally defined as the contribution and interaction of these particular factors which were selected following consultation with experts in the field, and with a subject who was not included in the final sample, as well as on the basis of extensive reviews of the literature and research on the topic, for example: comm~nication (wertz, lapointe & rosenbek, 1984); financial factors (bowling, 1995); family relationships (panting &\ merry, 1972); emotional, physical and social factors (bowling, 1995); and coping (hall et ai., 1994). , i currently in south africa, there has been a fundamental shift in the way that disabled people are viewed. the emphasis has moved away frdm the individual medical perspective to the social model which considers the human rights and development of not only those with disabilities, but also of their families (white paper on an integrated national disability strategy, 1997). based on this model, the current study sought to discover the effects of brain injury on the spouse/partner and family of the injured person. insight into the changes in family life, particularly the change il) /quality of the spouse's/partner's life as a result of traumatic brain injury has direct clinical. relevance. specific communicative, cognitive or, behavioural issues which are perceived by spouses/partners to interfere with adaptive family functioning might be targeted in therapy with the brain injured individual, as well as in family or spouse counselling sessions. by understanding family the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners 79 needs and expectations, staff might be able to provide the appropriate education and support to facilitate the setting and achievement of realistic goals for rehabilitation. it was also anticipated that, asa result of increased knowledge of the factors that appeared to correlate with a richer quality of life, professionals would be better equipped to advise families regarding strategies that might be used to improve their lives. communication is a primary ingredient for a favourable quality of life, fulfilling an essential role in the adjustment and psychological well being of humans in their social context (swindell, holland, & reinmuth, 1994). it is thus considered the domain of a speechlanguage therapist to investigate issues affecting quality of life such as social life, marital relationship and financial independence, many of which rely heavily on intact communication processes. for these reasons, the study endeavoured to investigate the impact of traumatic brain injury on the quality of life of the injured person's spouse/partner. various psychosocial concerns and perceptions of the spouse/partner that might contribute to quality of life were explored including financial, communication, social and marital factors as well as family functioning and coping mechanisms. methodology aim to investigate the psychosocial impact of traumatic brain injury on the quality of life of spouses/partners living with them. sub-aims in order to address the above aim, the following sub-aims were formulated: 1. to elicit subjects' perceptions regarding the communicative abilities of the individual with tbi which might contribute to psychosocial problems. 2. to obtain information on the perceived impact of the tbi on the occupational status of the injured / individual and the financial status of spouses / partners. . 3. to explore perceived phanges in family dynamics, roles and responsibilities as a result of the tbi. 4. to gauge the perceiv~d influence of the tbi on marital or common law relationships. 5. to determine the perc~ived emotional effects of the tbi on the individual'ls spouse/partner. 6. to assess the influence of the tih o~ the spouses/partners' social life. 6. to explore coping mechanisms of the subjects surveyed. research design an exploratory-descriptive, single group research design, involving the use of a self~administered questionnaire, was employed to investigate the aims of this study. this design was chosen because of the difficulties experienced in recruiting sufficient subjects who met the subject selection criteria, as well as the need for in-depth coverage of a wide range of dimensions thought to impact on qual~ty of life. subjects die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 subject selection criteria subjects were selected according to the following criteria: marital status: subjects were required to have been married civilly or by common law at the time of the injury as this study focused specifically on partners of persons with tbi. type of injury of spouse/partner: subjects' spouses/partners were required to have sustained a brain injury due to trauma, rather than cerebrovascular accident, where damage is usually more focal and specific than the damage affecting many aspects of physical, cognitive and psychological functioning (hagen, 1984) that results from acceleration-deceleration injuries. time since injury: at least two months had to have passed since the injury to allow the initial shock of the injury as well as many of the patient's cognitive impairments to have passed (hagen, 1984), giving way to more long-term psychosocial concerns on which this study focused. additional disabilities: subjects were required not to present with any additional known disabilities that might have confounded the results. living status: the subjects needed to physically live with the individual with tbi at the time of the study. subject selection procedure the researcher obtained a sample of 33 persons by conducting record reviews of persons with tbi who had been discharged from various rehabilitation hospitals in johannesburg as well as by approaching a support group for head injured persons and· their families, a nursing home for the long-term care of head-injured patients, speech therapists and a neuropsychologist. although it is acknowledged that non-representative, non-probability, purposive sampling may limit generalisation of the results of the study, it was anticipated that many of the subjects' psychosocial concerns might apply to other persons with tbi who had attended rehabilitation programmes. description of subjects of the 33 questionnaires that were sent out to potential respondents, 14 were returned, representing an adequate response rate (babbie, 1995). demographic information obtained from these 14 subjects is set out in table 1. the majority of subjects were females. ages of subjects ranged from 20 to 58 years. time since injury ranged from between 5 months to 10 years. they had lived with their spouses/partners from between 1 year to 35 years. all of the traumatically brain injured spouses had received speech-language therapy. research instrumentation a self-administered questionnaire was selected as a means of data collection, a copy of which is set out in appendix a. original questions were supplemented with items generated from existing scales (records, 1997), on the basis of research literature (livingston et ai., 1985). the questionnaire was divided into eight sections in order to elicit information on subjects and their spouses/partners as well as obtain data in respect of the seven sub-aims of the study. r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) table 1: demographic profile of subjects (n = 14) age of subjects -----~-~ gel!~er of subiects duration of marriage/ -living together ---------. age of injured spouse/ --_. ---" partner ---_ .. ---._--number of children ------------tij!le since injury the following sections were thus included: demographic information: this section was aimed at obtaining biographic information about subjects and their spouses/partners._ questions regarding the ages of subjects and their partners/spouses, time since the injury, number of children, and duration of marriage/living together appeared in this section. it was felt that time since the injury implied recovery and should therefore be considered in comparison of results. an additional reason for the inclusion of this factor is that marital functioning has been found to deteriorate with increased time since injury (livingston et ai., 1985). duration of marriage/living together may indicate stability, which .·would affect the adjustment of spouse/partner to injury. communication: the onset of a major communication disorder in a married adult frequently has a profound effect on the spouse/partner and the couple's relationship (rollin, 1988). as such, a section of the questionnaire was dedicated to communication and incorporated a checklist of dysfunctional linguistic patterns fo,und after tbi including vague, tangential language, word finding difficjllties and problems tamar wedclifte & eleanor ross 80 category number of subjects 20-25 years 2 --26-30 years 2 -31-35 years 0 36-40 years 3 41-45 years 3 46-50 years 2 50+ years 2 male 2 female 12 1-5 years 3 6-10 years 3 11-15 years 1 16-20 years 1 21-25 years 4 26-30 years 1 31-35 years 1 26-30 years 2 31-35 years 2 36-40 years 2 41-45 years 4 46-50 years 2 50+ years 2 0 1 i 1 2 6 3 3 4+ 3 5-8 months 6 9-12 months 3 1-5 years 2 5-10 years 3 experienced in distracting environments (snow & ponsford, 1995). these deficits comprised some of the items on the checklist c,omparing patients' premorbi'~ and postmorbid communication patterns. efforts were :made to use terms that could be easily understood by lay persons; however, it is still possible that subjects'may have assigned different interpretations to those interded. severity of language dysfunction was not assessed; nor were subjects asked to indicate which communication impairments they regarded as most or least important. question 1 elicited details regarding the speech of the injured person since speech problems resulting from a traumatic brain injury may contribute to decreased quality of communication (ponsford, 1995a). -question 2 dealt with the communicative burden placed on the uninjured spouse/partner and question 3 with the sensitivity of the person with tbi to interlocutors in general. an open-ended question was asked regarding the overall effects of altered comniunication patterns on the relationship in order to elicit individual expression of feelings. the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners 81 occupation and finance: financial strain has been documented as a consequence of traumatic brain injury. tbi has also been found to have an adverse, long-term impact on employment and productivity (hall et ai., 1994). thus, questions in this section dealt with past and present occupational status of both' the injured spouse/partner and the subject. in addition, since financial concerns tend to affect quality of life· (bowling, 1995), subjects were asked to compare their premorbid with their present income and standard of living. family life: following brain injury, there is likely to be a significant disruption of· premorbid roles and relationships within the immediate family as well as with parents-in-law (ponsford, 1995b). consequently, this section explored the relationship between subjects and their spouse/partner's family; the 'family's reactions to the individual with tbi; familial visits; the distancing or bonding effects of the' injury as well as the changed responsibilities. in addition, subjects were asked to rate their spouses/partners on a five point scale according to their abilities to perform various activities of daily living since functional recovery of patients has been related to family adjustment (mckinlay et ai., 1981). marital relationship: evidence in support of the stresses placed on marital relationships by traumatic brain injury comes from the figures for divorce after brain injury: seven of the nine severely brain injured married patients, whom thomsen (1984) followed up ten-to-fifteen years post-injury, had been divorced. questions in this section were based on factors found by previous studies (such as panting & merry, 1972) to affect marital relationships. areas that were 'assessed included: the frequency of arguments since the injury, acceptance of the spouse/partner's limits, consideration of divorce, satisfaction with the marriage, ability of the spouse/partner to fulfil the subjects' emotional needs and the strength of the marital relationship. emotional aspects: in this section spouses/partners were asked about their personalities prior to the injury since the past illness experience, whether psychiatric or medical, of relatives of persons who have suffered brain injury has been found td be highly predictive of their i psychosocial breakdown. omany of the deficits associated with brain injury preclude individuals' functioning and self-sufficiency, making! them dependent on family members for financial support, transport and decisionmaking. lack of independence often places a burden on family members and intetleres with their quality of life (livingston, 1987). thus, two questions assessed the dependence of injured spouses/partners on subjects and the effects thereof. subjects were also asked whether \ their own health had suffered as a result of the injury, since physical health has been implicated as a contributor to a good quality of life (bowling, 1995). readjustment of the spouse' s/partner' s personal schedule is often necessitated by tbi to allow for the assumption of new responsibilities or caring for the injured person and may detract from the quality of life of the subject. thus, a question regarding the cancellation of personal plans was included at the end of this section. social life: loss of friends and social isolation are commonly associated with chronic illness or disability and may impact on quality of life (bowling, 1995). for this reason, questions assessing social isolation and die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 interaction, as well as satisfaction with social life were included. coping resources: resources such as support groups, case management, medication, recreational activities and respite care have been proposed as potential avenues to relieve the burden of family members and improve quality of life (hall et ai, 1994). the extent to which these factors had been of assistance to subjects in coping with the stresses of the injury was tapped in ·this section. responses were considered important since it was anticipated that they would provide practical suggestions for improving quality of life, which was one of the aims of the study. procedure pre-testing the questionnaire as mentioned previously, the research instrument was based on an extensive literature review and early drafts were scrutinized by an expert in the field of tbi (de picciotto, 2000) in order to enhance content validity. efforts to' improve the reliability of the questionnaire included consultation with a statistician known to have extensive experience in questionnaire construction, as well as pre-testing the research tool on a subject who met the subject selection criteria but was not included in the final study. these procedures were designed to assess applicability and practicality of questions. following the pre-test, ambiguous questions were adjusted and the items finely tuned. data collection upon subjects' agreement to participate in the study, arrangements were made for them to receive, complete and return the hand delivered questionnaire. an information sheet set out in appendix a, explained the purpose of the research project, assured subjects that their anonymity would be respected, provided a contact name and telephone number in the event of the person having any queries, and included a commitment by the researchers to report back the results of the study to participating subjects. data analysis data were analysed using descriptive statistics in the form of frequency counts and percentages illustrated via a variety of tables and figures. results and discussion results are presented in accordance with the sub-aims of the study. perceptions regarding the communicative abilities of the individual with tbi figure 1 depicts the distribution of language problems that were reported by the sample. as evident from figure 1, disorganized, rambling, tangential language was reported by 9 of the 14subjects. ylvisaker and szekeres (1996) suggest that rambling discourse may result from the impaired executive functioning, attentional processes and organizational skills that are characteristic of prefrontal injury. since r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) many of the language patterns associated with tbi have been linked to underlying cognitive dysfunction, it has been suggested that speech-language therapists work within a cogmtive-communicative framework of intervention (ylvisaker & szekeres, 1996). moreover, spouses/partners should be informed about the basis for the communicative difficulties which invariably disrupt conversation and hence, interpersonal relationships, in order to assist their coming to terms with the frustration experienced when conversing with their apparently insensitive partners. deficits in selective attention (snow & ponsford, 1995), as well as a difficulty with the figure-ground tamar wedcliffe & eleanor ross 82 processing of salient auditory information may have been responsible for the perception of 9 out of 14subjects, that their injured spouses/partners experienced problems communicating in environments that were full of distractions. one may speculate that this limitation probably affected the subjects' quality of life since it implied a reduced number of locations in which meaningful social or communicative interactions might take place. in places where it is impractical to manipulate the environment in order to facilitate conversation with the injured person, spouses/partners may be forced to avoid communication completely, thereby limiting opportunities for social interaction in the outside world. fig. 1 changes in language patterns as perceived by the spouses/partners of individuals with tbi post-injury (n=14) difficulty following conversations -1 •••• 6 trouble with abstract language __ 5 problems understanding humour 5 difficulty understanding hints __ 9 problems communicating in distracting environments 9 difficulty understanding complex written language -_7 very limited amount of speech -_ 3 socially inappropriate language rambling, disorganized, tangential language ~ word-finding difficulty __ 6 ___ 8 9 trouble understanding difficult spoken language -_ 4 vague, sketchy, imprecise language ___ 6 of the 14 subjects, 9 noted that their injured spouses/partners had difficulty understanding hints. this problem might have resulted from deficits in reasoning ability, which has been defined by ylvisaker and szkeres (1996, p.549) as "the process of considering evidence and making inferences or drawing conclusions". the .. inability to understand hints may lead to frustration of spouses/partners at having to spell out all their requests directly. conveying information directly may not always be appropriate such as when speaking in front of children or in company. in addition, when the subtleties of sexual innuendo are. not understood, deterioration in intimate relationships~ri'\ay: result (ylvesaker & szekeres, 1996). word finding difficulty, which 8 out of 14 subjects reported, was also documented by thomsen (1975) as o 2 4 6 8 10 no. of subjects one of the more common linguistic problem following head injury. when the speaker has word retrieval difficulties, there may be an increased burden on the interlocutor, such that he/she must guess the intended words, encourage circumlocution or endure the frustration and helplessness of seeing the speaker struggling to express himlherself.· six subjects reported vague, sketchy.a{(d imprecise language, which may have been c.alised by listener insensitivity or word retrieval problems. it is likely that this linguistic pattern may be a 'source of frustration for the interlocutor who may experience difficulty comprehending the injured person's message. six of the 14 subjects characterized the language of their injured spouses/partners as being socially the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners 83 inappropriate. indeed, inattention to social context resulting in socially inappropriate behaviour and verbal 'dysdecorum' has been described as associated with prefrontal damage (alexander, benson & stuss, 1989). for example, one subject commented, "when in company, his communication is totally unacceptable. the things he says embarrasses everyone, including me." withdrawal from social situations and public gatherings may result from such embarrassment. spouses/partners may also have to endure verbal abuse, which might decrease their self-esteem and quality of life. of the 14 subjects, 6 perceived that their spouses/partners had difficulty following conversations; whilst 4 reported that their spouses/partners had trouble understanding difficult spoken language. presumably, such deficits might manifest in a loss of interest of injured persons when their spouses/partners attempt to discuss problems of daily living or issues in their relationship. thus the quality and quantity of interaction could be adversely affected. five out of the 14 subjects noted that their injured spouses/partners had problems understanding humour. comprehension of humour has been attributed to the ability to think abstractly, a capacity that is frequently damaged as a result of brain injury (hartley, 1995). if one member of a couple cannot appreciate humour, their relationship may lack a means by which to release tension in order to alleviate the gravity of the situation. when asked to elaborate on their spouse/partner's communication problems in response to the open-ended item, subjects mentioned lack of eye contact, motor speech difficulties, and speech that was either too soft, too slow or dysfluent. in addition, eight subjects reported that they sometimes found communication with their partners/spouses to be tiring. whilst four noted that communication was often tiring, only one subject reported never finding communication tiring. the fact that all but one subject found communication with their spouses/partners to be tiring seemed to highlight the communicative burden placed on the interlocutor by injury-related communication problems. this result may indicate use of ineffective communication techniques, a problem that perhaps shohld receive more prominence as an intervention goal of jpeech-language therapists. the concentration required to !guess the message of the person with tbi as well as th6 effort required to explain or rephrase to ensure the i comprehension of an injured spouse/partner might induce" fatigue or despair. as a result, spouses/partners might refrain from discussing their concerns with the individual with tbi, causing emotional burdens and stress to accumulate, not having had an opportunity to be expressed. persons with tbi, too, might be given fewer opportunities to express their own problems, causing frustration and aggression. the egocentricity (lezak, 1988), rigidity and lack of insight (giles & clark-wilson, 1993) that have been reported as sequelae of brain injury, might cause individuals with brain injury to demonstrate an inability to adapt to their conversational partners. in the current study, perceptions of the injured spouses/partners' sensitivity to the listener were gauged with reference to these particular manifestations. eight subjects reported that their spouses/partners rephrased, explained or repeated information when the listener failed to understand them. however, 6 injured persons were reported not to die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 demonstrate such sensitivity. in addition, 10 out of the 13 individuals who answered the question reported that their spouse/partners tended to overestimate or underestimate the listener's knowledge of the subject being discussed. as may have been expected, given the above-mentioned results indicating decreased listener sensitivity, all but 2 subjects reported that communication tended to break down between themselves and their spouses/partners. of these, half reported that breakdown occurred often; whilst the other half noted that breakdown only occurred sometimes. frequent conversational breakdown may cause a great deal of frustration and resentment to the communicatively impaired individual, who is often unaware of his/her deficits (snow & ponsford, 1995), as well as for the interlocutor. twelve of the 14 subjects reported that their injured spouses/partners with tbi often misinterpreted what they had said to them. if frequent breakdown or misinterpretation of communication is used as a measure of quality of life, then brain injury with its effects on communication may be said to have detracted from the quality oflife of 12 of the 14 spouses/partners. many relationship breakdowns have been attributed to faulty communication, even without the added burden of a neurogenic communication disorder (lapointe, 1999). in the face of the many expressive and receptive language difficulties that have been associated with traumatic brain injury, relationships are even more likely to be at risk. nine out of the 14 subjects in the current study affirmed that their spouse/partners' altered communication had affected their relationship in some way. verbatim quotes set out in table 4 starkly reflect the impact on sexual relationships, communication, roles and personality. in summary, a wide variety of communicative impairments were found to have detracted from the quality of life of most subjects in the current study, and appeared to suggest the need for speech-language therapists to assist couples to find more effective ways of communicating. impact of injury on the occupational status of the person with tbi and the financial status of spouses/partners: the current study found that of the 14 brain injured persons who were reported by their spouses/partners to have been employed full-time prior to the injury, 10 had not returned to work at all, 2 worked part-time, 1 ran errands for his spouse at work, and 1 was employed in a different capacity. these results are in line with the research literature which confirms that tbi often results in cognitive, physical, psychological or communicative deficits, which may preclude the injured person's return to work. return to work statistics range from 3% to 100% depending on the severity and sequelae of the injury, the demands of the job as well as a multitude of other factors (penn et ai., 1998). furthermore, economic issues relating to medical treatment, rehabilitation, earnings loss and caregiver role adjustment may create enormous concerns for individuals and families in health care crises (lapointe, 1999). in the current study, 9 subjects indicated that their income had dropped significantly since the injury, 2 stated that their income had dropped slightly while only 3 subjects r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) commented that their income had remained the same as it had been prior to the injury. these findings suggest that in the majority of cases, tbi had impacted on quality of life. the world health organization (1993) related quality of life to the individual's perceptions of hislher position in life in relation to hislher goals, standards and expectations. as such, satisfaction with standard of living may be said to impact extensively on perceived quality of life. in the current study, the number of subjects who expressed satisfaction with present standards of living compared to pre-injury standards was equal to the number of subjects who expressed dissatisfaction. this finding seemed. to indicate spouses/partners' adjustment and adaptation to the decreased financial status as a consequence of brain injury on the part of those subjects who reported feelings of satisfaction with living standards. however, a weakness of the research project was that self-administered questionnaires did not facilitate further probing of individual items. table 2: perceived effects of injury on children (n=l1) themes children's fear of parent with tbi injured parent's reaction to children roles/responsibilities of children the loss of a child's relationship with one parent may have the impact of draining the emotional resources of the uninjured parent. the latter might feel it necessary to devote more attention, time and love to the child at the expense of his or her own needs and quality of life. consequently, counselling of children and parents may ease the burden that the changes in family dynamics have imposed. .. in the current study, 13 of the 14 subjects expressed the view that their relationships with their spouse/partner's family had changed since the injury. in general, the injury was perceived by 6 subjects to have brought family members closer. three subjects did not perceive any effect on family cohesion. however, 4 subjects stated that the injury had caused negative changes in the form of friction and decreased support and had estranged family members. mauss-clum and ryan tamar wedr.liffe & eleanor ross 84 changes in family dynamics, roles and responsibilities: the majority i.e. 13 of the 14 subjects affirmed that there had been a change in their family relationships since their spouse/partner's injury. this finding is in accordance with family systems theory, which views the family as a homeostatic entity where each unit is dependent on every other. as such, a traumatic brain injury sustained by one member is likely to cause a disturbance in the equilibrium of the entire family. upon analysis of the comments of participants regarding changes in their family relationships, deterioration of relationships with children emerged as a common theme. examples of subjects' comments regarding the effects of the injury on children may be seen in table 2. quotes • he has very little patience with children and they have become wary of him, sometimes even scared. • children are too scared to talk to him because he does not understand when they are joking and when they are serious. • most of the children (mine) are • • • • • • nervous of him. he has very little patience with children. lost his love and relationship with children. very formal and irritable with children. takes very little interest in the children. elder son grew up quickly emotionally played father roles. new roles had to be filled by children. they are not as carefree as other kids. due to decreased finances had to let maid go, so children have to help around house. (1981) pointed out that there tended to be con,flict between the uninjured spouse and his or her in-laws. they explained that parents might see their role as protecting their child from the possibility of divorce and were likely to become possessive and jealous. decreased contact with immediate and extended family members might also have resulted from friction caused by reversal of roles or the family's discomfort with behavioural, communicative or cognitive changes. in this respect, rosin (1977) noted disengagement to be a/ met,hod of dealing with the brain injury of a relative. in the process, family and friends might be neglected due to lack of time following the spouses/partners' .assumption of additional responsibilities (boisclair-papillon, 1993). friends might also feel uncomfortable or awkward in the presence of the brain-injured person and decrease their contact with the spouse/partnertoo as a result. the south african journal o/communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the psychological effects of traumatic brain injury on the quality of life of a group of spouses /partners 85 however, although infrequent visiting and avoidance of the injured person might help the extended family to adjust to the effects of the injury, spouses/partners of the injured person may experience isolation and a lack of support due to the reduction in family contact. it is of interest that 8 subjects in the present study reported that the extended family, including aunts, uncles and cousins, tended to visit as often as they did before the injury. likewise, 7 subjects mentioned thauhe immediate family tended to visit as frequently as previously, while one subject reported that visits were more frequent following table 3: responsibility for various tasks pre and post-injury task pre-injui1 self spouse/ both partner with tbi caring for 5 2 1 children (n=8) dealing with 5 4 1 medical aid & social agencies (n=lo) running 6 2 2 household (n=lo) making 1 5 4 financial decisions (n=10) providing main 3 4 3 source of income (n=10) the injury. frequent visiting may indicate the presence of family support and adjustment to the injury. in order to foster increased understanding, spouses/partners should be provided with the emotional support as well as the information needed to explain the consequences of the injury to the injured person's family. . in order to gain a better understanding of the extent to which roles had shifted since the injury, the current study required subjects to indicate the person responsible for various tasks before and after the injury. post-injury self spouse/ both partner with tbi 7 0 1 10 0 0 9 0 1 9 1 0 7 3 0 numbers in the different categories do not total 14 as not all tasks were applicable to all subjects. table 3 shows that where the responsibility of caring for children had previously been that of the spouse/partner who had sustained the injury, it was now shared and where it had been a shared duty, the role had been assumed by the uninjured spouse/partner. the relinquishment by many of ~he injured persons of tasks such as dealing with medica'! aid and social agencies, i running the household, mak:ing financial decisions, and being the main source of income, is understandable if one considers that injury to the ~rontallobes of the brain tends to impair executive fupctioning including planning, problem solving, judgement and/decision-making (ponsford, 1995a). upon analysis of the reactions of subjects to role changes, most appeared to have accepted their additional responsibilities. only two subjects admitted to feeling angry or uncertain as a result of having to undertake new responsibilities. others appeared to acknowledge the difficulties, yet expressed acceptance of their lot. these results provide support for the literature which states that role reversal may impact extensively on the quality of life of the uninjured spouses/partners upon whom additional new roles and responsibilities are suddenly thrust (lapointe, 1999). perceived influence of injury on maritaucommon law relationships: die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 table 4 shows the subjects' extent of agreement or disagreement with various statements regarding the perceived influence of the injury on marital or common law relationships. half of the current sample reported that their relationship with their spouse/partner had deteriorated with the passage of time since the injury. however, although the small number of subjects precluded the computing of correlations, the time since injury did not appear to affect perceptions of marital decline. deterioration in marital relationships was noted by those whose spouses/partners had sustained the injury 5-10 years before as well as by those who had been injured between 5-12 months previously. however, 6 other subjects whose spouses/partners' injury had occurred between 1-5 years before as well as 5-8 months before, failed to report such a decline. in terms of the literature, marital functioning was noted to have decreased between 3 and 6 months post-injury in a study by livingston, brooks and bond (1985). duration of marriage also did not appear to influence the perception of marital decline over time as couples who had been married for 1 year, 6 years, 25 years and 28 years reported decline, while others with marriages of 7, 16 and 34 years duration failed to report deterioration. nevertheless, since half the subjects reported that they perceived their marriages to have deteriorated over time, referrals for marital counselling, guidance regarding future expectations, and long-term coping strategies may r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) need to be made available in an effort to conserve marriages and increase the quality of life of both partners. in the current study, 5 of the 7 subjects noted that their injured spouse/partner had become more aggressive and also reported pjore arguments since the injury. increased aggression and irritability are commonly reported personality changes following brain injury (giles and clark-wilson, 1993) and might lead to an increase in arguments. eight subjects stated that they had not considered divorce. lezak (1988) explains that feelings of responsibility, past gratitude to the spouse, guilt, and fears of social rejection might make it difficult tamar wedclitte & eleanor ross 86 to initiate separation or divorce procedures. results from the present study may also indicate that subjects had resigned themselves to their new roles, having managed to accept and adjust to changes in thl;!ir spouses/partners. indeed, 10 subjects admitted that they had accepted their spouses/partners' limits. in addition, the possibility of subjects furnishing 'socially desirable' responses to these very sensitive items cannot be discounted, and leaves the validity of this item open to question (rosnow & rosenthal, 1996). it is also possible that it was too early post-injury for respondents to assess the long-term effects of the injury on the marital relationship. table 4: perceived influence of injury on marital/common law relationship strongly disagree/ agree/agree neutral strongly disagree statement our marital relationship has not changed 10 1 3 despite the injury my relationship with my souse/partner 7 1 6 has deteriorated as time has passed since the injury i accept my spouse/partner's limits 10 2 2 i have considered divorce 3 no response 8 i feel as though i am married to a 7 5 2 stranger since the injury i have a close, confiding relationship 4 4 6 with my spouse/partner i keep my frustration inside myself 11 1 2 i am satisfied with my marriage 5 2 7 my spouse/partner can no longer fulfill 10 3 1 my emotional needs adequately we argue more now than we did before 7 3 7 the injury i note: responses from the 5-point rating scale were collapsed to form three categories. n=14 eleven subjects reported that they tended to keep their frustration inside themselves. the effect of a build-up of inner frustration has been shown to exert an adverse effect on people's physical and mental health (burnard, 1991). hence, rehabilitation personnel should be made aware that spouses/partners might appear from the outside t() be coping with their roles and their spouse/partner's deficits. however, internally, they might harbour much anxiety and frustration that needs to be expressed and addressed. half of the subjects in the current study agreed with the statement "i feel as though i am married to a stranger since the injury". in this respect, the personality change that results from brain injury has been reported to be most difficult for spouses/partners to deal with (mckinlay et ai., 1981; thomsen, 1984) presumably since it alters the dynamics and fulfilment of needs . within the relationship. the high number of neutral or uncertain replies to this item may have be¢n due to a 'central tendency response set' whereby subjects tend to choose the central response options rather lhan committing themselves to a definite agree 'or disagree response only 6 of the 14 subjects reported not having a close, confiding relationship with their injured spouse/partner. the fact that so few relationships were :'\aid to be close and confiding might indicate the need for marriage counselling of persons with tbi and their spouses/partners. ten subjects in the current study reported that their injured spouses/partners were unable to fulfil! their emotional needs adequately. this phenomenon may be explained by the fact that because brain irijured spouses/partners often tend to be childish, self-centred and irritable, they are unable to provide the emotional support that had formed an integral part of ,their relationships prior to the injury (mauss-clum & ryan, 1981). according to lezak (1988), spouses may suffer the loss of a relationship that satisfies even the most basic expectations of a marriage. one subject in the present study remarked that' her husband who used to be her "best friend and lover" had now become no more than a "child-like companion." half of the subjects in the current sample asserted that they were not satisfied with their marriages, probably indicating a perceived reduced quality of life. however, 5 subjects expressed marital satisfaction despite the injury, suggesting positive adjustment as well as a satisfactory quality of life. it is also p'ossible that the 'central tendency response set' was operating, whereby subjects responded similarly to various items (rosnow & rosenthal, 1996)/ . the south african journal of communication disorders, vol 48 2001 i r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners 87 subjects were asked to describe changes in the spouse/partner post-injury which had exerted the most impact on the relationship. analysis of the verbatim responses of subjects revealed certain common themes which are highlighted in table 5. table 5: changes in spouse/partner with tbi that had exerted the most impact on the marital/common-law relationship (n=l1) / / themes loss of sexual relationship communication changes personality changes: blunted emotion, increased aggression role change ; i ! separation \ i /' the profound effect of traumatic brain injury on the marital relationship is reflected in the statement by one of the subjects:. "between him and myself, he is just the patient and i am the caregiver/provider/ decision-maker. there is no other aspect to the relationship." many subjects mentioned the loss of the sexual, relationship. communication changes and role shifts were also reported to have affected the marital relationship as well as personality changes, particularly blunted emotion. these results appear to be in line with the findings of tate et al. (1989) who conducted a follow-up study six years post-injury, and found that marital breakdown had occurred in 63% of ma,rriages in the group of brain injured persons with moderate to severe brain injury and in 42% of those with good outcomes. quotes • he is constantly insecure because we do not have an intimate sex life. his brain cannot function in that way yet. i accept that. i have become very sympathetic. • i have lost my best friend and lover. we don't have fun anymore. we don't have sex anymore and i am very wary of confiding in him. • no love life. • between him and myself, he is just the patient and i am the caregiver / provider /decision-maker. there is no other aspect to the relationship. • no communication • we also can't communicate as well as we used to. • lack of emotion; increased aggression; onset of depression / negativism • his changed personality. he is quite aggressive now and it's like living on the edge of a volcano. • he is a different person. his personality has changed. • he is also very unemotional in positive loving ways. • he was also a very loving, touchy person. this has all gone. not only did we live together, play together etc., we also worked together in the same company, different departments. • loss of intellectual ability and confidence • i have become the senior partner iii running things which he is too proud to feel comfortable with. • the fact that he is not able to help with fetching and carrying of kids. • changes in roles. • the fact that he had been iii and out of hospital has had a dramatic impact on our relationship. perceived emotional effects of injury on spouse/partner: the occurrence of traumatic brain injury creates an immediate crisis for relatives, disrupting established relationships, roles, expectations and goals within the family unit (ponsford, 1995b). however, the crisis is often ongoing since character changes, altered communication patterns and cognitive limitations tend to be of a permanent nature. the advent of brain injury may die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48,2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) be said to mark the beginning of the spouse/partner's ride on an emotional roller-coaster. eight subjects in the current study appeared to deny the permanence of their spouse/partner's disability by reporting that they lived with the hope that their spouse/partner would wake up and return to hislher preinjury self. the remaining 6 subjects did not appear to have such unrealistic expectations. however, one stated that she expected her spouse/partner to recover slowly. based on extensive contact with 13 families of severely head injured patients, romano (1974) observed denial to be a powerful tool used to come to terms with sudden disability, one of the manifestations of which was the tendency towards fantasies. the tendency towards unrealistic expectations must be considered by rehabilitation personnel when working with spouses/partners, who might resist attempts at the rehabilitation of the injured person (ponsford, 1995b) or even blame therapists for the failure of the person to return to premorbid capabilities. livingston (1987) found that the post-injury adjustment of relatives correlated with their previous psychiatric and medical history. spouses/partners were thus asked to describe their personalities before the injury. ten subjects considered themselves to have been independent, and 9 said that they had been easy-going. these traits probably assisted greatly in the assumption of new ·responsibilities following the injury. eleven considered themselves sociable, perhaps implying a large framework of social support, or perhaps frustration in the event of social isolation. in terms of their reactions to their relative's disabilities, lezak (1988) pointed out the potential of relatives to become deeply conflicted between feelings of responsibility, anger and frustration, and hope for the recovery of the injured person, making them prone to depression. the emotional devastation felt by one of the subjects in the current study was poignantly expressed in the following statement: "all the changes in my husband have frightened and shocked me. i find myself lying about how things are just to keep the peace somewhere in this mess i lost me!" current findings showed neither anger nor irritability to be very prevalent, with only 5 out of the 12 subjects reporting these emotional reactions following the injury. sadness was reported by ten tamar wedcliffe & eleanor ross 88 subjects and the same number noted that their spouse/partner's disability had caused them to feel burnt out, possibly as a result of role overload. eleven of the 12 subjects who responded to this item in the current study noted that they felt frustrated as a result of their spouse/partner's disabilities and one subject reported feeling helpless. consequently, it is important that rehabilitation personnel and counsellors advise spouses/partners that negative emotions tend to be a natural consequence of disruption to life and marital relationships. notwithstanding the prevalence of negative emotions, feelings of acceptance were noted by 11 subjects in the current study, as was the case in relation to role changes explored in the third sub-aim. it is possible that subjects might have accepted the presence of disability intellectually. yet, in reality, on an emotional level, they may have experienced conflict and burdens resulting in frustration, anger and irritability. since anguish, fatigue and depression drain the spouse/partner of availability, patience and inventiveness, counselling of the spouse/partner is likely to have a positive effect on both the injured person as well as the entire family. the dependence of injured persons on their spouses/partners for activities of daily living may impact on the spouses/partners' perceived quality of life. indeed, 6 subjects in the current study noted that they felt tied down to a great extent by their spouse/partners' dependence on them. another 6 stated that dependence caused them to feel somewhat lacking in independence. only 2 subjects commented that they did not feel tied down at all despite their spouses/partners' dependence. in terms of dependence/ independence, several factors were considered, namely, transport, decision-making, finance, and communication with unfamiliar people. results are reflected in table 6. the finding that only 3 spouses/partners were completely independent in relation to transport, was not surprising considering that only one subject reported that herihis spouse/partner was able to drive well. however, in hindsight, it would seem that the terms describing driving ability were not adequately defined, for example, did average driving ability imply ability to drive independently? a further shortcoming of the study was that aspects such as decision-making: and finances were not probed further. table 6: extent of dependence of injured spouse/partner on respondents (n=4) factors totally dependent transport 6 decision-making 9 finances 10 communication with 8 unfamiliar people the effects of having to care for a spouse/partner as a parent cares for a child may increase the resentment and difficulties involved in care giving. provision of practical advice to increase the spouse/partner's perceptions of freedom might assist them to cope' better both psychologically and physically. by hiring a driver, the person with tbi might become independent in terms of transport. referral to a financial consultant for financial counselling and advice might assist the uninjured partially dependent completely independent 5 3 5 0 3 0 4 2 spouse/partner to meet the challenge o( financial planning and decision-making with more confidence and skill. speech-language therapy might equip the person with tbi to regain independence in the domain of communication. ten out of the 14 subjects reported that their physical health had suffered in some way as a result of the stress of their partner/spouse's brain injury. this result is not surprising since family members tend to put the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners 89 aside their own interests and needs to give maximal support to the injured· person. such sacrifice cannot be sustained without a significant physical or emotional toll (ponsford, 1995b). it is therefore critical that spouses/partners be cautioned by rehabilitation workers to take time out for themselves to maintain their efficiency as caregivers and their quality of life. the postponement or cancellation of personal plans as a result of their spouse/partners' injury was reported by 11 of the 14 subjects in the current study. ironically, many of the uninjured subjects experienced a degree of handicap, being unable to conduct their lives in accordance with their desired plans. however, whether they resented this postponement or merely accepted it as a fact, is open to speculation. according to lapointe (1999), health care professionals may fail to recognize the magnitude of the challenge of compromise that is involved in adapting to the new demands that necessitate a change of lifestyle. perceptions of a disappointing quality of life might cause the build-up of frustration and resentment, which might be expressed as anger towards the injured person or inadequate fulfilment of responsibilities. rehabilitation personnel and other family members should thus encourage the spouse/partner to accomplish their personal plans where possible and to develop their own interests. in addition, counselling of spouses/partners by therapists or psychologists should be encouraged in order to help them to express and work through the emotional and psychological impact of the injury. influence of social aspects on quality of life table 7 illustrates the effects of the injury on subjects' social life. with regard to the loss of friends, it is not clear how long after the tbi this loss occurred and needs to be researched in greater depth than allowed by the current study. although socially inappropriate language was only reported by 6 subjects (as discussed under the first sub-aim), 7 subjects noted that they experienced discomfort in social situations since their spouses/partners tended to say the wrong things at the wrong times. this finding is understandable if one considers that pragmatic impairment is a major component of language impairment in tbi (alexander, benson & stuss, 1989). in addition, it was not surprising that 5 subjects mentioned feeling embarrassed as a result of their injured spouse/partner's behaviour in company. interestingly, however, only 3 subjects admitted that they tended to avoid social contact. tabje 7: perceived effects of the injury on respondents' sociaj life (n=14) statement i often feel lonely. i feel responsible for meeting the social needs of my spouse/partner. i feel that i have lost many friends since the injury. i have made many new friends since the injury. i avoid social contact. i am embarrassed by my spouse/partner's behaviour in company. my spouse/partner says the wrong things at! the wrong time causing me dis~omfort in social situations. i the majority of subjbctsin the current study felt responsible for meeting the social needs of their injured spouses/partners with tbi.. by increasing their involvement with the injured person, spouses/partners might have less time to devote to the maintenance of their previous friendships. this finding is in line with the results obtained by kozloff (1987) who studied 37 persons with severe brain injuries and their families. this researcher found that relatives attempted to compensate for the patients' psychosocial inadequacies by expanding their involvement with the patients themselves. the fact that 11 of the 14 subjects also reported that they frequently experienced feelings of loneliness, could possibly be due to decreased time for social arrangements or estrangement from friends and from the spouse/partner. one subject affirmed this explanation saying "all our friends don't like to mix in as i am now considered a threat (so called)". it is likely that the loss of yes 11 11 5 4 3 5 7 die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 no 3 3 9 10 11 9 7 the companionship, guidance and support of a spouse/partner might be the greatest source of loneliness as one subject commented: "i have lost my best friend and 10ver. . .1 am very wary of confiding in him." consequently, the fostering of both new and old friendships, as well as membership of support groups should be encouraged on the basis that a larger social circle is likely to ultimately lead to an increase in emotional support and quality of life. no definitive trends emerged regarding the satisfaction of subjects with their present social life in comparison with their social life before the injury since responses were evenly distributed along the continuum. six subjects expressed satisfaction with their present social life, 2 remained neutral and 6 others reported dissatisfaction. nonetheless, rehabilitation personnel should be aware of the potential for decreased social opportunities to impact negatively on spouses/partners' r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) tamar wedciiffe & eleanor ross 90 quality of life. where necessary, counselling should be provided to assist individuals to deal with their frustrations. furthermore, spouses/partners and their families should be encouraged to seek additional opportunities for socialization, particularly, given the broad base of evidence that social support buffers the deleterious effects of stress and anxiety and contributes to psychological well-being (lapointe, 1999). the finding that 5 subjects had not received any form of psychological counselling suggested under-utilization of such services which could have been due to any number of reasons, including lack of access, the costs involved, as well as the stigma still associated by some people with this type of therapy. this finding also suggested the need for speech-language therapists to incorporate spouse/partner counselling into any therapy programme so that significant others who are not in contact with other professionals, may receive the necessary emotional support. ideally, psychological counselling provides an opportunity for the spouses/partners of persons with tbi to work through their emotional responses and to raise practical problems (ponsford, 1995b). exploration of coping mechanisms . subjects were asked to assess the degree to which certain factors had helped them to cope with the consequences of traumatic brain injury in their spouse/partner. resuitsare summarized in table 8. table 8: extent of helpfulness of coping resources (n=14) coping resource very helpful psychological counsellin~ 2 religion 8 support groups 5 domestic hel~ 5 friends 10 medication 4 somewhat helpful not at all not helpful applicable 5 3 4 3 3 0 2 2 5 6 1 2 2 2 0 5 3 2 the fact that a relatively large proportion of subjects felt that religion had helped them to come to terms with the devastation of tbi, is understandable if one considers that under such conditions, some people may adopt a philosophical outlook, searching life for meaning and exploring the significance of their existence relative to a higher being. while half the subjects reported that support groups had been either very helpful or somewhat helpful, it is of concern that 5 persons had either not had access to or had not made use of such services. table 9: coping strategies perceived as most effective (n=12)* themes quotes friends • support and good friends who listened, cooked or spent time with my husband. • caring friends family • family and friends' assistance and support • my children, sister, brother-in-law • plenty of family support and support from my spouse religion • prayer • faith in god • supportive church medication • medication for depression inner strength • my strong personality and determination to succeed and i kept saying to myself * i'll get you, you **** before i really understood his problem. then i had to swim or sink and i wasn't prepared to sink. i also had to cope with "another woman" and to accept that also was due to his injury. • i am a strong person. other • previous experience • having an outside 'care-manager' to co-ordinate / therapies, living skills, medical follow-ups, monitor 'scientific progress', move to new different levels· of therapy etc. / / • time, love / • avoiding dealing with it. • extremely supportive employer and spouse's colleagues the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners 91 * only 12 respondents answered this question. overall, subjects in the current study did not appear to rate domestic help as crucial. however, a limitation of the study is that type and frequency of domestic help was not probed variables which may have influenced the results of the study. information was also not sought regarding type of medication or whether medication was taken prior to the spouse/partner experiencing tbi. subjects reported that friends contributed most to coping with brain injury. despite 5 subjects having reported that they had lost many friends since the injury, 10 subjects related stories of having been helped to cope with their crisis to a large extent by friends "who listened, cooked or spent time with my husband to allow me time out". upon analysis of responses of subjects to a question assessing what had been most effective in helping them deal with the stresses resulting from traumatic brain injury, various common themes were evident, includingfriends,family, religion, inner strength and medication. direct quotations reflecting subjects' coping strategies may be seen in table 9. healthcare workers and counsellors should take cognizance of the positive coping strategies demonstrated by the spouses/partners of persons with tbi, in order to reinforce them and encourage their generalization to other difficult situations. it may also be helpful for rehabilitation personnel to attempt to discuss strategies to facilitate the coping of their clients such as recommending that they take vacations, keep it diary, attend inspirational lectures or use relaxation techniques. in addition, spouses/partners should be encouraged to participate in activities that have been found by others to decrease stress in an effort to enhance their perceived quality of life. summary of results , the findings in this study showed that a range of filctors affected the perceived quality of life of a group of spouses/partners of person~ who had sustained traumatic brain injury. communicati~e changes were found to have detracted from the quality [of life of most subjects in the current study; with the i most frequently mentioned dysfunctional linguistic i patterns being difficulty understanding hints; problems communicating in distracting en vironment$; jambling, disorganized, tangential language; and word-finding difficulties. almost three-quarters of the current sample reported that their injured spouses/partners had not returned to work post-injury. the remaining quarter reported either part-time or alternative employment. most s~bjects noted a drop in their income since the injury. yet,'no definitive trends were evident regarding satisfaction' of subjects with their standard of living, implyipg varying perceptions of quality of life if satisfaction with living standards was to be used to gauge this phenomenon. a change in family relationships, particularly the deterioration of the injured person's relationship with his/her children, was noted by all but one subject. alteration of the relationship between subjects and the injured spouse/partner's i family was prevalent, with reports of greater closeness being more common than increased friction. reallocation of the injured person's die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 roles to spouse/partner was evident in the domains of financial decision-making, dealing with medical aids and social agencies, providing the main source of income, running the household and caring for children. the vast majority of subjects in the current study reported that their marital relationships had changed since the injury, mainly owing to their spouses/partners' communicative changes, loss of sexual drive and personality changes, reflected particularly in their aggression and blunted emotion. emotional reactions of subjects to their spouses/partners' disabilities ranged from negative, for example, frustration, sadness, denial, burnout, to positive, for example, acceptance. most subjects reported . a perceived lack of independence and feeling 'tied down'. this finding was not surprising considering the frequent reports of complete or partial dependence of persons with tbi on their spouses/partners for transport, finances, decision-making and communication with unfamiliar people. the physical health of most subjects was reported to have suffered following the injury and almost· all reported having been forced to postpone or cancel personal plans due to the injury. loneliness predominated as a social consequence of a spouse/partner's injury despite the durability and support of pre-injury friendships. finally, in terms of coping resources, psychological counselling was not reported to have been particularly effective, possibly because not many subjects had availed themselves of this service. however, supportive friends, family, religion, support groups and domestic help were believed by participants to be the most effective coping strategies. conclusions evaluation of the study was deemed necessary in order to assess its effectiveness and to gauge the value of its results. as such the limitations of the study were considered. generalization of current results to the wider population of spouses/partners of persons with tbi in the country is limited due to the non-probability sampling, small sample size and disproportionate representation of the various ethnic, cultural and socio-economic groups in south africa. in addition, gender effects could not be probed due to the disproportionate ratio of females to males. the small sample size also precluded the investigation of statistical correlations between variables. the questionnaire designed for data collection was quite long and detailed and required self-administration. this method of administration posed a limitation in terms of the reliability of the study since it allowed the possible mlslnterpretation of questions and furnishing of incomplete or sketchy responses. ideally it should have been interviewer-administered to explain ambiguities and glean more detailed answers to open-ended questions. in addition, subjects may not necessarily have reported their beliefs accurately, being subject to social desirability bias or may have consulted other family members to assist them with the completion of the questionnaire. nevertheless, despite the limitations of the study, many important clinical implications emerged for speech language therapists, rehabilitation personnel, r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) spouses/partners of persons with tbi, families and friends of persons with tbi and these individuals themselves. in this study, communication difficulties were found to contribute to subjects' perceptions of decreased quality of life either directly or indirectly through their effects on marital relationships, occupational and social opportunities. speech-language therapists thus appear to have an important role in administering direct therapy to improve the communicative abilities of individuals with tbi. following on from the findings in this study, direct intervention might include focusing on. the development of the cognitive skills underlying language dysfunction, providing alternative methods of communication such as writing or gesture, encouraging word retrieval and conversational repair strategies including identifying and repairing breakdown, as well as developing increased linguistic and pragmatic skills. findings indicated the need for direct speech-language therapy involving both spouses/partners and persons with tbi in order to establish more effective methods of communication in an effort to prevent conversational breakdown and preserve marital harmony. in addition, the study highlighted the role of the speech-language therapist in explaining the cognitive-linguistic origin of communication problems to spouses/partners in order to increase their understanding and tolerance and to decrease their frustration. speechlanguage therapists appeared to have a crucial role to play in providing spouses/partners with emotional support as well as the infonnation needed to explain the consequences of the injury to family and friends. it is acknowledged that counselling might be conducted by psychologists, social workers and other rehabilitation personnel who have contact with the brain injured population and their families, not just speech-language therapists. moreover, counselling could be broadened to include not only individual therapy but also couple counselling, family-centred approaches, and group work which might possibly be more effective intervention modes. thus, findings appeared to have implications for all potential counsellors regardless of their discipline. throughout the study, findings suggested the need for healthcare workers to be sensitive to the emotional, social, marital and financial consequences of the injury for the couple. findings regarding financial difficulties pointed to the role of members of the rehabilitation team in helping spouses/partners to access financial resources by referring them to financial advisors or to the department of welfare for a grant or a disability pension. the injured persons might also be helped to find alternative occupations, possibly via referral to the association for the physically disabled or the department of labour. at this juncture in south african history, the employment equity act, legislates against discrimination in the employment of persons with disabilities. the necessity for counselling of spouses/partners to assist them to come to terms with the emotional and social implications of decreased financial status was also evident in this study. this study appeared to have implications for the marital counselling of spouses/partners of persons with tbi, indicating the need for guidance regarding future expectations and long-term coping strategies to conserve marriages. findings seemed to indicate that counselling of the entire family, particularly the children, should be tamar wedciitte & eleanor ross 92 instituted to assist them to deal with the changes in family dynamics and with the altered communicative patterns of the injured person. owing to the danger of role overload, findings pointed to the need to increase the capability of spouses/partners to deal with the burden of their new responsibilities. rehabilitation personnel might thus assist spouses/partners to access resources that might lighten their burden, such as the hiring of a driver to assist with transport as well as equipping the injured person to resume certain roles and to undertake various jobs in the home. the need for spouses/partners to seek or to be provided with increased opportunities for socialization was indicated, to overcome the loneliness and social difficulties that were evident in the study. in addition, rehabilitation personnel working with the target population need to be aware of the coping strategies that were found to have been successful in order to suggest them to other spouses/partners of head injured persons. in conclusion, the current study investigated many of the aspects that were perceived to affect the quality of life of the spouses/partners of persons with tbi. just as a seed rots in the ground before it germinates, destruction may serve to facilitate growth and development. as highlighted by lapointe (1999, p.15), "although quality of life may be altered, for every wreck there is a raft". by considering the various dimensions explored in the current study, rehabilitation personnel, family members and friends might 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(1984). apraxia of speech in adults. united states of america: grune and stratton inc. white paper on an integrated national disability strategy (1997). cape town: office of the deputy president world health organization (who) (1993). whoqol study protocol: the development of the who quality of life, assessment instrument, mnhlpsf/93.9. geneva, switzerland: division of mental health. r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) ylvisaker, m., & szekeres, s.f. (1996). communication disorders associated with closed head injury. in r. chapey (ed.), language intervention strategies in adult aphasia (4th ed.). baltimore: williams and wilkins. appendix a information saeet dear participant tamar wedclifte & eleanor ross 94 i am a final year· student of speech and hearing therapy at the university of the witwatersrand and am currently involved . in research on the impact of traumatic brain injury (tbi) on the quality of life of the spouse/partner of the injured person. research into this area has potential implications for improving our knowledge of the impact of brain injury on the quality of life of spouses/partners, the rehabilitation of persons with tbi, as well as counselling of their families. i appreciate that you probably have a busy schedule, but would nevertheless appreciate it-if you would complete the attached questionnaire and return it to me no later than , when i shall personally collect it. please place the completed questionnaire in the attached return envelope and hand it in to at headway. the questionnaire may also be returned should you decide not to participate in the study. please be aware that there are no right or wrong answers. all that is required is the answer that most accurately reflects your feelings and practices. responses will be kept strictly confidential and your anonymity will be preserved. in fact, you do not need to write your name anywhere on the questionnaire. please note that your participation in this study is completely voluntary and that you may withdraw at any time without it being held against you in any way. should you wish to be given a summary of the results of the study, these will be made available on request. if you have any questions, i may be contacted at 646-2229. your participation is highly appreciated. yours sincerely fourth year student supervisor the sollth african lournal o/communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners questionnaire on the impact of traumatic brain injury on quality of life of the injured person's spouse/partner demographic information your age: how long have you been married / living with your partner? number of children: age of spouse / partner: time in years and months since the injury: communication , 95 which of the following describes you spouse/partner's language patterns both before and after the injury? (tick whichever is applicable). ' before after vague, sketchy, imprecise language trouble understanding difficult spoken language word-finding difficulty rambling on and on, disorganized, going off on tangents socially inappropriate language very limited amount of speech difficulty understanding complex written language problems communicating in environments that are full of distractions difficulty understanding hints (such as indirect requests) problems understanding humour trouble with ab~tract language (relating to concepts or events that are faraway in time or space) difficulty following conversations please elaborate on the abovementioned / any other communication problems: 1. which of the following, if any, characterises your spouse/ partner's speech: (tick the relevant block) before after not applicable • · / i , i laboured i too soft i · stuttering i i too slow i too fast 2. do you find communidtion,with your spouse/ partner tiring? i never i sometimes i often 3. is your spouse/partner sensitive to the needs of the listener such that s/he: yes no repeats, explains or rephrases information when s/he is not understood yes no does not overestimate or underestimate the listener's knowledge of the subject being discussed 4. in order to convey what s/he intends to say, in addition to speech, does your spouse/partner use: yes no writing yes no gesture yes no facial expression die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) tamar wedcliffe & eleanor ross 96 5. how often does communication break down between you and your spouse/partner? i never i sometimes i often 6. does your spouse/partner often misinterpret what you have said to him or her? i no / 7. have your spouse/ partner's altered communication patterns had any effect on your relationship? i yes liyle~s ______ ~iln~o~ ____ ~_ h i / ?f if yes, please elaborate: j ................................................................................................................................... .if. ..... . , ............................ . :~:;~::~i~:d=~:~e~,:(:)lo'n:k:":uu~"m:and:(:)la·l!l~::: ::::::::::.::::: spouse/ partner's occupation before the injury: has your spouse/ partner returned to work? spouse/ partner's present occupation: increased andard of living compared to your standard of living before the ve dissatisfied 1. has there been a change in your family relationships since the injury? i yes i no please elaborate: 2. do you feel that your relationship with your spouse/partner's family has changed since the injury? i yes i no if yes, please explain how it has changed: 3. how does your spouse/partner's family react to him/her? / 4. did the injury have the effect of bringing family members closer or estranging them? i bringing closer i made no difference i estranging members the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners 5. does the extended family (i.e. aunts, uncles, cousins) visit as often as they did frior to the injury? i yes i no 6. does the immediate family visit as often as they did prior to the injury? i yes i no 7. this question looks at your roles and responsibilities before and after the injury: (please mark your responsibilities with (my) and those of your spouse/partner with (his/her). before the injury after the injury caring for the children dealing with medical aid, social agencies making financial decisions running the household main source of income 8. please rate your spouse/partner's ability to perform the following on a scale of 1-5 (1 = very poor; 5 = very good): 1 2 3 4 5 self-care e.g. dressing/feeding self hygiene household tasks shopping budgeting driving 9. how do you feel about having to take over the responsibilities of your' spouse/partner? marital relationship please complete this section irrespective of whether you are married or living in a common law relationship with your partner. (please tick the extent to which you agree/disagree with each item). i statement i strongly agree neutral disagree strongly i agree disagree 1. our marital relationship has not changed despite the injuh. ' 2. my relationship with my i spouse/partner has deterionlted as i time has passed since the injury. 3. we argue now more thaniwe did before the injury. / 4. i accept my spouse/partner's limits. 5. i have considered divorce. 6. i feel as ifi am married to a stranger since the injury. 7. i have a close, confiding relationship with my , spouse/partner. 8. i keep my frustration inside myself. 9. i am satisfied with my marriage. 10. my spouse/partner can no longer fulfil my emotional needs adequately. die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol,48, 200] 97 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) \ tamar wedciitte & eleanor ross 98 11. what jges in you, spou,""partne< (if any) sinoe the injury, have most affected you, marriage/relationship? i ::::::::::::::: :::: .. '\:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::".::" ... : ..... : ..... : ..... : ..... : ..... : ..... : ..... :: ... : ..... :: ... :: ... :: ... :: ... :: ... :: ................ . emotion 1. do yo 3. how do ou fa 1 abo an 5. to what extent do'y~u feel tied dependence? ~ " no no uplji~.'!ijllll ou for the following? (please tick the relevant item). completely inde endent g in your own independence as a result of your spouse/partner's not at all s a result of the stress of your spouse/partner's brain injury? no al plans as a result of the injury? i yes i no the south african journal a/communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the psychological effects of traumatic brain injury on the quality of life of a group of spouses/partners social aspects 1. please tick the applicable answer: i often feel lonely. yes no i feel responsible for meeting the social needs of yes no my spouse/partner. i feel that i have lost many friends since the yes no injury. i have made ma~ new friends since the injury. yes no i avoid social contact. yes no i am embarrassed by my spouse/partner's yes no behaviour in company. i my spouse/partner says the wrong things at the yes no wrong time causing me discomfort in social situations. 2. how satisfied/dissatisfied are you with your present social life in comparison with your social life before the injury? i very satisfied i satisfied i neutral i dissatisfied i very dissatisfied coping resources 1. please mark the extent of the contribution of the following to your coping with the consequences of the injury? (please tick those which are applicable). psychological counselling religion support groups domestic help friends medication / / very helpful somewhat helpful not at all helpful , , , i 2. what, if anything, has helped you most to deal with the stresses resulting from the traumatic brain injury? .......................................... j .................................................................... : ........................................................ . .............................................. j ........................................................................................................................... . --thank you very much for your co-operation. die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 99 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 100 information for contributo 1. nature of publication the south african journal of communication disorders publishes reports and papers concerned with research, and critically evaluative theoretical and philosophical conce tual issues dealing with aspects of human communication and its disorders, service provision, training and policy. the south african journal of communication disorde not accept material which has been published elsewhere 'r at is currently u(l~er review by other publications. \ 2. manuscript style and requirements • articles must he accompanied by a covering letter providing the author's address, telephone and fax num~ers land e-mail address. . 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( • three pnnt outs of the article must be\submitted. ! • . one exact copy 0'[ the article 00 dis&, il1ust be submitte filenames must include the first, autnor's initials and a clearly identifiable k~y word and must 'be, type-wlitten on ! t~t last line of the i~t page of the refe\ence list (for re; tri~val purposes only)\ " : • i artjcles must not excee,d 30 pages. \ ' '..1 the\title page ?f one ~ust contain: ~ i • title\pf the artjcle. ~ \' \~ • full n~mes of;ihe author~; , • institu'iional affiliation. \ ': . \ ' • abstra& of the article in tile language of the '~i .ie. • the titl page of the remtinirtg two c~oies ~ust not contain e auth9rls name~ o~ institution4 affii~ions. • each articl. must' contain an abstract of no\~\more t~an 200 words. . r \ 1\ ' • all abstract mu~t be in nglish, irres 'ec'iive f the language in w . c~ the article ~~s written. \ ~\ :, : ;~;~::,:": :::: l::::~:x:t~;;: specified in the publicati manual of tae~lneridan psychological association (apa pub. man., 1983). \ \ • headings are not numbered. the order o( impo ance is indicated as follows: . \ • ,main heading in capitals and bold print.' \ • sub-headings in capitals, hold and italic priht \ • sub-subheadings in upper and lower casci bold and! • ~~i~~:~~:~b-heading in upper and lower lase 01,' print. ~ • major headings, where applicable, must be in th orde 0 introduction, method, results, iisc sf sion, conclusion, acknowledgemen s, references. 'i / • all paragraphs should be indented. i • all tables, figures and illustrations must he numbered and provided with titles. • the title of tables, which appear above, and of figures, which appear below, must he concise but explanatory. • allow for 50-75% reduction in printing of tables, figures an illustrations. • each table, figure or illustration must appear on a separate page and be print ready. preferable not printed on colour printers. • do not include more than 10 tables, figures or illustrations. 3. • • • ust be revised for grammar and style prior to mi in. rna script style of the article must be strictly rding to the guidelines provided. y articles complying with the above requirements will ccepted for review. ingsystem • t e peer review of refereeing system is employed as a _ thod of quality control of this publication. • er reviewers are selected by the editor based on their e pertise in ,the field and each article is sent to two i dependent reviewers to assess the quality of the anuscript's scientific and technical content. . • he blind peer review system is employed during which the names of the author/authors are not disclosed to the reviewers. i the editor retains the final responsibility for decisidns regarding revision, acceptance or rejection of the manuscript. : deadline for contributions: 30'h june each year queries, correspondence & manuscripts: should he addressed to the editor, south african journal of communiction disorders south african speech-languagehearing association, postnet suite 62, private bag xl, florida hills, 171"9. tel. 011 675 3555, fax. 011 675 3785. copyright the copyright of all articles printed in the south africar:j journal of communication disorders is reserved by-the south african speech-language-hearing association (saslha). the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) abstract introduction literature methods results discussion conclusion acknowledgements references about the author(s) helena oosthuizen division of speech-language and hearing therapy, department of rehabilitation sciences, faculty of medicine and health sciences, stellenbosch university, south africa citation oosthuizen, h. (2019). speech therapy students’ perceptions of authentic video cases in a theory module on child language disorders. south african journal of communication disorders 66(1), a602. https://doi.org/10.4102/sajcd.v66i1.602 original research speech therapy students’ perceptions of authentic video cases in a theory module on child language disorders helena oosthuizen received: 04 june 2018; accepted: 17 oct. 2018; published: 22 jan. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: undergraduate speech-language therapy students often find it difficult to see the relevance of theoretical module content, which may negatively influence their motivation to learn. the real world of their future profession can be brought to life in the theory classroom by including authentic case study examples. video case studies are well suited to illustrating communication disorders and may also be easier to remember and relate to information already in the long-term memory. objectives: this article describes the perceptions of undergraduate students regarding the inclusion of authentic video cases in a theoretical module on developmental communication disorders. methods: a qualitative, interpretivist research design was followed. focus-group interviews were conducted with 22 second-year students in the programme b speech-language and hearing therapy. a modified contextualised content analysis approach was used to analyse interview data. results: the use of authentic video cases was perceived positively by participants. seeing a realistic example of a person with communication difficulties made it easier to understand, remember and engage with the module content. participants also felt they could more easily imagine themselves in that clinical context, which seemed to (re-) awaken in them a sense of purpose and motivation. being presented with real-life communication problems made them realise the relevance of their profession. however, participants experienced cognitive overload at times when the processing requirements of a task exceeded their available cognitive capacity. conclusion: video cases are valuable tools to enhance students’ engagement with theoretical content. to avoid cognitive overload, a scaffolded multimedia learning experience needs to be provided. introduction undergraduate students in the field of speech-language therapy often find it difficult to apply their theoretical ‘book knowledge’, in other words, to demonstrate competence in a clinical context (hoben, varley, & cox, 2007). during their early study years, the main focus is on obtaining the theoretical basis needed for clinical reasoning and problem-solving – that is, the ‘know’ and ‘know how’ levels of miller’s prism of clinical competence (miller, 1990) presented in figure 1 – and students typically venture onto clinical training platforms only after completing the relevant theory. the relevance of theoretical modules may therefore not always be clear to pre-clinical students. this can negatively influence their motivation to learn (kember, amber, & hong, 2008). the real world of their future profession can, however, already be brought to life in the theory classroom by including authentic case study examples (zipp & maher, 2010). figure 1: miller’s prism of clinical competence. research on multimedia learning suggests that, under certain circumstances, ‘people can learn more deeply from words and pictures than from words alone’ (mayer, 2014). presenting information as words (e.g. textbooks) along with pictures (e.g. videos) may facilitate deeper learning as students attempt to create associations between the two types of input. visual representations may also be easier to remember and relate to information already in the long-term memory (cherney, 2008; de leng, dolmans, van de wiel, muijtjens, & van der vleuten, 2007). if, however, one assumes that humans process verbal and visual material through different channels (dual-channel assumption), each of which has limited processing capacity (limited capacity assumption), the cognitive load of a multimedia learning opportunity needs to be carefully managed. otherwise, the processing requirements of a task may exceed a student’s available cognitive capacity and lead to cognitive overload (mayer & moreno, 2003). video case studies are particularly well suited to illustrating communication disorders, because they allow students to temporarily distance themselves from the real-time requirements of communication interaction and free up cognitive resources needed to engage with language as an object of study. also, because language is an abstract mental capacity, having a permanent record of a communication interaction with a language-impaired person is valuable to the novice not yet skilled in observing short-lived language behaviour. video clips from websites such as youtube are commonly used in lectures but these are seldom recorded with specific educational outcomes in mind and usually depict situations and behaviour that have little in common with the south african context. these limitations are especially problematic when considering the critical role that context and culture play in communication. against this background, and given that no studies could be sourced on how pre-clinical speech therapy students experience real video cases, funding was obtained to develop a database of authentic case studies of south african children with communication impairment and to pilot its implementation with students. the aim of this article is to describe how students perceived the video cases after they were exposed to them in a theory module on developmental communication impairment. literature benefits of using video cases in health sciences education range from enhancing memory for course content (cherney et al., 2008; de leng et al., 2007), improving clinical reasoning skills (hoben et al., 2007; lysaght & bent, 2005), stimulating shared cognition in a problem-based learning curriculum (balslev, de grave, muijtjens, eika, & scherpbier, 2005), and increasing student motivation (kember et al., 2008). authentic video cases have also been incorporated in speech therapy training programmes in the uk and usa. for instance, the uk-developed online repository of case studies known as patient assessment training system (patsy) contained ‘virtual’ patient cases in several clinical domains including speech and language (cox, & lum, 2004). this system made it possible for students to access raw assessment data and background information about real clients and to systematically test hypotheses about clients’ underlying cognitive processing difficulties, thereby improving their clinical reasoning skills. similarly, baharav (2008) reported on the development of a searchable database of video-recorded clinical sessions at the training clinic of western washington university and its application in undergraduate student training. although the aim of these two papers was not to describe undergraduate students’ perceptions of being exposed to real cases, both reported positive student feedback. medical students’ views on the added value of video cases in comparison to paper cases in a problem-based learning curriculum were examined in a qualitative study by de leng et al. (2007). findings from focus-group interviews indicated that video cases had several perceived benefits, such as: (1) being more true to life than text cases and therefore easier to visualise, (2) being memorable, (3) being motivating and making it easier for students to imagine themselves in certain situations and (4) representing a rich source of information. factors that hindered learning for these participants were videos that were too long and in which not enough structure was provided by the tutor. this study illustrates the potential value that video cases can add to students’ training and also highlights the importance of taking into account students’ perceptions when devising learning opportunities. based on the available literature, it was expected that inclusion of video cases would encourage deeper learning in the sense that participants in this study would have a better understanding of the module content, increased awareness of specific clinical populations and enhanced motivation for their studies. methods the study followed a qualitative, interpretivist research design, considered appropriate for the purposes of this study because it entails using participants’ ‘words and descriptions to record and investigate aspects of social reality’ (bless, higson-smith, & sithole, 2013). focus-group interviews were conducted with second-year students in the programme b speech-language and hearing therapy at stellenbosch university. focus-group interviews are considered an effective tool to explore subjective, emotional experiences (tracy, 2013) and were therefore considered appropriate for this study. context participants were enrolled in a 7-week module on communication disorders in specific clinical populations. a total of seven different topics were addressed during 3-h-long weekly lectures (see table 1). during the first hour, students wrote a short multiple choice questionnaire (mcq) test on the preparatory reading, watched one or two video cases ranging between 8 and 20 min and/or studied the written case history information. thereafter, students received a guest lecture by a speech therapist with clinical expertise in the particular area. during this 2-h lecture, theoretical information was discussed and related to the specific case study viewed in the video. cases had been developed in collaboration with the guest lecturer in order to provide students with ‘typical’ examples of the specific clinical population. the video cases depicted the child in an everyday context during an intervention session (assessment and/or therapy) and were edited by the author to depict the most salient aspects of the session in a shortened format. subtitles in english were provided for all child utterances, as well as for any afrikaans utterances used by the therapist. table 1: lecture topics and description of presented cases. participants participants were selected using purposive sampling. all 30 students who were enrolled in the module in which the videos were piloted were invited to participate in the study at the end of the module. students were recruited via email and followed up with a text message inviting them to take part in the study and 22 students agreed to take part (male = 1; female = 21; mean age 20 years). two focus groups were conducted with 9 and 10 students, respectively, in the language preferred by the group (afrikaans and/or english). three participants who were not able to attend the scheduled focus group interviews because of unforeseen events were later interviewed individually. in all interviews, an adaptive interview schedule consisting of standardised open-ended questions was used to guide the discussion and ensured consistency between interviewers. questions were related to themes identified in the literature review on students’ experiences of video cases. interviews were conducted by two independent persons not involved in students’ clinical training, namely a speech therapist and a phd student in clinical linguistics, both of whom have experience in qualitative interviewing and are fluent in both afrikaans and english. although the same interviewers conducted the focus group and individual interviews using a standardised interview schedule, it is acknowledged that differences in interpersonal dynamics in the two data collection methods may have influenced the nature of responses obtained. data analysis a modified contextualised content analysis approach was used to identify themes addressed by participants. to ensure reliability, the following audit trail was established: all interviews were orthographically transcribed by the author and the first interviewer. verbal and written feedback was obtained from both interviewers after completion of the interviews, highlighting key aspects of the interview process. the author further immersed herself in the data by reading and re-reading the transcripts and listening to the interviews, and made research memos to record personal insights related to certain sections of text. during this process, several recurring themes were identified and further grouped into four main themes that were coded into the data using atlas.ti software. to enhance the authenticity of findings, a member check was conducted. all participants were provided with the written transcript of the interview, as well as the preliminary results, and invited to approach the researcher if there were any disagreements regarding interpretation of the data. ethical consideration ethical approval was obtained from the health research ethics committee of the faculty of medicine and health sciences (n15/10/113) and the unit for institutional research and planning at stellenbosch university. permission to collect case study information was obtained from the western cape departments of education and health (20161027–5599). informed consent was obtained from all participants. all identifying personal information was removed from the written and video cases during editing, and from the interview transcripts, to protect the participants’ privacy. no personal details of participants were revealed to anyone not directly involved in the study. data were saved in a password-protected computer file to which only the researchers had access. videos were shown only to the students enrolled in the module and were not available for them to download or distribute. results findings from the two focus groups and three individual interviews will be discussed together according to the main themes outlined in figure 2. selected quotations are used throughout to illustrate themes in participants’ own words. figure 2: themes identified from focus group discussions on the inclusion of video cases in a theory module in an undergraduate speech therapy curriculum. having a mental picture improves memory and understanding ‘but for the things that i saw, i can speak about that.’ (focus group 1, female) ‘and now i understand what they say in the lecture, because i could see it.’ (focus group 1, female) the majority of students were of the opinion that video cases made the theoretical module content more memorable, because they now had a mental image that they could refer back to. having a real example helped them to more fully understand and engage with the theory, and several students recommended that real video cases already be used in first year. students also reported increased awareness of the communication characteristics of the clinical populations studied and knew better what to expect from their clinical training site the following year. however, they did not yet feel confident in their ability to actually do intervention. knowing what to look for ‘or even if they were to show us the whole long video, then just like stop it every five minutes and say, “did you see this and this and this? and now look out for this and this and this”. so just to guide your thoughts, so that you’re forced to focus as well.’ (focus group 1, female) ‘she’d like say okay um they’re prone to echolalia and then she shows us, this is what echolalia is, then she shows three or four, five second videos, then you’re like okay that makes sense now. instead of saying, remember in the video at the beginning or halfway through then you’re like…no. so yes, it just helps to have a referencing point.’ (focus group 1, female) students felt they would have been able to learn more from the video cases if they had had a better idea of what they were expected to focus their attention on, especially with longer videos. they felt they learned much better and were more engaged with the content when short video clips were integrated into the lecture to demonstrate important concepts, as this helped them to form associations between the theory they heard or read and what they saw. another way in which students felt the lecturer could better scaffold their learning experience was to let them view the video as a whole but to first give a short explanation and point out specific aspects to look out for. they also expressed a need to see more varied examples of each clinical population for a broader overview and in different contexts. better understanding of the profession ‘and you see the challenges that they [clients] face and then you realise that as a future therapist you have to be able to do and the skills that you need to have and how you need to go about to facilitate the development of those individual skills.’ (focus group 2, female) ‘when i watched the videos i asked myself about that one blind boy […] are you emotionally ready for your profession to basically work with these populations? so i think it just sparks that idea of, listen here, you’re on your way somewhere to actually go and make a difference.’ (focus group 2, male) participants found it very motivating to be exposed to real video cases, because they felt it gave them a better understanding of what their future profession entails and the type of clinical problems they will encounter. given the fact that second-year students still have relatively limited clinical exposure, they valued seeing the ‘bigger picture’ of what they were working towards in their studies. importantly, having an authentic record of a client–therapist encounter caused many students to identify and reflect on key interpersonal skills (such as patience) needed to be an effective therapist. this allowed them to construct a more realistic view of their chosen profession, their personal preferences (e.g. wanting to work with children) and the personal growth required of them. getting a real-life perspective ‘it’s not just a piece of paper. you get to visually watch the videos and see the actual children and see the actual lecturers giving therapies. it makes a difference to see the techniques and the children.’ (focus group 2, female) ‘i guess you kind of take it more seriously because it’s like a real thing. this isn’t like a fictional case or whatever, you know, this is like a real person who has gone through these real things, you know, like it’s kind of like you take it more seriously when dealing with people’s lives.’ (focus group 1, female) seeing video cases of actual therapists interacting with actual children with communication impairment made students realise the real-life implications of the content they were dealing with. although the main goal of viewing the videos were not to analyse the skills of the therapist, students nevertheless viewed the therapist as a role model in interacting with the child. the students also enjoyed the fact that, in most cases, the therapist in the video was also the guest speaker who presented the lecture and that they could learn from them in person. discussion the use of authentic video cases in an undergraduate theory module was generally perceived very positively by participants in this study. seeing a realistic example of a person with communication difficulties, reportedly made it easier to understand, remember and engage with the module content. this benefit of having a mental picture to refer back to echoes findings of previous studies (e.g. cherney, 2008; de leng et al., 2007) and is in line with the multimedia principle, namely that deeper learning is possible when learning through words and pictures than when learning from words alone (mayer, 2014). however, it is clear from the findings that unguided interaction with the videos limited the value of the experience for students. when faced with the rich source of information that a video case represents, pre-clinical students can easily feel lost or overwhelmed. as second-year students do not yet have an established knowledge base in long-term memory to guide their viewing of the videos, they need to mentally hold and manipulate the images and words in their working memory, which has limited capacity (mayer & moreno, 2003). students’ feedback seems to suggest that they experienced cognitive overload at times, either because of the length of the video, the perceived lack of guidance, the timing of the module or a combination of these factors. to avoid this, lecturers should consider incorporating short video clips into a traditional lecture format or providing clear instructions before students view the video case. the purpose for which a video case is used is likely to influence the learning outcome achieved. participants in this study felt that video cases fostered a greater awareness of the clinical characteristics of different clinical populations, but did not equip them with the practical skills they needed for intervention. to an extent, this finding was to be expected, because the focus of the module was largely introductory in nature and is followed up in third year with a year-long, dedicated clinical training site during which specific clinical skills are acquired. the exposure to authentic video cases seemed nevertheless to be highly motivating to students, partly because it gave them a better understanding of the extent and relevance of speech therapy. in line with findings by de leng et al. (2007), participants also felt they could more easily imagine themselves in that clinical context, which seemed to (re-)awaken in them a sense of purpose and motivation. seeing the range and extent of communication difficulties they will one day encounter, led them to critically reflect on the skills they would need to be an effective therapist. in that sense, the video case presented them with a valuable role model in the form of the therapist interacting with a client in a real-life clinical encounter (de leng et al., 2007). conclusion the inclusion of authentic video cases in an undergraduate theory module was generally perceived positively by the participants in this study, who felt that theoretical module content was easier to understand and remember when one had a mental image to refer back to. being presented with real-life communication problems made them realise the relevance of their profession and reflect on the skills they would need to cultivate to be effective therapists. in order to avoid cognitive overload, a scaffolded multimedia learning experience needs to be provided which takes into account students’ working memory and processing limitations. this study presents the subjective views of a specific group of participants at a particular point in time and needs to be followed up with more objective measures to determine if and to what extent the inclusion of video cases influences student performance. acknowledgements this research was made possible by a fund for innovation and research into learning and teaching (firlt) grant from stellenbosch university. the author is sincerely grateful towards every research assistant, speech therapist, teacher or headmaster, parent and child who willingly contributed their time and enthusiasm towards this project. competing interests the author declares that she has no financial or personal relationships that may have inappropriately influenced her in writing this article. references baharav, e. (2008). studentsʼ use of video clip technology in clinical education. topics in language disorders, 28(3), 286–298. https://doi.org/10.1097/01.tld.0000333602.76209.e7 balslev, t., de grave, w. s., muijtjens, a. m. m., & scherpbier, a. j. j. a. (2005). comparison of text and video cases in a postgraduate problem-based learning format. medical education, 39(11), 1086–1092. https://doi.org/10.1111/j.1365-2929.2005.02314.x bless, c., higson-smith, c., & sithole, s. (2013). fundamentals of social research methods: an african perspective (5th edn.). cape town: juta & company ltd. cherney, i. d. (2008). the effects of active learning on students’ memories for course content. active learning in higher education, 9, 152–171. https://doi.org/10.1177/1469787408090841 cox, r., & lum, c. (2004). case-based teaching and clinical reasoning: seeing how students think with patsy. in s. brumfitt (ed.), innovations in professional education for speech and language therapy (pp. 169–196). whurr publishers ltd.: london. de leng, b., dolmans, d., van de wiel, m., muijtjens, a., & van der vleuten, c. (2007). how video cases should be used as authentic stimuli in problem-based medical education. medical education, 41, 181–188. https://doi.org/10.1111/j.1365-2929.2006.02671.x hoben, k., varley, r., & cox, r. (2007). clinical reasoning skills of speech and language therapy students. international journal of language & communication disorders, 42(s1), 123–135. https://doi.org/10.1080/13682820601171530 kember, d., amber, h., & hong, c. (2008). the importance of establishing relevance in motivating student learning. active learning in higher education, 9(3), 249–263. https://doi.org/10.1177/1469787408095849 lysaght, r., & bent, m. (2005). a comparative analysis of case presentation modalities used in clinical reasoning coursework in occupational therapy. american journal of occupational therapy, 59(3), 314–324. https://doi.org/10.5014/ajot.59.3.314 mayer, r. (2014). cognitive theory of multimedia learning. in r. mayer (ed.), the cambridge handbook of multimedia learning (cambridge handbooks in psychology, pp. 43–71). cambridge: cambridge university press. https://doi.org/10.1017/cbo9781139547369.005. mayer, r. e., & moreno, r. (2003). nine ways to reduce cognitive load in multimedia learning. educational psychologist, 38(1), 43–52. https://doi.org/10.1207/s15326985ep3801 miller, g. (1990). the assessment of clinical skills/competence/performance. academic medicine, 65(9), s63–s67. https://doi.org/10.1097/00001888-199009000-00045 tracy, s. j. (2013). qualitative research methods: collecting evidence, crafting analysis, communicating impact. oxford: wiley-blackwell. zipp, g. p., & maher, c. (2010). use of video-based cases as a medium to develop critical thinking skills in health science students. journal of college teaching & learning, 7(1), 7–10. https://doi.org/10.19030/tlc.v7i1.72 abstract introduction methods data collection data analysis results discussion conclusion limitations of the study acknowledgements references about the author(s) merryl j. weimers department of speech pathology and audiology, faculty of health sciences, university of kwazulu-natal, durban, south africa mershen pillay department of speech pathology and audiology, faculty of health sciences, university of kwazulu-natal, durban, south africa speech and language therapy, massey university, auckland, new zealand department of health professions, manchester metropolitan university, manchester, united kingdom citation weimers, m.j., & pillay, m. (2021). pathogenic oral bacteria in hospitalised patients with dysphagia: the silent epidemic. south african journal of communication disorders, 68(1), a798. https://doi.org/10.4102/sajcd.v68i1.798 original research pathogenic oral bacteria in hospitalised patients with dysphagia: the silent epidemic merryl j. weimers, mershen pillay received: 16 oct. 2020; accepted: 24 may 2021; published: 30 july 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: aspiration pneumonia is a serious and fatal complication of dysphagia, secondary to the ingestion of bacteria-laden secretions. however, no studies have documented the oral hygiene features present in patients who present with dysphagia. objectives: the purpose of this study was to describe the oral hygiene problems of adults admitted to a sub-acute rehabilitation hospital and who presented with dysphagia. methods: a descriptive, cross-sectional survey was conducted, during which 40 participants – 57.5% (n = 23) male and 42.5% (n = 17) female – underwent a clinical swallow evaluation using the mann assessment of swallowing ability (masa) augmented with cervical auscultation (ca) and pulse oximetry (po), an oral hygiene assessment using an adapted version of the oral health assessment tool (ohat), followed by microbiology laboratory analysis of buccal swab samples to detect bacteria not considered part of the normal oral flora. results: results indicated that poor oral hygiene status was a common feature amongst all participants who presented with dysphagia. the most prevalent oral hygiene issues were related to abnormalities concerning saliva (60%), oral cleanliness (82.5%), the tongue (80%) and the use of dentures (71.4%). a high prevalence, 62.5% (n = 25), of opportunistic bacteria was found. the most commonly occurring bacteria groups were: (1) candida albicans (47.5%) and (2) respiratory pathogens (37.5%) such as klebsiella pneumoniae and staphylococcus aureus. conclusion: persons with dysphagia have poor oral hygiene which creates favourable environments for bacteria to flourish and increases the prevalence of pathogenic oral bacteria associated with the development of aspiration pneumonia. the management of oral health issues for persons with dysphagia should receive greater attention during hospitalisation. keywords: dysphagia; oral hygiene; aspiration pneumonia; oral bacteria; hospitalised patients. introduction the oral cavity of hospitalised and bedridden patients is often a reservoir for opportunistic respiratory pathogens (boaden et al., 2017; tada & miura, 2012), and can thus serve as a source of infection for the lungs if aspirated. there is a significant correlation between the presence of pathogenic bacteria in the oral cavity and the occurrence of respiratory diseases, such as pneumonia, especially in people who present with dysphagia (swallowing impairment) (fernández & clavè, 2013; konradsen, trosborg, christensen, & pedersen, 2012; simpelaere, nufflen, vanderwegen, wouters, & de bodt, 2016; sørensen et al., 2013; yoon & steele, 2012). swallowing is a complex neuromuscular activity that consists of oral, pharyngeal and oesophageal phases, and involves the coordinated function of many muscles (hiramatsu, kataoka, osaki, & hagino, 2015). physiological deficits in any of the swallowing phases result in dysphagia (gonzález-fernández & daniels, 2008) and may affect swallow efficacy (deficits with mechanical clearance) and/or safety of the swallow (subsequent aspirations). impaired safety of the swallow not only increases the risk for aspiration and the uncontrolled introduction of pathogenic pathogens into the lower respiratory tract (fernández & clavè, 2013), but has also been associated with the presence of gram-negative bacteria; dysphagia is thus an important risk factor associated with the development of aspiration pneumonia (ap). the incidence of pneumonia caused by aspiration of pathogenic bacteria in patients who present with dysphagia, increases both the mortality and the need for acute care hospitalisation (sørensen et al., 2013), which in turn can impact on oral hygiene (danckert, plummer, & williams, 2016; neto, de paula ramos, sant’ana, & passanezi, 2011; tada & hanada, 2010). this is partly because of the fact that oral infections often remain asymptomatic and may still result in bacteraemia despite an absence of overt symptoms (rautemaa, lauhio, cullinan, & seymour, 2007). oral care practices are often an overlooked component in the care of hospitalised patients (chipps et al., 2014) as poor oral hygiene is not a highly visible condition, and related concerns, such as gingivitis and dental plague require a closer inspection of the mouth (yoon & steele, 2012). furthermore, potentially pathogenic bacteria are frequently carried in the oral cavity and hospitalisation appears to create conditions that favour oropharyngeal colonisation (boaden et al., 2017). the problem, however, is that dysphagia is often a symptom of multiple diseases and disorders, such as neurological disorders, cerebrovascular and neurodegenerative diseases that often require hospitalisation. moreover, these diseases and disorders are often accompanied by impaired communication making dysphagia and its repercussions such as oral bacterial colonisation a highly invisible disorder and a silent epidemic. unless we increase our knowledge and strengthen our understanding of the risk posed by poor oral hygiene to individuals with dysphagia, opportunistic respiratory bacteria originating in the mouth have the potential to become the silent killer of vulnerable hospitalised patients who present with dysphagia. methods study design and setting a descriptive, cross-sectional study was conducted over an 8-week period, at a sub-acute neuro-rehabilitation hospital, in the private sector, in the eastern cape province of south africa. participants the study included 40 participants, 57.5% (n = 23) male and 42.5% (n = 17) female, aged 20–99. non-probability, convenience sampling was used to select participants for the clinical swallow evaluation (cse). as per the admission protocol of the research site, all new patients undergo an initial screening of swallow function on the day of admission, by the resident speech therapists. thus, potential participants were approached based on their dysphagia status as established on the day of admission. patients were excluded if they did not meet inclusion criteria, for example, if they were minors, if they were on a non-dysphagic diet or if consent was not provided. purposive sampling was used to recruit participants for the oral health assessment, as only those who were confirmed as having dysphagia, following the completion of the cse underwent the oral health assessment. the demographic, clinical diagnosis and nutritional status of participants included in the study are shown in table 1. table 1: demographic details of participants who presented with dysphagia (n = 40). data collection data were collected during two stages: (1) a cse and (2) an oral health assessment. the oral health assessment consisted of two components, namely visual inspection of the oral cavity and microbiology laboratory testing of oral swab samples. clinical swallow evaluation during the cse, the swallow function of each of the 40 participants recruited was assessed using the mann assessment of swallowing ability (masa). the masa is a bedside swallow assessment which measures 24 different skills pertaining to the oro-motor and sensory components of swallowing, to determine a patient’s swallow ability, in terms of efficacy and safety (mann, 2002). furthermore, the masa contains several discriminate items reflecting cognitive status, level of alertness and cooperation. as a result, it could effectively be used on participants who were unconscious or presenting with cognitive deficits (kwon et al., 2019). the masa score is measured using a 5–10 point rating scale, with 200 being the highest possible score. scores were used to characterise the clinical features of dysphagia, as well as provide an estimate of the risk of aspiration. the masa assessments were augmented with cervical auscultation (ca) and pulse oximetry (po). cervical auscultation was used to listen to the sounds of swallowing using a paediatric stethoscope to differentiate between normal and impaired swallow sounds (cichero & murdoch, 2006; groher & crary, 2010) and po was used to obtain participant oxygen saturation (spo2) levels during swallowing. for this study, po was used to confirm the association between swallowing abnormalities and oxygen desaturation, seen as the difference ≥ 3% between baseline spo2 and spo2 after the swallow. whilst on their own, ca and po provide contestable data about swallowing and/or associated respiratory function, they were included as adjuncts to the masa to increase the sensitivity and specificity of the assessment methods. oral health assessment the oral health assessment was used to characterise the oral hygiene status of participants as well as the degree of oral bacterial colonisation. oral health assessment tool to ensure that the most accurate and reliable findings regarding each participant’s oral hygiene were obtained, a qualified oral hygienist used an adapted version of the oral health assessment tool (ohat) (chalmers, king, spencer, wright, & carter, 2005) to visually assess and score a participant’s oral hygiene. the ohat used for this study was adapted from the version originally developed by chalmers et al. (2005). the ohat was adapted based on literature, findings from the pilot study and the inputs of a dentist, to refine the criteria assessed, thus providing more meaningful data related to the current study as well as to the south african setting. a pilot study was conducted over a 4 week period, at the same research hospital, to evaluate the reliability and validity of the data collection instruments, and to improve upon the study design and instruments. results of the pilot identified that the original version of the ohat focused on providing a specific score for each patient based on the health of the oral cavity. however, to meet the objectives of the current study, more emphasis had to be placed on identifying and describing oral hygiene problems, rather than simply screening and scoring. thus, the ohat used for the purpose of this study was modified in the following ways. whilst the eight categories of the original tool were maintained, more emphasis was placed on identifying and describing specific issues rather than simply scoring the responses. this allowed for additional structured observations that were added under each category to give a richer description of each area assessed and the scoring system was altered from three possible scores (0: healthy; 1: some changes; 2: unhealthy) to a range of 0–5. the altered scoring represented additional oral health abnormalities observed according to severity under each sub-category, which enabled the responses to not only indicate severity but also provide a descriptive result of the oral hygiene status. microbiology laboratory testing the oral hygienist collected samples from the buccal site of the participants’ oral cavities, using cotton-tip swabs. this was a once-off collection taken after the completion of the cse. the samples were transported to a biomedical-testing laboratory for microbiology laboratory, oral culture analysis. data analysis the clinical data from the masa, the ohat and the microbiology swab results were analysed, using descriptive statistics, namely univariate analysis, to describe and summarise patterns found in the data. statistical analyses of data included frequency distribution, central tendency (mean, median and mode) and measures of variability (range and standard deviation). pulse oximetry and ca were used as adjuncts to the masa assessment during the cse, as a means to increase sensitivity and specificity of the masa findings. to determine whether the relationship between the variables was statistically significant, categorical data from the po, ca and masa scores were tested using a test of independence, namely the fischer’s exact test. the statistical analysis was performed using spsstm version 24, a p-value of ≤ 0.005 being considered significant. a cross-tabulation between (1) masa scores and po and (2) masa scores and ca was done. more than 20% of the cells have an expected count of less than 5 and thus fischer’s exact test was used. the masa scores were split into three groups: (1) lower – score less than masa quartile 1 value for the 40 respondents; (2) average – score between masa quartile 1 and quartile 3 values; and (3) higher – score greater than masa quartile 3. a significant correlation was found between po and the masa score. the p value was less than 0.005. those who pass the po have significantly higher masa scores (almost double) than those who fail; thus confirming results of masa. similarly, the p value for ca to masa scores was 0.000 indicating a significant association between the two. results thus indicate that the two supplemental procedures po and ca had a high rate of agreement with the masa findings. ethical considerations the biomedical research ethics committee (brec) of the university of kwazulu-natal, south africa, approved this study (ethics reference number: be454/15). the process of informed consent was specifically designed for the purpose of this study given that participants had co-morbid cognitive–linguistic disorders, which affected attention, memory, language and in turn communication abilities. to respect the rights and ensure the autonomy of participants who were unable to verbalise, augmentative and alternative communication (aac) charts were used to indicate yes or no, which was accepted as a form of consent. furthermore, in cases where the participant was cognitively intact but unable to write or provide a signature, a thumbprint in the presence of a witness was considered as written consent. where patients were unconscious or presented with severe language deficits, their family members and/or next of kin were approached to provide consent. only participants for whom consent was obtained, were included in the study. results clinical features of dysphagia forty participants were initially identified as having dysphagia during sample selection. out of the initial 40 participants recruited, 57.5% male (n = 23) and 42.5% female (n = 17), were confirmed to present with dysphagia in varying degrees of severity. seventeen (42.5%) presented with severe, seven (17.5%) with moderate and four (10%) with mild dysphagia, as confirmed by the cse. twelve (30%) participants presented with little evidence of dysphagia (led). as the study aimed to investigate oral hygiene issues present in patients with dysphagia specifically, the decision was made to include participants who presented with a masa score of ≥ 178 indicating little evidence of disease (led), as these patients still presented with lower scores in the oral preparatory phase (lip seal, tongue strength and coordination) and oral phases (bolus clearance, oral transit time) of the swallow. from this sample of participants who had confirmed dysphagia, the majority (70%) presented with a degree of risk for aspiration, ranging from a definite to possible risk. clinical signs of dysphagia according to the results of the cse, 75% of participants presented with clinical signs of impaired efficacy of the swallow and 52.5% presented with clinical signs of impaired safety of the swallow. the five main clinical signs and symptoms of impaired efficacy of the swallow, as presented in table 2, were poor lip seal (77.5%), reduced tongue strength (67.5%), poor tongue coordination (62.5%), impaired oral transit (90%) and ineffective bolus clearance (92.5%). table 2: predominant deficits affecting efficacy of the swallow (n = 40). the main signs of impaired safety of the swallow (impaired cough, voice change, impaired hyolaryngeal elevation) are presented in table 3. these signs were accompanied by oxygen desaturation and abnormal swallow sounds, with 52.5% of the participants demonstrating some signs of penetration and/or aspiration whilst swallowing. signs of penetration were subjectively documented as gurgling during the swallow and coughing before, during or after swallowing which was detected in 12 (30%) and 9 (22.5%) participants respectively. twenty-six (65%) participants demonstrated difficulties with hyolaryngeal elevation. table 3: predominant deficits affecting the safety of the swallow (n = 40). the reflexive and voluntary cough response was ineffective in 57.5% of the participants, and 70% could either not cough on command, or presented with an inadequate or non-explosive (bovine) cough attempt. oral hygiene and degree of oral bacterial colonisation oral hygiene status was found to be very poor amongst all participants, with a high prevalence of bacterial colonisation, each participant presented with at least a minimum of one oral hygiene issue at the time of assessment, with a mean of 4.25, a median of 4 and a maximum of 7. oral hygiene status table 4 presents the oral hygiene issues participants presented with. the most prevalent oral hygiene issues were related to the use of dentures, saliva, oral cleanliness and the tongue, with 80% having hygiene-related issues for the latter. the next most prevalent issue was related to the condition of the gums and tissues, with 52.5% of participants demonstrating issues such as dryness (15%), red or white patches (5%), signs of inflammation (15%), oral mucosal lesions (15%) and signs of possible infection (2%). twenty-four participants (60%) had their natural dentition, which was in a good condition. of the 25 who had dentures, a large majority (71.4%) experienced problems relating to their use, such as poor fit attributed to the dentures being loose (21.4%), or resulting in pressure or broken areas (7.2%). the presence of tartar build-up on dentures was identified in three (10.7%) participants. table 4: oral hygiene indicators relating to the most prevalent conditions of the oral cavity. degree of oral bacterial colonisation of the 40 participants, only 15 (37.5%) presented with normal oral flora; thus, the majority (62.5%) presented with bacterial organisms that are not part of the resident oral flora. of the 15 patients who presented with normal oral flora, 66.6% (n = 8) presented with led according to their masa scores. higher masa scores, 178 and above, were thus associated with normal oral flora. on the other hand, lower masa scores, indicating a higher severity of dysphagia, were associated with an increased likelihood for the presence of pathogenic oral bacteria. seventeen (42.5%) had at least one bacteria strain present; seven (17.5%) had up to two strains and one (2.5%) participant had up to three bacterial strains present. table 5, lists the most commonly occurring organisms isolated from the oral cavity of participants, these include (1) candida and various strains of the candida species (47.5%) and (2) opportunistic respiratory pathogens (37.5%). twenty-two (47.5%) participants had only yeast; the remainder of the participants’ cultures had single isolates of opportunistic respiratory pathogens or opportunistic respiratory pathogens co-occurring with yeast. table 5: bacterial organisms isolated from the oral cavities of participants and the degree of colonisation. discussion this study found that the majority of participants did not present with satisfactory oral hygiene, with a high prevalence of bacterial colonisation. furthermore, poor oral hygiene status was associated with hospitalisation and not limited to those presenting with dysphagia. the findings support those of previous studies, which report the prevalence of oral health problems amongst acutely hospitalised patients to be very high (danckert et al., 2016; matthews et al., 2012; tada & hanada, 2010). in recent years, the interaction between opportunistic respiratory pathogens and candida albicans has been reported (dahlén, 2009). this finding was corroborated in the current study, as the most commonly occurring bacteria in the oral cavity of participants were (1) candida species and (2) opportunistic respiratory pathogens. in five (17.5%) participants, candida albicans was found to co-occur with an opportunistic respiratory pathogen. in the context of oral health, stroke can cause hemiparesis and hemiplegia to the muscles of the pharynx, tongue and palate and the muscles of mastication, resulting in an impaired ability to chew and grind food and reduced oral clearance. plaque biofilms are dislodged by the movement of the oral musculature, such as the cheeks and tongue, during speech and mastication (kilian et al., 2016). furthermore, studies have shown that effective salivary flow and swallowing is needed to clear bacteria-laden secretions from the oral and pharyngeal cavities (ortega et al., 2015; palmer, 2008). in this study, poor mechanical clearance of the bolus, which included the clearance of accumulated saliva, was found to be an area of significant difficulty for most participants with dysphagia. this resulted in oropharyngeal residue that was particularly related to tongue weakness and difficulties with coordination. according to palmer et al. (2001), the reduction in mechanical clearance of potential pulmonary and oropharyngeal pathogens may be the first step in the path that leads to oral pharyngeal colonisation and pneumonia. oropharyngeal residue that is not cleared promotes bacterial growth and invasion as pathogens have increased time in the mouth for proliferation. reduction in mechanical clearance could also account for the finding that all participants presented with deficient oral cleanliness related to the accumulation of plaque, saliva and debris. the motor function of the tongue is described to be related to its self-cleaning function. reduced activity as a result of weakness possibly accounts for the finding that 80% of the study participants had oral hygiene issues related to the tongue, more specific to tongue coating. this finding is concerning as studies have identified the dorsum of the tongue as a major oral site of bacterial multiplication, as well as a major source for the bacteria found in saliva. this indicates that many salivary bacteria mirrors those coming from the flora of the dorsum of the tongue (danser, go´mez, & van der weijden, 2003; kikutani et al., 2009; pace & mccullough, 2010) which could account for the high prevalence of pathogenic bacteria found in the oral cavities of participants with dysphagia. participants with dysphagia were found to have more food debris, plaque, poorer oral clearance and more denture problems. this can be ascribed to functional impairments of the oral phase of the swallow, such as reduced orofacial muscular control and loss of oral sensory function, which are symptoms and complications of disease processes, such as cerebrovascular accident (cva) that affect the efficacy of the swallow. these deficits may thus have the potential to significantly affect oral hygiene, creating a favourable environment for pathogenic bacteria to grow and colonise. it has been extensively researched and is well known that oral microbiota contributes to oral and general well-being and its loss can be detrimental to the health of the individual. numerous studies have implicated oral colonisation with pathogenic bacteria as a precursor condition contributing to ap risk. participants in the current study presented with an increased number of pathogenic oral bacteria, with only 15 participants presenting with normal oral flora. it was interesting to note that the larger majority of participants presented with bacteria strains commonly associated with the acquisition of nosocomial infections, such as bacterial pneumonia. infection control efforts are applied in hospitals to prevent nosocomial infections, with microbiology surveillance often put into place to detect harmful microorganisms before they have the chance to ensue disease. research states that as long as the microbial load is not too high, the harmony between pathogenic bacteria and oral resident flora will not be tilted toward infection (danser et al., 2003; rautemaa et al, 2007). however, the results of this study indicate that when bacterial species were found in the oral cavities of participants, the virulence was already quite high. this bacterial virulence suggested the delicate oral homeostasis had potentially already been tipped toward infection and if not treated could potentially lead to systemic disease such as ap. in this study, 70% of participants presented with some degree of risk for aspiration -– thus presenting with an increased likelihood to aspirate pathogenic bacteria, which could overburden the host defence mechanisms and lead to infection, resulting in longer hospital stays, costly care and possible death (terpenning & shay, 2002). the monitoring of oral bacterial colonisation may thus be crucial in determining the risk for pneumonia in hospitalised patients who present with risk factors such as dysphagia (yoon & steele, 2013). pain is a key indicator for patients and medical professionals, such as nurses, that something is wrong (germossa, hellesø, & sjetne, 2019). an interesting finding of the study was that although oral hygiene was poor, 83% of participants (n = 33) demonstrated no signs of oral and/or dental pain, with no participants having any verbal reports of pain. because of the nature of the clinical population, such as increased reliance on others for care including oral hygiene, communication disorders and the resulting inability to effectively communicate their needs, people with dysphagia can be regarded as a voiceless population. furthermore, it is known that oral hygiene issues may not be painful and often remain asymptomatic (dahlén, 2009), requiring further inspection. these patient factors in combination with the asymptomatic nature of oral hygiene problems highlight the silent nature of oral diseases. thus, because of the nature of the patient population, interprofessional collaboration and problem solving between dental staff, nurses and speech-language therapists is required to address patient oral care during hospitalisation. conclusion this study demonstrated that the oral hygiene status of hospitalised patients who present with dysphagia is concerning. patients with dysphagia may present with many oral hygiene problems, which may lead to a high prevalence of colonisation of respiratory pathogens. the findings of this study not only corroborate the findings from previous research, which indicated that oral hygiene is poor during hospitalisation, but also provide novel information regarding the oral hygiene problems people with dysphagia present with. furthermore, it highlights the fact that oropharyngeal swallowing disorders in conjunction with poor oral hygiene, constitute an increasing problem for the often silent hospitalised patient who presents with co-morbid communication disorders. hospitalised patients with dysphagia thus require greater vigilance in oral care, which may include improved screening of oral hygiene and frequent and professional dental care during hospitalisation, to minimise the potential effect of this undetected, silent killer. limitations of the study the study employed a relatively small sample size of only 40 participants. furthermore, the study location was a sub-acute rehabilitation hospital based within the private sector in south africa. patients admitted there thus had private medical aids and would present with very different socio-economic characteristics compared to those admitted to a government facility. as a result, the researcher does not expect the sample from this study to be representative of all hospitalised patients in south africa. future research in south africa should focus on obtaining population representative data by investigating oral hygiene in both private and government institutions, as well as utilising a larger sample size. acknowledgements the authors thank the hospital manager at the research site for allowing data collection to take place at the institution, and the participants and family members for their willingness to take part in the study. a special note of thanks is given to the oral hygienist n. grobler for contributing her services during data collection; ampath laboratories at greenacres hospital in port elizabeth and dr l. nut for their contribution toward interpretation of results and prof. m. pillay for his guidance and supervision during the write-up of the manuscript. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions m.j.w. and m.p. were involved in the conception and design of the idea. m.j.w. was responsible for data collection and analysis and interpretation. m.p. verified the analytical methods, supervised the findings of this work and assisted with interpretation of the findings. both authors discussed the results and contributed to the final manuscript. funding information this study was financially supported by the university of kwazulu-natal, college of health sciences (chs) postgraduate scholarship, grant number 532851. data availability the data that support the findings of this study are available on request from the corresponding author, m.j.w. the data are not publicly available as they contain information that could compromise the privacy of research participants. disclaimer the views expressed in the submitted paper are those of the researchers and not an official position of the university of kwazulu-natal. references boaden, e., lyons, m., singhrao, s.k., dickinson, h., leathley, m., lightbody, c.e., … higham, s. 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(2013). monitoring oral colonization as a risk for pneumonia in complex continuing care: lessons learnt from a pilot study. canadian journal of speech-language pathology & audiology, 37(2), 134–145. abstract introduction methods results discussion conclusion acknowledgements references about the author(s) kerry knight department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa bhavani pillay department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa jeannie van der linde department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa esedra krüger department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa citation knight, k., pillay, b., van der linde, j., & krüger, e. (2020). nurses’ knowledge of stroke-related oropharyngeal dysphagia in the eastern cape, south africa. south african journal of communication disorders, 67(1), a703. https://doi.org/10.4102/sajcd.v67i1.703 original research nurses’ knowledge of stroke-related oropharyngeal dysphagia in the eastern cape, south africa kerry knight, bhavani pillay, jeannie van der linde, esedra krüger received: 12 mar. 2020; accepted: 20 june 2020; published: 02 sept. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: early identification of stroke-related oropharyngeal dysphagia (opd) using screening by nurses can prevent adverse patient outcomes in lower middle-income countries. nurses are essential in the opd management team and should ideally be able to screen and prioritise dysphagia management in stroke patients. objective: the aim of this research was to describe nurses’ practices related to identification and management of patients with stroke-related opd. methods: qualified nurses from various healthcare levels in the eastern cape, south africa were invited to complete a previously published hard copy survey on the signs and symptoms, complications and management of stroke-related opd. a sample of 130 participants completed the survey. results: the mean scores of correct responses for each section were: 8.7/13 (66.7%) for signs and symptoms, 4.7/10 (47.3%) for complications and 3.8/7 (54.2%) for management practices. statistically, there were no differences between the levels of healthcare for the signs and symptoms section and the complications section. regarding management of opd, secondary-level (s) nurses demonstrated significantly better knowledge than primary-level (p) and tertiary-level (t) nurses (s–p: p = 0.022; s–t: p = 0.010). secondary-level nurses also scored significantly higher across all three sections (s–p: p = 0.044; s–t: p = 0.025) than those at the other levels. conclusions: the study found that nurses across all levels of healthcare had only moderate knowledge regarding identification and management of stroke-related opd. interdisciplinary collaboration between nurses and speech–language therapists may improve nurses’ knowledge in identification and management of stroke-related opd in lower middle-income settings such as south africa. keywords: oropharyngeal dysphagia; dysphagia screening; stroke-related dysphagia; nurse; interdisciplinary collaboration; south africa; lower middle-income country; survey. introduction in rural south africa, strokes result in approximately 30 000 deaths yearly and are the largest cause of disability in the country (maredza, bertram, gómez-olivé, & tollman, 2016). stroke is one of the leading causes of oropharyngeal dysphagia (opd) (behera et al., 2018; joundi et al., 2017). oropharyngeal dysphagia is often underdiagnosed in people with stroke, leading to adverse complications including aspiration pneumonia, malnutrition, dehydration, extended hospital stay and death (takizawa, gemmell, kenworthy, & speyer, 2016). early identification of opd using screening allows for prompt initiation of management plans, which may improve patient outcomes (sherman et al., 2018). nursing staff are more likely to be the first health professionals to detect the early symptoms of opd as they administer medication and feed patients (bhimte & rangasayee, 2015). people identified with swallowing difficulties should ideally be referred to a speech-language therapist (slt) for comprehensive assessment and management (american speech-language-hearing association [asha], 2016). only a limited number of slts are employed in the south african public sector, resulting in large caseloads (ostrofsky & seedat, 2016). contextual challenges of limited resources, both human and physical, are a barrier and often result in long waiting times for the patient and possibly insufficient clinical management of dysphagia cases (andrews & pillay, 2017). the importance of accurate early identification of stroke-related opd by nurses is thus evident, as this may guide its initial management, such as placing a patient nil per os until formal slt review (behera et al., 2018; cummings et al., 2015; palli et al., 2017). oropharyngeal dysphagia management may include changes in consistencies, positioning or swallow manoeuvres (south african speech-language and hearing association [saslha], 2011). ideally, nurses should effectively identify opd and risk for aspiration by screening patients’ swallowing abilities before administering food or liquids (behera et al., 2018; palli et al., 2017). nurses can implement initial swallowing precautions to prevent unfavourable outcomes until slts are able to perform comprehensive swallow assessments (sherman et al., 2018). patients who fail a screen and have possible opd should be referred to an slt for further assessment (sherman et al., 2018). in lower-middle-income countries (lmics) such as south africa, swallow screenings by nurses are inconsistently conducted because of insufficient screening protocols and limited material and human resources (blackwell & littlejohns, 2010). the result is a lack of clarity as to who has the responsibility to refer to slts and which patients require swallowing assessment following stroke (blackwell & littlejohns, 2010). in south africa, healthcare professionals may not have a large amount of experience or training in stroke-related opd (willie, 2011). a recent unpublished master’s study stated that there is also a shortage of nurses in the public sector in south africa, reducing the amount of time nurses may spend with patients (george, gow, & bachoo, 2013; robbertse, 2018). only 50% of nurses service the majority of patients in an under-resourced setting (blackwell & littlejohns, 2010). nurses who receive sufficient training and support to perform dysphagia screenings are more likely to use swallow screening protocols and appropriately refer to slts (sivertsen, graverholt, & espehaug, 2017). yet international studies report that nurses display difficulty identifying opd timeously following a stroke, delaying appropriate referral for intervention (bhimte & rangasayee, 2015). nursing staff in south africa demonstrated low awareness of the role of slts in opd management, possibly because of insufficient undergraduate training on opd and minimal interaction with slts in practice (albini, soares, wolf, & gonҫalves, 2013; robbertse, 2018). prevention of dysphagia-related complications and establishment of screening protocols to clearly indicate the roles and responsibilities of various professionals in a dysphagia team is the role of slts (asha, 2016). the slt’s involvement in interdisciplinary teamwork and collaboration with nurses could ensure that team members are informed and adequately prepared for identification of opd (rhoda & pickel-voight, 2015). more regular interaction between nurses and slts can allow for sharing of knowledge and expertise between professions (robbertse, 2018), which is essential within lmics (blackwell & littlejohns, 2010). improved interdisciplinary collaboration may lead to shorter hospital stays, lessen the number of patient complications and decrease mortality rates in people with stroke-related opd (dondorf, fabus, & ghassemi, 2015). the aim of this study was to describe nurses’ knowledge of stroke-related opd in the eastern cape, south africa which may identify possible training needs and guide future interprofessional collaboration between slts and nurses in this setting. methods study design and setting data were collected using a validated survey on eating and swallowing difficulties(rhoda & pickel-voight, 2015) and a quantitative descriptive study design (leedy & ormrod, 2014). the survey was distributed by hand to 135 nurses from five sites in a metropolitan area of the eastern cape, south africa. the study aimed to gather data in three areas: the identification, complications and management of stroke-related opd. study population and sampling participants were required to be qualified nurses working with people with stroke, who were proficient in english. using purposive sampling, 135 participants were recruited (leedy & ormrod, 2014). three surveys were returned incomplete, and two surveys were not returned; therefore, the responses of 130 participants were analysed. participant characteristics are presented in table 1. approximately half the participants (n = 66; 50.8%) had 10 or more years of experience, and 86 participants (66.2%) were working in medical wards (table 1). table 1: participants’ socio-demographic characteristics and professional experience (n = 130). data collection a published survey about eating and swallowing difficulties (rhoda & pickel-voight, 2015) was used to collect data. the survey was previously validated by five practising slts with experience in assessment and management of opd, and the test–retest method was used to ensure reliability (rhoda & pickel-voight, 2015). the survey consisted of four sections: demographic information and level of experience, signs and symptoms, complications and management of dysphagia. a pilot study was conducted with 10 participants prior to data collection to ensure clarity of questions and increasing reliability of the findings. data were collected from july to september 2018 by the first author, who distributed the hard copy surveys by hand and was available for clarification. nurses who did not wish to participate were able to refuse participation from the outset or withhold submission of the survey. data analysis the survey was scored using the guidelines of rhoda and pickel-voight (2015), tallying the number of correct responses in each section. each participant’s level of knowledge was classified as follows: a score of ≥ 75% was ‘high’, 50% – 74% was ‘moderate’ and a score of ≤ 50% was ‘low’ (rhoda & pickel-voight, 2015). data were analysed using the statistical package for the social sciences version 25, using descriptive and inferential statistics in consultation with a statistician. the cronbach’s alpha coefficient equalled 0.707, demonstrating the reliability of the questionnaire (goforth, 2015). p-values of <0.05 were considered statistically significant. variability of responses was noted across nurses and within levels. ethical considerations ethical clearance was obtained from faculty of humanities and health sciences, university of pretoria (protocol number gw20180105hs). permission was obtained from the required provincial department of health governing bodies, with voluntary participation and written informed consent from each participant. results level of experience most participants (n = 118; 90.8%) had cared for a patient who had had a stroke, whereas only 50% (n = 65) had received training on stroke patient care. the majority of participants (n = 100; 76.9%) had cared for stroke patients with swallowing difficulties, with only 26.9% (n = 35) having received training on opd and its management. interestingly, 81.5% (n = 106) of participants indicated that they were unsatisfied with their current knowledge of stroke-related opd, and most participants (n = 125; 96.2%) indicated a desire for further training. variability of responses was noted across participants and within the different levels of healthcare. identification of signs and symptoms of oropharyngeal dysphagia table 2 shows a comparison of participants’ understanding of the typical symptoms of opd. in tables 2 to 4, the p-values labelled ‘p–s’ (primaryand secondary-level groups), ‘p–t’ (primaryand tertiary-level groups), and ‘s–t’ (secondaryand tertiary-level groups) indicate whether correct responses differed significantly between groups. table 2: comparison of participants’ knowledge of signs and symptoms of oropharyngeal dysphagia (n = 130). as a group, participants performed best in the identification section, with a mean correct response score of 8.7/13, indicating that 66.7% of the symptoms were identified correctly. however, when asked whether patients always cough if they aspirate, only 5.4% (n = 7) of participants responded correctly. two other symptoms also generated low scores, namely ‘hoarse voice’ (49.2%; n = 64) and ‘chest pain’ (35.4%; n = 46). more common symptoms such as ‘coughing whilst eating’ (n = 114; 87.7%), ‘poor movement of the tongue’ (n = 115; 88.5%) and ‘food remaining in the mouth’ (n = 116; 89.2%) were accurately identified by most participants. statistically, there were no significant differences across nurses working at the various levels of healthcare in this section (p = 0.066). however, for the item ‘difficulty closing lips’, the percentage of correct responses differed significantly, with primary-level nurses scoring a high correct response rate (84.1%) and tertiary-level nurses scoring much lower (38.9%; p = 0.000). there was also a significant difference for this item between secondary-level nurses, with the next highest score (66.0%), and tertiary-level nurses (38.9%; p = 0.016). interestingly, primary-level nurses (56.8%) had significantly more correct responses to the item ‘hoarse voice’ when compared to the tertiary-level nurses (22.2%; p = 0.003). the same trend was seen for this item amongst secondary-level nurses (62.0%), who demonstrated significantly more correct responses than the tertiary-level nurses (22.2%; p = 0.000). complications of oropharyngeal dysphagia participants scored the lowest in this section of the survey, with a mean correct score of 4.73/10, revealing that only 47.3% of complications were accurately identified (table 3). table 3: comparison of participants’ knowledge of complications of oropharyngeal dysphagia (n = 130). three complications were incorrectly thought to be the result of a stroke, with only a small percentage of participants identifying them correctly (table 3). these were ‘anaphylactic shock’ (n = 32; 24.6%), ‘problems with digestion’ (n = 11; 8.5%) and ‘sudden heart attack’ (n = 36; 27.7%). professional nurses performed better in this section when compared to enrolled nursing assistants (p = 0.015) and to staff nurses (p = 0.020). table 3 shows that participants were not familiar with opd complications that could arise following stroke. for the item ‘increased mortality’, primary-level nurses demonstrated the best knowledge (70.5%) when compared to tertiary-level nurses (30.6%; p = 0.001). however, the tertiary-level nurses (58.0%) also scored significantly lower on this item compared to the secondary-level nurses (p = 0.016). a similar result was found for ‘general weakness’, where both primary-level (86.4%) and secondary-level (82.0%) nurses had high scores, demonstrating better knowledge than the tertiary-level nurses (61.1%). the correct response rate for ‘sudden heart attack’ was low across groups, with the tertiary-level nurses having the highest score (38.9%) and primary-level the lowest (15.9%). for ‘haematemesis’, the tertiary-level nurses had the best knowledge (55.6%), and the primary-level nurses had the fewest correct responses (25.0%). management practices for oropharyngeal dysphagia participants were required to determine whether or not certain management practices were appropriate (table 4). participants had a mean correct score of 3.8/7, reflecting an average of 54.2% for this section, indicating some difficulty identifying ideal management practices for patients with stroke-related opd. table 4: comparison of participants’ knowledge of the management of opd (n = 130). a few misconceptions were evident, indicated by low percentages of correct responses of disagreement with inappropriate management practices. these included that ‘thickened liquids should be avoided’ (n = 32; 24.6%), ‘watery liquids are the safest to drink’ (n = 30; 23.1%) and ‘all patients with difficulty swallowing require a feeding tube’ (n = 41; 31.5%). remarkably, the secondary-level nurses had better knowledge on the item ‘thickened liquid should be avoided’ (42.0%) when compared to both primary-level (13.6%) and tertiary-level (13.9%) nurses. for ‘watery liquids are the safest to drink’, the secondary-level (34.0%) and tertiary-level (30.6%) nurses scored similarly, whereas the primary-level nurses had a low score (4.5%). on the item ‘all patients with difficulty swallowing need a feeding tube’, the primary-level nurses scored the highest (43.2%), followed by the secondary-level nurses (34.0%), and the tertiary-level nurses scored the lowest (13.9%). finally, a significant difference was found for ‘the patient can always eat normal hospital food’ between the primary (84.1%) and tertiary (61.1%) levels (p = 0.024). statistically, for the management of opd section, the secondary-level nurses showed significantly better knowledge when compared to the primary-level nurses (p = 0.022) and the tertiary-level nurses (p = 0.010). the same is seen in the overall number of correct responses, with the secondary-level nurses displaying the best knowledge on opd, when compared to the primary-level nurses (s–p: p = 0.044) and the tertiary level nurses (s–t: p = 0.025). the study revealed moderate scores overall across all levels of healthcare with a mean correct score of 17.20/30 (57.33%). discussion despite regularly managing stroke patients, this study revealed that only half of the participants had received previous training on stroke, and only 26.9% of the participants had received training on stroke-related opd. although research shows that opd occurs in up to 80% of persons who have suffered a stroke (takizawa et al., 2016), the nurses in this study, who are vital in the management of opd, had received minimal training. in order to manage opd, it is important for nurses to have good knowledge of opd symptoms for early identification and avoidance of unfavourable outcomes such as malnutrition, aspiration pneumonia and death (behera et al., 2018; palli et al., 2017). the results revealed that all three levels of nurses had better knowledge of the symptoms than about the complications and management of opd. interestingly, tertiary-level participants had the lowest scores for most items in this section, which may be attributed to the management of stroke patients in the south african healthcare system: patients first present with a stroke at local clinics and are referred up the levels of healthcare as necessary; once medically stable, patients are often transferred back to a lower healthcare level for chronic management (kwazulu-natal department of health, 2014). therefore, tertiaryand secondary-level nurses often only manage acute stroke patients with opd. despite good knowledge of symptoms as a group, there was a misconception amongst participants on coughing as a sign of aspiration. patients do not always cough when they aspirate (miles et al., 2013); however, 83.1% (n = 108) of participants believed coughing was always present, indicating poor awareness of silent aspiration, a well-known symptom of stroke-related opd (felix, joseph, & daniels, 2019). similar results were found by rhoda and pickel-voight (2015), with 80.4% of nurses believing that coughing was always present during aspiration. if unidentified, silent aspiration places patients at risk for aspiration pneumonia (teuschl et al., 2018). therefore, it is essential for nurses across all levels of healthcare to be aware of all symptoms of opd to effectively manage patients. only 52.3% of participants believed that pneumonia was a complication of opd. a recent study indicated that stroke patients diagnosed with opd are 4.69 times more likely to get aspiration pneumonia than those without opd (feng et al., 2019). for this reason, it is vital that nurses be aware of complications associated with mismanaged opd and have knowledge of the importance of appropriate management. the participants had a mean correct score of 4.73/10 for identifying the complications associated with stroke-related opd, indicating that nurses across all levels of healthcare in this study were unaware of adverse consequences resulting from undiagnosed or mismanaged opd. the responses varied widely between items as well as between healthcare levels, which may result from the varying caseloads that nurses face. similarly, primary-level nurses were the most accurate in identifying both increased mortality (70.5%) and general weakness (86.4%), followed by secondary-level (58.0% and 82.0%, respectively) and tertiary-level nurses with the lowest scores (30.6% and 61.1%, respectively) for these complications. most participants (n = 89; 68.5%) believed that all patients with opd should be fed using nasogastric tubes, which may be because it is viewed as the predominant management option for stroke-related opd. secondary-level nurses had the best knowledge of the correct management procedures for patients with stroke-related opd. overall, secondary-level nurses had the highest scores (p = 17.80/30; s = 18.94/30; t = 16.50/30) across all sections of the survey and therefore had the best knowledge of stroke-related opd. nursing staff will most often be feeding or providing medication to persons with stroke; thus, knowledge of the delivery method of food and liquids, food consistency and positioning of patient is crucial (bhimte & rangasayee, 2015). most participants (75.4%) were unaware of the value of thickening agents in the treatment of opd. thickening agents do not improve swallow physiology, but research emphasises the use of thickeners as a compensatory measure to improve swallow safety and reduce aspiration risk by slowing the flow of the bolus (cichero et al., 2017). a south african study conducted in two provinces found that nurses identified limited staff and time, as well as insufficient knowledge and training on opd, as barriers to appropriate opd management (robbertse, 2018). the same can be seen in the current study, where the inconsistencies and misconceptions about opd demonstrate a need for more knowledge and training. similar results regarding knowledge and training across all sections of the survey were found by rhoda and pickel-voight (2015). nurses in the current study, as well as the study by rhoda and pickel-voight (2015), demonstrated the best knowledge in the signs and symptoms of stroke-related opd section of the survey. the previous study found a score of 64.62%, compared to 66.7% in this study. in contrast to the previous study, where the next best outcome was of the complications associated with stroke-related opd (58.15%), nurses in this research had the fewest correct responses (47.3%). lastly, nurses in the previous study scored 49.28% for management of stroke-related opd, in comparison to 54.2% in the current study. according to the classification of scores, both studies revealed that nurses had moderate knowledge of stroke-related opd, with previous research reporting a score of 57.34% and this study reporting 57.33%. this finding may indicate a need for improved training and opportunities for continued collaboration between slts and nurses for improving management of stroke-related opd so as to optimise patient outcomes. it is essential to develop effective training opportunities on opd in multiple modes and facilitate regular interaction between nurses and slts to improve the quality of patient care (robbertse, 2018). collaboration between slts and nurses, combining nurses’ experience with slts’ knowledge and expertise on stroke-related opd, can be used to maximise health resources in a constrained environment in order to improve the interdisciplinary management of stroke patients with opd in lmics (dondorf et al., 2015). limitations and future recommendations the research was conducted in only one municipality in the eastern cape, south africa comprising three levels of healthcare. as there is limited research available in the local context regarding nurses’ knowledge and needs relating to opd, reference was made to, and comparisons drawn from, an unpublished master’s study, given its relevance to this study. the data were collected in a metropolitan area, further limiting the generalisability of the findings. larger-scale studies of a similar nature across several provinces are recommended. further investigation may be done on the availability of training programs for nursing professionals, and support offered in hospitals regarding decisions for patients with stroke-related opd. research should aim to identify existing resources to implement better stroke-related opd identification and management procedures in hospitals. conclusion the study revealed that secondary-level nurses had better knowledge of symptoms and management of stroke-related opd than primaryor tertiary-level nurses. the findings highlighted nurses’ misconceptions about the possible complications associated with stroke-related opd. speech-language therapists need to assist in the development and implementation of sustainable protocols for opd screening and management within resource-constrained environments such as the south african health sector. integrated work relations with an emphasis on collaboration between nurses and slts will optimise the use of limited health resources, promote patient safety and improve outcomes (dondorf et al., 2015). acknowledgements the authors thank prof. marien graham (statistical analysis) and dr stacey rossouw (support of the project). competing interests the authors have declared that no competing interests exist. authors’ contributions k.k. conceptualised the project, collected and analysed data, and wrote the manuscript. e.k., b.p. and j.v.l. conceptualised the project and wrote the manuscript. funding information kerry knight received a 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(2011). access to public health facilities: taking stock of south africa’s rural eastern cape province. world medical journal, 57(5), 164–170. afrikaanse reseptiewe woordeskattoets (arw): toepaslikheid vir in groep nie-standaardafrikaanssprekende kinders opsomming mariekie buitendag, isabel uys en brenda louw departement kommunikasiepatologie universiteit van pretoria, pretoria 11 die behoefte aan kultureel toepaslike taaltoetse in suid-afrika het as motivering vir die studie gedien. die doel van die studie was om die toepaslikheid en aanpassingsmoontlikheid van die afrikaanse reseptiewe woordeskattoets (arw) (buitendag, 1994) vir 'ngroep seween twaalfjarige nie-standaardafrikaanssprekende kinders vanuit die kleurlinggemeenskap in gauteng, noordwes, mpumalanga en noordelike provinsie te evalueer. om hierdie doel te bereik is die arw (buitendag (1994) en 'n vraelys aangaande sosio-ekonomiese deprivasie op 'n proporsioneel gestratifiseerde ewekansige steekproef van 960 kinders toegepas. toetssydigheid is geevalueer deur die psigometriese eienskappe van die toets vir die navorsingsgroep te bepaal en met die van die normgroep te vergelyk. verskeie toetsaanpassingsprosedures is oorweeg, naamlik aanpassings van die rangorde van itemmoeilikheid, toetsbeginpunte en toetsprosedures. die resultate het aangedui dat dieselfde mate van vertroue in die twee groepe se toetstellings gestel kan word, die oorspronklike rangorde van itemmoeilikheid vir die navorsingsgroep behou kan word en soortgelyke verhogings vanarw-tellings met 'n toename in ouderdom by die twee groepe voorkom. die bevindinge impliseer dat die toets dieselfde vermoe by die twee groepe meet. alhoewel die vergelyking van die psigometriese eienskappe van die toets vir die navorsingsgroep met die van die normgroep nie toetssydigheid bevestig het nie, het intra-groepvergelyking aangetoon dat die toets linguisties sydig teenoor die sosio-ekonomies gedepriveerde groep kan wees. beduidende verskille het in individuele toetspretasies voorgekom indien sydige toetsitems 'n verskuiwing in die kind se basaal of plafonitem veroorsaak het. die toets se kulturele geldigheid kan verhoog word deur die toetsbeginpunte te verlaag en kultureel toepaslike response as korrek te aanvaar om gelyke erkenning aan standaarden nie-standaardtaal te gee. hierdie navorsing is 'n belangrike bydrae tot die uitbreiding van die spraak-taalterapeut se vaardighede en hulpbronne, wat dringend benodig word om kultuurtoepaslike dienste aan alle individue met kommunikasieafwykings in suid-afrika te lewer. abstract , ; the need for culturally approp1iate language tests served as motivation for this study. the aim of the study was to evaluate the suitability and adaptability of it he afrikaanse reseptiewe woordeskattoets (arw) (buitendag, 1994) for a group of seven and ten year old non-standard afrikaans speaking children from the coloured community in gauteng, north west, mpumalanga and northern province. in orde1r to achieve this goal the arw (buitendag, 1994), and a questionnaire regarding socio-economic i deprivation, were administered to a proportionally stratified randomized sample of 960 children. test bias was evaluated by comparing the psychometric characteristics of the test for the research group to those of the normative group. various test adaptation procedures were cohsidered, namely adaptations to the rank order of item difficulty, test starting points and test procedures. the results indicated the same degree of confidence in the test results of the two groups. it demonstrated that the original rank order of item difficulty does not need to be changed and that corresponding increase in arw scores is evident with an increase in age in both groups. the findings imply that the test measures the same ability in the two groups. although comparison of the psychometric characteristics of the test for the research group to those for the normative group failed to identify test bias, intra-group comparison indicated that the test may be linguistically biased against the socio-economically deprived sub-group. significant differences in individual arw scores occurred when a shift in the child's basal or ceiling item occurred as a result of the biased items. the test's cultural validity for the group may be increased by lowering the test starting points, in order to prevent reversed testing. culturally appropriate responses should be accepted as correct, in order to award equal credit to standard and non-standard language responses and to take intra-group differences into consideration. this research is an important contribution towards the expansion of the speech-language therapist's skills and resources, vitally needed to provide culturally relevant services in south africa to all individuals with communication disorders. sleutelwoorde: taalverskeidenheid, nie-standaardafrikaans, sosio-ekonomiese deprivasie, toetssydigheid en aanpassing, mrikaanse reseptiewe woordeskattoets (arw). die probleme verbonde l aan die evaluering van taalafwykings by nie-standaardtaalsprekende kinders het die afgelope twee dekades baie aandag van spraaktaalterapeute geniet (kayser, 1996). hierdie belangstelling het voortgespruit uit die uiteenlopende standpunte wat oor die relatiewe swak prestasies van minderbevoorregte en diesuid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 12 sommige nie-standaardtaalsprekende kinders op skolastiese, intelligensieen taaltoetse gehuldig word, te wete die taalafwykingsen taalverskilteorie (wardhaugh, 1988). onlangse sosiolinguistiese navorsing het bewys gelewer van die gelykwaardigheid van die verskillende varieteite van 'n taal, insluitende die verskillende standaardtaalvorme, geografiese, etniese en sosiale varieteite, asook verskeie registers en stylvariasies (lane & molyneaux, 1992). om 'n kind se kommunikasiebevoegdheid effektiefte evalueer, moet die spraaktaalterapeut 'n perspektiefvan die kind as taalverwerwer en -gebruiker binne die linguistiese en kulturele konteks van sy gesin en gemeep.skap ontwikkel en spesifieke kulturele veranderlikes in ag neem by die interpretasie van taaltoetsresultate (bebout & arthur, 1992). hierdie groter bewustheid en aanvaarding van linguistiese variasie het uitgeloop op die besef van die behoefte aan uitgebreide spraak-taalterapeutiese dienslewering in multikulturele, meertalige populasies en die ontoepaslikheid van bestaande taaltoetse vir gebruik by nie-standaardtaalsprekende kinders (scott, 1994; taylor & clarke, 1994). die evaluering van kommunikasieprobleme by niestandaardtaalsprekende kinders konfronteer die spraaktaalterapeut met die komplekse uitdaging om die kind se taalvaardighede op 'n nie-sydige wyse te evalueer, met die doel om tussen 'n taalafwyking en taalverskil te differensieer en toepaslike intervensie aan te beveel (hegde & davis, 1995). 'n omvattende taalevaluasie kan weens die leemte aan 'n enkele ideale taalevalueringsprosedure slegs uitgevoer word deur gestandaardiseerde en beskrywende taalevalueringsprosedures aanvullend tot mekaar te gebruik (mcfadden, 1996). die gebruik van gestandaardiseerde normgerigte taaltoetse is egter noodsaaklik vir die identifisering en diagnose van taalafwykings (owens, 1995; kayser, 1996). dit het die voordeel bo beskrywende evalueringsmetodes dat dit betroubare en geldige inligting aangaande die kind se taalvaardigheid verskaf en dat die beskikbaarheid van norme differensiasie tussen normale en patologiese taalgedrag vergemaklik (stockman, 1996). die gebruik van gestaridaardiseerde toetse in die kultureel en linguisties diverse kontekste bring egter die probleem van toetssydigheid mee (owen, 1995). die gebruik van tradisionele taaltoetse vir die evaluering van die linguistiese bevoegdheid van nie-standaardtaalsprekende kinders word sterk in die literatuur gekritiseer. die kritiek word gegrond op die feit dat gestandaardiseerde taaltoetse meestal op die standaardvarieteit, waardes en ervaringsveld van blanke kinders vanuit die middelklas gebaseer is. die toetse kan gevolglik kultureel sydig en onregverdig teenoor bepaalde etniese en laer sosioekonomiese groepe wees, wat tot foutiewe diagnoses en verreikende gevolge vir hierdie kinders se habilitasie en ontwikkeling kan lei (kayser, 1996). twee tipes foute kan in die differensiasie tussen 'n taalafwyking en taalverskil begaan word. deur onderkompensasie vir taalverskille kan die. spraak-taalterapeut 'n normale nie-standaardtaalsprekende kind verkeerdelik as taalafwykend diagnoseer, wat tot die verskaffing van ontoepaslike of oorbodige intervensie en gevolglike negatiewe selfbeeldontwikkeling by die kind kan lei. oorkompensasie vir die kind se varieteit, weens gebrekkige· vertroue in bestaande taaltoetse, kan weer daartoe lei dat 'n taalafwyking in die kind se varieteit nie gerdentifiseer word nie. hierdeur word die taalgestremde nie-standaardtaalsprekenrle kind van noodsaaklike taalterapie weerhou, wat tot skolastiese probleme, mariekie buitendag, isabel uys, brenda lou\\> frustrasie en kontinue taalgestremdheid tot in vol was_ senheid kan lei (owens, 1995). die probleem van toetssydigheid is veral prominent by woordeskattoetse, daar kulturele verskille primer in die leksikon van 'n taal gemanifesteer word (washington & craig, 1992). n avorsing het aangetoon dat gestandaardiseerde toetse ten spyte van bepaalde leemtes, steeds deur die oorgrot~ meerderheid spraak-taalterapeute gebruik word vir die bepaling van die bestaan van 'n taalafwyking (owens 1995). vanwee die volgehoue algemene gebruik va~ gestandaardiseerde toetsprosedures in spraak-taalterapie, is verskeie pogings aangewend om taaltoetssydigheid te verminder of uit te skakel. elke alternatief hou egter bepaalde nadele in: • herstandaardisering van bestaande toetse vir gebruik met 'n bepaalde groep: hierdie alternatief is onbevredigend· omdat lae norme tot vergelykings tussen bevolkingsgroepe kan lei en die tendens van laer verwagtinge vir minderbevoorregte groepe versterk (jensen, 1980; adler, 1990). • insluiting van 'n klein persentasie van die minderheidsgroepe in die standaardiseringsteekproef: die verteenwoordigendheid van 'n bepaalde groep kan egter onbevredigend bly, wat impliseer dat die toets steeds bevooroordelend of sydig teenoor die groep is (mcfadden, 1996). • aanpassing van bestaande taaltoetse om die toetsinhoud en -forma at meer toepaslik vir nie-standaardtaalsprekende kinders te maak: die geldigheid van die toets vir die doel van die identifisering van 'n afwyking . kan hierdeur verander, wat die veralgemeenbaarheid van die norme betwyfelbaar maak (owens, 1995). • ontwikkeling van 'n nuwe toets: hierdie alternatief is die ideaal, maar is 'n langdurige en baie duur proses en gevolglik dikwels nie prakties uitvoerbaar nie. die ontwerp en standaardlsering van taaltoetse word deur min navorsers aangedurf, as gevolg van die multidissiplinere kundigheid wat die taak van die navorser vereis. die vereiste kundigheid behels 'n grondige kennis van taal, universele ontwikkelingspatrone en variasie in kindertaalverwerwing, kindertaalevaluering, taalverskeidenheid, toetssydigheid, psigometriese kriteria van gestandaardiseerde toetse, en statistiese kennis ten aansien van steekproefnemirig, normbepaling en die evaluasie van psigometriese toets\ eienskappe (buitendag, 1994). : • die gebruik van nie-gestandaardiseerde taahnonsters en kriteriumgerigte toetse: die gebrek aan norme bemoeilik differensiasie tussen taalpatologie en normale nie-standaardtaal. evaluering van kindertaal deur middel van beskrywende evaluasieprosedures word veral gekompliseer deur die bestaande leemte aan normatiewe data oor nie-standaardtaalvarieteite (scott, 1994). verder waarsku jensen (1980) en stockman (1996) daarteen dat nie-gestandaardiseerde evaluasies dikwels meer sydig en onregverdig as gestandaardiseerde toetse kan wees. gestandaardiseerde toetse moet dus nie ten gunste van nie-gestandaardiseerde prosedures oorboord gegooi word voordat die sydigheid van die betrokke prosedure/s bepaal is nie. dit blyk dat gestandaardiseerde taaltoetse 'n belangrike rol in kliniese besluitneming bly speel en deurgaans verbeter sal word om in die praktiese behoefte aan akkurate the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 'kaanse reseptiewe woordeskattoets (arw): airl aslikheid vir 'n groep nie-standaardafrikaanssprekende kinders toep 13 ffektiewe instrumente vir die identifisering van ;:a~fwykings by verskillende groepe te voorsien (stockman, 1996). . .. in suid-afrika het die behoefte aan me-sydige gestand ardiseerde taaltoetse 'n krisispunt bereik. suid-afrika hat 'n multikulturele, meertalige populasie bestaande uit vi:r hoofbevolkingsgroepe en meer as 26 verskillende tale (sentrale statistiekdiens, 1991), sowel as verskillende varieteite van die tale. afrikaans, as een van die elf amptelike tale, is die fokuspunt van hierdie studie. afrikaans is gekies aangesien dit die moedertaal van 'n gedeelte van al vier die hoofbevolkingsgroepe is, insluitende ongeveer 58% blankes, 83% kleurlinge, 1,3% asiers en 026% swartes (sentrale statistiekdiens, 1991). , daar bestaan tot op hede slegs drie gestandaardiseerde taaltoetse vir die evaluering van afrikaanssprekende kinders se verbale taalvermoens, naamlik die toets vir mondelinge taalproduksie (tmt) (vorster, 1980), die afrikaanse semantiese taalevalueringsmedium (ast) (pretorius, 1989) en die afrikaanse reseptiewe woordeskattoets (arw) (buitendag, 1994). die toepaslikheid van die toetse vir nie-standaardafrikaanssprekende kinders kan egter betwyfel word, aangesien '0 groot persentasie van hierdie kinders (insluitende kinders van die kleurling-, swart-, asieren blanke gemeenskap) waarskynlik nie effektiewe beheer oor standaardafrikaans vertoon nie (van rensburg, 1991). die tmt (vorster, 1980) is volgens die studie van terblanche (1988) nie toepaslik vir 'n groep kleurlingkinders in eersterust nie. die toepaslikheid van die ast (pretorius, 1989) en die arw (buitendag, 1994) vir nie-standaardafrikaanssprekende kinders is nog nie nagevors nie. die evaluering van nie-standaardafrikaanssprekende kinders word verder gekompliseer deurdat informele beskrywende taalevaluasieprosedures nie 'n toereikende alternatiefvir gestandaardiseerde afrikaanse taaltoetse is nie, omdat daar beperkte normatiewe data en inligting oor die linguistiese eienskappe van hierdie varieteite van afrikaans bestaan (dreyer, 1986). die behoefte aan kultuurgeldige afrikaanse taaltoetse is veral eksplisiet ten ops',lgte van kinders van die kleurlinggemeenskap, aangesien bykans die helfte van die totale afrikaanssprekende taalgemeenskap kleurlinge is en 83,14% van die kleurlingb1evolkingsgroep afrikaans (eentalig) as huistaal het (serltrale statistiekdiens, 1991). i gesien in die lig van scott (1994) se uitspraak dat ongeveer 10% van nie-standaardtaalspf;ekers taalafwykings in hulle eie variheite vertoon, is daat dus tans meer as 272 700 afrikaanssprekende kleurlinie met taalafwykings. in suid-afrika is daar nog weinig navorsing oor toetssydigheid uitgevoer. die bestaande navorsing het hoofsaaklik betrekking op intelligensietoetse, wat in die verlede meestal vir die verskillende bevolkingsgroepe afsonderlik ontwikkel is en gevolglik nie aan die probleem van sydigheid onderworpe was nie (claassen 1989). slegs 'n beperkte aantal studies is oor sydigheid in gestandaardiseerde taaltoetse uitgevoer, onder andere deur terblanche (1988) en alant en beukes (1986). hierdie studies, alhoewel van 'n beperkte omvang, het die aandag op die ontoepaslikheid van die beskikbare taaltoetse vir gebruik by tweedetaalen nie-standaardtaalsprekende kinders in suidafrika gevestig. alhoewel waardevolle riglyne vir toetsaanpassing ten opsigte van die verskillende gemeenskappe verskaf is, was daar sover bekend nog geen omvattende studie om 'n bestaande taaltoets aan te pas nie. die behoefte aan geldige en betroubare taaltoetse vir die identifisering van taalafwykings by afrikaanssprek.ende kinders vanuit die kleurlinggemeenskap het as motivering vir die studie gedien. die afrikaanse reseptiewe woordeskattoets (arw) (buitendag, 1994) is vir die navorsing geselekteer, om die volgende redes : • woordeskattoetse is fundamenteel aan enige taaltoetsbattery weens die belang van woordeskat vir die kind se taalontwikkeling, metalinguistiese ontwikkeling, leesvermoe, simboliese denke, kognitiewe ontwikkeling, akademiese vordering en sosialisering (lidz en pefia,1996). • die toets het 'n wye kliniese gebruiksveld 'n reseptiewe woordeskattoets is dikwels die enigste evaluasieprosedure waarvolgens 'n aanduiding van baie jong, nie-verbale en taalaf'yykende kinders se taalvermoens verkry. kan word, aangesien die ontwikkeling van reseptiewe woordeskat ekspressiewe woordeskatontwikkeling voorafgaan en die toets geen verbale response van die kind vereis nie (owens, 1995). die arw (buitendag, 1994) is verder geskik vir 'n heterogene groep kinders, naamlik 'n bree ouderdomsgroep van twee tot dertienjaar en die toetsformaat kan aangepas word vir gebruik met ernstig gestremde kinders. die toets se prentherkenningsformaat hou die yoordeel in dat dit binne slegs 10 tot 15 minute toegepas kan word en dus vir die sifting van groot getalle leerlinge geskik is. die toets kan boonop vir verskillende doele aangewend word. alhoewel die arw (buitendag, 1994) se prim ere doel die identifisering van reseptiewe woordeskatafwykings is, maak die ontwerp van die antwoordblaaie voorsiening vir kwalitatiewe analise van foute. op grond van die hoe korrelasie tussen kinders se prestasies op die arw (buitendag, 1994) en intelligensietoetse, kan die toets ook gebruik word om 'n growwe aanduiding van kinders se algemene intelligensie te verkry (buitendag, 1991). • die toets vertoon potensiaal om aangepas te word vir gebruik met niestandaardafrikaanssprekende kinders tydens die oorspronklike ontwerp en standaardisering van die arw (buitendag, 1994) is pogings reeds aangewend om toetssydigheid te beperk, deur kinders van verskillende sosio-ekonomiese klasse, geslagte, geografiese gebiede en intellektuele ontwikkelingsvlakke ewekansig by die normgroep in te sluit, en potensiele sydige items tydens itemseleksie uit te skakel. • die toets bestaan uit 'n groot aantal toetsitems die arw (buitendag, 1994) se bree itemspektrum van 175 items, en gevolglike groot kritiese reeks per ouderdomsgroep, hou die voordeel in dat die voorkoms van 'n paar sydige items nie 'n beduidende invloed op die toetsresultate sal he nie (owens,1995). . moontlike aanpassing van die arw (buitendag, 1994) blyk die mees toepaslike benadering vir hierdie navorsing te wees. die voorkeur vir toetsaanpassing berus op die praktiese probleme en hoe koste verbonde aan die daarstelling van 'n nuwe toets. toetsaanpassing is ook verkieslik vanwee die sosiale en politi eke implikasies wat die herstandaardisering van die toets en verskaffing van aparte norme kan meebring. die groter wordende ooreenkomste wat vanwee voortdurende akkulturasie by mense van verskillende bevolkingsgroepe in suid-afrika voorkom, en die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 14 die toeganklikheid van skole vir leerlinge van aile bevolkingsgroepe, het boonop aanleiding gegee tot die behoefte aan eenvormige toetse wat vir verskillende groepe toepaslik is (claassen, 1989). metode doelstellings die doel van die studie is om die toepaslikheid en aanpassingsmoontlikhede van die arw (buitendag, 1994) vir 'n groep seween tien-jarige nie-standaardafrikaanssprekende kinders vanuit die kleurlinggemeenskap in gauteng, noord-wes, mpumalanga en die noordelike provinsie te evalueer. die volgende subdoelstellings is vir die realise ring van die hoofdoel gestel : 1. om die toetsprestasie van die navorsingsgroep met die van die normgroep te vergelyk om moontlike groepsverskille te bepaal 2. om die psigometriese eienskappe van die toets vir die navorsingsgroep met die van die normgroep te vergelyk om moontlike toetssydigheid te identifiseer 3. dm die invloed van sosio-ekonomiese status as moontlike verklaring vir die groepsverskille te ondersoek 4. om metodes te oorweeg waardeur moontlike sydige toetsitems en toetsprosedures aangepas kan word om die toepaslikheid van die toets vir kinders vanuit die kleurlinggemeenskap te verhoog 5. om 'n kwantitatiewe en kwalitatiewe item analise uit te voer om die toepaslikheid van die toetsitems vir die navorsingsgroep te ondersoek. navorsingsontwerp in hierdie studie is daar van intergroepsvergelyking gebruik gemaak, aangesien die toepaslikheid van die arw (buitendag, 1994) vir kleurlingkinders slegs bepaal kan word deur hulle prestasie op die toets met die van die normatiewe populasie te vergelyk. die dataversameling het 'n beskrywende of normatiewe veldopname behels (leedy, 1993). twee tipes data is versamel. inligting oor die proefpersone se begrip van woordbetekenis is deur middel van gestandaardiseerde waarneming versamel, terwyl sosio-ekonomiese status deur middel van 'n vraelys bepaal is. data-ontleding is by wyse van beskrywende statistiek, statistiese inferensie en kwalitatiewe analise uitgevoer (steyn, smit, du toit & strasheim, 1994). proefpersone 1. seleksiekriteria ten einde die resultate van die groepe vergelykbaar te maak, is dieselfde proefpersoonseleksiekriteria vir die navorsingsgroep as vir die standaardiseringsgroep gestel, naamlik: • moedertaal. aangesien kinders se begrip van gesproke afrikaanse woorde in die navorsing geevalueer word, moes al die proefpersone afrikaans as moedertaal (eersteof dominante taal) he. afrikaans vertoon 'n verskeidenheid varieteite. die omgangstaal van die kinders in hierdie studie is 'n niestandaard, sosiaal-geografiese varieteit van afrikaans (van mariekie buitendag, isabel uys, brenda lou", rensburg, 1991). • bevolkingsgroep. afrikaanse moedertaalsprekers word deur verskillende bevolkingsgroepe verteenwoordig (webb, dirven & kock 1992). ooreenkomstig die doel van die navorsing, moes sleg~ afrikaanssprekende kinders van die kleurlingbevolkings_ groep by die steekproef ingesluit word. • sosio-ekonomiese status. kinders uit aile sosiale, ekonomiese en opvoedkundige milieus moes by die steekproef ingesluit word, om te verseker dat die steekproef verteenwoordigend is van die populasie wat sosio-ekonomiese status betref (mcfadden, 1996). die hoe korrelasie tussen sosio-ekonomiese status en woordeskatontwikkeling word algemeen in die literatuur aangedui (dunn & dunn, 1981; alant & beukes, 1986; washington & craig, 1992). vanwee hierdie hoe korrelasie kan daar dus verwag word dat 'n minderbevoorregte groep swak op die arw (buitendag, 1994) sal presteer. • fisiese gesteldheid. aile leerlinge in skole van die voormalige administrasie: raad van verteenwoordigers in gauteng, noord-wes, mpumalanga en die noordelike provinsie moes by die steekproefneming betrek word, ongeag enige fisiese, motoriese, visuele, spraakofgehoorprobleme, om verteenwoordigend van die bree populasie te wees (mcfadden, 1996). • intellektuele vermoe. om te verseker dat die steekproef verteenwoordigend is van die inteilektuele vermoens van die populasie, moes kinders van aile inteilektuele ontwikkelingsvlakke in die steekproefingesluit word. die positiewe korrelasie tussen reseptiewe woordeskat en algemene intelligensie is reeds deur verskeie navorsers aangetoon (lidz & pena, 1996). • aantal proefpersone. in hierdie navorsing is 'n steekproefgrootte van 500 proefpersone per ouderdomsgroep as teiken gestel (stoker, 1993). dit kan as 'n algemene reel aanvaar wor:d dat die grootte van 'n steekproefminstens 100 moet wee's voordat 'n normale verspreiding van punte verwag kan word. om die betroubaarheid van toetsresultate te verseker, word 'n minimum steekproefgrootte van 400 egter geste'l (owen, 1995). \ • geslag. op grond van die feit dat daar kontroversie oor die moontlikheid van geslagsverskille in woordeskatontwikkeling bestaan, moes daar in hierdie ondersoek (soos in die arw-normgroep) ewe veel seuns en meisies in die steekproefingesluit word. • chronologiese ouderdom. die steekproef is tot twee ouderdomsgroepe beperk, naamlik seween tienjarige kinders. die r~des hierv09r is pr~ktiese en finansiele beperkings, asook die behoud van die kriterium wat ten opsigte van die steekproefgrootte gestel word. seween tienjarige leerlinge moes in die steekproef opgeneem word, omdat : die ouderdomsomvang van die stildie so groot as prakties moontlik gehou moes word; skoolgaande kinders wat vir taalevaluering verwys word meestal binne hierdie ouderdom~omvang val; ouer kinders the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) .afrikaanse reseptiewe woordeskattoets (arw): toepaslikheid vir in groep nie-standaardafrikaanssprekende kinders 15 prognose vir terapie afneem; die betroubaarheids~~effisiente van die arw (buitendag, 1994) vir kinders ouer. as 11:05 jaar nie hoog is nie; verteenwoordigende steekproefneming van kleuters en sesjarige kinders (waarvan slegs sommiges reeds in die primere skool is) deur praktiese struikelblokke bemoeilik word (buitendag, 1991; 1994). buiteskoolse kinders (skoolpligtige kinders wat nie skoolgaan nie), onder andere straatkinders, sou weens praktiese beperkinge nie by die steekproef ingesluit kon word nie. hierdie beperking kan tot sydigheid in die steekproefbydra. om buiteskoolse kinders by die populasie van die ondersoek in te sluit, blyk egter tans 'n taak van onmoontlikheid te wees. • geografiese gebied. hierdie navorsing behels die vergelyking van die steekproef se resultate op die arw (buitendag, 1994) met die van die standaardiseringsgroep. derhalwe moes die geografiese verspreiding van die twee groepe ooreenstem (stoker, 1993). aile proefpersone moes in die geografiese gebied van gauteng, noord-wes, mpumalanga en die noordelike provinsie woonagtig wees. omdat hierdie provinsies uit verskillende stedelike en plattelandse streke bestaan en verskillende geografiese varieteite van afrikaans in die gebied gebruik word, moes die steekproef-kinders van aile geografiese gebiede be trek word. ten einde die resultate van die twee groepe direk vergelykbaar te maak, moes die proporsionele verteenwoordiging van die geografiese strata van die steekproef met die van die standaardiseringsgroep ooreenstem (stoker, 1993). aangesien die geografiese verspreiding nie noodwendig verteenwoordigend van die kleurlingpopulasie is nie, kan die resultate nie gebruik word om norme vir hulle te verskaf nie. die doel was egter nie om aparte norme te bepaal nie, maar om te bepaal of die norme van die standaardiseringsgroep ook vir kinders vanuit die kleurlinggemeenskap geskik is. die huidige tendens is bowendien ten gunste van gemeenskaplike norme (owen, 1995). 2. steekproefnemingsmetode die proefpersone is by wyl van proporsioneel gestratifiseerde ewekansige steekprdefneming geselekteer (leedy, i 1993; stoker,1993). vanwe~ die moontlike invloed van geslag, maturasie'en geografiese verspreiding op woordeskatontwikkeling is die populasie in terme van die drie veranderlikes gestratifiseer:! , / • stratifisering van die populasie volgens geografiese gebied. die geografiese gebied wat deur die navorsing gedek moes word, is in die volgende strata van ongelyke groottes verdeel: gauteng: pretoria, johannesburg, oos-rand, wes-rand en suid-rand plattelandse gebiede: mpumalanga, noord-wes en noordelike provinsie. • proporsioneel gestratifiseerde steekproefneming van skole. die steekproefneming van skole is aan die hand van departementele rekords uitgevoer. engelse skole, sowel as afrikaanse en parallelmediuinskole waarvan die leerlingtal te klein is om die steekproef te akkommodeer, is eerstens uitgeskakel. hierna is 20 skole ooreenkomstig die proporsionele geografiese verteenwoordiging van die standaardiseringsgroep getrek. steekproefneming is onafhanklik vir die afsonderlike strata uitgevoer en die spesifieke aantal skole uit elke stratum is volgens waarskynlikheid proporsioneel aan grootte, geselekteer (stoker, 1993). die proporsionele geografiese verteenwoordiging van die navorsingsgroep stem grootliks ooreen met die van die toets se normgroep. • gestratifiseerde ewekansige steehproefi2eming van proefpersone 'n totale aantal van 960 proefpersone (480 seuns en 480 meisies) is by die steekproef ingesluit. uit elke skool is 48 proefpersone, naamlik 24 (12 :seuns en 12 meisies) sewejariges en 24 tien-jariges, geselekteer. materlaal die gestandaardiseerde toetsmateriaal van die arw (buitendag,1994) is gebruik om die proefpersone se begrip van woordbetekenisse te evalueer. die sosio-ekonomiese deprivasievrae1ys (sed-vrae1ys) van van den berg (1991) is gebruik om e1ke proefpersoon se sosio-ekonomiese status te bepaal. 1. arw (buitendag, 1994) hierdie toets is oorspronklik ontwerp en gestandaardiseer vir blanke afrikaanssprekende kinders tussen die ouderdomme van 2 :00 en 12:11 jaar. die toets beskik oor 'n bree itemspektrum van 175 kragitems met 'n meerkeusige prentidentifiseringsformaat. e1ke item bestaan uit 'n verba1e stimulus-woord en vier prentvoorstellings (eenvoudige lyntekeninge), waarvan een alternatief die koitekte antwoord is en die ander drie afleiers is. die toetsinhoud is 'n gebalanseerde en verteenwoordigende monster van afrikaanse leksikale items. die twee ekwivalente toetsvorms (vorm a en vorm b) is betroubaar en ge1dig vir die identifisering van woordeskatafwykings, asook vir hereva1uering. die toets is van twee tipes norme voorsien, naamlik standaardtellingekwivalente en ouderdomsekwivalente. die toetsmateriaal sluit 'n handleiding, 'n stimulusprentboek en antwoordblaaie vir elk van die twee toetsvorms in. in hierdie navorsing is slegs vorm a gebruik: 2. vraelys die sed-vrae1ys (van den berg, 1991) bestaan uit 22 vrae oor die kind se huis1ike omgewing, waarvolgens 'n indeks vir sosio-ekonomiese status bepaal word. opnameprosedures die empiriese studie is as volg uitgevoer: 1. data-insameling die arw (buitendag, 1994) is deur die navorser op elke proefpersoon individueel toegepas. die voorgeskrewe toepassingsen nasienprosedure van die toets is deurgaans nagevolg, beha1we in die geval van foutiewe response. indien die kind 'n foutiewe res pons gelewer het, is die standaardprosedure aangepas om vas te stel of die kind se foutiewe respons te wyte is aan gebrekkige kennis van die die suid-afrikaanse tydskrifvir kommunikasieafwyhings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 16 betrokke woord (linguistiese vorm) of aan gebrekkige begrip van die konsep wat deur die spesifieke item verteenwoordig word. die aangepaste toetsprosedure maak voorsiening vir die regmerk van korrekte alternatiewe verbale response op items wat die toetsling verkeerd beantwoord het. aile verbale response, hetsy alternatiewe woorde, woorddefinisies, spontane opmerkings, selfkorreksies ofvrae van die proefpersone, is aangeteken met die oog op kwalitatiewe itemanalise. die sed-vraelys (van den berg, 1991) is ten opsigte van elke proefpersoon deur die navorser voltooi, deur die kind se onderwyser te raadpleeg en die kind indirek uit te vra. 2. data-analise groepsverskille is bepaal deur die rekenkundige gemiddeldes van die 7en 10-jarige subgroepe van die navorsingsgroep te bereken en met die van die standaardiserings-groep te vergelyk. toetssydigheid teenoor die navorsingsgroep is ondersoek deur die toets se interne konsekwentheid (kr-21betroubaarheidskoeffisiente), rangorde van itemmoeilikheid (spearman se rho), korrelasie met ouderdom en skoolprestasie (pearsonkorrelasiekoeffisiente) vir die groepe vergelyk. die toepaslikheid van die toetsitems is geevalueer deur afleierdoeltreffendheid en itemmoeilikheidswaardes te ondersoek, en foutiewe response kwalitatief te ontleed (jensen, 1980; osterlind, 1983). die invloed van sosio-ekonomiese status op arwprestasie is ondersoek deur die proefpersone met behulp van 'n vraelys vir die bepaling van sosio-ekonomiese deprivasie (van den berg, 1991)te kategoriseer en die gemiddeldes van die sosio-ekonomies gedepriveerde subgroep en die sosio-ekonomies nie-gedepriveerde subgroep met mekaar en met die van die normgroep te vergelyk. verskillende toetsaanpassingsprosedures is oorweeg, naamlik aanpassing van die rangorde van itemmoeilikheid, toetsbeginpunte en roupunte. om te bepaal of die arw mariekie buitendag, isabel uys, brenda lou", (buitendag, 1994) se itemrangorde vir die navorsingsgroep ~ehou of verander moet word, is die navorsingsgroep se rangorde van itemmoeilikheid met die van die normgroep vergelyk. toetsbeginpunte vir die navorsingsgroep is volgens die gemiddelde bas ale van die twee ouderdomsgroepe bepaal. die invloed van sydige toetsitems op die navorsingsgroep se gemiddelde is ondersoek deur verkeerd beantwoorde items waarop korrekte verbale response gelewer is korrek te merk, die nuwe gemiddelde (roupunt 3) te bereken en met hulle gemiddelde volgens die oorspronklike toetsprosedure (roupunt 1) te vergelyk. om die kulturele toepaslikheid van toetsitems vir die navorsingsgroep te ondersoek en moontlike spesifieke woordeskateienskappe van die groep te bepaal, is 'n kwantitatiewe en kwalitatiewe foutanalise uitgevoer (washington & craig, 1992). re8ultate en be8preking i verskille tussen die gemiddelde roupunte van die normgroep en navorsingsgroep die vraagstuk oor sydigheid in gestandaardiseerde toetse het sy onstaan in die deurgaanse laer intelligensieen taaltoetsprestasies van bepaalde etniese en laer sosioekonomiese groepe, veral met betrekking tot swart sprekers van engels in amerika (miller, 1988). navorsing in suidmrika het aangetoon dat kinders vanuit die kleurlinggemeenskap ook dikwels relatief swak in gestandaardiseerde toetse pre steer (alant & beukes, 1986; claassen, 1989). 'n laer gemiddelde word gevolglik ten opsigte van die arw (buitendag, 1994) verwag. groepsverskille in arw-prestasie is bepaal deur die gemiddelde roupunte van die normgroep en navorsingsgroep met mekaar te vergelyk. die gemiddeldes, standaardmetingsfoute en 95%-vertrouensintervalle vir die normgroep en navorsingsgroep word in tabel 1 aangebied. uit tabel 1 blyk dit dat die navorsingsgroep deurgaans tabel i : gemiddeldes (x), standaardmetingsfoute (8mf') en 95%vertrouensintervalle (vi) vir ware tellings normgroep navor8ing8groep ver8kil ouderdom n2 x2 8mf' 950/0-vi ni xl 8mf 950/0-vi x2xl ; z 7:00 7:02 124 101,1 7,21 87 115 107 90,7 7,15 77 105 10,4 i 4,60 i , i 7:02 7:05 128 102,8 7,31 89 117 117 92,3 7,48 77 107 10,5 : 3,88 i 7:06 7:08 141 109,4 7,40 94 124 138 96,5 6,93 83 111 12,9 ,6,17 7:09 7:11 113 115,2 7,37 101 129 115 99,8 7,52 85 115 15,4 6,21 totaal 506 106,99 477 94,96 12,03 10,19 10:00 10:02 135 142,0 7,05 128 156 111 129,6 7,35 116 144 12,4 5,99 10:03 10:05 143 142,9 7,05 129 157 122 130,8 7,25 117 -145 12;1 . 6~30 10:06 10:08 139 145,6 7,11 132 160 126 132,1 7,43 117-147 13,5 7,89 10:09 10:11 104 148,8 7,14 135 163 111 134,1 6,84 121147 14,7 6,22 totaal 521 144,32 470 131,64 12,68 12,92 the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) ;\frikaanse reseptiewe woordeskattoets (arw): toepaslikheid vir 'n groep nie-standaardafrikaanssprekende kinders 17 swakker as die normgroep op die arw (1994) pre steer het. 2 evaluering van toetssydigheid die gemiddeldes van die navorsingsgroep se 7 -jariges en 10jariges was respektiewelik 12,03 en 12,681aer as die van die nonngroep. die gemiddeldes van die verskillende ouderdomsubgroepe verskil ook almal met 10-15 roupunte van mekaar. die z-waardes vir al die ouderdomsubgroepe is statisties betekenisvol op die 1 %-beduidendheidspeil. die vraag wat noodwendig hieruit voortvloei, is of die verskil tussen die gemiddeldes van die groepe klinies betekenisvol is. indien die betroubaarheid van die toets in ag geneem word, blyk die groepsverskille nie so groot te wees nie, aangesien die groepe se vertrouensintervalle met mekaar oorvleuel. uit tabel 1 blyk dit dat die 7:00-7:02 jarige subgroep van die navorsingsgroep se gemiddelde (91) 10 roupunte laer is as die gemiddelde (101) van die normgroep. indien die standaardmetingsfout in ag geneem word, kan daar met 95% sekerheid aanvaar word dat die ware telling tussen 1,96 smf bo en 1,96 smf onder die waargenome telling val (owen, 1995). die navorsingsgroep se ware telling val hiervolgens binne die vertrouensinterval van 77 -105 (91a 1,96 x7,15), terwyl die normgroep se ware telling binne die vertrouensinterval van 87-115 (101 a 1,96 x 7,21) gelee is. dit blyk duidelik dat die grense waartussen die twee groepe se ware tellings met 95% sekerheid gelee is in 'n groot mate oorvleuel. hieruit kan afgelei word dat slegs die tellings van hoe presteerders uit die normgroep en lae presteerders uit die na vorsingsgroep beduidend van mekaar verskil. tydens die interpretasie van verskille tussen groepe se gemiddeldes moet daar verder teen waninterpretasies en ongegronde afleidings gewaak word. alhoewel daar verskille tussen die twee groepe se arw-tellings voorkom, kan daar nie sonder meer beweer word dat die normgroep oor beter reseptiewe woordeskatvermoens as die navorsingsgroep beskik nie. die verskil tussen die gemiddeldes van groepe dui nie noodwendig daarop dat die toets eensydig ten gunste van die normgroep meet nie. indien 'n blote punteverskil tussen groepe as sydigheid beskou sou word, sou aile toetsitems sydig teenoor een of ander groep wees. verskille tuss~n groepe se gemiddelde~ kan werklike verskille in die vermoe wat getoets word reflekteer (jensen 1980). verskille in vermoens word deur genetiese vermoe en ontwikkelingsi faktore bepaal (claassen, 1989). voordat uitsprake oor die sydigheid of nie-sydigheid v~n die arw (buitendag, 1994) teenoor kinders vanuit die illeurlinggemeenskap gemaak kan word, moet daar derhalwe eers bepaal word dat die toets dieselfde vermoe ew~ akkuraat (gel dig) en ewe konsekwent (betroubaar) byidie twee groepe meet. sydigheid hou verband met 'n toets se konstrukgeldigheid, kriteriumverwante geldigheid en itemgeldigheid vir verskillende groepe (jensen, 1980). die indeling is kunsmatig, aangesien inhoudsgeldigheid en kriteriumverwante geldigheid ook dimensies van 'n toets se konstrukgeldigheid, as saambindende konsep, is. die toetsitems vorm deel van die interne kriteria vir die evaluering van konstruksydigheid, terwyl kriteriumverwante geldigheid eksterne konstrukgeldigheidskriteria is (owen, 1995). moontlike sydigheid van die arw (buitendag, 1994) teenoor die navorsingsgroep is geevalueer deur die konstrukgeldigheid (betroubaarheid en rangorde van itemmoeilikheid), kriteriumverwantheid en itemekwivalensie van die toets vir die twee groepe te vergelyk. nie een van die kriteria kan afsonderlik voldoende bewys van die bestaan van toetssydigheid lewer nie. elke kriterium lewer 'n gedeeltelike bydrae en verskeie kriteria verskaf gesamentlik 'n aanduiding van die mate waarin die toets die spesifieke konstruk meet (jensen, 1980). 2.1 verskille tussen die betroubaarheid van die groepe se arw-tellings die interne of interitemkonsekwentheid van 'n toets is 'n sensitiewe aanduier van sydigheid. beduidende verskille tussen die betroubaarheidskoeffisiente van groepe kan 'n aanduiding van toetssydigheid wees, omdat dit impliseer dat die toets die konstruk nie ewe goed by die twee groepe meet nie, of by een groep in 'n groter mate ander vermoens meet (jensen, 1980). die betroubaarheidskoeffisiente vir die navorsingsgroep en normgroep word in tabel 2 vir 7jariges en 10-jariges afsonderlik aangebied, om die invloed van ouderdomsvariasie te beperk. uit tabel 2 blyk dat die arw (buitendag, 1994) se betroubaarheidskoeffisiente vir die normgroep en navorsingsgroep tot'n groot mate ooreenstem. die verskille is gering vir proefpersone van aile ouderdomme en nie konsekwent hoer oflaer vir enige van die twee groepe nie. aangesien die betroubaarheidskoeffisiente almal hoog is, word die verskille nie as betekenisvol beskou nie. die ooreenstemmende betroubaarheidskoeffisiente impliseer dat die toets die konstrukte wat by die twee groepe gemeet word ewe konsekwent meet. daar moet ook in gedagte gehou word dat die kr-21-betroubaarheidskoeffisiente van die subgroepe laer is as die van die totale groep, naamlik 0,93. volgens jensen (1980) hoef die navorser nie verder tabel 2 : betroubaarheidskoeffisiente (rtt) vir die normgroep en navorsingsgroep rtt ouderdomsgroep normgroep navorsingsgroep 7 jr 7:00 7:02 0,86 0,76 7:03 7:05 0,85 0,82 7:06 7:08 0,84 0,82 7:09 7:11 0,80 0,87 lojr 10:00 10:02 0,76 0,82 10:03 10:05 0,82 0,76 10:06 10:08 1 0,77 0,78 10:09 10:11 0,86 0,80 die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 18 aan groepsverskille in betroubaarheid aandag te gee indien die interne konsekwentheid vir beide groepe hoog is en met mekaar ooreenstem nie. op grond van die bctroubaarheidskoeffisiente kan die afleiding gemaak word dat dieselfde mate van vertroue in die toetstellings van die twee groepe ges'tel kan word (jensen, 1980). die betroubaarheidsindekse lewer geen bewys van toetssydigheid nie. verskille of ooreenkomste tussen groepe se betroubaarheidskoeffisiente is nie genoeg bewys van die teenwoordigheid of afwesigheid van toetssydigheid nie. ooreenstemmende betroubaarheidskoeffisiente dui aan dat die toetsitems die konstrukte wat dit by die twee groepe meet ewe konstant meet, maar verskaf nie bewys dat dieselfde konstruk gemeet word nie (bachman, 1990). groepsverskille in itemmoeilikheid moet verder ondersoek word om die bestaan van sydigheid te bevestig (osterlind, 1983). 2.2 vergelyking van die rangorde van itemmoeilikhede vir die groepe om die konsekwentheid of ekwivalensie van itemmoeilikhede vir die groepe te evalueer, is die toetsitems vir elke groep afsonderlik volgens stygende moeilikheidsgraad gerangskik, waarna spearman se rangordekorrelasiekoeffisient (rho) tussen die twee stelle rangordes bereken is. die result ate verskyn in figuur 1. figuur 1: rangordekorrelasiekoeffisient tussen die navorsingsgroep en normgroep uit figuur 1 blyk dit dat die rangordekorrelasie tussen die twee stelle rangordes van die toets (rho = 0,97) hoog en statisties beduidend (p = 0,0001) is. aangesien die rangordekorrelasie hoer as 0,90 is (osterlind, 1983), en die korrehisie statisties betekenisvol op die 1 %-peil is, kan daar met 99% sekerheid beweer word dat die toets se itemmoeilikheid relatief ekwivalent vir die twee groepe is. op grond van die hoe rangordekorrelasie kan die afleiding gemaak word dat die toetsitems op dieselfde manier vir die groepe funksioneer en daar nie 'n beduidende mate van itemsydigheid voorkom nie. die bevinding dien as verdere bewys dat die toets dieselfde konstruk by die twee groepe meet (owen, 1995). op grond van die relatiewe gelyke konsekwentlieid van die itemmoeilikhede tussen die groepe kan daar aanvaar word dat die arw (buitendag, 1994) se itemrangskikking nie sydig teenoor die navorsingsgroep is nie (osterlind, 1983). die resultate impliseer dat die toets se oorspronklike rangorde van itemmoeilikheid vir die navorsingsgroep behou kan word. alhoewel interne kriteria sui werder aanduidings oor toetssydigheid kan verskaf as eksterne kriteria, vereis . konstrukgeldigheidsbepaling ook bewyslewering van die verb and tussenarw-tellings en ander verwante veranderlikes of eksterne kriteria. 2.3 kriteriumverwantheid: die verband tussenarwtellings en ouderdom indien 'n konstruk kruiskultureel dieselfde betekenis het, sal 'n toets wat die konstruk meet in verskillende kulture op 'n soortgelyke wyse met ander veranderlikes, mariekie buitendag, isabel uys, brenda louw onder andere ouderdom, verband hou (claassen, 1989). die toename in woordeskatvermoens met verhoogde ouderdom, ten opsigte van beide die grootte en diepte van die leksikon volgens universele en dus voorspelbare ontwikkelingstadia en -patrone, word algemeen in'die literatuur vermeld (owens, 1995). daar kan derhalwe verwag word dat kinders se puntetellings vir 'n woordeskattoets met ouderdom sal toeneem en dat populasiegroepe waarvoor die toets eenders funksioneer soortgelyke toenames sal vertoon (jensen, 1980). indien 'n toets dieselfde konstruk by twee groepe meet, moet beide toetse dus 'n positiewe korrelasie tussen roupunte en ouderdom vertoon. informele, visuele analise van die rekenkundige gemiddeldes van die verskillende ouderdomsgroepe, wat in tabel 1 verskaf is, dui daarop dat be ide die normgroep en navorsingsgroep se gemiddelde prestasies op die toets verhoog met ouderdom. die verskil tussen die gemiddelde prestasies van die 10-jarige en 7-jarige ouderdomsgroepe van die normgroep (144-107 = 37) en navorsingsgroep (13295 = 37) stem ooreen. by beide groepe het die ouderdomstoename 'n verhoging van 37 roupunte meegebring. die twee groepe se roupunte vertoon ook 'n soortgelyke toename vir elk van die drie-maande-ouderdomsubgroepe. die gemiddeldes van die 10:00 10:02jarige en 10:03 10:05jarige subgroepe verskil byvoorbeeld by beide groepe met 1 roupunt, terwyl die gemiddeldes van die ander 10jaarsubgroepe by be ide groepe telkens met 2 roupunte van mekaar verskil. dit blyk dat die arw (1994) by albei groepe tussen die woordeskatvermoens van kinders van verskillende ouderdomme differensieer. aangesien gelyke toenames in arw-tellings met verhoging van ouderdom by die groepe voorkom, kan die afleiding gemaak word dat reseptiewe woordeskatontwikkeling, soos dit deur die arw (buitendag, 1994) . gemeet word, bykans eenders in die twee groepe verloop en dat die toets dieselfde vermoe eenders by die twee groepe meet. die ooreenstemmende toename in die navorsings, groep en normgroep se arw-tellings met ouderdom dien as gedeeltelike bewys dat die arw (buitendag, 1994) in 'n groot mate dieselfde konstruk by die twee groepe meet. op grond van die toets se ooreenstemmende i1nterne konsekwentheid, rangordes van itemmoeilikheid (interne kriteria), en verband met ouderdom (eksterne krit~rium), is die gevolgtrekking bereik dat die toets dieselfde kohstruk by die twee groepe meet, dit wil se grootliks nie-sydig ten i opsigte van konstrukgeldigheid is. die afwesighe,d van sydigheid in konstrukgeldigheid dui volgens jensen (1980) ~an dat die verskille tussen die gemiddelde toetsprestasies van groepe werklike verskille in die vermoe reflekteer en nie aan kulturele sydigheid toegeskryf kan word nie. die afwesigheid van sydigheid in die konstrukgeldigheid van intelligensieen aanlegtoetse is 'n algemene bevinding in oorsese navorsing (jensen, 1980) en is ook in suid-mrika gevind (owen, 1995). die algemene bevinding van die afwesigheid van konstruksydigheid in toe'tse, hou belangrike implikasies vir die ontwikkeling van gemeenskaplike toetse vir verskillende bevolkingsgroepe in. die verskille tussen die groepe se vermoensvlakke is nie so groot dat verskillende toetse opgestel moet word nie. dit impliseer verder dat verskille in toetsprestasies nie noodwendig die konstrukgeldigheid van 'n toets belnvloed nie. die afwesigheid van konstruksydigheid sluit egter nie die moontlikheid uit dat sydige items 'n groep se vermoe as gevolg van linguistiese en ander sosiale veranderlikes the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) afrikaanse reseptiewe woordeskattoets (arw): toepaslikheid vir in groep nie-standaardafrikaanssprekende kinders 19 sistematies kan onder skat nie (osterlind, 1983). indien die om sydigheid van meerkeusige items se afleiers by doel van die toets is om taal te evalueer, reflekteer verskille kultureel diverse groepe te bevestig, moet die keuse van die in toetsprestasies waarskynlik werklike verskille in die bepaalde afleier na sosiokulturele groeplidmaatskap vermoe wat getoets word en is nie noodwendig die gevolg teruggevoer kan word (osterlind, 1983). kwalitatiewe van itemsydigheid nie (owen, 1995). moontlike sydigheid foutontleding van die geldentifiseerde items, met verdere van die toetsitems teenoor die navorsingsgroep word voorts bevestiging deur voorbeelde van toetslinge se verbale geevalueer. definisies, het aangedui dat die keuses van die spesifieke 2.4 evaluering van itemsydigheid 'n toetsitem kan as sydig beskou word indien dit op 'n sistematiese wyse verskillend funksioneer vir verskillende groepe en indien dit een groep onbillik bo 'n ander bevoordeel. die blote feit dat groepe se prestasie in 'n item verskil is nie noodwendig 'n aanduiding van sydigheid teenoor die groep met die laer prestasie nie. daar moet ook by wyse van kwalitatiewe beoordeling bepaal word waarom die item sydig is. die fundamentclc vraag in itemsydigheid is na die oorsaak van die sydigheid (owen, 1995). itemsydigheid is op verskeie maniere geevalueer, naamlik afleierdoeltreffendheid en itemmoeilikheidswaardes, en die resultate word vervolgens bespreek. 2.4.1 differensieie afleierdoeltreffendheid 'n meerkeusige toetsitem kan as sydig teenoor 'n bepaalde groep beskou word indien een of meer van die afleiers deur meer individue geselekteer word as die korrekte antwoord. die arw-items waarvan bepaalde afleiers deur 'n hoer persentasie proefpersone gekies is as die korrekte antwoord, word in tabel 3 verskaf. die kieserspersentasie van die afleier en die korrekte antwoord word vir elke item aangedui. slegs items onder die gemiddelde plafon van die navorsingsgroep se 10-jariges is geldentifiseer, om die invloed van itemmoeilikheidswaarde te beperk. vit tabel 3 blyk dit dat die afleiers van 9 items deur 'n groter persentasie proefpersone as die korrekte antwoord gekies is. by item 109 met di~ stimuluswoord onderrig, is die afleier tugtig (antwoordinoontlikheid 2) byvoorbeeld deur 29% meer proefpersdne gekies as die korrekte antwoord onderrig (antwoordmoontlikheid 1). tabel 3: items met mooltlike ontoepaslike afleiers i ; item stimulus % afleiers hoofsaaklik gebaseer is op geen kennis of gedeeltelike kennis van die betekenis van die stimuluswoord. gedeeltelike kennis van die betekenis van die stimuluswoord word gereflekteer deur ooren onderveralgemenings en verskillende konnotasies (duncan, 1989). geen kennis van die woordbetekenis word gereflekteer deur die gebruik van linguistiese interpretasiestrategiee, lukraak seleksie ofblote raai, en die seleksie van die afleier wat die meeste met die korrekte antwoord ooreenstem (owen, 1995). foutontleding vir die evaluering van die toepaslikheid van die afleiers, met inagneming van verbale response, word aan die hand van die volgende voorbeelde gelllustreer: item 141 (gerf) item 109 (onderrig) item 135 (regeer) item 142 (bot) item 146 (skerf) wantjy kerf met hom. (geen kennis: linguistiese interpretasiestrategie fonologiese ooreenkoms) diejonkie se moeder onderrig hom ... sy slat sy boude ani brand. (gedeeltelike kennls : verskillendekonnotasie) hulle regeer oor iets ... hulle fight. (geen kennis : linguistiese interpretasiestrategie moontlike verwarring met redeneer) hy spuit die plantjies nat lat hulle kan bot. (gedeeltelike kennis : blom oorveralgemening binne dieselfde semantiese kategorie) oorlat die bak gebreek het ... nou't hy so 'n skerf gekry. hy't geual. (gedeeltelike kennis: oorveralgemening binne dieselfde semantiese kategorie) vit die afleieranalises blyk dit dat die proefpersone se seleksie van die spesifieke afleiers op gebrekkige kennis afleier % % j korrekte : alternatief (foutiewe alternatief) verskil i 109 onderrig (1) 23,9 tugtig (2) 49,8 25,9 117 monument (1) 22,8 piramide (4) 23,4 0,6 135 regeer ( 1) 14,1 rusie/argumenteer (4) 26,3 12,2 136 onluste (2) 13,8 duik (4) en (1) onnutsig 16,0 en 17,0 2,2 en 3,2 141 gerf (2) 10,1 sekel (3) 29,5 29,4 142 bot ( 1) 11,2 blom (3) 17,0 5,8 146 skerf (1) 14,0 kraak (4) 17,7 3,7 147 harpoen (2) 10,1 boemerang (1) en hoepel (3) 13,5 en 15,9 3,4 en 5,8 148 oase (1) 5,8 vulkaan (2) en orkaan (3) 13,3 en 20,8 3,4 en 15,0 die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 20 van die betekenis van die toetswoorde gebaseer is en nie die gevolg van sosiokulturele verskille is nie. die resultate impliseer dat die afleiers nie sydig teenoor die navorsingsgroep is nie en gevolglik nie verander of vervang hoef te word nie. dit dien as verdere bewys van die konstrukvergelykbaarheid van die toets vir die twee groepe. 2.4.2 differensiele itemmoeilikheidswaardes 'n vinnige en eenvoudige metode om 'n voorlopige aanduiding .van die mate van sydigheid van 'n toets te bepaal, is om die moeilikheidswaarde van die items (pwaarde) vir die twee groepe te vergelyk (osterlind, 1983). sydigheid kan vermoed word vir enige item waarvan die moeilikheidswaarde van die algemene patroon van wisselende itemmoeilikheid tussen die groepe afwyk. die arw (buitendag, 1994) se roupuntberekening berus op die bepaling van 'n basaal (die hoogste agt opeenvolgende korrekte antwoorde) en 'n plafon (die laagste agt opeenvolgende antwoorde waarin 6 foute voorkom). gevolglik is aile items geydentifiseer wat volgens die navorsingsgroep se itemmoeilikheidswaardes meer as agt plekke van die moeilikheidsrangordening van die item volgens die normgroep verskuif het, met ander woorde items wat merkbaar makliker of moeiliker vir die navorsingsgroep as vir die normgroep is. die geydentifiseerde items word in tabel4 verskaf. uit tabel 4 blyk dit dat die itemmoeilikheidswaardes van heelwat items merkbaar van die van die navorsingsgroep verskil. 'n tweerigtingverskil kom voor, naamlik 29 items is vir die navorsingsgroep moeiliker as vir die normgroep en 28 items is makliker. beide moeiliker en makliker items verskil met soveel as 30 plekke in rangorde van itemmoeilikheid. item 46 (eekhoring) en item 66 (versier) is byvoorbeeld 30 plekke moeiliker, terwyl item 140 (dronk) 28 plekke makliker is. sommige items se moeilikheidswaardes vir die navorsingsgroep kan egter laer wees as aangedui, indien die korrekte alternatiewe verbale reponse in berekening gebring sou word, byvoorbeeld item 63 (seel / stamp) en item 72 (skaak / chess). moontlike sosiokulturele verklarings vir die verskuiwing in rangorde van itemmoeilikheid kan ten opsigte van verskeie items gelewer word. die merkbare laer moeilikheidswaarde van item 140 (dronk) hou waarskynlik verband met die hoe voorkoms van drankmisbruik in die kleurlinggemeenskap (booyens, 1996; attweil, 1997), en item 122 (jles) waarskynlik met die feit dat baie ouers skofte werk of ver van die huis af werk en daagliks kospakkies en 'n fles koffie of tee saamneem. flesse word ook nog dikwels gebruik in huise wat nie van elektrisiteit voorsien is nie (booyens, 1996). die hoer moeilikheidswaarde van item 68 (eekhoring), item 29 (seekoei) en item 32 (pikkewyn), kan byvoorbeeld na aile waarskynlikheid aan sosio-ekonomiese redes toegeskryf word, aangesien die diere nie algemeen voorkom nie, en baie kinders weens beperkte reisgeleenthede en ander inligtingsmedia nie die nodige blootstelling gehad het nie. dit blyk dat verskeie arw-items vir die navorsingsgroep moeiliker is as vir die normgroep op grond waarvan hulle as onbillik of sydig teenoor die navorsingsgroep bestempel kan word. 'n gelyke aantal items is egter vir die navorsingsgroep makliker as vir die normgroep, en behoort dan weer as sydig ten voordeel van die navorsingsgroep beskou te word. by die interpretasie van toetssydigheid op grond van wissellende itemmoeilikheidswaardes, moet in ag geneem mariekie buitendag, isabel uys, brenda louw word dat itemmoeilikheidswaardes tussen groepe, asook by dieselfde groep van een toepassing van die toets na 'n ander, altyd sal wissel. alhoewel individuele items se moeilikheidswaardes verskil, is die rangordekorrelasie tussen die twee stelle rangordes van itemmoeilikheid hoog, naamlik rho = 0,97 (vergelyk figuur 1), wat impliseer dat die oorspronklike items en itemrangorde vir die navorsingsgroep behou kan word. die onbeduidende invloed van die afwykende items is te danke aan die deeglike voorsorg teen potensiele bronne van sydigheid teenoor ander groepe wat tydens die oorspronklike ontwerp van die toets ingeskakel is, naamlik die vroegtydige uitskakeling van opsigtelik kultuurspesifieke items, en die daarstelling van 'n bree itemspektrum en groot kritiese reeks per ouderdomsgroep, wat die invloed van sydige items op die gemiddelde neutraliseer (jensen, 1980). die arw (buitendag,1994) is sover bekend die enigste woordeskattoets om hierin te slaag. die evaluasies van die interne konsekwentheid, rangorde van itemmoeilikheid, kriteriumverwantheid en itemgeldigheid van die toets oor die groepe dui aan dat die arw (buitendag, 1994), ten spyte van verskille tussen die groepe se gemiddeldes, betroubaar en geldig vir die evaluering van taalafwykings by die navorsingsgroep (as geheel) is. tydens die taalevaluering van kinders vanuit kultureel en linguisties diverse groepe is dit egter essensieel om intrakulturele subgroepverskille in aanmerking te neem (taylor & clarke, 1994; hegde & davis, 1995; valdes & figueroa, 1995). vanwee die algemene konsensus in die literatuur oor die deurslaggewende rol van sosioekonomiese status in taalontwikkeling en taalgebruik (edwards, 1989; abudarham, 1995), word die invloed van sosiale veranderlikes op die navorsingsgroep se arwtellings vervolgens ondersoek. 3 die verband tussen sosio-ekonomiese status en arw-tellings die invloed van sosio-ekonomiese status op die navorsingsgroep se arw-tellings is ondersoek om as 'n moontlike verklaring te dien vir die puntevariansie ten opsigte van die normgroep. die proefpersone se sosio-ekonomiese status is aan die hand van van den berg (1991) se sed-kaelys geevalueer, waarvolgens die proefpersone in t~e~ sosioekonomiese statusgroepe ingedeel is, naamlik 'rr sosioekonomies gedepriveerde groep en 'n sosio-ekonomies niegedepriveerde groep. i i i 3.1 vergelyking van die gemiddeldes van die sosioekonomiese subgroepe van die navorsingsgroep die sosio-ekonomies gedepriveerde proefpersone en sosio-ekonomies nie-gedepriveerde proefpersone se gemiddeldes is met mekaar vergelyk om moontlike subgroepverskille te bepaal. die resultate, wat in tabel 5 verskyn, dui aan dat sosio-ekonomies gedepriveerde proefpersone swakker as sosio-ekonomies nie-gedepriveerde proefpersone pre steer het. die verskil tusseln die gemiddeldes van die twee sosiale klasgroepe van 16 roupunte of 9 standaardtellingekwivalente is beide statisties beduidend. ondersteuning vir die bevinding dat .sosio-ekonomiese status 'n beduidende invloed op'woordeskattoetsprestasie het, word algemeen in die'literatuur aangetref (dunn & dunn, 1981; alant & beukes, 1986; washington & craig, 1992). die relayewe laer toetsprestasies van sosiothe south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) afrikaanse reseptiewe woordeskattoets (arw): toepaslikheid vir in groep nie-standaardafrikaanssprekende kinders 21 tabel 4 : items waarvan die moeilikheidsgraad merkbaar vir die groepe verskil opwaartse verskuiwing aantal plekke afwaartse verskuiwing (moeiliker) verskuif (makliker) 55. anker 90. fiks 58. swaard * 10 138. ventileer 97. kokon 72. skaak * 40. ghitaar 127. skarnier 12 50. buk 135. regeer 62. loer 142. bot 79. sproet 13l. reptiel 65. bier 77. ontsnap 13 136. onluste 32. pikkewyn 106. letter 47. elmboog 14 148. oase 4l. dek 69. lui 54. tref 15 14l. gerf 29. seekoei 95. graan 42. skakel * 16 102. eetgerei 119. afrig 134. gehoor 145. violis 82. rat * 70. spoor 17 132. medies 153. bouvallig 63. seeh * 18 155. afknou 19. skeidsregter 19 74. gewapen i 83. half i 112. vaatjie i 20 122. fles i 22 56. reisies i 23 ! 80. langs i 117. monument i 24 7l. snoet , , 124. fotograaf , ./ 25 110. trofee 26 99. beroof 108. paar 94. ponie 27 100. streel 28 140. dronk 109. onderrig 29 46. eekhoring 30 68. versier 30 i * woorde waarvoor toepaslike alternatiewe response gelewer is en die werklike moeilikheidswaarde derhalwe waarskynlik laer is. die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 22 ekonomies gedepriveerde kinders word nie aan gebrekkige vermoens toegeskryf nie, maar aan sosiale veranderlikes. die uitgangspunt is dat sosio-ekonomies gedepriveerde kinders onregverdig gepenaliseer word deur gestandaardiseerde toetse, wat gewoonlik op die standaardvarieteit en kulturele agtergrond van blanke middelklaskinders gebaseer is, aangesien hulle nie dieselfde kwantitatiewe en kwalitatiewe linguistiese blootstelling en ervaringsgeleenthede as kinders uit die middel en hoer sosiale klasse gehad het nie (edwards, 1989). 3.2 verskille tussen die gemiddeldes van die sosioekonomiese subgroepe en die normgroep die gemiddelde van die 7en 10-jarige proefpersone van die normgroep is met die gemiddeldes van die totale navorsingsgroep, die sosio-ekonomies nie-gedepriveerde subgroep en die sosio-ekonomies gedepriveerde subgroep vergelyk. volgens die resultate, wat in tabel 6 weergegee word, verskil die gemiddeldes van die navorsingsgroep (113) en normgroep (125) met 12 roupunte. die gemiddeldes van die sosio-ekonomies nie-gedepriveerde groep (122) en die navorsingsgroep (125) se gemiddeldes verskil baie min (3) van mekaar. 'n roupuntverskil van 3 is nie prakties betekenisvol nie. die sosio-ekonomies gedepriveerde subgroep se gemiddelde (106) is egter laer as albei die ander groepe .se gemiddeldes. dit is 19 roupunte laer as die van die normgroep, maar ook 16 roupunte laer as die gemiddelde (122) van die sosio-ekonomies nie-gedepriveerde groep. die resultate impliseer dat die verskil tussen die gemiddeldes van die normgroep en die totale navorsingsgroep tot 'n groot mate die gevolg is van sosio-ekonomiese verskille en dat die toets toepaslik is vir die sosio-ekonomies niegedepriveerde groep, maar nie vir die sosio-ekonomies gedepriveerde groep nie. mariekie buitendag, isabel uys, brenda louw dit blyk dat sosio-ekonomies nie-gedepriveerde proefpersone se arw-prestasie in 'n groter mate met die gemiddelde van die normgroep ooreenstem as met die van die sosio-ekonomies gedepriveerde subgroep sowel as die totale navorsingsgroep. aangesien die gemiddelde van die sosio-ekonomies nie-gedepriveerde subgroep so nou met die van die normgroep ooreenstem, kan beweer word dat die toets vir hulle toepaslik is. daar kan egter verwag word dat die toets sydig teenoor'n sosio-ekonomies gedepriveerde groep kan wees. die implikasie hiervan is dat prosedures oorweeg moet word om die toets se toepaslikheid vir sosioekonomies gedepriveerde kinders vanuit die kleurlinggemeenskap te verhoog. die resultate dui daarop dat die intragroepsvariasie wat sosio-ekonomiese status betrefby die navorsingsgroep groter is as die interkulturele verskille tussen die navorsingsgroep en die normgroep. hierdie bevinding ondersteun die uitspraak van marais (1968) dat die afrikaanssprekende blanke gemeenskap en kleurlinggemeenskap dieselfde kultuur deel en dat verskille tussen die twee groepe hoofsaaklik aan die algemene laer sosio-ekonomiese status van die kleurlinggemeenskap toegeskryfkan word. die sosioekonomiese oorsake van linguistiese verskille in die kleurlinggemeenskap is ook in die navorsing van coetzee (1989) aangetoon, naamlik dat die gestigmatiseerde taalvorme tot 'n goter mate in die taalgebruik van die laer sosiale klasgroepe voorkom. alhoewel die meeste niestandaardafrikaanssprekers nie slegs hulle eie varieteit magtig is nie, vertoon kinders van die laer sosiale klas dikwels ontoereikende beheer oor die standaardvarieteit weens gebrekkige standaardtaalblootstelling. die arw (buitendag, 1994), wat in standaardafrikaans opgestel is, kan gevolglik linguistiese sydigheid teenoor die groep inhou. verskillende alternatiewe vir die aanpassing van die toets om potensiele sydigheid te verminder, word vervolgens ondersoek. tabel 5 : roupunte vir sosio-ekonomies gedepriveerde en nie-gedepriveerde kinders ** proefpersone sed-indeks* n x 0 434 104,8711 1 516 95,9030 verskil 8,9681 p 0,0001 sosio-ekonomiese deprivasie-indeks : o = nie sosio-ekonomies gedepriveerd nie 1 = sosio-ekonomies gedepriveerd ste roupunte s x s i i 14,5645 121,7627 22,7133 i 13,9984 105,7345 24,5122 i i 0,5661 16,0282 -1,7988 0,0001 i i tabel 6: roupunte vir die normgroep en sosio-ekonomiese subgroepe van die navorsingsgroep x normgroep 124,66 / navorsingsgroep: • nie-sed subgroep 121.76 • totale groep 113.16 • sed subgroep 105.74 verskil 2,90 11,44 18,92 the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) af ·kaanse reseptiewe woordeskattoets (arw): rl l.kheid vir in groep nie-standaardafrikaanssprekende kinders toepas i 23 4 toetsaanpassingsmoontlikhede wat 'n toetsling verkeerd beantwoord het en toepaslike verskillende toetsaanpassingsmoontlikhede is onderek naamlik aanpassing van die rangorde van item-so , moeilikheid, toetsbeginpunte en roupunte. 4.1 aanpassing van rangorde van itemmoeilikheid toetse se rangorde van itemmoeilikheid word soms aangepas om dit meer toepaslik vir individue van verskillende kultuurgroepe te maak (alant & beukes, 198~). die hoe rangordekorrelasie (rho = 0,974) tussen die navorsingsgroep se twee stelle rangordes dui aan dat die arw (buitendag, 1994) se oorspronklike rangorde van itemmoeilikheid vir die navorsingsgroep behou kan word. 4.2 aanpassing van toetsbeginpunte die arw (buitendag, 1994) se toetsitems is volgens stygende moeilikheidsgraad gerangskik en vasgestel sodat 85% van die normgroep wat in 'n bepaalde chronologiese ouderdomsgroep val 'n basaal kan bereik, sonder dat daar terugwaarts getoets moet word of dat toetslinge te veel maklike items moet aile. aangesien die navorsingsgroep swakker op die toets pre steer het as die normgroep (vergelyk tabel 1), kan daar verwag word dat die toetsbeginpunte waarskynlik vir kinders vanuit die kleurlinggemeenskap te hoog sal wees. . uit 'n analise van die itemmoeilikheidswaardes het dit geblyk dat die toetsbeginpunte vir die navorsingsgroep heelwat verlaag moet word. die voorgestelde toetsbeginpunte volgens die navorsingsgroep se prestasie, word in tabel 7 tee no or die van die normgroep gestel. uit tabel 7 blyk dit dat die basale wat deur 85% van die 7 -jarige en 10jarige proefpersone bereik is, naamlik item 45 en item 82 respektiewelik, beide 24 items laer is as die bas ale wat deur 85% van die normgroep se 7en 10-jariges bereik is. die resultate impliseer dat die toetsbeginpunte van die arw (buitendag 1994) vir beide 7-jarige en 10-jarige kleurlingkinders ~et 24 ite~s vervroeg behoort te word, om terugwaartse toetsing te (erhoed of te beperk. 4.3 aanpassing van roupunte aangesien die ontwikkelijg van nuwe norme vir kinders vanuit die kleurlinggemeen$kap nie sosiopolities wenslik is nie (owen, 1995) en nie prakties geregverdig kan word nie omdat die sosio-eko1nomies nie-gedepri veerde pro~fpersone se toetstelling,s met die standaardiseringsgroep se tellings ooreenstem, is roupuntaanpassing as alternatief ondersoek. die toetsresponstaak en nasienprosedure is aangepas deur addisionele verbale reponse te ontlok op aile items tabel 7 : voorgestelde toetsbeginpunte volgens 85%-itemmoeilikheidsgraad vir die normen navorsingsgroep voorgestelde toetsbeginpunt i ouderdomsnormnavorsingsgroep groep groep 7-jariges 69 45 10-jariges 1106 82 verbale response korrek te merk. die groep se gemiddeldes volgens die aangepaste toetsprosedure (roupunt 3) en oorspronklike toetsprosedure (roupunt 1) is voorts met mekaar vergelyk. die resultate word in tabe18 weergegee. die gegewens in tabel 8 dui aan dat die aanpassing van die toetsresponstaak en nasienprosedure 'n geringe verhoging van 1,5794 in die gemiddelde toetsprestasie van die navorsingsgroep tot gevolg gehad het, wat statisties beduidend bevind is. 'n verskil van 2 roupunte in prestasie op die arw (1994), wat 'n verskil van 1 of uiters 2 standaardtellingekwivalente vir enige ouderdomsgroep uitmaak, is egter nie prakties beduidend vir die identifisering van reseptiewe woordeskatafwykings nie. sodanige verskil kan veral as onbenullig beskou word as daar rekening gehou word met die vertrouensintervalle wat vir die toets aangedui is. aangesien die sosio-ekonomies gedepriveerde subgroep se arw-tellings laer is as die van die sosio-ekonomies niegedepriveerde subgroep en gestigmatiseerde taalvorms veral met die taalgebruik van die laer sosiale klasse geassosieer word (coetzee, 1989), moet die moontlike differenshile invloed van roupuntaanpassing op die prestasies van die twee sosio-ekonomiese subgroepe ook in aanmerking geneem word by die oorweging van roupuntaanpassing. in die lig daarvan dat die sosio-ekonomies niegedepriveerde subgroep se arw-tellings met die normgroep s'n ooreenstem, kan daar verwag word dat prestasieverhoging met roupuntaanpassing hoofsaaklik op die sosioekonomies gedepriveerde subgroep betrekking sal he. die verskil tussen die gemiddeldes van die sosio-ekonomiese subgroepe volgens die oorspronklike (roupunt 1) en aangepaste responstaak en nasienprosedure (roupunt 3) word vervolgens in tabel 9 aangedui. uit tabe19 blyk dit dat die regmerk van korrekte verbale response 'n gemiddelde verhoging van 1,56 roupunte by die sosio-ekonomies gedepriveerde subgroep teweeg gebring tabel 8: roupuntverhoging deur die regmerk van verkeerd beantwoorde items waarop korrekte verbale response gelewer is veranderlike x s n roupunt 1 113,0568 25,0054 950 roupunt3 114,6362 34,3716 950 roupunt3 roupunt 1 1,5794 p 0,0001 tabel 9 : differensiele roupuntverhoging by die sosio-ekonomiese subgroepe veranderlike nie-sed sed (n = 431) (n = 580) roupunt1 121,76 105,74 roupunt3 121,79 107,30 roupunt3 roupunt1 0,04 1,56 p 0,4520 0,0001 die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 24 het. die verskil tussen die roupuntgemiddeldes is statisties beduidend (p = 0001), maar is nie vir die praktiese gebruik van die toets betekenisvol nie. die sosio-ekonomies niegedepriveerde groep se gemiddeldes verskil nie statisties beduidend (p = 0, 4520) nie en word vir praktiese doeleindes gelyk geag. . aangesien die verhoging van die sosio-ekonomies gedepriveerde subgroep se gemiddelde nie prakties betekenisvol is nie, kan die afleiding gemaak word dat die toets se oorspronklike responstaak en nasienprosedures vir kleurlingkinders van beide die sosio-ekonomiese groepe toepaslik is. alhoewel die regmerk van verkeerd beantwoorde items waarop korrekte verbale response gelewer is nie die gemiddeldes van die totale groep of die sosioekonomiese subgroepe betekenisvol belnvloed het nie, bestaan die moontlikheid steeds dat individuele toetsprestasie betekenisvol daardeur verhoog kan word. 5 samevatting oor groepsverskille die groepsverskille tussen die normgroep, navorsingsgroep en verskillende sosio-ekonomiese subgroepe word in terme van die vertrouensintervalle vir die ware tellings en die prestasieverspreidings op die normale verspreidingskurwe bespreek. 5.1 interpretasie van verskille tussen gemiddeldes volgens vertrouensintervalle van ware tellings tydens die interpretasie van taaltoetstellings moet in ag geneem word dat 'n toetstelling (verkree telling) nie 'n mariekie buitendag, isabel uys, brenda louw presiese meting is nie, maar'n skatting van die ware telling is. die ware telling is altyd onbekend en sal weens toevallige foute met herhaalde toetstoepassings altyd varieer. die verkree telling moet gevolglik in terme van die standaardmetingsfout (smf) gelnterpreteer word. die standaardmetingsfout gee 'n aanduiding van die grense waarbinne die individu se gehipotetiseerde ware telling waarskynlik volgens 'n bepaalde mate (95% of 99%) van sekerheid of vetroue gelee is (owen, 1995). indien groepe se gemiddeldes vergelyk word om groepsverskille te bepaal, moet die vertrouensintervalle waarbinne die lede se ware tellings waarskynlik ie derhalwe ook in aanmerking geneem word. figuur 2 illustreer die oorvleueling van die vertrouensintervalle vir die normgroep, totale navorsingsgroep en twee sosio-ekonomiese subgroepe se ware tellings in die oorspronklike toets, asook vir die navorsingsgroep en sosioekonomiese subgroepe se ware tellings (roupunte 3) in die aangepaste toets, volgens die 95%-vertrouensinterval. uit figuur 2 blyk dit dat die navorsingsgroep (en subgroepe) se vertrouensintervalle, waarbinne die ware telling 95 uit 100 kere sal val, almal in 'n meerdere of mindere mate met die van die navorsingsgroep oorvleuel. die vertrouensintervalle vir die sosio-ekonomies niegedepriveerde subgroep stem grootliks met die van die normgroep ooreen, wat die toepaslikheid van die toets vir die subgroep bevestig. die vertrouensintervalle vir die sosio-ekonomies gedepriveerde subgroep se ware tellings in die oorspronklike en aangepaste toets oorvleuel die minste met die van die normgroep (en sosio-ekonomies nie-gedepriveerde sub/ o 90 .... 95 .... 100 .... 105 .... 110 .... 115 .... 120 .... 125 .... 130 .... 135 .... 140 175 arw-roupunt figuur 2: verskille tussen gemiddeldes met inagneming van 95%vertrouensinterval vir ware tellings the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) afrikaanse reseptiewe woordeskattoets (arw): . toepaslikheid vir 'n groep nie-standaardafrikaanssprekende kinders 25 oep). die onderste grens van die vertrouensinterval vir ~e normgroep val bo die gemiddelde van die sosioekonomies gedepriveerde subgroep (met of sonder roupuntaanpassing), en oorvleuel met ander woorde slegs met teilings bo die subgroepgemiddelde. die resultate wek die suspisie dat die toets ontoepaslik is vir ongeveer die helfte van die groep (lae presteerders) en vestig weereens die aandag op die bestaan van aansienlike linguistiese variasie binne die laer sosio-ekonomiese groep. 5.2 interpretasie van verskille tussen gemiddelde standaardtellingekwivalente volgens verspreiding op normale kurwe die toepaslikheid van die arw-norme kan ook geevalueer word in terme van die navorsingsgroep se prestasieverspreiding op die normale verspreidingskurwe. in figuur 3 word die standaardteilingekwivalentverspreiding van die navorsingsgroep en die twee sosio-ekonomiese subgroepe op die normale verspreidingskurwe uitgebeeld. volgens figuur 3 het 47% van die kinders in die totale navorsingsgroep onder die gemiddelde standaardteilingekwivalent van 100 pre steer, en 33% van die sosioekonomies nie-gedepriveerde subgroep. die prestasieverspreiding van beide stem grootliks ooreen met die van die normgroep. die verspreiding van die sosio-ekonomies gedepriveerde groep verskil egter merkbaar van die ander groepe. dit blyk dat 60% sosio-ekonomies gedepriveerde kinders onder die gemiddelde van die normgroep presteer het, waarvan 37,'75% bo en 22,91 % onder een standaardafwyking onder die gemiddelde teenoor die normgroep se verspreiding van 34,14% en 15,86% respektiewelik. die grootste variansie ie dus aan die onderste punt van die kurwe. indien een standaardafwyking onder die gemiddelde as 'n klinies beduidende afsnypunt gebruik word (washington & craig, 1992), blyk dit dat 22,44% van die kinders woordeskatafwykings het. ; i persentasie gevalle onder gedeeltes van die normale verspreidingkkurwe \ 2,27% 013% 214% s -4s -3s ste 40 55 persentiel 1 totale navorsingsgroep 2,45% nie-sed subgroep 1,39% sed subgroep i 3,35% 1359% 3413% -2s -is 70 85 2 5 10 20 30 40 13,52% 8,76% 6,96% 23,21% 19,09% 33,46% die swakker prestasie van die sosio-ekonomies gedepriveerde groep kan, soos dikwels in die literatuur (washington & craig, 1992), aan sydigheid weens kultuurverskille toegeskryf word. gesien in die lig van die groep se sosiokulturele agtergrond is die waarskynlikheid egter groot dat die swak prestasie werklike gebrekkige woordeskatvermoens reflekteer. vermoens word deur verskillende veranderlikes bepaal, onder andere genetiese faktore, die hoe insidensie van bepaalde fisiese gebreke en siektetoestande soos gehoorpatologie en fetale alkoholsindroom (claassen, 1989; owens, 1995; attwell, 1997), en ontoereikende taalen kognitiewe stimulasie wat met armoede, die dikwels lae opvoedingspeil van die ouers en leemte aan voorskoolse onderwys geassosieer word (booyens, 1996). die primere doe i van enige toets is om tussen individue wat oor verskillende vlakke van 'n bepaalde vermoe beskik te diskrimineer, oftewel goeie presteerders van swak presteerders te onderskei (jensen, 1980). aangesien die arw (buitendag, 1994) se inhoud op normale ontwikkeling gebaseer is en 'n verteenwoordigende monster van niekultuurspesifieke leksikale items is; kinders van aile sosiale klasse ewekansig by die toets se standaardiseringsteekproef ingesluit was; daar reeds by wyse van roupuntaanpassing vir linguistiese sydigheid gekompenseer is; die prestasiec verspreiding van die groep steeds oor die totale spektrum van die normale kurwe strek en arw-prestasie met skoolprestasie korreleer, word die gevolgtrekking bereik dat die laer prestasie waarskynlik werklik gebrekkige woordeskatvermoens aandui en nie noodwendig sosioekonomies of etniessydig is nie. 6 kwalitatiewe foutanalise die moontlike aanpassing van die arw (buitendag, 1994) is tot dusver slegs vanuit die oogpunt van 'n verskil tussen die groepgemiddeldes ondersoek. ontleding van individuele toetsresponse het egter aangedui dat toepaslike altern a3413% 1359% 2,27% 214% 013% & +ls +2s +3s +4 100 115 130 145 170 50 60 70 80 90 95 98 99 35,38% 13,12% 2,13% 39.57% 21,34% 3,02% 31,96% 6,30% 1,38% figuur 3: standaardtellingekwivalentverspreiding op die normale verspreidingskurwe die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 26 tiewe verbale reponse by heelwat sosio-ekonomies gedepriveerde proefpersone voorgekom het. die aangepaste responstaak en nasienprosedure het ook in enkele gevalle 'n aansienlike verhoging in individuele toetsprestasies teweeggebring. die resultate verskyn respektiewelik in tabel 10 en tabel 11. tabel 10: frekwensie van voorkoms van korrekte alternatiewe verb ale response aantal aantal alternatiewe proefpersone verbale response 1-3 84 (16,5%) 1 56 (11,02%) 2 24 (4,72%) 3 4 (0, 78%) uit tabel10 blyk dit dat korrekte alternatiewe response, meestal engelse woorde, by 84 (16,5%) van die proefpersone voorgekom het. by 56 (11,02%) het korrekte alternatiewe response slegs een keer voorgekom, by 24 (4,72%) proefpersone 2 keer, en by slegs 4 (0,78%) proefpersone 3 keer. uit hierdie gegewens blyk dit dat indien die alternatiewe verbale response reggemerk word, individuele prestasie met hoogstens 3 roupunte verhoog. in gevalle waar die regmerk van toepaslike alternatiewe response egter 'n verskuiwing van die proefpersoon se basaal en/of plafonitem veroorsaak het, is 'n groter verskil in die roupunt soms teweeggebring, soos in tabel 11 aangedui. tabel 11: verhoging van individuele roupunte deur die regmerk van korrekte alternatiewe verbale response aantal aantal proefpersone roupunte 67 1 12 2 4 3 7 4 1 5 1 6 3 7 1 9 1 11 1 17 1 27 volgens tabel 11 wissel die prestasieverskille wat deur roupuntaanpassing teweeggebring is tussen 1-27 roupunte. alhoewel klinies betekenisvolle verskille slegs by twee proefpersone voorgekom het, hou die verskynsel belangrike implikasies vir die evaluering van nie-standaardtaalsprekende kinders in, naamlik die gevaar dat 'n kind met normale nie-standaardtaalvermoens vanwee taalverskille foutiewelik as taalafwykend gediagnoseer kan word. onderkompensasie vir die kind se varieteit en gevolglike foutiewe diagnose van taalpatologie en ontoepaslike behandeling, kan frustrasie en negatiewe selfbeeldontwikkeling by die kind veroorsaak. oorkompensasie vir taalverskille kan weer daartoe lei dat 'n taalafwyking in mariekie buitendag, isabel uys, brenda louw die kind se fokale varieteit nie geydentifiseer word nie en die taalgestremde nie-standaardtaalsprekende kind van noodsaaklike taalintervensie weerhou word (adler, 1990). die spraak-taalterapeut moet gevolglik deurgaans bedag wees op individuele variasie en verallet op die frekwensie waarmee verbale alternatiewe gelewer word en die opeenvolging daarvan, wat basaalen plafonverskuiwings kan veroorsaak (abudarham, 1995). 'n k wantitatiewe en kwalitatiewe foutontleding is verder uitgevoer om te bepaal by watter items alternatiewe korrekte verbale response die meeste voorgekom het en wat die aard daarvan is. in tabel 12 word die stimuluswoorde (en afleiers of foutiewe antwoordmoontlikhede wat gekies is) volgens die persentasie toetslinge wat die bepaalde afleier gekies het, aangebied. uit tabel12 blyk dit dat daar by die 7-jariges alternatiewe korrekte verbale response by 22 items voorgekom het, en by 10-jariges slegs by 10 items. die alternatiewe verbale response wat gelewer is, is meestal engelse woorde. dit is belangrik om daarop te let dat die woorde nie vir die kinders engels is nie, maar afrikaans is en die enigste vorm wat hulle ken (dreyer, 1986). by die meeste van die items het 'n groter persentasie 7jariges alternatiewe engelse response gelewer as die 10jariges. hierdie bevinding kan moontlik toegeskryf word aan die 10-jariges se langer blootstelling aan en groter kennis van standaardafrikaans. die relatiewe laer voorkoms van bepaalde alternatiewe (march, referee, judge, actor en bishop) by die 7 -jariges kan heel waarskynlik daaraan toegeskryfword dat minder 7 -jariges as 10-jariges die items afgele het weens hulle hoer moeilikheidswaardes. by nadere beskouing blyk dit dat enkele van die engelse woorde die afrikaanse morfologiese onderbou reflekteer, byvoorbeeld gehit (getref). die engelse woorde is ook algemeen met die ekstreme afrikaanse aksent uitgespreek, byvoorbeeld [stemp] vir stamp. die waarnemings sluit aan by die uitsprake van onder andere dreyer (1986) oor die kenmerke van die varieteit. aangesien 83% van die kleurlinggemeenskap afrikaans eentalig as moedertaal besig, verteenwoordig hulle engels die strukturele en fonologiese onderbou van afrikaans. alternatiewe afrikaanse woorde het slegs by twee items voorgekom. die meer informele en algemene vorm:bel is as alternatief vir skakel verskaf. die algemen,e vorm paddastoel en minder algemene vorm duiwelsbro9d is as alternatiewe vir sampioen verskaf. daar kan gespekuleer word dat bepaalde toetswoorde, byvoorbeeld safnpioen, ontoepaslik is, aangesien hulle hoer moeilikheidswaarde i op seldsaamheid berus (jensen, 1980). die argu~ent is egter nie aanvaarbaar nie, aangesien die engelse vorm mushroom meer algemeen as alternatief gelewe'r is en waarskynlik ook 'n moeiliker term as paddastoel is. die alternatiewe figuurlike term duiwelsbrood, wat na 'n giftige sampioen verwys, weerspreek ook die uitspraak. bykomend tot die bogenoemde alternatiewe, is spontane verbale response deur etlike proefpersone gelewer, byvoorbeeld penguin vir pikkewyn, gears vir ratte en smart vir deftig, alhoewel die stimuluswoorde bekend was en korrekte prentvoorstellings daarvan geydentifiseer is. hierdie response, wat in tabel 13 verskyn, verskaf 'n aanduiding van items waarvan die afrikaanse vorm moontlik vir ander toetslinge onbekend ,kan wees, en moet dus ook deur die spraak-taalterapeut in gedagte gehou word tydens die toepassing van die toets op niestandaardafrikaanssprekende kinders. uit die verbale responsanalise blyk dit duidelik dat die the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) afrikaanse reseptiewe woordeskattoets (arw): toepaslikheid vir in groep nie·standaardafrikaanssprekende kinders 27 meeste alternatiewe response wat verwag kan word engelse woorde is. ontleding van die verbale response het verder ook lig gewerp op die toepaslikheid van die itemformaat, naamlik toepaslikheid van die stimulusprente. uit die proefpersone se verbale woordomskrywings het dit duidelik geblyk dat hulle foutiewe antwoorde nie aan onduidelike of kultuurspesifieke prente, byvoorbeeld die prentjie van item 117 monument , toe te skryf is nie. die bevindinge impliseer dat die itemformaat nie sydig teenoor die navorsingsgroep is nie. tabel 12: toetswoorde en korrekte alternatiewe verbale response volgens frekwensie van voorkoms 7·jariges lo·jariges totale groep (n·471) (n=465) (n=936) item stimulus respons frekw % frekw % frekw % 42 skakel dial 7 1,48 7 0,74 bel 1 0,21 1 0,10 58 swaard sword 7 1,48 7 0,74 59 biblioteek library 3 0,63 3 0,32 61 dryf float 9 1,91 9 0,96 63 seel stamp 27 5,73 27 2,88 64 weerlig lightning 1 0,21 1 0,10 67 konstabel traffic cop 1 0,21 1 0,10 68 versier decorate 3 0,63 3 0,32 72 skaak chess 28 5,94 8 1,72 36 3,84 73 juwele jewellery 2 0,42 2 0,21 jewels 1 0,21 1 0,10 76 sampioen mushroom 6 1,27 6 0,64 paddastoel 2 0,42 2 0,21 ~uiwelsbrood 1 0,21 1 0,10 i , 81 kalkoen turkey 12 2,54 2 0,43 14 1,49 i 82 rat i 1 0,21 1 0,10 gears i 86 woestyn hesert 6 1,27 6 0,64 ! 88 gereedskap tools 12 2,54 5 1,07 17 1,81 ! 89 pruik i . 3 0,63 3 0,32 :wig / 92 neut nut 3 0,63 2 0,43 5 0,53 93 marsjeer march 2 0,42 4 0,86 6 0,64 104 jokkie jockey 1 0,21 1 0,21 2 0,21 107 skeidsregter referee 4 0,84 15 3,22 19 2,02 108 paar pair 1 0,21 1 0,10 115 regter judge 5 1,06 26 5,59 29 3,09 magistraat 129 akteur actor 1 0,21 1 0,10 i 151 biskop bishop 1 0,21 1 0,10 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 28 tabel 13: spontane alternatiewe verbale response op korrekbeantwoorde toetsitems itemno. toetswoord spontane respons 32 pikkewyn penguin 46 eekhoring squirrel 47 elmboog elbow 54 tref (ge)hit 57 geraamte skeleton 68 versier decorate 77 ontsnap escape 82 rat gears 87 deftig smart 99 beroof (ge)rob 110 trofee trophy 119 afrig coach 134 gehoor audience 136 onluste cn) riot 151 biskop bishop thtu 152 gewel gable 167 garnaal prawn gevolgtrekkings en aanbevelings die studie was gerig op die ondersoek van die toe paslikheid en aanpassingsmoontlikhede van die arw (buitendag, 1994). die resultate dui aan dat die toets reseptiewe woordeskatvermoens konsekwent en akkuraat by kinders vanuit die kleurlinggemeenskap meet. alhoewel die gemiddelde van die navorsingsgroep laer is as die van die normgroep, is die verskil nie prakties betekenisvol nie. die tradisionele statistiese tegnieke wat in die studie vir die bepaling van toetssydigheid gebruik is, het nie bewyse van konstruksydigheid en itemsydigheid opgelewer nie. die vergelyking van die vertrouensintervalle vir die toetsprestasies van die verskillende sosio-ekonomiese subgroepe van die navorsingsgroep met mekaar en met die van die normgroep, het egter bepaalde implikasies uitgelig. die sosio-ekonomies nie-gedepriveerde subgroep se gemiddelde stem nou met die normgroep se gemiddelde ooreen, wat die toepaslikheid van die toets vir die subgroep bevestig. die sosio-ekonomies gedepriveerde subgroep se gemiddelde is egter statisties beduidend laer as die van die normgroep. verder val die boonste grens van die vertrouensinterval vir die sosio-ekonomies gedepriveerde subgroep onder die gemiddelde van die normgroep, wat impliseer dat die toetsnorme moontlik ontoepaslik vir kleurlingkinders van die laer sosiale klasse kan wees. kwalitatiewe ontleding van die foutiewe antwoorde en alternatiewe verbale response het ook aanduidings van itemsydigheid opgelewer. dit het geblyk dat linguistiese vorm merendeels sydigheid by die sosio-ekonomies gedepriveerde groep meebring, vanwee die hoe voorkoms van engelse woorde in die varieteit (dreyer, 1986). 'n groot mate van intragroepof individuele variasie is egter waargeneem. in die lig van die ongewensdheid van die ontwikkeling van aparte norme, weens sosiopolitieke oorwegings (owen, 1995), en die hoe voorkoms van linguistiese variasie in die kleurlinggemeenskap (coetzee, 1989), blyk toetsaanpassing die aangewese prosedure te wees om die toets se toepaslikheid vir kinders vanuit die kleurlinggemeenskap mariekie buitendag, isabel uys, brenda louw te verhoog. die volgende aanpassings word aanbeveel: • op grond van die hoe korrelasie tussen die navorsingsgroep se prestasies op die oorspronklike en aangepaste rangordes van itemmoeilikheid blyk dit dat die toets se oorspronklike rangorde van itemmoeilikheid vir die navorsingsgroep behou moet word. • gesien in die lig van die navorsingsgroep se relatiewe laer gemiddelde, word aanbeveel dat die toetsbeginpunte vir 7-jariges en 10-jariges met 24 items vervroeg moet word, om terugwaartse toetsing te bekamp. • die toets se oorspronklike prentherkenningsformaat en nasienprosedure kan vir sosio-ekonomies nie-gedepriveerde kinders behou word, aangesien die subgroep se gemiddelde met die van die normgroep ooreenstem en roupuntaanpassing nie hulle arw-prestasies beynvloed het nie. • alhoewel die aangepaste responstaak en nasienmetode, te wete die regmerk van foutief beantwoorde items waarop korrekte alternatiewe verbale response gelewer is, die sosio-ekonomies gedepriveerde subgroep se gemiddelde met slegs 1,56 verhoog het, is groot verhogings in individuele toetstellings teweeggebring in gevalle waar die aanpassing 'n verskuiwing in die toetsling se basaal enlofplafon veroorsaak het. op grond van die individuele variasie ten opsigte van die invloed van roupuntaanpassing, word aanbeveel dat die aangepaste toetsprosedure vir abe sosio-ekonomies gedepriveerde toetslinge gebruik word. die verandering van die responstaak, naamlik alternatiewe verbale response, moet behou word eerder as die vertaling en aanbied van verskillende alternatiewe stimuluswoorde, omrede daar aansienlike variasie in die verbale response wat ten opsigte van 'n bepaalde item gelewer is, voorgekom het. erkennings die finansiele bystand van die sentrum vir wetenskap· ontwikkeling, en die geografiese stratifisering en steekproefneming van skole deur prof d j stoker van die buro vir statistiese en opnametegnologie, universiteit van fretoria, word met dank erken. die navorsing is gebaseer ?p die d. phil. 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(1992). performers oflow-income, african-american preschool and kindergarten children on the peabody picture vocabulary test revised. language, speech, and hearing services in schools, 23, 329-333. webb, v. n., dirven, r. & kock, e. (1992). afrikaans: feite en interpretasies. in v. n. webb (red.) afrikaans nei apartheid. pretoria: j. l. van schaik. die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 45,1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the process and power of group therapy for individuals with a closed head injury 3 an examination of the impact of participation in a conversation group for individuals with a closed head injury glenn goldblum, marna mulder and alexandra von gruenewaldt department of communication pathology, university of pretoria abstract this study describes the impact of participation in a conversational group for individuals with chronic closed head injury in the department of communication pathology at the university of pretoria over the period 1995-2000. the information was obtained through a combination of clinical observations by the writers; the examination of data from pragmatic measures; and a quality of life scale that was compiled and administered (to both the subjects and their significant others) examining the perceived effects of group therapy over time. the results showed that despite the plateauing of pragmatic competence over time, the impact of group therapy appeared to reveal itself in perceived improvements in social-communicative competence and quality of life by the subjects. recommendation and suggestions were made for the refinement of the qol scale to more reliably measure the subjective perceptions of group members regarding the perceived value of group therapy. in (lddition to addressing future implications to move the conversation group forward, the results of the current study lead the authors to advocate the establishment of conversation groups for individuals with chi who are suitable candidates. . introduction "what i was, i am not. what i was i am never going to be again. " (campbel!-korves, 1991, p.3) ./ the dawning of the new millennium is a worthy time / to examine the proces~ of group therapy as a viable therapeutic option for !individuals with chronic closed head injury (chi) within the changing south african context. penn (1993)\ has emphasized the unique challenges facing the speech-language therapist (slt) working with the south african client who may be multilingual and who, historically, may have had limited access to adequate facilities, owing to a variety of sociopolitical, economic and transportation factors. in the preface to her book, elman (1999a, p. xiii) stated that "group therapy is enjoying a renaissance" particularly given the economic constraints within which slts find themselves working. similarly, in south africa today, people are finding the luxury of individual therapy more and more unaffordable, and, group therapy is being advocated as a.,.,more cost-effective form of therapy. another benefit9f group therapy in south africa relates to the reported high client-therapist ratio (uys & hugo, 1997). given this situation, it is the current writers' contention that group therapy provides a relevant, effective and economic vehicle for providing neurogenic communication treatment. holland (in holland & ross, 1999, p. 116) has likewise emphasized die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 her current belief that "individual treatment has become a useful adjunct to group treatment". persons with chi may potentially experience a variety of long-term residual problems that could interfere with their ability to communicate efficientiy at home and in the workplace. this may result in a diminished sense of self-esteem and self-worth that ultimately affects their ability to re-enter and remain success full y in the community. gillis (1999) stated that one of the greatest difficulties faced by the individual with a chi for resuming a productive and enjoyable lifestyle is poor psychosocial skills. she refers to the longstanding advocacy for group therapy by ben-yishay and prigatano (1990), who believe that group interventions are necessary to address psychosocial needs. clearly, group treatment may be seen as an ideal vehicle to address the needs of the individual with chi owing to its inherent interactive, social and supportive components. a review of the current literature (elman, 1999a; elman & bernstein-ellis, 1999; gillis, 1999; holland, 2000; holland & beeson, 1999; holland & ross, 1999) reveals numerous other advantages of group therapy, including the following: a group acts as a microcosm of society (gillis, 1999; yalom, cited by adair ewing, 1999), creating a safe, non-threatening environment where relevant issues and cognitive-communicative deficits are dealt with. in addition, group therapy promotes interaction and interdependence among r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) glenn goldblum, marna mulder & alexandra von gruenewaldt 4 members, which adair ewing (1999) has identified as a crucial component in facilitating much of the progress that takes place by the group members. furthermore, the group environment provides a wider array of communication partners, and the opportunity to practise a range of pragmatic skills across contexts, thereby facilitating generalization to natural environments. in addition, opportunities are provided for the members to address self-awareness, monitoring, self-regulation, initiation and other important executive skills (ehrlich & sipes, 1985; elman & bernstein-ellis, 1999; gillis, 1999; wilcox & davis cited by elman, 1999b). daniels-zide & ben-yishay (2000, p.l92) have likewise advocated the concept of a group being an "ordered environment" where increased awareness and acceptance of disabilities facilitates a return to a life that is nevertheless meaningful. ylvisaker and feeney's (2000) use of collaborative projects in groups comprising individuals with chi has been shown to be effective in assisting these individuals to deal with the diverse challenges following chi. in addition to the benefits of group collaboration reported by ylvisaker and feeney, they note the value of engaging these individuals in group projects as expert contributors. when further examining the potential benefits of group therapy, kagan's (1998) concept of increased communicative confidence and participation in life is considered as being centrally important. the sense of empowerment and advocacy generated by group participation has also been acknowledged by kagan (2001), who in 2000 joined with a number of her colleagues to form the life participation approach to aphasia (lpaa) project group (chapey et.al., 2000). this group has put together a statement of values that they believe should guide assessment, therapy and research of the individual with aphasia. they advocate the empowerment of the individual to facilitate their more rapid return to active life, thereby reducing the long-term costs for the individual and society. the current writers believe that these values have equal application to intervention with individuals with chi. kagan's work (1998, 2001) is closely complimentary to that of lyon et al. (1997, p. 695) where enhanced communicative competence is considered to result in a restored sense of self, "strengthening a more active, selfdetermined and controlled role in daily life." this thinking ties in with the earlier writings of prutting (1982) who emphasised the role of one's social identity in relation to one's communicative and linguistic competence. sarno (1997, p.676) advocated the move towards developing models and methodologies for empowering clients to become "consumers and advocates for themselves." this process has been conceptualised by samo (1997, p.676) as improved quality of life for the individual, which she described as "an emerging and important rehabilitation issue." it incorporates parameters such as independence in communication, life status and coping skills. the above philosophy falls within the social disability model, referred to by coles and eales (1999), reflecting a shift away from focusing on the impairment to empowering the disabled individual and their significant others to coping with the restrictions they may face. the world health organisation's 1980 classification of consequences of disease has also recently been revised into the icidh-2 (1998) (lux, 1999), now called the international classification of functioning, disability and health. it sets out three interactive levels of functioning namely: impairments, activities and participations. group therapy appears to target these levels of functioning with particular emphasis on the latter two levels. . a review of the literature reveals a surprising lack of empirical research into the value and outcomes of group therapy for individuals with chi. elman (1999b), elman and bernstein-ellis (1999) and kearns (1994) have stressed the need for further research to validate group therapy particularly within the economic climate in which therapists find themselves working today. garrett (1999) has likewise urged clinicians to develop and standardise useful outcome measurement tools, as well as to report on the changes in communication status for individuals participating in group therapy programs. furthermore, this attitude reflects the recommendation of the lpaa project. group (chapey et ai., 2000) for clinicians to re-define their clinical and research efforts to facilitate the increased life participation of individuals with aphasia. the current writers would like to extend this invitation to the realm of rehabilitating individuals with chi within a group context. based on the· need for further data, this article describes the observations made by the writers of the apparent impact of participation in a conversational group over time for individuals with chi, together with the group members' and their significant others' perceptions of group therapy. method main aim of study the main aim of the study was to describe the overall impact of participation in a conversation group (cg) for individuals with chronic chi in the department of communication pathology at the university of pretoria (up). sub-aims of study to provide a historical overview of the cg from 1995-2000, highlighting the different phases through which the group has evolved over this time period. i to describe the changes occurring in the pragmatic skills of each individual subject. to describe the compilation and application of a qol scale examining the subjects and their significant others' perception of the role played by the cg in quality of life and social-communicative competence. to describe and compare the results reported on the qol scale by the subjects and their significant others. to make recommendations regarding the refinement of the scale that was used in the study. research design in this study, both qualitative and quantitative research data gathering and data analysis procedures were used. data was gathered and documented qualitatively by means of non-systematic clinical observations over six years since the inception of the cg the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the process and power of group therapy for individuals with a closed head injury 5 in 1995. these observations were made annually by the first writer of this paper (who has been involved with the running of the cg since its inception), together with student group facilitators working with the group members for a year at a time. the data from these observations were then examined retrospectively and cumulatively by the current writers. the administration of a scaled questionnaire reflects the use of a quantitative data collection procedure, as attempts were made to quantify the perceptions of the group members and their significant others with regard to the effects of group therapy. a scale 3.l10ws for fairly accurate assessment of the beliefs and opinions of individuals as opinions and beliefs are often thought of in terms of graduations (mcmillan & schumacher, 2001). historical overview of the cg phases through which the cg has evolved the cg for individuals with chi was established in 1995. since its inception, the group has functioned as an open group in order to accommodate the movement of members in and out of the group. there has, however, been a core of people who have remained members since its inception and who have ensured its continued development. thus, although the addition of a new member changes the dynamics of the group, this has not been found to revert the group back to its initial stages of group development. ' each year two final-year sl t students act as group facilitators under the guidance of the ·first writer of this paper, who was responsible for starting the group in 1995. the group consists of both english and afrikaans speakers and both languages are spoken interchangeably during the group meetings. the group meets once a week for an hour-and-a-half in the speech and hearing clinic of the' up in a one-way mirror room for student training purposes. since the speech and hearing clinic is part of the up, the group run~ according to the university timetable. i / data on the group process was gathered by means of / non-systematic clinical observation over several years. in retrospect, the applicati6n/ of tuckman's framework (cited by adair ewing, 11999) for conceptualising the formation and ongoing development of group process is useful. table 1 reflects i the cg's process within this framework from 1995 to 1 2000. tuckman has divided group development into fow useful stages, namely forming, storming, no~ng and performing. the forming stage usually occurs over the first few sessions. here introductions are made which set the .tone for the future sessions. during the storming stage, agreements and ways of operating within the group are ,set. it is at this time that conflicts may arise, creating a dynamic in which certain members take the lead and otpers follow. it is also at this time that individual personalities create the group personality. during the norming stage, rules are used to govern the group, and it is at this stage that the ground rules were established in the cg. the performing stage is characterised by increased cohesiveness and co-operation of the group members as a unit. members may also be noted to adopt lifelo~g changes during this final stage. . die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 group members table 2, displays the demographic features of the cg members, both past and present, since the inception of the group in 1995 until 2000. note should be taken that only four of the 21 group members are female. furthermore, only two of the group members (d & t) had a stroke, while the remaining group members sustained a chi at some point over the period 1986 to 2000. member d was included in this group since its inception, as he reportedly felt more comfortable in the cg than in the conversation group for individuals with aphasia (running concurrently in the same department) which, at the time, comprised mostly elderly women. he has enjoyed the status of "honorary member" of the cg and has been a valuable asset to the group ever since. it is apparent that younger individuals with aphasia are keen to join the cg for individuals with chi rather than the group for individuals with aphasia, as the former group comprises younger members. for this reason, member t joined the cg in 2000. members t and d were not included in this study, as the current study was concerned with individuals with chi only. table 3, shows the duration of group participation by each member, as well as the reasons for their leaving the group over the time period of 1995 to 2000. examination of tables 2 and 3 reveals the following: • over the period of 1995 to 2000 there has been a total of 19 group members with chi, and two with aphasia, with an average 6 to 8 group members at anyone time. despite the movement of individual members in and out of the group, it is clear that a core group of members (b, c, & d) have participated continuously since 1995. • the duration of coma ranges from no loss of consciousness to 7 months. • the education levels at the time of injury ranges from scholar to tertiary-level education. five of the seven members who have participated in the group for two years or longer were in the process of completing their tertiary education, or had already graduated at the time of their injury. • age at joining the group ranges from 20 to 46 years, with an average age of all the members being 27 years. for the individuals with a chi, the average age was 26 years. • duration of group therapy participation ranged from as little as 6 months to 6 years and ongoing. • reasons for members leaving the group included: obtaining jobs and starting their own business; returning to full-time studies in another province, or lectures clashing with the group meetings. other reasons included a lack of motivation to continue participating in the group, a desire to focus on individual therapy as well as member i's mother deciding that he was not coping in the group. • current education and employment status ranged from: five students (only taking one or two subjects per year in order to manage the completion of the degree) to three self-employed group members. three group members had part-time jobs which appeared to be unstable and constantly changing. ten of the members were unemployed and are receiving disability pension. r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) glenn goldblum, marna mulder & alexandra von gruenewaldt 6 table 1. evolution of the cg functioning based on stages of tuckman (cited by adair-ewing, 1999) date 1995 1996 1997 1998 1999 2000 members a,b,c&d b,c,d&e b, c, d; f, g, h,i, j & k b, c, d, f, i, j,k,l&m b, c, d, k, l,m,n&o b, c, d, j, k, m, p, q, r,s, t&u group functioning forming stage: group had pragmatic emphasis. group sessions structured: focused on individual cognitive-conimunicative needs. themes discussed: organisation & planning, decision-making, establishing priorities, developing insight, considering the views of others & flexible thinking. cognitive-communicative functions (e.g. short-term & longterm memory) and their management also discussed. goals established for following year: paying more attention to social skills, conflict management, self-acceptance & acceptance of others, improving self-confidence, & assertiveness without aggression. group thus moving into storminj! staj!e. storming stage: above-mentioned themes discussed. additional themes: concepts of independence, loneliness & establishment of trust with student facilitators. meetings structured & focused, but group members began moving away from confines of clinic setting. regular outings to local coffee shops & ·to nearby bird sanctuary. group members compiled letters to raise public awareness regarding chi, which were made available to hospitals, clinics & doctors. poster concerning group therapy made & was displayed at local hospitals. storming stage: needs-assessment implemented. group members decided on specific discussion topics, outings into community, & on format of open evening for dissemination of information to family members & to public (to become an annual event). norming stage: ground rules (a constitution) established for first time by members (under guidance of student facilitators) to navigate group activities & behaviour throughout year. ground rules still revised & updated at beginning of each year & include: ''freedom to disagree, keeping to a topic, giving each member a chance to speak, active listening, being sensitive to non-verbal cues, not interrupting & monitoring both yourself & others according to these rules". this fostered foundation of mutual trust & respect among group members & facilitators. members also planned visits & outings, watched thought-provoking videos & discussed topics established by needs-assessment. also decided that new student facilitators taking over group the following year be introduced to group earlier on to facilitate smoother transition. goals & emphasis shifted from being pragmatically focused within group context, to empowering group members into becoming confident advocates of chi within broader community. this is reflected by formulation of community projects starting in 1997 & ongoing, aiming to educate public about chi. first open evening held for family members and public to share personal experiences & respective roads to recovery. organization & format of open evening continues to be planned annually during group meetings. members given responsibility to prepare for talk, & to advertise event by e.g. contacting local press. increase in cohesiveness & teamwork in working towards a common goal reflects performing stage. performing stage: characteristic feature of 1998 was implementation of community service project and regular outings. during needs-assessment members expressed need to move beyond clinic confines into community to disseminate information reo chi. various local high schools visited, raising awareness among adolescent school-going population regarding causes & nature of chi. group members formulated personalised speeches about chi. another project initiated in 1998 & expanded in 1999: working as a team to compile bilingual information pamphlet (in english & afrikaans) about chi. pamphlet made available at schools & to general public during open evening. at end of 1998, preliminary self-rating scale developed to determine value of group to members. performing stage: main project: expansion of pamphlet on chi compiled in 1998. tips to facilitate communication with people with chi during acute & chronic stages of recovery were added. members planned to visit schools (as in 1998). members benefited by meeting & interacting with headway (s,upport group for individuals with chi) in johannesburg. self-rating scale refined into a quality of life scale administered to both group members and their significant others to determine impact of group on their quality of life. performing stage: group effort to educate public by trying to find sponsorships for group pamphlet, & other endeavours e.g. key rings, mugs & mouse pads for dissemination of information. no sponsorships found, but learning facilitated. group member j instrumental in co-ordinating formation of' national lobby group for individuals with brain injury. group members shared ideas with him, ,& attended launch of organisation. outings into community, & opportunities to practice improved interpersonal skills. open evening more ambitious than before. group members used role-playing to share information with general public re living with a chi. larger venue used on university campus with biggest turnout to date. / the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) t:::: ~. vl :0::: ~ ~ .... §' i:l a '" ...., ,<' i:l.. "" ~ ... ~ '" :::; i :0::: ;::s §' '" ;;;. ~ ~ ~. ~ ,... ~ n 8 ...... member a b c d e f g h i j k l m n 0 p q r s t u date of accident 1992 1986 1992 stroke-1987 1995 1996 1996 1996 1995 1995 1993 1995 1996 1998 1999 1995 1988 2000 1995 stroke 2000 1998 duration of educational level & coma employment status at time of injury 21 days --. -----.matric 7 months scholar matric. 18 days b com student 2-3 days b.com accountancy financial manager 2 months std 8 14 days std 9, computer courses 8 weeks matric. working on uncle's farm before commencing army service. 4 months std 7 and level 5 at technical college. 1 month technical college. working as electrician on a contract basis. 42 days mba 21 days matric. computer programmer in police force. 21 days b. eng. (ind.) 21 days national higher diploma 21 days mechanical engineering ii student 3 months ba i student, si~n language course 12 days matric. 6 months of graphic design diploma. 2 y2 months b.a. psychology iii student 26 days financial information systems at technikon. worked in computer industry. 3 weeks bsc (qs). worked as quantity surveyor at the post office. ? degree in industrial psychology, working full-time for a car-manufacturing company 6 weeks b.com accountancy ii student --3 --3 il' =-~ ~ ~ ., ~ q r') age at joining current educational & employment the group status (2000) 20 years self-employed-"odd lobs". 0 ~ '" e '" il' ~ = ., c. ~ ~ =~ ... ~ r') ., 26 years full-time student ba iii (taking one or two subjects at a time). 26 years unemployed. disability pension. 46 years unemployed. disability pension. 25 years self-employed; building machines. 20 years constantly changing employment in a parttime assistant-rece@onist capacity. 21 years part-time apprentice motor mechanic. 24 years unemployed. disability pension. 24 years unemployed. disability pension. 33 years self-employed. currently the chairperson of national lobby group for brain injury. 31 years unemployed. disability pension. ;q il' ..... ac':l ., ., ~ q = a. '0 ~ --3 =~ ~ n ., q ~ ~ '< ~ 8" ;;l ., il' !;" ~ q c. = ... < c':l c: ., = ~ il' [i;" '0 :i. ~ .... =29 years unemployed. disability pension. 35 years unemployed. disability pension. e il' ~ n ~ ;;l q '" 21 years full-time student, changing direction of studies to ba information science. 20 years full-time student, continuing studies. 23 years unemployed. disability pension. 33 years completed degree obtained a red & currently a ::j' ~ q c. e ::= .... ~ il' ~ c. ~ u1 ..... , .: t-j =' g ~ student doing a diploma in trauma debriefing. q 23 years unemployed. disability pension. 32 years full-time student, second year correspondence course in accountancy at technikon sa. 37 years unemployed. disability pension. 23 years self-employed. vending machine business. -.j r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) ;;1 ~ ~ ;: s~ ... 2' ;:: ~ ;: 3 ~ <q.. g § ;: ;:: ;:;' i:l 5' ;:: tl 0:;' <:) ... f} ~ ~ & n :5 ....... member years of group participation 1995 1996 1997 1998 a ./ ./ ./ ./ ./ ., .,~".->: wi"''' ~. ./ ./ ./ ./ ; <:;::'",',. ,w. d ' ./ ./ ./ ./ e 6 months f ./ 6 months g ./ h ./ i 6 6 months months ./ ./ " " ./ ./ ,,' ./ .x., n 0 p q r s t u' c./ i participation in conversation group ... group members who participatedin'study ~ '= :~ "~ ;. ... ' reason for leaving the group 'i' ~ ... 1999 2000 -. § got engaged and found a job as a sports-trainer. q .... ./ ./ jq .., ./ ./ q = ./ ./ ~ ~ = needed individual therapy. .., ... n' i :c. left to work full-time as an office assistant. i = ... s· ? needed to move on and lived far away. lack of motivation. currently plans to return . mother decided member wasn't coping in the group , = = q. ~ ~ = cil ;§ is cil ./ moved on to start own business, but is still in contact with the 8' ~ .., e. group. ./ ./ ./ no longer motivated. ./ ./ ./ returned to full-time studies in the cape. ./ returned to full-time studies. felt more competent, and that no longer belonged in the group. ./ ./ ./ ./ i q. c::r < = ~. f ... :: =-~ = (i ::i § = < :: ~ i = s:: ... ~ s· .., = ro ~ > .., ;q = ~ 'c = = ./ ./ =i' q. 9 .., = < ... q ie = ie ~ (j) i 2 n ~ = = = ~ = ~ s:: ... 00 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the process and power of group therapy for individuals with a closed head injury 9 group goals the main goals of the cg had been to improve the group members' pragmatic skills and quality of life by: • providing the opportunity for group members to improve, plan, implement and monitor the use of functional, compensatory communication strategies and appropriate conversational rules for the generalization of these skills outside the group setting. • facilitating the adjustment to, and acceptance of, functional cognitive-communicative deficits and their impact on interactions with other people. • instilling a sense of empowerment within the group members to take responsibility and control of their daily lives, as well as reaching out to the general community to become advocates for individuals with chi. data collection subjects only those members who had sustained a chi and who have attended the cg for two years or more (members b, c, j, k, l & m) were included in this study. owing to the fact that the pragmatic protocol was administered to the group members bi-annually, a minimum period of two years of participation in the group was selected as a cut-off period to ensure that there would be enough data for comparative purposes. the group members who participated in the current study are referred to henceforth as subjects b, c, j, k, l & m. the nature of the study was explained to those group members who were selected as subjects, and their verbal agreement to participate in the study was obtained. assurance was given that their identity would' remain anonymous at all times. materials for data collection ,// . / pragmatic protocol (prutting and kirchner, 1987) i the pragmatic protodol was selected as a means for data collection as it w~s designed to' be used while observing individuals; engaged in spontaneous conversation during ! unstructured communicative interactions (prutting, kitchn<;!r, hassan & buen, 1984 in binder, 1984). it is a societal appraisal rather than a clinical test, where cognizance is taken of how society will view the individual's communicative behaviour. thus, a behaviour may be incorrect, but not necessarily judged as inappropriate by society (prutting in binder, 1984). the pragmatic protocol comprises 30 pragmatic behaviours that are rated as appropriate or inappropriate based on societal perceptions. this pool of behaviour is known to be developed and used appropriately by children entering school, adolescents and adults, and together comprise an individual's communicative and social competence (binder, 1984). the communicative competence of each group participant was rated as a percentage of the number of appropriate pragmatic behaviours within each of the three pragmatic domains namely: verbal, paralinguistic and non-verbal. die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 200j quality of life scale the results obtained from the pragmatic protocol did not sufficiently reflect the nature and quality of ongoing changes and subjective improvements that were apparent to both the group facilitators and the subjects themselves. their apparent increased self-esteem and enhanced participation in life (chapey et. ai., 2000; holland, 2000; kagan, 2001) needed to be rated more effectively. schuessler, fisher & draper (cited by sarno, 1997) have identified the challenges inherent in measuring quality of life since it is not easily observable. sarno has suggested that of all the measures of quality of life, self-report (including interviews, questionnaires and rating scales) is the most frequently used measurement technique. given the apparent paucity of suitable scales available to date to assess these apparent quality of life changes, the current writers. developed a preliminary self-rating scale in 1998 on which individual subjects could rate dimensions of their quality of life. during 1999, this was further developed into the quality of life (qol) scale (appendix a). this scale emerged from an examination of available literature regarding quality of life measurements (ehrlich & sipes, 1985; laman & lankhorst, 1994; penn, 1998) and dimensions of the revised classification of the world health organization, the icidh-2 (lux, 1999). in addition, personal communication with various authorities including alant, (1998), holland, (1998), and kagan, (1999), assisted in the formulation of the qol scale. this qol scale was designed to determine the perceived effect of group therapy on the quality of life and social-communicative competence of each subject. a similar scale, namely the qol scale: perception of significant other was compiled for the significant others of the subject to complete. the scale was identical to the qol scale given to the subjects, with only the wording adapted to target the significant other. while perception is a personal and subjective experience, the current writers decided to include observation of the subjects' significant others in order to gain further information of the subjects' level of functioning beyond the confines of the cg setting. description of the qol scales • both qol scales comprise ten questions and are presented in appendix a. • the first and last questions of the qol scales are open-ended, requiring the subjects and their significant others to provide reasons why the subjects joined the group, and to describe what the cg has come to mean to them. • the remaining eight questions require the subjects and their significant others to rate their respective perception of quality of life and various socialcommunicative competencies on a self-anchored rating scale (fouche, 1998) from 1 to 10 (i-poor, 5average, lo-very good). these competencies include communication skills, self-image, assertiveness and advocacy regarding chi, participation in every day life, decision-making, overall self-acceptance specifically, as well as acceptance by society generally. in compiling this scale, attempts were made to incorporate the three r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) glenn goldblum, marna mulder & alexandra von gruenewaldt 10 interactive levels of functioning of the icidh-2 (1998) (lux, 1999) namely impairments, activities and participations. question 2 reflects the impairment level; while questions 4, 5 and 7 examine the activities level, and questions 3, 6, 8 and 9 reflect the participation level. • the qol scale incorporates three time dimensions. the subjects and their significant others were requested to rate their perceptions of quality of life and various social-communicative competencies as they were after the chi was sustained (but prior to enrolment with the cg), as they were at the time of completing the qol scale, and how they are expected to be with future participation in the cg. procedures for data collection administration of the pragmatic protocol (prutting & kirchner, 1987) the pragmatic protocol has been used by'the student facilitators since 1996 to rate the pragmatic skills of each individual subject at the beginning and the end of each year that they attended the group. the pragmatic protocols were completed independently of the subjects, and were considered to reflect valid perceptions of the subjects' communicative competence over these two time periods in a year. each pragmatic protocol was examined by the first writer of this article over the entire period (1996 to 2000) to ensure inter-rater reliability. any differences in ratings between the first writer and the student group facilitators were resolved through discussion. the number of pragmatic protocols administered to each subject depended on the year in which they joined the group. owing to the fact that a minimum of two years' participation in the group was selected as a cut off period for inclusion in 'this study, each subj'ect in this study had a minimum of four completed pragmatic protocols. administration of the quality of life scale towards the end of 1999, the qol scale was handed to each subject to complete themselves (with the assistance of the group facilitators where necessary). the qol scale: perception of significant other was sent home with each subject for their significap.t other to complete with a cover letter explaining its aim and nature. each subject was asked to rate their perceptions of their own social-communicative competencies and' quality of life as they were before joining the group (after sustaining the chi), currently and into the future with ongoing group participation. each subject's significant other was likewise asked to rate their perceptions of the family member or friend with a chi along the same dimensions. . . procedures for data analysis analysis of the pragmatic protocol the pragmatic protocol was examined by converting into percentages, each subject's pragmatic score (obtained for each year that the pragmatic protocol was administered) for the three pragmatic domains (namely: ~erbal; paralinguistic and non-verbal aspects). since prutting and kirchner (1987) theoretically divided the pragmatic protocol into these three specific domains, it was decided to examine these areas independently as opposed to an overall percentage pragmatic competence. for the purposes of comparison, these results are presented in bar graph format (see figures 1, 2 and 3). analysis of the quality of life scale the results of the subject's ratings on the,eight scaled questions were totalled, and a score was obtained out of 80 which was then converted into a percentage. this procedure was followed for their ratings over three time periods, namely: before joining the group (after sustaining a chi), current perceptions and future expectations. the results for each of these three time periods are presented on the same graph for each subject to facilitate comparison of changed perceptions over time. the responses made by the subjects to the two open-ended questions are discussed qualitatively. the same procedure was followed for the scales completed by the significant others. the ratings by the subjects and their significant others are presented on separate bar graphs, but will be discussed with reference to each other (see figures 4 and 5). pragmatic protocol verbal aspects the percentages obtained by each subject for this pragmatic domain are presented in figure 1. examination of figure 1 shows the improvements made over the years in the verbal domain of pragmatics by four of the six subjects. closer examination of these results reveal improvements in for example, topic selection and maintenance by subject c; improved repair and revision and topic introduction by subject l; and fewer interruptions by subject k. cg therapy addresses verbal pragmatic aspects directly as group members are referred to the ground rules regularly. these ground rules encourage, among others, keeping to the topic, active listening, being sensitive to non-verbal cues and not interrupting. the improvements noted in these! four subjects' verbal pragmatic skills may therefore be as~ribed to participation in the cg. an explanation for the lack of change in subject b's verbal pragmatics may be that he had his accident 14 years ago, in contrast to the pther subjects whose accidents were more recent. he received many years of individual cognitive-based speech thekapy, and by the time he joined the cg, his verbal skills appear to have reached a plateau. subject j's verbal pragmatic skills were consistently fully appropriate since he joined the cg. paralinguistic aspects the results of this pragmatic domain are presented in figure 2 . examination of figure 2 reveals improvements in only subject m, whose paralinguistic skills appeared to improve with increased confidence. on first joining the group, he was very quiet and withdrawn, speaking softly and relatively unintelligibly. over' time, his confidence appeared to grow and with it, a concomitant increase in intelligibility of speech. the overall minimal improvements in the cg subjects' paralinguistic pragmatic the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) · the process and power of group therapy for individuals with a closed head injury 100 80 q) c1) 60 ls !::: q) 8 40 q) 0.. 20 0 participants figure 1: percentage appropriate behaviours on the verbal dormin . of the pragrmtic protocol (prutting & kirchner, 1987) over the period b c j k l m participants figure 2: percentage appropriate behaviours on the paralinguistic domain of the pragmatic protocol (prutting & ~1996 eil1997 1111998 111999 .2000 11 behaviours were not unexpe~ted. paralinguistic aspects reflect the dysarthric qualityj of many of the subjects' spee~h (in particular, subje9ts b, j and l), which have remamed stable several years after the chi and are not directly addressed in cg th~rapy (with the exception of occasional reminding for relevant subjects to speak more i t slowly). it is interesting to note that subjects b and j (who were the most severely penalised in this pragmatic domain), were rated as the most appropriate in the verbal pragmatic domain, highlighting the disc'reteness of the three pragmatic domains defined on the pragmatic protocol. (see figure 1). i 10d, ............ . ' -............. ---.. -............................ -._ .................... , , 80 q) ci j!! 60 c:: ~ q) 40 q. 20 o b c j k l m participants figure 3: percentage appropriate behaviours on the non-verbal dormin of the pragrmtic protocol (prutting & kirchner, 1987) ov~r the period 1996-2000. die suid-afrikaanse tydskrijvir kommunikasieafwykings, vol. 48, 2001 ~1996 flilli1997 1111998 1111999 .2000 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) glenn goldblum, marna mulder & alexandra von gruenewaldt 12 non-verbal pragmatic behaviours may potentially powerfully intrude upon ones' perceived communicative competence. cg therapy is able to address selected nonverbal aspects such as physical proximity, physical contact, facial expression and eye gaze. other non-verbal behaviours such as body posture, footjieg and hand/arm movements and facial expression may reflect physical injuries sustained during the accident and may therefore be resistant or potentially more complicated to change. this may explain the limited overall improvement noted in the subjects' non-verbal domains. examination of figure 3 reveals that only selective gains were made by two of the subjects whose non-verbal pragmatic behaviours were specifically addressed within the cg context. for example, subject c's attention was drawn to improving eye gaze, facial expression and physical proximity. he responded well, and in so doing, became a more appropriate conversational partner. in summary, the above-described results of the pragmatic protocol reflect the emphasis placed on certain pragmatic aspects within cg therapy. because cg therapy inherently focuses on the interactive, conversational and social components; more attention is placed on verbal aspects, with attention to non-verbal and paralinguistic 100 90 80 70 ~ ~ 60 ell -= 50 ~ ij '"' 40 ~ 30 20 10 0 8 c j k aspects only where relevant. this may explain why more improvements were noted in the verbal pragmatic domain, than in the paralinguistic and non-verbal domains. given the limited overall improvements reflected by the pragmatic protocol, the group facilitators felt that these results did not sufficiently reflect the subjective improvements that were apparent in the form of improved self-confidence, and the desire to become advocates for individuals with brain injury generally. for example, subjects band j showed no and little pragmatic improvement respectively. despite this, they were the two cg subjects who demonstrated the most notable leadership and advocacy qualities. subject b regularly contacts the press about a range of issues related to public education and brain injury. subject j has played a major role in the formation of a national lobby group for individuals with brain injury. these observations confirmed the need to develop the qol .scale as another means of documenting the changes noted in individuals with chi participating in group therapy over time. quality of life scale results of subjects' rated questions l m d before joining the group ~ curren t perceptions • future expectations participants figure 4: quality of life questionnaire: subjects' perceptions of their social-communicative competencies and quality of life over three time periods. examination of figure 4 above reveals that all subjects, with the exception of subject c, showed that they perceived consistent improvements of their own performance on parameters of quality of life and socialcommunicative competencies (including self-esteem, assertiveness, increased life participation, and advocacy) from before joining the group, to present level of functioning. for example, subject b indicated a 50% improvement in his quality of life and socialcommunicative competencies from before joining the cg to the present. this subjective feeling of wellbeing may have motivated him to have sufficient confidence to become an advocate for individuals .~ith brain injury. in contrast to the other cg subjects, subject c does not feel that he has benefited from cg therapy. despite this, he has continued to attend cg therapy since its inception in 1995, and has indicated that he believes he will benefit from ongoing participation in the cg. his predictions that he will benefit from future participation (despite his current perception of not having improved since joining the,group) may be due to the social and interactive components of the group. alternatively, he may be optimistic that he may ultimately benefit from the ongoing 9hanges' and concomitant challenges that take place in ti{e group format and structure from year to year. brown, gordon and haddad (2000) maintained that quality of life resides solely in the target person's judgement"and feelings. given this, the most important implication of subject c's results is that he anticipates improved social-communicative skills the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the process and power of group therapy for individuals with a closed head injury 13 and quality of life with continued participation in the group. it is interesting to note that subject j (who is considered by the current writers to be functioning at a higher cognitive level than the other subjects) rated his quality of life and social--communicative competencies as lower as compared with the other subjects. this may reveal that awareness and insight into his deficits may have made him more 'self-critical. talbot and giroux (2000) has likewise noted that individuals with milder chi rated their quality of life poorer than those with more severe chi. in addition, examination of subject 1's performance on the pragmatic protocol reveals that he was severely penalized on the paraling~istic domain, reflecting' the dysarthric component of his speech. his ,sensitivity to listener's reactions and penalty when he talks may well be reflected in his lower ratings of his quality of life and socialcommunicative competencies. : in summary, in contrast to the minimal pragmatic gains made by the subjects, the improvements noted, on the ratings on the qol scale were considered to highlight the 100 90 80 70 <l) 60 01) ro c 50 <l) u .... <l) 40 0.. 30 20 10 , 0. b c j k i significant others l subjective value of the group process in facilitating improved perceived quality of life for the subjects in the cg. examination of the raw data show that all questions were rated with equal importance by the subjects, and that no question was identified as being worthy of a more extreme rating. this may imply that not one particular dimension of quality of life and social-communicative competence on the scale used was being targeted by the cg. rather, it would appear that each of these dimensions is perceived as being equally addressed within the group context. furthermore, these'findings validate the enhanced self-esteem and advocacy noted by the writers in the individual subjects of the cg over time. the writers are encouraged by these results, because, even though the subjects may no longer be making dramatic improvements and are living with the "sticky residuals" (holland, 2000, p.8) of chi, ultimately the personal experience of feeling confident and competent enough to participate more actively in daily life implies benefit gained from ongoing participation in group therapy. m d before joining the group iii current perceptions iii future expectations ! figure 5: quality of life questionnaire: i significant others' perceptions of their i soc~al-communicative competencies and results of significant others' rated questions examination of figure 5 reveals an overall optimistic trend in the significant others' perceptions of their family member's social--communicative competence and quality of life. as with the positive ratings made by the subjects, the writers find these results encouraging. even though significant others are not able to rate how the subject perceives his own quality of life, they are able to observe improvements in confidence, self-image and participation by the subject in daily life. the results therefore imply that the significant others attributed the positive changes noted in the subjects to, among others, participation in the cg. in addition, their anticipation of future improvements indicates that they are supportive of ongoing group participation. of particular interest is the rating made by subject 1's significant other who noted a 48% increase in her perception of subject 1's social-communicative skills and quality of life from before joining the group to the time of completing the scale. this supports the writers' observations of the increase in subject 1's confidence to become a strong advocate for individuals with brain injury in south africa. comparison of figures 4 and 5 shows that all the significant others (with the exception of subject k's significant other) rated the current and anticipated future level of social--communicative competence and quality of life as being higher than the subjects did themselves. this may reflect the ongoing hope by the significant other for die suid-afrikaanse tydskrijvir kommunikasieafwykings, vol. 48, 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) glenn goldblum, marna mulder & alexandra von gruenewaldt 14 their family member to continue to improve. it should however be noted that in this study, the significant other was not controlled for, and ranged from a parent to a sibling to a spouse. the ratings for subject k were made by his wife, who has subsequently divorced him. her lower ratings may have been confounded by many other negative sentiments about him. results of subjects' open-ended questions when examining the first open-ended question, namely "why did you join the group?" the following trends were apparent: • subjects wanted to meet other individuals with chi. • they wanted to find help in dealing with problems associated with chi in a supportive and stimulating environment. • they wanted to use the group to assist with longterm planning. examination of the second open-ended question, namely" what have you gained from the group?" revealed the following trends: • improved self-acceptance and feeling more accepted by others. • improved self-confidence. • improved social and interpersonal skills. • improved conversational skills. these trends highlight the subjects' focus on themselves and their interpersonal skills, with little reference to extending themselves for readiness to go out in the "real world" and independently re-enter life and the workplace. most of the subjects reportedly joined the group to socialise with individuals with the same kinds of difficulties, to find support and to gain confidence. the emphasis appeared to be on requiring a more informal, social environment, rather than a structured therapeutic group. despite the apparent absence of improved advocacy, many of. the subjects had been noted, by the writers to have become more empowered and confident via their increased active participation in the planning and implementation of events, such as talking to school children and the annual open evening. certain subjects had also begun corresponding via e-mail in an ongoing way with organizations, newspapers, peers and high profile personalities both nationally and internationally, in their effort to educate and inform the public about chi. a few of the subjects have been interviewed on radio programmes and in the newspapers where their stories and perceptions were shared. subject j has played a seminal role in the establishment of a national lobby group for individuals with brain injury in south africa, and this project has become an all-consuming commitment for him. results of significant others' open-ended questions when examining the first open-ended question, namely "why do you think your friend/family member joined the group?" the following trends were apparent: -. to find the opportunity to socialise and find support from other individuals with chi. • to improve communication skills. • to improve self-confidence. while these above-mentioned trends in the significant others' written replies highlight their recognition of the supportive and social aspects of the group, they do not indicate their frequently-verbalised anxieties concerning the ability of the subjects to ultimately be able to return to independent life and work. examination of the second open-ended question, namely " what do you feel he/she has gained from participating in the group?" revealed the following trends: • improved self-confidence and motivation. • improved communication skills. • improved assertiveness. • improved insight into their problems. • improved empathy with others. the above trends highlight the significant others' perceiving the group as being therapeutic and supportive in function, resulting in improved insight and selfconfidence. conclusion overall, the above-described findings lend support to holland (2000; 2001) and holland and ross's (1999) reference to the inherent power of groups, reflected in the subjects' perceptions of improved quality of life including increased self-confidence, assertiveness, acceptance and overall life participation. closer examination of the data revealed that despite the overall benefits of group participation, nine members left the ,group over time for various persorial and practical reasons. this finding validates the clinical observation that in addition to these reasons, groups are understandably not for every individual with chi. reservations and resistance to participating could include factors such as: the desire to "feel normal" and no longer be associated with a disability group; goals not perceived as addressing individual cognitive-communicative needs; and not feeling comfortable sharing and disclosing in a group context. the results from repeated administration :of the pragmatic protocol over time revealed onlyl slight pragmatic improvements. despite the plateauing of pragmatic competence, the inherent magic and: power (holland & ross, 1999) within the cg appeared t~ reveal itself in the reported improvements in the quality i of life dimensions and social-communicative competence\by the subjects and their significant others. thus, i when attempting to reliably measure and report on r'group changes over time, the pragmatic protocol needs to be supplemented by other scales that reliably measure dimensions of quality of life. garrett (1999) has likewise advocated the need to develop and standardise a range of tests to be used by therapists working with participants in long-term outpatient group settings such as universities. these tests need to cover the range of therapeutic goals focused on in the groups, and should be re-'administered over time, in order to record the perceived ongoing changes. /' the importance of subjective' perceptions, and their value in filling the gaps by traditional measures has been acknowledged by various authors (brown et ai., 2000; whiteneck, 1994) thus supporting the need for developing and using subjective measures and quality of the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the process and power of group therapy for individuals with a closed head injury 15 life scales in our clinical interventions. the qol scale . used in the present study was a pilot scale that needs to be refined and validated to assist in gaining more data into the perceived benefits by members participating in this kind of conversation group. broadly, recommendations for improvements to this scale could include refinements of the ratings and the questions posed to the group members to more conclusively tap into the insider experience of chi. more specifically, suggested improvements on questions related to the group experience could include, for example: "what, if anything, have you gained from the group?" and "do you phase 1 0 phase 2 have any suggestions for changing or improving the group? if so, please describe." in addition to the above findings, group therapy examined over a period of 2 years or longer, is clearly an evolving process. with reference to tuckman's 4 stages of group development (cited by adair ewing, 1999) (namely: forming; storming; norming and performing), . the current writers believe that group therapy at the performing stage evolves further through different phases that may be conceptualised as a continuum seen in the representation below: o phase 3 0 pragmatic emphasis: quality of life emphasis re-entry to life & work the shift from phase 2 to phase 3 is crucial to ensure that the group moves out of its "comfort zone", and the members extend themselves (within their limitations) to developing the skills that will be realistically required to function independently and successfully "out there" as they attempt to gain gainful employment and more successful life participation. (chapey et. ai., 2000; kagan, 2001). ylvisaker (2000) and ylvisaker and feeneys' (2000) concept of collaborative group participation in meaningful projects, where expert roles are created for the members are suggested as useful goals in the later stages of therapy for individuals with chi. in addition, group therapy would need to focus on assisting the members and their significant others to develop more realistic insight into their residual deficits and strengths, thereby preventing failure as they endeavour to participate more actively in the "real world." as benyishay (2000, p.l30) has noted, this is the phase where, "in spite of achieving less than a full return to one's preinjury abilities after rehabilitation, life is meaningful" as the individual finds value in being a gr<?wing and contributing human being. .. ' in conclusion, group; therapy constitutes a challenge /for both the therapist ana the group members, a process , that has been well ackn6wledged by adair ewing (1999). group therapy is not si~ply an extension of individual therapy, but requires the members' commitment to fully participating and sharink in the process, the resulting benefits will include, among others a sense of empowerment, a sense 6f greater control over their own lives with a concomitant increase in personal self-esteem (holland, 2000; 2001 &ylvisaker, 2000). the current writers believe that given the perceived benefits of participating in a conversational group for individuals with chi, together with its concomitant economic viability, more groups should be established in the diverse range of settings in which therapists work (particularly within the south african context). outcomes data should be gathered on an ongoing basis in order to make the process of group therapy more accountable, so that our understanding of the nature of these benefits can ~e better defined. acknowledgements this study would not have been possible without all the members of the cg, past and present, who were willing die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 to share the courageous manner in which they are living their lives. the current writers would also like to sincerely thank professor erna alant, (centre for augmentative and alternative communication, up) for her continuing support and belief in the value of the cg. we are extremely grateful to both her, and professor audrey holland (department of speech and hearing sciences, university of arizona) for their ongoing constructive input regarding this article. references adair ewing, s.e. 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(1998). participatory action research as a tool for sustainable social development and reconstruction. in as. de vos (ed.), research at grass roots: a primer for the caring profes~ions. pretoria: van schaik. ' talbot, l., & giroux, f. (2000). quality of life perception of head-injured persons: from hospi~al to community. brain and cognition, 44, 39-42. : uys, i., & hugo, r. (1997). speech-language pathology and audiology: transfonnation in teaching, res~arch and service delivery. health sa gesondheid, 2(2), 2329. ' whiteneck, g. g. (1994). measuring what matters: rehabilitation outcomes. the 44th annual john stanley coulter lecture. archives of physical medical rehabilitation, 75,1073-1076. ylvisaker, m. (2000). personal communicijtion. associate professor, college of saint rose, albany, new york. ylvisaker, m. & feeney, j. (2000). the proict approach in brain injury rehabilitation: theory and illustrations. mini-seminar presented at the american speech, language and hearipg association annual convention, washington, d. c. / the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the process and power of group therapy for individuals with a closed head injury appendix a: quality of life scale scale of self-perception by the group member with a chi g. goldblum, m. mulder & a. von gruenewaldt (1999) 1. why did you join the group? 2. how do you rate your communication skills (on a scale of 1-10) as you think they a) * were before joining the group b) 0 are now c) 1 will improve with further participation in the group? 2 3 4 5 6 7 8 9 poor average 3. how do you rate your self-image as you think it ... a) * was before joining the group b) 0 is now c) 1 will improve with further participation in the group? 2 3 4 5 6 7 8 9 poor average 4" how do you rate your ability to stand up for what you believe in ... a) * before joining thel group b) 0 as you see it nowl i c) 1 to improve with frrther participation in the group? 2 3 /4 5 6 7 8 9 poor average 5. how do you rate your ability to convey information about chi to others ... a) * before joining the group b) 0 as you see it now c) 1 to improve with further participation in the group? 2 3 4 5 6 7 8 9 poor average die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 17 10 very good 10 very good 10 very good 10 very good r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) glenn goldblum, marna mulder & alexandra von gruenewaldt 18 6. how do you rate your ability to participate in everyday activities, conversations and discussions ... a) * before joining the group b) 0 as you see it now c) 1 to improve with further participation in the group? 2 3 4 5 6 7 8 9 10 poor average very good 7. how do you rate your ability to make important decisions for yourself and your family ... a) * before joining the group b) 0 as you see it now c) 1 to improve with further participation in the group? 2 3 4 5 6 7 8 9 10 poor average very good 8. rate your acceptance by society ... a) * before joining the group b) 0 now c) 1 after further participation in the group? 1 2 3 4 5 6 7 8 9 10 poor average very good 9. how ok do you feel with yourself ... a) * before joining the group b) 0 now c) 1 after further participation in the group? 2 3 4 5 6 7 8 9 10 poor average very good 10. what have you gained from the group? ................................................................................................................................................................................. (. ................... . the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) / the process and power of group therapy for individuals with a closed head injury quality of life scale scale of perceptions of the group member by his/her significant other g. goldblum, m. mulder & a. von gruenewaldt (1999) 1. why do you think your friend/family member joined the group? 2. how do you rate his/her communication skills (on a scale of 1-10) as you think they a) * were before joining the group b) 0 are now c) 1 will improve with further participation in the group? 2 3 4 5 6 7 8 9 poor average 3. how do you rate his/her rate self-image as you think it ... a) * was before joining the group b) 0 is now c) 1 will improve with further participation in the group? 2 3 4 5 6 7 8 9 poor average 4. how do you rate his/her ability to stand up for what he/she believes in ... a) * before joining the group .b) 0 as you see it now / c) 1 to improve with further participation in the group? / 2 3 4 5 6 7 8 9 poor average 5. how do you rate his/her ability to convey information about chi to others ... a) * before joining the group b) 0 as you see it now c) 1 to improve with further participation in the group? i 2 3 4 5 6 7 8 9 poor average die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 19 10 very good 10 very good 10 very good 10 very good r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) glenn goldblum, marna mulder & alexandra von gruenewaldt 20 6. how do you rate hislher ability to participate in everyday activities, conversations and discussions ... a) * before joining the group b) 0 as you see it now c) 1 to improve with further participation in the group? 2 3 4 5 6 7 8 9 10 poor average 7. how do you rate hislher ability to make important decisions for himself/ herself and the family ... a) * before joining the group b) 0 as you see it now c) 1 to improve with further participation in the group? 2 3 4 5 6 7 8 9 10 poor average 8. rate hislher acceptance by society ... a) * before joining the group b) 0 now c) 1 after further participation in the group? 2 3 4 5 6 7 8 9 10 poor average 9. how ok do you think he/she feels with himselflherself ... a) * before joining the group b) 0 now c) 1 after further participation in the group? 2 3 4 5 6 7 8 9 10 poor average 10. what do you feel he/she has gained from participating in the group? very good very good very good very good i ....................................................................................................................................................... . . the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) about the author(s) leoni m. grobler department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa de wet swanepoel department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa susan strauss department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa piet becker department of health sciences, faculty of health, university of pretoria, pretoria, south africa zahan eloff occupational health department, anglogold ashanti, carletonville, south africa citation grobler, l.m., swanepoel, d.w., strauss, s., becker, p., & eloff, z. (2021). corrigendum: occupational noise and age: a longitudinal study of hearing sensitivity as a function of noise exposure and age in south african gold mine workers. south african journal of communication disorders, 68(1), a849. https://doi.org/10.4102/sajcd.v68i1.849 note: doi of original article published: https://doi.org/10.4102/sajcd.v67i2.687. correction corrigendum: occupational noise and age: a longitudinal study of hearing sensitivity as a function of noise exposure and age in south african gold mine workers leoni m. grobler, de wet swanepoel, susan strauss, piet becker, zahan eloff published: 08 nov. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. in the published article, grobler, l.m., swanepoel, d.w., strauss, s., becker, p., & eloff, z. (2020). occupational noise and age: a longitudinal study of hearing sensitivity as a function of noise exposure and age in south african gold mine workers. south african journal of communication disorders, 67(2), a687. https://doi.org/10.4102/sajcd.v67i2.687, there was an error in the affiliations. instead of: ‘authors: leoni m. grobler1 de wet swanepoel2 susan strauss2 piet becker3 zahan eloff4 affiliations: 1department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa 2department of speech-language therapy and audiology, faculty of humanities, university of pretoria, pretoria, south africa 3department of health sciences, faculty of health, university of pretoria, pretoria, south africa 4occupational health department, anglogold ashanti, carletonville, south africa’, it should be: ‘authors: leoni m. grobler1 de wet swanepoel1 susan strauss1 piet becker2 zahan eloff3 affiliations: 1department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa 2department of health sciences, faculty of health, university of pretoria, pretoria, south africa 3occupational health department, anglogold ashanti, carletonville, south africa’. the authors apologise for this error. the correction does not change the study’s findings of significance or overall interpretation of the study’s results or the scientific conclusions of the article in any way. abstract introduction methodology results discussion conclusion acknowledgements references appendix 1 footnote about the author(s) karin joubert department of speech pathology and audiology, university of the witwatersrand, south africa ndlovu wits audiology clinic and outreach programme, south africa ben sebothoma department of speech pathology and audiology, university of the witwatersrand, south africa khomotjo s. kgare ndlovu wits audiology clinic and outreach programme, south africa citation joubert, k., sebothoma, b., & kgare, k.s. (2017). public awareness of audiology, hearing and hearing health in the limpopo province, south africa. south african journal of communication disorders 64(1), a557. https://doi.org/10.4102/sajcd.v64i1.557 original research public awareness of audiology, hearing and hearing health in the limpopo province, south africa karin joubert, ben sebothoma, khomotjo s. kgare received: 24 mar. 2017; accepted: 31 july 2017; published: 28 sept. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the burden of hearing loss is on the increase, especially in low-income countries such as south africa. the need for urgent action to prevent ear and hearing problems is a priority, especially as in many cases permanent hearing loss is preventable. in south africa, as in other developing countries, there is a limited number of hearing health professionals and audiological resources. the lack of hearing health services may impact the general public’s awareness of hearing and hearing health. limited information is available on the south african public’s knowledge of audiologists and the services they provide, especially in underserved rural communities. aim: the aim of this study was to describe individuals’ awareness of the audiology profession, hearing and hearing loss, and hearing health in a rural area of the limpopo province. method: a cross-sectional survey design was employed for the purpose of this study. using a random sampling strategy, 297 households in four rural villages were selected and a self-developed questionnaire was administered to one individual (18 years and older) per household. the questionnaire consisted of 23 questions targeting awareness of the audiology profession, as well as knowledge of hearing, hearing loss and hearing health. results: only 14% of participants were aware of the audiology profession, indicating that individuals living in rural communities are not aware of the role of audiologists and the services they provide. doctors and nurses were identified by participants as the individuals who assist them with hearing-related problems. although most participants (87%) acknowledged that it is very important to undergo a hearing test, only 5% have previously visited an audiologist. most participants were aware that ear infections and excessive noise exposure can cause hearing loss. the majority also believed that ears must be kept clean at all times and used cotton buds to maintain ear hygiene. conclusion: there is a general lack of public awareness of audiologists and the services they offer. this study highlighted the need for the national department of health in collaboration with professional associations and hearing health professionals to develop and implement effective strategies to increase the south african public’s awareness of the profession and the services they provide. south african universities can also play a significant role in teaching students to develop context-relevant strategies to increase awareness of the profession. introduction audiologists are health care professionals who assess, diagnose and treat hearingand balance-related problems (martin & clark, 2015). in addition to the clinical aspect of audiology, prevention of hearing impairment and the promotion of hearing health are also critical and therefore incorporated into the realm of audiology (anderson & shames, 2011). despite the existence of the audiology profession since the 1940s, hearing impairment remains a major public health concern. the world health organization (who) recently highlighted the importance of intensifying action to prevent deafness and hearing loss as worldwide approximately 360 million people live with disabling hearing impairment1 (who, 2017). the prevalence of disabling hearing impairment for both adults and children is the highest in south asia, asia-pacific and sub-saharan africa (who, 2012). in south africa, the accelerated prevalence of communicable diseases [e.g. hiv and tuberculosis (tb)] and the subsequent use of ototoxic medications have exacerbated the prevalence and nature of hearing loss (harries et al., 2012). information on the prevalence and causes of hearing impairment (across the lifespan) is available for the south african population with the bulk of the research conducted in urban areas and/or within the private health care sector (meyer & swanepoel, 2011; ramma & sebothoma, 2016; strauss, swanepoel, becker, eloff & hall, 2012; swanepoel, ebrahim, joseph & friedland, 2007; tiedt et al., 2013). there is, however, limited information on the prevalence and causes of hearing impairment in rural south africa. rural areas in south africa are defined as remote areas with poor infrastructure, poor basic utility service provision, low levels of literacy, high levels of unemployment, limited access to health and education services and a high incidence of communicable diseases (watermeyer & barratt, 2013). impacted cerumen, middle ear pathology, exposure to excessively loud music and the use of ototoxic medication have been reported as the most prevalent causes of hearing impairment in rural areas (mulwafu, kuper & ensink, 2016; pullen, 2015; ramma & sebothoma, 2016). most of these causative factors can, however, be prevented, at least partially, by the improvement in the primary prevention of hearing impairment (olusanya, neumann & saunders, 2014). strategies for the primary prevention of hearing impairment across the lifespan have been outlined by olusanya et al. (2014). the guidelines on health education regarding ototoxicity, middle ear pathology, exposure to excessive and/or prolonged noise, the importance of immunisation as well as the promotion of appropriate personal hygiene provide a useful starting point for audiologists and other health care professionals. the implementation of these strategies as well as the early intervention of hearing loss can limit the devastating consequences hearing impairment can have on communication, psychosocial well-being, economic independence and overall quality of life. there is limited information on the general public’s awareness of audiology and the role of audiologists. an early study on the awareness of college students’ knowledge and awareness of hearing and hearing loss indicate that there is a lack of knowledge and understanding of the existence of and the role of audiologist (lass, woodford & everly-myers, 1990). although some survey-based international studies have attempted to provide insight into the general public’s awareness of the audiology, hearing and hearing health (di berardino et al., 2013; gabriel, mohammed & paul, 2015; lass et al., 1990; lee, govindara & hon, 2005; narayansamy, ramkumar & nagarajan, 2014), no information is available for the rural south african context. methodology aim the aim of this study was to describe individuals’ awareness of the audiology profession, hearing and hearing loss, and hearing health in the rural areas of the limpopo province. research context the research was conducted in four villages in the elias motsoaledi local municipality (emlm) area of the sekhukhune district in the southern part of the limpopo province. the sekhukhune district is one of the poorest districts in the country and is characterised by poor infrastructure and lack of safe water supply (health systems trust, 2017). the emlm has 62 settlements that are mostly rural villages and has an estimated population of 249 363. almost 99% of the population are black south africans. education levels are low as 46% of the population have no formal schooling. eleven per cent has completed some form of primary schooling and only 4% of the population have some form of higher education (emlm, 2013/2014). participants a systematic random sampling strategy was used to select participants in four villages in the emlm (table 1). these villages included elandsdoorn, ntwane, tambo and phooko. every third household in each of the villages was visited by the research team and only one adult individual per household was requested to participate in the study. individuals were only included if written consent was provided. table 1: number of households surveyed. a total of 297 individuals were included in the study. the average age of the participants was 38.5 years (range: 18–69; ±15.43) and the majority (73%; n = 216) were females. the home language of most participants was isizulu (58%; n = 171), followed by sepedi (21%; n = 63), whilst the remaining 21% (n = 63) speak a combination of xitsonga, tshivenda, isindebele and shona. most participants (57%; n = 169) were unemployed. only 51% (n = 151) of the participants had some form of high school education, and 12% (n = 36) had no formal education. measure a self-developed questionnaire was used to collect data (appendix 1). the questionnaire consisted of five sections and a total of 23 openand/or closed-ended questions. the five sections of the questionnaire were demographic information, knowledge and awareness of the audiology profession, hearing and hearing loss, and ear hygiene. the survey questionnaires were administered by trained research assistants fluent in isizulu, sepedi, xitsonga, tshivenda, isindebele and english. a pilot study was conducted prior to data collection. the research team comprised an audiologist and six research assistants (community members specifically trained for the purpose of the study). each research assistant was required to administer the questionnaire on five community members who met the same inclusion criteria as for the main study. the 30 pilot study participants resided in the same communities where the research was conducted. the objectives of the pilot study were to ensure the face and content validity of the questionnaire as well as to ensure that there were no discrepancies with regard to the documentation of participant responses. procedure ethical considerations ethical clearance was obtained from the human research ethics committee (medical) of the university of witwatersrand before the study commenced (protocol number m121006). permission to conduct the study was obtained from the relevant tribal authorities (e.g. chiefs). every third household in each of the villages was visited by the research team. individuals in each of the selected households were informed of the study and only one individual per household was requested to participate in the study. participants were fully informed about the nature of the study, and assured of confidentiality and their rights to withdraw from the study at any time without negative consequences. only participants who gave written consent were included in the study. participants who required hearing health care were referred to their local primary health care clinic or the audiology department. all completed questionnaires were verified for completeness by the audiologist and data were captured on a password-protected excel spreadsheet. raw data were stored in a locked cabinet and will be destroyed after a period of 5 years. results the results will be presented as it relates to the: (1) awareness of the audiology profession, (2) hearing and hearing loss and (3) hearing health. awareness of the audiology profession the majority of participants (86%; n = 255) were not aware of the audiology profession. a large majority indicated that other health professionals can test hearing (table 2). table 2: assistance with hearing problems (n = 297). only 14% (n = 42) of the participants were aware that audiologists are the health professionals responsible for testing hearing (n = 15) and to help with ear problems (n = 22). these participants indicated word-of-mouth (21%; n = 8) and information from other health workers (30%; n = 11) as their sources of information. awareness of the hearing and hearing loss despite the lack of awareness about the audiology profession, many of the participants (87%; n = 257) agreed that it was ‘greatly important’ to have their hearing tested. only two participants indicated that it was ‘not important at all’. the majority of participants (92%; n = 273) agreed that everyone’s hearing can be tested regardless of age. interestingly, only 5% (n = 16) of participants have previously visited an audiologist for a hearing test. participants were asked, using an open-ended question, what can be done if they have a hearing problem. a variety of responses were reported (table 3). table 3: what can be done if you have a hearing problem (n = 297). awareness of hearing health participants were questioned regarding the awareness of ear infection, noise exposure and ear hygiene. ear infection when asked whether an ear infection can cause hearing loss, the majority of the participants (87%; n = 257) indicated that ear infections can cause hearing loss. most participants (65%; n = 193) specified that they ‘hardly ever’ have ear infections, whilst only 5% (n = 15) have ear infections ‘frequently’ and 3% (n = 9) ‘almost always’. interesting responses were recorded regarding the actions that participants take when they have an ear infection. the majority 38% (n = 114) indicated that they consult with medical professionals at a clinic or hospital, whilst 7% (n = 22) reported that they do nothing. twelve per cent (n = 37) reported that they insert oil in their ears. the types of oil inserted included sweet oil (n = 12), cooking oil (n = 9), fish oil (n = 6), chicken fat or oil (n = 5), glycerine (n = 4) and castor oil (n = 1). only one participant reported consulting a traditional healer for treatment of hearing loss or/and ear infection. excessive noise exposure excessive noise exposure was also probed. an overwhelming majority (89%; n = 265) agreed that excessively loud noise can damage hearing. participants were required to indicate which type of noise typically found in their village can cause damage (table 4). listening to loud music in a taxi or on an mp3 player was reported to mostly cause damage. table 4: type of excessive noise that can damage hearing (n = 297). the last question probed how participants thought they can protect their hearing from excessive noise. the results are presented in table 5. the majority of participants indicated that they can protect their ears by avoiding loud music (38%; n = 112), lowering the volume of the music they are listening to (19%; n = 55) and using some form of ear protection, such as cotton wool and ear plugs (18%; n = 55). table 5: ways to protect hearing from excessive noise (n = 297). ear hygiene most of the participants believed that ears must be kept clean at all times and indicated that they use cotton buds, matchsticks and a variety of other items to clean their ears (figure 1). of the participants who indicated that they use cotton buds to clean their ears, 64% (n = 190) also use it when their ears are itchy. figure 1: items used for ear hygiene. discussion there is a general lack of awareness of audiology as a profession in the community where the research was conducted. this is despite the availability of audiological services at the two hospitals and one local non-government clinic in the emlm area. it is postulated that health care workers (professional nurses and doctors) based at the two hospitals and various primary health care clinics are not aware of the availability of audiological services in the emlm. participants who were aware of the audiology profession indicated that they were made aware of the services offered primarily by other health care workers and also through word-of-mouth. this supports the notion that the primary source of health-related information is through health workers who do health talks in hospitals and clinics (gabriel et al., 2015). only 10% (n = 30) of the participants did not know what to do if a hearing problem is noted. the majority of participants (78%; n = 234) correctly indicated that they will consult a health care worker (e.g. nurse, doctor and specialist) at either the clinic or the hospital. ten per cent (n = 28) also mentioned treatment options such as being fitted with a hearing aid or undergoing an operation. the consultation sources and suggested treatment options mentioned by participants are appropriate. however, without referral by health professionals to audiologists, the early identification and appropriate management of hearing impairment (e.g. hearing amplification devices and aural rehabilitation) may impact the quality of life of individuals with hearing impairment (olusanya et al., 2014). the participants’ awareness of ear infection as a cause of hearing impairment was good. the action that they would take if they have an ear infection ranged from doing nothing, consulting with health professionals at the clinic or hospital to treating it themselves by inserting a substance (usually a type of oil) into the ear. the practice of inserting oil to treat ear infection has also been reported in rural african communities (e.g. central kenya) (njoroge & bussmann, 2006). in kenya chicken fat, other industrial lubricants and 13 plant species were used to manage ear infection. participants were further aware of the impact of excessive and prolonged music exposure on hearing. the most prevalent form of noise exposure in these rural villages is music. music is often played very loudly in the close confines of taxis and shebeens as well as at most events and even in churches. the use of cell phones and mp3 players is also quite high as most teenagers and young adults use earphones to listen to music with these devices. the strategies suggested by the participants to protect their hearing from excessive noise exposure were mostly appropriate (e.g. avoid loud music, lower the volume and use ear plugs). however, some participants offered inappropriate suggestions (e.g. use cotton wool, clean ears regularly) or did not know how to protect hearing from excessive noise. ear hygiene practices comprised mostly the use of objects (cotton buds, matchsticks and pen or pencil) to clean or scratch ears. this is despite the potential complications associated with the use of these objects in ears. common complications associated with the use of cotton buds include otitis externa, otomycosis, laceration in the external auditory meatus, accumulation of wax and perforated tympanic membrane (lee et al., 2005). similar ear cleaning practices were reported in other studies conducted in developing countries such as malaysia, nigeria and south india (gabriel et al., 2015; lee at al., 2005; narayansamy et al., 2014). conclusion the findings of this study highlight the urgent call for action by all relevant stakeholders to increase existing public awareness of the audiology profession, hearing and hearing health services especially in the rural areas of south africa. recommendations based on the findings of the current study, it is recommended that health education for this rural population should focus on the following: (1) the audiology profession and its role in the identification and management of hearingand balance-related problems, (2) the availability of audiological services in the area, (3) the impact of excessive noise exposure on hearing and strategies on how to protect hearing and (4) ear hygiene, specifically why the use of cotton buds is not advised. it is, however, imperative that the national department of health prepare, implement and monitor a national plan for the prevention and control of major causes of avoidable hearing impairment within the framework of primary health care (olusanya et al., 2014). collaboration with professional hearing health organisations or associations, non-governmental organisations and hearing health professionals is required to support and coordinate these programmes. these programmes should not only be confined to health care facilities in urban areas, but should also be expanded to under-resourced rural areas. an important component of such a programme should be the development of culturally and contextually appropriate information and education for hearing protection and conservation for both the public and health care workers. it is essential that health care workers, especially doctors and nursing staff, at all levels of care should be educated about the role of the audiologist in the identification and management of hearing-related problems. it is further recommended that similar studies should be conducted in a variety of other contexts to determine the extent of education required to prevent avoidable hearingand balance-related problems. acknowledgements the authors would like to thank all the individuals who participated in the study. a special thank you to the following research assistants for their significant contribution to this study: godfrey mogashoa, jane mogashoa, johannes lukhele, winnie thebjane, koketso mashigo, dikeledi kgomo and emily chauke. the ndlovu wits audiology clinic and outreach programme is funded by the oticon foundation. competing interests the authors declare that there are no financial interests or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions k.j. participated in the conceptualisation of the project, provided guidance throughout the project and finalised the manuscript. b.s. conceptualised the research, trained the research assistants, participated in the data collection and prepared the first draft. k.k. participated in the development of the data collection tool, reviewed and gave input on the manuscript. references anderson, n.b., & shames, g.h. 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(2012). who global estimates on prevalence of hearing loss. retrieved november 28, 2016, from http://www.who.int/pbd/deafness/who_ge_hl.pdf who. (2017). prevention of deafness and hearing loss. retrieved june 10, 2017, from http://apps.who.int/gb/ebwha/pdf_files/wha70/a70_r13-en.pdf appendix 1 questionnaire participant no: ________________________________ research assistant no: __________________________ date of completion: ____________________________ instructions for completion: please answer all the questions demographic information date of birth: ____________________________ gender: male or female highest level of education: _________________ occupation: __________________________ home language: _________________________ area: ________________________________ closest clinic: ___________________________ closest hospital: _______________________ knowledge of the profession 1. what does an audiologist do? 2. where is your closest audiologist? (only if the participant knew what an audiologist is) 3. have you ever visited an audiologist? no or yes if yes, why? 4. from which source did you find out about an audiologist? a) word-of-mouth b) health workers c) radio d) tv e) other (please specify) knowledge or awareness of hearing and hearing loss 5. how important is it to have your hearing tested? a) greatly important b) considerably important c) important d) somewhat important e) not important at all 6. whose hearing can be tested? a) babies b) children c) teenagers d) young adults e) adults f) everyone 7. who can test your hearing? hearing 8. what do you think is the cause of hearing difficulties? a) ear infection b) noise (e.g. mp3 players, music) c) some medications (e.g. tb, hiv, malaria, etc.) d) family member having a hearing loss e) wax f) none of the above g) other 9. how would you know if you have a hearing loss? 10. where do you go for help when you have a hearing problem? a) clinic b) traditional healer c) church d) doctor e) no one f) other (specify) 11. where can your hearing be tested? a) clinic b) hospital c) private doctor d) i do not know e) other (specify) 12. what can be done if you have a hearing problem? ear infections 13. can an ear infection cause a hearing loss? a) yes b) no c) maybe d) i do not know 14. how often do you have ear infections? a) hardly ever b) occasionally c) sometimes d) frequently e) almost always 15. what do you do when your ears are painful? 16. what do you do if you have an ear infection? ear hygiene 17. how often do you clean your ears? a) hardly ever b) occasionally c) sometimes d) frequently e) almost always 18. what do you use to clean your ears? a) cotton buds (ear buds) b) matchsticks c) pen or pencil d) wet cloth e) nothing f) other (please specify) 19. what do you use when your ears are itchy? a) cotton buds (ear buds) b) matchsticks c) pen or pencil d) finger e) nothing f) other (please specify) noise versus hearing 20. do you think music or noise can damage your hearing? a) yes b) no c) maybe d) i do not know 21. do you think excessive loud noise can damage your hearings? a) yes b) no c) maybe d) i do not know 22. which of the following do you think can damage your hearings? a) music in taxi b) music in church c) listening to mp3 player d) listening to cell phone e) all of the above f) none of the above 23. how would you protect your hearing from being damaged by excessive loud noise? footnote 1. disabling hearing impairment: hearing loss > 40 db in the better hearing ear in adults and > 30 db in children. abstract introduction and literature review methodology ethical consideration results discussion conclusion acknowledgements references footnotes about the author(s) thandeka mdlalo livingstone school, durban, south africa penelope s. flack discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa robin w. joubert school of health sciences, university of kwazulu-natal, durban, south africa citation mdlalo, t., flack, p. s., & joubert, r. w. (2019). the cat on a hot tin roof? critical considerations in multilingual language assessments. south african journal of communication disorders, 66(1), a610. https://doi.org/10.4102/sajcd.v66i1.610 original research the cat on a hot tin roof? critical considerations in multilingual language assessments thandeka mdlalo, penelope s. flack, robin w. joubert received: 10 sept. 2018; accepted: 19 feb. 2019; published: 30 may 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: in speech-language pathology (slp), there is a paucity of resources to provide just and equitable services to south africa’s culturally and linguistically diverse population. although south africa is a multilingual country, english remains the dominant language. however, there is limited research on resources for english additional language (eal) speakers. objectives: this article addresses this gap by presenting the results of a critique of a commonly used language screening tool, the renfrew action picture test (rapt), on eal speakers. method: this tool is used as an example to broadly critique the use of culturally biased assessment instruments with eal speakers from an indigenous linguistic and cultural background. it is administered to children who are eal speakers and then critiqued by the children too. their voice, often ignored in research, is central to the research. a mixed methods approach is used, including focus groups and test administration. this article is based on the results of the thematic analysis used to closely examine the patterns that emerge. results: a key finding is that the cultural and linguistic background of the child assessed cannot be disregarded, as it plays a crucial role in understanding the response of the child. the interpretation of the response of the child to the presented material of the language assessment tool significantly influences the result of the assessment. conclusion: the speech language therapist has a responsibility to avoid skewed results based on uninformed interpretation of the response of the child. these findings provide useful insights for clinicians regarding culture-fair assessment. keywords: assessment; cultural and linguistic diversity; english additional language speaker; language dominance; language competence; speech-language pathology. introduction and literature review the title, the cat on a hot tin roof, draws on a drama, tennessee william’s drama (holder, 2016; williams, 1955), whose existentialist message is relevant to the issues argued. this article presents and discusses the results of a study that critically evaluated and interrogated the use of language assessment tools, in their current form, within the south african context. it also provides the guidelines for adaptations of these tools so that they will better accommodate english additional language (eal) speakers. the term ‘eal speaker’ is used in this article to specifically refer to south african multilingual individuals who are non-mother-tongue speakers of english and who are from indigenous language and cultural backgrounds.1 the existential message stems from the philosophy that humans are neither mere puppets that exist in the world, nor predestined victims of their conditions in the world. instead, they are conscious beings who exercise freedom of choice in the decisions that they take in spite of restrictions imposed (heidegger, 2008). this philosophy is revisited in the ‘discussion’ section of the article in relation to the profession speech-language pathology (slp). south africa is a linguistically and culturally diverse country with 11 official languages. the speakers of isizulu constitute the majority at 22.7% (stats sa, 2011). although there are less than 10% english mother-tongue speakers, english is a dominant language in the country. as the profession of slp is a microcosm of the wider sa society, this dominance is reflected within the profession (mdlalo, flack, & joubert, 2016). the majority of isizulu mother-tongue speakers are in the province of kwazulu-natal, where the research presented was conducted. although the focus of this article is children who come from the zulu culture and are isizulu mother-tongue speakers, issues of culture-fair assessment are broader. the problem of culture-fair assessment is not unique to south africa (laher & cockcroft, 2017; mcleod, 2014), but a global problem that has been identified in regions such as australia (ball & peltier, 2011), eastern europe (moro, 2008), usa (hamilton, 2014), new zealand (brewer & andrews, 2016) and canada (thordardottir, 2011). however, the suggestion proposed in the study is especially relevant to the south african context as it is based on african language and cultural experience (makiwane, nduna, & khalema, 2016). the use of standardised tests, with eal populations, in their current form has been criticised both locally and globally, firstly for linguistic bias, secondly, cultural bias and thirdly, disproportionate representation of different language and cultural groups in normative samples (caesar & kohler, 2007; kathard & pillay, 2015; pierce & williams, 2013). the use of english language assessment tools, in their current form, adversely impacts on the appropriate evaluation of individual clients from other culturally diverse backgrounds, thus preventing them from using their own frame of reference (moro, 2008; pascoe & norman, 2011). these tests are not only inappropriate for use in their current state without adaptation for the south african english mother-tongue speaker, but even more so for the african eal speaker who is of an indigenous language and cultural background. the speech language therapist (slt) needs to accommodate the variations in response, which requires an understanding of the south african child’s knowledge and experiences, and the language and vocabulary linked to their daily life and cultural practices (makiwane et al., 2016). these guidelines and principles could be used by language professionals to manage the assessment process and interpretation of findings from eal speakers in a more accurate, appropriate and equitable manner. one of the most common tools slts use for language screening, for all clients including african eal speakers who are from an indigenous language and cultural background, is the renfrew action picture test (rapt) (renfrew, 1997). the rapt is an expressive screening test for language development that was developed by catherine renfrew and originally standardised using english mother-tongue speaking british and irish children between the ages of 3 and 8 years (renfrew, 1997). research findings in the survey, referred to the methodology and reflected in table 1 revealed that the rapt is one of the most commonly used screening tests for language development by respondents in this survey in south africa for all clients, including african eal speakers who are from an indigenous language and cultural background (mdlalo et al., 2016). therapists have remarked that the advantage of using the tool is that it is short, easy to administer and cost-effective (roulstone et al., 2015). in spite of being aware that the screening tool does not accommodate the indigenous language and culture of the african eal speaker as it is based on western2 culture and experience, thereby reflecting a western world view, slts commented that their use of it and other tests that are not linguistically and culturally relevant to the sa context is influenced by the paucity of appropriate and culturally relevant resources (barratt, khoza-shangase, & msimang, 2012; gxilishe, 2008; mcleod, 2014; mdlalo et al., 2016). table 1: the research data description and data collection methods. as the study focused on the african eal speaker from an indigenous language and cultural background, research into the child’s indigenous knowledge system is crucial to ensure that any proposed adaptation is relevant to the daily experiences of the child, and will provide essential information that reflects the child’s indigenous world view (chivaura, 2006). failure to ensure this could result in an assumption of a language problem which does not exist, and lead to inappropriate recommendations or even intervention (cofresi & gorman, 2004). methodology the aims of the study were to establish the implications of using a currently favoured language screening tool in south africa, the linguistic and cultural relevance of this screening tool for isizulu-speaking children as an example, and how the language screening assessment tool could be adapted to be more linguistically and culturally relevant. a qualitative approach was used to determine the perspectives of the various groups of participants and to analyse the findings. this provided a relevant framework to illustrate how people drew in-depth meanings from their social actions, background, culture and world view, and how these responses could be interpreted, comprehended and appreciated. the rapt served multiple methodological purposes in this study, as reflected in phase 1 in table 1. it was used for individual testing of the children to demonstrate differences in interpretation and as an example for discussion in the focus groups with the children. the article mostly focuses on phase 1, where the participants were 90 children (see table 1). step 1: individual testing although the administration and scoring manual of the research instrument required that it be scored quantitatively (renfrew, 1997), in this particular research, it was used qualitatively as it was not used to identify language disorders per se, but was used as a ‘case study’ to demonstrate the effects of culture and different language upon interpretation of test stimuli. because it is one of the most commonly used language screening tools in south africa, the rapt was used in this study to determine whether there were consistent deviations in the responses from eal isizulu-speaking children to the questions on the various picture stimuli. it was applied to the children in the study who were from low socio-economic backgrounds and whose ages ranged from 6 to 8 years exactly as stipulated in table 1 and the responses were recorded verbatim, as indicated in the test administration manual. a total of 50 children were used for the test administration. these were then interpreted and analysed qualitatively. although the cultural and linguistic relevance of this commonly used screening tool was interrogated from four different viewpoints, this article focuses on the perspective of the children who are the target population of the tool. as language assessments are conducted with people who exist within a cultural context, the cultural capital is embedded in language (blair, 2016; espinoza-herold & gonzález-carried, 2017; haneda, 2014; smith, 2015; westby, 2009). this study focused on the relationship between language and culture and adopts an ecological approach to the problem; thus, a conceptual model that encompasses a strong ecological and cultural component was selected, that is, taylor’s (1986) cultural framework for viewing normal and pathological communication. step 2: children’s focus group a total of 40 children from the isizulu linguistic and cultural background were divided into focus groups consisting of five to six pupils in each group. prior to the actual testing, individual test administration piloting was conducted. piloting of both the test administration and the ‘voice of the children’ group was beneficial as it acted as a dress rehearsal for the actual test administration and also provided an opportunity to review data collection techniques (leedy & ormrod, 2010). the children’s focus group was piloted using a group of 10 children consisting of equal numbers of boys and girls. problems that were identified were addressed prior to the individual trial-testing and the children’s focus group sessions. these included improving the clarity of the questions, ensuring that sufficient rapport was established prior to the individual and group sessions and further clarification regarding which language the children should use in their responses was required. profile of the children in the study black, isizulu mother-tongue speaking children from both urban and rural schools participated in the study. the urban schools selected were ones that are categorised as ‘no-fee’ paying by government as the majority of the children came from low-income homes (burger, 2011), and were the children who went to the farm or rural areas during the holidays. their dual experiences, of both urban and rural environments, were reflected in their responses. in this study, only the urban school was english medium, while the rural schools were isizulu medium. the children in rural schools were only exposed to english at school or via the media. as the test was used to screen children, it was integral to this study that the voice of the children be heard (messiou, 2013). the soliciting of the voice of the children was performed through individual sessions and focus groups. table 1 summarises the data collection methods and data analysis strategies of the full study. ethical consideration ethical clearance for the research (ethical approval number hss/115/100) (see appendix 1) was provided by the university of kwazulu-natal humanities and social sciences research ethics committee. results the findings of the study, that is, individual children assessment and focus groups, were analysed and the emerging patterns discussed. the responses were reviewed, and based on the emerging patterns, the implications these findings had for the speech-language pathology (slp) profession were explored. the format used to depict the results was to present each picture from the renfrew action picture (rapt) and under each picture, the responses from each of the participants. the response was followed by a commentary. the visual stimuli3 and responses were categorised into the themes depicted in table 2. table 2: a table outlining the content of visual stimuli in the renfrew action picture test. interpretation of the patterns emerging and support for the assertions about the african culture and experience were drawn from the literature of various disciplines such as anthropological, psychological, linguistic and sociological writings (kunnie & goduka, 2006; okon, 2013) that are related to the themes emerging in the study. the black african culture, stories, philosophy and traditions have a formidable oral tradition that is reflected in, or is the underlying reason for, some of the practices that may be perceived as different, irrational, unreasonable, purposeless or even primitive when judged and viewed through the western4 lens (higgs, 2010; mucina, 2013). some of the actions or interpretations of the pictures of the participants in the study are embedded in this oral tradition and there may be a paucity of literature on them, for example hugging in black african culture. this paucity of literature presents with numerous difficulties and constraints in the interpretation and translation of the responses because the interpretation of the responses is influenced by language as ‘ideas and philosophies created in one language cannot always be adequately translated into another language without losing some meaning because each language speaks to a specific contextual symbolic encoding’ (mucina, 2013, p. 24) because of language translational limitation (barratt et al., 2012). mucina’s remark illustrates how the process of translating or interpreting across languages can present a challenge to accurate symbolic expression and cultural transmission of ideas and philosophies. when translating, there is an attempt to impose a certain level of resemblance and equivalence in word or concept meaning. however, the interpretation of the word or concept is influenced by factors such as culture, world view and frame of reference of the speaker. the result is what may be regarded as a logical deduction, but may not be relevant, as the mental representations differ despite the seeming resemblance and coincidences in meaning. an example is the root or stem in isizulu, – nde, encompassing both the meanings and associations linked to the words tall and long in english and often presents with many misinterpretations in conversations when directly translated. another example is use of the word ‘checkers’ to refer to the bag (in picture card 10). in townships, any grocery plastic bag is commonly referred to as a ‘checkers’. these examples show that words that have a meaning that may be clear for an english first language (l1) speaker may not necessarily have the same meaning from the perspective of an l2 speaker. they may be ambiguous based on how the l2 speaker has experienced their being used, that is, interlingual ambiguity. these restrictions manifest in the analysis of the responses. for example, the use of clan names between communicators may represent the same level of intimacy as hugging and yet, despite the seeming resemblance to nicknames in western culture, not have the same mental representation or meaning. picture card 8 on the rapt (see figure 1) has been selected in this article to illustrate the argument, as it was unanimously the most controversial picture. the controversy was around the black cat and how it is perceived in the black community (mutwa, 2003). a black cat is usually associated with witchcraft and negativity. as a pet, it is to protect the home by killing unwanted pests, such as snakes and mice (mutwa, 2003). the concept of rescuing a black cat was regarded by most focus group participants as inviting danger. the responses from the children (see tables 3 and 4) clearly indicated that the security of the man climbing the ladder was at stake. therefore, in the following phase of the study, the picture was adapted to be more culturally appropriate and the black cat on the roof was replaced by a ball that was to be ‘fetched’ from the roof of the house (mdlalo, 2013). figure 1: illustrating picture card 8 from the rapt (1997) (©speechmark ltd). table 3: some results of the voice of the children for each picture. table 4: children’s responses and reasons for adaptation of the renfrew action picture test expected responses. it was interesting that the concepts of witchcraft and traditional african values are usually mostly associated with the rural areas (durrheim, mtose, & brown, 2011), and yet it was the urban children who did not like the picture because of these associations. the rural children’s fear of a cat was similar to their fear of any other potentially dangerous animal and was not for culturally related reasons, whereas urban children’s aversion to the black cat as a dangerous animal was more reflective of the cultural view. this response suggests that assumptions that are often associated with the distinction between urban and rural communities are not always accurate. this finding shows that speech-language therapists (slts) should be cautious of using typical stereotypes pertaining to urban and rural communities (durrheim et al., 2011). the responses of the children illustrate that verbal associations with the picture or words may be different from those expected by the slt, as associations are linked to experience, background and culture. verbal associations are thus linked to sociolinguistic factors. the responses from the children were often characterised by pregnant pauses or slow responses. the detection of the words in the question and planning a response based on the detected word is a complex process when the question is not in the l1. this slowness in word detection may be misinterpreted as word-retrieval or word-finding problems. de rauville (2004) argues that in eal speakers, certain behaviours may seem to be word-finding errors, such as word-searching, whereas these errors may be a reflection of their limited semantic knowledge in the second language (de rauville, 2004, p.17) and therefore not a language pathology. discussion the responses from the children accentuate numerous critical issues that the slt needs to be aware of in working with culturally diverse populations. apart from the theory, the philosophical lens through which the slt views and interprets this information will determine how it is used and whether justice is served (arias & friberg, 2017; fricker, 2007; morreira, 2017). if the slt uses his or her own frame of reference to interpret, the picture presented may still be skewed. often, the perception of the dominant culture is used as a basis for whether it is pathological or not. in south africa, the western culture of the english l1 speaker is often part of this dominant culture and western standards become the basis and bias for the decision as to whether a communication difference is a communication difficulty or difference. the examples above of children’s utterances from pictures cards 4 and 10 provide an illustration of linguistic differences that may be misconstrued as part of a syntactic disorder but influenced by the l1 (table 5). table 5: linguistic differences that may be misconstrued as part of a syntactic disorder. language transfer occurs when the characteristics of one language affect those of another. these may occur at a morphological, syntactic, semantic or pragmatic level (myers-scotton, 2006). an understanding of the structure of isizulu as a language will help to make sense of these language differences, which may be depicted as errors because of misinterpretation or misunderstanding another illustration from the picture card 8 is the use of the word ladder. although the direct translation of the word is íleli, in practice it is commonly used interchangeably with amastepisi (steps) and this was reflected in the children’s responses. an slt who has no understanding of this frame of reference will regard the steps as inaccurate. based on the existentialist message in the introduction, slts are free to choose to use the client’s frame of reference despite the challenges of limited knowledge and resources that may exist. cultural sensitivity will help the slt to understand the responses and interpretation of responses that may seem inappropriate or irrelevant. within the profession, both globally and locally, there is consensus on the need to transform the current paucity of material and guidelines on the assessment and management of culturally diverse populations. research, assessment tools and profiles have been developed by professionals and tertiary institutions in an attempt to bridge this gap (pascoe & mcleod, 2016; singh et al., 2015; van der merwe & roux, 2014). there is, however, an acknowledgement that, despite these attempts, what has been produced to resolve this social reality is a drop in the ocean in terms of the needs within the profession (khoza-shangase & mophosho, 2018). anecdotal evidence suggests that there is a practice that, despite the extremely limited resources available for assessment of the eal speaker, the tools that exist, for example south african language assessment (sala – in all south african languages) and test of ability to explain for zulu speaking children (tate-zc), are not used. there has been very little research that has tapped into this issue in south africa. in this study, some of the changes made to the research instrument, the rapt, based on the responses of the participants, have already been made to other tests (solarsh, 2001; solarsh & alant, 2006), but these changes appear not to have been implemented in the use of these tests. they are still used in their original form, not taking into account the research-based adaptations for multicultural clients. the question that arises is whether slts are guilty of what critical theorists would describe as ‘social oppression’ by ignoring more culturally and linguistically appropriate resources for assessment. if the answer is positive, the critical theorists (han & price, 2015) propose a process of assisting them to become aware of the manner in which this social oppression operates through the process of conscientisation, that is, a process of creating awareness of another social reality, thereby helping to free them from social oppression. a critical theorist, drawn from the field of education, who advances this argument competently, is paulo freire. the process of conscientisation is also central to his educational theory of radical social change (freire, 2000), which focuses on the root causes of social and political problems rather than the symptoms, to allow for the planning of strategies to address them. freire argues that critical consciousness is essential to reassess the types of ideas, contexts and relationships that are typically ‘taken for granted’ or accepted as the norm prior to ascertaining the root causes of social oppression (freire, 2000). furthermore, he argues that authentic engagement with people you are committed to requires constant self-reflection. based on freire’s argument, a question that arises is whether slts are constantly self-reflecting on how to best engage with the challenge of eal speakers or are complacent with the current scenario of the scarcity of appropriate and culturally relevant assessment instruments for eal speakers from indigenous linguistic and cultural backgrounds. freire regards such a scenario as reflecting a degree of complicity. this means that slts may be aware of the gaps or contradictions but choose to turn a blind eye to them. from an slt perspective, we argue that conscientisation forms part of the solution. we believe that this process is long overdue and would play a significant role in addressing the social injustices of south africa’s past (kathard & pillay, 2013). the continued use of tests on eal speaking children that are normed on predominantly english-speaking uk or usa populations in their current form can present the slt with inaccurate findings that may be used to determine the future of the children assessed (arias & friberg, 2017; williams & mcleod, 2012). the future of these children therefore rests on the use of the rapt and any other language assessment test in a culturally and linguistically relevant manner. furthermore, the slt will be able to conduct a comprehensive assessment and make an informed decision based on a holistic picture of the child’s competencies. the slp profession has a responsibility to conscientise itself (kathard & pillay, 2013) in a culturally and linguistically relevant manner regarding the use of the currently available tools. practically, this entails slts understanding the language or culture of the client, understanding bilingualism and second language acquisition. conclusion the results of the study show that the heterogeneous nature of the south african population, especially pertaining to language and culture, places certain responsibilities on the slt to ensure ethical, just and moral assessments. it is pivotal to acknowledge that heightened consciousness and reflection form part of this process. as each slt is an intentional being (heidegger, 2008), this process cannot be a tacit one, but should be conscious and active as it has implications for the extent to which the slp profession can continue to engage in transformation that will result in just and equitable service provision for all the people of the country irrespective of colour, race, creed, culture, religion or gender (brewer & andrews, 2016; espinoza-herold & gonzález-carried, 2017). a collaborative effort by private, public and tertiary institutions is crucial for the success of this transformation. despite the intimidating nature of the process, we do not have the option to surrender and allow frustration to dictate the direction of transformation. as slts, we dare not to define ourselves by our external circumstance as we are not at the mercy of the limitations linked to diversity but can collaboratively, consciously and reflexively explore the alternatives as we celebrate this diversity. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. author’s contributions this article presents an aspect of t.m.’s phd, which was supervised by p.s.f. and r.w.j. the article was drafted by t.m., with input from both p.s.f. and r.w.j. references arias, g., & friberg, j. 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(2012). speech-language pathologists’ assessment and intervention practices with multilingual children. international journal of speech – language pathology, 14(3), 292–305. https://doi.org/10.3109/17549507.2011.636071 footnotes 1. not a homogenous group, there may be interand intra-linguistic and cultural variability. 2. despite the risk of overgeneralising as the western culture is not composed of a single, homogeneous set of values, the term ‘western’ has been used as reflected in the literature (miller, 2012). 3. the visual stimuli from the rapt, fourth edition published in 1997 and reprinted in 2010, were used in the study. the 2010 publication (accessed at the end of the writing of the study) of the rapt has revised visual stimuli. the content of the visual stimuli has been modernised and also reflects different races. these revisions are noted and acknowledged but do not change the findings and central arguments in this study. 4. variations in both interpretation and practice of african culture. abstract background methodology setting and study population data collection data analysis reliability and validity results barriers related to training and lack of knowledge barriers related to patients with dysphagia barriers related to the work environment discussion limitations and recommendations conclusion acknowledgements references about the author(s) andrea robbertse speech, language, and hearing therapy, medicine and health sciences, stellenbosch university, cape town, south africa alida de beer speech, language, and hearing therapy, medicine and health sciences, stellenbosch university, cape town, south africa citation robbertse, a., & de beer, a. (2020). perceived barriers to compliance with speech-language therapist dysphagia recommendations of south african nurses. south african journal of communication disorders, 67(1), a686. https://doi.org/10.4102/sajcd.v67i1.686 original research perceived barriers to compliance with speech-language therapist dysphagia recommendations of south african nurses andrea robbertse, alida de beer received: 17 oct. 2019; accepted: 20 june 2020; published: 10 sept. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: literature has shown that there is limited compliance amongst nurses with the dysphagia recommendations made by speech-language therapists (slts). poor compliance could have a significant impact on the health outcomes of patients with dysphagia. objectives: this study aimed to determine the specific barriers to compliance with dysphagia recommendations experienced by south african nurses, with the goal of identifying viable strategies to overcome these barriers. method: this cross-sectional study made use of a self-administered questionnaire to obtain quantitative data on nurses’ perceptions of barriers to the implementation of slt dysphagia recommendations. eighty-one nurses were recruited from two tertiary hospitals in two south african provinces. descriptive statistics were used to analyse the reported barriers to compliance. results: three main barriers to compliance were identified, namely a lack of knowledge regarding dysphagia, patient-related barriers and workplace concerns. knowledge barriers included poor familiarity with the role of the slt in dysphagia management, lack of knowledge regarding slt terminology, disagreement with dysphagia recommendations and insufficient dysphagia training. workplace concerns included staff shortages, heavy workloads and time constraints. poor patient cooperation was emphasised as a patient-related barrier. conclusion: for dysphagia recommendations to be followed by nurses, slts need to be aware of the barriers experienced by nurses within the relevant facility. speech-language therapists need to consider the provision of appropriate in-service dysphagia training and include nurses in the decision-making process when recommendations are made. speech-language therapists need to consider their role in both clear communication with the nurses and the development of supporting material, such as glossaries and visual aids. keywords: dysphagia; dysphagia recommendations; compliance; barriers to care; speech therapy; speech-language therapy. background the incidence and prevalence of non-communicable diseases are rising globally (institute for health metrics and evaluation, 2018; world health organization [who], 2014a), along with the sequelae of non-communicable diseases. dysphagia is a common consequence of non-communicable diseases, including acute neurological fallouts, degenerative conditions, various cancers (bremare, rapin, veber, beuret-blanquart, & verin, 2016; pace et al., 2009) and trauma-related injuries (takizawa, gemmell, kenworthy, & speyer, 2016). poorly managed dysphagia in acute settings could contribute to adverse outcomes such as poor nutrition, dehydration and aspiration pneumonia. dysphagia subsequently also impacts patients’ quality of life, often resulting in a lack of enjoyment of meals and social isolation if unable to partake in mealtimes as they did pre-morbidly (dziewas et al., 2017). dysphagia management is typically implemented by speech-language therapists (slts) and includes the identification, assessment and management of swallowing difficulties, as well as the prevention of related secondary medical complications. in the south african context, however, staff shortages amongst slts negatively impact the inpatient care process, with an estimated slt to south african citizen ratio of 1:25000 (kathard & pillay, 2013). subsequently, slts are often dependent on nurses to assist with the implementation of dysphagia management. nurses are in the unique position to positively influence inpatients’ health outcomes, as they spend the majority of their time interacting with patients (berry, 2009), allowing for opportunities to monitor swallowing safety and implement slt dysphagia recommendations. an interprofessional health model, where healthcare workers of different services provide comprehensive health services for patients, is recommended by the who (2010). this approach leads to improved coordination of health services and better patient health outcomes (dondorf, fabus, & ghassemi, 2016). in the south african context, however, interprofessional collaboration is not a consistently viable option because of time constraints, limited access to other professionals and often insufficient coordination between healthcare professionals (eygelaar & stellenberg, 2012; ostrofsky & seedat, 2016). according to the nursing scope of practice (south african nursing council, 2019), management of dysphagia would fall under ‘implementation of healthcare regimes’ and ‘monitoring of nutritional status’. nurses’ responsibilities in dysphagia management include administering oral and non-oral feeds, maintaining oral hygiene and ensuring that swallowing techniques and manoeuvres are performed as prescribed by the slts. nurses are also responsible for providing counselling to patients with dysphagia (broz, 2012; chadwick et al., 2013; jiang, fu, wang, & ma, 2016; langdon, lee, & binns, 2007; li, wang, hang, lu, & fang, 2015; seedat & penn, 2016). colodny (2001) investigated nurses’ compliance with slts’ dysphagia recommendations in a high-income country using the mealtime and dysphagia questionnaire (mdq). results of this study indicated compliance of less than 50%. reported barriers to compliance in dysphagia care included a lack of knowledge and training, lack of motivation and disagreement with the slts’ recommendations. these findings were supported by parmelee, lazlo and taylor’s (2009) findings, along with staff shortages and lack of physical resources. in the african context, several studies have found similar barriers to compliance (diendéré et al., 2016; eygelaar & stellenberg, 2012; rhoda & pickel-voight, 2015). general barriers to quality patient care in the south african healthcare environment include staff shortages, time constraints and increased workloads (eygelaar & stellenberg, 2012). however, a lack of research relating to barriers associated with dysphagia-specific knowledge and care within the unique south african context was revealed upon review of multiple databases (sciencedirect, pubmed, ebscohost, sabinet, and clinical key). although staff shortages are a global concern, these shortages are more severe in south africa (who, 2014b). a 2011 report from the who indicated that there are only 40.8 nurses and midwives per 10 000 south africans. staffing constraints are particularly prominent in the public healthcare sector, servicing 86% of the south african population (dondorf et al., 2016; steyn, klopper, coetzee, & van dyk, 2015), with only 46% of the nursing workforce being employed in this sector (george, gow, & bachoo, 2013). barriers to care are further exacerbated by the multitude of cultures, languages and religious views that are encountered and need to be considered in healthcare settings. south africa also experiences a quadruple burden of disease, resulting in medically complex patients needing to be cared for (kathard & pillay, 2013). these unique characteristics of the south african healthcare settings can result in increased time spent per patient in an already time-constrained environment. all of the unique south african characteristics limit the opportunities for interprofessional interaction and further professional development (eygelaar & stellenberg, 2012). given the numerous factors that could hinder quality patient care, queries can be raised about the specific barriers which nurses face when following slt dysphagia recommendations. speech-language therapists need to be aware of the barriers to compliance that nurses experience within their respective settings in order to develop meaningful and effective methods of addressing concerns regarding dysphagia management, to ultimately improve service delivery. considering the lack of research relating to barriers to compliance in the south african context, the following research question emerged: what are the barriers to compliance with slt dysphagia recommendations, as perceived by south african nurses in two tertiary hospitals? the study aimed to explore barriers related to: (1) knowledge and training, (2) patients with dysphagia and (3) the working environment. methodology study design and instrumentation this study followed a quantitative, cross-sectional research design. a revised version of the mdq, adapted with permission from colodny (2001), was used to collect data. adaptations to the mdq were made to ensure appropriate terminology and phrasing for the south african context, which is considered a lowto middle-income country. for example, ‘resident’ was changed to ‘patient’ to be more representative of the terminology used by south african nurses. questions were also added to the revised questionnaire to allow for the collection of data relating to dysphagia training received. a pilot study was conducted with 20 nurses with exposure to dysphagia management to ensure content validity and identify ambiguous or superfluous statements. no further changes were made to the revised questionnaire. the revised questionnaire included 28-likert scale responses that range from ‘strongly agree’ to ‘strongly disagree’ on statements regarding knowledge and training-related barriers, patient-related barriers and work-related barriers. facilitators to compliance were also investigated and are being reported in another publication. setting and study population a total of 81 participants were recruited from two tertiary hospitals (free state and western cape) in south africa. convenience sampling was used to ensure access to nurses who were available during the time data were collected. in order to be included, participants needed to be qualified nurses, be formally employed in the public sector and have at least 1 year of experience working with patients with dysphagia. data collection during the main data collection procedure, potential participants were identified according to the pre-determined inclusion criteria. informed consent was obtained from all participants after the research and expectations were explained by the researcher. once the questionnaires were distributed, participants completed them in their own time. the completed questionnaires were then collected within 24 h. data analysis descriptive statistics were used to analyse responses obtained, and therefore, no other statistical measurements were utilised. the percentages and frequency for all responses were determined and graphically represented. reliability and validity a pilot study for the questionnaire was conducted to ensure the reliability and validity of the test instrument. to ensure the validity of this study, sources of bias were reduced by avoiding test effects, as participants had no prior exposure to the testing instrument. to limit reactive effects, data were collected in an unobtrusive manner, by approaching participants in their everyday environment and engaging participants without special equipment, such as microphones. selection bias was avoided by applying strict inclusion and exclusion criteria, which also increased the generalisability of the study’s findings. corresponding scores on a split-halves reliability test indicated adequate reliability of the findings. ethical consideration permission to conduct the study was obtained from the university of stellenbosch’s health research ethics committee (s17/01/014). results the study samples obtained from both the hospitals were interpreted and described together because of the homogeneity of the participants’ responses. of the 81 participants, 39 (48%) mentioned their qualifications. eighteen (46%) were professional nurses, eight (21%) were staff nurses, 12 (31%) were enrolled nursing assistants and one (2%) was a community specialist practitioner. thirty-three participants (41%) had between 1 and 5 years of work experience, whilst 20 participants (25%) had between 6 and 10 years of experience. twenty-eight participants (34%) had work experience of longer than 11 years. table 1 refers to the barriers to compliance with slt dysphagia recommendations, analysed using descriptive statistics. table 1: summary of barriers to compliance with speech-language therapists’ dysphagia recommendations (as indicated by the percentage of responses). barriers related to training and lack of knowledge limited knowledge regarding the role of the slt in dysphagia management was reported by 46% of participants, whilst 72% of participants indicated poor familiarity with the terminologies used by the slts (particularly related to swallowing postures and manoeuvres). disagreement with the recommendations made by the slt was reported by 45% of participants. insufficient training regarding dysphagia management was also reported by 72% of participants. these responses are depicted in figure 1. figure 1: barriers to compliance related to knowledge and training. barriers related to patients with dysphagia eighty percent of participants indicated that they perceive patients with dysphagia as uncooperative during mealtimes, whilst 90% of participants reported that patients with dysphagia often dislike their meals, leading to poor cooperation and possibly exacerbating other existing barriers to compliance, such as time constraints. these responses are depicted in figure 2. figure 2: barriers to compliance related to patients. barriers related to the work environment significant barriers to compliance in the work environment were noted in this study, specifically staff shortages (91%), heavy workloads (66%) and time constraints (93%). these responses are depicted in figure 3. figure 3: barriers to compliance related to the working environment. discussion barriers to compliance were identified in three major themes, namely knowledge and training, patients with dysphagia and the work environment. the knowledge and training barriers identified, included poor familiarity with the role of the slt in dysphagia management and the terminologies used by the slts (particularly regarding swallowing postures and manoeuvres), as well as disagreement with the recommendations made by the slt. a possible explanation for the barriers identified could be the limited interprofessional contact with slts within the nursing environment because of the shortage of slts, particularly in public healthcare facilities (blackwell & littlejohns, 2010; pascoe & norman, 2011). exposure to other health professions has been reported to increase the transfer of knowledge and skills, leading to overall improved patient care and safety (berings, poell, & gelissen, 2008; goh, chan, & kuziemsky, 2013). limited contact with slts, along with inadequate knowledge of dysphagia management, can contribute to poor familiarity with terminologies used by slts. a lack of time allocated to discussing management plans with nurses should also be considered. during this discussion, slts could ensure understanding of their proposed dysphagia recommendations and ensure interprofessional agreement. disagreement with recommendations could stem from nurses’ own opinions, their perceptions of patients’ needs or uncertainty regarding the rationale for specific recommendations (colodny, 2001). barriers to compliance related to patients with dysphagia largely involved lack of patient cooperation. this could result from patients’ medical diagnoses, as well as from personal characteristics such as denial of the presence of dysphagia, dislike of modified diets or limited insights into the rationale for dysphagia recommendations (horner, modayil, chapman, & dinh, 2016). variation in patient compliance could also be linked to the diverse demographic of language, cultural aspects and religious beliefs within the context (riquelme, 2007). difficulty understanding and expressing oneself in a multi-lingual environment could influence compliance with slt dysphagia recommendations. considering barriers to compliance related to patients and the work environment, the observed lack of skills and knowledge amongst nurses potentially influences patients’ health outcomes negatively and could add additional strain for nurses who are already working in stressful environments. although nurses’ dysphagia knowledge has been investigated in other settings, this is (to the authors’ knowledge) the first study that explored dysphagia knowledge and training amongst south african nurses. work environment barriers were characterised by staff shortages, heavy workloads and time constraints. the current work environment, specifically in south africa’s public healthcare sector, is characterised by a shortage of staff (george et al., 2013; steyn et al., 2015), because of an insufficient number of undergraduate nursing students, as well as the migration of qualified nurses because of expectations of increased job satisfaction in the private healthcare sector. staff shortages directly contribute to heavy workloads and subsequent time constraints (george et al., 2013; steyn et al., 2015). similar work-related barriers have been noted in both international and african studies. barriers in the south african work environment are further exacerbated by patient-related barriers. these work-related challenges are often also exacerbated by patient-related barriers mentioned previously, which place further strain on nurses. speech-language therapists are not always in a position to directly address issues relating to the work environment and patient-related concerns, especially in the south african context, where a recommendation such as increasing staff numbers is not viable. however, by increasing nurses’ knowledge and training relating to dysphagia management, slts can equip them to better manage patients with dysphagia in challenging environments. training during undergraduate studies and in-service training is recommended to ensure both academic and clinical expertise in dysphagia management. interprofessional teamwork between nurses and slts is encouraged and needs to include task-sharing and patient discussions on the clinical platform. the who (2010) recommends strategies for facilitating collaborative practice between professions and highlights the need for population-specific institutional support, such as shared operating procedures and adequate time and space reserved for interprofessional interaction. a working culture of shared decision-making and routine team meetings is also encouraged. interprofessional teamwork will optimise referral systems and reduce time constraints, as referrals to slts can be made efficiently. given that nurses spend approximately 66% of their time in interaction with patients (berry, 2009; dondorf et al., 2016), miscommunication and disagreement could be resolved when dysphagia is managed by a collaborating interprofessional team. the nurses can guide the slts regarding patients’ personal, cultural or religious preferences. it is recommended that the slts consult the nurses when compiling dysphagia recommendations, to reduce disagreement and non-compliance because of a lack of knowledge or feelings of exclusion. when compiling dysphagia recommendations, patients with dysphagia should be included in the process, as part of patient-centred care. by accommodating patient-specific preferences and needs, realistic and relevant dysphagia recommendations are ensured, thereby potentially improving patient cooperation during mealtimes. interprofessional team meetings and in-service training should be scheduled around nurses’ availability to avoid increasing workloads or exacerbating time constraints. repeating short training sessions in small groups of two to three nurses rather than targeting entire shifts could ensure more efficient and convenient knowledge transfer. providing nurses written material or visual support as reference could help reduce the need for extended face-to-face contact time during training. considering the limited availability of slts in south africa, assistive aids can be used to ensure compliance in the absence of an slt. suggestions include visual aids in the form of charts or glossaries. nurses can then refer to these aids when an slt is not present to guide the implementation of the dysphagia management recommendations. reminders on agreed-upon dysphagia recommendations could also be placed next to patients’ beds and in patients’ medical folders. a communication or question book can also be made available for nurses to record questions or comments, which the slt could then check and respond to regularly. within the south african context, it is important for slts to recognise their changing role within dysphagia management, beyond direct assessment and treatment. speech-language therapists need to consider the identification of barriers to compliance and the training of nurses as part of their general patient management. in a context where multiple barriers exist and interact with one another, slts should aim to overcome identified barriers to care in their respective healthcare settings. limitations and recommendations limitations of this study included the use of convenience sampling, limited demographic information of participants and a lack of context regarding the various nursing qualifications. it is recommended that future studies make use of a random sampling method. obtaining sufficient demographic information is also recommended to allow for adequate generalisation of findings. sampling across other sites could also contribute to the generalisation of findings. the use of open-ended questions is also recommended to allow for a more in-depth understanding of participants’ experiences. it is also recommended that future studies investigate the causes of nurses’ disagreement with slt recommendations. conclusion this is the first study in south africa to examine nurses’ perceived barriers to compliance with slt dysphagia recommendations, with a focus on dysphagia knowledge and training, patients with dysphagia and the work environment. to ensure adequate quality of care and positive health outcomes for patients with dysphagia, recommendations are made to address barriers to compliance. speech-language therapists need to be aware of nurses’ perceived barriers to compliance within their specific contexts, and attempts should be made to improve inter-professional collaboration, as well as to provide in-service training for nurses regarding dysphagia management. acknowledgements the authors would like to thank mr j.s. le roux for the statistical analysis; dr. n. colodny for permission to adapt her mdq questionnaire; and the facilities involved for allowing data collection to take place. competing interests the authors have declared that no competing interests exist. authors’ contributions a.r. was responsible for the project conceptualisation, literature review, execution of field research and writing of the article content. a.d.b. was responsible for the project conceptualisation, supervision and guidance of project execution and writing of article content. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement original raw data were 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(2011). world health statistics 2011. geneva: world health organization. world health organization. (2014a). global status report on noncommunicable diseases 2014. geneva: world health organization. world health organization. (2014b). a universal truth: no health without a workforce. geneva: world health organization. abstract introduction research method and design data analysis results discussion conclusion acknowledgements references about the author(s) amanda b. thusi department of audiology, faculty of health sciences, university of kwazulu-natal, westville, south africa jessica paken department of audiology, faculty of health sciences, university of kwazulu-natal, westville, south africa citation thusi, a.b., & paken, j. (2022). the lived experiences and psychosocial impact of hearing loss on the quality of life of adults with multidrug-resistant tuberculosis. south african journal of communication disorders, 69(1), a823. https://doi.org/10.4102/sajcd.v69i1.823 note: additional supporting information may be found in the online version of this article as online appendix 1 and online appendix 2. original research the lived experiences and psychosocial impact of hearing loss on the quality of life of adults with multidrug-resistant tuberculosis amanda b. thusi, jessica paken received: 01 feb. 2021; accepted: 13 sept. 2021; published: 14 feb. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: aminoglycosides used in the treatment of multidrug-resistant tuberculosis (mdr-tb) are known to result in hearing loss. the effects of an acquired hearing loss with an mdr-tb diagnosis may have an increased adverse impact on the overall quality of life of an individual; however, there is minimal research in the area. objectives: this study explores the psychological and emotional impact of hearing loss in adults with mdr-tb; and describes the experiences of the social, economic, and vocational impact of hearing loss in adults with mdr-tb. method: a qualitative research study was conducted on 10 participants, with a confirmed diagnosis of mdr-tb and hearing loss. the researcher used a semi-structured questionnaire to collect data during face-to-face, audio-recorded interviews. results: hearing loss in patients diagnosed with mdr-tb has a significant adverse impact on the lived experiences of patients. stigma, discrimination, psychological distress, adverse changes in family status and family relationships, financial constraints, and social challenges were some of the common issues reported by participants. unemployment posed a significant challenge, resulting in participants having no economic stability because of mdr-tb, which was then worsened by the hearing loss; consequently, generating a great deal of stress. participants reported feelings of worthlessness, a loss of identity, lack of motivation, feelings of embarrassment, and loss of independence. conclusion: there is a significant irreversible social, psychological, and economic impact of hearing loss that has a direct impact on the lived experiences of mdr-tb patients and their families even after cure of mdr-tb. there is a need for improved treatment methods with psychosocial intervention strategies that equip patients to alleviate the adverse effects they experience. keywords: aminoglycosides; hearing loss; hearing impairment; mdr-tb; ototoxicity; psychosocial; quality of life; south africa. introduction the world health organization (who) reported that by 2050 nearly 2.5 billion people are estimated to have some degree of hearing loss, and at least 700 will require hearing rehabilitation (who, 2021). over 5% of the world’s population – or 430 million people – require rehabilitation to address their ‘disabling’ hearing loss (432 million adults and 34 million children). it is estimated that by 2050 over 700 million people will have a disabling hearing loss (who, 2021). the majority of people with disabling hearing loss (nearly 80%) live in lowand middle-income countries, especially in sub-saharan africa and in south and southeast asia (who, 2021). a contributor to the high incidence of hearing loss may be the quadruple burden of disease in south africa, namely communicable diseases such as human immunodeficiency virus and tuberculosis (hiv and tb); maternal and child mortality; non-communicable diseases such as hypertension and cardiovascular diseases, diabetes; as well as injury and trauma (who, 2019). these diseases have been identified as the leading causes of morbidity and mortality in south africa. considering the burden of disease, it is important to note that certain diseases may cause hearing loss either as a primary effect, as an opportunistic effect, or as a side effect of treatment options for that disease (khoza-shangase, 2020). one such disease is multidrug-resistant tuberculosis (mdr-tb). the mdr-tb is a disease resulting from exposure to mycobacterium tuberculosis strains, with resistance to isoniazid and rifampicin (who, 2014). the who (2019) world tb report, estimated that 11 000 people fell ill with mdr-tb in south africa in 2018, although the actual number might be as high as 16 000 (who, 2016). according to the global burden of disease study 2016, tb is the fifth leading cause of years of life lost and disability-adjusted life years in south africa. south africa, a country with high tb, mdr-tb, and hiv burden, contributes approximately 10% of global mdr-tb cases diagnosed and reported, with treatment success similar to the global rate at 54% and mortality at just above 20% (bridgen et al., 2019). the prevalence of tb (all forms) in south africa is estimated at 398.6 per 100 000, and the incidence of mdr-tb at 25 per 100 000 (bridgen et al., 2019). treatment of mdr-tb previously required: 18–24 months using second-line anti-tuberculosis drugs, and the daily administration of an injectable drug, i.e., aminoglycosides for at least 6 months, which are more toxic and less well tolerated than the first-line medications. (jenkins et al., 2011, p. 4) aminoglycosides were used to treat many gram-negative bacterial, staphylococcal, and mycobacterial infections, and were recommended as they have an intense action against multidrug-resistant gram-negative bacilli. they were, therefore, considered to be a vital component in the treatment of mdr-tb (zumla et al., 2015). however, according to the who (2019) global tb report, there is now a new drug regimen, bedaquiline (bdq), for the treatment of mdr-tb/extensively drug-resistant (xdr)-tb. it replaces the injectable agents in the short regimen and is given for a minimum duration of 6 months unless withdrawn early because of related toxicity or other contra-indications (who, 2019). research suggests that bdq is superior to aminoglycoside injectable in terms of safety and efficacy in the treatment of mdr-tb; thus, a modified shorter regimen, including bdq is considered more effective than the previous injectable-containing regimen (who, 2019). however, not all patients diagnosed with mdr-tb may be eligible for treatment with bdq. the exclusion criteria for mdr-tb treatment through the use of bdq as described by who (2019), are as follows: ‘any previous exposure to second-line anti-tb medicines for more than 1 month regardless of treatment outcome. all pre-xdr and xdr tb, any additional suspected resistance to second-line tb medicines, close contacts of patients with pre-xdr or xdr-tb, close contacts of patients with mdr-tb, close contacts of patients in whom rifampicin resistant (rr)/mdr-tb treatment has failed, complicated and/or severe forms of extra-pulmonary rr/mdr-tb disease, for example, meningitis, osteoarticular, pericardial effusion. rr/mdr-tb with extensive disease, for example, extensive bilateral cavitatory disease. any other situation in which the clinician is uncertain of a patient’s eligibility for the short treatment regimen’ (p. 18). despite the inability of the drug bdq to be used as a treatment option for all patients diagnosed with mdr-tb, the standardised, shorter mdr-tb regimen (with treatment duration of 9–12 months) can be offered to eligible patients who agree to the shorter treatment, but this requires a daily injectable agent for at least 4 months (who, 2019). this is an indication that the treatment of mdr-tb still requires the use of injectable aminoglycosides, thus a continued increase in hearing loss within this population. however, aminoglycosides have been reported to result in ototoxicity (reuter et al., 2017). according to bardien et al. (2009), ototoxicity is because of the death of the outer hair cells in the organ of corti of the cochlea and type 1 sensory cell in the vestibular organ. aminoglycoside induced hearing loss can occur intermittently or in a dose-dependent manner (bardien et al., 2009). aminoglycosides gradually accumulate in the endolymph and perilymph of the inner ear, and the half-life in these fluids is 5 to 6 times greater than that of plasma half-life (who, 2008). back-diffusion is dependent on the concentration of the aminoglycoside in plasma; hence, ototoxicity is more likely to occur in patients with persistently elevated concentrations in plasma (who, 2008). the effects of a hearing loss with an mdr-tb diagnosis may have an increased impact on the overall quality of life of an individual. while some patients may be able to return to their lives as they had been before their diagnosis of mdr-tb, most patients may continue life with considerable social, psychological, and emotional challenges that are overlooked during the treatment of mdr-tb (morris et al., 2013). ototoxic hearing loss tends to be permanent, and the societal impact of hearing impairment is profound (tambs, 2014). assessing quality of life can be used to demonstrate the importance that an individual places on specific aspects of their health or disease process. an indonesian study by sartika, insani and abdulah (2019) revealed that tb had extensive negative impacts on patient’s health-related quality of life, with physical domain being the most affected. these sentiments were validated by sineke et al. (2019), who reported health-related quality of life in south african patients receiving treatment for mdr-tb to be relatively low. however, sineke et al. (2019) found that mental health and well-being were lower among mdr-tb patients who self-reported experiencing an adverse effect. the study showed that patients on an individualised (injection-free) regimen had reported better mental well-being than those who were on a standard longor short-course regimen containing kanamycin (sineke et al., 2019). the study concluded that these negative effects of injectable agents on health-related quality of life need to be taken into consideration as countries decide to adopt oral or injectable regimens for rr/mdr-tb treatment in their national programmes (sineke et al., 2019). this, therefore, provided an impetus for the current study, especially since these patients with mdr-tb are likely to present with ototoxic hearing loss and quality of life may be worsened by the presence of a hearing loss. this information may be potentially useful in developing more appropriate therapies to assist in planning comprehensive strategies of care, which are essential in managing many chronic diseases. the provision of psychosocial interventions and rehabilitation for this patient population has not been documented in the south african context. the impact of the dual diagnosis of mdr-tb and ototoxic hearing loss on quality of life needs to be considered in the healthcare system during treatment, as this data may drive improved national healthcare planning with regards to the treatment of patients diagnosed with mdr-tb. the implementation of effective intervention requires a consideration of the impact of a hearing loss on the individual’s quality of life within the context of the mdr-tb diagnosis. however, there is a paucity of literature on the psychosocial impacts of hearing loss in patients diagnosed with mdr-tb. while studies have focused on the social, economic, and psychological impacts of mdr-tb and hearing impairment, these have been addressed as separate research areas. the term ‘quality of life’ extends both to the impact of treatment and side effects, and to the recognition of the patient as an individual, as a ‘whole person, body, mind and spirit’ (pukeliene & starkauskiene, 2011, p. 11). quality of life can only be described by the individual and can be further understood as the degree of satisfaction or dissatisfaction felt by an individual about various aspects of their lives (zumla et al., 2015). alternatively, quality of life can be regarded as the provision for the necessary conditions for happiness and satisfaction (zumla et al., 2015). it represents an aspect of health that is different from the generally used medical and biological methods of assessment, such as blood tests and clinical judgement. these tests have generally dominated healthcare and medicine, mostly because they are objective. the measurement of quality of life is subjective and entails the subjective views of the patients directly, and this should be used by healthcare professionals to supplement traditional assessments (bradbury‐jones et al., 2006). the measurement of quality of life should, therefore, also be used during assessments and management of mdr-tb. the conceptual framework employed in the present study draws from the world health organization quality-of-life scale (who, 2010), depicted in figure 1-a1 in online appendix 1. the scale identifies quality of life through specific domains, namely: physical, psychological, social, and environmental relationships. the scale identifies a further domain as ‘older specific facets’. these facets include areas of past, present and future activities; participation; and intimacy which are important aspects in the life of an individual. based on the framework, quality of life is directly influenced by these relationships. important concepts from the model were employed in the present study as they are closely related to the studied phenomenon. a comprehensive assessment of the patients’ health status should entail an assessment of the overall impact of mdr-tb and hearing loss on health and patients’ perception of well-being. besides routine clinical assessments, this assessment can be done by measuring the quality of life. assessment of quality of life should also be accompanied by the relevant interventions to help participants cope with changes during and after treatment, and should be informed by evidence-based research. therefore, the research question of this study is: ‘how does a hearing loss impact on the quality of life of patients diagnosed with mdr-tb?’. research method and design research aim and objectives the study aimed to describe the psychosocial impact of hearing loss on the quality of life of adults with mdr-tb. in order to achieve the aim of the study, the following objectives were formulated: to explore the psychological and emotional impact of hearing loss in adults with mdr-tb. to describe the experiences of the social impact of hearing loss in adults with mdr-tb. to describe the experiences of the economic and vocational impact of hearing loss in adults with mdr-tb. study design a qualitative research approach utilising phenomenological design was used to conduct this study. qualitative methods are typically more flexible as they allow the researcher to be spontaneous and adapt their interaction with the different participants (van den berg, 2001). qualitative methods use open-ended questions, which allow participants to respond in their own way and provide more information (van den berg, 2001). participants are, therefore, able to provide more detailed responses. in turn, the researcher has the opportunity to respond to what participants say immediately and ask additional questions that may be relevant to the information provided by the participant (van den berg, 2001). phenomenology is the study of the common meanings, which are shared by study participants in order to create an understanding of the participants’ experiences of a phenomenon (lester, 1999). this type of research mainly focuses on the individual’s perceptions of his or her experiences (lester, 1999). phenomenology aims to understand the way individuals see themselves in their environment. by understanding the meanings that individuals place on their particular experiences, a phenomenon is obtained (lester, 1999). therefore, it can be said that phenomenology leads in some way into at least some background conditions of individual experience (rodriguez & smith, 2018). the type of phenomenological design identified for the research study was transcendental phenomenology. it is descriptive, focuses on the discovery and description of the lived world, and is characterised by the following procedures: identify a phenomenon to study. bracket out researchers’ experience. collect data from participants who have experienced the identified phenomenon. analyse data and develop categories and themes of identified statements and quotes. develop a textural (what) and structural (how) descriptions of the participants’ experiences. setting the study was conducted at a district hospital in the city of johannesburg, gauteng province. the study site was appropriate as it is a public hospital which is reflective of the south african population, as more people access public health than private health. according to the latest general household survey conducted in 2019, only 17 in 100 south africans have medical insurance, which is required to access private healthcare (statistics south africa [stats sa], 2019). as many as 45 million or 82 out of every 100 south africans, do not have medical insurance, and are therefore largely dependent on public healthcare (stats sa, 2019). the hospital was selected because of its large referral base as it is utilised for the centralised management of all patients with mdr-tb from the five health districts, that is, city of johannesburg, ekurhuleni metro, city of tshwane, west rand, and sedibeng (stats sa, 2019). study population and sampling strategy the study population included patients who had acquired a hearing loss as a result of treatment for mdr-tb. all patients had baseline audiograms completed prior to initiation of mdr-tb treatment and all patients had presented with normal hearing on their baseline audiograms. this was corroborated with a review of the patient’s medical file. ten participants contributed data to the study. participants were aged between 26 to 40 years, and comprised of seven males and three females. a purposive sampling method was used to conduct this study. purposive sampling is most appropriate when the chosen data collection instrument is a semi-structured interview, as the focus is on obtaining an in-depth description of the case (babbie, 2010). choosing to engage in purposive sampling indicates that the researcher identifies sampling as a means of choosing with whom and where they are to conduct the research study (small, 2009); thus, implying that the researcher’s sample must be linked to the objectives of the study. the main goal of purposive sampling is to focus on particular characteristics of a population that are of interest, which best enables the researcher to answer the research question (small, 2009). participant selection participants for the study were selected based on the criteria identified as suitable for achieving the aims of this study. therefore, before conducting the research study, the following inclusion and exclusion criteria were stipulated, ensuring that only a particular group were selected. participant inclusion criteria the following criteria were used to include participants in the study: the participants had to have a laboratory-confirmed diagnosis of mdr-tb. the participants had to have been between 20 and 40 years of age, to ensure a fairly homogenous group who may have similar interests in terms of community and work life. the participant had to have been on the injectable agents (kanamycin, amikacin, capreomycin) drug regimen, as these drugs are known to have ototoxic side effects. the participant had to have completed or been on their mdr-tb medication for at least 6 months to allow enough time for exposure to their daily activities to identify psychosocial impacts. the participant had to have acquired a hearing loss during their course of mdr-tb treatment, as reflected by audiometric test results in his or her medical file. the participant had to be alert, cooperative, and able to participate fully in an interview. participant exclusion criteria the following criteria were used to exclude participants in the study: participants were excluded if they had a pre-existing hearing loss, not because of ototoxicity resulting from aminoglycoside treatment. participants who were not medically stable to speak. participants who were not fluent isizulu and/or english speakers, as interviews were conducted in isizulu or english. participants who presented with vestibulotoxicity, as the focus of the study was only on the ototoxic hearing loss and vestibulotoxicity may further impact the quality of life. data collection data collection method individual face-to-face semi-structured interviews were conducted by the researcher. a semi-structured interview allows an individual to answer questions on their own terms rather than the standardised interview. kumar (2005) viewed interview as the most suitable approach for studying sensitive areas, as the interviewer can prepare participants before asking sensitive questions and explain the questions to them in person. the researcher conducted one interview per day. furthermore, the interviewer took careful consideration not to interview patients if they were tired or unwell. patients were notified at the beginning and during the interview that should they need to discontinue or pause for a break, they were allowed to. interviews were conducted in either english or isizulu, based on the patient’s preference, as the interviewer is fluent in both languages. data collection equipment in addition to semi-structured interviews, field notes were manually recorded during the interview process. these assisted the researcher to note any gestures, expressions, or body language displayed by participants during the interview process. the researcher also made notes regarding the ease at which participants answered questions to gather if they were scared, or teary, or had other emotional responses during the interview process. to maximise reliability in the study, the researcher then compared the notes taken during the interview to the audio recordings. the researcher also used the field notes to reflect on the researcher’s feelings and thoughts during the data collection process. by writing the field notes, the researcher became aware of her reactions and emotions about the research process. all interviews were audio-recorded using a 16gb voice recorder usb dictaphone digital audio. data collection instrument a semi-structured interview schedule (see online appendix 2) was used to collect data. the data collection instrument was developed using tools and concepts by newman, weinstein, jacobson and hug (1991). these tools were identified as suitable as they addressed areas that were directly related to the research aim and objectives. the questions were open-ended, potentially giving participants the ability to express their thoughts and feelings (mainly when sensitive issues were being discussed) while offering more detail on the research subject (sarantakos, 1988). the interview schedule consisted of questions addressing aspects of medical history, psychological and emotional impact, social impact, employment and economic status. the interview questions were developed following the aim of the study. the interview schedule was structured into four sections. table 1-a1 in online appendix 1 provides an overview of the interview schedule with motivations for each section. the interview schedule was also translated to isizulu as isizulu is the second most commonly spoken language after english in johannesburg, gauteng (alexander, 2015). the interview schedule was back-translated into english by another audiologist, who had good knowledge about the topics covered in the interview schedule. data collection procedure following ethical clearance and permission from the study site, the resident audiologist, with the use of the information document, informed patients of the research study during their audiology follow-up appointments. participants were notified that participation in the study was voluntary and that they were free to withdraw from the study if they chose to. they were further informed that their choice would have no impact on their medical treatment; neither would it influence their audiological management. if they were willing to participate, they were required to sign an informed consent form, a copy of which was retained by the participant. interview times varied between 35 and 45 min and were scheduled at times, suitable for both participants and the researcher. all participants were asked the same questions, but the structure of the questions was adapted depending on the answers provided by each participant. each interview was conducted and audio-recorded by the researcher. interviews were held in a quiet, private room in a comfortable environment where seats were carefully arranged and where suitable lighting was available, to reduce the risk of any ambient noise, as background noise could have affected the patient’s ability to hear. lighting and seating arrangements were necessary, as some patients were dependant on lip reading for communication. infection prevention and control practices were implemented during the interview stage of the data collection process. the interviews were conducted with a vulnerable population, and it was essential to maintain a safe environment by reducing the risk of the potential spread of disease. gloves were not required as there was no physical contact between the researcher and the participants during the interview process. all windows were left open to provide natural ventilation since mdr-tb is an airborne disease, and the researcher did not have any illness at the time, which may have caused weakened immunity as that could have created the susceptibility to infection. after the interview, the researcher assigned pseudonyms to all participants. the audio-recorded interviews were fully transcribed verbatim. the interviews that were conducted in isizulu were translated into english and then transcribed verbatim. transcription of interviews was done through the nonotes.com transcription service. data analysis the chosen method of data analysis was inductive thematic analysis. thematic analysis reports on participants’ experiences, their meaning, and their reality. therefore, it can be used as a method to reflect reality or reveal the surface of reality (braun & clarke, 2006). inductive analysis is the process of coding the data without trying to fit it into a pre-existing phenomenon or the researcher’s assumptions. in this sense, this form of thematic analysis is data-driven (braun & clarke, 2006). an inductive approach to thematic analysis means the themes identified are strongly linked to the data themselves. transcribed and translated qualitative data obtained from the interview process were entered into the nvivo software programme. the field notes, especially those reflecting the participants’ emotions and reactions, were also included in the transcriptions. the data was then coded, analysed, interpreted, and verified. the process involved reviewing the data, breaking it down, closely examining it, comparing for relations, similarities and dissimilarities. different parts of the data were marked with appropriate labels or ‘codes’ to identify them for further analysis. sections of data that the researcher identified as significant were labelled into concepts as they allowed the researcher to group similar information to better understand the data. the data were analysed, categorised and organised into themes and further sub-themes, which emerged through the coding process. categories were created through organising and classifying the various codes into groups that share certain features. reliability and validity a pilot study was conducted before the main study. the pilot study was conducted by the researcher. the pilot study included four patients from the chosen study site. these were patients diagnosed with mdr-tb as well as a hearing loss. the patients who participated in the pilot study were not included in the main study. the results obtained from the pilot study indicated that the data collection method and tool were appropriate. no concerns were reported by participants with regards to the time taken to complete the questionnaire; however, the interviewer acknowledged that the duration of interviews could have been extended for the collection of information-rich data. all participants reported that the questions were easy to understand and respond to. therefore, no changes were made to the content. content validity of the study was ensured by selecting the participants according to the selection criteria to ensure that sufficient relevant data were obtained. the interviews were all conducted by the same researcher; thus, ensuring consistency of all interviews. construct validity was ensured in the research study through the pilot study and review of the pilot study. the qualitative approach is spontaneous in that the researcher must be aware of himself or herself within the research in order to avoid researcher bias and must continuously reflect on his or her own actions and thoughts with regards to how they may influence data collection and analysis (krefting, 1991). the researcher made use of field notes to reflect on the researcher’s feelings and thoughts during the data collection process. by writing the field notes, the researcher became aware of her reactions and emotions about the research process. all documents used for the collection of data had been translated to isizulu and back-translated to english to ensure that translation was accurate. field notes were taken during each interview. the notes were compared to the audio recordings of each interview. no errors were noted between the transcription and translation of the interview data. ethical considerations all participants were briefed about the nature of the study and study procedure. written informed consent was obtained from all participants. an explanation was provided in the consent form that all participants could withdraw from the research study at any given time as their participation was voluntary, and also that withdrawal would not have any negative consequences for them. participants were debriefed at the beginning and end of their interviews. the process of debriefing requires researchers to provide participants with information about the present study, expected outcomes, and what the study findings indicate (allen, 2017). the researcher took reasonable steps to minimise any harm to participants. at the beginning of the interviews, participants showed no signs of sadness. however, the researcher identified that participants became very sad during the interview process. the researcher asked participants to think of something that makes them happy during the debriefing process to make them happy as well as engage in small talk. participants were provided with referrals for counselling if there was a need indicated during the debriefing process. furthermore, they were given information about whom to contact should they have any questions or comments about the research. the study obtained ethical clearance from the university of kwazulu-natal biomedical research ethics committee (reference number: be274/19). results description of participants participants had provided details about their personal and employment life both before and after mdr-tb diagnosis and hearing loss. all 10 participants belonged to the black african community. all participants currently had a positive diagnosis of mdr-tb; four were still in hospital receiving treatment. all participants were unemployed. seven of the participants had children, while nine were single. participants were each been given pseudonyms to maintain confidentiality. the pseudonyms given to each participant were as follows: sarah (40), john (39), andile (34), vusi (29), mandla (40), bongi (29), sifiso (33), sandile (38), zinhle (26), and mary (31). a description of participant’s audiological and medical history is given in table 1. table 1: participant’s audiological and medical history. five distinct themes emerged from the research data. a hierarchy of the themes and sub-themes identified from the results is indicated in figure 2-a1 in online appendix 1. initial reaction to hearing loss in the current study, hearing loss was reported to have been sudden, although signs and symptoms varied from individual to individual. all participants expressed similar experiences of reduced hearing sensitivity bilaterally following the administration of aminoglycoside drugs for the treatment of mdr-tb. apart from not fully understanding their hearing loss and mdr-tb diagnosis, other initial reactions such as self-blame, internal shame, anger towards self, and pity were reported by participants, as they had previously been diagnosed with tb and defaulted on their treatment. these participants felt as though they had brought the hearing loss upon themselves, as reflected in table 2. table 2: participants’ responses on initial reaction to hearing loss. most participants’ initial reaction to hearing loss was fear. additionally, participants reported experiencing shock, panic, and confusion, and expressed uncertainty about the cause as well as the future of their hearing loss. apart from confusion and denial, other initial reactions such as self-blame, internal shame, anger towards self, and pity were reported by participants, as they had previously been diagnosed with tb and defaulted on their treatment. the experiences of previous treatment failures on the standard tb regimens had substantially shaped the psychological state of those participants. disclosure of hearing loss participants expressed challenges disclosing the diagnosis of mdr-tb, and the hearing loss, to their family. most of the participants expressed that they were afraid of how their families would respond to their hearing loss. they had struggled to disclose their mdr-tb status to their family members, as disclosure of mdr-tb itself was presumed as a sensitive issue. one of the challenges was expressed by a participant as: ‘i did not know what my family was going to say about my hearing loss. everyone can hear normal in my family. sometimes families do not understand that these things happen. i was scared of rejection.’ (zinhle, hearing loss: 4 years, assistive listening device: bilateral hearing aids) hearing impairment was reported to have affected participants soon after the diagnosis of mdr-tb, at a time when they reported that they were still overwhelmed with the diagnosis of mdr-tb. because of the short duration between the diagnosis of mdr-tb and acquiring a hearing loss, the psychological impact was likely more significant as the participants would not have had sufficient time to deal with the diagnosis of mdr-tb before acquiring a hearing loss: ‘it was hard because i still did not know how i got mdr-tb. i was still trying to understand the disease and what was happening to my body. the problem with the hearing made it very hard. there was no space between the two. everything was too much at the same time. i did not know what was happening to my body, honestly. yah, i had mdr-tb, and that is fine because it is a disease. we know diseases are real, but why did i lose my hearing? [shakes head in confusion]’ (mary, hearing loss: 1 year, assistive listening device: none) mental and emotional state participants felt that hearing loss and mdr-tb had negatively impacted their psychological and emotional well-being. the most common emotion expressed by participants was a feeling of hopelessness and fear. they shared that their initial concerns had changed to constant fear and uncertainty about their future, where they found it difficult to resonate with any positive emotions regarding their medical state as well as hearing loss. they expressed a lack of emotional support from all sources in their life. john reported that more focus was placed on physical and medical support and less on emotional well-being: ‘people here ask me how i am, like in the morning; the nurses will ask how you are feeling. they ask if you have any body pain or something, but they do not ask how you are feeling in your emotions.’ (john, hearing loss: 4 years, assistive listening device: none) vusi expressed a similar sentiment: ‘i have seen that many people think when you have something permanent like a hearing problem, you must move on. like when you lose a leg or something. they do not see that there are problems, you feel sad, you always ask why me?’ (vusi, hearing loss: 4 years, assistive listening device: bilateral hearing aids) gender roles challenges of gender roles were reported regarding emotional support, where males are usually seen as emotionally stronger and requiring less emotional support. one participant expressed how the challenge of gender roles was a barrier towards him obtaining any form of psychological support or understanding from his family: ’my wife struggled to support my emotions. maybe it was something she was not used to or did not know. i was still the ‘strong’ one, even if i was having problems. my children must also see me as strong because i am the father, so you see; there is never space for me to say i am not okay.’ (mandla, hearing loss: 3 years, assistive listening device: bilateral hearing aids) sarah reported that before being diagnosed with mdr-tb and acquiring a hearing loss, she had the responsibility of running the home as well as taking care of those within the home. the diagnosis of mdr-tb and a hearing loss had brought a sense of loss and worry for her as she was no longer able to carry out her role. she was worried about whether her family was coping without her. she had also felt like she had let them down: ‘i worry who is taking care of my family at home. i wonder if they are fine. i did a lot at home every day i was cooking and cleaning and making sure there is always food. i wonder if maybe they will feel that i left them on purpose.’ (sarah, hearing loss: 3 years, assistive listening device: bilateral hearing aids) sarah’s statement clearly demonstrates her worry for the well-being of her household and family as she was no longer able to perform her duties within the household. this loss of household activity may also impact individuals within the home as they may not have the abilities of the individual who routinely performed household activities. furthermore, this has had an impact on sarah’s psychological well-being, where she expressed concern that her family may think that she has left them intentionally. culture the impact of stigma around mental health within participants who all belonged to black african communities was evident amongst participants where mental health issues may be shunned. these challenges within the community may contribute towards participants not being willing to seek professional assistance for emotional and psychological challenges. one participant expressed: ‘in our community, i mean, we know we do not talk about these things; being sad for a long time is like white people things, so it is what it is. even at home, they will tell you something like “i do not understand depression,” so you see.’ acceptance of multidrug-resistant tuberculosis diagnosis and hearing loss challenges with acceptance brought about a negative shift, whereby participants felt as though their lives were different, that the impact of hearing loss and mdr-tb had brought on negative feelings about their physical and emotional state. their responses are expressed as follows: ‘it was hard emotionally when i lost my hearing. i did not cope with my mdr-tb diagnosis, and now i had a hearing problem [pauses]. i continued taking my medication and got better with the tb, but my ears never got better. that made me very sad, and i did not understand why my hearing was not getting better as my health improved. it still hurts my feelings so much. i cannot accept that i will never have normal hearing again.’ (sifiso, hearing loss: 3 years, assistive listening device: bilateral hearing aids) ‘i think it can be easy to accept something you did to yourself, you see; i did not do the hearing loss to myself.’ (mary, hearing loss: 1 year, assistive listening device: none) psychological support from healthcare providers in the form of informational counselling was noted to have brought about emotional relief; however, this support was only reported by one participant. most participants reported feeling overwhelmed as they had not received an explanation of their diagnosis and treatment, cause of their hearing loss, as well as assessment and possible rehabilitation outcomes of hearing loss. the emotional well-being of participants was further impacted upon by their experiences of hearing loss in the wider society. communication challenges had been found to have made it more difficult for participants to overcome these negative experiences reflections and projections for the future hopes for self were abandoned, to be replaced by the hope that life would not get worse. spirituality and belief in god gave strength for a better future. most participants reported that they felt close to a spiritual power that motivated them during this challenging phase of their lives. not all participants shared the same hopes for their future. feelings of uncertainty and hopelessness were maintained as some felt that their situation would not change regardless of how they may feel or function at present. sifiso expressed that it was hard to stay positive and motivated: ‘you find that you have much time, but you are not motivated to do anything, one day runs into the next, and you do not even know what day it is, it does not matter.’ (sifiso, hearing loss: 3 years, assistive listening device: bilateral hearing aids) other participants also expressed: ‘i am in a position that i cannot change. i do not know how my life changed so much so fast. i do not know. it feels very hopeless. i am just getting through the days [teary, shrugs].’ (zinhle, hearing loss: 4 years, assistive listening device: bilateral hearing aids) ‘there is very little hope. when you are very sick and then lose your hearing, it is hard to have any hope for a better life. we are human at the end of the day [she expresses a sarcastic laugh]. i see people get discharged and come back again and wonder if it is possible to be free of mdr-tb. i have never had a hearing problem before.’ (mary, hearing loss: 1 year, assistive listening device: none)) relationships with family and friends family and social relationships were reported to have been initially negatively affected by the diagnosis of mdr-tb and further impacted by the hearing loss. participants used a variety of words to describe how they felt about their family and social relationships. these words retrieved during the coding process of data analysis are indicated in figure 3-a1 in online appendix 1. from figure 3-a1 in online appendix 1, the use of terms such as ‘differently, disability, difficult, hopeless, judged’ are clear indicators of the tenuous relationship participants now shared with their family and social relationships. family support it had been reported that relationships did not remain the same following the diagnosis of mdr-tb. the long periods spent away from home during hospitalisation meant fewer stays at home and less time spent with family. this was expressed by a participant as: ‘my relationship with my family is different than what it was. i have been in the hospital for almost a year and have not seen my family. if you can go for so long without seeing someone that means you can survive longer without them. i know things have happened in my family, events, ceremonies, decisions made without me. this means i am no longer important now that i have a hearing loss. i am side-lined.’ (bongi, hearing loss: 2 years, assistive listening device: bilateral hearing aids) furthermore, changes in family support were reported. families were reported to have been initially supportive and understanding during the diagnosis of mdr-tb, but this had changed with time and when the hearing loss had developed. participants as parents parents had reported substantial shifts in their parenting roles because of both mdr-tb and hearing loss, as they felt absent from their children’s lives. they expressed great sadness on missing critical life events during hospitalisation for mdr-tb, which was aggravated by communication challenges imposed by the hearing loss even when participants returned home. where a child had passed on or encountered a negative life experience, parents experienced blame for having been absent. they felt as though outcomes for their children would have been different if they had been able to communicate effectively with them. others felt powerless where decisions were made regarding their children on their behalf. their responses are noted in table 3. table 3: participants’ responses on their relationships with their children. relationship with spouse or partner similar to family and family support, marriage was also reported to have been impacted by the diagnosis of mdr-tb and worsened by hearing loss. one participant went through a divorce as time away from home during treatment for mdr-tb put a strain on his marriage. he reported that his marital problems had worsened throughout the treatment duration, and these challenges were exacerbated by hearing loss. he expressed: ‘my relationship with my wife has been a challenge with my sickness. she found it hard to be the provider for money because i am not working. our marriage ended. i do not blame her. it hurts my feelings, but it was hard for her.’ where marriage may have possibly survived in the diagnosis of mdr-tb, the impact of hearing loss on marriage cannot be understated as the communication barriers brought on by hearing loss may have been too difficult to overcome. similarly, participants, who were not married, also reported relationship challenges with their romantic partners. social functioning participants reported reduced participation in their social life initially because of mdr-tb diagnosis, which then continued as a result of the hearing loss. the effect of treatment and hearing loss led beyond the physical to self-imposed social isolation. role functioning was also hampered. participants were unable to play their part in their family or society as they had hoped for or as they had done previously. time spent away from society, as a result of hospitalisation or staying indoors while home, was reported by participants to have resulted in reduced social interaction. participants found it challenging to maintain their social lives as they previously were, as much had changed in the society around them during their absence. sandile shared similar feelings of how being away from society for an extended time impacted his ability to re-integrate himself once he had returned home: ‘when i got better from the tb, my hearing was not good. now you can imagine going back to people you haven’t seen in a long time, and you cannot hear properly. i rather just stay at home. just imagine trying to do all that with a hearing problem.’ (sandile, hearing loss: 3 years, assistive listening device:unilateral hearing aids) unemployment all participants reported a significant decline in their financial situation as a result of their mdr-tb diagnosis and hearing loss. none of the participants were able to find stable work after completing their treatment. nine participants experienced unemployment and loss of finances during and after treatment, with a high level of unemployment amongst participants being mostly attributed to the hearing loss. social grant andile was a transport driver for school-going children, and this was a form of assistance for his parents with their transport business. he reported that a massive part of doing the work was to avoid sitting at home for the entire day, as he had been unemployed for 4 years since completing his mdr-tb treatment in 2015. the lack of employment was attributed to the communication difficulties resulting from the hearing impairment. social disability grants were the only source of income for most participants. the social grant was not only used for the individual but was also extended to support his or her family financially. for some families, the social grant had been the only source of income received and financial instability, therefore, extended towards the entire family. the lack of employment was attributed to the communication difficulties resulting from the hearing impairment. andile stated: ‘i am unemployed. i survive on a disability social grant. it is hard to find a job when you cannot hear [sighs]. coping in an interview is hard, and you are already judged. people see you as dumb [he shakes his head]; they think that you cannot do the job; they do not look beyond the hearing loss. it is hard. if i were to get a job, it would have to be one that does not need hearing, talking, and listening because i will not be able to do that properly. i am not ready to put myself there as yet.’ (andile, hearing loss: 3 years, assistive listening device: bilateral hearing aids awaiting cochlear implant) previously employed loss of self-esteem and confidence, resulting from hearing loss, were reported to have been barriers to re-employment. for two participants who had been previously employed, work had been significant in providing a purpose and structure to their day. they expressed how they had to leave the workforce unwillingly because of their diagnosis of mdr-tb. following treatment, hopes of re-integrating into the working environment were minimal because of the hearing loss. furthermore, much of the stress placed on relationships as a result of the unemployment was attributed to the changing of the breadwinner role in families, which is traditionally held by males. changing relationships within the family and the fact that one member of the family now spends more time at home with no clearly defined role can lead to frustration and resentment. bongi’s statements reiterate this point as he highlighted the massive reduction in his income and struggles to assist his family financially. in addition, he described feelings of guilt as he is not contributing to the family financially and believes that the breadwinner’s role should be his task. he expressed: ‘i was previously able to support my family with money as we [are] a large family in one home. now, i do not have money. even if they did need money, they would not ask me because they know that i do not have it. they will expect me to work once i get discharged, but it will be difficult to find work with my hearing loss. you see, hearing aids do not help me much. i feel a lot of stress and guilt.’ (bongi, hearing loss: 2 years, assistive listening device: bilateral hearing aids) financial constraints travel costs brought on much stress as participants often did not have the finances to travel to the hospital or clinic for their appointments. participants often had to travel long distances, which equated to higher travelling costs. the stress was reported to have worsened over time as participants were booked for regular monthly appointments both for the mdr-tb treatment as well as their hearing-related treatments. vusi expressed: ‘i live in orange farm, but i do my follow up at sizwe. to travel to sizwe from home, i must take four taxis to return, and i am not working. so it means i must have like r100 for one day, it is a lot of money. i go to the clinic and take the transport from there to sizwe. we wait for long, but at least it is free.’ (vusi, hearing loss: 4 years, assistive listening device: bilateral hearing aids) psychological experiences of unemployment participants in the present study had lost hope of finding work again, not because they were incapable or did not want to work but because they felt that their chances of employment were reduced because of the hearing loss. mandla expressed: ‘emotionally, it is difficult because you want to provide, but you cannot for those who depend on you. that can be difficult. say when one of the kids comes home from school, and they are looking for money for a school trip, and you must be honest with them, and it is very hard, to be honest with them. [trying to hold back tears]’. (mandla, hearing loss: 3 years, assistive listening device: bilateral hearing aids) these feelings were because of the communication challenges they experienced combined with the knowledge that for them, most of the ‘stable’ employment required excellent communication abilities which they did not possess. therefore, an individual with impaired hearing will have significant communication difficulties, many of which are situation-specific. even if participants were to gain employment, they may not have been able to stay employed as their communication challenges would continue. therefore, the inclusion of aural rehabilitation encompassing counselling and communication strategies training becomes more critical in the holistic management of these patients. once diagnosed with mdr-tb, those who had been employed were forced to leave their work because of the fear of infecting those around them as well as the inability to perform their job adequately as the hearing loss had posed severe communication challenges. the social grant was obtained either because of the diagnosis of mdr-tb or hearing loss. the social grant was a permanent monthly income when obtained as a result of the hearing loss and was often used to support the finances of the entire family. even though social disability grants are received monthly, the amount received is not sufficient to provide financial security and is therefore likely to result in chronic financial instability within families, therefore, there is a higher risk of mdr-tb because of poor treatment compliance, resulting in treatment with aminoglycosides and thereby increasing the risk of ototoxic hearing loss. discussion in the current study, each theme should not be viewed in isolation, as the content of one theme was sometimes reflective of aspects of another theme, or the result or cause of another theme. the participant’s diagnosis of mdr-tb and loss of hearing resulted in feelings of anger, disbelief, fear, and frustration, which in turn affected their mental and emotional state. the mental and emotional state was further impacted by unemployment. research findings have shown that unemployment can affect an individual’s psychological well-being. individuals: [h]ave deep-seated needs for structuring their time use and perspective, for enlarging their social horizon, for participating in collective enterprises where they can feel useful, for knowing they have a recognized place in society, and for being active. (jahoda, 1982, as cited in drydakis, 2015, p. 298) at the same time, their relationships with family and friends were negatively affected. these changes were further expounded on by what seemed to be a permanent state of unemployment. with a decline in their quality of life because of these changes, participants had very little hope for their future. the themes in the present study can be said to be similar to the quality of life scale proposed by who (2010), which identifies the domains of quality of life as physical, social, environmental, and psychological. the themes in the present study narrated the challenges participants had experienced across these domains. the alignment of themes to the quality of life model is indicated in figure 4-a1 in online appendix 1. quality of life is influenced by an individual’s physical and mental health, the degree of independence, and social relationships with the environment (zumla et al., 2015). an integrated evaluation of the quality of life must include all domains. the participants in the present study had significant challenges in all domains of their life, which is an indication of the decline in their overall quality of life. seemingly, clinical assessments remain stable over time, and yet patients report a worsening of their quality of life. the main purpose of the healthcare system is to increase the well-being of those it treats, but this can only be achieved if patient views are incorporated into treatment evaluations and rehabilitation, thereby ensuring that health and medical care are entirely evidence-based. the use of evidence based measurement scales may aid towards the evaluation of quality of life. measurement scales may be useful in allowing patients to identify those aspects of their quality of life that may have been affected; therefore, allowing for improved intervention. this, consequently, may aid in improving the patient’s quality of life. as the narratives have shown, there are significant emotional and psychological implications experienced by this population, both because of the disease and its treatment complexities as well as outcomes of hearing loss. one of the main findings which arose from the themes obtained during data analysis was the lack of psychosocial support received by participants. positive reception and support from families were limited. significant changes in family structure, loss of self-identity as well as the stigma around mdr-tb and hearing loss in present-day society had a significant impact on the participants’ relationships with society as well as their families. gender roles influenced the willingness of male participants to seek emotional and psychological assistance. it is crucial to consider the value of activities such as cooking, cleaning, and childcare that are commonly performed by women in the household in order to determine the impacts of disease on the household (ananthakrishnan & ehrlicher, 2007). ignoring the contribution of women to the household leads to an underestimation of the costs associated with mdr-tb with regards to household activities and care (ananthakrishnan & ehrlicher, 2007). relatively little attention has been given to the impact of mdr-tb on patients and their households. most studies have focussed on finances lost because of illness or death; thus, underestimating the cost of mdr-tb, particularly for women. participants experienced significant difficulty with acceptance of mdr-tb diagnosis and hearing loss. there was no mention of support outside the home or within the clinical setting. study findings emphasised the minimal role of healthcare providers with regards to counselling during treatment and intervention for mdr-tb patients who present with hearing loss. counselling was noted to have been insufficient throughout the patient’s medical journal as they had limited knowledge about ototoxicity as a side effect of aminoglycoside use. with the provision of appropriate counselling, participants may have had a clearer or better understanding of their medical conditions as well as reasons for the physical changes they had been experiencing. participants reported shock and confusion as reactions to hearing loss, suggesting that they may not have been adequately counselled about the side effects of mdr-tb, as is also evident in the findings of khoza-shangase, mupawose and precious (2009). khoza-shangase et al. (2009) reported that while all participants were instructed to take their medications and complete the treatment, they were unaware of the possible side effects of the medication. no reports of recommendations relating to the auditory function and reporting of potential ototoxicity related side-effects from the nurse or doctor were obtained (khoza-shangase et al., 2009). educational counselling may have provided participants with the knowledge of aminoglycoside-induced hearing loss as well as its progression and rehabilitation. talking therapies such as rehabilitative and mental health counselling may have provided participants with the ability to talk freely, without fear of criticism or judgement, and understand what may have caused their problems and how to cope with the emotional concerns they had been experiencing. poor mental health without any psychological intervention may also deter people with mdr-tb from disclosing their psychological symptoms and challenges. therefore, mental health disorders may be missed by health workers and, ultimately, by policymakers. in the current study, the ‘dual diagnosis’ of hearing loss and mdr-tb left individuals with feelings of hopelessness, a lack of self-identity, feelings of anxiety, and increased stress levels. significant changes in family structure, loss of self-identity as well as the stigma around mdr-tb and hearing loss in present-day society had a significant impact on the participants’ relationships with society as well as their families. the experience of stigma is in keeping with thiruvalluvan et al. (2017), who reported that patients diagnosed with mdr-tb experienced stigma from their family and community members. literature indicates that stigma may worsen psychological issues related to the disclosure of diagnosis. moreover, stigma also has a direct impact on patients, as it hinders adherence to treatment (thiruvalluvan et al., 2017). this finding is also in keeping with loveday et al. (2015), who reported that the effects of stigma included experiences of social seclusion or rejection from family members, friends, neighbours, and/or health providers; internalised shame; financial instability; discrimination; and its repercussions. it may be useful to educate not only patients but also their families on mdr-tb and hearing loss to help them understand the diagnosis and consequently overcome stigma. participants had not been able to reintegrate themselves into the community as a result of the amount of time spent away from society because of the long period of hospitalisation/treatment. even after recovery from mdr-tb, it was difficult for participants to maintain or be a part of a social circle because of the hearing loss. this led to participants being isolated from their friends and families. participants, as parents, were no longer able to fulfil their roles. they had been absent during treatment for mdr-tb. participants had lost their way of life as they had previously experienced it and had no means to improve their current state, leaving them with a permanent state of hopelessness. there was a high rate of unemployment amongst participants owing initially to mdr-tb diagnosis and then maintained and possibly worsened by hearing loss. participants experienced considerable financial decline and difficulty. they were unable to provide any financial stability for themselves and their families. some participants relied on a social grant as a monthly income, whereas some had no access to a social grant. participants did not have confidence in their ability to perform optimally in a position of employment because of the communication challenges they experienced as a result of hearing loss. the stigma of hearing loss has also made it difficult for participants to gain employment. as unemployment becomes long-term, its impact becomes more far-reaching, often affecting living standards substantially (wurie, cooper, horne, & hayward, 2018). if living standards are poor, the likelihood of the spread of infectious diseases is higher, and the individual’s recovery from the disease may be longer. ankale, nair, uppe, mathew and shah (2017) reported that mdr-tb is most prevalent in low-income households, where the quality of housing and the living conditions are typically poor, that is, poverty, malnutrition, poor hygeine, sanitation as well as overcrowding; thus creating a favourable habitat for the spread of the tb bacteria. low income is also known to be a determinant for poor adherence to tb treatment (wurie et al., 2018), and these patients may be trapped in a cycle of infection and reinfection fuelled by unemployment. it can be said that participants’ quality of life is largely decreased by their living standards and socio-economic status. it may be more difficult for them to improve their health status and prevent re-infection of mdr-tb if their standard of living does not improve. therefore, participants may find themselves in a permanent state of unimproved quality of life as they are continuously unable to find employment and improve their financial situation. the findings of this research study mirror the findings of previous research carried out to date on the impact of mdr-tb on quality of life, with the impact likely to be greater if there is also an acquired hearing loss. conclusion despite the pharmacological profile of patients, which is a necessary determinant for treatment outcomes, psychosocial profiles and interventions are a crucial aspect in achieving better treatment outcomes in many diseases, including mdr-tb. such non-medical interventions should be practiced mostly because of the adverse treatment outcomes on patient’s quality of life. with the current move towards the introduction of shorter treatment regimens for mdr-tb, which may be potentially less toxic, the consideration of how patients can be best supported should be an integral component of tb programmes. strengths of the study the study sample was small and limited to 10 participants, thus allowing for more in-depth information from participants. the researcher was bilingual being fluent in both english and isizulu which assisted the researcher to be able to probe further during interviews as the interview schedule was available in both english and isizulu. the research data was analysed through audio recordings as well as field notes. this assisted with increasing the reliability and validity of the study. these assisted the researcher to note any gestures, expressions, or body language displayed by participants during the interview process. to maximise reliability in the study, the researcher then compared the notes taken during the interview to the audio recordings. the researcher made use of field notes to reflect on the researcher’s feelings and thoughts during the data collection process. limitations of the study while steps such as coding were taken to reduce researcher bias during the data analysis process, the researcher’s involvement in designing the study and in data collection may have influenced the study findings. the study was conducted among patients with mdr-tb and hearing loss within a government health facility, with similar socioeconomic status and within one race group. the results obtained from the present study may be unique to the setting in which the study was conducted and may not be generalised to the entire population. however, the issues highlighted in the study are likely to be relevant to other countries with similar socioeconomic status and high mdr-tb burden similar to south africa. the study only looked at those patients who had been treated with aminoglycosides and not those who had been treated with bdq following aminoglycosides; therefore the study population may have not been a true representation of the entire mdr-tb population. acknowledgements the authors are grateful to the research participants of this research project for agreeing to participate in this study, and offering their time to answer the questionnaire. the authors are also grateful to the hospital management for allowing this study to be undertaken at the institution. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions a.b.t. was the project leader. j.p. was the supervisor of the project. a.b.t. performed all aspects of the project. j.p. made conceptual contributions. a.b.t. wrote the manuscript. a.b.t. and j.p. critically reviewed and amended the manuscript. both authors revised and approved the final manuscript. funding information the research received no specific grant from any funding agency in the public or private sectors. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the opinion or position of any affiliated agency of the authors. references alexander, s.p., fabbro, d., kelly, e., marrion, n., peters, j.a., & benson, h.e., … cgtp collaborators. 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(2015). the who 2014 global tuberculosis report—further to go. the lancet global health, 3(1), e10–e12. sajcd 66-1_2019_contents.indd http://www.sajcd.org.za open access table of contents i original research the cat on a hot tin roof? critical considerations in multilingual language assessments thandeka mdlalo, penelope s. flack, robin w. joubert south african journal of communication disorders | vol 66, no 1 | a610 | 30 may 2019 original research public awareness of ear health and hearing loss in jeddah, saudi arabia khalid a. alshehri, waleed m. alqulayti, bassam e. yaghmoor, hisham alem south african journal of communication disorders | vol 66, no 1 | a633 | 26 august 2019 original research knowledge of final year medicine, pharmacy, audiology and nursing students in south africa on drug-induced ototoxicity: a pilot study omphile mogole, natalie schellack, cara hollander, lebogang ramma south african journal of communication disorders | vol 66, no 1 | a606 | 14 november 2019 original research management of adult patients with tinnitus: preparedness, perspectives and practices of audiologists firdaus dawood, nasim b. khan, vedika bagwandin south african journal of communication disorders | vol 66, no 1 | a621 | 19 november 2019 original research shifting and transforming the practice of audiology: the inclusion of traditional healing dhanashree pillay, tshepang serooe south african journal of communication disorders | vol 66, no 1 | a635 | 20 november 2019 original research prevalence and associated prenatal and perinatal risk factors for oropharyngeal dysphagia in high-risk neonates in a south african hospital melissa a. da costa, esedra krüger, alta kritzinger, marien a. graham south african journal of communication disorders | vol 66, no 1 | a637 | 21 november 2019 original research infection prevention and control measures in audiology practice within public healthcare facilities in kwazulu-natal province, south africa nasim b. khan, chenay r. charles, naedene naidoo, amanda nokubonga, ndabenhle a. mkhwanazi, hella m.t.e. moustache south african journal of communication disorders | vol 66, no 1 | a636 | 02 december 2019 clinical perspective responsive communication coaching for early childhood practitioners in underserved south african contexts: clinical perspectives shabnam s. abdoola, renata mosca, bhavani s. pillay south african journal of communication disorders | vol 66, no 1 | a608 | 03 june 2019 58 65 71 83 93 102 110 124 page i of ii table of contents i opinion paper community service speech language therapists practising in adult dysphagia: is the healthcare system failing them? kim a. coutts south african journal of communication disorders | vol 66, no 1 | a615 | 18 july 2019 original research speech therapy students’ perceptions of authentic video cases in a theory module on child language disorders helena oosthuizen south african journal of communication disorders | vol 66, no 1 | a602 | 22 january 2019 original research statistical factors associated with utilisation of ototoxicity monitoring services for multi-drug-resistant tuberculosis patients in the western cape lebogang ramma, primrose t. nhokwara, christine rogers south african journal of communication disorders | vol 66, no 1 | a596 | 30 january 2019 original research contributing factors to high prevalence of hearing impairment in the elias motsoaledi local municipal area, south africa: a rural perspective karin joubert, donna botha south african journal of communication disorders | vol 66, no 1 | a611 | 20 february 2019 original research communication and school readiness abilities of children with hearing impairment in south africa: a retrospective review of early intervention preschool records ntsako p. maluleke, katijah khoza-shangase, amisha kanji south african journal of communication disorders | vol 66, no 1 | a604 | 28 february 2019 original research the piloting of a specific support programme for grade r teachers on attention deficit hyperactivity disorder: the process of development marguerite de jongh, anna-marie wium, wilna basson south african journal of communication disorders | vol 66, no 1 | a600 | 26 march 2019 original research exploration of factors influencing the preservation of residual hearing following cochlear implantation katijah khoza-shangase, katherine gautschi-mills south african journal of communication disorders | vol 66, no 1 | a607 | 10 april 2019 original research the effects of combined exposure of solvents and noise on auditory function – a systematic review and meta-analysis faatima nakhooda, benn sartorius, samantha m. govender south african journal of communication disorders | vol 66, no 1 | a568 | 09 may 2019 1 6 11 17 24 31 40 47 vol 66, no 1 (2019) issn: 0379-8046 (print) | issn: 2225-4765 (online)south african journal of communication disorders http://www.sajcd.org.za open access table of contents ii clinical perspective towards a south african model of language-based learning disability xoli mazibuko, penelope flack, jane kvalsvig south african journal of communication disorders | vol 66, no 1 | a634 | 22 november 2019 correction corrigendum: gestational age and birth weight variations in young children with language impairment at an early communication intervention clinic lauren c. fouché, alta kritzinger, talita le roux south african journal of communication disorders | vol 66, no 1 | a622 | 12 september 2019 131 139 reviewer acknowledgement south african journal of communication disorders | vol 66, no 1 | a697 | 12 december 2019 140 page ii of ii abstract introduction aim objectives methods statistical analysis ethical consideration results discussion conclusion acknowledgements references about the author(s) rizwana b. mallick department of communication sciences and disorders, university of cape town, south africa lehana thabane department of health research methods, evidence and impact, mcmaster university, canada a.s.m. borhan department of health research methods, evidence and impact, mcmaster university, canada harsha kathard department of health and rehabilitation sciences, university of cape town, south africa citation mallick, r.b., thabane, l., borhan, a.s.m., & kathard, h. (2018). a pilot study to determine the feasibility of a cluster randomised controlled trial of an intervention to change peer attitudes towards children who stutter. south african journal of communication disorders, 65(1), a583. https://doi.org/10.4102/sajcd.v65i1.583 original research a pilot study to determine the feasibility of a cluster randomised controlled trial of an intervention to change peer attitudes towards children who stutter rizwana b. mallick, lehana thabane, a.s.m. borhan, harsha kathard received: 17 oct. 2017; accepted: 22 apr. 2018; published: 18 july 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: while randomised controlled trials (rcts) are considered the gold standard of research, prior study is needed to determine the feasibility of a future large-scale rct study. objectives: this pilot study, therefore, aimed to determine feasibility of an rct by exploring: (1) procedural issues and (2) treatment effect of the classroom communication resource (ccr), an intervention for changing peer attitudes towards children who stutter. method: a pilot cluster stratified rct design was employed whereby the recruitment took place first at school-level and then at individual level. the dropout rate was reported at baseline, 1 and 6 months post-intervention. for treatment effect, schools were the unit of randomisation and were randomised to receive either the ccr intervention administered by teachers or usual practice, using a 1:1 allocation ratio. the stuttering resource outcomes measure (srom) measured treatment effect at baseline, 1 and 6 months post-intervention overall and within the constructs (positive social distance, social pressure and verbal interaction). results: for school recruitment, 11 schools were invited to participate and 82% (n = 9) were recruited. based on the school recruitment, n = 610 participants were eligible for this study while only n = 449 were recruited, where there was n = 183 in the intervention group and n = 266 in the control group. the dropout rate from recruitment to baseline was as follows: intervention, 23% (n = 34), and control, 6% (n = 15). at 1 month a dropout rate of 7% (n = 10) was noted in the intervention and 6% (n = 15) in the control group, whereas at 6 months, dropout rates of 7% (n = 10) and 17% (n = 44) were found in the intervention and control groups, respectively. for treatment effect on the srom, the estimated mean differences between intervention and control groups were (95% confidence interval (ci): -1.07, 5.11) at 1 month and 3.01 (95% ci: -0.69, 6.69) at 6 months. a statistically significant difference was observed at 6 months on the vi subscale of the srom, with 1.35 (95% ci: 0.58, 2.13). conclusion: a high recruitment rate of schools and participants was observed with a high dropout rate of participants. significant differences were only noted at 6 months post-intervention within one of the constructs of the srom. these findings suggest that a future rct study is warranted and feasible. introduction feasibility of randomised controlled trials among the various levels of evidence that are valuable in clinical practice, the randomised controlled trial (rct) is regarded as the gold standard because of its design strength (evans, 2003) and its power to draw conclusions (oakley, strange, bonell, allen, & stephenson, 2006; sibbald & roland, 1998). because of the large-scale nature of the rct and its stringent design, there are financial, resource and time implications that require careful consideration before one can be conducted. consequently, the literature recommends that it is vital to first conduct a comprehensive pilot study to determine feasibility and improve the validity and statistical power of a future rct (evans, 2003; leon, davis, & kraemer, 2011; oakley et al., 2006; shanyinde, pickering, & weatherall, 2011). it is further reported that the procedural rigour of the study is as important as the treatment effect benefit when evaluating the feasibility of an rct (oakley et al., 2006). procedural aspects and treatment effect are weighted equally in importance to determine feasibility of an rct, as this approach focuses both on the process of implementing and intervention as well as the outcome (determining the treatment effect) (evans, 2003; leon et al., 2011; oakley et al., 2006; shanyinde et al., 2011). therefore, this study aimed to determine the feasibility of a future rct by assessing two key components, the recruitment of schools and participants and dropout rate of participants, as well as the potential treatment effect of a classroom-based stuttering intervention. the process evaluations of a study are specifically recommended in longitudinal studies, such as this one, where repeated measures occur (oakley et al., 2006) at baseline, 1 and 6 months post-intervention. these process evaluations identify any organisational challenges and changes that are required (akobeng, 2005; bowen et al., 2009; kingston, 2004; oakley et al., 2006; thabane et al., 2010) to minimise potential flaws or bias (currie, seaton, & wesley, 2009; downs & black, 1998; lancaster, dodd, & williamson, 2002; oakley et al., 2006). the loss of participants is also reported as probable, particularly in longitudinal studies (keyzer et al., 2005; morton, cahill, & hartge, 2005). several aspects of process evaluations exist; this study focused on recruitment (school and participant) and dropout rate of participants because of the longitudinal nature of this study. the dropout rate was also selected, as the dropout rate of participants can result in incomplete or missing data (fitzmaurice, 2003). it may also result in a population no longer being representative, thus reducing the statistical power and validity of a study (toerien et al., 2009). this was clearly observed in a previous preliminary classroom-based stuttering intervention study (badroodien et al., 2011). at present, there are no documented feasibility studies in south africa within the domain of classroom-based intervention, which is essential for planning of future large-scale studies. comment on feasibility is also important, as research within the school context is challenging. common challenges relate to procedural aspects and treatment effect such as consent, participation and ethical concerns resulting from the vulnerable nature of conducting research with children. while it could be argued that this is the case for all studies, the complexity of school research adds to the level of difficulty that is often experienced when conducting school-based research. in terms of treatment effect, it is essential to also determine the potential treatment effect in a pilot study design prior to conducting an rct. lancaster et al. (2002) reported that an intervention may not appeal to all and thus acceptability of the intervention should be studied as part of determining treatment effect. questions around whether the intervention works and to what extent, whether the intended outcomes are achieved, its benefits and harms (including for whom) may also be answered through the study of potential treatment effect of an intervention (evans, 2003). in addition to knowing whether there is any potential shift in treatment effect, the inclusion of treatment effect measures may also determine when treatment effect should be measured, specifically, which time interval shows a greater shift, if any. a pilot study is therefore required so that when an rct is conducted, there are findings of a pilot study to show that time, resources and money can be justifiably invested into doing a rct study. for this reason, it is critical to focus on both aspects, procedural and treatment effect, to accurately inform the feasibility of an rct. classroom-based intervention stuttering, a communication disorder, presents with personal and social implications (negative self-perceptions, teasing and bullying), often occurring at primary school (dijkstra, lindenberg, & veenstra, 2008; murphy, yaruss, & quesal, 2007; swearer, espelage, vaillancourt, & hymel, 2010). despite the lack of training and resources to address communication difficulty and disabilities reported by teachers (penn, watermeyer, & schie, 2009), teacher involvement and training has been found to prevent teasing and bullying (blank et al., 2009). classroom-based intervention has therefore been advocated as a strategy to improve peer attitudes (langevin, 2009; merrell, gueldner, ross, & isava, 2008; murphy et al., 2007) internationally (langevin, bortnick, hamer, & wiebe, 1998) and in south africa (branfield et al., 2015; farelo et al., 2015; hobbs et al., 2016). internationally, persistent reports of teasing and bullying of children who stutter (cws) led to the development and study of the teasing and bullying (tab) resource, a classroom-based intervention in canada (langevin, 1998). the tab was created on the basis that attitude is learnt and can be changed (foster, 2006). the tab was found useful and feasible in targeting negative peer attitudes in a preand post-intervention study (over three to four temporal periods), without a control group, among grades 3–6 learners (langevin, 1998, 2009; langevin & prasad, 2012). however, it was not suitable for the south african population, linguistically or culturally. furthermore, the lack of a control group as a methodology does not align with the planning of a future rct. the tab resulted in the development of the classroom communication resource (ccr) intervention for south africa, the intervention being subjected to testing in this study. it was required specifically in south africa because of the prevalence of teasing and bullying and requests from teachers for support (abrahams, harty, st louis, thabane & kathard, 2016; hobbs et al., 2016). the focus of the ccr intervention is to target peer attitudes. the example of stuttering and communication is used in the ccr intervention but it can be extended to target difference, acceptance and teasing and bullying. the ccr intervention is a classroom-based resource that is administered by teachers, as the communication partner. the ccr intervention was studied and developed through small-scale studies by the university of cape town between 2009 and 2014 (badroodien et al., 2011; de grass et al., 2010; de freitas, geben, parusnath, relleen, & van den berg, 2012; filies, hartley, kaplan, & pettit, 2009; kathard et al., 2014; walters, 2014). in 2014, kathard et al. studied the attitudes of grade 7 peers of cws at pre-intervention and 1 month post-intervention, where the ccr was administered by teachers to intervention groups only. the stuttering resource outcomes measure (srom) was used to measure attitudes at pre-intervention and 1 month post-intervention in control and intervention groups in the areas of pro-social behaviours – positive social distance (psd), verbal interaction (vi) and social pressure (sp). the results of the study yielded minimal positive effects at 1 month post-intervention (kathard et al., 2014). kathard et al. (2014) subsequently recommended a large-scale study to explore peer attitudes over time, as they reported uncertainty around time intervals to determine treatment effect. this study therefore aims to build on the findings and recommendations of kathard et al. (2014) by exploring the treatment effect at both 1 and 6 months post-intervention as well as procedural aspects to assist with future planning of an rct. aim the aim of this study was to determine the feasibility of an rct through conducting a pilot study. objectives the study had two objectives: primary objective: to determine the recruitment rates of schools and participants and the dropout rate of participants secondary objective: to determine the treatment effect of attitudes towards stuttering among grade 7 students based on the srom and its subscales – the psd, vi and sp. methods study design a pilot, cluster, stratified rct design was used, where schools were the unit of randomisation. the cluster stratified rct design was emulated using a pilot study design to accurately comment on the feasibility of a future rct. the schools were stratified into two quintile groups (lower vs. higher) and randomised to receiving the ccr intervention or usual practice, using a 1:1 allocation ratio. participants the eligibility criteria included grade 7 participants, aged 11 years and older, in mixed-gender schools where the language of learning and teaching was english. the participants attended public primary schools in the lower (two and three) and higher quintiles (four and five). quintiles were included to ensure a representative sample was included. the schools were situated in the western cape metropolitan urban area in south africa. participants were not financially compensated in any way. all participating schools were provided with their own copy of the ccr intervention. schools could have cws in the classroom; however, once cws were identified they were approached to obtain consent to determine if the study could be conducted in their school. exclusion criteria included participants aged younger than 11 years from same-sex schools and schools within quintile 1. sample size a total sample size of n = 401 was included where n = 149 children were included in the ccr intervention and n = 252 children in usual practice (control group). a minimum sample size of n = 192 was recommended based on power analysis calculations from previous studies in the project stream using observations of treatment effects and mean differences (badroodien et al., 2011; kathard et al., 2014; walters et al., 2014). this study aimed to include a minimum of n = 384 (walters, 2014). intervention classroom communication resource intervention the ccr intervention included three key components, namely a social story, role play and teacher-led discussion. the teacher read the social story to his or her class. once the story was complete, the teacher selected participants to act out the role play. the purpose of the role play was to emphasise the story but also to provide participants with a first-hand account of how the characters of the story may have felt. finally, the teacher facilitated the discussion by using the guidelines in the ccr intervention. the discussion aimed to promote acceptance of diversity and difference related to stuttering, communication and generally, as well as discussions around teasing and bullying and how this related to what was happening at each school. the ccr intervention is considered self-sufficient for the most part. however, the teacher was provided with basic training on how to administer the ccr intervention. the focus on training was placed on the discussion aspect of the intervention, as many teachers had queries and concerns about how to best administer this section. in doing so, the ccr could be considered a supported classroom-based intervention that was used as a single-dose intervention. the researchers observed, without interference, the administration of the ccr intervention. the ccr intervention was only administered in the intervention groups, while control group teachers continued with their teaching without drawing attention to stuttering in any way. any questions that were asked after the intervention were to be answered and recorded by the teachers. outcomes measure procedural aspect the recruitment rate described the number of schools that were invited compared to those who agreed to participate during the recruitment phase of this study. this was described at a school-level, as this is how participants were initially recruited. thereafter individual recruitment was described in terms of those recruited from the eligible sample (based on school recruitment). the dropout rate described the loss of participants at baseline, 1 and 6 months post-intervention because of the longitudinal nature of this study. treatment effect: stuttering resource outcomes measure this study is concerned with the observation of a positive shift in the treatment effect (magnitude and direction) at 1 and 6 months post-intervention from baseline. the treatment effect was commented on using the global and sub-scale scores on the srom. the srom consisted of 20 questions making use of a likert scale. the srom sub-scales, including psd, vi and sp, are psychometrically approved constructs (walters, 2014). the srom was developed on the peer attitudes towards children who stutter (patcs). the patcs was developed by langevin (1998) in canada while the srom was developed for the south african population. the criterion reliability of the patcs (langevin, 2009; langevin, kleitman, packman, & onslow, 2009) and srom was met (walters, 2014). sampling and enrolment once-off randomised sampling took place to track participants from baseline, to 1 and 6 months post-intervention. continuous sampling was therefore not practical. data collection procedure upon obtaining the relevant consent and assent, all participants viewed a video of a cws. the participants were all asked to complete the srom at baseline. thereafter the teachers in the intervention groups received training, over a 60–90 min session, to administer the ccr intervention. the ccr intervention was then administered by the teacher to the participants in the intervention groups. no intervention took place in the control group. at 1 and 6 months post-intervention, all participants completed the srom. thereafter the control group teachers were provided with a copy of the ccr as well as teacher training. statistical analysis the procedural aspects are calculated as follows: the school recruitment rate was determined by examining how many schools were invited and agreed to participate. individual recruitment was similarly reported. the dropout rate was calculated into a percentage value at each time interval (from baseline, 1 month and 6 months post-intervention). it was reported as it is a common occurrence within the school setting and accounts for the participant numbers noted in this study. the inclusion of this information is essential for future planning of an rct. the treatment effect is calculated as follows. each participant’s srom scores were captured in microsoft excel, and r studio version 1.0.143 (http://www.studio.com) software was used to analyse the data. information such as knowing someone who stutters and scores according to gender was not reported on, as no significant differences were noted in previous studies (badroodien et al., 2011; kathard et al., 2014; walters, 2014). the random effect model was used to assess the intervention at 1 and 6 months post-intervention and was also used to account for potential correlation among the outcomes from schools. additionally, the intra-school correlation coefficient (icc) was reported on. an estimate of the icc difference between groups, 95% confidence interval (ci) and associated p-values (to three decimal places, with those less than 0.001 reported as p < 0.001) was reported. the analyses were adjusted for the stratification covariate quintile. sensitivity analysis was also performed to examine the treatment effect using linear regression, which did not account for the potential correlation among the outcomes from schools. ethical consideration ethical approval was obtained from the university of cape town health sciences human research ethics committee (510/2013). thereafter, permission was provided by the western cape education department. consent and assent were obtained from schools, principals, parents and participants. the ethical principles of autonomy, confidentiality, beneficence, non-maleficence and distributive justice were upheld at all times, as stipulated by the declaration of helsinki (williams, 2008). results feasibility aspects recruitment rate a total of 11 schools were invited, 10 schools responded to the invitation to participate, nine schools accepted the invitation and only eight participated in this study, as one school withdrew from the study. the recruitment rate was therefore 82%, as 9 out of the 11 schools invited agreed to participate in this study. based on the school recruitment, n = 610 participants were eligible for this study while only n = 449 were recruited, where there were n = 183 in the intervention group and n = 266 in the control group as a result of absenteeism and not providing consent. dropout rate the dropout rate in the intervention group at baseline was 23% (n = 34) and 6% (n = 15) in the control group because of consent not being provided and absenteeism. at 1 month post-intervention, a dropout rate of 7% (n = 10) was noted in the intervention and 6% (n = 15) in the control. at 6 months post-intervention, dropout rates of 7% (n = 10) and 17% (n = 44) were noted in the intervention and control groups, respectively (table 1). table 1: dropout rate at baseline, 1 and 6 months. preliminary estimates of treatment effect a total of n = 401 were analysed, with n = 149 in the intervention group and n = 252 in the control group, with 42% male in each group. a total of eight clusters (schools) were analysed, equally divided in terms of quintile to ensure a more representative sample. the baseline srom score mean was 73.17 (sd 12.05) in the intervention and 71.48 (sd 12.80) in the control group. the baseline characteristics are shown in table 2. table 2: baseline characteristics of study participants by study group. as shown in figure 1, the key findings indicate no significant differences (95% ci) in the srom with 2.01 (–1.07, 5.11) at 1 month post-intervention and at 6 months post-intervention with 3.01 (–0.69, 6.69). findings showed no significant differences at 6 months in the constructs of psd, 2.57 (0.67, 4.46), and sp, 1.04 (0.18, 1.89). the only significant difference noted was at 6 months within the construct of vi, with 1.35 (0.58, 2.13). figure 1: forest plot of treatment effect at 1 and 6 months on the stuttering resource outcomes measure and its subscales positive social distance, social pressure and verbal interaction (p = 0.001). a sensitivity analysis was also conducted ignoring clustering, which showed similar results as shown in table 3. table 3 includes the estimated differences between the intervention and control groups, along with 95% cis and p-values, adjusted for quintile, for the outcomes srom, psd, sp and vi. sensitivity analysis, ignoring clustering, showed similar results at 1 month post-intervention with 2.01 (–1.09, 5.12) and 6 months post-intervention with 2.46 (–1.05, 5.98). table 3: sensitivity analysis of treatment effect at 1 and 6 months on the stuttering resource outcomes measure sub-scales (p = 0.001). discussion generalisability of findings it should be noted that the findings of this study reflect schools in the western cape, south africa, from quintiles 2, 3, 4 and 5. findings should, therefore, be interpreted with caution when considering other provinces within south africa. feasibility aspects several challenges were encountered during this study, despite the anticipation of some general challenges that often arise during school-based research. it could be argued that all researchers experience varying degrees of difficulty with conducting research, while the complexity of school research added to the level of difficulty that was experienced in this study. the common challenges were experienced, such as consent and participation, which affected the recruitment of participants. the results indicate that the recruitment rate was high because schools were approached early in the year and could thus foresee making time available for the researchers, showing that school recruitment may be a feasible method of initial recruitment. while there is disparity in the numbers of control versus intervention groups, it should be noted that this was as a result of consent not being provided and absenteeism, all factors out of control of the researcher. furthermore, this was taken into account when interpreting the findings of this study. once the challenge of school recruitment was overcome, the researcher faced difficulty with recruiting individual participants. based on the eligible participants from school recruitment, far fewer participants were recruited, as a result of poor consent. it was challenging because the researcher relied on schools, principals, teachers, parents and participants to provide permission, consent and assent required for recruitment, while the researcher only had access to principals and some of the teachers. because of the strict design of rcts, the study will only be successful should schools agree to participate and facilitate return of consent forms from parents. once participants were recruited, the next challenge was to retain participants and prevent a large dropout of participants to ensure power analysis of this study. it was reported by schools that clearer communication is required. it is, therefore, vital that, in future, schools and teachers are made explicitly aware of the time commitments required of them so that they may make an informed decision as to whether they are able to participate in a future study and not experience the burden of participating in a study. upon discovering that data were to be collected at three separate intervals (baseline, 1 month and 6 months) in addition to another visit to the school where the teacher administered the ccr, schools expressed anecdotally great concern around the time commitments required of them. as a result, a dropout of participants was noted over time as well as difficulty arranging for data collection dates. this is commonly reported in longitudinal studies (galea & tracy, 2007). schools became increasingly hesitant to commit to an additional suitable time for data collection at 6 months post-intervention when compared to 1 month post-intervention. schools felt that they had already provided this study with a substantial amount of time and no longer perceived their participation to be beneficial, which is a common determinant of a dropout rate (galea & tracy, 2007; lundberg, thakker, hällström, & forsell, 2005). schools requested that, in future, data be collected over fewer time periods (i.e. perhaps only at 6 months) with fewer visits to the school. the researcher should also be understanding of the schools, their processes and preferred methods for participating and that all schools are different. researchers should also display an awareness of the sacrifices that schools make to be able to participate in research studies. because of the time constraints, schools asked that the research take place at the end of the school term. however, it meant that many participants were absent from school at the end of the term after completing their academic testing. this is reported by teachers in this study to be a common occurrence, as no new work was being taught at school. in terms of organisation, early planning and scheduling, logistically it was challenging to find suitable times for data collection, given the pre-existing busy academic calendar. schools found the research time-consuming and reported that they would not have committed to it had they realised the extent of the time needed to dedicate to this study. consequently, there were serious implications in terms of motivation to participate and the relationship between the researcher and the school. this was found to be especially true where telephonic contact was made. while it appeared to be the most convenient method, it was viewed as impersonal. face-to-face contact and direct contact is reported to improve building a relationship with schools, principals, teachers, participants and the researcher (galea & tracy, 2007). additionally, multimodal reminders may have been more effective with face-to-face contact as the primary method of contact (galea & tracy, 2007; hartge, 2006; keyzer et al., 2005). however, the methods of contact appeared to differ in each school. the research thus adapted according to the preference of the specific school. in addition to the administrative challenges discussed, related to planning and scheduling, other challenges included relationships and consistency of researchers. these factors collectively affected the recruitment and dropout rates. schools reported that the use of research assistants was inconsistent and reported that they were unable to build a relationship with and get to know the researcher and research assistant at their school. building a relationship early on with the school is recommended by galea and tracy (2007) and hartge (2006), as it has implications for data collection at future time intervals. schools reported feeling that it was challenging to deal with different people and that they did not know who the sole contact person was. schools further reported that if they had built a relationship with a consistent researcher, it may have been easier to make certain concessions where challenges around organisation and planning arose. consequently, this affected their motivation and willingness to participate in this study, especially given the time constraints that the school faced. given the demands that schools face and feedback that schools provided, it should be taken into consideration that data collection is an added responsibility taken on by the school. preliminary estimates of treatment effect though no significant result was observed at 1 month post-intervention, it is possible that it was too early for participants to have internalised their learning. this is supported by kathard et al. (2014), who stated that at 1 month post-intervention, an attitude shift was beginning but that more time was recommended and that 6 months post-intervention may yield further changes in treatment effect. in doing so, the results at 6 months post-intervention supported the use of the ccr at the 6-month interval in the construct of vi. this therefore illustrates that the use of the ccr intervention may facilitate a positive shift in the magnitude and direction of scores of attitudes towards cws. the results suggest an indication of the direction of change in treatment effect. despite the dropout of participants, the findings at 6 months show that evaluating treatment effect at 6 months post-intervention is a critical time period, as this is when the start of shift in treatment effect becomes apparent. the use of the ccr is important, as it may facilitate the holistic management of stuttering and communication difficulty by speech-language therapists (slts). it is important to note that while a potentially statistically significant result was observed at 6 months post-intervention within the vi construct of the srom, this is not the sole finding to influence the feasibility of the rct. it is repeatedly emphasised in the literature that collectively effectiveness of an intervention and procedural aspects are drawn upon to determine the feasibility of an rct (evans, 2003; leon et al., 2011; oakley et al., 2006; shanyinde et al., 2011). this study is an illustration of this and has emphasised the need to draw on both components of this study to tell the researcher about how future planning may be facilitated. conclusion overall, both procedural aspects and treatment effect trends provide important information about the feasibility of an rct. it is illustrated that collectively these factors suggest that an rct is feasible. the recruitment and dropout rates specifically showed that several factors should be considered to improve the feasibility of a future rct in terms of the procedural aspects of this study. additionally, the treatment effect shows that 6 months post-intervention proved to be an optimal and feasible time to determine the treatment effect, whereas in this study a significant result was noted only in one of the constructs at 6 months. it would be important to retain a sample to test the effectiveness of the ccr intervention in a more robust way. furthermore, it would be impractical to measure post-intervention attitudes at three intervals in future because of time constraints (reported by schools) and because of the repeated use of the same outcomes measure. strength, limitations and clinical implications the main strength of this study was its ability to achieve the objectives of determining the feasibility of an rct by drawing on the findings of this pilot study. the limitation of this study is the way in which schools experienced the study. clinical implications include that an rct is feasible and that there is a need for further research to enrich south african literature on classroom-based stuttering intervention. recommendations for future research an rct is recommended, with further development of the process. in order to conduct a methodologically sound rct, there are several factors that need to be considered and put into place, as described in the discussion. there are two main recommendations for this study: (1) to reduce the dropout rate of participants through stringent methods and (2) to determine treatment effect at baseline and 6 months post-intervention only. no significant results were noted at 1 month, suggesting that perhaps only 6 months post-intervention data may be necessary, as this is where the shift in treatment effect begins. by reducing the number of data collection intervals and being transparent about the number of visits that are required, the researcher may also alleviate time pressure and any burden schools may experience. acknowledgements r.b.m. and prof. h. kathard wish to acknowledge the programme for enhancement of research capacity grant, university of cape town that partially contributed to this study. prof. l. thabane wishes to acknowledge and was supported in part by funds from the carnegie african diaspora fellowship program. this study was funded in part by the programme for enhancement of research capacity grant, university of cape town, and the carnegie african diaspora fellowship program. competing interests the authors declare that they do not have any competing interests. there are no personal and/or financial relationships that may have influenced the writing of this article. authors’ contributions r.b.m., the corresponding author completed the research as part of her master’s study and was responsible for writing and compiling drafts of this paper. prof. h. kathard was the primary supervisor and prof. l. thabane was a consultant in this research study. a.s.m.b. conducted the statistical analysis of this study. h.k., l.t. and a.s.m.b. contributed to the writing and reviewing of this paper through a number of drafts. references abrahams, k., harty, m., st. louis, k.o., thabane, l., & kathard, h. 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(2014). changes in peers’ attitudes towards children who stutter after the administration of the classroom communication resource. unpublished postgraduate masters. cape town: university of cape town, south africa williams, j.r. (2008). the declaration of helsinki and public health. university of ottawa: canada. bulletin of the world health organization, 86, 650–652. https://doi.org/10.2471/blt.08.050955 20 ingrid w illenberg foundations for literacy: emergent literacy competencies of grade r learners on the cape flats ingrid willenberg university o f the western cape abstract international research has demonstrated that a considerable amount o f children’s literacy development occurs prior to form al schooling and that emergent literacy skills at school entry are strong predictors o f later literacy and general academic achieve­ ment. these findings have prom pted vigorous early intervention programmes aimed at promoting emergent literacy development to optimise the development o f conventional literacy. while there is considerable research conducted in developed countries, there is limited research on the emergent literacy skills o f children in south african contexts. in the light o f increasing evidence o fp o o r literacy performance o f south african children in the foundation phase o f schooling it is imperative that appropriate and timely intervention be undertaken. however it is important that intervention be informed by baseline assessments o f the children’s liter­ acy competencies in the fu ll spectrum o f socio-cultural contexts in this diverse country. this study documents the emergent liter­ acy competencies o f 101 grade r (the year prior to grade 1, equivalent to kindergarten in the united states) learners attending schools in historically disadvantaged coloured communities on the cape flats in the western cape. an emergent literacy and language assessment protocol was developed fo r use with this population. the children’s performance on the assessment tool indicated that in general they possessed a reasonable repertoire o f emergent literacy skills. although they displayed adequate skills to support acquisition o f print decoding skills necessary fo r flu en t reading, weaknesses in the decontextualised language skills that have been fo u n d to support later reading comprehension, were evident. key words: emergent literacy, child language, child development, kindergarten, grade r. introduction since the early 1980s research has demonstrated that children acquire a wealth o f knowledge, skills and orientations in rela­ tion to reading, writing and oral language prior to receiving formal reading instruction in grade 1 (e.g. mason, 1980; lomax & mcgee, 1987). in addition, research has further shown that children’s emergent literacy competencies are powerful predic­ tors o f their later achievement in literacy as well as in general academic skills (e.g. tabors, snow & dickinson, 2001). given the predictive value o f emergent literacy skills for later achieve­ ment in literacy in particular and academic achievement in gen­ eral, the united states for example has invested significant re­ sources on early literacy interventions such as reach out and read (http://www.reachoutandread.org) and america reads (http://www.ed.gov/inits/americareads/index.html). undoubtedly south africa will need to pay urgent atten­ tion to promoting emergent literacy development, especially in the light o f burgeoning evidence o f low literacy achievement of school-going children. a national foundation phase systemic evaluation conducted in 2002 (department o f education, 2003) on a stratified random sample o f 54 000 grade 3 learners (equivalent to 5% o f the cohort) found that the average total literacy score obtained was 54%, with the average score for reading comprehension and writing equal to 39%. similarly, a 2006 study o f 82 879 grade 3 learners in the western cape found that only 47.7% demonstrated the appropriate literacy skills expected at grade 3 level (western cape education de­ partment, 2007). however, before embarking on intervention programmes it is essential to understand the nature and trajecaddress for correspondence: dr. ingrid a. w illenberg faculty o f c om m unity & h ealth sciences u niversity o f th e w estern c ape p rivate bag x i 7, b ellville, s outh a frica phone: ( 2 7 2 1 )9 5 9 3638/2277 fax: ( 2 7 2 1 )9 5 9 2845 e-m ail: iw illenberg@ uw c.ac.za tory o f emergent literacy development in local conditions. un­ fortunately there is little published research on emergent liter­ acy development o f children in south african contexts. the current study investigated emergent literacy development in a local context by assessing the language and literacy competen­ cies o f grade r learners from historically disadvantaged com­ munities in the western cape. prior to introducing the method­ ology for the study, a brief overview o f emergent literacy is provided. what is emergent literacy? the term emergent literacy, initially introduced by marie clay (1966), refers to the knowledge, skills and orientations | pre­ schoolers display in relation to reading, writing and oral language, prior to receiving formal reading instruction (sulzby & teale, 1991). it is also used with reference to a paradigm o f literacy development which differs significantly from earlier theoreti­ cal conceptualisations o f literacy in that it views literacy devel­ opment as a continuum beginning at birth and proceeding through the early years of formal schooling, rather than begin­ ning at the onset o f formal schooling (whitehurst & lonigan, 1998). the assumptions o f the emergent literacy paradigm are: (a) children acquire knowledge about language, reading and writing before receiving formal instruction; (b) reading, writing and oral language develop concurrently and influence each other; (c) the development o f literacy occurs in everyday home and community life, in real and purposeful situations; and (d) children experience print independently but benefit from literacy models in their environment (teale & sulzby, 1986). x any further discussion regarding literacy must of necessity acknowledge opposing views on the nature of literacy. while traditionally literacy has been regarded as a monolithic entity, with a predominant emphasis on print, this conceptualisation has been challenged by theorists proposing the concept o f multiple literacies (e.g. barton, 1994). however, even proponents o f multiple literacies acknowledge that, because literacy is die suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.reachoutandread.org http://www.ed.gov/inits/americareads/index.html mailto:iwillenberg@uwc.ac.za foundations for literacy: e m ergent l iteracy c om petencies o f g rade r learners on the c ape flats 21 shaped by societal power relationships, certain types o f literacy, such as conventional school literacy, assume dominance and power over others (barton & hamilton, 1998). so, although it is evident that literacy practices assume a variety o f forms in differ­ ent communities, research has demonstrated that only certain kinds o f literacy experiences facilitate the acquisition o f conven­ tional literacy. in fact, there is widespread agreement that middle class children tend to be more successful at acquiring literacy skills precisely because their home experiences with literacy tend to endow them with the attitudes, skills and knowledge that en­ able them to benefit optimally from formal literacy instruction. this begs the question: what are the emergent literacy competen­ cies displayed by children prior to formal reading instruction? several systems for classifying these emergent literacy skills exist. mason and stewart (1990) identified 4 components o f emergent literacy: (1) concepts and functions o f literacy, e.g. knowledge o f the functions o f print and recognition o f environ­ mental print; (2) writing and composing: word and sentence writing, story composition; (3) knowledge about letters and words: letter knowledge, phoneme-grapheme correspondence, word recognition, and awareness o f sounds in words; and (4) listening comprehension and word understanding: story retell­ ing, narrative skills, and word definition. gunn, simons and kameenui (1998) proposed a framework o f emergent literacy incorporating the following areas: (a) awareness o f print; (b) knowledge o f the relationship between speech and print; (c) com­ prehension o f text structure; (d) phonological awareness; and (e) letter naming and writing. awareness o f print includes knowing the conventions o f print and understanding its uses and purposes. children’s awareness o f the relationship between print and speech is realised in their acquisition o f letter knowledge and phonological awareness. knowledge o f how written texts in gen­ eral and written narratives in particular are structured facilitates the comprehension and production o f written texts. whitehurst and lonigan (1998) proposed a model o f both emergent and con­ ventional literacy comprising two mutually dependent sets of skills and processes: “outside-in” and “inside-out”. outside-in processes are important for deriving meaning from print and in­ volve world knowledge, semantic knowledge and knowledge of the written context. inside-out processes are those which enable children to translate print into jsounds and sounds into print, e.g. letter knowledge and phonological processing skills. inside-out skills are important for decoding and encoding written language, while outside-in skills are essential for deriving meaning from what is read. essentially, prior to developing conventional liter­ acy children acquire an orientation to print and how it functions; knowledge about letters and sounds and how print maps onto speech; and knowledge o f the structure o f written language and the ways in which it differs from oral language. with reference to the classification systems for emergent literacy, an experimental protocol called the emergent literacy and language assessment protocol (ella) was developed for local use (willenberg, 2004). the aim o f this paper is to docu­ ment the pilot testing of the protocol and to describe the emergent literacy competencies o f the children from historically disadvan­ taged communities on the cape flats in the western cape prov­ ince. research question/objectives the aim o f the research was (1) to pilot test the ella and (2) to examine and describe the emergent literacy competencies o f the children prior to commencing grade 1. methodology participants the participants in the study were recruited from five schools in the following historically disadvantaged coloured1 communities on the cape flats: kensington, silvertown, grassy park and mitchell’s plain. no formal selection criteria were employed in identifying schools. classroom teachers assisted with recruiting the participants. the children considered eligible for the study were those who reached their sixth birthday during the calendar year o f the data collection, since 6 years was the official age for admission to grade r at the time. in addition, children were required to be english speaking. the latter criterion was applied because the protocol was only available in english, and also because o f the increased demand for english as a language o f instruction on the cape flats. the medium o f instruction in all the classrooms was english and none o f the schools had an afrikaans-medium grade r class due to heavy demand by parents for english as a medium o f instruction. children from an afrikaans background who had limited ability to communicate in english were excluded because they would be disadvantaged by being tested in english. african children from xhosa-speaking families were also excluded because they did not share similar linguistic or socio-cultural backgrounds with the coloured children. furthermore, their minority status in the participating schools meant that there would not be a large enough number o f children from african, xhosa-speaking backgrounds to include race and language background as variables in the analysis. approximately 150 recruitment letters and consent forms were distributed, but after non-returns and refusals, the final sample included 101 children (47 boys, 54 girls) ranging from 5 years 7 months to 6 years 10 months, with a mean age o f 6 years 2 months. since the home and school contexts o f the children exert an important influence on their literacy development, a brief overview o f these contexts is appropriate here. the fam­ ily socio-economic backgrounds o f the children were mainly working-class and lower middle class. ten point nine per cent (10.9%) o f families had a monthly income o f less than r3000 and 35.7% had an income between r3000 and r6999. the average parents in the study both had some high school educa­ tion and every parent had at least some primary schooling. thirty-one per cent o f both the mothers and fathers had com­ pleted secondary school. approximately half o f the parents were not first language speakers o f english: 58% o f the moth­ ers and 43% o f the fathers had afrikaans as the primary lan­ guage in their own families o f origin. in homes where parents were first language speakers o f afrikaans the typical practice was for adults to converse with each other in afrikaans but speak english to the children. at school, the children were all enrolled in english-medium classrooms ranging in size from 25 to 44 learners per classroom. classroom observations revealed a pre-eminence o f gross and fine motor activities and perceptual activities, but limited opportunities for rich engagement with language and literacy. although all classroom routines included a daily story time, children’s exposure to good quality books in a vari­ ety o f genres was extremely limited, as were opportunities to engage in extended discourse around a single topic or to learn new vocabulary. much o f the teacher talk involved attempts to control the children’s behaviour and provide instructions for classroom activities and procedures and little discussion was observed. procedures the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 22 ingrid w illenberg the ella comprises ten sub-tests covering three areas o f emergent literacy: (a) orientation to print skills; (b) knowledge o f speech-print relationships, and (c) language (see willenberg, 2004 for a complete description o f the admini­ stration and scoring procedures). an overview o f the sub-tests is presented in table 1. the ella sub-tests include researcher-developed measures, adapta­ tions o f measures use by other researchers, and a standardized test. while the aim was to make the ella comprehensive, it could not be exhaustive due to time and resource constraints. the protocol was administered during the last four months o f the school year. the assessments were conducted with individ­ ual children by a coloured female researcher in a quiet venue on the school premises. administration of the complete protocol took approximately 40 minutes, but to avoid challenging the children’s ability to concentrate, it was administered over two sessions lasting 20 minutes each. the administration o f the sub-tests is described briefly below. recognition o f environmental print each child was presented with several locally familiar logos and signs associated with food products, supermarket chains, a department store, a clothing store, a book store, a restaurant, popular fast food outlets, petrol sta­ tions, and telephone service providers. clay’s concepts about print test the original concepts about print test (clay, 1979) was administered. using the book, follow me, moon (clay, 2000) as the stimulus, each child was required to demonstrate concepts such as front versus back o f book, print direction and orientation, and vocabulary such as page, letter, word and read. letter naming each child was asked to describe the contents of a chart of upper and lower case alphabet letters to determine whether s/he was able to identify the print as letters or abcs, distinct from numbers. the next instruction was: “show me any letters you know and tell me their names”. sounds in words the child was asked to identify from a group of three words, two words with the same initial or final sound (see appendix a for stimuli). pict a b le 1: sub-tests o f the em ergent l iteracy a ssessm ent (ella ) and the c orre­ sponding d om ains o f e m ergent l iteracy ella measure c onstructs | source orientation to print environmental print recognition of environ­ mental print researcher-developed concepts about print writing and spelling knowledge o f print con­ cepts concepts about print; emergent writing; invented spelling; phono­ logical awareness clay (1979) adapted from bear, templeton, invernizzi, & johnston (2000) know ledge o f print-speech relationships letter naming alphabet knowledge researcher-developed sounds in words phonological awareness mason & stewart (1989) rhyme recognition phonological awareness; rhyme recognition ability researcher-developed, based on the oddities task by bryant and bradley (1978, cited by bradley, 1990) rhyme production phonological awareness; rhyme production ability researcher-developed language peabody picture vocabulary test (ppvt) word definitions fictional narrative receptive vocabulary definitional skill narrative production ability dunn & dunn (1997) adapted from the wechsler intelli­ gence scale for children (wisc r)(wechsler, 1974) snow et al. (1995) die suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 ture cues were provided to avoid taxing auditory memory. for example, the child was presented with a picture card depicting the words cat, ball and bag. the examiner said each word, while pointing to the corresponding picture and asked: “show me two that begin with the same sound”. rhyme recognition and production assessment of rhyming skill was modeled on bryant and bradley’s (bradley, 1990) oddities task, where children were asked to identify the word in each group that did not rhyme with the rest. on the rhyme recognition sub-test, the child was presented with a card containing three pic­ tures, for example, cat, hat and ring. the examiner said the words and pointed to the pictures. the child was then requested to point to the pictures representing the two words that sound "almost the same". training for this task included the use of three sets of rhyming pairs to illustrate the concept of rhyming words. on the rhyme production sub­ test, 5 o f the 10 items in the rhyme recognition task were used. a rhyming pair was said aloud and the child was requested to produce another word that "sounds like" the previous two. (see appen­ dix b for stimuli) emergent writing and spelling the children’s ability to produce invented spelling was assessed using the first two sections o f the primary spelling inventory (bear, in vemizzi, templeton & johnston, 2000). each child was asked to attempt to write the following words: fat, pen, dig, mop, and rope. if they were able to produce correct or invented spellings they were encouraged to try a few harder words: wait, check, slum, stink, shine. while it was expected that many children would not be able to produce invented spellings, the task nevertheless consti­ tuted an attempt to tap their conceptualization of what it means to write. in addition to the spelling inventory, children were also asked to write their name and any words they knew. receptive vocabulary ; the peabody picture vocabulary | test (ppvt iii-b) (dunn & dunn, 1997), a standard­ ised, norm-referenced test o f receptive vocabulary was administered and scored according to the guidelines prescribed by the authors o f the test. although the use o f this test was not ideal, it was included due to the absence o f locally standardised measures. the tests items were scrutinised care­ fully and found not to include americanisms. however, due to the profusion o f american televi­ sion programmes and films available locally, the use o f americanisms in local parlance has in­ creased dramatically during the past decade, which means that many words considered to be ameri­ canisms are likely to be understood and used by local children. in addition, caution was exercised in interpreting the scores obtained. thus, while the norms are not directly applicable in local contexts, the test nevertheless enables approximate compari­ sons with the norming sample, but more imporr ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) foundations for literacy: e m ergent literacy c om petencies o f g rade r l earners on the cape flats 23 tantly it permits comparisons within the research sample and also allows for tracking of changes in the performance of indi­ vidual children over time. fictional narrative the prompt for this task was the bear story developed by snow and colleagues (snow, tabors, nicholson, & kurland, 1995). the child was presented with three pictures bound to form a book, with the following prompt: “this book has p ic ­ tures but no words. i want you to look at the pictures and fig ­ ure out the story they tell. when you have finished i would like you to help me write some words to go with the pictures. you tell me what the story is about and i will write it down.” all narratives were audio-recorded, transcribed and then coded according to the conventions o f the chat (codes for the hu­ man analysis o f transcripts) transcription system (macwhinney & snow, 1995). the narratives were coded for story structure features, content, written discourse features and key microlinguistic features associated with narratives. word definitions following snow et al. (1995), the ability to produce word definitions was measured using the word definitions sub­ test o f the weschler intelligence scale for children (wisc-r) (wechsler, 1974). it required the definition of 13 familiar nouns {alphabet, bicycle, bird, clock, diamond, donkey, flower, foot, hat, knife, nail, thief and umbrella). the task was introduced with a practice item as follows: “here's a thinking game about words. when i say a word, i want you to tell me what it means. let’s try one example. the word is truck. what's a truck?” the child’s response was then elaborated by saying: “yes, a truck is something we ride in, and we can carry things in it.” if the child attempted to give a nonverbal response, the examiner said: “try to use words to explain what you mean” or ‘tell about what it looks like or what it is used for”. the task was audio-recorded and all responses were transcribed and coded in chat format (macwhinney & snow, 1995). instead o f using the wisc-r scoring guidelines, the responses were coded qualitatively coded for structure and content., analyses the word definition and fictional narrative data were first ana­ lysed using the computerized language analysis (clan) pro­ gramme developed at carnegie mellon university (see macwhinney & snow, 1995 or http://childes.cmu.edu/ for de­ tails). the clan programme generated the frequencies for each o f the codes in the word definition and narrative data, which were then entered into a data file using the statistical package for social sciences (spss) programme. descriptive statistics, correlations and reliability coefficients for nine sub­ tests (the emergent writing and spelling sub-test was ex­ cluded) were computed using spss. the distributions of the scores for each sub-test were examined and the kolmogarov smimov z test for normality was conducted. ethical considerations the research was approved by the institutional review board o f harvard university. recruitment letters explaining the pur­ pose of the study were sent to all parents. the details o f the commitment required were fully explained. all parents were required to provide written consent. both parents and children were informed o f their right to withdraw from the study at any time or to refuse to answer certain questions or to participate in specific activities. they were assured that data would be kept confidential and that all possible steps to protect the anonymity would be taken. there were no risks or material benefits in­ volved in participating in the research. all children were given a small gift and a certificate of participation at the end o f the study. findings emergent literacy competencies the descriptive statistics for nine of the ten sub-tests are pre­ sented in table 2. t a b le 2: d escriptive statistics for the literacy o utcom e m easures ( n = 101) mean so max, possible score m o n as % of max. score mfn.& max. s e w s environmental print 21.36 7.8 54 39.6 7, 42 concepts about print 7.46 3.4 24 31.0 1, 16 letter naming 7.32 8.1 26 28.1 0, 26 sounds in words 7.28 2.47 10 72.8 0, 10 rhyme recognition 6.68 2.38 10 66.8 0, 10 rhyme production 3.11 3.82 10 31.1 0, 10 ppvt-standard score 85.3 10.9 n/a n/a 60, 11 word definitions 33.6 11.1 n/a n/a 0, 65 fictional narrative 5.19 3.8 n/a n/a 0, 22 note. for the ppvt, n = 99 environmental print the mean score for this sub-test was 21.4 out of a possi­ ble 54, while the maximum score obtained was 42. fifty per cent o f the children scored 20 or fewer points. only seven of the 27 test items were recognized correctly by more than 50% of the children. evaluating performance on a test of environmental print recognition is challenging because performance is largely context dependent. the ability to recognize specific logos de­ pends largely on previous exposure, which could vary greatly across children. since each o f the children were able to recog­ nize at least some logos, this suggests that failure to recognize logos was due to lack of familiarity with the logo rather than a failure to attend to environmental print. further investigation regarding the appropriate logos used for measuring environ­ mental print recognition is needed. in addition, since environ­ mental print is context-specific, the application o f any one set of logos would only be appropriate for a limited range of contexts. concepts about print the mean score was 7.5 out of a possible 24 and the highest score obtained was 16. ninety per cent of participants scored 11 or fewer. more than 70% o f the children were able to identify the front o f a book, could tell that the story is in the print not the pictures, and knew that the left page is read before the right. seventy-two per cent grasped the concept of a letter, whereas only 18% displayed an understanding of the concept of a word. fewer than 50% o f children demonstrated a return sweep to the left when pretending to read, were able to identify the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://childes.cmu.edu/ 24 ingrid w illenberg the first and last letters o f a word, recognised when the print was upside down, and were able to match upper and lowercase letters. not surprisingly, none o f the children were able to de­ tect changes in letter, word or line order, since few were able to read conventionally. letter naming the mean number o f letters recognized by the children was seven. thirty-four per cent of the children did not name any letters, while a further 48% were able to recognize between one and thirteen letters. only 3% knew all the letters o f the al­ phabet. since systematic teaching of the alphabet is generally not part o f the grade r curriculum, the performance of the chil­ dren largely reflects informal learning and the influence of pa­ rental stimulation and high levels o f letter recognition are not necessarily expected. phonological awareness on the sounds in words sub-test, the average score was 7.5 out o f 10. closer examination o f the scores identified that performance on identification o f initial sounds was slightly better than for final sounds. thus, the children found it easier to identify that fish and fo o t had the same initial sound, but had more difficulty recognising that bat and cat had the same final sound. fifty-seven per cent o f the children scored the maximum on the initial sound recognition items, whereas only 23% scored the maximum on the final sounds recognition items, suggesting that initial sounds were more salient for the chil­ dren. the average score on the rhyme recognition sub-test was 6.7 out o f 10. the rhyme production subtest proved more challenging, with the average score being 3.1 and 50% of the children scoring zero. the children therefore found it relatively easy to identify that cat and hat rhyme but encountered diffi­ culty when asked to generate words that rhyme with cat. to counteract the effects o f vocabulary limitations on performance, the children were also credited for producing nonsense words. thus a limited vocabulary need not have been an impediment to good performance. however, poor vocabulary may have been a contributing factor to poor performance for children whose strategy for approaching the task involved a combination of phonology and semantics, rather than a purely phonological one. these phonological awareness tasks seemed to pose diffi­ culty for many children, who appeared to be unfamiliar with the task requirements. this was confirmed by classroom observa­ tions, which identified no specific focus on phonological awareness. thus, the difficulties may reflect a lack o f exposure to phonological awareness tasks rather than actual deficits. emergent writing and spelling all but one o f the children attempted writing their names: eight children produced approximate spellings and 92 were able to spell their names correctly. when asked to write anything other than their names, most children responded by saying that they could not write. only 28% o f the children at­ tempted to write the target words in the spelling task. because so few children attempted invented spelling, it was not feasible to use quantitative scoring. receptive vocabulary. on the ppvt iii-b the mean raw score was 67.3, which yields an age equivalent o f 5 years, 2 months, whereas the mean age o f the sample was 6 years, 3 months. the mean stan­ dard score obtained was 85.3. this standardised test has a mean o f 100 and a standard deviation o f 15. the average performance o f these participants is therefore approximately one standard die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 deviation below the mean o f the us english-speaking normative sample. standard scores ranged from 60, which is nearly three standard deviations below the normative mean, to 111, which is two-thirds o f a standard deviation above the normative mean. the lack o f south african normative data for the ppvt and the obvious problems with using foreign norms, means that the ppvt standard score results cannot be interpreted uncritically. nevertheless, they offer some indication o f the performance o f the children in comparison to other groups and can be used in comparing the children to one another or in tracking changes in individual performance over time. fictional narratives holistic examination found that narratives ranged from minimalist narratives, with four or fewer propositions, to rather lengthy ones. the narratives typically included a strong empha­ sis on what sulzby (1985) referred to as “following the action”, with few story structure, written discourse and micro-linguistic features. the absence o f story structure and written discourse features suggests limited exposure to written narrative. further­ more, the dearth o f micro-linguistic features and the preponder­ ance o f narrative events suggest a lack o f sophistication in nar­ rating. the narratives produced strongly resembled the chil­ dren’s everyday communicative use of language, characterised by contextualised use o f language relying on listener back­ ground knowledge and shared physical context between speaker and listener. word definitions the children produced mainly informal definitions, which suggests that either they were not clear of the task re­ quirements or they were not familiar with the definitional genre or both. however, since the ability to produce formal word defi­ nitions is generally regarded as a product o f explicit teaching in formal school settings (litowitz, 1977; snow, cancino, gon­ zalez & shriberg, 1989), the performance of the children may be appropriate given their age and lack o f formal schooling. the content o f the definitions produced tended to be personalised and linked to actual experience rather than being generalized and hypothetical (litowitz, 1977), which are regarded as the key features o f good definitions. for example, a typical defini­ tion o f the word bicycle would be “i ride my bicycle to the shop”, rather than “a bicycle is something that you ride on”. the children’s tendency to provide insufficient information, to use vague, non-specific words, and to gesture reflected a general difficulty in producing decontextualised language. reliability of the data the cronbach’s alpha coefficient for nine sub-tests was .74, which indicates a high degree o f internal consistency within the protocol. table 3 presents the statistics reflecting the contribu­ tion o f individual sub-tests to the reliability of the protocol. the sub-tests which contribute most to the internal con­ sistency o f the protocol are letter naming and ppvt, followed by environmental print and concepts about print. these are also the sub-tests which had higher internal consistency/by contrast, rhyme recognition and sounds in words, the sub-tests with the lowest internal consistency, contributed least to the internal con­ sistency o f the protocol. the cronbach’s alpha coefficients for individual sub-tests ranged from .71 to .96, suggesting that high proportions o f variance within the scores o f participants are due to true score variance rather than error variance. furthermore, the coefficients demonstrate that the participants’ performance on individual items in each o f these sub-tests was congruent r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) f oundations for literacy: e m ergent literacy c om petencies o f g rade r l earners on the cape flats 25 t a b le 3: individual c ronbach’s a lpha, item to t otal c orrelation and e ffect on the o verall c ron­ b ach ’s a lpha c oefficient o f individual sub-tests o f the e ll a sub-test alpha (bat* total correla­ tion hem deleted environmental print .79 .46 .74 concepts about print .80 .69 .73 letter naming .96 .66 .70 sounds in words .77 .44 .76 rhyme recognition .71 .28 .77 rhyme production .88 .40 .75 ppvt standard score n/a .63 .71 word definitions n/a .53 .74 fictional narrative n/a .38 .75 alpha for the 9-subtests .76 with their overall performance the sub-test. the high cronbach’s alpha coefficients also indicate that sub-tests scores are not unduly influenced by performance on a few items. twenty per cent o f the narratives and word definitions were coded by an independent rater and inter-rater reliability coefficients (cohen’s kappa) o f .83 and .86 were ob­ tained, which attests to the reliability o f the coding systems for these sub-tests. the kolmogarov-smimov z test for normality showed that scores on the ppvt, environmental print, concepts about print, and word definition sub-tests were normally distributed. this confirms that the sub-tests included an adequate combination of easy, medium and difficult items. however, scores for rhyme production and letter naming positively skewed, whereas scores for sounds in words were negatively skewed. floor ef­ fects were observed for rhyme production and letter recognition, with 50.5% and 33.7% o f participants respectively attaining scores o f zero. the skewed distributions of the above sub-tests suggests that the items did not have sufficient discriminatory power and included either too many easy or difficult items. although the fictional narrative scores were also positively skewed (i.e. toward lower values), because the narrative score is a summary score o f a qualitative analysis o f the data rather than a quantitatively scored test, the skewed distribution does not reflect dis­ criminatory power. instead the skewed distri­ bution reflects the infrequent occurrence of narrative and discourse features that reflect children’s awareness o f the features o f written language. the rhyme recognition scores were slightly asymmetrically distributed (the p-value associated with the kolmogarov smimov z statistic was equal1 to .045), which means that its discriminatory value was bor­ derline. correlations across sub-tests pearson correlation coefficients were calculated and from the correlation matrix in table 4, it can be seen that positive inter-correlations exist among all the emergent literacy outcome variables. these correlations range from .05 to .66, with a mean of .32. a surprising correlational relationship was the weak one between rhyme recognition and rhyme production (r = .36, p < .01), when a stronger one would have been anticipated. however this is indicative of the complexity o f rhyme pro­ duction and suggests that there are other factors beyond the ability to recognize rhymes that explain rhyme production. essentially the literacy outcome variables displayed mild to moderate positive inter-correlations, which suggests that these skills constitute a coherent package. however, the correlations between variables are not so high as to suggest that they are measuring the same constructs. discussion the ella protocol although this protocol is still an experimental one, the high reliability coefficients suggest that it has potential as a comprehensive measure o f emergent literacy and language development. furthermore, the absence of floor or ceiling effects on most sub-tests indicates that for the most part these tests included a suitable combination o f easy, medium and difficult items. in addition, content validity o f the protocol can be argued on the basis that it was developed with reference to theoretical clas­ sifications systems for emergent literacy. despite the floor effects on the letter recognition sub-test, it is a useful measure to include in view of the predictive value o f letter recognition for literacy achievement (muter, hulme, snowling & taylor, 1998). the preponderance o f high scores reflected in the negatively skewed distribution o f the sounds in words sub-test suggests that there are too many easy items on the test, whereas the floor effects on rhyme production task suggest that this task was too difficult for most children. these findings suggest that these tasks might not be the most best indicators o f phonological awareness for this group. it is further speculated that the borderline reliability coefficients for rhyme recognition and the low correlation with rhyme production may be as­ cribed to children guessing correct answers. a measure of rhyming ability would nevertheless serve as an important indicator of general phonological awareness, whereas substitution o f the sounds in words sub-test with a more challenging pho­ neme awareness task such as phoneme isolation (e.g. what is the first sound you hear in the word ‘cat'?) or segmentation (e.g. clap once for each sound you can hear in the word ‘cat’) would tap into a higher level o f phonological awareness.11 this would be particularly important for identifying children who exhibit general phonological awareness but not phoneme awareness. attempts to develop a formal scoring system for emergent writing and spelling proved difficult due to the fact that only 28.2% o f the children attempted to spell. however, since it is nevertheless t a b le 4: c orrelation m atrix for e m ergent literacy o utcom es (n= 98 -101) sub-test 1 2 3 4 s 6 ? 8 9 1 letter naming 1.0 2 sounds in words .44 *** 1.0 3 rhyme recognition .12 .53 ** 1.0 4 rhyme production .3 4 ** .39 ** .36 ** 1.0 5 concepts about print .66 *** .38 ** .29 ** .33 ** 1.0 6 environmental print .5 4 ** .26 ** .04 .06 .43 ** 1.0 7 ppvt std .53 ** .29 ** .2 0 * .26 ** .55 ** .39 ** 1.0 8 word definitions .39 ** .33 ** .2 5 * .33 ** .33 ** .29 ** .42 ** 1.0 9 fictional narrative .25 * .10 .16 .2 5 * .35 ** . 2 0 .3 4 ** . 1 8 1.0 *p >0.05 ** p < 0.01 * * * p < 0.001 ~ marginal significance (.1 0 > p > .05) the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 26 ingrid w illenben important to obtain some indication o f a child’s writing ability, it is suggested that an informal writing sample be obtained dur­ ing assessment. it is further suggested that the measurement o f phono­ logical awareness be adapted to include higher level phonologi­ cal awareness skills and that the protocol should be refined by conducting an item analysis, followed by substitutions for prob­ lematic items. further pilot testing of the instrument is then recommended. the children’s literacy competencies the performance o f the children on the ella shows that these children from historically disadvantaged backgrounds do in­ deed possess a reasonable repertoire o f literacy skills and knowledge as they prepare to enter first grade. the children could recognize environmental print and understand basic con­ cepts about print. most children were able to identify words with the same onset or rime, but had considerable difficulty generating words with similar rimes. they were only able to recognize and name a small number o f letters o f the alphabet, which is understandable given that the teaching o f the alphabet was not part o f the curriculum. the difficulties in the areas o f phonological awareness and letter knowledge may be related to the fact that these skills are not developed in the course of their daily school experiences. whereas attention to environmental print and concepts about print can develop as secondary conse­ quences in the context o f participating in activities other than literacy or by observing others, letter knowledge and phono­ logical awareness require much more explicit and structured exposure. all except one child were able to write their own name and a small percentage was able to spell phonetically regular words. assessment o f their discourse skills identified that in general, they had difficulty producing language with a high degree o f lexical and syntactic explicitness. they either assumed too much background knowledge on the part o f a lis­ tener or were simply not able to provide sufficient background to the listener. the children’s emergent literacy competency profiles suggest that they possess adequate skills to support acquisition o f print decoding skills necessary for fluent reading. however, they display weaknesses in the decontextualised language skills that have been found to support later reading comprehension (tabors, snow & dickinson, 2001). this suggests that while they are likely to have adequate skills for decoding print, which is largely the focus o f reading instruction in grade 1, as the in­ structional focus shifts from decoding to reading comprehen­ sion, if their decontextualised language skills have not been developed further, it is likely that their reading comprehension may be compromised. on both the word definitions and fictional narrative tasks the children displayed a tendency to provide insufficient information, to use vague, non-specific words, and to use ges­ ture. their limited use o f lexically and syntactically explicit language suggests that they have not developed an awareness o f differences between oral and written language, perhaps due to limited exposure to written narrative. while it can be argued that the children are more exposed to the oral storytelling tradi­ tion, interviews with parents revealed that parents o f children in these communities are more likely to read to their children than to engage in oral storytelling. thus, it seems that the problem for these children is not lack o f but rather insufficient exposure to written narrative. both the word definitions and narrative production tasks revealed the children’s difficulty in producing language that is lexically and syntactically explicit and not reli­ ant on listener background knowledge or contextual cues. although international research has shown that the acqui­ sition o f decontextualised language skill presents a challenge for all children (hemphill & snow, 1996), the challenge may be even greater for these children, many o f whose parents do not have english as a first language. although the children had rea­ sonable exposure to print, their opportunities for language stimulation in particular were limited in both the home and school contexts. as indicated earlier, many o f the parents were not first language speakers o f english and approximately half had had afrikaans as the primary language in their own families o f origin. however, even the children who were raised in homes where english was the primary or only language spoken, were not being exposed to standard south african english linguistic models. similarly, the children had restricted opportunities for exposure to rich language and literacy experiences in their class­ room contexts. although both the home and school contexts of the majority o f these children do offer opportunities for engag­ ing with literacy artefacts and activities, these opportunities tend to be geared towards developing print awareness rather than fostering the decontextualised language skills which support literacy. although the average findings are the main focus of this description o f the children’s literacy skills, there was variation in performance. the top performers were able to recognise all the letters o f the alphabet, spell a few sight words correctly and produce invented spellings closely approximating the target word. by contrast, one o f the lowest performers was unable to spell his name correctly and was only able to recognise two let­ ters o f the alphabet. although it would not be appropriate to establish norms for emergent literacy skills, assessment at grade r level or upon commencing grade 1 would be useful for plan­ ning instructional activities. in addition, benchmarks could also be identified to assist in identifying children with limited liter­ acy skills and concepts who would require an orientation to lit­ eracy prior to formal reading instruction. the average skill pro­ file of the children suggests that an optimal grade 1 instructional environment for them should include a strong focus on develop­ ing letter knowledge and phonological awareness skills and ex­ tensive opportunities for developing decontextualised language skill. to develop the decontextualised language skills necessary for children’s encounters with written text, teachers need to create scaffolded conversational interactions with children that entail recounting past events, planning future events, providing explanations, and engaging in pretend play which involves ver­ balizing roles and actions (dickinson, 1991). the key features o f scaffolded conversational interactions should be multiple utterances and/or multiple speaker turns pertaining to the same topic and conversational topics about phenomena or events out­ side o f the current classroom communication setting (dickinson, 1991). recent findings have shown that kindergarten children displayed better print-related concepts and decontextualised language skills when their classroom conversations with teach­ ers included “personal narratives, talk about past and present events, and discussion o f ideas” (dickinson, 2001, p. 251). al­ though the national curriculum statement (department o f edu­ cation, 2002) emphasises listening, speaking, reading and writ­ ing throughout the foundation phase, it is not clear to what ex­ tent this is practised in classrooms. it appears, that teachers on the ground do not have fully developed understandings of the importance of language in literacy development and are often not able to create classroom environments that provide rich lan­ guage stimulation for learners. in the western cape for exam­ ple, only 12% o f ecd practitioners have university training in die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) foundations for literacy: em ergent literacy c om petencies o f g rade r l earners on the cape flats 27 early childhood, 38% have informal training and 27% have no training (department o f education, 2 0 0 1 ). it is critical that the role o f language in liter­ acy development be emphasised in pre-service teacher training as well as continuing professional development for teachers. speech-language thera­ pists working within the education department have the potential to make an important contribution with regard to training in-service teachers to create lan­ guage-rich classroom environments, yet they are a resource that is not being sufficiently utilised. since the sample for the research was pur posively selected, no claims about the representative­ ness o f either the sample or the findings can be made. however, it can be argued that these children and their particular school contexts are mostly simi­ lar to other children and school contexts in their neighbourhoods. thus, the findings could give a reasonably accurate indication of the emergent liter­ acy skills o f learners in similar historically coloured urban neighbourhoods. although the emergent liter­ acy competencies displayed by the children showed promise in terms o f literacy development, these chil­ dren were not from the most poor families and com­ munities in the country, nor were the schools among the least resourced. it is therefore not unreasonable to speculate that the picture in more impoverished con­ texts would reflect even greater difficulties with emergent literacy competencies. in the light of the extensive cultural diversity and the vast disparities in opportunities and resources, it would be important to study the literacy competencies in other south afri­ can socio-cultural contexts. moreover, since the ma­ jority o f early childhood programmes in south af­ rica are not school-based and the quality o f school based early childhood programmes is generally bet­ ter than community-based programmes (department o f education, 2001), this implies that most children o f grade r age experience literacy development con­ texts that are less favourable than those experienced by these participants. thus, most children entering grade 1 in south africa are likely to commence for­ mal schooling with a more limited repertoire o f skills than those displayed by the participants in this study. although there are policies such as the national cur­ riculum and the national literacy strategy in place, it is imperative that a concerted effort be made to ensure that these are effectively implemented. unless children are provided with the resources and oppor­ tunities to acquire literacy, they will remain at the threshold o f the doors o f learning. acknowledgments this research was conducted as part of my doctoral studies, which were generously funded by the ful bright south africa programme, the spencer foun­ dation, and the harvard university graduate school o f education. partial funding for the data collection was also provided by the university of the western cape. the contributions of {catherine snow and lowry hemphill to my intellectual development in general and this research in particular are gratefully acknowledged. finally, thanks to seppo tuomi for his helpful comments on earlier drafts of this article. references b arton, d. 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(1990). emergent literacy assessment for instructional use in kindeigar ten. in l.m. m orrow and j.k. smith (eds.), assessm ent f o r instruction in early literacy (pp. 155 175). englewood cliff, n.j.: prentice-hall. m uter, v ., h ulm e, c., snow ling, m. & t aylor, s. (1998). s egm entation, no t rhym ing, predicts early progress in learning to read. j o u rn a l o f e xp erim en ta l c h ild psychology, 7 1 , 3 27. snow , c .e, c ancino, h ., g onzalez, p. & shriberg, e. (1989). g iving form al definitions: a n oral language correlate o f school literacy. in d. b loom e (ed.), c lassroom s a n d literacy (pp. 233 249). n ew jersey: a blex. snow , c .e., t abors, p.o ., n icholson, p. & k urland, b. 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(2001). h o m es and school to­ gether: s upporting language and literacy developm ent. in d. d ickinson and p. tabors (eds.), b eg in n in g literacy w ith language (pp. 313 334). b alti­ more: brookes. teale, w .h. & sulzby, e. (1986). introduction: e m ergent literacy as a p erspec­ tive for exam ining ho w children becom e w riters and readers. in w. teale and e. sulzby (eds.), e m erg en t literacy: w riting a n d re a d in g (pp. vii xxv). n ew jersey: a blex. w echsler, d. (1974). w echsler in tellig en c e s ca le f o r c hildren-r evised. new y ork: the p sychological c orporation. w estern c ape e ducation d e p a rtm en t (2007). g rade 3 literacy a n d num eracy results. m edia release. r e trie v e d sep tem b er 18, 2 0 0 7 fr o m h ttp .// w ced.w cape.gov.za/com m s/press/2007/49_gr32006.htm l w hitehurst, g. & l onigan, c. (1998). c hild developm ent and em erg en t literacy. c h ild d evelopm ent, 69 (3), 848-872. w illenberg, i.a. (2004). g etting se t fo r re a d in g in the ra in b o w nation: e m er­ g e n t literacy sk ills a n d literacy environm ents o f kindergarteners in south a frica. u npublished doctoral dissertation. h arvard u niversity, c am bridge, m assachusetts, usa. appendix a stimuli for sound in words word initial sounds word final sounds cat ball bag fan bat cat bath tie boy car fish star man cow milk snake cake rain sheep road ring keys trees leaf fish dog foot wall ball bat appendix b stimuli for rhyme recognition and production rhyme recognition rhyme production cat hat ring cat hat moon spoon dog pet wet cot cap tap sun gun cone cake bone glad mad sun bin gun map gap train rain rake bat coat boat clock sun sock wall ball bird duck truck cup note i it is acknow ledged th at the use o f racial labels is a contentious issue. h ow ever, since th e developm ental contexts o f th e participants have been inexorably shaped b y apartheid, it is considered im portant to identify this group by th eir racial designation. / ii c ontrary to th e earlier evidence o f b radley and b ryant (1983) and g osw am i and b ryant (1990) for th e p redictive valu e o f rhym ing ability for reading, m uter et al. (1998) found th at segm entation, not rh y m in g ability predicted reading during the first year o f schooling. h ow ever, rhym ing ability w as found to be a p redictor o f spelling ability in th e second year o f schooling. / d ie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) c o n t i n u o u s v e r s u s p u l s e d p u r e t o n e a u d i o m e t r y in a g r o u p o f s c h o o l a g e d c h i l d r e n c a th e rin e v a n d ijk * a n d n a e e m a o sm an d e p a r tm e n t o f c o m m u n ic a tio n p athology, u n iversity o f p retoria, s o uth africa a bstract p u re -to n e te s tin g is th e p rim a ry a u d io lo g ic a l te s t p r o c e d u r e fo rth e d iffe r e n tia ld ia g n o s is o f h e a rin g lossan d h e a rin g disor d e rs in s c h o o l-a g e d ch ild re n . n o re s e a rc h is c u rre n tly a v a ila b le in te rn a tio n a lly fo rc h ild re n 's re s p o n s e s to c o n tin u o u s versus p ulse d p u re -to n e s . t h e a im o f this e x p lo ra to ry in v e s tig a tio n w as to c o m p a re th e p e rfo rm a n c e o f a g ro u p o f sch o o l-a g e d ch ild re n o n c o n tin u o u s versus p ulsed p u r e -to n e a u d io m e try .t h e aim s w e re to d e te r m in e w h e th e r a th re s h o ld d iffe re n c e existe d b e tw e e n c o n tin u o u s versus p ulse d p u re -to n e s a n d to record w h e th e r a listen er p re fe re n c e existed b e tw e e n con­ tin u o u s versus p u lse d to n e s fo r th e fr e q u e n c y ra n g e o f 125 to 8 0 0 0 h z. e ig h te e n c h ild re n (3 6 ears) a g e d b e tw e e n 8 -1 2 years, p a r tic ip a te d in a h e a rin g e v a lu a tio n as w e ll as in a b r ie f th r e e -q u e s tio n in te rv ie w . d e s c rip tiv e statistics viz. a v e ra g e th re s h o ld , m e a n d iffe r e n c e a n d s ta n d a rd d e v ia tio n o fth re s h o ld s w e re u s e d to a n a ly s e d a ta .l is te n e rs 'p e rc e iv e d p re fe re n c e s w e re c a lc u la te d in p e rc e n ta g e s a n d re a s o n s fo r p re fe r rin g o n e s ig n a lo v e ra n o th e r w a s a n a ly s e d q u a lita tiv e ly .a lth o u g h th e a u to m a tic a lly p u ls e d to n e th r e s h o ld (a v e r a g e d a c r o s s t h e fr e q u e n c ie s t e s te d )w a s lo w e r th a n f o r th e c o n tin u o u s to n e ,th e d iffe re n c e w as o n ly 0.2 db in th e le ft e a r an d 0.5 db in th e rig h t ear. this sm all d iffe re n c e is n o t im p o r ta n t in clinical a p p lic a tio n s fo rw h ic h 5 d b in c re m e n ts a re used in p u r e -to n e a u d io m e tr y .w h e r e a listen er p re fe re n c e w as in d ic a te d , h o w e v e r, th e co n tin u o u s to n e s w e re p re fe rre d o v e r pulse d to n e s b y 5 6 % p e rc e n t o f subjects. t h es e fin d in g s d iffe r fro m sim ilar studies in v o lv in g adults. this re v e a le d th a t ch ild re n m a y y ie ld d iffe re n t p referen ces d u rin g p u r e -to n e te s tin g th a n a d u lts a n d th a t th e s e p referen ces sho u ld b e ta k e n in to co n s id e ra tio n d u rin g te s tin g . k e y w o rd s : a u d io m e try , c o n tin u o u s p u r e -to n e , listen er p re fe re n c e , p u lse d p u re -to n e , p u r e -to n e te s tin g , sc h o o l-a g e d c h ild re n , s tim u lu s signal, th re s h o ld d iffe re n c e . there are two methods o f presentation o f pure-tones, i.e. continuous tones and pulsed tones. pure-tone threshold measurement is a fundamental diagnostic tool in hearing evaluations (digiovanni 8c repka, 2007). pure-tone tests o f hearing, using audiometers,have been in use for nearly one hundred years and are quantifiable elec­ tronic extensions o f the same concepts developed in tuning fork tests (m artin 8c clark, 2 0 0 3 ). i t is the primary audio­ logic test procedure for the differential diagnosis o f hearing loss and hearing disorders in school-aged children (blandy 8c lutman, 2 0 0 5 ).j in addition, pure-tone threshold audi­ ometry has become the standard behavioural procedure for describing auditory sensitivity (margolis 8c saly, 2007). in 1978, the american speech-language-hearing association (a sh a ) developed clinical guidelines referred to as guide­ lines for manual pure-tone audiometry (a sh a , 1978). in these guidelines they recommended the use o f a one to two second sustained tone for threshold determination. this is referred to as a continuous tone. according to an american, survey o f audiometric practices two decades ago, the ma­ jority o f audiologists surveyed, used a manual presentation o f continuous tones (m artin 8c sides, 1985). although the a s h a guidelines (a sh a , 1978) recommend use o f a con­ tinuous tone, a substitution o f pulsed tones is also permitted by a sh a . a pulsed tone can be presented either manu­ ally or can be automatically generated by the audiometer. a manually presented pulsed tone would require the tester to present two consecutive tones with a short quiet interval be­ tween the two tones. this interval should be one second or shorter in duration (a sh a , 1978). studies on children’s performance on and preference for continuous versus pulsed pure-tone audiometry is lacking. a study conducted by burk and w iley (2004) on women aged 19 years to 4 4 years showed that pulsed tones are clearly ad­ vantageous in presenting what is perceived as an easier task. for many adult clients the pulsed tone is perceived as easier to hear at near threshold levels (newby 8c popelka, 1985). o ther published data suggests that using pulsed tones for adults having tinnitus may result in fewer false-positive re­ sponses (30% less than for continuous tones) and therefore may reduce the number o f presentations required to deter­ mine the threshold, resulting in more efficient audiological threshold evaluations (mineau 8c schlauch, 1997). there are selected studies that support the use o f pulsed tones rather than continuous tones in manual threshold au­ diometry for adults (dancer 8c conn, 1983; dancer, ventry 8c h ill, 1976; gardner, 1947; h ochberg 8cw altzm an, 1972; hood, 1955; mineau 8c schlauch, 1997). firstly, in comparauthor contact: department o f communication pathology university o f pretoria 0002 south africa fax: +2712 420 3517 tel: +2712 420 2357 e-mail: catherine. vandijk@up.ac.za th e s o u t h a f r ic a n j o u r n a l o f c o m m u n ic a t io n d iso rd er s, v o l 55 2 0 0 8 29 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:vandijk@up.ac.za c a th er ine v a n d d k a n d n a e e m a o s m a n ison to continuous tones, the use o f pulsed tones has been shown to decrease the number o f false-positives in both nor­ mal-hearing listeners and listeners with sensorineural hear­ ing loss with or without tinnitus (dancer & conn, 1983; dancer et al, 1976; mineau 8c schlauch, 1997). secondly, listeners with normal hearing and those with sensorineural hearing loss and tinnitus preferred pulsed tones to continu­ ous tones as a listening task (gardner, 1947; hochberg 8c waltzman, 1972). the use o f pulsed tones in bekesy audi­ ometry has also provided insight into using pulsed tones in conventional audiometry (jerger, 1960). in threshold ap­ plications o f bekesy audiometry, pulsed tones are typically presented to minimize the effects o f auditory adaptation to a continuous tone (hallpike 8c hood, 1951; jerger, 1960; reger, 1970; silman 8c silverman, 1991; sorensen, 1962). in addition, i f a 200-m illiseconds-on, 200-m illiseconds-off pulsed tone is used for threshold assessment, periodic supra­ threshold presentations o f the test tone acts as a cue for the signal frequency, thereby refreshing the client’s memory for the test stimulus (mineau 8c schlauch, 1997). furthermore, m cc om m ons and hodge (1969) found that the pulsed tones used in bekesy audiometry provide more feedback or cues by which the listener can make a decision regarding the presence o f the signal. the slight preference for pulsed tones in normal-hear ing listeners (burk 8c wiley, 2 0 0 4 ), coupled with previous reports demonstrating the benefits o f using pulsed tones in threshold assessment for listeners with sensorineural hear­ ing loss and tinnitus (hochberg 8c w altzman, 1972; m in e­ au 8c schlauch, 1997), supports the general use o f pulsed tones in audiometry. however, in practice it may seem that not all audiologists use this technique. from personal ob­ servations, south african audiologists often deviate from standard testing procedures and protocols conveyed to them by their undergraduate training institutions. a diversity o f testing techniques and methods are often applied by au­ diologists in practice and may be due to, amongst others, their employer’s personal preferred method o f testing that has been imparted to them. the type o f test signal (con­ tinuous or pulsed) used in pure-tone audiometry may affect the accuracy and reliability o f pure-tone thresholds. some data regarding adults’ responses to continuous and pulsed pure-tone audiometry is available (for example: burk 8c wiley, 2 0 0 4 ). however, similar data is currently unavailable for children’s responses to continuous versus pulsed tones. therefore, this study is necessary to explore i f children may respond differently in their preference to adults. indeed, this study has great relevance given that threshold audiometry by air conduction is a widely applied procedure for obtain­ ing auditory thresholds in children, the validity and vari­ ability o f tonal stimuli presented has not yet been addressed. indeed, the apparent simplicity o f conducting the test often masks the importance o f investigating specific procedures applied in pure-tone audiometry. effective pure-tone test procedures are imperative for the timely and accurate diag­ nosis o f hearing loss in children. hearing loss depending on severity, age o f onset, and a host o f other factors has a mild-to-profound impact on com­ municative functioning (yoshinaga-itano, sedey, coulter 8c m ehl, 1998). the prevalence o f hearing loss in ch ild ren is such that its diagnosis and management necessitates high prioritisation. i t is estimated that in 2 0 0 2 approximately 72 00 0 school-aged children in the united states o f a m er­ ica (u .s.a .) alone fell in the “hearing impairment category” (united states office o f special education programs, 2 0 02). in south africa, a developing context, prevalence o f hearing loss can be expected to be similar or even higher than in the u .s, but to date no statistical data is available for this popu­ lation. school-aged children with undetected hearing loss that have not received early intervention, often experience academic delays. as would be expected, the primary deficit areas for children with hearing loss are in those subjects that are language-based (johnson, benson 8c seaton, 1997). in addition, school-aged children with a hearing loss appear to have increased rates o f grade failures, need for educational assistance, and perceived behavioural issues in the classroom (johnson, benson 8c seaton, 1997). an undetected hear­ ing loss may have a cascading effect in terms o f habilitation. various effects are insurmountable such as economic sta­ tus, education, psychosocial stigma and eventually potential employment opportunities as an adult. fortunately, there is a continued emphasis nationally and internationally on ear­ ly identification and monitoring o f hearing loss. therefore, it is vitally important to obtain optimal thresholds for chil­ dren as these results have direct consequences on identifica­ tion, diagnosis and management o f a hearing loss. early de­ tection followed by appropriate intervention maximises the benefits to the child, family, and society (diefendorf, 2 0 0 2 ; pappas, 1998). part o f the intervention process includes the appropriate fitting o f hearing aids. however, i f optimal and reliable hearing thresholds are not obtained, over or under amplification may occur. although more objective tests have been developed as part o f the test battery to obtain auditory thresholds, one cannot move away from standard pure-tone audiometry (hall, 2 0 0 7 ). electrophysiological tests like a e p (audito­ ry evoked potentials) and e c o c h g (electrocochleography) are used to estimate hearing thresholds. however, these test procedures often require sedation, may have artefact con-' tamination, and are not suitable for all types o f losses, e.g. conductive hearing losses or mild sensori-neural hearing losses (hall, 2 0 0 7 ). electrophysiological tests cannot subj stitute the use o f pure-tone audiometry where reliable be! havioural responses can be obtained to determine frequency ! specific information. d ata regarding the pure-tone testing o f school-aged chil­ dren is o f significant importance as this population is most­ ly evaluated with pure-tone audiometry. school-aged chil­ dren often pose unique challenges to the audiologist during pure-tone testing (johnson, et al, 1997). these ch allen g-, es include assessment o f children with developmental de­ lays in, for example, receptive language, which reduces their comprehension and following o f test instructions resulting in troublesome test behaviour. some children will not toler­ ate earphones or ear inserts for long periods o f time as this makes them uncomfortable. in comparison to adults, chil­ dren have a limited attention span and cannot remain still or concentrate for long periods during testing. this may cause them to become restless and/or uncooperative. false-posi­ tive responses are p rev alen t in this population an d failure 30 | die su id -afr ik a a n se ty d sk r if vir k o m m u n ik a s ie -a f w y k in g s ,v o l . 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) c o n t i n u o u s v e r s u s p u l s e d p u r e t o n e a u d i o m e t r y in a g r o u p o f s c h o o l a g e d c h il d r e n to respond to stimuli close to their hearing thresholds are quite common. in addition, children’s reliability o f respons­ es tends to decrease as the time o f testing increases (jo h n ­ son et al, 1997). therefore, threshold data comparisons for continuous tones and pulsed tones in school-aged children are justified because it may be, for example, that one stimulus tone is perceived as an easier task to respond to, resulting in a shorter testing time. a shorter testing time may address assessment challenges such as reduced attention span and may increase the reliability o f responses. comparisons o f continuous and pulsed pure-tone thresholds may yield findings that indicate better thresholds obtained for one o f these methods. these findings may guide audiologists when deciding which stimulus tone to use when testing children with pure-tone stimuli. a review o f available professional literature has clearly revealed a lack o f data to enable comparisons o f continuous tones and pulsed tones in children using the manual pure tone technique (as recommended by a s h a , 1978). this exploratory investigation aimed to compare threshold data and listener preference for continuous and pulsed tones on a small group o f children. therefore, the main aim o f this study was to compare continuous and pulsed pure-tone audiometry in a group o f school-aged children. the sub­ aims o f the study were: • to determine whether a threshold difference existed between continuous versus pulsed pure-tone audiometry for the frequency range o f 125 h z to 8 000 h z; and • to determine listener preference for continuous ver­ sus pulsed tones for the frequency range o f 125 h z to 8000 hz. method design this exploratory study was mainly quantitative in na­ ture consisting o f pure-tone audiometric testing and a brief, three-question interview. a comparative based study em­ ploying a quasi-exp’erimental design o f research was used as not all variables could be controlled for (struwig 8c stead, 2 0 01). the main aim o f this study was to compare continuous and pulsed pure-tone audiometry in a group o f school-aged children. participants • ethical issues ! e thical clearance was obtained from the departmental research committee o f the university o f pretoria before the investigation was carried out. w ritten informed consent and assent was obtained from the participants and their guard­ ians. participants and their guardians were informed that their participation was voluntary and that they could with­ draw without consequence at any stage during the study. all identifying information was kept confidential and partici­ pants were not subjected to harmful or unjust procedures. participant selection criteria participants were required to respond reliably and had to concentrate for long periods (40 minutes or longer). for this reason, children between the ages o f 8 years to 12 years were selected. i t was felt that children in this age group were more able than younger children to perform these tasks consistently. participants had to present with normal hearing as the presence o f a hearing loss may influence the ability to distinguish between the continuous and pulsed pure-tone test signal. furthermore, most researchers are in agreement that when investigating the benefits o f any audiological test procedure, normative data should be recorded before similar investigations can be conducted on hearing-impaired popu­ lations (hall, 2007). in order to ascertain hearing status, all participants were subjected to a test battery prior to the study. the test battery included otoscopy, tympanometry, reflex testing, oto-acoustic emission screening and comprehensive pure tone bone and air conduction testing. sampling participants were purposefully selected by requesting fi­ nal year students to supply contact details o f family mem­ bers or acquaintances that had children between the ages o f 8 years and 12 years. the participants were expected to visit the h earing c linic at the university o f pretoria and there­ fore only children from the pretoria region were targeted. d escription o f participants eighteen children (36 ears) with normal hearing thresh­ olds for all seven tested frequencies were included. accord­ ing to katz (2002) and m artin and clark (2003) a range o f 0 db to 2 0 db can be regarded as normal hearing for school-aged children. e ig h t o f the participants were male and ten were female. the age distributions were as follows: three were eight years old, one was nine years old, four were ten years old, six were eleven years old and four were twelve years old. apparatus and m aterials apparatus an d m aterial f o r pre-selection o toscopic examinations were conducted using a w elch allyn otoscope. acoustic immittance measures were ob­ tained using a calibrated (according to s a b s 0154-1/2, 0182) tympanometer (g sitym pstar). a scout o to-a cous­ tic emission machine with 2 kh z to 6 kh z (4 db to 6 db for a pass) screening protocol was used to perform oto acoustic emission screening. pure-tone air and bone con­ duction thresholds were obtained using a twin channel di­ agnostic audiometer, the g s i 61. participants were seated in a sound-insulated booth (industrial acoustics com pa­ ny, in c.). calibration is conducted periodically in accord­ ance with american national standards institute (a n si) 1996 specifications and listening checks o f the equipment were performed prior to testing. results were recorded on a standard audiogram. apparatus and material for main study pulsed and continuous hearing thresholds were obtained using the same sound-insulated booth and diagnostic audi­ ometer employed for the pre-selection o f subjects. a n ad­ aptation o f a standard audiogram was used to record the results. the symbol that was used for both ears to indicate continuous hearing threshold level was an outline o f a cir­ cle and a solid circle indicated pulsed hearing thresholds. a brief three-question interview schedule was used after com ­ pletion o f the hearing test to obtain information about lis­ tener preference for the type o f test signal. procedures pure-tones were presented through earphones to assess conduction thresholds. the results o f the air conduc-air t h e s o u t h a fr ic a n j o u r n a l of c o m m u n ic a t io n d iso r d er s, vo l . 55 2 0 0 8 | 31 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) tion tests in both test conditions (continuous and pulsed) were plotted on an audiogram from which the results were compared. the ascending/descending method developed by carhart and jerger (1959) was used to obtain pure-tone thresholds bilaterally at 125 h z, 25 0 h z, 50 0 h z, 1000 hz, 2 0 0 0 h z, 4 0 0 0 h z, and 8000 h z. octave frequencies o f 3000 h z and 6 0 0 0 h z were excluded to reduce testing time. however, these octaves were included in the initial selec­ tion procedures to determine normal criteria. steps o f 5 db were used to confirm hearing threshold levels. participants took part in one testing session with two alternating sig­ nal conditions. the signal conditions were a manually pre­ sented continuous tone for one second to two seconds and two short pulses (rise-fall time o f 35 ms with a duration o f 20 0 ms onset to offset) automatically generated by the au­ diometer. the test signals were presented in an alternating manner to ensure that the same test signal (e.g. a pulsed pure tone) was not always presented in the same order to the particpant. for example, the participant would hear, at 125 h z, first a pulsed then a continuous tone. a t 2 5 0 hz, he/she would first hear a continuous then a pulsed tone.this would randomly vary from participant to participant. this presentation ensured reliability and validity o f results and yielded two sets o f thresholds (continuous and pulsed tones) for each ear. the first signal (either automatically pulsed or a continuous tone) was randomly chosen and followed al­ ternately by the other signal. a fter the hearing test, a brief three-question interview followed the pure-tone testing. subjects were asked i f they preferred one test signal above the other, and, i f so, which signal they preferred and why. their answers were recorded by the researcher on a space provided on the audiogram. testing and recording was done by a final year audiology student. a qualified audiologist su­ pervised the student during testing o f the first three subjects to ensure that test procedures were valid and reliable. the supervisor was available for consultation for the duration o f the testing. d a ta analysis data was organised and processed using “m icrosoft o f­ fice excel” software. a univariate procedure was used in order to draw comparisons between continuous and pulsed threshold values at discreet frequencies. the average thresh­ old, mean difference and standard deviation o f the two thresholds obtained with the two different types o f stimuli at each frequency tested for each ear, was calculated. l is ­ teners’preferences indicated in the interview were calculated in percentages to obtain the most preferred signal. reasons for preferring one signal to another was analysed qualita­ tively. during data analysis the results for each ear were not combined as literature suggests that ear differences oc­ cur (hochberg &. waltzman, 1972). the afore-mentioned statistical procedures used in the study were deemed appro­ priate for the small sample size and provided sufficient data in order to answer the research question comprehensively. results d eterm ining whether a threshold difference exists be­ tween continuous versus pulsed pure-tone audiometry the first sub-aim o f the study was to determine wheth­ er a threshold difference exists between continuous ver­ sus pulsed pure-tone audiometry in school-aged children. c a th er ine va n dijk a n d n a e e m a o s m a n these results included hearing threshold levels obtained for continuous as well as pulsed tones at frequencies 125 h z to 8000 h z in each ear o f each participant. the difference between the average o f the continuous hearing thresholds and the average o f the pulsed hearing thresholds for each ear and specific frequencies were determined. these dif­ ferences were calculated by subtracting the averaged pulsed tones from the averaged continuous tones and are depicted in figure 1. frequencies figure 1: difference between average hearing threshold levels o f continuous andpulsed tones in each ear (n=18) a difference value o f zero, which was obtained at 25 0 h z in the left ear and at 1000 h z in the right ear, indicated no threshold difference between the two stimulus types as presented in figure 1. negative values indicated that lower thresholds were obtained for continuous tones. continuous tones yielded better thresholds than pulsed tones at 50 0 h z in the left ear and 2 0 0 0 h z in the right ear. lower thresh­ olds were obtained for pulsed tones at all other frequencies for both ears. therefore, pulsed tones yielded lower thresh­ olds than continuous tones for the majority o f frequencies tested. in order to determine whether the signal type yielded a threshold difference at specific frequencies, findings per frequency for the respective ears were analysed. the stand­ ard deviation and the mean average o f the hearing threshold levels obtained at each frequency tested, for each stimulus figure 2 : m ean average an d standard deviation f o r continu­ ous andpulsed tones in the left ear (n=18) the average standard deviation for continuous tones was 8 db in the left ear. the average standard deviation for pulsed tones was 7.9 db in the left ear. continuous tones 32 | die su id -afr ika an se tydskrif vir k o m m u n ik a s ie -a fw y k in g s , vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) c o n t i n u o u s v e r s u s p u l s e d p u r e t o n e a u d i o m e t r y in a g r o u p o f s c h o o l a g e d c h il d r e n presented less variation in thresholds at 125 h z, 50 0 hz, 4 0 0 0 h z and 8 0 0 0 h z in the left ear while pulsed tones presented less variation in thresholds at 2 5 0 h z, 1000 h z and 2 0 0 0 hz. absolute differences in averaged thresholds at each test frequency ranged from 0 db to 1.9 db between 125 h z and 8 000 h z. averaged pulsed tones yielded slight­ ly lower thresholds at all frequencies except at 2 5 0 h z where thresholds were equal and at 50 0 h z where the continuous tones revealed slightly lower thresholds. similar to the left ear, findings per frequency were ana­ lysed for the right ear to determine whether the signal type yielded a threshold difference at specific frequencies. the standard deviation and the mean average o f the hearing threshold levels were obtained at each frequency tested, for each stimulus type, for the right ear, follows in figure 3. figure 3 : m ean averages an d standard deviation f o r continu­ ous an d pulsed tones in the right ear (n-18). the average o f the standard deviations for continuous tones was 7.3 db compared to 7.5 db for pulsed tones in the right ear. continuous tones presented less variation in all thresholds except at 1000 h z and 4 0 0 0 h z in the right ear. absolute differences in averaged thresholds at each test frequency ranged from 0 db to 1.4 db between 125 h z and 8 000 h z. i averaged pulsed tones yielded slightly lower thresholds at all frequencies except at 1000 h z where thresholds were equal and 2 0 0 0 h z where the continuous tones obtained slightly lower thresholds. w h en results o f both ears are considered, threshold standard deviations (averaged over all frequencies tested) showed that the pulsed presentation method yielded slight­ ly less variation (0.005 db) in thresholds, than the continu­ ous presentation method. o n average, pulsed tones yield­ ed slightly lower thresholds where the average pulsed tone threshold was 0 .4 db lower than for the averaged contin­ uous tone stimulus. these small differences in averaged thresholds and standard deviations obtained for both test tones reinforce the equality o f the two stimulus signals. based on the aforementioned, the overall differences would not be sufficient to recommend one signal above the other. findings for both ears at all frequencies were plotted to compare overall threshold differences due to different sig­ nals. these results are presented in figure 4. figure 4: a comparison o f the average hearing thresholds ob­ tain ed for continuous andpulsed tones in each ear (n-18). as may be noted in figure 4, the differences in thresh­ olds between the two stimuli were relatively small. this cor­ relates with results obtained by hochberg and waltzman (1 9 7 2 ), which indicated that both types o f signals obtained comparable threshold levels at all audiometric frequen­ cies tested, and did not vary by more than 1.6 db. across all frequencies tested in the left ear, an average o f 3 .8 db for continuous tones and 3.6 db for pulsed tones was ob­ tained. similarly, the average hearing thresholds obtained in the right ear were 5 .7 db for continuous tones and 5 .2 db for pulsed tones. although the automatically pulsed tone threshold (averaged across the frequencies tested) was low­ er than for the continuous tone, the average difference was only 0 .2 db in the left ear and 0.5 db in the right ear. this small difference is not important in clinical applications for which 5 db increments are used in pure-tone audiometry. taken as a whole, the pulsed tone stimuli produced slightly lower thresholds at all the test frequencies where the average pulsed tone threshold was 0.3 db lower than for the continuous tone stimulus. this differs from the study done on adults where lower thresholds (averaged across all frequencies) were obtained for continuous tones than for automatically pulsed tones, where the difference was 1.0 db (burk &. w iley, 2 0 04). the obtained minor 0.3 db differ­ ence would not result in a substantial difference in hearing threshold level, since these measurements are made in 5 db increments. d eterm ining whether a listener preference is perceived between continuous versus pulsed tones the second aim o f the study was to determine whether participants had a listener’s preference for one o f the two signals. the percentage o f participants preferring one signal over the other based on the three questions asked, was cal­ culated. these results are represented figure 5. th e s o u t h a f r ic a n j o u r n a l of c o m m u n ic a t io n d iso rd er s, v o l. 55 2 0 0 8 | 3 3 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) c a th er ine v a n dijk a n d n a e e m a o s m a n 0 continuous (beep w as easier) z pulsed (beep-beep was easier)___________ f ig u re 5 : l isten ers’ p referen ce f o r one stimulus type ov er the other (n=18). the difference in the percentage o f perceived preference was 11%, with 56% preferring continuous tones and 44% preferring pulsed tones. this differs from the findings o f a study (burk 8c wiley, 20 0 4 ) done on 2 4 adults, where it was found that 62% o f subjects preferred the pulsed tones and 38% preferred the continuous tones. o ver two-thirds o f normal and tinnitus subjects, in a study done by hochberg and waltzman (1972), preferred to listen to pulsed tones as opposed to continuous tones during threshold determina­ tion. the difference in the sample population group in the present study, which was done with children, may contribute to the disparity in the findings. results indicated that more participants preferred the continuous tone, although, the post-test comments across the signal types were very similar. this differs from pre­ vious investigations where persons experiencing tinnitus commented that continuous tones are more confusing than pulsed tones (m ineau 8c schlauch, 1997). findings revealed that the most common explanation given by those partici­ pants preferring the continuous tones was that it was louder and clearer and that it did not have interruptions. the most common reason given by those participants preferring the pulsed tones was that one could hear it a second time if one was unsure o f hearing the first presentation. a direct comparison provided further findings regard­ ing the correlation between the perceived listener’s prefer­ ence and the stimulus signal that produced the lower hear­ ing threshold level. seven subjects obtained lower hearing thresholds in both ears for the stimulus signal that was not their perceived preference. a further seven subjects per­ ceived preference correlated with a lower hearing threshold in one ear only. o nly four participants obtained better hear­ ing thresholds in both ears for the stimulus signal that they perceived as their preference. therefore, it would seem that listeners’ perceived preference did not correlate with a lower hearing threshold for the preferred stimulus signal. discussion and conclusion the aim o f this study was to compare continuous and pulsed pure-tone audiometry in a group o f normal-hearing school-aged children. this was done by comparing hear­ ing threshold levels obtained for both stimulus signals and determining i f a listener’s preference existed for one tone over the other. the value o f this study, was that data, unlike previous studies o f the same nature (burk 8c wiley, 2004; m ineau 8c schlauch, 1997), was recorded and analysed sep­ arately for each ear at the various test frequencies. in summary, the findings obtained for the averaged hear­ ing threshold differences at each frequency when comparing continuous to pulsed hearing threshold levels were: pulsed tones yielded slightly lower thresholds in both ears at 125 hz. a t 2 5 0 h z, no difference in hearing threshold lev­ els were obtained in the left ear and pulsed tones yielded slightly lower thresholds in the right ear. a t 5 0 0 h z, continuous tones yielded slightly lower thresholds in the left ear and pulsed tones yielded slightly lower thresholds in the right ear. a t 1000 hz, pulsed tones yielded slightly low­ er thresholds in the left ear and no difference in hearing threshold levels were obtained in the right ear. a t 2 0 0 0 h z, pulsed tones yielded slightly low­ er thresholds in the left ear and continuous tones yielded slightly lower thresholds in the right ear. pulsed tones yielded slightly lower thresholds in both ears at 4 0 0 0 hz. pulsed tones yielded slightly lower thresholds in both ears at 8 000 hz. the above-mentioned findings revealed that the pulsed tone stimuli produced slightly lower thresholds (0.3 db) on average at all the test frequencies than for the continu­ ous tone stimulus. literature does not provide an explana­ tion for why audiometric pulsed tones yield slightly lower thresholds, except that subjects tend to report that a pulsed tone seems to be more alerting than a continuous tone (m c commons 8c hodge, 1969). inter-aural differences were apparent at some test frequencies in this investigation and are also documented (hochberg 8c waltzman, 1972). the ear that produced the better pulsed tone thresholds var­ ied within the same subject, which makes the theory o f ear domination invalid for these cases. current literature does not aid in providing an explanation nor are the results o f this study useful to explain why these inter-aural differences are found for continuous and pulsed tone thresholds. however, differences are statistically so small that it does not warrant speculation as to why they occur. i t may be concluded that the use o f pulsed tones for audi­ ometric threshold measures in normal-hearing children had no clinically significant effect on obtained hearing thresh­ olds as 5 db increments are used in pure-tone audiometric testing. this differs from previous findings demonstrating the benefits o f using pulsed tones in threshold assessment for adults with sensorineural hearing loss and persons with tinnitus (burk 8c wiley, 2 0 0 4 ; hochberg 8c waltzman, 1972; m ineau 8c schlauch, 1997). these preliminary find­ ings may indicate that school-aged children yield different responses during pure-tone testing than adults. however, continuous tones showed a slight advantage in terms o f presenting what is perceived as an easier task with­ out adversely affecting the test’s outcome. a slight difference was obtained, with more participants preferring continuous tones than pulsed tones. the slight preference for continu­ ous tones in normal-hearing children also differs from the study done on adults, where the preference was for pulsed tones (burk 8c wiley, 2 0 0 4 ). in this study, it was also found 34 | die su id -afr ika an se tydskrif vir k o m m u n ik a s ie -a fw y k in g s , vo l. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) c o n t i n u o u s v e r s u s p u l s e d p u r e t o n e a u d i o m e t r y in a g r o u p o f s c h o o l a g e d c h il d r e n that, overall, listeners’ perceived preference did not correlate with a lower hearing threshold for the preferred stimulus signal. reasons for these findings are unexplained in litera­ ture to date. limitations the study presented limitations in terms o f sample size and ages included in the selected age range. in addition, as with most quasi-experimental studies, not all variables could be controlled for such as tester-bias and the participants’ at­ tention span. although, the person who conducted the test­ ing was the same person who analysed the data, the research­ er ensured that data was recorded and analysed as accurately and objectively as possible through supervision. the person conducting the testing reported that all participants dem­ onstrated sufficient attention span for the duration o f the test procedure. she indicated that, although some subjects showed obvious signs o f boredom, this resulted in only a few inconsistent responses and not more than one would expect during behavioural testing. despite these shortcomings, limited research is available to date that compares outcomes o f different test signals in pure-tone audiometry in children and this exploratory study provides preliminary data with some clinical considerations for audiologists in practice. clinical implications the benefits o f using pulsed tones over continuous tones have been documented with adults with hearing-loss as well as with adults suffering from tinnitus. however, in this ex­ ploratory study it would seem that using either continuous or pulsed pure-tone signals during testing with normal hearing children does not yield significant threshold differ­ ences. conversely, audiologists might consider asking their young clients during testing which signal they preferred. as revealed in this study, this may not result in obtaining better threshold levels. nevertheless, taking their preference into consideration may improve cooperation and make the test­ ing experience less strenuous for the young client. recommendations a future study could include a larger sample and smaller age intervals with more subjects per age interval to ensure more generalizability o f findings. this would also allow for inter variable analysis on the influence o f gender and audi­ tory maturation onj results. in addition, a larger sample may yield results that are more directly comparable to similar in­ ternational studies on adults. references american national standards institute. (1996). specifications fo r audiometers, s3.6. new york: ansi. american speech-language-hearing association. (1978). guide­ lines for manual pure-tone audiometry. asha, 2 0 ,279-301. blandy, s. & lutman, m. (2005). hearing threshold levels and speech recognition in noise in 7-year-olds. international journal o f audiology, 44, 435-443. burk, m.h. & wiley, t.l. (2004). continuous versus pulsed tones. american journal o f audiology, 1 3 ,54-61. carhart, r. &jerger, j. (1959). preferred methods of determination of pure-tone threshold. in j.w. hall & h.g. meuller (eds.). audiologists’ desk reference. san diego: singular. dancer, j.e . & conn, m. (1983). effects o f two procedural modi­ fications of the frequency of false-alarm responses during pure tone threshold determination. journal o f auditory research, 23, 215-219. dancerj., ventry, i.m. & hill, w. 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(2001). planning designing and re­ porting research. south africa: pearson education. united states office of special education programs. (2002). t h e s o u t h a f r ic a n j o u r n a l o f c o m m u n ic a t io n d iso rd er s, v o l. 55 2 0 0 8 | 3 5 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) child count: number served (ages 6-21), by disability and state. retrieved july 22, 2006, from http://www.ideadata.org/ta bles26th/ar_aa3.htm. cath er ine v a n d d k a n d n a e e m a o s m a n yoshinaga-itano, c., sedey, a.l., coultier, d.k., & mehl, a.l. (1998). language of earlyand lateridentified children with hearing loss. pediatrics, 1 0 2 ,1161-1171. 36 | die suid -afr ika an se tydskrif vir k o m m u n ik a s ie -a fw y k in g s , vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.ideadata.org/ta abstract introduction literature review methodology ethical consideration results and discussion summary and conclusions acknowledgements references about the author(s) sandra du plessis department of speech-language pathology and audiology, sefako makgatho health sciences university, south africa citation du plessis, s. (2018). male students’ perceptions about gender imbalances in a speech-language pathology and audiology training programme of a south african institution of higher education. south african journal of communication disorders 65(1), a570. https://doi.org/10.4102/sajcd.v65i1.570 original research male students’ perceptions about gender imbalances in a speech-language pathology and audiology training programme of a south african institution of higher education sandra du plessis received: 06 july 2017; accepted: 07 mar. 2018; published: 16 may 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the professions of speech-language pathology and audiology (slpa) are characterised by occupational gender segregation. reasons given by men are a lack of awareness of slpa; a perception of poor salaries; a perception of poor working conditions; a stereotype that the profession is a female occupation; and a perception that working with children is feminine. objectives: the aim of this study was to describe the perceptions of male students in a specific slpa training programme regarding gender imbalances. the objectives were to describe the influences of gender on the career orientation of students, the factors shaping students’ career choices and the experiences of students during their undergraduate training. method: this study followed a quantitative descriptive survey design. thirty-one conveniently sampled male slpa students, across different years of study, completed a self-administered questionnaire. results: participants indicated that they did not believe in the gendered nature of occupations and that slpa are not ‘female only’ professions. they (65%) recorded that they considered salary and career prospects for choosing a career, and 74% specified that they chose slpa because of a desire to help people. the perception of male students regarding their training appears to be positive as participants are comfortable with the clinical (71%) and learning (77%) activities. however, barriers were reported and some lecture information may be more obvious or applicable to female students. a need was identified to address the issue of working alone with paediatric clients and pertains to the societal awareness regarding sexual harassment of children, which may impact spontaneity in engagements. conclusion: the recruitment of male students should be prioritised to better reflect the client population served by the professions. recommendations include career counselling in rural schools, recruitment campaigns to identify interested students, public awareness regarding the professions and guidance regarding working with paediatric clients. introduction the speech-language pathology and audiology (slpa) professions are still characterised by extreme occupational gender segregation. globally, it is rare to come across a male slpa in practice (litosseliti & leadbeater, 2013). in south africa, no data are available on the number of registered male slpas and there is generally a paucity of gender studies in slpa. according to litosseliti and leadbeater (2013), there is limited research into the reasons of occupational gender imbalance as a potential key factor in career choice, despite calls to increase gender diversity in the health care professions. while young women currently may develop their potential and careers beyond the boundaries of the traditional femininity of the past, men appear to find it more difficult and are often still judged under the gender system and are expected to fit such an approach (deutsch, 2007; risman, 2009). deutsch (2007) further argues for a strong focus on the elimination of the gender system to create true equality between men and women. the development of the intersectionality theory, greatly advanced research into multiple forms of oppression in different social settings and became indispensable in the analysis of global gender inequalities (alinia, 2015). intersectionality highlights the fact that discrimination may overlap; for example, racial and gender discrimination may occur simultaneously in the workplace or in other arenas of life. although the intersectional theory advanced research on african women globally, peretz (2017) in his intersectional analysis of men’s pathways found that not only will our understanding of men improve by attending to men’s intersecting identities, but also our understanding of men as allies to women’s rights movements. in slpa, there appears to be no prospect of redressing the gender imbalance in the near future (boyd & hewlett, 2001). male speech-language therapists (slt) in the royal college of speech and language therapy’s continuing professional development network indicated why men do not choose slt as a profession. mckinson (2007) lists five reasons why men eschew a career in slpa, including a general lack of awareness of the profession, perceptions of costly training, poor salaries and poor working conditions, and the stereotype that this is a female occupation. client caseloads suggest that more male slpas would enable these professions to better reflect the population they serve as the majority of paediatric and adult clients are males. many different theories have been formulated to support the matching of therapists and clients on the basis of gender with the premise that people identify and understand people similar to themselves better. such shared understandings are thought to build stronger therapeutic relationships with more successful therapeutic outcomes (bhati, 2014). recruitment of more men into the profession requires addressing gender stereotypes. gender inequality in slpa appears entrenched and it is difficult to envisage how gender balance could be achieved. while a substantial body of research on women in male-dominated professions is available, fewer studies examine the experiences of men in female-dominated professions (budig, 2002). this article explores male slpa students’ perceptions, regarding the influences of gender imbalances in career choices, career opportunities, learning experiences and related challenges. literature review career orientation the industrial revolution of the 1750s resulted in the establishment of large-scale factories in which machines replaced handcraft in the manufacturing process, thereby leading to the division of tasks along maleand female-dominated fields. jobs were subdivided by allocating tasks that required more technical skills to use the new technologies to men and more routine and repetitive tasks to women (hall, 2005; litosseliti & leadbeater, 2013). while health care was mostly provided by women to family and friends in the pre-industrial times, the medical profession established itself as male-delivered for financial reward during the industrial revolution. the cures of the midwives and the untrained healers were discredited. during this time only middle and upper class men accessed male-dominated universities, while women, although not excluded from writing the examinations, were not allowed to attend the university classes. a small number of wealthy women passed the examinations after they found alternative approaches to studying (witz, 1992). in this patriarchal society, men therefore enjoyed gender privilege and dominated the medical profession. while society recognised the role of women in the private sphere of the home during the 19th century, the last few decades of that century showed change as women started to enter the workforce. professions such as nursing were highly recommended for women because these female-dominated jobs were perceived to demand more ‘emotional labour’ – the effort employees put into managing others’ and their own emotions (hall, 2005, p. 189). in the english-speaking sub-saharan african countries, the informal sector became an important socio-economic and political phenomenon during the past three decades. while some black african women improved their economic status after entering this sector, it caused greater burdens for others. some women experienced discrimination in terms of lack of access to credit, lack of access to property, insufficient capital, as well as police harassment. in addition, women encountered domestic violence as men felt threatened by women’s financial independence and their empowered roles in decision-making (ampofo, beoku-betts, njambi, & osirim, 2004). over the past few decades, the number of students in higher education in industrialised countries has risen partly because of the enrolment of more female students. however, as professions evolve, conflict is still evident in terms of gender issues, and student recruitment in certain professions is still presenting a gendered imbalance. it appears that students who enrol in gender-traditional professions often had an early preference for these programmes. notwithstanding this, the choosing of gender non-traditional programmes by students is increasing among both female and male students (mastekaase & smeby, 2008). mastekaase and smeby (2008) provided three explanations for gender segregation in career choice: firstly, the nurturing role of women may encourage them to choose caring occupations; secondly, women may choose professions in which it is easier to combine employment and family life; and, thirdly, men and women may be exposed to gender discrimination (usually from outside the professions) and therefore decide against certain professions. in addition, dick and rallis (1991) reported that remuneration and career advancement were usually more important factors in career choice for men. bai (1998) found that the market economy (the basis of the capitalist system) changed the values of university students in that they put self-interest before societal interests and rate money and power as the primary motivators for finding a job. furthermore, a profession’s perceived value is also determined by intrinsic factors such as intellectual interest and the desire to help people, as well as extrinsic factors such as salary expectation and the cost and length of future training (bai, 1998). while excellent progress has been made by women in previously male-dominated professions, such as business and medicine (ross & coleman, 2008), men in female-dominated fields do not necessarily have it easy. they report hostile behaviour, not from colleagues but from friends. they also report anxiety caused by a mismatch between stereotypical masculinity and working in a female-dominated field. men in these fields downplay the feminine aspects of their jobs and accentuate the masculine aspects (ross & coleman, 2008). in addition, men who choose female-dominated professions are often perceived as having degraded themselves in status (lassen, 2012). it appears that this perception, which is fortified by cultural and political understandings of acceptable gender roles, has dominated for men (ross & coleman, 2008). therefore, the following question arises: why men do pursue careers in female-dominated professions and specifically in slpa? factors that affect career choices the training of slt and audiologists is closely related, as both professions engage with individuals’ communication difficulties. historically students were trained in combined programmes as both slt and audiologists, but currently only single combined programmes are still offered in south africa, while the majority of the institutions of higher education offer separated programmes. speech-language pathology and audiology are regarded as small professions in countries such as south africa, new zealand and australia (byrne, 2010). although the statistics for male slpas in south africa are not available, litosseliti and leadbeater (2013) reported that male slts are found in the following percentages in the selected countries: 2.5% in the uk, 3% in australia and 4.1% in the usa. in 2015 and 2017, respectively, 106 and 130 male students were registered at the various institutions of higher education in south africa for slpa (table 1). table 1: demographic information of all male undergraduate students of all year levels registered at various institutions of higher education in south africa for speech-language pathology and audiology in 2015 and 2017. comparatively, the smaller percentage of male students (table 1) could be because of factors consistent with those reported in the literature. farmer (1985) explains that career choices can be linked to three interactive influences: background (e.g. gender and ability), psychological or personal factors (such as attitudes, beliefs and earlier experiences) and environmental or cultural factors (e.g. norms, peer pressure and media influences). a study by agarwala (2008) showed that fathers exerted the greatest influence on the career choice of students in india, for both male and female students. for female students, the second most important influence was their mothers, and for male students, the second most important influence was their friends. research results cited by mastekaase and smeby (2008) indicate that women favour support by parents in the choice of careers and are more likely to be influenced by peers, while contrary to the findings in the previous study, men tend to be more resistant to parental involvement. dick and rallis (1991) reported that parents and teachers were perceived to be the major influences on career choice, more often for students (both men and women) choosing careers in engineering and science. litosseliti and leadbeater (2013) conducted a study including face-to-face interviews with new graduates and practising qualified slts about factors contributing to their career choice and found four main factors. these included: (1) exposure to slt, being it through personal experience or a family member receiving therapy or through direct contact and encouragement from a relative or career advisor; (2) the influence of parents and relatives; (3) the perceived status, prestige and potential salary; and (4) personal motivation and interest in the selection of a career in slt. opportunities and challenges male students experience during teaching and learning in the health care professions in health care sciences training programmes, such as nursing and occupational therapy, more male students are entering these female-dominated fields and this raises the question whether students’ gender has implications for training. male nurses have expressed the frustration that they are assumed to be gay and also merely seen as muscle power to carry out heavy work (parish, carr, suwinski, & rees, 1990). male students in occupational therapy reported that female patients have refused therapy related to the field of dressing practice. these students also saw the craft activities as female orientated and indicated that they get ‘mothered and smothered’ by female staff members and students (parish et al., 1990, p. 69). smedley (1998) refers to the problems in recruiting male student teachers as a feminised curriculum, feminised assessment regimes and feminised assessment methods. in slpa there is a challenge for male students working alone with paediatric clients (boyd & hewlett, 2001). this pertains to the societal awareness and caution regarding the sexual harassment of children, which may have an impact on spontaneity when engaging with young clients (boyd & hewlett, 2001). the results obtained by litosseliti and leadbeater (2013) indicated an expectation that male therapists should rather work in specialities such as adult neurology. although the literature revealed some challenges for male students, there is limited data available on the advantages of being male in a female-orientated programme. in the research by litosseliti and leadbeater (2013), male slts as well as lecturers indicated that participants perceived that in terms of career progression and promotion opportunities, qualified male therapists progress faster than their female counterparts. they explained the large number of men in management positions by speculating that men make better managers because they are perceived to be more rational than women who are more emotional. the current research project wanted to describe male slpa students’ perceptions regarding the influences of gender in career choices, the factors shaping career orientation, learning experiences and related challenges in order to serve as an introduction of the topic in south africa. methodology the research project set out to describe the perceptions of male students in an slpa training programme in a south african institution of higher education regarding gender imbalances in career choice in a female-dominated programme. in particular, from the key areas outlined above, the following three objectives were formulated: to describe the influence of gender on the career orientation of male students to describe the factors shaping male students’ career choices to describe the experiences of male students during their undergraduate training. research design a descriptive survey design implementing the quantitative perspective was selected for the purpose of the research project. in the descriptive survey, data were obtained through questionnaires and limited open-ended questions were included. the research outcomes could not be extended to other groups and generalisation beyond the research context was not possible. participants male students were identified from class lists. out of 43 conveniently sampled undergraduate slpa male students of 2016 in a south african institution of higher education, 31 consented, completed and returned the questionnaires. the demographic information of the students who gave consent to participate in the research shows a spread of young adult male students between the ages of 18 and 29 (table 2). some of the students being in their late 20s may have indicated that they commenced their studies in slpa at a later age or may have completed other training programmes before entering the programmes. another factor to consider in south africa is that many students, because of financial constraints, may have had to work to save money before they can enrol in a university. table 2: demographic information of the participants (n = 31). it is interesting to note that all of the male students in the first-year class took part in the research. it is also positive to note that the number of participants from second to fourth year constitutes more than 50% of the responses, providing a balance in the perceptions of younger and more senior students. material the survey questionnaire was designed by the researcher as other tools were not specifically accurate for this study. the questionnaire content was developed after a literature review and was mainly based on earlier relevant research on male perceptions regarding the slpa and nursing professions by anderson (2014), litosseliti and leadbeater (2013) and boyd and hewlett (2001). the questionnaire was divided into four sections: section a: demographic information section b: influences on career choice section c: career orientation towards traditional and non-traditional occupations section d: opportunities and challenges that male students experience in teaching and learning. in section a, participants were requested to respond to a set of four personal questions. in sections b, c and d, the participants were asked to respond according to the likert scale. there were two sets of response options. the first set of questions included options relating to agreement, namely, strongly disagree, disagree, agree, and strongly agree. the second set of questions included options relating to frequency, namely, never, sometimes, mostly and always. participants were further requested to respond on the dichotomous scale to ‘yes/no’ questions and additional questions were also included to allow for clarification of responses where necessary. some counter-test items were included in the questionnaire to increase the validity of the participants’ responses. open-ended questions were included at the end of each section to allow participants to elaborate on the topic. a pilot study was conducted to assess the need for adaptations in the procedures or wording of the questionnaire. four male students (one per year level) from another institution of higher education in the speech-language pathology or audiology programmes formed the trial group of pilot study participants. during structured interviews, the pilot study participants approved the questionnaire and made no recommendations for change. this improved the face validity of the questionnaire. data collection permission to access the students was granted from the university and the department of speech-language pathology and audiology, and ethical clearance was obtained. the researchers met with all the participants in one setting, as a group, to explain what the questionnaire entailed and what would be expected from them. interested participants completed the consent forms and proceeded to completing the questionnaires given to them as a hard copy. the researchers were available during the completion of the questionnaires to provide clarity where necessary. data analysis in the analysis of results, the likert scale responses were collapsed to make it more manageable and strongly disagree and disagree constituted disagree, while agree and strongly agree constituted agree. data were entered onto an excel spreadsheet. data analysis was repeated to improve reliability. descriptive statistics (leedy & ormrod, 2005) were mostly utilised to describe the data and to illustrate trends within the research context. descriptive statistics used included frequencies and percentages to analyse quantitative data. qualitative data were manually organised into immerging categories or subcategories based on similarities (de vos, 2002). ethical consideration the research project was approved by the sefako makgatho university research ethics committee (smurec/h/59/2016:ug). ethical considerations of protection from harm, informed consent, right to privacy and honesty with professional colleagues were considered throughout the project. results and discussion influence of gender on career orientation in the questionnaire male students were requested to indicate on a likert scale the influence of gender on career orientation. more than half of the students (58%) indicated that they did not believe in the gendered nature of occupations and most of the students (65%) also did not perceive that gender should be considered when choosing a career. the difference of opinion, and the large number of students not affected by gender difference in their professions was unexpected. it is speculated that these students observed a gender mix in the health care professions on the campus of their place of study with which they could associate. in addition, the students may not have been exposed to the wider work environment and may not have experienced gender segregation in professions. the opposite was found by francis (2002) in her research with high school learners, which indicated gender dichotomy with girls still opting for the caring professions and boys choosing occupations where business, scientific and technical skills are required. the majority (68%) of participants indicated that both genders were affected by inequalities in the workplace, but only about half of the students (48%) thought that their gender would affect their future promotions. some unfavourable conditions often referred to as the ‘glass escalator effect’ and the ‘revolting door effect’ are experienced by women in male-orientated professions and vice versa. this refers to conditions of inequality in the workplace created by occupational gender segregation that adversely affect male as well as female professionals (litosseliti & leadbeater, 2013). the large majority of students (74%) indicated that the word ‘therapist’ does not remind them of a woman and they feel comfortable to be addressed as such. this contradicts litosseliti and leadbeater’s (2013) findings where slt students, slt lecturers, career counsellors and qualified slts indicated that the words ‘therapist’ and ‘therapy’ generally have a female connotation. in all four of these groups, participants indicated that the words ‘therapist’ and ‘therapy’ are in general female orientated. students were divided over the statement that women are natural communicators as 48% disagreed. it is postulated that students may know about the common perception that girls and boys differ from childhood, with girls performing well in communication skills and boys in manual skills. however, litosseliti and leadbeater (2013) agreed that the general perception is that women are better communicators as found in their study. it was also noticed that there may be a bias against male students in the selection of students to enrol into an slpa programme as a result of this perception. interestingly, the majority of students (65%) indicated that even though they consider salary and career prospects when choosing a career, 74% indicated that they chose slpa because of a desire to help others. this is very positive as it is generally known that there is a dire need for caring professionals to serve and care for the underserviced communities in south africa. on the other hand, it is also the right of a qualified therapist to earn a living wage and to have a career path ahead that includes promotions for work well done. the majority (97%) of students indicated that the careers (slpa) are not only for women and therefore not female professions. litosseliti and leadbeater (2013) indicated in their research that the career counsellors were the specific group of participants that considered them female professions. this finding has implications for the marketing of the professions where a more realistic view should be presented to prospective students and learners, especially by career counsellors who may influence the career choice of a prospective candidate. students were requested to complete three open questions regarding gender distribution in the department. categories that emerged as well as selected verbatim responses are presented in table 3. table 3: gender distribution in the specific department. the students in the research context were divided according to their expectations regarding the gender distribution in the programme before they entered into the programme (table 3). as the global tendency is that the professions are female-dominated (litosseliti & leadbeater, 2013), these results are rather unexpected. it raises the question whether some of the students have been in any contact with an slpa at all before entering the programme and may be indicative that they have not encountered an slpa because of the limited numbers of qualified slpas in south africa, or the unavailability of services in the rural areas or even the fact that the professions are unknown to a large majority of local population. the results further indicate a general feeling of disappointment for the students regarding the gender distribution and an expectation that more male students need to be recruited (table 3). in litosseliti and leadbeater’s (2013) study, the need to prioritise male slpa students’ recruitment was reported. boyd and hewlett (2001) reported that the existing low number of men in the professions is probably the main factor discouraging other men to be recruited into the professions. mckinson (2007) suggests to re-brand the image of the profession and to provide positive images of male slts in the media. although many students (15) did not consider a change in career as a result of the gender representation, a small but alarming number of students (3) considered changing their career choice as a result thereof (table 3). parish et al. (1990) found in their research that 28% of male occupational therapists contemplated leaving their profession as they felt dissatisfied with the career potential for male therapists in their profession. this emphasises not only the need for support of the male students in the programme, but also the need for appropriate career counselling to allow students to make informed decisions regarding something as important as a future career. factors shaping career choices in the questionnaire male students were requested to indicate on a likert scale (relating to agreement) the factors shaping their career choices. less than half of the students (48%) indicated that they knew what the profession entailed before enrolling. it is alarming that the other students enrolled without making informed decisions regarding their future career. it is speculated that slpa are not well-known professions among some african communities, especially in the rural areas of south africa. this may account for this response, as 55% of the students were from rural areas (table 2). eighty-four per cent of the students indicated that slpa was not their first-choice career. these students therefore applied for other programmes as first choice and considered slpa as an alternative. they enrolled in the programme after not being selected into their first-choice careers. these students, therefore, are not motivated and passionate about a career in slpa and may drop out of the programme without completing it or alternatively re-applying for their first choice after a year in the programme or on completion of the programme. although slpas add significant value to the quality of life of children and adults with speech, communication, language, swallowing and hearing disorders, it is clear from the literature (byrne, 2010) that there is a general lack of awareness among the public about these professions. this may have an impact on the choice of students to enter the profession of slpa. although 87% of students did not have any kind of contact or experience with slpas, they selected this as their future career. research by litosseliti and leadbeater (2013) found that experience with an slt was a common factor that influenced the choice of the career for students, therapists and lecturers. byrne (2010) found that the most influential factor that creates a desire to become an slt was to have contact with a therapist and understand what the profession entails. however, individuals who have received intervention themselves are less likely to enter the professions because of the experience and perception created through this encounter. interestingly, the majority of students indicated that they were not influenced by their parents (77%), teachers (81%) or media exposure (84%) to choose a career such as slpa. if the students were not influenced by their parents, teachers or the media, where did they learn about the professions? in an open question, the students indicated that they learned about the professions during the process of late application (25%), from the university prospectus (19%), from community members at home (19%), from the internet (16%), from current students (16%) and from therapists at their local hospital (5%). these results provide an indication of the importance of word of mouth in the marketing of the professions of slpa as not all prospective students may have access to internet in south africa. experiences of male students during undergraduate training in the questionnaire the male students were requested to respond on the dichotomous scale to ‘yes/no’ questions regarding their experiences during undergraduate training. the results are presented in table 4. table 4: perceptions regarding the experiences during undergraduate training (n = 31). the general perception of the male students regarding their experiences during undergraduate training appears to be positive as the majority of students were comfortable with both the clinical (71%) and learning (77%) activities. they could relate to examples in class (90%) and did not experience the activities as female orientated (74%) (table 4). the latter fact contradicts findings in other female-orientated professions. parish et al. (1990) found that their participants experienced the occupational therapy curriculum as female orientated and in the research by mills, martino and lingard (2004) male teachers reported female curricula in teacher education. however, some students found examples (42%), information (65%) and barriers (52%) in teaching and learning more obvious or applicable to female students and indicated that lecturers were unaware of this. it is speculated that the lecturers may be incognisant of the situation or alternatively unsure of how to handle these areas of teaching and learning. a need is therefore identified to alert lecturers about these perceptions of the students. parish et al. (1990) suggest that appropriate guidelines for both students and lecturers need to be developed as there is an indication that gender influences some of the activities undertaken. students were divided regarding the important issue of working with paediatric clients. the results indicated that 55% of students did not receive any guidelines on working alone with children, 52% of students responded that they were more aware about child abuse than female students, while 55% preferred working with adults rather than working with children (table 4). although there was no extreme positive or negative opinion from the students, there is a need identified that this matter should be addressed with the students. literature (boyd & hewlett, 2001; litosseliti & leadbeater, 2013; parish et al., 1990) highlights that a set of guidelines should be identified and formulated for male students and lecturers regarding working with children. such guidelines may also help to prevent male professionals from dropping paediatric clients from their caseloads once qualified. the students were requested to complete open questions regarding the advantages of being male in a female-orientated training programme. four categories of advantages of being male in a female-dominated training programme were analysed (table 5). selected quotes from the participants are used to illustrate each subcategory. table 5: advantages of being male in a female-orientated training programme (n = 24). an interesting category that emerged is the benefits of being male. while the students in the current study perceived their stronger physical abilities as positive and were willing to carry heavy objects around, participants in the study by parish et al. (1990) were negative about this and indicated that they perceived that they were merely seen as muscle power to carry out heavy work. a subcategory that emerged is that some male students were of the opinion that it is an advantage to be less attached to clients. this correlates to research by williams (1992), where male teachers indicated that they conscientiously remove themselves from the ‘mothering’ or emotional aspects when working with children and adopt a more neutral approach in interaction. it is indeed promising that the students in the current study realised that although they need to care and serve their clients, emotional involvement need not be overwhelming. in a further open question students indicated the challenges of being male in a female-orientated training programme. the categories and subcategories that emerged from the data analyses are summarised in table 6. table 6: challenges of being male in a female-orientated training programme (n = 22). many students (68%) who responded to this question experienced gender-based challenges in the educational setting (table 6). the fact that working with children needs to be addressed by the professions is noted once again. interestingly, some of the male students find it a challenge to be surrounded by women. the reason can be twofold as students may view the ‘mothering’ by some staff and fellow female students in a negative light as discussed earlier, but it may also be culturally difficult for african male students to be taught in a department with only female lecturers and supervisors. african culture is generally male-dominated, with woman acting submissively resulting in an unequal power relation between the genders (ngubane, 2010). therefore, it may be a challenge to find something outside the norm as seen in the slpa programme in the research context. some students indicated that they find it difficult to be creative (table 6). creativity is inherent to slpa, especially when working with children. this may be one of the reasons why some students prefer working with adults (table 4) as some of the activities with children may be perceived as female orientated. these results correlate with the results of parish et al. (1990), which indicated that the occupational therapy students experienced the craft activities as such. it is a concern that the students perceive that they have to change their behaviour and adopt ‘female behaviour’ in certain situations during their training. this indicates that gender definitely influences some of the activities undertaken. this result clearly indicates that the teaching and learning activities need to be transformed to make it appropriate and acceptable for male students. summary and conclusions to integrate both men and women in all professions does not only require the removal of barriers for women, but also includes the dismantling of barriers that men have to overcome in female-dominated professions such as slpa. in general, it is clear that there is great potential for male professionals in slpa and that men can add significant value to the intervention with both adults and paediatric clients. however, public perception, recruitment, work experience as well as career development need to be addressed in order to motivate men to join these professions. in summary, the following recommendations are drawn from the research: the need for career counselling in rural schools in south africa was identified in order to empower learners with knowledge before making important decisions regarding future careers. the need for recruitment campaigns was identified in order to select prospective students who really are interested in a career such as slpa. public awareness about the professions and the scope of practice need to increase, which may have benefits that are twofold: firstly, for the profession as appropriate referrals will increase access to services and, secondly, more people may act as resources and potentially recommend slpa as a career path for interested students. there was a need identified that the matter regarding working with paediatric clients should be addressed with the students and that a clear set of guidelines should be compiled in order to protect students and clients from any unpleasantness. the students’ experiences reveal that transformation of the teaching and learning activities are needed to make it appropriate for male students. limitation and strength the current study was an exploratory study and the findings cannot be presented as indicative of all male students in all contexts in south africa as they represent only the opinions of a specific group of students. although structured interviews could not be carried out because of time limitations, the questionnaire produced many spontaneous comments, thus increasing the depth of the survey. the current study is seen as an introduction to the topic in the south african context and needs to be explored through further research. acknowledgements the author greatly acknowledges the support of m.o. aphane, m.m. khoza and m.p. raedani from the department of speech-language pathology and audiology, sefako makgatho health sciences university, south africa, for data collection and contribution to data analysis. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. references agarwala, t. 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(1992). professions and patriarchy. london: routledge. abstract speech-language and hearing professions in south africa higher education context lacunae influencing factors to provision of linguistically and culturally appropriate speech-language and hearing services in south africa what speech-language and hearing students and practitioners need to carefully consider what needs to happen within the speech-language and hearing professions in south africa? conclusion acknowledgements references footnotes about the author(s) katijah khoza-shangase department of speech pathology and audiology, school of human and community development, university of the witwatersrand, south africa munyane mophosho department of speech pathology and audiology, school of human and community development, university of the witwatersrand, south africa citation khoza-shangase, k., & mophosho, m. (2018). language and culture in speech-language and hearing professions in south africa: the dangers of a single story. south african journal of communication disorders 65(1), a594. https://doi.org/10.4102/sajcd.v65i1.594 original research language and culture in speech-language and hearing professions in south africa: the dangers of a single story katijah khoza-shangase, munyane mophosho received: 27 feb. 2018; accepted: 12 may 2018; published: 09 july 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: speech-language and hearing (slh) professions in south africa are facing significant challenges in the provision of clinical services to patients with communication disorders from a context that is culturally and linguistically diverse because of historic exclusions of black and african language speaking candidates in higher education training programmes. over 20 years post the democratic dispensation, minimal changes have been noted in terms of the training, research as well as clinical service provision in these professions, although the demographic profile of students is seen to be transforming gradually. objectives: we offer this viewpoint publication as a challenge to the professions to interrogate their academic and clinical orientation in respect of african contextual relevance and responsiveness. method: we do this by identifying gaps within the higher education context, highlighting the influencing factors to the provision of linguistically and culturally appropriate slh training and clinical services in south africa, while asking questions about what slh students and practitioners need to carefully consider. results: we make recommendations about what needs to happen within the slh professions in south africa in order to stay safe from the dangers of a single story. conclusion: we invite debate in order to allow for constructive engagement with this complex issue within the south african slh professions. speech-language and hearing professions in south africa africa has and continues to experience significant health challenges, including those that affect speech-language, hearing and balance functions, which fall within the scope of practice of the speech-language and hearing (slh) professions. within the south african public health sector, these challenges include well-documented lack of appropriate skills, unfavourable professional-to-patient ratios with obvious incongruence between supply and demand, infrastructural constraints where access to health care services is severely compromised by limited well-functioning public health facilities, general lack of resources for the size of the population requiring health services, risk versus benefit assessments predicaments as well as challenges with translating knowledge and policies into practice for various reasons including linguistic and cultural diversity quandaries (barratt, khoza-shangase, & msimang, 2012; khoza-shangase, kanji, petrocchi-bartal, & farr, 2017). these challenges affect mostly the already vulnerable parts of the population such as the poor. moreover, the research illustrates that limited rehabilitation services have been allocated to people with communication disabilities (mckenzie, 1992; wylie, mcallister, davidson, & marshall, 2016). although one could find speech and hearing services at primary-, secondaryand tertiary-level health facilities, because of shortages of health care providers, most communities do not have the services of slh professions in the public sector (khoza-shangase et al., 2017). posts for qualified slh professionals are also still lacking. most slh professions’ services are in private urban or tertiary hospitals (makhoba & joseph, 2016). the health professions council of south africa (hpcsa) (2017) reports that there are 572 audiologists, 1024 speech therapists and 1541 speech therapists and audiologists currently registered to provide slh services in the country; however, these numbers do not reflect whether these professionals are in public or private health care, nor do they reflect the racial and/or linguistic profile of these professionals. this could be one of the areas that regulators such as the hpcsa need to highlight. efforts at redress by the south african government which are aimed at equity in health are acknowledged. the implementation of the national health insurance (nhi) as well as the establishment of a unified health system for moving south africa towards universal health coverage (uhc) remains silent on issues of transformation of the health care workforce, although it addresses challenges around staffing shortages. since the establishment of slh professions’ training in the country, services for people with speech and hearing disabilities can be divided into those that were provided through the special education sector, and those through the health care sector. these services, regardless of the sector where provided, have been and remain unequal and insufficient across the landscape of the country, with an acknowledged lack of contextually relevant resources (pascoe & norman, 2011). what has improved, however, is that the department of health (doh) does not provide services along racial lines anymore (van rensburg, 2004). however, despite these new developments, press reports and academic articles report that access to health is still not equitable, especially for the rural and poverty-stricken black communities (gilson & mcintyre, 2007; mckenzie & müller, 2006), hence the white paper on nhi. access to health care is also significantly impacted by language barriers. the use of english as the main language of consultation in health settings continues to create barriers for non-english speakers (makhoba & joseph, 2016; pascoe, klop, mdlalo, & ndhambi, 2017). this is particularly disturbing for the slh professions where the core function of the professions is to assess and treat language and communication pathology in patients. according to the 2011 south african speech language and hearing association (saslha) database, most slh professionals are in private practice (67%), in urban areas, and have a mother tongue english and/or afrikaans and only 5% are black african language speakers. no recent statistics providing such data could be sourced; however, experientially, current authors believe that these statistics still provide a fair picture of what the current reality is. with south africa’s demographic and linguistic profile, it is clear that the majority of black african language speakers with communication disorders do not receive health care services in their first language. this practice is contrary to what kathard et al. (2011) advocate when they emphasise that slh professions in south africa need to be socially responsive and population focussed in order to make meaningful contributions to development in this country. the current article argues for concerted efforts by the south african slh professions to increase their attention to the influence of linguistic and cultural diversity in the provision of speech-language therapy and audiology services within this context. the current authors, who are both black africans who speak african languages, are foregrounding this positionality in this viewpoint publication – black africanness. in approaching this viewpoint publication, the authors were guided by mignolo’s (2009:8) concept of epistemic disobedience which they find useful when confronting issues of exclusion, which is the current scenario for black africans in slh professions in south africa. mignolo points out that ‘the task of decolonial thinking is to affirm the epistemic right of the racially devalued’. he proposes what the current authors are calling for, a radical departure that visibilises the authors’ positionality. the current authors aim to raise the awareness of the south african slh professions to the reality that the professions are functioning within what mignolo (2009:8) refers to as geo-politics of knowledge, where ‘the epistemic privilege of the first world’ is the norm and where white knowledge and white history define and govern the professional culture. this is particularly important where the knowledge base used in the slh professions excludes that of the context. the exclusion of black african indigenous knowledge, which is the current position in the country, lends the profession to the dangers of a single story (adichie, 2009), where this single story creates stereotypes and beliefs about communication pathology which may be untrue or are incomplete for the south african context. stereotypes that might present dangerous narratives about linguistic, cultural, health-seeking and health-practicing beliefs of the non-dominant, in favour of the dominant – where what the african proverb ‘until the lion learns to write, the story will always glorify the hunter’ rings true. such stereotypes have significant implications for both assessment and management of patients from the ‘non-dominant culture’. this, interestingly, happens in a country where the ‘non-dominant’ culture is actually that of the dominant black majority which became ‘non-dominant’ through colonisation and apartheid, with the advent of democracy that has arguably not seen significant changes to the status quo. although the current south african political dispensation is that of a democratic state that is governed by a black afrocentric agenda, current authors are of the view that this remains largely at policy level and has failed to be realised at implementation (lived experience) level. the authors therefore pose specific questions that the professions should interrogate in order to swing the knowledge and clinical pendulum to be more inclusive and embrace linguistic and cultural diversity rather than tolerate it – which is arguably the current position in a country like south africa. these questions are also aimed at questioning positions that continue to maintain the status quo. the country has 55.6 million citizens, with black africans accounting for over four-fifths of the population in all provinces, with the exception of western cape and northern cape (statssa, 2016). furthermore, the country has 11 official languages (excluding sign language). the last official published statistics on the linguistic profile of the country indicates that the most commonly spoken languages are isizulu (22.7%) and isixhosa (16%), with afrikaans (13.5%) and english (9.6%) trailing behind, followed by setswana (8%) and sesotho (7.6%) (statistics south africa, 2011); and yet english (followed by afrikaans) is the dominant language in the slh professions. the south african constitution advocates for individual rights to access health services in their languages; however, this right is not protected nor enforced in practice – particularly in professions like slh professions where speech-language pathology is the diagnosis requiring both assessment and intervention. this article aims to highlight that language and culture in slh assessment and therapeutic interactions play a complex role, and should not be ignored and/or superficially managed. speech-language and hearing professions as the professions dealing with communication and communication pathology should play a centrally located role in arguing for the importance of language and culture in everyday lives, and the influence of these on health-seeking behaviours. as specialists who evaluate and treat patients with hearing, balance, speech, language, cognitive communication and swallowing disorders in individuals of all ages, from infants to the elderly, they are the professions best suited to lead the deliberations around language and culture and their influence on service provision. the current authors believe that the slh professions can advance the argument presented in this article if they begin to embrace diversity as a contextual strength rather than tolerate it as a contextual complication. within the south african context, this is in line with the south african constitution, ‘which does not tolerate diversity as a necessary evil, but affirms it as one of the primary treasures of our nation’ (judge langa – constitutional court decision in mec for education: kwazulu-natal v pillay). higher education context lacunae it is widely acknowledged that higher education programmes in the country reflect no or slow changes in curriculum transformation to be inclusive (seabi, seedat, khoza-shangase, & sullivan, 2014). higher education programmes, including slh programmes in the country, are largely still based on a eurocentric, western epistemology with minimal, if any, inclusion of afrocentric epistemology and ontology. this lack of transformation of the curriculum in higher education programmes has seen recently increased calls for ‘africanisation’ and ‘contextual relevance’ of curricula by students from the fees must fall, decolonise curriculum student movements across the country. furthermore, these movements have also agitated for deliberation and reviews of language policies within higher education. this language policy review call has a direct implication for south africa’s slh professions where the only languages that have been included in the curriculum are english and afrikaans, with the rest of the official languages being excluded (pascoe et al., 2017). this has also been entrenched by the fact that institutional language and culture has remained removed from that which typically represents african languages and cultures. the current authors hold a view that the existing definitions, theories, assessment and treatment strategies in slh are narrow and hegemonic and lack diversity, contextual specificity and relevance and indigenous knowledge, which is advocated by the united nations (un) reports on access to health services for indigenous people (un, 2015). the current authors’ view is further supported by kathard and pillay (2013) when they argue that south african slh professions’ professional knowledge is hegemonic and limiting; and they advocate for an equity-driven population-based approach at the meso level. du toit (2000) argues for there being a need to engage with the historical legacies of intellectual colonisation and racialisation as well as patriarchy. this is true for higher education as a whole, but is perhaps more urgent in the south african slh professions where the demographic profile of the profession maintains these historical legacies which exclude certain epistemologies, with minimal cosmetic changes. it is important to note that these minimal cosmetic changes, indicated by changes in the racial composition of undergraduate student enrolments, will not ensure an epistemological evolution, which is what the current authors are calling for. the maintenance of these historical legacies, under the guise of academic freedom that academic institutions boast about, has perpetuated institutional cultures of the training programmes to lack gender, knowledge, linguistic and cultural diversity. the fact that the slh professions in this country remain highly feminised, white, westernised, english and mostly urban perpetuate the single story narrative which limits the significant benefits the professions could gain from embracing diversity as a contextual strength. it is within this slh professions context that the current authors believe in what higher education south africa (hesa) (2014) puts forward about transformation when they state that: higher education transformation entails decolonising, deracialising,1 demasculanising2 and degendering3 south african universities, and engaging with ontological and epistemological issues in all their complexity, including their implications for research, methodology, scholarship, learning and teaching, curriculum and pedagogy. (p. 7) for slh professions, the implications extend to the clinical training and consequently clinical practice in a linguistically and culturally diverse context such as south africa. these implications are supported by evidence on global health, which indicates that groups who do not form part of the dominant culture have worse health outcomes than the dominant populations – with language as an example of a barrier to health care (flood & rohloff, 2018). these authors, for example, believe that indigenous languages are important for reasons of autonomy, rights, research ethics, programme efficacy and revitalisation of these languages; and they also argue that health programmes conceived and delivered using the clients’ languages are likely to be more efficacious (flood & rohloff, 2018). within slh professions, the current authors believe that actual diagnosis and treatment of language disorders cannot ethically and accurately happen without considerations of language and culture. currently, anecdotal evidence from graduates as well as evidence from informal appraisal of exit-level outcomes gleaned from examination papers from south african training programmes indicate that there are no set minimum standards for dealing with multilingual and multicultural societies at undergraduate level training. no minimum standards that are consistent across programmes exist for theoretical training as well as for clinical training in the influence of language and culture in slh. the lack of diversity in the demographic profile of teaching staff and clinical educators as well as of researchers (postgraduate students) across all training programmes adds to this challenge and maintains the status quo. this has a direct implication for clinicians who practice without minimum standards for practicing in diverse societies. these lacunae in the curriculum for training slh professions within this context limit the facilitation and development of knowledge, attitudes and skills that are relevant and responsive to the multilingual and multicultural south african context. the fact that cultural brokers, trained interpreters as well as culturally and linguistically appropriate assessment and treatment protocols continue to be reported and evidenced as significantly lacking in this context is an indictment on the profession 23 years after south africa achieved its democracy (pascoe, rogers, & norman, 2013). paucity of contextually relevant published research in the area does not encourage the progression and development of the professions in this area. the limited contextually relevant published research available in this area has mostly tended to focus on translation of assessment materials, development of word lists as well as on the performance of english second-language speakers on available resources and therapists’ preparedness in managing patients from diverse cultures and languages (barratt et al., 2012; gonasillan, bornman, & harty, 2013; khoza, ramma, mophosho, & moroka, 2008; mdlalo, flack, & joubert, 2016; pascoe & norman, 2011; pascoe et al., 2013). in 2016, one special issue journal of the south african journal of communication disorders (volume 63, number 2) was dedicated to language acquisition and impairment in the african languages. as significant as this special edition issue was, it is important to problematise its list of contributors who are largely white and english or afrikaans first-language speakers – single story narrative on display. a review of the published evidence in this only available south african profession-specific journal between 1977 and 2017 further proves the single story nature of the south african slh professions. the current authors, through this viewpoint publication, aim to instigate a self-reflection of the south african slh professions by asking uncomfortable questions which, when interrogated and answered in a truthful manner, might facilitate curriculum critiquing and reviewing, research questions and methods interrogating, clinical practice reflecting as well as future directions planning for the professions. these questions are framed around what nigerian writer chimamanda ngozi adichie’s cautions about ‘the danger of a single story’ – which requires that the south african slh professions acknowledge that the professions have and continue to present and celebrate a story that is not reflective of the diversity in the country, a story that excludes the multiple other stories that this country has to offer; and does this to the detriment of the professions’ growth and to that of efficacious clinical service provision. current authors are of the view that biographies and national narratives of pluralities focussing on education and training, as well as clinical service provision from members of the slh professions from diverse linguistic and cultural backgrounds within the south african context, need to be compiled and published in order to identify strengths and weaknesses of the professions as well as to archive historical data that will guide future interventions. continued exclusion of these other narratives (black people) and the treatment of diverse languages and cultures as barriers cannot continue to be ignored. mignolo (2009, p. 4) argues for the ‘unveiling of epistemic silences of western epistemology and affirming the epistemic rights of the racially devalued’. in this regard, he notes that knowledge should be reframed to focus on the ‘knower’ – in this context, be inclusive of black people in the slh professions within the south african context. influencing factors to provision of linguistically and culturally appropriate speech-language and hearing services in south africa it is not difficult to identify factors that have an influence on progress as far as provision of culturally and linguistically appropriate slh services in the country. the current authors have identified three main influencing factors. the first influencing factor is a challenge around student access into the training programmes that offer slh training. despite the acknowledged general lack of student access to, opportunity and success in higher education of black students, the slh professions, in particular, have historically and to a large extent still currently remain exclusive to white female students. of the gross participation rate of 17% that has been documented for the general student population, where numbers are significantly skewed to favour white students (black students 9%, mixed race students 13%, indian students 40% and white students 70%) (che, 2004, 2013, 2014) – the same pattern is seen in slh professions in the country. this unrepresentative demographic profile is seen at both undergraduate and postgraduate levels with promising changes starting to emerge at undergraduate level at some of the training programmes. this non-inclusive culture of the slh professions at university level is also seen in participation levels at professional association levels where demographic profiles of portfolio holders within professional associations do not reflect the linguistic and cultural diversity of the professions in the country, hence the recent establishment of the national black speech language hearing association (nabslha), which is seen as a clear indication of the non-inclusive nature of the current professional associations. this lack of diversity inadvertently affects the priorities that the associations engage with, their positions and stances on matters of national importance and their engagement with professional and health care challenges facing the country. this lack of diversity at training and professional levels has an influence on what the profession does and offers, and where this is performed and offered. the second factor that the current authors believe influences slh service delivery within a multilingual and multicultural society such as south africa is directly linked to the undergraduate student enrolments. the limited numbers of black african students who get enrolled into the training programmes do not show good throughput rates. anecdotal evidence as well as annual unpublished reports from the various institutions that are shared at the annual inter-university heads of departments meetings indicate that throughput, dropout and undergraduate success and graduation rates of black people in slh professions highlight a need for improved equity of opportunity and positive outcomes for these students. this is consistent with the general findings of the higher education student population in south africa, where, for example, in 2010, the graduation rate of black students was 16% (hesa, 2014). this factor requires careful deliberation by training programmes as access without success does not take the profession forward, and has ethical implications in a context where resources are scarce. it could also be an indication of the need for curriculum and teaching and learning strategies review to that which is not foreign to the context. the third and arguably most important influencing factor contributing towards lack of slh professions transformation in the country is what the authors wish to term a toxic context. this contextual toxicity consists of slh programmes’ institutional cultures that do not welcome or embrace diversity, but rather tolerate it as a regulatory imperative. this culture of exclusion is not conducive to contextually relevant growth of the professions, and directly impacts on the access and success of those who are deemed ‘minority’ in the professions even though they are the majority in the country. the toxic institutional culture is exacerbated by the ‘academic culture’ which excludes diverse or local knowledge base that allows for academic training that is inclusive and relevant. for example, the practice where researchers exclude participants in studies for not being fluent in english, and using that as an inclusion criterion, should be carefully interrogated and its influence on research findings questioned – besides the obvious ethical implications. this, in turn, has a direct impact on ‘clinical culture’ that is strongly western and eurocentric in nature and positioning. this western and eurocentric culture was reported by tuomi as early as in 1994 where he noted how south african slh training reflects british and north american educational models. this therefore calls for careful considerations of providing students with epistemological access rather than just physical access as well as honest debates about which epistemologies and by whom in order to disrupt this contextual toxicity. in order to forge a different path for the profession going forward, be it wilfully or in response to the growing discontent demonstrated by ‘fees must fall’ or ‘decolonise education’ movements, the current authors invite slh students and practitioners to carefully and honestly engage with the following questions, and take steps to address gaps where these exist – be it by engaging in research, by mentoring, by developing tools, by engaging in curriculum developments, and so on. what speech-language and hearing students and practitioners need to carefully consider for productive engagement with these questions, the current authors recommend that readers answer these questions from their own positionality and also from that of another, for example, a white clinician or educator must interrogate the questions also from the perspective of an african individual, indian individual or a mixed race individual. as a student, did you see yourself in the curriculum? did you see your client in the curriculum? do you think that the research output from your profession reflects your truth? does it reflect your world view? does it accommodate your voice? does it reflect the truth of the context you are in? (knowledge base – evidence-based practice) how have the dominant discourses that characterise the intellectual space in your profession developed and how have they been reproduced historically? how do they continue to be reproduced? does the maintenance of the status quo allow for best practice in your profession? what are the implications of the dominant discourses for social inclusion and social justice in your professions? what are the implications of the dominant discourses for ethical and efficacious clinical care of your clients in your profession? what are the prevailing conceptions of epistemology4 and ontology5 and to what extent have these been or are being deracialised, degendered and decolonised in your profession? how do the dominant cultures in your professions affect student learning, progress and success and social equity and redress? how do the dominant cultures in your profession affect your clinical engagements and success with your patients? how do the dominant cultures affect research and knowledge generation in your profession? how do the dominant cultures also affect the development and retention of a new generation of professionals that must reflect the demographic profile of the country? finally, how permeable is the current professional space in your professions to a critical reflexivity in terms of changing the status quo? what needs to happen within the speech-language and hearing professions in south africa? the current authors are of the strong view that honest acknowledgement of the serious shortcomings and problems around transformation in slh professions in south africa is required; and this viewpoint publication forms part of this invitation to honest engagement. acknowledgement of discrimination and racism as one of the key features of colonialism and apartheid that continue to profoundly shape the social composition of our professions nationally is overdue. the current use of language and culture to preserve slh professions’ whiteness needs confrontation. this reflection must also encompass deliberations around the feminised nature of our professions, and how this influences training and practice – as evidence shows that communication across gender is complex (padavic & reskin, 2002). such honest reflections will lead to greater recognition of the urgent need to re-look at and re-imagine slh training through enhancing academic capabilities of the south african training programmes. enhancing academic capabilities of training programmes in the form of academic support, the current authors believe, would be in line with what the che (2013) suggests. the che emphasised the importance of focussing on more than just teaching skills where tips for teaching better are provided, but should also focus on the value of meaningful reflection on contextual realities as well as thorough development of theories and scholarship on teaching and learning in this context – here the current authors refer to undergraduate curriculum reform that is of international standards but is afrocentric. speech-language and hearing training programmes from all south african universities have a moral obligation to actively engage with and address the legacy of apartheid in all their teaching and learning activities. responding to this moral obligation would have a positive impact in professionals produced by these programmes, with active and visible support by professional associations or bodies that would start to reflect the demographic profile of the country in terms of composition as well as priorities – who also actively address contextually relevant issues within this diverse south african context. conclusion as part of transformation, the slh professions in the country need to respond to the national calls to africanise institutions and service delivery, which include curriculum changes to incorporate more africa-centred courses and courses that are based on evidence that is contextually relevant and responsive; clinical care changes that are contextually relevant and responsive; research focus on local needs and issues for local benefit; clinical focus that will allow for ‘next practice’ and not just ‘best practice’; language policy that respects the fact that many people speak several languages and so teaching and learning (and clinical service provision) in only english or afrikaans creates challenges which need addressing and so on. in line with the goals of the south african government’s uhc through implementation of nhi, it is important that issues of diversity are addressed. if the slh professions in the country confront this knowledge and culture hegemony, they will be seen to be in covenant with the reconstruction and development programme (rdp), the constitutional mandate based on the section 27 of the constitution, the 1997 white paper for the transformation of the health system, as well as the vision 2030 of the national development plan vision 2030. transformation of the slh professions should deal with decolonisation6 of the curriculum by also introducing political consciousness and critical literacy diversity as recommended by stein (2010) where she advocates for a possession of a diversity grammar and vocabulary that facilitates a discussion of race, racism and antiracism, and parallel concepts employed in the analysis of other forms of oppression – this is performed within the regulations and scopes of the professions (national department of health, 2014). this is also advocated by pillay and kathard (2015) where they argue that if the south african slh professions do not address the impact of imperialism, colonialism and apartheid in the curriculum; these professions will continue to provide inequitable services to the majority of the south african population. the current authors strongly argue that political consciousness in the curriculum and training will teach students how to respond to cultural context, foster connection with patients or clients and will facilitate proper and productive investments in relationships with the communities they serve. the current status quo in the way the slh professions conduct clinical service provision with most of their patients leads to questionable efficacy and continued health inequalities, with a culture of planisa (phakathi, 2006) (where the use of ad hoc interpreters is accepted as norm) that needs to be minimised, if not completely eliminated. addressing human and language rights through policies based on social justice, human rights and equity in access to health care and rehabilitation services in slh curricula is complex. it requires awareness and attitude shifts in training institutions, academic and clinical educators, which are pivotal to teaching about cultural competency and social inclusion to successfully prepare knowledgeable and compassionate slh professionals. it also calls for commitment to ‘epistemic disobedience’ as conceived by mignolo (2009). in this article, epistemic disobedience means that the south african slh professions have to deliberately refuse to fit the script that has been crafted for them by the patriarchal, heterosexist, racist, capitalistic and colonial system; 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(2016). communication rehabilitation in sub-saharan africa: a workforce profile of speech and language therapists. african journal of disability, 5(1), a227. https://doi.org/10.4102/ajod.v5i1.227 footnotes 1. deracialisation: attenuate or eliminate distinctive racial qualities, free from appeal to race. 2. demasculanisation: attenuate or eliminate distinctive masculine qualities, free from appeal to masculinity. 3. degendering: to free from any association with or dependence on gender. 4. epistemology: theory of knowledge (the way we know things), the nature of knowledge and how it relates to truth, belief and justification. 5. ontology: nature of being (what things are), becoming, existence, or reality … what is meant by ‘being’. 6. decolonisation: act of getting rid of colonisation; freeing a country from being dependent on another country. 58 sajcd • vol 57 • december 2010 literacy development of english language learners: the outcomes of an intervention programme in grade r anna-mari olivier christine anthonissen frenette southwood department of general linguistics, stellenbosch university, w cape correspondence to: a-m olivier (annamari@iafrica.com) identifying children at risk of developing reading difficulties and providing timely and preventive intervention are starting points to addressing the challenge of low literacy rates in south africa. justice (2006a) proposes that many children do not exhibit basic reading proficiency at the expected stage of their development because schools fail to provide adequate educational support for children with certain characteristics which place them at risk of developing reading difficulties. several such risk factors, which leave preschoolers vulnerable to experiencing difficulties in acquiring critical emergent literacy skills, have been identified in the literature and include factors inherent to the child – e.g. language, cognitive and/or hearing impairment; attention deficits; a family history of reading difficulty; and/or low educational attainment of the mother – as well as factors pertaining to the environment, e.g. low socio-economic status (ses) and/or a first language that varies dialectally from that of the local academic curriculum (catts, fey, zhang & tomblin, 2001; cavanaugh, kim, wanzek & vaughn, 2004; duncan & seymour, 2000). according to mcgee and richgels (2003), the combination of limited proficiency in the language of education, minority status and a low ses is the best predictor that a child will fail to learn to read and write well. in south africa, monolingualism is the exception rather than the norm. this poses several challenges to parents and teachers in selecting and using a language of teaching and learning in educational programmes. in the western cape, where isixhosa, english and afrikaans are the three languages used as first languages (l1s) by the overwhelming majority of residents, the language policy of primary schools of november 2002 (western cape education department, 2002) contained two central recommendations: (i) to implement a policy of mother-tongue-based bilingual education in grades r to 6 from 2004/2005 in all primary schools in the province; and (ii) to institute incentives to guide all children towards electing to take the third official language of the province as their second additional language. parents have been encouraged by means of information brochures and media awareness programmes to enrol their children in mothertongue education; however, statistics from the western cape education department (wced) (personal communication, 2005) indicate that 25.7% of the learners attending english-medium primary schools in the western cape did not have english as their home language.* in the southern cape and karoo region of the western cape, where the present study was conducted, on average 20% of learners in englishmedium classrooms came from homes in which english is not the primary language spoken, and in some classrooms this figure rises to 92.3% (wced, personal communication, 2007). therefore, despite recommendations and efforts from the wced to promote mother-tongue education, parents choose to enrol their children at primary schools where english is the language of teaching and learning. this choice is related to the trend among non-englishspeaking south africans to raise their children as l1 english speakers (anthonissen, 2009; willenberg, 2004), as english is still widely regarded as the language of prestige and opportunity. limited proficiency in the language of education has been identified as a possible risk factor for literacy development difficulties; however, studies that have investigated the influence of oral language proficiency and early literacy knowledge so far have focused mainly on children with specific language impairment (sli) and children with phonological disorders (bird, bishop & freeman, 1995; boudreau & hedberg, 1999). very few studies have investigated the prevalence and literacy development of ells with reading disabilities (lipka & siegel, 2007). while there is wide variation in the effectiveness of educational programmes, it is known that minority language learners are at a higher than average risk for failure or difficulty in second language (l2)-only classrooms (genesee, paradis & crago, 2004). these learners face several challenges, such as acquiring a new language, integrating socially into a new peer group and learning new academic skills and knowledge, often doing so without the support of an educator who is proficient in their l1. on their own each of these factors could inhibit literacy development, with compounded risk when they have to be dealt with simultaneously. the cohort of l2 learners in english submersion educational programmes is indeed a highly heterogeneous group. not only do they enter formal schooling with different l1s and different levels of proficiency in their l1 and their l2, but there are several other factors abstract this study aims to contribute to the knowledge base on the status and development of emergent literacy skills of learners receiving formal education in their second or additional language. the focus is on young english language learners (ells), i.e. learners whose home language is not english but who have english as their language of teaching and learning. this article reports on a study that investigated ells’ emergent literacy skills prior to entering grade 1 and then evaluated the effectiveness of an evidence-based stimulation programme on early literacy skills in the south african context. using a quasi-experimental design, ells’ emergent literacy skills were assessed with an adapted version of 8 of the subtests of the emergent literacy assessment battery (willenberg, 2004) and were compared to those of english first language (l1) and of ell control groups, both before and after the 8-week purpose-designed programme. while learners showed significant improvement on 6 of the 8 subtests, the programme did not significantly improve ells’ skills in comparison to those of the control groups. possible independent variables contributing to the dearth of intervention effect include socio-economic status, learners’ l1, and teacherand classroom-specific characteristics, all of which were considered in this study. clinical implications for speech-language therapists with regard to assessment, intervention, service delivery and outcome measures are highlighted. keywords: emergent literacy, english language learners, language stimulation programme, preschoolers, second-language learners *for the purposes of this article, the term english language learners (ells) will be used for such learners, i.e. for learners who are educated through the medium of english, but who have an l1 other than english. vol 57 • december 2010 • sajcd 59 literacy development of english language learners that can also influence l2 acquisition, and consequently the child’s overall language proficiency. these factors include the timing of l2 acquisition (i.e. simultaneous v. sequential acquisition), the environment in which the l2 is/was acquired and the degree to which the home language is/was maintained, as well as innate characteristics such as personality, motivation and language aptitude (moore, pérez-méndez & boerger, 2006). environmental factors pertaining to the home environment further contribute to the heterogeneity within the ell population. parents’ level of proficiency in the child’s language of education, their interactive strategies, and their beliefs regarding and values attached to literacy and personal characteristics such as their psychological well-being have all been shown to have an effect on the quality of the home literacy environment (bennett-armistead, duke & moses, 2005; willenberg, 2004). in addition to the learner’s home environment, the quality of literacy exposure and instruction in the preschool classroom contributes to the heterogeneity of the ell population entering primary school (morrow, 2007). as many educators lack knowledge regarding the promotion and facilitation of ells’ oral language skills, the quality of conversational exchanges and literacy-related experiences in preschool settings are highly variable (dickinson & tabors, 2001, as cited in justice 2006a). a final factor contributing to the heterogeneity of the ell population in the south african context involves the variability of l1s spoken in any particular classroom. data from the wced (personal communication, 2005) indicated that the majority of learners attending english-medium primary schools in the western cape spoke either english, isixhosa, afrikaans or isizulu as home language, but that it is not unusual to come across l1 speakers of any of the seven other official languages, or unofficial languages, in these classrooms. while multilingual children are often credited with more advanced metalinguistic awareness than their monolingual peers (bialystok, 2001; genesee et al., 2004), teachers’ limited proficiency in the ells’ l1 and the limited availability of teaching assistants in l2-only classrooms may confine the potential advantages on which ells should in theory be able to capitalise. while learners educated in their l2 are identified as particularly vulnerable to reading difficulties, it is also widely acknowledged that an intervention programme should intervene at an appropriate level and should target identified and measurable areas of strengths and weaknesses. this study aimed to prevent literacy difficulties in a highrisk population and not to provide remedial therapy for diagnosed reading disorders. however, a precise understanding of a learner’s current level of language and literacy proficiency is essential for providing individual and personalised support for at-risk ells (mcgee & richgels, 2003). assessment of ells is a particularly contentious topic for slts and educationalists in south africa, as double jeopardy is always a possibility: we are assessing young learners with limited exposure to formal test situations who might be unfamiliar with task requirements, and we are often assessing children with limited exposure to the medium of print. the lack of appropriate assessment materials as well as the lack of normative data on typical bilingual development or early sequential bilingual development should also be borne in mind when assessing ells and drawing conclusions regarding their language abilities. in order to take into account the specific needs of the ell population, a dynamic assessment approach which includes both formal and more client-centred tasks is proposed (paul, 2007). by using different tasks (e.g. formal picture selection procedures as well as spontaneous language sampling), quantitative as well as qualitative information is gathered, and by supplementing formal test measures with dynamic and informal measures, the examiner can also adapt the protocol depending on the child’s familiarity with the task and the test environment, and can take aspects such as code switching into consideration when analysing and interpreting the child’s performance (müller, 2003). according to justice (2006a), the most desirable emergent literacy areas to assess are those that: (i) directly contribute to and are predictive of later reading and writing achievements; and (ii) are amenable to change through intervention. in a meta-analysis conducted by the national early literacy panel (2004, cited in justice, 2006a), the following areas were found to consistently and most strongly relate to later reading achievement: (i) alphabet knowledge i.e. receptive or expressive knowledge of the individual letters of the alphabet as well as phoneme-grapheme awareness (nancollis, lawrie & dodd, 2005); (ii) concepts about print – i.e. knowledge of the rules governing how print is used across various genres, e.g. books or environmental print; (iii) phonological awareness – i.e. sensitivity to the sound structure of spoken language, in particular on phoneme level; (iv) invented spelling – i.e. representation of the orthography of written language; (v) oral language – this includes syntactic, lexical and narrative abilities; and (vi) name writing. the emergent literacy assessment (ela; willenberg, 2004) is a comprehensive assessment battery that provides information on both conceptual and procedural emergent literacy skills. this assessment instrument was compiled by a south african researcher and used in her study with 101 grade r learners from historically disadvantaged communities in the western cape. use of the ela provided the opportunity to compare and contrast results with those of the comprehensive willenberg study; however certain changes were made to the original ela for the purposes of the present study based on the following limitations that were identified: 1. the small number of test items in some subtests heightened the possibility of chance responses, and extra items were therefore added. 2. in the original five items in the sound-in-word final test, onset-rime combinations were utilised, e.g. fan-bat-cat. phoneme segmentation proved to be a particularly consistent predictor of reading ability (hulme, hatcher, nation, brown, adams & stuart, 2002), and therefore five additional items were selected which required learners to isolate only the final phoneme, e.g. mop-tap-pen. 3. the inclusion of rhyming tasks in the assessment battery (and by implication also the predictive value in terms of later reading success) is a contentious issue in the literature. bradley and bryant (1983) argued that large phonological units (e.g. rhyming) have definite predictive value, while goswami and bryant (1990) confirmed that children normally progress from an awareness of syllables via onsetrime to phonemes, indicating a normal developmental pattern with prognostic value. goswami and bryant (1990) suggested that onset and rhyme sensitivity make a direct and specific contribution to word reading ability. while the jury is still out on this aspect, the two rhyming subtests of the ela were retained for the purpose of this study, for the following reasons: (i) a strong predictive relation between onset-rime awareness and reading development has been shown for english, the medium of assessment in the current study; and (ii) in view of the small body of research in the area of emergent literacy in south africa, and consequently the dearth of normative data, the willenberg (2004) study provided valuable comparative data for the current study. inclusion of these two subtests provided the researchers with more data regarding emergent literacy performance of south african preschoolers. 4. a fourth limitation of the ela battery is its exclusively linguistic perspective, primarily concerned with the description of different language-related behaviours. although the subtests suffice in identifying and describing areas of difficulty, no account is taken of underlying cognitive processes that might shed more light on the nature of the difficulties (stackhouse & wells, 1997). as no theoretical model of speech processing underpinned the compilation of the ela, no hypothesis can be generated about the level of breakdown that gives rise to specific literacy difficulties. a psycholinguistic approach in assessment of literacy development of ells might be particularly useful at the second and third tiers of assessment, when differential diagnosis of ells with literacy disorders becomes an important aim. 60 sajcd • vol 57 • december 2010 literacy development of english language learners 5. finally, while it is the authors’ belief that ells should be assessed in all their respective languages before any diagnoses regarding language delays or language impairments are made, the aim of assessment in the current study was not differential diagnosis of reading difficulties, but a discrete-point comparison of preschoolers’ emergent literacy abilities in order to monitor their progress during the first tier of literacy intervention (justice, 2006b). while the research was conducted in submersion classrooms where the ells’ l1 was not utilised in acquiring literacy skills, the ela battery was only conducted in english and not translated into any of the home languages of the ells concerned. several studies have indicated that sustained and intensive preventive interventions from preschool through to grade 2 are effective in reducing reading difficulties among at-risk learners (justice, 2006b; vaughn, linan-thompson & hickman, 2003). having reviewed the literature with regard to intervention studies for preschool ells, we synthesised findings to set up a framework for the delivery of emergent literacy intervention in the south african context. kaderavek and justice (2004) suggest an integrated approach to intervention. the authors distinguish two approaches to emergent literacy intervention: a ‘top-down’ holistic model and ‘bottom-up’ reductionist learning model. the holistic model emphasises whole-language principles through child-directed, informal and naturalistic interactions, while the ‘bottom-up’ model emphasises explicit and directive teaching of critical literacy concepts. examples of embedded holistic intervention strategies would include literacyenriched play settings, print-rich classroom environments and adultchild shared storybook reading (morrow, 2007; whitehurst & lonigan, 2002). examples of more explicit, structured and teacheror cliniciandirected approaches would involve intervention programmes that provide deliberate, scaffolded exposure to specific concepts and skills, e.g. phonological awareness, concepts of print and alphabet knowledge. kaderavek and justice (2004) propose an embedded-explicit model which synthesises two strands of evidence-based practices, i.e. holistic intervention through daily embedded opportunities by the slt in consultation and collaboration with the teacher and direct and explicit intervention of specific concepts and skills by the slt. in an attempt to develop such an embedded-explicit intervention programme for preschool ells in the south-african context, a pilot study was conducted in the southern cape and karoo region (cf. olivier, 2009). thirty-two grade r learners were assessed on 10 subtests of the ela battery (willenberg, 2004), and their performance was analysed by taking six independent variables into account. the learners’ age, gender and school and mothers’ level of education did not have any significant influence on their performance. however, those with a higher ses performed better on oral language-related subtests, and english l1 learners performed significantly better than their ell peers on 8 of the 10 subtests. based on these results as well as evidence-based recommendations in the literature, a stimulation programme (the bridging programme for ells to accelerate reading development skills (bears programme) was compiled to be implemented and evaluated in this study. acquiring literacy poses unique challenges in a context where learning takes place through medium of an l2, and our hypothesis was that a well-developed and comprehensive stimulation programme would have statistically significant benefits for the l2 learner. method the main research question was: ‘what is the effect of a particular emergent literacy stimulation programme in grade r on the development of literacy of ells in grade 1?’ in order to answer this question comprehensively, the study had the following specific aims: 1. to ascertain the emergent literacy skills of english l1 learners and ells in grade r, 4 months before entering grade 1. 2. after administering the developed programme to a selected group of ells, to determine the measurable effects on emergent literacy skills that are registered upon entering grade 1. 3. to establish whether independent variables such as ses, home language and school environment have an effect on performance on the eight subtests of the ela battery administered in this study. research design a quasi-experimental design compared four groups of participants with repeated measures, assessing performance on eight different emergent literacy subskills. two experimental groups and two control groups took part in this study. two subtests of the ela, namely emergent writing and spelling and environmental print, were not included in this study, as ells in the pilot study performed similarly to their english l1 peers on these subtests. these two subskills can therefore be regarded as areas of strength for ells. the subskills assessed by the remaining eight ela subtests are those in which the pilot study indicated notable differences between ells and english l1 learners; these were therefore regarded as priority areas of development to be included in the stimulation programme. a preand post-measurement intervention design was used, and results were analysed both quantitatively and qualitatively. participants based on feedback from principals regarding the language profiles in grade r classrooms, as well as their agreement to allow their learners to participate in the study, four primary schools in the eden and central karoo district were selected for inclusion in this study. permission was then obtained from the wced to conduct the main study in these four schools. table i outlines the profiles of the participating schools. participants all attended grade r classes in the four participating schools. two control classrooms (teachers b and d) and three experimental classrooms (teachers a, c and e) were selected within the four participating schools. within these five classrooms, participants were randomly selected from class lists and assigned to one of four groups (table ii), based on their home language. in order to control for teacher-specific qualities, the four groups were each made up of learners from at least two different classrooms (except for group 2, one of the control groups, which had learners in school c only). as the stimulation programme was developmental in nature and targeted ells who were considered at risk for literacy difficulties, no attempt was made to distinguish and exclude learners with possible language disorders, in order to create a true representation of the general grade r population. seventy-two participants were assigned to the four research groups and were assessed pre-intervention. six participants left the study, as their table i. profiles of participating schools school medium of instruction wced poverty index* total number of learners number of learners/ grade r classroom school a english-afrikaans parallel medium 5 342 26 school b english medium 5 598 27 school c english-afrikaans parallel medium 5 203 27 school d english-afrikaans parallel medium 5 409 23 *the wced uses the poverty index to classify schools according to the economic status of the neighbourhood. the index serves as a guideline for determining which schools need financial aid. schools on the 1st, 2nd and 3rd quintiles in the western cape are exempt from school fees. vol 57 • december 2010 • sajcd 61 literacy development of english language learners families moved out of the area during the course of the study, and they subsequently attended grade 1 outside of the eden and central karoo district. all participants attended schools classified on the fifth quintile of the poverty index used by the wced, indicating relatively similar socioeconomic environments. in order to better discriminate between participants in terms of their ses, an adapted version of the socioeconomic deprivation questionnaire (du plessis, 2003) was used to determine the ses of each participant. based on parental responses to 6 questions, participants were assigned to one of two categories of ses: either low (n=14) or high (n=52). the finding that a small number of learners fell into the low ses category concurred with the fact that the four schools were all on the fifth quintile of the wced’s poverty index. sixteen participants with english as their home language were assigned to one control group (group 1 no additional stimulation programme provided). fifty learners who did not have english as their home language, but did have it as their language of teaching and learning, were assigned to the three remaining groups: group 2 (control group receiving no additional stimulation programme); group 3 (experimental group receiving the first section of the stimulation programme, focusing exclusively on the development of oral language and conceptual knowledge); and group 4 (experimental group receiving the complete stimulation programme, focusing on oral language development as well as the stimulation of conceptual and procedural literacy skills and knowledge). these 50 learners had mostly either isixhosa (n=19) or afrikaans (n=25) as their home language, which is representative of the demographics of the western cape. six participants had alternative home languages less well represented in this region, namely isizulu (n=2), sesotho (n=3) and flemish (n=1). ethical considerations the study was approved by the wced, and participating principals gave permission for the study to be conducted in the respective schools. written consent was obtained from parents or guardians of all participants. parents were informed that they could terminate their child’s participation in the study at any time, without having to provide reasons for their decision. participants and schools were given code names to ensure anonymity. principals and teachers were contacted four times during the course of the study, to ensure understanding and to facilitate active participation. upon completion of the study, the four participating schools were provided with a copy of the revised stimulation programme and results of this study were communicated to the participating schools and to the wced. data collection procedures the data collection stage of the main study consisted of four phases which took place over a period of 4 months, although not consecutively: (i) orientation of all participating teachers and training of teachers in the experimental classrooms; (ii) assessment of all participants prior to the implementation of the stimulation programme; (iii) implementation of the stimulation programme in the experimental classrooms; and (iv) assessment of all participants upon entering grade 1. each participant was assessed on eight subtests of the adapted ela (willenberg, 2004). the content and scoring procedures of the ela subtests used in this study are presented in appendix a. data analysis procedures in accordance with willenberg’s (2004) study, a binary scoring system (1 = correct; 0 = incorrect) was utilised for 6 of the 8 subtests (refer to appendix a). qualitative rubrics were used to analyse responses on the remaining 2 subtests, namely word definition and fictional narrative. to limit researcher bias, these predesigned rubrics were used and, in order to control for inter-rater reliability for these 2 subtests, an agreement and consistency analysis was completed (statsoft inc., 2007). specifically, an intra-class correlation (icc) with a confidence interval was calculated to control for agreement and for consistency among raters. reliability of the data collection procedures was established by using experienced slts who were not involved in the intervention process and who were blind to the allocation of participants to the respective groups. in order to answer the respective research questions, the following statistical analyses were done: aim 1: participant characteristics, mean scores, standard deviations and analysis of variance (anova) were calculated and graphically represented, using the spss statistical software package (version 15; microsoft 2007). aim 2: preand post-intervention data were analysed using repeated measures anovas in order to determine any significant differences in scores for the main effects (namely time and intervention) as well as any interaction between the two main effects (time*intervention). where statistically significant differences were measured, appropriate posthoc tests were performed. anovas were calculated and graphically represented utilising both the statsoft and spss software packages. eight participants from each ell group were matched according to their performance on the peabody picture vocabulary test iii (ppvtiiib; dunn & dunn, 1997), and the scores of these 24 participants were analysed with the anova procedure to determine any significant differences in scores on the ela battery. aim 3: repeated measures anovas were performed to determine whether ses, home language or school environment had any significant effect on participants’ performance on the eight ela subtests. in addition, qualitative feedback was obtained from the three teachers in the experimental classrooms to inform any necessary changes to the bears programme. a questionnaire and feedback form were completed anonymously and consisted of both closed and open-ended questions. results and discussion table iii presents data on the performance of the four intervention groups on the eight subtests of the ela during the last term of grade r and before implementation of the intervention programme for the two experimental groups. anova indicated no significant difference in mean scores on the subtests sounds-in-words, rhyme recognition, letter recognition and concepts of print, indicating that l1 learners did not perform significantly better than their l2 peers with regard to these emergent literacy subskills. l1 learners (group 1) did not perform better than group 2, the ell control group (to be discussed below). however, the l1 learners did table ii. allocation of participants to groups group description school teacher n total n 1 english l1 learners school b b 13 no additional intervention school c d 3 16 2 english l2 learners school c d 10 10 no additional intervention 3 english l2 learners school a a 10 language-focused stimulation school b c 6 16 4 english l2 learners school b c 9 comprehensive stimulation school d e 15 24 62 sajcd • vol 57 • december 2010 literacy development of english language learners have significantly better mean scores than the ells in groups 3 and 4 on the following subtests: word definitions (group 4, p<0.001), narrative ability (group 3, p<0.05; group 4, p<0.001) and the ppvt-iiib (groups 3 and 4, p<0.001). as these three subtests are sensitive to receptive and expressive language proficiency, these group differences support the conclusions of previous studies that ells might exhibit a language delay with regard to grammatical and especially vocabulary development (catts et al., 2001; genesee et al., 2004). the evidence for vocabulary delay is more compelling than the case for grammatical delay; genesee et al. (2004) highlight the heterogeneity of the ell population and the impact that different degrees, contexts and quality of exposure to the language have on language development. it could be that vocabulary development correlates more closely with characteristics of the input to which ells are exposed than syntactic and morphological development. rosin (in justice, 2006a) comments on the difficulty researchers experience in controlling for variability in bilingualism and therefore, by implication, for variability in english language proficiency of ells. the heterogeneity of the ell population became apparent in the current study, providing support for rosin’s comment. ells in group 2 (the ell control group) performed significantly better than their ell peers in groups 3 and 4 (the two experimental groups) on two subtests, namely word definitions (group 3, p<0.01; group 4, p<0.001) and the ppvt-iiib (group 4, p<0.001). moreover, ells in group 2 performed significantly better than their ell peers (p<0.01) as well as their english l1 peers (p<0.001) on the subtest of rhyme production. furthermore, the pre-intervention results of this study highlight the considerable variation in performance of l2 learners, and the fact that some l2 learners exhibit similar emergent literacy skills than their l1 peers, at times even outperforming them, without intervention and before entering grade 1. the second research question pertained to the emergent literacy skills of the ells after the intervention period. table iv shows the performance of participants, first combined and then per group, on the eight ela subtests administered post-intervention, i.e. 4 months after the initial assessment. anova was conducted post-intervention and indicated significant differences between the four groups on all eight subtests. the anova and post-hoc bonferroni multiple comparison results are summarised in table v. whereas english l1 learners (group 1) before intervention outperformed their ell peers in the two experimental groups (groups 3 and 4) on measures of language ability only, table v indicates that, in addition to performance in the three language-related subtests, group 1 also performed significantly better post intervention than did groups 3 and 4 on the sounds-in-words and concepts of print subtests, respectively. furthermore, in comparison with results from the initial assessment, group 2 (the ell control group) performed significantly better than their l2 peers in the experimental groups on three additional subtests upon entering grade 1, namely rhyme recognition, concepts of print and letter recognition. in order to determine whether any of these observed differences in performance over the 4 months were brought about by the respective stimulation programmes in the experimental classrooms or by the curricula followed in the control classrooms, repeated measures anova was employed for the two main effects, namely time and intervention (time*intervention). a significant difference for the interaction between the two main effects was present on one subtest, table iii. pre-intervention mean scores (m) and standard deviations (sds), 4 months prior to entering grade 1 ela subtest all participants (n=66) group 1* (n=16) group 2† (n=10) group 3‡ (n=16) group 4§ (n=24) m sd m sd m sd m sd m sd sounds-in-words 9.6 4.2 10.7 3.9 10.7 5.8 8.4 2.6 8.5 4.5 rhyme recognition 8.7 3.6 9.2 2.3 9.6 4.4 8.1 3.1 7.8 4.2 rhyme production 2.6 3.3 1.3 2.9 6.2 3.5 1.0 1.9 1.9 3.1 letter recognition 8.3 7.4 11.1 7.0 9.1 8.5 8.3 7.5 6.1 7.0 concepts of print 5.4 1.9 6.0 1.7 5.5 1.8 5.4 2.1 4.6 1.7 word definitions 31.2 15.1 36.4 10.2 44.6 18.4 26.0 11.6 18.0 8.8 narrative ability 6.0 3.3 8.2 2.4 6.8 3.5 5.1 3.6 4.0 2.2 ppvt-iiib 83.2 14.5 94.3 11.9 89.8 5.3 77.9 12.6 70.7 10.6 *english l1 learners – no additional intervention. †ells – no additional intervention. ‡ells – language-focused stimulation, part of the bears programme . §ells – comprehensive literacy stimulation (i.e. complete bears programme). table iv. mean scores (m) and standard deviations (sds) upon entering grade 1, post intervention ela subtest all participants (n=66) group 1* (n=16) group 2† (n=10) group 3‡ (n=16) group 4§ (n=24) m sd m sd m sd m sd m sd sounds-in-words 12.3 3.8 13.9 3.2 13.9 4.5 10.3 3.3 11.0 3.4 rhyme recognition 9.9 3.0 10.3 2.5 12.2 2.9 8.4 2.5 8.6 3.0 rhyme production 4.2 3.7 4.2 3.3 7.3 3.7 2.1 2.9 3.2 3.7 letter recognition 12.1 8.0 15.3 6.7 18.8 7.5 9.0 7.0 9.2 7.4 concepts of print 5.7 1.6 6.3 1.5 6.4 0.8 5.4 1.7 4.8 1.4 word definitions 35.8 15.1 44.3 9.8 44.2 15.6 30.8 13.8 24.0 11.4 narrative ability 7.5 3.4 8.9 4.0 8.4 2.7 7.1 3.1 5.6 2.7 ppvt-iiib 83.5 17.0 96.3 11.6 93.2 8.1 76.4 13.1 68.1 13.4 *english l1 learners – no additional intervention. †ells – no additional intervention. ‡ells – language-focused stimulation, part of the bears programme. §ells – comprehensive literacy stimulation (i.e. complete bears programme). vol 57 • december 2010 • sajcd 63 literacy development of english language learners the letter recognition subtest, indicating that the observed difference in preand post-intervention scores for this subtest can be attributed to intervention effect as opposed to normal developmental changes. l1 learners and ells in the control group (groups 1 and 2) made significant progress with regard to alphabet letter knowledge over the 4-month period prior to entering grade 1. in relation to their peers, the two experimental groups on the other hand did not make any significant progress on this emergent literacy skill, despite having received additional intervention. possible explanations for this include: 1. the content of the curriculum followed and/or teacher-specific emphasis on alphabet letters in the two control classrooms contributed to the observed improvement in alphabet knowledge of learners in groups 1 and 2. learners in both these control groups were exposed to the letterland programme (wendon, 2003) which makes explicit use of letter-sound associations. some, but not all, learners in groups 3 and 4 were also exposed to the letterland programme as part of their normal class curriculum. 2. the amount of time and depth dedicated to alphabet letter knowledge in the bears stimulation programme was not sufficient to bring about significant improvement for ells in the experimental groups. 3. where learners are also lagging behind in other areas of language development, a 4-month period is not sufficient for ells to consolidate this particular subskill. this conclusion is supported by the fact that group 2 had already performed significantly better than their l2 peers on two language-related subtests pre-intervention (word definitions and the ppvt-iiib), which might indicate that they were better equipped to integrate and consolidate skills pertaining to alphabet knowledge. 4. learners in group 4, who received the comprehensive bears programme and were expected to show progress in this subskill, consistently scored lower than their peers in the ell control group on the language-related subtests, namely word definitions, narrative ability and the ppvt-iiib. on the ppvt-iiib, this group scored more than two standard deviations below the mean, indicating extremely delayed receptive vocabulary abilities. the group’s ability to understand instructions and process procedural literacy knowledge might have been restricted by the observed language delay in relation to their ell peers. in order to further investigate the observed performance of the english l2 control group (group 2) in relation to that of the two intervention groups, three possible confounding variables that could have resulted in the observed differences in performance were considered, namely ses, characteristics of the learners’ l1, and effect of curriculum or teacher characteristics. each will be discussed below. socio-economic status for the purpose of determining the possible confounding effect of ses, l1 learners were not included in the analysis of data, in order to eliminate the influence of home language on test results. fourteen ells were categorised in the low-ses group, while 36 learners were in the high-ses group. in line with previous studies on the effect of ses on literacy measures (dodd & carr, 2003; duncan & seymour, 2000), the ells performed as one would predict: participants in the low-ses group scored consistently lower than participants in the high-ses group across the eight ela subtests, both before and post intervention. anova was conducted to assess the impact of ses on learners’ performance on the ela over the 4-month intervention period. there was no significant interaction between time and ses for any of the eight subtests, confirming that while learners in the high ses group (n=36) both before and post intervention had higher mean scores than their peers from more disadvantaged backgrounds (n=14), this gap neither widened nor narrowed significantly over the 4-month period prior to entering grade 1. a substantial main effect for ses indicated that learners with high ses performed significantly better than their peers from disadvantaged backgrounds on the three language-related subtests: word definitions: f(1.48)=7.9, p<0.01; narratives: f(1,48)=6.8, p<0.05; and the ppvtiiib: f(1.48)=10.6; p<0.01. this result corroborates studies which found that language skill varies systematically as a function of ses (duncan & seymour, 2000; hoff, 2006). in an attempt to explain this phenomenon, hart and risley (1995) found that mothers with higher ses talked more, used a richer vocabulary and provided more information about objects being labelled than did mothers from a more disadvantaged socio-economic background. characteristics of learners’ l1 repeated measures anova were conducted to assess the possible influence of l1 on performance over the 4 months of intervention. the results of this analysis showed that there was no significant interaction between language and time (time*language), indicating that no language group (afrikaans l1, english l1, isixhosa l1 or other l1) performed significantly different to any of the other groups over the 4-month period prior to entering grade 1. effect of curriculum or teacher characteristics there was no significant interaction between time and teacher (time*teacher) on any of the eight subtests, indicating that teacherspecific characteristics or the specific curriculum followed in addition to the bears stimulation programme did not influence these learners’ performance on the ela over the 4-month intervention period. there was, however, a significant teacher effect on three language-related subtests, namely word definitions, fictional narratives and the ppvtiiib, with ells in the classroom of teacher e performing significantly poorer than their ell peers in the other experimental classrooms. while several variables could have contributed to the performance of teacher e’s learners, the combination of this teacher’s l1 (afrikaans), her considerably shorter teaching experience and the high percentage of ells in her classroom (impacting on peer learning opportunities) seems to offer a plausible explanation for her learners’ poor performance. conclusions the performance of the ell control group highlighted the heterogeneity of the ell population with regard to their emergent literacy abilities. while the bears programme was developmental in nature, aiming table v. significant differences in performance on ela subtests post intervention (p<0.05*, p<0.01†, p<0.001‡) ela subtest f (3.65) p post-hoc results sounds-in-words 4.3 0.008† group 1 performed better than group 3 rhyme recognition 5.2 0.003† group 2 performed better than groups 3 and 4 rhyme production 5.2 0.003† group 2 performed better than groups 3 and 4 letter recognition 6.2 0.001† group 2 performed better than groups 3 and 4 concepts about print 5.1 0.003† groups 1 and 2 performed better than group 4 word definitions 11.5 0.000‡ group 1 performed better than groups 3 and 4, and group 2 performed better than group 4 narratives 4.1 0.010* group 1 performed better than group 4 ppvt-iiib 21.1 0.000‡ groups 1 and 2 performed better than groups 3 and 4 64 sajcd • vol 57 • december 2010 literacy development of english language learners at providing a population at risk for reading difficulties with critical subskills to close the gap between them and their english l1 peers over a short period, it is clear that the growth trajectory of ells should be monitored very carefully over an extended period by means of culturally and linguistically valid assessment measures. as stated by hus (2001), a vast number of research findings confirm that in the population of children with significant reading problems, there is a disproportionate representation of children who come from poor, racial minority or cultural minority† groups and are l1 speakers of languages other than english. while the present study indicated that ell status in isolation does not necessarily result in delayed emergent literacy skills (cf. the performance of group 2, for instance), the combination of being an ell, coming from a disadvantaged background, being in a classroom with a high percentage of ells and having a teacher with limited experience with this population might have a compounded impact on these learners’ emergent literacy skills, in particular their oral language skills. for ells, a group with observed variability in receptive and expressive language abilities, teachers’ language use is even more important and thus warrants definite attention and focus as part of an emergent literacy intervention programme. dickinson and sprague (2002) conclude that providing high-quality further professional development opportunities to teachers is of critical importance. they have found two aspects of teachers’ conversations to be associated with end of kindergarten (grade r) assessment results, namely their use of rare and unfamiliar words and their ability to limit how much they said and hence to listen to what children were saying. weitzman and greenberg (2002) concurred with the importance of these two aspects which often warrant intensive training and specific guidance to teachers on how to adapt their language use to facilitate ells’ receptive and expressive language development. in this regard, the slt needs to fulfil a consultative role and be proactive with regard to early appropriate assessment and intervention for learners who lag behind their peers. with regard to the development and implementation of emergent literacy intervention programmes, the content, timing and predictive value of skills need careful consideration. although the bears programme was based on evidence-based principles and incorporated oral language, print awareness and phonological awareness components, learners did not show any significant improvement in relation to two control groups who followed a commercially available phonics programme. while ell participants in the experimental groups showed significant improvement in several subskills over the 4-month period, they did not close the gap between themselves and their l1 peers, or between themselves and an ell control group with age-appropriate language skills. however, when participants were matched with regard to receptive language pre-intervention, there was no significant difference in performance upon entering grade 1, suggesting that the area of oral language needs to be reconsidered in the development of emergent literacy programmes. a more explicit approach towards semantic and syntactic language development within the literacy curriculum for ells should be explored and evaluated (fey, cleave, long & hughes, 1993; justice, mashburn, pence & wiggins, 2008). in other words, what is often referred to as ‘general language stimulation’ (which usually involves reading stories and teaching vocabulary based on certain semantic themes) might not suffice for ells. rather, ells should be exposed to more specific scenarios which will give them the opportunity to acquire certain complex syntactic structures and also vocabulary items other than nouns, verbs, adjectives and adverbs (i.e. to also acquire, for example, quantifiers and conjunctions). finally, the results of this study call for researchers, clinicians and educators to be more rigorous in their approach to early literacy assessment and intervention, more accountable in their objective measuring of outcomes and more flexible in making the necessary changes when it becomes apparent that a particular approach is not providing optimal results. while there is still a paucity of scientific evidence for effective emergent literacy intervention programmes for learners educated in their l2, justice and pence (2004) recommend that practitioners integrate existing evidence with theoretical, practical and personal knowledge and continue to do so in the best interest of the ell population we serve. acknowledgement this material is based on work financially supported by the national research foundation (nrf) and western cape language committee (wclc). any opinions, findings, conclusions or recommendations expressed in this material are those of the authors and not of the nrf and wclc. references anthonissen, c. 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(2003). response to instruction as a means of identifying students with reading/learning disabilities. exceptional children, 69, 391-409. weitzman, e., & greenberg, j. (2002). learning language and loving it: a guide to promoting children’s social, language and literacy development in early childhood settings (2nd ed.). toronto: the hanen centre. wendon, l. (2003). letterland abc. retrieved on 14 january 2006 from http://www.letterland. co.za/index.php weschler, d. (1974). weschler intelligence scale for children-revised. new york: the psychological corporation. western cape education department. western cape language policy. 2002. retrieved on 24 february 2007 from http://wced.school.za/documents/lang_policy/index_exsum.html whitehurst, g. j., & lonigan, c. (2002). emergent literacy: development from prereaders to readers. in s. b. neuman & d. k. dickinson (eds.), handbook of early literacy research (pp. 11-29). new york: guilford press. willenberg, i. a. (2004). getting set for reading in the rainbow nation: emergent literacy skills and literacy environments of children in south africa. unpublished doctoral thesis: faculty of the graduate school of education, harvard university: proquest information and learning company. appendix a: content and scoring procedures of the emergent literacy assessment subtest description scoring procedures sounds-in-words a phoneme matching task in which children were expected to match each correct response was credited with one point. two (out of three) words that had either the same initial or the same final phonemes. picture cues were provided in order to minimise the effect of auditory memory. example: cat – ball – bag rhyme recognition children were expected to identify two (out of three) words that rhymed. each correct response was credited with one point. picture cues were provided in order to minimise the effect of auditory memory. example: cat – hat – ring rhyme production a rhyming pair was provided, and children were required to provide another each correct response was credited with one point. rhyming word. no picture cues were provided. word definitions this subtest was based on the word definition subtest of the weschler responses were directly transcribed and audio intelligence scale for children (wisc-r; weschler 1974) and required children recorded. transcriptions were checked against the to define 13 (assumedly) familiar nouns: alphabet, bicycle, bird, clock, recordings and then coded according to the chat diamond, donkey, flower, foot, hat, knife, nail, thief and umbrella. system (codes for the human analysis of transcripts; no picture cues were provided. macwhinney & snow, 1995). definitions were coded for structure and content. six points were awarded for super-ordinates ($supo), two or four points for functional actions ($fun) or definitional features ($dft) and one point each for examples, descriptions, associations and applications ($edaa). scores were summated to create a total word definition score. concepts about print this subtest was based on the original concepts about print test (clay, 1979) each correct response was credited with one point. and utilised clay’s (2000) book follow me, moon as stimulus. concepts such as the front and back of the book, print direction and orientation, and literacy related terminology such as word, letter or page were assessed. letter recognition children were provided with two alphabet charts with upper or lower case each correct response was credited with one point. letters randomly displayed and they were expected to name all the letter each letter of the alphabet was only credited once. names they knew. fictional narrative the bear story (snow, tabors, nicholson & kurland, 1995), made up of three narratives were directly transcribed and audio colour pictures, was presented and children were expected to formulate a recorded so that the transcription could be verified narrative based on these pictures. later. after verification, coding was done according to the chat system. story-structure features, content, written-discourse features and micro-linguistic features were analysed. one point was assigned for each feature, and points were summated to create a total bear story score. peabody picture the ppvtiii-b (dunn & dunn, 1997) – a standardised, norm-referenced scoring was done according to the instructions of vocabulary test assessment of receptive vocabulary – was administered. this formal assessment procedure. response: d. swanepoel 10 d e p a r tm e n t o f c o m m u n ic a tio n p a th o lo g y , u n iv e r s ity o f p r e to r ia , sa . h. k athard, e. n aude, m. pillay and e r research-driven: a scientific profession accountable within contextual realities audiology and speech-language pathology are professional qualifications in the sciences of these respective fields. they are sciences because the professions are founded on the princi­ ple of scientific enquiry which employs logical reasoning proc­ esses to describe, solve, understand and explore phenomena and relationships (maxwell & satake, 2006). as practitioners o f these respective sciences we owe our professions to the dedicated application o f scientific enquiry over time to the. field o f communication disorders and other basic sciences. because they are sciences, the practice o f audiology and speech language pathology are inherently research-orientated. this means that the professions are not only the offspring o f accu­ mulated research but also imply that practising it accountably requires that each clinician, to an extent, also be a researcher. it is this inextricably mutual relationship between research and practice that stimulates the growth and development of our services (walley et al., 2007). the development and improvement o f our professions should be guided by our scope o f practice and the populations to be served in the unique south african context. it should not therefore be guided by reigning political agendas but the pro­ fessions should rather abide by principles that transcend politi­ cal ideology, which reflect the deepest aspects o f human dig­ nity and respect for all persons. past political ideologies, which did not abide by this principle, resulted in a legacy of health­ care inequities in south africa. for example, approximately 80 to 85% o f the south african population relies on the public healthcare sector although the remaining 15 to 20% o f the population that accesses private healthcare services, utilizes 61% o f the country’s total health care expenditure (anc to­ day, 2005). this figure provides sufficient evidence that as professions we should not subscribe to political philosophies but should rather concern ourselves with upholding the princi­ ple o f respect for all persons within our professional capacity. the professions should therefore be aligned to a basic code of conduct that strives to provide equitable access to ac­ countable audiology and speech-language pathology services for all people within the contextual realities o f the south afri­ can population. this implies that the professions should be very closely involved with reigning issues of, for example, poverty and the burden o f infectious diseases in south africa, but within the confines o f our professional scope o f practice and in terms o f the populations which we are mandated to serve. these populations include two categories. firstly, pre­ vention in the professions encompasses the entire population in efforts to eliminate or minimize risks for, and sequelae of, communication disorders. in this broad category, aspects out­ side the professional scope impact directly on the effectiveness o f prevention, such as poverty which increases risks for com­ munication disorders (kubba et al., 2004; o ’connor, 2004). the second population is the sub-set o f individuals with a communication disorder for which intervention is provided. in this population many variables in a client’s environment influences the intervention at an individual level and profes­ sionals need to identify and address these at this level. as pro­ fessionals we are therefore obliged to engage in issues o f social justice and equity only as it relates to our professions at the level o f prevention and intervention. die suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 in engaging with these issues kathard et al. acknowl­ edge the crucial role o f research but raise questions regarding the appropriateness o f the empirical approach to research, re­ ferred to as a ‘cultural artifact ’, with respect to accomplishing this task. the current body o f professional knowledge on which our professions stand is presumed to be biased towards the populations from which this knowledge initially originated, i.e. ‘caucasian, middle-class, monolingual european speakers’. whilst it is true that the professions have been dominated by positivist empirical scientific enquiry, and in fact were founded on this very approach, it is important to consider their roles both as a vehicles for addressing current issues in the profes­ sions and as probable sources o f biased professional knowledge that may not be applicable to the majority o f south african populations. a positivist empirical research paradigm by definition implies a belief that there is objective truth which can be inves­ tigated and described by employing sound methods. it is im­ portant, however, to distinguish the type of research for which this positivist empirical approach is utilized (newman, 1997). a basic in contrast to an applied type of research is not influ­ enced by the population it is conducted on or by, and in fact will often not even utilize such samples towards its research ends. since our professions are based on the accumulation of decades o f basic research in the sciences underlying human communication such as anatomy, physiology and acoustics (maxwell & satake, 2006), the basic knowledge of our profes­ sions should not be influenced by research conducted by or on ‘mainly male, urban, middle-class, judeo-christian, european language speakers'. applied research, in contrast, is susceptible to bias due to the nature of the study population. this type o f research al­ though not necessarily constituting the basic knowledge o f our professions certainly constitutes the majority o f the research conducted by audiologists and speech-language pathologists and is referred to as professional research. since these profes­ sions are mainly concerned with addressing the challenges o f clients, the focus o f scientific enquiry is most often on solu­ tions which can be applied immediately (maxwell & satake, 2006). however, professional research should also aim to gen­ erate an authentic indigenous theoretical base for the profes­ sions (de vos, 2002). unfortunately, due to the past inequali­ ties o f south african healthcare services based on racial dis­ tinctions, the knowledge produced by applied research in healthcare professions such as audiology and speech-language pathology has certainly favoured a white cultural and linguistic minority. it is these inequalities, in terms o f access to services reflecting the cultural linguistic needs o f people in south af­ rica, which the professions should address by prioritizing ser­ vices and applied research to previously disadvantaged com­ munities. to address these reigning inequalities in research for the professions in the multicultural and multilingual south african context it is true that a positivist research paradigm may not be sufficient to describe the complexities o f the clients we serve as professionals. a holistic or eclectic approach, which combines positivist and phenomenological research paradigms and ap­ plies both quantitative and qualitative methods, may be more r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) im proving the r elevance o f speech-l anguage pathology and a udiology r esearch and p ractice 11 appropriate for the task. a phenomenological, in contrast to a positivist, research paradigm assumes that the world is socially construed and therefore all truth is subjective and relative (newman, 1997). combining research along the continuum o f the positivist and phenomenological extremes, investigating both abstract and concrete concepts to describe, solve, understand and explore professional practice and client profiles is therefore war­ ranted. this holistic or eclectic approach can provide a richer body o f professional knowledge that produces scientific fact within an understanding o f the subjective realities of the socio­ cultural populations which we serve. it is therefore not a matter o f abandoning old methods but rather o f embracing new ones alongside traditional research methods. to an increasing extent, this has been a trend in recent studies conducted by the profes­ sions in south africa (louw & avenant, 2002; van dijk, 2003; swanepoel et al., 2005). whilst it is necessary and useful to critically consider the research paradigms to be employed by the professions o f audiol­ ogy and speech-language pathology, on a more practical level it is essential that whatever the research being pursued, it must ultimately be published. research conducted by our professions in south africa unfortunately, remains unpublished in the over­ whelming majority o f cases. a marginal number o f publications, and especially international publications, have emerged from the respective fields o f audiology and speech-language pathology since the establishment o f the professions in south africa over five decades ago (swanepoel, 2006). credence and advocacy for our services rely in large part on the recognition o f the research we conduct. this is especially true in an era where evidence based practice has become a core principle o f professional prac­ tice. it is therefore o f great importance that we not only ensure the use of an holistic paradigm in our research but that we dem­ onstrate the worth o f our efforts by bringing them to fruition in the form o f internationally recognized peer-reviewed publica­ tions. the collective responsibility for establishing world-class research outputs that are locally relevant rests on the profession as a whole, and in particular on the academics and postgraduate students at tertiary institutions for audiology and speech language pathology. > ‘‘sociopolitical changes j have come and gone, but the challenge fo r the profession has remained the same to provide accountable services to the entire population based on quality training and contextual research efforts” (swanepoel, 2006, p.266). improving the relevance o f the research and practice of the professions o f audiology and speech-language pathology in south africa, as argued in response to the issues raised by response: ernaalant kathard et al., therefore relies on 1) the clear recognition o f the professions as sciences reliant on research development; 2) the adherence to basic principles of human dignity and respect for all persons instead of political ideologies; 3) the engagement of social justice and equity in our professional capacity only as these principles relate to scope of practice and the populations which we serve; 4) the utilization o f holistic research paradigms by embracing phenomenological methods alongside existing positivist methods; 5) the culmination o f research efforts being acknowledged in internationally recognized publications which serve an advocacy function in respect o f the professions and the respective services they render to the broader south african population. a n c t oday (2005). r esponding b etter to the health care n eeds o f com m unities. a n c t oday, 5(4 3 ). h ttp ://w w w .a n c .o rg .z a /a n c d o c s /a n c to d a y /2 0 0 5 / a t4 3 .h tm # artl de v os, a. (2002). scientific theory and pro fessio n al research. in a.s. de v os (ed.), r esea rch a t grass r oots. (2nd ed.) p retoria: v an schaik. 28-48. k ubba, h., m aca ndie, c., r itchie, k. & m acf arlane, m. (2004). is deafness a disease o f p overty? t he association betw een socio-econom ic deprivation and congenital hearing im pairm ent. in tern a tio n a l jo u r n a l o f a u diology, 43, 123-125. l ouw , b. & a venant, c. (2002). c ulture as co n tex t for intervention: developing a cu ltu rally co n g ru en t early intervention program . international p ediatrics, 17(3), 145-150. m axw ell, d.l. & satake, e. (2006). r eseach a n d sta tistic a l m ethods in co m m u ­ nication sc ien ces a n d disorders. c lifton park: t hom son d elm ar l earning. n eum an, w .l. (1997). so cia l r esearch m ethods: q ualitative a n d q uantitative a p p ro a ch es (3rd ed.), a llyn and b acon, boston. o ’c onnor, a. (2004). t he persistence in poverty. in d. potes & t. bow yer b ow er (e ds.) e a stern a n d southern a frica. d e ve lo p m en t challenges in a volatile region. e ssex: pearson e ducation l im ited.(pp. 89-117). s w anepoel, d. (2006). a udiology in south a frica. in tern a tio n a l j o u rn a l o f a u d io lo g y, 45, 262-266. s w anepoel, d ., h ugo, r. & louw, b. (2005). im plem enting infant hearing screening at m aternal and child health clinics: context and interactional processes. h ea lth sa g esondheid, 10(4), 3-15. v an d ijk, c.a . (2003). a n educational a u d io lo g y se rvice d elivery m odel: needs o f teachers o f children w ith hearing loss. u npublished d .phil. c om m unica­ tion p athology degree. u niversity o f pretoria. w alley, j., k han, m .a ., shah, s.k ., w itter, s. & w e, x. (2007). h ow to get research into practice: first g et p ractice into research. b ulletin o f th e w orld h ea lth o rganization, 85(6), 424-425. director: centre for alternative and augmentative communication, university o f pretoria, sa. a bou t being relevant: a com m ent on kathard, naude, pillay & ross (2007). i accepted the invitation to respond to this paper with pleasure, not only because i welcomed the critical thinking reflected in the paper, but also because i think the issues raised are vital to the long-term sustainability o f the professions of slp/audiology in this country. like others, i also have been deeply concerned about the profession and its future within the african continent. this concern is not based on a belief that the profession is irrele­ vant or peripheral to local development, but rather on the com­ plexities of the issues facing the field o f speech-language pa­ thology and audiology as well as other rehabilitation profes­ sions within poverty contexts. kathard et al. (2007) raises important issues upon which i would like to comment and include: • the issue o f relevance and different types o f research, • the role o f evidence-based practice and finally, • intervention in poverty contexts. for a long time, the western world has dominated the profession of speech-language pathology and audiology for good reasons. however, as the developing countries come into their own, the realization dawns that we can not translate strategies used in the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.anc.org.za/ancdocs/anctoday/2005/ abstract introduction the feedback model results and discussion hearing protection recommendations and conclusion acknowledgements references about the author(s) nomfundo f. moroe department of speech pathology and audiology, faculty of humanities, school of human and community development, university of the witwatersrand, johannesburg, south africa katijah khoza-shangase department of speech pathology and audiology, faculty of humanities, school of human and community development, university of the witwatersrand, johannesburg, south africa milka madahana centre for systems and control research, faculty of engineering, university of the witwatersrand, johannesburg, south africa otis nyandoro centre for systems and control research, faculty of engineering, university of the witwatersrand, johannesburg, south africa citation moroe, n.f., khoza-shangase, k., madahana, m., & nyandoro, o. (2020). feedback-based noise management matrix in action. south african journal of communication disorders, 67(2), a678. https://doi.org/10.4102/sajcd.v67i2.678 note: special collection: occupational hearing loss in africa. original research feedback-based noise management matrix in action nomfundo f. moroe, katijah khoza-shangase, milka madahana, otis nyandoro received: 23 sept. 2019; accepted: 06 feb. 2020; published: 01 apr. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: this article presents the details and findings of a practical implementation of a preliminary model for use in hearing conservation programmes (hcps) in the mining sector in south africa. objectives: the implementation is based on a previously published model, called feedback-based noise monitoring model (fbnmm), and represents its implementation as a tool of predicting occupational noise-induced hearing loss (onihl), as well as monitoring and managing hcps in the mining sector within the south african context. method: the article, utilising real miners’ data, demonstrates this basic static feedback model with its practical applications such as estimating, monitoring and providing quantitative information to aid miners, mining administrators and policymakers in decision-making around hcps, as recommended in the previous 2019 publication by moroe et al. this study was conducted in a south african platinum mine. evidence on the model’s sensitivity and practicability in early identification, intervention and management of onihl in the workplace is presented. results: findings show how the use of the model within an hcp viewed as a complex intervention can allow for early prediction of onihl, consequently affording more accurate early intervention as part of preventive audiology within the health and safety goals of mines. conclusion: the feedback-based model should be a useful tool for successful implementation and monitoring of hcps within south african mines. keywords: complex intervention; feedback-based noise monitoring model; hearing conservation programme; implementation; mining, noise-induced hearing loss; occupational noise; risk management. introduction occupational noise-induced hearing loss (onihl) is a complex disease (le, straatman, lea, & westerberg, 2017), which is recorded to be prevalent in the mining industry, with evidence suggesting that it is a leading work-related disability (ritzel & mccrary-quarles, 2008). ritzel and mccrary-quarles (2008) assert that, second only to presbycusis, onihl is a form of acquired hearing loss that presents the sufferer with significant negative consequences following exposure to high levels of noise (ritzel & mccrary-quarles, 2008). regardless of the fact that hearing loss has been considered as non-life-threatening, the presence of it, even in mild forms, is sufficient evidence to prove that if untreated it can lead to profound psychological and psychosocial consequences for the sufferer’s quality of life (tye-murray, 2009). furthermore, additional negative consequences of prolonged exposure to hazardous noise have been published, and these include increased fatigue and decreased concentration, which are known to increase human errors at work (amjad-sardrudi, dormohammadi, golmohammadi, & poorolajal, 2012; moroe, khoza-shangase, madahana, & nyandoro, 2019; picard et al., 2008). as far as the influence of onihl on the employee’s ability to execute or complete tasks that depend on auditory signals or verbal communication, evidence suggests negative outcomes for employees with onihl (thorne, 2006). in addition, the presence of onihl, which has a direct link to the employee’s communication handicap, may lead to workers being regarded as incompetent or inactive in their job, which eventually impacts negatively on teamwork and team productivity (momm & geiecker, 2009). this impact on teamwork extends to negative influences on communication amongst workers, which impacts not only the workers’ ability to communicate amongst each other, but also on their ability to observe safety standards. employees with onihl may be unable to hear and respond to warning and safety signals such as alarms that are often in high frequencies, which are often in high-frequency sounds that are the most affected in onihl. there is also the argument that tinnitus affects the quality of life, which could contribute to an increase in human errors and ultimately to an increase risk of accidents in this population (kirchner et al., 2012). thorne (2006) highlights an additional impact of onihl, which centres around employment opportunities and career options and advancement that a hearing impaired individual will experience. this additional limitation raises important economic burdens for both the individual affected and the state, particularly in lowand middle-income countries like south africa. the fact that onihl contributes to occupational injuries because of the employee’s inability to hear warning sirens, ill health and its subsequent absenteeism for various reasons, several authors argue that onihl leads to significant social and economic implications for everyone involved, including the employee, their families, communities and the state as a whole (amjad-sardrudi et al., 2012; coderio, clementa, diniz, & dias, 2005; hermanus, 2007; kramer, kapteyn, & houtgast, 2006; moroe et al., 2019). various risk factors have been documented for the development of hearing loss. these risk factors explain why individuals exposed to the same noise levels respond differently (daniel, 2007; sliwinska-kowalska et al., 2005; sliwinski-kowalska & davis, 2012). evidence suggests that these risk factors make an individual more susceptible to onihl than another. daniel (2007) categorises these risk factors under two groups: (1) modifiable factors, which fall within an individual’s control, for example, variables such as smoking and exposure to drugs that are known to lead to ototoxicity such as anti-tuberculosis, antiretroviral and anti-cancer drugs (khoza-shangase, 2013, 2019); and (2) non-modifiable factors, which fall outside the individual’s control. the presence of these risk factors, singly or combinedly, exacerbates the susceptibility of an individual exposed to hazardous noise levels to onihl, with its consequent negative sequelae to health and safety. reduction and/or elimination of onihl in the mining sector has been linked to successful implementation of hearing conservation programmes (hcps), where effective ways of assessing, monitoring and reducing or eliminating excessive workplace exposure to hazardous noise are adhered to (amedofu, 2007; chadambuka, mususa, & muteti, 2013; feuerstein, 2001; moroe, khoza-shangase, kanji, & nthlakana, 2018; moroe et al., 2019). efficacy of hcps is increased where the hierarchy of control is implemented accordingly, although in the mining sector noise is ubiquitous as engineering controls are not yet well developed to eliminate noise completely. efforts towards strategies to enhance the efficacy of hcps are therefore important. elsewhere, authors have presented a model called feedback-based noise monitoring model (fbnmm). the purpose of this model is to be utilised as a tool of managing onihl in the mining sector within the south african context. in moroe et al. (2019), the authors describe how the model was conceptualised from a risk management framework that acknowledges that onihl is a risk that needs to be eliminated or reduced through effective management strategies (moroe et al., 2019). the framework agrees with donoghue’s (2001) assertion that anything presenting a threat to health and safety within an organisation, which may put employees at risk for injury or harm, requires systematic management. this is in line with what hermanus (2007) argues when he states that in occupational health and safety: [t]he underlying premise of risk management is that improvements in health and safety can be made by correctly identifying and addressing hazards or factors (which may be underlying or direct) that contribute to occupational risk. (p. 536) the feedback model feedback model overview according to madahana, ekoru and nyandoro (2019): from figure 1, a mining employee represented by (s4) working in an environment with noise intensity equal or greater than 85 db is expected to adhere to the mandatory code of practice, summed up by the noise policy in the mines as shown in (s2). one of the policies requires the […] employees to wear hearing protection (s3). the employee undergoes periodic hearing check-up (s5) conducted annually or biannually. for our system, it is proposed that the check-up should be done at a much shorter interval for instance daily. the authors are cognizant that daily tests will require significant interventions and buy-in as this move has implications for production time as well as changes to behavioural aspects, all-inclusive of mental models that would require adjustments. additionally, this will have financial implications for staff, equipment and maintenance of the testing facilities; including transportation, since medical centres are not always available on site. the information obtained from the check-up is compared to the base line or reference (s1). if the employee has experienced significant threshold shift from the baseline, then, the mining administrators should apply other policies and the whole process repeats again. for effective communication to happen between the employees and the administrators, the information on the current state of hearing (daily threshold shift), is sent to the administrator via a data processing unit. (p. 4) figure 1: enhanced feedback-based noise management matrix. improvements to the current model the current model shown in figure 1 has the following enhancements from the previous models by moroe et al. (2019) and madahana et al. (2019), which was further improved by madahana, ekoru and nyandoro (in press): subsystem 1, which is also the baseline or the reference, is interpreted as the tracking unit. it is a non-constant reference. with sufficient hearing protection, the mine worker’s threshold shift is expected to closely follow the baseline. this would then be interpreted that the miner is only being affected by presbycusis and not occupational noise. actual values are used in the input noise intensity that is a disturbance to the system. the exposure levels for each mine worker are identified according to the drilling machine that the mine worker operates. to simplify the developed current model, the risk treatment is represented by the actuator (hearing protection) and the plant (iso equations that represent hearing loss). these are also considered to be on the forward path. feedback model validation data used for model validation were collected from all the individuals who work at the platinum mine. however, based on key findings by edwards and kritzinger (2012), when they conducted a study on nihl milestones, their research findings indicate that when comparing mine workers for the average percentage loss hearing (plh) in 1 year, for different occupations within the mines, the deep gold mine drillers were the worst. edwards et al. (2012) and wagner (2019) further explain that the deep gold mine drillers work in an environment that is at a depth of 2 km underground and up to 10 km on a vertical plane. the rock gold miners work on the rock face and their work hours usually exceed 8 h. they experience noise mostly from transportation, drilling equipment and ventilation. furthermore, the underground spaces are restricted with poor acoustics that affect the mine workers (phillips, heyns & nelson, 2007). the current study therefore targeted one of the worst-case scenarios of mine employees. these were the workers who are affected the most by occupational noise because of the nature of their tasks in the mine. edwards and kritzinger (2012) proposed that in order for hcps to be successful in ensuring zero harm (mhsc, 2014), they need to be commodity specific – and the current study’s commodity was platinum. these authors also recommend that hcps must be mine-specific, and the current study was specific to one platinum mine in south africa. lastly, edwards and kritzinger (2012) argue that hcps must be occupation-specific; and in the current study, for illustration of the fbnmm, drillers working in a deep platinum mine were chosen. the provided factors are not exhaustive with regard to the development of an effective hcp. other factors, for instance, the maturity (size as well as the staffing and resource allocation) of the company, may impact the success of an hcp. current hearing protection used in the platinum mine in this study, the two forms of hearing protection used by the rock drill mine operators are described below: 3m peltor h9a optime 98 over-the-head earmuff. noise reduction rating (nrr)*: 25 db. csa class a. *the nrr may overestimate the hearing protection provided during typical use. 3m recommends reducing the nrr by 50% for estimating the amount of noise reduction provided (3m south africa, 2019). personalised hearing protection with the highest attenuation of 18.35 dba and lowest attenuation of 7.1 dba custom-made clippers (kock, 2013) is sometimes used. consequently, the data shown in table 1 were used to validate the model. table 1: rock driller operators’ threshold shift for a deep platinum mine in south africa. sample set of the input data table 1 provides the sample data set used to simulate the different scenarios in the mines. assumptions while exploring the data set provided it is assumed that rock drill workers work for 8 h per day for 5 days (as per the report on the data set provided). the mine workers are not only exposed to drilling noise but also to the different sources of noise within the mine, for instance, from transportation. it is assumed that all rock drillers use the 18.35 dba and 25 dba attenuation setting provided and not the worst-case scenario of 7.1 dba. the data set did not indicate the exact hearing protection that the mine worker uses; hence, both case scenarios are simulated (i.e. the 25 dba and 18.35 dba). data collection method two hundred and ten rock drill operators employed in a platinum mine were chosen. their occupational exposure histories were collected. five variables which can influence hearing loss were used in the development of the predictive model. ethical considerations ethical approval to conduct the study was obtained from the human research ethics committee of the university of the witwatersrand (medical; protocol number m160264) on 18 april 2016. data used in the current study were obtained from a bigger study entitled ‘occupational noise-induced hearing loss in south african large-scale mines: from policy formulation to implementation and monitoring’ (moroe, 2018). the data were collected through retrospective document review of the mine. all procedures contributing to this work complied with the relevant national and institutional guidelines for research on human subjects and adhered to the declaration of helsinki 1975 as revised in 2008. results and discussion the presented results in figure 2 to figure 16 are for five mine workers, each with a unique baseline and threshold shift. the mine workers operate different types of drilling machines, hence the variation in the exposure levels. the mine workers, however, are provided with the same hearing protection irrespective of the machine they are operating. the mine workers use both the earmuffs (3m science south africa, 2019) and personalised hearing protection custom-made noise clippers (kock, 2013). therefore, the presented results show how the mine workers’ threshold shifts would change for both types of hearing protection. for each mine worker, three case scenarios of the attenuation levels provided are investigated using the fbnmm. the feedback model is a predictive tool that can be used as part of the hcp to predict the future threshold shift of mine workers, which then affords the mining administrators an opportunity to provide early intervention for preventive care. figure 2: forty-four years old at 2000 hz with exposure levels of 104 db. figure 3: forty-four years old at 3000 hz with exposure levels of 104 db. figure 4: thirty-nine years old at 4000 hz with exposure levels of 108 db. figure 5: thirty-nine years old at 3000 hz with exposure levels of 108 db. figure 6: thirty-nine years old at 2000 hz with exposure levels of 108 db. figure 7: thirty-eight years old at 4000 hz with exposure levels of 107 db. figure 8: thirty-eight years old at 3000 hz with exposure levels of 107 db. figure 9: thirty-eight years old at 2000 hz with exposure levels of 107 db. figure 10: fifty-five years old at 3000 hz with exposure levels of 110 db. figure 11: fifty-five years old at 3000 hz with exposure levels of 110 db. figure 12: fifty-five years old at 2000 hz with exposure levels of 110 db. figure 13: fifty-one years old at 4000 hz with exposure levels of 105 db. figure 14: fifty-one years old at 3000 hz with exposure levels of 105 db. figure 15: fifty-one years old at 2000 hz with exposure levels of 105 db. figure 16: forty-four years old at 3000 hz with exposure levels of 105 db. graphs that use the feedback-based noise monitoring model to predict hearing loss using historical data figure 2 to figure 16 represent a plot of the hearing threshold versus exposure time in years at specified frequencies (2000 hz, 3000 hz, 4000 hz), and specific exposure levels in decibels for each mine worker. the speech frequencies are used to predict how a mine worker’s thresholds would change for given attenuation. the graphs indicate the prediction of the threshold shift if the mine worker does not wear hearing protection, if the mine worker wears earmuffs or if the mine worker wears personalised hearing protection. the baseline for the mine workers was obtained from their audiograms as well as their years of employment in this particular mine. although some of the mine workers do have previous history of employment, the baseline used in the current study is the one that was obtained when the mine worker started employment at the mine specific to this study. deductions from the predictive tool and the audiograms of the mine workers the predictive tool using the provided inputs presents a futuristic estimation of how the thresholds will shift as shown in figure 2 to figure 16. current predictions reveal that as the platinum mine employed the predictive tool at the beginning of the careers of the five miners used as examples in this study, clear indications of future hearing loss are illustrated (table 2); and most importantly, onihls with the type of hearing protection provided by the mine are found. this prediction assumes that the mine worker consistently and appropriately wears their hearing protection at all times when exposed to occupational noise. the prediction also assumes that there are no additional toxins, such as ototoxicity, in the miners’ medical history. table 2: actual and predicted hearing using the feedback model. in table 2, the actual and predicted hearing loss is presented. nuanced descriptive analysis shows that the older mine workers present with a greater increase in their hearing loss than the younger age groups; hence, other methods of interventions should be considered for them in the mine’s hcp. the mine administrators should consider, for example, reducing their hours of work or providing them with hearing protection with sufficient noise attenuation. control measures can also be taken for this group, for example, investigating the quiet level of machines they use as well as the age of the machines being used. although these strategies would be important for all mine workers, current findings suggest more active and age-specific interventions, and hence the suggestions made for the older miner in this article. hearing protection it is observed in figure 2 to figure 16 that attenuation at 18.5 db and 25 db is similar such that the two attenuations superimpose on each other. it was expected that the 25 db would provide better attenuation of noise; however, from the manufacturer’s data sheet, it is stated that the earmuffs are recommended for time-weighted average noise exposures up to 98 db. this is an important consideration for the current mine as the mine workers are exposed to noise intensity levels between 104 db and 110 db – significantly more than the 98 db that the earmuffs were developed for. the implication of this is that the earmuffs currently used would not be able to actually provide an attenuation of 25 db which would have been considered sufficient for an effective hcp in this mine. the fbnmm that was put into action in this article clearly provided a prediction of how a mining employee’s hearing function would present with given attenuation at speech frequencies. suppose that this tool had been employed at the beginning of the employee’s career, then correct measure to ensure zero harm as required by the mine health and safety council would have been taken by the mine administrators in the performance of administrative controls and personal hearing protection pillars of their hcp. the fbnmm is significant to the hcp because it is a tool that can be used to predict hearing impairment and allow for provision of early intervention to prevent onihl (moroe et al. 2019). this tool would, however, efficiently work if other significant factors that affect susceptibility of the platinum workers to onihl, such as burden of disease in the form of tuberculoses (tb) and hiv, the presence of dust, ototoxic chemicals and cigarette smoking, are considered and managed as part of the hcp. these factors, which were not added into the fbnmm as inputs, are argued as the possible explanation as to why there was an inability of the graphs to closely track (follow) the baseline irrespective of the hearing protection provided. current implementation of the fbnmm reveals that, over and above what edwards and kritzinger (2012) list as key considerations for hcps, hcps should also be age-specific and baseline thresholds specific for accurate predictions and consequent efficient interventions to be provided. furthermore, hcps need to view onihl within this context to be complex, with many influencing factors, as evidenced by the slight differences in the actual and predicted results in the current study – which could only be accounted for by the lack of the fbnmm to include other inputs that may be significant in onihl. recommendations and conclusion putting the fbnmm into action in this article yielded positive findings that have important implications for hcps. furthermore, actionalising the fbnmm raised the following recommendations for future studies, which will be tested, documented and reported on an already planned follow-up paper: inclusion of more dynamic aspects to the system, for example, the use of an ear model of a human being inclusion of other aspects that affect the mining environment, for instance, acoustic environment, temperature and ventilation in account during the period values were selected versus, how it would be in the future? does it consider, for example, number of drills in operation at a time, or the acoustic environment variations machinery in operation, faults or dykes, water, etc.? inclusion of other risk factors, over and above age, gender, ethnicity, nutrition, exposure to chemicals (in the workplace as well as because of medication), family history of exposure and the likelihood of developing onihl at a faster rate once exposed previously that influence susceptibility of an individual to onihl in the model development of a preliminary working prototype to be used in monitoring of onihl in the mine inclusion of artificial intelligence and machine learning concepts in the working prototype. the use of metrics, as was performed in the current study, is argued by the authors to be advancement in the management of onihl and has significant value towards efficacious implementation and monitoring of hcps. the close link of metrics with artificial intelligence places this advancement at the forefront of audiology’s engagement with the fourth industrial revolution in combating onihl. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions n.f.m. and k.k.-s. conceptualised the article. n.m. collected and analysed the data with m.m. in consultation with k.k.-s. and o.n. all authors wrote up the study to completion across two disciplines (audiology and engineering). funding information the authors wish to thank the national institute for the humanities and social sciences (nihss) and the consortium for advanced research training in africa (carta) for financial assistance for publication charges of this manuscript. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views 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(2019). deep mining: a rock engineering challenge. rock mechanics and rock engineering, 52, 1417–1446. https://doi.org/10.1007/s00603-019-01799-4 article information authors: luisa petrocchi-bartal1 katijah khoza-shangase1 affiliations: 1department of speech pathology and audiology, school of human and community development, university of the witwatersrand, south africa correspondence to: katijah khoza-shangase email: katijah.khoza @wits.ac.za postal address: box 57, university of the witwatersrand 2050, south africa dates: received: 26 feb. 2014 accepted: 10 aug. 2014 published: 03 dec. 2014 how to cite this article: petrocchi-bartal, l., & khoza-shangase, k. (2014). hearing screening procedures and protocols in use at immunisation clinics in south africa. south african journal of communication disorders, 61(1), art. #66, 9 pages. http://dx.doi.org/10.4102/sajcd.v61i1.66 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. hearing screening procedures and protocols in use at immunisation clinics in south africa in this original research... open access • abstract • introduction • methodology    • the sample    • sample size, distribution and sampling procedure    • participants       • participant selection – inclusion or exclusion criteria • test p-protocol    • material and apparatus       • participant information sheets and consent forms    • procedures    • data analysis and statistical procedures    • reliability and validity • results    • otoscope availability    • otoscope usage    • evaluative methods/instruments used other than otoscopic evaluation to assess risk for hearing loss       • environmental sounds incorporating noisemaker and/or verbal stimuli (n = 29)       • reviewing medical records and conducting caregiver interviews (n = 30)    • referrals emanating from evaluative methods/instruments used to assess risk for hearing loss • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ background: there exists a need for context-relevant research aimed at facilitating the efficacious provision of early hearing detection and intervention services in south africa. objectives: this study aimed to determine the hearing screening procedures and protocols as well as referral protocols in use at maternal child woman's health (mcwh) immunisation clinics in south africa. method: thirty primary health care immunisation clinic managers or acting managers were interviewed in two south african sample groups. an exploratory, non-experimental, qualitative research design was employed incorporating both quantitative and qualitative information. an interview using a questionnaire was administered with all participants. the questionnaire encompassed areas such as work contexts, hearing screening contexts and information management systems, as well as quality control measures in place at these clinics. content analysis was then used to code emergent themes into specific categories. frequency calculations of these themes were calculated and results described qualitatively. results: no primary health care (phc) clinics placed within the identified sites provided formalised new-born/infant hearing screening and none of these facilities had equipment to do so. most sites attributed the lack of formalised hearing screening to budgetary and human resource issues, staff training in particular. non-formalised hearing screening protocols in place demonstrated inconsistencies in application across districts and none complied with health professions council of south africa (hpcsa) clinic guidelines or any international guidelines. conclusion: results from the current study have assisted in identifying procedural and logistical assets and barriers to implementation of hpcsa clinic guidelines for early hearing detection and intervention (ehdi) at immunisation clinics in south africa. introduction top ↑ literature has convincingly illustrated the importance of hearing function in childhood development as a fact that is evidence supported. a crucial interdependence between a child's ability to hear and his language development has been well documented (northern & downs, 2002). infancy has been reported as the critical period in which language learning is crucial to prevent life-long disadvantages (moeller, 2000; northern & downs, 1991; yoshinaga-itano, 2004). language learning can be significantly affected by hearing impairment. the negative influence hearing impairment usually exerts on a child's development may be pervasive, affecting areas such as cognition (olusanya, 2005), language, educational, social and emotional competence (northern & downs, 1991), literacy development (desjardin, ambrose, martinez, & eisenberg, 2009), as well as the individual's vocational and thus financial outcomes (olusanya, 2000; olusanya, ruben & parving, 2006). although the effects of hearing loss initially impact at the level of the individual once the everyday communication process is hindered (northern & downs, 1991), these subsequently develop into a societal economic long-term burden if the issue of reduced hearing ability is not addressed as soon as it can possibly be detected (health professions council of south africa [hpcsa], 2007; joint committee on infant hearing screening [jcihs], 2007; moeller, 2000; yoshinaga-itano, 2004). this extended societal burden and decreased quality of life for the individual can be prevented and/or aleviated by the ability of a hearing screening programme to effectively identify infants and implement intervention at the earliest opportunity (hutt & rhodes, 2008). internationally, early hearing detection and intervention (ehdi) has been accepted as a measure of child health care best practice (olusanya, 2005); with universal new-born hearing screening (unhs) being the most preferred model. this has been highlighted internationally as the preferred approach for hearing health care in private and public sectors of health care management (jcih, 2000; olusanya, luxon & wirz, 2005); where adherence to the early intervention principles as they pertain to audiology is the goal. these principles include a recommendation for diagnosis of hearing impairment with early intervention services implemented by six months of age internationally (jcihs, 2007), and by a maximum of eight months of age in south africa (hpcsa, 2007). in the united states of america (usa) (mehl & thomson, 2002; theunissen & swanepoel, 2008) and many other developed countries (jcihs, 2007); the feasibility and benefits of ehdi programmes are well documented; with some developing countries (yee-arellano, leal-garza & pauli-muller, 2006; olusanya, 2007) having in fact promulgated hearing screening policies based on jcih principles (yee-arellano, leal-garza, & pauli-muller, 2006). however, most developing world contexts have not formally recognised the advantages unhs presents and have consequently not legislated any hearing screening protocols (olusanya, 2007). reasons cited for this lack of ehdi implementation in most developing country contexts are unclear and complex. nonetheless, one can assume that additional factors often endemic to regions like sub-saharan africa, including poverty (olusanya, 2000) and the burden of life-threatening diseases such as human immunodeficiency virus and/or acquired immune deficiency syndrome (hiv and/or aids) and tuberculosis (streefland, 2005) have a measurable influence. arguably, in these contexts, hearing impairment may be low on the priority list and presents with comparatively less urgency; rendering implementation of ehdi to be less important (olusanya, 2005). it is well recognised that even within developed world contexts, ehdi's sustainability is challenged when implemented without the weighting of contextual relevance (olusanya, 2005) and without appropriate cohesion and collaboration between relevant stakeholders (white, 2006). therefore, ehdi programme efficacy and sustainability is reported to only be achievable if the setting in which it is to be implemented is considered specifically (olusanya, 2005). this is further supported by the acceptable tenet that ehdi programmes must be contextually relevant; hence even more crucial in the developing world, where the level of additional difficulties these regions face are considerable compared to developed world environments (swanepoel, louw & hugo, 2007). given south africa's inherent cultural and linguistic diversity (world bank, 2009), the hpcsa (2007) has recognised the need for contextual and cultural congruency for ehdi to be effective within the south african milieu. the hpcsa (2007) has in fact provided concrete guidelines, benchmarks and quality indicators for different ehdi contexts in their position statement (hpcsa, 2007). furthermore, in an effort to continuously improve ehdi services; this council has highlighted the importance of evidence-based assessments of these guidelines and benchmarks within these specifically defined contexts. hpcsa (2007) clinic screening benchmarks and quality indicators include: ninety-five percent of infants through their attendance of their six week immunisation should be screened after six months of initiation of the clinic screening programme, as reflected in the quality indicator of actual percentage of infants screened at their six week immunisation visit as well as the percentage of those screened at the age of six weeks. a less than 5% referral rate for audiological and medical assessment within one year of initiation of the programme. efforts to follow-up on a minimum of 95% referrals for a rescreen post the initial screen to be documented by the audiologist managing the ehdi programme, with adequate consideration of influencing factors such as (1) a lack of demographic information, (2) changes in contact details or addresses, (3) facility access, and (4) personal limitations including poverty. a return rate of 70% or more is considered ideal. further overall quality indicators include calculation and documentation of: percentage of bilateral refers for a rescreen/diagnostic evaluation targeting permanent bilateral hearing loss of a minimum of 40db averaged across 500hz, 1, 2 and 4 khz. percentage of unilateral refers requiring rescreens in six to nine months. percentage of refers who return for follow-up services, be they rescreens or diagnostic services. percentage of rescreen refers who are referred for audiologic and/or medical evaluation. percentage of families who refuse screening. percentage of caregivers who report a positive attitude towards the screening programme post the initial screen (hpcsa, 2007). literature review within sub-saharan africa indicates paucity of contextually relevant evidence. it is only countries such as nigeria and south africa that have published researched aspects of ehdi as they apply in varying contexts within this part of the developing world (olusanya & okolo, 2006). literature available in these countries reveals a non-systematic, piecemeal approach to evidence gathering, with a need for comprehensive and systematic research in all aspects of ehdi. to date, ehdi within the south african context can be argued to be under preliminary investigation, with only several published results available. three of these investigations are relatively recent research efforts, with earlier publications spanning the years 2006–2010. within the private sector specifically, swanepoel, ebrahim, joseph, and friedland (2007) investigated new-born hearing screening in a south african private health care hospital; and meyer, swanepoel, le roux and van der linde (2012) explored early detection of infant hearing loss in the private health care sector of south africa; while scheepers, swanepoel and le roux (2014) interrogated the reasons why parents refuse hearing screening and default on follow-up rescreening in south africa. the four located in different aspects of the government sector include an investigation by swanepoel, hugo, and louw (2006) on infant hearing screening at immunisation clinics in south africa; a study by theunissen and swanepoel (2008) on ehdi services in the public health sector in south africa; a retrospective review by kanji, khoza-shangase and ballot (2010) on hearing screening follow-up return rate in a very low birth weight project; and an analysis of the efficacy of a community-based hearing screening program utilising existing clinic personnel in western cape, south africa by friderichs, swanepoel and hall (2012). this relatively small number of published data reflects a lack of actualised hearing screening in different contexts of community practice. these studies, in fact, directly or by implication, recommend for intensified focus in researching the field of early hearing detection and intervention in the south african context so as to formulate appropriate hearing screening protocols based on scientific evidence. assessment of the viability of a hearing screening programme in its original and natural environment is a vital determinant regarding the feasibility of hpcsa ehdi guidelines and the associated unhs benchmarks in the south african context. it is within this position that the current study is located. the current study is located within the government sector where it has been observed that hearing screening, nationally, is not taking place as a matter of routine according to the protocols delineated (theunissen & swanepoel, 2008). it is within the public sector where clinical services are most commonly accessed by the majority of south africans, introducing another reason why the current study within the public sector is relevant. if the south african 1997 white paper on the integrated national disability strategy, which advocates equal opportunity for all, is to be actualised for those challenged by impaired hearing ability (office of the deputy president t.m. mbeki, 1997; theunissen & swanepoel, 2008); efforts to improve evidence-based practice need to be increased. specifically, if inroads are to be made towards actualising the ultimate aim of reducing disability through application of a contextually specific unhs programme, with appropriate combination of theoretical and logistical constructs, key issues within the specific screening context must be identified and explored (jcih, 2000; jcihs, 2007; hpcsa, 2007). the current study aimed to establish the hearing screening procedures and protocols in use at mother, child and woman health (mcwh) immunisation clinics in north-west and gauteng provinces; as part of a bigger study that explored the feasibility of implementing the hpcsa's (2007) guidelines for clinic based hearing screening in the south african primary health care clinic setting. methodology top ↑ the aim of the current study was to establish the hearing screening procedures and protocols as well as referrals in use at mcwh immunisation clinics in the north-west and gauteng provinces in south africa. the sample thirty primary health care nurses were selected as participants for the current study and were recruited from primary health care immunisation clinics located within the district mcwh cluster construct, where all services rendered were, and are at a health care level one. within the mcwh cluster, community nurses and lay volunteers provide services including the implementation of immunisation programmes, where yield (actual immunisations generated out of the possible population in the area) is reported to be 91.8% in gauteng and 71.4% in the north-west (day & gray, 2008). more specifically, these mobile and fixed clinics may be described as predominantly outpatient facilities, which incorporate the specific targeted population of infants requiring immunisations at 6, 10 and 14 weeks; 9 and 18 months, and 5 years (office of the president, k. motlanthe, 2009). for the purposes of the current study, in order to facilitate improved control over extraneous variables, as recommended by maxwell and satake (2006), only nurses stationed at fixed non-mobile clinics were included. participants were drawn from two provinces in south africa; namely gauteng and north-west provinces. these two provinces are considered to generally differ demographically in terms of socio-economic development based on the deprivation index as estimated from the community survey (statistics south africa, 2007), with the north-west population group considered to be more disadvantaged than that of gauteng province (day & gray, 2008). socio-economic indicators are considered to measure some of the most important health determinants within a primary health care approach (day & gray, 2008). the overall differences between north-west and gauteng provinces were aimed at facilitating a rural-urban divide, and these were thought to be useful for assessing hearing health care outcome determinants within the context of this study by the current researcher. sample size, distribution and sampling procedure thirty primary health care clinic nurses in charge of 30 primary health care immunisation clinics within the north-west and gauteng provinces (15 per province) were recruited according to accessibility and according to the district demographic classification (day & gray, 2008). this non-probability purposive participant recruitment strategy was adopted to ensure that the deprivation index difference in profile between the two provinces was maintained. these nurses were either officially within the position of operations manager or acting operations manager or heading the clinic at that time if the incumbent was unavailable for the interview. the interview location (for all interviews including those conducted for the pilot project) was the participant's immunisation clinic. within this selected demographic location, convenience sampling of appropriate primary health care clinics ensued, where the offering of immunisations to infants at 6, 10 and 14 weeks was a prerequisite (maxwell & satake, 2006). participants participant selection – inclusion or exclusion criteria for participants to be included in the current study, the following criteria had to be met: the health care nurse interviewed was required to be in charge of the individual clinic's overall functioning. as the study was located within the context of the department of health (doh)'s mcwh cluster, specifically the immunisation scheduled programme, the health care nurse in charge of the individual clinic's overall functioning (or in the position of acting clinic manager), was recruited for the interview process. a main reason for selecting the clinic manager as interviewee was that being at the helm implies insight as to the detailed workings of the particular clinic in question (s. mkoka, personal comm., august 11, 2009). health care nurses interviewed were required to be located within gauteng and north-west provinces in designated proportions as defined under sample selection. each participant needed to be conversant in english as the interviews were conducted in english. test p-protocol top ↑ material and apparatus the following materials were used to obtain data from the current study. participant information sheets and consent forms an information sheet(s) describing the purpose of the study and the process involved was presented to each participant prior to initiation of the interview: interview schedule: the interview schedule and questionnaire used were structured where most questions presented were factual and closed-ended. these were supplemented by several open-ended questions to enable documentation of free thought processes which the researcher transcribed verbatim. the questionnaire was adapted from a self-administered questionnaire previously used in a study conducted in a collaborative effort by ehdi south africa, the centre for deaf studies and deaf education, the university of pretoria and the university of the witwatersrand (theunissen & swanepoel, 2008). the interview schedule used in the face-to face interviews, consisted of the following sections: demographic information work context hearing screening context information management and quality control. tape recorder: a digital tape recorder (sony icd-ux81f) was used to record interviews to increase the accuracy of the responses documented by cross-checking the verbatim transcription of responses already conducted during the interview. using a tape recorder to verify transcriptions improves the quality of the data collection and reliability and validity of the transcription process (maxwell & satake, 2006). procedures prior to the study being conducted, permission was sought from the university of the witwatersrand human ethics committee (medical), and approval to conduct the research (clearance certificate number m091040) was obtained. this approval, together with a detailed research proposal was then submitted to the gauteng province and north-west province directors: policy, planning and research divisions. permission was obtained from the respective province directors. additional levels of written permission, as well as verbal permission were obtained from the specific sub-district divisions to ensure ease of access to the respective clinics. thereafter, permission was obtained from individual immunisation clinic managers or their assigned deputy so as to ensure the participants’ autonomy. formal informed consent and participant agreement to partake in the research process was provided prior to the commencement of each interview where permission to proceed was granted by the participant in writing. data was collected by the researcher (audiologist) via verbatim documentation of respondents’ answers and audio-taped recordings of interviews which were transcribed. questions were also asked in numerical order to ensure consistency of format and organisation between interviews. question explanation and probing was not applied beyond the methodological protocol in order to ensure consistency between interviews. to maintain consistency between interviews, digression from the interview script beyond pilot project alterations was avoided. conducting consistent and structured interview sessions, as per the procedures delineated, ensured uniformity between and within interviews. schiavetti and metz (2002) state that consistency in methods to collect and evaluate data enhances a study's reliability. consistency within the content analysis process is recommended in order to facilitate improved reliability of results obtained (neuendorf, 2002). subject bias, such as the hawthorne effect where participants heightened awareness that they form part of an evaluation process, may have influenced their performance. it must be acknowledged that participants are not passive partakers in the research process where they may potentially react to the content of the research as well as to the research process itself (maxwell & satake, 2006). these factors are seen to have been reduced but only to some extent, by having verbally ensured participant confidentiality with regard to their responses, with the added assurance that their job security could not be affected in any way. the time frame for administering the structured interviews spanned a maximum of one hour per interview. data analysis and statistical procedures as the research design was specifically qualitative in nature, direct cause-effect relationships could not be inferred (schiavetti & metz, 2002) from the attribute variables associated with the different socio-economic demographic variables of the provinces (north-west and gauteng) from which the target participants were derived. no variables were manipulated and the researcher evaluated comparisons and contrasts derived from the data obtained from the sample groups located purposefully in different demographic contexts. the data obtained was analysed using content analysis (neuendorf, 2002) where transcriptions were evaluated to determine and code the emerging themes (burns & grove, 2001; neuendorf, 2002). specifically, themes were not pre-determined but were words which were categorised according to common precepts and emergent themes identified. quantitative data analyses, through the use of frequency calculations were condensed into tabular format for ease of frequency comparison between regions. this quantitative process was used as a precursor to the descriptive process, and this combination of processes was conducted as per the area of investigation. comparisons and contrasts were evaluated between the two provincial sample groups. specific comparisons were made as follows: the focus was on analysis of trends pertaining to the procedures and protocols of new-born and infant hearing screening conducted in each province, with the added possible influence of differing demographic attributes as classified according to the deprivational index based on the community survey (cs) 2007, where the north-west province is considered to be more disadvantaged than the gauteng province (day & gray, 2008). questionnaire items addressed the specific procedures and protocol in use pertaining to new-born and infant hearing screening with the following areas of focus: otoscope availability otoscope usage evaluative methods or instruments used other than otoscopic evaluation to assess risk for hearing loss referrals emanating from evaluative methods or instruments used other than otoscopic evaluation to assess risk for hearing loss other risk for hearing loss methods and the timing thereof, including (1) reviewing medical records, (2) interviewing the infant caregiver, and (3) physically examining the infant. content analysis was applied to all responses transcribed verbatim where frequencies of emergent themes were calculated. further qualitative descriptive analyses were conducted in reference to the socio-economic demographics of the particular region in question positioned against its comparative counterpart as defined on the community survey deprivational index (day & gray, 2008). limitations of the chosen method of analysis include non-generalisability of results to larger samples of the population under investigation due to the small sample size of participants. results of smaller groups may not be representative of larger populations (babbie, 1995; maxwell & satake, 2006). reliability and validity in order to ensure research reliability in the current research study, controls were exercised pertaining to participant variables, parameters pertaining to the questionnaire used to obtain information and the interview procedures employed. over and above conducting site observations; utilising an independent rater during data analysis; a pilot study was also conducted to ensure reliability and validity in the current study. in order to validate the questionnaire and protocol used, a pilot study was conducted prior to the main research project. pre-test administration of the research instrument on three nursing immunisation clinic managers that shared target population criteria was conducted and this allowed the researcher to determine validity and reliability by identifying flaws in the research process, for example ambiguous questions and statements, leading questions, biased questions, timeframes associated with the interview process, and researcher bias (maxwell & satake, 2006). all methodological processes and procedures followed were those of the main study. these pilot study participants were not included in the sample for the main study. results top ↑ otoscope availability all mcwh primary health care clinics (phcs) had otoscopes readily available at their clinics, with one otoscope dedicated to each consultation room; with at least one spare per clinic. twenty four of the thirty respondents (80%; n = 30) reported these to be working, with the rest having commented that they were unsure whether all were in working order. of the respondents unsure of the working condition of the otoscope, there was an equal distribution between both provinces. otoscope usage as a first step in the integrated management of childhood illnesses (imci) ear screening process, it was considered important to understand any variance in otoscope usage application. as depicted in figure 1, the majority of respondents (76.7%; n = 30) stated that they only conduct otoscopic examinations on some babies, with only two respondents (one from gauteng [gp-coj], and one from north-west [nw-m]) having stated that they do not conduct otoscopic evaluations on any babies under the age of five years. this is reflected in figure 1. figure 1: otoscope usage on children below 5 years of age. otoscope usage on some babies was only slightly more prevalent in nw-p than in gp, with 11 gp respondents (73.3%; n = 15) and 12 nw respondents (80%, n = 15) doing so. twenty three respondents elaborated on when and why they only evaluated some babies. these were documented and categorised into themes as reflected in table 1. table 1: themes identified regarding otoscope usage on some babies (n = 23). as reflected in table 1, the identified themes revealed that the majority (69.9%) of otoscopic examinations was performed in accordance with infants’ presentation of upper respiratory tract-related symptoms. nw-m district was the only region not to conduct otoscopic examinations on children exhibiting ear-related discomfort problems or at doh (2004) rthc milestone ages. such discomfort was specified as ear scratching and/or pulling at ears, and/or crying when ears were touched. in addition, it was predominantly the nw-p region that conducted otoscopic examination on babies that presented with ear-related problems, although the nature of these problems remained unspecified. however, nw-p respondents (3; n = 6) demonstrated only a 50% confirmation that otoscopic examination was conducted on infants presenting with upper respiratory tract infection (urti) symptoms. in fact, two nw-p respondents claimed that the imci code of conduct only warranted otoscopic evaluation to investigate ear obstruction and ear drainage post medication to assess treatment efficacy. no documentation in support of these claims was accessible to the researcher. evaluative methods/instruments used other than otoscopic evaluation to assess risk for hearing loss a key element in the ehdi process is high yield from identification protocols at the earliest age possible (jcih 2000; jcihs, 2007; hpcsa, 2007). it was thus important not only to evaluate on which babies risk for hearing loss procedures were employed, but when these procedures were administered. only one respondent, located within the nw-m district, reported to not actively have used methods other than otoscopic evaluation on infants. predominant themes were identified from 29 interviewees (96.3%; n = 30) who reported to conduct evaluative methods other than otoscopic examination to assess risk for hearing loss. these included reviewing medical records (named as patient referral letters and rthc running notes), interviewing caregivers, and conducting examinations of infant responses to environmental sounds incorporating noisemaker and/or verbal stimuli. all respondents reported that no formalised hearing screening was conducted at their clinics, as they did not have the equipment or know-how to do so. budgetary and human resource constraints with no staff training were the main reasons cited. environmental sounds incorporating noisemaker and/or verbal stimuli (n = 29) twenty two respondents (75.9%; n = 29) revealed that they conducted a hearing screening comprised of presenting environmental sounds to the infant whilst monitoring the infant's behavioural responses, and 11 respondents (37.9%; n = 29) also commented that they evaluated the infant's behavioural responses to speech. these were reported to be conducted at different times, not necessarily on all babies but either when an ear related problem was indicated or at rthc milestone assessments. at rthc immunisations or milestones review, physically examining babies’ responses to noisemakers and/or speech stimuli was conducted by 30% (n = 30) of respondents (6 gp and 3 nw respondents). the techniques used to screen infants’ behavioural responses to environmental and speech sounds were described as elementary, with environmental sound presentation such as shaking a rattle, knocking the tip of a pen on an object, banging a door, and talking to the baby. some respondents detailed their stimuli (noisemakers and speech) as being presented loudly from behind the baby, whilst others indicated that this was not always the case, for example where presentation may have occurred within the child's visual field. reviewing medical records and conducting caregiver interviews (n = 30) reviewing medical records when a problem was indicated was conducted mostly (76.7%; n = 30; by 13 nw and 10 gp respondents) on babies where a problem was indicated. similarly, just over half (53.3%; n = 30) stated they conducted caregiver interviews. at rthc immunisations or milestones review, reviewing medical records was conducted by 63.3% (n = 30; by 11 nw and 8 gp respondents) of respondents, interviewing the caregivers was performed by 16.7% (n = 30) of respondents and physically examining babies’ responses to noisemakers and/or speech stimuli was conducted by 30% (n = 30) of respondents (6 gp and 3 nw respondents). regarding all of the above screening processes, what is of concern is that only 20% (n = 30) of respondents reported to review all babies’ medical records, 43.3% (n = 30) reported to interview all caregivers, and 26.7% (n = 30; by 4 nw-p and 2 gp-coj respondents) stated they performed physical examinations of the babies’ responses to noisemakers and/or speech stimuli on all babies. referrals emanating from evaluative methods/instruments used to assess risk for hearing loss twenty five of the 30 respondents (83.3%; n = 30; 13 gp and 12 nw) made referrals to the district's tertiary area specialist as soon as an infant was suspected of having a hearing impairment based on the various assessment techniques in current use. of the five remaining respondents (16.7%; n = 30), two nw-m reported that referrals were made at the immediate second clinic assessment or parental report of possible negative hearing repercussions. three of these remaining five respondents (2 gp-coj clinics, 1 nw-m clinic), reported a six month delay in referral for further evaluation. included in the imci otitis media and associated hearing loss protocol is the generalised reference to the importance of referrals of ‘all patients with speech, language and/or auditory perceptual problems’ (doh, 2005, p. 18). the aforementioned referrals of babies suspected of presenting with hearing loss were made either directly by the phc nurse or the phc facility doctor. the two sub-districts considered alike on the deprivational index (gp-coj and nw-m; gp-r/m and nw-p) (day & gray, 2008) performed similarly in terms of immediacy of referrals, with the two sub-districts deemed to be more advanced (gp-r/m and nw-p), demonstrating improved referrals as soon as a possible a hearing problem was detected. however, differences between the provinces were marked in reference to referral options, where gp demonstrated markedly more referrals (53.3%; n = 15) to regional audiologists or tertiary level speech therapy and audiology departments compared to only 2 (13.3%; n = 15) references made by nw participants to either a sub-district school nurse or an audiologist. neither districts made mention of use of a high risk register for referral of infants hearing assessment. discussion top ↑ results from the current study yielded results which are important to consider in efforts to implement ehdi in primary health care. with regard to otoscope availability, the primary health care package stipulates that otoscopes with spare batteries and bulbs is the basic equipment requirement in its integrated management of childhood illnesses (imci) protocol, as part of its norms and standards pertaining to prevention of hearing loss due to otitis media (doh, 2001; 2005). thus, the adequate supply of working otoscopes found in the current sample was anticipated across regions. the above results cite urti as a seemingly important marker of possible negative ear sequelae for phc health care providers. as otitis media with effusion is a well-established complication of urti (skoner, 2000), it is not surprising that urti is reported as the predominant alert to ear-related health issues for phc health care providers, and is so defined by the doh imci protocols and standards (doh, 2001; 2005). however, these primary health care package imci standards specify the use of an otoscope to inspect the external auditory canal and tympanic membrane in specific reference to the detection of otitis media and otitis externa (doh, 2005). these imci protocols also call for caregiver interviews pertaining to child behaviour in relation to ear discomfort and hearing (doh, 2001; 2005). one would thus have anticipated otoscope usage in diagnosis and treatment of infants to be more prevalent than what was evident in the current primary health care setting. the overall impression was one of inconsistent application of otoscopic evaluation, where the imci intention is for more vigilant use thereof in the diagnosis of otitis media with effusion and monitoring of its treatment efficacy (doh, 2005). the observation of compliance gaps within and across sub-districts may be attributable to the relative autonomy now exercised by districts pertaining to health care management (doh, 2009). furthermore, when comparing environmental sound stimulation techniques to the more standardised physiological audiological approaches for infant hearing screening, it becomes evident that these behavioural techniques require serious review since they have been proven to lead to false negatives, with their associated reduced sensitivity and specificity (lutman, 2000). from a clinical perspective, across districts, the behavioural techniques and procedures to screen risk for hearing loss found in the current study are in agreement with imci protocols, particularly as they relate to identification and treatment of otitis media in infants (doh, 2001; 2005), as well as rthc milestone hearing screenings (doh, 2004). however, it is the imci otitis media protocols (doh, 2001; 2005) that have been adhered to more consistently with regard to assessment of risk for hearing loss within the phc setting. the broader approach to assess for conditions other than otitis media has demonstrated less imci protocol adherence, with more inconsistency reported in assessing risk for hearing loss at rthc milestone age (doh, 2004). lack of consensus regarding the uniform application of techniques to assess for risk of hearing loss marginalises those children who don't present with a history of ear-related issues through medical record review, caregiver reporting, or the more obvious presentation of an ear-related problem. the silent epidemic of hearing loss, where its effects, particularly in less severe presentation, may not be obvious to the observer (swanepoel, hugo & louw, 2005), necessitates active pursuit in identifying and diagnosing hearing loss as is recommended in both developed and developing world contexts (jcihs, 2007; hpcsa, 2007). in addition, the methods advocated by the jcihs (2007) and hpcsa (2007) for detection of hearing loss are recognised as being more reliable and accurate, inclusive of inherent greater sensitivity and specificity than the rudimentary processes currently described to be in use in the phc setting included in the current study. this is cause for concern according to unhs goals, where targeted yield, through use of a formalised programme with objective physiological measures, is at least 95% of the population at large (hpcsa, 2007; jcihs, 2007). this has significant clinical implications for the need to render an improvement in hearing screening services to infants located within these districts. such improvements may be actualised by revisiting imci protocols, where inclusion of other etiologies of hearing loss are patently expressed in documentation and training processes, with less emphasis on otitis media and its possible hearing impairment consequences to the point of exclusion of other etiologies (doh, 2005). in addition, greater emphasis must also be made of the rthc hearing assessment protocol where hearing assessments are to be conducted routinely at 3 months, 6 months and over a year of age. in conjunction herewith, the local district authority's role in the variation of application of imci and rthc protocols must be incorporated, especially considering the greater sense of autonomy that districts are now able to exercise (doh, 2009). exploration of themes pertaining to the nature and timing of referrals made is paramount to understanding the diagnostic support available, should a hearing deficit be suspected. diagnostic follow-up is a critical ethical marker in the hearing screening process, where diagnostic services are propagated as inherent in any comprehensive and ethical hearing screening process (jcih, 2000; jcihs, 2007; hpcsa, 2007). the high referral rate to district tertiary area specialists is encouraging as a first step to early identification and intervention of hearing loss, which is paramount to improving communication outcomes (northern & downs, 1991), and associated literacy development and educational outcomes for those with hearing loss (desjardin, ambrose, martinez & eisenberg, 2009). with regard to the timing of referral for further investigation, the immediacy of such referrals is not specified, and given that symptoms in infants are not easily observable, and where false negatives are generally increased through subjective behavioural observation techniques (lutman, 2000), one may anticipate marked referral delays within the phc system when compared to the systems where more precise objective audiological techniques are used. late referrals for hearing loss are in direct conflict with jcih and hpcsa (jcih, 2000; jcihs, 2007; hpcsa, 2007) recommended guidelines, and are considered problematic because reduced timeous intervention renders hearing loss a severe threat to essential quality of life indicators (swanepoel, delport & swart, 2007). in addition, this overall reduced referral rate and use of audiology services may highlight lack of respondent knowledge of services rendered by audiologists and/or may reflect on the regional and district policy. again, closer examination of policy pertaining to district referrals of infants with hearing loss with consideration of the possible relative district autonomy (now permitted and considered as strategic by the doh (2009) is required to adequately draw conclusions. this is recommended for future research endeavours. conclusion top ↑ the current study revealed results which highlight the importance of establishing existing protocols in use; reviewing their implementation as well as their effectiveness before national plans are recommended; which might be challenging to implement due to barriers that might exist on the ground. the fact that findings in the current study indicated that none of the clinics offered or provided formalised new-born or infant hearing screening and none actually even had equipment to do so; indicates the urgent need for systematic planning at the various levels of health care service delivery in this country to ensure successful implementation of ehdi. deprivational index did not appear to influence current findings; which has implications for forward planning in phc. the fact that budgetary and human resource constraints were the main reasons given for the lack of formalised hearing screening; with staff training in particular being one of the main reasons, should be considered when planning is underway. it is of significant concern that even the non-formalised hearing screening protocols that are in place demonstrated inconsistencies in application across districts and that none complied with hpcsa (2007) clinic guidelines. this is over and above their lack of sensitivity and specificity. current findings are limited by the sample size; and their focus on only two provinces; although care was taken to select provinces thought to be a fair representation of the south african context. replication of this study nationally could yield results which are better generalisable. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions l.p-b. 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(2004). levels of evidence: universal newborn hearing screening (unhs) and early hearing detection and intervention systems (ehdi). journal of communication disorders, 37, 451–465. http://dx.doi.org/10.1016/j.jcomdis.2004.04.008 abstract introduction global perspectives on learning disability defining learning disability in south africa theoretical model of language-based learning disabilities for south africa theoretical approach to early prediction early predictors of language-based learning disabilities in south africa discussion conclusion acknowledgements references about the author(s) xoli mazibuko discipline of speech language pathology, university of kwazulu-natal, durban, south africa penelope flack discipline of speech language pathology, university of kwazulu-natal, durban, south africa jane kvalsvig school of public health, university of kwazulu-natal, durban, south africa citation mazibuko, x., flack, p., & kvalsvig, j. (2019). towards a south african model of language-based learning disability. south african journal of communication disorders, 66(1), a634. https://doi.org/10.4102/sajcd.v66i1.634 research project registration: project number: be220/14 clinical perspective towards a south african model of language-based learning disability xoli mazibuko, penelope flack, jane kvalsvig received: 17 mar. 2019; accepted: 08 oct. 2019; published: 22 nov. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: this conceptual article is inspired by the first phase of a doctoral research project that aimed to develop and validate a bilingual language assessment test for isizulu-english-speaking children in grades 1, 2 and 3 with language-based learning disabilities (l-b lds) in south africa. objectives: phase 1, systematic literature review, pretesting and formulating of a theoretical framework, with the aim to determine early indicators of l-b lds; this is important for developing a clinical language test as it determines its constructs. method: thematic analysis was used to develop the models. results: this article reviews the literature on indicators and definitions of l-b ld, introduces models that were developed in the study to conceptualise l-b ld and discusses implications for language test development. conclusion: the models provided in this article conceptualise l-b ld and identify its early indicators. the application of these models in both educational and clinical settings is proposed for differentiation of l-b ld. keywords: clinical assessments; early indicators; language-based learning disability; learning disability; systems approach. introduction isizulu is the first language to 78% of the population in the kwazulu-natal province, but english is most often used as a language of learning and teaching (lolt; department of basic education, 2012; statistics south africa, 2018). this puts english second language learners at a higher risk for learning disabilities (burr, hass, & ferreir, 2015). when an isizulu–english-speaking learner faces difficulties in the classroom, it is critical to distinguish which type of language impairment they could have. firstly, it could be because of language differences, which is related to differences expressed in semantic structure, speech sound production, vocabulary and pragmatics between the first and second languages (de lamo white & jin, 2011). secondly, it could be a primary language impairment, which is a significant deficit in language ability, affecting the first language, which cannot be attributed to hearing loss, low non-verbal intelligence or neurological damage (leornard, 2014). thirdly, it could be a specific learning disability (sld), referred to here as language-based learning disability (l-b ld), which is a group of disorders in listening, speaking, reading, writing and mathematics (american speech-language hearing association, 2015). this could be one of the scenarios where the learner is referred to speech language therapy (slt) for diagnostic differentiation. thus, it is critical to have a strong foundation to evaluate the factors that contribute to poor academic performance, particularly in literacy. considering this challenge, the relevance of speech and language assessment is underestimated within the education sector in south africa because of neglect of the connection between language processing and learning. clinical and non-clinical indicators have been proven to predict the possibility of l-b ld (mann, mccartney, & park, 2007; mazzocco & thompson, 2005; murray & wren, 2003). early prediction has benefits of early intervention that includes timeous referral for slt, remediation of weak skills and reducing the effects of the impairment on the child, family and education system (miller, vaughn, & freund, 2015). the significance of this article is based on the unknown prevalence of l-b ld in south africa, with the recent results released by progress in international reading literacy study (pirls) indicating that 78% of south african grade 4 learners could not read for meaning (mullis & martin, 2017). the pirls suggests that the reasons for poor reading are not unique to south africa, although some extrinsic or contextual factors, such as bullying and teacher training, have also contributed to poor learner perfomance (mullis & martin, 2017). with literacy being part of our role as speech and language therapists, it is our mandate to offer solutions to assist learners with l-b ld as it manifests in multiple domains of academic functioning, and primarily in those of literacy, such as vocabulary acquisition, reading and writing (american speech-language hearing association, 2015). moreover, identification of early indicators of l-b ld relevant to the south african context contributes to a greater task of developing assessment tools. thus, this article highlights the perspectives speech and language therapists should consider in assessing l-d ld. global perspectives on learning disability learning disability has been historically defined differently across the globe over the century. the fifth edition of the diagnostic and statistical manual of mental disorders states that sld is ‘history or current presentation of persistent difficulties in the acquisition of reading, writing, arithmetic or mathematical reasoning skills during the formal years of school’ (p. 1) (american psychiatry association, 2013). the clear identification of the academic manifestations in the american psychiatry association’s definition indicates that the identification of slds is based on academic skills, despite the nature of a presumed underlying and unspecified central nervous system disorder (montague & cavandish, 2013). moreover, the key academic manifestations of slds are associated with a conceptualisation of a learning disability that has to do with a language processing disorder (uys, van der walt, van der berg, & botha, 2007). because l-b ld is viewed as a brain-based difficulty, it is an intrinsic condition with specific causative factors (national center for learning disabilities, 2013). examples of causative factors include perceptual disabilities, brain injury, minimal brain dysfunctions, dyslexia and developmental aphasia (american speech-language hearing association, 2015). some definitions also incorporate the contribution of using more than one language in the home or school, with multilingualism being incorporated as one of the extrinsic (contextual) causative factors (american speech-language hearing association, 2015). defining learning disability in south africa defining learning disabilities in south africa is multidimensional, as it incorporates intrinsic and extrinsic barriers to learning. the intrinsic barriers are generally developmental, and incorporate a wide range of disabilities, including physical, visual, hearing and psychological conditions (department of education, 2005). academic difficulties experienced because of various factors, including physical, environmental and contextual disadvantages, are referred to as extrinsic barriers to learning (department of education, 2001). the terminology of barriers reflects sensitivity towards people with disabilities, promotes inclusivity and acknowledges that l-b ld is mainly recognised in academic settings. meanwhile, the term ‘barriers’ is extremely broad and sometimes confusing among professionals, as the term does not distinguish between l-b ld and other disabilities associated with social, cognitive or contextual factors related to education and policies (scanlon, 2013). generally, it is believed that learning difficulties arise from extrinsic factors (contextual) while learning disabilities are a result of intrinsic factors (specific to each person) and may persist in the presence of ideal learning conditions and support (zuma & dempster, 2008). south african studies further suggest that intrinsic and extrinsic factors interplay in the manifestation of slds (nel & grosser, 2016). there is strong evidence that cognitive and intellectual disabilities also form part of the group of barriers that can affect learning, reasoning, problem solving and memory negatively (jooste & jooste, 2011). there is an equally strong sense that socioeconomic factors, such as poverty and nutritional issues, affect the physical and socioemotional well-being of a child (geldenhuys & weavers, 2013). when the support structures are not functioning adequately between the educational and health systems in terms of detecting learning disabilities, there are also discrepancies in assessing and rehabilitating learners with l-b ld (nel & grosser, 2016). at policy level, there are guidelines for screening, identification, assessment and support for learners with l-b ld (department of education, 2008). however, in practice, there is still poor integration of services between schools and therapeutic services, as teachers and allied health workers struggle to translate policies into practice, specifically in the fluctuating public sector environment (engelbrecht, nel, nel, & tlale, 2015). this suggests continuous work into practices and models of identification and intervention for l-b ld. theoretical model of language-based learning disabilities for south africa a number of explanatory models have been proposed to guide the determination of learning disabilities. these include comprehensive frameworks that are conventional, such as the cognitive processing, and alternative models that seek to extend beyond low achievement to ‘responsiveness to intervention’ and dynamic assessment (fuchs, compton, fuchs, bouton, & caffrey, 2011; johnson, mellard, & buryd, 2005). therefore, key components have been identified to guide models and provide a comprehensive approach to l-b ld. scruggs (2003) emphasised that a model should preserve a concept of l-b ld that includes various aspects beyond low achievement; ensuring the identification of learners with l-b ld reliably for differentiation; acknowledging its multifaceted nature, not only reading difficulties, and its persistence across the life span; as well as establishing the technical adequacy of assessment measures across the school. since l-b ld has underlying neurological processes, a model should apply to all language and cultural groups showing consistency in both the concepts and operational definitions of l-b ld settings (sideridis, 2007). thus, figure 1 illustrates the composite models of definitions of l-b ld developed for this research project as compiled by the authors. defining and conceptualising l-b ld in south africa is complex; thus, the model acknowledges the broad nature of learning disabilities and various factors that directly and indirectly contribute to it, supported by the global literature (anthony, anthony, & dunkelberger, 2011). figure 1: model describing language-based learning disability for south african context. the terms sld, ‘language learning disability’ and ‘dyslexia’ are often used interchangeably by professionals and parents alike. the term l-b ld instead of the more generic ‘sld’ is used in this article for accuracy and clarity. in box 1, the model adopts l-b ld as a merging concept from various definitions of learning disability (national joint committee on learning disabilities, 2007). the emphasis on ‘language-based’ highlights specific verbal rather than non-verbal factors that influence learning disability (fuchs, deschler, & reshly, 2004). l-b ld is also preferred because of the relationship between spoken and written language, as many learners with reading problems also have spoken language problems (roseberry-mckibbin, 2008). box 2 in the model shows that, broadly speaking, there are intrinsic and extrinsic factors that predispose to l-b ld. the intrinsic factors, as shown in box 3, mainly relate to neurological development disorders and medical conditions that predispose to l-b ld. the neurological development disorders are linked to possible underlying impairments in auditory perception, cognitive skills or language processing skills, as indicated in box 4 (mazzocco & thompson, 2005; swanson & alexander, 1997). box 5 shows that impairments in both verbal and non-verbal skills interact to present l-b ld reflected in literacy difficulties in learning outcomes of listening, speaking, reading, spelling and numeracy shown in box 6 (national center for learning disabilities, 2013). regarding extrinsic factors, in figure 1, causal factors are because of environmental, systemic or contextual dynamics. of these, language culture is critical to l-b ld although other factors may affect its severity (sideridis, 2007). language culture is a concept based on the social identity theory, which suggests that an individual’s social identity represents an amalgamation of cultures across boundaries that fuse together to create one’s own culture and combinations that is unique to each individual. viewing culture through this lens prevents categorising individuals by race, tribe or religion because individuals may not belong to the same culture despite being a member of the same ‘culture’ through family or country (straub, loch, evaristo, karahama, & srite, 2003). in the model, language culture can be formed through lifestyle, use of english as a second language, exposure to multiple languages in different contexts, language support and school attended. language factors such as language difference, incompetency in different languages used in the context of multilingualism and use of english as a second language at school are not impairments but risk factors that may be indicative of l-b ld for south african children and contribute to literacy difficulties in listening, speaking, reading, spelling and mathematics (national joint committee on learning disabilities, 2007). the definition of l-b ld proposed by the model is: l-b lds are difficulties in listening, speaking, reading, spelling or mathematics that manifest because of limitations in auditory perception, cognitive and language processing skills that can be caused by various intrinsic factors, including developmental, neurological or medical conditions, and influenced by extrinsic factors, such as environmental, systemic, language or cultural factors. theoretical approach to early prediction the systems approach views processes as parts of an overall system, all of which need to function for the system to work well (friedman & allen, 2014). many systems impact a learner’s developmental outcomes but this study focused on six that influence the proximal system of the learner with l-b ld. the adoption of the systems approach was based on the concept of the adjusted process–person–context–time model, which states that different systems are the contexts of an individual’s development (bronfenbrenner & morris, 2007). the interactions between different systems affect student achievement, staff training and development programmes (furst-bowe, 2011). relating the systems approach to a learner with l-b ld, the parameters in a learner’s home, community or school environments may invite, permit or inhibit engagements in sustained, progressively complex interaction with the immediate environment, forming microsystems (bronfenbrenner, 1994). figure 2 also provides a schematic view of some of the possible mesosystems that interact with macro systems that should be considered for clinical language assessment. assessment should incorporate foundational knowledge in physiological (age, health and nutrition), educational (grade and language difficulty status), linguistic (languages spoken at home and language experience in english as lolt), cultural (beliefs and values), political (school attended) and social (group culture, norms and practices) systems (brea-spahn, 2014). figure 2: the system of language-based learning difficulties. the systems approach applies in the south african context as barriers to education can be found in the school, individual learner and home levels (navsaria, pascoe, & kathard, 2011). other systemic factors in politics, health, education and economics are acknowledged as likely to exacerbate an existing l-b ld (mann et al., 2007). thus, speech and language therapists must consider the whole system affecting the learner with l-b ld and attend to intrinsic and extrinsic indicators for both assessment and intervention. early predictors of language-based learning disabilities in south africa generally, developmental delays in speech and language, cognitive processing skills, perception, reasoning, social interaction, motor coordination and other developmental areas relevant to meeting educational goals are indicative of some form of learning disability (baddely, gathercole, & papagno, 1998; frijters et al., 2011). these indicators may occur concomitantly with problems in self-regulation, attention or social interaction (tranter & kerr, 2016). although various systems contribute to l-b ld, research on early intrinsic predictors has mainly focused on the neurological and physiological factors. using thematic analysis where patterned meanings across journal articles were analysed, a flow diagram was created for this article to summarise the intrinsic l-b ld indicators that were evaluated in our study. figure 3 focuses on language processing tasks, bearing in mind that they indirectly assess underlying cognitive processing functions (de lamo white & jin, 2011). these subskills inform the possibility or risk of l-b ld, referred to in the model as intrinsic early indicators. to align with global definitions of l-b ld and south africa’s curriculum learning outcomes, the language processing indicators were grouped into five sections, as also indicated in box 6 of figure 1. figure 3: intrinsic indicators of language-based learning disabilities. since these intrinsic indicators are based on underlying neurological processes, they are generally assumed to be universal and cross-lingual (frijters et al., 2011). extrinsic factors in the home and school contexts have been established as predictive for l-b ld while socioeconomic, political, educational and cultural systems are indicative of the severity of the learning disability as well as the success of an intervention or performance (mann et al., 2007). figure 4 details the extrinsic factors identified in the literature review as relevant to the south african context. in figure 4, poor instruction, teacher’s negligence in the class, lack of remedial classes and the overall school environment have a major contribution to early prediction of l-b ld and can perpetuate l-b ld (kavita, shamilla, & darshan, 2012). figure 4: extrinsic indicators of language-based learning disabilities. the recent pirls supported the effect of various school-related factors as impacting english second language learners as it found teachers to be insufficiently equipped to teach esl learners. a minority possessed graduate and postgraduate training proving that teacher training and experience has a contribution to l-b ld identification (willenberg, 2018). additionally, bullying, a community-level contribution, negatively affected 42% of learners in south africa (willenberg, 2018). in some south african homes, parental awareness, family literacy levels and reading behaviour were found to be significant contributing factors to reading difficulties (willenberg, 2018). poverty affects at least 55.5% of south africans and remains the driving force for parental behaviour such as low parental involvement in school, poor access to books, negative reading behaviour and parent anxiety once the child is diagnosed with l-b ld (mullis & martin, 2017; statistics south africa, 2017). the challenge is not only on acknowledgment of these factors in l-b ld assessments but in the application of remedial actions that affect the home and school levels as well. ethical considerations this research was approved by the biomedical research committee of the university of kwazulu-natal in 2014 as well as the department of education in kwazulu-natal province. discussion the purpose of language assessment in the determination of l-b ld is to differentiate between l-b ld and other language disorders in order to inform and support parents and educators. clinical assessment aims to determine the core indicators of l-b ld including those that are abstract, uncommon and context specific. l-b ld assessment, based on the models presented, should account for all intrinsic and extrinsic indicators, as well as consider carefully the impact of the home and learning environments. an assessment approach that combines qualitative and quantitative methods and takes a holistic approach to analysis and intervention is encouraged. heavily criticised norm referenced measures assume that children are exposed to the same concepts, vocabulary and life experiences (laing & kahmi, 2003). hence, application of sociocultural assessment principles is highlighted here with the models identifying parameters for assessing different dimensions of a learner. this approach allows for parent and teacher involvement in assessment, and considers age-related maturational changes, the influence of language, culture, and school experience on test performance and learning outcomes in intervention. a recommendation from this article is use of grade levels instead of age as an alternative to interpret language test results as studies in sub-saharan africa found less robust association of chronological age with test performance (kar, rao, & chandramouli, 2008; nampijja et al., 2010). this article also suggests that universal early predictors of l-b ld need to be confirmed for south african languages through research and applied appropriately for isizulu language, not just because it is ethnographically transparent but also because of different language cultures (zuma & dempster, 2008). some historical differences between south african english and isizulu cultures involving children are still relevant in the present day. these influence how people speak and interpret what happens in their lives including diagnosis with illness and disabilities. a mixture of christian and ancestral belief, use of traditional healing, zulu parenting styles, family concepts and zulu folklore are some examples of persistent cultural differences that contribute to different language cultures (singh & rampesad, 2010). using the presented models is not just for acknowledgement of cultural factors in assessment but focussed on using this diversity for impact in intervention. speech language therapies should explore use of current technology and social media platforms such as instagram and whatsapp groups to inform teachers, involve parents and support therapy. additionally, this article questions the relevance of some indicators to nguni languages. for instance, rapid automated naming and forward digit span are well recognised as predictors of l-b ld; however, poor performance on the digit span test was observed in gambia and linked to linguistic bias for wolof-speaking learners (jukes & grigorenko, 2010). secondly, urban placement of learners may be an advantage as better performance of urban learners from sub-saharan africa in tasks such as digit span was found to be because of adaptation and fostering of cognitive skills (jukes & grigorenko, 2012). thirdly, the nature of the assessment task may not be linguistically appropriate. in a south african study, typically developing afrikaans-speaking grade r learners obtained an average score of 52% while the score for monolingual english-speaking children was 55% on a digit span test (gagiano & southwood, 2015). notably, both groups performed much better in sentence repetition tasks, achieving an average of 73% in afrikaans speakers and 86% for english speakers. additionally, the use of english items and academic-based concepts of letters and numbers was noted to be a limitation for a working memory test involving isizulu primary school children (mazibuko, 2018). therefore, what appears to be minor language differences may yield to significant statistical differences. hence, there should be emphasis on verifying the applicability of universal early predictors and the implications for each language. conclusion the prevalence of l-b ld is unclear in south africa because of the lack of nationally accepted definitions across the health and education spectrum, and the interplay between intrinsic and extrinsic factors that result in l-b ld. thus, it is essential to define the term ‘learning disability’ clearly, conceptually and contextually. this article presented three models to conceptualise l-b ld and identify its early indicators. the application of these models in both educational and clinical settings is proposed for differentiation of l-b ld. these models have been utilised in the blueprint of a bilingual language test for isizulu–english grade 1, 2, and 3 learners. that test sought to differentiate between l-b ld and normal language behaviour of multilingual learners or process of esl language development, taking note of linguistic, cultural and systemic contexts. this article contributes to a discussion of fair clinical language assessment practices and use of innovative methods and tools designed for south african population. it encourages debate regarding evaluating the language and literacy concepts for different language groups in south africa. acknowledgements the study was supervised by dr p. flack and dr j. kvalsvig. the article was edited by mrs c. martin (ukzn editorial services). competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions x.m. was the principal researcher and wrote the article. p.f. supervised the research project, made a substantial contribution to conceptions and design as well as edited the manuscript draft. j.k. co-supervised the study, made a substantial contribution to data analysis and edited the manuscript. funding information this article received scholarship funding from the university of kwazulu-natal. it also received funding from sindisa health solutions. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references american psychiatry association. 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(2008). isizulu as a language of assessment in science. africa journal of research in smt education, 12(2), 31–46. https://doi.org/10.1080/10288457.2008.10740633 103 the asha way: growth through standards charlena m. seymour president, american speech-language hearing association (asha) summer, 1997 'lb say that it is a pleasure to be here with you today would hardly capture the magnitude of my feelings about being asked to address this esteemed audience. the opportunity for the human communication professionals of two nations to open the door to a brand new working relationship is truly monumental. the professions of speech-language pathology, audiology, and speech and hearing science together make up a field which is like no other in health care or education. i say this, because the ability to communicate effectively is the compass by which all people navigate their way through life. it is so essential to quality oflife, that for most people, the difficulties of being limited in how they communicate is virtually unthinkable. yet you and i know that the world is full of good, hard-working, creative individuals with communication disabilities many of them with a lot to say these people look to us to help them learn how to say it. yes, ours is a noble, ifnot always glamorous profession. in my many years as a leader in the asha governance structure, i have observed that certain character attributes are common to an overwhelming number of people who enter our field. probably the most common of these character attributes is that we care. indeed, the very nature of the services we provide require an unusual level of interaction between the caregiver and the patient. this quality the ability to genuinely care and relate to our patients is responsible for the tremendous success our professions have enjoyed over the years in america, and it should not be overlooked. while in south africa i have observed your caring qualities in the various academic institutions that i have visited. in cape town, durban, and johannesburg the concern for high standards in the admission and matriculation of college students was consistently a priority. the programs cared about the professional preparation of every student and because of their high standards for academic preparation, students from south africa are recruited for professional work all over the world. ~ut nowhere was the caring quality of professionals more ob,?~us than in the community based service programs that i visited. grass roots programs like lkana labantu in cape town, community centers in durban and the ~:nm,:nitybased rehabilitation workers of joh;nnesburg, a. trying to provide quality of services because it is the fight thing to do. howeve . r, our carmg nature alone tells only a fraction of the story. ours is a profession of academic and scientific research that has progressed at a speed rivaling that of technology itself. indeed, communication professionals today know more about the causes and possible solutions to an incredibly and increasingly diverse number of disorders. from the audiologist screening infants' hearing or utilizing space age devices to the speech-language pathologist tailoring fluency, we know more about how to effectively and efficiently help our patients rise to the highest level of communication possible than we ever have in the past. the body of research and treatment techniques has grown at a mind-boggling rate over the last, say, 30 years. most amazingly, that rate of growth of knowledge and technique is today growing faster than ever. there are a number of factors that are responsible for this whirlwind of growth. what i firmly believe is responsible, more than anything else, for the rapid advances in the field of communication disorder sciences, is the degree to which we have learned to work together. what do i mean by working together? understand where i am coming from. i am the president of an enormous association, strategically headquartered just outside of washington, d.c. the american speech-language-hearing associatio.n, asha as we affectionately refer to it in america, is 87 thousand members strong. that is huge, even by american association standards. as a central organization, with members who represent the diverse, and sometimes disparate, independent professions which exist within our field, asha has created an environment whose mission is: to promote the interest of and provide the highest quality services for professionals in audiology, speechlanguage pathology, and speech and hearing science; and to advocate for people with communication disabilities. in all kinds of ways, asha, by its very existence, has opened the door for interdisciplinary cross fertilization in research and the formulation of testing and treatment procedures. our conferences, conventions, and educational programs provide opportunities for professionals to share their latest accomplishments, discoveries, and challenges with each other. our numerous publications inform members of cutting edge developments. our governmental affairs division makes sure that new and more effective treatment techniques are allowable and reimbursable in today's challenging health care insurance world. in america, asha's policy-making role sets the standard for what is considered best for the public. * this article d was presente as the keynote address by dr c m seymour at the saslhaannual general meeting in pretoria, 1997 die s ·d ul -afrikaanse tydskrifvir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 104 my point is that not only is the association a tie that binds professionals together, but professionals are the tie that binds the association together. you see, the very foundation ofthe association is built on the bedrock belief that we can achieve more together than anyone of us could have achieved alone. that concept is the thread that runs through everything ashahas ever accomplished. the very nature of an association is to work together to benefit from each others' experiences. i stand before you today as the representative of an association that has literally built a profession in america. asha has, over the years, defined and redefined what it means to be a speech-language pathologist or audiologist. in fact, even the very language the public uses to describe us speech-language pathologist, for example is determined by what asha policy stipulates that professionals in the field today can and should be expected to do for their clients. even the fact that our professionals are described by the public as having "patients" or "clients", instead of "students" is a function of asha having brought the profession into the category of health care, even though a majority of our members still practice in a school-based setting. both from within and without, asha sets the standard. we have gotten as far as we have by the power of working together. the history of our association is a story of bridge building: between individuals, between practice-settings, between disciplines, and yes ... between continents. asha is, for example, a proud member of the international association of logopedics and phoniatrics. this is reflective of asha's view that it has much to gain and much to offer as an active partner in building the "massive international bridge" which is currently under construction in our profession. it is from this perspective that i got on a plane and flew to south mrica. i am here to continue in the footsteps of my asha predecessors to find new ways to work together with fellow professionals. this ·is a new and exciting adventure: to open up a relationship between asha and the south mrican human communications professional community. it is, in a manner of speaking, merely the next logical step in asha's continuing commitment to increasing the quality of care we provide by increasing the depth and breadth of the collaboration we employ. i am here to play my part in opening a door. i firmly believe that we have a tremendous amount to gain from one another. more importantly, i firmly believe that our consumers our clients and patients have an inexpressible amount to gain from our working together. our job right now, is to uncover opportunities. as rhetoric, this all sounds very lovely, i know. but there is no hiding from the stark fact that figuring out how to best benefit from a relationship worth one another is no small undertaking. to put it another way, we don't even know each other. our educational systems are structured totally differently. it may be that our compensations and reimbursement procedures are totally different. we might . not even recognize many ofthe daily activities in each others' workloads. i want to know in what ways we are similar and in what ways we are different. there is a lot we need to learn about each other. this is a daunting task. it is not our job today to finish the work, but i think we can make a pretty good start. as i continue, there is one point which i wish to impress on you today more than any other. this will be the theme of my comments to you today: ashais, at it's very core, an organization whose role is to dr. charlena m. seymour set standards. standards. <pause> that concept is what makes us who we are. it is by setting standards for our professions, that we have successfully increased our public recognition and respect. asha is not a federally chartered organization. no one forces the public, or even ever informed the public that some organization, namely the american speech-languagehearing association, will serve as a regulatory body for the professionals and treatment standards in the field of human communications. asha's role has been defined and fought for by its membership. the public recognition we enjoy is a direct result of carefully crafted efforts. the establishment of standards, and within that context, of a detailed code of ethics, is the cornerstone by which we define ourselves, and indeed, justify our powerful role. in my remarks today, i hope to give you a sense of asha's history in america and the importance of standard setting as a key role for any association. i will then talk about some ofthe specifics of asha's standards program, including how it has evolved over the years, how it works today, and where it is heading in the future. having given you·a sound idea of who we are, i hope to paint at least a little bit of a picture of what it is like to be a speech-language pathologist or audiologist in america in the 1990s.1t is my hope that this introduction to asha, to our standards program, and to the environment in which we practice today, will give us a base from which we can begin to learn about one another and, as i said earlier, uncover opportunities to work together to provide the highest quality of service to people with communication disorders and to promote the interests of professionals in audiology, speech-language pathology, and speech and hearing science. the american speech-language-hearing association is a not-for-profit scientific and professional association for speech-language pathologists, audiologists, and speech and hearing scientists. asha is committed to the consumers of its services, the millions of americans with communication disorders. according to the national institute on deafness and other communications disorders (an arm of the united states federal government), there are more than 42 million people in the united states with hearing impairmep.ts and speech, language, or voice disorders. asha's mission has always been to ensure that all people with speech, lai).guage, and hearing disorders receive quality services from welleducated professionals. i the association certifies practising clinicians, cdnducts and accredits educational programs for its metnbers, informs the public about communication disorders, ptoduces and markets educational materials, monitors legislation, and lobbies state and federal governmental bodies. asha's steadily growing membership, exceeds 87,000. the asha story starts in the spring of 1925, when the first meeting to discuss an association of individuals with an interest in communication disorders was held. the purpose of the meeting was to discuss the need for an association separate from the national association of teachers of speech, the organization thatat the. time included those with an interest in communication disorders. later that year, 11 clinicians and researchers formed the american a~ademy of speech correcti~n. members would meet certain requirements of'study and practical experience, [we're talking about standards.j so that the .people they treated would receive the highest quality care. in 1930, the organization offered its first major convention program, voted to start its first official the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the asha way: growth through standards publication, established new membership requirements [standards], and approved an ethical practice statement [also in the category of standards]. in 1947, making official the long-recognized link between speech and hearing, the organization was renamed the american speech and hearing association. we are celebrating almost 50 years of having this focus. that association, numbering 1,859 members, established criteria in 1951 for members to offer clinical services, a major step to assure people with communication disorders that they would receive quality services. [again, what am i talking about here? standards. again and again, the story of this organization is defining the profession through establishing ever more meaningful standards.] by 1957,association membership had increased to more than 4,700, and the code of ethics was revised and expanded. asha opened its first national office in january of the following year, 1958. with the establishment of national headquarters, increased attention was given to dissemination of professional knowledge and to the development of professional standards. the journal of speech and hearing research was first published in 1958, and asha, the association's magazine, was introduced the following year. the association began accrediting academic programs and clinical facilities in 1962. [here they go again with the standards!]. in 1965, membership requirements were set at the master's level, guidelines for ethical conduct were established, and clinical certification standards were raised. again you hear the message: standards, standards, standards. throughout the 1960s, new programs were developed to improve and expand services to the membership and people with communication disorders. additional journals were added. programs were added. programs were established to serve members based in schools and clinics. an office devoted to urban and ethnic affairs, now the office of multicultural mfairs, which i will talk about a bit later on, was created in 1969. special attention was given to educating the general public and government officials about communication disorders. by 1976, membership reached 24,000. in 1981, asha was redamed the american speechlanguage-hearing associ~tion. this new name, which remains today, reflects the ptofessions'historic involvement with language disorders. i by the end of1981, asha'k membership totalled well over 35,000. the association's growth continued throughout the 1980s as knowledge and tec~nology increased and dramatic changes were made in the provision of health care services. the asha continuing educ~tio~ program was established in 1980 [standards again!]. to strengthen asha's influence in public policy making, asha created in 1985 a separate political entity, known in american politics as a political action committee, or pac. certification standards were updated following a 3-year study, and in 1987, asha welcomed its 50 thousandth member. in late 1994, a science and research department was created to recognize and provide for the special needs of speech, language, and hearing scientists. in 1995, asha entered the information age by offering the membership such capabilities as fax-on-demand, e-mail, and internet. to strengthen communication with members, a new communication plan has been implemented in recent years. this plan includes the publication of the asha leader, a twice-monthly newspaper that informs the membership of the latest professional and association news. 105 i think it is plain to see that standards, in the general sense of the word, are the ongoing theme that runs through asha's history. the standards program has been a work in progress for the association, evolving over a period of more than 30 years. the standards represent the collective input of thousands of professionals in speech-language pathology and audiology. they reflect, as well, the evolutionary trends in service delivery. our standards reflect and define the components and parameters of quality service delivery. they are the association's basic foundation not only for assessing and recognizing specific programs, but also for stimulating and guiding the continued development and improvement of clinical services wherever they are offered. client care, clinician performance, and administrative procedures are but a few examples of areas which have been dramatically improved by dynamic standards. the key word there is "dynamic". standards must be fluid in a field where technological, clinical, and scientific advances occur so rapidly. from 1925 to 1952, asha did not have a certification program, per se, and the minimum requirement to be a speech-language pathologist or audiologist was a bachelor's degree. in 1952, realizing that this requirement was antiquated, the association established a formal certification program with requirements for a clinical practicum and passage of a written examination. later, in 1965, the term certificate of clinical competence (ccc) came into being. the ccc, which required, among other things, the obtainment of a master's degree was at that time adopted as the minimum requirement for membership into asha. c's, as this certification has come to be called in popular nomenclature, has since become the standard for practice of audiology and speech-language pathology in america. additional requirements that encourage yet higher standards of quality continue to occur today at asha. the goal remains the same to ensure that the high professional standards and consumer protection continue to elevate. an example of a recent development is the idea, currently under review, of requiring a professional-doctorate in audiology. although the au.d as this proposed degree is being called has not yet been adopted, the very fact that it has been suggested demonstrates clearly that the association and its membership continue to investigate ways to raise the quality of the services we provide. another example of a proposed change under review is the creation of a category of professionals called speech-language pathology assistants. by having standards that allow for the formal acceptance of a practice that has been going on in our field for years, speech-language pathologists may soon be able to spend more time addressing clinical issues that require complex decision making and less time on routine procedures. assistants, who possess less expertise than certified speech-language pathologists, many people believe, have a beneficial role to play. they will help us expand and enhance the services of speech-language pathologists. our standards, although formally written, have always allowed for autonomy and interpretation by the practitioner. this flexibility has become extremely important to our professional growth. more than ever, we currently strive to develop standards that are flexible rather than prescriptive. we value the ability of practitioners to be innovative in the way they perform their duties. asha's view is that services provided to consumers should be outcome-based. by die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 106 stretching the boundaries and encouraging our members to be more experimental within the context of our requirements, we hope to facilitate the development of cutting-edge services without sacrificing objective minimum standards. you see, we use our standards as the foundation for continued educational and professional development and the improvement of clinical services. they are created to challenge the individual professional to strive to reach higher and further than previously imagined. our standards are truly just the beginning point for our members. because our standards have always been dynamic and continuously developing, they have enhanced rather than limited the growth of the field. by having autonomous and constantly evolving standards, the professions of speech-language pathology, audiology, and speech, language, and hearing science have been able to expand upon their scopes of practice. individuals who would not have been treated for a communication disorder 25 to 30 years ago are now receiving the services they need. infant hearing screening, cochlear implants, voice prostheses, treatment for oro facial myofunctional disorders are but a few of the many advances the professions have made because of asha's standard setting methodology. additionally, by having open-ended standards we have been able to facilitate the growth of the lifeblood of our association research and science. through the creation of treatment outcome measurement tools, we have been able to collect data on prevalency of speech, language, and hearing disorders. this information is going a long way in showing the medical community the necessity of our services. in addition to formulating guidelines and quality indicators for clinical competency, academic programs, and clinical programs, ashastandards are currently being used: • to educate consumers and the general public about clinical service programs in audiology and speech-language pathology; • to inform other professions, accrediting bodies, funding sources, and other regulatory agencies of the essential elements of quality in programs that provide speechlanguage pathology and audiology services; • to guide the process in the development of new clinical service programs; • to provide a basic framework for self evaluation, program modification, and future planning in existing programs; • to help students and practicing professionals understand the essentials required to provide quality care; • recognize and stimulate creativity and diversity in thoughts and views; and • promote the development of knowledge, skills, and procedures required for effective clinical practice. let's take a look at some of the specifics ofasha's standards program as it exists today. in short, there are three areas in which we apply standards: clinicians certification academic programs accreditation clinical programs accreditation the correlation between asha standards and our code of ethics can be seen in how we define these three main dr. charlena m. seymour components in becoming a certified speech-language pathologist or audiologist: academic training, demonstration of clinical competence, and clinical experience. ethics, as embodied in the asha code of ethics, is the overarching concept that unifies the entire standards program. the code of ethics guides and shapes all asha standards. like our standards, our code of ethics is a fluid document. it is rewritten and adjusted periodically to meet the new demands of the professions and the marketplace. the asha's code of ethics sets a minimal standard, a base on which to build. speech and hearing professionals have not always had such a reliable support. concern over charlatans and unscientific and unscrupulous practitioners was one of the factors which sparked the formation of asha in the first place. we are now at the forefront in standards and ethics because of our historic commitment to the highest quality care for people with communication disorders. asha's current code of ethics retains our commitment to high personal standards of excellence. but, the emphasis has now shifted from the clinician to the client. to illustrate, let me read to you the first principle of our code of ethics: "individuals shall honor their responsibility to hold paramount the welfare of persons they serve professionally". as you can see, we emphasize a strong commitment to our clients. they come first; we exist to serve them, to promote their well-being. ethics affects all areas ofthe professions and all practice settings. ethics, however, is not an easy topic to discuss. with ethics, there are no absolutes. although the underlying principles remain constant, matters of ethics are relative to time and place; quite frankly, they change. with our scope of practice continually expanding, understanding ethical aspects is crucial to our professional standards. we are working with a variety of diverse populations, with new technologies, and in a wide array of workplace settings. we work on interdisciplinary teams and as case managers. more and more of us are entering the field as private practitioners who need to cope with the pressures of running a business. ethical accountability has a significant role in helping students and practitioners deal with the changing p',ractice situation. overseen by asha's ethics council, a comprehensive and thoughtful program of ethics education is offered through a variety of workshops, conferenc~s, and materials. this education program also, infuses jthical considerations into the graduate cun'iculum arid the workplace and enables us to provide ever higher duality services to our clients. ' 'i first and foremost in ethics is the issue of competency. technological advances, the knowledge explosion, changing expectations and an expanding scope of practice present the association with constant challenges. i believe that competence is a personal decision, a professional commitment and an ethical mandate. to put it in reverse, it is a violation of our code of ethics to provide services without the proper education, training, and experience in the specific area in which services are being/provided: if a person wants to work with infants and'toddlers in a neonatal intensive care unit, he or she must be prepared for that work prepared by educatio,n, training and experience, not credentialing alo'ne. a second key issue in ,ethics is the pressure of the marketplace on practitioners in all settings. in schools, it may take the form of a heavy case load and the over-reliance /' the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the asha way: growth through standards on support personnel. in private practice, hospitals and clinics, it may take the form of confusion over reimbursement: what is and what is not reimbursable? should services continue if they are not reimbursed? the pressure for accountability is heavy. insurers, government agencies, private consumers and the general public are demanding that we set and apply standards of practice. a third key ethical issue arises from the professional commitment embodied in our code of ethics to help all of those who need our services. we are required by our code to strive to educate the public about communication disorders and professional services and to provide and increase services to persons who need them. let me say that differently: it is our responsibility to ensure the accessibility of our services to all who need them. this means, for example, that we have an ethical commitment to ensure that unserved and underserved populations get help for communication disorders. these issues are challenging. as individual professionals, we can face them effectively by basing our actions on the principles set forth in the asha code of ethics. as you can see, asha has promoted ethics by establishing standards and then enforcing them through a professional code of ethics. i feel confident in saying that asha has made communication professionals leaders in standards and ethics because of an unyielding commitment to the highest quality care. just'as importantly, we have successfully made our standards the standards for our profession. when members market their services to their clients and referral sources, it is the asha certificate that they reference. asha's certificates of clinical competence are the backbone of credentialing for our professions and are the national standards against which state regulatory standards are compared. additionally, requirements for the cccs have been adopted by various federal agencies and by private and government financing systems in their own regulatory efforts. i asha certification has such respect with governmental, regulating, and advocacy ~~ups that even though asha certification is optional, it is virtually mandatory for any audiologist or speech-ianguake pathologist who realistically expects to practice in the uillted states. r we have talked about as:ha's history and taken a good look at our philosophy of standards. before closing, i would like to spend just a little bit o:ftime to paint for you a picture of what it is like to practice speech-language pathology and audiology in america in the i990s. hopefully, by giving you this view of what our day to day practice is like, we can begin to uncover ways in which we can work together. let's take a look, then, at what's taking place in today's health care arena in the united states and what impact the current environment is having on speech-language pathology, audiology, and speech, language, and hearing science. the health care marketplace in the united states is radically changing. long criticized for being costly, fragmented, wasteful, and redundant, our health care system is in a state of continual reform, upheaval, and evolution. shrinking health care dollars and the advent and evolution of managed care are changing the way we practice, where we practice, and how we are compensated for the services we deliver. changing demographics also have changed who we serve as well as who enters the p~ofessions. our professions and the work we do reflect every aspect of diversity. we have 107 been at the forefront when it comes to sensitivity to diversity. our population, and therefore our consumers, are increasingly diverse, as are our colleagues. the economics of health care and the profound diversity inherent in our society and our professions have had a tremendous impact on the changes in health care today. i want to elaborate on these two aspects for the purpose of describing today's health care environment the environment in which we practice. the financial realities of health care expenditures are staggering. in 1960, for example, the cost of health care in the united states totalled 27 billion dollars. by 1995, it was approximately 903 billion dollars. a remarkable increase! so, it's not surprising that today 'cost containment', 'managed care', and 'capitation' have become buzzwords in our professions. the message is clear "cut health care costs"! controlling cost has become paramount which is one reason why managed care which controls costs by restricting how and where people seek medical attention and other cost-saving measures have thrived over the last several years. managed care is remaking health policy and forcing us to realign our profession in order to protect our place in the health care arena. audiologists, speech-language pathologists, physical therapists, occupational therapists, and other non-physician health professionals have had to join efforts to ensure that managed care organizations and other health plans do not exclude non-physician health professionals from their plans solely on the license or certification they hold. ' government funded programs for the poor and for the elderly will likely be met with efforts to cut benefits or make structural changes in the programs. once again, nonphysician health professionals will need to fight against cutbacks in diagnostic and rehabilitation services, which would affect both the program beneficiaries as well as providers of those services. it's no longer business as usual. as health care dollars shrink in the united states, the need for proof of quality care is increasing. for us to be valued in a managed care environment, we must be able to prove our worth. health care financing demands it. we now must be able to document treatment outcomes and costs for treatment through accurate, comparative data. today in the world in which we practice we must ask and answer these questions: what was achieved? how long did it take? how much did it cost? and did it make a difference? these are questions that many audiologists and speech-language pathologists are answering as they negotiate with managed care companies, state legislators, and health insurance administrators. and professionals in health care settings are not the only ones affected. service providers from all disciplines, in all settings are being affected. asha's executive board, and numerous other boards and committees have been very active in their efforts to influence health care reform decisions and to prepare our members for the resulting changes. we have formed the task force on treatment outcomes and cost effectiveness, offered marketing and reimbursement workshops, published manuals on the subjects of managed care with strategies for our practitioners, and tirelessly lobbied lawmakers. but proving the value of the services our members provide to managed care organizations and lawmakers is not enough in our health care arena. our professionals must die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 108 also prove their value to the general public. another buzzword common in the world in which we practice is "marketing". communicating the services we provide to the general public is important, but so too is the role of our professions to raise awareness about communication disorders . practitioners must position themselves as players in the health care marketplace. marketing is the way our members do this and it too is a significant part of the world in which we practice. the current health care environment also has forced asha to make other changes as well . changes in how it develops policy, changes in how quickly and efficiently it responds to critical issues, and changes in it's overall, dayto-day operation and scope of practice. another element so critical to understanding the world in which we practice is diver sity. not only demographic changes in our client base and among our colleagues but also the diversity inherent in an association that represents nearly 90,000 individuals who make up three separate but interrelated professions. to make certain that we hear from all voices, we reach out and listen to the concerns of the national black association for speec h-langua ge and hearing, formed about 20 years ago, as well as to the asian/ indian caucus; the hispanic caucus; asianlpacific islander caucus; native american caucus, and l'gasp the lesbian, gay, and bisexual audiologists and speech-language pathologists. we reach out to our scientific communities and members through open-forum, face-to-face meetings too . we continue to seek out racially and ethnically diverse future professionals in order to best represent the populations we are serving. asha works vigorously to ge t members from under represented g roups to serve on committees, boards, and councils. ashahas been proactive about infusing multiculturalism into every part of the association . one example is our multicultural action agenda 2000 an affirmative action plan designed to "promote parity among raciavethnic minorities within all aspects of the association and the professions throughout the 1990s and beyond". this plan provides guidance for building the future of our professions with emphasis on our minority m embers and the minority consumers we serve. our population also reflects diversity. immigration patterns have changed dramatically and the united states now has growing russian, middle eastern, indian, filipino, and laotion populations . these changing demographics will continue at a rapid pace as we approach the millennium . our work settings today also reflect a strong sense of diversity. the practice, work, and research of audiologists, speech-language pathologists, and speech, language, and hearing scientists take place in many, many types of facilities such as public and private schools, hospitals and rehabilitation centers, colleges and universities, private practice offices, home health agencies, adult day care centers, nursing facilities, and state and federal government agencies. clinical services are provided to infants and children, adolescents and adults, and the elderly. we continue to adapt to differences in the world in which dr. charlena m. seymour we practice. as communication professionals, we need to be adept at "translating" each other; at "reading" each other. this is true even when we speak the same lang uage. we recognize that the english language is composed of many linguistic varieties, including standard english, new york dialect , spanish-influenced english , and ebonics or mrican-american english. in recognizing the diver sity of this language we too must accept that a linguistic variety is not a disorder. but that the social dialects spoken by our diversity clientele and colleagues are symbolic representations of the historical , societal , and cultural background of the speakers.ashadid recogni ze this by taking an official position on the topic of social dialects over 14 years ago. we have come a long way to reach this understanding. historically, some educators consider e d the use of nonstandard english a disorder and many students were referred for speech-language services or placed in special education classes . but thirty years ago there was no area within communication sciences and disorders that focused on multicultural studies, or cross-cultural communication. since then, ethnolinguistic and sociolinguistic r esearch has spulted a growing appreciation of how culture and social experiences affe ct the development and use oflanguage and speech. the information gave way to greater understanding of the nature of la nguage and led to clinicians' diagnosing communication disorders based on the individual's own linguistic background and community. the recent attention to the ebonics issue underscores the longtime commitment of speech-language pathologists to help children with speech and language problems develop their communication skills. the topic captured the attention of the nation and the news media for several months and consumed educators, legislators , parents, and civil rights leaders in a highly emotional battle to determine whether ebonics was a language or a dial ect and whether it had a place in america's public schools. but what is more important is the ability to distingui sh a linguistic variety from a true communication disorder. we must be sensitive to all linguistic va rieties. finally, diversity means difference and we must respect , value, and appreciate differences. differences help build a stronger community. differences invite us to tap into the creativity of all people . asha is very much an inclusive association that celebrates, expands, and encourages diversity within our organization. and diversity, perhaps more than any other single term, defines the world in which american communication professionals of the 1990s practice. finally, i want to thank you for giving me the opportunity to begin this rel ationship. i have sha r ed with you what i believe to be the very essence of asha standards. through standards, asha has been able to ensure that the quality of the services we provide is not only maintained , but is constantly improving and evolving. we have used our standards to s tretch and expand our profession. we have never and will never allow our standards to be complacent. as our profess ion continues to grow, standards will continue to evo lve. communication professionals of south africa, let's evolve together. th e south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) discover the difference that .100% digital hearing aids can mal<e • ~1=ocus is a 100% digital hearing aid from oticon. this unique hearing aid uses the same kind of technology as compact disc players to provide crisp and clear sound. • even when you're in difficult listening situations. ~1=ocus lets speech come through clearly. • you'll never have to fiddle with vol ume or remote controls. because ~1=00js is fully automatic. • digifocus can be tailor-made to fit your individual needs. it looks discreet and feels so natural that you might even forget you're wearing it • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • digifocus try digifocus oticon · call (0 ii) 478-2456 (ask for ext i) or fdx (0 ii) 478-2048 today; e-mail info@oticon.co.za and get more infonnation about this unique digital hearing aid. • • • nii i t'\'ntvo ll o wi lh ii h ool. illl; d ifficli ll y i ~ it r. .tttditl.tl" r" r lwa r ing illst mmt ' lll s . itj .ri lilt, 1)i"li'fi ts ii i il mp liftc at il) tl 01" ,1' vary. • otir.tjll stru ngl y i'f:.:ommt'll ri s ihnl ht~arin !-\ i.af n profpss in t1 rt b nllt! t1 sf)r~ rll ll ~, d iscli ss iiii' h(' tt l'fi ls i tl lel li m it at ion s o f iwar ing in slrlll11t1t1 1 tl st', • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) information for contributors the south african journal of communication disorders publishes reports and papers concerned with research, and critically evaluative theoretical and philosophical conceptual issues dealing with aspects of human communication and its disorders, service provision, training and policy. the south african journal of communication disorders will not accept material which has been published elsewhere or that is currently under review by other publications. manuscript style and requirements manuscripts should be accompanied by a covering letter providing the author's address and telephone numbers. all contributions are required to follow strictly, the style specified in the publication manual of the american psychological assoc. (3rd ed., 1983) (apapub. man.), with complete internal consistency. four copies of triple-spaced high quality type-written manuscripts with numbered pages, and wide margins should be submitted. they should be accompanied by one identical disc copy of the paper. filenames should include the first author's initials and a clearly identifiable keyword or abbreviation thereof and should be typewritten on the last line of the last page of the reference list (for retrieval purposes only). as a rule, contributions should not exceed much more than 30 pages, although longer papers will be accepted if the additional length is warranted. the first page of two copies should contain the title of article, name of author(s), and institutional affiliation (or address). in accordance with the apa pub. man. style (1983, p.23) authors are not required to provide qualifications. in the .remaining two copies, the first page should contain only the title. the second page of all copies, should contain only an abstract (100 words), written in english and mrikaans. mrikaans abstracts will be provided for overseas contributors. major headings where applicable should be in the order of method, results, discussion, conclusion, acknowledgements, references. all paragraphs should be indented. tables and figures which should be prepared on separate sheets (one per page), should be copied for review purposes and only the copies sent initially. figures, graphs, and line drawings that are used for publication, however, must be originals, in black ink on good quality white paper, but these will not be required until after the author has been notified of the acceptance of the article. lettering appearing on these should be uniform and professionally done, allowing for a 50% reduction in printing. on no account should lettering be typewritten on the illustration. any explanation or legend should appear below it and should not be included in the illustration. the titles of tables, which appear above, the figures, which appear below, should be concise but explanatory. both should be numbered in arabic numerals inorder of appearance. the number of illustrative ma terials allowed, will be at the discretion of the editor (usually about 6). references references should be cited in the text by surname of the author and the date, e.g., van riper (1971). where there are more than two authors, after the first occurrence, et al. after the first author will suffice, except for six or more when et al. may be used from the start. the names of all authors should appear in the reference list, which should be listed in strict alphabetical order in triple spacing at the end of the article. all references should be included in the list, including secondary sources, (apa pub. man. 1983, p. 13). only acceptable abbreviations of journals may be used, (see dsh abstracts, october; or the world list of scientific periodicals). the number of references should not exceed much more than 30, unless specifically warranted. examples locke, j.l. (1983). clinical psychology: the explanation and treatment of speech sound disorders. j. speech hear. disord., 48339-34l. penrod, j.p. (1985). speech discrimination testing. in j. katz (ed.), handbook of clinical audiology (3rd edj. baltimore: williams & wilkins.c davis, g.a. & wilcox, m.j. (1985). adult aphasia rehabilitation: applied pragmatics. san diego, ca: college-hill. editing acceptable manuscripts may be returned to the author for revision. additional minor changes may also be made at this stage, but a note on the manuscript acknowledging each alteration made by the author is required. the paper is then returned to the editorial committee for final editing for style, clarity and consistency. reviewing system the peer review of refereeing system is employed as a method of quality control of this publication. peer reviewers are selected by the editor based on their expertise in the field and each article is sent to two independent reviewers to assess the quality of the manuscript's scientific and technical content. the blind peer review system is employed during which the name of the author/ authors are not disclosed to the reviewers. the editor retains the final responsibility for decisions regarding revision, acceptance or rejection of the manuscript. ' reprints: 10 reprints without covers will be provi~ed free of ~~. : i deadline for contributions: the preferred date is the 31st may each year, but papers will be accepted until 30th june by arrangement. queries, correspondence & manuscripts: should be addressed to the editor, south african journal of communication disorders, south african speech-language-hearing association, p.o. box 600, wits, 2050, south africa. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) inligting vir bydraers die suid-afrikaanse tydskrif vir kommunikasieafwykings publiseer verslae en artikels wat gemoeid is met navorsing, of handel oor krities evaluerende, teoretiese en filosofiese konseptuele kwessies wat oor menslike kommunikasie en kommunikasieafwykings, diensverskaffing, opleiding en beleid gaan. diesuid-afrikaanse tydskrifvir kommunikasieafwykings sal nie artikels aanvaar wat reeds elders gepubliseer is, ofwat tans deur ander publikasies oorweeg word nie. manuskrip: styl en vereistes: manuskripte behoort deur 'n dekkingsbriefvergesel te word wat die skrywer se adres en telefoonnommers bevat. daar word van alle bydraers verwag om die styl, soos gespesifiseer is in die "publication manual of the american psychological assoc. (3rd ed., 1983) (apa pub. man."), nougeset te volg met volledige interne ooreenstemming. manuskripte moet getik, van hoe gehalte en in drievoud-spasiering met wye kantlyne wees. vier kopiee van die manuskrip moet verskaf word. een hiervan moet 'n identiese skyfkopie van die artikel wees. leername behoort die eerste skrywer se voorletters en 'n duidelik identifiseerbare sleutelwoord of afkorting daarvan in te sluit en moet op die laaste lyn van die bladsy van die v~rwysingslys getik word (slegs vir naslaan doeleindes). as 'n reel moet bydraes nie 30 bladsye oorskry nie, maar langer artikels sal aanvaar word indien die addisionele lengte dit regverdig. op die eerste bladsy van twee van die afskrifte moet die titel van die artikef, naam van die skrywer(s), en instansie (of adres) verskyn. in ooreenstemming met die "apa pub!. man." se styl word daar nie van skrywers verwag om enige kwalifikasies te verskaf nie. op die eerste bladsy van die twee oorblywende afskrifte moet slegs die titel van die artikel verskaf word. die tweede bladsy van alle afskrifte moet slegs 'n opsomming (100 woorde)in beide engels en mrikaans bevat. mrikaanse opsommings sal vir buitelandse bydraers voorsien word. hoofopskrifte moet, waar van to~passing, in die volgende volgorde verskaf word: metode, ri!:sultate, besprekings, gevolgtrekkings, erkennings en verwysings. aile paragrawe moet ingekeep iword. tabelleen figure wat op!afsonclerlike bladsye (een bladsy per tabel/illustrasie) moet verskyn, moet vir referent-doeleindes gekopieer word en slegs die kopiee moet inisieel verskaf word. figure, grafieke en lynt~kening~ wat vir publikasie gebruik word, moet egter oorspronklike weer~awes wees en moet in swart ink op wit papier van 'n hoe gehalte wees. die oorspronklikes sal slegs verlang word nadat die artikel vir publikasies aanvaar is. letterwerk wat op bogenoemde verskyn, moet eenvormig wees, professioneel gedoen word en daar moet in gedagte gehou word dat dit leesbaar moet wees na 'n 50% verkleining in drukwerk. letterwerk by illustrasies moet onder geen omstandighede getik word nie. verklarings oflegendes moet nie in die illustrasie nie, maar daaronder, verskyn. die opskrifte van tabelle (wat bo-aan verskyn), en die onderskrifte van figure, (wat onderaan verskyn), moet beknop, maar verklarend wees. n umering moet deur middel van arabiese syfers geskied. tabelle en figure moet in die volgorde waarin hulle verskyn, genommer word. die aantal tabebe en illustrasies wat ingesluit word, word deur die redakteur bepaal (gewoonlik nie meer as 6 nie). verwysings verwysings in die teks moet voorsien word van die skrywer se van en die datum, b.v., van riper (1971). wanneer daar egter meer as twee skrywers is, moet daar na die eerste verskaffing van al die outeurs, van et ai., gebruik gemaak word. in die geval waar daar egter ses ofmeer outeurs ter sprake is moet et ai. van die begin af gebruik word. al die name van die skrywers moet in die verwysingslys verskyn wat aan die einde van die artikel voorkom. verwysings moet alfabeties in trippel-spasiering gerangskik word. al die verwysings moet in die verwysingslys verskyn, insluitende sekondere bronne, ("apa pub. man." 1983, p.13). slegs aanvaarbare afkortings van tydskrifte se titels mag gebruik word, (sien "dsh abstracts, october"; of the world list of scientific periodicals). die aantal verwysings moet nie meer as 30 oorskry nie, tensy dit geregverdig is. let op die volgende voorbeelde: locke, j.l. (1983). clinical psychology: the explanation and treatment of speech sound disorders. j. speech hear. disord., 48, 339-341. penrod, j.p. (1985). speech discrimination testing. in j. katz (ed.), handbook of clinical audiology (3rd ed.). baltimore: williams & wilkins. davis, g.a. & wilcox, m.j. (1985). adult aphasia rehabilitation: applied pragmatics. san diego, ca.: collegehill. resensering resensering deur vakkundiges word toegepas as 'n metode van kwaliteitskontrole van hierdie publikasie. resenseerders word deur die redakteur geselekteer op grond van hulle spesialiskennis en elke artikel word na twee onafhanklike resenseerders gestuur om die kwaliteit van die manuskrip se wetenskaplike en tegniese inhoud te beoordee!. die naam van die outeur/outeurs word nie aan die resenseerder bekend gemaak nie. die redakteur behou die verantwoordelikheid vir die finale beslissings aangaande wysigings, aanvaarding of afkeuring van die manuskrip. redigering manuskripte wat aanvaar is, mag na die skrywer teruggestuur word vir hersiening. addisionele kleiner veranderinge mag ook op hierdie stadium aangebring word, maar 'n nota ter aanduiding van abe veranderinge wat op die manuskrip voorkom, moet verskafword. die artikel word dan aan die redaksionele komi tee vir finale redigering van styl, duidelikheid en konsekwentheid teruggestuur. herdrukke: 10 herdrukke sonder omslae sal gratis aan die outeurs verskaf word. sluitingsdatums vir bydraes: bydraes word verkieslik teen 31 mei elke jaar verwag, maar artikels sal nog tot 30 junie vir aanvaarding oorweeg word. navrae, korrespondensie en manuskripte: moet geadresseer word aan die redakteur, die suid-afrikaanse tydskrif vir kommunikasieafwykings, die suid-afrikaanse spraak-taal-gehoor vereniging, posbus 600, wits 2050, suidmrika. the south african journal of communication disorders, vol. 45,1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) editorial introduction: evidence based practice how do we know i f what we do works? this ques­tion is a central concern to practitioners and re­searchers focused on the notion o f evidence based practice (e b p ). since its introduction in the 1990s, many disciplines, especially in medicine and related health care professions, have embarked on a drive toward creating an evidence base to argue for their clinical decision-making. this volume o f the south african journal o f communi­ cation disorders (s a jc d ) contains a focus on e b p and speech-language therapy and audiology. three short, invited, opinion articles are shared for con­ sideration by this journal’s readership. all three articles are written by editors o f professional speech pathology and/or audiology journals. p ro f sharynne m cl eod (australia) is editor o f the international journal o f speech-language pa­ thology. d r g eetha mukundan (india) is editor o f the jour­ nal o f the indian speech and hearing association and d r laura justice (united states o f america) is editor o f the american journal o f speech-language pathology. laura justice, p h .d ., is professor in the school o f teach­ ing and learning at the o hio state university. in this role, justice has appointments to the p h .d . areas o f reading/ literacy as well as early childhood and teaches doctoral courses on such topics as research methods and reading dif­ ficulties. d r justice also directs the preschool language and literacy lab, a research lab in which a multidisciplinary staff conducts large-scale empirical studies o f child learning and development within various contexts, with a primary fo­ cus on children at risk. d r justice is presentiy the e d itor o f american journal o f speech-language pathology, and pri­ or to this she held such appointments as founding editor o f e b p briefs and associate editor o f language, speech, and hearing services in schools. she is an ad hoc member o f the american speech-language-hearing association (a sh a ) publications board and until recently was also a member o f the a s h a advisory com mittee on evidence based practice. in addition to engaging in regular writing activities concerned with evidence-based practice, d r jus­ tice has written more than 100 articles and chapters on top­ ics o f relevance to learning and teaching in early childhood, and is the author o f 9 textbooks on similar topics, including scaffolding with storybooks (international reading asso­ ciation), shared storybook reading (paul h . brookes), and clinical approaches to em ergent literacy intervention (plural publishing). geeta mukundan, p h .d ., is the head o f the d epart­ ment o f speech-language pathology at the a .y .j. national institute for the hearing handicapped, m umbai in india. d r mukundan is mainly involved in training speech-lan guage pathologists/audiologists at graduate and postgradu­ ate levels and is a recognized guide for the p h .d . (speech and hearing) programme o f her affiliating university. she is active in several research and developmental activities, as­ sesses indian professional training institutions for the purm e rs h e n pillay e d ito r-in -c h ie f, u n iversity o f c a p e t o w n , s o uth africa poses o f recognition o f various programs for bodies such as rehabilitation council o f india, state governments and the affiliating universities. d r mukundan also serves as chair­ person o f the scientific com m ittee o f the indian speech sc hearing association (is h a ) and is editor o f is h a ’s jour­ nal. sharynne m cleod, p h .d ., is associate professor in speech and language acquisition at charles sturt univer­ sity, australia. she is the current editor o f the international journal o f speech-language pathology. she also serves as v ice president o f the international clinical linguistics and phonetics association and is a fellow o f both the am eri­ can speech-language-hearing association (a sh a ) and speech pathology australia. across their opinion articles, all authors refer to the e b p processes o f making clinical decisions with reference to pro­ fessional, clinical research; to clinical expertise and/or own experience, and to the inclusion o f clients/patients’ in their own clinical decision making. justice and m cl eod make reference to sackett, rosenberg, gray, haynes and r ich ­ ardson (1996) who are credited with coining the popular definition o f evidence based medicine that has given rise to e b p (sackett, et al, 1996:71): “e viden ce based medicine is the conscientious, explicit, a n d judicious use o f current best evidence in m aking decisions about the care o f in dividu al patients. the practice o f ev i­ dence based medicine means integrating in dividu al clinical expertise w ith the best a v a ila b le extern al clinical evidence fr o m systematic research. by in d iv id u al clinical expertise w e mean the proficiency a n d ju d g m en t th at in dividu al clini­ cians acquire through clinical experience a n d clinical practice. increased expertise is reflected in many ways, bu t especial­ ly in more effective a n d efficient diagnosis an d in the more thoughtful identification a n d compassionate use o f in d iv id ­ u al p a tien ts’ predicaments, rights, a n d preferences in m ak­ ing clinical decisions about their care. by best av ailab le ex­ tern al clinical evidence w e mean clinically relevant research, often fr o m the basic sciences o f medicine, but especially fr o m p a tie n t centred clinical research into the accuracy a n d p reci­ sion o f diagnostic tests (including the clinical exam ination), the p o w e r o f prognostic markers, a n d the efficacy a n d safety o f therapeutic, rehabilitative, a n d p rev en tiv e regimens. e x ­ tern al clinical evidence both invalidates previously accepted diagnostic tests a n d treatments a n d replaces them w ith new ones th at are more pow erful, more accurate, more efficacious, a n d safer. ” the prime driving force for e b p has been rapid health care reforms in economically developed countries such as the author contact: school o f health and rehabilitation sciences faculty o f health sciences, f45 old main building groote schuur hospital, observatory 7925 cape town, south africa tel: +27 31 2611077 e-mail: mershen@hotmail.com 4 die su id -afr ika an se ty dsk r if vir k o m m u n ik a s ie -a fw y k in g s , v o l 55, 2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:mershen@hotmail.com united kingdom, the united states o f america and aus­ tralia. as part o f these countries’ economic constraints, it has become vital for professions to prove their worth rela­ tive to economic concerns. in south africa, the situation is no different albeit within a focus on the provision o f basic health care services. indeed, in its fourteenth year o f democ­ racy, post-apartheid south africa remains strongly focused on establishing basic health, social and education services to the majority o f its citizenry. during the south african pol­ icy euphoria o f the early 1990s, one o f the first government policy documents to refer to e b p was the w h ite paper for the transformation o f the health system in south africa (department o f h ealth [d o h ], 1997). as part o f an inte­ grated strategy for organizing and managing health-related research o f essential national h ealth research (e n h r ), it was emphasized that the research agenda should initiate a process involving “scientist decision-making” and popu­ lation representatives to serve as equal, inclusive partners (d o h , 1997). this strategy has been reiterated in sev­ eral later policies including the h ealth research policy in south africa (d o h , 2 0 0 1 ). w h ile the policy context sup­ ports e b p, south african audiology and speech pathology practitioners’ involvement in e b p may best be described as confined to the realms o f academic interest. currently, one will be hard-pressed to locate focused e b p publications for consumption by sa practitioners. in considering the american perspective, d r justice ar­ gues for practitioners to further develop what she has re­ ferred to as structures (such as systematic reviews and meta­ analyses, treatment studies, and clearinghouses) so as to bolster the evidence base that ought to drive practice. jus­ tice’s reference to ‘craft-based’ versus ‘evidence-based’ deci­ sion making models represents the broader discomfort typi­ cal o f most professions who have begun to consider their praxis. in the mainstream, audiology and speech-language pathology practitioners share this interest toward gather­ ing evidence to support their practice with their colleagues in medicine, dentistry, nursing, social work, psychology and in the other therapeutic disciplines such as physiotherapy. these disciplines hjave each defined and interpreted, some­ times subtly, what e b p means to their practice. for exam­ ple, in m ary law ’s je b p text for rehabilitation practitioners she has highlighted the notion o f ‘creativity’ (law, 20 0 2 ) as essential for use in relation to practice realities. additionally, jane gilgun in divulging the parallels between qualitative research and e b p has strongly advocated for a focus on the practitioner as a ‘person.t his person-centred focus on the practitioner is offered as a fourth component o f e b p specifically highlighting what practitioners can, and can­ not, provide fully and ethically (gilgun, 2 0 0 6 ). therefore, disciplinary/professional foci and geo-political contexts, as may be noted within all three opinion articles, prescribe the nature o f e b p within audiology and speech-language ther­ apy. continuing this train o f thought, d r mukundan pro­ vides a review o f how e b p has developed within the indian context. interestingly, mukundan argues that indian prac­ tice cosmology lends itself to the study o f human behavior in holistic (versus reductionistic) frameworks. in referenc­ ing e b p to contexts where high case-loads place unrealistic demands on practitioners she questions the applicability o f e b p for all practice settings. finally, m cl eod provides an examination o f how aus­ tralian researchers and practitioners not only interact with data from their own practice sites but also with research from other countries. particularly appealing in m cl eo d ’s review is her suggestion to consider the client’s voice within e b p in as much as it is relevant for australian (and other) contexts, south african practitioners too have to configure the subjective nature o f clients’/patients’ stories o f disorder relative to their pursuit o f empirical, objective evidence. similar dilemmas were discussed with reference to the development o f relevant research for south africa in the editorial lead article o f last year’s volume o f the s a jc d (kathard, et al., 20 07). deliberations about what constitutes good’ research, may also be applied when considering what constitutes ‘good’ ebp. predictably, the quantitative-qualita­ tive dichotomy has been raised (see for example, proceedings o f conferences such as the qualitative evidence based prac­ tice conference, 20 0 1 ; goldsmith, bankhead 8c austoker, 2 0 0 7 ). law (2002) has discussed myths/ realities pertaining to e b p such as that it is based on “cookie-cutter” medicine, and that it is no more than cost-cutting mechanisms to be reinforced by methods like randomized control trials. these, and other issues remain unchallenged as part o f a deeper epistemological debate that reflects what may be referred to as a crisis o f knowledge (sm ith, 2 0 04). this so called crisis, relevant to ebp, may be due to a heavy reli­ ance on technically-oriented, scientific (empirical) methods. peers, e.g. social w ork practitioners (see trinder 8c rey­ nolds, 20 0 0 ) question the kind o f science used when under­ standing evidence to develop practice within inter-subjec­ tive phenomena such as therapeutic contexts and complex phenomena such as human communication and its disor­ ders. audiologists and speech-language therapists may wish to critically engage e b p by considering questions such as those listed below: are the kinds o f evidence required to diagnose cancer, liver disease or cardiac arrhythmia valuable for diag­ nosing the lived experience or clinical phenomena o f hear­ ing disorders, aphasia, phonological processes and suchlike? w h a t is valid evidence? w h o decides what this is? does the patient/client have a role in this process? c an we unequivocally identify the “thing that made the difference” when we look at complex therapies and rich interactions? is good audiology/speech-language therapy the re­ sult o f a competent, ethical, hard working practitioner? o r does good practice result from the theory driving her/his work? is e b p developing practice in audiology and speech-language therapy toward being more ordered, pre­ dictable and technically sound? i f so, do we risk minimizing its complexities and phenomenology? it is hoped that the following articles provide inspira­ tion, stimulate debate and develop practitioners’ engage­ ment with e b p in south africa. th e s o u t h a f r ic a n j o u r n a l o f c o m m u n ic a t io n d iso rd er s, v o l. 55 2 0 0 8 | 5 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) references department of health (1997). the white paperfor the transforma­ tion o f the health system in south africa. pretoria: south afri­ can government printers. department of health (2001). health research policy in south a f­ rica. pretoria: south african government printers. gilgun, j. (2006). the four cornerstones of qualitative research. qualitative health research, 1 6 ,3,436-443. goldsmith, m .r, bankhead, c.r. 8c austoker, j. (2007). theory and methods: synthesising quantitative and qualitative re­ search in evidence-based patient information. journal o f epi­ demiology and community health, 6 1,262-270. kathard, h., naude, e., pillay, m. 8c ross, e. (2007). lead ar­ ticle: improving the relevance of speech-language pathology & audiology research and practice, sajcd, 54-55. law, m. c. (2002). evidence based rehabilitation: a guide to prac­ tice. thorofare, nj: slack. qualitative evidence based practice: taking a critical stance (2001). university of coventry, leeds: uk. retrieved au­ gust 16, 2008 from http://brs.leeds.ac.uk/~beiwww/beia/ qebp2001 ,htm#titl. sackett, d. l., rosenberg, w. m., gray, j. a., haynes, r. b., 8c richardson, w. s. (1996). evidence based medicine: what it is and what it isn’t: it’s about integrating individual clinical ex­ pertise and the best external evidence. british medical journal, 312,71-72, smith, d. (ed.). (2004). research highlights in social work 45: so­ cial work and evidence-based practice. london: jessica kingsley publishers. trinder, l. 8c reynolds, s. (eds) (2000). evidence-based practice: a critical appraisal. london: blackwell science. walker, b.b. 8c london, s. (2007). novel tools and resources for evidence-based practice in psychology. j clin psychol, 63, 633 642. 6 | die suid -afr ika an se tydskrif vir k o m m u n ik a s ie -a fw y k in g s , vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://brs.leeds.ac.uk/~beiwww/beia/ abstract swallowing problems in the normal ageing population tracey wilkinson and janet de picciotto department of speech pathology and audiology university of the witwatersrand 55 this study investigated the prevalence of subjectively reported swallowing problems in a group of normal ageing subjects. twenty-five retirement village residents were included in the sample. a cross-sectional descriptive survey research design was utilised. data was obtained through the administration of a devised interview schedule. the prevalence of reported swallowing problems in the sample was determined. the nature of the swallowing problems were examined and compared to those reported to occur in the normal ageing population. the utility of the interview schedule was critically evaluated. results revealedan overall prevalence of 44 % of subjects who experience swallowing problems that interfere with their day to day functioning. of these, 64 % experienced swallowing difficulties affecting all phases of the swallow while 36 % experienced difficulties affecting the pharyngeal and oesophageal phases. the interview was found to be a useful screening measure in identifying the presence of swallowing problems. the role of the speech pathologist in dysphagia in the normal ageing population is highlighted andjustified. opsomming hierdie studie het die voorkoms van slukprobleme by 'n normale groep bejaardes ondersoek. vyf-en-twintig aftree-oordinwoners was by hierdie studiegroep ingesluit. 'n deursnee, beskrywende navorsings-ondersoekplan is gebruik. gegewens is verkry deur die toepassing van 'n onderhoudprogram. die 'voorkoms van slukprobleme in die studiegroep is persentasiegewys bepaal. die aard van die slukprobleme is ondersoek en vergelyk met dit wat beskryf word in die literatuur. die bruikbaarheid van die onderhoudprogram is krities geevalueer. resultate het getoon dat 44 % van die persone wat slukprobleme ondervind se daaglikse funksionering daardeur bei'nvloed word. 64 % van die persone het probleme ondervind met die orale, faringale en esofagale fases van die slukproses terwyl 36 % probleme ondervind het met faringaleen esofagale fases. die onderhoud was 'n nuttige siftingsmetode om die aanwesigheid van slukprobleme te identifiseer. die rol van die spraakpatoloog in disfagie onder die gewone bejaarde bevolking word beklemtoon en geregverdig. key words: swallowing problem, normal ageing, screening interview / "swallowing impairmjnt increases in prevalence with persons (baker, 1993; robbins et ai., 1992). advancing age and is a niajor health care problem in the the symptoms of dysphagia can be painful and anxiety aged" (ekberg & feinbetg, 1991, p. 1181). recent literaprovoking. they may include the sensation of swallowed ture suggests that the swallow undergoes changes during substances not going down or going down partially and then the normal ageing process1that can lead to swallowing probsticking (langley, 1987; massey & shaker, 1997). dysphagic lems (logemann, 1990; robb~ns et ai., 1992; ward et ai., patients may experience pain or pressure in the throat or 1989; sheth and diner, 1988; sorties et ai., 1988; tracy et chest, which may be so severe that they think it is caused ai., 1989). in order to understand the impact of swallowing by their hearts. patients may have to regurgitate a stuck disorders, it is necessary to develop an appreciation of the bolus, while at other times material may regurgitate sponclinical problem, both for the individual patient and for taneously. impaired swallowing can result in coughing and society as a whole (massey & shaker, 1997). choking while eating. it may also result in food coming out enjoying a meal or drinking a glass of water are acts of the nose or in an inability to breathe due to a blocked that most people take for granted. swallowing foods or liqairway (kavanaugh, 1994; massey & shaker, 1997). uids occurs automatically (kavanaugh, 1994). this is not patients with swallowing problems often have to inodify the case for patients with impaired swallowing. rather, the their diets and eating habits to avoid the above symptoms. fact that dysphagic patients have to remain watchful of some patients eat so slowly that they are always the last such a normally subconscious act as swallowing to avoid person to finish their meal, if they finish it at all (massey discomfort or even death, means that their swallowing dis& shakei-, 1997). patients often avoid certain foods because orders greatly interfere with normal living (massey & they have learned that these items cause them difficulty shaker, 1997). since mealtime remains the focus of social (hildebrandt et ai., 1997). alternatively, patients may atand interpersonal activity for many elderly persons, disortempt to eat problematic foods using compensatory behavdered swallowing can have a negative impact on the health, iours such as chewing-their meat to mush before swallownutritional status, self esteem and quality oflife of elderly ing or mashing up their food (lindgren & j anzon, 1991). die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 56 despite these efforts, instances of swallowing difficulty inevitably occur. thus, it is clear that dysphagia can be a socially debilitating condition which adversely affects the person's self-esteem (bloem et al., 1990; robbins et al., 1992). in extreme cases, patients with swallowing difficulties may die from asphyxiation. they may develop aspiration pneumonia, which can be fatal (feinberg et al., 1990). dysphagic patients may rupture their alimentary canal by trying to regurgitate a stuck bolus. they may develop severe weight loss and malnutrition, making them more vulnerable to developing infections (bloem et al., 1990). this is particularly hazardous in the elderly population whois already at a greater risk for mortality (hildebrandt et al., 1997). up to now, the impact of dysphagia on the individual, with special reference to the elderly patient has been discussed. a consideration of the societal burden of swallowing disorders is necessary. although there is no data available on this issue, the potential exists for a substantial burden from dysphagia on the health care system and a significant economic impact on society as a whole (massey & shaker, 1997). dysphagic patients often require expensive diagnostic and therapeutic interventions including videofl uoroscopy, feeding tube placement and surgery. thus, the chronic nature of swallowing disorders results in ongoing health care costs (massey & shaker, 1997). this is of particular concern in a country like south africa, where economic resources are limited. this study proposed the adaptation of a devised interview schedule (boolkin, 1998) as a subjective screening tool to identify the presence of-swallowing disorders in the elderly population. this inexpensive method of identification may promote the early identification and subsequent early treatment of swallowing disorders, prior to the onset of debilitating and costly complications such as malnutrition and aspiration pneumonia. since swallowing can involve such serious consequences, it is imperative to identify groups of patients who are at risk for having the disorder. one such group is the elderly population. the process of ageing brings about changes in the oral, pharyngeal and laryngeal structures, all of which work in synchrony in the swallowing process (logemann, 1990). oral phase changes: according to logemann (1990), there is an increase in fatty and connective tissue in the tongue with age. atrophy of the alveolar bone may occur if dentition is lost. there may be an overall decrease in masticatory strength (sheth & diner, 1988). elderly people exhibit a tendency to hold the bolus more posteriorly in the mouth prior to swallowing (logemann, 1990). they may have difficulty moving the tongue to control the food (kavanaugh, 1994). additional tongue movements have also been noted to occur in the elderly (sonies et al., 1988). elderly people may have weak facial muscles causing food to collect in their cheeks. they may have reduced mouth sensations making them unable to feel where food is located in the mouth (kavanaugh, 1994). in addition, there is a deo' crease in the production of saliva with advancing age (martin, 1991). pharyngeal phase changes: the triggering ofthe pharyngeal phase of the swallow has been found to be delayed in elderly persons and may be as a result of an increase in swallowing threshold with age or to slower neural processing time (logemann, 1990). the temporal organisation of the pharyngeal phase also appears to be affected. maximal tracey wilkinson and janet de picciotto laryngeal elevation lasts longer and the larynx may descend more slowly. in this way, cricopharyngeal opening is prolonged (tracy et al., 1989). in addition, robbins et al. (1992) measured longer pharyngeal transit times. there is delayed clearing of the pharynx due to decreased muscular tonicity (sheth & diner, 1988). the epiglottis is smaller and sharper and is slower to tilt down and backward (sheth & diner, 1988). elderly persons demonstrate palatal weakness which may result in nasal regurgitation (kavanaugh, 1994). oesophageal phase changes: muscle tone in the oesophagus may decrease resulting in reduced peristalsis (sheth and diner, 1988; logemann, 1990). oesophageal transit time is prolonged (logemann, 1990). finally, the incidence of hiatus hernias and gastroesophageal reflux is increased with ageing (sheth & diner, 1988). the issue of normalcy in swallowing is a problematic area of debate. researchers in swallowing disorders face a formidable challenge in determining appropriate definitions and parameters for normalcy in deglutition (massey & shaker, 1997). for example, if one uses the subjective absence of swallowing problems as a sign of normalcy, this definition will frequently be at odds with objective measures of what is felt to be abnormal ~wallowing (massey & shaker, 1997). it is not unusual to find a patient aspirating silently without having complaints of swallowing difficulty and no physical indicator such as coughing. conversely, patients may complain of difficulty swallowing and show no abnormalities in bolus transport on videofluoroscopic measures (massey & shaker, 1997). thus making use of objective measures of swallowing parameters to define normalcy may also be problematic. for many of the parameters of swallowing, abnormality may be a matter of degree, rather than a "state-change" from normal to abnormal (massey & shaker, 1997). thus, a large area of overlap may exist between abnormal and normal populations for a given parameter. exactly when slow swallowing in the elderly should be considered abnormal remains an area of q.ebate (robbins, 1995; massey & shaker, 1997). in spite of this, in south africa, where objective diagnostic measures are not easily accessible, the need to develop and evaluate a subjective device to identify swallowing problems is indicated. the foregoing discussion has shown that swallowing disorders in general, and in the elderly population spe~ifically, constitutes an important health care problem. t~e need for intervention in this population has been recognised by speech pathologists in the united states of americ~ and in britain where they are employed as "swallowing therapists" in nursing homes (kavanaugh, 1994). however, spe'ech pathologists in south africa have not followed the above trend. the lack of literature on dysphagia in the elderly population in south african journals supports the view that the role ofthe speech pathologist in this population is currently underdeveloped in this country. the purpose of this study therefore was to determine whether normal functioning elderly people experien'ce swallowing difficulties that interfere with their day to day functioning. in so doing, the study aimed to highlight for south african speech pathologists their diagnostic' and rehabilitative role in the area of dysphagia with this population. finally, the study aimed to propose the utilisation of a subjectiv~ device to identify the presence of swallowing problems in elderly patients.' the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) swallowing problems in the normal ageing population methodology alms the aim of the study was to determine whether normal functioning elderly residents in retirement villages experience swallowing difficulties that interfere with their day to day functioning. more specifically, the sub aims were threefold. • firstly, to determine the prevalence of swallowing problems in the sample of normal ageing subjects titilising a subjective measure. • secondly, to examine the nature of these swallowing problems and to compare them to the nature of swallowing difficulties reported to occur in the normal ageing population. • thirdly, to evaluate the usefulness of the devised interview protocol in detecting swallowing problems in elderly patients. research design a cross-sectional descriptive survey constituted the research method (leedy, 1989). according to rosner and rosenthal (1996), "in descriptive research, the goal of investigation tends to be the careful mapping out of a situation or set of events. the research objective is to describe what is happening behaviourally. causal explanations are. not of direct concern except perhaps speculatively" (p. 15). subjects subjects were selected based on a number of criteria. subjects were required to be residents of retirement villages (i.e., not living in frail care). retirement village residents were selected for the purpose of this investigation because it was felt that this group most adequately reflected n»rmal functioning across the ageing process since they are of sufficiently good health to live and function independently. i an age selection crit~rion of 65 years and above was stipulated. according to robbins et ai. (1992) the swallow begins to slow from as eatly as 45 years, although the most noticeable changes occur ~etween 65 and 75 years (robbins, 1995). no cut-off ceiling ~as used in the study in order to address' a criticism of many previous studies on swallowing in the elderly which have failed to include the oldest old (above 85) in their samples (logemann, 1990). subjects were required to be female to exclude the possible variable of gender in the study. subjects could only be included in the study if they did not present with any of the following conditions which are common causes of swallowing problems: neurological damage, diseases affecting muscular strength and co-ordination such as muscular dystrophy and cerebral palsy, forms of cancer, progressive neurological disease, injury to face or neck including surgery (baker, 1993). subjects were required to obtain scores that fell within the normal range according to age on the mini-mental state examination (folstein, folstein & mchugh, 1975) in order to rule out the presence of cognitive dysfunction. a score of 25 is the lower limit in the range for normal subjects in the 60 69 year old age group. a score of 26 is 57 the lower limit in the range for normal subjects in the 70 79 year old age group. a score of 24 is the lower limit in the range for normal subjects in the 80 89 year old age group (bleeker, bolla-wilson, kawas & agnew, 1988). finally, subjects were required to be able to speak english in order for administration of the interview to be possible. the subjects are described in table one. twenty-five subjects from two retirement villages participated in the study. subjects ranged in age· from 65 to 88 years with a mean age of 77.4 years (s.d. 4.87). the characteristics of diabetes, arthritis and smoking are included in the subject description as this information was required for the interpretation of the results. subjects were recruited from two retirement villages. the researcher contacted all subjects and visited each participant at their homes. informed consent was obtained from each subject. measuring techniques a structured interview schedule was devised based on a compilation ofthe literature on swallowing disorders. the interview schedule is available from the authors on request. questions were adapted from various sources including boolkin (1998), langley (1987), hildebrandt et ai., (1997), and kavanaugh (1994). questions were chosen to tap five broad areas related to swallowing problems. these areas were the locus .of swallowing difficulty (questions aimed at obtaining information pertaining to the oral, pharyngeal and oesophageal phases of the swallow respectively), food avoidance behaviours, th~ use of strategies to facilitate swallowing, effect offood temperature and consistency on the swallow and consequences of swallowing problems such as weight loss and pneumonia. closed and open questions were included in the interview. closed questions yield information which is easily quantified and ensures comparability of questions across respondents. however, this method of data elicitation leaves little room for unanticipated discoveries and salient issues may be missed (breakwell, 1996). to provide this information, open-ended questions were included in the interview. the questionnaire was constructed to address the internal consistency ofthe subject's responses. similar questions were posed to the subjects to identify any inconsistencies in the pattern of answers. this served to assess the validity of the data obtained and improves the reliability of interview schedules. interviewer effects were controlled for in the study by ensuring that the same researcher conducted all the interviews. this promoted consistency in question presentation (breakwell, 1996). a pilot study was carried out to address the issue of validity of the interview. this procedure is a data gathering technique that helps define the parameters of the study and provides preliminary warnings and assistance to researchers (kane, 1985). modifications to the questionnaire were made based on the results of the pilot study and the final version compiled. the modified interview schedule was administered to participants and their responses were tape-recorded for later transcription. subjects who were identified as having swallowing difficulties were referred to a speech pathologist for further management. the mini-mental state examination (folstein, folstein & mchugh, 1975) was administered prior to the interview. die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 58 data analysis in order to address the first aim of the study, the percentage of subjects in the sample who experience swallowing problems was computed. the prevalence of swallowing disorders according to age was calculated using percentages. in order to address the second aim ofthe study, a profile of the nature of swallowing difficulties experienced by the subjects affecting the oral, pharyngeal and oesophageal phases of the swallow was constructed. the fisher exact test was utilised to identify the presence of statistical relationships between swallowing problems and other variables. this test is an appropriate non-parametric statistic for testing the relationship between two variables if the sample size is small. the fisher exact test computes the exact probability under the null hypothesis of obtaining the current distribution of frequencies across cells, or one that is more uneven (rosner & rosenthal, 1996). a 5 % level of significance (p<0.05) was accepted as indicating significant statistical relationships. relationships which were significant at the 10 % level (p<0.10) were also reported due to the exploratory nature of the study (silverman, 1993). the third aim of the study was addressed by critically evaluating the usefulness of the interview schedule. results and discussion results are presented addressing each aim of the study. tracey wilkinson and janet de picciotto prevalence of swallowing problems in this study, seven (28%) of the 25 subjects reported that they experienced difficulty swallowing. four (16%) of the subjects who reported that they did not experience difficulty swallowing, demonstrated evidence upon further questioning to suggest that they were in fact experiencing swallowing difficulties. taking the overall prevalence, 44% of the subjects were found to experience swallowing problems. the above finding is clinically relevant since it appears that a substantial proportion of elderly people, who are of sufficiently good health to live and function independently, experience swallowing problems that interfere with their day-to-day functioning. however, it is recognised that the finding of 44 % is only an estimate of true prevalence of swallowing problems in the sample because of the absence of objective measures, such as videofluoroscopy, to confirm pathology. groher and bukatman (1986) completed a review of known prevalence studies of swallowing disorders. only one study by trope, siebens ~nd siebens (1984) focussed on swallowing problems in the elderly population. two subsequent studies, one by bloem et al. (1990) and the other by lindgren and janzon (1991) examined the prevalence of dysphagia in the elderly population. table 2 presents a comparison between the current findings and these studies. table 1: relevant information pertaining to subjects in the study subjects age mini-mental score diabetes smoker ex-smoker 1 65 28 2 77 29 26 4 79 6 77 7 77 29 8 77 28 9 27 10 82 28 11 77 27 12 80 26 13 77 28 14 79 27 74 16 77 29 17 70 28 74 26 19 88 28 20 74 28 21 71 27 22 80 26 27 27 28 /' the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) swallowing problems in the normal ageing population the current findings, which suggest a prevalence of 44%, are therefore somewhat reduced in comparison to the trupe et a1. (1984) findings and elevatedin comparison to the other two studies. a number of possible explanations for the discrepancies exist. firstly, the different settings of the studies may have influenced the results. residents in a nursing home are more likely to be ill and in need offrail care. the subjects in the trupe et a1. (1984) study may have been suffering from diseases, which, according to baker (1993) are direct causes of swallowing problems, such as neurological damage, cancer and diseases affecting muscular strength and co-ordination. these were not controlled for in the trupe et a1. (1984) study which is in contrast to the present study which excluded subjects with these diseases from the sample. similarly, the other two studies focussed on sectors of the elderly population that are likely to be fairly healthy rather than in need of frail care. secondly, the difference in sample sizes between the studies needs to be considered. thirdly, different methods of assessment were used to determine whether swallowing problems were present. in addition to analysing the prevalence of swallowing problems for the normal ageing sample as a whole, the subjects were divided into three age groups. according to logemann (1990), investigations on the effects of ageing on the swallow usually categorise persons into one of three age groups (1) the old (65-75 years); (2) the old, old (76-85 years) and (3) the oldest old (over age 85). this convention was followed in an attempt to determine the prevalence of swallowing problems according to age. one ofthe 4 (25%) subjects in the old age group reported swallowing difficulties. ten of the 19 (47%) subjects in the old, old age group reported swallowing difficulties. neither of the 2 (0%) subjects in the oldest old age group reported swallowing difficulties. these findings are presented in figure 1. the current findings indicate that if one ignores the oldest old group, there appears to be a relationship between advancing age and increas~d prevalence of swallowing impairment. no statistical r.elationship was demonstrated, however this may be accohnted for by the limited size of / i the sample in the study. tpe literature on swallowing disorders corroborates the fino/ng that swallowing impairment increases in prevalence with advancing age ( borgstrom et i , 59 ai., 1988; groher and bukatman, 1986). the fact that no swallowing problems were repor.ted in the oldest old is an interesting finding that does not correspond with the above pattern. a possible explanation may be due to the limited number of subjects in the sample who fell into this age group. the limited representation of this age group in the study may be due to few persons in the oldest old age group living in retirement villages as they tend to no longer be able to function independently. nature opswallowing difficulties in the elderly subjects table 3 presents a summary profile of the nature of the swallowing difficulties experienced by the elderly subjects in the present study. symptoms are divided according to the three phases of the swallow that may potentially be affected: the oral, pharyngeal and oesophageal phases. the current findings, as highlighted in table 3, will be discussed and compared to findings reported in the literature. the overall locus of swallowing difficulties will also be considered. .oral phase difficulties difficulty with chewing was reported by two of the subjects who experienced swallowing difficulties. one of the subjects reported having to spit lumps of food out during 50% :g, 40% -e 30% ~ 20% .... ~ 10% 0% 47% r--25% r--0% old 65-75 old, old 76-85 oldest, old 85+ age groups figure 1. histogram illustrating the prevalence of swallowing difficulties according to age in percentage. table 2: a comparison between the current findings and those from previous prevalence studies on swallowing disorders in the eld~rly population. current study trupe et al. (1984) bloem et al. (1990) lindgren and janzon (1991) subject of study prevalence in the overall prevalence prevalence in a prevalence in the sample community general population setting retirement villages nursing home subjects living in urban population their own homes population 25 volunteer residents all residents 130 elderly persons 600 persons between 50 (85 years and older) and 79 years of age method interview questionnaire, chart interview questionnaire review, physical exam results 44% 50% 16% 35% die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 60 eating. these symptoms may be the result of a decrease in masticatory strength that is reported to occur in the normal ageing population (logemann, 1990). dry mouth was reported by six of the subjects who experienced swallowing difficulties. according to logemann (1990) and martin (1991), there is a decrease in the production of saliva with advancing age. in addition, certain medication may interfere with salivary secretions (schulzedelrieu & miller, 1997). only one subject reported food, drink or saliva dribbling from the mouth. according to the literature this may occur as a result of poor mouth closure and reduced oral sensations which occur with ageing (langley, 1987). food remaining in the mouth after swallowing was not reported by any of the subjects despite this symptom being reported as a potential difficulty in the elderly population (kavariaugh, 1994). no statistical relationship was found between the above oral phase symptoms and the presence of swallowing difficulties. pharyngeal phase difficulties difficulty,initiating a swallow was reported by 7 ofthe subjects wh~ experienced difficulty swallowing. the relationship between experiencing difficulty initiating a swallow and the presence of a swallowing problem was significant (p=0.000686 by fisher exact test). this finding is supported by reports in the literature that the triggering of the pharyngeal phase of the swallow is delayed in elderly persons (logemann, 1990; kavanaugh, 1994). the need to swallow more than once on a single mouthful offood was reported by 7 of the subjects. this symptom may also be related to the delayed triggering of the pharyngeal phase of the swallow that occurs with age (kavanaugh, 1994). the relationship between swallowing more than once on a single mouth offood and the presence of a swallowing problem was significant (p=o .0072 by fisher exact test). tracey wilkinson and janet de picciotto the need to wash food down with liquids was reported by 5 of the subjects who experienced swallowing difficulties. the relationship between washing food down with liquids and the presence of a swallowing problem was significant (p=0.0087 by fisher exact test). this behavioural method of compensation may be enac,ted in order to attempt to assist the pharyngeal phase of the swallow to occur since it may be delayed in elderly persons (kavanaugh, 1994). taking time to swallow was reported by 7 of the subjects who experienced swallowing problems. the relationship between taking time to swallow and the presence of swallowing difficulties was significant (p=0.017 by fisher exact test). the literature supports the finding of slower swallows in the elderly (robbins et ai., 1992; sonies et ai., 1988). coughing during eating was reported by 5 of the subjects who experienced swallowing difficulties. the relationship between coughing during eating and the presence of swallowing difficulties was significant (p=0.056 by fisher exact test). choking while eating was reported by 4 ofthe subjects demonstrating a significant relationship with swallowing problems (p=0.0087 by fisher exact test). the above symptoms may occur as a result of defective closure of the larynx due to difficulty co-ordinating the muscles that close and protect it, which is reported to occur with age (kavanaugh, 1994; schulze-delrieu and miller, 1997). one subject reported the experience of a wet sounding or gurgly voice when eating. this is commonly reported as a symptom of dysphagia in the elderly (kavanaugh, 1994) and in general in dysphagic patients (martin, 1991). no statistical relationship was found between the experience of a wet voice and the presence of a swallowing problem. food coming through the nose was not reported by any of the subjects despite this symptom being reported as a potential difficulty in the elderly (kavanaugh, 1994). table 3: summary profile of the nature of swallowing difficulties reported to be experienced by the elderly subjects in the present study oral pharyngeal oesophageal subject choke wet wash feeling pain while voice food offood behind eating after ica,ccrungl breast eating bone ~ subjects who did not perceive themselves to have swallowing problems the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) swallowing problems in the normal ageing population oesophageal phase difficulties nine subjects reported that they experienced the sensation offood catching below the level of the larynx. the relationship between the sensation of food catching and the presence of swallowing difficulties was significant (p=0.0000269 by fisher exact test). reduced or less efficient peristalsis due to a decrease in muscle strength may occur with ageing (sheth & diner, 1988; logemann, 1990). this may account for the sensation of food catching in the oes9phagus. four of the subjects reported experiencing pain behind the breastbone after eating. the relationship between this symptom and swallowing difficulties was significant (p=0.026 by fisher exact test). four of the subjects reported that food comes back up their throat during eating a statistically significant relationship was demonstrated between the presence of swallowing difficulties and food coming back up the throat (p=0.056 by fisher exact test). the incidence of hiatus hernia and gastric reflux is increased with advancing age (sheth & diner, 1988) and may account for the two symptoms described above. two of the subjects reported that they feel like being sick after eating. five of the subjects reported that they experience heartburn frequently. although these two symptoms are reported in the literature as indicators of swallowing problems (langley, 1987), no statistical relationship between these symptoms and the presence of swallowing difficulties was demonstrated. overall locus of swallowing difficulties the current findings indicate that 64 % of the subjects appear to have difficulties that affect all three stages of the swallow. 36 % of the subjects appear to have difficulties affecting both the pharyngeal and oesophageal phases of the swallow. these findings, presented in table 4, may be compared to two studies by feinberg and ekberg (1991) and ekberg and feinberg,(1991) in which the locus ofswallowing difficulty in the samples was determined. / the differences in percentages in the above studies may be accounted for by the differences in the populations studied, the difference in the sdmple sizes and the different methi i 61 ods of assessment to determine the nature of the swallowing difficulties. however, the current finding that difficulties affecting oral, pharyngeal and oesophageal phases are experienced by elderly people is supported oy the ekberg and feinberg (1991) and feinberg and ekberg (1991) studies. usefulness of the interview schedule the devised interview schedule successfully detected symptoms of swallowing problems in 11 of the 25 subjects. as mentioned earlier, only 7 of these subjects perceived themselves as experiencing difficulty swallowing. four of the subjects who did not perceive themselves as having swallowing difficulties demonstrated evidence to suggest that they were in fact experiencing swallowing problems. the above discrepancy may be viewed as indicative of the usefulness of the interview in detecting swallowing problems in elderly persons, including those who are either unaware of the difficulties or have not considered them to be a problem. however, it is important for the clinician to exercise caution and avoid giving dysphagia to those who do not have it (robbins, 1995). apart from detecting the presence of swallowing difficulties, the interview schedule provided information regarding symptomatology relating to the various phases of the swallow. information regarding the locus of the swallowing problem, oral, pharyngeal and oesophageal, was gleaned. however, it is important to note that the information obtained was based on the perceptions ofthe individual subjects and is highly subjective. further investigations involving objective measures would be necessary to confirm the locus of pathology and to determine the severity of the problem. for the above reasons it would seem appropriate to make use of the interview as an initial screening measure in determining the presence of a swallowing problem. the interview may highlight the need for further investigations such as the bedside evaluation and videofluoroscopic examination. the use of the interview as a screening tool may be of particular value in the south african context where resources are limited and advanced diagnostic measures such as videofluoroscopy are expensive and often inaccessible. the interview schedule proved useful in terms of hightable 4: a comparison of current findings regarding locus of swallowing difficulties with findings from two studies: feinberg and ekberg (1991) and ekberg and feinberg (1991). • i i current study feinberg and ekberg ekberg and feinberg (1991) (1991) population 25 normal functioning retiremen 50 patients known to aspirate 56 persons with no symptoms of village residents dysphagia or eating difficulty mean age 77.4 years 87 years 83 years method interview videofluroscopy videofluroscopy results 64 % with difficulties involving 46 % abnormalities of oral stage. 63 % oral abnormalities. all three phases of the swallow. 20 % abnormalities of pharyn25 % pharyngeal abnormalities 36 % with difficulties involving geal phase. 39% pharyngoesophageal segment both the pharyngeal and 34 % abnormalities of oral and abnormalities. oral phases. pharyngeal phase. 36 % oeophageal abnormalities 0% with difficulties in only one phase. die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 62 lighting a number of other factors either related or not related to swallowing problems in the elderly. these included diabetes, arthritis, smoking, use of dentures, food avoidance patterns, food consistency, difficulty swallowing tablets, use of "tricks" during eating and aspiration pneumonia. a discussion of these findings follows. diabetes, arthritis and smoking: no statistical relationship was found between subjects with diabetes and the presence of swallowing problems despite reports in the literature that diabetic subjects frequently experience dysphagia(boolkin, 1998). the small sample size may account for the absence of this finding. similarly, no relationship between subjects with arthritis and the presence of swallowing difficulties was found. smoking was also not found to be related to the presence of swallowing problems. however, the limited sample size may account for the absence of these relationships. dentures: no statistical relationship was found between the use of dentures and the presence of swallowing problems. this finding is in contrast to a study by hildebrandt et al. (1997) which found that compromised dental function, including the use of prostheses, results in the swallowing of poorly chewed food, food avoidance patterns and dietary inadequacies. the limited sample size may account for the contrasting findings. food avoidance patterns: the relationship between food avoidance and the presence of swallowing problems was significant (p=0.000983 by fisher exact test). adequate nutritional intake is of great medical importance in the elderly (hildebrandt et ai., 1997). the individual's ability to comfortably swallow certain.food types is an important component of nutritional intake. current findings indicate that the swallowing difficulties experienced by the subjects iinpact on their diets to the extent that particular foods are avoided. avoidance of chewy foods (such as beef and steak) and crunchy food (such as vegetables) was reported by four of the subjects, howeve~ this was not found to be statistically significant. meat and vegetables are important dietary sources of protein, iron, vitamins and fibre. careful monitoring of sufficient intake. of these food types is critical in the elderly patient (hildebrandt et ai., 1997) avoid?-nce of crumbly foods (such as biscuits or cake) and dry foods (such as bread) was statistically related to swallowing problems (p=0.026 and p=0.072 respectively by fisher exact test). crumbly foods fall apart in the mouth and are reportedly more difficult to swallow (langley, 1987). according to hildebrandt et al.(1997), involuntary weight loss may occur as it result offood avoidance's and is a risk indicator for mortality in the elderly. although the elderly subjects in the present study commonly reported weight loss, it was often ascribed to other factors such as illness, depression and ·diabetes. difficulty swallowing tablets: the relationship between difficulty swallowing tablets and the presence of swallowing problems was significant (p=0.082 by fisher exact test). this finding is of concern since many elderly people , are reliant on medication for their wellbeing. ifelderly patients struggle to swallow tablets they may avoid taking their medication which could have detrimental consequences (massey & shaker, 1997). this may be an area where altered medicine preparations may be warranted to facilitate compliance in elderly people in taking their medication. use of "tricks " during eating: many of the subjects with tracey wilkinson and janet de picciotto swallowing difficulties reported making use of certain "tricks" to help them eat more efficiently. these included sitting up straight while eating, cutting food finely, chewing very well, mashing up food ami grating fruit and vegetables; t~king liquid with all food, moistening all food with spreads ~nd gravy, eating siowly and.concentrating carefully on swallowing. these"tricks" indicate that the subjects are engaging in compensatory behaviours in order to cope with their difficulties. most.of these seem to be positive adaptations to the changes in their swallowing abilities. food consistency: subjects with swallowing difficulties reported that it is easier to swallow mincemeat in comparison to steak. the relationship was significant (p=0.033 by fisher exact test). this finding is in contrast to reports in the literature, which suggest that crumbly food's with uneven consistency are more difficult to swallow. the extra effort necessary to chew steak and the corresponding decrease in masticatory strength that occurs with ageing (logemann, 1990) may account for the above finding. pneumonia: no relationship between the presence of swallowing problems and the experience of pneumonia was found. pneumonia is a commonly reported symptom of dysphagia (feinberg et ai., 1990; massey & shaker, 1997). the relatively mild nature of the swallowing difficulties experienced by the elderly subjects may account for the absence of this finding. the prevalence and nature of swallowing impairment in the normal ageing population and the related factors found in this study have implications for the individual, society and the clinician. . conclusion the study showed that a substantial proportion of the sample of elderly subjects e}{perience swallowing problems that interfere with their day to day functioning. the nature ofthese difficulties was described and findings indicated that dysphagia • prevalence • nature of swallowing i problems i : /' + ~:; health nutrition selfes'teem \ • aspiration , • malnutrition • social pneumonia • weight loss isolation • death , ~r ~ " / health care costs quality of life j~ societal / burden figure 2: diagrammatic,representation of the impact of dysphagia on the elderly person and on society. the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) swallowing problems in the normal ageing population 64 % ofthe subjects experienced difficulties affecting all three phases of the swallow while 36 % experienced difficulties affecting the oesophageal and pharyngeal phases of the swallow. this study demonstrated the utility of the devised interview schedule as an inexpensive means of detecting swallowing problems in the south african elderly population, where objective measures are inaccessible. a number of theoretical implications arise from this study. in order to understand the,importance ofthe field of dysphagia, it is necessary to have an appreciation of the clinical problem, both for the individual patient and for society as a whole (massey & shaker, 1997). a model ofthe implications of dysphagia for the elderly individual and society at large is presented in figure 2 the prevalence and nature of swallowing inipairment can have a negative impact on the health of the elderly to the extent that complications, such as aspiration pneumonia develop which can lead to death (feinberg et ai., 1990). dysphagia can negatively affect the nutritional status of the elderly person which may result in malnutrition and severe weight loss (bloem et ai., 1990). these are risk indicators for mortality in the elderly (hildebrandt et ai., 1997). finally, disordered swallowing may negatively impact on the elderly person's self-esteem and may lead to social isolation because of an unwillingness to eat in front of others (bloem et ai., 1990). this is often exacerbated in elderly persons due to the importance of mealtime as a social and interpersonal activity (baker, 1993). the impact of dysphagia on the health, nutritional status and self-esteem of the elderly person all negatively impact on the quality of life of these individuals (massey & shaker, 1997). the impact of dysphagia on the health ofthe individual, the chronic nature of the difficulty and the need for expensive diagnostic and therapeutic interventions implies a substantial burden on the health care system and a significant economic impact on society as a whole. the need for early identification and treatment of dysphagia to prevent the onset of costly complications cannot be overstated in an economically limited country like south africa. a further theoretical implication ofthe study relates to the issue of normalcy in swallowing. as discussed in the introduction, determining appropriate definitions for normalcy and accurate means for assessing the presence of swallowing problems remkins problematic for researchers in the field of swallowink disorders (massey & shaker, 1997). in south africa, costly objective measures are not easily accessible. there is la need to develop and evaluate a subjective device to identify the presence of swallowing dis, /' orders. the present study has attempted to address this need by proposing the use of the devised interview schedule as a dysphagia screening measure. this device was able to detect the presence of swallowing problems. however, it was unable to further clarify the debate surrounding appropriate definitions for normalcy. perhaps the model in figure 3 suggests a way to approach the issue of normalcy, that is, by eval uating the extent to which the patient's quality of life is affected. therefore, rather than just attempting to define normal versus disordered swallowing, an instrument which measures the handicapping effect of this swallowing difficulty on quality of life may be indicated. the findings of the study raise clinical implications. the role of the speech pathologist in the area of dysphagia in the normal ageing population is highlighted and justified. a large proportion of subjects who could potentially benefit from diagnostic and therapeutic interventions specific to 63 their swallowing disorders was identified. it is the responsibility of the speech pathologist to promote the identification and treatment of swallowing disorders in the elderly population. this is of particular importance in the south african context, where the role of the speech pathologist in dysphagia in the elderly population is currently underdeveloped. south african speech pathologists are urged to address the need by promoting our services with this population in old age homes and retirement villages. the interview schedule is a device that can be administered by speech pathologists and other health care professionals who have contact with elderly people. most retirement villages and old age homes have medical clinics on the premises. healthcare-workers employed in these clinics should administer the interview to' patients who attend the clinic in order to detect swallowing problems. a speech pathologist could then be called in to intervene with further diagnostic measures and therapeutic techniques. from a clinical perspective, it is therefore hoped that south african speech pathologists will embrace their role in working with elderly subjects with swallowing difficulties an area that is overlooked at present; the present study had a numberoflimitations that included the following. the limited sample size makes generalis ability of the results difficult. response bias may have been introduced into the study in that subjects with symptoms of swallowing difficulty may have been more willing to participate in the study (massey & shaker, 1997). this may have resulted in over-representation of the findings. finally, the validity of the questionnaire as an assessment tool is a problematic issue because of its subjective nature and the lack of consensus about normalcy in swallowing in the literature. the need to develop a device which measures the effect of swallowing impairment on quality of life is indicated. the results ofthe study provide several implications for future research. ongoing research into this population using larger samples is necessary in order to add strength to the current findings regarding the prevalence of swallowing difficulties in the normal ageing population. the current findings should be compared to findings from objective measures such as videofluoroscopy, in order to substantiate the findings and to determine the sensitivity and reliability of the interview schedule. investigation of the social ramifications of swallowing problems and the development of a device which measures the impact of swallowing impairment on the quality of life of the individual is necessary. in conclusion, this study has served to highlight the diagnostic and rehabilitative role of speech pathologists in the area of dysphagia in the normal ageing population. it is hoped that as south african speech pathologists, we will begin to meet the challenge of asserting our role as "swallowing therapists" with the normal ageing population. in so doing, we may effectively improve the wellbeing and quality of life of our elderly patients. "the magnitude of the dysphagia burden for individual patients and society at large is ample reason .... to strive to meet these challenges" (massey &shaker, 1997, p. 11). references baker, d.m. (1993). assessment and management of impairments in swallowing. nursing clinics of north america, 28 (4), 793805. die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 64 bleeker, m.l., bolla-wilson, k., kawas, c. and agnew, j. (1988). neurology, 38,1566. bloem, b.r, lagaay, a.m., van beek, w., haan, j., roos, ra.c., wintzen, a.r (1990). prevalence of subjective dysphagia in community residents aged over 87. british medical journal, 300,721-722. boolkin, l. (1998). the incidence of dysphagia in diabetic patients. unpubli'shed masters research report, university of the witwatersrand, johannesburg. borgstrom, p.s. and ekberg, o. (1988). pharyngeal dysfunction in the elderly. journal of diagnostic imaging, 2, 74-8l. breakwell, g. (1996). research methods in psychology. london, sage. ekberg, o. and feinberg, m.j. (1991). altered swallowing function in elderly patients without dysphagia: radiologic findings in 56 cases. american journal of roentology, 156 (6), 11811184. feinberg, m.j. and ekberg, o. (1991). videofluoroscopy in elderly patients with aspiration: importance of evaluating both oral and pharyngeal stages of deglutition. american journal of radiology, 156 (2), 293-296. feinberg, m.j., knebl, j., tully, j., segall, l. (1990). aspiration and the elderly. dysphagia. 5,61-71. folstein, m.f., folstein, s.e. and mchugh, p.r (1975). minimental state: a practical method for grading the cognitive state of patients for the clinician. journal of psychiatric research, 12, 196-198. groher, m.e. and bukatman, r (1986). the prevalence ofswallowing disorders in two teaching hospitals. dysphagia, 1,3-6. hildebrandt, g.h., dominguez, b.l., schork, m.a, loesche, w.j. (1997). functional units, chewing, swallowing and food avoidance among the elderly. journal of prosthetic dentistry, 77 (6), 588-595. kane, e. (1985). doing your own research: basic descriptive research in the social sciences and humanities. london, marion boyars. kavanaugh, k.m. (1994). "understanding and treating swallowing problems". chicago, il. illinois council on long term care. langley, j. (1987). working with swallowing disorders. winslow press, oxon. leedy, p.d. (1989). practical research: planning and design. 51h edition, macmillan, new york. lindgren, s. and janzon, l. (1991). prevalence of swallowing complaints and clinical findings among 50 79 year old men tracey wilkinson and janet de picciotto and women in an urban population. dysphagia, 6, 187-192. logemann, j.a (1990). effects of ageing on the swallowing mechanism: head and neck diseases in the elderly. otolaryngologic clinics of north america, 23 (6), 1045-1056. martin, a.w. (1991). dietary management of swallowing disorders. dysphagia, 6, 129-134. massey, b.t. and shaker, r (1997) "introduction to the field of deglutition and deglutition disorders" chapter 1 in perlman, al. and schulze-delrieu, k.s. (eds.) deglutition and its disorders. anatomy, physiology, clinical diagnosis and management. singular publishing group, inc., san diego. robbins, j. (1995). translating current research into clinical practice: physiology of swallowing. asha: special interest division: swallowing and swallowing disorders (dysphagia). 4(3), nov, 7-10. robbins, j., hamilton, j.w., lof, g.l. and kempster, g.b. (1992). oropharyngeal swallowing in normal adult of different ages. gastroenterology, 103, 823-837. rosner, rl. and rosenthal, r (1996). beginning behavioural research: a conceptual primer. 2nd edition. prentice hall, london. schulze-delrieu, k.s. and miller, rm. (1997) "clinical assessment of dysphagia" chapter 5 in perlman, a.l. and schulzedelrieu, k.s. (eds.) deglutition and its disorders. anatomy, physiology, clinical diagnosis and management. singular publishing group, inc., san diego. sheth, n. and diner, w.c. (1988). swallowing problems in the elderly. dysphagia, 2, 209-215. silverman, f:h. (1993). research design and evaluation in speechlanguage pathology and audiology: asking and answering questions. prentice hall, englewood cliffs. sonies, b., parent, l., morrish, k., et al. (1988). durational aspects of the oral-pharyngeal phase of the swallow in normal adults. dysphagia, 3, 1-10. tracy, j.f., logemann, j.a, kahrilas, p.j., jacob, p., kobara, m., krugler, c. (1989). preliminary observations on the effects of age on oropharyngeal deglutition. dysphagia, 4, 90-94. trupe, e.h., siebens, h., siebens, a (1984). prevalence of feeding and swallowing disorders in a nursing home. arch phys med rehabil, 65, 651-652. ward, p.h., colton, r, mcconell, f., malmgren, l., kashima, h., woodson, g. (1989). aging of the voice and swallowing. otolaryngology and head and neck surgery, 100 (4). 283-286. the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the im pact o f v isual sequencing o f g raphic sym bols on the sentence c onstruction o utput o f c hildren w ho have a cquired language 105 the im p a c t o f v is u a l s e q u e n c in g o f g r a p h ic s y m b o l s o n t h e s e n t e n c e construction output of children who have acquired language erna alant*, amelia du plooy and shakila dada centre fo r augmentative and alternative communication university o f pretoria a b s t r a c t although the sequence o f graphic or pictorial symbols displayed on a communication board can have an impact on the language o u t p u t o f children, very little research has been conducted to describe this. research in this area is particularly relevant f o r p ri­ oritising the importance o f specific visual and graphic features in providing more effective and user-friendly access to communi­ cation boards. this study is concerned with understanding the impact o f specific sequences ofgraphic symbol input on the graphic and spoken output o f children who have acquired language. forty participants were divided into two comparable groups. each group was exposed to graphic symbol input with a certain word order sequence. the structure o f input was either in typical eng­ lish word order sequence subject-verb-object (svo) or in the word order sequence o f subject-object-verb (sov). both input groups had to answer six questions by using graphic output as well as speech. the findings indicated that there are significant differences in the pcs graphic output patterns o f children who are exposed to graphic input in the s o v and svo sequences. fur­ thermore, the output produced in the graphic mode differed considerably to the output produced in the spoken mode. clinical im­ plications o f these findings are discussed. key w ords: augmentative and alternative communication, graphic symbol input, graphic symbol output, spoken output, sen­ tence construction, word order. introduction the field o f augmentative and alternative communication (aac) essentially deals with ways in which speech can be aug­ mented or replaced by nonverbal strategies. a significant pro­ portion o f these strategies include the use o f graphic symbols, for example, line drawings as a means to provide access to communication and learning for children and adults who might not have good reading or writing abilities. the use o f these graphic symbols on the children’s re­ ceptive and expressive abilities has, however, not been well documented. relatively few studies have been done to explore the impact o f the use o f graphic symbols on the language devel­ opment o f children. j one o f the main issues in understanding the impact of the use o f aac strategies on the language development o f chil­ dren has to do with the acknowledgement o f the asymmetrical relationship between the children’s input, which is largely audi­ tory with visual support (asj with typical children) and their output which is much more focused on the aac strategy as a means to augment existing communication. smith and grove (2003) discussed the asymmetry in input and output o f indi­ viduals that use aac and maintained that there are at least three factors that can influence the language acquisition process of an individual using aac, these being the structural charac­ teristics o f the target language (spoken language), the nature of the input provided (auditory and/or visual), as well as the up­ take, referring to the child’s processing o f the input received. the influence o f the structural characteristics o f the target lan­ guage is related to the degree o f congruence between the struc­ ture o f the target language and the sequencing o f the graphic symbols on the display. the demands that the aac strategy address: c entre fo r a ugm entative and a lternative c om m unication u niversity o f p retoria p retoria , 0002 ' south a frica telephone: **21 12 420 2001 fa*: **21 12 420 4389 email: e m a.alant@ up.ac.za imposes on the cognitive processing o f the individual and how these demands impact on the uptake o f the individual, is o f additional concern. the relative importance o f all o f these fac­ tors is, however, unresolved (harris, 1992; mcdonald, 1997). regarding the development o f syntactic skills in persons using aac, research evidence points to atypical patterns of expression, such as a reliance on single-word utterances (bruno, 1989; von tetzchner & martinsen, 1996), relatively high frequency o f word order errors (grove, 1995; grove & dockrell, 2000; van balkom & donker-gimbrere, 1996) and lack o f internal morphological or clause structure (grove, 1995). when considering possible influences leading to atypi­ cal syntax amongst aac users, oxley and von tetzchner (1999) acknowledge that syntax and morphology o f graphic systems are connected to the visual properties o f the systems. furthermore, construction o f graphic ‘sentences’ might be compromised by the user’s motor skills and coordination. structure might be imposed by the forced choices users must make given the availability o f graphic signs. there has been increased interest over the past years in the organisation o f the aided symbol displays and how to match these as closely as possible to internal cognitive or lexical strategies held by the aac user (light, et al., 2004). the as­ sumption is that the user would find it easier to identify sym­ bols if the display board more closely resembles the sequence o f the language o f input. nakamura, newell, aim and waller (1996) asked english-speaking adults to compose picture-based sentences using a computer-based system. subject, verb and object picture communication symbols (pcs) (mayer johnson, 1985) could be selected by activating the correspond­ ing button on the computer screen. this particular study util­ ized two conditions to analyze the impact o f symbol ordering on picture-based sentence construction. in the svo condition, the symbols were in the typical english word order sequence (subject-object verb) and in the sov condition, the symbols were in the atypical word order sequence (subject-object verb). twentyone subjects were assigned to the svo condi­ tion and 22 subjects were assigned to the unfamiliar sov conthe south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:ema.alant@up.ac.za 106 e m a alant, a m elia du plooy and shakila dada dition. the results showed that the english sub­ jects used english word order in both conditions. in this study both groups were able to express themselves in the english word order regardless of the sequence o f the graphic symbols on the dis­ play. in spite of the presentation o f the symbols in an order not similar to that o f their mother-tongue, adults were able to make the adjustment to present their answers in the correct symbol order. it is against this background that the ques­ tion arises as to the impact that the sequence in which symbols are presented could have on the output o f children who have already acquired lan­ guage. furthermore, the graphic output mode needs to be compared to a spoken output mode. this study specifically investigated the impact of a subject-verb-object (svo) sequence and a sub­ ject -object-verb (sov) sequence o f symbols on graphic displays for children with intact language acquisition. as a first step, this research was con­ ducted on typically developing children to provide a basis for application to users with little or no functional speech. this information will thus en­ hance understanding o f how typically developing children are able to manipulate graphic symbols in the process o f language learning. methodology aims the study aimed to answer the following ques­ tions: • what is the syntactic structure o f the graphic output constructed by children who have ac­ quired language in response to a svo graphic input condition (i.e. the selection display is organised in a svo structure)? • what is the syntactic structure o f the graphic output constructed by children who have ac­ quired language in response to a sov graphic input condition? • how does the syntactic structure o f the graphic output compare for the two input conditions? • how does the graphic output compare to spo­ ken output? design a control group design was used. the participants were randomly assigned to two groups. h alf o f the participants received the svo input and the other half received sov input. even distribution of male and female participants in the two groups was ensured. participants all the participants o f this study were typically developing children who met the following selec­ tion criteria: the children and their parents con­ sented to their participation in the study, they were between the ages of 7.5 to 8.5 years; spoke eng­ lish as the primary language; had no reported lan­ guage impairments; had reportedly normal vision and hearing; had prior experience with using computers and had the ability to use a mouse. material the graphic-based communication system the study was conducted using a computer-based program specially designed for the purpose. it consisted o f a computer-generated story that was told to the participants using graphic symbols and then providing them with questions based on this story. these questions had to be answered by looking at graphic symbols presented in two different sequences, namely svo and sov sequences. where vetch to s i / f i ' choose categay ,__ .. people i i ® “ls ?i — 1 ta g s s m j4 n a w f ll . q ib ; j unkrewn * ■' a ■ freshed sentence undo last conduction stop •available symbols f a categay— jo h n mary apple boy wteh i \ figure 1: a nsw ering questions using pcs: the sv o exposure .q uestions. 1 w t t f i * i •choose categwy— ■; finished sentence conrtiiaton stop available symbols ftx category— casts [-sentence cons&ueton area— chocolate ----“ i gpptemaintains * m w figure 2: a nsw ering questions using pcs: t he so v exposure die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the impact o f v isual sequencing o f g raphic sym bols on the sentence c onstruction o utput o f c hildren w ho have a cquired language 107 the graphic-based communication system was developed on a rsonal computer (pc) using the picture communication sym­ bols (pcs) construction package boardmaker™ (mayer johnson, 1985) and the software program visual basic. a mouse-driven interface was provided. in the ‘choose a cate o r y ’ section, three buttons were displayed on the screen corre­ sponding to the three basic parts o f speech: a subject button (people), a verb button (action), and an object button (things). each of these buttons, when activated, provided a list o f appro­ priate pcs symbols and participants could then choose one of the pcs symbols. for example, if a participant touched the subject button, five pcs symbols representing subjects (namely john, mary, witch, apple boy and village people) were displayed. when the participant chose a particular sub­ ject, the selected symbol was displayed on the screen and the computer spoke the corresponding word. in the svo input the sequence o f buttons in the “choose a category” section was in the typical english word order sequence (subject-verb-object) and in the sov input the word order was subject-object-verb. a visual cue (moving face) was provided to assist the participants in finding their marker on the screen. a button was included to delete unwanted symbols. the learners indicated that they had completed a question by clicking on the “finished” button. the computer recorded the participant’s responses, including deleted symbols. by including the deleted symbols, some insight into the underlying process o f pcs sen­ tence construction can be acquired. for more information on the communication system please consult du plooy (2004). the story nakamura et al. (1996) developed a picture communi­ cation system and a set o f questions based on the japanese folk story “momo-tarou” (the apple boy). adaptations were made to the story to ensure age and cultural appropriateness for the participants. the teachers’ suggestions and the pilot study re­ sults were used to make the necessary adaptations. see appen­ dix a for the adapted story as well as the questions used in the study. seven illustrations were made using the boardmaker™ program to use as visual stimuli to support the computer gener­ ated story. procedure training the participants were trained in groups o f 5. the train­ ing included teaching the categorization process needed to se­ lect a pcs symbol, practising the combination o f pcs symbols into sentences as well as listening to “the apple boy”. the training procedure was audio-recorded. during the categorization process the researcher ex­ plained the concept o f graphic symbols and introduced the pcs symbols. the trainer then asked the participants to place the symbols in the categories of people, actions and things. then they were trained on how to construct sentences using these graphic symbols by presenting them with sentences e.g. “boy reads book” and asking them to represent these using graphic symbols. this training took place away from the computer. the final stage in the training process required that they had a first exposure to the “apple boy story” away from the com­ puter using stimulus pictures to ensure their familiarity with it once they were exposed to the computer generated version o f the same story. testing procedure , the participants were tested individually. they listened to a recorded version o f the “apple boy” on the computer. illustra­ tions were shown as the computer told the story. the partici­ pants were told that they had to listen to the story again, be­ cause they had to answer some questions about the story. the participants were introduced to the pcs symbols that they had to use in order to answer the questions. each question was spoken by the computer in correct english syntax and key con­ cepts were represented by the pcs symbols. the question “where did the witch live?” for example, was accompanied by the symbols ‘where’, witch’ and ‘live’. each participant an­ swered six questions by choosing and selecting pcs symbols on the computer to form sentences. when the participant chose a particular symbol, it was displayed on the screen and the computer spoke the corresponding word. figures 1 and 2 in­ serted before provide screenshots o f question 1: svo input and question 1: sov input respectively. participants had to click on the finished button to go on to the next question. re­ sponses were automatically saved on the computer the same questions were then asked verbally and each participant was required to give a spoken answer. their re­ sponses were recorded. the spoken response mode always followed the picture-based answers. reliability o f data procedures were recorded and 20% of the data was rated for procedural integrity by an independent rater. results showed 97.5 % integrity for the training procedure across all four groups and 100% integrity on the testing procedure. analysis o f data two hundred and thirty two pcs responses were analysed, 112 for the svo graphic input condition, and 120 for the sov graphic input condition. two hundred and twenty five spoken responses were analyzed. each symbol was classified as subject (s), verb (v) or object (o). the responses were then classified into four types. the following responses are examples o f responses classified as svo: “live castle”, “witch live castle”, “give chocolate monkey” and “apple boy give monkey chocolate”. the sec­ ond type, namely sov responses, include responses like “castle live”, “monkey chocolate give”, and “witch castle live” as well as “apple boy chocolate monkey”. the third type was the single symbol utterances and the fourth type was used for sentences that could not be categorized into any of these types. results and discussion a chi-square test was done to test for a relationship between input and output sequence. however due to small frequencies in some o f the cells, the test may not be valid and for the dis­ cussion o f table 1, emphasis will be placed on the difference between the expected and actual frequencies for this data. table 1 indicates that the total frequency for outputs in the svo input condition (112) was slightly lower than for the sov input condition (120). a different pattern of responses between the two groups is also evident. for the svo condi­ tion, the expected frequency for svo outputs is 25 whilst the actual row frequency is 11. this reflects less svo outputs than expected. for using single symbols, the expected frequency is 58 whilst the row frequency is 73. this suggests that partici­ pants produced less multiple symbol outputs in the svo input condition than expected and more single utterances. the ten­ dency to use more single utterances is not surprising as single the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 108 e m a a lant, a m elia du plooy and shakila dada t able 1: a nalysis o f different pcs output sequences utterances are often used as responses to questions (von tetz­ chner & martinsen, 1996). for the sov input condition the output frequency for svo is 41 which is higher than the expected frequency o f 27, whilst outputs in terms o f single symbol utterances are lower (47 than expected 62). this implies that the children, even on a graphic level, were able to correct for the sov presentation o f symbols to respond with the traditional svo sequence. the fact that few sov responses were given confirm this finding. when comparing the row percentages between the dif­ ferent input conditions for graphic output responses in table 1, the most striking o f the differences include the higher percent­ age of svo responses (34%) in the sov input condition and the lower percentages (39%) o f single symbols in the sov in­ put condition. both these findings could reflect a more con­ scious effort from the children in the unfamiliar sov input se­ quence condition in fulfilling the requirements o f the task, re­ sulting in more grammatically complete responses. on the other hand, the svo input condition elicited more automatic re­ sponses from the children reflecting more single utterance re­ sponses and less full sentences. thus, despite their intact ex­ pressive and receptive language, these children used an overall high percentage o f single symbol utterances (65% and 39%). these findings are supported by smith (1996) who found simi­ lar patterns o f picture reduction in typical children when using graphic output. t able 2: a nalysis o f the percentages o f different spoken output se­ quences die suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 overall, a total o f 25 % and 27 % (for svo and sov input conditions respectively) o f graphic output utterances of the participants deviated from the accepted english word order. these percentages are obtained by adding the percentages of utterances classified as sov and those classified as ‘other’. this relatively high percentage might suggest that the students found the task quite difficult in both input conditions. table 2 represents the spoken outputs o f the children in the two groups (svo input condition and sov input condi­ tion). overall number o f utterances indicated that the sov in­ put condition produced slightly less spoken utterances (107 as opposed to 118). when compared in terms o f the different cate­ gories o f spoken output, it is evident that there are no signifi­ cant differences between the speech outputs o f the two groups in response to the questions. no responses categorized as “other” or sov speech output were noted. all participants had acquired language, and it is thus not surprising that there is no statistical difference between these two groups on the type of verbal outputs. when comparing each o f the input modes, it becomes evident that in both the svo and sov input modes, the graphic outputs were more varied, whilst the speech output of both groups was very similar. the above findings are both in­ teresting and thought-provoking in terms o f clinical implica­ tions for intervention. it is indicated that for graphic outputs, the sov input condition had a significant impact on the ex­ pression o f the participants. these findings evoke interesting questions in relation to principles o f symbol organization on communication boards. if the child is using graphic input and output, where one symbol represents one concept, attention to the sequence o f the graphic symbols on the communication board is likely to impact on expression, even if the child has acquired syntactic abilities. in contrast, a child using verbal language output will use his/her internalized syntactical knowledge to organise output. this impact o f the sequence o f graphic symbol input might be reduced if other visual features that could impact on symbol selection e.g. color coding, were employed. the aided language stimulation approach by goossens’, crain and elder (1992) for example, colour codes the different parts o f speech (nouns, verbs etc.), which might aid correct output sequencing, provided the user has the metalinguistic knowledge to use such colour coding to his or her advantage. also, when using graphic systems that do not have a one-on-one relationship concept-to-symbol (such as those em­ ploying semantic encoding), sequencing of symbols; on the display might not influence the syntax o f output in tlie same way. semantic encoding employs combinations o f a finite set o f graphic symbols to generate an infinite number o f concepts. arguably the syntax o f output would be more directly related to the child’s inherent linguistic and specifically syntactic abili­ ties. these findings can also be interpreted in relation to lin­ guistic processing in a visual versus an auditory mode. when children had to provide graphic output based on graphic input, the syntax o f their output deviated from the accepted english word order, in spite o f the fact that they had ,intact syntactic abilities, as evidenced by their correct verbal output. this might reflect that these children were less experienced to trans­ late their answers into a visual mode, while they were well able to formulate syntactically correct answers in a spoken (auditory) mode. one could argue that as these children are relatively young and not well established in reading and writ­ ing skills, they might be less able to construct correct sentences on a visual processing level. this alludes to a difference bem 3 single symbols m o m m total svo input observed frequency expected frequency row percentage 11 25 10 73 58 65 5 4 4 23 25 21 112 sov input observed frequency expected frequency row percentage 41 27 34 47 62 39 3 4 3 29 27 24 120 frequency 52 120 8 52 232 total percentage 22 51 3 22 100.00 chi-square: df 3; v alue 23.88; p < 0001 note: 25% o f the cells have expected counts less th an 5. svo single ut­ terance total svo inp u t. observed frequency expected frequency row percentage 33 35 31 74 72 69 107 sov input observed frequency expected frequency row percentage 41 39 35 77 79 65 118 frequency 74 151 225 total row percentage 66 134 100 chi-square: df 1; v alue 0,3876, p= 0,5336 no t significant r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the im pact o f v isual sequencing o f g raphic symbols on the sentence c onstruction o utput o f c hildren w ho have a cquired language 109 tween the auditory and visual processing skills o f the chil­ dren at this stage o f their development. the task o f re­ coding a message from speech to a graphic or visual mo­ dality is complex for aac users (smith & grove, 2003) and based on the results o f this study even for individuals with intact language abilities. the cognitive processing d e m a n d s for aac users that have speech as input and graphic symbols as an output have been better understood from a dual coding theory perspective (paivio, 1971; 1986). dual coding theory outlines two separate cognitive subsystems that process stimuli, depending on whether the stimulus is verbal or nonverbal. the idea o f separate sub­ systems implies that they are structurally and functionally d istin c t. the two systems are independent in terms o f infor­ mation processing. however, activity in one subsystem is said to trigger activity in the other. this implies an under­ lying assumption that there are interconnections between the two systems. from an aac perspective, the argument has been that these interconnections serve to facilitate lan­ guage development in aac users as the two modalities complement and not compete with each other. however, one could argue that interconnections between the systems is less developed in the participants in this study as they had already acquired language, and had no experience with an aac system as output mode. critical evaluation of the study and future research this study has several limitations which are important in view o f the interpretation o f the data. in the first instance, the study was done on typically developing children who have acquired language. since little is known about the impact o f graphic input on language output, the use o f typi­ cal children allows the examination o f this association be­ fore extending knowledge to children with physical or in­ tellectual disabilities in the performance o f the same tasks. generalization to other populations, for example, children with little or no speech should; thus be done with great cau­ tion. j secondly, the potential' effect o f the ungrammatical sequence o f the graphic input could have been more promi­ nent if the questions asked included more open questions. future research must incorporate more open questions to confirm whether the ungrammatical input has an inhibiting effect on responses requiring more free expression. thirdly, the tasks used 'provided limited symbols on a screen, which is not necessarily representative o f a com­ munication overlay as generally used by aac users. fur­ ther research could investigate the impact o f communica­ tion boards sequenced differently on the output o f children and adults o f different ages. in addition, the impact o f vis­ ual factors, for example, colour coding and its role in mini­ mizing the impact o f unfamiliar visual sequencing e.g. sov on ease o f use in children and adults, could shed light on the basic importance o f symbol sequence as one feature to consider in the development o f communication displays. a c k n o w l e d g e m e n t s r ef e r e n c e s bruno, j. (1 9 8 9 ).c ustom izing a m in sp eak system for a preliterate child: a case ex am ple. augmentative a nd alternative communication, 5, 89-100. du plooy, a. (2004). the impact o f visual sequencing o f pictures on the picture based sentence construction o f english-speaking grade 2 learners. m a ste r’s thesis, c entre fo r a a c , u niversity o f p retoria, s outh africa. g oossens, c., crain, s., & elder, p. (1992). communication displays fo r engineered preschool environments: books 1 and 2. s olana b each, ca: m ayer-johnsonc o. grove, n . (1995). an analysis o f the linguistic skills o f signers with learning disabili­ ties. u npublished doctoral d issertation, u n iv ersity college, london. grove, m . & d ockrell, j. (2000). m ulti-sign com binations by children w ith intellec­ tual im pairm ents: a n analysis o f language skills. journal o f speech, language, and hearing research, 43, 309-323. h arris, m . (1992). language experience and early language development. hove: l aw rence e rlbaum a ssociates. h em m eter, m . l., & k aiser, a. p. (1994). e nhanced m ilieu teaching: e ffects o f parent-im plem ented language intervention. journal o f early intervention, 17(1), 85-99. light, j., d rager, k., m cc arthy, j. m ellot. s., m illar, d., p arrish, c ., et.al. (2004). p erform ance o f ty p ically developing four-and five-year-old children w ith a a c system s using d ifferen t language organization techniques. augmentative and alternative communication, 20(2). 63-88. mayer-johnson, r. (1985). the picture communication symbols. solana beach: mayer johnson. m cd onald, j. (1997). l anguage acquisition: t he acquisition o f linguistic structure in norm al and special populations. annual review o f psychology, 48, 215-241. n akam ura, k ., n ew ell, a., f. aim , n ., & w aller, a. (1996). h ow do m em bers o f different language com m unities com pose sentences w ith a picture-based com m u­ nication system ? a cross-cultural study o f picture-based sentences constructed by e nglish and japanese speakers. augmentative and alternative communica­ tion, 14, 71-79. o xley, j., & von t etzchner, s. (1999). r eflections on the developm ent o f alternative language form s. in f.l oncke, j. clibben, h. a rvidson, & l. l loyd (eds.), aug­ mentative and alternative communication: new directions in research a nd p rac­ tice (pp. 62-74). l ondon: w hurr. paivio, a. (1971). imagery and verbal responses. toronto: r innehart and w inston. p aivio, a. (1986). mental representations: a dual coding approach. n ew york: o xford u n iv ersity press. sm ith, m. m. (1996), the m edium o r th e m essage: a study o f speaking children using com m unication boards. in s. v o n t etzchner, & m . g. jensen (eds.) aug­ mentative an d alternative communication: european perspectives (pp. 137-152). l ondon: w hurr publishers. sm ith, m ., & g rove, n . (2003) a sym m etry in input and output. in j. l ight, d. beu kelm an, & j. r eichel (eds.) communicative competence f o r individuals who use a a c (pg. 163-198). l ondon: p aul h b rookes. v an b alkom , h. & d onker-g im brere, m. (1996). a psycholinguistic approach to graphic language use. in s. von t etzchner, & m . je n sen (eds.), augmentative and alternative communication: european perspectives (pp. 153-170). london: w hurr. v on t etzchner, s. & m artinsen, h. (1996). w ords and strategies: c onversations with young children w ho use aided language. in s. v on t etzchner, & m . g. jensen (eds.) augmentative and alternative communication: european perspectives (pp. 65-88) l ondon: w hurr publishers. this study was originally based on a masters study in aac by amelia du plooy under the guidance o f prof ema alant and dr shakila dada at the caac, university o f pretoria. rina owen from the department o f statistics at the university ° f pretoria assisted with the data analysis o f the study. the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 110 e m a a lant, a m elia du plooy and shakila dada appendix story john and mary were living in a village. sometimes, a witch who lived in the castle came to the village to steal the people’s money. one day, john went to the mountain and mary went to the river. when mary was washing their clothes in the river, a big apple floated towards mary. mary picked it up and took it home. a baby was bom from the apple. john and mary named the baby apple boy. they loved him very much and took good care o f him. when the apple boy grew up, he decided to fight the witch. on the way to the castle, the apple boy met a monkey and gave a chocolate to it. the monkey was so pleased that it promised to help the apple boy fight the witch. with the help of the monkey, the apple boy beat the witch. the witch was then forced to apologize to the village people. questions 1. w h ere did th e w itch live? 2. w here did jo h n go? 3. w h ere did m ary go? 4. w h a t did th e a p p le b oy give and to w hom ? 5. t he a p p le b o y and th e w itch h ad a b ig fight. w h a t happ en ed ? 6. w h a t did the w itch finally do? die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) die stemaanvangstyd van apraktiese en disartriese sprekers erentia gillmer β (log) (prat)', anita van der merwe ma (log) (pret)t 'addington hospitaal durban en tdepartement spraakwetenskap, spraakheelkunde en oudiologie universiteit van pretoria opsomming die oard van die neuromotoriese disfunksie wat in verbale apraksie en verworwe disartrie voorkom word tans in diepte ontleed η belangnke vraag wat beantwoord meet word, is wat die verskil tussen hierdie twee tipes spraakprobleme is i m e szle word cue fonetiese parameter, stemaanvangstyd (sat) ondersoek. die doel is om te bepaal ofkenmerkende aj^kin std ^t ty verbale apraksie en verworwe disartrie voorkom. by laasgenoemde is ataktiese en hipokinetiese disartrie ir^slu^t afwyker^ z z z a n 8 t " ^ a t a k n 7 r a p m k t i e s e g w e p e 8 e v i n d · d i e m e e s t e v a r i a s i e i n d i e semete tydsintervalle is by tgroep met ataktiese disartrie opgemerk. stemhebbende klanke is deur beide groepe met stemlose klanke vervang. ondetbrekings tn die stempulsenngs is by die apraktiese sprekers waargeneem. daar is gevind dat daar verskille in sat by die apmktiese en dis artriese sprekers voorkom. die verskille was egter klein en onkonstant. apramese en ais abstract the nature of the neuromotor dysfunction in verbal apraxia and acquired dysarthria is currently being analysed in great detail an important question to be answered relates to the difference between these two types of speech l n ^ m ^ s t phonetic parameter, voice onset time (vot) was investigated. the aim was to determine whether characteristic djiatioloccur z z v m r a x l a a t i r € d dysart,hria· withm the latter' ataxlc a n d hyp°kinetic dy^ria were conszeredzztefydezl v™.occu;red" t h € ap™lc" a t a x i c 8wups· n e g r e a t e s t v a r i a t i o n i n t i m e lnte™1* ™ observed in atjc dysarthria substitution of voiced sounds with voiceless sounds occurred in both groups. interruptions in the voice pulses wezbsezd ^he apraxic speakers. it was concluded that there were differences in vot in the apraxic and dysarthric group howzer the differences were small and inconsistent. x ^ nuwever, neuromotoriese spraakprobleme ontvang tans baie aandag in die literatuur. 'n voorbeeld van so 'n neuromotoriese spraakprobleem is verbale apraksie. verbale apraksie word gedefinieer as artikulasiefoute wat die gevolg is van 'n defek, te wyte aan breinskade, in die programmering van eerstens die posisionering van spraakspiere vir die willekeurige produksie van foneme, en tweedens die opeenvolging van spierbewegings vir woordproduksie.6 daar bestaan egter 'n polemiek oor die term apraksie. sommige outeurs beskou verbale apraksie as 'n fonologiese eerder as 'n motoriese probleem. in die jongste literatuur is daar egter bewyse dat apraksie wel 'n uitval in spraakmotoriek is. die studie deur itoh, sasanuma en ushijima,6 wat die velere bewegings tydens spraakproduksie by apraktiese sprekers ondersoek het, dien as so 'n bewys. bogenoemde outeurs het 'n dissinchronisering tussen die velum en tong gevind, nl. die velere ialing vir /n/ het nie gekorreleer met die van die tongbeweging vir apikale sluiting nie. 'n fonetiese fout waar /n/ na /d/ veranier, was die gevolg. 9 sasha 1983 die gemelde bevindings dui daarop dat die fonetiese vervangings van apraktiese sprekers nie die gevolg van 'n fonologiese uitval is nie, maar wel 'n uitval in spraakmotoriek. aan die ander kant is dit 'n welbekende feit dat disartrie 'n spraakmotoriese uitval is. die vraag ontstaan nou wat presies die verskil tussen hierdie gemelde motoriese spraakprobleme is. daar moet egter in gedagte gehou word dat disartrie nie 'n homogene afwyking is nie, maar eerder 'n versamelnaam vir 'n groep spraakafwykings wat deur 'n versteuring in die neuromuskulere kontrole van die spraakmeganisme gekenmerk word. hierdie muskulere versteuring is die gevolg van letsels in die sentrale of perifere senuweesisteem. 'n letsel in die basale ganglia het 'n hipokinetiese disartrie tot gevolg, terwyl 'n serebellere letsel aanleiding gee tot 'n ataktiese disartrie. die simptome van hierdie twee tipes disartrie stem nie ooreen nie.3 om hierdie rede is beide die groepe disartriee met verbale apraksie vergelyk. die fonetiese parameter stemaanvangstyd (sat), word in hierdie studie ondersoek, aangesien die apraktiese en d i s a r t r i e s e the south african journal of communication disorders, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die stemaanvangstyd van apraktiese en disartriese sprekers foute eers van mekaar onderskei kan word as die fonetiese aspekte van die foute begryp word. die doel van die studie is om te bepaal of daar enige beduiden de afwykings in die sat van apraktiese en disartriese sprekers is, en indien wel, wat die aard daarvan is; asook om te bepaal wat die verskil is, indien enige, tussen die sat van apraktiese en disartriese sprekers. eksperimentele metode proefpersone die proefpersone in die eksperimentele groep het 'n verworwe neuromotoriese disfunksie vertoon en is deur twee groepe ver teenw<x>rdig, nl. 'n groep wat disartriese spraak vertoon (een proefpersoon met basale gangliaskade, e,, en drie met seree l e n e 4 ) e n ' n g r o e p m e t ~ die proefpersoon met basale gangliaskade het k*rkinsonisme gehad aangesien dit die enigste siektetoestand is wat in sy 2vangstadium 'n suiwer basale ganglialetsel verteenwoord " die apraktiese proefpersone is by die spraakkliniek van dfe univereiteit van pretoria gediagnoseer en die disamie e γ d t r t r 0 l ° ° g gediagnoseer. 'η κοηΐ groep. (k.-k6) wat met die eksperimentele groep ooreengestem het ten opsigte van geslag, ouderdom en j , m ^ z t die afwesigheid van 'n neuromotoriese disfunksie, is m g e s l l materiaal i s s i a f h e t u , ! . 2 ° e e n ' e t t e r i r e p i g e sinvolle woorde met nisiele eksplosiewe konsonante /p; b; t; d/ bestaan die i n i s le konsonante is deur die vokale en diftone /a· n t ™ / derskeidelik opgevolg. g ' ' c e u ; a a / o n s p ^ w ' r v 5 t c n c i n d e m e e r t u u r l l k e issst^r-'-ss verwerking van resultate 5 5 0 dens analise van γ f bandopnemer gemaak. tyvandaar die se-n na'd ' n ^ f ^ ^ ^ ^ gevoer. h i e ^ e t u f ^ h e r h a l e s l y n model 2a se spraak vir na ^ n t ^ 1 ^ s t o o r o ^ v e e r 2 , 5 sek. se,n is op die s t ^ ν g e s e l e k t e e r d e d e e l van die spraak1200b) vertoon s x m ! t n " ° s s i l l ° s k o o p (hewlett-ftckard luidspreker is j ^ t s ^ ^ t ^ ^ m o n i t o r " d i * spraak kon luser. o n d ^ o e k e r terselfdertyd na ^ s m v a n ^ e s n l n t e n f s t 6 m v ° ° r d i e e k s p ^ i e f is nie, is loskoopskerm ^ s t e l ri ̂ l i n k e r k a n t v a n d l e osdlh v a " d ' e skerm tot w a a r ^ s z f t ' j * w * * l i n k e r k a n t d o e n · by klanke wanke begin het, gevan d i e o s s ^ e z t i t ^ ^ ^ i s d i e van die skerm gestel en ̂ ιιπτιμ ^ a a n d i e l i n k e r k ^ p l 0 s 1 6 f b e g · in s u c ^ a n e t d ^ t 0 t d i e e k s 35 p.ng van lug met aanvang van die eksplosi word σ τ e s s i e f e g a t i t ^ d u i d i e * a a n waatmee stem e eksplosief voorafgegaan het (stemvoorloop). ο negatiewe waardes positiewe waardes ontsnapping van lug met aanvang van die eksplosief metings het getoon dat stemhebbende eksplosiewe van klanke d i e r v 3 n g ^ l 3 ^ g a l e v i b ~ die plof of voorafgaan 6f η kort stemnalooptyd toon hier teenoor word stemlose eksplosiewe deur ·„ r e l l l a n g e " n a : ooptyd gekenmerk. stemhebbende klanke word dus geasso dtl η iiemaanvangstye w 3 t i n t w c e ° " d ^ o k e gebfede ^ n d s 6 " 6 v e r s k y n s d ^ 3 1 d c u r b a i e "aresultate die resultate van metings word grafies in figure 1 tot 6 voorged , c v , c r a a n v angsklanke word apart aangegee en wr ι— ϊ ϊ.ιλ # tsr •5 ϊ| ι jt η l a f̂e, s > ' · 1 o^el „llu5°kondc/° 70 so f ' 9 u u r 1 g e m i d d e , d e ^ ^γ die klank /p/ vir alle sprekers λ sat negatief genoteer. ν kornmunikasieafwykings, vol. 30, 1983 « 4 0 stemaanvajigatyd in „ u l l s e k o „ a „ i n miiiisexondes s ° i e 9 e m i d d e , d e ^ v i r d i e k l a n k * vir alle r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 36 erentia gillmer en anita van der merwe 4 0 0 3 5 0 -200 -150 -j00 -50 gemiddelde itema.nv.ns.tyd in mllll.ekondes figuur 3 die gemiddelde sat vir die klank /b/ met groot negatiewe waardes vir alle sprekers 1 5 1 0 5 0 5 gemiddelde stemaanvangstyd 10 lillisekondes ε — β β < «ο α> v -η «η η _ β j£ i · 3 0 =20 mo ο 10 20~ gemiddelde stemaanvangstyd in mllllsekondes figuur 4 die gemiddelde sat vir die klank /b/ met 'n waarde naby nul vir alle sprekers 4j u f • u γ c u—γ ρ « s i 1 α α ι. μ « α > α 4 5 0 4 2 0 3 9 0 3 6 0 3 3 0 3 3 0 0 2 / 0 2 4 0 2 1 0 1 8 0 1 5 0 1 2 0 90 60 30 ο * gemiddelde stemaanvangstyd in mllllaekondes *iguur 5 die gemiddelde sat vir die klank /d/ met groot negatiewe waardes vir alle sprekers iie /b/ en /d/-klanke is daar 'n verdere verdeling gemaak. die " e d e hiervoor is dat tydens die metings van /b/ en /d/ dit opvalend was dat daar soms 'n groot negatiewe waarde gemeet is figuur 6 die gemiddelde sat vir die klank /d/ met waardes naby nul vir alle sprekers en soms 'n waarde wat naby nul le. die twee soorte waardes is gevolglik apart geneem en word apart in die grafieke weergegee. wat die gemiddelde sat vir die klank /p/ vir alle sprekers (fig. 1) betref, blyk dit dat die kontrolegroep se variasie van die gemete tydsintervalle oor die algemeen kleiner is as did by disartriese sprekers. daar kon geen duidelike verskil in die gebiede waarin die stemaanvangstye vir die kontrolegroep of vir die eksperimentele groepe te le gevind word vir ipl nie, daar die gebiede waarin hul stemaanvangstye varieer, oorvleuel het. in hierdie studie blyk die gemiddelde sat vir /p/ in afrikaans korter te wees as did in engels aangesien dit van ongeveer 15-50 m. sek. strek. waardes vir engelse stemlose eksplosiewe soos aangegee deur lisker en abramson" is 60-100 m sek. en did deur blumstein2 is 35-80 m. sek. aangesien die kontrolegroep se gemiddelde waardes baie varieer, kan daar nie norms opgestel word vir die sat vir /p/ in afrikaans nie, en kan geen uitspraak oor die lengte van die sat in hierdie geval gemaak word nie. wat die gemiddelde sat vir /t/ vir alle sprekers betref, geld baie van die oorwegings by /p/ ook vir /t/ soos bv. dat die gemiddelde sat vir die normale sprekers weer eens baie varieer. baie opvallend was die klein omvang wat by ataksiese (e3 en e4) en hipokinetiese (e,) disartriese sprekers voorgekom het in vergelyking met die by /p/. die apraktiese sprekers (e5 en e6) se omvang van sat by /t/ is ook kleiner as did by /p/. dit lyk dus of /t/ oor άϊέ algemeen makliker is om uit te spreek vir persone met 'n neuromotoriese disfunksie. die gemiddelde stemaanvangstye vir /t/ verskil egter nie ooglopend van die gemiddelde stemaanvangstye vir /p/ nie. uit die literatuur het dit geblyk dat die sat toeneem soos wat die piek van artikulasie na agter in die mond beweeg 11 uit hierdie resultate kan so 'n afleiding egter nie gemaak word nie. wat die gemiddelde sat vir /b/ met 'n groot negatiewe waarde vir alle sprekers betref, is die gemiddelde sat vir die stemhebbende klanke met 'n negatiewe waarde baie langer as die gemiddelde sat vir stemlose klanke. die rede hiervoor kan gevind word daarin dat stem vir 'n redelike lang tydperk die "plof' voorafgaan. 'n baie groot variasie is weer eens by die the south african journal of communication disorders, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die stemaanvangstyd van apraktiese en disartriese sprekers ataktiese disartriese groep gevind. hierdie groep het ook so •n groot variasie by /p/, wat ook 'n bilabiale klank is, getoon. dit is moontlik moeiliker om bilabiale klanke te produseer, aangesien die lippe twee organe is waarvan die beweging gesinchroniseerd moet plaasvind. wat die gemiddelde sat vir die klank /b/ met 'n waarde naby nul betref, het die /b/-klanke van 'n paar sprekers, nl. k3, k5, κβ, ε, en e5 geen waardes in hierdie gebied nie. hierdie sprekers het moontlik die klanke meer bewustelik goed geartikuleer sodat 'n duidelike negatiewe waarde voorgekom het. die sprekers vir wie daar wel grafieke opgeteken is, het hierdie /b/-klanke dus meer geproduseer soos wat dit in spontane spraak sou voorkom en wel met 'n waarde naby nul." 13 die fonasie het gevolglik saam met die ploffing of baie kort daarna voorgekom. dit word in die literatuur egter steeds as normaal beskou. wat die gemiddelde sat vir die klank /d/ met 'n groot negatiewe waarde betref, geld dieselfde oorwegings wat vir die vorige klanke geld, ook hier, dit wil se dat daar geen duidelike verskil in die gemiddelde sat vir afgepaarde sprekers is nie die variasie by die ataktiese disartriese groepe is vir /d/, met groot negatiewe waardes, groter as wat dit nog by enige ander klanke was. in teenstelling met die groot variasie by /d/ was daar weer baie min variasie by /t/. die gemiddelde sat vir /d/ met waardes naby nul: hierdie resultate is soortgelyk aan die klein waardes vir /b/, dit wil se geen noemenswaardige verskil in die gemiddelde sat kon raakgesien word nie. tydens die metings van stemaanvangstye is sekere kwalitatiewe waarnemings gemaak en 'n aantal foto's (fig 7 en 8) is vanaf die ossilloskoopskerm geneem ten einde die resultate beter te illustreer. figuur 7 is 'n voorbeeld van 'n negatiewe 37 a β ^ ρ γ β κ τ s a t b y / b / s 0 0 s ""sespreek deur •„ n o r s ^ s 0 0 s u l t g 6 s p r e e k d e u r normale spreker. die mevoorltd γ t 3 ^ 1 1 " 1 a t 0 t * p u n t b · hierdie is dus 'n g a a n t l r ' τ 8 3 ' 6 v i b r a s i e s d l e "plof' lank voorafgeas die l i n f t 0 r l 0 0 p ) ' d " h e t ^ d i e eksperimentele sowel blykbaar γ g r ° e p v o o r g e k o m · hierdie verskynsel kom soos wat d γ v ° ° r ί η e n k e l w o o r d e en kort sinne en neem af 8 i s 'n t i p i e s e v n ^ f γ ^ i n s p ° n t a n e s p r a a k " f i g u u r disftinje d v a " p e r s o o n m e t ' n neuromotoriese w a t p°°g o m /fa/ te produseer, maar dan /p/ produafrikaanse tydskrifvir kommunikasieafwykings, vol. 30, 1983 a β persoon p r ° d u k s i e ^ ^ n e u r °™tories-gestremde seer. die persoon probeer hier /bad/ se, maar die resultaat wat voortgebnng is, was /pad/. hierdie verskynsel van oorvleueling tussen stemhebbende en stemlose klanke deurdat die stemhebbende klank deur 'n stemlose klank vervang is, het dikwels by proefpersone met ataktiese disartrie en ver'bale apraksie voorgekom. dit het by ongeveer 50% van die stemhebbende uitings van bogenoemde sprekers voorgekom. bespreking van resultate die verskynsel dat die gemiddelde sat by die normale sprekers baie gevarieer het in die opsig dat die omvang van die sat-waardes nie konstant was nie, het resultate baie gekompliseer. daar was wel oorvleueling van waardes by die verskillende indiwidue, maar nie by die groep as 'n geheel nie. hierdie bevinding is teenstrydig met did soos verkry deur zlatin13 waar hy gevind het dat die omvang van sat by normale sprekers wel konstant is. jansen8 het egter uit praktiese ondervinding gerapporteer dat die sat by normale sprekers baie wissel van indiwidu tot indiwidu. as gevolg van die bogenoemde feit was dit nie moontlik om norms vir normale sat in afrikaans te bepaal ten einde fyner waarnemings te maak nie. die volgende verskille is gevind tussen klanke ten opsigte van sat: dit blyk dat middelalveoler bladlinguale klanke vir die ataktiese disartriese sprekers makliker is om te produseer as bilabiale klanke, aangesien die variasie by /t/ relatief kleiner was as did by /p/ en /b/. bilabiale klanke is moontlik moeiliker omdat twee organe, nl. die lippe gesinchroniseerd moet beweeg in teenstelling met 'n enkele orgaan, nl. die tong wat by middelalveoler bladlinguale klanke moet beweeg. beter koordinasie word dus in die eerste geval vereis. aangesien algemene ongekoordineerdheid 'n eienskap van ataksiese disartrie is verklaar dit moontlik die verskynsel dat bilabiale klanke moeiliker is om te produseer as middelalveoler bladlinguale klanke, daar dit meer koordinasie verg.9·12 die ataksiese disartriese sprekers het baie meer variasies in sat getoon as die ander sprekers. dit is dus vir hierdie groep moeilik om hul sat te beheer. dit kan die gevolg wees van die algemene wankoordinasie, onwillekeurige bewegings en hipotonus wat in ataktiese disartrie voorkom. die hipotonus gee aanleiding tot parese van die spiere met gevolglike vinnige uitputting.5·12 hierdie uitputting van die spiere met gevolglike stadige spraak kon moontlik bygedra het tot die variasie in die sat. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 'η ongeveer 50%-oorvleueling van stemhebbende en stemlose klanke is by twee (e2 en e3) uit die drie persone in die groep met verworwe serebellere letsels (ataktiese disartrie) opgemerk. stemhebbende klanke is met stemlose klanke wat ooreenstem ten opsigte van piek van artikulasie, vervan'g. grunwell en huskins5 rapporteer dieselfde bevinding in hul studie. hierdie stemhebbende/stemlose vervangings kan moontlik toegeskryf word aan 'n verlies aan sinergisme van die spierbewegings. die sat is moontlik afhanklik van die sinchronisering van die beweging van die glottis, die lippe en die tong. die verskynsel dat die derde persoon (e,) in die bogenoemde groep nie oorvleueling van stemhebbende/stemlose klanke vertoon het nie, kan moontik verklaar word aan die hand van die resultate soos verkry deur kent, netsell en abbs.10 hierdie skrywers het 'n afwyking in die sat, ooreenstemmend met die graad van aantasting, by ataktiese disartrie gevind. die afleiding wat gemaak word, nl. dat hierdie persoon se graad van disartrie ligter is as did van die ander word gesteun deur die feit dat die betrokke persoon liggaamlik minder aangetas is as die ander twee persone. die proefpersoon met basale gangliaskade het min variasie in die omvang van sat-waardes getoon en in teenstelling met die ataktiese disartriese sprekers, het geen vervangings van fonetiese kategoriee, bv. /b/ /p/ voorgekom nie. did persoon se stemaanvangstydwaardes blyk ook nie afwykend van die normale, soos in hierdie studie verkry, te wees nie. dit kan waarskynlik die gevolg wees van die medikasie wat die persoon tans gebruik. die medikasie verminder die onwillekeurige bewegings wat kenmerkend van piarkinsonisme is, en sal gevolglik die mate van dissinchronisering tussen verskillende organe ook verminder. dieselfde oorvleueling van stemhebbende en stemlose klanke soos by die groep met ataktiese disartrie gevind is, is by een van die twee persone met verbale apraksie (ee) aangetref vyftig persent van die stemhebbende klanke is ouditief as stemlose klanke waargeneem. hierdie oudi(iewe waarneming is bevestig deur die ossillasies op die ossilloskoopskerm wat tipies verteenwoordigend van stemlose klanke was. dit stem presies ooreen met die resultate soos verkry deur freeman sands en harris.4 dissinchronisering van die velum en die tong kom by apraktiese sprekers tydens artikulasie voor.7 dit is moontlik dat daar ook dissinchronisering by die beweging van artikulators, nl. die tong en die lippe onderskeidelik en die glottis kan voorkom wat 'n gevolglike invloed op die sat sal he. hierdie resultaat stem ook ooreen met did soos verkry deur blumstein, cooper, zurif en caramazza.1 hulle het gevind dat pasiente met anterior serebrale letsels hoofsaaklik 'n gebrek aan sinergisme en dus fonetiese vervangings vertoon. die fonetiese vervangings was in verskeie gevalle foutiewe allofone van bv. /t/ wat dan eerder as behorende tot /d/ waargeneem is die huidige studie was nie intensief genoeg om so 'n waarneming te maak nie, maar die moontlikheid bestaan dat dit hier ook die geval kon wees. die dissinchronisering hier ter sprake lyk na 'n probleem met betrekking tot die beheer van willekeunge spierbewegings. hierdie fonetiese afbraak is weer eens 'n bewys dat artikulatoriese apraksie 'n motoriese uitval erentia gillmer en anita van der merwe stem voor die fyn ossillasies wat die stemhebbende eksplosief verteenwoordig, gebruik het nie. die vraag of die genoemde probleem idiosinkraties van aard is, het by die bogenoemde skrywers ontstaan. uit die huidige studie blyk dit dat dit moontlik 'n idiosinkratiese probleem is, aangesien die proefpersone met verbale apraksie, wel stemvoorloop getoon het dit moet egter gemeld word dat stemvoorloop by e« nie konstant voorgekom het nie, maar slegs af en toe. die ander klanke deur hierdie persoon geproduseer wat deur middel van luistertoetse as stemhebbend geklassifiseer is, het waardes naby aan nul gehad. hierdie waardes neig dus meer na positiewe stemaanvangstydwaardes waar klanke as stemloos waargeneem word. dit is moontlik 'n aanloop tot die fonetiese vervangings wat waarskynlik 'n afwyking in ooreenstemming met die graad van aantasting van die spreker is. indien bogenoemde wdl so is, is dit moontlik dat die proefpersone wat freeman, sands en harris4 gebruik het in hul studie 'n erger graad van aantasting vertoon het as die persone wat vir hierdie studie gebruik is. daar kan egter slegs oor hierdie aspek gespekuleer word. tydens die meting van die sat van die proefpersone met verbale apraksie, is 'n onstabiliteit in die stem opgemerk wat nie by die normale of disartriese sprekers voorgekom het nie hierdie onstabiliteit het die volgende behels, nl. dat 'n paar pulsenngs van stem voorgekom het waarna die stem heeltemal opgehou het om dan weer later in die produksie te begin dit stem ooreen met resultate soos verkry deur freeman, sands en harris.4 die verskynsel kan moontlik toegeskryf word aan die soekbewegings na die piek van artikulasie wat die spreker vertoon, nadat hy reeds begin het om stem te inisieer. die stem stop dan vir die tydsduur van die soekbewegings om weer te begin, nadat die spreker die piek en omvang van artikulasie gevind het. beide die apraktiese sprekers se spraakspoed was stadiger as normaal met gevolglike verlies aan prosodie. dit is heel waarskynlik as gevolg van hul pogings om foute te vermy, aangesien hulle ten voile daarvan bewus is wanneer hulle 'n foutiewe produksie lewer. daar kon egter geen betekenisvolle effek van die stadige spraakspoed op die gemiddelde sat van hierdie sprekers gesien word nie. ge volgtr ekkings opsommend kan dus gese word dat die sat by die apraktiese en ataktiese disartriese sprekers wel afwykend is soos gesien teenoor die normale. dit is egter nie omdat daar 'n verskil in die gemiddelde waardes van sat is nie, maar in die grootte van die omvang van die stemaanvangstydwaardes. die meeste wisselvalligheid is by die groep met ataktiese disartrie opgemerk, aangesien hierdie sprekers baie groter vanasies in die gemete tydsintervalle toon in vergelyking met die ander groepe. die hipokinetiese disartriese spreker se omvang van die stemaanvangstydwaardes is nie beduidens groter as did van die normale sprekers nie. is. freeman, sands en harris4 het gevind dat apraktiese sprekers nooit 'n stemvoorloop, met ander woorde teenwoordigheid van by sowel die groep met verworwe serebellere letsels as die groep met verbale apraksie is fonetiese vervangings ten opsigte van stemhebbendheid en stemloosheid gevind, nl. dat die stemhebbende klanke met stemlose klanke verva'ng word. the south african journal of communication disorders, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) die stemaanvangstyd van apraktiese en disartriese sprekers die gemiddelde stemaanvangstye vir sowel die twee eksperimentele groepe as die kontrolegroep stem in so 'n mate ooreen dat daar nie vir elke groep 'n afsonderlike kenmerkende sat bepaal kon word nie. etlike verskille in die fonetiese parameter sat is dus tussen apraktiese en disartriese sprekers opgemerk. die verskille was egter baie klein en nie konstant beduidend nie. verwysings 1. blumstein, s. e., cooper, w. e., zurif, ε. b. en caramazza, a. (1977): the perception and production of voice-onset time in aphasia. neuropsychologic! 15 371-383. ' ' 2. blumstein, s. e., cooper, w. e., goodglass, h., statlender, s. en gottlieb, j. (1980): production deficits in aphasia: a voice-onset time analysis. brain and language 9, 153-170. 5 ' 3. darley, f. l., aronson, a. e. en brown, j. r. (1969): differential diagnostic pattern of dysarthria. journal of speech and hearing research, 12, 246-269. 4. freeman, f. j., sands, e. s. en harris, k. s. (1978): temporal co-ordination of phonation and articulation in a case of verbal apraxia: a voice-onset time study. brain and language, 6, 106-111. 5. grunwell, p. en huskins, s. (1979): intelligibility in acquired dysarthria a neuro-phonetic approach: three 39 ca ŝe studies. journal of communication disorders, 12, 6. itoh, m. sasanuma, s. en ushijima, t. (1979): velar movements during speech in a patient with apraxia of speech. brain and language, 7, 227-239 7. itoh, m., sasanuma, s., hirose, h., yoshioka, η en ushijima, t. (1980): abnormal articulatory dynamics in a patient with apraxia of speech: x-ray microbeam observation. brain and language, 11, 66-75 8. jansen, l. p. c. (1982): for. wet. laboratorium, pretoria persoonlike mededeling. 9. kent, r. en netsell, r. (1975): a case study of an ataxic dysarthnc: cineradiographic and spectrographic obseru5tl0134 j o u m a l ° f s p e e c h a n d h e a r i n 8 research, 40, 10. kent, r. d„ netsell, r. en abbs, j. h. (1979): acoustic characteristics of dysarthria associated with cerebellar disease. journal of speech and hearing research 22 627-648. ' ' 11. lisker, l. en abramson, a. s. (1967): some effects of context on voice-onset time in english stops. language and speech, 10, 1-28. 12. netsell, r. en kent, r. d. (1976): paroxysmal ataxic dy^ΐίίγ j o u m a l o f s p e e c h a n d hearing disorders, 41, 13. zlatin, m. a. (1974): voicing contrast: perceptual and productive voice-onset time, characteristics of adults the journal of the acoustical society of america, 56 981-994. ' ' ^'d-afrikaanse tydskrifvir kommunikasieafwykings, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction methodology results and discussion implications for inclusive education support systems conclusion acknowledgements references about the author(s) tejal manga speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa speech pathology and audiology department, tembisa hospital, johannesburg, south africa khetsiwe p. masuku speech pathology and audiology department, tembisa hospital, johannesburg, south africa citation manga, t., & masuku, k.p. (2020). challenges of teaching the deaf-blind learner in an education setting in johannesburg: experiences of educators and assistant educators. south african journal of communication disorders, 67(1), a649. https://doi.org/10.4102/sajcd.v67i1.649 original research challenges of teaching the deaf-blind learner in an education setting in johannesburg: experiences of educators and assistant educators tejal manga, khetsiwe p. masuku received: 18 july 2019; accepted: 22 mar. 2020; published: 11 june 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: evidence suggests that educators of deaf-blind students in the south african context have specific challenges in the educational setting because of their lack of adequate knowledge on deaf-blindness and a lack of sufficient training on communication, teaching and learning strategies. objectives: the aim of this study was to describe the challenges experienced by educators and assistant educators of children with deaf-blindness. method: ten educators and assistant educators were selected purposively to participate in the study (male = 3; female = 7; age range 31–49 years). participants were recruited from a school for the deaf-blind in johannesburg. participants completed semi-structured interviews on the challenges that they experienced when educating learners who are deaf-blind. results: findings from the data after inductive thematic analysis suggested the following: (1) under-preparedness of educators and assistant educators, (2) communication challenges, (3) challenges related to the diversity of deaf-blind learners and (4) lack of support structures for educators and assistant educators. conclusion: there is a need for ongoing educator training on communication strategies, cultural diversity and inclusive strategies. a collaborative model of delivering training and inclusive education that will encompass educators and therapists as a means of supporting both the educator and the learner who is deaf and blind is needed. such a collaboration may result in positive outcomes for both the educator and the deaf-blind learner. keywords: deaf-blindness; learners; educators; inclusive education; challenges; south africa. introduction deaf-blindness is a rare condition that affects approximately 1 million individuals worldwide. many children who are deaf-blind are yet to be identified because of the complication of diagnosis owing to the comorbidities (deafblind sa, 2009). even though the majority of the deaf and blind population in south africa are adults, there still exists a percentage of children who present with deaf-blindness (deafblind sa, 2009). deaf-blindness refers to a dual sensory impairment, which means that it is a combined condition of a loss of hearing and vision co-occurring in the same individual (dammeyer, 2014; deafblind sa, 2009; miles, 2008; wittich, southall, sikora, watanabe, & gagné, 2013). it ranges from mild loss of hearing and vision to a complete deafness and blindness depending on its differing combinations (ask larsen & damen, 2014) and it can either be congenital or acquired (dammeyer, 2014; molly, 2003a). persons who are deaf-blind may present with a diversity of needs across all areas of development, such as communication, parent–child relationships, cognition, motor and perceptual development (deafblind sa, 2009), which causes severe educational needs that cannot be accommodated in special education programmes solely for children with deafness or children with blindness (wolford, 2016). learning occurs through vision and hearing (nelson & bruce, 2016); therefore, learners who are deaf and blind need services that are provided by a team of skilled professionals and paraprofessionals who can create appropriate communication and learning opportunities for them (riggio & mcletchie, 2008). providing learners who are deaf-blind with appropriate communication and learning opportunities is imperative, because these learners depend on others to make language accessible to them and to provide them with the desire to communicate (miles, 2008). there is a need for multiple communication strategies which should be implemented in both at the home and school environments to ease the communication challenges for both parties. section 29 (1) of the constitution of the republic of south africa (1996); the education white paper #6, on special needs education (department of education [doe], 2001); article 24 of the convention of the rights of persons with disabilities (crpd) (united nations [un], 2006) and sustainable developmental goals 4 and 10 (united nations [un], 2015) commit to provide equal educational opportunities to all learners, including those learners with special educational needs. these legislative documents make specific reference to those learners who experience barriers to learning and development or who have dropped out of the education system because of the inability of the education system to accommodate the diversity of their learning needs (doe, 2001). in south africa, the provision of equal educational opportunities for all learners, and especially those with special educational needs, was operationalised through the drive for inclusive education. inclusive education, a field that has been given importance by law, requires that educators are knowledgeable about policies and practice in inclusive education and that they are competent to teach in classes with diverse learners (walton, 2018). the white paper #6, in particular, acknowledges that educators are the primary resource for achieving the goal of an inclusive education and therefore commits to improve their skills and knowledge and to further assist them in facilitating the development of new skills (doe, 2001). the white paper #6 further highlights the significant difference that schools can make if they were to provide a quality and relevant education for children with disabilities (doe, 2001). challenges of implementing the white paper #6 in south africa have been widely documented in the literature, such as in the works of donohue and bornman (2014), lebona (2015), kamper (2008), engelbrecht and green (eds. 2007) and hay, smit and paulsen (2001). the gap that exists in the skills and training of educators of children with special education needs, specifically in inclusive education and in special schooling environments, has been highlighted as one of the significant challenges of inclusive education in south africa (dalton, mckenzie, & kahonde, 2012). the results of these teacher training and skills gaps are evident in the quality of care and engagements that deaf-blind individuals experience (van dyk, 2003). because of the lack of knowledge and skills on communication, educators of deaf-blind students often miss or misinterpret the subtle, slow-paced and often difficult to understand interactions of these children, resulting in frustration for both the educator and the child with deaf-blindness (van dyk, 2003). gaps in the implementation of the white paper #6, and ultimately inclusive education, therefore, have negative consequences for both the deaf-blind learner and the educator. within their formal basic teaching qualifications, mainstream educators do not receive, preparation on how to react within mainstream classrooms when teaching children with diverse learning needs (ladbrook, 2009). educators of children with special needs, including educators of learners who are deaf-blind, are therefore not exempted from these training gaps. educators experience specific challenges (such as under-preparedness) to deal with learners presenting with multiple disabilities (such as deaf-blindness) because of their lack of adequate knowledge on different disabilities and the lack of training on communication, teaching and learning strategies (charles, 2014; janssen, riksen-walraven, &van dijk, 2003). these findings were further echoed by maguvhe (2014) in a south african study where the author investigated the perceptions of teachers of deaf-blind learners on curriculum design, implementation and parental involvement. maguvhe (2014) reported that there was a need to establish effective training for educators of deaf-blind learners and to also establish unit standards with achievable outcomes for teaching learners with deaf-blindness, which was in line with the requirements of the south african curriculum. the aforementioned challenges are further exacerbated in boarding school facilities where a wide diversity of the learners with deaf-blindness are cared for often by a limited number of staff for longer periods of time. south africa, being a diverse country both culturally and linguistically, further contributes to the different ideas, not only about the needs of children with disabilities but also to best practices and beliefs regarding how they should be educated (donohue & bornman, 2014:3). traditionally, there has been a deprivation of adequate and appropriate support services for learners, teachers and schools (barrat, 2016). there is, therefore, a need for a shift towards the inclusion of educational support services in special schools (donald, lazarus, & lolwana, 2010), specifically to include services of speech therapists and audiologists in schools for learners who are deaf-blind. speech therapists and audiologists may work with students who are deaf-blind, alongside each other to address communication issues because of sensory losses and additional disabilities (rodriguez-gil, 2009). this can be done by introducing strategies and interventions, such as alternative ways of communication with the deaf-blind learner. these will assist educators to cope with a diversity of learning and teaching needs to ensure that learning difficulties are addressed. in that way, the educator will be trained and supported. international studies on the subject of deaf-blindness have focused on the communication challenges experienced by children with deaf-blindness and access to technology to increase communication access (emerson & bishop, 2012; hersh, 2013), whilst others have highlighted the need for identification and intervention strategies for children who are deaf-blind (anthony, 2016; wiley, parnell, & belhorn, 2016). in south africa, and africa at large, deaf-blindness as a subject has generally been under-reported, with a plethora of research studies focussing on the implementation of inclusive education in schools for learners with special education needs. deaf-blindness is one of those fields so often neglected, possibly because, as maguvhe (2014, p. 1487) terms it, ‘it is a minority within a minority’, therefore making research in this area important and necessary. the lack of basic on-the-groundservices and support in the field of deaf-blindness is of more concern as it perpetuates the continued social exclusion of this population, such as institutionalisation, stigmatisation, isolation and lack of appropriate roles in society (maguvhe, 2014), often with debilitating results. ultimately, the rights of this population continue to be contravened despite the fact that the crpd has explicitly declared the rights to access for all (un, 2006). in particular, there is a paucity of research focusing on the training of educators of children who are deaf-blind. the purpose of this article was to explore the challenges experienced by educators and assistant educators of children who are deaf-blind in a school specialising in the education of deaf-blind learners located in johannesburg, south africa. the specific research question was as follows: what are the experiences of educators of learners who are deaf-blind? this article argues that if educators of learners who are deaf and blind are provided with the necessary training on the skills and knowledge of facilitating communication with their learners, this would, in turn, contribute positively towards teaching and learning outcomes. possessing the necessary skills of communicating with children who are deaf and blind would potentially lessen the frustration of both parties. whilst educator training is a step in a positive direction, educator training alone would not be sufficient. educators of and learners with deaf-blindness need to be provided with adequate educational support from communication specialists, such as speech-language pathologists and audiologists. in addition to educational and communication support from speech-language pathologists and audiologists, educators need to be provided with the services of psychologists who will be able to provide them with emotional support and counselling. methodology research design this study aimed to describe the challenges experienced by educators of learners who are deaf-blind in an education setting in johannesburg. to achieve this aim, the study utilised an exploratory qualitative research design. exploratory research design is a design of enquiry in which the researcher conducts a study in an area where there is a paucity of research already done (mcmillan & schumacher, 2001). this was an appropriate approach to use to study educators’ challenges of caring for the deaf-blind learners as the area of deaf-blindness is under-researched, possibly because of the low prevalence of the condition (deafblind sa, 2009). the study implored answers to the following questions: (1) describe the barriers of teaching learners who are deaf-blind; (2) ‘what are the facilitators of teaching learners who are deaf-blind?’ and (3) ‘what kind of support structures are available to educators of learners who are deaf-blind?’. participants and setting a purposive sample of 10 educators and assistant educators were included in the study. the ages of the participants ranged from 24 to 49 years, with the average age being 38.8 years. seven of the participants were women, whilst only three were men. three participants had formal teaching qualifications in the form of a university degree, three had matric qualifications, whilst the remaining four had not completed their high school qualifications. five participants had a working experience of 10 years and more, with the average work experience being 7.8 years. the study setting was a public boarding school situated in johannesburg, south africa, which specialises in the education of learners with deaf-blindness. the school has a total of 13 educators and educator’s assistants. procedures and data collection prior to the commencement of data collection, ethical approval was obtained. all participants were provided with written consent forms for the interviews and for audio recordings before commencing with the interviews. there was no risk of harm to the participants. anonymity and confidentiality were guaranteed and maintained. participants were also informed of their right to withdraw at any point in the study if they felt uncomfortable, with no negative consequences. data were collected through semi-structured interviews. the interview questions focused on the experiences of teaching and caring for learners who are deaf-blind. all interviews were conducted in english and audio recorded using a digital recorder. data were transcribed verbatim by the primary investigator. transcripts were subsequently checked against the original data by the second author for accuracy. data analysis data were analysed by the two authors using inductive thematic analysis, applying the procedures proposed by braun and clarke (2013), namely familiarisation, coding, searching for themes, reviewing themes, defining and naming themes and writing up. ultimately, themes were constructed from patterns on the data sources. for consensus, we relied on a coding procedure to identify themes from words, phrases, sentences and paragraphs that represent or symbolise issues relating to experiences of the participants. trustworthiness strategies trustworthiness strategies, such as credibility, transferability, confirmability and dependability, proposed by shenton (2004) and holloway and wheeler (2013) were applied to the study. the primary investigator established a trusting relationship with the site and participants prior to the collection of the data. as investigators, we conducted frequent debriefing meetings during the entire process of the study. the project was subjected to peer reviews for scrutiny to ensure quality control. during interviews, member checking, probes and iterative questioning were applied. furthermore, we kept a reflective journal to track the development of the study (eds. chilisa & preece, 2005; shenton, 2004). ethical consideration ethical approval to conduct the study was obtained from the human research ethics committee (hrec) of the university of the witwatersrand (project number sta_2017_09), the department of speech pathology and audiology sub-committee, university of the witwatersrand and department of education. results and discussion four themes emerged from the analysis of the data collected: (1) under-preparedness of educators and assistant educators, (2) communication challenges, (3) challenges related to the diversity of deaf-blind learners and (4) lack of support structures for educators and assistant educators. these themes are discussed in detail below. theme1: under-preparedness of educators and assistant educators because of the lack of education and training on teaching leaners with deaf-blindness, a majority of participants reported being under-prepared in their role of teaching the learners. in response to whether educators and assistant educators had any history of and training or education on teaching deaf-blind learners, participants shared the following: ‘the time when i first got here – it was a very, very difficult time for me because i didn’t have any idea or any experience in teaching learners who are deaf-blind. i didn’t have any idea about sign language and things like that …’ (24 years old, female, teaching assistant) ‘the first one [challenge] is that we don’t have training. no workshops either are provided to us. no training was provided.’ (49 years old, male, teacher) ‘if they can give us more time … in terms of more time for us to learn about these disabilities … they usually give us two or three days and sometimes that is not enough.’ (30 years old, male, teaching assistant) ‘i have never had any training except that i went for observations to worcester in 2006 … so i never went to any college or university … but maybe it’s because i also didn’t know if there is any course to do with the deaf-blindness that is available to capacitate us.’ (49 years old, female, teacher) current findings support the narrative that educators, assistant educators and staff working in schools catering for children with deaf-blindness are not adequately equipped with the necessary skills and knowledge to teach and care for children with deaf-blindness. these impact the teaching, guidance and communication support that they provide to the children with deaf-blindness (desimone & parmar, 2006; maccini & gagnon, 2006). the lack of training on deaf-blindness results in teachers believing that they are not adequately prepared to instruct learners with deaf-blindness (desimone & parmar, 2006), which is often frustrating for them. teachers find themselves in situations where they have to take on the task of teaching, caring and supporting these children, regardless of the lack of preparedness; consequently, they resort to educating themselves on deaf-blindness (gendreau, 2011). theme 2: communication challenges participants in this study experienced challenges communicating with learners who are deaf and blind. these communication challenges are attributed to the lack of skills necessary for educators to facilitate communication between themselves and the learners. participants particularly struggled with skills and knowledge for facilitating tactile as a means of communication. furthermore, they reported difficulty in interpreting information communicated to them by the learners. participants recounted using their previous experiences of what worked, with other deaf-blind learners, to improve current communication skills. this finding is expressed in the following quotes: ‘he can’t say i need the water or i am hungry or i need to go bathroom. i have to just think that he needs something and that i should give her water, then maybe she doesn’t want that water, then take her to the toilet, then she doesn’t want to go toilet … it’s a challenge because i don’t know what is going on … i wish to know what is going on but i can’t know and i just have to assume.’ (31 years old, female, assistant educator) ‘i was never taught how to communicate with them.’ (49 years old, male, educator) ‘it is a barrier because even though they can’t see, they can’t talk, they can’t hear, you still have to teach them sign language... but they won’t understand like … it will take time for them to understand.’ (45 years old, male, assistant teacher) ‘just something to motivate us, not to say we are stressing them. as i said maybe they aren’t talking but me, i am a human being and sometimes i don’t know what is going on, so sometimes they will cry really … like the whole day and i don’t know what to do what’s going on with them.’ (31 years old, female, assistant educator) as a result of the communication challenges, learners who are deaf-blind expressed their frustration through the display of challenging behaviours such as tantrums, as be seen in the following quote: ‘my interpretation of what they want can be wrong. so when i do something maybe the child will throw tantrums because i am not responding to what he or she wants from me.’ (24 years old, female, educator assistant) frustration as a result of communication barriers was also experienced by some educators and assistant educators, as evident in the following quotes: ‘at first i thought i was in another world when i first came here, and even now i sometimes still feel this was because ultimately you are speculating and searching and you have to do the searching until you find what the problem you must guess what he wants is, it does become frustrating.’ (49 years old, female, educator) ‘i want to know is how can... how can i communicate with these types of people, how i can talk, how can i see when he/she is cross … how can i.’ (43 years old, female, assistant educator ) ‘“ultimately you are speculating and searching and you have to do the searching until you find what is the problem” and that, “you must guess what he wants” it can get hard.’ (24 years old, female, teaching assistant) the findings of the study confirmed that the ability to foster a means of communication with a deaf-blind child is both the most important and the most challenging requirement (miles, 2008). this is particularly true in school settings where educators lack training on communication strategies (charles, 2014). the obvious difficulty for the person who is deaf-blind in trying to communicate is that very few people understand their communication attempts (eds. aitken, buultjens, clark, eyre, & pease, 2000). consequently, the lack of an effective communication system interferes with and hinders activities of daily living for the child with deaf-blindness (omugur, 2016). communication challenges in children who are deaf-blind, coupled with difficulties with self-regulation and self-monitoring, may trigger frustration and result in challenging behaviours in this group (greg, 2017; nelson & bruce, 2016). communication challenges can further cause frustration also for the communication partners (greg, 2017), who in this case happen to be the educators and assistant educators of these children. it is therefore imperative that an effective method of communication is fostered to prevent misinterpretations between the two parties (gendreau, 2011). this can be established by training educators and assistant educators on deaf-blindness, communication strategies and facilitating communication. theme 3: diversity of deaf-blind learners south africa is home to a variety of cultures. it is a culturally diverse country with many different teachings, values and practices that are unique to each culture. this diversity was also noted in the learners at the study site. learners presented with diversity in terms of their age, family, social, religious and cultural backgrounds. this diversity presented a challenge for educators and assistant educators as it had implications for the type and level of sign language to which learners are exposed, the level of support that learners receive from their families and the acceptable way of engaging with learners undergoing adolescence. this is captured in the following statements: ‘in terms of culture, because the deaf-blind children cannot express themselves so because of this lack of expression the diversity of the culture sometimes restricts us as the educators … there are times when the child will get irritated in the class room and the culture does not allow the teacher to assist that child – so as a teacher what must i do? so that’s why i am saying the diversity regarding the culture is a barrier because the children come from different cultural backgrounds.’ (49 years old, female, educator) ‘ay it’s really difficult because they are from a different environment and as we are here and we have to try to make them feel at home here. they are from different homes and different upbringing and here we must take care of them as if they are from one family, you see.’ (49 years old, male, educator) ‘“it’s so painful”… even their parents … some of them can just say “go to the school and i don’t want to know what is happening” because they are feeling shame and when the child is at home they will just lock him or her in the room and so the mother can go up and down and the people they can’t see the kid, you see.’ (43 years old, female, assistant educator) the findings of this study support the notion that the rich diversity of south africa contributes to the different theories about the needs of children with disabilities, as well as best practices and beliefs regarding how they should be cared for and educated (donohue & bornman, 2014, p. 3). whilst diversity is acknowledged and appreciated, it however presents challenges for educators of deaf-blind children, especially in a boarding school facility. omugar (2016) asserts that much of the work of educators of deaf-blind teachers is mired by exterior influences. factors such as different family, social, cultural environments and varied moods of the students make it difficult for educators to cope with their levels of sign language and communication needs (omugar , 2016). it is a well-known fact that in special educational contexts, children often vary in terms of age, which makes it difficult for teachers to cope with specifically knowing how to deal with those deaf-blind learners going through adolescence (omugar, 2016). theme 4: lack of support structures for educators and assistant educators the majority of educators and assistant educators in this study had no basic formal teaching qualifications; furthermore, they had not been capacitated and supported to deal with children presenting with deaf-blindness. educators and assistant educators were not provided with support that they needed in terms of workshops, training, counselling and debriefing, as evident in the following quote: ‘not in south africa … at all … nothing in south africa. nothing for deaf-blind. no one in south africa assisted us with workshops or training.’ (49 years old, female, educator) in response to being questioned about receiving counselling and/or debriefing, one participant replied as follows: ‘when the schools are closed, we get days off, we can get somebody who can come in to counsel us because sometimes when things are happening, you can say it’s an easy thing but in your mind we are feeling something bad and anger and … you see, those things.’ (43 years old, female, assistant educator) the findings of this study arecorroborated by other studies that have emphasised the need for educators and assistant educators to be supported if children with special educational needs, such as deaf-blindness, are to succeed in the education setting (bornman & rose, 2010; dalton et al., 2012; frankel, gold, & ajodhia-andrews, 2010; nel et al., 2016). sustenance and care that educators capable of offering to learners depend on the knowledge, skills and resources provided to them (nel et al., 2016). therefore, if teachers lack the necessary knowledge, skills and resources, they will not be able to fulfil the necessary roles in adequately supporting children with deaf-blindness. if the goal of inclusive education for children with disabilities is ever to be realised, educators need to be provided with new skills, training and support, which will enable them to appreciate and address the variety of diverse learning needs of these children (dalton et al., 2012; frankel et al., 2010). implications for inclusive education support systems the role and influence of educators and assistant educators as teachers, communication partners and carers of children with deaf-blindness cannot be overemphasised. communication is central to deaf-blindness and therefore it is imperative that a communication method that is understood by the educator and peers of the deaf-blind child is established early in the child’s life. a functional communication method is imperative in the deaf-blind learner’s establishment of relationships, facilitation of social participation, facilitation of independence, access to social activities and, most importantly, in their progress across their education trajectories. establishing a functional communication method, and ultimately the access to education, for children with deaf-blindness will not be possible if the lack of knowledge, skills, preparedness and support on the part of educators and assistant educators continues as the norm in deaf-blind schools. the lack of proper training amongst teachers of children with deaf-blindness is one of the major hindrances to the education of these children; therefore, it needs to be addressed as a matter of urgency. the department of education (doe) therefore needs to train educators and assistant educators and capacitate them through ongoing workshops and courses on disability, specifically deaf-blindness, communication strategies and facilitating communication with these children. the doe must also realise the challenges associated with being a teacher and a carer for a deaf-blind child and establish support structures in the form of peer support, counselling and debriefing. assistant educators play a vital role in the education of pupils with complex learning disabilities, routinely supporting students on a 1:1 basis without the direct supervision of teachers. therefore, there is a need to also include them in the training that is provided for educators. conclusion the findings of this study suggest that communication is at the centre of the learner–educator partnership for the deaf-blind learner. therefore, if the right support is provided to educators, assistant educators and carers of deaf-blind children, learners would thrive in their educational contexts. children who are deaf-blind also have the right to access teachers who have specific knowledge and training on deaf-blindness and also to information and resources specific to their needs. training needs to cut across the following areas: knowledge training on disability and specifically deaf-blindness, skills development on managing children with deaf-blindness and communication strategies for the deaf-blind, and it should be considerate to the individual cultural and linguistic characteristics of the learner. providing constant support to educators and assistant educators of deaf-blind students would also ease the external challenges negatively affecting their role. therefore, there is a need for a collaborative model of delivering inclusive education that will encompass educators, therapists and families of children with deaf-blindness as a means of supporting both the educator and the learner who is deaf and blind. such collaboration will potentially result in positive outcomes for both the educator and the deaf-blind learner. acknowledgements the authors thank dr munyane mophosho for her assistance with the conceptualisation of the article. competing interests the authors have declared that no competing interest exists. authors’ contributions t.m. collected and analysed the data and contributed to writing the manuscript. k.m. analysed data, conceptualised theanuscript and wrote the manuscript. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the opinion or position of any affiliated agency of the authors. references aitken, s., buultjens, m., clark, c., eyre, j., & pease, l. 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(2016). a school psychologist’s guide to deafblindness: identifying & supporting students with combined hearing-vision loss. ohio center for deafblind education. retrieved from https://ohiodeafblind.org/tools-and-resources/ocdbe-products/6-a-school-psychologist-s-guide-to-deafblindness-identifying-supporting-students-with-combined-hearing-vision-loss-2016/file abstract introduction methods and materials results and discussion conclusion acknowledgements references appendix 1 about the author(s) naedene naidoo discipline of audiology, school of health sciences, university of kwazulu-natal, westville campus, durban, south africa nasim b. khan discipline of audiology, school of health sciences, university of kwazulu-natal, westville campus, durban, south africa citation naidoo, n., & khan, n.b. (2022). analysis of barriers and facilitators to early hearing detection and intervention in kwazulu-natal, south africa. south african journal of communication disorders, 69(1), a839. https://doi.org/10.4102/sajcd.v69i1.839 clinical perspective analysis of barriers and facilitators to early hearing detection and intervention in kwazulu-natal, south africa naedene naidoo, nasim b. khan received: 02 may 2021; accepted: 02 nov. 2021; published: 31 jan. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: there is slow progress in early hearing detection and intervention (ehdi) services within south africa. audiologists are ehdi gatekeepers and can provide valuable insights into the barriers and facilitators that can progressively move ehdi towards best practice in south africa. objectives: the study aimed to determine the barriers and facilitators to ehdi in kwazulu-natal as reported by audiologists/speech therapists and audiologists (a/stas). method: a descriptive qualitative approach was used. telephonic interviews were conducted with 12 a/stas working in public and private healthcare facilities, using the strengths, weaknesses, opportunities, threats (swot) conceptual framework. data was analysed using thematic analysis in conjunction with nvivo software. results: one of the main barriers perceived by a/stas, affecting ehdi was the lack of resources in healthcare facilities. the participants indicated that although there was a guideline in place to guide practice, it may be more suited to an urban area versus a rural area. poor knowledge and awareness of ehdi was also identified as a barrier. information provided from a/stas at grassroots level, in the various provinces, may benefit in developing a more contextually relevant and practical guideline. facilitators included; development of task teams specifically for ehdi programmes, creation of improved communication networks for collaboration and communication, training of healthcare professionals and improving data management systems. conclusion: strategies such as an increase in resources, further education and training, development of contextually relevant, culturally, and linguistically diverse practices and protocols need to be in place to improve ehdi implementation. further research, clinical implications and limitations are provided emanating from the study. keywords: ehdi; swot analysis; barriers; facilitators; south africa. introduction hearing loss is seen as a silent epidemic because of its invisible nature, as many clinical examinations fail to identify it (petersen & ramma, 2015) and is more predominant in neonates compared to other disorders routinely screened for (imam, el-farrash, taha, & bishoy, 2013). undetected hearing loss in a newborn can result in devastating long-term consequences such as emotional disturbance, communication delays, cognitive deficits, and social-emotional problems leading to educational barriers, career limitations, and employment difficulties (bezuidenhout, khoza-shangase, de maayer, & strehlau, 2018; olusanya, 2008). in south africa, approximately 6357 children annually are born with a permanent hearing loss or develop it at an early age, with the majority being born in the public healthcare sector (teixeira & joubert, 2014). the prevalence of infants born with a permanent hearing loss in the public sector in south africa is 3–6 per 1000 births (khoza-shangase, kanji, petrocchi-bartal, & farr, 2017; michal & khoza-shangase, 2014). the early hearing detection and intervention (ehdi) guidelines were released by the health professions council of south africa (hpcsa) (hpcsa, 2007, 2018). ehdi programmes are the proposed standard of care for newborns and infants presenting with a hearing loss, enabling them to develop to their full potential (hpcsa, 2018). universal newborn hearing screening (unhs), one of the key ehdi imperatives, is the standard practice internationally which is mainly limited to the developed world, yet the majority of hearing-impaired children are living in developing countries (harbinson & khoza-shangase, 2015). research evidence has suggested that unhs may not be attainable in south africa, particularly in the public healthcare sector, because of insufficient resources, manpower, and demand whereby more than 80% of the population access public healthcare services (kanji, 2016; khoza-shangase et al., 2017). furthermore, the public and private sectors also have other challenges including cost, poor infrastructure, and limited hearing screening programmes, thus affecting the implementation of newborn hearing screening (nhs) across low-and-middle-income countries (krishnan & donaldson, 2013). this is further exacerbated, as additional burdens such as poverty or life-threatening conditions, that is tuberculosis (tb) and human immunodeficiency virus and/or acquired immunodeficiency syndrome (hiv and/or aids), are viewed as an urgent priority, whilst hearing loss may be viewed as less urgent (petrocchi-bartal & khoza-shangase, 2016). moreover, the covid-19 pandemic which has taken the world by surprise has exacerbated the challenges to conducting nhs (yoshinaga-itano, 2020). nhs services may be operational, but family concerns can be present when taking babies for screening or diagnostic assessments during the crisis, so reassurances and counselling are essential to make sure babies are provided with timely services (yoshinaga-itano, 2020). few healthcare facilities in south africa offer nhs, resulting in late diagnosis and intervention among these children (petersen & ramma, 2015; swanepoel, 2006; swanepoel, delport, & swart, 2004). improvement in the initial age of screening was noted from a retrospective study conducted in johannesburg, which revealed that the median age for initial hearing screening was 11 months (opperman & kanji, 2015). unfortunately, this still does not meet the hpcsa ehdi stipulated guidelines, which states hearing screening by 1 month and no later than 6 weeks and intervention by 6 months and no later than 8 months (hpcsa, 2007, 2018). however, this is a positive finding which emphasises that with continued implementation, the guidelines can be met, as compared to previous studies that have shown later identification (van der spuy & pottas, 2008; butler et al., 2013; khoza-shangase & michal, 2014; swanepoel et al., 2013; störbeck & young, 2016). there seems to be a limited collaboration between stakeholders and other professionals such as nurses, early interventionists, and otolaryngologists in developing the ehdi guideline, which is important for successful implementation of unhs. educational level, family income, parental perception, and social factors are other barriers impacting timely screening, follow-up, and management (yun et al., 2017). it is therefore important to gather information about parental or caregiver perspectives on nhs to ensure appropriate advocacy and interventions (jatto, ogunkeyede, adeyemo, adeagbo, & saiki, 2018). furthermore, nhs programmes are not mandatory in south africa (bezuidenhout et al., 2021), thus necessitating parents being aware and knowledgeable of the risk factors for infant hearing loss (govender & khan, 2017). the stigma that is associated with deafness can be a barrier preventing individuals from accessing rehabilitative services (das, seepana, & bakshi, 2020). further challenges identified from merugumala, pothula and cooper’s (2017) study related to cultural, educational, transportation, and financial barriers affecting the access to services, especially those in rural areas and from lower socioeconomic statuses. intervention services are usually provided at health facility level (hpcsa, 2018). thus, access to support, assessment and intervention may be challenging for the vulnerable population or families (samuels, slemming, & balton, 2012). cultural beliefs may be associated with hearing loss, thus healthcare professionals should demonstrate cultural competence when providing services, in countries that are culturally and linguistically diverse, like south africa (govender & khan, 2017). parents of a child who is deaf, may spend large sums of money in the beginning, visiting orthodox medical practitioners thereafter traditional healers before receiving rehabilitative intervention (rajagopalan, selvarajan, rajendran, & ninan, 2014). these attitudes may arise from indigenous traditions attributed to the stigma of hearing loss and deafness, leading to resistance to hearing aids and sign language (rajagopalan et al., 2014). south africa is a multicultural society and the context and the manner in which information is provided to parents regarding the importance of hearing screening is imperative (moodley & störbeck, 2012) as well as follow-up services. the majority of studies that have been published focus on the implementation and the challenges or barriers to ehdi services (khoza-shangase, barrett, & jonosky, 2010; petrocchi-bartal & khoza-shangase, 2014; theunissen & swanepoel, 2008). however, the strengths and achievements should also be identified for ensuring best practice and standard of care in ehdi service delivery. thus, evaluation of the feasibility of the hpcsa ehdi guidelines and practices, to determine the barriers and facilitators is essential within the south african context (petrocchi-bartal & khoza-shangase, 2014), specifically in kwazulu-natal (kzn). this study aimed to explore the barriers and facilitators to ehdi in kzn, as reported by audiologists/speech therapists, and audiologists (a/stas). the objectives of the study were to (1) describe the weaknesses and threats (barriers), and (2) describe the strengths and opportunities (facilitators) identified by a/stas to ehdi. methods and materials study design an exploratory-descriptive research design was used in this study with qualitative methods of analysis. telephonic interviews were conducted with all the participants. study population and sample purposive, convenience sampling enabled the researcher to choose 12 a/stas conveniently located in public healthcare facilities and private practices, in kzn. the participants had to be registered with the hpcsa and employed in healthcare facilities (private or public) within kzn. therapists that were dually registered working in kzn were also included and individuals of different races, ages, and gender were included to ensure diversity. the pilot study was conducted with two a/stas, who were not a part of the main study. the results from the pilot study indicated that the data collection method and interview time were appropriate. no concerns were reported regarding the understanding of the questions. however, one participant indicated that some of the questions were too long and required multiple aspects. another concern reported by one participant was that there should be questions about the diagnostic and intervention aspects of ehdi, and not only on screening. therefore, adjustments were made to the content of the telephonic interview schedule, questions were separated and more probing questions were added. data collection tool telephonic interviews were used to collect detailed information, in a semi-structured session through the use of general guideline questions (carey & asbury, 2016). it took between 45 min and 60 min to conduct an interview, and it was audio-recorded. the telephonic interview schedule (appendix 1) comprised of 8 main open-ended questions, which targeted the areas related to the guidelines, nhs, initial age of screening, screening protocols and platforms, age of diagnosis and intervention, loss to follow-up, and data management, which allowed the researcher to gather rich contextually relevant, informal and free-flowing information, enabling the participants to respond in any way they chose (brace, 2013; magnusson & marecek, 2015). probe questions were further adapted from white and blaiser’s (2011) questionnaire and all principles mentioned in the hpcsa ehdi 2007 and 2018 guidelines were included. a strengths, weaknesses, opportunities, threats (swot) conceptual framework (see figure 1) was used to guide the telephonic interviews. the conceptual framework was used to learn about the experiences from a/stas to enable the researcher to cultivate their perspective and knowledge (ravitch & riggan, 2012, 2016). the swot analysis contrasts and compares weaknesses, strengths, threats, and opportunities to a set of criteria (silva et al., 2014). the swot is a qualitative research tool that observes external factors (threats and opportunities) and internal factors (weaknesses and strengths) (silva et al., 2014). a comprehensive analysis allows one to capitalise on the advantages or strengths and provides the foresight to detect looming threats to prepare (sarsby, 2016; silva et al., 2014). figure 1: conceptual strengths, weaknesses, opportunities, threats framework adapted for this study. furthermore, aspects from ehdi guideline generation through to clinical application incorporating various levels, that is professional, political, social, institutional, practice, and educational levels that could affect ehdi service provision was adapted from haines, kuruvilla and borchert (2004). professional level factors are the standards of practice, policies and guidelines, and the appropriateness, practicality, and feasibility of these towards rendering ehdi services in the south african context. political level areas include the governmental departments of health or education who play a big role in the decision-making process. institutional level factors include human resources equipment, type, structure, and area of healthcare facilities. practice level areas include the protocols in healthcare facilities, healthcare professionals’ practices, and settings of practice. social level factors include people’s beliefs about the health system and their health-seeking behaviours. educational level areas include knowledge, information, and training about health services by healthcare professionals, parents or caregivers, and the government. study procedure identified participants were contacted through phone calls, and the informed consent letter was emailed to them. once confirmation was received, details of the interview, such as time and date were scheduled. the main study consisted of 12 telephonic interviews as the saturation point was reached and no new information was being obtained. the data was then transcribed and member checking was conducted. copies of the transcribed interviews were emailed to the participants to check for their accuracy (kiyimba, lester, & o’reilly, 2018) and ensure the credibility and trustworthiness of the data. the participants were given 3 to 5 days to check and email the transcribed interviews back to the researcher, with a total of six participants (50%) emailing back and no changes being made to the transcribed interviews. data analysis a statistician was contacted to aid with the data analysis. the data for each question was inputted on an excel spreadsheet, cleaned, and then imported to nvivo for further analysis. nvivo is a qualitative data analysis programme that makes the analysis of qualitative data easier and efficient by coding the data (opie & brown, 2019). nvivo was used as the sole coding method for the first round of data analysis and is reported to be the best method for small-scale studies (saldana, 2012), with the second part involving inductive thematic analysis, whereby categories were used to label similar coded data (saldana, 2012; willing & rogers, 2017). ethical considerations the proposed research study was sent to the university of kzn humanities and social science research ethics committee to obtain the ethical approval (reference number: hssrec/00001003/2020) to conduct the study. the helsinki declaration was used to ensure that human participants’ rights were protected and treated with respect (gallin, ognibene, & johnson, 2017). all data collected was available only to the researcher and supervisor. participant anonymity and confidentiality were maintained throughout the study. an informed consent letter was provided to the participants once they were identified, as consent is voluntary and participants should be aware that they can withdraw at any time during the study (bhattacherjee, 2012; crowther & lauesen, 2017). the data will be stored for 5 years and will be disposed of in january 2025, through shredding. results and discussion most participants were female, between the ages of 21 and 30 years, having a bachelor’s degree, employed in public healthcare facilities, in an urban area, and within the ethekwini district. the results and discussion are present according to the five main themes. these include: (1) ehdi guideline improvements; (2) investment in resources and infrastructure for ehdi; (3) facilitating and strengthening intersectoral collaboration; (4) evaluating protocols and procedures for screening and managing follow-up; and (5) engaging, understanding, and supporting caregivers or families early hearing detection and intervention guideline improvements the first theme related to ehdi guideline improvements and included the aspects linked to guideline development, implementation, and review. the feedback received in relation to this theme is summarised in table 1. table 1: strengths, weaknesses, opportunities, and threats for theme 1: early hearing detection and intervention guideline improvements. all of the participants reported that at a professional and institutional level it was beneficial that there is an evidence-based guideline with contextual adjustments being evident to direct practice, but felt that it was more suited towards private compared to public healthcare. the participants believed that the people developing the guidelines or policies are not always the individuals working at ground level, which was one of the weaknesses identified as stated in table 1. furthermore, the participants believed that the guideline should have been revised or reviewed more regularly and not after approximately 10 years. a major weakness reported was that there is a lack of ehdi statistical data for south africa, as there is no national data management system. however, most participants stated that an online or computer-based data capturing system would not be practical in certain rural areas, because of a lack of resources. an opportunity identified would be to develop a general protocol based on the hpcsa edhi guidelines, for each area or district to ensure that it was more relevant to specific contexts. a recommendation for data management identified by one participant was the use of a tracking system such as the assistive devices electronic management system (adems): ‘it is a good way in terms of you know going paperless … and … sort of you know… [getting] all the information on one database and things like that. i think in terms of the practicality of it … it’s a bit iffy … you could say ….’ (participant c, female, bachelor’s degree, public sector) the participants also felt that there is too much emphasis on the initial screening and that there is little information about follow-up and monitoring of hearing status. ehdi remains an important need in africa due to the global incidence and prevalence rates of childhood hearing loss (khoza-shangase & kanji, 2021). studies have identified the impracticalities of implementing first-world models for hearing screening, in low-and-middle-income countries (swanepoel et al., 2004; swanepoel, hugo, & louw, 2005). continuously evaluating hearing screening position statements or guidelines, facilitates evidence-based practice and ensures programme implementation (khoza-shangase et al., 2017). evaluation and interrogation of the feasibility of hearing screening programmes by a/stas, are critical in determining the practicality of the hpcsa ehdi guidelines and associated unhs benchmarks, within the south african context (petrocchi-bartal & khoza-shangase, 2014). a top-down approach seems to be used for developing the ehdi guidelines and even though there is some involvement by stakeholders at the ground level, it is limited. an ehdi programme needs to be established by each of the country’s nine provinces, who will then be responsible for improving and maintaining the services (khoza-shangase & kanji, 2021). the position statements of the joint committee of infant hearing (jcih), the american academy of pediatrics (aap), and the world health organization (who) newborn and infant hearing screening documents were used to guide the development of the ehdi guidelines. however, despite the availability of the guidelines and adaptations to the south african context, there are still gaps in their implementation. a study conducted in the united states of america (us) revealed that 91.4% of healthcare facilities were compliant in reporting paediatric hearing data to state ehdi programmes (chung et al., 2017). unfortunately, in south africa, one of the challenges is that there is no standardised national data management system in place, which is a huge weakness impacting how the programme is evaluated, monitored, and reviewed. a national database is needed to correlate data uniformly and facilitate communication with screening and intervention services (hpcsa, 2018). according to the guidelines, it has been recommended that for data collection the provincial coordinators develop and circulate an excel template (hpcsa, 2018), but the completion of an excel document was reported to not be feasible. nevertheless, one needs to be cognisant when implementing an online or electronic system, as challenges include limited staff for data entry and lack of time (moodley & störbeck, 2017). according to the study conducted by joubert and casoojee (2013) at primary healthcare clinics in gauteng on nurses performing immunisations, the majority of nurses did not even record screening results on either card or chart (road-to-health chart and city of johannesburg child health services blue card). the absence of a proper database or data management system is a threat affecting the monitoring of nhs in south africa. a proper database will assist in obtaining accurate prevalence rates of infant and newborn hearing loss in south africa and can provide information regarding the age of hearing screening and diagnosis (hpcsa, 2018). investment in resources and infrastructure for early hearing detection and intervention the second theme alluded to resource availability and constraints and included the aspects linked to financial, human, and infrastructure resources. the feedback is summarised in table 2. one of the main threats identified by the participants, at a political level was the lack of funding or limited budget provided to public healthcare facilities. at an institutional level, the participants stated when a/stas tried to motivate for equipment in public healthcare facilities, they were always told that there is no budget or funds. all of the participants reported that there is a shortage of audiologists, leading to them conducting targeted or high-risk screening programmes at their healthcare facility only and not unhs even if the equipment was available. furthermore, they also reported that a large number of individuals access public healthcare services compared to private, impacting time spent per patient. the participants reported that there seems to be a lack of confidence, especially among community service audiologists, in providing diagnostic services to young children: ‘that’s a large factor in why we are failing, even when we have the equipment, we can still be failing because we’re not good at diagnosing children at a young age.’ (participant f, female, bachelor’s degree, private sector) table 2: strengths, weaknesses, opportunities, and threats for theme 2: investment in resources and infrastructure for early hearing detection and intervention. a threat described by the participants was that many public healthcare facilities do not have the appropriate equipment to provide the necessary services. results from the study indicated that it depends heavily on whether the medical or finance manager sees the importance of getting audiology equipment, compared to medical equipment for doctors. a weakness as stated in table 2, was the long waiting list or appointment date that is given in public healthcare facilities. ‘[y]ou can’t do screening without follow-up, so if you doing screening you have to go through with your intervention and management thereafter. i will refuse to screen if we can’t … that’s why we don’t do universal screening because we don’t have the manpower and the personnel to follow in terms of intervention, management, hearing aids fittings, etc. you don’t screen and put them on a waiting list … you screen to diagnose and treat and manage them.’ (participant d, female, bachelor’s degree, public sector) the translation of policy into practice is greatly influenced because of resource constraints (khoza-shangase & kanji, 2021). the barriers to ehdi in the public sector relate to lack of finance and funding in government and healthcare facilities, affecting the employment of staff and provision of equipment and hearing aids in public healthcare facilities, which is consistently cited in several studies (khoza-shangase et al., 2017, khoza-shangase & kanji, 2021; petrocchi-bartal & khoza-shangase, 2014; theunissen & swanepoel, 2008). audiologists are crucial for each aspect of the ehdi process (hpcsa, 2007); however, there is a shortage of qualified audiologists in south africa, compared to the population size, with the most obvious mismatch occurring in the public sector (petrocchi-bartal & khoza-shangase, 2016), posing a threat to nhs (kanji, 2018). the statistics from the hpcsa indicated that in january 2020, 788 audiologists and 1612 speech therapists and audiologists were registered (khoza-shangase & kanji, 2021). therefore, considering the shortage of audiologists documented within the african context, global access to human resources through tele-audiology for supervision needs to be explored (khoza-shangase & kanji, 2021). tele-audiology can then become another method of service delivery, and audiologists can serve as the programme managers with trained nurses and screeners conducting screening services (khoza-shangase & kanji, 2021). limiting hearing screening to at-risk babies is not recommended (jcih, 2007), but it may be a practical and feasible approach in resource-constrained contexts (das et al., 2020). one should be cognisant that all programmes have to start somewhere, thus recognise that targeted or high-risk screening is a good foundation or starting point, compared to doing nothing at all, especially as the public sector is under-resourced (kanji, 2018). amplification is seldom provided before 12 months to infants and children, which is far from the set standards recommended by the jcih and hpcsa ehdi guidelines (hpcsa, 2018; jcih, 2007; khoza-shangase et al., 2010). thereafter, if the child has been fitted with hearing aids they may not be provided with appropriate and intensive aural rehabilitation as compared to the private sector because of the large workload in public. research studies mainly focused on early detection and early intervention services are under-scrutinised (störbeck & young, 2016). additionally, emphasis is greatly placed on nhs in the hpcsa guidelines however, one should be aware that the absence of diagnostic assessment implementation and intervention ehdi programmes cannot be successful (hpcsa, 2018). research indicates that in south africa there is a lack of a nationally agreed battery of protocols and tests to diagnose hearing loss in babies and infants (khoza-shangase & kanji, 2021). currently, there is no existing evidence-based method, which will decrease non-adherence towards hearing testing and intervention (khoza-shangase & kanji, 2021). facilitating and strengthening intersectoral collaboration the third theme corresponded to knowledge and intersectoral collaboration between healthcare professionals and included the aspects related to knowledge, awareness, education, and training, and intersectoral collaboration. the feedback is summarised in table 3. table 3: strengths, weaknesses, opportunities, and threats for theme 3: facilitating and strengthening intersectoral collaboration. all of the participants stated that there is a general lack of awareness and knowledge about ehdi services among some healthcare professionals and within the different government sectors, which was identified as a weakness as stated in table 3. poor collaboration between audiologists in the public and private sectors was noted. the participants also reported little to no collaboration between the department of health and education, rather a disconnect as indicated by the participants. a recommendation was the possible creation of whatsapp groups between professionals working in the department of health and education that could facilitate better service delivery: ‘[b]ecause what can happen is they can share policies, they can share information, expertise, and we can uplift the public side of our healthcare system. if we have a little bit more collaboration between … between both sides. i think that’s one thing i’d really like to see, which will facilitate screening services.’ (participant f, female, bachelor’s degree, private sector) contrasting views were obtained from the participants regarding the inclusion of nurses for screening with some participants agreeing that nurses conducting screening when babies come for immunisations may assist with identification whereas others felt that nurses already have huge caseloads and are not knowledgeable about hearing loss. one opportunity identified was that if the hpcsa ehdi guidelines were made mandatory then institutions will be obliged to follow it and this will facilitate services. the poor levels of awareness among healthcare professionals regarding ehdi and audiology services correlated with other study findings (olusanya, 2008; swanepoel, ebrahim, joseph, & friedland, 2007; swanepoel, störbeck, & friedland, 2009). further correlating ravi et al.’s study, that indicated nhs team members showed gaps in their knowledge, necessitating the need for educational and outreach programmes (ravi, gunjawate, yerraguntla, & rajashekhar, 2018). there have been no studies conducted in south africa, to evaluate or describe the knowledge level and awareness of individuals working in government sectors and this should be an area that is explored. audiologists need to advocate and promote ehdi and nhs, which can be done through private-public partnerships and non-government to government collaborations (khoza-shangase & kanji, 2021). communication and collaboration between professionals is a key aspect and effective ehdi services rely on a team approach (hpcsa, 2018). this will help facilitate a seamless flow of children from the health sector to the education sector. communication and collaboration are important as it can facilitate information sharing and enhance awareness about services offered, referral pathways could be developed to decrease the workload or waiting times, especially in public healthcare facilities. current studies and guidelines recommend de-specialisation of hearing screening services to other personnel who will be trained and will have to adhere to regulated standards (khoza-shangase et al., 2017; khoza-shangase & kanji, 2021). equipment that is easy to use and sensitive, creates opportunities to use non-professionals as screeners, to reach contexts where audiologists are not available (bezuidenhout, khoza-shangase, de maayer, & strehlau, 2021; khoza-shangase & kanji, 2021). there are successful programmes in the united kingdom, which indicates 99% of parents allow for nhs services, which is conducted during a home visit by a nurse or in a hospital (who, 2010). nurses being the backbone of primary healthcare, which is the first contact point in the healthcare system for more than 80% of south africans, necessitates the need to ensure that this level is well resourced and equipped for implementation of nhs (khoza-shangase & kanji, 2021). most of the participants from khan and joseph’s (2020) study were agreeable towards nurses routinely screening for hearing loss during immunisation visits. thereafter, once the programme is established further consideration should be given to better develop the programme in place (khoza-shangase & kanji, 2021). the key successes and challenges of programmes should be shared by audiologists at forums to develop programmes at the national and provincial levels (khoza-shangase & kanji, 2021). regulations, ethics, and scopes of practice need to be adhered to if non-audiologists, like nurses, are involved in nhs (khoza-shangase & kanji, 2021). at a political level, mandating the guidelines would reduce challenges, thus individual preferences will not hinder best practice and facilitate healthcare professionals’ education and support (scheepers, swanepoel, & le roux, 2014). according to the study by khan and joseph (2020), practitioners had a positive view towards hearing screening being mandatory and that it should form part of the birth package offered to mothers. currently, unhs has not been mandated by the department of health and additionally, there is a scarcity of contextually relevant evidence-based challenges regarding the implementation of nhs in the public healthcare sector (bezuidenhout et al., 2018). hearing screening programme performance needs to be audited through formalised evaluations of pilot programmes, which should include primary, secondary and tertiary healthcare contexts which are coordinated by the department of health in conjunction with tertiary hospitals (hpcsa, 2007, 2018). evaluating protocols and procedures for screening and managing follow-up the fourth theme related to evaluating the process and methods for screening and thereafter the follow-up, and included aspects linked to screening platforms and procedures and the follow-up rates. the feedback is summarised in table 4. table 4: strengths, weaknesses, opportunities, and threats for theme 4: evaluating protocols and procedures for screening and managing follow-up. a threat identified by the participants at an institutional level is the high rate of loss-to-refer or the poor follow-up rate, experienced in both the public and private healthcare settings. another threat as noted in table 4, indicated that the medical aids, specifically for the private sector, are not paying for the hearing screening. some participants mentioned that using otoacoustic emissions (oaes) to screen babies before discharge from the hospital may not be a practical method, as it is highly dependent on the middle ear state, size of the baby’s ear, and state of the baby. the inclusion of an automated auditory brainstem response (aabr) test was noted to be debatable between a/stas as strengths and weaknesses were identified as stated in table 4: ‘i’m always worried about giving the results to mom if the baby has passed the oae because we don’t know about those auditory neuropathies … so i feel that we are missing that … but that is my personal opinion … i always maintain that.’ (participant e, female, bachelor’s degree, private sector) in public healthcare facilities, the sedation provided to the child, specifically for electrophysiological testing, was reported to be problematic, as in many instances the infant or child does not fall asleep and they are rebooked to redo or continue the test. an opportunity mentioned was the collaboration between doctors and audiologists in developing a good sedation protocol for all health professionals to follow, specifically for babies requiring further electrophysiological testing. the ehdi guideline states that screening should be conducted before discharge (hpcsa, 2018). it can be problematic as babies’ ears can have vernix, birth fluid, or wax, which can prevent obtaining a true result. according to khoza-shangase and kanji (2021), hearing screening is possible postpartum within 6 hours. however, it is more practical and efficient to screen infants at their 3-day appointment after birth, which can significantly reduce false positives. screening using aabr provides advantages of a higher rate of true positives, lower referral rates, effective screening at a younger age, and the ability to identify neural hearing losses (de kock, swanepoel, & hall, 2016). it should be noted that there have been new developments in aabr technology, which addresses the problems with preparation, test time, and disposable costs (cebulla & shehata-dieler, 2012; cebulla, hofmann, & shehata-dieler, 2014) and are broadening the application opportunities for aabr screening even in community-based contexts settings (de kock et al., 2016). auditory brainstem response (abr) testing under sedation is currently the gold standard and is used to diagnose hearing loss in young children and infants who are unable to complete behavioural testing or are not developmentally ready (abulebda et. al., 2017). there is no specific sedation protocol that is recommended by the hpcsa ehdi guideline (hpcsa, 2018). therefore, hospitals follow different protocols, depending on what is prescribed by general practitioners or doctors. the type of sedation prescribed influences whether the infant or child will sleep long enough for the necessary audiological testing. sometimes the child may not sleep, affecting the reliability of the test results, causing the child to be rebooked, further causing delays in diagnosis and intervention. the loss to follow-up or loss-to-refer is a challenge in nhs programmes worldwide (hpcsa, 2018). reducing the poor follow-up rates necessitates the need for proactive reminders and more effective communication with caregivers (scheepers et al., 2014). the outpatient follow-up rescreen should be available to families, without barriers like language, literacy levels, transportation, or cost (thomson & yoshinaga-itano, 2018). engaging, understanding, and supporting caregivers or families the fifth theme alluded to caregiver and family factors and included aspects related to socio-economic factors, traditional and cultural factors, and knowledge of parents and caregivers. the feedback is summarised in table 5. table 5: strengths, weaknesses, opportunities, and threats for theme 5: engaging, understanding, and supporting caregivers or families. the barriers, as reported by the participants, included the cost of transport for parents or caregivers especially in the rural areas, and the cost of the test in private healthcare. in rural areas, there is a lack of availability of audiology services which results in patients having to travel far to get access to services that they require. results from the participants revealed some traditional and cultural beliefs posed as a challenge, but those working in rural areas reported it to be a barrier impacting follow-up rates: ‘so i gave her a follow-up date for four weeks and she told me i can’t make it when the baby is four weeks because culturally, she’s not allowed to leave her house once she’s discharged from hospital. so i think culture can affect … definitely can affect …’ (participant f, female, bachelor’s degree, private sector) the participants indicated that parents may be more knowledgeable about audiology and ehdi services in private compared to public healthcare facilities, as a/stas may be more visible. a threat to ehdi as reported by the participants was the cycle of grief experienced by parents or caregivers, and opportunities to aid in this have been identified in table 5. logistical barriers to ehdi as reported by the participants correlated with the results from khoza-shangases’s (2019) study. studies have indicated that there are significantly greater barriers related to access, experienced by rural versus urban communities, which include time, distance, and cost of receiving healthcare services (jackson et al., 2006; stuckler, basu, & mckee, 2011). there is a need for reliable and affordable transport, especially because of the large distances and limited healthcare facilities in rural communities (gaede & versteeg, 2011). service delivery and access need to be driven depending on the needs of individuals being served (khoza-shangase, 2019). south africa has a richly diverse population in culture and language, thus clinical interactions need to be conducted using a mode or language of communication which patients understand (hpcsa, 2019). however, english is a dominant language used for communication and imparting health knowledge orally or through handouts in public healthcare (janse van rensburg, 2020). this education is essential for the prevention of disease and promotion of health, but many individuals may have poor ability to understand what they read or hear (griffen, mckenna, & tooth, 2006). therefore, culturally and linguistically appropriate management should be provided by affording unbiased and fair opportunities to people from different cultural and language groups seeking services (hpcsa, 2019). professionals should be knowledgeable about various cultural practices that can influence care and reflect on personal discomforts, such as cultural biases which will aid in providing family-centred care (grandpierre et al., 2019). traditional healing also plays an important role in south african’s health-seeking behaviours, with traditional healers being synonymous in black african communities (pillay & serooe, 2019). eight out of 10 black people from south africa are believed to use only traditional health practitioners or in conjunction with western medicine (ross, 2010), other studies indicated approximately 70% of black south africans use traditional health practitioners (bopape, 2016; latif, 2010; ramgoon, dalasile, paruk, & patel, 2011). in south africa, traditional healing methods are highly debatable because of the controversies surrounding the possible negative impacts of traditional healing (pillay & serooe, 2019). caregivers and parents need to be part of the assessment process which will aid in their understanding of the assessment management process (kovacs, 2012). attention should be provided to create awareness and counselling should include the entire family, as an individual member’s poor knowledge can lead to a delay in identification and management of the hearing loss (rajagopalan et al., 2014). data indicates that the resolution of grief with early identified children and their families may occur faster compared to later-identified children, but only if these children develop strong communication and language skills (yoshinaga-itano, 2003). south africa has very little data regarding caregiver perceptions of early identification of hearing loss (hpcsa, 2018) and further research should be conducted towards ‘culturally congruent screening programmes’ (hpcsa, 2018, p. 23). conclusion research indicates that early intervention principles were not applicable for south africa, because of language barriers, socio-economic factors, cultural diversity, lack of resources, and awareness which affect audiology service delivery (khoza-shangase et al., 2010). the main barriers affecting ehdi implementation included lack of resources, poor follow-up rates, limited knowledge and education, socio-economic status, and practicality of the ehdi guidelines. these findings emphasise the need for context-specific solutions and strategies to facilitate effective practice and implementation of ehdi services, because of the rich and diverse contexts: children with hearing loss are as much part of the future of the country as those with normal hearing and it is through effective ehdi services that the active and equal participation of these children will be secured among their hearing peers to change, influence and direct the future of south africa. (hpcsa, 2018, p. 47) limitations and recommendations the study sample and size are representative of a/stas employed in private and public healthcare facilities in the kzn province only and therefore, the results may not be generalisable in a probabilistic sense (marshall & rossman, 2010). the time limit of 45 min – 60 min scheduled for the telephonic interview may have affected the depth of information obtained from the participants, as many a/stas working in healthcare facilities have very busy schedules. audio recordings of the telephonic interviews had certain limitations as the quality of recording of one or two of the interviews was affected because of the background noise, in the participant’s workplace (howitt, 2016). therefore, certain words/phrases in the audio recordings were unable to be transcribed. it may be necessary for de-specialisation of hearing screening services to healthcare professionals such as nurses to facilitate unhs and achieve goals and principles as set out by the hpcsa ehdi (hpcsa 2018) guideline. future research should investigate the barriers and facilitators of ehdi implementation, in the various provinces, using a larger quantitative, online survey-based study in south africa. assessment and evaluation of resources and protocols available in healthcare facilities in all the provinces of south africa should be conducted, which can assist with developing proper ehdi programmes and for implementation purposes. a national database can assist in obtaining accurate prevalence rates for newborn and infant hearing loss, in the south african context and provide information regarding the age of hearing screening and diagnosis of hearing impairment (hpcsa, 2018). acknowledgements the authors would like to acknowledge the contribution of all the participants of the study. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions this article is based on a master’s study by n.n., who was supervised by n.b.k. the article was drafted by n.n. and the supervisor contributed substantially to all subsequent drafts and the final article. funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability data sharing does not apply to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references abulebda, a., patel, v.j., ahmed, s.s., tori, a.j., lutfi, r., & abu-sultaneh, s. 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(2017). sage handbook of qualitative research in psycology (2nd ed.). thousand oaks, ca: sage. appendix 1 semi-structured telephonic interview schedule the broad swot framework was used to aid in guiding the telephonic interview questions. the participants had to elaborate on some or all of the levels in relation to the strengths, weaknesses, opportunities and threats. fluency and aphasia: a p r a g m a t i c reconsideration abstract ihe fluency behaviour of fourteen adh ' 0ps0mm1ng m a classificatory concept vlotheid is by veertien afat' — d i s r a p , i 0 1 1 o r p r e s e r v a t i o n ' * * expressive out™,, „ s e r v a t l o n o f auencv in anh^.v , . p -a ιwineia en ι frequently in the literature. i n i c m t i? t h " pressive output which has for j e d the i ^ m e n s i o n of exof classificatory schemes in a p h a s l a w * ̂ n u m b e r for example, that at least 75% o f * ^ e t a i · ' 6 ^'aim, can be distinguished along th! h u e n ' t ^ a differentiation is made betweenth^ e s s e n ^ u y , agrammatic) patient, who n ° " f l u e n t " ^ r i o r , o r halting and effortful w ^ p r 0 d u c t i ° n i s <w*»by mistakes, short u t t e r a n c e ^ ° v t * ' p r « a t i o n o f action words a t ^ ^ j t ^ a n d «mission p^sents with fluent, γ ^ ' ^ ι ,η " 1 1 6 " " ' 3 p h a s i c effortless sentences aid tel, l π 0 π π 3 1 p r o s o d * w grammar. a n g w e l l-presented articulation and s u c h classificatory c " l a t 1 0 n a n d syntax l t 0 ϊ λ τ ^ b u t ^ " ° n a i definitions offluetcv a ' η ° f fluen<* tradim o s t for example e m ? ' h ° w e v e r ' l e s s encompassing ^ sequential ons, repetitions and interrupt^ w 3 s p a u s e s ' hesita2 ' s denved f r o m the " ο „ 2 o n 3 , t e r n a t i v e perspecadherence to the rules ofzt, a " g u a g e u s a « e and includes ^ y « ^ s e s i 8 u s e o f ~ "^tyreek. heavily o n tte s e j ^ j 1 1 j ^ f · tetaions d e p e n d s the communication system τΐγίτ fte ° v e r a 1 1 p o t e n c y of should be perce,ved s o r e as an e:nch d l s n i p t l 0 n i n type and locus of brain d a m a ^ but "0t * the of communicative c o m ^ n f e ' . " b r ° a d e r « » * » an investigation of fluenctdkn " ^ d l s t u r b a n c e s and f r o m children. i„ . ^ ^ * » language-impaired taneous speech ofbroca's anh, l c o m p a r i n g the sponcontrols, though 7 e fi^t t ^ " ' ^ ^ aphasics'speech was t h r e e l m e ™ d f f l u e n c i e s the trol group, the nature of^ese dy ^ ^ * * ° f t h e connormal patterns. the fact that o r d i ^ b m r e s e m b , e d l n this study and that the dal £ ϊ 3 8 p 3 t i e n t s w e r e u s e d —..fticuce in hi phrases rather than soontan™ a " a , y s i s ^ elicited clearly, i n " d l s c o u ^ · sions which may be made w" h s p c e c h ' l i m i t s t h e conclufluency z s t j · a r e k e r n e d with both t l 0 n a s a whole. howtver γ τ * ^ 3 p h a s i c popula: : r ^ ^ ^ ^ l · r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) is the concept of nonfluency as opposed to dysfluency, the former referring to a disruption in copiousness of verbal output, the latter to a disruption of speech flow. in discourse, the presence of fluency problems has been shown to interfere with overall cohesion. in a study investigating the spontaneous discourse of a group of language-impaired children, fluency (or lack thereof) was found to be a feature of discourse significantly differentiating their overall cohesion in relation to that of matched normals.1 it thus seems pertinent for the language pathologist to examine fluency from a slightly different perspective than usual, i.e. as a feature of speech behaviour potentially capable of interfering with the basic communicative effectiveness of the message. in other words, it can be argued that fluency is a pragmatic phenomenon one which is influenced by the context of the communicative event. the above points provided the rationale for the inclusion of the fluency dimension as part of an investigation of broader pragmatic capabilities in a group of aphasic patients* the specific methodology and results of the fluency analysis will now be described. method in an attempt to investigate the relative importance of fluency in the overall assessment of communicative appropriateness, a scale was devised to reflect pragmatic competence in fluency terms. the purpose of this analysis was to examine the nature of the relationship between results on the fluency scale and type and severity of aphasia as measured on a traditional structable 1 case history details pertaining to subjects used in the claire penn tured measure of aphasia the boston diagnostic aphasia examination (bdae).9 subjects (ss) fourteen english-speaking adult aphasic patients were selected for the study according to certain criteria. these included confirmed presence of aphasia, neurological stability and the absence of gross concomitant problems. etiology of aphasia was not held constant in the group; neither were classification or severity of aphasia (as measured on the bdae). table 1 illustrates relevant case history information pertaining to the subjects. testing the data base for analysis was a twenty-minute videotaped language sample. the sample for each s was recorded in the context of a conversation with a familiar speech therapist. each interactive language sample was divided into twenty oneminute 'chunks' which served as the units for analysis. two trained judges (speech pathology graduates) were required to rate the fluency behaviours during each conversational unit for each patient, along the dimensions presented in table 2. the categories selected to describe the fluency behaviours of the ss are those suggested by yairi and clifton17 who examined fluency breakdown in three groups of normal speakers. in addition, the categories of 'false start' and 'word-finding difficulty' were included, as both aspects were felt to be characteristic of aphasic language3 and both cause fluency disruption. the judges were required to characterise the overall apstudy subject age sex bdae bdae severity rating classification bdae severity rating behavioural classification 1 53 f anomic 3-4 2 59 f broca's 3-4 fluent 3 50 μ conduction nonfluent 4 63 f broca's 1 1 1 fluent 5 58 μ global — broca's 1 1 1 nonfluent 6 24 μ global wernicke's 1 1 1 nonfluent 7 61 μ ? broca's 1 1 1 mixed 8 63 μ wernicke's mixed 9 10 53 59 μ μ aphemic ? broca's 4 fluent mixed 11 36 f broca's 3 mixed 12 63 f wernicke's 2 nonfluent 13 41 μ anomic fluent 14 72 f wernicke's 2-3 fluent 2-3 fluent' table 2 fluency rating scale e x p l a n a t h n : s. i u d 9 l n 9 ^ a p p m p r i a t e n e s s °f ^ ^ τ — ^ conversational unit behaviours considered e x a m p l k ^ ^ ^ l ^ c n k r l y r ^ ^ e x a m p l e s 0 f ^appropriate u s e i n context use in context interjections repetitions revisions incomplete phrases false starts pauses word-findirig difficulties items traditionally associated with a measurement of nonfluency, viz. aspects which break the normal flow of speech normal acceptable non-fluencies which do not interfere with listener's understanding of message * this paper is based on a section of the writer's phd thesis, em,tied "syntactic and pragmatic aspects of aphasic language". non-fluencies which interfere with coherence, timing or sequence of the message. inappropriate interference in transition smoothness between segments the south african journal of communication disorders. vol. 30. 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) fluency and aphasia: a pragmatic reconsideration s l z f o ? h ; u b j e c t ' s ^ ^ b e h 3 v i 0 u r c h con-versational un,t on a f,ve-po,nt rating scale with the following the patient's control of fluency was not appropriate within this conversational unit the patient's control of fluency was mostly inap propriate within this conversational unit the patient's control of fluency was mostly appropriate within this conversational unit the patient's control of fluency was appropriate within this conversational unit it is difficult to decide whether the patient's control of fluency was appropriate or not for this conversational unit this format was selected on the ha<sk nf ,κ» , s 5 s s 5 u l j , , patient's behaviour as being appropriate data analysis j higher the association hetu/f^n e„ • „ behaviour, the higher t h e ^ j „ £ « < * generated cluster tree a h™h m t h e computerderived, repre ent ng i ^ f l d d ^ b e ship between ss t h o s e t r l ^ 8 p h l c , m a n n e r ' t h e relationreported in terms of th r a l s i m i l 3 r t 0 6 a c h o t h e r are in the cluster fidd s s s m a 7 ^ " f a n d similar, with d e c r e a s i n g , ΐ π 7 c i r c l e s judged most larger drcles 8 ^ r e p r e s e n t e d * inclusion in 6 0 5 3 5 3 81 63 64 34 56 « 44 55 75 37 37 9 40 37 60 23 24 7 25 t7 2 8 42 4 10 24 8 , 2 44 38 39 20 33 31 43 35> 4 99 / 4 2 38 48 47 37 43 44, j / 4 4 38 54 54 45 49 50. figure 1 linkage tree demonstrating degree of similarity between subjects on fluency scale v results fro c i u f s a v a i l a b l e f 0 r c l u s t e r i " g sets of suitable for the present ^ * * * w ° u l d b e m ° s t l l n ^ e d i a g r a 7 d e n t n v e s t l g a t l 0 n w e r e <*™*>η of a field. figufest 2 ' η ζ 0 8 ' 3 1 1 1 ^ c ° u n t e ^ r t ' * * cluster p r o g r a m r d i r t s e n t ί* ***** ( t r e e ) d i a 8 ^ , ^ s i s o f ^ l t i 1 u f r , f i e l d a c t i v e l y for the '"g of ss is i n £ t s h 8 ^ ^ h n k a g e d i a g r a m ' ^ groupi e above a p a s ^ ^ t ^ ° f ^ ^ s e c t i o n of the ζ s ' . t h e strength n f t j * d i a 8 0 ^ 1 line starting next to numerical values in rh , association is represented by t 0 1 0 0 a n d represent corrdat' ^ t ^ a r e s c a l e d 1 correlations from 0,00 to 1,00. thus, the a . „ — " " " ιιυιπ υ,υυ to s u i d ^ ^ e t y d s k r i f . j vir *immumkasieafivykings, vol. 30, 1983 figure 2 dendrogram demonstrating degree of similarity between subjects on fluency scale v 6, 2 8 12 and 10) showed relatively distinct * i t distinctions will be considered under e a s t o s ^ u p ' a. appropriate group ttxaizlsz&sz r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 6 instances of the nonfluent behaviours identified by table 2 occurred predictably in all ss. s14 showed considerably fewer of these behaviours than other ss in this group. in feet, both judges commented on her behaviours as being 'too fluent'. in many conversational turns there were no examples of nonfluencies at the expected junctures. this could perhaps be tied to a self-monitoring defect, which will be discussed later. this is illustrated by: s14 t: so you're doing a lot of work at home? p: well i must. it's the only way. first of all it's easier for me to learn things as i do. ( ) *when they speak to me i ask them. it's a lovely feeling. it really is. it's difficult but it slowly slowly come right. writing nicely. my writing's very well. it improved a lot i think so it makes a i feel so good then i start again then it's lovely. s3 showed, by contrast to s14, instances of revision, repetition and hesitation which, though judged as largely appropriate, were sometimes seen as interfering with communicative flow. this aspect was also noted in si's sample. her frequent use of 'er' and occasional word-finding difficulty were felt to interfere with the flow of the message though overall fluency was maintained through the discourse, e.g.'s: s3 t: you want to go and see the top man? p: right right. so um about um he'll give us a letter an answer you see. about a month later had a chat this fellow on the telephone. 'look what do you think?' he says no i'm sorry we can't do it but i'll send us a letter. he will send us a letter which is three months later. (note revision or "high level amendment" to use butterworth's3 term.) si p: my son is in er escom but er it's in germiston and er he has to er by six o'clock he must er he goes by car but actually he goes afterwards by er train, it's easier you know because er er not so expensive to go by car. s6 (a(b)) warrants special comment. his tie with the other ss in this group was low (0,53). all aspects of nonfluency were observed by the judges to occur very frequently. this s's rapid rate of speech, however, provides the listener with an overall impression of fluency. thus judgments of inappropriate were in part offset by this factor, e.g.: s6 t: so you hit your hand? p: ja ja ja ag you know lovey. um you see this one. this look now what ( ) t: the drink p: you see how look but if you ( ) like this one i'll never you'll do the same lovey. i never said you know i promise you i had enough. b. inappropriate the severely restricted output of ss 2 , 4 and 5 made judgments of fluency difficult in terms of the categories suggested on the fluency scale (table 2). thus these ss are grouped together in the cluster analysis, the few possible opportunities for judgment indicating that repetitions, false starts and incomplete phrases hindered overall communicative flow, e.g.: s2 t: why did they have collars round their necks? p: they had something ( ) * unintelligible utterance. claire p e n n t: oh so they had something done to them? p: no one the man who the man who was ( ) the manner of speaking in ss 7 and 9 (b(a)) also seemed to account for judgments of their fluency being very similar both of these ss have a particularly slow rate of speech resulting in lengthy unfilled pauses. other aspects of nonfluency in these ss (e.g. interjection and repetitions) were felt to be appropriate and not a hindrance to communicative flow, e.g.: s7 t: don't your grandchildren go to school? p: no they they a small. they too small yet. they er er the er oldest one he does to s kindergarten you know and er the other one he can't walk yet. s9 t: do you prefer some programmes to others on tv? p: no. er er sport 1 like and er um er progra and er a few programmes a week. the remaining five ss (b(b)) were all judged to.have many instances of inappropriate fluency behaviours in their samples (despite the fact that three of this group could be traditionally classified as 'fluent' ss). all behaviours delineated by the scale were noted in all ss but the following were commonly felt to interfere specifically with communicative flow: interjections and repetitions (in four out of five ss), pauses and word-finding difficulties (in all five ss) and incomplete phrases and false starts (in three ss). it appeared that the longer the conversational turn on the part of the s and the higher the frequency of non-fluent behaviours in such a turn the more likely it was that the s would be judged as being inappropriate with regard to fluency. this was particularly noticeable for s12: t: she lives here? p: no in ei'near durban. they've got a farm and er i feel there's something funny so i phoned her and er she said. well she er i'm fine honey am um i'm not so well but i'm fine but er did you get my letter? so i said no. anyway um so i waited for the letter and er then the letter that worried me so much because she told me that um that i had flu. broca's patients, ss 10 and 11 had relatively impaired syntactic output in relation to other ss in this group and their nonfluencies e.g. repetitions, revisions and interjections were felt in part to be not altogether successful attempts to compensate for this, e.g.: 510 t: how would you change a tyre? p: well i don't to i would put er a a jack and then i would put a wheel up a little bit and then i would get the bolts er in the not in the bolts and put it in under the see? 511 t: what did you do? p: um talk. hospital um um um. two time a week. t: you go there for therapy? p: yes um um um yes um my hand, my leg. word-finding behaviours seemed to affect fluency judgments of ss 8 and 13. e.g.s: s8 t: could you tell me how to change a tyre? p: yes well 111 know what it is. obviously and went on but it's hard hard to get something. t: what do you do? p: you know it's difficult um you know i told all forever in ( ) things like that. beautiful well unforthe south african journal of communication disorders, vol. 30 19s3 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) fluency and aphasia: a pragmatic reconsideration tunately as it went down down and so i was getting useless. but how do i do it? s13 p: it's a sort of thing you wind up and a thing you get to play records not records but it's a records record sounds like a records something. t: a tape reorder? p: no no no not a tape recorder. um t: not a record player? p: no no no not a record. not strictly a record player. it's for infants of the age 2 to 6. t: is it one of those fisher price toys? p: fisher price. fisher price. yes. fisher price. high med low bdae severity rating figure 3 clustering of the subjects on fluency scale in relation to appropriateness and severity ratings by way of a summary, in figure 3 the main clusters of patients are plotted against overall degrees of appropriateness and the bdae seventy rating for fluency ratings. for reasons described above, ss 2, 4 and 5 were not included in this analysis. of the remaining subjects, three were judged to have overall high levels of appropriate fluency, one showed a somewhat equivocal pattern and three by virtue of their severe agrammatism could not be effectively judged. seven ss were rated as having instances of inappropriate fluency either related to manner of production, length of turn or word-finding difficulties. clusters suggest more cases of inappropriate nonfluency in the group of ss as a whole than appropriate nonfluency and further that aphasia type does not necessarily correlate with judgments of appropriateness. clear-cut distinctions were not found on this scale either with regard to appropriateness or severity. discussion the results obtained confirm to a large extent recent published findings with regard to the fluency disorder in aphasia, viz· that aphasics show many instances of dysfluency and that these dysfluencies are greatly influenced by word position/grammatical function. ~ that there is not always a correlation between clinical form of aphasia and type of fluency that the measurement and rating of fluency is not a simple matter v that the examination of fluency in aphasic speech may offer some insight into the mechanisms of normal speech production3·6 die suid-akaanse tdskrif kommunikasieafwykings, vol. 30, 1983 with the exception of s 14, all the subjects in the present study demonstrated many instances of dysfluency in their expressive language samples. this confirms a large body of literature which discusses dysfluency phenomena in aphasia 2 "· the relative dearth of research into aphasia in relation to normal nonfluencies make such results difficult to interpret. in spite of this, the present data tends to confirm suggestions of workers such as butterworth3 that the type and locus of dysfluencies in aphasia are similar to those in normals. though the frequency of such behaviours was not directly measured in the present study it was this aspect which appeared to influence judges' qualitative decisions. with regard to type of dysfluency observed, judges noted instances of all behaviours delineated on the scale, viz· interjections, repetitions, revisions, incomplete phrases, false starts and word-finding difficulties. these occurred at predictable junctures in terms of the literature on normal dysfluency phenomena, e.g. at syntactic boundaries, before content words and after an error in production.* the feet that most aphasic subjects by definition have greater difficulty in formulating verbal output would lend support to the idea that associated dysfluency would be higher. this is clearly not the case in s14 who conforms to the classic description of jargon aphasia offered by kinsbourne and warrington,'3 viz: "the jargon aphasic speaks in a copious flow uninterrupted by hesitation and correction". unlike the patient described by butter worth,3 s14 showed no instances of hesitation prior to the production of neologisms, nor indeed at expected junctures. this provides some support for the 'disinhibition' explanation advanced for this type of aphasia. essentially it refers to a lack of self-monitoring such subjects have over their own output. acknowledging that an analysis of hesitations and associated non-fluencies may provide an indicator of how the speaker monitors his production, the nature of this type of aphasic deficit is thus apparent. it became clear during the rating of this scale that the assessment of fluency, particularly with regard to appropriateness is a very complex matter. judges' verbal and written justifications were often not specifically related to the frequency locus or type of dysfluency per se but on the overall impression gained. a measurement of fluency control inter alia involves aspects such as number of words, speaking time and speaking rate (which in themselves comprise variables such as phona tion rate, number and duration of silent pauses)/ the present study did not include rate as part of the fluency scale (cf. yairi et al.). rather this was seen as a paralinguistic behaviour to be measured on another scale. similarly, hesitation analysis was subsumed broadly under 'pauses'. in the sense that global rather than quantitative decisions were required in the present study, this somewhat restricted taxonomy of fluency aspects is acceptable. it does, however, suggest that ratings may have been made on the basis of behaviours other than those delineated by the scale. finally, and of particular relevance, the results on the fluency scale showed that there was not always a correlation between the clinical form of aphasia and type of fluency rating this supports the findings of deloche et a l / who showed that when certain aspects of fluency are considered, no clearcut differentiations in terms of aphasic types suggest themselves. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) the results of the present study suggest that some dysfluencies actually enhance the communicative process since they reflect underlying linguistic processing on the aphasic's part and apparently shadow normal strategies. in other words they appear to be an indication to the listener that the aphasic is attempting to retrieve the word, is self-monitoring and is employing (however inefficiently) search strategies which reflect communicative motivation. it is only when such behaviours occur with high frequency or at unexpected junctures that they are judged inappropriate. the fact that these behaviours occur in all but one of the subjects studied casts some doubt onto the question of the utility of the fluency/non-fluency dichotomy which has been used to differentiate aphasics. this point will now be expanded. implications the writer would suggest on the basis of the above results that the dichotomy of "fluent" versus "nonfluent" aphasia is a potentially misleading one. if this terminological distinction is used to separate patients on the basis of expressive output alone, and if the definitions involved are specified clearly and precisely, then it does have the advantage of reducing terminological confusion.16 however, as research on both normal and abnormal speakers suggests, fluency is a very complex phenomenon comprising a number of component parts and is hence difficult to measure. deloche et al.« point out that traditional aphasic classification schemes often incorporate different aspects into their definitions of fluency. even on the fluency scale in this study which incorporates components traditionally associated with an analysis of fluency, clear-cut distinctions in terms of appropriateness could not be consistently made between nonfluent and fluent ss thus many of the so-called 'fluent' ss were judged to be inappropriate along these dimensions. a problem of definition arises here. the components of the fluency scale are certainly more conventional than the broad definitions applied by aphasiologists and hence may well have been too restricted to derive differences among patients. notwithstanding this, the writer would suggest that the terms nonfluent/fluent have many potential pitfalls in terms of definition and specification and that possibly a distinction should be drawn between 'fluency' as characterised in traditional terms and incorporating prosodic features such as rate, hesitations and repetitions, and between fluency in grammatical, lexical and semantic terms. if indeed there is a correlation between clinical forms of aphasia and these separate types of fluency then the distinction is possibly worth retaining. but as the results of the present study suggest, from both terminological and conceptual viewpoints, the use of a fluent/nonfluent dichotomy in the characterisation of aphasic language probibly warrants reconsideration. acknowledgements rhe writer gratefully acknowledges the help and guidance of ler supervisor, prof. m. l. aron, head, dept. of speech claire penn pathology and audiology, university of the witwatersrand. for financial assistance, the writer is indebted to the human sciences research council and to the senate and council research committees of the university of the witwatersrand references 1. berger, h. & sinoff, a. aspects of cohesion, tense and pronoun usage in the discourse of the older languageimpaired child. s.a.j. comm. dis., 1978, 25, 3-16 2. brown, c. s. & cullinan, w. l. word-retrieval difficulty and disfluent speech in adult anomic speakers. j speech hear. res., 1981, 24, 358-365. 3. butterworth, b. hesitation and the production of verbal paraphasias and neologisms in jargon aphasia. brain lang., 1979, 8, 133-161. 4. cohen, j. weighted kappa: nominal scale agreement with provision for scaled disagreement or partial credit psychol bull. 1968, 70, 213-220. 5. dalton, p. & hardcastle, w. j. disorders of fluency. london: edward arnold, 1977. 6. deloche, g., jean-louis, j. & seron, x. study of the temporal variables in the spontaneous speech of five aphasic patients in two situations, interview and description brain lang., 1979 8, 241-250. 7. dixon, w. j. & brown, μ. b. mbdp 79 los angeles· u california press, 1979. 8. goldman-eisler, f. psycholinguistics london and new york: academic press. 1968. 9. goodglass, h. & kaplan, e. the assessment of aphasia an£ related disorders. philadelphia: lea and febiger, 10. holland, a. l. communicative abilities in daily living baltimore: university park press, 1980. 11. holland, a. l. observing functional communication of aphasic adults. j. speech hear dis., 1982, 47, 50-56. 12. kertesz, a. aphasia and associated disorders. new york: grune & stratton, 1979. 13. kinsbourne, m. & warrington, e. u. jargon aphasia neuropsychologia, 1963, i, 27-37. 14. morris, r„ blashfield, r. & satz, p. neuropsychology and cluster analysis: potentials and problems. j. clinical neuropsychology, 1981, 3, 79-99. 15. quinting, g. hesitation phenomena in adult aphasic and normal speech. the hague: mouton, 1971 16. wagenaar, r„ snow, c. & prins, r. spontaneous speech of aphasic patients: a psycholinguistic analysis. brain lang, 1975, 2, 281-303. 17. yairi, e. & clifton, n. f. disfluent speech behaviour of preschool children, high school senior and geriatric persons. j. speech hear. res., 1972, 15, 714-719 18. yairi, e„ gintavitas, j. & avent, j. r. disfluent speech associated with brain damage. brain lang 1981 14 49-56. ' ' the south african journal of communication disorders vol. 30 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) philips hearing aid services a division of s.a. philips (pty) ltd. philips hearing aid services e e . ? , f f i 0 ? i ° ° 5 c a v e n d i s h c h a m b e r s , 183 ^gpp^street, p.o. box 3069, johannesburg. philips die suid-afrikaanse 7wrw · „ •yasmj w kommunikasieafwykings, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) article information authors: harsha kathard1 freda walters1 kareemah frieslaar1 thembeka mhlongo1 melissa rhoode1 raeesa shaboodien1 julia weidmann1 nicole zimmerman1 amy zoetmulder1 fatemah camroodien-surve1 affiliations: 1department of health and rehabilitation sciences, university of cape town, south africa correspondence to: harsha kathard email: harsha.kathard @uct.ac.za postal address: f45, old main building, groote schuur hospital, observatory 7925, south africa dates: received: 18 mar. 2014 accepted: 05 aug. 2014 published: 03 dec. 2014 how to cite this article: kathard, h., walters, f., frieslaar, k., mhlongo, t., rhoode, m., & shaboodien, r. et al. (2014). classroom intervention to change peers’ attitudes towards children who stutter: a feasibility study. south african journal of communication disorders, 61(1), art. #80, 11 pages. http://dx.doi.org/10.4102/sajcd.v61i1.80 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. classroom intervention to change peers’ attitudes towards children who stutter: a feasibility study in this original research... open access • abstract • introduction • methodology    • objectives       • primary objective    • secondary objectives    • study design    • participants    • inclusion criteria    • exclusion criteria    • sample size    • method of recruitment    • research instruments and their validity and reliability    • ethical considerations    • data collection • analysis of data • results    • treatment effect    • gender effect    • exposure to stuttering • discussion    • treatment effect    • exposure    • gender    • limitations of the study    • clinical implications    • recommendations for further research • conclusion • acknowledgements    • competing interests    • authors’ contributions • references • appendix: a • appendix b abstract top ↑ background: before interventions are implemented, the potential treatment benefit must be determined. objectives: the primary objective of this feasibility study was to assess if peers’ attitudes towards children who stutter (cws) change one month after the administration of the classroom communication resource (ccr). the secondary objectives of the study were to determine if differences in peer attitudes were related to gender and to previous exposure to a person who stutters. method: the study used a cluster randomised control trial design. the study included 211 grade 7 participants from schools in the cape town metropole. the ccr intervention was administered to 97 participants in the experimental group, whilst 114 participants in the control group did not receive the intervention. the stuttering resource outcome measure (srom) used as the outcome measure during preand post-test period. statistica was used for in-depth data analysis. results: an overall positive direction of change in scores was observed for the experimental group compared with the control group. however, the magnitude of change in the experimental group was not statistically significant (p = 0.2683). male and female participants did not differ significantly in their scores on the srom across pre-test and post-test periods. participants who had exposure to individuals who stutter had significantly more positive scores on the srom in the pre-test and post-test periods compared to those who had no direct exposure to stuttering. conclusion: this result indicated the beginning of positive attitude change which may be attributed to the intervention. further investigation is warranted. introduction top ↑ social interactions and associations with peers are important for learners who are typically between 10 and 13 years. (evans, healey, kawai et al., 2008; parker & asher, 1993). they are under pressure by peers to conform to group norms, particularly for those individuals who differ beyond what is considered ‘acceptable’ (evans et al., 2008), predisposing them to teasing and bullying. whilst bullying is regarded as the use of force and emotional, verbal and/or physical abuse to coerce another, teasing is viewed as a lighter form of bullying and refers to mocking or provoking an individual in a playful but hurtful manner (langevin, 1997). in the short-term, teasing and bullying may lead to low self-esteem and low self-confidence (liang, flisher & lombard, 2007) of victims and can also lead to negative long-term psychological, emotional, physical and social consequences (langevin, 2009). communication disorders such as stuttering are often not viewed as ‘acceptable’ individual differences (murphy & quesal, 2002). children who stutter (cws) are perceived to be shy, less extroverted and less popular compared to their peers. (evans et al., 2008). peers feel that cws are ‘less competent’ than those who speak more fluently (dietrich, jensen & williams, 2001). as a consequence of these negative attitudes held by peers, cws have been found to be at greater risk of being teased and bullied compared to their fluent peers (turnbull, 2006; hughes, 2014). the overall incidence of bullying in primary school learners in the united states of america (usa) lies between 49% and 58%; however, this incidence increases to 81% for cws (murphy, yaruss & quesal, 2007). in south african schools teasing and bullying is a widespread problem of increasing concern (mestry, van der merwe & squelch, 2006). consultation with teachers in the western cape indicated that teasing and bullying of cws was a common problem and they requested support (filies, hartley, kaplan & pettit, 2009). as part of a comprehensive approach to intervention which considers the individual and his or her environment, speech-language therapists (slts) therefore must consider interventions aimed at improving attitudes of peers towards cws as a strategy for minimising teasing and bullying (yaruss, 2007). one strategy is classroom-based intervention aimed at improving peers’ attitudes to cws. the teasing and bullying: unacceptable behaviour (tab) programme was one of the first formal classroom-based interventions to be developed in canada. the intervention comprises of a 14-minute video and six units of classroom-based lessons originally designed for grade 4–6 learners, with the biggest impact occurring in the fourth grade (langevin, 2000). this resource can be used on its own in classrooms or as part of anti-bully campaigns across the school, as well as in individual counselling the tab was not found to be suitable for the south african context, given its length and socio-cultural relevance. in response, a new intervention – classroom communication resource (ccr) – was developed in south africa. development of the ccr began in 2009 which gathered teacher and learner responses to the classroom resource aimed at improving peers attitudes to cws (filies et al., 2009). further studies revised and refined the ccr (badroodien et al., 2011; de grass et al., 2010; de freitas, geben, parusnath, relleen, & van den berg, 2012) into its current form. the intervention was found to be better suited to grade 7 learners because teasing was also prevalent during this grade and they had developed literacy and comprehension skills in english to benefit from the intervention. the intervention requires that teachers are provided with education on stuttering and on the purpose and administration of the intervention. the learners are directly involved in the intervention via a story and role-play. thereafter, the teacher and learners discuss the issues which commonly include understanding stuttering, difference, diversity, prejudice, teasing, bullying and social inclusion. the intervention targets three domains of attitude change viz. positive social distance, verbal interaction and social pressure. teachers are required to reinforce the learning related to the intervention as part of regular classroom activities. in order to investigate the effect of the ccr on peer attitudes towards cws, an outcomes measure called the ‘stuttering resource outcomes measure’ (srom) was developed and validated (walters, 2014). however, before a new intervention is adopted, it is imperative that it is assessed for potential benefit as part of a feasibility study (thabane, et al., 2010). the main objective of this study was to ascertain if there was potential treatment benefit of the ccr intervention in improving peers’ attitudes towards cws one month post-intervention. a further study currently in progress will examine the treatment benefits at 6 months post-intervention. together, these studies will inform the feasibility of a larger randomised control trial (rct). there is a dearth of studies which assess the benefits of classroom interventions for stuttering. the literature available in this area is mainly on the tab and its development. a recent study by langevin and prasad (2012) was the only study to determine the treatment benefit of the tab, a classroom-based intervention. they used a pre-test/post-test design to measure attitude changes 3–4 week post-intervention. they reported significant differences between preand post-test scores on their outcomes measure, the ‘peer attitudes toward children who stutter’ (patcs) scale. these results suggested that the tab may be effective in improving peer attitudes towards cws. initial positive changes were observed during the initial period 3–4 weeks post-intervention. (langevin & prasad, 2012). nonetheless, it appears important to address attitudes over an extended period of time to effect real change (whitehead, 2001). it is also possible that attitudes may not shift or perhaps worsen when learners do not respond positively. therefore, it is critical to determine the direction of change as a way of assessing the intervention effect. the magnitude of change is also useful to observe. however, because this study is examining change at one month post-intervention, the magnitude of change may not be clearly evident. historically, research suggests that gender may influence peer attitudes towards cws. however these results have been inconclusive (wiesel & spektor, 1998; dietrich et al., 2001; langevin, kleitman, packman et al., 2009). more recently, st. louis (2012) also confirmed that research on the influence of gender on peers’ attitudes towards stuttering was inconclusive. as a secondary objective this study therefore examines how male and female participants compare in their attitudes towards cws before and after intervention. a further secondary objective of this study is to ascertain how individuals who are exposed to stuttering compare to those who do not have direct exposure. langevin & hagler (2004) reported that children with no prior exposure to stuttering typically have less positive attitudes compared to their peers who have exposure. this study adds to the limited body of literature on the issue of exposure and attitude change. methodology top ↑ objectives primary objective to determine if participants’ attitudes towards cws change in direction and magnitude one month after the administration of the classroom communication resource (ccr) intervention. secondary objectives to determine if the changes in attitudes were influenced by the participants’ gender. to determine if the changes in attitudes were influenced by the participants’ previous exposure to a person who stutters. study design this study used a cluster randomised control trial design. this design allows for identification of cause and effect relationships within a controlled environment (leedy & ormrod, 2005), whilst striving for equivalence of groups prior to implementation of the intervention (lindegger, 2006). as this was a preliminary study to assess potential benefit of the intervention, the sample size could not be exactly calculated given that the cluster effect was not known at this stage of the study. therefore, whilst the design elements were aligned with that of a randomised control trial, it was not the intention of the study to make conclusive statements about whether the treatment effects were significant or not. instead, the intention was to observe the potential treatment effect. the stuttering resource outcomes measure (srom) was administered to both the experimental and control groups preand post-intervention. the intervention, the classroom communication resource (ccr) was only administered to the experimental group, as suggested by creswell (2009), whilst the control group did not receive the intervention during the study period. participants in south africa, schools fall within five (5) quintiles based on the national poverty distribution table, with quintile 1 representing the lowest socio-economic strata and quintile 5 the highest (department of education, 2008). whilst this study drew learners from quintiles 2 and 3 (lower quintiles), the larger study drew learners from the remaining quintiles so that the overall sample was drawn from across school quintiles. inclusion criteria the participants were required to be grade 7 learners, in mixed gender classes from english dual-medium schools in cape town, falling within quintiles 2 and 3 on the national poverty distribution table. learners were also required to have adequate english literacy skills to complete the questionnaire, the srom. exclusion criteria learners from schools that had on-site speech therapy services and learners from schools that have previously participated in similar studies (prior to 2013) were not included in the study. sample size according to lenth (2001), a sample of sufficient size is necessary to yield statistical significance in randomised control trials. however, given that this was an initial study, the sample size estimate was based on the number of participants who could be recruited into the study within the capacity of the research team. the intention was to recruit a sample size that would exceed 192 participants, a sample size which would be larger than previous undergraduate studies. this rationale was informed by the mean observed difference between the experimental and control groups in the studies which developed the ccr. using this power analysis as a guideline, this study recruited 211 participants, with 97 in the experimental and 114 in the control group. of this total sample, 108 were males and 103 were females. the majority of participants (197) reported to have been previously exposed to people who stutter, whilst 44 reported no previous exposure. the average age of participants was 13 years. cluster randomisation design was applied with schools as the unit of cluster. a list of all the schools in cape town was obtained from the western cape education department (wced). from this list, only those schools that fell within quintiles 2 and 3 on the national poverty distribution table and those that were english dual-medium were considered part of the sampling cluster. three schools (schools a, b and c) were randomly selected and randomised to either the experimental or control group. although the classrooms were used as the unit of intervention, it was necessary to randomise schools rather that classrooms to prevent contamination effect (lindegger, 2006). two schools were assigned to the experimental group, whilst the control group comprised of one school. from these schools, the necessary sample size of participants that met the selection criteria was able to be obtained. method of recruitment three schools were contacted telephonically and then in person to invite them to participate in this study. written permission from the principals and grade teachers was obtained. informed consent was obtained from the participants’ parents and assent was attained from the participants themselves. research instruments and their validity and reliability stuttering resource outcomes measure (srom): the srom is a questionnaire based on the patcs. it measures peer attitudes toward children who stutter through the use of a five-point likert scale. the original 36 items of the patcs were reduced to 20 items in order to decrease the amount of time needed for administration (badroodien et al., 2011; de freitas et al., 2012; de grass et al., 2010). the 20 test items have been selected and adapted to be an accurate reflection of the three content areas of the patcs (‘positive social distance’, ‘social pressure’ and ‘verbal interactions’; langevin, 2009). ‘positive social distance’ is defined as the general degree of acceptance or comfort peers display in the presence of cws; ‘social pressure’ is concerned with what peers think about cws; and ‘verbal interaction’ taps into aspects of frustration or annoyance through interaction with cws (langevin, 2009). in addition, the items were culturally and linguistically adapted to the south african context. this validated measure (walters, 2014) was used in this study. classroom communication resource (ccr): the ccr is a classroom-based stuttering resource. it aims to increase peers’ awareness about communication disorders, stuttering in particular, as well as to improve negative attitudes. the revised ccr consists of two parts. in the first part, information is provided to teachers to explain the nature of stuttering and the aim of the resource as well as guidelines on how to manage a child who stutters in the classroom. the second part of the ccr outlines the administration guidelines and contains the actual classroom resources, namely a social story, a role play and class activities and discussions. this revised intervention tool was used in the current study. ethical considerations prior to the study being conducted, permission was obtained from the faculty of health sciences human research ethics committee and the western cape education department (wced). ethical research ensures that the rights of the participants involved are preserved through the ethical principles of autonomy, confidentiality, beneficence, non-maleficence and justice, as stated in the helsinki declaration (williams, 2008) data collection the data-collection process occurred in three phases:phase 1:pre-intervention phase. both the experimental and the control group were shown a video clip of a child who stutters and provided with a definition of stuttering. in this way, all participants were expected to have an understanding of stuttering as the focus of intervention. before data collection, the researchers split into two groups for data collection and data analysis. in this way, the researchers who analysed the data could not distinguish between the experimental and control group. this blinding procedure is recommended for randomised control trials, and was thus utilised in this study (lindegger, 2006). the pre-intervention srom was then administered to all participants in experiment and control groups by the researchers. unrelated practice items were provided so that participants could familiarise themselves with completing a questionnaire using the likert response format. the researchers were available to clarify any questions the participants have regarding their understanding of items. participants completed the srom, selecting the responses that were most applicable to them. prior to the intervention the researchers conducted a thirty-minute training session with the experimental group teachers to discuss the aims and administration of the ccr. teachers were equipped with the ccr booklet, guidelines on how to use and administer the ccr, as well as strategies to manage stuttering in the classroom. phase 2:intervention phase. during the intervention phase, the ccr was administered by the grade teachers to the experimental group only. the control group did not receive the ccr during the study period. the researchers observed the administration process so as to ensure that the classes received similar administration of the ccr. following the administration of the ccr, teachers were reminded about the strategies that could be used to reinforce the discussion based on the srom to promote positive attitudes during the one month time interval between preand post-testing. phase 3: post-intervention phase. in the post-intervention phase, the srom was re-administered to both the experimental and the control group one month post administration of the ccr in order to measure changes in attitudes (if any) towards cws. the researchers furthermore provided teachers with strategies to sustain any positive behavioural changes that might have occurred. whilst the researchers were aware of the limitations of using the same measure as the post-test measure, there was no equivalent additional measure that was considered suitable. therefore, the srom was used as the only outcome measure. a six month follow-up will be conducted on both the experimental and control group. after this, the control group teachers will be trained on administering the ccr and the control group will receive the intervention. a summary of the research process is in appendix a and appendix b. analysis of data top ↑ the researchers themselves undertook preliminary analyses of the data, whilst a statistician checked the results and conducted more in-depth analyses. a score was allocated for each response on the srom, with the response ‘strongly disagree’ reflecting a score of -2 and the response ‘strongly agree’ a score of 2. the response ‘not sure’ corresponded with a score of 0. all negatively worded items were reverse scored. the total scores obtained on the srom were used for data analysis. the minimum total score obtainable was -40, reflecting a negative attitude, whilst the maximum was 40, indicating a positive attitude. the reliability in terms of internal consistency of items on the srom was confirmed using cronbach's alpha. descriptive statistics were used to analyse the srom total scores in both the pre-test and post-test periods for the experimental and control group participants. in particular, the range, mean and standard deviation of total scores were analysed in terms of differences in mean total scores between groups (experimental vs. control), gender (male vs. female) and exposure (yes vs. no). inferential statistics were used to determine the effect of the intervention. for this, the distribution of the total score was assessed both visually on a histogram and by means of the shapiro-wilk's test, which evaluates normal distribution of a sample (panik, 2005). results were found to be adequately normally distributed. thus, analysis of variance (anova) was used to determine whether a statistically significant difference in attitudes (as measured by the srom) was observed between groups (experimental vs. control), gender (male vs. female) and exposure (yes vs. no). however, given the limitations of the sample size, the results cannot be regarded as conclusive (see table 1, table 2 and figure 1). figure 1: pre-test and post-test scores experimental and control group. table 1: total score by group, gender and exposure; pre-test vs. post-test. table 2: a summary of the anova results when analysing group, gender and exposure over the pre-test and post-test. results top ↑ treatment effect the primary objective of this study was to observe if participants’ attitudes towards cws change in direction and magnitude one month after the administration of the classroom communication resource (ccr). during the pre-test, the experimental group had a statistically significant higher average total score than the control group (f(df = 1) = 4.34; p = 0.0379). the significance level was set at α = 0.05, which represents a confidence level of 95%. the average total score of the experimental group was χ = 9.51 (σ = 14.10), whilst that of the control group was χ = 7.96 (σ = 11.96). based on this result, it can be inferred that the experimental group began with more positive attitudes towards cws than the control group pre-intervention. the high standard deviations in both groups, however, indicate that individual total scores were spread over a large range. in the experimental group, total scores ranged from -25 to 40; in the control group, the range was from -32 to 34. in the post-test the experimental group again had a statistically significant higher average total score than the control group (see table 2). the average total score of the experimental group was χ = 12.22 (σ = 13.42), whilst that of the control group was χ = 8.32 (σ = 13.95). within the experimental group, there was a higher post-test average total score than pre-test, reflecting a shift in scores in a positive direction. however, the magnitude of the shift was not found to be statistically significant (f(d.f. = 1) = 1.23; p = 0.2683; α = 0.05). nonetheless, the pre-test average total score (χ = 9.51, σ = 14.10) increased by 2.71 to an average total score of χ = 12.22 (σ = 13.42) during the post-test period. in the control group there was no statistically significant change between the pre-test and post-test scores (see table 2). although the average total score during the pre-test period (χ = 7.96, σ = 11.96) increased to χ = 8.32 (σ = 13.95) during the post-test period, this increase was minimal (mean shift = 0.36) and not found to be statistically significant. given that the results of the experimental group changed from pre-test to post-test scores whilst that of the control group did not change significantly, it can be inferred that the intervention had a positive effect but not a significant effect one-month post-intervention (see figure 2). figure 2: mean shift in item average total scores of the subscales of the srom between pre-test and post-test: experimental group. the mean shift scores from pre-test to post-test for the experimental group indicated that the shift occurred predominantly in the positive social distance subscale compared to the verbal interaction and social pressure subscales (see figure 3). figure 3: pre-test and post-test scores for male and female participants. gender effect in the pre-test scores, there was no difference in attitude between males and females (see pre-test gender means, table 1). in the post-test period, males showed a slightly greater positive shift in attitude than females. however, this difference was not found to be statistically significant (f(df = 1) = 0.03; p = 0.8643; α = 0.05). post-intervention, males had an average total score of χ = 10.55 (σ = 13.97), whilst the average total score for females was χ = 9.66 (σ = 13.71). the standard deviations for both males and females post-test indicate that there was individual variation in each of these groups. nonetheless, these results indicate that gender did not have a significant effect on participants’ attitudes towards cws (see figure 4). figure 4: pre-test and post-test scores for participants who had exposure/no exposure to stuttering. exposure to stuttering on the srom pre-test, participants who were previously exposed to stuttering had more positive scores than participants with no exposure (f(df = 1) = 12.58; p = 0.0004; α = 0.05). the average total score for participants with exposure during pre-test was χ = 9.62 (σ = 13.23), whilst that of participants with no exposure was χ = 5.07 (σ = 11.42). during the post-test, this trend did not change; participants with previous exposure continued to show a statistically significant more positive scores than those without previous exposure (see table 2). in addition, post-test results showed that scores for participants with exposure were higher than during pre-test, whilst those in participants without exposure remained the same post-intervention. whilst the average total score of participants with exposure increased to χ = 11.47 (σ = 13.71) post-intervention, that of participants without exposure decreased slightly to χ = 4.95 (σ = 13.09) post-intervention. overall, results indicated that previous exposure to individuals who stutter has a positive effect on participants’ attitude towards cws during both pre-test and post-test and that the intervention has a positive impact on the previously exposed group compared with the group that had no exposure at one month post-intervention. discussion top ↑ treatment effect the results indicated positive scores in participants in the experimental group pre-intervention as compared to the control group. this difference may have occurred, as participants from the experimental group were from a different school than those of the control group. although these schools were from similar areas in cape town, schools themselves are likely to be different and therefore may display varied attitudes. for example, schools may vary in the emphasis they place on issues of teasing and bullying. the strength of randomisation in the research design is that it is aimed at ensuring that each participant has an equal chance of being in experimental or control groups, thereby reducing the selection bias (lindegger, 2006). groups also differed from each other post-intervention, with the experimental group again showing statistically significant more positive scores than the control group. within the experimental group, the difference in average total scores between the pre-test and post-test period was 2.71. although this difference was not found to be statistically significant with regard to the magnitude of the shift, the ccr appears to influence the change in attitudes in a positive direction. overall, standard deviations were high in the experimental and control groups, indicating variation amongst participants. the treatment effect may have been influenced by the time period. the post-test administration of the srom occurred one month after the intervention of the ccr. although langevin and prasad (2012) found a statistically significant difference in attitude over the same time period (i.e. 3–4 weeks), their intervention was more intensive than the ccr. the tab intervention was provided on six occasions within the time period, as opposed to the current study which only provided an intervention on one occasion, i.e. a single dose of the intervention. other research conducted by the national disability authority (2006) suggests that this time period may be too short to effect statistically significant attitude change. attitude changes usually occur over longer periods of time and can take up to a few years. the results of the current study suggest that an attitude shift is beginning to occur in the experimental group. more time may be necessary to observe a greater shift in positive attitudes towards cws. a follow-up study aiming to investigate the influence of the intervention after a six month interval may show further trends in attitude changes. the sample size of the experimental group may have been too small to observe a significant difference in attitude in this study. the experimental group in this study consisted of 97 participants. the langevin and prasad study (2012) observed significant effects on a sample of 608 participants. a larger sample size in an rct may therefore be helpful in observing changes with greater clarity. the results of the subscale analysis may also help to understand which aspects of attitude shifts occurred post-intervention. the subscale ‘positive social distance (psd)’ showed the greatest positive shift compared to the social pressure and verbal interaction subscales. items from the psd subscale, for example (‘i would like having a child who stutters live next door to me’) refers to neighbourly relations, which may indicate that the ccr has begun to effect attitude change amongst peripheral relations. the same can be argued for ‘i would let a child who stutters hang out with us’ as psd is linked to how comfortable the peer is around a cws (langevin et al., 2009). the intervention appeared to have a positive impact on social acceptance. the other two subscales showed less positive shifts after intervention. ‘social pressure (sp)’ showed limited improvement and a slight negative shift in items such as ‘i would not go to the shop with a child who stutters.’ sp is linked to how one feels about what other peers think about cws (langevin et al., 2009). the ‘verbal interaction (vi)’ subscale showed the least positive shift in attitudes overall. vi reflects feeling of frustration when communicating with cws, for example ‘children who stutter should not play games that involve talking’ (langevin et al., 2009). the results at this stage of the study suggested that the ccr brought positive shifts in social acceptance of participants but not yet in levels of frustration during communication with cws. since the shift in the experimental group is comparatively larger than that of the control group, the positive shift may possibly be attributed to the effects of the ccr on the experimental group. this result was consistent with findings by langevin and prasad (2012) which showed that participants had more positive attitudes towards cws following the implementation of tab intervention. however, before an rct is considered, the results of the six-month post-intervention measure should be considered. particularly, the negative effect must be monitored carefully, as raising awareness could also have negative effects if not managed carefully. exposure the results indicated that exposure to stuttering has an effect on peers’ attitude towards cws; a statistically significant more positive attitude towards cws was noted in participants with previous exposure. the literature points towards a positive effect of exposure on attitudes. children who have been exposed to stuttering may have a greater sense of empathy and understanding of cws (wiesel & spektor, 1998). this would positively affect their perception and attitudes towards cws. the higher post-test score for participants with exposure may indicate the potential of the ccr to improve existing positive attitudes. no change was observed between pre-test and post-test for those with no previous exposure. this result may indicate that a longer time period may be necessary to effect attitude change in individuals who have not been exposed to this communication disorder. contrary to this study, langevin and prasad (2012) found that children who did not know someone who stutters had higher change scores on their outcome measure compared to those exposed to stuttering. they suggested that the tab could mobilise children who have not had previous exposure to stuttering to support their peers who stutter. although no changes were noted in the current study in participants with previous exposure to stuttering, the ccr may still be a tool to increase awareness of cws and reduce associated teasing and bullying. the results of this study point to the need for a closer examination of exposure to stuttering at 6 months post-intervention. gender results indicated that gender did not have an effect on peers’ attitude towards cws. the study by langevin and prasad (2012) showed no significant effect of gender on peer attitudes towards cws. the results of the current study are consistent with this last finding, indicating that gender may not be a factor that influences attitudes towards cws. therefore, it may not be a variable to pursue in a further study unless the observation changes at 6 months post-intervention. limitations of the study after completing this segment of the study, some limitations were brought to light. the main limitations include: the srom being the only measure of attitude change. participants were of diverse linguistic backgrounds and had varied english language proficiency, which might affect their performance on the srom. although the researchers took all available steps to ensure that the items were understood, this factor remains an area of concern. the sample size in the experimental group was smaller than the experimental group due to absenteeism which was beyond the control of the study. clinical implications the findings of this study point to the potential effect of the ccr as an intervention which can facilitate positive attitude change. the study raises awareness of the importance of a focus on changing negative attitudes of peers towards cws, in south africa. whilst clinicians commonly work on an individual basis with children, their attention is directed to the impact of negative attitudes of peers. this intervention provides insights into classroom-based interventions as a possible strategy for intervention. furthermore, in a context like south africa, as well as other contexts where under-resourcing is a common problem (kathard & pillay, 2013), therapists can include teachers as intervention partners as a strategy to reduce negative attitudes towards peers who stutter. the study also highlighted that participants who were exposed to children who stutter had more positive attitudes compared to their peers who were not exposed. therefore, it is vitally important that therapists encourage children in classrooms to interact with cws – in close proximity activities to facilitate exposure as a strategy to reduce negative attitudes. recommendations for further research as this was a small scale study which considered attitude changes at one month post-intervention, it is essential that attitudes changes in further studies are considered over a longer term period in lower quintile schools. a further study examines attitude changes in higher quintile schools (walters, 2014). a further large-scale study must consider cluster effect to determine the appropriate size of the sample of a future rct. it is envisaged that further studies would require larger samples to accommodate the cluster effect. further studies should seek to determine the clinical significance of findings. whilst this study focused on the statistical significance, a further investigation could consider literature guidelines and clinician guidelines for what can be considered clinically significant results in classroom-based interventions such as the ccr. conclusion top ↑ the results in this study at one month post-intervention indicated a positive shift direction in treatment effect, indicating improved attitude towards cws in participants of the experimental group as compared to the control group. the magnitude of the attitude change was not statistically significant. gender did not appear to influence participants’ attitude towards cws. previous exposure to stuttering had a significant positive effect on participants’ preand post-test attitudes to cws. this study concluded that treatment effect of the ccr was small but positive at one month post-intervention, warranting further study. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions h.k. (university of cape town) was the primary investigator and first author. f.w. (university of cape town) and f.c-s. (university of cape town) contributed to the development of the study and are senior authors of this article. k.f. (university of cape town), t.m. (university of cape town), m.r. (university of cape town), r.s. (university of cape town), j.w. (university of cape town), n.z. (university of cape town) and a.z. (university of cape town) planned and executed the study and contributed actively to writing the article. references top ↑ badroodien, r., bielovich, j., lilienfeld, s., naiker, p., stevens, m., & weavind, j. (2011). changes in peer attitudes towards children who stutter after the administration of a classroom communication resource. unpublished undergraduate thesis, university of cape town, south africa. creswell, j. 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(2008). the declaration of helsinki and public health. bulletin of the world health organization, 86, 650–652. http://dx.doi.org/10.2471/blt.08.050955 yaruss, j.s. (2007). application of the icf in fluency disorders. seminars in speech and language, 28, 312–322. http://dx.doi.org/10.1055/s-2007-986528 appendix: a top ↑ the items of the srom according to subscales appendix b: top ↑ flowchart procedure abstract background methods results discussion conclusion acknowledgements references footnote appendix 1 about the author(s) karin joubert department of speech pathology and audiology, university of the witwatersrand, south africa ndlovu wits audiology clinic and outreach programme, south africa donna botha department of speech pathology and audiology, university of the witwatersrand, south africa private practice, edenvale, south africa citation joubert, k., & botha, d. (2019). contributing factors to high prevalence of hearing impairment in the elias motsoaledi local municipal area, south africa: a rural perspective. south african journal of communication disorders, 66(1), a611. https://doi.org/10.4102/sajcd.v66i1.611 original research contributing factors to high prevalence of hearing impairment in the elias motsoaledi local municipal area, south africa: a rural perspective karin joubert, donna botha received: 17 sept. 2018; accepted: 03 dec. 2018; published: 20 feb. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: there is evidence that the factors contributing to the prevalence and aetiology of hearing impairment vary widely from one country to another. in south africa, as in other low-income and middle-income countries, more context-specific information on the estimated prevalence of hearing impairment and the factors that contribute to its onset is required. aim: the aim of this study was to provide decision-makers and hearing health professionals with local and accurate information on the prevalence of ear and hearing disorders in the elias motsoaledi local municipal (emlm) area of the limpopo province, south africa. methods: the world health organization (who) protocol for population-based surveys of prevalence and causes of deafness, hearing impairment and other ear diseases was utilised. a random multi-stage cluster sampling strategy, two-stage sampling, was utilised to select the seven municipal wards and 357 households through the probability proportional to size method. a total of 850 participants were included in the study. results: the overall prevalence of hearing impairment was 19.88% (95% confidence interval [ci]: 0.15–0.2) and 8.94 (95% ci: 0.08–0.12) for disabling hearing impairment. the prevalence of ear disease was 13.19% (95% ci: 0.10–0.15), with impacted cerumen and otitis media reported most often. associations with hearing impairment were established for age, gender and hypertension. conclusion: the study has shown a higher prevalence of disabling hearing impairment in the rural emlm area of the limpopo province compared to global prevalence rates. in addition, known factors associated with hearing impairment were confirmed. background the devastating consequences of disabling hearing impairment1 for interpersonal communication, psychosocial well-being, economic independence and quality of life, irrespective of age of onset, are well documented in the literature (olusanya, neumann, & saunders, 2014; wilson, tucci, merson, & o’donoghue, 2017). global estimates indicate that the prevalence of disabling hearing impairment has increased from 5.73% in 2005 to 6.12% in 2018 (who, 2018). the years lived with disability (yld) are high, as for disabling hearing impairment, the estimated yld was 4.49% of the total ylds because of all causes in 2015. hearing impairment, now ranked as the fourth leading contributor of yld, has thus become a major global health concern (wilson et al., 2017). several factors contribute to the increased global prevalence estimates of disabling hearing impairment. most notable is the significant association between hearing impairment and advanced age, which is attributed to increased mean life expectancy in many countries (gbd, 2016; lin, thorpe, gordon-salant, & ferrucci, 2011; olusanya et al., 2014; world health organization [who], 2018; wilson et al., 2017). the improvement in the technology used for the early detection of hearing loss as well as the widespread use of ototoxic medications (e.g. for treatment of cancer, human immunodeficiency virus [hiv] and tuberculosis) are further cited as contributing factors (who, 2018; wilson et al., 2017). exposure to damagingly loud sounds (e.g. via occupational and recreational noise exposure) is also a growing concern (who, 2018). other risk factors for hearing impairment (from prenatal through to adulthood) are outlined by olusanya et al. (2014). approximately 50% of hearing impairment can be prevented and most of the remainder can be treated successfully (who, 2017; wilson et al., 2017). depending on the cause of hearing impairment, the treatment may include surgical and medical management, hearing aids, cochlear implants and other assistive listening devices. to prevent the onset of disabling hearing impairment and mitigate the impact of non-preventable hearing impairment (such as presbycusis) on the individual, family and society at large, improvements in the prevention thereof are imperative. the causes of hearing impairment, however, vary widely from one area to another (e.g. district, province and country) (wilson et al., 2017). prevention can thus only be effective if there is thorough understanding of the prevalence and aetiology of hearing impairment in a specific population. the available estimates of the prevalence of hearing impairment and causes thereof in low-income and middle-income countries are limited (who, 2018), despite the fact that more than 80% of the people with disabling hearing impairment live in these countries (who, 2012). the findings of who ear and hearing surveys conducted in a variety of developing countries at provincial or subnational levels indicate that the prevalence of disabling hearing impairment ranges from 2.07% to 9% (pascolini & smith, 2009). in south africa, a middle-income country, the estimated prevalence of hearing impairment is based primarily on information obtained from the national census data (ramma & sebothoma, 2016). hearing impairment is the third highest reported disability after visual impairment and physical disability in south africa (statistics south africa, 2012). additional information obtained regarding the prevalence and causes of hearing impairment across the lifespan is available; however, the majority of these small-scale studies were conducted in urban areas and/or within the private healthcare sector (joubert, sebothoma, & kgare, 2017). one of the first population-based surveys conducted in cape town, an urban metropolitan area in south africa, reported a 4.57% estimated prevalence of disabling hearing impairment (ramma & sebothoma, 2016). to reduce the burden of hearing impairment, the implementation of context-specific and targeted prevention programmes is vital. however, limited information is available on the prevalence and causes of hearing impairment as well as factors that contribute to the prevalence of thereof in the underserved, rural areas of south africa (joubert et al., 2017). the aim of this study was thus to provide decision-makers and hearing health professionals with local and accurate information on the prevalence of ear and hearing disorders in the elias motsoaledi local municipal (emlm) area of the limpopo province, south africa. the objectives were to determine the prevalence of and factors associated with hearing impairment in this area. methods a cross-sectional population survey design was used to determine the prevalence of hearing impairment and auditory pathology in the emlm area of the limpopo province. the ear and hearing disorders survey protocol (who, 1999) and an adaption of the who ear and hearing disorders examination form–version 8.3 (appendix 1) were used to generate standardised data which allow for comparison among surveys conducted in different countries and regions (ullauri et al., 2014). this form includes five areas: demographic information, hearing examination, basic ear assessment, cause of ear disease or hearing impairment and action needed. context the emlm area located in the southern part of the limpopo province forms part of the sekhukhune district, the second poorest district in south africa (health systems trust, 2017). the emlm has 30 municipal wards with an estimated population of 249 363 residing in 60 200 households with an average household size of four individuals (statistics south africa, 2012). this predominantly rural area is characterised by poor infrastructure, lack of safe water supply, high unemployment rates and low education levels (health systems trust, 2017). participants sampling strategy a random multi-stage cluster sampling strategy, two-stage sampling, was utilised to select the clusters (municipal wards) through the probability proportional to size (pps) method. the first stage entailed the random selection of seven clusters using a rural sampling frame. this resulted in the exclusion of five wards (e.g. those where the two major towns were situated and those with a large number of residents). the second stage involved the selection of households by dividing the total number of households in the five selected wards by the total number of households to be tested. this indicated that every 35th household in each of the selected wards was to be included in the survey. the total number of households in each selected ward was divided by 35 in order to determine how many households to visit in each ward. in cases where the individuals in the selected households declined participation, the research team visited the household to the left of the household that refused. sample size the required sample size of 1428 participants was based on the 10% estimated prevalence of disabling hearing impairment with precision of 3.4% (confidence interval [ci]: 95%) (oishi & schacht, 2011). the final sample size included 357 households and 850 individuals from the selected households (59% of the proposed sample size). all individuals living in the selected households who gave consent and/or assent to participate were included in the study. the smaller than anticipated sample size can be attributed to the absence of many individuals (mostly men) on the day of the visit. these individuals were reportedly elsewhere because of work commitments. only a small number of participants refused to participate in the study, citing time constraints and prior commitments as the reasons for refusal. participant description the majority of participants (54.71%, n = 465) were between 15 and 64.11 years of age (table 1). the unequal gender distribution could be attributed to the fact that in rural communities, men are more likely to work in more urban areas where the likelihood of finding employment is higher and as migrant workers, only returning home once a month, over long weekends or holidays (food and agriculture organisation, 2014). table 1: distribution of participants by age and gender (n = 850). research team the research team consisted of four individuals: a qualified audiologist with 2 years’ clinical experience in the public healthcare sector and three research assistants. the research assistants were members from the study community and fluent speakers of the indigenous languages spoken in the area. the research assistants all completed grade 12, and had previous experience in interpreting and conducting research through their involvement with a non-governmental organisation. two of the research assistants had previous training and experience in performing hearing screening prior to their participation in the data collection for the current study. the research assistants received comprehensive training prior to the commencement of the study on the purpose of the study, how to approach households, obtaining informed consent, biologic calibration and use of equipment, accurate completion of the data collection forms, infection control and reviewing the maps of the areas where data collection took place. all research assistants signed confidentiality agreements after training and prior to data collection. pilot study a pilot study was conducted in a randomly selected ward in the same area to refine the study protocol. households were selected as per the sampling strategy and potential participants informed about the study in their home language. forty participants from nine households (average household size was 4.4 individuals) were included in the pilot study after giving written consent and/or assent. the same steps as outlined in the main study were followed and the study protocol completed with each participant. data collected from these participants were not included in the main study. the majority of participants were female (65%; n = 26). the mean age of pilot study participants was 17.6 years (1 month – 62.4 years; ±19.98). following the pilot study, the role of the research assistants expanded to include pure tone audiometry and automated auditory brainstem response (aabr) screening (with the interpretation of testing findings made by the researcher). in addition, the protocol for entry into the households was changed to first approach the house to explain the purpose of the study and to determine equipment needs (based on the ages of individuals in the household). this was more practical as the houses were too small to accommodate the research team and all the equipment. assessment procedures and equipment average ambient noise level measured during testing was 55.53 dba (±2.5) (bruel & kjaer 2239 type ii integrating sound-level meter). no statistically significant relationship between the level of ambient noise during testing and different degrees of hearing impairment was found (independent samples t-test). once pertinent case history information was obtained, an otoscopic examination (welch allyn otoscope) was conducted. the study protocol for participants younger than 4 years included distortion product otoacoustic emissions (dpoaes) (otoread), tympanometry (titan) and aabr (maico mb11). for participants older than 4 years, tympanometry (titan) and pure tone audiometry (as608 screening audiometer) were conducted. the screening results were recorded on the ear and hearing disorders survey form. data collection procedures once ethical clearance for the research study was obtained from the human research ethics committee (medical) of the university of the witwatersrand (protocol number: m130238) and permission granted by the limpopo department of health and social development, data collection commenced. community entry was made through permission sought from ward councillors and tribal authorities (e.g. village chiefs) prior to entry into the selected wards. the community was informed of the study by announcing the research project on moutse fm, the local radio station. the research team visited each selected household and if permission was granted to enter the household, each individual was presented with the participant information sheet (if age appropriate) and the study was verbally explained to them. the participants were fully informed of the nature of the study and assured of confidentiality and their rights to withdraw from the study at any time without negative consequences. only participants who gave written consent and/or assent were included in the study. the audiometric assessment was conducted as per the study protocol and participants who required ear and hearing health care were referred to their nearest health facility. all completed survey forms were verified for completeness by the audiologist and data transferred onto an excel spreadsheet by the audiologist. reliability and validity non-random errors were minimised as research assistants received comprehensive training on the study protocol under field conditions and had access to the comprehensive training manual throughout the study. the routine audiological test procedures used in the study are all valid measures with high sensitivity and specificity. all the equipment used in the study was calibrated prior to the start of the study (sabs 0154-1; 0154-2). daily listening checks and biological calibration were performed before each data collection session. the audiologist accompanied the research assistants on all visits and completed the same data collection forms as the assistants to determine the inter-rater reliability. inter-rater agreement was 100%. data analysis sas version 9.3, a statistical software programme, was used to conduct data analysis. descriptive statistics used included measures of central tendency and variability. an independent t-test (p = 0.05) was used to determine the relationship between ambient noise levels and hearing thresholds obtained. binomial proportion confidence intervals (p = 0.05) were used to estimate the probability (odds) of hearing impairment. the relationship of various factors associated with hearing impairment was analysed with binomial logistic regression (p = 0.05). ethical consideration approval was granted for this study with ethical clearance number: m130238. results prevalence of hearing impairment the prevalence of hearing impairment (>26 db) in this population was 19.88% (95% ci: 0.15–0.21) (table 2). table 2: proportion of participants with hearing impairment (%) according to gender and world health organization age group categories (n = 191). with the specific classification of hearing loss into various degrees, the prevalence of slight hearing impairment was 10.94% and that of disabling hearing impairment was 8.94% (table 3). the prevalence of moderate hearing impairment was 5.88%; for severe impairment it was 2.24% and for profound hearing impairment it was 0.82%. as expected, the highest prevalence of disabling hearing impairment at 46.48% (95% ci: 0.36–0.53) was found in the >65 year age group. table 3: proportion of participants with hearing impairment (%) per age group (n = 850). because of the nature of the screening measures (dpoae and aabr) used for children 0–3.11 years of age, it was not possible to differentiate between the degrees of hearing impairment. instead, results were recorded as either ‘pass’ or ‘refer’. a ‘pass’ result indicated that they presented with normal middle ear and outer hair cell functioning. only 37.5% (n = 21) of the children in this age group obtained a ‘refer’ result. the majority of these participants were males (57.2%; n = 12). factors associated with hearing impairment the cause of ear disease and/or hearing impairment was reported as per the who classification (who, 1999). the prevalence of ear disease in this population was 13.19% (95% ci: 0.10–0.15), with impacted cerumen as the most prevalent (10%), followed by otitis media (2.48%) (table 4). table 4: types of ear disease according to gender and world health organization age group categories (n = 112). of the participants who presented with disabling hearing impairment (n = 169), the majority (66%; n = 112) reported that the cause of their hearing impairment was unknown (undetermined). table 5: factors associated with disabling hearing impairment. the association between hearing impairment and age, gender, hypertension and use of potentially ototoxic medication (for cancer, tuberculosis and self-reported hiv) was determined. the findings of the current study indicate that age and self-reported hypertension were associated with hearing impairment (table 5). ear and hearing care services required thirty-one per cent (n = 261) of the participants required referrals to the hospital or primary healthcare clinic for further management. whilst the overwhelming majority of these individuals (68%; n = 178) required diagnostic audiometry to confirm the type and degree of hearing impairment, cerumen management was required for 35% (n = 92) and medical management was required for 10% (n = 26) of these participants. discussion a key finding of this study is that the prevalence of disabling hearing impairment in this rural population (8.94%) is higher than the reported global estimate of 6.12% (who, 2018) and other developing countries where the prevalence rates ranged, for example, from 4.7% (in southern vietnam) to 7.6% in nigeria (who, 2012). most notable is the fact that the prevalence rate found in the current study is significantly higher (p < 0.0001) than the estimated prevalence rate (4.57%) reported for the cape town metropolitan area, south africa (ramma & sebothoma, 2016). the high prevalence of ear disease reported in the current study was mainly because of impacted cerumen and otitis media. globally, the prevalence of impacted cerumen varies widely. in the united kingdom, between 2% and 6% of the general population present with cerumen impaction at any given time, whilst the diagnoses of 3.6% of emergency visits for otologic complaints in the united states were impacted cerumen (schwartz et al., 2017). the reported prevalence of impacted cerumen (10%) in the current study is similar to the findings of a population-based survey conducted in brazil, which was between 8.4% and 13.7% (ullauri et al., 2014). hearing loss as a result of cerumen occlusion can range from 5 db to 40 db depending on the degree of canal occlusion (schwartz et al., 2017). although otitis media is a common condition, only 2.48% of the population in this rural area presented with otitis media as confirmed with otoscopy and tympanometry. this rate is lower if compared to the rates reported globally (11%) (who, 2018) as well as in other developing countries such as sri lanka (9%), myanmar (8%), brazil (6.8%), vietnam (5.99%) and india (6%) (beria et al., 2007). residents in the rural community studied were not exposed to the typical high risks for otitis media, such as living in overcrowded households (average household size is 4.4) and lack of hygiene (copley & friderichs, 2010). various factors are reported to contribute to the increased global prevalence of disabling hearing impairment (gbd, 2016; lin et al., 2011; olusanya et al., 2014; who, 2018; wilson et al., 2017; ramma & sebothoma, 2016). in the current study, the main factors associated with disabling hearing impairment were age, gender and a self-reported history of hypertension. the significant association between disabling hearing impairment and advanced age is well reported (lin et al., 2011; who, 2018; wilson et al., 2017). although age-related hearing impairment is not preventable, the impact thereof on interpersonal communication, psychosocial well-being and quality of life can be mitigated by early identification and appropriate management. the current study further supported the hypothesis that there is an association between cardiovascular disease and disabling hearing impairment (ramma & sebothoma, 2016; rosenhall & sundh, 2006; solanki, 2012). a systematic review of the literature correlated cardiovascular disease to low-frequency hearing loss, especially in women (rosenhall & sundh, 2006). a recent south african study reported low-frequency hearing impairment in 5% of individuals between the ages of 40 and 55 years (n = 92) diagnosed with cardiovascular disease (solanki, 2012). in addition to the factors already discussed, the limited availability of comprehensive ear and hearing care programmes and services is postulated to be a major contributing factor to the high prevalence of disabling hearing impairment in the study population. this study is, to the best of our knowledge, the first study to determine the prevalence of disabling hearing loss in a rural area of south africa. the use of the standardised who ear and hearing disorders survey (who, 1999) allowed for comparisons to be made to other contexts: locally, nationally and globally. the study also has limitations. firstly, as this was a cross-sectional study, it is not possible to establish true cause and effect relationships based on the data. secondly, the use of self-reported diagnosis of cardiovascular disease and hiv may have resulted in an underestimation of the prevalence of these diseases and its effect on hearing. future research to determine the prevalence of ototoxic and noise-induced hearing loss in developing countries as well as the effectiveness of targeted, context-specific ear and hearing care services should be conducted. in summary, our data have shown a higher prevalence of disabling hearing impairment in the rural emlm area of the limpopo province compared to global prevalence rates. in addition, known factors associated with hearing impairment (age, gender and cardiovascular disease) and ear disease (cerumen impaction and otitis media) were confirmed. although ototoxicity and noise-induced hearing loss were not associated with hearing impairment in this population, the importance thereof in causing hearing impairment should not be negated. conclusion the study was successful in providing the decision-makers in the national and provincial departments of health as well as hearing health professionals with information on the prevalence and causes of ear and hearing disorders in this rural area. the findings can be used to plan for and implement more accessible ear and hearing care services that are specifically tailored to the needs identified. the strategies outlined by olusanya et al. (2014) provide a road map for the prevention of hearing loss that can be tailor-made for this community. they suggest that prevention can be carried out at three levels – primary, secondary and tertiary levels – and provide examples of specific activities that can be implemented across the lifespan. following the implementation of improved and more accessible ear and hearing care services in the emlm area, the findings of this study will serve as a baseline for future surveillance studies to monitor performance and determine impact. acknowledgements the authors would like to thank the research assistants for their significant contribution to this study and the oticon foundation for providing funding for this research. the funding organisation had no role in the design of the study; collection, analysis or interpretation of the data; writing of the manuscript; or the decision to publish the results. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contribution k.j. co-conceptualised and designed the study, supervised the project and drafted the manuscript. d.b. was the principal investigator of the study, co-conceptualised and designed the study and reviewed the manuscript. both authors read and approved the final version of the manuscript and have approved its submission for publication. references beria, j. u., raymann, b. c. w., gigante, l. p., figueiredo, a. c. l., jotz, g., roithman, r., … smith, a. 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(1999). who ear and hearing disorders survey: protocol for a population-based survey of prevalence and causes of deafness and hearing impairment and other ear diseases. geneva: world health organization. world health organization. (2012). mortality and burden of diseases and prevention of blindness and deafness: global estimates on prevalence of hearing loss. retrieved from http://www.who.int/pbd/deafness/hearing_impairment_grades/en/ world health organization. (2017). deafness and hearing loss. fact sheet. retrieved from http://www.who.int/mediacentre/factsheets/fs300/en/ world health organization. (2018). addressing the rising prevalence of hearing loss. retrieved from http://apps.who.int/iris/bitstream/handle/10665/260336/9789241550260-eng.pdf?sequence=1 appendix 1: figure 1-a1: world health organization ear and hearing disorders examination form: version 8.3. footnote 1. disabling hearing impairment: hearing loss > 40 db in the better hearing ear in adults and > 30 db in children. article information authors: anita van der merwe1 mia le roux1 affiliations: 1department of speech-language pathology and audiology, university of pretoria, south africa correspondence to: anita van der merwe email: anita.vandermerwe @up.ac.za postal address: po box 70030, the willows, pretoria 0041, south africa dates: received: 09 apr. 2014 accepted: 10 aug. 2014 published: 03 dec. 2014 how to cite this article: van der merwe, a., & le roux, m. (2014). idiosyncratic sound systems of the south african bantu languages: research and clinical implications for speech-language pathologists and audiologists. south african journal of communication disorders, 61(1), art. #86, 8 pages. http://dx.doi.org/10.4102/sajcd.v61i1.86 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. idiosyncratic sound systems of the south african bantu languages: research and clinical implications for speech-language pathologists and audiologists in this original research... open access • abstract • introduction • sound system characteristics and the associated motoric mechanisms    • lexical tone variation    • air stream mechanisms and sound classes    • nature of air stream release    • nasalised consonants    • syllable structure in isizulu and setswana • stimuli selection in research and clinical practice • potential effects of expressive and receptive disorders on communication in speakers of bantu languages    • speech and voice production    • expressive and receptive language    • hearing • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ the objective of this article is to create awareness amongst speech-language pathologists and audiologists in south africa regarding the difference between the sound systems of germanic languages and the sound systems of south african bantu languages. a brief overview of the sound systems of two bantu languages, namely isizulu and setswana, is provided. these two languages are representative of the nguni language group and the sotho group respectively. consideration is given to the notion of language-specific symptoms of speech, language and hearing disorders in addition to universal symptoms. the possible impact of speech production, language and hearing disorders on the ability to produce and perceive speech in these languages, and the challenges that this holds for research and clinical practice, are pointed out. introduction top ↑ speech-language pathologists (slps) and audiologists in south africa have to serve a linguistically diverse population. additionally, slps and audiologists come from different language backgrounds. south africa is a multilingual country with 11 official languages. two of these languages, english and afrikaans, are germanic languages, whilst the remaining nine are south african bantu languages. the bantu languages of south africa belong to the bantu language family which is a single, fairly homogeneous family of languages. the linguistic uniformity of this family of languages was noted by early linguists and, in 1862, bleek (ziervogel, 1967:7) introduced the term ‘bantu languages’ for referring to languages sharing certain linguistic characteristics. the term ‘bantu language family’ therefore refers to a family of languages that shares various linguistic features. between 300 and 600 bantu languages are spoken in large areas of central and southern africa, and are geographically the most widespread language group in sub-saharan africa (guthrie, 1948; herbert, 1990). guthrie (1948) divided the languages belonging to the bantu language family into 16 geographical zones labelled from a–s, with subdivisions within the zones indicated numerically. the south african bantu languages belong to the south-eastern bantu language zone, and more specifically to zone s. within south africa, there are four language groups: the nguni group, sotho group, venda group and tsonga group (cole, 1992; doke, 1967; jacobson & traill, 1986; poulos & bosch, 1997). the focus in this article is on isizulu and setswana. isizulu belongs to the nguni group, and setswana belongs to the sotho group. the subdivisions within the bantu language family in sub-saharan africa are summarised in figure 1. figure 1: language groups found in the south-eastern zone of africa, with special reference to the nguni and sotho sub-groups. the distribution of languages spoken in south africa is reflected in figure 2. isizulu is the most widely spoken; it is the first-language of about 22.7% of the country's population of approximately 50 million people. most isizulu speakers reside in the province of kwazulu-natal. as first-language, setswana is spoken by 8.2%, english by 9.6%, and afrikaans by 13.5% of the population (statistics south africa, 2012). setswana is primarily spoken in the north west province of south africa. according to guthrie's (1948) classification, isizulu is indicated as belonging to zone s. 42, whilst setswana belongs to zone s.30. figure 2: distribution of languages spoken in south africa. the objective of this article is to introduce slps and audiologists who are not first-language african language speakers, to the unique sound systems of isizulu and setswana. many of the sound characteristics to be discussed also apply to other languages from the nguni and sotho groups and to tsonga and venda. the intention is not to present an exhaustive account of the sound systems. for such detail, the reader should consult the relevant references cited in this article, and van der merwe and le roux (2014). the aim is rather to introduce the reader to this topic and to raise awareness of the difference in sound systems of the bantu languages and germanic languages, and to point out some of the research and clinical implications. the ultimate aim is to create awareness of the notion of language-specific symptoms of speech, language and hearing disorders (miller, lowit & kuschmann, 2014). salient features of disorders as portrayed in the literature are mostly based on english language studies. these could be universal language-independent symptoms and may portray signs as they would be presented in a germanic language and in other languages such as the bantu languages. however, the idiosyncratic features of the sound systems of the bantu languages suggest the reality of bantu language specific symptoms. as background to such a statement and its consideration in clinical practice and research, it is firstly necessary to briefly outline the idiosyncratic characteristics of the sound systems of isizulu and setswana as models of the bantu languages. sound system characteristics and the associated motoric mechanisms top ↑ the following discussion focuses on the sound system features that are characteristic of isizulu and setswana, but which are not present in germanic languages. these features are important to take note of as each is phonemic and carries lexical or grammatical meaning. for example, the absence of a specific feature may change a specific phoneme into another phoneme. examples of phonemic differentiation are presented in the following discussion. as slps and audiologists, we have to be aware that an inability to accurately produce these features during speech production will affect the intelligibility of a message. on the other hand, the inability to hear or understand these features will affect the accurate reception of a message. various phoneticians have worked in the field of bantu language phonetics. the information in the following sections and in table 1 was compiled from a number of sources (e.g., cole, 1992; cope, 1983; doke, 1967; poulos & bosch, 1997; taljaard & snyman, 1993; ziervogel, 1967). however, a rich body of literature exists on this topic. table 1: occurrence of specific sound system characteristics in english, setswana, and isizulu. lexical tone variation lexical tone is also referred to as word tone, contour tone or syllabic tone. lexical tone should be distinguished from intonation which is a prosodic feature of germanic languages and of bantu languages. intonation refers to meaningful pitch changes at the sentence level. other prosodic features include speech rate (tempo), stress (loudness) and rhythm (crystal, 2003; zerbian & barnard, 2008). tone, as opposed to intonation, comprises syllable level pitch variations and may distinguish different meanings in phonologically similar words. all bantu languages are tone languages (cole, 1992; doke, 1967; khumalo, 1990; zerbian & barnard, 2008). tone languages use pitch contrastively at the word level to indicate word meaning (wong, perrachione, gunasekera and chandrasekaran, 2009). both isizulu and setswana implement two phonological tones – high tone (h) and low tone (l). these may occur in different combinations in words; for example, hh, ll, hl or lh on bi-syllabic words. tone is apparent on vowels and syllabic consonants. tonal information is not indicated in the orthography of these languages (cole, 1992; doke, 1967; khumalo, 1990; zerbian & barnard, 2008). the following two tswana words illustrate two phonemically similar words that are only distinguished by tone: bó.nà (to see) and bò.ná (they). in these examples, tone is indicated to illustrate the function of tone variation. tone in the first word is hl (or: rising, falling) and in the second word it is lh (or: falling, rising). tone variation is achieved by manipulation of the length of the vocal folds. the physical attribute is fundamental frequency, and the perceptual correlate is voice pitch. the acoustic change results from the state of this single articulator. laryngeal muscle contraction and relaxation, which determine vocal fold tension, must be sequenced to produce pitch variation (zhang, 2008). absence or distortion of tone variation will affect intelligibility. inaccurate tone may render a word as jargon or a substitution with another word. air stream mechanisms and sound classes an exclusively pulmonic air stream is implemented in germanic languages. on the other hand, the air stream utilised during the articulation of the sounds of isizulu and setswana is pulmonic, glottalic egressive, glottalic ingressive or velaric (lingual). the following sounds occur in isizulu and setswana: vowels, plosives, implosives (present in isizulu), ejectives, affricates, trills, fricatives, approximants, nasals and clicks. clicks are characteristic of nguni languages. the different click positions are: dental, palatal and alveo-lateral. consonant clusters do not occur in the bantu languages (cole, 1992; finlayson, jones, podile, & snyman, 1990; ladefoged & maddieson, 1996; zerbian, 2009; ziervogel, 1967). the pulmonic air stream is utilised to produce vowels, plosives, affricates, trills, fricatives, approximants and nasals. these are sounds that occur in both germanic and bantu languages. use of the pulmonic air stream mechanism implies that lung air is pushed through the vocal tract by the action of the respiratory muscles. implosive sounds in isizulu make use of the glottalic ingressive air stream. ejectives in both isizulu and setswana implement a glottalic egressive air stream and are stops that require the larynx to be raised rapidly upwards to increase supraglottal pressure. air above the glottal closure is then released with greater amplitude in the stop burst. the velaric air stream is used to produce clicks (ladefoged & maddieson, 1996:78). a combination of air streams may be used in sounds such as nasalised clicks in isizulu. both the pulmonic and velaric air stream mechanisms are employed: the pulmonic air stream mechanism for articulation of the nasal segment, and the velaric air stream mechanism for articulation of the click component (cole, 1992; ladefoged & maddieson, 1996; zerbian, 2009; ziervogel, 1967). speech production in the bantu languages necessitates alternation between the pulmonic and other air stream mechanisms or the simultaneous control of more than one air stream. nature of air stream release isizulu and setswana speech sounds can be voiced, voiceless or aspirated. in isizulu, sounds can also be breathy-voiced (partial or fully breathy-voiced). aspirated sounds and breathy-voiced sounds are phonemic and can therefore differentiate lexical meaning in isizulu and setswana. in both languages, aspiration is usually indicated in the normal orthography by an ‘h’. for example, in setswana, thaba means ‘mountain’ whilst taba means ‘case’, such as a legal case. aspiration of the sound differentiates these two phonemes (/t/ and /th/). breathy voice is not indicated in the orthography of isizulu, but is phonemic (taljaard & snyman, 1993; van rooy & grijzenhout, 2000). for production of both aspirated and breathy-voiced sounds, a greater rate of airflow than occurs in modal voice is forced through the vocal folds. during aspirated sounds, the arytenoid cartilages may be further apart than during voiceless sounds (ladefoged & maddieson, 1996:48). the term 'breathy voice’ describes sounds that have a high respiratory flow rate and a loose form of vibration of the vocal folds (ball & rahilly, 1999; ladefoged & maddieson, 1996:48, 57). production of both aspirated and breathy-voiced sounds has to be controlled on the level of the vocal folds and by adaptations in the rate of expiratory airflow. the vocal fold movements and airflow manipulation have to be coordinated over and above the diadochokinetic abduction and adduction movements of the vocal folds for voiced and voiceless sounds. nasalised consonants pre-nasalisation or partial nasalisation of sounds are features of isizulu. pre-nasalised or partially nasalised sounds differ from nasal sounds. during nasal sounds, the velum is lowered and air from the lungs is directed out through the nasal passage alone. nasalisation refers to nasal airflow that accompanies oral airflow (ladefoged & maddieson, 1996:102, 118). affricates, plosives and clicks can be pre-nasalised or partially nasalised in isizulu (cope, 1983). production of nasalised sounds requires change of the velar position while maintaining essentially static positioning of the other articulators (ladefoged & maddieson, 1996:118). syllable structure in isizulu and setswana in bantu languages, syllables may consist of a single vowel (v), a single consonant (c) – a syllabic c, or a cv structure. word stems are usually disyllabic, but prefixes and suffixes may be added to represent, for example, a noun class prefix, diminutive, female sex, past tense, passive form of the verb, locative adverbs, or the plural (cole, 1992:52; taljaard & snyman, 1993; snyman, 1989; ziervogel, 1967). isizulu and, to a lesser extent, setswana make use of this conjunctive orthography. conjunctivism refers to the convention of writing different elements of the same word conjunctively, that is, as one word (louwrens, 1994:34). according to cole (1992), the crux is word division and writing of certain groups of syllables conjunctively or disjunctively. the result of the agglutinating nature of isizulu in particular is that words may contain several syllables. what appears to be a single word may in fact be a more comprehensive description with each affix adding meaning to a word stem or root. in table 1, the sound system characteristics of isizulu and setswana are compared with the sound features of english, and information is provided on the number of consonants and vowels and the types of consonants and vowels that occur in these languages. stimuli selection in research and clinical practice top ↑ the brief overview of the idiosyncratic features of the sound systems of two bantu languages highlights the importance of stimuli selection in research and clinical practice. irrespective of our field of research, we have to be aware that the bantu languages contain sound characteristics that do not occur in the germanic languages and that are not in all instances portrayed in the orthographical representation of a word. to the non-bantu language speaker, the latter fact may pose a challenge in research and clinical intervention. consequently, stimuli selection has to be considered carefully. the sound systems of each language or language group differ, and therefore best practice for an individual researcher or clinician is to focus on a specific language or language group and to become familiar with the idiosyncratic features of that particular bantu language or language group. as slps and audiologists, we should involve experts in african languages during the planning stage of research. it is also evident that the mere translation of english assessment protocols is inefficient. there is a dire need for research that could inform clinical practice. the development of stimuli (e.g., word lists) for a particular research project should be driven by the aims of the project. if the aim is, for example, to determine the effect of a particular communication disorder on tone variation, then tone patterns across the different stimuli should be controlled. it is also important to determine if each selected stimulus word is one of a minimal pair in terms of phonemes that occur in the word. orthographically, a minimal pair will appear similar, but the tone pattern will determine the meaning of the word; this is of particular importance if pictures are used to depict a particular word. the development of clinical assessment protocols and stimuli for research purposes is complicated by the absence of a dewey-type index of relative phoneme and syllable frequency and an index of word frequency. the latter does exist for southern sotho. there is an absence of standardised passages or other comparable word lists for reading or other elicitation of speech (jacobson & traill, 1986). jacobson and traill (1986) developed intelligibility word lists for five bantu languages with the aim of assessing intelligibility in speakers with glossectomy. to our knowledge, further research has not been done on these word lists. these lists may prove to be valuable for stimuli selection in different areas of research. regarding the development of speech and language in the bantu languages, a few studies have been published (e.g., maphalala, pascoe & smouse, 2013; naidoo, van der merwe, groenewald & naude, 2005). this line of research needs to be continued in all of the local languages as normative data guide the compilation of assessment protocols and the treatment of children with speech and language disorders. it is important to determine at which age specific sounds and specific sound features are mastered. also, the issues of effective tone variation and the syllable structure of words produced at certain ages need to be determined. as indicated previously, the affixes in words convey meaning, and the ability to add semantically meaningful prefixes and suffixes to word stems at certain ages should be explored. the development and standardisation of articulation assessment protocols and language development assessment protocols for each of the bantu languages spoken in south africa appears to be a necessity and a good starting-point for research regarding speech and language development. all sound features of a language should be represented in the words that are included in articulation assessment protocols. in language assessment protocols, the conjunctive or disjunctive writing style in these languages should be considered. however, to be able to develop such protocols, researchers and clinicians need data regarding communication development. the number and range of studies that need to be done are numerous. a few randomly selected examples of research questions are presented below. the intention of this article is to facilitate awareness of the idiosyncratic features and the need for research in this field, and not to provide an exhaustive account of all possible research topics. the following are examples of research questions that could be addressed in individual studies: at what age does a first-language isizulu-speaking (or setswana-speaking) child start to vary syllabic tone in cvcv words? at what age does a first-language isizulu child start to differentiate between breathy-voiced and modal voiced sounds? what is the order of development of dental, palatal and alveo-lateral clicks in first-language isizulu-speaking children? what is the appropriate syllable structure for words included in assessment protocols at different ages? potential effects of expressive and receptive disorders on communication in speakers of bantu languages top ↑ the sound characteristics of african languages may have very specific implications for speech, language and hearing levels of processing and disorders on these levels. internationally, very few studies have been done to determine language-specific signs and symptoms in languages other than english. reference is made in the following sections to a few studies. as slps and audiologists in south africa, we have to address the issue of language-specific symptoms in addition to universal symptoms of communication disorders. in the following discussion, the potential effects of expressive and receptive disorders on bantu language-specific signs will be considered. almost no research has been done in this field. the possible effects on different disorders, as mentioned in the following sections, are mere predictions and are speculative. the aim of the following discussion is to facilitate research and consideration in clinical practice in the respective fields. speech and voice production the nature and typical signs of speech and voice disorders as described in the literature are largely based on the results of studies using speakers of the english language. the typical signs of these disorders as they present in english may be generalised to other germanic languages, but it is likely that additional signs or idiosyncratic variations of these signs, driven by the sound systems of, for example, the bantu languages, may be present. the study of such symptoms may elucidate the nature of speech disorders (van der merwe & le roux, 2014). an awareness of language-specific symptoms may also better equip clinicians. lexical tone variation has been studied in some populations with communication disorders, but these studies are mostly in east-asian tone languages such as mandarin chinese (whitehill & wong, 2007; wong, et al. 2009). one study has been published that focused on tone disruption in speakers of shona, a bantu language spoken in zimbabwe (kadyamusuma, de bleser & mayer, 2011). the participants presented with either left hemisphere or right hemisphere brain damage. they found lexical tone disruption and an inability to manipulate pitch in both left and right hemisphere-damaged shona-speaking participants. there was also a discrepancy between the production and perception of lexical tone for both groups of brain-damaged clients (kadyamusuma, et al. 2011). two research projects have been undertaken at the university of pretoria to explore the nature of speech signs in bantu language speakers with motor speech disorders. an unpublished study (apraxia of speech in a multilingual individual: speech signs across languages) by coetzee, de jager, and van der merwe (2011) found speech signs in a multilingual individual with apraxia of speech (aos) which were similar to the signs described for english. however, additional errors specific to the sound systems of the two african languages (isizulu and setswana) were click distortion, click deletion, de-aspiration, and omission of syllabic tone variation. the latter was the most frequent of all speech errors. the second unpublished study (dysarthria speech characteristics of african language speakers) (mahwayi, uys & van der merwe, 2011) explored signs of dysarthria in two isizulu speakers. one participant presented with severe dysarthria whilst the other presented with a unilateral upper motor neuron (umn) dysarthria after a stroke. the first participant's speech was severely affected and language-specific errors could not be identified. the second participant who presented with the typical left-sided unilateral spastic paresis of the lower quarter of the face and half of the tongue displayed the characteristic slight distortion of articulation, but also unexpected errors such as omission of syllabic tone variation, de-aspiration of aspirated sounds, and pre-nasalisation errors. the latter are unexpected as the vocal folds, the velum, or breathing muscles are not affected in a unilateral umn dysarthria. the noted errors affected intelligibility severely. the effect on intelligibility was disproportional to the mild nature of signs reported in english language studies (duffy, 2013:42). these preliminary studies indicate language-specific signs in motor speech disorders in the bantu languages. the studies may also suggest that speech production in isizulu and setswana places high demands on the speech control system. for example, tone variation adds another level of control of the vocal folds during syllable production over and above the abduction and adduction of the vocal folds for the production of voiced and voiceless sounds and the change in intonation across the sentence. also, the alternation between different air stream mechanisms, which is not necessary in germanic languages, may affect ease of control. the bantu languages contain no consonant clusters and diphthongs that may ease motor control demands but, on the other hand, these languages have more phonemes, and therefore more core motor plans need to be stored in the sensorimotor memory (van der merwe, 1997; 2009). further research in the field of neurogenic motor speech disorders, but also many other speech production disorders such as stuttering, cleft lip and palate, and also voice disorders as they present in african languages, is necessary. the outcomes measures could be accuracy of production in speech-focused studies. data analysis procedures could entail acoustic analyses or narrow phonetic transcription that notes errors such as distortion of sounds and word tone errors. broad perceptual analysis is not appropriate as this method only focuses on errors such as substitutions, additions and omissions of phonemes. it needs mentioning that narrow perceptual analysis is a specialised skill that has to be developed with experience. in clinical practice, clinicians have to be aware of the potential effect of speech production disorders on speech intelligibility. treatment of a speaker of a bantu language should target the specific sound characteristics of the language, such as lexical tone variation, aspiration, pre-nasalisation, breathy-voiced sounds, click production, and articulation of long conjunctively written words containing numerous syllables. examples of possible research questions in this field could be: do voice disorders affect tone variation? is tone variation affected by stuttering? does the presence of dysarthria affect the ability to produce aspirated as opposed to non-aspirated sounds? what is the effect of ataxic (or hyperkinetic/hypokinetic) dysarthria on the alternation between air stream mechanisms during the production of words? do multilingual individuals with apraxia of speech (or acquired dysarthria) display equal numbers of speech errors across the germanic and bantu languages that they are equally proficient in, and in which error category is there a difference, if any? is speech intelligibility equally affected across germanic and bantu languages in bi/multilingual individuals with a motor speech disorder (e.g., unilateral umn dysarthria)? of particular importance in this field is the development of speech intelligibility tests in all south african bantu languages. change in intelligibility is an important outcomes measure in evidence-based practice in the field of speech disorders. an intelligibility test in sepedi (northern sotho) was developed by fouche and van der merwe in 1999. the test contains four word lists, each comprising 27 words, and a set of 12 multiple-choice items for each word. the phonetic environments of plosives, fricatives, continuants and trills are controlled in the stimuli. language-appropriate aspirated bilabial, alveolar and velar sounds are included. the authors had at the time some knowledge of the language, but a lack of in-depth knowledge of the sound system of sepedi prevented development of stimuli that were representative of all the sound classes of the language and that considered tone differentiation during the production of words (van der merwe & le roux, 2014). although it was an important first step, this test has to be developed further. there are lessons for future researchers to be learnt from this attempt (see van der merwe & le roux, 2014 for a discussion of this issue). expressive and receptive language the relevance of the sound system of a language is not as obvious in language disorders as in motor-based communication disorders. however, there appears to be some relevance. in language disorders such as aphasia, delayed language development, and developmental phonological disorders, the sound characteristics of bantu languages could also drive some of the presenting signs. in bantu languages, the reception and use of, for example, lexical tone variation may be compromised in aphasia and in children with delayed language development. to our knowledge, no research has been conducted to establish if, for example, tone production is affected in individuals suffering from broca's aphasia or tone reception in individuals with wernicke's aphasia. moreover, the agglutinating nature of isizulu words in particular may challenge expressive and receptive processes in individuals with aphasia or children with delayed language development. the following are examples of possible research questions in this field: does a receptive language disorder also affect the reception and comprehension of lexical tone variation? are bantu language-speaking children with delayed language development also delayed in their use of lexical tone variation? do the same developmental norms in auditory perception tests apply for first-language tone language-speaking children and non-tone language-speaking children? hearing a hearing loss may affect the reception and production of spoken language during communication in a bantu language in a very specific way. the individual with a hearing loss may be unable to perceive and therefore produce tone variation or the aspirated, breathy-voiced, implosive or pre-nasalised elements of sounds – all of which carry lexical meaning. differentiation between phonemes in bantu languages is dependent on these factors in addition to those that determine phoneme differentiation in the germanic languages. these variables may be important in the selection of hearing aids for different language groups. the effect of a hearing loss on the intelligibility of bantu language-speakers may also be an interesting field of research. additionally, normative data utilised in temporal auditory tests need to be verified for both tone language and non-tone language-speakers as this may affect the diagnosis of the nature of a hearing disorder. this is a totally unexplored field, and the thoughts offered are merely speculative. the following are examples of research questions that could be posed in this field: is there any relationship between the frequency range of a hearing loss and the reception of different sound system features such as voicing of sounds, plosive sounds, breathiness and breathy-voiced sounds? are speakers of a bantu language who present with a hearing loss able to perceive lexical tone variation in minimal pairs of words? do first-language speakers of tone languages and non-tone language speakers perform equally on temporal auditory tests? conclusion top ↑ a brief overview of the idiosyncratic features of the sound systems of two south african bantu languages and the potential implications for clinical practice and research are presented in this article. such a review clearly shows that, as researchers and clinicians, we have to heed the effect of speech, voice and hearing disorders on intelligible speech and effective communication in these languages. we have to be aware of language-specific signs in communication disorders. the review points out many areas of potential research and emphasises the great need for such research. the intent of the current article was not to focus on the consequences of bi/multilingualism upon disorders of language or speech production. however, the topic under discussion also highlights that the conditions in which we function in south africa offer rich possibilities for studying bi/multilingualism and its consequences upon the presenting signs of speech and language disorders. to serve all individuals in need of speech-language or hearing intervention in their preferred or dominant language in south africa is a daunting task (pascoe, rogers & norman, 2013). however, this challenge, viewed from a different perspective, becomes a fascinating opportunity for conducting research. the intent of this article is to provide some guidance for future research that in turn will inform clinical practice. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions a.vd.m. 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[textbook for the speech sounds and sound changes in the bantu languages of south africa] pretoria: university of south africa press. abstract introduction study objectives results and discussion implications conclusion acknowledgements references about the author(s) kim coutts department of speech pathology, university of the witwatersrand, johannesburg, south africadepartment of speech-language pathology, university of kwazulu-natal, durban, south africa mershen pillay department of speech-language pathology, university of kwazulu-natal, durban, south africa speech and language therapy, massey university, auckland, new zealand department of health professions, manchester metropolitan university, manchester, united kingdom citation coutts, k., & pillay, m. (2021). decision making and the bedside assessment: the speech language therapists’ thinking when making a diagnosis at the bed. south african journal of communication disorders, 68(1), a790. https://doi.org/10.4102/sajcd.v68i1.790 original research decision making and the bedside assessment: the speech language therapists’ thinking when making a diagnosis at the bed kim coutts, mershen pillay received: 28 july 2020; accepted: 29 apr. 2021; published: 30 june 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the bedside assessment is often seen as a screener because of its high variability in sensitivity and specificity, whilst the instrumental measures are viewed as gold standards because of the ability of speech-language therapist (slt) to visualise the swallow more objectively. objectives: this research article explores how the value needs to be placed on the decision-making abilities of the slt rather than on the assessment measure itself. method: a mixed methodology concurrent triangulation design was employed to collect data in two phases: the first phase included observing seven slts conducting assessments using a standardised bedside measure together with pulse oximetry and cervical auscultation. the second phase was a focus group discussion based on the findings from the first phase. data were analysed thematically using a bottom-up approach. results: the following factors were found to influence the decision-making process at the bedside: bedside assessment data sets, patient, multidisciplinary team, context and then slt. the availability of more data from the assessment from different data sets improved the confidence of the slt at the bedside when needing to make clinical decisions. clinical instincts are developed through experience and observation of those more experienced. these skills need to be developed from junior years. conclusion: this research study showed that a bedside assessment can provide valuable information that will allow for diagnostic decisions to be made at the bedside. this study also highlighted the importance of critical thinking using clinical instincts, and that these are the factors that need to be valued and emphasised rather than the assessment measures themselves. keywords: speech-language therapy; dysphagia; clinical decision making; clinical swallow evaluation; pulse oximetry and cervical auscultation. introduction coutts (2019) recently wrote an opinion paper on dysphagia during the coronavirus disease 2019 (covid-19) era, in which she brought up the topic about the significance around the bedside assessment and the decision-making processes around assessment at the bedside (coutts, 2019). this research article is a follow-up from the opinion paper and her phd study. during the outbreak of the covid-19 pandemic, the global healthcare systems are under severe strain because of a lack of personal protective equipment (ppe) and a general lack of resources both personnel and otherwise. this resulted in a global limitation of speech-language therapists’ (slt) access to instrumental measures for dysphagia assessments. this situation, therefore, led to focussing on the decision-making processes and critical thinking around the utilisation of a bedside assessment as the primary assessment measure for diagnostic purposes. this article explores how slts make diagnostic decisions when using a bedside assessment and discussing how slts use critical thinking in a south african context. this article emphasises the value of critical thinking rather than placing the value solely on the dysphagia measure itself. the assessment measures for the purpose of this study, it is important to make a distinction between screening and assessment. the clinical swallow evaluation (cse) has typically been more valued as a screening tool as it gathers clinical information from various endpoints (bours, speyer, lemmens, limburg, & de wit, 2009). it is also often used as a primer for instrumental measures (antonios et al., 2010). videofluoroscopy (vfss) and fibreoptic endoscopic evaluation of swallowing (fees) are considered the gold standard assessment measures because of the detailed visual information that can be obtained (boaden, nightingale, bradbury, hives, & georgiou, 2019). the literature and policies from various international bodies have foregrounded the instrumental measures as gold standards. this has then translated into clinical practice patterns. in the south african context, the frequent lack of access to instrumental measures, especially in the public sector where the majority of the population is being treated, opens up the discussion around how slts use the information gathered from a cse to make clinical decisions that is relevant to the context and the patient. when discussing on decision-making processes, it is important to understand the inter-rater reliability of the different assessment measures. this has been researched before, especially the inter-rater reliability around vfss. despite being a gold standard measure and having the visual confirmation, there is still a high level of disagreement between raters (scott, perry, & bench, 1998; stoeckli, huisman, seifert, & martin-harris, 2003). these data show that slts can be presented with the same case and reach different clinical conclusions regardless of what measure is being used. this implies that there are other factors that can have an influence on decision-making processes when making diagnostic decisions. swan, cordier, brown and speyer (2019) took this idea a step further by evaluating the tools used to interpret both vfss and fees studies. she concluded that because of the lack of standardisation and statistical significance, there is currently no tool that can be classified as an effective measure to interpret the findings of even these gold standard measures (swan et al., 2019). even with visual confirmation, the decisions around what slts are viewing appears to be different. this was an interesting finding for the authors of this study as it implies that critical thinking around dysphagia is clearly a complex process that is highly individualised. the findings such as this one start to reveal how clinical decision making and reaching a diagnosis are far more complex than just the assessment measure itself. perhaps, slts need to focus on the clinical data that can be obtained from measures that are available in their context in order to make clinical decisions. the current challenge with the cse is that there is significant variability in terms of how slts utilise it, both locally and internationally (andrews & pillay, 2017; bateman, leslie, & drinnan, 2007; rumbach, coombes, & doeltgen, 2018). this variability, in practice, often revolves around what aspects should be included in a cse protocol. what is well known is that in isolation the cse has a highly variable accuracy (lynch et al., 2017). the other aspects, such as cervical auscultation (ca) and pulse oximetry (po), when used in isolation also have poor reliability (britton et al., 2018). however, when looking at including measures such as ca with the cse, reliability of both measures can be improved. a study combined ca with a water swallow test to determine the presence of dysphagia (watanabe et al., 2020), which revealed that even non-swallowing experts were able to accurately detect dysphagia using these methods. bergström, svensson and hartelius et al. (2014) carried out an interesting study evaluating the use of ca together with the bedside assessment and then compared their findings with fees. their findings revealed that if an slt is trained in ca, then by adding it as an adjunct to the cse, can improve its sensitivity to detect the presence of dysphagia, and this can be more accurate than just the cse in isolation (bergström et al., 2014). this was supported by another study, which suggested that ca can be used as an adjunct to the bedside assessment (frakking et al., 2016), the findings of which were also supported in a systematic review carried out by bours et al. (2009). this an important study that evaluated all of the current literature in the field regarding dysphagia bedside assessments at the time, the conclusions of which showed that there is a significant value in using multiple data sources at the bedside, such as the cse and the ca. in terms of pulse oximetry, a systematic review by britton et al. (2018) indicated that because of the lack of standardised protocols and interpretation of findings, it too should not be used in isolation to detect the presence of dysphagia but some studies have concluded that po can be a helpful adjunct to the bedside assessment as it provided relevant physiological data (britton et al., 2018; colodny, 2000; zhou, salle, daviet, stuit, & nguyen, 2011). at the bedside, the use of each of these measures in isolation is clearly not recommended but when using them simultaneously is a helpful adjunct. this is because there are more clinical data on which slts can make a clinical decision. there is a significant clinical value in all assessment measures. however, when looking at policies, and the research, instrumental measures are often foregrounded. given the high variability around decision making in all of the assessment measures, there is a need to shift what is valued in the assessment process. dysphagia assessments are not solely about the use of a particular measure but that the value is rather in the critical thinking of the slt pertaining to how the available clinical data from these measures are being used (plowman & humbert, 2018). given the complexities of covid-19 era, this article has chosen to focus on the critical thinking around the cse as slts will need to be making diagnostic decisions at the bedside more frequently, and thus, this process requires more exploration, especially in the south african context. clinical decision making the south african healthcare context is complex when compared with other developed countries. the contextual limitations of access to skilled staff members, instrumentation and health profile mean that slts often have to make clinical decisions based on multiple contextual, patient, linguistic and cultural factors. how this is carried out has not yet been explored. speech-language therapists have started to research on the impact of critical thinking and decision-making processes in dysphagia; however, these studies are based in economically developed countries. although findings from developed countries are useful, it may not be easily extrapolated to fully understand what happens with slts in south africa. a study by tohara, saitoh, mays, kuhlemeier and palmer (2003) made an interesting suggestion when evaluating the inter-rater reliability of fees, suggesting that when an evaluation criterion, that is, a standardised form, is available, the decision-making process improves (tohara et al., 2003). the same study also mentioned the importance of clinical experience in this decision-making process. this finding was linked to vose, kesneck, sunday, plowman and humbert (2018) who evaluated the clinical decision making of slts when evaluating a vfss. they concluded that there was significant variability amongst slts, and that the key contributing factor was the lack of consensus and understanding of what a normal swallow was and what are normal deviations (vose et al., 2018). these findings were linked to an australian study that assessed the variability of practice patterns for the bedside assessment and what implications this had for slts (mcallister, kruger, doeltgen, & tyler-boltrek, 2016). their findings suggested that rather attempting to find standardised items on a recording form that rather the clinical value needs to be placed on the decision-making process itself and what information slts used to make conclusions. these findings seem to imply that clinical decision making is a multifaceted process that is influenced by various factors. humbert (2015) suggested that decisions are made by integrating evidence together with experience, which develops clinical instincts that is developed over time (croskerry, 2009). the study by pillay and pillay (2020) developed a dysphagia clinical reasoning framework that echoes the findings from humbert (2015). this framework suggests that junior slts move along a novice to expert continuum by gaining clinical knowledge and experience together with understanding diseases and their progression. at the end of the continuum, through the combination of the different factors, these slts develop clinical reasoning, which can be used in making decisions at the bedside when assessing dysphagia. considering the factors above, the aim of this study was to describe the decision-making processes of slts when conducting a cse. this research study stemmed from a doctoral study that focused on developing an integrated bedside assessment method. the focus of this study is on the data obtained from the decision-making processes of the slts when using these measures. in an everchanging world, given the current dysphagia guidelines in place (sashla, 2020), this shift in how slts use information from a cse to make a diagnosis is becoming increasingly important, especially in the complex sa healthcare context. the research question was how do slts make the decision regarding the presence of dysphagia, aspiration or penetration at the bedside? study objectives this study used a mixed methodology concurrent triangulation design to address the following objectives: describe what factors slts use to determine the possible presence of dysphagia, penetration and/or aspiration at the bedside. explore how the slts used these factors to make these decisions at the bedside. site this study was conducted at a tertiary-level public sector hospital in johannesburg. the public sector was chosen for this study as it serves over 78% of the population with minimal resources, both personnel and otherwise (coovadia, jewkes, barron, sanders, & mcintyre, 2009). participants and sampling method convenience sampling was used to obtain a sample group of seven slts who worked at the research site presenting with different levels of experience from 1 to 8 years. all participants included were female. the two participants who had the most years of experience had been colleagues for 4 years, and three were registered as slts and audiologists. the four participants with the least experience were registered as slts. data collection tools the mann assessment of swallowing ability (masa) (mann, 2021) was used as the cse protocol for this study. it is a standardised tool that assesses the anatomical and physiological aspects of the patient’s swallow, with different swallowing trials being conducted at the bedside. it was standardised on an adult neurogenic population. this tool has proven validity and reliability for clinical use in a variety of adult populations (chojin et al., 2017; ohira et al., 2017). at the end of an assessment, the slt participants classified the outcome on a ranked scale as follows: 0 – no abnormalities detected (nad), 1 – dysphagia, 2 – penetration or 3 – aspiration for analysis purposes. for the purposes of this study, the ranking of a score of 1 = dysphagia (oral and pharyngeal), which was defined as difficulty with swallowing but no presence of penetration or aspiration. the ranking of a score of 2 = penetration, which was more severe than 1 as it represents the presence of an oral and/or pharyngeal dysphagia and penetration. a score of 3 was the most severe and was defined as the presence of aspiration. the ca aspect allowed the slts to classify the swallow sounds at the start, during and end of the swallow. the po readings were collected prior to the assessment as a baseline, during and 2 min post swallow. the same ranked outcomes of 1–3 were used for po and ca. the researcher used an observation schedule to conduct the bedside observations. this schedule included aspects around slt, patient, environmental or contextual and multidisciplinary team (mdt) factors. the data collection schedule for the focus group (fg) discussion included a semi-structured questionnaire that focused on asking key questions on the decision-making processes based on the clinical factors indicated by the slt for each case, as well as the observation notes. the researcher would allow the slt to explain how they reached the conclusion of dysphagia or aspiration or penetration based on the clinical information that was recorded at the bedside. clarification of concepts was made during the interview process. data collection the first phase of data collection patients with a neurogenic dysphagia were assessed within 24 h using the masa and the ca and po procedures as set out by cichero (2006). each patient was then re-assessed 24 h later by a different slt using the same procedures. this was a blinded process. simultaneously, the researcher conducted observations for the different slts using an observation schedule to understand the bedside assessment environment and to enhance the discussion in the fg. the second phase of data collection after analysing the results from the bedside assessments and observations, the researcher looked for any differences in outcomes between the two slt participants for the same patient. these different outcomes, as well as the notes from the observations, were then discussed in a fg with all the participants. data analysis the data from the fg discussion were analysed thematically using a bottom-up approach (braun & clark, 2006). the transcriptions were analysed using the four phase analysis process suggested by vaismoradi, jones, turunen and snelgrove (2016), initialising of the data, construction of themes, rectification of themes and finalisation of the story line. trustworthiness the use of triangulation method, that is, using more than one data collection method improved the credibility and transferability of the findings (heale & forbes, 2013). the three different data sets included the cse assessments, the observations and the fg discussions. ethical considerations ethical approval was obtained from the university of kwazulu-natal biomedical research ethics committee, reference number: be362/15. participant consent was obtained prior to data collection. results and discussion objective 1: describe what factors speech-language therapists use to determine the possible presence of dysphagia, penetration and/or aspiration at the bedside based on the data obtained from the first phase of data collection, the following themes were identified: the factors from the bedside assessment, the patient, the multidisciplinary team, the context and then the slt factors. the relationship between these factors is depicted in figure 1. figure 1: decision-making factors when using a bedside assessment. there are different factors that inform the overall decision, but slt factors are used to integrate the information and make the overarching clinical decision. how these factors work together and allow for integration will be explained under objective 2. objective 2: explore how the speech-language therapists used these factors to make these decisions at the bedside ‘…as the oxygen saturation levels did not drop and i did not hear any gurgling, delay or bubbling…’ this statement made by slt 4 in the fg discussion depicts the integration needed in the decision-making process quite aptly. it shows how an slt uses physiological data from different assessment measures to make a diagnostic decision at the bedside. this statement will be deconstructed in the discussion according to the different factors that were identified above. the bedside assessment factors all participants were observed to have followed a similar core cse protocol, which included the case history, oral sensory motor examination, language and speech screening followed by food trials, usually starting with a liquid. this stems from their understanding of the theoretical knowledge relating to dysphagia assessments. the general status of the patient was always considered prior to the start of the assessment, which included the level of alertness or cognitive functioning, factors such as oxygen support and patient compliancy. on average, the bedside assessment that included po and ca evaluations provided more physiological data when compared with the use of the cse alone. when using the cse alone, the slts used one to two data sets on which to make a clinical decision at the bedside as to whether the patient presented with just oral dysphagia or possible penetration and/or aspiration. when using the cse with po and ca, the slts used three to four data sets. this extra data improved the slt confidence, as seen in the opening statement from slt 4. this is also supported by slt 6 who stated that ‘she … felt more confident with ca’. the presence of aspiration when deciding on the presence of aspiration using the masa, all slts commented on the presence of decreased laryngeal elevation followed by a gurgly vocal quality or wet sounding chest and poor cough. for the cse with po and ca, a diagnosis of aspiration was seen using aspects, such as multiple swallows, decreased breathing abilities, a drop of more than 3% on oxygen saturation levels and a gurgly vocal quality. together with the patient observations, the data from po and ca allowed the slt participant to either further suspect aspiration or penetration. this was confirmed by slt 4 as mentioned in the opening statement. conversely, slt 3 cited about another patient in the fg discussion, line 153, ‘she showed significant signs of aspiration with coughing, and choking and i heard a change in breathing with an 11% drop in oxygen saturation’. the presence of penetration a diagnosis of penetration was rarely made and only seen once in the patients where there was a difference in outcomes between two slts. the diagnosis of penetration was made using the bedside assessment with po and ca, and the slt used poor tongue movement, gurgly vocal quality, wheezing and multiple swallows as key indicators. an interesting finding was that this diagnosis was also made by the most experienced slt participant in the department. the more experienced slts tended to not diagnose the patient with aspiration but rather dysphagia or penetration when compared with the more inexperienced slts in the department. as the symptoms of penetration are more subtle, perhaps clinical experience leads to improved confidence when deciding on the more subtle presence of penetration. this theme of experience will be discussed more under slt factors. the presence of dysphagia in the case of the diagnosis of dysphagia, the most common diagnosis made by all participants, the clinical symptoms that were used were residue in the oral cavity, oral weakness as seen from the oral sensory motor examination or the presence of a motor speech disorder, poor bolus control and delayed oral transit time. this was possibly the more common diagnosis as these are the symptoms that are more easily identifiable at the bedside. in summary, in terms of the bedside assessment protocol that she used, slt 5 stated that: [i]n community service, you follow a strict protocol because that is what you know and feel comfortable with, with experience and being exposed to different patients, you then change the protocol as you see fit. (p. 5) this was an interesting statement that was linked to the concept of confidence that can improve critical thinking. it became apparent that slts with more experience were willing to make a diagnosis of penetration and/or aspiration more easily than those with less experience. when the slts were diagnosing penetration and/or aspiration, the availability of the data from ca and po further assisted them in the decision-making process rather than just the data from the bedside assessment. as aspiration and/or penetration cannot be seen from the bedside, slts valued the availability of the extra physiological data. the patient factors there is a need for the bedside assessment protocol to be adapted to accommodate the requirements of the patient. patient compliance and language were significant sub-themes that emerged in observations, slt 1 stated that ‘patient factors can definitely affect my ability to conduct a good assessment at the bedside,’ and slt 4 confirmed this by referring to ‘the use of instrumental measures in an assessment protocol that is highly patient dependent’ and with slt 6 stating ‘…it all depends on the patient’. this is a pertinent challenge when working with patients who have neurological conditions, as well as in a public sector hospital where access to instrumental measures is a further challenge. the need to use instrumental measures and when to refer a patient for one was closely related to slt knowledge and experience. the patient compliance and language abilities will also influence the assessment findings in terms of the information that the slt can obtain from the patient and how accurate their assessment may be. this can be highly pertinent for patients with neurological impairments, such as cva cerebrovacular accident and tbi = traumatic brain injury (zimmerman, murdock, & shank, 2010). the multidisciplinary team factors the frustration of slt participants became apparent with the challenges that can arise from working with other professionals when assessing dysphagia at the bedside. slts 1, 2 and 4 expressed that their greatest challenge was working with the nursing staff. slt 1 noted that ‘the input that you receive from the nurses is often inaccurate in terms of whether they are tolerating their current feeds’. slt 2 mentioned, ‘often the information that is on the balfec (intake) chart is incorrect’. slt 4 further supported this by saying ‘i take the opinions of certain staff members with a pinch of salt’. this led the participants to consensus in the fg of needing to rely on their findings in the bedside assessment, often above what the other professionals had described. in opposition to that, the discussion with other professionals (including nurses) was important for some participants as mentioned by slt 2 who stated that ‘i chatted to the nurses about her eating…’ as she wanted to find out how the patients were presenting during other mealtimes. slt 7 mentioned, ‘… i like to see what others have said…’ this was to acquire a holistic picture of the patient. an slt also had a discussion with the family during one of the assessments. there were discussions with other members of the team, which contributed to decision making by the slts as this provides input from different situations. slt 4 was also able to observe the occupational therapist feeding her patient, which allowed for a different view on the eating process as said by ‘you need to take other professionals point of view into account…’ the contextual factors the challenge of a high patient load was also pertinent, and the participants made note of the importance of time and resource efficiency for the assessments. some assessed two areas whilst performing one activity in order to save time, that is, receptive language simultaneously with an oral sensory motor examination. another efficient method was using food that was readily and easily available, and replicated a functional eating situation. slt 1 mentioned that ‘i need to make a plan by creating an easy ward kit which helps to conduct full assessments at the bedside’. slt 4, who had more clinical experience, said, ‘i can conduct a good assessment and not have anything on me but purely with what i find in the ward’. whilst their ideas were the same, their approaches were different. the differences in their approach could be because of experience in the field, as well as the contextual factors. the participants would often try to use food that was readily available at the patient’s bed or what came from the ward in order to achieve an adequate assessment at the bedside, as this also helped to assess the patient in a more natural eating situation. it needs to be noted here that this could be a distinct advantage of using a bedside assessment over an instrumental measure, the need to assess in a realistic environment, otherwise known as ecological validity (andrade, 2018). one of the more senior slts summed up this discussion on resources well in relation to having limited access to fees that …‘i feel that we are doing excellent assessments without barium swallows’. this was an important statement as she felt that adequate clinical decisions were being made at the bedside by slts. the speech-language therapist factors: how it is all pulled together the decision-making process at the bedside is strongly associated with slt knowledge and experience in dysphagia. the junior slts were more inclined to talk about clinical factors that related directly to procedural knowledge as found in statements, such as ‘i decided to start with water as it is the safest consistency…’ (slt 3, line 40) and ‘i needed to position the patient appropriately first…’. slts 2 and 3 both referred to using three trials of one consistency before making a decision. another junior slt highlighted that ‘[i]t is a confidence thing that comes from experience’. these quotes highlight that as junior slts have less experience that they felt the need to actively mention procedural or theoretical facts that perhaps more experienced slts just do instinctually. what is a novel finding, this research observed a strong theme of clinical instincts, and it was clearly evident that the slts gained experience through practice. this was described in ways such as ‘practice makes perfect’ (slt 2) and ‘i make decisions based on outcomes from previous cases’ (slt 1). interestingly, three of the participants mentioned the use of ‘gut feelings’ or ‘instincts’. slts 2 and 5 also made a statement to support this, ‘…i also know from my previous experience…’ and ‘[i]t is a confidence thing that comes from experience’. slt 2, with 1 year of experience, and slt 3, with 3 years, both mentioned that they were ‘learning to trust my gut a bit more’ when making a diagnosis at the bedside but the extra physiological data did assist in this process. it appeared that the more experience slts had, the more inclined they were to trust the results of the bedside assessment and their clinical instincts. this was confirmed by slts 1 and 2 who also mentioned instincts and ‘trusting their gut’. this concept of experience better assisting in decision making is supported by the finding that the senior slt was the only participant who was comfortable to diagnose the more subtle ‘penetration’ instead of choosing ‘aspiration’ as an outcome. these findings link clearly to the dual processing theory, as suggested originally by croskerry (2009) and then later by humbert (2015). this notion of experience influencing decision making was also referred to by pillay and pillay (2020, in press). it is important to note that some people learn in different ways as slt 3 seemed to rely on external sources for her decision making rather than purely on her clinical instincts. this was evident in the comments, ‘i like to discuss the case with the doctor first’ and ‘i gained my experience from drawing on the knowledge of others and reading. i also found that attending courses was helpful for me’. this raised an interesting point as the relationship between colleagues may then have a role to play in this learning and/or mentoring process. this highlights the importance of placing junior slts in facilities where they can be mentored by more experienced slts in dysphagia, as this is a valuable learning opportunity (coutts, 2019). in summary, there were a variety of terms used by the participants throughout the fg discussion, which signified what cognitive factors slts use to make decisions at the bedside. these factors around critical thinking included aspects around praxis defined as the interdependence and integration of theory, practice, research and development, thought and action (whitehead, 2002). praxis is a completely individual process and proves that no assessment measure is without some element of subjectivity. this links to how participants used other factors, such as experience and gut feelings, to make these decisions. table 1 summarises these cognitive factors and the frequency of their occurrence: table 1: cognitive factors used and the frequency of occurrence. it was apparent that the slts gained knowledge and experience in different ways, which resulted in diverse ways of developing clinical thinking or as this study could suggest, clinical instincts. one of the participants summed it up well and supports the use of the term ‘clinical instincts’ when she said, ‘it made me realise how much of my decision-making is unspoken and based on very subtle things … it was difficult to explain those subtleties…’. this is important when considering undergraduate teaching, as well as mentorship for junior slts as they proceed into their community service year (coutts, 2019). as shown in the table, clinical instincts are a predominant feature of critical thinking, and needs to be nurtured and developed from junior years. implications motivation for a bedside assessment measure this research study has started to explore the potential value of a bedside assessment through the decision-making process when extra physiological data are available. this study further confirms findings from previous studies, which suggest that when using a cse with ca and po, it improves the decision-making process at the bedside. this is because of two aspects, the first is by bours et al. (2009) whose systematic review highlighted the value of an integrated bedside assessment using different measures because the use of extra measures improves the overall reliability. the second is that by having the extra physiological data, there is increased confidence to make decisions at the bedside. the ability to make decisions at the bedside not only assists with making a diagnosis but is also important for future therapy planning. most participants regardless of their experience followed a similar bedside assessment protocol; however, this process needs to be flexible as it can be influenced by patient, mdt and contextual factors. the ability of an slt to make appropriate changes requires critical-thinking skills, which are developed through experience and from the observation of more experienced slts in the field. for clinical decision making clinical decision making has been studied in a variety of other healthcare professions, including physiotherapy, nursing and medicine. the physiotherapy studies have assisted in developing student training and shaping education (smith, higgs, & ellis, 2008). the nursing studies have resulted in the development of models, which also has an impact on student training as well as guidelines (hoffman, donoghue, & duffield, 2004). the area of decision making is relatively new in the field of dysphagia and has not yet been investigated in the south african context. this study has, therefore, provided theoretically novel data as the starting point for future research. this study has also provided data on how decision making occurs during a cse; data from this perspective are also novel in the field. the findings from this study echo those from croskerry (2009), humbert (2015) and pillay and pillay (2021, in press). decision making is a complex process influenced by various factors but the key component to this is how clinical instincts and confidence to make diagnostic decisions are linked to clinical experience. for the sa context, this is helpful in terms of needing to potentially revise undergraduate training and looking at how community service is potentially structured. given the complexities of the sa healthcare system and the recent shift to online teaching pedagogies, it is imperative to understand how to foster and develop these critical-thinking skills in students along with the development of their clinical skills. by understanding how junior slts move along this continuum can assist academics and those involved in student training. by harnessing the reliability of an integrated bedside assessment and improving the integration of the various patient and contextual factors can then advance the overall delivery of an efficient, real time, contextually relevant dysphagia service. these data were gathered before the covid-19 pandemic, although relevant, the data need to be potentially updated as the patient, mdt and contextual factors will need to include the factors that covid-19 brings with it, such as social distancing. conclusion the science of dysphagia, our research methods used in dysphagia and how slts align those into research papers should become more integrated to what occurs in the real world. pillay, kathard and samuel (1997) argued for a shift in how we use our science to practice in the real-world context. they referred to science as knowledge that was constructed from and of the real-world context. this study further confirms that a positivistic science is unsuitable for engaging dysphagia practitioners in clinical thinking. unlike a positivist (or empirical) science that seeks to establish a singular truth via the myth of objectivity, we argue that dysphagia practitioners need a more critically oriented science. such a science should celebrate, not deny, subjectivities, such as that articulated by the participants in this study. this may better facilitate thinking, holistic and ecological system-based approaches as useful paradigms for bedside or cses. this article suggests theoretical novelty in how clinical decision making is carried out within a healthcare setting by slts with varying levels of experience. this is a complex process that requires multiple levels of analysis; however, the hope is that this study has started to contribute towards how slts in south africa move along this novice to expert continuum. this study suggests that the priority needs to be placed on the development of the critical-thinking processes rather than on the measure itself when developing clinical competence. this needs to be honed from undergraduate years. critical thinking is based on developing clinical instincts, especially when making decisions at the bedside. these skills are developed predominantly through clinical experience and observation of others. these data can possibly assist in future training of both undergraduate and postgraduate students. acknowledgements we would like to thank the participants for their contribution to the study. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions m.p. was responsible for the conceptualisation and k.c. was responsible for data collection and write up of the article. funding information this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references andrade, c. 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(2010). prevalence of dysphagia in traumatic brain injury [abstract]. retrieved from https://mospace.umsystem.edu/xmlui/handle/10355/9390 "by the end of this course you should be able to...": towards constructive alignment in the slp curriculum michelle pascoe and shajila singh division of communication sciences and disorders, university of cape town, south africa abstract this paperdescribestheway in which constructivealignmentisbeing implemented inthespeech-language pathology (slp) programmeata south african university. we focuson oneofthecourses, human communi­ cation development, that comprisesthefouryearprogrammeof study. afirstyear,first semester coursethat is attended by both slp and audiology students, it aims to introduce fundamentals of the communication process and its development at a pre-clinical level. we aim to show how theoretical principles from higher education can be implemented at a micro level in a course of the slp programme.the principles of construc­ tive alignment are introduced and exemplified through description of the revision of this course. all aca demicandclinicalstaffinvolvedintheprogrammecontributed tothedevelopmentofthecourse.atemplate for curriculum revision is presented which allows for the explicit alignment of intended learning outcomes, teaching and learning activitiesand criterion referenced assessment. staff participants recorded reflections ontheirownlearninginpersonalreflectionlogs.throughthisjournalingprocessparallelsaredrawn between the'teachers'voyage of discovery and that of the students. keywords: constructive alignm ent, curriculum developm ent, speech-language pathology. all speech and language pathologists (slps) are involved in education: we work in class­rooms with learners and educators; we edu­ cate parents and colleagues about speech, language and feeding / swallowing difficulties; we teach cli­ ents about various aspects o f communication, and educate ourselves and our colleagues in an ongoing way about the content and practice o f our profession. those o f us involved directly in educating future slps through their university academic and clini­ cal training are also involved in education: although typically our focus! as lecturers and clinical educators in s l p programmes will have been on the content o f what we teach. our expertise and interest typically lie in the clinical areas in which we have studied and worked, rather than in the process o f adult education itself. chadwick (2 0 0 4 , p .267), notes in the context o f orthodontic specialist training a different profes­ sion but with links to our own that: “traditionally curriculum design is one aspect o f education that most o f us would not have expected to have any direct involvement in. however, much o f the creativity and power in teaching lies in the design o f the curriculum. changes to the curriculum have implications for current and future trainees, teachers on specialist programs and all providers o f special­ ist care.” in the field o f slp there are entire texts that have been dedicated to the subject o f professional educa­ tion o f slps (e.g. stengelhofen, 1993; mcallister et al., 1997; brumfitt, 2 0 0 4 ) and papers which focus on s l p curricula both internationally (e.g. davis & v an der gaag, 19 9 2 ; kamhi, 1995) and in the south a f­ rican context (e.g. kritzinger & louw, 2 0 0 3 ; khan, 2 0 0 7 ). however the amount that has been writ­ ten about professional education remains extremely small in relation to the large literature on theoreti­ cal aspects o f communication difficulties. similarly in medicine, it is only fairly recently that knowledge o f medical education has been amassed and the area has become one o f interest in its own right. w hat are the challenges for slp curricula? along with other professions such as dentistry and medicine, training o f slps requires professional education: a process different to that of higher edu­ cation for a theoretical degree. the aim is to produce author contact: division o f communication sciences and disorders f 4 5 old main building groote schuur hospital observatory 7925 south africa e-mail: michelle.pascoe@uct.ac.za the south african journal of c o m m u n ic atio n disorders, v o l 55 2008 | 91 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:michelle.pascoe@uct.ac.za michelle pascoe & shajila singh professionals who are not only able to carry out the ‘techni­ cal’ or subject-specific challenges o f being an slp but also have an understanding o f ethical aspects o f practice, are able to demonstrate flexibility o f thinking, problem-solv­ ing skills, creativity as well as communication and interper­ sonal skills that allow the facilitation o f change in their cli­ ents’ lives. pascoe, stackhouse and wells (2006) talk about ‘thinking therapists,’ i.e. slps who are able to evaluate their practice in an ongoing and self-critical way. it is not sur­ prising therefore that although institutions can provide teaching in subject-specific content and even professional methods, the application has to be found within the actu­ al work context. inevitably many students face difficulties in transferring their theoretical knowledge to clinical set­ tings. the divide between theory (what happens in lectures) and therapy (what happens in clinics) is often perceived by staff and students alike as wide. whitworth, franklin and dodd (2004) describe slp students in the uk whose clin­ ical practice reflected what they had experienced in clini­ cal placements, irrespective o f their theoretical knowledge gleaned in lectures. in order to be able to practice their profession, students must meet the criteria specified by the profession’s regula­ tory body in whatever country they choose to work. edu­ cators designing curricula need to steer a tricky course be­ tween ensuring that these outcomes are met by the end of the programme, but that at the same time the experience o f students is a rich and interesting one affording them the op­ portunity for deep, rather than surface learning. deep learn­ ing has been defined as learning which achieves outcomes because students are engaged with their learning and have no desire to cut corners. they wish to fully understand their subject. in contrast surface learning is where students are not engaged fully with their learning. their main focus is to pass a course rather than achieve mastery o f a subject. learning does not happen in a long-lasting and effective way (biggs 8c tang, 2007). chadwick (2004) writing about orthodontic specialists training in the united kingdom not­ ed that whether constructive alignment can be achieved in the curriculum ultimately depends on the relationship be­ tween these aspects o f the educational process and the vari­ ous bodies responsible for their delivery in the uk. similar­ ly toohey (1999) notes that while professional competence standards can be very useful sources for guiding curriculum design their tendency is to focus on the technical perform­ ance o f specific tasks and roles. i f learning outcomes include technical competency these should be balanced by outcomes in knowledge and attitudes that contextualise these skills (chadwick, 2004). in addition to the complex task o f managing academic and clinical learning, sl p courses face a challenge in that -they are typically heavily loaded courses in terms o f con­ tent (whitworth et al., 2004). the timetable from most slp programmes typically leaves little room for self-study or reflection, skills which are increasingly shown to be im­ perative for deep learning (gultig, lubisi, parker & wede­ kind, 1998; irving & young, 2005). sl p is a profession that draws heavily on the combined knowledge o f other disci­ plines such as psychology, linguistics and biomedical sci­ ences. the slp curriculum in south africa in south africa, there has already been rapid transfor­ mation in the education o f slps since the mid-1990’s when training programmes began making changes in line with the new democracy and the urgent need to address previous im­ balances in the country’s higher education system and to provide equitable service to the underserved majority o f the population. many o f the slp programmes in sa have been aggressively recruiting students who represent the diversity o f the sa population. graduates are urgently needed who will be able to speak languages other than english and a f­ rikaans (as has traditionally been the case), and who them­ selves will be able to access the diverse array o f cultures in the country. furthermore, since there are few universities in africa which train slps apart from those in'south a f­ rica, there are a great many students from the continent who have languages and cultures beyond those o f only this coun­ try. linguistic and cultural diversity is a great asset and the richness o f diversity in our classrooms is an exciting asset to be embraced. nevertheless studying in a language that is not a first language poses challenges. in addition to linguistic diversity students come from a variety o f cultural and edu­ cational backgrounds. their experience o f language for aca­ demic purposes varies widely: some students will arrive at university equipped with basic academic skills such as being proficient in reading academic texts, using glossaries and in­ dexes, writing definitions and carrying out literature search­ es. other students will not have been exposed to tasks such as these and will need support to master these basic skills. in a profession in which language is central to the job, linguis­ tic diversity can present complex dilemmas. as for all slp graduates, slps wanting to work in sa must exit their programmes o f study with the necessary knowledge and skill to work independently as stipulated by the health professions council o f south africa (h pcsa, 2003). the situation in south africa is different to countries such as the uk and usa where slps will typically work in settings where formal mentoring and supervision arrange­ ments will be in place to ensure that newly qualified clinil cians continue to develop their skills in a supervised way1. in south africa, such mentoring and supervision is typi­ cally not available: new graduates carry out a year o f com-; munity service in communities which are often rural and remote, where they may be the only slp indeed they may be faced with establishing services where previously none, have existed, and educating and advocating for the role of sl p services. thus it is imperative that graduates are able to practice competently and independently: not only do we need to produce the ‘thinking therapists’ already described but we also need to develop agents for change who will be able to bring about broader socio-political changes as they develop and advocate for services for the population o f their country. ^ the training o f slps in sa has historically been differ­ ent to education o f slps in other countries such as the usa and uk, in that training leading to a dual registration in both speech pathology and audiology was until recently offered at each o f the training institutions. now many o f the training institutions, including our own, offer separate pro­ grammes in speech pathology and audiology since these 92 die suid-afrikaansetydskrif vir kommunikasie-afwykings,vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t o w a r d s c o n s t r u c t iv e a l ig n m e n t in t h e slp c u r r ic u l u m are entirely separate professions. these programmes aim to be responsive to the wider population o f south africa, tak­ ing into account the burden o f disease profile o f the country: h iv / a ids and t b are prevalent in southern africa and require specific services from both slps and audiologists. these aspects have not always been included in training pro­ grammes in south africa and may not receive the same level o f emphasis in training programmes elsewhere, which are likely to have their own population-specific issues. primary health care (ph c) is a key philosophical underpinning of health programmes in south africa, and the training pro­ grammes for slp and audiology thus aim to include not only training that focuses on rehabilitation, but which also gives emphasis to p h c ’s continuum o f care which includes prevention o f communication difficulties, and promotion o f communication more generally. against this backdrop, courses such as ‘human communication development’ re­ main common to both speech-language pathology and audiology programmes which means that the course needs to be designed so that it is appropriate for students study­ ing in both programmes. separating speech-language pa­ thology and audiology programmes has meant that some unloading o f the overloaded curriculum has occurred but the courses remain very high in terms o f credit weightings when compared to other similar 4 year programmes (brum fitt, 2004). w hat are the challenges for higher education? many o f the challenges described in our specific context are not unique: biggs and tang (2007) note that around the world, the range o f academic ability in university class­ es is wider than it has ever been: “the brightest and most committed students still go to university, as they have in the past, but they sit alongside students o f rather different academic bent.” (p.2). these authors note that around the world about 40% o f school leavers now attend university, in contrast to figuresjof approximately 15% ten years ago. in addition to these changing demographics, there is an in­ creasing pressure for j universities to offer value for money in their curricula: education is a commodity than can be bought and students view themselves as consumers entitled to an appropriate service. traditionally those involved in higher education may have regarded teaching as second priority to research, but the increasing pressure onuniversities to provide a relevant, quality and value-for-money learning experience has meant that universities are now striving to create a more learner friendly environment. many universities around the world now place emphasis on funding o f teaching/ learning cen­ tres, as well as recognising that research into teaching of one’s content area is as important as research into one’s con­ tent area per se (gultig et al., 1998; biggs 8c tang, 2007). it has been suggested that the solution to the challenges that learners and educators face in higher education is to immerse students in an environment that makes clear the intended outcomes o f the learning process, and follows cur­ ricula that explicitly encourage this. constructive alignment has been used to achieve this aim and has been described as an effective yet flexible approach to learning in higher edu­ cation (biggs, 1996; biggs 8ctang, 2007). w hat is constructive alignment? constructive alignment is a form o f outcomes based ed­ ucation in which intended learning outcomes (ilos) are clearly defined and drive the rest o f the educational proc­ ess (biggs, 1996, 1999). there are two parts to constructive alignment: 1. constructivism: students construct meaning from what they do in order to learn. they build on the knowl­ edge they already bring to the process. rather than passive participants who have knowledge transmitted to them, they are active participants in the process (biggs 8ctang, 2007). constructivism is a theory o f learning that can be seen on a continuum so that there are actually a variety o f types o f constructivism rather than one unified theory (doolittle, 1999). these include social constructivism, cognitive con­ structivism and radical constructivism (see fosnot, 1996 for further discussion o f learning theories). holmes et al. (2001) have developed a new educational theory ‘communal con­ structivism’ based largely in response to the development of technology and its increasing use in education through i c t applications. communal constructivism purports to move beyond social constructivism and sees individuals construct­ ing meaning together not just alongside each other but for each other, often through join t development o f information and communication technology (ic t ) applications. 2. alignment: the teacher or lecturer aligns the planned learning activities with the learning outcomes. the basic premise is that the curriculum is designed so that the learning activities and assessment tasks are aligned with the il o s that are intended in the course. a course is con­ structively aligned when (a) the il o s are stated clearly, and explicitly communicated to the students; (b) the teaching and learning activities (tlas) match the ilo s, and (c) the assessment(s) match the ilo s. figure 1 illustrates these principles o f constructive alignment. biggs and tang (2007) describe the process o f construc­ tive alignment which can take place at a range o f levels: in­ f ig u re 1. aligning learning outcomes, learning and teaching activities and the assessment. adaptedfrom biggs (1 9 9 9 )p .2 7 the south african journal of c o m m u n ic atio n disorders, vol. 55 2008 93 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) michelle pascoe & shajila singh dividual courses, programmes and in institutions. this pa­ per describes the constructive alignment process that took place with one course within our sl p programme, but was carried out as a micro part o f a larger and ongoing process of constructive alignment for the entire programme. biggs and tang (2007) suggest that when considering a single compo­ nent o f a programme, constructive alignment is achieved by carrying out the following steps: defining the intended learning outcomes. • selecting learning and teaching activities likely to enable the students to attain the outcomes. • assessing the students' outcomes and grading the students learning. defining the intended learning outcomes there is a large body o f literature on the use o f learning outcomes in higher education (e.g. d ’andrea, 1999; biggs 8c tang, 2007). learning outcomes have been described as the middle ground between over generalized statements of learning (e.g. ‘aims’) and over-specified statements o f learn­ ing (e.g. ‘objectives’) (chadwick, 2004). il o s determine the curriculum content, the teaching and learning approaches or activities carried out and the assessment techniques used to evaluate the end result. i f students are made aware o f ilo s then they are likely to take more responsibility for their own learning. furthermore, when students focus their attention on assessment tasks (as inevitably happens), they should be able to see the explicit links between the il o s and the as­ sessment task. the criteria for assessment should only differ from the il o s by the fact that assessment tasks will neces­ sitate more detail o f performance levels required for specific results or grades. the logic underpinning constructive align­ ment is very simple. biggs and tang (2007) use the analogy o f a parent who wants their child to learn to dress herself. the il o in this case would be for the child to be able to dress herself independently; the teaching and learning ac­ tivity would be for the child to practice dressing herself; and the assessment would be how successful the child is in inde­ pendently dressing herself. ilo s are specified by use o f verbs: w e want students to actively do something, e.g. apply, list, hypothesise etc. in considering the verbs to describe learning outcomes, we can draw on research that has focused on kinds o f knowledge and levels o f understanding. biggs (1999) identifies four different types o f knowledge: 1. declarative knowledge: knowing what, or knowing about, in other words the ‘content’ o f knowledge 2. procedural knowledge: knowing how to do things 3. conditional knowledge: knowing when to do things 4. functioning knowledge: knowing how to employ the first three types o f knowledge to solve problems and function as an effective professional. functioning knowledge is built on the other three types o f knowl­ edge. the relationship between the four different types of knowledge is shown in figure 2. the distinctions between the different types o f knowl­ edge are important as they relate to what the curriculum should be about. i f we want our students to demonstrate functioning knowledge then we need to ensure that the cur­ riculum has outcomes which tap into this level. neverthef ig u re 2. relationships between different kinds o f knowledge (adaptedfrom biggs and collis, 1982) less it is appropriate to mix the levels o f learning required, and a developmental progression should be noted. in a first year course it would be expected to have some lower lev­ el outcomes that deal with the basic facts, moving towards having higher levels that require the students to deal with new situations. the so l o (structure o f the observed learning outcome) taxonomy (biggs 8c collis, 1982) provides a systematic framework for describing how learners’ understanding in­ creases in complexity as they master academic tasks. it has also been used to (a) develop il o s: what is the desired level o f a student’s understanding at the end o f a course?, and (b) evaluate learning outcomes so that we can determine the level at which individual students are actually operating. a visual representation o f the so l o taxonomy is shown in table 1. selecting learning and teaching activities likely to enable the students to attain the outcomes. ' there is increasing awareness that traditional lectures are no longer appropriate for effectively meeting the needs of diverse student populations (biggs 8c tang, 2007; whit-| worth et al, 2004). looking beyond the lecture room there1, are a wide range o f teaching and learning methods suitable i for small or larger groups o f students. some o f these have been systematically researched and evaluated for effective­ ness (see brown 8c atkins, 1988 for a review). problem-based learning (p bl) is an example o f an alter­ native approach to teaching and learning which has received considerable attention and been the source o f some con­ troversy. p b l involves confronting students with problems from practice which provide a stimulus for learning (boud 8c feletti, 1991). p b l typically occurs in small group,-where students are considered to be active participants i n their own learning. facilitators typically select authentic assign­ ments or cases from the discipline. students are required to locate and evaluate various resources in the field (savin baden 8c wilkie, 2004; tan et al., 2005). t o date p b l has been widely implemented in medical curricula (biggs, 2003) but has shown a more limited spread outside medicine. its 9 4 | die suid-afrikaansetydskrif vir kommunikasie-afwykings, vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t o w a r d s c o n s t r u c t iv e a l ig n m e n t in t h e slp c u r r ic u l u m table 1. a summary o f the solo taxonomy (biggs & collins, 19 8 2 ) with hierarchy o f verbs that can be used toform ilos level o f understanding description verbs w hich describe ilos a t that level prestructural the learner m isses the point unistructural the learner’s know ledge is accurate but concrete and m inim alistic identify; do sim ple procedure; m em orize m ultistructural the learner understands boundaries but not o f system s; links between concepts are not made enum erate; describe; list; com bine; do algorithm s; classify relational the learner orchestrates between fact and theory; action and purpose; links are made betw een concepts. compare / contrast; explain causes; analyse; relate; apply; integrate extended abstract t he learner is required to conceptualise at a level beyond w hat has actually been taught theorize; generalize; hypothesise; reflect effectiveness is controversial: proponents o f p b l claim that learning that occurs through p b l is deep and a greater re­ tention o f knowledge occurs (dolmans & schmidt, 1994). students who were asked to evaluate p b l in an occupa­ tional therapy curriculum reported benefits in managing information, critical reasoning, communication and team­ building (hammel et al, 1999). despite some o f the advantages associated with p b l , it has been found to be a resource-intensive approach which means that many university programmes simply do not have the budget to adopt p b l in its pure form. critics o f p b l suggest that there is no real difference in the outcomes of p b l versus non-pbl curricula (colliver, 2000). while students seem to enjoy the approach and may show clini­ cal skills such as problem-solving in advance o f their non p b l peers, the students ultimately lack a solid theoretical foundation and perform more poorly when their theoreti­ cal knowledge is assessed (nandi et al, 2000). furthermore it seems unlikely that p b l alone would give students suf­ ficient opportunity to develop their clinical skills and at­ titudes, e.g. the development o f interpersonal skills and therapeutic manner is something which needs to be learnt in real-life clinical settings with clients, under supervision (grundy, 2004). given the resource issues associated with implementing full-scale p b l , the debate surrounding its efficacy is aca­ demic for many programmes. whitworth et al. (2004) de­ scribe the implementation o f case-based problem-solving for slp students. in' this approach some o f the principles o f p b l were drawn on, but small group problem-solving was just one o f the teach­ ing and learning approaches used in com­ bination with a range o f other methods. brainstorming, role-plays, tutorials and workshops are all teaching and learning activities (tla s) which have been used to good effect. assessing the students' outcomes and grading the students learning. constructive alignment suggests that consideration needs to be given to how students’ learning is assessed, and how a final grade is arrived at. there are two main approaches to assessment: norm referenced assessment and criterion-ref­ erenced assessment. the tradi­ tional norm referenced assessment model is where students’ ‘learning’ is assessed by their responses to individual questions with marks assigned to their ‘correct’ respons­ es. biggs and tang (2007) note that this often encourages stu­ dents to go for a mark ‘trawl’ in exams, trying to pick-up marks here and there rather than being motivated to learn because o f self interest and attempting to under­ stand what it is they have learnt. norm-referenced assessment is where students are compared to each other: those who use this system will typically end up with a bell-shaped curve with a small group o f students who obtain a grades, a larger group obtaining bs, and the big­ gest group obtaining cs, while students with ds and e ’s and f ’s again decrease in number. biggs and tang (2007) describe this as ‘grading on the curve’ (p.166.) criterion-referenced assessment is where grades are awarded according to how well students meet the desired learning outcomes. using this approach, one is required to identify the outcomes that you aim to develop and to what extent as part o f the unit planning and documentation. this becomes sound evidence for students that they have indeed developed in some way these particular attributes. table 2 shows an example o f a generic criterion-referenced grading system. nearly all degree programmes will require the criteria grades to be converted to a grade: this is fairly straightfor­ ward; a good ‘a’ gets 85%, a bare ‘a’ gets 75%, and so on. for a more in-depth discussion o f assessment, see biggs (1999, chapters 8 and 9). formative assessment is assessment that affords students the opportunity to gauge how well they are meeting ilo s. they may receive marks but these do not count towards their final grades for the course. formative assessment is part o f the instructional process. when incorporated into classroom practice, it provides the information needed to adjust teaching and learning while they are happening. in this sense, formative assessment informs both teachers and table 2. example o f a generic criterion-referenced grading system grading criteria g ra d e s w ill d e p e n d o n h o w w e ll y o u c a n d e m o n s tra te th a t you h a v e met all ilo s: a : a w a rd e d if y o u h a v e c le a rly m e t all th e o b je c tiv e s , d is p la y in g d e e p k n o w le d g e o f th e c o n te n t, c re a tiv e / o rig in a l th in k in g , a p p ly in g th e c o n c e p ts e ffe c tiv e ly to n e w s itu a tio n s b: a w a rd e d w h e n a ll o b je c tiv e s h a v e b e e n m e t w e ll a n d e ffe c tiv e ly c: a w a rd e d w h e n th e o b je c tiv e s h a v e b e e n a d d re s s e d s a tis fa c to rily , o r w h e re e v id e n c e is s tro n g fo r s o m e o b je c tiv e s , b u t w e a k e r in o th e rs . f: l e s s th a n c, o r w o rk n o t s u b m itte d (adapted from biggs, 2003) the south african journal of c o m m u n ic atio n disorders, vol. 55 2008 | 95 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) michelle pascoe & shajila singh students about student understanding at a point when time­ ly adjustments can be made. summative assessment also af­ fords students the opportunity to gauge how well they have met il o s but these marks are used towards final grades. in a balanced and transparent assessment system, both sum­ mative and formative assessments are an integral part o f in­ formation gathering. constructive alignment was developed in order to pro­ mote quality learning at university (biggs, 1996, 1999) and to address some o f the challenges associated with higher education outlined in the previous section. proponents of constructive alignment aim to move students away from surface learning toward deep learning. rather than having students ‘cramming’ for examinations but not being able to remember and truly understand what is learnt in the longer term, constructive alignment aims to promote active learn­ ing where students take responsibility for their own learn­ ing and leave university as life-long learners equipped with the necessary skills and motivation to continue to develop their learning in the workplace. these are important aims for slp educators (whitworth et al., 2004; penn, 2007). this study aims to describe how principles o f constructive alignment were applied to a first year course in our slp programme (human communication development), a key foundation for both sl p and audiology programmes. method aim the main aim o f this paper is to describe the curriculum revision process that took place with one sl p course based on the principles o f constructive alignment. more specifi­ cally the study aimed to describe the intended learning out­ comes (ilos); teaching and learning activities (tlas) and assessment that have been devised for this course, and to present a template which can be used for mapping these. design and overview this study was carried out following principles o f partici­ patory action research which focused on one specific course within an slp programme that is treated as a self-contained case. participatory action research focuses on the effects of researchers’ actions within a community with the goal of improving the performance o f the community (reason 8c bradbury, 2001). a cyclical method o f planning, taking ac­ tion, observing, evaluating and critical reflecting are em­ ployed. it is a collaborative method to test new ideas and implement action for change, and for these reasons was ap­ propriate for the ongoing nature o f the curriculum revisions within the slp programme. three phases o f the study are described in this paper. these phases are: phase 1: preparatory work and review o f existing course phase 2: framework and principles .phase 3: documentation two remaining phases (implementation and evaluation) are part o f the participatory action research cycle that have yet to be carried out. participants ah academic and clinical staff working in the slp and audiology programmes participated in the study (n=13). it was considered that although clinical educators are not di recdy involved in carrying out academic teaching and have no clinical contact with slp students in first year, they could provide valuable input into the curriculum based on their own experiences as slp/audiology students, then as qualified slp/audiologists in the workplace and through their clinical teaching experiences with slp students o f lat­ er years. first year slp and audiology students (n=34) con­ tributed to phase 1 o f the study. procedure phase 1: preparatory work and review o f existing course slp staff met for two hours on a weekly basis over the course o f one university term. initial meetings focused on establishment o f a contract for the sl p ‘curriculum working group’, whereby all staff were invited to participate in the curriculum revision process in a collegial atmosphere and with respect for each others opinions. it was agreed that the curriculum work should reflect the consensus o f the group and belonged to the entire staff rather than to one or two individuals. although course convenors were assigned ul­ timate responsibility for each course, it was agreed that all would give input and in theory any member o f staff should be able to teach the course. a time frame was agreed. staff carried out readings to develop their knowledge of current practice and research into curriculum design and universi­ ty teaching / adult education. discussions o f readings took place and staff decided to document their own personal per­ spectives on this learning process in reflective logs. these reflections were an ongoing part o f the research described here, rather than being limited to a specific phase o f the study. the course outline for the existing course was dis­ cussed and reviewed in the light o f readings into curricu­ lum design. the process was documented and placed on the intranet for students o f the programme to give input on, as they could not attend the curriculum discussions given their busy schedules. anonymous student feedback about the existing course was collected using a written questionnaire. thirty-four stu­ dents completed feedback sheets at the end o f the course. the questionnaires used a 5 point rating scale to assess as­ pects o f the course related to (a) learners own knowledge that they brought to the course; (b) clarity and explicitness o f il o ’s o f the course; (c) content o f the course; (d) the teaching and learning activities used; (e) assessment meth­ ods, and (f) overall rating o f the learning experience and the effect o f the course on the student's interest in the sub­ ject. in addition space was provided in the written feedback sheet for learners’ to add their own comments on any as­ pects o f the course. phase 2: framework and principles in this phase, the staff agreed on a guiding framework and principles that would ensure the new course curriculum was educationally sound and based on a body o f theoretical knowledge. in addition to consideration o f these theoreti­ cal aspects, attention was given to practical aspects such as a template which could be used to capture the discussion o f key components o f constructive alignment. phase 3: documentation in the final phase, the specific details o f the constructive alignment was documented using the template devised in phase 2. results for phase 2 and 3 are presented separately, but in keeping with the nature o f participatory action re­ 96 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, v o l 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t o w a r d s c o n s t r u c t iv e a l ig n m e n t in t h e slp c u r r ic u l u m search they were closely linked and in reality overlapped to a great extent, e.g. when the template was actually used it was found to be missing key aspects, and this necessitated revision o f the template; at various points we reconsidered theoretical underpinnings and continued to read widely throughout. results results are presented following the three phases o f the study. phase 1: preparatory work and review o f existing course the course human communication development (h cd ) is a first year, first semester course that all students in the four year slp and audiology programmes are required to take. the course aims to introduce students to normal processes o f human communication and give them an understanding o f how communication develops over the life-span. it is a pre-clinical course that forms the foundation o f most other courses in the sl p and audiology programmes. it consists o f 48 contact hours and in 2008 was taken by 34 students, from both speech pathology and audiology programmes. the course was previously known as “normal speech, lan­ guage and hearing development” but the title was changed to reflect the diversity o f communication development ver­ sus one ‘standard’ norm. this thinking fits with the pro­ gramme’s philosophy o f inclusiveness o f cultural and lin­ guistic diversity o f learners in current classes. appendix 1 shows the unrevised version o f the course aims. immediately striking about the existing course outline was that there are a great many aims and objectives. biggs and tang (2007) suggest that il o ’s should not exceed more than about 7 or 8 since greater breadth o f coverage typically means that the depth o f understanding is compromised. in the existing course outline there were 4 broad aims, and 12 more specific objectives which were grouped into knowl­ edge, skills and attitudes categories. many of these will re­ main appropriate but consideration needs to be given to the core knowledge that is essential for students to acquire rath­ er than the knowledge, skills and attitudes that are ‘nice to have.’ in order for constructive alignment to occur il o s will need to be specifically stated using appropriate verbs which can then be used to guide the t l a s and assessments. the existing aims had been outlined from the educators’, rather than the learners’ point o f view, e.g. ‘t o provide a compre­ hensive working knowledge o f normal speech, language and hearing development from birth, through the infant-, tod­ dler-, pre-school and school-age phases.’ the information in appendix 1 shows the emphasis that previous curriculum revisions have placed on content rather than on tla s and assessment. as it stood the course objectives were considered to be broadly appropri­ ate as ilo s: they used verbs which fit with the frameworks outlined in the previous section. nevertheless these needed to be prioritised, and reviewed so that they linked up explic­ itly with the teaching and learning activities used to achieve outcomes (not included previously) and assessment (also not detailed previously). no sense was given in this docu­ ment o f the criteria by which students’ performance on this course would be judged. students evaluated the existing, unrevised course (in which they participated in the first semester o f 2008) by anonymously completing a written questionnaire handed to them in the last session o f that course. the results will be compared with the results from the new cohort of first year table 3. summary o f first year student feedback o f existing human communication development course area of evaluation -t i i 1 mean rating (1 unsatisfactory; 3=average; 5=excellent) qualitative comments a: learners own knowledge that they brought to the course j 3.25 b: clarity and explicitness of ilo’s of the course j 4.16 c: content of the course' 1 3.91 “very interesting.’ “stimulating and easy to cope with.” “unstimulating in terms of content.” d: the teaching and learning activities used 4.25 “it would be nice to watch more movies about speech.” “the lecturer should use more methods to attain the students’ attention better." “a touch boring at times...should be more interactive.” “slides got a bit boring at times." “more visuals and practicals would help us from getting bored." e: assessment methods and feedback 3.8 “i didn’t feel i could adequately judge my progress.” “have more tests so we can judge our progress better." “have spot tests and more practise throughout the course.” “mark tests more strictly so that we know the “perfect answer.” “i loved the project on child development: creative activities are fun and help learning." f: overall rating of the learning experience and the effect of the course on the student's interest in the subject 4.12 “it has given me a broad base to build on." “on the whole has gone well but i find it hard to keep up with reading.” the south african journal of c o m m u n ic atio n disorders, v o l 55 2008 | 97 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) michelle pascoe & shajila singh students who will experience the revised course in the first semester o f 2009. results from key questions o f the student evaluation feedback are presented in table 3. table 3 shows that while the overall rating given by stu­ dents was good; the areas around which most critical feed­ back was obtained was in the area o f teaching and learning activities, and assessment. in terms o f t la s many students noted that they would have preferred more interaction, rather than the lecture-based format which was primarily employed. in terms o f assessment it was interesting to note that several students asked for many assessments so that they could develop a greater sense o f how their learning was progressing. some o f the qualitative comments provided support for the use o f a practical assignment. all in all the course received a positive evaluation, but there is certainly room to improve each o f the aspects outlined in table 3 and most specifically the t l a s and assessments. at this point in staff participants’ learning journey there was a general sense o f excitement and o f the importance of transforming the curriculum, however uncertainty about the outcome o f the process was also high as illustrated by ex­ cerpts from staff reflective logs below: participant 1: “reading a wide-range o f papers on teach­ ing and learning was fascinating. i never knew that this whole body o f literature existed despite my job as a lec­ turer and being involved in education in schools [as an slp]. however, i ’m not sure how this knowledge will be applied to our curriculum and what we are actually hoping to achieve?” participant 2: “i know that there are problems with the course but i ’m not sure how we intend to tackle these and whether sessions like this are the best way o f using precious time.” participant 3: “the discussion about the most relevant taxonomy felt like it might be theoretically interesting but it felt divorced from the real problems with the curriculum. i felt overwhelmed and unsure about the contributions i could make. i feel like a ‘back-row’ girl. this really isn’t my area o f expertise.” participant 4: “w e have decided to document the [cur­ riculum review] process as a research project. it’s immedi­ ately made me view my teaching colleagues as research col­ laborators too and made the team feel stronger. w e started discussing the rationale for what we were doing, aims and methods and it felt exciting to be all pooling our ideas and moving forward, planning future sessions etc. i am still not entirely sure about what the outcome will be but i feel more accepting o f this now because that is what research is all about.” phase 1: summary at the end o f this phase it was concluded that the course has many strengths as it stands: the content is appropriate for the level o f the programme and is broadly aligned with the il o s o f the programme. however, aims and objectives need to be reconsidered so that a smaller and more focused set o f il o s are chosen. these then need to be used to guide the t la s and assessment. criterion referenced guidelines for students taking this course need to be developed. feed­ back from students suggests that the course is currently working well but that students have specific criticisms re­ lated mainly to the t la s used and the assessments. phase 2: framework and principles constructive alignment was the overriding principle used to guide the curriculum review process. it was agreed that for each course the following process should be followed: a. ilo s: list a small set o f ilos. these should capture the core outcomes that are required for students to achieve by the end o f each course. each il o will require an ap­ propriate verb since we want the emphasis to be on what the students can do by the end o f the course (see table 1). each il o can be broken down further into the type (see figure 2) and level o f knowledge (table 1) that is required. where appropriate, skills and attitudes that will be required to achieve the il o should be explicitly stated to ensure that a progression o f learning takes place. b. content: outline the content o f the course by top­ ic area, including a specification o f the depth o f each top­ ic to be covered ranging from minimal depth (*) to mod­ erate depth (**) to most in-depth (***). content should be pared down to what is essential to know, rather than what is ‘nice to know’ following principles o f curriculum unloading (biggs & t a n g , 2007). c. tla s: describe tlas. these should link explicitly with ilo s, thus for example if students are required to ap­ ply knowledge o f normal communication to specific cases (an il o ), then they should be given opportunity to do so in tl a s, e.g. either through case-based learning or through visits to appropriate clinical / educational sites. since it is known that lectures are no longer appropriate as the only t l a , a wide range o f more innovative and effective t la s should be considered. d. assessment: describe assessment. both formative and summative assessments should be included for each course. assessments should be explicitly aligned with il o s and tl a s. in some cases assessments will be the same as tla s and this is when alignment is perfect and should not be regarded as a problem (biggs & t an g , 2007). linked to the assessment tasks is the need for each course to contain a criterion referenced guideline where students’ perform­ ances are described in terms o f attributes (e.g. see table 2 for a generic example). these criteria can be used in assess­ ing students’ performance in both formative and summative assessment tasks; as well as helping students to be explicitly aware o f where they are currently at in their learning, and what they will need to achieve in order to progress to an­ other grade level. e . philosophical underpinnings. ensure that the philo­ sophical underpinnings o f the programme are reflected appro­ priately in each specific course. alignment can take place at a range o f levels. one way in which we aim to ensure that each specific course meets the needs o f the context and is relevant to the broader programme and institutional agenda is by explicitly considering key themes or philosophical un­ derpinnings o f the programmes. in our programme these include: a. primary health care and contextual relevance b. disability and burden o f disease c. ethics and human rights d. biopsychosocial models o f health e. developing agents for change 98 | die suid-afrikaansetydskrif vir kommunikasie-afwykings, vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t o w a r d s c o n s t r u c t iv e a l ig n m e n t in t h e slp c u r r ic u l u m f. equity and affirmation o f diversity. each o f these aspects should be included where possi­ ble in relevant sections o f the courses under discussion. a checklist at the end o f the template reminds participants to consider whether key themes have emerged in the curricu­ lum outline, and where necessary these can be more explic­ itly included. staff participants showed a mixed range o f feelings at this point in the process: some were overwhelmed and ap­ prehensive about the amount o f work that needed to be done and the amount o f time that it would take. others were excited about the progress that had been made and the innovations that could be implemented. specific examples include: participant 7: “wow! i ’ve always thought that the first years o f training are just about theory, and as a clinical edu­ cator i didn’t think i ’d have much to offer. but now i ’m re­ alising how we have to think ahead to the clinical practice years, and i think we really can make a difference in filling the gap between classroom and on-site learning.” participant 2: “i ’m so excited... almost euphoric at this realisation that as long as we follow guidelines from the the­ ory we can facilitate learning in whatever innovative ways we choose... ” participant 9: “i have always felt bad, like a bit o f a shirk­ er if i don’t lecture classes for the full 2 hours. but through this project i am realising that this is absolutely fine desir­ able even especially as we know il o s can be met through other more exciting ways.” participant 12: “it’s just all come together. i think we are all understanding what it’s all about! and actually to take that a step further and understand more about the learning process and the challenges that our students go through... it’s been the same for us.” phase 2: summary, a t the end o f this phase, staff participants had arrived at a template which could be used to capture all the necessary elements for constructive alignment at the level o f individ­ ual courses. the blank template is included in appendix 2. phase 3: documentation revision o f the existing course following principles o f constructive alignment has meant that the new course has ilo s that are closely aligned with t l a s and assess­ ment. table 4 shows the newly-aligned h c d course which speech-language pathology and audiology students will take in the first semester 2009. the layout o f the table helps to make the alignment visually explicit. column a: ilo s the first column o f table 4 delineates the il o s which were selected for this specific course. this column is un­ doubtedly the most important o f the table: the cornerstone on which the remainder o f the table depends. this impor­ tance was reflected in the large amount o f discussion and debate that was generated among staff participants for each il o . each o f the six il o s for this specific course is ac­ companied by an explicit statement about the level and type o f knowledge required based on the theoretical frameworks summarised in table 1 and figure 2. six ilo s were selected to capture the core outcomes of the course. this smaller number was in contrast to the larger number o f aims / objectives stated in the previous version o f the course (a ppendix 1). through the careful selection o f these il o s, the course has been ‘unloaded.’ i t is our belief that this will encourage deep learning o f essential informa­ tion that students will be able to retain and build on in fu­ ture courses, rather than surface learning o f a large number o f facts which most students will forget shortly after the final examination. the focus has shifted from breadth to depth as suggested by biggs and tang (2007). the verbs included in our il o s for this course are limited only to ‘list’ (e.g. i l 0 4 : “list principles o f normal develoment’) and ‘describe’ (e.g. i l 0 3 : ‘describe anatomy and physiology o f the auditory system and speech mechanism.’) and thus are reflective of declarative knowledge (knowing ‘what’) at the multistruc tural level. it was felt that these low level verbs are appropri­ ate for a first year, first semester course, and in our planning o f courses that follow this one the developmental progres­ sion to higher levels o f knowledge is seen. i l o l (‘describe the scope o f practice o f speech-lan guage pathology and audiology professions’) may seem an unusual choice o f outcome for a course in typical develop­ ment o f communication. however, given the overall aims o f the programme: to produce competent professionals who meet the exit level criteria o f the h pc sa , staff participants considered it important to explicitly and upfront expose first year students to issues surrounding scope o f practice. this course is an obvious place to do so. il o s typically focus on knowledge, which is clearly a key component o f our tem­ plate. however it was felt that skills and attitudes should also be explicitly stated in our template as linked to each outcome. table 4 shows common threads in both o f these areas: staff participants felt strongly that skills possessed by ‘thinking therapists’ such as the ability to critically self-re flect (see il o s 1 and 4), work well in groups (see il o s 2 and 3), and be respectful and accepting towards diversity o f all kinds (see il o s 4, 5, and 6) are skills which should be encouraged from the earliest part o f the curriculum, and not only in the clinical practicum o f the programme. i l 0 3 ‘describe anatomy and physiology o f the auditory system and speech mechanism’ has been included as slp students will no longer take an in depth 12-week course on anatomy and physiology o f the ear, hence further unloading. column b : content column b focused on content areas that will need to be covered in the course, and is analogous to a course outline in more traditionally formatted student handouts. since previ­ ous curriculum work had focused primarily on content, the content o f the course did not differ substantially to that o f the original course (as shown in appendix 1). one o f the changes in the area o f content links to il o 1: the overview o f the professions. however, one o f the advantages o f con­ structive alignment is that once the issue o f what students should achieve by the end o f the course has been addressed (i.e. il o s formulated) the content leads on from here in a fairly straightforward way. the major challenge associated with selection o f content is that one cannot include eve­ rything on a given topic! authors such as irving and potts (2004), and biggs and tang (2007) note that dominance o f content limits the aims o f teaching and reduces develop­ ment o f skills. the south african journal of c o m m u n ic atio n disorders, vol. 55 2008 99 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) michelle pascoe & shajila singh table 4. the revised human communication development course showing alignment of ilos, tlas and assessment a. intended learning outcome (ilo) b. content * minimal depth " moderate depth " * most in-depth topic c. teaching and learning activities d. assessment, il01 knowledge: describe the scope of practice of speech-language pathology and audiology professions. • level: multistructural • type: declarative skills: ability to reflect on own communication attitudes: appreciation of the scope and boundaries of each profession; willingness to make links with those in other health related courses. “ what is a speech-language pathologist? "w h a t is an audiologist? “ terminology such as communication, speech, language, disability, hearing impairment and deafness lecture (introductory) self-directed study • internet search for information relating to the professions of slp / audiology in south africa and one other country. • creation of own glossary of terms formative: spoken explanation to first year students on another course (e.g. occupational therapy, physiotherapy or medicine) about what is meant by slp or audiology. together students fill out a worksheet which encourages self-reflection. il02 knowledge: describe the communication chain, and list difficulties which might occur when breakdown happens at different points in the chain. • level: multistructural • type: declarative skills: ability to solve problems; and develop logical thinking. attitudes: develop an appreciation for benefits of working in a group " * the communication chain * breakdown in the communication chain and difficulties that may occur. lecture (introductory) peer-learning • small group discussion of communication chain and areas of breakdown • problem-solving worksheet where groups of students are required to map specific communication difficulties onto the communication chain. formative: class quiz il03 knowledge: describe anatomy and physiology of the auditory system and speech mechanism. • level: multistructural • type: declarative skills: ability to solve problems; and develop logical thinking. attitudes: develop an appreciation for benefits of working a group 'anatomy and physiology of hearing and balance 'effects of hearing loss 'm ost common pathologies. 'five physiological processes needed for speech production (respiration, resonance, phonation, prosody and articulation) together with key anatomical structures 'effects of difficulties with the above processes 'common speech / language difficulties. lectures self-directed study • intranet worksheets • adding of new terminology to glossary peer-learning • problem solving worksheet where small groups of students are required to discuss and make links between given symptoms and possible causes. formative: intranet worksheets and quiz; class presentations/plenary from problem solving activities / 100 | die suid-afrikaansetydskrif vir kommunikasie-afwykings, v o l 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t o w a r d s c o n s t r u c t iv e a l ig n m e n t in t h e slp c u r r ic u l u m il04 knowledge: list principles of normal development. • level: multistructural • type: declarative skills: engagement with young children: ability to carry out critical / structured observation; make links between observations and literature; self-reflection skills. attitudes: respect and appreciation of diversity in peer and clients; professional behaviour. 'developmental patterns 'developmental predictability 'developmental milestones 'developmental opportunities 'developmental phases 'individual differences & multicultural issues lecture (introductory) self-directed learning: • reflection task: students contact a relative who knew them when they were younger and share information on their own early language learning and achievement of developmental milestones. feedback to small groups in class. experiential learning: • students spend 2 hours in a local creche carrying out semi-structured observations of young children. students work in pairs, unless this is not practical for the setting (room too small; child overwhelmed etc.) in which case they should work individually but still have a partner with whom they share observations. formative: • small group discussions where a pair of students discuss their observations with another pair. • individual self reflection worksheet based on creche observations experience il05 knowledge: list main categories of development, and be able to identify behaviours that fall within each area and key milestones. • level: multistructural • type: declarative skills: engagement with young children; ability to carry out critical / structured observation; make links between observations and literature; development of writing and presentation skills; referencing of appropriate sources of information attitudes: respect and appreciation of diversity in children; professionalism; empowered to use literature for problem-solving and become life­ long learners; they can be agents of change by educating parents and promoting communication development. 'motor development: gross and fine 'cognitive development and play 'social-emotional development 'communication development including speech, language and auditory development " a framework for describing language development: form, content and use lecture (introductory) experiential learning: • students spend a further 2 hours in a local cr&che (as above) carrying out further semi-structured observations. peer-learning: • students are grouped according to the ages of children they observed. these small groups pool their findings and give an oral presentation based on creche observations. communal constructivism: • material development for prevention of communication difficulties / promotion of communication skills (i.e. pamphlets, posters) together with short essay on rationale for selection and use in specific contexts which can be formative: • peer presentation based on creche observations; different student groups to focus on different age groups) summative: • material development (i.e. pamphlets, posters) together with short essay on rationale for selection and use in specific contexts the south african journal of c o m m u n ic atio n disorders, v o l 55 2008 | 101 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) michelle pascoe & shajila singh stored in a file in clinical resources room and accessed by all students and staff for use with clients / parents. il06 knowledge: describe key aspects of communication development in children aged 0-3 years; 3-6 years and 6+ years. level: multistructural • type: declarative skills: engagement with young children; ability to carry out critical / structured observation; make links between observations and literature; development of writing and presentation skills; referencing of appropriate sources of information attitudes: respect and appreciation of diversity in children; awareness of influence of contextual factors, e.g. culture; professionalism; empowered to use literature for problem-solving and become life-long learners. ’ relationship between thought and language* **lnfant-caregiver interactions: universals and socio-cultural differences; joint reference, joint action, turn-taking "h earing and auditory development (suprasegmental, segmental and auditory processing) **play (early interactive, symbolic and associative) "expressive and receptive language "d evelopm ent of language form (syntax, morphology and phonology) "d evelopm ent of language content (semantics) "d evelopm ent of language use (social and conversational) 'metalinguistic and literacy development lecture (introductory) video: depicting and discussing aspects of typical language development. experiential learning: students spend a further 2 hours in a local creche (as above) carrying out further semi-structured observations. peer learning: • students are grouped according to the ages o f children they observed. these small groups pool their findings and give an oral presentation based on creche observations. communal constructivism: • as above formative: peer presentation based on creche observations; different student groups to focus on different age groups) summative: • material development (i.e. pamphlets, posters) together with short essay on rationale for selection and use in specific contexts • submission of a reflective log outlining individual experience of creche visits. checklist: themes underpinning all aspects of the curriculum 1. primary health care and contextual relevance 2. disability and burden of disease 3. ethics and human rights 4. biopsychosocial models o f health 5. developing agents for change 6. equity and affirmation of diversity explicitly included in il01 (c); il05 (c,d); il06 (c;d) il02; il03 (b) il06 ilo 4 il01 (d); il05 (c,d); il06 (c;d) ilo 4 (b, c); ilq5; ilq6_________ one way in which we tried to manage the volume o f content in this course (and others) is by using a system for grading the depth to which a specific topic should be cov­ ered. thus for example, i l 0 4 (‘list principles o f normal development’) includes a fairly large number o f key topics, but these are content areas that have been graded as mini­ mal depth (*) and are thus considered important enough to be included, but relatively unimportant in relation to topic areas marked with two (**) or three (***) stars. column c : t l a s having selected il o s appropriate for the course, tla s are normally relatively easy to select since they should speak directly to what it is that we want students to be able to do by the end o f the course. it is acknowledged that lectures are no longer sufficient and appropriate for the type o f learning that is needed at university (biggs 8c tang, 2007; brum fitt, 2004; whitworth et al, 2004). through this curriculum revision process staff have become creative and more flex­ ible about the alternatives to traditional lectures. neverthe­ less table 4 shows how for all o f the six ilo s some tradi-, tional lectures have been included. for il o s 1,2,4,5 and 6 \ these will take the form o f introductory or ‘scene setting’ j lectures which may last from a 15 minute talk to 45 min­ utes. for il o 3 ‘describe anatomy and physiology o f the 1 auditory system and speech mechanism’ more lectures will take place. the inclusion o f lectures as t la s in this revised course may to some extent reflect the difficulty that lectur­ ers, used to teaching largely in this way (and most likely having been taught themselves predominantly through this' t l a ), feel when having to abandon this method o f teach­ ing. indeed the title ‘lecturer’ says it all! another reason for maintaining some lectures in the revised curriculum is that many o f the other t l a s carry associated costs which are high in terms o f budget and time: experiential learning outside o f the university is undoubtedly valuable but needs to be balanced with other more cost-effective and practical means o f teaching / learning. in addition to traditional lectures, the tla s for the h c d 102 | die suid-afrikaansetydskrif vir kommunikasie-afwykings,vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t o w a r d s c o n s t r u c t iv e a l ig n m e n t in t h e slp c u r r ic u l u m course are grouped into 4 main categories: (1) self-directed study, (2) peer-based learning, (3) experiential learning, and (4) communal constructivism. self-directed study activities encourage learners to engage with novel concepts in active ways which make students more likely to use and ‘own’ the associated language, than if only passively hearing the lan­ guage in lectures. our planned self-directed study activities include intranet and internet research, and the development o f a glossary o f key terms which can be built on through­ out the 4 years o f study. peer-based learning involves stu­ dents working together and learning from each other. spe­ cific activities involving peer learning in this course include small group discussions on specific topics (e.g. see i l 0 2 ) ; completion o f problem solving exercises (see il o s 2, 3) and group presentations (see ilo s 5, 6). experiential learning occurs where students learn ‘on the job’ and this has typi­ cally occurred in later years o f the slp programme. how­ ever, bearing in mind the ultimate outcomes o f the pro­ gramme, and frequent complaints from clinical educators that students do not know what to expect from, for exam­ ple, a typically developing three-year old, it was considered important for students to have contact with children from as early as possible in the course. note that the outcomes around the experiential learning activities in the local creche not only include acquisition o f knowledge about how typ­ ically children develop and behave, but also skills aspects such as learning to present oneself in an appropriate profes­ sional manner. in the h c d course students will spend a total o f 6 hours in the local creche and much o f the tla s and assessment centre around this. students will be given specific time slots, previously used for lectures, to visit the creche. our final t l a is that o f communal constructivism where students are given the opportunity to create materials that can be used in their own future clinical years to prevent communication difficulties and promote normal communi­ cation development. jthese materials will be housed in the departmental resource library where they can be freely ac­ cessed by students of|all years, and it is envisaged that future years o f students will contribute and develop them further. this is an example o f how students are to be tasked not only with constructing their own knowledge but also with cre­ ating tangible academic materials with and for each other. this assignment is a modified version o f the assignment that was carried out in the unrevised version o f the course, and which students appeared to find useful and engaging as ex­ emplified by the student comment in table 3: “...creative activities are fun and help learning.” column d : assessment the final column o f table 4 focuses on assess­ ment o f ilo s. these are divided into formative and summative, and is an aspect o f the course in which major changes were made. in the unre­ vised version o f the h c d course there were few if any formative assessments carried out, leading students to make the following comments: “have spot tests course.” (from table 3). and more practise throughout the the revised course now includes several formative assess­ ments taking a variety o f formats which include both in­ dividual and group work, e.g. i l o l is assessed by asking students to complete and submit a self-reflective worksheet; i l 0 2 is assessed though a short written quiz taken in the first 10 minutes o f the sessions; i l 0 5 is assessed through peer presentations in which small groups will share findings with the class. w e envisage giving the presenting students qualitative and quantitative feedback from both the course lecturer and the student audience. summative assessment centres around the communal constructivism task where students are required to develop materials for prevention / promotion purposes. it will be noted that this assessment is identical to the t l a , something which biggs and tang (2007) suggest should not be viewed as a problem but rather an example o f good alignment: recall the example o f the child learning to dress herself where the t l a is dressing herself and the assessment is how well she dresses herself. the materials development is divided into two components: firstly students will receive a group mark for the materials that they develop as a team; secondly they receive an indi­ vidual mark for their own written essay that explains ration­ ale and thinking beyond the development o f the materials. the final summative assessment is submission o f a reflective log outlining the individual experience o f the creche visits. in the unrevised version o f the course, final assessment in­ volved a two hour written exam which included a range o f multiple choice / true-false and short answer questions cov­ ering a broad range o f information in minimal depth. in table 4 it can be seen that there is an overlap be­ tween assessments and ilo s. each il o needs to be as­ sessed, but it does not mean that each il o needs to have its own unique assessment. for example, one assessment task may measure the level o f attainment o f a number of related learning outcomes as shown in figure 3 below which maps the links between ilo s and summative assessment tasks. our assessment criteria for each o f the assessment tasks in this course follows a criterion based approach where stu­ dents are not graded ‘against a curve’ or assigned marks for each fact that they remember, but rather are assessed in terms o f a set o f graduate attributes. these are shown in table 5. f ig u re 3. relationship between ilos and summative assessment tasks l earning o u tc o m e s s u m m a tiv e a s s e ss m e n t “i didn’t feel i could adequately judge my progress.” “have more tests so we can judge our progress better.” the south african journal of c o m m u n ic atio n disorders, v o l 55 2008 | 103 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) michelle pascoe & shajila singh checklist of key themes the final component o f table 4 is consideration of the key themes or underlying philosophy o f our slp pro­ gramme. here it can be seen that each o f the key themes has come through at some point in the revised curriculum for the h c d course. the themes are addressed to varying depths and revisited over the entire curriculum, e.g. theme 3: ethics and human rights will emerge more clearly, in for example, the early intervention course that follows this course in the second semester. the checklist is included to remind us o f the key themes; ensure that at least o f some o f them are covered and enable us to determine at a glance which have been covered and which will need to come through strongly at other points in the curriculum. staff participants shared a range o f mixed feelings about the curriculum revision process at this point. on the one hand there was a great sense o f accomplishment, exempli­ fied by comments such as: participant 2: “w e have done so well. w hat a good team! i am really pleased and impressed at how everyone has con­ tributed.” participant 8: “i feel really pleased. it was harder than i thought it would be and i feel my brain has had a good workout. it has been great working on this together and it shows how our collective brains are better than one!” at the same time participants were realistic about the great amount o f time and work that had been demanded of them, and the fact that there was a great deal more work to follow: participant 10: “it has been great and i think we all feel a strong sense o f accomplishment. i do feel sad and a bit sorry for all my previous student groups... they didn’t have the benefit o f these new teaching / learning experiences.” participant 11: “it’s been amazing. i am proud to have been part o f the team and that we worked together so well. it is a lot o f hard work.. .and it isn’t finished yet.” phase 3 summary in this phase o f the study staff participants used the tem­ plate developed in phase 2 to redesign the ilo s, t la s and assessment for the h c d course. the course was unloaded in terms o f content, and il o s reduced to six clear state­ ments linked to theoretical models o f learning, and with requisite knowledge, skills and attitudes described. in ad­ dition it contributed to the unloading o f the sl p curricu­ lum as inclusion o f i l 0 3 ‘describe anatomy and physiology o f the auditory system and speech mechanism’ permitted one 12 weekvcourse to be removed. new t l a s were out­ lined so that students have the opportunity to engage more closely and hands-on with their studies. a greater variety o f assessments were described giving students the oppor­ tunity to more accurately gauge their own progress through the course through formative assessment, and moving away from examination situations which encourage shallow learn­ ing. through the use o f a checklist staff participants were able to ensure that this one specific course stills emphasises the key philosophical underpinnings o f the programme as a whole. discussion advocates o f constructive alignment are many (e.g. co­ hen, 1987; biggs, 1996; biggs 8c tang, 2007; harden, crosby 8c davis, 1999): it is an approach which has strong intuitive appeal. however, there are critics o f constructive alignment who argue that its true value has yet to be dem­ onstrated (e.g. jervis 8c jervis, 2005). indeed it is true that while a literature search for ‘constructive alignment’ yields a great many papers, few o f these can be considered evalua­ tions o f the effectiveness o f the approach. how will the success o f our newly aligned h c d course be evaluated? one way in which we plan to evaluate effec­ tiveness is through the use o f the student evaluation ques­ tionnaire that was described in phase i o f this study. a l­ though the quantitative data from that instrument showed largely positive feedback, the qualitative comments suggest­ ed a range o f difficulties specifically with t l a s and assess­ ment. the written questionnaire which students completed at the end o f the course for evaluation purposes was not designed specifically for the research described here, but is rather a generic student feedback evaluation. more sensitive and specific evaluation materials need to be designed which can take into account aspects o f the revised curriculum and constructive alignment, e.g. students might be asked more explicitly for comments about the nature o f ilo s, and whether t l a s are helpful in facilitating these. quantita­ tively, student grades might be compared preand post cur­ riculum changes. however such an exercise may fail to cap­ ture the changes that have been brought to the course: the student cohorts who are being compared will be different; the grades may differ because o f the marking criteria used and the nature o f the assignments. it will be a challenge to know whether it is the explicit alignment itself that may have brought about changes, or the use o f more innovative t l a ’s or indeed more wide-ranging assessments which in­ clude formative tasks. challenges in evaluating the effec­ tiveness o f curriculum changes are numerous and may be one o f the reasons why there are very few studies which have actually demonstrated the value o f constructive alignment in learning outcomes when compared to courses which are for example, not explicitly aligned. brabrand (2007) describes positive changes that were brought about through the constructive alignment process in his science course, but these changes centre around his own subjective opinions rather than objective measures of these changes. he notes: “.. .it is my experience that.. .constructive alignment pro­ vides... insights on where and how to optimize the teach­ ing system for student learning in making sure the students have the necessary incentive and support for learning. it is also my own personal experience that the course and the quality o f the projects handed in by the students improved significantly with alignment.” (p.13). braband (2007) did evaluate his students’ satisfaction with the course pre-and post alignment, and also, includes some qualitative data from student feedback forms howev­ er as has been noted before it is difficult to account for why: change occurred and whether it is due to teaching methods and alignment, or the student group itself. , : . another criticism o f constructive alignment is that the focus on outcomes is too limiting especially in higher educa104 | die suid-afrikaansetydskrifvir kommunikasie-afwykings,vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) towards constructive alig nm ent in the slp curriculum table 5: hum an c om m unication d evelopm ent: grading criteria grades will depend on how well you can demonstrate that you have met all ilos: grade excellent performance: in-depth understanding of course content across all ilos; offers creative information and innovative solutions. demonstrates that knowledge is supplemented by ongoing and additional reading / observations beyond what is expected in this course. student has sound knowledge and excellent reasoning to work independently. shows advanced self-reflection skills and works well in all groups. 75+ very good performance: very good understanding of the course content. comprehensively covers all issues with minimal support from facilitators and takes initiative to provide additional information. shows awareness of literature and ability to access it independently and use it appropriately. reasoning skills are developing well and student shows good evidence of self-reflection skills and ability to work in groups. 70-74 good performance: student demonstrates good understanding of the course content, although some ilos are met more completely than others. needs refinement in clinical reasoning, and development of self-reflection skills. make some attempt to refer to literature but needs to develop knowledge of links between what is read and what is observed; works well in groups but needs to develop group working skills further and spend more time engaging with learning to develop depth of knowledge in all areas. 60-69 pass, fair performance: meets ilos at a minimally acceptable level; understands course content but at minimal depth and may have difficulty linking to literature; or may have specific difficulties with achieving particular ilos. reasoning skills and self-reflection skills are adequate at a basic level for the year group and show potential to develop; group work may be a challenge and the student may rely heavily on others in the group. 50-59 below minimumjcompetence: student has not met all ilos and shows limited or shallow learning; no links to literature; poor or lacking in reasoning and reflection skills; attitudinal issues may be problematic; student will not be adequately prepared to function in a clinical setting; student is able to contribute minimally to group work. ............................ i ................................ .. ..................... .. 45-49 unsatisfactory: student has achieved few if any ilos; learning is shallow and limited; student shows no evidence of reading or awareness of literature beyond course notes; attitudinal issues are noted; student will not be able to function in clinical setting; contributes minimally if at all to group work; self-reflection and reasoning skills are minimal or non-existent 0-45 tion and will result in “the death o f originality and serendip­ ity” (jervis 8cjervis, 2005, p. 7; and see also hamilton, 1999) as students may obtain other outcomes through t l a ’s that were not planned for by the course designers. this is an issue already mentioned in the context o f the key themes o f our programme: we expect all key themes to explicitly emerge in this course. however theme 3: ethics and human rights is likely to emerge in a fairly limited way, but it might be that some particular circumstance gives rise to in-depth discus­ sion o f this topic (e.g. in the experiential learning setting). should this happen this would be an excellent opportunity; however it is not expected that this will happen. adopting this perspective seems to us likely to ensure that serendip­ ity is not lost in the learning experience; but at the same the south african journal of c o m m u n ic atio n disorders, vol. 55 2008 | 105 time that the focus o f the course is not lost. a clear idea of the desired outcomes does not have to be restricting, as the methods o f achieving the outcomes are still flexible. a final criticism o f constructive alignment is that it is in fact something that academics have been doing for years and that curriculum alignment or curriculum congruence are philosophically more accurate terms since true construc­ tivism is not typically demonstrated in aligned approaches (mccune 8c hounsell, 2005). in response to the first as­ pect that constructive alignment is something that aca­ demics are already doing without being aware o f the fact our own experiences have clearly shown that this is not the case. through our curriculum revisions staff participants frequently became sidetracked with aspects o f content that r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) michelle pascoe & shajila singh we felt should be included; t l a s that we felt were suitable or assessments that we were comfortable with. however, focusing on our il o s was a constant reminder to ask our­ selves: what is it we want the students to be able to achieve by the end o f this course? and then, in turn, how do con­ tent, t l a s and assessment all fit with this? constructive alignment has given us a theoretical framework for under­ standing why this particular course and ultimately the pro­ gramme as a whole occurs the way it does. mccune and hounsell (2005) have gone on to suggest that constructive alignment is a misnomer since constructivism is not neces­ sarily demonstrated in aligned approaches. this may be the case: it is not difficult to imagine how one might end up with an aligned curriculum that is devoid o f constructivism. however, our approach has been to explicitly incorporate both ‘constructivism’ and ‘alignment’ in our curriculum re­ vision. the explicit inclusion o f communal constructivism is one way in which we have assured that constructivism is a part o f the curriculum and throughout the curriculum revi­ sions we have strived to have students actively engaging and building their knowledge, e.g. consider the glossary build­ ing activities o f il o s 1 and 3. while some have described constructive alignment as something which academics typically do already (mccune & hounsell, 2005) other authors have acknowledged that constructive alignment is extremely difficult to achieve: houghton (2004) notes that it is virtually impossible to get it right first time. for this reason reflective practitioners are required, i.e. teachers who constantly adapt course design and delivery, continually moving their course or programme towards (unattainable) perfect constructive alignment. this approach o f constantly revising and reworking courses fits with the methodology described here: the revised h c d course will take place in 2009 and it remains to be seen whether the newly aligned course will result in more effec­ tive learning for students. the reflective logs o f staff offer some insights into our own perceptions o f constructive alignment. here we share three key themes which emerged from staff logs and high­ light the parallels between ‘teachers’ and ‘learners’, as the staff participating in this project become learners them­ selves, grappling with a large body o f unfamiliar literature. m in d the gap: the divide between theory and practice much has been written about the difficulties that slp students and others o f related disciplines face when having to make links between the theory that is typically taught in lectures, and ‘doing the job’ in a clinical setting (brumfitt, 2004; grundy, 2004). it should come as no surprise when one considers the different outcomes expected o f students in both settings; and given the fact that there are many practis­ ing clinicians who battle to bridge this divide as exempli­ fied in claire penn’s editorial response entitled: “don’t give me the theory, just tell me what to do in therapy...” (penn, 2007). this theory / practice gap was also closely felt by all staff participants as we grappled with the unfamiliar litera­ ture o f educational theory. all staff were able to grasp the key concepts o f the educational literature required for our project, but having achieved this through a set o f readings did not mean that we could effortlessly apply the knowl­ edge to revise the curriculum (or indeed in its implementa­ tion). many o f the staff participants felt out o f their depth and inadequately prepared to do so despite having done our homework and ‘learnt’ the theory. feeling ‘inadequate about how to do this’; ‘like a back-row girl’; ‘completely out o f my depth’ are all feelings that staff described at the start o f the process. these are surely some o f the same com­ ments that we will have heard our students make in their clinics. reflecting on our feelings o f uncertainty and how these gradually gave way to a more confident feeling can only serve as a helpful reminder o f the challenges that our students face. one o f the key motivators for the curriculum work de­ scribed in this paper has been to bridge the divide between theory and practice so that the two are able to link more seamlessly with each other. rather than the sorry state o f af­ fairs penn (2007) described we strive for graduates who will say: “i ’ll do i t ... and i can give you the theory that underpins what i do!” one way o f moving towards this scenario is to keep our focus on the ultimate outcomes o f the programme (who are those thinking therapists, those agents for change that we want to produce?) and ensure that courses from the very start o f the programme work towards that goal. in the revised h c d curriculum described in this paper we have included a range o f aspects that work towards this goal. having clinical educators as well as academic staff involved in the project is another way in which we have attempted to bridge the divide. this was something which almost all staff seemed to express in their comments on the process. the bridging o f the gap between theory and practice works both ways: not only should we be introducing practical as­ pects and clinically-linked skills earlier in the programme, but theoretical aspects should be incorporated explicitly in clinical work in the later years. students should be able to make reference to appropriate literature and the rapidly ex­ panding evidence base in slp, when called upon to do so and for their own peace o f mind and professionalism as a matter o f course. building together: communal constructivism communal constructivism aims to move beyond social constructivism and sees individuals constructing meaning together not just alongside each other but for each other, working together to create something. in the h c d course we have included some tl a s and assessment tasks which closely follow this principle: students are required to work in small groups with a key aim o f the activity being to build materials that can be shared with all present and future stu­ dents in the division. intuitively this approach appeals to staff and students alike: the value o f resources that are ac­ tually needed, used by many and freely available to all who may need them is easy to see. it is more than just doing assignments for a mark, but about contributing in a mean­ ingful and socially responsive way. our aim is that students from a diverse range o f backgrounds will relate to this-and find meaning in the assessment activities. our own curriculum work resonated with the principles o f communal constructivism: the curriculum does not be­ long to any o f us individually, it belongs to all and is some­ thing that will be used and modified and for the benefit o f current and future students in our programme. our difficul­ ties in grappling with the theory were given meaning and 106 | die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t o w a r d s c o n s t r u c t iv e a l ig n m e n t in t h e slp c u r r ic u l u m purpose when we consider what it is we have jointly con­ structed. as one staff participant noted: “i f i had taken a test or exam on educational theories and curriculum development after i had just read the chapters and papers on the subject, i would have failed or maybe just scraped a pass... if i reflect back on when i really learnt, it was when we had to produce something [the revised course] and we all started putting the pieces o f the puzzle togethner. this comment illustrates both components o f commu­ nal constructivism the communal reflected in “we all... together” and constructivism in “producing something” or “putting the pieces...” comments from staff participants also reflected the rewards and challenges associated with working in groups, and many o f these comments reflected those o f our students, some of whom just like usface the prospect o f working in groups with dread! in the re­ vised h c d course, the emphasis on group working is clear­ ly shown it is included as an explicit outcome (e.g. see i l 0 3 which includes the attitudinal component: ‘develop an appreciation for benefits o f working in a group’ and care­ fully aligned t l a s involve opportunity to develop this skill. working in a group does bring with it unique challenges: it is our belief that the benefits outweigh the challenges and that students (and staff) should be encouraged to develop in this area, especially since part o f an sl p ’s role may well involve facilitating individuals working in groups. research findings suggest that while students can gain factual knowl­ edge equally effectively by studying individually or by par­ ticipating in collaborative learning, critical thinking is sig­ nificantly improved in the latter (gokhale, 1995). students perform at higher intellectual levels in cooperative learning situations (vygotsky, 1978), because problem solving strat­ egies are improved when presented with different interpre­ tations. further, peer support allows students to convert knowledge and critical thinking skills into tools for intel­ lectual functioning (bruner, 1985). a spiral oflearning i an interesting paradox which emerged from some o f the staff participants’ logs is that while the focus o f the curric­ ulum work has been bn specifying clearly delineated out­ comes, the entire process o f curriculum revision does not have a clearly delineated outcome. it will involve ongoing revisions and refinements that mean progress, although it will be necessary to constantly revisit and reflect on what is we are achieving or not achieving. for some this is ‘frus­ trating,’ ‘daunting’ and ‘a bit depressing.’ houghton (2004) notes that constructive alignment cannot be achieved or maintained in an institutional system that does not allow frequent modification o f module descriptions. for others it reminds us about the lifelong nature o f learning: learning can never be finished. this is an important message that we wish to convey to our students: they need to become life­ long learners who are empowered to access information and continually construct their knowledge throughout their life­ time. w e cannot teach them everything that they need to know about slp in four years o f study: the best we can do is ensure they meet exit level criteria, and are equipped with an awareness o f how to continue developing their knowledge. the way forward first year students will experience the revised h c d course in the first semester o f 2009. the course will be evaluated and modified in light o f the feedback received, continuing the spiral o f participatory action research. staff participants continue to work together as a team to modify all courses o f the sl p programme using the principles o f constructive alignment outlined in this paper. the ultimate aim is for all the courses comprising the slp programme to be aligned at a micro level, and all courses within the programme to be aligned with each other at a macro level. the curriculum process is not only about alignment; con­ structive alignment is brought in through an awareness of how best we can ensure students engage with their learn­ ing and build their knowledge in an ongoing and often communal manner. the example o f t l a s and assessment given in this paper show some o f the ways in which we aim to achieve this goal. it is clear that changes to the h c d course will need to be made based on students and educator feedback, as well as the changing needs o f the student body and the profes­ sion o f slp. w e are certain that we will not have achieved perfect constructive alignment right away, but consider that the first attempt described here may be useful to others con­ sidering or working through the process themselves. acknowledgements: the authors gratefully acknowledge 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(2004). case-based problem solving for s l t students. chapter in s. brumfitt (e d ), innovations in professional education for speech and lan­ guage therapy. w hurr publishers: london. 108 | die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t o w a r d s c o n s t r u c t iv e a l ig n m e n t in t h e slp c u r r ic u l u m appendix 1. unrevised version o f the human communication development course r n u r s e aims: 1. to build on the knowledge of [psychology course] and to link this to normal communication development across the human life span. 2. to provide a comprehensive working knowledge of normal speech, language and hearing development from birth, through the infant-, toddler-, pre-school and school-age phases. 3. to develop a sound understanding of the nature and development of phonology, syntax, morphology, semantics, pragmatics, meta-linguistic abilities and literacy. 4. to present an overview of the significant issues pertaining to the cultural diversity in south africa and their impact on our understanding of normal communication development. course objectives; 1. knowledge: at the end of the course the student will be expected to; a. describe the nature of human communication. b. d escribe the principles and patterns o f norm al speech, la ngua ge and hearing develop m e nt. c. describe the significant milestones in normal speech, language and hearing development across the human lifespan. d. define and describe the domains and development of phonology, syntax, morphology, semantics, pragmatics, meta-linguistic abilities and literacy. e. outline the issues involved in the establishment of relative developmental norms. f. outline the issues of linguistic and cultural diversity in the south african context, and their i. relevance to the description and assessment of normal communication development ii. implications for interventions in multi-lingual contexts. 2. skills: in preparation for clinical practice, the student should be able to; a. gauge significant milestones in normal speech, language and hearing development, with consideration of relevant issues of diversity. b. discern non-negotiable universals versus contextual variables in speech, language and hearing development. c. identify and access methods of community resource mapping for the development of culturally appreciative, criterion referenced communication development profiles. d. (collaborate with caregivers to negotiate relevant expectations of communication development. 3. attitude: the student should be able to appreciate and apply learning of; a. the w hole-perso n approach : that is; speech, langua ge and hearing d e ve lo p m e n t in the context of ! i. the child’s general development. [ ii. the child’s environmental context. b. diversity issues (contextualization, appreciation of socio-cultural impacts, etc). the south african journal of c o m m un ic atio n disorders, vol. 55 2008 | 109 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) michelle pascoe & shajila singh appendix 2: a blank template for facilitating curriculum alignment 1. intended learning outcome (ilo) 2. content * minimal depth ** moderate depth *** most in-depth topic 3. teaching and learning activities 4. assessment il 0 1 : knowledge: level: type: skills: attitudes: il02: knowledge: level: type: skills: attitudes: il03: knowledge: level: type: skills: attitudes: checklist: key themes: included 1. 2 . 3. 110 i die suid-afrikaansetydskrif vir kommunikasie-afwykings, vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) information for contributors 1. nature of publication the south african journal o f communication disorders publishes reports and papers concerned with research, and critically evaluative theoretical and philosophical conceptual issues dealing with aspects of human communication and its disorders, dysphagia, service provision, training and policy. the journal will accept the following three types of manuscripts: research manuscripts defined as reports based on qualitative or quantitative research. original general manuscripts which are reports of work usually, but not exclusively, theoretical in nature and regarded as providing a significant, critically evaluative contribution to the field of human communication and its disorders and/or dysphagia. • review manuscripts which are usually written by authors invited by the journal’s editorial team to comment, express opinions and or critically evaluate a topic. the journal will not accept material which has been published elsewhere or that is currently under review by other publications. 2. manuscript submission & style requirements • manuscripts must he accompanied by a covering letter providing the author's address, telephone and fax numbers and e-mail address. • one electronic copies of the manuscript must be submitted to the saslha office manager for the editor-in-chief (email: admin@saslha.co.za). • the title page o f the manuscript must contain: • title o f the manuscript. full name(s) of the author(s). institutional affiliation, postal address, full contact details. • abstract of the manuscript in english. if the language of the manuscript is not in english then an additional abstract in the language the manuscript must be included. • the manuscript copies must not contain any statements/features that identify the author(s) names, institutional affiliations or any other details that reveals the identity of the author(s). the filename must include the first author's initials and a clearly identifiable key word and must he type-written on the last line of the last page of the reference list (for retrieval purposes only). • the editor-in-chief and/or the south african speech-language-hearing association (saslha) office manager will acknowledge receipt of the manuscript within a maximum of 7 days. if at this stage, no acknowledgement has been received by the author, the author is kindly requested to follow this up with the saslha office. ms word must be used for the text. ms word or ms powerpoint should be used for figures, and ms excel for tables. • manuscripts must be in double spacing and in a font size of 12. manuscripts must be on a4 pages in double spacing and in a font size of 12 • filenames must include the first author's initials and a clearly identifiable key word. ' • manuscripts must not exceed 30 pages. the order of the manuscript should be: title page, abstract and key words, text, references, tables, legends, and figures. each manuscript must contain an english abstract of no more than 200 words with 5-7 key words. j strict adherence to the publication manual of the american psychological association (5lh ed., 2001) is required. headings are not numbered. the order of importance is indicated as follows: • main heading in capitals and bold print. • sub-headings in capitals, bold and italic print. • sub-subheadings in upper and lower case bold and italic print. • sub-sub-sub-heading in upper and lower case bold print. major headings, where applicable, must be in the order of introduction, method, results, discussion, conclusion, acknowledgements, and references. all paragraphs should be indented. • all tables, figures and illustrations must be numbered and provided with titles. the title of tables, which appear above, and of figures, which appear below, must be concise but explanatory. allow for 50-75% reduction in printing of tables, figures and illustrations. • each table, figure or illustration must appear on a separate page. do not include more than 10 tables, figures or illustrations. • colour graphics are not preferred. if submitted, extra cost of colour reproduction and printing must be covered by the author prior to publication. a short running title should be listed at the top left-hand corner of the title page. any information about grants or other financial support should be supplied as an unnumbered footnote to the manuscript title. graphics, audio and/or video files (not exceeding 2mb) may be submitted for future publication as an electronic online journal. consult the editor-in-chief regarding required file formats. authors must use gender-, race-, and creed-inclusive language. authors must ensure adherence to national and/or international ethical codes. british spelling (e.g. centralise not centralize, behaviour not behavior) is preferred. 3. referencing references must be cited in the text by author’s name and the date, e.g. van riper (1971). where there are more than two authors, after the first occurrence, et al. may be used. the names of all authors must appear in the reference list, which must be listed in strict alphabetical order in triple spacing at the end of the manuscript. • all references must be included in the list, including secondary sources. • only acceptable abbreviations of journals may be used, (see dsi-1 abstracts, october; or the world list o f scientific periodicals). author(s) should use references that reflect an international diversity among authors of both source articles and cited articles. the number of references should not exceed 30, unless specifically warranted. examples locke, j.l. (1983). clinical psychology: the explanation and treatment of speech sound disorders. j. speech hear disord., 48 339-341. penrod, j.p. (1985). speech discrimination testing. in j. katz (ed.), handbook o f clinical audiology (3rd ed.). baltimore: williams & wilkins. davis, g. & wilcox, m.j. (1985). adult aphasia rehabilitation: applied pragmatics. san diego, ca: college-hill. editing manuscripts must be corrected for grammar and style prior to submission. • only manuscripts complying with the above requirements will be accepted for review. reviewing system the double-blind peer review system is employed as a method of quality control of this publication and ensures that author(s) and reviewers do not know each others’ names. • each manuscript is sent to two independent reviewers, selected according to their area of expertise, to assess the quality of the manuscript's scientific and technical content. author(s) must ensure that the manuscript does not contain information/clues as to the identity of the author(s). the editor-in-chief retains the final responsibility for decisions regarding revision, acceptance or rejection of the manuscript. this process is usually done in consultation with the manuscript’s editor and/or the editorial team, as necessary. deadline for contributions. 28lh/29lh february each year publication fee: authors will be expected to pay a publication fee. the exact amount is determined by printing costs. queries and correspondence: should be addressed to the editor-in chief, south african journal o f communication disorders, south african speech language-hearing association, po box 10813, linton grange, 6015, south africa. email saslha at admin@saslha.co.za for the current e ditor-in-chiefs email address. author’s responsibility: the south african journal of communication disorders is not responsible for authors’ views and does not endorse any of the products or materials advertised in the journal. copyright: the copyright of all manuscripts printed in the south african journal of communication disorders is reserved by the south african speech-language hearing association (saslha). 2008 editorial team editor-in-chief dr mershen pillay editors a/profharsha kathard, dr michelle pascoe, prof eleanor ross technical editor: andre-pierre du plessis layout & design: andre-pierre du plessis administrative officer: mrs claudine emmerick publication manager: mrs diane hoctor the south african journal of communication disorders, vol. 55 2008 111 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:admin@saslha.co.za mailto:admin@saslha.co.za abstract introduction methods results discussion conclusion acknowledgements references about the author(s) seema panday department of audiology, school of health sciences, university of kwa zulu-natal, durban, south africa harsha kathard department of health and rehabilitation sciences, faculty of health sciences, university of cape town, cape town, south africa wayne j. wilson school of health and rehabilitation sciences, faculty of health and behavioural sciences, the university of queensland, queensland, australia citation panday, s., kathard, h., & wilson, w.j. (2020). the validity of an isizulu speech reception threshold test for use with adult isizulu speakers. south african journal of communication disorders, 67(1), a690. https://doi.org/10.4102/sajcd.v67i1.690 original research the validity of an isizulu speech reception threshold test for use with adult isizulu speakers seema panday, harsha kathard, wayne j. wilson received: 31 oct. 2019; accepted: 16 july 2020; published: 09 nov. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: this study continued the development of an isizulu speech reception threshold (zsrt) test for use with first language, adult speakers of isizulu. objectives: the objective of this study was to determine the convergent and concurrent validity of the zsrt test. methods: one hundred adult isizulu first-language speakers with normal hearing and 76 first-language, adult isizulu speakers with conductive or sensorineural hearing losses ranging from mild to severe were assessed on pure tone audiometry and a newly developed isizulu srt test. convergent validity was established through agreement of the zsrt scores with pure tone average (pta) scores. concurrent validity was assessed by examining the steepness of the psychometric curve for each word in the zsrt test for each type and degree of hearing loss. results: intraclass correlation coefficient analyses showed zsrt scores were in substantial to very high agreement with pta scores for the normal hearing and hearing loss groups (nh – right ear icc consistency = 0.78, left ear icc = 0.67; hl – right ear icc consistency = 0.97, left ear icc consistency = 0.95). the mean psychometric slope (%/db) at 50% correct perception for all words in the zsrt test was 4.92%/db for the mild conductive hearing loss group, 5.26%/db for the moderate conductive hearing loss group, 2.85%/db for the moderately severe sensorineural hearing loss group and 2.47%/db for the severe sensorineural hearing loss group. these slopes were appropriate for the degree of hearing loss observed in each group. conclusion: the zsrt test showed convergent and concurrent validity for assessing srt in first language, adult speakers of isizulu. keywords: speech reception threshold; convergent validity; concurrent validity; adults; isizulu. introduction this article reports on the convergent and concurrent validity of an isizulu speech reception threshold (zsrt) test for use with first-language, adult speakers of isizulu with and without hearing loss. with evidence-based practice now being prioritised for clinical practice, the need for validity evidence of newly developed tests continues to grow amongst clinicians and researchers alike (friberg & mcnamara, 2010). in the case of speech audiometry, evidence of the validity of its tests has been dominated by reports of the psychometric functions (also called the performance intensity functions) for the word stimuli used in these speech audiometry tests (e.g., harris et al., 2001; 2004; harris, kim, & egget, 2003; nissen, harris, jennings, eggett, & buck, 2005; nissen, harris, & slade, 2007). whilst such reports provide some evidence of validity and reliability, systematic assessments of the validity of speech audiometry tests remain rare. this is concerning as the clinical use of any test in audiology should be based on a rigorous, strict and systematic investigation of its validity and reliability, and the lack of such investigation limits the use of these tests in clinical practice (ma, mcpherson, & ma, 2013). in general, validity refers to the degree to which a test or measurement tool achieves what it is supposed to measure (maxwell & satake, 2006; mendel, 2008). historically, validity has been presented as separate subtypes (cronbrach & meehl, 1995) including construct validity – the degree to which a test or instrument measures the theoretical construct under investigation. it is recommended that all subtypes of validity be considered for test validation, with authors such as messick (1995) offering unified validation frameworks to achieve this goal. central to this framework’s consideration of validity is the placement of construct validity as the overarching type of validity (messick, 1995, in dellinger & nancy, 2007). construct validity is then broken down into content, convergent and divergent, and criterion or concurrent validity. messick’s (1995) framework is useful as it allows several levels of evidence to be gathered to argue for or against the overall validity of any new test. for this article evidence relating to convergent and concurrent validity will be the focus. speech reception threshold (srt) testing remains a core component of the audiological test battery (ramkissoon, estis, & flagge, 2014). on hearing a list of words that have been pre-recorded or presented by live voice, the listener is asked to repeat each word as heard. by scoring the responses, an examiner can determine the listener’s srt as the level at which he or she correctly repeated the words 50% of the time. this srt score can then be used to quantify the listener’s speech reception ability, to cross-check other audiometric results such as the pure tone average threshold obtained from pure tone audiometry, to confirm or deny sites of lesion along the auditory pathway and to guide some forms of auditory rehabilitation (gelfand, 2001). whilst srt testing has been used in audiology clinics around the world since the 1950s, it continues to face several challenges. perhaps the largest of these challenges is the need to match the words used in an srt test to the contextual, linguistic and clinical factors relevant to the target population. such a challenge is of particular relevance in a country such as south africa that has 11 official languages: afrikaans, english, ndebele, northern sotho, sotho, swazi, tsonga, tswana, venda, xhosa and zulu. at present, the majority of srt tests have been developed in the english language and particularly in american english (ballachanda, 2001; ramkissoon, proctor, lansing & bilger, 2002). use of these tests in south africa has some (albeit limited) prima facie value with south african english being spoken as the primary language at home by 8.1% of the population (statistics south africa, 2018), making it the sixth most commonly primary spoken language in south africa after isizulu (23%), isixhosa (16%) and afrikaans (14%). south african english is also one of several languages commonly used in most urban areas in south africa (statistics south africa, 2018) and is the dominant language spoken in government and media settings. despite this, it remains clear that the use of srt tests in english (and the dominant american english) on the south african population is culturally and linguistically inappropriate at best (ramkissoon et al., 2002) and invalid at worst (aleksandrovsky, mccullough, & wilson, 1998; martin & hart, 1978; harris et al., 2003, 2004; ramkissoon et al., 2002). in response to the need for valid speech audiometry tests in south africa, researchers have begun to develop locally relevant tests (hanekom, soer, & pottas, 2015; khoza, ramma, mophosho, & moroka, 2008; naude, 2018). this includes the development of an srt test in the most spoken language in south africa, isizulu, which is spoken as the primary language at home by approximately 23% of the population (statistics south africa, 2018; panday, kathard, pillay, & govender, 2007, 2009; panday, kathard, pillay, & wilson, 2018a, 2018b). the current recording of this zsrt test consists of 28 common, bisyllabic isizulu words spoken by a male, first-language speaker of isizulu. these words have been shown to be linguistically familiar and homogenous in audibility in first-language, adult speakers of isizulu (panday et al., 2007, 2009, 2018a, 2018b) and this test has been shown to produce reliable srts when used on such adults with normal hearing sensitivity (panday et al., 2018a). if this new zsrt test is to be used on first-language, adult speakers of isizulu in south africa, then its validity when applied to individuals with and without hearing loss must be assessed. the aim of this study was to determine whether the zsrt test is a valid measure of srt in the firstlanguage, adult speakers of isizulu with and without hearing loss. methods research design this study used an analytical, observational design (maxwell & satake, 2006) to collect and analyse quantitative data in two parts, one involving participants with normal hearing and one involving participants with hearing loss. participants all participants were first-language, adult speakers of isizulu (self-reported) and permanent residents of kwazulu-natal. for part one of the present study, 100 participants with normal hearing aged 18–60 years (mean age 37 years) were recruited through advertisements and selected based on consecutive sampling (maxwell & satake, 2006) from the ethekwini and surrounding areas of kwa zulu-natal. participants had to have unremarkable case history and their hearing status had to be confirmed by audiometric testing. for part two of the present study, 76 adults with hearing loss between the ages of 21 and 59 years (mean age 39 years) were purposely sampled from the clinical databases of two audiology departments in two provincial hospitals and the audiology clinic of a university in ethekwini, kwa zulu-natal, south africa. the hearing status of each participant was identified from their hospital or clinical database records and confirmed by audiometric assessment at the research facility. these 76 participants were grouped by the degree of hearing loss in their better hearing ear. this created four groups: mild conductive hearing loss (26–40 db, n = 15), moderate conductive hearing loss (41–55 db, n = 20), moderately severe sensorineural hearing loss (56–70 db, n = 21) and severe sensorineural hearing loss (71–90 db, n = 20). the isizulu speech reception threshold test the zsrt test used in this study has been reported in detail by panday et al. (2007, 2009, 2018a, 2018b). it consists of 28 bisyllabic isizulu low-tone verbs that are linguistically familiar and homogenous in audibility for isizulu-speaking adults. the words were recorded to a compact disk with a calibration tone and test instructions (in isizulu) for the listener. test administrator all tests were conducted by an audiologist with 6 years clinical experience who had been trained by the present study’s first author (panday). this audiologist was the first-language speaker of isizulu. procedure all tests were performed in an isolated industrial acoustics company twin audiometric soundproof booth of double wall construction meeting ansi (1977) standards using a grayson-stradler gsi 61 twin channel clinical audiometer with tdh-49 telephonics earphones and mx41-ar cushions, a technics (slpg390) compact disk player and a gsi tympstar clinical middle ear analyser. testing occurred in two sessions. participants in part one of the present study only participated in testing session one. participants in part two of the present study participated in testing sessions one and two. session one in the first session, all participants completed pure-tone audiometry, tympanometry and srt testing using the zsrt test. pure tone audiometry was conducted at octave frequencies from 250 hz to 8000 hz using the modified hughson-westlake threshold technique (carhart & jerger, 1959). the pure tone average (pta) (the average hearing threshold for 0.5, 1 and 2 khz) and the zsrt were calculated and recorded. for the zsrt testing, each participant listened to the words being read aloud by the tester, and was given the opportunity to clarify any unfamiliar words (as recommended by asha, 1988). a modified version of the chaiklin and ventry (1964) descending method (as cited in gelfand, 2001) was used to conduct the srt testing. this method was modified by changing the starting level from 25 db sl relative to a two frequency pure-tone average to 10 db sl relative to the three frequency (0.5, 1 and 2 khz) pure-tone average. if the participant was unable to repeat the initial word played, then the srt test sequence was restarted by presenting a new word at the initial presentation level plus 10 db. once the participant was able to repeat a word, then a further two words were presented at the same presentation level. if all three words were not correctly repeated, the audiologist increased the presentation level by 5 db and played the next three words. once all three words were correctly repeated, the audiologist reduced the presentation level by 5 db and played the next three words. this was repeated until the participant incorrectly repeated any one of the words in a three-word block, at which point the audiologist played another three words at the same level to get a score out of six. if the participant correctly repeated three out of the six words, then the presentation level of those words was deemed to be the participant’s srt and the srt testing was stopped. if the participant correctly repeated fewer than three out of the six words, then the presentation level was increased by 5 db, and another set of six words were presented. if the participant correctly repeated more than three out of the six words, then the presentation level was decreased by 5 db and another set of six words were presented. this sequence of increasing or decreasing the presentation level was repeated until the participant correctly repeated three out of a six word block, the presentation level of which was deemed to be the participant’s srt and the srt testing was stopped. to brief, a participant’s srt was deemed to be the lowest presentation level at which he or she correctly repeated three out of a block of six words. session two in the second session, only participants with hearing loss completed word recognition testing using the zsrt test words played at varying presentation levels to obtain psychometric functions for each word in the zsrt test. each participant was instructed in isizulu by the test administrator that a series of words would be played through the headphones to his or her better hearing (or to the right ear if the hearing was symmetrical). the task was to repeat each word as heard. all 28 words on the zsrt test were first played at 20 db sl to familiarise each participant with the words, and then in a randomised order at 35–70 db hl (dial setting) in 5 db steps for participants with mild conductive hearing loss, at 40–75 db hl (dial setting) in 5 db steps for participants with moderate conductive hearing loss, 50–85 db hl (dial setting) in 5 db steps for participants with moderately severe sensorineural hearing loss and at 70–95 db hl (dial setting) in 5 db steps for participants with severe sensorineural hearing loss. participants were given two 5-min rest breaks during this testing to improve co-operation and reduce fatigue. all participant responses were scored by two scorers (the researcher and the isizulu-speaking audiologists). data analysis the pta (the average hearing threshold for 0.5, 1 and 2 khz) and zsrt scores for both participant groups were confirmed as meeting parametric assumptions by inspecting their histograms, box and whisker plots, and q-q plots (data not shown). agreement between the pta and zsrt results for each participant group separately, for right and left ears separately, were assessed using intra-class correlation coefficient (icc) analyses (bartlett & frost, 2008; rankin & stokes, 1998; shrout & fleiss, 1979). the strength of these icc values was classified using the general (although arbitrary) guidelines reported by landis and koch (1977) of < 0 indicating poor agreement, 0.01–0.20 indicating slight agreement, 0.21–0.40 indicating fair agreement, 0.41–0.60 indicating moderate agreement, 0.61–0.80 indicating substantial agreement and 0.81–1.00 indicating almost perfect agreement. differences between the pta and zsrt results for all participants as a single group, for right and left ears separately, were assessed using linear mixed model analyses. these analyses were conducted with threshold (db hl) as the dependent variable, threshold method (pta, zsrt) as an independent variable and fixed effect, participants as an independent variable and random effect (with unstructured co-variance type) and the intercept included in the model. from session two, logistic regression analyses were used to determine the psychometric function of each of the 28 words in the zsrt recording for each of the four subgroups in the hearing loss participant group separately. for each word in the zsrt recording, and for each participant subgroup, logistic regression equations were fitted, the slope of each model was determined and the word threshold (50% correct) was calculated. this analysis was not completed for the normal hearing participant group as it had been completed on a separate sample of participants with normal hearing and reported elsewhere (panday et al., 2009, 2018a). all statistics were conducted using ibm spss statistics, version 24, release 24.0.0.0 for personal computers. ethical consideration ethical clearance was granted by the faculty of health sciences human research ethics committee of the university of cape town to conduct the study (clearance number: hrec 652/2012) and subsequent annual clearance was obtained during the data collection period. informed consent was obtained from all participants prior to their participation in the study. results for part one of the present study, table 1 shows the mean pta and srt values for participants with normal hearing and with hearing loss. table 2 shows the intraclass correlation coefficients (icc) between the two threshold measures (pta and zsrt) for each group by ear. the icc values ranged between 0.67 and 0.88 for each ear for both single measures (single threshold method) and average measures (averaged between both threshold methods) for the normal hearing group and were > 0.95 for single measures (single threshold method) and average measures (averaged between both threshold methods) for the hearing loss group. table 1: pure tone average and isizulu speech reception threshold measurements for right and left ears for participants with normal hearing and with hearing loss. table 2: intraclass correlation coefficient (2, 1) results for agreement between pure tone average and isizulu speech reception threshold measures for participants with normal hearing and with hearing loss. table 3 shows results of the linear mixed model analyses for the both participant groups by ear for differences between the two threshold measures of pta and zsrt. a significant (p < 0.001) difference between pta and zsrt was observed for each participant group. table 3: the linear mixed model analysis results for differences in thresholds by threshold measure (pure tone average vs. isizulu speech reception threshold) for participants with normal hearing and participants with hearing loss. for part two of the present study, table 4 shows the psychometric function measures and figure 1 shows the psychometric functions for the participants with hearing loss by degree of loss. the psychometric data obtained from the present study’s normally hearing participants are not reported here as they have already been reported in panday et al. (2018a). psychometric data obtained from another group of normally hearing participants using a precursor zsrt recording to the one used in the present study have also been reported by panday et al. (2009). figure 1: the psychometric functions for each of the 28 words in the zsrt speech reception threshold test, for each participant group by degree of hearing loss: (a) mild conductive hearing loss (b) moderate conductive hearing loss (c) moderately severe snhl (d) severe snhl. table 4: psychometric function measures for the 28 isizulu words for the participants by degree of hearing loss. discussion the present study’s results suggest that the zsrt test is a valid measure of srt in first language, adult speakers of isizulu with and without hearing loss. the convergent validity of the zsrt test was supported by the very high agreement (icc values ≥ 0.80) observed between participant pta and zsrt values for participants with and without hearing loss, for both right and left ears. this support is drawn from this study’s use of the zsrt and pta scores as measures of the theoretical construct of hearing threshold. the degree to which the zsrt and pta measures of this construct were related suggests high convergent validity. the zsrt results can reasonably be expected to show high levels of agreement with the established pta results for first-language, adult speakers of isizulu with hearing loss, when these tests are applied in clinical settings. whilst the zsrt and pta values were in very high agreement in this study’s participants, mixed model analyses showed the zsrt values to be significantly (p < 0.005) higher than the pta values by an average of 2.9–3.0 db for participants with normal hearing and by an average of 2–3 db for participants with hearing loss. whilst statistically significant, these differences were not considered to be clinically significant given the minimum step size for presentation level used in this study was 5 db, and differences 6 db or less between srt and pta having been taken to indicate agreement between those two measures for tests in several languages (carhart, 1971; han et al., 2011; marinova-todd, siu, & jensad, 2011; sreedhar, ventatesh, nagaraja, & srinavasan, 2011; wang, mannel, newall, zhang, & han, 2007). the concurrent validity of the zsrt test was supported by the psychometric functions for each word in the zsrt test being consistent with the degrees and types of hearing loss shown by the study’s participants with hearing loss by subgroup, that is, mild conductive, moderate conductive, moderately severe sensorineural and severe sensorineural hearing loss. for increasing degrees of hearing loss, the psychometric functions showed the expected increases in threshold and decreases in slopes (wilson & carter, 2001) for the zsrt test words. similarly, wang et al. (2007) found that when participants with sensorineural hearing loss were evaluated with mandarin bisyllabic words, the psychometric functions slopes were more shallow compared with results with normal hearing counterparts. a closer inspection of the psychometric functions of individual words in the isizulu test across the four hearing loss groups indicates some variability in curves amongst individual words. for example, the psychometric functions for the words /wina/ and /minya/ were consistently very shallow for all degrees and types of hearing loss. this suggests these words could be lowering the concurrent validity of the zsrt test overall and the removal of these words from the zsrt test wordlist could be considered. clinical implications the present study’s findings further support the potential use of the zsrt test as a valid and reliable measure of srt in first-language, adult speakers of isizulu speakers. this zsrt test has now been shown to contain words that are linguistically familiar and homogenous in audibility in isizulu-speaking adults (panday et al., 2007, 2009, 2018a, 2018b), to produce reliable srts when used on adult speakers of isizulu with normal hearing sensitivity (panday et al., 2018b), and to produce valid srts when used on adult speakers of isizulu with and without hearing loss (current study). the present and previous studies reporting the development of this zsrt test also support the use of rigorous, systematic and multiple methods particularly based on a unified validation framework to accumulate evidence for the validity and reliability of any new test. previous attempts to use only one or two methods to confirm the validity and/or reliability of new tests should not be considered sufficient for such purposes. it is important to view multiple sources of evidence regarding the validity and reliability on new tests before such tests can be properly considered for clinical use. conclusion the present study’s results suggest the zsrt test is a valid measure of srt in first-language, adult speakers of isizulu with and without hearing loss, showing both convergent and concurrent validity when used in these populations. this study’s findings are limited by its participants being predominantly recruited from ethekwini and surrounding regions in kwazulu-natal, south africa, although the test words did represent a central dialect of isizulu. it could also be limited by its use of the srt method described by chaiklin and ventry (1964, cited in gelfand (2001) with modification, which may not immediately generalise to srt scores contained using other methods. acknowledgements the authors acknowledge yusentha balakrishna from the medical research council of south africa, durban, south africa and dr asad khan from the school of health and rehabilitation sciences, the university of queensland, australia, for assistance with statistical analyses. the authors also acknowledge the assistance of mr sandile kgotshane for the tests administration during data collection. the authors also acknowledge oticon foundation for research funding support. competing interests the authors have declared that no competing interest exists. authors’ contributions authors s.p., h.k. and w.j.w. contributed conceptually to the study. s.p. is the lead investigator of this study and the larger study containing this study. s.p. contributed to the data collection; s.p. and w.j.w. contributed to writing, structure and layout; and s.p., h.k. and w.j.w. contributed to the editorial aspects of this article. funding information this research received funding from oticon foundation. data availability statement the data that support the findings of this study are available from the corresponding author (s.p.) upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references aleksandrovsky, i.v., mccullough, j.k., & wilson, r.h. 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(2001). relation between slopes of word recognition psychometric functions and homogeneity of the stimulus materials. journal american academy, 12(1), 7–14. 31 babbling of an infant with a repaired cleft lip: a case study carol brenner and karen levin department of speech pathology and audiology university ofthe witwatersrand abstract the infant born with a cleft lip is faced with risk factors that threaten the development of speech-language skills. the earlier the age of identification and management of the developmental delay, the better the outcome. the attainment of the mature syllable is considered to be a critical measure of babbling competency. this single case study aimed to determine whether the formedness of the syllable in babbling would be affected by the cleft lip repaired prior to the onset of meaningful speech. three samples of babbling in a naturalistic environment were video-recorded. data was analysed following the principles of infraphonology, employing a perceptually-based method. a profile of infraphonological features was obtained. results showed that the development of the mature syllable was attained. the results support the theories that babbling is a robust phenomenon. clinical and research implications are discussed. opsomming 'n baba wat met 'n gesplete lip gebore is, vertoon 'n risiko om vertraagde spraaken taal-ontwikkeling te vertoon. hoe vroeer die identifikasie en regs telling van hierdie ontwikkelingsagterstand geskied, hoe meer suksesvol sal die uitkoms wees. die bemeestering van die lettergreepstruktuur word beskou as 'n noodsaaklike maatstaf vir babbel-bevoegdheid. die doel van hierdie stu die was om te bepaal of die ontwikkeling van die lettergreepstruktuur bernvloed sal word deur die herstel van 'n gesplete lip voor die ontwikkeling van betekenisvolle spraak. drie afsonderlike spraakmonsters is met behulp van videokassetopnames in natuurlike omstandighede ontlok. die data is geanaliseer deur middel van 'n perseptuele metode en toepassing van infrafonologiese beginsels. 'n infrafonologiese profiel is saamgestel. uit die resultate blyk dit dat die ontwikkeling van die lettergreepstruktuur wei bereik is. die resultate ondersteun die teoriee dat babbel 'n kragtige ontwikkelingsverskynsel is. klinie$e en navorsingsimp,likasies word bespreek. i i keywords: cleft lip, can6nical babbling, infra phonology, precursor vocalisation, syllable structure. introduction few infants with cleft liplwithout any other defect are referred to the speech-iangu~ge pathologist (slp) because of the apparent insignificance of the repaired structural abnormality. according to :gohmander-agerskov, soderpalm, frieds, persson and lilja11994), the extent of the cleft is directionally proportional to the speech abnormality. research has shown that, in general, children born with clefts of the lip and/or palate have a slower overall rate of development when compared with their non-cleft peers (savage, neiman & reuter, 1994). by all measures, a cleft lip is a mild structural defect (bzoch, 1989), which implies that a speech abnormality in a child with a cleft lip will be minimal, if present at all. however, it is well recognised that speech-language development in children is vulnerable to a wide variety of risk factors (rossetti, 1996). infants born with cleft lips face an array of risk factors. these include prolonged hospitalisation for surgery, feeding difficulties and poor bonding with the caregi ver as a result of aesthetically displeasing physical features (bzoch, 1989; morris, 1989). because of these primary and secondary factors,' children with cleft lips are at risk for developmental speech delays. the early identification of speech-language delay has been advocated for many years because it has been established that the earlier any form of developmental delay is identified and intervention provided, the better the outcome (rossetti, 1996). until recently babbling was not considered continuous with speech (menn, 1992), but it is now widely accepted that it is directly and unequivocally related to later linguistic development (kent & miolo, 1995). a number of studies have demonstrated differences in the babbling of infants at-risk for communication disorders (for example: levin, 1999; o'gara & logemann, 1988; steffens, oller, lynch & urbano, 1992; stoel-gammon, 1989). the study of babbling in infants who are at risk for later speechlanguage development is critical because of the need for early identification and management of the delay. very few infant-assessment profiles include a comprehensive evaluation of babbling and the methodologies for the study of babbling are not well developed (levin, 1999). for example, there is no consensus as to which measures of babbling are valid. much research into babbling has made use of phonetic analysis of utterances but because the phonetic structure of babbling is immature, these studies die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 45,1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 32 may not be valid (oller, eilers, steffens, lynch & urbano, 1994). the syllable is one of the most critical notions that has been the centre of research on babbling. most contemporary theories on phonology hold that the syllable is the criterion that defines the "speechiness" or the "essential auditory quality of speech" (kent & miolo, 1995, p. 310). furthermore, many researchers have proposed that the syllable appears to be the basic phonological unit that the infant uses to learn the structure of his phonological system (kent & miolo, 1995; stoel-gammon, 1992). oller and his colleagues at the miami state university have developed a system of analysing babbling based on the principles of what they have termed 'infraphonology' (lynch, oller & steffens, 1989; oller, 1980; oller, eilers, bull & carney, 1985; oller et al., 1994, oller & lynch, 1992). the infraphonological model provides an explicit characterisation of the infrastructure of the phonology system by specifying the nature of phonetically well-formed elements and the relations between them (oller & lynch, 1992). the canonical syllable is defined by oller & lynch (1992) as one minimal rhythmic unit. it is perceived by adult speakers as a wellformed syllable with at least one consonant, a full adult-like vowel and a normally rapid transition between them. contrary to phonetic studies, within this model pre-canonical or underdeveloped syllables can be easily compared with wellformed mature speech (oller & lynch, 1992). studies have shown that the development ofthe canonical syllable occurs despite the presence off actors that are known to affect speech-language development. researchers such as oller et al. (1994) and pettito & marentette (1991) have described this as a result ofthe flexibility ofthe development of babbling. it would be valuable to assess the development of the canonical syllable in infants who have cleft lips to determine whether a structural abnormality in the prespeech period is a challenge to the theory of the robustness of babbling. it would also be of value to use babbling as a measure of early speech-language development for the identification of speech-language delay in the first months of life. this single case study aimed at evaluating the development of babbling, from an infraphonological perspective, of an infant with a repaired cleft lip. the study included an evaluation of the production of canonical syllables, marginal (immature) syllables and precursor vocalisations (such as growls and shrieks). methodology subject subject selection criteria stringent criteria for selection were set to isolate the effects of the repaired cleft lip on babbling. subject case history was obtained through completion of a detailed case history form (department of speech pathology & audiology, university of the witwatersrand) by the subject's mother, and followed by an interview. paediatric and surgical records were accessed for medical information. the subject was expected to be between the age of nine and eleven months, with a repaired cleft lip. by this age i he normally developing child has developed canonical babbling (oller et al., 1994). this means that at least 20% ofthe subject's syllables comprise at least one consonant, a full vowel and a rapid transition between them (oller, 1980). it was expected that the repair to the lip had been performed preferably by 5 months of age, at which stage canonical carol brenner & karen levin babbling would not typically have begun. the subject was required to have normal hearing and no family history of hearing loss because ofthe documented effects of hearing loss on babbling (stoel-gammon & otomo, 1986). visual response audiometry and tympanometry was performed to determine hearing status. the subject was expected to come from a middle-to-high socio-economic background because differences in the babbling of infants from low socio-economic groups have been demonstrated (oller et al., 1994). socio-economic status was determined by the educational and professional status of the parents as in oller et al. (1994). description of the subject the subject was 9 and a half months old at the time of testing and presented with a right-sided unilateral complete cleft lip at birth. an anatomical lip-plasty was performed at five months of age, with no complications. length of hospitalisation was negligible. the subject's right nares was deviated after the repair, however the only surgery further recommended was for cosmetic purposes. it was confirmed that there was no additional cleft of the hard or soft palate and no other cranio-facial abnormalities were present. there was no family history of speech-language or hearing difficulties. pregnancy and birth history were unremarkable. primary caregivers were not concerned about any aspect of the subject's communicative or physical development and no feeding difficulties prior to or after surgery were reported. method the study comprised the collection of data, training of raters, transcription of data and analysis of results. collection of data the subject was video-recorded at her home on three occasions, for half an hour at a time. following levin (1999), video-recordings as opposed to audio recordings allowed for accurate determination of when utterances were unintelligible as a result of a hand or object in the mouth. recordings were made at the subject's home to allow for a more natural environment and typical interaction patterns. three recordings were made because of the dd,cumented inter-sessional variability in the babbling of one child (e.g., levin, 1999; oller et al., 1985). data was collected'within 10 days to account for developmental factors. : the first author set up and controlled the e~uipment and was present as an undisguised participant at all three sessions (shaugnessy & zechmeister, 1990r a sony handycam ccd-f340e video-recorder was used to record the sessions. steffens et al. (1992) report that the amount of vocalisation can be influenced by the presence of an interlocutor. each session therefore consisted of.2 components: a) the subject playing by herself with toys that made minimal noise (15 minutes). b) the primary caregiver interacting naturally with the subject (15 minutes). / vocalisation was encouraged using the subject's own age appropriate toys, smiling, eye contact and verbalisations on the part of the interlocutor (o'gara & logem~nn, 1988). all data used for analysis was confirmed by the caregivers as being typical of the type of babbling patterns produced by the subject within a natural environment. the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) babbling of an infant with a repaired cleft lip: a case study 33 training of raters transcription of data according to steffens et a1. (1992), after a period of training, adult listeners are consistent in judging vocalisations using infra phonological analysis. studies have demonstrated this consistency in the miami group's research (lynch & oller, 1992; oller et ai., 1994; lynch et ai., 1989). a study conducted independently from this group of researchers determined that listeners could be trained within short periods oftime in infra phonological analyses, with good consistency (levin, 1999). the three raters rated the audio-visual recordings of the subject as a group. this structure has been found to lessen the time needed for analysis and adds to reliability as it decreases the chance for error (levin, 1999). data was coded according to the principle categories of infraphonology after lynch et ai., (1989) and recorded on an infraphonological analysis profile (ifap) which was developed by levin (1999). three raters were selected all of whom had been trained phonetically. one ofthe raters had previous experience with infraphonology. the raters were twined by the second author who is familiar with infraphonology theory and analysis. training comprised a single-day session where the raters were provided with theoretical background on infraphonology and introduced to concepts necessary for analysis. a home video-recording of the subject in a natural environment was used to demonstrate theoretical concepts. training was considered complete when inter-rater reliability was 90% for utterances in this training sample (oller et ai., 1994). the ifap comprises of3 sections. the first is an analysis of utterances produced. utterances are defined as vocalisations that "do not include a previously used arbitrary rule requiring that vocalisations be separated by a fixed duration of silence (e.g., 1 second)" (steffens et ai., 1992, p. 239). this definition allows the rater to use tacit awareness of phrasing and grouping of sounds and judgement is based on perceived ''breath groups" regardless of the duration of the silence. according to lynch et ai., (1989) interobserver agreement improves when analysis is in accordance with this definition. the second section ofthe if ap is a checklist of precursor vocalisations (defmed in table 1). these are included in infraphonological analysis since they are considered part of the infant's repertoire of speech-like sounds which employ the characteristics of timing, frequency and amplitude. they all training and. analysis employed a 35 cm grundig t.v. monitor and a jvc hr-j727ms stereo video-recorder with audio signals routed through a 5 channel pioneer vs * 505s av system. table 1: definitions of infraphonological categories (mter lynch et ai., 1989., oller et ai., 1985., oller et al., 1994., steffens et al., 1992) precursor vocalisations squeals growls glottal stop sequences and glottal fricative sequencesl yells whispers raspberries clicks ingressive-egressive sequences' syllable affricates and fricatives vocalisations at high pitch, usually falsetto, distinctly out of the range that would be typical in speech. vocalisations at low pitch, often in a creaky voice, distinctly out of the range that would be typical in speech. squeals and growls are considered to be explorations of pitch sequences wherein vowels or quasi-vowels occur in syllable-like sequences with glottal consonants, which require no formant transitions because there is no supraglottal articulation distinct from cries yells and whispers are considered explorations of amplitude labiolingual or labial trills and/or vibrants suction stops often occurring in clusters these are viewed as explorations of the airstream mechanism these are viewed as explorations of frication. syllable structure categories quasi-resonant vowels (qrv) fully resonant vowels (frv) marginal syllables (ms) canonical syllables (cs) vowel-like sounds produced with the vocal tract at rest and with normal phonation, considered developmentally primitive or less speech-like perceived as being produced with the vocal tract open, and with normal phonation, likened to vowels produced by adult speakers. the appearance of frv's marks the beginning of the exploitation of the resonating potential of the vocal tract these include at least one consonant, a full vowel, and a slow transition between them (typically longer than 120 milliseconds). they are considered developmentally primitive. perceived as well-formed syllables with at least one consonant, a full vowel, and a rapid transition between them,. they are considered to be prototypical units and are the basic building blocks of all languages. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 34 occur frequently in babbling and are significant in the development of speech (kent & miolo, 1995). the third section of the ifap is a checklist of developmentally-primitive and well-formed syllables. the syllable structure categories all symbolise syllabic units with or without key features of well-formedness. the principle categories of syllable structure are defined in table l. inter-rater reliability was set at 90% agreement for canonical syllables (oller et ai., 1994). for all other features of the syllable structure acceptable inter-rater reliability was reduced to 85% (oller et ai., 1994). according to these same atithors,precursor vocalisations may be categorised without reliability measures as coding is essentially inherent. this study did, however, include reliability measures for precursor vocalisations since infraphonology has had limited exposure outside miami state university. by assessing the reliability of precursor vocalisations, it was possible to determine whether theoretical concepts in the literature were adequately explained to be understood and applied by the individual raters. good inter-rater reliability (oller et ai., 1994), for canonical and marginal syllables was obtained in sessions 1 & 3 (refer to table 2). the comparatively poor inter-rater reliability in session 2 was attributed to the small number of these syllables recorded during the session. inter-rater reliability was close to or 100% for all precursor vocalisations. the overall high levels of agreement indicate that infraphonological principles were reliably applied by the raters after a limited period of training. analysis of data 1. well-formedness measures according to steffens et ai. (1992) ratios are more valuable than frequency counts in the broader background of the total number of syllables produced. the syllable structure categories all symbolising syllabic units with or carol brenner & karen levin without key features of well-formed ness, were recorded in the total number of syllables produced on the ifap. for each feature ofthe syllable structure a ratio was calculated by dividing the number of representative syllabic units by the total number of syllables within a sample (oller et ai., 1994). the canonical babbling ratio (cbr) is the measure against which phonetically well-formed utterances are judged and was considered the key ratio of this study. a cbr of 0.15 was considered the minimum ratio to evidence canonical syllables and a cbr of 0.2 assigned the child to the "canonical stage of babbling" (oller et ai., 1994). 2. precursor vocalisations frequency counts for precursor vocalisations were recorded for each session. results and discussion the results will be presented in two sections. the first section will describe the utterance and syllable counts, and the analysis of the utterances and syllables that could not be analysed. these results are presented first because all results of the infraphonological analysis presented need to be evaluated against this background. the second section presents an analysis of the canonical syllables and the precursor vocalisations produced by the subject. analysis of utterances and syllable counts table 3 represents a frequency count for utterances and syllables produced in each of the three half hour recording sessions. more than 70 utterances were produced in each of the three sessions of which only the first 70 were coded. this is the convention of the miami group studies. steffens et ai., table 2: percentage inter-rater reliability for three sessions feature session 1 session 2 session 3 ; total utterance 97 93 100 i total syllables 92 99 94 : : i syllable structures i i fully resonant vowel 100 100 94 i " quasi-resonant vowel 93 89 89 i canonical syllable 92 71 92 marginal syllable 85 67 85 precursor vocalisations squeal 95 100 100 yell 100 100 100 whisper .-{oo ,. trill 100 click 100 100 ingressive-egressive sequence 100 100 .mfricate 100 75 fricative 100 the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) babbling of an infant with a repaired cleft lip: a case study 35 (1992) found that neither normally developing nor children with down syndrome always produced this minimum in a half-hour recording session. levin (1999) reported that year old infants with cerebral palsy also frequently did not produce as many as 70 utterances within the same time frame. there is no normative data on what is considered an appropriate amount of babbling within a period of time. oller et al. (1994) defined the number of utterances per minute as a measure of volubility while other researchers value different measures such as "mean babbling level" (stoel-gammon, 1989), and multiple measures (e.g.: jenkins, boggild-anderson, schmidt, ankerhus & hansen, 1988). there certainly appears to be a positive correlation between the amount of vocalisation and subsequent speech and language development (stoel-gammon, 1992). it is clear that there is no consensus in the literature on measuring volubility. the importance of volubility in the subject is unknown and since the infra phonological framework does not include this measure, inferences from this single case study could not be made. inter-sessional variability regarding total number of syllables produced was marked (see table 3). in session 3, almost double the number of syllables were recorded in a sample of70 utterances than were in session 2. kent (1992) ascribes inter-sessional variability to the developing motor pattern not yet well established in the infant, as well as to interpersonal preferences. variability in babbling has been described by many authors (e.g.: kent, 1992; stoelgammon, 1989), and the inter-sessional variability of the present study provides a strong rationale for the collection of at least three samples of data within a given time period. during session 3 the subject produced reduplicative sequences that were deliberately taught by her caregivers. sequences were categorised by repetitive lateral movements of the tongue from side to side of the mouth. the consonant in the sequence sounded like an iii but was perceived as a marginal syllable and was produced frequently in this session. each occurrence ofthi,s marginal syllable had to be counted in accordance with the infraphonological framework. this explains the relatively: high number of both total syllables and marginal syllablks produced in session 3. i the ifap was designed to include a count of utterances that were produced with a hand or toy in the mouth to prevent invalid codings duj to sound distortions from external obstructions. this b~haviour occurs frequently in infants. stark (1980) describes babbling as the satisfaction of a need for sensory and mhtor stimulation. by placing her hand in her mouth, the infant·was pairing the sensory input with motor stimulation (morris, 1989). hands-in mouth occurred in sessions 1 and 2 (refer to table 3). although the use of visual recordings can influence the rating of essentially auditory-perceptual methodology, visual information is critical for the validity of codings. many babbling studies have not made use of videorecordings (e.g.: grunwell & russell, 1987; lohmanderagerskov et ai., 1994). infraphonological analysis table 4 illustrates the frequency counts and ratios of the infra phonological features in the three sessions. canonical babbling ratio the subject produced a canonical babbling ratio (cbr) of greater than 0.20 in sessions 1 and 3. the relatively low cbr in session 2 was attributed to personal and environmental factors. it is clear that the subject was able to produce canonical syllables and her cbr was sufficient to assign her to the canonical babbling stage. the repaired cleft lip thus had no effect on the development of the syllable. results are typical of a normally developing child (kent & miolo, 1995). it is interesting that the infra phonological model excludes /w/ and /hi from the definition of a canonical syllable because of the slow formant transitions. as a result, frequently occurring phonemes in this study had to be excluded from canonical syllable counts. according to oller (1980) the quasi-resonant vowel is the most commonly used non-vegetative vocalisation type across the stages of babbling even though fully resonant nuclei may be used from around 4-6 months. the subject used predominantly quasi-resonant vowels in session 2 where she was preoccupied with ornamental birds and imitated the interlocutor. it is possible that although she showed an ability to produce fully resonant vowels and canonical syllables, her choice ofthe use of quasi-resonant vowels in this session was personal. in sessions 1 & 3, for every canonical syllable, at least 2 marginal syllables were produced. this was not unexpected even at the stage of canonical babbling. according to steffens et al. (1992), marginal syllables persist beyond this stage of babbling until the child is at least 2 years old. the fact that this ratio was not reflective of session 2 was once again attributed to intnipersonal variability. precursor vocalisations the subject did not produce growls, glottal stop sequences, glottal fricative sequences or raspberries. there was some consistency in the production of other precursor vocalisations across sessions (see table 4), but intersessional variability was evident. variations between the table 3: frequency counts of utterances and syllables produced per session feature session 1 session 2 session 3 total utterances analysed 70 70 70 undecided utterances 2 5 1 r analysable utterances 62 58 68 un analysed utterance (technical) 0 2 1 hands-in-mouth i 6 5 0 total syllables 105 98 181 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 36 frequency of production of different precursor vocalisations have been reported in studies of high-risk populations such as premature infants (oller et al., 1994) and hearing impaired infants (oller et al., 1985) and in normally developing children (oller et ai., 1994). oller et al. (1994) offer that this is because any individual plays with a sound repetitively and after a period of time excludes it from the babbling repertoire and selects other sounds with which to experiment. the reduced number of precursor vocalisations relative to the number of syllable structure features recorded in each session is indicative of the subject's progression towards mature speech (oller & lynch, 1992). it is expected that with age there is a decrease in the production of precursor vocalisations as they begin to lose their communicative function (stoel-gammon & otomo, 1986). conclusions the subject developed canonical babbling age appropriately therefore demonstrating that the repaired cleft lip had no effect on the development of infra phonological features. the subject also produced a variety of precursor vocalisations demonstrating an ability to manipulate the components of frequency, amplitude and timing that comprise mature speech. this single case study suggests that in children with cleft lip and palate it is probably primarily the cleft palate that affects the development of the components of speech necessary for the production of canonical syllables. the consistency of this vocal development despite the structural abnormality illustrates the flexibility of the speech-learning mechanism, and reinforces the concept of babbling being a robust phenomenon. larger samples and analyses of other mild structural oral-motor abnormalities (e.g. tongue-tie) are needed to reinforce the current findings. the results suggest that the slp need be more involved in the management of a child with a cleft lip when other carol brenner & karen levin risk factors (e.g. hearing loss) that predispose a child to speech or language disability co-exist with the cleft lip. the slp may also assume a counselling role in informing caregivers that the structural abnormality, once repaired should not affect babbling and speech. in this vein, since speech is one ofthe key measures by which the success of surgical repair is evaluated (bzoch, 1989), infraphonological analysis preand post-surgery may be of value as most repairs will be completed before the child is able to produce adult syllables. assessments of babbling should be included in developmental assessments which need be at regular intervals to monitor the child's development over time. it would seem that the infra phonological model is a useful starting point for the analysis of babbling, but is insufficient as it is to adequately provide predictive data. it is evident that infraphonology and the methodologies for the study of babbling are in themselves in their infancy, and like babbling, will take practice, time, feedback, and quantity to mature and become meaningful. the analysis o.fbabbling development in the cleft lip and! or palate population is an area that warrants further exploration because ofthe importance of babbling for later speech-language development. this single case study was an attempt to add to the literature additional information concerning early vocal development in infants with cleft lips. acoustic, phonetic and infra phonological studies are needed, and longitudinal data would be invaluable. references bzoch, k. r (1989). communication disorders related to cleft lip and palate (third edition). boston: college-hill publications. grunwell, p., & russell, j. (1987). vocalisations before and after cleft palate surgery: a pilot study. british journal of disorders of communication, 22, 1-17. jenkins, t. s., boggild-anderson, b., schmidt, j., ankerhus, j., & hansen, e (1988). perinatal risk factors and first year vocalisations: influence on preschool language and motor table 4: infraphonological features: frequency counts and ratios (in brackets) feature session 1 session 2 session'3 syllable structure : fully resonant vowels 4 (0.03) 3 (0.03) 36 (0.20) i quasi-resonant vowels 15 (0.14) 82 (0.84) 27 (0.15) i canonical syllables 27 (0.26) 7 (0.07) i 38 (0.21)' marginal syllables 59 (0.56) 6 (0.06) 80 (0.44) precursor vocalisations squeal 20 11 14 yell 7 4 8 whisper 0 0 1 / trill 2 0 0 click 1 0 1 ingressive-egressive sequence 10 2 0 syllable affricate 2 0 4 syllable fricative 0 0 1 the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) babbling of an infant with a repaired cleft lip: a case study 37 performance. developmental medicine and child neurology, 30, 153-161. kent, r. d. (1992). the biology of phonological development. in ferguson, c.a., menn, l., & stoel-gammon, c. (eds.), phonological development: models, research, implications. maryland: york press. kent, r. d., & miolo, g. (1995). phonetic abilities in the first year of life. in fletcher, p., & mcwhinney, b. (eds.),handbook of child language. oxford: blackwell. levin, k. (1999). babbling in infants with cerebral palsy. clinical linguistics and phonetics, 13 (in press). lohmander-agerskov, a., soderpalm, e., frieds, h., persson, e., & lilja, j. (1994). pre-speech in children with cleft lip and palate or cleft palate only: phonetic analysis related to morphologic and functional factors. cleft palate-craniofacial journal, 31, 4, 271-279. lynch, m. p., oller, d. k., & steffens, m. (1989). development of speech-like vocalisations in a child with congenital absence of cochleas: the case of total deafness. applied psycholinguistics, 10,315-333. menn, l. (1992). building our own developmental phonology comes of age. in ferguson, c.a., menn, l., & stoel-gammon, c. (eds.), phonological development: models, research, implications. maryland: york press. morris, s. e. (1989). development of oral-motor skills in children. dysphagia, 3, 135-154. o'gara, m. m., & logemann, j. a. (1988). phonetic analyses of the speech development of babies with cleft palate. cleft palate journal, 25, 2, 122-134. oller, d. k. (1980). the emergence of the sounds of speech in infancy. in yeni-komshian, g. h., kavanagh, j. f., & ferguson, c. a. (eds.), child phonology: volume 1. new york: academic press. oller, d. k., eilers, r. e., bull, d. h., & carney, a. e. (1985). prespeech vocalisatlons of a deaf infant: a comparison with normal metaphonological development. journal of speech and hearing research, 28,47-63. oller d. k., & lynch, m. p. (1992). infant vocalisations and innovations in infraphonology. in ferguson, c.a., menn, l., & stoel-gammon, c. (eds.), phonological development: models, research, implications. maryland: york press. oller, d. k., eilers, r. e., steffens, m. l., lynch, m. p., & urbano, r. (1994). speech vocalisations in infancy: an evaluation of potential risk factors. journal of child language, 21, 3358. pettito, l. a., & marentette, p. f. (1991). babbling in the manual mode: evidence for the ontogeny of language. science, 251, 1493-1496. rossetti, l. m. (1996). communication intervention: birth to three. san diego: singular publishing group. savage, h. e., neiman, g. s., & reuter, j. m. (1994). a developmental perspective on assessment of infants with clefts and related disorders. infanttoddler intervention: the transdisciplinary journal, 4, 221-234. shaugnessy, j. j., & zechmeister, e. b.j1990). research methods in psychology (2nd edition). new york: mcgraw-hill publishing company. stark, r. e. (1980). stages of speech development in the first year of life. in yeni-komshian, g. h., kavanagh, j. f., & ferguson, c. a. (eds.), child phonology: volume 1. new york: academic press. steffens, m. l., oller, d. k., lynch, m., & urbano, r. c. (1992). vocal development in infants with down syndrome and infants who are developing normally. american journal of mental retardation, 97,235-246. stoel-gammon, c (1989). prespeech and early language development of two late talkers. first language, 9,207-224. stoel-gammon, c (1992). prelinguistic vocal development. in ferguson, c.a., menn, l., & stoel-gammon, c. (eds.), phonological development: models, research, implications. maryland: york press. stoel-gammon, c., & otomo, k. (1986). babbling development of hearing impaired and normally developing subjects. journal of speech and hearing disorders, 51, 033-041. die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) im proving the r elevance o f speech-l anguage pathology and a udiology r esearch and p ractice 11 appropriate for the task. a phenomenological, in contrast to a positivist, research paradigm assumes that the world is socially construed and therefore all truth is subjective and relative (newman, 1997). combining research along the continuum o f the positivist and phenomenological extremes, investigating both abstract and concrete concepts to describe, solve, understand and explore professional practice and client profiles is therefore war­ ranted. this holistic or eclectic approach can provide a richer body o f professional knowledge that produces scientific fact within an understanding o f the subjective realities of the socio­ cultural populations which we serve. it is therefore not a matter o f abandoning old methods but rather o f embracing new ones alongside traditional research methods. to an increasing extent, this has been a trend in recent studies conducted by the profes­ sions in south africa (louw & avenant, 2002; van dijk, 2003; swanepoel et al., 2005). whilst it is necessary and useful to critically consider the research paradigms to be employed by the professions o f audiol­ ogy and speech-language pathology, on a more practical level it is essential that whatever the research being pursued, it must ultimately be published. research conducted by our professions in south africa unfortunately, remains unpublished in the over­ whelming majority o f cases. a marginal number o f publications, and especially international publications, have emerged from the respective fields o f audiology and speech-language pathology since the establishment o f the professions in south africa over five decades ago (swanepoel, 2006). credence and advocacy for our services rely in large part on the recognition o f the research we conduct. this is especially true in an era where evidence based practice has become a core principle o f professional prac­ tice. it is therefore o f great importance that we not only ensure the use of an holistic paradigm in our research but that we dem­ onstrate the worth o f our efforts by bringing them to fruition in the form o f internationally recognized peer-reviewed publica­ tions. the collective responsibility for establishing world-class research outputs that are locally relevant rests on the profession as a whole, and in particular on the academics and postgraduate students at tertiary institutions for audiology and speech language pathology. > ‘‘sociopolitical changes j have come and gone, but the challenge fo r the profession has remained the same to provide accountable services to the entire population based on quality training and contextual research efforts” (swanepoel, 2006, p.266). improving the relevance o f the research and practice of the professions o f audiology and speech-language pathology in south africa, as argued in response to the issues raised by response: ernaalant kathard et al., therefore relies on 1) the clear recognition o f the professions as sciences reliant on research development; 2) the adherence to basic principles of human dignity and respect for all persons instead of political ideologies; 3) the engagement of social justice and equity in our professional capacity only as these principles relate to scope of practice and the populations which we serve; 4) the utilization o f holistic research paradigms by embracing phenomenological methods alongside existing positivist methods; 5) the culmination o f research efforts being acknowledged in internationally recognized publications which serve an advocacy function in respect o f the professions and the respective services they render to the broader south african population. a n c t oday (2005). r esponding b etter to the health care n eeds o f com m unities. a n c t oday, 5(4 3 ). h ttp ://w w w .a n c .o rg .z a /a n c d o c s /a n c to d a y /2 0 0 5 / a t4 3 .h tm # artl de v os, a. (2002). scientific theory and pro fessio n al research. in a.s. de v os (ed.), r esea rch a t grass r oots. (2nd ed.) p retoria: v an schaik. 28-48. k ubba, h., m aca ndie, c., r itchie, k. & m acf arlane, m. (2004). is deafness a disease o f p overty? t he association betw een socio-econom ic deprivation and congenital hearing im pairm ent. in tern a tio n a l jo u r n a l o f a u diology, 43, 123-125. l ouw , b. & a venant, c. (2002). c ulture as co n tex t for intervention: developing a cu ltu rally co n g ru en t early intervention program . international p ediatrics, 17(3), 145-150. m axw ell, d.l. & satake, e. (2006). r eseach a n d sta tistic a l m ethods in co m m u ­ nication sc ien ces a n d disorders. c lifton park: t hom son d elm ar l earning. n eum an, w .l. (1997). so cia l r esearch m ethods: q ualitative a n d q uantitative a p p ro a ch es (3rd ed.), a llyn and b acon, boston. o ’c onnor, a. (2004). t he persistence in poverty. in d. potes & t. bow yer b ow er (e ds.) e a stern a n d southern a frica. d e ve lo p m en t challenges in a volatile region. e ssex: pearson e ducation l im ited.(pp. 89-117). s w anepoel, d. (2006). a udiology in south a frica. in tern a tio n a l j o u rn a l o f a u d io lo g y, 45, 262-266. s w anepoel, d ., h ugo, r. & louw, b. (2005). im plem enting infant hearing screening at m aternal and child health clinics: context and interactional processes. h ea lth sa g esondheid, 10(4), 3-15. v an d ijk, c.a . (2003). a n educational a u d io lo g y se rvice d elivery m odel: needs o f teachers o f children w ith hearing loss. u npublished d .phil. c om m unica­ tion p athology degree. u niversity o f pretoria. w alley, j., k han, m .a ., shah, s.k ., w itter, s. & w e, x. (2007). h ow to get research into practice: first g et p ractice into research. b ulletin o f th e w orld h ea lth o rganization, 85(6), 424-425. director: centre for alternative and augmentative communication, university o f pretoria, sa. a bou t being relevant: a com m ent on kathard, naude, pillay & ross (2007). i accepted the invitation to respond to this paper with pleasure, not only because i welcomed the critical thinking reflected in the paper, but also because i think the issues raised are vital to the long-term sustainability o f the professions of slp/audiology in this country. like others, i also have been deeply concerned about the profession and its future within the african continent. this concern is not based on a belief that the profession is irrele­ vant or peripheral to local development, but rather on the com­ plexities of the issues facing the field o f speech-language pa­ thology and audiology as well as other rehabilitation profes­ sions within poverty contexts. kathard et al. (2007) raises important issues upon which i would like to comment and include: • the issue o f relevance and different types o f research, • the role o f evidence-based practice and finally, • intervention in poverty contexts. for a long time, the western world has dominated the profession of speech-language pathology and audiology for good reasons. however, as the developing countries come into their own, the realization dawns that we can not translate strategies used in the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.anc.org.za/ancdocs/anctoday/2005/ 12 h. k athard, e. n aude, m. pillay and e. ross industrialized contexts to developing contexts in uncritical ways. similarly, the knowledge-base o f the western world is equally limited in addressing issues o f poverty and diversity. we know that a significant proportion o f what we have learned and success­ fully applied in this countiy is based (at least partly) on what our international counterparts have developed. many o f the interven­ tion issues that parents and professionals in the western countries experience are similar. however, on a continuum many o f these issues are intensified within poverty contexts. the issue o f hiv/ aids certainly adds a further critical dimension. an example is the fragmentation of services relating to early childhood interven­ tion, which is a major problem in many countries. in south africa where parents have lack o f access to services to start off with, fragmentation o f services can have a pronounced impact on fami­ lies in poverty and their ability to participate in intervention, par­ ticularly also in the context o f hiv/aids. the average more edu­ cated parent has significantly more resources in coping with di­ verse messages impacting from different professional angles. how do we manage an effective intervention service to young children in a country that rates low (unicef, 2006) in terms o f provision o f health and education to children? what is the responsibility o f the profession in the face o f these issues? do we ignore them, or actively engage with them? do we really have a choice? whilst this is not a profession-specific problem, the issue o f transdisciplinary service provision clearly is an important con­ sideration. why when we know that community-based interven­ tion in homes is more effective than institution-based intervention are most o f our interventions still in hospitals and school clinics? the caac recently conducted a nationwide survey with some of our multi-professional graduates (speech-language pathology, audiology, occupational therapy, etc.) on the location o f where services are rendered. just about all the therapy was focused on multi-disciplinary, institution based models o f intervention. these practice contexts prompt questions such as the following: in sa, are we getting better at addressing the issues we face when provid­ ing young children in need with access to therapy? are we plan­ ning and training for impact if we promote multidisciplinary ser­ vice models in contexts where there seldom are rehabilitation pro­ fessionals to fill a team? let me admit that i do understand (and have been reluctantly involved in) the professional boundary is­ sues in relation to what is occupational therapy, speech language therapy/audiology and physiotherapy domains. does this type o f “professional protection” really advance our services to those in need? are we moving forward by systematically build­ ing a bigger private practice speech/language therapy and audiol­ ogy professional base? when is our commitment to our profession more overtly going to focus on government support and liaisons to develop service and intervention models that could work for reha­ bilitation in our country? one o f the present-day realities for any profession focuses on the accountability o f the outcomes o f services and not only outcomes, also impact. kathard et al. (2007) refer to the un mil­ lennium development goals to alleviate poverty and state that we should be guided by priorities to create a more equitable world. this point highlights the issue of sustainability o f our intervention outcomes over time (alant, 2005). is it enough to prove effective­ ness? what about long-term efficacy and sustainability o f change? the authors continue by stating that “the use o f highly valued em­ pirical research methodologies has functioned to develop our pro­ fessional interest” and then proceed to question the social validity o f these processes. towards the end of the paper they also argue for the development o f ecological frameworks o f practice. these issues are indeed relevant, as, regardless o f methodologies used, one needs to ask how findings and data translate into the improve­ ment o f everyday working reality for those in need. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 there is a significant difference between research ap­ proaches focused on identification o f generalities, i.e. the no­ tion o f context-free laboratory-type experiments, and those interested in understanding phenomena entrenched within the social context o f living. as we know, these are not mutually exclusive but both form an important part o f development of knowledge and applications in any field. however, good re­ search or high level evidence is, as we know, not determined by the methods used, but by the degree to which the processes and recording show a high regard for issues relating to trust­ worthiness or validity. the real issue therefore is not so much whether we need to use different research approaches in an­ swering different questions essential to improving practice, but a deep commitment towards making sure that the methods used are credible in the data and interpretations proposed. having said that, it is important to ensure that we ask relevant questions in guiding practice and that we do allow different researchers to add to the existing body o f knowledge by not imposing pre-conceived notions of what is “good re­ search” on the process. in this regard david beukelman (2001), based on the work o f boyers and rice (1990), identi­ fies at least five different types o f researchers necessary to expand a field, which include researches focused on the repre­ sentation o f knowledge, integration o f knowledge, advance­ ment o f generalized knowledge, advancement o f individual­ ized knowledge and application o f knowledge. all these dif­ ferent types o f researchers are important to develop a field and we need to remain cognizant o f the importance o f encour­ aging different ways o f inquiry to add to the richness in un­ derstanding complex phenomena o f the field. can research findings, however, dictate decisions on clinical practice? how do we decide on what is the best inter­ vention approach to take with a specific client? schlosser and raghavendra (2004) outlined what they describe as the proc­ ess o f evidence-based practice in augmentative and alterna­ tive communication as focusing on three factors, i.e. best and current research evidence, clinical/educational expertise and thirdly relevant stakeholder perspectives. from this model it is clear that an evidence-based practice does not mean the aban­ donment of stakeholder involvement or clinical and educa­ tional expertise, but rather the incorporation of these in the process o f sound decision-making relating to a specific client and context. evidence-based practice thus implies that the clinician is not only able to search and access relevant re­ search findings, but also that s/he is able to meaningfully in­ terpret these findings within his/her own working context/ expertise together with a sound understanding and interaction with the client s/he serves. the responsibility that lies with the speech-language pathologist/audiologist thus remains one o f integrating the research evidence with the professional exper­ tise and consultation with the client served. herein lies a ma­ jor ethical and professional responsibility not just to use the therapeutic approaches best known to the speech-language pathologist/audiologist, but to ensure that the choice o f strate­ gies applied are those most relevant to the client! the authors ask the question “can we rely on an em­ pirical science to enable us to adequately engage what are issues o f social justice?” clearly, one can never replace hu­ man responsibility with scientific processes. clinical expertise o f the interventionists, their understanding arid caring will always remain pivotal to the process o f meaningful interven­ tion. the challenge is to explore the relationship between the part and the whole,,the individual and the system or con­ text without confusing them as being the same or inter­ r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) im proving the r elevance o f speech-l anguage pathology and a udiology r esearch and practice 13 changeable. we have to understand what is going on in the whole system to understand the individual just as we need to inquire about the individual to learn about the whole. as we listen to the stories o f individuals and families in distress, we also need to “be-in-the-world” (heidegger’s concept o f “da sein”, 1996) which implies an openness and understanding o f possibilities within the world. this will enable us to pick up impressions and ideas and explore these with our clients and families in moving towards discovering ways to assist them not only to cope and survive, but live. speech-language patholo gists/audiologists need to be conscious enough o f their own assumptions to ensure that these do not become an imposition on others. only by realizing one’s own limitations and preju­ dices can one move forward in understanding and meaningfully assist those who live in society’s “black holes”. this idea is best expressed in the words of eudora welty, quoted by marga­ ret wheatly (1999, p. vi) “ my continuing passion is to part a curtain, that invisible shadow that falls between people, the veil o f indifference to each other’s presence, each other’s wonder, each other’s human plight”. response: claire penn a lant, e. (2005). intervention issues. in e. a lan t & l.l. l loyd (eds). a u g m en ­ tative and a lternative c om m unication and s evere d isabilities: beyond poverty. w h u rr p ublications: l ondon (pp. 9-29). b eukelm an, d. r. (1993). a a c research: a m ultidim ensional learning com ­ m unity. a u g m en ta tiv e a n d a ltern a tive c om m unication, p (l), 63-68. boyers, e., & r ice, r.e. (1990). the n e w a m erica n scholar. c arnegie f oun­ dation: pittsburgh. h eidegger, m. (1996). b eing and t im e (a tran slatio n o f sein und z eit). a l­ bany, state u n iv ersity o f n ew y ork press. schlosser, r. w ., & r aghavendra, p. (2004). e vidence-based practice in aug­ m entative and alternative com m unication. a u g m en ta tiv e & a ltern a tive c om m unication, 20(1), 1-21. u n ic e f (2006). the sta te o f the w orld's children 2007: w omen a n d children, the d o u b le d iv id e n d o f g e n d e r e q u a lity n e w y ork: u n ic e f. w heatley, m . j. (1999). l ea d ersh ip a n d the n ew science: d isc o verin g o rd e r in a chaotic w o rld (2nd ed.). san francisco: b errett-k oehler. school o f human and community development, university o f the witwatersrand, sa. “d o n ’tg iv e m e the theory, ju s t tell m e w hat to do in therapy!”: the slippery slope challenge f o r the south a frican professions o f speechlanguage pathology a n d a udiology the above frequent plea o f the clinician attending a refresher course has resonated in my ears over the years. in this paper i address the reasons and frustrations caused by this enjoinder and in responding to the lead article, will reconsider priorities o f our discipline and its implications for selection, training, funding and practice. i will argue that the discipline in this country is at an important crossroads and that future flourishing will depend on a proactive and firmly grounded commitment to scientific research. ; regardless o f context, the twin disciplines o f speech language pathology and audiology have always fought for sci­ entific identity. the reasons for this have been multiple. the fact that their subject matter j human communication is an interdisciplinary one has required a grounding in several main and historically secure fields: medicine, psychology, linguistics and physics to mention a few. thus methods used for research in our disciplines have often been those borrowed from such fields and include a range o f clinically based observations, ex­ perimental and descriptive designs. while there has been a his­ torical effort to establish a unique identity for the disciplines, as reflected in some interesting debates on this topic, we are not yet there (ringel, trachtman, & prutting, 1984; perkins, 1985; siegel, 1987; siegel & ingham, 1987). the discipline in this country is 70 years old and this makes it a mere teenager in relation to some o f its parents and like a teenager, possibly still uncertain o f its identity and auton­ omy and o f which route to take towards this. if one looks at the history o f our discipline, both here and elsewhere, we have fol­ lowed and not taken the lead. thus there has been a tendency to follow the current zeitgeist o f medicine, psychology, and lin­ guistics when searching for methods and explanatory frame­ works. we take others’ methods and theories and adapt them. in order to play the grant game and the publications game in research, this adherence to mainstream enables funding, ac­ knowledgement, promotion and recognition. when you live at the cusp o f another discipline you w on’t be noticed until you play that game and speak their language. an example is offered from the field o f aphasia, my own specialization, which can be characterized as having a number o f distinct phases. starting in the field o f neurology with a strong tradition o f case studies one can trace the influ­ ences of psychology, the preference for large scale group stud­ ies and the influences o f early linguistic theory and the behav­ ioural approach to communication o f the 1960s. pragmatics dominated the 1980s leading to current social approaches and we now see a return to the neural model with the advent of advanced functional neuroimaging. the influence o f the who framework has been pervasive and is also mentioned in the lead article (see penn, 2004a and penn, 2005 for further consid­ eration o f these issues). any scholar o f aphasia who is caught unawares and proposes a non-mainstream idea during a particular era has a challenging time getting an audience or arguing their case. non mainstream ideas are tolerated or perhaps used as a platform for dialogue and debate. those who work and think outside the box certainly add texture and depth to the discipline and serve (if a political analogy is allowed) as a type o f opposition party in order to refresh and remind those who are heading towards a dictatorship. often such streams o f thought are published in different journals and at best attend parallel sessions at the same conferences. but such argument and debate we are told is essential for paradigm change and no discipline can thrive or grow without such mechanisms (kuhn, 1970). the search for a scientific and research identity and autonomy in our disciplines has been difficult, and remains in my opinion, elusive. the first reason may be because o f the profoundly complex domain o f study. human behaviour is unpredictable and is influenced each day by a myriad o f fac­ tors, as the lead article makes explicit. the influence o f gender, race, poverty and socio political history have profound effects the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) abstract introduction methods ethical consideration results discussion conclusion acknowledgements references about the author(s) lauren c. fouché department of speech-language pathology and audiology, university of pretoria, south africa alta kritzinger department of speech-language pathology and audiology, university of pretoria, south africa talita le roux department of speech-language pathology and audiology, university of pretoria, south africa citation fouché, l.c., kritzinger, a., & le roux, t. (2018). gestational age and birth weight variations in young children with language impairment at an early communication intervention clinic. south african journal of communication disorders 65(1), a584. https://doi.org/10.4102/sajcd.v65i1.584 original research gestational age and birth weight variations in young children with language impairment at an early communication intervention clinic lauren c. fouché, alta kritzinger, talita le roux received: 24 oct. 2017; accepted: 01 june 2018; published: 17 sept. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: south africa presents with high preterm birth (ptb) and low birth weight (lbw) rates (14.17%). numerous conditions characterised by language impairment are associated with lbw and/or ptb. speech-language therapists may fail to identify older children whose language impairment may have originated from lbw and/or ptb. objective: to describe the frequency of lbw and/or ptb, in comparison with full-term birth, and associated conditions in children at an early communication intervention (eci) clinic. methods: retrospective data of 530 children aged 3–74 months were analysed, with 91.9% presenting with language impairment. results: almost 40% had lbw and/or ptb, and late ptb was the largest category. factors associated with lbw and/or ptb were prenatal risks, including small-for-gestational age, perinatal risks, including caesarean section, and primary developmental conditions. secondary language impairment was prevalent, associated with genetic conditions and global developmental delay. conclusion: the frequency of lbw and/or ptb was unexpectedly high, drawing attention to the origins of language impairment in almost 40% of the caseload at the eci clinic. introduction as a low-to-middle-income country, south africa presents with preterm birth (ptb) (< 37 weeks gestational age) and low birth weight (lbw) (< 2500 g) rates as high as 14.17%, as opposed to 7% in high-income countries (feresu, harlow, & woelk, 2015; howson, kinney, & lawn, 2012; pattinson, 2013). apart from a high mortality risk and neonatal illness, the neurodevelopmental concerns within this population of children are diverse and can be long term (allen, 2008). severe developmental disabilities associated with lbw and/or ptb include cerebral palsy (cp), sensory impairments of vision and hearing, mental disability and seizure disorder (allen, 2008; van de weijer-bergsma, wijnroks, & jongmans, 2008). these disabilities may all be associated with secondary language impairment. in addition, neurodevelopmental functions, such as attention, cognition, executive functioning, emergent literacy, sensory processing, gross and fine motor skills, communication and language, as well as feeding and swallowing, may be affected in children with lbw and/or ptb, and associated with less severe clusters of impairments and disorders (allen, 2008; howson et al., 2012; mathisen, carey, & brien, 2012). language impairment in children born preterm and with lbw may also co-occur secondary to various genetic syndromes or congenital conditions. one of these conditions is foetal alcohol spectrum disorder (fasd), a congenital disorder affecting 6% of the south african population (foundation for alcohol related research [farr], 2016). children born with fasd are small-for-gestational age, which is associated with intrauterine growth restriction and often also accompanied by ptb (peranich, reynolds, o’brien, bosch, & cranfill, 2010). low birth weight and/or preterm birth has recently been identified as a risk for autism spectrum disorder (asd) (kihara & nakamura, 2015). infants born with syndromic cleft lip and/or palate (clp) are at risk for lower birth weight of up to 600 g less than unaffected infants (nyarko, lopez-camelo, castilla, & wehby, 2013). similarly, infants who are exposed to the human immunodeficiency virus (hiv) are at risk for very lbw, atypical length and head circumference, and neurodevelopmental deficits and feeding difficulties associated with hiv-encephalopathy (kihara & nakamura, 2015). it has also been found that lbw could be associated with down syndrome (nyarko et al., 2013). low birth weight and/or preterm birth are thus recognised as potential causes of language impairment and swallowing disorder in young children with a wide variety of neurodevelopmental conditions (mathisen et al., 2012). in addition to the numerous neurodevelopmental sequelae that may result from lbw and/or ptb, it is also necessary to consider the wide array of underlying biological, medical and environmental interactional factors significantly associated with lbw and/or ptb. genetic influence, race and ethnicity, very young and advanced maternal age, in vitro fertilisation, multiple pregnancies, maternal history of ptb, maternal infections and chronic conditions such as diabetes and high blood pressure, smoking, alcohol and substance abuse, reduced spacing between births, poor antenatal care and nutrition, induced or caesarian birth, high levels of outdoor air pollution, poverty, minority status and certain migrant subgroups have been shown to be associated with lbw and/or ptb (barrett, 2014; howson et al., 2012; johansson & cnattigius, 2010; organisation for economic co-operation and development [oecd]/world health organization [who], 2016; urquia et al., 2010). globally, the risks for lbw and/or ptb are increasing, with preventative efforts not yet effective (editorial, 2016; howson et al., 2012). it is clear that lbw and/or ptb is a complex condition in children requiring current knowledge and in-depth understanding of all its implications. the terms lbw and ptb are distinct, yet closely related indicators and are recommended to be used in combination to indicate a new born infant’s immaturity. intrauterine growth restriction may cause misclassification of gestational age and over-representation in studies when only birth weight is used (johansson & cnattigius, 2010). infants with lbw and/or ptb do not have an established risk for delayed development but may represent an at-risk population with neurodevelopmental disabilities or disorders, often presenting as complex co-occurring conditions within one child (rossetti, 2001). speech-language therapists and other health professionals may fail to identify disorders related to lbw and/or ptb in their caseloads of older children. the detail of case histories of older children and the significance of late ptb may be overlooked. there may also be a perception that infants with lbw and/or ptb outgrow early language delay (van niekerk, kirsten, nel, & blaauw, 2014). research is required to better understand the prevalence of and co-occurring conditions associated with language difficulties in preschool children who were born preterm and with lbw. while preterm infants are expected to achieve normal growth and weight between the ages of 2 and 3 years (rasmussen, wong, correa, gambrell, & friedman, 2006), recent studies indicate that many developmental sequelae may persist throughout life (american psychiatric association [apa], 2013; bailey & sokol, 2008; kihara & nakamura, 2015; nyarko et al., 2013; van de weijer-bergsma et al., 2008). language impairment in children with lbw and/or ptb involve deficits in receptive and expressive components, grammar, vocabulary and articulation (feldman, lee, yeatman, & yeom, 2012; schults, tulviste, & haan, 2013; wolke, samara, bracewell, & marlow, 2008). the language difficulties may persist throughout primary school, a period during which language development should stabilise and mature (boyer et al., 2014; wolke et al., 2008). it is not clear from these studies whether children with lbw and/or ptb present mostly with primary language impairment or language impairment secondary to conditions associated with lbw and/or ptb. preterm birth and lbw is therefore considered as a complex condition that may originate from different causal factors, and may be associated with a wide array of outcomes, affecting the child in various degrees of severity and persistence. since it is a prevalent condition in south africa and other low-to-middle income countries (pattinson, 2013), a description of the frequency of lbw and/or ptb, co-occurring conditions and developmental characteristics of children with language impairment may create an increased awareness in speech-language therapists and health care professionals managing these children. the purpose of this study was, therefore, to describe the frequency of lbw and/or ptb, in comparison to being born with normal birth weight (nbw) and full term (ft), as well as associated conditions in children at an early communication intervention (eci) clinic. methods study sample a comparative, retrospective design was used. the study was conducted at an eci university-based clinic. the clinic provides assessment and intervention services to young children and their families, who visit the clinic owing to concerns regarding the child’s communication and language development. on average, 50 new clients are annually assessed at the clinic. a uniform assessment protocol, including the rossetti infant-toddler language scale (rossetti, 2006), was used for all play-based communication assessments, and informed consent was obtained from parents prior to each assessment. all children who attended the eci clinic between 2003 and 2015, and of whom complete datasets were available, were included in the study. the datasets equated to 530 participants, which consisted of preschool children (mean = 28.47 months, mode = 13 months, sd = 14.66 months, range = 3–74 months), with a gender distribution of 333 (63%) males and 197 (37%) females. the male gender bias in the sample is a known risk factor in children with language impairment (korpilahti, kaljonen, & jansson-verkasalo, 2016). table 1 describes the family and participant demographics of the study sample. table 1: demographical characteristics of study sample. as seen in table 1, the study sample was diverse but consisted mainly of white people (77%), afrikaans speaking (59.3%) children who stayed at home with a parent during the day (23.7%) and were exposed to only one language (67.1%). the majority of the sample originated from an urban residential setting (94.9%), made use of private healthcare services (77%), with just more than half (52.7%) of the caregivers having completed tertiary education. the use of private health care and the high education level of mothers suggest that the sample included mostly middle-income families, and as a result, this study sample is not representative of the south african population. the characteristics of the sample may relate to the middle-income urban geographical location of the university where the clinic operates from. data collection procedures and material the patient register of the eci clinic was reviewed in order to identify children who were assessed between 2003 and 2015. the clinical files of the children with complete data were drawn from the filing cabinets and then reviewed retrospectively. an electronic database was developed to organise and capture the data in a consistent format. data collected included demographical and medical information, case history questionnaires containing documented risk factors and communication assessment results. data analysis stata statistical software package (version 21) was used to analyse the data. data were divided into two distinct groups: the lbw and/or ptb group, which included all children who were born preterm, or lbw or were born preterm with lbw; and the nbw and/ or ft group, which included children who were ft or post-term, with normal or high birth weight. for this distinction, the who classification system for ptb and lbw was used (howson et al., 2012; reidy et al., 2013). preterm birth was categorised into three gestational ages: extremely preterm (< 28 weeks gestational age), very ptb (28 – < 32 weeks gestational age) and moderate to late preterm (32–37 weeks gestational age); and lbw was categorised as: lbw (< 2500 g), very lbw (< 1500 g) and extremely lbw (< 1000 g) (howson et al., 2012; reidy et al., 2013). the eci clinic where data were collected provides intervention services to children who are within the pre-lingual period, as well as those who are busy acquiring language. the population receiving eci services at the clinic, therefore, includes children with communication delay, but the term language impairment as suggested by owens (2014) was used to refer to the multiple aspects of the children’s communication and language difficulties. the degrees of language impairment were used as recommended by rossetti (2006), where mild refers to a 3–6 month delay, moderate refers to a 6–12 month delay and severe refers to a 15 month delay or more. a criterion-referenced developmental assessment scale (anderson, fowler, & nelson, 1978) was used to determine the children’s developmental status regarding socio-emotional, perceptual-cognitive, play, gross and fine motor, and self-help skills. in this study, primary language impairment refers to language impairment as the only relevant factor, whereas secondary language impairment is used when a child presented with a condition other than his or her language difficulties, which may have language impairment as a secondary outcome. global developmental delay was used when a child does not meet his or her developmental milestones in several areas of intellectual functioning at the appropriate age (apa, 2013). genetic or congenital conditions and asd occurring in the sample were diagnosed by an independent medical specialist. descriptive statistics were calculated for all variables, including means, standard deviations and proportions. student’s t-tests were used to determine significant differences between the two study groups. the chi-squared test (fischer’s exact) was used to identify significant associations between variables. associations between variables were investigated for the two groups to determine if there were significant differences between children with lbw and/or ptb, and children born ft with nbw. a significance level of p ≤ 0.05 was deemed significant. owing to the retrospective nature of the study, patient files were not all complete for every variable considered. results were, therefore, based on the available data for each variable. ethical consideration institutional ethical clearance was obtained for the study before data collection was initiated (protocol number 12142078-gw20160314hs). results frequency of low birth weight and preterm birth table 2 depicts the mean gestational age and birth weight for the two groups, respectively. table 2: frequency of low birth weight and preterm birth. according to table 2, 209 (39.4%) of the children were in the lbw and/or ptb group, and 319 (60.6%) in the nbw and/or ft group (n = 528). the average gestational age for the lbw and/or ptb group was 35 weeks, which is considered late preterm (32–37 weeks), whereas the average for the nbw and/or ft group was 39.3 weeks, which is ft (38–41 weeks). the average birth weight for the lbw and/or ptb group was 2303.3 g, which corresponds with infants born late preterm (stolt et al., 2016), and 3269.3 g for the nbw and/or ft group. the distribution of birth weight and gestational age across the study sample can be seen in table 3. table 3: distribution of birth weight and gestation age (n = 530). table 3 shows that nbw (72.3%) and ft (64.7%) combined with post-term birth (2.1%) were the most prevalent groups in the sample. the second largest groups were 21.5% of the study sample with a birth weight of between 1500 g and 2500 g (lbw), and 27% with a gestational age within the late preterm range. this corresponds with the average birth weight and gestational age of the lbw and/or ptb group (table 2), highlighting the prevalence of children born late preterm and with lbw but not in the very lbw category in this sample. the difference in percentages between birth weight and ptb, which is expected to correspond, is owing to infants being born small-for-gestational age (below the 10th percentile for gestation), thus their birth weight is lower than the expected weight for gestational age. just more than 6% of the study sample had a birth weight of less than 1500 g, and were born before 32 weeks’ gestational age, representing the small group of very lbw and very ptb in the sample. the majority of this sample with language concerns presented with birth weights above 1500 g (lbw) and were born later during the gestation period (after 32 weeks). language impairment table 4 indicates the distribution of the degrees of language delay across the entire study sample, as well as distribution thereof between the two study groups. although all children in the sample attended the eci clinic owing to concerns regarding their communication and language development, only 91.86% of the entire sample were found to present with primary or secondary language impairment after assessment at the clinic. presence of language impairment for a few children could not be determined owing to a very young age, and the remaining were found to have typical language development. the reason why 33 out of 528 children (6.25%) of the sample did not present with language delay could be related to parents requesting an assessment but no delay was found. ten children (1.89%) were infants under three months of age who presented with down syndrome or another established risk condition but could not be scored on the rossetti infant-toddler language scale (rossetti, 2006) as the instrument requires a delay of more than three months to be classified as language delay. table 4: degrees of language delay across study sample. according to table 4, almost half (49.1%) of the entire study sample had severe language delay. within the lbw and/or ptb group, 93.4% of children had language delay. differences between the lbw and/or ptb group and the nbw and/or ft group were minimal in all degrees of language impairment, with differences of no more than 5.2% between groups. this indicates that lbw and/or ptb children within this sample did not present with more severe language impairment than their ft peers with language impairment. primary developmental conditions the primary developmental conditions of the children in this study sample can be seen in table 5. the established risk categories according to rossetti (2001) were used to categorise the different conditions found in the sample. table 5: primary developmental conditions associated with preterm birth and low birth weight. according to table 5, a wide array of primary developmental conditions and accompanied language impairment occurred in both study groups. statistically significant differences were found between the two groups for genetic conditions, global developmental delay, asd and non-syndromic clp. some of the conditions occurred more in the lbw and/or ptb group, while some conditions were statistically more prevalent in the nbw and/or ft group. genetic conditions and global developmental delay were strongly more significant in children with lbw/ptb (18.7%) than those born nbw and/or ft (8.7%). global developmental delay was statistically more significant in the lbw and/or ptb group. cleft lip and/or palate occurred more frequently in children born nbw and/or ft, but only marginally significantly. this finding shows that lbw and/or ptb did not occur more in children with non-syndromic clp, but when accompanied by a genetic condition, such as pierre robin sequence and velo-cardio-facial syndrome, lbw and/or ptb can be expected. autism spectrum disorder was highly associated with children born nbw/ft, but not in the lbw and/or ptb group. however, lbw and/or ptb occurred in 22.5% of the 70 children with asd, presenting much higher than the south african lbw and/or ptb rate of 14.17%. primary language impairment without any associated conditions was equally represented in both groups and was also the most prevalent developmental condition for both groups. no significant difference in the frequency of primary language impairment was found between the two groups, indicating that primary language impairment was not increased in the lbw and/or ptb sample. within the sample of children with lbw and/or ptb, 27.8% presented with primary language impairment, and 68.9% presented with secondary language impairment. as already indicated in table 4, almost all children with lbw and/or ptb assessed at the clinic presented with some form of language impairment, but language impairment was not more severe in the lbw and/or ptb group. preterm birth and lbw did not occur significantly more in any of the other primary developmental conditions. the conditions occurred too rarely in the sample to show any significant differences. risk factors associated with low birth weight and preterm birth table 6 depicts which risk factors were significantly associated with the lbw and/or ptb group. the different risk factors considered under prenatal, postnatal and family risks are supplied in table 7. factors showing no association with lbw and/or ptb in the sample were gender, ethnicity, family risk for language impairment, feeding difficulties at the time of assessment, family risks (such as low education level of parents), use of public or private medical services, monoor multilingual language exposure and child attendance of day-care. table 6: associations between preterm birth and/or low birth weight and other risk factors. table 7: prenatal, postnatal and environmental risks associated with low birth weight and preterm birth. according to table 6, the most significant risk factors associated with lbw and/or ptb in this study sample were small-for-gestational age, maternal prenatal risks, multiple pregnancy, postnatal risks, the primary developmental condition (genetic conditions and global developmental delay), caesarean section delivery and language impairment, specifically in the mild to moderate category. infants born small-for-gestational age are usually lbw, hence the association with the lbw and/or ptb group. prenatal risk factors, such as medical conditions and treatment during pregnancy, high blood pressure, pre-eclampsia, multiple pregnancy, smoking and alcohol use during pregnancy, pose known risks for preterm labour and delivery of an infant, and were, therefore, significantly associated with lbw and/or ptb (nyarko et al., 2013; reidy et al., 2013; rossetti, 2001; wardlaw, blanc, zupan, & ahman, 2004). postnatal risks, such as length of stay in the neonatal intensive care unit (nicu) and feeding difficulties, were associated with lbw and/or ptb, as 126 (60.3%) of the children in the sample were admitted to the nicu. the primary developmental conditions associated with lbw and/or ptb were genetic conditions, and global developmental delay, as also indicated in table 3. elective caesarean section deliveries are known to contribute to late ptb (howson et al., 2012). caesarean births in south africa have been reported to constitute 21% of births in general, and 43.1% of births among white women (biswas, su, & mattar, 2013; department of health, 2007). although the male gender was predominant in this study sample, there was no significant association found with lbw and/or ptb. discussion study results indicated that almost 40% of children assessed at an eci clinic were born preterm with lbw. the sample consisted mostly of young preschool children with a mean age of 28.47 months, and 13 months as the mode. almost all children in the study sample (91.9%) had language impairment. this high frequency occurrence is linked to the clinic’s typical service users, that is, young children with communication and language concerns. the majority of the preterm children in the sample, 143 out of 176 (81.25%), were late preterm (35 weeks), with lbw (2303.3 g). it is known that late ptb represents the largest group of children with lbw and/or ptb, occurring five times more than children born before 32 weeks’ gestational age, or 80% of the population (saigal & doyle, 2008; vohr, 2010). because of late preterm infants being almost similar in size and weight to their ft peers, they are often treated in the same manner as an ft infant by both parents and medical professionals (engle, tomashek, & wallman, 2007). these infants are physiologically and metabolically immature, placing them at high risk for medical complications and infant mortality (engle et al., 2007). within this study sample, 95.8% of late ptb children presented with language impairment. although the results represent data from a single eci clinic from a majority middle-income group, the distribution of lbw/ptb categories was similar to those reported by vohr (2010). the sample comprised participants with access to private health insurance; however, their study population was of a higher educational background (vohr, 2010). the current study also highlights the many associated conditions and high prevalence of secondary language impairment in the children with late ptb. it appears that research typically focuses on the language and communication outcomes of very preterm and extremely preterm children (nosarti, murray, & hack, 2010; rayco-solon, fulford, & prentice, 2005; sansavini et al., 2015). late ptb children can, therefore, easily be overlooked, as the focus of research is often on the population at greater risk for severe disability. seizure disorder, cp and other neurological conditions occurred rarely in the current sample and were not more prevalent in the lbw and/or ptb group than in the nbw and/or ft group. conditions known to be associated with lbw and/or ptb were genetic conditions and global developmental delay. genetic conditions, such as down syndrome which was the most common genetic condition found in the study sample (45/530; 8.4%), are linked to lbw and/or ptb (rasmussen et al., 2006). velo-cardio-facial syndrome, also known as 22q11.2 deletion syndrome, occurred in four (0.75%) children in the sample. pierre robin sequence is a genetic condition and occurred in 11 children within this sample (2.1%), with an incidence varying between 1 in 8500 and 1 in 14 000 live births (rathé et al., 2015). the condition starts developing during embryology, and is caused by a sequence of events caused by micrognathia, resulting in posterior placement of the tongue, which in turn prevents complete closure of the palate (de buys roessingh, herzog, cherpillod, trichet-zbinden, & hohlfeld, 2008). global developmental delay, a diagnosis given to children under five years who have not met several developmental milestones at the appropriate age, and who cannot yet be reliably assessed for intellectual disability (apa, 2013), was frequently found in the sample (58/530; 10.9%). it appears that global developmental delay is the most frequently occurring developmental condition in children with lb and/or /ptb, and that it predicts language development (rushe, 2010). autism spectrum disorder has been identified as a risk for lbw and/or ptb (kihara & nakamura, 2015). in this study, 70 (13.2%) children had asd, and 16 (22.5%) of these children had lbw and/or ptb. this number is considerably higher than the national lbw rate in south africa, therefore, this study confirms the risk for lbw and/or ptb in children with asd. all these associated conditions add to the complexity of children with lbw and/or ptb and can easily mask their low gestational age and birth weight. therefore, most children with lbw and/or ptb within this study sample presented with multiple risk factors, language impairment and often another developmental disorder as well. primary language impairment did not occur more in the lbw and/or ptb group (27.8%) than in the nbw and/or ft group (26.8%). rushe (2010) found that, when children with cognitive disability are excluded from comparisons, the prevalence of language impairment between children born preterm and those born at term remains consistent. this perspective suggests that language impairment in children with lbw and/or ptb occurs secondary to their cognitive disability. in contrast, schults et al. (2013) found that more children with lbw and/or ptb present with primary language impairment, with poorer expressive and receptive language, than their ft counterparts. further research is required to better understand language impairment in children with lbw and/or ptb. factors found to be most significantly associated with ptb and lbw in this study were small-for-gestational age, maternal prenatal risks, caesarean section delivery and postnatal risks. maternal prenatal risks were found to be significantly associated with lbw and/or ptb. factors such as medical conditions and treatment during pregnancy; mental health conditions; placental problems such as pre-eclampsia; multiple pregnancy; and smoking, alcohol and drug use during pregnancy are known risks for lbw and/or ptb (allen, 2008; nyarko et al., 2013; reidy et al., 2013; sansavini et al., 2015; stolt et al., 2016). it is also known that, for various reasons, multiple pregnancy often results in ptb before 32 weeks gestational age (allen, 2008; zhu, tao, hao, sun, & jiang, 2010). postnatal risk factors were significantly associated with lbw and/or ptb in this study. in the study sample, postnatal risk factors included feeding difficulties and a period in a nicu. infants born preterm often present with feeding difficulties as their neurological systems are still underdeveloped (mathisen et al., 2012; nosarti et al., 2010; rayco-solon et al., 2005). conclusion the frequency of lbw and/or ptb was almost 40% in the study sample of children with language impairment. in this predominantly late lbw and/or ptb sample, secondary language impairment was prevalent and found to be associated with genetic conditions and global developmental delay. the finding concurs with some studies suggesting that primary language impairment is not more prevalent among children with lbw and/or ptb than among those born nbw and/or ft, but rather occurs as a secondary impairment. the large sample size of the study strengthens the reliability of the findings. limitations of the study include the sample size being limited to a single eci clinic with a predominantly middle-to-high income population within south africa, thus not offering insight applicable to the wider population of children with language impairment in south africa. furthermore, the lbw and/or ptb group were compared to ft children with language impairment, not with typically developing children. further research in the prevalence of language impairment among preterm infants within the south african population, and the distinction between primary and secondary language impairment within this population, may provide further insight into the impact that ptb and/ or lbw has on language development. children with lbw and/or ptb can be identified early, as they enter the health care system upon their untimely birth. with a known risk for language impairment and subsequent risk for learning difficulties, timely eci is essential. the lbw and/or ptb population in south africa and elsewhere is a growing health concern requiring attention and public awareness. young children with lbw and/or ptb and their mothers should ultimately benefit from the national integrated early childhood development system, as ‘many disabilities are preventable or could have their severity limited if pregnant women, infants and young children received access to early quality screening, preventative and rehabilitative care’ (republic of south africa [rsa], 2015:24). acknowledgements l.c.f. thanks prof. a. kritzinger and dr t. le roux for their continued support, guidance and valuable input into this article. he also thanks his family and friends, who stood by him through the writing process, lending an ear to listen as he phrased and rephrased sections. he also appreciates all the support he had during his journey. authors’ contributions l.c.f. was the main author and researcher. a.k. the primary supervisor and t.l.r. the co-supervisor. references allen, m. c. 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(2008). specific language difficulties and school achievement in children born at 25 weeks of gestation or less. journal of pediatrics, 152(2), 256–262. https://doi.org/10.1016/j.jpeds.2007.06.043 zhu, p., tao, f., hao, j., sun, y., & jiang, x. (2010). prenatal life events stress: implications for preterm birth and infant birthweight. american journal of obstetrics and gynecology, 203(1), 34.e1–34.e8. https://doi.org/10.1016/j.ajog.2010.02.023 abstract introduction research methods and design results discussion conclusion acknowledgements references footnote about the author(s) zandile m. shezi department of audiology, faculty of health sciences, university of kwazulu-natal, durban, south africa lavanithum n. joseph department of audiology, faculty of health sciences, university of kwazulu-natal, durban, south africa citation shezi, z.m., & joseph, l.n. (2021). parental views on informational counselling provided by audiologists for children with permanent childhood hearing loss. south african journal of communication disorders, 68(1), a799. https://doi.org/10.4102/sajcd.v68i1.799 original research parental views on informational counselling provided by audiologists for children with permanent childhood hearing loss zandile m. shezi, lavanithum n. joseph received: 26 oct. 2020; accepted: 09 jan. 2021; published: 25 may 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the absence of best practice guidelines on informational counselling, has caused lack of clarity regarding the information audiologists should provide to parents and caregivers following the diagnosis of a hearing loss. research shows that informational counselling provided by audiologists is limited and often biased, with little evidence of how parents experience this service. objectives: to explore the nature and practice of informational counselling by audiologists. method: this study was descriptive in nature and adopted a survey design to obtain information on the current practices of informational counselling from the perspective of parents and primary caregivers. ninety-seven face-to-face semi-structured interviews were conducted across kwazulu-natal province of south africa. descriptive statistics and thematic analysis using nvivo software were conducted. results: the majority of the parents reported receiving some form of informational counselling. however, the information provided by audiologists was considered to be biased as it included a favoured communication option, school and rehabilitative technology. there was a lack of information related to aural rehabilitation and family-centred intervention. the provision of all communication options, school options and rehabilitative technology were identified as gaps that contribute to an unfavourable decision-making process. conclusion: there are inefficiencies experienced by families of deaf and hard of hearing children during informational counselling. however, this understanding, together with the identified gaps by parents, can help address the professional response to caring for families with deaf and hard of hearing children. keywords: informational counselling; communication options; aural rehabilitation; family-centred intervention; paediatric hearing loss. introduction it is reported that 90% – 92% of children who are deaf are born to hearing parents who have little or no experience of deafness (mitchell & karchmer, 2004; national deaf children’s society, 2015). experiencing deafness for the first time, these parents have no knowledge about how to manage the intricacies presented by the hearing loss. when deafness is confirmed, parents rely on professionals to provide them with information about the intervention options that are available for their child (american speech and hearing association [asha], 2008; gilliver, ching, & sjahalam-king, 2013; tye-murray, 2019) and this process is conducted through informational counselling. informational counselling can be defined as the dissemination or impartation of information that relates to but is not limited to the interpretation of the audiogram, and deciding on technology, educational and communication options (asha, 2008). currently, there are no evidence-based studies that provide information that parents require from audiologists to make informed decisions about intervention. audiologists need to provide families with information that will assist them in the decision-making process; however, this is often a challenge. it has become common practice for audiologists to filter a substantial amount of information, which they should present to parents during informational counselling (asha, 2008). extensive research conducted in the united kingdom has shown that only after engaging with certain intervention services did parents realise that the information provided by professionals regarding available options to support linguistic and social development for their children who are deaf or hard of hearing was limited (beazley & moore, 1995; eleweke & rodda, 2000; young, 2003; young, jones, starmer, & sutherland, 2005), indicating that informational counselling provided by audiologists is limited and biased. however, there is a lack of evidence in the literature about the actual experiences of parents regarding informational counselling provided by audiologists. current literature does not address the gaps that parents have identified in informational counselling provided by audiologists following diagnosis of the hearing loss. in addition, there is scarce literature regarding the factors that audiologists need to consider when providing informational counselling, that is, factors that are relevant and unique to these families, which will influence how informed decision-making occurs related to intervention options and how the informational counselling will be perceived. this situation, together with the unique challenges experienced by parents in countries with huge linguistic, cultural and socio-economic diversity such as south africa, led to the interest in this study. literature review according to the literature, a parent’s primary concern relates to communication choices (young, carr, hunt, skipp, & tattersall, 2006). the issue was not so much that a particular communication option was right or wrong, but the issues stemming from three positions. firstly, if parents do not have access to all relevant information required to make informed decisions, the appropriateness of the basis on which such decisions are made is questionable. secondly, the information provided to parents did not provide all available options because it was either denied, not acknowledged or resourced. lastly, if the professional’s attitude and bias dominates, this influences the potential of the parent–professional relationship to be one of empowerment (young et al., 2006). according to young (2002), parents reported that they were predominantly presented with the medical model of deafness and in hindsight were exposed to the socio-cultural model and other approaches. another domain, although not well researched, was the aspect of deaf parents who were not provided with all options. this was attributed to either the assumption that they would not require certain information because they were deaf or the information could not be linguistically communicated to them (young et al., 2005). it must be pointed out however that the audiologist is responsible for the facilitation of informed decision-making across the clinical care process and journey (oestreich, 2019). according to english (2008), there still remains a need for effective informational counselling to be considered in the body of audiological literature. according to watermeyer, kanji and cohen (2012), informational counselling guidelines are non-existent for the audiology population. the following suggestions have been made on how informational counselling should be carried out as a service to patients (margolis, 2004; musiek, weihang, & oxholm, 2007): for the benefit of decision-making, the information needs to be adequate, clear and concise; concrete instructions should be explicitly provided; important information should be provided first; information needs to be repeated; the terminology used should not mislead and confuse the patient with verbal descriptions supplemented by an anatomical model or diagram depicting the ear. during informational counselling, cultural diversity, linguistic barriers and inclusion of a third party should be considered (watermeyer et al., 2012). language barriers can contribute to diminished access to information related to primary and preventative care. this barrier can contribute to the patients’ weakened comprehension ability, minimise adherence and cause reduced patient satisfaction (wilson, chen, grumbach, wangs, & fernandez, 2005). the reality in south africa is that there are 12 official languages and diverse cultural beliefs and healthcare interventions are centred within these unique linguistic and cultural barriers (penn, 2007). also, a typical south african patient accesses traditional healers parallel to biomedical options (de andrade & ross, 2005). these factors have implications for diagnosis and how intervention is carried out regardless of the informational counselling received. in south africa, the average age of diagnosis is 2 and a half years and this is considered to be late (van der spuy & pottas, 2008). late diagnosis affects the cognitive, communication, social and educational development of this child (yoshinaga-itano, sedey, coulter, & dehl, 1998), which makes the process of decision-making for the parents even more complicated and urgent. with so many children diagnosed late with a permanent childhood hearing loss in south africa, immediate and urgent intervention is required to combat the developmental gap created by this delay. this then requires parents to make important intervention decisions and this process is dependent on the information or intervention options that parents receive. the addition of limited and biased informational counselling exacerbates this challenge of hearing loss particularly in the south african context and contributes to a further delay, thus prohibiting any opportunity of minimising or closing the developmental gap. although extensive research has been conducted about informational counselling being viewed as biased and limited, not much is known about the actual current practices of informational counselling provided by audiologists. the purpose of this study was to explore the practices of informational counselling provided by audiologists when children are diagnosed with a permanent hearing loss, with a view to identify information needed by parents or primary caregivers to make informed decisions regarding intervention and factors that need to be considered when providing informational counselling. the research question posed was the following: ‘what is the nature of the informational counselling provided following the diagnosis of a permanent childhood hearing loss?’. thus, the study aimed to determine the practices of informational counselling provided by audiologists in kwazulu-natal (kzn) province in south africa in the past 5 years, identifying gaps in informational counselling and exploring contextually relevant factors that audiologists need to consider during informational counselling with parents and primary caregivers of children who are deaf or hard of hearing. research methods and design the study was descriptive in nature with both qualitative and quantitative components. a descriptive survey was conducted using face-to-face interviews. an interview schedule with open-ended questions was used. study population the participants were hearing parents and primary caregivers of children who are deaf or hard of hearing residing in kzn province. this was done to facilitate homogeneity of the participants looking at the region. the parents and primary caregivers were accessed from 31 hospitals within all 10 districts representative of kzn providing paediatric audiology services. sampling method to recruit the participants, random sampling was employed. patient files were accessed from the public hospitals and contact numbers were retrieved. participants who met the selection criteria were contacted telephonically and were addressed in english or isizulu by the researcher who is a first language isizulu speaker. for participants who were non-literate, the study was verbally explained to them. the participants were contacted to provide details regarding the study, and to schedule a convenient date, time and place to conduct interviews. private audiologists made contact with potential participants regarding the study. interested participants contacted the researcher. the researcher randomly selected parents and primary caregivers from all public hospitals (80) and private clinics or hospitals (17) using the kwazulu-natal department of health database. limited participation from some private facilities was attributed to paediatric audiology services not being offered and some audiologists withholding access to potential participants on their caseload. sample size a statistician was hired to ascertain the sample size. a sample size of 97 randomly selected parents produced a two-sided 95% confidence interval with a width equal to 0.20 or 20% (i.e. ± 10%) when the sample proportion is 0.50 or 50% (non-informative assumption, assumes maximum variability) (fleiss, levin, & paik, 2003; hintze, 2013; newcombe, 1998). a total number of 97 parents and primary caregivers were interviewed. description of the sample the sample included 1 (1%) father, 40 (41%) mothers and 56 (58%) primary caregivers (grandparents, siblings or aunts). a total of seven (14%) parents were first language english speakers, with the remainder being first language isizulu speakers. the age range of participants was between 18 and 62 years. the level of education of the participants ranged between grade 2 and an honours degree. all participants had children who were deaf or hard of hearing diagnosed within the past 5 years in 31 public hospitals and three private clinics within kzn and had an age range between 8 months and 9 years. data collection instrument the data collection instrument, that is, interview schedule, was derived from the literature taking into consideration the research question. the interview schedule comprised a demographic section and open-ended questions related to the age of diagnosis, type of counselling received, the content areas covered during informational counselling, grieving process, identified gaps in informational counselling, factors audiologists need to consider when providing informational counselling, family-centred intervention, the decision-making process and views on the informational counselling received. face-to-face semi-structured interviews were conducted by the researcher in either english or isizulu. the duration of the interviews ranged from 10 min to 37 min and the interviews were audio recorded. procedure a pilot study was conducted on 12 participants and data obtained during this process were not used in the main study. changes were made to the revised interview schedule. the interviews were audio recorded using the olympus digital voice recorder dm-650, olympus audio sa and transcribed by a professional transcribing company. thematic analysis using nvivo 12 was conducted to process and analyse the data. all interviews in isizulu were transcribed into english and then backtranslated by a professional company. these were then verified by the researcher before being uploaded into nvivo for analysis. ethical considerations all ethical considerations were adhered to in this study. issues related to informed consent, voluntary participation, withdrawal and anonymity were addressed. ethical clearance was obtained from biomedical research ethics committee of the university of kwazulu-natal (ethical clearance number: be267/16). results experience of informational counselling of the 97 participants interviewed, six (6%) participants reported that they did not receive any informational counselling from the audiologist or any other health professional, whilst two (2%) could not recall if they had received any informational counselling. the remaining 89 (92%) participants reported to have received some form of informational counselling; however, the content areas addressed and the manner in which the information was provided during these sessions varied for all participants.1 one participant stated: ‘no, we were never counselled, she just got tested and they diagnosed her with hearing loss and they said she will get a hearing aid and they made an appointment for us to come and get the hearing aid.’ (p1, granny, public sector) figure 1 presents the content areas that were covered during informational counselling (n = 89). figure 1: content areas discussed during informational counselling (n = 89). all 89 (100%) participants who were counselled reported to have received information about hearing aids and south african sign language as the only communication option mentioned. only nine parents of the 89 who received counselling (10%) reported that the audiologist counselled them about all the available communication options, such as total communication, oralism and bilingual–bicultural, and only four (4%) reported to be informed about more than one education methodology. two parents (2%) reported receiving information about communication strategies and only one (1%) parent was reported to be informed about cochlear implants as an available rehabilitative technology. a total of 76 (85%) of the 89 parents or primary caregivers reported that the parent advisors from a national non-profit organisation offering a home-based care programme provided detailed information; however, this information was only on sign language and the bilingual bicultural education methodology. these parents reported that although the information was extensive, they would have preferred extensive information on other communication options as well. these parents also reported to have benefitted from the basic sign language lessons provided by the representative from the home-based care programme, as evident in the following quotes: ‘they gave me the information based on their views.’ (p2, mother, private sector) ‘there is nothing else they explained to us, they just explained about the sign language.’ (p3, mother, public sector) the majority, (85, 88%) of these parents or primary caregivers reported to be informed about the availability of a disability grant, whilst almost the same number (84, 87%) reported to have been informed about one education methodology, that is, bilingual–bicultural school for the deaf. whilst 46 (47%) parents or primary caregivers reported information about the diagnostic results, only 29 (30%) reported counselling about aural rehabilitation and the significance of family-centred intervention and the implications of the hearing loss in terms of communication. perception of gaps in informational counselling the identified gaps represented information that parents deemed critical for intervention decision-making, which was either absent, limited and/or biased during the informational counselling they received. these content areas are presented in figure 2. figure 2: information that parents deem critical for intervention decision-making (n = 97). more than 50% of the participants reported that informational counselling needs to include aetiology of the hearing loss, all education methodologies, parent-to-parent support groups, all communication options, family communication strategies and sign language classes. about 30% – 45% of the participants in the study reported that there are gaps in information related to implications of the hearing loss, diagnostic results and hearing aid benefits. the remaining content areas identified as gaps were considered by less than 30% of the participants. the number of participants in relation to the content areas identified as gaps was based on the information that each participant deemed critical based on whether they did or did not receive it. a total of 64% of participants reported that audiologists need to provide information on the cause of the hearing loss, as shown in the following quotes: ‘i can say at the hospital, we got information, but something we never got was what the cause was for her hearing loss. that it was natural or what.’ (p4, father, public sector) ‘the only suggestion i have is that as a mother of the child, i was all alone and the father left me after finding out that the child has a hearing loss. they were supposed to tell me what the reason is, what the reason for my child losing her hearing was this and that.’ (p5, mother, public sector) a total of 77% of participants reported that not all education methodologies were provided. the majority of these participants were reported to be informed of one education methodology and only later found out about other education methodologies, as clear from the following quote: ‘they advised me about special schools only, they never spoke, explained the results. no they didn’t explain in detail and the cause you see?’ (p6, mother, public sector) parent-to-parent support groups were reported as a gap during informational counselling by 72% of the parents and primary caregivers: ‘i wanted to know from other people that how did they react to it when it happened to their kids.’ (p7, mother, private sector) a total of 62% of parents or primary caregivers reported that the provision of all communication options was a gap. a total of 88% of parents or primary caregivers reported gaps in the provision of information about communication intervention strategies, whilst 71% of these parents or primary caregivers reported sign language classes as a gap during informational counselling. the impact of the hearing loss on speech and language development was reported as a gap by 44% of the parents or primary caregivers. amongst other reported gaps by participants were care pathways (1%), hearing aid benefits (31%) and troubleshooting (9%), websites (19%), support systems (21%), environmental modifications (1%) and all available rehabilitative technologies (28%). aspects to consider during informational counselling some parents and caregivers reported that for informational counselling to be relevant and influence compliance for follow-up sessions, various aspects need to be considered and evident during informational counselling. figure 3 depicts the aspects that need to be considered during informational counselling. figure 3: aspects to consider during informational counselling. twenty-one (22%) parents and primary caregivers reported that when providing informational counselling, audiologists need to factor in their cultural beliefs only, whilst 28 (29%) parents and caregivers stated that a combination of spiritual beliefs and cultural beliefs needed to be considered during informational counselling. interestingly, 48 (49%) parents and caregivers reported that audiologists had to factor in their spiritual beliefs as opposed to culture when providing informational counselling. all parents (100%) in the study reported the significance of considering the socio-economic status during informational counselling. as the majority of the parents were first language isizulu speakers, 67 (69%) proposed that audiologists consider the language used during the provision of informational counselling. furthermore, 63 (65%) parents reported the significance of considering family dynamics in the provision of informational counselling. discussion this study revealed that the majority of parents were only informed about hearing aids and the bilingual–bicultural communication option during informational counselling. these findings concur with the study by duldulao and ramsey (2013), who reported that it is common practice for audiologists to place emphasis on providing hearing aids as opposed to communication intervention despite aural rehabilitation being considered a significant component in the management of hearing loss. according to these authors, with rapid advances in hearing technology, technology alone is not adequate to address the hearing needs of individuals with hearing loss. in addition, prendergast, lartz and fiedler (2002) discovered that more than half of the parents in the study were not told about more than one communication option. similar to the findings of this study, the professionals included in the study by young (2002) overtly sided with a particular communication method and provided detailed information on their preferred communication method, hence neglecting other communication options. the ease of access and availability of a communication method could be attributed to such practices, although it is not justified. provision of one communication option could lead to one education methodology as there is a link between communication options and education methodologies. for this study, the informational counselling on one communication option could be attributed to the ease of referring these families to schools that adopt the bilingual–bicultural approach for the child to acquire south african sing language (sasl) as opposed to providing auditory verbal therapy or total communication services. the sasl is defined as a language used by many individuals in the deaf community. it is the primary language of deaf south africans with its own grammar, structure and syntax which differs from the spoken language (deafsa, 2006). these findings may also speak about the availability and accessibility of certain schools or aural rehabilitation services within the contexts of the families. additional to these issues could be issues related to the age of diagnosis and its influence on the developmental gap in speech, language and communication. literature reveals that when parents select a school, they consider cost, geographic location and benefits of enrolling in that school (calderon, 2000). when only one education methodology is presented to families, this minimises the choice and infringes on informed decision-making. in this study, a great number of parents and caregivers were exposed to information regarding the disability grant. whilst it is commendable that audiologists are providing these families with the opportunity to access these funds for the benefit of the child with the disability, audiologists should not lose sight of the ethical benefits of this grant and their role in the rehabilitation process to ensure independent individuals in the future. this grant should not be used as a substitute for rehabilitation; however, it should be used in conjunction with rehabilitation to assist families and children who are deaf or hard of hearing to be independent, employable south african citizens. this notion does not disregard the socio-economic status of the majority of these families and the role of the disability grant; however, it supports focus on these children being rehabilitated. interestingly, the majority of parents were not informed about aural rehabilitation. this questions our stance as rehabilitation specialists, the availability and accessibility of these services and our perceptions of our role as audiologists. these results question the difference between our scope of practice and that of other hearing service providers such as acousticians. the audiologist’s role goes beyond that of diagnosis and extends to that of rehabilitation; however, the results of this study contradict this role in some contexts within kzn province. according to the hpcsa (2012), audiologists are expected to provide aural rehabilitation. duldulao and ramsey (2013) reported that whilst some patients may not be inclined to being participants in aural rehabilitation sessions, the informational counselling around aural rehabilitation as a service should be provided, as well as the benefits of aural rehabilitation. in this study, the participants reported that there was a lack of information regarding the cause of the hearing loss. the lack of providing the cause of the hearing loss by audiologists could be attributed to uncertainty and limitations in the scope of practice as ear, nose and throat (ent) specialists are expected to provide this information. the fact that some parents blame themselves or are blamed by their spouses when the child is diagnosed with a hearing loss makes the aetiology pertinent for these caregivers. it is when the cause of the hearing loss is known that some parents can deal with the emotions that are aroused by the confirmation of the hearing loss. this also contributes to how parents address and manage the implications of the hearing loss thereafter in relation to traditional beliefs. the participants in this study stated the need for parent support groups. this was also reported by the participants in the study by jackson, wegner and turnball (2010) as one-third of the parents (n = 73) reported to have participated in some kind of parent support group. the common theme identified in this study was the desire for the parents to have access to a parent-to-parent support network. this was a similar finding in this study. engaging with ‘similar others’ created a sense of belonging for new parents of children who were deaf or hard of hearing and also reduced anxiety that comes as a result of the diagnosis of hearing impairment (zaidman-zait, 2007). the parent-to-parent support allows parents to identify the reality of what it is like to have a child who is deaf and hard of hearing and address how parents can make decisions regarding intervention. this may reduce delays in that parents may not try out all available options before making an informed decision, for example, regarding communication options, schooling and rehabilitative methodologies (narr & kemmery, 2015). according to lederberg and golbach (2002), you need to be a parent of a deaf or hard of hearing child to comprehend the depth of parenting a deaf or hard of hearing child. for the participants in this study, as ancestral beliefs and religious beliefs are part of who they are, some parents felt that approaching the hearing loss from a medical and cultural model (inclusive of cultural and spiritual beliefs) (de andrade, 2015) would put them at ease of knowing that they had explored all available avenues to try and support their child who is deaf or hard of hearing. in addition to the combination of the medical and cultural model, the parents and primary caregivers in this study felt that the inclusion of financial implications during informational counselling for parents to be aware of and be prepared for the upcoming expectations on their part was critical. this would facilitate improved adherence and compliance rates to follow-up sessions and intervention options. the socio-economic status is able to influence how the speech and language may develop (fernald, marchman, & weisleder, 2014) and accessibility to hearing rehabilitation (mehra, eavey, & keamy, 2009). chang, ko, murray, arnold and megerian (2010) reported that because of low socio-economic backgrounds of some families in ohio, the united states of america, there was an increased non-compliance rate to follow-up sessions. another aspect was the parents of children who are deaf or hard of hearing being counselled by audiologists who spoke a language different from theirs. the profession of audiology and speech language therapy is dominated by white therapists who speak english and afrikaans, whilst the client base is dominated by black individuals who adopt african languages (eds. moonsamy & kathard, 2015). this mismatch has been attributed to the history of colonialism and apartheid; however, 26 years into democracy, little change has been observed regarding the demographics of these professions. additional to this aforementioned issue is the recent increase in migration of individuals from other african countries into south africa, which increases the diversity even more of the potential client base. the majority of clinicians were reported to be providing services to clients who do not use english as a home language (eds. moonsamy & kathard, 2015). strengths and limitations of the study the sample size was a strength of this study as it allowed the researcher to obtain in-depth information that allows for generalisability within the region. the disproportion in the number of participants accessed from the public and private sectors was a limitation of the study. implications and recommendations for future research this study highlighted contextually relevant factors that need to be considered during the facilitation of informational counselling that contributes to the relevance and decision-making process. future research may explore the outcome of including contextually relevant factors and how this facilitation may contribute to the decision-making process of parents and caregivers. conclusion as a result of the controversies and conflicting views on education methodologies, communication options, medical treatment and sensory devices, parents need to be appropriately counselled so that they can be equipped to make informed decisions about the controversial issues that surround intervention for a deaf or hard of hearing child. the information provided for these families through counselling needs to be balanced and at the proficiency level and rate at which family members can absorb the information whilst coping with their emotional reactions. this study highlighted the inefficiencies and lack of service experienced by families of deaf and hard of hearing children. the participants identified informational counselling needs to include the cause of the hearing loss, all available communication options, educational methodologies, rehabilitative technologies and available parent support groups. audiologists also needed to consider the socio-economic status of the family, cultural and spiritual beliefs and language during the facilitation of informational counselling. this will influence the relevance of informational counselling offered. an understanding of the scope of counselling by audiologists, together with the identified gaps by parents themselves, can help to address the professional response to caring for families with deaf and hard of hearing children, as well as promote parents as advocates for their children. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions this article is based on a phd study by z.m.s., who was supervised by l.n.j. the article was drafted by z.m.s. and the supervisor contributed substantially to this draft. funding information funding for this study was provided through the developing research, innovation, localization and leadership in south africa (drill), college of health sciences grant. this program is funded by the fogarty international center of the national institutes of health under award number: d43tw010131. data availability the authors confirm that the data supporting the findings of this study are available within the article. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily 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(2007). parenting a child with a cochlear implant: a critical incident study. the journal of deaf studies and deaf education, 12(2), 221–241. https://doi.org/10.1093/deafed/enl032 footnote 1. for the purpose of this article, participants have been given an identifier code p1–p7, as different participants were selected and reported only once. sajcd 242 the effect of two different visual presentation modalities on the narratives of mainstream grade 3 children d klop, phd; l engelbrecht, m slt division speech-language and hearing therapy, department of interdisciplinary health sciences, faculty of medicine and health sciences, stellenbosch university, tygerberg, cape town, south africa corresponding author: d klop (dk@sun.ac.za) objective. this study investigated whether a dynamic visual presentation method (a soundless animated video presentation) would elicit better narratives than a static visual presentation method (a wordless picture book). method. twenty mainstream grade 3 children were randomly assigned to two groups and assessed with one of the visual presentation methods. narrative performance was measured in terms of microand macrostructure variables. microstructure variables included productivity (total number of words, total number of t-units), syntactic complexity (mean length of t-unit) and lexical diversity measures (number of different words). macrostructure variables included episodic structure in terms of goal-attempt-outcome (gao) sequences. results: both visual presentation modalities elicited narratives of similar quantity and quality in terms of the microand macrostructure variables that were investigated. conclusion. animation of picture stimuli did not elicit better narratives than static picture stimuli. keywords: digital technology, narratives, narrative elicitation procedures s afr j cd 2013;60:21-26 doi:10.7196/sajcd.242 appendix a is available with the online pdf of this article at http://dx.doi.org/10.7196/sajcd.242 digital technology has transformed the way we produce, distribute and receive information. children are exposed to multiple forms of literacy including an assortment of digital literacies such as the internet, social networks (e.g. facebook), cell phones, text messaging, instant messaging and video games, and they are also active participants in these practices. digital technology, e.g. cd-roms, electronic games and electronic books, is also increasingly used in schools for learning activities such as finding information and teaching numeracy and literacy. the availability of digital technology has changed the way speech-language therapists (slts) interact with their clients. an internet search for technological applications for use in speech-language therapy revealed a plethora of sites promising ‘to make speech-language pathology easier, more fun, or just plain better’ (http://onlinespeechpathologyprograms.net/speech-sites/#tech-res). it is observed daily in university clinics how student clinicians use their cell phones and ipads during assessment and intervention. for the past 5 years it has also been observed that students presenting seminars on the topic ‘new advances in speech-language therapy’, often choose topics that involve the use of technology in speech-language therapy practice. the use of digital technology may also offer more appropriate, objective and unbiased ways to assess speech-language skills. computerised assessments may, for instance, be used to screen large groups of children for speech-language problems, making it more cost-effective than individual assessments. clinicians who are not proficient in their clients’ home languages may use computerised tests with prerecorded instructions during assessments. the use of digital assessments can also increase the reliability of assessment measures during research because the standardisation of procedures can be assured. the goal of assessment in speech-language therapy is to obtain valid data on a child’s communication performance so that appropriate goals for clinical intervention can be formulated (owens, 2004). the assessment of children’s narratives can provide valuable information not only about their speech-language skills, but also about their cognitive, pragmatic and social abilities (liles, 1993). it is no surprise that narrative abilities are linked to academic success. the ability to tell a story links oral language skills and literacy, because it requires children to plan and produce decontextualised and cohesive narratives. several studies (botting, 2002; hester, 2010; paris & paris, 2003) found a positive relationship between children’s reading comprehension and narrative abilities. other studies found that narrative ability is one of the best predictors of academic success for children with language impairments (bishop & edmundson, 1987; oakhill & cain, 2007). the selection of inappropriate stimuli to elicit narratives or assessment procedures that are unfamiliar to children may result in language samples that do not reflect the child’s true ability and even lead to misdiagnosis. in contrast with traditional methods such as wordless picture books and sequence cards, videos and animated sequences may be more suitable to elicit narratives in south african children because they may be more familiar with information communication technologies than print texts. it can be speculated that retelling favourite televised stories may be a more common experience for them than retelling stories from other sources like storybooks. more dynamic visual modality story presentations, such as animated stories or sequences, may therefore represent more naturalistic and familiar contexts to assess their narratives. this article reports the findings of a study that investigated whether silent animated videos elicit better narratives than a wordless picture book from typically developing grade 3 children. the quality of narratives was judged in terms of microand macrostructural variables. no other studies were found that compared children’s narratives elicited by these two tasks using the same pictorial content. the next section will provide a brief overview of the existing literature about animation and static pictures as presentation formats and the use of visual and auditory tasks to elicit narratives for language assessment of children. dynamic versus static picture presentation static and animated pictures are both examples of a pictorial presentation format. animation has been defined as ‘any application which generates a series of frames, so that each frame appears as an alteration of the previous one, and where the sequence of frames is determined either by the designer or the user’ (bétrancourt & tversky, 2000 as cited in schlosser et al., 2012, p. 342). because animations portray temporal change, they are well suited to convey information that is inherently dynamic such as actions and movement. it seems logical that it would be easier for children to form mental models from animated sequences because the relationships between actors and scenes can be observed. in contrast, static pictures represent less realistic representations of events and require that children interpret the static events into their own dynamic representations (gazella & stockman, 2003). in a review of research about the efficacy of animated over static pictures to convey complex systems, tversky, morrison and bétrancourt (2002) found limited evidence to support the notion that animated pictures are superior to static ones. they found that the benefits of animation over static pictures could usually be attributed to extra information or added procedures that were provided, and not the animation as such. they also cite evidence that animations may interfere with learning because they are too complex or distracting, or move too fast. more recently, studies by stoner, beck, dennis and parette (2011) and schlosser et al. (2012) also failed to prove that animated pictures are better to facilitate vocabulary learning in preschool children than static pictures. of particular relevance to the present study, are the results from an intervention study by verhallen, bus and de jong (2006) that investigated the effects of animated storybooks and static storybooks on children’s narrative skills. their study population comprised preschool children learning a second language. children were exposed to stories presented on a computer screen. the static format was a voice reading a story while the pictures appeared on the screen, while the animated format was the same story supplemented by multimedia features such as animation, music and sound effects. it was found that the children exposed to the animated version obtained higher scores for story comprehension, vocabulary and syntax after repeated viewings, compared with only modest improvement in the group exposed to the static format. the researchers concluded that the additional non-verbal features in the animated format enhanced the children’s awareness of implied story elements such as the causal relationships between events and mental states of the protagonists. narrative assessment the assessment of narratives is considered by researchers and clinicians to be an ecologically valid way of investigating communicative competence (botting, 2002) and to be more valid, sensitive and less biased than norm-referenced tools for assessment in some populations (manolitsi & botting, 2011; norbury & bishop, 2003). the inclusion of a narrative test is therefore a valuable component in any speech-language assessment battery. oral narratives also allow clinicians to analyse multiple linguistic features, such as microstructural aspects, e.g. lexical diversity, and macrostructural elements, e.g. story grammar, using a relatively short language sample (heilmann, miller, nockerts & dunaway, 2010). it is, however, important to be aware of the different task and modality demands when selecting stimuli and procedures to elicit narratives that are valid representations of a child’s speech and language abilities (boudreau, 2008). research has shown that both the comprehension and production of narratives can be influenced by a number of aspects, e.g. the elicitation context (structured or unstructured), story genre (story retellings or story generation or personal stories), narrative themes, the child’s experiences and world knowledge, the presentation modality (audio, visual or combined audiovisual input), and the familiarity of the listener (gazella & stockman, 2003; liles, 1993). visual and auditory input modalities in narrative assessment several researchers found that different auditory and visual presentation modes have significant effects on narrative performance. schneider (1996) and schneider and dubé (1997, 2005) compared narratives produced in response to visual-only input, audio-only input and audiovisual input. schneider (1996) found that 5to 9-year-old children with language impairment produced the largest number of story grammar units in response to the audio-only condition (story retelling with no pictures) compared with the picture-only condition. schneider and dubé (1997) found that normally developing preschool children used references more adequately in response to an audio-only presentation than when formulating stories themselves from pictures only. schneider and dubé (2005) used the same three elicitation modalities as they had previously used (1997) in similar study populations, but investigated the impact of the presentation modalities on story grammar units produced by the children. their results indicated that all children performed similarly during the visual-only modality, and that this modality elicited the least story grammar units for both age groups. for the audio-only and combined audiovisual presentations, developmental differences were observed. preschool children produced more story grammar units in the audiovisual condition than in the picture-only condition. grade 2 children produced more story grammar units in both audio conditions (audio-only and audiovisual) than in the visual-only condition. they concluded that children have poorer narrative performance in visual-only tasks (pictures), because they need to apply their own internalised story knowledge to interpret the information and to produce a coherent narrative. a few studies have also explored the use of animation in narrative assessment. most of these studies used commercially available videos or animations that were not specifically designed and compiled for narrative elicitation (gutierrez-clellen & iglesias, 1992; meringoff, 1980; lorch, berthiaume, milich & van den broek, 2007). other studies adapted existing commercially available videos (merritt & liles, 1987; scott & windsor, 2000). commercial videos may have high interest value to children, because they may be more familiar with the content of the stories. however, video stories that were not designed to contain the specific structural aspects of narratives under investigation may fail to elicit these structures in retellings. children may fail to include certain aspects of narratives, such as settings and goals of characters, because the story did not provide enough contextual clues about these narrative aspects. this may result in lower narrative scores and stories that are not representative of children’s true narrative abilities, as a result of the story content rather than the presentation modality. wordless picture books in contrast to animated videos, wordless picture books have routinely been used in narrative assessment and narrative research studies. the books are usually selected because they portray the narrative structures under investigation, such as story grammar elements (i.e. settings, characters, problems, solutions). the wordless picture book frog where are you? (mayer, 1969) in particular, has been used by many researchers (gutierrez-clellen & iglesias, 1992; trabasso & rodkin, 1994). according to arizpe (2013) wordless picture books are often considered by researchers the ‘ideal medium’ to investigate language development and storytelling skills because the books are usually brief, deal with themes that interest young readers and minimise bias against participants with lower literacy levels. the present study narratives are usually analysed at two levels, namely microstructure and macrostructure. microstructural analyses focus on the internal linguistic structures used in the construction of the narrative, such as noun phrases and conjunctions. macrostructural analyses, by contrast, focus on higher-order hierarchical organisation such as episodic structure and story grammar components (heilmann et al., 2010). microstructure and macrostructure variables therefore represent two distinct areas underlying narrative competence. the variables investigated in this study were grouped into these two broad categories. this study fell within a quantitative, comparative, between-subjects paradigm and was guided by the following research question: what is the effect of two different visual presentation modalities, an animated video and a wordless picture book, on the narrative skills of mainstream grade 3 children? our specific research questions were: what are the differences between the narratives of children who viewed a silent animated video and children who viewed a wordless picture book in terms of the following aspects of microand macrostructure: microstructure • quantity (number of words and number of t-units)? • lexical diversity (number of different words)? • syntactic complexity (mean length of t-units)? macrostructure • story structure (number of complete goal-attempt-outcome (goa) sequences)? since the focus was on the effect of visual presentation, no model story or audio input was given to the participants. they were required to generate their own stories from the pictures, in other words, story generation or telling instead of retelling. our expectation was that animation of pictures would result in longer and more complex narratives because the portrayal of movement would facilitate better understanding of the goals and intentions of characters. a t-unit (terminal unit) comprises a main clause with all its concomitant subordinate clauses and phrases (owens, 2004:190). simple sentences, e.g. the children played outside, and complex sentences with embedded clauses e.g. whatever she told you was true comprise one t-unit. a compound sentence where two or more clauses are conjoined, e.g. the children played outside while their mother made supper, comprises two t-units. method ethical approval the original study from which the present study’s data were extracted was approved by the institutional ethical review committee of stellenbosch university (n09/01/016). formal written consent was obtained from the western cape education department (2009/0320-0010), school principal, parents and participants prior to the study. participants this study reports data of 20 children who were part of a larger project (engelbrecht, 2010) that investigated the effect of different visual modality and task conditions on the narratives of 29 grade 3 children in a mainstream school. the initial study’s participants were recruited from a primary school in the western cape, south africa by sending letters to the parents of grade 3 learners in two afrikaans-medium classes. selection criteria specified that they should be in grade 3, afrikaans home language speakers receiving their formal education in their home language, and that they have no speech or language problems and normal hearing. the children came from the same suburban community, cultural group and middle-class socio-economic background. a parent questionnaire was used to exclude participants with a history of speech or language problems, chronic otitis media or hearing problems. for inclusion in the study, children had to pass otoscopic examinations and pure tone hearing screening at 20 db levels at 500, 1 000, 2 000 and 4 000 hz (stach, 1998). a gsi 38 screening audiometer was used for the hearing screening. children who failed the hearing screening test were excluded from the study and referred for hearing tests. participants’ receptive language skills were assessed by means of the afrikaanse reseptiewe woordeskattoets (arw) (buitendag, 1994), a formal standardised test developed for use in the south african population. the data of 9 children who obtained arw standard scores that were below 1 standard deviation (sd) from the average, indicative of receptive language impairments, were excluded from the study. this article reports the results of 20 children from the original study, aged between 8 years 5 months and 9 years 4 months who complied with all the abovementioned selection criteria, and whose parents reported no history of hearing or language impairments. the original cohort (n=29) was randomly assigned to either a group presented with a wordless picture book or a group presented with an animated video. the participants of this study (n=20) were equally distributed between the two randomised groups. group 1 (wordless picture book presentation) comprised 8 girls and 2 boys, and group 2 (animated video presentation) 7 girls and 3 boys. one-way analysis of variance (anova) showed no differences between the groups for age, f(1,18)=0.29, p=0.60 and arw standard scores, f(1,18)=1.20, p=0.29. materials and instrumentation wordless picture book an original story, the bird’s nest, was developed by the researchers and illustrated by a professional illustrator (see appendix a for pictorial content). we aimed to create a story with settings (house, garden, hospital), characters (children, neighbour, doctor) and events (being bored inside the house, playing outside with a ball, getting a ball from the roof, discovering a bird’s nest, getting hurt, being treated by a doctor) that would be familiar to typically developing south african children growing up in suburban areas. the picture book contained 15 colour pictures, 1 per page, and no accompanying words. the layout and printing were done by a professional company. the pictures were specifically created to convey the characters’ emotions and intentions through their facial expressions and gestures. the backgrounds were kept simple so as not to distract the viewer’s attention from the storyline while still providing clear settings for the events. the storyline comprised an obvious sequence of events and narrative structure. the story events in the wordless picture book in this study were constructed to portray five possible gao sequences. (in order for children to tell coherent narratives, they must display knowledge of the goals or plans of story characters that cause other events, attempts or outcomes in the story (trabasso & rodkin, 1994). these are known as goal-attempt-outcome (gao) sequences and are based on a shared feature of story grammar theory and the causal network model, namely a focus on characters’ goals and motivations in a story and the actions and outcomes as a result of their goals (flory et al., 2006). the content of the two visual modalities in our study was specifically designed to portray linked gao sequences. no other studies could be found that have investigated modality presentation effects on children’s production of goal-directed narratives and the inclusion of gao sequences.) each gao consisted of three linked elements that were defined as follows: goals: content that depicted characters’ intentions, e.g. children pointing to a ball on a roof. attempts: content that depicted characters’ overt actions to achieve a goal, e.g. boy climbing on the roof to get the ball. outcomes: content that depicted occurrences that demonstrated the results of their successful or unsuccessful attempts to reach their goals, e.g. boy falling off the roof without getting the ball. animated video the animated video used the same picture sequences as the wordless picture book, but animation was added by a graphic designer to create a 2-minute video. the video was without sound, in order to simulate the wordless picture book presentation, and the pictures on the computer screen were similar in size to those in the picture book. animation effects portrayed the movements of characters, soundless facial speaking movements and fading between pictures. a laptop computer (hp pavilion dv5000) was used to present the animated story presentation, one picture at a time. procedures each participant was exposed to the same test conditions to increase the validity and reliability of the assessment procedures. narratives were collected by one of the researchers, an slt familiar with the use of narratives in assessment and intervention procedures. assessment took place over a period of 1 week. each child was assessed individually in a quiet room at the school. all the participants in each group were presented with the same animated video and wordless picture book by the same researcher and each session was videotaped using a canon mv 790 video camera. story presentation procedures wordless picture book each participant was asked to preview the wordless picture book before telling the story. the researcher sat next to the child while the child paged through the book. the book was then closed and the child was asked to tell the story to the researcher, without looking at the pictures in the book. participants were expected to tell the story without looking at the pictures or paging through the book again to create similar telling conditions between the wordless picture book and animated video presentation. during the story telling, the researcher responded with neutral responses such as ‘hmm’, ‘yes’ and ‘what else?’ to prompt the child to continue the story or to provide more information. if the child stopped the story without providing a formal ending, the researcher asked the child, ‘tell me when you have finished’. animated video presentation the child viewed the animated video on a laptop computer, while the researcher sat next to the child. the child was asked to tell the story immediately after viewing the video to the researcher without looking at the video again. during the story telling, the researcher used the same neutral responses described for the wordless picture book presentation. data coding and analyses transcription and pruning all coding was done manually by the researchers. after the narratives were collected, each participant’s narrative was transcribed and all revisions or self-corrections, word repetitions, interjections (e.g. ‘uhm’) and incomplete utterances were excluded. the remaining data were then segmented into t-units and coded for total number of words (tnw), total number of t-units (tot t), number of different words (ndw), mean length of t-unit (mlt) and number of complete gao sequences according to scoring protocols compiled by the researchers. a complete gao was defined as a linked sequence of events where the narrator provides a goal statement expressing a protagonist’s intention; followed by an action statement that is directly linked to the goal, i.e. an attempt to accomplish the goal; and an outcome statement, linked to the goal and the attempt, that specifies the outcome of the attempt or action, i.e. whether the goal was accomplished or not. data analyses to establish inter-rater reliability, an slt who was blinded to participants’ group assignment recoded six (30%) data sets randomly selected from all the narratives according to the coding protocol compiled by the researchers (engelbrecht, 2010). the results of the inter-rater agreements were as follows: transcriptions 99%; tnw 99%; tot t 100%; mlt 95%; ndw 99%; gaos 98%. differences were resolved through discussion so that consensus was reached for coding decisions. a commercial software package, statistica 9, was used for the statistical analyses of the data by a biostatistician. in order to examine the differences between the participants in the groups exposed to either the animation task or the wordless picture book task, one-way anovas were used. a 5% significance level (p<0.05) was used as a guideline for determining significant effects of variables. results and discussion the main aim of this study was to determine if a dynamic visual modality in the form of an animated video presentation would elicit better narratives than a static visual modality in the form of a wordless picture book. table 1 provides a summary of the descriptive statistics of the participants in each group with regard to age, receptive vocabulary scores and microand macrostructural variables. in summary, no significant differences between the wordless picture book and animated video modalities were found with regard to the quantity, lexical diversity and syntactic complexity measures. anova showed no significant differences between the groups for tnw, f(1,18)=0.39, p=0,54; tot t, f(1,18)=0.24, p=0.62; ndw, f(1,18)=1.31, p=0.27; mlt, f(1,18)=0.19, p=0.67; and gaos, f(1,18)=0.00, p=1.0. both visual modalities elicited narratives of similar quality in terms of the microstructural variables that were investigated. these findings concur with those of gazella and stockman (2003) and schneider and dubé (2005) who also found no differences between children’s narratives when elicited by visual-only presentation modalities. the inclusion of linked gaos was regarded as the crucial element of macrostructural organisation in participants’ narratives. a novel story portraying events that represented five potential gaos was created by the researchers. it was hypothesised that the animation effects that portrayed movement of the characters and their facial expressions would make it easier for children to infer goals and intentions and causal connections between events. instead we found no significant difference between the two groups with regard to the inclusion of linked gaos. the similar performances for microand macrostructural measures may be because, as previously reported by schneider and dubé (1997), school-age children are less influenced by the elicitation modality (visual, audio or audiovisual) and require less visual support when telling stories, than preschool children. our grade 3 participants were aged between 8 years 5 months and 9 years 4 months. it is possible that preschool children would have benefited more from a dynamic presentation mode relative to a static presentation mode and that group differences would have occurred in preschool children. another unexpected finding was the low frequency of goas in the participants’ narratives. four participants in each group, i.e. 8 of the 20 participants, included no gaos at all in their narratives; 9 participants included only 1 gao; 2 participants included 2 gaos; and only 1 participant included 3 gaos. previous research (stein & glenn, 1979; trabasso & rodkin, 1994) has shown that preschool children seldom include information about the goals, intentions and internal reactions of protagonists when telling or retelling fictional narratives. the explicit inclusion of internal state terms of protagonists develop later in children’s narratives and represent more advanced story grammar and narrative organisational skills (van den broek, lorch & thurlow, 1996). however, we expected that the participants in our study, grade 3 learners aged between 8 and 10 years, would include more goas in their retellings, particularly in the animation group. we offer three possible explanations for the low occurrence of gaos in participants’ narratives: first, our predetermined coding criteria for gaos were strict in an attempt to protect the internal validity of our non-standardised protocol. participants were only credited for the explicit statements of goals that were expressed with mental verbs such as ‘want’ and ‘decide’, goal statements that clearly denoted the intentions of protagonists, e.g. ‘he climbed onto the roof to get the ball’ and goal statements linked to attempt and outcome statements. statements where goals were implied were not credited. participants may have omitted statements of goals or intentions because they assumed that the listener could deduce these from their actions or attempt statements. as stated by trabasso and rodkin (1994), we cannot assume lack of goal plans or awareness of protagonists’ goal-directed behaviour if a child does not explicitly link action and goal statements. the inclusion of focused questions to elicit explicit goal statements after the telling may have given us additional information about the participants’ mental representations. the second possible reason for the low inclusion of linked goal statements in both groups may be the result of the visual-only presentation modalities. we tried to portray intentions and emotions through the characters’ facial expressions and gestures, but audio input such as dialogue between characters verbalising their goals and intentions may have facilitated the inclusion of more goal statements in the retell narratives. thirdly, the participants told their narratives to the same person who presented them with the elicitation stimuli. while this listener condition resembles the typical clinical assessment situation, researchers usually make use of a naïve listener for retellings to control for the effect of assumed shared knowledge (gazella & stockman, 2003; schneider & dubé, 2005). it is possible that participants would have included more explicit gao statements to a different person acting as a naïve listener. study limitations the small sample size of this study population was a limitation. a larger sample may elicit more significant statistical differences between the visual modalities, and allow for more accurate generalisation of the results to the target population of typically developing grade 3 children. future research on younger and language-impaired children could be beneficial in determining the developmental order of narratives in response to these two visual modalities and task conditions. clinical implications the results of this study have several clinical implications for narrative assessment practices. we expected that the children would be more interested in the animated version of the stories and that the movement of the characters would elicit longer and more complex language. participants, however, produced comparable narratives in terms of microand macrostructural measures in response to both visual modalities. it seems from our results that, for older typically developing children, there is no difference between the two methods. this leaves the clinician with the decision of choosing between the two modalities for narrative assessment. while the animated video may be more interesting to children, it may not be the most practical modality for clinical use. aspects that must be kept in mind are the availability of equipment, like a television, computer or visual screen, to display the video. therefore, in the absence of evidence that animation is superior to static elicitation stimuli the use of wordless picture books may be more practical, affordable, accessible, easily transportable, and probably less time-consuming than videos. the findings of this study provide information with regard to typically developing grade 3 children’s production of linked gaos in their narratives. our results showed that 40% of the children produced no gaos in response to pictures that portrayed a story with several episodes. they did not explicitly state every possible goal in the narrative and implied some goals by their attempt statements. this finding suggests that a narrative production measure on its own may underestimate a child’s narrative abilities. the use of an additional comprehension measure with focused questions to elicit gaos would have provided additional insight in our participants’ understanding of the story. in clinical practice it may also be advisable to elicit more than one narrative, for example also a retell narrative in response to a model story, to gain a more valid representation of a child’s narrative competence. acknowledgement. this paper is partly based on the second author’s work towards a master’s thesis at stellenbosch university under the supervision of the first author. this research was supported in part by a grant from the harry crossley foundation to the second author. we are grateful to the children, teacher, school and the western cape education department, whose participation and assistance made this project possible. references arizpe, e. 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(2011). the use of instructional technology in direct vocabulary instruction. journal of special education technology, 26(3), 35-46. trabasso, t. & rodkin, p. c. (1994). knowledge of goal/plans: a conceptual basis for narrating frog where are you? in r. a. berman & d. i. slobin (eds). relating events in narrative: a cross-linguistic developmental study (pp. 85-106). hillsdale, ny: lawrence erlbaum associates. tversky, b., morrison, j. b. & betrancourt, m. (2002). animation: can it facilitate? international journal of human-computer studies, 57, 247–262. doi:10.1006/ijhc.1017. van den broek, p., lorch, e. p. & thurlow, r. (1996). children’s and adult’s memory for television stories: the role of causal factors, story-grammar categories, and hierarchical level. child dev, 67, 3010-3028. verhallen, m. j. a. j., bus, a. g. & de jong, m. t. (2006). the promise of multimedia stories for kindergarten children at risk. journal of educational psychology, 98(2), 410-419. doi:10.1037/0022-0663.98.2 3 communication pathology: the way in mrica* rene hugo head: department of communication pathology university of pretoria opsomming universiteite in suider-afrika moet tans in diepte besin oar die transformasie wat nodig is om tersiere onderrig van wereldgehalte te verseker. in besonder, wat beroepsgerigte tersiere programme betref, word dit al hoe belangriker dat antwoorde op vrae verkry word soos: is die akademiese uitsette van hoer onderrig relevant vir en verantwoordbaar in die konteks van beroepsbeoefening? wat die departement kommunikasiepatologie aan die universiteit van pretoria betref, is die pad duidelik: 'n beroepsgerigte onderrigprogram wat leergeleenthede bied aan studente wat uiteindelik 'n diens aan 'n bepaalde deel van die bevolking moet lewer diegene wat nie kan praat of hoor nie moet die spesifieke aard van die gemeenskap wat bedien word as vertrekpunt gebruik vir enige langtermyn strategiese beplanning. die gemeenskap is 'n afrika-gemeenskap. onderrigprogramme, navorsingsaktiwiteite en gemeenskapdienslewering sal derhalwe verafrikaniseer moet word. abstract universities in southern africa are currently deeply involved in transformation processes in order to ensure world class tertiary education. more specifically in the case of vocationally oriented tertiary programmes, it has become necessary to provide answers to questions like: are the academic outcomes of higher education relevant to and accountable in the context of the workplace? for the department of communication pathology at the university of pretoria the answer is unequivocal a programme that aims to provide learning opportunities for professionals who must eventually render a service to a specific population (the individual with a speech, voice; language or hearing disorder), should ensure that the characteristics of this population serve as the basis for strategic planning. this population is an african population. educational programmes, research projects and community service must therefore be africanised. key words: south africa, transformation, tertiary education,africanised // introduction ex africa semper aliquia novi. out of africa always something new. the emphadis on renewal currently forms a large part of the discussibn surrounding the transfori mation of universities. one cifthe viewpoints which is most clearly stated is the call for ~niversities to africanise. the rationale behind this is thatafricanisation is the only way to ensure that fundamental transformation, and not mere cosmetic reformation, will take place within the universities (nigga, 1997). this idea is not as new as its proponents would have us believe. in 1922 caseley hayford, a west african, called for the institution of an 'africa university' which would create an 'africa ethos'. this request was stated even more dramatically by dr kwame nkrumah: "we must in the development of our university bear in mind that once it has been planted on african soil, it must take root amidst african traditions and values" (in sono, 1996:120). this philosophical premise is often quoted in south i * this article is based on an inaugural address delivered on 8th october, 1998, university of pretoria africa as part ofthe big debate about the transformation of tertiary institutions, with prof makgoba as the most prominent and best known proponent thereof. in 1992 a conference organised by the cup came to the eventual conclusion that, although there is an urgent need for universities to africanise, the specific characteristics of such a process is still unclear .. in most academic debates it is often the terminology or concepts which cause the most uncertainty. this is also true in the africanisation debate and it is evident from the literature that it is easier to explain what africanisation does not entail, than to explain what it does. • it is not the acquisition of black staff and students, irrespective of merit; • it is not a lowering of standards; • it is not the establishment of campuses where instigation, strikes and corruption are rampant. according to makgoba, the africanisation of universities implies the following: " ... an african university should be one who's cultural and philosophical foundations are located within the african paradigm in its values and ethos. like all traditional· roles of a university it should pursue knowledge and social responsibility. it should strive die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 4 for excellence and high standards of teaching, research and community service. its curricula and culture should reflect the culture of africa in its fullest sense, that is: diverse, vibrant, dynamic, accommodating and tolerant" (makgoba, 1996:115). in essence, it is the establishment of a specific ethnocentric ethos as matrix within which tertiary education must take place. it is important that the opposing premise should also be recognised. according to this, it is impossible to africanise any university, primarily because there is no entity that truly represents 'mrica'. how can one really characterise the nature of mrica? it is a continent that stretches from cape to cairo; it is three times the size ofthe usa; it comprises 53 diverse countries and houses approximately 700million inhabitants. furthermore the concept of africanisation is untenable because it is a philosophical absurdity. in the same sense it is impossible to 'anglicanise' oxford or to 'americanise' harvard. the core and essential nature ofa university does not lie in the hands of an american, a briton, or an mrican. it is the scientist, the academic, and their quest for knowledge, which forms the true core of any university. in this respect sono explains: "knowledge is universal, not parochial ... knowledge cannot be kraaled or parcelled out in nationalistic terms ... all true knowledge makes people seek and embrace it without regard for its origins" (sono, 1996:123). communication pathology: the science and the profession the science of communication pathology can be described as the study of normal and abnormal human communication, including its development. pienaar defined' it as early as 1962 as: "logopaedics studies the different abnormalities in the communication process ... a specialised medical auxiliary science which is indispensable in a modern habilitation programme, due to the dependence of the individual as a social being on his means of communication with other group members (pienaar, 1962, in cilliers, 1980:1). communication can broadly be subdivided into the components of reception (mainly through the auditory sense) and expression (mainly through speech and the voice). the system of symbols that is the foundation of both these components, is language. it is therefore logical that the two main professions related to pathological communication are that of speech-language therapy and audiology. the latest document on a national curriculum for the profession, presented to the professional board for speech-language therapy and audiology, provides the following definitions of the two professions: • a speechlanguage therapist is a person who practices the science of communication pathology in order to make a difference in the lives of people with a speech, voice or language disorder; those with a disorder in the social and cognitive processes which are the foundation of such capabilities, and those with a disorder in the speech and/or language production system that has a negative effect on their communication. • an audiologist is a person who practices the science of communication pathology in order to make a difference in the lives of people with a hearing loss, auditory processing disorders and/or those who experience difficulty communicating due to a loss of hearing. rene hugo conservatively estimated, this population of persons with a communication disorder forms approximately 10% ofthe total population. it remains inconceivable that, despite this high occurrence, and with the exceptional emphasis that is placed on the importance of communication today, the role of communication pathology is stili not sufficiently recognised. in her inaugural address in 1993, my predecessor, prof. isabella uys, discussed in sufficient detail the development of tertiary education in communication pathology since its initiation in south mrica in 1937. it is therefore not necessary to repeat these facts. however, within the theme of africanisation, it would indeed be worthwhile, to consider the development of this tertiary programme at the university of pretoria more closely. in 1959 prof. p de v pienaar started the course in logopaedics at pretoria in the former department of speech science and speech therapy. he established his undergraduate programme on a european foundation, based on his involvement with the french and german universities where he received his initial training. he was succeeded by prof. izak hay, who had a strong technocratic influence from his engineering background, linked to the american model of professional practice, which he developed during his years of study at the central institute for the deaf (cid) in illinois. (it is interesting to note that it was probably izak hay who, although he was no rehabilitator himself, through his association with the cid, established a tradition at the university of pretoria of oral communication for the hearing impaired.). on his retirement, he was succeeded by prof. uys. she also had an american orientation, but other than that was a great supporter of holism. as a result of this, the professional education of speech-language therapists and audiologists at up was influenced as follows: g through prof. uys's efforts the department of communication pathology moved closer to university structures, systems and standards, so that the department could make a meaningful contribution within the broad tertiary system. o secondly, she realised the importance of professional transformation related to the demands of the south african community and made a special attempt to promote this amongst communication pathology clinicians (uys, 1993). against this background, the logical question is what should be the future of professional training in communication pathology at the university of pretoria? as part of the transformation of universities, vocationally oriented programmes should urgently attempt to provide answers to questions such as the following: "are academic outcomes of higher education provision relevant to and deliverable in the workplace setting?" (seagraves et ai, 1996:157). as far as the department of communication pathology is concerned, the future principle is clear: a vocationally-oriented programme that educates students to deliver a service to a certain sector of the population those that cannpt speak or hear should recognise that the specific nature of this community must serve as the basic point of departure for" all their educational programmes. this community is an mrica community. education will therefore have to be africanised. the africanisation of educational programmes will afthe south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) conununication pathology: the way inafrica fect the profession in two respects, namely: firstly, the existing western model of service provision to the person with a communication disorder is one which is generally considered a luxury available for the few that can afford it. this implies that a communication pathologist is trained to diagnose and treat patients on a one-to-one basis, usually in a clinical setting and upon payment of the necessary fee. the large masses with communication disorders, for whom successful communication is not a luxury, but a matter of survival, who live far from clinics and other services, are not taken into account. there is an urgent need to bring the service to the people. instead of bringing the people to the service (uys & hugo, 1997:24). secondly, the western model has an inherent feature that makes it alien to africa: it is disorder-oriented. communication pathologists are taught to diagnose and treat someone with a specific hearing, speech or language disorder. what the people with a communication disorder in africa need more than anything else, is the provision of a functional service that includes such functions/tasks as awareness programmes for the general public, prevention programmes, multi-disciplinary consultation, and early intervention. a paradigm shift from disorder-orientation to function-orientation is necessary to meet the demands of africa (uys & hugo.1997:24). as far as the science that forms the basis ofthis change in the nature of the profession is concerned, the following premise must be upheld: "africanisation seeks to provide a basis for originality and uniqueness that can contribute meaningfully to global knowledge and civilisation" (makgoba, 1997:64). aspects of africanisation africanisation does not mean that all existing (western) influences must summarily be disregarded and that everything with an mrica stamp should indiscriminately be embraced. it would be meapingless to undertake a philosophical migration to one corner of the universe, while the rest of the world is busy integrating! (madi, 1995). the warning issued by ann berhstein during a national forum in february 1998 on the role of universities should therefore be taken into consi:<ieration. she says: "if something is working in the university system, understand it, nurture it, preserve it. destr'uction will take a few short years: recreating excellence t.vill take generations" (cde 1998:23). : / against this framework, it is my opinion that the department of communication pathology will have to africanise, both in its essence, and as an inseparable part of the university of pretoria. what does this africanisation entail, and what is already in place within this transformation process? this question can best be answered against the traditional functional framework of a university: education, research and community service. africanisation of education the most comprehensive manner in which a philosophical and practical basis for the africanisation of tertiary education can be realised, is to establish the premise of life-long learning on a competence-based foundation. it is therefore important for the department of communication pathology to accept the following statement as the 5 basis of its teaching programmes: "education is a path not a destination and not the accumulation of nuggets of knowledge or repertoire of skills. competency represents the point along this path where the learner understands the foundation of his or her skills and has internalized appropriate professional values to work independently in normal settings and manage his or her own continued growth" (chambers, 1993:791). this concept is presented in figure 1. beginner =:> competent graduate =:> expert +---------------+-------------+ undergraduate =:> post graduate figure 1: educational path of the lifelong learner undergraduate programmes should be driven by a competency-based curriculum. from figure 1 it is clear that, at undergraduate level this will allow the student to development along the educational road, from beginner to a competent young graduate. it also recognises the importance of postgraduate training, aimed at the eventual crystallisation of a scientific specialist. this educational philosophy is influenced and structured by a number of 'africa' trends, only a few of which can be mentioned here. africanisation of education and the multicultural context in conjunction with the development of an ethical consciousness, which is the most important feature of our modern renaissance, universities worldwide have also come to realise that they are in the midst of a multicultural situation. various tertiary institutions have attempted to handle this situation in different ways, frequently with a lesser degree of success. one of the most important mistakes that has been made, has been to believe that a department makes provision for multiculturality by adding snippets and pieces of information about different cultures to the curriculum. this can never be more than a cosmetic patchwork process. another mistake is to accept that people from 'other' cultures have necessarily been educationally andlor culturally deprived, and then to recognise their multiculturality by providing programmes to members of this so-called deprived group, so that they can be 'compensated andlor developed'. as far as the department of communication pathology is concerned, we believe that we have an advantage because we not only have multicultural student groups and staff, but we are positioned in the reality of a multicultural communication impaired community which functions as a teaching laboratory. in order to ensure the full assimilation ofmultuculturality the following premises are made: • multiculturality forms an inherent component of all our teaching programmes. it can be clearly observed in the important role which modules such as community-based rehabilitation, play in the syllabus. at the microlevel of learning material, it is even more evident in teaching-content that includes: how to work with and through die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) "f 'ty needs' how to intt'i'ji\'('!.l'i's; how to ldcnli y commum , init.i,ti,(, lay !.millillg' for different cultural ?toups, etc, " i 'i' .. « curnculum that 'i'll<' dl'p:lrtllu'lll. strong' y llll leves, a , ' l'<'ll,'('/,~ till' "ii/turi's, l)('rsl)('i:livl~s and luslones o( ethiii!' ~"iii/i)s i/iil/ 111'11) .. , sludenls lo achieve at h~gher /i'/ll'/,~ hl'i'i/i/si' sl/ililmis lnlrn besl in an educatwnal ,'/wirollllll'lit thai ljalidall~s lheir cultures and is consisll'lit with ill/' ways in which lhey learn" (banks, 1986:47), • the departmental teaching philosophy completely incorporates the aspect ofmulticulturality, based on the model of banks (1986:23), figure 2 is used as a point of departure: the multicultural professional and .academic context ", .. ',xii'.".,.:' .::""" .... , ... ,,:,':,.,. .. .,/':( .. ' ...... ,::::,:: ... ,.,.... : ,' .. ;,:;: .... , ., department has norms and values which reflect and legitimise ethnic and cultural diversity, staff upholds attitudes and value systems based on knowledge and insight in the multicultural composition of the general public, the communication disordered population and the student corps, teaching and evaluation of students promotes social and ethnic equality, curriculum and teaching materialllaboratories are aimed at providing multicultural perspectives, concepts, questions and problems, figure 2: a multicultural teaching programme source: adapted from banks 1986:23 • finally, it is also our conviction that lecturers cannot function successfully within a multicultural context and with ethnically diverse students if they are not well prepared at a professional level to do so, "the degree to which multicultural education becomes a reality in our schools depends largely upon the attitudes and behaviours of teachers" (roderiquez, 1983 in gay, 1986:154), changes in health care and the implications for africanisation of education the africanisation of education in communication pathology is closely linked to the related transformation of the health care system of southern africa, the most important feature of this is the acceptance of the alma ata ideal of 'health for all by the year 2000', mainly through the application of the policy of primary health care, in essence, primary health care is: "the first level of contact of individuals, the family and community with the national health system, bringing health care as close as possible to where people live and work, and constitutes the element of a continuing health care process" (alma ata, 1995), primary health care has certain features that are of particular importance for rehabilitation' services and thus also for the tertiary teaching programmes of the department of communication pathology, the department of health emphasises that its objective is to formulate a complete primary health care package, which encompasses the rene hugo t fheall'ng rehabilitation and preventative serv-elemen so, , , i' 't' this are services such as health educa-ices, imp ici m , " , , ll'ng commumty-based rehabilitation, pre-hon counse 1 , ", " t' and the early identification of potential ventative ac ion th logy (department of health, 1995), pa 0 'cation patholomsts this means that they for commum b l , , i ti'nue along the former road of speclahst can no onger con , ' " e-to-one situation wlthm the context of services in a on , ' f lid ' ti'c hospitals this is a move away from re erra iagnos " ' ' institution-based services, to provldmg commumty-based , 'th much greater emphasis on those tasks of services, wi a , communication pathologists that were previously ~egarded as being 'secondary', namely education, prevention, consultation and counselling, the department of communication pathology has already made a paradigm shift with the new undergraduate curriculum which meets all the above-mentioned demands, a curriculum is, however, only a teaching blueprint, in the case of vocational education programmes, the laboratory in which teaching takes place, is of the utmost importance, for this reason the department is thankful for the opportunity offered by the department of health of mpumalanga to participate in the agreement with up, and in this way make staff available at the witbank hospital, who play an active role in the teaching of students, here our students can experience health care in the actual situation, the first groups already received their training there in 1998, and the possibility exists that this project may be expanded to the northern province during 1999, in conjunction with this, attempts have been made to expand the teaching of community-based rehabilitation with the appointment of sotho-speaking lecturers, in conjunction with active teaching of community rehabilitation service in areas such as hammanskraal. this altered pattern of primary health care and community services also demands that the department of communication pathology develops additional programmes to satisfy the training needs of other (related) specialist services, programmes such as certificate programmes for communityrehabilitation workers, speech and hearing assistants who render area-specific services, interpreters, etc, as well as diploma programmes such as those fqr hearing aid acoustics, are demands which have been made, and which will have to be met, i africanisation of tertiary educat!on related to changes in the schools , the present south african education system is also i characterised by transformation, which has important implications for the services communication pathologists are required to provide in the education context, certainly the most important aspect of this is accepting the fact that the foundation of a quality education for all, is the principle of ' an inclusive learning environment', for speech-language therapists and audiologists, this means that in the future they will also need to render a service to the child who previously attended a special school, but who has now been incorporated into mainstream education, some of the important,tasks they will have to fulfil, include: • participation in early/pre-school programmes with specific focus on the development of communication; • the provision, development, adaptation and maintenance of assistive devices (hearing aids, communicathe south african journal of communication disorders, vol, 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) conununication pathology: the way in africa tion systems) that can help pupils overcome specific barriers to learning; • overcoming learning inaccessibility. an example of this is the fact that one of the most important features of curriculum 2005 is its auditory basis. unfortunately, the traditional school environment is, by the very nature of its facilities (echoing classrooms, hard reverberating floors, glass walls and corridors that distort sound), acoustically largely inaccessible. here the audiologist has an important consultative role to perform; • community-based rehabilitation of the schoolgoing child with a communication impairment; • participation in the development of relevant school curricula in order to make it accessible for pupils with communication disorders (quality education for all, 1997). th perform these tasks, the primary role of communication pathologists within the education system, will have to change. greater emphasis will have to be placed on the communication pathologist's role as a facilitator and consultant within a trans disciplinary team. one of the important features of the department of communication pathology at the university of pretoria is that the department has always been able to function pro-actively and to be an important participator in policy formation. it is therefore not strange that this 'new' role in education is already reflected in the existing activities of the centre for early intervention in communication pathology and the centre for augmentative and alternative communication. from 1999 kommunika will provide innovative programmes to undergraduate students as well as to other educational professionals in order to ensure that the communication pathologist of the future will be equipped to function successfully as a valuable and appreciated member of the educational team. t-he change in the education policy offers the department an excellent opportunity to participate in transdisciplinary tertiary programmes aimed at the teacher and related professions. the ex.isting diploma developed in conjunction with the depa~tment of didactics, the further diploma in specialisediteaching (hearing-impaired persons), is an example of the new trends in this niche. \ africanisation of education associated with language influences , as far as language is conicerned, it is true that southern africa is currently, both officially and unofficially, engaged in a veritable confusio'n of tongues. for the communication pathologist, this situation is a dilemma as well as an opportunity. in the case of most other health professions, language is the medium to rehabilitation, while for the communication pathologist, it is both the medium and the eventual goal. this implies, in the first instance, that there is a great need for communication pathologists who are first-language speakers in all the different african languages, who can provide a meaningful service to the entire communication impaired population. this is an important prescriptive requirement in respect of the student corps of this department. in the school classroom, language is of exceptional importance if one takes into consideration that it is the 'medium' whereby knowledge is conveyed. as a result of the changing education policy, there are increasingly larger groups of children in schools today for whom the teaching 7 medium is strange and who, due to their language incapabilities, require intervention. the communication pathologist of the future must therefore be much better equipped than in the past to participate in support programmes to non-first language speakers in the schools, as well as to make a contribution to the development of second language teaching programmes. a final aspect concerning language that should receive attention, is the sign language of the deaf. as has already been stated, the audiologist is the professional who is mainly involved with individuals and groups of people who have suffered a loss of hearing, and the audiologist is primarily responsible for offering support in respect oftheir communication. a section of this population are the deaf, who have accepted south african sign language as their first language. it is therefore important that the audiologist should be proficient in this language, in order to play a role in developing the skih of people who wish to acquire this language. africanis;p'ion of education and technology there is irrefutable proofthat technology will probably be the channel through which economic and social growth will take place in the next millennium. this is true for the professional functioning of communication pathologists worldwide. the question is what is the relation between the africanisation of education at universities on the one hand, and technology on the other? while compiling a research policy for higher education in south africa, whiston came to the conclusion that south africa is not exclusively a first (high technology) or a third world country, but rather "different worlds in one" (whiston, 1995:11). in order to cope with this ambivalence he proposes that "south africa has to appreciate that it is part of africa, and that it has experience and knowledge to share but it has much also to learn from other societies. it should see itself as a participant in joint ventures in science and technology on the continent ... " (whiston, 1995:224). in the practical situation this can be ensured by bringing the operational and maintenance demands of new technology in line with the skills and knowledge of the community that is going to use the technology (serpelke & nabletzol, 1991). it is the task of the department of communication pathology to give shape to the abovementioned proposal: to make africa technologically accessible to individuals with communication disorders, and to ensure that the value and benefits of technological developments do not pass by the africa-impaired. in this way, communication pathology can contribute to an improved quality of life. technology that is already incorporated in the education programmes at the department of communication pathology includes cochlear implants and digital hearing aids for severely hearing impaired persons, as well as the use of computerised communication systems for the severely physically handicapped. africanisation of research in communication pathology a science is nourished by the research that generates it. for this reason it is unacceptable to believe that the africanisation of research would in reality mean that no research should be conducted. proponents ofthis idea, such die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 8 as fyle (1985), argue that research is a luxury that african countries cannot afford, and that the dissemination of research information is the best that they should be capable of. in contrast to this, i maintain that research must be seen as the cornerstone upon which the africanisation of education can be developed. however, this research must be characterised by innovation in order to satisfy the demands of africa. the following are a few proposals to achieve this innovation: • according to whiston (1995) researchers have the specific ethical responsibility to execute relevant and effective research. this means that research must be socially justifiable and relevant to the context. the field of communication, as the medium and eventual aim of human social existence, lends itself pre-eminently to such research. • in conjunction with this, the generation of multi-disc iplinary and trans disciplinary research is becoming all the more important a demand that is particularly applicable and acceptable to the humanities, because their primary research subject is man in all his facets (voster, 1995). • the commission on health research for development identifies research as the process whereby equality of development can be achieved. they also request that research in the field of essential health aspects should be given preference. once again, this is an area in which the department of communication pathology can and will make a contribution. a study of the departmental annual reports of the last decade indicates that the department has already contributed to this research area by conducting research on topics such as: the provision of habilitation services in rural areas; the occurrence and implications of specific african diseases, such as malaria, for communication pathology; noise pollution and hearing protection in industries such as the gold mines, etc. • given the nature of africa, and in conjunction with the demands of justifiable and relevant research, the dissemination of research results is becoming all the more important. this specifically does not mean that research should at the conclusion be wrapped up in an article package and presented to other specialists in a learned debate. on the contrary, it implies that departmental research should adapt a research philosophy that includes dissemination as an inherent component of the total process. the foundation of this viewpoint is contained in the following figure: 100% 80% 60% 40% 20% 0% research development figure 3: participative research source: powell et al., 1989. and uys & hugo, 1997 rene hugo figure 3 clearly indicates that research does not take place in a vacuum, but in collaboration with a 'research associate', which can be an individuavgroup/entity and which has a shared responsibility for the entire process. the researcher has the greatest responsibility for carrying out research (but he does not bear this responsibility alone). the associate, in contrast, has the greatest responsibility for the implementation and acceptance of the research results the eventual and greatest aim of dissemination. with such a research philosophy incorporated in the departmental mission it must be accepted that research in the department of communication pathology has made much progress along the road of africanisation. africanisation and community service the responsibilities of a university are generally acknowledged as being threefold: teaching, research and community service. ofthese three, the latter is commonly seen as the 'cinderella' and is sometimes regarded by academics as a last ditch attempt by universitil::)s to "leave their ivory tower and reach out to the community" often with a secondary motive of financial gain linked to the attempt. yet, it cannot be denied that it is precisely the community that plays such an important role in academic life: it identifies general teaching objectives, influences the curriculum and sets priorities for teaching and research (altman, 1996). the university of pretoria is defined as being a community-based institution that has a social responsibility to place its knowledge and skills at the disposal of the community. this role is clearly spelled out in its mission statement, and realised in the establishment of structures such as the centre for reconstruction and development (audit portfolio, 1997). it is also significant that statements such as the following were made in up's annual review of 1997: ''departments that launch community servo ice projects increasingly find innovative ways of integrating such projects in their teaching and research agendas"{up annual report, 1997:5). however, the abovementioned attitude is not sufficient for true africanisation. universities and departments should not render a service to communities n in that way they will never become part of the community. rather they should be involved in the community and this involvement must be a symbiotic process. a department may not merely offer skills and expertise to the community in a one-way relationship (which also contains a quality of "i'm ok you're not ok" in such a relationship). the departdemonstration application adoption the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) _.nunication pathology: the way inafrica co ..... •• t must also be receptive to receive input like skills me; expertise from the community. in this way departan ntal education and research programmes are not only ~~tiated, but the nature and quality of these programmes :e driven by the community. the result ofthis is that the department can then comply with one of the most important demands tertiary education has to face today that of relevance in its curriculum and areas of research expertise. such a viewpoint necessarily means that community involvement will playa much greater role in the functioning of a department than is generally recognised or accepted. this has also important implications for aspects such as subsidy formulae and staff-student ratios. in the department of communication pathology, this principle has for years been accepted, and is reinforced through the existence of units such as the speech, voice and hearing clinic, the centre for augmentative and alternative communication, the centre for early intervention in communication pathology, chrib and kommunika. there are, however, still important gaps, that must be filled in order to ensure that these structures satisfy the demands of an mrican community. in conclusion i am privileged to be an academic to be able to contribute to the development of the youth of today and south mrica's future. privileges may, however, not be summarily claimed. privileges are linked to responsibilities. one of these responsibilities is adaptability. in the 1997 annual review of the university of pretoria, the principal declares that universities throughout the world must adapt to changes in the market place (van zyl, 1997:4). programmes for professional education and training are responsible for taking a very specific sector of the market place as their point of departure: the community that is served by the profession. for speech-language therapists and audiologists who have rec~ived and are receiving their training at the university ofipretoria, this population is irrefutably the communication impaired african. i therefore believe that the only way forward for the department of communication pathology runs through the heart of africa. references altman, i. (1996). higher education and psychology in the millennium. american psychologist, 51 (4) :371-378. audit portfolio, up. banks, j a. (1986). in banks, j a & lynch, j. (eds). multicultural education in western societies. london: holt rhinehart & winston. cde round table, no 2. \~1998). the centre for development and enterprise, johannesburg. chambers, d w. (1993). the challenges of modularization. innovations in education and training international, 32 (2): 96 105. cilliers, g. (1980). 'n beroepstudie van spraakterapeute en oudioloe. hsrc report no mm79. department of health annual report, 1995. gay, g. (1986). multicultural teacher education. in banks, j a & lynch, j. (eds). multicultural education in western societies. london: holt rhinehart & winston. madi, p. (1995). moving the centre. people dynamics. march:1216. makgoba, w. (1996). south african universities in transformation: africanise or perish. politica, 15 (2):114-118. nigga, c. (1997)trends in health and health care in south africa. in lemon, a. (ed) the geography of change in south africa. seagraves, s. (1996), a campus of our own. change, march/april, pp 153-160. sono, t. (1996). do african universities need an african ethic? politica 15 (2) :119' 121 quality education for all. (1997). report of ncsnet & ncess, department of education, uys, i c. (1993). kommunikasiepatologie: onderrig vir die toekoms. inaugural address, university of pretoria. uys, i & hugo, r, (1997). speech-language pathology and audiology: transformation in teaching, research and service delivery. health sa gesondheid, 2 (2):23-29. van zyl, j (1997). overview by the vice-chancellor and principal. university of pretoria annual review 1997. voster, p j. (1995). africanisation: an explanation and some educational implications. south african journal of education. 1995,15 (1) : 6-12. whiston, t g. (1995). research policy in the higher education sector of south africa. frd. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) abstract introduction methods results discussion conclusion acknowledgements references about the author(s) ben sebothoma department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation sebothoma, b. (2020). middle ear pathologies in adults within the mining industry: a systematic review. south african journal of communication disorders, 67(2), a679. https://doi.org/10.4102/sajcd.v67i2.679 note: special collection: occupational hearing loss in africa. original research middle ear pathologies in adults within the mining industry: a systematic review ben sebothoma received: 30 sept. 2019; accepted: 05 feb. 2020; published: 30 mar. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: literature suggests that risk factors for middle ear pathologies, such as traumatic injuries and human immunodeficiency virus (hiv), exist in mines. however, studies on hearing health in mines seem to focus primarily on occupational noise-induced hearing loss and ignore middle ear pathologies. as a result, there is little documented evidence on the trends of middle ear pathologies in mine workers. objectives: the aim of this study was to explore and document published evidence reflecting trends in middle ear pathologies in mine workers. method: a systematic literature review of studies that reported middle ear pathologies in mine workers was conducted. medline, cinahl, pubmed, psychinfo and google scholar databases were searched for studies in english published between january 1994 and december 2018 and reporting on trends in middle ear pathologies in mine workers. results: two research studies met the selection criteria and were included for analysis. one research study used tympanometry with 226 hz probe tone, while another study used interviews to determine the presence of middle ear pathologies. while these studies indicate that middle ear pathologies exist in individuals working in mines, the evidence is limited. conclusion: while current data indicate that individuals working in mines may present with middle ear pathologies of varying severities, the evidence is too small to provide a clear trend of middle ear pathologies in individuals working in mines. therefore, the current limited data suggest a need for further studies to examine middle ear pathologies in individuals working in mines. keywords: middle ear pathologies; mining industries; systematic review; adults; trends. introduction although the mining industry plays an important role in the economic growth of any country, especially african countries, health hazardous conditions such as the auditory pathologies continue to be the biggest threats to this growth (cawood, 2011). consequently, the mine health and safety council (mhsc) of south africa in 2003, which was revised in 2014, called for urgent action to prevent and manage auditory pathologies. however, the occupational noise-induced hearing loss (onihl) became the central focus in the literature, with little or no focus on middle ear pathologies (amedofu, 2002; chadambuka, mususa, & muteti, 2013; kanji, khoza-shanagse, & ntlhakana, 2019; moroe & khoza-shangase, 2018; musiba, 2015). according to the world health organization (who), middle ear pathologies are amongst the most common auditory pathologies affecting over 700 million people worldwide (who, 2018). although middle ear pathologies can be treated with simple antibiotics (vouloumanou et al., 2009), the prolongation of middle ear pathologies can cause complications. according to who (2018), over 30 million people with acute otitis media (aom) will develop chronic suppurative otitis media (csom), of which approximately 50% will develop permanent hearing loss. kolo, salisu, yaro and nwaorgu (2012) also found an association between csom and sensorineural hearing loss (snhl). in addition, middle ear pathologies have also been linked with auditory processing difficulties (villa & zachetta, 2014). and intracranial complications (sharma, jaiswal, barnerjee, & garg, 2015). given the trends of middle ear pathologies across the world, it is plausible that these pathologies also exist in mines. furthermore, literature has reported that risk factors associated with middle ear pathologies exist in mines. donoghue (2004) reviewed occupational health hazards in mining and found that human immunodeficiency virus (hiv) and minor traumatic injuries were key amongst the health hazards. hermanus (2007) argued that the existence of hiv in mining can be attributed to the living and working conditions of the miners. the united states agency for international development (usaid) also reported that the conditions of the mines may contribute to the risky sexual activities engaged by mine workers as a coping mechanism (martins-fonteyn et al., 2017). numerous studies have found an association between hiv and middle ear pathologies (ensink & kuper, 2017; matas, angrisani, magliaro, & segurado, 2014; obasineke, amdi, ibekwe, ezeanolue, & ogisi, 2014; sebothoma & khoza-shangase, 2018; tshifularo, govender, & monama, 2013; vajpayee, negi, & kurapati, 2013). these studies suggest that hiv incapacitates the immune system, making it ineffective to fight the invading pathogens. consequently, middle ear pathologies occur from the opportunistic infections (vajpayee, negi, & kurapati, 2013). the prevalence of middle ear pathologies in individuals living with hiv can be as high as 60% (matas et al., 2014). on the contrary, møller (2006) argued that traumatic injury to the ear can interrupt the ossicular chain, reduce the sound energy into the ear and cause conductive hearing loss (chl). in a prospective analytical study conducted by sogebi, oyewole and mabifah (2018), 47.8% of the 205 participants with various forms of ear trauma presented with tympanic membrane perforation. of these, 20.8% of the ear trauma were categorised to be accidental or self-inflicting injuries. arguably, these accidental injuries may relate to the one described by donoghue (2004) in the review. while sound reduction appears to be an immediate consequence of impaired middle ear system (møller, 2006), non-pulsatile tinnitus and vertigo are also found to be associated with traumatic injuries of the middle ear (delrue et al., 2016). these conditions can have a significant impact on individuals’ day-to-day living and affect the quality of life (anderson, parbery-clark, white-schwoch, drehobl, & kraus, 2013; holman, drummond, hughes, & naylor, 2019). in light of the risk factors for middle ear pathologies that are reported to exist in mines, and the common trends of middle ear pathologies, the present study aimed to explore and document, through a systematic review, published evidences reflecting trends in middle ear pathologies in mine workers. methods data sources and literature search this systematic literature review was conducted in line with the cochrane collaboration guidelines in conjunction with the preferred reporting items for systematic reviews and meta-analysis (prisma) (moher et al., 2009). a comprehensive search was conducted on articles that had reported on middle ear pathologies in mine workers. a computer-aided search of online journal databases, including medline, cinahl, pubmed, psychinfo and google scholar, was undertaken. the following keywords were used: ‘middle ear pathologies’ or ‘middle ear disorders’ or ‘middle ear infection’ or ‘ear infection’ or ‘otitis media’ or ‘conductive hearing loss’ or ‘hearing loss’ or ‘hearing impairment’ or ‘ear trauma’ or ‘ossicular disorder’ and ‘work-related’ and ‘mining’ or mineworkers. inclusion criteria the search was conducted on articles published between january 1994 and december 2018. this time frame was similar to the one used in another systematic review on mining workers and onihl (moroe, khoza-shangase, kanji, & ntlhakana, 2018). studies were included in this review if they were published in peer-reviewed journals, included mine workers and documented their middle ear status. furthermore, studies had to be written in english. studies were also included even if they were not randomised controlled trial (rct) studies (higgins & altman, 2011). data extraction and synthesis a total of 4494 titles were retrived. of these, 12 studies were removed as these were duplicates. as a result, 4482 studies were considered and screened. of the 4482, 4458 studies were excluded based on the titles and/or abstracts because they were not in line with the present study. a total of 24 articles were assessed for eligibility, but 22 studies were exlcuded with reasons (e.g. studies did not measure middle ear function). finally, a total of 2 studies were included for analysis. the prisma flow diagram, showing the process of selecting studies for inclusion in this review is included (figure 1). figure 1: the preferred reporting items for systematic reviews and meta-analysis flow diagram describing the inclusion of studies. ethical considerations this article followed all ethical standards for a research without direct contact with human or animal subjects. results table 1 summarises the results identified for the review through literature search. a total of 4494 studies were retrieved from all four databases. of these studies, 4470 were excluded as they did not meet the selection criteria and 24 records were selected based on their titles and/or abstract. of the 24 selected records, 22 were excluded because of duplication and the fact that they did not report on middle ear status of individuals working in mines. finally, two research articles met the criteria for analysis. table 2 summarises the studies included for analysis. table 1: summary of research studies identified through database search. table 2: middle ear pathologies in mine workers. measure of middle ear assessment this review identified two research studies that had used different measures to determine the presence of middle ear pathologies in individuals working in mines. landen, wilkins, stephenson & mcwilliams, (2004) examined the middle ear status of the miners using tympanometry with 226 hz probe tone. the cut-off values of tympanometry used in this study was adopted from the criteria described by margolis and shanks (1985). saunders et al. (2013), on the contrary, used an interview method to determine whether participants presented with middle ear problems. participants in this study were asked to indicate whether they have or had a history of ear discharge (otorrhoea). rates of middle ear pathologies one research study that used tympanometry with 226 hz probe tone (landen et al., 2004) reported that 6.4% (n = 19) of the participants recruited from the sand and gravel mine presented with some form of abnormal tympanometry. however, the types of abnormal tympanograms (e.g. type a) were not reported. these participants were ultimately excluded from the main study because the primary purpose of the study was to examine inner ear hearing loss. however, for the purpose of this review, this number (n = 19) was included for analysis. the study by saunders et al. (2013), who used interview methods to determine the presence of middle ear pathologies, reported that 14% of the participants reported prior ear drainage (otorrhoea). in this study, only ear drainage was enquired about. other middle ear-related symptoms, such as aural fullness, itchiness and otalgia, were not reported. discussion the aim of this systematic review was to summarise evidence reflecting trends in middle ear pathologies in individuals working in mines. specifically, this systematic review aimed to look at the rates of middle ear pathologies, middle ear measures used, severity and risk factors. to the author’s knowledge, this is the first systematic review that explored and documented middle ear pathologies in individuals working in mines. because of the heterogeneity of the studies included in this review, only qualitative synthesis was conducted. this systematic review identified two research studies that reported on middle ear pathologies in individuals working in mines. these studies reported that middle ear pathologies exist (landen et al., 2004; saunders et al., 2013), perhaps in varying severities. for example, saunders et al. (2013) reported that their study participants presented with otorrhoea. møller (2006) indicated that otorrhoea is often consistent with advanced form of middle ear pathologies, such as chronic otitis media with effusion. however, because otoscope and tympanometry results were not reported, it is difficult to determine the nature of the middle ear pathologies. given that individuals working in mines are susceptible to traumatic injuries, and have been shown to have high prevalence of hiv (hermanus, 2007), it is surprising and concerning that middle ear pathologies in this population are largely ignored. baltazar et al. (2015) reported that the conditions of the mines may contribute to the risky sexual acitiviies engaged by mine workers. tuan (2010) found that miners engage in risky sexual behaviours as a coping mechanism. baltazar et al. (2015) also reported that 22.3% of mozambicans working in south african mines were living with hiv. of those, approximately 75% of the participants did not know their hiv status. this means that the majority of participants (75%) were not on hiv treatment, making them even more prone to middle ear pathologies (obasineke et al., 2014; van der westhuizen, swanepoel, heinze, & hofmeyr, 2013). the findings of this systematic review suggest that hearing conservation programmes (hcps) need to include middle ear assessment. this may provide a better management and quality of life of individuals working in mines. the author suspects partly that the paucity of evidence of this important auditory information may be because of lack of involvement of audiologists in mines, as highlighted by moroe and khoza-shanagse (2018). conclusion this is the first systematic review to look at the trends of middle ear pathologies in adults working in mines. however, this review highlights the paucity of research in the area of middle ear pathologies in individuals working in mines. there were only two research studies that reported on middle ear pathologies in adults working in mines. while these studies indicate that middle ear pathologies exist in adults working in mines, evidence is too small and weak to suggest any trends. therefore, the findings of this review suggest that there is a need for assessment of middle ear pathologies in individuals working in mines. the inclusion of middle ear assessment will contribute to early detection and intervention of middle ear pathologies, thus potentially increasing the quality of life. acknowledgements the author wishes to thank prof. katijah khoza-shangase, his phd supervisor, for the support during the writing of this article. competing interests the author declares that he has no financial or personal relationships that may have inappropriately influenced him in writing this article. author’s contributions b.s. is the sole author of this research article. funding information the author thanks the national institute for the humanities and social sciences (nihss) and the consortium for advanced research training in africa (carta) for providing financial assistance for the publication of this manuscript. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any affiliated agency of the author. references amedofu, g.k. 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(2018). addressing the rising prevalence of hearing loss. retrieved august 06, 2019 from https://apps.who.int/iris/bitstream/handle/10665/260336/9789241550260-eng.pdf;jsessionid=997dbef8d9509748eeb7ab8c65581929?sequence=1 abstract background methodology data sources and eligibility criteria results discussion potential study implications conclusion acknowledgements references about the author(s) nazeera f. karani department of speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa jenna sher department of speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa munyane mophosho department of speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation karani, n.f., sher, j., & mophosho, m. (2022). the influence of screen time on children’s language development: a scoping review. south african journal of communication disorders, 69(1), a825. https://doi.org/10.4102/sajcd.v69i1.825 original research the influence of screen time on children’s language development: a scoping review nazeera f. karani, jenna sher, munyane mophosho received: 15 feb. 2021; accepted: 28 sept. 2021; published: 10 feb. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: an exponential increase in screen time amongst children and adults, has given rise to a plethora of studies exploring the influences that this exposure may have on children’s development. objectives: this review is specifically concerned with understanding the influence of screen time on children’s language development. method: a scoping review was conducted to explore the available literature relating to the impact of screen time on children’s language development. the scoping review was based on the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr) framework and the joanna briggs institute (jbi) framework. the data were analysed using thematic content analysis. results: this review identified 12 articles. it made an argument for the multifactorial relationship between screen time and language development, given the associated positive and negative effects. the results revealed core themes such as the influence of screen time being dependent on various factors and the diverse effects of screen time on children’s language development, with the inclusion of parents’ monitoring of and participation in viewing, playing a vital role in language development. conclusion: the review indicated that an increase in the amount of screen time and an early age of onset of viewing have negative effects on language development, with older age of onset of viewing showing some benefits. video characteristics, content and co-viewing also influences language development. this study demonstrates that the negative influences of screen time appear to outweigh the positive influences. keywords: language development; screen time; children; positive effects, negative effects. background the fourth industrial revolution (4ir) has led to an increased exposure to screen time in both children and adults globally (kardefelt-winther, 2017; rideout & hamel, 2006). south africa has similarly shown an escalated usage of screen time amongst children and adults (muthuri et al., 2014). the increased screen exposure may influence the overall development of children. according to nurturing care: for early childhood development (2020), 38% of children were at risk of poor development in 2015. in addition, no data is available in south africa relating to early stimulation, children’s books and playthings in the home environment (nurturing care: for early childhood development, 2020). these are especially vital for children’s language development in the first 1000 days (3 years) of life, as this is a critical stage for brain development and maturation, and is the most intensive period of acquiring speech and language skills (cusick & georgieff, 2016). however, because of the increase in screen time in children, its influence on language development may be an area that needs to be explored. according to current literature, ‘screen time’ can be defined as the duration of time that is spent with any screen such as phones, video games, televisions, computers, laptops and tablets (ponti et al., 2017). in addition, ‘screen time’ may refer to either active or passive screen time (sweetser, johnson, ozdowska, & wyeth, 2012). active screen time is the child’s ability to engage cognitively or physically in digital activities (sweetser et al., 2012), whereas passive screen time includes inactive screen-based activities and/or obtaining digital (screen-based) information in a passive manner (sweetser et al., 2012). it is important to distinguish between active and passive screen time as it will assist in understanding the specific effects of screen time (i.e. either positive or negative). according to a review of research on physical activity, sedentary behaviour, nutrition, and overweight in children and adolescents (3–18 years old) from south africa conducted by the sports science institute of south africa (2018), children in rural areas spend 70% of the day sedentary, which is comparable to children attending preschools in lowand high-income urban areas spending approximately 73% of the preschool day sedentary (draper et al., 2019). children in lowand high-income urban areas, as well as rural areas in south africa exceeded the limit of two hours of screen time per day (with pre-schoolers having a limit of 1 h per day) and are exposed to over three hours daily, excluding that for schoolwork (draper et al., 2019). according to the studies in the united states (us), this may be because of parents in the rural and urban areas allowing their children to watch television as it acts as a ‘babysitter’ while the parents are at work or occupied. furthermore, screen time may be perceived to be educational and beneficial to their child’s brain development (ruangdaraganon et al., 2009). the review of the literature revealed both positive and negative effects of screen time on children’s development (ruangdaraganon et al., 2009). the link between screen time and speech and language development is not straightforward, and several factors need to be considered. these factors include the duration of screen time, the presence of a co-viewer, video characteristics, and additional factors that may affect language. this will be elaborated on further under discussion. the positive effects include educational value, expansion of vocabulary, exposing children to various experiences and cultural and linguistic diversity, and keeping them occupied in a safe manner (balton, uys, & alant, 2019; jordan, 2005; rideout & hamel, 2006). while these studies have reported positive effects, others have reported negative effects on speech, language, motor, cognitive and social development. children begin understanding information after the age of two and may have trouble transferring information learnt from a device’s screen (ponti et al., 2017). therefore, it is important for children to be stimulated and that they interact with family members and caregivers through face-to-face interactions to facilitate learning more efficiently. television with the purpose of educating children can allow for the learning of language, literacy, and cognitive development. adults should be cognizant of background television in the presence of children as studies have shown that an increase in background television can adversely affect a child’s language usage, executive functioning, quality of their play, language acquisition, attention, and cognition in children younger than 5 years of age. in addition, excessively watching television may also affect mathematic skills, language and reading at a young age (ponti et al., 2017). because of the increased exposure of screen time in children and the lack of research in this area, the current study aimed to gain a deeper understanding of the relationship between screen time (exposure) and the impact on language development (outcome) in children (population). thus, this study aimed to answer the following research question: what effects does screen time have on children’s language development? methodology a scoping review was conducted to explore the available literature, on the influence of screen time on language development (munn et al., 2018). the scoping review methodology allowed for the broad exploration of the topic and allowed the researchers to be more versatile when reporting on the diverse literature present (colquhoun et al., 2014). the research team followed the methods advised by levac, colquhoun and o’brien (2010) and involved two researchers. these two researchers decided on the study issue, the search terms, keywords, and the databases to be searched. the researchers followed arksey and o’malley’s (2005) five-phase approach, which included the following steps: (1) defining the research question, (2) locating relevant publications, (3) study selection, (4) charting the data, and (5) compiling, summarising, and publishing the results. according to peters et al. (2015), data extraction enables the researcher to create a logical and systematic summary of the literature that is related to the scoping review’s purpose, objectives, and research question. the researchers created a data extraction table to extract and retain pertinent information relating to the effects of screen usage on language development. it must be noted that this process was limited because of the university almanac and scheduling. the table contains information on the article number, the title of each research/source, author(s), year in which the source was published, the country, study’s aims and objectives, study design, participant description, sample size, and findings. data sources and eligibility criteria the initial search was carried out in july 2020 across the following electronic databases: google scholar, pubmed, ebsco, jstor, wiley online library, sciencedirect, sage journals, and springerlink. the eligibility criteria included studies published in english from 2000 onwards (until 2020), with an emphasis on language development and screen time. because of a lack of translation resources, only english-language publications were included. inclusion criteria also included full-text publications and sources. the titles and abstracts of the articles were obtained from the above databases and a search was conducted on these databases using the following keywords and combinations: (child or children) and (‘screen time’ or ‘digital devices’ or ‘media use’ or television or technology) and ‘language development’ and ‘speech development’. search strategy the researchers analysed the titles and abstracts of the articles obtained from the databases and thereafter conducted a search on these databases using the following keywords and combinations: ‘child/children, screen time’ or ‘digital devices’ or ‘media use’ or television or technology and; language development. the articles were required to present research on children’s exposure to screen time, television, and media, with one of the study’s objectives or components addressing the influence of screen time on language development. finally, publications were to report on research completed globally between 2000 and 2020, to ensure that the literature was current, as concerns about screen time are new and growing as technology advances (hawi & rupert, 2015). two reviewers blindly retrieved specific information from the studies to ensure their reliability. according to joanna briggs institute (jbi) arksey and o’malley (2005), the first level review looked at titles, the second at abstracts, and the third at full-text articles (refer to figure 1). entries that did not match the study’s minimum inclusion requirements were omitted. an abstract relevance screening spreadsheet with high level reviewer agreement (overall kappa) more than 0.8 was employed by the researchers (viera & garrett, 2005). source selection was done blindly to improve inter-rater consistency. two reviewers searched relevant databases for sources and evaluated them against the inclusion/exclusion criteria. when a disagreement emerged, the third reviewer was consulted for conflict resolution to make a final decision. the reviewers screened the sources’ reference lists prior to examining the titles and abstracts for inclusion and removal. figure 1: preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews flow diagram of article search results. the internet browser (google chrome was recommended) was to be opened on a personal computer (pc) and the name of the database (google scholar, pubmed, ebsco, jstor, wiley online library, sciencedirect, sage journals or springerlink) to be entered. the ‘advanced’ search option was selected and the reviewer typed the following key terms: (child or children) and (‘screen time’ or ‘digital devices’ or ‘media use’ or television or technology) and ‘language development’ and ‘speech development’. thereafter under filters, the years between 2000 and 2020 were selected under the publication date, with english and ‘peer-reviewed’ being selected before clicking search. the screening protocols were then utilised when going through the search results. data charting and analysis thematic analysis was used since it is the most powerful and effective method of qualitative data analysis because it captures the complex meanings contained within texts (guest et al. 2011). clarke and braun’s (2013) six-phase theme analysis plan was employed in this investigation. ethical considerations this article followed all ethical standards for research without direct contact with human or animal subjects. results search results figure 1 depicts the prisma-scr flow diagram showing the data collected by searching through the various databases. a total of 930 articles were identified in the initial searches. after removing the duplicate studies, the total number of studies to be screened was 546. following the title and abstract screening, 385 and 136 articles were excluded, respectively, as they did not meet the inclusion criteria and the screening criteria. therefore, 25 full-text articles were screened with 13 of these articles being excluded as certain articles were grey literature, which falls part of the exclusion criteria, and because of the articles containing minimal information relating to language development. the remaining 12 articles included in the review for analysis are summarised in the data extraction table (figure 1) and table 1. the researchers analysed the data gathered from the literature and identified themes. the reviewers utilised mendeley data for data management and to arrange the various sources obtained. table 1: summary of the location and study designs of the included studies. characteristics of the included sources majority of the sources aimed at evaluating the relationship between language and screen time. two sources examined the language used by children when communicating through technology and evaluated television and young children in relation to the american academy of paediatrics (aap) guidelines that state that children below 2 years of age should not be exposed to screen time. these two sources differed from the other sources, that is, screen time was not accounted for. a summary of the study locations and study designs utilised in the included studies is provided in table 1. majority of the sources reported on television as the type of screen media; one source reported on videos and another source reported on television and videos. it can be inferred that screen time not only involves television but also computers, smart phones, videos, dvds, etc. discussion recently a rise in screen time has occurred. parents use screen time when concerned about their infant’s development, when parental interaction is reduced (blankson et al., 2015; byeon & hong, 2015; perdana, medise, & purwaningsih, 2017), and to provide opportunities for learning and to improve cognition (hinkley & mccann, 2018). in the current scoping review, two themes and six sub-themes were generated (see figure 2). figure 2: diagram of themes and sub-themes identified. many factors exist that may affect the link between screen time and language development, which include the quantity of home communication provided, genetics (zengin-akkus, celen-yoldas, kurtipek, & ozmert, 2018), parent-child interaction (blankson, o’brien, leerkes, calkins, & marcovitch, 2015; byeon & hong, 2015; linebarger & vaala, 2010), and male gender (okuma & tanimura, 2009). duch et al. (2013) reported that children who have a television in their room spend more time watching television compared to their counterparts. this is important as the amount of time spent exposed to screen time may influence language development. the study by perdana et al. (2017) concurred with the study by duch et al. (2013) and zengin-akkus et al. (2018) which stated that no relationship exists between a child’s sex, the existence of a television in children’s bedrooms, and delayed language development. furthermore, child characteristics (existing vocabulary, age, etc.) and environmental contexts (interacting with the same content repeatedly and for a long period of time, adult co-viewing and the quantity and quality of adult–child interactions) can also influence language (linebarger & vaala, 2010). videos may refer to youtube videos, videos on various screens, etc. several studies show that stimulus characteristics can also influence language development. it is advisable to consider video characteristics when deciding on a programme for children. videos that are rapidly paced with fewer close-ups, flashing/changing images, reduced language, and increased frame rate can cause language delays. rapidly paced videos may be cognitively burdening for children (duch et al., 2013; linebarger & vaala, 2010). linebarger and vaala (2010) stated that programmes like blue’s clues and dora the explorer have a positive effect on vocabulary, while teletubbies have a negative effect on expressive language because of the video characteristics present. finance and neighbourhood safety influence the duration of screen time which children are exposed to. a study conducted in soweto, south africa, and the us reported that children viewed a larger amount of television if the neighbourhood was perceived to be more dangerous as opposed to a safer neighbourhood, as children were safer indoors compared to playing outdoors where it could be unsafe (balton et al., 2019). according to perdana et al. (2017), as children grow older, the duration of screen time increases. this implies that a direct relationship exists between the duration of screen time and age. the duration of screen time is also dependent on cultural and socio-economic factors, and may be affected and influenced by the habits of family members and parents of the child. several articles report a link between the duration of screen time and receptive and expressive language delays (byeon & hong, 2015; duch et al., 2013, perdana et al., 2017). this shows that increased exposure to screen time in children is not recommended. according to hudon, fennell and hoftyzer (2013), the quality of the programme may affect language development more than the duration of time spent watching the programme. background television refers to content, which may not be understandable, resulting in poorer cognition as little to no attention is paid to it, and parent-child interaction is reduced which is important for cognitive development (anderson & subrahmanyam, 2017; pempek, kirkorian, & anderson, 2014). as previously mentioned, excessive background television may have adverse effects on children. it is distractive, disrupts playtime and results in slower language development and lower vocabulary scores as parent-child interaction is reduced. screen time may occur when supervised by an adult (adult-directed) or by the child independently (child-directed). adults are expected to ensure that their children have access to linguistically and age-appropriate content (watt, 2010). watching two or more hours of child-directed tv a day showed 6.25 times greater vulnerability to lower communication scores as compared to the same amount of adult-directed tv (duch et al., 2013). this implies that child-directed viewing may negatively impact a child making adult-directed viewing the preferred option. co-viewing encourages language acquisition. screen time can help promote learning, but not as much as what can be learnt through social interactions (strouse, troseth, o’doherty, & saylor, 2018). the value of a competent adult, such as parents, caregivers, or siblings, providing stimulation by means of posing questions and interacting with the child during screen media is highlighted as this will promote vocabulary, vocalisations, and comprehension. often televisions and screen media are used as ‘babysitters’ to distract children when parents are busy or when they are not present (nikken, 2019). this implies that a competent adult may not always be present and that viewing may be child-directed. this may influence children’s language development. according to kemp (2021), 98.2% of people in south africa have a mobile phone, 98% have a smart phone, 85.4% have a laptop/computer, 43.2% have a tablet, 16.7% have a streaming television or device, and 18.8% have a smart watch. these statistics are important as it assists in understanding the percentage of individuals who own the above devices. language develops early through interaction with parents and caregivers who provide the child with the means to learn the forms and features of the language (blankson et al., 2015; byeon & hong, 2015). in south africa, many people use english as a second language. research on the impact of media which differs from the child’s first languages indicates that children may be negatively impacted and places the child 14.7 times more at risk of a language delay. this is because of the difference in language and grammatical order of the language which may be confusing for the child and reduces the amount of guidance provided by the parents during co-viewing (perdana et al., 2017). the age of exposure to screen time may result in language delay. according to the apa, children below the age of two should not be watching television (perdana et al., 2017). this is because children should comprehend the concept of dual representation which begins to develop around the age of two and is not fully developed until after the child is 2 years old (linebarger & vaala, 2010). screen time has positive effects on a child’s cognitive abilities, higher-order language, and literacy skills (blankson et al., 2015; watt, 2010). screen time may increase vocabulary and language production skills in two-and-a-half-year-old children (linebarger & vaala, 2010). several experiments show that sufficient repetitive exposure to a programme improves a child’s problem-solving abilities, ability to imitate and the ability to learn new words (linebarger & vaala, 2010). repeated exposure allows for processing difficulties to be overcome and facilitates learning of vocabulary and content (linebarger & vaala, 2010). however, children below 22 months old were not able to learn novel words with repeated exposure to a child-directed television programme, but were able to learn similar new words within their natural environment (krcmar, 2014). increased exposure to stimuli that is absorbed but not developmentally constructive may influence brain development and language acquisition (watt, 2010). ‘heavy’ use may negatively impact attention that may affect the child’s literacy with these adverse effects outweighing the advantages to cognition and literacy (watt, 2010). screen time can negatively affect language acquisition, early language development (byeon & hong, 2015) and play (lin, cherng, chen, chen, & yang, 2015). the first 3 years of a child’s development are important for brain development, which is affected by environmental influences (watt, 2010). literacy is also affected as spell-check gadgets reduce spelling abilities with technological communication facilitating spelling errors to go unnoticed (watt, 2010). it is the role of speech-language therapists (slts) to identify, assess and manage individuals presenting with speech and language difficulties (kathard et al., 2011). potential study implications this study may contribute to limited research as the impact of screen time on children’s language development has not been sufficiently researched, and the sources included in the analysis were not within the south african context. current guidelines relating to screen time are set by the world health organization (who) and apa, and correlate with that from canada, australia, and south africa. it states that children below 2 years of age should not be exposed to screen time, children between the ages of 2 and 4 years should not exceed one hour daily, and 2 h per day should not be exceeded in 5to 17-year-olds. this scoping review may contribute to guidelines relating to language development of children exposed to screen time and will inform future research exploring the relationship between screen time and language development. future studies could include specific socio-economic factors and a range of languages and cultures. an assessment could also be conducted with children to assess the impact of screen time on their language development considering parents’ perceptions. this scoping review may have clinical implications and has the potential to guide speech-language therapy. it could also provide insight relating to guidance and recommendations for parents. speech language therapists should provide parents with strategies and skills to promote language stimulation and the importance of co-viewing (canadian 24–hour movement guidelines, 2020; the conversation, 2019; who, 2019). as schools move away from paper-based activities (shonfeld & meishar-tal, 2017), this study could inform education policies with regards to the increased duration of time spent with screen time which may have adverse effects on language development. conclusion this review has provided valuable information on the influence of screen time on language development. the review revealed that the influence of screen time is multifactorial and includes both positive and negative influences on children’s language development. majority of the studies analysed indicate that an increase in the amount of screen time and the early age of onset of viewing has negative effects on language development, especially for the children under the age of two with older age of onset of viewing showing some benefits. in addition, video characteristics, content and co-viewing also influence language development. parents play a critical role in language development. although, there are both positive and negative effects. it appears that the negative influences outweigh the positive influences, and the researchers invite further enquiry into this area. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions n.k. conceptualised and designed the topic, conducted the scoping review, and authored the initial draft. j.s. and subsequently m.m. supervised this research project and contributed throughout, providing crucial input on analysis, interpretation, revisions, and editing issues. all authors have given final approval to the published version of the manuscript. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy of any affiliated agency of the authors. references anderson, d.r., & subrahmanyam, k. 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(2018). speech delay in toddlers: are they only ‘late talkers?’. the turkish journal of pediatrics, 60(2), 165–172. https://doi.org/10.24953/turkjped.2018.02.008 abstract introduction method ethical consideration results discussion limitations conclusion acknowledgements references about the author(s) juan bornman centre for augmentative and alternative communication, university of pretoria, south africa maryann romski department of communication, college of arts and sciences, georgia state university, united states kerstin tonsing centre for augmentative and alternative communication, university of pretoria, south africa rose sevcik department of psychology, college of arts and sciences, georgia state university, united states robyn white centre for augmentative and alternative communication, university of pretoria, south africa andrea barton-hulsey research in neurodevelopmental disabilities lab, georgia state university, united states refilwe morwane centre for augmentative and alternative communication, university of pretoria, south africa citation bornman, j., romski, m., tonsing, k., sevcik, r., white, r., barton-hulsey, a. et al. (2018). adapting and translating the mullen scales of early learning for the south african context. south african journal of communication disorders 65(1), a571. https://doi.org/10.4102/sajcd.v65i1.571 original research adapting and translating the mullen scales of early learning for the south african context juan bornman, maryann romski, kerstin tonsing, rose sevcik, robyn white, andrea barton-hulsey, refilwe morwane received: 10 july 2017; accepted: 16 oct. 2017; published: 08 mar. 2018 copyright: © 2018. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: south african speech-language therapists have identified the need for culturally valid and sensitive assessment tools that can accommodate multiple languages and cover a reasonable age range. the mullen scales of early learning (msel) extend from birth to 68 months, contain five separate subscales including receptive language, expressive language, gross motor, fine motor and visual reception scale, are straightforward to administer and have been successfully used in other african countries, such as uganda. it also identifies a child’s strengths and weaknesses and provides a solid foundation for intervention planning. objectives: this research aimed to demonstrate the appropriateness and usefulness of the translated and culturally and linguistically adapted msel across four south african languages (afrikaans, isizulu, setswana and south african english) through two sub-aims: (1) to describe differences, if any, in msel performance across language groups and (2) to describe differences, if any, in msel performance between age groups. method: a total of 198 typically developing children between the ages of 21 and 68 months spread across the four language groups were individually assessed with the culturally and linguistically adapted and translated msel. results: a one-way analysis of variance (anova) showed no statistically significant differences between the four language groups for total msel scores. a welch’s one-way anova showed that the total msel scores were significantly different between age groups. conclusion: the translation and adaptation of the msel was successful and did not advantage or disadvantage children based on their home language, implying that linguistic equivalence was achieved. the msel results differed between age groups, suggesting that the measure was also successful in differentiating the performance of children at different developmental levels. introduction finding reliable and valid ways to assess and profile developmental skills in children is an essential step in ultimately developing and providing effective and meaningful interventions. measuring the effectiveness of intervention, comparing different intervention approaches and/or intensities and being able to predict the effect of additional risk and opportunity factors on children’s development all require reliable and valid assessment tools and methods (kammerer, isquith & lundy, 2003). speech-language therapists in south africa have identified the need to develop culturally valid and sensitive assessment tools for this context (barrat, khoza-shangase & msimang, 2012; kathard et al., 2011; pascoe & norman, 2011). attempts to address this need have included the translation, adaptation and renorming of existing test material (bornman, sevcik, romski & pae, 2010; gonasillan, bornman & harty, 2013; also see mphahlele, 2006, for a summary) or the development of new assessment materials (bortz, 1992, 1997; rangaka, 1999; also see mphahlele, 2006, for a summary). the development of new assessment material may, in some ways, be superior to the translation of existing material, as such materials are typically based on locally developed norms and procedures (pascoe & norman, 2011). in south africa, attempts have been made to collect normative data through language samples and observations around certain aspects of child language development within diverse cultural and linguistic groups. for example, bortz (1992) collected data on the language abilities of 18-month-old isizulu-speaking children, while mtshazo (1988) did the same for 3-, 4and 5-year-old isizulu speakers. kvalsig, liddell, reddy, qotyana and shabalala (1991) studied the communication and teaching situations occurring in the homes of isizuluand sesotho-speaking preschoolers, while ligthelm (2001) studied the interaction patterns between black south african caregivers and their children. suzman (1990) collected longitudinal naturalistic language samples from isizulu-speaking children between the ages of 1 year 10 months and 3 years 5 months and described the children’s grammatical development. various studies have also been conducted to collect data on the language development of afrikaans-speaking children (e.g. vorster, 1983). these have resulted in the afrikaans version of the language assessment, remediation and screening procedure (larsp) (penn & jordaan, 2016). language tests have also been developed and normed for some of the other south african languages (see mphahlele, 2006, for a summary), with more development in afrikaans than in any other language. the only language assessment instruments known to the authors that were developed to cover various south african languages are the south african language assessments (sala; bortz, 1997). bortz originally devised this test in isizulu (zulu expressive receptive language assessment; bortz, 1992, based on knowledge of isizulu grammar and language samples from young children. the test was normed on 303 isizulu-speaking children aged 3 years 9 months to 4 years 2 months. this test was then translated into setswana, sesotho, tshivenda and shangaan, although it was not normed for these languages. while longitudinal large-sample studies to gather developmental data from typically developing children in specific contexts and from specific cultural and language groups would certainly be desirable as a credible foundation for developmental assessments, funding, time, access, human resource and other limitations hardly permit such studies to be executed in lowand middle-income countries (kammerer et al., 2013). test translation and adaptation can be an alternative, provided that a rigorous process is followed to adequately address linguistic and cultural factors (bornman et al., 2010; peña, 2007). this method, whereby an existing test is translated and then normed on a population from a different language background, has often been used in response to the lack of assessment material in south african languages. for example, the peabody picture vocabulary test (ppvt) was translated, adapted and re-normed for northern sotho-speaking children (pakendorf, 1996); the reynell language development scales iii for afrikaans-speaking toddlers (oosthuizen, 1999) and portions of the mullen scales for early learning (msel) (van rooyen, 2004; visser, 2004) and the ages and stages questionnaire (louw, 2004) for afrikaans-speaking children. however, the complexity involved in test translation in terms of the test equivalence between the different languages is indeed challenging (haupt & alant, 2002; pakendorf & alant, 1997). pakendorf (1996) evaluated and published guidelines to be considered in translating and adapting language assessment materials for the south african context. based on this procedure, various translations and renorming of language tests have produced some normed assessments. however, while a number of different tests have been translated into south african languages, there has not been a test that has been consistently translated across all languages (mphahlele, 2006). the msel (mullen, 1995) are individually administered, norm-referenced measures. they have been used to assess the development in young children in other countries in africa. for example, the msel have been employed effectively to evaluate the effects of interventions to improve cognition in ugandan children exposed to human immunodeficiency virus (hiv) (boivin et al., 2013; lorencz & boivin, 2013). bodeau-livinec, cot, koura and boivin (2013) also employed the msel to assess the cognitive skills of children in uganda for a study of maternal anaemia and its effect on child development. these authors concluded that the scales showed promise as a valid assessment measure, covered a reasonable age range (birth to 68 months) and were straightforward to administer. they can be completed by clinicians (speech-language pathologists, occupational therapists and physiotherapists) and teachers and, on average, take 15 min to complete for 12-month-old children, 25–35 min for 36-month-old children and 40–60 min for 60-month-old children (mullen, 1995). this instrument contains separate scales for receptive and expressive language, as well as three other scales (gross motor, fine motor and visual reception). t-scores (a commonly used standardised test statistic with mean of 50 and a standard deviation of 10) can be obtained for individual scales, and an optional early learning composite serves to provide an overall estimate of cognitive functioning. the msel, therefore, allow the examiner to obtain a general developmental profile of a child as well as information on receptive and expressive language skills, gross and fine motor skills, and visual reception skills. no standardised tools have yet been designed to assess infant development in the population of south african children, although attempts have been made to determine whether the bayley scales of infant development iii could be used on black african urban infants in south africa (rademeyer & jacklin, 2013). the focus of this article, however, is on the msel as a broad developmental measure and specifically its applicability as a language measure. in view of the significant need for the development of culturally valid and reliable communication assessment tools that can accommodate multiple languages and that cover a reasonable age range, translation and cultural adaptation of the msel (mullen, 1995) was undertaken for four south african languages. the aim of this study was therefore to translate and adapt the msel (mullen, 1995) across four south african languages, namely, afrikaans, isizulu, setswana and south african english, and pilot test it in a south african context. two subaims were formulated to address this aim: (1) to compare performance across language groups and (2) to compare performance across age groups. method participants participants were recruited from 20 early learning centres in low-income urban and semi-urban areas of gauteng. these centres were selected on the basis of using either afrikaans, isizulu, setswana or english as the language of teaching and learning. in gauteng, these four languages are among those spoken most frequently as a first language, with 13.3% of the population speaking english, 12.4% speaking afrikaans, 10.8% speaking isizulu and 9.9% speaking setswana. they also rank within the top six most frequently spoken first languages nationally, with isizulu being spoken by 22.7% of the total population, afrikaans by 13.5%, english by 9.6% and setswana by 8% (statistics south africa, 2012). other languages in the top six include isixhosa (16%) and sepedi (9.1%). the fact that the four languages targeted in the study represent the first language of only slightly more than 50% of the population reflects the extent of south africa’s multilingual reality. these early learning centres differed in size, but all provided a basic play-based child development curriculum. permission was obtained from the director of african self help trust (asha) pre-school association in south africa who provided us with the relevant schools we could conduct the research. a total of 205 children with typical development (as determined by teacher report) ranging in age from 21 to 68 months (mean = 45.9 months) were recruited for this study. although the msel can be used with children from birth, 21 months was selected as the entry point as many children start attending early learning centres at this age. we recruited children whose home language was the same as the language used for teaching and learning in the early learning centre they attended. this resulted in 57 children in the afrikaans group, 54 in the isizulu group, 52 in the setswana group and 42 in the english group. attempts were made to increase the sample size of the english-speaking group, but we were unsuccessful in recruiting more children who spoke english at home and who attended an early learning centre in the catchment area of the research. children also had no known visual or hearing problems and no report of developmental delay in any area as reported by either the parent or the teacher. of these 205 children, seven children (3%) did not complete the assessment because of a number of reasons, including not being interested or cooperative or requesting to stop, resulting in a total of 198 children (97%) completing the assessment. a 1:1.1 (male:female) ratio was recorded with 24:29 (boys:girls) in the afrikaans group, 29:23 in the isizulu group, 26:25 in the setswana group and 17:25 in the english group, respectively. table 1 provides the numbers and mean ages in each group. at least five children per age band per language were included. table 1: participant age groups across languages. material mullen scales of early learning the msel provide an overall measure of cognitive ability for children from birth to 68 months of age through four subscales (fine motor, visual reception, receptive and expressive language) and an optional fifth gross motor scale that only measures skills to 36 months (mullen, 1995). the inclusion of receptive and expressive language subscales means that a specific indication of children’s language abilities can also be obtained. the first four scales are referred to as the cognitive scales from which an early learning composite score can be derived. these were the only scales that were interpreted in this study. the msel were selected for use in this study, as bornman et al. (2010) had already conducted a pilot study to adapt these scales for the south african context with 47 typically developing children (aged 36 months [n = 13], 42 months [n = 8]; 48 months [n = 8], 52 months [n = 8], 60 months [n = 10] from afrikaans-speaking backgrounds (bornman et al., 2010). the msel are performance-based assessments, and the 124 items are unique to the specific subscale. each scale is comprised of interactive tasks that can be completed by the child. for example, the gross motor scale includes standing, walking and running; the visual reception scale includes matching, sorting and nesting cups; the fine motor scale includes stacking blocks, drawing and stringing beads; the receptive language scale includes recognising body parts and following commands; and the expressive language scale includes answering questions and completing analogies. the response format depends on the item type, and items had been carefully developed to pose a challenge only in the modality being assessed (e.g. the receptive language scale does not require verbal expression) (mullen, 1995). the item scoring also varies according to the specific item. the msel include many items where 1 indicates a correct response and 0 indicates an incorrect response. other items include 1, 2, 3, 4 or 5 possible score points, and on some items the task scores must be summed to obtain the item score (mullen, 1995). the scale items are presented in hierarchical order of difficulty, and scale administration is discontinued after three consecutive wrong responses (ceiling level is reached). a basal level is established if the child scores at least one point on three consecutive items. the maximum achievable raw score per scale is 50 for the visual reception scale, 49 for the fine motor scale, 48 for the receptive language scale and 50 for the expressive language scale. however, it should be noted that younger children are not expected to achieve maximum scores on the scales in order for their skills to be considered age appropriate, as this is a developmental measure. we translated all five of the msel (mullen, 1995) subscales culturally and linguistically into four languages frequently spoken as the home language in the northern region of south africa: afrikaans, isizulu (from the nguni language group), setswana (from the sotho language group) and south african english (e.g. using ‘nappy’ as opposed to ‘diaper’) using a rigorous translation procedure. to ensure that we translated the assessment both culturally and linguistically into each language, we employed the guidelines recommended by peña (2007). we used a process of forward translation, blind-back translation and subsequent review panel to translate all scales with instructions (bornman et al., 2010; peña 2007). two bilingual translators for each language group translated the msel from english (source language) into the target language. two other bilingual translators then translated the target language back into the source language. a six-person review committee (four translators and two of the authors) compared the two english versions. this strategy was repeated for each of the four languages. all of the translators were therapists (speech-language, occupational or physiotherapists) or formally qualified teachers employed at a tertiary institution with at least 10 years’ of experience in working with children. discrepancies were discussed, resolved and incorporated into the assessment measure by consensus. equivalence across all four languages was also ensured by comparing the four different source language translations (e.g. as the word ‘purple’ did not exist in either isizulu or setswana, it was replaced by the word ‘pink’ in all four languages). the review committee ensured that cultural adaptations (e.g. inches to centimetres and dollars to rands) were incorporated into the assessments in each language. changes were also made to reflect the use of appropriate objects and materials for the context (e.g. using south african coins). two teachers and two speech-language therapists served as an expert panel and reviewed the adapted scales to ensure functional equivalence. minor changes were suggested and incorporated into the final versions of the adaptation. data collection the msel were administered by either formally qualified teachers or therapists (speech-language therapists and occupational therapists) registered, respectively, with the south african council for educators (sace) or health professions council of south africa (hpcsa), who underwent the collaborative institutional training initiative (citi) training on ethical issues relating to human participant research. the 12 different examiners were all employed at a tertiary institution, had a minimum of 7 years’ experience in assessing children and were all trained in the scoring of the msel. children were assessed individually according to the guidelines in the item administration book of the msel (mullen, 1995). the measure was administered in the child’s home language following its standardised format by an examiner who was a fluent speaker of the target language and who was suitably trained to complete the assessment. during the assessment, the child and the examiner sat at a child-size table in a quiet room at the centre and while one examiner presented the items to the child, the second examiner who was also trained in the msel completed the score sheet based on the child’s responses. after the assessment was complete, the two examiners reviewed and clarified the scoring and resolved any potential differences to obtain one consensus score. scores for each item (and, where appropriate, scores for individual tasks making up an item) and summed raw scores for each scale were transferred onto excel spreadsheets. in order to check the reliability of the data captured onto the excel spreadsheets, an independent reviewer checked all entries against the original score sheets. overall raw score total per scale was also recalculated using the sum function in excel and compared with the raw scores summed manually on the score sheets. any disagreements between the score sheet and excel spreadsheet were noted. the percentage agreement was calculated by dividing all agreements by the sum of agreements and disagreements. percentage agreement amounted to 98.2%, indicating that data were captured reliably. all incorrectly captured scores were corrected. the complete assessment of each participant was videotaped to ensure procedural integrity and for further analysis if needed. administration took between 25 and 60 min, depending on the age of the child. data analysis to address the first sub-aim, namely to determine if there were significant differences in msel performance between language groups, total msel raw scores and total raw scores on each subtest of the msel were used in separate one-way analysis of variance (anova). when examining total msel raw score between language groups, there were no outliers as assessed by boxplots, and data were normally distributed for each language group as assessed by q-q plots. there was homogeneity of variances as assessed by levene’s test of homogeneity of variances (p = 0.390). when examining each subtest of the msel (visual reception, fine motor, receptive language and expressive language), there were no outliers for the visual reception, fine motor, receptive language and expressive language subscales as assessed by boxplots, and data were normally distributed for each group as assessed by q-q plots. there was homogeneity of variances as assessed by levene’s test of homogeneity of variances for the fine motor, receptive language and expressive language subtests, respectively (p = 0.634, p = 0.135, p = 0.333). there was not homogeneity of variances as assessed by levene’s test of homogeneity of variances for the visual reception subtest (p = 0.041); hence, the one-way anova for the visual reception subtest was corrected using welch’s f. welch’s f adjusts f and the residual degrees of freedom to combat problems arising from violations of the homogeneity of variance assumption (field, 2009). to address the second sub-aim, namely, to determine if total msel raw score performance and performance on each of the four subscales differed significantly between children from each of the eight age groups (21–26; 27–32; 33–38; 39–44; 45–50; 51–56; 57–62 and 63–68 months), total msel raw scores and total raw scores on each subtest of the msel were used in separate one-way anovas, each corrected using welch’s f. welch’s f was again used to correct for heterogeneity in variances as assessed by levene’s test for total msel score between age groups (p = 0.0005), and all subtests of the msel (visual reception, p = 0.0005; fine motor, p = 0.051; receptive language, p = 0.003 and expressive language, p = 0.001). boxplots assessed for total msel score revealed five outliers (two in the 27–32 months age group and one each in the 33–38, 57–62 and 63–68 months age group). there were six outliers found for the visual reception subscale (four in the 27–32 months age group and one each in the 45–50 and 57–62 months age groups), 11 outliers for the fine motor subscale (one each in the 27–32, 33–38 and 45–50 months age groups and two each in the 51–56, and 63–68 months age groups, and four in the 57 – 62 age group), one for the receptive language subscale in the 63–68 months age group, and seven outliers in the expressive language subscale (two each at 27–32 and 63–68 months, and one each at 39–44, 51–56 and 57–62 months). games-howell post hoc analyses were used to compare performance between age groups in all anovas and are robust to interpreting differences between groups of unequal variance and sample size. ethical consideration ethics approval was obtained from the institutional review board (irb) at georgia state university and the research and ethics committee at the faculty of humanities at the university of pretoria, south africa. informed consent was obtained from both principals and teachers at the early learning centres. information letters were sent to parents to inform them of the details of the study and request their consent for their child to participate in the study. informed consent was obtained from each parent before an individual child participated. in addition, children were asked to provide assent themselves. results the results are discussed according to the two sub-aims. differences between the four language groups table 2 reports mean total msel raw scores, standard deviations, confidence intervals and the range of scores for each language group. there were no significant differences in total msel scores between the four language groups included in this study [f (3, 194) = 1.202, p = 0.310]. table 2: mean total mullen scales of early learning raw scores, standard deviations, confidence intervals and the range of scores for each language group. in addition, there were no significant differences in performance between language groups on the four individual msel subscales (visual reception, fine motor, receptive language and expressive language). results of each one-way anova for each msel subscale are reported in table 3. table 3: one-way analysis of variance results for each mullen scales of early learning subtest by language group. differences between the age groups table 4 reports mean total msel raw scores, standard deviations, confidence intervals and the range of scores for each age group on the msel. mean msel total scores increased in order from low to high between each of the eight age groups. total msel scores were significantly different between age groups [f (7, 79.302) = 229.129, p < 0.0005]. post hoc analysis revealed that the mean difference in msel total score was statistically significant between each age group except for the difference between the upper age ranges of 51–56 months, 57–62 months and 63–68 months (p = 0.857, p = 0.109 and p = 0.467, respectively). table 4: mean total mullen scales of early learning raw scores, standard deviations, confidence intervals and the range of scores for each age group. tables 5–8 present the mean visual reception, fine motor, receptive language and expressive language raw scores, standard deviations, confidence intervals and the range of scores for each age group, respectively. one-way anovas performed for each msel subscale revealed significant differences between age groups and are reported in table 9. table 5: visual reception mullen scales of early learning raw scores, standard deviations, confidence intervals and the range of scores for each age group. table 6: fine motor mullen scales of early learning raw scores, standard deviations, confidence intervals and the range of scores for each age group. table 7: receptive language mullen scales of early learning raw scores, standard deviations, confidence intervals and the range of scores for each age group. table 8: expressive language mullen scales of early learning raw scores, standard deviations, confidence intervals and the range of scores for each age group. table 9: one-way analysis of variance results for each mullen scales of early learning subtest by age group. tables 5–8 highlight results from each post hoc analysis for mean differences found between age groups by each msel subscale. mean differences in msel visual reception scores for each age group were significantly different from the mean of the previous age group, with the exception of scores at 39–44 months, 51–56 months, 57–62 months and 63–68 months (p = 0.260, p = 0.113, p = 0.998 and p = 0.078, respectively). mean differences in msel fine motor scores for each age group were significantly different from the mean of the previous age group, with the exception of scores at 51–56 months, 57–62 months and 63–68 months (p = 0.973, p = 0.215 and p = 0.940, respectively). mean differences in msel receptive language scores for each age group were significantly different from the mean of the previous age group, with the exception of scores at 39–44 months, 51–56 months and 63–68 months (p = 0.139, p = 0.949 and p = 0.998, respectively). mean differences in msel expressive language scores for each age group were significantly different from the mean of the previous age group, with the exception of scores at 27–32 months, 39–44 months, 51–56 months, 57–62 months and 63–68 months (p = 0.381, p = 0.193, p = 1.000, p = 0.144 and p = 0.960, respectively). discussion the results obtained from the translated and adapted msel did not differ between language groups. this suggests that the translation and adaptation was successful as it did not advantage or disadvantage any group of children based on home language, implying that linguistic equivalence had indeed been achieved (peña, 2007). the total msel results differed between age groups, showing that the measure can distinguish the performance of children of different ages, as is expected from a developmental measure. this would also strengthen the confidence in the ability of the translated msel to measure changes in a child’s skill profile preand post-intervention over and above those that are developmentally expected. the measure is less sensitive in detecting differences between children in the upper age ranges. the expressive language subscale is also variable in its age sensitivity. overall, the translated msel show promise as a developmental assessment tool that can be used with children aged 21–68 months from four south african language backgrounds. a uniform measure across different language groups is helpful for researchers and clinicians alike, as it can assist in ensuring equitable service delivery and equitable inclusion in research projects aimed at service development across different populations. formal assessment tools such as the msel should never be used in isolation. however, combined with a thorough and culturally sensitive understanding of a child’s medical and developmental history, caregiver concerns and observational methods of assessment (andersson, 2004), the msel can nevertheless assist in guiding clinical decisions-making (including service eligibility and discharge decisions) and monitoring progress. research projects that concern the measurement of the effectiveness of intervention, the comparison of different intervention approaches and/or intensities and the prediction of the effect of additional risk and opportunity factors on children’s development likewise require reliable and valid assessment tools and methods (kammerer et al., 2003), and the translated msel, in combination with other assessment methods, show promise in this regard. the translated msel can be used as a ‘first draft’, which, through additional processes of expert review, piloting, item review, tests–retest and statistical procedures such as item goodness of fit through logistic regression (gladstone et al., 2008) can be refined to be a reliable and valid assessment tool with suitable norms for children from various south african language backgrounds. limitations there were some limitations in this study. firstly, teachers at early learning centres were requested to identify potential participants with typical development. this could have influenced the recruitment process as formal training of teachers at early learning centres has only recently been addressed in policy with the adoption of the national integrated early childhood development policy (south africa, 2015). secondly, the sample size per age and language group was small and homogeneous in terms of ses and recruitment area; therefore, results obtained are unsuitable for attempting to obtain formal measures of validity and reliability, and also to obtain norms. for example, while mean scores increased between each of the eight age groups across subtests, there was a smaller mean increase in performance between children at older ages, particularly above 51 months of age. the limited change in raw score performance beyond 51 months of age suggests that there may be less sensitivity of the msel when used with children between 51 months and 68 months of age. a larger sample size at each age range would permit specific claims about the sensitivity of the msel at older ages to be made. lastly, no further background information (apart from age, home language and language exposure in school) was obtained about the participants. therefore, it is not possible to rule out the influence of these additional background factors on the findings. conclusion in conclusion, the translation and adaptation of the msel was successful and did not advantage or disadvantage children based on their home language, indicating that linguistic and cultural equivalence was achieved. the msel results differed between age groups, suggesting that the measure was also successful in differentiating the performance of children at different developmental levels. overall, these findings suggest that the msel have potential to be used as part of a language assessment battery with clinical populations including children with neurodevelopmental disorders (romski et al., 2018). acknowledgements funding for the study was provided by the national institutes of health’s fogarty international center through grant number tw-008999 to maryann romski. this research was supported by the united states national institutes of health’s fogarty international center (grant number tw-008999) to maryann romski. the content of the article is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. the authors thank all the children, caregivers, teachers and clinicians for participating in this study. competing interests the authors declare that they have no conflict of interest with regard to the writing of this article. authors’ contributions j.b. was the south african project leader. m.a.r. was the us project leader and grant holder. j.b., k.t, r.w and r.m. collected the data. r.s. and a.b.h. and k.t. analysed the data. all the authors prepared the manuscript. references andersson, l.l. 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(2004). die toepaslikheid van die afrikaanse vertaling van die ‘mullen scales of early learning’ vir afrikaans sprekende peuters tussen die ouderdom 36 en 49 maande [the appropriateness of the afrikaans translation of the ‘mullen scales of early learning’ for afrikaans-speaking toddlers between the ages of 36 and 49 months]. unpublished undergraduate research report, university of pretoria, pretoria, south africa. vorster, j. (1983). aspects of the acquisition of afrikaans syntax. unpublished doctoral dissertation, university of south africa, pretoria, south africa. the swallowing and voicing characteristics of pharyngeal dystonia: a single case study 21 the swallowing and voicing characteristics of pharyngeal dystonia: a single case report loren" kahn heila jordaan department of speech pathology ,and audiology university of the witwatersrand johannesburg south africa abstract this paper describes the swallowing difficulty and abnormal voicing characteristics of a subject with pharyngeal dystonia. this rare form of dystonia, considered to be a neurological condition resulting in involuntary spasm of the muscles of the pharynx, has not been documented in terms of its effects on the acoustic properties of the voice. this study revealed that during pharyngeal spasm, there are significant delays in voice onset time, a reduction in fundamental frequency, an increased percentage of sub-harmonics and variability in the amplitude perturbation quotient as well as shimmer. there was also evidence of these characteristics during periods of 'spasmjree' voice production, suggesting that the condition might be more consistent than what the subject described. resonance disturbances were observed in spasm, which might explain the 'hollow' and affected voice quality. the subject also reported severe swallowing difficulties during the periods of spasm, characterised by a tight constriction at the level of the subject's throat. it is clear that an abnormality at the level of the cricopharyngeal muscle has a dual effect on the acoustic properties of the voice and on swallowing. key words: pharyngeal dystonia; dysphagia; resonance; acoustic properties; voice onset time introduction // this study describes the abnormal swallowing and / voicing characteristics of a relatively rare condition known as pharyngeal dystonia. the purpose of this research is to contribute to the limited body of literature on this disorder and to r~ise awareness of the condition among medical and rehabilitation professionals. according to the; dystonia medical research foundation (1999), pharyngeal dystonia is a condition in which the muscles of the 'pharynx contract uncontrollably due to a neurological disruption at the level of the basal ganglia. this may be due to hereditary factors or as a result of trauma, toxins, drugs, neoplasms or infarction. this form of dystonia is one of many dystonias including: involuntary contractions of· the eye muscles (blepharospasm), abnormal contractions of the muscles of the head, neck and spine (spasmodic torticollis), muscular rigidity of the jaw, lips and tongue (oromandibular dystonia), muscular spasm of the vocal chords (spasmodic dysphonia) and disturbed fine motor hand functioning (writer's cramp). in mest patients, the cause of the dystonia cannot be identified. in the early stages of the disorder, dystonia can involve a single muscle group and later; progress to others (aronson, 1985). die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 no definitive tests exist in the diagnosis of dystonia (dystonia medical research foundation, 1999): instead, observations of the abnormal movements, which vary from person to person, are made. this underlines the importance of detailed descriptions of the symptoms of the condition; which enables accurate diagnosis. current trends in the treatment of dystonia include botulinum toxin a (botox) injections, drug therapy as well as several 'types of surgical procedures (moore, 1995). botox has become the method of choice in treating a variety of dystonias. this" substance works by temporarily paralysing the affected muscles and may, in some cases of dystonia, be indicated as the primary form of treatment (dystonia medical research foundation, 1999). only two reports of pharyngeal dystonia could be found in the literature (kostas karam, langhans, & vasquez, 1995; dunne, hayes, & cameron, 1993). neither of these studies, however, described disordered voicing as part of the symptomatology. in the most recent of these two studies, (kostas et ai., 1995), the researchers described patient's cricopharyngeal dysfunction as being an inadequate relaxation of the cricopharyngeal muscle which kept the larynx from lifting and moving forward. the researchers treated the swallowing disorder using localised injections of botulinum toxin a (botox) into r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the cricopharyngeus muscle. the patient's swallowing was reported to improve significantly following the botox injections (kostas et ai., 1995). prior to this study, the case of an 86 year old male with intermittent mild dysphagia was described, in whom striking recovery occurred in the pharyngeal phase of swallowing following the injection of botox into the cricopharyngeus muscle (dunne et ai., 1993). as is evident from these two accounts, pharyngeal dystonia is a potentially disabling condition that could be treated successfully if it is correctly identified and diagnosed. pharyngeal dystonia is likely to affect both swallowing and voice production because the pharynx comprises the upper end of the respiratory and digestive tract thereby assuming the dual purpose of transmitting air from the nasal cavity to the larynx and food from the oral cavity to the oesophagus the pharynx is a wide, muscular structure situated behind the nose and mouth and above and around the larynx and consists of striated (voluntary) muscle on the posterior and lateral walls, which enables rapid movements for swallowing and speech. the pharynx consists of the nasopharynx, oropharynx and the laryngopharynx. the unit functioning of the laryngeal and pharyngeal structures in swallowing and voice production is extremely important when considering a disorder such as pharyngeal dystonia. in cases where swallowing and voice are both affected, one needs to fully understand the anatomical and physiological relationships between the larynx and the pharynx. the larynx and the pharynx function as a unit, which means that they function jointly during swallowing and voice production. during the pharyngeal stage of the swallow, for example, the larynx and the hyoid bone are pulled both upward and forward. this movement enlarges the pharynx. it also creates a vacuum in the hypopharynx, pulling the bolus downward (dobie, 1978; logemann, 1983, 1989, 1997). during the laryngeal stage of the swallow, the epiglottis drops down over the top of the larynx, protecting the airway and diverting the bolus into the pyriform sinuses. the external and internal pharyngeal constrictor muscles play a fundamental part in swallowing (ekberg & nylander, 1981). the external muscles, namely the superior, middle and inferior constrictors, contract in a series of contractile movements from the top down, propelling the food downwards to the oesophagus. the inferior constrictor muscle consists of two parts, a propulsive part known as thyropharyngeus and a sphincteric part known as cricopharyngeus (groher, 1997). the cricopharyngeus muscle is located. in the laryngopharynx, and lies posterior to the cricothyroid cartilage of the larynx (crafts, 1966). an abnormality at .. the level of the cricopharyngeus would cause defective sphincteric operation at the lower level of the pharynx, which may lead to bolus retention in the pharynx (groher, 1997). the stnictures of the larynx are connected to each other and to adjacent structures via ligaments and muscles, within which a state of equilibrium appears to exist (vilkrnan, sonninen, hurme & korkko, 1996). the internal muscles of the pharynx (stylopharyngeus, loren kahn & heila j ordaan 22 salpingopharyngeus and palatopharyngeus) and the muscles in the floor of the mouth are involved in the elevation of the larynx during swallowing and speech (bhatnager & andy, 1994 p. 237). the suprahyoid muscles, i.e., the digastric, the mylohyoid, the geniohyoid, the hyoglossus and the genioglossus muscles as well as the infrahyoid muscles (thyrohyoid, sternothyroid, sternohyoid and omohyoid), have an indirect effect on the larynx which is to move it upward, forward and backward as well as downward in the case of the infrahyoids, (colton & casper, 1996). according to colton and casper (1996) the lowered laryngeal position results in lengthening of the vocal tract, which has an effect on vocal resonance. these authors also contend that a more direct effect on the voice may result from the restriction of thyroid cartilage movement that is caused by contraction of this muscle group (p. 320). thus affecting vocal pitch regulation through changes in vocal fold length, tension and mass. other indirect muscular forces include those produced by the palatal, oesophageal, and buchal musculature, of which the palatopharyngeal muscle also has a partial connection to the larynx (vilkrnan et ai., 1996). the connection between the larynx and the palatopharyngeus is significant as hyperfunction of the palatopharyngeus muscle is believed to create a 'cul-desac' resonance quality, i.e. a voice quality that is perceived as "hollow and affected." this type of resonance results from a substantial decrease in the dimensions of the oropharyngeal outlet, and is produced when the tongue is retracted into the back of the mouth, causing the origin of the resonance to be situated too posteriorly in the oral cavity (prater & swift, 1984). the speech production mechanism consists of an air supply, a sound source which sets the air in motion, and a set of resonators that modify the sound in various ways. the lungs supply the air. the sound source is the larynx, where the vocal cords are situated. the filters comprise the organs above the level of the larynx, namely the pharynx, the oral cavity and the nasal cavity. together, the source and the filters form the vocal tract (o'grady, dobrovolsky & aronoff, 1993). , muscular abnormalities of the pharynx, such as pharyngeal dystonia will result in 'cul-de-sac' resdnance if the involuntary contractions involve more gene~alised regions of both the upper and lower pharyngeal constrictor muscles. in pharyngeal dystonia, indeased muscle contraction could affect the voice in two :ways. firstly, the larynx may be displaced by the spasm, possibly affecting the initiation of voicing, speci~cally voice onset time. secondly, the narrowing of the pharyngeal opening due to the abnormal contraction of the posterior pharyngeal wall would alter the physical dimensions of the pharynx, which would affect the resonance properties of the vocal tract. this study focuses on describing the articulation-laryngeal co-ordination (voice onset time) and acoustic properties of the voice in/order to determine the effect of pharyngeal dystonia on voicing. a· brief description of the pharyngeal swallow will supplement the voice data to provide a complete profile of pharyngeal dystonia. /' the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the swallowing and voicing characteristics of pharyngeal dystonia: a single case study 23 method aims the specific aim of this case report was to describe the swallowing pattern and voicing characteristics of a patient with pharyngeal dystonia. subject description the subject of this study approached the speech and hearing clinic of the university of the witwatersrand for an assessment following a referral from a neurologist. the subject was a 41-year-old english-speaking female. she presented as a subject of convenience and her cooperation was voluntary. her presence in' the clinic provided a unique opportunity to examine the characteristics of her vocal tract in detail. she consented in writing to participate in the study. the subject (j), presented initially with swallowing difficulties and intermittent periods of "tightness" in voice production. while a neurologist had diagnosed her with pharyngeal dystonia approximately 2 months prior to this study j reported that she had been experiencing these symptoms for approximately three years. 1's episodes of pharyngeal spasm were initially reported to occur only once or twice a year. however, at the time of this study, she experienced the spasms more regularly (every three to four weeks). j also reported consistent and marked swallowing difficulties, characterised by a tight throat during swallowing and difficulty getting the bolus down. these swallowing abnormalities were reportedly present all the time and worsened during periods of spasm. the voicing abnormalities were felt to be present only during periods of spasm and were not as consistent as the swallowing abnormalities. her subjective reports of spasm were characterised by "tightness" during swallowing and by abnormal voicing, which will be described later in this paper. 1's case history revealed no accompanying trauma, upper respiratory tra¢t infection or neuropsychiatric , episode or crisis. the: neurological reports ruled extra pyramidal and systerhic illnesses. she was not on neuroleptic agents at the time of onset of these symptoms. furthermote, there was no family history of dystonia. she was tre~ted with the anti-dystonic drugs artane and rivotril following her diagnosis two months prior to the study, but ino improvement was noted in her condition. i reports from an ear, nbse and throat (ent) surgeon excluded the presence of any structural abnormality of her larynx. no overt spasms of the adductor vocal apparatus were found. at the time the research was conducted, j had been assessed by a speech therapist, but she reported that she had not received therapy. assessment of the swallow a videofluoroscopic examination of the subjects swallow was conducted by a speech pathologist and a radiologist under the supervision of the consulting neurologist. this investigative procedure was conducted at the same time as the voice data was obtained. in this study, videofluoroscopy was used to define the anatomical and physio~ogical abnormalities causing the subject's swallowing difficulties. die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 materials standard videofluoroscopic recording equipment was used to record the swallow. the subject was seated on a platform attached to the fluoroscopy table. the swallow was recorded on a videocassette from which, stilled images were later selected using video. editing equipment. procedures three consistencies of materials were used in the modified barium swallow to investigate the subject's complaints pertaining to swallowing difficulties. thin liquid barium (water consistency), barium paste (chocolate pudding mixed with barium paste). and a biscuit coated in barium paste which required chewing. at least two swallows of each material were given to the subject in the following order: iml, 3ml, 5ml, loml and cup drinking of thin liquid, 113· teaspoon of pudding and 114 of an eat-sum-more biscuit coated in barium were then given to the subject (logemann, 1993 p. 169). these substances were given to the subject and she was instructed to feed herself. this was done in an attempt to simulate a normal eating situation. the pharyngeal stage of the swallow was assessed in the anteroposterior view to observe the anatomical symmetry and in lateral view in order to track the bolus on its path down to the oesophagus. voice assessment 1. assessment of voice onset time (vot) equipment the subject's voice was recorded in a sound treated booth using a lapel microphone (ross multimedia rma 200) attached 10 cm from the subject's mouth to maintain a constant mouth-to-microphone distance. recordings were made using a sony tcm-359v cassette recorder. two sets of recordings were obtained on the same day. procedures the subject was required to produce three consecutive repetitions of the vcv phrases lebel, ledei and legei (baken, 1987). the first set of recordings were of 1's voice in a reportedly 'normal' state while the second set were recorded while j reported pharyngeal spasm. while emg recordings would have provided on objective measure of demonstrating spasmodic activity in the pharyngeal muscles, the subject was unwilling to consent to this invasive procedure. it was therefore necessary to rely on the subject's perception of spasmodic activity to determine the presence or absence of pharyngeal spasm. the absence of spasm was determined by the subject's reports as well as by her ability to swallow normally. during spasm, the subject reported feeling "strangled". due to the inconsistent nature of the subject's symptoms, it was not possible to set up a time and place to objectively measure her voice using computer software. it was for this reason that audio-taped data was analysed as this did not restrict the researchers and allowed the unpredictable symptoms of this disorder to be recorded. r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) materials the specific vowel-consonant-vowel (vcv) combinations [ebe],[ede] and [ege] were selected for the following reasons: specific segments of a given utterance are often difficult to identify, thus the use of vcv segments made boundary identification easier (baken, 1987). the vowel lei was selected for use as there were norms available for its production (baken, 1987). plosives were used to measure vot of segments in the utterances lebel, led£! and leg£! as there was a large body of literature documenting norms of production (baken, 1987). data analysis of voice onset time (vot) the computer speech laboratory (csl) acoustic analysis system was used in the analysis of voice onset time (vot) (kay elemetrics corporation, 1993). positive vot can be defined as the interval in time between the release of a stop consonant and the initiation of glottal pulsing (colton & casper, 1990) and is normally less than 25ms for voiced stops (baken, 1986). in this study, vot refers to positive vot as defined above. time wave displays and narrowband spectrograms were prepared using the csl software, (kay elemetrics corporation, 1993). the spectrographic displays were used to identify the presence of a stop burst. vot measures were made by marking the first evidence of stop release to the onset of voicing. a dual display of the sound wave and a narrowband spectrogram was used. the time cursors of the two displays were linked to ensure more accurate marking. the utterances [ebe] , [ede], [ege] were used and the vot of the middle plosives were measured. the time cursor was placed on the. moment of plosion (0 value). the second cursor was placed at the onset of periodic energy, which is indicative :of vocal fold vibration (kent oc read, 1992). the time ··lapse between the two cursors was then measured in milliseconds. these values were then compared to the normal value (25 ms). data analysis motion. and stilled images of the swallow were analysed to allow the dynamic process of swallowing to be observed,. in the oral, pharyngeal and oesophageal stages of the swallow. 2. acoustic dimensions of voice . equipment the multi-dimensional voice program (mdvp) was used to quantitatively assess the subject's voice quality, calculating more than 22 parameters on a single vocalization. the normative references of the mdvp have been based on an extensive database of normal and . disordered voices. results were graphically and numerically compared to these normative threshold values (kay elemetrics corporation, 1993). procedures the subject was required to produce a sustained la:1 for a 5 second duration three consecutive times, which was recorded. furthermore, it has been suggested that the vowel la:/be used to assess the resonating properties of loren kahn & deila jordaan 24 the vocal tract (prater and swift, 1984). during the period of spasm experienced by the subject, only two repetitions of la:1 were obtained due to the variable nature of the presenting spasm which must be considered when interpreting the data. data analysis in this study, the acoustic parameters that were examined include fundamental frequency, degree of soft harmonics (dsh), amplitude perturbation quotient (apq) and shimmer. these 5 parameters were selected, as they were the only voice parameters that were consistently found to be abnormal on the multi dimensional voice programme (mdvp) analysis. reliability for purposes of reliability, the vot of the first utterance in each set of utterances (e.g. first [ebe] of the three) was reanalysed by the researcher, who was blinded to the data labels. the researcher also randomly reanalysed the vot and acoustic dimensions of the voice samples. results and discussion swallowing the video swallow revealed involuntary muscle contractions of the pharyngeal wall, presented as selected stilled images in figure 1. limitations exist in presenting the dynamic process of swallowing using stilled images, as the dynamic sequence of swallowing events is not clearly visible. however, the isolation of individual events during the swallow can be.a valuable diagnostic tool, if used in conjunction with a video recording of the event. the stilled images of the swallow demonstrate the functional abnormalities of the pharyngeal cavity during a single swallow. in the first frame, the subject takes her first mouthful of the liquid barium and achieves adequate oral clearance (frame 2). in frame 3, the abnormal muscular contraction of the pharynx is strikingly obvious. in. this frame, onj can clearly see the barium above the level of constriction, pooling in the valleculae, as well as barium below the i constriction, continuing downwards to the oesophagus. in addition, the pharyngeal walls create a complete constriction, preventing the barium above this level from flowing down towards the oesophagus. this hyperfunction of the pharyngeal walls is described as characteristic of pharyngeal dystonia (langhans, personal communication 1999). in the fourth frame, the pharyngeal tube re-opens allowing the barium to flow downwards. at this stage, some degree of abnormality is still apparent at the level of the cricopharyngeal muscle (the fourth cranial vertebra). in the fifth frame, the' remainiqg' barium is observed to flow in an anti-gravitational direction back towards the oropharynx, pooling oiice again in the valleculae. the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the swallowing and voicing characteristics of pharyngeal dystonia: a single case study 25 fig. 1: the anlfltomi,cal structures of the larynx and pharynx frame 1 frame 2 die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) loren kahn & deila jordaan 26 frame 3 frame 4 frames frame 6 frame 7 frame 8 fig. 1: the abnormal swallowing pattern of a subject with pharyngeal dystonia in frame 6, the barium continues upwards, with some evidence of barium in the upper region of the pharynx. in frame 7, the barium passes up to the base of the tongue, where the pharyngeal phase of the swallow is re-initiated. in the final frame (frame 8), j achieves adequate oral and pharyngeal clearance, and the remaining portion of the barium passes down to the oesophagus for the final phase of the swallow. results of voice onset time measures table i presents the voice onset times of [ebe], [ede] and [ege] produced three times each, under two conditions: vot (1) no spasm, and vot (2) in spasm. figure 2 is a graphic representation of the mean •. vot"s of [ebe], [ede] and [ege] both in and out of spasm (as per subject's report). the means and standard deviations for each set of data are provided under both conditions. reliability measures revealed that re-analysis of the same utterance by the same researcher produced in and out of spasm yielded a value that was within one millisecond of the first measurement. this indicates a high degree of repeatability between measures. the vot's recorded during a pharyngeal spasm, were significantly longer in comparison to those re~orded during spasm free speech, with an overall mean vot of 29 ms during spasm, compared to a mean of ?o ms without spasm. there were instances of normal i voice onset time during the production of [ebe] in\ both conditions, but the [ede] and [ege] utterances in spasm yielded consistently abnormal results. table 1 clearly reflects the delays in vot during spasm and reflect the subject's inability to co-ordinate her articulators and vocal cords. a muscular spasm within the pharynx disrupts the co-ordinated movement required for normal voicing. normal vots were recorded for production of the bilabial group [ebe] , but the most delayed vots were recorded for the [ede] group, both with and without spasm. / these findings are significant in light of the fact that the videofluoroscopic study showed,the pharynx to be locally affected at the level of thecricopharyngeal muscle. the value of combining videofluoroscopy with acoustic voice measures is clear as the two serve to confirm the isolated observations made using each procedure. the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the swallowing and voicing characteristics of pharyngeal dystonia: a single case study table 1: voice onset times for [ebe], [ede] and [ege] in milliseconds 27 (norm = 25 ms) vcv vot(i) no spasm (ms) vot(2) in spasm 12.8 [ebe] 1 12.9 reliability check [ebe] 2 13.2 [ebe] 3 13.9 mean sd 13.3 0.5 22.8 [ede] 1 reliability check 22.5 [ede] 2 28.9 [ede] 3 29.5 mean 27.1 sd 3.8 16.4 [ege] 1 i reliability .check 16.4 [ege] 2 23.4 [ege] 3 20.7 mean 20.2 sd / /' 3.44 the vot's of the subject's spasm-free voice when producing [ede] did not always fall within normal limits (baken, 1987). this could suggest delayed voice onset time even during spasm free periods, d~spite the voice being perceived as 'normal' by the researcher and subject during these productions. .an important option to consider is that dystonia is characterised by slow, abnormal muscular movements and there may be a short period where the subject is not aware of the spasm. an objective measure of spasm such as electrodes attached to the subject's throat should be used under ideal die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 (ms) 17.7 17.1 19.3 17.7 18.2 0.94 41.3 42.3 36.2 38.7 38.7 2.74 29.1 31.1 28.4 34 30.5 2.5 circumstances to identify instances of unperceived spasm. results of acoustic measures the multi dimensional voice programme (mdvp) (kay elemetrics corporation, 1993) revealed that some parameters were consistently abnormal during both spasm and spasm free voicing. for the purposes of this case report, only the parameters that fell out of the normal range of values were discussed. r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) loren kahn & heila jordaan 28 45 40 38.7 35 30 t/) e 25 r:: i20 0 > 15 10 5 0 ebe ede ege utterances iii!!ivoice onset time without spasm iiilvoice onset time with spasm i fig. 2: graphic representation of mean voice onset times (vots) for [ebe], [ede], [ege] with and without spasm fundamental frequency (fo) table 2: fundamental frequency (fo) with and without spasm fo in hz nosllasm initial measure repeated measure 183.31 183.20 182.20 182.89 182.51 178.81 mean= 182.67 mean= 181.63 note: fo norm is 189hz. range is 168hz-208hz. table 2 presents the measurements of fundamental frequency (fo) obtained for three productions of the with spasm initial measure repeated measure 164.35 164.10 177.99 177.59 / / mean= 171.17 mean= 170.85 sustained vowel /a:/ during spasm free voice and two productions in sp~sm. fundamental frequency reflects the the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the swallowing and voicing characteristics of pharyngeal dystonia: a single case study 29 vibratory rate of the vocal folds. during spasm free voice, j's fo and thus vibratory rate, consistently fell within normal limits according to normative data (colton & casper, 1990). during spasm, j's fo was lower on degree of sub-harmonics (dsh) average and at times dropped to 164 hz, falling just below the minimum normal level of 168 hz and was not considered to be a significant finding. table 3: degree of sub harmonics (dsh) with and without spasm dsh (in %) noslasm initial measure repeated measure 20.8 16.46 5.88 9.20 5.75 4.76 mean = 10.47 mean = 10.13 note: dsh norm = 1.00% table 3 represents the measurements of degree of sub-harmonics. dsh is an estimated relative measurement of sub-harmonics to fo components in the voice sample. in the samples that were analysed, there appeared to be variability between the relative amounts of sub-harmonics to fo components. this finding is supported by spectrographic findings, which indicate a visible decrease in harmonics during spasm (when compared to the same segment out of spasm), and out of spasm (when compared to spectrographic analyses of a normal speaker's productions of fa:f). clear reductions in the degree and amount of harmonics represent the disturbed resonance in j's voice, both during spasm and during spasm free periods. the reduction in harmonics may indicate the presence of aperiodic vocal fold vibration, which is con~istent with a spasmodic disorder. aperiodic vibration may therefore become one of the ,// with spasm initial measure repeated measure 5.00 9.94 8.24 8.43 mean = 8.65 mean = 9.20 diagnostic criteria used in the diagnosis of pharyngeal dystonia. amplitude shimmer perturbation quotient (apq) and table 4 indicates the measurements made for the amplitude perturbation quotient (apq) and shimmer. the apq evaluates'the variability in peak-to-peak amplitude within the voice. shimmer reflects the cycle-to-cycle variations in amplitude. in spasm free voicing, there was a surprisingly high degree of variability in the amplitude peaks of the voice as compared to the reduced degree of variability observed in spasm. these observations were supported by the reduction in cycle-to-cycle variations of amplitude during spasm. in spasm therefore, reduced variation in peak and cycle amplitude were evident. table 4: amplitude perturbation quotient (apq) and shimmer with and without spasm i . 1 i apq (in %) ! no sllasm with spasm initial measure ! /repeated measure initial measure repeated measure 7.17 7.00 2.98 2.83 3.55 4.25 3.56 3.55 3.65 3.12 mean = 4.73 mean = 4.79 mean = 3.27 mean = 3.19 shimmer (in db) initial measure repeated measure initial measure repeated measure 1.00 0.97 0.37 0.35 0.46 0.56 0.42 0.42 0.49 0.39 mean = 0.65 i mean = 0.64 mean = 0.40 mean = 0.39 note: apq norm = 3.07% shimmer norm = 0.35db die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) in all but two instances, the apq values exceeded the nonnative value (3.07). this indicates that a high degree of variability exists between the peak-to-peak amplitudes of the analysed voice samples with more variation present in spasm free voice. using 0.35 db as a guideline for the presence of shimmer according to nonnative data (baken 1987), it appeared that there was generally more shimmer present in spasm free voice when compared to the voice sample with spasm. ' the overall reduction in the apq and in the degree of shimmer may be due to the increased tension of the vocal cords during spasm. this finding may assist in the diagnosis of pharyngeal dystonia as a decrease in the apq value and reduced shimmer may indicate an overall reduction in the amplitude of the voice. summary of voice measures generally, j's voice contained some identifiable deviations from what would be considered nonnal, both during pharyngeal spasm and during periods of spasm free voicing. this may suggest that there is a degree of sub clinical acoustic irregularity in this subject's voice despite the apparent lack of awareness or perceptual evidence of such abnonnality. conclusions this research was a first attempt at describing the swallowing and voice characteristics of pharyngeal dystonia. it is significant that the dysphagia was so easily identifiable and that so many abnonnal laryngeal and acoustic parameters were observed in the voice of this subject. this study could thus be seen as a preliminary guide for the development of a future diagnostic protocol in cases where pharyngeal spasm may be suspected. comprehensive follow up of this case obviously needs to be implemented to detennine whether the voice symptoms in particular, become more consistent and identifiable over time. the findings of this study confinn the importance of the pharynx with regards to its resonance properties as well as its effect on the structures of the larynx during times of pharyngeal spasm. the findings in this case indicate that the pharynx is of considerably more importance in voice production than most textbooks have acknowledged. the need for more research into the specific relationship between the larynx and the pharynx will make the disorder of pharyngeal dystonia easier to understand. the integrated functioning of the pharyngeal structures is emphasised in the literature (greene, 1972). this study suggests that both gross and fine movements of the pharynx have the potential to drastically alter the resonance characteristics of the voice. resonance disturbances are clearly observable when comparing the . 'degree of sub harmonics in the sustained production of the /a:/ vowel produced in spasm to the same vowel produced with nonnal resonance. the resonance disturbance in the subject's voice could be described as cul-de-sac resonance that can be observed using spectrographic data. the subject's self perceptions of 'tight' voice production have physiological reality. evidence of these abnonnalities exists in the physiological and acoustic loren kahn & heila jordaan 30 abnonnalities observed during periods of spasm in this study. in addition, the acoustic results of this study show clear secondary effects on the larynx. despite the absence of reported or perceived laryngeal abnonnalities in the case being studied, secondary effects are caused by the pharyngeal muscle spasm resulting in voice disturbances, such as the significant delay in voice onset times during spasm. this study bears implications for a treatment programme for j and provides a baseline measurement from which the success of any intervention can be evaluated. at this stage, treatment options for this case are limited due to the lack of available resources and the inconsistent nature' of her symptoms. botox has been used in the treatment of some cases of pharyngeal dystonia (kostas et ai., 1995; dunne et ai., 1993). botox injections into the cricopharyngeal muscle would result in a paralysis of the pharynx. in south africa, botox has become increasingly popular in the treatment of a variety of dystonias. few specialists, both in south africa and internationally, are experienced in placing the injection because the cricopharyngeal muscle is hidden behind the cricoid cartilage. inaccurate injection could paralyse other muscles in the area, resulting in a worse dysphagia. a paralysed pharynx could benefit j during periods of spasm, but due to the inconsistent nature. of her symptoms these injections could be to her detriment during periods of no spasm. the fact that very few cases of pharyngeal dystonia have been documented does not mean that they do not exist, instead, it suggests that perhaps too little is known about the signs and symptoms of this disorder which may affect it's diagnosis. the need for further research into this disorder is essential so that clinicians diagnose and manage individuals with pharyngeal dystonia more accurately. references aronson, a. e. (1985). clinical voice disorders an interdisciplinary approach (2 nd edition.). new york; thieme. i baken, r. j. (1987). clinical measurement of s'peech and voice. london: taylor francis ltd. . bhatnager, s. c. & andy, o. j. (1994). neurosdience for the study of communicative diso~ders.' baltimore: williams and wilkins. 1 colton, r. h. & casper, j. k. (1990). understafzding voice problems a physiological perspectivj for diagnosis and treatment. baltimore: williams and wilkins. crafts, r. c. (1966). a textbook of human anatomy. roland press: new york. dobie, r. (1978). rehabilitation of swallowing disorders. american family physician, 17,84-95 . dunne, j., hayes, m. & cameron, d. (1993). botulinum a toxin for cricopharyngeal dysto~ia. lancet, 6! 342-559. dystonia medical research foundation (1999). understanding dystonia. chicago: illinois. ekberg, o. & nylan~er,g. (1981). pharyngeal constrictor paresis'. in' ~ patients with dysphagia: a cineradiographic study. clinical radiology, 33, 253. the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the swallowing and voicing characteristics of pharyngeal dystonia: a single case study 31 greene, m. c. l. (1972). the voice and its disorders. great britain: pitman press. groher, m. e. (1997). dysphagiadiagnosis and management (3rd ed.). massachusetts: butterworthheinemann. kay elemetrics corporation. (1993). multidimensional voice program (mdvp) model 4305 operations manual: new jersey. kent, j. f. & read, c. (1992). the acoustic analysis of speech. san diego: singular publishing group, inc. kostas, s. p., karam, f., langhans, j. l. & vasquez, a. b. (1995). treatment of dysphagia resulting from cricopharyngeal dysfunction with botox: preliminary thoughts and observations. the florida journal of communication disorders, 15,22-25. logemann, j. (1983). evaluation and treatment of swallowing disorders. austin, texas: pro-ed. logemann, j. (1989). short course in diagnosis and remediation of swallowing disorders. oakland, california. die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 logemann, j. a. (1993). manual for the video fluoroscopic study of swallowing. austin. texas. pro-ed. logemann, j. (1997). structural and functional aspects of normal and disordered swallowing. in ferrand and bloom (eds.), introduction to organic and neurogenic disorders of communication (pp. 229246). boston: alyn and bacon publishers. logemann, j. a. (1998). evaluation and treatment of swallowing disorders 2nd ed.). texas: pro-ed. moore, a.p. (1995). handbook of botulinum toxin treatment. oxford: blackwell science. o'grady, w., dobrovolsky, m. & aronoff, m. (1993). contemporary linguistics: an introduction (2nd ed.). usa: martins publishers. prater, r. j. & swift, r. w. (1984). manual of voice therapy little, usa: brown and company. vilkman, e., sonninen, a., hurme, p. & korkko, p. (1996). external laryngeal frame function in voice production revisited: a review. journal of voice, 10(1),78-92. r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) abstract introduction research methodology results discussion conclusion acknowledgements references about the author(s) vera-genevey hlayisi division of communication sciences and disorders, department of health and rehabilitation sciences, faculty of health sciences, university of cape town, cape town, south africa citation hlayisi, v. (2022). increasing unemployment rate amongst health professionals: will there be jobs for newly graduated south african audiologists post-covid-19? south african journal of communication disorders, 69(2), a909. https://doi.org/10.4102/sajcd.v69i2.909 original research increasing unemployment rate amongst health professionals: will there be jobs for newly graduated south african audiologists post-covid-19? vera-genevey hlayisi received: 31 jan. 2022; accepted: 24 apr. 2022; published: 01 aug. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: before the coronavirus disease 2019 (covid-19) pandemic in early 2020, the unemployment rate in south africa was at its highest in history at 29.1%. during the covid-19 pandemic to date, unemployment rose even higher to 35.3%. in this context, there has been an increase in the number of unemployed health professionals in south africa. objectives: this study aimed to determine the employment rates of newly graduated south african audiologists and identify the challenges in obtaining and maintaining employment for audiologists in south africa. methods: a descriptive online survey design was used. participants were recruited online through professional association webpages using the snowball sampling technique. all qualified audiologists registered with the health professionals council of south africa were eligible to participate. results: a total of 132 audiologists completed the survey. in the first-year postgraduation, 16% of the participants were unemployed, and this increased to 19% in the second-year postgraduation. in the majority (81%) of employed participants, almost a fifth (19%) were working within non-audiology/healthcare fields. the most common workplace challenges reported were remuneration (37%) followed by lack of resources (18%), workload (18%), work environment (10%), working hours (9%) and, lastly, interprofessional relationships (8%). conclusion: findings from this study are the first to document employment rates amongst south african audiologists. these findings have the potential to influence the critical discourse on hearing healthcare human resource planning, hearing healthcare labour capacity and potential for growth in the south african context post-covid-19. keywords: employment; unemployment; human-resources; healthcare; audiology. introduction unemployment is a socio-political challenge worldwide and a major challenge in south africa where the current national unemployment rate is the highest (du toit, de witte, rothmann, & van den broeck, 2018; statistics south africa, 2021). statistics south africa (2022) reports a 35.3% official unemployment rate, the highest since 2008, which translates to almost 8 million people who are able (skilled) to work and actively seeking jobs (alenda-demoutiez & mügge 2019). the expanded unemployment rate, which would include those who are not actively seeking jobs skilled (alenda-demoutiez & mügge 2019) or otherwise, is much higher and is up to 46.2% of the south african population (statistics south africa, 2021). even more staggering is the unemployment rate amongst the youth, which is currently at 65.5%. more than 15 years ago, the growing unemployment crisis in south africa was described then, as a ‘beast’, with an ‘effect on economic welfare, erosion of human capital, crime and social instability’ (kingdon & knight, 2007). in response to the annual increase in unemployment, the government has shown a wide range of policy efforts and interventions to curb the crisis and impact, especially amongst the youth (du toit et al., 2018; lannoy, graham, patel, & liebbrandt, 2018). one of the key interventions has been increasing access and quality of education with the aim of increasing the number of skilled youth that would be more employable as per labour market skills demand or need (de witte, rothmann, & jackson, 2012; du toit et al., 2018). in post-apartheid south africa, increasing access, quality and levels of education have been a key focus as research has shown that educated or skilled young people stand a better chance of finding employment, faster than their peers with lower levels of schooling (acquah, 2009; lannoy et al., 2018; mlatsheni & rospabe, 2002). however, there seems to still be a persistent case of unemployment even amongst skilled graduate professionals in south africa to date, despite vast efforts invested in access and quality of education (lannoy et al., 2018). graduate unemployment is problematic because it wastes scarce human capital that is detrimental to the economy in the long run (oluwajodu, blaauw, greyling, kleynhans, 2015). currently, south africa’s labour market consists of formal and informal employment. formal employment is defined as employment created by businesses or the government where an employee is hired under established working agreements (alenda-demoutiez & mügge, 2019; quain, 2018). in 2014, only 25% of south africa’s workforce were skilled workers with formal employment, that is, including graduate health workers (statistics south africa, 2014). in 2016, 405 000 south african citizens with tertiary-level education including health professionals were unemployed (mngoma, 2016). graduate unemployment is an important area of study because the south african economy experiences severe skills shortages, however, simultaneously unable to generate and sustain sufficient job opportunities for skilled labour (pauw, bhorat, & goga, 2006). the issue of graduate unemployment, therefore, contradicts studies suggesting that the higher a participant’s education level, the higher the probability of finding employment; for example, health professional graduates with specialised education are expected to be fully absorbed into the skills starved labour market (cohen & moodley, 2012; mncayi & dunga, 2016; oosthuizen, 2007). the south african healthcare economy and setting are complex (coovardia, jewkes, barron, sander, & mcintyre, 2009). there is a rise in health human resource and service wastage through unemployment, low worker retention and low overall system efficiency as influenced by the macro socio-economic and political issues that are not unique to south africa but are in most developing african countries (dovlo, 2005). the term wastage of health human resources is used by previous researchers in the field (dovlo, 2005) to describe the loss in utility of health workers/health professionals resulting from underuse or non-use of trained personnel, unemployment, retrenchment or the labour force’s inability to absorb skilled graduates. some researchers argue that many of the south african healthcare challenges are rooted in distinct features of the apartheid history, which sustained health inequity through its successive segregationist policies (delobelle, 2013; pillay, tiwari, kathard, & chikte, 2020). to date, there has been a recent increase in unemployed health professionals, including audiologists (maqhina, 2019; msomi, 2019; statistics south africa, 2021; van dyk, 2017). audiologists are the primary hearing healthcare professionals involved in the identification, prevention and evaluation of auditory and balance disorders. moreover, audiologists are the single most important resources for the rehabilitation of hearing loss (gelfand, 2009). audiology is relatively young amongst other south african health professions and has been growing in the last half-century from an adjunct to speech therapy to its own autonomous profession (swanepoel, 2006). currently, audiology training as a singular, autonomous profession is available at some of the seven higher education institutions offering the degree in south africa with approximately 100–150 new graduates recorded annually (department of higher education [dhet], 2017; singh et al., 2015; swanepoel, 2006). it is worth noting that this is a low number of audiologists entering into healthcare system to meet the high need of hearing health services as influenced by the disease and disability burden in south africa (khoza-shangase & mophosho, 2018; pillay et al., 2020). lower supplies of rehabilitation health professionals like audiologists is a common challenge in lowand middle-income countries, including many located in sub-saharan africa, where the need of the skills tends to be greatest (gupta, castillo-laborde, & landry, 2011; pillay et al., 2020). the health professions council of south africa (2022) iregister indicates approximately 1175 audiologists and 2205 speech therapists and audiologists currently registered to provide hearing healthcare services in the country of over 60 million in population size. pillay et al. (2020) estimated a ratio of 39 audiologists per 1 million population, based on the 2017 world bank estimate for the population of south africa of 56.7 million. audiologists in south africa are mostly employed and function in the public healthcare system (khoza-shangase & mophosho, 2018; pillay et al., 2020; swanepoel, 2006). the south african public healthcare system is unfortunately marred with several challenges including well-documented lack of skilled professionals, infrastructural constraints, limited well-functioning facilities, general lack of resources for the size of the population, risk versus benefit assessment predicaments and challenges with translating policies into practice (barratt, khoza-shangase, & msimang, 2012; khoza-shangase, kanji, petrocchi-bartal, & farr, 2017; khoza-shangase & mophosho, 2018). these challenges affect mostly the already vulnerable parts of the population such as the poor with communication disabilities such as hearing loss (khoza-shangase et al., 2017; mckenzie, 1992; wylie mcallister, davidson, & marshall, 2016). it is also worth noting that the coronavirus disease 2019 (covid-19) pandemic brought with it many challenges that will undoubtedly have an impact on unemployment or employment across many sectors, including audiology. manchaiah, eikelboom, bennett and swanepoel (2022) in their international survey with audiologists exploring the effects of covid-19 on the workplace state that the pandemic has resulted in significant disruptions to audiological practice. some of their key findings show that 97% of audiologists surveyed reported significant changes to their workplace, with up to 76.4% reporting reduced caseloads and 38.7% reported reduced working hours. covid-19 will undeniably alter the practice of audiology, and emerging research is already showing an increase in the need to adapt and incorporate telehealth in audiology practice (eikelboom et al., 2022; manchaiah et al., 2022). some of these early research reports on workload, work hours and incorporation of telehealth are likely to inform hearing healthcare human resource policies and planning, hearing healthcare labour market needs versus capacity and hearing healthcare context and future. therefore, this study sought to investigate and describe challenges in obtaining and maintaining employment of audiologists as scarce skilled health human resources in the context of the rising unemployment rates in south africa. research methodology research design a descriptive cross-sectional online survey was used. a descriptive survey was chosen as both a research design and a tool for the data collection of this study (barbour, 2014). the study design was chosen based on its many advantages including its cost-effective nature and its ability to overcome geographical boundaries when seeking to collect data from widely dispersed participants (barbour, 2014). study setting this study was facilitated online using the web-based surveymonkey platform with target participants from the south african hearing healthcare sector that comprises both public and privately practicing audiologists. an online survey setting was chosen as it would enable target participants to have anonymity to share their responses to the research question openly and honestly (barbour, 2014). participants sample size the sample size was calculated using an online calculator on the surveymonkey platform. an acceptable margin of error for survey studies is between 5% and 10% (suresh & chandrashekara, 2012). a lower margin of error increases the value of the sample, and the accuracy of the value reduces the risk of the sample not representing the population under investigation (singh & masuku, 2014). using these parameters, 330 audiologists were calculated as the needed sample size. however, the response rate to previous south african research requiring audiologists to complete online surveys has been poor. in a recent south african study by makhoba and joseph (2016), only 45 responses were obtained from 1440 audiologists invited to complete the survey. therefore, a sample size of 200 audiologists was targeted as the more feasible number to reach. sampling and recruitment method the snowball sampling technique was used to allow for recruited participants to recruit other eligible participants they had access to (etikan, alkassim, & abubakar, 2015). this method was appropriate based on the limited time and budget for this study. employing this sampling method further increased the chances of having a diverse sample. prospective participants were recruited online. audiologists known by the researcher were sent a formal email to invite them to participate in the research study. the email contained an informational letter with all details of the study and the link to the survey. before completing the survey, participants were required to provide electronic informed consent. within the email, a request was made to forward the email to other audiologists they were in contact with. additionally, audiologists were recruited on various social media platforms including facebook and whatsapp. inclusion criteria for inclusion in the study, participants had to be graduate audiologists registered with the health professions council of south africa. study materials survey tool a 24-item questionnaire was designed for the study to collect data on (1) participant demographics, (2) education information and (3) unemployment or employment status and details. the questionnaire response formats included closed sets like multiple choices and open-ended narratives. the questionnaire was piloted prior study commenced to determine validity. face and content validity of data collection tool according to previous research using questionnaires, face and content validity were essential psychometric properties to measure when developing such instruments (connell et al., 2018). face validity refers to whether the instrument appears to measure what it was intended to measure (connell et al., 2018). content validity refers to whether the instrument covers all aspects of content related to the construct it is being measured (heale & twycross, 2015). to ensure face and content validity, seven audiologists provided feedback on the (1) overall appearance (e.g. ease of response, response formats, etc.), (2) content covered and (3) overall flow in the design of the questionnaire. feedback from the seven audiologists included changing some questions to be open ended to allow participants to give additional information, and in terms of the overall design, there was a need to redirect participants to the next appropriate question and sections of the survey. based on this feedback, the questionnaire was modified prior the data collection commenced. data collection data were collected online using the surveymonkey platform where the questionnaire was administered. the online link to the questionnaire was open for 6 months, and data were stored online on a password-protected cloud that only the researcher had access to. data analysis quantitative data descriptive statistical methods were used to analyse quantitative data. categorical data were analysed using frequency tables and percentages. numerical data were analysed using means and standard deviation. qualitative data a thematic analysis was conducted for the qualitative data collected. the following steps were included in the thematic analysis: data familiarisation – researcher read through the qualitative data collected and made notes to gain a better understanding of the data and to assist in a comprehensive analysis (nowell, norris, white, & moules, 2017). coding – the data were then reviewed to determine key characteristics that could be coded. codes were determined by highlighting similarities across participant responses. categorisation – similar codes were grouped together in themes. all codes within the themes were then reviewed to establish whether they were classified into the appropriate themes. ethical considerations this study was guided by the ethical principles outlined by the world medical association (wma) in the declaration of helsinki (world medical association, 2013). ethical approval was granted by the human research and ethics committee (hrec) of the university of cape town (reference no: 815/18). results a total of 219 audiologists responded to the study questionnaire, and 132 complete responses were collected. only the results from the 132 completed questionnaires were included in the analysis. participant demographics majority of the participants (89%) were female, south african youth between the ages of 25–34 (67%) (see table 1 for more participant demographic data). table 1: participant demographic information (n = 132). (un)employment rate first-year postgraduation of the 132 participants, the majority (84%) were employed by the government in the public sector through the community service (cs) program. of the 16% unemployed participants, 9% experienced a delay (1–2 months on average) in their employment through the cs program placement, 7% were not employed at all (not placed in cs program at all) and 1% did not meet requirements for cs program employment as they were non-sa citizens. second-year postgraduation of the 132 participants, the vast majority (81%) were employed. important to note is that of the employed participants, up to 19% were working within non-audiology fields: employment characteristics of those working in audiology fields (n = 107) show that most participants were employed within the public sector (47%) and in clinical settings (52%) (see table 2). when asked to rate workplace challenges, most ratings (37%) were on remuneration followed by lack of resources (18%), workload (18%), work environment (10%), working hours (9%) and, lastly, interprofessional relationships (8%). table 2: employment demographics within audiology (n = 107). the number of unemployed graduates increased to 19% in the second-year postgraduation (see table 3 on the duration of unemployment and possible employment barriers). challenges in obtaining employment are reported as themes in table 4. table 3: unemployed participants in the second-year postgraduation (n = 25). table 4: challenges obtaining employment. discussion unemployed health professionals with the highest unemployment rate and the increasing challenges in healthcare human resourcing in south africa, this study sought to describe challenges in obtaining and maintaining employment for audiologists (pillay et al., 2020; statistics south africa, 2021). the main findings of this study indicate that up to 16% of audiologists are unemployed in their first-year postgraduation, and this increases to 19% in the second-year postgraduation. an unemployment rate between 16% and 19% is very high in the context of the estimated total annual number of audiology graduates from the seven institutions that offer the audiology program in south africa, which is approximately between 100 and 150 graduates (dhet, 2017; singh et al., 2015; swanepoel, 2006), thus implying the possibility of an entire class of audiology graduates from one institution potentially unemployed in their firstand second-year postgraduation. this is the first study, to the knowledge of the researcher, to document and describe unemployment rates in audiology graduates in south africa. a similar study was done recently to describe human resource challenges in environmental health graduates in south africa (mbola, human, & melariri, 2019). key findings from mbola et al. (2019) did not include unemployment rates, but documented major problems regarding the decreasing number of employment opportunities for environmental health graduates (mbola et al., 2019). other associated reports of unemployment of healthcare professionals as a whole have mainly been in various media outlets over the last five years in south africa with headlines such as ‘sa can’t give hundreds of its new doctors jobs’ (ntsaluba, 2019). community service program it is important to note that in the firstand second-year postgraduation, since 1998, all south african health professional graduates are mandated to work for the national department of health (ndoh) for community service (cs) in order to be certified by the health professions council of south africa (hpcsa) as qualified-independent practitioners (mbola et al., 2019; reid, peacocke, kornick, & wolvaardt, 2018). the intentions of the ndoh cs program were to combat the disparaging effects of the pre-1994 apartheid south african healthcare system that did not offer equal access to basic healthcare outside metropolitan areas (reid et al., 2018). therefore, a 16% – 19% unemployment rate for audiologists or any other health profession indicates that ndoh is failing to employ health professionals in line with their mandatory cs program. the south african public healthcare system has been cited to be facing, amongst other challenges, constrained financial resources that have led to difficulties in absorbing, retaining and remunerating all health professionals in the public healthcare system (delobelle, 2013). it is also worth noting that the overall healthcare industry may also be influenced by the vast inequalities in the macro socio-economic sphere and the present covid-19 factors that are not unique to healthcare but are seen to be impacting in all sectors in south africa. furthermore, recent research indicates that the south african economy as a whole is not growing fast enough to absorb the rising annual number of jobseekers, skilled such as health professionals or otherwise (mahadea & kaseeram, 2018). this state of affairs has debilitating implications for the public healthcare system as well as the cs program and pertinent to this study, cs for audiologists. therefore, it is key to consider that moving forward, if the ndoh is unable to sustainably maintain and fund cs, it is fitting to interrogate (1) the mandatory nature of the cs program as it stands for south african health graduates and (2) the linking of cs program to the health regulator’s, hpcsa, independent practice certification. although well-intentioned, the mandatory cs program, as shown by this study findings, may be doubly disadvantaging health professional graduates as it not only cannot employ all graduates but further denies the unemployed graduates an opportunity to obtain the necessary accreditation to enter and serve in the broader healthcare market outside the ndoh (mbola et al., 2019). having any unemployed health professionals highlights a domino effect of negative ramifications that amount to a high loss of investment across multiple sectors (pillay et al., 2020). some of the key affected sectors include (1) higher education considering the cost attached to producing scarce skills, (2) the department of health with ‘wastage in the health workforce’ through unutilised critical skills and goals of healthcare access not being realised 20 + years post-apartheid for those in need and (3) the economy with non-contributing skilled labour adding to the already high (65%) unemployed youth under 35 years of age (pillay et al., 2020). post-covid-19, there may be a place for strongly considering the incorporation of telehealth innovations not only for ensuring the much-needed hearing healthcare access but also to open up discussions on how to utilise technology to increase employment and business capacity amongst newly qualified health graduates. education and skills do not equal employability? in the last 20 years in post-apartheid south africa, research proposed that increasing access, quality and levels of education will increase employability and benefit multiple sectors through skilled labour (acquah, 2009; lannoy et al., 2018; mlatsheni & rospabe, 2002). and through policy and action, the national skills development strategy in line with the skills development act of 1998 and skills development levies act of 1999 has seen south african tax revenue contribute financially to the goal of transforming access to and resourcing quality education and training (pauw et al., 2006). however, the study findings may be indicating that the relationship between education and employability is not necessarily linear. for health professional graduates specifically, there may need to be a thorough investigation and understanding of the healthcare labour market’s capacity to absorb new graduates whilst retaining the current workforce and growing in line with the healthcare consumer needs (mbola et al., 2019; pillay et al., 2020). in particular to specialised fields like audiology, there may be a need for interrogation into the unique influences in the hearing healthcare market that in turn affect employability. the findings of this study are key for the hearing healthcare sector to consider career pathing for health professionals like audiologists in terms of considering alternative employment opportunities and options outside of the purely clinical sectors such as the ndoh. telehealth and the future of health human resources globally, there is a growing interest and proven value in using technology in hearing healthcare (aggarwal, dhanshree gunjawate, yerraguntla, & ravi, 2022; eikelboom et al., 2022; manchaiah et al., 2022). for south african audiology, telehealth may be a viable option to investigate how skills matching and human resource gaps can be facilitated to curb unemployment of hearing health professionals. eikelboom et al. (2022) in their study assert that there is now more than ever within the covid-19 climate, a positive outlook and potential for an increase in telehealth usage in audiology practice. aggarwal et al. (2022) in their scoping review of the impact of covid-19 on audiology practice also argue for careful considerations in planning for audiology practice post-pandemic. the findings of this study also imply that a thorough look into the future of audiology practice and what modes of employment can be sustainable to avoid health human resource wastage, and making audiology work during and post-covid-19 is needed. swanepoel and hall (2020) put it simply that whilst covid-19 is posing a tremendous threat, it is simultaneously inciting a rapid deployment of innovative telehealth approaches to respond to a changing landscape. study strengths and limitations this study is, to the knowledge of the researcher, the first to explore and document unemployment rates and challenges in audiologists in south africa. this study’s findings can be foundational to guide future research to expand investigations into the subject matter. a possible limitation of the study is in its cross-sectional design in that findings cannot be used to predict and/or analyse unemployment over a period, and the snapshot nature of the design means that findings may not be representative of the whole population of interest. conclusion up to 16% of audiologists are unemployed in their first-year postgraduation, and this increases to 19% in the second-year postgraduation. this study’s findings are the first to document the unemployment rate of newly graduated hearing healthcare professionals in south africa. these findings have the potential to influence the critical discourse on hearing healthcare human resource policies and planning, hearing healthcare labour market needs versus capacity, and hearing healthcare context and potential for growth in the south african context, especially post-covid-19. acknowledgements the author would like to acknowledge and thank the university of cape town audiology students (tersia davids, yusrah du toit, mendy luthuli, shanine meyer, thashil pillay, ilhaam rejaldien) for their contribution to data collection for this study. competing interests the author declares that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. author’s contributions v.h. is the sole author of this article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability raw survey data (anonymised) can be made available on request. disclaimer the views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any affiliated agency of the author. references acquah, a. 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(2017). dozens of health workers still unemployed as departments scramble for posts. retrieved from https://bhekisisa.org/article/2017-02-09-00-clinical-associates-are-still-unemployed-as-health-departments-scramble-for-posts/ wylie, k., mcallister, l., davidson, b., & marshall, j. (2016). communication rehabilitation in sub-saharan africa: a workforce profile of speech and language therapists. african journal of disability, 5(1), a227. https://doi.org/10.4102/ajod.v5i1.227 abstract introduction and literature review material and methods results and discussion conclusions and recommendations acknowledgements references appendix 1 about the author(s) katerina ehlert department speech-language pathology and audiology, sefako makgatho health sciences university, south africa citation ehlert, k. (2017). perceptions of public primary school teachers regarding noise-induced hearing loss in south africa. south african journal of communication disorders 64(1), a185. https://doi.org/10.4102/sajcd.v64i1.185 original research perceptions of public primary school teachers regarding noise-induced hearing loss in south africa katerina ehlert received: 20 sept. 2016; accepted: 05 feb. 2017; published: 28 mar. 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: noise-induced hearing loss (nihl) is an increasingly growing problem in young children. this is attributed to recreational noise being the most common cause of this problem. in young children, hearing problems can delay language development and reduce academic achievements. south africa, in particular, has limited information and protective measures regarding the conservation of hearing in school-aged children. objectives: the main aim of the study was to determine the perception of primary school teachers regarding nihl. the study also aimed to determine if any hearing conservation programmes are being implemented in schools and the need for training of primary school teachers regarding nihl. method: a survey was conducted. in order to cover the population of interest, the sampled schools in pretoria were clustered into urban, semi-urban and rural areas. results: the majority of the teachers included in this study are aware of nihl and its effects. they, however, lack the necessary resources and knowledge to effectively use this information. most (67.5%) of the teachers indicated that they have never been exposed to children with nihl in a school setting. it was also found that the majority (84%) of the schools included in the study do not implement hearing screening and conservation programmes. conclusion: although the sample size was limited, the results correlate with other research in this field indicating a need for planning and implementation of hearing conservation programmes in schools, including training of teachers in order for these programmes to be effective. introduction and literature review noise-induced hearing loss (nihl) is a hearing impairment caused by excessive or prolonged exposure to loud sounds. the sound results in changes in the mechanism and metabolism of the inner ear as the outer hair cells (ohcs) of the cochlea are over stimulated. the endolymphatic fluids of the cochlea are also affected in the sense that the high energy transfer causes metabolic stress, which in turn results in swelling and degeneration of the balance and hearing nerve terminals that attach to the inner hair cells (ihcs). degeneration of the hair cells of the cochlea and damage to the auditory nerve result in either temporary or permanent noise-induced threshold shifts (nits) (edwards, 2008). nihl may be sudden or progressive. with the latter, it develops gradually and is more rapid in the first decade of exposure with continuous exposure being more damaging than intermittent exposure. sudden nihl is caused by acoustic trauma, which results from sudden exposure to high intensity sound levels that cause instant damage to the hearing mechanism, for example, explosion or gun fire at close range (taljaard, leischman & eikelboom, 2013). apart from the loss of hearing sensitivity, two other common symptoms related to nihl exist. one is tinnitus or ringing in the ears and the other is temporary threshold shift (tts). a tts is defined as a temporary increase in hearing thresholds after exposure to loud sounds. it can be caused by continuous noise and impulse noise. continuous noise can be harmful when exposed to noise of 85 db or more for more than 8 h and impulse noise of 140 db or more. with continuous noise, for every 5 db increase from 80 db, exposure time halves, for example, 80 db = 16 h, 85 db = 8 h [south african national standards (sans), 2004, p. 10083]. following exposure to a period of loud sounds, a ‘temporary’ mild hearing loss (e.g., after a long flight or bus journey, or following a loud music concert) may be present. during this period, everything sounds quieter. immediately after exposure, the thresholds may consistently increase by as much as 40 db. however, the thresholds return to normal after a recovery time (harrison, 2008; plack, 2014). the tts usually disappears within 16 to 48 h after exposure to loud noise. these experiences tend not to cause concern, partly, because there appears to be a full recovery. however, it is widely recognised that repeated episodes of tts can result in permanent changes within the cochlea and hearing loss. if the ohcs in the cochlear do not recover within the hours mentioned above, then the hearing loss becomes permanent, which is known as permanent threshold shifts (ptss) (biassoni et al., 2014). it is suggested that the noise exposure causing tts alters the delicate micromechanics of the cochlea, including the linkages between hair cell stereocilia, and that the recovery of such insults may not be complete. it is, therefore, suggested that any noise exposure that leads to tts should be avoided (harrison, 2008). the pts results in hearing loss that is of the sensory-neural type, usually bilateral and symmetrical (taljaard et al., 2013). intense sound levels do not affect the outer ear but it can affect the middle ear to a lesser degree, for example, in the case of a combination of hazardous sound levels as well as severe air pressure changes (smeltzer, bare, hinkle & cheever, 2010). table 1 describes what is too loud, and how loud is too loud. table 1: what is too loud and how loud is too loud? tinnitus can be defined as the perception of sound without external stimuli, that is, a sensation of a ringing, buzzing or whistling sound in the ear (edwards, 2008). although there are a number of types of tinnitus, not all are the result of cochlear damage. it is common for tinnitus to be temporary, and it is normal to sporadically hear a brief ringing in the ear, which disappears within a few seconds. however, when chronic tinnitus is experienced after exposure to loud sounds, it is not just a warning sign, but a clear indicator of cochlear injury. the ringing sound indicates that the hair cells and neurons are actually in the process of being destroyed. these cells generate a neural injury discharge because the cell membrane breakdown causes repeated depolarisation (excitation) or uncontrolled release of neurotransmitters. following severe acoustic trauma, tinnitus can persist and becomes permanent. it has been suggested that the initial neural injury discharge sets up (synaptic) connections in a network of auditory neurons at a more central (cortical) brain level and that these cells continue to fire spontaneously (perhaps because a local positive feedback circuit is established or because local inhibitory neuron activity is reduced). chronic tinnitus can be as damaging to quality of life as the effects of hearing loss (harrison, 2008). individuals suffering from tinnitus could additionally present with sleep disturbances, mood swings, concentration problems, personality changes and speech recognition difficulties (edwards, 2008). loud sounds can also lead to frustration, stress and anger, resulting in ineffective communication as the individual will need an increased effort to hear and talk. other effects include disturbances in executive functioning such as thinking processes and execution of tasks as well as performance effects that include but are not limited to annoyance, decreased work efficiency, inability to hear alarms and danger signals, speech intelligibility miscommunication and psychological distress (edwards, 2008). evidently, recreational activities that induce tinnitus should be averted. individuals with nihl have poor speech perception, speech processing problems as well as reduced supra-threshold functioning (edwards, 2008). they usually understand speech in quiet environments compared with that with the presence of background or competing noise (edwards, 2008). the communication difficulties experienced by these individuals affect their quality of life (levey, fligor & kagimbi, 2012; ringdahl, erikson & anderson, 1998). nihl is the most common form of hearing loss after hearing loss related to age (levey et al., 2012). hazardous sound levels in african countries are more dominant in formal sectors and seen as the most common occupational disease. manufacturing or mining; informal occupational sectors, for example, vehicle repairing; and non-occupational sectors, for example, environmental and leisure noise, are cited as the main causes of nihl [bomela, 2005; world health organization (who), 2015]. industrial workers are known to be at more risk of acquiring nihl than any other occupation. this was attributed to employees, employers and the public’s lack of knowledge and awareness about noise and its effects resulting in ineffective hearing conservation programmes. most research studies have focused on occupational hearing loss rather than any other form of nihl. this is not surprising because historically, hearing loss was known as a disease that affects the elderly only. in terms of general population studies, a report (niskar et al., 2001) from a large-scale american national health survey indicated that 12% to 15% of school-aged children have some hearing deficits attributable to noise exposure. in canada, there are no large surveys that specifically address nihl. statistics canada data indicate that 13% of children (up to 14 years of age) have some hearing disability, but it does not separate specific causes (statistics canada, 2006). the american academy of audiology estimates that one in eight children has sustained nihl (american academy of audiology, 2008). it is estimated that 16% of teenagers in the united states have sustained nihl (kean, 2010). work safe bc (workers compensation board of british columbia) (2005), in a large survey of young workers entering the workforce, reports that over 20% have some early signs of hearing loss, but this includes all causes of hearing loss, not only nihl. a study conducted in the united states by henderson, hartnick and testa (2011) indicates a significant increase in the prevalence of nihl in youths compared to 20 years ago. this was investigated by comparing studies on noise threshold shifts amongst us youths conducted in 1994 to 1998 and 2005 to 2006 that has shown significant increases in threshold shifts especially in males. recent studies have shown a significant increase in the prevalence of nihl in youth and younger children resulting from voluntary exposure to noise (henderson et al., 2011). young people expose themselves to potentially damaging loud sounds during leisure activities, and nihl is diagnosed in an increasing number of adolescents (biassoni et al., 2014). sources of environmental hazardous sounds that young people are exposed to include, but are not limited to, noisy toys, personal entertainment or listening devices, clubs, rock concerts, fireworks and lawn mowing (keppler, vinck & dhooge 2010). taljaard et al. (2013) presented information about the market to indicate growth of the use of personal listening devices (plds) in children and adolescents. their study indicated that the popular pld, which is the apple ipod, has sold over 50 million within the past 5-years. as the years go by, these devices are improved with features like louder output without sacrificing battery drainage. therefore, individuals are now able to listen to louder music for longer periods of time with the maximum sound level for many portable music players (pmps) ranging from 80 db to 115 db. different types of earphones potentially increase the output by 7 db to 9 db. in some cases, it is possible to reach over 120 db (taljaard et al., 2013). there is a need for standards and guidelines for maximum output of toys in south africa as certain children’s toys may exceed safe listening levels, placing children at risk for nihl (joubert & ellis, 2012). furthermore, teenagers frequently play their plds at louder intensities than other pld users, without perceiving the intensity and claiming that they could not enjoy their music at lower volumes. although some pld users may be aware of the dangers of loud and extended listening on their hearing, social factors and status result in the listeners ignoring the possible dangers. plds have become an ‘urban sherpa’, people rely on their plds to steer their circumstances and pld is seen as a necessity in life (bull, 2007, levey et al., 2012). guidelines have been developed to decrease the risk of nihl from plds, for example, individuals should not listen for more than 1.5 h at 80% of the maximum volume when using plds (fligor, 2006; levey, levey & fligor, 2011; portnuff, 2016). in summary, guidelines for appropriate listening levels and duration as well as appropriate headphone use contribute to the prevention of nihl. the secondary effects of nihl greatly depend on the degree or severity of the hearing loss. individuals with mild hearing losses may experience minimal problems related to the effects of nihl. it is, therefore, important to prevent minimal losses from progressing. nihl is, however, preventable (who, 2015). it is unfortunate that even though this is the case, the prevalence of nihl in children still continues to rise. for a child with nihl, the degree of deficit is expected to be mild or moderate, rather than severe or profound. however, such a loss still creates a barrier to effective communication, especially in noisy environments such as the school classroom. furthermore, a mild-to-moderate hearing loss may not be immediately apparent to a child (similarly to adults who do not recognise that they have age-related hearing loss). parents and clinicians should be attentive. measures of speech discrimination often more accurately reveal a hearing problem than the simple audiogram or hearing screening tests. hearing loss can affect language development in young children. this cascading effect results in reduced academic achievements if information is being missed at school. for adolescents, communication difficulties can lead to social isolation. there have been reports of suicide resulting from social isolation. if hearing aid use is required, the adolescent may also have problems with the cosmetic appearance of the device or the stigma attached to wearing hearing aids. this may result in the adolescent not using the aids, or they may choose to become socially isolated or only socialise with small selected groups. this ultimately will have an influence on their quality of life (harrison, 2008). thus, hazardous noise levels have been reported to have a negative impact on academic performance which in turn results in increased rates of absenteeism and academic failures (needham, crosnoe & muller, 2004). these occur due to all the effort that is required for one to perform simple tasks such as concentrating and listening which will affect academic performance (needham et al., 2004). plds are not the only major cause of nihl in teenagers. significant threshold shifts were also found in adolescents who were in schools, where they practice tasks such as welding and wood processing. noise levels in such areas were found to range from 92 db to 100 db, which exceeds the recommended standard noise exposure levels of 85 db which is time-dependent, that is, longer exposure results in more significant threshold shifts. this poses a great risk of nihl in the learners, especially as they have limited use of hearing protectors (paunovic, 2013). in 2001, a study by griest, folmer and martin aimed to investigate the pervasiveness of nihl in younger children. during the study, the researcher screened 5300 children’s hearing in the united states, aged 6–19. thirteen percent of the children were found to have some degree of nihl (mazzola, 2013). another research study conducted by martin, sobel, griest and howarth (2013) indicated that out of 273 third-grade students, 97% of them were at risk for acquiring nihl, that is, they were exposed to hazardous sound levels. a study conducted in 2006 by professor ray hull of wichita state university indicated that approximately 75% of high school seniors presented with a minimal hearing loss. youths also have a risk of acquiring nihl in movie theatres, as the sound levels can go as high as 118 db. from this study, ray (2006), cited in mazzola (2013), concluded that the probable cause of high school children’s compromised hearing was nihl because of prolonged exposure to elevated noise levels. therefore, over the short term, the effects of noise overstimulation may not be noticeable, but the accumulated effects of damaging incidents will eventually lead to significant hearing loss. it is important to highlight the redundancy of hair cells in the cochlea. there are many more sensory components than required; therefore, substantial cell loss can occur before there are clinical signs of a hearing loss. however, following repeated insults, the fixed complement of hair cells ultimately runs out. this is one reason why noise-induced damage in early years may not immediately be noticeable, but may become a problem later in life (harrison, 2008). therefore, the issue of nihl concerning school-aged children is a major cause of hearing loss, and hearing impairment amongst children and teenagers is increasing mostly due to voluntary exposure to loud noise (i.e., using plds or attending amplified music concerts) (daniel, 2007). the only treatment for nihl is hearing aids, but these do not fully restore normal hearing. this should serve as a motivation to provide substantial attention to hearing loss prevention in children (harrison, 2008). it is evident that nihl amongst youths is prominent, and hearing conservation programmes have an important place at schools. according to sekhar et al. (2014), nihl in primary school children goes undetected until later stages because hearing screening programmes used in schools are ineffective in detecting high frequency hearing losses. the hearing screening programmes were found to be more effective in detecting low frequency hearing losses as school-aged children most likely present with conductive hearing losses resulting from otitis media (sekhar et al., 2014). it is important that teachers are aware of the significant risks, effects of nihl and ways in which they can prevent it. one of the studies conducted by lass (1985) stated that teachers do not have enough knowledge about nihl. in 1988, a further study researched about the health books that teachers use at schools, and it was found that the books do not have enough information on how nihl should be prevented; however, they had sufficient information on the anatomy and physiology of hearing (frager, alan & khan, 1988 in mazzola, 2013). recommendations were made 30 years ago stating that hearing conservation education programmes should be implemented in all schools in the united states, but still the programmes are not being implemented effectively. this is evident in the rise of number of children acquiring nihl. a survey was conducted on the effectiveness of hearing conservation programmes at schools in florida, usa, which includes promoting and implementing hearing conservation programmes, educating the learners about the effects of loud noise on the quality of life, academic performance and social life (mazzola, 2013). only a few schools had successful hearing conservation education programmes. in other schools, the programmes were not successful because most teachers have limited knowledge on nihl, and they are expected to implement the programmes and be successful (mazzola, 2013). the centre for disease control stated that teachers’ lack of awareness and knowledge regarding nihl and its effects is the reason why the hearing conservation programmes are not successful at schools. problem statement many research studies have been conducted internationally to investigate the prevalence and the prevention of nihl in children; however, there is little research available on nihl in south africa. considering the specific risks that are often unavoidable in south africa, for example, exposure to excessively loud music in public transport vehicles, which is commonly a mode of transport in order to get to and from school as well as exposure at social gatherings and religious services, highlights the need for research specifically in the south african context. current international research focuses more on setting standards and guidelines for pld use. in south africa, research studies regarding the prevalence of nihl in youths are extremely limited. a study conducted in 2005 in gauteng, south africa, on teachers’ attitudes about hearing loss indicated that teachers do not have adequate knowledge, skills and training for effective implementation of hearing conservation programmes (pottas, 2005). no further studies focusing on nihl in youths have been performed. the who (2015) states that: children and adolescents must be educated about the possible dangers of exposure to loud sounds from the misuse of personal listening devices and encouraged to develop safe listening habits. such information should be part of the health education curriculum and also be taught as part of music and dance classes. (p. 15) the lack of research in south africa highlights the need to determine the knowledge and perceptions of primary school teachers regarding nihl, and hearing conservation is vital in order to identify possible solutions for effective implementation of hearing conservation programmes in schools. it may also create awareness that teachers and audiologists should work together for identification and management of learners with nihl and also in promoting nihl prevention programmes at schools. healthy behaviours are more easily established during childhood compared with adulthood. it would, therefore, be better for children to grow up in an educational environment whereby health promotion is emphasised in order to change listening habits and attitudes. this can only be achieved if teachers are aware of nihl as well as its effects. material and methods overview a descriptive research design was used for the purpose of this study, that is, a quantitative study whereby researchers seek to obtain insight and answer questions that the researcher has about the population of interest (de vos, strydom, fouche & delport, 2002). this research design was applicable to the research study as the researchers wanted to gain insight into teachers’ knowledge regarding nihl, without any attempt to change this. data were collected with the use of a survey. the main aim of this study was to determine the perception of primary school teachers (from grade 5–7) in pretoria, regarding nihl. the study also aimed to determine what and if any hearing conservation programmes are being implemented in schools and the need for training and education of primary school teachers regarding nihl and hearing conservation. participants a combination of purposive sampling (a form of non-probability sampling) and multistage sampling (i.e., division of the study population into clusters and stratifications) methods was used. the purpose of using the two methods was to increase the feasibility and efficacy in order to accomplish certain goals of the research design. from a population of 283 public primary schools in pretoria, a number of 164 schools were the representative sample. a 5% confidence interval and 95% confidence level was used to calculate the representative sample, which is most commonly used in quantitative research. to cover the population of interest, the sampled schools were clustered into urban (centurion, arcadia, pretoria west, pretoria central and pretoria east), semi-urban (ga-rankuwa) and rural areas (hammanskraal) with each cluster consisting of 55 schools. the selection criteria included qualified teachers, educating students in grade 5–7. as most of the literature regarding nihl in youths has focused on teenagers, targeting an age group before adolescence was deemed appropriate. all teachers that complied with the inclusion criteria were given the opportunity to participate in the study. materials semi-structured questionnaires were used. these are the kind of questionnaires that include both closeand open-ended questions. the questionnaires were adapted from two studies. the first study was that conducted by taljaard et. al. (2013) about plds and the prevention of nihl in children. the second one was that conducted by mazzola (2013) about the minority adolescent perceptions of perceived risk of hearing loss and hearing conservation. the questions were divided into four sections for the following purposes: section a: to obtain demographic information; section b: to obtain information regarding the perception and knowledge of teachers regarding nihl; section c: to obtain information regarding the perception and knowledge of teachers regarding hearing conservation; and section d: to determine the need for education and training of teachers regarding nihl and hearing conservation. refer to appendix 1 for the questionnaire. reliability is the consistency with which a measuring instrument yields a certain result when the entity being measured has not changed (leedy & ormrod, 2005). the researchers made sure that the questions in the questionnaire are topic specific and straight forward. double barrelled and leading questions or negative statements were not included. validity refers to the extent to which the instrument (questionnaire) measures what it is supposed to measure (leedy & ormrod, 2005). the researchers adapted questionnaires from previous studies with relevant, clear and simple questions to increase validity of the measurement instrument. a pilot study was conducted to increase the validity and reliability of the measurement instrument. no changes were made, and the participants of the pilot reported that the questions were clear and easy to answer. analysis a statistician was consulted to assist with data analysis. descriptive statistics (mean, standard deviation and variance) was used to analyse the different variables. the statistical packages for social sciences software was used to store and analyse the data. ethical consideration ethical approval was granted by sefako makgatho health sciences university research ethics committee (09 april 2015, smurec/h/93/2015:ug), department of basic education and principals from the participating schools. participants had to give written consent before completing the questionnaires and voluntary participation was emphasised. researchers ensured confidentiality by having the participants complete the questionnaires anonymously. the semi-structured questionnaires were sent to the participating schools together with consent forms via emails, with some being hand delivered. those that were hand delivered allowed clarification of questions and were collected immediately after being completed and some were collected a few days after completion. those sent through emails were emailed back to the researchers. results and discussion out of the 164 targeted schools, only 59 were able to take part in the study. the return rate was 5% (59/283), with 19 schools from the urban area, 20 from the semi-urban area and 20 from the rural area. de vos et al. (2002) stated that an acceptable return rate is 25% from the sample size. this suggests that the return rate for this study is low and cannot be generalised to the population of teachers in pretoria and other contexts. however, this study forms the basis for future research in this area and implementation of successful hearing conservation programmes in schools. section a: participant demographics figure 1 describes the participant demographics. figure 1: participant demographics. following statistical analysis, insignificant differences were found between teachers in urban, semi-urban and rural settings. this could be due to the fact that only seven universities in south africa provide teacher training and they are in urban settings. the results are therefore mostly reported by combining the responses from all the 219 participants. section b: perception of primary school teachers regarding noise-induced hearing loss from the results obtained, most of the participants were able to describe hearing loss as they knew people living with hearing loss but this was not in a school setting. this is because the majority of the participants were never exposed to learners with hearing loss in a classroom. consequently, only a minimal number (32%, n = 70) of the participants were able to describe the behaviours of a hearing impaired learner. according to peel (2004), hearing impaired children are excluded from regular education schools, thus mainstreaming education is not yet global in south africa. the results from this study, therefore, correspond with previous research as mostly teachers in special schools seem to be exposed to learners with hearing loss in the south african context. pottas (2005) stated that although inclusive education is something that is supposed to be practised nationwide in south africa, teachers’ negative attitudes towards hearing loss will firstly have to be addressed as they are the ones who are supposed to implement the inclusive education approach. teachers’ negative attitudes towards the inclusion of the child with hearing loss are related to their personal experiences with hearing loss. this results in teachers excluding learners with hearing loss from regular educational settings thus resulting in fewer regular schools that allow for teaching these learners. there is a clear contrast in results of research which was conducted in ohio, usa, which found that the majority of the respondents had classroom experience with teaching children with hearing loss. the research study was focused on teachers’ experience with hearing loss, educating children with hearing loss and their willingness to work with students with hearing impairment (hayes, 2014). in this study, only 26% (n = 57) of the participants indicated that they had experience in teaching learners with hearing loss, 74% (n = 162) had no experience within this area. furthermore, the majority (79%, n = 173) of the participants indicated that audiologists, teachers and parents are responsible for identifying hearing loss in learners. intensity of sounds was indicated as the most common risk condition for nihl, followed by the frequency of the sound and the duration of exposure to the sounds. non-occupational noise was identified as the least common risk condition. the majority of the participants indicated that all of the following are effects of hearing loss in order of most to least importance: academic failures, cognitive difficulties, language and speech difficulties, and social problems. these results suggest that the majority of the teachers have an idea of the impact of hearing loss in children; however, their knowledge in this area is limited as social problems, language and speech problems were indicated as the least common impact of hearing loss, and it is clear that they do not understand the cascading impact of hearing loss on a child in school. according to doyle and dye (2002), the impact of hearing loss in children has a specific order and these effects vary with the significance of the hearing loss. this order is as follows: speech and language difficulties, academic problems and social and emotional issues. the centre for disease control stated that teachers’ lack of awareness and knowledge regarding nihl and its effects is due to lack of training. other studies conducted by haller and montgomery (2004) suggest that teachers who are mostly aware of the various effects of hearing loss in children are those who have received training and thereby work in special schools. teachers’ knowledge regarding nihl indicated that 3% (n = 6) of the participants were of the opinion that hearing loss can be reversed, 86% (n = 188) said nihl can happen to anyone at any age and 10% (n = 22) thought that hearing loss can be reversed and can happen to anyone at any age. only one participant (0.5%) thought that hearing loss only happens to old people. the results suggest that most of the teachers are aware that nihl can affect any one at any age; however, a small percentage of teachers are of the opinion that nihl can be reversed. this emphasises the need for training teachers to work with hearing impaired learners. the teachers’ awareness of the characteristics of hearing loss will improve as they gain more experience and training in working with hearing impaired children (haller & montgomery, 2004). regarding the impact of noise exposure on hearing, 98% (n = 216) agree that loud sounds or music can damage hearing; however, 4% (n = 3) of the participants were not aware of this fact. supporting these results is a study conducted by richburg and goldberg (2005), who addressed teachers’ knowledge of and opinions towards minimal hearing loss. the study evaluated teachers’ perception of five myths about minimal hearing loss. amongst the five myths, one of them was that hearing conservation programmes are not necessary for students. the results of this study indicated that the majority of teachers reported that they think hearing conservation programmes are necessary for their students as they are frequently exposed to leisure noise which can lead to hearing loss therefore suggesting that they disagree with the myth. the impact of early identification and management of hearing loss was investigated. the majority 87% (n = 191) of the participants in all clusters know the importance of early identification and treatment of hearing loss. this is supported by the results of the study conducted by hayes (2014). in this study, teachers were asked if they were willing to make accommodations and work with learners that have hearing loss. a vast majority of teachers reported ‘yes’, that is, that they were willing to work with students with hearing loss in the classroom environment and make the necessary accommodations because they know that with appropriate management and support, their learners with hearing loss would succeed just like those without hearing loss (hayes, 2014). knowledge regarding the management of nihl is represented in figure 2. figure 2: management of noise-induced hearing loss. sixty percent of teachers have an understanding on how hearing loss is managed; however, 66% of the teachers never provide this kind of information to parents. furthermore, it was noted that the majority of the teachers that reported that they do provide the information were mostly the ones who reported having experience in teaching learners with hearing loss in class. this coincides with the statement by haller and montgomery (2004) indicating that teachers who are exposed to learners with hearing loss in the school setting are most likely the ones to be involved in providing parents with specific information regarding hearing loss and associated problems. regarding prevention of nihl, 69% reported that wearing hearing protection was the best way of preventing nihl. being fitted with hearing aids was the second most common answer. similarly, hayes (2014) conducted a study in ohio that focused on knowledge of teachers regrading hearing loss and assistive listening technologies. when the teachers were asked whether they agreed that preferential seating was enough for management of hearing loss, 31% of the 45 teachers reported that they ‘disagreed’ or ‘strongly disagreed’, 36% agreed and 33% had no opinion. these results suggest that the majority of the teachers were of the opinion that preferential seating is sufficient to support children with hearing loss in the classroom setting. these results could, however, be influenced by the manner in which the questions were posed or the options that the teachers were given to answer these questions. in the same study, the teachers were asked whether they are familiar with hearing aids as a form of managing hearing loss, and the majority of the teachers (77%) reported being ‘familiar’ or ‘somewhat familiar’ with the use of amplification devices. the study conducted in 1988 in the united states regarding limited information on hearing loss in teacher health books is clearly still relevant today and applicable to the south african context, as teachers still seem to have limited knowledge regarding hearing loss, and specifically the prevention of nihl (frager, alan & khan, 1988 in mazzola, 2013). section c: determining if any hearing conservation programmes are being implemented in schools and description thereof from the urban areas, 19% (n = 14) of the participants reported that they have hearing screening programmes, 6% (n = 5) from the semi-urban area and 16% (n = 10) in the rural areas. this suggests that the urban and the rural areas have more schools with hearing screening programmes than the semi-urban areas. however, overall only 13% (n = 29) of the schools from all clusters do have hearing screening programmes in place. it is also not clear if these hearing screening programmes are sensitive to identifying nihl. according to mazzola (2013), most schools did not have hearing conservation programmes and those ones who have programmes were not successful because most teachers have limited knowledge on nihl from the schools that do have hearing conservation programmes running, 8% (n = 18) of the schools indicated that these programmes have been functional for more than 3 years. national prevention programmes have been described in the united states (listen to your buds, dangerous decibels, it is a noisy planet), united kingdom (do not lose the music) and australia (cheers for ears, noise), (who, 2015); however, such programmes have not been initiated in south africa. the majority (94%, n = 206) of the teachers reported that they do not have the necessary equipment required to run these programmes optimally. the professionals in charge of running the hearing conservation programmes were as follows: from the urban areas, 9% (n = 7) of the participants indicated audiologists, 3% (n = 2) of them revealed speech therapists and 12% (n = 9) of them indicated nurses. from the semi-urban areas, 1% (n = 1) of the participants indicated audiologists and 2% (n = 2) revealed speech therapists. from the rural areas, 8% (n = 5) of the participants indicated audiologists and 13% (n = 8) revealed nurses. this suggests that the majority (19%, n = 25) of the school programmes are run by nurses in the urban and rural areas, with audiologists being the second most common professionals across all clusters. under normal circumstances, hearing screening programmes should be managed by educational audiologists as they are the ones who can train other professionals to effectively take part in the programmes (johnson & seaton, 2012). educational audiologists focus on children with hearing impairment within educational settings. duties include identification and management of hearing loss, aural (re)habilitation (hearing evaluation, language, auditory training, speech reading and speech conservation) and collaboration with teachers and school personnel in order to develop and implement individualised education plans (ieps) for each child identified with a hearing loss. informational and affective counselling and guidance for children, parents and teachers is a key responsibility for educational audiologists. the process of selecting, fitting and determining effectiveness of amplification is also an essential duty of educational audiologists, including participation in measurement of classroom acoustics and instructions for teachers with assistive technology. clearly, educational audiologists have the skills necessary to collaborate with teachers in order to ensure the academic success of children with hearing loss. with the guidance and support of educational audiologists, teachers can be provided with the necessary tools and education to make the appropriate adaptations for children with hearing loss and implement successful hearing conservation programmes (educational audiologist association, 2009). section d: determining if there is a need for training and education of primary school teachers regarding noise-induced hearing loss and hearing conservation the results obtained suggest that the majority (87%, n = 190) of the teachers from all clusters have not received any prior training. an even higher percentage (91%, n = 199) of the participants indicated that they would like to be trained. these results agree with those obtained by pottas in 2005. the study indicated that teachers do not have adequate skills and lack training for effective implementation of the hearing conversation programmes. although teachers are educated in the methodology of providing academic education to all students, they may lack detailed information regarding the specific needs of children with hearing loss in the typical classroom. however, with the knowledge and confidence to assist children with hearing loss in the classroom, teachers can promote academic success in this population as well as support hearing conservation programmes. the most preferred method of training and education was workshops (59%, n = 125); the second most common method was presentations (69%, n = 150) with posters (8%, n = 18) being the least common method. in a study conducted by thompson, pakulski, price and kleinfelder (2013), it was indicated that the most preferred method of training was the internet (49%), followed by journals (33.2%) and workshops (30.8%) were the least preferred methods. in the study conducted by hayes (2014), the teachers were not given options, they were only asked if they were willing to attend an in-service training and 50% of the teachers said they were unsure, 43% said yes and 7% said no. these results may be greatly influenced by the context within which the studies were done as well as the options that the teachers were given. conclusions and recommendations the main aim of this study was to determine the perceptions and knowledge of public primary school teachers regarding nihl in pretoria, determine if there are hearing screening programmes and also the need for education and training. the results of the study indicated that the majority of the teachers are aware of nihl and its effects on children. however, the results also proved that most of the teachers do not have adequate information on prevention and management of nihl. the results further indicated that most of the primary schools in pretoria do not implement early identification programmes as well as hearing conservation programmes. school-based hearing screening protocols have typically been designed with one of the two fundamental purposes as follows: (1) an educational orientation to identify children with a hearing loss that might have negative academic consequences or (2) medically oriented programmes designed for the early identification of existing health conditions that necessitate medical referral. therefore, a preventive approach for the purposes of identifying early signs of nihl has not been a focus for school-based hearing screening programmes (meinke & dice, 2008). although a mild high frequency sensory-neural hearing loss (snhl) is more common in this population, this can have a severe impact on academic achievements as children can miss up to 20%–30% in a classroom environment [american speech-language-hearing association (asha), 2011]. the need for training and education was also highlighted as most of the teachers are willing to receive training and education regarding nihl in the form of workshops and presentations. aspects that should be included in hearing conservation programmes for school-aged children should include information with regard to plds, type of earphones or headphones used, and other potential noise dangers for children that include powered garden and domestic equipment, such as mowers and leaf blowers, as well as the recreational use of firearms. use of hearing protectors should also be included, as well as clarification of the notion that it is not just the intensity of noise that is a problem but also the duration of exposure. from these results, the following recommendations are made: (1) training and educating teachers about nihl and (2) planning and implementation of hearing screening and hearing conservation programmes with an educational audiologist overseeing the programme. strengths of the study the study sample was obtained from different clusters, that is, urban areas, semi-urban areas and rural areas, representing all sectors of gauteng. furthermore, although the results of the study cannot be generalised, this study serves as an initial study that can be used to investigate hearing conservation programmes in other provinces and educational sectors. additionally, the majority (85%) of the participants were able to complete the questionnaires appropriately, suggesting that the questionnaire was clear and the participants understood what the questionnaire required and can, therefore, be successfully used in future research. the anonymous aspect of this survey could be representative of the truthful responses of the teachers as there could be no consequences from their answers. limitations of the study there were insufficient participants in order to generalise the results of this study to the larger population. the limited participants could be due to method of questionnaire delivery and limited time frame of the research project. nulty (2008) reported a trend in research of surveys from academic review from college students with lower response rates for electronic delivery of survey questionnaires when compared to paper delivery methods. teachers may be more likely to respond to a request hand delivered to them rather than emailed to them. in future studies, private schools in all provinces of south africa and teachers in all grades should be included in order to obtain information for a larger representation of the population. from the 258 questionnaires that were received back, only 219 of them could be used during data analysis. this is attributed to the fact that, firstly, teachers, who did not meet the inclusion criteria, completed the questionnaires and, secondly, not all the questionnaires were completed correctly. due to the small sample size, the results of this study may not be conclusive; however, it serves as an effective pilot study that can be used for further research and to highlight the need for teacher training. acknowledgements celeste coetzer, sefako makgatho health sciences university, department speech-language pathology and audiology, south africa co-supervised the research process. nditsheni dagada, veronica khumalo and helga mokota, sefako makgatho health sciences university, department speech-language pathology and audiology, south africa, performed data collection and analysis. donald tshabalala, sefako makgatho health sciences university (statistician) performed data analysis. competing interests the author declares that she has no financial or personal relationships that may have 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(2015). hearing loss due to recreational exposure to loud sounds: a review. geneva: world health organization. appendix 1 questionnaire instructions: please complete the following questions to reflect your opinions as accurately as possible and to answer the questions to the best of your knowledge. make a tick mark in check boxes for selection of options and use the space provided for answering the other questions. your information will be kept strictly confidential. section a: demographic information 1. gender □ male □ female 2. age □ 21–30 □ 31–40 □ 41–50 □ 51 and above 3. how many years have you worked as a teacher? □ 1 month-12 months □ 1 year-3 years □ 3 years-6 years □ 6 years-9 years □ more than 9 years 4. which grade(s) are you currently teaching? □ grade 5 □ grade 6 □ grade 7 section b: perception and knowledge of teachers regarding noise-induced hearing loss 1. how would you describe hearing loss? ________________________________________________ 2. has anyone you know, or have ever known had any type of communication deficits including hearing loss, cochlear implants, ringing in the ears, the use of hearing aids, etc. ________________________________________________ 3. hearing loss □ only happens to old people □ never happens to kids □ can be reversed □ can happen to anyone at any age 4. did you know that loud noise/music/sound can damage your hearing? □ yes □ no 5. who do you think is responsible for identifying noise-induced hearing loss in learners? □ audiologist □ doctor □ speech therapist □ nurses □ parents □ teachers 6. which of the following conditions do you think puts a learner at a risk of having noise-induced hearing loss? (you may choose more than one answer) □ loudness of sound □ frequency or pitch of sound □ duration of exposure □ non-occupational noise e.g. firecrackers, children’s toys, sporting events, car stereo etc. 7. which of the following do you think will be as a result of the noise-induced hearing loss? (you may choose more than one answer) □ academic failures □ cognitive difficulties □ language and speech difficulties □ social problems 8. do you know the impact of excessive loud sounds on hearing? □ yes □ no 9. do you think that learners with noise-induced hearing loss that are identified and receive early treatment can develop like learners with normal hearing? □ yes □ no 10. did you ever have a learner or learners with hearing loss in your class? □ yes □ no 10.1. if yes, how would you describe their behaviour? ________________________________________________ 11. how do you think noise-induced hearing loss is treated? □ avoidance of noise □ hearing protection □ hearing aids section c: perception and knowledge of teachers regarding hearing conservation 1. does the school have any programmes aimed at identifying learners with noise-induced hearing loss? □ yes □ no 1.1. if yes, describe the programme ________________________________________________ 1.2. how long has it been implemented? □ 0–12 months □ 1–2 years □ more than 3 years 2. is there a hearing screening programme in your school? □ yes □ no 3. if yes, who is in charge of the programme? (you can choose more than one answer) □ audiologist □ doctor □ speech therapist □ nurses □ parents 4. does the school have equipment that can be used by the above mentioned people in order to identify noise-induced hearing loss? □ yes □ no 5. do you provide specific information to parents to help them identify possible noise-induced hearing loss? □ yes □ no 6. which of the following ways is a good way to prevent hearing loss? □ wear hearing protection □ get hearing aids □ get closer to the noise □ turn up the volume section d: questions to determine the need for education and training of teachers regarding noise-induced hearing loss and hearing conservation. 1. have you ever received training and education on how to identify and work with learners who have noise-induced hearing loss? □ yes □ no 2. are you willing to receive more information, training and education about identifying learners with noise-induced hearing loss? □ yes □ no 3. if yes, in what form would you like the training and education to be? □ presentations □ workshops □ posters sajcd 247 revisiting the roles and responsibilities of speech-language therapists in south african schools a m wium,1 dphil; b louw,2 dphil 1 department speech-language pathology and audiology, university of limpopo, pretoria, south africa 2 professor emeritus, department communication pathology, university of pretoria, pretoria, south africa corresponding author: a m wium (anna-marie1.wium@ul.ac.za) the role of speech-language therapists (slts) in schools in south africa needs to be revisited based on the changing educational needs in the country. this article builds on a paper by kathard et al. (2011), which discussed the changing needs of the country with regard to the role of slts working in schools. south african policy changes indicated a shift from supporting the child to supporting the teacher, but also place more emphasis on the support of all learners in literacy in an effort to address past inequities. this paper addresses several of the questions that emerged from kathard et al. and explores the collaborative roles played by slts on four levels in the education context. collaboration at the learner level (level 1) focuses on prevention and support, whereas collaboration at the teacher level (level 2) is described in terms of training, mentoring, monitoring and consultation. collaboration can also occur at the district level (level 3), where the focus is mainly on the development and implementation of support programmes for teachers in areas of literacy and numeracy. collaboration at the level of national and provincial education (level 4) is key to all other roles, as it impacts on policy. this last level is the platform to advocate for the employment of slts in schools. such new roles and responsibilities have important implications for the preparation of future slts. suggestions for curricular review and professional development are discussed. it is proposed that saslha responds to the changes by developing a position statement on the roles and responsibilities of slts in schools. keywords: roles and responsibilities, collaboration, south africa, speech-language therapists, teachers, learners, literacy, communication s afr j cd 2013:60:31-37 doi:10.7196/sajcd.247 significant changes have occurred in the education landscape over the past two decades. this requires a critical review of the roles and responsibilities of speech-language therapists (slts) and the education context. the process of redressing past inequities aims to benefit all learners equally. the current focus on inclusive education created a dire need for support of both teachers and learners, thus placing new demands on slts in the schools. the traditional pull-out model is now considered to be inappropriate, and replacement with the collaborative/‘push-in’ model of service delivery has been suggested (earley & bubb, 2004). furthermore, the scope of the profession has expanded and slts are also required to provide language and literacy support to all learners in the classrooms. in addition to endemic issues in the education system, existing contextual factors such as language issues (e.g. the multilingual population, the dearth of speech-language pathologists (slps) proficient in african languages, and the preference of many parents for english as language for learning and teaching (elolt) (du plessis & louw, 2008) further complicate the role of the slt in schools. in addressing these crucial issues in schools certain key questions need to be addressed, namely how should slts go about their work in schools to have maximum benefit for both learners and teachers, and what are the implications of such suggested changes for training of future professionals? currently two documents are available that guide slts in schools, namely the south african speech-language hearing association (saslha) document for private practitioners working in schools (south african speech language and hearing association standards and ethics committee, 2007) and the american speech-language hearing association (asha)’s guidelines (2010) on the roles and responsibilities of slts in schools. the current set of guidelines for the provision of speech-language services by private practitioners in schools that was compiled by the saslha ethics and standards committee (2007), focuses mainly on the practicalities of setting up private services in a school setting. it includes guidelines on contractual issues, the referral process, screening procedures, and consent from parents, record keeping, supersession, fees and arrangements regarding language enrichment programmes. the guidelines state that whenever language enrichment programmes are required by the school, the slt needs to act as consultant and facilitator to teachers and parents, on condition that the costs should be carried by the school. these guidelines were intended to regulate professional behaviour rather than addressing the specific roles and responsibilities of the slt in schools. however, because of the changes in the education system and the expansion of the profession, a need for more comprehensive guidelines that would formalise the roles and responsibilities of slts in the education system was identified by kathard et al. (2011). these authors conclude that it is imperative to take further action to ensure that the speech-language therapy and audiology (slta) professions participate meaningfully in supporting basic education. the current article responds to the call for action by kathard et al. (2011) to critically address the roles and responsibilities of the slt in south african schools. in response to a recent call from the health professions council of south africa (hpcsa) (2012) to guide and document roles and responsibilities of slts in schools, the aim of this article is to critically review and explore the roles and responsibilities of slts in the schools and to consider the implications for professional and university training programmes. ehren (in kathard et al., 2011) suggested that such a definition of the roles of slts be guided by specific questions (refer to fig. 1). each of these questions is considered individually, although this article focuses on the third question which relates to the roles of slts in schools. fig. 1. a critical review of the roles and responsibilities of slts in schools (based on ehren, 2011 in kathard et al., 2011). what are the needs of south africa? education is the backbone of an economy as it develops human potential. however, education outcomes are currently not met in south africa, despite policy changes which aim at creating equal opportunities for all through the policy of inclusive education (department of education, 2008), and a revised national curriculum statement that was presented as curriculum assessment policy statements (caps) (department of basic education, 2010). the current education system is not meeting the needs of the country. learners’ performance in literacy and numeracy have been found to be unacceptably low (motshekga, 2011). in order to become globally competitive, it is of the utmost importance to increase learner performance. in an effort to raise education standards, literacy and numeracy, as well as teacher training and support, have since become national priorities in basic education. slts have an important role to play in this regard. what has to happen in education to create the type of citizen that south africa wants? in order to improve the quality of education, several systemic issues need to be addressed to create an environment conducive to teaching and learning: grade r is now included in the formal curriculum, and has become mandatory to prepare young learners for formal education and to reduce underpreparedness from 2014 on. diversity needs to be accommodated by allowing learners to be educated in their home language until grade 3, and learners learning in a language other than their own, need to be supported (kathard et al., 2011). there is a need for adequate facilities and resources, and their proper management. there is also an urgent need for more effective leadership and management of schools, which is being addressed at national and provincial levels. in order to eliminate underperforming schools the national government currently invests a significant portion of the national budget for infrastructure improvement, school nutrition, scholar transport, school safety initiatives and learning materials to facilitate learning (creecy, 2009). the number of learners in foundation-phase classrooms needs to be reduced. the new curriculum requires more parent involvement in the support of their children. the central role of teachers is acknowledged, but they need to be in class, on time and teaching. more teachers are required, and those currently in the system have to be retrained and supported to implement the curriculum (motshekga, 2011). slts are well equipped to support teachers with in-service programmes in facilitating language for literacy. what are the roles and responsibilities of slts in south africa to contribute to the grand plan? the scope of practice of speech-language therapy has grown and expanded over the years. similarly to the situation in south africa, asha was driven by educational reforms, legal mandates and evolving professional practices. these developments led to a redefinition of roles and responsibilities of slts working in schools, with the focus on four areas considered to be integral to service provision: critical roles, range of responsibilities, collaboration, and leadership (asha, 2010). these four areas are equally relevant to the south african context, but application needs to consider specific south african contextual needs. critical roles in education slts have integral roles in education and are essential members of school facilities. they need to share in the responsibility of attaining educational goals. this implies that they work across all educational levels, which requires them to understand the curriculum with its learning outcomes and assessment criteria. slts need to understand how to make adaptations for learners with special educational needs. in south africa inclusive education policies are in place, which require slts to work with children with a range of communication and speech-language disorders. slts have to understand how the curriculum ‘...provides the context... not the content of intervention’ (ehren, in kathard et al., 2011), as well as understand specialised curricula and integration of services. slts need to ensure educational relevance and address issues (e.g. culturally relevant and linguistically appropriate services) in their assessments and interventions which could impact on educational goals. it requires them to differentiate between language difference and a language disorder, work with interpreters and translators to accommodate culture and diversity (sowden, 2007), and to develop and translate assessment tools and materials for the local context (pascoe & norman, 2011). above all, assessment and intervention practices are required to be evidence-based. it is important to understand the impact that communication disorders have on the child as a whole (e.g. in terms of personal, social/emotional, academic, and vocational needs). such a holistic approach is also applicable in contexts where slts work in special education and they are required to be proficient in treating feeding and swallowing impairments and be aware of the effect of such difficulties on the child as a whole. the complexities of the clients and contexts, as well as the diverse scope of practice, require a range of roles and responsibilities when slts are working in education contexts. range of roles and responsibilities the range of roles and responsibilities of slts in the education system are varied. the professional issues statement of asha (2010) corresponds to the exit-level outcomes specified for slt graduates by the hpcsa (2005): prevention: slts need to contribute to the prevention of academic failure in an evidence-based approach. it requires slts to support all learners in literacy (particularly in the foundation phase), and to collaborate with teachers. in south africa prevention of language problems can be done through making teachers aware of the role of language in learning, the nature and consequences of language problems, as well as how to adapt their language to meet learners’ needs (o’connor & geiger, 2009). assessment: slts need to conduct assessments in collaboration with others in order to identify learners with communication disorders. assessment results need to inform instruction and intervention, which is consistent with evidence-based practice (ebp) (asha, 2010). the implication is that in south africa slts need to be skilled to use standardised and authentic assessment tools and techniques. currently this is a challenge because of the dearth of assessment measures developed in, and normed for african languages. in south african schools slts are often required to assess english as an additional language (eal). there is also a dire need for slts to develop assessment material that meet the diverse needs of their clients (pascoe & norman, 2011). whenever necessary, slts have to consult with professionals from other disciplines (e.g. teachers, occupational therapists, psychologists, physiotherapists, etc.) to obtain their input to plan suitable assessment and intervention. currently there is little evidence of local interdisciplinary collaboration in terms of assessment practices in the education system (kathard et al., 2011). this may impact on the reliability of assessments and the eventual treatment outcomes. intervention: slts are required to provide intervention that is appropriate to the age and learning needs of each individual learner, and is selected through an evidence-based decision-making process (asha, 2010).when dealing with learners with disabilities, the therapy techniques are clinical in nature as service delivery models are typically more diverse in the school setting than in other settings. slts working in the education system in south africa, however, also have to focus on literacy and the role of language in both special and mainstream schools (kathard et al., 2011) in order to improve education outcomes. programme design: it is essential that slts configure school-wide programmes that employ a continuum of service delivery models in the least restrictive environment for learners with disabilities, and that they provide services to other learners as appropriate (asha, 2010). south african schools require that slts are skilled in whole-class intervention, which implies working with larger groups. currently the trend in south africa is for intervention to be provided mainly by private practitioners who work with individual learners and small groups. however, whole-class intervention programmes in the foundation phase to support teachers and learners, and which focus on the development of language skills to underpin the curriculum, are required. slts have a particular role to play within this approach. their expert knowledge of language, phonology and literacy make them ideally suited to provide teacher support in the schools (o’connor & geiger, 2009). it also requires collaboration at district and provincial levels to implement such programmes. data collection and analysis: according to asha (2010) slts are accountable for their clients’ outcomes. slts in south africa have to base their decision making on reliable data and therefore need to plan the collection of data during treatment and interpret such data (either for individual learners or for overall programme evaluation) to ensure that decision making is indeed data-based. in addition, they share the responsibility for learners’ outcomes with educators (asha, 2010). compliance: slts are responsible for meeting government policies in performance of their duties (asha, 2010). in south africa, slts have to comply with national and provincial regulations, as well as guidelines compiled by saslha (2007), and the hpcsa (2005). although individualised education plans (iep) are not required by all schools, slts are encouraged to develop such plans to ensure appropriate and effective treatment. the roles and responsibilities of slts in education contexts have changed and increased significantly over the past decade. in view of the current needs of the country, learners, as well as teachers, need support in literacy and language in order to raise education standards. this turns the focus to the collaborative role of slts working in education contexts. collaboration in the educational system political reform resulted in the department of education (doe) drastically reducing positions for slts in schools in south africa. such measures resulted in private practitioners becoming more involved in providing services to learners with communication disorders however, such services are not accessible to all learners, as private practitioners are mostly remunerated by medical funds and/or parents who have the means to do so. the collaborative approach, as recommended by the doe, focuses on identifying and managing barriers to learning at the learner, teacher, curriculum, and institutional levels (doe, 2001b). collaboration is therefore an integral part of all four levels as depicted in the concept map in figure 2, which was created based on an in-depth literature review. fig. 2. the levels of collaboration of slts in the education context. level 1. collaborative support to learners the ultimate aim of all intervention practices in schools is to benefit learners. at the learner level the slt needs to play a preventive and supportive role. prevention of communication disorders is one of the exit-level outcomes specified by the hpcsa (2005). this includes the prevention of further learning problems (hpcsa, 2005), which is a broadening of their previous role which focused mainly on learners with communication disorders. within an inclusive approach they are required to provide all learners with support in communication skills (including literacy), which relates to their role on level 1 as depicted in figure 2. this calls for active engagement in planning, implementing and monitoring learners’ progress, depending on the age and ability levels of the learners. prevention is best conducted by providing preschool and foundation-phase learners with suitable intervention for literacy development and by addressing reading and writing skills in older learners (asha, 2010). as was pointed out by kathard et al. (2011), it is imperative that young children acquire adequate listening skills, as it allows them to perceive speech in a meaningful manner. the facilitation of listening skills allows learners to become competent in the use of language, which is a prerequisite for the acquisition of literacy skills. learners need to develop metalinguistic skills to identify and analyse specific sounds to enable them to read and write. the acquisition of language skills is equally important for the development of numeracy, as it relies particularly on vocabulary and problem-solving skills. learners who do not have adequate and age-appropriate listening and language skills when entering formal education may be at risk for academic failure. the inability to perform academically, in turn, may cause problems such as low self-esteem, social maladjustment, and ultimately vocational problems. academic failure can be prevented by ensuring that learners acquire age-appropriate listening and language skills preferably before they enter formal education. however, this is not possible in all cases in the south african context. for learners in many contexts these skills need to be targeted in the foundation phase with support provided to both teachers and children by the slt. part of slts’ roles in classrooms is to identify and support learners with language disorders and also to focus on foundational language elements that support mastery of subjects (kathard et al., 2011). they should focus on language for learning and include listening, reading, writing and speaking (o’connor & geiger, 2009). slts have an important role to play to support all learners, whether providing intervention directly or indirectly. level 2. collaborating with teachers riley and roach (2006) singled out the support of teachers as the key to high-quality early childhood development programmes. this has implications for the extension and growth of teachers on a national level (fig. 2). the provision of continued professional development (cpd) activities is an important form of support to teachers (wium & louw, 2011). slts can contribute to learners’ achievement as such teacher support has been found to be significant, particularly for learners in low-achieving, low-income urban and rural schools (johnson, mims-cox & doyle-nichols, 2006). working within a collaborative approach in schools requires that a range of service delivery models need to be considered, depending on the context and the needs of the learners and teachers (cirrin et al., 2010). teachers need to be supported through a process of training, mentoring, monitoring, and consultation. because of the relationship between language, literacy and learning, it is imperative that teachers and slts work as a team in supporting learners in their acquisition of literacy. team members need to firstly respect each other and show an ability to work towards similar outcomes. the collaborative model of support encourages team members to share their disciplinary knowledge. slts could share their knowledge of facilitating communication, language development and literacy acquisition, whereas teachers could provide insight into the context, the process of teaching and learning, the learners and the curriculum (kathard et al., 2011). based on their knowledge and expertise in communication and language, slts have much to offer teachers and other education role players in the form of continuing professional development (cpd) activities to enhance the performance of learners in schools (asha, 2010). in addition, teacher support in the form of cpd activities contributes to a school culture and ethos that make teachers feel valued and motivated, renews their enthusiasm and prevents burnout (earley & bubb, 2004). roles of teachers the norms and standards for teachers (doe, 2000) assigns specific roles to the practice of teachers. teachers have to be: ‘...mediators of learning, interpreters and designers of learning programmes and materials, leaders, administrators, and managers, scholars, researchers and lifelong learners, community members, citizens and pastors, assessors and learning area or phase specialists’. teachers need not only to be masters of the content of their subjects, but should also understand how children learn. since the inception of the revised ncs in 2002, teachers have been expected to make a paradigm shift regarding their teaching and learning practices in the classroom (doe, 2006). collaboration is a two-way process; therefore, teachers as curriculum experts need to guide the slt in curriculum matters, and support him/her in managing large groups, e.g. whole-class teaching (bauer, iyer, boon, & fore, 2010). collaboration requires that teachers allocate time in their schedule for the slt to discuss specific learners, the learning objectives and how these can be achieved. with reference to the preventive role of slts, teachers can work with slts to include all learners in the classroom (whole-class teaching), which relates to the principles of outcomes-based education. roles of slts the collaborative role of slts in schools is to work with teachers, other professionals and parents to meet the learners’ needs. slts need to develop an understanding of the roles of all professionals working in schools (e.g. occupational therapists, school psychologists, social workers, etc.). collaboration will enable all parties to share their knowledge and expertise in the planning and assessment of learners at team meetings. if children are to be viewed holistically, collaboration should extend to their home environments as well. collaborating with parents is integral to supporting the child as communication is central to the social, emotional, and academic development of young children (owens, 2002). this aspect remains challenging in south africa. although parent involvement is seen as integral to the education of a child (doe, 2002) it is not often observed in under-resourced contexts (o’connor & geiger, 2009). slts have to explore and find ways to collaborate with parents and include them as partners to work towards improving language development and/or other communication problems. within a systems approach, not only teachers and parents should be involved in supporting the child, but the whole community. slts working in schools are part of the school community and therefore are responsible for presenting talks and information to parent associations and school governing bodies on how they can provide support to learners and teachers. for example they can be encouraged to make donations of resources (e.g. scrap paper, books, volunteer to support reading in grade 1 classrooms), or donate equipment for schools that will enhance learning (e.g. fans, carpets). being part of the school community will require slts to participate in fund-raising activities that will allow the school to employ additional staff. it should be cautioned that slts exercise careful time management so as not to lose focus of their primary roles in the school. collaboration is further extended to assuming leadership roles in the school setting where slts have to articulate their roles and responsibilities and ensure delivery of appropriate slt services. slts must advocate for appropriate programmes and services for learners. apart from allocating time for assessment and intervention, they need to be allowed sufficient time for planning, meetings, consultation with parents and other professionals. slts also need time to attend professional development activities for cpd accreditation purposes and professional growth. asha (2010) states that slts have a responsibility to articulate their roles and responsibilities to teachers, other school professionals, administrators, support personnel, families, and the community. they also need to work to influence the development and interpretation of laws, regulations, and policies to promote best practice. another leadership role of slts working in schools involves the supervision and mentoring of new and inexperienced colleagues in the school context, as well as providing supervision to university students. this leadership role requires slts to engage in research, as it is important for evidence-based practice, particularly on collaborative practices related to assessment and intervention practices (asha, 2010). slts, as expert practitioners, should continually seek new information to improve intervention effectiveness. despite the emphasis on collaborative practices in schools, inter-professional collaboration remains challenging. giess et al. (2012) reported that slts at times experienced themselves as assistants to the teacher, which is unacceptable as it does not allow them to focus on their specialised skills regarding language and literacy intervention. in south africa, slts working in schools often experience the situation where teachers prefer them not to be in their classrooms (personal communication, e. naude, august 2012). such challenges can only be overcome when teacher and slt training programmes emphasise working as a team as best practice, and by an effort from both disciplines to regard these challenges as opportunities to solve problems as a team (giess et al., 2012). in south africa the understanding of collaborative practices between slts and teachers is in the development phase. in some contexts teachers are positive about it (du plessis & louw, 2008), while others do not share the same feelings. effective collaboration between slts and teachers requires that both parties understand their individual roles, and that slts take the educational environment into account. it is necessary to identify each discipline’s individual knowledge base and approaches, as well as the new knowledge, skills and approaches required to work together in supporting learners in south african classrooms. level 3. collaborating at district level according to the doe (2001a) slts’ supportive role needs to expand to district levels (see level 3 in fig. 2) as well. at district level slts can assist in the planning and implementation of support programmes for teachers. considering the number of primary schools in south africa (kathard et al., 2011), slts will be best applied at level 3 where they could have maximum effect on a much larger number of teachers. slts could function as members of a support team which plans and implements support programmes for teachers, but could also visit schools and classrooms on a rotation basis to identify learners who experience challenges (particularly with literacy and communication). such support will allow teachers to plan and facilitate language and learning, e.g. by implementing a balanced approach to literacy where there is an integration of the whole-language and phonetic approaches (paul & norbury, 2012). according to education white papers 5 and 6 (doe, 2001a, 2001b), specific needs of individual learners may be addressed within the school context, or alternatively learners will be referred to full-service schools, where they will receive the necessary support from a team of professionals, but remain integrated in mainstream classrooms. learners who experience severe challenges will be referred to schools for learners with special needs (doe, 2008). this will require involvement of teams at district level. level 4. collaborating at strategic level slts also have a collaborative and consultative role to play at the level of strategic planning, which occurs at provincial and national levels (level 4 in fig. 2). slts need to promote the profession by creating an awareness of their important role in contributing to learners’ educational success and enabling all learners to meet their education goals. by becoming involved at the provincial and national education levels, slts may contribute to regulations and policies (kathard et al., 2011), which in turn may impact on their role in schools (levels 1 and 2). in south africa it is important that slts continue to advocate for positions for slts in schools, which is currently the case with saslha engaging in such discussions with the doe (kathard et al., 2011). collaboration at the strategic level (refer to level 4 in fig. 2) will ensure that all learners, particularly those who are vulnerable and at risk for educational failure receive the support they are entitled to. these roles and responsibilities of slts in schools, as depicted in figure 2, have important implications for training curricula and continued professional development in south africa. such support on all four levels can contribute significantly to meeting the grand plan of the country. are these roles contributing towards the grand plan? in answer to the fourth question, slts as expert practitioners should continually seek new information to improve intervention effectiveness. it is necessary for slts to participate in research to generate and support the use of evidence-based assessment and intervention practices (asha, 2010). they need to develop a deeper understanding of the nature of learning, teaching and the educational process. practice-based evidence (pbe) provides the necessary information for decision making. education officials need such data for planning and implementation of strategy to improve education outcomes, which links the role of slts in education with the fourth level (refer to the strategic level in fig. 2). based on such evidence, and with regard to the current needs of the country, it is suggested that the doe implements a policy that employs slts in schools. such a policy also has to define their specific roles and responsibilities. the service delivery models to be used in schools, as well as curriculum training guidelines, would have to be developed. it is suggested that the monitoring of service delivery be done as a joint effort between the hpcsa and the doe. slts therefore have a crucial role to play in providing support at learner, educator, curriculum and strategic levels. however, the changing roles and responsibilities of slts in schools have a range of important implications. implications of the new roles and responsibilities for professional preparation and development the requirements of the world of work raises the question of how well future slts are prepared to perform these roles and meet the challenges of providing services to both learners and teachers in schools. it is important to critically assess whether the theoretical course work content of undergraduate students and the application to clinical practice in the schools is sufficient to prepare them to become independent school-based clinicians. universities have long been striving to implement contextually relevant training, and because curricula can never be static, but have to adapt to meet the changing needs of the country, it is necessary to continuously review curriculum content. implications for undergraduate curricula one of the issues to be considered for the curricula will be implementing inclusive education, which requires that slts move away from the ‘pull-out’ model of service delivery, and increasingly make use of the collaborative/‘push-in’ model as it allows learners to receive direct therapy from the slt without missing out on classroom instruction. the ‘push-in’ model of support where learners are supported in the classroom is most suitable for learners who are struggling with the learning material because of language difficulties (office of special education and student services, 2011). the preparation of university students therefore needs to address supportive strategies for both learners and teachers. for some learners, practitioners may want to initially use a direct, rather than an indirect, approach. newly acquired skills should ideally be generalised through a more indirect approach in the classroom. slts traditionally used the pull-out model of service delivery, as their professional training experiences required them to provide individual and group intervention outside the classroom (brandel & loeb, 2012). classroom support (‘push-in’ model) is not necessarily the answer to all interventions, as the pull-out model may still be used to provide specialised instruction for learners with, for example, articulation, language, voice, fluency, or swallowing disorders. the decision to follow the pull-out model will be determined by the nature and severity of some disabilities, or the needs and characteristics of the client (brandel & loeb, 2011; cirrin et al., 2010). another option to be considered is that of community-based instruction where learners are given the opportunity to generalise their skills in community settings (e.g. use of augmentative and alternative communication devices). in line with collaborative practices slts may want to consider co-teaching, team-teaching, or make use of peer-learning strategies (owens, 2002). it is agreed that team-teaching, where both teachers and slts play equal roles, is the most appropriate method within a collaborative approach (giess et al., 2012). team teaching strategies such as paraphrasing of information, creating graphic organisers, and teaching strategies for vocabulary learning (office of special education and student services, 2011) are valuable tools to use in classroom settings. the decision regarding the model of service delivery needs to be a joint decision of the slt and the teacher. the curriculum should therefore equip slt students with knowledge about team work, specifically team building, role release and the management of conflict. in a collaborative model of support, teachers learn to reinforce speech, language and literacy goals and to assess the learner’s progress. they have to learn to implement specific techniques that will be of benefit to all learners and not only those with communication disorders. slt students should not only learn about the collaborative model in their theoretical coursework, but also be provided with opportunities to gain clinical experience in working in the classroom and to adapt the curriculum for learners with special needs. strategies for sequencing and for developing narratives are also relevant for a curriculum. students should learn how to provide cues and prompts to specific learners, and modify the language level of instruction to meet individual learners’ needs. there may also be a need for small-group instruction in the class, and students should be prepared for it. in south africa, public service has an obligation to support universities in preparing students for the workplace, as universities generate future employees and colleagues. slts working in schools often collaborate with university training programmes to provide invaluable clinical supervision to university students. it is important that both universities and slts in schools collaborate to provide students with high-quality and relevant training to adequately prepare them to function as efficient professionals in the school setting. slts as supervisors could also involve students in practice-based research where they take part in intervention data collection, literature reviews on clinical issues, or have students participate in clinical research projects. means (2009) suggested that curricula address legislative policies related to education, contextually based assessments, curriculum and therapeutic integration, assessment criteria of the various grade levels, and the use of the workload model rather than caseloads. it was also suggested that universities increase collaboration with school sites through the use of supervisor survey feedback which would allow pedagogical changes, and by inviting school-based slts as guest lecturers or guest speakers. slt students need to be well prepared in conducting valid and reliable assessments. the use of standardised tests is a challenge in the south african context with eleven official languages (pascoe & norman, 2011). students therefore have to make use of alternative assessment methods, and need to be trained to do so. practical experiences should allow students to provide therapy, monitor progress and write assessment and evaluation reports specifically in school contexts. university training programmes should ensure that slp students are equipped to address multiple speech-language problems (giess et al., 2012). the emphasis on literacy by the doe requires slts to work with whole classes, which necessitates that students learn the skill to work with large groups. university training programmes should therefore create opportunities where students collaborate with teachers to present curriculum content (e.g. phonological awareness) to the entire class. furthermore, interprofessional education, where slts and education students could share course work and clinical experiences and learn to collaborate pre-professionally, is an exciting new avenue for universities to explore. because collaboration is one of the key roles of slts working in schools, this aspect should not only be addressed in theory, but should be experienced in practice. the problem may arise that students doing their practical training in school contexts are supervised by slts who have not yet adapted to such a shift (means, 2009), and continue to adhere solely to traditional ‘pull-out’ service delivery methods. it is therefore important to ensure that the supervisors are comfortable with collaborative practices as they are role models to students. universities have an important role to play in terms of cpd to inform and familiarise supervisors with such practices. slp students who are trained and prepared to collaborate in school/education contexts may feel more confident to enter the schools and to provide high-quality services which will be to the benefit of both the learners and teachers. curriculum content therefore needs to cover the expanding role and responsibilities, as well as current information regarding the education system in south africa. training in collaborative strategies and methods for implementing support for the learner and the teacher, at the district and the national level, is imperative. slts have to become familiar with the caps and although it is not expected that they become curriculum experts, such as is required of teachers (doe, 2000), it is necessary that they develop a basic understanding of the curriculum (kathard et al., 2011) and focus on the linguistic and meta-linguistic foundations of curriculum learning. in south africa slts are required to emphasise the importance of language and the role of language in literacy (e.g. listening, speaking, reading and writing), as well as in numeracy. in the usa concerns were raised with regard to the preparedness of slps for schools (giess et al., 2012; means, 2009). to respond to these concerns, asha’s special interest group (sig) 16, school-based issues, developed a university outreach committee document for training programmes to prepare slp students to work in schools (giess et al., 2012). this document on the ‘roles and responsibilities of speech-language pathologists in schools’ (asha, 2010) provides learning outcomes, formative assessments, projects and suggestions for training programmes for use in the preparation of students to work in schools. based on the asha (2010) document and the process described by giess et al. (2012), it is proposed that a resource document be developed for south african slp training programmes to prepare students for careers in schools. such a document should specifically address the role of collaborative support as depicted in figure 1. this would ensure that future slts are well prepared to enter the school system to perform the crucial role of partnering and collaborating with other professionals to meet learners’ needs in the local context. it could also be beneficial for university supervisors to engage in professional discussions on curricula and coursework weaknesses and collaboratively develop basic coursework that address school-based issues. implications for professional development the changing roles and responsibilities of the slt in schools also necessitate consideration of educational opportunities for professionals. presenting cpd opportunities on collaborative methods and strategies in the classroom to both slts and teachers will strengthen the collaborative role of slts in the school system. using slts who are already working within collaborative frameworks in schools as guest lecturers and workshop presenters will further this cause. traditionally slts were trained in university clinics with a clinical perspective of use of standardised assessments (means, 2009: 97), which relates to the medical or specialist’s model. in order to work in schools slts now need an educational background which also emphasises the integration of school-based curricular concepts and non-standardised assessment methods to be used in the south african context. many of the slts currently working in schools may require re-skilling through cpd programmes to make a mind-shift from pull-out to collaborative service delivery models. these slts could then further support student training. conclusion a critical review of the changing role of the slt in schools in south africa has major relevance to the important question regarding the grand plan (ehren, 2011 in kathard et al., 2011). slts can make an essential contribution to education and preparing citizens of the future if the roles and responsibilities of the slt in schools can be formalised in a document by saslha, if negotiations with the doe can result in a structure to employ slps in schools, and if training curricula can be guided by a professional document. such actions would assign a key role to collaboration and secure the future of slts in schools. currently there is a shortage of slts working in the schools in south africa. at present many learners are served by slts contracted by individual schools or parents, and in some cases by slp students during their clinical practicum. it is important that sashla, as the professional body, continues to advocate for the profession. the possibility of community service in school contexts where the need for increased education outcomes are most pressing should be considered (kathard et al., 2011). the changing roles and responsibilities of slts also point to the urgency for undergraduate training curricula to reflect these changes and to prepare students to develop as independent school-based clinicians. in conclusion, there is a pressing need for saslha to establish a specialist task team to address the issues raised in this article. firstly, it is suggested that a research-based, collaborative approach be followed to determine what training programmes currently offer and what suggestions they may have to prepare students for careers in the schools. in addition teachers, education officials, and teaching programmes need to be consulted in a true collaborative fashion to determine their needs and suggestions. based on these results, recommendations for slt curricula and interprofessional education opportunities could be formalised for university training programmes. secondly, a need was identified for a new official document that guides the roles and responsibilities of slts working in schools. saslha has a proud tradition of responding to changes in and challenges of the south african landscape and one of the association’s objectives is to act as a resource for its members. the development of such a guideline would ensure optimal outcomes for learners. such actions by saslha would contribute to forging the future development of contextually relevant practice in south african schools to the benefit of both the learners and the teachers. references asha. 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(2011). teacher support – an exploration of how foundation-phase teachers facilitate language skills. south african journal of communication disorders, 58 (2), 86-94. doi:10.7196/sajcd.66 abstract introduction methods and materials results discussion limitations, implications and recommendations conclusion acknowledgements references about the author(s) nasim b. khan discipline of audiology, faculty of health sciences, university of kwazulu-natal, durban, south africa nolwazi mthembu discipline of audiology, faculty of health sciences, university of kwazulu-natal, durban, south africa aishwarya narothan discipline of audiology, faculty of health sciences, university of kwazulu-natal, durban, south africa zamahlase sibisi discipline of audiology, faculty of health sciences, university of kwazulu-natal, durban, south africa qiniso vilane discipline of audiology, faculty of health sciences, university of kwazulu-natal, durban, south africa citation khan, n.b., mthembu, n., narothan, a., sibisi, z., & vilane, q. (2022). health sciences students’ perception of the communicative impacts of face coverings during the covid-19 pandemic at a south african university. south african journal of communication disorders, 69(2), a890. https://doi.org/10.4102/sajcd.v69i2.890 original research health sciences students’ perception of the communicative impacts of face coverings during the covid-19 pandemic at a south african university nasim b. khan, nolwazi mthembu, aishwarya narothan, zamahlase sibisi, qiniso vilane received: 31 jan. 2022; accepted: 27 mar. 2022; published: 27 july 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the use of face masks and/or shields can pose a challenge during communication. they block facial expressions thus removing visual cues and affect sound transmission making it difficult to hear speech clearly. given the widespread use of face coverings, it seems reasonable to clarify if communication in typical speakers and listeners has significantly differed. health science students as future practitioners need to understand challenges that arise from using face coverings. objective: this study aimed to determine health sciences students’ perception of the communicative impacts of face coverings. method: the study employed a descriptive, self-administered online survey, obtaining information from 96 health science undergraduate students. results: all participants changed their manner of speaking in that they spoke louder when wearing masks and focused more on eye contact when someone was wearing masks. these were statistically significant (p = 0.450 and p = 0.035 respectively). fifty-three percent reported using more listening effort and feeling anxious when communicating. approximately 33% indicated that it was challenging to read emotions, such as sad or unhappy, when someone wore a mask. most, 61%, were positive or very positive about wearing masks. the level of difficulty differed depending on the listening environment. it was harder to understand the doctor, nurse, or other healthcare workers when they wore face coverings than when listening to their friends and family, which had little effect, this being statistically significant (p = 0.025). conclusion: challenges envisaged in practice included frequent communication breakdowns, inability to connect and build trust between patient and practitioner, and communicating in noisy environments. coping strategies, future clinical and research implications were proposed, and limitations acknowledged. keywords: communicative impacts; face coverings; covid-19 pandemic; perceptions; challenges. introduction the covid-19 pandemic has rapidly transformed the delivery of healthcare services globally. everyone has to wear a mask or face covering (chodosh, weinstein & blustein, 2020). the use of face masks or personal protection equipment (ppes) is encouraged and made mandatory in some countries for all their citizens and healthcare professionals because of the risk of rapid transmission of covid-19 in healthcare settings (lima, simões, taguchi, & araújo, 2020; who, 2021). furthermore, face coverings have become essential in public areas if social distancing is impossible (saunders, jackson, & visram, 2020); however, in south africa both interventions are recommended. different types of face masks, including but not limited to n-95 masks and surgical masks, and various face shields, are utilised by healthcare practitioners to prevent and control the spread of the virus. this has proven to be critical in curtailing the spread of the virus (corey, jones, & singer, 2020; saunders et al., 2020). wearing face masks, social distancing, proper hygiene, proper disposal of waste products and contact tracing measures are essential components of infection control (magee et al., 2020; nguyen et al., 2021; saunders et al., 2020; sharma et al., 2020). the control measures and protective benefits to curb the virus are well understood and well established; however, less is known about the potential barriers of masks and shields on communication. communication is the transmission of messages from one person to another (vermeir et al., 2015). this includes verbal and nonverbal interpersonal communication such as eye contact, facial expressions and body language, illustrating empathy, sincerity and emotions (murphy, lewis & gormley, 2021; saunders et al., 2020). face-to-face conversations are beneficial for an entire discussion and the proper meaning behind words using body language and facial expressions (kratzke, rosenbaum, cox, ollila, & kapadia, 2021). effective communication is vital in healthcare settings, both between a practitioner and a patient and among practitioners themselves. communication is at the forefront of the patient–practitioner relationship, which is crucial for forming trusting relationships, explaining complex concepts and involving patients in joint decision-making, while considering their expectations and concerns (kratzke et al., 2021). expressing emotions and exchanging nonverbal communication are essential foundations for practitioner–patient clinical encounters (houchens & tipirneni, 2020). a trusting practitioner–patient relationship is associated with increased patient satisfaction, patient adherence and a higher quality of life (kratzke et al., 2021). using face masks and shields also creates barriers for empathetic communication, which is essential between healthcare workers and patients. empathetic communication builds trust, which is crucial in healthcare settings and for achieving healthcare goals. essentially, practitioners are seen as less empathetic when a face covering is used (ten hulzen & fabry, 2020). in a study by kratzke et al. (2021), only 22% of patients reported complete trust in their surgeon’s decisions when the surgeon donned a covered mask versus a clear mask. extensive use of face masks, especially during the pandemic, also poses a challenge for healthcare practitioners working with paediatric caseloads. a study by shack, arkush, reingold and weiser (2020) found that half of the children aged 4–10 years preferred doctors using only face shields compared with masks, with some children even citing that they feared doctors wearing masks. nonverbal communication helps to build trust in therapeutic relationships that lead to improved clinical outcomes (houchens & tipirneni, 2020). in addition to this, all medical information should be reliable, unambiguous, accurate and well understood by professionals and patients. viable communication between medical healthcare workers and the patient or their family is fundamental to guarantee that medical care is conveyed adequately and delivered effectively and efficiently (ten hulzen & fabry, 2020). poor communication in healthcare settings can have various negative impacts, such as compromising the safety of patients, patient dissatisfaction, discontinuity of care and the inability to use valuable resources efficiently (vermeir et al., 2015). conversely, patients who hear and understand their healthcare provider will likely comply with treatment and follow recommendations appropriately. poor communication may lead to miscommunication between health practitioners and patients. in most cases, the underlying cause for miscommunication is an age-related problem as older people suffer from hearing loss; however, it has received little attention (blustein et al., 2020). health care is also delivered in extremely noisy and distracting settings for patients with alarms beeping, multiple activities simultaneously and ongoing competing conversations between patients and providers. some people speak softer than others and can often not be heard because of ambient environmental noise around them. increased effort is thus needed in listening strategies (ten hulzen & fabry, 2020). communication can be challenging in loud and very noisy environments (magee et al., 2020). multiple distractions, often with background noise with a lower signal-to-noise ratio (snr), significantly hinder communication (magee et al., 2020). hospitals are sites where communication is critical and vital. the challenging listening situations described above are more difficult for people with hearing loss to understand speech. this creates a barrier to care that leads to a communication disadvantage compared with normal hearers (martin, 2020). speech intelligibility is further compromised when face coverings block complementary visual cues (magee et al., 2020), making it difficult to perceive emotions such as happiness, anger, or disgust and impairing facial recognition and identification (naylor, burke, & holman, 2020). the inability or reduced ability to view visual cues, facial expressions and failure to lip-read the other person, necessary to supplement verbal information, make it very difficult to hear and comprehend speech and deliver the intended message (kratzke et al., 2021; mheidly, fares, zalzale, & fares, 2020; saunders et al., 2020). this is more pronounced in individuals with a hearing loss who rely on visual cues to understand others effectively (kratzke et al., 2021; saunders et al., 2020), an approach lost once the face shield or mask is used (houchens & tipirneni, 2020). research evidence has shown that face masks and shields can interrupt sound transmission, thereby affecting speech signal quality and clarity (magee et al., 2020; nguyen et al., 2021; saunders et al., 2020; sharma et al., 2020). atcherson et al. (2017) reported that higher frequencies are dampened when speaking through a face mask. higher frequencies aid in differentiating similar sounds; however, masks muffle speech sounds, which hinders speech perception, particularly in environments that are very noisy or when someone has a hearing loss (hampton et al., 2020). the acoustic effect of someone speaking while wearing a face mask and the resultant voice distortion because of attenuation is comparable with the listener experiencing a slight high-frequency hearing loss (chodosh et al., 2020; corey et al., 2020; gaeta, 2020). the type of masks worn can also contribute to the lack of speech intelligibility and degradation of speech signal (nguyen et al., 2021). the n95 respirators impact speech understanding by listeners, with word intelligibility dropping between 1% and 17% (nguyen et al., 2021). the study carried out by nguyen et al. (2021) showed that a mask’s filtering ability and its features also determine the voice level, although the degree to which a speaker wearing a mask adjusts his or her phonation style may differ. a few studies have investigated the effect that surgical masks have on speech perception among healthcare workers in their work environment. bandaru et al. (2020) assessed the impact of using an n95 mask and face shield on speech perception among healthcare workers with normal hearing in india. the results revealed an increase in speech reception threshold (mean of 12.4 db) and a decrease in speech discrimination score (mean of 7%), with this being statistically significant, demonstrating that these coverings impair speech perception. however, the study was conducted in a sound-treated room without any external noise. in hospitals, there is a much background noise; hence, further research needs to be undertaken with background noise to conclude how much worse the situation can be. goldin, weinstein and shiman (2020) measured the listener’s comprehension at the acoustic level presented by the different surgical masks worn by the healthcare workers. acoustic degradations were reported whereby medical masks act as low pass filters. for simple surgical masks, high frequencies in the range of 2000–7000 hz are attenuated by about 3–4 db, and for n95 masks up to 9–12 db – the latter results support the study by bandaru et al. (2020). furthermore, developments in another study showed that speech quality degradation in an environment with noise and not being able to lip-read because the mask has covered the lower part of the face causes greater difficulty in understanding speech (nguyen et al., 2021). similar to the goldin et al.’s (2020) study, saunders et al. (2020) found that masks act as low pass filters, attenuating sounds above 2 khz. these masks can reduce sound intensity up to 20 db, with the least attenuating masks being surgical masks, decreasing sound by 2–4 db. martin (2020) also reported reduced sound levels at high frequencies. thus, surgical masks may not have that great impact on speech intelligibility. the listeners understand speech irrespective of background noise or whether the listener had a hearing loss (saunders et al. 2020). a study was conducted by toscano and toscano (2021) to determine mask effectiveness among different types of masks on speech recognition in various levels of background noise. two cloth masks, an n95 respirator mask and a surgical mask, were used. the surgical masks produced the slightest effect of speech recognition reduction, similar to not wearing masks. the cloth masks yielded the worst effect where poor speech recognition results were obtained. it was noted that face masks have a small impact on speech recognition at low noise levels. at high noise levels, the effects of the different types of masks were visibly noticed as the cloth masks, and an n95 respirator revealed the poorest speech recognition thresholds (toscano & toscano, 2021). a study by giovanelli, valzolgher, gessa, todeschini and pavani (2021) aimed to clarify the impact of face masks on speech understanding starting from one of the most common communication modalities imposed by social distancing, namely, video calls. speech comprehension was tested in typical hearing participants while conducting video calls with talkers in three different conditions: with a mask on, without a mask on and, their name only appearing on the screen. lower performance was observed when only the name appeared on the screen or when the lips were concealed with a mask. this was accompanied by lower confidence scores and increased perceived effort, demonstrating that face masks impact speech comprehension, whether in person or via a video call (giovanelli et al., 2021). speech audibility is also negatively affected by social distancing as sounds become softer as they travel away from the source (ten hulzen & fabry, 2020). because of speech audibility being affected, communication and interaction between people are also affected, and hence distance issues have been created, causing communication barriers (ten hulzen & fabry, 2020). while speech perception accuracy worsens at longer distances, speaking with a mask exacerbates the situation (nguyen et al., 2021). thus, multiple factors affect communication, and the effect’s magnitude depends on the speaker, type of mask worn, the listener’s hearing ability, visual cues available and background noise (nguyen et al., 2021; spitzer, 2020). this can then range from negligible to considerable effects (nguyen et al., 2021). healthcare practitioners thus need to understand the impacts of face coverings when they speak or listen to their patients who present with any condition, disorder or disability. furthermore, healthcare practitioners must be aware of the challenges faced by persons with hearing loss to understand speech, exacerbated by face coverings. individuals with hearing loss require various services as they may need to have an eye test, need to get medication from a pharmacist and so forth. thus, this understanding among different professionals is essential, given that the dire consequences of hearing loss on clinician–patient communication, substantially magnified with the pandemic (chodosh et al., 2020). because of the circumstances caused by covid-19, patients who may need to arrive with family members and interpreters would be restricted from the healthcare setting, which causes detrimental impacts on the quality of health care provided and communication. communication can be misinterpreted easily when the healthcare professional and the patient use universal masking. if one or both of them have a hearing loss, there would be reliance on oral communication, leading to significant negative impacts (ten hulzen & fabry, 2020). this can lead to practitioners experiencing communication stressors because interpersonal communication is negatively affected, with face coverings obscuring the mouth, limiting visual cues, and reducing understanding (campagne 2021). a study by heider et al. (2021) that aimed to determine the prevalence of voice disorders in healthcare workers of high-risk hospital care units found that nearly 33% of healthcare personnel reported voice disorders during the pandemic period; this being higher than the prevalence of voice disorders in general population at any other time which is around 7%. this was exacerbated by long work hours and increased use of masks during covid-19. to obtain speech understanding with 90% accuracy, the signal above the noise source should be around 10 db–15 db (way et al., 2013 cited in heider et al., 2021). thus, with an estimated background noise level of 65 db sound pressure level (spl), health personnel to be understood with 90% accuracy would have to speak at levels of 80 db spl (way et al., 2013 cited in heider et al. 2021). thus, regardless of the purpose of use, the face mask is perceived to lead to vocal fatigue, discomfort and communication difficulties. this is particularly important to be considered in individuals who use face masks for professional and essential healthcare-related activities (nguyen et al., 2021). communication is a crucial aspect of the interaction between people and occurs daily. understanding communication while wearing a mask is essential. communicating clearly and naturally is necessary for accurately understanding speech requiring less listening effort than if speech is in any way degraded (nguyen et al., 2021). from a user’s perspective, face coverings can also mean increased vocal effort and reduced auditory feedback (nguyen et al., 2021). face masks and face shields cause a hindrance as the message that is sent between people is often miscommunicated (chodosh et al., 2020). given the current widespread use of face masks, it seems reasonable to clarify whether speech and hearing in healthy speakers and listeners have significantly differed with face coverings. this study aimed to determine the perception of health sciences students on the communicative impacts of face coverings during the covid-19 pandemic. to meet the aim of this study, the following objectives were devised: (1) to determine health science students’ perceptions of the communicative impact of face coverings during the covid-19 pandemic as speakers, (2) to determine health science students’ perceptions of hearing and communicative impact of face coverings during the covid-19 pandemic as listeners, and (3) to determine health science students’ perceptions of the communicative impact of face coverings during the covid-19 pandemic in a clinical setting. methods and materials research design a quantitative descriptive research approach was used. this type of design is based on the standard of gathering information regarding the situation at hand and describing the relationship between variables (hulley, cummings, browner, grady, & newman, 2007). a descriptive survey describes events, phenomena and attitudes towards a problem. these studies typically involve one contact with the study population and are reasonably cheap and less time-consuming to undertake (kumar, 2005; lodico, spaulding, & voegtle, 2010). study sample, sampling technique and sample size this study was conducted with undergraduate students from the school of health sciences (shs) at the university of kwazulu-natal, westville campus. all students from first to final year registered in the shs were invited to participate in the study through the university intranet notice system. the included disciplines were audiology, pharmacy, speech-language pathology, optometry, physiotherapy, occupational therapy, dental therapy or dentistry, and sports science. the statistician consulted from the college of health sciences utilised the gpower software version 3.1.9.7 for sample size calculation. it was estimated that a sample size of at least 96 participants was required to detect an effect size of 0.5 about 80% of the time. according to the statistician, the sample size is the minimum number needed based on the study type, questions and required responses. all firstto final-year students, from the age of 18 years and above, irrespective of gender, or ethnicity, registered in the disciplines mentioned above were included in the study. while first-year students do not have any clinical blocks, they still need to understand the impacts of face coverings to apply this to their clinical settings. while it was envisaged that audiology and speech-language pathology students might be a bit more knowledgeable about communication, wearing masks is unusual for all students in this current pandemic, and they were included. students below 18 years and who are not currently registered in the shs were excluded from the study. a convenience sampling technique was utilised, allowing for a larger sample to be analysed as the required information is also acquired quickly. participants were selected based on accessibility, availability, flexibility and feasibility (leedy & ormrod, 2015; maxwell & satake, 2006). the demographic information obtained from the study revealed that most of the them, 85.3% (n = 82), were female participants at the age of 21 years, 36.5% (n = 35). the majority, 24.0% (n = 23) participants, were from the discipline of audiology, followed by physiotherapy, and from the third year of study, 42.7% (n = 41). most (75.0%, n = 72) of the students’ first language was isizulu, with 81.3% (n = 78) indicating their ethnicity as african. table 1 summarises the demographic information of the participants. table 1a: summary of the demographic information of the participants. table 1b: summary of the demographic information of the participants. table 1c: summary of the demographic information of the participants. table 1d: summary of the demographic information of the participants. table 1e: summary of the demographic information of the participants. table 1f: summary of the demographic information of the participants. data collection and analysis in order to facilitate data collection, a survey questionnaire was used, which was adapted from saunders et al. (2020) and nguyen et al., (2021). the questionnaire included 25 questions with both open-ended and closed-ended questions, together with likert scale options. section a comprised of demographic information, section b included perceptions of the communicative impact of face coverings during the covid-19 pandemic as speakers. section c included perceptions of the communicative implications of face coverings during the covid-19 pandemic as listeners. finally, section d included perceptions of the communicative impact of face coverings during the covid-19 pandemic in a clinical setting. using an online questionnaire minimised the printing costs and saved much time distributing and collecting questionnaires. online survey questionnaires have been deemed to be the upcoming preferred research method as they will allow researchers to gather large quantities of data effectively without exceeding monetary constraints (lefever & dal, 2007). online surveys also lower the probability of data and interviewer errors by eliminating the potential of human error during the manual entry. moreover, online surveys are self-administered. the participants can often commence and pause at their convenience, and it can be completed at any desired location (lumsden, 2007). however, limitations of online survey questionnaires include low response rates and incomplete responses. a notice was sent via the university web notification system to all shs students requesting their participation in the study with a link to google forms. participants were given a link to google forms, asking for their consent to participate in the study. they received additional information on the research and what was required from them. the participants were asked to complete the questionnaire in three weeks. after three weeks, an additional two weeks were given to students to complete the questionnaire for improving the response rate. regular reminders were posted on the university notice system to remind students to participate. the study was kept open for a total of six weeks. by word of mouth, the respective class representatives were also asked to help in sharing the online link with their classmates and encouraging them to participate in the study. while the recruitment letter indicated that the study was only targeting undergraduate students, three post-graduate students answered the questionnaire; however, their results were not included in the study analysis. a pilot study was conducted with five participants, each from a different discipline, before the commencement of the primary research. the intention was to get one participant from each of the eight fields; however, only five participants from five different disciplines responded to the pilot study. the student researchers accessed the pilot participants through word of mouth and personal contact with fellow students to participate voluntarily. the documents were made available to these pilot participants on google forms, including an information document, consent form, questionnaire, and a pilot feedback form for the questionnaire. in addition to the comments on the questionnaire’s content, the participants were asked to indicate if the questionnaire was of appropriate length, suitable language, and if the time taken to complete the questionnaire was adequate. all five pilot participants suggested that the language was reasonably straightforward to understand. most felt the time was right at 15 minutes to complete the questionnaire. three participants thought it was okay, that is, neither too long nor too short. four participants felt the questions were clear, and there was no ambiguous question. two participants felt that the questionnaire was a bit too long and repetitive and made it difficult to follow, especially q17, and the last six questions seemed to be repeated. these were adjusted by combining four questions into two questions and rephrasing some of the options to make it easier to follow. the information and feedback obtained from the pilot study enabled the researchers to make necessary adjustments as stated above. the results of the pilot study were not included in the main study. the findings of this study were analysed using both descriptive and inferential statistics. data were coded, entered on excel, and then exported to spss (v27). the descriptive statistics were displayed in the form of frequencies and percentages. the results were represented graphically in charts, graphs and tables. the study tested independent associations between two categorical variables. the chi-square test or fisher’s exact test depending on the frequency distribution was used to evaluate these associations. examples of associations include gender, year and level of study versus the perceptions as speakers, listeners and envisaged challenges in clinical settings. the confidence level was set at 95%, with a significance level of 0.05. the above data analysis was carried out in consultation with a statistician from the college of health sciences. reliability and validity cronbach’s alpha was utilised to ensure reliability and to test the study’s internal consistency. the purpose of cronbach’s alpha is to estimate reliability from correlations obtained from the data collected within the questionnaire (andrew, pedersen, & mcevoy, 2011). the overall chronbach alpha score received was 0.836 for the questionnaire based on 37 individual items within the questionnaire. according to biddle (2006), the reliability of normative data, 0.8 to 0.89, demonstrates good reliability and good internal consistency. efforts to improve the reliability and internal validity of the study included conducting an in-depth review of the literature in order to ensure that the research methodology was aligned with other studies. a pilot study was undertaken to ensure that the questionnaire and online system were appropriate for this study. external validity refers to how the results obtained from the study apply to contexts beyond the proposed study population (leedy & ormrod, 2015). due to the type of sampling techniques and sampling effects such as inadvertent selection bias, it was envisaged that results might not be generalised to other contexts. ethical considerations prior to data collection, ethical clearance was obtained from the humanities and social sciences research ethics committee, university of kwazulu-natal (reference number: hssrec/00002749/2021). gatekeeper permission was granted by the registrar of the university. the researchers completed a web-based ethics training course from the training and resources in research ethics evaluation (trree). participants were made aware that their participation is voluntary, and they can withdraw from the research study at any point (bhattacherjee, 2012). anonymity indicates that the researchers who have completed the final report cannot identify specific responses to a particular participant. no personal information was collected as the researcher had no way of knowing which participant responded, and the email address was not linked. confidentiality involves the researcher’s promise that they will refrain from divulging a participant’s identity in the report, even if they can identify the response (bhattacherjee, 2012). the above attempts to ensure participant anonymity and confidentiality is consistent with the protection of personal information act (popia) (4 of 2013) as enshrined in section 14 of the south african constitution. the online data obtained will be password protected and kept safely in a locked cabinet in the university’s audiology department for five years and will only be available to the researchers and their supervisor until the research has been completed. after that any hard copies will be destroyed by shredding and the online data by deleting. results the results are presented according to the three objectives of the study. all the descriptive statistics are given; however, only some significant associations are shown for the inferential statistics. objective 1 to determine health science students’ perceptions of the communicative impact of face coverings during the covid-19 pandemic as speakers. the participants were given two general questions about their self-reported hearing ability and attitudes towards wearing masks and shields. the majority, 78% (n = 75), reported that their hearing was good (42%) or very good (36%). of the remaining participants, 17% stated that their hearing was average and 5% poor or very poor. most 61% (n = 59) were positive about using masks, 31% (n = 30) were neutral, and a few participants (n = 7) were negative or very negative about wearing masks. most participants who were generally negative or neutral about wearing masks stated that they pull their face mask down when they feel that the other person cannot hear or understand them, and this was statistically significant (p < 0.001) (pearson chisq. test). participants had to provide information on how face masks or shields change the manner in which they speak, how the content of their conversation is affected, how the length of their utterances is affected and information on their interpersonal communication. with regard to the length of utterances that were affected by face masks or shields, the majority of participants, 70% (n = 67), speak louder than usual to compensate for the face masks or shields so that people hear them; 17% (n = 16) of participants speak briefly and keep words to a minimum as far as possible as depicted in figure 1. regarding the language spoken, all participants stated that they changed their manner of speaking in that they speak louder, with increased pitch, when wearing masks, which was statistically significant (p = 0.450; fisher’s exact test). figure 1: speakers adjust content, manner and length of utterances when using face coverings (n = 96). with regard to interpersonal communication, about 49.0% (n = 47) were sometimes even more expressive with their voice when speaking using face masks that they would without, and 46.9% (n = 45) sometimes used bigger hand gestures and movements when speaking using face masks (see table 2). the majority of them, 71.9% (n = 69), focused more on eye contact when speaking using face masks, to check whether people were listening to them. there was a statistically significant association between gender and use of hand movements and eye contact (p = 0.012; pearson chisq. test) (p = 0.035; fisher’s exact test), respectively, with more women, indicating that they use bigger hand movements and more eye contact when communicating. however, results must be viewed with caution given the male-to-female ratio of 1:5.6 in this study. table 2: summary of interpersonal communication. when asked how they felt about wearing masks, 40.6% (n = 39) did not feel more self-conscious when speaking using face masks. however, 30.2% (n = 29) of participants felt more self-conscious when speaking with face masks. most of them, 40.6% (n = 39), pull their face mask down when they think that the other person cannot hear or understand them, and 51.0% (n = 49) sometimes overcompensate and exaggerate speech to make it more intelligible to get someone to hear or understand them. however, more of the isizulu speakers versus the other language groups tended to pull down their masks when speaking if others could not hear them. this was statistically significant (p = 0.040; pearson chisq. test); however, the results must be viewed with caution given that the majority of the participants were isizulu speakers. the majority, 76.0% (n = 73), felt that face masks and shields make it difficult to see facial expressions, and 60.4% (n = 58) reported difficulties to be heard clearly by others when they are wearing a mask, and most believed that it is difficult for one to be heard clearly by others when you are wearing a mask, this being statistically significant (p = 0.024; fisher’s exact test). objective 2 to determine health science students’ perceptions of the communicative impact of face coverings during the covid-19 pandemic as listeners. in this section, participants were asked to provide information on their level of difficulty in listening to people wearing face masks and shields. overall, the majority, 55% (n = 53), of the participants reported that it was moderately difficult to hear a person who is speaking through a mask and shield, followed by 39% (n = 37) who said that it was slightly difficult to listen to a person who is speaking through a mask or shield (figure 2). figure 2: level of difficulty in hearing a person speaking through a mask or shield (n = 96). most 53.1% (n = 51) reported that they always use more listening effort when someone is using mask or shield, and 46.9% (n = 45) said they sometimes use effort when listening to someone wearing a mask or shield. most of them, 47% (n = 45), experienced moderate difficulty when someone was wearing a cloth mask, and 50% (n = 48) surgical mask. about 40% (n = 38) had difficulty when someone was wearing a surgical mask and shield, and 37.5% (n = 36) an n95 mask; 19.8% (n = 19) found it very difficult when both an n95 and face shield were used (see figure 3). most with self-report of poor hearing were more likely to say that it was difficult to hear when someone wore both a surgical mask and shield, with this being statistically significant (p = 0.009) (fisher’s exact test). figure 3: difficulties in listening to a person wearing different types of face coverings (n = 96). a third, 33.3% (n = 32), of the participants reported that it was very difficult for them to see the other person’s mood (sad or unhappy) when wearing a mask; however, 27.1% (n = 26) reported that it was moderately difficult for them. a third, 33.3% (n = 32), also said it was moderately difficult to see if another person wearing a mask seemed happy or joyful, followed by 24% (n = 23) who reported that it was slightly difficult. interestingly 11.5% (n = 11) of the participants said that it was not difficult, and equally, 11.5% (n = 11) reported that it was extremely difficult for them to see if a person who wore a mask seemed happy or joyful. regarding how they feel when they do not understand what the other person wearing a mask is saying, most 52.1% (n = 50) reported feeling anxious. in comparison, 45.8% (n = 44) reported that they feel frustrated, followed by 36.5% (n = 35) feeling stressed and overwhelmed, 24.2% (n = 23) felt embarrassed, and 23% (n = 21) who felt upset that they could not hear what the other person is saying. the majority said they felt anxious irrespective of language when communicating with someone wearing a mask. this was statistically significant (p = 0.037) (pearson chisq. test). concerning the impact of face coverings by the listening situation on the ability to hear and understand, the majority, 51% (n = 49), reported no effect on their family members, followed by 36.5% (n = 34) who reported that there is no effect on their friends when socialising. between 49% (n = 47) to 53% (n = 51) had difficulty with health workers and in lectures or clinic situations respectively (figure 4). most who were positive about wearing masks said it was harder to understand the doctor, nurse or other healthcare workers when they wore face coverings than when listening to their friends, which had little effect; this being statistically significant (p = 0.025; fisher’s exact test). figure 4: impact of masks on the ability to hear and understand by the listening situation (n = 96). the exact number of participants, 47.9% (n = 46), reported that it was harder for them to feel engaged and connected to the lecturers and tutors when they wore face coverings in face-to-face clinics or lectures and with doctors, nurses, and other healthcare workers. more of the participants, 46.9% (n = 45), said they had no effect with family members in terms of feeling connected or engaged, and 36.5% (n = 35) with friends when socialising (figure 5). the thirdand fourth-year students thought that it was more demanding than firstand second-year students to feel engaged in the conversation and feel connected to the speaker, especially healthcare professionals and lecturers versus friends and family. this was statistically significant (p = 0.033; fishers exact test). figure 5: difficulties in feeling connected and engaged with face masks being worn (n = 96). objective 3 to determine health science students’ perceptions of hearing and communicative impact of face coverings during the covid-19 pandemic in a clinical setting. participants were provided two open-ended questions and were asked as future healthcare practitioners in their respective fields of study what they think would be the issues they will encounter in practice and strategies to mitigate the challenges on the communicative impacts of wearing masks. a total of 89/96 (n = 93%) commented on these. fifty-six percent (n = 50/89), reported on potential communication challenges that could arise, including strained communication between patients and practitioners and personal discomfort. emotional difficulties were reported by 20% (n = 18). challenges related to covid-19 pandemic, as alluded to by 24% (n = 21), related to issues around lack of social distancing and patient education, overcrowding, and so forth (see table 3). participants further provided various strategies to mitigate some of the challenges ranging from covid-19-related strategies to control the spread of the virus to communication and environmental strategies. about 47% (n = 42/89) of participants emphasised the importance of adhering to covid-19 protocols, with most indicating the use of face shields and vaccinations. about 37% (n = 33/89) further suggested that practitioners mainly speak louder and slower and use clear and transparent masks. environmental strategies were proposed by 13% (n = 12) of participants (see table 3). table 3: challenges and strategies to mitigate these. discussion participants in this current study adjusted the way they speak in relation to manner, content and length of utterances when wearing face coverings. this correlates with a study by mheildy et al. (2020), where participants compensated by increasing the volume of speech and speaking more slowly to reduce the effect of muffled speech behind a facemask. the length of utterances is also affected by face masks, and positive outcomes are possible with communication when the length of utterances is changed (bonnell, 2020). additionally, a study by asadi et al. (2020) found that people will adjust their speech or project their voice when using face coverings as these attenuate the sound. exaggerated speech is more intelligible for someone to hear, and this speech cue seemed to enhance memory traces for sentences produced, enabling listeners to retain more information (smiljanic, keerstock, meemann, & ransom, 2021). a study by goldin et al. (2020) also found that speech rate was lower for n95 and surgical masks, as speakers compensate to improve intelligibility. a study by saunders et al. (2020) revealed that people misheard information during a conversation. words are often misheard as masks reduce high pitch sounds where consonants that start or end with a high pitch sound are often misunderstood and therefore change the word’s meaning (rahne, fröhlich, plontke, & wagner, 2021). the use of face masks resulted in an increased vocal effort of the speaker, affecting the voice-breathing coordination, thereby limiting the overall communication and altering the perceptual features of the voice (karagkouni, 2021). regarding interpersonal communication, most participants in the current study sometimes used bigger hand gestures and movements when speaking. a study by mheidly et al. (2020) reports that people express their ideas using hand gestures to facilitate the communication process. nonverbal communication can vastly influence the social environment, such as facial expressions, body movements and eye messages, which can support or substitute verbal communication (mheidly et al., 2020). participants stated that they focus more on eye contact when speaking. this correlates with a study conducted by mheidly et al. (2020), which states that when wearing face masks, people focus more on the eyes to understand the other person’s facial expressions. however, one has to be cognisant that in certain cultures like the zulu culture, eye contact is avoided as a sign of respect (niba, 2011). however, according to niba, (2011), in his study, he explains that the trend is slowly changing in cross-cultural south africa as the benefits and advantages of eye contact were observed by participants and a growing acceptance that if healthcare workers maintained eye contact during the consultation process, it was polite as it assured them that the healthcare workers were paying attention to what they were saying. eye contact can be used to show empathy and concern for others, manage feelings, express interest, or help with communication (mheidly et al., 2020). most participants felt that face masks and shields make it difficult to see facial expressions. this correlates with a study by chodosh et al. (2020), which states that with the use of face masks, one cannot access the facial expressions and lip movements vital to daily communication as face coverings prevent lip reading and muffle sound. facial expressions play a critical role in communication, relaying important information that people perceive to help them predict events and situations and develop appropriate responses (mheidly et al., 2020). the loss of visual and auditory information may be compensated by increased use of other information, such as a gentle nudge and visual clues that increase body language (campagne 2021). murphy et al. (2021) bring attention to dramatic arts, used in ancient greece where actors used masks in theatres. the skills developed in the dramatic arts can be used in healthcare practitioner training, such as increasing the volume of voice, using hand gestures, using fewer words, and emphasising keywords to show care and empathy. additionally, most participants stated that they pull their face mask down when they feel that the other person cannot hear or understand them. similar findings were reported in a study by ogoina (2020) were participants reported that they struggled with communication, engaging in a proper conversation and breathing when wearing a mask. they also reported that their words sounded muffled so they pull their mask down when talking. while most of the participants in the current study did not feel more self-conscious when speaking using face masks, about a third of participants felt more self-conscious when speaking using face masks. communication stress emanates when interpersonal communication is negatively affected, as with face coverings (campagne 2021), and can make you feel more distracted and self-conscious, further weakening your connection with others (pryor, 2020). essentially, most of the participants in the current study reported some difficulties in hearing other people when they are wearing a mask which correlates with an investigation by saunders et al. (2020). participants had reported that face masks and coverings have an overall negative impact on hearing. in this current study, the results revealed that most participants felt moderately difficult in hearing someone speaking through a mask, while 40.6% reported that it was slightly difficult to hear someone speaking through a mask and shield. a possible reason for participants in this study only having moderate or slight difficulty could be that they are a group of young individuals who reported overall good self-reported hearing. a few studies that have examined the impact of face masks on communication have reported a mask-induced attenuation of the voice between 2 db and 12 db (atcherson et al., 2017; goldin et al., 2020; mendel, gardino, & atcherson, 2008). in this current study, most participants reported hearing difficulty when speaking with someone using an n95 mask and face shield and a surgical mask and face shield. in agreement with the statement above, a study by rahne et al. (2021) revealed a greater listening effort in noise if the face masks are placed between the speaker and the listener. the face masks increased the absolute threshold of the hearing effort function, which reflects increased listening effort. the different types of masks worn may uniquely affect acoustic and speech perception, as masks differ in how they are composed and designed to sit on the person’s face. in a study by toscano and toscano (2021), the n95 respirator revealed the poorest speech recognition thresholds and speech intelligibility. corey et al. (2020) and magee et al. (2020) found that acoustic signals above 4 khz were attenuated the most, regardless of the type of mask worn by the talker with disposable surgical face masks offering the best acoustic performance. most participants reported that it was difficult to understand the other person’s mood when wearing a mask, and some said it was extremely difficult to see a person’s mood while wearing a mask. a study by (gabrielle, jackson, & visram 2021) reported that face masks impair people’s ability to classify emotional expressions accurately. participants reported feeling anxious, frustrated, stressed and embarrassed when communicating. a study by gabrielle et al. (2021) found that the communication issues associated with face coverings elicited a diverse array of negative emotions, including anxiety, isolation, feeling stupid and losing confidence. some clinicians also experience adverse psychological symptoms associated with mask-wearing (marler & ditton, 2021; xiong et al., 2020). the mouth transmits the emotional content and meaning of the message, and one can already perceive messages from the speaker’s mouth, such as happiness, sadness, anger and doubt. facial recognition is thus an important social and psychological input for both children and adults (campagne 2021). most participants reported that it was harder for them to feel engaged/connected to the lecturers, tutors, doctors, nurses, and other healthcare workers than their friends and family. a study by saunders et al. (2020) found that the reported impacts of face coverings vary by listening situation. the implications of communicating in a healthcare setting are more significant than communication with families or friends. this could be interpreted as suggesting that the perceived impact of the face covering is associated with some combination of the importance of information being discussed, the familiarity of the person or people speaking, and the predictability of the content of the discussion, rather than solely the acoustic environment in which communication is taking place. it is not surprising then, those healthcare situations in which a relatively unfamiliar individual often shares essential information in an already stressful situation are particularly anxiety-provoking (saunders et al., 2020). most participants commented on the communication breakdowns between health workers and patients because of strained communication. this leads to more communication errors, multiple repetitions and more listening effort as a result of using face coverings compounded by noise levels (bandaru et al., 2020). with the increased workload, effective communication between practitioners and patients is essential to ensure that health care is delivered effectively (bandaru et al., 2020). effective communication is a central necessity in building therapeutic relationships, with functional professional relationships a prerequisite in providing high-quality care (ha & longnecker, 2010). a study conducted by altschuler (2021) found that patients, healthcare providers and caregivers experienced serious communication challenges both within and outside the hospital. the use of a face mask compromises communication, especially in competing noise (yi et al., 2021). face masks obscure facial expressions and communication and may affect the doctor–patient relationship and overall treatment outcome (padhy, rina, & sarkar 2020). when healthcare practitioners cannot show emotional rapport and expression, the goal of the clinical encounter will not be fulfilled. it will be hard to build relationships, promote rapid trust, encourage information sharing, and show compassion and concern (padhy et al., 2020). expressions of emotion and reciprocity of nonverbal communication serve as important foundations for clinical encounters (houchens & tipirneni, 2020). many of the suggestions provided by the participants to the challenges they envisage in practice are similar to those in a study by mheidly et al. (2020) related to raising awareness about the impact of face coverings on communication, emphasising nonverbal communication, concentrating on speech rate and loudness, paying attention to noise levels in a different setting, and use of telecommunication and online strategies. it is anticipated that strategies such as greater use of nonverbal cues, using a raised voice and other coping mechanisms may be helpful for speakers and listeners in enhancing intelligibility in conditions that require face coverings to be worn and may ease communication challenges (saunders et al., 2020). lapel or clip-on microphones may be used in conjunction with transparent plastic window masks, which will allow visual cues without destroying the high-frequency sounds where the lapel microphones are placed above and below the mask. this combination has been recommended by corey et al. (2020). participants also suggested more online work, including for an example tele therapy, speaking louder and slower when communicating and writing down information to get the message across to patients. the use of videos and pictures to explain information and write down things is also supported by a study carried out by simpe (2021). practitioners can be responsible for developing and circulating well-informed, consistent communication guides for all patients and practitioners experiencing communicative challenges, exacerbated by mask wearing (marler & ditton, 2021; martinelli et al., 2021). limitations, implications and recommendations limitations of online surveys include not having stable internet and data connection; control over participants’ answers are limited and response rates may be low. this study was conducted at one university only the interpretation is limited to the study site. therefore, the findings cannot be generalised. some clinical implications resulting from the study findings necessitate more education and training students in health science disciplines and possibly the wider university community on the use of face coverings and shields and communication impact. this includes more education and information on the effects that different face masks and shields have on hearing and communication and the impact on interpersonal communication, ways in which communication breakdowns can occur with face masks and shields, and how to mitigate these. research implications could include how patients with hearing loss receive appropriate healthcare information and how they adhere to instructions given by the audiologist when both are wearing masks and face coverings. in south africa, we have patients from various cultural and language backgrounds and dialects; the added challenge posed by face coverings needs to be explored further. implications of how communication is affected when wearing face coverings on students receiving the lecture content when lecturers wear a mask need to be researched. perhaps, a larger study needs to be conducted, including other health sciences disciplines from other universities, to obtain a more comprehensive view of face coverings, shields and communication impact, and how to mitigate discipline-specific challenges. studies need to be conducted utilising interviews as opposed to questionnaires as this would allow more in-depth, accurate reflections on perceptions, feelings and attitudes as opposed to self-administered questionnaires. conclusion the covid-19 pandemic has changed the face of healthcare delivery globally. everyone is now expected to wear a mask or face covering, which is likely to be a feature of patient care for a long time to come. however, face coverings while being protective against the virus are also known to impact communication. health science students are future health practitioners who need to understand the communicative impacts of face coverings. all participants in this current study changed their manner of speaking when wearing masks and focused more on eye contact when someone was wearing masks and they used more listening effort. they reported feeling anxious when communicating and found it challenging to read emotions. the level of difficulty differed depending on the listening environment. most demonstrated good understanding of challenges they could face as future practitioners and provided some strategies to mitigate these. therefore, it is envisaged that improved understanding, increased awareness and practical strategies on clear, effective communication will assist in guiding patient-practitioner communication and interaction during the pandemic and beyond. acknowledgements the authors thank all the research participants for their invaluable contribution to this study. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions this article is based on an undergraduate study by n.m., a.n., z.s., and q.v. who were supervised by n.b.k. this was drafted by n.b.k. and the students contributed substantially to all subsequent drafts and the final article. funding information this research work received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references altschuler, t., santiago, r., & gormley, j. 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(2020). impact of covid-19 pandemic on mental health in the general population: a systematic review. journal of affective disorders, 277, 55–64. https://doi.org/10.1016/j.jad.2020.08.001 yi, h., pingsterhaus, a., & song, w. (2021). the adverse effect of wearing a face mask during the covid-19 pandemic and benefits of wearing transparent face masks and using clear speech on speech intelligibility. retrieved from https://www.semanticscholar.org/paper/the-adverse-effect-of-wearing-a-face-mask-during-of-yi-pingsterhaus/99587b2ef9ac90b2f2b23cc655cc3bce88ce8ceb abstract introduction methods results and discussion conclusions acknowledgements references about the author(s) katijah khoza-shangase department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa nomfundo moroe department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation khoza-shangase, k., & moroe, n. (2020). south african hearing conservation programmes in the context of tele-audiology: a scoping review south african journal of communication disorders, 67(2), a670. https://doi.org/10.4102/sajcd.v67i2.670 note: special collection: occupational hearing loss in africa. original research south african hearing conservation programmes in the context of tele-audiology: a scoping review katijah khoza-shangase, nomfundo moroe received: 19 aug. 2019; accepted: 15 jan. 2020; published: 03 mar. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the limited involvement of audiologists in occupational noise-induced hearing loss (onihl) management through hearing conservation programmes (hcps) is a global issue. in lowand middle-income (lami) countries such as south africa, this is also exacerbated by demand versus capacity challenges. tele-audiology is an option requiring serious deliberation by the audiology community within hcps in lami contexts. objectives: this scoping review explores if tele-audiology has a potential value in hcps and reviews what has been documented in the literature on the use of tele-audiology in hcps. method: a scoping review was conducted using the arksey and o’malley’s framework. a search was conducted in five electronic bibliographic databases including science direct, pubmed, scopus medline, proquest and google scholar and the grey literature to identify publications presenting considerations around tele-audiology in the implementation of hcps. results: findings revealed significant dearth of evidence specific to the use or application of tele-audiology in onihl and/or hcps both within the african context and internationally, despite the purported potential benefit of this service delivery model, particularly in resource-constrained contexts such as lami countries. of the publications deemed potentially relevant to this scoping review, none were found that specifically investigated or addressed the use of tele-audiology in onihl or hcps as their main objective. nuanced analysis of publications revealed that in the last decade, indication for potential growth in the use of tele-audiology within occupational audiology is indicated. conclusion: because of the significant demand versus capacity challenges in lami countries, and because of the need for scaling up audiology professionals’ management of hcps, careful consideration of teleaudiology as a platform to deliver services in these contexts is required. keywords: audiology availability; e-health; e-medicine; e-practice; hearing conservation; noise; occupational; resource constrained; tele-audiology; tele-health; tele-medicine. introduction employees in the mining and several other industries contract various occupational health medical conditions, with occupational noise-induced hearing loss (onihl) (reviewed in rawool, 2011) being one among them (lie, skogstad, johnsen, engdahl, & tambs, 2015). this condition presents as a permanent sensorineural hearing loss as a consequence of exposure to hazardous or excessive levels of noise during the performance of one’s occupational duties (nelson, nelson, concha-barrientos, & fingerhut, 2005; thorne, 2006). this hearing loss may be disabling in nature and is symbolised by hearing thresholds below 40 dbs (yadav, yadav, netterwala, khan, & desai, 2015). however, other criteria have been used to determine disabling hearing loss including 25 dbhl (rawool, 2018) mainly because of individual variability in factors such as activity limitations and participation restriction (olusanya, neumann, & saunders, 2014). dugan (2003, p. 3) asserts that disabling hearing loss is the ‘most prevalent, least recognised and least understood physical disability’. this view is supported by copley and frederichs (2010) as well as hermanus (2007) who argue that permanent disabling hearing loss is a major contributor to the global burden of disease for individuals, families, communities and countries. globally, onihl has been placed number one on the list of work-related disabilities and is the second most common form of acquired hearing loss after presbycusis (mostaghaci et al., 2013; ritzel & mccrary-quarles, 2008). nandi and dhatrak (2008) predicted that onihl will gain more prominence as an important public health priority because of populations living longer and the spread of industrialisation, thereby adding to the global burden of this affliction. within the south african context, the high burden of communicable diseases such as hiv, aids and tb within the mining population, which has been found to impact negatively on the severity of onihl, significantly adds to this public health challenge (khoza-shangase, 2019a). acquiring hearing loss in the workplace has significant implications for employees’ health, safety, career sustaining and advancement, job performance and overall quality of life (amjad-sardrudi, dormohammadi, golmohammadi, & poorolajal, 2012; hong, kerr, poling, & dhar, 2013; kane-berman, 2017; picard et al., 2008; thorne, 2006), with adverse consequences for the economic outlook of both the employers and the employees (chadambuka, mususa, & muteti, 2013; rikhardsson, 2004; yongbing & martin, 2013). these authors argue that the effects of incurring hearing loss in the workplace have adverse consequences on the health, safety and economic outlook of the affected individuals, their families, societies and the state as well; yongbing and martin (2013) declare that onihl is a potentially costly public health issue, especially in the lowand middle-income (lami) countries. developing an onihl minimises possibilities and opportunities for further employment (kane-berman, 2017), and therefore, it negatively impacts the career stability and advancement. a hearing loss, even a mild one, may have a profound impact on the safety and work-related injuries for the affected employee (amjad-sardrudi et al., 2012) because the employee’s ability to perform or complete tasks significantly depends on auditory signals or verbal communication (thorne, 2006). such a scenario consequently results in a communication handicap, which impacts teamwork and group productivity. additionally, prolonged exposure to hazardous noise in the workplace can potentially lead to increased fatigue and decreased concentration, leading to increased human errors (amjad-sardrudi et al., 2012; picard et al., 2008) and increased health and safety risks. all these present significant quality-of-life challenges for the employee (moroe & khoza-shangase, 2018; moroe, khoza-shangase, madahana, & nyandoro, 2019). financially, hong et al. (2013) argue that although the impact of onihl on one’s health and quality of life cannot be quantified in tangible measures or standards, compensation costs for incidents of onihl are consistently increasing. as an illustration, the approximated total cost for occupational accidents and diseases ranges between 1% and 3% of the gross domestic product (gdp) in various countries (rikhardsson, 2004). this is high for lami countries, although exact statistics on the burden of onihl in these countries are not readily available (nelson et al., 2005). chadambuka et al. (2013, p. 899), nonetheless, argue that 80% of individuals affected by onihl reside in lami countries where onihl presents a ‘much heavier burden than in developed regions of the world’. it is for this reason onihl is considered one of the greatest threats to a country’s economy as well as its public health. in south africa, the mining industry is one of the influential backbones supporting the country’s political and economic growth. economically, mining contributes a hugely significant amount, r286 billion, towards south africa’s gdp. furthermore, this sector is considered a major employer, producing 4.5 million jobs, and contributes r10bn to the fiscus annually through pay as you earn (paye) (teke, 2017). occupational noise-induced hearing loss, therefore, has an impact beyond the individual affected, and hence the importance of hearing conservation programmes (hcps). despite the implementation of hcps, which are aimed at protecting workers with significant occupational noise exposures (occupational safety and health administration – osha, 2002), onihl remains a prevalent condition in the south african mining industry (edwards, dekker, franz, van dyk, & banyini, 2011; kanji, khoza-shangase, & ntlhakana, 2019; khoza-shangase, 2019b; ntlhakana, kanji, & khoza-shangase, 2015; strauss, swanepoel, becker, eloff, & hall, 2012; van coller, 2015). in developed countries, the incidence of onihl has been documented to be decreasing or at least stabilising because of advances in technology that have seen these countries investing in quieter equipment and machinery in industries prone to excessive noise (morata & meinke, 2016; safe work australia, 2010). buying quiet is part of successful hcps, which the south african mine health and safety council (mhsc) aspires towards. the south african mhsc states one of its goals as ‘every mine worker returning from work unharmed everyday: striving for zero harm’ (mhsc, 2015). as far as ear and hearing health are concerned, this goal has not been realised despite the concerted efforts of the mhsc and the chamber of mines in south africa (booyens, 2013). the reality is, approximately 73.2% of miners in south africa are exposed to excessive noise surpassing the legislated occupational exposure limit of 85 dbs, despite hcps being implemented in the mining sector (edwards et al., 2011; strauss et al., 2012), with numerous evidence from this context indicating little, if any, success of hcps (edwards et al., 2011; edwards, milanzi, khoza, letsoalo, & zungu, 2015; edwards & kritzinger, 2012; kanji, khoza-shangase, & ntlhakana, 2019; moroe & khoza-shangase, 2018, 2019b; moroe, khoza-shangase, kanji, & ntlhakana, 2018; ntlhakana et al., 2015; strauss et al., 2012). literature suggests that the success of hcps is heavily dependent on adhering to all hcp pillars (amedofu, 2007; hong et al., 2013). these pillars include periodic noise exposure measurement and monitoring; engineering controls; administrative controls; personal hearing protection; employee and management education, motivation and training; risk-based medical examination; medical surveillance and audiometric evaluations, as well as record keeping (amedofu, 2007; hong et al., 2013). these fall within the scope of audiology, although the role of audiologists in the mining industry has not received much attention, with evidence from the south african context indicating very limited involvement of audiologists in hcps. moroe and khoza-shangase (2018) found that the small numbers of audiologists within this field in south africa experience scope-context misalignment, juniorisation as experts, questions about their role and value, as well as limited training in occupational audiology. these authors conclude that evidence from their study highlights important gaps in hcps in south africa, with audiologists being only minimally and peripherally involved in the management of onihl in the south african mining sector. this minimal involvement of audiologist is arguably because of the fact that the south african department of labour regulations into onihl minimise the role of audiologists with prominence given to occupational health officers and otorhinolaryngologists (department of labour, 2019). this is despite health professions council of south africa (hpcsa, 2012) regulations and the american academy of audiology (1997) providing guidance that audiologists should be the principal advocates for and the supervisors of hcps. a profession’s ability to fulfil its functions and mandate in any context is influenced by the availability of resources. south africa has significant challenges when it comes to manpower resources, and these challenges negatively influence service provision nationally, with the mining sector also being affected. demand versus capacity rages on as a single big barrier to the provision of health care, particularly in the public sector which caters for approximately 80% of the south african population. (khoza-shangase, 2019a). this demand versus capacity challenge becomes far worse in contexts that are not traditional spaces of practice for audiologists in south africa, such as occupational audiology contexts. for a population of over 55 million, hpcsa records reflected negligible numbers of speech language and hearing (slh) professionals registered with the hpcsa by october 2018. specifically, there were only 1589 speech therapists and audiologists, 642 audiologists and 157 hearing aid acousticians for the entire south african population – servicing both the public and private sectors. the audiologists’ numbers are worse in the four main provinces where mining is the largest industry – north west (8), limpopo (17), mpumalanga (38) and northern cape (7). these numbers show the demand versus capacity challenge clearly in the provision of slh services in the country (khoza-shangase, 2019a), with obvious implications for the implementation and monitoring of hcps where required. this highlights the importance of exploring tele-audiology within this context. tele-audiology has been defined as a subset of tele-health that has its goal as increasing access to audiological services primarily in areas with limited access to health care because of shortage of resources, as in the south african context and, for the current paper, more so in the occupational audiology sector. telecommunication technologies are utilised in order to access patients, reduce barriers to optimal care in underserved areas, improve user satisfaction and accessibility to specialists, decrease professional isolation in rural areas, help medical practitioners expand their practice reach and save patients from having to travel or be transported to receive high-quality care (krupinski, 2015). there are obvious advantages of tele-audiology in the south african occupational health context requiring deliberation, hence the rationale for current scoping review. methods this scoping review commenced as a systematic review; however, because of dearth of sufficient evidence to allow for this type of review, it was changed to a scoping review, where the first step was the establishment of a research team consisting of two individuals with expertise in onihl, hcps and research synthesis, as advocated by levac, colquhoun and o’brien (2010). the team advised on the broad research question to be addressed and the overall study protocol, including identification of search terms and selection of databases to search. the researchers adopted arksey and o’malley’s (2005) framework while adhering to recommendations by levac et al. (2010). the review included the following five key phases: (1) identifying the research question, (2) identifying relevant publications, (3) study selection, (4) charting the data and (5) collating, summarising and reporting the results (arksey & o’malley, 2005). research question the current review was directed by the following question: ‘does tele-audiology have a potential value in hcps and what has been documented in the literature on the use of tele-audiology in hcps?’ this question was guided by the prevailing demand versus capacity challenges in lami countries, and the researchers wanted to conduct this review in order to synthesise available evidence so as to map the literature on tele-audiology and hcps and gain access to an opportunity to identify gaps in the evidence, and types and sources of evidence to inform training, practice, policy-making and research– as advised by daudt, van mossel and scott (2013) on the value of scoping reviews. data sources and search strategy the initial search was implemented on 27 march 2019, in six electronic databases: science direct, pubmed, scopus medline, proquest and google scholar. the databases were selected to be comprehensive and to cover the use of tele-audiology in hcps. the selected studies were restricted to studies published in english with a focus in tele-audiology. the search query consisted of the following terms: e-health, e-medicine, e-practice, tele-health, tele-audiology, tele-medicine, industry, occupational, hearing conservation, resource constrained and audiology availability were considered by the authors to describe the scoping review and its methodology. applying the same search process or string that was used for the search in science direct, pubmed, scopus medline and proquest, a web search was conducted in google scholar to identify grey literature. the a priori decision was made to screen only the first 10 hits (as sorted by relevance by google scholar) after considering the time required to screen each hit and because it was believed that further screening was unlikely to yield many more relevant articles (stevinson & lawlor, 2004). the following websites were also searched manually: the mhsc, minerals council south africa, department of mineral resources and occupational health and safety websites. furthermore, the reference list of all the screened articles was also manually searched for further articles not yet captured. the following citations were included: audiology australia (2015), norris et al. (n.d.), meinke et al. (2017), brennan-jones, eikelboom and swanepoel (n.d.); swanepoel et al. (2010), swanepoel, matthysen, eikelboom, clark and hall (2015) and maclennan-smith, swanepoel and hall (2013). snowball sampling was adopted where citations meeting the inclusion criteria within publications were searched. a subsequent search of the above-mentioned bibliographic database and grey literature was conducted again in august 2019 to ascertain if there were additional publications post the initial search. one new hit, dietz (2019), was identified. citation management all citations were imported into the web-based bibliographic manager endnote. duplicate citations were removed manually with further duplicates removed when found later in the process for subsequent title and abstract relevance screening and data characterisation of full articles. eligibility criteria a two-stage screening process was used to assess the relevance of publications identified in the search. publications were eligible for inclusion if they contained the keywords and phrases, and if they broadly described the use of tele-audiology in onihl and/or hcps in order to determine and characterise the existing evidence based on the use of tele-audiology in hcps. because of limited resources for translation, only evidence published in english were included. publications that described tele-audiology without mentioning hcps and/or onihl assessment and management were excluded from the analysis. title and abstract relevance screening for the first level of inspection, only the title and abstract of citations were reviewed for efficient time management – where resources could be wasted by obtaining articles that did not meet the minimum inclusion criteria for this coping review. the researchers used a title and abstract relevance screening spreadsheet that they developed. the spreadsheet had previously been used by the same research team to evaluate reviewer agreement, where the overall kappa of the pretest was >0.8 which is considered to represent a high level of agreement (viera & garret, 2005). the title and abstract of each citation were independently screened by both researchers. titles for which an abstract was not available were included for subsequent review of the full article, which was done for all publications, in the data characterisation phase. the researchers met regularly during this process to ensure that any conflicts were resolved, with the lead author making the final decision where disagreements were present. a high level of agreement was found with the overall kappa at 0.83. data characterisation all full citations that were found to be relevant for the current scoping review on tele-audiology and hcps after title and abstract inspection were extracted for later review of the full-text article or document. a spreadsheet was developed by the authors where relevance of the publication was confirmed and where details of the publication such as type of publication, author and publication year, title, focus and aims, methodology, context, results and/or recommendations and reported challenges, gaps and limitations were recorded. the characteristics of each publication were extracted by both authors. further publications were excluded at this phase if they did not meet the minimum eligibility criteria. in line with levac et al. (2010), following independent reviews of all the publications, the authors met to resolve any conflicts and ensure consistency between them as well to make sure that the publications were consistent with the set research question and purpose. data summary and synthesis the data were compiled in a single spreadsheet and imported into microsoft excel 2016 (microsoft corporation, redmond, wa) for descriptive analysis (figure 1). figure 1: preferred reporting items for systematic reviews and meta-analysis (prisma) flow diagram for included publications. ethical considerations this article followed all ethical standards for a research without direct contact with human or animal subjects. results and discussion the research question for this scoping review was as follows: ‘does tele-audiology have a potential value in hcps and what has been documented in the literature on the use of tele-audiology in hcps?’ findings revealed significant dearth of evidence on the use or application of tele-audiology in onihl and/or hcps both within the african context and internationally, despite the purported potential benefit of this service delivery model, particularly in resource-constrained contexts such as lami countries (audiology australia, 2015; brennan-jones et al., n.d.; krupinski, 2015; swanepoel et al., 2010). of the publications deemed potentially relevant to this scoping review, not a single publication was found that specifically investigated or addressed the use of tele-audiology in onihl or hcps. nuanced analysis of publications revealed that in the last decade, evidence of tele-audiology in general audiology practice is increasing, with indication for possible growth in the use of this service delivery model within occupational audiology, as concluded by the current authors. this potential increase in tele-audiology use within this field is indicated by studies such as those investigating the following aspects which the current authors believe have implications for tele-audiology in onihl and its management (table 1): the use of mobile technology for booth-less audiometry; use of wireless and booth-less technology for hearing testing in industry; conducting pure-tone audiometry outside a sound booth using earphone attenuation, integrated noise monitoring and automation; validity of diagnostic pure-tone audiometry without a sound-treated environment and with position papers and clinical guidelines on the need, use and potential benefits of tele-audiology in under-served communities. all these publications indirectly speak to the audiometric evaluations pillar of hcps with no evidence found looking at the other pillars such as periodic noise exposure measurement and monitoring; engineering controls; administrative controls; personal hearing protection; employee and management education, motivation and training; risk-based medical examination and medical surveillance, as well as record keeping, all of which the current authors believe are amenable to tele-audiology. table 1: studies with implications for tele-audiology in occupational noise-induced hearing loss and its management. as far as the use of mobile technology for booth-less audiometry is concerned, current evidence indicates that the use of technologies such as internet is possible, as long as ambient noise can be efficiently managed (norris et al., n.d.), and hence the importance of studies investigating booth-less audiometry. this is particularly important as accessibility of audiometry has been argued to be significantly impeded by the cost of sound booths (brennan-jones et al., n.d.), over and above the shortage of hearing health personnel in the south african context (moroe & khoza-shangase, 2018). norris et al. (n.d.), from their two studies evaluating a prototype noise attenuating, wireless audiometric headset that pairs with a mobile device to administer automated audiograms, had positive outcomes which proved that conducting audiometry using internet technologies is possible if ambient noise is controlled. norris et al.’s (n.d.) findings are consistent with their recent findings (meinke, norris, flynn, & clavier, 2017) on the use of wireless and booth-less technology for hearing testing in industry, which found comparable performance with the use of innovative, mobile wireless automated hearing test system (wahts) in occupational audiometry and valid thresholds in diverse test locations without the use of sound-attenuating enclosures. this study focused on the test–retest variability of hearing thresholds obtained with wahts with enhanced sound attenuation to test industrial workers at a worksite as compared to standardised automated hearing thresholds obtained in a mobile trailer sound booth. these findings have significant implications for the audiometric evaluation pillar of hcps. additionally, maclennan-smith et al.’s (2013) research on the validity of diagnostic pure-tone audiometry without a sound-treated environment indicates that valid diagnostic findings can be obtained in a natural environment with recently developed technology, again offering the possibility of access to diagnostic audiometry in communities such as the south african occupational audiometry context where sound-treated booths may not be available. the automated aspect of this study as it investigated the validity of an automated mobile diagnostic audiometer with increased attenuation and real-time noise monitoring for clinical testing outside a sound booth has direct implications for the tele-hcps’ audiometric evaluation pillar. in their study, these authors found that air-conduction thresholds corresponded within 0 to 5 db in 95% of all comparisons between the two test environments, and bone-conduction thresholds did the same in 86% of comparisons. when assessing the validity of an automated mobile diagnostic audiometer during conduction of pure-tone audiometry outside a sound booth using earphone attenuation, integrated noise monitoring and automation, swanepoel et al. (2015) also demonstrated reliable hearing assessments. dietz (2019) raises cautions about validation, sensitivity and specificity in his deliberations on technological innovations around smartphones, tablets and the mobile internet – which has led to commercially available tablet audiometers seen as the future in hearing conservation. such evidence is supported by recommended clinical guidelines and position papers that guide the profession of audiology with tele-audiology use, although the evidence is restricted to only one pillar of hcps. these position papers and guidelines do not specifically speak to the context of occupational audiology, a context which comprises of several factors that require consideration. these factors include (1) the nature of the service required (hcps with specific pillars), (2) demand versus capacity challenges with regard to availability of audiologists practicing within this area and (3) litigation risks linked to occupational injury claims for onihl, therefore the importance of valid and reliable measures that can not only guide clinical management but can also stand up to the scrutiny of the courts. audiology australia (2015) provides a response to the medicare benefits schedule (mbs) review taskforce’s consultation paper, where they argue for inclusion of tele-audiology as it is likely to shape future audiological practice by changing the way services are delivered to remote areas of australia where populations have limited access to health services. audiology australia’s position is that tele-practice is an appropriate model of service delivery for the audiology profession. the implication of this position paper for the current scoping review and the possible implementation of tele-audiology within occupational audiology in the south african context is that of medical insurance cover – an issue that south african health care has not addressed in both practice and regulations. swanepoel et al. (2010) cautioned about reimbursement questions surrounding tele-audiology when they listed challenges that still require attention including aspects such as quality control, licensure, jurisdictional responsibility and certification. within the south african context, siegfried, wilkinson and hofman (2017) report that south africa has not made significant strides in its progress for health technology assessment (hta). a legal and policy landscape analysis reveals that no specific provision in the national health act exists, and hta is narrowly and incompletely defined (siegfried et al., 2017). siegfried and colleagues take this into account and call for the national department of health to host an hta summit in order to gain consensus on an acceptable and useful definition of hta appropriate to the south african context and to deliberate on the policy and legislative requirements for a national hta agency or alternative mechanism in south africa. these authors also suggest that consideration should be given to the revision of relevant national legislation and policy in order to align with the imminent national health insurance (nhi) that has universal health coverage as a goal, and the current authors believe that this is the opportune time for the audiology community to also advance considerations around tele-audiology as a service delivery model in occupational audiology. it is hoped that resolutions from this summit will positively impact tele-audiology in hcps agenda and general developments in the field of hta within the south african context. this positive impact might extend to include audiologists’ awareness, confidence and their use of tele-audiology, which is currently low. in eikelboom and swanepoel’s (2016) international survey of audiologists’ attitudes towards tele-health, findings indicated positive attitudes towards tele-health and associated technology. although positive attitude was displayed by respondents, less than a quarter of the participants had actually utilised tele-audiology in their practice. current authors argue that such findings might actually be worse in lami contexts, such as south africa, where over and above attitudes influencing the use of tele-audiology, access to technology as well as connectivity might place additional impact on the uptake of this service delivery model. these challenges, low numbers of audiologists willing to utilise tele-audiology as well as limited access to technology and connectivity, will hamper all efforts to increase access to audiological services – particularly with the known and documented demand versus capacity quandary within the south african occupational health context. in reviewing hcps and all the pillars that comprise them, the current authors strongly suggest that increased strategic efforts be deliberated by the south african audiology community on the use of tele-audiology as an alternative and/or interim measure in delivering the much-required services in this population. the current authors suggest that the south african audiology community should be ready for structured, systematic and sustainable implementation of tele-hcps once summit resolutions are adopted; their recommended deliberation around the tele-hcp implementation options is depicted in figure 2. figure 2: possibilities of tele-audiology use in hearing conservation programmes for all pillars (tele-hearing conservation programmes). this deliberation would require careful look at all the hcps pillars and evidence gathering on how tele-audiology could be used efficiently and ethically in this field, whilst maintaining standards and adhering to regulations and scopes of practice as advocated by the hpcsa and the south african department of labour. maintaining standards and adhering to regulations are particularly important in this field as paraprofessionals, nurses or trained volunteers will be required to facilitate the tele-practice set-up at the industrial site which is remote to the audiologist managing the hcp, and this necessitates the use of recordings, online interactive engagements and/or real-time via interactive videoconferencing. figure 2 suggests ways in which the pillars of hcps, including administrative controls, engineering controls, periodic noise exposure monitoring, personal hearing protection, audiometric evaluations, employee and management education and training and record keeping, could all be conducted and managed via tele-audiology. efficacy of this service delivery model would require future investigation in order to ensure that methods adopted are evidence-based and best practice for the south african context. investigating other service delivery models such as the united states service model where certified occupational hearing conservationists can provide some hearing conservation services under the indirect supervision of an audiologist or a physician should also be considered. conclusions the current scoping review clearly indicated lack of evidence on the use of tele-audiology in onihl and/or hcps. this indicates a missed opportunity to increase access to audiological services for this population, particularly with the reviewed evidence of technological advancements that have applicability in the audiometric evaluation pillar of hcps. technological advances with their counterparts’ recent advances in tele-health have increased possibilities for alternative service delivery models that are contextually responsive, such as tele-audiology in hcps. with regard to the audiometric evaluations pillar of hcps, the introduction of mobile technology for booth-less audiometry; use of wireless and booth-less technology for hearing testing; conduction of pure-tone audiometry outside a sound booth using earphone attenuation, integrated noise monitoring and automation; conduction of diagnostic pure-tone audiometry without a sound-treated environment; and hearing screening using mobile apps are advances that have significantly increased the audiology community’s ability to provide hearing services to remote and resource-limited contexts, such as the occupational setting within the south african context. expansion of tele-audiology services to the rest of hcps pillars is a real possibility that has the potential to be productively exploited via both real-time synchronous and asynchronous ‘store-and-forward’ tele-hcps. these recommended tele-hcps must take careful cognisance of policy and regulation challenges, with strict adherence to ethics, human rights and medical law. in their quest to increase access to audiological services within the occupational audiology space where medico-legal claims are a possibility, audiologists must utilise this service delivery model ensuring that the six ethical challenges related to tele-audiology, as presented by naudé and bornman (2019), have been resolved and that there are clear guidelines and regulations around them. these six challenges, including licensure, competence, privacy and confidentiality, informed consent, effectiveness of services and program validation, and reimbursement for services, are key for efficient, successful and ethical use of tele-hcps. the readers are cautioned to interpret current findings having taken cognisance of identified limitations in this scoping review. firstly, very few articles were found to have included experimental research to investigate the efficacy of remote audiological monitoring, which led to the recommendation for investigations made by the current authors. secondly, some of the articles found (e.g. those by swanepoel) raise questions about conflict of interest or bias because this author is the inventor of the booth-less auditory threshold equipment. lastly, the challenge of connectivity, which is a significant challenge in lami contexts, is silent in the papers reviewed. acknowledgements the authors would like to thank mandla shangase for figure 2 illustration. competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions both authors co-conceptualised the idea for the research as well as the design and methodology adopted. n.m. collected the data for the study. k.k.s. analysed it with n.m. k.k.s. was the lead author in the writing up of the manuscript for publication with input from n.m. both authors read and approved the final manuscript. funding information the authors thank the national institute for the humanities and social sciences (nihss) and the consortium for advanced research training in africa (carta) for providing financial assistance for the publication of this manuscript. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references amedofu, g.k. 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(2013). noise induced hearing loss in china: a potentially costly public health issue. journal of otology, 8(1), 51–56. https://doi.org/10.1016/s1672-2930(13)50007-9 abstract introduction background research method and design results discussion conclusion acknowledgements references about the author(s) dhanashree pillay department of speech-language pathology and audiology, university of the witwatersrand, johannesburg, south africa tshepang serooe department of speech-language pathology and audiology, university of the witwatersrand, johannesburg, south africa citation pillay, d., & serooe, t. (2019). shifting and transforming the practice of audiology: the inclusion of traditional healing. south african journal of communication disorders, 66(1), a635. https://doi.org/10.4102/sajcd.v66i1.635 original research shifting and transforming the practice of audiology: the inclusion of traditional healing dhanashree pillay, tshepang serooe received: 28 mar. 2019; accepted: 23 aug. 2019; published: 20 nov. 2019 copyright: © 2019. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: societal diversity encompasses an array of cultural, religious and spiritual beliefs that influence an individual’s perspective of illness and diseases. healthcare providers are challenged with the task of considering these diversities in clinical practice. the symbiotic relationship between the healthcare provider and the traditional healer in any healthcare field is rare. objectives: the aims were to determine the perspectives of audiologists with regard to traditional healing in south africa (sa) and to document if and how the audiologist engages with traditional healing in practice. method: a questionnaire containing closed and open-ended questions was utilised. thematic analysis was conducted on the qualitative data, and the quantitative data were displayed using tables and figures. results: forty-one audiologists working at public and private hospitals and clinics in sa were included in this study. the personal experiences of audiologists resulted in varying definitions of a traditional healer. audiologists reported that patients utilised traditional healing methods such as pouring urine or motor oil into the ear. strategies of accommodation included being culturally appropriate during conversations, respecting and acknowledging the individual’s cultural and religious beliefs. twenty-seven audiologists were willing to collaborate with traditional healers to support the patient. conclusion: there is a need for an integral holistic model of care in audiology. there is a lack of communication structures to facilitate the implementation of a collaborative model of care in the current medical model of practice of audiology. the global trend of holistic and person-centred care is evident, and the field of audiology cannot negate the role of traditional healers as alternate healthcare providers in sa. keywords: traditional healers; hearing impairment; integral holistic care model; alternative healthcare; healing. introduction a client describes to the audiologist how a traditional healer played a significant role in the series of events that unfolded after she noticed that her child had a hearing impairment. the above scenario may vary in its ending. however, the perceptions of the audiologist with regard to traditional healing will ultimately shape the future of the service delivery. so what is traditional healing, and do audiologists engage with traditional healing in south africa (sa)? the south african population includes individuals from diverse cultural, religious and linguistic backgrounds. the agenda in sa has shifted from separation and oppression during apartheid to reconciliation and oneness in a democratic society. however, the effects of a deep-rooted apartheid system cannot be instantly overturned. intentional thoughtful actions are required to ensure that the mandate of transformation occurs within every sector in sa. the existence of diversity does not naturally equate to the acceptance of diversity. transformation and decolonisation were debated and discussed in length by freedom activists during apartheid as a view towards a democratic sa, also known as ‘azania’. post-1994, these discussions became a reality, and south africans were tasked to implement fair policies and practices to transform the country. transformation within the healthcare sector was evident as the faces of the healthcare practitioner and the population seeking healthcare were not the status quo of apartheid. society has a role to play in transforming the present to account for the injustices of the past, and so active participation is warranted in every sector. thus, understanding the differences in healthcare practices and health-seeking behaviours of the diverse south african population is vital. the notable diversity of cultures, beliefs and practices between the health practitioner and the individual seeking healthcare calls for attention in the healthcare sector. traditional healing forms a significant role in the health-seeking behaviours of south africans, and healthcare cannot negate the impact of traditional healing in the south african context. traditional healers in sa are synonymous with black african communities; however, the multicultural south african population encompasses racial groups with different traditional, cultural, religious and spiritual backgrounds (van vugt & cloete, 2000). audiologists in sa form part of the multidisciplinary healthcare team who provide care that is expected to be culturally and contextually significant to the person receiving care. traditional healing practices within the current healthcare sector in sa are highly debated because of controversies surrounding the possible adverse impact of traditional healing. therefore, it was anticipated that this study would seek to determine the audiologists’ views about traditional healing within the dynamic current discourse to transform the service delivery in the healthcare sector in sa. background traditional healers have existed for centuries in sa. the forefathers of the different ethnic groups such as african, indian and asian groups still rely on traditional healers for spiritual guidance and medical advice (shapiro & selin, 2006). the south african indian population includes islamic and hindu healers and religious leaders who perform ceremonies and prayers for the sick using herbs (ross, 2007). there are three types of south african muslim traditional healers: the moulana, who is a spiritual leader who is consulted when there is a psychological, medical and social issue; the hakeem, who is a muslim physician; and the gift healer, who is blessed with supernatural powers to provide various treatments for illness and disabilities (ross, 2007). in the hindu community, there are different priests and gurus: the brahman, who is ranked at the top of the castes across india, who occupy the position of priest in the temples of major gods; and the sudha sannyasin and the yogi, who are respected traditional healers (ross, 2007). in the asian community, there are different methods of healing such as acupuncture, herbs and ayurvedic therapy (xu & chen, 2011). christianity is predominant in sa and individuals who belong to the religion vary in relation to racial and cultural backgrounds. christians have priests and pastors who are consulted for spiritual support in sa. section 1 of the traditional health practitioners (thp) act (2007a) categorises traditional health practitioners as ‘diviners, herbalists, traditional birth attendants and traditional surgeons’. the act categorises individuals as per african traditional healing definitions and mandates so that individuals who practise african traditional healing without registering are committing an offence. since the establishment of the act, there have been debates pertaining to the inclusion of ethno-medicine, such as hypnotherapy, within the act. ms r ramatsoi, of the national department of health, stated at the traditional health practitioners bill: public hearings (2007b) that: … the categories that were covered in the bill were those that the committee defined as being based on african medicine traditional practices. ethno-medicine was not included because it was not entirely based on african traditional medicine. (p. 1) the allied health practitioners council of sa accepted ethno-medicine in 2011. however, the 2012 council reversed the decision as they deemed ethno-medicine to belong under the thp act (ethno-medicine practitioners association of south africa [epasa], 2015). the application of the act to traditional healers other than african traditional healers is becoming increasingly moot in sa. traditional doctors in sa are also known as izinyanga, who are males who serve an apprenticeship under another inyanga for at least one year and pay their mentors in cash or cows (meyiwa & maseti, 2016; williams, olopade & falkson, 2006). traditional doctors are seen as herbalists, priests and psychologists who can diagnose and treat individuals in a direct manner as would a medical doctor (davids et al., 2014). diviners are also known as izangoma; they are usually females and only people who have a calling from the ancestors can become one (ogana & ojong, 2015). an isangoma can have a consultation with the family without the individual being there, and through the use of spiritual insights, these diviners can interpret the cause and consequence of the illness, and they are capable of determining the cause of the problem or illness by consulting ancestral spirits (ross, 2010). the faith healers who are also known as abathandazi are professed christians, who belong to one of the independent african churches, and they heal by prayer, holy water or ash, and the laying on of hands on the individual who needs healing (ross, 2010). race, spirituality and religion are not closed groups of individuals, and healthcare professionals in sa are guaranteed to encounter the diversity and intertwining of beliefs and practices. individuals in sa consult different types of traditional healers for various reasons such as protection against witchcraft, illnesses, their ability to prophecy about future events, divulgence of secrets and annual check-ups (ross, 2010). research pertaining to traditional healing has predominantly focused on conditions such as mental health (ae-ngibise, coopet, adiibokah, lund, & doku, 2010), acquired immune deficiency syndrome (aids) (somse et al., 1998), tuberculosis (tb) (colvin, gumede, grimwade, maher, & wilkinson, 2003) and sexually transmitted infections (stis) (peltzer, mngqundaniso, & petros, 2006). studies in relation to communication impairments and traditional healers have focused on the areas of cleft lip and palate, stuttering and aphasia (dagher & ross, 2004; platsky & girson, 1993; legg & penn, 2012). research conducted in the field of audiology focused on the perspective of traditional healers regarding hearing impairments (de andrade & ross, 2005) and the training that traditional healers obtain in relation to hearing impairments (de andrade, 2011). the south african population consults traditional healers for different illnesses including hearing loss (de andrade, 2011; summerton, 2006), and the audiologist cannot negate the impact of traditional healing within the biopsychosocial sphere of the individual. people consult traditional healers for hearing impairments, and the traditional healers have various ways of managing the individual (de andrade & ross, 2005). in a south african study, the management of a hearing impairment by traditional healers included animaland plant-based remedies, and rituals such as the laying on of hands to treat the hearing problems (de andrade & ross, 2005). one of the major concerns surrounding treatment methods of the traditional healer is the dispensing of remedies into the ear even when the tympanic membrane is ruptured, which may result in further middle ear complications (snow, wackym & ballenger, 2009). some traditional remedies such as skanama and matekwane (marijuana) may also result in memory problems, damage to internal organs such as the lungs and cerebral atrophy (kaplan & sadock, 1991). the collaboration between the audiologist and traditional healers may prevent damage and ensure that the individual is supported within an integrated and holistic model of service delivery in healthcare. audiologists can gain insight and knowledge into the principles and foundations of the traditional healers’ treatment methods that will enhance the healthcare service delivery system. traditional healers in sa indicate that they are willing to collaborate with the medical professionals (champbell-hall et al., 2010; de andrade & ross, 2005). however, studies revealed that the medical professionals were not willing to collaborate with the traditional healers (mills et al., 2006; peltzer et al., 2006; somse et al., 1998). medical professionals are unwilling to collaborate with the traditional healers because of a lack of scientific proof of the traditional practices (de andrade & ross, 2005). in the 1970s, the who called for the inclusion of traditional health practitioners in the provision of primary healthcare and for the social and technical training of traditional health practitioners in an effort to include traditional health practitioners in health promotion activities (who, 1978). the south african traditional health practitioners act (2007a) attempted to bring principles of regulation into traditional practice. however, the doctors for life group, which represents over a thousand medical professionals in sa, objected to the government’s plan to legitimise the traditional healers (madomombe, 2006). the group objected to the plan as traditional healers are not validated scientifically, and many individuals experience complications because of the use of traditional medicines (madomombe, 2006). the doctors for life group also believed that this law would result in legal controversies and medical complications. the group urged that all the traditional remedies should be thoroughly researched before being approved. even though the doctors for life group objected to the government’s plans to legitimise the traditional healers, there were some medical professionals that pointed out that with or without the support of the law, traditional healers are already providing services in many communities. therefore, these medical professionals supported the inclusion of traditional healers within primary healthcare for a collaborative environment between the two service providers (madomombe, 2006). despite the unwillingness of the medical professionals to collaborate with traditional healers, many south africans continue to consult both the traditional healer and the medical professional for various reasons (champbell-hall et al., 2010). there is a need to understand the spiritual, cultural and religious beliefs of the individual with a hearing loss within any context. audiology is a branch of science and medicine which focuses on the sense of hearing and balance (johnson & seaton, 2011). the humanistic aspect of healthcare must include the social element in the service delivery model. audiology in sa traditionally operates under the principals of the medical model, which focuses on clinical medicine that is based on the principles of the natural science. the audiologist utilises western methods of care that focuses on the individuals’ biological processes rather than their social, emotional and spiritual processes (alderfer, 2010). in contrast, the traditional healer uses various substances and methods based on social, cultural and religious belief systems that are not scientifically proven (albertyn, berg, numanoglu & rode, 2015), yet the south african population still chooses to consult traditional healers. the areas of science and spirituality have been seen as separate entities in healthcare, and specifically in audiology, for far too long. there is a desire and willingness from the traditional healers in sa to collaborate with the audiologist (de andrade & ross, 2005). however, there is a dearth of information pertaining to the audiologists’ perspective. it is essential to bridge the gap between the traditional healers and audiologists to ensure that the services provided to the individual with a hearing loss are culturally and contextually appropriate to meet the needs of the dynamic and diverse south african society. this study assists in filling the gap that pertains to the audiologists’ perspective in relation to the possibility of an integral and holistic model for collaborating with the traditional healers in sa. will audiologists continue to be shaped by the western medical model of care, or are audiologists entering a new era of change towards a more holistic integral model of healthcare? research method and design aims of the study to determine the perspectives of audiologists with regard to traditional healing in sa. to document if and how the audiologist engages with traditional healing in practice. research design and instrumentation a non-experimental cross-sectional survey research design was utilised in this study. a self-developed questionnaire utilising openand closed-ended questions provided qualitative and quantitative data. the researchers developed a questionnaire that was electronically distributed to all participants. sample and sampling purposive sampling was used to recruit participants from the online healthcare association registers in sa. participants were required to be registered with the health professions council of south africa (hpcsa) and had to be practising in sa. this study also included audiologists who are dually trained as speech therapists who work within the public and private healthcare sectors in gauteng. male and female participants of different ages were included in this study. questionnaires were electronically sent to 100 participants; 52 participants agreed to participate in this study. however, only 41 participants completed the questionnaire. the detailed responses in this study are worth noting despite the 41% response rate. the quality of responses should not be ignored. however, a larger sample size would provide greater generalisation of findings. ethics and data analysis thematic content analysis was used to analyse the open-ended questions. the closed-ended questions were analysed using quantitative methods. data were grouped and displayed descriptively using tables and figures. ethical considerations ethical clearance was granted by the university of the witwatersrand’s, non-medical ethics committee on 16 april 2016 (clearance number: sta_2016_01). informed consent was obtained from each participant prior to answering the questionnaire. anonymity and confidentiality were adhered to for all participants. results participant demographic information forty-one participants comprising of 38 female, two male and one other, who chose not to identify with either male or female, participated in this study. the majority of participants were christian (20). english was the first language of the majority (24) of participants as per table 1. the participants had different years of experience as a practising audiologist as seen from table 1. participants had completed their audiology degree at either the medical university of south african (medunsa) (2), university of the witwatersrand (wits) (19), university of pretoria (up) (7), university of cape town (uct) (3), university of kwazulu-natal (ukzn) (7) and the university of stellenbosch (1), and four participants did not state where they had completed their degree in audiology. table 1: participants’ demographic information. south african audiologists’ description of a traditional healer a traditional healer was described as: ‘traditional does not equate to bad, backward, worse, negative – it’s just ‘different’ to the imposed ‘normal.’ (p1, female, audiologist) ‘a traditional healer includes individuals who have not studied a medical degree. they generally use alternative medicines. they are frequently portrayed as using voodoo including spells.’ (p2, no gender, audiologist) ‘a person that uses their cultural and or religious beliefs for healing the ill.’ (p8, female, audiologist) ‘someone who sees themselves as being called to help others, in terms of healing from physical, emotional or psychological illnesses or diseases. they do not have any official and/or academic qualifications, it is more a calling.’ (p9, female, audiologist) ‘someone who functions in a community … makes use of healing methods that are not necessarily supported by medical research … often thought to be selected by a spiritual presence.’ (p10, female, audiologist) ‘in the south african setting i view a traditional healer as the colloquially called witch doctor.’ (p12, female, audiologist) ‘provides medical attention to their community through traditional methods that have been passed down through generations … the community respects their knowledge about illnesses and problems … can have a coexisting training in modern medicine but do not solely rely on that training when treating patients.’ (p29, female, audiologist) table 2 presents the examples of traditional healers that were provided by participants. table 2: examples of traditional healers. two participants stated that traditional healers may have coexisting training in modern medicine, but they do not solely rely on that training when treating clients. three participants stated that consultations with traditional healers are common in the specific racial groups in sa. participants stated that traditional healers could also be spiritual healers from other cultural and religious groups, such as the muslim, jewish, hindu and chinese groups. south african audiologists’ engagement with traditional healing do audiologists ask about traditional healing? thirteen participants reported that they ask about traditional healing during the case history or the feedback session. two themes were identified, which show that asking about traditional healing: facilitates an understanding of the clients’ belief system provides insight into the health-seeking behaviour of the clients, prior to seeing the audiologist. audiologists ask about traditional healing to gain knowledge and understanding of the client in a holistic manner. the quotes pertaining to the above themes include: ‘it gives me an idea of what the patient’s belief system is, what their health seeking behaviours are, and how they will respond to my intervention.’ (p1, female, audiologist) ‘i ask what have you done or who have you been to see, to help with the problem. this is generally when patients will offer information and then i will probe further.’ (p11, female, audiologist) ‘i have asked about it when i worked in state hospitals and for research purposes. the use of traditional healers can sometimes conflict with our practice, and it is important to ascertain what the patient believes in.’ (p13, female, audiologist) ‘often african people going to the traditional healer first, is not taboo. and often patients come to hospitals only when the traditional route has failed. as an audiologist this often came up at the end of the session but now it’s part of the first few questions i ask about especially for patients with discharging ears or unknown sudden hearing losses.’ (p2, non-gender, audiologist) ‘for counselling purposes. most patients don’t believe in congenital hearing loss. so they go to traditional healers first before they seek any rehabilitation or medical attention.’ (p34, female, audiologist) twenty-eight participants reported that they do not ask about traditional healing during the case history and feedback sessions, and one participant reported that he or she asks occasionally. themes that were identified were: information is not deemed to be relevant. information is deemed to be intrusive. some participants have never considered asking about traditional healing as it is not within their scope of practice, and they have asked only direct medical questions pertaining to the ears. the reasons for not asking about traditional healing include: ‘it generally would not affect the patient’s hearing. i would only ask if the patient mentioned having been to a traditional healer or had a traditional healer suggest to them that their hearing loss may be caused by angry spirits/ancestors.’ (p5, female, audiologist) ‘i feel like this information needs to be volunteered by the client should they wish to share this information.’ (p6, female, audiologist) ‘it feels too intrusive into someone’s traditions and religious beliefs.’ (p9, female, audiologist) ‘it doesn’t seem relevant in my population of patients/context.’ (p15, female, audiologist) ‘never thought about it.’ (p24, female, audiologist) ‘i don’t ask about traditional healing directly, i ask more specifically if they have received any form of assessment or treatment from anyone regarding their ears. such as for pain, noises in the ear or anything else related to the ears and hearing.’ (p29, female, audiologist) ‘it’s a sensitive topic.’ (p31, female, audiologist) i have never come across a situation where i have to, but patients have enquired about them on treatment options.’ (p36, female, audiologist) do audiologists receive client reports of traditional healing? nineteen participants reported that clients have never informed them about consulting with a traditional healer. participants, who received a report, stated the following accounts: ‘[the parents] took the child to an inyanga after the child lost his hearing post meningitis. the inyanga recommended she come to the hospital.’ (p2, no gender, audiologist) ‘unfortunately, the traditional healer let the client wear a cord around his stomach. the traditional healer also threw red and blue beads into the client’s ears. it did not work for the client’s condition.’ (p9, female, audiologist) ‘the tongue was stuck to a button and it was released through surgery but she [the mother] was disappointed as the child didn’t learn to talk thereafter.’ (p11, female, audiologist) ‘a young boy with meningitis having his hair shaved in the form of a cross to heal him. it did not help him. he nearly died.’ (p12, female, audiologist) ‘a patient told me he was advised to put motor oil into his child’s ears.’ (p17, female, audiologist) ‘making small lacerations on the chest for tuberculosis [tb] treatment. pouring oil and herbs in the ear to assist with infections or hearing loss.’ (p18, female, audiologist) ‘the patient was diagnosed with spinal tuberculosis and meningitis and the patient’s family was burning herbs in the ward. the patient was provided with traditional healing medication and was not taking the prescribed medication from the doctor.’ (p23, female, audiologist) ‘they mentioned that they did go see an isangoma, as the patient believed that someone from the community performed black magic causing her to lose her hearing. recommendations suggested that she drink something that was made up by the isangoma.’ (p28, female, audiologist) ‘the healer instructed her to put her own son’s urine into his ear to help with the pain and infection.’ (p29, female, audiologist) ‘they saw a prophet and had to pay a lot of money to them, their child still remained profoundly deaf afterwards. (p37, female, audiologist) ‘this has happened many, many times – more than 50 times. the traditional healer was almost always consulted to provide input or treatment for an adult or child who had lost their hearing or was ill … the client was told that the afflictions were a message from their ancestors, and this did give them some peace, having what they believed to be a cause for the difficulty. in several cases, the treatment actually caused further medical concerns.’ (p40, female, audiologist) are audiologists accommodating of the client’s cultural and religious beliefs in practice? two participants stated that they do not accommodate their clients’ cultural and religious beliefs, and 39 participants are accommodating as per box 1. participants stated that they accommodate their clients by not forcing intervention (e.g., the use of hearing aids). they ensure that communication style is culturally appropriate, and they try to communicate with the client in the client’s first language. box 1: strategies used by audiologists to accommodate the client’s cultural and religious beliefs. participant 22 was the only audiologist to describe a direct interaction with a traditional healer while consulting with a hearing impaired individual: ‘i had a patient actually come to see me with his traditional healer. he had a long history of discharging ears and poor functional hearing. he had gone to this lady for assistance. she (the traditional healer) at some point realised that her medication would not work and recommended that he should see a doctor at a clinic. it was quite interesting as i explained what otitis media is and how it manifests and how it should be treated with antibiotics and medical treatment, and how the ear needs to be kept dry as one of her treatment plans was inserting water with stuff in. they were quite receptive and the traditional healer said she would pass the message on to her colleagues, which was encouraging to hear.’ (p22, female, audiologist) collaboration between traditional healers and audiologists thirty-nine participants reported that they have never received a referral from traditional healers, one participant reported that he or she had received a referral from a traditional healer and one participant did not answer this question. twelve participants did not answer the question pertaining to a referral to a traditional healer, one participant stated he or she has never been in a situation to refer, 27 participants reported that they would not refer the client to a traditional healer, and one participant stated that he or she would refer. themes that were identified included: the lack of scientific evidence to support traditional healing personal beliefs of the participant. participants stated that they would not refer the client to traditional healers because the methods are not scientifically proven. participants indicated that traditional healers are not qualified medical professionals, and if something goes wrong, the audiologist who has made the referral may be held responsible. four participants stated that traditional healing is not within the medical scope of practice; therefore, they would rather refer to other medical professionals. participants also stated that this would be against their own beliefs, as they do not believe in traditional healing. however, there were some participants who stated that if the client has psychological or emotional issues that could be addressed by the clients’ spiritual leaders, they would ‘let’ them consult with a traditional healer. when asked about a referral to a traditional healer, the following answers were provided: ‘no. i’m not versed in traditional healing; i don’t have evidence of its efficacy, so i would not refer a patient to them for audiological management.’ (p1, female, audiologist) ‘my faith may interfere especially if they say one was bewitched.’ (p3, female, audiologist) ‘no i don’t know any traditional healers.’ (p4, female, audiologist) ‘no i don’t believe in alternative medicine.’ (p21, female, audiologist) ‘no not part of my belief system.’ (p25, female, audiologist) ‘no. never. if there is no audiological or medical basis for the patients complaint, the patient is counselled and discharged. in some cases i have referred the patient to a psychologist.’ (p33, female, audiologist) one participant stated that she would refer clients to traditional healers: ‘not yet but if i encountered such a case i would. reason being i, myself believe in alternate treatments as well as the evil eye.’ (p16, female, audiologist) twenty-seven participants stated that it would be beneficial to have a formal model for the collaboration with traditional healers as the majority of the south african population consults with traditional healers. the themes that were identified include: collaboration supports holistic client care. there are clear boundaries for collaboration. a participant stated that the collaboration should begin with educating each group about the other, as this would lead to a multidisciplinary team that accommodates the clients’ beliefs. there were participants who were against the idea of collaboration as they deemed it ‘confusion’. they stated: ‘as long as the traditional healer is a christian and uses herbs and no witchcraft.’ (p3, female, audiologist) ‘there is room for both views and understanding both views are important for the sake of the client.’ (p6, female, audiologist) ‘i believe there is a big gap in collaboration. and perhaps that lies within our ignorance as healthcare professionals. perhaps we do not know enough about traditional healing to make the appropriate referral. perhaps our views have been influenced by the stereotype of what we think traditional healing is. an idea would be to start with education – from both sides … perhaps if traditional healers include medical research into their practice, their practice would become safer/more medically recognised.’ (p10, female, audiologist) ‘traditional healers are central to how certain communities run. they carry a lot of power. they are often the first place parents go for help when they notice a problem. this collaboration could assist in early identification and intervention.’ (p11, female, audiologist) ‘i think there is great power in collaborating and sharing ideas.’ (p12, female, audiologist) ‘i don’t know the role of traditional healers and would be nervous about this.’ (p15, female, audiologist) ‘i don’t think it’s something i would do.’ (p18, female, audiologist) ‘it is important to consider the patient holistically and take their needs into consideration. traditional healers might be able to tap into areas that medical practice is not able to tap into.’ (p23, female, audiologist) discussion in this study, the general consensus is that a traditional healer is well respected in the community with a calling to help others through non-medical means. a vital finding in this study is that traditional healers are thought to use herbal remedies, surgery, prayer, spiritual rituals and practices to heal a physical, emotional or psychological illness or disease. the participants stated that the traditional healer does not have an official or academic medical qualification but they treat medical illnesses and diseases. south african audiologists perceived the traditional healer’s methods to be unscientific, which reiterates the medical western view of traditional healing practices. participants perceived that traditional practices may sometimes have benefits to improve the client’s health, but they may become dangerous or contradictory when used with modern or western medicine. the methods are dictated by the cultural and religious beliefs, which have been passed on from generation to generation through ancestors. the descriptions of a traditional healer that were provided by participants were similar to the who classification of a traditional healer. traditional healers are well-respected people in their respective communities. however, the participants did not see traditional healers as equals or as medical professionals because they do not have the academic qualifications and their methods are not scientifically proven. traditional healing is based on spirituality which may result in conflict and misunderstandings between the traditional healer (colvin et al., 2003) and the western medical professional, whose point of view is based on scientific proof (poudyal et al., 2003). the participants in this study stated that they do not ask about traditional healing because it is a very sensitive topic that seems intrusive, highlighting that audiologists are reluctant and possibly unequipped to appropriately converse about aspects such as spirituality and traditional healers within the healthcare practices. based on the hpcsa 2008 guidelines for good practice in healthcare, it is the healthcare worker’s duty to have the client’s well-being and best interest at focus. the healthcare worker has a duty to make sure that the client’s personal beliefs do not cause any harm or injury (hpcsa, 2008). therefore, an integral and holistic model of care is vital to ensure that all facets of the client’s life are included in the care process. the results of this study revealed that audiologists have encountered negative aspects of traditional healing practices that compromise the client’s health as some clients were reluctant to take the medical treatment when they were taking the traditional medication, and the methods that were reported by the participants seem unconventional when compared to western medical management. in sa, some traditional healing methods may cause harm to the client (de andrade & ross, 2005). however, there are other international studies (ross, 2010) that reveal the benefits of traditional healing methods. this study indicates the need for prevention and promotion of the scope of practice of western medical professionals and traditional healers and the implementation of an integral model of care, without contradictions. it is evident that audiologists must consider the inclusion of questions that pertain to spirituality and traditional practices to ensure that models of care are culturally and contextually appropriate for the south african population. when the healthcare provider initially establishes rapport with his or her client, the client develops a trust relationship with the healthcare provider. the clinician who builds a trust relationship with the client can motivate for compliance when implementing intervention (hegde & davis, 2009). the south african society is multidimensional, and therefore, an integrated holistic service delivery model is vital in the practice of audiology. a second opinion is a free choice, and it is a right afforded to the client; however, the medical model has shaped this right to suit only a medical second option. it is evident that the majority of audiologists do not refer to traditional healers, and they do not receive referrals either. traditional healers in other studies were willing to collaborate with the western doctors; however, they acknowledged that the medical healthcare providers do not respect traditional healing methods (madomombe, 2006). the transformation of clinical and academic training of audiologists in sa must include information that focuses on cultural and religious beliefs within the curriculum. the advantages of collaboration can be a holistic and integral service delivery model that cares for an individual with a hearing loss and his or her family. the biopsychosocial-spiritual model assists in considering the client’s biological factors, psychological factors, social factors and spiritual factors (sulmasy, 2002). internationally, and within sa, there are still debates about the inclusion of traditional healers in the healthcare system because of their non-scientific methods of healing (colvin et al., 2003). however, there is evidence of successful collaborations between the medical and traditional worlds (chipfakacha, 1997; peltzer et al., 2006; pillay & moonsamy, 2017, 2018; poudyal et al., 2003; somse et al., 1998). tools that may aid in promoting integral healthcare, such as the faith and beliefs, important, community and assess in care (fica) and source of hope, organized religion, personal spirituality and practice, effects on medical care (hope), could assist the healthcare provider in introducing spirituality into the session (saguil & phelps, 2012). conclusion the foundations of service delivery and practice in audiology have been solely based on the medical model of healthcare. the illnessand disease-centred model is effective as it assesses and manages the hearing loss; however, it negates the humanistic aspects related to the individual’s experiences. this article opens a door to discussing the audiologists’ perspectives of traditional healing, which plays a significant role in the field of audiology in sa. the pertinent findings in this article highlight the real-life experiences of south african audiologists. collaboration with traditional healers may unlock the possibility for formalising an integrative holistic model of healthcare service delivery in audiology. audiologists are starting to accommodate clients’ beliefs during consultations. however, there is uneasiness when considering collaborations with traditional healers. the lack of knowledge about the scope of practice of both the audiologist and the traditional healer must be dealt with to ensure that holistic and integrated care is provided to the individual with a hearing loss. with reference to holistic healthcare, it is recommended that audiologists consider the following: the audiologist should reflect on personal beliefs, thoughts and assumptions that impact one’s practice. a self-reflection session may include questions such as: how is ultimate health understood? how do you understand affliction and suffering? what are the different parts of a person? how is hearing loss understood and explained? what intervention and care are seen as necessary? what do you understand by the word ‘healing’? who is seen as qualified to address the different parts that need healing? what are your thoughts on religious, traditional and spiritual care in general and hearing loss in particular? do you believe in traditional healing, and if you do not believe, then how would you handle a situation where a patient believes in traditional healing? what are your thoughts with regard to the collaboration with non-medical individuals in the management of a hearing loss? would you consider initiating a multidisciplinary team that includes religious, spiritual and traditional healers in the care of an individual with a hearing loss? the audiologist is advised to re-evaluate the history-taking process and consider the inclusion of questions pertaining to religious practices and belief systems. the audiologist may consider asking the following questions: do you believe that the hearing loss may be a result of a non-medical cause? do you believe in god or a higher power, and if so, how do you understand the hearing loss in relation to your belief? have you sought any other form of help for the hearing loss, for example, prayer, traditional methods? is there someone who supports you spiritually? would you like to include non-medical support structures in the process of management of the hearing loss? the authors leave you with the challenge of exploring your own spiritual, religious and traditional beliefs so that you may afford the client with the same opportunities. acknowledgements the authors thank the participants of this study for their participation. competing interests the authors have declared that no competing interests exist. authors’ contributions all authors contributed equally to this work. funding information this research received no specific grant from any funding agency in 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(2011). integrating traditional medicine with biomedicine towards a patient-centered healthcare system. chinese journal of integrative medicine, 17(2), 83–84. https://doi.org/10.1007/s11655-011-0641-2 quality of life after total glosso-laryngectomy leanie engelbrecht and anita van der merwe q uality o f l ife after t otal g losso-l aryngectom y 29 department o f communication pathology, university o f pretoria astract the article explores the quality o f life o f two participants who had undergone total glosso-laryngectomy as treatment fo r advanced tongue base cancer. semi-structured interviews were conducted and questions relating to the effects o f treatment on physical, functional, social and psychological well-being were asked. thematic analysis o f the interviews was done to determine recurring themes in the answers o f the participants. the findings showed that total glosso-laryngectomy has a significant impact on quality o f life. a good quality o f life can be maintained in a patient who has an extensive support structure and can achieve intelligible oral communication. pre-operative counselling by a multi-disciplinary team is important fo r a person to make an informed decision regarding surgery fo r head and neck cancer. shared decision making needs to be addressed in the south african service delivery context. key words: quality of life, physical well-being, functional well-being, social well-being, emotional/psychological well-being, glossectomy, glosso-laryngectomy introduction in 1947 the world health organisation's definition o f health changed from "absence of disease and infirmity" to "a state of physical, mental and social well-being" (world health organi­ sation, 1997). this definition emphasises the value of preserv­ ing physical, social and mental health. quality of life for head and neck cancer patients has become a much debated topic and a crucial area of research in the last two decades (major, bumpous, flynn & schill, 2001; petruson, silander & hammerlid, 2003). the reason for this interest in quality o f life o f a person who has head and neck cancer is that treatment of this type of cancer may be curative, but may also have a dra­ matic effect on many aspects o f life for such a person. the per­ son who receives the diagnosis o f head and neck cancer has to make an informed decision regarding treatment. the speech language pathologist will in many instances be an important resource for information regarding the consequences of treat­ ment and therefore needs to be informed o f the possible effect of surgery for head and neck cancer on quality o f life. surgical treatment forj advanced head and neck cancer often entails total glossectomy and total glosso-laryngectomy (harrison, ferlito, shaka, bradley, genden & rinaldo, 2003). t1 tumours (2cm or less in greatest dimension) and t2 tumours (more than 2cm but not more than 4cm in greatest dimension) can be treated with a single modality, for example, surgery or radiotherapy. t3 tumours (more than 4cm in greatest dimen­ sion) and t4 tumours (extensive tumour infiltrating adjacent structures), however, may require combined treatment such as surgery followed by radiotherapy or chemoradiation (shah, 1996; harrison et al., 2003). when surgery is the treatment modality of choice, total glossectomy may be performed. a laryngectomy may also be performed concomitant with total glossectomy to prevent aspiration o f liquids and food that may follow after total glossectomy (davidson, brown & gullane, 1993). in extensive tumours where the valleculae and/or larynx are infiltrated, total laryngectomy has to be performed together d epartm ent o f c om m unication p athology u niversity o f p retoria . p retoria 0002 e-m ail: leanie.2305@ vodam ail.co.za south a frica o r anita.vanderm erw e@ up.ac.za with the glossectomy to obtain clear surgical margins. this operation is known as a total glosso-laryngectomy. although surgery for base of the tongue cancer is often life saving, this type of surgery may lead to various problems post-operatively, thereby affecting the patient's quality o f life. despite advanced reconstruction techniques and methods of rehabilitation, total glossectomy patients are still faced with deficits in eating, speaking, breathing, shoulder movement and also deformed physical appearance (ruhl, gleich & gluckman, 1997; vickery, latchford, hewison, bellew & feber, 2003). if a total laryngectomy is performed too, the person will not only lose the tongue, but also the ability to produce voice. total glossectomy and total glosso-laryngectomy may impact on physical well-being, social well-being, psychological well­ being and functional status (chen, frankowski, bishop-leone, hebert, leyk, lewin & goepfert, 2001; morton, 2003). the term health related quality o f life (hrqol) is fre­ quently used to focus on the clinical effects o f a disease and its treatment. this concept highlights those aspects of life that are affected by healthcare interventions (fayers & machin, 2000; ferlito, rogers, shaha, bradley & rinaldo, 2003). the exact meaning of the term hrqol has not been adequately defined and according to fayers and machin (2000) the aspects that the term encompasses may vary from study to study. the term quality o f life refers to a broader scope o f aspects than pure clinical effects as encompassed in hrqol. quality o f life has been described as a broad concept that applies to a person’s general well-being and life-satisfaction (walter & shannon, 1990). according to morton (2003) quality o f life relates to a range o f physical and psychological parameters that describe an individual's ability to function and derive satisfaction from life. to make sense of the many aspects o f quality o f life, some main components o f quality o f life has been suggested. according to morton (2003) the components o f quality o f life can be divided into four domains, namely physical func­ tioning, social interaction, psychological state and somatic sen­ sation. fayers and machin (2000) state that general health, physical functioning, physical symptoms, emotional function­ ing, cognitive functioning, role functioning, social well-being and functioning, sexual functioning and existential issues are components o f quality o f life. five broad domains o f hrqol are identified by gift and atchison (1995) and these are: opthe south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:leanie.2305@vodamail.co.za mailto:anita.vandermerwe@up.ac.za 30 leanie e ngelbrecht and a nita van der m erwe portunity/resilience, health perception, functional status, impair­ ments/disease and duration of life. fang, tsai, chien, chiu, wang, chen and hsiung (2005) explain that quality of life has two fundamental premises. first, it is a multidimensional survey incorporating physical, functional, social, emotional and psy­ chological domains. second, it is subjective and must be self reported according to the patient’s own experience. these con­ ceptualisations o f quality of life (or hrqol) encompass the three dimensions specified by the icidh-2 classification of the consequences of health conditions. these dimensions are: the body dimension which “comprises two classifications, one for functions of body systems, and one for the body structure”; the activities dimension which includes “the complete range of activities performed by the individual”; and the participation dimension which “classifies areas o f life in which an individual is involved, has access to, and/or for which there are societal opportunities or barriers” (who, 2007 p. 1). many self-completion questionnaires for assessing qual­ ity of life o f head and neck cancer patients are available (ferlito et al., 2003). established and well-known instruments for qual­ ity o f life assessment in head and neck cancer patients include the following: functional assessment o f cancer therapy — h ead and n eck version (fact hn); performance status scale fo r head and neck cancer (pss hn); university o f washington quality o f life questionnaire (uwqol); the sickness impact profile (sip); european organisation fo r research and treat­ ment o f cancer core questionnaire head and n eck module (eortc hn); life satisfaction scale (lsc); h ead and neck radiotherapy questionnaire (hnrq); locus o f control (loc); the general health questionnaire (ghq) (ferlito et al., 2003). the majority of quality o f life questionnaires include a global quality o f life measurement as well as focus on diseaseand treatment specific outcomes and psychosocial issues. areas of quality o f life that are usually assessed by quality of life instru­ ments for patients with head and neck cancer, include physical-, functional-, social-, and emotionalor psychological well being (pretorius, 2004). these dimensions are also used in the current study. thus a model that encompasses all levels of functioning and disability (who, 2007) as determinants o f quality o f life is adopted in this study. patients with head and neck cancer face many conse­ quences of this disease and its treatment. first o f all there is the fear of death and dealing with the knowledge of having a life threatening disease (vickery et al., 2003). head and neck cancer patients have many o f the same risk factors for suicide as pa­ tients with other forms o f cancer. it has been well documented that patients with a diagnosis of cancer are at increased risk of committing suicide (henderson & robert, 1997). surgery may result in visible and extensive facial and neck disfigurement. facial disfigurement is one o f the most potentially distressing aspects of head and neck cancer because of the vital importance o f the facial region to self-concept, interpersonal relationships and communication (katz, irish, devins, rodin & gullane, 2003). katz et al. (2003) found that head and neck cancer pa­ tients with greater facial disfigurement were more depressed than patients with less facial disfigurement. similarly, gamba, romano, grosso, tamburini, cantu, molinari and ventafrida (1992) found a significantly higher impact in head and neck cancer patients with extensive disfigurement versus head and neck cancer patients with minor disfigurement with regard to changed self-image, a worsened relationship with a partner, reduced sexuality, and increased social isolation. functionally, swallowing, speech and the ability to work may be affected. one of the main factors that influence the perception o f quality o f life of head and neck cancer patients, is their ability to eat and swallow normally (kendall & leonard, 1999; hutton & williams, 2001). in almost all cultures eating is a social activity and patients who are not able to eat normally may withdraw from these activities. morton (2003) also stated that life satisfaction scores for head and neck cancer patients were related to pain, dysphagia and speech difficulty. prolonged disability and the cost of treatment threaten the socio-economic stability of patients and their families and patients fear that they may become a social and financial burden (vickery et al., 2003). the effects of surgery, radiotherapy and chemotherapy can lead to limitation of social activities, a delayed return to work and feelings of isolation (vickery et al., 2003). quality of life in head and neck cancer patients will thus encompass many parameters such as survival, pain, aesthetics, functional changes, job changes and social and existential issues. quality of life has been explored in several head and neck cancer populations overseas, but only a few studies have been done regarding the quality o f life of patients who have undergone total glossectomy (davidson et al., 1993; ruhl et al., 1997). with regard to total glosso-laryngectomy no such studies have been undertaken. in south africa patients are often diagnosed with advanced head and neck cancer and extensive surgery may be the only treatment option. the issue o f debate is whether the quality of life after operations such as total glossectomy and total glosso-laryngectomy justify this drastic surgery. the answer to this question is of the utmost importance as it has implications for the patient who is going to have a total glossectomy or glosso-laryngectomy. in order to survive, pa­ tients are often willing to tolerate any form of surgery. if a good quality o f life can be achieved, it makes the use o f these radical procedures more acceptable to the patient and the surgeon. mor­ ton (2003) emphasised that patients may learn to cope well with dysfunction and disability by adjusting their lifestyle so that overall quality o f life was not related to the treatment received. functional status and quality o f life are thus not equivalent, and function itself cannot predict quality of life (ruhl et al., 1997). therefore, observed dysfunction, disability and disfigurement do not necessarily reflect the patients’ rating of their own qual­ ity of life. also in total glossectomy and total glosso laryngectomy patients, one should be careful not to equal post­ operative functioning with quality of life. it is possible' that a patient could be content with his/her quality o f life, post operatively. a patient may feel that functional restrictions are bearable in the light of survival and may adapt well to func­ tional changes. it is therefore necessary to obtain information regarding quality of life as experienced by patients themselves. information with regard to factors that affect' post­ operative adaptation is thus of the utmost importance as it has implications for pre-operative counselling as well as post­ operative support. if the multidisciplinary rehabilitation team, including the speech-language pathologist, is aware o f the fac­ tors that may influence quality o f life, the team will be better equipped for appropriate pre-operative counselling and post­ operative psychosocial support. a well-prepared patient may also adapt better post-operatively than an unprepared patient. feedback from the patient in terms o f quality of life may thus influence surgeons' choices and speech-language pathologists' rehabilitation practices. ^ method / aim the aim of this study was to determine the quality o f life of two participants who had undergone total glosso-laryngectomy. d ie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) q uality o f life after total g losso-l aryngectom y 31 research design a qualitative research design was followed in the form o f two case studies (parallel case studies) o f patients who had under­ gone total glosso-laryngectomy. case studies refer to qualitative studies o f one or a few illustrated cases. it is a method involving systematically gathering enough information about a particular person, social setting, event or group to permit the researcher to effectively understand how the subject operates or functions (berg, 2007). information regarding quality o f life was obtained from the two participants through semi-structured/semi-standard face-to-face interviews and open-ended questions were asked (terre blanche & durrheim, 1999; berg, 2007,). berg (2007) explains that the semi-standard interview is more or less structured, that questions may be recorded during the interview, that the wording of questions are flexible, that the level o f language may be adjusted, that the interviewer may an­ swer questions and make clarifications and that the interviewer may add or delete probes during the interview. according to patton (1990) semi-structured interviewing begins with the as­ sumption that the perspective of others is meaningful. the object o f such interviews is to get the person being interviewed to talk about their experiences, feelings, opinions and knowledge (patton, 1990). open-ended questions are utilised in order to encourage the participants to identify areas of importance to them, using their own vocabulary (patton, 1990). materials and methods the researcher developed an interview schedule (appendix a) containing a set o f questions regarding different domains of quality o f life (neumann, 2000). a topic guide ensured that the same information was obtained from both participants (patton, 1990). the interview-questions were designed according to information obtained from the literature regarding quality of life in head and neck cancer patients. the interview schedule in­ cluded questions about physical-, functional-, socialand emo­ tional/psychological well-being. the interview schedule was used to direct the interviews w ith th e participants, but the wording and order o f the questions were not fixed (patton, 1990). questions were asked in the participants’ first language. multiple and leading questions were avoided to limit any suggestions of a desired answer from the subject (terre blanche & durrheim, 1999). the interviews were conducted in the office of tlie researcher (first author) by the researcher. the interviews were recorded on a high quality panasonic rq-l10 tape recorder. audio recording of the inter­ view sessions allowed both the researcher and the participant to cross check the data gathered, thus enabling a means o f validat­ ing the data. participant 1, who was non-verbal, communicated by means o f writing. during this interview, the speech o f the researcher was tape-recorded to ensure complete transcription of the interview. the researcher transcribed the recordings and listened to the tapes several times to ensure that all data were transcribed correctly. participant selection criteria the following selection criteria were set: the participant should have undergone total glosso-laryngectomy; should not have suf­ fered from any other medical condition than the glosso laryngectomy; should not have had any other communication disorder; and should have been afrikaans or english speaking as these were the languages in which the interviewer could conduct an interview. both participants were patients at an academic hospital in gauteng at the time o f the study. this was an example o f a purposive or judgmental sampling, where anyone in a hard-to find target population was selected (neumann, 2000). at the time o f the study there were only two surviving total glosso laryngectomy patients that could be tracked in the gauteng region. participant 1 had surgery six weeks prior to the time of the interview and participant 2, seven years prior to the interview. participant 1 was a 51-year-old afrikaans speaking white male who had a t4n3m0 squamous-cell carcinoma of the tongue-base and larynx. he underwent a total glosso laryngectomy and bilateral radical neck dissections on the 4th of february 2004. the oral cavity was reconstructed with a pectoralis major musculo-cutaneous flap. the interview was conducted on the 23rd o f march 2004. the patient's course of radiotherapy began on the 29th o f march 2004. the patient made use of facial expressions and gestures to augment written communication. at the time of the interview the participant was divorced, had lost his job as a security inspector and had poor social support. he was from a low socio-economic income group. participant 2 was a 63-year-old afrikaans speaking white male who had a t4n3m0 squamous-cell carcinoma of the tongue-base and larynx. he underwent a total glosso laryngectomy and bilateral radical neck dissections on the 2nd of december 1996. a pro vox prosthesis that makes tracheo­ esophageal voice production possible was inserted at the time o f the operation. the participant received a six-week course of radiotherapy post-operatively. the interview was conducted on the 9th of march 2004. the participant was a very lively com­ municator. his speech was fairly intelligible. he made use of a slow speech rate, intonation, eye contact, gestures and facial expressions to augment his speech. at the time of the interview the participant was married, resumed his work and had an ex­ cellent support structure. he was from an average socio­ economic income group. a summary of the participants' charac­ teristics is shown in table 1. participants table 1: d escription o f the tw o participants participant 1 participant 2 age 51 years 63 years gender male male race white white language afrikaans afrikaans treatment received at time of interview total glosso laryngectomy bilateral radical neck dissections total glosso laryngectomy bilateral radical neck dissections post-operative radio­ therapy time span since sur­ gery six weeks seven years voice prosthesis in­ serted no yes functional speech no yes swallowing oral (liquid diet) oral (liquid diet) work unemployed employed social support poor good socio-economic group low average the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 32 leanie e ngelbrecht and a nita van der m erwe content analysis is a careful, detailed, systematic examination and interpretation o f a particular body o f material in an effort to identify patterns, themes, biases, and meanings (berg, 2007). thematic analysis o f the content o f the interviews was con­ ducted at five levels, according to the guidelines o f patton (1990) and terre blanche and durrheim (1999). terre blanche and durrheim (1999) describe the process o f data analysis as reading through your data repeatedly, and engaging in activities o f breaking the data down (thematising and categorising) and building it up in novel ways (elaborating and interpreting). dur­ ing this process the researcher steered clear o f imposing prior theoretically derived concepts on the data. instead, careful in­ spection o f the narrative facilitated the generation and develop­ ment o f new concepts from the research data via an inductive analysis. the following steps were followed: familiarisation and immersion: the researcher read through the data repeatedly and intensely. relevant information was selected, irrelevant informa­ tion was eliminated, key words were identified and notes were made during the reading o f the data. a summary was made of each o f the components o f the interview schedule (general infor­ mation, physical well-being, functional well-being, social well­ being and emotional/psychological well-being). inducing themes (in relation to the research question): the researcher identified the organising principles that “naturally” emerged from the data. this was done by inductive analysis, meaning that themes emerge from the data as opposed to themes being imposed on the data prior to data analysis. coding: coding means breaking data up in analytically relevant ways. the copy-and-paste func­ tion o f a word processor program was used to move bits o f text around to fit the identified themes. elaboration: elaboration means the discovery o f new dimensions o f the subject that are being studied or looking at data in a fresh way. comparisons were made o f sections o f text that appeared to belong together and comparisons were made between themes identified from the two interviews. interpretation and checking: themes were dis­ cussed in relation to available literature. ethical considerations before initiating the research, the researcher received ethical clearance for the research project from the research and ethics committee o f the human sciences faculty o f the university of pretoria. written informed consent was obtained from both par­ ticipants and ethical issues regarding tape recording o f inter­ views, anonymity, confidentiality and withdrawal from the re­ search project were discussed. both participants gave consent that results o f the study may be published. both participants were patients o f a speech therapy department at an academic hospital and supportand follow-up services were available. trustworthiness measures to ensure trustworthiness that were implemented in this qualitative study included, truth-value, applicability, consis­ tency and neutrality (de vos, 2002). truth-value establishes how confident the researcher is with the truth o f the findings, based on the research design, in­ formants, and context (de vos, 2002). on the research design level, truth-value was established by designing the interview schedule according to information obtained from the literature regarding quality o f life in head and neck cancer patients. semi­ structured interviews, which are an acknowledged tool in quali­ d ata analysis tative research, were conducted in the participants’ first lan­ guage (afrikaans) to allow for free expression. interviews were recorded to permit transcription o f every utterance. participant 1 wrote down his answers. all the answers o f participant 2 were transcribed and unintelligible utterances were later verified with him. in the results direct quotes (translated into english for the purpose o f publication o f the data) from the transcribed data are presented. applicability refers to the ability to generalise from the findings to the greater population (de vos, 2002). one perspec­ tive on applicability in qualitative research suggests that the ability to generalise is not relevant in many qualitative research projects. results o f case studies can to some extent be general­ ised, but it was not the intent to generalise the findings o f this study to the greater population o f total glosso-laryngectomy patients. each person’s situation is unique and there are different variables that may influence quality o f life after total glosso laryngectomy. since total glosso-laryngectomy is such a radical surgical procedure with very specific effects on function, it is possible that some o f the experiences may be similar in persons who have undergone total glosso-laryngectomy. berg (1997) is o f the opinion that case studies could not only represent the spe­ cific individual, group or event studied, but could also provide understanding about similar individuals, groups or events. consistency indicates whether the finding would be con­ sistent if the enquiry were replicated with the same subject or in a similar context (de vos, 2002). this study can be viewed as consistent, as an interview schedule with a specific topic guide was used to obtain the information. the themes that emerged from the different questions were checked with the participants to assure that the message that the participant was conveying to the interviewer was understood correctly. neutrality refers to the degree to which the findings are a function solely o f the informants and conditions o f the research and not o f other biases, motivations and perspectives (de vos, 2002). questions were asked in such a way that it should not have influenced the answers o f the participants. the researcher merely determined and reported the views, perspectives and feelings o f the participants. to establish whether the categories, explanations and interpretations o f the data were reliable, the data were also analysed by a clinical psychologist with a doc­ toral degree and who has experience in qualitative research stud­ ies and content analysis. the themes that were identified by the researcher and the conclusions were discussed with the psy­ chologist, and a few discrepancies were resolved. results and discussion the most prominent themes that emerged from the thematic analysis are described and discussed in this section. the themes are summarised in table 2. for the purpose o f gaining a compre­ hensive view of the experiences and feelings o f the two partici­ pants, the original categories o f the interview schedule namely physical-, functional-, socialand emotional/psychological well­ being will be slightly adapted. experiences in these different domains interact and it may be artificial to categorise them ac­ cording to the theoretical guidelines that were followed in the interview schedule. themes that do not fit any o f the original categories emerged and these will also be described. functional well-being speech and communication at the time o f the interview, which was six weeks post­ surgery, participant 1 was still not able to communicate verbally die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t a b le 2: sum m ary o f quality o f life as perceived by the tw o participants q uality o f life after total g losso-l aryngectom y 33 tim m p a i f m p it l participant 2 speech non-verbal, feelings of isolation, uselessness has functional speech and that enhanced integration into the community work/finances unemployed affected self-image negatively employed affected self-image positively perception of other peoples’ reaction towards them very aware and sensitive, perceived reaction as rejection ambivalent (in the process of becoming less sensitive) isolation prefer to be alone, avoid people, but also want to make contact with people part of the community (progressed from isolation to integration) acceptance and support little acceptance/support accepted by most significant others and excellent support structure changed self-image perceives himself as abnormal perceives himself as abnormal adjustment patient still in the process of adjustment, poor coping skills patient has adjusted well and has overcome most problems overall/global quality of life poor good pre-operative counselling patient not counselled prior to surgery patient partially prepared for surgery and its effects role of the speech-language pathologist speech rehabilitation swallowing rehabilitation support speech rehabilitation swallowing rehabilitation support and this circumstance had far reaching consequences. the inability to speak resulted in him losing his job and led to high levels o f frustration. being a security-inspector, he relied on verbal communication. the inability to speak also prevented him from fully expressing his thoughts, feelings and desires. communication needs could only be fulfilled in a limited way by writing. he said: will never be able to speak again. it is incredibly difficult to be suddenly mute after 51 years o f talking. it is a strange world. totally strange. because i c a n ’t speak i have lost my jo b and i am struggling financially. without speech i am useless to the company, because i have to speak with a radio control as well as to clients. ’ participant 2 experienced the same problem initially, but his life changed since he learned to speak. he could express his feel­ ings, resume his work with greater ease and frustration was re­ duced. he expressed his experience o f the loss o f speech as fol­ lows: . / i n the beginning it was j difficult to communicate be­ cause nobody understood me. everywhere i went as well as at work i had to write i f i wanted to communicate with anyone. a n d that was frustrating. after i started with speech therapy and i could speak to people, this has improved. ’ j communication is a major function o f the face and neck. tilting the head, facial expressions such as smiling and frowning, and above all, speech, laughter and other emotional expressions are all part o f human interaction (boone & mcfarlane, 1994). the sound o f one’s vocalisation often mirrors one’s internal emo­ tional state (boone & mcfarlane, 1994). it seems as though patients who are able to communicate verbally do better emo­ tionally and psychologically than those who have to rely on writing. a loss o f communication may also signify a loss o f closeness and love. we create closeness through communica­ tion (ventegodt, andersen, rromann & merrick, 2003). the importance o f verbal communication to quality o f life confirms the role o f the speech-language pathologist in providing inter­ vention that will enable the patient to achieve intelligible speech. work/finances the ability to work had a major impact on the partici­ pants’ quality o f life. because he has not been able to work, participant 1 experienced feelings of worthlessness and not be­ ing able to make a contribution to life. he said: ‘people see me as a sort o f parasite that wants to live on other people. people also see me as someone that has nothing to contribute. without speech i am useless to the company, because i have to speak with a radio control as well as to clients. ’ in contrast, participant 2 experienced pride and found satisfac­ tion in his ability to continue his career and provide for his fam­ ily. this impacted positively on his self-image. he was able to go back to work two months after the operation. this fact con­ tributed to his feeling o f pride. the ability to communicate ver­ bally allowed participant 2 to resume his work and that en­ hanced his process o f integration into the community. this was not possible for participant 1 who was non-verbal. social well-being perception o f other peoples ’ reactions towards them both participants were very perceptive with regard to the reactions o f people towards their “disability”. at the time o f the interview participant 1 was more intensely sensitive than par­ ticipant 2. the fact that participant 1 was interviewed only six weeks after his total glosso-laryngectomy, may explain why his sensitivity towards the reactions of people was more intense than those of participant 2. participant 1 preferred to be alone and actively avoided people, although he longed to make con­ tact with people as he did before. his inability to communicate verbally and the abnormal way in which he eats caused reac­ tions from people in his environment. participant 1 said: 7 am shy. yesterday the wife o f the guy lying in the room opposite me came to visit him. the way in which i eat is fu n n y because i must place the fo o d at the back o f my mouth, and it upsets me i f people watch me while i ’m eating. there is a lady in the ward that calls me a “rude bastard” because i ’m not talking to anyone until i wrote her a message to explain why i ’m not talking to anyone. a ll strange (might be a better translation: unfa­ miliar) people think i ’m rude. they accept my condition but are clearly uncomfortable. ’ seven years after his total glosso-laryngectomy, participant 2 the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 34 l eanie e ngelbrecht and a nita van der merwe has possibly come to terms with these reactions, although he contradicted himself about this issue during the interview. he was still very self-conscious while eating. initially, his altered way o f speech also drew attention. participant 2 said: 7 am very self-conscious and i think people are looking at me — that is my problem. or when i speak, people look at me in a fu n n y way. when i speak, people stare at me, especially children. it did bother me, but not any more. unfamiliar people do not bother me any more when i interact with them. they go on as i f nothing is wrong with me. in other words they look p a st the prob­ lem. ’ isolation both participants experienced a degree o f isolation and o f being “separate” from other people. participant 1 possibly experienced this more intensely, as he was not able to communi­ cate verbally. he said: 7 d o n ’t have a problem to write what i want to say. i f people only wanted to read! it is the only way to tell people that although i do not have a tongue or a voice, i still am a person with feelings, trying to share those fe e l­ ings. ’ participant 2 was also isolated initially, but over the years has gradually returned to the community. only after seven years did he have the courage, for example, to attend a church camp. the fact that participant 2 could communicate verbally facilitated the process o f reintegration into the community. he could re­ sume his work and communicate with family and friends. par­ ticipant 2 said: 7« the beginning i d id n ’t take part in any activities. but that has now changed. one must never isolate one self. i have tried that, but it d idn’t work. because i couldn’t speak, i avoided going to church fo r a whole year. acceptance and support participant 1 struggled to cope due to a very limited sup­ port structure. he expressed his wish for his mother’s accep­ tance and support more than once during the interview. al­ though his sister, ex-fiancee and ex-wife supported him, he ex­ pressed the longing for support from his mother. he also did not receive support from his children, previous colleagues or friends. participant 1 said: ‘most fam ily members and friends accept me as i am. but there are others that do not want to understand. like my mother, fo r example. she is very impatient with me. i f i write her a message, i can see that she does not really want to read it. i f i snap my fingers to attract her atten­ tion, she says that she is not a dog that i can snap my fingers at. ’ participant 2 reported that his wife, family and friends accept him as he is. he had persistent support from his wife since the time o f diagnosis. she supported him every step o f the way in all practical and emotional aspects. two o f his three children, people from his church and neighbourhood, his general practi­ tioner and colleagues provide a great deal o f support. his em­ ployer accommodated him and supported him in the process o f resuming his work after the operation. participant 2 has possibly coped with all the changes because o f his excellent support structure. he said: 7 went on a church camp in february fo r the fir st time, where the people treated me as a normal human being. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 they treated me like a normal human being. it is wrong i f people do not treat you as a normal human being. but in general people accept me fo r who i am. nobody re­ jects me. my fam ily has supported me physically and emotionally. no one rejected me. we go on holiday to­ gether when we can. one must have support — it is very important. ’ social support can be defined as the resources provided to peo­ ple through their interactions with other people. morton (1995) stated that lack of adequate family support has a negative im­ pact on quality o f life. head and neck patients should be pro­ vided with the necessary support services early in the process, as well as with follow-up later in the process (casper & colton, 1993). support should include medical as well as psychological help (harrison, 1983). as psychological distress is common in patients with head and neck cancer, psychosocial support has a role in reducing this distress (hutton & williams, 2001). in addition, social support, from either family members or groups, can help restore some o f the loss o f control that cancer patients may experience (sheridan & radmacher, 1992). thus, they need to be provided with as many opportunities as possible to increase their sense o f control. vickery et al. (2003) further stated that the physical and psychological stresses from head and neck cancer could also be substantial for patients’ partners. partners may in fact report greater distress than patients may on some quality of life scales (vickery et al., 2003). partners or significant others may also go through a process o f grief while accepting the changes in the person close to them. support ser­ vices should always be available to the patient and his or her significant others. structured education and support-group based services play a major role in meeting information and supportive needs (todd, roberts & black, 2002). emotional/psychological well-being changed self-image self-image refers to our overall perception o f ourselves, and the way we feel about how others see us (appleton & ma chin, 1995). both participants experienced feelings o f being "different" from other people. participant 1 expressed the changes in his way of eating and communicating as being the causes o f this perception o f being "different". change in physi­ cal appearance is another reason the participants experienced themselves as "different". participant 1 stated: 7 get a frig h t each time i look in the m irror’. participant 2 insisted that people should treat him as "a normal human being". these words may suggest that he still has not completely accepted himself as "normal" or that he constantly needs affirmation that he is not “abnormal”. even though par­ ticipant 2 acquired the ability to communicate verbally, the glossectomy speech and tracheoesophageal voice does not sound normal. this fact may contribute to his feeling o f being different. facial appearance is part o f our overall self image and an important entity in establishing interpersonal relationships. the face is the most visible bodily area w here/all the major senses are located, as well as being the area o f a person's self identity. disfigurement in this area has far-reaching implica­ tions for a patient’s psychosocial interaction with the world and adversely affects the patient’s self-esteem (appleton & machin, 1995). gamba et al. (1992) suggested that a head and neck can­ cer patient’s self-concept should be studied as a possible diag­ nostic parameter to identify individuals at high risk for psycho­ social maladjustment. the fact that patients "no longer recog­ r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) q uality o f l ife after t otal g losso-l aryngectom y 35 nise themselves" was the most frequently expressed reason why patients felt that treatment for head and neck cancer was not worth the effort (gamba et al., 1992). the issue o f identity needs to be carefully considered in total glosso-laryngectomy patients. they may experience them­ selves as “changed” or “different” not only because of the facial disfigurement but also due to the loss o f voice. the voice of a person is as characteristic o f the person as the face is. facial disfigurement, loss of voice and the inability to communicate are all closely bound to a sense o f loss of identity. speech-language pathologists should be aware o f how the patient's self image has altered following total glosso-laryngectomy. they should also be aware o f the patient's resources for coping and o f any grief reactions that are evident. the patient should be referred for appropriate counselling if needed (casper & colton, 1993). adjustment adapting to a major change in one’s life such as a total glossectomy or total glosso-laryngectomy is a process that may take many years and even a lifetime. participant 1 was still in the beginning phase o f the process o f adapting to a new life, and did not yet posses the skills to help him cope with all the changes in his life. he was not even prepared for the changes that were imposed on him by the surgery. he said: 7 fe e l like a baby in an unknown world. i have to learn to crawl before i can walk again. ’ participant 2, who had the surgery seven years prior to the inter­ view, reported that his depression decreased over the seven years as he adapted to his situation. he had come to terms with many o f the changes in his life, including an altered way o f eat­ ing and communicating. he described this coming to terms as a process that took place over the years. he went through different phases o f growth towards acceptance. the gradual acceptance by family and friends could also promote patient adaptation as is evident for participant 2. he said: 7 « the beginning i didn't take p art in any activities. i was disheartened and p itie d , myself. but this has now changed. never lose hope. i was extremely hopeless at some stage. i f it wasn ’t f o r my wife, the speech therapist / and the grace o f god, i wouldn ’t have been here today. never pity yourself. it doesn ’t work. life is tough. it does not help to sit in the ashes. one should never give up hope! one should live into the future, not in the past. never isolate yourself. i did that and it didn ’t work. ’ head and neck cancer and its treatment place significant adap­ tive demands on patients and their families (katz et al., 2003). during the first year o f treatment, almost a third o f head and neck cancer patients reported having mood disorders (petruson, et al., 2003). casper and colton (1993) explained that some in­ dividuals with head and neck cancer could initially withdraw from social contact, especially if people show evidence o f dis­ comfort with their condition. this withdrawal is a normal stage in the process o f accepting changes in their self-image or func­ tional abilities. hutton and williams (2001) reported that de­ pression tends to decrease with time after the onset of head and neck cancer, and also decrease with increasing age. morton (1995) reported life-satisfaction scores in head and neck cancer patients to increase over time. q uality of life 1 the participants were asked questions about their perception of changes in their quality o f life. participant 1 felt that his quality o f life has drastically decreased since the surgery. he was still mourning the loss o f communication and the ability to eat nor­ mally. he said: ‘before the operation i could do so many things that are no longer possible. ’ participant 2 on the other hand felt that his quality of life after the surgery was better than his quality o f life shortly prior to surgery. since the operation he has adapted his life to accom­ modate his changed abilities. he has again found meaning in life and was continuing to improve his quality o f life by expand­ ing social contact. quality of life as globally assessed by patients does not directly correlate with measures o f physical function, but ap­ pears to depend on psychological, spiritual, and existential fac­ tors and also support systems (simmons, bremer, robbins, walsh & fischer, 2000). kim and alvi (1999) found that 94% o f patients who had been diagnosed with cancer, feared death, metastasis, recurrence, and the loss o f the ability to swallow, speak or breathe in the usual manner. uncertainty over the fu­ ture and the reality o f the loss they experienced impact on the subjective perception o f quality of life. hopefulness and having a life purpose help to balance the worse outcomes (dow, ferrell, leigh, ly & gulasekaram, 1996). a dditional themes pre-operative counselling both participants received very little pre-operative infor­ mation or counselling. according to both participants the ab­ sence o f pre-operative counselling impacted negatively on their post-operative recovery and quality o f life. adjustment to the major changes in self image and functional ability was compro­ mised because they were not empowered to prepare themselves for post-operative changes. participant 1 expressed his shock at the way his body was changed when he woke up after the operation. he was also not aware o f the fact that he was going to lose his voice. partici­ pant 1 said: 7 was upset, but what does it help? when i woke up i saw there was a hole in my throat. the hole in my chest was ju s t a big shock; nobody told me that there is going to be a hole in my chest. ’ participant 2 received some information regarding swallowing and speech from his surgeon, but also did not receive any coun­ selling from other members o f the multidisciplinary team such as the speech-language pathologist. he said: ‘h e told me it was going to be a big operation. he ex­ plained to me what to expect, also with regard to speech and swallowing. he told me that i w on’t be able to speak normally again. ’ shared decision making (sdm) is currently recommended as a standard o f care, especially when there are alternative treat­ ments available or when there is uncertainty about the outcomes o f treatment (mandelblatt, krelling, figeuriedo & feng, 2006). according to fayers and machin (2000) many patients and pa­ tient support groups demand to be given full information about the consequences o f the disease, its treatment and the impact on aspects o f quality o f life. patients should also be able to express their opinions (fayers & machin, 2000). street (1997) found that patients with breast cancer who had more actively partici­ pated in their consultations with their doctors, particularly in the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 36 l eanie e ngelbrecht and a nita van der merwe terms o f offering opinions, assumed more responsibility for treat­ ment decisions. davidson et al. (1993) stated that candidates for total glossectomy should be carefully considered and that pre-operative psychiatric evaluation could assist the surgeon in making apt deci­ sions regarding treatment. newell, ziegler, stafford and lewin (2004) found that head and neck cancer patients need individual­ ised pre-treatment information in an appropriate environment and that there should be more than one opportunity for patients to dis­ cuss their options. thereby the patient would be able to make an informed decision to undergo surgery. if the experiences o f the two participants in this study are a true reflection o f the nature o f the local service delivery model, the relevant professionals need to take a serious look at the issue o f pre -operative counselling, shared decision making and informed con­ sent before glossectomy and glosso-laryngectomy in south africa. pre-operative assessment and counselling by a multidisciplinary team including the surgeon, psychologist, social worker, physio­ therapist and speech-language pathologist would be the ideal. the team should prepare the patient and family for what the operation entails and how it will affect post-operative functioning. role o f the speech-language pathologist both participants highly valued the contribution o f the speech language pathologist to their rehabilitation and quality of life. the speech-language pathologist has knowledge o f the effects o f total glosso-laryngectomy on swallowing and speech and also insight into the emotional and social effects of altered ways o f swallowing and communication and is therefore equipped to sup­ port patients. by providing preand post-operative counselling as part o f a multi-disciplinary team and speech and swallowing inter­ vention, the speech-language pathologist can make a major contri­ bution to improve quality o f life for patients with a glossectomy or glosso-laryngectomy. conclusion total glosso-laryngectomy represents the extreme of extensive head and neck cancer surgery. both participants expressed their appreciation o f being alive, but stated that their quality of life was greatly affected by the surgery. the results o f this study showed that they tend to feel isolated and different from other people. they are very sensitive to the reaction o f others towards their physical appearance and their changed way o f eating and speaking. func­ tional speech, as well as acceptance and support from significant others appear to be the most important protecting factors o f quality o f life. time appears to be a contributing factor to adapting to physical and functional changes. an important outcome o f this study is the raised awareness that shared decision making and pre-operative counselling o f the patient and significant others in our local service delivery context needs to be addressed. a multidisciplinary team which includes the surgeon, speech-language pathologist, physiotherapist, psychologist and social worker should prepare the patient and significant others for the consequences o f surgery for head and neck cancer. to make, an informed decision regarding surgery, it is crucial that the patient is aware o f all the effects o f total glosso-laryngectomy on physical appearance, swallowing, and communication. the choice to undergo surgery remains with the person with head and neck cancer. in the case o f participant 2 the choice to undergo a glosso-laryngectomy to cure him from cancer was a worthwhile deci­ sion. after seven years he was still alive and was leading a fulfilled life in spite o f the changes in functional ability. in the case o f participant 1 there is no easy answer. participant 1 passed away 6 months after the interview due to massive local recurrence and metastases. references a ppleton, j. & m achin, j. 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(2007). international classification o f functioning and disability: a new release from w h o . r etrieved on 2007/08/07 from the w orld w ide w eb: http ://w w w .w ho.int/inf-pr-1999/en/note99-19.htm l. the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.who.int/inf-pr-1999/en/note99-19.html 38 appen d ix a interview schedule for s em i-s tructured interview s l eanie e ngelbrecht and a nita van der m erw e general information what surgery did you receive? when did it take place? did you have any other treatment? was it before or after surgery? how were you informed of the diagnosis o f cancer? did you have a choice in the type of treatment you could receive? were the implications/consequences of the surgery discussed with you? physical well-being how did the surgery affect your quality of life in terms of your general physical well-being? can you independently perform daily activities since the surgery? did you experience any difficulties in breathing? did you experience pain? do you have sufficient energy since the surgery to perform daily activities? do you have full range of movement in the shoulder and neck areas? are there any other physical problems you experienced since the surgery? functional well-being feeding what were the effects of the surgery on your ability to eat and to swallow? describe how you eat. did your diet change since the surgery? did your appetite decrease after surgery? did you experience any weight loss after surgery? did your experience of eating in a social context change since the surgery? communication what were the effects of the surgery on your ability to communicate? how do you communicate with other people? do you think that people understand your speech? how do your communication abilities affect your interaction with people? how do you feel about your way of communication? work and finances what job did you have before surgery? could you go back to work? did the surgery or your physical health cause financial problems? social well-being social interaction and family relationships how did the surgery affect your social interaction? how did it affect family relationships? do you take part in less social activities since the surgery? how do family and friends react during social interaction? how do you feel about these reactions? support who supported you since you were diagnosed with cancer? did your family support you physically and emotionally since the surgery? which other medical professionals except your surgeon were involved with you before the surgery and how did they help you? which other medical professionals except your surgeon were involved with you after the surgery and how did they help you? emotional/psychological well-being what were the effects of the surgery on your emotional or psychological well-being? / what emotions did you or do you experience since the surgery? / how does your quality of life before surgery compare to your quality of life after the surgery? how would you describe your life as a whole now? how do you see your future? if you could have the choice again, would you decide to undergo this operation? die suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) e v i d e n c e b a s e d p r a c t i c e in s p e e c h l a n g u a g e p a t h o l o g y : s c a l i n g up laura m . justice t h e o h io s tate u niversity, c o lu m b u s , o h io , u n ite d states | a bstract e v id e n c e -b a s e d p ra c tic e is a process t o w h ic h clinical professionals a d h e re w h e n m a k in g decisions c o n c e rn in g th e as­ sessm ent o r tr e a tm e n t o f a g iv e n c o n d itio n . w ith in th e fie ld o f s p e e c h -la n g u a g e p a th o lo g y , it is in c re a s in g ly a d v o c a te d as b est p ractice. as o u r profession seeks to tra n s fo rm its e lf fro m o n e th a t is p rim a rily c ra ft-b a s e d to o n e th a t relies on e v id e n c e -b a s e d processes, it m u s t d e v e lo p a n d im p le m e n t a series o f structures th a t w ill fo s te r th is tra n s fo rm a tio n .t h is a rtic le describes th re e specific structures th a t are in creasin g ly a v a ila b le w ith in th e f ie ld o f s p e e c h -la n g u a g e p a th o lo g y in th e u n ite d states to g u id e tra n s fo rm a tio n o f th e profession: system atic rev iew s an d m e ta -an alyses, tr e a tm e n t studies, and clearin g h o u ses. w ith o u tth e s e stru ctu ral su p p o rts, it is u n lik e ly th a t e v id e n c e -b a s e d p ra c tic e c a n b e scaled u p in a w a y th a t has p o sitive im p a c ts o n practice. keywords: e v id e n c e -b a s e d p ractice, system atic rev iew , m eta-analysis. evidence-based practice is a process to which clini­cal professionals adhere when making decisions concerning the assessment or treatment o f a given condition. this process involves careful consideration and integration o f various types o f evidence so that the most effective solution can be identified; these types o f evidence include, minimally: (1) clinical expertise, (2) patient values and perspectives, and (3) best available scientific evidence (sackett, rosenberg, gray, haynes, 8c richardson, 1996; sackett, straus, richardson, rosenberg, 8c haynes, 2000). evidence-based practice is recommended for use not only by speech-language pathologists, but also those involved with clinical decision-making in medicine (called evidence based medicine; evidence-based m edicine w orking group, 1992), nursing (porter-o ’grady, 2 0 0 7 ), psychology (spring, 2 0 0 7 ), physical therapy (cibulka 8c aslin, 2 0 0 1 ), and special education (c ook 8c shirmer, 2 0 0 6 ), among others. regard­ less o f one’s discipline and, by consequence the nature and impact o f the decisions to be made, the process o f evidence based practice is largely identical regardless o f whether one is selecting a treatment regiment for high blood pressure, for clinical depression, for stuttering, or for reading disability. as members o f the speech-language pathology community, it can be particularly insightful to examine the structures being put into place in other professions medicine and education, for instance as we transform our profession to ­ wards one that is evidence-based. i f we look to the larger literature on evidence-based prac­ tice, it is evident that all professions seeking transformation from craft-based to evidence-based clinical decision-mak­ ing models are in the process o f designing and implement­ ing complex types o f structures to not only ease this transfor­ mation but to make it even possible in the first place; some professions are much further along than others. b y struc­ tures, i am referring to tangible items and tools that must be developed to allow a profession to become more embedded in evidence. these structures include, for instance, provid­ ing guidelines to clinicians as to how to formulate well-built clinical questions (schlosser, koul, 8c costello, 2 0 0 7 ), devel­ oping consensus statements regarding how much and what type o f evidence is needed for a treatment to be “empiri­ cally validated” (gersten, fuchs, compton, coyne, g reen­ wood, 8c innocenti, 2 0 0 5 ), and articulating the sequenced steps that clinicians must follow so that they might conduct their own critical appraisals o f the scientific literature (e.g., fey 8cjustice, 20 0 6 ; justice 8c snell, 2 0 07). w ith in the field o f speech-language pathology, these and many other struc­ tures necessary for the successful transformation o f a profes­ sion to one that is evidence-based are in the process o f being developed and have not, to any large extent, yet been taken to scale. nonetheless, all signs point to the scaling up o f evi­ dence-based practice in the near future given that many rel­ evant structures are being put into place. evidence-based practice in the united states: stru c­ tures prom oting scalability in this article, i discuss three specific structures that are increasingly available within the field o f speech-language pathology in the united states: systematic reviews and meta-analyses, treatment studies, and clearinghouses. these three structures are, in my opinion, necessary tools for clini­ cians to engage in evidence-based practice and for a field to successfully transform itself to one that is evidence-based; their increasing availability provide evidence o f the scaling up o f evidence-based practice. systematic r ev iew s a n d m eta-analyses historically, speech-language pathologists in the u n it­ ed states have used practice guidelines (also called clinical guidelines) to help them answer pressing clinical questions. practice guidelines are statements developed by teams o f ex­ perts to guide practitioners in how to make decisions regard­ ing specific circumstance (field 8c lohr, 1990). although they may be developed through a systematic process, prac­ tice guidelines do not typically involve a comprehensive re­ view o f the literature on a specific topic nor a critical analysis o f available statistical data; they may, as a result, offer flawed interpretations o f the literature that represent the biases o f author contact: laura m . justice, 356 arps hall, 1945 n h igh street, the ohio state university, columbus o h 43210, united states e-mail: justice.57 @osu. edu the s o u t h a f r ic a n j o u r n a l of c o m m u n ic a t io n d iso rd er s, v o l . 55 2 0 0 8 | 7 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mnemonic training) with that o f other treatment approaches (visual imagery, executive strategy training), nor did it pro­ vide a summary o f the average strength o f effects associated with a specific training. i t may be that one approach has very strong effects compared to other approaches, but the qualitative systematic review does not involve this type o f analysis and therefore such interpretations are not possible. a unique strength o f the meta-analysis is in the statistical combining o f data across multiple studies and the resulting effect size estimates. for professions that are seeking transformation towards being evidence-based, an important recent event is the shift towards generation o f evidence-based systematic reviews and evidence-based clinical guidelines as replacements for traditional practice guidelines. these are similar to tradi­ tional practice guidelines in that they attempt to offer clini­ cians useable knowledge regarding a particular clinical prob lem> but they are generated through a much more systematic the identified body o f work. a qualitative systematic review process than occurs with practice guidelines. the american does not involve statistical analysis o f the research findings speech-language-hearing association, in response to rec aggregated across studies, whereas a quantitative systematic ommendations o f the jo in t coordinating com m ittee on review also called a meta-analysis is a type o f quantitaevidence-based practice (american speech-language tive research design that involves statistically examining the hearing association, 2 0 05), has shifted from generating aggregated results o f a systematic review to determine the practice guidelines to evidence-based systematic reviews average level o f effects attributable to a specific independent and is in the process o f accepting nominations for topics to variable. the independent variable may involve treatment address. the first evidence-based systematic review has un (e g , average effects attributable to receiving specific types dergone public comments and will be published in the near o f treatment), measurement (e.g., average diagnostic accufuture; it examines the accumulated literature on the efficacy racy o f specific types o f tests), and general aspects o f develo f constraint-induced language intervention for use in apha opment or disability (e.g., average concurrent or predictive sia rehabilitation. the academy o f neurologic com m unica association between two aspects o f development, such as tion disorders and sciences (2001) also has embarked on reading skill and intelligence or language ability and history developing evidence-based practice guidelines relevant to o f otitis media). typically, a meta-analysis reports average e fmanagement o f communication disorders in neurologically fe e t sizes associated with a specific treatment or measure that impaired individuals, to include traumatic brain injury, de­ ls created by combining and then averaging data provided in mentia, and aphasia, among others. each study in a set. a n effect size is, essentially, the strength in addition to these initiatives at the national level, it is o f an effect as represented in standard deviation units, typialso relevant to note that several meta-analyses have been cally reported using cohens d i or estimating differences beproduced in recent years that greatly benefit clinicians’ en tween groups (e.g., for analyses o f variance), or percentage gagement in evidence-based practice. the results o f metao variance accounted for, reported using r2 for correlational analyses permit the speech-language pathologist to make data. there are guidelines available in the literature, the most more informed decisions about the benefits that can reason commonly used being those o f c ohen (1988), that discuss ably be expected from a particular type o f treatment in the how to interpret effect size estimates so that one knows i f an area o f treatment, meta-analyses have studied general treat average effect reported in a meta-analysis is small, medium, m ent effects for aphasia (robey, 1998), child language disor or large in size. m eta-analysis is most suitably applied when ders (law, garrett, & nye, 2 0 04), communication problems there are a reasonable number o f studies available on a given associated with autism (goldstein, 2 0 0 2 ), fluency disorders topic, as too few studies can bias the results o f a meta-analy(andrews, guitar, & howie, 1980), and attention problems sis m both positive and negative directions. associated with traumatic brain injury (park & in g les, 2 0 01), l o successfully engage in evidence-based practice, clito name several. m ore specific aspects o f treatment have also nicians must have access to systematically conducted, valbeen explored, such as the average effects associated with id systematic reviews o f the accumulated literature to date, particular treatment approaches (e.g., intratympanic gen qualitative systematic reviews can be particularly helpfiil for tamicin for m eniere’s disease; cohen-kerem et a l , 2004 clinicians to understand what is known about a particular behavioral treatments for stuttering; herder, howard nye’ mqm7 ‘ lnstance, coelho, deruyter, and stein & vanryckeghem, 2006) or treatment contexts (e.g.fpull (1996) provided a useful synthesis o f efficacious treatment out for inclusive models o f language intervention; m cg in ty approaches for cogmtive-communication impairments o f & justice, 2 0 06). table 1 lists several meta-analyses that are adults secondary to traumatic brain injury. this article sumlikely to be o f interest to clinicians. marized the results o f various approaches to treating this meta-analyses are usefiil not only for estimating the ef condmon, although it did not statistically compare the averfects o f specific approaches to treatment, they are also quite age effects associated with anyone treatment approach (e.g., important for demonstrating to the field where there are laura m . justice 8 | die suid -afr ika an se tydskrif vir k o m m u n ik a s ie -a fw y k in g s , vol. 5 5 ,2 0 0 8 those experts who are involved in generating the guidelines (w oolf, grol, hutchinson, eccles, & grimshaw, 1999). in the field o f medicine, experts express concerns that clini­ cians’ use o f practice guidelines can result in use o f “ineffec­ tive, harmful, or wasteful interventions” (w o o lf et a l, 1999 p. 329). as medicine and other professions, like speech-language pathology, seek to take evidence-based practice to scale, we see increased utilization o f alternatives to practice guidelines the systematic review and the meta-analysis that offer a more systematic and potentially less biased approach to ­ wards synthesizing available research literature for the clini­ cian. a systematic review is a scientific investigation o f the available literature on a given topic. the review is systematic because the individual(s) completing the review adheres to a rigorous and preplanned process for identifying potential research articles for inclusion, appraising these articles to identify key findings, and for synthesizing findings across r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) serious gaps in our knowledge. for instance, m cg in ty and justice (2006) conducted a meta-analysis o f outcomes at­ tributable to various treatment contexts (e.g., classroom based, pull-out) for children with language disorders; they identified only three studies to date that have explicitly ad­ dressed this issue. as this example shows, as the field o f speech-language pathology scales up evidence-based prac­ tice within the clinical realm, speech-language researchers must also ensure that the kinds o f studies they are conduct­ ing produce useable knowledge that contributes to timely and pressing issues within clinical practice. treatm ent studies speech-language pathologists who engage in evidence based practice will turn not only to meta-analyses for guid­ ance in decision-making but also to individual treatment studies. as noted earlier, a meta-analysis is really only use­ ful when there are enough studies in a given area that ag­ gregation o f findings is possible. however, in many areas o f practice there are far too few studies available on a given topic for a meta-analysis to be useful. for instance, the clini­ cian who works with an adolescent who stutters and wants to treat the child’s anxiety and embarrassment about speak­ ing publicly will find no meta-analysis available on this top­ ic (yaruss & pelczarski, 2 0 07). the clinician will then have to look towards individual treatment studies and examine these for guidance on a particular approach that appears to be efficacious. w h ile this seems straightforward, the field o f speech language pathology is plagued by a paucity o f treatment studies. o ne recent study o f group-design treatment stud­ ies published in three flagship american journals in speech language pathology (language, speech, a n d h earin g services in schools; am erican j o u r n a l o f speech-language pathology; jo u r n a l o f speech, language, an d h earin g research) found that only 52 such studies were published over a 10-year period averaging about 5 studies per year (justice, nye, schwarz, m cg inty, & rivera, 12008). given that these studies address a broad range o f treatment foci o f relevance to speech-lan guage pathology (e.g., fluency, voice, language, speech, liter­ acy), it is clear that clinicians’ access to treatment research is inadequate for meeting the broad range o f clinical questions they encounter in everyday practice. as noted by members o f the american speech-language-hearing association, a consequence o f the field’s transformation to evidence-based practice is the urgent need for research that addresses press­ ing clinical questions (american speech-language-h ear ing association, 2 005). some evidence suggests that the generally limited pro­ duction rate o f treatment research is on the brink o f change, and this is largely in response to shifts in the funding streams that support empirical research in speech-language patholo­ gy. the institute o f education sciences, which funds the ma­ jority o f educational research in the united states, has dra­ matically shifted its funding priorities in the last five years to emphasize the production o f more useable knowledge. as a result, funds provided to researchers who study the effica­ cy and effectiveness o f specific interventions and treatments using randomized controlled trial (r c t ) research designs have greatly increased. m any o f these studies are o f direct relevance to speech-language pathologists, such as studies o f e v id e n c e b a s e d p r a c t ic e th e s o u t h a fr ic a n j o u r n a l the efficacy o f various language curricula for children at-risk for academic difficulties (justice, m ashburn, pence, & w i g gins, 2 0 0 8 ). the national institutes o f health and particu­ larly the institute that funds a great deal o f research relevant to speech-language pathologists, the national institute on deafness and o ther communication disorders (n id c d ) has recently reported its intent to prioritize funding for “patient-oriented research” over less clinically-relevant ba­ sic research. o ne particular funding mechanism available through n i d c d prioritizes treatment research through its emphasis on funding research that “translates basic research findings into clinical tools” (n id c d , 2 0 07). types o f re­ search activities supported through this funding mechanism include: (a) dosage studies, (b) intervention development studies, and (c) studies o f prevention programs. in light o f relatively stagnant levels o f funding for social and behavioral research within the united states and the increasingly com­ petitive nature o f research funding, it is likely that we will see more speech-language researchers shift their research towards more treatm ent-oriented work, thereby fostering an increase in the number o f treatment study publications. in ­ deed, members o f the american speech-language-hear ing association (2005) have specifically recommended an increase in the conduct o f randomized controlled trials by researchers in speech-language pathology. a n important issue related to treatment studies and their relevance to clinicians’ engagement in evidence-based prac­ tice regards the quality and quantity o f studies available on a given topic. the quality o f an empirical study, particular­ ly those investigating treatments, largely concerns its in­ ternal validity and its external validity. study methodolo­ gies that promote internal validity (e.g., randomization o f patients, blinding o f assessors) are what allow researchers to make strong causal statements regarding the manipulat­ ed independent variable (e.g., treatm ent x ) and a specific dependent variable (e.g., language comprehension). study methodologies that promote external validity (e.g., ran­ dom selection from a population) are what allow research­ ers to make strong statements regarding the generalization o f findings from their sample to a larger population. n ot all studies are done well (justice et al., 20 0 8 ) and those that are o f poor quality can lead the clinician engaging in evidence based practice to make undesirable treatment recommenda­ tions. the quantity o f studies available on a given topic is an additional issue o f relevance to evidence-based practice. the clinician’s access to one study showing a positive effect for a given treatment should not be nearly so influential to his or her decision-making as having access to five studies that show consistently positive treatment effects. knowledge is created through the accumulation o f evidence and our prac­ tices should change only when there is a preponderance o f compelling high quality evidence. an important structure that has yet to be developed in the field o f speech-language pathology in the united states is explicit guidance regarding how many treatment studies are needed for a given treatment to be considered “empiri­ cally validated.” a t the present, a speech-language pathol­ ogist may consider a specific treatment to be “empirically validated” or scientifically based on the basis o f only a single study o f any design reporting positive effects o f that treatin s p e e c h l a n g u a g e p a t h o l o g y : s c a l in g u p o f c o m m u n ic a t io n d iso rd er s, v o l . 55 2 0 0 8 | 9 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) laura m. justice table 1. e xam ples o f m eta-analyses on clinically relev an t topics in speech-language p athology topic citation i t reatm ent of law, j., g arrett, z , & n ye, c. child language (2 0 0 5 ). t h e efficacy o f treatm ent for ; disorders children with developm ental speech and langu age delay/disorder: a m eta-analysis. j o u rn a l o f s p e e c h , l a n q u a g e , a n d h e a r in g r e s e a rc h , 4 7, 9 2 4 -9 4 3 . :■ im pact of c ohen, s. m , d upont, w . d , & voice gourey, m. s. (2 0 0 6 ). q uality o f life i disorders on impact of non-neoplastic voice quality of life disorders: a m eta-analysis. a n n a ls o f o to rh in o la ry n g o lo g y , 115, 12 8 s* 134. : t reatm en t of w hurr, r , lorch, m ., & n ye, c. aphasia (1 9 9 2 ). a m eta-analysis of studies : carried out betw een 19 4 6 and 1988 concerned with the efficacy of speech and langu age therapy treatm ent for aphasic patients. in te rn a tio n a l j o u rn a l o f l a n g u a g e a n d c o m m u n ic a tio n d is o rd e rs , 27, 1-18. i t reatm ent of r obey, r. (1 9 9 8 ). a m eta-analysis aphasia of clinical outcomes in the treatm ent of aphasia. j o u rn a l o f s p e e c h , l a n g u a g e , a n d h e a rin g r e s e a rc h , 4 1 , 172 -1 8 7 . ! t reatm en t of boutsen, f , c annito, m . p , taylor, spasm odic m ., & b ender, b. (2 0 0 2 ). botox 1 dysphonia treatm ent in adductor spasm odic with botox dysphonia. j o u rn a l o f s p e e c h , l a n g u a g e , a n d h e a rin g r e s e a rc h , 4 5 , 4 6 9 -4 8 1 . i treatm ent of r uotsalainen, j. h , s ellm an, j., ! functional lehto, l., jauhiainen, m , & i dysphonia verbeek, j. h. (2 0 0 7 ). interventions for treating functional dysphonia in adults. c o c h ra n e d a t a b a s e o f s y s te m a tic r e v ie w s , 3 (# c d 0 0 6 3 7 3 ) i t reatm ent of hopkins, c , yousaf, u ., & i hoarseness pedersen , m. (2 0 0 6 ). acid reflux i secondary to treatm ent for hoarseness. c o c h r a n e acid reflux d a t a b a s e o f s y s te m a tic r e v ie w s , 1 (# c d 0 0 5 0 5 4 ) ment. this is problematic in a number o f ways, the least be­ ing that the authors o f a study may readily argue positive treatment effects even when the study design does not per­ m it strong causal claims or there was a fatal flaw in the de­ sign. o ther fields have set minimal standards regarding the strength o f evidence needed in terms o f both quantity and quality o f treatment studies for a practice to be empirically validated (e.g., lonigan, elber, & johnson, 1998). however, the field o f speech-language pathology has yet to develop this important structure which, in my opinion, is absolutely necessary for clinicians to be discerning consumers o f the accumulating empirical literature and to successfully engage in evidence-based practice. clearinghouses speech-language pathologists are busy. in an era o f lim ­ ited financial resources, clinicians are constantly being asked to do more for less. as a result, it is unreasonable to expect speech-language pathologists to conduct a thorough high quality review o f the empirical literature for every clinical issue that they must address. n ot only do clinicians lack the time to engage in such activities, but they may not have ac­ cess to the physical resources to do so (e.g., electronic jour­ nals, databases) and they may not have the skills necessary to conduct what amounts to an informal meta-analysis o f the accumulated research papers available on a given topic. consequently, an absolutely critical resource necessary for the scaling up o f evidence-based practice is the development o f clearinghouses that allow clinicians to study condensed and useable descriptions o f the accumulated scientific lit­ erature on a specific topic. currently, there are two types o f clearinghouses that provide interpretations o f the empirical literature: (1) clearinghouses that publish systematic reviews and meta-analyses that are commissioned or volunteered to address specific topics, and (2) clearinghouses that provide links to resources on evidence-based practice, such as lists o f studies on a given topic and links to practice guidelines on specific topics. examples o f this latter type o f clearinghouse include the american speech-language-hearing associa­ tion’s compendium o f e b p guidelines and systematic r e­ views (www.asha.org), and the national guideline clear­ inghouse (www.guideline.gov), an initiative o f the united states departm ent o f h ealth and human services’ agency for healthcare and quality. o f the two types o f clear­ inghouses, the former is the decidedly more useful to the clinician engaged in evidence-based practice, as it provides access to systematic reviews and meta-analyses that sum­ marize a body o f work for the busy clinician. these reviews and meta-analyses are typically prepared by experts in the field and they must follow specific guidelines regarding how to identify studies on a specific topic, how to analyze these, and how to report findings. likely the two most well known clearinghouses are that o f the cochrane collaboration (www.cochrane.org) and the campbell collaboration (www.campbellcollaboration.org). b o th are international non-profit organizations that exist specifically to develop systematic reviews o f the available literature on treatment and assessment in the field o f health and medicine (cochrane) and social and behavioral sciences (campbell). n ot only do these organizations provide access to a large database o f reviews on a range o f clinically rele­ vant topics, but numerous tools are available to support one’s developing knowledge o f how to engage in evidence-based practice and how to conduct critical reviews o f the scientific literature. a more recent addition is the w h a t works clear­ inghouse (ies.ed.gov) o f the united states departm ent o f education; this clearinghouse both commissions and dis­ seminates systematic reviews o f educationally-relevant in10 | die s u id -a fr ik a a n s e ty d s k r ifv ir k o m m u n ik a s !e -a f w y k in g s ,v o l . 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.asha.org http://www.guideline.gov http://www.cochrane.org http://www.campbellcollaboration.org e v id e n c e b a s e d p r a c t ic e in s p e e c h l a n g u a g e p a t h o l o g y : s c a l in g u p tm diei m d m k d t y relevant t o fiu m speech-language pathology topic ‘ t re a tm e n t for child la n g u a g e disorders t re a tm e n t fo r child phon ological disorders t re a tm e n t for p relinguistic c o m m u n icatio n t re a tm e n t o f stuttering t re a tm e n t fo r a p h a s ia t re a tm e n t fo r d e m e n tia citation t reatm ent for reading difficulties throneburg, r. n ., c alvert, l. k., sturm, j. j-, param bo ukas, a. a., & paul, p. j(2 0 0 0 ). a com parison of service delivery models: effects of curricular vocabulary skills in the school setting. a m e ric a n j o u rn a l o f s p e e c h -l a n g u a g e p a th o lo g y , 9, 1020 . tyler, a. a., lewis, k. e., haskill, a., & tolbert, l. c . (2 0 0 3 ). o utcom es of different speech and language goal attack strategies. j o u rn a l o f s p e e c h , l a n g u a g e a n d h e a rin g r e s e a rc h , 4 6 (5 ), 1 0 7 7 1094. yoder, p. j., & w arren, s. f. (2 0 0 1 ). r elative treatm ent effects of two prelinguistic comm unication interventions on langu age develo pm ent in toddlers with developm ental delays vary by < m aternal characteristics. j o u rn a l o f s p e e c h , l a n g u a g e , a n d h e a rin g r e s e a rc h , 44 (1 ), 2 2 4 -2 3 7 . riley, g . d ., & ingham , j. c. (2 0 0 0 ). acoustic duration changes associated with two types of treatm ent for children w h o stutter. j o u rn a l o f s p e e c h , l a n g u a g e a n d ' h e a rin g r e s e a rc h , 4 3 (4 ), 9 6 5 -9 7 8 . i elm an, r. j . , & bernstein-ellis, e. ; (1 9 9 9 ). t h e efficacy o f group i comm unication treatm ent in adults t with chronic aphasia. j o u rn a l o f ! s p e e c h , l a n g u a g e a n d h e a rin g r e s e a rc h , 4 2 (2 ), 4 1 1 -4 1 9 c hapm an, s. b., w ein er, m . f., * rackley, a ., h ynan, l. s ., & zientz, j. (2 0 0 4 ). effects of cognitive-com munication stimulation for a lzheim er's disease patients treated w ith d onepezil. j o u rn a l o f s p e e c h , l a n g u a g e a n d h e a rin g r e s e a rc h , 4 7 (5 ), 1 1 4 9 1163. berninger, v . w ., v erm eu le n , k., abbott, r. d., m cc utchen, d ., cotton, s., c ude, j., et al. (2 0 0 3 ). c om parison o f three approaches to supplem entary reading instruction for low-achieving second-grade readers. l a n g u a g e , i s p e e c h , a n d h e a rin g s e rv ic e s in s ch o o ls. 3412), 1 0 1 -1 1 6 ._________ terventions on various topics (e.g., phonological awareness training, shared b o o k reading) but also gives “ratings o f effectiveness” to specific interventions that include positive effects, potentially positive effects, mixed effects, no dis cernable effects, and potentially negative effects; addition­ ally, studies included in their reviews are also graded for the quality o f the design (strong, weak). several other clearinghouses aside from cochrane, campbell, and w h a t works may also offer information o f relevance to speech-language pathology. the california evi­ dence-based clearinghouse for child welfare (www.cachil dwelfareclearinghouse.org) is organized similarly to that o f the w h a t works clearinghouse and provides commissioned reviews o f topics related to child welfare. o n the basis o f the available evidence, specific interventions are rated for the strength o f evidence (e.g., well-supported by scientific evi­ dence, lacks adequate research evidence). although many o f the reviews available are not directly relevant to the speech language pathologist, some may be informative to clinical practice, such as the reports in the topic areas addressing youth transitioning into adulthood and parent training. the coalition for evidence-based policy offers summaries o f well-conducted randomized controlled studies on a va­ riety o f topics through their social programs that w ork clearinghouse (www.evidencebasedprograms.org). recent reports describe effects associated with the nurse-family partnership (a home visitation program) and the abecedar­ ian preschool project (an early intervention program). the c enter for d ata-d riven reform in education offers sum­ maries o f scientific reviews in its b est evidence encyclope­ dia (www.bestevidence.org). reviews concerning the use o f technology to teach reading and approaches to promoting literacy in english language learners may be o f interest to speech-language pathologists. the promising practices n et { work offers the programs that w ork clearinghouse (www. i promisingpractices.net), which offers summaries o f effica j cious programs relevant to intervention for and education j o f children; programs are organized into categories based s on the apparent strength o f evidence (e.g., proven programs, | promising programs). i concluding comments j evidence-based practice is a process to which speech j language pathologists may adhere when making decisions ! concerning the assessment or treatment o f communica i tion disorders. the clinician who engages in evidence-based practices carefully considers and integrates various types o f 1 evidence to arrive at the most effective solution to a specific s clinical question. the types o f evidence examined include, ! at the least: (1) clinical expertise, (2) patient values and per 1 spectives, and (3) best available scientific evidence (sackett et al., 1 9 9 6 ,2 0 0 0 ). w h ile the former two types o f evidence 1 are readily available to the clinician, accessing the best avail 1 able scientific evidence may take a great deal o f work and ] presents one o f the largest challenges the clinician faces who seeks to engage in evidence-based practice. consequently, \ structures must be put into place that enable the speech-lan j guage pathologist to readily access and synthesize the rel ! evant empirical literature and to consider its implications 1 for a given clinical question. these structures are what will j permit the scalability o f evidence-based practice, and int h e s o u t h a f r ic a n j o u r n a l o f c o m m u n ic a t io n d iso rd er s, v o l . 55 2 0 0 8 11 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.evidencebasedprograms.org http://www.bestevidence.org laura m . justice elude, in part, systematic reviews and meta-analyses, treat­ ment studies, and clearinghouses that together provide use able reports, syntheses, and interpretations o f the scientific literature. w ith o u t these structural supports, it is unlikely that evidence-based practice can be scaled up in a way that has positive impacts on practice. future efforts regarding the promotion o f evidence-based practice must focus not only on training clinical professionals how to engage successfully in this practice, but also the building o f those structures nec­ essary for the field to successfully transition from relying on craft to one that relies largely on evidence. references academy of neurologic communication disorders and sciences (2001/ evidence based practice guidelines fo r the management o f communication disorders in neurologically impaired individuals. retrieved june 15, 2008 from http://www.ancds.org/practice. shtml. american speech-language-hearing association. (2005). e v idence-based practice in communication disorders [position statement]. retrieved from http://www.asha.org/policy. andrews, g , guitar, b , 8c howie, p. (1980). meta-analysis of the effects of stuttering treatment. journal o f speech and hearing disorders, 4 5 ,287-307. cook, b. g., 8c schirmer, b. r. (2006). what is special about special education? examining the role o f evidence-based practices. austin: pro-ed. cibulka, m. 8c aslin, k. (2001). how to use evidence based prac­ tice to distinguish between three different patients with low back pain .journal o f orthopedic and sports physical therapy, 31, 678-695. coelho, deruyter & stein (1996). cognitive-communicative dis­ orders resulting from traumatic brain injury in adults.journal o f speech, language and hearing research, 3 9 ,5-17. cohen, j. (1988). statisticalpower analysisfor the behavioral sciences (2nd ed.). hillsdale: lawrence earlbaum associates. cohen-kerem, r., kisilevsky, v , einarson, t , kozer, e , koren, g , 8c rutka, j. (2004). intratympanic gentamicin for meniere’s disease: a meta-analysis. the laryngoscope, 114, 2085-2091. evidence-based medicine working group (1992). evidence based medicine: a new approach to teaching the practice of medicine. journal o f the american medical association, 268, 2420-2425. fey, m , 8c justice, l. m. (2006). evidence-based decision-mak­ ing in communication intervention. in r. paul and p. cascella (ed.), introduction to clinical methods in communication disorders (2nd ed.). baltimore: paul brookes. field, m. j., 8c lohr, k. n. (eds.). (1990^ clinical practice guide­ lines: directions fo r a new program. washington: national acad­ emy press. gersten, r , fuchs, l., compton, d , coyne, m., greenwood, c., 8c innocenti, m. (2005). quality indicators for group experi ' mental and quasi-experimental research in special education. exceptional children, 7 1 ,149-164. goldstein, h. (2002). communication intervention for children with autism: a review of treatment efficacy. journal o f autism and developmental disorders, 32, 5,373-396. herder, c , howard, c , nye, c , 8c vanryckeghem, m. (2006). effectiveness of behavioral stuttering treatment: a systemic re­ view and meta-analysis. contemporary issues in communication sciences and disorders journal, 3 3 ,61-73. justice, l. m , mashburn, a , pence, k., 8c wiggins, a. (2008). ex­ perimental evaluation of a comprehensive language-rich cur­ riculum in at-risk preschools. journal o f speech, language, and hearing research, 51, 1-19. justice, nye, schwarz, mcginty 8c rivera (2008). methodological quality of intervention research in speech-language pathology: analysis of 10 years of group-design studies. evidence-based communication assessment and intervention, 2, 46-59. justice, l. m., 8c snell, m. (2007). illustration of a three-step proc­ ess for identifying the level and quality of empirical support for manualized treatments. evidence-based communication assess­ ment and intervention, 1 ,37-47. law ,j, garrett, z., 8c nye, c. (2004). the efficacy of treatment for children with developmental speech and language delay/disor­ der: a meta-analysis. journal o f speech, language, and hearing research, 47, 924-94. lonigan, c., elber, j., 8c johnson, s. (1998). empirically support­ ed interventions for children: an overview. journal o f clinical child psychology, 2 7 , 138-145. mcginty, a. s., 8c justice, l. m. (2006). classroom-based versus pullout speech-language intervention: a review of the experi­ mental evidence. e b p briefs, 1,1 ,1 -2 5 . national institute on deafness and other communication disor­ ders (2007). nidcd research grants fo r translating basic r e­ search into clinical tools fo r human health (r01). retrieved june 10, 2008 from http://grants.nih.gov/grants/guide/pa files/par-08-017.html. park, n .w , 8c ingles, j. l. (2001). effectiveness of attention reha­ bilitation after an acquired brain injury: a meta-analysis. neu­ ropsychology, 1 5 ,2 ,199-210. porter-o’grady t. (2007). push parameters forward using evi dence-based approaches. nursing management, 3 8 ,6,58-61. robey, r. (1998). a meta-analysis o f clinical outcomes in the treatment of aphasia. journal o f speech, language, and hearing research, 4 1 ,172-187. sackett, d. l , rosenberg, w. m , gray, j. a , haynes, r. b , 8c ' richardson, w. s. (1996). evidence based medicine: what it is and what it isn’t: it’s about integrating individual clinical ex­ pertise and the best external evidence. british medical journal, 312, 71-72. sackett, d., straus, s., richardson, w., rosenberg, w. 8c haynes, r. (2000). evidence-based medicine: how to practise and teach e b m (2nd ed). london: churchill livingstone. schlosser, r., koul, r., 8c costello, j. (2007). asking well-built questions for evidence-based practice in augmentative and al ternative communication. journal o f communication disorders, 4 0 ,3,225-238. spring, b. (2007). evidence-based practice in clinical psychology: what it is, why it matters; what you need to know. journal o f clinical psychology, 63, 611-631. woolf, s. h , grol, r , hutchinson, a , eccles, m , 8c grimshawj. (1999). clinical guidelines: potential benefits, limitations, and harms of clinical guidelines. british medical journal, 318, 728 730. yaruss, s., &c pelczarski, k. (2008). evidence-based practice for school-age stuttering: balancing existing research with clinical practice. e b p briefs, 2 , 4 , 1-8. 1 2 | die suid -afr ika an se tydskrif vir k o m m u n ik a s ie -a fw y k in g s , vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.ancds.org/practice http://www.asha.org/policy http://grants.nih.gov/grants/guide/pacommunication, symbolic play, and play-extension in pre-school hearing-impaired children denise ε segal, ma (speech pathology) (witwatersrand) speech therapy department hillbrow hospital, johannesburg abstract * ^ ' ^ e d , pre-school munication modalities during play a^anz^tll^lz tl°u™°fdevelop™»<· ^e children's use of their cornmaterials, was assessed. the same czdretzdblnnltt ° , ^ b e y 0 n d t h e ^diacy of the play independent °f communication^lwe^^i!^s^em terms of symbolic and non-symbolic ̂ lay activities based approach was adopted, with pelrllevm^z^ j pjt obse™'io™1 ™d ethplogically'move away from'the immediate p b ^ ^ ^ s ^ ^ ^hudren attained no tion is important during play, subsequen^to tte omet tfsmboum pl°y-it was suggested that communicaissues pertaining to the relationship between langzeztcogntznί ί ί ^ γ 7*"* " °f helical sign language. clinical suggestions and u n p j l t ^ z ^ ^ z ^ t " ' ^ *» approach versus opsomming mumkasiemodahteue tydens spelen lertspetlzsie^ontwikkelmg geneem. die kinders se gebruik van hulle komis beoordeel. dieselfde kinders is j z ^ n t z e v l n i l ^ " ^ ™ ° n m i d d e l l i k e spelmateriaal te voer, munikasie) beoordeel. hierdie b e j ^ t a s t ^ z ^ t i z m n i e ^ i e s e spelaktiwiteite (onafhanklik van koming is gehandhaaf waar gedrag b e u ^ ™ g ^ i ^ j j ^ ' ^ en etologiese benaderspelkonteks kan wegbeweeg nie alhozl hulle zns s ^ e t l ' ^ τ ' τ ^ g l a d ™ ™ d i e onmiddellike spelsituasie belangrik is, lar slegs n a l ^ ^ j ^ ^ ^ w' ^ ™ ^ ^mmunikasie in die soos die verhouding tussen taal en kognisie die rol in zhntjz „ ? 8 ^ d i e u« v a n t e o r e t i e s e »enke en implikasies vir verdere zo^ggentz^g " ^ ^ ^ ^ ^ c u w h f " γ ° f p l 3 y b 0 t h a c r o s s s p e c i e s a n d across v s ? n h , ° n g r e c ° i n i ^ d . play has been viewed as a r e c e n ^ ' r 1 " 3 " 1 3 c t i v i t y o f ^ h o o d . ' however, only " ' γ f e g a r d e d 3 8 3 p ° s s i b l e c l u e to " " d e r s t a n 'ng h u m ^ b e h a v i o u r ' * * * * * ^ th t h e l i c ° z e 1 t a j l y j h e a r i n g " i m p a i r e d c h i l d h a s continually been children h f a c ! i c c ° n j e c t u r e · hearing-impaired their hearin regarded 3 8 behaviourally equivalent to these c h i l i ? ^ ^ 3 m ° v e 3 w a y f r o m t h e e a r l i e r that educatbnalkk τ t ^ ° γ c o n c r e t e b o u n d however, impai^en h 3 c k n ° w l e d g e p ^ u n d effect that hearing consequent ^ d e v e l o p m e n t o f v e r b a l language and majority j ^ development of communication.5 the have i n l l n f , ( s u c h a s b y ^ r and quigley)" gression n e v , ! ' t ' ^ ^ d i f f e r e n t l i n g u i s t i c p">in>ponanf e r t h e l e s s ' the extent to which verbal language is c o g m t l v e development remains contentious, and suid-afrikaa ® sasha 1983 " " t y d s k r i f v i r fofwnikasieafwykings, vol. 30, 1983 there have been comparatively few studies of cognition and its relation to language and play in this population group. symbolic play and gesture are believed to be derived from the same developmental r o o t s , ^ w i t h s y m b o l i c p l a y a s sion from early gestures and an integral part of communication development. the close association between play, verbal language and gesture during the course of development highlights the importance of assessing symbolic play in hearing-impaired children. researchers, for example, goldinmeadow and feldman,' have concluded that the visual modality equals the auditory modality as a medium for language learning and that the hearing-impaired child favours the visual modality. recent investigations have tended to support piaget's hypothesis'2 which emphasizes that cognition forms the basis tor all intelhgent behaviour including language. piaget argues that language is not an essential prerequisite for symbolic play r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) • 42 development.12 however, vygotsky's position2' in relation to that of piaget has not been clarified and it suggests that language may assume an important role subsequent to the onset of symbolic play. studies with older hearing-impaired children (for example that by pruning and skarakis)" have generally indicated a parallel performance on cognitive tasks in which verbal language is not an inherent part of the task itself. relatively few studies of this nature have investigated the pre-operational period even though symbolic play, being observable, lends itself to investigation. the hearing-impaired child is particularly difficult to assess because the majority of play scales include language, whether directly or indirectly » the hearing-impaired child may use gesture or sign language during play, similar to the hearing child's use of language (except that the play sequence would be temporarily interrupted by a gestural movement). for this reason, a play analysis has either to exclude language altogether, or, to include all communication modalities and not verbal language alone the hearing-impaired child's use of any compensatory modality other than that of verbal language would suggest that verbal i m p o r t a n t a t e a r l y s t a g e o f c o g n i t i v e the term 'symbolic play' was applied in accordance with piaget to refer to a behaviour in which assimilation predominates over accommodation allowing for "the deform f i , 1 0 " a n d . s u b 0 r d i n a t i 0 n o f reality to the desires of the self it is implicit that the behaviour occurs out of context and that the child is aware of the distortion of reality the present researcher applied the term only to that which was observable from the child's performance, drawing no inferences about his competence. the term play-extension' was coined by the present researcher18 to refer to the process of "going beyond the information given"2 within the narrow context of play this refers to the process of 'moving away from' the play materials within the play situation, rather than moving away from the play situation itself. play-extension is viewed along a continuum with 'immediacy' providing the earliest stage and nonimmediacy' the most advanced stage.8 it is argued that verbal language may play an important role during the preoperational stage of development, subsequent to the onset of symbolic play, rather than as a prerequisite for the emergence of symbolic play. if symbolic play is assessed independently of communication in hearing-impaired children, a finding of delayed or different play performance would suggest either that verbal naming, specifically, is required for the onset of symbolic play, or that a gestural or signing method is not as efficient as verbal naming in this process. the present researcher was concerned with the qualitative changes that occur in play and communication and with their continual interaction during the course of development a quantitative measure was considered to be too broad to reflect he subtle changes which are important for clinical practice " in addition, ,t was aimed to use passive observation and description as an aid to diagnosis and therapy for the hearingimpaired child in conjunction with findings from the study of normal children, rather than relying upon the latter alone it must be emphasised that the early effects of congenital hearing impairment on verbal language complicate the separation of denise s. segal general experiential differences from the effect of communica tion differences, on subsequent development.22 for this reason, in the theoretical questions posed, the role of verbal language necessarily implies the factor of general experience as well. on the basis of the above, the present study investigated plavextension, that is, the child's use of communication modalities during play. prior to this, symbolic play was assessed in terms of play type and play complexity along a scale derived from piaget s"2 categories and along the lunzer* scale, respectively this preliminary study is not included in the present paper however, in summary, it was found that, at a non-verbal level' where any form of communication was excluded from the analysis of play, the hearing-impaired children demonstrated equivalent play complexity to their hearing peers with a delay in symbolic play activities.'8 this then served as the basis for analysis of play-extension. the purpose of the present study was to determine whether the hearing-impaired child uses his communication modalities during play and, if so, whether he uses communication to extend play beyond the immediacy of the play materials clinically, this study aimed to assist speech and hearing therapists by providing therapeutic insights into the general play behaviour, aspects of communication and abstracting abilities (that is, ability to 'move away from' the immediate context) of the small sample of hearing-impaired children furthermore, it aimed to clarify some of the vagueness surrounding the field of play as well as attempting some elucidation of the ill-understood relation between verbal language and cognition. 6 6 methodology subjects a total of ten white children of middle class south african families, aged between 15 and 41 months, served as subjects the experimental group comprised 5 hearing-impaired children who presented with severe congenital hearing losses and who had been fitted with hearing aids between 8 and 12 months of age. five hearing children were matched with the experimental subjects for chronological age and sex (see table i). it must be emphasised that this sample of hearing children did not comprise a control group. rather, it constituted a sample from which to ascertain guidelines for a developmental sequence for play-extension. no attempt was'made in analysis to compare individual hearing-impaired subjects with the associated hearing peer. from table i below it can be seen that an age bias always favoured the hearing-impaired children. the age range included the 18-month level for the onset of symbolic play as well as the 3-4 year peak of development.12 all children were of average intelligence and presented with no primary emotional problem or concomitant neurological or physical handicap. impairment of language or hearing was ruled out with regard to the 'normal' subjects. all h e a r i n g impaired subjects were attending the unit for hearingi 7 a ' r e d c w l d r e n university of the witwatersrand, which afforded daily speech and language therapy, auditory training and parent counselling. children taught sign language would the south african journal of communication disorders, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) communication, symbolic play, and play-extension table 1 age and sex characteristics of the subjects \ hearing impaired subject a age 16 months sex f predominant communication modality vocal vocal vocal and gesture verbal and gesture vocal and gesture β 18 months μ predominant communication modality vocal vocal vocal and gesture verbal and gesture vocal and gesture c d ε average age = 27 months 34 months 41 months 27,2 months μ μ f predominant communication modality vocal vocal vocal and gesture verbal and gesture vocal and gesture = 2,3 years hearing subject f age 15 months sex μ predominant communication modality vocal verbal verbal verbal verbal g η i j average age = 18 months 22 months 34 months 36 months 25 months μ μ μ f predominant communication modality vocal verbal verbal verbal verbal 2,1 years have been communicating at a level equivalent to that of normal children using verbal language.5 for this reason, it was necessary to investigate children taught by oral-aural means in order to be able to answer the question concerning the role of verbal language in symbolic play rating scales a rating scale for play-extension was compiled on the basis of observation of the sample of hearing and hearing-impaired children. an ethologically-oriented approach3 was adopted in that categories were formulated to describe the observed behaviours rather than 'squeezing' the behaviours into previously devised categories. the subjectivity of the behaviours themselves, and of the rating by a single judge, are recognised as limitations. all behaviours involving language only, play only, or extension beyond the situation itself (versus play-extension) were assigned a score of 0 since only the simultaneous occurrence of play and communication was of interest. a score of 0 therefore implies a lower level only with regard to the interest,'of the present investigator and to the nature of the behaviours being investigated. levels 1-5 accord with die broad category of 'immediacy' indicating that the child is bound to the immediate context. levels 6-8, the broad category of 'non-immediacy',8 indicates that there is a 'move away from' that which is immediately present. from level 5 mehrabian's framework8 was found to be no longer applicable since it describes development of communication per se, thereby deviating from the emphasis in the present study, oral, verbal and gestural means of communication are included in the scale.18 procedure each child, alone with his/her mother was videotaped from setti 3 ° n e " w a y m i r r o r i n a n unstructured nursery school ng at the university of the witwatersrand unit for recnrh m p a i r e d c h i l d r e n · a sony betamax video cassette prleh fin ° d e l s l 8 0 ° 0 ) w a s u s e d ' t h e environment comfccilitaf , f l e c t i o n o f materials which was designed to materi 1 s e l f ~ l m t i a t e d ' spontaneous child activity. the play ais comprised commercially available objects as well as j " k material. thre ' γ ε ε 5 6 5 5 1 0 1 1 5 per child were recorded at two-month intervals die suid-afriν jnkaanse tydskrif vir kommunikasieafwykings, vol. 30, 1983 so as to tap peak periods in development as well as the progression over time. the experimenter then described the ongoing play behaviours from the videotape onto a tape recorder while two raters simultaneously rated these behaviours. an index of inter-rater consistency was established by summing those categories that were rated the same by both judges and by computing the ratio of these judgements to the total number of judgements made. values above 0,8 were considered to reflect high consistency. measures obtained were 0,86; 0,92; 0,81; 0,83; 0,93; and 0,81. the verbal description was transcribed in written form and checked for objectivity and accuracy by another independent observer. this served as the data for derivation of the playextension scale. separate scales were drawn up for verbal, vocal and gestural modalities, which were subsequently coordinated. a time-sampling procedure was favoured despite its 'unnatural' quality, since event-sampling is problematic when rating vocal behaviour18. every ten-second period constituted a unit of analysis, and each behaviour within a ten-second period was analysed into type and extension categories. communication is frequently of brief duration, however duration bears no relation to play-extension. as an example, a brief utterance such as, "they're home", may alter an entire sequence of behaviours and imply a complex extension. timesampling was a suitable compromise to overcome some of these difficulties. since many levels may occur within any one play event, only the focal behaviour for any ten-second period was scored.10 at the higher levels of play-extension in which events are difficult to separate into isolated units, cohesion was afforded by means of this procedure. lower levels, if not focal, were excluded in rating. whether or not one is able to accurately interpret what a child is attempting to express in his play, is questionable. it is evident that the researcher is limited to that which the child chooses to display overtly or to communicate. for this reason, the present study was concerned exclusively with performance. an example which will serve to highlight these difficulties is evident when one is presented with two children, one of whom has adequate verbal facility and the other, a nonverbal child. when both children draw circles, the verbal child r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 44 •ο φ σ> ce ο) c lu φ έ ® σ> « c φ ο ι ιοοη 90|~ 80| 7 0 60 5 0 4 0 3 θ ι 20 10 graph i subject f 1 0 0 ^ 9 0 h 8 0 •d φ ο) 7 0 (0 σ> c lu 6 0 φ ε 5 0 ρ φ ο) 4 of « c φ 3 0 £ 2 0 | 1 0 ι ι 0 j — 1 1 2 3 4 5 6 7 ~ t play-extension graph iii subject η 2 3 4 5 6 ? 1 play-extension graph v subject j play-extension 100 9 0 s 80 i 7 0 s 60 i 5 0 ® λ λ. ι 5 4 0 c 8 3 0 20 1 £ ϊ •ο φ σ> ce σ> c lu φ έ φ ο) « c φ ο i 100γ 9 0 l 8 θ ί 7 0 ί 6θ(~ 5θ(~ 4 0 γ 3 0 , 2 0 * 10 denise s. sega graph ii subject g 2 3 4 5 6 7 8 play-extension graph iv subject i 1 2 3 4 5 6 7 8 5 6 ~ 7 ~ έ ~ play-extension x axis: 0,6cm = 1 unit of play-extension y axis: 0,6cm = ioo/0 0f total time play-extension 0 = play only; communication only = non-denotational = denotational = naming = play + communication accompaniment = play anticipation = play extension = play through communication + action = play replacement by means of communication figure 1 2 s t · " μ " " " β w , < i n p ' a ! m m e n s i 0 n combined ,o, ,he hearing,.paired the south african journal f communication disorders, vol. 30 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) co ι iinmunication, symbolic play, and play-extension graph i subject a •o ® σ> a σ> c lu φ ε f © σ> a «·* c φ υ φ α l o o h 9080 70 60 50| 40 30! 3 1001" 9 0 h 80l· 7ol· 2 3 4 5 6 7 8 play-extension graph iii subject c ό φ σι η σι £ 60 » ε φ σ> « έ φ 2 0) 0. 5 0 40 30 20 ί ο 1 j ! 2 3 4 5~ 6~7 play-extension graph v subject ε l 8 ja 1 0 0 ^ 90r „ 8 0 φ i 70 c lu φ ε graph ii subject β φ σ> <5 c φ ο £ 60 5 0 40r 3 0 2 0 1 0 1 2 3 4 5 6 7 8 play-extension 1 0 0 f 9 0 ( •d 8 0 ( -φ ο) (β 7 0 ο) c lu 6 0 <d ε i 5 0 | φ ο) 3 c φ ο 4 0 [ φ ο) 3 c φ ο 3 0 [ £ 2 0 | graph iv subject d ι i 1 play-extension 8 x axis: 0,6cm = 1 unit of play-extension y axis: 0,6cm = 10o/o of total time play-extension 0 = play only; communication only = non-denotational = denotational = naming = play + communication accompaniment = play anticipation = play extension = play through communication + action = play replacement by means of communication 2 3 4 5 6 7 8 play-extension ^iqurq ο ρ ' ^ percentage of total time engaged in play-extension with the three sessions combined for the hearing suid-afrikaanse tydskrifvir komnunikasieafwykings, vbl. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 46 may state that "this is a moon" or even simply "moon". it cannot be assumed, however, that the non-verbal child did not intend his circle to represent a 'moon' as well. it may be argued, in the light of piagetian research, that differences may be expected in the performance of the hearing-impaired children since verbal language is included in analysis. however, if language assumes no role during play then the hearingimpaired children should perform equivalently to their hearing peers even though language is included in rating. findings from the first part of the study, mentioned earlier, served as a baseline for evaluating the role of language during play. the same procedure as adopted in the derivation of the playextension scale was followed in the final rating, with percentages being obtained for each category. results the commonalities noted in the performance of five children (whether hearing or hearing-impaired), does not imply the presence of an underlying average. on the basis of performance of such a small sample, no inferences can be drawn with regard to performance in the general population. only major trends both within and between the two groups of subjects, were analysed. since the data was nominal and not independent7 despite the superimposition of time-sampling, bar graphs were utilised to present visual displays of the most frequently occuring play and communication behaviours over time. each child's performance was analysed individually, in accordance with case study analysis, to determine a possible developmental progression over the three two-month intervals. since no significant differences were found to occur between the three sessions for play-extension, the results were combined and group trends only were considered. the time interval between sessions obscured the developmental changes occurring for any one subject. the results for play-extension are represented in figures 1 and 2. each figure comprises five graphs, representative of the children in each group. they are ordered in terms of increasing age from top to bottom, according to a left-right-left progression on the page. graph i on either figure corresponds to the youngest subject in the group (subject a, figure 1 and subject f figure 2) with graph v corresponding to the oldest subject (subject e, figure 1 and subject j, figure 2). it is evident from figure 2, that subject f stands apart from subjects g, η, i and j, the latter all displaying fluctuation over a broad range for play extension. this suggests that there is a 'levelling-off effect' for play-extension with increasing age. once the child has reached a certain developmental stage he is able to use the full range of levels for play-extension as measured on this particular scale. these higher levels are best considered as types with no inherent complexity grading a flaw of the scale in that it foils to discriminate fine differences between the higher levels. the hearing-impaired children, on the other hand, demonstrated little variation from child to child with increasing age (figure 1, subjects a, β and c), thereby yielding similar graphic displays to that for subject f (fig. 2). in subject ε (fig. 1) there is a suggestion of change which difdenise s. segal fers from that of subject d (fig. 1) and subjects g, η, i and j (fig. 2) in two ways: first, the majority of scores for subject ε cluster at the lower levels as occurs for subjects a, b, c and ε and for subject f (fig. 2). on the other hand, subject d (fig 1) and subjects g, η, i and j (fig. 2) present fewer scores for levels 1 and 2, with greater numbers varying across the scale second, for subject ε (fig. 1) there are no examples of nonimmediacy (that is, levels 6, 7 and 8) as for subjects d (fig l) and subjects g, η, i and j (fig. 2). a consideration of individual differences affords a few possible explanations for these findings: subjects a, β and c (fig 1) and subject f (fig. 2) display clustering at the lower levels these subjects were all at a level of vocal activity and pointing in communication. the other subjects were using either verbalisation or gesture (with or without vocalisation) as a predominant means of communication. this situation persisted from session one to session three for all subjects. in other words, no subject was using only vocal activity in the first session with a progression to verbal or gestural activity in the following session or sessions. in addition, subject ε (fig. 1) can be differentiated from subjects g, η, i and j (fig 2) and from subject d (fig. 1), in that this subject was using gesture predominantly, whereas the other subjects were all using predominantly verbal language. subject d (fig. 1) was using a combination of gesture and verbalisation and was thus able to attain levels equivalent to those of the hearing children. it is difficult to draw conclusions on the basis of a single subject's performance, but it is suggested that the onset of verbalisation or gesture possibly affords the child a means of expressing himself during play, whereas verbal language affords a greater range of types for play-extension than does gesture. more particularly, all the verbal subjects attained nonimmediacy whereas subject ε (fig. 1) (gestural) with a small verbal vocabulary, attained only the highest level of immediacy. there are two possible explanations for this: first, spontaneous gesture as a modality for elaboration of play through communication may not be as 'efficient' a modality as verbal language. for this reason, verbal language and gesture occur equally at the lower levels, but gesture does not occur at the higher levels. second, subject ε (fig. 1) may be unrepresentative of the group of hearing-impaired subjects as a whole. in order not to fall prey to experimenter bias in assuming that the communication modality is the major factor giving rise to these results, the frequencies for every vocal, verbal and gestural activity as well as combinations of these, were summated for the groups of hearing-impaired children and hearing children for all three sessions, to determine whether trends did emerge.18 it is evident that the verbal modality was used predominantly by the hearing children. even though the hearing-impaired children did have small verbal vocabularies, they did not use verbalisation (during play) which was intelligible to the rater or to the mother. in the hearing-impaired children, gesture, with or without vocalisation, was frequently used (as compared with the dearth of gestures displayed by the group of hearing children). however, the higher levels for nonimmediacy (levels 6, 7 and 8 for play-extension) were never attained by the hearing-impaired children. finally, vocal activity predominated in the hearing-impaired group as opposed to verbal activity for the hearing group. the south african journal of communication disorders, vol 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) c o m m u n i c a t i o n , symbolic play, and play-extension these trends suggest that the communication modality is an important differentiating factor determining levels of performance for play-extension. the type of communication affected the levels or types of play-extension obtained. more importantly, they suggest that communication is closely related to play, that the hearing child uses verbal language to enhance his play, and that the hearing-impaired child, though he uses gesture in the same way, cannot attain equivalent levels. the scale used provided a differentiation of levels for playextension (as evident in subjects d, η and i). these findings suggest that verbal language may be important in the early cognitive stages. this is contrary to piaget's view12 that language affects cognition only at the higher stage of logical operations. it is evident that communication and play are integrally related and that separation of these processes provides only a partial indication of the picture of play as a whole.19 verbal language was used by the hearing children to enhance their play. however, the hearing-impaired children did not compensate by means of spontaneous gesture although they might have displayed nonimmediacy had they been competent in sign language. discussion from the preliminary study (mentioned earlier), it was evident that language did not prevent the attainment of symbolic play. since symbolic play is regarded as one form of abstracting21, it is evident that these hearing-impaired children were able to abstract within a non-verbal context. the findings for play-extension indicated that language was used by hearing children during play to extend beyond the immediacy of the play materials as well as to accompany and to anticipate play activities. the hearing-impaired children used gesture similarly, to accompany and to anticipate play activities, but no examples of nonimmediacy were present in their performance. in other words, they did communicate during play but communication was not used for the purpose of 'abstracting' or moving away from' as used by the hearing children. these findings suggest that language does assume a role during play. children with predominantly vocal activity were still able to engage in symbolic play but only those who possessed verbal facility engaged in play-extension. in accordance with the view that language and symbolic play arise during the same developmental stage, (piagefs pre-operational stage), it was round that only those children who had reached this cognitive « j f γ " 8 3 8 6 4 1 m p l a y e x t e n s i o n . it must be kept in mind that complete exclusion of language (that is, the child's knowledge l a n i u a g e ) is not possible in assessment. w n findings s u g g e s t 3 n e e d t 0 reconsider the role of ' i n s w " p l 7 d e v e l 0 p m e n t t h e t e r ™ 'symbolic play' and which γ p y ' m u s t b e v i e w e d w i t h i n t h e framework in when τ v ? c ° n c e p t u a l i s e d ; t h e y a r e not equivalent, but peanor f u n i v e r s a l t e ™ s , independent of the euroa loose fa™ p s y c h o l ° g i c a l orientations, they seem to afford of the t p r l e g r a t l ° n : p l a y ~ e x t e n s i o n approaches vygotsky's use a s used bv γ ^ τ " 6 p l a y ' 2 ' w i t h ^ term 'symbolic play' h as been l j ? 8 ! 1 ' , f ° r m m g a s u b s e t °f this category. this mind that th ! e l s e w h e r e b y s e s a l > ' 9 but it must be kept in the term 'imaginative play" as used in the present die suid-afrikn jnkaanse tydskrifvir kommunikasieafwykings, \bl. 30, 1983 47 study, is not equivalent to vygotsky's original use of the term, since the latter occurred within a soviet framework. even in the early cognitive stages, the hearing-impaired children did not attain levels comparable to their hearing peers and the cumulative effects of delayed and different performance with further development, cannot be ignored. furthermore, the acquisition of processes in the 'different' child may not be as linear as that for the 'normal' child with regard to stages.15 the disagreements between the different educational approaches to hearing-impaired children are highlighted in the present findings. the hearing-impaired children may have failed to use language to extend play because gesture is not as efficient a medium as verbal language in this regard. sign language may be a suitable medium for play-extension or, it may afford the child a modality for increased communication during play but not for play-extension (that is, verbal language may be the necessary modality for play-extension). further research is required to elucidate this issue. arising from the above discussion, the findings and methodologies of previous researchers require additional consideration.8·23 the previous emphasis on the ease of acquisition of actions in symbolic play versus language appears to be less enlightening with regard to the hearing-impaired child than the gestural link between symbolic play and communication. the hearing-impaired child's delayed rather than different performance and his ability to engage in symbolic play, seems to negate the possibility of a general representational deficit. the present findings support the view outlined by arnold,1 that verbal language is not required for cognitive development in hearing-impaired children. however, the cumulative effects of delayed language may contribute to later difficulties at the level of logical operations. cognizance must be taken of the close relation existing between language, symbolic play and gesture when dealing with all 'language-different' children. play, being both nonverbal and observable, appears to be a useful clinical tool affording differential diagnosis of language abilities. (for detailed diagnostic and therapeutic implications, see segal20). playextension may provide a means of conveying the principle of abstracting to hearing-impaired children with regard to both the play context and the use of language. qualitative analysis affords the derivation of a clinical profile of each child's cognitive, communicative and play-extension abilities, and provides for therapeutic direction.20 the relation between communication and play is still relatively unexplored in normal children as evidenced in a comprehensive review of the field of play by fein.4 the few studies that have dealt with language, communication, or metacommunication and play (for example, nicolich and raph"), have not used scales equivalent to that of playextension. in relation to hearing-impaired children, this field remains in its infancy. implications for future research include longitudinal investigations of play and communication with large samples of normal and hearing-impaired children to afford detailed comparisons across groups; pertinent diagnostic indicators separating groups, for example, language-impaired from hearing-impaired children (using play analysis as the r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 48 major assessment tool); similarities and differences between verbal language and sign language in relation to play; and testretest reliability measures. in addition, longitudinal studies wou d indicate whether symbolic play and play-extension parallel each other in development thereby giving rise to two branches in the cognitive sphere which may affect different logical processes at a later stage.18 in a relatively unexplored field of research, it is hoped that this study will serve as an incentive for subsequent investigations. acknowledgements this paper is based in part on a section of a masters dissertation submitted to the university of the witwatersrand, johannesburg. the writer expresses her gratitude to prof μ l aron and dr. c. penn who served as supervisor and informal adviser respectively. in addition, the writer wishes to acknowledge the financial assistance received from the university of the witwatersrand, the human sciences " o n ° u n c i l a n d ^ s ° u t h 3 n d references 1. arnold ρ p h . d . ( 1 9 7 9 ) chang.ng views of the deaf child. journal of the british association of teachers of the deaf 5(6), 178-192. 2. bnaner, j. s. (1966). on cognitive growth i, ii. chaps 1 and 2 in studies in cognitive growth, bruner j s olver ν f ^ g r e e n f i e l d ' r m · (eds.), john'wiley, new york, pp. 1-67. 3. eibl-eibesfeldt, i. (1970). ethology: the biology of behaviour. holt, rinehart, winston, new york 4. fein, g. g. (1981). pretend play in childhood: an integrative review. child development, 52, 1095-1118 5. goldin-meadow, s. & feldman, h. the creation of a communication system: a study of deaf children of hearing parents. sign language studies, -8, 225-236, 6. lunzer, e. a. (1959). intellectual development in the play ' of young children. educational review, 11 205-217 7. mccall r. b. (1970). fundamental statistics for psychology. harcourt, brace and world u s a 8. mehrabian, a. (1972). nonverbal communication. aldine-atherton, chicago, u.s a 9. millar, r. (1968). the psychology of play. penguin books harmondsworth, england. 10. miller, r. (1976). the development of competence and denise s. segal behaviour in infancy. unpublished doctoral thesis submuted to the faculty of arts, university of the witwatersrand, johannesburg, south africa 11. nicolich, l. & raph, j. (1978). the relation of symbolic maturity as observed in play to spontaneous vocal imita tion in early language development. journal of psycholinguistic research, 7, 401-417 j <1951)· pl«y> dreams and imitation i n childhood. routledge and kegan paul, london. 13. piaget, j. (1966). response to brian sutton-smith chap 22 in child's play, herron, r. and sutton-smith β (eds.), john wiley, new york; 1971 14. power, d. j. & quigley, s.p. (1973). deaf children's acquisition of the passive voice. journal of speech and hearing research, 16, 5-11. 15. prutting, c. a. (1979). process /pra/, ses / n: the action of moving forward progressively from one pbint to another on the way to completion. journal of speech and hearing disorders, xliv, 3-30 16. prutting, c. a. & skarakis, e. a. (1971). communication development. chap. 13 in audiometry in infancy, gerber s. a. (ed.), grune and stratton, new yorkpp 247-262 17. segal, d. (1980a). relationship between verbal language and symbolic play a case study. the south african journal of communication disorders 27, 37-55 18. segal, d. (1980b). symbolic play and communication in congenitally hearing-impaired children. unpublished dissertation submitted to the department of speech pathology and audiology, university of the witwatersrand, johannesburg, south africa 19. segal, d. (1982). symbolic play and communication in hearing-impaired children: piaget and vygotsky reconsidered. the south african journal of psychology, 12, 111-116. 20. segal, d. (in press). play and communication a cognitive-based approach to language therapy for the hearing-impaired child. journal of the british association of teachers of the deaf. 21. vygotsky, l. s. (1933). play and its,role in the mental development of the child. in play its role in development and evolution, bruner, j. s., jolly, a. and sylva κ (eds.), penguin books, harmondsworth, england. 1976, pp. 537-554. ; 22. watts, w. j. (1970). the developmental theory of jean piaget and the deaf child. teacher of the deaf 68, 23. werner, h. & kaplan, b. (1963). symbol formation: an organismic-developmental approach to language and the expression of thought. john wiley, new york. the south african journal of communication disorders, vol. 30, 1983 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) sajcd_v67_i1_2020_contents.indd http://www.sajcd.org.za open access table of contents original research the core vocabulary of south african afrikaans-speaking grade r learners without disabilities danél hattingh, kerstin m. tönsing south african journal of communication disorders | vol 67, no 1 | a701 | 20 july 2020 original research maternal knowledge and views regarding early hearing detection and intervention in children aged 0–5 years at a semi-urban primary care clinic in south africa katerina ehlert, celeste coetzer south african journal of communication disorders | vol 67, no 1 | a681 | 21 july 2020 original research south african speech-language therapists’ opinion of their training in cleft lip and palate and craniofacial deformities emad ghabrial, kurt w. bütow, steve a.s. olorunju south african journal of communication disorders | vol 67, no 1 | a695 | 30 july 2020 original research nurses’ knowledge of stroke-related oropharyngeal dysphagia in the eastern cape, south africa kerry knight, bhavani pillay, jeannie van der linde, esedra krüger south african journal of communication disorders | vol 67, no 1 | a703 | 02 september 2020 original research contextual influences on sentence repetition as a tool for the identification of language impairment in grade 3 sepedi-english bilinguals: a case against bilingual norms heila jordaan, monene h. ngwanduli south african journal of communication disorders | vol 67, no 1 | a762 | 04 september 2020 original research perceived barriers to compliance with speech-language therapist dysphagia recommendations of south african nurses andrea robbertse, alida de beer south african journal of communication disorders | vol 67, no 1 | a686 | 10 september 2020 original research ‘a blender without the lid on’: mealtime experiences of caregivers with a child with autism spectrum disorder in south africa skye n. adams, raeesa verachia, kim coutts south african journal of communication disorders | vol 67, no 1 | a708 | 29 october 2020 original research grammatical number inflection in arabic-speaking children and young adults with down syndrome bassil mashaqba, haneen abu sa’aleek, anas huneety, sabri al-shboul south african journal of communication disorders | vol 67, no 1 | a702 | 05 november 2020 71 79 87 93 100 108 114 123 page i of iii table of contents original research perceptions of mothers with preterm infants about early communication development: a scoping review elanie van schalkwyk, samantha gay, julia miller, elani matthee, berna gerber south african journal of communication disorders | vol 67, no 1 | a640 | 29 january 2020 original research prevalence of hearing loss and tinnitus in a group of adults with human immunodeficiency virus alison millar, karin joubert, alida naude south african journal of communication disorders | vol 67, no 1 | a631 | 04 february 2020 original research an audiological profile of a cohort of school-aged children with hiv and aids attending an antiretroviral clinic in south africa vuyelwa z. peter, jessica paken, lavanithum joseph south african journal of communication disorders | vol 67, no 1 | a651 | 20 april 2020 original research the hearing function of sound engineers: a hearing conservation perspective liepollo ntlhakana, angie a. heliopoulos south african journal of communication disorders | vol 67, no 1 | a638 | 28 april 2020 original research a descriptive analysis of assessment measures on the effectiveness of a comprehensive stuttering intervention approach: a single case study tasneem f. karani, anniah mupawose south african journal of communication disorders | vol 67, no 1 | a648 | 29 april 2020 original research perspectives and practices of ototoxicity monitoring jessica paken, cyril d. govender, mershen pillay, vikash sewram south african journal of communication disorders | vol 67, no 1 | a685 | 19 may 2020 original research post-stroke dysphagia: an exploration of initial identification and management performed by nurses and doctors maggie pierpoint, mershen pillay south african journal of communication disorders | vol 67, no 1 | a625 | 28 may 2020 original research challenges of teaching the deaf-blind learner in an education setting in johannesburg: experiences of educators and assistant educators tejal manga, khetsiwe p. masuku south african journal of communication disorders | vol 67, no 1 | a649 | 11 june 2020 1 9 16 25 32 41 51 64 vol 67, no 1 (2020) issn: 0379-8046 (print) | issn: 2225-4765 (online)south african journal of communication disorders http://www.sajcd.org.za open access table of contents original research the validity of an isizulu speech reception threshold test for use with adult isizulu speakers seema panday, harsha kathard, wayne j. wilson south african journal of communication disorders | vol 67, no 1 | a690 | 09 november 2020 original research development and evaluation of the ingwavuma receptive vocabulary test: a tool for assessing receptive vocabulary in isizulu-speaking preschool children xolisile mazibuko, moses chimbari south african journal of communication disorders | vol 67, no 1 | a780 | 19 november 2020 original research the use of diet modifications and third-party disability in adult dysphagia: the unforeseen burden of caregivers in an economically developing country kim a. coutts, maxine solomon south african journal of communication disorders | vol 67, no 1 | a777 | 25 november 2020 130 137 147 editorial occupational hearing loss in africa: an interdisciplinary view of the current status katijah khoza-shangase, nomfundo f moroe, anita edwards south african journal of communication disorders | vol 67, no 2 | a700 | 03 march 2020 original research south african hearing conservation programmes in the context of tele-audiology: a scoping review katijah khoza-shangase, nomfundo moroe south african journal of communication disorders | vol 67, no 2 | a670 | 03 march 2020 original research risk versus benefit: should not audiologists assess this in the context of occupational noise-induced hearing loss in the mining industry? katijah khoza-shangase, nomfundo f. moroe south african journal of communication disorders | vol 67, no 2 | a671 | 03 march 2020 original research recent advances in hearing conservation programmes: a systematic review nomfundo f. moroe, katijah khoza-shangase south african journal of communication disorders | vol 67, no 2 | a675 | 03 march 2020 original research burden of disease: a scoping review of hiv/aids and tb in occupational noise-induced hearing loss katijah khoza-shangase south african journal of communication disorders | vol 67, no 2 | a669 | 03 march 2020 169 172 182 191 202 original research does occupational noise matter amongst manufacturing (small and medium enterprises) workers? empirical evidence from magaba, mbare, zimbabwe miston mapuranga, eugine t. maziriri, ralebitso k. letshaba, anos chitamba south african journal of communication disorders | vol 67, no 2 | a680 | 03 march 2020 original research classification of audiograms in the prevention of noise-induced hearing loss: a clinical perspective zumbi musiba south african journal of communication disorders | vol 67, no 2 | a691 | 03 march 2020 original research chemicals, noise and occupational hearing health in south africa: a mapping study mershen pillay south african journal of communication disorders | vol 67, no 2 | a693 | 10 march 2020 original research occupational noise and age: a longitudinal study of hearing sensitivity as a function of noise exposure and age in south african gold mine workers leoni m. grobler, de wet swanepoel, susan strauss, piet becker, zahan eloff south african journal of communication disorders | vol 67, no 2 | a687 | 17 march 2020 original research a critical analysis of the current south african occupational health law and hearing loss warren g. manning, mershen pillay south african journal of communication disorders | vol 67, no 2 | a694 | 24 march 2020 211 222 227 238 245 original research a retrospective review of speech-language therapy services provided to adult inpatients at a central-level hospital in gauteng, south africa jennifer stone, azra hoosen, hayley hochfelden, innocent maposa, shajila singh south african journal of communication disorders | vol 67, no 1 | a707 | 26 november 2020 opinion paper dysphagia services in the era of covid-19: are speech-language therapists essential? kim a. coutts south african journal of communication disorders | vol 67, no 1 | a709 | 29 july 2020 155 163 page ii of iii vol 67, no 2 (2020) special collection: occupational hearing loss in africa, sub-edited by katijah khoza-shangase and nomfundo moroe (wits) http://www.sajcd.org.za open access table of contents original research estimating miners at risk for occupational noise-induced hearing loss: a review of data from a south african platinum mine liepollo ntlhakana, gill nelson, katijah khoza-shangase south african journal of communication disorders | vol 67, no 2 | a677 | 26 march 2020 original research occupational noise-induced hearing loss in the mining sector of south africa: perspectives of occupational health practitioners on how mineworkers are trained nomfundo f. moroe south african journal of communication disorders | vol 67, no 2 | a676 | 30 march 2020 original research middle ear pathologies in adults within the mining industry: a systematic review ben sebothoma south african journal of communication disorders | vol 67, no 2 | a679 | 30 march 2020 256 264 270 original research engineering noise control for mines: lessons from the world milka c. madahana, otis t. nyandoro, nomfundo f. moroe south african journal of communication disorders | vol 67, no 2 | a684 | 31 march 2020 original research feedback-based noise management matrix in action nomfundo f. moroe, katijah khoza-shangase, milka madahana, otis nyandoro south african journal of communication disorders | vol 67, no 2 | a678 | 01 april 2020 reviewer acknowledgement south african journal of communication disorders | vol 67, no 1 | a800 | 22 december 2020 275 280 289 page iii of iii p h o n e m i c testing a. g. e p s t e i n (speech therapist) tamperdalsvej ii. arhus. denmark articulation testing of children with so-called "articulatory disorders" is carried out by almost every speech therapist. in logopedic literature "articulatory disorders" are divided into "omissions, distortions and substitutions". i would say that firstly, the expression "articulation testing" is not very good unless one is speaking about dysarthria, and secondly, that the division of different kinds of errors into 4 "omissions, distortions and substitutions" is not a satisfactory classification from my present point of view. in the following article i shall attempt to elucidate this viewpoint and afterwards demonstrate how by testing the children, one can get an exact figure which measures their performance in the test. this figure can be entered into a system of coordinates with the figure of the test performance as the ordinate and time as the abscissa. to master a language one must: (a) know its system of phonemes and use it in the correct way, (b) possess a sufficiently large vocabulary in that language, (c) have an adequate knowledge of its grammar. instead of "articulation tests" which test speech, one should speak of testing the phonemic system i.e. a testing of language and not speech. in this frame of reference, "omissions" mean "the use of too few phonemes", for example, where you get 'p' for 'pr' ('pice' for 'price') 's' for 'sn' ('sow' for 'snow') or nothing for 'r' ('ice' for 'rice'). "substitutions" mean "the wrong use of phonemes", for example, 't' substituted for 'c' ('tat' for 'cat'). if the substitution of 't' for 'c' remains consistent, one has an omission at the same time, as the 'c' phoneme is not used at all. such a case could be termed an "omission-substitution". "distortion" can be considered as a real speech defect, a faulty articulation of a phoneme. the distortion of an 's' for instance, is understood as an 's' and does not reduce the number of phonemes used in a language. t h u s while distortions are speech defects, omissions and substitutions are defects in ' ι linguistic expression i.e. they are language defects. to master a language it is necessary to use its units of expression correctly. there are a certain limited number of single consonants, vowels and consonant groups i.e. a 'limited number of linguistic units of expression. t o master the total number of expressive units means to master the vocabulary in its correct normal form, which is immediately understood by anyone speaking that language. in the english language the total number of expressive units is between 100 200. this modest sum includes single consonants, in initial, medial and final positions, plus all conjunctive consonant groups (i.e. appearing within one syllable). the danish test of the arhus institute has 225 units, as some disjunctive consonant groups, appearing in different but neighbouring syllables, act conjunctively, e.g. the word "cocktail", are included. these disjunctive groups may however be omitted in a test examining the linguistic expressive units. the person to be tested is asked to repeat these expressive units, which have been put into words. the examiner says the word once. note is taken of each response and an estimate is made of the correct responses. if at the first testing, 100 answers of the 225 units are correct, the degree of mastery of the expressive units of the language is stated as 100/225. at a test about one or two months later, the person may give incorrect responses where previously they were correct. for instance, 5 units which were correct at the first test may now be incorrect; and at the same time ten units, previously incorrect, may now be correct. thus he will have advanced five points (10 5) on his previous score i.e. he is now scoring 105/225. on a sheet of graph paper, it is possible to make a system of co-ordinates, as previously described, counting one unit per millimeter on the ordinate, and one month per ten millimeters on the abscissa. each millimeter line represents a date divisable by 3. in this way a curve showing progress in the acquisition of linguistic expressive units will be obtained. it might also be useful to find the relationship between the increase (positive change) and decrease (negative change) on a certain date of testing i.e. how great is the vacillation. this can be established in ths following way: a horizontal line, or zero line, 3 0 4 0 millimeters from the lowest edge of the paper is drawn. this is used as the abscissa. a point is made on the zero line, vertically under the testing date. from this point a line is drawn upwards representing in millimeters the number of new correct answers. this line is continued under the zero line for a length corresponding in millimeters to the number of incorrect answers which were formerly correct. the difference in length of the two lines thus drawn above and below the zero line expresses the gain or loss on the date in question. journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 2 journal of the south african logopedic society december r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) http://www.sajcd.org.za open access page 1 of 1 reviewer acknowledgement acknowledgement to reviewers in an effort to facilitate the selection of appropriate peer reviewers for the south african journal of communication disorders, we ask that you take a moment to update your electronic portfolio on https:// sajcd.org.za for our files, allowing us better access to your areas of interest and expertise, in order to match reviewers with submitted manuscripts. if you would like to become a reviewer, please visit the journal website and register as a user. in order to be considered, please email submissions@sajcd. org.za indicating your intention to register as a reviewer for the journal. to access your details on the website, you will need to follow these steps: 1. log into the online journal at https://sajcd. org.za 2. in your ‘user home’ [https://sajcd.org.za/index. php/sajcd/user] select ‘edit my profile’ under the heading ‘my account’ and insert all relevant details, bio statement and reviewing interest(s). 3. it is good practice as a reviewer to update your personal details regularly to ensure contact with you throughout your professional term as reviewer to the south african journal of communication disorders. please do not hesitate to contact us if you require assistance in performing this task. publisher: publishing@aosis.co.za tel: +27 21 975 2602 the editorial team of the south african journal of communication disorders recognises the value and importance of the peer reviewer in the overall publication process – not only in shaping the individual manuscript, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank and recognise the following reviewers for their precious time and dedication, regardless of whether the papers they reviewed were finally published. we apologise for any names that have been inadvertently left out. these individuals provided their services to the journal as a reviewer from 01 october 2021 to 30 september 2022. alida ellis alta m. kritzinger anniah i. mupawose bea staley ben sebothoma bhavani pillay bolajoko o. olusanya boledi k. maleka caitlin m.s. wakefield carmen milton christine rogers claire keeley delicia appana dilys m. jones erika bostock esedra kruger faheema mahomed-asmail gabriel darong hanlie degenaar hope c. reed isabella schimper jackie clark jacqueline l. schoeman jaishika seedat jenny pahl joanne f. neille karen wylie karin joubert katerina ehlert katie chadd katijah khoza-shangase khetsiwe p. masuku laura gaeta leigh biagio de jager maggi soer maria du toit meera rijhumal mershen pillay mianda van zyl michal harty michelle frewen mikateko ndhambi mpilo booi musa g. makhoba nasim b. khan nasreen allie natalie buttress nola j. chambers nomfundo f. moroe nondumiso a. gina nuha khatib renate vermaas robert h. eikelboom rohit ravi samantha m. govender selvarani moodley sharon moonsamy susan h. foster-cohen tarryn m. reddy thiani pillay vera g. hlayisi victor de andrade vishakha w. rawool vrinda rathiram vuyelwa z. peter yvette hyter http://www.sajcd.org.za� https://sajcd.org.za� https://sajcd.org.za� mailto:submissions@sajcd.org.za mailto:submissions@sajcd.org.za https://sajcd.org.za� https://sajcd.org.za� https://sajcd.org.za/index.php/sajcd/user https://sajcd.org.za/index.php/sajcd/user mailto:publishing@aosis.co.za acknowledgement to reviewers article information authors: mariska lundie1 zandria erasmus1 ursula zsilavecz1 jeannie van der linde1 affiliations: 1department speech-language pathology and audiology, university of pretoria, south africa correspondence to: ursula zsilavecz postal address: department of speech-language pathology and audiology, communication pathology building, east campus, university of pretoria, pretoria 0002, south africa dates: received: 06 sept. 2013 accepted: 09 mar. 2014 published: 27 june 2014 how to cite this article: lundie, m., erasmus, z., zsilavecz, u., & van der linde, j. (2014). compilation of a preliminary checklist for the differential diagnosis of neurogenic stuttering. south african journal of communication disorders, 61(1), art. #64, 10 pages. http://dx.doi.org/10.4102/ sajcd.v61i1.64 copyright notice: © 2014. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. compilation of a preliminary checklist for the differential diagnosis of neurogenic stuttering in this original research... open access • abstract • introduction • method    • aim    • research design    • participants • material used for data collection    • instrumentation for data collection    • data collection procedures • data analysis procedures • results    • case history    • cognitive awareness    • affective aspects    • linguistic functioning    • speech motor functioning    • social functioning • ethical considerations • discussion • conclusion • acknowledgements    • competing interests    • authors’ contributions • references • appendix    • checklist for differential diagnosis of neurogenic stuttering abstract top ↑ background: neurogenic stuttering (ns) is the most frequently occurring acquired form of stuttering in children and adults. this form of stuttering is primarily caused by neurological incidents. owing to controversies with regard to similarities between developmental stuttering (ds) and ns symptomatology, differential diagnosis is problematic. differential diagnosis will guide the appropriate management of persons who stutter (pws). objectives: the aim of this study was to describe and highlight the characteristics of ns in order to compile a preliminary checklist for accurate diagnosis and intervention. method: an explorative, applied mixed method, multiple case study research design was followed. purposive sampling was used to select four participants. a comprehensive assessment battery was compiled for data collection. results: the results revealed a distinct pattern of core stuttering behaviours in ns, although discrepancies existed regarding stuttering severity and frequency. it was also found that ds and ns can co-occur. the case history and the core stuttering pattern are important considerations during differential diagnosis, as these are the only consistent characteristics in people with ns. conclusion: it is unlikely that all the symptoms of ns are present in an individual. the researchers scrutinised the findings of this study and the findings of previous literature to compile a potentially workable checklist. introduction top ↑ interest in the sudden onset of ‘stuttering-like’ behaviour is not novel. this phenomenon has been both discussed and obliquely alluded to in stuttering literature (shapiro, 2011). cases of acquired stuttering are nevertheless generally considered to be rare. for this reason stuttering and stutter-like behaviours have often been categorised together and treated as if all dysfluencies were indications of developmental stuttering (shapiro, 2011). there is currently still a lack of information regarding the evidence for and the prevalence of neurogenic stuttering, but it is becoming increasingly apparent that speech–language pathologists (slps) often have a higher caseload of clients with neurogenic stuttering than they are aware of (theys, van wierengin & de nil, 2008). despite the fact that neurogenic stuttering (ns) shares several symptoms and perceptual characteristics with developmental and psychogenic stuttering (van borsel & taillieu, 2001), these three forms of stuttering should not be confused. failure to distinguish between them could lead to ineffective assessments and generally inappropriate stuttering intervention, which in turn would prevent adequate progress in stuttering therapy (balasubramanian, cronin & max, 2010). a holistic approach during assessment of and intervention with people who stutter or manifest dysfluencies will ensure accurate diagnosis and an appropriate and individualised therapy plan. a therapy plan ideally reflects a thorough evaluation of all possible symptoms and etiologies. a checklist providing the distinctive features of ns will guide therapists to make a differential diagnosis between ns, developmental stuttering (ds), and acquired psychogenic stuttering (de nil, 1999). a differential diagnosis remains challenging as similar symptoms may manifest, especially in the case of ns and psychogenic stuttering. a client with ns is often not aware of the dysfluencies but can be annoyed with his or her speech; similarly, in the case of psychogenic stuttering the client may be indifferent to his or her speech (guitar, 2014). in both ns and psychogenic stuttering onset is sudden and dysfluencies are fairly consistent (guitar, 2014). any form of stuttering and especially neurogenic stuttering (ns) can be viewed as a multidimensional speech disorder since it has an impact on the individual’s physical ability, emotions and mental health, environment, and psycho-social functioning (yaruss, 2007). ns is classified as an acquired speech disorder (theys et al., 2008). this form of stuttering is the most frequently occurring acquired form in both adults and children (van borsel & tallieu, 2001). it is most often the result of a neurological incident, be it a stroke, a traumatic brain injury (tbi) or any other event that could damage brain functionality (theys et al., 2008). for this reason it is imperative to manage ns according to the international classification of function (icf). according to the model, the following need to be addressed: (1) impairments, which are the characteristics that can be observed; (2) disability, which refers to the speaker’s functional communication difficulties, and (3) the handicap, which refers to the negative influence on the speaker’s quality of life (yaruss & quesal, 2004). like any other form of stuttering, ns causes serious communication difficulties, possibly resulting in a perceived disability (helm-estabrooks, 1999). communication difficulties can include social ineptitude and a negative self-perception as well as a negative perception of communication, which leads to social isolation, thus having a negative impact on the quality of life. accurate and expeditious identification of ns can reduce or even prevent such communication difficulties (manning, 2010). currently the field of ns does not seem to be receiving much academic and clinical attention; but those professionals who have recognised this condition deem it crucial that slps are made aware of the characteristic features (manning, 2010; tani & sakai, 2011; theys et al., 2008; shipiro, 2011). in many cases, the reason why ns is not identified or diagnosed is that the individual displays no serious symptoms. it is also difficult to associate stuttering with fleeting neurological incidents that were not perceived as critical (manning, 2010). these clients are often not even hospitalised, so no record of a tbi presents on their medical history. the clients with more severe tbis are admitted to hospital with survival as the main goal and no attention can be given to speech evaluations at that time. these clients are then discharged without any warning of possible communication difficulties, such as ns, that can arise. the diagnosis can be further complicated when the onset of the ns occurs only months after the tbi. canter (1971) compiled a set of seven characteristics for the purpose of facilitating the accurate identification of persons with ns. helm-estabrooks (1999) adapted these characteristics to formulate six common symptoms. the symptoms helm-estabrooks (1999) identified are as follows: 1. dysfluencies, which are equally observed on function words and content words during an utterance. 2. the speakers do not seem to be fearful or aware of the stuttering events. they do seem annoyed and surprised, however, at the occurrence of these events. 3. repetitions, blocks and prolongations appear in all positions in words and expressions. 4. during stuttering events, people do not present with the secondary behavioural symptoms, such as facial contortions, eye blinking or fist clenching associated with the moment of stuttering. 5. the clients do not demonstrate adaptation effects. 6. stuttering occurs consistently across different speech tasks and communication contexts. furthermore, tani and sakai (2011) cautioned therapists to take cognisance of the fact that some clients manifest added symptoms of aphasia and dysarthria. more recently lundgren, helm-estabrooks and klein (2010) argued that the six symptoms as presented by helm-estabrooks (1999) are of questionable reliability as indicators. they contend that a person should present with all six of the symptoms associated with ns as well as a history of a neurological incident in order to be diagnosed with ns. in a study conducted by perino, famularo and tarroni (2000), on the other hand, the client did not present with all six of the symptoms mentioned. they found that ns could be diagnosed due to the presence of a neurological incident and only two of the six symptoms associated with ns (perino et al., 2000). general consensus amongst researchers has not been achieved regarding the characteristic symptoms of ns and their frequency. the frequency and type of symptom are in turn dependent on the severity of the neurological incident and the site of the lesion. these discrepancies in the literature serve to emphasise the thorough and meticulous evaluation required if clinicians are to identify and address the specific symptoms as presented in any individual client. it also becomes apparent that professionals require information and guidance regarding the frequency of symptoms associated with ns. a checklist of symptoms associated with ns would facilitate differential diagnosis, as it would enable the slp to consider all possible symptoms and etiologies in order to identify the presence of ns effectively, as well as to differentiate between this particular kind of stuttering and other forms of dysfluency. when a clinician plans to assess an individual who stutters, several assessment batteries are available but none that address the unique symptomatology of ns (manning, 2010; shipley & mcafee, 2009). van borsel and taillieu (2001) examined the feasibility of performing a differential diagnosis by using only speech sample analysis. the diagnosis was based on the opinion of the various professionals involved. these researchers had access to the recordings only. no other information, for example a case history of the client, was provided. they concluded that it is not sufficient to rely only on the speech characteristics of a client in order to diagnose and treat ns correctly. the current study, therefore, incorporated a complete case history and analysis of not only the audio recording but also a video recording, which provided the opportunity to analyse all observable behaviour associated with ns. although research findings on ns have been reported, there are various limitations to these studies. single case studies (e.g. perino et al., 2000) cannot necessarily be generalised to a larger ns population (as explained by ringo & dietrich, 1995). the study conducted by theys et al. (2008) incorporated a larger number of clients with ns, but must be at risk for personal bias and subjectivity since the participants themselves were not included in the study; they were described by the slps only in terms of their speech patterns and presenting symptoms. the current study includes multiple participants; it takes the form of a multiple case study. by using a case study approach the researchers were able to gather ample information, including a detailed account of the assessment process (theys et al., 2008). the researchers were also able to give a more comprehensive representation of the ns population with multiple participants. theys et al. (2008) suggested that data should be gathered that are more reliable and representative of a group of ns clients with similar conditions of origin – in other words, as in the case of this study, tbi. the study in hand was designed to address the shortcomings of previous studies. as a result of the controversies and limited clinical guidelines in the literature, the following research question is posed: what are the distinctive characteristics of ns to be included in a preliminary differential diagnostic checklist? method top ↑ aim the aim of the study is (1) to obtain data about the characteristics of four participants with ns and (2) to identify trends and similarities in the characteristics ascertained in the participants and from current literature that could be used to compile a preliminary checklist for differential diagnosis in ns. research design an explorative, applied mixed method, multiple case study research design was selected for this study. the mixed method approach used is referred to as a dominant–less-dominant model (creswell, 1994; de vos, 2002), in which the quantitative data were the dominant and qualitative data the less-dominant component. the researchers made use of a cross-sectional time frame in the study as a small group of individuals were assessed at a specific moment in time (bless & higson-smith, 2000). case study approaches are most effective in fields of practice that are not well understood or that require more in-depth studies (leedy & ormrod, 2014). for this reason the current approach is deemed appropriate. participants the population targeted for this study was people who stutter (pws). the researchers made use of a purposive sampling method to select four participants. the participants were deliberately selected on the basis of specific characteristics (maxwell & satake, 2006). all four participants have a history of neurological incidents. three of the participants suffered diverse neurological incidents (see table 1). in this study participants were either 3or 4-year students or already qualified and employed. high-functioning adults were selected in order to eliminate the possibility of a language disorder and/or cognitive impairment. furthermore, participants were selected from the stuttering clinic’s database at the department of speech-language pathology and audiology, university of pretoria. this enabled the researchers to access and scrutinise previous records regarding the therapy progress and medical history of the participants selected.all four participants had made minimal progress during previous stuttering therapy and had experienced frequent relapses. people who present with ns do not show the expected progress when traditional stuttering therapy techniques are used (balasubramanian, et al. 2010; lundgren et al., 2010). only adults were included in the study as they are more likely to give a detailed account of their late childhood and early adulthood experiences relating to stuttering. the participants granted the researchers permission to contact their parents and/or relevant medical practitioners in order to obtain information regarding the participants’ medical history and early childhood. in the case of recent neurological incidents reports were obtained from the neurologist and general practitioners. the participants had to be proficient in either afrikaans or english as these are the languages in which the researchers can converse with professional confidence. in order to be included in the study, the participants were required to have a history of a tbi incident. there is a correlation between ns and a tbi (jokel, de nil & sharpe, 2007). individuals who had suffered a stroke or have a neurological degenerative disorder were not included in the study, because research in a single etiology of ns is required (theys et al., 2008). all four participants (see table 1) were diagnosed with ns; however, one participant had a history of ds (normal dysfluency) as a pre-schooler. gender was not a criterion for participant selection. material used for data collection top ↑ a combination of two assessment batteries was used to ensure that the researchers could highlight the majority of distinctive characteristics associated with ns (manning, 2010). the researchers consulted assessment guidelines (shipley & mcafee, 2009) and ‘the assessment battery of acquired stuttering in adults’, or abasa (manning, 2010:518), in order to compile a comprehensive assessment battery for the study. the combined assessment battery for the study is tabulated in box 1. box 1: the compiled assessment battery. the constituent components of the comprehensive stuttering assessment were carefully selected to elicit all possible response types in order to formulate a comprehensive representation of each participant’s stuttering behaviour. this comprehensive representation was obtained by taking into account cognitive, affective, linguistic, motor and social functioning (yaruss, 2007). in the case of this research study only high-functioning participants were included, and therefore the cognitive component was not evaluated formally. an information-gathering interview (shipley & mcafee, 2009) was conducted as part of the selection process to confirm level of cognition. cognitive awareness, however, was established utilising the same materials as with the affective and social component. the ability to have insight into one’s emotional responses and experience of stuttering was evaluated with: overall assessment of the speaker’s experience of stuttering, or oases (yaruss & quesal, 2010), perceptions of stuttering inventory, or psi (woolf, 1967 as cited in guitar, 2014), perceptions of self semantic differential task (kalinowski, lerman & watt, 1987) and locus of control of behaviour scale, or lcb scale (craig, franklin & andrews, 1984 cited in guitar, 2014). in addition to the pragmatic protocol (prutting & kirchner, 1987), an informal verbal and written assessment was conducted as a means of assessing the linguistic component. the speech-motor component was evaluated informally. reading passages, stimulability probes and fluency-enhancing techniques were used to determine consistency or adaptation of dysfluency in speech. spontaneous speech samples were collected to determine the severity and frequency of the stuttering behaviour. the instruments used to determine the abovementioned were: stuttering severity instrument, or ssi (riley, 1980), fluency charting grid, calculating the dysfluency index, assessment of associated motor behaviours, and assessment of physiological factors associated with stuttering (shipley & mcafee, 2009). spontaneous conversations in three different communication contexts provided the researchers with the opportunity to observe each participant’s communication abilities and consistency of stuttering behaviours when presented with different communication situations. an overall language assessment was deemed necessary so as to exclude the presence of a linguistic deficit. language could not be assessed by means of formal standardised tests, as no uniform, culturally appropriate tests are available in south africa to assess these abilities in each participant’s first language. however, by means of informal verbal and written assessment in the participants’ academic and/or business language (afrikaans or english) the researchers were able to confirm the absence of any language deficits. an assessment of narrative writing was conducted to evaluate vocabulary, punctuation, spelling and story composition (shipley & mcafee, 2009). the study made use of inter-rater reliability since three independent interpretations of the video recordings were made by the researchers. the reliability of these interpretations was deemed high as the independent interpretations clearly correlated with one another. during the study, the researchers ensured internal validity by means of methodological triangulation by combining components of both qualitative and quantitative research (de vos, 2002). the instruments that were used during each participant’s stuttering or dysfluency assessment are standardised and are specifically compiled to assess different stuttering behaviours, therefore enhancing the content validity of the study (delport, 2002). internal validity was further enhanced by making use of the purposive sampling method through which participants were selected on the basis of specific characteristics (maxwell & satake, 2006). by following this procedure, the researchers ensured that the most relevant data could be gathered. instrumentation for data collection a video recording of each participant’s assessment was made by means of a samsung digital camera, model vp-mx10a. the video recorder was placed on a slik tripod, model u8000 placed 1.5 m from the participant. it was positioned in such a way that a full frontal view of the participant’s face, shoulders, chest, hands and arms was obtained. an audio recording of each assessment was made with an olympus digital voice recorder, model dm-550. the audio recorder was placed on a soft surface next to the participant. the video and audio recordings enabled the researchers to analyse not only the speech and language components of the assessment but also the behavioural aspects such as the associated motor behaviours, core stuttering behaviours and secondary behaviours associated with stuttering. data collection procedures the assessment battery discussed above was implemented for a comprehensive stuttering assessment conducted on each participant individually. during each assessment the same sequence of procedures was followed. the assessment commenced with the information-gathering interview and a spontaneous conversation with the researchers. the interview was followed by the speech fluency assessment consisting of reading a passage, the introduction of stimulability probes for fluency, spontaneous conversation with an unfamiliar conversation partner and an unprepared telephone conversation, in that sequence (see box 1). thereafter the researchers requested that each participant write a short paragraph about any topic of interest and a complete oral–facial examination was conducted. the final task for each participant entailed the completion of the various self-perceptions checklists as identified in box 1. thereafter, three independent researchers interpreted the data collected and inter-rater interpretation was deemed reliable. data analysis procedures top ↑ the process of data analysis and interpretation of the qualitative data utilised in the current study are classified by cresswell (1994:195) as a ‘data analysis spiral’, in which the researcher moves in analytical circles instead of using a static linear approach (de vos, 2002). the data analysis spiral allows researchers to move between phases of data analysis, resulting in the adequate presentation of descriptive data that resulted in a sound understanding of the ns. the analysis spiral consists of the following phases: ‘[c]ollecting and recording data, managing data, reading and writing memos, describing, classifying and interpreting’ and, lastly, ‘representing and visualising’ (de vos, 2002:340). the researchers viewed each participant’s video recording of the stuttering assessment. the data was then organised in file folders, from where it was converted to text units as a means of simplifying analysis. after rereading the researchers to familiarise themselves with the data set by rereading the data, the spiral circled to the category formation phase. the researchers noted regularities in the subsections of the assessment conducted on participants, which led to generating categories of meaning in which internal convergence and external divergence was established. these categories or patterns were then challenged in order to search for plausible explanations. the final phase consisted of the representation and visualisation of the characteristics of ns presented in a preliminary differential diagnostic checklist. the quantitative data was analysed by using descriptive statistics such as simple frequency distribution. triangulation of method was utilised by mixing quantitative and qualitative approaches in order to determine an overlap between the data (quantitative and qualitative) and consequently obtain more comprehensive results. results top ↑ during this study, specific trends and shared characteristics amongst the four participants were identified. in order to compile a preliminary checklist, it is necessary to describe the specific trends according to the areas of the case history, cognitive functioning, affective aspects, linguistic functioning, speech motor abilities and social functioning. case history specific trends with regard to the neurological incident, family history and previous therapeutic interventions were found. with regard to the neurological incident, the participants in this study all presented with a history of a tbi. however, each tbi was different in terms of the nature, severity, age of occurrence and impact on the participant. it was noted that it is important to obtain information with regard to the client’s medical history from birth to the time of the assessment. the most pertinent information with regard to early childhood and the neurological incident was obtained by consulting relevant family members rather than the participants themselves. two participants presented with a history of meningitis during childhood in addition to the history of tbi. previous studies have found that meningitis can affect brain functioning (gazzolo et al., 2004). altered brain functioning has been identified as one of the various causes of ns (helm-estabrooks, 1999; manning, 2010). with regard to family history, the findings of this study concur with reports by manning (2010) and yairi (2007) that individuals with a family history of ds are predisposed for the occurrence of ns. ludlow and loucks (2003) provide an additional affirmation of the ds–ns connection, namely: the presence of ds results in increased susceptibility to ns following a neurological incident. cognitive awareness results regarding cognitive awareness were obtained by means of the oases (yarus & quesal, 2010), the perceptions of self semantic differential task (kalinowski et al., 1987), the psi (woolf, 1967 as cited in guitar, 2014:168) and the lcb scale (craig et al., 1984 cited in guitar, 2014). the first participant (p1), who presented with a mild ns, was unaware of the presence of the stuttering behaviour. where the onset of ns occurred in early childhood (see table 1), as in the case of p2 and p3, awareness of and reaction to the stuttering behaviour were evident. the participants’ awareness of and reaction to their stuttering are possibly due to continuous negative reaction by communication partners over a long period of time. a person can also present with a combination of stuttering behaviours when a positive history of ds and additional tbi are present, as in the case of p4. he was aware of the stuttering behaviour associated with the ds, but not of the additional ns behaviours. the onset of the ds occurred in early childhood, whereas the onset of the ns occurred in late childhood, with symptoms of both types of stuttering behaviour continuing into adolescence and early adulthood. table 1: description of participants. all the participants in this study presented with a history of a closed tbi which resulted in diffuse brain damage. p1, p2 and p4 presented with appropriate cognitive awareness. it can therefore be deduced that cognitive awareness is not always negatively affected in all cases of ns in the presence of a history of a tbi. affective aspects similarly to cognitive awareness, the affective aspects were identified by means of the oases (yaruss & quesal, 2010) and the perceptions of self semantic differential task (kalinowski et al., 1987). during this study, it was found that individuals who differ in terms of the severity of the stuttering behaviour presented with different affective responses. p1, who presented with a mild ns, exhibited only agitation and annoyance. additional negative emotions, such as frustration, anxiety and anger, were experienced by p2, p3 and p4. since p2 and p3 presented with severe ns from early childhood, undesirable reactions by communication partners and increased self-awareness over a long period of time resulted in negative emotions on their part. the negative emotions exhibited by p4 are related to the history of the ds. in agreement with the findings of yaruss and quesal (2004), pws’s awareness of their stuttering behaviour leads to anxiety and frustration and limited social interaction. the different affective responses of all the participants subsequently led to a low self-esteem and impaired self-perception. although the participants reported that they are competent individuals in tasks that do not require social interaction or speaking, their self-esteem and self-perceptions had a negative impact on verbal interaction with communication partners. this finding contradicts reports which state that in the case of ns no or minimal awareness manifests (manning, 2010). linguistic functioning persons presenting with ns may or may not present with language impairment (manning, 2010; tani & sakai, 2011). only participants with competence in english or afrikaans as their academic or business language were included in the study. in the case of p3, minor language difficulties, such as word retrieval, were identified in his second language (english). these difficulties were also present as reported by his family members in his first language (isizulu). the possibility of an aphasic element should be further investigated (tani & sakai, 2011); however, his overall linguistic competence was not compromised. the other three participants presented with above-average language functioning. the site of the neurological lesion in persons presenting with ns is likely to have a differential impact on language functioning. moreover, linguistic skill has been found to be genetically determined to a large degree (di sciullo, 2010). language functioning, therefore, does not need to be regarded as a significant factor to consider during differential diagnosis of ns.results on pragmatic behaviour were obtained by means of the pragmatic protocol (prutting & kirchner, 1987). all four participants presented with pragmatic deficits associated with a neurological incident. pragmatic behaviours characteristic of ds were also observed in p4. depending on the nature of the neurological incident, additional pragmatic deficits may be present (dardier et al., 2011; douglas, 2010). during differential diagnosis it is important to identify the pragmatic deficits related to the neurological incident, as well as pragmatic deficits associated with the stuttering behaviour. pragmatic behaviours that were observed (p1–p4) to be associated with the ns included deficits in cohesion, physical proximity, topic initiation and maintenance, and conciseness. these behaviours are consistent with pragmatic breakdown found in persons with left and right hemisphere brain damage (bloom & obler, 1998). pragmatic behaviours associated with ds (p4) included deficits in turn-taking ability and paralinguistic aspects in an attempt to disguise or avoid the stuttering behaviour (guitar, 2014). therefore, it is of importance to be vigilant in the identification of specific pragmatic deficits associated with a neurological incident. the nature of the different pragmatic deficits can guide the slp in terms of differential diagnosis. speech motor functioning the ssi (riley, 1980), fluency charting grid, calculating the dysfluency index, assessment of associated motor behaviours, and assessment of physiological factors associated with stuttering (shipley & mcafee, 2009) were used to obtain results on the speech motor functioning of the participants. all the participants presented with varying degrees of stuttering severity when presented with different communication situations such as having a conversation with the researchers, talking to a complete stranger, and having a telephone conversation. other researchers (tani & sakai, 2011) have also demonstrated that individuals who present with ns do not always perform consistently throughout different communication situations. on the other hand, some researchers have found that individuals with ns present with consistent stuttering behaviours in various communication situations (manning, 2010; jokel, denil & sharpe, 2007). varying stuttering severity across communication situations may therefore be one of the many reasons why the slp does not immediately identify these presenting stuttering behaviours as being related to ns. on assessing adaptation and consistency of stuttering behaviour, it was noted that consistency was high and adaptability low. this is characteristic of ns (manning, 2010) and is an important characteristic to identify during the differential diagnosis between ns and ds. by means of fluency probes p2 was able to maintain fluency for a short period of time. the other three participants achieved fluency during automatic speech tasks, but were not able to produce more fluent speech when presented with the different fluency probes. it can be deduced that some persons presenting with ns do benefit from fluency probes, but the application is limited in the sense that communication presents as deviant from what is deemed natural speech. three out of the four participants who were included in the study did not benefit from the various stimulability probes. balasubramanian et al. (2010) and helm-estabrooks (1999) reported similar findings. consequently, poor adaptation of speech when the pws is presented with fluency probes should be considered an indicator in the differential diagnosis between ns and ds. in general, ns poses challenges with regard to differential diagnosis. diagnosis of ns is complicated by the long-term nature of the problem, co-occurring language disorders and the additional presence of ds. the percentage of core stuttering behaviour relative to total occurrence of all behaviours across participants is presented in figure 1. figure 1: predominant core stuttering behaviours presented by p1 – p4. figure 1 clearly illustrates that the participants presented an array of core stuttering behaviours that exemplify the distinctive features of ns. repetitions were the most dominant core stuttering behaviour which was present in all four participants. repetitions consisted predominantly of sound and part-word repetitions in the initial, medial and final position of words. the presence of sound and part-word repetitions in the medial and final position of words is characteristic of ns, as described by helm-estabrooks (1999) and tani and sakai (2011). furthermore, the findings of initial sound and part-word repetitions concur with the findings in the study conducted by tani and sakai (2011). although part-word repetitions are generally accepted as core stuttering behaviours present in ns, these may also occur in ds and ps. for this reason a holistic approach is essential in order to identify other co-occurring characteristics predicting neurogenic involvement. associated motor behaviours in an attempt to escape the stuttering moments were present in three of the participants (p1, p3 and p4). in addition, in the case of p2 apraxia-like symptoms, such as oral searching and groping movements, were observed. this corroborates with findings by tani and sakai (2011), suggesting that the slp should be aware of soft neurological signs during the differential diagnosis between ds an ns. social functioning the participants’ participation in social situations was evaluated by means of the oases (yaruss & quesal, 2010) and the lcb scale (craig et al., 1984 cited in guitar, 2014). it is the experience of all the participants that their stuttering behaviours influenced their social, academic and occupational functioning negatively. for instance, p4, who presented with ds and ns, was overly aware of his limitations, thus withdrawing from social and occupational contexts. p1, p2 and p3 experienced themselves to be limited in speaking situations, due to external barriers created by different communication partners. this observation supports the findings of yaruss (2007). ethical considerations top ↑ the study was cleared by the research committee of the department of speech-language pathology and audiology, university of pretoria. the participants were provided with a document containing information regarding the nature and the purpose of the study. the participants were also informed that they would be allowed to withdraw from the study at any time without any consequences. the participants were informed that all their personal information and assessment results will be kept confidential. the participants provided written consent. discussion top ↑ the importance of considering each individual client with his or her stuttering behaviours is highlighted in this study. the four participants presented with differences with regard to their stuttering behaviour patterns as well as the severity and frequency of the stuttering behaviour. the researchers found consistent core stuttering behaviours, however, amongst the four participants. core stuttering behaviours consisted mainly of repetitions of sounds in the medial and final position of a word, a lack of adaptation, high consistency and rapid firing speech. these stuttering behaviours are considered predictors of ns, as similarly described in the literature (helm-estabrooks, 1999; jokel, de nil & sharpe, 2007; tani & sakai, 2011).the case history and the core stuttering patterns are an important consideration during differential diagnosis of ns. the occurrence of a neurological incident and the core stuttering patterns are the only consistent characteristics in individuals presenting with ns and they should be considered predictors of this dysfluency disorder. other factors that may be considered during differential diagnosis are variable, but it is important to note that the presence of one ns symptom in combination with the detailed case history guides the differential diagnosis and planning of ns intervention (helm-estabrooks, 1999). this study found that it is unlikely that all the symptoms of ns will be present in a single client. this finding concurs with the study conducted by perino et al. (2000). additional findings of this study were similar to those reported in recent literature regarding the occurrence of ns in combination with ds (manning, 2010; yairi, 2007). it is evident that there is much yet to be discovered about the complexity of ns. it was found that ds can present simultaneously with ns, and that the onset of ns can occur in early childhood. this finding highlights the importance of making a clear differential diagnosis in early childhood in order to ensure the most effective intervention from an early age. the preliminary checklist for differential diagnosis of neurogenic stuttering (see appendix 1) takes into consideration all the relevant characteristics for differential diagnosis of ns. besides the findings reported in current literature, additional features were identified in this study, for instance some participants presented with increased cognitive awareness, contradicting findings by helm-estabrooks (1999) and guitar (2014). the characteristics identified in the participants as well as the features described in the current literature were included in the compilation of the preliminary checklist. these characteristics are categorised as either predictive or non-predictive factors. a high occurrence of predictive factors is indicative of ns, whereas non-predictive factors may be present in either ns, ds or psychogenic stuttering. the checklist has been compiled in such a manner that it should be user friendly as the slp needs to answer only ‘yes’ or ‘no’ questions. furthermore, guidelines for the interpretation of responses are included in the checklist. the applicability of the compiled checklist was evaluated informally by a professional speech-language pathologist with extensive experience in working with pws. the checklist was deemed comprehensive and potentially a valuable tool. since the differential diagnostic applicability of this tool has not been researched in depth, the checklist should be evaluated in future research. it is recommended that the checklist should be implemented on a diverse group of individuals presenting with fluency disorders. in addition to the application of the preliminary checklist on a diverse group, an increase in the sample size is recommended for future research. this is considered necessary since the nature of this study’s explorative research design led to the inclusion of a small sample size. although the preliminary checklist appears to be comprehensive, further research is warranted in order to determine the validity and reliability of the tool. in addition, future research is needed to determine the relationship between ds and the long-term nature of ns with regard to the level of awareness of the stuttering behaviours as well as the specific effects on overall communication. conclusion top ↑ owing to controversies regarding similarities between ds and ns symptomatology, differential diagnosis is problematic. the study aimed to describe and highlight the characteristics of ns in order to compile a preliminary differential diagnostic checklist (see appendix 1). the results were analysed and the literature was scrutinised in order to develop the checklist. this checklist guides slps in the differential diagnosis of ns and in turn should improve the appropriate management of individuals with both ns and ds. although the trustworthiness of the checklist has not been confirmed through research, the clinical application as such proves useful as the most prevalent symptoms of ns are highlighted. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions u.z. 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(2010). oases: overall assessment of the speaker’s experience of stuttering. bloomington, mn: pearson/ags. appendix top ↑ checklist for differential diagnosis of neurogenic stuttering sajcd_v68_i1_2021_contents.indd http://www.sajcd.org.za open access table of contents original research acoustic immittance measures and middle ear assessment: current practice by south african audiologists ben sebothoma, katijah khoza-shangase south african journal of communication disorders | vol 68, no 1 | a818 | 07 june 2021 original research it’s crunch time: exploring the sensibility of food textural acoustics for individuals with dysphagia tasneem f. karani, mershen pillay south african journal of communication disorders | vol 68, no 1 | a806 | 30 june 2021 original research decision making and the bedside assessment: the speech language therapists’ thinking when making a diagnosis at the bed kim coutts, mershen pillay south african journal of communication disorders | vol 68, no 1 | a790 | 30 june 2021 original research preliminary reliability of south african adaptation and northern sotho translation of the modified checklist for autism in toddlers, revised with follow-up carlien vorster, alta kritzinger, lovina e. coetser, jeannie van der linde south african journal of communication disorders | vol 68, no 1 | a831 | 22 july 2021 original research sports audiology: ear hygiene practices of gym users who wear earphones aimee flowers, dhanashree pillay south african journal of communication disorders | vol 68, no 1 | a794 | 28 july 2021 original research contextualising clinical reasoning within the clinical swallow evaluation: a scoping review and expert consultation thiani pillay, mershen pillay south african journal of communication disorders | vol 68, no 1 | a832 | 29 july 2021 original research pathogenic oral bacteria in hospitalised patients with dysphagia: the silent epidemic merryl j. weimers, mershen pillay south african journal of communication disorders | vol 68, no 1 | a798 | 30 july 2021 original research a chasm: consequences of poor collaboration between health and education in paediatric cerebral palsy care in johannesburg martha lydall, berna gerber south african journal of communication disorders | vol 68, no 1 | a817 | 19 august 2021 70 77 89 97 104 111 123 130 page i of ii table of contents original research impact of drug-resistant tuberculosis treatment on hearing function in south african adults: bedaquiline versus kanamycin katijah khoza-shangase, marina prodromos south african journal of communication disorders | vol 68, no 1 | a784 | 26 january 2021 original research outcomes of newborn hearing screening at an academic secondary level hospital in johannesburg, south africa jacqueline k. bezuidenhout, katijah khoza-shangase, tim de maayer, renate strehlau south african journal of communication disorders | vol 68, no 1 | a741 | 27 january 2021 original research ‘we are in this together’ voices of speech-language pathologists working in south african healthcare contexts during level 4 and level 5 lockdown of covid-19 skye n. adams, jaishika seedat, kim coutts, kelly-ann kater south african journal of communication disorders | vol 68, no 1 | a792 | 18 february 2021 original research identifying hearing impairment and the associated impact on the quality of life among the elderly residing in retirement homes in pretoria, south africa samantha m. govender, marguerite de jongh south african journal of communication disorders | vol 68, no 1 | a788 | 01 march 2021 original research promoting emergent literacy in under-served preschools using environmental print lauraine giacovazzi, sharon moonsamy, munyane mophosho south african journal of communication disorders | vol 68, no 1 | a809 | 17 may 2021 original research factors influencing speech language pathologists’ and audiologists’ decision to pursue postgraduate studies in south africa ben sebothoma, khetsiwe masuku, nomfundo moroe south african journal of communication disorders | vol 68, no 1 | a796 | 18 may 2021 original research parental views on informational counselling provided by audiologists for children with permanent childhood hearing loss zandile m. shezi, lavanithum n. joseph south african journal of communication disorders | vol 68, no 1 | a799 | 25 may 2021 original research patterns of noise exposure and prevalence of hearing loss amongst cape town minstrel carnival musicians lebogang ramma south african journal of communication disorders | vol 68, no 1 | a789 | 31 may 2021 1 9 17 29 38 49 56 64 vol 68, no 1 (2021) issn: 0379-8046 (print) | issn: 2225-4765 (online)south african journal of communication disorders http://www.sajcd.org.za open access table of contents original research successes and challenges of speech language therapy service provision in western kenya: three case studies bea staley, ellen hickey, david rochus, duncan musasizi, rachael gibson south african journal of communication disorders | vol 68, no 1 | a838 | 27 september 2021 original research the sensitivity and specificity of wideband absorbance measure in identifying pathologic middle ears in adults living with hiv ben sebothoma, katijah khoza-shangase, duane mol, dipuo masege south african journal of communication disorders | vol 68, no 1 | a820 | 30 september 2021 original research vulnerable mothers’ experience of feeding their preterm infant in neonatal care elanie a. van schalkwyk, berna gerber south african journal of communication disorders | vol 68, no 1 | a842 | 28 october 2021 opinion paper language and culture in speech-language and hearing professions in south africa: re-imagining practice katijah khoza-shangase, munyane mophosho south african journal of communication disorders | vol 68, no 1 | a793 | 03 june 2021 138 147 154 163 opinion paper audiologists should not fail with falls: a call to commit to prevention of falls in older adults christine rogers south african journal of communication disorders | vol 68, no 1 | a841 | 30 september 2021 correction corrigendum: occupational noise and age: a longitudinal study of hearing sensitivity as a function of noise exposure and age in south african gold mine workers leoni m. grobler, de wet swanepoel, susan strauss, piet becker, zahan eloff south african journal of communication disorders | vol 68, no 1 | a849 | 08 november 2021 reviewer acknowledgement south african journal of communication disorders | vol 68, no 1 | a889 | 22 december 2021 172 177 178 page ii of ii 3 a pilot study of verbal fluency in the zulu speaking population with preliminary application to traumatic brain injury terri-leigh sperinck and janet de picciotto department of speech pathology and audiology university of the witwatersrand abstract this study investigated the semantic verbal fluency (vf) abilities of non-neurologically impaired (nni) zulu speaking subjects in order to obtain normative data for this population. the data were analysed in terms of the total number of words generated in one minute, the number of words generated over four fifteen-second time periods and the strategies employed. where possible, these results were compared to performance of south african english speaking nni subjects. the responses of three traumatically brain injured (tbi) zulu speaking subjects on vf tasks were obtained and compared to the nni subjects. the nni subjects performed significantly poorer than the current norms and poorer than the south african english speaking population. the tbi subjects generated fewer words than the nni subjects. the strategies used by the tbi subjects were similar in type but were less efficiently used than the zulu speaking nni subjects. the results of this study are particularly relevant to the clinical role of speech pathologists in the multicultural and multilingual population of south africa. opsomming hierdie studie is 'n ondersoek na die vermoe van nie-neurologies-gestremde zoeloesprekers om woorde te herroep en produseer na aanleiding van semantiese kategoriee. die doel van die studie was om norma tie we data te verkry vir hierdie groep sprekers. die totale aantal woorde in een minuut geproduseer; die aantal woorde wat oor vier vyftien-sekonde periodes geproduseer is; en die strategiee wat deur die proefpersone gebruik is, is ontleed. waar moontlik is die resultate met die van engelsprekende proefpesone vergelyk. data is ook verkry van drie zoeloesprekers met geslote hoo/beserings, en met die data van die nie-neurologies-gestremde groep vergelyk. die nie-neurologies-gestremde zoeloesprekers het swakker gevaar as die engelsprekende groep sowel as die gepubliseerde norme. die prbefpersone met traumatiese hoo/beserings het minder w.oorde geproduseer as die nie-neurologies-gestremde groep, en alhoewel hulle dieselfde strategiee gebruik het as laasgenoerade, het· hulle dit minder doeltreffend gebruik. die resultate van hierdie studie is veral van belang binne die multikulturele, veeltalige suid-afrikaanse konteks. i key words: verbal fluehcy, semantic verbal fluency, multicultural, multilingual i . verbal fluency (vf) is a ,task commonly incorporated in the assessment batteries of speech pathologists and neuropsychologists in south africa. in a population as culturally diverse as south africa's, it is essential to recognise the need for normative data pertaining to assessment tasks conducted on the non-english speaking population in order to provide a basis against which to compare the performance of our clients. this study investi" gated vf abilities in aspecific group from the zulu speaking population of south africa. in addition, a small sample of zulu speaking traumatic brain injured (tbl) subjects was investigated. a discussion of vf and the provision of a rationale for the choice of zulu speakers as the subject of investigation in this study, follows. gruen, frankie & schwartz (1990) define verbal fluency (vf) as "a language based task employed to measure word associate generation and divergence" (p.163). a review of the literature revealed a number of studies on vf in different population groups including the elderly; non-neurologically impaired; alzheimer's disease; parkinson's disease; huntington's disease; dementia; progressive supranuclear palsy and head injury populations (adams, reich & flowers, 1989; bolla, lindgren, bonaccorsy & bleecker, 1990; borkowski, benton & spreen 1967; cauthen, 1978; de picciotto, 1997; gruen et ai., 1990; hanley, dewick, davies, playfer & turnbull, 1990). numerous studies have shown that results ofvf tasks may be influenced by age, sex and verbal intelligence (bolla et ai., 1990; cauthen, 1978; hanley et ai., 1990). the two vf tasks most utilised by researchers and clinicians are phonemic a~d semantic category tasks (adams et ai., 1989; borkowski et ai., 1967; depicciotto, 1997; hanley et ai., 1990). in phonemic tasks, subjects are required to generate words that begin with a specific letter, whereas in semantic category tasks subjects are required to generate words that are part of a specific category. phonemic vf is dependent on the "phonologically based word store" (rosser die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 4 & hodges, 1994, p. 1389). semantic vf requires the individuals to make an exploration of their conceptual knowledge followed by a lexical search according to semantic categories (cardebat et ai., 1996). the lexicon involved in semantic categories is stored in the semantic memory; the system oflong term memory which contains general information about the world (rosser & hodges, 1994). battig & montague (1969), as cited by adams et ai. (1989), found that the categories which are chosen for vf tasks have extensive effects on the scores of the subjects. there is a relationship between language and thought in the culture in which the language is spoken, therefore language and culture are reciprocal (berry, poortinga, segall & dasen, 1992). consequently, when choosing categories for vf tasks it is imperative to ensure that the categories are culturally appropriate. when obtaining normative data on an assessment tool for a population on which it was not originally normed, it is not enough to simply translate the test into-the required language. as stated by payne (1986), the roots of language are embedded in culture and as a result the two cannot be separated and thus it is necessary to adapt the test to the culture for which it is being normed. when considering the applicability of the two types of vf tasks.in the zulu speaking population, the semantic category task of vf may be more appropriate than the phonemic tasks owing to the complexity of noun class marker and noun class agreement exhibited in zulu (suzman, 1996). therefore a phonemic vf task was not felt to be appropriate because zulu speakers make use of noun class prefixes when speaking, thus words would not simply be named but rather they would be said with their class prefixes. for example, "sock" in zulu is "isokisi" however, the"i" which occurs at the beginning of the word is. the noun class marker and not in fact the initial letter of the word. vf tasks are performed over a 60-second time period. this performance can be further analysed in terms offour 15-second time periods. adams et ai. (1989) found that the non-neurologically impaired (nni) subjects or subjects with dementia of the alzheimer type (dat) generated the most words during the initial fifteen-second time period, however, the dat subjects exhibited a distinctive decrease in the number of responses in the ensuing time periods. studies conducted by cardebat et ai. (1996) on right brain damaged subjects, and crowe (1992) of tbi subjects, showed that there was a decrease in the number of words generated after the first 30 seconds. when performing vf tasks the individual tends to use strategies. the ability to switch strategies when the series of associations runs out, as well as good organisational skills enhance performance in tasks ofvf (cauthen, 1978). there is currently limited data on strategy use in different populations. a review ofliterature regarding tasks ofvf revealed a paucity of research on vf using non-engiish speaking subjects. benton & hamsher cited by lezak (1995) established letter ranking norms in vf tasks in french, germa:n, italian and spanish. there appears to be no published literature on vf research carried out in any african languages. normative data for tasks ofvf in african languages are important in the south african context because assessments currently being on non-english speaking clients are normed on english speakers. south africa is a country with vast ethnic diversity and a total population of 38 million. mother tongue zulu speakterri.leigh sperinck and janet de picciotto ers comprise 22,4% (6,4 million) of the total population. within the gauteng province, 18,4% of the people speak zulu as their home language (central statistical services, 1998). zulu is the predominant african language spoken in south mrica. the most common language spoken southern mrican townships is a hybrid of either zulu or xhosa (maake, 1991). it can therefore be deduced that zulu speakers form a large proportion of the speech pathologist's caseload. in order to treat populations of various languages it is necessary to understand their languages and the way in which they organise their thoughts. estes (1974) suggests that tasks of vf represent an ideal method of examining how subjects organise their thinking. thus, normative data of zulu speakers is imperative in order to establish baseline measures for the purpose not only of diagnosis but also for intervention. the performance of south mrican zulu speakers as compared to south african english speakers on tasks of vf may provide valuable insight into cultural and linguistic differences in their approach to vf tasks. there are numerous problems facing speech pathologists working in culturally and linguistically diverse populations. one of the most critical problems that the speech pathologist is faced with is "the absence of adequate assessment tools needed to provide valid and reliable evaluations" of linguistically and culturally disparate populations (vaughn-cooke, 1986, p. 23). the need for culturally appropriate tests is vital as the employment of invalid assessment tools has direct impact oii the client's results which in turn have far reaching implications for ·diagnosis, intervention and outcome (vaughn-cooke, 1986; watt, penn & jones, 1996). one population typically seen in speech pathologist's caseloads is tpat oftbi clients. the national head injury foundation (nhif) defines tbi as "an insult to the brain that is caused by an external force that may produce diminished or altered states of consciousness which results in impaired cognitive abilities or physical functioning" (ponsford, 1995, p.1). statistics show that 70% of tbl's are caused by motor vehicle accidents (mva) and that it is mostly men between the ages of 15-35 years that are affected (gillis, 1996). most of the men that are affected by tbi are from lower socio-economic classes who may have limited educational attainment (ponsford, 1995; watt, penn & jones, 1996). i the mechanisms that occur as a result oftbi are complex and involve both focal and diffuse injuries (gil:lis, 1996; ponsford, 1995). research has shown that there kre cognitive, behavioural and language consequences oftbi (borkowski, benton & spreen, 1967; gillis, 1996; gruen et ai., 1990; ponsford, 1995; schmitter-edgecombe, 1996). the phenomenon of tbi is common worldwide although the pattern of causation differs from country to country. while. the largest cause of tbi in south mrica is attributed to motor vehicle accidents the statistics show that tbi in the african populations is mostly as a result ofviolence (brown & nel, 1991) and this etiology is adding to the statistics of tbi. verbal fluency abilities have been explored in the tbi population. tbi subjects generate fewer words on tasks of vf than nni subjects (gruen et ai., 1990). the aforementioned result may be attributed to the disruption in organisational skills in tbi subjects, which are important requirements for tasks of vf (gruen et ai., 1990). furthermore, results of studies of tbi subjects indithe south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) a pilot study of verbal fluency in the zulu speaking population with preliminary application to traumatic brain injury 5 cate that while they make use of similar strategies as nni subjects in vf tasks, the injury appears to influence the speed and effectiveness of the strategies that are employed (gruen et al., 1990). anatomically the frontal lobes appear to playa vital role in vf tasks and the well-documented vulnerability of the frontal lobes to injury in tbi may account for the above finding (crowe, 1992; rosser & hodges, 1994). the purpose of this study was therefore to gather normative data on vf tasks for the zulu speaking population and compare this performance to that of south . african english speakers in order to facilitate culturally and linguistically appropriate assessment, diagnosis and intervention. furthermore, this study aimed to examine a sample of zulu speaking tbi clients in order to obtain an indication of their performance in comparison to the nni population. methodology the research methodology followed the framework of de picciotto (1997) with adaptations for the specific population of this study. aims this study aimed to explore vf performance in zulu speaking subjects in order to gather normative data. the sub-aims were fourfold: » firstly, to determine the number words generated . by zulu speaking nni subjects and compare them to south mrican english speaking nni subjects. » secondly to determine the performance of zulu speaking tbi subjects. » thirdly to compare the results obtained by the zulu speaking nni and zulu speaking tbi subjects. » finally to describe any strategies used by the zulu speaking nni and zulu speaking tbi subjects dur. 'ing vf tasks. // research design i a structured survey design was used to achieve the aims of this research as the data' are quantified and managed by means of descriptive statistics. j i table 1: description of zulu speaking tbi subjects. subject # 1 age 18 etiology assault coma 1 week time since injury 6 months education level std.8 premorbid employment status unemployed current i employment status unemployed subjects the subjects were required to meet the following criteria. all subjects had to be male zulu speakers in the age range of 18-30 years with a minimum of 10 years of formal education. to control for the large diversity of educa~ tional standards within the south african geographical context (hosking, 1992), subjects were required to have been raised and educated in the urban areas of gauteng to achieve uniformity of the dialects of zulu that the patients spoke and ensure that the patient's educational backgrounds were similar. in addition, the three tbi subjects had to be at least 3 months post head injury in order to allow for neurological stabilisation (lezak, 1995). the zulu speaking nni group was represented by forty subjects and three zulu speaking tbi subjects were selected. the zulu speaking nni subjects ranged in age from 18-30 years (mean age = 23.58 years; sd = 4.03 years). formal education of the nni subjects ranged from 10-15 years (mean education = 10.15; sd = 0.99 years). owing to the small sample size ofthe zulu speaking tbi subjects statistical inferences could not be made, however, their details are provided in table 1. testing in order to ascertain performance of the zulu speaking nni subjects as well as zulu speaking tbi subjects on tasks of semantic vf, three categories were chosen, namely: "animals'" "food" and "transport", as they are most commonly used by researchers in studies of vf (gruen et ai., 1990; hanley et al., 1990). these three categories were the .ones that were least likely to be affected by culture (berry et al., 1992). the subjects were given a trial category of "clothes" before beginning the task. the procedure employed required that each subject generate as many words as possible over a one-minute time interval for each of the three categories. the categories were presented in the following order: "animals", "food" and "transport". the interpreter verbally requested the subjects to continue if they stopped before the full minute (joannette et al., 1988). at no time during the task were the subjects provided with cues. a tape recorder was used to record the subjects' responses and a stopwatch was used to time each task. the number of words generated in one minute for each category was totalled. the oneminute time interval was subject#2 subject#3 25 19 mva stab wound unknown unknown 15 months 18 months std.8 std.8 storeman unemployed unemployed unemployed die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 6 then divided into four time intervals of fifteen-seconds each. the number of words generated in each of the four fifteen-second time intervals were then summed for each category. the strategies used by the subjects were analysed in terms of type and efficiency. a strategy was presumed if a subject's response was related to the word immediately preceding it (gruen et ai., 1990). once the instructions for the semantic vf task had been translated they were. piloted on a small group of zulu speaking males. a number of alterations were made and these included a more explicit explanation of the 60-second time period for each category as well as clearer instructions not to make use of proper nouns. owing to the fact that all testing was conducted in zulu, a translator was required to translate the instructions of the vf tasks into zulu. the translator was chosen according to the criteria suggested by van ede (1996), that is, he was required to be proficient in english and zulu, in order to translate the instructions for the task into zulu from english. once the material had been translated, the process of back translation was employed. this is a process whereby a second person, proficient in both languages, translates the material back into the original language. the second translator does not have any previous knowledge of the original material, thereby ensuring that he is not biased. back translation is conducted to guard-against any errors that the first translator may have made. these errors include grammatical structures, word complexity and overall resemblance of the meaning (van ede, 1996). the original translator was used as an interpreter because he was proficient in both english and zulu and he had knowledge of the testing material. he was then instructed in the administration of the vf tasks and worked with the researcher.in transcribing the responses. data analysis in order to address the main aim, normative data were depicted by tabulating the results ofthe 40 zulu speaking nni subjects. the means for the number of-words for each category were established as well as for each time period within each category. according to von fraunhofer & murray (1976), the most common method of ascertaining 'normal' is to determine the mean. standard deviation (sd), for the number of responses in each category and the number of responses for each time period, was then calculated. sd was used to determine how much the individual values deviated from the mean values. the percentage of sd to the mean was calculated to obtajn an indication of the relative differences between the sd. this calculation was carried out for each category and for each time period of each category. these calculations were used to compare the results between the three categories and to compare. the results of each of the four time periods within the three categories. the results were then depicted graphically in order to ascertain whether any patterns or tr.ends were present. the results of the zulu speaking nni subjects on the categories of "animals" and "transport" were compared to the results of south african englispspeaking nni subjects (de picciotto, 1997). the category "food" was not included in this comparison since it was not used in the study on south african english speakers. the means for the number of responses for each catterri-leigh sperinck and janet de picciotto egory were tabulated into frequency distributions and then represented graphically in the form of a distribution curve. these graphs were plotted in order to ascertain whether there was a gaussian (normal) distribution about the mean or whether there was a poisson (skewed) distribution about the mean (von fraunhofer & murray, 1976). to address the second aim of the study the result of each zulu speaking tbi subject was calculated and analysed descriptively. to address the third aim of the study the responses ofthe zulu speaking tbi subjects were compared to those of the zulu speaking nni subjects. percentile ranking was used for each of the zulu speaking tbi subjects. this analysis provided information as to each zulu speaking tbi subject's relative position in the normative sample (anastasi, 1982). finally, the results of the zulu speaking nni subjects were examined to look for 'patterns' of strategies within the responses. types of strategies that can be used are alphabetical or subordinate categories. however; these strategies may be language specific. when naming in the zulu language all words begin with vowel such as 'i'; 'u'; 'a'. thus to analyse the results in terms of the alphabet would not have been linguistically appropriate. likewise; the use of subordinate categories can be subject to the influence of culture. for example the category of food may be analysed in terms of food groups (vegetable, fruits, starches, meat etc.); meals (breakfast, lunch & supper); staple diet (the foods that are indigenous to the culture); and finally ceremonial foods (those foods that are eaten during important occasions). the subordinate categories used were analysed according to culture-specific organisation. where possible the responses were arranged into groups for each subject. these groupings by subject were analysed numerically and separated according to perceived 'use' or 'non-use' of subordinate categories. the mean number of words achieved by the two groups was calculated and compared to assess efficiency of the subordinate categories. 'efficiency of applying a strategy' was defined as the comparative degree to which those subjects utilising a strategy generated ahigher mean number of words than the subjects who did not use a strategy. results and discussion i results are discussed according to each aim of the stlldy. i words generated by zulu speaking nni subjects in total and over four fifteensecond time periods. table 2 depicts the results obtained on the vf tasks for the zulu speaking nni subjects. the mean number of words generated for the categories "animals" and "food" was similar (means of 11.52 .and 11.65 respectively) however, for the category of "transport", fewer words were generated (mean of 7.75). the results for the category of "transport" may be attributed to the fact that there are a limited number ofpossible~esponses for the category. when the standard deviation (sd) was cajculated as a percentage of the mean for the total words, the results within each category ~ere relatively similar across the groups of "animals", ·"food"· and "transport" (27.51 %; 28.87% and 26.61% respectively). this result may imply that the word gener-ation abilities that are being / the south african journal of communication disorders, vol. .46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) a pilot study of verbal fluency in the zulu speaking population with preliminary application to traumatic brain injury 7 used are working consistently across all three categories. overall, the number of words generated by the zulu speaking nni subjects of this study is much lower than the normative data currently being used (bayles & tomoeda, 1991; bayles & tomoeda, 1993; goodglass & kaplan, 1972). according to the normative data the norm for "animals" is 22.5 (sd=6.8) and for "transport" is 13.4 (sd=3.2). when compared with the mean for "animals" (11.53) and "transport" (7.78) obtained in this study, the large difference suggests that a test with linguistically appropriate norms would be more appropriate. in addition when comparing the results of the zulu speaking nni subjects to that of south african english speaking nni subjects obtained in a previous study (de picciotto, 1997) there was a sigriificant difference (p<o.oo 1) (table 2). tl)e zulu speaking nni subjects generated fewer words for the categories of "animals" than the south african english speaking nni subjects (means of 11.53 & 23.30 respectively). this inter-group difference was highly significant (t= -17.23, p<o.ool). the zulu speaking nni subjects generated fewer words for the categories of'transport' than the south african english speaking nni subjects (means of 11.65& 17.30 respectively). this intergroup difference was highly significant (t= -17.93, p<o.ool). no comparison could be made forthe category of "food", as this category was not used in the study of south african english speaking subjects. the four fifteen-second time periods for each task were analysed. across individual time periods, similar patterns were observed across all categories (table 2 & figure 1). the highest number of words was generated during the first time period across all categories. a decrease in the mean number of words generated over time was noted, as can be seen in table 2. this decrease in the number of words occurred most notably between the first and second time period. the slopes of the three graphs displayed in figure 1 are similar and it could imply a consistency across categories in the word generation ability of the subjects. the time periods of the zulu speaking nni subjects were also compared to the time periods of the south african english speaking nni subjects for "animals" and "transport" (table 2). for the category "animals" all time periods differed significantly although time period 4 was only significant at p<o.01. for the category "transport" all time periods differed significantly. the frequency distribution curves displayed in figure 2 approximate a normal distribution for all three categories which can not be deduced purely from an analysis of the standard deviations. a normal distribution indicates that the population behaved as a coherent whole. this normal distribution implies th~t any decisions that are made based on this normative data should be valid consistently across the zulu speaking population. words generated by tbi subjects in total and over four fifteen-second time periods. three tbi subjects were used in order to obtain an initial' indication of the performance of neurologically 'impaired cases that may be seen in the speech pathologists caseload. the results obtained from the vf tasks of the three tbi subjects are depicted in table 3. as can be seen from table 3; a subject who performed table 2: responses on each semantic verbal fluency task for zulu speaking and south african english speaking nni subjects (df=53) mean of zulu standard speaking nni deviation (sd) subjects of zulu / i speaking nni / i / subjects i animals 1 ~.575 1.448 animals 2 ~.775 . 1.265 animals 3 ~.825 1.217 animals 4 .1.250 1.565 total altimals' :h.525 3.170 food 1 5.825 1.981 food 2 2.825 1.299 food 3 1.675 1.265 food 4 1.100 1.257 total food 11.650 3.363 transportl 4.675 1.207 transport 2 2.100 1.128 transport 3 0.850 1.027 transport 4 0.150 0.427 total transport 7.775 2.069 key: 1-4 = first to fourth 15-second time period p<o.l p<o.ool sd % of mean 25.97 44.00 66.85 125.00 27.51 32.88 45.98 74.41 114.27 28.87 25.80 53.71 120.82 93.30 26.61 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 mean of south t values african english speaking nni subjects 9.60 -2.87'" 6.07 -4.32""" 4.40 -3.65"" 3.27 -1.77" : 23.3 -17.23·~ '. 8.33 -7.27" 3.53 -3.78". 3.13 -4'.89"" 2.40 -4.54"" 17.30 -17.93" r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 8 well on one category did not necessarily do so on the other categories. the subject who performed most consistently was subject #3. the number of words generated by all three subjects for all categories were well below the current norms. the number of words generated for "animals" and "food" is greater than for "t;ransport" except for subject number 1. this may be attributed to the fact that "transport" is a more difficult category with a limited number of possible responses. ideally it would have been valuable to compare performance over four time periods ofthe tbi subjects to the performance ofthe zulu speaking nni subjects. however, given the small number of tbi subjects this comparison was not possible. examination of the tel responses show a trend for most words to be generated in the first time period although this trend was not consistent for example, subject number 2 and subject number 3 for the category of "food". comparison of verbal fluency performance in zulu speaking nni & tbi subjects although no direct comparison between the two groups was possible, the results ofthis study are consistent with previous research on tasks of vf in tbi subjects (de picciotto, 1997; gruen et ai., 1990). table 3: responses on each semantic verbal fluency task for the three tbi subjects. tbi tbi tbi subject #1 subject #2 subject #3 animals i 2 2 2 animals 2 2 1 0 animals 3 1 1 1 animals 4 2 0 1 total animals 7 4 4 food i 3 4 0 food 2 0 1 0 food 3 1 3 1 food 4 0 0 3 total food 4 8 4 transport 1 2 2 2 transport 2 1 0 1 transport 3 1 0 0 transport 4 1 0 0 total transport 5 2 3 key: 1-4 = first to fourth 15-second time period table 4:an example of strategy use in semantic tasks of verbal fluency by zulu speaking nni subject # 20 for the categories ''food'' and ''transport''. food transport • staple: amazi,beans, pap, • daily: car, taxi, bus, train, cabbage, spinach, bread, wagon, lorry, bicycle rice • ceremonial : heart, brain, liver, tongue ... .. terri-leigh sperinck and janet de picciotto the tbi subjects generated considerably fewer words than the nni subjects. this pattern was also seen over the four time periods. based solely on this descriptive analysis the tbi subjects are not performing as well as the nni subjects. the performance of each tbi subject was so poor that their results did not reach the tenth percentile of the normative sample. strategy use of zulu speaking nni subjects versus tbi subjects the strategies were analysed descriptively according to subordinate categories. for the category "animals" the zulu speaking nni subjects appeared to use the subordinate categories of "wild animals"; "farm animals" and "domestic animals". the subjects appeared to make use of the subordinate categories "staple diet" and "ceremonial food" for the category of "food", although some of the subjects also made use of the category of "fruit". for the category of "transport" the nni subjects appeared to make use ofthe subordinate category of "daily transport". however, it should be noted that the above-mentioned strategies were all inferred, as the subjects were not required to describe each strategy. the zulu speaking nni subjects made use of strategies that were different from the expected strategies. for the category of "transport", instead of using subordinate strategies of "land", "sea" & "air" (de picciotto, 1997), the subject's first choice of the subordinate category could be called "daily transport". the south african english speaking subjects appeared to make use of a wider range of more specific subordinate categories such as for "land": "animal driven", "two wheel", "four wheel" and "recreational equipment"skateboard, rollerblades & rollerskates (de picciotto, 1997). the difference in subordinate categories used by the zulu speaking nni and the south african english speaking nni subjects could be attributed to the different backgrounds and experiences of the two groups. the category of "food?' in the zulu speaking nni subjects highlights this point in that they made use of subordinate categories of "staple food" and "ceremonial food" instead of possibly more expected subordinate categories of "fruit"; "vegetable"; "meat" and "starch". an example of this' pattern can be seen in table 4. i the tel subjects tended to use similar subordinate categories to those used by the zulu speaking nni fubjects. however, an analysis of the data indicated tha~ the tbi subjects were not using the strategies as efficiently as the zulu' speaking nni subjects. the tbi subjects generated fewer words in the subordinate categories than:the zulu speaking nni subjects. an example of this pattern can be seen in table 5. owing to the limited number of words generated by the tbi subjects inferred strategies were difficult to identify. once again it is necessary to re-iterate that owing to the small sample size inferences cannot be generalised to the broader tel population. general discussion the tbi subjects tended to generate fewer words than the zulu speaking nni subjects, which is.in agreement with the findings of crowe (1992);de picciotto (1997) and gruen et al. (1990). as with the zulu speaking nni subjects, the tel subjects generated the most words within /' the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) a pilot study of verbal fluency in the zulu speaking population with preliminary application to traumatic brain injury 9 the first time period and thereafter a decrease in the number of responses was observed. all three tbi subjects reported memory and attentional deficits as a result of their injury so perhaps the decrease in the number of responses may be attributed to these cognitive deficits (schmitter-edgecombe, 1996). . the results from the data ofthe zulu speaking nni subjects indicate a decrease in the number of responses across the four time periods, notably so between the first and the second time period. this finding concurs with adams et ai. (1989) who found that the most responses were generated by nni subjects during'the first time period. the zulu speaking nni subjects appeared to have made use of subordinate categorisation as a strategy for word generation but the use of'subcategories' varied. the majority of the subjects appeared to generate words in one category until they had exhausted their lexicon while the remaining subjects appeared to switch between 'sub-categories'. while the, tbi subjects appeared to have made use ofthe same subordinate categorical strategies as used by the zulu speaking nni subjects, the tbi subjects did not make use ofthem as efficiently as the zulu speaking nni subjects. this inefficiency of strategy use could be seen by the fewer words generated by the tbi subjects for each subordinate category. the same results were seen in a study conducted by gruen et ai. (1990). the results from the tbi subjects cannot be generalised to the larger tbi population owing to the small nature of the sample size. conclusion normative data were obtained with regard to the performance and use of strategies in zulu speaking nni subjects on semantic vf tasks. a further result of this study, that zulu speaking tbi subjects perform more poorly than zulu speaking nni subjects, concurred with previous studies (bprkowski et ai., 1967; crowe, 1992; de picciotto, )997; gruen et ai., 1990). a pattern of performance over four fifteen-sec6nd time periods was obi served for both groups with the tbi subjects performing more poorly thad the zulu speaking nni group. while the tbi subjkcts appeared to use simii lar strategies to the zul~ speaking nni subjects when generating words, the tbi subjects did not use the strategies as efficiently. finally, this study provided an indication of the-performance of zulu speaking tbi individuals. from the results obtained a number of clinical and theoretical implications can be drawn. the use ! , i • i • i ijs. key: t i patient's strengths and weaknesses that may in turn affect the therapy process, using assessment tools on patients for whom the tools have not been normed, may not provide the clinician with a true reflection of the patients' ability. while it may appear that tasks ofvf are not culturally biased, the choice of the semantic category may not be equivalent across all population groups. the use .of vf tasks may be of great benefit during diagnosis, assessment and intervention with different population groups on the ill 7 '" 5 6 ~ q. ~ 5 ............... o 4 -............. .8 3 § 2 --:... c ~ 1 .. :;; 0 t1 t2 t3 t4 time period ~ ~ 7 '" a 6 ~ q. ~ 5 ~ o 4 ~ .8 3 § 2 --c ~ 1 .. :;; 0 11 ~ t2 time period t3 t4 food ~ 7 .. a 6 q. e 5 ~ 0 4 ............. ~ 3 § 2 ............... c --~ 1 .. :;; 0 11 t2 time period t3 14 transport animals i til(ld i lran~p(jrt i = o 15 sec t2 = 16 30 sec t3 = 31 45 sec t4 = 46 60 sec .. of tests that have been appropriately normed can figure 1: mean number of responses of zulu speaking nni playa crucial role in the correct identification of a subjects plotted as a function of vf task and time period. table 5: an example of strategy use in semantic tasks of verbal fluency by tbi and zulu speaking nni subjects. strategy tbi subject # 2 nni subject # 21 organise words into subordinate • domestic: dog / cat • farm: cow / goat / chicken / sheep categories • farm: cow • wild: lion / leopard, / snake / crocodile • wild: baboon / elephant / porcupine/ . i • domestic: dog / cat hare / squirrel/jackal/owl / buffalo die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 10 proviso that the categories assessed are culturally and linguistically appropriate. if tbi individuals are using the same word generation strategies as the nni individuals, the clinician may be better able to assist the tbi individual in maximising the use of compensatory strategies. it is important to bear culture in mind when teaching compensatory strategies, as different cultures may make use of different strategies. as clinicians we have to be sensitive to these subtle differences. a number of research implications emerged from this study. while the results obtained in this study provide initial normative data for the zulu speaking population it is essential to replicate this study in order to gather additional support for these findings. this study has highlighted that vf tasks are not free from cultural bias in terms ofthe semantic categories that may be utilised. thus it is important to determine which semantic categories are most culturally appropriate for 36 33 30 £! 27 ~ 24 d 21 " 18 ~ 15 o 12 f!.. 9 6 3 0 3-5 6-8 9-11 12 -14 15 -11 1820 total words animals 36 33 30 £! 27 ~ ~~ " 18 :. 15 o 12 f!.. 9 6 3 0 3-5 6-8 9-11 12 -14 15 -11 18 20 total words food 36 33 30 j!! 27 ~ ~~ " 18 :. 15 o 12 f!.. 9 6 3 0 3-4 5-6 7-8 9 -10 11 -12 total words transport • anim.ds • ftji)(j .t. iransp{lrt terri-leigh sperinck and janet de picciotto specific population groups. a study making use of a large group of tbi subjects is necessary owing to the fact that the results obtained from this study cannot be generalised to the broader tbi population because of the nature of the sample size. further investigation into this population group would be imperative to the clinician owing to the ever-increasing number oftbi individuals seen on our caseload, given the discrepancy between the normative group in this study and the norms currently being used, the need for research in the african languages is essential if we, as clinicians, are to provide all our clients with appropriate assessment and intervention. in conclusion, south mrica, with its multilingual and multicultural population, needs normative data for assessment materials for language groups other than english. this study presents initial normative data for semantic vf tasks for the zulu speaking population. as clinicians and researchers in south mrica, we need to be aware of the effects of tests and therapy methods which are not always appropriate for the different cultures and languages with whom we are required to work. ifthese tests can be administered in the client's language and compared with appropriate normative data, the clinician may obtain a clearer understanding of their clients' true abilities and thus better assist them in the therapy process. references adams, m.l., reich, a.r., & flowers, c.r. 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(1991). epidemiology of traumatic brain injury in johannesburg-i. methodological issues in a developing country context. social science and medicine, 33 (3), 283-287. brown, d.s. & nel, v. (1991). epidemiology of traumatic brain injury in johannesburg-ii. morbidity, mortality and etiology. social science and medicine, 33 (3), 289296. cardebat, d., demonet, j .f., viallard, g., faure, s., puel, m., & celsis, p. (1996). brain function profiles 'in formal and semantic fluency tasks: a spect study in normals. brain and language, 52; 305-313. cauthen, n.r. (1978). verbal fluency: normative data. journal of clinical psychology, 34 (1), 126"129 . central statistical services (1998). census ,october 1996. south africa. figure 2: percentage of zulu speaking nni subjects plotted as a function of vf task and total number of word~. crowe, s.f. (1992). dissociation of two frontal lobe syndromes by a test of verbal fluency. journal of clinical and experimental neuropsychology, 14 (2), 327-339. ' de picciotto, j. (1997). verbal fluency: an indicator of mild / the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) a pilot study of verbal fluency in the zulu speaking population with preliminary application to traumatic brain injury 11 traumatic brain injury. m.a. speech pathology, university of the witwatersrand, johannesburg estes, w.k. (1974). learning theory and intelligence. american psychologist, 26, 740-749. gillis, r. (1996). traumatic brain injury: rehabilitation for speechlanguage pathologists. boston: butterworth-heinemann. goodglass, h., & kaplan, e.f. (1972). boston diagnostic aphasia examination. philadelphia: lea & febiger. gruen, a.; frankie, b., & schwartz, r. 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(1986). cultural and linguistic groups in the united states. in o. talyor (ed,). nature of communication disorders in culturally and linguistically diverse populations. california: college-hill press. ponsford, j. (1995). mechanisms, recovery, and sequelae of traumatic brain injury. in j. ponsford, s. sloan & p. snow (ed.), traumatic brain injury: rehabilitation for everyday adaptive living. hove: lawrence erlbaum associates. rosser, a., & hodges, j.r. (1994). initial letter and semantic category fluency in alzheimer's disease, huntington's disease, and progressive supranuclear palsy. journal of neurology, neurosurgery and psychiatry, 57,1389-1394. schmitter·edgecombe, m. (1996). effects of traumatic brain injury on cognitive performance: an attentional resource hypothesis in search of data. journal of head trauma rehabilitation, 11 (2),17·30. suzman, s. (1996). personal communication. linguistics department. johannesburg: university of witwatersrand. van ede, d.m. (1996). how to adapt a measuring instrument for use with various culture groups: a practical step-by-step introduction. south african journal of higher education, 10 (2), 153-160. vaughn.cooke, f.b. (1986). clinical principles for language intervention for language disorders among nonstandard speakers of english. in o. taylor (ed.). treatment of communication disorders in culturally and linguistically diverse populations. californfa: college·hiii press. von fraunhofer, j.a. & murray, j.j. (1976). statistics in medical, dental and biological studies. london: tri-med books. watt, n., penn, c. & jones, d. (1996). speech-language evaluation of closed head injured subjects in south africa: cultural applicability and ecological validity of a test battery. the south african journal of communication disorders, 43, 85-92. die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) abstract introduction methods results discussion conclusions acknowledgements references about the author(s) amisha kanji department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation kanji, a. (2022). newborn and infant hearing screening at primary healthcare clinics in south africa designated as national health insurance pilot sites: an exploratory study. south african journal of communication disorders, 69(1), a840. https://doi.org/10.4102/sajcd.v69i1.840 original research newborn and infant hearing screening at primary healthcare clinics in south africa designated as national health insurance pilot sites: an exploratory study amisha kanji received: 07 may 2021; accepted: 18 oct. 2021; published: 26 jan. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: primary healthcare (phc) is the first point of entry, providing basic services to individuals. south africa is in the process of re-engineering its phc as part of national health insurance (nhi) plans to ensure universal healthcare coverage. aim: this study aimed to establish whether newborn and infant hearing screening (nihs) could be integrated into the re-engineering process of the phc as part of the nhi framework. setting: the nhi pilot clinics in five provinces in south africa. methods: a non-experimental, descriptive, cross-sectional survey research design was adopted. questionnaires were sent to nursing managers, unit managers or acting managers at phc facilities. nineteen of these self-administered questionnaires were completed. data were analysed using descriptive statistics. results: immunisation services were the most common type of service offered at the clinics. over a quarter of the respondents indicated that nihs services were offered at their facility in the form of universal nihs. equipment was limited with a lack of valid and reliable screening measures. only 2 (11%) respondents indicated budgetary resources. follow-up and referral pathways were reported by 10 (53%) respondents, which did not include an audiologist. conclusions: there is a need for careful and systematic planning in terms of early hearing detection programmes at phc level. planning needs to commence with considerations of who will perform nihs, training of these personnel by audiologists and the role of the audiologist within the teams outlined in the nhi bill. keywords: newborn hearing screening; integration; primary healthcare; national health insurance; south africa. introduction healthcare in south africa comprises both public and private sectors. this two-tiered system is considered intricate, with an additional, hierarchical structure within the public healthcare sector. this hierarchical structure in the public sector requires that advanced levels of care may only be accessible following assessment and referral from the respective lower levels, and is based on the implemented primary healthcare (phc) approach (cullinan, 2006; mahlathi & dlamini, 2015). primary healthcare is the first level of care and entry for individuals into the healthcare system, which is accessible at phc clinics and community health centres (chcs). the services at these healthcare facilities include maternal and child care, immunisations, family planning and care for chronic illnesses, usually managed by nurses with advisory support and regular visits by medical practitioners and other relevant healthcare specialists (bresick, von pressentin, & mash, 2019; cullinan, 2006). such services can more broadly be categorised as preventative, promotional, curative and rehabilitative in nature (cullinan, 2006; schellack, meyer, gous, & winters, 2011). an earlier review of the quality of services was conducted at 16 clinics in johannesburg. poor quality child health services for children who are ill was observed in relation to waiting periods, staff skills, triage and promotional, prevention and curative care. this was further accompanied by insufficient developmental assessment (thandrayen & saloojee, 2010). of the 16 clinics, inconsistency was noticed in terms of immunisation and rehabilitation in 14 and 5 clinics, respectively. the integrated management of childhood illnesses (imci) approach was only utilised in 3 clinics, despite 12 having had an imci-trained professional. these findings by thandrayen and saloojee (2010), although not the most recent, serve as important considerations when deciding on an appropriate and feasible model for early detection of hearing loss, particularly in phc contexts. as phc sites provide an extensive package of basic services, which includes maternal and child health, newborn and infant hearing screening (nihs) can be argued to fall within this service. early identification of hearing loss involves nihs using various objective screening measures such as otoacoustic emissions or automated auditory brainstem response and is a beneficial preventive strategy that forms part of early hearing detection and intervention (ehdi). the ehdi guidelines of the health professions council of south africa (hpcsa) (2018) highlight six principles as the foundation to effective ehdi systems in south africa. these principles include (1) access to hearing screening using physiological measures, including phc clinics and midwife obstetric units (mous) as possible contexts for access to these services in order to ensure screening by 1 month of age, (2) access to an effective referral system to ensure prompt diagnosis of hearing loss by 3 months or 4 months if nihs is aligned to immunisation visits at phc facilities and (3) access to intervention services following diagnosis of hearing loss before 6 months or 8 months of age for infants who were enrolled in nihs programmes aligned with immunisation visits at phc facilities (hpcsa, 2018). the phc clinics have been suggested as a setting for nihs by the hpcsa with the justification that this level of care allows a larger reach, resulting in increased coverage of screened infants and a higher attendance at follow-up appointments (hpcsa, 2007, 2018; swanepoel, hugo, & louw, 2006). khoza-shangase and harbinson (2015) also proposed the incorporation of the mou 3-day assessment clinic as a nihs platform in order to ensure improved coverage rates. although an earlier pilot study conducted at two immunisation clinics indicated the potential implementation of hearing screening at these sites with a good coverage rate and collaborative nursing personnel in most instances, there were a number of documented barriers to successful implementation (swanepoel et al., 2006). more recently (in 2016), community-based nihs programmes have been initiated within the phc platform of the western cape. hearing screening was administered by trained nurses using a two-stage distortion product otoacoustic emission protocol at maternal and child health care clinics over a period of 19 months (de kock, swanepoel, & hall, 2016). the return rate for follow-up appointments was generally good but differed between clinics. however, coverage rates (32.4%) were poor across clinics and did not meet the criteria specified by the key benchmarks in the hpcsa (2007) ehdi position statement (friderichs, swanepoel, & hall, 2012). although not specifically investigated, the authors acknowledge that findings may have been affected by the high staff turnover at some clinics and the use of nursing staff as screeners who experienced difficulty including screening as part of their other regular priority tasks (friderichs et al., 2012). although this study utilised trained nursing staff, it lacked information about the existing resources and whether or not the setting is ready for the provision of these services. such information is necessary in order to facilitate planning for sustainable service provision. another study conducted at mous reported good follow-up return rates (de kock et al., 2016). these studies have been based on measuring the outcomes in relation to specific key indicators such as coverage rates, follow-up return rates and referral rates. however, there has been limited research into whether phc clinics are actually equipped and ready to take on nihs considering the proposed national health insurance (nhi) framework with a particular focus on dealing with infants at risk for hearing loss – who may require more prompt services. other studies related to the provision of nihs have been conducted at immunisation clinics in north west and gauteng (petrocchi-bartal & khoza-shangase, 2014a, 2016). information gathered through interviews with nursing staff highlighted that clinic managers were eager to have hearing screening incorporated into their workload provided that specific barriers related to aspects such as budget and equipment resources were addressed (petrocchi-bartal & khoza-shangase, 2014a, 2016). the availability of current resources needs to be carefully considered within the context of each province before implementing nihs programmes nationally, particularly in view of phc re-engineering within the proposed nhi framework. a study exploring the perception of professional nurses in the private sector with regard to nhi was mixed. whilst nurses acknowledged the purpose of the nhi, there were concerns regarding the current shortage of personnel, inadequate resources and a lack of stakeholder engagement and transparency with regard to implementation (molokomme, seekoe, & goon, 2018). similarly, general practitioners at one of the tshwane district pilot sites expressed frustration at the lack of infrastructure and equipment (surender, van niekerk, & alfers, 2016). the lack of communication and exclusion in nhi policy formulation was also expressed in recent findings from in-depth interviews with public service managers in the johannesburg health district (murphy & moosa, 2021). the re-engineering of phc services will centre around community-based outreach and home-based service provision aimed at promotion, prevention and quality curative and rehabilitative services (doh, 2011). according to the recent nhi bill, these services will be provided through various means, namely district clinical specialist teams, integrated school health services, municipal ward-based phc outreach teams and contracting of private healthcare professionals at a non-specialist level (doh, 2015, 2019). the municipal ward-based phc outreach teams will provide services within specified areas, led by a nurse associated with a phc facility (doh, 2011, 2015; naidoo, 2012). these teams will foster community engagement in terms of the detection of health problems associated with the risk for disease and need of preventative, curative and rehabilitative services. health promotion education is also another role that will be played by these teams (doh, 2011, 2015; naidoo, 2012). based on the assessments during home visits, community healthcare workers would need to make appropriate referrals to a phc facility. hence, the role of the phc nurse is important to the early identification of hearing loss in newborns or infants. piloting of the nhi suggests the need to explore nihs programmes within this proposed healthcare funding model. prior to the actual implementation of such programmes, it is important to gather the necessary information to determine the preparedness and readiness of this level of healthcare for provision of nihs services. according to myezwa and van niekerk (2013) each medical profession, including rehabilitation professionals need to assess their service delivery in terms of quality, financial allocation of resources and personnel, and their response to the burden of disease. gathering information related to the availability of services and resources at the defined nhi phc pilot clinics will assist in the planning and clinical implementation phases of nihs programmes at phc level within the proposed nhi framework. this is particularly important considering that insufficient planning, resource shortages, inconsistent communication and inadequate coordination were factors that hindered the success of nhi phase 1 implementation within pilot districts (genesis, pwc, chp, & insight, 2019). this study aimed to describe the current resources available for nihs for future nhi implementation by (1) describing the services offered for early detection of hearing loss in newborns and infants, (2) determining the resources available for nihs, (3) describing the protocols and procedures for screening of well babies and high-risk newborns and infants and (4) describing the follow-up and referral pathways. methods study design a non-experimental, descriptive, cross-sectional survey research design was adopted. setting the study comprised seven nhi pilot phc clinics in five provinces in south africa from which permission was obtained. within these five provinces, seven phc clinics have been listed as designated nhi sites in the north west province, five are designated nhi sites in the northern cape, six in mpumalanga, six in limpopo and eight in the eastern cape. sampling and sample the study used a non-probability, purposive sampling strategy. participants comprised nursing staff who are unit managers, clinic managers and acting managers at various phc facilities in south africa, particularly those facilities within the nhi pilot districts. data collection a questionnaire was sent to nursing managers, unit managers or acting managers at various phc facilities in south africa, particularly those phc facilities that fall within the pilot districts for nhi. the questionnaire comprised 23 closed-ended and 7 open-ended questions related to services offered for early detection of hearing loss in newborns and infants, resources available for newborn hearing screening, protocols and procedures for screening of well babies and high-risk newborns and infants, as well as follow-up and referral pathways. the questionnaire was adapted from other similar studies (khoza-shangase, kanji, & ismail, 2021; petrocchi-bartal & khoza-shangase, 2016). questionnaires were either distributed electronically or via courier, depending on the preferred method of dissemination communicated by each of the facilities. approximately 25 questionnaires were sent via courier services and 6 were sent electronically. reminders were sent in an effort to improve the response rate. data analysis data were analysed using descriptive statistics. ethical considerations ethical clearance (reference number: m170859) was obtained from the university’s medical ethics committee. permission to conduct the study in various provinces was obtained through application on the national health research database (nhrd). of the nine provinces, five provided permission via the nhrd. of the nine provinces, permission was obtained from district managers in five provinces, namely mpumalanga, north west, northern cape, limpopo and eastern cape, where the nhi sites were located. informed consent was obtained from all the participants or respondents. anonymity was ensured through the exclusion of personal details from the questionnaire and was further ensured via email correspondence, by sending it to the clinic administrator’s email address. results a total of 7 of the available 32 nhi pilot clinics (from two of the five provinces) responded to the invitation to be part of the research study, resulting in a 22% response rate. a total of 19 questionnaires were completed and returned via courier delivery. reasons for non-consent to participation included the clinic manager being unavailable, no answer despite repeated calls or staff previously contacted no longer working at the site and electronic network challenges in specific areas. of the 19 respondents, all but 4 (79%) were professional nursing staff. of these four respondents, one was a medical officer, one an ear nose and throat (ent) specialist and two were operational managers. a total of 14 respondents (74%) indicated the number of years of experience in their profession. this provided a mean of 11 years, with a minimum of 1 year of experience, a maximum of 30 years of experience and a range of 29 years. of the 17 responses, the average number of babies seen per month ranged from 24 to 960 (see table 1). table 1: average number of babies seen at the primary healthcare clinics designated as national health insurance sites. in terms of the types of services offered at the phc facility, most respondents across all clinics, with the exception of clinic d indicated immunisation services (n = 18; 95%), followed by post-natal care (n = 16; 84%) and antenatal care (n = 15; 79%). a total of 10 respondents (53%) indicated that screening for developmental delay is offered at the phc facility at which they are employed, whereas services such as delivery of low-risk neonates and screening for visual and hearing impairment were only reported by 6 (32%) and 5 respondents (26%), respectively (see figure 1). the six respondents were from clinics a, b and f, and the five respondents were from clinics a, b, f and g. figure 1: types of services offered at primary healthcare facilities. with regard to early detection of hearing loss in newborns and infants, 7 respondents (37%) from clinics a, b, f and g indicated that hearing screening services have been provided at their facility. in terms of the number of years that these services have been offered, two respondents indicated a period of more than 2 years, one indicated it being offered for more than 1 year, two for less than 6 months, one for less than a month and one respondent reported that these services were offered by the speech therapist who visited the site monthly but that there have been no services since 2018 as a result of no appointment of a therapist. a total of 5 respondents (26%) from clinics a, f and g indicated these services to be in the form of universal newborn and infant hearing screening (unihs), whereas 3 respondents (16%) indicated screening based on parental or caregiver concern. one respondent from clinic a indicated a combination of unihs, risk-based nihs and screening based on parental or caregiver concern. in terms of equipment resources, only 2 respondents (11%) from clinics d and f indicated having an otoscope at their facility. the remaining respondents did not indicate having any equipment with one of these respondents mentioning conducting screening through communicating with the mother and baby and observing responses, whilst two other respondents mentioned using the imci protocols as a guide for screening. with regard to staffing or human resources, 13 respondents (68%) provided information related to the number of nursing staff at their phc facility. these numbers ranged from a minimum of 2 to a maximum of 15. only 2 (11%) of these respondents (from clinics f and g) indicated having been trained to conduct nihs. in terms of financial resources, only 2 respondents (11%), both from clinic f in the north west province indicated having a budget for nihs but indicated that this budgetary amount is unknown. when asked about the measures used to screen for hearing loss in low-risk or well babies, 2 respondents (11%) from clinics d and f indicated using an otoscope, whilst another two from clinics f and g mentioned the use of imci protocols for infants between 1 and 3 months of age. with regard to high-risk babies, more (n = 11; 58%) respondents indicated making use of the imci protocols to identify risk factors associated with hearing loss. a total of 2 respondents (11%) from clinic a indicated that should infants be suspected to be at risk of hearing loss they would request a rescreening through referral to another phc facility. a total of 3 respondents (16%) from clinics d and f indicated that they would refer for a diagnostic assessment, with one of these respondents (from clinic d) specifying this to be in the form of referral to an ent. a further 7 (37%) respondents from clinics a, e, f and g indicated ensuring caregiver education in this regard. more specifically, in terms of follow-up and referral pathways for infants suspected to have hearing loss, 2 respondents (11%) from clinic f indicated booking follow-up appointments at the same phc facility, 3 (16%) from clinics a and d indicated booking a follow-up at the nearest healthcare facility with a doctor, 5 (26%) from clinics d, e, f and g indicated referring to a healthcare facility with an ent and 1 (5%) from clinic b to a nearest tertiary hospital. options related to referral or follow-up at a healthcare facility with audiological services or to the next level of healthcare (i.e. district level) were not options considered by respondents. discussion this study aimed to establish whether nihs could be integrated into the phc re-engineering process as part of the nhi. this study’s findings are positioned in phases 1 and 2 of the nhi implementation plan. these phases have been planned to include piloting of different interventions in preparation for complete implementation of nhi, such as infrastructure and work streams, as well as the development and amendment to nhi and related legislation (genesis et al., 2019). despite these phases, healthcare professionals have expressed their concerns regarding the implementation of nhi. findings from a recent survey study representative of 30 medical professions (including audiologists) indicated that they do not believe that the nhi will assist in improving service delivery and proposed that the healthcare system would need to be restored (welthagen, 2019). survey respondents in this study primarily comprised professional nursing staff, followed by operational managers and medical doctors. nurses are the largest category of healthcare workers in south africa (who, 2017). staffing models related to the phc re-engineering in south africa have suggested that all clinics should have a professional nurse to manage the facility (daviaud & subedar, 2012). nurses form the backbone of phc in south africa and are made up of three cadres, namely professional nurses requiring 4 years of training, enrolled nurses requiring 2 years of training and nursing assistants requiring 1 year of training (who, 2017). the average number of years of experience of respondents is lower than other studies involving professional nursing staff. findings from a recent study by muthathi, levin and rispel (2020) indicated the mean number of years of experience as 22 and 28 years in phc clinics in mpumalanga and gauteng, respectively. although direct comparison cannot be made to this study’s findings because of the inclusion of different provinces, findings suggest varying years of experience between and within provinces in south africa. despite the development of staffing models over the years, there are as yet no agreed national human resource norms for phc in south africa (who, 2017). this has implications for resourcing, service delivery and planning and ensuring appropriate staff:patient ratios. as discussed previously, phc facilities have been proposed as a platform for nihs (hpcsa, 2007, 2018; swanepoel et al., 2006), with the argument that this could facilitate coverage rate, particularly as phc includes immunisations and post-natal care, as reported by respondents in this study. despite this argument, only five respondents in this study indicated the inclusion of screening for hearing impairment of low-risk neonates or infants. when asked specifically about early detection of hearing impairment in newborns and infants, less than half of the respondents indicated recent implementation of hearing screening services, with varied responses within the same clinic. although unihs was reported by some respondents in this study, implementation of these services is questionable; particularly as information pertaining to resources was suggestive of limited to no availability of appropriate hearing screening equipment. this has significant implications for the provision of valid and reliable nihs and appropriate referral. the findings of this study are consistent with other studies conducted at phc facilities in south africa. a study conducted by petrocchi-bartal and khoza-shangase (2014b) with phc nurses at immunisation clinics in the northwest and gauteng provinces revealed no formalised nihs programmes, with cited key concerns related to limited training, budgetary, human resource and equipment constraints. similar findings were reported by phc nurses in kwazulu-natal. a total of 35 of the 75 nurses indicated the availability of otoscopes in comparison to 3 indicating the availability of a pure tone audiometer and tympanometer (khan, joseph, & adhikari, 2018). this suggests the lack of, and an under-preparedness for, formalised nihs at phc facilities in south africa, which may be attributed to the reported human resource and budgetary constraints. the nhi bill (republic of south africa, 2019) suggests the implementation of municipal ward-based teams, which include community healthcare workers. these community healthcare workers could be trained to facilitate nihs service delivery at the primary healthcare level and ensure appropriate referral to higher levels of care. this shifting of tasks could also be a possible solution to addressing human resource constraints. audiologists would need to be considered as part of the team in order to ensure efficient and effective management of such programmes. this is particularly important, as current procedures and protocols used at phc facilities are inadequate for the early identification of hearing impairment (khan et al., 2018). respondents in this study reported the use of observational responses to speech as a screening method and the use of the imci protocol as a screening guideline and to identify infants at risk for hearing impairment. behavioural observation is no longer recommended in international guidelines as it is not a conditioned response and therefore does not yield reliable and valid information regarding hearing sensitivity (jcih, 2019). the imci aims to decrease mortality, illness and disability and promote improved growth and development amongst children under 5 years of age (who, 2020). with regard to hearing, the imci protocol’s primary focus is on the detection of otitis media using questions, visual inspection and touch (doh, 2019). although otitis media is a risk factor for hearing impairment, there are other factors specified by the hpcsa (2018) ehdi guidelines that increase the risk of hearing impairment in newborns and infants. the use of the imici protocol has been reported in previous literature, along with the voice test (khan et al., 2018; petrocchi-bartal & khoza-shangase, 2014b), all of which are subjective measures with notable limitations in terms of validity. with regard to follow-up and referral pathways for infants suspected to be at risk for hearing loss, a few respondents indicated referral to an ent or nearest healthcare facility with a medical doctor, whilst seven mentioned caregiver education. similar responses were noted in the study by khan et al. (2018), whereby phc nurses reported referrals to various health professionals, including ent specialists and general practitioners and indicated provision of information about the importance of ehdi to parents or caregivers. however, contrary to this study’s findings, phc nurses indicated referral to audiologists and paediatricians and specified referral to higher levels of care at the district hospital or clinic and paediatricians. whilst referrals to healthcare professionals, particularly ent specialists, are relevant, appropriate referral pathways are vital and need to be streamlined to ensure timely screening and diagnosis and to ensure continuity of care. mukudu, otwombe, moloto, fusheini and igumbor (2021) compared self-referrals and headcounts at outpatient departments before and after the contracting of medical practitioners between pilot and non-pilot nhi districts. findings indicated an increase in self-referrals and headcounts, resulting in a perceived improvement in quality care. however, structures need to be improved to ensure coordination between phc and district level hospitals, by improving down-referral and the supervision of the phc team by clinical specialists, which would further assist with the shortage of medical professionals. budgetary constraints and a lack of control over allocated funds have been reported by phc managers in a recent study (muthathi et al., 2020). some facility managers reported a lack of transparency in terms of budget, whilst others reported to have no authority in decision making for the allocation of funds and provision of equipment. similarly, two respondents in this study reported not knowing how much had been allocated to nihs at their clinic. this has implications for resource allocation and the purchase of audiological screening equipment necessary for nihs service delivery. conclusions results of this study indicate limited to no implementation of nihs at phc nhi pilot sites. the availability of equipment and appropriate procedures and protocols is inconsistent despite government’s drive towards phc re-engineering. similarly, referral and follow-up practices for hearing screening are inconsistent, which impacts the continuity of care that is necessary for ehdi. there is a need for careful and systematic planning in terms of early hearing detection programmes at phc level in order to ensure the provision of successful, streamlined services. this planning needs to commence with considerations of by whom nihs will be performed, the training of these personnel by audiologists and the role of the audiologist within the teams outlined in the nhi bill. as a result of the small sample size in this study and the poor response rate, findings cannot be generalised. future research should be conducted on a larger sample size and should explore aspects related to governance, attitudes, infrastructure development and information systems. acknowledgements the author would like to thank all participants for their contribution to this study. competing interests the author declares that she has no financial or personal relationships that may have inappropriately influenced her in writing this article. author’s contributions a.k. declares that she is the sole author of this article. funding information this work was supported by the andrew w mellon foundation. data availability data is available only on request due to privacy and ethical restrictions. disclaimer the views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any affiliated agency of the author. references bresick, g., von pressentin, k.b., & mash, r. 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(2006). infant hearing screening at immunization clinics in south africa. international journal of pediatric otorhinolaryngology, 70(6), 1241–1249. https://doi.org/10.1016/j.ijporl.2006.01.002 thandrayen, k., & saloojee, h. (2010). quality of care offered to children attending primary health clinics in johannesburg. south african journal of child health, 4(3), 73–77. welthagen, n. (2019). healthcare workers’ knowledge of, insight into and opinion of the proposed national health insurance. pretoria. retrieved from https://gildes.solidariteit.co.za/wp-content/uploads/sites/23/2019/10/2019-10-30_ngv-verslag-07-okt-2019-n-welthagen_eng-2.pdf who. (2017). primary health care systems (primasys): case study from south africa. retrieved from https://www.who.int/alliance-hpsr/projects/alliancehpsr_southafricaprimasys.pdf?ua=1 who. (2020). maternal, newborn, child and adolescent health: integrated management of childhood iillness (imci). retrieved from https://www.who.int/maternal_child_adolescent/topics/child/imci/en/ sajcd 233 hearing-screening record-keeping practices at primary healthcare clinics in gauteng karin joubert,1 phd; aisha casoojee,2 ma (audiology) 1 department of speech pathology and audiology, university of the witwatersrand, johannesburg, south africa 2 private practice, johannesburg, south africa corresponding author: a casoojee (aisha.casoojee@gmail.com) objectives. as little is known about hearing screening practices at primary healthcare (phc) clinics in south africa, the study aimed to describe hearing-screening and record-keeping practices of nurses during typical immunisation sessions at phc clinics in gauteng, south africa. methods. data were obtained through observations (n 2=80) and questionnaires (n 1=20) which were then cross-checked with retrospective information collected from the road-to-health charts and city of johannesburg child health services blue cards of children observed during typical immunisation sessions. results. a key finding of this study was that phc nurses who participated in this study do not adhere to the hearing-screening record-keeping practices as outlined by the national department of health. conclusions. poor record-keeping practices hinder the efficacy of hearing-screening programmes. accurate record keeping is important in order to document outcomes which can be used to evaluate service delivery and the efficacy of hearing-screening programmes. keywords: hearing screening, primary healthcare, record keeping, nurses s afr j cd 2013;60:27-30. doi:10.7196/sajcd.233 early hearing detection and intervention (ehdi) generally constitute programmes aimed at identifying hearing impairment in infants as early as possible. the health professions council of south africa (hpcsa) proposed universal newborn hearing screening (unhs) as part of ehdi in south africa as an integrated part of primary, secondary and tertiary levels of healthcare (hpcsa, 2007). these guidelines proposed that screening be conducted as soon as possible after birth but before 3 months of age, diagnosis made by 4 months of age and intervention started before 8 months of age (hpcsa, 2007). despite these guidelines, it is evident that ehdi in south africa has yet to achieve these targets. this is mainly due to the prevailing adverse health and socio-economic conditions and restricted resources (swanepoel, störbeck & friedland, 2009; venter & viljoen, 2008; van der spuy & pottas, 2008). health priorities in south africa are mainly focused on the hiv/aids pandemic as opposed to individuals with hearing loss (swanepoel, hugo & louw, 2006). the average age of diagnosis of hearing impairment in gauteng, south africa, is 31 months, the average age of initial hearing aid fitting is 39 months, and the average age is 43 months for enrolment into an early intervention programme (venter & viljoen, 2008). similar findings were reported for a larger-scale study conducted in the western cape, where the mean age of initial hearing aid fitting was reported as 28 months, and 31 months for the enrolment into an early intervention programme (van der spuy & pottas, 2008). it is therefore evident that screening alone cannot ensure that a child with a hearing impairment will be identified early. it has been found that a co-ordinated flow of activities that involves efficient tracking, reporting, and follow-up of children identified with hearing impairment will facilitate early identification and intervention (ncham, 2012). the implementation of tracking systems that allow for effective follow-up and referral systems will, however, ensure that those infants at risk of a hearing impairment are provided with appropriate services within the critical period for language development (swanepoel et al., 2009). an integrated information system to manage data within each district health system in south africa is recommended by the hpcsa (2007). although a secure and comprehensive centralised database is required, south african ehdi programmes currently utilise manual reports to drive programme evaluation efforts. with almost 90% of south african children fully immunised by the age of 1 year, it is recommended that infant hearing screening should be performed at immunisation clinics within the current primary healthcare (phc) structures (day, barron, monticelli & sello, 2010; swanepoel et al., 2006). within the south african healthcare sector, phc nurses, who see the child most often, have the opportunity of monitoring auditory development of these children. the phc package (doh, 2002) stipulates that hearing screening should be conducted by phc nurses using two hearing screening methods, the swart questionnaire (swart, 1996) and the voice test (pirozzo, 2003). the swart questionnaire comprises a series of questions to be asked for two different age groups (3 months and 6 months) in order to obtain information on the development of sound awareness in infants (swart, 1996). the voice test is conducted on children from 12 months onward and is viewed as a simple yet accurate test of hearing impairment (pirozzo, 2003). with the voice test the child is required either to repeat what is said or follow a simple one-part instruction in response to the nurse talking from behind the baby at an arm’s length away (doh, 2005). guidelines stipulate that phc nurses record the results of the hearing screening conducted during a typical immunisation session on the road-to-health chart (rthc) and the city of johannesburg (coj) child health services blue card. the rthc is a record of a child’s health and development which remains in the possession of parents/caregivers. this card should be presented to the phc nurse or health worker at every visit to the phc clinic or other healthcare facility (swart, 1996). the rationale for recording the details of a child’s progress on the rthc is to encourage a partnership between the health professional and parents/caregivers, promote effective decision making and to establish continuity of care (swart, 1996). the same information is essentially recorded on the coj child health services blue card, but is retained by the clinic. both records include four sections, namely developmental, family, obstetric and pregnancy history. it includes space for recording immunisations, nursing care plans, child development and growth plotting. the child development chart guides the nurses to assess age-appropriate milestones (including hearing and speech) (thandrayen, 2008). the rthc and coj child health services blue cards provide an opportunity to facilitate a national information system that meets the requirements for hearing-screening record keeping, as recommended in the hpcsa (2007) position statement. these cards serve as means of record keeping for phc clinics until such time as a national electronic information infrastructure is developed for the management of ehdi programmes which could provide data for audit and future service development decisions. it is, however, important for these records to provide accurate information that could assist in predicting the incidence of hearing impairment (traynor, 2011). methods objective the aims of the study were to describe the hearing-screening and record-keeping practices of nurses during typical immunisation sessions at phc clinics in gauteng, south africa. study design a descriptive, survey research design was implemented for the purposes of the study. data were obtained through observations and questionnaires which were then cross-checked with retrospective information collected from the rthcs and coj child health services blue cards. participants probability, simple random sampling was used to select the 20 phc clinics in the coj metropolitan council included in the study. the participants comprised two groups: • participant group 1: nurses. twenty nurses (n 1=20) employed at the selected phc clinics were included in the study. they were required to be registered as a professional nurse or an enrolled nursing auxiliary as these are the categories of nurses who conduct immunisations at phc clinics. they were further required to perform immunisations within their work contexts. on average participants had been qualified for 13.8 years (range: 1 40 years; standard deviation (sd) 11.41). they had worked as phc nurses for an average of 4.97 years (range: 0.6 24 years; sd 5.82). • participant group 2: child patients. this participant group included the children (n 2=80) who were attended to by the nurses in participant group 1. four immunisation sessions were observed for each of the nurses. a retrospective review of the rthc and coj child health services blue cards records was conducted for each child. the average age of the children was 20.06 months (range: 6 62 months; sd 16.14). thirty-five per cent (n2=28) of the children in the sample were in the age group 6 – 11 months old, 37.6% (n2=30) were aged 12 – 23 months old and 27.5% (n2=22) were between 24 months and 6 years of age. materials three data collection tools (available on request) were developed for the purpose of the study: (i) nurses’ observation form; (ii) nurses’ questionnaire; and (iii) the retrospective data compilation sheet. the nurses’ observation form was developed for use during the observation of immunisation sessions performed by the nurse participants. the form consisted of 40 items in eight categories and aimed to identify the implementation of and adherence to protocols in a typical immunisation session, as well as to obtain information on how patient-specific administrative procedures are documented. the nurses’ questionnaire was completed by the nurse participants. this structured questionnaire probed nurses’ self-reported adherence to guidelines and protocols used when conducting immunisation and hearing screening. for the purpose of this article, only the information obtained from the tracking and record-keeping systems employed at clinics will be reported. the retrospective data compilation sheet was developed to review the hearing-screening result and proposed management plan documented on the rthc and coj child health services blue cards of participants in group 2. procedures ethical considerations procedures followed were in accordance with the world medical association’s declaration of helsinki (2008). ethical approval for the study was obtained from the university research ethics committee. written informed consent was obtained from the coj department of health (doh), clinic managers and all participants, using approved methods. all participants in the study were fully informed about the nature of the study, and assured of confidentiality and their right to withdraw from the study at any time, without any negative consequences. data collection data collection took place at a time that was proposed as most convenient by the clinic managers. the nurses’ observation form was completed while observing four immunisation sessions per participant. the records (rthc and coj child health services blue cards) of children attended to by the nurses during observation sessions were then reviewed and recorded on the retrospective data compilation sheet. the nurses then completed the nurses’ questionnaire independently while the researcher conducted the record review. the completed questionnaires were collected by the researcher immediately after completion. lastly, a focus group was held with nurses to obtain more information on reasons for current record-keeping practices. reliability and validity • reliability: twenty-five per cent of the records were reviewed by an interrater with 4 years’ clinical experience in the field of audiology. the interrater agreement was 99.3%. • validity: face and content validity of the data collection tools was established by conducting two pilot studies. the use of the simple random sampling strategy to select a representative sample for inclusion in the study enhanced the external validity of the study. data analysis data were documented on all relevant measuring instruments and encoded according to data definitions. the data were tabulated and analysed using the south african statistics (sas) software, version 9.1.3 for windows (sas institute inc, 2002 2003). descriptive statistical measures (averages, means and standard deviations) were used to analyse the data. results retrospective record review a retrospective review was conducted of immunisation information recorded by the phc nurses on the rthc and coj child health services blue cards of the participants in group 2 (n 2=80). the information reviewed included preand perinatal histories, birth weight, birth length, head circumference, apgar scores and hearing-screening results. it is evident from the results presented in table 1 that in the majority of cases phc nurses did not record information obtained during typical immunisation sessions on the documents prescribed in the government policies and guidelines. this is especially true for the hearing-screening tests conducted by nurses. for those children for whom the swart questionnaire was applicable at 3 months of age, it was found that results were recorded on 25% (n 2=20) of the rthc reviewed. in contrast, results were recorded on 65% (n 2=52) of the coj health services blue cards. in only 3 cases were the 3-month hearing-screening results recorded on both cards. thirty-four per cent (n 2=7) of the children had no hearing-screening results recorded on either card. it was found that for the 6-month hearing screening (using the swart questionnaire), results were recorded on 9% (n 2=7) of the rthc, and 69% (n 2=55) of the coj health services blue cards. in 7.5% (n 2=11) of the records reviewed, results were recorded on both cards. in 29% (n 2=23) of the cases, neither card was found to contain information regarding sound localisation at 6 months of age. the voice test, conducted at 12 months of age, was applicable in only 69% (n 2=55) of the records reviewed. the voice test results were recorded on 11% (n=6) of the rthc and 65% (n=36) of the coj health services blue cards. the voice test results were not recorded on either of the cards in 41% (n=23) of the records reviewed. overall, of the records reviewed, 11% (n 2=9) of rthc and 66% (n 2=54) of the coj health services blue cards contained information on hearing-screening results, while in 4% (n 2=3) of the cases the hearing-screening results were recorded on both cards. conducting and recording hearing-screening results hearing-screening practices sixty-five per cent (n 1=13) of participants indicated that they conducted the swart questionnaire and 75% (n 1 =15) indicated that they performed the voice test on all children. one participant (5%) indicated she does not do the voice test but conducts the swart questionnaire on all children. a variety of alternative hearing tests was indicated by the participants, including using noisemakers, knocking a teaspoon against a cup, finger snapping, talking to the child, and hand clapping or squashing paper near the child’s ear. the immunisation sessions were observed by the second author to determine whether the doh-stipulated hearing-screening procedures (swart questionnaire and voice test) were conducted, as well as whether the observed procedures were age-appropriate and procedurally correct. of the nurse participants observed during the study, 5% (n 1=1) assessed all the children correctly in terms of both test procedures and age-appropriateness. twenty-five per cent (n 1=5) of the participants conducted both the screening tests at an appropriate age but followed the incorrect procedure. twenty-five per cent (n 1=5) of the participants conducted the test procedure appropriately but at an incorrect age. forty-five per cent (n 1=9) of the participants did not conduct the voice test for children older than 12 months of age. of the immunisation sessions observed, doh-stipulated hearing-screening procedures were conducted in 51% (n 2=41) of cases. the results are presented in table 2. recording of hearing-screening results all nurse participants (n 1=20) reported that they recorded hearing-screening results on the clinic-retained coj child health services blue card while 80% (n 1=16) reported that they recorded the results on the patient-retained rthc. forty-one hearing-screening tests were conducted during the immunisation sessions observed and contrary to nurses’ reports, in 73% (n=30) of all cases screening results were not recorded on either of the cards. focus group results although the focus group participants reported that the rthc and the coj child health services blue card are equally important, they felt that the information to be recorded on each differs. in their view, immunisations are recorded on the rthc while the results of the physical examination conducted on the children are recorded on the coj child health services blue card. they further reported that because of staff constraints and the high patient load, they tend to record only the results that they deem most pertinent following a consultation. discussion the retrospective record review confirms the feedback from the focus group participants that hearing-screening results were not deemed pertinent information. results of the physical examination (e.g. birth weight, length and head circumference) were thus most often recorded on both the clinicand patient-retained records. this was followed by preand perinatal history and the apgar scores. a key finding of this study is that phc nurses who participated in this study do not adhere to the hearing-screening and record-keeping practices as outlined by the doh (2002). it is postulated that the introduction of the prevention of mother-to-child transmission (pmtct) guidelines, necessitated by the hiv/aids pandemic in south africa, requires nurses, in addition to the current requirements, to obtain and record a comprehensive hiv/aids-related case history. this, combined with high patient loads, as specifically mentioned during the focus group discussion, further limits the time available for nurses to conduct appropriate hearing-screening procedures. it is hypothesised that the current system of keeping duplicate patient records (e.g. clinicand patient-retained cards) at phc level increases the workload of nurses in immunisation clinics, forcing them to limit their administrative responsibilities. the findings of the current study confirm this, and concur with the results of previous studies that found that hearing-screening results are more often recorded on the clinic-retained records than the patient-retained rthc (petrocchi-bartal, 2011; thandrayen, 2008). poor record-keeping practices may make it difficult to track patients who may have defaulted from clinics, or hamper the continuity of care for those patients who do return. poor record-keeping practices hinder effective service delivery as they prevent early diagnosis and subsequent intervention for hearing impairment (kanji, 2010; olusanya, 2007). accurate record-keeping practices provide a means of recording outcomes measures of the efficacy of hearing-screening programmes (johnson & danhauer, 2002). results of the current study elucidate the fact that there is no consistency across clinics despite the presence of the existing framework within the rthc and coj child health services blue cards that allow for record keeping of developmental milestones, including hearing. conclusion the information yielded by this study contributes to the expansion of evidence-based data on the current hearing-screening practices at phc clinics in south africa. the context-specific barriers to the implementation of ehdi as it relates to record-keeping practices have been highlighted. optimising the implementation of current governmental hearing-screening protocols, nurses’ awareness and understanding of the importance of hearing screening will pave the way for more structured ehdi programmes in years to come. the adherence to the existing protocols by phc nurses henceforth will provide relevant statistical data on the prevalence of possible hearing impairments, which would eventually justify the implementation of widespread universal hearing-screening programmes in south africa. the results of this study should be cautiously interpreted in the light of its exploratory nature, small sample size and context limitations. future research should address the replication of this study with a larger sample size in a variety of provincial and municipal clinics in south africa. the administrative responsibility of phc nurses as a contributory factor to the quality control of hearing-screening programmes needs to be addressed. the recognition of the importance of accurate recording and collection of data from the various stakeholders is critical for the success and future of ehdi programmes in south africa. references day, c., barron, p., monticelli, f. & sello, e. (eds). (2010). department of health district health information system database 2009. district health barometer 2008/09. durban: health systems trust. department of health. (2002). the primary health care package for south africa – a set of norms and standards. pretoria: department of health. department of health. (2005). guidelines for the prevention of hearing impairment due to otitis media. retrieved 21 august 2010 from: http://www.doh.gov.za/factsheets/guidelines/hearing.pdf health professions council of south africa (hpcsa). (2007). professional board for speech, language and hearing profession: early hearing detection and intervention programmes in south africa, position statement year 2007, 1-42. retrieved from: http://www.hpcsa.co.za/downloads/speech_education/early_hearing_detection_statement.pdf johnson, c. e. & danhauer, j. l. (2002). handbook of outcomes measurement in audiology. canada: singular publishing. kanji, a. (2010). audiological function in a group of very low birth weight neonates in a tertiary hospital in johannesburg, gauteng. (masters dissertation). 2010. retrieved from http://www.wiredspace.wits.ac.za/bitstream/handle/10539/8464/kanji national center for hearing assessment and management (ncham). (2012). the ncham e-book: a resource guide for early hearing detection and intervention. utah state university. http://www.infanthearing.org/ehdi-ebook/index.html olusanya, b. o. (2007). addressing the global neglect of childhood hearing impairment in developing countries. plos med 4(4): e74. doi:10.1371/journal.pmed.0040074 petrocchi-bartal, l. (2011). clinic based hearing screening protocols: the feasibility of implementing the health professions council of south africa year 2007 guidelines. (masters dissertation). retrieved from http://wiredspace.wits.ac.za/bitstream/handle/10539/10134/petrocchi-bartal pirozzo, s. (2003). whispered voice test for screening for hearing impairment in adults and children: a systematic review. bmj 327(7421), 967. doi:10.1136/bmj.327.7421.967 sas institute inc. (2002 2003). sas software, version 9.1.3 for windows. cary, nc: sas institute inc. swanepoel, d., hugo, r. & louw, b. (2006). infant hearing screening at immunization clinics in south africa. int j pediatr otorhinolaryngol 70(7), 1241-1249. doi:org/10.1016/j.ijporl.2006.01.002 swanepoel, d., storbeck, c. & friedland, p. (2009). early hearing detection and intervention in south africa. int j pediatr otorhinolaryngol 73(6), 783-786. doi:org/10.1016/j.ijporl.2009.01.007 swart, j. g. (1996). hearing assessment in general practice – cradle to grave. cme 14(5), 649-665. thandrayen, k. (2008). the quality of child health services offered at primary health care clinics in johannesburg. unpublished research report: university of the witwatersrand. traynor, m. (2011). bibliometrics as politics: the case of emerging disciplines. int nurs rev 58(1), 26-27. doi:org/10.1111/j.1466-7657.2010.00874.x trochim, w. m. k. (2006). research methods knowledge base. (2nd ed.). retrieved from: http://www.socialresearchmethods.net/kb/ van der spuy, t. & pottas, l. (2008). infant hearing loss in south africa: age of intervention and parental needs for support. international journal of audiology, 47(suppl 1), s30-s35. doi.org/10.1080/14992020802286210 venter, c. & viljoen, j. (2008). children with hearing loss: parental needs regarding diagnosis. 2008. unpublished b. communication pathology research report. university of pretoria. world medical association declaration of helsinki (2008). ethical principles for medical research involving human subjects. retrieved from: http://www.wma.net/en/30publications/10policies/b3/index.html.pdf 65 suprasegmentele spraakeienskappe van prelinguaal gehoorgestremde kinders met kogleere inplantings, gehoorgestremde kinders sonder inplantings en n ormaalhorende kinders adri ligthelm en emily groenewald departement kommunikasiepatologie universiteit van pretoria opsomming 'n oorsig van relevante literatuur toon 'n leemte in die kennis van suprasegmentele spraakeienskappe van prelinguaal gehoorgestremde kinders met kogleere inplantings. met die studie word beoog om sekere suprasegmentele spraakeienskappe van prelinguaal gei"nplanteerde kinders deur middel van perseptuele luisteraarsbeoordelings en akoestiese analises te ondersoek en te vergelyk met die van prelinguaal gehoorgestremde kinders sonder inplantings en normaalhorende kinders van dieselfde ouderdom. twaalf afrikaanssprekende kinders tussen die ouderdom van ses tot tien jaar is in drie groepe ingesluit. 'n gei"ntegreerde beskouing van die perseptuele en akoestiese resultate toon dat die kogleer-gei"nplanteerde kinders se suprasegmentele spraakeienskappe 'n groter ooreenkoms toon met die van die normaalhorendes as met die van die gehoorgestremdes. abstract a review of the relevant literature indicates a lack of knowledge regarding suprasegmental speech characteristics in prelingual hearing impaired children with cochlear implants. this study is aimed at examining certain suprasegmental features in the speech of pre lingual hearing impaired children with cochlear implants by perceptual ratings and acoustic analyses, comparing these results to that of prelingual hearing impaired children without implants, and normal hearing children of the same age. twelve afrikaansspeaking children between the ages of six and ten years were included in three groups. an integrated view of the perceptual and acoustic results shows that the cochlear implanted children's suprasegmental speech characteristics bear closer resemblance to those of the normal hearing group than those of the hearing impaired group. sleutelwoorde: suprasegmentele eienskappe, kogleere inplanting, perseptuele beoordeling, akoestiese analise inleiding 'n kogleere inplanting as fllternatiewe prosedure by die hulpverlening aan gehootgestremdes het 'n potensieel ingrypende effek op die sptaaken taalontwikkeling van die prelinguaal gehoorgestr~mde kind (tyler, 1993). hierdie studie behels 'n ondersoek na die aard van die suprasegmentele spraakeienskappe van die prelinguaal gelnplanteerde gehoorgestremde kind soos dit vergelyk met die van die gehoorgestremde en normaalhorende kind. suprasegmentele eienskappe word volgens crystal (1981) as linguistiese, kontrasterende klankeffekte gedefinieer wat nie beskryf kan word deur na 'n enkele segment te verwys nie, maar wat strek oor 'n uiting of wat 'n effek op een of meer segmente in verskillende dele van 'n uiting het. volgens ohde en sharf (1992) is intonasie, tempo, klem, binding en ritme aspekte van spraakproduksie, wat die grense van individuele foneme oorskrei en waarna in die literatuur verwys word as suprasegmentele eienskappe (minifie, 1973); nie-segmentele eienskappe (crystal, 1981) of pros odie (sloat, taylor & hoard, 1978). hierdie terme word gereeld as sinonieme gebruik en daar is ook tans geen universeel aanvaarde definisie ofklassifikasie hiervan nie. coles (1990), kent en read (1992), crary en tallman (1993) en grant en walden (1996) beskou intensiteit (waargeneem as luidheid), fundamentele frekwensie (waargeneem as toonhoogte) en duur eienskappe, as die primere akoestiese parameters wat die suprasegmentele eienskappe van spraak oordra. coles (1990) onderskei egter tussen suprasegmentele en prosodiese eienskappe. die suprasegmentele eienskappe van toonhoogte, luidheid en duur manifesteer volgens haar op 'n linguistiese vlak as prosodiese eienskappe. crystal (1981) maak ook 'n onderskeid tussen die fisiese kenmerke en hulle linguistiese gebruik. hy beskou die linguistiese gebruik van toonhoogte as intonasie, die linguistiese gebruik van luidheid as klem en die linguistiese gebruik van duur as tempo. hy verwys verder na die linguistiese gebruik van ritme as ritmisiteit en na die linguistiese gebruik van stilte as pouse. ohde & sharf(1992) verklaar dat, afgesien van die term watgebruik word, 'n analise van intonasie, tempo, klem, binding en ritme vir 'n volledige begrip van die eienskappe van normale en afwykende spraak nodig is. crystal (1981) onderskei vyfrolle van suprasegmentele eienskappe in spraak, naamlik grammatikaal, semanties, emosioneel, sielkundig en sosiaal. volgens minifie (1973) voorsien suprasegmentele eienskappe die variasies in die akoestiese sein wat die luisteraar in staat stel om die korrekte semantiese betekenis van die boodskap te onttrek. die onderskeie suprasegmentele eienskappe is wat funksie die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 66 betref, taalgebonde (kent & read, 1992). in sommige tale, byvoorbeeld tsjeggies, val die hoofklem altyd op dieselfde sillabe van 'n woord, maar in tale soos afrikaans, engels, nederlands en duits kan die hoofklem op verskillende sillabes in die woord val en sodoende betekenisverskil teweegbring. alhoewel van wyk (1981) 'n uitvoerige beskrywing van die suprasegmentele eienskappe van afrikaans en hulle funksies gee, is daar egter beperkte inligting beskikbaar aangaande die ontogenetiese ontwikkeling van suprasegmentele eienskappe in afrikaans. die ontwikkeling van supraseglnentele eienskappe vorm deel van die spraaken taalontwikkeling van die kind as taaldeelnemer. spraak word van nature deur middel van die ouditiewe sisteem aangeleer. n avorsers beweer dat hoe vroeer 'n kind bewus word van klank en die betekenis daarvan, hoe meer doeltreffend sal hy leer om klank te gebruik (fryauf-bertschy, tyler, kelsay & gantz, 1992). tydens die eerste paar lewensmaande word daar nie slegs foneme gedekodeer en in die geheue gestoor nie, maar word suprasegmentele eienskappe soos ritme van aaneenlopende spraak, klempatrone van verskillende tipes uitinge en ander aspekte van natuurlike taal aangeleer (van tasell, 1981). die suprasegmentele kenmerke van tabas se vokaliserings weerspieel al op so vroeg as ses maande die prosodiese patrone van hulle moedertaal (crystal, 1981). teen ongeveer ses tot agt maande is nabootsing van kardinale belang, en begin die kind om die klanke wat sy ouers maak, na te boots en intonasiepatrone daarop toe te pas. dit begin eers in babbel en later in woorde, frases en sinne (coles, 1990). 'n gehoorverlies belemmer egter kongenitale en prelinguale dowe kinders se aanleer en produksie van segmenteleen suprasegmentele aspekte van spraak (kirk & hill-brown, 1985). boothroyd (1982) meen dat hierdie beperkinge wat die kind ondervind, eerstens toege.skryf kan word aan die feit dat 'n gehoorverlies die ontvangs van spraak vanuit die omgewing inperk. tweedens meng die gehoorverlies gedeeltelik of algeheel in met die kind se vermoe om sy eie spraak met behulp van ouditiewe terugvoer te monitor. coles (1990) verklaar dat ouditiewe insette vanuit die omgewing sowel as ouditiewe terugvoer reeds in die eerste paar lewensmaande van kardinale belang is in die kind se vermoe om die komplekse reekse van suprasegmentele eienskappe in spraak aan te leer. die implikasies wat 'n gehoorverlies vir die aanleer en gebruik van suprasegmentele eienskappe inhou, is dus verreikend. northern en downs (1991) noem dat uitermatig gehoorgestremde kinders oor die algemeen 'n hoer fundamentele frekwensie as normaalhorendes vertoon en dat die eienskappe van klem en intonasie verlore gaan wat 'n monotone kwaliteit aan hulle stemme gee. oormatige variasie in toonhoogte mag egter ook voorkom, wat lei tot toonhoogte-breuke en skielike veranderinge in hulle spraak (kirk & hill-brown, 1985). verder spreek dowe kinders beklemtoonde en onbeklemtoonde sillabes gewoonlik met dieselfde duur of met minder variasie in duur uit. kirk en hill-brown (1985) noem ook dat dowe sprekers geneig is om stadig te praat, wat 'n negatiewe effek op die ritme en kwaliteit van hulle spraak het. die rehabilitasie van persone met 'n gehoorverlies het die afgelope dekade beduidende vooruitgang gemaak. ten spyte hiervan bly die hantering van .persone met uitermatige bilaterale sensories-neurale gehoorverliese, wat min of geen voordeel uit gehoorapparate ontvang nie, 'n probleem (cohen, waltzman & shapiro, 1985). navorsing in verband met kogleere inplantings is spesifiek geynisieer adri ligthelm en emily groenewald in 'n poging om 'n alternatief aan hierdie persone te bied. in vergelyking met gehoorapparate bied kogleere inplantings inherente voordele in terme van bandwydte, dinamiese gebiedbeperkinge en vryheid van akoestiese terugvoer (boothroyd, 1993). baanbrekerswerk is reeds sedert 1966 op die gebied gedoen en verskeie navorsingsgroepe het in die sewentigerjare by die ontwikkeling van verskillende kogleere prosteses betrokke geraak, wat tot grootskaalse kliniese toepassing van kogleere inplantings gelei het (dowell, meckleburg & clark, 1986). voordele verbonde aan hierdie tegnologiese vooruitgang is ook telkens deur studies aangedui (waltz man, cohen en fisher, 1992). die ouditiewe kwaliteit van die spraaksein wat deur elektriese stimulasie ontvang word kan egter tot 'n groot mate verskil van die ouditiewe kwaliteit van spraak wat deur akoestiese stimulasie ontvang word. die klank wat die ge'inplanteerde persone waarneem, word as nie normaal beskryf en het 'n 'meganiese' of 'staties-agtige' kwaliteit. postlinguale do we persone moet dus leer om hierdie onbekende akoestiese kode te gebruik en toe te pas in hulle daaglikse kommunikasie (spivak & waltzman, 1990). alhoewel prelinguale dowe kinders nie die ouditiewe geheue van gesproke taal het om hulle te help met die interpretasie van die elektriese sein van die kogleere inplanting nie, meen tyler (1990) dat prelinguale dowe kinders nie noodwendig so erg hierdeur benadeel word nie. osberger (1994) noem ook dat die aanpasbaarheid van die sentrale senuweestelsel prelinguale kinders tot hoe vlakke van funksionering in staat stel. heelwat navorsing is reeds al in verb and met die spraakvermoensvan persone met kogleere inplantings gedoen. die fokus van hierdie studies was oor die algemeen op spraakontvangs met sekondere waarnemings oor spraakproduksie (tobey, 1993). die voordele wat multikanaal kogleere inplantings vir postlinguale do we persone inhou ten opsigte van segmentele spraakproduksie, is reeds hieruit bewys. navorsing dui aan dat multikanaal kogleere inplantings beduidend meer van die nodige inligting vir die persepsie van spraak verskaf (spivak & waltz man, 1990; tye-murray, lowder & tyler, 1990). studies deur cummings, groenewald, hugo, muller en van der linde (1994) en langereis, bosman, van olphen en smoore'pburg (1997) bevestig 'n verbetering in verskillende aspekte van die spraakproduksie van 'n postlinguaal ge'inplanteerde persone. die effek wat 'n kogleere inplanting op hul suprasegmentele spraakeienskappe het, blyk ook d~delik uit studies in die verband. uit navorsing van dowell':et al. (1986) en spivak en waltzman, (1990) wat die funksionering van postlinguale dowes met kogleere inplantings ondersoek het, is aangedui dat daar duidelike verbeteringe in die persepsie van suprasegmentele eienskappe na inplantering voorkom. cummings et al. (1994) het bevind dat 'n kogleere inplanting by postlinguale dowe persone tot 'n verbetering van suprasegmentele spraakeienskappe kan lei. die verbeterde ouditiewe ontvangs wat deur die kogleere inplanting meegebring word behoort daarom ook 'n positiewe invloed te he op die ontwikkeling van spraaken taal by prelinguale kinders wat uitermatig geh60rgestremd is. aspekte soos die ouderdom van inplantering kan egter 'n invloed op die verbetering van die kind se vaardighede he. tye-murray, spencer en woodworth (1995) en kirk en hill-brown (1985) noem dat jong~r kinders klaarblyklik 'n vinniger tempo van verbetering in hulle spraakvaardighede as ouer kinders na inplantering vertoon. langtermyn /' the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) suprasegmentele spraakeienskappe van prelinguaal gehoorgestremde kinders met kogleere inplantings, gehoorgestremde kinders sonder inplantings en normaalhorende kinders 67 gebruik van 'n kogleere inplanting is ook nodig voordat meetbare verbeteringe in ouditiewe vaardighede waargeneem kan word (fryauf-bertschy et al., 1992). heelwat navorsing is reeds in verband met die spraakproduksie ontwikkeling by prelinguaal gelnplanteerde kinders uitgevoer, waar die klem veral op segmentele aspekte van spraak geval het (tye-murray et al., 1995; kirk & hillbrown, 1985). min aandag is egter tot dusver geskenk aan die produksie van suprasegmentele spraakeienskappe deur prelinguale dowe kinders wat geynplanteer is, hoe wei enkele studies dit wei by hul ondersoek na spraakproduksie ingesluit het. tye-murray et al. (1995) het in hulle ondersoek gekyk na die prestasie van toetspersone op die fundamental speech skills test (fsst), en het gevind dat kogleere inplantings veral voordelig kan wees vir die ontwikkeling van suprasegmentele eienskappe soos sillabeklem en intonasie. kirk en hill-brown (1985) meld dat hul resultate wat op perseptuele beoordelings gegrond was, ook verbetering in die produksie van suprasegmentele eienskappe by kinders met kogleere inplantings aangetoon het. daar is sover vasgestel kon word, nog geen akoestiese of spektografiese data beskikbaar met betrekking tot die suprasegmentele spraakeienskappe van prelinguaal gelnplanteerde dowe kinders nie. met die studie word daarom gepoog om die effek van 'n prelinguale kogleere inplanting op die ontwikkeling van suprasegmentele eienskappe van die jong kind perseptueel en akoesties te ondersoek. metode doelstellings die doel van die studie is om die aard van die suprasegmentele spraakeienskappe vanjong prelinguale kinders met kogleere inplantings te ondersoek en te vergelyk met die van uitermatig gehoorgestremde kinders sonder kogleere inplantings en normaalhorende kinders van dieselfde ouderdomsgroep. die volgende subdoelstellings is vir die realisering van die hoofdoel gestel: ./~m die suprasegmentele eienskappe van al die proefpersone perseptueel te beoordeel met verwysing na die toonhoogte, luidheid;en tempo van spraak soos geproduseer in verskillende linguistiese kontekste. • om die suprasegmentel~ eienskappe van al die proefj persone akoesties te analiseer wat betref die frekwensie, intensiteit en duur eie~skappe soos geproduseer in verskillende linguistiese konfekste. • om die aard van die suprasegmentele eienskappe van kinders met kogleere inplantings met die van normaalhorende en gehoorgestremde kinders te vergelyk. navorsingso~erp die navorsing kan as oorsakend-vergelykende eksperimentele navorsing beskryf word (salkind, 1991). die suprasegmentele spraakeienskappe van jong kinders wat op grond van 'n gegewe eienskap; naamlik gehoorstatus,in drie groepe verdeel is, word onderling vergelyk. twee tipes data, naamlik perseptuele beoordelings en akoestiese metings van verskillende eienskappe in spesifieke linguistiese kontekste is versamel. data is tot groepsgemiddeldes en/of persentasies verwerk en kwalitatief en kwantitatief vergelyk. ' proefpersone die twaalf proefpersone wat in die ondersoek ingesluit is, is in drie groepe ingedeel volgens hulle gehoorvermoens. die eksperimentele groep bestaande uit vier jong kinders tussen die ouderdom van ses en tien jaar met kogleere inplantings, 'n tweede groep bestaande uit vier jong kinders tussen dieselfde ouderdomme wat uitermatige gehoorverliese vertoon en 'n derde groep bestaande uit vier normaalhorende jong kinders binne dieselfde ouderdomsgrense. proefpersone in die onderskeie groepe is sover moontlik afgepaar wat ander eienskappe betref om vergelykbaarheid tussen die groepe te verhoog. spesifieke kriteria ten opsigte van proefpersoon-seleksie is daargestel ten einde vergelyking tussen groepe moontlik te inaak. seleksiekriteria die deelnemers se gehoorstatus was die bepalende faktor vir insluiting. die normaalhorende kinders moes gemiddelde suiwertoondrempels vertoon tussen odb en 15db sonder enige middeloorpatologie. gehoorgestremde kinders sonder kogleere inplantings moes uitermatige bilaterale sensories-neurale gehoorverliese, dit wil se 'n gehoorverlies van 90 db of meer in beide ore vertoon (boothroyd, 1993) om vergelyking met die geynplanteerde proefpersone moontiik te maak. hulle moes verder almal met toepaslike gehoorapparate gepas wees wat optimaal funksioneer. kinders met kogleere inplantings moes uitermatige bilaterale sensories-neurale gehoorverliese vertoon het aangesien dit 'n voorvereiste is om te kwalifiseer vir 'n kogleere inplanting (tye-murray, 1993). hierdie gehoorverlies moes verder prelinguaal in aanvang geneem het, om sodoende te verseker dat die prestasie van die kinders met die kogleere inplanting aan die versterkingsapparaat toegeskryfkan word en dat vorige ondervinding van spraak nie 'n rol speel nie. verder moes die kinders in hierdie groep suksesvol met 'n spectra 22 kogleere inplanting gelnplanteer wees en van die speak-spraakprosesseringstrategie gebruik maak. die speak-spraakprosesseringstrategie is uitgesonder aangesien dit die mees resente tegnologie was tentye van die inplantering van die proefpersone wat vir die studie' beskikbaar was. daar is ook verder vereis dat hierdie proefpersone ten minste twee jaar ondervinding met die kogleere inplanting gehad het om te verseker dat hulle genoegsame geleentheid gehad het om die nodige spraak-en taalontwikkeling teondergaan om te kan deelneem aandie studie. addisionele kriteria was daarop gerig om proefpersone sover moontlik afte paar en groepe sodoende sover moontiik te laat ooreenstem. skoolgaande kinders in die juniorprimere skoolfase tussen die ouderdom van ses en tienjaar is oorweeg om sodoende te verseker dat die kinders almal oor genoegsame spraaken taalontwikkeiing, sowel as kognitiewe en skolastiese vaardighede beskik om die take wat verwag was, uit te voer. normaalhorende kinders uit staatsgesubsideerde skole en kinders met kogleere inplantings wat suksesvol in hoofstroom skole funksioneer, is ingesluit. gehoorgestremde kinders sonder kogleere inplantings moes in 'n ouditief-verbale omgewing onderrig ontvang om te verseker dat hulle oor genoegsame spraaken taalvaardighede beskik om die verwagte response te lewer. ai die kinders wat geselekteer was vir deelname aan die studie moes verder onderrig ontvang in hulle moedertaal om die invloed van 'n tweede taal uit te sluit, aangesien die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 68 suprasegmentele eienskappe taalgebonde is (kent & read, 1992). aile proefpersone moes om dieselfde rede een gemeenskaplike moedertaal he, wat in hierdie geval afrikaans was. geen onderskeid is gemaak ten opsigte van die geslag van persone wat in die studie ingesluit is nie. die kinders in die twee kontrolegroepe is egter wat geslag aanbetref, afgepaar met die kinders met kogleere inplantings om vergelykbaarheid tussen die groepe te verhoog. prosedures vir seleksie vier kinders met kogleere inplantings wat voldoen aan die kriteria vir seleksie, is geselekteer uit die kliente wat gereeld die kogleere inplantingseenheid van die universiteit van pretoria se kliniek vir spraak, taal, stem en gehoor besoek vir rehabilitasie en instelling van die spraakprosesseerder. die gehoorgestremde kinders sonder kogleere inplantings is met die hulp van die spraakterapieen oudiologie-personeel en onderwyspersoneel verbonde aan sonnitus skool vir gehoorgestremdes geselekteer. normaalhorende kinders is in oorleg met die onderwyspersoneel van 'n plaaslike laerskool geselekteer. suiwertoontoetsing is oor die frekwensiegebied van 250 tot 8000 hz uitgevoer om die kogleer gelnplanteerde proefpersone en normaalhorende persone se gehoorsensitiwiteit te bepaal aangesien daar resente gehoorevaluasies vir elke gehoorgestremde beskikbaar was, is die mees onlangse evaluasieverslae vir die seleksie van hierdie groep gebruik. materlaal en apparaat 1betsmateriaal die toetsmaleriaal is saamgestel uit sinne met die tipiese intonasiekontoer van 'n stelsin, vraagsin, bevelsin en bevestigende sin. die verskillende sinstipes is verteenwoordigend van verskillende linguistiese kontekste waarin die suprasegmentele spraakeienskappe 'n funksionele rol spee1. daar word voortaan na verwys as sinstipe 1, sinstipe 2, sinstipe 3 en sinstipe 4. die volgende toetssinne is gebruik: die seun was die hand. (sinstipe 1); hoe laat is dit? (sinstipe 2); los uit my handoek! (sinstipe 3); en die meisie is siek, is sy nie? (sinstipe 4). lyntekeninge is as stimulusprente gebruik om die sinne te ontlok. opname-apparaat die opnames is met behulp van 'n marantz bandopnemer, modelnommer cp 430 op 'n philips fx 90 ferro oudiokaset vasgele. 'n aankniptipe yoga kondensor mikrofoon, modelnommer em 060, is vyftien sentimeter vanaf die toetspersoon se mond vasgeknip om optimale seintot-ruis verhoudings te yerseker. perseptuele beoordelingskaal die perseptuele beoordeling van die suprasegmentele spraakeienskappe is gedoen aan hand van 'n perseptuele beoordelingskaal. coles (1990) se perceptual checklist is aangepas om dieselfde eienskappe wat deur die akoestiese analise ondersoek is, in die perseptuele beoordeling in te sluit, n1. toonhoogte/frekwensie, luidheidlintensiteit en tempo/duur. drie herhalings van elke sin is beoordeel ten opsigte van toonhoogtevariasie, tipe toonhoogtekontoer, adri ligthelm en emily groenewald luidheidsvariasie en spraakspoed. hierdie eienskappe is afsonderlik op 'n vyfpuntskaal beoordeel en op 'rr beoordelingsvraelys wat vir die doel opgestel is, aangeteken. normale produksie is op hierdie vyfpuntskaal voorgestel in die midposisie en die aard en graad van die afwyking vanafnormaal, aangedui aan weerskante van die skaal drie luisteraars met agtergrondskennis en ondervinding van die spraak van normaalhorende sowel as gehoorgestremde kinders, sowel as van suprasegmentele spraak eienskappe en die produksie van hierdie eienskappe in spraak is vir die beoordelings gebruik. al die luisteraars moes oor normale gehoor beskik wat 'n gemiddelde suiwertoondrempel tussen 0 en 25 db impliseer. die luisteraars moes ook afrikaanssprekend wees om te verseker dat hulle oor genoegsame kennis rakende die suprasegmentele eienskappe van die taal beskik. akoestiese analise-apparaat die akoestiese analises van die toetsmateriaal is met behulp van die computerized speech lab (model' 4300b) van kay elemetrics company uitgevoer. die basiese csl50 program is vir 'n klankgolf en spektografiese analise van elke sin gebruik, en die cslvp2 visie-pitch opsie is vir die berekening en vertoning van 'n grondtoonkurwe en energiekurwe gebruik. prosedure data-insameling 'n eenmalige opname van elke toetspersoon se sinsproduksies, is in 'n klankdigte kamer gemaak om inmenging van omgewingsgeluide tydens die opname uit te skakel. toetspersone is vooraf bewus gemaak van die verskillende tipes sinne en die feit dat hierdie sinne normaalweg nie dieselfde prosodiese eienskappe vertoon nie. voorbeelde is ter verduideliking verskaf, waarna daar van elke toetspersoon verwag is om 'n voorbeeldsin te formuleer aan die hand van die voorbeeld stimulusprent. daarna is elke toetsitem driemaal deur die proefpersoon geproduseer om sodoende die betroubaarheid, van die resultate te verhoog. die proefpersone se herhaalde produksie van die spesifieke toetsitems is opgeneem vir analise doeleindes. . data-analise en data·verwerking dit het bestaan uit 'n tweeledige proses, naamlik die perseptuele beoordeling van elke kind se sinsprosodie en 'n akoestiese analise van spesifieke supraglottale eienskappe. perseptuele analise die perseptuele analise is individueel d'eur die luisteraars uitgevoer aan die hand van die vyfpunt beoordelingskaal die opnames van elke proefpersoonis aan elk van die luisteraars voorgespeel waarna'die spesifieke sinsproduksie beoordeel is ten opsigte van toonhoogtevariasie, tipe toonhoogte.kontoer,luidheidsvariasie en spraaktempo. beoordelings vir die drie herhalings van die vier tipes sinne is gedoen. die'data vir die onderskeie parameters is deurgaans afsonderlik oorweeg en verwerk. die volgende verwerkings is op die beoordelings van die / the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) suprasegmentele spraakeienskappe van prelinguaal gehoorgestremde kinders met kogleere inplantings, gehoorgestremde kinders sonder inplantings en normaalhorende kinders 69 luisteraars uitgevoer: 'n persoonlike gemiddelde van elke proefpersoon se drie herhalings van 'n sinstipe, soos beoordeel deur elkeen van die drie luisteraars, is bepaal. sodoende is 'n persoonlike gemiddelde toonhoogtevariasie, _luidheidsvariasie en -spraakspoed vir elke proefpersoon bepaal. elke proefpersoon se persoonlike gemiddelde toonhoogtekontoer korrektheid vir elke sinstipe is bereken deur die luisteraarsbeoordelings te vergelyk met die norme volgens ohde en sharf (1992) en as korrek of verkeerd te beoordeel. 'n gemiddeld oor die drie herhalings is bereken en as 'n persentasie toonhoogtekontoer korrektheid uitgedruk. die drie afsonderlike luisteraarsbeoordelings vir elke proefpersoon is verder verwerk na 'n totale perseptuele beoordeling vir elke proefpersoon, deur die gemiddelde beoordeling tussen die drie luisteraars vir elke sinstipe te bepaal. die totale perseptuele beoordelings is gebruik om perseptuele groepsgemiddelde beoordelings vir die vier sinstipes by elk van die drie groepe te bereken, om 'n vergelyking moontlik te maak. akoestiese analise 'n akoestiese analise van die drie herhalings van elk van die vier sinne, soos geproduseer deur elkeen van die twaalf proefpersone, is uitgevoer. daar is ses metings vir elke produksie uitgevoer, naamlik die minimum en maksimum grondtoonfrekwensie, die aard van die grondtoonfrekwensie se verloop, die minimum en maksimum energie intensiteit en die tydsduur van elke sinsuiting. die metings is die fisiese ekwivalente van die perseptuele parameters wat beoordeel is en om die vergelyking tussen die perseptuele en akoestiese aard van die suprasegmentele aspekte te vereenvoudig word daar voortaan as volg na die ses metings verwys: toonhoogte minimum, toonhoogte maksimum, tipe toonhoogtekontoer, luidheidsmaksimum, luidheidsminimum en sinsduur. dieselfde prosedure is telkens vir die akoestiese analises gevolg. 'n klankgolfvertoning in kombinasie met 'n wyeband spektogram is verkry en die sinsduur is met behulp van tydskursors bepaal, afgelees en aangeteken in sekondes. verder is 'n toonhoogtekurwe analise-opsie (pitch contour) gebruik om die minimum en maksimum grondtoonfrekwensie van elke sinsproduksie te bepaal. die tipe toonhoogtekontoer is as tipe 1 tot 5 geldentifiseer volgens ohde en sharf (1992) se l,iiteensetting van die intonasiekontoer wat as normaal vir 'n spesifieke tipe uiting geag word. daarna is die enerbekurwe analise-opsie (energy contour) gebruik om die maksimum en minimum luidheid in elke sinsproduksie te b~paal die volgende verwerkings van die roudata is vir elke proefpersoon uitgevoer en die vier akoestiese parameters is deurgaans afsonderlik oorweeg. toonhoogte-omvang (hz) is bereken deur die verskil tussen die maksimum en minimum grondtoon-frekwensie-waarde vir elke produksie te bepaal. die tipe toonhoogtekontoer soos voorgestel deur die toonhoogte-kurwe, is vol gens die norms soos voorgestel deur ohde en sharf (1992) geklassifiseer. die korrektheid oftoepaslikheid van die toonhoogte-kontoer, ~ir elk van die spesifieke sinstipes, is volgens hierdie klassifikasie as korrek aldan nie, beoordeel. die luidheidsomvang (db) is bereken deur die verskil tussen die maksimum en minimum intensiteitswaardes te bereken. spraakspoed (sillabes per sekonde) is bereken deur die duur van elke sin deur die aantal sillabes in die sin te deel (ohde & sharf, 1992). die aantal sillabes van elke tipe sin is vo'oraf ouditief deur die navorser bepaal. vervolgens is 'n persoonlike gemiddelde vir elke proefpersoon vir elk van die onderskeie akoestiese parameters bereken deur die gemiddeld van die drie herhalings te bereken. die gemiddelde toonhoogte, die gemiddelde luidheidsomvang en gemiddelde spraakspoed vir elke proefpersoon is op die wyse bereken. die persoonlike gemiddelde persentasie korrekte kontoere is bereken deur die aantal korrekte kontoere uit die .drie herhalings tot 'n persentasie te verwerk. op grond van hierdie persoonlike gemiddeldes is groepsgemiddeldes vir die vier proefpersone in elk van die drie groepe, vir elk van die onderskeie parameters bereken. die groepsgemiddeldes vir die onderskeie akoestiese parameters in die verskillende sinstipes is gebruik om die resultate van die drie groepe onderling te vergelyk. resultate en bespreking die resultate van die perseptuele en akoestiese ontledings word aangebied met verwysing na die onderskeie suprasegmentele parameters en die gelntegreerde resultate vir die kogleer gelnplanteerde groep word daarna vergelyk met die van die normaalhorende en gehoorgestremde groep. die resultate van die perseptuele en akoestiese ondersoeke word, vir elk van die suprasegmentele parameters, bespreek aan die hand van grafiese voorstellings van die groepsgemiddeldes wat vir die vier sinstipesbereken is. toonhoogtevaluasie die resultate soos grafies voorgestel in figuur 1a toon dat die toonhoogtevariasie van die normaalhorendes se sinsproduksie oor die algemeen as normaal beoordeel is. die gehoorgestremdes se resultate wissel daarenteen grootliks met gemiddelde beoordelings wat tussen monotoon en abnormale variasie strek en varieer dus tussen die uiterste grense van die beoordelingskaal. coles (1990) noem ook dat gehoorgestremde kinders se vermoe om hul stemtoon te beheer grootliks verskil. daar is byvoorbeeld gevind dat gehoorgestremde kinders se spraak soms monotoon klink, en dat hulle geneig is om min toonhoogtevariasie te vertoon. sommige gehoorg~stremde sprekers is weer geneig tot uitermatige of onbeheersde toonhoogteveranderinge, of toonhoogtebreuke. hierdie bevindinge word ook bevestig deur kirk en hill-brown (1985) en davis & hardick (1981). wat die kogleer gelnplanteerde persone se produksie van toonhoogte-variasie betref, is dit vir al vier sinne beoordeel as min tot normale variasie en vertoon dus groter ooreenstemming met die normaalhorendes as die gehoorgestremdes. soos blyk uit figuur 1b is dit duidelik dat die normaalhorende groep met die akoestiese analise die grootste toonhoogte-omvang vertoon in drie van die sinstipes. die kogleere groep se toonhoogte-omvang is effens nader aan die van die normaalhorendes in sinstipe 2 en 3, terwyl die gehoorgestremdes effens nader aan normaal vertoon in sinstipes 1 en 4. 'n gelntegreerde beskouing van die perseptuele beoordelings en die akoestiese analises van toonhoogtevariasie of -omvang, dui aan dat die kogleere groep in hul produksies van al vier sinstipes groter ooreenkoms met die normaalhorende groep toon as met die produksies van die gehoorgestremde gro'ep. die kogleere groep en die gehoorgestremde groep se akoestiese metings van toonhoogtedie suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 70 omvang val buite die normale grense, maar dit wil voorkom asof die kogleere groep se gebruik van toonhoogtevariasie meer toepaslik is as die van die gehoorgestremdes en dat dit waarskynlik daarom deur die luisteraars as meer normaal beskou is. coles (1990) het in haar ondersoek ook tot diese1fde gevolgtrekking gekom. abnormale variasie 5 te veel variasie 4 normale variasie 3 min variasie 2 manatoon , sinstipe 1 sinstipe 2, sinstipe 3 sinslipe 4 figuur 1.a: perseptuele analise 200,--------------------------------, 160 +-------120 hertz (hz) 80 40 sinslipe 1 sinslipe 2 sinstipe 3 sinstipe 4 figuur l.b: akoestiese analise figuur 1: grafiese voorstellingvan die groepsgemiddelde vir toonhoogte-variasie toonhoogtekontoer die normaa1horende groep se groepsgemidde1de vir die korrektheid van toonhoogtekontoer is oor al vier sinstipes perseptueel as die beste beoordeel, soos blyk uit figuur 2.a. die gehoorgestremde groep se groepsgemiddeldes daarenteen, verskil grootliks van die resultate wat vir die normaa1horendes verkry is en toon groot verskille trissen die individue se produksies in die onderskeie sinne. die kog1eere groep se produksie van die korrekte toonhoogtekontoer is perseptueel beoordeel om in al vier sinne groter ooreensteming met die resultate van die normaalhorendes as met die van die gehoorgestremde groep te vertoon. die akoestiese resultate toon dat die normaa1horende groep deurgaans die hoogste persentasie toonhoogtekontoerkorrektheid vertoon in al vier sinne. die gehoorgestremdes se toonhoogtekontoer-korrektheid is vir al vier sinsproduksies die swakste en vertoon weereens groot individuele verskille. die kogleere groep se toonhoogtekontoer-korrektheid daarenteen is deurgaans nader aan die van die normaa1horendes in a1 vier sinne soos aangetoon in figuur 2b. die resultate van die perseptuele beoordeling en akoestiese analise vertoon dieselfde beeld soos blyk uit figure 2a en 2b. die gelntegreerde resultate ten opsigte van die toepaslikheid van toonhoogtekontoer dui dus daarop dat die kogleere groep in verskillende linguistiese kontekste adri ligthelm en emily groenewald nader aan die normaalhorende groep as aan die gehoorgestremdes presteer. 100,------------------------80 w!l-------jj 60 persentasie (%) 40 20 sinstipe 1 sinstipe 2 sinstipe 3 sinstipe 4 figuur 2.a: perseptuele analise l00~~------------------------~~--~ 80 60 persentasie (%) 40 20 sinslipe 1 sinstipe 2 sinslipe 3 sinstipe 4 figuur 2.b: akaestiese analise r gehoorgeslremd figuur 2: grafiese voorstelling van die groepsgemiddelde vir korrektheid van toonhoogte-kontoer luidheidsvariasie figuur 3a toon dat die normaalhorende groep se luidheidsvariasie vir al vier die sinstipes as normaal beoordeel is. die gehoorgestremde proefpersone toon opvallend groot individuele verskille inluidheidsvariasie met beoordelings wat vanaf geen tot abnorma1e variasie strek. davis en hardick (1981) noem dat sommige gehoorgestremde kinders swak kontrole oor hulle produksie van luidheid het'. dit blyk ook geldig te wees vir die gehoorgestremde proefpersone in hierdie studie. die kogleere groep se luidheidsvariasie toon volgens die' perseptuele beoord~ling groter ooreenstemming met die van die nortnale groep en toon by sinstipe 1,2, en 3' hee1wat k1einer variasie as, die van die gehoorgestremdes. 1 die resultatevan die akoestiese metings van luidheidsomvang soos voorgestel in figuur 3b dui daarop dat' die normaa1horende groep die 'grootste luidheidsomvang vertoon in drie van die vier sinstipes. die luidheidsomvang van die gehoorgestremdes is egter groter as die van die normaa1horendes in sinstipe 3 en is feitlik dieselfde in sinstipe 4. 800s blyk uit figuur 3b vertoon die kogleere groep deurgaans die kleinste luidheidsomvang oor al vier die sinstipes: / ." hierdie resultate weerspreek met die eerste 00gops1ag die perseptuele waarnemings maar wanneer die akoestiese en perseptuele resultate egter gelntegreer word, blyk dit dat die luidheidsvariasie van die gehoorgestremdes oor al die sinne negatief beoordeel is. d1t wil dus voorkom asof die gehoorgestremdes wei 'n groot luidheidsvariasie vertoon, maar dat dit waarskynlik ongekontroleerd of ontoepaslik the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) suprasegmentele spraakeienskappe van prelinguaal gehoorgestremde kinders met kogleere inplantings, gehoorgestremde kinders sonder inplantings en normaalhorende kinders 71 is en daarom deur die luisteraars as abnormaal beskou hill-brown, 1985; davis & hardick, 1981). dit blyk egter word. dit is opvallend dat die normale groep ook 'n groot dat die spraakspoed van die kogleere groep groter mate van luidheidsomvang vertoon, maar dat dit deur die ooreenstemming to on met die van die normaalhorendes in luisteraars as normaal beskou word. drie van die vier sinne wat geproduseer is. abnormale variasie 5 te veel variasie ,4 normale variasie 3 min variasie 2 geen variasie sinslipe 1 sinstipe 2 sinstipe 3 sin stipe 4 figuur 3.a: perseptuele analise 25,--------------------------------, 20 t----------m 15 desibel (db) 10 sinstipe 1 sinstipe 2 sinstipe 3 sinstipe 4 figuur 3.b akoestiese analise figuur 3: grafiese voorstelling van die groepsgemiddelde vir luidheidsomvang spraakspoed die normaalhorende groep se spraakspoed is oorwegend as normaal beoordeel, met die uitsondering van sinstipe 1 soos blyk uit figuur 4a. die -gehoorgestremdes se spraaks'poed is oor die algemeen as normaal tot stadiger as normaal beoordeel. die grootste variasie in hierdie groep se spraakspoed kom by sin stipe 4 voor, met perseptuele beoordelings wat vanaf ~bnormaal stadig tot normaal wissel. vit die literatuur is: dit ook duidelik dat uitermatig gehoorgestremde person~ geneig is om 'n stadiger as normale spraakspoed te vertoo~jkirk & hill-brown, 1985; davis & hardick, 1981; coles, 1990), en dat hulle stadiger spraakspoed geneig is om die ritme en kwaliteit van hul spraak negatief te belnvloed (kirk & hill-brown, 1985). die kogleere groep se produksie van spraakspoed is vir beide sinstipe 1 en 2 is perseptueel beoordeel as tussen 'n normale tot vinniger as normale spraakspoed. in sinstipe 3 is die groep se spraakspoed as normaal en sinstipe 4 as stadiger tot normaal beoordeel. die normaalhorende en kogleere groep is dus meer geneig om 'n normale tot vinniger spraakspoed te he, terwyl die gehoorgestremde groep se spraakspoed deurlopend stadiger tot normaal was. die akoestiese analises van die normaalhorende groep se spraakspoed, to on die hoogste groepsgemiddeldes vir al vier die sinstipes. 800s voorgestel in figuur 4b is dit duidelik dat die gehoorgestremde groep se spraakspoed die stamgste is vir drie van die sinstipes. dit stem ooreen met waamemings van ander navorsers (coles, 1990; kirk & die perseptuele en akoestiese resultate stem dus ooreen en die gelntegreerde resultate dui daarop dat die kogleere groep 'n stadiger spraakspoed as die normaalhorende groep vertoon, maar dat hul spraakspoed waarneembaar vinniger as die van die gehoorgestremde groep is. dit blyk dus uit die ondersoek dat die kogleer gelnplanteerde kinders se suprasegmentele spraakeienskappe, in 'n verskeidenheid van linguistiese kontekste, 'n groter ooreenkoms toon met die van die normaalhorende groep as met die van die gehoorgestremde groep. abnormaal vinning 5 ,--------------------------------, vinniger as norrnaal 4 t-.,,---.----,-------,--,-------------------: normaal3 stadiger as normaal 2 abnormaal stadig 1 +-____ ~ ____ ~ ______ ~ __ ~ __ sinstipe 1 sinstipe 2 sinstipe 3 sinslipe 4 figuur 4.a: perseptuele analise sillabes per. sekonde sinstipe 1 sinstipe 2 sinstipe 3 sinstipe 4 figuur 4.b: akoestiese analise , " ormaal gehoorgestremd figuur 4: grafiese voorstelling van die groepsgemiddelde vir spraakspoed gevolgtrekkings die ondersoek verskaf 'n vergelykende beeld van die suprasegmentele spraakeienskappe van jorig kindel's met uiteenlopende gehoorvermoens en ouditiewe moniteringsopsies. bevindings dui daarop dat prelinguale gehoorgestremde kindel's grootliks baat vind by die terugvoer en monitering wat die kogleere inplantingstegnologie bied. die studie toon dat diejong prelinguaal gehoorgestremde kind binne twee jaar na 'n kogleere inplanting, reeds sekere suprasegmentele spraakvaardighede bemeester. daar is verdere aanduidings dat sodanige vaardighede by kogleergelnplanteerdes 001' die algemeen, betel' ontwikkel is as by gehoorgestremdes van dieselfde ouderdom wat van konvensionele gehoorapparaatgebruik maak. dit wil ook voorkom of die gelmplanteerde kindel's tot so 'n mate voordeel trek uit die tipe stimulasieen terugvoer wat hul ontvang, dat hul suprasegmentele spraakvaardighede binne enkele jare na inplantering reeds ooreenkoms to on met die die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 72 van normaalhorende kinders van dieselfde ouderdom. dit is egter belangrik om in gedagte te hou dat die studie 'n beperkte aantal proefpersone ingesluit het en dat die resultate van die studie waarskynlik nie sondermeer veralgemeen kan word nie. individuele verskille tussen die proefpersone in 'n kleiner groep kan die beeld wat die groep as 'n geheel vorm makliker belnvloed. die resultate verskaf nogtans 'n sterk aanduiding van die positiewe invloed van 'n prelinguale kogleere inplanting op die produksie van suprasegmentele spraakeienskappe by jong kinders. 'n aanbeveling vir verdere ondersoeke in die verband is dus die insluiting van 'n groter aantal proefpersone wat die veralgemening van bevindings kan ondersteun. dit is egter ongelukkig so dat die aantal kogleer-gelnplanteerde persone relatiefbeperk is. slegs spesifieke suprasegmentele eienskappe is in die studie ondersoek, en dit gee dus nog net 'n gedeeltelike beeld van die proefpersone se produksie van suprasegmentele spraakeienskappe. die ondersoek van suprasegmentele eienskappe in spontane spraakuitings van jong, pre linguaal-gelnplanteerde kinders, waardeur spesifieke suprasegmentele aspekte in 'n natuurlike linguistiese konteks geevalueer kan word, mag verder interessante inligting verskaf. die tweeledige aard van die ondersoek, wat 'n perseptuele sowel as akoestiese analise ingesluit het, het bygedra tot groter insig in die aard van die suprasegmentele eienskappe. die benadering word sterk aanbeveel vir verdere studies in die verb and, om 'n meer volledige beeld van die aard van suprasegmentele spraakeienskappe te verkry. die bevindings van die studie is 'n verdere aanduiding van die positiewe gevolge van kogleere inplantings, en bevestig die beeld wat uit ander navorsing met betrekking tot die spraakproduksie van kinders met kogleere inplantings na vore kom (cummings, groenewald, hugo, coetzee & van der linde, 1995; tye-murray et ai., 1995; kirk & hill-brown, 1985). osberger (1994) noem dat 'n kogleere inplanting 'n opmerklike voordeel vir die ontwikkeling van spraakpersepsie en spraakproduksie by uitermatig gehoorgestremde kinders inhou en dat die prestasie van hierdie kinders tot dusver selfs die verwagtinge van die meeste professionele betrokkenes en ouers oortref. sy spreek die mening uit dat geen ander sensoriese apparaat tot op hede so 'n dramatiese invloed op die verbetering van orale kommunikasie in uiterm:;j-tige gehoorgestremde kinders gehad het nie. die bevindings van hierdie studie dui daarop dat hierdie mening geregverdig is. verwysings boothroyd, a. 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(1981). praktiese fonetiek vir taalstudente:'n inleiding. durban: butterworth en kie. waltzman, s.b., cohen, n.l. & fisher, s.g. (1992). an experimental comparison of cochlear implant systems. seminars in hearing, 30, 195-207. ' the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) abstract introduction literature review conclusion acknowledgements references about the author(s) zumbi musiba sustainable communities, barrick gold corporation, dar es salaam, tanzania citation musiba, z. (2020). classification of audiograms in the prevention of noise-induced hearing loss: a clinical perspective. south african journal of communication disorders, 67(2), a691. https://doi.org/10.4102/sajcd.v67i2.691 note: special collection: occupational hearing loss in africa. original research classification of audiograms in the prevention of noise-induced hearing loss: a clinical perspective zumbi musiba received: 31 oct. 2019; accepted: 05 feb. 2020; published: 03 mar. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: noise induced hearing loss (nihl) is a major contributor to disabling hearing loss. engineering controls are superior to hearing protection devices (hpds) in prevention of occupational noise induced hearing loss (onihl), although the latter are more commonly used. effective use of audiometry requires quick categorization of audiograms. the uk health and safety executive (ukhse) scheme for the categorization of audiograms is a tool that accomplishes this. objectives: the objective of this paper is to provide an overview of the classification of audiograms and build a case for the preferential use of the ukhse’s scheme to achieve this. method: the author provides a literature review of methods of classification for audiograms and uses a case study in a tanzanian mining company to demonstrate how the ukhse scheme was successfully used to enhance the existing hearing protection program. results: the literature review identified several methods of classification based on a variation of threshold shifts from baseline. the difference was in the frequency and level of threshold shift used to determine hearing loss, and the recommended course of action once hearing loss is detected. the ukhse scheme is simple and provides guidance on steps to be taken thereafter. this was demonstrated in a case study among miners in a mining company in tanzania. conclusion: the ukhse audiogram classification scheme has the advantage of providing a straightforward, easy to determine classification that allows for intervention appropriate to the findings. keywords: onihl; audiogram classification; hearing surveillance; threshold shift; ukhse categorization scheme; audiometry; hierarchy of controls. introduction occupational noise-induced hearing loss (onihl) contributes significantly to the burden of disabling hearing loss (nelson, nelson, concha-barrientos, & fingernut, 2005). the mechanisms by which noise causes hearing loss and the available options for prevention have been studied extensively and have been well known for decades (morata & meinke, 2016). interestingly, the prevalence of onihl continues to rise despite the knowledge available for its prevention. the rise is most prominent in lowand middle-income (lami) countries and may be related to industrialisation (nyarubeli et al., 2019). it is well known that the best way to prevent onihl is to follow the hierarchy of controls with elimination, substitution or engineering methods of controlling noise at the source being more effective than methods further down the hierarchy such as use of hearing protection devices (hpds). although the principle of the hierarchy of controls is widely accepted, there are few, if any, studies that have evaluated the impact of engineering controls on the reduction of noise exposure and ultimately onihl (morata & meinke, 2016). there is, however, a plethora of studies that have examined the efficacy of hpds and hearing surveillance; two methods lower down, if not at the bottom of, the hierarchy of controls. this trend of hierarchy reversal has its roots in the significant challenges with instituting controls higher up the ladder (moroe, khoza-shangase, madahana, & nyandoro, 2019). because hpds seem to be the bedrock of hearing conservation programmes (hcps), this article seeks to provide an overview on classifications of audiograms, with a case built for the use of a specific classification – the uk health and safety executive (ukhse) scheme for the categorisation of audiograms as a valuable tool for the early recognition and early intervention for protection from onihl. literature review noise-induced hearing loss (nihl) is prevalent in many industries on the african continent and the world at large. historically, there have been very few studies conducted on onihl in african countries, as priority was given to primary healthcare issues. over the years, data have been collected on this subject as occupational health practice begins to take root in areas where it did not previously exist (stevens et al., 2011). the prevalence of onihl seems to be dependent on the method used to define it. the methods used to define onihl vary from the use of the classical boiler makers’ notch to the use of average hearing thresholds at the frequencies most affected by noise (regis, crispim, & ferriera, 2014). in ghana and tanzania, there have been studies conducted in the mining, textiles and steel industries. the results were rather alarming as the prevalence rates were high and seemed to affect a fairly young age group. these studies include the one conducted in tanzania among miners where the prevalence of onihl was 47% with the youngest age group of 20–29 years being most affected (musiba, 2015). in another study among textile workers in tanzania, the prevalence of nihl was found to be 58.8% (abraham, massawe, ntunaguzi, kahinga, & mawala, 2019). a cross-sectional study among tanzanian steel workers revealed a prevalence of onihl of 48% (nyarubeli, tungu, moen, & bratveit, 2019). in ghana, a study conducted among gold mine workers showed a prevalence of 23% (amedofu, 2002). the huge burden of onihl and the bid for industrialisation in most lami countries such as tanzania requires comprehensive hcps that adequately protect workers’ hearing. the term ‘reasonably practicable’ is often used in safety science to denote the need for a risk–benefit analysis for using a particular control or intervention. this practice translates to whether or not the management of a company, with advice from relevant safety professionals, sees the benefit of instituting the control as far outweighing the risk of not doing so. because of the cost and technical difficulties, compounded by the time limit factor in mining, the industry heavily relies on the use of hpds (fausti, wilmington, helt, helt, & martin, 2005). given the pressure to deliver results in a cost-effective manner, employers are more likely to lean towards the cheaper and less effective control measures further down the hierarchy of controls, such as hpds (suter, 2012). this phenomenon, which has great significance in relation to onihl, has also been observed in the construction industry in australia (kosny et al., 2016). morata and meinke (2016), in their review of hcps, could not find any papers addressing the effectiveness of engineering controls. the reviewed publications mostly dealt with the use of hpds, training on the recognition of onihl hazards and on the proper use of hpds and hearing surveillance (morata & meinke, 2016). given the heavy reliance on hpds, audiometry presents a unique opportunity to identify at-risk individuals or those who already suffer from onihl. one of the benefits specific to the work context is that of preventing the condition or protecting a non-suspecting onihl worker from the hazards of being unable to hear warning sirens or signals (mcbride, 2004). the value of audiometry lies in the interpretation of the results and actions taken thereafter, without which it is a compliance tick in the box with very little benefit to the workforce. there are a number of audiogram interpretation or classification options available – all having their associated advantages and disadvantages. unfortunately, most of them are geared towards compensation for hearing impairment. in south africa, the percentage loss in hearing (plh) has previously been used for the purposes of hearing conservation and compensation (bronkhorst & schutte, 2013). the method requires a baseline audiogram which ‘serves as a reference value’ for comparison with periodic measurements to determine loss in hearing. much as this method is effective when used competently, the requirement of a baseline audiogram is challenging, given that labour in the most at-risk industries is often mobile and workers rarely have access to their baseline audiograms. furthermore, the calculations required may preclude classification of audiograms in busy centres. the method is now solely used for compensation and a new regulation based on standard threshold shift (sts) has been adopted. the regulation 839 issued by the department of mineral resources advocates the use of sts based on a ‘mile stone baseline’. the mile stone baseline is described as a current audiogram taken under prescribed conditions which serves as the audiometric zero. the sts is defined as (south african department of mineral resources, 2016): [a]n average change in hearing of 10 db or more at frequencies of 2000 hz, 3000 hz and 4000 hz in one or both ears as compared to the employee’s milestone baseline audiogram. (n.p.) although a much better classification method than the plh, it gives little guidance on what steps are to be taken other than reporting to the employer and counselling the employee. this method is very similar to that adopted by the us occupational safety and health administration (osha) which also uses a standard threshold shift (osts). the major difference lies in the option for age adjustment of hearing levels using standard tables to account for age-related hearing loss (osts-a). in addition, the us method provides specific instructions on steps to be taken when osts is detected. the national institute for occupational health and safety (niosh) advocates what it calls a significant threshold shift (nsts), defined as a 15-db change from baseline at any test frequency. the method discounts correction for age and requires a third audiogram to confirm the sts. in terms of steps to take when an sts is detected, the niosh method provides clear guidance including retraining of employees on noise hazards, the use of hpds and relocation to a quieter work environment. a study comparing the nsts, osts and osts-a methods in terms of hearing impairment detection showed a higher prevalence for the nsts than the other two methods. the prevalence using the osts and osts-a methods yielded 36% and 74% less detections, respectively, than the nsts method (masterson, sweeney, james, themann, & wall, 2014). despite all its merits, the nsts is only a recommendation and not a legal compliance requirement. this means employers are at liberty to choose the osts method that is less onerous and is a statutory requirement. in addition, its indiscriminate use of any test frequency reduces its specificity towards identifying onihl. in the same vein, an alternative method uses the temporary threshold shift (tts) that occurs immediately after exposure to predict the likelihood of a significant threshold shift (mcbride, 2004). the ukhse developed a simple and practical method for categorising audiograms (codling & fox, 2017). this method utilises the sum of hearing thresholds at 1 khz, 2 khz, 3 khz, 4 khz and 6 khz as compared to reference tables stratified by sex and age to determine the level of hearing (musiba, 2015). the audiograms are ultimately categorised into acceptable hearing, mild hearing impairment, poor hearing and rapid hearing loss (as depicted in table 1). this classification also sets levels for warning the employee of impending onihl or for referral to an ent specialist (table 2). this method provides a simple and straightforward means for the classification of audiograms, which comes complete with steps that should be taken in terms of hearing conservation. the age stratification, which is part of this method, has the advantage of taking presbycusis into consideration such that age-related hearing loss is not used to exclude older employees from gainful employment. table 1: uk health and safety executive categorisation scheme based on sum of hearing at 1 khz, 2 khz, 3 khz, 4 khz and 6 khz. table 2: uk health and safety executive categorisation according to age bands. the ukhse categorisation scheme has come under great criticism for not utilising the characteristic notch at 4 khz, which is regarded as an early sign pathognomonic of onihl. in addition, the criticism has arisen because of the use of a predominantly urban caucasian reference population to formulate the classification; therefore, this scheme has limited generalisability (cheesman & steinburg, 2010). the justification for gender-based thresholds has also been criticised for not having a scientific basis (cheesman & steinburg, 2010). as much as this criticism may be valid, the notch and the shape of the audiogram are still available to the occupational physician or practitioner interpreting the audiogram. it would, therefore, be a matter of just a glance at 4 khz to check for the presence of the characteristic notch in addition to the summation of the frequencies most affected by onihl. in short, all the data used to assess the results of audiograms in other categorisation or classification schemes are readily available on the audiogram for the sceptics to use to supplement the diagnosis. limitations of the scheme for use in lami contexts such as africa include the fact that no specificity or sensitivity tests have been conducted to compare it against other available methods in a predominantly ethnic group. in addition, because of the small number of occupational physicians, ent specialist referrals may not be as effective as they are in developed countries such as the uk that has an abundance of such practitioners. the tanzanian case although there is no doubting the fact that the most effective controls for onihl are higher up in the hierarchy of controls, and include substitution for quieter equipment, elimination of processes that generate excessive noise and automation, there are few studies evaluating the effectiveness of these controls (morata & meinke, 2016). the commonest controls utilised are hpds. it is worth noting that the use of hpds is affected by risk perception and comfort (le, straatman, lea, & westerberg, 2017). in addition, poor enforcement of legislation, coupled with more pressing priorities, leave workers exposed to noise levels that are detrimental to their hearing (ologe, 2006). audiometry, a health surveillance tool, can be used to motivate workers to protect their hearing and to invest in engineering controls. in order for audiometric results to be used in this manner, audiograms ought to be classified and data presented in a manner that allows both the employer and employee to make sound decisions. in 2015, the ukhse categorisation of audiograms was used to determine the prevalence of onihl among miners in a tanzanian mining company (musiba, 2015). prior to this, audiograms were not classified and therefore most cases of onihl were only detected during exit medical examinations. once the cases were deemed to be occupational in origin, the affected employees received compensation and now had to deal with a life of disability. using the ukhse categorisation scheme, historical audiograms were classified and an nihl prevalence of 47% was determined. the data were used to develop a procedure that required occupational health practitioners who conducted audiometry to classify audiograms immediately after audiometry so as to determine the next step in the care of at-risk workers. workers exceeding the warning level were to receive in-depth counselling on noise as a hazard and the proper use of hpds. those who exceeded the referral limit were sent to an ent specialist for examination and a diagnostic audiogram. workers returning from an ent visit would be required to go through a return-to-work process that manages the risk of onihl. this was to include audiometry at a frequency determined by the severity of hearing impairment and occupational hygiene measurements of their workplace. individuals that were at high risk of worsening the severities of onihl were to be reassigned to work that significantly reduced the risk. to date, the procedure is firmly in place and has ensured the place for audiometry in the company’s hearing protection programme. conclusion health surveillance through audiometry plays a key role in hearing conservation. the practice is beneficial only if it prompts the correct actions towards preventing nihl. in order for audiometry to be effective, assuming that the technicians are competent and the equipment adequately calibrated, the audiograms need to be classified. the classification utilised ought to also be able to prompt occupational health practitioners to take the next vital step in preventing nihl. unfortunately, the majority of classification methods seem to be more suitable for compensation than for prevention purposes. the ukhse audiogram categorisation scheme is simple and straightforward and requires basic addition skills. furthermore, it prompts specific actions for every level of hearing threshold determined. coupled with adequate training in the identification of noise hazards and the correct use of hpds, the scheme can be a valuable tool in the prevention of nihl. the method was used successfully in a tanzanian mining company and continues to assist the early diagnosis and intervention of onihl. acknowledgements competing interests the author declares that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. author’s contributions z.m. is the sole contributor for this article. ethical considerations this article followed all ethical standards for a research without direct contact with human or animal subjects. funding information the author thanks the national institute for the humanities and social sciences (nihss) and the consortium for advanced research training in africa (carta) for providing financial assistance for the 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(2012). engineering controls for occupational noise exposure: the best way to save hearing. sound and vibration 45th anniversary issue, pp. 24–31. a n a t o m y a n d p h y s i o l o g y of speech h a r o l d m . k a p l a n head, department of physiology, southern illinois university mcgraw hill book co., inc., new york. 1960 this book by a. m. kaplan represents a milestone in the literature of speech pathology. for many years the need has been felt for a concise presentation of the anatomy and physiology of the speech mechanism. up to now the speech therapist has been frustrated by the arduous task of piecing together information derived from many sources not particularly orientated towards speech and attempting to apply it to his particular field of work. kaplan states that his study "attempts to unify the present known and prominent anatomical and physiological data into an orderly account of the normal sensory and motor aspects of speech". he directs the text to students of speech. he has as the central theme of the book the operational method by which man transmits information. he considers the importance of the fact that the structures involved in speech production were not primarily concerned with speech. the text covers the regulators of speech (nervous, autonomic, and endocrine), the respiratory system, the larynx, the velopharyngeal mechanism, the nose and sinuses, the structures for articulation and the ear as a sound receptor. in his discussion of each aspect of the speech mechanism, kaplan always attempts to relate anatomical and physiological facts to speech production. his discussion of the larynx as "the structure for phonation" and his chapter on the applied anatomy and physiology of the larynx illustrate this well. througout the text references to speech production occur, e.g. in dealing with the function of salivary glands, kaplan points out that "with decreased salivary flow, the movements of the lips, tongue, and cheeks against the teeth are accomplished less smoothly and efficiently. this condition handicaps speaking or singing". the speech therapist is thus provided with an abundance of information which leads to a clearer understanding of the problems with which he is often faced. the wealth and basic quality of the information presented make this book one of outstanding value — an essential to every therapist. its detail makes it particularly valuable to the graduate therapist, but a little complicated for the student therapist. however, there is no doubt that the beginner could gain much from this book. freida abrahamsohn journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) p a r e n t a l p e r c e p t i o n s a n d p r a c t i c e s of e m e r g e n t l i t e r a c y d e v e l o p m e n t in y o u n g c h i l d r e n w i t h d o w n s y n d r o m e : t h e d e v e l o p m e n t of i n t e r v e n t i o n g u i d e l i n e s cherie van heerden and alta kritzinger clinic for high risk babies (chrib) centre, university of pretoria, south africa key findings of emergent literacy research conclude that emergent literacy experiences correlate with later reading successandthatemergentliteracyinterventionforchildrenwith special needsisessential.asagroup with special needs, children with down syndrome require emergent literacy intervention.they may attain functional literacyskillsandtheirlanguagedevelopmentdeterminestheirreadingability.speech-language therapists have an important role to play in emergent literacy programme development in south africa. as a first step towards programme development and emergent literacy intervention goal selection, the aim of this study was to determine the applicability of a self-administered questionnaire to describe parental perceptionsandpracticesregardingtheemergentliteracydevelopmentoftheiryoung children with down syndrome. aquantitativeresearchapproachwasusedwithinacross-sectionaldescriptivesurvey.fifteenliter ate parents, with preschool children with down syndrome aged between two and five years were selected asparticipants.datawerecollectedviaemailand/orfacsimile.theresultsshowedthatallparticipantsvalued emergent literacy development.they appeared to have knowledge about book-reading but not about the broad spectrum o f emergent literacy experiences to which they might expose their children. participants were actively promoting emergent literacy development of their children, but they had certain needs that could potentiallybeaddressedbyspeech-languagetherapistsworkinginearlycommunicationintervention. the questionnaire proved to be applicable, but changes are required for application with illiterate parents andthosewith lowliteracyskills.basedontheresultsaframeworkwithguidelinesforemergentliteracygoal selection is provided. ! keywords: emergent literacy development; parental perceptions; emergent literacy intervention; down syndrome; earlyjcommunication intervention. as a developmental construct emergent lit­eracy has become a dynamic field o f study in recent years. key research findings such as the correlation between emergent literacy experi­ ences and later reading success, and the necessity of emergent literacy intervention for children with spe­ cial needs (ezell & justice, 2 0 0 5 ), focus the attention on the importance o f emergent literacy knowledge and facilitation skills for all involved in early child­ hood interventions. in the u sa , a s h a (2001) advocates the view that speech-language therapists play an important role in promoting literacy for young children with commu­ nication disorders. however, there appears to be a dearth o f information on the promotion o f emergent literacy development across the diverse spectrum of south african contexts, despite the fact that many young children are at risk for communication dis­ orders and have special needs. apart from a major study by willenberg (2007) on the emergent literacy competencies o f grade r learners on the cape flats in the western cape province and the development o f an assessment tool for young children, the inclu­ sion o f literacy skills in early communication as­ sessment protocols (kritzinger 6c steenkamp, 20 0 6 ; kritzinger &c louw, 2 0 0 2 ), and minor surveys such as kritzinger and louw (1997), pieterse (1998) and prinsloo (1998) to determine awareness o f emergent author contact: cherie van heerden an d alta kritzinger, clinic f o r high risk babies (chrib) centre, university o f pretoria, lynwood road, pretoria, 0001 south africa th e s o u t h a fr ic a n j o u r n a l of c o m m u n ic a t io n disord er s, v o l . 5 5 2 0 0 8 37 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) cherie v a n heer den a n d alta k r itzin g er literacy skills among parents, little is known about interven­ tion efforts by speech-language therapists in south africa during the earliest stage o f literacy development. in a literate context, emergent literacy represents the first stage (birth to five years), followed by the early literacy stage (five to seven years) on the continuum o f literacy develop­ ment (justice, 2 0 0 6 ). according to ezell and justice (2005), emergent literacy describes the concepts, skills and knowl­ edge that preschool children acquire about the process o f reading and writing before beginning their formal educa­ tion. em ergent literacy not only refers to the child’s foun­ dational skills o f print knowledge, but also includes phono­ logical awareness, writing skills such as invented writing and name writing, and oral language skills, which include gram­ mar, vocabulary and narration. although emergent literacy development is closely related to language and communica­ tion development (owens, 2 0 0 5 ), it constitutes a separate developmental construct and is not merely a useful medium to facilitate early language development. typical characteristics o f children in the emergent lit­ eracy stage o f development include having a keen interest in print despite not being able to read, viewing themselves as being able to read, particularly with familiar storybooks, playing with writing utensils and media, viewing their read­ ing and writing attempts as meaningful, using and enjoy­ ing books as a play or relationship-building activity, play­ ing with the phonology o f oral language, such as reciting or making up rhymes, identifying alliterative patterns across words, demonstrating awareness o f words, syllables, pho­ nemes and numbers, and utilising literacy themes or props within their dramatic play. exposure to print includes be­ ing made aware o f print in books and in the everyday envi­ ronment such as street signs and brand names on products, the ability to handle books correctly, the knowledge o f print directionality and the knowledge o f major book elements, such as knowing that the cover o f a book holds the title o f the book, as well as exposure to numeracy skills (boudreau, 2002; buckley, 2 0 0 0 ; justice, 2 0 06). since acquisition o f these diverse emergent literacy char­ acteristics and skills facilitates successful reading at a later stage (ezell & ju stice, 2 0 05), emergent literacy development should begin very early in a child’s life. exposure to a rich variety o f books at home, in early childcare settings and pre­ schools is assumed. em ergent literacy centers around books and may be viewed as a non-essential commodity when re­ sources are scarce. these important developmental experi­ ences may not be accessible to all children in south africa, including those with special needs. l ocal research is there­ fore needed to determine the nature o f emergent literacy development in young children from families who represent the entire spectrum o f literacy, from fully literate, to those with low literacy skills, to illiteracy. d ata obtained can direct emergent literacy intervention programmes to train parents and caregivers to optimise the emergent literacy stage o f young children with various special needs. the involvement o f parents and caregivers in emergent literacy development is consistent with the emergent literacy intervention ap­ proach (justice, 2 0 0 6 ) and the principles o f early communi­ cation intervention (rossetti, 2 0 01). according to kumin (2003) reading can be a very suc­ cessful route in assisting children with down syndrome to learn language, and emergent literacy experiences have posi­ tive effects on receptive and expressive language, cognitive and memory skills. em ergent literacy skills were found to enhance a young child’s vocabulary, speech and other ex­ pressive language skills such as syntax, morphological skills and syntax length, the initiation o f conversation, under­ standing o f concepts and awareness o f sound structure. the future learning o f young children with down syndrome is also enhanced as emergent literacy promotes reading and writing, educational progress, inclusion, independence, op­ portunities for employment and quality o f life (boudreau, 2 0 0 2 ; buckley, 2 0 0 0 ; elias, hay, homel, 8c freilberg, 20 0 6 ; ezell 8c justice, 2 0 0 5 ; kumin, 2 0 0 3 ). since many children with d ow n syndrome can attain functional literacy skills in inclusive education (bochner, outhred 8c pieterse, 20 0 1 ) and the finding that language skills are a strong predictor o f their reading ability (boudreau, 2 0 0 2 ) it is important that parents and caregivers are sufficiently informed about the long-term effects o f early communication and emergent lit­ eracy intervention. inform ation on the advantages o f emergent literacy skills and parental involvement are available to south african parents with children with down syndrome and who have access to the internet, on the down syndrome association o f south africa website (www.downsyndrome.org.za/main. aspx?artid=67).the association is also involved in promoting literacy in a paper-based publication, the d ow n syndrome b ulletin (2000, 2 0 0 1 , 20 0 2 , 2 0 0 3 and 2 0 06). the question remains as to whether parents actively promote the emer­ gent literacy skills o f their children with down syndrome or i f they only have the knowledge o f emergent literacy devel­ opment but do not put this knowledge into practice. the advantages o f emergent literacy intervention are en­ hanced when children have access to literacy experiences in their homes (ezell 8c justice, 2 0 0 6 ). according to owens (2006) o f all the factors predicting reading success, early book-reading practices by parents to their children and a literate atmosphere at home appear to be most important for early reading success. elias et al. (2006) confirm that the, frequency and quality o f parent-child reading is an impor­ tant determinant o f a child’s later literacy attainment. kad-j eravek and justice (2004) emphasize that parents can be! literacy facilitators, which implies that literacy can be fa-! cilitated throughout the day in a number o f different ac tivities. according to roberts, jurgens and burchinal (2005) the responsiveness and support o f the home environment is the strongest and most consistent predictor o f children’s language and emergent literacy skills. these research find­ ings confirm the importance o f parent involvement in sup­ porting emergent literacy development. yet, it appears that they may not always sufficiently facilitate emergent literacy development in their children. ^ according ezell and justice (2005) there is considerable variation among american school children in language and literacy skills when they enter the early literacy stage. the variation may be partly due to insufficient exposure to lan­ guage-rich experiences during adult-child storybook read­ ing. a local study by kritzinger and louw (1997), described the book-reading practices o f 25 mothers and their young 38 | die su id -afr ika an setydsk r if vir k o m m u n ik a s ie -a fw y k in g s , vo l. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.downsyndrome.org.za/main t h e d e v e l o p m e n t o f in t e r v e n t io n g u id e l in e s children, 0 -2 years old with risks for communication dis­ orders. the results indicated that only 36% o f the mothers were aware o f the value o f jo in t book-reading, 12% were unsure and 52% were unaware o f the value o f jo in t book reading. in contrast with the majority o f participants’ lack o f knowledge about the benefits o f book-reading, a study by prinsloo (1998) showed that 80% o f the parents with infants aged 6 -2 4 months with down syndrome knew that their children could benefit from early jo in t book-reading. these two studies focused on jo in t book-reading activities only and not on the broader perspective o f emergent lit­ eracy experiences. furthermore, these studies were already conducted nine and ten years ago. i t is therefore important to continue investigating emergent literacy development in children with d ow n syndrome so that guidelines for emer­ gent literacy programme development may be obtained. as research participants, parents and caregivers may be utilised to determine strengths and areas o f need in their children’s emergent literacy experiences (bennett, w eigel 8c m artin, 2 0 0 2 ). since children with down syndrome repre­ sent a group with special needs that requires emergent lit­ eracy and early communication intervention to optimize success in inclusive education (kumin, 2 0 0 3 ), their parents were targeted in the present study. i t was not known to what extent parents expose their children to the wide range o f ac­ tivities associated with emergent literacy skills and the value they placed on the development o f these skills in their chil­ dren with down syndrome. moreover, it appears there is a dearth o f research on emergent literacy development in children with down syndrome within the south african context. the available literature mostly describes the a meri­ can and british contexts, including the work o f authors such as bird and buckley (2007), boudreau (2002) and kumin (2003). in order to start the process o f emergent literacy pro­ gramme development, and to involve parents from the be­ ginning, a self-admlinistered questionnaire was developed to determine parental perceptions o f the broad spectrum o f emergent literacy activities and what they report doing regarding emergent; literacy development in their children. the research question was how applicable the questionnaire proved to be as a tool to determine a literate sample o f par­ ents’ perceptions and practices o f emergent literacy support o f their children, and i f clinical guidelines might be gained from the results. method aim s o f the study the main aim o f the study was to determine the appli­ cability o f a self-administered questionnaire to describe pa­ rental perceptions regarding emergent literacy development in their young children with down syndrome in order to provide guidelines for clinical practice in an emergent liter­ acy intervention programme. the following sub-aims were identified to achieve the main aim: t o determine the value parents attach to the de­ velopment o f emergent literacy development in their young children with down syndrome. to describe the materials parents report using to facilitate the development o f emergent literacy in their chil­ dren. to describe parental reporting on how they facili­ tate the emergent literacy development o f their children. to determine the parental perceptions o f the time they spend on facilitating the emergent literacy develop­ m ent o f their children. to determine the needs o f parents to facilitate emergent literacy development in their children. research design the research study took the form o f a cross-sectional sur­ vey. data on parental perceptions regarding emergent lit­ eracy development o f young children with d ow n syndrome were collected on ce-off and described without determining relationships between the variables. a self-administered questionnaire with mostly closed ended questions was used to collect data. d ata were there­ fore measurable and could be described quantitatively. since quantitative research uses methods that enhance objectivity when variables are measured, conclusions may be less biased (leedy 8c ormrod, 2 0 05). a self-administered question­ naire allowed participants to complete the questions at their own time, without interference from the researcher. self-ad ministered questionnaires were successfully used in previous studies with parents o f children with down syndrome such as bennett et al. (2002) and boudreau (2005). this data col­ lection method also permits anonymity, although it may be compromised when the questionnaire is returned via email or facsimile. the use o f electronic media for data collection, however, did not lim it the participants to a small geographi­ cal area and avoided possible delays with postal services. research ethics e thical clearance was obtained from the research e th ­ ics com m ittee o f the departm ent o f communication pa­ thology, university o f pretoria, before commencing with data collection. informed consent was obtained from all the research participants. the participants were informed that they could withdraw from the study at any point in the re­ search process. data were analysed and reported anonymously, although the one researcher knew the participants’ identities, as she received the questionnaires. w h en questionnaires were re­ turned, all identifying information such as facsimile num­ bers and email addresses were removed from the copies and coded. a t the time o f data analysis the questionnaires could not be traced back to any specific participant. no deception was used and data were analyzed and reported from a group perspective. a ll data were treated with confidentiality and were securely stored according to university regulations. participants since the study targeted literate parents o f young chil­ dren with d ow n syndrome (two to five years) to determine the applicability o f the questionnaire for this group, a lim­ ited number o f participants were available. the research par­ ticipants were selected according to the following criteria: parental status the research participants were the parents (mothers and/ or fathers) o f young children with down syndrome, between the ages o f two to five years. according to kumin (2003) and buckley (2000) young children with d own syndrome o f two to three years are usually able to learn to read. language proficiency and level o f education th e s o u t h a f r ic a n j o u r n a l o f c o m m u n ic a t io n diso rd er s, v o l. 5 5 2 0 0 8 | 39 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) c h e r if v a n heer den a n d alta k ritzin g er table 1. participant characteristics (n=15) c h a ra c te ris tic s v a lu e 1. age of parents (years) 26 -3 0 3 1 -3 5 36 -4 0 > 40 ye a rs m o th e rs: 1 4 7 3 f ath ers: 1 4 4 5 2. position of child with down syndrome in the family first: 6; second: 7; third: 2 t o ta l: 15 3. first language spoken at home english: 9; afrikaans: 5; southern sotho: 1 t o ta l: 15 4. additional languages spoken english: 4; afrikaans: 5; germ an: 1; french: 1; northern sotho: 1; swazi:1; no additional languages spoken: 2 t o ta l: 15 5. place o f residence pretoria: 3; hoedspruit: 1; johannesburg: 6; port elizabeth: 1; c ape town: 1; bloemfontein: 2; krugersdorp: 1 t o ta l: 15 6. level of education m a tric d ip lo m a d eg ree m o th e rs: 7 5 3 f ath ers: 6 5 3 7. em ployment of parents mothers: 15; fathers: 13 8. age of children with down syndrome r an g e: 2y4m to 5y a v e ra g e a g e : 3y10m 9. number of children in families only child: 3; two children: 8; three children: 3; four children: 1 t o ta l: 15 10. speech-language therapy 11 children w ere receiving speech-language therapy at the time of the study3 children received speech-language therapy in the past 1 child had never received speech-language therapy t o ta l: 15 the participants had to be liter­ ate and competent in english and/ or afrikaans in order to answer the questionnaire. this questionnaire was only available in english and afrikaans. as a first step in emer­ gent literacy programme develop­ ment, literate parents were target­ ed in this study. it was hoped that useful information might be gained from this study so that research tools might be designed for follow up studies with parents with low lit­ eracy and those with limited func­ tional literacy skills. access to technology the participants needed to have had access to either internet or fac­ simile facilities in order to be able to receive and return the question­ naires. access to the internet and facsimile were required, as these op­ tions are more efficient than postal services and suited the short dura­ tion o f the research project. geographical location since the study was conducted via email and/or facsimile, the par­ ticipants were not limited to a spe­ cific geographical region. for the purpose o f this study, in ­ clusion criteria did not require that the toddlers with down syndrome had received speech therapy in the past or were receiving therapy at the time o f the study. participant sampling design two sampling procedures were selected for this study, namely purposeful sampling and snowball sampling. a c­ cording to struwig and stead (2001), purposeful sampling provides a sample o f inform ation-rich participants as the participants show specific characteristics that the researcher is interested in. the down syndrome association o f south africa was contacted and a list with potential participants for the study was obtained. participants were also selected from the c linic for h igh risk babies (c h r ib ) research database, university o f pretoria. the c h r ib database con­ tains datasets o f families who have children with develop­ mental disabilities, including down syndrome (kritzinger, louw 8c rossetti, 2 0 0 1 ). families with children with down syndrome aged between two and five years old were recruit­ ed. additional participants were then obtained from infor ■mation provided by the initial participants, via snowball sampling (struwig 8c stead, 2 0 0 1 ) .this technique was used to locate possible participants for the study. p articipant selection procedure the down syndrome association o f south africa sup­ plied a list o f 16 parents with children with down syndrome aged between two and five years from their membership list. the head o f c h r ib granted permission to use the c h r ib database to identify possible participants in the study and a list o f nine families were obtained. a ll the potential par­ ticipants were contacted by telephone requesting their par­ ticipation in the research study. o f the 2 5 parents from the combined list received from the down syndrome asso­ ciation o f south africa and c h r ib database, 15 verbally agreed to participate. through snowball sampling, another nine parents were contacted and all o f these verbally agreed to participate. participant information brochures and letters o f informed consent were sent out to 2 4 parents with chil­ dren with down syndrome. | a total o f 15 parents sent their letters o f consent back and those parents were selected as participants for the rej search study. a ll 15 questionnaires were returned after one reminder. the participant characteristics are described in table 1. according to table 1, the characteristics o f the partici­ pants provide the following profile o f parents and their chil­ dren with down syndrome: the majority o f the parents were in their middle adult years, with the majority o f their chil­ dren with down syndrome being the second or third born child. this may indicate that the participants were^experi­ enced in parenting. w h ile the majority o f the families spoke english as their first language, most o f the families were bilingual. there were also a variety o f different languages spoken at home, reflecting the multilingual nature o f south african families (swanepoel, 2 0 0 4 ). the participants were geographically widespread, thus the means o f communica­ 40 | die suid -afr ika an se tydskrif vir k o m m u n ik a s ie -a fw y k in g s , v ol. 55, 2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t h e d e v e l o p m e n t o f i n t e r v e n t i o n g u id e l in e s table 2. content o f the questionnaire s f c t io n 1: b io g r a p h ic a l in f o r m a t io n c o n te n t j u s t if ic a t io n in fo rm a tio n w a s g a th e r e d a b o u t th e p a r e n ts ’ a g e , o c c u p a tio n a n d le v e l o f e d u c a tio n , th e ir to w n o f r e s id e n c e , la n g u a g e s s p o k e n , n u m b e r o f c h ild re n , p o s itio n o f th e ch ild w ith d o w n s y n d ro m e in th e fa m ily , a n d th e c h ild ’s a g e . t h is s e c tio n w a s im p o rta n t a s it p ro v id e s b a c k g ro u n d in fo rm a tio n re g a rd in g th e p a rtic ip a n ts a n d th e ir c h ild re n w ith d o w n s y n d ro m e . t h is p ro v id e d th e r e s e a r c h e r w ith d e e p e r u n d e rs ta n d in g o f th e fa m ily (s h ip le y & m c a f e e , 2 0 0 4 ) a n d th e d a ta w e r e u s e d to in te r p re t th e re s u lts . s e c t io n 2: t h e v a l u e o f e m e r g e n t l it e r a c y q u e s tio n s in c lu d e d a s k in g w h e r e p a r e n ts h e a r d a b o u t th e im p o rta n c e o f e m e r g e n t lite ra c y , w h e th e r th e y p a r tic ip a te d in d e v e lo p in g th e ir c h ild ’s e m e r g e n t lite ra c y a n d w h e r e th e y re c e iv e d th e ir in fo rm a tio n re g a rd in g th e im p o rta n c e o f e m e r g e n t lite ra c y . t h is s e c tio n p r o v id e d in fo rm a tio n p e rta in in g to th e s o u th a fric a n c o n te x t. it w a s im p o rta n t to d e te r m in e th e v a lu e p a r e n ts p la c e d o n e m e r g e n t lite r a c y so th a t s p e e c h -la n g u a g e th e r a p is ts m ig h t k n o w w h ic h g u id e lin e s s h o u ld b e p ro v id e d to fa m ilie s w ith c h ild re n w ith d o w n s y n d ro m e . e m e r g e n t lite ra c y fa c ilita te s c o m m u n ic a tio n d e v e lo p m e n t a n d a c a d e m ic le a r n in g skills in c h ild re n w ith d o w n s y n d ro m e (k u m in , 2 0 0 3 ) . s e c t io n 3: t h e m a t e r ia l s p a r e n t s u s e t o f a c il it a t e e m e r g e n t r e a d in g s k il l s q u e s tio n s w e r e a s k e d a b o u t th e ty p e s o f b o o k s p a r e n ts re a d to th e ir c h ild re n w ith d o w n s y n d ro m e , w h e r e th e y o b ta in e d t h e s e b o o k s , th e ir c rite ria fo r s e le c tin g b o o k s to r e a d a n d a d d itio n a l lite ra c y e x p e r ie n c e s to w h ic h th e child w a s e x p o s e d . it w a s im p o rta n t to id e n tify w h a t m a te r ia ls p a re n ts w e r e u sin g to fa c ilita te e m e r g e n t lite ra c y d e v e lo p m e n t. r e a d in g m a te ria l n e e d s to b e a g e a p p r o p r ia te in te r m s o f h o w th e b o o k n e e d s to b e h a n d le d (e .g . c a r d b o a r d p a g e s v e r s u s p a p e r p a g e s ) a n d w h a t kind o f in fo rm a tio n it p r o v id e s (e .g . s iz e o f print a n d ty p e s o f p ic tu re s ). l ite r a c y g o e s fa r b e y o n d b o o k -r e a d in g a n d is th u s im p o rta n t to d e te r m in e w h e th e r p a r e n ts e x p o s e th e ir c h ild re n to th e e n tir e s p e c tru m o f e m e r g e n t lite ra c y e x p e r ie n c e s (b o u d r e a u , 2 0 0 5 ) . s e c t io n 4 : s t r a t e g ie s a n d m e t h o d s p a r e n t s u s e t o f a c il it a t e l it e r a c y d e v e l o p m e n t q u e s tio n s w e r e a s k e d to d e te r m in e th e e n v ir o n m e n t in w h ic h th e child w a s re a d to a n d th e s tr a te g ie s p a r e n ts u s e d w h ile re a d in g to th e ir ch ild . i ! r e s e a r c h h a s s h o w n th a t c e r ta in s tr a te g ie s a n d m e th o d s , s u c h a s jo in t b o o k -r e a d in g , u s e d in e m e r g e n t lite r a c y c o n trib u te to th e d e v e lo p m e n t o f la n g u a g e skills (j u s tic e , 2 0 0 6 ) . it is im p o rta n t to d e s c r ib e h o w p a r e n ts e n h a n c e b o o k -re a d in g in o r d e r to p r o v id e a p p r o p r ia te g u id e lin e s . s e c t io n 5: f a c t o r s r e g a r d in g t im e a s p e c ts s u c h a s jth e a m o u n t o f tim e s p e n t re a d in g a n d th e tim e o f d a y th a t re a d in g o c c u rs , w e r e a d d r e s s e d . i m o r e tim e s p e n t o n e m e r g e n t lite ra c y d e v e lo p m e n t c a n re s u lt in m o r e b e n e fits fo r c o m m u n ic a tio n d e v e lo p m e n t (k a d e r a v e k & s u lz b y , 1 9 9 8 ) . id e n tify in g h o w m u c h tim e p a r e n ts s p e n d on lite ra c y a c tiv itie s m a y p ro v id e in fo rm a tio n w h e r e g u id e lin e s c a n a g a in b e g iv e n , s in c e c h ild re n w ith d o w n s y n d ro m e le a rn b e s t if m e a n in g fu l a c tiv itie s a re r e p e a te d o fte n (k u m in , 2 0 0 3 ) . s e c t io n 6: p a r e n t a l n e e d s q u e s tio n s re g a rd in g th e s p e c ific n e e d s p a r e n ts h a d re g a rd in g e m e r g e n t lite ra c y . a d d itio n a l s p a c e w a s p ro v id e d fo r p a r e n ts to s u p p ly th e ir s p e c ific n e e d s . t h e id e n tific a tio n o f p a r e n ta l n e e d s is a n im p o rta n t e m e r g e n t in te rv e n tio n p rin c ip le (r o s s e tti, 2 0 0 1 ) , if p a r e n ta l n e e d s a r e k n o w n , e m e r g e n t in te rv e n tio n m a y b e a p p lie d in a s s is tin g p a r e n ts to fo c u s o n th e e m e r g e n t lite ra c y d e v e lo p m e n t o f th e ir c h ild re n w ith d o w n s y n d ro m e . tion via email and facsimile were advantageous. a ll the par­ ticipants were well educated having completed matric and about h alf o f the parents had tertiary qualifications. m ost o f the parents were employed. the majority o f the children with down syndrome had siblings and thus had opportuni­ ties for interaction with other children. m o st o f the chil­ dren with down syndrome had received speech-language therapy, which could imply that the participants were aware th e s o u t h a f r ic a n j o u r n a l o f c o m m u n ic a t io n diso rd er s, v o l. 55 2 0 0 8 | 41 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) cherle v a n heer den a n d alta k r itzin g er o f the importance o f early communication intervention. m aterial the materials used in the study were the participant in­ formation brochure, letter o f informed consent and the self­ administered questionnaire. the questionnaire was made available in both english and afrikaans and targeted the ar­ eas based on the main and sub-aims o f the study. the ques­ tionnaire content and arguments to justify the inclusion o f questions are summarized in table 2. procedures a pilot study was conducted to determine whether the material and procedures were appropriate and applicable for the study. a parent with similar participant characteristics as the target group was selected. the child with down syn­ drome in the pilot study was aged 7, slightly older than the children in the main study in order not to utilize a partici­ pant from the limited pool o f participants available for the main study. the pilot study gave a clear indication that the questionnaire and information brochure would be suitable for the purposes o f the study. validity and reliability to ensure validity o f the data collection instrument, the questions in the questionnaire were based on a review o f recent literature regarding emergent literacy development o f children with down syndrome (bird 8c buckley, 2 0 0 7 ; bochner et al., 2 0 0 1 ; boudreau, 2 0 0 5 ). the pilot study in­ creased the reliability o f the questionnaire. the questionnaire was designed to ensure accurate and consistent data. reli­ ability amongst participants was further enhanced, as they all received the same questionnaire without prior knowledge about the questionnaire from the researcher. data collection the questionnaires were sent via email and/or facsimi­ le, according to the participant’s preference. questionnaires sent via email or mail may pose certain problems. there are often low response rates, at times the questionnaires may be completed by someone other than the intended participant and participants may not understand some o f the questions or how to complete the questionnaire (struwig 8c stead, 2 0 0 1 ). to ameliorate the disadvantages, the researcher en­ closed an information brochure explaining the value o f the research. the questions were easy to answer, well formulated and did not test knowledge. participants were encouraged to share their views and may have felt positive about the op­ portunity to report on their practices to develop their chil­ dren’s literacy skills. follow-up phone calls were made to remind participants o f the deadlines for returning the ques­ tionnaires, but care was taken not to pressurize participants to reach a point o f involuntary participation. data analysis the raw data were converted into more meaningful and interpretable information by means o f encoding. the encod­ ed information was entered on a spreadsheet (m icrosoft e x ­ cel© ). o nce the coding was done, the data were statistically analyzed and frequency counts, averages and ranges were determined. no inferential statistical analysis procedures could be carried out since the number o f participants was limited (leedy 8c ormrod, 2 0 05). text data were analysed according to recurring themes and reported as comments. results and discussion sub-aim 1: the value parents attach to the development o f emergent literacy development in their young children with d ow n syndrome a ll 15 participants valued emergent literacy develop­ ment. a total o f 87% o f participants regarded this devel­ opmental area as very important, while the remaining 13% viewed emergent literacy as moderately important. a study by prinsloo (1998) showed that 80% o f the parents valued the practice o f book-reading with their young children with down syndrome. the higher result obtained in the present study may be attributed to the time that has passed between the two studies and the improved resources and technology now available to parents. the high value placed by parents on emergent literacy development may also be a function o f the nature o f the study, i.e. parents could have concluded that a positive answer was desired. a few participants also explained why they placed such a high value on the emergent literacy development o f their children. reasons included the fact that they knew the im ­ plications o f emergent literacy on their child’s future de­ velopment. i t therefore appears that participants knew that emergent literacy is the basis for further learning at school and independent functioning later on in life. the different sources from which the participants re­ ceived information about emergent literacy development are reported in table 3. t able 3. the d ifferen t sourcesfrom w hich th e p articip an ts receiv ed in form ation abou t em ergent literacy developm en t (n=15) s o u r c e s o f in fo r m a t io n n u m b e r o f p a r tic ip a n ts 1. s p e e c h la n g u a g e th e r a p is t 9 2 . p o p u la r m e d ia : p a r e n t m a g a z in e s , te le v is io n , in te rn e t 6 3. p h y s io th e ra p is t, o c c u p a tio n a l th e ra p is t, s p e c ia lis t in lite ra c y , c h ild ’s te a c h e r 4 i 4. n o in fo rm a tio n o b ta in e d r 3 5. o w n k n o w le d g e fro m fie ld o f s tu d y (te a c h e r ) 2 1 6. f rie n d s 2 7. d o w n s y n d r o m e a s s o c ia tio n 2 ! participants received emergent literacy information mostly from a speech-language therapist and also from other early intervention team members. this was a positive result and suggested that speech-language therapists and other professionals were keeping up with the new trends in emergent literacy development for young children with down syndrome. popular mass media also played an impor­ tant role in providing information about emergenttiteracy. even though most o f the participants were recruited from the down syndrome association o f south africa, only two participants indicated receiving information on emergent literacy development from the association. the association is actively involved in promoting emergent lit­ eracy in publications such as the d ow n syndrome bulletin 42 | die suid -afr ika an se tydskrif vir k o m m u n ik a s ie -a fw y k in g s , vol. 5 5, 2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t h e d e v e l o p m e n t o f in t e r v e n t i o n g u id e l in e s ( 2 0 0 0 ,2 0 0 1 ,2 0 0 2 ,2 0 0 3 and 2 0 0 6 ) but the information may not have been noted by the parents in this study. i t is a con­ cern that three participants did not receive any information on emergent literacy. i t therefore appears that much can still be done to ensure that all parents who have young children with down syndrome receive information on emergent lit­ eracy.̂ the next question enquired about the people who read books to the child. i t appeared that persons who read to the child with down syndrome were mostly family mem­ bers, i.e. mothers (14), the fathers (10), grandmothers (9) and siblings. o nly one child in the study was not read to by anyone. even though being read to is only one activity o f all the possible emergent literacy experiences, it is consid­ ered as the most important. shared book-reading promote timely development o f oral language and other areas o f emergent literacy development (ezell 8c justice, 2 0 0 5 ). a c­ cording to e zell (2006) storybooks offer an opportunity to decontextualise language, which implies that the events and concepts are not restricted to the here and now. d econtex tualised language may be more linguistically advanced than contextualised language and therefore challenges cognitive development. children with down syndrome may therefore require support in understanding the decontextualised dis­ course o f storybooks. knowing that most o f the children with down syndrome in the present study were exposed to jo in t book-reading through their parents and others implies that their communication development and their future ac­ ademic success could be enhanced by these experiences. it appeared that grandparents and siblings played a sig­ nificant role in emergent literacy experiences and it is rec­ ommended that the speech-language therapist should utilize them as an additional source to facilitate the de­ velopment o f the emergent literacy skills o f children with down syndrome. since children with down syndrome learn more effectively i f skills are reinforced, the option o f multi­ ple readers in jo in t book-reading should be utilised (spiker 8c hopmann, 1997). sub-aim 2: h ie materials participants report using to fa­ cilitate the development o f em ergent literacy in their young children with d ow n syndrome m ost participants used children’s and baby books when reading to their children. depending on the child’s develop­ mental age, these types o f books are appropriate for the pre­ school years, which was the age range o f the children in this study. the extensive use o f children’s books instead o f baby books may not have been appropriate for all the children in the study, who may be on a lower developmental level. a c­ cording to kumin (2003) books with cardboard pages, flaps, and touch-and-feel features help children to explore and manipulate books, thus making the reading experience more enriching. cardboard books are more durable and are thus a good alternative for the child who mishandles books. as a result o f low muscle tone, cardboard books make book han­ dling and turning the pages an easier task for the child with down syndrome (ezell 8cju stice, 2 0 0 5 ; kumin, 2003). ten participants indicated using magazines as materi­ al to read to their children. magazines are not the optimal reading source for young children because the size and type o f paper is unsuitable for young children in the oral phase o f mouthing objects (kritzinger 8c louw, 1997). homemade books, photo albums, birthday cards given to the child, toys with letters and words, flash cards and multimedia appara­ tus were used to a limited extent by the participants. the results therefore indicated that the participants require in­ formation about appropriate emergent literacy materials for their children. m ost participants reported that they bought their own books for their children or they have their own collection o f books. this was a positive result as it showed that par­ ticipants did not have resource needs to obtain books. m ost participants reported that they had more than nine books available for their children. participants also indicated the content o f books they had for their children to read. the books ranged from books about different concepts such as colours and shapes, books with vocabulary on certain topics, such as the body and ani­ mals, general vocabulary, such as a child’s first 100 words, books with narratives such as disney stories, picture books and books with nursery rhymes. books with different physi­ cal characteristics such as pages with tactile and auditory stimulation were also listed as being used by the partici­ pants. this large variety o f books indicated that children were exposed to many different book-reading experiences and these experiences were likely to enhance the child’s de­ velopment. there are currently a large variety o f books for young children available in stores (owens, 20 0 6 ) and it ap­ pears that the participants in this study were making use o f these resources. the participants’ educational level and parenting experience (see table 1) may have contributed to the knowledge they possessed regarding the selection o f dif­ ferent books available for young children. table 4 indicates the criteria participants reported us­ ing when selecting reading material for their child. the il­ lustrations in the book, the child’s lev el o f interest and the story line were the three most important criteria for par­ ticipants when choosing a book. the illustration in a book is central to sustaining the child’s attention and enhancing understanding (ezell 8c justice, 2 0 0 5 ). i t appears that the participants selected books according to the most important criterion to maintain their child’s interest. participants also reported choosing books with bold graphics and few words, which according to kumin (2003) are appropriate for chil­ dren at the emergent literacy level. although participants may have needed guidance on the variety o f sources and ap­ propriate materials they could use for emergent literacy de­ velopment in their children, they appeared to know how to choose appropriate books. table 5 indicates the different literacy experiences to which participants exposed their children, apart from that o f book-reading. in general, it appears that the majority o f participants did not expose their children to a wide variety o f experiences. this may have been due to a lack o f knowl­ edge and a lack o f information provided by speech-language therapists and other information sources regarding the va­ riety o f emergent literacy experiences. a few participants added comments on the questionnaire and wrote that they thought exposure to some o f these literacy experiences was too advanced for their child with down syndrome. e x ­ posure to experiences such as being made aware o f brand th e s o u t h a f r ic a n j o u r n a l of c o m m u n ic a t io n d iso rd er s, v o l 55 2 0 0 8 | 43 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) c h er ie va n heer den a n d alta k ritzin g er table 4. criteria participants use to select reading m aterial table 5. literacy experiences participants expose their chil (n=15) dren to (n=15) c r it e r ia v a lu e • a c c o rd in g to th e p ic tu re s a n d /o r illu stratio n s in th e bo o k 13 • a c c o rd in g to c h ild ’s le v e l o f in te re s t 1 2 • a c c o rd in g to th e sto ry line 1 0 • a c c o rd in g to bold g ra p h ic s (e .g . fe w y e t bo ld w o rd s p e r p a g e ) 7 • a c c o rd in g to c h ild ’s atte n tio n s p a n 5 • a c c o rd in g to th e length o f th e sto ry 4 • a c c o rd in g to th e fa m ilia rity o f th e story 3 • a c c o rd in g to c h ild ’s fa m ilia rity o f th e story 2 • d o n o t h a v e crite ria b u t ra th e r g iv e a n y b o o k for child to re a d 1 names and logos does not happen formally but rather within the environmental context where print recognition may oc­ cur (owens, 20 0 6 ) and it is the task o f the speech-language therapist to make parents aware o f the variety o f inciden­ tal emergent literacy experiences to which they can expose their children. sub-aim 3: participants’ reports on how they facilitated the em ergent literacy o f their children alm ost all the participants read to their children in a comfortable environment in their homes. m any participants ensured that the environment was well lit and sat next to their child while reading, or the child sat on the parent’s lap. i t appeared that participants were aware o f the benefit o f books being shared by both parent and child when posi­ tioned in this way (ezell & justice, 2 0 0 5 ). o nly a few par­ ticipants reported that they limited background noise while reading. lim iting background noise is an important strat­ egy to enhance jo in t book-reading to children with down syndrome, as they are at risk for poor listening skills (hugo, louw, kritzinger & sm it, 2 0 0 0 ) due to recurrent otitis me­ dia and auditory processing difficulties (kumin, 2003). m any participants indicated that they took the lead to read to their children as well as participatd in interactive book-reading where they elicited participation from their children. som e parents indicated that they combined three approaches i.e. reading to their child without eliciting much interaction, participating in jo in t book-reading and leav­ ing their child to read alone. according to e zell and ju s­ tice (2005) jo in t book-reading is the ideal reading activity as both parents and children are active participants. i t appears that parents may need more information regarding jo in t book-reading and its benefits. m o st participants regarded reading as play time. this _ .was a positive result as children learn best through their play experiences and when the experiences are active, pleasur­ able, spontaneous and voluntary in their involvement with the environment (owens, 2 0 06). early reading experience should be fun since the advantage is to create a positive atti­ tude towards reading in the future (justice, 2 0 0 6 ). literacy enriched play settings foster children’s exposure to print and interactions with other literacy experiences (kaderavek 8c e m e r g e n t lite r a c y e x p e r ie n c e s v a lu e e n co u ra g e child to scribble 12 d raw child’s attention to w ords on toys 7 t each child to re c o g n ize their n a m e and siblings’ n a m e s in print 7 d ra w child’s attention to w ords on food item s o r to specific brand n am e s 5 d ra w child’s attention to w ords o r num bers on clothing 4 d ra w child’s attention to letters/num bers on your cell phone 4 d ra w c hild’s attention to posters or pictures with print 3 point out w ords on the television screen 3 d ra w child’s attention to billboards w hile driving 2 d ra w child’s attention to road signs w hile w alking a n d /o r driving 1 point out c a r’s registration n u m b e r a n d /o r logo 1 point out street n a m e and house num ber 0 d ra w c hild’s attention to w ords on co m p u ter s creen s and letters on keybo ards 0 justice, 2 004). table 6 indicates the various strategies parents reported using during reading activities. i t appeared that parents had an idea about certain strategies but were not fully aware o f all the strategies that are available to use with their chil­ dren during reading activities. these strategies, compiled as a checklist in the questionnaire, can be viewed as interven­ tion techniques to train parents to use while reading to their children (justice, 2006). sub-aim 4: participant perceptions o f the tim e they spent on facilitating the em ergent literacy development o f their young children m o st o f the participants’ children were read to once a day, for 1 0 -1 5 minutes, four to six days per week. a few partici­ pants indicated they read for less than 10 minutes because o f their child’s short attention span. according,to ezell arid justice (2005) children should be read to on a daily basis with a recommended length o f a 10-m inute session. e ach child is, however, different and these guidelines should be adjusted to suit each family. m o st participants reported that they read for an appropriate amount o f time and some for even longer. the appropriate and extended time parents read to their children may be attributed to the criteria parents used when selecting books, as seen in table 4, as well as the strategies parents reported using, in table 6, which could help to sustain their child’s attention. justice (2006) s u g -, gests that reading on a regular basis is more important than the length o f a reading session. m o st participants appeared to be reading on a regular basis to their children, but about h a lf o f the participants indicated that they did not have a specific reading routine. having a regular reading routine may assist children to anticipate reading time and help to teach children about routine in other daily activities. 44 die su id -afr ika an se tydskrif vir k o m m u n ik a s ie -a fw y k in g s , v o l 55, 2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t h e d e v e l o p m e n t o f in t e r v e n t i o n g u id e l in e s table 6. the strategies participants used while reading to their children w ith d ow n syndrome (n=15) s tra te g ie s v a lu e u s e an a n im a te d voice 11 u s e short s e n te n c e s 10 r e a d favo rite b oo ks ve ry often 10 m a k e rea d in g fun a n d en jo y a b le 10 a d a p t th e story to child’s level o f und erstand ing 10 r e a d a t a rate child can c o p e with 9 r e p e a t an d p ractice w ord s th a t a re beco m in g m o re fa m ilia r w ith b o o k reading 8 e x p a n d on th e stories th a t a re read 8 link th e pictu res in the boo k to real w orld e x p e rie n c e s 8 s h o w real objec ts re lated to th e pictu res in th e story 7 u s e a v a rie ty o f rea d in g m a te rials 7 le t child ta lk a n d tell the story 6 o n ly re a d s e le c te d w o rd s from the story 4 r e a d the story w ord for w ord 4 u s e p a u s e s w h ile rea d in g to child 4 a sk o p e n -e n d e d qu es tio n s 3 t a k e turns w h ile reading 3 s o u n d o u t th e letters in w o rd s read 1 in c o rp o ra te re a d in g into activities o f d aily life 1 a d a p t th e b o o ks for e a s y handling 0 even though not all participants had a specific reading routine, most o f them read to their children in the evenings during the week and on weekends. this may be attributed to the fact that most parents in the study were employed (see table 1) and therefore only had time to read to their chil­ dren in the evenings during the week and on weekends. sub-aim 5: the!needs o f participants regarding teach­ ing emergent literacy to their young children w ith down syndrome j the participants experienced a number o f problems when trying to read to their children. m any parents felt that they did not have time to read to their children because they were too busy. participants commented that apart from the time constraints they experienced, there were many other devel­ opmental issues o f their children with down syndrome that needed to be considered. em ergent literacy was not always the priority. m any participants also mentioned that their child’s attention span was too short for them to appreciate reading. some parents also indicated that they were too tired when they get home from work to still read to their chil­ dren. o ne solution would be to ask significant others to read to the child i f parents’ schedules are too hectic and i f they are too tired to read to their children (ezell scju stice, 2005). i t is important for the speech-language therapist to ensure that parents and significant others receive training and in­ formation about establishing a reading routine and allocate sufficient time for the activity. the participants also utilized the opportunity to describe their needs in terms o f the emergent literacy development o f their children. m any parents identified their need to know what reading material was age appropriate. table 4 showed that parents have knowledge when selecting books for their children to read, but age appropriate selection requires spe­ cific knowledge o f a child’s literacy developmental function­ ing. the speech-language therapist can assess the child’s lit­ eracy skills, as they have specialized knowledge regarding development and emergent literacy. participants therefore needed guidelines in terms o f choosing books according to their child’s developmental age. m any participants identified the need to learn effective reading strategies and how to teach reading to their children with down syndrome. table 6 provided an indication that parents were aware o f some strategies to teach reading but all reported a need to learn more, especially to keep their child’s attention. teaching reading to children w ith d ow n syndrome: a guide f o r parents a n d teachers by logan oelwein (1995) and e arly communication skills f o r children w ith d ow n syn­ drome. a guide f o r parents a n d professionals by kumin (2003) are two resources that provide specific strategies for the fa­ cilitation o f emergent literacy skills for children with down syndrome. o ne participant indicated that it was only after having her child’s eyesight tested and ascertaining that her child was diagnosed as extremely far-sighted, that her child’s abil­ ity to participate in early reading experiences improved. a f­ ter her child received glasses, the participant reported that her child’s concentration and interest in reading had “grown in leaps and bounds”. since children with down syndrome are at risk for visual problems (kumin, 2 0 0 3 ) their eyes should be tested in order to ensure optimal literacy experi­ ences and book-reading. lastly, participants described what they liked and en­ joyed most about reading with their children. the major­ ity o f the participants described the jo y they experienced in the closeness, interaction and time spent together during their reading activities with their children. seeing their chil­ dren’s reactions and facial expressions when understanding and recognizing familiar pictures and stories was another aspect parents enjoy while reading to their children. partici­ pants also derived pleasure from the excitement their chil­ dren showed during reading activities. according to owens (2005) reading is a highly social activity in which both par­ ents and children participate. sensitive, responsive and sup­ portive strategies used by parents during book-reading is said to support positive parent-child interaction (roberts et a l.,2 0 0 5 ). i t was clear that participants were actively promoting and enjoyed the emergent literacy development o f their children, but they had certain needs that should be addressed by the speech-language therapist working in early communication intervention. conclusions and recommendations the main aim o f the study was achieved by describing the participants’ perceptions and practices o f various aspects o f emergent literacy development in their young children with down syndrome. the questionnaire proved to be ap­ plicable to collect sufficient data to describe the results o f a t h e s o u t h a f r ic a n j o u r n a l o f c o m m u n ic a t io n diso rd er s, v o l. 55 2 0 0 8 45 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) c h e r le v a n heer den a n d alta k ritzin g er literate group o f participants and to provide guidelines for intervention. the results indicated that participants valued emergent literacy development and most thought that it was very im ­ portant for their children. i t appeared that participants had a general knowledge o f book-reading but they were una­ ware o f the broader spectrum o f emergent literacy experi­ ences such as the exposure to logos and posters or pictures with print. the majority o f participants were unaware o f daily life experiences that may provide rich opportunities for enhancing emergent literacy development in their children. participants also needed guidelines on how to facilitate the broader spectrum o f emergent literacy experiences such as exposure to print on clothing or cereal boxes so that their children could learn from these diverse experiences and gain a stronger foundation for their future literacy development. since computers play such an important role in accessing information in the 2 1 st century, the facilitation o f basic com ­ puter skills in preschool children may be considered as an expansion on emergent literacy development. w h ile most o f the participants received information re­ garding emergent literacy from their speech-language thera­ pists, it appeared that there were speech-language therapists who did not provide information to their clients regarding this important developmental area. the effect o f the emer­ gent attainment o f literacy skills on a child’s later achieve­ ments emphasizes the importance o f developing an effective model o f emergent literacy intervention (kaderavek 8c jus­ tice, 2 0 0 4 ). according to kaderavek and justice (2004) the em bedded-explicit model o f emergent literacy intervention takes into account natural, meaningful and intentional daily experiences o f literacy as well as focused clinician directed intervention to target skills necessary for later reading suc­ cess. i t is important for the speech-language therapist to use a model o f emergent literacy intervention to design emer­ gent literacy programmes, particularly for populations o f children at risk for communication disorders, such as chil­ dren with down syndrome (kaderavek 8c justice, 2 0 04). the results revealed that participants were aware o f the various types o f reading materials available for their chil­ dren with down syndrome but they were unaware o f the developmental appropriateness o f the books for their chil­ dren. participants also revealed knowledge with regard to the most important criteria that might be used when select­ ing books for their children. participants reported that they selected books according to illustrations, the child’s level o f interest and the story line, but more criteria may be used to select developmentally appropriate books for children. i t is the role o f the speech-language therapist to assess the devel­ opmental age o f children and provide guidelines to partici­ pants regarding relevant types o f books, i.e. books with card­ board pages or children’s books that would be best suited for the child’s developmental age. the results indicated that specific information needs to be provided by the speech language therapist regarding how to choose books, which books are developmentally appropriate and the criteria that one needs to adhere to when selecting books, such as the size o f pictures. the results also showed that most participants ensured that the reading environment was conducive to learning. w h ile some o f the participants acknowledged participat­ ing in jo in t book-reading, it would benefit parents to be in ­ formed o f the advantages o f jo in t book-reading with their children with down syndrome instead o f leaving children to page through books on their own. join t book-reading re­ quires care and attention to important elements such as the physical arrangement o f seating, materials selected, reading style and the opportunity to engage in conversation with the child which may yield impressive results over time with regard to children’s language and emergent literacy skills (ezell 8c justice, 2 0 05). the results further indicated that participants needed training regarding the various strategies that can be used during emergent literacy experiences such as asking the child open-ended questions and using pauses while reading to the child. again, the speech-language therapist has an important role to fulfill in providing information and train­ ing on these different strategies and a rationale as to why these strategies may benefit emergent literacy experiences. it is also important for the speech-language therapist to com ­ ment on and commend parents on their efforts with regard to the time they spend reading to their children with down syndrome, in order to encourage regular jo in t book-reading routines. i t appeared that the greatest concerns expressed by par­ ticipants were that they did not always have time to read to their children, their child’s attention span was too short and that they as parents were often too tired to engage in reading activities. the speech-language therapist can assist in providing parents with realistic guidelines in terms o f what can be done to alleviate these pressures. as suggested by ezell and justice (2005), a reading schedule can be cre­ ated to suit each family, which can include significant oth­ ers to help during specific reading times. another solution would be to incorporate emergent literacy activities within the daily activities o f the child and family (kumin, 2 0 03). the speech-language therapist has a role to play in facilitat­ ing ideas that can be used in order to meet individual family needs, so that a family-centered approach to emergent lit­ eracy intervention may be followed. the clinical implications o f this study are that speech language therapists need to provide the appropriate and comprehensive guidelines to parents with children with down syndrome with regard to emergent literacy develop! ment as part o f a comprehensive emergent intervention pro­ gramme. speech-language therapists need to keep abreast o f new research and should inform and train parents regard­ ing techniques to enhance the development o f emergent lit­ eracy skills in their children with down syndrome. further implications are that parents need to be recog­ nized and guided in what they are already doing for their children’s literacy development in order to follow an asset based approach. m ore emphasis needs to be placed on uti­ lizing the broader spectrum o f emergent literacy experienc­ es as optimal learning opportunities. in order to ensure full participation in literacy experiences the vision o f children with down syndrome should be tested at a young age. v is­ ual problems as well as hearing difficulties in children with down syndrome may interfere with emergent literacy de­ velopment and should be diagnosed and treated. 46 die su id -afr ika an se ty dsk r if vir k o m m u n ik a s ie -a fw y k in g s , vo l. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t h e d e v e l o p m e n t o f in t e r v e n t i o n g u id e l in e s in order to summarize pa­ rental needs that emerged from the results, a compre­ hensive framework for emer­ gent literacy intervention in young children with down syndrome is presented in f ig ­ ure 1. the different guide­ lines may be used by speech language therapists to select goals for emergent literacy intervention, and to expand the current focus o f emergent literacy facilitation o f both therapists and parents. a number o f limitations were identified throughout the study. although a coun­ try-wide survey was possible, only a small group o f parents with children with down syndrome agreed to partici­ pate in the study. m o st o f the participants came from simi­ lar cultural backgrounds, rep­ resenting middle class fam i­ lies. a n attempt was made through the down syndrome association o f south africa to include a culturally diverse participant sample but this was not achieved. thus the results o f this study cannot be generalized to all cultural groups within the south a f­ rican context. j there are a number o f rec­ ommendations for further research. i t is recommended that this study be replicated with a larger target popu­ lation that includes differ­ ent cultural groups. sepa­ rate studies should also be conducted with participants with low literacy skills and illiterate parents. this would change the research design to a qualitative study where interviews would need to be carried out, but some o f the questions in the questionnaire may still be relevant. i t has been demon­ strated by armstrong (1 9 9 8 ) that parents with low literacy skills may enhance their own literacy skills when they are trained to read books to their children. further recommendations are to adapt and apply this study to other at-risk populations such as young children with cleft-lip and palate in order to identify a broader spec­ trum o f emergent literacy training needs so that speech-lan­ guage therapists can provide specific guidelines for emergent literacy intervention to different populations o f children with special needs.. 1. c o n d u c t a c o m p re h e n s iv e a s s e s s m e n t to d e te rm in e th e c h ild ’s la n g u a g e a n d c o g n itiv e fu n c tio n in g t h e as sess m e n t should include the use of a joint book-reading checklist such as th e k ad e rav ek-s u lzb y book r ead in g o bservational protocol (1 9 9 8 ) in order to d eterm ine the child’s interest in books and level o f book-reading involvem ent. t h e questionnaire designed for this study m ay also be used as a self-co m pleted as sessm ent instrum ent__________ 2. r e fe r th e c h ild fo r a v is io n te s t in o rd e r to e lim in a te v is u a l b a rrie rs to lite ra c y d e v e lo p m e n t h e a rin g te s tin g is a ls o a b a s ic re q u ire m e n t b e fo re c o m m e n c e m e n t w ith in te rv e n tio n __________________ 3. b a s e d o n th e a s s e s s m e n t re s u lts , a c o m p re h e n s iv e e m e rg e n t lite ra c y in te rv e n tio n p ro g ra m s h o u ld b e d e s ig n e d fo r th e c h ild , fa m ily a n d c a re g iv e rs . t h e fo llo w in g to p ic s s h o u ld b e i n c l u d e d : _____________________________________ f igu re 1. a fram ew ork with guidelinesfor g o a l selection in emergent literacy intervention f o r young children w ith down syndrome further research can be conducted to determine the value that speech-language therapists place on the emergent lit­ eracy development in young children with down syndrome and to determine what they do in emergent intervention with regard to emergent literacy development. the current study indicated that not all speech-language therapists giv­ ing therapy to the participants’ children provided informa­ tion on emergent literacy development. as a component o f early communication intervention, the importance o f emer­ gent literacy intervention in young children with down syn­ drome should be recognized by speech-language therapists, as “emergent literacy experiences should be a regular, enjoy­ able part o f life for the young child with down syndrome. reading is an important, empowering skill and helping the young child with down syndrome to read is an effort that will have great rewards” (kumin, 2 0 0 3 , p.291). th e s o u t h a fr ic a n j o u r n a l o f c o m m u n ic a t io n d iso rd er s, v o l . 55 2 0 0 8 | 47 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) c h er ie v a n heer den a n d alta k ritzin g 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(2001). planning, designing and re­ porting research. cape town: pearson education sa. swanepoel, d. (2004). a review of the south african context: in­ formation for community-based speech-language and hearing services. clinica: applications in clinical practice in communica­ tion pathology. monograph 7,11-16. university of pretoria. willenberg, i. (2007). foundations for literacy: emergent literacy competencies of grade r learners on the cape flats. the south african journal o f communication disorders, 5 4 ,20-28. 48 | die su id -afr ika an se tv dsk r if vir k o m m u n ik a s ie -a fw y k in g s , vo l. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.down abstract introduction methodology results and discussion implications, limitations, and recommendations conclusion acknowledgements references about the author(s) ben sebothoma department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa katijah khoza-shangase department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation sebothoma, b., & khoza-shangase, k. (2022). middle ear status – structure, function and pathology: a scoping review on middle ear status of covid-19 positive patients. south african journal of communication disorders, 69(2), a910. https://doi.org/10.4102/sajcd.v69i2.910 original research middle ear status – structure, function and pathology: a scoping review on middle ear status of covid-19 positive patients ben sebothoma, katijah khoza-shangase received: 31 jan. 2022; accepted: 12 may 2022; published: 25 july 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the coronavirus disease 2019 (covid-19) pandemic is the latest public health emergency that has presented challenges globally. limited evidence exists on the association between covid-19 and middle ear pathologies, regardless of the respiratory nature of some of the core symptoms. objective: this scoping review aimed at exploring evidence on the effects of covid-19 on middle ear functioning as part of symptom mapping and preventive planning for ear and hearing care. method: electronic bibliographic databases, including medline, proquest, pubmed, science direct, eric and scopus, were searched to identify peer reviewed publications, published in english, between december 2019 and january 2022, related to the effects of covid-19 on middle ear functioning. the keywords used as mesh terms included ‘middle ear pathology’, ‘middle ear disorder’, ‘otitis media’, ‘hearing loss’, ‘hearing impairment’, ‘audiology’ and ‘covid-19’ or ‘coronavirus’. results: from eight studies that met the inclusion criteria, the findings revealed that middle ear pathologies occur in this population, with the occurrence ranging from 1.15% to 75%. tympanic membrane structural changes, otitis media and conductive hearing loss (chl) were commonly reported. the current findings must be interpreted with caution given that most of the studies reviewed had extremely small sample sizes or were case studies or series, thus limiting generalisability. conclusion: the findings highlight the value of strategic research planning to collate data during pandemics, ensuring that future studies use appropriate and well-designed methodologies. trends and patterns of middle ear pathologies in this population must also be established to determine the need for periodic monitoring. keywords: covid-19; middle ear function; scoping review; pathology; symptoms. introduction the latest pandemic (coronavirus disease 2019[covid-19]) that ‘caught the world by surprise’ (clark et al., 2020) is caused by severe acute respiratory syndrome coronavirus-2 (sars-cov-2) that leads to severe respiratory diseases. since the discovery of covid-19 pandemic, the number of cases has been increasing rapidly and exponentially, spreading to multiple countries around the world (chowdhurry & oommen, 2020). as of 27 january 2022, the world health organization (who) has reported that there are approximately 360 million confirmed cases of covid-19, with approximately 5.6 million deaths reported globally (world health organization, 2022). the usa has the highest number of covid-19 infections, reaching 100 million, with african countries having the least number of cases and south africa leading in these numbers (world health organization, 2021). since the advent of covid-19, there has been a global effort to understand and establish its clinical manifestations to formulate preventive measures, as well as treatment plans. current evidence indicates that the clinical manifestations of covid-19 are primarily respiratory in nature (da rosa mesquita et al., 2020; hu, guo, zhou, & shi, 2021). some patients infected with covid-19 exhibit respiratory-related symptoms such as cough, fever, fatigue and myalgia (zu et al., 2020), while other patients may remain asymptomatic (parasher, 2021). the complexity of the prevention of the transmissibility of the virus seems to be because some patients remain asymptomatic (huang et al., 2020), and the virus is not clearly detectable during this stage (pan et al., 2020), thus making transmission difficult to detect and prevent. while covid-19 predominantly affects the respiratory system, auditory and vestibular difficulties such as vertigo have also been reported among individuals infected with the covid-19 virus (aljasser, alkeridy, munro, & plack, 2021; jafari, kolb, & mohajerani, 2021). a systematic review conducted by almufarrij and munro (2021) indicated that the prevalence of hearing loss is approximately 8%, with sensorineural hearing loss (snhl) being the most common type of hearing loss. kilic et al. (2020) posit that snhl, which is predominantly sudden in nature, results from the effects of the virus on the cranial nerves, while jafari et al. (2021) and mustafa (2020) suspect that the snhl results from the direct effects of covid-19 infection on the organ of corti, stria vascularis and/or spiral ganglion. given this evidence, although not significant, early ear and hearing pathology identification and intervention methods may need to be prioritised for patients infected with covid-19. this should include implementation of preventive programmes such as hearing screening or/and monitoring programmes, as well as referral for covid-19 testing where patients present with middle ear pathologies during this pandemic. given that covid-19 appears to affect the auditory system, the need for hearing health professionals such as audiologists is very clear and crucial, particularly for early identification and intervention of auditory pathologies. research has indicated that auditory pathologies such as middle ear pathologies, if not identified early, can have multiple impacts such as impaired processing of information and communication difficulties (brennan-jones et al., 2020; kolo, salisu, yaro, & nwaorgu, 2012), and overall negative effects on the affected individual’s quality of life (reddy, priyanka, sreenath, & reddy, 2015). furthermore, untreated middle ear pathologies have been shown to cause life-threatening conditions such as brain abscess (ibrahim, cheang, & nunez, 2010). therefore, in the midst of covid-19, which directly or indirectly affects the auditory system, audiologists should form part of the preventive and management care of patients infected with the virus. while initial evidence indicates that the auditory system may also be impacted by covid-19, limited research exists that reports on the effects of covid-19 on the middle ear system. given that coronaviruses affect the immune system (bobcakova et al., 2021), the upper respiratory system (weiss & navas-martin, 2005), which is often associated with the development of middle ear pathology, there is a need for further research in this area. an exploration of this area of research may provide an insight into the need for early identification and intervention, and resource allocation to prevent the long-term consequences of untreated middle ear pathologies resulting from covid-19 and improve the quality of lives. methodology aim this study aimed to review published evidence on the effects of covid-19 on middle ear functioning. research design a scoping review was adopted for the purpose of this study (levac, colquhoun, & o’brien, 2010). this review was deemed to be appropriate for this study as researchers intended to explore the literature and determine the type of evidence that exists on covid-19 and middle ear function (nelson & gilbert, 2021). this scoping review was conducted according to the framework by arksey and o’malley (2005), where (1) the broad research question was identified, (2) the relevant publications were found, (3) the study was selected, (4) data charting was performed, and (5) the results were collated, summarised and reported. research question this current review was guided by the following broad question: what has been published about the effects of covid-19 on middle ear function? this question is motivated by strategic planning needs for both covid-19 spread prevention and early identification and management of middle ear pathologies, pathologies which are otherwise treatable and their effects reversible. this question is over and above establishing a link between covid-19 and middle ear pathologies so that the covid-19 disease symptomatology can be comprehensive. data sources and strategy the initial search was carried out in december 2021. a comprehensive search of papers that have reported on covid-19 and middle ear pathologies was conducted using online databases, including medline, proquest, pubmed, science direct, eric and scopus. published articles were included if they were published between december 2019 and january 2022 to coincide with the advent of covid-19, if they reported on covid-19 and middle ear function, and were published in english. the search terms that were used for this scoping review included ‘middle ear pathology’, ‘middle ear disorder’, ‘otitis media’, ‘hearing loss’, ‘hearing impairment’, ‘audiology’ and ‘covid-19’ or ‘coronavirus’. citation management all citations were imported into the web-based bibliographic manager endnote, where duplicate citations were removed. title and abstract relevance screening each researcher, using arksey and o’malley’s (2005) framework, independently screened the titles and abstracts of the articles retrieved through the database search. in the first phase, the titles of the articles were screened to determine whether they were relevant. if the title of the article seemed relevant, an abstract review was conducted in the second phase. if the article met the inclusion criteria, then a full manuscript review was conducted in the final phase. in cases where the article did not have an abstract, but the title seemed relevant, the article was included for full review in the third phase. the title, abstract and full article review were conducted by each researcher. an inter-rater agreement was calculated to determine the level of agreement for studies included and excluded for this review. a high inter-rater agreement of 94.3% was achieved between the reviewers, which indicates an almost perfect agreement (viera & garrett, 2005). characterisation of included studies after all the articles were screened, and agreement was made between the researchers on which articles were relevant for this review, the researchers developed an excel spreadsheet which was used to document pertinent details of each article. table 1 depicts the important details that the researchers charted. such details included the author’s name and date of publication, title of the publication, context from which the study was conducted, aim of the study, signs and symptoms of middle ear pathology, conclusion, and recommendations. table 2 depicts the test procedure used in various studies. data was charted by both researchers. in this phase, researchers maintained constant engagement to resolve any differences that may have been present. table 1: details of study characteristics of each study included. table 2: details of the study test procedure for determining middle ear pathologies (mep). data summary and synthesis all data were recorded in a microsoft excel 2016 (microsoft corporation, redmond, wa, usa) spreadsheet for descriptive analysis, where thematic analysis following braun and clarke (2006) was conducted. the initial search yielded a total of 2771 articles as depicted in the preferred reporting items for systematic reviews and meta-analyses (prisma) diagram (figure 1) (moher, liberati, tetzlaff, altman, & the prisma group, 2009). after removing duplicates from different database, 235 records remained, of which 32 articles were fully reviewed. of these 32 articles, a further 25 articles were excluded as they did not provide any information on the link between covid-19 and middle ear function or pathology. this resulted in eight articles included for analysis. figure 1: the prisma flow diagram describing the process of study selection. ethical considerations this scoping review followed all ethical standards for a study that does not involve direct contact with human or animal participants. this entailed researchers engaging in reflexivity and observing informed subjectivity, adhering to audience-appropriate transparency, as well as informed selective inclusivity, as guided by suri (2020). results and discussion as shown in table 1, pertinent information from the studies that were analysed thematically were provided. a total of eight studies that were finally included for analysis comprised of a range of studies conducted in different contexts. studies included in this scoping review were mainly case studies or case series, with the remaining studies consisting of a multicentre, retrospective observation and a systematic review. among the studies, 4 were conducted in lowand middle-income countries (lmics) (iran/nepal and india), while 3 originated from high income countries (hics) (spain, united states of america, and turkey) (world bank, 2021), and one study was a systematic review. findings of this study are presented and discussed within the following themes: middle ear related symptoms, anatomical changes due to middle ear pathologies, middle ear pathologies based on acoustic immittance measure, and hearing loss with a conductive element. middle ear related symptoms six out of eight studies indicated the occurrence of middle ear-related symptoms, which include otalgia and aural fullness. among the symptoms, otalgia appears to be the most common type of middle ear-related symptom reported in these studies (bhatta et al., 2021; boroujeni et al., 2021; fidan, 2020; maharaj et al., 2020; raad et al., 2021; wanna et al., 2021). a multicentre study conducted by bhatta et al. (2021) with 331 participants who were covid-19 positive reported an incidence of 1.8% for otalgia and 11.4% for aural fullness, while raad et al. (2021) found that six out of eight participants presented with otalgia. while some studies have not explained the occurrence of otologic symptoms such as otalgia and aural fullness, which may be linked with the presence of middle ear pathologies at times (stach & ramachandran, 2022), bhatta et al. (2021) suspect that these symptoms may be because of the inflammation in the nasopharynx, resulting from dysfunctional eustachian tubes. while the incidence of otologic symptoms such as otalgia and aural fullness seems to be varied in these studies because of different sample sizes within the studies reviewed, their occurrence highlights the need for further investigation and proper documentation in order to prioritise and implement early identification and intervention in patients infected with covid-19. kreisman et al. (2014) report that otalgia and sense of fullness may result from middle ear pathologies such as otitis media or otitis externa. stach and ramachandran (2022) also reported that otologic symptoms such as otalgia and aural fullness may suggest the presence of auditory disorders such as middle ear pathologies and warrant a referral to a physician for further investigation and management. therefore, otalgia and aural fullness must be considered as possible symptoms when a patient presents with covid-19. in fact, boroujeni et al. (2021) recommend that covid-19 must also be suspected where patients’ only symptom is otalgia. anatomical changes because of middle ear structures middle ear pathologies can change the anatomical structure(s) of the middle ear system, particularly the tympanic membrane (møller, 2013). in this review, three studies (dharmarajan et al., 2021; fidan et al., 2020; wanna et al., 2020) have reported on the anatomical changes, particularly of the tympanic membranes, in patients infected with covid-19. fidan et al. (2020) reported hyperaemia and bulging of the tympanic membrane, while in a case series by dharmarajan et al. (2021), four participants presented with retracted tympanic membrane and two had dull tympanic membranes. while the third study (wanna et al., 2020) did not specifically report on the anatomical structure of the tympanic membrane, this case study reported that a participant presented with purulent otorrhea, which may be indicative of tympanic membrane perforation (ali & alshareda, 2017). although structural changes of the tympanic membrane indicate the presence of middle ear pathologies, the presence of otorrhea, which indicates chronic middle ear pathologies, is difficult to attribute to covid-19. chronic middle ear pathologies are results of longstanding pathologies that were left untreated. given that the study that reported on the purulent otorrhea was a case study (wanna et al., 2020), further research with a large sample size is required to explore the presence of chronic otitis media in patients infected with covid-19. despite this, covid-19 seems to contribute to middle ear pathologies that affect the tympanic membrane. this calls for hearing health professionals to be cognisant of the possibilities of structural changes in the tympanic membrane because of middle ear pathologies. given that some structural changes may not necessarily affect the mobility of the tympanic membrane and hearing, but if left untreated may become chronic (who, 2018), causing complications, it is crucial that hearing health professionals remain vigilant to this possibility. the use of measures that have high sensitivity and specificity in identifying these structural changes is important. the use of video otoscopy is recommended to clearly visualise structural changes in the tympanic membrane and make appropriate referrals (sebothoma & khoza-shangase, 2018). this measure is also appropriate as it allows for remote assessment via tele-audiology (khoza-shangase, moroe, & neille, 2021). middle ear pathologies based on acoustic immittance measure three of the studies reviewed (bhatta et al., 2021; boroujeni et al., 2021; fidan, 2020) measured acoustic immittance to determine the presence or absence of middle ear pathologies. all these studies reported on tympanometry, while only one study (boroujeni et al., 2021) presented on acoustic reflex thresholds as well. type b tympanogram was the common type of tympanogram measured, with three studies indicating its presence in participants infected with covid-19 (bhatta et al., 2021; boroujeni et al., 2021; fidan, 2020). bhatta et al. (2021) reported an incidence of 5.1% people presenting with type b tympanogram, with only 1.15% presenting with type c tympanogram. these studies provide crucial information about the presence of middle ear pathologies that affect the mobility of the tympanic membrane. given that some hearing health professionals do not always include acoustic immittance measures such as tympanometry in their test battery (emanuel, henson, & knapp, 2012; sebothoma & khoza-shangase, 2021), this review indicates that these measures must be included, especially when assessing patients presenting with covid-19. while these studies have provided some crucial information about the mechano-acoustic characteristics of the middle ear, it is worth noting that this information is limited. two of these studies were case studies (boroujeni et al., 2021; fidan, 2020) with single participants, with only one study utilising a multicentre design (bhatta et al., 2021). therefore, future studies with large sample sizes and use of methodologies that allow for comparison of participants with and without covid-19 are warranted. furthermore, all studies have used tympanometry with single probe tone to measure the presence or absence of middle ear pathologies. given the low sensitivity and specificity of tympanometry with single probe tone (kaf, 2011), future studies need to incorporate sensitive measures of middle ear function such as the wideband acoustic immittance (wai) (robinson, thompson, & allen, 2016; sebothoma, khoza-shangase, mol, & masege, 2021). hearing loss with a conductive element a total of six studies (bhatta et al., 2021; boroujeni et al., 2021; dharmarajan et al., 2021; fidan, 2020; maharaj et al., 2020; raad et al., 2021) indicated the occurrence of hearing loss with a conductive element. bhatta et al. (2021) reported the occurrence of mild conductive hearing loss (chl) in 3.2% participants infected with covid-19. while the other studies reported the occurrence of chl, two of those studies did not report on the severity of the chl. only the study by boroujeni et al. (2021) indicated that the severity of chl in a participant infected with covid-19 was mild to moderately severe. the occurrence of chl in these studies seems to be because of the middle ear pathologies. in the studies by bhatta et al. (2021) and boroujeni et al. (2021), participants presented with abnormal tympanograms (e.g. type b), while in the other studies the presence of chl seemed to co-occur with a type or a sequelae of middle ear pathology such as otitis media or tympanic membrane perforation. as limited evidence exists in the studies reviewed, it is difficult to make a comparison of the proportion of chl with studies from the general population or/and those with participants infected with other viruses such as the hiv. in the studies reviewed, three of the studies were case studies, with one being the systematic review. despite the limited evidence from the reviewed studies, available evidence indicates the occurrence of chl in this population, and therefore, highlights the need for further investigation of the possible hearing loss of this nature in this population. møller (2013) reported that untreated chl may cause the deprivation of sound into the auditory system and affect speech perception and communication. therefore, assessment of chl using appropriate test battery that will allow for early identification and intervention is crucial. implications, limitations, and recommendations this review provided some crucial information about middle ear function and pathologies in patients infected with covid-19. important implications for the study are raised. the study suggests that there is a need for continued audiological evaluation and possibly periodic monitoring for patients infected with covid-19. resource allocation that includes sensitive measures of middle ear pathologies is required, and initiatives to ensure that preventive audiological programmes are implemented and encouraged by current findings. there is a need for development of audiological guidelines that can be used with patients infected with covid-19 as well as those not diagnosed with covid-19 but presenting with new middle ear pathologies during the pandemic. hearing health professionals also need to be aware of the risks of covid-19 on middle ear function in order to implement effective preventive care, and to provide education and counselling to patients and their families. finally, findings from this review raise implications for future research regarding covid-19 and middle ear function, research that will assist clinicians with a comprehensive understanding of the association between covid-19 and middle ear function. such research should include longitudinal designs and must involve large sample sizes. conclusion this scoping review found limited studies on the effects of covid-19 on middle ear function. however, the available research highlights that covid-19 may potentially affect middle ear function. this is because covid-19 has been found in the middle ear system of patients infected with the virus (jeican et al., 2021). furthermore, covid-19 was shown to cause upper respiratory tract infection (weiss & navas-martin, 2005), which can contribute to the development of middle ear pathologies. findings of this research raise implications for future studies to use appropriate methodologies and to include large sample size. trends or patterns of middle ear pathologies must also be established to determine the need for periodic monitoring if there is a need. finally, although further investigation is warranted, hearing health professionals must be cognisant of the possibility of middle ear involvement in patients infected with covid-19 and should incorporate sensitive measures of middle ear pathologies such as wai in their audiological test battery. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions b.s. and k.k.s. co-conceptualised the study and the methodology. b.s. collected the initial data. both b.s. and k.k.s. screened and analysed the data. both the authors contributed to the writing of this manuscript, read and approved the final draft for submission. funding information the authors thank the national research foundation (nrf) and the national institute for the humanities and social sciences (nihss) for providing financial assistance for the publication of this manuscript. data availability data are available from the first author upon a reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references ali, a.h., & alshareda, i.m. 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(2020). coronavirus disease 2019 (covid-19): a perspective from china. radiology, 296, e15–e25. https://doi.org/10.1148/radiol.2020200490 abstract introduction research methods and design results discussion conclusion acknowledgements references about the author(s) vrinda rathiram department of speech-language pathology, faculty of health sciences, university of kwazulu-natal, durban, south africa lauren o. neilson department of speech-language pathology, faculty of health sciences, university of kwazulu-natal, durban, south africa azraa syed kassim department of speech-language pathology, faculty of health sciences, university of kwazulu-natal, durban, south africa winnie t. mokone department of speech-language pathology, faculty of health sciences, university of kwazulu-natal, durban, south africa caitlin c. green department of speech-language pathology, faculty of health sciences, university of kwazulu-natal, durban, south africa citation rathiram, v., neilson, l.o., kassim, a.s., mokone, w.t., & green, c.c. (2022). communication experiences of healthcare students whilst managing adults with communication disorders. south african journal of communication disorders, 69(1), a870. https://doi.org/10.4102/sajcd.v69i1.870 original research communication experiences of healthcare students whilst managing adults with communication disorders vrinda rathiram, lauren o. neilson, azraa syed kassim, winnie t. mokone, caitlin c. green received: 14 nov. 2021; accepted: 27 apr. 2022; published: 31 may 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: research has found that people with communication disabilities are three times more likely to encounter medical mishaps. almost a third of patients with speech-language therapy (slt) diagnoses have other medical conditions across more than one of the burden of disease categories. fifty per cent of these patients present with communication disorders. student healthcare curriculums focus on patient dynamics and field-specific diversities. it does not often include the skills and knowledge required to effectively communicate and treat those with communication disorders. objectives: this study aims to describe the communication challenges and strategies employed by a group of final year nursing, medicine, dietetics and human nutrition, physiotherapy and occupational therapy students when managing adults with communication disorders. method: a qualitative, phenomenological study design was used. questionnaires were electronically distributed, and results were analysed thematically. results: the most significant challenges whilst managing adults with communication disorders were patients’ receptive and expressive language difficulties. further challenges included lack of knowledge surrounding communication disorders, lack of training in the use of appropriate communicative assistive devices, factors within the physical environment and gaps in students’ clinical performance. strategies used to facilitate communication included caregiver assistance, gestures and written language. conclusion: this study revealed that there is a need to develop healthcare students’ skills in managing adults with communication disorders. this is because of the challenges faced and inefficiency of the strategies used. future research should focus on determining solutions for improved communication with adults with communication disorders. the study highlights the need for further education and training to address students’ communication needs with patients. keywords: communication experiences; healthcare students; adults; communication disorders; challenges; strategies. introduction there are many risk factors contributing to communication disorders in adults living in south africa. in a study conducted at a south african hospital, 77.48% of adults with speech-language therapy (slt) diagnoses presented with non-communicable diseases, whilst 26.99% presented with communicable diseases. of these 44.68% presented with speech disorders, 33.31% with language disorders and 10.95% presented with cognitive communication disorders. a total of 29.27% of these patients presented with multiple medical conditions across several burden of disease categories (stone, hoosen, hochfelden, maposa, & singh, 2020). according to chichirez and purcãrea (2018), communication is a clinical skill that is crucial in establishing a trusting relationship between the healthcare professional and the patient. once trust is established, the patient becomes more comfortable in receiving services and disclosing personal information critical to the diagnosis (ha & longnecker, 2010). when the patient is confident that the healthcare provider has their best interest in mind, prognosis seems promising (chichirez & purcãrea, 2018). patients with communication disorders often cannot communicate effectively, thus creating a challenge for self-advocacy that impacts their quality of life (stans, dalemans, de witte, & beurskens, 2013). it is the responsibility of healthcare professionals to ensure that patient’s medical safety, such as correct diagnoses, well-communicated treatment plans, medication dosage information and follow-up appointments, is prioritised during service delivery (vermeir et al., 2015). according to murphy (2006), communication disorders cause a specific problem in primary care. this can compromise medical safety as it results in ineffective communication with healthcare professionals. this may lead to increased expenditure for unnecessary testing, the inappropriate prescription of medication, numerous referrals, which may result in increased cost as patients are required to attend more hospital appointments. nurses working with adult neurological patients reported feeling responsible for communication with patients. however, because of miscommunication, nurses often felt guilty of providing inadequate care as conversations were frustrating, leading to impatience and resulting in patients being dismissed (hur & kang, 2021). this highlights that miscommunication can lead to medical mishaps as the patient may not receive services in time to prevent their illness from deteriorating (vermeir et al., 2015). these issues can be avoided with effective communication measures. according to stransky and morris (2019), individuals with communication disorders experience challenges in interacting with their medical care team and difficulties in accessing medical care. thus, adults report that their quality of health is reduced compared with others without communication disorders. murphy (2006) found that patients encountered various challenges before consultations and when making bookings for medical appointments. these challenges included difficulty in using the phone, understanding the receptionist’s speech and the inability to write down an appointment date and time. during consultations, some patients required help from their carers whilst others felt disrespected when doctors addressed their caregivers instead of them. some patients described unfair treatment from healthcare professionals, leading to misdiagnoses and poor implementation of treatment events (sharby, martire, & iversen, 2015). general practitioners’ limited understanding of the nature and implications of communication disorders, results in mismanagement of adults with communication difficulties (murphy, 2006). a study conducted by sharby et al. (2015) highlighted that environmental modifications enable persons with disabilities to participate in daily activities, which positively affect their quality of life. factors in the physical environment such as lighting (type and position), acoustic environment, humidity and temperature, setting and furniture placement, written information and the availability of augmentative and alternative communication (aac) systems (communication boards, manual signing eye gazing, etc.) is said to affect those with communication disorders and hinder their effectiveness in communication (stans, dalemans, de witte, smeets, & beurskens, 2017). morris, dudgeon and yorkston (2013) studied adults who use aac and found that many barriers to receiving high-quality care existed, including difficulty in communicating with physicians, relationship building and establishing rapport. stans et al. (2017) also identified written information and the availability of aac as being a facilitator to improved understanding and communication between healthcare professionals and communication impaired patients. healthcare students are known to experience a great deal of stress during their training, including balancing their time to meet deadlines, studying for examinations and preparing for their practicals. as a result of these and many other factors, healthcare students may overlook the importance of effective communication with their patients (teutsch, 2003). although communication training is compulsory in most medical schools in south africa and internationally, these usually focus on interpersonal skills and simplified communication in terms of medical jargon. however, a paucity of literature exists on whether this training includes skills focusing on communicating with those who have disabilities (matthews & van wyk, 2018). for this reason, healthcare students may be unaware of the implications that miscommunication may have on treatment (o’halloran, hickson & worrall, 2008). some challenges that healthcare professionals encounter whilst working with adults with communication disorders are because of their lack of knowledge about communication interactions (burns, baylor, dudgeon, starks, & yorkston, 2015; fox & pring, 2005; hemsley et al., 2008; law et al., 2005; morris et al., 2013; murphy, 2006, as cited in baylor, burns, mcdonough, mach, & yorkston, 2019). according to studies conducted both in south africa and the united states of america, this lack of knowledge is a result of limited exposure and experience to communication disorders (bastable & dada, 2020; sharby et al., 2015). other challenges include lack of skills utilising aac systems and communicating with those presenting with sensory impairments (o’halloran et al., 2008). mcmillan et al. (2017) stated that to overcome the barriers and challenges that student healthcare professionals face, consultation with an slt in order to develop skills and improve clinical practice with these patients is required. shadowing of slts will improve skill development and collaborative interaction. these skills learnt as students will carry over to future interactions, resulting in better patient care. successful intervention requires student healthcare professionals to consider and understand the patient, the multidisciplinary team and their caregivers. this includes the burden and stress of long-term care and life adjustments when caring for these individuals. therefore, healthcare professionals should consider factors that might impact the emotional adjustment of caregivers (toner & shadden, 2002). després (2017) identified strategies that student healthcare professionals can develop for effective communication to take place. these include being familiar, respectful, flexible and consistent with the patients’ preferred communication needs and methods. these recommended strategies could be taught to student healthcare professionals, thus allowing adequate time for their development in professional practice. stransky and morris (2019) stated that general education on patient-provider communication is available; however, advanced training to address the needs of people with communication disorders is rare. stransky and morris (2019) stated that physicians rarely use supportive communication strategies that slts commonly train communication partners to use. this reflects a lack of exposure to these strategies. it was reported that doctors did not utilise strategies that patients found useful during communication. strategies included writing down keywords whilst speaking, the use of visual aids to reinforce communication and the consistent use of meaningful gestures. these findings indicate a lack of healthcare professional awareness and adequate training on strategies to manage patients with communication disorders. this is further supported by student healthcare professionals reporting a lack of adequate training on how to interact with people with disabilities (sharby et al., 2015), emphasising the need for further student healthcare training. in a study by murphy (2006), it was found that general practitioners need information about communication strategies and practical tools to help improve medical consultations with individuals with communication disorders. similarly, mcmillan, burrus, willis and grabowsky (2016) stressed the importance of teaching communication strategies to nursing students and highlighting its importance. nurses reported a desire to learn communication methods and emphasised a need for support and education to facilitate communication. nurses reflected that improved communication would ensure that patients are not excluded from benefits because of their communication impairments (hur & kang, 2021). suggestions for how to teach communication strategies include instruction, role-playing activities or handouts. they also recommend professional terminology to be simplified to facilitate patient understanding. the slts can liaise with general practitioners to raise awareness of communication disorders and to facilitate improved communication (murphy, 2006). a need to improve patient–provider communication in order to facilitate patient’s satisfaction and overall health outcomes is emphasised (sharby et al., 2015). according to haidet et al. (2002), cultural differences between healthcare professionals and patients were identified as a barrier to communication. student healthcare professionals’ awareness of this barrier can better prepare them to manage the cultural differences between themselves and their patients. to avoid negative attitudes and feelings towards healthcare professionals and the treatment they provide, it is important that student healthcare professionals have knowledge about the cultural and linguistic background of the various cultures in south africa. stans et al. (2013) identified factors influencing effective communication in patients’ immediate social environment. these include efforts to improve communication, professionals’ knowledge, use of aac devices, communication time constraints and the influence and power of the client. the study concluded that for effective communication healthcare professionals should develop better attitudes, awareness, knowledge and skills regarding their patients’ communication disorder. further attention should be provided to adequately and effectively use aac devices in clinical sessions to improve communication. ultimately the goal of healthcare provision is to improve the quality of life for those receiving it and miscommunication between healthcare professionals and patients may act as a barrier (o’halloran et al., 2008). furthermore, student healthcare professionals need to be mindful of the possible communication barriers between them and their patients. in addition, they require training of strategies to overcome these barriers to facilitate effective communication (norouzinia, aghabarari, shiri, karimi, & samami 2016). therefore, the purpose of this study was to describe what healthcare students identify as challenges and effective strategies when interacting with adults with communication disorders. research methods and design aim the aim of the study was to describe the communication challenges and strategies of healthcare students whist managing adults with communication disorders. research design a qualitative, phenomenological research approach was suitable for the study in identifying the lived experiences and perspectives of student healthcare professionals (edmonds & kennedy, 2017; mohajan, 2018). the phenomenon being studied was the communication experiences of student healthcare professionals when interacting with adults with communication disorders. the chosen design allowed the researchers to describe the communication challenges and strategies of healthcare students when interacting with adults with communication disorders. setting participants were included from the school of clinical medicine, the school of nursing and public health, discipline of dietetics and human nutrition and the school of health sciences (physiotherapy and occupational therapy [ot]) at a university in south africa. as a result of the covid-19 pandemic and lockdown restrictions, an electronic questionnaire was used. study population a purposeful sampling method was used as it allowed the researchers to deliberately select and identify healthcare students who were particularly experienced or had information about interactions with adults with communication disorders (palinkas et al., 2015). the sample population consisted of 23 participants, which comprised medical (mbchb), nursing, physiotherapy (pt), ot and dietetics and human nutrition students. the sample size fell within the recommended criteria for a phenomenological approach of 5–25 participants (creswell, 2009). inclusion criteria required healthcare students to be in their final year of study and registered at this specific university in south africa. medical and allied healthcare students who would typically form part of the multidisciplinary team managing adults with communication disorders were included. participants were included if they had experience in managing adults with communication disorders. the exclusion criteria were participants in their year of study other than their final year as their clinical exposure may not yet have included experience with adults with medical conditions resulting in communication disorders. participants were identified and recruited via the university notice system, student referrals and a link was emailed to the head of disciplines for circulation. expert review an expert review was conducted by a qualified slt who provided his or her knowledge and expertise to the research study and approved its appropriacy and relevance (asha, n.d). the results of the expert review revealed that the data collection instrument and the aims and objectives were adequate to obtain information, which addressed the research question. modifications were made to the length of the data collection instrument, and an estimated completion time was provided to participants, as recommended by the reviewer. pilot study this pilot study aimed to determine the effectiveness, credibility and appropriateness of the data collection tool developed by analysing the appropriateness of the results and its relevance to the proposed study. it also aimed to determine whether participants could understand and answer questions easily and accurately if the data collection tool was time effective and whether the layout, format and wording were appropriate. the pilot study followed the inclusion and exclusion criteria of the study to test the credibility of the data collection tool. an electronic questionnaire was administered and participants provided useful feedback about the readability of the data collection instrument and time taken to complete the questionnaire. changes were made to the length and readability, by reducing redundancy and rephrasing questions, accordingly. data collection as a result of the covid-19 pandemic, an electronic survey employing the use of a self-administered questionnaire was utilised, allowing better accessibility to all participants and to answer at their leisure without feeling overwhelmed, ensuring reliable results. the questionnaire included an informed consent page, allowing only those willing to participate to proceed. the participants were provided with a link to access the questionnaire, which was conducted via surveymonkey. sixteen questions and 12 follow-up questions were included. questions were primarily exploratory open-ended, some closed-ended and others follow-up questions requiring participants to elaborate on previous responses. the questionnaire concluded with questions directed at gaining possible solutions from the target population on the subject matter. data analysis data were analysed using a thematic analysis with a general inductive approach to derive superordinate and subordinate themes. the first superordinate theme, communication challenges, included the following subordinate themes: (1) most common communication difficulties, (2) understanding the patient’s communication intent using nonverbal means, (3) physical environment and (4) the impact of communication disorders on providing an accurate diagnosis, treatment and patient compliance. the second superordinate theme, communication strategies, included the following subordinate themes: (1) implementation of communication strategies, (2) effectiveness of communication strategies implemented and (3) patient and caregiver involvement. ethical considerations ethical clearance to conduct this study was obtained from the biomedical research ethics committee of university of kwazulu-natal (no. brec/00001280/2020). the questionnaire on surveymonkey commenced with an information sheet, which provided the nature and purpose of the study, together with an informed consent form. once participants provided consent, they completed the survey. results a total of 23 final-year healthcare students over the age of 18 years, who were involved in the management team for adults with communication disorders, completed the questionnaire. seven medical students, four nursing students, six physiotherapy students, two ot students and four dietetics and human nutrition students participated. the data collected from all participants were analysed and discussed according to superordinate and subordinate themes. theme 1: communication challenges sub-theme 1: most common communication difficulties seen out of 23 healthcare students, 20 reported difficulty communicating with patients with communication disorders. participants noticed challenges in their ability to obtain case history, understand the patient’s attempts to describe symptoms, provide instructions that would result in effective treatment and monitor progress. as reflected in table 1, most participants found it difficult to communicate with patients and highlighted patients’ expressive language difficulties as most common, with some difficulties in patients’ receptive language. out of the 23 participants, 7 allied healthcare students and 4 medical students indicated that difficulty in expressive language was most commonly seen. table 1: participants’ responses on the most common communication difficulties seen. sub-theme 2: understanding the patient’s communication intent using nonverbal means fourteen medical and allied healthcare students were able to, at times, understand patients’ communicative intent when expressing themselves non-verbally, with nine students reporting that they most often understood patients’ communicative intent. this included the use of gestures, eye gaze, vocalisations, etc: ‘it’s very much trial and error in addition to getting to know the client’s mannerisms and what their alternate methods of communicating are.’ (ot 1, august 2020) ‘i’ve used a pen and paper before to communicate with patients but i had no idea that if falls under the aac. it’s my first time hearing about the aac actually. i think they be very helpful, especially with patients who have motor aphasia. it gives the healthcare practitioner and the patient the ability to communicate and create rapport, thus working together for the patient’s rehabilitation which requires cooperation from the patient.’ (mbchb 4, august 2020) as reflected in table 2, participants in the study reported feeling emotionally strained, frustrated and helpless when they struggled to understand a patient’s attempt to express their concerns using emotions, gestures and/or behaviours. table 2: participants’ feelings related to difficulty understanding patients. the use of aac systems during assessment and therapy sessions by patients, yielded different results for each healthcare discipline. physiotherapy students mainly reported that their patients did not use aac systems. all ot and dietetics and human nutrition students reported that their patients use aac systems during the treatment sessions. nursing students reported that their patients mostly use aac systems. however, all medical students reported that their patients do not use aac systems: ‘makes communication less difficult as it provides extra means of communication style.’ (nursing 3, august 2020) participants who reported that they are not trained to use aac systems or devices were also asked if they would consider using these strategies. participant responses indicated that some would consider using aac: ‘i feel like with proper training of these methods it can help facilitate a more effective communication between the elderly and the nurse and attend the elderly’s needs.’ (nursing 3, august 2020) all participants in the study agreed that written information and the use of aac facilitate communication. they further explained that it helps them understand the patient better and fosters a more effective two-way communication. sub-theme 3: physical environment twelve healthcare students felt that the physical environment does not affect their communication with patients. however, as reflected in table 3, some participants reported that it does affect communication. healthcare students noticed that acoustic factors, such as a noisy or busy environment, lighting and temperature, impact effective communication. table 3: factors in the physical environment that affect communication. sub-theme 4: impact of the communication disorder on providing an accurate diagnosis, treatment and patient compliance in this study, 20 of the 23 participants agreed that inadequate healthcare, incorrect diagnosis and inappropriate medication are provided when the patient has difficulty in communicating. as reflected in table 4 most participants stated that if the patient could not communicate adequately, this may lead to misdiagnosis. many also stated that healthcare is not the same when a communication barrier exists. a medical student further noticed that it can lead to misdiagnosis, undertreatment and overtreatment. table 4: participants’ responses on the impact of communication difficulties on adequate service provision. participants who did not agree with the above were asked what in their communication efforts with patients, ensured that their goals were achieved. a physiotherapy student shared that they make use of manual techniques, which would provide indicators, and they would also make use of medical files or other members of a multidisciplinary team. a medical student shared that patients often come in with a family member and so they provide information that is required for further management of the patient. all medical students reported that their patients comply with treatment plans; additionally, eight allied healthcare students reported the same. in comparison, eight allied healthcare students shared that their patients do not comply with provided treatment plans: ‘at first presentation these patients come with a family member so we utilise them in acquiring necessary information that will guide further management of the pt.’ (mbchb 5, august 2020) ‘i am in the physiotherapy field and we use manual techniques that would provide us with answers or indicators. when patients are unable to communicate during interview then we refer to the medical file or ask the other members of the mdt.’(pt 1, august 2020) healthcare students were asked whether their patients complied with treatment programmes or not. they were then asked to reason why. healthcare students who said that their patients do comply with treatment programmes reasoned that the patients either know they are being provided with help or they want to be discharged, thus motivating them to comply with treatment programmes. those who shared that their patients did not comply with treatment programmes were also asked to reason why. as reflected in table 5, participants shared that patients often lose hope, and thus intensive motivation is required; some patients had difficulty in understanding and being able to ask questions regarding the treatment plans. table 5: participants’ responses on the effect of communication disorders on patient compliance to treatment programmes. majority of the healthcare students agreed that gaps in clinical performance do serve as a barrier. further participant elaboration observed that a lack of learning and full understanding impacts clinical performance and in turn communication: ‘i don’t know how to explain; however, lack of clinical performance prevents proper communication with the patient and thus not reaching a proper diagnosis early.’ (mbchb 3, august 2020) ‘you can’t provide good service with gaps.’ (nursing 1, august 2020) theme 2: communication strategies sub-theme 1: implementation of communication strategies when communication difficulties arise, all nursing and dietetics and human nutrition students reported the implementation of communication-specific strategies. most ot and physiotherapy students also implement strategies. in comparison, 4 of 7 medical students reported that they do not implement communication strategies. the most common strategies implemented across all disciplines were the use of gestures and writing down key information. table 6 reflects the types of communication strategies used by participants when communicating with patients. table 6: participants’ responses on the types of communication strategies used. sub-theme 2: effectiveness of communication strategies implemented fifteen allied healthcare students and five medical students found that the communication strategies implemented were effective; however, some participants felt that their lack of training and limited resources hindered effective communication with patients: ‘with the communication barrier it’s difficult to gauge progress. i’m well aware that it’s my deficiency as a professional more than it is my client having a communication difficulty.’ (ot 1, august 2020) ‘the inability of the patients to express themselves, especially if they cannot write.’ (mbchb 1, august 2020) sub-theme 3: patient and caregiver involvement fourteen participants across all disciplines said that they requested caregiver assistance on occasion, with some of the nursing students reporting that they did not request caregiver assistance at all: ‘sometimes the patient is confused, and we need confirmation from the caregiver.’ (dietetics 3, august 2020) ‘if the patient cannot verbalise properly about what happened. the caregiver provides a history. also, in terms of taking consent. nurses help if there is a language barrier.’ (mbchb 2, august 2020) eleven healthcare students, including five allied and six medical students, in this study reported that they are not aware of how the patient feels when they request assistance from caregivers. the remaining participants are aware and thus adjust their approach to the patient and caregiver, ensuring patient inclusivity: ‘yes i would always first ask the client and then would respectfully ask if the caregiver/nurse could add to the conversation but ensuring the client is involved and engaged as much as possible, also making sure the client agrees with what his caregiver/nurse is saying.’ (ot 2, august 2020) ‘i still communicate with the patient directly and ask the family member occasionally if i do not understand.’ (dietetics 1, august 2020) participants who were not aware of how the patient feels when they request assistance from caregivers have considered how it negatively impacts patient’s feelings and attitudes. one medical student said that they ‘have not thought of it’ and that their patients ‘have probably gotten used to it.’ ‘yes. it even affects me because the quality of healthcare provided to the patient is decreased and my goal is care to be patient-centred.’ (mbchb 4, august 2020) ‘i have not thought of it, as some patients actually look at their caregiver to give the answer as they probably have gotten used to it.’ (mbchb 3, august 2020) discussion theme 1: challenges this study found the presence of both expressive and receptive language disorders in patients to be the most common difficulty impacting communication with healthcare students. likewise, burns, baylor, dudgeon, starks and yorkston (2017) stated that qualified healthcare professionals experience difficulty whilst communicating during medical interactions with adults with communication disorders. mcknight et al. (2002) further reported that qualified nurses and physicians expressed problems obtaining patient-specific information, timeously, creating a challenge for patient self-advocacy, impacting quality of life (stans et al., 2013). healthcare students’ lack of exposure to simple communication tools and a need for further education is evident in this study. these findings are similar to those by murphy (2006), in which general practitioners required information about communication strategies and practical simple tools to help improve communication with patients. according to mcgilton et al. (2012), interacting with people who have communication disorders requires patience, sensitivity and understanding. as observed from the results in this study, healthcare students experience difficulty in understanding their patients’ concerns when expressed by gestures/behaviours and/or emotions. this highlights the need for all healthcare students, to have learning experiences with patients who have difficulty in communicating, in order to develop their skills and knowledge. however, this is rarely being done in learning and education environments. the results in this study imply that allied healthcare students may have more knowledge and exposure to aac systems compared with medical students. this may be because of the limited exposure to aac and knowledge on how to check whether patients use aac systems during their time of study. a study conducted by sharby et al. (2015) found that individuals with disabilities feel that student healthcare professionals do not have the appropriate skills to effectively communicate with them. this is supported by murphy (2006), who shared that general practitioner staff reported insufficient training in communication disabilities. similarly, in this study, it was found that students in healthcare degrees reported a lack of sufficient training, leading to a feeling of less competence when working with patients with disabilities. this in turn can affect patient’s healthcare and healthcare experience. many healthcare students in this study reported a lack of knowledge about aac. in agreement with these findings, mcmillan et al. (2016) stated that to overcome the challenges that healthcare students face, improved clinical practice with patients and their slt will provide more exposure to develop their skills. possible medical error and misdiagnosis because of communication disorders were found in this study. these findings are supported by a study by després (2017) who observed that patients with communication disorders are at a higher risk of medical error because of the increase in communication breakdowns. medical errors with patients can lead to misdiagnosis, serious injury to the patient and, in extreme cases, death (després, 2017). patients with communication disorders need safer communication environments that require training to develop skills in this area, which current healthcare professionals lack. patients’ noncompliance with medical plans is often attributed to a feeling of disrespect as seen in a study by sharby et al. (2015), which included healthcare students. in contrast, the findings in this study indicated that many patients did comply with treatment plans. this could be attributed to the motivation provided by individual healthcare students. theme 2: strategies various communication strategies were successfully implemented by participants in this study. these findings are supported by those in a study by baylor et al. (2019), who reported that patients who have communication disorders benefit when student healthcare professionals use multimodal communication such as gestures, writing and pictures. diehl (2016), who found that the use of multimodal communication with patients reduces communication breakdowns, thus improving patient’s understanding and ability to express themselves lends further evidence in this regard. lack of adequate participant training in this study influenced the effectiveness of communication strategies used with patients. this barrier in communication can be attributed to the healthcare professional’s lack in patient–provider communication skills whereby information provision to the patient is inadequate further impairing patient understanding (baylor et al., 2019). therefore, miscommunication contributes to poor service delivery and ineffective treatment. common situations that led participants in this study to request assistance from caregivers included inability to obtain case history information from the patient, confused patients, if the patient had difficulties understanding instructions, was unresponsive or hard of hearing. similarly, findings in a study by baylor et al. (2019) found that factors contributing to student healthcare professionals request for assistance from caregivers were communication difficulties because of aphasia and dysarthria. in support of this study’s findings, burns et al. (2015) also observed that patients and caregivers often worked together to ensure communication success when interacting with physicians when communication breakdowns occur. however, caregivers in this study felt that physicians should direct their questions to their patients instead of directly at the caregivers as a sign of respect. similar findings were noticed by burns et al. (2015). burns et al. (2015), stated that although physicians want to try to adjust their communication approaches, they may not know how to. this was evident from a medical student’s response in this study, which reflected that their lack in communication skills affects the quality of services they provided. conclusion the aim of the study was to describe the challenges experienced and strategies utilised by healthcare students whilst managing adults with communication disorders. their lack in expertise and communicative flexibility often leads to healthcare students being overwhelmed and anxious, affecting the quality of healthcare provided. various challenges existed including lack of knowledge surrounding communication disorders, training in the use of appropriate communication assistive devices, acoustic and visual factors within the physical environment. strategies utilised to facilitate communication predominantly included writing down key information, using gestures and caregiver assistance. a study limitation is that participants included healthcare students from only one university in the country, and therefore the results of the study cannot be generalised to a wider body of healthcare students. the study indicates that whilst students studying at this university employ several strategies when challenges are encountered, there is still a need to further develop their skills and training when managing adults with communication disorders. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions v.r. acted as the research supervisor and l.l.n., a.s.k., w.t.m. and c.c.g. conducted the study. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references american speech-language-hearing association (asha). 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(2015). communication in healthcare: a narrative review of the literature and practical recommendations. the international journal of clinical practice, 69(11), 1257–1267. https://doi.org/10.1111/ijcp.12686 abstract introduction methods results discussion conclusion acknowledgements references about the author(s) simone zevenster department of audiology, school of advanced education, research and accreditation, castellón de la plana, spain alida naudé centre for augmentative and alternative communication, faculty of humanities, university of pretoria, pretoria, south africa citation zevenster, s., & naudé, a. (2022). contralateral suppression of transient evoked otoacoustic emissions in adults: a normative study. south african journal of communication disorders, 69(1), a929. https://doi.org/10.4102/sajcd.v69i1.929 original research contralateral suppression of transient evoked otoacoustic emissions in adults: a normative study simone zevenster, alida naudé received: 11 feb. 2022; accepted: 26 may 2022; published: 08 dec. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: whilst otoacoustic emission (oae) testing has proved to be valuable in revealing information about cochlear outer hair cell integrity, it does not provide insight into the afferent and efferent pathways once the stimulus has reached neural receptors. this information can be obtained objectively through contralateral acoustic stimulation (cas) suppression. however, obtaining normative data is essential in the implementation of such tests. objectives: the primary aim was to undertake a small pilot study to collect the cas suppression across a predefined frequency range in order to provide a preliminary normative data set to be used with the newly developed transient evoked otoacoustic emission (teoae)-cas module (path medical, germering, germany). secondary aims included the analysis of the relationships between left and right cas suppression, between male and female cas suppression and between teoae signal-to-noise ratio (snr) and cas suppression. methods: the purpose of this study was to determine preliminary normative data for contralateral teoae suppression from 40 normal ears of 20 healthy young adults (10 males and 10 females). subjects were recruited using purposive sampling. the cas suppression responses were obtained automatically by means of the data-collection protocol on the device used. from the data obtained, correlations between teoae snr and cas suppression were made using pearson’s correlation coefficient. results: the data were statistically processed to form a normative database which possesses the potential of serving as a basis for further research aimed at determining the utility of cas suppression testing when evaluating ear pathology. a mean cas suppression of 0.8 decibels (db) (0.61 sd) was obtained. there was no statistically significant relationship between teoae snr and cas suppression. there was no significant suppression difference in terms of laterality of ears or gender. conclusion: normative values for cas suppression of teoaes in a group of normal-hearing individuals were obtained using the newly developed teoae-cas module (path medical, germering, germany). the availability of normative data for contralateral teoae suppression using the studied module allows for it to become commercially available, which will enable researchers and audiologists to perform this measurement in different populations in the evaluation of ear pathology. keywords: contralateral suppression; transient evoked otoacoustic emission; normative data; otoacoustic emissions; efferent system; medial olivocochlear bundle. introduction early pioneering research led to two audiological discoveries which have initiated a greater understanding and prompted further studies of how the auditory system functions. the first is that of the efferent auditory pathway between the cochlea and the brain (rasmussen, 1946). years later, the discovery of the otoacoustic emission (oae) by david kemp allowed clinicians to obtain a better understanding of cochlear functioning (kemp, bray, alexander, & brown, 1986). the coalescence of these findings, combined with recent hearing research, has resulted in further understanding of how the peripheral and central hearing systems function together. otoacoustic emissions are generally understood to be acoustic sounds that originate secondary to movement of outer hair cells (ohcs) (robinette, cevette, & probst, 2007). unlike other sensory receptor systems, the cochlea generates signals of the same type as that which it is designed to receive (siegel, 2008). during the process of sensory transmission and transduction, both an afferent signal to the auditory nerve and an efferent signal travelling back through the middle ear to the outer ear canal are elicited (siegel, 2008). it is here that an oae can be measured (mcfadden, pasanen, raper, lange, & wallen, 2006). a present oae suggests normal pre-neural ohc functioning and middle-ear status (nobili, vetešnik., turicchia, & mammano, 2003). not only can an oae test be used to objectively determine whether the cochlea is responding to sound, but studies are showing that an oae response can also change with sound presented to the opposite ear (garinis, glattke, & cone-wesson, 2008; geven, de kleine, free, & van dijk, 2011). contralateral noise presented during a recording has been shown to result in a reduction of the oae amplitude in normal-hearing individuals, also referred to as the suppression of oaes (joseph, suman, jayasree, & prabhu, 2019). there are several types of oaes, namely spontaneous, distortion product and transient evoked oaes (teoaes). transient evoked oaes, the focus of this study, are evoked by a brief sound stimulus (usually a click) that has a wide (broadband) range of frequencies (vasconcelos, serra, & de farias aragão, 2008). using a nonlinear click train protocol ensures that the stimulus artefacts of a linear nature are removed from the recording, allowing for maximum reliability of the teoae recording (hatzopoulos, petrucell, morkt, & martini, 2003; von specht, ganz, pethe, leuschner, & pytel, 2001). this article specifically focuses on the amount of contralateral teoae suppression, from here on referred to as contralateral acoustic stimulation (cas) suppression, that is found in a group of normal-hearing adults. whilst oae testing has proved to be valuable in revealing information about ohc integrity, it does not provide insight into the afferent and efferent pathways once the stimulus has reached neural receptors. the effect of contralateral noise on oae amplitude has been reported to be caused by the reduction in gain from the cochlear amplifier which is modulated by efferent pathways (guinan, 2006). efferent pathways originate from the superior olivary complex (soc), and these descending fibre bundles provide direct, bilateral input to the cochlea via two efferent divisions, namely lateral and medial (kumar, grover, publius, sanju, & sinha, 2016). the medial efferent division is known as the medial olivocochlear bundle (mocb) and innervates and modulates the ohcs of the cochlea (kumar et al., 2016). it is therefore assumed that stimulation of the mocb will result in an alteration of ohc motility and hence affect oaes. the main effect of contralateral stimulation on teoaes is the reduction of ipsilateral teoae amplitude of about 1 db – 4 db (berlin et al., 1993; berlin, hood, hurley, & wen, 1994; collet et al., 1990; collet, veuillet, bene, & morgan, 1992; ryan, kemp, & hinchcliffe, 1991; veuillet, collet, & duclaux, 1991). therefore, the teoae amplitude is thought to be suppressed by contralateral stimulation by up to 4 db (berlin et al., 1993, 1994; collet et al., 1990, 1992; ryan et al., 1991; veuillet et al., 1991). the amount of suppression (cas response) is dependent on the type of stimulus used. white noise, which consists of energy from 20 hz to 20 000 hz, stimulates the whole contralateral cochlear portion and activates the largest number of mocb efferents, thus making it an effective stimulus in suppressing teoaes (kalaiah, nanchirakal, kharmawphlang, & noronah, 2017). further stimulus parameters can change the cas suppression. in a study conducted on the appropriate click and noise levels for testing cas suppression, it was found that lower oae intensity level clicks yielded greater amplitude suppression when the intensity of the contralateral noise was approximately 60 db sound pressure level (spl) (hood, berlin, hurley, cecola, & bell, 1996a). furthermore, hood et al. (1996a) suggested using 55 db or 60 db peak equivalent (p.e.) spl for ipsilateral oae testing with the overall intensity level of the contralateral noise set at, or 5 db higher than, the ipsilateral oae click intensity. it is important to avoid using higher oae click intensities, such as 70 db spl, to reduce the risk of middle-ear muscle reflex participation (acoustic reflex) (guinan, 2006; velenovsky & glattke, 2002). contralateral acoustic stimulation suppression testing is not yet routinely performed in clinical practice and not considered part of the basic test battery (hall, 2017). the reason for this might be because acoustic reflex threshold (art) testing is used in the test battery to assess for the site of lesion of the efferent pathway (kung & willcox, 2007). however, more information about the functioning of the mocb can be obtained from the presence, absence and amount of suppression (muchnik et al., 2004). although limited, research holds promise for the usefulness of cas suppression tests in the diagnosis of pontine lesions, either extrinsic (e.g. acoustic neuromas) or intrinsic (e.g. multiple sclerosis) (prasher, ryan, & luxon 1994). measures of cas suppression can therefore indicate the status of the functioning of these olivocochlear bundle (ocb) efferent nerve fibres (kumar et al., 2016). furthermore, cas suppression can provide information about the interaction between afferent and efferent pathways and the interaction between peripheral and central hearing loss, thereby aiding in differential diagnosis (hood, berlin, hurley, & wen, 1996b). in a study done by hood et al. (1996b), it was recommended that teoae suppression be used in patients with auditory neuropathy as a differential measure of auditory function. the importance of measures that are efficient and effective in forming part of the audiological test battery is well known. hall (2017) discusses the importance of using tests that are not only sensitive but also specific. one aspect of this speaks to the reliability of a measure. in a study done on the reliability of cas suppression, it was found that the suppression measures were reliable across test sessions of 1–2 days, and it concluded that cas suppression provides a good test of the mocb system over time (stuart & cobb, 2015). normative data on cas suppression in literature are limited. norms for the manual recording of teoaes before and after contralateral stimulation have been done using middle-ear analysers from grason-stadler and otodynamics to record the teoae and audiometers from natus and grason-stadler to present the contralateral noise (garinis et al., 2008; geven et al., 2011; van zyl, swanepoel, & hall, 2009). one study used the ilo292 from otodynamics to record the teoae response in the ipsilateral ear with probe 1 and presented the contralateral white noise with probe 2 (abdollahi & lotfi, 2011). however, the device did not calculate the suppression automatically, and the researchers were required to perform manual calculations. the primary aim of the current study was to undertake a small pilot study to collect the cas suppression across a predefined frequency range in order to provide an appropriate normative data set to be used with the newly developed teoae-cas module (path medical, germering, germany) which is not yet commercially available, making this the first study on this specific module. one must consider that each device used for audiological assessment (and the protocols selected within that device), each clinical test environment and each patient is unique. therefore, it is particularly important to have normative data gathered from the specific device used (campbell, 2013). secondary aims of the current study included the analysis of the relationships between left and right cas suppression, between male and female cas suppression and between teoae signal-to-noise ratio (snr) and cas suppression. normative data would allow researchers to gain a better understanding of the relationships between the efferent pathway and other audiological tests such as art, pure tone audiometry (pta) and speech audiometry testing. furthermore, it will provide the opportunity to compare results with other tests of auditory nerve functioning, such as auditory evoked potentials. establishing norms allows for further research and increases the potential for cas suppression to be used as a clinical audiological investigation tool in the evaluation of tinnitus, learning difficulties, acoustic trauma and hyperacusis (garinis et al., 2008; urnau & tochetto, 2012). methods a nonexperimental analytical quantitative research design was used to obtain normative data, because this design does not require the manipulation of an independent variable (edmonds & kennedy, 2017). normative data describes values that are usual in a reference group and allows for comparison to subsequent values (campbell, 2013). subjects purposive sampling was used to obtain subjects with normal bilateral auditory sensitivity. normal auditory sensitivity was defined as air conduction pta ≤ 20 db hearing level (hl) for test frequencies at octave intervals from 1000 hz to 4000 hz. normal middle-ear function indicated by type a tympanograms and present ipsilateral and contralateral acoustic reflexes were required. all subjects included in the study had no noticeable abnormalities according to the otoscopic examination, present and normal teoae responses at 80 db p.e. spl bilaterally and no history of ototoxic drug treatment, chronic middle-ear disease, or family history of hereditary deafness. data were obtained from 40 ears, 10 females and 10 males, with an age range of 18–25 years. a summary of subjects’ ages is shown in table 1. written consent was obtained from each subject. table 1: summary of subjects’ ages. data collection general protocol the general protocol included case history as well as audiometric, immittance and teoae testing in a sound-insulated booth to identify those participants complying with the inclusion criteria. continuation of the protocol was dependent on the results of the tests noted above. figure 1 denotes the protocol used to determine if participants met the selection criteria. figure 1: protocol for testing whether subjects met the selection criteria. all 40 ears were required to present with normal auditory sensitivity and middle ear functioning as summarised in table 2. when normal auditory sensitivity was indicated, cas suppression was recorded by means of two oae probes: one to record the response in the ipsilateral ear and the other to present the contralateral stimulus. table 2: results of acoustic reflex threshold and pure tone audiometry from normal ears (n = 40). transient evoked otoacoustic emission testing the sentiero advanced teoae module (path medical, germering, germany) was used to record teoae responses using an 80 db p.e. spl nonlinear click train. a teoae was considered present and normal if a response spectral peak was apparent at 9 db above the noise floor in all third-octave bands from 1000 to 4000 hz (mishra & lutman, 2013; stuart & cobb, 2015). contralateral acoustic stimulation suppression responses the sentiero advanced teoae-cas module (path medical, germering, germany) was used to measure cas suppression responses. contrary to other manufacturers, this module comprises a proprietary algorithm which uses the teoae click stimulus rather than white noise as the contralateral suppressor stimulus for the other ear. the method employs a stimulus sequence that records teoae unsuppressed and teoae suppressed for both ears simultaneously by alternating between ears. the method uses two averaging buffers per ear, collecting unsuppressed and suppressed teoae separately. suppression effect was detected by calculating the difference trace between these buffers and performing a signal statistical evaluation on the difference trace, which is done automatically on the device. figure 2 shows a graphical representation of the calculation of the suppression effect. two consecutive trials of the cas suppression recordings were done, with subjects instructed to remain quiet and motionless to avoid displacement of the probe tip. figure 2: graphical representation of the suppression calculation. (a) unsuppressed, (b) suppressed and (c) difference. statistical analysis the data were analysed quantitatively and captured electronically and were analysed using the data analysis function in microsoft excel 365, version 2104. additionally, descriptive statistics were employed to describe and summarise the data. the data were described in terms of the mean cas suppression and standard deviation and further correlated with teoae snr. the data were then correlated for gender and laterality differences, using pearson’s correlation coefficient. ethical considerations ethics approval was obtained from the research ethics committee of the university of pretoria, south africa, (reference number: 04348664 [hum030/0519]). results test-retest reliability of contralateral acoustic stimulation suppression test-retest reliability of cas suppression within the same session was analysed by computing the correlation between the cas suppression responses from the first and second measurement using pearson’s correlation coefficient. test-retest reliability was confirmed by a strong correlation for cas suppression, r = 0.806 (p = < 0.001) in conditions of not more than 5 min between recordings. van zyl et al. (2009) also showed that a stable teoae suppressive effect over 5-min intervals was obtainable. this means that the mocb can recover from a suppression effect on ohcs within 5 min. transient evoked otoacoustic emission signal-to-noise ratio all 40 ears showed clear teoae responses for snr of ≥ 9 db at 1000 hz – 4000 hz bilaterally using an 80 db p.e. spl nonlinear click stimulus. table 3 shows the data obtained for teoae snr for each frequency. the teoae total overall snr ranged between 9 db and 29.7 db with a mean of 15.91 db (sd 5.53). although the teoae snr for right ears seemed lower than that of left ears, there was no statistically significant difference (p = > 0.05). table 3: right and left transient evoked otoacoustic emission’s signal-to-noise ratio (db) from normal ears (n = 40). contralateral transient evoked otoacoustic emission’s suppression the mean cas suppression responses were determined with the main aim of the study in mind. table 4 shows the data collected for cas suppression bilaterally. the mean cas suppression determined for this study sample was 0.8 db. the data were calculated into percentiles, which are depicted in table 5. data indicated suppression of 1.1 db (for example) in the 70th percentile. this means that 70% of suppression values from the sample were 1.1 db or lower. a cas suppression value of 0.5 db was found at the 30th percentile. therefore, 30% of the suppression values were 0.5 db or lower, and 70% were higher than 0.5 db. thus, the mean cas suppression obtained in this study falls between the 50th and 60th percentile. the suppression for the lower limit (5th percentile) was 0.0 db, and the suppression for the upper limit (95th percentile) was 1.8 db. table 4: contralateral acoustic stimulation suppression (db) from normal ears (n = 40). comparison between transient evoked otoacoustic emission’s signal-to-noise ratio and contralateral acoustic stimulation suppression to determine the degree to which suppression was a function of teoae snr, teoae snr and cas suppression were correlated using pearson’s correlation coefficient. as indicated by the p value, no statistically significant relationship, r(18) = 0.06, p = > α (α = 0.05) was found between teoae snr and cas suppression. these results are represented graphically in figure 3. the correlation coefficient depicted by a scatterplot cluster around the regression line confirms that these two variables are not related to one another. figure 3: linear regression graph of transient evoked otoacoustic emission’s signal-to-noise ratio and contralateral acoustic stimulation suppression. contralateral acoustic stimulation responses in right and left ears contralateral acoustic stimulation suppression for the right and left ears are summarised in table 6. using a two-sample t-test, the difference between mean right and left values was not statistically significant (p = > 0.05), suggesting that the efferent pathways reacted similarly to sound presented bilaterally in this group of subjects. table 5: normative data for the percentile values of suppression level for a transient evoked otoacoustic emission’s click. table 6: contralateral acoustic stimulation suppression for right and left ears (n = 40). contralateral acoustic stimulation suppression in women and men mean female and male cas suppression were analysed using a two-sample t-test assuming equal variance. contralateral acoustic stimulation suppression for female and male subjects are summarised in table 7. the gender differences were shown not to be statistically significant (p = > 0.05), suggesting that normative data obtained could be used across both genders. table 7: contralateral transient evoked otoacoustic emission’s suppression data for females and males (n = 40). discussion this study was primarily intended to determine the cas suppression elicited in a group of normal-hearing young adults to construct normative data. analysis of the results showed clearly measurable suppression for all 40 ears. this study correlated with other studies that showed the suppression of teoaes using a nonlinear click train with the introduction of a contralateral teoae stimulus (abdollahi & lotfi, 2011; de ceulaer et al., 2001; garinis et al., 2008; geven et al., 2011). results indicated a range of −0.1 db (minimum suppression value) and 2.5 db (maximum suppression value), with a mean value of 0.8 db. one-third of suppression values were 0.5 db or less, which implies that 70% of the suppression values obtained were higher than 0.5 db. this finding correlates with a previous study reporting normal suppression values to be 0.5 db – 1 db (collet et al., 1992). this agreement suggests that automated calculation of cas suppression is a valuable addition to the test battery, increasing the efficacy of the procedure. a study performed by de ceulaer et al. (2001) reported normative suppression values as low as −0.35 db and as high as 3.89 db. they found that optimal suppression was obtained using a click level of 12 db above each individual’s teoae response threshold and a contralateral white noise at 40 db sl. these minor differences emphasise that normative values from each study should be evaluated in accordance with the specific stimulus parameters employed in the study and that different equipment used to measure cas suppression may result in different normative data. this information highlights the importance of the aim of this study to obtain equipment-specific normative data. there was no statistically significant relationship between teoae snr and cas suppression. for the use as a differential test, these results are expected to provide insight into how cas suppression tests could be used to identify cochlear dysfunction in patients with normal-hearing sensitivity and suppression but with abnormal teoae responses or, conversely, identifying mocb dysfunction by the presence of teoaes and absence of suppression. such a study was conducted by sarathy and jaya (2017), where subjects with tinnitus and normal hearing sensitivity were evaluated in terms of teoae responses and cas suppression. the findings from this study showed that abnormal teoae in patients with tinnitus having normal hearing sensitivity indicated cochlear dysfunction, with the absence of suppression indicating mocb dysfunction (sarathy & jaya, 2017). findings related to teoae snr and cas suppression of the left and right ears agree with other studies of teoae responses, suppression and laterality (muchnik et al., 2004; sanches & carvallo, 2006). however, asymmetries in auditory function have been reported at different levels of the auditory nervous system (garinis et al., 2008). in the study by garinis et al. (2008), a notable difference in the amount of suppression occurred in the right-ear control group (normal hearing). a significant difference in laterality would indicate the need for separate normative data for left and right ears. the current study, however, found no statistically significant difference between left and right ears and therefore the normative range could be applied binaurally. similarly, no statistically significant gender difference was observed related to cas suppression. other studies have, however, reported gender differences (abdollahi & lotfi, 2011; cassidy & ditty, 2001). mean suppression values from 60 normal-hearing participants, using a similar parameter setup to that of the current study, were found to be 2.07 db in males and 1.54 db in females, which was statistically significant (abdollahi & lotfi, 2011). durante and carvallo (2006) also found larger suppression values in neonate males than females. one potential reason for the current finding being in contrast with these studies might be related to their larger sample sizes. researchers do not know the exact reason for gender differences in suppression, but there are some hormonal and structural explanations for these findings (abdollahi & lotfi, 2011). research has shown that larger suppression amplitude for emissions can be obtained with clicks with a lower intensity level when the intensity of the contralateral noise was at or near 60 db spl (hood et al., 1996a). this study, however, was in accordance with the results from hood et al. (1996b) stating that contralateral intensity levels set at, or 5 db higher than, the ipsilateral click intensity, indicated positive cas suppression. therefore, this data can be used for further studies on the teoae-cas module using differing stimulus parameters. conclusion contralateral acoustic stimulation suppression is a relatively underused area of research in the field of audiology, with a potential future in applications of objective diagnosis of pathologies of the mocb. having normative data on cas suppression that are specific to a device to maximally interpret the data acquired on an individual can allow for further research on pathologies of the efferent system. observations on suppression in patients with tinnitus, auditory processing, hyperacusis and auditory neuropathy, as well as other intrinsic or extrinsic lesions, can be clinically and objectively evaluated and interpreted using specific normative data obtained on a larger group of subjects. furthermore, the evaluation of cas suppression can also be further studied with regard to differences between apparatus used. acknowledgements the authors would like to express their gratitude to path medical that made the software module available at no charge and for sharing the details on the software algorithm with the researcher. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions a.n. and s.z. conceived of the presented idea. a.n. developed the theory and structure of the study. s.z. carried out the experiment and wrote the manuscript with support from a.n. funding information the authors received no financial support for the research, authorship, and/or publication of this article. data availability raw data were generated at hear clear sa. derived data supporting the findings of this study are available from the corresponding author on request. disclaimer the views expressed in this article are solely from those of the authors and not from an institution or company. references abdollahi, f.z., & lotfi, y. 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(2001). linear versus non-linear recordings of transiently-evoked otoacoustic emissions – methodological considerations. scandinavian audiology, 30(1), 116–118. https://doi.org/10.1080/010503901300007263 abstract background method results reliability: cohen’s kappa validity sensitivity and specificity discussion acknowledgements references appendix 1 about the author(s) kelly-ann kater department of speech pathology, school of human and community development, faculty of humanities, university of the witwatersrand, johannesburg, south africa jaishika seedat department of speech pathology, school of human and community development, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation kater, k-a., & seedat, j. (2023). weighing up the pros and cons of dysphagia triage in south africa. south african journal of communication disorders, 70(1), a941. https://doi.org/10.4102/sajcd.v70i1.941 original research weighing up the pros and cons of dysphagia triage in south africa kelly-ann kater, jaishika seedat received: 21 july 2022; accepted: 31 oct. 2022; published: 21 feb. 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: early identification of dysphagia followed by intervention reduces, length of hospitalisation, degree of morbidity, hospital costs and risk of aspiration pneumonia. the emergency department offers an opportune space for triage. triaging offers risk-based evaluation and early identification of dysphagia risk. a dysphagia triage protocol is not available in south africa (sa). the current study aimed to address this gap. objectives: to establish the reliability and validity of a researcher-developed dysphagia triage checklist. method: a quantitative design was used. sixteen doctors were recruited from a medical emergency unit at a public sector hospital in sa using non-probability sampling. non-parametric statistics and correlation coefficients were used to determine the reliability, sensitivity and specificity of the checklist. results: poor reliability, high sensitivity and poor specificity of the developed dysphagia triage checklist was found. importantly, the checklist was adequate in identifying patients as not being at risk for dysphagia. completion time for dysphagia triage was 3 minutes. conclusion: the checklist was highly sensitive but not reliable or valid for use in identifying patients at risk for dysphagia. contribution: the study provides a platform for further research and modification of the newly developed triage checklist, which is not recommended for use in its current form. the merits of dysphagia triage cannot be ignored. once a valid and reliable tool is confirmed, the feasibility of implementation of dysphagia triage must be considered. evidence to confirm that dysphagia triage can be conducted, when considering the contextual, economic, technical and logistic aspects of the context, is necessary. keywords: dysphagia; triage; emergency unit; south africa; speech–language therapy; evidence-based practice; dysphagia triage. background dysphagia, that is, failed or impaired bolus transit, may be caused by either a mechanical or inflammatory response (triggs & pandolfino, 2019). to mitigate aspiration, aspiration pneumonia, morbidity and mortality, length of hospitalisation and associated medical costs, early detection of dysphagia by way of screening is advocated (sherman et al., 2021). for screening to have the desired outcome, that is, a pass or fail indication of dysphagia, adherence to parameters is compulsory. additionally, regular and consistent implementation will positively impact the ability or practice of screening and identification of dysphagia (george et al., 2009). sherman and colleagues confirmed that the dysphagia screening rate for patients with stroke in the united states and china ranged from 56.7% to 80.8% (sherman et al., 2021). this variability in screening suggests that not every patient is being screened, and the risk of patients with dysphagia being missed still exists even in developed contexts. reasons underpinning the variable implementation of standardised screening tools in well-resourced contexts are important to consider when understanding how best to accommodate screening in less-resourced and challenging contexts. the south african public healthcare sector may well be considered such a context, being fast-paced, inadequately staffed, suboptimally resourced and patient-heavy (brooke-sumner et al., 2019). khoza-shangase (2021) highlighted the challenges facing our south african public healthcare context and despite her content talking to challenges around implementation of universal new-born hearing screening, the challenges she identified hold true when conceptualising a dysphagia screening undertaking. thus, a viable alternative, as advocated by pierpoint and pillay (2020), is the use of informal screening practices in dysphagia. informal screening would constitute a focused observation of clinical signs and symptoms without a formal checklist or tool which generally has specified pass or fail criteria (pierpoint & pillay, 2020). an alternative that alleviates the increased demands associated even with a screening (which is in any case quicker than a diagnostic assessment but which nevertheless still requires staff training, use of foods and liquids, as well as time) is triage. prioritising patients according to medical need and urgency before their entry into the hospital emergency room safeguards the usage of available personnel, equipment and beds, which may be in short supply. this underpins triage and its value in a resource-constrained context (wuerz et al., 2000). constraints intrinsic to the public health sector context in south africa and which have been supported by pillay and pillay (2020) include imbalanced speech therapist to patient ratios, patient discharge prior to consultation by the speech therapist, high workloads of speech therapists and an inability by speech therapists to see all the patients who require their services, hence poor service delivery. globally, screening for dysphagia may be undertaken by nurses as well. in a study by heaton, farrell and bassett (2019) in australia on nurse-led (n = 3726) long-term screening over a 9-year period, an average hospital-wide compliance rate of 74% and an accuracy rate of 82% with regard to dysphagia were reported. importantly, a survey on nurse satisfaction associated with the screening showed high levels of satisfaction. outcomes from nurse-led screening protocols show positive results and success (cornwell et al., 2016; lees et al., 2006). given the challenges with workload and staffing among nurses in south africa (morton et al., 2020), adding screening to their duties is an aspect that will require further research before implementation. literature abounds with evidence on the association of dysphagia to aspiration pneumonia, malnutrition, weight loss, frequent hospital admission with prolonged length of stay, increased mortality and decreased quality of life (altman et al., 2010; carrión et al., 2015). simply put, mistimed intervention increases the management burden in an already vulnerable patient group with consequent increased economic cost to the healthcare institution and sector (patel et al., 2018). the challenge in a resource-constrained context is staff availability to conduct the screening (whether it be by speech therapists, nurses or any health professional), training prior to implementing screening, time availability and willingness to undertake the screening regularly. these variables pose a challenge in the government health sector in south africa and are likely to curtail implementation of a dysphagia screening protocol in any government health facility, similar to the challenges identified by khoza-shangase in terms of newborn hearing screening. it is thus prudent to consider how dysphagia may be identified quickly and early to navigate optimal intervention, and if not by screening, then an alternative way. research on dysphagia triage is scarce, with only one research study published in this area (cichero et al., 2009). more recently, an opinion piece on triage in south africa did shed critical insights on triage as a means to address early identification of dysphagia for patients who may be at risk (kater, 2022). the scarcity of research in this area requires critical reflection. one is cautioned against making assumptions about inadequacy around the notion of triage in dysphagia or assumptions about poor feasibility leading to limited publications in this area. the proposed study will try to provide more insight on why triage in dysphagia continues to remain a reasonable proposition that could be viable in challenging and constrained healthcare contexts. dysphagia triage is a cost-effective method that does not require additional personnel or resources (broussard & altschuler, 2000; cichero et al., 2009). not requiring training but rather identification based on presenting symptomatology facilitates easy completion of a checklist pertaining to swallowing variables. the use of a dysphagia triage checklist would allow for immediate patient identification, timely referral for ongoing care and reduced waiting time. the triage concept enables one to identify the presence or absence of dysphagia within a short space of time without the use of food or liquids and informs the need or not for further diagnostic assessment by a speech therapist (cichero et al., 2009; jean, 1990). implications for patient prognosis are central to triage, with positive outcomes enhanced for variables such as complications, finances, length of hospital stay and so forth. dysphagia triage for all patients who come into the hospital emergency department will provide an opportune time and space to identify if that patient is at risk for dysphagia, regardless of the reason for admission. thus, the outcome of triage would be identification of risk for dysphagia and necessary intervention thereafter (cichero et al., 2009). given the key role of doctors in accident and emergency departments, knowledge about dysphagia is valuable. cichero et al. (2009), in their study, successfully integrated nurses and doctors into the critical role of swallow triage. the rationale behind the study by cichero et al. (2009) was to reduce the risk of a patient commencing oral intake inappropriately or unsafely, as poor nutritional intake may intensify costs related to recovery and length of stay of the patient. dysphagia triage would ensure that patients receive the correct diet, thus preventing incorrect diet allocation and food wastage. additionally, identification and provision of assistance to patients who require assistance when eating may be attributed to dysphagia triage (cichero et al., 2009). triage protocols maximise the use of limited available resources and keep patients and providers safe. triage versus screening versus diagnostic assessment for dysphagia in a resource-constrained context such as south africa regardless of the route chosen by a speech therapist to identify dysphagia in a patient, the result is what remains important (etges et al., 2014), as it ultimately initiates the management of dysphagia. globally, and as supported by etges et al. (2014), diagnostic standardised assessment and screening protocols remain widely known to those practising in dysphagia, and they remain heterogenous in nature, with many having been developed for: specific patient populations, for example, adults, paediatrics, geriatrics (denuit et al., 2021) specific underlying pathology, for example, stroke, head and neck cancer (audag et al., 2019) implementation by a particular professional, such as the nurse or speech therapist (oliveira et al., 2019). the context in which one is practising ultimately dictates choice. figure 1 elucidates some considerations linked to choice. figure 1: considerations for clinical-decision making when choosing among diagnostic assessment versus screening versus triage. given the features linked to a triage tool, and the evidence from khoza-shangase (2021) commenting on the challenges associated with screening, it seems necessary to investigate triage as a method to identify patients with dysphagia or at risk for dysphagia. one is reminded that with the current status of government hospitals in south africa, that is, poorly resourced, overcrowded, understaffed and underfunded (maphumulo & bengu, 2019; rajan & englebrecht, 2018), it is uncertain if a dysphagia triage protocol could be accommodated within the current functioning of the accident and emergency unit. the time to complete an additional area of triage by doctors and their willingness to take this on (i.e., staff attitude) are unknown. the current study was therefore a first step to establish the feasibility of dysphagia triage in public-sector hospitals. the current study included the compilation of a triage tool as well as implementation of the tool. currently, no dysphagia triage protocol exists for the south african context. while the current study investigated the reliability and validity of a self-developed triage checklist, the authors will critique the relevance of a standardised triage tool and challenge dysphagia therapists to critically reflect on what the end goal pertaining to dysphagia is. is it a standardised tool that in being compliant loses its relevance and becomes arduous to complete, or is it a quick triage checklist that is more likely than not to alert us to a patient at risk for dysphagia, knowing that these patients were likely to have been missed anyway? is this not what is wanted and needed for a resource-constrained context? method the aims of the study were to compile a dysphagia triage checklist following a review of current screening tools and thereafter to establish the reliability and validity of the developed dysphagia triage checklist. a quantitative design was used. sixteen medical staff participated in the study. the participants were medical staff working at the meu, and they were selected using purposive convenient sampling. thus, the researchers did not impose any changes or restrict criteria for inclusion or exclusion. any medical staff member who was allocated to work at the meu and who agreed to participate in the study was recruited. this contributed toward the validity of the tool, as participant criteria aligned with the reality of the context. all patients who were treated at the meu at the time of data collection were triaged for dysphagia as well. to establish the sensitivity and specificity of the triage checklist, it was necessary for all patients who underwent the dysphagia triage to be screened for dysphagia, regardless of pass or fail. the researchers completed the dysphagia screening but were blinded to the results of the triage until after the screening was completed. the south african dysphagia screening tool (sads) (ostrofsky & seedat, 2016) was used. as per figure 2, any patient who failed the sads was referred for diagnostic assessment of dysphagia, regardless of the results of the triage. the diagnostic dysphagia assessments were completed by the speech therapy department at the research site. figure 2: procedure followed for patients admitted to the medical emergency unit at the hospital. the dysphagia triage checklist was developed by the researchers for the study. it was developed following a review of dysphagia screening tools to establish the items for inclusion in the checklist. the following dysphagia screening tools were reviewed and adapted: the standardised swallow assessment (perry, 2001a, 2001b) massey bedside swallowing screening (massey & jedlicka, 2002) the yale swallow protocol (leder & suiter, 2014) the sads (ostrofsky & seedat, 2016). the developed dysphagia triage checklist was divided into four sections and consists of eight test items (appendix 1). the dysphagia triage checklist was administered by the doctors in the meu over an 8-week period. description of the dysphagia triage checklist section a items 1, 2 and 3 were aimed at determining the patient’s level of alertness as well as their ability to maintain an adequate respiratory status. a decreased level of alertness and state of consciousness may affect the patient’s ability to swallow safely (cichero, 2006). respiratory-compromised patients may experience swallowing difficulty as the effort required to maintain an adequate respiratory rate may make swallowing a challenging and demanding task, thus putting the patient at risk of dysphagia (cichero, 2006). section b item 4 was aimed at determining whether or not the patient can manage their own saliva. poor saliva management could be indicative of poor head control, inability to close the mouth, abnormal tongue mobility and reduced intra-oral sensation (cichero, 2006). additionally, a gurgling vocal quality after swallowing of secretions may indicate pooled material in the pharynx (cichero, 2006). item 5 assessed the patient’s ability to produce voice. the ability to produce voicing provided information regarding laryngeal functioning (cichero & murdoch, 2006). if a patient is unable to produce voicing when they receptively understand the instruction, this may be indicative of respiratory problems and laryngeal weakness (cichero & murdoch, 2006; murray, 1999). the true vocal folds may not be fully adducting as a result of paralysis, trauma or disease leading to less or no protection of the airway and aspiration (cichero, 2006). additionally, the presence of wet or ‘gurgly’ breath sounds and/or vocal quality may be indicative of pooled secretions in the pharynx (johnson & scott, 2006). section c item 6 determined the patient’s receptive language abilities. the ability of the person to communicate may give important information about the person’s abilities to follow instructions and an example of purposeful oral motor skills (murray, 1999). items 7 and 8 assessed the patients’ ability to voluntarily clear their airway and the type of cough a patient presents with, respectively. measuring a volitional cough is not a predictor of the patients’ cough reflex in the event of laryngeal penetration or aspiration (murray, 1999). a volitional cough is not a reflexive cough, but the patient’s ability to cough voluntarily needs to be determined, as there is an increased risk for aspiration in patients who have a weakened voluntary cough. the elicitation of a volitional cough helps the clinician to determine whether the patient is capable of organising the motor movements necessary to clear their airway and expel any penetrated or aspirated material (murray, 1999). a productive cough produces phlegm or mucus (sputum), while a nonproductive cough is dry and does not produce sputum (ainslie, 2009). cough is abnormal if it is persistent, painful or productive (ainslie, 2009). administration of the checklist for each test item, the administering doctor was required to indicate the result with a tick mark or an ‘x’. a fail or ‘x’ result for any of the test items indicated that the patient was at risk for dysphagia. the checklist was designed to take under 2 minutes to complete. pass or fail criteria the administrator of the test was required to indicate a pass or fail result for each test item. a fail result for any of the test items was indicative of a patient being at risk for dysphagia. the data obtained from the use of the dysphagia triage checklist and the results of the dysphagia screening were analysed using quantitative measures, specifically correlational coefficients ethical considerations ethical approval to conduct this study was obtained from the university of the witwatersrand human research ethics committee (medical) (ref. no. m160679, 13/09/2017). medical staff working at the emergency unit were provided with information about the study. after allowing time for them to consider participation, they were required to provide written consent. results the aims of the study were two-fold: firstly, to compile a dysphagia triage tool, and secondly, to establish the reliability and validity of the tool. as noted above, after critical engagement with several existing tools, a triage tool was compiled and has been described in the methodology above. this section of the results will address the second aim, that is, the reliability and validity of the tool that was developed. sixty-seven patients were triaged by doctors at the meu over an 8-week period. as can be seen in table 1, 59.7% (n = 40) of the patients passed and 40.2% (n = 27) failed the dysphagia triage checklist. as described above, after completion of the dysphagia triage checklist, all 67 patients (regardless of triage result) underwent a dysphagia screening, using the sads (ostrofsky & seedat, 2016) as a measure of the validity of the dysphagia triage checklist. it was vital to establish the validity of the researcher-developed triage checklist to confirm that the checklist was accurate in identifying and prioritising patients in terms of their risk for dysphagia. results are seen in table 2. table 1: results of dysphagia triage (n = 67). table 2: results from the dysphagia screening (n = 67). bearing in mind that 27 patients failed the dysphagia triage, table 2 highlights that five patients failed the dysphagia screening tool. the results of the sads indicated that 7.46% (n = 5) of the patients presented with dysphagia and 92.54% (n = 62) of the patients did not. the percentage of agreement between the dysphagia triage checklist and the dysphagia screening was found to be 59.7%. this means that 59.7% of the patients who were triaged for dysphagia elicited the correct results, that is, correct passes and fails. however, because of the percentage of agreement being criticised as a poor measure of inter-rater reliability, the correlation between the dysphagia triage checklist and the dysphagia screening was worked out using cohan’s kappa. cohen’s kappa was calculated as 0.04, which shows poor reliability. reliability: cohen’s kappa the relationship between the dysphagia triage checklist and the dysphagia screening assessment (sads) was evaluated using correlation coefficients (schiavetti & metz, 2002). thus, through the use of cohen’s kappa, measures of positive agreement and negative agreement provided information regarding the types of agreement that presented between the dysphagia triage checklist and the dysphagia screening assessment (sads). this is seen in table 3. thus, 59.7% of the patients who were triaged for dysphagia elicited the correct results, that is, correct passes and fails. however, cohen’s kappa is a preferred measure of inter-rater reliability as it incorporates a calculation of hypothetical probability of chance agreements, as opposed to percentage agreement (wood, 2007). table 3: calculation of percentage of agreement. the correlation coefficient for cohen’s kappa can range from -1.0 to +1.0, whereby a kappa of 1.0 is indicative of perfect agreement, and a kappa of 0 shows a poor correlation between the two variables. for the purpose of medical studies and diagnosis, a kappa that lies between 0.40 and 0.70 is an appropriate inter-rater reliability. for this study, cohen’s kappa is 0.04, which shows poor reliability. reasons contributing to the poor reliability have been addressed in the discussion. validity validity is the degree to which a researcher has measured what they aim to measure (kumar, 2005). content validity, face validity and concurrent validity were all included in the research analysis. content validity content validity refers to whether the method of measurement measures what it is expected to measure (schiavetti & metz, 2002), that is, whether the signs and symptoms of dysphagia are accurately identified by the use of the dysphagia triage checklist. despite the dysphagia triage checklist being developed after reviewing already-established dysphagia screening tools, it was found not to be specific enough, and as a result of this, patients failed for reasons other than dysphagia, such as being on oxygen. kaplan and saccuzzo (2012) explain that there are no statistical measures to determine content validity; thus, such validity is greatly dependent on clinical reasoning, judgement and expertise. it is possible that a higher sample size of patients may have improved the content validity. face validity face validity refers to the suitability of a given instrument as a source of data on the subject under investigation (schiavetti & metz, 2002). it is based on the users’ judgement, but it is important to consider it as it describes the way the user views the dysphagia triage checklist as valid and has implications for administration of the checklist in a way that is accurate and unbiased. face validity should have been confirmed through the completion of the questionnaire by doctors in the meu; however, the response rate was poor. as a result of the poor response rate, face validity cannot be commented on. one must bear in mind the workload and performance demands placed on doctors within the south african context. this study reveals that regardless of minimising the time required to complete the online self-developed questionnaire, even these few minutes were too much. concurrent validity concurrent validity is a form of criterion validity. concurrent validity was important to consider for this particular study. concurrent validity is concerned with how well a new shorter version of a measure compares to the existing longer measure; that is, how well the dysphagia triage checklist correlates with the dysphagia screening. the percentage of agreement (59.7%) refers to the agreement between the results of the dysphagia triage checklist and the dysphagia screening (sads). however, as a result of percentage agreement being a criticised measure, cohen’s kappa was used and provided information regarding the types of agreement that were present between the dysphagia triage checklist and the sads. cohen’s kappa was calculated to be 0.04, which shows poor reliability and thus indicates poor concurrent validity. this means that there is poor correlation between the dysphagia triage checklist and the dysphagia screening. sensitivity and specificity a measure of sensitivity and specificity of the dysphagia triage checklist was calculated. the measures of sensitivity and specificity are binary classification statistical measures. sensitivity measures the proportion of true positives which were correctly identified as such (i.e. the percentage of at-risk dysphagia patients who were correctly identified as being at risk of having dysphagia). specificity measures the proportion of true negatives which are correctly identified (i.e. the percentage of patients with normal swallowing who were correctly identified as not being at risk of dysphagia). sensitivity and specificity were calculated, as shown in table 4. the following calculations were performed: table 4: sensitivity and specificity of the dysphagia triage checklist. the dysphagia triage checklist can therefore be defined as being highly sensitive in detecting patients at risk for dysphagia. the specificity of the dysphagia triage checklist is significantly lower than that of the sensitivity; however, it is still adequate in identifying patients as not being at risk for dysphagia when they do not present with the disorder. the specificity calculation indicates that participants failed the dysphagia triage checklist when in fact they did not present with the disorder, based on the results from the screening; that is, false positives were problematic. discussion the triage checklist that was developed for this study was one that could be completed quickly (within 2 minutes), did not require use of words or written detail but instead the use of a tick or cross and did not require that the healthcare professional completing it be trained. the content of the developed checklist ensured that it could be used for any patient who came into the emergency department; thus, it was not designed for use with a specific diagnosis. no additional resources such as foods or liquids were required, as completion of food trials would be time-consuming and have financial implications. thus, in addressing the second aim of the current study, the findings confirm that the developed checklist had flaws in that reliability, validity and specificity were poor. nonetheless, the checklist was sensitive in identifying a patient with or at risk for dysphagia. as a first level of filtering, the potential remains for the checklist investigated in the current study or a modified version of this triage checklist with improved reliability, validity and specificity. in a context where identification of patients with dysphagia is often late, where patients may be discharged before being seen by a speech therapist or where the presence of dysphagia may lead to other complications (andrews & pillay, 2017; stone et al., 2020), the rationale behind the use of dysphagia triage must outweigh the preconceived barriers for reasons explained below. initial concerns around the use of triage (for dysphagia) include the pace of work in an emergency department and associated time availability, the priority of lifesaving versus identification of a patient who may be at risk (for dysphagia) and the increased load for (speech) therapists at the hospital, as well as the implication of this should a patient require screening or thereafter diagnostic assessment (da costa et al., 2021). it is perhaps because of these very same concerns that triage must be considered as a solution, for while there may be short-term implications, the long-term benefits are likely to outweigh these. thus, it is valuable to consider the following: any new intervention is initially viewed with trepidation, and there are often forgone conclusions that it will culminate in more work, the need for more staff and perhaps financial implications. literature confirms, however, that new interventions have long-term multilayered benefits to the institution, professionals, patients and indeed overall service delivery (wensing & grol, 2019). there may be an initial phase of familiarisation with the intervention, managing logistics and working through procedures; however, with time and experience, these should resolve, paving the way for the checklist to become part and parcel of the workings of the emergency department. given the rationale and understanding of how triage works and its implications for patients, it is inevitable that there will be an initial increase in patient numbers. however, research confirms that patient numbers do stabilise over a period of time with enhanced throughput (spencer et al., 2019), given that there should be minimal to no referrals coming via wards or colleagues, except in cases where dysphagia presentation may be late for that patient. the goal of early dysphagia identification must remain central. thus, if triage facilitates identification of patients who may be at risk (based on the signs and symptoms displayed at the emergency department), then this goal is closer to being realised. patients may not be missed; necessary management may begin, preventing further exacerbation and presentation of complications and comorbidities (cichero et al., 2009). the likelihood of false positives remains; however, given that the triage takes 2 min and a screening approximately 7 min (ostrofsky & seedat, 2016), this ‘wasted time’ is worthwhile. for dysphagia therapists working in contexts that are demanding and where delivery of dysphagia services to patients is suboptimal (from a timing perspective), having a realistic perspective on the value of a standardised tool for triage must be queried. the impracticality of this increases as one acknowledges then the requirement for every hospital to have its own tool, given that staffing, structure, functioning and logistics vary across institutions. an easy-to-use, quick and short checklist with minimal requirements from the professional completing it, aside from patient observation, would be ideal. notwithstanding false positive identification of patients, if those identified at risk are found to have dysphagia, then one must concede that dysphagia intervention is one step closer to the goal of ideal. finally, and an aspect that one may view as being controversial, is that of professional ethics, patients’ rights and ubuntu (which is not a single thing but a broad concept involving characteristics such as unselfishness and caring, ‘i am who i am because of you’). in making a choice to work with individuals who are vulnerable, in need of our assistance, advice and services, the implications of the burden this places on the professional cannot be over-emphasised. being knowledgeable of the consequences of delayed or lack of dysphagia services, speech therapists may not be justified in using contextual or logistical challenges to support their lack of service provision. recognition that we hold the power to make a difference in a patient’s quality of life must be taken seriously (iserson, 2020). the current study shows that triage for dysphagia is possible, and with the correct tool that has reliability and validity, it will provide a more rigorous method to commence early identification and intervention for dysphagia. this will inform considered development of workflow from triage to screening through to diagnostic assessment. with a well-coordinated and documented process from triage through to management, one may have an overview of the value of each step in attaining the overall goal of improved timing of dysphagia intervention, improved patient quality of life and not leaving any patient behind. in the interim, however, the checklist developed in the current study may still provide a preliminary way to filter patients who are and are not at risk for dysphagia and who can be monitored by nursing staff for any swallowing difficulties, if transferred to a ward. limitations there are some limitations to the current study. the staff at the emergency department did not participate in providing qualitative feedback on the use of the checklist. the addition of qualitative feedback would have provided necessary understanding of the process, implementation of the checklist, barriers, facilitators and recommendations. not all emergency departments at the hospital site consented to participate in the study. this limited the number of patients with whom the checklist could be trialled, and the sample of doctors who implemented the checklist was also smaller. thus, the researchers were not able to gather sufficient depth on the usefulness of the checklist as part of the reliability and validity process. gathering data not only from the different emergency units within the same hospital but also from multiple hospital sites would have also provided a broader understanding on the receptiveness of dysphagia triage and provided a larger sample for more detailed analysis. acknowledgements the authors would like to thank all the participants who participated in the study. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions k.k. conceptualised the research project and carried out the research. both authors discussed the results and contributed to the final manuscript. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study are available from the corresponding author, k.k., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references ainslie, g. 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(2000). reliability and validity of a new five-level triage instrument. academic emergency medicine, 7(3), 236–242. https://doi.org/10.1111/j.1553-2712.2000.tb01066.x appendix 1 dysphagia triage checklist      please complete: patient hospital number: __________________   patient name: ___________________________ name of hospital: ________________________   administered by: _________________________ date of assessment: ______________________   date of screening: ________________________ medical diagnosis: _______________________ instructions: familiarise yourself with the checklist prior to administering it the checklist should take you no longer than 2 minutes to complete the checklist should be administered as part of the triage process in the emergency department for each test item, you will be required to an indicate ‘√ ‘or ‘x’ result. the entire checklist must be completed and if there are any ‘x’ a speech therapy referral is indicated if you are unsure refer to a speech therapist put the original copy in the sealed box for the researcher and the duplicate in the patients file indicate ‘√ ‘or ‘x’ section a 1. is the patient awake and alert? 2. is the patient responsive? 3. is the patient able to breathe freely? (i.e. no difficulty breathing or maintaining sats) section b 4. can the patient maintain control of their saliva? 5. does the patient have a wet or hoarse sounding voice? section c 6. can the patient understand your instructions? 7. can the patient cough when asked to? 8. is the patient’s cough productive? note: checklist adapted from: the standardised swallow assessment; massey bedside swallowing screening, yale swallow protocol; the south african dysphagia screening tool (sads) http://www.sajcd.org.za open access page 1 of 1 original research acknowledgement to reviewers in an effort to facilitate the selection of appropriate peer reviewers for the south african journal of communication disorders, we ask that you take a moment to update your electronic portfolio on https://sajcd.org.za for our files, allowing us better access to your areas of interest and expertise, in order to match reviewers with submitted manuscripts. if you would like to become a reviewer, please visit the journal website and register as a reviewer. to access your details on the website, you will need to follow these steps: 1. log into the online journal at https://sajcd. org.za 2. in your ‘user home’ [https://sajcd.org.za/ index.php/sajcd/user] select ‘edit my profile’ under the heading ‘my account’ and insert all relevant details, bio statement and reviewing interest(s). 3. it is good practice as a reviewer to update your personal details regularly to ensure contact with you throughout your professional term as reviewer to the south african journal of communication disorders. please do not hesitate to contact us if you require assistance in performing this task. publisher: publishing@aosis.co.za tel: +27 21 975 2602 tel: 086 1000 381 the editorial team of the south african journal of communication disorders recognises the value and importance of the peer reviewer in the overall publication process – not only in shaping the individual manuscript, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank all reviewers who participated in shaping this volume of the south african journal of communication disorders. we appreciate the time taken to perform your review(s) successfully. andrea robbertse anita van der merwe anniah mupawose berna gerber bhavani pillay caitlin wakefield candice randall carianne vermeulen carlien muller-vorster claudine storbeck deodat kritzinger dhanashree pillay erika bostock fatemah camroodien-surve frenette southwood haina keke harsha kathard heather wilkinson israel nyarubeli jaishika seedat jane herbert jenny pahl jill murray juan bornman julie durando julize van niekerk karen michel karin joubert karyn casey kathryn schie katijah khoza-shangase kim coutts lebogang ramma lidia pottas liezel schlebusch lucretia petersen maggi soer marguerite de jongh mari viviers meera rijhumal melissa bortz michal harty michelle pascoe mpilo booi mukovhe phanguphangu musa makhoba navin singh nomfundo moroe nondumiso gina norman khoza ondene van dulm piers dawes sadna bolton saira karrim samantha govender shabnam abdoola tarryn reddy victor de andrade vishakha rawool willie deysel zenzo chakara http://www.sajcd.org.za� https://sajcd.org.za� https://sajcd.org.za� https://sajcd.org.za� https://sajcd.org.za/index.php/sajcd/user https://sajcd.org.za/index.php/sajcd/user mailto:publishing@aosis.co.za article information authors: roha m. thomas1 ramesh kaipa1 affiliations: 1department of communication sciences and disorders, oklahoma state university, united states of america correspondence to: ramesh kaipa email: ramesh.kaipa@okstate.edu postal address: 042 murray hall, oklahoma state university, stillwater, ok 74078, united states of america dates: received: 19 mar. 2014 accepted: 06 sept. 2014 published: 10 feb. 2015 how to cite this article: thomas, r.m., & kaipa, r. (2015). the use of non-speech oral-motor exercises among indian speech-language pathologists to treat speech disorders: an online survey. south african journal of communication disorders, 62(1), art. #82, 12 pages. http://dx.doi.org/10.4102/sajcd.v62i1.82 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the use of non-speech oral-motor exercises among indian speech-language pathologists to treat speech disorders: an online survey in this original research... open access • abstract • introduction • methods    • research design       • development of the online survey       • procedure       • participants       • ethical clearance       • data analysis • results    • participants preferring to use nsomes       • current or past usage of nsomes       • length of using nsomes       • conditions for which nsomes were used       • types of speech disorders for which nsomes were used       • types of nsomes used       • types of materials used for nsomes       • frequency of usage of nsomes       • reasons for believing that nsomes are effective       • use of nsomes in future    • participants not preferring to use nsomes       • current and/or past usage of nsomes       • rationale for not using nsomes       • awareness of research discouraging the use of nsomes       • factors that would encourage consideration of nsomes • discussion    • what is the percentage of slps using nsomes to treat speech disorders, and rationale for using nsomes?    • what are the types of speech disorders for which nsomes are used?    • what are the types of nsomes used to treat speech disorders?    • what is the percentage of slps preferring not to use nsomes, and their justification for this choice?    • association between the length of clinical experience and preference to use nsomes • limitations • conclusion • acknowledgements    • competing interests    • author contributions • references • appendix    • the use of non-speech oral-motor exercises in india questionnaire abstract top ↑ objective: previous surveys in the united states of america (usa), the united kingdom (uk), and canada have indicated that most of the speech-language pathologists (slps) tend to use non-speech oral-motor exercises (nsomes) on a regular basis to treat speech disorders. at present, there is considerable debate regarding the clinical effectiveness of nsomes. the current study aimed to investigate the pattern and extent of usage of nsomes among indian slps. method: an online survey intended to elicit information regarding the use of nsomes was sent to 505 members of the indian speech and hearing association. the questionnaire consisted of three sections. the first section solicited demographic information, the second and third sections solicited information from participants who did and did not prefer to use nsomes, respectively. descriptive statistics were employed to analyse the responses that were clinically relevant. results: a total of 127 participants responded to the survey. ninety-one percent of the participants who responded to the survey indicated that they used nsomes. conclusion: the results suggested that the percentage of slps preferring to use nsomes is similar to the findings of surveys conducted in the usa, the uk, and canada. the indian slps continue to use nsomes based on a multitude of beliefs. it is important for slps to incorporate the principles of evidence-based practice while using nsomes to provide high quality clinical care. introduction top ↑ non-speech oral-motor exercises (nsomes) refer to oral activities that are believed to influence speech production without actually executing speech (forrest, 2002). they include activities like lateral tongue sweeps, pursing and puckering of lips, puffing of cheeks, blowing, and sucking. speech-language pathologists (slps) in many countries continue to use nsomes to treat various speech disorders (hodge, salonka & koollias, 2005; lof & watson, 2008; mackenzie, muir & allen, 2010). clark (2003) indicated that most of the slps tend to use nsomes to treat speech deficits associated with motor speech disorders (msds). the term msds includes the dysarthrias and apraxia of speech (aos). dysarthria refers to a group of neurologic speech disorders that reflect abnormalities in the strength, speed, range, steadiness, tone or accuracy of movements required for the breathing, phonatory, resonatory, articulatory, or prosodic aspects of speech production (duffy, 2013). on the other hand, aos refers to a motor planning and programming disorder in which the volitional production of speech is compromised (theron, van der merwe, robin & groenewald, 2009). the use of nsomes in the treatment of speech disorders has been one of the most debated topics within the scope of communication disorders (mccauley, strand, lof, schooling & frymark, 2009). research carried out in the past two decades has searched for experimental evidence regarding the clinical utility of nsomes, and has resulted in equivocal results (mccauley, strand, lof, schooling & frymark, 2009). a recurring theme in studies investigating the clinical utility of nsomes is the possible transfer and/or generalisation of treatment effects of nsomes to speech production (hodge, 2002; weismer & liss, 1991). the above authors opined that treatment of speech disorders should be task specific (i.e. using speech activities to treat speech disorders), rather than using nsomes to treat speech deficits. on the other hand, clark (2003) emphasised the potential applications of nsomes in treatment of specific speech disorders. it is essential for clinicians to understand the theoretical underpinnings of specific nsomes (e.g., blowing, sucking, lip puckering), and the type of speech disorder they could be applied to. for example, strengthening exercises could be beneficial in treatment of an execution disorder like dysarthria, rather than treating aos, which is a speech motor planning disorder. in spite of this ongoing debate surrounding the use of nsomes, a majority of the slps around the world continue to use nsomes based on anecdotal evidence. lof and watson (2008) surveyed 2000 slps in the usa, of which 537 slps responded, a response rate of 27.5%. the results indicated that 85% of slps used nsomes to treat speech disorders. mackenzie, muir, and allen (2010) surveyed the use of nsomes in the treatment of acquired dysarthria among slps in scotland, wales, and northern ireland. postal questionnaires were sent out to 341 slps, and yielded responses from 191 slps, a response rate of 56%. the results of the survey indicated that 81% of the slps used nsomes in the treatment of acquired dysarthria. a similar study in canada revealed that 85% of slps preferred to use nsomes to treat speech disorders (hodge, salonka & koollias, 2005). recently, mccauley, strand, lof, schooling, and frymark (2009) performed a systematic review of the evidence for using nsomes to improve speech production. the results of the review indicated that there is insufficient evidence to refute or support the use of nsomes to improve speech production. over the past few years, there has been an emphasis that the application of nsomes should be guided by evidence-based practice (clark, 2003; lass & pannbacker, 2008; muttiah, georges & brackenbury, 2010). the term ‘evidence-based practice’ (ebp) refers to using the best, research-proven assessment and treatment techniques to deliver the most effective services to patients (american speech, language, and hearing association [asha], 2005). according to the asha's position statement on ebp: the goal of ebp is the integration of: (a) clinical expertise, (b) best current evidence, and (c) client values to provide high-quality services reflecting the interests, values, needs, and choices of the individuals we serve. even though, ebp emphasises the integration of all the above three aspects, it is possible that clinicians and academic researchers could differ on these three aspects. the clinicians, on the one hand, could be focused just on the clinical expertise and their personal opinions. academic researchers, on the other hand, could be focused on finding the current evidence, neglecting the clinical perspective of the ebp. hence, both researchers and clinicians have an obligation to work together to deliver the best practice for all the patients encountered. at present, there is insufficient evidence to support or refute the use of nsomes. until well-grounded research is conducted to prove or disprove the use of nsomes, it is essential to consider the clinical perspective of slps with regard to the use of nsomes, which is one of the three aspects of ebp. even though slps continue to use nsomes on a regular basis, it is important for them to understand the scientific rationale behind the application of nsomes, and the speech disorders that can potentially benefit from nsomes. currently, there is limited information as to why slps prefer to continue using nsomes. the scanty data available is based on the surveys conducted in the usa, canada, and the uk. there are no data regarding the use of nsomes among slps in india. in india, there are approximately 1500 slps (indian speech & hearing association [isha], 2011) serving a population of approximately 1.2 billion (office of the registrar general & census commissioner, india, 2011). the decisions regarding the use of nsomes among indian slps can have a major impact on clinical practice in india. hence, the rationale of the current study was to investigate the extent of usage of nsomes among indian slps, and if the application of nsomes is guided by scientific evidence. specifically, the current study aimed to answer the following four research questions, (1) what is the percentage of slps using nsomes to treat speech disorders in india, and rationale for the use of nsomes, (2) what are the types of speech disorders for which nsomes are used, (3) what are the different types of nsomes used to treat speech disorders, and (4) what is the percentage of slps not preferring to use nsomes, and the rationale for not using nsomes. methods top ↑ the general purpose of the current study was to investigate the views and usage of nsomes among indian slps. specifically, the current study aimed to explore the demographics regarding the percentage of slps using, and not using nsomes, the type of nsomes used to treat speech disorders, and the type of speech disorders for which nsomes were used. research design the current study implemented a cross-sectional survey research design to achieve the above aims. a cross-sectional design provides a snapshot of a set of characteristics that exist in a population at a specific point of time (levin, 2006). survey research involves collecting information regarding a specific topic from a group of individuals through their responses to the questions. survey designs are relatively inexpensive, and can potentially elicit responses from individuals in remote locations (bartlett, kotrlik & higgins, 2001). for the above reasons, the researchers deemed the cross-sectional survey design to be appropriate for this study. development of the online survey a questionnaire was created using the qualtrics© software (qualtrics, provo, ut, 2005) for the purpose of online data collection. the questions listed on the survey were prepared specifically to suit the nature of academic training related to communication disorders in india, and the work environment of indian slps. the questionnaire comprised three sections of 27 questions in total, and took approximately 10 min to complete. the questionnaire included multiple-choice and yes/no questions. a majority of the questions allowed the respondents to choose multiple answers from the provided options. however, a small number of questions required the participants to choose just one option. the first section of questions solicited demographic details of the participants such as the type of work setting, work experience, education, gender, and area of clinical specialty. the second section consisted of questions related to the use of nsomes by the participants including, though not limited to clientele information, speech disorders for which nsomes were used, type of nsomes used, and frequency of use of nsomes. if the participants indicated that they did not use nsomes, they were directed to the third section of questions. the third section elicited information from respondents who did not use nsomes in their clinical practice (please see appendix for the complete questionnaire). procedure an e-mail was sent to 505 members listed in the online directory of the isha. the e-mail consisted of an introductory message that invited the respondents to participate in the survey, the web link to the online survey questionnaire, and instructions to successfully complete the survey. in addition, the details of the survey and the link to the survey were posted on the research webpage of the isha. participants a total of 127 individuals responded to the online survey. all the participants provided consent to participate in the current study. with regard to the education level of the participants, 75% had completed a master's degree in communication sciences and disorders, 16% had completed a bachelor's degree, a small number of participants had obtained a ph.d. (6%), and 4% obtained a master's degree from a different field (e.g., psychology). a majority of the participants (74%) had 0–5 years of clinical experience. a small percentage (18%) reported that they had clinical experience ranging from 6–10 years, whilst a handful of participants (2%) reported that they had clinical experience ranging from 16–20 years, and another 2% had experience of more than 20 years. with regard to work settings, a little less than half the number of participants (48%) worked in universities, another 48% of the participants worked in hospitals, around 34% worked in private practice, and only 7% worked in schools. some of the respondents indicated that they worked in multiple settings, leading to an overlap of the responses. the male participants accounted for 31% of the respondents. the demographic information related to participants is presented in table 1. table 1: demographic details of the participants. ethical clearance the institutional review board at the authors’ institution approved this study. informed consent was obtained from all the participants. the participants’ responses were completely anonymous to protect their identity. the participants were made aware that they could withdraw their participation at any stage of the survey. data analysis previous survey questionnaires that were used to collect data about the use of nsomes were compared to the current study's questionnaire to ensure criterion validity. an indian slp with five years of clinical experience reviewed the content of the questionnaire in order to ensure that it was appropriate for eliciting valid information regarding the use of nsomes. this served as a measure of content validity. unfortunately, the test-retest reliability of this survey could not be determined as the same respondents were unable to take the survey for the second time. descriptive statistics were used to analyse the obtained data. the participants’ responses to each item on the questionnaire were aggregated and converted to a percentage by the qualtrics© software. in addition, the strength of association between certain variables on the questionnaire was measured using the chi-square test of association. the alpha level was set at 0.05. results top ↑ a total of 127 participants responded to the online survey, yielding a response-rate of 25.4%. the aggregated responses of participants are reported under two main sections: participants preferring to use nsomes, and participants not preferring to use nsomes. participants preferring to use nsomes with a view to gaining a better insight regarding the clinicians’ perspective and rationale for using nsomes, the results of the following aspects that are relevant to the aim of this study are reported: current or past use of nsomes in speech therapy, length of usage of nsomes, conditions for which nsomes are used, different disorders for which nsomes are used, types of nsomes used, types of materials used for nsomes, frequency of usage of nsomes, reasons for believing that nsomes are effective, and future use of nsomes. the percentage responses that are reported below are based on the responses from participants who preferred to use nsomes. current or past usage of nsomes a majority of the participants (91%) indicated that they either used, or had been using nsomes as a speech therapy technique. length of using nsomes with regard to the length of using nsomes as a speech therapy technique, a small number of participants (8%) reported using nsomes for less than one year. around 13% indicated they were using nsomes for 3–4 years. there was a roughly equal representation of participants who had been using nsomes for 1–2 years (20%), 2–3 years (19%), 4–5 years (22%), and more than 5 years (17%). conditions for which nsomes were used most of the participants (96%) reported that they were using nsomes to improve the motor aspect of the articulators (e.g., to improve the strength, tonicity). around 65% used nsomes to improve the sensory deficits of oral structures (e.g., hypersensitivity). some of the participants (61%) also indicated that they used nsomes to manage feeding problems in children. a sizable number of participants (83%) also reported that they used nsomes with their clients to control drooling. a small number of the participants (8%) indicated that they used nsomes for other conditions such as speech sound disorders, developmental aos and child language disorders such as autism (to improve oral sensory issues). types of speech disorders for which nsomes were used an overwhelming number of participants (92%) used nsomes to treat msds. this was followed by 82% of the participants using nsomes to treat swallowing disorders. approximately half the number of participants (51%) used nsomes to treat speech sound disorders. around 27%, 29%, and 21% of the participants used nsomes to treat clients with developmental language disorders, adult language disorders, and resonance disorders, respectively. in addition, a small percentage of the participants (7%) used nsomes to treat voice disorders and another 7% of the participants used nsomes to treat fluency disorders. types of nsomes used most of the nsomes were used by an equal number of participants. lip puckering was used by a majority of the participants (90%), followed by blowing (87%) and puffing of cheeks (87%). lateral lip movements, lateral tongues sweeps, alternative lip puckering and/or smiling, sucking and vertical tongue movements were used by 73%, 80%, 83%, 75%, and 81% of the participants, respectively. types of materials used for nsomes the most frequently used material for nsomes was straw, which was used by 84% of the participants. this was followed by paper strips (83%) and brushes (83%). blowing whistles, balloons and cotton balls were used by 76%, 67%, and 56% of the participants, respectively. horns were the least frequently used materials (25% of the participants). frequency of usage of nsomes a little more than half the number of participants (56%) indicated that they used nsomes occasionally (25–50% of the therapy sessions). around 40% of the participants indicated that they used nsomes frequently (more than 75% of the therapy sessions). only a small number of participants (5%) indicated that they used nsomes rarely (less than 10% of the sessions). reasons for believing that nsomes are effective most of the participants (84%) believed that nsomes seemed to be effective, because they helped to strengthen the articulators, thereby improving speech intelligibility. a little less than half the number of participants (43%) indicated that they used nsomes as they thought they are useful for improving the sensory problems of the oral-facial region. around 34% of the participants reported that they used nsomes, as they have read journal articles or book chapters about the efficacy of nsomes. approximately 31% of the participants believed that speech develops from non-speech tasks (like blowing), and hence using nsomes to treat speech disorders seemed to be logical. finally, 31% of the participants believed that nsomes were effective based on their personal experience. use of nsomes in future around two-thirds of the participants (75%) reported that they would continue to use nsomes in future along with other speech therapy techniques. a small number of participants (13%) mentioned that they would continue to use nsomes for a long time. another 13% of the participants indicated that they might use nsomes for some time in future and would discontinue them if there are better speech therapy techniques. the responses of the participants who preferred to use nsomes as a speech therapy technique are presented in table 2. table 2: findings related to participants preferring to use nsomes. participants not preferring to use nsomes with regard to the participants not preferring to use nsomes, the results of the following aspects that are relevant to the aim of the current study are reported: current and/or past use of nsomes, rationale for not using nsomes, awareness of research discouraging the use of nsomes, factors that would encourage consideration of nsomes. the percentage responses that are reported below are based on the responses from participants who did not prefer to use nsomes. current and/or past usage of nsomes around 9% of the participants who responded to the survey reported that they did not use nsomes as a speech therapy technique. rationale for not using nsomes among the 9% of the participants who did not prefer to use nsomes, the main reasons cited for not using nsomes were: (1) around half the number of participants (50%) were not seeing clients who required the use of nsomes, (2) personal experience (38%), (3) lack of research supporting the use of nsomes (38%), and (4) attending continuing education events that did not encourage the use of nsomes (25%). awareness of research discouraging the use of nsomes more than half the number of participants (63%) indicated that they were aware of research that discouraged the use of nsomes as a speech therapy technique. factors that would encourage consideration of nsomes all the participants (100%) reported that they would consider using nsomes if there was adequate evidence supporting the use of nsomes in clinical practice. around two-thirds of the participants (75%) indicated that they would consider nsomes if they had personal experience of having success in using nsomes with their clients. a small number of participants (25%) mentioned that they would consider using nsomes in future if they witnessed an increasing number of clinicians using nsomes. the responses of the participants who did not prefer to use nsomes are presented in table 3. table 3: findings related to participants not preferring to use nsomes. in addition to the participants’ responses to specific items on the questionnaire, the authors were interested to see if there was an association between the length of participants’ clinical experience and preference to use nsomes. the results of a chi-square test revealed that there was a significant association between length of clinical experience and preference to use nsomes, χ 2 (4, n = 99) = 11.01, p < 0.05. discussion top ↑ the findings of past studies investigating the use of nsomes among slps in the usa, the uk, and canada revealed that a significant number of slps preferred to use nsomes. the current study aimed to investigate the pattern and extent of usage of nsomes among indian slps. some of the findings of the current study align with previous studies of similar nature. the clinical findings relevant to the four primary research questions that were posed at the beginning of this paper are discussed below. what is the percentage of slps using nsomes to treat speech disorders, and rationale for using nsomes? around 91% of the participants indicated that they used nsomes to treat speech disorders. similar estimates have been reported in the usa (85%) (lof & watson, 2008), the uk (81%) (mackenzie, muir, and allen, 2010), and canada (85%) (hodge, salonka & koollias, 2005). there are several factors that can be attributed to the high percentage of slps using nsomes in india. firstly, nsomes are relatively easy to be administered with clients. it is typical for clinicians in india working in private clinics and hospitals to have a large caseload. the availability of oral-motor kits makes it convenient for clinicians to administer nsomes during therapy sessions rather than incorporating activities that require extensive preparation. secondly, the clinical practice of speech-language pathology in india has been influenced by western countries to some extent in the form of webinars, textbooks, and research articles. this can be another reason for the high percentage of indian slps using nsomes similar to slps in western countries. finally, the idea of nsomes is more of a cultural transmission from one generation of slps to another. this cultural transmission is a likely reason why nsomes have survived in india for so many years. with regard to the rationale for using nsomes, an overwhelming majority of the participants indicated that they used nsomes as they believed that they helped in developing the muscle strength of the articulators. even though the use of nsomes as a speech therapy technique has been fraught with controversy, it is likely that nsomes could be useful in a small percentage of clinical population who present with articulatory weakness. (clark, 2003; duffy, 2013). a common argument against using nsomes to strengthen the articulators is that individuals require only a small proportion of their oral muscular force to produce speech (muller, milenkovic & macleod, 1985). according to this notion, an individual with reduced muscular force of the tongue will still be able to produce the necessary force required for normal speech production. however, luschei (1991) argued against this notion. he stressed that, whilst high force may not be required during lingual speech movements, adequate power might be a prerequisite for agile articulatory movements. in this case, strength training to improve the power rather than the force could prove beneficial to a patient with lingual weakness (clark, 2003). duffy (2013) also recommended using nsomes only to treat articulatory deficits that are associated with weakness. thus, the rationale expressed by a majority of the indian slps for using nsomes seems to be in line with previous literature that advocated the use of nsomes to treat speech deficits associated with oral weakness. less than half the number of participants indicated that they used nsomes because they thought they improved the sensory problems of the oral-facial region. marshalla (1985) proposed that the sensorimotor experience in early childhood serves as a foundation for speech development. therefore, it is logical to assume that sensory deficits contribute to deficits in speech production. however, remediating oral-sensory deficits to improve the motoric aspect of speech production seems to be questionable, and needs to be further explored. previous studies have not been able to establish a relationship between sensory acuity and speech proficiency. the clinicians need to be aware that treating oral-sensory issues in order to improve the speech production could be a futile attempt. some of the other reasons provided by the participants for using nsomes were: speech develops from non-speech tasks (like blowing), reading research articles or book chapters about the efficacy of nsomes, and personal experience. previous research has revealed that during the early stages of development, the movements for a motor pattern for non-speech activities such as chewing tend to be different from motor pattern during speech (moore, smith & ringel, 1988). the rationale expressed by some of the slps that speech develops from non-speech activities does not seem to hold ground based on the existing evidence. in general, the current study reveals that slps in india continue to use nsomes based on a multitude of beliefs. at present, the only rationale that seems to be supported by some form of evidence is that nsomes could be helpful in strengthening of the articulators. however, slps should be aware that this could be applicable only to disorders like flaccid dysarthria that are associated with weakness of the articulators. what are the types of speech disorders for which nsomes are used? the survey results indicated that nsomes were used more frequently by indian slps to treat msds. the questionnaire in the current study did not differentiate the specific types of msds for which the nsomes were used (e.g., dysarthria vs. aos). however, the questionnaire had a separate option titled ‘other’, where the participants were able to indicate the specific disorders and/or conditions for which they used nsomes. a small percentage of the participants did indicate that they used nsomes to treat aos. weakness is one of the common motor impairments that accompany both developmental (e.g., cerebral palsy), as well as acquired dysarthria (e.g., following a stroke) (clark, henson, barber, stierwalt & sherrill, 2003; dworkin & aronson, 1986; dworkin, aronson & mulder, 1980; dworkin & hartman, 1979; gentil, perrin, tournier & pollak, 1999; langmore & lehman, 1994; murdoch, attard, ozanne & stokes, 1995). it is not surprising that nsomes intended for strength training are frequently applied to treat an execution disorder like dysarthria. in fact, the findings of lof and watson (2008) revealed that slps in the usa used nsomes more frequently to treat dysarthria than other disorders. however, applying nsomes to treat a planning-based disorder like aos may be questionable, as there is no consensus between the control of non-speech oral movement and planning speech movements (ziegler, 2003). it is easy for clinicians to be misguided by several commercially available resources that recommend nsomes as an intervention for individuals with aos. however, clinicians should be critical in generalising the benefits of nsomes to other types of msds such as aos. participants also indicated that they used nsomes to treat speech sound disorders, swallowing and/or feeding disorders, developmental language disorders, resonance disorders, voice, as well fluency disorders. at first glance, these findings may seem to be surprising. however, it is possible that the participants reported using nsomes to treat oral motor deficits that co-occurred with the above disorders rather than the primary disorder, per se. it is not uncommon to find literature that reports oral motor deficits associated with speech sound disorders (chapman-bahr, 2001), swallowing disorders (adams, callister, & mathisen, 2011) and autism spectrum disorders (asds) (belmonte et al. 2013). for example, belmonte et al. found a correlation between oral motor deficits and the speech and language abilities in a cohort of children with asds. a caveat on using nsomes to treat different types of speech disorders is that the outcomes of nsomes could not only vary when applied to different speech disorders, but could prove to be harmful as well. the decision to apply nsomes to a certain speech disorder should begin with analysing the pathophysiology of the speech disorder. if the underlying pathophysiology does not tend to be at the level of motor speech execution, the potential attempt at using nsomes should be avoided. what are the types of nsomes used to treat speech disorders? it was found that lip puckering was used by a majority of the participants (90%). other nsomes such as lateral lip movements, lateral tongue sweeps, vertical tongue movements, blowing, sucking, puffing of cheeks, and smiling were used on an almost equal basis. the lack of empirical support for the use of nsomes makes it necessary for slps to understand the influence of different nsomes on the oral muscular physiology, and how they can act on the underlying speech impairments. before slps can decide on using a specific oral-motor exercise, they should evaluate the physiological impact of that exercise on the underlying speech impairment. for example, if the goal is to improve the lingual weakness, an appropriate strength training protocol (in the form of isometric and/or isotonic exercises) should be chosen. the ultimate goal of a strength-training programme is to enhance strength, endurance, and power of the affected muscles. however, this enhancement is only possible when the muscle is taxed beyond its normal workload (clark, 2003). in the present study, the participants were not provided with an opportunity to express as to why they preferred using a certain exercise over other exercises; this is a limitation that needs to be addressed in future research. in general, slps need to be rational and choose nsomes that could have a positive impact on the underlying impairment rather than choosing nsomes that tend to be more popular with other slps. what is the percentage of slps preferring not to use nsomes, and their justification for this choice? a small percentage of participants (9%) indicated that they did not prefer to use nsomes. around half the number of participants stated that they did not use nsomes as they were seeing clients who did not require the application of nsomes. the other reasons provided by participants for not using nsomes were lack of evidence supporting the use of nsomes, and personal experience. however, a majority of these individuals considered using nsomes in the light of adequate evidence supporting their use. the rationale expressed by the participants for not using nsomes seems to be in agreement with the published literature criticising the use of nsomes (forrest, 2002; loff & watson, 2008). over the past few years, an increasing number of researchers have expressed concern over the use of nsomes as a speech therapy technique (lass & pannbacker, 2008; ruscello, 2008). recent research has subjected nsomes to the test of ‘ebp’, and the results have indicated that there is minimal evidence for the success of nsomes as a speech therapy technique (lass & pannbacker, 2008; ruscello, 2008; powell, 2008). in addition, there has been a plethora of published literature criticising the theoretical foundations of nsomes. mccauley, strand, lof, schooling, and frymark (2009) recommended clinicians to use speech treatments of which the efficacy is already established, rather than using nsomes. the usage of nsomes seems to be widespread owing to the clinical perspectives of slps, rather than based on the scientific evidence. it is not surprising that the participants in the current study were reluctant to use nsomes, as they were not convinced of the treatment efficacy of nsomes. association between the length of clinical experience and preference to use nsomes as data were collected from participants with clinical experience ranging from almost no experience to more than 20 years, the authors were interested in exploring whether clinical experience had any influence on decision-making regarding the use of nsomes. the results indicated that there was significant association between the length of clinical experience and the preference to use nsomes. a majority of the participants who preferred to use nsomes had clinical experience ranging from 0–5 years. the participants’ preference to use nsomes decreased as their clinical experience increased. two reasons can be accounted for this finding. firstly, it is possible that participants who had no or limited clinical experience (0–5 years) experimented with the outcomes of nsomes by using them as a speech therapy technique on a regular basis. over the course of years, the participants could have realised there were limited benefits in using nsomes to treat speech disorders. this could be one of the reasons why participants with more clinical experience did not prefer to use nsomes. secondly, most of the slps (74%) who participated in the study had clinical experience ranging from 0–5 years. the data could have been skewed by including very few participants with more than five years years of clinical experience, which would have made it appear as if participants with limited clinical experience use nsomes regularly compared to participants with more clinical experience. hence, this finding should be extrapolated with caution. limitations top ↑ there were some obvious limitations in the current study that could have had a bearing on the results. the first limitation is a low response rate from the prospective participants. the responses of the participants discussed in this study do not represent the views of the entire slp community in india. hence, the information regarding the clinical application of nsomes among other slps remains unknown. the second limitation is that the questionnaire used in this study did not differentiate the application of nsomes between acquired and congenital disorders, as well as between dysarthria and aos. this could have provided more information regarding how participants differ in the application of nsomes to treat a congenital vs. acquired speech disorder, and whether slps understand the rationale in applying nsomes to an execution based disorder (dysarthria) versus motor planning disorder (aos). the third limitation is the inclusion of a limited number of participants with varied clinical experience. a majority of the participants in the current study had limited clinical experience. recruiting participants with different lengths of clinical experience would have allowed the authors to investigate whether the attitude towards the use of nsomes changes with increasing clinical experience. conclusion top ↑ the controversy surrounding the use of nsomes has been an ongoing issue for the past several years, and will continue until both sides of the argument agree to work together with the intention of answering unsolved questions. the application of ebp is essential to the growth of a clinical profession like speech-language pathology. ebp encourages the integration of clinical expertise, best available research evidence, and the client's values (muttiah, georges, & brackenbury, 2011). in the process of applying ebp to the use of nsomes, two distinct groups have emerged: clinicians and researchers. muttiah, georges, and brackenbury (2011) mentioned that there is considerable difference of opinion between clinicians and researchers regarding the implementation of nsomes. clinicians, on the one hand, tend to be concerned with their clinical perspective, and could neglect searching for quality evidence. on the other hand, researchers tend to spend a lot of time in laboratories, and have minimal contact with actual practitioners. both researchers as well as clinicians have to realise that they have a shared responsibility in promoting ebp with regard to the use of nsomes. even though a majority of the slps continue to use nsomes, it is essential for them to document the outcomes and share them with researchers in order to increase transparency in clinical practice. the findings of the current study revealed that a majority of slps are inclined to use nsomes in spite of the surrounding controversy. an ideal way to resolve this controversy would be to conduct well-designed single case experimental studies that evaluate the treatment benefits of nsomes. acknowledgements top ↑ the authors would like to thank the participants and the secretary of the indian speech and hearing association (isha). competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. author contributions r.m.t. 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(2003). speech motor control is task-specific: evidence from dysarthria and apraxia of speech. aphasiology, 17, 3–36. http://dx.doi.org/10.1080/729254892 appendix top ↑ the use of non-speech oral-motor exercises in india questionnaire abstract introduction method results discussion conclusion clinical impact acknowledgements references about the author(s) skye n. adams department of speech pathology and audiology, school of human and community development, faculty of humanities, university of the witwatersrand, johannesburg, south africa jaishika seedat department of speech pathology and audiology, school of human and community development, faculty of humanities, university of the witwatersrand, johannesburg, south africa kim coutts department of speech pathology and audiology, school of human and community development, faculty of humanities, university of the witwatersrand, johannesburg, south africa kelly-ann kater department of speech pathology and audiology, school of human and community development, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation adams, s.n., seedat, j., coutts, k., & kater, k-a. (2021). ‘we are in this together’ voices of speech-language pathologists working in south african healthcare contexts during level 4 and level 5 lockdown of covid-19. south african journal of communication disorders, 68(1), a792. https://doi.org/10.4102/sajcd.v68i1.792 original research ‘we are in this together’ voices of speech-language pathologists working in south african healthcare contexts during level 4 and level 5 lockdown of covid-19 skye n. adams, jaishika seedat, kim coutts, kelly-ann kater received: 24 aug. 2020; accepted: 29 nov. 2020; published: 18 feb. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: sars-cov-2 (covid-19) has had a significant impact on every south african but more specifically healthcare professionals, including speech-language pathologists (slps). in response to the covid-19 pandemic, south africa implemented a nationwide lockdown as confirmed cases continued to rise. understanding the impact of covid-19 on slps has a three-fold purpose: to re-evaluate service provision, service delivery platforms and to identify the need for support to slps during a time of crisis. it is also crucial in guiding how policies and interventions need to be modified. objectives: the study aimed to better understand how the workspace of slps in hospitals was impacted by covid-19, how they experienced this process and the implications for them as healthcare professionals in both the private and public sector throughout south africa. methodology: an exploratory cross-sectional study design was used to meet the aims of the study. thirty-nine slps from different provinces in south africa, working in government and private hospitals during covid-19, responded to the online survey. results were analysed using descriptive statistics and thematic content analysis. results: slps’ roles, responsibilities and service delivery were impacted by covid-19. it was necessary for typical outpatient therapy services to be modified; there were changes to the role of the slp in the hospital and inpatient services were curtailed. conclusion: this study provides insightful information to slps employed in hospitals to know that they are experiencing similar challenges. it also confirms the resilience of healthcare professionals, including slps, when faced with novel and unprecedented situations. keywords: covid-19; coronavirus disease; healthcare workers; service delivery; south africa; speech-language pathologist. introduction the outbreak of the sars-cov-2 virus that causes coronavirus (covid-19) in december 2019 caused a global pandemic within a short space of time (lancet, 2020). spreading from wuhan, china, it quickly became necessary for countries across the world to institute different levels of lockdown to decrease the number of infections. as a result, south africa (sa) entered a nationwide ‘hard’ level 5 lockdown on the 27 march 2020. the country came to an abrupt halt, as movement of all but essential service providers were restricted. businesses closed and many, where possible, had to work from home. despite the sanctions to limit and stop the spread of the virus, the number of infections continued to rise and hospitals became increasingly overwhelmed because of restricted resources. south africa saw its peak in cases in july with approximately 1300 new cases being reported daily. consequently, all healthcare professionals, including speech-language pathologists (slps), were impacted in various ways (adams & wall, 2020). the need arose to understand the impact that covid-19 had and is continuing to have on patients, the health system, as well as on the different healthcare professionals. furthermore, given the uncertainty around the development, acceptance and roll-out of a vaccine for covid-19, the country needs to ensure that the impact on future health service provision is minimised. therefore, sa will need to find ways to create surge capacity to treat covid-19 patients whilst maintaining essential services. in some ways, covid-19 may have levelled the playing fields in private and public healthcare with regard to access and resource allocation of healthcare services (labuschaigne, 2020). in addition, south africa’s healthcare provision in private and public is rife with inequalities with regard to who accesses these services and the availability of resources (pillay, tiwari, kathard, & chikte, 2020; shai & ogunnubi, 2018). thus, it was important to understand how healthcare professionals in both private and public, who are working in lowand middle-income countries such as sa, experienced the impact of covid-19 at the strictest levels of lockdown. during covid-19, as hospitals struggled with high patient loads, many healthcare professionals took on additional roles, including slps, which had an impact on their scope of work as well as service delivery. in addition, there has been an increase in the adverse effects of healthcare workers that include risk and exposure to covid-19 (cipolotti et al., 2020). speech-language therapy professional boards worldwide published revised practice guidelines for the slp during covid (american speech-language-hearing association [asha], 2020; new zealand speech-language therapists’ association, 2020; royal college of speech and language therapists [rcslt], 2020; speech pathology australia, 2020). governments globally initiated a clear directive to refocus service provision to emergency and high-risk, high-priority (in)-patients only (predominantly dysphagia and some post-surgical), with outpatient services either being postponed or provided via teletherapy (mann, chen, chunara, testa, & nov, 2020). at the time the study was conducted (june 2020), an aspect that appeared to have been neglected somewhat was the impact of the change in roles, additional roles and the anxiety associated with potential exposure to covid-19 on the mental and emotional well-being of slps. the current study sought to examine how slps working in healthcare facilities in sa experienced covid-19, both professionally and personally. speech language pathology and covid-19 hospital-based slps have had to adjust to the new policies and guidelines from the government regarding how to reconsider and revise their workspace and service provision to contain the infection and protect the most vulnerable amongst their patients. with hospitals redirecting admissions and making provisions for patients who require admission for covid-19, there were a number of workload implications for slps as hospitals attempted to accommodate priority patients. implications for a reduction in services to both inpatients and outpatients were thus inevitable (asha, 2020; gregory, henley, & amaya, 2020; rcslt, 2020). coto, restrepo, cejas and prentiss (2020) in their study on the impact of covid-19 on allied health professionals (ahps) reported that 10% of the 920 participants in their study were reassigned to perform other duties that included screening patients (2.1%), taking temperatures (2.1%), scheduling (1.6%) or triaging patients (1.1%). in sa, there was a need for all healthcare professionals to adhere to government regulations (south africa disaster management act no. 57 of 2002), for only essential services to be rendered and for staff to be re-deployed to roles and areas where health services were required within an institution. for slps (and other ahps) it is unclear how hospitals defined essential and high-risk patients. given the relationship between covid-19 and respiratory compromise, these patients were predominantly those requiring dysphagia-related intervention. the saslha dysphagia guidelines provided some direction in this regard (saslha dysphagia guideline, 2020). at the time of the study, there was limited evidence on how general slp services have been impacted and what this might mean for patient care as well as the impact on slps themselves who may be at risk for exposure to covid-19. thus, it was imperative to understand the implications covid-19 may have had on the slps’ scope of practice, patient populations and service delivery both during this time and for the future. amongst the various areas that slps work in, dysphagiaand dysphagia-specific populations such as patients with tracheostomy and laryngectomy may pose an increased risk to slps because of their probability of coughing and need for suctioning (saslha dysphagia guideline, 2020). both coughing and suctioning have been identified as aerosol generating procedures (bolton, mills, wallace, brady, & group, 2020). thus, the use of personal protective equipment (ppe), implementing social distancing and patient positioning are considerations that impact service delivery from the perspective of both the patient and the slp. as sars-cov-2 has been identified in the saliva of infected patients, transmission through contact and respiratory droplets brought on by coughing and choking may be expected (bolton et al., 2020; sabino-silva, jardim, & siqueira, 2020). thus, there was a need to understand how slps working with patients and aerosol generating procedures cope, manage and provide these services. slps may have had to take on other responsibilities in the hospital such as covid-19 screening over and above service delivery to high-risk patients. as hospital policies changed as levels of lockdown eased, knowledge of how this impacted the service provision by slps was important to explore, given the uncertainty of when repercussions of the pandemic will be resolved. method the objectives of the current study were as follows: to describe the impact that covid-19 had on slps’ perceptions of working in healthcare contexts both on a personal and a professional level to understand how covid-19 impacted service delivery specifically. research design an exploratory qualitative cross-sectional study design was used using an online questionnaire, based on the literature related to healthcare worker’s experiences working during covid-19 (see chew et al., 2020; dimer et al., 2020; franza et al., 2020) (appendix 1). this design enabled the researcher to obtain an understanding of how slps were experiencing covid-19 within the hospitals being studied (creswell, 2014). in addition, based on the restrictions because of covid-19, an online questionnaire was deemed most appropriate as it complied with the lockdown regulations of appropriate social distancing, was cost-effective and allowed for data to be collected in a short amount of time across different provinces. participants participants were slps from across sa to represent a heterogenous group, diverse in their contexts and working conditions. data were collected using an online questionnaire from participants who met the following inclusion criteria: (1) slps registered with the health professions council of south africa (hpcsa), (2) slps working at a public or private hospital and (3) slps working during the covid-19 period. thirty-nine slps comprised the sample. table 1 provides an overview of the provinces they worked in and their work setting. most respondents were from gauteng (n = 16), followed by western cape (n = 11), with 23 slps from the public sector, and 16 working in the private health sector, namely, 13 working in a private hospital and three slps working in a private rehabilitation context. it was unfortunate that the response rate was not higher, given that there are currently 2643 slps registered with the hpcsa (pillay et al., 2020). whilst acknowledged under the limitations, the researchers were cognisant of the timing of data collection – there were an unusually high number of surveys being completed at the time of the data collection because of the coronavirus pandemic. thus, the sample of 39 was deemed acceptable. furthermore, the data added value to how slps in healthcare settings were experiencing the pandemic in the south african context. table 1: participant description and characteristics. procedures and data collection following ethics approval, the south african speech language and hearing association (saslha) was used to recruit participants. the web questionnaire for this study was conducted from 15 june 2020 to 29 june 2020 level 3 of the nationwide lockdown. all participants were provided with consent forms prior to completion of the online questionnaire. there was no risk of harm to the participants. participants were also informed of their right to withdraw at any point in the study. the questionnaire consisted of both structured and open-ended questions, including: demographic information (understand where participants are from and their work setting) previous and current role/duties (work routines prior to and under covid-19) challenges and benefits of working in the hospital as an slp in the current context (facilitators and barriers of working under covid-19 to better inform clinical practice for as long as covid-19 pandemic is present) the impact of covid-19 on their patients/services (to gain insights into how slp prioritised patients and the reasons underlying their choices). reliability and validity four experts who had experience in working in the field of slp in the hospital setting reviewed the questionnaire. after review, all experts commented on the relevancy and appropriacy of the questionnaire, and no changes were made. this improved the face validity of the questionnaire. following the review, the questionnaire was piloted and reviewed for validity in two participants. data analysis descriptive statistics (i.e. frequencies) were performed using spss version 22. inductive and deductive thematic content analysis of responses to open-ended questions was used for additional context. ethical consideration this study was approved by the university of witwatersrand, human research ethics internal committee (non-medical) h20/05/01. results the results are presented in line with the stated objectives of the study. objective 1: how did covid-19 impact both a personal and a professional level? of the total sample, 32 slps identified that covid-19 had impacted their typical role/s within their work setting and seven slps noted no change. in addition, of those who reported an impact, 23 were from the public sector. the major themes that emerged with regard to the impact of covid-19 on slp role within the work setting were as follows. theme 1: changes to inpatient services service provision to individuals receiving intervention across the private–public spectrum was adversely impacted. slps reported that outpatient services stopped, and inpatient services were impacted by covid-19 in different ways with some not seeing any patients as reported by p30 ‘… not yet seeing patients …’ and p29 ‘currently none at all’, to not seeing patients under investigation (pui) for covid-19, ‘currently not working with pui or positive patients’ (p19), to only seeing patients when their results for covid-19 came back negative, ‘… only see patients when test negative for covid-19’ (p20), as well as continuing to see inpatients in the wards ‘i see patients in wards where there are persons under investigation for covid-19’ (p2). changes to inpatient services were implemented to reduce the risk of infection for slps. however, p5 noted that whilst she is not in contact with covid-19 patients she still risks infection from other hospital staff, ‘i am not involved with patients who have contracted covid, however i am in contact with colleagues who may have had exposure to undiagnosed patients’ (p5). thus, the exposure and transfer of the virus could not be circumvented completely given the nature of hospital work. theme 2: additional roles taken on by speech-language pathologists during covid-19 ten slps noted being involved in a range of covid-19 screening, prevention and promotion services and roles within the hospital that they would otherwise not have been required to fulfil: ‘i was part of the community screening and testing.’ (p2, western cape, public sector) ‘we are currently helping out with community testing and screening …’ (p3, western cape, public sector) ‘i participate in screening at the main entrance of the hospital in order to identify patients at risk who need to be triaged and tested for covid-19.’ (p19, gauteng, public sector) as noted above, despite precautions being taken to prevent transmission of infection by patients to slps, their involvement in hospital services, while noteworthy and necessary, may have inadvertently placed them at risk given the nature of screening, as noted by p19. this was also picked up in the response by p37 ‘i coordinate and perform screening of all outpatients and visitors to the hospital for covid-19’. a theme that emerged in terms of the personal impact that slps experienced from covid-19 that of vulnerability and risk (see below). results suggested that the personal risk impact was underpinned by the additional roles that slps were involved in. in addition to screening, other additional roles taken on by slps included health prevention and promotion regarding covid-19 such as community education: ‘we do health promotion and education in the community regarding covid-19 signs and symptoms as well as infection control (i.e. washing hands, wearing a mask, etc.)’, (p3, western cape, public sector) as well as running tutorials and compiling policies around infection control and sanitisation: ‘… i am a member of the covid crisis task team at the hospital. i am involved in writing and proof-reading sops and policies at the hospital, which are around covid-related issues currently’. (p37, western cape, public sector) personal impact of covid-19: vulnerability and risk: twenty-nine of the 39 slps noted that they felt comfortable in their personal knowledge about covid-19. thus, whilst they were aware of what covid-19 was, how it was spread, protocols that needed to be adhered to and they had knowledge of infection control procedures, feelings of risk were still expressed by all participants on a scale from feeling at high-risk to low-risk. some reasons underpinning this anxiety as expressed by participants were the need for more factual data by their employers, regular statistics, updates on the virus itself in terms of spread and reinfection, as well as more attuned training and information for ahps: ‘more transparency on numbers of infected patients, where in the hospital they are situated, deaths, etc.’. (p1, eastern cape, public sector) ‘it would be helpful to know the most up-to-date information, with supportive evidence, on certain aspects such as safety protocols to protect both patients and staff, current symptoms being experienced by the south african population, and when a person with covid-19 is most infectious versus when it is safe to reintegrate into a normal ward’. (p4, western cape, private sector) ‘information about contracting the virus a second time? what are known expectations around that? is it worse/better the second time? what’s the expected time frame?’ (p6, western cape, private sector) ‘i would like more guidelines from hospital management on how to manage isolation and quarantining if in contact with pui’s or confirmed positives without adequate ppe’. (p20, kwazulu natal, private sector) thus, a need for not only tangible resources in the way of ppe was necessary to reduce feelings of risk, but reassurance in the form of information was needed to enable slps to feel protected and considered by their employers. slps commented that attention to these aspects by employers would assist with the emotional and psychological distress they were experiencing, p22 ‘hospital does not provide support regarding mental health’. one participant specifically noted that information provision, coupled with attention to psychological well-being for their employees, would cultivate feelings of trust by the healthcare workers: ‘management needs to communicate the status of the hospital with respect to the number of staff who are infected or are puis, as well as the number of patients admitted with covid, to prevent rumours and create trust. there is a need for information about the process of contact tracing. management needs to set clear guidelines for the wearing of appropriate ppe and take steps to prevent wastage and ensure consistent availability of ppes’. (p37, western cape, public sector) theme 3: improved interand intra-professional teamwork twenty-five of the 32 participants, who noted that there was an impact on them professionally, felt that the impact was positive, with improvement in teamwork emerging as the major theme both intraand inter-professionally: ‘better team work with nurses, doctors and the rest of the multidisciplinary team, a feeling of “we’re all in this together”’. (p27, western cape, private sector) ‘we are working together as a team with community based care workers, nurses and allied health team’. (p3, western cape, public sector) ‘increased team work in department and mdt’. (p23, gauteng, public sector) ‘we now collaborate with pharmacy as well and doctors recognise our scope more. we are becoming involved in cases that typically we would be overlooked for’. (p35, gauteng, prublic sector) therefore, despite the changes covid-19 had on the slps’ role in the hospital, many still reported a positive impact, specifically around teamwork both within the department and with other multidisciplinary members. this highlighted the notion of ‘being in this together’ and the sense of community that the lockdown ‘enforced’. this was described in more detail: ‘my department has shown their solidarity and support towards each other and their commitment to their patients. we have tried new ways of engaging with our patients therapeutically, which will broaden the way we serve our patients after this pandemic is over. the crisis has allowed the staff with really strong work ethic and a heightened sense of commitment to the greater good of our patients to find each other and work together outside of the usual silos; there has been better collaboration and an opportunity to meet people from other departments and work on activities other than direct patient management, and this bodes well for the post-covid hospital, if management is willing to use the strengths that the pandemic has revealed’. (p37, western cape, public sector) theme 4: increased time for departmental duties in addition to lockdown improving healthcare staff collaboration and teamwork, it also provided the participants in this study the time and space to concentrate on departmental needs. as patient load reduced, it provided slps’ additional time to focus on aspects of their work that they did not always have time to do as stated: ‘lots more time doing research, reviewing protocols … in order to improve services. we’ve also started projects like toy making from waste products that will be used to improve our relevance to context when we bring out patients back and also to show parents at home how to make toys to use in lockdown from waste’. (p7, gauteng, public sector) ‘reviewing of our infection control protocols … extensive work on our practice guidelines … resource development … emotional resilience and adaptability … creating visibility about our services’. (p9, gauteng, private sector) ‘time to reflect more on clinical experiences. time to deep clean and re-arrange folders’. (p33, western cape, private sector) this was relevant for departments with fewer slps, where the typical work situation prioritised inpatient and outpatient services over other administrative tasks. objective 2: how did covid-19 impact speech-language pathologist service delivery? only two participants noted that covid-19 did not impact service provision to patients, with 37 noting a significant impact. the two participants were from the private sector. all participants working in the public sector agreed on the impact of covid-19 on service provision for patients. theme 1: quick discharge and covid-19 inpatient prioritisation: with regard to inpatients, slps reported that covid-19 patients were prioritised which resulted in discharging patients very quickly as reported: ‘patients are being discharged very quickly, limiting our provision of services in the acute phase’. (p19, gauteng, public sector) ‘patients from referring hospitals are being discharged from hospital at a rate that we cannot match’. (p4, western cape, private sector) however, slps did not find this ideal and felt that it compromised patient prognosis, and potentially necessary assessment and intervention, as they sometimes did not get to see the patient prior to discharge: ‘non-covid patients are discharged very quickly, often within 24 hours. little opportunity for follow-up because of lockdown restrictions’. (p27, western cape, private sector) ‘patients are admitted and then discharged very quickly without adequate time for full assessment or treatment’. (p32, gauteng, private sector) p6 noted, that when seen, it was a time-consuming process: ‘seeing covid-19 patients is much more time consuming given all the donning and doffing…’. (p6, western cape, private sector) ‘sessions have been cut shorter because of limiting the exposure time to patients. masks have affected the way in which osme and ome are done as many patients have difficulty with understanding the sta’. (p20, kwazulu-natal, private sector) ‘inpatient hospital numbers have reduced significantly – doctors discharging patients home straight from the acute setting, patients and families do not want to be in a hospital setting with no visitors allowed. the expense of ppe, not being able to move between units if treated a pui …’. (p31, western cape, private sector) as can be seen from these excerpts, a variety of factors and considerations were impacting inpatient services under covid-19 and with good reason. theme 2: decreasing and stopping of outpatient services: the outpatient populations who were most impacted were paediatrics (noted by nine participants), and generally high-risk patients (noted by all 35 participants). these included patients with comorbidities, immunocompromised patients and high-risk patients (tracheotomised patients): ‘children who are high risk to come to a hospital and be exposed (children with down syndrome & trachy). adults who have just suffered a stroke or tbi’. (p20, kwazulu-natal, private sector) ‘cp patients (immunosupressed patients)’. (p16, eastern cape, public sector) ‘those fall into high-risk groups such as the elderly or those with co-morbidities’. (p12, mpumalanga, public sector) eleven participants out of 37 commented that services to outpatients had stopped: ‘not allowed to see any speech therapy out-patient’. (p10, limpopo, public sector) ‘we have had to stop our outpatient clinics’. (p22, eastern cape, public sector) it was, however, noted that changes to outpatient services impacted and improved inpatient services: ‘outpatients are not being seen although inpatient care has probably improved’. (p1, eastern cape, public sector) theme 3: covid-19 protocol adversely impacting patient care: twenty-nine participants reported that their hospitals had specific covid-19 ppe protocols in place, although there was a lack of ppe at certain hospitals: ‘some private hospitals not providing appropriate ppe, therefore pt [patient] was unable to be seen immediately’. (p17, western cape, private sector) it is for this reason that the practice of donning and doffing, use of masks, social distancing and disinfection protocols were crucial regardless of the challenges this posed for effective service delivery: ‘it has impacted on the manner in which i interact with my patients. for communication it has resulted in significant difficulties with the facilitation of treatment for patients with cognitive and speech deficits who rely on visual stimulus (i.e. seeing your mouth) to participant [participate] in communication/therapy. it has been difficult to provide them with the best care …’. (p26, gauteng, private sector) p26 states the negative impact the mask had on patient interactions in that patients with cognitive and linguistic challenges could no longer benefit from the use of visual cues. theme 4: redirection of speech-language pathologists services: for outpatients, patients were redirected to receive therapy using a hybrid model which composed of telephonic consultations, teletherapy via a device, home programmes, caregiver training or whatsapp as described by participants: ‘telephone calls to follow up. whatsapp video calls. teletherapy for a very small percentage’. (p14, western cape, private sector) ‘tele rehab for those who are able to. we are also keeping strict lists of patients who aren’t receiving any therapy now (if they non urgent or and can’t do tele rehab) in order to prioritize at in person appointments them when it is safe to do so’. (p6, western cape, private sector) ‘offer of home programmes and caregiver training. follow-ups and referrals for families who did not wish to continue virtual therapy’. (p32, gauteng, private sector) however, in instances where the outpatient was unable to accommodate this, therapy stopped. patients, who were required to travel to hospitals for services, were considered high-risk, and so discouraged from attending therapy and rather were given the option of a tele-form of service delivery (noted by 12 participants), failing which no services were provided. patients, who were not comfortable coming into a hospital, were also offered a tele-form of service, and again, if they were unable to accommodate this, then they too received no service. discussion the data from this study provided valuable insights into the workspace of slps in hospital settings, who worked during level 4 and 5 of lockdown in sa. not only were there implications for slps themselves, but for the patients, and other health and medical professionals, as well as management structures and perhaps professional bodies and training institutions. current literature abounds with information around the management of covid-19 patients and those presenting with respiratory concerns, breathing challenges, as well as patients with comorbidities especially diabetes and cardiac conditions (see adams & wall, 2020; cipolotti et al., 2020; koliaki et al., 2020; sommer et al., 2020). these studies, many of which are medically oriented, are published almost daily, providing valuable direction for the management of covid-19 patients. however, a concern raised in the current study was that there were a number of patient population groups who may have been neglected during this covid-19 era. the medically stable patients, who still require some form of rehabilitation for improved functioning and prognosis, are often not receiving optimal and timely services. these patients include majority paediatrics as well as those as being labelled as high risk (i.e. patients presenting with comorbidities). as a result, these patients are placed on waiting lists and only being seen later creating a patient backlog. the literature with evidence that talks to the importance of acute phase and regular and consistent intervention (bicas, guijo, & delgado-pinheiro, 2017; gravel et al., 2020; houtrow & murphy, 2019) has had to be ignored to focus and manage the current situation. however, given the context of the south african healthcare system with regard to the already backlogged waiting lists and limited availability of therapists, this creates a significant problem. covid-19 brought along its own stressors and anxieties for healthcare workers (coto et al., 2020), but healthcare and health service provision in the post-covid arena is something that will require creative input and possible collaboration from various stakeholders in different sectors for this already struggling sector in sa to withstand the onslaught from this pandemic. the results of the current study suggest that these negotiations should already be in progress as current lockdown restrictions have been eased, as participants commented on already excessive waiting lists. another aspect raised in the study was how the regulations such as social distancing, mask use and use of gloves were barriers in therapy situations, for both inpatients and outpatients. given the nature of the work as slps, these barriers, while required, place slps (and likely other healthcare workers) in a juxtaposition. this situation forces slps to assess whether the services that are being offered are effective, valuable and whether those who require services are being seen. furthermore, given the shortened duration of interactions, and the inconsistent basis on which patients are seen, which is contrary to the evidence (bicas et al., 2017; gravel et al., 2020; houtrow & murphy, 2019), it is difficult to justify certain service delivery decisions under covid-19 restrictions. the current study thus raises many questions around delivery of patient services (or lack thereof), and andrews et al. (2020) in their paper also grappled with aspects around patient triage and prioritisation, as well as rationing of services to cater for those with covid-19. they further deliberated perceptions about quality of life and social determinants of health that resonate with the perceptions by some of the participants in the current study. the current study did address some positive changes noted by slps, which was the aspect of improved interand intra-professional teamwork. these results are supported in the current literature with regard to how an increase in how teamwork, sense of solidarity and internal support amongst healthcare workers was present (liu et al., 2020; salas-vallina, ferrer-franco, & herrera, 2020). slps stated that although covid-19 resulted in a number of negative experiences and changes in their current roles, there was still an internal resilience and spirit of togetherness amongst slps and their colleagues. however, it must be noted that participants in the study spoke to the need for additional support from hospital management, specifically in terms of being provided with the minimum resources to ensure that the work could be done efficiently, effectively and safely. this included the availability of ppe, being kept updated with information on covid-19 as well as training on infection control protocols. another point of success that emerged from this study was the improved attention to infection control and the diligence with which infection control and sanitisation practices were implemented over the covid-19 period. similar trends were noted in studies by barba et al. (2020) and shanafelt, ripp and trockel (2020) that documented the benefits of improved adherence to infection control protocols. in line with the improved teamwork that materialised as discussed above, the responses from the participants belied a sense of ownership for their place of employment. when analysed across participants, it was clear that many participants saw themselves as healthcare professionals first. their flexibility to take on roles that were not typical such as screening, prevention and promotion tasks to patients and communities alike, compiling policies and protocols, suggested that they were able to work outside of the typical slp role. acknowledgement for slps to be equipped to embrace these kinds of roles seamlessly must, in part, be attributed to the minimal exit level outcomes stipulated for undergraduates by the hpcsa (annexure k: regulations relating to the undergraduate curricula of speech language pathology). the importance for slps not only to be trained on content-specific material, but to have a broad overview in terms of collaboration, management, information provision, coordination and compiling protocols, as part of their training, to ensure that they had the skills to carry through with tasks that required these skills when practising, was evident from this study, and is something that the hpcsa advocates for. perhaps one of the most documented and published areas for many healthcare workers (as well as educators) currently is that of the implementation and benefits of tele-health services (bustamante, stevens, & robinson, 2020; law, polovoy, kornak, & hutchins, 2020; roger & grimsley, 2020; weidner & lowman, 2020). the evidence clearly confirms that tele-health which has increased in use since covid-19 can have remarkable benefits to many patients. whist this was seen, to some extent, as reported by some participants, there was also evidence to the contrary for the south african context. this situation clearly highlighted the obvious technology gap that exists in our society, and this had a significant impact on service provision for many slps (dimer et al., 2020; pillay et al., 2020; shai & ogunnubi, 2018). telehealth services, and the myriad forms this could take, was not an option for many patients, leaving slps with no alternative but to place them on waiting lists. with reference to the point made earlier regarding the ethics around this, it raises an awareness around how this may contradict what we learn about early and regular interventions. thus, whilst feelings of anxiety about this were expressed from the participants in this study, perhaps a more necessary source of information, would be to gather the insights from the patients and caregivers themselves, on how this pandemic impacted them. this information then needs to be disseminated to higher bodies to accommodate the provision of these services. with the implementation of the national health insurance (nhi), teletherapy is definitely a mode that needs to be included and addressed. the participants in the study expressed degrees of vulnerability, anxiety and perceptions of risk. inadequate and irregular information, as well as poor distribution of information, were the main contributors to these feelings. consequent implications for emotional and psychological well-being were highlighted in the current study. an increase in mental health conditions has spiked for a number of hcp during this time (greenberg, 2020). this trend is not typical only to the south african context but was in fact seen globally and in all healthcare professions (adams & wall, 2020; cipolotti et al., 2020; pfefferbaum & north, 2020). this pandemic has further highlighted existing gaps in addressing and supporting the mental health and well-being of all healthcare workers. this is an area that also requires extensive collaboration and a unique solution. finally, the researchers considered if the covid-19 experience by an slp working in the public versus the private sector would be different. the results of this study did not confirm this. whilst there appeared to be some differences in terms of how patient services changed, and how the role/s of the slp also transitioned, it was not noteworthy. although there were differences with regard to the management of inand outpatients, slps generally shared similar experience with regard to the shortage of ppe and the impact of covid-19 protocols on patient care and service delivery. conclusion this study provided valuable insight into the current experiences of slps, specifically during the covid-19 era. these insights can assist various healthcare and academic institutions to address gaps such as telehealth practices, use of ppe in therapy and mental health challenges in future policies and guidelines. positive factors such as improved team work and time for administrative tasks are perhaps aspects that need to be maintained going forward. the authors are aware of a number of limitations of the current study. there was a small sample size in the current study relative to the number of practicing slps currently working in sa. the limited sample size could have been attributed to the number of surveys being sent to slps during this time and increased workload stressors. in the study, there was no quantitative measure of burden for the slps; in addition, using a self-administered form did not allow for the researcher to probe on certain topics. however, the researchers wanted to access participants during the pandemic in different geographical locations and use a method that was both convenient and cost-effective, thus the use of a questionnaire was deemed appropriate. future research should include more interviews to get a more holistic picture of the challenges experienced by slps and other healthcare workers who are working in hospitals as well as other facilities (e.g. schools, private practice) during covid-19. clinical impact the findings provided insightful information to the slps employed in both government and private hospitals, whereby they may be able to share experiences, problem-solve challenges and learn from each other. the results also provided vital information to guide student training once lockdown measures are eased. it will enable academics to prepare students for what they may encounter in the hospital and equip them with skills and resources to guide them in their experience upon return to the hospital. the findings also reveal caveats of excellence in professional training to equip graduates to be dynamic, think on their feet and be critical problem-solvers in unexpected and novel circumstances. acknowledgements the authors would like to thank all the slps who participated in this study, shared their experiences and made this research possible. competing interests the authors have declared that no competing interests exist. author’s contributions s.a. conceptualised the research project. all authors carried out the research, discussed the results and contributed to the final manuscript. funding information s.a. was supported by consortium for advanced training in africa (carta) andwas funded by the carnegie corporation of new york (grant no.: b 8606.r02), sida (grant no.: 54100029) and the deltas africa initiative (grant no.: 107768/z/15/z). data availability statement the data that support the findings of this study are available from the corresponding author (s.a.), upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references adams, j.g., & walls, r.m. 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(2020). telepractice for adult speech-language pathology services: a systematic review. perspectives of the asha special interest groups, 5(1), 326–338. https://doi.org/10.1044/2019_persp-19-00146 36 de wet swanepoel and karen steyn short report: establishing normal hearing for infants with the auditory steady-state response de wet swanepoel* (corresponding author) and karen steyn department of communication pathology university of pretoria abstract this study investigated the use of the dichotic multiple frequency assr technique for characterising normal hearing in a group of infants. a descriptive research design was implemented to describe assr thresholds obtained in 10 normal hearing infant ears (3 male, 2 female participants) between the age of 3 and 8 weeks. normal hearing was controlled for by conducting a dpoae screening test on all ears and ensuring no risk factors for hearing loss were present. results indicated mean assr thresholds at 0.5, 1, 2, and 4 khz to vary between 30 and 37 db, ±8 11 db within a range of 20 50 db hl. eighteen percent of assr thresholds were obtained at 20 db, 45% were obtained at 30 db, and 38% were obtained at elevated levels of 40 and 50 db. the recorded dichotic multiple frequency assr thresholds for infants with normal hearing were within the mild to moderate hearing loss range which makes differentiating between less severe degrees of hearing loss and normal hearing difficult. until future research has been conducted, caution must be practiced when interpreting assr thresholds below 60 db in young infants and additional techniques such as the abr must be used to cross-check results. key words: auditory steady state response, diagnostic audiology, paediatric audiometry, objective audiometry, infant hearing, electrophysiological audiometry. introduction the importance of early intervention, to ensure optimal outcomes for infants with hearing loss, is firmly established and clearly evidenced in the increasing number of newborn hearing screening programmes implemented world-wide (yoshinagaitano, 2003). the successful outcomes for infants with hearing loss is, however, foremost dependent on the accurate characterisation of hearing ability as all subsequent intervention practices build on this cornerstone (gorga, 1999). since the hearing of young infants is not easily evaluated by conventional behavioural audiometric measures, diagnostic assessments utilising electrophysiologic techniques such as the auditory brainstem response (abr) is used to estimate hearing thresholds. the abr has served as the gold standard electrophysiological procedure for determining hearing loss in neonates and young infants incapable of providing conditioned auditory responses to sounds for the last three decades. it is only recently that another clinical instrument for estimating hearing thresholds in infants, the auditory steady-state response (assr), has become available (swanepoel & hugo, 2004). the assr promises a number of advantages over the abr such as frequency specific threshold estimation similar to pure tone audiometry; elevated maximum stimulation levels up to 120 db hl allowing differentiation between severe and profound hearing losses; objective threshold determination by reliable statistical techniques; aided threshold estimations with less stimulus and output distortion; and time, efficient testing using the dichotic multiple frequency technique, which allows assessment of multiple frequencies in * department of communication pathology university of pretoria south africa pretoria 0002 tel: 27 12 4202949 fax: 27 12 4203517 e-mail: dewet.swanepoei@up.ac.za die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 52, 2005 both ears simultaneously (picton et al., 1998; ranee, dowell, rickards, beer & clark, 1998; swanepoel & hugo, 2004; swanepoel, hugo & roode, 2004). rickards et al. (1994) were the first to demonstrate that assrs can be successfully recorded from normal full-term sleeping neonates. subsequent assr studies in neonates and young infants using a single frequency technique have consistently demonstrated its effectiveness in characterising moderate to profound hearing losses with increasingly accurate estimations for more severe hearing losses (cone-wesson, dowell, tomlin, ranee & ming, 2002; ranee et al., 1998; ranee & briggs, 2002; ranee & rickards, 2002; swanepoel & hugo, 2004). the closer correlation between assr and behavioural thresholds for severe and profound hearing losses has primarily been attributed to the recruitment effect (ranee et al.1, 1998). few reports are however available for assr threshold! estimations in normal hearing infants and no reports on assr thresholds for mild hearing losses are available to date (john, | brown, muir & picton, 2004; luts, desloovere, kumar, vandermeersch & wouters, 2004; ranee & rickards, 2002). ! ranee and rickards (2002) reported typical assri thresholds for normal hearing neonates and babies to be between 30 and 40 db hl compared to mean assr thresholds between 25 and 40 db hl reported by rickards et al. (1994). a more recent study by john et al. (2004) reported average assr thresholds for the 500 hz stimulus in infants in their first few days of life to be approximately 40 db hl. the average thresholds at 1000, 2000, and 4000 hz were reported to be between 10 to 15 db better and the data suggest an improvement in thresholds,of approximately 10 db within the first few months of life except at 500 hz (john et al., 2004). it was also concluded that the amplitude of the response was significantly increased when mixed modulations (frequency and amplitude) were used and that responses were more easily detected in infants older than three weeks of age relative to the first few days after birth (john et al., 2004). r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) mailto:dewet.swanepoei@up.ac.za short report: establishing normal hearing for infants with the auditory steady-state response 37 the assr has already demonstrated exciting benefits but more comprehensive descriptions of assr threshold estimations for young infants, especially for the dichotic multiple frequency technique, are required to ensure it is used in a scientifically accountable manner (luts et al., 2004). the dearth of assr reports for normal hearing neonates and infants using the dichotic multiple frequency assr and preliminary evidence of assr threshold changes over the first few months has provided the rationale for the current investigation. in this study, dichotic multiple frequency assr thresholds are investigated in 10 normal hearing ears of infants younger than two-months. method the institutional review board at the university of pretoria approved this project before any data were collected. informed consent from the parent/legal guardian was also obtained before any testing was conducted. participants a sample of 5 participants (10 ears) with normal hearing was enrolled using a convenience sampling method. three of the participants were male. all participants were between the age of 3 and 8 weeks with a mean age of 5 weeks. normal hearing was controlled for by ascertaining that no risk indicators for hearing loss, as specified by the jcih year 2000 position statement (jcih, 2000), were present and all ears passed a dpoae screen. although oae testing is only a test of pre-neural integrity of the outer hair cells in the cochlea, normal hearing may be inferred with a high degree of confidence based on an oae pass result since oae screening has evidenced consistent specificity rates above 97% (lutman, 2000; prieve & stevens, 2000). cases of auditory neuropathy, which may present with oae's and absent auditory responses from the auditory nerve or brainstem, was controlled for by ensuring that no risks for hearing loss including admittance to the nicu was present in any of the participants. auditory neuropathy has been shown to be highly correlated with risk factors especially those associated with admittance to the nicu (rapin &,gravel, 2003; sininger, 2002). the risk factors were controlled for by an interview with the caregiver. the oae screening j was conducted using a biologic abaer cub screener (ver 2.9.0) with a distortion product oae screening protocol requiring three! out of four passes for frequencies between 1 to 5 khz. all infants were tested during natural sleep and in certain instances more than one appointment was scheduled to gather all the necessary information. stimuli presented through ear 3a insert earphones calibrated in hearing level. the stimuli were separately calibrated for each frequency using pure tones according to the as 1591.2 standard. all measurements were made with a briiel and kjaer sound level meter model investigator 2260, an artificial ear type 4152 and a microphone type 4144. recordings all assr recordings were obtained in a single-walled sound booth within a sound treated room. assr measurements: assr assessments were performed on the biologic master system (version 1.8) using a dichotic multiple frequency technique. this dichotic multiple frequency technique implies that multiple frequencies were evaluated in both ears simultaneously. this type of simultaneous stimulation has been demonstrated to be a time-efficient way of determining assr thresholds (dimitijevic et al., 2002; perez-abalo et al., 2001). electrode discs of ag/agci were fixed with electrolytic paste to the scalp at cz (active), midline posterior neck (reference), and fpz (ground). all electrode impedances were below 5 kohm at 10 hz and the inter-electrode impedance values were kept below 3 kohm. the bioelectric activity was amplified and analog filtered using a 3 to 300 hz bandpass filter. a maximum of 32 sweeps containing 16 epochs each was recorded per trial. each epoch was 1.024 s and a complete sweep lasted 16.384 s. the electrophysiological recording was converted using a fast fourier transform (fft) after each sweep. the presence of a response was determined using a f-ratio comparing the fast fourier components at the stimulus modulation frequencies to the 120 adjacent frequencies (60 bins above and 60 bins below the frequency) to determine if the difference was significantly different (p < .05) from the background noise. if a sweep contained more than 40 μ ν electrophysiological noise it was rejected. a recording was halted once a pre-set probability of 95% response significance was achieved after averaging at least five sweeps, or when a statistically significant probability value could not be achieved within 32 sweeps (524,29 s). the threshold-seeking procedure utilised a 10 db intensity step. a recent study indicated that a smaller 5 db step compared to a 10 db step did not make the estimate more precise and increased the recording time which negatively influences assr recordings (luts & wouter, 2004). the initial stimulation intensity was 40 db hl. if a significant response was not obtained in both ears at this intensity, the intensity was increased until a significant response was obtained in both ears. once a significant response was obtained for both ears, the intensity was lowered to obtain a threshold in both ears. threshold was taken as the lowest intensity where a response was elicited with no response found at a lower level. assrs were evoked using a dichotic multiple frequency technique stimulating both ears simultaneously with four carrier frequencies per ear. test stimuli were 0.5, 1, 2, and 4 khz tones modulated in amplitude and frequency with a relative am/fm phase difference of 90°. the tones were 20% frequency modulated and 100% amplitude modulated at 82, 84, 87, and 89 hz respectively for the 0.5, 1, 2, and 4 khz tones in the left ear and 91, 94, 96, and 99 hz for the 0.5, 1, 2, and 4 khz tones respectively in the right ear. these modulation rates were according to the default specifications of the biologic corporation master system (version 1.8). modulation rates in excess of 70 hz were used to ensure that a satisfactory signal to noise ratio would exist for detection of responses during sleep or sedation. test stimuli were the south african journal of communication disorders, vol. 52, 2005 results assr thresholds were obtained for all frequencies evaluated in the sample of infants. table 1 indicates the mean, standard deviatable 1. assr thresholds (n=40)* for 10 normal hearing infant ears khz mean ± sd all ears (db hl) mean ± sd left ears (db hl) mean ± sd right ears (db hl) range (db) 0.5 37 ± 8 36 ± 9 3 8 + 8 3 0 5 0 1 34 ± 10 34 + 11 34 ± 9 2 0 5 0 2 3 4 + 1 1 36 ± 1 1 32 ±11 2 0 5 0 4 3 0 + 1 1 32 ± 8 30 ± 14 2 0 5 0 * number of assr thresholds recorded for the sample of ears r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 38 de wet swanepoel and karen steyn tion, and range of the 40 assr thresholds obtained for the sample of ears (4 frequencies χ 10 ears). the mean assr thresholds for the entire sample varied between 30 and 37 db with the closest approximation to normal hearing levels at 4 khz and the furthest at 0.5 khz. standard deviations varied between 8 and 11 db with the smallest deviation at 0.5 khz and the largest at 2 and 4 khz. the assr thresholds for the sample ranged between 20 and 50 db. figure 1 indicates the distribution of the assr thresholds for the sample of ears. 2 0 3 0 4 0 h e a r i n g l e v e l ( d b h l ) figure 1. distribution of assr thresholds (n=40) almost half (45%) of assr thresholds were obtained at 30 db whilst only 18% were obtained at 20 db. a large proportion (38%) of assr thresholds for this sample of normal hearing infants were obtained at elevated levels of 40 and 50 db. half (50%) of 0.5 khz thresholds and 30 to 40% of thresholds for the higher frequencies (1 to 4 khz) were obtained at these elevated intensities (40 to 50 db). figure 2 represents the thresholds of two assr recordings illustrating the ear with the closest approximation and the ear with the furthest approximation of normal hearing levels for pure tones (0 to 15 db) (goodman, 1965; clark, 1981). 0 . 5 k h z 1 k h z 2 k h z 4 k h z 0 1 0 2 0 3 0 4 0 5 0 60 7 0 80 9 0 100 1 _ll 1 ii lj nnr~ πγ jj •• •htz 1 ii || | 1 • • c ι if ϊ 1 | ii || 1 jl jl 1 1 ii ii 1 jl jl 1 1 ii ii 1 ii ii 1 1 ii ii 1 ii ii 1 b e s t recording w o r s t recording figure -2. best and worst assr estimation of normal hearing in sample of infant ears according to clark's (1981) modification of goodman's (1965) scale for classifying hearing loss according to pure tone thresholds, the assr thresholds in the ear with the best approximation of normal hearing presents with a mild hearing loss (26 to 40 db) whilst the ear with the worst approximation presents with discussion the accuracy of assr thresholds are measured by how closely they approximate pure tone behavioural thresholds which provide the gold standard for hearing status. the results of the current study indicate that the majority (83%) of assr thresholds for young infants with normal hearing were within the mild to moderate hearing loss range according to the scale of hearing loss severity for pure tone thresholds (clark, 1981). this finding is in agreement with previous studies conducted using the single frequency assr technique in which the majority of thresholds for normal hearing infants were reported to be between 25 and 40 db hl (ranee & rickards, 2002; rickards et al., 1994). studies reporting assr thresholds for normal hearing infants using the dichotic and monotic multiple frequency technique also suggest similar average values between 25 and 40 db (john et al., 2004; lins et al., 1996). john et al. (2004) indicated that after the first three weeks of life the assr thresholds may improve by 10 db. the current study investigated infants older than three weeks and a 10 db improvement in the 25 to 40 db average was not observed. a smaller intensity step of 5 db compared to 10 db may have resulted in closer estimates of behavioural thresholds although a recent study indicated that a 5 db step size did not make the estimate more precise but increased testing time by up to 60 minutes (luts & wouter, 2004). the general trend of the current research evidence does however suggest that assr thresholds improve within the first several months of life for infants with normal hearing (john et al., 2004; lins et al., 1996; ranee & rickards, 2002). this improvement in hearing within the first few weeks means that normal hearing infants present with elevated assr thresholds as seen in the current study, which makes differentiating between mild-tomoderate hearing losses and normal hearing in young infants very difficult. although ranee and briggs (2002) concluded that the assr can reliably quantify hearing loss in infants, their study cohort only included infants with moderate to profound hearing loss. no studies have demonstrated the ability of the assr to differentiate between mild and mild-to-moderate hearing losses and normal hearing in young infants. caution is therefore necessary when interpreting assr threshold data up to 50 db hl to ensure that appropriate diagnoses are made which clearly differentiates between milder hearing losses and normal hearing in infants. the importance of correctly characterising hearing loss in such cases have been indicated by several studies which demonstrate that mild or moderate and even minimal degrees of hearing loss can lead to significant delays in language development and academic achievement in children (bess, dodd-murphy & parker, 1988; carney & moeller, 1998; davis, elfenbeiri, schum & bentler, 1986). ' to improve assr estimations, regression formulae to predict behavioural thresholds from assr threshold data were developed by ranee and colleagues (ranee, rickards, cohen, de vidi & clark, 1995; ranee & rickards, 2002) based on threshold data from a large cohort of participants with varying degrees of hearing loss. these formulae, used by the gsi audera system to predict actual behavioural thresholds, has proved useful in making confident estimations in infants with assr,thresholds above 60 db (ranee and briggs, 2002). the algorithms have not yet however demonstrated the capability to clearly differentiate between slight, mild and mild-to-moderate hearing losses and normal hearing in young infants. this lack of research evidence supporting the efficacy of assr estimations of mild hearing loss emphasises the need for caution when interpreting assr threshdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) short report: establishing normal hearing for infants with the auditory steady-state response 39 olds below 60 db hl in young infants. in such cases, additional testing, using the abr with click and tone burst stimuli, is required to cross-check the assr data (swanepoel, schmulian & hugo, 2004). in conclusion, this study indicated that dichotic multiple frequency assr thresholds for infants with normal hearing are recorded within the mild to moderate range of hearing loss. these elevated assr thresholds suggest difficulties differentiating between normal hearing and slight, mild, and moderate hearing losses in young infants from assr data alone. future studies are needed to investigate the accuracy of the assr technique for describing mild and moderate hearing losses in infants to allow for accountable and evidence-based implementation of the assr technique. current clinical practice however, requires that assr thresholds > 60 db hl in young infants be cross-checked by additional electrophysiological techniques such as the abr. references bess, f.h., dodd-murphy, j., & parker, r.a. (1998). children with minimal sensorineural hearing loss: prevalence, educational performance and functional status. ear and hearing, 19(5), 339-54. carney, a.e., & moeller, m.p. (1998). treatment efficacy: hearing loss in children. journal of speech language and hearing research, suppl. 41, 61-84. clark, j.g. (1981). uses and abuses of hearing loss classification. ash a, 23, 493-500. cone-wesson, b., dowell, r.c., tomlin, d., ranee, g., & ming, w.j. (2002). the auditory steady-state response: comparisons with the auditory brainstem response. journal of the american academy of audiology, 13, 173-187. davis, j.m., elfenbein, j.l., schum, r., & bentler, r. (1986). effects of mild and moderate hearing impairments on language, educational, and psychosocial behavior of children. journal of speech and hearing disorders, 51, 53-62. dimitrijevic, α., john, m.s., van roon, p., purcell, d.w., adamonist, j., ostroff, j., nedzelski, j.m., & picton, t.w. (2002). estimating the audiogram using multiple auditory steady-state responses. journal of the american academy of ^audiology, 13, 205-224. j goodman, a. (1965). reference zero levels for pure-tone audiometer. ash a, 75, 262-263. | gorga, m.p. (1999). predicting auditory sensitivity from auditory brainstem response measurements. seminars in hearing, 20(1), 29j john, m. s., brown, d.k., muir, pj., & picton, t.w. (2004). recording auditory steady-state response in young infants. ear and hearing, 25(6), 539-553. joint committee on infant hearing (2000). year 2000 position statement: principles and guidelines for early hearing detection and intervention programs. american journal of audiology, 9, 9-29. lins, o.g., picton, t.w., boucher, b.l., durieux-smith, α., champagne, s.c., moran, l.m., perez-abalo, m.c., martin, v., & savio, g. (1996). frequency-specific audiometry using steadystate responses. ear and hearing, 17, 81-96. lutman, m.e. (2000). techniques for neonatal hearing screening. seminars in hearing, 21(4), 367-378. luts, h., desloovere, c., kumar, α., vandermeersch, e., & wouters, j. (2004). objective assessment of frequency-specific hearing thresholds in babies. international journal of pediatric otorhinolaryngology, 68, 915-926. luts h., & wouter, j. (2004). hearing assessment by recording multiple auditory steady-state responses: the influence of test duration. international journal of audiology, 43, 471-478. perez-abalo m.c., savio, g., torres, α., martin, v., rodriguez, e., & galan, l. (2001). steady state responses to multiple amplitude modulated tones: an optimized method to test frequency specific thresholds in hearing impaired children and normal subjects. ear and hearing·, 22, 200-211. picton, t.w., durieux-smith, α., champagne, s., whittingham, j., moran, l., giguere, c., & beauregard, y. (1998). objective evaluation of aided thresholds using auditory steady-state responses. journal of the american academy of audiology, 9, 3 1 5 3 3 1 . prieve, b., & stevens, f. (2000). the new york state universal newborn screening project: introduction and overview. ear and hearing, 21, 85-91. ranee, g., & briggs, r.j.s. (2002). assessment of hearing in infants with moderate to profound impairment: the melbourne experience with auditory steady-state evoked potential testing. annals of otology, rhinology and laryngology, 111 suppl 189, 22-28. ranee, g., dowell r.c., rickards, f.w., beer, d.e., & clark, g.m. (1998). steady state evoked potential and behavioral hearing thresholds in a group of children with absent click evoked auditory brainstem response. ear and hearing, 19, 48-61. ranee, g., & rickards, f. (2002) prediction of hearing threshold in infants using auditory steady-state evoked potentials. journal of the american academy of audiology. 13, 236-245. ranee, g., rickards, f.w., cohen, l.t., de vidi, s., & clark, g.m. (1995). the automated prediction of hearing thresholds in sleeping subjects using auditory steady-state evoked potentials. ear and hearing, 16, 499 507. rapin, i., & gravel, j, (2003). "auditory neuropathy": physiologic and pathologic evidence calls for more diagnostic specificity. international journal of pediatric otorhinolaryngology, 67, 707-728. rickards, f.w., tan, l.e., cohen, l.t., wilson, o.j., drew, j.h., & clark, g.m. (1994). auditory steady state evoked potentials in newborns. british journal of audiology, 28, 327-337. sinninger, y.s. (2002) identification of auditory neuropathy in infants and children. seminars in hearing, 23(3), 193-200. swanepoel, d., & hugo, r. (2004). estimations of auditory sensitivity for young cochlear implant candidates using the assr: preliminary results. international journal of audiology, 43(7), 377-382. swanepoel, d., hugo, r., & roode, r. (2004). auditory steady state response thresholds of children with severe to profound hearing loss. archives of otolaryngology head and neck surgery, 130, 531-535. swanepoel, d., schmulian, d., & hugo, r. (2004). establishing normal hearing with the dichotic multiple frequency auditory steady state response compared to an abr protocol. acta otolaryngology, 124, 62-68. yoshinaga-itano, c. (2003). universal newborn hearing screening programs and developmental outcomes. audiological medicine, 1,199-206. the south african journal of communication disorders, vol. 52, 2005 i r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract introduction research methods and design findings discussion conclusion acknowledgements references about the author(s) martha lydall department of speech-language and hearing therapy, faculty of medicine and health sciences, stellenbosch university, stellenbosch, south africa speech therapy department, forest town school, johannesburg, south africa berna gerber department of speech-language and hearing therapy, faculty of medicine and health sciences, stellenbosch university, stellenbosch, south africa citation lydall, m., & gerber, b. (2021). a chasm: consequences of poor collaboration between health and education in paediatric cerebral palsy care in johannesburg. south african journal of communication disorders, 68(1), a817. https://doi.org/10.4102/sajcd.v68i1.817 original research a chasm: consequences of poor collaboration between health and education in paediatric cerebral palsy care in johannesburg martha lydall, berna gerber received: 16 jan. 2021; accepted: 01 july 2021; published: 19 aug. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: nearly 20 years since the establishment of the national rehabilitation policy, strides have been made within the health and education sectors to improve accessibility to rehabilitation services as well as the quality of life of children with cerebral palsy (cp). shortfalls, however, still exist in implementing the policy. an in-depth study into the implementation of policy would be beneficial in identifying and understanding the shortfalls of the rehabilitation process. objectives: to investigate the perceptions of speech-language therapists (slts) working in the gauteng department of health (gdh) and gauteng department of education (gde), in johannesburg region a, about systemic strengths and weaknesses surrounding the service delivery for children with cp, from birth to 6 years. method: a qualitative study was conducted. thirty-one (31) slts working in public hospitals, clinics and schools for learners with special educational needs participated in eight focus group interviews. interviews were audio-recorded for transcription and subsequent thematic analysis. results: the participants reported a lack of resources and knowledge that contributed to a perceived chasm between the gdh and gde, resulting in fragmented and uncoordinated service delivery for children with cp leaving the health system and entering the education system. conclusion: the results suggest that a cohesive plan should be formulated to bridge the perceived chasm between gdh and gde in the referral process of children with cp from the health setting, into the school environment. this may facilitate communication, collaboration, education, as well as resource-sharing between the departments. rehabilitation professionals should actively participate in such planning processes. keywords: perceptions; rehabilitation; disability; referral; education; procedure; south africa. introduction the south african department of social development (2009) states that there remain fragmented and unequal services for children with disabilities in the country. government departments are uncoordinated and act in isolation. early identification of disabilities and tracking of progress through early childhood to school-going age remain systematically deficient (department of social development, 2009). this is the situation, despite progress made in legislative and policy reform. furthermore, as noted by rule, lorenzo and wolmarans (2006), many children are receiving formal rehabilitation for the first time when they enter the formal schooling system. given the socio-economic environment of the country, despite policy dictating that a child’s formal education begins at 6 years of age, this can often be later (munnik & smith, 2019). speech-language therapists (slts) working in the public sector, given their interaction with the systems and procedures in place with regard to the management of children with cerebral palsy (cp), can provide valuable insight into the effectiveness of policies. an in-depth investigation into the perceptions of such slts could assist in identifying deficiencies in existing policies as well as suggestions to rectify these. this could facilitate improved service delivery, and cohesion and collaboration between sectors. cerebral palsy is a neurodevelopmental disorder that affects movement and posture because of nonprogressive damage to the immature brain, thus affecting the child throughout his or her life (rosenbaum, paneth, leviton, goldstein, & bax, 2006). as a child develops into an adult, the severity of the disability and functional level of the individual changes. the functional level achieved as an adult is entirely dependent on the levels of function that the individual was able to reach as a child. achieving the best possible outcomes is facilitated through continuous rehabilitation to achieve maximum potential and prevent functional deterioration from occurring (vos et al., 2013). for a long time in south africa, continuous rehabilitation had not been provided to children with disabilities. therefore, a need arose to develop a strategy that addresses the neglect of paediatric rehabilitative services. this gave rise to the integrated national disability strategy that was established in 1997 by the office of the deputy president of south africa (1997). for optimal functional levels to be reached and maintained within children with disabilities, by means of rehabilitation, the integrated national disability strategy proposed a national rehabilitation policy (nrp) (office of the deputy president, 1997). the nrp was finalised and published in 2001. simultaneously in 2001, the department of education (doe) issued a framework policy document called white paper 6 (wp6): special needs education, building an inclusive education and training system (department of education, 2001). this policy document set out the government’s proposal for future legislation regarding special needs education. the policy acknowledged that all children and youth can learn and those requiring remediation to cope with educational demands should be provided with support. furthermore, the policy aimed to acknowledge the education structures, systems and learning methodologies required to meet the needs of all learners (department of education, 2001). in 2013, the south african department of health recognised that to address the health inequalities experienced by persons with disabilities in our society, a transformation of the current south african health system had to occur. hence, the framework and strategy for disability and rehabilitation services in south africa (national department of health, 2016) was compiled. this framework aims to reconfigure rehabilitation as an integral part of health services across all programmes, within all levels of care. it aims to increase access, equitability, inclusivity and participation for the population living with disabilities within their communities (national department of health, 2016). the framework recognises that rehabilitation services are a vital link between medical treatment and the transformation of a person’s restored capacity into a productive and health-promoting social and economic life (national department of health, 2016). furthermore, it highlights a number of challenges that complicate the effectiveness of rehabilitation services within the population of children with cp in south africa such as poor collaboration between sectors, and poor knowledge in the rehabilitation chain regarding the specific needs and challenges of persons with disabilities (national department of health, 2016). furthermore, the framework states that appropriate referral pathways create access to suitable care and these must be aligned with departmental policy. louw et al. (2018) stated that access to effective rehabilitation is a basic human right and that rehabilitation has the ability to economically optimise health outcomes and the overall quality of life. however, the 20 rehabilitation professionals (physiotherapists, occupational therapists, slts, podiatrists, rehabilitation managers or directors) who participated in louw et al.’s (2018) study stated that, despite the south african government’s efforts to re-engineer public healthcare, rehabilitation services at primary healthcare level have not improved (louw et al., 2018). a study on the experiences and challenges faced by rehabilitation community service therapists within the south african public health care (phc) system (ned, cloete, & mji, 2017) revealed that the conditions at community healthcare level are particularly difficult as there is a scarcity of professionals, failures in resource allocations, as well as overcrowding. a study conducted by khoza-shangase and mophosho (2018) supported this finding, specifically stating that there is a shortage of slts working in the public health sector. when referral happens, in some instances, there are no human resources available to receive these referrals at the community level (hussey, maclachlan, & mji, 2017). premature discharge from tertiary and secondary levels of care, with referral into the primary level of care, often creates problems with carryover of care because of a lack of follow-up between institutions. collaboration between the various levels of care would result in comprehensive insight amongst all stakeholders in the care chain into contextual issues of disability and further promote investigations by these stakeholders into health systems (ned et al., 2017). nearly 20 years since the development of the nrp and wp6, strides have been made in both the health and education sectors to implement policy in order to improve accessibility to all rehabilitation services and thereby improve the quality of life of children with disabilities (department of basic education, 2015). yet, anecdotal evidence as well as research conducted by the national department of health (2016), louw et al. (2018) and ned et al. (2017) suggests that limited collaboration exists between these sectors, resulting in continued fragmented and uncoordinated service delivery. the main aim of this study was to investigate the perceptions of slts working in the public health and education sectors in the greater johannesburg region, about institutional strengths and weaknesses within service delivery for children with cp, from birth to 6 years of age. the objectives were as follows: to report on the slts’ perceptions about the availability of services for children with cp in the public health and education sectors. to describe the carryover of rehabilitation of children with cp between hospitals, clinics and schools. to identify the strengths and weaknesses of the referral pathway for children with cp in the public sector. research methods and design study design a qualitative research design was used. qualitative research methods can provide detailed descriptions of the insights of individuals, useful quotes that bring realism to applied research, as well as information about how different healthcare settings operate (taylor, bogdan, & devault, 2015). setting participants were recruited from public health and education institutions in region a of johannesburg. johannesburg was selected for this study because of its cosmopolitan nature. two central hospitals are located in this region. furthermore, the first author works as an slt in this region and had professional motivation to investigate the research objectives as they apply to this particular geographic area. study population and sampling strategy a purposive sampling strategy was used for this study. qualified slts working with children with cp in the public health (hospitals and community health centres [chcs]) and education (learners with special educational needs [lsen] schools) sectors were asked to participate (table 1). participants ranged in age from 23 to 65 years, with varying levels of experience ranging from less than 1 year working experience to 43 years of experience. speech-language therapists were included based on the following criteria: minimum of a 4-year degree in speech-language therapy or speech-language therapy and audiology. registered with the health professions council of south africa. working in hospitals (tertiary, central and district hospitals), chcs and lsen school settings in the public sector, in region a of johannesburg, gauteng province. therapists specifically working with children with cp from birth to 6 years as part of their current caseload, or within their last 6 months. table 1: number of speech-language therapists who participated in the study. all participants met the inclusion criteria. three therapists working in the hospitals and five working in the chcs were completing their year of compulsory community service. therapists with more than 10 years’ working experience with children with cp were based at the lsen schools. this level of experience did not exist in the hospital and clinic settings. data collection methods an interview guide was used to conduct semi-structured interviews with the participants. ensuring trustworthiness the trustworthiness of a study refers to ensuring credibility, confirmability, dependability, as well as transferability (elo et al., 2014). credibility was achieved through the pilot study and member checking processes, confirmability through consultation with colleagues and peers, dependability through the use of purposive sampling, and transferability by providing an accurate and honest description of the research process, context and participants. pilot study a pilot study was conducted to evaluate the feasibility of the study, specifically the effectiveness and appropriateness of the interview guide. the guide was developed to address the research objectives after a comprehensive literature review was undertaken. focus groups and depth-interview the interviews were conducted in the hospitals, chcs and school settings where there was a team of slts working with children with cp. they were conducted at the therapists’ place of work. the therapists working at the chcs all travelled to a central chc to participate in the focus group. the number of participants in each focus group ranged from three to eight. all interviews were conducted in a space free from external noise. the interviews lasted approximately 30 min – 60 min each. eight focus groups were conducted in total, and one individual depth-interview, where there was only one therapist employed at the institution. four of the focus groups and the individual depth-interview were conducted at the hospitals, one focus group was conducted at a chc, and three were conducted at the schools. audio recordings each participant was required to sign consent for the interview to be audio-recorded for later transcription and analysis. author a listened to the recordings and transcribed all the interviews verbatim. the abbreviations ‘ht’ (hospital therapist), ‘ct’ (clinic therapist) and ‘st’ (school therapist) were used to protect the participants’ identities. data analysis thematic analysis using the approach proposed by braun and clarke (2006) (figure 1) was used in the analysis of the data. figure 1: thematic analysis as proposed by braun and clarke (2006). ethical considerations an application was made to stellenbosch university’s health research ethics committee (hrec) for permission to proceed with the research. the permission was granted in june 2019 with the hrec reference number: s19/05/093. a further request to conduct research at the specified hospitals, chcs and lsen schools was sought and granted. an information sheet and informed consent form was given, in person, to each potential participant, explaining the aim of the research and the research procedure. only participants who provided informed consent were interviewed. findings the findings are summarised in figure 2. three major themes emerged, highlighting institutional shortcomings within service delivery for children with cp. the circles represent the relationship between the themes: the lack of resources, lack of knowledge, and the consequent ‘chasm’. the arrows represent the cyclic process of how a lack of knowledge together with weighting, a process of assigning values to different disabilities based on pre-determined formulas for the purposes of staffing allocation, entrenches a lack of resources whilst failures in interdepartmental collaboration perpetuate a lack of knowledge. figure 2: visual representation of research data obtained through thematic analysis. perceptions of a lack of resources time, infrastructure and adequate staffing are the resources that were identified by the participants as lacking in the public sector. high caseloads with low staff complements, accompanied by poor physical infrastructure and time constraints, resulted in increased frustration levels, low morale, and a sense of despair amongst the participants. the sense of defeat stemming from the inadequate current institutional facilities available for children with cp, such as the number of therapists in department of health (doh), lsen schools, training and stimulation centres (institutions that provide care and/or education for children with lower cognitive abilities), and the genuine concern about the lack of vocational institutions available for these children once they leave school, was palpable. perceptions of a lack of knowledge a strained relationship with the gauteng department of education (gde), as a bureaucratic collective, was communicated by most of the participants. the participants perceived a general lack of understanding by the administrators at the gde as to the nature of cp and what therapeutic interventions are required to ensure the best possible outcomes for this population. participants working in school settings felt that the gde did not focus on the best interest of the children with cp during the admissions process. the perception of the participants was that the gde did not appropriately allocate children to specific lsen schools, given the children’s cognitive and physical level of functioning. this constituted an important aspect of the narrative. participants conveyed dissatisfaction about several facets, namely a general lack of consultation from the gde, a lack of urgency in lsen school placement, inappropriate admissions into lsen schools hampering the efficacy of the curriculum, inappropriate admissions into lsen schools with weighting scores for learners and the negative consequences of this on staffing, and the lack of infrastructure. participants working in the school setting reported that inappropriate weighting of learners in lsen schools negatively affected the staffing at the school. they stated that if the schools did not appropriately admit learners with specific disabilities, they did not achieve the desired child-to-staff ratio, and this resulted in fewer allocations of therapists and teachers to schools. perceptions of a chasm between the department of health and the department of education a consistent theme that emerged from the data indicated the perception of a chasm between the gauteng department of health (gdh) and the gde. the participants reported that this perceived chasm resulted in a belief amongst caregivers that the ‘transfer into the next stage of life’ (ht3) will fail. some participants stated that the caregivers experienced apprehension in leaving the hospital and/or clinic setting and entering the education system. the participants expressed that the fear of the unknown accompanied by the slow process, such as waiting lists at the district-level of the education sector, resulted in delayed procedures and reluctance and distrust of caregivers to move their children’s rehabilitation from the familiar healthcare sector. a further finding was that there was a desire in hospital, clinic as well as school-based participants to close this chasm that seems to exist between the two departments, by creating collaborative, interdepartmental systems. they were aware that improved communication between therapists during carryover procedures will improve handover of the child’s care. discussion given that cp is a lifelong condition that requires ongoing intervention to assist the child and family to function in the most effective way possible (levitt & addison, 2019), it is paramount that governments provide adequate staffing and infrastructure within public hospitals, clinics and schools. yet, the provision of specialised facilities with adequate staff for this population is an ongoing challenge in south africa. not all healthcare and educational facilities equally accommodate the varied needs of children with cp. without sufficient and appropriate facilities, therapists are often unable to refer children to a facility where their specific needs will be met. johannesburg, being home to the largest cosmopolitan population in the country (statistics south africa, 2016), is one of the most resourced regions in the country. the insights gained through this study into difficulties in departmental collaboration, communication and handover, are thus noteworthy. the participants in our study reported that interinstitutional collaboration assists in the mitigation of therapeutic regression of each child that can occur because of handover from one institution to the next. where given the opportunity, relationships between participants at different institutions in gauteng region a have been created, attesting to a sense of agency amongst these therapists. however, administrative hurdles in the provincial doh and the doe made it difficult for collaborative interinstitutional relationships to develop. each child with cp is unique and this highlights the importance on the referral process from one rehabilitation institution to the next. there was an overwhelming sense of frustration amongst participants in both the provincial health and education sectors that highlighted a desperate need to address the lack of communication between these two sectors. according to the national department of health’s framework and strategy for disability and rehabilitation services in south africa (national department of health, 2016), rehabilitation should be decentralised and begin as early as possible and should extend from community to tertiary and specialised rehabilitation levels. the frustration amongst the participants resonates with the findings of watermeyer, penn, scott and seabi (2019) regarding difficulties with communication in decentralised tuberculosis care. it seems that when communication between healthcare, education institutions and administrative entities fails, responsibility for communication and continuity of care is unduly shifted onto the patient or caregiver (watermeyer et al., 2019). as reported by some of the participants, the therapists are often excluded from the school admissions process because of procedures that rely on the simplified classification of cognitive abilities of each child, from a limited group of medical professionals, signifying a medical model approach. yet, the department of basic education (2014) specifically states that the medical assessment on its own must not be used to make decisions about admission to a special school. the assessment should be conducted by all the relevant professionals. without in-depth diagnostic assessments performed by rehabilitation professionals, it is unsurprising that inappropriate school placements for children with cp are common. the slt’s specialised understanding of a child’s communication difficulties and other associated complications in the management of cp should not be overlooked in the referral process. procedural review and reform at the gde could be instrumental in removing barriers to interprofessional communication and ensuring that rehabilitative gains made at hospital and clinic-level are carried over reliably into the therapeutic environment at lsen schools in the province. furthermore, a consultative process with rehabilitation professionals, including slts, occupational therapists, physiotherapists, as well as educational psychologists working at lsen schools, could substantially reduce the incidence of inappropriate admissions. failure to place children into schools where the existing resources and infrastructure are aligned with the specific needs of the child, placed enormous strain on the participants. participants reported that feedback that suggested a particular school was not a suitable placement for specific children with cp was often met with resistance by the gde. according to the guidelines of the department of basic education (2014) appropriateness of placement should be reviewed annually or at least every 2 years. the reason why the gde appears to act in a manner contrary to this departmental policy was not investigated in this study. the overall effect of this perceived lack of understanding seems to be that there is an inappropriate distribution of resources, a lack of direction in the establishment of new infrastructure, and the destruction of the existing cohesive elements within the system. the participants perceived a gap in communication between the doh and the doe in the referral process of children with cp from the hospital or clinic setting, into the school environment. the findings of this study suggest that a cohesive plan needs to be formulated and executed to bridge this chasm, and to facilitate communication, collaboration, education, as well as resource-sharing between the two departments. bidirectional communication enabled by a cohesive plan may improve the referral pathway and result in improved handover and carryover of therapeutic strategies into appropriate lsen schools, preventing children from ‘falling through the cracks’ (ht8). this will also assist caregivers in making the transition from the health setting into the education setting and thus improve their trust in the ‘system’ and individual institutions. therapists who deliver services to clients and families can and should be actively part of or even initiate and drive such planning. rather than assuming a position of reliance on higher level administrative divisions for reforms and plans, rehabilitation professionals should confidently and assertively fulfil their advocacy role within the healthcare and education systems. the multidisciplinary rehabilitation team possess a wealth of knowledge and skills. speech-language therapists are valuable as experts in communication and may develop, monitor and evaluate communication processes. strengths and limitations as qualitative research is focused on attaining in-depth understanding of the perceptions of participants, the number of participants is necessarily limited. the limited sample size of 31 participants forming eight focus groups was, however, representative of the region under investigation, as many therapists approached via the purposive sampling strategy agreed to participate (31 out of 36). this yielded good insight into the perceptions of the participants with data saturation being achieved, giving credence to the findings. however, conclusions about the perceptions, practices and procedures of therapists working in other parts of the province and country should not be drawn. recommendations as the gde is responsible for placing children in schools, further research should be conducted at the administrative district level of the gde to further investigate the perceived chasm between the provincial departments of health and education. with the insights obtained from such an investigation, further recommendations can be made for the implementation of improved communication procedures and strategies between sectors and institutions. this communication needs to be bidirectional and create opportunities for the gde to inform the gdh of the services available in lsen schools, and for the gdh to be able to share relevant referral information about a child, when assisting with school placement. this communication should be conducted in a manner that fosters trust. although the study was set out to investigate the (dis)continuity of speech-language therapy services for children with cp in the public sector specifically, the results highlighted that some of the contributing factors fall outside the direct purview of slts. further research could include investigating the perceptions of the doctors making diagnoses and referring to the educational districts for lsen school placement. their perceptions of the various lsen schools and motivations for recommending one school as opposed to another can further increase understanding and possible improvement of the referral process. lastly, further investigations similar to the current study should be conducted in other provinces, as well as with other health professionals such as physiotherapists and occupational therapists, to establish whether there are correlations with the findings of the current study. conclusion cerebral palsy is a lifelong condition that requires ongoing intervention. it is therefore paramount that governments should provide adequate staffing and infrastructure within public hospitals, clinics and lsen schools. each child with cp is unique, which reinforces the importance of the referral process from one institution to the next. by far, the most prominent theme which emerged was the perceived chasm between the health and education sectors with regard to communication rehabilitation. carryover of therapeutic goals and strategies within the referral pathway is negatively affected by a general lack of communication, collaboration and resource-sharing between the two departments. there is also little relationship between the slts working in the public health sector and those working in the education sector. acknowledgements we are grateful to the participants in this study for their honest contributions to this work. to our editor, lilané joubert, thank you for your technical acumen and valuable recommendations. the authors would like to thank the reviewers for taking the time to read and critique our manuscript. their valuable insight has strengthened this study. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions both m.l. and b.g. conceptualised the study together. m.l. completed the study as part of her thesis for her master’s qualification and b.g. acted as their research supervisor. m.l. orchestrated and compiled the manuscript, whilst b.g. reviewed the manuscript and provided suggestions and contributions. funding information we acknowledge the financial assistance received for this study from the harry crossley foundation. data availability data available on request because of privacy and ethical restrictions. the data that support the findings, the original transcripts of the conducted interview and focus groups, of this study are available only on request from the corresponding author, m.l., should compelling reasons be provided. the transcripts are not publicly available because of restrictions, in that they contain information that could compromise the privacy of research participants. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the author. references braun, v., & clarke, v. 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(2019). bench, bed and beyond: communication and responsibility in decentralised tuberculosis care. health sa gesondheid, 24, a1208. https://doi.org/10.4102/hsag.v24i0.1208 abstract introduction method results and discussion limitations and future directions conclusion acknowledgements references appendix 1: about the author(s) skye n. adams department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa raeesa verachia department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa kim coutts department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation adams, s.n., verachia, r., & coutts, k. (2020). ‘a blender without the lid on’: mealtime experiences of caregivers with a child with autism spectrum disorder in south africa. south african journal of communication disorders, 67(1), a708. https://doi.org/10.4102/sajcd.v67i1.708 original research ‘a blender without the lid on’: mealtime experiences of caregivers with a child with autism spectrum disorder in south africa skye n. adams, raeesa verachia, kim coutts received: 06 apr. 2020; accepted: 16 aug. 2020; published: 29 oct. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: evidence suggests that caregivers of children with autism spectrum disorder (asd) and associated feeding difficulties have specific mealtime challenges in the home environment because of the limited interventions that are appropriate and responsive to the needs of the child as well as the family. objectives: to describe: (1) common feeding difficulties in children with asd, (2) mealtime challenges for the caregiver and (3) mealtime strategies used by the caregiver. method: forty caregivers were purposively sampled to participate in the study. participants were recruited through asd-specific schools in johannesburg, south africa. participants completed an online questionnaire focusing on their mealtime experiences with their child with asd. results: findings from the data after thematic analysis indicated the multitude of challenges caregivers have when feeding their child with asd as well as their individualised way of dealing with these difficulties. conclusion: the findings emphasised the importance of incorporating the family’s beliefs, values and needs into feeding management and highlight the importance of a holistic approach to intervention. the study also provided information about mealtime strategies that are being used in the home environment to support the child as well as the caregiver. this information can be used to inform management to improve therapeutic outcomes and feeding challenges in the home environment. keywords: autism; family-centred care; feeding; mealtimes; picky eating; south africa. introduction the prevalence of autism spectrum disorder (asd) is increasing globally, requiring improved service delivery (eslabbagh et al., 2012). the exact prevalence of asd in south africa is unknown; however, lamb (2018) has estimated that currently over 1 million individuals are living with asd in south africa. children with asd present with a wide range of associated difficulties, including communication, behaviour and those related to feeding. research has shown that 46–89% of children with asd will present with feeding difficulties (ledford & gast, 2006), which may be related to problems with food acceptance, food selectivity, food progressions and challenging mealtime behaviours (bandini et al., 2010; gray et al., 2018; matson & fodstad, 2008; nadon, feldman, dunn, & gisel, 2011). children are at risk of a number of nutritional and developmental inadequacies if feeding difficulties are not managed or resolved. children with asd may also experience contextually specific feeding difficulties that may differ at school, in therapy and at home. thus, there is a need to improve understanding of the feeding challenges associated with asd in a range of contexts to better inform feeding interventions. family mealtime routines and rituals mealtimes are a complex process that constitutes both the cultural and social commensality of family routine. commensality is the practice of eating together and sharing food (ochs & shohet, 2006; tuomainen, 2014). the most fundamental of commensalities are those related to family mealtimes. in many societies and communities, mealtimes are seen as a symbol of unity and family stability (hamilton & hamilton wilson, 2009). each household will have their own way of expressing mealtime routine, rituals and patterns. in majority of families, the caregivers have a strong influence on their child’s eating behaviours (quansah, ohene, norman, mireku, & karikari, 2016; scaglioni, arrizza, vecchi, & tedeschi, 2011). children with asd may present with feeding difficulties that in turn may influence the family’s mealtime process because of their specific dietary requirements and feeding needs. if the feeding needs of the children with asd are not met, then the child may refuse to eat (ausderau & jaurez, 2013; bagby, dickie, & baranek, 2012). this raises pertinent questions as to whether children can influence family mealtimes and to what extent this impacts the caregiver and the mealtime process. thus, it is important to explore this phenomenon in the context of the home environment, as this will allow for a greater understanding of the impact of context and culture on feeding difficulties in children with asd as well as the caregiver. impact of feeding on the caregiver children with asd present with a number of associated difficulties that can negatively influence the family life and functioning within daily routines. studies have indicated that caring for and feeding a child with asd place added stressors on the family because of the multitude of difficulties that children may exhibit (ledford & gast, 2006; nadon et al., 2011; schreck & williams, 2006). research that has explored this phenomenon have highlighted that many caregivers will feel an increase in stress, anxiety, stigma and depression when caring for children with asd (ausderau & juarez, 2013; blanche, diaz, barretto, & cermak, 2015; gray, 2002; hutton & caron, 2005; suarez, atchison, & lagerwey, 2014; van tongerloo, van wijngaarden, van der gaag, & lagro-janssen, 2015; rogers, et al., 2012; shu, 2009). thus, it may be understood that caregivers’ raising a child with asd may experience greater caregiver burden and may be more susceptible to depression and anxiety disorders (lai, goh, oei, & sung, 2015). however, there is a paucity of local and international research on the impact the mealtimes may have on caregivers, specific caregiver mealtime experiences and the strategies that may be used to assist them. in addition, research has failed to look at the experiences of caregivers from more diverse contexts in low and middle income countries (lmics) like south africa. caregivers living in south africa may have their own cultural structuring of the mealtime with regard to certain customs and rules. thus, understanding the experiences of the caregivers who are living in diverse contexts is vital when trying to obtain a holistic view of caregiver experiences when feeding a child with asd. mealtime strategies research has indicated that context and culture will influence intervention compliance and outcomes (hwang & charnley, 2010). literature has also shown that feeding management provided by the therapist will be unsuccessful if it is not sensitive to the needs of the family and does not incorporate the families’ own cultures, beliefs and values (ausderau, john, kwaterski, nieuwenhuis, & bradley, 2019; ochs & shohet, 2006). to date, there is limited research into feeding interventions that are appropriate within the context of the home environment in south africa. when working with children, interventions require a family-centred approach to care, taking into account not only the needs of the child but also those of the family. in particular, from the key areas outlined above, the following three objectives were formulated: to describe common feeding difficulties in children with asd to describe mealtime challenges for the caregiver to describe mealtime strategies used by the caregiver. method study design an exploratory qualitative study design was employed using a questionnaire to meet the aims of the study. participants were purposively sampled from different asd-specific schools in south africa. recruitment of participants was done using a questionnaire that was available both as an online form and as a printed hard copy to increase the participant response rate (appendix 1). data were collected from the caregivers who met the following inclusion criteria: (1) having a child with a primary diagnosis of asd, (2) having a child between 3 and 10 years of age and (3) reported some form of feeding difficulty from the caregiver. this age range was chosen because by the time the child is 3 years of age, they should be accepting a wide variety of food types and textures, and using a caregiver-reported questionnaire is still appropriate for children up to the age of 10 years (seiverling, towle, hendy, & pantelides, 2018). participants a total of 164 questionnaires and links were sent out to caregivers with a total of 40 responses received (24% response rate). participant descriptions and characteristics are described in table 1. thirteen participants (32.5%) filled in a hard copy of the questionnaire and the rest submitted online. caregivers who participated in the study were between 18 and 65 years of age with the average age range between 30 and 35 years (33.3%, n = 13). those who answered were predominantly mothers (84.6%, n = 34). in addition, 70% (n = 28) of the caregivers were formally employed and working in a variety of full-time positions, with the remainder being unemployed. this highlights the economic diversity of the participants, which is pertinent for the results of the study. table 1: participant description and characteristics. all the families in the study reported only one child with asd between the ages of 3.0 and 9.6 years with a mean age of 7.2 years (standard deviation [sd] = 1.2). most of the children were male. with regards to asd severity, 22.5% (n = 9) presented with level 1, 45% (n = 18) with level 2 and 32.5% (n = 13) with level 3 (table 2). autism spectrum disorder severity and functioning levels were determined using the diagnostic and statistical manual of mental disorders, 5th edition (dsm-5) criteria and associated severity ranking reported by the caregivers (american psychiatric association, 2013; matson & fodstad, 2008). according to the dsm-v criteria, children are characterised according to three levels of severity: level 1, requiring support; level 2, requiring substantial support and level 3, requiring major support (esler & ruble, 2015). the severity can be used as a predictor in terms of the associated problems the child may present with; however, it is important to note that this is not an indicator on the impact the diagnosis may have on the caregiver or family. table 2: themes and sub-themes. procedures and data collection all participants were provided with consent forms before completing the questionnaire. written and online consents were obtained. there was no risk of harm to the participants, who were also informed of their right to withdraw at any point in the study. data were collected from six asd-specific schools; one private school (gauteng) and five government schools (gauteng [n = 2], mpumalanga [n = 1], kawzaulu-natal [n = 1] and the eastern cape [n = 1]). in south africa. the schools are all for children with a confirmed diagnosis of asd. the questionnaire consisted of demographic information on the caregiver and child, as well as six open-ended questions. the use of a questionnaire was deemed appropriate as it was cost-effective, convenient and allowed the inclusion of participants from different provinces in south africa. the questionnaire allowed participants to respond in their own time, and there are no limitations to geographical location of where the participants live. the original questionnaire was piloted and reviewed for validity. four experts who had experience in working with children with asd reviewed the questionnaire. after review, all experts commented on the relevancy and appropriacy of the questionnaire, and no changes were made. this improved the face validity of the questionnaire. data analysis inductive thematic analysis was used as suggested by braun and clarke (2013). the researchers also engaged in reflective note-taking throughout the research process to acknowledge and record any bias. all the responses were recorded verbatim and then coded inductively on a line-to-line basis. ideas that were recurring in a large number of the transcripts or those that related to the research questions were categorised. these categories were then grouped into themes and sub-themes. the second author then validated the themes and analysed all the transcripts independently to ensure inter-coder agreement. inter-coder agreement was established when the same categories were reached by the second author (braun & clarke, 2013). all the themes and sub-themes were then discussed and agreed upon by all three authors. trustworthiness to ensure ethical and trustworthy methods, the following steps outlined by schwandt, lincoln and guba (2001) were considered. dependability was determined by detailing all aspects of the methodology and data analysis to replicate the study. investigator triangulation was also used by including the perspectives of all three authors in the data analysis. confirmability was established through reflexivity to reduce the risk of bias. researcher reflexivity was important, and each researcher independently reflected on their own positionality within the social context being studied. during the data analysis, all researchers’ viewpoints were discussed and consensus was then made on the final themes. ethical consideration this study was approved by the university of witwatersrand, department of speech pathology and audiology internal research ethics committee (hrec non-medical) (sta_2019_01) and the department of education. all participants provided written informed consent. results and discussion the results will be described according to the study aims. the following themes were identified as seen in table 2. theme 1: feeding challenges in children with autism spectrum disorder many children in the current study presented with associated feeding challenges and struggled with family mealtimes with regard to foods eaten and feeding times. thirty-five per cent of caregivers reported no mealtime challenges whilst the remaining 65% reported some form of difficulty experienced. caregivers who reported difficulty had children who were in the younger as well as older age range. although many children with asd and associated difficulties will improve as they become older, there are a number of children who do not manage or resolve their feeding challenges and end up with persistent feeding challenges. in addition, children in the current study who were grouped as less severely affected by asd (levels i and ii) presented with less associated feeding difficulties. some studies have reported that there may be a strong predictive relationship with an increase in children’s repetitive and ritualistic behaviours and parent-reported difficulties (johnson et al., 2014; sharp et al., 2013). however, there is limited literature to support the finding that there is a correlation between asd severity and feeding difficulties in children with asd. those children who experienced feeding challenges will be discussed in greater detail in the following section. picky eating amongst the caregivers who reported feeding challenges, 73% stated that they struggled with feeding their child because of their child’s picky eating and resultant restricted diet. caregivers commented that their children preferred to eat only certain types of food related to taste, texture and/or colour: ‘the only part that concerns me is that he is so choosy about what he eats. he lives off cereal, noodles, yoghurt and loves pastas. if he does not like something he won’t eat it. he mainly eats love burgers, pizza and pasta. so i give him that.’ (participant 7, mother, gauteng) ‘he is fixed into eating savoury food that is green, white and brown. and would eat colour only on fruits. so i stick to that. i don’t know what else to do.’ (participant 38, mother, gauteng) further, caregivers reported that they had to ensure that favoured foods were available for their child, even if this meant that different meals had to pre-prepared: ‘we just have to make sure there is always cereal and milk at home as well as noodles. if he doesn’t eat or won’t eat the food (i make) he will eat cereal or noodles.’ (participant 2, mother, gauteng) ‘to ease stress and frustration i prepare food that i know he will enjoy and have separate food for me and my husband and my other boy.’ (participant 27, father, gauteng) these findings support the notion that many caregivers are struggling with their child’s restricted food selections and are unsure how to provide a more nutritionally balanced diet (nadon et al., 2011; seiverling et al., 2018). caregivers find their child’s picky eating to be frustrating, and many find it easier to give the child food that they will eat, even though these may not be what the rest of the family is eating. furthermore, these findings highlight how children with asd can directly impact the foods that families buy and prepare with regard to the extra planning of mealtimes and cost associated with food items. eating times (too slow or too fast) participants in the current study reported feeding challenges related to eating times with regard to both eating too slowly and eating too fast. in all, 43% of caregivers raised eating times as a cause of concern. the reason for children eating slowly could be attributed to a number of reasons such as oral sensitivity, reduced oral motor control and/or behavioural factors (nadon, et al., 2011; sieverling, et al., 2018). many caregivers felt annoyed at the increased time it took to complete mealtimes (longer than 30 min): ‘i feel good when i see my son eating nicely enjoying his meal but sometimes especially mornings i feel very annoyed when he eats very slowly when it’s time to go to school.’ (participant 14, mother, gauteng) an interesting finding in the current study was the concerns of caregivers about their children who ate too quickly. this was related to concerns that their children were not chewing their food properly and may choke or vomit. one mother commented that her child’s quick eating created a lot of mess and described it as being a blender without the lid on. another caregiver stated: ‘my child eats very fast, wish that she could eat slowly to allow to chew… in public places like restaurants she will eat so fast with excitement our fears are that she may choke or vomit.’ (participant 14, mother, gauteng) the findings support the literature regarding children with asd taking longer to eat, not self-feeding and not eating enough food (malhi, venkatesh, bharti, & singhi, 2017). however, the current study also reported on children eating too fast and making a mess; these findings have not been explored in much detail in previous literature. in the study, children who ate too quickly were also classified as being independent eaters, and caregivers were concerned that if they assist their child to eat and decrease the speed that they would then remove their child’s independence. it is therefore imperative that caregivers understand not only the feeding challenges but also the impact that it can have on the child if not managed appropriately; more input is required on different intervention strategies for this type of eating challenge. furthermore, it is important to acknowledge what is more important for the caregiver and how all of these can be incorporated into intervention. this finding perhaps also emphasises the need to have multidisciplinary team input for intervention for feeding challenges in children with asd. theme 2: caregiver mealtime challenges caregivers who reported no difficulty generally stated that their child was an independent eater or loved all food and did not have any challenges. interestingly, caregivers also stated that even though their children still had a restricted diet that if they were able to sit at the table or eat without making a mess, then they did not consider their feeding habits to be a challenge. caregivers who did report on feeding difficulties described mealtimes as being difficult, stressful, very messy and challenging and one that many caregivers dreaded. this is further explored in the following sections. eating together one of the most significant findings in the present study was the caregiver’s perceptions of what a successful mealtime was. caregivers reported that to them a successful mealtime was when all family members sat at a table, ate together and shared their stories. many caregivers reported that the child with asd would refuse to sit at the table or they would disrupt the rest of the family during mealtimes with a preference for eating alone: ‘it is stressful. i would love him to have a nice hearty meal with his sister and myself and dad. he refuses to try “normal” food and his reaction really makes me sad. mealtimes are divided because sometimes even the sight of our food will upset him. we would love to sit at the table and all eat together.’ (participant 32, mother, eastern cape) the findings of this study are corroborated by other studies that have emphasised the importance of family mealtimes and using them not only as a way to eat but also to socialise and connect with one another (ausderau & juarez, 2013; ochs & shohet, 2006). in all, 86% of the caregivers in the current study felt that eating at the table with the rest of the family was the most pertinent issue, regardless of other feeding challenges such as preference for certain foods or additional preparation time. this was echoed in a study by suarez et al. (2014) where many mothers felt that they were missing a family connection and opportunities to connect as a family when their child with asd did not eat with the rest of the family. therefore, there is a need to transform mealtimes to suit the family needs and also take into account the needs of the child. intervention needs to acknowledge that intervention needs to be multifaceted and take into account the needs of the child and the family. financial implications this was a significant finding as 30% of the caregivers in this study were unemployed. that said, financial implications for feeding was a significant finding for 70% of caregivers who struggled to feed their child-specific foods and accommodate the food needs of the rest of the family. this implies that even those caregivers who had an income experienced financial concerns in terms of dietary management. the child’s restricted diet often resulted in caregivers having to cook two meals, which resulted in financial stress and burden for the caregiver. however, there were also a few caregivers who were unable to provide the child with their preferred foods and had to force the child then to eat what the rest of the family was eating: ‘it is difficult because of money and that food is not good but that is what he wants. it is so much money.’ (participant 13, mother, gauteng) ‘it is really a challenge because he likes certain things and sometimes i don’t have the money to buy his favourite food, so i have to force him to eat.’ (participant 22, mother, gauteng) the findings of the financial burden of fussy eating support the impact that context and culture can have on family mealtimes. in south africa, there are a number of families living with food insecurity and has been largely ignored by researchers in the field (guler, de vries, seris, shabalala, & franz, 2018; rogan, 2016). many caregivers living in south africa have financial difficulties, and children with feeding challenges can increase the financial strains because of the caregiver spending money on food as well as food waste. more support and education are required to assist families with possible food insecurity challenges, especially in a context like south africa. therapists also need to be more cognizant of these challenges when recommending intervention strategies. unsupportive friends and family in this study, 40% of caregivers felt a lack of support from their family. this made feeding difficulties in their child more pronounced and limited with regard to where they can go to eat and who they can visit. this further restricted mealtimes to the home for families of children with asd: ‘some family members do not understand him and they are impatient with him. this hurts me.’ (participant 24, mother, gauteng) ‘as a mom i have to adjust and go with his flow because no one will understand him better than me in the family but negative impact is that my parents are not with me always to give me support with my boy as i am facing lot of challenges with our neighbours and even some of my friends.’ (participant 14, mother, gauteng) because of the lack of support from family and friends, many caregivers reported that they chose to avoid certain places or events because of the challenges experienced with their child’s feeding and eating behaviours. this avoidance can result in further exclusion and isolation for the caregivers and the child. these findings highlight the importance of a strong support system and the impact that the absence of one can have on the emotional, social and psychological well-being of caregivers. in addition, if caregivers are experiencing any negative feelings, this can further result in reduced support for their child. a caregiver needs to be able to take care of themselves before they can adequately take care of their child (hastings et al., 2005). support for the caregiver should be incorporated into the management plan by all team members, when working with children with disabilities. theme 3: mealtime strategies in this study, 70% of caregivers reported that their mealtimes required some sort of adaptation in their typical family routine to promote eating and mealtime participation. strategies were often aimed at trying to encourage a mealtime that mirrored a more ‘typical’ representation of what caregivers thought mealtimes should be. thus, strategies focused on having the child sit with the rest of the family, eat what the rest of the family is eating and reducing mealtime distractions promote a more socially inclusive environment. caregivers also used strategies to try and alleviate their own stressors (table 3). table 3: mealtime strategies used by caregivers to manage feeding difficulties in children with autism spectrum disorder. caregivers struggled to include their child with asd in the family mealtime, and this caused great distress as the focus and representation for family mealtimes were to sit together and share a meal. previous research on feeding management has always focused on improving restrictive eating and the child with asds acceptance of non-preferred food items (koegel et al., 2012; seiverling, williams, sturmey, & hart, 2012; stough, gillette, roberts, jorgensen, & patton, 2015). however, the current study highlighted how caregiver’s strategies were aimed at not only getting the child to increase their food selectivity but also to stay at the table, engage with family members or eat a greater quantity of a preferred food. one caregiver commented that her child had very selective eating but reported no mealtime challenges, as he was able to sit at the table with the rest of the family. when managing feeding difficulties, ausderau et al. (2019) explored the strategies parents use to support the mealtime participation of their child with asd and found similar findings in mealtime strategies being used at home such as using parent-directed strategies. further, both the study by ausderau et al. (2019) and the current study emphasise that although the intake of new foods is important to many parents, and often the focus of many speech language therapy feeding interventions, it is not always the caregivers’ main area of concern or focus. therefore, the findings emphasise that therapists should be aware of feeding difficulties in children with asd reported in the current study. therapists should also be aware of the impact of mealtimes on the caregiver and the associated challenges some caregivers may have. further, therapists should incorporate the investigation of current feeding strategies being used by the caregivers to use them as a starting point to provide further support and assistance. limitations and future directions the authors are aware of a number of limitations of the current study. firstly, there was no quantitative measure of stress and quality of life for the caregivers in this study; in addition, using a self-administered form did not allow for the researcher to probe on certain topics. however, the researchers wanted to access participants from different geographical locations and use a method that was both convenient and cost-effective; thus the use of a questionnaire was deemed appropriate. secondly, the authors are also aware of the language limitations and that caregivers were required to be proficient and literate in english. english is not the main language of many south african families. lastly, all children in the current study were attending school. there may be differences to children who are not in school and the subsequent feeding difficulties experienced by their caregivers. although, schools were chosen as children all have a confirmed diagnosis of asd. future research should include more interviews and observational data to obtain a more holistic picture of the challenges as well as the way in which strategies are being used by the caregivers when feeding their child with asd. the current study also focused on the caregiver report, primarily mothers. including additional family members could enhance the understanding of mealtime experiences with a child with asd in the south african context. implications the following recommendations are drawn from the research and situated within a family-centred approach: therapists need to be aware about the associated feeding challenges in children with asd, which may have benefits that are twofold: firstly, for early identification and treatment and, secondly, the opportunity for more support and education for families of children with asd. the experiences reveal that their needs are not always considered when targeting feeding in children with asd and the need for more contextually relevant and responsive interventions as well as the incorporation of each families’ individual feeding routines, beliefs and values into intervention conclusion this study has shed some light on the experiences of caregivers feeding their children with asd within the south african context. a noticeable strength of the current study is that the sample population and the focus on caregivers from lmics such as south africa are novel and necessary to transform therapist management. these findings highlight the multitude of challenges that caregivers have when feeding their child with asd and the different mealtime strategies that they use. these findings have assisted to identify the gaps in the field, which require further exploration. acknowledgements the authors would like to thank all the families who participated in this study, shared their experiences and made this study possible. in particular, the authors would like to thank the johannesburg school for autism, randburg clinic school and centre for autism research (care) for their involvement with the research. s.n.a. was supported by consortium for advanced training in africa (carta) who was funded by the carnegie corporation of new york (grant no: b 8606.r02), sida (grant no: 54100029) and the deltas africa initiative (grant no: 107768/z/15/z). competing interests the authors have declared that no competing interests exist. authors’ contributions r.v. carried out the research. s.n.a. and k.c. helped in supervising the project; s.n.a. ran the qualitative analysis and wrote the manuscript with support from r.v. and k.c. all authors discussed the results and contributed to the final manuscript. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement the data that support the findings of this study are available from the corresponding author (s.n.a.), upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references american psychiatric association. 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(2015). mealtime behaviors associated with consumption of unfamiliar foods by young children with autism spectrum disorder. appetite, 95, 324–333. suarez, m.a., atchison, b.j., & lagerwey, m. (2014). phenomenological examination of the mealtime experience for mothers of children with autism and food selectivity. american journal of occupational therapy, 68(1), 102–107. https://doi.org/10.5014/ajot.2014.008748 tuomainen, h. (2014). eating alone or together? commensality among ghanaians in london. anthropology of food, s10, 7718. van tongerloo, m.a., van wijngaarden, p.j., van der gaag, r.j., & lagro-janssen, a.l. (2014). raising a child with an autism spectrum disorder: ‘if this were a partner relationship, i would have quit ages ago’. family practice, 32(1), 88–93. https://doi.org/10.1093/fampra/cmu076 appendix 1: list of questions: what feeding difficulties does your child with asd present with? please describe how these impact on mealtimes with you and your family? as a caregiver of a child with asd, how do you feel about the feeding process and mealtimes? how does it impact on you and your family? are there any strategies or methods that you use to manage your child’s feeding difficulties? please elaborate. do the feeding difficulties restrict you from going to certain places or participating in particular activities? if yes, what? sajcd 132 speech-evoked cortical auditory responses in children with normal hearing a almeqbel, phd, msc, bsc audiology hearing and speech sciences department, health science center, kuwait university, kuwait corresponding author: a almeqbel (aseel.m@hsc.edu.kw) objective. cortical auditory-evoked potentials (caeps), an objective measure of human speech encoding in individuals with normal or impaired auditory systems, can be used to assess the outcomes of hearing aids and cochlear implants in infants, or in young children who cannot co-operate for behavioural speech discrimination testing. the current study aimed to determine whether naturally produced speech stimuli /m/, /g/ and /t/ evoke distinct caep response patterns that can be reliably recorded and differentiated, based on their spectral information and whether the caep could be an electrophysiological measure to differentiate between these speech sounds. method. caeps were recorded from 18 school-aged children with normal hearing, tested in two groups: younger (5 7 years) and older children (8 12 years). cortical responses differed in their p1 and n2 latencies and amplitudes in response to /m/, /g/ and /t/ sounds (from low-, midand high-frequency regions, respectively). the largest amplitude of the p1 and n2 component was for /g/ and the smallest was for /t/. the p1 latency in both age groups did not show any significant difference between these speech sounds. the n2 latency showed a significant change in the younger group but not in the older group. the n2 latency of the speech sound /g/ was always noted earlier in both groups. conclusion. this study demonstrates that spectrally different speech sounds are encoded differentially at the cortical level, and evoke distinct caep response patterns. caep latencies and amplitudes may provide an objective indication that spectrally different speech sounds are encoded differently at the cortical level. keywords: cortical auditory-evoked potentials (caeps), electroencephalogram (eeg), p1 and n2 components, children with normal hearing s afr j cd 2013;60:38-43.doi:10.7196/sajcd.132 cortical auditory-evoked potentials (caeps) are one type of electroencephalogram (eeg) that is a good method for understanding the neural representation of time-varying signals, including acoustic cues important for speech perception (taylor & baldeweg, 2002). the caeps, developed by davis (1939), are a non-invasive instrument that can provide objective information on the functioning of the central auditory nervous system. one component of the caep is the p1-n1-p2 complex, made up of three peaks, the latencies and amplitudes of which are determined partly by the characteristics of the stimulus used to evoke them. traditionally, the p1-n1-p2 complex has been described in terms of amplitude and latency. amplitude refers to the strength of the responses (measured in microvolts) and latency refers to the time after stimulus onset (measured in milliseconds). the number of recruited neurons, extent of neuronal activation and synchrony of the neural responses all contribute to the resulting morphology of the caeps. the caeps are believed to reflect the activity of excitatory postsynaptic potentials at the level of the thalamus and higher auditory cortex (primary auditory cortex and association areas) (cone-wesson & wunderlich, 2003; ponton & don, 2003; purdy, kelly & thorne, 2001; sharma & dorman, 2006; tremblay, piskosz & souza, 2003; wunderlich & cone-wesson, 2006). each peak of the caep waveform appears to originate from multiple neural generators (ponton & don, 2003; sharma & dorman, 2006). for example, research has shown that p1 peak is a positive waveform occurring at around 50 ms post stimulus onset, n1 is a negative peak occurring at 80 100 ms, and is followed by p2, the next positive waveform, at around 175 200 ms (näätänen & picton, 1987). individual components are labelled and can be seen as distinct peaks on the waveform. they are also called the vertex potential, because it was originally best recorded at the vertex (davis, mast, youshie & zerlin, 1966). early studies focused on how the p1-n1-p2 complex is evoked by acoustic changes in the auditory environment. for instance, some of the earliest changes noted were systematic changes in the p1-n1-p2 complex with changes in stimulus intensity (davis et al., 1966). since that time, the p1-n1-p2 complex has been used to study neural detection of consonant-vowel transition, periodicity changes, amplitude envelope variation and spectral contact change (ostroff, martin & boothroyd, 1998). because these evoked potentials are sensitive to acoustic parameters of speech, this response is frequently used to study the neural detection of spectral and temporal cues in people with impaired speech understanding. in young adults with normal hearing, the caeps contain two main vertex positive peaks, commonly termed p1 and p2, and one main vertex negative peak, n1 (purdy et al., 2001). one other negative peak, n2, frequently follows p2. the response represents combined activity from a number of generators in the higher auditory nervous system. the p1-n1-p2 complex has been shown to be sensitive to acoustic parameters of speech signal, and as result this complex is frequently used to study the neural detection of spectral or temporal cues in populations with impaired speech difficulties. in children, the n1 component of the caeps is not consistently present until 9 years of age and older, and maturation of caeps is very complex. the maturation and developmental course of the caeps are important, because changes in children’s caep continue well into adolescence. the maturation of the thalamocortical portions of the central auditory system can be assessed by recording age-related changes in the neurophysiological responses evoked by auditory stimulation. in contrast to adult caep waveforms, which are dominated by n1, children’s waveforms are typically dominated by p1 (sharma & dorman, 2006). this positive peak typically occurs at a longer latency of 100 300 ms post stimulus onset (kraus & mcgee, 1994; sharma & dorman, 2006). sharma, kraus, mcgee and nicol (1997) demonstrated that the development of p1 component can vary between 14 and 26 years of age, and beyond. the age when the n1 and p2 components first appear in young children is debated. some authors have noted that they appear around 3 8 years, while others have suggested that they are absent in all young children (ceponiene, rinne & näätänen, 2002; pang & taylor, 2000; sharma et al., 1997) and that the n1 peak is not consistently present until age 9 years (ponton, don, eggermont, waring & masuda, 1996). therefore, n1 cannot be used as a reliable measure in young children, and this reflects maturation of the neural processes generating the n1 response (wunderlich, cone-wesson & shepherd, 2006). many studies have demonstrated that caep component peak latencies are shorter in adults than in young infants, children or adolescents. sharma et al. (1997) compared the maturation of caeps in 86 normal-hearing children aged 6 15 years with 10 normal-hearing adults. they identified clear age-related changes in the p1 and n1 components of caeps. the maturation changes included a decrease in the latencies of both p1 and n1 and a decrease in the amplitude of p1 with increasing age. sharma, dorman and spahr (2002a) then studied the maturational changes in the latency of p1 component in 136 normal-hearing children, aged from 1 month to 20 years. the authors found that the latency of p1 decreases with increasing age, and that this continues until around 20 years of age. the changes in p1 latency occur at a more gradual rate in the second decade of life than the rapid decrease seen earlier (sharma et al., 2002a). the maturational changes reported in the components of caep waveforms appear to be consistent with the general development of the central nervous system. specifically, a general decrease was observed in all caep components, which appears to agree with the positive changes in myelination and synaptogenesis that continue during the first 20 years of life (sharma et al., 1997). cunningham, nicol, zecker and kraus (2000) recorded caeps to synthesised /ga/ in 150 participants aged 5 78 years. they showed that the p1-n1-p2 changes throughout the period from childhood to old age, and that the p1 latency did not change significantly during the primary school years (5 7, 8 10 and 11 12 years). additionally, p1 latency was similar for those aged 19 27 and 55 78 years. p1 amplitude was not significantly different between those aged 5 – 7 and 8 10 years, but it was considerably larger for these younger children than for older children and adults (11 12, 13 15, 19 27 and 55 78 years). moreover, the authors found that n1 presence was variable in children but was more consistent in both younger and older adults. on the other hand, the n2 component was seen more consistently in the younger children than in the adult participants. similarly, ceponiene et al. (2002) reported that children’s caeps are dominated by p1 and n2 peaks. they compared caeps in eight 4-year-olds, eight 9-year-olds and 17 young adults (mean age 26 years). they used complex tones of 100 ms duration, presented bilaterally through loudspeakers to evoke the caeps at a 700 ms inter-stimulus interval (isi). their findings demonstrated that the 4-year-olds and 9-year-olds showed p1-n2 responses, whereas adults showed p1-n1-p2-n2 responses. wunderlich et al. (2006) studied the maturation of caeps in three groups of paediatric populations: (i) newborns with normal hearing (less than 7 days old); (ii) toddlers (13 41 months old); and (iii) young children (4 6 years old). they compared these with nine adult participants’ caeps. the researchers showed that the peak latencies of all caep components were considerably shorter in adult participants than in children. this trend is typical of most auditory-evoked potentials, which decrease in latency with maturational changes in myelination and synaptic efficiency. the above studies all illustrate that the caeps maturation is complex and the negative n1 component is not well developed in children; rather, the dominant negative component in children is n2. the development of speech and language in children with prelingual hearing impairment depends on the perception and discrimination of a broad spectrum of speech sounds. the recording of caeps to human speech sounds in infants and young children can provide an index of the functional integrity of the regions of the cortex which process those acoustically complex stimuli that are critical for developing normal speech and language (novak et al., 1989). for example, rance, cone-wesson, wunderlich & dowell (2002) found that the development of reasonable speech perception performance in children with auditory neuropathy spectrum disorder (ansd) was correlated with p1 and n2 of normal latency, amplitude and morphology, whereas the absence of caeps was associated with poor speech recognition scores. for these reasons, caeps are thought to reflect the functional integrity of the auditory pathways involved in processing complex speech stimuli (novak et al., 1989; ostroff et al., 1998; tremblay, friesen, martin & wright, 2003). in the study reported here, we evaluated the p1 and n2 of the caep components as a function of three speech sounds /m/, /g/ and /t/ of low-, midand high-frequency regions, respectively, at the level of the auditory cortex in school-aged children with normal hearing. we aimed to determine whether the naturally produced speech stimuli /m/, /g/ and /t/ evoked distinct caep response patterns that could be reliably recorded in normal-hearing children, and whether the caep could be an electrophysiological measure to differentiate between these speech sounds. method objective the main aim of the study was to determine whether the naturally produced speech stimuli /m/, /g/ and /t/, with different frequency patterns, evoked distinct p1 and n2 response patterns in terms of morphology, latencies and amplitudes that could be reliably recorded in children with normal hearing. we also investigated whether the caep is an objective tool that can measure the ability to detect and discriminate between each of these different speech sounds in normal-hearing children, which, in turn, provides us with normative data. research design a cross-sectional research design was employed to describe the basic analysis of caep amplitudes and latencies for different speech sounds. participants we recruited 18 school-aged children (8 males, 10 females) with normal hearing, aged 5 12 years (mean 8.77, standard deviation (sd) 2.28). participants had pure-tone air conduction thresholds within a normal limit (≤15 db hl at octave frequencies from 250 hz to 8 khz) and normal middle-ear function (shown with normal tympanograms), and no history of hearing problems or difficulties in understanding speech in quiet or noisy environments. parents of all children reported no previous history of language and reading problems. all participants scored ≥90% using the manchester junior word lists (mjwl) (watson, 1957). prior to testing, the children and their parents signed a consent form. data collection all participants had otoscopic evaluation prior to testing to check for occluded wax or any sign of tympanic membrane abnormality. air conduction and bone conduction pure-tone thresholds were determined using a calibrated clinical audiometer (ac33 interacoustics 2 channel audiometer) using a modified version of the hughson and westlake procedure (cahart & jerger, 1959). tympanometry was undertaken using a calibrated immittance audiometer (gsi-tympstar v2, calibrated as per ansi, 1987) using a standard 226 hz probe tone. speech perception was performed using the mjwl (watson, 1957). materials we used the natural speech stimuli /m/, /g/ and /t/ to evoke caep in the participants. we chose naturally produced speech stimuli, as recommended by picton, alain, otten, ritter and achim (2000), because our goal was to apply the results to speech perception in everyday life. the speech stimuli /mum/, /guy/ and /two/ were produced by an english female speaker, and were of 30 ms duration and ramped with 5 ms rise and fall time to prevent any audible click arising from the rapid onset or offset of the waveform. the stimuli were generated using a 16-bit digital-to-analogue converter with a sampling frequency of 44.1 khz and low pass filtered with mono recording. the speech stimuli /m/, /g/ and /t/ included very little vowel transition and were chosen because they have a spectral emphasis in the low-, midand high-frequency regions, respectively. therefore they have the potential to provide information about the perception of speech sounds at the level of the auditory cortex in different frequency regions. the frequency spectrums for /m/, /g/ and /t/ tokens are shown in figure 1. fig. 1. frequency spectrum for /m/ /g/ /t/ tokens smoothed. speech sounds were edited using the programme cool edit 2000. the onset-to-onset duration isi was 1030 ms. details are summarised in table 1. stimulus presentation all speech stimuli used in the electrophysi­ology procedure were presented at 65 db sound pressure level (spl), as measured at the participant’s head, which approximates normal conversational level. presentation was via a loudspeaker placed 1 metre from the participant’s seat at a 0 azimuth. set-up participants sat on a comfortable chair in a quiet room at an electrophysiology clinic and watched a dvd of their own choice. the volume was set at silent and the subtitle was activated to make sure that participants would be engaged with the movie and pay no attention to the stimuli. all participants were instructed to be relaxed and not to pay attention to the sounds being presented, and not to fall asleep while the caeps were recorded. data acquisition a neuroscan and 32-channel neuamps evoked potential system was used for evoked potential recording. all sounds were presented using neuroscan stim 2 stimulus presentation system. recording evoked potentials were recorded in continuous mode (gain 500, filter 0.1 100 hz) and converted using analogue-to-digital sampling rate of 1 000 hz using scan (version 4.3) via gold electrodes placed at c3, c4 and cz with reference electrode a2 on the right mastoid bone and ground on the contralateral ear on the mastoid bone. electrode impedances were maintained below 5 kω for all participants. the test session, including electrode application and evoked response recording, lasted about 20 minutes. none of the participants showed signs of fatigue during the testing. all sound levels presented were calibrated using bruel & kjaer slm 2. off-line data analysis the eeg files with a -100 to 500 ms time window were obtained from the continuous file relative to the stimulus onset. any responses on scalp electrodes exceeding ±100 µv were rejected. prior to averaging, eeg files were baseline corrected using a prestimulus period (-100 ms); this -100 ms prestimulus time window was used to establish a baseline to correct for the dc level of background eeg activities. averaging was digitally band pass filtered from 1 to 30 hz (zeroshift, using a 12 db/octave slope zero-phase filter) to smooth the waves for the final figures. larger amplitude responses are recorded from the midline scalp locations, and neural patterns to speech stimuli have been reported to be similar at electrode locations surrounding the midline (tremblay et al., 2003). therefore the peak p1 and n2 latencies were detected based on the recordings from the cz electrode site (cz refers to the vertex midline placement). individual participants had two averaged caep waveforms, resulting in a grand average waveform of 200 (i.e. 100 x 2) sweeps for each stimulus presentation. we measured the p1 in the children from the highest positive peak after the stimulus onset, and the n2 was measured as the immediate negative component occurring after the p1, usually present around 200 250 ms after stimulus presentation. participants were divided into two groups, a younger group aged 5 7 years and an older group aged 8 12 years, and the results are discussed separately below. data analysis for each participant, the individual grand average waveform was computed, visually identified by two experts in electrophysiology. the same eeg files were transferred to excel and subjected to suitable statistical analyses using spss (version 18). the smaller groups of participants necessitated the use of non-parametric analysis. results caep: younger children (5 7-year age group) the caep components p1 and n2 were easily recognised for all speech stimuli, /m/, /g/ and /t/, at the cz electrode for all children in this group (fig. 2). fig. 2. grand averaged caep waveforms in response to the three speech stimuli in the 5 7-year age group. p1 amplitude mean and sd peak amplitudes for the p1 component in response to /m/, /g/ and /t/ speech stimuli for the 5 7-year age group are shown in table 2. visual inspection revealed robust p1 amplitude of /m/, /g/ and /t/ at about 2.7, 4.5 and 2.1 (μv) respectively. changes in p1 amplitude were observed as a function of three different speech stimuli that differ in frequency information. the friedman test compared the mean p1 amplitude in response to the three speech stimuli /m/, /g/ and /t/. the results indicated a statistically significant difference in p1 amplitude of the caep across the speech stimuli (chi-squared=6.000, p<0.05). inspection of the median values showed changes in p1 amplitude of the caep from /m/ (3.2), /g/ (4.4) and /t/ (2.7). the wilcoxon signed ranks test was performed to test (post hoc analysis) for a significant difference in the means of pairs of speech stimuli. results revealed a significant difference in mean of the p1 amplitude between the speech sounds /g/ and /t/ (z= -2.375, p≤0.05), and the speech sounds /g/ and /m/ (z= -2.261, p≤0.05). p1 latency mean peak and sd latencies for p1 in response to /m/, /g/ and /t/ for the 5 7-year age group are shown in table 2. visual inspection revealed robust p1 latency of /m/, /g/ and /t/ at about 93, 91 and 100 ms, respectively. changes in p1 latency were observed as a function of three different speech sounds that differ in frequency information. the friedman test was performed to compare the mean p1 latency in response to the three speech tokens /m/, /g/ and /t/. the results indicated no statistically significant difference in p1 latency of the caep across the speech sounds (chi-squared=2.333, p>0.05). inspec­ -tion of the median values showed changes in p1 latency of the caep from /m/ (100), /g/ (96) and /t/ (105). n2 amplitude mean and sd peak amplitudes for n2 in response to /m/, /g/ and /t/ speech stimuli for the 5 7 years old group are shown in table 2. visual inspection revealed robust n2 amplitudes of /m/, /g/ and /t/ at about 4.3, 5.5 and 3.8 μv, respectively. changes in n2 amplitude were observed as a function of three different speech sounds that differ in frequency information. the friedman test was performed to compare the mean n2 amplitude as function of the three speech stimuli /m/, /g/ and /t/. the results indicated a statistically significant difference in n2 amplitude of the caep across the speech sounds (chi-squared=5.900, p<0.05). inspection of the median values showed changes in n2 amplitude of the caep from /m/ (3.6), /g/ (5.9) and /t/ (3.5). the wilcoxon signed ranks test was performed to test (post hoc analysis) which pairs of speech stimuli were significantly different. results revealed a significant difference in n2 amplitude in the younger age group between the speech sounds /g/ and /t/ (z= -2.201, p≤0.05), and the speech sounds /g/ and /m/ (z= -2.176, p≤0.05). n2 latency mean and sd n2 latency in response to /m/, /g/ and /t/ speech sounds for the 5 7-year age group are shown in table 2. visual inspection revealed a robust n2 latency of /m/, /g/ and /t/ at about 233, 219 and 245 ms, respectively. as expected in this age group, there was no evidence of an n1 component in the majority of children. in both the individual and grand average responses, changes in n2 latency were observed as a function of three different speech sounds that are different in frequency region. the friedman test was performed to compare the mean n2 latency as function of the three speech tokens /m/, /g/ and /t/. the results indicated a statistically significant difference in n2 latency of the caep across the speech stimuli (chi-squared=7.000, p<0.05). inspection of the median values showed changes in n2 latency of the caep from /m/ (235), /g/ (222) and /t/ (250). finally, the wilcoxon signed ranks test was performed to test (post hoc analysis) which pairs of speech stimuli were significantly different. results revealed a significant difference in n2 latency in the younger age group between the speech sounds /g/ and /t/ (z= -2.201, p≤0.05), and the speech sounds /g/ and /m/ (z= -2.131, p≤0.05). caep: older children (8 12-year age group) p1 amplitude mean and sd peak amplitudes for p1 in response to /m/, /g/ and /t/ speech sounds for the 8 12-year age group are shown in table 3. visual inspection revealed smaller p1 amplitude of /m/, /g/ and /t/ at about 3.0, 3.1 and 1.2 μv, respectively. changes in p1 amplitude were observed as a function of three different speech sounds that differ in frequency region. the friedman test was performed to compare the mean p1 amplitude as function of the three speech tokens /m/, /g/ and /t/. results indicated a statistically significant difference in mean of the p1 amplitude of the caep across the speech tokens (chi-squared= 7.185, p<0.05). inspection of the median values showed changes in p1 amplitude of the caep from /m/ (2.8), /g/ (3.7) and /t/ (2.3). the wilcoxon signed ranks test was then performed to test (post hoc analysis) which pairs of speech stimuli were significant. results showed a significant difference in p1 amplitude in the older group between the speech sounds /g/ and /t/ (z= -2.197, p=<0.05), and between /m/ and /t/ (z= -2.201, p≤0.05). p1 latency mean and sd peak latencies of n2 in response to /m/, /g/ and /t/ for the 8 12-year age group are shown in table 3. visual inspection revealed a robust p1 latency of /m/, /g/ and /t/ at about 93, 96 and 94 ms, respectively. changes in p1 latency were observed as a function of three different speech sounds that differ in frequency region. the friedman test was performed to compare the mean p1 latency as function of the three speech tokens /m/, /g/ and /t/. results indicated no statistically significant difference in p1 latency of the caep across the speech tokens (chi-squared=2.909, p>0.05). inspection of the median values showed changes in n2 latency of the caep from /m/ (92), /g/ (95) and /t/ (90). n2 amplitude mean and sd peak amplitudes for n2 in response to /m/, /g/ and /t/ speech sounds for the 8 12-year age group are shown in table 3. visual inspection revealed smaller n2 amplitude of/m/, /g/ and /t/ at about 4.1, 4.7 and 2.3 μv, respectively. changes in n2 amplitude were observed as a function of three different speech sounds that differ in frequency region. the friedman test was performed to compare the mean n2 amplitude as function of the three speech tokens /m/, /g/ and /t/. results indicated a statistically significant difference in n2 amplitude of the caep across the speech tokens (chi-squared=11.143, p<0.005). inspection of the median values showed changes in n2 amplitude of the caep from /m/ (4.8), /g/ (5.9) and /t/ (3.4). further analysis using wilcoxon signed ranks test to test (post hoc analysis) which pairs of speech stimuli were significant revealed that the significant difference in n2 amplitude in the older group was between the speech sounds /g/ and /t/ (z= -2.371, p≤0.05). n2 latency the mean and sd latencies of n2 in response to /m/, /g/ and /t/ for the 8 12-year age group are shown in table 3. visual inspection revealed a robust n2 latency of /m/, /g/ and /t/ at about 249, 237 and 244 ms, respectively. changes in n2 latency were observed as a function of three different speech sounds that differ in frequency region. the friedman test was performed to compare the mean n2 latency as function of the three speech tokens /m/, /g/ and /t/. results indicated no statistically significant difference in n2 latency of the caep across the speech tokens (chi-squared=2.905, p>0.05). inspection of the median values showed changes in n2 latency of the caep from /m/ (235), /g/ (232) and /t/ (240). test and retest reliability the spearman’s rho test was performed to individually test the correlation between the first and second trial of each stimulus. there was a high correlation between the test and retest condition, r≥0.5 and p<0.05. discussion the main aim of this study was to determine whether different speech sounds that encompass three spectral information frequencies (low, mid and high) could be differentiated from each other based on response latency and amplitude of the caep measures, in particular the p1 and n2 components, in school-aged children with normal hearing. robust p1 and n2 responses were obtained from all participants for all speech stimuli tested. notably, there was a distinct difference in morphology of the caeps between the two groups (younger vs. older): the younger group had a more robust and larger p1 component than the older group. the n2 component was also larger in amplitude in the younger group. in the older group of children, a small amplitude but a definite n1 peak was revealed in particular for the speech sounds /g/ and /m/ (fig. 3). this finding supports the ongoing maturation of the caeps in childhood until they reach the adult-like caep waveforms; however, the maturation aspect of the caep is not discussed here (for reviews, see eggermont & ponton, 2003; fox, anderson, reid, smith & bishop, 2010; gilley, sharma, dorman & martin, 2005; novak et al., 1989; pang & taylor, 2000; pasman, rotteveel, massen & visco, 1999; ponton et al., 1996; ponton, eggermont, kwong & don, 2000; ponton, eggermont, khosla, kwong & don, 2002; sharma & dorman, 2006; sharma et al., 1997; sharma, dorman & spahr, 2002b; sharma et al., 2002a; wunderlich et al., 2006). fig. 3. grand averaged caep waveforms in response to the three speech stimuli in the 8 12-year age group. in the younger group, p1 amplitude changed significantly as a function of the /m/, /g/ and /t/ speech sounds. the largest amplitude was for /g/ and the smallest amplitude was for /t/. the statistical analysis revealed that a significant mean difference of p1 amplitude occurred between /g/ and /t/ and between /g/ and /m/. p1 latency changed slightly as a function of these speech stimuli; however, the change was not significant. n2 amplitude in the younger group changed significantly as a function of these sounds, and the significant changes were between the speech sounds /g/ and /t/ and between /g/ and /m/. there was no significant difference between /m/ and /t/. the largest n2 amplitude was for /g/ and the smallest was for /t/. n2 latency also changed significantly as a function of the speech sounds /g/, /m/ and /t/; the significant changes were between /g/ and /t/ and between /g/ and /m/. in the older group, there was significant mean difference in p1 amplitude between /g/ and /t/ and between /m/ and /t/. however, there was no significant mean difference in p1 latency across these speech stimuli. n2 amplitude in the older group showed a significant difference only between /g/ and /t/. n2 latency changed as a function of these speech sounds; however, the changes were not significant. taken together, the results indicate that the amplitude of the p1 and n2 in both groups showed significant changes in mean in response to /m/ (low-), /g/ (mid-) and /t/ (high-frequency) sounds. the largest amplitude of the p1 and n2 component was always for the speech sound /g/ and the smallest was for the speech sound /t/. the p1 latency in both age groups, however, showed no significant difference between any of these speech sounds. the n2 latency showed a significant change in the younger group but not in the older group. moreover, the n2 latency of the speech sound /g/ was always noted earlier in both groups. there are different morphology, latency and amplitude p1 and n2 responses evoked by the different speech tokens that encompass different frequency patterns recorded in children with normal hearing. therefore the caep can be used as an objective measure to detect and discriminate between each of these different speech sounds. research on the tonotopic organisation of the primary auditory cortex and the effect of the stimulus frequency on the auditory cortex has found that the cortical areas that respond to low-frequency auditory information are located more superficially (closer to the surface of the scalp) than cortical regions for high frequency (located more deeply within the scalp) (jacobson, lombardi, gibbens, ahmed & newman, 1992; wunderlich et al., 2006; yetkin, roland, christensen & purdy, 2004). low-frequency speech sounds such as /m/ and /g/ may therefore activate more superficial cortical layers and so produce a larger amplitude than higher frequency speech sounds such as /t/, which might activate a deeper cortical layer in the scalp and thus have a smaller amplitude when surface scalp recording electrodes are used. the results from this study demonstrate that the frequency organisation of the auditory system can be revealed in both amplitude and latency measures of the caep. specifically, we have demonstrated that the p1 and n2 amplitude for both younger and older groups is larger in amplitude in response to the /g/ speech sound than to /m/ or /t/ speech sounds. we have also shown that the peak latency of n2 is earlier in response to the /g/ speech sound than to the /m/ and /t/ speech sounds. these findings demonstrate that the speech stimuli for low-, midand high-frequency information, such as /m/, /g/ and /t/, encode differently at the cortical level, and it may be assumed that each of the three speech sounds activates a different neuronal population in the auditory cortex, based on their latency and amplitude responses. thus these caep evoked by speech sounds could be used as an objective test to evaluate speech discrimination. conclusion the cortical auditory-evoked response can be elicited by speech sounds that encompass three frequency information groups, namely low, mid and high frequencies. these speech sounds are /m/, /g/, /t/. interestingly, the /g/ speech sounds evoked larger amplitude and shorter latencies than /m/ and /t/ speech sounds that were dominated by lowand high-frequency energy. thus p1 and n2 responses of the caep may be used to objectively measure differences in neural encoding and the perception of spectrally different speech sounds. in the current study we have described and provided normative data from school-aged children in response to three different speech sounds that differ in spectral information. therefore this objective measure provides us with a tool to investigate the neurophysiological processes that underlie our ability to perceive speech. further studies should test these results on a population who are difficult to assess by behavioural responses, and investigate how these sounds are evoked in a disordered population. references cahart, r. & jerger, j. (1959). preferred method for clinical determination of pure tone thresholds. j speech hear disord, 24, 330-345. ceponiene, r., rinne, t. & näätänen, r. (2002). maturation of cortical sound processing as indexed by event-related potentials. clin neurophysiol, 113(6), 870-882. cunningham, j., nicol, t., zecker, s. & kraus, n. (2000). speech-evoked neurophysiologic responses in children with learning problems: development and behavioral correlates of perception. ear and hearing, 21(6), 554-568. cone-wesson, b.k. & wunderlich, j.l. (2003). auditory evoked potentials from the cortex: audiology application. current opinion in otolaryngology & head & neck surgery, 11(5), 372-377. davis, p.a. (1939). effects of acoustic stimuli on the waking human brain. journal of neurophysiology, 2(1), 494-499. davis, h., mast, t., youshie, n. & zerlin, s. (1966). the slow response of the human cortex to auditory stimuli: recovery process. clin neurophysiol, 21(2), 105-113. eggermont, j. & ponton, c. (2003). auditory-evoked potential studies of cortical maturation in normal hearing and implanted children: correlations with changes in structure and speech perception. acta otolaryngol, 123, 249-252. kraus, n. & mcgee, l. (1994). mismatch negativity in the assessment of central auditory function. am j audiol, 3(2), 39-51. fox, a., anderson, m., reid, c., smith, t. & bishop, d. (2010). maturation of auditory temporal integration and inhibition assessed with event-related potentials (erps). bmc neuroscience, 11, 49. gilley, p., sharma, a., dorman, m., & martin, k. (2005). developmental changes in refractoriness of the cortical auditory evoked potentials. clin neurophysiol, 116, 648-657. jacobson, g., lombardi, d., gibbens, n., ahmed, b. & newman, c. (1992). the effects of stimulus frequency and recording site on the amplitude and latency of multichannel cortical evoked potentials (caep) component n1. ear hear, 13, 300-306. novak, g., kurtzberg, d., judith, a., kreuzer, g., herbert, g. & vaughan, j. (1989). cortical response to speech sounds and their formants in normal infants: maturational sequence and spatiotemporal analysis. clin neurophysiol, 73, 295-305. näätänen , r. & picton, t. (1987). the n1 wave of the human electric and magnetic responses to sound: a review and an analysis of the component structure. psychophysiology, 24(4), 375-425. ostroff, j.m., martin, b.a. & boothroyd, a. (1998). cortical evoked response to acoustic change within a syllable. ear hear, 19(4), 290-297. pang, e. & taylor, m. (2000). tracking the development of n1 from age 3 to adulthood: an examination of speech and non-speech stimuli. clin neurophysiol, 111, 388-397. pasman, j., rotteveel, j., massen, b. & visco, y. (1999). the maturation of auditory cortical evoked responses between (preterm) birth and 14 years of age. eur j paediatr neuro, 3, 79-82. picton, t., alain, c., otten, l., ritter, w. & achim, a. (2000). mismatch negativity: different water in the same river. audiol neurootol, 5, 111-139. ponton, c.w. & don, m. (2003). cortical auditory evoked potentials recorded from cochlear implant users: methods and applications. in h.e. cullington (ed.), cochlear implants: objective measures. london: whurr publishers. ponton, c.w., don, m., eggermont, j., waring, m. & masuda, a. (1996). maturation of human cortical auditory function: differences between normal-hearing children and children with cochlear implants. ear hear, 17(5), 430-437. ponton, c., eggermont, j., khosla, d., kwong, b. & don, m. (2002). maturation of human central auditory system activity: separating auditory evoked potentials by dipole source modeling. clin neurophysiol, 113, 407-420. ponton, c., eggermont, j., kwong, b. & don, m. (2000). maturation of human central auditory system activity: evidence from multi-channel evoked potentials. clin neurophysiol, 111, 220-236. purdy, s.c., kelly, a.s. & thorne, pr. (2001). auditory evoked potentials as measures of plasticity in humans. audiol neurootol, 6(4), 211-215. rance, g., cone-wesson, b., wunderlich, j. & dowell, r. (2002). speech perception and cortical event related potentials in children with auditory neuropathy. ear hear, 23, 239-253. sharma, a. & dorman, f. (2006). central auditory development in children with cochlear implants: clinical implications. adv otorhinolaryngol, 64, 66-88. sharma, a., dorman, f. & spahr, a. (2002a). a sensitive period for the development of the central auditory system in children with cochlear implants: implications for age of implantation. ear hear, 23, 532-539. sharma, a., dorman, f., & spahr, a. (2002b). rapid development of cortical auditory evoked potentials after early cochlear implantation. neuroreport, 13, 1365-1368. sharma, a., kraus, n., mcgee, t. & nicol, t. (1997). developmental changes in p1 and n1 central auditory responses elicited by consonant-vowel syllables. clin neurophysiol, 104(6), 540-545. taylor, m.j. & baldeweg, t. (2002). application of eeg, erp and intracranial recordings to the investigation of cognitive functions in children. developmental science, 5(3), 318-334. tremblay, k., friesen, l., martin, b. & wright, r. (2003). test-retest reliability of cortical evoked potentials using naturally produced speech sounds. ear hear, 24, 225-232. tremblay, k., piskosz, m & souza, p. (2003). effects of age-related hearing loss on the neural representation of speech cues. clin neurophysiol, 114, 1332-1343. watson, t. (1957). speech audiometry in children. in a. ewing (ed.), educational guidance and the deaf child. manchester: manchester university press. wunderlich, j.l. & cone-wesson, b.k. (2006). maturation of caep in infants and children: a review. hear res, 212(1-2), 212-223. wunderlich, j., cone-wesson, b. & shepherd, r. (2006). maturation of the cortical auditory evoked potential in infants and young children. hear res, 212, 185-202. yetkin, z., roland, p., christensen, w. & purdy, d. (2004). silent functional magnetic resonance imaging (fmri) of tonotopicity and stimulus intensity coding in human primary auditory cortex. the laryngoscope, 114, 512-518. im proving the r elevance o f speech-l anguage pathology and a udiology r esearch and practice 13 changeable. we have to understand what is going on in the whole system to understand the individual just as we need to inquire about the individual to learn about the whole. as we listen to the stories o f individuals and families in distress, we also need to “be-in-the-world” (heidegger’s concept o f “da sein”, 1996) which implies an openness and understanding o f possibilities within the world. this will enable us to pick up impressions and ideas and explore these with our clients and families in moving towards discovering ways to assist them not only to cope and survive, but live. speech-language patholo gists/audiologists need to be conscious enough o f their own assumptions to ensure that these do not become an imposition on others. only by realizing one’s own limitations and preju­ dices can one move forward in understanding and meaningfully assist those who live in society’s “black holes”. this idea is best expressed in the words of eudora welty, quoted by marga­ ret wheatly (1999, p. vi) “ my continuing passion is to part a curtain, that invisible shadow that falls between people, the veil o f indifference to each other’s presence, each other’s wonder, each other’s human plight”. response: claire penn a lant, e. (2005). intervention issues. in e. a lan t & l.l. l loyd (eds). a u g m en ­ tative and a lternative c om m unication and s evere d isabilities: beyond poverty. w h u rr p ublications: l ondon (pp. 9-29). b eukelm an, d. r. (1993). a a c research: a m ultidim ensional learning com ­ m unity. a u g m en ta tiv e a n d a ltern a tive c om m unication, p (l), 63-68. boyers, e., & r ice, r.e. (1990). the n e w a m erica n scholar. c arnegie f oun­ dation: pittsburgh. h eidegger, m. (1996). b eing and t im e (a tran slatio n o f sein und z eit). a l­ bany, state u n iv ersity o f n ew y ork press. schlosser, r. w ., & r aghavendra, p. (2004). e vidence-based practice in aug­ m entative and alternative com m unication. a u g m en ta tiv e & a ltern a tive c om m unication, 20(1), 1-21. u n ic e f (2006). the sta te o f the w orld's children 2007: w omen a n d children, the d o u b le d iv id e n d o f g e n d e r e q u a lity n e w y ork: u n ic e f. w heatley, m . j. (1999). l ea d ersh ip a n d the n ew science: d isc o verin g o rd e r in a chaotic w o rld (2nd ed.). san francisco: b errett-k oehler. school o f human and community development, university o f the witwatersrand, sa. “d o n ’tg iv e m e the theory, ju s t tell m e w hat to do in therapy!”: the slippery slope challenge f o r the south a frican professions o f speechlanguage pathology a n d a udiology the above frequent plea o f the clinician attending a refresher course has resonated in my ears over the years. in this paper i address the reasons and frustrations caused by this enjoinder and in responding to the lead article, will reconsider priorities o f our discipline and its implications for selection, training, funding and practice. i will argue that the discipline in this country is at an important crossroads and that future flourishing will depend on a proactive and firmly grounded commitment to scientific research. ; regardless o f context, the twin disciplines o f speech language pathology and audiology have always fought for sci­ entific identity. the reasons for this have been multiple. the fact that their subject matter j human communication is an interdisciplinary one has required a grounding in several main and historically secure fields: medicine, psychology, linguistics and physics to mention a few. thus methods used for research in our disciplines have often been those borrowed from such fields and include a range o f clinically based observations, ex­ perimental and descriptive designs. while there has been a his­ torical effort to establish a unique identity for the disciplines, as reflected in some interesting debates on this topic, we are not yet there (ringel, trachtman, & prutting, 1984; perkins, 1985; siegel, 1987; siegel & ingham, 1987). the discipline in this country is 70 years old and this makes it a mere teenager in relation to some o f its parents and like a teenager, possibly still uncertain o f its identity and auton­ omy and o f which route to take towards this. if one looks at the history o f our discipline, both here and elsewhere, we have fol­ lowed and not taken the lead. thus there has been a tendency to follow the current zeitgeist o f medicine, psychology, and lin­ guistics when searching for methods and explanatory frame­ works. we take others’ methods and theories and adapt them. in order to play the grant game and the publications game in research, this adherence to mainstream enables funding, ac­ knowledgement, promotion and recognition. when you live at the cusp o f another discipline you w on’t be noticed until you play that game and speak their language. an example is offered from the field o f aphasia, my own specialization, which can be characterized as having a number o f distinct phases. starting in the field o f neurology with a strong tradition o f case studies one can trace the influ­ ences of psychology, the preference for large scale group stud­ ies and the influences o f early linguistic theory and the behav­ ioural approach to communication o f the 1960s. pragmatics dominated the 1980s leading to current social approaches and we now see a return to the neural model with the advent of advanced functional neuroimaging. the influence o f the who framework has been pervasive and is also mentioned in the lead article (see penn, 2004a and penn, 2005 for further consid­ eration o f these issues). any scholar o f aphasia who is caught unawares and proposes a non-mainstream idea during a particular era has a challenging time getting an audience or arguing their case. non mainstream ideas are tolerated or perhaps used as a platform for dialogue and debate. those who work and think outside the box certainly add texture and depth to the discipline and serve (if a political analogy is allowed) as a type o f opposition party in order to refresh and remind those who are heading towards a dictatorship. often such streams o f thought are published in different journals and at best attend parallel sessions at the same conferences. but such argument and debate we are told is essential for paradigm change and no discipline can thrive or grow without such mechanisms (kuhn, 1970). the search for a scientific and research identity and autonomy in our disciplines has been difficult, and remains in my opinion, elusive. the first reason may be because o f the profoundly complex domain o f study. human behaviour is unpredictable and is influenced each day by a myriad o f fac­ tors, as the lead article makes explicit. the influence o f gender, race, poverty and socio political history have profound effects the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 14 h. k athard, e. n aude, m. pillay and e. ross on human behaviour. to exclude these from research, to at­ tempt to control for these variables or worse, to ignore them in explanations for what we find, leads to superficial and hege­ monic conclusions. secondly this makes the really important questions in our field (such as ‘does therapy work?’) almost impossible to answer to the satisfaction of the scientific com­ munity. take for example the heated debate around the (now) infamous lancet study (lincoln, mulley, jones, mcguirk, len drem, & mitchell, 1984) which showed that therapy for aphasic patients in a certain setting did not work or at least did not work any better than no therapy. this controversial and (as it turns out) scientifically flawed study retrospectively had a major in­ fluence on the field. it caused sufficient levels o f outrage and indignation among researchers and practitioners alike to gener­ ate a flurry o f counter arguments and a body o f well designed and reassuring studies on the efficacy o f aphasia therapy (wertz et al., 1986; wertz, 1987). thankfully, some people were read­ ing the literature and justice was served. however the random­ ized controlled trial remains the gold standard for therapy effi­ cacy in aphasia and hence most articles will be excluded from international data bases such as the cochrane collaboration (clarke & horton, 2001). as the lead article correctly suggests, the emphasis on evidence based practice (ebp) may have ig­ nored some highly relevant material. further as the lancet and other studies have shown, there has often been an insecurity in our disciplines which has come with the fact that we are a newer discipline and that we started o ff (and remain in some contexts) an “allied” discipline. leary (1997) for example in relation to cerebral palsy describes the role of therapists in neurorehabilitation as “motivators, fa­ cilitators and informal counsellors”, further suggesting that “it is the therapist’s personality and approach to her patients rather than what she does which is to their advantage”. dim praise indeed, perpetuating an image o f dependence, disempowerment and gender stereotype in the professions. but it is also possible that we have earned our own reputation and now we reap the fruits o f our labour (or lack thereof). unfortunately this appears particularly true for the discipline in our country. several rea­ sons suggest themselves. firstly there has been a reluctance to publish systemati­ cally. there are very few research-active individuals in the country with a sustained record o f excellence. there are not enough postgraduate students in the field. this has been exacer­ bated by the introduction o f community service and the depart­ ment o f health’s insistence that clinicians may not register for a higher degree while fulfilling their community service (despite the profoundly valuable material they are working with). out­ side the academic context, persons with higher degrees are not adequately recognized or remunerated. there is a considerable drop in the number o f papers submitted to and published in this journal. there is not enough diversity in the papers submitted and it is not clear what the standard of evaluation have been applied. this trend is not unique to our context. there is a chronic shortage o f doctoral students in the discipline in the united states (gallagher, 2006). people would rather subscribe to clinical journals than to the journal o f speech and hearing research. back home there are no research posts and little research funding available for our profession. university staffs, even those with particular research competence and leadership are obliged to focus on the clinical skills o f their students. re­ searchers are leaving the field and joining other disciplines. it would be tempting to blame this state o f affairs on what galla­ gher (2006, p. 34) refers to as “the prevailing academic culture die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 in the discipline that emphasizes clinical activities, clinical in­ struction and clinical career models” but this is not the whole story. in the face of increasingly prescriptive curricula and training methods imposed by the professional bodies, some aspects o f the curriculum have to give. sadly some training departments are considering dropping the 4th year research re­ quirement in this country or limiting the project to a literature review or the development o f a research proposal rather than the implementation o f such a projectdespite a crying need and opportunity for relevant research especially. this is not unique. many training programmes in the united states have even dropped a research requirement at masters level. the hard earned reputation of our profession may be losing ground. second, the adoption o f methods from other disciplines appears to have been haphazard and often informed by neces­ sity rather than systematic choice. there is as we all know a difference between clinical significance and research signifi­ cance (goldstein, 1990) but unless we can articulate this differ­ ence convincingly, our research will not be published. the problems we research require the application o f novel research methodologies and it is probable that historical methods may have been too narrow. as we confront many of our current clinical challenges, methods and explanatory paradigms may extend beyond those disciplines which initially fed us and guided our direction. for example earle (2001) has argued very convincingly for the value o f teaching sociology to our disci­ plines as sociology is multi paradigmatic and inherently reflex­ ive and is thus most suited to social behaviour. as i have ar­ gued elsewhere, (penn, 2004b; penn, 2005) there is a rich heri­ tage o f methods from other fields which can and should be brought to bear on some o f the important issues especially in a culturally diverse context. however most courses in research methods do not teach these (or do not teach them properly). certainly the textbooks written for researchers in our field often specifically eschew or ignore these aspects. there may be a level o f insecurity for the researcher who seeks valid applicable methods in the field of anthropology or interactional sociolinguistics, for example. and venturing into this new uncharted domain requires caution. the choice o f method should be driven by the research question. no researcher or discipline should abandon quantita­ tive methods simply because they cannot understand them. i fear that the questioning o f mathematics as a potential entrance requirement at universities will have that impact, not just in our field but in other areas such as education. the consequence of this is that researchers will choose elementary qualitative meth­ ods simply because they cannot choose anything else ‘if you don’t (or can’t) teach statistics then they will not do statistics’. as i see research emanating from different sources in this coun­ try, i believe that i can already see a direct relationship between the type o f research conducted and the changes in admission criteria for the disciplines at training institutions. there is a trend called “qualitative” in our field \yhich does not really meet the rigorous requirements o f proper re­ search. it is really too easy to indicate that context is so impor­ tant and our measures so complex that we don’t need methods o f the past. but there are equally many misconceptions about qualitative research which are rife. as many authors have pointed out there are a range o f criteria for rigorous qualitative research (johnson & long, 2000; evans & pearson, 2001; sharts-hopko, 2002; simmons mackie & damico, 2003; walsh & downe, 2006). ethnography is not a “helicopter” visit (to use the words o f a respected mentor, peter cleaton-jones) but at least a sixmonth commitment to participant observation. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) im proving the r elevance o f speech-l anguage pathology and a udiology research and practice 15 properly conducted scientific qualitative research is time-consuming and profoundly challenging and as i can per­ sonally attest, publishing it in our field is even more difficult! the guidelines that exist for evaluating the quality o f qualita­ tive research should be heeded and applied particularly by editors and reviewers o f our journals if we are to make pro­ gress when judging the scientific merit of an article. the edi­ tors o f this journal have an important role to play in quality control as well as in empowering the researcher. and in ad­ vancing research effective science is when you use the right method for the right question. the most difficult scientific choice occurs at the beginning o f the project when you have to match the method to the question. acknowledgements o f the influence o f cultural and contextual indices such as family, gender, arte­ fact, history, geography, religion, education, myths and atti­ tudes does not imply that these factors cannot be studied meaningfully in a quantitative way. it depends on the research question. i believe it is quite possible for a research question to have equipoise in terms o f the method o f choice. in other words it may well be answered in a number of different ways. if i ask whether a particular voice technique works for patients with parkinson disease, i have a choice of design: i could adopt a group approach and do it in a time series way (following a psychology tradition); i could use a control group who does not have the intervention (see sapir, spielman, ramig, story, & fox, 2007 for an example o f this); i could measure outcomes on a spectrograph (drawing on technology and theory from linguistics); i could measure out­ comes via open ended questionnaire and satisfaction scales (drawing on psychology and quality of life research); i could observe the use of voice in a number o f contexts (using meth­ ods o f description and observation); i could ask caregivers and family members o f the participants about the social impact of the voice, or i could use any o f the above in combination. all o f these would be acceptable methods provided there is a reason, and that reason may depend on the phase of the investigation, the scope o f the study, the time frame and its clinical imperatives. what seems to matter is that i am aware that there are such options in research design and that there is scientific rigour as 1 move along. to ignore alternative de­ signs, because of a limitation o f knowledge is to deny the roots and the essence of our discipline. i believe it is not only acceptable, but a sign o f academic maturity to adopt and com­ bine methods and theory from some of our disciplinary part­ ners. but when this is done, it must be done properly. it seems a pity that the iwriters of the lead article do not explore more carefully the publications that have been pro­ duced in their own journal and other journals in the field, nor the issues which have been researched in this country. i think they would find some pioneering and honest attempts to re­ solve the challenges they have posed and to embrace and merge different paradigms. some common approaches to research deserve some attention. therapy effectiveness studies have a long tradition and often take the format o f single case studies (see herson & barlow, 1984). such studies are ideally suited for our field, because o f the diversity o f our clinic populations, the huge difficulty in finding sufficient participants for a group study and because of the compelling nature o f therapy effectiveness. but there is often confusion between scientific single case studies and clinical case studies and as finn, bothe and bram-| 5 lett (2005) have pointed out, the field abounds with single case reports which are no more than a case description and which do not incorporate the essential elements of control which are the hallmarks of a true single case study including the multiple baseline measurement, randomization as well as clarity , reliability and validity o f measure. another example comes from the measurement o f the impact of training programmes (understandably a common interest in this context). a mistake is made to assume that a training programme is effective merely because there is a change in the participants’ knowledge after that training pro­ gramme. for example if there is a training programme to teach nurses about dysphagia and they show improved scores on a dysphagia quiz after that training, it proves nothing about the effectiveness o f the training programme, only about the nurses’ memory. yet this is a standard design which i have seen pub­ lished and would be classified as a weak or “pseudo” design (finn et al., 2005). to turn this into a proper research study would involve comparing this programme with another, and measuring the impact on the quality of nursing care measured, either in terms o f quantitative outcome (such as patient weight, or length o f stay in hospital) or qualitative measures (such as patient satisfaction). the retention of such practice is also an important variable to measure. survey research is another method frequently used in our field. knowledge, attitude and practice (kap) research is frequently done, and its methods familiar and comforting but its relevance has to be questioned in some cases (cleland, 1973). there seems to be little scientific merit in showing what we already know and what is instantly obvious. what do gps know about language impairment? what do nurses know about dysphagia? (e.g. pelletier, 2004) what services are lacking in rural areas? do new graduates feel confident with hearing aid fittings? unless you are the health minister (or perhaps in our current case, because you are the health minister) there is not much use exploring the attitudes o f health professionals to­ wards post shortages. even armed with that outcome, there is little that can be done with that research to change practice or policy. we could generate a number o f research questions which could be asked. but are all worth asking? feasibility and relevance are different things and should not be confused. this links closely the central theme o f relevance dis­ cussed in the lead article. i agree that there is an urgency of service delivery in south africa i am the first to agree we can­ not ignore the political agenda o f our context. indeed statutory bodies and universities pick up such challenges and define and fund specific research thrusts. but these may not overlap with the ethical imperatives o f our profession and some communi­ ties may hence be severely marginalized. one has to think for example o f the impact o f the aids epidemic on research fund­ ing opportunities outside that broad field in this country and the huge grant money in the us currently diverted to the field o f cognitive neuroscience. research goes where the money is and when last i checked, very little was flowing into research for the cerebral palsied in rural populations in this country de­ spite a desperate need for understanding barriers to care (barratt, 2007). sadly many practicing clinicians fail to see the rele­ vance o f research at all. this brings me back to the haunting recurrent words o f the title of this article. without the disci­ pline o f science, we will simply remain a group o f ‘practicing’ clinicians and we will never achieve mastery or acknowledge­ ment. we can ‘practice’ doing science but what is needed is for science to be done with authority, with an audience, with peer review, with argumentation and with energy. conclusions this much i know. unless our disciplines in this country strive the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 16 h. k athard, e. n aude, m. pillay and e. ross for, sustain and improve their research agenda and profile, we are vulnerable in the extreme. we will be absorbed first into multidisciplinary schools and into multidisciplinary service cohorts and then eventually into technikons. our functions will be (if they are not already) subsumed by ents, secretaries and assistants. the signs are there for all to see. we are expensive; we are probably too few in number to be heard. we have a limited proven effectiveness (reilly, douglas, & oates, 2004) and the leaders o f our professional body appear to have com­ pletely different agendas from those o f research excellence and scientific autonomy. i end with some questions and challenges to the profession, the universities and the journal: • why is there such a shortage o f postgraduate students? • why can’t people do research without research funding? • what steps have our national professional bodies taken to encourage, endorse and fund research? • why do people think that research is only for those who are not clinically inclined? • what will happen when this ageing cohort o f researchers in this country (amongst whom i proudly place myself) stops doing it? • what will happen if the international profile and contribu­ tion that we have earned is eroded as we cease to publish in international journals and as our own journal readership dwindles? as the lead article suggests, south africa is a unique testing ground and clinician-researchers here have a huge potential to inform world practice and theory around issues o f diversity, multilingualism and the unique disease profile. based on our caseloads, our training, our daily interface and the splendid goals o f our country’s constitution, we could be world leaders in critical speech-language pathology and audiology (penn, 2000). why is this not happening? while heavy caseloads are frequently cited as a reason why clinicians cannot engage in research, conversely that very fact should make the research process more compelling, accessible and easier. it is up to us to recognize and act on these opportunities and to publish them where they will make a difference. perkins (1985, p. 13) said that “our field is haunted by a fallacy. we are predominantly a profession o f practicing cli­ nicians. that was not our origin. beginning as scientists in search o f understanding the nature o f disordered speech were hardly out o f our infancy before our scientific pursuits were outdistanced by the pressing need to help the millions who were speech and hearing handicapped”. our identity is still a problem in this country. review committees don’t know where to place us. university restruc­ turing committees and faculty members are puzzled by our multidisciplinary curricula. barring this journal we don’t know where to publish our articles. there will be no progress in our identity for our professions until we have proven their scien­ tific status. i f we don’t know what we are, we can hardly ex­ pect others to know. being teenaged is not all bad but there is a critical time for introspection. our identity has to have scien­ tific credibility and should be respected so members o f the profession can compete with others at scientific fora and for research money. there is a place for hard science. there is a place for other methods, but until it is done properly in either domain we will not get the recognition we need. the universities have a critical role to ensure research productivity in staff and to develop post graduate numbers. we need curriculum changes, additional funding and support for postgraduate study, representation on national research bodies and importantly, an attitude o f curiosity. above all there should be an appeal to explanatory theory, if necessary drawn from more mature, well grounded and respected scientific disci­ plines. this journal has a critical role to play in encouraging and developing research which meets international standards. this research can (and should) be original and proactive and inform world practice about relevant issues o f culture. the journal has a critical role to play in the profession in south af­ rica and in reminding its members about our origins. it has the responsibility not only o f calling for papers but o f setting the scientific tone o f the profession, by advocating and endorsing the full range o f scientific methods, for applying international standards o f excellence in review o f different methods and out­ come research (robey & schultz, 1998; finn et al., 2005) and for asking for help when it is needed. our accountability to our clients and to our own profes­ sion’s continued existence lies not solely in our clinical skills and our ability to convince the likes o f leary that we have nice personalities. i believe that some current developments in the south african profession are setting us back and i offer a chal­ lenge to the profession and its members and particularly to the journal to address and rectify those problems. autonomy is the ability to thrive and “the capacity to think, decide and act on the basis o f such thought and decision freely and independ­ ently” from the controlling interferences both by others and from personal limitations that prevent meaningful choice (after gillon, 1985, p. 60). the autonomy o f our profession lies pri­ marily in demonstrating its scientific basis. it also involves establishing a strong relationship with its partners. to ignore this is to continue a slow descent into obscurity. in conclusion i commend the authors o f the lead article in posing a challenge. it is timely and should be heeded. i con­ cur that it is time to tackle the challenges o f context and to adopt frameworks o f investigation and explanation which may be alternative to the mainstream positivistic ones. i do however recommend that this shift is done with caution and is grounded properly in the traditions o f the disciplines framing such a shift. we cannot afford to be lukewarm about scientific endeavour. the requirement o f scientific rigour transcends any one particular approach and remains the only way in which, our own disciplines can flourish through meaningful interface with other professions, with the international community and with the communities we serve. i acknowledgements many o f my ideas have emerged and slowly developed from an exciting opportunity i had to engage in a series o f interactions on the topic “is speech pathology a science?” with gerald siegel, carol prutting and gene brutten. their insights and ideas have profoundly affected our profession and my own career path and they taught and inspired research by-example. i am grateful to jennifer watermeyer for her research assistance and to peter fridjhon for his critical and helpful ear as well as many hours o f shared enthusiasm on this topic. profound thanks to friend and colleague dilys jones who always acts as a sounding board for me and whom i con­ sider to be a true example o f the perfect clinician-researcher. d ie suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) im proving the r elevance o f s peech-l anguage p athology and a udiology r esearch and practice 17 b arratt, j. (2007). the experiences o f ca rin g f o r a c h ild w ith cereb ra l p a lsy in tonga, m pum alanga. u npublished m asters d issertation, u niversity o f the w itw atersrand. c larke, m ., & h orton, r. (2001). b ringing it all together: l ancet-c ochrane collaborate on system atic review s. the l a n cet, 357, 1728. c leland, j. (1973). a critique o f k a p studies and som e suggestions for their im provem ent. studies in f a m ily pla n n in g , 4, 42-47. earle, s. (2001). t eaching s ociology w ith in the speech and l anguage t h er­ apy c urriculum . e d u ca tio n f o r h ealth, 14, 3 8 3 -3 9 1 . e vans, d., & p earson, a. (2001). s ystem atic review s o f q u alitative research. c linical e ffectiven ess in n ursing, 5, 111-119. finn, p., b othe, a ., & b ram lett, r. (2005). science and pseudoscience in c om m unication d isorders: c riteria and a pplications. a m erica n jo u rn a l o f speech-l anguage pathology, 14, 172-186. g allagher, t. 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(1997). interventions for children w ith neurodevelopm ental delay. south a frica n m ed ica l journal, 87, 1680-1683. l incoln, n ., m ulley, g., jones, a ., m cguirk, e., l endrem , w ., & m itchell, j. (1984). e ffectiveness o f speech th erap y for aphasic stroke patients: a random ised controlled trial. the lancet, 323, 1197-1200. p elletier, c . (2004). w hat do certified n u rse assistants actually k n o w about dy sphagia and feeding hom e residents? a m erica n jo u rn a l o f speech l a n g u a g e pathology, 13, 99-113. , penn, c.. (2000). c ultural narratives: b rid g in g the gap. south a frica n jo u rn a l o f c om m unication d isorders: s p ecia l edition on c om m unication d iso r­ d ers in m ultilingual populations, 47, 71-78. response: shajila singh university o f cape town, cape town, sa. penn, c. (2004a). c ontext, culture and conversation. in s. b yng and j. d uchan (eds.), c hallenging aphasia therapies: b roadening th e discourse and extending the boundaries (pp. 83-100). psychology press: london penn, c. (2004b). ‘f estin a len te’: a case for m aking haste slow ly in reflective practice. a response to f erguson and a rm strong. in tern a tio n a l j o u rn a l o f l a n g u a g e a n d c om m unication d isorders, 3 0 , 490-497. penn, c. (2005). w ho's tired o f the w h o ?: a co m m en tary on r oss and w ertz, "a dvancing appraisal: a p h asia and the w h o ." a phasiology, 19, 875-879. perkins, w. (1985). f ro m clinical d isp e n ser to clinical scientist. s em in a rs in s p eech a n d language, 6, 13-21. r eilly, s., d ouglas, j., & o ates, j. (2004). e vid en ce b a se d p ractice in speech p athology. london: w hurr. ringel, r., t rachtm an, l., & prutting, c. (1984). the science in h um an c o m m u ­ nication sciences. a sh a, d ecem ber, 33-37. r obey, r ., & schultz, m . (1998). a m odel for conducting clinical outcom e re­ search: a n adaptation o f the standard pro to co l for use in aphasiology. a p h a si­ ology, 12, 787-810. sapir, s., spielm an, j., r am ig, l., story, b., & fox, c. (2007). e ffects o f intensive voice treatm ent (the lee silverm an v oice t reatm en t [lsv t]) on vow el ar­ ticulation in d ysarthric individuals w ith idiopathic parkinson disease: a coustic and perceptual findings. jo u rn a l o f speech a n d h ea rin g research, 50, 89-912. sharts-h opko, n . (2002). a ssessing r igor in q ualitative r esearch. jo u rn a l o f the a sso c ia tio n o f n urses in a id s care, 13, 84-86. siegel, g. (1987). the lim its o f science in com m unication disorders. j o u rn a l o f speech a n d h e a rin g d isorders, 52, 306-312. siegel, g., & ingham , r. (1987). t heory and science in com m unication disorders. j o u rn a l o f s p eech a n d h ea rin g d isorders, 52, 99-104. s im m ons-m ackie, n ., & d am ico, j. (2003). c ontributions o f qualitative research to the know ledge base o f norm al com m unication. a m erica n jo u rn a l o f speech l a n g u a g e pathology, 12, 144-154. w alsh, d., & d ow ne, s. (2006). a p praising the q uality o f q u alitative research. m idw ifery, 22, 108-119. w ertz, r. (1987). l anguage treatm ent for aphasia is efficacious, bu t for w hom ? topics in l a n g u a g e d isorders, 8, 1-10. w ertz, r ., w eiss, d., a ten, j., b rookshire, r ., g arcia-b unuel, l., h olland, a ., et al. (1986). c o m p ariso n o f clinic, hom e, and deferred language treatm ent for aphasia: v eterans a dm inistration cooperative study. a rch ives o f n eurology, 43, 653-658. a p la ce f o r m ixed methodologies? response to: the relevance o f speech-language pathology and audiology research and practice challenges f o r the professions the authors are to be commended for raising pertinent issues relating to the ways in which the professions conduct research and the relevance for accountable practice, especially at this point in our professions’ and nation’s history. given our past and current realities the challenge is to advance research and professional practice responsibly and responsively. in the new spirit o f redressing previous inequities, and increasing the access o f the majority o f south africans to professional ser­ vices, there has arisen an urgent need for research that guides ethical service delivery in the context o f cultural and linguistic diversity, poverty, and the ravages o f pandemics such as tu­ berculosis and hiv/aids. posing solutions to the questions raised by the authors might sug­ gest that there are ready answers which is, manifestly not the case. hence this treatise considers some o f the issues relating to the production o f knowledge and the challenge of making it respon­ sive to professional practice. how do we produce knowledge? the ways in which knowledge is produced reflects particular worldviews which have changed over time. critics (such as habermas, 1972; and lincoln & guba, 1985) o f the modem posi­ tivist approach which espouses that the natural causal laws govthe south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) abstract introduction methodology results and discussion conclusion acknowledgements references about the author(s) katijah khoza-shangase department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation khoza-shangase, k. (2022). in pursuit of increasing the application of tele-audiology in south africa: covid-19 puts on the alert for patient site facilitator training. south african journal of communication disorders, 69(2), a900. https://doi.org/10.4102/sajcd.v69i2.900 original research in pursuit of increasing the application of tele-audiology in south africa: covid-19 puts on the alert for patient site facilitator training katijah khoza-shangase received: 26 jan. 2022; accepted: 08 apr. 2022; published: 20 july 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the coronavirus disease 2019 (covid-19) presented and highlighted new and unanticipated challenges to the provision of clinical services, raising an urgency for the application of different models of service delivery, including tele-audiology. in many tele-audiology encounters, a site facilitator is needed at the patient site to help with the hands-on aspects of procedures, and the implications of this requirement are significant for the resource-constrained african context. objectives: the aim of this scoping review was to investigate published evidence on training provided to patient site facilitators (psfs) for tele-audiology application to guide the south african audiology community in tele-audiology application initiatives. method: electronic bibliographic databases including science direct, pubmed, scopus medline and proquest were searched to identify peer-reviewed publications, published in english, between 2017 and 2021 related to training of psfs. the guidelines of the preferred reporting items for systematic reviews and meta-analysis (prisma) were followed during the screening process as well as for illustrating the process. results: findings are discussed under four key themes: (1) type of tele-audiology and the implications thereof, (2) length of training and its implications, (3) diversity in the range of psfs used and its implications for the training, and (4) heterogeneity in the training. conclusion: the findings highlight important considerations for tele-audiology application within the african context, specifically decision-making around who can serve in the role of psfs, as well as content and nature of training required, with implications for policy and regulations as well as human resource strategy. these findings are important for the covid-19 pandemic era and beyond. keywords: audiology; covid-19; human resources; patient site facilitators; south africa; tele-audiology; training. introduction the need for, and therefore access to, ear and hearing services is undisputed globally. the world health organisation (who, 2018) provides estimates of disabling hearing loss to be over 6.1% of the global population (466 million individuals), with statistics indicating that these numbers will rise over the years, with estimates of up to 630 million by 2030 and above 900 million in 2050. closer to home, the prevalence of hearing loss is documented to be higher in sub-saharan africa than in other regions of the world (mulwafu, kuper, & ensink, 2016; wonkam tingang et al., 2020), with south africa reported to have 4 million deaf and hard of hearing people (western cape government, 2020). evidence suggests that these numbers will rise over the coming decades with hearing loss linked to the burden of diseases most prevalent in this context such as tuberculosis (tb), human immunodeficiency virus (hiv) (christopher, edward & sabrina, & agnes, 2013; khoza-shangase, 2010, 2017, 2020; tshifularo, govender, & monama, 2013) and presbycusis influencing the prevalence. farmer et al. (2010) also predict that 70% of cancers will occur in low-and-middle-income countries (lmics) by 2030, including cancers of the ear, nose and throat, where ototoxicity linked to chemotherapeutic agents become a concern. all these factors, including the possible and documented impact of the coronavirus disease 2019 (covid-19), long covid and its treatments on cochleovestibular function in adults (fancello et al., 2021; jacob, flannery, & mostert, 2020; koumpa, forde, & manjaly, 2020; munro, uus, almufarrij, chaudhuri, & yioe, 2020), highlight a strong need for careful planning around innovative models of ear and hearing healthcare service provision in sub-saharan africa. this is also applicable to other similar lmic contexts, where capacity versus demand challenges as far as availability of audiologists is concerned and is an additional stress to ear and hearing care (khoza-shangase, 2021; pillay, tiwari, kathard, & chikte, 2020). the speech-language and hearing professions board of the health professions council of south africa (hpcsa) strongly advocates for best-practice guided assessment and intervention services, within service delivery models that are contextually, linguistically and culturally congruent with the south african context and population (khoza-shangase, 2020a). this best practice includes the use of telehealth and mobile practice in rendering clinical services. literature on tele-audiology in south africa has focused primarily on reaching many people who live in underserved areas (dawood, mahomed asmail, louw, & swanepoel, 2020; sandström, swanepoel, laurent, umefjord, & lundberg, 2020; van wyk, mahomed-asmail, & swanepoel, 2019). given that south african audiological practice is still based on euro-western epistemology and ideology (khoza-shangase & mophosho, 2018, 2021), there is a need for careful considerations and deliberations around the delivery of audiological services through telehealth systems, including the use of and the role of patient site facilitators (psfs), who are linguistically and culturally diverse and have been appropriately trained for the context, with this approach potentially enhancing contextual relevance of the services provided. the well-documented challenges relating to the availability of audiologists for the size of the population requiring ear and hearing care (capacity versus demand), as well as the advent of covid-19 and its direct patient interaction challenges, over and above the vestibulocochlear signs and symptoms linked to it (khoza-shangase, in press), call for a serious re-imagining of the human resource strategy as well as the service delivery model for ear and hearing care within the south african context (khoza-shangase & masondo, 2021; muñoz, nagaraj, & nichols, 2020; saunders & roughley, 2021; sebothoma, khoza-shangase, masege, & mol, 2021). key to this re-imagining exercise is a paradigm shift that embraces the application of innovative service delivery models with the inclusion of paraprofessionals (khoza-shangase, 2021). the practical use of existing and emerging technologies for provision of clinical services as part of tele-practice has been documented to (1) increase and expand access to specialised expertise that is otherwise not readily available, (2) enrich clinicians’ efficiency and output and (3) increase access to quality services whilst maintaining costs (khoza-shangase & sebothoma, 2022). furthermore, telepractice in the form of tele-audiology within the south african context opens job opportunities where paraprofessionals are utilised in task-shifting roles where they serve as psfs. within audiology, tele-audiology can create such job opportunities where people with no background in audiology such as family members, community members and others can have an opportunity to receive training on new skills as psfs and be employed in ear and hearing care programmes that are instituted remotely. however, successful, ethical and clinical service and patient-safe tele-audiology service provision requires effective and efficient training and management of psfs. although telepractice has been around for over two decades (kim et al., 2020), its application has gained much popularity during the covid-19 pandemic (sebothoma et al., 2021). due to the virus’s highly infectious nature, non-pharmaceutical measures to prevent its spread had to be implemented, and these significantly affected person-to-person contact for clinical care provision (khoza-shangase, moroe, & neille, 2021). national lockdowns with accompanying travel restrictions, regulations around social distancing, isolation and quarantining, hand washing and sanitisation, as well as community containment remain the only measures available (because efficacy of vaccines and vaccine access and hesitancy remain a challenge), and these have a measurable effect on clinical service provision (department of co-operative governance and traditional affairs, 2020; khoza-shangase et al., 2021; perez et al., 2020). kim et al. (2020) argue that these measures influenced the increased need for telepractice services, with tele-audiology falling within these services (a). tele-audiology allows audiologists to have access to patients in remote areas, over considerable distances, without compromising the validity and reliability of the service being provided, whilst affording patients easier access to an even wider range of ear and hearing healthcare services (kim, jeon, kim, & shin, 2021; ratanjee-vanmali, swanepoel, & laplante-levesque, 2019). in low-and-middle-income countries (lmics) such as south africa, provision of ear and hearing care services is confronted by numerous challenges, with capacity versus demand challenges being one key difficulty. tele-audiology is therefore an opportunity requiring much more thoughtful and deliberative consideration (khoza-shangase et al., 2021), with covid-19 having made this need starkly obvious (swanepoel & hall, 2020). its application within these contexts remains at its infancy, with limited evidence in the use of psfs as part of the service delivery model. although tele-audiology offers numerous well-documented benefits, there are also a few challenges that might be encountered in its application, particularly in the african context. these challenges became pronounced during the covid-19 pandemic as large-scale application had to be applied. besides lack of sufficient knowledge and skills in tele-practice by audiologists (ravi, gunjawate, yerraguntla, & driscoll, 2018; sebothoma & khoza-shangase, 2021), access to the required infrastructure and technology by both patients and clinicians as well as software information and technical limitations (molini-avejonas, rondon-melo, de la higuera amato, & samelli, 2015; ravi et al., 2018; sebothoma et al., 2021), good internet connectivity (wolfgang, 2019), reimbursement and licensure barriers (ravi et al., 2018) and lack of reliable electricity supply within the south african context are some of the challenges encountered. for the focus of the current paper, access to psfs who are skilled and able to facilitate the provision of a tele-audiology service can be a significant barrier, which became highlighted by the covid-19 pandemic within the south african audiology clinical context, with this role mostly being filled by audiologists and/or audiology students (sebothoma et al., 2021). most tele-audiology services require the presence of a psf at the patient site to assist with technical support and the hands-on aspects of the tele-audiology session, such as patient positioning and orientation to the equipment for the duration of the appointment, as well as assisting with instructions and general communication with the patient where necessary (coco, davidson, & marrone, 2020; krumm, 2016; wolfgang, 2019). coco et al. (2020) also refer to psfs as patient-site presenters, telepresenters, assistants and e-helpers, and they maintain that even in the presence of advanced technology, psfs are still very helpful in ensuring provision of the best services and in increasing the efficiency of tele-audiology. furthermore, lancaster, krumm, ribera and klich (2008) argue that properly trained psfs are probably the most critical component of telehealth applications, and yet no internationally documented or available standard of training exists. although it is clear that psfs are key characters in successful application of tele-audiology within the south african context, no standard nor regulated training programme exists for these cadres, nor do minimum standards exist for who can get trained and what constitutes the training, unless this becomes part of the job description of the newly formalised hpcsa audiology assistants’ minimum standards and regulations (hpcsa, n.d.). these, however, are yet to be implemented (moroe, personal communication, hpcsa professional board). south african studies on the application of tele-audiology reveal diverse practices, including varied individualised training, use of either nurses or audiology students and use of psfs for varied functions, depending on what the study was investigating (mahomed-asmail, swanepoel, & eikelboom, 2016; sebothoma et al., 2021; yousuf hussein, swanepoel, mahomed, & biagio de jager, 2018). this is in line with the findings by coco et al. (2020) where psfs were found to come from various backgrounds and perform a variety of duties. with the range of potential and recorded duties of psfs as well as the diversity of individuals who can perform these duties, the training of these individuals becomes paramount for successful, safe and ethical tele-audiology practice, hence the purpose of this scoping review aimed at documenting published evidence on the training provided to psfs for tele-audiology application, in order to guide the south african audiology community in tele-audiology application initiatives. methodology aim the aim of this scoping review was to document published evidence on the training provided to psfs for tele-audiology application. review approach based on a definition of a scoping review by munn et al. (2018), this review, first of its kind looking at this specific question, used the arksey and o’malley’s (2005) framework for conducting a scoping review and adhered to the following stages of conducting a review: (1) specifying the research question, (2) identifying the relevant literature, (3) selecting studies to be included in the review, (4) mapping out the data, as well as (5) summarising, synthesising and reporting the results. the guidelines of the preferred reporting items for systematic reviews and meta-analysis (prisma) were followed during the screening process as well as for illustrating the process. stage 1: identification of the research question the population (psfs), concept (training of psfs) and context (in tele-audiology) population (or participants), concept, context (pcc) framework by the joanna briggs institute was used to formulate the research question. for the current review, the following question was formulated: ‘what training is provided to psfs for tele-audiology application?’. stage 2: data sources and search strategy the literature search was conducted in december 2021 on databases including proquest, pubmed, scopus, science direct and medline. to identify papers relevant for this review, the following terms and combination of keywords were used: tele-audiology training, as well as training of psfs and tele-audiology, telehealth, tele-audiology, psfs, tele-audiology and facilitators, psfs and training. other websites such as south african speech language and hearing association (saslha) and the hpcsa website were searched to identify any grey literature, as well as the reference lists of the screened papers. ghalibaf (2017) says that using a combination of keywords increases the likelihood that the search yields specific and relevant papers and eliminates the irrelevant studies. inclusion criteria to yield contemporary evidence, the search was restricted to recent studies published in english not more than 5 years ago (between the year 2017 and 2021). to form part of the review, the studies had to be peer-reviewed, based on tele-audiology, include the use of psfs and describe the training of the psfs. exclusion criteria studies were not eligible for inclusion if they were published more than 5 years ago, as the study was deliberately investigating recent contemporary evidence, and if they were not published in english. it was very important to include studies in the past 5 years to accommodate the possible impact of both recent technological advances in audiology as well as covid-19. studies were excluded if they did not address the research question and if they did not include the combination of the search keywords. studies that spoke about psfs but were not in a tele-audiology setting were also excluded. stage 3: study selection in total, the database search from all databases identified 85 articles. all identified database citations were exported to endnote, a web-based bibliography manager. through endnote, duplicate studies were identified and removed. after the duplicates were removed, 63 studies remained, and of these, 22 were excluded at title screening. following this step, 41 abstracts were screened guided by the search question. of these, 22 studies were excluded due to not being related to tele-audiology. nineteen studies were then assessed for eligibility; of these, six were excluded because they did not include psf training. consequently, a full-text screening resulted in 13 studies meeting the inclusion criteria and being included in this scoping review. figure 1 shows a prisma flowchart for the literature search, retrieval and inclusion process of this scoping review. figure 1: prisma 2020 flow diagram for the current scoping review which included searches of databases and other sources. stage 4: data extraction and charting after the reference search, a total of 13 studies were included in this review, and these are depicted in table 1. the table included the following details about the included articles, with detailed analysis and discussion of the contents of the table presented next: researcher/s and the year of publication title of the study country of publication type of tele-audiology patient site facilitator psf duties psf trainer duration of facilitator training content of the training table 1: summary of studies included in the scoping review documenting the training of patient site facilitators. table 1 (continued...): summary of studies included in the scoping review documenting the training of patient site facilitators. stage 5: collating, summarising, and reporting results as suggested by levac, colquhoun and o’brien (2010), this stage was separated into three phases, namely, the analysis, reporting overall results and the implications phase. thematic analysis was adopted when analysing the evidence and findings reported in accordance with the stated aim of the study. lastly, the implications of current findings are raised for training of psfs for the south african context’s tele-audiology application initiatives. ethical considerations in this scoping review, ethical standards were adhered to and there were no risks as there were no human participants involved. common forms of search biases, such as database bias, country bias, availability bias, familiarity bias and multiple publication bias, as advocated by suri (2020), were considered. results and discussion analysis of results raises four key themes, and these will be presented within a narrative discussion below: (1) type of tele-audiology and the implications thereof, (2) length of training and its implications, (3) diversity in the range of psfs used and its implications for the training and 4) heterogeneity in the training. type of tele-audiology and the implications thereof as depicted in table 1, firstly, the 13 studies included in the current review revealed a significant preference for synchronous or live face-to-face tele-audiology, with three papers reporting on the application of the asynchronous model (erkkola-anttinen et al., 2019; govender & mars, 2018; ravi et al., 2020). this is a challenge as this model truly and mainly addresses the geographic challenge as a driving force for tele-audiology application and not necessarily the workforce challenge, which south africa also confronts. the fact that the audiologist needs to be physically there in real time via video connection between them and the patient, with the psf being required for ‘hands-on’ tasks, limits the possibilities of access because the audiologist needs to be present and running the consultation (bennett, swanepoel, manchaiah, & eikelboom, 2020). in lmics, there must be serious considerations of asynchronous tele-audiology applications as well. the fact that most of the evidence on the training of psfs is based on the synchronous model of application should therefore be held in cognisance, and planning should consider the asynchronous model for the african context. with the asynchronous (store-and-forward) tele-audiology model, the audiologist does not need to be present for the consultation, but the patient and/or psf does. in the south african context, the current author recommends that the audiology technician ‘runs’ the programme to obtain results that then get stored and forwarded to the audiologist for interpretation, synthesis, and clinical decision making (bennett et al., 2020). consequently, training of psfs (or in the south african context, possibly audiology technicians) would need to be more intensive for the asynchronous tele-audiology model and the list of duties more comprehensive, and in both models, duties would need to be very well defined. in the south african context, audiology technicians are mid-level workers for whom the south african national department of health has been liaising with the hpcsa about developing minimum standards and regulations, in order to increase access to ear and hearing care services in south africa. although these cadres are not in existence yet, an hpcsa (n.d.) guideline for planning sta (speech therapy and audiology) services at all levels of health care in south africa clearly specifies what the anticipated scope of practice will be for the audiology technicians. with ehdi standing for early hearing detection and intervention, chw for community healthcare worker and crw for community rehabilitation worker, this guideline specifies the following in relation to audiology technicians (hpcsa, n.d., p. 4): conduct promotion and prevention activities (e.g. hearing conservation programme, ear care) screen (ehdi, ototoxicity, middle ear status) and identify clients at risk and with established risk for hearing and balance difficulties using basic screening audiology equipment otoscopic examination immittance measures pure tone (air conduction) otoacoustic emissions automated auditory brainstem response cerumen management implement intervention plan and monitor progress of patients with hearing difficulties facilitate support services (e.g. caregiver support groups) follow-up care post hearing aid fittings assist clients with (re-)integration (optimal participation and activity) into the community and return to work or school liaise with: all community structures and organizations including other primary health care service providers (e.g. chw, crw) other institutions the author argues that, as the curriculum and registration of these cadres (audiology technicians) will be regulated by the hpcsa, and because they are to be supervised by audiologists during their practice, tele-audiology psf activities can arguably be efficiently inserted into the audiology technician’s training and scope of practice. however, until this recommendation is in place, and perhaps, separately to this suggestion, careful planning by the south african audiology community is required around the competency and use of psfs during tele-audiology to make sure that patients remain protected whilst best practice is applied. this is particularly important as current findings seem to indicate heterogeneity in the training. coco and marrone (2020, p. 1) highlight four key considerations that audiologists planning on engaging in tele-audiology should keep in mind, and the current author suggests that these be the same areas under careful cognisance for psfs: (1) ‘laws, regulations, and payment and coverage issues; (2) which services to provide; (3) hardware, software, and environmental considerations; and (4) patient safety and privacy’. these considerations should form part of the planning for psfs, their training, as well as regulations surrounding their employment. length of training and its implications the earlier presented finding on significant preference for synchronous tele-audiology in the studies reviewed is consistent with the second finding from this scoping review, that of a short period of training documented for psfs. fundings indicate training that ranges from 1 h (erkkola-anttinen et al., 2019) to a maximum of 5 days (eksteen et al., 2019; ramkumar et al., 2018), again revealing the diversity in the character of the training practices. because in synchronous tele-audiology, the audiologist is present via video connection, ongoing in-service training can occur and close monitoring of the psf is possible. the current author, however, believes that the time frame for the training as reflected in the current review does not allow for extensive and comprehensive training, and limits both the breadth and depth of content covered, even for a paraprofessional, which the psf can be argued to be. these recorded time frames might have been appropriate in the studies reviewed because the psfs had very specific tasks assigned to them, and so restricted training based on the assigned tasks was therefore appropriate. this finding has implications for content and practical training for psfs if asynchronous tele-audiology will also be included, as might be the case if audiology technicians are utilised and within hybrid models in the south african context. diversity in the range of psfs used and its implications for the training the third finding from this scoping review reveals the diversity in the range of psfs used, as they have a variety of backgrounds; it also has significant implications for the nature and type of training provided. in the current review, village and community health workers were the most common individuals who served as psfs (coco et al., 2021; eksteen et al., 2019; ramkumar et al., 2018; ravi et al., 2020). this has been documented in south africa, for example, in a study by yousuf hussein et al. (2018) on community-based hearing screening for young children using an mhealth service delivery model, where community health workers served as psfs. in the current review, generally, healthcare facilitators (lundberg et al., 2017), teachers (monica et al., 2017), community members (govender & mars, 2018), audiologists or speech pathologists students and professionals (hughes et al., 2018; venail et al., 2018), audiometric technicians (hatton et al., 2019), nurses (coco et al., 2020) and parents (erkkola-anttinen et al., 2019) were used as psfs, with the roles played and intensity of training appearing consistent with the documented psfs. bennett et al. (2020, p. 12) suggest use of patients themselves as psfs and describe this as ‘self-management: where the client is actively involved in tasks that immediately or consequently affect their health’, with thai-van et al. (2021) putting this to clinical practice. the current author believes that the use of audiologists or speech pathologists as well as students in these professions as psfs is not cost-effective nor sensible in the long run as it fails to achieve the goal of increasing access. audiologists and audiology students should be the ones managing the tele-audiology programmes and supervising psfs, particularly within the south african context where capacity versus demand challenges have been well documented (khoza-shangase & sebothoma, 2022; pillay et al., 2020). therefore, the decision of who can serve as psfs is an important one that should carefully consider contextual realities. generally, the scoping review results reveal that there is a heterogeneity, lack of regularisation, standardisation and structure in the training programmes adopted. this lack of uniformity in the training can negatively impact best practice and compromise patient care during tele-audiology applications. tao et al. (2018) caution about the negative impact of inconsistent and non-standard or lacking training of psfs. only one of the reviewed studies detailed a training programme with structured content (coco et al., 2021). coco et al.’s (2021) study described their training as comprising three levels: (1) introductory level where topics on basic information about causes and effects of hearing loss were covered, as well as basic tele-audiology and its benefits, (2) intermediate level where the focus was on technology, roles of the tele-audiology service delivery team, as well as on tele-audiology technology and patient safety and confidentiality and (3) facilitator level where knowledge and hands-on skills required to serve as psfs were the focus. this is also the only study from the review that reported that the psfs training also included them attending a 4-h in-person observation at a university-based adult audiology clinic with details of the components of audiology observed at the clinic provided. heterogeneity in the training the content of the training documented in the reviewed studies, which was mainly provided by audiologists and physicians or otologists with appropriate scope-of-practice qualifications, can be grouped into five areas: (1) infection control (monica et al., 2017), (2) patient and equipment management (e.g. placement of transducers, insertion of probes, positioning of otoscopes, orientation of equipment, handling, manipulating and using hearing aids and accessories, troubleshooting) (govender & mars, 2018; lundberg et al., 2017; monica et al., 2017; ravi et al., 2020; tao et al., 2021; venail et al., 2018), (3) how to perform and evaluate certain tasks (e.g. conducting otoscopy, oaes, abr, conducting hearing screening, setting up the microphone and web camera for videoconferencing, connecting audiological equipment to the laptop) (coco et al., 2021; eksteen et al., 2019; erkkola-anttinen et al., 2019; govender & mars, 2018; hatton et al., 2019; hughes et al., 2018; lundberg et al., 2017; ramkumar et al., 2018; ravi et al., 2020; tao et al., 2021), (4) computer, technical and proper software use (e.g. clinical use smartphones, operating the laptop and ensuring proper connectivity of the computer hardware remotely, using the internet and using the mobile hotspot) (coco et al., 2021; monica et al., 2017; ravi et al., 2020; tao et al., 2021; venail et al., 2018) and (5) working and connecting remotely, with very limited reports on training on anatomy of the ear such as venail et al. (2018), who covered anatomy of the external and middle ear in their training. these areas, with the exclusion of those specific to remote connectivity, mirror those included in the audiology technician’s scope of practice, thus supporting the recommendation by the current author that this role be included in those paraprofessionals’ training (hpcsa, n.d.). conclusion current findings revealing heterogeneity in the training provided to psfs highlight the need for careful interrogation of this core aspect of tele-audiology during covid-19 and beyond, where covid-19 has thrust this model of service delivery to the forefront. when planned and implemented properly, this planning can have a significantly positive impact in the provision of ear and hearing care for the african context, with possibilities of contextually relevant and responsive service provision where psfs are drawn from the same populations where the remote service is being provided, enhancing linguistic and cultural diversity considerations in clinical care (khoza-shangase & mophosho, 2018, 2021). as valuable as psfs are to the application of tele-audiology, access to them can be just as challenging as access to audiologists within the african context (biagio, swanepoel, laurent, & lundberg, 2014; crowell, givens, jones, brechtelsbauer, & yao, 2011), hence the importance of careful planning around who can serve in this role as well as clarifying the nature and extent of training required. the limited published evidence on the training of psfs highlights this gap in practice and research, hence the importance of current and future planning. this planning should also consider cost implications that are related to human resource regulations, including issues around medical aid coverage should this service be reimbursable. lastly, standardised training of psfs will ensure that these cadres possess the same minimum competency levels, allowing for easy, fair and transparent accreditation and registration processes for adherence to regulations and policies governing healthcare provision in south africa. quality standards within best practice models in ear and hearing care can be maintained and patient safety safeguarded. acknowledgements competing interests the author declares that she has no financial or personal relationships that may have inappropriately influenced her in writing this article. author’s contributions i declare that i am the sole author of this research article. funding information the author thanks the national institute for the humanities and social sciences (nihss) for providing financial assistance for the publication of this manuscript. data availability the data that support the findings of this study can by made available upon reasonable request. disclaimer the views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any affiliated agency of the author. references arksey, h., & o’malley, l. 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(2018). community-based hearing screening for young children using an mhealth service-delivery model. global health action, 11(1), 1467077. https://doi.org/10.1080/16549716.2018.1467077 abstract introduction aims and objectives methodology results and discussion limitations conclusion and recommendations acknowledgements references about the author(s) milka madahana school of electrical and information engineering, university of the witwatersrand, johannesburg, south africa katijah khoza-shangase department of audiology, school of human and community development, university of the witwatersrand, johannesburg, south africa nomfundo moroe department of audiology, school of human and community development, university of the witwatersrand, johannesburg, south africa daniel mayombo school of electrical and information engineering, university of the witwatersrand, johannesburg, south africa otis nyandoro school of electrical and information engineering, university of the witwatersrand, johannesburg, south africa john ekoru school of electrical and information engineering, university of the witwatersrand, johannesburg, south africa citation madahana, m., khoza-shangase, k., moroe, n., mayombo, d., nyandoro, o., & ekoru, j. (2022). a proposed artificial intelligence-based real-time speech-to-text to sign language translator for south african official languages for the covid-19 era and beyond: in pursuit of solutions for the hearing impaired. south african journal of communication disorders, 69(2), a915. https://doi.org/10.4102/sajcd.v69i2.915 original research a proposed artificial intelligence-based real-time speech-to-text to sign language translator for south african official languages for the covid-19 era and beyond: in pursuit of solutions for the hearing impaired milka madahana, katijah khoza-shangase, nomfundo moroe, daniel mayombo, otis nyandoro, john ekoru received: 31 jan. 2022; accepted: 22 june 2022; published: 19 aug. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the emergence of the coronavirus disease 2019 (covid-19) pandemic has resulted in communication being heightened as one of the critical aspects in the implementation of interventions. delays in the relaying of vital information by policymakers have the potential to be detrimental, especially for the hearing impaired. objectives: this study aims to conduct a scoping review on the application of artificial intelligence (ai) for real-time speech-to-text to sign language translation and consequently propose an ai-based real-time translation solution for south african languages from speech-to-text to sign language. methods: electronic bibliographic databases including sciencedirect, pubmed, scopus, medline and proquest were searched to identify peer-reviewed publications published in english between 2019 and 2021 that provided evidence on ai-based real-time speech-to-text to sign language translation as a solution for the hearing impaired. this review was done as a precursor to the proposed real-time south african translator. results: the review revealed a dearth of evidence on the adoption and/or maximisation of ai and machine learning (ml) as possible solutions for the hearing impaired. there is a clear lag in clinical utilisation and investigation of these technological advances, particularly in the african continent. conclusion: assistive technology that caters specifically for the south african community is essential to ensuring a two-way communication between individuals who can hear clearly and individuals with hearing impairments, thus the proposed solution presented in this article. keywords: artificial intelligence; covid-19; hearing impaired; machine learning; speech; south africa; text; translation; sign language. introduction the world health organization (who) projected that approximately 2.5 billion people globally will have some degree of hearing loss by 2050, and rehabilitation will be required for 700 million individuals (who, 2021a). currently, over 430 million people in the world are in need of rehabilitation for hearing impairment (who, 2021a). hearing impairment can range from a mild to profound hearing loss (jorgensen, benson, & mccreery, 2018) and can be unilateral or bilateral, thus leading to an individual having challenges in hearing loud sounds or conversational speech (who, 2021a). individuals whose hearing loss ranges from mild to severe are usually referred to as hard-of-hearing individuals (xie, potměšil, & peters, 2014). these individuals communicate using spoken language and, in most cases, may use hearing aids, cochlear implants or any other assistive devices and captioning (who, 2021a; xie et al., 2014). when hearing loss in an individual is neglected, it can negatively impact various aspects of an individual’s life, including their communication needs (gbd 2019 hearing loss collaborators, 2021; russ, tremblay, halfon, & davis, 2018). irrespective of age, hearing impairment affects the psychosocial well-being, quality of life, interpersonal communication and economic independence of an affected individual (joubert & botha, 2019; khoza-shangase, 2019; maluleke, khoza-shangase, & kanji, 2021; olusanya, neumann, & saunders, 2014). among children, hearing impairment slows down progress in speech and language development, thus restricting their educational growth through limited career choices and vocational growth (casoojee, kanji, & khoza-shangase, 2021; olusanya, et al., 2014). children with hearing impairments are at an increased risk of emotional, sexual, physical and social abuse, and in worst-case scenarios, they may be murdered (lomas & johnson, 2012; sebald, 2008). in adults, hearing difficulties may result in occupational stress, comparatively low earnings, abuse, prejudice, embarrassment, stigmatisation, difficulties in relating to family members and those close to them, social isolation, loneliness, depression and psychiatric disturbances (khoza-shangase, moroe, & edwards 2020; moroe, khoza-shangase, madahana, & nyandoro, 2019; mousley & chaudoit, 2018; olusanya et al., 2014). basic functional auditory abilities are significant for navigating daily activities at home, work, business and in social contexts (dobie & van hemel, 2004). sound identification, localisation, detection and recognition are made possible by audition. another important role played by auditory abilities is the ability to perceive and comprehend spoken language (dobie & van hemel, 2004). hearing is, therefore, one of the essential senses that plays a significant role in communication. challenges in hearing can jeopardise the communication process and influence the quality of life and well-being of an individual (ramma & sebothoma, 2016). therefore, hearing is essential for survival, including accessing health awareness campaigns. considering the significance of audition for survival, it is therefore imperative that individuals with hearing impairments, where possible, be provided with assistive technology; for example, the use of captions can be included when information is being passed via the television. currently, the world is navigating a pandemic caused by coronavirus disease 2019 (covid-19), an infectious disease caused by the novel coronavirus (perez, perez, & roman, 2020). regulations and guidelines have been implemented in most countries to curb the spread of the disease (who, 2021b). in south africa, some of the regulations were and are not limited to isolation for individuals infected or exposed to the covid-19 virus, varying levels of lockdown, mandatory wearing of face coverings in public spaces for all individuals aged seven and above, as well as maintaining a distance of at least one and half metres from each other (south african government, 2021) – with these regulations being adapted regularly based on the infection rate in the population. while physical distancing strategies and wearing of face coverings are important to slowing down of the spread of the disease, they have yielded unintended consequences such as the isolation of individuals who are hard of hearing, as some of them may use lip reading when they cannot hear someone properly (homans & vroegop, 2021; mckinney, 2020). face masks are worn to cover the lower part of the face, specifically, the nose and mouth. in relation to speech, face masks act as low-pass filters, and they attenuate medium to high frequencies of an individual’s speech (goldin, weinstein, & shiman, 2020). recent studies indicate that for n95 respirators and surgical masks, sound reduction ranges from 3 db to 12 db (atcherson et al., 2017; corey, jones, & singer, 2020; goldin et al., 2020; wolfe et al., 2020). this, therefore, significantly decreases speech recognition for all individuals, particularly so for individuals with hearing loss (brotto et al., 2021; rahne, fröhlich, plontke, & wagner, 2021). fiorella, cavallaro, di nicola and quaranta (2021) maintained that the propagation of sound waves is altered when an individual speaks while wearing a mask, with certain spectral components of the acoustic energy signal being filtered or attenuated. the masks are reported to also alter consonant intelligibility, and discrimination of unfamiliar speech sounds is also compromised (corey et al., 2020; fiorella et al., 2021). furthermore, masks obstruct facial expressions and lip movements, which are critical sources of nonverbal communication (brotto et al., 2021; homans & vroegop, 2021). additionally, face masks are reported to impact on the content of the information being communicated (saunders, jackson, & visram, 2021). clear face masks have been presented as a solution for this dilemma (mckee, moran, & zazove, 2020); however, the usage and access to clear face masks varies from one individual to another, with uncontrollable adherence in varied social settings. studies conducted in south africa indicate that individuals with hearing impairment who need to lip read in order to understand found it very difficult to communicate with others while they are wearing masks (mckinney, 2020). considering the pressure that covid-19 currently places on health care, economic and social structures, it is imperative that all stakeholders have an ability to communicate swiftly and accurately during this pandemic (sahni & sharma, 2020). in this global public health crisis, efficient dissemination of knowledge results in prompt awareness and preparedness, which results in a less burdened health care system and less risk for health care workers (weiner, balasubramaniam, shah, & javier, 2020). the information should be disseminated very swiftly at a rate that is faster than the spreading epidemic (sahni & sharma, 2020). there is a need for the information disseminated to be reliable and accurate. sahni and sharma (2020) believed that this would result in quick implementation of policies; thus, compliance with prevention measures would lead to the number of cases of infection significantly declining. delays in relaying of vital information by policymakers are detrimental to preventive measures. globally (tavanai, rouhbakhsh, & roghani, 2021) and in south africa (adigun, vivekanantharasa, & obosu, 2021; mckinney, 2020), hearing-impaired individuals have faced various challenges in accessing news and information on the covid-19 outbreak, as well as in accessing educational and health awareness material, which heightened their psychological trauma (adigun et al., 2021). coronavirus disease 2019 seems to have further widened the already existing gap with regard to access to health-related information and health care services (adigun et al., 2021). the lack of access to health care services by the deaf has been previously attributed to limitations in understanding and use of english-language vocabulary, limited use of sign language interpreters, infrequent contact with health care providers and the lack of adequate knowledge of various medical terms (adigun et al., 2021; kritzinger, 2011; mckinney, mckinney, & swartz, 2020). in south africa, some individuals with hearing impairment have limited access to advanced technology, and mostly rely on television or radio to access information on covid-19. the south african department of health provided information about covid-19, its transmission and prevention through the media which included the use of television, radio, media briefings and social media. individuals who are deaf or with various levels of hearing impairment were excluded from accessing this information because some of the media briefings did not include sign language interpretation, there was a lack of closed captioning and some of the information provided was not accessible to individuals who are hard of hearing but at the same time do not have the literacy level that allows them to be able to read and understand the subtitles (mckinney, 2020). some television broadcasters increased access by ensuring that sign language interpreters were available, but this was only for main news bulletins and official briefings and not in the majority of other shows where crucial information was being shared. moreover, sign language interpreters only facilitated access to the deaf and not the hearing impaired, who still use spoken and not south african sign language. innovative technology (e.g. real-time captioning of live news) can be used, and this can expand access to the hearing impaired; however, currently available technology only caters for populations that can speak in english. the fact that real-time captioning can only be done in english in a linguistically diverse south african context, where english was reported to be spoken as a home language by less than 10% of the population (alexander, 2021), is a challenge requiring a solution, hence the importance of the proposed artificial intelligence (ai)-based real-time speech-to-text to sign language translator for south african official languages. globally, covid-19 news is constantly being updated, and rapid access to information is essential; however, individuals with hearing impairment challenges have struggled to keep up with news on television and on the radio. anecdotally, students with hearing impairment have also struggled with the online live lecture experience, which was the forced teaching method adopted by most educational institutions following the implementation of covid-19 regulations globally. prior to the onset of the covid-19 pandemic, hearing loss was already linked to isolation for individuals who are deaf and hard of hearing (park, 2020). the covid-19 prevention policies and public health recommendations have disproportionately affected the social well-being of individuals. meanwhile, covid-19 has increased and highlighted existing inequalities for individuals with hearing impairment (park, 2020). the literacy rate and numeracy rate of deaf learners have been historically known to be low. in south africa, the average age of deaf adults who have attended schools for the deaf is lower than the international average, which is said to be at fourth grade level (ng’ethe, blake, & glaser, 2015). in addition to that, apartheid caused racial inequalities in education development among the deaf, resulting in varying levels of literacy across different groups (ng’ethe et al., 2015). development of an end-to-end south african translator would facilitate two-way communication among individuals who can hear and those who cannot hear. application of ai approaches is one of the effective solutions that have been previously employed in other nations to design such tools. artificial intelligence refers to a machine’s capacity to imitate aspects of human intelligence, with the objective to create machines that are capable of using the characteristics of human intelligence to problem-solve and adapt to an ever-changing environment (sennott, akagi, lee, & rhodes, 2019). artificial intelligence has its roots in various fields, including mathematics, philosophy, psychology, neuroscience, linguistics, economics and computer engineering. recently, ai has been used in disability research (domingo, 2021; sennott et al., 2019). concepts associated with ai include machine learning (ml) and natural language processing (sennott et al., 2019). machine learning is a type or form of ai that enables machines to learn without being explicitly programmed (domingo, 2021). machine learning can be used in speech recognition to sense, interpret and facilitate new ways of assisting people with disability to access communication more readily (sennott et al., 2019), and these are documented to already be in regular use in high-income countries (hics). in automatic speech recognition (asr), the raw speech is preprocessed, important features are extracted and ml is applied in recognising speech. application of ai and ml in feature extraction and classification has been observed to have an accuracy of 99.01% (adeyanju, bello, & adegboye, 2021). lowand middle-income countries (lmics) like south africa need to explore advances in technology that is currently available in hics that cater for the hearing impaired. considering the current paradigm shift in south africa and the transition towards the fourth industrial revolution (4ir), it is imperative that current technologies being developed in south africa include ai and ml concepts in their design of solutions that are targeted towards bridging communication between the normally hearing and the hearing impaired. alexander (2021) reported that english is only spoken by less than 10% of the south african population. the rest of the population uses their home languages to communicate, which includes isizulu, south africa’s most widely spoken language, used by almost a quarter (23%) of the population, isixhosa (spoken by 16%), afrikaans (13.5%), sesotho sa leboa (sepedi) (9%), setswana and sesotho (both 8%), xitsonga (4.5%), siswati and tshivenda (both 2.5%) and isindebele (2%). translation of speech-to-text in other south african languages over and above english is therefore essential to ensuring effective communication with the entire linguistically and culturally diverse south african population during this covid-19 pandemic era and beyond. hearing assistive technologies (for instance, frequency modulation and loop systems, telecommunication devices, sign language interpretation, alerting devices and captioning services) have been developed to assist individuals who are hard of hearing (crandell & smaldino, 1999; kricos, 2007; mcpherson, 2014; van leeuwen et al., 2021). with the well-documented limited access to such technologies for large numbers in lmics, lip-reading and sign language remain key to communication access for the hearing impaired and the deaf. furthermore, real-time captioning has only been developed for english-speaking individuals, and sometimes, depending on one’s accent, the translation of english speech-to-text may also not be accurate. therefore, this article proposes the development of an ai-based real-time speech-to-text to sign language translator for south african languages following a scoping review. this translator can be used during and beyond the covid-19 pandemic era. this research work forms part of a series of investigations that consider the end-to-end translation of speech-to-text or speech-to-text to sign language, or speech-to-sign-language using the ai approach. each stage of the translation has real-life applications to individuals with varying levels of hearing impairment. for example, the speech to speech-to-text sign language will be mainly used by individuals whose level of literacy allows them to read and type. the speech-to-sign-language could be used for individuals who may not have a level of literacy that allows them to read and type but they understand sign language. the end-to-end translation will ensure that communication is two-way between individuals that can hear and those that cannot hear. aims and objectives the main aim of this study is to identify the gaps that exist in south africa in the application of ai and ml techniques for the translation of speech-to-text to sign language, with the following specific objectives: to identify peer-reviewed publications published in english between 2019 and 2021 to explore evidence available that apply ai and ml techniques for the real-time translation of speech-to-text to sign language as a solution for the hearing impaired in south africa. to propose the real-time translator of speech-to-text to sign language for south african official languages, which applies ai and ml techniques that can be used by hearing-impaired individuals who still use spoken and not south african sign language. methodology adhering to levac, colquhoun, and o’brien (2010) methodology, the researchers came to an agreement on a broad research question that was the focus of the scoping review and on the global study protocol, including specification of mesh terms terms/keywords/phrases and selection of databases to be searched. for this scoping review, the arksey and o’malley’s (2005) framework was adopted, with the broad question that guided the current scoping review being, ‘what evidence is available on artificial intelligence-based real-time speech-to-text to sign language as a solution for the hearing impaired?’ this question was explored as a preliminary step towards the development of the proposed speech-to-text to sign language translator. the search was conducted in december 2021 in the following five electronic databases: scopus, medline, sciencedirect, pubmed and proquest. only studies published in english between 2019 and 2021 (covid-19 era) were included. the search consisted of the following terms: ai, speech-to-text to sign language, communication with hearing impaired, translation for hearing impaired. initially, a total of 84 publications were identified for potential inclusion in this study. during data collation and organisation, seven studies were deleted as they were duplicates; therefore, only 77 studies were then considered. of the 77, 37 were removed based on the titles and/or abstracts that were deemed as not meeting the focus of the study. subsequently, 40 studies were evaluated for eligibility, and from these, 28 studies were excluded as they did not meet the study’s inclusion criteria. during the full-text review, a further six manuscripts were excluded, thus leaving six manuscripts for analysis (see figure 1). figure 1: the preferred reporting items for systematic reviews and meta-analyses flow diagram describing the process of study selection. ethical considerations this article followed all ethical standards for research without direct contact with human or animal subjects. results and discussion as depicted in table 1, the review yielded six studies: ezhumalai, raj kumar, rahul, vimalanathan and yuvaraj (2021), papastratis, chatzikonstantinou, konstantinidis, dimitropoulos and daras (2021), harkude, namade, patil and morey (2020), shinde and dandona (2020), baumgärtner, jauss, maucher and zimmermann (2020) and shezi and ade-ibijola (2020). thematic analysis revealed that of these studies, three were conducted in india (ezhumalai et al., 2021; harkude et al., 2020; shinde & dandona, 2020), one in germany (baumgärtner et al., 2020) and one in south africa (shezi & ade-ibijola, 2020). the remaining one was a literature review study conducted by papastratis et al. (2021), thus not specific to one country. it is noteworthy that three studies were conducted in india. india, like south africa, is classified as an lmic, with limited resources and high incidence of hearing impairment. table 1: summary of studies included in the scoping review documenting evidence on ai-based real-time speech-to-text to sign language as a solution for the hearing impaired during coronavirus disease 2019. granular analysis of articles included in this review revealed that four studies were at conceptualisation stages – sign language recognition (continuous sign language recognition and isolated sign language recognition) or sign language representation (using realistic avatars) (ezhumalai et al., 2021; harkude et al., 2020; papastratis et al., 2021; shinde & dandona 2020). only one study by shezi and ade-ibijola (2020) was at implementation phase – application (deaf chat application). current review findings exposed the noticeable lack of urgency in developing effective ai technology for communication that includes people who are hard of hearing. furthermore, these findings indicate a significant dearth of evidence focusing on the real-time speech-to-text to sign language translation for hearing-impaired individuals. such a lacuna in evidence is an indictment on those involved in ensuring access to communication by everyone, including those with barriers to communication. the dearth of studies indicates the lack of aligning clinical research with emerging technologies, as well as missed opportunities in maximising innovations that ai and ml have introduced – systems that can be trained to develop asr to convert speech-to-text to sign language for people with communication difficulties (agarwalla & sarma, 2016). these innovations would have been of immense benefit during the covid-19 era had they been taken advantage of earlier. evidence suggests that in relation to sign language and ai, there is a plethora of studies conducted for sign language users in different parts of the world; however, currently there is limited research on the application of ai and ml in africa. a systematic review conducted by adeyanju et al. (2021) on sign language recognition describes the recent advances in ai and how the advances have paved the way for researchers to apply ai in sign interpretation operations. specifically, these authors discuss intelligence-based sign language recognition systems, specifically interpretation services, real-time multiperson recognition systems, games, virtual reality environments, natural language communications, online hand tracking of human communication in desktop environments and human–computer interactions (adeyanju et al., 2021). save for robotics and virtual reality environments (avatars), as well as hand gestures, none of the listed technologies were gleaned from the studies analysed in the current scoping review. therefore, there is the potential for creating intelligent solutions to real-time speech-to-text to sign language translation for people with hearing impairment in south africa. furthermore, none of the studies in the review conducted real-time captioning in languages other than english. the results of the review also indicate that there are currently very limited documented studies conducted in south africa that utilise ai and ml techniques in the translation of south african languages from speech-to-text to sign language, thus highlighting the gap that exists. in the development of a translation tool for south african languages, this current research work will firstly consider the real-time translation of south african languages from speech to text using ai, which may be used, for instance, in creating real-time closed captions that can be used by individuals who have hearing impairments that require assistive technology. south africa currently has 11 official languages, excluding south african sign language, which has recently attained official language status as the twelfth. in south africa, english is spoken with various accents and is usually mixed with words from afrikaans and african languages (lanham, 1996). isizulu, isixhosa, isindebele and siswati, referred to as nguni languages, have clicking phonemes. xitsonga has very few clicks, while sesotho, setswana and tshivenda are tonal languages (schulz, laine, aunio, & philippova, 2019). at present, there is limited published evidence on speech-to-text conversion for african languages using ai or ml concepts. translation of south african english to text with south african accents is not accurately interpreted with the existing google english-to-text translator. researchers in south africa have recently begun to develop tools and applications (apps) to help individuals with hearing impairments. for example, shezi and ade-ibijola (2020) introduced a model and a tool (deaf chat) to communicate with hearing-impaired individuals based on ai. currently, this tool targets the english-speaking south african population. awezamed is a recently developed south african app that uses ai for users to pick pairs of languages to translate between (schwartz, 2020). there thus remains a great need for the development of tools and apps in african languages that can be used for individuals with hearing impairment. these tools and apps must consider (1) the socio-economic factors restricting access to any device or tool that is expensive; and (2) linguistic diversity, multilingualism and their influence on the english accents – and all the unique features of south african languages. thus, a multilingual speech-to-text translator that is inclusive of all south african languages would make a great contribution to individuals with hearing impairment within this context. to design an end-to-end speech-to-text translator, speech recognition is applied. speech recognition is a computer science term that refers to a process that converts speech into text (katyal et al., 2014). speech recognition is said to be advantageous for people who are hard of hearing, as this technology can be used to convert the speech to text on a computer and other devices (katyal et al., 2014). automatic speech recognition systems typically follow the process illustrated in figure 2. figure 2: illustration of the automatic speech recognition process. to translate speech to text for south african languages using ml, huge data sets are required to be used in training the ml model. therefore, several sources of data sets that could be used in this research work were identified. firstly, there exist a few corpora for south african languages, including the african speech technology project (roux, louw, & niesler, 2004), the lwazi project (badenhorst, van heerden, davel, & barnard, 2011), the south african corpus of code-switched soap opera speech (van der westhuizen & niesler, 2018) and the national centre of human language technology (nchlt) project (barnard, davel, van heerden, de wet, & badenhorst, 2014). the nchlt project expands the efforts of the works in roux et al. (2004) and badenhorst et al. (2011) to enable the development of large-vocabulary speech recognition systems for practical applications. there are other existing databases, such as the wall street journal (garofolo, graff, paul, & pallett, 1993), globalphone (schultz, 2002) and google (butryna et al., 2020) corpora. however, these only contain data for the english language. secondly, the work in van der westhuizen and niesler (2018) introduced a speech corpus containing 14.3 h of multilingual code-switched speech created from 626 episodes of a south african soap opera. the corpus is divided into four balanced subcorpora, each containing an equal amount of english and bantu speech: english–isizulu, english–isixhosa, english–setswana and english–sesotho. code-switched speech refers to the alternation of speech between two or more languages during the discourse. thirdly, the nchlt speech corpus contains wide-band prompted monolingual speech from approximately 200 speakers per language, in each of the 11 official south african languages (barnard et al., 2014). wikipedia text was used to generate english prompts, while for a few of the languages, a crowd-sourcing approach was followed to generate prompts; for most of the languages, however, prompts were created using text from the south african government website (barnard et al., 2014). the nchlt speech corpus contains 50 h of speech per language. once the data sources have been identified, the first part of asr, as shown in figure 2, involves speech pre-processing, which is done to prepare the speech signal for accurate feature extraction. the acoustic environment may have great effects on the generated speech. these include background noises and reverberations that are undesirable. pre-processing of the speech is, therefore, a necessary step to solve these problems and ultimately improve the accuracy of speech recognition. speech pre-processing generally involves noise filtration, pre-emphasis, smoothing and echo removing, which could be easily achieved using open-source software such as audacity. feature extraction is the next step, which is an integral part of asr, which aims to reduce the number of features in a data set by selecting prominent features that should ideally retain information regarding the content (speech) while discarding irrelevant information such as speaker accent, speaker identity and environmental conditions like noise and echoing. the features being used can have a significant effect on the performance of the system. several previous works in asr have proven mel-frequency cepstral coefficients (mfcc) to be one of the most prominent features of asr systems. the mfcc features are based on the natural perception of sound in the human ear which makes them suitable for speech recognition. the process of extracting mfcc is shown in figure 3. the speech frame is passed through a hamming window after pre-processing, and then the energy distribution is calculated using a fast fourier transform. the effects of harmonics are then eliminated using a mel filter bank, and finally, the discrete cosine transform is applied (vazhenina & markov, 2020). figure 3: block diagram for extracting mel-frequency cepstral coefficients. the last step of asr in figure 2 entails the application of ml techniques. some of the ml techniques that have been previously applied and successfully used in the translation of speech to text include artificial neural network (ann), convolution neural network (cnn) and recurrent neural network (rnn) techniques (basystiuk et al., 2021; gibadullin, perukhin, & ilin, 2021; lin, guo, zhang, chen, & yang, 2020; kamble, 2016; morgan, 2011; passricha & aggarwal, 2020). an ann is a collection of algorithms modelled after the human brain for pattern recognition and classification. neural networks have several advantages, such as reduced computational complexity and the ability to learn any complex relationship between input and output. however, its ‘black-box’ nature can be a disadvantage. recurrent neural network is derived from anns but can learn much faster and effectively. it has feedback connections between its different layers, output–hidden, hidden–output and output–input, forming multiple loops. some of the loops are in delay form, allowing rnns to recall past outputs and make selections motivated by what they learned from the past. convolution neural networks are most prevalent in image processing and computer vision projects. they are made up of filters or kernels which are used to extract relevant features from the input by a convolution operation. to implement the south african speech-to-text translator using ml, the authors of this work propose the use of the nchlt speech corpus for training as it is a sufficiently large data set, containing approximately 50 h of speech per south african language. the nchlt contains monolingual speech that allows for the training of the algorithm for each language independently. the data set contains speech prompts in the form of short phrases that will be used to train the ml models. in addition, another data set will be collected from volunteering individuals which will be used for testing the trained models. three ml architectures will be explored, namely, cnn, rnn and ann. the models will be trained to recognise the phrases in one of 11 south african languages. the speech signal will be used as input, while the corresponding text will be used as the expected output. each speech file is annotated with the corresponding text. the data will be split into two, 80% of which will be used for training and 20% for testing. figure 4 illustrates how a speech signal would be recognised. a raw speech signal is an input to the system, it passes through a pre-processing stage where it undergoes pre-emphasis, echo removing and noises cancellation, and then the key features are extracted into a feature vector. the features are then used as input to the trained ml model which performs pattern recognition to recognise the speech signal and outputs the corresponding text. in figure 4, the zulu greeting ‘sanibonani!’ is input as a speech signal and the corresponding text representing the audio signal is outputted. figure 4: an illustration of the implementation plan and expected results. limitations this work has only proposed the approach that will be used to conduct the translation from speech to text, without practically demonstrating its application using collected data. the next publication will demonstrate it using real data, the translation from speech to text for south african languages. the work has also not demonstrated how the translation from speech-to-text to sign language and from speech to sign language will be conducted. this will be covered in the publications to follow, as this work forms part of a series. conclusion and recommendations this article highlights that there is a dearth of evidence in the use of ai and ml applications in africa, with very limited or no tools for speech-to-text to sign language translations for south african languages using ai and ml. this lagging became heightened during covid-19 and prompted the current researchers to engage in this study. an implementation plan of speech to text using ml for south african languages has thus been presented. currently, it is viewed that south africa and africa as whole seldom apply ai in the development of their systems, especially systems used for the improvement of the social lives of their citizens (shezi & ade-ibijola, 2020). there is a need for a paradigm shift to inclusion of ai and ml as the country transitions towards the 4ir. model validation using real speech data has currently not been performed and therefore forms part of future plans, together with speech-to-sign-language and speech-to-text to sign language, which will be in subsequent publications. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions m.m. was the main researcher, and coordinated the entire project. k.k. assisted with the concept, method and the scoping review. n.m. conducted the scoping review. d.m. contributed to the data extraction and the write-up. o.n. contributed to the analysis. j.e. contributed to the method and application of ai. funding information the authors thank the national institute for the humanities and social sciences for providing financial assistance for the publication of this manuscript. data availability data are available from the corresponding author. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references adeyanju, i.a., bello, o.o., & adegboye, m.a. 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(2014). children who are deaf or hard of hearing in inclusive educational settings: a literature review on interactions with peers. journal of deaf studies and deaf education, 19(4), 423–437. https://doi.org/10.1093/deafed/enu017 abstract introduction methods – how telesupervision and online case-based learning were used results – what we found summary and conclusions acknowledgements references about the author(s) lindy l. mcallister faculty of medicine and health, university of sydney, sydney, australia marie atherton department of speech pathology, faculty of health sciences, australian catholic university, melbourne, australia alison winkworth private, albury, australia stephanie wells private, london, united kingdom dien k. le an bình hospital, ho chi minh city, viet nam karina sandweg college of education, health and human development, university of canterbury, christchurch, new zealand thuy t.t. nguyen medical committee netherlands vietnam (mcnv), hanoi, vietnam natalia henderson-faranda natalia hf speech & language therapy, christchurch, new zealand sharon broadmore kinela speech therapy, melbourne, australia citation mcallister, l.l., atherton, m., winkworth, a., wells, s., le, d.k., sandweg, k., … broadmore, s. (2022). a descriptive case report of telesupervision and online case-based learning for speech and language therapy students in vietnam during the covid-19 pandemic. south african journal of communication disorders, 69(2), a897. https://doi.org/10.4102/sajcd.v69i2.897 original research a descriptive case report of telesupervision and online case-based learning for speech and language therapy students in vietnam during the covid-19 pandemic lindy l. mcallister, marie atherton, alison winkworth, stephanie wells, dien k. le, karina sandweg, thuy t.t. nguyen, natalia henderson-faranda, sharon broadmore received: 26 jan. 2022; accepted: 05 june 2022; published: 15 aug. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: vietnam’s first speech and language therapy (slt) degrees commenced in 2019 utilising international educators. continuity of the degrees was impacted by travel restrictions during the coronavirus disease 2019 (covid-19) pandemic. objectives: this article presents a descriptive case report exploring the viability of online learning to continue clinical education (ce) of slt students in vietnam during the pandemic. method: students were scheduled for face to face placements throughout 2021. international slt educators were to travel to vietnam and work with interpreters and locally trained certificate level therapists to provide placement supervision. when travel became impossible, tele-supervision by international therapists working remotely and in partnership with local therapists and interpreters was arranged. the second wave of covid-19 excluded students from healthcare settings early in their placements. to conclude these placements, tele-supervisors led online case-based discussions with students. for subsequent placements, vietnamese and international therapists facilitated two to three weeks of online case-based group discussions for students, using cases with videos or avatars. results: learning outcomes for students, as evidenced in written and oral assessments demonstrated attainment of many of the learning objectives of the placements. satisfaction for all participants (students, tele-supervisors, online group facilitators) was high. students will undertake face to face placements in the future; however they will commence these placements with heightened clinical reasoning and planning skills. conclusion: online ce is possible in lmic and, as part of a program which includes face to face placements, can support essential ce outcomes and enhance preparation for subsequent direct experiences with patients. keywords: covid-19; pandemic; lowand middle-income countries; speech and language therapy; education; clinical placement; online learning; case-based learning; telesupervision. introduction cessation of face-to-face teaching because of coronavirus disease 2019 (covid-19) pandemic lockdowns meant a rapid pivot for many health profession degrees to online learning, including telehealth placements, with or without telesupervision (ts). lyons et al. (2021), for example, described the rapid development of a telehealth service in ireland to enable student placements, whilst kamper, dario, waibel, o’connor and bourne (2021) described the rapid repurposing of existing telehealth services to include student placements during the pandemic. other programmes in high-income countries (hics) used online case-based learning (cbl) and/or online simulation-based learning (sbl) (see, e.g. taylor & salmon, 2021). this pivot was possible in many hics where information and communications technology (ict) device ownership is high and there is access to high-speed internet with sufficient bandwidth to support online learning; it was also made possible by many universities and affiliate health care facilities having existing telehealth services, teleplacements and ts programmes, cbl or sbl programmes or the capacity to rapidly develop or acquire cases for online learning (see, e.g. may, grotowski, walker, & kelly, 2021). to date, few studies have addressed the use of online learning in health degrees in lowand middle-income countries (lmics) during the pandemic. li et al. (2021) reported a range of barriers and facilitators to online medical and nursing education in china during the pandemic. in discussing occupational therapy placements in south africa during the pandemic, gurayah (2021) reported challenges including the cost of data, student access to laptops and learning how to use virtual conferencing and online learning platforms. the present article adds to the small body of literature about the use of online learning in lmics by describing the use of ts and online cbl for speech and language therapy (slt) students in vietnam during the covid-19 pandemic. telesupervision is defined as ‘the use of ict for communication between university-based staff, clinical supervisors and/or students undertaking placements in the presence or absence of a clinical supervisor onsite’ (nagarajan et al., 2016, p. 18). high-quality ts requires the management of technology-related issues, including access to equipment, internet, good bandwidth, data security and confidentiality and ethical considerations such as patient consent and privacy (see nagarajan et al., 2018). mccabe, purcell, baker, madill and trembath (2009, p. 309) defined cbl as ‘the use of real-life or hypothetical clinical cases to promote student thinking and learning in ways that simulate clinical practice’. various researchers have reported good learning outcomes for students using ts (see, e.g. lyons et al., 2021; nagarajan et al., 2016; overby, 2018; taylor & salmon 2021) and for cbl (mccabe et al., 2009). in vietnam, online learning and simulation were rarely used in university programmes prior to the pandemic; therefore, banks of cases for conversion to online cbl were not available. students mostly had smart phones but not necessarily laptops, and internet with good bandwidth was often limited in their homes. when the pandemic hit, two university-based slt degrees were being run in vietnam – 14 students were completing a two-year master in slt (mslt) at university of medicine and pharmacy in ho chi minh city, and 20 students were completing a four-year bachelor in slt (bslt) at da nang university of medical technology and pharmacy. development and delivery of these degrees were undertaken through a multilateral international partnership between two nongovernmental organisations: the vietnam-based medical committee netherlands vietnam (mcnv) (https://mcnv.org/) under its slt education development project, funded by u.s. agency for international development (usaid) through viethealth, with the australia-based trinh foundation australia (tfa) (https://trinhfoundation.org/) providing professional input. the students had completed one or two of six planned face-to-face placements before the pandemic lockdowns halted all placements and classroom-based learning. this article’s focus is on the perspectives of vietnamese and international clinical educators involved in the two degree programmes, although it is acknowledged that the perspectives of students are also important and under-researched (lyons et al., 2021; overby, 2018). methods – how telesupervision and online case-based learning were used telesupervision the first ts of a clinical placement (cp2) was a two-week (ten-day) intensive course for both mslt and bslt cohorts simultaneously, working with voice patients in the two university slt teaching clinics with two telesupervisors: one in australia and one in the united kingdom. three slt-trained interpreters living in vietnam interpreted online in shifts during the two weeks. facilitated by the telesupervisors and supported with interpreters, students not only participated in sessions directly with patients in the university clinics but also observed each other’s sessions and came together via zoom for facilitated planning and debriefing discussions. figure 1 illustrates key inclusions in the placement. figure 1: cp2 voice: real patients in classroom with students, educators and interpreters online. supported by written teaching materials translated in advance, the schedule for the two weeks included refresher learning activities in the first two days, followed by six days of patient sessions intermingled with discussions, debriefing and planning to guide clinical reasoning. the schedule was deliberately designed to include facilitated discussions before and after all patient sessions, with a focus on clinical reasoning. students were assessed by the telesupervisors for clinical competence in voice (60% of grade) and their individual (mslt) or paired (bslt) case presentations (40%) conducted over the last two days of the placement. the synchronous online sessions occurred on the zoom platform, and there were various technical difficulties, mostly because of intermittent poor audio or video quality. despite these difficulties, the rollout of the subject was successful, especially considering the complexity and logistics of managing two zoom accounts, using microphones for amplification in the classrooms, telesupervisors each in different time zones, three interpreters in different shifts and locations and students together in two university clinics for patient sessions, then at their home or work later for facilitated discussion sessions. prerecorded videos of telesupervisors working with patients were made as backup in case patients were unable to attend at short notice. these did not have to be used, as all patients attended as planned. telesupervision was also planned for the penultimate and final placements in both degrees. students were to be placed in vietnamese hospitals, with patients organised by vietnamese speech and language therapists (hereafter therapists) in those facilities. workloads of vietnamese therapists meant they could not manage supervision of students and their normal clinical work simultaneously, and so international therapists were recruited and trained to provide online ts, using remote viewing of student interactions with consenting patients or families. however, in the weeks prior to the first ts placement for mslt students, some hospitals advised they would not allow remote viewing of patients by ts, even though patients had consented to this. where allowed, tablets were used to transmit a student’s session with a patient, and the interpreter typed on her computer, translating live. the telesupervisor provided suggestions for the student through the interpreter in real time. unfortunately, within the first week of the ts placement, the second wave of the pandemic meant students were excluded from these and all subsequent placements. online case-based learning the inability to continue face-to-face contact with patients during placement via ts required a rapid switch by the telesupervisors to online cbl. the goals of the online cbl for both the mslt and bslt placements were to develop students’: ability to identify key diagnostic and other relevant information about a patient’s communication and/or swallowing difficulties (cswd) knowledge of assessment and intervention options for a range of patients with cswd skills in planning culturally appropriate assessment and intervention sessions clinical reasoning ability and their capacity to articulate this, with reference to the evidence-base, the international classification of functioning, disability and health (world health organization, 2001) and cultural considerations. for the first week of the terminated placement, the international telesupervisors provided patient cases from their clinical experiences for online discussion with students. interpreters were present for all discussions. patient information, assessment priorities, tools and findings were discussed, and management priorities and strategies were identified. differences were also explored regarding how patients might be managed in vietnam versus the hic where the telesupervisors were based, with a focus on identifying culturally and contextually relevant management objectives, resources and supports. given the time-intensive nature of developing multiple culturally relevant cases for discussion, licences were purchased for each student and cbl group leader for a commercially available, english language cbl platform comprising patient documentation, videos and avatars. the platform was considered to offer a more ‘authentic’ experience for students than paper-based cbl alone. further, the platform provided extensive case notes about patient presentations, social and contextual information, assessment and treatment. cases were selected from the platform to illustrate a variety of paediatric and adult cswd arising across the lifespan. for the paediatric placement, cases related to children with complex disabilities (e.g. cerebral palsy, autism spectrum disorder, down syndrome, traumatic brain injury [tbi] and hearing loss); for adult placements, cases illustrated cswd arising from stroke, motor neurone disease, head and neck cancer and tbi. we were aware that cases from an hic might be limited in terms contextual and cultural appropriateness and relevance. therefore, vietnamese authors on the present article reviewed cases, selected those that were contextually relevant and provided advice around cases and materials that required modification to reflect the local context. selected cases were typical of patients seen in vietnamese health care settings. summaries of information relevant to each case were prepared in vietnamese for the students. case-based discussion with the students included time for critique of which assessment and treatment approaches used in the case study were relevant to the vietnamese context and how assessments and interventions for this case could be made more culturally and contextually appropriate. students and cbl group leaders worked through zoom from their homes using personal laptops or phones. both local vietnamese and non-vietnamese international therapists led the discussions, with an interpreter present for the non-vietnamese-speaking group leaders. groups generally comprised one cbl group leader and four to six students. when larger groups of students were necessary, students were allocated into smaller groups in zoom breakout rooms, and the group leader rotated through the rooms to support student discussions before reconvening the whole cohort. the duration of the group sessions was generally 2–3 hours per day for up to 10 hours per week over 4–5 weeks. format of case-based learning discussion sessions case-based learning group leaders guided students through nominated cases and associated learning materials and tasks, set activities for students to complete between group meetings and provided feedback between sessions. some of the activities were determined by the learning materials for each case, but activities that addressed discussion points raised in group meetings were also set. group discussions supported all students to be involved and encouraged open debate, both between students and between students and group leaders. as a means of debriefing and ensuring as equitable an experience as possible for all students, the group leaders met via zoom at the end of each week to discuss their experiences and plan for the following week. ethical approval to report telesupervisor and cbl facilitator perspectives was not required, as the information was collected as part of a routine teaching evaluation. ethical considerations as information presented in this article was collected as part of routine teaching evaluation, ethics approval was not required. results – what we found challenges encountered and strategies used to manage these we expected to manage challenges using ts and cbl. these included communicating through interpreters, intermittent and various difficulties with internet connection and some difficulties determining student engagement. forward planning was essential for scheduling and working with interpreters, including translation and editing of written materials well in advance. furthermore, in real-time online zoom sessions, the use of the text-based chat box assisted all parties (educators, interpreters and students) as it provided written text that could be tracked, in addition to viva voce simultaneous interpreting. with stakeholders in various locations and different time zones, patchy internet access and bandwidth were to be expected, especially with sessions that took place whilst students logged in from their homes instead of the classroom. at times, it was difficult to identify whether students had internet connection issues or were experiencing difficulty engaging with the learning activities and discussions. students were all encouraged to write their questions down, either in the chat box for immediate translation where possible or for submission to the interpreter for translation to the educator who could answer them in the next discussion session. table 1 summarises these challenges and strategies. table 1: challenges encountered and strategies used. for ts and cbl or sbl, it was also critical to recruit educators who had relevant experience or provide training ahead of time. for cbl or sbl specifically, it was important to develop culturally and locally relevant cases of appropriate complexity for the student cohort. learning outcomes for students learning outcomes for students in all placement subjects in which ts or cbl was used demonstrated attainment of many of the placement learning objectives written in subject outlines before the pandemic. assessments in the telesupervised cp2 placement showed that all students met expected learning outcomes for assessment and treatment for common voice disorders, and most students achieved high case presentation scores. students’ written reflections based on the requirement to observe all patient sessions when they were not involved in direct patient care demonstrated growth in clinical knowledge as well as increased awareness of their own progress towards competency. assessment of students for the cbl involved written case studies and individual and small group presentations of cases and associated oral exams. assessments followed a developmental trajectory in that over the duration of the placements, students were required to demonstrate increasing ability to identify, analyse and synthesise relevant information, consider holistic and person-centred approaches to assessment and management and tailor these to the vietnamese context. for the first mslt cbl placement, nine students passed in their first attempt, with five students successful on a resit. these five students received additional input that included detailed written and verbal feedback and tutorial support to improve the content and delivery of their presentations. on subsequent cbl placements, all mslt students and bslt students passed written case studies and/or small group case presentations and oral vivas in the first attempt. experiences of telesupervisors and online case-based learning group leaders the experience of online teaching was challenging for the telesupervisors and cbl group leaders. internet reliability and signal dropout were not uncommon for students, interpreters and educators. facilitating critique of the cbl cases for contextual and cultural relevance was challenging for non-vietnamese cbl group facilitators, who sought advice from their vietnamese colleagues also involved in cbl groups. despite having interpreters trained in slt terminology, the open-ended nature of discussions sometimes meant interpreters encountered unfamiliar english vocabulary and would need time to develop an appropriate interpretation. in addition, interpreters were occasionally unavailable for scheduled classes because of personal health issues. furthermore, the online environment, with cameras sometimes off to reduce draw on bandwidth and avoid dropout, meant that the telesupervisors and cbl group leaders found it difficult to gauge students’ levels of engagement and respond appropriately. overall, however, the telesupervisors and cbl leaders reported the challenges of teaching online were managed as well as possible and that good learning outcomes were achieved for students. all expressed satisfaction with their contributions and indicated willingness to stay involved in educating the vietnamese slt students in the future. they found online teaching to be an ‘invaluable experience’, providing comments such as ‘wonderful to see students gain confidence with online supervision and case discussion’, and ‘students generally well prepared and engaged; brought interesting cases for discussion’. they found in particular that most students were able to solve problems with sound clinical reasoning. a well-experienced vietnamese slt who acted as a cbl group leader reported that ‘the varied and well-structured cases favourably assisted the students for [face to face] placement later’. summary and conclusions the pandemic has caused many disruptions and challenges for university education of health professionals globally, particularly for lmics, but the use of ict to facilitate synchronous online learning offers a practical solution. the use of ict and innovative educational design for ts and cbl for slt education in lmic in this case has meant that students’ ce was progressed and extension of courses averted. this was critical given funding rules and timelines for the project. although ict and language differences created communication issues, these were not insurmountable, and students had access to powerful learning experiences with expert guidance and facilitation in real time, including practice with voice patients who also benefited from the students’ and educators’ skills. on reflection, what was a rapid pivot to enable ongoing ce for slt students in vietnam has provided numerous lessons for embedding cbl and ts in future slt education in vietnam. online cbl strengthened students’ clinical reasoning skills, evident in subsequent face-to-face placements. therefore, we plan to include cbl (either online or face-to-face) as preparation for placements in future slt degrees in vietnam. ideally, vietnamese speech and language therapists should begin to develop banks of culturally and contextually appropriate cases, reducing both the need for and cost of commercial banks of cases which still require modification. we have also learnt that there should be a backup interpreter available at all times should availability issues arise because of internet or personal challenges for scheduled interpreters. the communication issues because of language differences which we encountered will naturally reduce as the growing number of vietnamese therapists take over education of slt students in vietnam from international slts participating in the initial degrees. however, ts will remain as an option to support local vietnamese therapists to develop expertise in ce and supervision. we believe that the methods reported in this article and possibilities for embedding in future degrees will be of interest to other slt degrees in lmics. in this article, we have not focused on the students’ experiences of online learning, but their views will be gathered as part of a large-scale evaluation of their courses, with a view to future reporting. online learning is not a full replacement for real placement experience, and therefore we are planning for clinical placements for both cohorts of students as soon as the pandemic allows the resumption of face-to-face placements and supervision. acknowledgements the authors thank dr huynh bich thao for the contribution to the educational activities described in this article. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions l.l.m., m.a. and a.w. conceptualised the development of the activities and methodologies and implementation of activities described in this article, contributing also to the writing of the original draft and to the writing and review of the article in various stages. l.l.m., m.a., a.w. and t.t.t.n. managed resource acquisition and logistics for the activities described. s.w., d.k.l., k.s., n.h-f. and s.b. all contributed to the implementation and evaluation of the activities described and to the writing and review of the article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data pertaining to this article are available from the first author upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references gurayah, t. 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(2021). enhancing peer learning through online placements for health and social care professions. international journal of practice-based learning and health and social care, 9(2), 1–10. https://doi.org/10.18552/ijpblhsc.v9i2.723 world health organization (who). (2001). international classification of functioning, disability and health. geneva: world health organization. retrieved from https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health abstract introduction evaluation of risk versus benefit factors influencing benefit or risk evaluation in hearing conservation programmes what the regulator and audiologists need to consider decision-making: principles to consider when deciding on the options immediate plan: what audiologists should do future directions acknowledgements references about the author(s) katijah khoza-shangase department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa nomfundo f. moroe department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation khoza-shangase, k., & moroe, n.f. (2020). risk versus benefit: should not audiologists assess this in the context of occupational noise-induced hearing loss in the mining industry?. south african journal of communication disorders, 67(2), a671. https://doi.org/10.4102/sajcd.v67i2.671 note: special collection: occupational hearing loss in africa. original research risk versus benefit: should not audiologists assess this in the context of occupational noise-induced hearing loss in the mining industry? katijah khoza-shangase, nomfundo f. moroe received: 18 aug. 2019; accepted: 30 jan. 2020; published: 03 mar. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: hearing conservation programmes (hcps) are an important aspect of occupational health efforts to prevent occupational noise-induced hearing loss (onihl). in lowand middle income (lami) countries, where the incidence of onihl is significant, it is important to deliberate on the risk or benefit of hcps. objectives: this article is an attempt at highlighting important strategic indicators as well as important variables that the occupational health and audiology community need to consider to plan efficacious hcps within the south african mining context. method: the current arguments are presented in the form of a viewpoint publication. results: occupational audiology vigilance in the form of engagement with hcps in the mining industry has been limited within the south african research and clinical communities. when occupational audiology occurs, it is conducted by mid-level workers and paraprofessionals; and it is non-systematic, non-comprehensive and non-strategic. this is compounded by the current, unclear externally enforced accountability by several bodies, including the mining industry regulating body, with silent and/or peripheral regulation by the health professions council of south africa and the department of health. the lack of involvement of audiologists in the risk or benefit evaluation of hcps during their development and monitoring process, as well as their limited involvement in the development of policies and regulations concerning ear health and safety within this population are probable reasons for this. conclusions: increased functioning of the regulatory body towards making the employers accountable for the elimination of onihl, and a more central and prominent role for audiologists in hcps, are strongly argued for. keywords: occupational noise-induced hearing loss; monitoring protocol; risk; benefit; conservation; vigilance. introduction mining plays a vital role in the growth and development of any nation in the world (agwa-ejon & pradhan, 2018). in south africa, mining and its related industries are critical for socio-economic development. in 2018, the mining sector reportedly contributed r351 billion to the south african gross domestic product (gdp) (minerals council south africa, 2019). south africa accounted for about 1.82% of the global mineral production in 2015, with a corresponding value of around us$113bn (reichl, schatz, & zsak, 2017). in 2016, the mining sector in south africa accounted for about 7.9% of the total gdp (stats sa, 2017), which since has declined by 15% (van zyl, 2019). south africa’s mineral resources have yielded, and are reported to continue to yield, significant economic wealth. yet, decades of colonialism, apartheid, capital flight and challenges in the neoliberal post-apartheid era have resulted in high rates of occupational lung disease, hearing loss and challenges, with low rates of compensation for ex-miners (kistnasamy et al., 2018). given the growing advocacy and activism around occupational health issues, initiatives were launched by the south african government in 2012 towards addressing the legacy of injustice, and this included addressing minimising and/or eliminating occupational health hazards. the african union (au) (2009), in its africa mining vision, carefully presented a way forward for mining on the continent. the au views this as a route towards economic development and industrialisation; however, they are very clear that this should not happen at the expense of a ‘sustainable and well-governed’ sector, which is, amongst other criteria, ‘safe’ and ‘healthy’ (african union [au], 2016). coulson (2018) argued that over the last decade, the rush for economic growth on the african continent, where the pressure for job creation and poverty alleviation is palpable, can deflect attention away from the goal of a safe and healthy workplace. this author asserts that occupational health and safety (ohs) has a poor base in africa, especially if the workplace is hazardous (coulson, 2018). in many instances, ohs legislation is incomplete or outdated; there is a lack of enforcement by labour inspectorates, and reported data on accidents and occupational disease are low (alli, 2008); and current authors believe this to be the case within the south african context as well. in spite of the reported progress that has been made in combating occupational injuries, evidence suggests ongoing complex barriers and confirms the assertion by kistnasamy et al. (2018) that there is considerable underfunding with regard to the systems required for sustained prevention and social protection (including compensation). this underfunding calls for urgent attention. these authors believe that with ‘class-action suits’ in the process of settlement, the globalised mining sector is now beginning to be held accountable. similar trends are observed in south africa with the recent successful landmark silicosis class-action suit, which resulted in an r5bn settlement (niselow, 2019). this has raised the expectation of employer accountability through this critical rights-based approach, which highlights the need for a review of risks versus benefits of hearing conservation programmes (hcps) for occupational noise-induced hearing loss (onihl), and the interrogation of who is well placed to conduct this risk–benefit assessment. occupational noise-induced hearing loss is an occupational disease (lie, skogstad, johnsen, engdahl, & tambs, 2015), which is described as a permanent sensorineural hearing loss because of exposure to hazardous levels of noise during the performance of one’s vocation (nelson, nelson, concha-barrientos, & fingerhut, 2005; thorne, 2006). it is described as the second most common risk factor in the workplace, behind workplace injuries (who europe, 2017). globally, onihl is reported to be the number one work-related disability and the second most common form of acquired hearing loss after presbycutic hearing loss (mostaghaci et al., 2013; ritzel & mccrary-quarles, 2008). in south africa, with the high prevalence of tuberculosis (tb) and human immunodeficiency virus (hiv) or acquired immunodeficiency syndrome (aids) in the mining sector, onihl has gained prominence as an important public health priority because of these burdens of disease contributing towards the occurrence and degree of the hearing loss in this population (khoza-shangase, 2019). in addition, the increased attention is because onihl is a potentially costly public health issue, especially in a resource-constrained country like south africa, where issues such as the minimum wage are still in the public discourse. it has been documented that hazardous noise in the workplace results in an invisible condition, which does not readily manifest itself (tye-murray, 2009). in this condition, employees acquire a permanent disabling hearing loss, characterised by a hearing threshold below 40 dbs (yadav, yadav, netterwala, khan, & desai, 2015). copley and frederichs (2010) and hermanus (2007) argued that permanent disabling hearing loss is a major contributor to the global burden of disease on individuals, families, communities and countries. this burden has serious consequences for those affected. occupational noise-induced hearing loss has adverse consequences on the health, safety and economic outlook of the affected individuals, their families, societies and the state as well (moroe, khoza-shangase, kanji, & nthlakana, 2018). at an individual level, onihl can negatively impact on the possibilities and opportunities of further employment for the affected employee (kane-berman, 2017). it can have a significant impact on the safety of the employee as far as work-related injuries are concerned (amjad-sardrudi, dormohammadi, golmohammadi, & poorolajal, 2012), with prolonged exposure to hazardous noise levels in the workplace potentially leading to increased fatigue and decreased concentration, which ultimately increases human errors (amjad-sardrudi et al., 2012; picard et al., 2008). furthermore, the individual impact can spread to group effects where excessive noise exposure can potentially reduce the worker’s ability to perform or complete tasks that are significantly dependent on auditory signals or verbal communication (thorne, 2006). this, subsequently resulting in a communication handicap, will ultimately affect team work and group productivity (momm & geiecker, n.d.). at family, society and state levels, onihl effects are not only limited to the individual who is affected but also extend to their families, as in most cases these workers are the sole providers for or breadwinners of their families. furthermore, this impact has an effect on the company or organisation, as these companies incur costs through compensation for ohs claims and lose productivity when employees absent from work because of this occupational injury. lastly, because onihl is a disability, most workers diagnosed with a hearing loss cannot continue with their occupations. consequently, they must rely on state resources for their upkeep as well as that of their dependants. according to hong, kerr, poling and dhar (2013), the impact of onihl on one’s health and quality of life cannot be quantified in tangible measures or standards although the compensation cost for onihl is consistently increasing. for instance, in south africa, onihl is the second most compensated occupational health condition in the mining sector (balfour-kaipa, 2014), second only to occupational lung disease (silicosis), when the recent lawsuit settlement is excluded. statistics on the burden of onihl in developing countries are not readily available (nelson et al., 2005); nevertheless, chadambuka, mususa and muteti (2013, p. 899) argued that 80% of the individuals affected by onihl reside in lowand middle-income (lami) countries where onihl presents a ‘much heavier burden than in developed regions of the world’. it is for this reason that onihl is considered as one of the biggest threats to the country’s economy as well as public health. kanji, khoza-shangase and ntlhakana (2019) argued that current evidence about the continued existence of onihl as well as the reported high-compensation claims paid for onihl as an occupational health condition in south africa speaks for the lack of success of hcps in south african mines. it is for this reason that there is a need to interrogate risk–benefit assessments of hcps within the health-resource-constrained context of the mining industry. a key challenge with hearing conservation within the south african mining sector is that of a well-documented lack of appropriate skills as far as ear and hearing care specialists are concerned. only a small number of south african audiologists are functioning within the occupational audiology scope of the profession, leading to unfavourable professional-to-patient ratios with obvious incongruence between demand and supply for those who do (moroe & khoza-shangase, 2018). within this sector, there is also heavy reliance on mid-level workers, such as audiometricians, by the mining industry. another challenge is that of translating knowledge and policies into practice for various reasons, including linguistic and cultural diversity quandaries, as well as risk versus benefit assessments predicaments. risk–benefit assessments refer to the evaluation of safety signals (medical and/or surgical) within the health care industry, and their value has been well-documented in pharmacology (guo et al., 2010). such risk–benefit evaluations have not been conducted in occupational health, including in onihl. because of the continued increased prevalence of onihl in the mining industry globally, south africa in particular, these evaluations need increased attention from the occupational health community as part of their health and safety vigilance strategies. this article argues for increased attention to occupational audiology in africa and the rest of lami countries, with clear roles for the audiologists within the team during the risk and benefit evaluation of hcps where hazardous noise exposure has been established. over and above the illustration of the central and leading role that audiologists should play in the process of evaluating risk versus benefit in hcps, which this article aims to do, the centrally located and more visible role of the minerals council of south africa (previously chamber of mines) within the multidisciplinary and multi-stakeholder team in ensuring adherence to regulations has been discussed. the mine health and safety council (mhsc) has ‘every mine worker returning from work unharmed everyday: striving for zero harm’ as one of its key goals (mhsc, 2016). in spite of all documented efforts by the mhsc and the minerals council south africa to achieve this goal as far as ear and hearing health is concerned, this goal has not been achieved as yet (booyens, 2013). evidence suggests that over 70% of miners in south africa are exposed to excessive noise levels, well above the legislated occupational exposure limit of 85 dbs, in spite of the presence of hcps in this sector (edwards, dekker, franz, van dyk, & banyini, 2011; strauss, swanepoel, becker, eloff, & hall, 2012). efficacy of hcps has been found to be limited to non-existent, with published south african studies revealing that hcps have not been successful in the mining industry. after the formal implementation of hcps in 1996, subsequent to the promulgation of the mine health and safety act of 1996, numerous studies that have been conducted to evaluate the effectiveness and efficacy of management of onihl within the south african mining industry have yielded findings that indicate little, if any, success with hcps (edwards, milanzi, khoza, letsoalo, & zungu, 2015; edwards et al., 2011; edwards & kritzinger, 2012; kanji et al., 2019; moroe, 2018; moroe & khoza-shangase, 2018; ntlhakana, kanji, & khoza-shangase, 2015; strauss et al., 2012). evaluation of risk versus benefit the obvious goal in hcps is to recognise the harmful effects of excessive noise exposure by qualified professionals, utilising objective measures, before any serious injury is experienced by employees (byrne, 2005). in addition, this goal extends to the elimination and/or minimisation of harmful noise (byrne, 2005) through a hierarchy of controls that include elimination of the hazard, engineering controls, substitution of equipment and administrative controls before the provision of hearing protection devices. unfortunately, hcps and onihl identification, and monitoring protocols have not been standardised or strictly adhered to nationally as well as internationally; therefore, with limited to no evidence of industry best-practice sharing, final analyses of their efficacy are not always entirely dependable and/or generalisable. more importantly, the role of the audiologist, whose scope of practice hcps falls under, is not prominent within the south african occupational health industry. it is for this reason that the audiology community needs to directly engage in the development of policies and regulations around hcps, the development process of the hcps as well as in the implementation and monitoring of these programmes (moroe, 2018). the current authors assert that comparative evaluation of benefits (positive effects – efficacy) and risks (potential harm) of hcps within the south african mining industry is of paramount importance in occupational health. one would argue that the responsibility for this evaluation lies with the mining companies (employers) whose benefit or risk monitoring of their hcps should be ongoing, taking careful cognisance of contextual factors such as burden of disease in their workforce. the goal would be to ensure that once a risk assessment for noise has been carried out, minimisation, if elimination is not possible, of safety hazards and maximisation of hcps benefits ensues. the health and safety authority (n.d.) highlights that regulation 124 states that determination and assessment of risks must be carried out by the employer, and that during this task, the employer must ensure that the risk assessment meets the requirements of the regulations. this assessment must be conducted: when employees are liable to be exposed to noise at work, which is above lower levels of exposure. when employees are exposed to levels of noise whose safety or health is particularly at risk. when any effects on employees’ safety and health result from any interactions between noise and work-related ototoxic substances, and between noise and vibrations. when there is an indirect effect on employees’ safety or health from interaction between noise and warning signals, or other sounds that need to be observed to reduce risks of accidents. when information on noise emission is provided by the manufacture of work equipment, in accordance with section 16 of the safety health and welfare at work act 2005. if there is an extension of noise exposure beyond the normal working hours. this comes under the employer’s responsibility, or the action value, and the employer must consult with his or her employees or their representative and make an appropriate assessment to reduce the risks involved. when alternative equipment is made available to reduce noise emission. close analysis of the afore-listed occasions as to when risk assessment should take place, and by whom, reveals budgetary needs, which the current authors argue would sharply raise possible conflict of interest if there is no independent external risk assessor and strict accountability checking by the regulator. these costs extend to remediation requirements, for example, the availability of alternative equipment, which might be required to reduce the noise emission levels, availability and use of ear protection, as well as costs for review of risk assessment where the results of health surveillance show it to be necessary – as per regulation 131. the remediation steps that the employer can take to prevent or control the risks associated with onihl, as with any other hazard, fall under a hierarchy of control options that include elimination, substitution, personal protection equipment (ppe) and so on. specifically, noise elimination and control can be seen as engineering (e.g. control of vibration by damping or tightening parts in the noise source), administrative (e.g. by good procurement or ‘buying quiet’ or by rescheduling work to decrease exposure time of the employees involved) and personal protection (as a last resort by the use of suitably selected personal ear protection). the costs involved in removing the source of noise from the workplace, controlling the noise at source, implementing collective control measures (e.g. by engineering controls, such as enclosing the noise source; workplace design, such as isolating the noise source; or having suitable acoustics within the work area to reduce the transmission of noise) and supplying individual control measures (personal protective equipment) if the measures above are not adequate as an interim measure are the responsibility of the employer – and this has implications for the company’s bottom line. this is where the current authors identify the consequent introduction of a conflict of interest should the employer be expected to self-regulate; as is currently the expectation. the fact that companies use ppe (in the form of personal hearing protection devices) as their main hearing conservation measure, while failing to meet the basic rule of making the workplace as quiet as possible first, is an example of cost-cutting measures fuelled by conflict of interest of the employers. the current authors wish to raise a flag of caution about this conflict and argue that this situation is possibly at the core of the reasons why elimination of onihl milestones is not being met within the south african context. it therefore becomes critical that such benefit or risk evaluations of hcps are comprehensive, inclusive and ongoing with representation of all stakeholders – but with management and leadership from the regulating body – externally to and independent of the employer. standard hcps consist of six components designed to reduce the level of noise and to identify other ways to protect workers from onihl. these are: noise measurement; education and training for workers; engineered noise control; hearing protection devices; hazard awareness, including warning signs; and hearing tests for workers (amedofu, 2007; hong et al., 2013). over and above the conflict of interest issues raised earlier, the absence of audiologists as key members of the team in south african hcps raises important implications for onihl and hcps where ongoing benefit or risk evaluations are conducted. khoza-shangase (2017), in conducting the same exercise linked to pharmacovigilance, argued that benefit or risk evaluation should, at a minimum, be conducted by researchers (including those in the engineering field); physicians or clinicians or audiologists acting on behalf of their patients (employees); the patients themselves (employees or their unions’ representatives); and the regulatory authority, which decides on whether an hcp should be approved or not, whether it should be reviewed or withdrawn or not, while making recommendations about the alternative onihl-preventative measures for intermediate action. as in pharmacovigilance within the south african context, numerous challenges can be identified with each of these groupings responsible for this benefit or risk evaluation, particularly within the developing country context with unlimited employer–employee challenges and enforcement of regulation barriers. factors influencing benefit or risk evaluation in hearing conservation programmes within the south african context, benefit or risk evaluation can be significantly impacted by factors such as nature of the problem and its impact, indication for hcps and population under the programme, economic factors (such as costs involved, including compensation claims), stakeholders with vested interests in the hcp, as well as time, data and resources constraints. firstly, the nature of the problem that determines the time course of action, which usually defines the socio-medical seriousness of the suspected adverse noise exposure reaction and its potential threat to life, can be limiting when it comes to the inclusion of important quality of life side effects such as onihl. this is particularly so because onihl is a silent and invisible disability that, in this case, afflicts mostly the already vulnerable members of the society (poor uneducated older black men, who are sometimes immigrants from neighbouring countries). consequently, quality of life in the benefit or risk evaluation becomes less prioritised and requires much deliberation in the planning, implementation and monitoring of hcps. secondly, indication for hcps and the population under the programme also influences the benefit or risk evaluation. audiologists and regulators working in mines’ hcps need to be aware of the risks in the workplace (established through the determination and assessment of risks), factors influencing risks (such as age, burden of disease, exposure to concomitant risks to onihl and so on) and be aware of all circumstances where there are no reasonable elimination alternatives, and plan their hcps appropriately. for example, employees on treatment for tb at risk for ototoxic hearing loss are at an even greater risk for more significant onihl as the two ear toxins (noise and ototoxic medications) act synergistically; therefore, an hcp for these employees needs to take this into consideration. such hcps should acknowledge that hcps are complex interventions, as suggested by moroe (2018), and adopt more individualised strategies where required. when elimination is not possible, carefully planned and executed education and training of employees around hearing conservation with appropriate use of ppes should be provided, with stringent monitoring and early intervention strategies in place. thirdly, economic factors (such as costs involved, including compensation claims), particularly in lami countries like south africa, play a major role in benefit or risk evaluations (khoza-shangase, 2017). employers, in their concern about their bottom line quest for high profits, might accept health and safety conditions with less favourable benefit–risk balance because of the drive for profits as well as affordability of the hcp, when compared to the alternative; for example, ‘buying quiet’ might be more expensive than paying compensation for onihl. this is where the lobbyist role of audiologists should become heightened and the regulatory role of the minerals council south africa should be enforced, where mining companies are directly engaged with to ensure ethical accountability around employees’ health and safety where both profits (productivity) and employees’ quality of life are taken careful cognisance of. economic factors in benefit or risk evaluation are concerned with trade-offs and weighings where economic efficiency in terms of the difference between benefits and costs is measured (khoza-shangase, 2017). if quality of life’s ‘side-effects monitoring’ such as annual audiometric monitoring assessments did not form part of the hcp development process, then economic factors might be miscalculated. for onihl, permanent long-term hearing loss brings with it significant economic costs to both the patient and the state if not prevented and/or eliminated. firstly, loss of employment because of a hearing loss has implications for the economy of the country, and secondly, rehabilitation costs such as fitting of hearing aids and aural habilitation cannot be underestimated. this is over and above the compensation claims that the companies have to pay for onihl. fourthly, stakeholders with vested interests in the hcp, such as employees, occupational health physicians, mining companies, academics, ethics and health and safety committees, regulatory authorities, other public health bodies, compensation funds, labour and trade unions, may all have very different perspectives on benefit or risk evaluation of hcps. it is therefore important to be aware of who the stakeholders were during the determination of the benefit or risk of an hcp. as practicing clinicians and audiologists, the employees’ perspective seems the logical site for evidence base for objective collection of audiological data for onihl. in the south african context, sensitivity towards the influences of language and cultural diversity as well as the demographic and medical profile of employees to clinical management involved in hcps is important. two employees exposed to the same benefits and risks may view the risk differently, may be affected by the risk differently, may accept the risk differently and may also make different decisions around the risk. influences of language and cultural diversity may compound this level of risk evaluation. nonetheless, it is important that such a risk is clearly communicated to the employees not only for informed consent but also because proper pre-exposure counselling and education about side effects of excessive noise has been shown to improve adherence to safety measures, such as use of ppes (balkhyour, ahmad, & rehan, 2019). lastly, time, data and resources constraints significantly influence benefit or risk evaluation (council for international organizations of medical sciences [cioms], 1998). this is particularly important when the potential major risk is urgent. as onihl may not be considered a major occupational injury, the time urgency may not be taken seriously. however, it is important that sufficient data on comparator hcps or other hearing conservation strategies be obtained as early and as reasonably quickly as possible. that means accurate and sensitive standard hearing as well as noise measurement and monitoring protocols need to be implemented in all sites where noise levels above regulated levels are present. systematic, comprehensive and standardised hcps would facilitate collation of large databases that would allow for an easy review of onihl and the context and conditions surrounding it. the current status of hcps in south africa, which consists of non-standard and semi-regulated monitoring programmes, mostly conducted and managed by people whose jobs fall outside the scope of hcps, would negatively influence benefit or risk evaluation of any programme component. besides standardising the monitoring protocols, the audiology community as well as the regulating body would also need to address the issue of manpower and equipment constraints that are major contributors to the limited and less successful hcps in the south african context. within the south african context, when there are limited audiologists to population size, with an even lesser engagement of audiologists in occupational health settings, careful consideration about utilising trained non-audiologist screeners to implement hcps under strict audiologist management, as per regulations, need to be made. furthermore, serious deliberations around the use of tele-audiology to increase access, quality and control need to be undertaken. what the regulator and audiologists need to consider for benefit or risk evaluation in hcps, the regulator and the audiology community need to carefully engage in scoping the context, benefit evaluation, risk evaluation, benefit–risk evaluation, options analysis, as well as deciding of the available options, which are appropriate for the context. firstly, as far as scoping the context is concerned, each context needs to establish the risk profile of the mine’s context as well as the specifications or descriptions of the hcp implemented within their context. this needs to be continuously updated as new risks (e.g. introduction of additional toxins such as ototoxic medications) and/or new noise-generating equipment or hearing protection devices (hpds) are introduced in the mine. establishing indications for use and review of hcps based on the factors, such as levels of noise, burden of disease as well as the various shifts within the mining industry, is crucial. once indications have been established, identification of one or more alternative preventive measures (including ‘buying quiet’) forms part of the important considerations. lastly, scoping the context also includes establishing and providing descriptions of the suspected or established onihl diagnosis. establishing the time, the degree and the progression of tinnitus and hearing loss is important. secondly, benefit evaluation is another important consideration to be made during benefit–risk evaluation. the current authors strongly believe that this should be led by the regulating body. this evaluation involves studies of the incidence or prevalence and the natural history of the target disease (khoza-shangase, 2017) – in this case onihl. it also entails establishing the purpose of hcps, and how this influences the occurrence of onihl in this population. furthermore, benefit evaluation involves comparison of information on efficacy and general toleration data toalternative preventive measures. these alternatives include the use of other strategies, such as pharmacotherapeutic intervention strategies namely, the use of oto-protective agents as well as the option of elimination of noise. thirdly, an area where audiologists should be significantly involved is risk evaluation. risk evaluation is another consideration where the weight of evidence for the suspected risk (onihl) in terms of incidence and/or prevalence is established. it is also the process where ‘risk profiles’ with their most common reactions to the target hcp as well as similar profiles for alternative hcps are drawn up, and comparisons are made. this requires proper record-keeping as well as the use of standardised protocols that will allow for proper and accurate comparisons. risk evaluation for onihl would include detailed presentations and analyses of evidence such as audiograms, distortion product (dp)-grams and noise-level measurements, where extraneous variables such as concomitant treatments (e.g. in hiv or tb treatments), concomitant presbycutic hearing loss and so on are either eliminated or carefully controlled for. considerations of preventability, predictability and reversibility of onihl also form part of risk evaluation. strategies such as the use of ppes, oto-protectors, less ototoxic medications, where such medications are prescribed for medical conditions such as tb in employees, redeployment to less noisy environments when the risk is higher, shift manipulations and so on become key during this process. fourthly, all the above-listed considerations allow for benefit–risk evaluation where the purpose and effectiveness of hcps as well as benefits related to the seriousness of onihl are summarised. moreover, dominant risks and their severity, duration and incidence are also summarised. lastly, taking into account alternative preventive measures, the benefit–risk relationship is also summarised. this process can be properly performed only if evidence with regard to appropriate medical, audiological, engineering and administrative controls has been collated, analysed and presented during the establishment of the benefit–risk relationship. lastly, once the risk–benefit relationship has been established, it is important for audiologists to engage in options analysis where a list of all appropriate options for action is determined. this is where the pros and cons and the likely consequences (impact analysis) of each option under consideration are described, and the manner in which the consequences of the recommended action should be monitored or assessed is suggested (cioms, 1998). it is anticipated that this is the process that would be the most challenging for audiologists in this industry where available options are significantly influenced by financial implications for the companies involved, as well as demand-capacity challenges. these available options include maintenance of the status quo when there is no evidence for onihl concern; ‘watching and waiting’ which involves monitoring subsequent experience of onihl if insufficient evidence exists and additional data are gathered; intensive additional data gathering or new research that can be clinical or non-clinical involving standardised protocols for data collection in clinical and non-clinical settings; modifications to the hcps or their use or amendments to the information on hcp components; suspension of hcp licence if found not to be efficacious; withdrawal of the hcp from the specific mine, which can be voluntary or mandatory; as well as communication of new or reinforced information to the regulating body, the mines, the occupational health profession or the employees about the hcp. decision-making: principles to consider when deciding on the options decision-making during benefit–risk evaluation needs to be conducted by a multidisciplinary and/or multi-stakeholder team guided by principles including objectivity, equity and accountability (cioms, 1998; khoza-shangase, 2017). objectivity, firstly, refers to objectivity of the evidence base for all relevant sources by a variety of methods (observational, epidemiological and experimental) and evidence gathered by people who are not conflicted with regard to conflict of interest. secondly, it refers to expertise, which is led by the regulator and includes the employers as well as the employees. the principle of objectivity ensures avoidance of bias and conflict of interest. it calls for scientific decision-making such as use of algorithms and matrices, and it ensures that decision-making is based on explicit predetermined criteria (khoza-shangase, 2017; tsintis & la mache, 2004). the audiology community would need to establish and standardise monitoring protocols that can facilitate objectivity in decision-making. as far as the principle of equity is concerned, all evidence-based hcps should be treated fairly. this principle dictates that decision-making must be transparent, sensitive and specific; follow due process; be an open process; and involve consultation with relevant stakeholders, utilising an appropriate comparator (khoza-shangase, 2017). the principle of accountability highlights that the expected outcomes must be specified or estimated; that criteria should be established for determining and assessing the effectiveness of the actions chosen; and that if action was not total elimination of noise, data must continue to be collected for ongoing monitoring of safety. immediate plan: what audiologists should do audiologists need to make sure that when excessive occupational noise exposure is present, pre-exposure education to ensure awareness and therefore use of ppes is in place. this is after the hierarchy of controls has been observed. in spite of the fact that there are currently limited alternative options where elimination is not possible or has not been implemented for an employee who is desperate for employment, it still remains an ethical obligation to inform the employees of potential harm in the form of onihl. this has the benefit of facilitating prevention and/or early identification of onihl because the employee will be aware of, and adhere to, hcp strategies, and will also be encouraged to attend monitoring sessions. furthermore, pre-exposure education about possible impacts of noise has a positive impact on programme adherence, as employees will be less likely to default on preventive measures because of unknown, unexplained or unanticipated signs and symptoms. regardless of the fact as to whether typically permanent threshold shift has occurred, the cochlea cannot recover and so early identification of onihl is crucial. along with rimary prevention, early detection of hearing loss is important for providing management options, such as changing or modifying of hearing protection devices to potentially more effective, custom-made hpds; manipulating shifts and exposure times for the employees involved; planning audiological management and counselling; complete removal from noise if synergistic effects of ototoxicity and noise are at play; amplification in cases of severe hearing loss; compensation, among others as far as alternative medical intervention is concerned, audiologists, physicians and pharmaceutical companies should intensify their efforts towards development and building the evidence base for oto-protective agents, which can serve as a preventative measure where excessive noise exposure cannot be avoided. oto-protective agents in the form of compounds, such as vitamins a, c and e (ace) magnesium, d-methionine (sulphur-containing compound) and l-n-acetylcysteine, should be investigated (le prell et al., 2014). furthermore, restorative care that involves regeneration of hair cells damaged by toxins through the use of neurotrophins also needs careful consideration (wissink, moes, beisel, & fritzsch, 2006). these strategies are especially important in lami country contexts for strategic long-term financial savings that will be made by eliminating potential litigation costs, amplification device costs, rehabilitation costs as well as social-grants-linked costs because of the economic impact associated with unemployment of the affected individual (khoza-shangase, 2017). future directions the regulating body needs to carefully deliberate on its role in regulating adherence to regulations around occupational health in the south african mining industry. the current player or referee role that the mining industry holds when it comes to health and safety of its employees needs to be reviewed – with external independent accountability in place. for large sets of data that can be used to establish evidence that is enough for benefit or risk evaluation in hcps, audiologists need to engage in occupational audiology studies where onihl vigilance is prioritised in order to meet the elimination targets. this vigilance should take careful cognisance of the influence of the burden of disease, such as ototoxicity, because of tb in the mining population. while the above studies will involve currently implemented hcps, parallel studies on alternative hcps, including ‘buying quiet’ and using oto-protective agents, should also be run in order to allow for the development of lists of options for ethical benefit or risk assessments. this is important because establishing benefit or risk without any alternative options can be argued to be an unethical practice. also continuing to expose employees to noise levels with well-established ear and hearing effects because there are no alternatives is not best practice, and it impinges on the employees’ human rights. audiologists’ active and strategic involvement in hcps, through establishing hearing, monitoring and educational programmes, would facilitate the establishment of evidence in these contexts to demonstrate the important role that the audiologists have in both the assessment and treatment of employees at risk for onihl. their active involvement in task teams putting together hcp guidelines, using evidence base to continuously inform policy, would ensure that this often neglected disability is also considered in the benefit or risk evaluation processes. audiologists’ role in lobbying and advocating for their expanded role in health and safety programmes, hcps approval, and hcps implementation and monitoring is paramount for a useful engagement in benefit–risk assessment for all hcps. involvement in advisory panels on benefit, risk and cost management of hcp components where the risk of onihl is a reality, as well as providing recommendations on communication and awareness programmes for the employees on onihl, should form part of the workload for audiologists involved in hcps. all this can be performed through employing various service delivery models, including the use of tele-audiology and task shifting. risk versus benefit assessments in this context should be guided by the amount of risk the employees are exposed to as well as the contributing factors. therefore, exposure quantification as well as noise level measurements are key in determining the timeline or frequency as to when the risk or benefit evaluations should be performed (biannually, annually, etc.). at a bare minimum, risk or benefits should be performed annually within a dynamic risk assessment approach, with audiologists playing a key role in leading and managing the process. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions k.k.s. took the lead in the writing of the manuscript, with inputs from n.m. both authors co-conceptualised the idea for the research as well as the design and methodology adopted, and read and approved the final manuscript. ethical considerations this article followed all ethical standards for a research without direct contact with human or animal subjects. funding information the authors thank the national institute for the humanities and social sciences (nihss) and the consortium for advanced research training in africa (carta) for providing financial assistance for the publication of this manuscript. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references african union (au). 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(2015). noise induced hearing loss and its correlation with audiometric observation in heavy vehicle operators suffering with metabolic disorders. international journal of medical and clinical research, 6(1), 315–320. abstract introduction contextualisation of the study empirical literature theoretical model and hypotheses formulation research purpose research results acknowledgements references about the author(s) miston mapuranga school of managerial leadership, the da vinci institute for technology management, johannesburg, south africa eugine t. maziriri department of business management, faculty of economic and management sciences, university of the free state, bloemfontein, south africa ralebitso k. letshaba department of human resource management, faculty of management sciences, vaal university of technology, vanderbijlpark, south africa anos chitamba graduate school of business and leadership, college of law and management studies, university of kwazulu-natal, durban, south africa citation mapuranga, m., maziriri, e.t., letshaba, r.k., & chitamba, a. (2020). does occupational noise matter amongst manufacturing (small and medium enterprises) workers? empirical evidence from magaba, mbare, zimbabwe. south african journal of communication disorders, 67(2), a680. https://doi.org/10.4102/sajcd.v67i2.680 note: special collection: occupational hearing loss in africa. original research does occupational noise matter amongst manufacturing (small and medium enterprises) workers? empirical evidence from magaba, mbare, zimbabwe miston mapuranga, eugine t. maziriri, ralebitso k. letshaba, anos chitamba received: 01 oct. 2019; accepted: 04 feb. 2020; published: 03 mar. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the significance of how occupational noise can influence attitudes towards occupational noise exposure, susceptibility to hearing loss and job performance has generally been neglected in the past studies. objectives: the aim of this study was to determine the impact of occupational noise on attitudes towards occupational noise exposure, susceptibility to hearing loss and job performance of manufacturing small and medium enterprises (smes) workers in zimbabwe. method: a survey was conducted involving 250 respondents, including manufacturing sme workers, and the hypotheses were analysed by applying structural equation modelling. results: occupational noise had a positive and significant effect on attitudes towards occupational noise exposure and perceived susceptibility to hearing loss amongst manufacturing sme workers. in addition, attitudes towards exposure to occupational noise and the perceived susceptibility of hearing loss have had a positive and significant impact on manufacturing sme workers’ job performance. conclusion: the novelty of the research is its analysis of occupational noise as an indicator of attitudes towards occupational noise exposure and susceptibility to hearing loss as well as job performance. this study provides practitioners with beneficial implications. collective knowledge on occupational noise could help manufacturing sme managers in recognising the perceptions of employees on occupational noise and how it ultimately affects job performance. moreover, this study is intended to add new knowledge to the current body of african occupational noise literature – a context that has not received much research attention in developing countries. keywords: attitudes towards occupational noise exposure; job performance; occupational noise; perceived susceptibility to hearing loss; sme workers. introduction globally, noise has become a typical work-related danger and is probably the biggest reason for hearing loss (nelson, nelson, concha-barrientos, & fingerhut, 2005). occupational hearing loss is undeniably an inevitable condition of occupational health taking place all over the world. it could be exacerbated by a couple of components at workplace, for instance, ototoxic substances and noise (liu et al., 2015). a basic medical concern with economic outcomes is noise-induced hearing loss (nihl) at workplace (lie et al., 2016). occupational noise-induced hearing loss (onihl) is a disease that arises from exposure to noise in working environment or from non-noise agents (martínez, 2012). it takes place at a wide range of workplaces, including printing, food production, metal mining and assembly (liu et al., 2015). in a lowand middle-income (lami) nation such as zimbabwe, the factories and works act, chapter 14:08 (zimbabwe government, 1996a) anticipates that supervisors would lawfully make every single viable move for the welfare and protection of employees and individuals at their premises. this act specifies that all workers ought to be appropriately trained and, when under supervision, are appropriately supervised by a capable individual, furnished with personal protective equipment and clothing where necessary, and that these are utilized, so that these workers are shielded against risky machinery, dangerous procedures, as well as dust and noise (chadambuka, mususa & muteti, 2013). singh, bhardwaj and deepak (2013) attest that exposure to occupational noise (on) actually leads to onihl. obviously, onihl has become an unavoidable work-related condition throughout the world, and is accounted to occur in quite a number of workplaces. as commented by dudu and jeche (2014): approximately 11 million people in the united states alone are exposed to hazardous noise levels in the workplace and 9 per cent of the total workforce in sweden is exposed to this conceivably dangerous level of noise. (p. 22) in china, onihl is predominantly found ‘among workers in municipal solid waste landfills’ (liu et al., 2015:1). a large portion of these examinations are directed in developed nations. evidence from lami countries such as india shows that employees in indian smes perform in a less technically developed and much noisier environment, and yet very limited literature is available on onihl in such contexts (singh et al. 2013). arising from the previously mentioned international investigations, research focussing on on in manufacturing smes, especially in africa, is inadequate. al-arja and awadallah (2020) have clarified that in developed nations, not many investigations have examined on. therefore, it would be naïve to assume a priori that findings from developed countries in europe or from the united states of america, or even from the newly developed countries in asia, apply in africa. perhaps, an exploration on the effect of on on attitudes towards on exposure, susceptibility to hearing loss and job performance in the african settings could yield insightful outcomes in comparison to those from the developed nations of the world. subsequently, neither to affirm nor disconfirm past investigations, this investigation focuses on on in manufacturing smes of africa. this was long overdue, as this lacuna merits exact assessment on account of an overlooked setting of manufacturing smes in developing nations. even though past investigations have examined the impact of on on human well-being because of unidentified reasons, small enterprises, industries and workshops have not been included, although limited studies, especially in lami nations, have directed their attention towards this issue (jabbari et al. 2016). anjorin, jemiluyi and akintayo (2015) observe that research has been conducted to assess industrial noise in the refining, mining, oil and gas, construction and manufacturing industries, and the findings have shown that a high percentage of industrial workers in these industries have been subjected to more than 85 decibels (a-weighted) (db[a]) noise levels. despite this evidence, high noise levels have been underestimated in small enterprises in lami nations, such as zimbabwe – focus of this article. to date, few studies have investigated occupational hazards, such as noise levels in the working environment, in zimbabwe. this research was conducted in a different context, focusing on the following industries in zimbabwe: prevalence of nihl amongst mining employees (chadambuka et al., 2013); occupational health and safety concerns amongst workers in the wood processing industry in mutare (jerie, 2012); study of hearing protection system (hcp) at a mining company (mutara & mutanana 2015) and evaluation of industrial noise levels in plastics industry (dudu & jeche, 2014). in this way, deducing from the previously mentioned examinations directed on zimbabwe, it is noted that studies concentrating on how on affects attitudes towards on exposure, susceptibility to hearing loss and job performance amongst manufacturing sme workers is regularly portrayed as shallow and needs further scholarly introspection. moreover, lack of research on on, attitudes towards on exposure, susceptibility to hearing loss and job performance relationship are without doubt incomprehensible and warrant scholarly examination. maybe the most convincing contention for examining the effect of on on attitudes towards on exposure, susceptibility to hearing loss and job performance emanates from the way the past investigations (girard et al., 2015, p. 88; mctague et al., 2013, p. 3; sriopas, chapman, sutammasa, & siriwong, 2016, p. 1) on these constructs have, for the most part, centred around large firms and little was examined in the case of smes. this is all the more astonishing, considering that smes are commonly seen as the engine for business growth, financial progress and transformation in both developing and developed nations (chinomona & pretorius, 2011). besides, these earlier investigations have, to a great extent, focused on developed nations (chinomona, lin, wang, & cheng, 2010). in this way, little is known on these issues in sami nations of the world, for example, african nations – specifically zimbabwe. therefore, this lacuna merits observational assessment on account of the disregarded setting of manufacturing smes in developing nations. furthermore, it is important to point out that not many scholars (if any) have used structural equation modelling (sem) to check the causal links of on, attitudes towards on exposure, susceptibility to hearing loss and job performance. regarding this study’s conceptual model, it is exceptional as it is tested in a developing nation setting. this article pursues a structured set. to begin with, this examination is placed in context. secondly, the empirical literature for the study’s variables is reviewed, thus prompting development of research hypotheses. thirdly, the section on research design and methodology follows. finally, there is a presentation of findings, discussions, conclusion, limitations and directions for the future research. contextualisation of the study background of the study area this section provides details about the study site, magaba, in mbare, harare. mbare township is a high-density suburb, originally designed as a dormitory location to house black africans working as domestic servants and industrial workers in harare city (helliker, chiweshe, & bhatasara, 2018; zinyemba & changamire, 2014). magaba (meaning ‘empty tins’), a geographical area within mbare, is approximately 3.9 km from harare’s central business district (helliker et al., 2018). it was unofficially established in the 1950s by a small group of tinsmiths who produced tin cans and other steel products to generate income. magaba is also home to businessmen running informal businesses ranging from welding, tinkering and engine mechanics to sales and catering of building materials (zinyemba & changamire, 2014). in addition, heavy-duty businesses, requiring technical skills as well as physical power, characteristics mainly attributed to men in zimbabwe’s society, are primarily established in magaba (zinyemba & changamire, 2014). dongo (2016) discovered that in magaba’s residential-cum-industrial area, the sound of welding machines could be deafening; to communicate, and to be audible, people usually shout over the noise. rationale and importance of selecting manufacturing small and medium enterprises and their workers laird, olsen, harris, legg, and perry (2011, p. 145) note that smes face unique problems in the area of occupational health and safety (oh&s) as opposed to larger companies, primarily because the risk of occupational hazards is greater and the capacity to mitigate hazards is lower in smes. similarly, reinhold, järvis and tint (2015) claim that on concerns in smalland medium-sized businesses are increasingly an after-effect of inadequate hazard management and lack of resources than the real size of present hazards. small businesses are widely acknowledged to be exposed to extreme on and have limited resources to monitor such risk, but the literature, in general, tends to focus on small businesses as a matter of regulatory and enforcement (hasle, limborg, kallehave, klitgaard, & andersen, 2012). employees of smes are subjected to industrial noise from a wide range of sources, such as compressors and hydraulic machines in garages, warehouses and repair areas, portable power tools, heavy machinery and other equipment (anjorin et al., 2015). moreover, nihl has been recorded in the five main occupational illnesses in zimbabwe (chadambuka et al., 2013). empirical literature this section centres on exploring literature on the variables under scrutiny. occupational noise abulude, fagbayide and akinnnusotu (2018) state that noise should be seen as a performance impediment within an organisation. wang, qin, lui, han and chen (2013) elucidate workplace noise as a repetitive sound heard at a place of work. occupational noise is defined in a similar vein as any unwanted sound being produced in working environments (al-arja & awadallah, 2020). zare et al. (2015) have stated that the most lethal industrial factor experienced in developing countries is on. in zimbabwe, the factories and works regulations (general) 1976 (zimbabwe government, 1996b) specifies that ‘no one shall be subjected to sound levels exceeding the limits, 90 dba, unless that individual is equipped with ear protectors’. past empirical studies have shown substantial evidence of positive relationship between workplace noise and blood pressure as well as the heart rate of workers in the steel industry (zamanian, rostami, hasanzadeh, & hashemi, 2013), speech recognition (prell & clavier, 2017), quality of life (otoghile, onakoya, & otoghile, 2018) and hearing abilities of workers in the quarry sector (gyamfi, amankwaa, sekyere, & boateng, 2016). therefore, it is important to understand how on could influence attitudes towards on exposure and perceived susceptibility to hearing loss (psthl). attitudes towards occupational noise exposure an attitude is a person’s enduring favourable or unfavourable evaluations, emotional feelings and action tendencies towards a certain behaviour (roberts-lombard & parumasur, 2017). attitudes can be characterised as the general assessment of an individual playing out a particular conduct (celik & yilmaz, 2011). if the behavioural attitude is positive, the willingness of the individual to execute that specific behaviour rises (ajzen, 1991). in light of the above clarifications, it could be seen that if an individual has a horrible frame of mind towards on, their activity execution (job performance) is probably going to be influenced. therefore, with the end goal of this investigation, the researchers are seeking to determine attitudes towards on exposure. gyamfi et al. (2016) clarified that initial sensitivity to ambient noise is perceived as a rise in the hearing threshold. nevertheless, sogebi, amoran, iyaniwura and oyewole (2014) argued that apart from being widely accepted as an inconvenience and a source of attention loss, workplace noise exposure often affects the output of employees. the authors also cautioned that the hearing loss was caused in workers who are regularly exposed to workplace noise. a research conducted by nyarubeli, tungu, bratveit and moen (2019) has reported that in developing nations, nihl is an emerging problem of public health. nyarubeli et al. (2019) credit this to rapid industrialisation as well as failure by institutions, that is, government departments and organisations, to provide preventative measures. for instance, regulators, such as inspectorates from the ministry of labour, international labour organisation (ilo), zimbabwe office, the ministry of public service, labour and social welfare, and the national social security authority (nssa), need to accommodate precautionary measures against noise. rantanen, lehtinen, valenti and lavicoli (2017) acknowledged that there is scant literature and awareness amongst the working population about noise exposure. nyarubeli et al. (2019) suggest that this shortage of literature has an impact on the information that workers have on on. perceived susceptibility to hearing loss perceived susceptibility, according to cornford (2018), is the feeling of being vulnerable to a disease and the degree to which the patient feels he or she is at risk of reaching that condition. safari, ahmadi, sare and ghorbanideh (2018) have stated that because noise is an occupational hazard, being exposed to tremendous on could result in a range of problems related to one’s work. a research carried out by khala, al-shereda and al-ansary (2012) has revealed that, since the industrial revolution, hearing loss because of exposure to workplace noise has been a topic of discussion. according to ismail et al. (2013), nihl is a short-term or long-term sensorineural impairment of hearing caused by exposure to on for a considerable period of time. khala et al. (2012) have reported that exposure to a loud sound or exposure to a sound for an ongoing duration destroys hair cells in the inner ear, resulting in noise-induced threshold shift (nits), a disorder attributed solely to noise. timmins and granger (2010) conclude that hearing loss caused by noise could occur immediately or slowly. khala et al. (2012) have further emphasised that the threshold change caused by the intensity and frequency of noise (nits) may be either temporary or permanent. job performance job performance in this study is regarded as the behaviours, attitudes and outcomes in which individual employees engage or bring about that contribute to the goals of an organisation (mafini, 2015). job performance is influenced by three main factors (farh, seo, & tesluk, 2012; kacmar, harris, collins, & judge, 2009), namely, declarative information (reality knowledge, concepts and objects), organisational knowledge and expertise (declarative knowledge execution capability) and motivation (engagement preference, commitment and persistence). workplace noise was found to be one of the most important predictors of job performance (al-omari & okasheh, 2017). based on its results, job performance is correlated with a variety of organisational outcomes, including customer service and product quality (blignaut, 2011), manager–employee relations and employee turnover (dalal & hulin, 2008), and job satisfaction (bono & judge, 2003). therefore, in terms of its meaning, job performance appears to be multifaceted and has a wide range of applications in terms of its outcomes. theoretical model and hypotheses formulation a theoretical model for the management of empirical examination is proposed, as shown in figure 1. the hypothesised relations between research constructs are discussed hereafter. figure 1: theoretical model. occupational noise and attitudes towards occupational noise exposure it is important to elucidate on the connection between on and attitudes towards exposure to on. a study conducted by alzahrani et al. (2018) has illustrated that 30% of reported cases of hearing loss are ascribed to exposure to on. according to keppler, dhooge and vinck (2015), a growing body of literature concurs that excessive on affects the attitudes of employees towards exposure to occupation noise. in a study carried out by abulude et al. (2018), on is taken as a nuisance occupational exposure. on the contrary, in gunny et al.’s (2018) study, on is seen as a distressing workplace noise exposure. therefore, the following hypothesis was formulated: h1: occupational noise has a positive and a significant impact on attitudes towards on exposure amongst sme workers. occupational noise and perceived susceptibility to hearing loss preliminary work on psthl undertaken by cornford (2018) revealed that exposure to on results to susceptibility to hearing loss. in addition, a study carried out by khala et al. (2012), which determined the effect of noise on basrah petrochemical factory’s workers, revealed that workplace noise leads to loss of hearing. world health organisation (who, 2015) further affirms that on damages the auditory system, thereby resulting in hearing loss. research carried out by kurt, mckenna, gunbeyaz and turan (2017), which investigated workplace noise exposure in a ship recycling yard, revealed that workers were at increased risk of induced hearing loss as a result of sustained, dangerous levels of noise at work. hence, a second hypothesis is formulated on the basis of this presumption: h2: occupational noise has a positive and a significant impact on perceived susceptibility to hearing loss amongst sme workers. attitudes towards occupational noise exposure and job performance studies conducted by klatte, berstrom and lachmann (2013) and hume, brink, and basner (2012) have revealed that on has an impact on job performance. in the same vein, nassiri et al. (2013) concur that exposure to on significantly affects the performance of employees. abbasi et al. (2019) further buttress the finding that on exposure increases stress levels and job dissatisfaction, which, in turn, affects the overall job performance of employees. deriving from the above studies and empirical evidence, following is hypothesised: h3: attitudes towards on exposure has a positive and a significant impact on job performance of sme workers. perceived susceptibility to hearing loss and job performance according to cornford (2018), the perceived susceptibility is the feeling of being susceptible to a disease and the degree to which the patient feels he or she is at risk of developing the condition. a study by wagner-hartl and kallus (2018) shows that hearing loss has a considerable impact on employee’s job performance. furthermore, a study conducted by edwards et al. (2011) in south africa expressed that hearing loss influences the job performances of employees. hence, it can be conceivably hypothesised that: h4: perceived susceptibility to hearing loss has a positive and a significant association with the job performance of sme workers. research purpose inferring from the hypothetical statements formulated in the preceding section, the purpose of the current research is to determine the impact of on on attitudes towards on exposure, susceptibility to hearing loss and job performance of manufacturing smes workers in zimbabwe. this would help devise strategies and establish preventive measures that could help minimise the risk of work hearing loss amongst exposed populations. the specific aims of this work are formulated as follows: to determine the impact of on on on exposure to examine the impact of on on psthl to assess the impact of attitudes towards on exposure on job performance to determine the impact of psthl on job performance. methodology the research philosophy of this study was positivism. hence, the study embraced a quantitative approach. quantitative research is to be based on a positivist paradigm of measuring variables (rahman, 2017). therefore, a quantitative research approach was used for this study. the design was suitable for requesting the information concerning on, attitudes towards on exposure, and psthl and job performance. the data were collected in 2019, and the population included workers from smes located in magaba, mbare. self-administered questionnaires were distributed to respondents from 350 manufacturing smes. of the distributed questionnaires, 250 were completed satisfactorily, resulting in a response rate of 71.4%. the research included both male and female workers of smes, who were aged 18 years and more. nonetheless, lack of reliable and accurate list of participants means the research was amenable to sampling procedures based on non-probability. the convenience sampling technique was used in the absence of an appropriate sampling frame (churchill, brown, & suter, 2010), as it has been cited as very beneficial practical method. measurement instrument and questionnaire design all the constructs in this article, except respondents’ demographic profile, were measured on a five-point likert rating scale with the endpoints of 1 = strongly disagree to 5 = strongly agree. the multi-item approach were adopted from past investigations and modified to fit the setting of the present examination (cornford, 2018; kaynak, toklu, elci, & toklu, 2016; nyarubeli et al., 2019; realyvásquez et al., 2016). the construct and scale sources, scale items utilised and cronbach’s alpha values for the scales are given in table 1. table 1: measurement scales and their sources. data collection the data were collected in magaba, mbare, zimbabwe. data collection refers to the detailed and systematic compilation of views and opinions that have the ability to resolve the research issue (murthy & bhojanna, 2010). for this analysis, a data collection survey method was suitable because a quantitative approach was used. mcdaniel and roger (2007) clarify that survey approach is used to obtain information about participants, including their views, attitudes and behaviour. similarly, blumberg et al. (2008) argue that this approach is the most preferred methodology for collecting essential information. precisely for data accumulation, the investigation utilised a structured questionnaire comprising a list of questions. the utilisation of the questionnaire was aimed at producing essential data valuable for enhancing response rate during the survey. ethical considerations permission was obtained from the administration of the harare city council. the researchers acquired the permission letter which permitted them to gather information from manufacturing sme workers. ethical clearance approval was affirmed genuinely, and this study acted as per the ethical benchmarks of scholastic research, which incorporate, in addition to other things, protecting the identities of respondents and guaranteeing secrecy of accumulated information obtained from respondents. data analysis data were analysed using the social sciences statistical package (version 25.0) for descriptive statistics, whilst model fit and path modelling were carried out using analysis of moment structures (amos) statistical software (version 25.0). the next section contains descriptive statistics related to respondents’ profiles. research results demographic profile summary table 2 shows the participants’ representation. the respondents were asked to report their demographic data, including gender, age and educational levels. the respondents were mainly males (80.0%). the average age of the respondents was between 40 and 49 years (18.4%). as far as the level of education was concerned, 37.6% (n = 94) of respondents had a diploma, 30.0% (n = 75) confirmed having a degree, 28.4% (n = 71) revealed having some basic training and the remaining 4.0% (n = 10) had no formal education. table 2: scale accuracy analysis. scale accuracy analysis the scale accuracy analysis is described in table 2, accompanied with a discussion on the reliability and validity of measurement scales. reliability and validity of measured items the internal consistency of the measured items was evaluated using the cronbach’s alpha coefficient, item-to-total correlation values, factor loadings, extracted average variance and composite reliability (cr). according to hair, black, babin and anderson (2010), the alpha value should be greater than 0.6 for constructs to be considered reliable. the test of reliability (table 2) for all the constructs suggests alpha values to be greater than 0.6. in addition, item-to-total correlation values ranged from 0.501 to 0.897, which reach the appropriate threshold of 0.5 (anderson & gerbing, 1988). this means that measurement instruments were accurate, and convergent validity was present. the loadings should be more than 0.5 (hair, black, babin, anderson, & tatham, 2006), as shown in table 2. in this study, the factor loadings ranged from 0.543 to 0.981, reaching the required value of 0.5. composite reliabilities and average variance extracted (ave) for each construct were computed by using the following formulae proposed by fornell and lacker (1981, p. 22): where crη is the composite reliability, (σλyi)2 is the square of the summation of factor loadings and (σεi) is the summation of error variances. where vη is the ave, σλyi2 is the summation of the square of factor loadings and σεi is the summation of error variances. as shown in table 3, the minimum cr value of 0.80 is well above the recommended value of 0.6 (hulland, 1999), whilst the lowest ave value of 0.53 is also above the recommended value of 0.4 (fraering & minor, 2006). it demonstrates the achievement of convergent validity, and shows the excellent internal consistency and reliability of the measuring instruments used. as such, all constructs showed a sufficient degree of discriminating validity (see table 3). such findings have, by and large, provided evidence of acceptable levels of reliability of the study scale (chinomona & chinomona, 2013, p. 20; chinomona & mofokeng, 2016). table 3: sample demographic characteristics. the discriminant validity refers to items measuring different concepts (field, 2013). the findings of the discriminant validity study are reported in table 4. as depicted in the table, all correlation coefficients of this study were below 0.70, thereby confirming the theoretical uniqueness of each variable in this research (field, 2013). table 4: inter-correlations for independent and dependent variables. structural equation modelling approach a double-step approach was followed to conduct sem. firstly, the psychometric properties of the measurement model were inspected through confirmatory factor analysis, whilst the second step (sem) concentrated on testing the structural model and determining causal relationships amongst variables. the following section provides the model fit investigation of these two stages. model fit analysis acceptable model fit indices used in this study included the following: chi-square/degree of freedom (χ2/(df)) ≤ 3.00, comparative fit index (cfi) ≥ 0.90, tucker and lewis index (tli) ≥ 0.90, incremental fit index (ifi) ≥ 0.90, normative fit index (nfi) ≥ 0.90, goodness of fit (gfi) ≥ 0.90 and the root mean square error of approximation (rmsea) ≤ 0.08 (lysons & farrington, 2012). table 5 provides the general model fit indices for both confirmatory factor analysis (cfa) model and sem. table 5: general model fit statistics. outcome of hypotheses testing for the present study, hypothesis testing was conducted by assessing path coefficient values and p-values for structural model (table 6). path coefficients were generated in the model by the causal relationships proposed in this analysis. based on the coefficients, the hypotheses were examined. table 6: summary of hypotheses testing. outcome of testing hypothesis 1 hypothesis 1 states that ‘occupational noise has a positive and significant impact on attitudes towards occupational noise exposure amongst sme workers’. in light of the outcomes of the last model tested, the connection between on and attitudes towards on exposure shows coefficient β = 0.364 at p < 0.01. this shows that h1 is supported. subsequently, it is noticed that on impacts the attitudes towards on exposure of workers within smes. it is likewise fundamental to make reference to the fact that these discoveries authenticate the outcome of the research conducted by ranga, yadav, yadav, yadav, and ranga (2014, p. 117), who explained that on is a key worry for the workers utilised in the work environment having tenacious exposure to noisy atmosphere. the consequences of this examination, in addition, discover support in the investigation conducted by mohammadi et al. (2016, p. 1740), who exhibited that on is amongst the most genuine business-related dangers, which, notwithstanding on exposure, can deliver troublesome impacts on worker’s physical and mental prosperity. outcome of testing hypothesis 2 hypothesis 2 affirms that ‘occupational noise has a positive and a significant impact on perceived susceptibility to hearing loss amongst sme workers’. the structural model (figure 2) displays connection between on and psthl as evidenced by β = 0.257 at p < 0.01. subsequently, h2 is supported. the outcomes imply that on impacts apparent vulnerability to hearing loss amongst labourers in assembling smes. the outcomes received from testing this speculation concur with literature. for example, cornford (2018) uncovered that presentation to on brings about powerlessness to hearing loss. lie et al. (2016) underscored the positive and significant impact of workplace noise on perceived vulnerability to hearing loss amongst manufacturing sme workers. moreover, a study conducted by stucken and hong (2014) complements that on may add to the present moment or long haul edge changes; in any case, even momentary limit changes may incite a worker to conceivable enduring hearing loss. figure 2: the final structural model of the study. outcome of testing hypothesis 3 hypothesis 3 expresses that ‘attitudes towards occupational noise exposure has a positive and significant impact on job performance of sme workers’. in view of the results of the path model, the relation between attitudes towards on exposure and job performance shows β = 0.232 at p < 0.01. this proof exhibits that h3 is bolstered. the outcomes suggest that attitudes towards on exposure impact job performance of manufacturing sme workers. this is in accordance with the findings of hume et al. (2012) that attitudes towards on affect job performance. they are also in accordance with the findings of nassiri et al. (2013), who examined the impact of clamour on human execution. their investigation uncovered that exposure to on was found to be basic in diminishing job performance. it was additionally found by chandrasekar (2011, p. 1) that on presentation has a quick and imperative connection with efficiency and job performance of workers. outcome of testing hypothesis 4 hypothesis 4 expresses that ‘perceived susceptibility to hearing loss has a positive and a significant association with the job performance of sme workers’. in light of the results during the hypothesis testing stage, the relation between psthl and job performance shows β = 0.573 at p < 0.01. this proof exhibits that h4 is supported. the outcomes suggest that psthl has an association with job performance of manufacturing sme workers. it is additionally worth referencing that these discoveries fortify the outcomes arrived at in the investigation carried out by guarnaccia, mastorakis and quartieri (2013, p. 38), who set up that psthl influences job performance of workers. hong, kerr, poling and dhar (2013) confirm that there are various extreme negative results of hearing loss, including correspondence hindrance that could liberally affect down-to-earth limit, worker certainty and job performance. managerial implications the current examination involves a few implications for scholastics. a study of the findings indicates that on and psthl affect each other, as attested by a path coefficient of 0.257. for scholastics in the field of occupational hearing loss and independent company board, this discovery improves their comprehension of the connection between on and psthl, making this investigation a significant addition to existing literature. on the practitioners’ side, the outcomes of the present investigation provide arrangements from which sme managers and supervisors can profit. given the powerful connection between helplessness to hearing loss and job performance, as demonstrated by path coefficient of 0.573, directors of emerging smes in magaba, zimbabwe, should focus on methodologies that limit on inside their workplace, as noise is a contributing variable to hearing loss. conclusions, limitations and future research directions the present investigation affirms that on has a positive and significant impact on attitudes towards on exposure and psthl. moreover, attitudes towards on exposure and psthl had a positive and significant effect on job performance. regardless of the pertinent bits of knowledge offered by this study, current discoveries ought to be deciphered, considering significant methodological shortcomings. firstly, information utilised has been collected from manufacturing sme workers and not those in supervisory positions. the current authors concede that the outcomes would have been more thorough and intensive if information from both cadres was obtained. furthermore, the present investigation was restricted to a small manufacturing smes in one territory of zimbabwe, and surveys were utilised to gather information from respondents. this leads to the issue of generalisation of findings to the bigger populace, and the degree to which the consequences of the investigation might be summed up in different settings and situations. thirdly, the investigation technique embraced was quantitative. a qualitative enquiry could have incited knowledgeable and more beneficial data, for example, acquiring views on workplace noise from focus groups of sme workers and reporting the same as verbatim responses. along these lines, a subjective procedure could have uncovered that had it formed part of the methodological strategy. eventually, utilising triangulation would eradicate bias of the common method used. the future investigations could take into account these methodological shortcomings. besides, similarities and differences between the findings of this study and those acquired from different firms in various areas or through meta-investigations could likewise be considered later on. moreover, it is imperative to note that lack of noise and audiometry outcomes is also a major limitation of this study; even if a retrospective outcome of previous surveys and medical surveillance by workers had been furnished, this would have given a better picture of the problem under investigation. acknowledgements the authors would like to thank the editor and all anonymous reviewers for their invaluable comments and feedback. the authors are also thankful to the manufacturing sme workers who responded to this study. competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions m.m. and e.t.m. initiated this research and were the project leaders, concept developers, article structure designers, writers and data analysts. r.k.l. and a.c. reviewed the empirical literature section of the article and contributed to the writing of the research introduction and ramifications. funding information the authors wish to acknowledge the national institute for the humanities and social sciences (nihss) and the consortium for advanced research training in africa (carta) for financial assistance provided for publication charges of this article. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references abulude, f., fagbayide, d., & akinnusotu, a. 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(2014). challenges and survival strategies for women in small scale catering business: a case study of siyaso magaba, mbare. international journal of business, economics and management, 1(11), 372–381. about the author(s) katijah khoza-shangase department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa nomfundo moroe department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa ben sebothoma department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation khoza-shangase, k., moroe, n., & sebothoma, b. (2023). erratum: conducting clinical research in the era of the covid-19 pandemic: challenges and lessons for speech-language pathology and audiology research. south african journal of communication disorders, 70(1), a942. https://doi.org/10.4102/sajcd.v70i1.942 note: doi of original article published: https://doi.org/10.4102/sajcd.v69i2.898 correction erratum: conducting clinical research in the era of the covid-19 pandemic: challenges and lessons for speech-language pathology and audiology research katijah khoza-shangase, nomfundo moroe, ben sebothoma published: 23 may 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. in the published article, khoza-shangase, k., monroe, n., & sebothoma, b. (2022). conducting clinical research in the era of the covid-19 pandemic: challenges and lessons for speech-language pathology and audiology research. south african journal of communication disorders, 69(2), a898. https://doi.org/10.4102/sajcd.v69i2.898, an author name was incorrectly spelt as monroe. the correct spelling is moroe. the publisher apologises for this error. the correction does not change the study’s findings of significance or overall interpretation of the study’s results or the scientific conclusions of the article in any way. a transdisciplinary conceptual framework for the early identiocation of risks for comm disorders in young children 33 a transdisciplinary conceptual framework for the early identification of risks for communication disorders in young children alta kritzinger and brenda louwt, louis m rossettil i clinic for high risk babies centre for early intervention in communication pathology department of communication pathology university of pretoria 2 centre for communicative disorders university of wisconsin oshkosh, usa abstract the early identification of infants with communication disorders or at risk for communication delays is still one of the biggest challenges of early communication intervention (eci) and threatens to compromise its efficacy. current approaches to the early identification of young children at risk for communication disorders involve strategies aimed at the identification of general developmental delays and may not be sufficiently sensitive and specific enough to detect the early stages of communication disorders. the risks for mortality and health are often identified early in life, but the concomitant risks for communication disorders in the same young children are frequently not identified at that opportune time. the current study involved a descriptive survey, describing the identification of communication disorders in 153 subjects, whose data was stored in and retrieved from a customized eci database system. the findings revealed that the subjects were assessed at the average age of 18 months, but that identifications of risk conditions occurred prenatally, at birth, after the perinatal period and later in life. the time of identification related to the different communication disorders identified in the subjects and caregivers played a major role in detecting the first signs of communication disorders in their children. in order to provide a guideline for clinical practice, a transdisciplinary conceptual framework towards a coordinated effort for the early identification of risks for communication disorders in young children is proposed. i key words: caregivers, communication disorders, early communication intervention, early identification, '::::;;::;:~~:;:;:~ncel'ua1fnune"o'k i the process by wh~ch a family with an infant at risk for, or already presenting with a communication disorder, enters an early corfununication intervention (eci) programme is by way of identification of the risk condition. the importance of the earliest possible time of identification of a condition disrupting the typical communication development of a young child is now widely recognized and advocated in the field of eci (eddey, robey, zumoff & malik, 1995). according to rossetti (1993) the early identification of infants eligible for eci and the extent of ,parental involvement in the intervention process are the two strongest factors proven to significantly enhance the efficacy of the services. furthermore, the efficacy of early identification of communication disorders is based on the assumptions that the successful treatment of all communication disorders depends on early detection and treatment of the disorder or risk factors leading to a delay (asha, 1991) and that a strong correlation exists between communication skills and future school success (capute, palmer & shapiro, 1987). die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 yet, the early identification of infants with communication disorders or at risk for communication delays is still one of the biggest challenges of eci and threatens to compromise its efficacy (bland, 1996; squires, nickel & eisert, 1996). according to kochanek and buka (1995) available epidemiological data reveals exceedingly low identification rates of children with developmental disabilities from birth to three years of age. alternatively, the number 'of infants and toddlers with identified disabilities represents a small proportion of those children later identified with disabilities at ten years of age (kochanek & buka, 1995). some of the difficulties inherent in the early identification of communication disorders are the nature of identification programmes, the kind of identification strategies to apply to different populations of young children at-risk, the coordination of the different approaches and the implementation of these approaches in different contexts. cultent approaches to the early identification of young children at risk for communication disorders involve unidisciplinary or multidisciplinary strategies aimed at the identification of general developmental r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) delays and may not be sufficiently sensitive and specific enough to detect the early stages of communication disorders, such as infants and toddlers with autistic spectrum disorders (wetherby, prizant and hutchinson, 1998). the problem with unidisciplinary or multidisciplinary actions is also ~a~ there.}s liplited interaction across the differerit ,disciplines and early signs of communication disorders may not be "recognised as' such in a young child, or relayed to a speech-language therapist or an audiologist if these professionals are not present at the time of identification of delayed development. . the various identification strategies currently used by speech-language therapists and different professionals involved in the broad field of early intervention include developmental surveillance which entails brief evaluations of developmental skills over a period of time, applied to the total population of children, with the aim to monitor child progress (kochanek & buka, 1995; squires, et al., 1996); the use of epidemiological data, if available, to provide estimates of the total number of infants in different communities who are at risk for communication disorders (pattinson & hay, 1999; venter, christianson, hutamo, makhura & gericke, 1995); the medical diagnosis of established risk conditions such as chromosomal anomalies or genetic disorders, neurological . disorders, congenital malformations, inborn errors in metabolism, sensory disorders, atypical developmental disorders, severe toxic exposure, chronic medical illness and severe infectious disease (rossetti, 1996) of which the sequelae include communication disorders; strategies to employ caregivers' expert knowledge on their children's development in order to act upon their concerns (glascoe, 1997) and developmental screening with the sole aim not to exclude children and . families from early intervention services (hock long, 1996; kochanek & buka, 1995). emerging data regarding the efficacy of the various screeping strategies for different populations of infants at risk for communication disorders in different settings, indicates that the universal screening of all neonates for hearing loss appears to be a comprehensive strategy, since high risk registers employed in the past fail to identify those infants with a hearing loss of unknown origin (asha, 1994; boswell, 1998; northern, 1993). although universal hearing screening is a strategy proposed to improve the early identification rates of infants with hearing loss, it appears not to be a viable identification strategy in south africa, since no legislation and infrastructure exists to support such a national identification programme. the use of a risk register as a screening instrument, although found to be ineffective to detect hearing loss of all different origins, may be used in other populations of infants at risk for communication disorders. a checklist .' of risk factors known to be associated with delayed communication development and knowledge of specific predictors of communication disorders, such as prolonged feeding problems in infants at biological risk (kritzinger, 1994) may improve the reliability of screening measures employed. according to rossetti (1996) knowledge of infant mortality rates and the causes of inf.tnt death, provide valuable information about those infants eligible for early communication alta kritzinger, brenda louw & louis m rosetti 34 intervention, since the causes of infant death are also the causes of infant disability. however, the risks for mortality and health are often identified early in life, but the concomitant risks for communication disorders in the same young children are frequently not identified at that opportune time. , . . . . '. . . since speech and language disorders have the highest prevalence' of . any disability in children during the preschool years (gerber, 1990) and constitute the most common symptom of developmental disability in this population (rossetti, 1996), it is important to have a co. ordinated team :approach to identification in early intervention, utilising existing identification strategies for . the effective early identification of different types of , communication disorders in young children. the purpose of the article is to describe the process of identification of risks for communication disorders in a group of young children in a university-based early communication intervention programme. based on these findings a transdisciplinary conceptual framework for the early identification risks for communication disorders in young children is proposed which may be applied in different contexts in south africa. methodology the research design was a descriptive survey and the following aims were formulated: aims the main aim of the study was to describe the characteristics of a group of young children and their families participating in. an university-based eci programme and explain the initial process of identification of risks for communication disorders in these children, in order to propose a transdisciplinary conceptual framework for an improved identification approach in eci. the following sub-aims were formulated: • to describe when the risks for communication disorders were identified in the children. • to provide reasons for the course of events:in the identification process and how they pertain ito the different risks for communication disorders lin the children. . • • to indicate who identified the risk~, for conimunication disorders in the children. subjects the subjects employed in the study were 153 infants arid toddlers and their families referred to and assessed at chrib, an early communication intervention service delivery and student training facility. chrib has been operating at the department of communicatign pathology, university of pretoria, as a formal assessment and intervention clinic since 1990 (annual report 1990, department of speech pathology and audiology) and now forms part of the centre for,early intervention in communication pathology.' . the client population of infants and toddlers and their families served by. chrib is varied and depends on different referral' sources which includes a facial the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) a transdisciplinary conceptual framework for the early identification of risks for comm disorders in young children 35 deformities clinic, the down syndrome association, speech-language therapists, other allied health professionals, caregivers themselves and, to a lesser extent, medical professionals. sampling and selection criteria since no attempt was made to include each subgroup of the population of infants at risk for communication disorders in south africa in the selection of the subjects, the method of non probability convenience sampling was utilized (leedy, 1997). the subject characteristics in the present study will indicate a bias toward families who can afford to pay for services, as chrib is universitybased and not supported by the public health system as in the case of early intervention clinics based at public hospitals and primary health care clinics. the following two criteria for the selection of the subjects were applied: the subjects had to be assessed in chrib and had to have undergone the complete chrib assessment protocol (louw& kritzinger, 1995). subject characteristics -cleft lip and palate -down syndrome each subject had to be assessed by at least three of the team of four qualified and experienced data collectors employed at chrib, in order to ensure consistent data collection and recording procedures. (two data collectors worked simultaneously, the one to interview the parents and the other one to assess the child. the third and fourth data collectors took turns to perform the hearing testing). by applying the least restrictive subject selection criteria, it could be ensured that the largest possible number of subjects could be recruited within the time constraints of the empirical study. therefore, all infants and toddlers, together with their families, who were assessed at chrib between march 1996 (the starting date of the chrib database) and october 1999, and who complied with the selection criteria, were recruited as subjects for the empirical study. permission to use the data for research purposes was obtained prior to the assessment. as all families with infants or toddlers referred to and assessed in chrib received a letter to request that the data be used for research purposes, all clients were regarded as potential subjects in the empirical study. 79 51% 23 15% -other established risk conditions 8 5% -autistic spectrum disorder -multiple births -low birth weight and prematurity only -delayed speech and language development only -tongue tie only -afrikaans -english -portuguese -northern sotho -zulu -swazi -urdu -pretoria region -gauteng excluding pretoria -northern province & mpumalanga -north west province -kwazulu natal -free state -indian -african die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 4 3% 15 10% 10 7% 11 7% 1 1% 2 1% 71 46% 82 53% 101 66% 41 26% 4 2% 3 2% 1 1% 1 1% 1 1% 1 1% 86 56% 40 26% 9 6% 5 4% 4 3% 4 3% 1 1% 1 1% 135 88% 7 ·5% 6 4% 5 3% r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) according to table 1 the main diagnostic categories of the subjects reveal a wide variety of different conditions which pose an established risk for communication disorders, i.e. cleft lip and palate, down syndrome, autistic spectrum disorders, sensorineural hearing loss, microcephaly, agenesis of the corpus callosum, fetal alcohol syndrome, fetal roaccutane® syndrome, subarachnoid haemorrhage after surgery to remove a cyst and a suspected genetic disorder in one subject which was' unconfirmed at the time of data collection. while established risk conditions occurred in the majority of the subjects, 17% of the subjects presented with biological risks, such as low birth weight and prematurity, and multiple births. the remaining 9% of the subjects were categorized according to the main developmental problem they presented with, and could not be classified under the established or biological risk conditions already mentioned. these subjects presented with delayed speech and language development (11 subjects), a tongue-tie (one subject) and hyperactivity (two subjects). although not clearly evident in table 1, the different categories, especially the biological risk conditions and speech and language delay, were found not to be mutually exclusive and more than one risk condition occurred in each subject. the characteristics of the 153 subjects in table 1 revealed a markedly heterogeneous group of children, representing many of the young children from diverse backgrounds requiring eci in south africa. the similarities among the subjects' characteristics disclosed that the majority were boys of about 18 months old, presenting with cleft lip and palate, living in the pretoria region, are from white families and speak afrikaans as a home language. materials and apparatus the materials used in the empirical study were the chrib case history form (kritzinger & louw, 2000), the chrib assessment protocol (louw & kritzinger, 1995) and the chrib database system, which was modelled on these assessment materials. the chrib case history form (kritzinger & louw, 2000) is a questionnaire completed by the caregivers prior to the chrib assessment and supplies information regarding the child and family's biographical detail, the child's coriun.unication problem and diagnosis, the medical and ,developmental history, the caregivers' concerns about the child's speech-language development and hearing' abilities, their efforts to help the child thus far, and thei~:expectations of the assessment. the nature of the information obtained from the caregivers in the questionnaire were factual data as well as perceptioris, providing the researchers with information regarding the caregivers' knowledge and attitudes relating to their chifd's condit,ion. according to . girolametto, weitzman & clements-baartman (1998) and glascoe (1997), it is now generally accepted that caregivers are reliable sources of information about their children, although they may lack the specialized knowledge to interpret the information correctly. by obtaining the caregivers' opinions about their children's conditions, a family-centered approach to data collection could be achieved. alta kritzinger, brenda louw & louis m rosetti 36 the chrib assessment protocol (louw & kritzinger, 1995) was developed to provide the child with opportunities to display a variety of spontaneous and elicited communicative behaviours which were interpreted by utilizing developmental criteria, a variety of developmental scales and a few norm-referenced measurements. the protocol is based on the stage process model of early development and adapted from the holistic assessment model for infants with cleft lip and palate developed by louw (1986). the protocol covers all developmental areas, adhering to the principle that 'communication development is closely related to all other aspects of development and an assessment protocol should address these relationships (louw, 1986; prizant & wetherby, 1995). the database designed to store the data for the current study is a microsoft® access (aitken, fulton, plumley & wempen, 1997) relational database management system, structured according to the fifth normal form, and denormalized according to practical needs (kritzinger, , 2000). the database was installed in an intel pentium windows® based system, which contained the necessary hardware specifications in order to support the software of the chrib database system. procedures following the completion of the chrib case history form (kritzinger & louw, 2000), the subjects were assessed and all data was recorded and entered into the chrib database in the form of text data, numerical data and age interval data. in order to control the accuracy of information in the database, the data entering was done by the first author only. in order to perform statistical analyses, the data in the .chrib database system was converted to a flat-file structure in excel (microsoft® office 1997) so that the data could be processed and analyzed by' the sas® (1999) computer package. the different fields or data categories were analyzed by calculating frequency distributions, means, and two-way frequencies in. some circumstances. text data was analyzed and des~ribed qualitatively. i v alidity and reliability in order to ensure the validity and reliability of the study, careful consideration was given to the theor6tical validity of .the materials and the reliability of the assessment instruments, so that the same results will be obtained under-comparable conditions. the guidelines for the administration of the different assessment materials were adhered to, in order to . ensure consistent data collection procedures by all the data collector:s. a statistician was consulted in order to ensure relevant analyses for the particular type of data. the last step employed to demonstrate the internal validity of the empirical study, was to ensure that the fina(conclusions of the research were adequately supported by the data (de vos, 1998; mouton & marais, 1990). the south african journal of communication disorders, vol 482001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) a transdisciplinary conceptual framework for the early identification of risks for comm disorders in young children 37 results and discussion the advantages of data retrieval by means of an electronic database imply that voluminous amounts of data are readily available and the researcher is intimately involved with the process of data generation and manipulation. using the chrib database system (kritzinger, 2000) to access the large amounts of data, only the results pertaining to the identification of risks for communication disorders in the subjects were retrieved and will now be discussed. time of identification of risks for communication disorders in the subjects table 2 characteristics of the process of identification of risks for communication disorders in the subjects (n=ls3) according to table 2 the subjects presented with a broad spectrum of ages at the time of their chrib assessments, from three weeks to 77 months, with an average age of 18 months. the lower margin of the subject ages indicates that chrib succeeds in recruiting clients from the earliest possible stage, i.e. the neonatal stage, which is considered as one of the indicators for 41% 49% 10% 11 7% 8 5% 90 59% 8 5% 47 31% effective eci services (rossetti, 1993). effectiveness of intervention efforts is also illustrated in the finding that 59% of the subjects had some form of eci services before their assessment at chrib. on the other hand, the upper limit of 77 months indicates that 11 % of the subjects were only assessed at a very late age. table 3 print out of chrib database query of subjects older than 3 years (n=l1) key to table headings * id refers to the subject's chrib database identification number ** diagnostic classifications were made according to the icd-jo (css, 1996) the reasons for the late assessments of the 11 subjects in association. as these two subjects had no prior contact chrib are described in table 3 involved the following with any eci services and their conditions were circumstances: identified late, it is of great concern that subjects with two subjects were true late diagnoses and were conditions which may be readily identified at birth or subsequently diagnosed with established risk conditions. early in life, went unnoted. one subject (chrib id 62) was diagnosed with a four subjects (chrib id 57,78, 119 & 157) were moderate hearing loss at the assessment and was referred already receiving speech-language therapy al!d. were to chrib by the caregivers themselves, while the other referred to chrib by their speech-language therapists subject (chrib id i 171) was diagnosed with a for consultation with the chrib team, as these therapists developmental delay associated with microcephaly and requested specialist assessment and treatment guidelines. was referred to chrib by the down syndrome three of the four subjects were found to present with die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48,2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) autistic spectrum disorders when assessed at chrib and the fourth subject was found to have delayed speech and language development associated with recurrent otitis media. ' the remaining five subjects had various types of cleft lip and palate and were diagnosed as such at birth, but were referred to chrib as their speech-language therapists requested a consultation with the chrib team, or as a result of the caregivers' late response to an earlier referral to eci services. the results indicate that late identifications and referrals occurred very rarely among the 153 subjects and that early identification of risks for communication disorders is happening. the critical importance of time in eci is, however, emphasized in the example pertaining to the late diagnoses of subjects with autistic spectrum disorders, a concern also described by squires, et al. (1996) and wetherby, et al. (1998). according to these authors the diagnoses of autistic spectrum disorders are usually not confirmed until between two and a half and three years of age at best, which indicates that this population of infants who present with a serious alta kritzinger, brenda louw & louis m rosetti 38 communication disorder, is currently underserved by eci. the late diagnosis of subjects with autistic spectrum disorders assessed in chrib corresponds with findings of late diagnosis in clinical practice elsewhere (squires, et ai., 1996; wetherby, et al., 1998). as the first evident symptoms of autistic spectrum disorders are a delay in speech development, and very little is known about these children's early functioning to, accurately diagnose them at a young age (wetherby, et ai" 1998), it appears that eel can contribute to identify these children earlier. as further indicated in table 2 most of the subjects' risk conditions were identified early, i.e., at birth or during the perinatal period, or even prenatally by means of real time ultrasonography in a few instances (see table 4 as well). the reasons for the successful identification of the subjects at birth or during the perinatal period, may relate to the visual nature of cleft lip and palate and the relative familiarity of health care professionals with down syndrome (gerber, 1990; lubker, 1991). the early identification of subjects indicates that the majority could benefit from eci at a very early age, if referrals to eci were successful. table 4 prenatal diagnosis of the subjects' risk conditions (n=8) key * client id refers to the subject's chrib database identification number the results presented in table 4 not only indicate the high technological prenatal care which resulted in the earliest possible diagnosis in some of the subjects, but also reveal a new role for speech-language therapists (louw & kritzinger, 1998), specifically in chrib. this role involves the prenatal counseling of families in order to make informed decisions and to be. adequately prepared regarding the developmental risks of the diagnosed conditions in their unborn children and the importance of commencing with eci after birth. the advantage is that caregivers can be prepared prior to the time of active parenting of a child with a risk condition (louw & kritzinger, 1998). the results reported in table 4 indicate that prenatal informative counselling (thomson, 1995) and promoting increased public awareness of eci services should be seen as important functions in chrib. potential caregivers' increased .knowledge of risk conditions for communication disorders can lead to the earlier identification of infants at-risk and eventually to a higher success rate in the prevention of disabilities (gerber, 1990; kochanek & buka, 1995). as further indicated in table 2 and now elaborated in table 5, the remainder 47 (31 %) of the subjects were identified after the perinatal period. according to table 5 the identification of risk conditions in 31 % of the subjects after the perjnatal period includes a surprisingly wide spectrum of i conditions, from established risk conditions such as cleft palate and down syndrome, which are relatively easily diagnosable at birth, to conditions which only betome apparent when the child fails to start talking, to acquired conditions which can only be identified after\ the causative incident, e.g. acquired sensorineural he~ng loss and brain haemorrhage~ i upon closer inspection of the results, the 16 subjects with established risk conditions diagnosed after the perinatal period include five subjects with cleft palate in the absence of a cleft lip, which results in a less visible disorder and possibly easier to overlook at birth, tht; four subjects with autistic spectrum disorders who were already discussed as a subgroup of children most likely to be identified late, two subjects with down syndrome and one subject with each of the following dis6rders:' fetal alcohol syndrome, sensorineural,. 'hearing loss, microcephaly, an unknown sy,ndfome which was unconfirmed at the time of dat~/collection of the study, and agenesis of the corpus sallosum. the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) a transdisciplinary conceptual framework for the early identification of risks for comm disorders in young children 39 reasons for different times of identification for risks for communicaiton disorders in the subjects table 5 number of subjects per risk condition identified after the perinatal period (n=47) the results relating to the subjects with acquired communication disorders, expressive specific language impainnent, autistic spectrum disorders and hyperactivity indicate that not all subjects requiring eci services could be identified before or at birth, as there were no established or biological markers to indicate a risk status in the subjects. it appears that a conceptual framework for effective eci services at chrib should make provision for earlier identification on a continuum for subgroups of children who can only be identified later in life when their communication development becomes a concern. the other subjects in table 5 with conditions identified after the perinatal period, involved the 16 subjects with biological risk conditions present at birth, i.e. low birth weight, prematurity and multiple births. although presenting with risk conditions early in life, these subjects were only identified when their communication delay became a concern. the two subjects with hyperactivity were both identified by a child psychiatrist, and also only when their communication development became a concern. the one subject with hyperactivity was found to present with a communication delay and the other subject was found to present with nonnal communication development, but at risk for communication delay when assessed in chrib. the variety of conditions identified in the subjects after the perinatal period provides possible explanations to the concern raised by kochanek and buka (1995) that epidemiological data revealed low identification rates of children with disabilities between the ages of birth and three years. since the problem of late identification in the subjects was not restricted to one type of risk condition only, it could relate to a failure of caregivers and professionals to respond to the first identifiable signs of any of the risk conditions in the subjects. this failure to detect the earliest signs of a communication disorder could relate to a lack of knowledge about the condition as well as the sl}_btlety of its initial stages, and limited transdisciplinary communication across disciplines involved with young children. apart from the variety of conditions identified after the perinatal period in the subjects, these subjects were identified at different times in their lives by different people. each of these variables will be analyzed in tables 6 and 7 and the ensuing discussions. tllble 6 ages of subjects identified with communication delay after the perinatal period (n=45)* , average age: 19m average age: 25m key * the two subjects, chrib id 89 and 151, with acquired conditions were omitted according to table 6 the subjects with communication delay in the absence oj established risk jactors were identified at the average age of 19 months while the subjects with established risk conditions, even though they were identified after the perinatal period, were identified much earlier, at an average age of 10 months. this finding confinns rossetti's view (1996) that special attention should be afforded to the identification of infants at-risk, as the identification rate of infants with established risks is much higher. further analysis of ,the subjects in table 6 clarified the fact that the ag~ of identification of the risk die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 conditions in the subjects did not result in an earlier age of assessment at chrlb. numerous factors, some of which were discussed earlier, can be presented as possible explanations for the time lapse between the age of identification of risk conditions in a subject and the chrib assessment. some of the factors which could have influenced the age of the chrib· assessment in certain of the subjects relate to late identifications, late referrals, consultations requested by speech-language therapists and audiologists, late response of caregivers to referrals, the unavailability of eci services in the immediate community, the possibility that the caregivers and/or professionals were not aware of r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) eci and the benefits for very young children, and that a waiting list at chrib could have delayed some of the assessments. alta kritzinger, brenda louw & louis m rosetti 40 despite the different contributing factors to the late identification of risk conditions in the subjects in table 6, the subjects' caregivers played an important role in the identification of risk conditions in their young children. roles of caregivers and professionals in the identification of risks for communic~tion disorders in the subjects table 7 the roles of caregivers and professionals in identifying risk conditions in subjects after the perinatal period (n=47) . according to table 7 most of the subjects, i.e. 64% were first identified by their caregivers when they noticed a communication delay in their children. the remainder of the subjects, 36% were identified by professionals as presenting with a condition associated with communication qisorder, but it can be reasoned that the caregivers of these subjects had to be concerned about their childreri in the first instance in order to consult a professional. this confirms the major role that caregivers play in identifying risk conditions in their children and reiterates recent findings that caregivers are correct 79% of the time when they suspect a problem with their child's development (glascoe, 1997). it appears, however, that the caregivers' potential to contribute to th~ early identification and treatment of communication, disorders in chrib is largely untapped, as they were aware of their children's problems long before they were assessed. as the effectiveness of eci depends on the earliest possible identification of those children requiring the services (rossetti, 1996), the identification of clients needs to be viewed on a continuum. depending on the particular subgroup of children requiring eci and the nature of the child's communication disorder, early identification is an ongoing process over time and an eci service provider must be knowledgeable when certain subgroups of children can be identified and who the likely people are to identify them first. it appears that an early identification model relying on risk factors only will overlook some important subgroups of children requiring eci. a relevant model has to afford a key position to caregivers as it appears that they are uniquely positioned to identify communication delays and disorders in their children, provided they have the necessary knowledge about eci. the importance of caregivers at each stage on the continuum of early identification of risk conditions in their children echoes the centrality already afforded to caregivers in the entire service delivery process of eci (guralnick, 1997; rossetti, 1996) .. conclusions and implications the results of the study clearly indicated that there were limitations in the early identification of young children at risk for communication disorders. although most of the established risk conditions for communication disorders in the subjects were well known and commonly occurring congenital disorders, some of these subjects were not identified at the earliest possible times. the implications are that intervention could not start early enough to prevent the sequelae of the condition and that the benefits of early intervention eluded the child and the family. rare congenital disorders, such as fetal roaccutane® syndrome (briggs, freeman & jaffe, 1994), agenesis of the corpus callosum (kurtz, dowrick, levy & batshaw, 1997) and an unconfirmed genetic disorder also presented in the subjects which implies that not all established risk conditions are easily identifiable at birth or later in life. the results further indicated that autistic spectrum disorders and communication delays in the absence of other risk factors, are also conditions ~hich are difficult to diagnose early, most probably as a result of the subtlety of the initial stages of the communic~tion disorder (wetherby, et ai., 1998). \ importantly, the results also indicated subjects with biological risk conditions for communication disor~ers such as low birth weight and prematurity, multiple bij,1hs and hyperactivity were identified early in life, but the risk for communication disorders inherent to their conditions, was disregarded. since early identification and early commencement with intervention is one of the most important predictors of effective eci services (rossetti, 1993), the results of the empirical study emphasized the difficulties experienced in clinical practice to attain the goal of the earliest possible identification of all infapts' with risks for communication disorders. / :. the south african journal of communication disorders, vol48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) a transdisciplinary conceptual framework for tbe early identification of risks for comm disorders in young children 41 / / preconception 'period periconception period embryonic period fetal period perinatal period postnata~ i period i later periods in life careqivers origins of genetic and chromosomal disorders language impairment multiole births continued defective gene action and teratogens causing: malformations disruptions deformations syndromes uteroplacental abnormalities premature birth low birth weight perinatal complications feeding difficulties disease recurrent otitis media hospitalizations injuries delayed communication development i" other communication ,disorders i informative counselling if family history of the following are known: -genetic conditions -language impairment real time ultrasonography other prenatal diagnostic tests informative counselling parental guidance: information on communication development, risks and local eci services hearing screening screening for communication delay developmentally appropriate care continued eci diagnostic assessments supportive counselling parent guidance: information on communication development, risks and local eci services serial assessments figure i transdisciplinary conceptual framework for the early identification of risks for communicatio'n disorders figure i was conceptualized from: allen, 1995; glascoe, 1995; louw & kritzinger, 1998; rossetti, 1996; rubin, 1995; sadler, 1995; 1999; shprintzen, 1997; thomson, 1995; tomblin, 1989. die suid-afrikaanse tydskrifvir ko'mmunikasieajwykings, vol. 48,2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) since the results identified caregivers as key persons in the identification of risk conditions in their children, the implication is that they need to be equipped with knowledge of the risks for communication disorders in conditions such as low birth weight, prematurity and multiple births occurring in the infants, and how to act on their concerns about the infant's development. suggestions for the improvement of early identification in the subjects were indicated in the results. although caregivers are ideally placed to identify risks for communication disorders in infants as a result of their continuous involvement in their children (squires, et al., 1996), professionals, ass,isted by many different technologically based diagnostic procedures, are also present at important times when identification of risk conditions are possible. different health care professionals are involved at different times in young children's lives, e.g. at the prenatal diagnosis of risk conditions, at birth, during the perinatal period, at primary health care facilities and at family health care practices. various professionals, equipped with the necessary knowledge about risks for communication disorders and utilizing different identification strategies, are therefore indispensable members of the extended collaborative eci team responsible for early identification of risks for communication disorders, since eci has the unique opportunity to intervene at the earliest possible time iri an infant's life, early identification of risk conditions is the primary function of the eci approach, late identification of infants with risks for communication disorders results in late diagnoses, late referrals and late intervention efforts, which compromise the whole process of efficacy of eci. in order to face the challenge of the multifaceted problem of early identification of communication disorders in young children a transdisciplinary conceptual framework, which addresses the questions of who must be identified, when and by whom, is proposed in figure i (kritzinger, 2000), as illustrated in figure i the transdisciplinary conceptual framework for early identification of risks for communication disorders is proposed as a guideline for best practice to assist the eci service provider to identify the critical times of cascading biological events which can negatively impact on the young child's communication development and to identify these events as possible opportunities on a continuum for the identification of risks for communication development in the young child concerned. technological advances now allow the prenatal diagnosis of certain risk conditions in children which also affords the eci service provider the opportunity to provide informative counselling and support to caregivers. the conceptual framework also demonstrates the continuum of risk throughout a young child's life and indicates the different professional functions of eci during these periods. the different functions, executed by . ,different professionals involved in the early identification process, include the following: informative and supportive counselling to prospective caregivers, raising public awareness about risks for communication disorders and eel during the prenatal period. clinical efforts directed at transdisciplinary work with radiologists, geneticists and nurses involved in the prenatal identification and risk conditions for communication disorders must be explored alta kritzinger, brenda louw & louis m rosetti 42 (louw & kritzinger, 1998). this way the process of role transition, starting with role extension, and continuing with the phases of role enrichment, expansion, exchange, release and support, of transdisciplinary team interaction can be achieved (briggs, 1997). hearing screening, screening for communication delay, assessment, intervention in the form of developmentally appropriate care and information to caregivers about risks for communication disorders during the perinatal period. transdisciplinary activities and/or direct involvement by eci professionals must be initiated during this period where collaboration with paediatricians, nurses in labour wards, well baby nurseries and special care nurseries can improve the age of identification of infants at risk for communication disorders. developmental surveillance and serial assessments, followed by treatment by means of parent training, continued parent support and guidance during the postnatal period and later in the child's life. the set of professionals involved in the postnatal health care of infants, such as paediatricians, primary care doctors and nurses, in urban settings or community-based primary health care, as well as those providing daycare to infants, must also be viewed as members of a transdisciplinary team for the early identification of communication disorders in infants. lastly, health care professionals, such as primary care doctors and nurses, various medical specialists involved in health care of young children with disabilities, trauma and injuries, and persons involved in day care of young children must be equipped to identify risks for communication disorders later in a child's life and refer the families to local eci services. the focus of the identification efforts, as role exchange actions in the transdisciplinary process, should also be on communication disorders, such as stuttering, articulation disorders, voice disorders and other communication disorders not discussed in the present study. the conceptual framework for early identification of risk conditions for communication delay is proposed as a guideline for the eci service provider to be an active participant, directly or through transdisciplinary ~ction, throughout the critical periods of possible harmful biological and other events in a young child's life. the aim of the framework is therefore to assist the', eci service provider in identifying key periods where the identification of risk conditions is possible arid to develop essential steps to address caregivers' information needs thereby establishing a coordinated effort for early identification of risks for communication disorders. this can only be achieved when holistic partnerships with caregivers and professionals from different disciplines are formed (briggs, 1997; rossetti, 1996). the early identification of children with risks for communication disorders will increase the efficacy of eci ,services and the transdisciplinary conceptual framework for early identification as illustrated in fig'ure i is proposed to provide a guideline for coordinated action in clinical practice. the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) a transdisciplinary conceptual framework for the early identification of risks for comm disorders in young children 43 references aitken, p., fulton, j.; plumly, ,so & wempen, f. 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(1999). cary, north carolina: sas institute, inc. r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) alta kritzinger, "brenda louw & louis m rosetti 4-1 shprintzen, r. j. (1997). genetics, syndromes and communicatioll disorders. san diego: singular publishing group, inc. squires, j., nickel, r. e. & eisert, d. (1996) . early detection of developmental problems: strategies for monitoring young children in the practice setting. developmental and behavioural pediatrics, 17(6): 420-427 . thomson, e. j. (1995). a genetics primer for early service providers. in blackman, 1. a. (ed.) medical aspects of early intervention. gaithersburg: aspen publishers, inc. tomblin, b. j. (1989). familial concentration of developmental language impairment. journal of speech and hearing disorders, 54 : 287-295. venter, p. a., christianson, a. l., hutamo, c. m., makhura, m. p. & gericke, g. s. (1995). congenital anomalies in rural black south african neonates. south african medical journal, 85: 15-20. wetherby, a. m., prizant, b. m. & hutchinson, t. a. (1998). communicative. sociavaffective, and symbolic profiles of young children with autism and pervasive developmental disorders. american journal of speech -language pathology, 7(2): 79-91. the sollr" aji"io lll .i(1lfl"l/a! o(collllllflll icarioll disorders, vo!-i8 2ijij/ --lgv0 ) f corinth healthcare wor ld l y w is e a member of i he cor i n r h group it pays to talk to the healthcare specialists call corinth, your fast track to the uk 0800 20 11 20 e-mail corinth@icon.co.za or corinthdrs@icon.co.za speech and language therapists nd miid 7'l7y a mc ill bt 'r 01 :iw r('lftul lll{'nl dne l ilnplc l\ /n t'nl r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) in the treatment of difficult and severe cases it is interesting to follow their progress in this way. it becomes possible to state in figures what would otherwise have to be subjectively evaluated. i do not propose to discuss the problem of whether a test administered by means of pictures in preference to oral stimulation is more satisfactory, but it may be said that either test cannot replace the other as each tests different things. a picture test examines spontaneous speech, the ability to recall linguistic expressive units which already exist within the child's mind. t h e answers evoked by oral stimulation are influenced by knowledge of the linguistic units of the language as well as the given stimulation and the person's ability to use this stimulation. the latter depends on how much previous stimulation he has had which has resulted in a knowledge of the expressive units. it is only possible for a person to repeat words and sentences if he has a knowledge of the expressive units of that language. an english speaking person will hardly be able to repeat zulu words and sentences the first time he hears them. the graph shown here represents the curve of progress of a danish boy. the point 54/225 obtained at the first examination on the 19th april, 1955, can be compared with the point 202/225 obtained on the 16th september, 1956 at the last examination. the graph thus demonstrates the rapid increase in the boy's ability to repeat the expressive units of the language. the question may be asked whether the correctly repeated linguistic units will be carried over into spontaneous speech. the answer to this must be — not always. it is not to be expected that the ability to mobilize i.e. to recall the expressive units in spontaneous speech is identical with the ability to repeat them after oral stimulation in words. also, if the correctly repeated units are correctly used in spontaneous speech, it does not necessarily mean that other words with the same sound combinations will be correctly used in spontaneous speech. the term '"articulation testing" is therefore misleading as one does not test articulatory motor ability but purely central linguistic ability, namely the use of the expressive units of the language. it is useful to know how many of these units have been mastered and how they have been mastered. since 1952 i have used this method of describing the development of the mastery of language in the children i have treated. a comparison of a great number of units might perhaps give us some valuable information. book reviews learning to talk — a guide for parents by m . c. l. g r e e n e william heinemann medical books ltd., london, 1960 this delightful little book (75 pages), written by a speech therapist, is intended to add something to parents' enjoyment of their children's speech through an understanding of the pattern of normal speech development. with its emphasis on the normalacy of distorted speech in young children, this book should be of great help to parents of children who have, or are suspected of having speech defects. the author gives many charming and human examples of her own daughter's speech, e.g. "i expressed the pious hope that when judy came to tea with us, heather would let her play with her beautiful doll's house. "i won't". "well then, you will have to play in your bedroom." "yes, i take my dolly's house with me and i lock the door." mrs. greene outlines motor, social and emotional development (including feeding problems, toilet training, the importance of routine, discipline, etc.) and shows very clearly how they inter-act with each other, and contribute to the growth of language. she describes each stage (called simply "the first twelve months", "from one to two", etc. u p to five years), with illustrations of speech and language characteristics, stressing individual differences in maturation. her suggestions to parents are practical and clearly expressed, e.g. "a baby learns more easily from the following sample of motherly prattle than the more adult way in which one might address him. "now up you get. off with your pyjamas. here's your vest. over your head it goes. that's fine. now your pants. in go your feet", etc. almost incidentally, she describes certain speech difficulties which may be encountered, and her handling of this aspect is, in my opinion, very good. repetitions and hesitations are dealt with in a matter-of-fact way. she suggests that, when these occur, and when the child's speech seems confused, the parent should ask a question here and there, as it may 'break the tension and get the words flowing again' etc. " t h e car ever so fast went wham into the-and-andthe-the." journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) this is the moment to put in something like this since he seems to have forgotten the word "other". "and the other car? what happened?" t h e author points out that if a speech difficulty persists, however, or if the parent is concerned about the child's speech, it is advisable to consult a therapist, who will be able to give expert help if necessary. this is a stimulating little book of interest i would say to parents and speech therapists, and of real value to the parents of a child with a speech problem. p a t a l l s o p p stuttering — a symposium j o n e i s e n s o n , editor harper and brothers publishers, new york. 1958 this excellent book is a most significant contribution to the literature on stuttering. jon eisenson has as his basic premise the fact that, in order to find "some answers to the disorder or disorders of speech referred to as stuttering, many different points of view need to be presented." he has therefore selected the foremost authorities in the field to present their viewpoints and so attempt to clarify many of the problems associated with stuttering. the contributors to the symposium include oliver bloodstein, i. peter glauber, joseph sheehan, robert west, jon eisenson and charles van riper. wendell johnson has written the preface. he has, in accordance with his semantic approach, attempted to indicate to the reader that much of the disagreement between authorities is to be found in their language usage. jon eisenson, as editor, imposed upon each contributor the limitation that they should attempt to answer the following questions: "(1) what is stuttering? (2) what is the cause or what are the causes of stuttering? (3) in the light of your concept of stuttering, what are your suggestions for the treatment of stutterers." it is bloodstein's belief that stuttering is a "joint product of more than one factor." in his chapter "stuttering as an anticipatory struggle reaction" he gives a great deal of evidence to support this hypothesis. · a resume of salient factors in therapy, including the handling of resistance, is presented in a most lucid way. glauber's chapter on "the psychoanalysis of stuttering" presents the viewpoint that stuttering is a neurotic disorder and therefore that an understanding of "unconcious mental life" is essential to the rehabilitation of the stutterer. sheehan presents his concept that stuttering is an approach-avoidance conflict. his scientific approach to the problem and the application of his hypothesis to therapy makes sheehan's contribution one of the most valuable. west titles his chapter "an agnostics speculations about stuttering" because he doubts that "answers are availalble to certain fundamental questions." he attempts to relate stuttering to certain physical disorders thus emphasizing a physiololgical basis to stuttering. eisenson presents his own chapter on "a perseverative theory of stuttering". according to his viewpoint stuttering "is a transient disturbance in communicative, propositional language usage." his emphasis of the communicative aspects of the disorder make this a most thought provoking chapter. van riper's contribution to the sympoium takes the form of a report on "experiments in stuttering therapy". it represents an exploration of the disorder for over twenty years. an almost day to day account is given of the therapy carried out with groups of stutterers. the practical knowledge to be gained from this chapter is great because the emphasis is on therapy. it is my opinion that this book is an excellent addition to the available lilterature. f r u m e t . lubinsky — < f westdene products (pty.) ltd. for books on speech defects and therapy johannesburg: 23 e s s a n b y house, 175 jeppe street (23-0314) cape town: 408 g r a n d p a r a d e c e n t r e , castle st. (41-1061), durban: 66/67 n a t i o n a l m u t u a l bldg., smith st. (2-4975) ; pretoria: 210 m e d i c a l c e n t r e , pretorius st. (3-3487) ί • 4 journal of the south african logopedic society december r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract background method results discussion conclusion acknowledgements references about the author(s) alexa cohen department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa jaishika seedat department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa cynthia sawasawa department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation cohen, a., seedat, j., & sawasawa, c. (2023). dysphagia and pill swallowing in hiv/aids in south africa: results of a scoping review. south african journal of communication disorders, 70(1), a955. https://doi.org/10.4102/sajcd.v70i1.955 review article dysphagia and pill swallowing in hiv/aids in south africa: results of a scoping review alexa cohen, jaishika seedat, cynthia sawasawa received: 02 nov. 2022; accepted: 11 feb. 2023; published: 31 mar. 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: south africa has the highest prevalence of human immunodeficiency virus (hiv) worldwide. highly active antiretroviral therapy (haart) is expected to improve the quality of life for these individuals but requires long-term medication intake. poor pill adherence and related dysphagia are undocumented for individuals on haart regimens living in south africa. aim: to conduct a scoping review describing the presentation of pill swallowing difficulties and dysphagia experiences of individuals with hiv and acquired immunodeficiency syndrome (aids) in south africa. method: this review describes the presentation of pill swallowing difficulties and dysphagia experiences of individuals with hiv and aids in south africa using a modified version of the arksey and o’malley framework. five search engines targeting published journal articles were reviewed. two hundred and twenty-seven articles were retrieved; however, following the exclusion criteria based on pico, only three articles were included. qualitative analysis was completed. results: the reviewed articles identified swallowing difficulties that adults with hiv and aids experienced and confirmed non-adherence to medical regimens. barriers and facilitators of pill swallowing with dysphagia due to the side-effects of the pill itself were documented with physical properties of the pill not influencing adherence. conclusion: the speech-language pathologists (slps) role with individuals with hiv/aids to facilitate improved pill adherence was lacking with limited research on the management of swallowing difficulties in this population. the review identified dysphagia and pill adherence management by the slp in south africa as caveats for further research. contribution: speech-language pathologists must monitor swallowing during mealtimes as well as pill swallowing in individuals with hiv/aids due to the compromise of their oral health and oral structures. speech-language pathologists therefore have to advocate for their role in the team managing this population of patients. their involvement may reduce the risk of nutritional compromise as well as patient non-compliance with medication stemming from pain and inability to swallow solid oral dosage forms of medication. keywords: hiv; aids; haart; adult dysphagia; pill swallowing; south africa; primary healthcare; slp. background although south africa (sa) is classified as an upper-middle income country, it still faces unique public health challenges associated with a quadruple burden of disease (pillay-van wyk et al., 2017). despite the remarkable improvement in the initiatives targeting human immunodeficiency virus (hiv) prevention and improved accessibility to highly active antiretroviral therapy (haart) for treatment, it remains a health challenge (biney et al., 2020). an estimated 7.5 million (18%) people are living with hiv and/or acquired immunodeficiency syndrome (aids) in sa, making it the country with the highest prevalence in the world (statistics south africa, 2020). consequently, sa has the largest haart treatment programme which has reduced fatalities and incidence of opportunistic infections among people living with hiv (meintjes et al., 2017), increasing their life expectancy and improving their quality of life (qol). highly active antiretroviral therapy is a long treatment regime that consists of a combination of three or more antiretroviral drugs (ford et al., 2018) to inhibit viral replication, reduce the transmission of hiv, improve immune function and prevent drug resistance (thompson et al., 2012). moreover, it consists of either a combination pill taken daily, or several pills taken twice daily (myhre & sifris, 2020). it is recommended that haart commence within 7 days of confirmed hiv diagnosis (eggleton & nagalli, 2022). due to the inability of haart to completely destroy the virus, treatment is typically lifelong (henderson et al., 2019); hence, adherence is critical. regrettably, poor adherence to haart prevails (myhre & sifris, 2020), with pill burden and dysphagia (azia et al., 2016) being major contributors. dysphagia is characterised by the inability or difficulty swallowing (badger & verma, 2018). although swallowing happens in phases, being a continuous process, any difficulty or impairment in one of the phases, that is, oral, pharyngeal or oesophageal can influence the others, inadvertently impacting the entire swallowing process (soutinho et al., 2021). there are various causes of dysphagia (badger & verma, 2018) leading to negative health consequences such as malnutrition, dehydration and aspiration pneumonia (dobak & kelly, 2021). due to opportunistic infections such as oesophageal candidiasis, the herpes simplex virus, and aphthous ulcerations, dysphagia is common in this population. the presentation of dysphagia is thus characterised by reduced awareness and sensitivity in the pharynx causing adverse consequences such as choking, coughing or aspiration. dysphagia may also be induced by the physical properties such as size and texture of pills (radhakrishnan et al., 2021) or the side-effects of the drug composition of pills (fields et al., 2015). these may result in the dysfunction of the swallowing mechanism as a whole (all phases) due to the effect of the medication, but there may be specific effects on the smooth or striated muscle function of the oesophagus (fields et al., 2015). the design and purpose of pills is not particularly focused on making the pills easy to swallow, but rather to ensure beneficial medical outcomes, hence physical properties of pills remain a common source of frustration among individuals. larger pills require multiple swallows to clear the oesophagus and are prone to causing pill-induced dysphagia (radhakrishnan et al., 2021). the effects of pill swallowing difficulties can range from mild discomfort to life threatening complications such as aspiration. speech-language pathologists (slp) assess and manage dysphagia within a team of other individuals. over and above limited knowledge about the role of the slp in the treatment of pill-induced dysphagia for people living with hiv/aids (alborough, 2012), there is sparse information available about pill-swallowing difficulties, dysphagia and the subsequent effect on pill adherence in this population. method this review described the presentation of pill-swallowing and dysphagia experiences of individuals with hiv/aids in sa, specifically documenting how pill adherence is affected by pill swallowing difficulties and dysphagia among individuals with hiv/aids, the presentation of their experiences, the impact their swallowing difficulties and dysphagia have on their adherence to medication, and the possible involvement of the slp in the treatment and management of pill swallowing and dysphagia. the participants in the articles were individuals who were diagnosed with hiv and/or aids living in sa and presenting with difficulty swallowing pills. five databases were used (table 1) with search terms specific to each database. journal articles, theses and dissertations published from 2000 until 2020 were reviewed. keywords, titles and abstracts of all selected articles were analysed. no additional articles emerged from reviewing the reference list of each selected article. descriptive statistics identified characteristics that could influence the outcomes affecting the research in a meaningful way. thematic content analysis examined the ways in which events, realities and experiences manifested. table 1: search terms and databases included in the scoping review. ethical considerations an ethics waiver was obtained from the university of the witwatersrand human research and ethics committee (non-medical) (waiver number sta_2021_3w). results figure 1 provides the completion of the preferred reporting items for systematic reviews and meta-analysis flow diagram modified for the scoping review process (prisma-scr) from the joanna briggs institute (peter et al., 2019). it ensured applicable and appropriate recordings of data. figure 1: preferred reporting items for systematic reviews and meta-analysis flow diagram for scoping reviews (prisma-scr). as seen in figure 1, 227 records were identified from the five databases. duplicates were removed (n = 3) leaving 224 articles. titles and abstracts were screened for eligibility against the inclusion and exclusion criteria. two hundred and thirteen articles were excluded as they did not meet the inclusion criteria, leaving the researcher with 11 articles. eight articles were not relevant leaving three articles for inclusion in the scoping review. table 2 highlights the major themes that emerged from analysis of the articles (bladon & ross, 2007; naidoo, 2009; peltzer & phaswana-mafuya, 2008). table 2: emergent themes in relation to the objectives of this study. objective 1 (part 1): barriers to pill swallowing side-effects of highly active antiretroviral therapy from the three articles, 55% of participants identified side-effects of haart such as nausea, dizziness and insomnia as barriers to pill swallowing. complex regimens with multiple pills each with their own ingredients also affected pill swallowing. seventy nine point two percent of participants reported side-effects of haart medication, such as dry mouth, nausea and sores developing in the mouth or throat. fifty nine point three percent of the sample in the study by peltzer and phaswana-mafuya (2008) reduced their food intake due to the medication side-effects. co-existing medical symptoms all three articles referred to dysphagia resulting from comorbidities that contributed to the inability or difficulty in swallowing pills. naidoo (2009) identified the herpes simplex virus, hepatitis, diabetes, lipodystrophy or a low cd4 count as contributory factors to difficulty swallowing pills and ultimately non-adherence. in comparison, bladon and ross (2007) identified candidiasis of the oral cavity and upper digestive tract, herpes simplex virus infections such as small, painful, fluid-filled wounds in and around the mouth, gastro-oesophageal reflux disease or oesophageal dysmotility as impeding medication adherence. participants reported odynophagia (i.e. pain while swallowing), across the stages of the disease which impacted adherence (peltzer & phaswana-mafuya, 2008). this could potentially lead to reduced oral intake of essential liquids and foods. they established that malnutrition had a negative effect on the immune system resulting in a decline of cd4 t-cells, suppression of delayed hypersensitivity and abnormal b-cell responses. as a result, the individual with hiv/aids was susceptible to a higher risk of opportunistic infections causing symptoms and side-effects that were detrimental to pill swallowing or swallowing in general. personal factors contextual limitations: naidoo (2009) found two main reasons for poor medication adherence. (1) working far from their residence and regularly forgetting to take medication and (2) not being included in the decision-making process and so unwilling to take the medication. in addition, peltzer and phaswana-mafuya (2008) highlighted age, low education level, insufficient food intake due to contextual factors and reliance on a government-funded grant as indicators for non-adherence. psychosocial factors: all three articles linked psychological and social factors as barriers to pill swallowing. socially, the stigma attached to hiv/aids impacted adherence to haart (naidoo, 2009). non-adherence was associated with younger age and more specifically among young females (naidoo, 2009). body pain and odynophagia contributed to anxiety impacting swallowing (bladon & ross, 2007). similarly, peltzer and phaswana-mafuya (2008) reported that participants experienced high levels of psychological stress such as fear, concern, depression and anxiety when dealing with their hiv/aids status, which impacted their pill compliance. objective 1 (part 2): facilitators to pill swallowing personal factors understanding the diagnosis: eighty three point six percent of participants stated that when they were provided sufficient information on why medication was necessary and the procedure for correct medication intake, it increased their confidence making them more comfortable and compliant with their regimes (naidoo, 2009). furthermore, information provided by their healthcare professionals about hiv/aids facilitated understanding, leading them to accept their diagnosis and comply with the medical recommendations (naidoo, 2009). access: naidoo (2009) reported that reliable access to healthcare professionals and information improved dosage schemes with participants experiencing less adverse and undesirable medication effects, ultimately improving pill compliance. similarly, peltzer and phaswana-mafuya (2008) found that participants’ access to conducive living conditions and environments, as well as nutrition, that is, food security, assisted in the management of symptoms related to hiv/aids and this resulted in a positive response to the prescribed medical treatment. management strategies all articles provided strategies to circumvent non-adherence to medication. naidoo (2009) suggested a reminder system such as a short message services on one’s cell phone or setting an alarm on wrist watches to prompt medication intake. bladon and ross (2007) documented that 58.9% of their participants used ‘self-help’ techniques to reduce their swallowing difficulties such as drinking more water and avoiding solid foods and foods that induce heartburn. compensatory techniques such as cyclic ingestion, bolus placement and using head extension during a swallow for gravity to propel the bolus into the pharynx (bladon & ross, 2007) were also used. some participants identified antiacids effective in relieving side-effects of the medication. objective 2: how dysphagia or swallowing difficulties affect pill adherence physical dysfunction naidoo (2009) highlighted that participants’ who experienced symptoms of dysphagia were physically unable to swallow the pills. similarly, bladon and ross (2007) identified dysphagia and odynophagia as common complaints at all stages of the disease. this resulted in discomfort during the swallow, increasing anxiety. reports pertaining to salivary gland function were noted (bladon & ross, 2007) as saliva is integral to swallowing, aiding in lubrication, bolus formation and bolus propulsion. participants with hyposalivation reported increased pain and difficulty while swallowing, consequently affecting their ability to comply with their medical regimens. consequently, participants’ reduced oral intake to avoid pain and discomfort adversely impacted nutritional intake and ultimately adherence (bladon & ross, 2007). thus, swallowing difficulties meant poor pill adherence and a consequent decrease in cd4 count resulting in more severe swallowing difficulties, hence a vicious cycle. oral intake highly active antiretroviral therapy treatment regimens are complex and require individuals to take a large quantity of pills on a full stomach. participants whose medical regimes required them to complete a full meal while also experiencing symptoms of dysphagia were not able to comply with pill adherence (naidoo, 2009). objective 3: the involvement of the speech-language pathologists in the management of hiv and aids late involvement due to limited knowledge of the role of the speech-language pathologists despite the link between pill swallowing and swallowing difficulty, the slp featured very little, if at all in the reviewed articles. while featured in the article by bladon and ross (2007) this was likely because bladon is a slp. they noted that when slps are involved in management, it is generally at later stages of disease presentation when the swallowing difficulty is severe and more explicit. importantly, management by the slp positively impacted nutritional intake and qol. it is likely that healthcare professionals may be unaware of the full extent of the role of the slp given that it featured in only one article. discussion with only three articles in the final review, it is clear that there is limited research on pill adherence in relation to dysphagia among individuals with hiv/aids in sa. the role and involvement of the slp with this population is scarce and was found in one article only. while the exact number of individuals with hiv/aids who experience dysphagia and pill swallowing difficulty is unknown, all the articles noted a high percentage, confirming the need for more research in this area. when slps are only involved in the later stages of hiv/aids undesirable consequences are more likely (bladon & ross, 2007) having a knock-on effect on individuals not adhering to their medical regimens and reducing their qol (malouh et al., 2020). notwithstanding the limited literature on the role of slp in the assessment and treatment of dysphagia in this population (warner, 2015), existing data confirms the need for slp involvement to manage additional pathologies that are known to occur as a direct result of hiv/aids. earlier intervention of dysphagia is believed to improve the therapeutic and medical outcomes and overall qol of individuals (nel & ellis, 2012). malouh et al. (2020) highlighted that the role of the slp with pill swallowing was not acknowledged to be within the scope of dysphagia management for the slp while the hiv/aids pandemic was rife in sa during the 1980s – 1990s. however, it is likely that other professionals may not have recognised the relationship between the role of the slp and pill swallowing (malouh et al., 2020) compounding late referral and involvement of slps (jackson et al., 2008). without the involvement of the slp, individuals remain unaware about dysphagia and the reasons contributing to their poor adherence (seedat & zayannakis, 2020). thus, doctors continue to prescribe medication that the individual cannot adhere to. this vicious cycle has the ability to unnecessarily alter an individual’s qol. the world health organization (who) defines qol as an individual’s overall welfare and safety in relation to their physical health, psychological well-being, social affiliations and the environment in which they live in (who, 2014). when ensuring qol of an individual, one turns to the international classification of functioning, as it defines the prominent relationship between dysphagia and contextual factors of the individual. it allows the slp and other healthcare professionals to specify how dysphagia has the ability to cause harmful and undesirable effects on the individual’s qol. these include a decline in nutritional intake, weight loss or increased risk for secondary infections (warner, 2015). these effects can lead to an individual resorting to social and complete isolation (bladon & ross, 2007). quality of life is affected when the individual’s activities and participation in daily living are decreased compared to their premorbid way of life, purely as a result of their health condition (warner, 2015). in addition to the presence of dysphagia impacting qol, it is important for all healthcare professionals, including the slp to be cognisant of how pills may contribute to, and exacerbate, an already existing dysphagia, or else present as a pill induced dysphagia. the physical properties (size, shape, texture, coating), chemical make-up, and the side-effects of the pills may further adversely impact existing dysphagia (radhakrishnan et al., 2021). for individuals with hiv/aids, this is especially relevant given the varying pills needed. highly active antiretroviral therapy reduces viral load, increases immunity and resistance to the virus (myhre & sifris, 2020), thus when not taken, the effects may be detrimental. it is therefore important that the slp advocates their role within all populations where pill swallowing and medication intake form a major part of their progress and recovery. this review confirms the need for more specific research on pill adherence in the hiv/aids population, their lived experience of pill swallowing, and the influence that slp intervention has on pill swallowing and adherence. conclusion dysphagia is an emerging and promising field, and while research on the hiv/aids population is increasing, more is needed. while this study was specific to pill swallowing difficulties in this population, pill swallowing difficulty is not selective. research implications for other populations dependent on medication intake warrants investigation. the limited research on the role of slps in the management of pill swallowing difficulties of individuals with hiv/aids needs to change. it is possible that if individuals with hiv/aids are not adhering to their medication due to reasons pertaining to dysphagia – whether it be pill-induced or typical dysphagia; there are implications for further referral, consultation and collaboration between slps in a multidisciplinary team which may ensure optimal and well-rounded care for individuals with hiv/aids. limitations during this scoping review a limitation was noted. quality of life is not typically covered in literature when looking at the management of a disease, such as hiv and aids, specifically in the management of pill adherence. the impact of swallowing pills does cover the effects on qol and hence it should be something that future researchers conducting reviews are aware of. additionally, having a broader scoping review that looked at africa as a whole and not specifically sa would have allowed the researchers to work with a larger range of literature pertaining to the subject. this is therefore also recommended for future reviews in this area. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions a.c., j.s. and c.s. were involved in the study to various degrees. contributions to the publication was made by all authors. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any affiliated agency of the author. references alborough, k. 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(2014). who quality of life-bref. retrieved from https://www.who.int/tools/whoqol 51 early communication intervention with young children with pierre robin sequence lisl fair and brenda louw centre for early interv~ntion in communication pathology department of communication pathology university of pretoria abstract young children with pierre robin sequence are at considerable risk to develop delayed or disordered communication development. this study investigated the effectiveness of early communication intervention with four young children wtth pierre robin sequence, aged 5 to 28 months. the proportional change index (wolery, 1983) was used to determine the amount of child progress that took place during the intervention period. the results indicated that regular early communication intervention sessions over an extended period of time produced positive results, especially for expressive language abilities. the presence of a slight hearing loss due to otitis media, seemed to have influenced the effectiveness of early communication intervention. one subject displayed an associated disorder and evidenced the slowest rate of development for receptive and expressive language abilities as well as a limited phonetic repertoire for consonants. all but one subject had limited phonetic repertoires possibly due to velopharyngeal incompetence. early communication intervention services should be delivered regularly over an extended period of time and the hearing abilities and speech production skills of young children with pierre robin sequence should be followed closely during early communication intervention. opsomming jong kinders met pierre robin-volgpatroon vertoon risikofaktore om vertraagde of afwykende kommunikasie-ontwikkeling te he. hierdie studie het die effektiwiteit van vroee-kommunikasieintervensie met vier jong kinders met pierre robinvolgpatroon, tussen die ouderdomme van 5 en 28 maande, ondersoek. die proporsionele veranderings-indeks (wolery, 1983) is aangewend om die mate waarin die proefpersone tydens die intervensie-tydperk gevorder het, aan te dui. die resultate het aangetoon dat gereelde vroee-kommunikasielintervensie sessies oor 'n uitgebreide tydperk, veral vir ekspressiewe taalvaardighede, positiewe resultate lewer. die teenwoordigheid van 'n geringe gehoorverlies as gevolg van otitis media, het moontlik die effektiwiteit van vroee-kommunikasie-interven'sie bei"nvloed. een proefpersoon het pierre robin-volgpatroon en 'n geassosieerde afwyking getoon en die resultate het aangetoorl dat haar ontwikkelingstempo vir reseptiewe en ekspressiewe taalvermoens die stadigste was en ook dat sy 'n beperkte foneti~se repertoire vir konsonante getoon het. drie uit die vier proefpersone het beperkte fonetiese repertoires getoon, moontlik bs gevolg van velofaringeale onbevoegdheid. vroee-kommunikasie-intervensie-dienste aanjong kinders met pierre robin-vblgpatroon behoort op 'n gereelde basis oor 'n uitgebreide tydperk gelewer te word en die gehoorvermoens en spraakproduksie-vermoens van hierdie kinders moet gemonitor word gedurende intervensie. i key words: pierre robin;sequence, early communication intervention, effectiveness in the past two decades young children with communication disorders have received increased attention within the field of communication pathology (guralnick, 1997). any factor illfluencing the way a child interacts with his environment can be considered to be a potential risk factor contributing to a developmental delay (rossetti, 1996). infants with pierre robin sequence are classified as highrisk infants since a number of risk factors are associated with pierre robin sequence (elliot, studen-pavlovich & ranalli, 1995). three distinct symptoms mark the presence of pierre robin sequence in a young child, namely mandibular hypoplasia, glossoptosis as well as a wide u-shaped cleft of the palate (shprintzen & bardach, 1995), which cause a number of medical problems1for these children. elliot et al. (1995) list the following medical complications frequently occurring in young children with pierre robin sequence: airway obstruction, hypoxia, respiratory infections, otitis media and feeding problems like an insufficient sucking pattern and aspiration. in addition to these medical complications, children with pierre robin sequence may also exhibit problems like cerebral palsy (bull, givan, sadove, bixler & hearn, 1990), congenital heart problems, cognitive impairments and visual problems (sadewitz, 1992). the medical care necessitated by these early medical complications and associated disorders often require that infants with pierre robin sequence are hospitalized for prolonged periods of time (savage, 1997). the communication development of young children with pierre robin sequence is traditionally described as being characterised by the same impairments as that of children with cleft lip and palate, namely: velopharyngeal incomdie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 52 petence, nasal emission, hypernasality, compensatory articulation patterns and delayed language development (mcwilliams, morris & shelton, 1990). infants with cleft lip and palate are classified as presenting an established risk for communication disorders (rossetti, 1996), but the combination and magnitude of the risk factors present in the case history of most young children with pierre robin sequence can have an even greater influence on their communication development. a combination of established, biological and environmental risk factors are often associated with young children with pierre robin sequence and may have a negative influence on the way a child with pierre robin sequence interacts with his environment. these risk factors are summarised in table 1. children with pierre robin sequence are described indepth in the literature due to the complexity ofthe disorder (sadewitz, 1992) and special attention is given to research on the early medical complications accompanying pierre robin sequence (bull et ai., 1990; elliott et ai., 1995; sadewitz, 1990). in spite of the number of studies on the medical complications of pierre robin sequence and the atrisk status of young children with pierre robin sequence, a dearth in the literature exists regarding information about the outcome of their communication development. an early study conducted by pashayan and lewis in 1984 provided information regarding the speechand language development of children with isolated pierre robin sequence as well as of children with pierre robin sequence and an additional syndrome. the speechand language development of children with isolated pierre robin sequence was found to be impaired and the speech-and language development ofthose children with pierre robin sequence and an additional syndrome was found to be even more impaired and delayed than those with isolated pierre robin sequence. since the study conducted by pashayan & lewis (1984), limited research was reported on the communication development of young children with pierre robin sequence, rendering their work to be a valuable source of information on the early communication development of these children. according to shprintzen and bardach (1995) additional syndromes exist in more than half of all pierre robin sequence cases, such as stickler syndrome (34% of all pierre robin sequence cases) and velocardial facial syndrome (11% of all pierre robin sequence cases). the presence of an additional syndrome in young children with pierre robin sequence places them at greater risk to display delayed or disordered communication development. speech-language therapists delivering services to young children are advised to take cognisance ofthe fact that a relatively high number of children with pierre robin sequence may have an additional syndrome and to provide services that are responsive to the individual needs of each child (shprintzen & bardach, 1995). lislfair & brenda louw the presence of a hearing impairment can also negatively influence the communication development of young children with pierre robin sequence. handzic, bagatin, subotic and cuk (1995) found that these children are at-risk for a congenital sensory-neural, conductive or mixed hearing loss, with or without the presence of congenital malformations of the ear. these authors also found that children with pierre robin sequence have a slight hearing loss due to middle ear effusions. elliot et al. (1995) further indicate that 90,9 % of all children with pierre robin sequence have at least one episode of otitis media. the presence of a slight hearing loss may have a negative influence on the communication development of a child since receptive language development is dependent on adequate and constant auditory input (friel-patti, 1990). due to the established risk displayed by young children with pierre robin sequence, early communication intervention seems to be the only viable option in considering treatment alternatives. early communication intervention is a relatively new field of study within the discipline of communication pathology and is currently viewed as the best form of intervention for at-risk children (rossetti, 1996). early communication intervention is aimed at the prevention of communication disorders by facilitating communication development and optimising developmental outcome through parent centred therapy (savage, 1997; kritzinger, louw & hugo, 1996). the revision of the south mrican speech-language hearing association's code of ethics in 1997, placed renewed focus on the issue of accountable and effective service delivery in south africa (sashla, 1997). the revised code of ethics emphasises the fact that clients should benefit from service delivery and that professionals should adhere to their professional responsibility in conducting speech-language therapy services (sashla, 1997). according to carney (1996) and boston (1994) accountable and effective service delivery is important since data from effective service delivery can be used in advocacy activities like motivating the allocation of funds from medical aid schemes and donor organisations. the early communication intervention services rendered by speechlanguage therapists to young children with pierre robin sequence should be accountable and effective to en'sure that these children gain maximum benefit from intervention and reach their full developmental potential. i the provision of early communication intervention services to at-risk children is strongly advocated: and the effectiveness ofthese practices is a current topic in literature (lee & khan, 1997). several authors concur that early communication intervention programmes ar~ indeed effective, but factors influencing the effectiveness of these programmes have been identified (rossetti, 1996; savage, table 1: risk factors associated with pierre robin sequence(compiled from rossetti, 1996; sadewitz, 1992 and savage, 1997). ' established environmental biological /' risk factors risk factors risk factors / , , • pierre robin sequence • prolonged and multiple • respiratory problems • associatied disorders hospi talization • feeding problems • disruption of parent-infant • failure to thrive interaction • recurrent otitis media • family stressors the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) early communication intervention with young children with pierre robin sequence 53 1997; guralnick, 1997). factors influencing the effectiveness of early intervention include: the age of onset ofintervention (the younger, the more benefit), degree of involvement of the parents (the more involved the greater the benefit), home and centre based components included in the programme (both should ideally be included) and the quality of intervention services (the higher the quality the higher the benefits) (rossetti, 1996; savage, 1997; guralnick, 1997). speech-language therapists delivering early communication intervention services to young children with pierre robin sequence should take cognisance of these factors and incorporate them into service delivery to ensure that a high standard of service delivery is maintained. the measurement of effective service delivery in early communication intervention is currently a controversial subject in literature (lee & khan, 1997), since the amount of child progress has traditionally been used to determine the effect of early intervention. by simply comparing preand post intervention data to determine child progress, the effect of natural maturation is not accounted for and the comparison may yield a false picture of the effect of intervention on the development of the child (rossetti, 1996). lee and khan (1997) suggest that the natural maturation of the child as well as the child's rate of development prior to intervention should be taken into consideration when determining child progress and programme effectiveness. any formula used to determine child progress and programme effectiveness must account for these two factors, to ensure that the progress in development is due to intervention and not only to natural maturation (lee & khan, 1997). currently several methods of measuring the developmental progress of children in early communication intervention programmes, exist. these include developmental age comparisons, developmental quotient comparisons, indexes of change, actualpredicted score comparisons and modelling individual growth (lee & khan, 1997). in a study conducted to determine the most effective way to determine child progjess and programme effectiveness lee & khan (1997) applied all ofthese methods to a sample of children who recei{red early intervention. their results indicated that using hn index of change, namely the proportional change inde*(pc!), which was developed by wolery (1983), provides the most appropriate way of measuring child progress and~ programme effectiveness in early intervention. by meas~ring change in the rate of development, this method acc6unts for natural maturation as well as the child's rat~ of ,development prior to intervention and will therefore provide an accurate indication of the progress a child has made in intervention. the early communication intervention approach currently used in the centre for early intervention in communication pathology, department of communication pathology, university of pretoria is a parent centred approach and was developed as an appropriate and effective approach to early communication intervention by louw & hugo (1987). it includes the use of three intervention strategies namely education, counselling and training of parents, and intervention sessions are conducted monthly due to the distances parents often have to travel as well as the limited number of speech-language therapists providing early intervention services in south mrica (louw & hugo, 1987; louw, hugo, kritzinger & pottas, 1997). speech-language therapist~ in southmrica applying this approach and aiming to provide quality services to the young children with pierre robin sequence need to be aware of matters pertaining to the measurement of effectiveness in early communication intervention. rossetti (1996) stresses the importance of accountable service delivery in early communication intervention by referring to the term best practice. he concludes that best practice can only be achieved by carefully measuring programme outcomes. in order to establish whether the early communication intervention approach currently being used in south africa for the treatment of young children with pierre robin sequence constitutes best practice it is necessary to measure the outcome of intervention. the measurement of the effectiveness of early communication interventiori with young children with pierre robin sequence may provide an indication of the appropriateness and possible shortcomings in the approach currently followed. the aim of this study is to establish whether early communication intervention with young children with pierre robin sequence is effective. methodology 1. alms the purpose of this study was to determine the effectiveness of early communication intervention with four young children with pierre robin sequence and the following subaims were formulated: • the measurement of the effectiveness of early communication intervention for the receptive language abilities of the subjects, • the measurement of the effectiveness of early communication intervention for the expressive language abilities of the subjects, • the measurement of the effectiveness of early communication intervention for the cognitive abilities of the subjects and, • the measurement of the effectiveness of early communication intervention for the speech production abilities of the subjects. 2. research design an aba quasi-experimental case study research design was used to measure the progress of the subjects in intervention because all the variables in the study could not be controlled (mcburney, 1994). the phases of the research process are graphically depicted in figure 1 and included the following: the ai phase consisted of the pre-treatment assessment conducted in the clinic for high risk infants (chrib) at the centre for early intervention in communication pathology, department of communication pathology, university of pretoria. the b phase consisted of early communication intervention, which the subjects received for varying periods of time and the ~ phase consisted of the post-treatment assessment conducted in the home of each subject. this research design allows for the description of the individual performance of each subject but the design does not allow for generalisation ofthe findings (mcburney, 1994). 3. subjects the subjects (ss) were extracted retrospectively from file data at the clinic for high risk babies (chrib), which die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 54 phasea. pre-treatment assessment conducted at chrib phaseb early communication intervention phase~ post-treatment assessment conducted at the home of each subject figure 1: phases in the research process serves as a diagnostic and intervention facility for the centre for early intervention in communication pathology, aimed at service delivery to high risk infants and toddlers and their families. a total of four subjects were available when the following criteria were applied: the subjects must have been diagnosed as having pierre robin sequence and they must have been between 5 and 30 months of age during the post-treatment assessment. the following factors were not considered during the selection procedure: number of early communication intervention sessions received, the presence of associated disorders and slight to moderate prematurity. the absence of associated disorders were not included in the selection criteria since shprintzen and bardach (1995) found that more than fifty percent of children with pierre robin sequence also display associated disorders. slight to moderate prematurity was also not considered since caouette-laberge, bayet and larocque (1994) indicated that up to eight percent of infants with pierre robin sequence are born prematurely. the four subjects' ages ranged from 5 months to 28 months and all received early communication intervention for varying periods, initiated after each subject's pretreatment assessment. one subject (s4) displayed an associated disorder (velocardial-facial syndrome) as well as slight prematurity and another (si) evidenced moderate prematurity. all of the subjects had had episodes of otitis table 2: description of the subjects (n=4) characteristics subject 1 gender male pre-treatment age in months 11 , post-treatment age in months 25 diagnosis pierre robin sequence prematurity moderate associated disorders none medical problems otitis media eci received (months) 14 eci received (sessions) 13 eci received at private practitioner key: eci = early communication intervention lisl fair & brenda louw media. table 2 provides a detailed description of the subjects. 4 procedure 4.1 assessment and data collection each subject underwent comprehensive preand posttreatment assessments utilising the chrib evaluation protocol (louw & kritzinger, 1994). the chrib evaluation protocol (louw & kritzinger, 1994) covers all aspects of early communication development and includes the use of several other published evaluation instruments, as well as clinical guidelines for the interpretation of descriptive data. the pre-treatment assessments of all four subjects were conducted in chrib by the same experienced clinicians, whereas the post-treatment assessments were carried out in the homes of the subjects by the first author. the posttreatment assessments were conducted in the homes of the subjects as the home environment is considered to be a naturalistic context and a more reliable representation of the child's functioning can be obtained in the context of the child's home (rossetti, 1996). the fact that the preand post-treatment assessments were not conducted in the same setting implies that an extra variable was introduced, but as the data used in this study was part of a wider research project (fair, 1997) this variable could not be controlled. during both the preand post-treatment assessments an interview was conducted with the parents of the subjects in order to obtain background information and the subjects' communicationand general developmental skills were elicited in a controlled play context. infant behaviour was recorded using evaluation instruments such as the rossetti infant toddler language scale (rossetti, 1990), the developmental assessment schema (das) (anderson, nelson & fowler, 1978), as well as the developmental activities screening inventory ii (dasi-ii) (fewell & langley, 1984). infant behaviours such as vocalizations and verbalizations were also recorded and used as descriptive data. videoand audio-recordings were made during both the preand post-treatment assessments utilizing a subject 2 subject 3 subje~t 4 i , female female fem~le , , 9 10 5' 28 19 10 pierre robin pierre robin pierre robin sequence sequence sequence none none slight none none velocardialfacial syndrome otitis media otitis media .. otitis media 19' 9 5 14 1 2 chrib chrib chrib the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) early communication intervention with young children with pierre robin sequence 55 panasonic r33 vhs-c movie camera and a sakyno sk-2100 portable cassette recorder. these recordings were used to accurately document and describe infant behaviours. after the data was collected it was processed by using guidelines and procedures described in the published materials and literature in order to determine the developmental levels of the subjects and to describe their behaviour accurately (rossetti, 1990; anderson et al., 1978; fewell & langley, 1984; mcwilliams et al., 1990; shprintzen & bardach, 1995). for the purpose of this study only evaluation areas pertaining to communication development were considered since the main focus of early communication intervention is the facilitation of communication skills (louw & kritzinger, 1991). these areas were receptive and expressive language development, cognitive development and the speech production abilities of the subjects. cognitive development was included in the study as rossetti (1996) indicated that in children younger than twenty four months of age the development of language and cognition is so integrated that it cannot be separated and louw & kritzinger (1991) list the facilitation of cognitive development as an aim for early communication intervention. a data collection form was compiled and the following information was copied from the pre-and post-treatment evaluation data in order to analyse the data: the developmental ages of the subjects yielded by the rossetti infant thddler language scale (rossetti, 1990) for receptive and expressive language abilities, the developmental age of the subjects for cognitive development, determined by the dasiii (fewell & langley, 1984) and a qualitative description of the subjects' phonetic repertoires for consonants. although the chrib evaluation protocol (louw & kritzinger, 1994) allows for eliciting and describing information regarding the type and number of consonants, syllable structure as well as the level of vocalizations during the evaluation of speech production abilities, only the type and number of consonants were considered in this study. the type and number of consonants were selected and qualitatively described as ,children with pierre robin sequence often display limited phonetic repertoires and experience problems in prodricing pressure consonants and fricatives (mcwilliams et al.! 1990, shprintzen & bardach, 1995). i 4.2 data analysis i i the data regarding the receptive, expressive and cognitive development ofthe subjects on the data collection form was analysed and compared using the proportional change index (pci) (wolery, 1983) to determine the amount of child progress that took place. the pci is calculated using the following formula: pci (developmental gain in months + time in intervention in months) + (pretest developmental age + pretest chronological age). mter calculation the pci (wolery, 1983) yields a numerical statement of the relationship between the rate of development prior to intervention and the rate of development during intervention. a score of 1.0 indicates that the rate of development prior to intervention is identical to the rate of development during intervention, while a score of more thdn 1.0 shows that the rate of development during intervention is faster than the rate of development prior to intervention. a score ofless than 1.0 indicates that the rate of development during intervention is slower than the rate of development prior to intervention. if the pci score surpasses 1.0 the programme is regarded as effective (lee & khan, 1997; wolery, 1983). the data on the data collection form regarding the phonetic repertoires of the subjects was analysed by comparing the number of consonants that the subjects used during the preand post-treatment assessments, as well as listing the different consonants that the subjects used during the pre-and"post-treatment assessments. as clinical guidelines for assessing the development of consonants are not readily available and a developmental age level pertaining to this area of communication development could therefore not be established, the pci (wolery, 1983) was not used in the analyses of the phonetic repertoires of the subjects. oller, eilers, steffens, lynch and urbano (1994) describe alternative approa~hes to measuring the development of consonants in young children but as the data used in this study was part of a wider research project (fair, 1997), the chrib evaluation protocol (louw & kritzinger, 1994) was deemed to be appropriate to assess this area of development. the results of the receptive, expressive and cognitive developmental progress of the subjects as well as the qualitative description of the phonetic repertoires of the subjects were then further analysed by using descriptive statistics in order to display the results graphically in the form of bar charts. results and discussion the developmental age levels of the subjects pertaining to their receptive and expressive language development, as well as cognitive development, is presented in figure 2 in order to provide an overview of the development of the subjects during the preand post-treatment assessments. figure 3 indicates the chronological ages of the subjects at the time of the preand post-treatment assessments. all the subjects showed progress in receptive and expressive language development as well as cognitive development from the pre-treatment assessment to the posttreatment assessment, as indicated in figure 2. during the post-treatment assessment subject one and four evidenced delayed development in receptive and expressive language development as well as in cognitive abilities (see figures 2 and 3). subject two's developmental age for receptiveand expressive language development as well as cognitive abilities during the post-treatment assessment was slightly above her chronological age whereas subject three evidenced appropriate development for cognitive abilities and receptive language abilities but showed a delay in her expressive language development during the posttreatment assessment (see figures 2 and 3) receptive language abilities figure 4 indicates that two of the four subjects (ss1 and 2) showed faster rates of development during intervention than prior to intervention, as their pci scores were 1.14 and 1.42 respectively. subjects three and four showed slower receptive language development during intervention than prior to intervention, their scores being 0.91 and 0.8 respectively. die suid-afrikaanse tydskrifuirkommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 56 the fact that subjects one and two's rate of development was accelerated during intervention may be attributed to the number of early communication intervention sessions they attended, which amounted to thirteen and fourteen respectively (see table 2). subjects three and four only attended one and two early communication intervention sessions respectively and were also involved in intervention for a shorter period of time (see table 2). these results seem to indicate that greater benefit is derived from early communication intervention if sessions are presented at least once a month over an extended period of time. this finding is in agreement with the early communication intervention approach used at chrib (louw and kritzinger, 1991) during which early communication intervention is conducted monthly from when the child enters the programme until approximately twenty four months of age after which intervention becomes more child centered and is provided on a twice monthly or weekly basis. all the subjects displayed episodes of otitis media during 33 '" 30 -b 27 c 0 s 24 .8 il.) 21 gl 18 til 15 .... q il.) 12 §, 0 9 ~ 6 il.) 0 3 0 2 key: lisl fair & brenda louw the intervention period and the slight hearing loss associated with otitis media could have had a negative influence on the rate of their receptive language development (friel-patti, 1990). subject four, who obtained the lowest score had chronic otitis media with effusion during the whole intervention period and the severity of the condition could have influenced her rate of development during the intervention period in particular. in addition to the otitis media, her rate of development for receptive language could also have been influenced by the velocardial-facial syndrome she displays, since shprintzen and bardach (1995) indicated that children with velocardial-facial syndrome exhibit delayed language development, as well as by the fact that she had only attended two therapy sessions. expressive language abilities figure 5 illustrates the rate of development of the subjects' expressive language abilities. their pci scores 3 4 subjects ei receptive language skills at pre-treatrrent assesstrent fjll receptive language skills at post-treattrent assesstrent \ iiid bq:>ressive language skills at pre-treatrrent assesstrent rei bqjressive language skills at post-treat:rrent asses~rrent m cognitive abilities at pre-treatrrent assesstrent figure 2: developmental ages of the subjects .5 <u od '" '" "'..c .~ ~ ode ~ a c 2 ..c u 30 25 20 15 10 5 0 2 3 subjects idchronological age at the pre-treatment assessment i::iichronological age at the post-treatment assessment 4 figure 3: chronological ages of the subjects , m cognitive abilities at post-treattrent assesstrent 1.6 1.4 1.42 1.14 1.2 ~ 1 e u on 0.8 u 0.6 0.. en qi u./s i-1[1] receptive skills 0.4 i-i-0.2 r-r-0 / 2 3 4 subjects figure 4: rate of development for receptive language abilities (n=4) / the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) early communication intervention with young children with pierre robin sequence 57 (wolery, 1983) indicate that three of the four subjects displayed accelerated rates of development during intervention (.1.31, 1.21 and 1.18 respectively). the fourth subject's rate of development remained the same (1.0). the relatively fast rate of development of expressive language abilities displayed by the first three subjects may be due to the respective periods of early intervention they received. the two subjects who attended the most early communication intervention sessions (ss 1 and 2) showed the most accelerated rate of expressive language development. the results ofthe subjects' rate of expressive language development confirms the results of the rate of receptive language development and indicates that the frequency and duration of intervention has an influence on the effectiveness of intervention. it is possible that the subjects could have derived more benefit from intervention if the sessions were conducted once weekly, as is advocated by international literature (guralnick, 1997; rossetti, 1996; lee & khan, 1998), but challenges such as geographical distribution of available services and the number of speechlanguage therapists in the south african context, necessitated a revision of the recommended practice and resulted in early communication intervention sessions being conducted once monthly (louw et ai., 1997). subject four showed the same rate of development for expressive language abilities prior to and during intervention. the fact that she has velocardial-facial syndrome could have influenced her stagnation in rate of development since pashayan and lewis (1984) indicated that the expressive language abilities of children with pierre robin sequence and associated disorders are more delayed than those of children displaying pierre robin sequence only. subject four's slow rate of development for receptive language abilities could also have had a negative influence on her expressive language abilities since the development of expressive language is considered to be dependent on the development of receptive language (owens, 1995). cognitive abilities , , i according to figure 6 the results of the subjects' rate of cognitive development indic1ates that three of the four subjects had a slower rat1e of development during intervention than prior to int~rvention (0.86,0.9 and 0.65 respectively). subject four had :the same rate of development during intervention than prior to intervention (1.0). 2 3 subjects i i 4 expressive skills figure 5: rate of development for expressive language abilities (n=4) the slower rate of development that three ofthe subjects displayed during intervention may be attributed to the fact that the instrument used to assess the cognitive development of the subjects, namely the dasi-ii (fewell & langley, 1984), is a screening instrument and not an in-depth diagnostic tool. apart from the fact that the data derived from the dasi-ii (fewell & langley, 1984) might not be an accurate indication of the subjects' cognitive abilities, the benefit that the subjects received from early communication intervention for their cognitive development should be interpreted in conjunction with their progress in language development since the development of cognition and language cannot be distinguished before twenty four months of age (rossetti, 1996). during the pre-treatment assessment subjects two and three showed cognitive development levels one and two months above their chronological ages respectively (see figures 2 and 3). these two subjects' cognitive development levels were equal or slightly above their chronological ages at the time ofthe post-treatment assessment. this indicates that, although their developmental rates seem to be slower during intervention than prior to intervention, their cognitive development is still within the normal limits for their chronological age. in contrast with subjects two and three, subject four had a two month lag in her cognitive developmental level during the pre-treatment assessment (see figures 2 and 3). she maintained this delay in her development during the intervention period and as a result her rate of development stayed the same. these results are confirmed by researchers who indicate that children with pierre robin sequence and an associated disorder have poorer developmental outcomes than those children with pierre robin sequence only (pashayan & lewis, 1984; shprintzen & bardach, 1995). subject one also had a slower rate of development during intervention than prior to intervention. during the pretreatment assessment his cognitive development level was equal to his chronological age (see figures 2 and 3). at the time of the post-treatment assessment his cognitive development was, however, two months below his chronological age although his developmental quotient was still average. the fact that subject one showed a slower rate of cognitive development during intervention than prior to intervention may be attributed to the fact that he suffered trauma due to an accident causing a burning wound on his face, as schoenbrodt & smith (1995) indicated that trauma may have a detrimental effect on development. the results of the subjects' rate of cognitive development 1.2 ~ 0.8 0 i ~ cognitive skills u 0,6 on 0 q,. 0,4 0,2 ° 2 3 4 subjects figure 6: rate of development for cognitive abilities (n=4) die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 45,1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 58 indicate the complex nature of early development. although early language development and early cognitive development are interrelated (rossetti, 1996), results indicate that three of the subjects derived benefit from early communication intervention for early language development, but not for cognitive development. this fact may either point to the need to increase the focus on the facilitation of cognitive development during early communication intervention or may indicate limitations in the chrib evaluation protocol (louw & kritzinger, 1994). the results of the subjects' developmental rate of receptiveand expressive language abilities, as well as cognitive abilities illustrate the effectiveness of the pci (wolery, 1983) as a measurement of the amount of child progress made in intervention. as the subjects were not matched a big difference existed between the ages of the subjects and the period of intervention each received varied considerably (see table 2). the pci (wolery, 1983) yields a uniform numerical statement which accounts for individual differences, making it suitable for clinical and research purposes. speech production abilities figure 7 indicates the development of the subjects' speech production abilities by comparing the number of consonants they produced at the pre-treatment assessment to the number of consonants they produced during the posttreatment assessment and table 3 illustrates the different consonants that each subject produced during the preand post-treatment assessments. according to figure 6 and table 3 all the subjects showed l!l 16 c 14 co c 0 12 '" c 10 0 0 8 .... 0 6 ... <u .d 4 e :l 2 z 0 2 3 4 subjects fsi number of consonants present during the pre-treatment evaluation ie! number of consonants present during the post-treatment evaluation figure 7: development of phonetic repertoires for consonants (n=4) lisl fair & brenda louw development in their phonetic repertoires for consonants during the intervention period. only one subject (sl) produced pressure consonants during the pre-treatment assessment and did not exhibit any indication of velopharyngeal incompetence during vocalization. this subject (sl) acquired eight consonants during the early communication intervention period of fourteen months (see table 2). subject four acquired four consonants during the early communication intervention period of five months (see table 2), but although she acquired these consonants, her phonetic repertoire was marked by a limited use of pressure consonants during the pre-and post-treatment assessments (see table 3). as the effect of natural maturation could not be accounted for in the analysis of subjects' consonant development, these results seem to indicate that the combined effect of natural maturation and the early communication intervention subjects one and four received, produced positive results. subject two acquired 7 consonants during the early communication intervention period of nineteen months (see table 2). as is often observed in children with pierre robin sequence (mcwilliams, et al., 1990), she displayed nasal emission during speech production as well as limited use of pressure consonants indicating velopharyngeal incompetence during both the pre-and post-treatment assessments (see table 3). although she attended the most early communication intervention sessions, she seemed to have derived limited benefit from early communication intervention for her speech production abilities. subject three acquired the least consonants during the intervention period (3 consonants over a 9 month period (see table 2» and also displayed nasal emission during speech production as well as limited use of pressure consonants indicating velopharyngeal incompetence during the pre-and post-treatment assessments (see table 3). these results may be attributed to the fact that she only received one early communication intervention session during a nine month period and therefore she may not have received enough adequate stimulation for her speech production abilities. brodsky, holt and hue ritter-schmidt (1992) mention that few studies confirm the effectiveness of speech therapy for velopharyngeal incompetence and conclude that the prognosis of children with velopharyngeal incompetence appears to be better if intervention starts early. the results of the subjects' speech production abilities empha!size the complexity of determining the effectiveness ofi speech therapy for velopharyngeal incompetence and sugg~st that the early presence ofvelopharyngeal incompetence'may be an indication of a later delay and disorder in ispeech production abilities. . table 3: the subjects' phonetic repertoires for consonants phonetic repertoires for consonants subject pre-treatment assessment post-treatment assessment 1 [p], [b], [x], em], en], en] [p], [b], [t], ed], [k], [g], [w], [v], [s], [x], [h([m], en], en] 2 [h], em], [n] [t], [k], [g], [w], [v], [s], [x], [h], [m], en] 3 [w], em], en], [x], [k], [h] [p], [t], [k], [w], [v ( [x], [h], [m], en] 4 [h] [p], [t], [g], [h], [m] the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) early communication intervention with young children with pierre robin sequence 59 subjects one, two and three had undergone surgery to repair their cleft palates at the time of the post-treatment assessment but subject four, who had a submucosal cleft, had not had surgery at the time of the post-treatment assessment. only one subject (sl) produced pressure consonants and had no evidence of velopharyngeal incompetence during both the preand post-treatment assessments, whereas all the other subjects did not produce pressure consonants as part of their phonetic repertoires during the pre-treatment assessment and still showed limited use of pressure consonants during the posttreatment assessment. this may be an indication of the pervasive effect that pierre robin sequence has on the speech production abilities of children displaying this disorder even after surgery has been performed. these results may further point to the need for the use of a different approach towards speech production intervention for young children with pierre robin sequence displaying signs ofvelopharyngeal incompetence or it might indicate that the complexity ofthe disorder is not fully understood. conclusion guralnick (1997, p. xvi) indicates that the effectiveness of early intervention has been well documented and that the current challenge in efficacy research is not to establish whether early intervention is effective, but to 'determine what interventions work best, for whom, under what conditions and toward what ends'. the results of this study confirmed the general effectiveness of early communication intervention with young children with pierre robin sequence but raised specific concerns about programme features. the early communication intervention that the subjects received seemed to have had positive effects on their expressive language abilities and also on the receptive language abilities of two of the subjects. only one subject seems to have derived adequate benefit from early communication intervention for his speech production abilities and a poor developmental rate was found for the 1 cognitive abilities ofthe subjects. the importance of reghlar early communication intervention sessions over arl. extended period of time was i also emphasised by the results. the subjects who attended the most early communicati6n intervention sessions over the longest periods of tim~, derived the most benefit. guralnick (1997) advocates tliat early intervention sessions i should be conducted once weekly but the current south african context poses a nu~ber, of challenges to early communication intervention service delivery, such as geographical distribution of available services and a shortage of therapists trained in early intervention. the early communication intervention approach devised by louw et al. (1997) for the south african context accounts for these challenges and indicates that sessions conducted once monthly are adequate. authors concur, however, that early communication intervention should start as early as possible and coritinue until the development of the child is satisfactory (louw & kritzinger, 1991; rossetti, 1996; guralnick, 1997). the presence of a slight hearing loss due to otitis media may have influenced the em~ctiveness of early communication intervention regarding the subjects' receptive language abilities. in order to monitor the effect of the slight hearing loss accompanying otitis media on language development, it is suggested that effective practice should include periodic monitoring of hearing at least every three months (kritzinger, louw & hugo, 1996). subject four who' was diagnosed with pierre robin sequence as well as an associated disorder, namely velocardio-facial syndrome, attended only two early communication intervention sessions and it appears as if she derived limited benefit from therapy. these results concur with literature indicating that children with pierre robin sequence and an associated disorder have poorer developmental outcomes than children with pierre robin sequence only (pashayan & lewis, 1984; shprintzen & bardach, 1995). this fact emphasizes the need for individualised early intervention services for children with pierre robin sequence and an associated disorder and indicates that they may require more intensive services with the focus on strengthening their strong points and facilitating the weak areas in their development. the fact that the subject with the associated disorder (ss4), as well as moderate prematurity, showed the slowest rate of development for expressive and receptive language abilities, but maintained her rate of cognitive development and expanded her phonetic repertoire, emphasizes that the causes of a communication problem should be viewed according to a transactional model. the transactional model acknowledges the dynamic interaction between a child and his or her environment and allows for change over time (rossetti, 1996). when this model is applied to young children with pierre robin sequence, who are at-risk for developing communication disorders, it becomes clear that there is not a direct linear cause-and-effect correlation between the number and magnitude of risk factors and the extend of delay in communication development (kritzinger, louw & hugo, 1996). the transactional model applied to early communication intervention service delivery to young children with pierre robin sequence implies that the clinician should view each child within the context of his or her individual strengths and weaknesses and that prognostic statements about the communication development of young children with pierre robin sequence should be made with care. the pci (wolery, 1983) that was used to determine the amount of child progress, proved to be a valuable formula since it provided an accurate indication of the benefit that the subjects derived from the early communication intervention they received, by accounting for natural maturation as well as the child's rate of development prior to intervention. the new application of the pci (wolery, 1983) to determine the amount of child progress during intervention seems to be an appropriate way to determine the outcome of intervention and may be used in further research or as a clinical tool to provide outcome-based intervention. the data derived from the pci (wolery, 1983) did not account for the synergistic nature of early development since the assumption that development occurs in a linear fashion underlies the construction of the pci formula (lee & khan, 1998). although the pci (wolery, 1983) currently seems to be an appropriate way of determining child progress in early communication intervention programmes, the utilization of a new method to determine programme effectiveness might be necessary in the fulurc in order to account for the non-linear nature of early development (lee & khan, 1998; kritzinger, louw & hugo, 1996). the influence of variables related to child outcomes in early intervention are described by lee & khan (1998) and die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 60 guralnick (1997) who conclude that early intervention is a dynamic process with a number of child, family/parent and programme variables potentially influencing the effectiveness of early intervention. they emphasize the need for future research in early intervention where variables are carefully controlled and where the complex correlation between child and family characteristics and programme features and outcomes is addressed (guralnick 1997' lee & khan, 1998). ' , the quasi-experimental design of this study allowed for subjects to be selected without controlling all the variables related to child outcomes in early intervention (mcburney, 1994). the variables that could not be controlled in this study, such as age at programme entry, parents' age, parents' education level, the settings of the preand post-treatment assessments and the locus of service delivery could each have contributed or have a detrimental effect on the positive effects that were indicated in general by this study. it is clear that further efficacy research, where variables are controlled more carefully, is required to fully understand what constitutes best practice regarding service delivery to young children with pierre robin sequence. the role of the speech-language therapist with children with craniofacial anomalies is described as 'assisting the child with craniofacial anomalies to achieve his or her maximum communication potential' (brodsky et ai., 1992, p.230). speech-language therapists involved with young children with pierre robin sequence can fulfil this role by endeavouring to provide accountable and effective services to these children. further research on the early communication development of young children with pierre robin sequence as well as the effectiveness of early communication intervention with this population will lead to greater insight into the complexity of the disorder and to more effective service deli very. references anderson, d., nelson, j. & fowler, s. (1978). developmental assessment schema. in northcott, w.h. (editor), curriculum guide: hearing impaired children (0·3 years) and their parents. washington dc: the alexander bell association for the deaf, inc. boston, b.o. (1994). destiny is in the data. a wake-up call for outcome measures. american speech-language-hearing association, november, 35-38. brodsky, l., holt, l. & hue ritter-schmidt, d. (1992). craniofacial anomalies: an interdisciplinary approach. new york: mosby year book. bull, m.j., givan, d.c., sadove, a.m., bixler, d. & hearn, d. (1990). improved outcome in pierre robin sequence: effect of multidisciplinary evaluation and management. paediatrics, 86(2),294-301. carney, a.e. (1996). introduction to supplement on treatment efficacy: part 1. journal of speech and hearing research, 39, s3-s4. caouette-laberge, l., bayet, b. & larocque, y. (1994). the robin sequence: review of 125 cases and evolution of treatment modalities. plastic and reconstructive surgery, 93(5), 934-942. elliot, m.a., studen-pavlovich, d.a. & ranalli, d.n. (1995). prevalence of selected paediatric conditions in children with pierre robin sequence. american journal of paediatric dentistry, 17(2), 106-111. lisl fair & brenda louw fair, l. (1997). vroee kommunikasie-ontwikkeling van jong kindel's met pierre robin volgpatroon. unpublished b.communication pathology research report. university of pretoria. fewell, rr & langley, m.b. (1984). developmental activities screening inventory. austin: pro-ed, inc. friel-patti, s. (1990). otitis media with effusion and the development oflanguage. topics in language disorders, 11(1), 11-22. guralnick, m.j. (1997). the effectiveness of early intervention. maryland: paul h. brookes publishinj;' co. handzic, j., bagatin, m., subotic, r & cuk, v. (1995). hearing levels in pierre robin syndrome. cleft palate craniofacial journal, 32(1), 30-36. kritzinger,a., louw, b. & hugo, r (1996). early communication functioning of infants with cleft lip and palate. the south african journal of communication disorders, 43,77-84. lee, s. & khan, j.v. (1997). measures of child progress and program effectiveness in early intervention. infant-toddler intervention: the transdisciplinary journal, 7(4), 215-233. lee, s. & khan, j.v. (1998). child progress and related variables in early intervention. infant-toddler intervention: the transdisciplinary journal, 8(1), 83-10l. louw, b. & hugo, r (1987). ouergesentreerde interaksie-terapie. sashla national conference abstracts. johannesburg. louw, b. & kritzinger, a. (1991). infants with down syndrome: description of an early intervention approach. the south african journal of communication disorders, 38, 25-31. louw, b. & kritzinger, a. (1994). chrib evaluation protocol. centre for early intervention in communication pathology, department of communication pathology, university of pretoria. louw, b., hugo, r., kritzinger, a. & pottas, l. (1997). kommunikasie intervensie vir 0-2 jarige hoerisiko-babas. workshop presented by centre for early intervention in communication pathology, department of communication pathology, university of pretoria, 13 june 1997. mcburney, d.h. (1994), research methods (3,d edition). pacific grove, california: brooks/cole. mcwilliams, b.j., morris, h.l. & shelton, rl. (1990). cleft palate speech. new york: associated press. oller, d.k., eilers, re., steffens, m.l., lynch, m.p. & urbano, r (1994). speech-like vocalizations in infancy: an evaluation of potential risk factors. journal of child language, 21 3358. ' owens, re. (1995). language disorders: a functional approach to assessment and intervention. needham heights: allyn & bacon. pashayan, h.m. & lewis, m.b. (1984). clinical experience with the robin sequence. cleft palate journal, 21(4) 270-276. rossetti, l.m. (1990). the rossetti infant-toddler la~guage scale. illinois: lingui systems, inc. i rossetti, l.m. (1996). 'communication intervention: birth to three. san diego: singular publishing group inc. : sadewitz, v.l. (1992). robin sequence: changes in thinking leading to changes in patient care. cleft palate craniofacial journal, 29(3),246-253. : sashla. (1997). code of ethics. ethics and stahdards committee. : savage, h.e. (1997). an early intervention guide to infants born with clefts. infant toddler intervention: the transdisci'plinary journal, 7(4),271-284. schoen brodt, l. & smith, ra. (1995). communication disorders and interventions in low incidence pediatric populations. san diego: singular publishing group inc. shprintzen, rj. & bardach, j. (1995). cleft palate speech management. a multidisciplinary approach. new york: mosby books inc. wolery, m. (1983). proportional change index: an alternative for comparing child change data. exceptional children, 50(2), 167170. / ~. the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) development of a zulu speech reception threshold test for zulu first language speakers in kwazulu-natal seema panday, harsha kathard, mershen pillay & cyril govender discipline o f audiology school o f audiology, occupational therapy and speech-language pathology university o f kwa zulu-natal the d e v e lo p m e n t o f a z ulu speech r eception threshold t est for z ulu first l anguage speakers in k w a z ulu-n atal 111 a b s t r a c t the measurement o f speech reception threshold (srt) is best evaluated in an individual’s first language. the present study f o ­ c u s e d on the development o f a zulu srt word list, according to adapted criteria fo r srt in zulu. the aim o f this paper is to p re ­ sent the process involved in the development o f the zulu word list. in acquiring the data to realize this aim, 131 common bisyllabic zulu words were identified by two zulu speaking language interpreters and two tertiary level educators. eighty two percent o f these words were described as bisyllabic verbs. thereafter using a three point likert scale, 58 bisyllabic verbs were rated by 5 linguistic experts as being familiar, phonetically dissimilar and being low tone verbs. according to the k endall’s co-efficient o f concordance at 95% level o f confidence the agreement among the raters was good fo r each criterion. the results highlighted the importance o f adapting the criteria fo r srt to suit the structure o f the language. an important research implication emerging from the study is the theoretical guidelines proposed fo r the development o f srt material in other african languages. further­ more, the importance o f using speech material appropriate to the language has also being highlighted. the developed sr t word list in zulu is applicable to the adult zulu first language speaker in kzn. key words: speech reception threshold, zulu first language speaker, srt word list development, familiarity, phonetic dissimi­ larity, low tone verbs introduction the speech reception threshold (srt) test is part o f the ini­ tial conventional audiological test battery. srt is defined by the (american speech and hearing association [asha], 1988) as the hearing level in decibels (db) at which the individual can respond correctly to 50% of the test words presented to him/ her. however, in order to recognize and understand the test words the individual should be familiar with the words (lyregaard, 1997). therefore, balkisson (2001) suggests that it is best achieved if the test materials used are presented in a language in which the individual is most familiar, i.e. in his/her first language. furthermore, testing patients with materials re­ corded in a language other than their native tongue would "adversely affect performance ' and interpretation o f re­ sults” (nissen, harris, jenningk, eggert & buck, 2005, p. 392). in considering the above recommendation, there is a need for linguistically matched, easily understandable and highly familiar words for the' establishment of srt in zulu. the need for linguistically matched speech materials has moti­ vated many researchers to embark on the formidable task o f developing word lists in the client’s mother tongue language. some o f these researchers include, ashoor & proschazka (1985) who developed test words in arabic, plant (1990) fo­ cused on the development o f words in walpiri and tiwi; and more recently, nissen et al. (2005), who developed words in mandarin. nissen et al. (2005) also strongly argued that to develop a suitable word list in a language other than english requires an in-depth understanding o f the linguistic structure of the language because the criteria for the original english srt materials have been designed around the structure o f english. it !s also well known that each language has its own linguistic structure. therefore, the rules governing one language may not always be applicable to other languages. hence, it was deemed necessary to develop a word ilist that was relevant to the zulu language in kwa zulu-natal (kzn). the need for linguistically-matched speech materials for zulu first language speakers (zfls) is a reality when considering the demographic profile o f kzn. zulu is the first language o f 80% of the 9.426 million people in kzn (population census, 2001). in fact, zulu is the nguni language spoken by almost 8.5 million people in the whole o f south af­ rica (grimes, 1992). zulu is also one o f the eleven official languages o f south africa. the concentration of zulu speakers is, however, in kzn. in spite of zulu speakers being the major­ ity o f the population o f kzn, the development o f linguistically appropriate materials has been lacking. speech audiometry, like most other areas of speech, language and hearing services in south africa, has a paucity o f relevant test materials to evaluate the majority of the individuals who do not speak eng­ lish as their first language (bortz, 1992). as a consequence the service provided to african first language speakers of kzn is poor (pillay, kathard and samuel, 1997). in order to address this shortcoming, appropriate and relevant tools should be de­ veloped and made available for clinical use. the lack of carefully developed zulu materials has re­ sulted in audiologists following one o f three trends in current practice in kzn. john (1990) indicates that speech reception testing is omitted from the initial test battery, or that the srt is obtained using the standard english material viz. central insti­ tute for d eaf cid wi and w2 spondee word list. finally, srt is obtained using modified methods and non-standardized ran­ domly selected bisyllabic words in zulu. however, according to nissen et al. (2005), the use o f such materials could affect the performance and interpretation of the results. thus casting doubt on the validity o f the test. the underlying reason for this is that one of the most important characteristics of srt materials and srt testing is familiarity of stimuli to the client (carhart, 1965). furthermore, knight (1997) warns that developing linguistically matched word lists should be based on specified criteria such as familiarity o f the words in the language. in addition, rudmin (1987) also stated that each na­ tion’s linguistic milieu should be considered when offering the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) speech audiometry services. the current practice o f using eng­ lish material or randomly selected bisyllabic words for the as­ sessment o f srt in zulu is problematic and a more valid tool is required. clearly, the inappropriate practice in the current con­ text provided the rationale for the development o f a word list in zulu. furthermore, the measurement o f hearing threshold for speech is integral to the comprehensive diagnostic evaluation of hearing (ramkissoon, proctor, lansing, bilger, 2002). this is so since the understanding o f speech is an important human faculty and the speech signal according to martin (1997) forms the basis o f auditory stimulation that occurs in everyday life. young, dudley & gunter (1982) and asha (1988) also assert that speech audiometry evaluates the listener's ability to hear, recognize and understand speech communication in the every­ day environment. in addition speech audiometry, inclu ding srt test­ ing, complements the other conventional tests o f audiometry, such as pure tone audiometry. it is well known that pure tone audiometry provides the ‘gold standard’ for the initial audi ological assessment o f hearing (roeser, valante & horsford dunn, 2000) nonetheless, while pure tone thresholds are impor­ tant in predicting the hearing patterns at discrete frequencies, the speech threshold test is able to provide a more comprehen­ sive and realistic description o f hearing in everyday life. nissen et al. (2005) explains that speech testing contributes more infor­ mation about the hearing impairment o f an individual than do pure tones. moreover, gelfand (1997) reported on the clinical value of srt which is described as, srt quantifies the listener’s hearing level for speech. srt also serves as a validity check for pure tone audiometry. srt provides diagnostic and prognostic value to the total audiometric test battery and is the reference point for suprathreshold speech tests. srt has also serves as a tool to assess medical, surgical and rehabilitative intervention. the clinical value o f srt testing, confirms its importance in the test battery. therefore, in view o f the important clinical value, developing appropriate materials for srt testing is clearly war­ ranted. the focus o f this paper therefore is on the process to­ wards the development o f a word list for zfls in kzn, with specific emphasis on the key theoretical considerations that emerged during this process. this aspect was one o f three aims that were a part o f a larger study conducted by panday (2006). however, for the purposes o f this paper the development aspect o f the srt word list is presented. the nature o f the topic under discussion also required reference to several seminal references and current literature. in order to develop materials for the establishment o f the srt in zfls, there should also be an understanding o f how speech is perceived. lyregaard (1997) explains speech percep­ tion as a pattern recognition process where the listener hears certain acoustic cues and selects the appropriate category where the item fits. the important aspect o f this selection is that it is not only based on acoustic or phonetic factors, but also on the syntax, semantics and the overall context (lyregaard, 1997). it is therefore clear that the perception o f speech is a complex task. the context, semantic, syntactic cues and the cognitive resources o f the listener assists in the processing of the signal. therefore, most listeners are able to perceive the signal under difficult listening conditions. the implication o f contexts is best seen when words are presented to individuals acquiring a second language (criag, 1997). identical speech signals presented to one group o f listeners who are first lan­ guage speakers and to those who are second language speakers 112 d ie suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 results in latter group being unable to hear subtle sounds seg­ ments and prosodic nuances. first language listeners however are able to appreciate these differences (criag, 1997). words having a higher frequency o f occurrence are more easily recog­ nized than those that have a lower frequency o f occurrence. this is particularly relevant for the development o f the materials in zulu. the zfls would be more familiar with the zulu words from both the acoustic properties o f the words and the prosodic, semantic and lexical aspects. these elements fa­ cilitate easier recognition o f the words when the stimulus is closer to threshold. in view o f the foregoing argument on the influence of both contexts and the acoustic properties o f the language on the perception and understanding of speech, the process towards the development of a suitable srt word list in zulu has to also be guided by the rules that govern the language. zulu is an nguni language. the nguni languages are part o f a larger related group o f south eastern bantu languages. in terms o f structure, zulu is an agglutinative language, which commonly has roots bound to prefixes and suffixes (jacobson & trail, 1986). the root o f the word usually carries lexical mean­ ing. the word structure without the prefix and suffix would be purely a bisyllabic word in the consonant vowel, consonant vowel sequence (cvcv), e.g. /hamba/ meaning “to go” in eng­ lish. this word form only appears as a verb imperative and hardly ever as a noun. noun classes in zulu are often trisyllabic in nature because o f the prefix formative e.g. /ihashi/ meaning “horse’ in english (jacobson & trail, 1986). this aspect o f the language had to be carefully considered, as the type o f stimuli selected for the srt material in zulu is dependent on the avail­ ability o f stimuli in the language. an important consideration therefore, with regard to the development o f the word list, relates to the type o f stimuli to be considered. historically researchers focused on developing srt words that were bisyllabic and equally stressed, known as spon­ dees (silman & silverman, 1991; gelfand, 1997). the main advantage o f using spondees centered on the need for words to have equal stress on each syllable. this allowed for uniformity and precise testing. on the contrary, hodgeson (1980) stated that spondee words were not so common in english since the stress o f bisyllabic words is usually placed on the first syllable. many words such as, “baseball”, “hotdog”, “cowboy’ j easily satisfied the criterion if care was taken to stress the first' sylla­ ble. the change in stress pattern is permissible in english and does not alter the meaning of the word. therefore, several words o f this structure were selected for the original word list. however, while zulu is able to satisfy the criterion o f bisyllabic words, the use o f equally stressed words is unavailable structur­ ally. this is so since zulu is a “non-stress” language where stress is not used to indicate emphasis nor is used to differenti­ ate words or syllables as seen in english (cope, 1982). furthermore, unlike english, the introduction o f artificial stress patterns on each syllable in zulu could possibly alter the meaning o f the words. this is so since zulu is a tonal language (rycroft & ncgobo, 1979). tonal variations are lexically sig­ nificant in zulu (rycroft & ncgobo, 1979), implying that the pitch o f the word corresponds to the difference in,meaning. to illustrate, the word /inyanga/ can mean “doctor” or “moon” or “month” depending on where the pitch o f the word occurs. the role o f tone has three distinct functions in zulu, i.e. semantic (affecting the meaning of words), grammatical, and emotional (cope, 1982). these tonal variations may influence the meaning o f the stimuli, thus having implications for speech understand­ ing. if zulu does not have the linguistic characteristic o f seem a panday, h arsha k athard, m ershen pillay & c yril g o v e n d e r r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the d evelopm ent o f a z ulu speech r eception threshold t est for z ulu first language speakers in k w a z ulu-n atal 113 equally stressed words, then the criteria for srt materials needs adaptation or the development o f new criteria to suit the struc­ ture o f the language is required. this point o f view has been widely supported by studies conducted in languages other than e nglish, e.g. plant (1990) who developed the tiwi and walpiri word lists, and nissen et al. (2005), who developed mandarin word lists. studies such as these emphasize important theoreti­ cal considerations regarding the structure o f the language at a lexical, phonological and syllable level. the tiwi and walpiri languages were found to have a different stress pattern to that of e nglish i.e. the stress o f the word is usually placed on the penul­ timate syllable, (plant, 1990). these structural differences there­ fore required adaptation o f the original srt criteria. nissen et al. (2005) also supported the notion adapting the original srt criteria to suit the structure o f the language. nissen et al. (2005) concluded that 24 trisyallbic mandarin words could be utilized to measure an individual’s srt if the native language was mandarin. their study showed highly fa­ vorable results when the trisyllabic words were assessed, with results comparable to those o f english. locally the literature with regard to word list develop­ ment is in its infancy. however, the issues raised in the some of the african and south african studies support the contention made in the present study. chetty (1990) reported that the choice o f bisyllabic words and the tone o f the words appear to be critical to the overall development o f a zulu word list. in fact, the abundance o f commonly used bisyllabic verb impera­ tives with low -high tones in zulu was considered a suitable option for srt word list development in zulu (chetty, 1990) as consequence o f chetty’s work it was considered necessary to evaluate the low tone, bisyllabic verbs under more stringent methodological conditions. closer inspection o f the historical criteria for srt word list development suggested by hudgins, hawkins, karlin & stevans in 1947 confirms the need for adaptation or review o f these criteria to suit the language o f zulu. these criteria in­ clude familiarity, phonetic dissimilarity, and homogeneity with respect to audibility or intelligibility. familiarity refers to the choice o f vocabulary used. how­ ever, on perusal o f the literature the concept o f familiarity is explained on the basis o f two perspectives viz, familiarity as it relates to the test product (word list) and familiarity as it relates to the test process (testing), (kruger & kruger, 1997). for the purpose of this study an acceptance o f both these concepts are considered. wilson & margolis (1983) explained familiarity as it relates to the test product. these authors explain that words selected for the srt test must be based on the number o f times the listener uses the word in everyday speech. to this end, the above authors claim that the most commonly used words are considered to be the most familiar words. thus, familiarity has remained an important criterion for the development srt words. there is both historical and current acceptance amongst researchers to include familiarity as a criterion. this has been repeatedly reinforced in the historical and current literature (hirsh, silverman, reynolds, eldert & benson, 1952; wilson & margolis, 1983; young et al, 1982; asha, 1988; ramkisson, 2000; nissen et al., 2005). familiarity is "arguably one of the most important criteria to be considered in word list develop­ ment" (nissen et al., 2005, p. 1). this position is also supported in the present study, as common and familiar words are avail­ able in the zulu language. however, researchers must be cognizant o f what makes a word list familiar. the "inherent flexibility o f the human lan­ guage causes it to be extremely variable and changes over time", (akamajian, demers, farmer & hamish, 1990, p. 265). therefore, it is reasonable to suggest that the s h e lf life o f the words chosen must be considered. vocabulary within a lan­ guage is ever changing and expanding according to the influ­ ences o f a changing society (fromkin & rodmin, 1993). thus, despite familiar words being available in zulu, careful consid­ erations o f how words are selected to represent this criterion is important. the concept o f familiarity within the english lan­ guage was addressed by consulting a formal list such as the list o f word frequency compiled by thorndike and lorge, (1944) as cited in jacobson & trail (1986). this method of selecting words has assisted researchers such as hirsh et al. (1952) to apply this criterion. there is however, a paucity of adequate tools for the zulu language (jacobson & trail, 1986). there­ fore, the need for alternative methods of selecting common fa­ miliar words is advisable. jacobson & trail (1986) suggested the utilization o f informal methods, such as consulting language educators and linguists. this method is well supported in the literature by plant (1990) who suggested utilizing highly skilled linguists to assist with the complexities in the language when word lists are being developed. consequently, the use o f speak­ ers o f the language and linguistic experts allows for words to be more representative o f the language at any given time as com­ pared with making mere references to the dictionary. in addition to the way words are selected, the criterion of familiarity is also influenced by other sociolinguistic aspects e.g. borrowed words in a language. many of the african lan­ guages spoken in south africa have been historically influenced by dominant languages such as english and afrikaans. these languages were predominantly spoken in the educational, tech­ nical, commercial and industrial spheres (jacobson & trail, 1986). the inclusion o f borrowed words in a list allows for the word list to be applicable to the majority o f the zulu speaking people in kzn. familiarity as a criterion is relevant, but the socio-linguistic factors relevant to each language, such "shelf life" o f vocabulary and borrowed words must also be consid­ ered. the complexity o f satisfying historical criteria in mother tongue languages is further demonstrated when the concept of phonetic dissimilarity is reviewed. hudgins et al. (1947) as cited in silman & silverman (1991), suggests that the test material must consist o f stimuli that vary in terms of consonant and vowel combinations within the language being used. phonetic dissimilarity in a word list prevents confusion between words (silman & silverman, 1991). however, this criterion has not received the attention that other criteria such as familiarity and homogeneity o f audibility has received. this could perhaps be related to the difficulty in satisfying this criterion in lan­ guages that have fewer consonant and vowel combinations. the basic five vowel system in zulu could possibly influence the criterion o f phonetic dissimilarity and may require adapta­ tion accordingly. however, the complex consonant system, with the addition o f the click sounds that appear frequently in the vocabulary o f zulu, which has implications for the development o f the word list i.e. inclusion o f click phonemes in the word list may influence the variability o f phoneme choices in the words. the foregoing discussion indicates that key theoretical considerations have been raised and these have implications for the development o f an appropriate zulu word list. the word list development in this study, therefore, was based on the interac­ tion o f both the socio-linguistic and structural aspects of the language. moreover, the need to adapt the original criteria for srt words to suit these theoretical principles is warranted and is well supported in the literature. thus, in view o f the uniqueness o f srt, its contributing value to the conventional test battery and the structure o f the the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 114 seem a panday, h arsha k athard, m ershen pillay & cyril govender zulu language the need to develop an appropriate srt word list for the zfls in kzn is justified. in so doing the linguistic needs o f the clients serviced by audiologists in kzn would be appropri­ ately met. therefore the aim of this study was to develop a srt word list for zfls in kzn and to answer the following critical question “what is the process involved in establishing appropriate criteria for the development o f a srt word list for zfls in kzn? methodology aim the aim o f the study was to develop a zulu word list for srt testing. this aim generated two objectives i.e. objectives • to identify commonly used bisyllabic zulu words and sec­ ondly • to rate the commonly used bisyllabic zulu words according to the adapted srt criteria for zulu viz.: familiarity, phonetic dissimilarity, and tonal patterns o f the words. study design the design strategy adopted for this aim of the study was a de scriptive-survey design. a descriptive-survey design was consid­ ered a suitable choice because it focused on describing the process involved in the establishment of appropriate criteria relevant to the development o f a srt word list in zulu. hence, a survey ap­ proach and a rating strategy were adopted to realize this aim. the descriptive design "describes a situation as it is" in order to gain more information (leedy & ormrod, 2005, p. 179). thus, for this aim the researcher was concerned with describing the develop­ ment o f an srt word list for zulu. in the process, relevant lan­ guage specific information about the suitability o f criteria to be used in the selection o f zulu words was explored. this aim was realized through two distinct objectives. objective one and two incorporated the criteria for selecting srt words i.e. identifying bisyllabic zulu words that were common and ensuring that the words met the criteria of familiarity, phonetic dissimilarity and low tone verb imperatives. objective 1: the identification of commonly used bisyllabic zulu words for adult zfls in kzn participants two zulu language educators from a tertiary institution and two zulu language interpreters were considered for this objec­ tive o f the study. four participants were considered adequate be­ cause the word pool generated at this stage o f the study was rated and validated by linguistic experts in objective 2 o f the study. the educators and interpreters were selected through purposive sam­ pling, as they were most familiar with the use o f the zulu lan­ guage as spoken by the adult population on whom the new word list would be used. the educators were also familiar with zulu as a language, since it is their subject o f specialty. the interpreters used the language daily and are familiar with zulu as a language in the kzn community specifically the dialect spoken in the greater durban and pietermarizburg region. selection criteria f o r the participants the criteria for the selection o f the zulu language educa­ tors were; • the educators had to speak zulu as a first language • the educators needed to have at least five years o f tertiary teaching experience. the criteria for the selection of the zulu language interpreters were: • the interpreters had to be zulu first language speakers. • they had to reside in kwa zulu-natal (durban, pietermariz­ burg region) for more than five years. • the language interpreter had to have passed grade 12 as a minimum academic qualification. the above criteria ensured that the participants had sufficient experience with the language. their experience would thus fa­ vorably influence the word choices made in terms o f the com­ monality of the words. sampling method the purposeful sampling technique was used to select the participants for this objective of the study. purposive sam­ pling allowed the researcher to choose a sample that represented some feature or process in which the researcher was interested in (mcmillan & schumacher, 2001; leedy & ormrod, 2005). therefore, this method was selected, as the participants chosen were representative o f the linguistic group for which this word list would be relevant to i.e. zfls in kzn. furthermore, the participants were informed of the topic of interest i.e. zulu word selection. selection criteria f o r the words the criteria for selection of the words included, com­ monly used bisyllabic words in zulu. for the purposes of this study, common words refer to the most frequently used bisyl­ labic words in zulu in the durban, pietermarizburg region of kwa-zulu-natal. the linguistic structure o f zulu permitted the selection of bisyllabic words. further, zulu has many bisyllabic words that can be considered common and would satisfy the requirements of an srt word list (chetty, 1990). the words considered as being common had to also be identified by two or more participants. data collection instrument a modified word identification schedule (appendix a) adapted from (balkisson, 2001) was provided to each! partici­ pant to record the chosen words. the use of the word identifica­ tion schedule ensured that a standard method o f recording the words was maintained across all four participants. j ii data collection process j ethical clearance was obtained from the university of kwa zulu-natal ethics committee. permission from the head of the department o f zulu of a tertiary institution was subsequently sought to gain access to the zulu language educators. the inter­ preters, however, were approached personally with regards to their participation, outside o f their formal work time. informed consent from the language educators and interpreters was ob­ tained regarding their willingness to participate in the study. the language educators and interpreters were advised on the nature of the study via a meeting with each participant inde­ pendently. an instructional letter concerning objective 1 was provided to each participant. each participant was asked to identify a separate list of bisyllabic zulu words commonly used by zfls in kzn (durban, pietermarizburg region). a mini­ mum o f one hundred words per participant was required. one hundred words per participant ensured that the final list was not too small in terms of the set size. this decision is in keeping with the suggestion made by punch & howard (1985). die suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the d evelopm ent o f a zulu speech r eception threshold t est for z ulu first l anguage speakers in k w a z ulu-n atal 115 analysis the words were extracted from the identification sched­ ule and captured onto an excel spread sheet. the spreadsheet vvas designed to represent each participant's response in terms of the words identified. all words were arranged alphabetically on the spreadsheet. the researcher manually extracted those words that met a fiftypercent or more inclusion criteria. this implies that if a word was suggested by two or more of the par­ ticipants, the word was included for the next objective o f the study. the fiftypercent or more criterion is also known as the two-word selection criteria. this method o f inclusion and ex­ clusion has been recommended for word selection by (madden, 1996). those words that did not meet the 50% inclusion crite­ rion were excluded from the study. descriptive statistics were used to analyse the most com­ mon words suggested by the respondents. frequency counts, bar graphs and pie charts were among the tools utilized. these techniques indicated the most and least commonly identified words (mcmillan & schumacher, 2001). a second level of analysis included the categorization of the words into different word classes selected i.e. nouns, verbs, adjectives, pronouns etc. percentage counts were used to describe the word class distribu­ tion. after careful analysis of the words using the inclusion and exclusion criteria stipulated above, the common bisyllabic words selected were included in objective two of the study viz.: selection o f the words according to the adapted srt criteria for zulu. objective 2: selection of words according to the srt crite­ ria that suited to the zulu language. participants five linguists from two tertiary institutions in kzn par­ ticipated in objective two of the study. for this objective, the linguists rated the words selected in objective one according to the following criteria i.e. a) familiarity, b) phonetic dissimilarity and c) low tone bisyllabic verb imperatives. selection criteria f o r participants the participants had to| be linguists who were knowl­ edgeable in zulu phonology and the linguistics o f zulu. they had to be familiar with the dialect o f zulu spoken in durban pietermarizburg region of kzn. the linguists had to have a masters degree in linguistics as a minimum qualification. this was in keeping with the recommendation by plant (1990) who reported that the use of highly skilled linguistic experts is re­ quired in development of a word list. sampling method purposeful non-probability sampling was also used for this objective o f the study. purposive sampling allowed the re­ searcher to select linguists who were represented as experts in the field o f zulu. data collection instrument an instructional letter accompanied with the three rating scales i.e. rating scale for familiarity, low tone verbs, phonetic dissimilarity of the hundred and thirty one words (131) selected in objective one were presented to each of the linguists (see panday, 2006). the three point likert scale was used. the scal­ ing system chosen was similar to most studies of this nature (hirsh et al. 1952; madden, 1996). this likert scaling method represented e.g. the most familiar, fairly familiar and very unfa­ miliar words in the list. the scaling system was rank ordered and could also be described as a graphic numerical scale. this scale allowed for accurate description of beliefs and opinions in terms o f familiarity (mcmillan & schumacher, 2001). the three point scale as opposed to a five point or seven point scale was considered due to the nature o f the task. the researcher was concerned with identifying the most familiar words versus the most unfamiliar words in the list. therefore, the limited rating options provided to the linguists prevented the linguists from providing too many unsure responses. the items on the scale were presented down the left hand side of the scale with 1, 2, and 3 in the column adjacent to each word. this format allowed for uncomplicated and rela­ tively quick completion of the task, whereby the participants had to tick in the appropriate column or merely selected the number that represented their opinion. data collection process ethical clearance was obtained as described in objective one above. the researcher obtained informed consent from each o f the linguists in order for them to participate in the study. a meeting was held with all linguists to provide them with an in­ structional letter informing them of the nature of the. study and the requirements for this objective. each linguist was presented with the rating scale o f the one hundred and thirty one words selected in objective one. the words were rated according to chosen criteria. the linguists worked independently so that per­ sonal judgments could be made. in order to control for proce­ dural variables the same set o f instructions were presented to all participants as per the instructional letter. prior to confirming participation in the study, the length of the scale was discussed with all participants, so as to minimize the loss of interest dur­ ing its completion. it was emphasised that this was not a test and that there were no right or wrong answers. the data ob­ tained were then analysed. analysis o f data data were analyzed using a quantitative analysis ap­ proach. all statistical procedures and analysis were carried out using the spss version 11.6 computerized statistical program. the statistical analysis was completed under the advisement of a statistician (ms. cathy connolly & ms. rebecca shunmugam) at the medical research council of south africa in durban in august 2006. mean scores were calculated so that the degree o f famili­ arity, phonetic dissimilarity and low tone verbs could be meas­ ured across all raters. the words that achieved an average rating of 1.5 or less on all of the criteria, as indicated in previous stud­ ies (hirsh et al. 1952; madden, 1996) were to be selected. mean scores are calculated by adding all the scores and dividing by the number of scores (leedy & ormrod, 2005). the mean is the most frequently used measure of central tendency (mcmillan and schumacher, 2001). in addition the kendall's co-efficient of concordance was used to assess inter-rater reliability. the rationale for the use of the kendall’s test was to determine the extent to which the rat­ ers agreed about what they rated (mcmillan & schumacher, 2001). the kendall's coefficient o f concordance estimates agreement among multiple raters for ordinal responses as indi­ cated in this study. kendall's statistic is a measure of the asso­ ciation among appraisers' ratings (kendall & babington-smith, 1939). kendall's statistic therefore can only be used when the data has three or more possible levels with natural ordering, such as strongly disagree, disagree, neutral, agree, and strongly agree. therefore, this test of inter-rater reliability was suitable because the present study utilized three levels of natural order­ ing. the following table illustrates the values in terms of the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 116 seem a panday, h arsha k athard, m ershen pillay & c yril g ovender strength of the agreement when kendall's w score is consid­ ered. table 1 was used in the interpretation of the kendall's w score in this study. the coefficient was calculated using the spss ver­ sion 11.6 and a w score was calculated. a score between 0 to l was regarded significant in terms o f overall inter-rater reliability. this score assisted the researcher in terms of overall strength o f the information received from the partici­ pants. it also confirmed that there was consistency in the measurement or rating o f the words. after careful analysis using the above procedures, the words were selected. value of kappa value of kendall strenath of <0.20 -1.0 t o -0.2 poor 0.21-0.40 -0.6 to -0.2 fail 0.41-0.60 -0.2 to 0.2 m oderate 0.61-0.80 0.2 to 0.6 g ood 0.81-1.0 0.6 to 1.0 v e ry g ood table 1: values representing strength of agreement for kendall's w score. reliability and validity the following considerations were made to ensure reliability and validity for this aim of the study and for the larger study conducted by panday (2006). with regards to reliability all participants were provided with the same in­ structions regarding their role in the study, the data obtained for this aim and for the larger study were verified by linguis­ tic experts. the rating scales used were standard across all raters. further, the kendall’s coefficient of concordance was used to assess reliability and consistency among the raters. considerations related to validiy o f the results were ensured by the overall two phase methodological approach of the panday (2006) study. the words were developed and as­ sessed based on both audiological and linguistic principles. resu lts and discussion a total word pool o f five hundred and five common words was obtained from the four participants. the average num­ ber of words identified per participant was 126 words. the number of words identified ranged from 123 to 133. appen­ dix b, illustrates the words suggested by each participant. many o f the words obtained by each o f the four participants were repeated by more than one participant. the 505 words were categorized for inclusion and exclusion in terms o f a 50% inclusion criterion. one hundred and thirty one words o f the 505 words (26%) met the inclusion criterion. seventy four percent o f the words were excluded. appendix b illus­ trates the distribution o f the 131 words according to the number of participants that suggested the words for objec­ tive one. there were 57/131 words that were suggested by two participants. three of the participants suggested 52/131 words and 22/131 words were suggested by all four o f the participants. however, all o f the 131 words pre-selected were included in objective 2 o f the study. the 131 words identified were further categorized in terms of the character­ istics of the words identified. figure 1 illustrates the per­ centage of words according to the word classes. the majority (82%) of the words chosen were bisyl­ labic verbs with pronouns being (6%), adverbs (5%), con82% figure 1: pie chart illustrating the percentage of the words according to word classes junctions (4%), and nouns (3%) respectively. examples of words within this distribution can be found in table 2. these findings are in accordance with the linguistic structure of zulu. the majority of bisyllabic words in zulu are verbs rather than nouns (r. bailey personal communication, april, 2006). the nguni languages like zulu and xhosa share this linguistic feature (jacobson & trail, 1986). bisyllabic nouns in zulu are few because most noun classes have a prefix formative e.g. / ubisi/ meaning milk in english. thus, the syllable structure becomes trisyllabic. the present study con­ sidered the use o f bisyllabic verbs. this decision was based on the abundance and availability o f bisyllabic verbs in zulu compared to the paucity o f bisyllabic nouns. further, the majority (82%) o f the words pre-selected within the present study was verbs. it was also necessary to maintain uni­ formity in the word classes o f the words. for objective two, the 131 words were rated by the linguists, so that careful decisions were made to exclude words that were not verbs. the words were only adjusted on the basis of the results of objective two. the five-hundred and five bisyllabic words generated at this stage o f the study appeared adequate, even though many o f the words were repeated across the four participants. this was in ac­ cordance with the madden (1996) study that generated 720 familiar words using similar methods of word pool generation, as indicated in the present study. the large word pool at the preliminary phase of the study prevents the final word list from being limited in num­ ber. the overall number o f words selected has been documented as an important consideration for researchers and clinicians. this fol­ lows the argument that srt scores improve significantly if there are a limited number o f srt words (fewer than 36) in the final word list (punch & howard, 1985). the underlying reason for the improvement is related to the possible learning effect as would be the case if there are too few words. therefore, to prevent the learn­ ing effect, the present study supports the above contention of gen­ erating a large pool o f words. t able 2: examples of bisyllabic words according to their different word classes b fs y h a m c y iro s pronouns adverbs conjunc­ tions klatirie bhala zake lapha futhi n yam a g xeka zabo phansi nyanga khanya phezu g eza muva d ie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the d evelopm ent o f a z ulu speech r eception threshold t est for z ulu first l anguage speakers in k w a z ulu-n atal 117 jng effect, the present study supports the above contention of generating a large pool of words. the exclusion of 74% of the words could possibly be related to the methodological choice made within the study i.e. only common words were selected. the literature however is not explicit about standard methods used. knight (1997) suggests that words must be selected after careful analysis o f written texts, articles and national radio and television newscasts. fur­ thermore, studies such as hirsh et al. (1952) used dictionaries and word resources such as the thousand most common words spoken in a language. the use o f dictionaries and word re­ sources has been known to historically generate large word pools that are representative o f the most common words in a language. this method could be considered a good starting point for word selection. however, this method of selection is appro­ priate for languages where there are well-developed dictionaries and word list resources e.g. the english thorndike's list o f word frequency, used in the (hirsh, 1952) study. the south african zulu language literature has not yet come to consensus in so far as the most common words spoken in zulu are concerned (r. bailey, personal communication, september, 2006). therefore, the paucity o f such resources in the african languages has re­ sulted in the researcher considering the present methods of word selection, by utilizing tertiary educators and zulu language in­ terpreters. the use o f speakers o f the language to identify common words as indicated in the present study implies that the words generated may have more relevance in present times. generating a word pool from the speakers o f a language at the time would naturally result in the words being more familiar than if words were selected out o f a dictionary that might have been devel­ oped many years prior to the study. this also supports the notion that vocabulary does indeed possess a "shelf life" and that all living languages change over time (fromkin & rodmin, 1993). a closer analysis o f the common words selected indicate that a small percentage of the words (3.8 %) or (5/131) were words borrowed from english e.g. "wina". thus, indicating that all words considered common i may not be completely indige­ nous to the language. the inclusion o f the borrowing merely enhances the relevance of the list in terms being common, to the diverse zulu-speaking clinical population. the support for the inclusion o f borrowing in a language is limited to what linguists and language rights activists state i.e. that languages have devel­ oped over the years through "liberal borrowings from neighbor­ ing languages" (alexander, 2006, p. 3). zulu should be no dif­ ferent, especially when one considers the present state o f global­ ization within the south african context. t he p r e s e n t r e ­ searcher argues that while an indigenous word list for zulu is relevant, the content o f the words list must be highly familiar to the population for which it is meant for. this argument also il­ lustrates that researchers could possibly run the risk o f excluding highly familiar and common words should their methodological design follow rigid and traditional methods of relying on dic­ tionaries and standard dialects. these standard dialects are often spoken on newscasts for television and radio, which would ex­ clude words that may be borrowed from another language. the results obtained in objective one o f the study, there­ fore, indicate that careful consideration o f the linguistic structure of that language is certainly relevant in word list development. in addition, this study demonstrated that in the development phase of a word list, the researcher has to develop astute meth­ ods of generating the word list. while adhering to linguistic and audiological principles for word choices, reliability and validity in the data were ensured. therefore, in order to fulfill objective two, six linguists were asked to rate the 131 words on a three point likert scale for the following criteria i.e. familiarity, pho­ netic dissimilarity and tonal patterns o f the words. words in­ cluded in objective two o f the study had to achieve a mean rat­ ing score o f 1.5 or less on all criteria. the scores o f five of the six linguists were analyzed, as one linguist did not complete the criterion on tone and many o f the words in the other two sections were omitted. therefore, in terms of reliability of the data, the ratings from five linguists were analyzed. in terms o f familiarity, the majority (106/131) (81%) of the words obtained a mean rank of less than 1.5 on the likert rating scale across all five raters. eighty one percent o f the words in the pre-liminary list were regarded as very familiar and a mere 19% were indicated as being unfamiliar. however, the final selection of the words also depended on the mean ranks for tone and phonetic dissimilarity as discussed below. in terms o f tone of the words a larger number of words obtained a mean score greater than 1.5 (45%) compared to the results obtained for familiarity. fifty five percent of the words obtained a score o f less than 1.5 on the likert scale. these words were thus indicated as low tone words. the remaining 45% were considered high tone verbs. for the purposes o f this study the low tone verbs were selected. in terms o f the results obtained for phonetic dissimilar­ ity, the majority (102/131) of the words were rated as phoneti­ cally dissimilar. however, there were a small percentage of words that were highly similar in their phonetic structure. pho­ netic dissimilarity was determined by the focusing differences in consonant and vowel structures within each word. careful analysis o f each o f the mean ranks for each cri­ terion resulted in the selection of 58 words. the 73 words that did not meet the criteria were excluded from the study. the 58 selected words satisfied the criteria for familiarity, tone and phonetic dissimilarity and are included in appendix c. in addition to the above result, the researcher measured the reliability of the ratings across all five linguists. the test statistic in table 3 indicates that a w score 0.823 was obtained for the criterion o f familiarity. this implies that a very good agreement existed among all five raters. the agreement is noted at 0.05 level o f confidence (assyp.sig= 0.000<0.05). therefore, with 95 % confidence there was little difference among the raters with regard to the rating of the words for fa­ miliarity. however, the coefficient o f concordance for criterion of tone was 0.431 which implies that there was a moderate agreement among the 5 raters for the criteria of tone. these results suggest that there were also no significant differences in the rating of the tone o f the words, even though the agreement was moderate as compared to very good agree­ ment in the familiarity aspect. similarly the coefficient of con­ cordance o f 0.665 for phonetic dissimilarity which implied that there is good agreement among the 5 raters at the 0.05 level of significance (asymp. sig. = 0.000 < 0.05). familiarity phonsuedissim ilarity tone n* 5 5 5 kendall’s w 0.823 0.431 .665 chi square 481.488 252.067 388.906 df 117 117 117 asym. sig .000 .000 .000 * number o f raters the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 118 seem a panday, h arsha k athard, m ershen pillay & c yril govender table 3: test statistic for the kendall’s co-efficient of concordance for familiarity, phonetic dissimilarity and tone the researcher could therefore accept the contention that the 58 words rated as familiar, low tone and phonetically dissimilar by the 5 raters were reliable. these 58 words were further assessed for the criterion o f homogeneity with respect to audibility using logistic regress ion analysis. however the details o f this aim o f the study are beyond the scope of this paper and would be pre­ sented in a subsequent paper. this high percentage o f words (81%) that were rated as very familiar confirms that these words identified by participants in objective 1 are common to the kzn zulu speaking population. this result also reinforces the conten­ tion that words considered most common in everyday environ­ ment can be considered to be the most familiar words in that environment (wilson & margolis, 1983). with regard to fa­ miliarity o f words in other studies, it would appear that re­ searchers have relied on various methods for the selection of familiar words. traditionally hirsh et al. (1952) utilized a judg­ ing system whereby english words were rated on a likert scale. a recent study conducted on mandrin speakers selected familiar words on the basis o f dictionaries that existed in their language. in addition the use o f judges was only considered for screening the word list for culturally insensitive words which were deemed unfamiliar. however, in the present study taking into account the paucity o f dictionaries that indicates the most fre­ quently occurring bisyllabic verbs in zulu, having all the 131 words rated for familiarity by linguistic experts was a suitable alternative. while the mean ratings for the familiarity o f the words indicated that the majority o f the words were highly familiar, the selection o f the words for the study was also dependent on the tone and phonetic dissimilarity o f the words. low tone verbs were introduced as an adapted criterion for srt words in zulu. this criterion was introduced after careful analysis o f the lin­ guistics o f zulu. zulu has only one main stress in most words, which prevents the language from having spondee words. however, after consultation with a linguist o f zulu it would appear that low tone verbs allows for the lengthening o f the penultimate syllable, thus allowing for the final syllable to gain prominence. tone is a complex phenomenon in zulu and even linguists and users o f the language have grave difficulty identi­ fying tonal patterns (r. bailey, personal communication, febru­ ary, 2004). the complexity of the tone o f zulu is also expressed by buell (2004). there are “scant sources for lexical tone in zulu” (buell, 2004, p.l). this could possibly explain the results obtained within the present study with regards to the rating o f the tone o f the words. the moderate level o f agreement among the linguists, i.e. the kendall’s w score of 0.431 is indicative that even lin­ guistic experts differ with regard to low tone and high tone verbs. however, the agreement is still considered reliable at 95% o f confidence. these results merely confirm the complex­ ity o f languages and also illustrate that developing a word list with adapted criteria requires extensive resources and expertise. the 55% o f the words indicated as low tone words were veri­ fied against a list o f zulu verbs with tone markers compiled by buell (2004). further, within the present study the use o f low tone verbs limited the variability o f the phonemes among the words. low tone verbs generally end in the same vowel /a/ e.g. bhala, bhema, gqoka. hence, the second syllable o f most verbs in the list could potentially be very similar in phoneme structure. this suggests that words in the final list for zulu would possibly have variability o f consonants and vowels in the first syllable, die suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 but variability would be limited in the second syllable as illus­ trated in the example. however, zulu has a much more com­ plicated consonant system than english. in addition to the known sound system like fricatives, stops and plosives, zulu has the prominent click sounds. the inclusion of the click sounds in the phoneme distribution of the words contributes to consonant variability in the words. thus, within the present study, because o f the importance of low tone verbs, the re­ searcher concentrated on the variability o f the consonant struc­ ture and to lesser extent on the variability o f the vowel system. this standpoint was supported by the linguistic choices made within the study. the overall agreement among the raters for the criteria o f familiarity, tone and phonetic dissimilarity provided the necessary reliability with regard to the choice o f words for the study. the choice of words, using the adapted and modified criterion discussed above, is a clear indication that the words selected represent the linguistic structure of the zulu language, the acoustic properties o f zulu and the sociolinguistic aspects. this principle is the inherent theoretical premise that fore­ grounded this study. the clinical usage of the test tool was also dependent on the very important criterion o f homogeneity o f audibility that was used to assess the words for inclusion into phase two o f the study which is documented in panday (2006). co n clu sio n and rec o m m endations this study therefore concluded that 131 words were identified as common bisyllabic words for the adult zfls. descriptive statistics indicated that the majority o f the words identified were bisyllabic verbs which was in accordance with the struc­ ture o f zulu. objective two o f the study concluded that 58/131 words satisfied the criterion o f familiarity, phonetic dissimilar­ ity and low tone verbs. these words were rated on three point likert scale by linguistic experts. the kendall’s coefficient of concordance was found to be very good for familiarity, moder­ ate for tone and good for phonetic dissimilarity. these were obtained at 95% level of confidence. therefore the results ob­ tained were reliable. these words can be used to form a suit­ able srt word list for zulu first language speakers, i therefore the following recommendations are made i.e.! • the present paper can be used as an example o f how words could be developed in mother tongue languages by| adher­ ing to both the audiological and linguistic principles inher­ ent in speech reception testing. j • the present paper could also serve as a guideline towards the development o f linguistic relevant srt materials in other african languages locally and internationally. • the developed word list was assessed for its application to a normative clinical population as described in panday (2006). the final word list therefore could be assessed for application on a varied clinical population. • the final word list developed in panday (2006) may be used clinically with caution via recorded material for the assessment o f hearing for speech for the adult zfls. further clinical and research implication for the test tool is available in panday (2006). ^ ack n o w led g em en ts this article is the culmination o f thesis submitted to the uni­ versity o f kwa zulunatal by the first author for the requirer ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the d evelopm ent o f a z ulu speech r eception threshold t est fo r z ulu first language speakers in k w a z ulu-n atal 119 g^ferences akm ajian, a., d em ers, r. a., f arm er, a. k , h am ish. r. m. 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(1982). t hresholds and psychom etric functions o f the individual spondaic w ords. journal o f speech and hearing research, 25, 586-593. the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.codesria.org/links/publications/ http://www.fizzylogic.com/users/bulbul/school/zuluverblist.html http://wwjw.lmp.ucla.edu/profiles/profz01 http://www.southafrica.info/ess_info/ 120 seema panday, harsha kathard, mershen pillay & cyril govender appendix a identification schedule: adapted from balkisson (2001) p lease list the most commonly u sed bi-syllabic zulu w ords u sed by zulu f irst language speakers in kzn. each individual must f i l l a minimum o f 100 words no commonly used em -syllabic zulu words n o commonly u s e d b l -syllabic l u l u words 1 51 2 52 3 53 4 54 5 55 6 56 7 57 8 58 9 59 10 60 11 61 12 62 13 63 14 64 15 65 16 66 17 67 18 68 19 69 20 70 21 71 22 72 23 73 24 74 25 75 26 76 27 77 28 78 29 79 i 30 80 31 81 ' 32 82 33 83 34 84 35 85 i 36 86 ‘ 37 87 38 88 39 89 , 40 90 4191 42 92 43 93 44 94 45 95 46 96 4 7 97 48 98 49 99 50 100 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) appendix b a description of the words obtained per participant for objective one the d evelopm ent o f a z ulu speech r eception threshold t est for z ulu first l anguage speakers in k w a z ulu-n atal 121 words suggested by any of the two participants w ords suggested by any of the three participants w ords suggested by any o f the fo u r participants ^ i b h a l a bona bhaka 2.bhema banga biza 3 .buza bheka bola 4.cela cwewa cacha 5 .chela dinga cinga 6.dansa dlala donsa 7 .duda faka g cina 8.dula futhi g eza 9. fika ganga hamba 10-funa goba khipa 11 .funda gxeka landa 12.finya hleka netha 13.gcaca hoya ndiza 14.gqoka hlala pheka 15.hola hluba phuma 16.jika hlupha shaya 17jula hlenga siza 18jaha jeza shada 19khiye khanya thatha 20.khala kheta vala 21.klekha khola w oza 22letha khaba yifa 23.lima lala 24.loya linda 25.lapha luma 26.minya lunga 27.ngena m anje 28.nuka mina 29.nyanga mila 30phansi i muva 31phezu j ncam a 32.phuza j nyama 33qeda | phupha 34.qonda ( phosa 35.qina | phapha 36.senga ! pheza 37.sula i qala 38.sefa i q oba 39.shiya q uela 40.sika q haqha 41.sina q aqa 42.susa shesha 43.thola thenga 44.thula thanda 45.thela vuka 46,tshala vula 47.veza vum a 48.w aw a w asha 49.xoxa w ina 50,xola xosha 51,yeka yeba 52.yanga yosa 53.yenza 1 54.yona 55,zakhe 56.zosha 57.zabo r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) appendix c the fifty eight words selected according to the criteria of familiarity, phonetic dissimilarity and tone 122 seem a panday, h arsha k athard, m ershen pillay & c yril g o v e n d e banga hlala loya veza bheka hleka lunga vula bhema hlenga minya vuma chela hluba pheka washa cinga hola phonsa wina dansa jaha qoba xola dinga jeza sefa yanga donsa khaba shada yeba faka khanya shaya yeka finya kheta thanda yenza geza khipa thatha yifa goba landa thela yona gonda letha thenga yosa gqoka lima thola gxeka linda vala die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) information for contributors n a t u r e o f p u b l i c a t i o n the south a frican journal o f com m unication disorders p u b lis h e s re p o rts and papers con ce rn e d w ith re s e a rch , and c ritic a lly e v a lu a tiv e th e o re tic a l and p h ilo so p hica l c o n c e p tu a l issues d e a lin g w ith a spects o f h u m a n c o m m u n ication and its d is o rd e rs , d y s p h a g ia , se rvice p ro v is io n , tra in in g and policythe jo u rn a l w ill a cce p t th e fo llo w in g th re e ty p e s o f m a n u s c rip ts : research m anuscripts d e 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ro v id in g th e a u th o r's ad d re ss, te le p h o n e and fa x n u m b e rs and e -m a il ad d re ss. , three p rin te d copies o f th e m a n u s c rip t m u s t be s u b m itte d . the t it le page o f one c o p y m u s t c o n ta in : t itle o f th e m a n u s c rip t. full n a m e s o f th e a u th o rs . in s titu tio n a l a ffilia tio n . a b s tra c t o f th e m a n u s c rip t in th e la n g u ag e o f th e m a n u s c rip t. • the t it le page o f th e re m a in in g two copies m u s t not c o n ta in th e a u th o r(s ) n a m e s o r in s titu tio n a l a ffilia tio n s . . one e x a c t e le c tro n ic co p y o f th e t it le page and m a n u s c rip t on disk m ust be s u b m itte d . f ile na m e s m u s t in clu d e th e fir s t a u th o r's in itia ls and a c le a rly id e n tifia b le ke y w o rd and m u s t he ty p e -w r itte n on th e last line o f th e la s t page o f th e r eference lis t ( fo r re trie v a l pu rp o se s on ly). • an e le c tro n ic co p y o f th e t it le page and m a n u s c rip t m u s t be e m a ile d to a d m in @ s a s lh a .c o .z a . the e d ito r-in -c h ie f a n d /o r th e s o u th a frica n s p e e c h -l a n g u a g e -h e a rin g a s s o c ia tio n (saslh a) a d m in is tr a to r w ill a c k n o w le d g e re c e ip t o f th e m a n u s c rip t w ith in a m a x im u m o f 7 days. i f a t th is s ta g e , no a c k n o w le d g e m e n t has been rece ive d by th e a u ­ th o r, th e a u th o r is k in d ly re q u e s te d to fo llo w th is up w ith th e saslha office. • ms w ord m u s t be used f o r th e te x t. ms w ord o r ms p ow erp oint should be used fo r fig u re s , and ms excel fo r ta b le s . • m an u scrip ts m u s t be in d o u b le sp a cin g and in a fo n t size o f 12. • m an u scrip ts m u s t be on a4 pages in d o u ble sp a cin g and in a fo n t size o f 12 ' • filenam es m u s t in clu d e th e f ir s t a u th o r's in itia ls and a c le a rly id e n tifi­ able key w o rd . • m a n u scrip ts m u s t n o t exceed 30 pages. • the o rd e r o f th e m a n u s c rip t sh o u ld be: t it le page, a b s tra c t and key w ords, t e x t, re fe re n c e s , ta b le s , le g e n ds, and fig u re s . • each m a n u s c rip t m u s t c o n ta in an english a b s tra c t o f no m o re th a n 200 w o rd s w ith 5 -7 key w o rds. • s tric t a d h e re n c e to th e p u b lica tio n m anual o f th e a m e ric a n psycho­ logical a s so cia tio n (5 th e d ., 2 0 0 1 ) is re q u ire d . • h eadings a re not numbered. the o rd e r o f im p o rta n c e is in d ic a te d as fo llo w s : main h e a ding in c a p ita ls and bold p rin t s u b -h e a d in g s in u p p e r and lo w e r case and bold s u b -s u b h e a d in g s in u p p e r and lo w e r case bold and ita lic p rin t. s u b -s u b -s u b -h e a d in g in u p p e r and lo w e r case ita lic p rin t. • m a jo r h e a ding s, w h e re a p p lic a b le , m u s t be in th e o rd e r o f intro duc­ t io n , method, results, d isc u ssio n , conclusion, acknow l­ edgements, and references. • all p a ra g ra p h s sho u ld be in d e n te d . • all ta b le s , fig u re s and illu s tra tio n s m u s t be n u m b e re d and p ro v id e d w ith title s . • the t it le o f ta b le s , w h ich a p p e a r a b o v e , and o f fig u re s , w h ic h a p p e a r below , m u s t be concise b u t e x p la n a to ry . • a llow f o r 5 0 -7 5 % re d u c tio n in p rin tin g o f ta b le s , fig u re s and illu s tra ­ tio n s. • each ta b le , fig u re o r illu s tra tio n m u s t a p p e a r on a separate page. • do n o t in clu d e m ore th a n 10 ta b le s , fig u re s o r illu s tra tio n s . • c olour g ra p h ic s are not p re fe rre d . i f s u b m itte d , e x tra c o s t o f c o lo u r re p ro d u c tio n and p rin tin g m u s t be co v e re d by th e a u th o r p rio r to p u b lica tio n . a s h o rt ru n n in g t it le sh o u ld be liste d a t th e to p le ft-h a n d c o rn e r o f th e title page. a n y in fo rm a tio n a b o u t g ra n ts o r o th e r fin a n c ia l s u p p o rt should be s u p p lie d as an u n n u m b e re d fo o tn o te to th e m a n u s c rip t title . • g rap h ics, a u d io a n d /o r vid e o file s ( n o t e x ce e ding 2m b) m a y be s u b m itte d f o r fu tu re p u b lic a tio n as an e le c tro n ic o n lin e jo u rn a l. c o n s u lt th e e d ito r-in -c h ie f re g a rd in g re q u ire d file fo rm a ts . • a u th o rs m u s t use g e n d e r-, ra c e -, and c re e d -in c lu s iv e la n g u ag e . • a u th o rs m u s t e n s u re a d h e re n c e to n a tio n a l a n d /o r in te rn a tio n a l e th ic a l codes. • b ritis h s p e llin g (e .g . c e n tra lis e n o t c e n tra liz e , b e h a v io u r n o t b e h a v ­ io r) is p re fe rre d . referencing • r eferences m u s t be cite d in th e te x t by a u th o r's na m e and th e d a te , e .g . van r iper (1 9 7 1 ). • w h e re th e re are m o re th a n tw o a u th o rs , a fte r th e fir s t o cc u rre n c e , e t al. m a y be used. • the n a m e s o f all a u th o rs m u s t a p p e a r in th e r eference l ist, w hich m u s t be lis te d in s tr ic t a lp h a b e tic a l o rd e r in tr ip le spacing a t th e end o f th e m a n u s c rip t. • all re fe re n c e s m u s t be in clu d e d in th e list, in c lu d in g se c o n d a ry sources. • o n ly a c c e p ta b le a b b re v ia tio n s o f jo u rn a ls m a y be used, (see d s i-1 abstracts, o c to b e r; o r the world list o f s cientific periodicals). • a u th o r(s ) sh o u ld use re fe re n c e s th a t re fle c t an in te rn a tio n a l d iv e r ­ s ity a m o n g a u th o rs o f b o th so u rc e a rtic le s and c ite d a rtic le s . • the n u m b e r o f refe re n ces sh o u ld n o t exceed 30, unless s p e c ific a lly w a rra n te d . exam ples locke, j.l. (1 9 8 3 ). c linical p sychology: the e x p la n a tio n and tr e a tm e n t o f speech sound d is o rd e rs . j. speech h ear d isord., 4 8 3 3 9 -3 4 1 . penrod, j.p. ( 1 9 8 5 ). speech d is c rim in a tio n te s tin g . in j. k a tz (ed.), handbook o f clinical audiology (3 rd e d .). b a ltim o re : w illia m s & w ilkin s. d avis, g. & w ilc o x , m.j. (1 9 8 5 ). a d u lt aphasia re h a b ilita tio n : a pplied pragm atics. san diego, ca: c o lle g e -h ill. editing • m a n u s c rip ts m u s t be c o rre c te d f o r g ra m m a r and s ty le p rio r to s u b ­ m issio n . • o n ly m a n u s c rip ts c o m p ly in g w ith th e a b o ve re q u ire m e n ts w ill be acce p te d fo r re v ie w . reviewing system • t he d o u b le -b lin d p e e r re v ie w s y s te m is e m p lo y e d as a m e th o d o f q u a lity c o n tro l o f th is p u b lic a tio n and e n s u re s th a t a u th o r(s ) and re v ie w e rs do n o t kn o w each o th e rs ' nam es. • each m a n u s c rip t is s e n t to tw o in d e p e n d e n t re v ie w e rs , se le cte d a cco rd in g to th e ir area o f e x p e rtis e , to assess th e q u a lity o f th e m a n u s c rip t's s c ie n tific and te c h n ic a l c o n te n t. • a u th o r(s ) m u s t e n s u re th a t th e m a n u s c rip t does n o t c o n ta in in fo r ­ m a tio n /c lu e s as to th e id e n tity o f th e a u th o r(s ). • the e d ito r-in -c h ie f re ta in s th e fin a l re s p o n s ib ility fo r d e cisio n s re g a rd in g re v is io n , acce p ta n ce o r re je c tio n o f th e m a n u s c rip t. t his process is u s u a lly done in c o n s u lta tio n w ith th e m a n u s c rip t's e d ito r a n d /o r th e e d ito ria l te a m , as necessary. deadline for contributions. 2 8 th/ 2 9 th f e b ru a ry each y e a r publication fee: a u th o rs w ill be e xp e c te d to p ay a p u b lic a tio n fee. the e x a c t a m o u n t is d e te rm in e d by p rin tin g costs. queries and correspondence: sh o u ld be a d dressed to the e d ito r-in -c h ie f, south a frican journal o f com m unication disorders, s o u th a fric a n s p e e c h -l a n g u a g e -h e a rin g a s s o c ia tio n , po box 1 0 8 13 , l in to n g ra n g e , 6 0 1 5 , s o u th a fric a . e m a il s a slh a a t ad m in @ s a s lh a .c o .z a fo r th e c u rre n t e d ito r-in -c h ie f's e m a il address. a u th o r's r e s p o n s ib ility : the s o u th a fric a n jo u rn a l o f c o m m u n ic a ­ tio n d is o rd e rs is n o t re s p o n s ib le f o r a u th o rs ' v ie w s and does n o t e n ­ d o rse a n y o f th e p ro d u c ts o r m a te ria ls a d v e rtis e d in th e jo u rn a l. c o p y rig h t: the c o p y rig h t o f all m a n u s c rip ts p rin te d in t he s o u th a fric a n j o u rn a l o f c o m m u n ic a tio n d is o rd e rs is re se rve d by t he s o u th a fric a n s p e e c h -l a n g u a g e -h e a rin g a s so cia tio n (saslh a). 2 0 0 7 editorial board e d ito r-in -c h ie f: d r m ershen pillay e d ito rs: p ro f h arsha k a th a rd , d r elsie n aude, p rof e le a n o r ross e d ito r (a s s is ta n t): dr. m ichelle pascoe (e d ito r-e le c t 20 08 ) t ech n ica l e d ito r: ms c arm en m ilton r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:admin@saslha.co.za mailto:admin@saslha.co.za abstract introduction methods results and discussion conclusion acknowledgements references about the author(s) jacqueline k. bezuidenhout department of paediatrics, faculty of health sciences, university of the witwatersrand, johannesburg, south africa katijah khoza-shangase department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa tim de maayer department of paediatrics, faculty of health sciences, university of the witwatersrand, johannesburg, south africa renate strehlau department of paediatrics, faculty of health sciences, university of the witwatersrand, johannesburg, south africa citation bezuidenhout, j.k., khoza-shangase, k., de maayer, t., & strehlau, r. (2021). outcomes of newborn hearing screening at an academic secondary level hospital in johannesburg, south africa. south african journal of communication disorders, 68(1), a741. https://doi.org/10.4102/sajcd.v68i1.741 original research outcomes of newborn hearing screening at an academic secondary level hospital in johannesburg, south africa jacqueline k. bezuidenhout, katijah khoza-shangase, tim de maayer, renate strehlau received: 20 apr. 2020; accepted: 12 nov. 2020; published: 27 jan. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the health professions council of south africa (hpcsa) issued early hearing detection and intervention guidelines, which has universal newborn hearing screening (unhs) as one of the important goals. despite established evidence of the importance of unhs globally, there has been no mandated formalised and standardised implementation as yet in south africa. objectives: the aim of this study was to describe the outcomes of newborn hearing screening (nhs) in an academic secondary level hospital in johannesburg, south africa. methods: this was a prospective non-experimental feasibility study over a 3-month period, involving conducting hearing screening of 121 neonates. audiologists conducted a risk factor assessment, otoscopic examinations and distortion product otoacoustic emissions (dpoaes) screening on each neonate, with follow-up appointments for re-screening and diagnostic audiological assessments for all neonates with refer findings. data were analysed using stata intercooled version 11©, through both descriptive and inferential statistics (fisher’s exact test), with significance established where p-values less than 0.05 were considered statistically significant. results: of the 121 neonates screened, the majority (75%) were screened in the first 24 h of life. a high refer rate (47%) of the total sample was found on dpoae screening. no maternal or neonatal risk factors were found to be significantly associated with refer findings. conclusion: findings contribute towards the existing evidence base that raises implications for successful implementation of nhs programmes in public healthcare in south africa. screening protocols need to consider the timing of screening, the measures and procedures adopted in the screening protocols, as well as the follow-up strategies. keywords: otoacoustic emission; newborn hearing screening; refer rates; risk factors; public healthcare; outcomes. introduction the lowand middle-income world, where south africa is located, is reported to be home to two-thirds of the world’s children with hearing impairment (olusanya, luxon, & wirz, 2004). the prevalence of hearing impairment in south africa is three to six in every 1000 live births, with the public healthcare sector recording the highest numbers of individuals affected (swanepoel & storbeck, 2008). this is one of the reasons why the health professions council of south africa (hpcsa, 2018), in carrying out its mandate to protect the public and guide the professions, recently published guidelines on early hearing detection and intervention (ehdi). currently, there remains a paucity of sufficient evidence regarding the current status of neonatal hearing screening programmes in south africa both in the public and private healthcare sector. the available evidence indicates limited success with implementation of these programmes within the south african context (maluleke, khoza-shangase, & kanji, 2018; swanepoel, storbeck, & friedland, 2009). theunissen and swanepoel (2008) reported that only 27% of public sector hospitals in south africa were implementing any form of newborn hearing screening (nhs). these findings were not that far different from the private healthcare sectors, where resource constraints are not as prevalent as in the public healthcare sector (khoza-shangase, 2021b). in a national survey of the audiological services for diagnosis and intervention in the private healthcare sector in south africa, findings revealed that there is significant delay in the overall diagnosis and provision of intervention for hearing impairment (kanji & khoza-shangase, 2018b; khoza-shangase, barratt, & jonosky, 2010; meyer, swanepoel, & le roux, 2014). universal newborn hearing screening (unhs) is when every newborn baby is screened for hearing impairment at birth. currently, in south africa, no legislation exists to implement unhs and because of resource constraints, the approach to nhs has been targeted screening (hpcsa, 2018). targeted hearing screening, where babies with risk factors for hearing loss are screened, has the risk of missing a significant number of infants with hearing impairment, and assumes the universality of the listed risk factors. however, kanji (2018) strongly argues for the implementation of this as an interim measure within the south african context – if contextual responsiveness is adopted. nonetheless, studies have shown that by screening only those infants considered ‘high-risk’, approximately 50% of infants with hearing impairment would be missed (chu et al., 2003; kanne, schaefer, & perkins, 1999). khoza-shangase (2021b) recommends this adoption of targeted nhs as a starting point or interim approach, particularly in a hospital setting, with inclusion of nhs at the first follow-up visit at midwife obstetric units for all babies, including those without risk factors as well as those who were born at home. this author believes that this approach respects both the documented evidence of established risk factors for hearing impairment and the contextual challenge of resource constraints. evidence suggests that in south africa, where different types and levels of healthcare exist, nhs programmes have neither been standardised, nor have they been uniformly or universally implemented nationally (khoza-shangase & kanji, 2021). in a study examining infant hearing screening in two south african provinces, findings indicated lack of formal, standardised and systematic ehdi implementation at all three levels of public healthcare (khoza-shangase, kanji, petrocchi-bartal, & farr, 2017). the authors of this study proposed that some of the reasons for the lack of ehdi included lack of equipment, budgetary constraints, human resource challenges, as well as lack of political mandate by the south african government. these findings have highlighted the need for ensuring that context-specific studies in infant and neonatal hearing screening are conducted to ensure that contextually relevant strategies are put in place, which allows for evidence-based practice (khoza-shangase et al., 2017). another recent study from the south african context which explored factors associated with follow-up return rate in a risk-based nhs programme found that addressing the challenges to implementation of nhs is imperative towards successful ehdi (kanji & khoza-shangase, 2018b). in this study, 66.5% of the participants returned for repeat screening, and this follow-up return rate decreased to below 50% for follow-up diagnostic assessment. various reasons for poor return rate were identified, with one of the key challenges contributing to nonattendance being changes in residential location. the authors suggest that strategic bookings of appointments for screening where there is improved alignment of hearing screening appointments with other medical follow-up services are key to successful implementation of neonatal screening (kanji & khoza-shangase, 2018b). other factors influencing successful implementation of hearing screening within the south african context, particularly unhs, include the insufficient number of audiologists available to provide screening, the high rate of false positive test results and the high rates of loss to follow-up (bezuidenhout, khoza-shangase, de maayer, & strehlau, 2018; khoza-shangase, 2021b). furthermore, the quadruple burden of disease that guides priorities within the south african healthcare sector places hearing impairment low as a risk priority. conditions high on the priority list tend to be those deemed life-threatening such as human immunodeficiency virus (hiv), acquired immune deficiency syndrome (aids) and tuberculosis which are in the top five contributors of death in south africa (khoza-shangase, 2021a; statssa, 2016). regardless of hearing impairment being placed low on the government’s priority list, sufficient evidence exists to support the importance of identifying it early and providing intervention by 6 months of age (hpcsa, 2018; khoza-shangase & kanji, 2021). the year 2019 position statement from the joint committee on infant hearing (jcih) advocates the ehdi 1:3:6 goals. these goals state that infants must have initial hearing screening done by 1 month of age, have their hearing status confirmed by 3 months of age and be receiving appropriate intervention by 6 months of age. sufficient evidence exists proving the positive benefits of ehdi towards cognitive, linguistic, literacy and educational, social, and emotional development, with consequent positive vocational and thus financial outcomes (dillon, cowan, & ching, 2013; maluleke, khoza-shangase, & kanji, 2019; tomblin et al., 2015). it is therefore important that ehdi receives increased research focus to aid appropriate planning and budgeting for the south african health department. this planning should include efficient and effective screening protocols to ensure that nhs is conducted in a valid, reliable and ethical manner. hence, the current study aimed to describe the outcomes of nhs at an academic secondary level hospital in johannesburg, south africa. the rationale of the study is to contribute towards contextually relevant evidence that facilitates efficacious provision of ehdi services in the south african context, particularly from a mother and child hospital setting where it is assumed early detection and intervention would be higher on the priority list than in a general hospital. early detection of hearing loss is the initial stage to any ehdi programme and is conducted by means of nhs, the focus of the current study. methods study design this study was part of another study programme titled ‘universal newborn hearing screening in public healthcare in south africa: challenges to implementation’ (bezuidenhout et al., 2018), where the design was a prospective non-experimental cohort study that looked at the feasibility assessment of a unhs programme. in that study, the focus was on identifying challenges to implementation of the screening programme. the current study examines parameters that were being assessed. these included the time taken to screen, the risk factor profile of the newborns, the otoscopic examination results, as well as the follow-up rates during the programme. for this part of the study, the parameters being investigated were specific to the outcomes of the screening. some of the findings, presented and discussed in depth in this study, were published in the bezuidenhout et al.’s (2018) study. study population and sample the study population was drawn from all neonates born at rahima moosa mother and child hospital (rmmch), an academic secondary level hospital in johannesburg, south africa, using stratified systematic sampling. selected neonates from the postnatal wards, the neonatal unit and neonatal intensive care unit (nicu) were assessed during a 3-month period. because of the limitation of availability of only one audiologist to screen the babies, a task they took on in addition to their clinical caseload, a stratified sample of neonates was recruited. at the time of the study, the hospital had a delivery rate of 20–30 babies a day, with a caesarean section rate of 30%. by selecting 30% of the neonates to be tested from the caesar theatre birth register and the remaining 70% from the labour ward register, a representative sample of the delivery profile specific to the testing hospital was ensured. a total of 10 neonates were identified every day to be screened, by selecting every third neonate appearing on the registries. this stratified, systematic sampling was done at the start of each weekday by the researcher, who assigned a study number to each of the pre-identified neonates requiring screening. inclusion criteria any neonate born at rmmch within the specific 3-month period. at the time of screening, infants were to be younger than 30 days of chronological age to minimise the influence of extraneous variables such as hearing loss because of other causes, as well as residential location changes. exclusion criteria neonates who spent more than a month in nicu were excluded as they would have exceeded the age cut-off of 1 month. any neonate whose parent/caregiver refused to provide informed consent. neonates not born at the hospital site (transferred from other facilities). study procedure hearing screening took place at the secondary academic hospital during weekday working hours by the audiology department team, comprising four audiologists who are registered with the hpcsa as being qualified to conduct all measures included in this study a part of their regulated scope of practice. one audiologist was assigned to screen each day, and this audiologist would receive a list of 10 names from the researcher and would attempt to screen as many neonates as possible from the list. the audiologist would explain the purpose of the screening to the caregiver, both verbally and via an information sheet. if the caregiver was in agreement, written informed consent was obtained prior to the hearing screening. once informed consent had been obtained, the audiologist would note the starting time so that the duration of the screening process could be recorded. each neonate who was screened first underwent an otoscopic examination to assess patency of the ear canal as this could potentially impede the screening procedure and impact the results. thereafter, distortion product otoacoustic emission (dpoae) screening was conducted through the use of a natus bio-logic audx® device, giving either a ‘pass’ or ‘refer’ result. for contextual relevance, although inclusion of automated auditory brainstem response (aabr) audiometry would have been ideal and is an important part of a two-stage screening protocol, aabr is not readily available in most south african healthcare contexts, but oaes are becoming increasingly so (kanji & khoza-shangase, 2018a; kanji, khoza-shangase, & moroe, 2018), and aabr was not available at the research site. the same motivation is proffered for the use of dpoaes instead of teaoes. kanji and khoza-shangase (2018a) discuss differences in screening measures in various contexts and populations with teaoes being the most commonly used of the two measures. however, dpoaes are also widely used in places such as the united states of america, where dpoaes are second to aabr in frequency of use. china has also been reported to use dpoaes within the different stages of the hearing screening protocol; therefore, the sensitivity of this measure in this population is not questionable (who, 2010). a ‘pass’ result was recorded if the patient passed the dpoae test across at least 60% of the tested frequencies (1000 kilohertz [khz], 2000 khz, 3000 khz, 4000 khz and 5000 khz) at 25 decibels (db) – 30 db hearing level, in both ears, where response level relative to the noise floor signal-to-noise ratio (snr) should be at least 6 db, with a minimum response level of −5 db to −8 db spl and an acceptably low noise floor (−4 db sound pressure level [spl] or less) (barker, lesperance, & kileny, 2000; iowa hearing detection and intervention program, n.d). the current study included 1000 hertz (hz) in the analysis in an attempt to cover lower frequencies. a ‘refer’ result implies that the patient did not pass the hearing screening test across at least 60% of the tested frequencies (1000 khz, 2000 khz, 3000 khz, 4000 khz and 5000 khz) at 25 db – 30 db hearing level, in both ears. babies receiving a ‘pass’ result were discharged without a planned follow-up, unless follow-up was clinically indicated. it is acknowledged that discharging a baby after a pass on the initial screening may have resulted in false-negative findings which cannot be accounted for in this study; however, the resource allocations did not allow for the alternative. newborns receiving a ‘refer’ result were rescreened within a month of initial screening. the rescreening procedures included an otoscopic examination, a tympanogram and a repeat dpoae. if the results of the rescreening procedures were still inconclusive, the infant was referred for diagnostic auditory brainstem response (abr) performed at a referral tertiary academic hospital. healthy neonates were screened within the first few days of life, whilst neonates with complications preventing earlier screening were screened when possible within the first 30 days of life. the neonates’ clinical history was obtained in all cases prior to the screening. this was obtained both verbally from the parent through an informal interview once consent had been given and by obtaining information documented in the neonate’s hospital file. a study data sheet was completed for each neonate that was screened. the study data sheet comprised three sections which included general information of the baby, the presence of risk factors and the findings on clinical assessment. firstly, the general information section provided information regarding the demographics of the babies being screened and included type of delivery, birth weight, hiv exposure, apgar scores, as well as ward where the neonate was located. secondly, a risk factor assessment was completed for each neonate screened. the following items were included: a family history of permanent childhood hearing loss; admission to nicu, and if so, was assisted ventilation required; exposure to ototoxic drugs such as aminoglycosides or loop diuretics; hyperbilirubinemia requiring exchange transfusion; congenital infections such as cytomegalovirus, herpes, toxoplasmosis, rubella, syphilis, hiv and malaria; and the presence of craniofacial abnormalities (hpcsa, 2018). lastly, examination of findings on clinical assessment section where all data from the initial screening as well as the rescreening procedure were recorded. data analysis data were entered into microsoft office excel©, and later analysed using stata intercooled version 11© (statacorp, 2009). data were analysed using both descriptive and inferential statistics. a fisher’s exact test was used to assess the association between the risk factors and dpoae results, with significance established where p-values less than 0.05 were considered statistically significant (bonita, beaglehole, kjellström, & world health organization, 2006). ethical consideration the study adhered to the singapore statement on research integrity guidelines in terms of research into human subjects (lucas, 2010). therefore, prior to the commencement of the study, ethical approval was obtained from the university of witwatersrand’s human research ethics committee (protocol number m111119). results and discussion study population during the 3-month study period, 2740 neonates were born at rmmch, with a total of 490 neonates being identified and assigned study numbers. of the identified neonates, two mothers refused consent for their infants to be screened. because of the challenges discussed in bezuidenhout et al. (2018), only a total of 121 neonates were screened, representing 24% of the identified neonates. thus, of the 2740 neonates born at rmmch during the 3-month study period, only 4.4% underwent nhs (bezuidenhout et al., 2018). figure 1 depicts the time when hearing screening was conducted for each neonate included in the study. a large majority, 91 (75%), of the 121 neonates were screened in the first 24 h of life. only two (1.6%) were screened on day 7 of life. the fact that many of the neonates were screened within the first 24 h is a positive finding as it indicates that hearing screening can be performed prior to discharge from the hospital. this is particularly important in the south african context where mothers and their neonates may be discharged home as early as 6 h post-normal vaginal delivery (nvd), according to the south african department of health guidelines for maternity care (doh, 2015). this, however, is only a positive finding if confounding variables to screening, such as the presence of vernix caseosa and the use of a two-stage approach, are actively addressed prior to the screening being conducted. the mean time taken to screen each neonate was 11 min 17 s, with the longest duration being 40 min, and the shortest screening time being 5 min. the median time taken to screen was 10 min. technical difficulties with the dpoae machine, the presence of vernix caseosa and high ambient noise were the main contributors to the prolonged screening time (bezuidenhout et al., 2018). figure 1: time when hearing screening occurred in the current sample (n = 121). hearing screening results otoscopic examination results otoscopic examinations revealed a large majority, 86 (71%) neonates, had vernix caseosa in their external auditory canals, and 39 (32%) were subjectively considered to have narrow ear canals (figure 2). other otoscopic findings included the presence of blood in the ear canal (n = 1), a pre-auricular skin tag (n = 1) and an ear canal that collapsed during testing (n = 1). figure 2: otoscopic findings in neonates prior to hearing screening (n = 121). the occurrence of a narrow ear canal was a subjective finding identified on otoscopic examination in 39 cases; 18 (46.2%) of which required a repeat dpoae testing versus 39 (47.6%) of those without a narrow canal (odds ratio [or]: 0.86, 95% confidence interval [ci]: 0.46–1.61, p = 0.88) – on additional statistical analysis. ear canal clearance was not performed on the participants because the study was meant to reflect the reality of the screening context. however, without artificial intervention, the high prevalence of vernix caseosa in the external auditory canal and its well-documented impact on oaes raises important implications for the practicing audiologists and/or anyone involved in hearing screening, particularly in the first 24 h of life (doyle, rodgers, fujikawa, & newman, 2000; kumari & rangasayee, 2016). for efficient implementation of unhs, neonatal assessment and management protocols that include standard manual otoscopy as well as compulsory external ear canal cleaning (vernix caseosa clearing) prior to oae screening need to be considered. this is particularly important in the south african context where discharge can be as early as 6 h post-birth (doh, 2015). this inclusion in screening protocols will improve efficiency of unhs significantly, possibly reduce the high refer (false positives) rates and consequently reduce costs related to repeat screening which include emotional costs to parents when refer findings have been communicated to them. distortion product otoacoustic emissions of the total sample, 57 of the 121 participants (47%) had a refer result at the initial screening, whilst the remainder were discharged from the programme because they passed the screening bilaterally. all neonates that had refer findings were booked for a repeat dpoae screening with only 20 (35%) of them returning for follow-up. of the 20 that returned for repeat screening, all presented with normal otoscopy and tympanometry results, with only two presenting with refer findings on dpoae screening. these two were referred for diagnostic testing including abr testing. the tympanometry findings were all clearly defined single peaks type a tympanograms (carmo, costa, & momensohn-santos, 2013). tympanometry data were not captured at the initial screening because of the unavailability of high frequency probe tone (1000 hz) tympanometry at the time, which is the measure that has high sensitivity and specificity in this population (carmo et al., 2013). this is a significant well-documented challenge with south african audiology practices which requires serious attention (sebothoma & khoza-shangase, in press). the two infants that were to be referred for diagnostic abr measurements could not be tested because of technical issues with the abr equipment. this resulted in a third dpoae being conducted on the one infant who returned for the follow-up. this infant passed dpoaes bilaterally, whilst the second infant defaulted follow-up. the rate of true versus false positive results could not be determined in the current sample. this is another important finding for this context where loss to follow-up can negatively influence the outcomes of an already compromised hearing screening programme. repeat testing was required for 57 (47%) neonates; however, only 20 infants returned for repeat dpoae. this referral rate of 47% after initial screening is much higher than the hpcsa’s recommendation of <5% (hpcsa, 2018), which is in agreement with the guidelines from the jcih that less than 4% of all newborns should fail the initial screening and be referred for repeat screening (jcih, 2007). the target referral rate is a means of applying quality control to the screening programme. the high refer rates may have been attributed to inappropriate testing circumstances with excessive ambient noise interference, the presence of vernix and the faulty dpoae machine. at least two of these contributing factors can be remediated to improve the referral rate. for example, a dedicated quiet room can be allocated for hearing screening in the wards with constant noise-level monitoring during screening. in addition, protocols can be put in place where vernix caseosa is routinely removed from the neonates’ ears as soon as it is safe to do so to facilitate screening via oaes. the world health organization recommends 6 h as the earliest safe time when vernix can be removed (who, 2018). the high referral rate of 47% also contributed to increasing the burden of work for the under-resourced screening team. the return rate of those who require further diagnostic evaluation after failing the initial screening should be at least 95% (kanji & khoza-shangase, 2018b). this highlights the importance of increasing all efforts to ensure that when screening happens, a two-stage approach is adopted in order to minimise the high referral rate. risk factor assessment of the total sample of neonates screened, two (1.7%) had been admitted to nicu and both had required assisted ventilation. the first neonate had an nicu stay of 6 days and passed the initial dpoae which was conducted on day 7 of life. the second neonate was admitted to nicu for 8 days and was considered high risk for a possible hearing deficit as several risk factors were identified, namely: a positive family history (the maternal uncle) of permanent childhood hearing impairment the presence of a congenital syphilis infection intermittent positive pressure ventilation in nicu for 6 days postnatal exposure to aminoglycoside antibiotics. in this neonate, the initial dpoae result was that of a bilateral refer, but upon screening after discharge from nicu the results were a bilateral pass. other risk factors identified in the screened population included a family history of a permanent childhood hearing loss recorded in 10 (8.3%) neonates. four of the neonates with a positive family history had a refer result on their initial dpoae, and the caregivers were requested to return for follow-up testing. only one infant was brought back for a second dpoae, which was passed successfully. the remaining three infants were lost to follow-up. exposure to ototoxic medications in the form of aminoglycosides was recorded in three (2.5%) neonates in the screened cohort. one of these neonates with ototoxic drug exposure required a repeat dpoae, which was successfully passed. one neonate born at full term with a birthweight of 2.8 kilograms (kg) had a raised bilirubin level of 332 micromole per litre (µmol/l) at 72 h of life. according to the nice guidance for neonatal jaundice, phototherapy was all that was required as the management (nice guidance, 2010). although the initial dpoae generated a refer result, the infant passed the repeat dpoae. table 1 displays the risk factors according to the two groups – those that passed the initial dpoae (n = 64) and those requiring a repeat test (n = 57). table 1: outcome groups on initial distortion product otoacoustic emissions screening and recorded risk factors. findings depicted in table 1 indicate no significant relationship between refer findings on dpoaes and risk factors. however, the small sample size was a limitation to the interpretation of the risk factors as it relates to history, risk factors and actual conditions. although current screening findings indicate no significant relationship between the refer findings and risk factors, it is important to note that the screening protocol only included peripheral hearing screening tools in the form of oaes and could have missed retrocochlear hearing impairment such as auditory neuropathy which can only be identified by abr. despite this limitation, current findings raise a need for interrogation of the relationship between risk factors and hearing impairment, as well as investigations on risk factors per specific context. targeted screening programmes where risk factors were developed by organisations based in resource-rich nations may not identify risk factors which are prevalent in resource-scarce countries, for example, infectious diseases, non-elective caesarean delivery, maternal hypertension and malnutrition (olusanya, 2011). a recent south african study by le roux, swanepoel, louw, vinck and tshifularo (2015) retrospectively reviewed 264 paediatric patients who had received cochlear implants and assessed the diagnosis and associated risk factors. they reported that a positive family history of a permanent childhood hearing loss, admission to nicu and prematurity were significant risk factors for profound hearing loss. although these risk factors were present in the current study’s screened cohort, no neonates were found to have impaired hearing. the infant who defaulted on the third oae had no significant risk factors on history, and was a well full-term neonate who had been delivered vaginally. conclusion findings from this study revealed challenges with conducting a nhs programme in a south african academic secondary level mother and child hospital. current findings were influenced by three key factors: (1) the capacity versus demands in as far as insufficient number of audiologists available to provide hearing screening at the facility, (2) the high rate of false positive test results which were influenced by vernix as well as the fact that only one-stage screening protocol was used and (3) the unacceptably high rates of loss to follow-up (bezuidenhout et al., 2018). of the 121 neonates screened, the majority (75%) were screened in the first 24 h of life. a large majority (71%) of these neonates presented with vernix caseosa on otoscopic examination. a high refer rate (47%) of the total sample was found on dpoae screening. no maternal or neonatal risk factors were found to be significantly associated with refer findings in the screening programme. all these findings are not new for the south african context; however, they are when one considers that this is a hospital dedicated to mothers and children – where resource allocation and service delivery models adopted should be geared to be conducive to early detection and intervention. the findings of this study raise implications for the implementation of nhs programmes in the south african context. firstly, the staffing challenge needs to be addressed by possibly increasing the working hours of audiologists in the public healthcare sector to include evenings and weekends as babies are born and discharged during these times too. this is particularly important in a mother and child hospital facility. this, on its own, will not address the capacity versus demand challenge. however, when used in conjunction with task shifting this may significantly increase screening coverage. because of the limited number of audiologists in the country, non-audiologists (including volunteers and/or nurses) should be trained to be screeners with supervision provided by audiologists in this task-shifting model of care. secondly, as part of the screening programme, removal of vernix caseosa from the external auditory meatus needs to be done routinely in order to ensure that this does not become a confounding variable in the screening findings. this is particularly important as often otoscopic examination does not routinely form part of standard screening protocols. because of the early discharge and the high likelihood of the presence of vernix caseosa within the south african context, inclusion of otoscopic examination in the screening protocol has been demonstrated to be important. thirdly, repeat screening for all neonates with refer findings following vernix caseosa removal should be done before discharge to ensure reduction of the high refer (false positives) rates that have negative impact of parental anxiety as well as on resource use. fourthly, establishment of reasons for poor return rates for follow up need to be investigated for this context, and solutions put in place as return rate is important for success of any screening and intervention programme. one key recommendation, to ensure that follow-up appointments for repeat screening and/or diagnostic testing are aligned with other medical follow-up services, should be consistently adhered to in screening programmes (kanji & khoza-shangase, 2018b). fifthly, the south african audiology community should lobby for a national political mandate of unhs by the south african government to facilitate strategic implementation and monitoring of hearing screening programmes as part of mandated early childhood intervention programmes such as the first 1000 days campaign. lastly, planning of screening programmes in the south african context should consider continuity of care, which comprises availability of functional diagnostic audiological equipment for confirmation of screening findings. current findings must be interpreted taking into consideration the identified methodological limitations. the 3-month time period used for data collection was the main limitation of the study. it is believed that a longer time frame where other variables could have come into play might have influenced the findings of the study (bezuidenhout et al., 2018). secondly, the study was in an academic hospital in johannesburg where resources are significantly better than in several other hospitals in the country, therefore limiting the generalisability of the findings. lastly, the small sample size has an influence on the generalisation of the findings and raises implications for future studies. it is important therefore that current findings be interpreted with these limitations in mind, and that future studies consider these in their study designs. nonetheless, these findings add to the contextually relevant evidence from the south african context, and raise implications for clinical planning as well as strategic planning around when screening should be conducted, what measures to put in place to improve efficiency of hearing screening programmes, the importance of investigating and mitigating poor return rate to follow-up, as well as investigations of the validity of risk factors to hearing impairment – and the implications of these in hearing screening programmes. acknowledgements the authors would like to acknowledge rahima moosa mother and child hospital speech therapists and audiologists who conducted the hearing screening. competing interests the authors have declared that no competing interest exists. authors’ contributions j.k.b., k.k.-s. and t.d.m. designed the study and analysed the data. all authors were involved in the writing of the manuscript. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the 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(2018). who recommendation on bathing and other immediate postnatal care of the newborn. retrieved from https://extranet.who.int/rhl/topics/newborn-health/care-newborn-infant/who-recommendation-bathing-and-other-immediate-postnatal-care-newborn#:~:text=who%20recommendation%20on%20bathing%20and%20other%20immediate%20postnatal%20care%20of%20the%20newborn,-17%20february%202018&text=bathing%20should%20be%20delayed%20until,for%20ambient%20temperature%20is%20recommended abstract relevance of falls to audiologists steps audiologists should implement to identify and manage fall risk conclusion acknowledgements references footnote about the author(s) christine rogers department of health and rehabilitation sciences, division of communication sciences and disorders, faculty of health sciences, university of cape town, cape town, south africa citation rogers, c. (2021). audiologists should not fail with falls: a call to commit to prevention of falls in older adults. south african journal of communication disorders, 68(1), a841. https://doi.org/10.4102/sajcd.v68i1.841 opinion paper audiologists should not fail with falls: a call to commit to prevention of falls in older adults christine rogers received: 24 may 2021; accepted: 18 july 2021; published: 30 sept. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract globally, falls are a serious economic and public health concern. while all age groups are impacted by falls, the threats to morbidity and mortality are most severe in older adults. recent literature has linked hearing loss, and related issues such as an increase in sedentary behaviour, to a greater risk of falls. therefore, this opinion article aims to raise audiologists’ awareness of falls in ageing patients or clients, and calls for change in terms of having these rehabilitation professionals embrace identification and management of fall risk. keywords: falls; fall prevention; fall risk; older adults; hearing impairment; audiology. population ageing is arguably one of the most significant social transformations of the 21st century with direct and obvious implications to healthcare and health policy: … ageing, of course, is inevitable and older people are more likely to have multiple, coexistent, and interrelated health problems. this fact, together with geriatric syndromes, frailty and impaired cognition, continence, gait, and balance, suggests the need for a more thorough ‘retooling’ of the healthcare system and workforce to meet the health challenge of ageing. (stucki, bickenbach, gutenbrunner, & melvin, 2018, p. 309) (italicised by author) globally, falls are a serious economic and public health concern (haddad, bergen, & florence, 2019). injurious falls present a significant morbidity and mortality threat to the lifespan from early infancy (alonge & hyder, 2014) to young, middle (verma et al., 2016) and late adulthood (shen et al., 2017). a fall describes an individual unintentionally and involuntarily moving towards the ground or other lower level (lima, ricci, nogueira, & perracini, 2018), which is not the result of a major intrinsic event or hazard (lamb, jørstad-stein, hauer, & becker, 2005). intrinsic events are idiosyncratic health-related issues, such as visual acuity or balance deficits (gazibara et al., 2017), which may include age, sex and ethnicity (kosma, 2014). this opinion article aims to raise audiologists’ awareness of falls in ageing patients or clients and calls for change in terms of identifying and addressing the risk of falls. falls are an important clinical concern for older adults, associated with increased morbidity and mortality rates, as well as having major implications for public health (gazibara et al., 2017). as the world’s population ages, the rate of falls is growing disproportionally. the ranking of fall-related deaths has increased over some decades, with the world health organisation (who) confirming that falls are the second leading cause of deaths and unintentional injury deaths after road traffic accidents worldwide (who, 2018). in the united states of america, falls are the predominant cause of injury across almost all ages (timsina et al., 2017). an older adult in america falls every second, requires emergency services for fall-related injuries every 18 s with a fall-linked death being reported every 20 minutes (cdc, 2016). lowand-middle-income countries are neither spared the phenomenon of injurious falls nor ageing. data from 17 countries across four different income rankings suggest that falls are associated with rural settings, increasing age,1 female sex and current or previous alcohol use (raina et al., 2016). in south africa, alcohol represents a significant health and social problem, with one of every three adults consuming alcohol and one in seven binge drinking (vellios & van walbeek, 2018). intrinsic fall risk factors already described, some of which are linked to social determinants of health, combine with environmental hazards, such as poor infrastructure in public places, and should result in placing falls firmly on the agendas of rehabilitation professionals. relevance of falls to audiologists hearing loss is linked to falls as humans age, sensorineural hearing loss (presbycusis) develops (nordvik et al., 2018). meta-analysis has suggested that hearing loss established with pure tone audiometry results in an almost seven-fold increased risk of falling (jiam, li, & agrawal, 2016). other correlates of hearing impairment in older adults relevant to an increased fall risk include sedentary behaviour, slower gait speed (shayman, earhart, & hullar, 2017), social isolation and withdrawal (criter & honaker, 2013), and cognitive decline (rutherford, brewster, golub, kim, & roose, 2017). with an ageing population, the number and rate of individuals seeking audiology services will increase (criter & honaker, 2016). thus, audiologists have extensive access to older adults, and are in a pivotal position to screen for falls and associated risk factors. despite the opportunity for audiologists to act as gatekeepers for identifying the risk of falls in their hearing-impaired patients, disappointingly in practice, at least in the united states of america, less than one-third attempt any form of screening (criter & honaker, 2017). holistic balance assessment historically, audiologists had a role in assessing vestibular integrity, likely because of the location of the end organs in the inner ear and correlations between labyrinthine disorders, which may affect both hearing and balance. internationally, increasing numbers of audiologists are involved in the assessment and management of patients with vestibular dysfunction (nelson, akin, riska, andresen, & mondelli, 2016). in south africa, services include audiological assessments, clinical and instrumented vestibular evaluations, and vestibular rehabilitation therapy (seedat, khoza-shangase, & sebothoma, 2018). professional scope of audiology mandates that virtually all physical outcome measures related to fall risk assessment would be included. more advanced testing, for example, using the minibestest to explore the different constructs of balance and fall risk (magnani et al., 2020), would require more in-depth training and some experience. in 2011, south african audiology degree training programmes were directed to include vestibular management as an exit level outcome (hpcsa, 2018). notwithstanding the necessity for graduate professionals to have skills in vestibular management, audiologists in south africa have been slow to embrace vestibular practice (seedat et al., 2018). it is possible that by starting with a small but patient-valued service, such as screening older adults for fall risk, professional confidence could be built, and audiologists would be inspired to engage more fully in this critical area. dizziness and vertigo increase fall risk dizziness and vertigo are common complaints reported in older populations (hall & meldrum, 2016), some of whom consult an audiologist, who may function either in a team of professionals or as the sole provider. numerous researchers have described the link between vestibular deficits and falls. for example, a case-control study reported that 80% of older adults with clinically significant vestibular impairment fell (liston et al., 2014). even if participants’ symptoms of dizziness had settled because of compensatory processes, their fall risk remained elevated (liston et al., 2014). another study of patients with vestibular impairment and associated dizziness suggested an increased risk of falls by a factor of 12.3 (allen, ribeiro, arshad, & seemungal, 2017). overall, these and other studies support the view that audiologists should be questioning all older adults regarding falls, not just those who complain of dizziness. indeed, it is argued that because of the predictability of falls, failing to evaluate older adults’ risk of fall is a significant neglect in the duty of care to audiology patients. calls for agency and change the key roles of an audiologist include disease prevention and health promotion activities at all levels of healthcare. decades ago, calls were made for audiologists to concern themselves with the ‘balance’ system rather than purely vestibular function and evaluation (jacobson, 2001). leaders such as jacobson and other audiologists continue to remind us to embrace balance and fall issues; however seemingly, little progress has been made in changing the clinical practice of audiologists. a directive for audiologists performing vestibular assessments with american medicare beneficiaries to conduct fall risk assessment and formulate plans of care (bassett & honaker, 2016) offers a glimmer of hope. however, much work remains to encourage more widespread adoption of plans for fall prevention and health promotion activities within our profession. indeed, the focus in emerging regions needs to shift from curative services to health promotion at all ages and levels of care. moving towards rehabilitation the profession experiences a challenge because audiologists do not necessarily embrace rehabilitation (hull, 2018) as do other professionals, such as physioand occupational therapists (babatunde, macdermid, & macintyre, 2017). current practice has a diagnostic focus, rather than deeply engaging with patients and building strong therapeutic alliances (hull, 2018). there is convincing evidence that vestibular rehabilitation is effective in managing symptoms of vestibular deficits (dunlap, holmberg, & whitney, 2019). thus, programmes based on vestibular rehabilitation and applied in a fall prevention context could be argued to be relevant to audiologists and their patients. moreover, many effective exercise-based fall prevention programmes exist, with compelling evidence to support them. here, audiologists can play a role by discussing the impact of hearing loss and its associated sedentary behaviour and withdrawal, raising awareness in their patient populations and encouraging physical activity (pa) and appropriate referral to community resources. more detailed strategies are discussed in the following section. steps audiologists should implement to identify and manage fall risk the second part of this opinion article suggests simple strategies for audiologists to identify and manage fall risk amongst older adult patients or clients. prescribe activity interestingly, a large number of research studies on fall risk focus on factors that are not responsive to therapeutic interventions, for example, chronological age and sex. otherwise, attention is directed to medical management like medication review. issues such as activity-based strategies for fall risk management have received less attention. for example, few authors have examined sedentary behaviour (as previously observed, associated with both ageing and hearing loss) and found that challenging this lifestyle with pa is a potentially treatable cause of falls (thibaud et al., 2012). thibaud et al. (2012) considered the role of pa and falls by meta-analysis. the results revealed that for older adults, pa is a protective factor for falls, particularly injurious falls. physical activity may address intrinsic risk factors for falls by improving balance and gait speed, muscular and physical strength. therefore, pa should be recommended in the management of fall risk. furthermore, cochrane reviews have addressed multiple interventions to fall risk, including exercise-based fall prevention programmes, with evidence in favour of the latter (gillespie et al., 2012; sherrington et al., 2019). a systematic review by sherrington et al. (2020) was undertaken to inform the who guidelines on pa and sedentary behaviour, which re-affirmed the value of exercise, particularly balance-related activities including tai chi, to reduce the risk of falls in older adults (sherrington et al., 2020). if audiologists are empowered with quality information, they are better informed to educate their older adult populations. screen for fall risk numerous instruments exist to screen for falls and fall risk. ideally, previous falls, fear of falling, and the number of prescribed medications should be ascertained and noted along with the age and sex of the patient. polypharmacy is the simultaneous use of multiple drugs by an individual and is present in approximately half of all older adults from high-income countries (morin, johnell, laroche, fastbom, & wastesson, 2018). there is little reason to believe that the narrative is any different in south africa (saka, oosthuizen, & nlooto, 2019). thresholds for the number of medications that constitute polypharmacy vary but are usually between three and six (gutiérrez-valencia et al., 2018). there are increasing links between polypharmacy, falls and the onset of frailty (gutiérrez-valencia et al., 2018; wastesson, morin, tan, & johnell, 2018). fear of falling may occur despite no recent fall and is a powerful risk factor for future falls, likely because of self-restriction and cautious gait (auais et al., 2017; denkinger, lukas, nikolaus, & hauer, 2015; lavedán et al., 2018). fear of falling may in fact be enabling if an older adult is willing to explore strategies to address the fear, such as embarking on an exercise programme. a fall reported within the previous year similarly increases the risk of another fall, and thus, helpful information is obtained from simple questioning (lusardi et al., 2017). physical outcome measures for falls there are four tests suitable for everyday clinical practice that have evidence to support them (lusardi et al., 2017). these include the timed up and go (tug) test, which will be discussed here, the five times sit to stand test, single leg stance test and preferred walking speed; however, more research studies are required to definitively link them to fall risk. briefly, the tug test requires an individual to get up from a chair, walk 3 m around a traffic cone, return and sit down again. several balance-related activities are required, such as transitioning from sitting to standing, changing direction around an obstacle and ambulation. the test is timed, and ageand sex-matched normative data are available (bohannon, 2006; ibrahim, singh, & shahar, 2017; pondal & del ser, 2008). the tug is recommended for primary care by the american and british geriatric societies (smith et al., 2016), and can be administered quickly and efficiently. variations for the tug exist (manual and cognitive) and have promise for refining fall risk. individuals whose result (time to complete tug in seconds) falls outside the centers for disease control and prevention’s (cdc) 12 s cut-off should be considered at risk of falls and referred appropriately. a copy of the test procedure can be downloaded from https://www.cdc.gov/steadi/pdf/tug_test-print.pdf. manage holistically consider referral back to the primary care provider with the results of the audiological assessment, which might suggest an increased risk of falls. steps such as medication review may be advisable. clinical assessment of vestibular function, falls history and risk, and balance and gait (either with an audiologist with a special interest or a physiotherapist) could be indicated. resources such as the cdc’s stopping elderly accidents, deaths and injuries (steadi) programme are helpful (https://www.cdc.gov/steadi/index.html) and provide information for patients and healthcare professionals. checklists to manage potential fall hazards at home are appreciated by patients and their families alike and are freely available on the internet. call systems in case of falls are useful for older adults who live alone. finally, a pamphlet demonstrating how to get up after a fall (e.g. see https://www.stayonyourfeet.com.au/wp-content/uploads/2016/01/soyf-up-off-the-floor-knees-v1-lowres.pdf) or a video link can be empowering if patients practice how to get up safely after a fall. conclusion audiologists have multiple roles, including being rehabilitation professionals, enhancing disease prevention and health promotion activities, and being advocates of change. first, compelling evidence exists to support that exercise is ‘medicine’ (sallis, 2009), with the implication that all healthcare professionals should be prescribing it. second, the case for exercise and pa to reduce the risk of falls is strong. specific to fall risk, which is enhanced by factors such as ageing and hearing loss, audiologists are ideally situated as gatekeepers and should be an additional entry point to management of older adult populations with falls. screening for falls is simple and quick, even in constrained settings; however, the impact of falls is life-changing for individuals who fall and their families. as africa greys, let us embrace our role and start identifying and managing the risk of fall amongst the older adult populations! until the great mass of the people shall be filled with the sense of responsibility for each other’s welfare, social justice can never be attained. (keller, 1914) acknowledgements competing interests the researcher has previously acted as a consultant to a medical communications company and prepared continuing professional development materials for their client, a naturopathic company. she has previously consulted for an equipment manufacturer and produced newsletters for management of dizzy patients on behalf of the company. she has not been involved in marketing any equipment for that company. the researcher has and continues to work as a consultant or an expert witness for several insurance companies, specifically the insurance ombudsman of south africa. appearances at congresses as an invited speaker have been paid for by congress secretariats or funded from the researcher’s personal research funds. none of these roles present a conflict of interest. author’s contributions the author declares that she is the sole author of this article. ethical considerations this article followed all ethical standards for research without any direct contact with human or animal subjects. funding information this research work was supported in part by the national research foundation of south africa (grant no. 110802) and the harry crossley fellowship, 2017, university of cape town. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references allen, d., ribeiro, l., arshad, q., & seemungal, b.m. 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(2018). falls fact sheet 344. retrieved from http://www.who.int/mediacentre/factsheets/fs344/en/ footnote 1. note the referenced study only considered ages between 30 and 70 years. abstract introduction inclusive education the diagnosis of developmental language disorder the support of learners with developmental language disorder in the mainstream schools purpose of the study research methods and design results discussion significance of the study limitations of the study recommendations conclusion acknowledgements references about the author(s) nettie n. ndou department of educational psychology, faculty of education, university of pretoria, pretoria, south africa margaret f. omidire department of educational psychology, faculty of education, university of pretoria, pretoria, south africa citation ndou, n.n., & omidire, m.f. (2022). systemic support for learners with developmental language disorders in zimbabwe and south africa. south african journal of communication disorders, 69(1), a850. https://doi.org/10.4102/sajcd.v69i1.850 original research systemic support for learners with developmental language disorders in zimbabwe and south africa nettie n. ndou, margaret f. omidire received: 16 aug. 2021; accepted: 21 nov. 2021; published: 16 feb. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: teachers play a significant role as early identifiers of learners with developmental language disorder (dld). they provide important information to other professionals for further specialist support of such learners. professionals, such as educational psychologists, speech–language therapists (slts) and learning support therapists are involved in assisting learners with dld; hence, inter-professional collaboration (ipc) amongst these professionals is of paramount importance in meeting the needs of learners. objectives: this study aimed to examine systemic support strategies available to learners with dld. method: this was a multiple case study of zimbabwe and south africa. purposive sampling was used to select participants. the study consisted of 56 participants: 5 teachers, 2 slts, a learning support therapist, an educational psychologist and 47 learners. a qualitative research approach was employed and data were collected using interviews, focus group discussions and classroom observations. the data were analysed thematically and categorised. results: support strategies employed by teachers include remedial lessons and promoting a culture of reading for leisure to enhance learners’ vocabulary and narrative skills. the slts and the learning support therapist use speech–language programmes and assistive technologies. limited ipc and the absence of slts in district based support teams were some of the challenges identified. the results also indicate that slts receive referrals mostly from primary schools compared with secondary schools. conclusion: raising awareness of dld in schools and communities is deemed essential. inter-professional collaboration is recommended to support learners with dld as it increases the exchange of ideas and mutual acknowledgement of expertise amongst professionals. keywords: developmental language disorder; inter-professional collaboration; inclusive education; systemic support; teaching and learning; medium of instruction; second language. introduction developmental language disorder (dld) is a condition in which there are unexplained persistent difficulties with language. learners with dld experience significant challenges in learning, understanding and using spoken or written language (mcgregor, 2020). this is exacerbated when teaching and learning takes place in circumstances where the medium of instruction (moi) is a second or additional language as is the situation in many schools in both zimbabwe and south africa. in these instances, the learners have further difficulty developing cognitive academic language proficiency (calp). at secondary school, learners are required to use complex vocabulary and more complex sentence structures in a second language and for learners with dld, which can be a challenge (ossai & uzoegwu, 2019). inclusive education (ie) guidelines stipulate that such learners must be supported to thrive like typical developing learners. bronfenbrenner’s (1990) ecological systems theory on human development suggests a learner’s ecology, which is made up of interwoven network systems to support learners with special needs such as dld (panopoulos & drossinou-korea, 2020). it has been suggested that inter-professional collaboration (ipc) amongst speech–language therapists (slts), educational psychologists, audiologists, social workers and teachers is likely to reflect the needs of a learner with dld (liu et al., 2018; as cited in mcgregor, 2020). however, ipc remains scarce in practice (lakkala et al. 2021). thus, there has been a continued concern on the support of learners with special needs such as dld in the mainstream schools (dockrell, rickets, palikara, & charman, 2019), and the current scholarship is limited on the support of such learners (joffe, rixon, & hulme, 2019). hence, the main thrust of this study was to explore systemic support strategies for secondary school learners with dld and gravitate towards more inclusive opportunities for them to learn. inclusive education inclusive education is based on commonality and ipc amongst professionals, parents and learners (lakkala et al., 2021). it is a reform that supports diversity amongst all learners (unesco, 2001). unesco (2005, p. 13) defines ie as ‘a process of addressing and responding to the diversity of needs of all learners through increasing participation in learning … reducing exclusion within and from education’. it promotes a flexible curricular arrangement, where all learners’ needs are accommodated (sithole & mafa, 2015). inclusive education is widely supported in international human rights law, international conventions ratified by members and most human rights instruments. such instruments include the universal declaration of human rights (united nations, 1948), the convention on the rights of the child (united nations, 1989) and the convention on the rights of persons with disabilities (majoko, 2016). inclusion policy in zimbabwe zimbabwe subscribes to all the above-mentioned international human rights instruments. several policies and legislations mandate ie (majoko, 2013). these include the education act of 1987 as revised in 2006, the constitution of zimbabwe amendment number 20 of 2013, section 75, the disabled persons act of 1996, and recommended practice circulars, including the secretary’s circular number 2 of 2000 and the directors’ circular number 7 of 2005 (majoko, 2018). the department of schools psychological services (sps) and special needs education (sne) of zimbabwe provide various programmes and services to facilitate access, participation, acceptance and achievement of all children in quality regular education (majoko, 2018). these programmes and services include needs-driven expansion of national provincial and district education officers and school heads and teachers (munjanganja & machawira, 2015). inclusion policy in south africa south africa also endorses international instruments that support ie. in south africa’s constitution, an explicit section on the rights of people with disabilities is included. education white paper 6 (ewp6) (department of education, 2001, p. 10) outlines the government’s new policies for a single and undivided education system for all learners (danohue & bornman, 2014). according to danohue and bornman (2014), ewp 6 is designed to change the south african education system through the inclusion of all learners using a curriculum that is more flexible and suitable for the needs of all learners, developing district-based support teams and school-based support teams (sbsts). these teams shall provide systemic support for teachers who need it to cope with diverse classes. it is important to highlight that ewp6 (south african government [sa gov.], 2001) constituted certain support structures to support learners with special needs, such as dld. these support structures include a support team at the school level, namely the sbst. the team comprises mainly teachers at the schools but may also involve health professionals from the community. the district based support team (dbst) consists of a variety of support professionals (learning support teachers, health professionals and curriculum specialists) who provide support to all schools in the district area (nel & grosser, 2016). ewp 6 (sa gov., 2001) says that the critical function of the dbst is to support all learners, teachers and the system as a whole so that the full range of learning needs can be met. the aim is to assist teachers in schools in creating greater flexibility in their teaching methods, assessing learning, evaluating programmes, diagnosing their effectiveness, suggesting modifications and providing direct interventionist programmes to learners. the key functions of the sbst are to coordinate all learners, teachers, curriculum and institutional development support within the school and identify institutional needs. the diagnosis of developmental language disorder in the international classification of diseases (icd-10) and in the diagnosis statistical manual (dsm iv-r), on the definition of ‘specific disorder of language acquisition’, a distinction is made between expressive and mixed expressive-receptive (mld) types of language impairment (assous et al. 2018). in the dsm-5, language disorders are included in the neuro-developmental disorders category and ‘the distinction between expressive and mixed types has been removed’ (assous et al., 2018, p. 2). the dsm-5 diagnosis is also based on the basis of age-appropriate non-verbal and exclusionary criteria. recent research also suggests that learners with dld have deficits in linguistics and non-linguistics aspects of the language disorder (thomas, schulz, & ryder, 2019). in this article, the term dld is used as it was recommended by the criteria and terminology applied to language impairments: synthesising the evidence (catalise) panel. in 2015–2016, an international group of experts in the area of speech, language and communication needs, the catalise panel, came together to agree on children’s diagnostic terminology on language problems (bishop, 2017). they recommended that the term dld be used to refer to neuro-developmental language deficit (mcgregor, goffman, horne, hogan, & finestack, 2020). this condition emerges in early childhood and frequently persists into adulthood, and it can affect a person’s ability to learn effectively, establish relationships and seek gainful employment (cronin, 2017; cited in walker & haddock, 2021). learners with dld can be supported in the mainstream school where specialist provisions and services are provided, in special schools and in support centres where learners are supported as individuals or groups (dockrell et al., 2019). this article focuses on the support of such learners within the mainstream schools. the support of learners with developmental language disorder in the mainstream schools it has also been widely accepted that delayed or lack of diagnosis and intervention for learners with dld often leads to poor education outcomes, longer periods of unemployment, low self-esteem and a high risk for depressive and anxiety disorders (thomas et al., 2019). therefore, such learners must be identified so that professionals would collaboratively offer them support. however, bishop, snowling, thompson, greenhalgh and catalise consortium (2016) stated that the complex and multifaceted nature of language adds to the difficulties of identifying and categorising dld. as a result, learners with dld are not always easily recognised. many learners with dld may have an undetected or hidden difficulty with language acquisition. this is because such learners often develop compensatory strategies, for example, always agreeing or disagreeing with the conversational partner, remaining silent or responding using learned phrases (national behaviour support service [nbss], 2011; walker & haddock, 2021). in an inclusive teaching and learning environment, pedagogy, curricula and assessment are planned and delivered to engage all learners in learning that is meaningful, relevant and accessible (hewett, douglas, mclinden, & keil, 2020). hamre and pianta (2005) observed that schools need to set high expectations for what every child can achieve. these high expectations can be complemented with support structures and services: positive learning environments offer strong instructional and emotional support. hence, teachers must be knowledgeable in the identification of learners who may need additional support (prezas & ahyea, 2017). although teachers are not responsible for making decisions related to language proficiency or assessment, they play a very important role as early identifiers of learners who may or may not need further observation or assessment (prezas & ahyea, 2017). consequently, identification and referral of learners with dld to other professionals for further assistance is commonly the teachers’ responsibility. responsibility is placed on teachers as they spend more time with the learners (christopulos & kean, 2020). they provide important information (e.g. academic or social) to other professionals for determinations of educational need for services in the schools. however, limited understanding of dld by teachers negatively affects learners with dld in the mainstream schools, they remain undiagnosed. teachers’ limited awareness may be explained by the fact that the signs of dld are difficult to track (adlof, 2020). after conducting a study, christopulos and kean (2020) concluded that mainstream teachers are responsible for most referrals made to special education but demonstrated difficulty in correctly identifying learners with dld. inaccuracy in identifying and referral process by teachers has been attributed to a lack of understanding of language structure and learners’ language needs (christopulos & kean, 2020). limited awareness of dld is also a result of a cacophony of terms that have been used to explain dld (bishop, 2014). for instance, language delays, specific language deficit, specific language impairments and deviant language. hence, limited awareness amongst the general population has resulted in inadequate service delivery for supporting learners with dld and limited number of research studies in this area (mcgregor et al., 2020). the use of a second language (l2) as the moi inevitably affects many learners and more so those learners with dld (tribushinina, dubinkina-elgart, & rabkina, 2020). the presence of language difficulties has a significant impact on the academic success and educational attainment of learners with dld. often, such learners’ function at the basic interpersonal communication skills (bics) level and do not develop calp (lillywhite, 2011). academic language skills include the use of inferential language, that is, communicating about ideas across contexts, use of narrative language, where learners are expected to describe a series of events and understanding of the range of academic vocabulary and grammatical structures (wissel, 2016). it is therefore not surprising that learners with dld are in a dire situation in terms of poor academic achievement (tuite, 2019). still, there is limited literature on the effect of the use of l2 as moi on learners with dld (tribushinina et al., 2020; zoutenbier & zwitserlood, 2019). it is against this background that there is need to support such learners, and because of the complex and multifaceted nature of dld, ipc is necessary to effectively identify and support them. the role played by inter-professional collaboration in support of learners with developmental language disorder teachers offer initial support to learners with dld to enhance learners’ language skills in the areas of vocabulary, narrative and expository skills. the complexity of language use increases in secondary schools and teachers must break down large amounts of information into shorter paragraphs (roehling, herbet, nelson, & boharty, 2017). teachers also play a primary role in the identification of learners with special needs under a referral-based format (christopulos & kean, 2020). usually, professionals such as slts, educational psychologists and learning support therapists’ work begins when teachers have challenges with assisting learners with dld in the classrooms. inter-professional collaboration has been recommended as a means by which the needs of learners with additional needs can be met (gallagher et al., 2020). inter-professional collaboration is a shared expertise, whereby team professionals create strategies together, learning from professionals in other fields (lakkala et al., 2021). speech–language therapists contribute specialist knowledge and skills regarding learners with dld; they are specialists trained to diagnose and assist learners in speech–language and communication needs (slcns). hence, slts have an integral role in education. in linguistics aspects, they assess grammar, phonology and semantics, whereas in non-linguistics aspects, they assess phonology awareness, phonological short term and working memory. these are addressed in tests such as clinical evaluation of language fundamentals (celf-5) and the comprehensive test of phonological processing 2 (thomas et al., 2019). augmentative and alternative communication (aac) devices are also used to support learners with dld (uthoff et al., 2021). augmentative and alternative communication tools and strategies include visual schedules, picture and written supports for spoken language. according to speech-language and audiology canada (sac) (2015), aac tools and strategies for supporting expressive communication include object or picture-based choice making, communication displays, alphabet boards, symbol and text-based speech-generating devices and alternative access methods. intervention models have been proposed for the effective support of learners with dld. prezas and ahyea (2017) proposed a multi-tiered support system for learners with dld. this tiered framework is used to provide early detection and prevention through academic and or behavioural support to learners. a response to treatment model of intervention has also been proposed to identify learners at risk of poor learning outcomes and to identify learners with speech, language and communication needs (walker & haddock, 2021). ebbels, mccartney, slonims, dockrell and norbury (2019) also presented a tiered intervention model for learners with dld. these models recommend a strong ipc amongst professionals in assisting learners with dld. whilst the first two models emphasise the role played by slt in assisting learners with dld at the last stage or tier, ebbels et al. (2019) emphasised that the role of slts must not only begin at the last stage or tier but they should also offer the education field guidance and support throughout the process of educating. they must influence public awareness and policies, provide advice and problem-solve evidence-based programmes. they must also be active in assessment, planning, training and monitoring others delivering indirect intervention and monitoring of progress, as well as being actively involved in assessment and monitoring of progress on an individual learner (ebbels et al., 2019). however, ipc is a complex phenomenon and a collaborative advantage is difficult to achieve (gallagher et al., 2019). this leaves many learners at risk of poor social, emotional and educational outcomes (gallagher et al., 2020). professionals involved in assisting learners with dld come from different backgrounds, which make it difficult to share a common understanding of dld (gallagher et al., 2020). although much had been done in the past years to address terminology and criteria to identify learners with dld (bishop, 2017; bishop et al., 2016), there is still not sufficient consensus amongst professionals who support learners with dld. a review of the literature on ipc between teachers and slts in the support of learners with dld concluded that there was little common understanding of dld between the professions. these different views are also evident in practice. the literature concurs that although much had been done in the past five years to address issues of terminology and criteria to identify learners with language disorders (bishop, 2017; bishop et al., 2016), there was still not sufficient consensus between these professions. current scholarship lacks crucial insights into collaborative work between teachers and slts on intervention strategies to support learners with dld. based on the literature reviewed, most literature on dld originates in the speech–language therapy field of inquiry rather than the education field of inquiry. furthermore, the referral-based system works well when teachers have the expertise of identifying learners with dld. however, in the context of limited training and knowledge about identification and support of learners with dld by teachers, very few learners are being supported (roberts & simpsons, 2016). the knowledge of typical language development in children is essential to recognise indicators that a learner may be presenting with signs of dld. information about speech–language development is however often minimal or absent in many initial teacher training programmes (walker & haddock, 2021). a lack of awareness of dld by teachers may also be explained by the fact that the signs of dld are difficult to track (adlof, 2020). furthermore, proper identification of dld by teachers is made even more complicated in a multilingual context (belanger, mayer-crittenden, & minor-corriveau, 2020) as dlds are often confused with language barriers. it must be observed that the terms language ‘disorder’ and language ‘barrier’ is different and cannot be used interchangeably. therefore, limited awareness of dld amongst teachers greatly affects effective identification and support of learners with dld. the scarcity of trained professionals such as slt to work with learners with dld and limited evidence of base underpinning effective interventions have raised serious concerns on the support of learners with dld (dockrell et al., 2019), yet there has been no attempt to map the support of such learners in the mainstream schools (dockrell et al., 2019). it has been observed that there are limited slt services and specialist provisions particularly for secondary school learners with dld (dockrell et al., 2019). limited support of such learners in the mainstream secondary settings negatively affects learners with dld. harthshorne (2011) explained the challenges faced by learners with dld in secondary schools as a ‘cycle of neglect’. many of these challenges are interrelated and impact each other. when very few learners are identified with dld in secondary schools, there are restricted services for learners with dld that do not reflect the actual level of needs. there is limited awareness of the importance of speech–language communication needs by teachers, general school staff and the community as there is an assumption that language development and early intervention only happens early in the primary years and not in secondary school. there is a narrow understanding of the role of language in the secondary school curriculum. with time, there are fewer professionals with skills and knowledge to support learners with dld and limited resources and assessment tools for early identification and support of such learners. in zimbabwe, there are limited support services for learners with dld. cooley (2007) observed that ideally learners with dld should be assisted by slts in schools. however, it is important to observe that this may not be feasible in developing countries such as zimbabwe. zimbabwe desperately needs slts to work in public institutions such as schools. currently, there are very few slts working in public service in zimbabwe. this was also confirmed by the permanent secretary in the ministry of health and child care, dr. gerald gwinji, who argued that the government does not have money to pay specialists’ salaries. he added that zimbabwe trains slts but cannot retain them because their expertise is highly marketable and they work for private organisations (hutchins, 2016). in addition, lack of support from the sne is another challenge facing teachers in schools in the support of learners with special needs such as dld. inclusion is grounded in the social, physical, cultural and emotional integration of learners with unique needs and those who are at risk of exclusion and marginalisation in general education (majoko, 2018). ideally, the sps and sne place and support learners with special needs in mainstream classrooms (majoko, 2018); however, limited involvement of these specialists has led to overburdening of teachers. hence, the functions of sps and sne have become the responsibility of teachers who also do not have expertise in assisting learners in need (sunal & mutua, 2013). in south africa, learners with dld fail to achieve the necessary outcomes in language and literacy. however, slts do not play an effective role in public sector education because of several factors; notably, the current human resource capacity of slts is severely limited (kathard, jordaan, wium, pottas, & khan, 2011). the available human resource data indicated that there are ‘186 speech therapists across the country appointed at special schools, whilst there were 73 ‘office-based 46 therapists (a general category that includes occupational therapists and physiotherapists)’ (kathard et al., 2011, p. 65). furthermore, southwood and dulmo (2015) observed that there is still an absence of appropriate assessment and remedial material for afrikaans and african languages (southwood & dulmo, 2014). linking bronfenbrenner’s (1990) ecological systems theory in the support of learners with developmental language disorder the conceptual framework utilised in this study was bronfenbrenner’s (1990) ecological systems theory on human development in explaining ie’s ecology. inclusive education is based on a belief that the inclusion of children with special needs in mainstream schools is beneficial for their studies and growth (nai-kwai lo, 2007). bronfenbrenner’s theory’s central point relates to the interactions created between the developing and active individuals and the social context that surrounds them and influences them directly and indirectly (panopoulos & drossinou-korea, 2020). the theory presents five ecological system theories that influence the psychological development of a learner. these are the microsystem, mesosystem, exosystem, macrosystem and chronosystem (bronfenbrenner, 1990). these five systems describe the interwoven networks of transactions that create a learner’s ecology. teachers must identify and support learners with dld early in their school career. teaching methods used by teachers must be inclusive to meet the needs of learners with dld. teachers must be equipped with the necessary skills to assist learners with dld in the mainstream classroom (microsystem). inter-professional collaboration is essential to meet the needs of the affected learners. hence, professionals such as slts, learning support therapists and educational psychologists must work closely with teachers in supporting the learners (mesosystem). other support structures such as the family are also important in meeting the needs of affected learners. the general school environment must be inclusive to cater to the needs of all learners. the school timetable must accommodate support services offered by teachers or other professionals (exosystem). educational policies such as ie must be implemented to meet the needs of learners (macrosystem). finally, learners with dld receiving support at the primary level of education must continue receiving the necessary support at the secondary level of education (chronosystem). purpose of the study the study sought to examine systemic support strategies in the inclusion and support of secondary school learners with dld. although there is evidence of effective support strategies for learners with dld in preand primary school-aged learners, there is limited evidence of effective strategies to support secondary school learners with dld (dockrell et al., 2019; joffe et al., 2019). based on the purpose of the study, the research question guiding the study was what are the current support services available for secondary school learners with dld? to answer this research question, a qualitative approach was applied to find out strategies used by professionals to support secondary school learners with dld. research methods and design the study was designed as a qualitative study within the interpretive paradigm employing a multiple case study design. a case study investigates a real-life case or cases over time through detailed, in-depth data collection involving multiple sources of information (creswell, 2013). the two cases selected were situated in zimbabwe (case 1) and south africa (case 2). a multiple case study enabled an investigation of systemic strategies used to support learners with dld in two different contexts. this design allows investigation of the phenomena under study through the use of a replication strategy. this made this study more interesting as the data analysed were derived from two different contexts (diop & liu, 2020). setting the study was carried out in five secondary schools: two located in bulawayo khami district in zimbabwe and three located in johannesburg central district in south africa. the secondary education system in zimbabwe lasts for six years. it consists of lower secondary and upper secondary. the lower secondary level is a four-year cycle: from 1 to 4 that leads to awarding of the ordinary level certificate. at upper secondary, learners are offered advanced level studies meant to prepare them for university education (the republic of zimbabwe, 2019). similarly, secondary education in south africa lasts for six years in duration (from grade 7 to grade 12). it is also divided into lower (senior phase) and upper secondary further education and training (fet). the senior phase lasts through grade 9 and fet lasts through grade 12 (macha & kadakia, 2017). study participants and sampling strategy the inclusion criterion was based on the aim to gather evidence from experienced professionals who work with learners with dld showcasing their first-hand knowledge and supporting such learners. hence, participants were purposively selected. in zimbabwe, three schools were purposively selected to take part in the study. this decision was based on familiarity with the location. however, one school withdrew from the study. in school a, 10 learners and 1 teacher were part of the study, and in school b, 15 learners and 1 teacher were part of the study. other professionals, such as the slt and the learning support therapist, also participated in the study. in south africa, three schools were purposively selected and the decision was also based on geographical location and familiarity with the location. in school c, nine learners and one teacher were part of the study. in school d, eight learners and one teacher participated in the study, and finally, in school e, five learners and one teacher were part of the study. the slt and an educational psychologist also participated in the study. from both countries, learners who participated in the study were in the lower secondary level of education. their age ranges between 13 and 17 years. teachers were english language teachers. teachers were requested to select learners with dld in their respective schools; this selection was based on their understanding of dld. the number and nature of participants were determined by the nature of the study; being a qualitative study, the desire was to explore in-depth systemic strategies used to support secondary school learners with dld. data collection a set of the semi-structured interview guide was developed based on the topic under study. each question was intended to stimulate discussion on issues relevant to the research questions. interviews were conducted with nine professionals. classroom observations and focus group discussions were also used as means of collecting data for research. table 1 presents a summary of the data generation process in zimbabwe and south africa, respectively. table 1: data generation process–summary structure for zimbabwe and south africa. data analysis inductive thematic analysis was used to analyse the data. thematic analysis is a method for analysing qualitative data involving searching across data set to identify, describe and interpret data, analyse and report repeated patterns (kiger & varpio, 2020). coding helped to reduce the data into themes that emerged from the analysed data (plano & creswell, 2010). atlas ti was used as data analysis program software. transcriptions were checked for accuracy, and the files were entered into atlas ti for analysis. trustworthiness to ensure the trustworthiness of the research findings, engagement with participants was prolonged and data sources (semi-structured interviews, focus group discussions and classroom observations) were triangulated. space triangulation (case 1 in zimbabwe and case 2 in south africa) was also used in an attempt to overcome parochialism (cohen, manion, & morrison, 2011). another reliability test to ensure trustworthiness was member checking, where transcribed data were emailed to adult participants for verification (gunawan, 2015). ethical considerations ethical clearance was obtained from the faculty of education, university of pretoria (clearance number: ep 18/10/01). permission to conduct research in bulawayo khami district in zimbabwe and johannesburg central district in south africa was granted. informed consent, confidentiality and voluntary participation were incorporated throughout the study. results three themes emerged from data analysis, conceptualisation of dld, support services available for learners with dld and the effect of using a second language (l2) as the moi on learners with dld. however, this article focuses on the second theme: support services available for secondary school learners with dld. this theme yielded four sub-themes. the qualitative study provided a credible and rich description of the systemic strategies used by professionals in supporting such learners. teachers teachers explained how they identify learners with dld in the classroom. according to teachers a and b, learners with dld struggle to read and understand a comprehension passage and fail to narrate a story’s events. such learners cannot construct proper sentences and make spelling challenges. teacher c mentioned that learners with dld tend to make spelling errors. they also fail to copy correctly what is written on the board. teacher e argued that learners with dld fail to construct proper sentences and cannot spell words correctly. she added that during reading sessions, such learners do not come for the lessons. if they are in the classroom, they try by all means not to be picked out to read, have some stammer and lack confidence. figure 1 summarises support services offered by teachers to support learners with dld. figure 1: services offered by teachers. teacher a used the performance lag address programme (plap) to help learners with dld. the programme assists learners to learn simple english and mathematical skills. for a learner with dld, plap helps learners to read stories and discover some new words. teacher a also uses group work; she argued that in groups, learners help one another discover new english words. teacher b conducts remedial lessons to assist learners with dld. she groups the learners and helps them to learn some new words and concepts at a slow pace. she sometimes gives them beginners’ readers such as the sunrise collection and they learn so many new simple english words. she also uses group work to assist the learners. she argues that learners in groups complement each other and they will be assisting each other. learners confirmed support strategies used by their teachers. they confirmed that they are given books to read on their own. sometimes they are put in groups and do some tasks as a team. one learner also mentioned that their teacher once grouped several learners who had challenges in understanding some concepts and assisted them. however, the use of the terms ‘sometimes’ and ‘once’ by learners explains the support strategies’ frequency. it can be deduced that teachers do not regularly assist the learners. teachers explained that they do their best to assist learners with dld, although they are not qualified specialists in special needs. learners with dld also receive limited support due to insufficient contact hours with the teachers. teacher–learner ratio and minimum parental involvement were also highlighted as challenges that hinder effective implementation of the support strategies. furthermore, teachers also identified a need for more support from the sps and sne department in assisting learners with special needs. in south africa, teacher c explained that learners with dld are called ‘learners at risk’ in the school. he argued that they are at risk because there is a high probability of their failure in their grade 12 exit examination. he argued that they design an intervention plan or a remedial plan to assist the learner. teacher c also mentioned that in some cases, where a learner presents with a severe dld, they refer the learner to the dbst for further assessments and assistance. teacher d highlighted that she gives learners with dld more reading books and sometimes conducts remedial lessons. however, she stressed that she could not offer them long-term services. she argued that she receives little support from the dbst. she mentioned that: ‘[t]he problem is there is no one to help these learners, the system depends on me trying different ways to assist, one thing they encourage is that they call it differentiation … but you realise i don’t have the time, so we normally do what i call ‘quick fix …’ (p33, si, ln20–25) she added that: ‘i can’t offer a long-term service. it’s just what can i do to make you pass and proceed to the next grade, so it’s not something long term … there are no support structures …’ (p33, si, ln35–38) furthermore, teachers c and d argued that the team of sbst is made up of unqualified special education teachers who are full-time teachers with a full workload. hence, it becomes challenging to assist learners with special needs such as dld. teacher c highlighted that: ‘the sbst assists such learners, but the problem is they are not qualified special education teachers, they are just qualified in their subject area … they are also full-time teachers with their workloads, so they are overwhelmed.’ (p32, si, ln27–30) teacher e also added that they are required to complete an accommodation form for a learner with special needs to be submitted to the dbst; however, most teachers evade completing the form because it is too long. teachers also argued that they do not have the expertise to assist learners with dld; hence, it becomes a challenge to identify such learners fully for further assistance. other challenges highlighted by teachers were class size, limited contact hours, lack of cooperation from the learners and limited parental support, absence of a slt in the sbst and dbst, limited expertise in assisting learners with dld. speech–language therapists in zimbabwe, the slt highlighted the following services they use to support learners with dld: screening, development of individual education plans (ieps), development of speech programmes and the use of speech training mirrors. he explained that they have a checklist they use to screen learners. in screening, they gather information from parents and teachers regarding the learners’ language skills, conduct the hearing screening, administer some tests or even use observation methods. the slt argued that they first train teachers on how to identify learners with dld and how to implement the speech training programmes. the slt clarified the services they offer secondary school learners with dld. his accounts are shown here: ‘[i]n principle, we do have programmes for learners at the secondary school level, but when we go there, we find out that the majority of our secondary school learners do not want to be identified with such programmes. so, i wouldn’t say we have the functional language speech programmes for them as such, but in primary schools, yes, we do.’ (p01, si, ln24–28) he added that: ‘[l]earners in the secondary school … are not willing to take up these programmes, but the programmes are there. i think there is some stigma that is attached to one being found in this speech programme when you are in form 4 or 3.’ (p01, si, ln108–110) the slt was also requested to clarify whether secondary school teachers were aware of support services on offer to support such learners with dld. he explained that very few secondary school teachers were aware of dld. he argued that most people are aware of physical disabilities as they can be seen, but when it comes to neurodevelopmental disorders such as dld, most teachers are not aware. he explained that very few secondary school teachers are willing to take up duties in the sne department. here is what he said: ‘[w]e need to train teachers; they come out of college without any background on learning disability … it is the duty of the teachers to assist these learners to be identified so that we can assist them … so the problem is in our higher learning institutions.’ (p01, si, ln128–139) he also showed his concern for secondary school learners with dld who do not want to be associated with sne. these were his views: ‘[t]here are many learners with language problems at primary level but very few at a secondary level … would it be that they did not proceed to secondary school than [we] will say no, the majority do proceed … maybe there are there in secondary school … they are afraid of their peers.’ (p01, si, ln122–127) the slt highlighted that there are programmes designed for learners with dld in secondary schools but they are not ‘functional’. therefore, slts concentrated more on supporting primary school learners with dld. this was also confirmed by one learner who said: ‘i have never seen other people coming here to help us, but some came to my school whilst i was in grade 5 at [primary school]. they would come to teach us, give us some words and then we were tasked to pronounce … they only came two times …’ (l08, fgd, secondary school learner) in south africa, the slt mentioned that they first give learners some tests as a screening process, and if a learner fails, then they do an in-depth assessment. the slt highlighted that they then do screening for speech–language ability. at this stage, they identify learners with dld. she added that they have speech programmes that they use to assist the learners with language stimulation services, where they introduce vocabulary to a learner to enrich a learner’s vocabulary. they also have aac devices. these are divided into two categories: non-electronic aac includes pictures, symbols, spellings and phrases to communicate, whilst electronic aac includes the use of any electronic equipment to communicate, such as microphones and voice amplifiers. the slt also mentioned that they mostly receive learners from the primary level of education. she also argued that they are under pressure because they are only two of them serving learners from both primary and secondary schools in the district. learning support therapist the learning support therapist explained that they conduct their diagnosis in three phases. figure 2 presents the assessment phases used by the learning support therapist to identify learners with dld. figure 2: assessment phases followed by the learning support therapist. in the pre-assessment phase, parents or guardians of the learner are asked questions about the family’s history and background. he explained the pre-assessment as follows: ‘[w]ill be asking questions about history in the family background, remember learning difficulties are genetic; were these milestones achieved on time or delayed? … we then bring the child for familiarisation.’ (p02, si, ln21–26) the second phase is the assessment phase. the learning support therapist highlighted that they determine the nature of the challenge facing the learner. for example, for a learner with dld, the slt run a series of speech–language tests with the help of another specialist. a full report on the learner’s condition is presented to the parents or guardians. in the final phase, they develop an iep for the learner and they involve the learner’s school class teacher. they also do a pull-out system where the learner will be attending sessions three or four times a week for an hour or two. however, this depends on the parents’ or guardians’ ability to pay as most of their services are quite expensive. they also have assistive technologies such as c-pen readers and the kurzweil 3000 app, which help learners with dld. however, these assistive technologies are expensive to buy and maintain. educational psychologist an educational psychologist highlighted that she first conducts a full cognitive assessment of the learner. she commented: ‘i do the full cognitive assessment … so, once i get the intellectual image of a child; iq of the child, if it is average or above my expectations, even just a little below average … am expecting this child to be able to read and write, even if it … but you find some students have high iq, the above average, some functioning super but they still can’t read and write then the learner has difficulties in language acquisition.’ (p31, si, ln6–13) she added that she does not offer support services, but she recommends the learner to the slts or audiologists after her series of tests. discussion five systems outlined by bronfenbrenner’s theory describe the interwoven networks of transactions that create a learner’s ecology. the school is the most important microsystem of a learner. the school environment, the learning process and the relationships learners with dld develop with their peers and teachers, contribute to their social, cognitive and academic development (anderson, boyle & deppeler 2014). therefore, elements within the school (the curriculum, teaching methods, learners, teachers, the principal, support teams and their relationships) must support learners with dld to realise their potential. hence, strategies to support learners with dld are required. the research findings indicated that teachers use several strategies to support learners with dld. these strategies enhance learners’ vocabulary and narrative skills and have been proven by several scholars as effective (lowe & joffe, 2017; murphy et al., 2017; spencer et al., 2017). however, teachers highlighted challenges that negatively affect the smooth implementation of these strategies: lack of expertise in assisting learners with dld, limited contact hours with the learners and the class sizes, which do not promote effective learner-centred learning. it must be emphasised that more learners with special needs are being educated in mainstream classrooms than ever before, resulting in higher expectations of mainstream teachers’ abilities to meet the needs of such learners (gilmour & wehby, 2020). however, educational training for teachers in mainstream classrooms rarely prepares them for working in diverse classrooms. it does not equip teachers with the knowledge and skills to effectively support learners with special needs such as dld (zwane & malale, 2018). this lack of skills limits teachers’ expertise and confidence in assisting learners with special needs such as learners with dld. teachers play a primary role in the identification of learners with special needs for referrals under a referral-based format (christopulos & kean, 2020), hence they must be equipped with skills and expertise in sne for easy and early identification of learners who need extra support. the study’s findings also indicate limited ipc amongst professionals who deal with learners with dld. for instance, teachers identified a need for more support from specialists in assisting learners with special needs such as dld. in contrast, the slts argued that they received very few secondary school learners for support. this shows a limited inflow of information between teachers and slts, who are the key specialists in assisting learners with dld. this becomes a serious setback in support of secondary school learners with dld. for many years, ipc has been recommended as a means by which the needs of children with additional needs can be met (gallagher et al., 2019). even the conceptual framework has shown that there is a need for the collaboration of professionals at the mesosystem level in assisting learners with dld. however, the study results have shown that effective ipc remains rare in practice leaving many learners at risk of social, emotional and educational outcomes (gallagher et al., 2020). consequently, the functions of the specialists become the responsibilities of teachers who also do not have the expertise in the areas (sunal & mutua, 2013). class size can also affect teaching methods used by teachers. over-crowdedness in the classroom creates negative attitudes amongst teachers towards learners with disabilities in inclusive settings (chimhenga, 2016). this hinders the effective implementation of strategies to support learners with special needs such as dld in mainstream secondary schools. teachers cannot practice various methods such as higher-order questioning and active learning approaches; they are effectively confined to the chalk and talk instructional method (marais, 2016; ngwenya, 2019). the slts highlighted that they had several speech–language programmes for learners with dld. however, they argued that they received more primary school learners than secondary school learners with dld. this means that many secondary school learners with dld are not receiving support from the slts who are the specialists in slcn. whilst secondary school teachers show discontentment over minimal support from other professionals such as the slts, the slts argue that they receive referrals mostly from primary schools. for instance, the slt from zimbabwe highlighted that there are support services for secondary school learners with dld, but they are not ‘functional’. this raises serious concerns about the support of such learners in mainstream secondary schools. so, limited involvement of these professionals has left teachers with the responsibility. yet, teachers also have limited expertise in assisting such learners (sunal & mutua, 2013). there is evidence of lack of collaboration between secondary school teachers and slts (gallagher et al., 2019). there is also limited inflow of information amongst the sps, sne department and secondary school teachers. significance of the study the study’s significance lies in the fact that it fills a gap in literature and practice on the support of secondary school learners with dld. the absence of in-depth studies on strategies to support secondary school learners with dld constitutes a vacuum in the current understandings of strategies to support learners with dld. as joffe et al. (2019) pointed out that there is limited evidence of effective strategies to support learners with dld in secondary schools. yet to date, there have been limited attempts to provide learners with dld professional support in the mainstream schools (dockrell et al., 2019). furthermore, there is still limited literature on the effect of the use of a second language as moi on learners with dld (tribushinina et al., 2020; zoutenbier & zwitserlood, 2019). limitations of the study this study was a multiple case study carried out in two schools in khami district and three schools in the johannesburg central district. whilst the sample size facilitated the in-depth exploration of the phenomenon under study, the results of the study were limited to the participants’ experiences, geographical location and nature of the schools. strategies highlighted by the participants to support learners with dld in the area of study may be different from what other schools do to support learners with dld. as a result, research’s findings may not be generalised to the greater populations of the two countries. recommendations the framework adopts the ecology of an ie framework for systemic strategies to support learners with dld (see figure 3). a well-rounded curriculum and inclusive language of instruction that caters to all learners is recommended. in classroom instruction, teachers must apply both the ‘acquisition theory’ and ‘learning theory’ to language development. this way, all learners (typically developing and those with dld) are accommodated. a school-based support structure that comprises qualified personnel in key areas in the education system (slt, an educational psychologist, learning support therapist, counsellor and physiotherapist); in-service training of all teachers on sne, for instance, in-service training can be offered on speech, language and communication needs and enlightening the community about common problems, which can affect children as they learn such as dld. the role played by slts in assisting learners with dld cannot be understated. speech–language therapists’ duties in the school are to influence public awareness and policies, assessment, planning, direct intervention, monitoring of the progress of the learners and assessment, planning, training and monitoring teachers’ indirect intervention (ebbels et al., 2019). figure 3: proposed framework for supporting secondary school learners with developmental language disorder. conclusion language in education plays a key role in effective teaching and learning worldwide. yet, there is limited evidence of effective strategies to support learners with dld in secondary schools (joffe et al., 2019). this may be attributed to a limited understanding of dld by teachers and may lead to inaccuracy in identifying learners with dld (christopulos & kean, 2020). limited awareness of dld in local communities may also lead to very few learners with dld being referred to specialists such as slts. to achieve a systemic change in support of learners with dld in secondary schools, there is a need for in-service secondary school teachers’ training on slcn. if secondary school teachers are imparted with knowledge on slcns, more learners with dld will be assisted and are accurately referred to specialists for further diagnosis and assistance. zwane and malale (2018) pointed out that education training for teachers in mainstream classrooms rarely prepares teachers for working in diverse classrooms. therefore, the inclusion of in-depth sne courses in the general teacher training courses is recommended. teachers in-training must be fully prepared to work in inclusive, diverse classrooms. teachers also identified a need for more support from specialists in assisting learners with special needs such as dld. inter-professional collaboration between teachers and other professionals is the key to meeting the needs of learners with dld. there must be smooth communication and cooperation between teachers and other professionals such as slts for effective support of learners with dld. hence, the implication is that there is a need for early identification, support and improved assessment tools with greater public awareness of dld for secondary school learners with dld to be fully supported. acknowledgements the authors would like to thank the participants for their contribution to the study. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions both authors co-conceptualised the idea for the research, the design and methodology adopted, the analysis of the data and the finalisation of the results of the study. n.n.n. was the lead author in writing manuscript for publication with input, supervision and support from m.f.o. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study are available from the corresponding author, n.n.n., upon request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references adlof, s.m. 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(2018). investigating barriers teachers face in the implementation of inclusive education in high schools in gege branch. south african journal of disability (online), 7, 1–12. https://doi.org/104102/9jod.v7io.391 abstract introduction creating a space for discussion themes provocative statements for moving forward conclusion acknowledgements references about the author(s) bea staley college of health and human sciences, charles darwin university, casuarina, australia marise fernandes school of health and human sciences, university of north carolina, greensboro, nc, united states of america ellen hickey school of communication sciences and disorders, dalhousie university, nova scotia, canada helen barrett faculty of health and education, manchester metropolitan university, manchester, united kingdom karen wylie curtin school of allied health, curtin university, perth, australia college of health sciences university of ghana, accra, ghana julie marshall faculty of health and education, manchester metropolitan university, manchester, united kingdom school of health sciences, university of kwazulu-natal, durban, south africa mershen pillay institute of education, massey university, palmerston, new zealand discipline of speech language pathology, university of kwazulu-natal, durban, south africa harsha kathard department of health and rehabilitation sciences, university of cape town, cape town, south africa ryann sowden bristol medical school (population health sciences), university of bristol, bristol, united kingdom david rochus yellow house health and outreach services, kisumu, kenya carol e. westby bilingual and multicultural services albuquerque, albuquerque, nm, united states of america t. rosario roman bilingual and multicultural services albuquerque, albuquerque, nm, united states of america sally d. hartley school of health sciences, university of east anglia, norwich, united kingdom citation staley, b., fernandes, m., hickey, e., barrett, h., wylie, k., marshall, j., … hartley, s.d, (2022). stitching a new garment: considering the future of the speech–language therapy profession globally. south african journal of communication disorders, 69(1), a932. https://doi.org/10.4102/sajcd.v69i1.932 clinical perspective stitching a new garment: considering the future of the speech–language therapy profession globally bea staley, marise fernandes, ellen hickey, helen barrett, karen wylie, julie marshall, mershen pillay, harsha kathard, ryann sowden, david rochus, carol e. westby, t. rosario roman, sally d. hartley received: 14 mar. 2022; accepted: 30 june 2022; published: 21 nov. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract providing equitable support for people experiencing communication disability (cd) globally is a historical and contemporary challenge for the speech–language therapy profession. a group of speech–language therapists (slts) with ongoing and sustained experiences in majority and minority world contexts participated in five virtual meetings in 2021. the aim of these meetings was to develop provocative statements that might spur a global discussion among individuals and organisations that support people experiencing cd. the following questions were discussed: what is our vision for the future of the profession globally? what are the global challenges around access to speech–language therapy services? four main themes emerged: (1) the need to centre people experiencing cd as the focal point of services, (2) participation, (3) equity and (4) community. the themes relate to the need for a process of de-imperialism in the profession. suggestions were made to develop more suitable terminology and to establish a global framework that promotes more equitable access to communication services. we seek the adoption of approaches that focus on reciprocal global engagement for capacity strengthening. alternative models of culturally sustaining and equitable service delivery are needed to create impact for people experiencing cd, and their families worldwide. contribution: provocative statements were developed to prompt global conversations among speech–language therapy professionals and associations. we encourage readers to consider the questions posed, share their viewpoints and initiate positive change towards a global strategy. keywords: communication disability; global practice; equity; future; majority and minority world contexts. introduction we will not go back to normal. we are being given the opportunity to stitch a new garment. one that fits all of humanity and nature. sonya renee taylor global healthcare inequities predate the coronavirus disease 2019 (covid-19) pandemic, but these inequities were illuminated and worsened by the pandemic, particularly for people who experience disabilities. the medicalisation of disability has been reinvigorated, resulting in calls to revisit the biopsychosocial model of disability. health inequities are more obvious in majority world countries, which are under-resourced countries where most of the world’s population live. this contrasts with the relatively small and privileged population living in high-resourced contexts in the minority world (e.g. canada). the majority world contexts also exist within the minority world countries, for example, for aboriginal and torres strait islander people in australia. most people experiencing communication disability (cd) live in the majority world, and issues around equitable communication support are both a historical and a contemporary challenge (pillay & kathard, 2018). an estimated 7% – 10% of the world’s population experience cd, which is extrapolated from estimates that 30% – 50% of the population who seek community rehabilitation or special education services experience cd (hartley & wirz, 2002). the term ‘people experiencing cd’ acknowledges that those with communication impairment(s) experience varying degrees of disability because of the dynamic interplay between their communication skills; health condition; social, physical and legal environments; and personal and contextual situations (such as support networks or individual resilience). in minority world countries, speech–language therapists (slts) are the key service providers for people experiencing cd. ratios of trained slts to population are relatively high in minority world compared to majority world countries, where formal speech–language therapy training is either nonexistent or has only recently been established (pillay & kathard, 2018; wylie, mcallister, davidson, & marshall, 2018). stringent standards of training at the university level, certification and/or licensure of slts by regulatory bodies result in highly qualified but few specialised professionals. at current rates of training slts, it would take several 100 years to address the population need in the majority world. simply creating more training programmes in the majority world is insufficient. the curricula and knowledge for training slts in the majority world are largely exported from the minority world, with few modifications (wickenden, hartley, kariyakaranawa, & kodikara, 2003). such attempts to duplicate a profession in different cultural, economic and linguistic contexts need challenging (hyter, 2014). the prioritisation of knowledge and practices from minority world settings may result in services that are neither relevant nor culturally responsive. a possible solution in majority world contexts is to build a workforce with a wider range of skills, including the capacity to support people experiencing cd (pillay & kathard, 2018; wylie et al., 2018). concerns around inequities and the limited development of services to meet the global needs of people experiencing cd prompted the authors to hold a global virtual retreat to discuss the following questions: what is our vision for the future of the speech–language therapy profession globally? what are the challenges around global access to speech–language therapy services? the aim in this article was to develop provocative statements that might spur a global discussion among individuals and organisations that support people experiencing cd. the authors seek to inspire innovation to reduce inequities and ensure communication as a human right (mcleod, 2018). creating a space for discussion in late 2020, bea staley and sally hartley invited 15 colleagues to participate in this virtual forum. thirteen people participated in the virtual retreat and in the subsequent writing of this article. among us, this authorship group has decades of experience working and collaborating across minority and majority world contexts. four of the participants or authors are from majority world countries (south africa, uganda and bolivia). the other nine have significant experience living and working in at least one majority world country in sub-saharan africa, south america, asia and/or the south pacific. five two-hour discussions were held on zoom in january 2021. the schedule was created so that participants could attend three to five of the meetings, depending on their time zone. during the meetings, participants shared their perspectives and brainstormed ideas that could underpin a more equitable global strategy. meetings were recorded and contemporaneous notes were taken. although participants varied across meetings, the conversation was treated as a single narrative, with summaries at the beginning and end of each meeting. recordings were available for those meetings that individual participants were unable to attend. recordings and notes were used to develop themes and suggest principles. themes participants recognised that consensus might not be reached on each topic, nor should consensus be a goal. for example, there exists disagreement among authors about the neoliberal roles played by the united nations and affiliated agencies, such as the world health organization and the world bank group. nonetheless, four recurrent major themes were identified from the narratives: (1) the need to centre people experiencing cd as the main focal point of services, (2) participation, (3) equity and (4) community. these themes were discussed and further refined in a series of collective writing groups to develop provocative statements for change. a summary of each theme is provided. centring people experiencing communication disability as a group, the authors noted that the conversation often converged on their own values, needs and beliefs as professionals and clinicians, instead of on those of the individuals and families that they work with. there is a need to centre people experiencing cd, recognising communication as both a human right and an essential function of being human (mcleod, 2018). furthermore, the disorder-specific language the present authors use to identify people experiencing cd tends to utilise a deficit model, despite intentions to centre the person. for example, people with ‘speech sound disorders’, or ‘dysphasic’ and ‘stammerer’, are all examples of highly specific descriptors that largely centre on health conditions or on body structures and functions. the authors concluded that the term ‘people experiencing cd’ helps us better recognise and imagine the overall need for services to support people experiencing communication disabilities. the experience of disablement by an individual is a complex synthesis of elements, such as the communication environment, accommodations made by communication partners and/or the perceptions of the individual. these are represented in the international classification of functioning, disability, and health (icf; who, 2001) as a dynamic interaction among the key components of body functions and structure, activities and participation, and personal and environmental factors (physical and social). these experiences are unique to each person; therefore, each of these components and their interaction need to be addressed to maximise the efficacy of communication-related services and support. arguably, the experience of cd and the resulting needs and wishes must be recognised as the main concern for speech–language therapy as a profession. participation while the icf has been adopted nominally by national speech–language therapy organisations and many training programmes in the minority world, the profession continues to focus on specific communication disorders. speech–language therapy in the minority world prioritises the medical model of rehabilitation, with assessments typically focused on identifying specific deficits in speech, language or swallowing functions. intervention tends to centre around tasks intended to reduce the perceived deficit by increasing specific speech and language skills (e.g. increasing utterance length or articulatory precision), rather than attending to the necessary functional skills needed for participation at home or in community contexts. in the past two decades, there has been some movement in the minority world towards life participation approaches to services by reducing barriers or improving support for participation, but these approaches are still considered fringe. a notable exception is the area of augmentative-alternative communication that has always kept participation at the fore. alternative approaches focus more on participation at a societal level (pillay & kathard, 2018). to improve life participation of people experiencing cd worldwide, services that uniquely support communication within specific communities need to be offered. for example, for people experiencing cd, participation could be enhanced through slts’ engagement with existing frameworks and models, such as community-based rehabilitation (cbr) or community-based inclusive development (cbid). community-based rehabilitation aims to enhance the lives of people experiencing disability by ensuring inclusion and participation (who, 2010). speech–language therapists in majority world contexts where cbr services exist (e.g. brazil, india and south africa) have an important role to play in capacity strengthening in collaboration with cbr workers. equity equitable speech–language therapy services demand systems that achieve fairness in access to effective communication-related support for people experiencing cd globally. while equality is giving everyone the same opportunity or the same treatment, equity is giving people what they need to succeed by providing appropriate adjustments and support. equity necessitates consideration of race, gender and other social determinants of health in our frameworks for practice (pillay & kathard, 2018). equitable services need to target varied dimensions of disability, from individual treatment focusing on communication disorders to communication partner training that supports life participation to systemic changes that support inclusion. models that support broader community engagement must be developed for equitable service provision to become a reality. examples include advocacy and prevention activities to reduce systemic barriers (pillay & kathard, 2018). given that communication, language and culture are intricately intertwined, importing minority world approaches into majority world contexts is unlikely to result in equitable speech–language therapy service provision. equitable services must be personally relevant, culturally sustaining, flexible and holistic. the following examples demonstrate the innovation necessary to develop equitable services in regions where slts are scant. in western kenya, a service model originally developed in rwanda was adapted to better meet the needs of children with disabilities. ‘communication camps’ were created to empower families to take the lead in facilitating their children’s communication skills and participation in daily life with close support from parent liaison officers (staley, hickey, rochus, musasizi, & gibson, 2021). in eastern kenya, community consultations were held to determine the needs of people experiencing cd. some groups then developed advocacy programmes that utilised local singing and dancing groups, which were the traditional mechanism for community education and public health messages (hartley, murira, mwangoma, carter, & newton, 2009). finally, in rwanda, working with the united nations high council on refugees, the refugee population selected and adapted a programme from the united kingdom (uk) to increase communication accessibility in the community. the programme was then delivered by and to members of the community (marshall et al., 2021). community speech–language therapists must work collaboratively with community stakeholders to build models of equitable service delivery that increase accessibility and inclusivity for people experiencing cd (hartley & wirz, 2002; pillay & kathard, 2018; wylie et al., 2018). as illustrated in the examples above, this requires adapting to the contextual factors of local communities. intervention and support must respond to the myriad of cultural variations in beliefs and values that facilitate (or inhibit) the ability of people experiencing cd to participate at home and in the community (e.g. hyter, 2014; westby, 2013). thus, services based on the concepts of communication and disability will differ from one place to another. sustainability of services must also be considered and is often achieved by collaborating with invested community stakeholders, including those in formal or informal roles. related professionals such as teachers, occupational therapists and physiotherapists sometimes assume responsibility to address the communication needs of people experiencing cd. community members such as pastors, community elders, herbalists, traditional or indigenous healers and family members often provide substantial informal support for people experiencing cd. community-based rehabilitation and cbid models are implemented through the combined efforts of people experiencing disability and their families and communities, as well as relevant government and non-government health, education, vocational, social and other services. these efforts to support people experiencing cd are met with varying success. speech–language therapists need to involve themselves in enhancing this support through capacity strengthening (hartley & wirz, 2002; pillay & kathard, 2018; wylie et al., 2018) and active participation and sharing of expertise (barrett & marshall, 2012). provocative statements for moving forward the themes discussed above were used to develop provocative statements that slts might use to actively seek change to ensure more equitable service provision for people experiencing cd. this study proposes the following three actions for the speech–language therapy profession globally. terminology needs to change to centre people experiencing communication disability and reframe speech–language therapy globally language matters: the words we choose position our worldviews. for example, speech–language pathology denotes the profession is situated in the medical model by the use of pathology or pathologists. we also question the appropriacy of ‘speech–language therapy’ to describe the work we do, given that speech and language are only two aspects of communication. the term ‘therapy’ positions us as professionals who ‘fix’ or seek to make ‘normal’ the varied speech and language skills of individuals. what if we viewed variation in communication as valuable and focused on use, participation and function? what name would better reflect a profession whose primary role is to support and advocate for people experiencing cd? communication therapists or cd specialists are possibilities but are terms that have their own limitations. our professional terminology (e.g. ‘treatment’) needs to be reviewed to reflect underlying concepts related to human rights and social models of disability. the act of addressing our client group as ‘people experiencing cd’ can affect a simple shift in focus and a significant reframing of the work we do. we advocate for centring people experiencing cd. a de-imperialised framework for global speech–language therapy needs to be established there is a pressing need for a process of de-imperialism to establish a framework of practice generated through reciprocal global engagement and a genuine sharing of perspectives among stakeholders. if equitable access to communication-related support and services is our professional goal, and community is our context, then priorities around training and advocacy need re-assessment. this necessitates minority world speech–language therapy organisations and training programmes relinquishing their power as consultants and experts and allowing majority world practitioners to lead the change in their own countries. majority world organisations, programmes and practitioners would then lead the application of communication-related knowledge to develop professional training and services that meet the needs of their context. the role of minority world practitioners would be one of support. if we genuinely want a global change in the profession, minority world speech–language therapy organisations, practitioners and university programmes need to engage with diverse voices, frameworks and models, including those from other disciplines (e.g. disability studies and public health). the aim is to shift speech–language therapy practice everywhere away from medical models that focus on individuals and impairments towards greater engagement with social models that prioritise communities and contextual factors of disability. co-designing services with communities we advocate for developing communication services that focus on capacity strengthening by partnering with communities and adapting contexts to better support communication. speech–language therapists need to listen to people experiencing cd about where and how they seek support, particularly in communities where speech–language therapy services are unavailable, minimal or inaccessible. we must also seek to understand why services are not sought where they are available; for example, within minority world countries where majority world contexts exist, here historical injustices create distrust in professionals or organisations. in those communities and sectors without slts, cross-sectoral collaboration is essential to improve communication support and services (hopf, crowe, verdon, blake, & mcleod, 2021; wylie et al., 2018). how we as a profession choose to engage with community stakeholders will influence how cd is understood and the type of advice and support available or needed in the community. better community engagement would also facilitate more culturally responsive and culturally sustaining services. embracing a full cadre of workers (community health care assistants, family members, parent liaison, etc.) would enhance availability of communication support and services. when utilising a global framework, specifics will likely differ in each country or context. thus, partnering with community stakeholders to co-design services across multiple sectors is essential to achieve these goals (hartley et al., 2009; pillay & kathard, 2018; wylie et al., 2018). conclusion we are not the first to suggest the speech–language therapy profession needs a new way forward (see also hopf et al., 2021; khoza-shangase & mophosho, 2021). the covid-19 pandemic has forced us to confront ongoing global inequities in health care, education and employment sectors. the time of lockdown allowed us to reflect on the world we currently live in versus the world we want. now is a time for professional transformation, for professional leadership as communication specialists and for listening carefully to diverse global voices. we seek to engage reciprocally with colleagues and with other disciplines to ensure that all people who experience cd have access to culturally sustaining communication support and services and to ensure the necessary realisation of communication as a human right (mcleod, 2018). we all agree that change is necessary, but the methods of change are not yet agreed. some of us look to larger institutions for leadership and guidance, while others believe that grassroots organisations are best placed to innovate. from our collective experience, change comes in a myriad of forms, using both top-down and bottom-up approaches. innovation is needed to develop equitable and sustainable services globally. an inclusive umbrella term that centres attention on all who may need access to communication support and services is required. contextually responsive forms of communication support and service delivery and evidence for the benefits of these programmes are essential. we must embrace various ways of knowing and being, extending far beyond the minority world’s domination and gatekeeping of knowledge. this is a call for speech–language therapy practitioners, organisations and people who experience cd to become involved in re-imagining the profession. we encourage consideration of the following questions. what is your vision for the future of the speech–language therapy profession? what changes in the speech–language therapy profession are needed to support culturally sustaining and equitable service provision in your locale, and globally? we invite you to share your ideas so that our profession can move forward purposefully and collaboratively with communities and people experiencing cd everywhere to achieve equity of access to support and services that enable them to lead rich and fulfilling lives of their choice. imagine the garment that we can stitch to fit all of humanity. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions this project was proposed by s.h. and led by b.s. conceptualisation was developed by b.s., s.h., k.w., j.m. and h.b. in the first instance. the authorship group collectively wrote and edited the article in sections. m.f and e.h. contributed substantially to framing and editing final drafts and editing based on reviewer feedback. ethical considerations this article followed all ethical standards for research without direct contact with human or animal subjects. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references barrett, h., & marshall, j. (2012). implementation of the world report on disability: developing human resource capacity to meet the needs of people with communication disability in uganda. international journal of speech language pathology, 15(1), 48–52. https://doi.org/10.3109/17549507.2012.743035 hartley, s.d., murira, g., mwangoma, m., carter, j., & newton, c.r.j.c. (2009). using community/researcher partnerships to develop a culturally relevant intervention for children with communication disabilities in kenya. disability and rehabilitation, 31(6), 490–499. https://doi.org/10.1080/09638280802061944 hartley, s.d., & wirz, s.l. (2002). development of a ‘communication disability model’ and its implication on service delivery in low-income countries. social science and medicine, 54(10), 1543–1557. https://doi.org/10.1016/s0277-9536(01)00136-8 hopf, s.c., crowe, k., verdon, s., blake, h.l., & mcleod, s. (2021). advancing workplace diversity through the culturally responsive teamwork framework. american journal of speech language pathology, 30(5), 1949–1961. https://doi.org/10.1044/2021_ajslp-20-00380 hyter, y.d. (2014). a conceptual framework for responsive global engagement in communication sciences and disorders. topics in language disorders, 34(2), 103–120. https://doi.org/10.1097/tld.0000000000000015 khoza-shangase, k., & mophosho, m. (2021). language and culture in speech-language and hearing professions in south africa: re-imagining practice. south african journal of communication disorders, 68(1), a793. https://doi.org/10.4102/sajcd.v68i1.793 marshall, j., barrett, h., mukagatare, c., muragijemariya, g., anwar, s., harris, c., … hussein, n. (2021). meeting the needs of refugees who experience communication disabilities in rwanda – adapting the communication access uk (cauk) training materials. paper presented at rcslt conference, october, online. mcleod, s. (2018). communication rights: fundamental human rights for all. international journal of speech-language pathology, 20(1), 3–1. https://doi.org/10.1080/17549507.2018.1428687 pillay, m., & kathard, h. (2018). renewing our cultural borderlands: equitable population innovations for communication (epic). topics in language disorders, 38(2), 143–160. https://doi.org/10.1097/tld.0000000000000151 staley, b., hickey, e., rochus, d., musasizi, d., & gibson, r. (2021). successes and challenge of speech language therapy service provision in western kenya: three case studies. south african journal of communication disorders, 68(1), a838. westby, c.e. (2013). implementing recommendations of the world report on disability for indigenous populations. international journal of speech language pathology, 15(1), 96–100. https://doi.org/10.3109/17549507.2012.723749 wickenden, m., hartley, s., kariyakaranawa, s., & kodikara, s. (2003) teaching speech and language therapists in sri lanka: issues in curriculum, culture and language. folia phoniatrica et logopaedica, 55(6), 314–321. https://doi.org/10.1159/000073255 world health organisation (2001). international classification of functioning, disability and health. geneva: who. world health organisation (2010). community based rehabilitation: cbr guidelines. wylie, k., mcallister, l., davidson, b., & marshall, j. (2018). communication rehabilitation in sub-saharan africa: the role of speech and language therapists. african journal of disability, 7, 338. https://doi.org/10.4102/ajod.v7i0.338 this is the moment to put in something like this since he seems to have forgotten the word "other". "and the other car? what happened?" t h e author points out that if a speech difficulty persists, however, or if the parent is concerned about the child's speech, it is advisable to consult a therapist, who will be able to give expert help if necessary. this is a stimulating little book of interest i would say to parents and speech therapists, and of real value to the parents of a child with a speech problem. p a t a l l s o p p stuttering — a symposium j o n e i s e n s o n , editor harper and brothers publishers, new york. 1958 this excellent book is a most significant contribution to the literature on stuttering. jon eisenson has as his basic premise the fact that, in order to find "some answers to the disorder or disorders of speech referred to as stuttering, many different points of view need to be presented." he has therefore selected the foremost authorities in the field to present their viewpoints and so attempt to clarify many of the problems associated with stuttering. the contributors to the symposium include oliver bloodstein, i. peter glauber, joseph sheehan, robert west, jon eisenson and charles van riper. wendell johnson has written the preface. he has, in accordance with his semantic approach, attempted to indicate to the reader that much of the disagreement between authorities is to be found in their language usage. jon eisenson, as editor, imposed upon each contributor the limitation that they should attempt to answer the following questions: "(1) what is stuttering? (2) what is the cause or what are the causes of stuttering? (3) in the light of your concept of stuttering, what are your suggestions for the treatment of stutterers." it is bloodstein's belief that stuttering is a "joint product of more than one factor." in his chapter "stuttering as an anticipatory struggle reaction" he gives a great deal of evidence to support this hypothesis. · a resume of salient factors in therapy, including the handling of resistance, is presented in a most lucid way. glauber's chapter on "the psychoanalysis of stuttering" presents the viewpoint that stuttering is a neurotic disorder and therefore that an understanding of "unconcious mental life" is essential to the rehabilitation of the stutterer. sheehan presents his concept that stuttering is an approach-avoidance conflict. his scientific approach to the problem and the application of his hypothesis to therapy makes sheehan's contribution one of the most valuable. west titles his chapter "an agnostics speculations about stuttering" because he doubts that "answers are availalble to certain fundamental questions." he attempts to relate stuttering to certain physical disorders thus emphasizing a physiololgical basis to stuttering. eisenson presents his own chapter on "a perseverative theory of stuttering". according to his viewpoint stuttering "is a transient disturbance in communicative, propositional language usage." his emphasis of the communicative aspects of the disorder make this a most thought provoking chapter. van riper's contribution to the sympoium takes the form of a report on "experiments in stuttering therapy". it represents an exploration of the disorder for over twenty years. an almost day to day account is given of the therapy carried out with groups of stutterers. the practical knowledge to be gained from this chapter is great because the emphasis is on therapy. it is my opinion that this book is an excellent addition to the available lilterature. f r u m e t . lubinsky — < f westdene products (pty.) ltd. for books on speech defects and therapy johannesburg: 23 e s s a n b y house, 175 jeppe street (23-0314) cape town: 408 g r a n d p a r a d e c e n t r e , castle st. (41-1061), durban: 66/67 n a t i o n a l m u t u a l bldg., smith st. (2-4975) ; pretoria: 210 m e d i c a l c e n t r e , pretorius st. (3-3487) ί • 4 journal of the south african logopedic society december r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) e d i t o r i a l the field of speech therapy in south africa, as elsewhere, is dynamic and one must therefore expect changing ideas, needs and trends. in recent years there has been a growing awareness that we have based the practice of our profession on research studies that have been carried out elsewhere. the time has come for south african therapists to attempt their own research and become more acquainted with the unique conditions that exist in the country in which they work. s. bauman and m. aron have in their article indicated the need for research in south africa. we hope that this contribution will stimulate the initiation of many research projects. m. marks has brought to our attention another important need in our profession: namely the importance of a closer co-operation between allied professions in the treatment of speech disorders. her particular emphasis is on the need for a teamwork approach to cleft palate rehabilitation in south africa. south african therapists have always relied on the knowledge of those who have studied elsewhere. visitors from overseas and those of us who have travelled, have brought the knowledge that nutures our profession. a. g. epstein, having recently visited our country, presents in his article some new and interesting ideas on the testing of articulation disorders. in this issue we have therefore attempted to indicate some of the most urgent needs of speech therapy in south africa as well as presenting some new ideas. it is our earnest hope that further interest in these fields will be stimulated. i journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) volume 69, issue no. 1 (2022) volume 69, issue no. 2 (2022) our mandate about the author(s) anita edwards department of social science, africa health research institute, mtubatuba, south africa department of audiology, faculty of health sciences, university of kwazulu-natal, durban, south africa faheema mahomed-asmail department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa anna-mari olivier private practice, mossel bay, south africa jeannie van der linde department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa katijah khoza-shangase department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa nomfundo moroe department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa joanne neille department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation edwards, a., mahomed-asmail, f., olivier, a.-m., van der linde, j., khoza-shangase, k., moroe, n., & neille, j. (2022). in pursuit of best practice through contextually relevant, accountable and responsive research. south african journal of communication disorders, 69(1), a945. https://doi.org/10.4102/sajcd.v69i1.945 editorial in pursuit of best practice through contextually relevant, accountable and responsive research anita edwards, faheema mahomed-asmail, anna-mari olivier, jeannie van der linde, katijah khoza-shangase, nomfundo moroe, joanne neille copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. in this year of recovery from the coronavirus disease 2019 (covid-19) pandemic, the authors and editors of the south african journal of communication disorders (sajcd) have, once again, contributed towards the body of knowledge in our two professions of speech-language pathology and audiology. the year 2022 has offered professionals from these professions two valuable journal issues. issue 1 included 19 articles aimed at improving knowledge on pertinent issues such as screening and provision of services. the authors followed various methodologies, which included original research papers, an opinion paper and three clinical perspective pieces. issue 2 illustrates just how busy the researchers and practitioners in our professions were during the pandemic, with 22 articles that document the challenges as well as the valuable lessons learnt during the covid-19 pandemic regarding research, training as well as clinical service provision. volume 69, issue no. 1 (2022) issue 1 adds to the body of knowledge in the areas of prevention of hearing loss and language developmental delay through screening and early identification, and the provision of these services. these include ototoxicity monitoring in oncology and in community-based drug-resistant tuberculosis as well as reporting on how the lack of such programmes impacts on people’s lives. articles on new-born and infant hearing screening programmes in primary health care facilities also expanded on existing knowledge of the prevention of hearing loss. the opinion paper on dysphagia triage in an emergency unit and the review of evidence on the influence of screen time on language development synthesises our knowledge on these topics. the focus of the sajcd extends to issues of training of future professionals addressed in the evaluation of the community service programme as well as the evaluation of inter-professional collaboration for language development, and the experience of health professionals when treating patients with communication and or swallowing disorders. volume 69, issue no. 2 (2022) issue 2 was dedicated to exploring the impact of covid-19 on speech language and hearing (slh) professions in low-middle-income countries (lmics), with a direct focus on covid-19’s impact on research, teaching and clinical service provision. topics reported on fell into three main themes. the first theme evaluated the impact of the pandemic on conducting clinical research in slh, a key component of ensuring best practice in both training and clinical care provision. the second theme was that of clinical training of future slh practitioners during the pandemic with the constraints resulting from the pandemic. the topics that were reported on included the use of simulations for clinical training, using intensive writing programmes to develop critical thinking, online teaching and learning and the use of tele-supervision during clinical training. the third theme reported on the impact of the pandemic on our service provision. this included providing treatment for aphasia, neonatal feeding, speech, language and swallowing services and audiological rehabilitation, where the environments of residential care homes and hospitals were the contexts for some of the studies. in this theme, the impact of the virus on middle ear status and the cochlea-vestibular system was also explored. the real impact of these research initiatives and publications will however only be of value if we ensure that we do not stop at simply disseminating the knowledge in peer-reviewed journals, but that we move into finding practical ways to use the knowledge and evidence provided to inform best practice in our clinical settings. we need to apply these findings to actively change how we provide services to our clients and how we prepare the next generation of practitioners as well as how we prepare for the next global pandemic. knowledge translation into practice will close the gap between the knowledge published in our journal and our practice. the key words for knowledge translation are ‘use’ and ‘action’. some potential actions for researchers, practitioners and professional associations as well as academic institutions are to actively use the knowledge shared on these issues as suggested by the authors. for example, ‘the use of a dysphagia triage checklist could have implications for patient health outcomes’. other practical examples are ‘multidisciplinary teamwork’ and ‘simplified national ototoxicity monitoring protocol’. further recommended actions and uses focus on ‘urgent community service programme review, with the aim of standardising and redefining its intended outcomes and pertinent criteria’, and some mentioning ‘careful and systematic planning’ and ‘strategies to increase resources’. our mandate in some countries, and for some research funders, knowledge translation from research into practice is embedded in the mandate. the call to action by all slh professionals is essential to prevent the knowledge generated from lying dormant on the journal pages. it is also incumbent on us to be collaborating inter-professionally to ensure widespread improvement of services to our clients, as was done in the research where collaboration with colleagues in engineering was achieved around the use of artificial intelligence and machine learning in our professions. another example was exploring communication difficulties by healthcare workers when interacting with patients with communication disorders. advocacy for the use of knowledge both by our clients and practitioners and importantly by policy and decision makers is the responsibility of all slh professionals, not only the authors and editors of journals. as the sajcd’s 2022 editor-in-chief, section editors and guest editors, we urge all authors and practitioners to take our mandate seriously and ensure the relevance of our research on our training, research and clinical service provision. abstract introduction methods results discussion conclusion acknowledgements references footnote about the author(s) carlien vorster department of speech-language pathology and audiology, faculty of humanities, university of pretoria, south africa alta kritzinger department of speech-language pathology and audiology, faculty of humanities, university of pretoria, south africa lovina e. coetser department of statistics, faculty of economics and business management, university of pretoria, south africa jeannie van der linde department of speech-language pathology and audiology, faculty of humanities, university of pretoria, south africa citation vorster, c., kritzinger, a., coetser, l.e., & van der linde, j. (2021). preliminary reliability of south african adaptation and northern sotho translation of the modified checklist for autism in toddlers, revised with follow-up. south african journal of communication disorders, 68(1), a831. https://doi.org/10.4102/sajcd.v68i1.831 original research preliminary reliability of south african adaptation and northern sotho translation of the modified checklist for autism in toddlers, revised with follow-up carlien vorster, alta kritzinger, lovina e. coetser, jeannie van der linde received: 14 mar. 2021; accepted: 02 june 2021; published: 22 july 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: there is a shortage of validated autism screening tests in the 11 official languages of south africa. the modified checklist for autism in toddlers, revised with follow-up (m-chat-r/ftm), a validated and well-known screening test, had already been adapted (in english) and translated into northern sotho for use in south africa. objectives: the aim was to collect pilot data to determine the preliminary reliability and feasibility of the two tests to confirm the equivalence of the adaptation and translation. method: the study was conducted in a peri-urban community in south africa. twenty-one first-language northern sotho caregivers of children aged between 18 and 48 months were recruited by employing snowball sampling. the participants were asked to complete the northern sotho and the culturally adapted english m-chat-r/f, which were presented in random order. results: the preliminary content validity and equivalence were evident, with no difference at the 5% interval of the wilcoxon signed rank test. all 21 toddlers screened presented with a low risk for autism following the recommended execution of the follow-up section for the toddlers in the medium risk category. all participants completed the two screening tests, with none indicating unfamiliar words or constructs. a higher preference for the english adapted version was found but a need for the northern sotho screening test was also evident conclusion: the northern sotho translation of the m-chat-r/f, as well as the adapted english version, appears feasible and is ready for comprehensive validation. keywords: autism screening; m-chat-r/f-northern sotho translation; preliminary reliability; low and middle-income country; south african adapted english m-chat-r/f. introduction the lack of culturally appropriate screening instruments for autism has become a universal concern (hyman, levy, myers, & aap council on children with disability, 2020; malcolm-smith et al., 2013). most autism screening tools are available in english only, as they derive from english-speaking countries (soto et al., 2015). cultural and linguistic differences in the understanding of test items and concepts are some of the factors that may lead to disparities in screening outcome (barton, dumont-mathieu, & fein, 2012; soto et al., 2015). in an attempt to address the shortage of validated, cultural and linguistic appropriate screening tools, and amidst a worldwide steady increase in the prevalence of autism (maenner et al., 2020), the authors had previously adapted and translated one of the most commonly used autism screening tests for use in south africa (vorster et al., 2021). limited research has been performed to develop and validate screening instruments on the african continent (de vries, 2016; franz, chambers, von isenburg, & de vries 2017). in a multicultural and multilingual country such as south africa, local translation and validation of autism screening tools are important (franz et al., 2018). early detection of developmental conditions is a high priority and advocated by the world health organisation (who), because identification at a young age may decrease the impact of impairments as it promotes early management (who, 2013a). the original english modified checklist for autism in toddlers, revised with follow-up (m-chat-r/ftm) (robins et al., 2014) was adapted and translated into northern sotho. the international test commission (itc, 2017) and who (2013b) guidelines were used. a rigorous translation and adaptation methodology, which involves cultural adaptation, forward and back translation, has become well established in recent years (itc, 2017). a multidisciplinary specialist panel reviewed the test after a double translation procedure. the comprehensive process resulted in two versions of the original test, a south african culturally adapted english version as well as a culturally appropriate northern sotho translation of the m-chat-r/f (vorster et al., 2021). test translation without cultural adaptation may ignore item bias and may therefore contribute to invalid screening outcomes (itc, 2017). the value of a screening test in an indigenous african language and an adapted english version was shown by van der merwe et al. (2017). the study investigated the language preference of isizulu-speaking parents of two versions of a developmental screening tool, the parents’ evaluation of developmental status [peds] (glascoe, 2013), in a peri-urban community. the results showed that 54% of the isizulu-speaking participants preferred the english version of the peds, whereas 46% preferred the isizulu translation. this finding demonstrates that both the english as well as the indigenous language versions are accepted and desired in south africa, as english is considered an urban language (posel & zeller, 2016). apart from variation in the language preference of caregivers who complete a screen, it is also important to consider cultural variability in the perception of child behaviour. differences in the perception of behaviour may influence screening outcomes (barton et al., 2012; soto et al., 2015). as most parent-completed questionnaires are based on observed child behaviour, a clear rationale is evident for the cultural adaptation of instruments. to promote fairness in testing, screening tools need to be developed for populations that are not first-language english speakers (hyman et al., 2020). the m-chat™ has already gone through a rigorous revision process to simplify the language for greater comprehensibility, making it an ideal screening test to translate (robins et al., 2014). numerous translations and/or adaptations of the m-chat™ and m-chat-r/f™ resulted in 67 different versions of the instrument (robins, fein, & barton, 2018). an example of such an adaptation and translation was carried out by brennan, fein, como, rathwell and chen (2016). the authors developed an albanian version of the m-chat-r/f (m-chat-r-a) by translating the instrument and removing three test items. the omission of items improved the positive predictive value, supporting the need for test adaptation for a specific setting. a systematic review of cultural adaptation and translation of autism-specific screening instruments found that rigorous adaptation and translation often result in more modifications such as adding cultural appropriate information and/or behavioural examples, employing alternative words and constructs (soto et al., 2015). with the current adaptation of the screen for south african users, unfamiliar cultural constructs were identified in word use, interpretation and descriptions of child behaviour. four changes were made to the m-chat-r/f™. the first involved a child’s eye contact when communicating with a caregiver. making direct eye contact with superiors is inappropriate in various southern african cultures (mncwango, 2009). the item was thus adapted to ‘does your child look in your direction or in the eye when you are talking to them?’. ‘make-believe’, ‘soft toys’ and ‘playground equipment’ were also identified as unfamiliar constructs in northern sotho culture and were adapted to ‘acting’, ‘toys’ and ‘trees’, respectively. these items read: ‘if you point at something across the room, does your child look at it? (for example, if you point at a toy or an animal, does your child look at the toy or animal?)’; ‘does your child act?’ and ‘does your child like climbing on things? (for example, furniture, trees, or stairs)’, respectively. the greatest challenge with the translation of the m-chat-r/f™ was ensuring accurate and equivalent translation of the technical content of the test administration instructions. the two versions of the m-chat-r/f were available to be tested by the intended users, that is, northern sotho-speaking caregivers in south africa. the aim of the study was to collect pilot data that allowed item analysis, assessment of the preliminary reliability, and degree of agreement between the two test versions. a second aim was to describe the referral rate of the adapted and translated versions. lastly, caregivers’ preference of the two versions of the test was investigated. if any discrepancies between the tests or difficulties were shown by the results, adjustments could have been made before further validation with a large sample. a descriptive comparative design was employed to achieve the study aims. methods participants a total of 21 participants, living in a peri-urban community in gauteng, south africa, were selected with snowball recruiting. the first point of contact was two active community residents known to the researcher. these residents identified families with toddlers aged between 18 and 48 months, with no diagnosed conditions, at a community church and a day care centre. participants were first-language northern sotho-speaking mothers and grandmothers of 18to 48-month old toddlers. the m-chat-r/f™ was initially developed for toddlers between the ages of 18 and 30 months. yama et al. (2012) however, found that the m-chat-r/f™ is relevant for children up until 48 months of age. similar to the requirements to complete the original m-chat-r/f™, participants had to have passed grade 4 and be able to read northern sotho or sepedi1 and english. participants were excluded from the study if their toddler had been diagnosed with conditions such as a sensory deficit (e.g. hearing loss), a genetic syndrome or cerebral palsy. using the road to health booklet developmental screen and parental report, the aim was to exclude toddlers with developmental conditions whilst including typically developing children in the reference population. the culturally adapted english m-chat-r/f, as well as the northern sotho translated m-chat-r/f were used as screening instruments. a socio-demographic questionnaire was included to allow for comprehensive sample description (table 1). following the completion of the 20 questions of each version of the m-chat-r/f, participants were requested to complete the caregiver feedback form which included three questions about the test: (1) ‘do you prefer to answer the test in english or northern sotho/sepedi?’; (2) ‘were there any words that you do not know? if yes, please list the words’; (3) ‘were there any items in the m-chat-r/f that you did not really understand? if yes, please mark the items’. table 1: participant characteristics (n = 21). following institutional ethical clearance, participants were required to provide written informed consent. the two versions of the m-chat-r/f were presented in a random order to participants. eleven participants completed the northern sotho translation first and the remaining 10 completed the english adaptation first. the random presentation controlled for a learning effect to ensure reliability of data. when a toddler was identified as being at medium risk for autism, the follow-up section of the instrument was conducted telephonically afterwards as per m-chat-r/f™ instructions. no high-risk cases were identified. data analysis both screening instruments were scored according to the existing test instructions, to determine the child’s risk for autism. questions 2, 5 and 12 require ‘no’ or ‘aowa’ as the negative screen. for the remaining items ‘yes’ or ‘ee’ was deemed an accurate answer for a negative screen. for each answer deviating from the prescribed norm, a score count of 1 was allocated. following the allocation of 0 or 1, the sum of the score was determined, whereafter the risk category was identified. three risk categories for autism are indicated in the test. low-risk occurs when a score between 0 and 2 is obtained, medium risk is a score between 3 and 7 and a high-risk score is more than 8. if a toddler obtains a medium-risk score, the follow-up section of the m-chat-r/f should be completed following the initial completion of the screen. if a high-risk score is identified, a child should be referred to a medical professional immediately. the two sets of completed test items were compared to determine inconsistencies in the participants’ answers. descriptive statistics were used to describe the population and the percentage agreement between the two versions. the non-parametric test was employed to determine if there were any significant differences between the two caregiver-completed test versions. non-parametric statistical analysis was used because of the small sample size employed in the pilot study. wilcoxon signed rank test was used to determine agreement between test items of the two versions, supporting the preliminary reliability. the risk profiles were analysed to describe the referral rate of the two versions. data were further interpreted to determine which items were not completed, not understood or required clarification. ethical considerations the study was approved by the university of pretoria, faculty of humanities research ethics committee on 11 november 2019 (reference number: 29026319 [hum041/0919]). the authors have permission from diana robins to adapt, translate and validate the m-chat-r/f™. all the participants signed an informed consent letter that has been approved by the institutional research board. as part of the informed consent, the participants provide consent for the anonymous use of the data collected in scientific papers. results the 21 data sets represented 420 pairs of completed test items. two participants showed a single response difference, answering ‘yes’ to a specific question in the one screening test and ‘no’ in the other. a third participant had two items with a difference in answers. this difference resulted in 416 pairs (99%) yielding an equivalent answer and four pairs (1%) presenting differing answers. the differences are evident in table 2 and figure 1. in figure 2, this difference is evident with 18 data sets having no difference and three data sets presenting with ‘a negative difference’. figure 1: comparison between northern sotho versus adapted english modified checklist for autism in toddlers, revised with follow-up (m-chat-r/f). figure 2: wilcoxon signed rank test results with item correlation between english adapted version and northern sotho version of the modified checklist for autism in toddlers, revised with follow-up. table 2: response frequency for northern sotho and adapted english modified checklist for autism in toddlers, revised with follow-up. the wilcoxon signed rank test was used to determine item correlation between the two versions. despite only three item differences in participant answers between the english and northern sotho versions, the wilcoxon signed rank test identified no difference between the two versions of the m-chat-r/f scores at a 5% level, with a score of 0.102. this provides preliminary evidence of near-perfect agreement and reliability of the two versions. figure 2 indicates the agreement between the two versions and depicts three differences between the english and northern sotho versions. the two items showing a once-off difference in two different data sets were items 3 and 13. two of the three identified participants additionally presented with a difference when answering item 11. in all instances, participants gave a ‘yes’ answer in english and a ‘no’ answer in northern sotho. in two of the three cases, the english version was completed first. for instance, a participant indicated ‘yes’ that the toddler smiles back when the caregiver smiles at her, but in the northern sotho version she stated ‘no’ it does not happen. another example shows ‘yes’, the child can walk and in the northern sotho version ‘no’ the child does not walk. in the case history completed by the participants, no delayed milestones were identified. none of the participants indicated that they had any difficulty understanding words or concepts with no underlying pattern in the errors evident. similar risk profiles of the toddlers were found in the two versions of the test as evident in figure 3. the mean risk-score of the adapted version was 0.810, (σ = 0.814) (total raw score of 0–2 indicates low-risk for autism). no follow-up questions were therefore necessary. the mean risk-score for the northern sotho version, before completing the follow-up questions, was 1.0 (σ = 1), also low-risk. as evident in figure 2, the northern sotho follow-up questions were required for two participants whose children scored in the medium-risk category (total raw score between 3 and 7), whilst no participants required follow-up from the adapted version. the follow-up questions were items 5, 11 and 13 in both sets, respectively. after completion of the follow-up questions, the two toddlers showed low-risk profiles. figure 3: risk profile according to the raw score for each version of the modified checklist for autism in toddlers, revised with follow-up. although no risk for autism, the children showed some developmental risks such as pre-term birth with a gestational age lower than 36 weeks, low birth weight and apgar scores below 5. the apgar score is a universally used new-born health assessment considering the infant’s muscle tone, heart rate, reflex, respiratory effort, irritability and colour (cnattingius et al., 2017). of the 21 participants, only 8 (38%) indicated that they prefer the northern sotho version and 13 (62%) stated that they would rather complete the english adapted version of the screening test. the small sample size did not allow for statistical analysis to determine if a correlation exists between the participants’ language preference, age and level of education. discussion key findings the two south african versions of the m-chat-r/f were previously developed by our team (vorster et al., 2021) and were now piloted with a small sample of northern sotho-speaking caregivers. the study aimed to determine the agreement, equivalence and preliminary reliability of the two south african versions of the screening test. additionally, participants’ understanding of the language and constructs used in the tests, and their test version preference were investigated. equivalence between the two test versions, with no difference at the 5% level regarding item correlation, is evident. linguistic, construct and technical equivalence were shown by comparing the answers to both versions as recommended by dubay et al. (2021). the absence of variation between the responses to the two versions is an indication that the versions yielded the same answers, confirming the preliminary test-retest reliability of the tests. both the initial 20 questions as well as specific follow-up questions were used in this study. this resulted in comprehensive use of the two test versions. no additional changes are necessary before a large-scale validation study can commence. the referral rate of the northern sotho version, with two children initially showing a medium risk for autism, but low-risk after the follow-up questions, was similar to that of the initial validation study of the m-chat-r/f™ conducted by robins et al. (2014). despite a smaller sample size (n = 21), the construct validity of the translated northern sotho version appears to be similar to the m-chat-r/f™ when comparing the follow-up rate. in the current study, a total of 90.4% of the screenings indicated that the toddlers were low risk for autism (screening negative) and (n = 2) 9.6% of the toddlers identified required the follow-up questions. the two toddlers were 25 and 36 months of age, respectively. the large validation study (n = 16 071) identified 92.5% toddlers as screening negative (low-risk) for autism and 7.5% screening positive for a follow-up session (robins et al., 2014). the function of the follow-up questions is to provide caregivers with an opportunity for clarification as different examples of behaviour are included to prevent false-positive results. with the completion of the follow-up questions, none of the pilot study participants’ toddlers was found to be at risk for autism showing that an additional opportunity to clarify their answers was necessary. the high number of low-risk cases found in the pilot study is to be expected with a sample size of only 21 despite the global increase in the prevalence of autism. consistent with the use of snowball sampling, there may have been selection bias, thereby including more toddlers who were typically developing than could be expected from a random population sample. as the aim of the study was to test the preliminary reliability of the two versions of the screen based on parental understanding of the test items, sample bias may not have affected the results. according to hyman et al. (2020), an increased rate of 1 in every 59 children is currently diagnosed with autism in the united states of america. no prevalence data are available for south africa as a result of lack of resources for epidemiological studies (de vries, 2016). similar to the study conducted by van der merwe et al. (2017), the test language preference of the participants was leaning towards english. in a multicultural, multilingual country such as south africa, language proficiency and preference are commonly investigated topics. posel and zeller (2016) investigated the change in language use in south africa from 1996 until 2011 by using the national census results. the study found that english is considered a dominant language in the public office, business and education spheres, including literacy. the language-in-education policy 3(4)(m), national education policy, 1996, encourages first language instruction for learners and recommends the acquisition of english as a second language. the research was conducted in a peri-urban area which is part of a large city where english is commonly used (posel, hunter, & rudwick, 2020). the preference for english by participants supports the development of the culturally adapted english version of the m-chat-r/f. the northern sotho version of the m-chat-r/f was accepted by all participants, even though it was preferred by the minority. greater support for the use of the northern sotho m-chat-r/f may be expected in rural areas of south africa where less prominent use of english is evident (posel & zeller, 2016). according to the census, 61% of citizens who identified northern sotho as their home language did not have a second language in 2011, with only 19.8% of individuals identifying english as their second language (statssa, 2012). most indigenous african language speakers still prefer to use their home language as it has a ‘symbolic significance as a marker of their identity’ (posel et al., 2020; posel & zeller, 2016). the need for a northern sotho translation was confirmed, as 38% of participants indicated that they would rather complete the screening test in northern sotho. strengths and limitations the study results agree with the initial validation study of the m-chat-r/f™ (robins et al., 2014). the sample size, in line with a pilot study, limited the statistical analyses but fulfilled the purpose of determining feasibility of the two versions of the screening test in the current study. participants indicated a desire for both versions of the south african m-chat-r/f. implications or recommendations the two south african versions of the m-chat-r/f are ready for validation which will support early identification of toddlers at-risk for autism in the multicultural and multilingual lowand middle-income country (lmic) context. early identification may contribute to earlier diagnosis and intervention. a large-scale validation study is thus recommended before the publication of the instruments. conclusion the adapted english and northern sotho m-chat-r/f were shown to be equivalent versions of the m-chat-r/f™ in a small-scale pilot study. preliminary reliability was established. a need for the validation of the northern sotho version as well as the adapted english version was identified. please contact the first author for access to the two preliminary versions of the m-chat-r/f. we would gladly make the two preliminary versions of the m-chat-r/f available to readers, but the tests are undergoing further validation and changes may be indicated. as soon as the final versions of the tests become available, the link will be made available to the editor of the sajcd. it is anticipated that the two versions will eventually be available on the official m-chat website. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions c.v. conceptualised the study, collected the data, drafted the article and collaborated with the statistician during the data analysis process. a.k. was the supervisor of the study and continuously contributed to the article as well as the design of the study and the critical reading thereof. l.e.c. supported with the statistical analyses and guidance on the sample size. she supported with the review of the results and discussion. j.v.d.l. was the co-supervisor of the study. she assisted with the conceptualisation of the study and reviewed the article. funding information this project received funding from the organization for autism research (2020g11). data availability the raw data and additional statistical analysis will be made available from the corresponding author, c.v., upon reasonable request. disclaimer the work included in this manuscript was created by the identified authors with no additional external influences. references barton, m.l., dumont-mathieu, t., & fein, d. 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(2013b). autism spectrum disorders & other developmental disorders. from raising awareness to building capacity. geneva: who. retrieved from https://www.who.int/mental_health/maternal-child/autism_report/en/ yama, b., freeman, t., graves, e., yuan, s., & campbell, m.k. (2012). examination of the properties of the modified checklist for autism in toddlers (m-chat) in a population sample. journal of autism and developmental disorders, 42(1), 23–34. https://doi.org/10.1007/s10803-011-1211-3 footnote 1. northern sotho is also referred to as sepedi or sesotho sa leboa. the correct designation for this language is an ongoing debate of which the authors are aware. 13 early communication intervention within a community-based intervention model in south mrica lisl fair and brenda louw centre for early intervention in communication pathology department of communication pathology university of pretoria abstract infants and toddlers with special needs within the developing context in south africa are not currently receiving adequate early communication intervention services. the development of a model for service delivery to this population is impera· tive for the successful implementation of early communication intervention in the developing context in south africa. the basic model of early intervention service delivery provides a theoretical basis for early intervention service delivery but has certain limitations when applied to the developing context in south africa. community· based intervention is proposed as an avenue for the delivery of health care services within primary health care although constraints in the application of community-based intervention exist. an integrated model of early communication intervention service delivery within community-based intervention is proposed and illustrated by presenting a case example. opsomming jong kinders binne die ontwikkelende konteks in suid-afrika wat 'n risiko toon om 'n kommunikasie-probleem te ontwikkel, of wat reeds 'n probleem toon, ontvang tans nie voldoende vroeekommunikasie-intervensie-dienste nie. die ontwikkeling van 'n diensleweringsmodel vir die populasie is noodsaaklik vir die suksesvolle implementering van vroeekommunikasieintervensie in die ontwikkelende konteks in suid-afrika. die basiese model van vroee-intervensie-dienslewering verskaf 'n teoretiese basis vir vroee-intervensie-dienslewering, maar het sekere beperkinge binne die suid-afrikaanse konteks. gemeenskapsgebaseerde intervensie binne die primere gesondheidsorg-model is voorgestel as die wyse waarop gesondheidsdienste in die ontwikkelende konteks ge'implimenteer behoort te word, alhoewel die toepassing van gemeenskapsgebaseerde intervensie sekere probleme kan oplewer. 'nge'integreerde model van vroeekommunikasieintervensie-dienslewering binne gemeenskapsgebaseerde intervensie word voorgestel en geiuustreer deur middel van 'n / gevallestudie. ) i key words: early comfnunication intervention, developing context, community-based intervention 1 introduction early intervention hasi been established internationally as accepted practice for se~ice delivery to infants and toddlers with special needs over the past two decades (guralnick, 1997). early intervention constitutes services aimed at the prevention of developmental disorders and the facilitation of age appropriate developmental skills in infants and toddlers with special needs (thurman & widerstrom, 1990). in south africa early communication intervention, as a field within speech-language pathology, developed gradually over the past twenty years to provide infants and toddlers with special needs with communication-based intervention aiming at the prevention of communication disorders and the age appropriate facilitation of early communication skills (louw, 1998). the current context in south africa in which early communication intervention services are delivered is heterogeneous, since mixed dev;eloped and developing sections are present in south africa (schoeman, 1991). approximately half of the population live in developing rural areas, while the rest live in developed urbanized areas. the 1996 sensus indicated that the population in south africa is of diverse nature, constituting of indigenous africans, asians, people from caucasian decent and also people with a mixed racial heritage (pickering, mcallister, hagler, whitehill, penn, robertson, mccready, 1998). apart from these demographic indicators influencing early communication intervention service delivery in south africa, the transformation of the national health system to primary health care, also implies that service delivery by speechlanguage pathologists must be tailored to fit.into the criterion of primary health care (pickering et al., 1998). the diverse nature of the current context in south africa poses a number of unique challenges to the speechlanguage therapists delivering early communication intervention services in south africa. challenges such as the multilingual and multicultural nature of communities, the limited number of speech-language therapists working in south africa, the geographical distribution of die suid·afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 14 young children with special needs, limited literacy skills of caregivers often present in developing communities, as well as environmental risk factors exist in the current south african context (louw, 1998; uys & hugo, 1997). a significant number of young children in south africa is considered to be at-risk to display developmental difficulties (who, 1997). although a body of research has emerged over recent years concerning infants and toddlers in developing communities in south africa, little is documented about the current status of early communication intervention service delivery in that context and it is generally accepted that the infants and toddlers with special needs in the developing context in south africa are not receiving adequate services (louw, 1998). a dire need ex~ ists to expand the early communication intervention services currently being'delivered in south africa to include young children in developing communities. in order to deliver effective and accountable early communication intervention services to young children and their families in the developing context in south africa, the development of a model for early communication intervention service delivery in disadvantaged communities is imperative. the purpose of this article is to provide an overview of issues pertaining to early communication intervention as well as community-based intervention service delivery models and secondly to propose an integrated model of early communication intervention service delivery within community-based intervention. models of early communication intervention service delivery in presenting.a basic model of an early communication intervention service delivery system, discussion of the terminology underlying the model, basic tenets of early intervention and service delivery issues pertaining to early intervention as well as a critical review of the basic model, is imperative. the discussion will provide a basis from which the basic model can be interpreted and expanded. definition of terms since different disciplines have contributed to early intervention literature, and terminology is not always used consistently, it is necessary to define the basic terminology inherent to early intervention. early intervention refers to both the assessment and treatment of infants and toddlers who are at-risk for or who are displaying a developmental delay (asha, 1989). early communication intervention constitutes early intervention from a communication-based perspective and these services are delivered by speech-language therapists (rossetti, 1996; mcdonald & carroll, 1995). as international early intervention literature describes the whole early intervention process and not communication-based intervention per se (for example guralnick, 1997; blackman, 1995), the early intervention service delivery system will be described first and communication-based intervention will then be placed within the framework of the comprehensive early intervention system. at-risk infants and toddlers refer to those young children who have the potential to develop a disorder based on biological, environmental or behavioral factors (asha, 1991; rossetti, 1996). in'addition, children with disorders such as syndromes or craniofacial anomalies are considlisl fair and brenda louw ered to have an established risk to have developmental problems since deviant or delayed development are often associated with established disabilities (rossetti, 1996). the term, infants and toddlers with special needs (mitchell and brown (1991), is used in this article as an umbrella term to refer to both at-risk children as well as children with an established risk. basic model of an early intervention service delivery system early intervention evolved from research indicating that infancy is a sensitive period for development, especially to individuals who have special needs arising from risk factors or established disorders (baird & mcconachie, 1995, mitchell & brown, 1991). in addition to the importance of early experience, the high-risk population is rapidly expanding due to advances in medical care, the subsequent need to provide services for these children led to a further expansion in early intervention services (ferguson & brynelson, 1991). a growing recognition also exists of the rights of infants and toddlers with special needs to have equal opportunities to develop to their full pot~ntial(mitchell & brown, 1991). these factors led to legislation in the usa in 1986, part h of usa public law 99-457 (pl 99-457), which mandates early intervention services to infants and toddlers with special needs resulting in an expansion in early intervention services to infants and toddlers with special needs as well as a growing body ofliterature on early intervention (guralnick, 1997). early intervention is mainly concerned with the prevention of developmental disorders (mitchell & brown, 1991). prevention can take place on thre'e levels, namely on primary level where the occurrence of a disorder is completely prevented, on secondary level where the negative outcome of a present risk or disorder is minimized and on tertiary level where rehabilitation is provided for an established disorder (who, 1995). early intervention is considered as secondary prevention and aims to identify, evaluate and treat young children with special needs as early as possible in order to minimize the potential ~ega­ tive developmental outcome of the risk or disorder (mitchell & brown, 1991). . figure 1 provides a graphical representation of a basic model of early intervention service delivery and indicates that such a system usually comprises four basic corp-ponents, namely an early identification programme, an assessment facility as well as a treatment programme which is managed and supported by an administrative component (rossetti, 1996; mitchell & brown, 1991; baird & mcconachie, 1995). as indicated in figure 1; each component of early intervention has distinct goals in order to realize the primary goal of early intervention, which is to prevent developmental disorders and minimize the potential negative effect of risk factors and established disorders by facilitating development (mitchell & brown, 1991). the goal of the identification component is to identify infai1ts and toddlers with special needs as early as possible and to usher them into the assessment component of the early intervention system (rossetti, 1996). the assessment component serves as a diagnostic facility and provides a profile of strengths and weaknesses by identifying the developmental level of the infants and toddlers served. the information obtained from the assessment serves as the basis / thesouth african journal of communication disorders, vol, 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) early communications intervention within community·based intervention model in south mrica 15 from which treatment is planned (rossetti, 1996). the treatment component consists out of the age appropriate facilitation of developmental skills, within a family centered approach, in order to assist· the high·risk infant or toddler to reach his or her full developmental potential (mitchell & brown, 1991). the basic model describing an early intervention service delivery system is simplified. certain tenets are fundamental to the early intervention service delivery system and a number of service delivery issues arise from the basic model. these tenets and issues are discussed in the following sections. basic tenets of early intervention asha (1989) emphasizes four basic principles that should be included in an early intervention service delivery system by stating that services should be comprehensive, community-based, family-centered and that services should be coordinated adequately. children who are considered to be at-risk or display an established risk often have complex and diverse developmental and health needs and an early intervention service delivery system should provide a comprehensive array of services to meet the needs of these children within their communities (guralnick, 1997; asha, 1989). the importance of the context in which development takes place is increasingly recognized (thurman & widerstrom, 1990). this recognition led to the inclusion of parents and families within the early intervention process (guralnick, 1997). the comprehensive nature of early intervention service delivery necessitates the effective coordination of the different services that infants and toddlers with special needs often need to .receive to prevent the fragmentation and duplication of services (guralnick, 1997). service delivery issues pertaining to the early intervention service delivery model different settings of service delivery are discussed in literature, these include centre-based services, home-based services as well as a combination of homeand centre-based services (rossetti, 1996). centre-based early intervention services are provided within the context of an early intervention centre, whereas home-based services are provided at the home of the family with the infant or toddler with special needs (rossetti, 1996). within an centre-based setting parents have greater access to professionals and more early intervention primary goal: to prevent the occurrence of developmental delays and disorders and to reduce the severity of existing developmental delays and disorders as early as possible through the facilitation of development. ' ' basic components of an early intervention service delivery system /' identification / s,creening goal: early identification of infants and toddlers who d i emonstrate or art; at-risk for demonstrating: a delay or disorder in de~elopment. assessment goal: to determine the high-risk toddler's infant level or of functioning in his or her respecti ve developmental domains, in order to compile a profile of strong and weak points in development from which, treatment can be planned. administration component treatment goal: to facilitate the acquisition and use of age appropriate developmental skills in young children, including all' their developmental domains, within a family focused treating plan, goal: to manage, coordinate and support the early intervention service delivery system, and to provide logistic services such as attendance to administrative details. figure 1: basic modeliof an early intervention service delivery system(conceptualized from mitchell & brown, 1991; baird & mcconachie, 1995; rossetti, 1996). die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 16 opportunities to meet other parents with children with special needs, but the home environment utilized by the home-based approach is considered to be a more natural and functional context in which to provide services (rossetti, 1996) pl-457 made the involvement of a team in early intervention mandatory and since teamwork is no longer an option but a necessity in the usa, a renewed focus was placed on ways teams can be organized in effective ways (mcgonigel & garland, 1995). three models of team involvement in· early intervention are described by numerous authors, namely multidisciplinary teamwork, interdisciplinary teamwork and transdisciplinary teamwork (mcgonigel & garland, 1995; ferguson & brynelson, 1991; rossetti, 1996). multidisciplinary teamwork is considered to be the least collaborative of the teamwork models and the functioning of multidisciplinary teams have been described as similar to parallel play in young children 'side by side but separate' (peterson, 1987 p. 484 in mcgonigel & garland, 1995). the interdisciplinary model of service delivery allows for more interaction and collaboration between team members by providing a framework for interaction between team members (mcgonigel & garland, 1995). assessments are carried out by each team member separately and a meeting is scheduled where each professional shares his or her assessment findings and views. the parents are usually considered as team members and the services of a family service coordinator (case manager) are utilised to co-ordinate the process (ferguson & brynelson, 1991). the transdisciplinary team model of service delivery is currently viewed as one of the most efficacious ways to provide services to infants and toddlers with special needs and their families (briggs, 1997). during transdisciplinary team functioning the focus is on the sharing of information, skills and knowledge while professionals cross traditional disciplinary boundaries and parents are viewed as equal team members (rossetti, 1996). clinically, trans disciplinary team work is carried outby conducting a play-based arena assessment where all team members are present but only one team member elicits a sample of behaviour from the child. the team members will then make inferences pertaining to their area of expertise and share it with the team after the assessment (mcgonigel & garland, 1995). intervention is planned in a collaborative manner and one team member is chosen to provide all the services to the child and family while consulting with the other team me~bers (rossetti, 1996). the choice of a team: involvement model will depend largely on the orientation of the team members. if the team members arenot prepared to cross disciplinary boundaries and have trouble with role release, the transdisciplinary model is not likely to work. the choice of a team involvement model is not always an either or issue since some teams prefer to switch between multiand transdisciplinary functioning in order to meet specific family needs (ferguson & brynelson, 1991). communication-based intervention with· in the early intervention service deliverymodel communication~based assessment and intervention are described as an early intervention approach focussing on the communication development of infants and toddlers lisl fair and brenda louw with special needs (rossetti, 1996; mcdonald & carroll, 1995; asha, 1989). speech-language therapists are qualified to provide these services and have traditionally provided communication-based services to infants and toddlers with special needs, but in accordance with the trans disciplinary team model it is increasingly advocated c that other team members also adapt comm unication-based intervention as approach to service delivery (rossetti, 1996; mcdonald & carroll; 1995). the following reasons are cited why communicationbased intervention should be incorporated into service delivery by team members other than the speech-language therapist: • communication is often the primary vehicle used by team members for assessment and intervention; • goals would be reached more easily if professionals can communicate more readily with infants and toddlers; • children learn communication during every social contact and the right strategies used consistently could assist them in their learning process (rossetti, 1996; mcdonald & carroll, 1995). as early communication skills are considered to be the best predictor for future school success, it is imperative that early communication skills be facilitated (capute, palmer & shapiro, 1987). the utilisation of communication-based intervention strategies by team members other than the speech-language therapist can assist in the further facilitation of communication development in infants and toddlers with special needs. critical review of the basic early intervention service delivery model south africa consists of a unique mixture of developed and developing components, and this fact limits the rei· evance of service delivery models created in developed countries such as the usa, canada and britain (louw, 1998). whereas legislation played a significant role in the development of early intervention programmes in the usa, the south african government has not yet seen the need to mandate and fund early intervention services to infants and toddlers with special needs. the lack of legislation and funding may be due to limited resources availa~le in south mrican as issues such as unemployment, lack of housing and inadequate health care facilities are considered priorities for funding (schoeman, 1991). i apart from legislative and financial challenges, a lim· ited number of speech·language therapists are currently practicing in south mrica and uys (1993) estimates that by the year 2000 there would be a shortage of approximately 5000 communication pathologists in south africa. the number of speech-language therapists competent to deliver early communication intervention services is further limited by the fact that not all are trained in ~arly intervention on an undergraduate level. those who qualified before early intervention was part of university curricula and did not attend any continuing education events on the subject, can not be considered as qualified to deliver early intervention services to infants. and toddlers with special needs (louw, 1998). certain linguistic and cultur3l constraints also exist in the diverse south mrican context (pickering et ai., 1998). more than eleven languages are spoken in south africa / the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) early communications intervention within community-based intervention model in south mrica 17 and each linguistic group has unique cultural practices (department of national education, 1996). assessment and intervention material developed in a western culture like the usa and canada may not be culturally appropriate in south mrica and needs to be applied with care (louw, 1998). the shortage of speech-language therapists trained in early intervention is magnified against the background of cultural diversity in south africa since a further shortage of culturally and linguistically diverse speech-language therapists exists although training institutions have applied policies to alleviate the discrepancies of the past (uys & hugo, 1997). certain elements of the basic model of early intervention service delivery have the potential to be applied with success in south africa. community-based service delivery may be a successful strategy in south africa, since the national health system has been changed to district based primary health care in recent years (government gazette, 1997). health care facilities providing primary health care are placed within communities providing a potential platform from which to launch early interven-, tion services in all communities, both developed and developing. other elements of the basic early intervention service delivery model which could also be applied successfully within the district based primary health care system in south africa are home visiting and family centered care. bryant & maxwell (1997) indicated by reviewing several early intervention programmes with disadvantaged families that for very poor families home visiting may be beneficial. it is estimated that 61% of children in south africa live in poverty (government gazette, 1997), and it is proposed that the home visiting approach to early intervention may provide a way to reach these children and their families. the transdisciplinary model ofteam functioning also has the potential to contribute to early intervention service delivery in south africa (louw, 1998). the general shortage of speech-language pathologists can be accounted for in part by empowering other professionals or volunteers to provide communication-based early intervention services. speech-language pathologists providing early intervention services can be involved in a consultative i capacity and reach more infants and toddlers with special needs in this way. i from the discussion above it is clear that although the international literature provides a useful framework for early intervention, the speech-language pathologist providing early intervention: services, especially in the developing context in south mrica, needs to be critical and creative when providing early intervention services in the context in which he/she works. community-based intervention models community-based rehabilitation (cbr) grew out of the need to provide rehabilitation services to people with disabilities within the context of their families and greater communities especially in developing countries. it meant a shift away from institutionalized care where people with disabilities often received care in isolation from their families and greater communities (chaudhury, menon-sen & zinkin, 1995). a joint position statement issued by the international labour organization (ilo), the united nation educational, scientific and cultural organization (unesco) and the world health organization (who) (1lo, unesco & who, 1994) provided a formal definition of cbr stating the following: 'community-based rehabilitation is a strategy within community development for the rehabilitation, equalization of opportunities and social integration of all people with disabilities. community-based rehabilitation is implemented through the combined efforts of disabled people them'selves, their families and communities, and the appropriate health, education, vocational and social services.' although this definition serves as a guideline to many cbr programmes around the world, many variations exist amongst cbr programmes and it is generally accepted that, there is no true blueprint for cbr programmes (chaudhury et al., 1995). who advocates the use of tpe primary health care (phc) system as a platform from which to implement cbr programmes and places specific emphasis on health care issues as goals in cbr (who, 1995; chaudhury et al., 1995; werner, 1987). as south africa recently changed its national health care system to phc, the discussion in this article will focus on cbr as an integrated part of the phc system. some comments on the use of the term communitybased rehabilitation are warranted. the word rehabilitation implies the tertiary form of prevention where rehabilitation is provided for an established disorder. the term cbr therefore excludes primary and secondary prevention activities, and since early intervention is considered as secondary prevention, it would be impossible to integrate the two service delivery models if one excludes the other by definition. it is suggested that the term community-based intervention (cbi) is used to provide a basis from which primary, secondary as well as tertiary prevention activities can be executed. based on the basic definition provided above, the main aim of cbi is to bring about a balance between the needs and the resources of disabled people in a given community through community mobilization, initiative and participation (lombard, 1991; ilo, unesco & who, 1994). this aim emphasizes community participation and initiative in cbi but who (1995) as well as chaudhuryet a1., (1995) acknowledge that cbi seldom starts without a stimulus from outside the community making the community aware ofit's"'needs and resources to deal with those needs. the external stimulus can be phc pe!rsonnel, nongovernmental organizations involved with disabled people or academic institutions (chaudhury et al., 1995). ' two types of goals are used in order to achieve the main aim of cbi namely task goals and process goals (lombard, 1991). task goals are considered to be mainly focused on obtaining results in the form of concrete tasks to be done or securing specific resources whereas process goals focus on the development of the people through the process of achieving a specific goal (lombard, 1991; swil, 1982). both taskand process goals are viewed to be essential in cbi but process goals like community participation, empowerment and responsibility are considered to be more important than simply the completion of tasks (swil, 1982). it is postulated that if a community went through a self-development phase (process goal) while striving for a specific goal (task goal) that the community will show ownership towards the desired goal and will possess the necessary die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 18 skills and responsibility to maintain that specific goal (lombard, 1991). figure 2 provides a graphical representation of a basic model of a cbi programme within a prc system. as indicated in figure 2, two broad functional groupings are typically involved in cbi in a given community, namely managerial and consultative participants and local (or direct) participants in the cbi process (werner, 1987; chaudhury lisl fair and brenda louw et al., 1995). the managerial and consultative participants consist out of the government institution responsible for health policies (ministry of health), the regional hospital with specialized services as well as the local primary health care clinic. these participants are responsible for mandating, planning and staffing cbi services in communities. in addition to these roles the managerial and consultative participants are also involved in the training and support i basic model of community-based intervention within phc i (i ministry of health i) ;t • managerial and consultative regional r--..participants in hospital the cbi process ~ ~~ phc district clinic + ~~ ~~ ---------~~ , , , ~ , " , ~ am " " i i , \ .. ~ .. ~ ...... local i \ .=::::::::,. i i ";::-;!~:~;'" 4 participants in \ 1~4'+r4'+ ~4'+ i ................ \ , " " , , " ~ the cbi process " , ~~ local phc "--' ---------i community community volunteer community worker i + i : i i i 1. recognize problem / need ~ 6. evaluation of process • t r--..-the cbi process 2. analyze situation 5. take action • t 3. do fact finding .. 4. planning / figure 2: basic model of community-based intervention within a primary health care system (conceptualized from werner, 1987; dunham (1970) in swil, 1982; chaudhury et a!., 1995; who, 1995; lombard, 1991) / the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) early communications intervention within community-based intervention model in south africa 19 of primary health care community workers and the regional hospital and primary health care clinic serve as referral facilities offering specialized services and consultation to community workers and communities (who, 1995; werner, 1987). academic institutions and non-governmental organizations can also be managerial and consultative participants in cbi (chaudhury et ai., 1995), but as these two structures are not typically associated with phc it was not included in the basic model of cbi within phc. the local participants in the cbi process as indicated in figure 2 consist of the community itself, the local community volunteer as well as the phc community worker (werner, 1987; who, 1995). the phc community worker can be of any primary discipline like physiotherapy, occupational therapy; phc nursing and speech-language therapy or the person can be a mid-level health worker with a two year training in basic health issues (who, 1995; government gazette, 1997). the role of the phc community worker is to facilitate the cbi process, to serve as a consultant to the community and to make the resources of the phc system known to the local community (who, 1995). the local community volunteer can be any person who is willing to serve the community as a volunteer in conjunction with the phc community worker. chaudhury et ai. (1995) as well as werner (1987) state that a person with a disability may be the ideal candidate to be a local community volunteer since he or she usually has first hand experience with issues relating to disabilities. the local community volunteer may also be a group of people instead of an individual (werner, 1987). the role ofthe local community volunteer (or group of volunteers) is to work in conjunction with the phc community worker to introduce the community to cbi and to assist them through the whole cbi process (werner, 1987). the community is the key role player in the cbi process and a community can be defined as a group of people living in the same geographical area and utilizing a mutual infrastructure (lombard, 1991). as community participation and initiative are key components of cbi, the role of the community in cbi can be described as one of self-development during which the community grows to fecognize needs and resojrces within its own ranks and utilize actions to bridge those needs with available resources (lombard, 1991; werner, 1987). the cbi process as desdribed in figure 2 is derived from a problem solving approdch to community work from a social work perspective b~ dunhum (1970) in swil (1982). dunhum's approach to coinmunity work (dunhum (1970) in swil, 1982) is executed by the phc community worker, local community volunteer and the community and starts with step one as the recognition of the problem or need. this step involves the creation of an awareness amongst a community that a certain need (for example, inadequate facilities for disabled people) exists (lombard, 1991). the next step is described by dunhum (1970 in swil, 1982) as situation analyses and involves compiling a profile of existing needs and potential resources in a community. when a profile of the community has been compiled the next step namely, fact finding, is executed (dunhum (1970) in swil, 1982). the specific actions during the fact finding phase will largely be determined by what the perceived needs and resources of the community are. the next step described by dunhum (1970 in swil, 1982) is planning and wernerl(1987) states that it is essential that the community be fully involved in decision making and the setting of realistic goals in order to ensure that the community possesses a sense of ownership over the project. the next logical step after the planning has been done, is for action to be taken by the community (dunhum (1970) in swil, 1982). the last step in dunhum's approach (dunhum (1970) in swil, 1982) is the evaluation of the process and who (1995) describes it as a crucial element in cbi in order to ensure that the process has been successful and to gain understanding of how the process can be enhanced within the community. the description of a basic model of cbi within phc is a simplified description of a complicated system where considerable variations exist between programmes (chaudhury et ai., 1995). the phc approach has also been depicted in a simplified manner in the model in figure 2 since in practice one phc district clinic will often serve more than one community and a substantial number of phc district clinics are associated with one regional hospital (government gazette, 1997). for the scope of this article, the basic model does however supply an adequate point of departure for the integration of early communication intervention into a cbi model if cognizance is taken of the following critical review of the cbi model. critical review of the community-based intervention (cbi) model within primary health care one of the problems identified in cbi is that of collaboration between the different participants in the cbi process (chaudhury et ai., 1995). the needs and resources that the community perceives may not be those that the other participants in the cbi process anticipated and different sections of the community may have different perceptions of the needs, resources and action that needs to be taken (chaudhury et ai., 1995). another potential problem in cbi is that of conflicting priorities where issues like extreme poverty, violence, hunger and homelessness in a community may override the phc community worker's priority of for example facilitating care for children with disabilities in a community (chaudhury et ai., 1995). chaudhury et ai. (1995) warns that cbi cannot be implemented within selective phc where fundamental principles of phc (for example community participation and comprehensive, integrated health care) are not adhered fo. a full impleli}entation of comprehensive and integrated phc is therefore necessary before cbi can successfully be integrated into phc. the phc system in south africa is still in its infancy as it was only formally instituted in 1997 (government gazette, 1997) and limited personnel, support services, training in cbi and experience may pose a unique challenge to cbi in south africa. an essential element of cbi, namely the availability of support services like phc clinics and regional hospitals, is imperative to the success of cbi programmes (chaudhury et ai., 1995). it will be unethical if a community is made aware of its" needs but the phc personnel is unable to provide resources or train local people to provide services. some obstacles to effective cbi may also lie within the community itself. a presupposition of cbi is that communities are eager to be empowered and are willing to take responsibility for their needs but communities are not always able to take responsibility (chaudhury et ai., 1995). the incapacity to take responsibility for a cbi prodie suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 20 lisl fair and brenda louw gramme may be due to poverty and lack of infrastructure, lack of confidence in their own abilities or lack of interest in the goals of a specific project (chaudhury et al., 1995). mcconkey (1995) also warns that the cultural perceptions of a specific community towards disabilities may be a barrier to the successful implementation of cbi and a broad social change in attitude may be necessary as part ofthe cbi process. another factor potentially influencing the success of a cei programme is the availability and attitude oflocal community volunteers. they often have their'own issues and problems within the community and it may have a detrimental effect on the cbi process (chaudhury et al., 1995). cbi should not be viewed as a low cost option for the poor in developing countries as even developed countries like the usa and britain are implementing communitybased care as part of comprehensive health services (chaudhury et al., 1995). it is clear that the cbi process is not void of challenges, but it still is considered as an excellent way to provide services to people with disabilities within the context of their communities (chaudhury et al., 1995). implementation of early communication intervention services through cbi institution, planning and staffing of early communication intervention services within cblby the managerial and consultative participants in cbi recruitment of local community volunteer by phc personnel execution of cbi process' to establish early intervention services in the community by the phc community worker, the local community volunteer and the community task goals 1. recognize need + 2. analyze situation t 3. find facts 4. plan t t 5. execute action 6. evaluate process + 7. institute change process goals goal: create awareness of the importance of early communication development and the relevance of communication development for school success. goal: compile a profile of needs and resources in the community. for example, resources include: birth attendants and a group of primary care givers are willing to participate in project, whereas needs include: no services for infants and toddlers with special needs exists at the moment. goal: find facts pertaining to needs and resources. for example, conduct a survey about the number of infants and toddlers with special needs in the community; find out about the possibility of state funding for a local day care centre, goal: draw up goals pertaining to the implementation of services for infants and toddlers who are at-risk for communication disorders. for example plan 'how these infants will be identified, how they will be assessed, how intervention will be provided and where support services may be found. goal: implement the early communication intervention services in the community by for example training the birth attendants and primary care· givers in principles regarding identification and training the local community worker how to make referrals and provide basic intervention strategies. goal: evaluate the process by reflecting on the value of the services and process to the community by for example determining the developmental outcomes of the recipients of the services. goal: based upon the evaluation of the implementation of early communication intervention services through the ebi process, make changes to the service" delivery system to be more effective. figure 3: basic implementation of early intervention services through community-based intervention (derived from dunhum, 1970 in swil, 1982; mcconkey, 1995) / the south african journal of communication disorders; vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) early communications intervention within community-based intervention model in south mrica 21 integrated model of early intervention service delivery within community-based intervention from the discussion of an early intervention service delivery model and a community-based intervention model it is clear that mutual objectives exist between these models of service delivery. both models emphasize the role of the family in the intervention process, advocate the implementation of community-based services and focus on the empowerment and training of others (louw, 1998). early communication intervention can make a valuable contribution in the integration of the two models by placing emphasis on prevention whereas cbi can bring a new dimension into early communication intervention service delivery with its focus on community participation. the individual strengths ofthe two models integrated into one model of service delivery may provide a powerful tool for the primary, secondary and tertiary prevention of communication disorders through the participation of the community in south africa. the proposed integration of the two service delivery models is presented in two sections. firstly, the implementation of early communication intervention services through cbi is discussed as a point of departure for the discussion on the integration of the two models. the integration ofthe two models is then discussed by referring to a case example of the functioning of early communication intervention service delivery within a cbi model. figure 3 provides a graphical representation of the implementation of early communication intervention services through a cbi model. as indicated in figure 3, the establishment of early communication intervention service delivery within a cbi model can start once the managerial and consultative participants in the cbi process (e.g. the ministry of health, regional hospitals and the primary health care clinics) have instituted legislation for early communication intervention to be applied through cbi, planned the implementation thereof and provided the necessary personnel to implement the process (chaudhury et ai., 1995). i the next step in the provision of early communication intervention through the <bbi process would be to recruit local community voluntee*s to participate in the process. any person could be choseri to be a community volunteer as long as they are motivated, have literacy skills and have a positive respectful attitud~ towards people with disabilities (mcconkey, 1995). o'toole (1988) mentions that people with a higher qualification status often discontinue to be community volunteers because of other career opportunities available and may not be the most suitable candidates. a community volunteer should receive training in basic issues surrounding disabilities and the quality of the training will often determine the quality of the programme (mcconkey, 1995). training material about communication disorders for the training of community volunteers is available and involves basic issues pertaining to communication deve,lopment and disorders (werner, 1987). the cbi process as derived from dunhum (1970 in swil, 1982) is used for the implementation of early communication intervention services through the combined efforts of the prc community worker, the local community volunteer and the community. the task goals described in figure 3 are the steps outlined by dunhum (1970 in swil, 1982) with one addition ~amely the institution of change after the cbi process has been evaluated. this step was added by the authors to ensure continued community change and growth after the cbi process has been completed. this circular effect is further indicated by the double pointed arrows between the different steps ofthe cbi process (see figure 3). the process goals are indicated by the highlighted words on the right of the task goals in figure 3 and it is presumed that the community would grow and change through the process of creating awareness, compiling a profile, finding facts, planning and implementing action, evaluating the process and instituting new changes. examples are provided in figure 3 of the possible outcomes of the different steps in the cbi process. figure 4 provides a graphical representation of a case example of the functioning of eariy intervention service delivery that has been implemented through a cbi model as described above and serves as a practical example of the integration between the two models. as indicated in figure 4 three of the basic components of the early intervention service delivery system has been incorporated into the integrated model of early communication intervention through cbi, namely identification, assessment and treatment (see figure 1). it is supposed that the administration component is handled by the phc personnel. the identification component of early communication intervention within the cbi model is conducted at community level by a member of the community (a birth attendant) in the case example in figure 4. in could also have been conducted by the local community worker, the phc community worker or any other informed member of the community. after the child with the established risk (e.g. cleft lip and palate) has been identified he and his family are referred to the local community worker and the phc community worker. although the local community worker and the prc community worker are presented as an inseparable team in figure 4 it is often the case that they function individually with the phc community worker acting as consultant for more than one local community volunteer (mcconkey, 1995; o'toole, 1988). the local community volunteer and the phc community worker accompany the family to the phc clinic where a prc speech-language therapist conducts a communication evaluation and refers the child and his family for specialized assessment and intervention by a craniofacial team at the regional hospital if it is necessary. the craniofacial team conducts whatever specialized assessments and interventions necessary and refers the child back to the phc clinic, but stays available in a consultative manner. the phc speech-language therapist then designs an individualized service plan in conjunction with the parents and the phc community worker and community volunteer who will provide the hands-on intervention services to the family. if necessary, the phc speech-language therapist provides training to the prc community worker and the local community volunteer on cleft lip and palate and the associated communication and feeding problems and monitors the intervention process while providing support to the prc community worker and the local community volunteer. as the process described in figure 4 is a case example of the proposed integration of early communication and cbi service delivery models it is a simplified description of a system. in practice, one local community volunteer will be providing help to three to four families a week die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 22 (chaudhury et al., 1995) and one prc community worker will oversee a number oflocal community volunteers. the integrated model focuses on the implementation of early communication intervention services through cbi, but if the basic tenets of early intervention are considered more accountable service delivery could be achieved if a comprehensive model of early intervention within cbi is followed. this would imply that all the developmental areas of infants and toddlers with special needs are considered in service delivery and would require the efforts of a comprehensive .team of professionals like, occupational therapists, physiotherapists and social workers, which may not be available at prc clinic level. ifcomprehensive early intervention services could be ~upplied through cbi, the transdisciplinary model of early.intervention service delivery may. provide valuable principles as to the functioning of a prc early intervention team within a cbi model. conclusion the di~e need for early communicati6n intervention services in the developing context in south africa may be met by the implementation of the proposed integrated "model of early communication intervention service delivery throughcbi. in order for this model to be implemented an 'agent of change' or 'agents of change' are required to. facilitate the process on governmental as well as commu'nity level.. werner (1987, p. 408) states that 'what is necessary is that the. agent of change be someone who respects ordinary people, and is committed to helping them join lisl fair and brenda 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(1997). trends in health status. http://lynx.who.chiprogrammesiinf/pub-inf.htm. locum & permanent vacancies for: .:.asa • locums speech therapists in the uk • free personal tax advice • free indemnity & pa insurance • uk entry clearance advice • accomodation often arranged • rcslt registration refund* *subject to conditions angela shaw associates call us free from south africa on: 0800 990 767 call: +44 (0)20-8554 7691 fax: +44 (0)20-8554 9900 email: locums@asa-iocums.co.uk montrose house, 412-416 eastern avenue, liford, essex, ig2 6nq, uk. die suid:afrikaanse tydskrifuir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) abstract introduction method results and discussion facilitators and advantages of providing speech, language and swallowing intervention via teletherapy barriers and disadvantages of providing speech, language, swallowing intervention via teletherapy access to teletherapy conclusion acknowledgements references appendix 1: questionnaire about the author(s) zahraa tar-mahomed department of speech pathology and audiology, faculty of humanities, school of human and community development, university of the witwatersrand, johannesburg, south africa kelly-ann kater department of speech pathology and audiology, faculty of humanities, school of human and community development, university of the witwatersrand, johannesburg, south africa citation tar-mahomed, z., & kater, k. (2022). the perspectives of speech–language pathologists: providing teletherapy to patients with speech, language and swallowing difficulties during a covid-19 context. south african journal of communication disorders, 69(2), a902. https://doi.org/10.4102/sajcd.v69i2.902 original research the perspectives of speech–language pathologists: providing teletherapy to patients with speech, language and swallowing difficulties during a covid-19 context zahraa tar-mahomed, kelly-ann kater received: 30 jan. 2022; accepted: 22 june 2022; published: 11 aug. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the coronavirus disease 2019 (covid-19) pandemic has had a huge impact on every facet of life. this directly included the delivery of health care from allied health professionals such as speech–language pathologists (slps) in south africa. research has shown that there is limited research done locally on the impact of covid-19 relating to stroke care. consequently, this results in a lack of research on the provision of speech, language and swallowing intervention using teletherapy after a stroke from an slp point of view. objectives: the aim of this study was to explore the experiences of slps with regard to their use of teletherapy in a covid-19 context when providing speech, language and swallowing intervention for patients after a stroke. methods: this study made use of a qualitative approach. an electronic questionnaire was sent to slps inviting them to participate in the study. purposive sampling was used to recruit participants and thematic content analysis was used to analyse the open-ended qualitative questions. results: the findings show that slps experienced a variety of facilitators and barriers to using teletherapy. additionally, issues of access differ across the private and public sector slps for both the clients and the slps. conclusion: the current study provided research in the field of teletherapy, which is relatively new in the south african context. the study, whilst small in scale, provided some insight into the changes experienced from the shift to teletherapy. keywords: teletherapy; stroke; communication disorders; swallowing disorders; speech therapy; speech–language pathologist (slp); stroke intervention. introduction speech–language pathologists (slps) play an integral role in the screening, assessment, management and rehabilitation of stroke survivors who present with dysphagia, communication and/or cognitive-linguistic impairments. early diagnosis and referral to an slp is critical, as is intensive intervention as soon as the patient is able to participate. this helps to ensure better patient outcomes (dilworth, 2008). with the current coronavirus disease 2019 (covid-19) pandemic and the shift to teletherapy being relatively new in the south african context, it is important to understand the various barriers and facilitators to health care that may affect the service delivery of slps. south africa had its first covid-19 case on 06 march 2020, and on 27 march 2020, the government instituted a nationwide level 5 lockdown. restrictions on movement during the level 5 lockdown specifically required individuals to remain in their place of residence, with the exceptions of those performing an essential service, obtaining essential goods or services, collecting a social grant or pension or seeking emergency, life-saving or chronic medical attention (siedner et al., 2020). as hospitals struggled with an increase in caseloads, many health care professionals took on additional roles and outpatient services were either suspended or delivered via teletherapy (adams, seedat, coutts, & kater, 2021). based on the research done on telerehabilitation, it was found that it has the ability to change the delivery of health care beyond stroke to other neurological conditions (tenforde et al., 2020). this may be different in the south african context, where factors such as socio-economic status, culture, education and so on need to be considered. research shows that there are various barriers to the implementation of telerehabilitation in the public sector and telerehabilitation in general in south africa (mars, 2011). this is because telerehabilitation requires information and communication technologies, their associated infrastructure and electricity. in the context of south africa, technology problems such as unreliable electricity supply and low bandwidth are barriers to the successful implementation of telemedicine (cilliers & flowerday, 2014). telemedicine in africa is approximately 10 years behind the developed world (mars, 2011). research suggests that the service delivery of allied health care to rural or remote communities displays a huge problem in many countries (lincoln, hines, fairweather, ramsden, & martinovich, 2014). in a developing country like south africa, this is even more prevalent (maphumulo & bhengu, 2019). telerehabilitation may overcome patient anxieties and is seen as being more cost effective and safe (eron, 2010). telerehabilitation avoids the use of personal protective equipment (ppe), reduces the risk for the stroke team, allows a reasonable stroke evaluation and avoids unnecessary interfacility transfers (markus & brainin, 2020). the role of the slp in providing therapy for stroke patients is well known in terms of face-to-face intervention; however, the lines become blurred when it comes to managing the consequences of stroke using teletherapy in a context like south africa during covid-19. there is research that has been done on stroke care using telerehabilitation that is not specific to the covid-19 and the south african context but which can be applied. a study done by tchero, tabue-teguo, lannuzel and rusch (2018) illustrates that telerehabilitation can be a suitable alternative to usual rehabilitation care in poststroke patients, especially in remote or underserved areas. at the beginning of the covid-19 pandemic, the south african government decreed all health workers (which include rehabilitation services) part of essential services (south african speech–language and hearing association [saslha], 2020). the south african speech–language and hearing association consequently stated that the profession of speech–language pathology is an essential service with emphasis on the fact that communicating and eating are basic human rights. this has led to an increase in terms of the use of teletherapy in south africa since covid-19 and was found to have huge benefits to many patients with communication, hearing and swallowing disabilities (adams et al., 2021; saslha, 2020). the aim of stroke rehabilitation is to reduce the disabilities and enable the patient to return to the community. however, with the implementation of the lockdown restrictions and the subsequent cessation of face-to-face therapeutic interventions, south african slps had to find ways to maintain essential services. the impairments associated with a stroke exhibit a wide diversity of clinical signs and symptoms. disability, which is multifactorial in its determination, varies according to the degree of neurological recovery, the site of the lesion, the patient’s premorbid status and the environmental support systems (teasell & hussein, 2016). in addition to the physical impairments caused by stroke, many individuals may experience changes in their cognitive, communication and swallowing abilities (dragga, 2015). dysphagia and communication impairment are common consequences of stroke. stroke survivors with either or both of these impairments are likely to have poorer long-term outcomes than those who do not have them (dilworth, 2008). speech–language pathologists are trained to evaluate and treat disorders such as communication disorders, swallowing difficulties (dysphagia) and cognitive disorders that are a consequence of stroke. they are an integral part of the rehabilitation team (dragga, 2015). they also play a role in counselling both patients and their family members. additionally, they play an important role as part of a multidisciplinary team and may need to consult with other professionals to improve patient outcomes (desrosiers et al., 2002). the communication deficits associated with stroke are diverse; they can be described as affecting one or more of these areas: language, motor speech, swallowing and/or cognitive communication. an assessment is conducted to identify how these areas are affected post stroke. this is achieved by gaining a full picture of the patients’ life before the injury through a case history. a thorough assessment is then conducted and a therapy programme is devised for the patient (dilworth, 2008). communication disorders in adults can have a significant effect on their quality of life and that of their families. speech–language pathologists face several challenges in providing assessment and treatment services to such people. challenges include facilitating equitable access to services and providing appropriate management within a changing social and economic context (theodoros, 2008). the aim of stroke rehabilitation is to reduce the disabilities and enable the patient to return to the community. this is achieved by joint efforts of physicians, physiotherapists, occupational therapists, slps, nurses, social workers and psychologists (nair & taly, 2002). rehabilitation of a person who had a stroke begins as soon as any impairment is perceived and comprises traditional exercise programmes as well as neuropsychological approaches with the primary aim of restoring patient mobility. it also deals with issues related to dysphagia, which is where the slp comes in (nair & taly, 2002). understanding the impact of covid-19 on slps has a three-fold purpose: to re-evaluate service provision, to reassess service delivery platforms and to identify the need for support to slps during a time of crisis. given the uncertainty around the development, acceptance and roll-out of a vaccine for covid-19, the country as a whole needed to ensure that the impact on future health service provision was minimised. therefore, south africa needed to find ways to create surge capacity to treat covid-19 patients whilst maintaining essential services (adams et al., 2021). it is well known that south africa’s health care provision in private and public is rife with inequalities, but in some ways, covid-19 may have levelled the playing fields regarding resource allocation of health care services because of the above (labuschaigne, 2020). despite the increase in use of teletherapy in south africa since covid-19, there are certain disadvantages and advantages that accompany this new practice (mars, 2011). this study aimed to look at the shift from face-to-face therapy to teletherapy and the various concerns that come with it for slps treating speech, language or swallowing disorders after a stroke. it was important to conduct this research in the south african context as it allowed one to explore the barriers and facilitators to teletherapy from the perspective of the slps, especially as south africa is such a diverse nation and there are other factors that come into play, such as cultural and language differences that may impact the experiences of the slps in using teletherapy (adams et al., 2021). method the aims of the study were to describe the facilitators and barriers of providing speech, language and swallowing intervention via teletherapy, as well as to describe the access of south african slps in providing teletherapy for a person who had a stroke. a qualitative design was used. the researcher aimed to have a sample size of 20–30 participants (peytchev, 2013). selecting a larger sample size would have provided a better representation of the population targeted in the study (peytchev, 2013). however, it proved difficult to obtain an adequate number of responses, as it could not be guaranteed that every individual invited to participate in the study would respond. because of the current circumstances of the covid-19 pandemic, where aspects such as survey fatigue become prominent, only 12 participants were obtained. the demographics of the participants are illustrated in figure 1 and figure 2. figure 1: number of participants per province. figure 2: participants’ years of experience. despite the questionnaire being circulated to slps in all provinces, only slps from gauteng, the western cape, kwazulu-natal and the eastern cape participated in this study. this could be because the western cape, gauteng, kwazulu-natal and the eastern cape have considerably higher practitioner per 10 000 population ratios than the north west and northern cape (pillay, tiwari, kathard, & chikte, 2020). furthermore, 75% of these participants practise in the private sector, whereas only 25% practise in the public sector. this links to previous research where it was found that nationally, only 22% of slps are employed in the public sector (pillay et al., 2020). data collection occurred by means of a self-administered questionnaire (appendix 1) which was circulated via google forms. the questions on the self-administered questionnaire aligned with the overall research question, as well as the objectives of the study. the questionnaire was developed by the researcher and was made up of 22 questions, which were a combination of closed-ended and open-ended questions. a pilot study was conducted whereby the length of the questionnaire and appropriateness of the questions in relation to the aims were determined. the questionnaire began with demographic questions and later probed the advantages and disadvantages in terms of the provision of slp services with regard to stroke intervention using teletherapy. once data were collected and responses were transcribed, the data were then analysed using thematic content analysis (clarke, braun, & hayfield, 2015). ethical considerations following ethical approval from the institutional review at a large gauteng public university (reference number: sta_2020_32), participants were recruited via purposive sampling. all participants had to be registered with the health professionals council of south africa (hpcsa) and working with stroke patients. participants were contacted and invited to participate in the study through electronic mail and links on social media as well as via sashla in order to reach as many slps as possible. speech–language pathologists from both the public and private sector were invited to participate in the study. results and discussion the aim of this study was to provide a description of the experience of slps who provided teletherapy to stroke survivors in a covid-19 context. findings from this study suggest that slps perceived the delivery of teletherapy to be feasible and worthwhile, despite facing some challenges with technology and connectivity. facilitators and advantages of providing speech, language and swallowing intervention via teletherapy participants mentioned that the following were facilitators and advantages to providing teletherapy: easier access to patients given the lockdown levels, a decreased risk of exposure to covid-19 and reduced financial strain in terms of travel and hospital costs on the patient and family. the limited risk of exposure for slps was highlighted as a key advantage to the introduction of teletherapy, as sessions were being held remotely. in addition, the use of teletherapy reduced the need for ppe, thus saving on costs for the patient and family as well as the slp: ‘less risk to patient in terms of potentially contracting infection such as [covid-19].’ (participant 4) improved family involvement in the rehabilitation process was noted, and research further highlights that teletherapy allows for fewer constraints on time, as sessions can be planned around the household schedule, and limits the time taken to travel, thus enabling more members of the family to participate. furthermore, it allows the therapist to see the family in their living space, which is their most natural environment (burgoyne & cohn, 2020). this was seen by participants as family members were forced to take more responsibility and participate as facilitators in the therapeutic environment: ‘very positive! all have participated, asked questions, reviewed sessionals and did extra. i’m so happy with how the caregivers are helping.’ (participant 1) ‘very involved and assist greatly. it has made the integration of caregivers into therapy much easier. it has been very very useful and beneficial.’ (participant 3) barriers and disadvantages of providing speech, language, swallowing intervention via teletherapy in the context of south africa, technology problems such as unreliable electricity supply and low bandwidth were identified as barriers to the successful implementation of telemedicine (cilliers & flowerday, 2014). this is seen clearly in the experiences of the slps, where load-shedding and connection difficulties were seen as barriers to service delivery. research suggests that high internet speed affects the quality of the consultation and can positively influence patients’ acceptance of and satisfaction with teletherapy (almathami, win, & vlahu-gjorgievska, 2020). it is known that contextual relevance is important in health care, especially when it comes to establishing infrastructure and rolling out technology to promote health services. in a context like south africa, where social determinants of health have contributed both to the inequitable distribution of health resources and access and to failure in redressing the injustices of the past, careful consideration must be taken to ensure that these service delivery models are both feasible and sustainable (govender & mars, 2018). based on the participants’ responses below on the disadvantages, it is seen that teletherapy might not always be feasible in the context of south africa where there are financial constraints, which can be further exacerbated by the need for data, technological devices and abilities for teletherapy: ‘cost of data, patients are already struggling to pay for bare necessities. lack of access to technology.’ (participant 7) furthermore, the slps felt like therapy was less personal and like there was a lack of rapport-building, which is important to consider as an slp as clinician–client relationships may influence slp treatment success (ebert, 2017). these were considered disadvantages for the slps, as seen below: ‘there is a restriction in the naturalness of the interaction and somehow you do not connect as easily with the individual.’ (participant 4) research shows that it is difficult for both clients and therapists to enter a therapy mindset when using teletherapy at home, as there is a sequence that typically precedes and follows face-to-face therapy that does not take place with teletherapy for clients (burgoyne & cohn, 2020). this allows for distractions in the environment that were experienced by the slps in this study, as seen by participant 4: ‘…noises and disturbances from people at home where my computer is’. positive intervention for language-based disorders such as aphasia and cognitive-linguistic disorders was able to be conducted via teletherapy. three factors were identified as important for their management: (1) family involvement, (2) good planning and (3) adaptation to resources, as seen below: ‘require very good planning so that patient can have the right resources – use what they have at home.’ (participant 2) ‘much the same as face to face – just at times adaptations to therapy materials need to be made.’ (participant 6) the similarities between signs of aspiration as well as the symptomatology of covid-19 highlighted the need for dysphagia service provision from admission until discharge and rehabilitation (saslha, 2020). thus, making the provision of dysphagia services is vital; however, this seems to have been greatly affected because of the shift to teletherapy, as most of the slps were unable to do this via teletherapy. participant 10 noted, ‘i am not doing any dysphagia treatment via teletherapy’. access to teletherapy in order to provide and receive teletherapy, one needs to have access to both devices and data. when looking at the client’s ability to access teletherapy services and the slp’s ability to provide teletherapy services, one can expect major discrepancies given the south african context. a stark division was noted between the public and private sectors, which places emphasis on the country’s social divide. however, this must be interpreted with caution, as there were only three slp participants who worked in the public sector. literature suggests that challenges experienced in the public sector are well documented and include poorly maintained facilities and reduced access to resources (young, 2016). this directly links to the experience of the participants working in the public sector, as they have poor access to resources such as devices and data, as seen below: ‘i have to use my own money to acquire data and are not reimbursed by the government.’ (participant 11) ‘very limited resources available in the government sector. so, i do not have access to devices.’ (participant 12) private health care is very different to public health care in south africa in that it is at an advantage in terms of better facilities and availability of adequate resources (young, 2016). this again directly links to the experiences of the slps working in the private sector, as they have better access to resources such as access to devices and data, as seen below: ‘access to data is not a concern for me.’ (participant 4) ‘i have a work laptop and can access appropriate platforms for telehealth. at work, there is great internet connection.’ (participant 8) similar trends were noted with regard to the patients being seen for teletherapy. participants reported that patients had poor access to devices across both private and public sectors: ‘i’ve done therapy over a whatsapp voice call and even through a neighbour’s phone.’ (participant 1) ‘the community i service are very poor and cannot afford to acquire devices or data to do online therapy.’ (participant 12) in terms of access to data, it was found that clients from the public sector had limited access whilst the majority of those in the private sector had access. this is backed up by the responses where a participant working in the private sector stated that ‘[c]lients have wi-fi which help in terms of having good connection for the duration of the session’ (participant 8), in contrast to a participant working in the public sector who stated that ‘[l]ow income equals no money to buy data. it is a challenge’ (participant 12). factors such as socio-economic status, culture, education and income, as well as access to information and communication technologies, their associated infrastructure and a stable electricity supply need to be taken into account. the technology gap between the public and private sectors is a main factor that impacted the service provision of many slps. in addition, issues such as unreliable electricity supply as well as cost of data and access to wi-fi are identified as barriers to the successful implementation of teletherapy (cilliers & flowerday, 2014). research suggests that high internet speed affects the quality of the consultation and can positively influence patients’ acceptance of and satisfaction with teletherapy (almathami et al., 2020). geographic location is known to cause inconsistencies in accessing therapeutic services, as it has implications in terms of time and money on the patient. the implementation of teletherapy has shown to eliminate the need to travel long distances, and treatment can be instantaneous. additionally, families responded positively when asked about their willingness to participate in future telehealth visits. the treatment of apraxia and dysarthria were identified to be dependent on severity of the disorder, particularly in the private sector: ‘the approach mainly stays the same depending on the severity of the apraxia or dysarthria. the patients i see do well with visual and phonemic cueing. surprisingly, this is easier over telehealth.’ (participant 8) the same treatment was more challenging in the public sector because of teletherapy being done telephonically rather than via video conferencing platforms. participant 12 stated, ‘this is challenging as the patient cannot see your mouth over the telephone when trying to model the strategies, techniques, etc.’ this links back to the stark contrast seen in the public and private sectors in south africa in terms of access to resources (young, 2016). from the above responses, it can be seen that the shift to teletherapy has had to become the new normal for practicing slps in south africa because of covid-19; however, it is met with great challenges that need to be addressed in order to ensure adequate access and equity of service provision. conclusion the study provided general insights into the transition from face-to-face therapy to teletherapy and the experiences of slps in this regard for stroke care. it further highlighted how practices in speech–language pathology have changed because of the covid-19 pandemic. furthermore, results from this study can inform practices with regard to management of stroke-related speech, language and swallowing difficulties using teletherapy in south africa and thus develop guidelines on this new practice. despite the small sample size, results of this study provide important insights into slps’ experiences with regard to the use of teletherapy for rehabilitation post stroke. speech–language pathologists who engaged in teletherapy reported on a variety of advantages and facilitators as well as disadvantages and barriers to service provision. speech–language pathologists in the private sector had different experiences in terms of access to data and devices compared to slps in the public sector, and the overall slp experiences differed. essentially, it is seen that teletherapy, whilst challenging at times, can provide surprising benefits such as improved family involvement. we do not yet understand how the covid-19 pandemic will impact our lives in the long term; however, given the importance of providing therapy services to patients after a stroke, it is important to establish best practices to ensure that clients’ needs are being met in both the private and public sectors. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions z.t.-m. conceptualised the research project and carried out the research. both z.t.-m. and k.k. discussed the results and contributed to the final manuscript. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study are available from the corresponding author, k.k., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references adams, s.n., seedat, j., coutts, k., & kater, k.a. 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(2008). telerehabilitation for service delivery in speech-language pathology. journal of telemedicine and telecare, 14(5), 221–224. https://doi.org/10.1258/jtt.2007.007044 young, m., private vs. public healthcare in south africa. (2016). honors theses. 2741. https://scholarworks.wmich.edu/honors_theses/2741 appendix 1: questionnaire what province are you currently practicing in? gauteng kwazulu-natal western cape limpopo eastern cape mpumalanga north west free state northern cape how many years of experience do you have in the field of speech–language pathology? 1–5 years 5–10 years more than 10 years which sector are you currently working in? public private approximately how many stroke patients do you see in a 6-month period? are you currently making use of or have you previously made use of teletherapy in providing services for speech, language and swallowing difficulties for patients after a stroke? what do you think are some of the advantages of teletherapy? what do you think are some of the disadvantages of teletherapy? what are your experiences using teletherapy in terms of patient participation? what are your experiences with patient outcomes using teletherapy in terms of teletherapy vs. face-to-face? what are your experiences with your clients in terms of access to devices and being able to use these devices? what are your personal experiences in terms of access to devices and being able to use these devices? what are your experiences with your clients in terms of access to data? what are your personal experiences in terms of access to data? what are your experiences with caregivers and their involvement in the teletherapy process? what are your experiences with managing dysphagia, and how has this changed now that you have changed to teletherapy? what are your experiences with managing aphasia, and how has this changed now that you have changed to teletherapy? what are your experiences with managing motor speech disorders (dysarthria and apraxia), and how has this changed now that you have changed to teletherapy? what are your experiences with managing a cognitive-linguistic deficit, and how has this changed now that you have changed to teletherapy? what are your experiences in terms of the multidisciplinary team and being able to include aspects of co-treatment, now that you are making use of teletherapy? what are your experiences with counselling the patient and their family post stroke using teletherapy? what were your main successes with teletherapy? what were your main challenges with teletherapy? 73 the impact of a digital speaker on a teacher's interaction with a child with limited functional speech elsa popich and erna alant centre for augmentative and alternative communication, department qf communication pathology, university of pretoria abstract this paper describes the impact of the implementation of a digital speaker and teacher training on the quality of a teacher's interaction with an aac user. the data was obtained by recording and analysing classroom story time interactions. the types of utterances directed at each child in the class, the types of questions used as well as the messages recorded onto the digital speaker were determined for each research phase. there were four major phases in the research, namely, a pre-implementation phase, a post-implementation phase, a post-training phase and a post-withdrawal phase. the results indi.cated that the implementation of the digital speaker and the training of the teacher resulted in certain changes in the way that the teacher interacted with the aac user. utterance types such as answering and imitating were used more frequently after the implementation of the device. there was also a much greater variety in the teacher's use of questions as well as in the messages that were recorded onto the digital speaker after the five training sessions were completed. this study highlighted the importance offormal training for the communication partners of the aac user. one of the most important communication partners of the school-aged aac user is the classroom teacher. opsomming hierdie studie beoog om die impak van die implementering van 'n digitale spreker en die opleiding van die onderwyser op die kwaliteit van die onderwyser se interaksie met die aak-gebruiker te bepaal. die data is verkry deur die opneem en analisering van klaskamer-storietyd-interaksies. die tipes interaksies wat aan elke kind in die klas gerig is, sowel as die tipes vrae wat gebruik is asook die boodskappe wat opgeneem is op die digitale spreker gedurende elke navorsingsfase is bepaal. daar was vier fases in die navorsing, naamlik, 'n voor-implementeringsfase, 'n na-implementeringsfase, 'n naopleidingsfase asook 'n na-ontrekkingsfase. die resultate het daarop gedui dat die implementering van die digitale spreker en die opleiding van die onderwyser gelei het tot sekere veranderinge in die onderwyser se interaksies met die aak-gebruiker. in~efaksie-tipes soos antwoorde en nabootsing het meer dikwels voorgekom na die implementering van die digitale spreker. dimr was ook 'n groter verskeidenheid boodskappe op die digitale spreker na die vyf opleidingsessies voltooi is. hierdie navorsing beklemtoon die belang van formele opleiding vir al die mense wat met die aak-gebruiker kommunikeer. een van die mees belangrike mense ,wat met die skoolgaande aak-gebruiker in interaksie tree, is die onderwyser. , keywords: classroom i~teraction, device implementation, teacher training, use of questions literature has indicated:that}eachers adjust to children with limited speech by changing their interaction patterns (light, 1988; cicognani & zani, 1992). teachers take more turns and initiate conversations more often. they use more direct questions, attention directing utterances and requests, and less answers, imitations, praise and higherlevel questions with the children who have limited or no functional speech (light, 1988; cicognani & zani, 1992). owing to the exclusion from interaction and the teacher's use of certain types of interactions and questions, the child who has limited or no functional speech (lnfs) can adopt an exaggerated passivity and develop an attitude oflearned helplessness (basil, 1992). aprevious study was done (popich & ai ant, 1997) which examined the verbal interactions which occurred between a teacher and two groups of children (children with lnfs as well as children who were speaking). descriptive data, generated by analysing ten lessons, suggested that the teacher's interaction with the children with limited or no functional speech (lnfs) differed, in terms of quantity and quality. the teacher directed approximately 10% less interaction at each of these (children with lnfs) three children, when compared with the number of interactions that the teacher directed at each of the five speaking children. however, as can be expected, she also did not spend an equal amount of time interacting with each of the children with lnfs. her interaction with these children was dominated by questions, attention directing and requesting. interaction types, such as answering and imitating did not occur at ali in the teacher's interaction with the children with lnfs. the children with lnfs therefore had different learning experiences in the classroom to the speaking children. these results formed the basis for the cilrrent research study as the researchers wanted to determine whether these patterns in the teacher's interaction with the individuals with limited or no functional speech wou~d die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 74 be influenced by the implementation of a voice output device. there is little doubt as to the positive effects of the implementation of aac systems on children with lnfs. children who use aac in the classroom have demonstrated better communication competence, initiate more frequently, use more complex sentences and demonstrate more control in interactions (smith, 1994). there are also a greater number of aac users who now participate in education and recreation and the number of aac users being employed is also increasing (beukelman, 1991). aac gives the user access to communication and interaction and increases participation and learning. a greater ability to interact results in improved social abilities, an increase in social acceptance by the community and an improvement in the quality of life. increases in participation and learning result in progress at school and a higher level of education for the individual who has limited or no functional speech. however, in a classroom situation, where the goal is not only to interact or to learn language, but also to use language to acquire knowledge and skills, one is no longer only concerned with how the implementation of an aac system such as a voice output device (voca) will affect the child's interaction, but also with how the device will affect the child's primary interaction partner in the school setting, namely the teacher. if a voca is implemented in a classroom the teacher takes on many new roles and responsibilities. the teacher will need to adapt the curriculum and write objectives for the aac user. materials such as device overlays will have to be made and the teacher will have to record messages onto the device., furthermore the tea,cher will be responsible for assessing progress, providing ongoing skill development, identifying vocabulary and communication needs as well as many other administrative tasks (locke & mirenda, .1992). these additional roles and re" '. sponsibilities may affecttheteacher's attitude towardsaac . implementation as well as the aac user. the teacher is a significant interaction partner and will greatly influence the success or failure of the aac device as a communication tool in the classroom ( dalton & 'bedrosian, 1989). the teacher may, however, not be fully equipped for many ofthe new responsibilities resulting from aac device implementation and training is critical in order to ensure success (locke & mirenda, 1992; baker, 1993). the majority of teachers working with children who use aac devices desire further inservice training and workshops (locke & mirenda, 1992). teachers primarily feel the need to increase their knowledge on aac techniques and aac devices but also to improve their skill in management issues such as identifying appropriate vocabulary. research (soto, 1997) has found a direct correlation between teachers' perceptions oftheir own levels of skill with their attitudes towards aac implementation. furthermore teachers' perceptions of their own skills had a direct influence on their impression of the aac users' abilities to improve their communication effectiveness. . the effects of training on the teachers' ability to adapt to the presence of an aac user in the class, will depend greatly on the content ofthe inservice training. if the training concentrated on the development of skills, such as the understanding of technical aspects of the aac device or on the necessary preparations (for example making an overlay) for the use of the aac device then one would expect changes to occur in these areas. on the other hand iftrainelsa popich anll·erna alant ing emphasised the development of strategies, such as the teacher's style of interaction and use of questions, then changes in this area would be expected. for the benefit of the aac user, however, it is necessary to pay attention to the development ofthe teacher'soperationiil skills and the development of strategies in order to ensure the'most effective implementation of aac (bl~ckstbne, 1986). it would be important to determine whether the!provision oftraining, to the teacher, would result in an increased utilisation of the aac device in the classroom as well as whether it would result in changes in the teacher's interactions with the aac user. ' previous studies have found training in the use ofquestions to result in significant positive changes in the ,teacher's questioning techniques (greenberg & woodside, 1994). questioning is one of the most important and most frequently used teaching techniques. teachers use questions to stimulate thought, to assess progress, to motivate children to pay attention, to maintain control, to provide repetition and emphasise key issues (camp, 1993). the types of questions teachers use have a signifi~ant influence on the amount of initiations made by the children, the types of responses given, the amount ofle,arnirtg a~d the level of thought obtained (cicognani . &, zani, 1992~)"owell & lawton, 1992; greenberg &woods}de, 19!,)4). iilsufficient research has, ho,,:,ever, been done ~ri' the effects of training on teachers' use of questions wi'th ¥c users,'changes in general interaction styles and the e.ffe~t of training on t,he utilisation of aac devices in,classrooms. method aim this study aims to describe the impact of aac device implementation and teacher training, in a classroom situation, on the teacher's interactions with the aac'~ser. the types of utterances that were directed at the speakingchil~' dren were compared to the utterances that were directed at the children with lnfs and the aac user. furthermore" the use of questions and the selection of messages on the aac device, by the teacher, during each of the four rese1rch·· phases were determined. the results of each of the rese~rch ': . phases were compared in order to ascertain the effe~t of ' ,'. the implementation of the voca, the teacher training ~es" sions as well as the period of withdrawal. research design although there were nine children in the class of whom three had limited or no functional speech, only one alac device was implemented. the focus of the study was on the teacher's interaction with the individual who was using the aac device. a single case quasi-experimental design with multiple measurements (aba with withdrawal) was used as it is ideally suited to studying the effect of individual variables on communicative behaviour (in this case classroom interaction) and provides empirical data for clinical interventions. // . there were four major phases in the research, namely a1, b1, b2 and a2. during each research 'phase six measurements were made of the teacher interacting with the whole class and six measurements were made of the teacher interacting with the aac candidate on an individual basis, during a period of two weeks. it was necessary to use six the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the impact of a digital speaker on a teacher's interaction with a child with limited functional speech 75 measurements to ensure that consistent baseline data was obtained. group as well as individual sessions were used in order to determine whether the teacher's interactional style was influenced by the situation. ir..wlei\ientathin tit,\ii\'i;'\(;si· ...... '\!lj:'\.... \\tiiiiji{.\\\,\l ('fthe v(icc\ witi[tiie"e.\ciier fifuintr\ct six six six six six six six six giu>uf' ini)jvjl)ual group indivi])ual groui' in[)[viijual group !nr)jvlllli,\i_ 1 ll i rlr twelve twelve twelve twelve measurements measurements rvleasurerdents measurement" 1 1 1 1 "re pelst p(ist i'ost i ii\'ii'lementat((in 'i\ii'lei\ientati( in t1{ainin(; ivithill<aw,il i i'uase phase i'ii,.\se phase ai iii i\~ a2 figure l:'the research phases during the measurements ofthe first phase the child was not using the digital speaker in the class (pre-implementation phase, a1). after this phase was completed the digital speaker was implemented in the classroom. prior to this the aac user had only used the digital speaker during speech therapy sessions. although the aac user was trained to operate the device the teacher had not received any training yet (post-implementation phase or, alternatively, pre-training phase, b1). after this phase five training sessions, of approximately one hour each, were held on five consecutive days. after the training was completed more measurements were made (post-training phase, b2). a withdrawal phase of eight weeks followed (post-withdrawal phase, a2). a pilot study was conducted in order to determine the effectiveness of the' recording and analy~is procedures. // subjects . description of the teacher i the teacher was a fifty-one (year old,female wi th approximately twenty years teachirtg experience, seventeen of which had been in teaching ~hildren with disabilities in the same school where the research was conducted. her professional preparation included a three year teaching diploma. description of the aac user the aac user was a 4,8 year old male. he had no siblings and his home lc!-nguage was afrikaans. his primary disability was described as a developmental delay with ataxia as an additional complication. before the digital speaker was implemented he was exposed to pcs (picture communication symbols) during therapy and could use it to express a few basic needs. he did not use it in the classroom, however, but depended on vocalisations and gestures to communicate. his expressive vocabulary was less than 15 words and consisted of the words mother, grandmother as well as his teacher's name. he voluntarily used vocalisations to express desires, gain attention, maintain contact during an interaction, express denial and protestations, to obtain an object as well as to comment on an event. he visually attended to others, tracked moving objects and maintained eye-contact during interactions in all environments and situations. he also sometimes turned his head away as a signal that he did not wish to engage in interaction. he often used intentional gestures to manipulate the environment around him and he would respond to the use of gestures by others. he primarily used gestures to gain attention, direct attention to a specific object or event and to communicate a basic need. the use of recognisable facial expressions also occurred spontaneously and appropriately in all situations. he often used facial expressions to indicate a response to questions and statements. he spontaneously initiated interactions with peers and certain, familiar adults but did not exhibit appropriate turn-taking behaviours. furthermore he was not able to repair conversational breakdowns or provide revisions of unclear messages. according to the word-findings vocabulary scale -revised, (renfrew, 1972) he obtained a score of zero for his expressive vocabulary as he could not name any ofthe items in the test. the speech therapist and the'teacher agreed that this was a reliable reflection of his expressive language abilities. according to the peabody picture vocabulary test -revised, (dunn & dunn, 1981) his score placed him in the lowest possible category. the speech therapist, however, did not consider the test to be an accurate reflection of his receptive vocabulary as he did not co-operate during the evaluation. however, an in depth analysis (by the researcher) of his functioning within the classroom context (in terms of the vocabulary he could understand as well as the types of commands that he responded correctly to) placed him on a level more or less equivalent to that of a three year old child. a large discrepancy, therefore, existed between his expressive language abilities and his receptive language abilities. hearing tests revealed normal, bilateral hearing. description of the whole class this study was conducted at a school for children with special needs. the school caters for afrikaans as well as english pupils and has three levels, namely a beginner's phase, a junior phase as well as a senior phase. for the purpose of this study each of the children in the class was described by a speech language pathologist (table 1). these descriptions were important as they formed the basis for the differentiation between the children who had limited or no functional speech and the children who were speaking. the information was obtained by means of observations and formal testing as well as from the school records. as shown in table 1, there were three children who had less than fifteen words in their verbal expressive vocabulary (children with lnfs). anaac device was implemented for one of these three children (child a). procedures teacher training procedures training took place at the school where the research was completed. prior to the training sessions consent was obtained from the school principal for the participation of the die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 76 teacher, by means of a formal letter. the letter explained the teacher's participation in the research project and the importance of the training sessions for the benefit of the aac user. an informal, friendly atmosphere was created during the training with the use of flowers, refreshments and an informal conversational style (knowles, 1983). the training involved the teacher as well as the aac user. the other children in the class were not involved in the training sessions so that the trainer could focus on developing the teacher's skill in interacting with the aac user. five training sessions of one hour each were held on five consecutive days from llhoo 12hoo. the time of day was chosen to coincide with the break time so that the teacher was without responsibilities and could give her undivided attention to the training. the sessions took place in a separate room that was familiar to the teacher as well as the aac user. training was done on a one-to-one basis to accommodate the teacher as it was felt that she would be more comfortable with this arrangement. the training sessions included some theoretical discussions as well as some practical sessions where the teacher had to apply the theory in a real-life situation with the aac user. this was done to ensure that the teacher would be able to use her newly acquired skills in the classroom. content of training sessions a description of the content of the training sessions is given in table 2. from this table it is clear that the training' sessions concentrated on the development of operational as well as strategic skills. the focus was on the practical implementation in the classroom context. data collection procedures during each phase six recordings were made of the teacher interacting with the whole class and six recordings table 1: a summary of parameters for each child elsa popich and erna alant were made of the teacher interacting with the aac user on an individual basis. each of the recordings was approximately fifteen minutes in length and took place between nine and nine thirty in the morning. the curricular activity with which the class was busy during that time was "story time". this activity was chosen because it provided the researcher with the best opportunity for observing the teacher in interaction. the recordings took place on mondays, wednesdays and fridays. all the messages that were recorded onto the voca were selected by the teacher in order to suit the story. it was decided that the teacher should select the messages to be recorded onto the device so that any changes in the types of utterances recorded could be measured and discussed. the messages were recorded onto the digital speaker prior to the start of the sessions. during the second research phase (post-implementation phase, b1), the speech therapist recorded the messages onto the device. mter the training sessions were completed, however, the messages were recorded on to the device by the teacher. the group as well as individual recordings were done in the aac user's classroom. the group recordings were completed first, after which followed the individual recordings. the classroom assistant engaged the other children in activities such a; drawing in the work area in the west end of the classroom while the teacher and the aac user remained in the "story time" area in the east end of the room for the individual sessions. a video recording was made while an audio cassette recorder, which was attached to the teacher with a harness, was used to make an audio soundtrack. mter the recordings were completed they were transcribed and analysed by the researcher as well as by an independent transcriber. . material and equipment the stories "goldilocks and the three bears" (creative child press, 1990), "where is otto" (hill, 1992) and "otto parameters description i , child a b c d e f g h i i i chronological age i (jan 1996) 4,8 3,0 3,0 4,0 3,6 3,4 3,10 3,5 3,0 i i i home language mrikaans afrikaans mrikaans mrikaans mrikaans mrikaans afrikaans afrikaans mrikaa~s i primary disability developcerebral cerebral developcerebral . developcerebral cerebral mentally mental palsy palsy mental palsy mental palsy palsy impaired delay delay delay additional ataxia squint squint cleft lip none none epilepsy none none complications and palate primary means of aac (digital) full phrases full phrases vocalisingle word full gestures communication speaker) sentences sentences sations utterances sentences more than ./ verbal expressive less than more than 20-40 more than less than 20-40 more than less than vocabulary 15 words 50 words words 50 words 50 words 15 words words 50 words 15 words use of gestures for ,/ symbolic commuyes no no yes yes no no no yes nication ./ the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the impact of a digital speaker on a teacher's interaction with a child with limited functional speech 77 goes for a walk" (hill, 1992) as well as pictures from the stories were used during the training sessions. the researcher made use of overlay grids with 4 spaces for pictures while making overlays during the training sessions as well as during the classroom interactions. a list oftypes of interactions as well as a list of types of questions was used for training the teacher in the use of a variety of utterance types as well as for analysing the data that was obtained during the forty-eight classroom interactions. table 2: contents of individual training sessions (occurred between phase b1 and b2) day people aims theoretical discussions practical sessions equipment present used 1 teacher improve operational technical working of the the teacher and trainer grid trainer skills with regards to digital speaker went through the story story book the digital speaker needs and abilities of and selected relevant pictures and making overlays the individual aac user pictures for the grid and digital increase awareness of different types of then recorded messages different utterance speaker types interaction and adjusted the volume teach strategies for adapting to the individual child 2 teacher improve skill at using none a recording was made of story trainer different utterance the teacher telling the book aac user types aac user a story. story teach strategies for the recording was used to overlay selecting appropriate prompt a discussion on tape overlay items the use of different recorder utterance types and tape overlay items digital speaker 3 teacher improve skill at using the importance of the the teacher went through grid trainer a variety of questions use of questions in the the story and selected story book teach strategies for classroom relevant pictures for the pictures using questions for a different types of grid, recorded the mesdigital variety of reasons questions sages and adjusted the speaker volume the trainer only prompted 4 teacher improve skill at using none a recording was made of storybook trainer different utterance the teacher telling the story / / aac user types aac user a story, using overlay / teach strategies for the story overlay tape selecting appropriate the recording was played recorder overlay items back and the teacher's tape use of different question digital types and overlay items speaker was discussed 5 teacher im~rove~technical . none the teacher made a story grid trainer skills with regards to overlay without assiststorybook aac user the digital speaker ance pictures and the making of a recording was made of story overlays as well as the the teacher telling the overlay use of various types of aac user a story, using tape utterances and the story overlay recorder questions the recording was played tape teach strategies for back and the teacher's digital adapting the digital ' use of different utterance speaker speaker to the child as and question types was well as selecting discussed appropriate items for the number of items on the overlay the overlay, the length of the messages as well as how the aac user coped was discussed die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 78 twenty-five tdk d60 tapes, a phillips d628 cassette recorder, a panasonic nv-s20b video camera, forty-eight vhs video cassettes as well as an aiwa condenser lapel microphone were used to record the training sessions as well as the classroom interactions. a blackhawk digital speaker from adam lab was used as the voice output device for the aac user, during the training sessions as well as during the classroom interactions. data analysis procedures transcriptions the audio soundtrack was transcribed verbatim and the video screen display was used to clarify to whom each statement had been addressed. the external rater simultaneously made an independent transcription and analysis, and points of disagreement were reconsidered until 100% agreement was achieved. in order to ensure that the raw data was transcribed consist.ently correctly by both transcribers, certain transcription rules were followed (stuart, vanderhoof & beukelman, 1993). repetitions of words were included; vocalisations that were not actual words were represented and transcribed in a consistent form, e:g. mhmmm, uhhuh, huhuh, mmm, uh, ah, aw, whoop; numbers were typed as proper nouns; contractions were typed as such that the proper form was spelled out only when it was spoken that way, e.g., don't was typed as don't and do not was typed as do not; standard abbreviations were included, e.g., dr.lmrs.; during the transcription of a communication segment that was unintelligible and the entire segment was skipped even when a few intelligible words were available. a spell checker was used on all transcripts before proceeding with further analysis. analysis of categories after the audio recordings of the interactions had been transcribed verbatim the researcher determined the types of verbalisations that the teacher directed at each child. twelve types of verbalisations had been defined (adapted from a study by romski, sevcik, reumann & pate, 1989), and the teacher's verbalisations during each session were categorised accordingly. the teachers choice of utterances to be recorded on the digital speaker, for the aac user, for each story session, was also categorised according to the twelve types of verbalisations. the twelve types of verbalisations are as follows: 1. questioning: a sentence adapted by order of words, punctuation or intonation to elicit information (e.g. "is it a shirt? sharon? tell me ... "). 2. attention directing: to guide the child's thoughts to a specific topic (e.g. "look here"). 3. answering: a reply to a child's verbalisation, but not merely negating or affirming (e.g. ''yes you may"). 4. requesting: asking for an action, object or comment, . but not a question (e.g. "fetch me the cow"). 5. imitating (the child): to mimic the child's utterance, with or without expansion (e.g. "i want" "i want"). 6. naming: to designate an object or action (e.g. "it's a shirt"). 7. negating: to imply that what the child said or did was wrong (e.g. "no it's not a shirt, uh-uh"). 8. affirming: to imply that what the child said or did was elsa popich and erna alant right (e.g. "you are very clever"). 9. greeting: a salutation (e.g. "hello friends"). 10. self-repetition: to reproduce one's own verbalisations in more or less the same form (e.g. "whatis it? what is it?"). 11. informative: to state facts or opinions about a certain topic (e.g. "they run with these pants"). 12. uncodable: the utterance does not fall into one of the above communication function categories(e.g. "huh?" or an incomplete sentence). utterances categorised as questioning were analysed further according to bloom's taxonomy, (wilson, lanza & barton, 1988). the categories within bloom's taxonomy are as follows, namely: 1. levell knowledge: the simple recalling of information that was given earlier (e.g. "what happened in this picture?"). 2. level 2 understanding: the awareness of interpretation abilities. this includes explaining the meaning of a word as well as answering why questions (e.g. "what is this?"). 3. level 3 application: applying what is already known or previously learnt in a different context (e.g. "do you like porridge?"). 4. level 4 analysis: the ability to break information down, into its separate elements to determine the interrelatedness of the elements (e.g. "why were the bears cross with goldilocks?"). 5. level 5 synthesis: the integration of elements into a meaningful whole (e.g. ':what did goldilocks do in the house?"). 6. level 6 evaluation: requires a well motivated critical evaluation of or reflection on the material (e.g. "what should goldilocks have done when she saw that nobody was hornet'). statistical analysis a bar chart was used in order to display the utterance types that the teacher directed at the speaking children: in comparison with the utterance types that she directed lat the children with lnfs. a bar chart was also~ used to co~­ pare the types of questions that the teacher directed at the aac user during the different research phases. ewma charts were used to display changes in the teachers use lof answers 'and imitations during the four research phas~,s. an ewma chart for quality control detects a shift in tl'ie standard deviation of 0,50 within 12 observations and can, therefore, highlight where significant changes occurred. pie charts were used to display the types of messages that were recorded, by the teacher, onto the aac device. results and discussion types of interactions used figure 2 gives an overview of the types of utlerances' that the teacher directed at the children in the class. the figure indicates ~hich three utterance type's were directed most frequently at each of the individuals. in other words, of all the utterances directed at a rra~ticular child during the research (100%) the proportions of the three utterance types that were most frequently directed at the child are ,/ the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the impact of a digital speaker on a teacher's interaction with a child with limited functional speech 79 given in figure 2. the teacher's interactions with each of the children with lnfs (child a, child f and child i) is characterised by the frequent use of requesting (such as "show me") and attention directing (such as "look there"). although child a, the aac user, had access to a device during three of the four research phases the teacher's interactions with this child still contained a large proportion of requesting and attention directing. the teacher's interactions with the speaking children (child b, child d, child e and child h), however, is characterised by the frequent use of answering (such as "because ifhe doesn't put ajersey on he will get cold") and affirming (such as "yes, he is a naughty dog"). there is, therefore, a trend in the differences between the types of interactions that the teacher directs at these two groups (children with lnfs and speaking children) of children. although the teacher's interactions with the aac user (child a) resembles her interactions with the other children with lnfs the teacher also directs a large proportion of affirming utterances at the aac user. this is an utterance type that was frequently directed at the speaking children. the teacher's interactions with the aac user, therefore, resemble the interactions with the children with lnfs as well as the interactions with the speaking children. the teacher's interactions with the children with lnfs as well as with the speaking children did not change significantly during the four research phases. the results of this study correlate with previous research findings which found that the quality of interactions directed at speaking children differs from the quality of interactions directed at the children with lnfs (mirenda & donnellan, 1986). a previous study that was conducted by the authors indicated that the type of interactions used by the teacher is affected by the child's level of verbal output (popich & alant, 1997). research has also indicated that teachers use more direct questions, attention directing and requests as well as less answers, imitations and praise with children with lnfs (romski, sevcik, reumann & pate, 1989; cicognani & zani, 1992). although the teacher's interaction with the other children in'the class was consistent over the entire period of research, the teacher's interaction with theaac user (child / children with limited or nolfunctional speech 30 25 20.6 20.69 21.43 21.69 21.08 20 15 15.06 10 5 0 a f b d a) was not consistent over the entire period of research. in the teacher's interaction with theaac user, the use of some utterance types such as answering and imitating varied during the four research phases. the ewma chart was used to display patterns in the teacher's use of answering and imitating with the aac user in the group sessions and in the individual sessions. the ewma chart for quality control should detect a shift in the standard deviation of 0,50 within 12 observations. increases or decreases in the frequency of occurrence of a certain utterance type are therefore displayed. figure 3 displays patterns in the teacher's use of answering and imitating with the aac user. the x-axis represents the measurements over time (twenty-four individual sessions as well as twenty-four group sessions were analysed). measurements one to six occurred during phase one (pre-implementation phase), measurements seven to twelve occurred during phase two (post-implementation phase), measurements thirteen to eighteen occurred during phase three (post-training phase) and measurements nineteen to twenty-four occurred during phase four (post-withdrawal phase). they-axis represents the percentage of answers or the percentage of imitations that were used during each classroom interaction. in other words, of all the utterances that were directed at the aac user during a specific session (100% for each session) the proportion of answers or imitations that occurred during each session is presented in this figure. the percentages for each session can be compared with the percentages obtained during other sessions in order to determine trends. trends in the teacher's use of answering utterances with the aac user during the individual sessions can be seen in the graph. there is a dramatic increase in the use of answering from measurement thirteen. the five training sessions were held in between measurements twelve and thirteen. this means that the teacher used answering more frequently after the training sessions. a similar change in the use of answering can be seen in the teacher's interactions with the aac user during the group sessions. during the second half of the research, in the individual sessions as well as in the group sessions, the teacher used answering utterances more frespeaking children 25.61 e h o requesting d attention directing • affirming ~negating !il questioning • answering • informative figure 2:an overall comparison between the types of interactions directed at the children with limited or no functional speech ~nd the speaking children die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 80 quently. contrary to the change in the teacher's use of answering the use of imitating utterances already increased after the implementation of the aac device. there is an increase in the teacher's use of imitating utterances during individual sessions as well as group sessions from the seventh measurement. in other words, not only did the voice output device enable the aac user to interact, but it also resulted in an increase in utterances that were as a result of the aac user interacting (teacher imitating the aac user). types of questions used questioning is one of the most important and most frequently used teaching strategies. it is, however, important to look at the types of questions that are used as they could significantly influence the amount of initiations made by the children, the types of responses given, the amount oflearning and the level of thought obtained (cicognani & zani, phase 1 phase 2 oj 30 i: § 25 'e 20 cl 15 i: .;: " q) ~ 10 i fil i: 5 <i: , ;,!! b 0 0 elsa popich and erna alant 1992; fowell & lawton, 1992; greenberg & woodside, 1994). figure 4 displays the teacher's overall use of different types of questions for each research phase. there is no significant difference between the teacher's use of questions in the pre-implementation phase and the post-implementation phase. during both these research phases the teacher only used three types of questions, namely, knowledge, understanding and a small percentage of application questions. according to bloom's taxonomy these three types of questions are the lowest three cognitive levels of questioning. after the teacher received training, however, there was a noticeable change in the use of questions. during the posttraining phase and the post-withdrawal phase the teacher used questions on all six cognitive levels, with the majority of the questions on level 3 (application). although the teacher used all six types of questions in the post-training and post-withdrawal phases only a small percentage were on the higher cognitive levels (level 4, level 5 and level 6). phase 3 phase 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 measurements over time ---answering: individual sessions u answering: group sessions ---imitating: individual sessions 'imitating: group sessions i figure 3. the teacher's use of answering and imitating with th eaac user during individual and group sessions 70 .-----------------~~-------------------------------------------: ~ 60 ~~~----------------­ e.... 50 c: g 40 (5 30 g20 a: 10 o pre-implementation postimplementation post-training post-withd rawal / .-------------------------------------------------------------------~/ • level 1 questions: knowledge iii level 3 questions: application iii level 5 questions: synthesis iii level 2 questions: understan~ing • level 4 questions: analysis/·· jjij3 level 6 questions: evalu6tion· figure 4. the teacher's overall use of different types of questions with the aac user during each phase / the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) the impact of a digital speaker on a teacher's interaction with a child with limited functional speech 81 messages recorded onto the digital speaker during each of the research phases where the aac user was using the voca in the classroom (phases b1, b2 and a2) the teacher had to decide what messages to record on to the device. the messages that were recorded on to the device would determine the aac user's access to relevant material so that he could participate in classroom discussions. the presence of certain types of messages such as answering messages as well as the variety of message types can be seen as a means of determining the extent to which the device was being utilised in the classroom. figure 5, figure 6 and figure 7 display the types,of messages recorded onto the digital speaker during the postimplementation phase, the post-training phase and the post-withdrawal phase during group as well as individual sessions. during the post-implementation phase (figure 5) the teacher recorded a limited variety of messages (naming, informative and questioning) and the largest proportion was naming (79%). after the teacher received training, however, a larger variety of messages were recorded (figure 6) and the percentage of naming messages decreased to 2%. the largest proportion ofthe messages, during the post-training phase (figure 7), was answering (29%). after the period of withdrawal the answering messages decreased to 7% and the naming messages increase again to 13%. furthermore, a couple of previously unused message types (negating=2% and greeting=2%) also occurred. the increase in the number of different message types with each consecutive research phase indicates that the aac user had access to a greater variety of utterance types and could express himself better. furthermore, the increase in the number of different message types in the final two phases of research correlates with the increase in the teacher's use of a greater variety of question types. after the training sessions the teacher was, therefore, more aware of the number of different types of messages that could be recorded as well as the range of questions that could be used in order to facilitate the aacuser's language devel/ opment. ,/ conclusion i the quality of interaction it hat was directed at the speaking children was different to; the quality of interaction that was directed at the children with lnfs. the teacher's interaction with these childre~ was characterised by the frequent use of requesting and att~ntion directing while the interaction with the speaking children was characterised by the frequent use of answering and affirming. the implementation of the aac device (phase b1) resulted in an increase in the teacher's use of imitating and answering with the aac user. after the teacher had received training (phase b2) there was' afurther increase in the use of answering. these responses by the teacher, to the aac user's initiations can be seen as encouragement to tl:te aac user to participate. according to a study done by hart and risley (1995) children who receive input that is responsive and encouraging perform significantly better. the implementation of the digital speaker and the training of the teacher in the use of different utterance types resulted in the creation of a richer language environment for the aac user. although the implementation of the aac device resulted in an increase in the teacher's use of imitation and answerinformative 19%· questioning 2% figure 5: the types of messages recorded into the dig· ital speaker during the post. implementation phase requesting 20% answering 29% naming 2% attention directing 3% uncodable 12% figure 6: the types of messages recorded onto the digital speaker during the post· training phase. uncudablc 10% r\lienlinn dirccling h% dattention directing iiiianswering ii requesting dnaming ii negating dgreeting iiiilnformative iiuncodable dquestioning figure 7: the types of messages recorded onto the digital speaker during the post·withdrawal phase die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 82 ing with the aac user the teacher's interaction with the other children in the class remained the same throughout the four research phases. as mentioned previously the aac user was not the only child in the class with lnfs. the fact that the teacher's interaction with the other two children with lnfs did not change as a result of the training that the teacher received is interesting. this confirms the notion that skills acquired while working with a particular child with lnfs do not automatically carryover to other children. although one could argue that the other students with lnfs did not have the same access to messages as they did not use vocas, the trend in the behaviour of the teacher could indicate the limitations of technology focused training for implementation. the question of how to ensure that aac implementation is beneficial for the whole class must be considered! not only was the teacher's use of interaction types influenced by the training sessions but the teacher's use of questions was also influenced. the teacher's use of questions on higher cognitive levels was positively influenced by the training sessions. this means that implementation of an aac device alone will not result in the best possible interactional environment. training of the interactional partners should be part of the implementation process. this underlines the importance of training for the teacher of an. aac user in order to increase the aac user's exposure to interactions that result in maximum cognitive development. the teacher did not spontaneously record a variety of messages onto the digital speaker. the aac user only had access to a limited variety of utterance types until the teacher received training. one can see, by the teacher's choice of a greater variety of messages on the aac device that, by the final two research phases, the teacher had become more sensitive to the needs.of the child. access to a limited variety of utterance types could impair the aac user's participation and development. it is, therefore, critical that the teacher of an aac user should recei ve adequate training on the selection of appropriate items to be included on the device display. research has found that aac users in residential settings direct less than 5% of their interactions at communication partners who have not received formal training (dalton & bedrosian, 1989). formal training of communication partners, therefore, forms a critical part of the aac implementation process. acknowledgments the financial assistance of the human sciences research council (hsrc) towards this research project is gratefully acknowledged. opinions expressed and conclusions arrived at are, however, those of the author and are not necessarily to be attributed to the hsrc. references baker, l.a. 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(1972). word-finding vocabulary scale. renfrew publications, oxford. i romski, ma., sevcik, ra., reumann, r & pate, j. (1989). youngsters with moderate or severe mental retardation and severe spoken language impairments 1: extant communicativelpatterns. journal of speech and hearing disorders, 54: 366-~372. smith, m.m. (1994). speech by any other name: the role of dommunication aids in interaction. european journal of disorders of communication, 29(3): 225-240. i soto, g. (1997). special education teacher attitudes towardaac: preliminary survey. augmentative and alternative communication, 13(3): 186-197. stuart, s., vanderhoof, d. & beukelman, d.r (1993). topic and vocabulary use patterns of elderly women. augmentative and alternative communication, 9(2): 95-107. wilson, c.c., lanza, j.r & barton, j.s. (1988). developing higher level thinking skills through questioning techniques in the speech and language setting. language, speech and hearing services in schools, 19(4): 428-431. the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) abstract background method results discussion study limitations conclusion acknowledgements references about the author(s) ben sebothoma department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa katijah khoza-shangase department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation sebothoma, b., & khoza-shangase, k. (2021). acoustic immittance measures and middle ear assessment: current practice by south african audiologists. south african journal of communication disorders, 68(1), a818. https://doi.org/10.4102/sajcd.v68i1.818 original research acoustic immittance measures and middle ear assessment: current practice by south african audiologists ben sebothoma, katijah khoza-shangase received: 22 jan. 2021; accepted: 18 apr. 2021; published: 07 june 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: limited research exists regarding south african audiologists’ practice with acoustic immittance. this study was part of a bigger study titled ‘wideband acoustic immittance in adults living with human immunodeficiency virus’. objectives: the purpose of the study was to explore current practice of south african audiologists regarding acoustic immittance measures, and to explore their perceived knowledge and views on acoustic immittance advancements. method: a quantitative survey with a cross sectional design was employed. an electronic questionnaire was distributed to participants via professional associations of audiologists. data was analysed through descriptive and inferential statistics. results: most audiologists worked in private practice and conducted tympanometry with 226hz probe tone and ipsilateral acoustic reflexes. there was no association between clinical setting, levels of qualification, and the use of tympanometry. none of the participants included multifrequency and multicomponent tympanometry (mft) and/or wideband acoustic immittance (wai) in their test battery. most of the participants were not familiar with mft and wai. familiarity with mft and wai were only associated with the level of qualification. limited training and lack of equipment were major barriers to conducting some of the acoustic immittance measures. most participants believed that they would include mft and/or wai in their test battery if they had access to the equipment. conclusion: current findings raise training and clinical implications for the south african audiologists, including training institutions. these findings provide motivation for strategic resource allocation, planning and distribution of audiology clinics in the country if positive preventive audiology outcomes are to be achieved. keywords: acoustic immittance; audiological practice; middle ear function; south africa; audiology; tympanometry. background acoustic immittance measures consist of tympanometry, acoustic reflex threshold (art) and acoustic reflex decay (ard) (martin & clark, 2015). these measures are designed to assess middle ear function (hunter & shahnaz, 2014) and to provide a differential diagnosis for various disorders along the auditory pathway (british society of audiology [bsa], 2013). as a result, acoustic immittance measures form part of the standard audiological test battery for both adults and children (american academy of audiology [aaa], 2012; health profession council of south africa [hpcsa], 2012). despite the established value of this measure, there seem to be discrepancies in the literature about its use in clinical practice (emanuel, henson & knapp, 2012). in lowand middle-income countries (lmics), including south africa, there is limited research on the practice of audiologists regarding acoustic immittance. this research is particularly important where preventive audiology is arguably a part of the re-engineered primary healthcare strategy adopted by the south african government and where the main study ‘wideband acoustic immittance in adults living with human immunodeficiency virus’ is located. macdonald and green (2001) showed that 91% of their participants in canada always include tympanometry with 226 hz probe tone in their basic audiological test battery and 77% always include both ipsilateral and contralateral reflex threshold testing. however, a survey conducted in the united states of america (usa) by emanuel et al. (2012) found that only 61% of their participants use tympanometry with 226 hz probe tone routinely. both these studies found that over 70% of their participants never use multi-frequency and multicomponent tympanometry in their clinical practice. these studies support an earlier study by martin, champlin and chambers (1998) who found that approximately 10% of the participants reported using multi-frequency and multicomponent tympanometry in the usa. overall, evidence indicates that, firstly, it is not known whether there is any change in the use of acoustic immittance in clinical settings globally. secondly, available studies on acoustic immittance measures were mainly conducted in western high-income countries, with limited research from lmics. finally, none of these studies have investigated the use of wideband acoustic immittance (wai). variability in acoustic immittance practices among audiologists is concerning, given the high prevalence and impact of middle ear pathologies in both adults and children. the world health organization (2018) reports that middle ear pathologies affect over 700 million people per annum globally, with lami countries being the most affected (deantonio et al., 2016) because of multiple risk factors such as human immunodeficiency virus (hiv), lack of awareness and knowledge (joubert, sebothoma, & kgare, 2017; sebothoma & khoza-shangase, 2020). whilst middle ear pathologies can be treated medically (rosenfeld et al., 2016), prolonged or late identification and intervention may lead to further complications (kolo et al., 2012), which are difficult to treat and may require specialised services that are scarce in lmics (mulwafu et al., 2017). therefore, it is crucial that audiologists include acoustic immittance measures in their basic audiological test battery in order to identify early signs of middle ear pathologies, for preventive ear and hearing care to occur. in south africa, the standard audiological test battery requires inclusion of acoustic immittance for identification of middle ear pathologies and making referrals accordingly. literature has suggested that acoustic immittance measures provide important clinical information about the mechanical characteristics of the middle ear system (kramer & brown, 2019). bess and humes (2008) reported that the mechanical properties of the middle ear system are often affected by the presence of middle ear pathologies. therefore, the use of acoustic immittance allows the audiologists and other ear and hearing health professionals to objectively identify the abnormalities within the middle ear system. as a result, the inclusion of acoustic immittance measures in the test battery is recommended (bsa, 2013). although acoustic immittance forms part of the standard audiological test battery, tympanometry with 226 hz probe tone remains the most routinely used measure of middle ear assessment in audiological clinics (martin & clark, 2015). emerging research has indicated that tympanometry with 226 hz probe tone has poor sensitivity and specificity in the identification of middle ear pathologies (kaf, 2011; sebothoma & khoza-shangase, 2018). the continuous use of tympanometry with 226 hz probe tone results from the ease with which these measures can be performed and obtained and results can be interpreted (hunter & shahnaz, 2014). it is therefore clear that audiologists, especially those working in resource-constrained contexts, need to move towards including more accurate measures of middle ear pathologies to improve early identification and intervention and to reduce costs associated with untreated middle ear pathologies. multi-frequency and multicomponent tympanometry and wai have been shown to be more accurate in detecting middle ear pathologies than the traditional tympanometry with 226 hz probe (shahnaz & polka, 1997). the superiority of these advanced acoustic immittance measures is reported to be a result of their clinical parameters, which include the ability to measure middle ear function over a wide range of frequencies (sanford et al., 2013) and detect resonant frequency (rf) (iacovou et al., 2013). these clinical parameters allow such measures to accurately identify early signs of various middle ear pathologies (ibraheem, 2014) and predict conductive hearing loss (keefe et al., 2012). assessing whether audiologists include advanced acoustic measures such as multi-frequency and multicomponent tympanometry and wai has implications for clinical practice and resource allocation, particularly in lmics. these implications include early identification and timely interventions for middle ear pathologies, as part of the preventive healthcare approach that south africa embraces. based on the information presented above, the purpose of this study was to explore the current practices of south african audiologists regarding acoustic immittance and to explore their perceived knowledge and views regarding advanced measures such as multi-frequency multicomponent tympanometry and wai. the specific objectives of the study were to: determine the acoustic immittance measures conducted by south african audiologists in clinical practice describe facilitators and barriers to the use of acoustic immittance in clinical practice describe audiologists’ familiarity with advanced acoustic immittance measures. method this was a quantitative survey research study with a cross-sectional design (leedy & ormrod, 2013). this design was deemed appropriate as the research aimed to explore current acoustic immittance practices by south african audiologists. a web-based survey was employed as it allowed the researchers to gather data from audiologists across south africa (khoza-shangase & masondo, 2020). wright (2005) reported that survey research provides access to participants from distant locations. data collection method data collection for this study started with survey development. the questionnaire was developed based on previous surveys that were conducted in western countries such as canada and the usa (emanuel et al., 2012; macdonald & green, 2001). however, items for this study were modified to suit the current study and the south african context. the survey questionnaire was reviewed by two qualified audiologists who were selected based on their routine use of and expertise in acoustic immittance measures. they provided feedback on clarity of the questions and content, that is, relevance of the items for the study. a pilot study was then conducted with five audiologists who met the inclusion criteria to determine the feasibility of the questionnaire and to obtain additional inputs about the survey. the final version of the questionnaire was uploaded onto surveymonkey, which was used to create the survey. participants a non-probability purposive sampling method was used to recruit potential participants who met the inclusion criteria (leedy & ormrod, 2013). participants had to be practising audiologists registered with the hpcsa. participants holding a dual degree in speech language pathology and audiology (slp/a) but working primarily as speech language pathologists (slps) were excluded from the study. the completed survey questionnaire was sent to two professional associations (south african association of audiologists [saaa] and south african speech language hearing association [saslha]) for distribution. the south african speech language hearing association distributed the survey link by emailing it to all their members, but saaa distributed the survey link on their social media pages such as facebook and whatsapp. a 3-month cut-off time was set for participants to respond to the survey. reminders were sent to potential participants by saaa and salha. data analysis data were analysed using the statistical package for the social sciences (spss) version 25. both descriptive and inferential statistics were employed (ali & bhaskar, 2016). pearson’s chi-squared test was used to determine the association between variables of interest: level of education, clinical setting and the use of tympanometry with 226 hz probe tone. the p-value for statistical significance for this study was set at p ≤ 0.05. reliability and validity to determine content and face validity, following the review by two experienced audiologists, a pilot study was conducted where the questionnaire was sent via surveymonkey using the same procedure as described for the main study. the audiologists who formed part of the pilot study were asked to comment and provide feedback on the content and to determine whether the content of the questionnaire is in line with the objective of the study (satake, 2015). findings at this stage of the study revealed that the content of the questionnaire was appropriate for the study and captured what was being investigated. furthermore, the pilot study also revealed that the questionnaire could be completed in approximately 10 min. it should be noted, however, that validity was compromised by the very nature of online surveys, where results might not have been a true reflection of assessment practices. ethical considerations all procedures in this study adhered to the world medical association (wma) declaration of helsinki (millum, wendler & emanuel, 2013) ethical guidelines. ethical clearance was obtained from the human research ethics committee (hrec) (non-medical) of the university of the witwatersrand, johannesburg, south africa (protocol number: h19/02/30). participants gave written informed consent by clicking the button on the surveymonkey after reading and understanding the study information sheet. results forty-five audiologists responded to the survey. over half (53.3%) of the participants were employed in public sector facilities, such as public hospitals, primary healthcare sectors and schools, whilst 40% (n = 18) of the participants worked in private practice. very few participants worked in university clinics (2.2%; n = 1) and non-profit or non-governmental organisations (4.4%; n = 2). participants had various levels of experience and numbers of hours they provided clinical audiological services per week. figure 1 summarises the number of years that participants had been in clinical practice, whilst figure 2 provides the average number of hours that participants spent providing clinical audiological services in their respective settings. most of the participants (64.4%; n = 29) hold an undergraduate degree, which is a standard practice in south africa. an undergraduate degree is sufficient for registration to practice. figure 1: number of years practising as audiologists. figure 2: number of hours spent on clinical practice tasks on a weekly basis. conventional acoustic immittance measures table 1 summarises the frequency with which participants included various acoustic immittance measures, whilst table 2 shows different age groups assessed by various acoustic immittance measures. a majority of participants (68.9%; n = 31) indicated that they always include tympanometry with 226 hz in their audiological test battery, with very few participants indicating that they never (2.2%; n = 1) include it or rarely (2.2%; n = 1) include it in their audiological test battery. of those who include tympanometry with 226 hz probe tone, 57.8% (n = 26) reported that they use it to assess patients who are over 6 months old, whilst 40% (n = 18) of the participants use tympanometry with 226 hz probe tone with all patients. table 1: use of various acoustic immittance measures. table 2: age of patients assessed by various acoustic immittance measures. pearson’s chi-squared test indicates that there was no statistically significant association between the levels of participant qualifications (e.g. bachelor of science [bsc] or master of arts [ma]) and the use of tympanometry with 226 hz probe tone (p = 1.000). there was also no statistically significant association between working in any setting (e.g. public or private) and using tympanometry with 226 hz probe tone (p = 0.116). tympanometry with 1000 hz probe tone was used infrequently, with only 26.7% (n = 12) of participants always including it in their audiological test battery. a majority of participants (64.4%; n = 29) used tympanometry with 226 hz probe tone only with children aged 0–6 months. just below half (48.9%; n = 22) of the participants stated that they always include art as part of their audiological test battery, with a negligible number (2%; n = 1) who never include art. there was no association between level of education (p = 0.84) or clinical setting (0.95) and the use of art. of those who included art, 71.1% (n = 32) of the participants indicated that they only included ipsilateral art. however, there was no association between level of education and the type of art included (p = 0.068). of this sample, 33.3% (n = 15) of the participants indicated that their equipment did not provide both the ipsilateral and contralateral art tests, whilst others cited lack of time (24%) in conducting both ipsilateral and contralateral testing. almost all participants (80%) never included ard in their audiological test battery. chi-squared test also revealed that there was no association between the level of education (p = 0.8796) or clinical setting (p = 0.315) and the inclusion of ard. advanced acoustic immittance measures a majority of participants never included multi-frequency and multicomponent tympanometry (82.2%; n = 37) and/or wai (73.3%; n = 33) in their audiological test battery. those who did not include multi-frequency and multicomponent tympanometry and/or wai cited the lack of equipment for multi-frequency and multicomponent tympanometry (26.7%; n = 12) and wai (33.3%; n = 15) and training for both tests (51.1% and 44.4%) as the main reasons. regarding familiarity, only 2.2% (n = 1) of the participants were familiar with multi-frequency and multicomponent tympanometry and wai. further analysis indicated that familiarity with multi-frequency and multicomponent tympanometry (p = 0.0004) and wai (p = 0.0273) was associated with participants’ levels of education. however, the familiarity with multi-frequency multicomponent tympanometry (p = 0.913) and wai (p = 0.994) was not associated with the type of clinical setting (e.g. private vs. public). participants were also asked if they would include multi-frequency and multicomponent tympanometry and/or wai if they had equipment; 57.8% (n = 26) and 35.6% (n = 16) confirmed this and 37.8% (n = 17) and 60% (n = 27) were unsure. discussion the aims of this study were to explore the current practice of south african audiologists regarding acoustic immittance measures and to describe their familiarity with advanced acoustic immittance measures. the results reveal that 68.9% (n = 31) of the participants include tympanometry with 226 hz probe tone in their audiological test battery. these results are consistent with previous studies conducted in canada and usa, which established that audiologists always include tympanometry with 226 hz probe tone in their audiological test battery (emanuel et al., 2012; macdonald & green, 2001). a higher number of participants’ frequent inclusion of tympanometry with 226 hz probe, and less of other tympanometry, could be attributed to its availability and the ease with which the test can be performed and its results can be interpreted (erkkola-anttinen et al., 2014). for example, only 2% (n = 1) of the participants indicated not having equipment. those who did not always include tympanometry with 226 hz probe tone cited ‘other’ reasons other than availability. a high number of participants indicated that they did not always include tympanometry with 1000 hz probe tone; instead, they used tympanometry with 226 hz probe tone with all patients. these findings are inconsistent with the survey conducted by meyer, swanepoel and le roux (2014), which found that most of the participants included high-frequency tympanometry. the difference between these studies can be attributed to different sample sizes and settings. the latter study sampled participants only from the private sector, whilst the current study included participants from various clinical settings. therefore, the differences are not surprising given that those in the private sector are known to have more resources than those in the public sector (teixeira & joubert, 2014). despite the differences in the findings, not including tympanometry with 1000 hz probe tone raises implications for early identification and intervention of middle ear pathologies in children under the age of 6 months. kramer and brown (2019) reported that tympanometry with 226 hz is invalid in identifying middle ear pathologies in young children under the age of 6 months, perhaps because of the residual mesenchyme in the middle ear (shanks & shohet, 2009). park et al. (2015) found the sensitivity of tympanometry with 226 hz prone tone in identifying middle ear pathologies in children under the age of 6 months to be poor, ranging from 0% to 6.6%. however, the continuous use of tympanometry with 226 hz probe tone in patients of all ages affects early detection (hpcsa, 2018). furthermore, given the scarcity of resources to deal with severe middle ear pathologies (fagan & jacobs, 2009), the use of tympanometry with 226 hz probe in all patients might have long-term negative consequences. in terms of art and ard, almost 50% of the participants always included art, whilst a majority (80%) never included ard. of those who include art, a majority (71%; n = 32) only include ipsilateral art because their equipment only provides this option and does not provide an option for contralateral art. these findings are consistent with the results of a study by emanuel et al. (2012) who found that a majority of their participants always included art, but few included ard in their assessments. unlike in the current study, a majority of participants (91%) in the study by emanuel et al. (2012) used both ipsilateral and contralateral art. given that art and ard are essential for differentiating cochlear from retrocochlear disorders (kramer & brown, 2019), it is concerning that some art and ard are not consistently conducted. some participants (24.4%; n = 11) stated that they had no time to conduct both the ipsilateral and contralateral art. this may be because of time management, scheduling of appointments and workload challenges in their practices. a majority of participants in our study indicated that they did not include multi-frequency and multicomponent tympanometry and wai and were not familiar with these tests. a higher number of participants stated that they were not trained in the use of these tests and did not have the required equipment. tympanometry with a wide range of frequencies such as wai is not yet widespread in clinical practice (kramer & brown, 2019), particularly in developing countries because of the lack of normative values (sebothoma et al., submitted). several studies have already indicated that tympanometry with a wide range of frequencies have higher sensitivity and specificity in identifying middle ear pathologies (kaf, 2011; shahnaz et al., 2009); therefore, academic institutions in south africa need to teach and update audiology students and graduates – through seminars and workshops – advancements in audiology. it was comforting to see that over 80% of the participants were amenable to using multi-frequency and multicomponent tympanometry and wai if they were to receive the equipment. in an attempt to establish if there were any trends in the data that could explain the outcomes in terms of current practice, factors such as the level of qualification, sector of employment and length of employment were carefully qualitatively scrutinised. of these factors potentially influencing practice, only private practice placement seemed to have a positive influence on current practice, possibly because of the availability of resources that are otherwise not widely available in state institutions that are fraught with resource constraints. the level of education of the participants appeared to have no influence in current findings. this was expected as middle ear assessment forms part of the hpcsa minimum standards for undergraduate qualification in audiology in south africa, with postgraduate training comprising research only, research report and research coursework, with no clinical training at postgraduate level (khoza-shangase & masondo, 2020). study limitations whilst this study provided information about practices of south african audiologists regarding acoustic immittance, there are methodological limitations that need to be taken into consideration whilst interpreting the findings. although the associations’ data basis used represents a large number of audiologists in the country, unlike any other, the recruitment method used in this study permitted access only to audiologists affiliated with these associations (saaa and saslha) and those with internet access to participate. this has resulted in a small sample size that is not necessarily a representative of a sample of the audiologists working in various sectors in south africa, thus limiting the applicability in terms of guideline implementation and generalisation to the majority of the country’s practitioners. this limitation raises implications for future studies to explore the same question by including participants who are not associated with saaa and saslha. for example, future studies should consider recruiting participants through the national forum as well, the national black speech language hearing associations and other existing platforms to increase the representation of audiologists. conclusion the results of this study indicate that south african audiologists do not regularly conduct acoustic immittance measures, with a majority conducting only tympanometry with 226 hz prone tone and ipsilateral art regularly. the variance in practice is mainly attributed to the lack of resources and limited training at undergraduate level. it was also noted that most of the audiologists are not familiar with multi-frequency multicomponent tympanometry and wai. therefore, this study highlights the need for enhanced training and appropriate resource allocation where audiological services are provided. educating both undergraduate and postgraduate students about the importance of including acoustic immittance in routine test battery and the various measures for specific circumstances is required. furthermore, equipping south african audiologists with the knowledge of advanced acoustic immittance measures that are more effective in identifying middle ear pathologies, such as wai, may keep them abreast with new developments in the field. all this may contribute positively to early identification and consequent early treatment of middle ear pathologies as part of preventive healthcare measures within this lami context, where a high burden of diseases that increase occurrences of middle ear disease, such as hiv or aids, exists. acknowledgements the authors would like to thank saaa and saslha for distributing the survey questionnaire to their members. the authors would also like to thank south african audiologists for taking part in this study. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions b.s. contributed to the conceptualisation of the study, design, developing the survey, data collection, analysis and writing of this manuscript. k.k.-s. contributed to the conceptualisation of the study, design, developing the survey, collecting data, analysis and writing of this manuscript. both authors have read and approved the final manuscript. funding information the authors thank the national institute for the humanities and social sciences (nihss) for providing 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(2018). addressing the rising prevalence of hearing loss. retrieved from https://apps.who.int/iris/bitstream/handle/10665/260336/9789241550260-eng.pdf?sequence=1&isallowed=y wright, k.b. (2005). researching internet-based populations: advantages and disadvantages of online survey research, online questionnaire authoring software packages, and web survey services. journal of computer-mediated communication, 10(3), jcmc1034. https://doi.org/10.1111/j.1083-6101.2005.tb00259.x parental perceptions o f c haracteristics and o utcom es o f c hildren and fam ilies in the pretoria c ochlear im plant program m e 47 parental perceptions of characteristics and outcomes of children and families in the pretoria cochlear implant programme marguerite jessop, alta kritzinger and nellie venter department o f communication pathology university o f pretoria abstract in order to address the pretoria cochlear implant programme’s (pcip) need fo r an in-depth analysis o f the variables related to outcomes o f children with cochlear implants and their families, a comprehensive postal questionnaire was used in a cross-sectional study employing quantitative methods. the aim was to determine the perceptions o f parents/caregivers o f children with cochlear implants in the pcip o f the children's outcomes, and to collate relevant data pertaining to 45 children and their families. results indicated that several key factors played a role in determining a positive outcome in the children’s audiological, linguistic, social and educational functioning leading to placement in an inclusive educational setting. the most important indicators were: early age at diagnosis, early intervention with hearing aids and early cochlear implantation. the importance o f early intervention is em­ phasized. the study was a first attempt to document the outcomes o f the pcip, indicating a need to establish a computer database to store data o f all clients, which can be usedfor research and regular programme audits. keywords: cochlear implant programme, outcomes, early intervention, variables affecting success, inclusive education, specialized education in tro d u ctio n since the advent o f cochlear implantation in children in the mid 1980’s, remarkable progress has been made in the technology o f the device and its speech processor, in surgical techniques and in intervention programmes (clark, cowan & dowell, 1997). infants are now being implanted at increasingly younger ages (wright, purcell & reed, 2002). this places a paediatric cochlear implant programme firmly within the realm o f early communication intervention (eci) services. thus, in such a programme as with all eci programmes, families are o f the utmost importance as many biological and environmental fac­ tors play a role in the child’s progress (rossetti, 2001). a ma­ jo r goal o f eci is early identification o f risk factors for com­ munication delay, including hearing impairment. there is a worldwide trend toward eariy identification o f hearing loss in infants and children (wright et al., 2002). families and their children are therefore entering cochlear implant programmes earlier. in order to best utilise this time advantage (mayne, yo shinaga-itano & sedey, 2000), it is necessary that cochlear assessment protocols be fast, efficient and family-centred and that motivation for funding be handled quickly and effectively to decrease the time delay between the family’s initial contact with the cochlear team and approval for a cochlear implant, and between approval and implantation. the best possible early rehabilitation services must then follow, therefore opening the possibility for placement o f the child in inclusive education instead o f special education. the outcomes o f an intervention such as a paediatric cochlear implantation are largely dependent on the family con­ text in which the child finds him/herself (rossetti, 2001). the selection criteria for implantation o f children take into consid­ eration the child’s support network (katz, burkard & medwet sky, 2002), thus ruling out many children who would not have derived benefit from the implant due to a lack of follow-up support. once enrolled in the cochlear implant programme, however, it is imperative that the family be kept involved throughout the entire process. rossetti (2001) supports the idea o f utilising parental report and o f viewing the parents as accurate sources o f infor­ mation. this approach is in accordance with the notion of fam­ ily centered assessment, which serves as a tool to include the family as team members, rally their co-operation, empower them as informed decision makers and thereby ensure their continued involvement in the programme. increased levels of parental involvement also serve to enable parents to better ful­ fill their role as advocates for their children (moog, 2002). the pretoria cochlear implant programme (pcip) had been operating for over a decade, and thus the gathering of descriptive data regarding this rapidly growing and changing population o f patients was imperative for ongoing research, information sharing and efficacy of service delivery to families. there is increased pressure for outcome studies, or programme audits, to justify the cost of cochlear implantation and to dem­ onstrate accountability for this cost in terms of efficacy (summerfield & marshall, 1999). if there is to be state subsi­ dising of cochlear implants in south africa for those children whose parents do not have the means to fund the procedure privately, strong motivation needs to come from sound re­ search on the efficacy and cost benefits o f cochlear implants for children who are profoundly d ea f in order to describe the outcomes o f the programme, a programme audit was required. since existing data were incomplete, the problem statement for the present study arose directly from this need. while both measured and perceived outcomes should be described for a complete database of a cochlear implant programme, the pre­ sent study was undertaken with the focus on a family-centred approach and for this reason, outcomes as perceived by parents were described. in order to conduct a study involving outcomes of children with cochlear implants, descriptive data on the child as well as his/her context were required. as demonstrated in the outcomes reports of the notting­ ham (outcomes report, 1990-2000) and birmingham paediat­ ric cochear implant programmes (outcomes report, 1997), a revision and a constant shifting o f the boundaries of selection criteria for paediatric cochlear implantation have accompanied the developments in technology and the decreasing age o f im­ plantation (katz et al., 2002). since the south african context is unique, in terms o f population characteristics and the fact that no state funding is available for cochlear implants, local research within its cochlear implant programmes, it is neces­ sary for programmes to revise their own selection criteria. the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 48 m arguerite jessop, a lta k ritzinger and n ellie v enter since selection criteria ultimately dictate the profile o f a programme’s clients, it follows that careful review o f both a programme’s outcomes and selection criteria are required to build an accurate picture o f the clients in that pro­ gramme (chester-brown, 2005). in addition, knowledge of the variables sur­ rounding a child with a cochlear implant and his/her family, which either con­ tribute to or hinder success, can provide guidelines for the adaptation o f selec­ tion criteria to the population potentially being served by a programme. as information is the key to making informed decisions, it follows that a paediatric cochlear implant programme, which makes life-changing deci­ sions regarding a child’s future, requires detailed information about its clients. it followed that a standard system needed to be developed for the pcip, which could address the need for retrospective data collection to complete case histo­ ries o f children implanted for the past ten years, as well as to record prospec­ tive data on current and new clients. it was anticipated that a protocol firmly grounded in current research would fulfill the programme’s information needs as trends move toward earlier implantation, new surgical techniques, more sophisticated technology, changing selection criteria and the pressure for regu­ lar outcome studies (wright et al., 2002). it was further envisaged that analy­ sis o f the data might reveal trends that would assist the programme’s team in planning more efficiently for the changing profile of patients. the aim o f the study was therefore to describe the defining characteristics and perceived out­ comes of children and their families enrolled at this programme. throughout the literature on paediatric cochlear implantation, it is evi­ dent that the variables affecting the success of a child’s use of this technology are numerous and complex, and o f a highly individual nature. as greater vol­ umes o f data become available and early paediatric implantees grow older and can be tracked, the profile o f clients’ shifts and variables are better under­ stood. figure 1 summarises and illustrates some o f the factors explored by the study. v ariables affecting the s u c c e s s o f a c h ild w ith a c o c h le a r implant 1. age at identification of hearing loss and age at onset of hearing loss 2. age at implantation and experience with the cochlear implant 3. cause of hearing loss 4. biological and medical factors 5. environmental factors: socio-economic status, cultural variables and parental edu­ cation 6. variables related to hearing and auditory system structures 7. device variables and programme variables 8. mode of communication * o utcom e s o f child with c o c h le a r im p la n t 1. language acquisition, speech perception and production 2. academic success, later employment and independence 3. educational placement 4. socialization 5. family dynamics * o u tco m e s o f co c h le a r programme 1. cost effectiveness and funding 2. programme evaluation 3. relevance to south african context 4. shifting selection criteria 5. protocol revision 6. research and future planning through tracking o f patient profiles /. comparison and communication with other programmes c onceptualised from: a rchbold, n ikolopolous, tait, o ’d onaghue, l utm an & g regory (2000); c lark et al. (1997); m e ren stein & g ardner (1998); s um m erfield & m arshall (1999). figure 1: sum m ary o f factors affecting client and program m e outcom es. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 m ethod aims the main aim o f the study was to formulate a de­ scription o f defining characteristics and outcomes pertaining to the children with cochlear implants (16 years o f age and younger) in the pcip and their families, as perceived by their parents/caregivers. the four sub-aims involved: ® a description of the children’s preand perina­ tal, medical, developmental, audiological and educational histories; • the compilation o f a descriptive profile o f the families o f children with cochlear implants; ® a description o f the children’s current out­ comes as perceived by their parents in terms of audiological, communicative and educational functioning with the cochlear implant; ® the identification o f variables affecting the success o f the child with a cochlear implant in the pcip. r esearch design the study took the form o f a descriptive survey, as it involved acquiring information about the co­ chlear implantees and their families, by asking the parents questions and tabulating their answers (leedy & ormrod, 2005). the study was cross sectional as it provided descriptive data at one fixed point in time; however, much o f the informa­ tion was attained retrospectively. since the study involved mainly discrete data, from a fixed set of questions, a quantitative approach was followed. the study was non-experimental, and no variables were manipulated, thus no dependent and inde­ pendent variables were incorporated (leedy & ormrod, 2005) and no causal relationships were explored. e thical c onsiderations the research proposal and proposed questionnaire were submitted to the research proposal and eth­ ics committee o f the faculty o f humanities, uni­ versity o f pretoria, as well as to the head | o f the pcip. permission was obtained from the ear, nose and throat specialist in charge o f the programme, to collect and use the participants’ data for research purposes. his conditions as well as those o f the ethics committee were taken into account before undertaking the study. participants were required to sign and return a consent form accompanying the letter o f consent and questionnaire (strydom, 2002). / p articipants the target group was the children enrolled in the pcip and their families. non-probability conven­ ience sampling was used in participant selection, which precluded generalisation of the results of the survey to,the wider population o f children enrolled in cochlear implant programmes in south africa. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) parental perceptions o f c haracteristics and o utcom es o f c hildren and fam ilies in the pretoria c ochlear im plant program m e 49 the selection criteria required that the participants had to be parents or caregivers whose children had undergone cochlear implantation, were not older than 16 years o f age, and were enrolled in the pcip. the register containing the names and telephone num­ bers o f the children enrolled in the pcip was requested, and parents were then telephonically contacted to determine will­ ingness to participate in the study. only 71 o f the 73 parents and children enrolled in the programme qualified as partici­ pants in the study, since two families resided in remote geo­ graphic locations and were inaccessible by post. o f the 71 questionnaires that were sent out, 45 were returned, represent­ ing a 63.4% response rate. according to edwards et al. (2002), a response rate o f over 60% is considered acceptable in a study involving postal questionnaires. description o f participants in general, the majority o f the participants’ children in the pcip were white (91%), afrikaans speaking (73%) chil­ dren representing both genders (49% female and 51% male), living with both parents (76%) and having at least one sibling (73%>). the children were more often the youngest children in the family (64%), and spent the majority of their time with their mothers (65%). two languages were spoken in the homes (with the exception of one home in which three languages were spoken). children were between 2 and 16 years of age, and were likely to fall in the categories 2-6 years (pre-school), 7-12 years (primary school) or 13-16 years (high school). a wide distribution o f ages was thus seen in the participants. regard­ ing the families, the majority of parents were employed, with fathers/paternal caregivers employed in all families except one. the majority of the families lived in gauteng (86%), and was thus relatively close to the pcip for access to services. the participants o f the questionnaire were the children’s biological mothers in all cases except one, a mother o f two children with cochlear implants in the pcip, where the child’s grandmother was the participant in consultation with the mother. materials i the aims o f the study as well as the time and financial con­ straints in the particular setting underscored the need for a data collection instrument that could collect large volumes o f quan­ titative data from a large number of participants who were spread over a wide geographic area, in the shortest time span and the most standardised | way possible (leedy & ormrod, 2005). a postal questionnaire was therefore selected as the data collection instrument. the researcher compiled the parent questionnaire, with input from other members o f the pcip team. the questionnaire consisted o f discrete items and was divided into five sections covering the areas of biographical information, prenatal and birth history, medical history, developmental history, family history, audiological history and current functioning of the child post-implantation. the questionnaire was available in both english and afrikaans, depending on the'language prefer­ ence o f the participant. since the questionnaire was extensive, closed type questions were chosen for ease and speed of an­ swering. along with the questionnaire, parents received a cov­ ering letter outlining the aims o f the study and the possible value thereof, as well as a consent form to sign. content and compilation o f the questionnaire the questionnaire’s content was compiled according to each sub-aim using various sources from various fields. the questions in the tool were drawn questions from the chrib case history form (kritzinger & louw, 2000) used by the cen­ tre for early intervention in communication pathology at the university of pretoria, as well as other questionnaires used at the department o f communication pathology, university of pretoria. furthermore, the questions and justification for ques­ tions were influenced by various sources in the fields o f eci (rossetti, 2001), neonatal intensive care (merenstein & gard­ ner, 1998), paediatric cochlear implants (clark et al., 1997), assessment in childhood communication disorders including hearing impairment (katz et al., 2002), and family assessment (rossetti, 2001). the format of the database being compiled by the tygerberg cochlear implant programme was consulted for comparative and evaluative purposes, and the questionnaire was adapted to include information in this tool. only questions that could be answered by the parents were asked. structure o f the questionnaire the first section of the questionnaire involved bio­ graphical information pertaining to the child’s family circum­ stance. questions were chosen to render information about the socio-economic status of the family and the level o f education o f the people providing stimulation to the child (dollaghan et al., 1999), as well as the family structure and languages spo­ ken. these questions, as well as those in the next four sections, were used to fulfill the need for information regarding the fac­ tors influencing the success o f a child with a cochlear implant, visually depicted in the upper section in figure 1. the next section, covering the history o f pregnancy and birth history, was included since many causes o f hearing im­ pairment have their origin in the prenatal period or with birth trauma (merenstein & gardner, 1998; rossetti, 2001). more specific, closed-ended questions regarding the child’s condition after birth were included in table format to cover all the possi­ ble risk factors for hearing loss and developmental delay in this time period (kritzinger & louw, 2000). the medical history o f the child, including hospitalisa­ tions as well as a table listing conditions associated with sen­ sorineural hearing loss, additional disabilities and developmen­ tal delay influencing success with a cochlear implant, com­ prised the next section (blair, ramey & hardin, 1995; rossetti, 2001). thereafter, the developmental history o f the child was covered in a table detailing developmental milestones, the de­ velopment of feeding and parental perceptions o f their infants’ development prior to the onset of hearing loss. the fam ily his­ tory surrounding the child was documented next, with empha­ sis on the presence of a hereditary component to the child’s hearing loss (angeli et al., 2000; matsushiro et al., 2002), as well as other disabilities, which may affect progress with a cochlear implant such as a learning disability or genetic syn­ dromes (pisoni, 2000). the child’s audiological history prior to and after co~ chlear implantation was then probed followed by the last sec­ tion of the questionnaire which used categorical type multiple choice questions arranged in tables o f options to describe the child’s current educational setting, use o f his or her cochlear implant, level o f communication, audiological development and the level o f speech intelligibility attained by the child (ching, psarros, hill, dillon & incerti, 2001). this section related to the perceived outcomes o f the child with a cochlear implant depicted in figure 1. the scales used in the questionnaire for rating audiological development and the child’s attained level o f speech intelligibility were respectively adapted and included the lip profile (listening progress profile) of environmental sounds (archbold, 1993) and the sir speech intelligibility the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 50 m arguerite jessop, a lta k ritzinger and n ellie venter rating scale (allen, nikoloploulos & o ’donoghue, 1998). fur­ ther questioning involved the support services and rehabilitative therapy available to the child, the child’s use of a telephone and the ability to enjoy music. p rocedures reliability and validity a thorough literature review served as underpinning for the questionnaire. the questionnaire was structured in a logical way, using simple response choices, easily answerable questions and a user-friendly format. a pilot study was conducted in order to increase the reliability and validity o f the study. pilot study the aims of the pilot study were refinement and adjust­ ment o f the structure and content o f the questionnaire based on pre-testing (leedy & ormrod, 2005). the participant was the biological mother of one child with a cochlear implant, who was slightly above the maximum age defined for participant selec­ tion in this study. the participant o f the pilot study was therefore not utilised in the main study. the participant was given the choice to participate in the pilot study o f her own free will and complied with all participant selection criteria set for the main study, besides the age o f the child. valuable comments were made by the participant, which aided refinement o f the question­ naire for the optimal collection o f accurate information for the study. since only one participant was utilised in the pilot study, it is recognized as a weakness. data collection procedures data were collected via a comprehensive questionnaire filled in by the parents/caregivers of the children in the pcip. questionnaires were posted to all families as well as postage paid, return-addressed envelopes and informed consent letters. prior to posting of questionnaires, the families were contacted telephonically. this initial phone call served as a means to ex­ plain the nature o f the study and its ethical issues, request per­ mission to use data and determine willingness to participate in the study. follow up phone calls three weeks after posting the questionnaires served as reminders to those respondents who had not yet returned their questionnaires. no further reminders were given, since it may have violated the ethical principle of voluntary participation. data recording/preparation and analysis procedures data were organised using manual coding strategies for each answer to questionnaire items, after which it was entered into a microsoft excel spreadsheet. a computerised system for the analysis o f descriptive statistics, namely the sas® (statistical analysis system, 1999) was used to provide fre­ quency and percentage information. both dichotomous and cate­ gorical nominal, as well as ordinal and numerical measurement scales were used due to the variety of information being gath­ ered. for the same reason, both measures o f central tendency and o f dispersion were used to provide the rich description re­ quired by the data. results and discussion the findings o f the study are presented and discussed according to the sub-aims. where appropriate, the sample was divided into two groups, namely those participants attending specialised schools and those in inclusive educational (ie) settings, and a comparison was made between the groups. this was used to aid die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 the search for variables that could contribute to the success of a child with a cochlear implant in terms o f the auditory, linguistic everyday functioning and academic skills considered by parents and professionals when deciding on the choice of educational placement. as summarised in figure 1, a number o f audiologi­ cal, biological and environmental factors affect the outcomes of a child with a cochlear implant, and the family unit is the key to understanding the development o f the child. for this reason the variables relating to the families o f participants were discussed, in addition to variables directly related to the children in the study. the outcomes o f children, as measured by parental re­ port, were presented and expanded on by comparison to out­ comes o f other programmes, and by linking these outcomes to various possible contributing factors in the children’s histories. the complete description o f the results o f the study may be found in jessop (2005). r esults for sub-aim 1: a description of the p re n atal, p erin a­ tal, medical, developm ental, audiological and educational histories o f the p a rtic ip a n ts’ children cause o f hearing impairment according to table 1 the largest group, namely those in which the cause was unknown to the parents, is o f particular interest since this may in part represent the non-syndromic ge­ netic mutations (bjb2 gene) as described in the literature as being frequent in the caucasian population (matsushiro et al., 2002). angeli et al. (2000) report that there are at least 20 dif­ ferent mutations o f this gene, caused by hereditary or disease processes; and that the numbers o f these children in cochlear implant programmes warrant standard screening for this aetiol­ ogy. the joint committee on infant hearing (jcih, 2000) stated that, in the near future, advances in knowledge regarding recessive genes responsible for non-syndromic hearing impair­ ment could dramatically reduce the number o f children whose aetiology o f hearing impairment is unknown. table 1. c auses o f hearing loss in children (n=45) cause o f he a rin g lo s s percentage o f c h ild re n (%) unknown 17(38%) meningitis 4 (9%) genetic syndrome associated with hearing impair­ ment 4 (9%) prenatal complications 3 (7%) birth trauma (foetal distress, asphyxia) 3 (7%) hereditary hearing impairment 3 (7%) congenital rubella syndrome 3 (7%) maternal cytomegalovirus infection 2 (4%) viral infection 1 (2%) kidney disorder 1 (2%) y chronic otitis media 1 (2%) ototoxic medication / 1 (2%) medication ingested by mother whilst pregnant 1 (2%) myelin sheath disorder 1 (2%) total / 45(100% ) r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) parental perceptions o f c haracteristics and o utcom es o f c hildren and fam ilies in the p retoria c ochlear im plant program m e 51 nature o f the hearing loss only 16% o f children in the current study had an ac­ quired hearing impairment, while the hearing impairment was congenital in 84% of cases. data revealed that 28% o f chil­ dren (including those with congenital and acquired hearing impairments) reported a progressive hearing loss, and in 7% of cases this was o f a fluctuating nature. the reasons for the progression were the presence o f reno tubular fanconi syn­ drome, hereditary hearing loss, unknown causes and cmv. the majority o f children, with the exception o f those affected by meningitis and perinatal factors, had congenital hearing impairments, which emphasizes age at implantation as a cru­ cial factor in language development. o f the 7 children (16%) in the sample whose hearing loss was acquired, 85% o f par­ ents reported that development prior to the onset o f hearing loss was normal, indicating the absence o f early developing additional conditions. children with acquired hearing loss have the advantage o f early exposure to sound and possibly some linguistic development, and generally develop language at a faster rate post-implant than children with congenital hearing loss (katz et al., 2002). these characteristics of the children added to the complexity and heterogeneity o f the data, and imply an additional dimension to the planning, ex­ pectations and outcomes o f cochlear implant programmes. biological and medical variables the medical histories o f the participants’ children with cochlear implants were compared when they were divided into two distinct groups, i.e. those in inclusive education (ie), and those in specialised education (se). the only significant difference highlighted by this comparison was the greater number o f children in the se group who suffered from add/ adhd (reported by parents), namely 5% o f the ie group as opposed to 21% o f the se group. this finding corresponds with that o f pisoni (2000), calling for more emphasis in co­ chlear implant research on issues o f information processing such as attention; memory; perception and learning to explain the individual differences in outcome after paediatric cochlear implantation. the group in ie also seemed to suffer from fewier bouts o f general childhood illnesses such as measles, mumps and chicken pox that could be interpreted to indicate a generally higher resistance to infectious illness and possibly better general immunity and' health leading to fewer absences from school and missed learning opportunities. both groups indicated that middle ear infections as well as upper respiratory tract infections were frequent occur­ rences, which would have a temporary negative impact on auditory functioning. the jcih (2000) reported otitis media to have an especially negative effect in children with sen­ sorineural hearing loss. none o f the children in ie suffered from a chronic illness, as opposed to one participant in the se group. 1 the severity o f the disorders o f vision, not indicated by these broad categories, revealed itself to be significant on closer inspection. the children in inclusive settings had mild visual acuity problems, corrected with lenses,1 while those in the second group had more severe visual complications in­ cluding retinitis pigmentosa. history o f diagnosis o f hearing loss and intervention hearing loss was generally suspected by mothers/ parents by 12 months o f age (62%), although 18% o f parents suspected that their infants1 could not hear by 6 months. all children’s hearing losses were suspected by 44 months. in 44% o f cases it was the mother who noticed the child’s lack of response to sound, in 42% o f cases both parents, in 9% o f cases the grandparent, in 3% o f cases it was other people, and in only 2% o f children was it a teacher or therapist. only 4% o f children were diagnosed by 6 months, a figure which lends support to the idea of compulsory hearing screening after birth as implemented in the usa (mayne et al., 2000). in five cases, it was reported by parents through the addition o f information not directly asked in the questionnaire, that doctors did not react immediately to moth­ ers’ concerns regarding their children’s development, despite find­ ings indicating the high reliability o f parental reports o f concern (rossetti, 2001). there was a substantial delay between three steps: concern, diagnosis and treatment o f hearing loss in the participants’ chil­ dren. the 28% o f children with progressive hearing loss, as well as the 7% whose hearing losses fluctuated, may have contributed to the delays. a shorter time delay between the three steps in the process prior to cochlear implantation would necessarily imply a younger age of implantation and should be a goal of healthcare professionals (mayne et al., 2000) and the health system in south africa. figure 2 depicts the length o f time that the child wore hear­ ing aids, implying the time between fitting o f hearing aids and cochlear implantation. ages of subjects figure 2: period for w hich children w ore hearing aids prior to cochlear im plantation. from figure 2 it can be seen that, while the required period for wearing hearing aids prior to establishing candidacy for cochlear implantation was 6 months, most participants’ children wore hear­ ing aids for longer than this period prior to cochlear implantation. it is an important requirement of the pcip that while the child is wearing hearing aids during the trial period, he/she should either be included in a specialised classroom or receive intensive, appro­ priate auditory stimulation. the highest percentage o f children (27%i) wore hearing aids for between 6 and 12 months, with a large percentage (40%) wearing hearing aids for 13-36 months. these children received little or no benefit from their hearing aids in this time, as this is a candidacy criterion for cochlear implanta­ tion. several factors may play a role in affecting the duration o f hearing aid use prior to cochlear implantation, such as late referral to the cochlear implant programme, difficulty obtaining the neces­ sary funding for the cochlear implantation, delays in the process of making the decision to operate as well as in the process o f es­ tablishing candidacy, and the health o f the child in order to make the surgery viable. all of these variables may play a greater or the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 52 m arguerite jessop, a lta k ritzinger and n ellie v enter lesser role in determining the speed with which a child is im­ planted, although in the pcip delays are not generated by an annual quota o f cochlear implants or a lengthy waiting list as it is largely still an elective procedure and thus part o f the private health care sector. funding can pose a significant barrier to early implanta­ tion for many south african children. o f the 45 children, only one received a small amount of state funding for the procedure. in 84% o f cases the family’s medical aid scheme paid for the implantation, and some cases were funded privately by the family and through donations. this implies a waiting period before cochlear implantation as many families raise the neces­ sary funds themselves. a ge at cochlear implantation the distribution o f ages at which children in the study received their cochlear implants was between 12 months and 10 years. the largest groups, in descending order, were those im­ planted at age 2-3, age 1-2, and age 3-4 years respectively. a world-wide trend toward earlier cochlear implantation exists (archbold et al., 2000). results therefore indicated that the pcip data were in accordance with this trend, with more chil­ dren being implanted prior to age 5 years than later. audiological variables: side o f implant and reasons in most children (60%) the right side was chosen for cochlear implantation, while 36% had their left ear implanted and 4% received bilateral implants. when the hearing loss was similar in both ears, the dexterity o f the child was taken into account by the surgeon. as most people are right handed, this could explain the high percentage o f right side implants. reasons f o r choice o f side f o r cochlear implantation the largest group o f participants (38%) chose the child’s poorer ear (with less residual hearing), with handedness, most normally formed cochlea and hearing nerve, ear which had the most stimulation and thus had the most residual hear­ ing, frequent middle ear infections on one side, facial nerve implications or the child’s own choice as the other reasons for choice o f cochlear implantation. side of implant may be af­ fected by many factors where there is not a clear structural or surgical choice of side. as selection criteria shift to include children with greater levels of residual hearing, this decision becomes more complex as the possibility o f ‘losing’ the resid­ ual hearing in the implanted ear due to the effects o f surgery, including cochlear trauma and connective tissue growth, be­ come relevant (kiefer et al., 1998). in general, the side with the least residual hearing is then implanted, affording two advan­ tages to the child and the family, namely the psychological sense of security that his/her hearing sense will not be obliter­ ated completely, as well as the possibility o f making use o f the binaural/bimodal advantage with a well fitted hearing aid on the non-implanted ear. philosophies and viewpoints regarding the choice of ear to be implanted have changed in the pcip as a function o f time, new research findings, shifting selection crite­ ria .and changing surgical techniques (katz et al., 2002). as a rule, the largest number o f participants in the current study had chosen their children’s ‘weaker’ ear for implantation. this raises the next issue, namely the use o f a hearing aid on the non -implanted side. h earing aid use on non-implanted ear only 44% of children wore a hearing aid on the contra lateral ear. reasons given for not wearing a hearing aid in­ cluded the fact that the ear had too little residual hearing to benefit, not knowing that it was advisable, and the child’s re­ fusal to wear the hearing aid. the reasons for wearing the hearing aid included better sound, better localization, stimula­ tion o f the acoustic nerve, the school’s policy, more balanced hearing, making use o f residual hearing, and recommendation by the audiologist. in pretoria, the majority o f specialised schools advocate the wearing o f a hearing aid on the non implanted side, at least during school hours. this, together with the audiologists o f the pcip’s own frequent recommenda­ tions to encourage this practice, may have accounted for a large percentage of the participants’ motivation to do so, al­ though this is a fairly recent development based on more re­ cent research and the advent o f bilateral cochlear implants as a viable option. studies demonstrating the advantages o f bilat­ eral implants are growing in number (ertmer, 2002). in the pcip only two children had received bilateral cochlear im­ plants, both in successive operations as opposed to simultane­ ous operations. according to the parents, o f the two, one wears both his devices well and the other refuses to wear the second device. r esults for sub-aim 2: c om pilation of a descriptive profile of the families of children with cochlear im plants in the p c ip in this section a profile was created o f the families o f children with cochlear implants in the study was created, including in­ formation on the prevalence of hearing loss or additional disor­ ders o f speech, language or learning in families and educa­ tional level and employment status o f parents. in eight chil­ dren’s families there existed a history o f childhood hearing loss. participants were further asked to report on a family his­ tory o f speech/language or academic difficulties not related to hearing loss. in the se group, 17% o f families had a history of learning/academic and serious speech/language difficulties in childhood. this was higher than the 5% reported in the ie group, and may have been a factor contributing to the need for se. the presence o f these difficulties in the parent might have affected their level o f stimulation o f the child (dollaghan et al., 1999), while the presence o f these hereditary traits in the children themselves could have hampered their success in ac­ quiring language and academic progress. j environmental variables related to the family unit were reported as parental education and employment status in order to give an indication o f socio-economic status and the amount o f time spent at home with the children by the maternal and paternal parents/caregivers respectively. it followed that the parent spending the most time with the children would !play a greater role in academic development, and this parent’s own educational status might then be o f greater relevance. the re­ sults showed that mothers/maternal caregivers o f the children in ie had a higher level o f educational status in general. the most pronounced differences were seen in the highest level, namely university degree that included 26% o f mothers in the ie group and only 8% o f mothers in the se group. the lowest level measured, namely standard 8, included only-5% of moth­ ers of children in inclusive settings and 17% of mothers in the se group. a similar trend was seen with paternal parents/ caregivers, where 37% o f fathers o f children in ie had a uni­ versity degree as opposed to 23% o f fathers o f children in spe­ cialised settings. thus it would appear from these data that the level o f maternal and paternal educational status might play a role in the academic success o f a child with a cochlear implant. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) parental p erceptions o f c haracteristics and o utcom es o f c hildren and fam ilies in the p retoria c ochlear im plant program m e 53 results for sub-aim 3: d escription of ch ild ren ’s c u rre n t p e r­ ceived outcomes in term s of auditory, com m unicative an d edu­ cational functioning auditory outcomes: use o f the device all participants reported that the cochlear implant device was worn at all times (all waking hours), at home and at school. auditory performance speech was most easily detected and identified by the par­ ticipants, which was probably due to the cochlear implant’s bias toward providing access to sounds in the speech frequency (gibson, rennie & psarros, 2000). while over 93% o f participants could detect music, their own names and family names, soft sounds and whispered speech, fewer participants could also dis­ criminate these sounds. access to sound, however, was greatly improved by cochlear implantation. linguistic outcomes: m ode o f communication from the breakdown in table 2 it was evident that the ma­ jority o f children was using the auditory-oral mode of communica­ tion as opposed to signing, and was in various stages o f develop­ ment o f spoken language. the largest number of children was cate­ gorized in the ‘functional language’ column, which in this context meant that they were using connected speech in complete or in­ complete sentences more often than 3-word utterances or shorter units o f language. more children in this study were using single words than more complex word combinations, however, an even larger group was using mature sentence forms. this indicated that in the present cross sectional study, more children were in either the earlier, or the more advanced stages o f language acquisition than in the mid­ dle stages. this result did not necessarily imply that these children were o f a certain age group, since the linguistic outcome o f paedi­ atric cochlear implantation is highly variable. the population is a “notoriously heterogeneous population with great variation in their auditory, cognitive and linguistic maturity that may be impossible to quantify before inter­ vention (o ’donague et al., 2.000, p.467), however, duration o f de­ vice use could play a role. j table 2: m ode o f com m unication and level o f language developm ent for all children (n =45) j a possible cause of the variation in speed and extent of linguistic outcome was the central auditory processing mecha­ nisms that are crucial to the perception of speech through a cochlear implant, and for which there are as yet no reliable measures (o ’donague et al., 2000). from this discussion it is evident that cochlear implantation resulted in access to a wide range o f sounds, including speech and soft environmental sounds for most o f the children in the pcip, although children in the ie group showed slightly better outcomes. all the chil­ dren wore their cochlear implants, and the majority was ac­ quiring, or had acquired, speech through listening. educational placement outcomes: comparison o f variables and outcomes fo r children in ie and those in se settings. for most cochlear implant programmes the goal o f early implantation is to allow the child to be placed into an ie setting and to function among his/her normal hearing peers. the nottingham paediatric cochlear implant programme (1997) reported placing 53% of their preschool age children in inclusive settings at two years post-implant, while the bir­ mingham paediatric cochlear implant programme (2000) re­ ported placing 17% of their total population, of all ages, in regular classrooms. tables 3 and 4 endeavour to profile various characteris­ tics and outcomes as they pertain to children in ie, and those in se settings. two children were at home with their mothers and were not in any educational setting; therefore the total for the two groups was 43 children. only two children attended schools for the deaf where sign language was a medium o f tuition. ® age at diagnosis o f hearing loss the children in the preschool ie group received a diagnosis slightly earlier than those in the se group, with an average difference o f 6 months, as illustrated by tables 3 and 4. the same trend was seen in the primary school (average difference 17 months) as well as the high school (average difference 9 months) groups. since diagnosis is the first step toward ampli­ fication and cochlear implantation, it seems that the children in the se group were, in general, at a slight time disadvantage from the start (yoshinaga-itano, sedey, coulter & mehl, 1998). • age at fitting o f hearing aids in general, children in the three groups in ie were fitted with hearing aids earlier and younger than those in se settings. the ie group thus had access to sound, prior to cochlear implanta­ tion, at a younger age than the se group, allowing important neurological development to take place in the auditory cortex (katz et al., 2002). * age at cochlear implantation the largest group o f ie preschoolers was implanted between the ages o f 1 and 2, while the majority o f se preschool chil­ dren received their cochlear implants between the ages o f 2 and 3 years o f age. this represented a significant difference in the children’s groups in terms o f neural plasticity and capacity to acquire age-appropriate language, although it is worth not­ ing that the majority of children in this age range were im­ planted at or before 3 years of age. as seen in tables 3 and 4, no children were implanted prior to age 3 years in the primary school se group, and this group received their cochlear im­ plants on average 14 months later than their peers in the ie group. since age has been identified through-out the literature as the major determining factor in successful paediatric comode/level of communication development p e r*» » la § e o f children using often sounds 36% natural gestures 38% word approximations 31% average for preverbal level 35% single words 36% average for transitional level 36% two word combinations 1 29% three word combinations 29% average for level acquiring functional language 29% incomplete sentences 36% complete sentences 47% average for functional language level 42% sign language 11% speech plus sign: total communication 22% the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 54 m arguerite jessop, a lta k ritzinger and n ellie venter t a b le 3: d escription o f characteristics o f children in inclusive educational settings (n =19) ddivision o f group into ag e categories characteristics preschool n=6 primary school n=10 high school n=3 age at diagnosis of hl* 6-16m 6-18m 10-33m age at fitting of hearing aids 7-18m 9-19m 10-34m age at cochlear implantation 19-24m: n=4 32m: n=1 42m: n=1 22-75m 52-140m cause of hl • unknown:3 • hereditary: 1 • syndrome (waardenburg):1 . cmv:1 • unknown:3 • hereditary:2 • meningitis:1 • cmv:1 • complications in pregnancy: 1 • unspecified syndrome:1 • myelin sheath disorder: 1 • unknown:1 • maternal medication:1 • meningitis.! congenital hl all n=7 n=2 progressive hl none n=2 n=1 acquired hl none n=1 none married parents all n=6 n=2 older siblings all n=5 n=2 no. of languages spoken in home 1-2 1-2 2 sir** category of speech intelligibility 2-5 5: n=7 4: n=3 5 no. currently enrolled in speech therapy all (previously & currently) n=5 (all previously) n=1 (all previously) no. currently enrolled in occupational ther­ apy n=1 (2 previously) n=1 (5 previously) n=0 (2 previously) able to use telephone n=2 n=8 n=3 use of fm system none n=6 n=1 prenatal complications none n=3 none perinatal complications none n=6 n=1 feeding problems n=2 n=2 n=0 developmental milestones excluding speech delayed: n=2 delayed: n=1 delayed: n=1 hospitalizations and reasons • insertion of grommets for otitis media • respiratory tract infections • digestive tract illness • insertion o f grommets for otitis media • respiratory tract infections • digestive tract illness • meningitis • trauma • blood transfusions • insertion o f grommets for otitis media • meningitis 1 * hl: h earing loss; ** sir: speech in telligibility r ating scale chlear implantation (mayne et al., 2000), these results point to the urgency for more efficient systems o f diagnosis, referral to cochlear implant teams, establishing o f candidacy and funding for cochlear implantation in the pcip. • cause o f hearing loss the etiologies o f hearing loss for which the numbers were com­ parable between the two groups were genetic syndromes and unknown causes. more se than ie children lost their hearing due to congenital rubella syndrome and birth trauma, while more children in ie had hereditary hearing loss. children who experienced birth trauma might be expected to have suffered further developmental consequences o f neonatal asphyxia (merenstein & gardner, 1998), including increased risk for de­ velopmental delays in all areas including sensory, motor, cogni­ tive and speech/language development (rossetti, 2001). heredi­ tary, non-syndromic hearing loss is more likely to go unaccom­ panied by additional disabilities (angeli et al., 2000; matsushiro et al., 2002), implying that this specific cause o f hearing loss may be related to higher levels o f success with a cochlear im­ plant. i • nature o f hearing loss: progressive and congenital hearing loss in tables 3 and 4 it can be seen that slightly more children in ie had exposure to sound prior to the onset o f their hearing losses, placing them at an advantage in terms o f neurological matura­ tion o f the auditory cortex, even if exposure to sound was brief (ponton, don, eggermont, waring & masuda, 1996). • marital status o f parents most o f the parents o f children with cochlear implants in both groups were married. most children thus benefited from two parents, nuclear family contexts, found to be positively corre­ lated with significantly better academic and language outcomes (calderon & low, 1998). die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) parental perceptions o f c haracteristics and o utcom es o f c hildren and fam ilies in the p retoria c ochlear im plant program m e 55 table 4. d escription o f children in specialised educational settings (n=24) division o f group into age categories characteristics preschool n=11 primary school n=9 high school n=4 age at diagnosis of hl* 7-26m 10-48m 23-36m age at fitting of hearing aids 11-36m 11-48m 26-36m age at cochlear implantation <2yrs:n=1 2-3:n=7 3-5:n=3 40-84m <3yrs:n=0 3-5:n=2 96-120m <3yrs: n=0 3-5: n=0 cause of hl • birth trauma:1 • unknown:6 • hereditary: 1 • rubella:1 • syndrome (waardenburg): 1 • complications in pregnancy: 1 • birth trauma:1 • unknown:2 • hereditary: 1 • rubella:2 • meningitis:1 • otitis media: 1 • maternal cmv: 1 • birth trauma:1 • unknown:1 • syndrome: 1 (with kidney disease) • maternal medication: 1 congenital hl n=10 n=8 n=3 progressive hl n=3 n=1 n=2 married parents n=9 divorced =1 live toqether = 1 n=8 remarried =1 n=2 widowed=1 divorced=1 older siblings n=8 2=middle 7=youngest n=5 n=2 (1=only child, 1=youngest of 3) no. of languages spoken in home 1-2 language: n=10 3 languages: n=1 1-2 languages 1-2 languages sir category of speech intelligibility 1:n=3 2:n=3 3:n=1 4:n=3 5:n=1 1:n=1 2:n=0 3:n=3 4:n=2 5:n=3 1:n=0 2:n=0 3:n=1 4:n=2 5:n=1 no. currently in speech therapy n=6 (9 previously enrolled) n=5 (6 previously) n=3 (4 previously) no. currently in occupational therapy n=0 (4 previously) n=2 (6 previously) n=0 (1 previously) able to use telephone n=5 n=4 n=3 use of fm system 5 n=2 n=0 prenatal complications n=2 n=3 n= 0 / perinatal complications n=11 n=9 n= 2 feeding problems n=5 n=0 n=0 developmental milestones excluding speech | delayed: n=6 delayed: n=2 delayed: n=1 ii / hospitalizations and reasons • insertion o f grommets • fever • failure to thrive • reaction to vaccination • poisoning • respiratory tract infections • digestive tract illness • meningitis • trauma • blood transfusions • meningitis • insertion o f grommets for otitis media • respiratory tract infections • respiratory tract infections • skeletal fractures *hl: h earing loss • presence o f older siblings this variable was explored due to the possible advantages to language acquisition o f having an older sibling as a peer lan­ guage model. results indicated that slightly more o f the chil­ dren in the ie group had the advantage o f an older sibling in the home. in general, most children in this study were the youngest and had older siblings (62-68%). • number o f languages spoken in the home the majority o f families in both groups spoke one or two lan­ guages in the home. the possible effects o f language confusion on the child were not significant in either group, and closer in­ spection revealed that in both groups, bilingual families at­ tempted to speak only one language in the home to accommodate the participant. the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 56 m arguerite jessop, a lta k ritzinger and n ellie v enter • speech intelligibility according to the speech intelligibil­ ity rating scale (sir) the rating scale used, namely speech intelligibility rating scale (allen et al., 1998) (sir), grades speech intelligibility in 5 levels as follows: 1 indicates unintelligible speech; 2 indicates that intelligible speech is developing in single words in a known context; 3 means speech is intelligible to a listener who concentrates and lip-reads; 4 indicates speech which is intelligible to a listener without much prior experi­ ence o f deaf speakers; and 5 means speech is intelligible to all listeners. in general, the sir level reported was higher for preschool children in ie than in se, and no children in ie had a rating indicating unintelligible speech. for the pri­ mary school children, the difference became more pro­ nounced with children in ie reported as having normal or near-normal speech, as opposed to the se children whose ratings varied widely and tended to be lower. ie children in high school were all rated at the maximum score as being normally intelligible, whereas their peers in se were gener­ ally rated as being more difficult to understand. this vari­ able showed a marked difference between the two groups, indicating that speech intelligibility is likely to be affected by, and affects, decisions regarding educational placement. • speech-language and occupational therapy: children currently and previously enrolled in therapy o f the preschoolers depicted in tables 3 and 4, a larger per­ centage in ie were enrolled in speech-language therapy than those in se. this could be due to the greater support given in class by specialised settings, or due to the increased pres­ sure on children in ie to keep up with their normal hearing peers, requiring support services outside the school. how­ ever, as the ages o f children increased, more children in se were still making use o f the services o f a speech-language therapist in primary and high school than those in ie. this appeared to indicate that ie required greater levels o f sup­ port services initially, but that this tends to decrease as the child gets older and becomes fully integrated into the sys­ tem. • telephone use as shown in tables 3 and 4, in both the primary and high school groups, the vast majority o f study children in ie could use a telephone to communicate successfully, while the percentages were smaller for the se group. this may give an indication of hearing with the cochlear implant, cen­ tral auditory processing o f a less than ideal signal such as that heard over a telephone line as well as reliance on speech reading. • use o f an f m system at school o f the preschool age children, almost half (45%) o f those in se used an fm system at school, while none o f the ie group did. however, at primary school age only 22% o f se chil­ dren were using an fm system as opposed to 60% o f chil­ dren in ie, presumably as the listening demands in an inclu­ sive classroom increase in the formal education system whereas more adaptations are made for listening in se classes. the conclusion can be drawn that fm systems are still important after cochlear implantation in order to opti­ mize the listening environment. this is true especially in inclusive primary school classrooms where no special acoustic adaptations are made, class sizes may be large, and children’s auditory processing skills are still developing in order to cope with listening in background noise. • biological contributing factors: prenatal and perinatal compli­ cations or conditions in general, more children in the se group presented with prenatal or perinatal complications or conditions than children in the ie group: 39% o f the se group as opposed to 17% o f the ie group (see tables 3 and 4). due to their far-reaching implications (rossetti, 2001), these variables may have played a role in placing the chil­ dren in the se group at a developmental disadvantage, which in turn may have resulted in their educational placement in special school settings. • feeding difficulties in neonatal and early childhood stage according to tables 3 and 4, the group which reported the largest incidence o f feeding difficulties was the preschool se group, al­ though a small number o f children in the ie preschool and primary school group also reported feeding difficulties. early feeding diffi­ culties are a well-known risk factor for communication delay in children (rossetti, 2001). • developmental milestones (excluding speech and language milestones) significantly more o f the preschoolers and primary school children in the se group were reported to have presented with delays in achieving developmental milestones than their peers in ie. this may indicate the presence o f additional delays in development o f the children who were subsequently placed in se settings, in areas not directly related to the hearing loss such as motor, sensory and self-help skill development. • hospitalisations reasons for hospitalisation were similar for the se and ie groups, including both the causes o f acquired hearing loss (meningitis) and most frequently illnesses affecting the respiratory and digestive systems. results for sub-aim 4: identification of variables affecting the success o f children with cochlear implants in the pcip this sub-aim was fulfilled using the results and discussions arising from the division o f the participant group into two groups based on educational outcomes. the purpose to provide a set o f variables that could be linked to outcome measures of fully ie placement, which implies positive speech, language and auditory outcomes as demonstrated in the preceding results and discussions. in general it can be seen that, in the children o f this study, the variables [listed in table 5 were linked to positive outcomes. • j table 5: e leven m ost im portant variables associated w ith successful out­ com es o f children w ith cochlear im plants in the pcip , 1. early age at diagnosis, intervention with hearing aids, and cochlear implantation 2. absence of prenatal and perinatal complications 3. higher level of maternal education 4. developmental milestones achieved at normal ages 5. absence of early feeding difficulties ^ 6. use of an fm system in early schooling (primary school level) 7. intelligible speech 8. access to eci 9. presence of an older sibling x 10. absence of birth trauma and congenital rubella syndrome as causes of hearing loss. (more successful outcomes when cause of hearing loss was hereditary and non-syndromic, or unknown) 11. later onset of hearing loss: acquired (few children) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) parental perceptions o f c haracteristics and o utcom es o f c hildren and fam ilies in the p retoria c ochlear im plant program m e 57 variables associated with success with a cochlear implant fo r children in the pcip: (as measured by placem ent in ie settings) in order to provide clarity and structure, these variables in table 5 can be used by the pcips team o f professionals to guide programme planning in terms o f selection criteria, intervention decisions and counseling regarding realistic expectations in parents o f children with cochlear implants. each child and family’s individual profile o f risks, strengths and needs can be ascertained, and planning can be opti­ mised. early diagnosis, early intervention with hear­ ing aids and early cochlear implantation, also con­ firmed by other studies (yoshinaga-itano, 2000; yo shinaga-itano et al., 1998) stand out as the most im­ portant variables associated with successful outcomes o f children with cochlear implants in the pcip. conclusion the study produced valuable data on the chil­ dren in the pcip in 2004, yet the results represent only 63.4% o f those children and their families. es­ tablishing a computer database to store and retrieve client data continuously for regular programme audits and research is recommended to monitor outcomes and to ensure best practice in the programme. a data­ base provides the opportunity to store data on direct clinical observations and measurements, overcoming the limitations o f research on parental perceptions o f outcomes a clear limitation o f the present study. the children o f this study, although differing widely in age, educational level and setting, and cir­ cumstances leading to cochlear implantation, were not representative o f the south african population or the population of south african children with severe to profound bilateral hearing loss as a whole. as co­ chlear implantation is still an expensive, elective pro­ cedure falling almost exclusively in the realm o f the private health care sector in this country, this profile o f "clients is unlikely to change until state funding for cochlear implantation is secured. this can only be achieved by the concerted jefforts of clinicians and researchers to generate similar studies on which to base strong motivation for cochlear implantation, universal infant hearing screening and follow-up pro­ grammes for all south african hospitals and clinics in addition to the use of high risk registers, and eci (swanepoel, 2004). the study has provided descrip­ tions and guidelines for translating theory into action to prioritise early intervention for children with hear­ ing loss. such an effort requires an “unprecedented level o f commitment and cooperation by all those involved: state and community agencies, professional groups and practitioners, parents, advocacy organiza­ tions, researchers, and institutions o f higher educa­ tion” (guralnick, 2001: p. 18). with the challenge of early identification of hearing loss, access to early intervention services for all, and state funding ena­ bling earlier implantation and the reaching o f a more representative section o f the population realised, the outcomes o f cochlear implantation in south africa may exceed the most optimistic expectations. references a llen, m .c ., n iko lo p o u lo s, t. n ., & o ’d onoghue, g. m. 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(1998). t he lan­ g u age o f earlyand later identified children w ith hearing loss. pediatrics, 102, 1161-1171. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) abstract introduction the south african public health sector national health insurance the speech-language therapist in south africa dysphagia triage challenges with early dysphagia identification conclusion acknowledgements references about the author(s) kelly-ann kater department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation kater, k-a. (2022). triage and dysphagia: are hospitals in the south african public health sector ready? south african journal of communication disorders, 69(1), a852. https://doi.org/10.4102/sajcd.v69i1.852 opinion paper triage and dysphagia: are hospitals in the south african public health sector ready? kelly-ann kater received: 09 sept. 2021; accepted: 14 apr. 2022; published: 30 june 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract dysphagia screening is unequivocally beneficial for individuals who may be at risk of swallowing impairment. benefits range from capitalising on early intervention, facilitating hydration and nutrition, reduced financial costs for the patient and prevention of dysphagia-related complications. why then is there a need for triage? inefficiencies and often non-existence of screening and referral processes require one to consider if triage may be a more viable option in the public healthcare context. dysphagia triage could potentially prioritise emergency swallowing care and identify patients who need immediate swallowing attention because of the nature or severity of dysphagia. the use of a dysphagia triage checklist could have implications for patient health outcomes in terms of the safety of oral diets, development of aspiration pneumonia, malnutrition, administration of oral medication and overall patient prognosis. keywords: dysphagia; emergency department; triage; speech-language therapy; evidence-based practice; dysphagia triage. introduction dysphagia is a common cause of aspiration and subsequently a common cause of morbidity and mortality (white, o’ rourke, ong, cordato, & chan, 2008). early detection of dysphagia is essential to reduce length of hospitalisation, degree of morbidity, hospital costs and the risk of pneumonia (ostrofsky & seedat, 2016). the emergency department (ed), being the first entry point for any patient into the hospital, could be the most opportune time and space to triage a patient for dysphagia. triaging patients enables identification of patients at risk of dysphagia. early detection of dysphagia improves health outcomes. given the south african hospital context, the limited number of speech-language therapists (slts) practicing in the public sector, the working hours of slts in hospital settings and the high patient-to-therapist ratio, triaging for dysphagia in the ed could facilitate identification of patients at risk of dysphagia, which in turn may enable early and appropriate referral to a slt. the south african public health sector the south african public health sector caters to approximately 84% of the total population, the majority of whom are poor and uneducated (naidoo, 2012). ‘the inequalities and poor quality in the health system are aggravated by a skewed distribution of key health professionals between the public and private sectors’ (department of health [doh], 2017). [t]he shortage of key health professionals is being experienced in a time of the growth of the population dependent on public healthcare services, and the increasing burden of disease among the population. (p. 23) this has placed extraordinary strain on public sector health services and on the staff who work in public sector facilities. this, in turn, has contributed to the poor health outcomes of south africans, particularly for the lowest income populations and households. in south africa, there are insufficient slts to manage the patient demand (pillay, tiwari, kathard, & chikte, 2020), with only a small percentage actually providing comprehensive dysphagia services (andrews & pillay, 2017). dysphagia services have evolved in response to the increasing evidence base for the role of the multidisciplinary team (mdt) members in screening for dysphagia and the role of slt in the assessment, diagnosis and management of dysphagia (brady & roe, 2020). however, dysphagia care pathway designs and provision are hugely driven by service capacity or national guidance (brady & roe, 2020). as the national health insurance (nhi) is still within the planning phase, it may prove to be beneficial for dysphagia triage to be included in the care pathway for dysphagia. national health insurance [the] nhi is a health care financing system that is designed to pool funds to actively purchase and provide access to quality, affordable personal healthcare services for all south africans based on their health needs, irrespective of their socioeconomic status. (doh, 2017, p. 13) the nhi aims to cover services that are delivered on a people-centred integrated healthcare system (doh, 2017). this will require a more responsive and accountable health system. the health system would need to consider sociocultural and socioeconomic factors. in addition, this people-centred integrated healthcare system platform aims to improve user satisfaction and in turn should lead to a better quality of life and improved health outcomes across all socioeconomic backgrounds (doh, 2017). the features of the nhi include efficiency and effectiveness. this means that healthcare resources should be allocated and utilised in a manner that optimises value for money by using the resources to maximum advantage and by maximising the welfare of the community by achieving the right mixture of healthcare programmes for the entire population (doh, 2017). the nhi further aims to ensure that the health system meets acceptable standards of quality and achieves positive health outcomes (doh, 2017). on paper, the concept of dysphagia triage fits into the nhi framework, however, it appears as if the south african health context has a significant way to go in terms of staff numbers and access to resources before these systems may be effective. furthermore, international research is moving towards the notion of models of care and ‘the ideal patient journey’ (new south wales [nsw] health, 2012). this concept is based on the following: early assessment and streaming to an appropriate model of care a team approach to patient care ensuring tasks are performed by the medical practitioner who can most efficiently perform the task (where ‘efficiency’ balances quality, cost and minimising duplication of work) coordinated patient care strong monitoring and evaluation measures adherence to the principles of models of care (nsw health, 2012). looking at these principles of the ideal patient journey, early identification of dysphagia in at-risk patients would fit well into this model (barnard, 2011). whilst in theory and based on the literature, dysphagia triage is of value to the acute health system, it is unlikely at this stage that south african eds would be able to cope with the additional demand of the dysphagia triage checklist, as the focus of any ed is to stabilise medically unstable patients, with the risk of dysphagia and aspiration unlikely to be a priority at that time. the speech-language therapist in south africa screening, assessment, diagnosis and management of dysphagia typically falls under the scope of practice of the slt because of their training in the anatomy, neuroanatomy and physiology of deglutition (cichero, heaton, & bassett, 2009; logemann, 1998). the aims and objectives of the slts’ interventions for dysphagia depend on the type and nature of the dysphagia, the underlying cause and the needs and preferences of the individual (cichero et al., 2009). however, because of the high patient-to-therapist ratio (pillay et al., 2020), limited resources and late patient referrals, screening may not be regularly conducted in south african hospitals within the public sector. the dysphagia guideline set out by the south african speech language hearing association (saslha), advocates for screening procedures to be conducted by other mdt members, which includes but is not limited to doctors and nurses (saslha, 2011). currently, it is likely that screening may be carried out by slts on an ad hoc basis, depending on time, staffing and the availability of students in training from universities who may be of assistance. despite there being several south african and global dysphagia screeners, no standardised national screening guideline for dysphagia exists, suggesting that each context or hospital within the public healthcare sector may be operating in line with their institutions’ human resources, patient numbers and logistical availability. like the universal newborn hearing screening guidelines which exist for audiologists, similar studies pertaining to dysphagia have not been undertaken or published. this risk-based hearing screening programme has been found to be practical and feasible for south africa (kanji & khoza-shangase, 2016). however, the inefficiencies and often non-existence of dysphagia screening and referral processes require one to consider if triage may be a more viable option in the public healthcare context. considering the safety of swallowing, managing aspiration and preventing complications are of utmost importance (logemann, 1998). a policy developed by the royal college of speech and language therapists (rcslt) in the united kingdom recommends that there should be at least one full-time slt per 10 beds in every stroke unit (rcslt, 2007). furthermore, the policy suggests that if the ratio of slts per 10 patients falls below this then it would impede timely assessments and follow-up management (rcslt, 2007). however, slts in south africa comprise a small percentage of practicing healthcare professionals and often find themselves trying to service large caseloads in a country that has limited resources (blackwell & littlejohns, 2010; pillay et al., 2020). in addition, slts are most commonly available during regular working hours on weekdays. thus, nurses and doctors play a pivotal role in patient care and communication between other professionals as they provide 24-h care. south african speech language hearing association recommends that the management of dysphagia requires mdt involvement with regard to screening; however, assessment is within the scope of practice of the slt (saslha, 2011). dysphagia triage dysphagia triage could potentially prioritise emergency swallowing care and identify patients who need immediate attention because of the nature or severity of dysphagia. in order to understand the concept of triaging it is important to differentiate between triaging and screening. triage refers to identifying the possibility of the presence or absence of a dysphagia and does not involve food trials, whereas screening examines (1) the likelihood of dysphagia, (2) the requirement for further swallowing assessment, (3) the safety of patient oral intake and (4) the requirement for alternative nutritional support. it is proposed that the dysphagia triage checklist takes place at the earliest point in the patient’s presentation to the hospital (i.e. the ed). triaging would require minimal training, could be administered in less than 2 min and does not use food trials. it can be administered by any medical professional and can be used on a variety of patient populations and is not limited to a specific diagnosis (e.g. stroke). a fail result for any of the test items indicates that the patient is at risk of dysphagia and therefore a screening is indicated. the literature advocates for dysphagia triage; however, context and environmental circumstances need to be considered. the knowledge that early interventions may prevent dysphagia complications leads to the recognition that it would be worthwhile to perform dysphagia triaging in the ed (barnard, 2011). personnel in the ed have the potential to affect the patient care in a positive way, advocate for early recognition of the signs and symptoms of dysphagia and potentially guide the management of this disorder (barnard, 2011). however, the implementation of a dysphagia triage protocol goes beyond recommendations from international literature and is hugely dependent on the context, particularly in south africa. challenges with early dysphagia identification there are many challenges surrounding effective identification of patients who present with dysphagia in developing contexts. these challenges include timing of identification of a swallowing difficulty and the timing of the assessment (ostrofsky & seedat, 2016; seedat, 2014). thus, clinicians are faced with using current research and evidence-based practice to make decisions for patients and to demonstrate that this research improves clinical outcomes (jones, roop, pohar, albrecht, & scott, 2015). ‘knowledge translation is an active process that facilitates the introduction of new evidence into practice and may identify optimum strategies to close the gap between research and clinical practice’ (jones et al., 2015, p. 2). the dynamics of knowledge flow are dependent on many factors, some of which include the nature of the research and the targeted level of implementation, whether it be implemented at a clinical or organisational level (jones et al., 2015). changing clinical behaviour (in this case, the implementation of the dysphagia triage checklist) is dependent not only on individual factors but also factors such as hospital policy, funding and organisational or management influence and staff workload (jones et al., 2015). thus, the implementation of a tool such as the dysphagia triage checklist requires a bottom-up method of implementation, as it requires the buy-in from both management and staff on the ground level. conclusion early identification of dysphagia has implications for patient management and outcomes. as a result of the poor prognostic outcome of patients with dysphagia, the need to identify reasonable means of early identification is imperative. inefficiencies and often non-existence of screening and referral processes require one to consider if triage may be a more viable option in the public healthcare context. dysphagia triage could potentially prioritise emergency swallowing care and identify patients who need immediate swallowing attention because of the nature or severity of dysphagia and would help to combat inequities, such as the limited number of slts practicing in the public sector, the availability of slts outside of working hours and the high patient-to-therapist ratios. however, given the current status of the healthcare system in south africa, that is, poorly resourced, over-crowded, understaffed and underfunded (doh, 2017), it is uncertain if a dysphagia triage protocol could be accommodated within the current functioning of the accident and emergency unit. acknowledgements competing interests the author declares that she has no financial or personal relationships, which may have inappropriately influenced her in writing this article. author’s contributions the author declares that she is the sole author of this article. ethical considerations ethical approval was obtained from the university of the witwatersrand human research ethics committee (medical), reference number: m160679. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article as no new data were created. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references andrews, m., & pillay, m. 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(2007). policy statement: the specialist contribution of speech and language therapists along the care pathway for stroke survivors. royal college of speech and language therapists. retrieved from www.stroke-in-stoke.info/otherfiles/policynov07.pdf seedat, j. (2014). knowledge translation in dysphagia – a south african study. doctoral dissertation, department of speech and hearing therapy, university of the witwatersrand, south africa. south african speech-language and hearing association (saslha). (2011). guidelines: dysphagia in adults. durban, south africa: saslha. white, g., o’ rourke, f., ong, b.s., cordato, d.j., & chan, d.k. (2008). dysphagia: causes, assessment, treatment, and management. geriatrics, 63(5), 15–20. abstract introduction methods results discussion implications for future research limitations conclusion acknowledgements references appendix 1 appendix 2 appendix 3 appendix 4 about the author(s) bilqees achmat division of speech-language and hearing therapy, faculty of medicine and health sciences, stellenbosch university, tygerberg, south africa berna gerber division of speech-language and hearing therapy, faculty of medicine and health sciences, stellenbosch university, tygerberg, south africa citation achmat, b., & gerber, b. (2022). challenges to infection control in early communication intervention: a scoping review. south african journal of communication disorders, 69(2), a911. https://doi.org/10.4102/sajcd.v69i2.911 research project registration: project research number: 21897 original research challenges to infection control in early communication intervention: a scoping review bilqees achmat, berna gerber received: 31 jan. 2022; accepted: 19 may 2022; published: 03 aug. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: personal protective equipment (ppe) and infection prevention and control (ipc) measures are crucial to preventing the spread of coronavirus disease 2019 (covid-19). this study used a scoping review to investigate the challenges that exist when speech–language therapists (slts) use ipc measures for providing early communication intervention (eci). objectives: to describe existing, recent literature on ppe and ipc measures used in early intervention through a scoping review (steps 1–5) and to consult local clinicians to investigate how slts who provide eci in south africa relate to these findings (step 6 of the scoping review). method: a scoping review was performed which followed the prisma-scr framework. because of limited literature on ppe and ipc measures used by slts in providing eci, the inclusion criteria were adjusted to include ppe and ipc measures used by healthcare workers (hcws) who provide early intervention to the population of infants and toddlers up to 3 years old. at the time of the review, articles were not older than 10 years and were published between 2011 and 2020. the scoping review included a consultation with south african slts who provide eci, including during the covid-19 pandemic. a pilot study was conducted prior to the consultations. seventeen clinicians were included in total. data from both the pilot study and main consultation were transcribed and analysed in the results using thematic analysis. results: fourteen articles were included in the study. the scoping review of existing literature identified challenges to implementing ipc measures, namely the care and behaviour of young children, infrastructure and system challenges, poor compliance and lack of training and a lack of standard ipc protocols. clinicians in the consultation phase confirmed these challenges and reported that ipc measures did not consider eci populations nor the settings in which services were provided. suggestions from the literature for improved infection control included hand hygiene, improved supplies and infrastructure and education and training. clinicians in the consultation added practical suggestions for implementing ipc measures within eci, which included an increase in parent-led intervention as well as cleaning and disinfection strategies. conclusion: this study identified challenges and recommendations of slts who use ppe and ipc measures whilst providing eci. understanding these challenges can benefit eci services and future research efforts focused on improving eci services whilst maintaining ipc standards. keywords: early communication intervention; early intervention; personal protective equipment; infection prevention and control measures; infection control; scoping review, prisma-scr. introduction the coronavirus disease 2019 (covid-19) pandemic has disrupted healthcare services around the world (manto et al., 2020). speech–language therapists (slts) who provide early communication intervention (eci) have faced exceptional challenges during the pandemic because of the nature of eci, which includes face-to-face exchanges and close proximity to patients (owens, 2016). as a result, slts providing eci and their clients are at risk of exposure to infectious agents. one clear strategy to reduce the spread of covid-19 is the use of personal protective equipment (ppe) and infection prevention and control (ipc) measures (sarma et al., 2020). personal protective equipment may, however, disrupt eci services, as face masks obstruct visual access to the mouth and can reduce speech perception (atcherson et al., 2017; hashikawa et al., 2020; khan et al., 2019). in addition, implementing ipc measures may be particularly challenging in eci as young children are unable to perform adequate self-hygiene without supervision (hashikawa et al., 2020). thus, a balance is needed between the optimal delivery of eci services and the maintenance of ipc standards. for slts to devise the best strategies for implementing ipc measures as well as providing effective eci services, the existing ppe and ipc measures used within eci need to be identified and described. a review of existing literature revealed no recommendations for the best practice of ipc measures by slts within eci. there is also limited available literature on ipc measures used by other healthcare workers (hcws) within early intervention for children from birth to 3 years. furthermore, most of the relevant studies were conducted in high-income countries (hics) (buser et al., 2013; gupta & pursley, 2011; verma et al., 2020; yin, schweizer, herwaldt, pottinger, & perencevich, 2013). this challenges the transferability of research findings in the relevant literature to settings in lowto middle-income (lmics) countries. for example, in lmics such as south africa, the implementation of ipc measures may be restricted by the lack of available and affordable ppe as well as insufficient healthcare infrastructure (blignaut, nemutandani, & samaranayake, 2020; sokunbi et al., 2020). infection prevention is essential for providing high-quality and safe healthcare services to vulnerable populations such as neonates (dramowski et al., 2020). the aim of this study was, firstly, to identify the ppe and ipc measures used in early intervention as reported in existing and recent literature and, secondly, to investigate how local clinicians (slts who provide eci in south africa) relate to the scoping review findings. this was achieved through two research objectives: (1) to describe the recent research literature on ppe and ipc measures used in early intervention through steps 1–5 of a scoping review and (2) to reflect on these literature review findings through consultations with south african slts involved in eci, as step 6 of the scoping review. early communication intervention ‘early intervention’ refers to services provided by hcws to the population of birth to 3-year-old infants, toddlers and their caregivers (south african speech-language-hearing association, 2017). ‘early communication intervention’ is distinguished from early intervention in that it focuses on communication and language skills and is provided by slts (south african speech-language-hearing association, 2017). during eci, slts are often in close proximity to young children (e.g. when playing, feeding and cleaning) and are exposed to bodily fluids and secretions (e.g. drooling, mouthing, crying, uncontrolled respiratory secretions and incontinence), which places slts at risk of exposure to potential infectious agents (hashikawa et al., 2020; siegel, rhinehart, jackson, & chiarello, 2007). as young children are not able to adopt the same infection control practices as adults, it is essential that practitioners observe the proper use and disposal of ppe and ipc measures to protect both vulnerable patients and staff. personal protective equipment and infection prevention and control measures personal protective equipment refers to barriers and respirators that are used to reduce contact between infectious agents and airways, skin and clothing. there are different types of ppe, including gloves, gowns, face masks, goggles, face shields and respiratory protection. the ppe is selected according to the most likely mode of transmission and nature of hcw–patient interaction (siegel et al., 2007). infection prevention and control measures are defined as actions that inhibit or reduce the spread of disease within an environment (khan et al., 2019). standard precautions should be used for all patients, and additional transmission-based precautions should be used for the management of droplets, close contact and airborne transmissions (siegel, 2007). adherence to ipc measures may include implementing teamwork, education and training, screening of patients, hand hygiene, disinfection and isolation of the ill (khan et al., 2019; northway, langley, & skippen, 2011; siegel et al., 2007). challenges the covid-19 pandemic has compelled hcws to adopt certain ppe and ipc measures to combat the spread of the disease. this includes wearing face masks, maintaining social distancing, following respiratory etiquette (covering a cough) and handwashing (chu et al., 2020; hashikawa et al., 2020). these ppe and ipc measures may present challenges to slts providing eci. for example, face masks cover visual cues and expressions (such as smiles, frowns and smirks) which are crucial when targeting pre-linguistic skills in eci (atcherson et al., 2017; keen et al., 2016). in addition, social distancing may cause speech to be less audible or even completely unheard (grieco-calub, 2021). furthermore, infants and toddlers can bring about barriers to implementing ipc measures. for example, eci involves close physical interactions with young children who may not practise proper cough etiquette, and this increases the need for respiratory protection (northway et al., 2011; siegel et al., 2007; south african speech-language-hearing association, 2017). in addition, young children often expel bodily fluids and secretions when held; however, there is little guidance on the frequency of changing gloves and gowns. lastly, young children frequently mouth their hands and touch surfaces. this requires repeated disinfection of surfaces, which can be challenging in settings with limited time and resources (hashikawa et al., 2020). there are strategies that can be implemented to alleviate these challenges. firstly, coaching parents is an effective method of providing eci, which can reduce close contact encounters with young children. however, eci consists of multiple components, of which parent-led intervention is only one (dathan rush, 2021). secondly, virtual communication or telecommunication is recommended as a practical and efficient method of providing care during the social distance restrictions of the covid-19 pandemic (sarma et al., 2020). however, virtual communication cannot fully replace in-person encounters, and individuals in lmics may have technological constraints and/or difficulty accessing networks and the internet (manto et al., 2020; sokunbi et al., 2020). context in south africa, the majority of children live in underserved and disadvantaged communities. these children are at increased risk for communication delay because of poverty, disease and psychosocial hazards (du toit, van der linde, & swanepoel, 2021; samuels et al., 2012). in addition, children in low-resource settings are at increased risk of developing healthcare-associated infections (hais) because of host factors (e.g. human immunodeficiency virus [hiv] and acquired immunodeficiency syndrome [aids], malnutrition) and health system factors (e.g. poor infrastructure and lack of ipc practices) (rothe, schlaich, & thompson, 2013). consequently, there is a high demand for eci services which implement efficient ipc measures. there is limited research on the implementation of ipc measures by south african slts during the covid-19 pandemic (adams, seedat, coutts, & kater, 2021). a study by adams et al. (2021) highlighted the impact of covid-19 on the services delivered by slts. although the study did not focus on eci, the findings indicated that paediatric and high-risk patients were most impacted by disrupted outpatient services during the pandemic. furthermore, blignaut et al. (2020) described south africa’s response capacity to the pandemic in comparison to hics. south africa was described as having additional challenges such as a lack of resources (e.g. ppe) and chronic infrastructure challenges (e.g. regular electricity and water shortages) (blignaut et al., 2020). challenges to implementing infection control existed in south africa prior to the covid-19 pandemic. according to dramowski, cotton and whitelaw (2017), previously existing environmental challenges to hai prevention in neonates and children included overcrowding, high patient-to-staff ratios, lack of ipc provision, lack of isolation facilities, inadequate cleaning and reuse and sharing of equipment. these previous inadequacies in healthcare have most likely worsened because of the covid-19 pandemic (sokunbi et al., 2020). the purpose of this study was to describe ppe and ipc measures used in early intervention through a scoping review of existing and recent literature and consultation with south african slts who provide eci. methods this study followed a scoping review design and comprised six steps in accordance with existing methodological guidance (arksey & o’malley, 2005; levac, colquhoun, & o’brien, 2010; aromataris & munn, 2020). the scoping review consisted of a systematic literature search (steps 1–5) followed by a consultation with local clinicians (step 6). the consultation took the form of online focus group discussions (fgds). the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr) was used as a reporting guideline to ensure methodological transparency in the scoping review (tricco et al., 2018; see appendix 1). in addition, the joanna briggs institute (jbi) (aromataris & munn, 2020) recommends cross-checking the synthesised findings of the scoping review to assign a level of credibility. thus, stages 1–5 of the scoping review were cross-checked by a research assistant (ra) with knowledge of and experience in scoping reviews as well as eci. step 1: identifying the research question according to levac et al. (2005), the purpose of the scoping review should be considered whilst articulating the research question. the purpose of this scoping review was to describe ppe and ipc measures used in early intervention as reported in the current literature and to reflect on the scoping review findings by consulting with stakeholders, namely south african slts involved in eci. therefore, the research question and sub-question were as follows: (1) what is known from the existing international literature about the available ppe and ipc measures used within early intervention? and (1.1) how do slts in south africa who provide eci relate to the literature (scoping) review findings with regard to ppe and ipc measure used for eci? step 2: identifying relevant studies the jbi’s (peters et al., 2020) three-step iterative search strategy was used to guide the identification of relevant studies. firstly, a search of the topic was conducted on nine online databases. this was followed by an analysis of the text words in the title, abstract and index terms used to describe the retrieved sources. a second search was then conducted across 13 databases using the identified keywords and index terms. the databases included clinical key, cochrane library, pubmed, science direct, scopus, web of science, google scholar, university of stellenbosch library, sabinet african journals, african journals online, african digital repository web of science, african education research database and ebscohost research databases. because of the extensive number of keywords used across studies, 16 different combinations of search strategies were developed. an example of the combination of keywords included [‘personal protective equipment’ or ‘personal protection equipment’ or ‘risk control equipment’] and [‘infection prevention and control measures’ or ‘infection control’] and [‘health care professionals’ or ‘health care providers’ or ‘health care workers’ or ‘health care staff’] and [‘early childhood intervention’ or ‘early childhood development’ or ‘early communication intervention’]. then, a third search was undertaken using the reference lists of identified sources. professionals and scholars in the field were also contacted to provide any additional relevant literature not identified through the database searches (peters et al., 2020). inclusion criteria for the selected studies any existing literature (published or unpublished) which met the inclusion criteria were accepted, for example, primary research studies, reviews, letters, guidelines, meta-analyses, websites and books. the selected studies were those which: were written in english were not older than 10 years at the time of the search and published between 2011 and 2020 focused on early intervention services provided by hcws focused on services delivered to the population of children from birth to 3 years focused on ppe and/or ipc measures in delivering the early intervention services were available through the university of stellenbosch library service. step 3: study selection the first author independently screened the titles of the search results, and the collected sources were cross-checked by the ra. then, both the first author and the ra conducted an abstract and full-text review. the inclusion of studies within the data set was discussed upon the completion of each screening process. the suitability of each study was determined by the inclusion criteria. in instances where a consensus could not be reached, a successive screening process was conducted. for example, the abstract review was succeeded by a full-text review, which was then succeeded by a preliminary data extraction exercise. studies were included if the information provided in the data extraction process was sufficient to answer the research question. step 4: charting the data the data charting process was iterative and included an initial trial to ensure that all relevant results were extracted through the data charting form (levac et al., 2010; peters et al., 2020). the final data chart included space to record the authors, year of publication, source, country where the research was conducted, research design, research setting, ppe and/or ipc measure(s) described, function of or rationale for the ppe and ipc measures, person or team involved, age range of children, duration of data collection, aims, results, limitations and recommendations (see appendix 2). the ra cross-checked the data extracted from a random selection of 28.57% of the selected studies. this was above naudé and bornman’s (2018) recommended cross-checking of 20% of the data to increase reliability. a trial analysis was conducted to reach a consensus on any discrepancies. step 5: collating, summarising and reporting the results numerical analysis was used to describe the characteristics of the studies selected in step 4 (arksey & o’malley, 2005; see appendix 3). thematic analysis was used for qualitative data to identify, analyse and provide a detailed report on patterns (themes) of meaning (braun & clarke, 2006). braun and clarke’s (2006) six phases of thematic analysis were utilised and included (1) familiarisation, (2) generating codes, (3) searching for, (4) reviewing, (5) defining themes and (6) producing the report. the ra reviewed the completed thematic analysis of step 5 to ensure that the themes and codes were aligned with the research question and objectives. no changes were required in this regard. step 6: consultation with local early communication interventionists a consultation exercise was conducted to share the preliminary scoping review findings (of steps 1–5) with local stakeholders to validate the findings and to inform future research (levac et al., 2010; pollock et al., 2021). the target population comprised registered slts who provided eci in south africa during the covid-19 pandemic. participants were selected using the nonprobability sampling technique of critical case sampling. this involved the researcher purposefully selecting individuals based on specific characteristics or inclusion criteria (onwuegbuzie & collins, 2007). to be included in the consultation, participants had to: be south african slts (including community service slts) registered with the hpcsa provide eci during the covid-19 pandemic for a minimum of 3 months (as the pandemic necessitated the use of ppe and ipc measures when providing eci) must have sufficient access to the internet (as the consultation was conducted online). participants were recruited through an online advert to take part in the research. the advert was posted on the social medial platforms facebook and whatsapp and was also distributed via e-mail. speech–language therapists who were interested in participating in the study were required to complete an eligibility survey based on the inclusion criteria. participants were required to complete an informed consent form before they were included in the study. twelve participants took part in one of two online fgds. the fgds included a 20-minute presentation of the preliminary findings of steps 1–5 of the scoping review as well as a 60-minute semistructured group interview, both conducted by the first author (b.a.). the second author (b.g.) attended both online fgds to provide technical or any other support required. the interview questions were directly related to the scoping review findings (see appendix 3). this enabled the researcher to describe the extent to which south african slts related to the research findings in terms of their own experiences, challenges and perceptions. prior to the online fgds, a face-to-face pilot study was undertaken by the first author with five slts to determine the suitability of the presentation and interview questions, as well as to become more familiar with the process of facilitating fgds. the pilot study also provided information on possible biases within the fgd design (naudé & bornman, 2018). this was done by using an anonymous feedback questionnaire which enabled the pilot study participants to comment on the presentation and fgd questions and provide suggestions for improvement. the feedback resulted in minimal changes to the presentation (e.g. repeating abbreviations and reducing the pace of the presentation) and no changes to the fgd interview questions. data from the pilot study were included in the results of the scoping review, along with the main fgd findings. therefore, a total of 17 clinicians took part in the consultation phase. clinicians were all registered slts who provided eci within different provinces of south africa, in both the private and public sectors. all clinicians had at least 3 months’ eci work experience during the covid-19 pandemic, which necessitated the use of ppe and ipc measures when providing eci. the online and pilot fgds were transcribed and analysed using thematic analysis. a theoretical (deductive) approach to thematic analysis was followed (braun & clarke, 2006) as the transcripts were analysed based on the findings of steps 1–5 of the scoping review. atlas.ti version 9 software was used to aid the data coding process and create visual representations of the data. a summary of the results was sent to participants as a form of member checking to increase the credibility of the research findings (varpio, ajjawi, monrouxe, o’brien, & rees, 2017). out of the 17 participants included in the study, 13 responded to the member checking. all clinicians who responded agreed with the research findings and no changes were suggested by the clinicians. ethical consideration ethical approval to conduct the study was obtained from the health research ethics committee (hrec) of stellenbosch university (ethical clearance number s21/03/047). results selection of sources the literature search and selection of sources are depicted in a prisma-scr flow diagram (figure 1). there were 113 820 024 sources identified in the initial search across 13 online databases. a total of 30 282 studies were screened after duplicates were removed. ‘other sources’ included the search of reference lists, which resulted in the identification of 31 studies, as well as contact with relevant professionals, which provided an additional nine studies. within the data extraction, more than half (nine) of the studies were obtained through ‘other sources’. this demonstrates the importance of expanding the literature search beyond electronic databases. figure 1: prisma-scr flow diagram of results. characteristics of the included studies appendix 4 represents the characteristics of the 14 studies included in the scoping review. studies were published over a 10-year period between 2011 and 2020. there was no relevant grey literature identified for inclusion in the study. according to the world bank classification (chartsbin statistics collector team, 2016), the majority of studies (n = 9) were conducted in hics. furthermore, the only study to include a nonmedical setting was that of ibfelt, engelund, schultz and andersen (2015). there were no studies identified which discussed ppe and ipc measures used by slts in providing eci. the included studies all discussed ppe and ipc measures used by hcws who provided early intervention to the population of birth to 3-year-old infants and toddlers. more than half (n = 8) of the studies included a team of hcws, which suggests that the task and responsibility of carrying out ipc measures was well distributed amongst different individuals within the relevant healthcare settings. however, caregivers, who are integral to early intervention services (owens, 2016), were only included in one study (buser, fisher, shea, & coffin, 2013). the selected studies focused significantly more on ipc measures than on ppe. this has a bearing on the nature of challenges reported in the selected studies in relation to early intervention. thematic results in this scoping review, the main results of the literature search (steps 1–5) included challenges and suggestions to implementing ipc measures within early intervention by different hcws. during the consultation exercise, practitioners related all of the literature search findings to their professional experience and shared additional challenges and suggestions relating to infection control used within eci, with relevance to the south african context. the combined results of the literature review and consultation phase revealed three core themes, namely challenges to establishing ipc measures within early intervention, challenges to conducting eci when utilising ipc measures and overcoming the challenges. the results of the literature search and consultation are concurrently presented and discussed below. the identity of stakeholders in the consultation phase has been anonymised by the code p (pilot study), f1 (fgd 1) or f2 (fgd 2) followed by the p (participant) number; for example pp1 refers to participant 1 in the pilot study. discussion theme 1: challenges to establishing infection prevention and control measures within early intervention the literature search highlighted several challenges to establishing ipc measures within early intervention. during the consultation, practitioners reflected on these findings in relation to the eci services they provide in south africa. the challenges included five major barriers to implementing ipc measures. the nature of care and behaviour of young children young children receiving eci are not developmentally capable of understanding and practising infection control without caregiver supervision (hashikawa et al., 2020). only one of the selected studies in the literature review included caregivers in ipc practices (buser et al., 2013). moreover, none of the studies considered the nature of care and behaviour of young children. on the other hand, practitioners in the consultation frequently described barriers to implementing ipc measures because of the nature and behaviour of young children. participants stated that young children frequently touch surfaces, mouth objects, pull off their face masks, pull off the practitioner’s face mask and have difficulty with social distancing (see figure 2). in addition, toys are often used in intervention (koutlakis-barron & hayden, 2016). the practitioners reported that certain toys (e.g. ‘teddies’ [pp2], ‘playdough’, ‘sand’ [f1p4]) and feeding kits (e.g. ‘spoons and bowls’ [pp2]) were often difficult to disinfect and not easily replaced. figure 2: organic network showing the nature of care and behaviour of young children in response to infection prevention and control measures within early communication intervention as reported in the focus group discussions, generated by atlas.ti version 9. infrastructure and system challenges in the literature search, infrastructure and system challenges were the most frequently occurring barriers to ipc measures within early intervention. these challenges included overcrowded wards, understaffing, lack of isolation facilities, inadequate ventilation, a lack of time to apply infection control standards, a lack of screening procedures and resource limitations such as poor access to ppe (dramowski, whitelaw, & cotton, 2016; gupta & pursley, 2011; olivier et al., 2018; reid et al., 2011; salem & youssef, 2017; triantafillou, kopsidas, kyriakousi, zaoutis, & szymczak, 2020; verma et al., 2020). during the consultation, practitioners reported that healthcare facilities had poor rather than lacking screening procedures. practitioners reported that screening procedures were often ‘not strictly enforced’ (f2p2) and unreliable because of ‘false information’ (pp3) provided by caregivers. ‘i have experienced with some patients [that] they lie during the screening procedure just to get into the healthcare facility.’ (f2p2) practitioners based in nonmedical settings (such as ‘private practices … schools …homes’ [f2p6]) related to the lack of funding for ppe and added that ppe was not covered by patients’ medical aid schemes. moreover, ipc measures consumed session time which could not be billed. therefore, both the cost and time of implementing ipc measures were financial burdens. in the words of f2p6, ‘how do you balance the time sanitising and therapy and then billing for that?’ practitioners considered these challenges to be more prevalent in lmics, such as south africa, in comparison to hics. most studies included in the scoping review were from hics (n = 9), which almost certainly have a greater availability of resources and technology compared to lmics (scherzer, chhagan, kauchali, & susser, 2012). participants commented that more research is required on infection control within eci in lmics, as ipc measures designed in hics may not be easily generalised to lmics. differences in infection prevention and control measures between medical and nonmedical settings only one of the selected studies in the scoping review was based in a nonmedical setting (ibfelt et al., 2015), which suggests a shortage of research in this regard. during the consultation practitioners related to the need for greater awareness of ipc practices beyond medical settings. as slts often work in a variety of different locations (pillay & pillay, 2021), they were able to list key differences in infection control between these two settings. in comparison to medical settings, nonmedical settings were stated to have less ‘access to information’ (f2p6) regarding infection control, less ‘variety of ppe’ (pp1) and a lack of standard ipc ‘protocols’ (f2p6). in addition, practitioners regarded the risk of cross-contamination to be greater in nonmedical settings because of working in more than one location and the patients’ exposure to multiple contacts (e.g. peers, teachers and family). in contrast, medical settings might have isolation cubicles or restricted contact between patients and visitors, which limits the risk of cross-contamination beyond the one setting: ‘[t]hey’re in contact with so many other kids and teachers and parents. whereas your inpatient client, sometimes they’re in their own room where they don’t have a lot of contact with other people.’ (f1p3) poor infection prevention and control compliance amongst healthcare workers, patients and caregivers poor ipc practices by hcws were also frequently reported in the selected studies. siegel et al. (2007) stated that adherence to ipc measures amongst hcws can range between 43% and 89%. the comments during the consultation expanded on poor ipc compliance to include patients and caregivers: ‘the staff and everyone can have the most amazing ppe and hygiene and cleaning. but if the parent doesn’t comply, then they are even putting us at risk for further infections.’ (pp1) education and training have been associated with improvements to ipc compliance (siegel et al., 2007). however, a lack of ipc training for staff members and caregivers was also identified as a barrier and is discussed below. lack of infection prevention and control training for staff members and caregivers the literature review identified a lack of training for hcws as a barrier to compliance with ipc measures. the study by triantafillou et al. (2020) reported a lack of continued education and training on infection control, starting with undergraduate education at university. practitioners taking part in the consultation agreed with this finding and further motivated for the ipc training of caregivers: ‘with the caregivers … we all have that responsibility in teaching, training, empowering. to tell them why it’s important to understand, and then i think they’ll comply much easier.’ (pp2) the importance of training caregivers on infection control within eci is twofold. speech-language therapists should include caregivers in eci services, because young children will imitate the behaviour of their parents (owens, 2016). at the same time, the inclusion of caregivers in ipc training is important because young children do not practise adequate infection control without adult supervision (koutlakis-barron & hayden, 2016). buser et al. (2013) investigated the inclusion of parents in the infection control programme of a hospital facility. the results indicated that parents were willing to collaborate with hcws and that empowering parents to participate in infection control practices can improve child health. theme 2: challenges to conducting early communication intervention when utilising infection prevention and control measures participants in the consultation described five central challenges to conducting eci when utilising ipc measures (see figure 3). these challenges were additional to those found in the literature search and demonstrate the value of conducting a consultation with local stakeholders to determine the applicability of research findings for slts in south africa. figure 3: organic network showing the challenges to conducting early communication intervention when utilising infection prevention and control measures as expressed during the focus group discussions, generated by atlas.ti version 9. difficulty targeting prelinguistic skills firstly, practitioners described difficulty in targeting prelinguistic skills within eci as face masks and/or face shields cover most of the face. prelinguistic skills can be seen as the building blocks of communication development and greatly rely on face-to-face exchanges to gain and maintain a child’s interest (keen et al., 2016; owens, 2016). speech–language therapists must work harder and more creatively to motivate infants to participate in episodes of joint attention, whilst still maintaining ipc standards. difficulty providing facial cues secondly, practitioners had difficulty providing visual cues with their mouths when wearing a face mask. speech–language therapists can use visual cues to increase speech perception or model the phonetic placement of speech sounds for patients to imitate (atcherson et al., 2017; owens, 2016). face masks hinder slts’ ability to provide visual cues which can improve speech perception and production (atcherson et al., 2017). in addition, face masks filter the acoustic speech signal, which can further reduce speech recognition. certain types of masks may reduce the signal more than others (grieco-calub, 2021). it has been recommended that face shields or face masks with transparent windows should be used to provide visual cues and facilitate speech recognition (thibodeau, thibodeau-nielsen, tran, & de souza jacob, 2021). however, clinicians in the consultation reported that face masks with windows and even face shields tend to ‘mist up’ (f1p6), which diminishes their purpose in providing visual access to the mouth. in addition, the material used to manufacture shields and masks with windows may filter acoustic properties worse than surgical or cloth masks (corey, jones, & singer, 2020). thus, the benefits of using transparent equipment are limited to the extent that they diminish the speech signal. personal protective equipment is impersonal thirdly, practitioners felt that that wearing ppe felt impersonal and created a barrier to developing a relationship or bond with patients and caregivers. according to van veenendaal et al. (2021), parents in the neonatal intensive care unit (nicu) during the covid-19 pandemic felt that face masks affected bonding with their infants and depersonalised interactions with staff members. over-compliant caregivers fourthly, findings in the literature search indicated a lack of basic infection control education for caregivers, which increases the risk of disease transmission (buser et al., 2013; dramowski et al. 2016). however, during the consultation it was reported that since the covid-19 pandemic, most caregivers are well-informed on ipc measures. in contrast to the existing literature findings, some caregivers were reported to be over-compliant or ‘over-protective’ (f2p3) with regard to infection control. this could be disruptive to the therapy session as ipc practices took time to implement and explain, which resulted in the loss of engagement with patients: ‘at times i felt parents were not trusting of the health care workers, that we actually implement all of the ipc measures … there was a situation where i took about 20 min of my 30 min time slot to explain to the parents that we are hand washing, we are sanitising, we do have our ppe.’ (f2p3) moreover, practitioners reported on a few cases where caregivers were reluctant to attend therapy sessions during the covid-19 pandemic. an effective strategy in these predicaments was the use of visible ipc measures such as screening procedures. visible ipc practices appeared to signify that there were sufficient ipc measures in place for patients to attend eci services. ‘the hospital had very strict screening protocols at [the] entrance, and some parents stated that this put them at ease and [they] trusted the ipc measures that were in place. the less-reluctant parents were then happier to come for outpatient therapy, as they felt safe within the hospital.’ (f2p1) the use of teletherapy is suggested as a strategy to provide healthcare during social distance restrictions (sarma et al., 2020). none of the studies included in the scoping review mentioned this strategy, and only one participant alluded to the difficulty of interacting with young children over a screen. teletherapy was, however, mentioned as an effective strategy to inform caregivers of ipc practices in eci. ‘we had an online meeting … just putting out the disclaimer to say, “this is our practice policies in terms of ipc measures” so that they are little bit more at ease.’ (f2p3) special needs populations are not considered lastly, the most frequently reported challenge reported by practitioners was the lack of consideration for populations with special needs when implementing ipc measures within eci. practitioners reported that these populations present with unique characteristics and that the implementation of ipc measures in such cases is often problematic. ‘ipc procedures don’t always take into account the special populations we work with in the eci field, like our asd kiddies and kiddies with intellectual impairments that might not understand the ipc procedures as well.’ (f2p6) theme 3: overcoming the challenges the importance of hand hygiene was emphasised by all 14 studies in the scoping review. the study by lorenzini, costa and silva (2013) declared hand hygiene to be the most effective and least expensive method for preventing and controlling hais. then, two frequently reported recommendations were improved ‘supplies and infrastructure’ and ‘education and training’ for hcws and caregivers. salem and youssef (2017) reported that without basic supplies and infrastructure, it is not possible for staff members to meet ipc standards or provide an acceptable level of care. during the consultation, practitioners agreed with these recommendations and provided three additional suggestions to improve ipc practices within eci. firstly, practitioners discussed the difficulty of disinfecting intervention material. cleaning strategies were mentioned such as using ‘different boxes’ (f2p3) to indicate the sanitised and unsanitised toys, quarantining therapy material which could not be sanitised such as the ‘sand’ (f1p4) in sensory boxes and placing pictures in ‘plastic sleeves’ (f1p6) so that they could be cleaned more easily. an alternative strategy was to avoid disinfection altogether by asking caregivers to bring therapy material from ‘home’ (f1p1) or to make toys using ‘recyclable materials’ (f1p1) which could easily be disposed of or given to patients after a single use. secondly, practitioners reiterated the difficulty of young children not understanding or following ipc instructions. one practitioner suggested having ‘regular hand sanitising times’ (pp4), especially with children who frequently touch objects and surfaces. thirdly, the close contact nature of eci was discussed. practitioners stated that their approach to eci had shifted to become more ‘parent-led’ (f2p2) in an attempt to maintain their social distance from the children. this required slts to train caregivers on eci strategies and explain why ipc measures were in place. these modifications were useful in transferring eci techniques to the patients’ homes and empowering caregivers to take more responsibility for infection control. parent-led intervention or parent coaching is, of course, the recommended practice to follow in the communication intervention of young children (dathan rush, 2021). the resilience of practitioners in navigating solutions during unprecedented times is commendable, especially considering the lack of standard ipc protocols for eci. overall, there was a clear need for eci-targeted ipc guidelines which take into consideration both the characteristics of the population (e.g. young children with special needs) and the settings in which services are provided (e.g. nonmedical and low-resource settings). the predicament remains of eci strategies compromising the effectiveness of ipc measures. understanding the challenges to implementing ipc measures within eci can be seen as the first step to overcoming them. implications for future research further research is needed to determine whether ipc measures and/or eci strategies can be modified to collectively maintain their effective implementation. the findings of this study echo those of adams et al. (2021), who described the resilience of slts providing effective services in the light of barriers caused by ppe and ipc measures. a related area of research is investigation of the effectiveness of different types of ppe. existing literature in this field includes the study by van der sande, teunis and sabel (2008), who investigated the effectiveness of different face masks in preventing respiratory infections. the benefits of such research to slts involve knowing the risk of exposure to infectious agents, as slts tend to select ppe which presents the least interference to intervention – for example, wearing a face shield with a transparent cover instead of a face mask which obstructs visual cues. knowing which ppe is most effective can be useful in low-resource settings, where there is often a need to prioritise limited available supplies. a gap in the research literature includes investigations on the effect of certain ppe on early language development of infants and toddlers. such research findings would be beneficial to all professionals involved in early intervention to ensure that the best outcome is achieved whilst maintaining ipc standards. limitations the limitations of this scoping review involved the collection of sources of evidence, which were restricted to studies written in english and studies that did not require paid access. potentially relevant studies may have been missed because of these restrictions. moreover, the consultation was with a relatively small number of stakeholders, which reduces the generalisability of the findings. however, the purpose of conducting the consultation was fulfilled in disseminating and validating research findings, as well as identifying research gaps (levac et al., 2010; pollock et al., 2021). conclusion this scoping review utilised a literature search of recent international literature as well as consultation with local clinicians to describe the implementation of ppe and ipc measures within general early intervention and eci. the findings of the literature review included several challenges faced by hcws in implementing ipc measures within early intervention. the consultation revealed that slts in south africa faced similar challenges in eci as those reported in the literature review findings. the slts described additional challenges to conducting eci whilst utilising ipc measures. these challenges included difficulty targeting prelinguistic skills, difficulty providing facial cues, the impersonal impression of ppe, over-compliant caregivers and the lack of consideration for populations with special needs. limited literature is available on how to overcome the challenges that are specific to eci. future research is needed to guide slts on the use of ppe and ipc measures within eci, whilst maintaining the effectiveness of each practice. acknowledgements the authors would like to thank mrs elanie van schalkwyk for reviewing the charted data. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. author’s contributions b.a. and b.g. conceptualised the study together. b.a. collected and analysed the data and drafted the manuscript. b.g was present during the consultations and closely supervised the research process and critically reviewed the draft manuscript. funding information the authors received no financial support for the research, authorship and/or publication of this article. data availability the data that support the findings of this study are available from the corresponding author, b.a., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors, and the publishers. references adams, s.n., seedat, j., coutts, k., & kater, k.a. 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(2013). benefits of universal gloving on hospital-acquired infections in acute care pediatric units. pediatrics, 131(5), e1515–e1520. https://doi.org/10.1542/peds.2012-3389 appendix 1 table 1-a1: preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr) checklist. appendix 2 table 1-a2: data charting table. appendix 3 table 1-a3: consultation phase (step 6): interview guide. appendix 4 table 1-a4: characteristics of included studies. abstract introduction research methods and design results discussion conclusion acknowledgements references about the author(s) nicola e. bloye department of speech language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa shabnam s. abdoola department of speech-language pathology and audiology, faculty of health care sciences, sefako makgatho health sciences university, pretoria, south africa casey j. eslick department of speech language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa department of speech-language pathology and audiology, faculty of health care sciences, sefako makgatho health sciences university, pretoria, south africa citation bloye, n.e., abdoola, s.s., & eslick, c.j. (2023). ‘why do people who stutter attend stuttering support groups?’. south african journal of communication disorders, 70(1), a958. https://doi.org/10.4102/sajcd.v70i1.958 original research why do people who stutter attend stuttering support groups? nicola e. bloye, shabnam s. abdoola, casey j. eslick received: 30 nov. 2022; accepted: 06 apr. 2023; published: 03 aug. 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: stuttering support groups (ssgs) have been a long-standing invaluable resource for people who stutter (pws) but research into ssgs is only emerging. speech-language therapists (slts) need further insight to successfully facilitate ssgs. objectives: to determine pws’ perspectives regarding why they attend ssgs in south africa. method: thirteen pws who attend ssgs, between 20 and 58 years old, were a part of this qualitative study. purposive sampling was utilised. semi-structured telephonic interviews were used and data was analysed thematically. results: four themes, namely, ‘altered perceptions’, ‘increased sense of community’, ‘support group reciprocity’, and ‘support group environment, participants and topics’, were identified. the results yielded clinical implications which included slts encouraging: (1) improved perceptions of being a pws through education and self-empowerment, (2) pws’ connections between meetings to increase the sense of community, (3) reciprocity in meetings, (4) sharing personal stories to promote learning and general self-management and (5) support, praise and education to empower and encourage pws. this study’s findings show that ssgs helped pws accept their stutter and gain confidence. this study showcased how ssgs can help pws manage their fluency and gain confidence. additionally, this study supports current research which suggests that dysfluency and social-emotional well-being should be equally addressed. conclusion: recommendations were generated from pws’ perspectives and included focusing discussions on fluency, emotions and sharing personal stories. insights from pws helped better inform slts of their role within ssgs including guiding and facilitating conversations. contribution: people who stutters’ perspectives can be used in clinical practice to help slts meet the needs of pws and guide best practice when facilitating ssgs. keywords: dysfluency; people who stutter; perspectives; social support; speech-language therapists (slts); stuttering; stuttering support groups (ssgs); quality of life. introduction stuttering is commonly associated with overt disfluent speech; however, the negative emotional and psychological effects have a far greater impact on the lives of people who stutter (pws). many pws experience challenges that extend beyond their ability to communicate, such as high levels of psychological distress, negative affect, fear, shame or embarrassment (beilby, 2014; blumgart et al., 2014; tichenor & yaruss, 2019; tran et al., 2011). social anxiety is also common in pws and may cause avoidance of speaking situations, potentially leading to feelings of social isolation (iverach & rapee, 2014). these difficulties may persist throughout their lives, from educational settings, where negative effects on educational achievement can be seen, to the workplace, where pws may choose occupations that require less communication (guitar, 2014; isaacs, 2021; mcallister et al., 2012; o’brian et al., 2011). as such, these challenges may result in pws not reaching their full vocational, occupational and educational potential. the personal and environmental barriers experienced by pws have been found to limit their participation in everyday activities, with a lower quality of life (qol) reported in a number of domains (craig et al., 2009; figliomeni 2015; mohammadi et al., 2013; nang et al., 2018). previous research has demonstrated that the qol of pws can be improved by attending stuttering support groups (ssgs) (blumgart et al., 2014; boyle, 2013). stuttering support groups are usually facilitated by speech-language therapists (slts) and offer a safe environment where pws can come together as a community and share their feelings and experiences without being judged (boyle, 2013). many studies have shown the value of ssgs (craig et al., 2011; gerlach et al., 2019; plexico et al., 2019). through pws’ perspectives, past research determined that social support could protect pws against the negative effects of stuttering and possibly enhance participation in activities of daily living (gerlach et al., 2019; tran et al., 2011). stuttering support groups also play an important role in reducing pws’ internalised stigma, accepting their stutter and improving pws’ psychological well-being (boyle, 2013). stuttering support groups can provide a setting in which individual stuttering therapy progress can be maintained (guitar, 2014). it is thus evident that research into the benefits of ssgs is extensive; however, a review of the literature did not showcase any formalised guidelines for slts on how to effectively facilitate and manage ssgs. although slts usually take on the role of facilitating ssgs, it is the community of pws’ voices that need to be heard to contribute their perspectives and experiences. people who stutter’s perspectives can provide a valuable contribution to the field of stuttering treatment as including people with disabilities in decision-making and goal-setting has been shown to improve clients’ rehabilitation experiences, motivation, and functional outcomes (brown et al., 2021; evans, 2012). the degree of motivation can inspire and influence a pws’ desire to seek intervention or to be productive during therapy (ratner & tetnowski, 2014; sønsterud et al., 2020; weigel, 2013). it is therefore essential to understand the perspectives of pws so as to best help them further their personal goals beyond traditional stuttering therapy settings. people who stutter’s perspectives can provide evidence-based clinical implications that may assist slts in tailoring ssg activities, topics of discussion, and goals to better meet the needs of pws who attend. this research also has the potential to help slts to motivate pws to attend and actively participate in ssg meetings. research methods and design design the research design was descriptive and phenomenological as the study aimed to understand and describe pws’ perspectives regarding why they attend ssgs (leedy et al., 2021; sandelowski, 2010). setting a south african ssg served as the research setting. the selected ssg has two groups that run in gauteng. both groups meet monthly and are facilitated by slts who are experts in the field of dysfluency. at one of the ssg groups, final year slt students also facilitate, under the supervision of a qualified slt, and are referred to as ‘slt students’ in this article. population and sampling strategy purposive sampling was used to select pws who had first-hand experience attending ssgs. the slts who coordinate the ssgs were sent a letter requesting permission to recruit members of their respective ssgs to participate. on the researcher’s behalf, the coordinators distributed an information letter and informed consent document to members of their groups. group members were invited to read the document and ask the researcher questions prior to engaging in the telephonic portion of the research process. interested members were invited to sign the informed consent document and email it back to the researcher. the following inclusion and exclusion criteria were applied: (1) be a pws, (2) be between the ages of 18 and 65, (3) have attended at least three ssg meetings, (4) be able to read and converse in english, (5) have access to an email address and a mobile phone, and (6) have no other self-reported or formally diagnosed communication difficulties. thirteen people from 20 to 58 years old (mean = 35 years old), three females and 10 males, were selected to participate. table 1 presents detailed demographic information about the participants. table 1: participant demographics. the final sample size was determined when information power was reached, as recommended by malterud et al. (2016). ‘information power indicates that the more information the sample holds, relevant for the actual study, the lower amount of participants is needed’ (malterud et al., 2016:1753). the information power was considered to have been reached at 13 participants as the information contained was dense and relevant enough to adequately answer the study’s aim. data saturation, the point when no additional information is identified, data repeats, and further data collection becomes redundant (kerr et al., 2010), was also considered and occurred after four interviews. data collection after providing informed consent, participants were telephonically interviewed in a semi-structured manner for approximately 60 mins. the interview schedule included 34 questions, consisting of both open-ended and closed-ended questions. closed-ended questions were used to obtain biographic and demographic information. open-ended questions were used to invite the participants to share information. the questions were divided into four sections: (1) biographic and demographic information, (2) fluency history and behaviours, (3) speech-language therapy treatment, and (4) support groups. the interview schedule was adapted from medina et al. (2020) with additional questions added to gain further insight into pws’ perspectives regarding ssgs. a pre-test was conducted to rule out ambiguous questions and ensure the content and face validity of the interview schedule (brink et al., 2018; leedy et al., 2021). after two qualified slts reviewed the interview schedule, some questions were altered to ensure clarity and elicit more specific responses from participants. questions were determined to be representative, clear and appropriate as per the aim of the study. data analysis data analysis followed braun and clarke’s (2006) six-phase thematic analysis framework. firstly, recorded interviews were transcribed by the researcher. secondly, each transcript was re-read for increased data familiarity, and initial codes were generated using atlas.ti software (braun & clarke, 2006). the initial codes were semantic in nature but were then reviewed to generate latent codes. maguire and delahunt (2017) describe semantic codes as those that capture the explicit meaning of participants’ perspectives, while latent codes probe deeper into these perspectives. a bottom-up approach to data analysis was used, as suggested by terry et al. (2017) where codes were the starting point to develop meaningful themes. as suggested by braun and clarke (2006), some of the themes were reviewed twice by the co-authors and all three authors then defined and named the themes. some descriptive statistics were used to summarise answers to direct (e.g. yes/no) questions. ethical considerations the faculty of humanities’ research ethics committee at the university of pretoria provided ethical clearance (reference: 17069892 [hum025/0521]). all participants provided written informed consent and their privacy was maintained by using an alphanumeric code in place of names. participants’ informed consents, recordings, and transcriptions of their interviews have been securely stored and archived on the university of pretoria’s data repository. results during data analysis, four major themes emerged in relation to the ssgs and are as follows: ‘altered perceptions’, ‘increased sense of community’, ‘support group reciprocity’ and ‘support group environment, participants and topics’. theme 1: altered perceptions when asked if attending an ssg had a positive influence on their perception of their stutter, 12 participants (92.3%) reported it did alter their perception positively. one participant (7.7%), however, reported no influence. the participant (p5) who experienced no change in their perception of their stutter through attending ssg meetings explained that this was due to negative listener reactions and attitudes; ‘the world out there, still thinks very very bad of us… so i still have a bit of a negative view of not being able to speak fluently’ (p5, 33 year old, male). subtheme 1.1: increased acceptance of stutter many participants reported ssg meetings helped them to accept their stutter (p1, p3, p4, p6, p8, p9, p10, p11) (n = 8; 61.5%). participants reported that accepting themselves as a pws played a role in them developing a more positive perception of their stutter (p1, p9, p11) (n = 3; 23.1%), influenced their emotional well-being (p4, p8, p10, p11) (n = 4; 30.8%) and/or helped them to better cope with their stutter (p3, p10) (n = 2; 15.3%). the participants’ quotes can be seen in box 1. box 1: quotes for theme 1: altered perceptions; subtheme 1: increased acceptance of stutter. subtheme 1.2: improved confidence attending ssg meetings helped improve the confidence of some participants (p4, p7, p8, p10, p12) (n = 5; 38.5%). participants reported that their improved confidence allowed them to challenge themselves to complete new tasks and improve their communication. four participants (p4, p7, p10, p12) (n = 4; 30.8%) linked improved confidence to a more positive perception of their stutter. the participants’ quotes are shown in box 2. box 2: quotes for theme 1: altered perceptions; subtheme 2: improved confidence. theme 2: increased sense of community participants (p1, p2, p3, p4, p8, p9, p13) (n = 7; 53.9%) reported that attending an ssg helped them realise they are not alone in their stuttering journey. these reduced feelings of isolation resulted in pws (p1, p2, p3, p4, p8) (n = 5; 38.5%) having a more positive perception of their stutter, improved emotional well-being (p4, p13) (n = 2; 15.4%) and for one participant (p1) (n = 1; 7.7%), played a role in coping with their stutter. one participant (p8) (n = 1; 7.7%) reported that becoming aware they are not alone improved their speech fluency. participants’ quotes can be viewed in box 3. box 3: quotes for theme 2: increased sense of community. theme 3: support group reciprocity three participants (23.1%) emphasised the reciprocal nature of ssgs. according to the participants (p1, p2, p5), an ssg is a valuable setting for both sharing and receiving ‘insight’ (p2, 20 year old, male), ‘upliftment’ (p1, 50 year old, male), ‘help’ (p1, 50 year old, male; p5, 33 year old, male) ‘support’ (p1, 50 year old, male), and ‘advice’ (p5, 33 year old, male). subtheme 3.1: learning from others the results in this sub-theme revealed that participants (p1, p2, p4, p5, p9, p12, p13) (n = 7; 53.8%) value the opportunity to learn techniques and coping strategies from other pws. it was mentioned that learning from other pws was both an effective way to help one cope with their stuttering (p2, p4, p6, p13) (n = 4; 30.8%) and an aspect of ssg meetings that participants enjoy (p2, p4, p5, p12) (n = 4; 30.8%). quotes from the participants can be seen in box 4. box 4: quotes for theme 3: support group reciprocity; subtheme 1: learning from others. subtheme 3.2: encouragement and empowerment five participants (p1, p3, p5, p6, p10) (38.5%) reported that they felt encouraged during and after attending the ssg meetings for a variety of reasons. participants reported being encouraged and motivated by listening to others’ stories (p1, p10) (n = 2; 15.4%) and watching others persevere through difficult disfluent moments (p5) (n = 1; 7.7%). p6 explained that praise from other pws also made them feel more empowered. lastly, p3 explained that attending an ssg had made them feel more positive and optimistic about their speech. the participants’ quotes are shown in box 5. box 5: quotes for theme 3: support group reciprocity; subtheme 2: encouragement and empowerment. theme 4: support group environment, participants and topics subtheme 4.1: environment participants (p1, p2, p3, p4, p6, p7, p8, p10, p12) (n = 9; 69.2%) expressed how the ssg meetings created an environment where they felt heard, safe, relaxed, free and/or experienced a sense of belonging. some of the participants’ (n = 5; 38.5%) quotes can be seen in box 6. some participants (p4, p5, p13) (n = 3; 23.1%) voiced their desire for monthly ssg meetings to occur more frequently, with a wider range of dates and times for greater flexibility. box 6: quotes for theme 4: support group environment, participants and topics; subtheme 1: environment. subtheme 4.2: value of speech-language therapists as facilitators two participants (p3, p6) (n = 2; 15.4%) expressed that they enjoyed having slts and slt students as ssg facilitators. one of these participants mentioned that having slts at the meetings allowed those who stutter and those who treat stuttering to collaborate – ‘it’s so valuable as well to have … that collaboration between like the people who experience it every day and then the people who are actually educated on it’ (p3, 25 year old, male). p3 also felt encouraged that slts were trying to help and advocate for pws – ‘it’s encouraging. you feel as if there’s like people who are trying to help’ (p3, 25 year old, male). the other participant, p6 (52 year old, female) (n = 1; 7.7%), stated that they believed slts should participate to ‘guide the conversation,’ ‘coordinate it [an ssg meeting] with professionalism’, and that ssg attendees are ‘aligning to the agenda’. p6 also expressed that the unique theoretical and clinical knowledge slts bring to ssg meetings further reinforced their value. p6 explains, ‘they’ve [slts] got the knowledge that’s different to us living with it [stuttering]. so i understand myself, but they would understand everybody’ (p6, 52 year old, female). p2 (7.7%) mentioned that: ‘there were times when [they were] the only participant in the group that was a stutterer and it felt like all of the attention was on [them], and almost like an interrogation.’ (p2, 20 year old, male) p2 therefore suggested that slts should also answer questions and share their insights to prevent pws feeling as though they are being interrogated. subtheme 4.3: meeting topics participants (p2, p3, p6, p7, p8) (n = 5; 38.5%) suggested ssg meetings should focus on speech and dysfluency. these participants suggested that topics should involve ‘… things going on in the world of dysfluency …’ (p3, 25 year old, male) and be ‘centred around stuttering’ (p6, 52 year old, female). p7 (34 year old, male) suggested that activities be ‘… more stuttering related’. p8 (44 year old, female) reported that ‘unpacking all the emotions attached to stuttering’ during ssg meetings was beneficial. p3 expressed that they found it positive when ssg meetings were ‘educational but … supportive at the same time’ (25 year old, male). p2 said: ‘… [the ssg] has been an important safe space where you can express your emotions and … the emotional aspects of disfluent moments and sharing that, talking about it, that really helps a lot …’ (p2, 20 year old, male) discussion people who stutter and attend ssgs shared their thoughts and opinions on why they attend ssgs. their perspectives highlighted important clinical implications for slts who facilitate ssgs. these clinical implications were used to inform recommendations for slts, such as guidance on the role of slts in meetings, the purpose and structure of ssgs, and suggested topics of discussion and activities. altered perceptions as one participant reported, and in congruence with prior research, negative listener reactions can negatively impact pws’ perception of their stutter (bajaj et al., 2017; yaruss & quesal, 2004). it is therefore important that slts facilitate interactions that include relatives and listeners who are not pws. during ssgs, slts can provide pws with means to encourage positive interactions, such as sharing individual experiences, or using self-advertising or self-disclosure statements, which have been reported to yield more positive listener reactions (kittilstved, 2014; mcgill et al., 2018). the findings identified that ssgs aided pws in accepting their stuttering, which contrasts with previous research completed by de nardo et al. (2016) who found no link between support groups and self-acceptance. one participant reported that stuttering is part of who they are and should not define their individual identity, raising the idea of stuttering and identity. similarly, blumgart et al. (2014) and boyle (2013) found that attending ssg meetings can result in a changed self-identity as a pws, and improved self-acceptance. as self-acceptance of a pws is linked to an improved qol (swartz et al., 2014), slts should address acceptance during ssg meetings. according to sheehan (2018), education promotes self-acceptance. speech-language therapists can ensure that pws receive a holistic, comprehensive, and accurate understanding of their stuttering, possibly through presentations, guest speakers, and question-and-answer sessions. speech-language therapists can also encourage self-empowerment by using ‘i’ statements when referring to stuttering, and validate members’ stories, vulnerable moments and honesty, to foster an accepting environment, and ensure that no member’s efforts to share are dismissed (sheehan, 2018). people who stutter reported increased participation in previously avoided tasks as a result of increased confidence, a finding that is supported by blumgart et al. (2014). gore and luckman margulis (2022) proposed activities that can improve confidence in a therapy setting. these activities can be adapted for ssgs and can include sharing stories about successful communication interactions, discussing ways to foster cognitive resilience and combat negative reactions. speech-language therapists should emphasise that ssgs encourage a sense of hope and agency for future communication opportunities. increased sense of community a supportive social network fosters greater psychological resilience (boyle, 2015) which can protect pws from the negative psychosocial effects of stuttering including social isolation (craig et al., 2011; gerlach et al., 2019; iverach & rapee, 2014). one pws stated they had previously formed a buddy system with another pws in their ssg where they would communicate with each other and practise fluency techniques between ssg meetings. speech-language therapists can facilitate a supportive network by creating a secure platform where members who wish to connect outside the ssg setting can share their contact details. these connections, which extend beyond a pre-arranged group meeting, may further increase the sense of community and reduce feelings of isolation. the expressed desire for increased frequency of ssg meetings indicates pws’ interest in more frequent connection and can increase the sense of community within the ssg. speech-language therapists could also use a hybrid approach for ssg meetings, where both in-person and online meetings are available. a hybrid approach removes a location barrier, may improve attendance and can increase the number of ssg attendees. although research has shown that rehabilitation services can be made further accessible through an online platform (molini-avejonas et al., 2015), it is still important to consider that many people in south africa do not have access to the means needed for online services. further research could therefore investigate how slts can make ssgs more accessible for pws throughout south africa. support group reciprocity ‘learning from others’ and ‘encouragement and empowerment’ were the two subthemes under theme three. under each of these subthemes, participants alluded to the theme of reciprocity of an ssg. participants expressed value in learning coping techniques from other pws because it gave them insight from peers who could relate to them and their experiences. past research has shown that listening to a pws share their own story can reduce the stigma associated with stuttering (boyle et al., 2016). facilitating slts could give pws the opportunity to share their stories and encourage active listening to help reduce the negative stigma associated with stuttering. speech-language therapists could also invite guest speakers who stutter or who are professionals in the management of stuttering. group meetings can be an ideal setting for people with disabilities to learn about self-management, which can be facilitated by members sharing their knowledge and skills with others (world health organization [who], 2010). thoits’ (2011) discussion found that ssgs allow pws to share their feelings and worries, receive support and affirmation, and be compassionately understood. similarly, the participants in this study wanted to support and be supported by others and to uplift and be uplifted. participants also felt encouraged by watching others with greater stuttering severity persevere through difficult stuttering moments. future research should investigate the impact of pws’ perception of their stutter when they meet pws with less severe stuttering than their own. people who stutter and slts need to be informed about how this experience may impact a person’s reaction in order to address this within ssgs. receiving support and praise from other pws was both encouraging and empowering for the participants in this study, a finding that is also supported by previous research (tichenor & yaruss, 2019). as the combination of education and empowerment is shown to effect positive change, empowerment is an important component of stuttering therapy (gore & luckman margulis, 2022). empowerment has also been found to be achieved through gaining knowledge and information (barak et al., 2008). speech-language therapists who facilitate ssgs can help pws learn about their stuttering from other pws and professionals. speech-language therapists can encourage group members to share stories about self-disclosing their stuttering, and personal tips (gore & luckman margulis, 2022). an ssg can also provide a safe environment in which pws can apply and troubleshoot self-disclosure techniques taught in individual speech therapy. speech-language therapists could encourage members to discuss any stigma they have encountered in their lives and share strategies they used to challenge or overcome this stigma (gore & luckman margulis, 2022). speech-language therapists can also encourage friends and family members to attend meetings occasionally, and centre the agenda on information about stuttering and ways in which they, as family members and friends, can best help pws. support group environment, participants and topics according to craig et al. (2011), social support promotes a sense of belonging. similarly, the pws in this study valued how the ssg’s supportive environment made them feel heard, safe, and relaxed, and/or gave them a sense of belonging. therefore, to help all members feel heard, slts could monitor each member’s contribution in the ssg meeting, and direct questions or points of discussion to those who have not contributed as much. people who stutter did, however, value knowing that they are not expected to speak during the ssg setting, should they not wish to. therefore, slts should reassure members that they are not required to contribute verbally in order to attend ssg meetings. maintaining confidentiality is also important in the field of ssgs as it has been linked to increased self-disclosure within a group setting (doshi et al., 2019). the slt can request that members do not share personal information, details and/or stories about their fellow group members with others outside of the ssg. the who, however, highlights that different cultures may view confidentiality in various ways and therefore suggests that the rules of confidentiality be decided by the group (who, 2010). participants expressed the opinion that ssg meetings should focus on speech and dysfluency, in addition to addressing the emotional aspects of stuttering. as the slt is often the person who creates the agenda for the meeting, he or she must ensure both of these topics are covered. to assist with this, slts could ask members at the end of each ssg meeting what topics they would like covered in the next meeting. the researcher was unable to locate any studies that have been conducted to date, with the purpose of determining what topics pws would like to discuss within ssg meetings. this is therefore a topic that could be researched further in order to ensure that the topics discussed are of interest, importance, and relevance to the ssg members to best meet their needs. the who proposed that people with similar disabilities, as well as rehabilitation professionals should share information, ideas, and experiences to encourage mutual understanding and collaboration (who, 2010). this is supported by this study as pws value and enjoy having slts facilitate support groups. in previous research, people who stutter expressed appreciation for the facilitators of their ssg meetings. they specifically valued how facilitators ensure equal speaking opportunities for members, allowed members freedom to go off-topic, generated topics for meetings and planned the meetings (medina et al., 2020). people who stutter in this study support and further expand on findings by medina et al. (2020) regarding their perspectives of the slts’ role within the ssg. people who stutter in this study suggested that slts collaborate as much as possible with pws during ssg meetings, advocate for pws, facilitate conversations in which slts can develop a deeper understanding of pws and their experiences, and share their clinical and theoretical knowledge. although the pws in this study viewed slts as a positive presence in their respective support groups, past research has shown that slts’ presence can be perceived negatively if they are only there for observational purposes (trichon, 2007). therefore, slts must strike a balance between active and passive participation. conclusion this study used the perspectives and voices of pws, along with previous research, to guide evidence-based recommendations for slts who facilitate ssgs. the pws in this study expressed that they valued having a welcoming, safe, and relaxed environment. findings also highlighted that slts need to strike a balance between being passive and active participation, so that they do not over-contribute but are also not perceived as observers. topics for ssgs could include fluency as well as the emotional aspects of stuttering. speech-language therapists can use ssgs to help pws have a more positive attitude towards themselves and their stuttering, as well as provide the tools and resources they need to have more positive experiences when speaking with people who do not stutter. interestingly, pws suggested that forming relationships outside of the ssg should also be encouraged. speech-language therapists can also encourage ssg members to share their stories when they are ready, and facilitate the discussion so that all members benefit from each meeting. as suggested by pws, facilitating slts should also consider increasing the frequency of meetings. speech-language therapists can empower members by educating them about their stuttering and facilitating conversations in which pws can learn from other pws and professionals. with these clinical implications derived from pws’ personal perspectives and opinions, facilitating slts may now be able to better tailor activities, topics of discussion, and goals, for the pws who attend ssgs. this may encourage pws to pursue personal goals outside of traditional stuttering therapy settings and experience a greater sense of confidence across a variety of communication settings. acknowledgements the authors would like to thank the participants for their honesty, for sharing their stories, and for their time given participating in this research. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions n.b., as the primary researcher, conducted the data collection and analysis as well as compilation of the article. s.a. and c.e., as the research supervisors, conceptualised the study, provided guidance on data collection and analysis, as well as contributed to writing of the article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study are not openly available due to reasons of sensitivity and confidentiality. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references bajaj, g., anil, m., varghese, a., bhat, j., sheth, p., & hoode, a. 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(2004). stuttering and the internal classification of functioning, disability, and health (icf): an update. journal of communication disorders, 37(1), 35–52. https://doi.org/10.1016/s0021-9924(03)00052-2 abstract introduction aim objectives research methods and design setting study population and sampling strategy criteria for selection of participants research instrumentation procedures for data collection reliability and validity data analysis results identification of learners with possible specific language impairment discussion conclusion acknowledgements references about the author(s) heila jordaan speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa monene h. ngwanduli speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation jordaan, h., & ngwanduli, m.h. (2020). contextual influences on sentence repetition as a tool for the identification of language impairment in grade 3 sepedi-english bilinguals: a case against bilingual norms. south african journal of communication disorders, 67(1), a762. https://doi.org/10.4102/sajcd.v67i1.762 original research contextual influences on sentence repetition as a tool for the identification of language impairment in grade 3 sepedi-english bilinguals: a case against bilingual norms heila jordaan, monene h. ngwanduli received: 21 apr. 2020; accepted: 20 june 2020; published: 04 sept. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: specific language impairment (sli) is difficult to identify because it is a subtle linguistic difficulty, and there are a few measures available to differentiate between typical and atypical language development in bilinguals. sentence repetition (sr) has strong theoretical foundations and research evidence as a valid tool for the identification of sli in bilinguals. objective: this study assessed the value of sr using peer group comparisons to identify sepedi-english bilingual children at the risk of sli. method: one hundred and two grade 3 learners in three different contexts of education were assessed on equivalent english and sepedi sr measures. results: eleven participants who scored between 1 and 2 standard deviations (sd) below the peer group means on both the english and sepedi sr tests were identified with possible sli. learners in the english language of learning and teaching (lolt) – sepedi additional language (sal) context obtained similar scores in both languages, a higher score in english than the english lolt group and a higher score in sepedi than the sepedi lolt – eal group. the english lolt group obtained a significantly higher score in english than in sepedi and a significantly lower score than the other two groups in sepedi. the sepedi lolt group obtained a significantly higher score in sepedi than in english, their additional language, in which they obtained a significantly lower score than the other two groups. conclusion: sentence repetition tasks are valid screening tools to identify bilingual children with sli by comparing them to peer groups. the sr tests were sensitive to language practices in different educational contexts. it was observed that a bilingual approach that uses both english and the home language as academic languages leads to better language outcomes. keywords: sentence repetition; sepedi-english bilingual; specific language impairment; educational contexts. introduction south african speech-language therapists are tasked with the identification of language impairment in children who speak a variety of languages and, in most cases, a combination of languages, because the majority of the population are bilingual or multilingual. specific or primary language impairment (sli) is particularly difficult to identify because it occurs in the absence of any obvious physical, cognitive, neurological, visual or hearing disabilities (bishop, snowling, thompson, greenhalgh, & the catalise-2 consortium, 2017). the term sli describes a subset of children with developmental language disorder (dld) who, when compared to their typically developing peers, demonstrate an impairment in language that is not based on a biomedical condition or related to an intellectual difficulty (volkers, 2018). a group of child language clinicians and researchers across the world (the catalise consortium) used the delphi process to arrive at a consensus definition for the broader term, dld. this group recommended that the term dld be used to describe children who have an impairment in language, with or without an intellectual disability (green, 2020), thus contrasting the term with sli. the manifestations of sli are linguistic and often subtle, so it may go undetected in the preschool period (tomblin, nippold, fey, & zhang, 2014), particularly in the south african context, where basic physical, health and nutrition needs take preference over early language development. when children with sli start formal schooling, their language problems may affect their literacy and academic skills, and their communication impairments may be addressed for the first time. bilingual children with sli will demonstrate impairments in both languages and should therefore be assessed in both languages (kohnert, 2010). however, the identification of sli in bilingual children is complicated by similarity in the language characteristics of typically developing bilingual children and children with sli (armon-lotem & de jong, 2015) as well as variations in the linguistic skills within and across the languages of bilingual children (kohnert, 2010). the lack of appropriate assessment tools for bilingual children adds to this dilemma and may result in overor under-identification of language impairment (bedore & pena, 2008; restrepo & guti´errez-clellen, 2004). the consequences are that bilingual children are either over-represented in special educational services or do not receive intervention at all because their difficulties are attributed to acquiring two language systems. in this study, we propose that sentence repetition (sr) may be a valuable screening tool in the identification of sli in bilingual children because it has a strong theoretical basis and supporting research evidence. historically, sr tasks have long been included in test batteries for language, for example, the clinical evaluation of language fundamentals (celf)–r (semel, wiig, & secord, 1994) and the test of language development–primary (told–p) (newcomer & hammill, 1997) or general abilities, for example, wechsler preschool and primary scale of intelligence – revised (wechsler, 1992). sentence repetition tasks have also been used to explore the processing abilities of children with sli and other conditions (e.g. ellis-weismer, evans, & hesketh, 1999; redmond, 2005). in the early 2000s, studies began to explore the use of sr as a clinical marker for sli (e.g. conti-ramsden, botting, & faragher, 2001). currently, there is substantial research evidence for the sensitivity and specificity of sr tasks in the identification of sli in monolingual children who speak english (conti-ramsden et al., 2001; oetting, mcdonald, seidel, & hegarty, 2015) as well as other languages (christensen, 2019; leclercq, qu´emart, magis, & maillart, 2014; stokes, wong, fletcher, & leonard, 2006). recently, there have also been studies to support sr as a means of distinguishing between typical and atypical language development in bilingual children (armon-lotem & meir, 2016; ebert, 2014; fitton, hoge, petscher, & wood, 2019; hamann & abed ibrahim, 2017; thordardottir & brandeker, 2013). theoretically, the multicomponent working memory model (baddeley, 2012) views sr tasks as depending primarily on the efficiency of an episodic buffer (alloway, gathercole, willis, & adams, 2004), which links the subsystems of working memory and long-term memory (repovs & baddeley, 2006) and is believed to place constraints on language acquisition (boyle, lindell, & kidd, 2013). in addition, in line with the regeneration hypothesis proposed by lombardi and potter (1992), sr is a multi-faceted task that engages virtually all aspects of language processing. after hearing a sentence, the listener creates a conceptual representation of the sentence and then goes through a series of processes including activating relevant lexical knowledge, grammatical encoding, phonological realisation and speech production to repeat the sentence (klem et al., 2015). the methods employed in the studies mentioned above, involve using sr to assess children already identified with sli and comparing them to control groups of typically developing peers. in this study, we adopt a different approach to assess the value of sr in identifying children with sli by comparing them to peers who speak the same language pair and have had the same experiences with their exposure to the two languages. we argue that even bilingual children who speak the same language pairs are not a homogenous group. in their study, armon-lotem and meir (2016, p. 716) proposed that bilingual children should be compared to ‘bilingual norms’ as opposed to ‘monolingual norms’ to improve the diagnostic accuracy of sr. whilst we agree with the strategy of comparing bilingual children to age-matched peers, we hypothesise that sr accuracy will depend on exposure to and experience of the learners in each language. therefore, in this study, we assessed three groups of bilingual children in different contexts of education, where the use of their two languages varied considerably. these contexts have evolved out of the post-apartheid education system in which language-in-education practices should promote additive bilingualism, which enables all the learners to acquire english, the language of social, economic and educational advancement, whilst still maintaining the home language (language in education policy, 1997). in the first context, the language of learning and teaching (lolt) is english from grade 1, whilst the children still speak their home language (sepedi) at home. in the second context, the lolt is the home language (sepedi) until grade 4 and english is taught as an additional language in the foundation phase. we were also able to identify a third context in which the lolt is english and sepedi is taught as an additional language. sepedi is the standardised dialect of northern sotho (sesotho sa leboa) and is one of the 11 official languages in south africa. according to the 2011 census, it was the first language of 4 618 576 people, principally in the provinces of limpopo, gauteng and mpumalanga (posel & zeller, 2016). aim the aim of the study was to evaluate sr in english and sepedi as a tool to identify bilingual children with sli in three educational contexts. objectives to compare the sr scores obtained by the participants in each of the three educational contexts. to compare the sr scores obtained by the participants in english and sepedi. to identify children within each educational context who may present with sli. research methods and design study design the design of this study was quantitative, comparative and cross-sectional in nature (schiavetti, metz, & orlihoff, 2011). the study was quantitative in that the sr assessments in english and sepedi yielded numerical data, which were analysed using statistical methods. the study comprised both within (participants’ scores on the english and sepedi sr tests) and between group comparisons (sr scores in both english and sepedi were compared between the three contexts). the study was cross-sectional as the data was collected at a single point in time. there was no experimental manipulation of variables. setting the study took place at three schools located in the seshego and polokwane areas of the limpopo province. the three schools represented the three educational contexts described in the introduction. the first (english lolt) and the third (english loltsepedi additional language) contexts were suburban public primary schools across the street from each other in the eastern part of polokwane. the first was an ex-model-c school (webb, lafon, & pare, 2010) and the third was a school that was opened 2 years post-democracy in 1996. mostly, children from middle class backgrounds attended both the schools. the second context (sepedi lolt english additional language) was a township school in central seshego, attended by children of mostly poor backgrounds. study population and sampling strategy a total of 102 grade 3 learners with an average age of 8 years, 8 months participated in the study. table 1 provides a description of the participants in each context in terms of number, gender and mean age. table 1: description of participants. non-probability, purposive sampling was employed to select participants who met the selection criteria. the principals of the identified primary schools were approached to allow learners to participate in the study. information sheets, consent forms and parent questionnaires were distributed to the parents and/or legal guardians of all grade 3 learners at each school, and those learners whose parents and/or legal guardians gave written permission for their participation were included in the study provided they met the selection criteria. criteria for selection of participants learners were required to be in grade 3 of their respective schools to ensure that they had sufficient experience with the respective languages to cope with the sr tasks. previous research (marshall, 2013) showed that grade 3 learners coped better with sr tasks than grade 1 and 2 learners. they were also required, according to parental questionnaire, to speak sepedi as their primary home language and to comply with the formal definition of sequential bilingualism, that is, to have acquired english as an additional language after the age of three (genesee & nicoladis, 2009) to ensure homogeneity with respect to bilingual acquisition profile. learners should not have suspected, reported or identified physical, cognitive, hearing or visual impairments that may have obviously affected their language development. however, learners with subtle language impairments were included as the study aimed to identify them. research instrumentation parent questionnaire a parent of each learner was requested to complete a questionnaire to obtain information pertaining to the dominant home language and other languages spoken, relative amount of exposure to english and other languages at home, years of exposure to english, milestones in the development of the home language and general health and development. recalling sentences subtest from the clinical evaluation of language fundamentals-4 (celf-4) the recalling sentences subtest of the celf, 4th edition (celf-4) (semel, wiig, & secord, 2003) was used as the english sr measure. this subtest, consisting of 32 items, assesses the ability to recall sentences of increasing length and complexity and repeat them without changing word meanings or sentence structure. this sr test was used in this study because previous local research had shown that it was a valid test for use with english language learners. a study by marshall (2013) found a strong positive correlation between the recalling sentences subtest (semel et al., 2003) and the redmond sentence repetition test (redmond, 2005) [r = 0.69; p > r = 0.001), which establishes concurrent validity. in turn, the redmond sentence repetition test (redmond, 2005) was found to have a strong correlation with all language measures on the diagnostic evaluation of language variation-criterion referenced test (delv-cr) (seymour, roeper, & de villiers, 2003) in a study by jordaan (2011). this supports the research evidence suggesting that sr is related to virtually all aspects of language processing (klem et al., 2015). the use of the delv-cr as an accurate measure of language processing in south african children has been piloted in a number of studies (jordaan, 2011; marshall, 2013; meirim, jordaan, kallenbach, & rijhumal, 2010). the translated and adapted sepedi version of the recalling sentences subtest of the clinical evaluation of language fundamentals-4 (celf-4) the sentences of the recalling sentences subtest were translated into sepedi and then back-translated into english by the second author, who is proficient in both english and sepedi. the back-translations were direct translations maintaining the sepedi word order. the back translations were compared to the original english sentences to check that the number of clause structure elements (subject, verb, object, adverb, etc.) was maintained as described in the language assessment remediation and screening procedure (larsp) (crystal, fletcher, & garman, 1976). this procedure is recommended by marinis and armon-lotem (2015) who developed the litmus-srep tasks in different languages within cost action is0804. to further ensure the validity of the sepedi sr test, we made use of eight adult verifiers who spoke sepedi as a first language, were residents of sheshego or polokwane and therefore from the same sociolinguistic environment as the learners (thornton, 2015). the adult verifiers were asked to comment on the appropriateness of the sepedi sentences and vocabulary items were changed if the majority of verifiers agreed on more appropriate terms. procedures for data collection the learners were assessed individually on both the english and sepedi sr tests by the second author at their respective schools. in each school, half the learners were assessed in sepedi first, followed by english and the other half in english first, followed by sepedi. this was to counterbalance any order effects. the assessments took place in a quiet room during school hours but with minimal disruption to the academic programme. instructions to the learners were standardised and provided in the language of testing, that is, ‘please repeat these sentences after me’. responses were recorded online by the researcher and one adult verifier by marking errors on pre-printed lists of sentences for each participant. assessment took approximately 15 min – 20 min per learner for both sr tests. all items were administered and no ceiling procedure was used to discontinue item administration. in accordance with the administration manual, we implemented a graded scoring system for both the english and sepedi tests. learners were awarded three points for semantically and syntactically intact sentences, two points if there was one error in the sentence, one point for two to three errors and zero points for four or more errors. any variation in the pronunciation of words because of articulation errors or accent was not considered as error. reliability and validity validity of the sr measures has been addressed in their descriptions above. test–retest reliability was addressed by testing a small sample (n = 5) in each group of learners twice. reliability in scoring was addressed by ensuring 100% agreement between the researcher and adult verifier in scores awarded to each participant. data analysis the total raw score out of a possible 96 (32 sentences × three points for a perfect repetition) for each language was recorded for each participant on an excel spreadsheet, containing an assigned number, the participant’s educational context, gender and age. the mean raw scores and standard deviations (sd) obtained by the participants in each language in each educational context were calculated. between-group comparisons were performed using independent sample t-tests to determine whether there were significant differences between the performance of learners in the three educational contexts on either the english or sepedi sr tests. within-group comparisons were performed using paired sample t-tests to determine whether there were significant differences between the learners’ performances in english and sepedi within each educational setting (howell, 2013). according to the guidelines proposed by rice (2009) and bishop and mcdonald (2009), learners whose scores were between 1 and 2 sd below the peer group means on the sr tests were identified as possibly language impaired. these authors suggest that children with sli will generally score between 1 and 2 sd lower than their typically developing peers on most language measures. ethical consideration the human research ethics committee (non-medical) of the university of the witwatersrand, johannesburg, issued an ethical clearance certificate (protocol no: h14/04/34) approving the study. permission was obtained from the limpopo department of education and from the respective school principals. as the participants were under the legal age of 18, informed consent was obtained from their parents and/or legal guardians and assent was obtained from those learners whose parents gave consent to their participation in the research. anonymity was maintained by assigning a number to each participant. learners who were identified with possible language impairment were managed through appropriate mechanisms. the researchers notified the parents and/or guardians of the identified learners in writing and enclosed a referral letter citing the learners’ performance on the two sr measures and any scholastic difficulties identified by the grade teacher as reasons for referring these learners for further speech and language assessment at either seshego or polokwane hospital. results the mean raw scores, sd and range of scores obtained by the learners in each educational context on the english and sepedi sr tests are presented in table 2. raw scores have been converted to percentages for ease of interpretation. table 2: mean raw scores, standard deviations and range of scores obtained by learners in each educational context on the english and sepedi sentence repetition tests. between-group comparisons with respect to the mean english sr test scores, learners in the elolt and elolt-sal contexts obtained significantly higher scores (43.86 and 52.81, respectively) than those in the slolt-eal context (18.09) (t = 11.10; p = 0.0000; df = 69) (t = 12.62; p = 0.0000; df = 64). the difference between the mean english scores in the elolt and elolt-sal context was not significant (t = 3.36; p = 0. 0.3422; df = 65). on the sepedi sr test, learners in the elolt context obtained a significantly lower mean score (29.14) than the learners in both the slolteal (t = 11.63; p = 0.0000; df = 69) and the elolt-sal contexts (t = 11.98; p = 0.0000; df = 65), where the mean scores were 49.97 and 51.61 respectively. the difference between the means obtained by the elolt-sal and slolt-eal learners was not significant (t = 1.22; p = 45.5225; df = 64) on the sepedi sr test. within-group comparisons the mean score on the english sr test (43.86) was significantly higher than on the sepedi sr test (29.14) in the elolt group (t = 13.05; p = 0.0000; df = 35), whilst the mean score on the sepedi sr test (49.97) was significantly higher than on the english sr test (18.09) in the slolt-eal group (t = 25.04; p = 0.0000; df = 34). the difference between the means on the english (52.81) and sepedi (51.61) sr tests was not significant in the elolt-sal group (t = 1.41; p = 33.8920; df = 30). identification of learners with possible specific language impairment as previously stated, learners whose scores were between 1 and 2 sd below the peer group means on the sr tests were identified as possibly language impaired, according to the guidelines proposed by rice (2009) and bishop and mcdonald (2009). the process of identifying learners with possible sli in each context, using the means and sd, is illustrated in table 3. table 3: criteria for identification of learners with possible specific language impairment in each educational context. initially, 13 learners who scored between 1 and 2 sd below the peer group mean on either the english or the sepedi sr tests were identified and their scores are reflected in table 4. the scores of participants who scored 2 sd below the peer group mean are highlighted in yellow, whilst those scoring 1 sd below the mean are highlighted in blue on the table. table 4: scores obtained by learners identified with specific language impairment in each educational context on the english and sepedi sentence repetition tests. discussion the mean raw scores and percentages captured in tables 2 and 3, suggest that best accuracy scores obtained by the grade 3 learners in this study were between 50% and 55% in both languages. although these scores may seem low and suggest that sr is not a simple task for these grade 3 children, marshall (2013), who conducted a study on the performance of grade 2 eal learners on the celf-4 english sr measure, found that her participants obtained an even lower mean raw score of 32/96 (34%). in addition, the celf-4 scoring manual reflects a normative mean raw score on the sr test for 8 year 8 month old monolingual children as between 50 and 55/96 (52% – 57%). the results achieved by the children in this study are thus in line with the normative data, which suggests that the results are valid. however, the results of this study also confirm that bilingual children who speak the same languages are not a homogenous group and their sr abilities depend on their exposure to and experience in each language. the data highlight the importance of considering educational context in interpreting the results of language assessments and support the argument that establishing ‘bilingual norms’ (armon-lotem & meir, 2016, p. 277) is not feasible. the comparisons between the three contexts investigated in this study showed that participants obtained better scores in the lolt, irrespective of whether this was english or sepedi. the group who had english as an lolt and were taught sepedi as an additional language provide very informative results. not only was the difference between their sr scores in english and sepedi non-significant, they obtained a higher score in english (55.01%) than the english-lolt (45.69%) group and a slightly higher score in sepedi (53.76%) than the sepedi lolt group (52.05%). although these differences were not statistically significant, they do support an additive approach to bilingualism where both languages are developed in an academic context. their results also show that a bilingual approach can be achieved by teaching the home language as an additional language and that this leads to higher levels of bilingualism. the english lolt group obtained a significantly higher score (45.69%) in english than in sepedi (30.35%) and a significantly lower score than the other two groups in sepedi. their poor performance in the home language suggests that these children may be experiencing a shift in language dominance to english and possible attrition of the home language, which is disconcerting given the imperative to promote bilingualism and maintain the development of all south african languages (liep, 1997). in schools where english is the lolt, teachers and parents should make every attempt to use the home language, not only for daily communication but also as a language of learning. this can be done by relating what is taught in english to the home language. the sepedi lolt group obtained a significantly higher score in sepedi (52.05%) than in english (18.84%), which is their additional language and in which they obtained a significantly lower score than the other two groups. given that these learners are to transition to english as the lolt in grade 4, this is a worrying finding as it suggests that they have not mastered english sufficiently to use it for academic purposes. the fact that their sepedi sr score (52.05%) is very similar to that of the group who were taught sepedi as an additional language (53.67%), would counteract any argument that their language skills may be negatively affected because they were from a lower socio-economic group than the other two groups. it may also suggest that sr is not as sensitive to socio-economic differences as other assessment measures, such as vocabulary tests. nonetheless, the implications for this group are either that much more needs to be done to develop their english proficiency or the home language needs to be used as the lolt beyond grade 3 in this context. this study has demonstrated that sr, a relatively quick and easy task to administer, can be used as a screening tool to identify bilingual children with possible sli by comparing them to a peer group. as shown in table 4, 13 learners were initially identified with possible sli. of these, one learner (p1) in the english lolt context could be excluded, because although he scored 2 sd below the mean in english, he did not score below the mean in his home language, sepedi. similarly, p12 in the elolt-sal context, who scored 1 sd below the mean on the english sr test but not below the mean on the sepedi sr test, could be excluded. both these participants seemed to be in the process of acquiring english, but have stronger language skills in their home language. however, if their assessments were based on english only, they would have been over-identified as language impaired. therefore, the importance of assessing bilingual children in both languages is underlined. these two learners merely need support in english as the lolt. two learners (p3 and p13) obtained scores 2 sd below the peer group means in both english and sepedi and may be considered severely impaired. two learners (p2 and p4) in the english lolt group obtained english sr scores 2 sd below the mean and sepedi sr scores 1 sd below the mean, suggesting slightly better home language skills and significant difficulty acquiring the lolt. these learners would be at a risk of academic difficulty but may benefit from support in english and their home language. these results also show that sr scores can estimate the degree of difficulty in each language. of the five learners identified in the sepedi lolt –eal context, two (p6 and p7) should be followed up for further assessment because they scored 1 sd below the peer group mean on the sepedi sr test, although their english scores were not below the 1 sd cut-off score. as sepedi is their home language and lolt, they may well be at risk for sli. three learners in the sepedi lolteal context (p5, p8 and p9) and two learners in the english loltsal context (p10 and p11) scored 1 sd below the peer group mean on both the english and sepedi sr tests and may be confidently identified with possible sli. conclusion the findings of this study suggest that speech-language therapists working in educational contexts can use sr tasks as screening tools to identify bilingual children with language impairments by comparing them to peer groups. this population-based strategy is likely to yield far more accurate and valid identification than other measures. of course, this would require the development of sr tests in all south african languages, but clinicians and researchers are encouraged to take up this challenge, particularly because sr has strong theoretical foundations as a comprehensive language assessment tool. the sr tests used in this study were clearly sensitive to language practices in different educational contexts, which enhance their validity. in this regard, the study also highlights a number of important implications for language-in-education practices and confirms that a bilingual approach in which both english and the home language are fully developed as academic languages leads to better language outcomes. although a bilingual approach may be challenging in schools where home languages are highly heterogeneous, ways of enhancing the development of learners’ first languages should be sought as far as possible. acknowledgements the authors would like to thank the learners, teachers and parents of the participating schools. competing interests the authors have declared that no competing interests exist. authors’ contributions all authors contributed equally to this work. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data are available on request from the corresponding authors. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references alloway, t.p., gathercole, s.e., willis, c., & 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(1992). wechsler intelligence scale for children-third edition. san antonio, tx: the psychological corporation. abstract introduction solutions way forward and conclusion acknowledgements references footnotes about the author(s) katijah khoza-shangase department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa munyane mophosho department of speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation khoza-shangase, k., & mophosho, m. (2021). language and culture in speech-language and hearing professions in south africa: re-imagining practice. south african journal of communication disorders, 68(1), a793. https://doi.org/10.4102/sajcd.v68i1.793 opinion paper language and culture in speech-language and hearing professions in south africa: re-imagining practice katijah khoza-shangase, munyane mophosho received: 01 sept. 2020; accepted: 20 mar. 2021; published: 03 june 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract south african speech-language and hearing (slh) professions are facing significant challenges in the provision of clinical services to patients from a context that is culturally and linguistically diverse (cld) due to historic exclusions in higher education training programmes. over 20 years postapartheid, little has changed in training, research, as well as clinical service provision in these professions. in line with the health professions council of south africa’s (hpcsa) slh professional board’s quest to transform slh curriculum and in adherence to its recently published guidelines for practice in a cld south africa, in this review article, the authors deliberate on re-imagining practice within the african context. they do this within a known demand versus capacity challenge, as well as an existing clinician versus patients cld incongruence, where even the clinical educators, a majority of whom are not african, are facing the challenge of an ever more diverse student cohort. the authors systematically deliberate on this in undergraduate clinical curriculum, challenging the professions to interrogate their clinical orientation with respect to african contextual relevance and contextual responsiveness (and responsibility); identifying gaps within clinical training and training platforms; highlighting the influencing factors with regard to the provision of linguistically and culturally appropriate slh clinical training services and, lastly, making recommendations about what needs to happen. the afrocentric batho pele principles, framed around the concept of ubuntu, which guide clinical intervention within the south african healthcare sector, frame the deliberations in this article. keywords: clinical curriculum; culture; diversity; epistemic disobedience; resource constraints; south africa; speech-language; transformation. introduction seabi, seedat, khoza-shangase and sullivan (2014) explored how speech-language and hearing (slh), psychology and social work students experience living, learning and teaching in higher education in south africa, revealing that there was a general feeling of dissatisfaction with the lack of transformation of the curriculum in these fields. in this study, factors negatively impacting the learning process were found to include high workload, english as a medium of instruction and limited access to ‘other’ resources (epistemological freedom). this study asserts that this limited access to epistemological freedom remains the prevailing condition within the slh programmes in south african universities because of the consequences of the historic exclusion of black and african language-speaking candidates from south african higher education training programmes. this is because the epistemological frames that enjoy purchase in south african universities are ‘… largely still based on a eurocentric, western epistemology with minimal, if any, inclusion of afrocentric epistemology and ontology’ (khoza-shangase & mophosho, 2018, p. 3). the current authors published an article entitled ‘language and culture in slh professions in south africa: the dangers of a single story (2018)’, framed around novelist chimamanda ngozi adichie’s (2009) ted talk ‘the danger of a single story’. this review article is a continuation of the process of confronting the dangers of ‘a single story’ started in 2018 by the current authors, which is a deliberate process for epistemic freedom and disobedience in the curriculum of these professions. in a study of south african medical students by matthews and van wyk (2018), findings indicated a strong desire for cultural competence in the curriculum to improve delivery of services and provide support to culturally and linguistically diverse (cld) groups. factors in epistemological access and language of instruction have been presented by the current authors in detail elsewhere (khoza-shangase & mophosho, 2018), cautioning against a ‘single story’ in slh professions. the health professions council of south africa’s (hpcsa) board for slh professions recently produced guidelines for practice in a culturally and linguistically diverse south africa, where one of its key recommendations is that training institutions ought to (hpcsa, 2019): [u]se findings from locally relevant research to inform curricula; acknowledge and interrogate colonial influence in all its forms (power, being and knowledge) and move towards a repositioning of the professions to better serve all south africans. (p. 15) these guidelines are a major milestone in the tangible steps that the council has taken to ensure that clinical service provision within the south african context is afrocentric and cld competent. however, measures to ensure that the guidelines are adhered to by the south african slh professionals are still not in place, but active enforcement of the guidelines by employers, professional associations through continued professional development (cpd) initiatives and the council in its annual cpd compliance audits of practitioners can facilitate compliance. speech-language and hearing practice in the culturally and linguistically diverse south african context khoza-shangase and mophosho (2018) suggested recommendations for the south african context that as part of transformation and decolonisation: (1) the slh professions need to actively engage with the national calls to africanise institutions and clinical service delivery, (2) clinical care changes that are contextually relevant and responsive, (3) research focus on local needs and issues for local benefit, (4) clinical focus that will allow for ‘next practice’ and not just ‘best practice’, (5) language policy that respects that many people speak several languages and so teaching and learning (and clinical service provision) in only english and/or afrikaans creates challenges, which need addressing and so on (p. 6). these arguments are anchored in the constitution of the republic of south africa (1996) and are supported by evidence from statistics south africa (2018), which estimates the country’s population to be at 57.7 million. this population consists of a diversity of cultures, languages, religions, nationalities and ethnicities, with 80.2% of people being black africans – a majority of which speak isizulu (23.8%) as a home language, with english being spoken as a home language by only 9.6% of the population. this evidence highlights the need for re-visiting and re-imagining practice in slh to come in line with lived context to ensure positive patient outcomes. this would also be in line with the universal declaration of human rights (united nations, 1948), the 2003 national language policy framework and the 2012 use of official languages act as outlined by the south african department of arts and culture (2003). the department of health (doh) standards for accreditation in undergraduate programmes in slh state that curriculum for academic and clinical education ought to ‘ensure that provision of services to clients or patients is not compromised where the clinician does not speak the client’s or patient’s language’ (doh, 2014, p. 7). furthermore, on the african continent, it behoves local professions to move away from euro-centric thinking and embrace decolonial practices. decolonisation entails ‘deconstruction and reconstruction’, that is (ndlovu-gatsheni, 2018): [d]estroying what has wrongly been written – for instance, interrogating distortions of people’s life experiences, negative labelling, deficit theorising, genetically deficient or culturally deficient models that pathologizes [sic] the colonized [sic] other – and retelling the stories of the past and envisioning the future. (p. 38) the intellectual landscape of slh programmes in training institutions could adopt the ubuntu worldview. this worldview, ‘… recognises the importance of others, of history, of context and community in the formation of one’s identity and the interdependent relations between individuals and collectives’ (oelofsen, 2015, p. 141). sufficient evidence exists to support the positive outcomes linked to health interventions conceived and implemented, taking careful cognisance of patients’ language and culture. matthews and van wyk (2018) asserted that integrating culture and language in teaching and learning may be a facilitating factor in developing cultural competence for medical students and improving healthcare and outcomes in the south african context. this is supported by evidence on global health that indigenous groups worldwide tend to have worse health outcomes than corresponding non-indigenous populations (anderson et al., 2016). flood and rohloff (2018) stated that global health interventions planned and delivered using indigenous languages are likely to be more successful, that groups that are not part of the dominant culture have less positive health outcomes than the dominant communities, with language presenting as a barrier to healthcare delivery, and that real indigenous language sensitivity includes not only the use of interpreters and translators, but also the creation of language-oriented programmes from the initial stages. sue and sue (2003) maintained that patients seen by healthcare providers whose racial and linguistic background matches their own continue to attend their treatment sessions and maintain treatment plans for longer duration; and this speaks directly to adherence, which is an important factor in slh intervention success. kathard and pillay (2013, p. 85) recommended that speech-language therapists acquire political consciousness, which implies that they ‘… be tolerant and accepting of being disrupted in order to challenge and change historical, taken-for granted practices’. in this regard, pillay and kathard (2018) recommended using the equitable population-based innovations for communication (epic) framework, which aims to decolonise the slh profession by developing services that are equitable and which meet the needs of underserved populations. sue and sue (2003) advocated for racial-cultural competence, which obligates therapists to be able not only to interpret the knowledge that they have about their client’s culture, but also the ramifications of race. subsequently, acquiring raised awareness of racial aspects of diversity is important because diversity is not only about culture, gender, socio-economic status, disability or language but also includes race. frequently, white individuals regard racial-cultural differences (e.g. expressiveness of verbal and non-verbal communication of african people) as a form of deviance (sue & sue, 2003), and this misinterpretation has serious ramifications for professions dealing with communication disorders. clinicians ought to be cautious about these misconceptions, as they may lead to misdiagnosis. oelofsen (2015) advised white academics in south africa, such as herself, to move away from their identity of advantage and embrace a hybrid identity, which has values and concepts from the traditional african concepts. she advocates that white academics ought to learn an african language as part of performance appraisals. universities ought not to stay silent when injustice unfolds; they are instead obliged to speak up, talk back and push the boundaries to become relevant to the context (bell, canham, dutta, & fernández, 2019). if university personnel adopt such strategies, they facilitate the development of multicultural competence within their spaces, which leads to lifelong practice outside. it is of importance to note that for multicultural competence to be lifelong practice, it is essential that it should be developed initially as part of clinical training (falender, shafranske, & falicov, 2014b). the slh professions both in south africa and more globally must accept that sensitivity to their patients’ cultural and linguistic context – in the form of critical diversity literacy – is pivotal. the ultimate point of achieving critical diversity literacy is being conscientised at a cognitive and affective level. the slh professions in south africa need to be conscientised to the fact that the burden of disease and structural inequalities affect the poor, which, because of apartheid oppression, are mostly the black people. these constitute the majority patients in the public hospitals (kathard & pillay, 2013). as asserted by freire (1998), conscientisation requires both reflection and action, with action being fundamental in dismantling the status quo as key to the slh professions in south africa. stein (2010) reiterated that symbolic and material values of hegemonic identities do become established in social relations. healthcare professionals need to be able to identify the ways in which issues such as whiteness, masculinity, heterosexuality, able-bodiedness and middle-classness are accepted as the norm and are reproduced in contexts such as healthcare. furthermore, it becomes highly challenging to change mindsets in society and shift the status quo. ethnic disparities in obtaining medical care are a good example in the south african context. as part of its mandate to ‘protect the public’ and ‘guide the professions’, in its concerted and sustained effort to transform the slh professions in south africa, the hpcsa (2019) slh professional board released guidelines for practice in a culturally and linguistically diverse south africa. these guidelines propose five main principles to be adhered to by the slh professions. principle 1: contextual relevance as an overarching philosophy for more relevant practice that will lead to more effective management of communication difficulties (to take cognisance of the processes and protocols adopted in clinical practice); principle 2: focus on assessment and intervention (to practise epistemic disobedience in terms of what knowledge and which knower is the respected source); principle 3: importance of local knowledge and calls for a shift in how the profession values it (khunou, canham, khoza-shangase, & phaswana, 2019) (to examine the ‘how’ of clinical training within the south african context); principle 4: focus on clinical training (remaining vigilant in continued professional development of critical consciousness); principle 5: lifelong development of critical consciousness. the current authors believe that these principles, if adhered to and practised, would not only lead to positive slh services outcomes but would also contribute significantly towards the transformation goals of the slh programmes to make them more afrocentric. this would, therefore, require enforcement and accountability – as the voluntary, optional ‘goodness of the heart’ approach does not seem to have yielded tangible outcomes over two decades after the democratic dispensation. this article is a clarion call to the hpcsa slh board, departments of health and education (as largest employers) and slh training institutions to ensure that translation of these principles into practice occurs. on the importance of epistemological and language diversity access, for example, southwood and van dulm (2015) argued that even though more speech language therapists who can work in african languages are entering the profession now than before, the lack of access will continue to make it difficult to disentangle children who are speakers of african languages and who are typically developing but still in the process of acquiring english (or afrikaans) from those who have underlying language impairment. they lament that this is because such a differential diagnosis requires knowledge of the status of the child’s language skills in his or her first language, which most clinicians are not privy to. they therefore conclude, similar to current authors, that recruiting first or other language speakers of african languages into slh training programmes promises to change levels of service delivery more than specialised training or maturation as an slh practitioner. these authors, as argued by khoza-shangase and mophosho (2018), suggested that such recruitment and the appropriate training of african language speakers into slh professions ought to be performed concurrently with development of linguistically and culturally appropriate assessment and remediation materials if efficacious contextually relevant research evidence-based assessment and intervention is to be provided (southwood & van dulm, 2015). pascoe and smouse (2012) also argued that: [c]linicians within the slt profession have an ethical responsibility to effectively assess and manage their clients in the client’s first language, even where a language mismatch between client and clinician exists. (p. 471) gaps in the south african speech-language and hearing clinic the south african context shows significant mismatch between slh practitioners and the population they serve with regard to language (english and/or afrikaans) and culture (mostly western). this incongruence creates a barrier to provision of efficacious clinical services and prevents growth and development of the professions. with only approximately 5% of hpcsa registered practitioners being black african language speakers – in a country that has over 70% of its population speaking an african language as their first language – an obvious gap exists. this gap is not localised to the clinical service provision by graduates but exists in the staffing profile of academics and clinical supervisors and/or educators in universities and clinical training platforms. this reality means that even african language-speaking students who enrol into south african training programmes receive training that is not ‘africanised’. consequently, they do not necessarily graduate in a better professional position than non-african language speakers. this is well described by letsoalo and pero (2020), who pointed to the white gaze and its persistent influence over the curriculum.1 if the demographic profile of teaching and research staff is not diversified in order to reflect the contextual profile, there is limited, if any, epistemological access, which in turn influences the beliefs held and approaches adopted about communication disorders and their assessment and management. this extends to the development of assessment and intervention resources that are linguistically and culturally appropriate over and above the translation and adaptations of resources, which has its own limitations and weaknesses for this context. as a result of the very nature of the slh professions to assess and treat language and communication pathology in patients, this gap cannot continue to be ignored (khoza-shangase & mophosho, 2018; mophosho, 2018; mdlalo et al., 2019; pascoe et al., 2017). in fact, khoza-shangase (2019) presented a tripartite threat to the helping professions (slh) professions in south africa (figure 1), as including ignorance and naivety about the influences of linguistic and cultural diversity over and above its contextual realities, such as burden of disease, resource constraints, poverty and inequality. moreover, it is pivotal for clinical educators to acknowledge that their primary goal is to facilitate: ‘… thoughtful, systematic reflection about the contextual and multicultural factors affecting the clinical and supervisory relationships’ (falender et al., 2014b, p. 60). figure 1: tripartite threat to the survival of speech-language and hearing professions in south africa. influencing factors to the provision of linguistically and culturally appropriate speech-language and hearing clinical training services the current authors believe that a key challenge in achieving linguistically and culturally appropriate slh clinical services in south africa is the knowledge base, theory, research evidence (academic curriculum) that fails to reflect diverse knowledge, particularly to the exclusion of african epistemologies (khoza-shangase & mophosho, 2018). reeler (2015) argued for a curriculum that ‘deliberately aims to interrupt the usual hierarchy of knowledge’, calling for: … content which consciously aims to engage with african epistemologies, be it through teaching postcolonial theory; deconstructing dominant canons or worldviews; using african examples, texts and contexts; correspondent examples or theories from other parts of the so-called majority world countries; or a pedagogy that uses african languages as learning resources. (p. 1) this study is grounded in postcolonial theory that addresses the current political, aesthetic, economic, historical and social impact of european colonial rule around the world (elam, 2019).2 although postcolonial theory takes many different shapes and interventions, the authors support elam’s (2019) assertion that all the variations incorporate an important contention, namely that our understanding of the world is unfeasible outside of relating it to the history of imperialism and colonial rule, in terms of europe’s colonial encounters and oppression around the world. this is argued here to be the case in slh within the african context. these influencing factors within the clinical training and training platforms in the south african context, as reflected in figure 2, are further impacted by several other factors, which can be grouped into five aspects: people, places, practices, processes and policies, guided by national center for culturally responsive educational systems and invitational education theory (purkey, 1999), which the current authors adapted for the current review article. figure 2: the 5 ps of influencing factors towards decolonial speech-language and hearing professions in south africa. in terms of people, the current cohort of students, including clinical supervisors and/or educators, as well as the current combination of clinicians and patients, are mismatched both culturally and linguistically. the current cohort of clinical educators is not reflective of the demographic profile of the country, and consequently their linguistic and cultural competence and awareness of the context are limited. furthermore, evidence of restricted training in african cultural and linguistic knowledge, for example, cultural humility, is seen to be generally lacking in the slh curriculum. limited tuition in courses such as african anthropology and sociology, over and above african languages, has been observed in all training programmes. these weaknesses exist in the context of a student body that remains largely non-linguistically and non-culturally diverse, with small numbers of african students assimilating into a distinctly non-african curriculum. firstly, as far as practices as an influencing factor are concerned, the highly structured curricula of the various programmes, in line with the hpcsa regulations, seem to be to the exclusion of cld – unless there is a specific staff member interest. this leads to optional input in different programmes and unequal access and competency by students from different institutions. secondly, the current authors argue that there is generally limited critical consciousness in clinical practice, with supervisors and/or educators not being aware of the influence of factors such as power, cultural capital, etc., in clinical provision and clinical training. we need to recognise that power and culture intersect within communicative interactions. according to hyter and salas-provance (2019), power can be exerted using different measures, such as structural violence, physical violence, symbolic violence, manufactured consent and organisation of work. speech-language and hearing practices ought to avoid all these power differentials, especially symbolic violence, where benefits of one group depend on the disadvantage or deprivation of another group. there is a need for programmes to deliberate on culturally responsive pedagogy and practice with training provided as part of clinical educators’ training. thirdly, there is unabated use of cld inappropriate resources, where it is deemed acceptable to simply translate resources without following structured protocols or considering the adaptations and expertise of translators. barratt, khoza-shangase and msimang (2012) stated that translating and adapting a test are critical processes that need to consider the personal characteristics of individuals translating the test, which will influence how the test is translated. these authors raise caution about, for example, any inappropriate use of vocabulary or sentence structure, which they argue are some of the factors that may dilute the complexity of the translated material. the current authors feel strongly that translations and adaptations ought to be performed by expert speakers of the target language, preferably from an academic linguistics department, who would understand the importance of maintaining the validity and usefulness of the test measure. furthermore, current authors recommend that where translations and adaptations are performed, specific documented protocols ought to be followed, over and above simply translating and piloting the materials. specifically, protocols followed ought to include translating and adapting the measure, reviewing the translated or adapted version of instrument, adapting the draft instrument based on the comments of the reviewers, pilot testing the instrument, field testing the instrument, standardising the scores and performing validation research (geisinger, 1994). peña (2007) aptly asserts that during translation: [t]ypically, the translation process focuses on ensuring linguistic equivalence. however, establishment of linguistic equivalence through translation techniques is often not sufficient to guard against validity threats. in addition to linguistic equivalence, functional equivalence, cultural equivalence, and metric equivalence are factors that need to be considered… (p. 1255) the current culture of using planisa as a lingua franca in cld resources ought to be called into question, as it not only negatively impacts the accuracy and efficacy of clinical practice, but also infringes on patients’ rights. mophosho (2016, p. 162) describes planisa as ‘… they get on and get by in the hospitals through their improvisation and the teams’ self-initiated action’.3 furthermore, the use of untrained interpreters during assessments and intervention with limited use of cultural brokers forms part of the planisa-linked factors influencing the provision of linguistically and culturally appropriate slh clinical training services within the south african context. south africa has a strong constitutional, legal and policy dispensation that protects patient rights. at the policy level, implementation and monitoring of the language policy in the doh and batho pele (people first) principle; translating existing policies and regulations around cld in healthcare into practice; confronting the use of academic freedom by training institutions to defend lack of social accountability and responsibility around cld matters; raising and sharpening political will and government mandate around cld; as well as confronting the silence around clinical practice without cld competence in the ethical codes of conduct all present significant challenges. councils such as the council of higher education (che) and hpcsa, involved in quality assurance of higher education training, have a significant role to play here. their failures in this regard illustrate the disjuncture between the universal aspiration of human rights as norms and the complexities arising in their implementation. as far as places (physical environment in which people interact), as a factor, are concerned; it is a context where many of the speech language therapists and audiologists do not speak the language of their clients, consequently limiting their work. the paradox remains a structural mechanism in contemporary south african public health system that does not seem to be responsive to the needs of the citizens. again, the context is also limited by existing interpreter resource challenges. given that cultural and linguistic diversity has a profound effect on the ways in which families and professionals inter-relate cross-culturally and participate together in treatment programmes, the doh ought to invest in finding trained interpreters to assist healthcare providers and patients in government institutions. in public settings where there are no mediated or interpreter services, the objectives of the national language policy framework are certainly contravened. lastly, as far as processes (systematic series of actions directed to some end) are concerned, penn, mupawose and stein (2009) attributed the lack of preparedness of speech language therapists and audiologists in a south african health context to professional, technical, systemic, managerial, interpersonal and ethical challenges. these can be attributed to a variety of complex factors, including gaps in resources including research, culturally appropriate intervention tools and relevant human resources. solutions falender, shafranske and falicov (2014a) observed culturally responsive pedagogy in clinical training to include personal dimensions, institutional dimensions and instructional dimensions, as depicted in figure 3. figure 3: clinical training through culturally responsive pedagogy (and practice). in line with figure 3, which defines culturally responsive pedagogy as requiring attention to the personal, institutional, as well as instructional dimensions; the aforementioned gaps and influencing factors, as numerous as they are, are not insurmountable. a multipronged approach is required, where a number of factors are simultaneously addressed as possible solutions to the current cld conundrum facing the south african slh professions. key to this is the transformation of students and staff demographic profiles to become reflective of the country’s cld profile. speech-language and hearing professions need to also understand change processes in public policy implementation within the institutional dimension (wylie, mcallister, davidson, & marshall, 2013). within the personal dimension, cultural competence humbles the practitioner and stimulates cultural humility. in addition, it enhances patient care, as the understanding of patient belief systems becomes integral to their healthcare (juarez et al., 2006). this leads to cultural humility, which is defined as a lifelong learning process that incorporates openness, power-balancing and critical self-reflection when interacting with people for mutually beneficial partnerships and institutional change (tervalon & murray-garcia, 1998). at an instructional level, slh departments need to have a student-centred vision and mission statement, commitment to diversity, provide culturally and linguistically appropriate services, with equitable and supportive learning environments, such as the conceptual framework for responsive global engagement (hyter & salas-provance, 2019). furthermore, in relation to the clinical component, the current researchers recommend that clinicians collaborate with other disciplines, such as sociology and anthropology, and include clients and their families to understand the cultural history of persons on their caseloads. the worldview, cultural assumptions and practices of the client are considered in the clinical service by incorporating them into assessment and intervention plans (hyter & salas-provance, 2019). research into cld knowledge base and clinical practice, leading to development of cld resources that are evidence based, is also paramount. furthermore, taking a social action approach would be pivotal. this is the highest level on the banks’ (1989) model, which involves students taking decisions and actions on important social issues. this can happen if training institutions have the political will and if programme leadership lobby not only for policy formulation around clinical care and clinical practice more generally but also specifically for training purposes in training platforms. for example, training institutions can play a major role in influencing the inclusion of official and trained interpreters in staff establishments such as hospitals, which serve as training platforms. furthermore, clinical educators need to be trained to engage diverse and/or afrocentric minds when consuming literature or clinical training sources, so as to ensure that their teaching and assessment approaches are contextually relevant. in addition to this engagement of diverse minds, clinical educators need to be assisted in developing multicultural competence, where their awareness of influence of culture on clinical presentation and clinical interaction is raised and where their awareness of the influence of culture on the supervision process is highlighted. all these speak about culturally responsive (and competent) pedagogy (falender et al., 2014a) and cultural humility (as counter to ethnocentricity or white privilege) during the supervisory – supervisee/therapist – client dynamics. clinical supervision of slh students that are cld competent requires commitment to social justice and advocacy, where such a commitment underlies the attitude necessary for effective diversity and multicultural competence (vasquez, 2012). those involved should have a clear understanding of environmental contributions to human development, including pathology. therefore, the curriculum needs careful interrogation in order to be cld sensitive and competent. this is for both assessment and intervention with development of guidelines for clinical educators and clinician students forming part of the core clinical curriculum. the core curriculum should include diversity sensitivity programmes such as those provided by the people for awareness on disability issues (padi), an academic service-learning programme for first-year slh students with disability awareness workshops run over the span of one semester specific to language and culture. these should not be optional as they currently are in most programmes. these types of service-learning projects also enhance civic responsibility in students because they focus ‘… on meeting both communities’ needs and learning objectives; it emphasises critical thinking to improve skills and civic responsibility’ (pillay & ramkissoon, 2020, p. 1075). linguistic and cultural consciousness and critical diversity literacy should form part of the cld enhancing tuition in slh programmes. way forward and conclusion it is important that when south african slh professionals deliberate on transformation of the profession, they should also face the decolonisation of the curriculum by introducing political consciousness and critical literacy diversity. political consciousness in the curriculum and training is not just about learning to pass, but it teaches students how to respond to cultural context, foster connection with patients or clients and invest in relationships with the communities. the slh professions in south africa need to show greater recognition of the urgent need to both examine and re-imagine slh clinical training, which will have a positive effect on clinical outcomes and will inform academic curriculum. training programmes need to identify environmental and instructional elements of culturally (and linguistically) responsive training and training platforms so as to ensure that these elements are optimised for their students’ clinical training. training institutions need to deliberate on and define culturally (and linguistically) responsive pedagogy and hold themselves accountable to it with education and training regulating bodies, including this as part of institution evaluation and accreditation processes. this includes identifying features of culturally (and linguistically) responsive pedagogy – as recommended by the national center for culturally responsive educational systems (nccrest, n.d.). the south african undergraduate clinical curriculum needs to undergo reform, where standards followed are international, but afrocentric with slh training programmes from all south african universities understanding that they have a moral obligation to actively engage with and address the legacy of apartheid in all their teaching and learning activities (including their cpd offerings). student clinicians and qualified clinicians ought to demonstrate an understanding of their client’s challenges, causes of the problems and work collaboratively with their clients in identifying ways to overcome them. supervisory relationships should have a framework that has multicultural perspectives and diversity mindfulness; in addition, it should consist of an explicit antiracism and anti-oppression standpoint (porter, 2019). as far as the cpd offerings are concerned, professional associations/bodies have an important role to play as accreditors of cpd events and cpd providers themselves, in making sure that cld activities are also prioritised. the south african government must be lobbied to address the cld-related challenges in healthcare facilities, which serve as clinical training platforms, as state responsibility. in re-imagining practice, the current authors have presented a number of suggestions, including decolonisation of the slh professions with responsibility to context through best practice-driven clinical training that is contextually relevant and responsive. this is important if the slh professions provide efficacious services within the national health insurance where universal health coverage is the goal. if the status quo remains, where there is a lack of demand-driven engagement, south african slh practitioners will continue to rely on the single story, which impedes provision of effective intervention. this will continue to maintain the cycle of exclusion, with patients or clients entering the healthcare system but exiting without receiving effective treatment or care, because language and culture remain barriers in an environment where communication pathology is the presenting disability. social structures of clients ought to be considered contextual factors when planning slh assessments and interventions. for the slh professions to be effective and relevant within the south african context, practitioners need to deal with the unequal relations of power and strive to maintain equality in these relations with those they serve – both in clinical training and clinical service provision. the authors have deliberately not included a template or a case example to illustrate implementation of the suggestions they have provided. this series remains a call for independent critical deliberations and engagements with the slh practice, which must leave room for independent creativity in re-imagining slh practice within the african context, thereby allowing us to carve out next practice for our context. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions both authors co-conceptualised the idea for this opinion piece. k.k.s. was the lead author in writing up the manuscript for publication with input from m.p. both authors read and approved the final manuscript. ethical considerations this article followed all ethical standards for research without direct contact with human or animal subjects. funding information the authors thank the national institute for the humanities and social sciences (nihss) for providing financial assistance for the publication of this manuscript. data availability the authors confirm that the data supporting the findings of this study are available within the article. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references adichie, c.n. 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(2013). changing practice: implications of the world report on disability for responding to communication disability in under-served populations, international journal of speech-language pathology, 15(1), 1–13. https://doi.org/10.3109/17549507.2012.745164 footnotes 1. white gaze is a popular term in the discourse of african-american literature, which captures black lived experience in white spaces, where whiteness imposes itself as a lens for knowledge, knowing and the knower (khunou et al., 2019). 2. other anti-colonial positions such as african humanism, black marxism, social theory also pertain. 3. phakathi (2013) describes planisa as a type of fanakalo (mining lingua franca), collaged together from various languages for miners to help them problem-solve day-to-day challenges. abstract introduction methodology discussion implications strengths and limitations conclusion acknowledgements references about the author(s) harsha kathard department of health and rehabilitation sciences, faculty of health sciences, university of cape town, cape town, south africa prianka parusnath department of communication sciences and disorders, faculty of health sciences, university of cape town, cape town, south africa lehana thabane department of health research methods, evidence and impact, faculty of health sciences, mcmaster university, hamilton, canada mershen pillay department of speech and language therapy, institute of education, massey university, auckland, new zealand department of speech-language pathology, faculty of health sciences, university of kwazulu-natal, durban, south africa zheng jing hu department of health research methods, evidence and impact, faculty of health sciences, mcmaster university, hamilton, canada jane le roux department of health and rehabilitation sciences, faculty of health sciences, university of cape town, cape town, south africa michal harty department of health and rehabilitation sciences, faculty of health sciences, university of cape town, cape town, south africa shelley o’carroll wordworks, cape town, south africa rizwana b. mallick division of communication sciences and disorders, faculty of health sciences, university of cape town, cape town, south africa citation kathard, h., parusnath, p., thabane, l., pillay, m., hu, z.j., le roux, j., … mallick, r.b. (2022). a survey of communication supports in grade r classrooms in the western cape, south africa, south african journal of communication disorders, 69(1), a871. https://doi.org/10.4102/sajcd.v69i1.871 original research a survey of communication supports in grade r classrooms in the western cape, south africa harsha kathard, prianka parusnath, lehana thabane, mershen pillay, zheng jing hu, jane le roux, michal harty, shelley o’carroll, rizwana b. mallick received: 02 nov. 2021; accepted: 30 june 2022; published: 27 oct. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: early classroom communication supports are critical in influencing oral language development and emergent literacy skills. it is both support from peers and adults, as well as the environment that impacts the quality and efficacy of language learning. schools in particular play a key role in communication development, which will be further explored in this article. objectives: to describe how communication was being supported in the classroom by teachers in the areas of language-learning environment (lle), language-learning interactions (llis) and language-learning opportunities (llos) to focus on classroom communication supports to strengthen literacy outcomes for grade r learners. method: a cross-sectional descriptive survey of classrooms was conducted using a structured observation method in 136 classrooms. the communication supporting classroom observation tool was used to make 223 observations across classrooms of lle (19 items), lli (20 items) and llo (5 items). a descriptive analysis of frequency of occurrence of items was conducted for each domain. results: language-learning environment had more frequently occurring observations, with 12 out of 19 items being observed with a frequency of occurrence greater than 65%, indicating that the environment had adequate basic resources (e.g. good light). language-learning interactions scores indicated that 3 out of 20 items were observed frequently, while 17 out of 20 items were observed less frequently (56.5%), including interactive strategies (e.g. turn-taking). language learning opportunities scores indicated that teacher-led behaviours (e.g. including children in small group activities) were infrequently observed on all items. conclusion: while the physical environment was generally supportive, the behaviours in the interactive domains of lli and llo were observed less frequently. there is potential for speech–language therapists to work collaboratively with teachers to develop communication supporting classrooms as a critical primary-level intervention for language-literacy learning. keywords: communication; pre-school; literacy; language; grade r. introduction there are two key components of education, viz. communication and language. communication, as speech–language therapists have come to understand it, refers to the sending and receiving of messages with shared understanding, while language refers to the complex system of symbols that are used in a variety of modes for communication and thought (huff & christensen, 2018). without meaningful communication, learning cannot happen, and without language, shared meaning and complex thoughts such as an understanding of literacy cannot develop. language is the golden thread that underlies listening, speaking, writing and reading and is essential to literacy learning (sturm & clendon, 2004). early classroom communication supports are critical in influencing oral language development and emergent literacy skills. vygotskian-oriented and social interaction theories (wertsch, 2004) focused the zone of proximal development that highlighted need for quality interaction between a child and a more knowledgeable adult (like a parent, teacher or speech–language therapist) because it facilitates oral language learning (kaderavek, 2015). oral language comprises vocabulary development, awareness of grammar, syntax, knowledge of narrative structures and precursors to comprehension skills (carroll, bowyer-crane, duff, hulme, & snowling, 2011). furthermore, it is not adult support alone that plays a key role in moving a child through the zone of proximal development but environment as well (shabani, mohammad, & ebadi, 2010). while oral language development is facilitated in multiple contexts (home, school and social), teachers play a critical role in facilitating literacy skills for academic learning. language-literacy learning is used in this case because the development of oral language is interlinked with early literacy development in early education settings (bedore, pena, fiestas, & lugo-neris, 2020; moonsamy, 2015; pelatti, piasta, justice, & o’connell, 2014). communication will also be used interchangeably as we refer to the broad scope of language learning, literacy learning and the development of oral and written skills in each area. in south africa, one of the most significant influences on early language and literacy development, is the reception year (grade r or kindergarten) that is the entry into the foundation phase of learning (janse van rensburg, 2015). indeed it is the quality of a child’s grade r year that is a determining factor on how they will develop the language, cognitive and social skills required to build a solid academic foundation (isaacs, roberts, spencer-smith, & brink, 2019). classrooms supporting effective communication development are critical, particularly for children of low-income and under-served backgrounds who may have limited language-literacy learning opportunities in their home environments (carolus & moonsamy, 2019; dickinson, hofer, & rivera, 2019; neuman, kaefer, & pinkham, 2018). dockrell, bakopoulou, law, spencer and lindsay (2012) analysed 62 articles and identified three areas of support to facilitate oral language development: (1) language-learning environment (lle), (2) language-learning opportunities (llos) and (3) language-learning interactions (llis), which together create communication supporting classrooms (dockrell et al., 2012). teachers are skilled and experienced with implementing the grade r curriculum, but typically may not receive specific training on how to create communication-supporting classrooms (justice, mashburn, hamre, & pianta, 2008; pence, justice, & wiggins, 2008). teachers implement structured aspects of curricula but may be less adept at the process of implementing the conversational dimensions and therefore may benefit from collaborating and being supported by speech-language therapists (slts) (justice et al., 2010). the slts have in-depth knowledge around language and communication development and are uniquely equipped to support students, teachers and parents to ensure the achievement of learning outcomes in school (wium & louw, 2013). however, slts are not experts in classroom teaching. therefore, slts and teachers can partner together to develop equitable primary-level intervention (pillay & kathard, 2018) designed to promote healthy classroom communication environments and behaviours for learning (dockrell et al., 2012), which potentially benefit teachers and all children. the authors of this article hold the view that teachers have a vast experiential knowledge base about their classrooms and children, and a partnership approach between teachers and slts has potential to strengthen communication supporting classrooms. in south africa, grade r is the first point of entry into a 4-year foundation phase of learning (grades r–3) in the school system for most children between 5 and 6 years of age (department of education, white paper 5, 2001). this is the case for children in low-income marginalised communities who typically do not have access to formal early childhood education between 3 and 5 years (leseman, 2002). in stark contrast, children in socio-economically advantaged communities have access to quality early learning (praesa, 2018). as a means of addressing the inequality in the south african education system, grade r education was expanded in 2001 in south africa for the majority, marginalised population. despite significant investment in the grade r infrastructure (department of basic education [dbe], 2013) there are poor outcomes in the quality of education received by learners (samuels et al., 2015). this situation may be explained by arguing that the educational challenges in south africa are a consequence of longstanding influences of colonialism and apartheid, which has created a vastly unequal society. in south africa’s post-1994 democracy, inequality continues to be reflected in an economic area where nearly half of black africans live below the poverty line compared with 1% with white south africans (amnesty international report, 2020). in the post-1994 context, children’s futures are determined by where they are born (geography), their economic status and skin colour. despite the efforts of the department of education (doe), children of mixed race from marginalised backgrounds continue to fall behind their white peers (johnson, pesky, & aulum, 2021; msila, 2007). government rural schools in poor communities and urban township schools continue to be impacted by poverty, ill health, poor school infrastructure, limited resources and materials, large numbers of learners per class, limited teacher preparation and didactic instructional techniques (nel, mohangi, krog, & stephens, 2016; probyn, 2018). while the rapid expansion of grade r learning was a means to address the education inequality gap in south africa by placing emphasis on basic numeracy, literacy and life skills, there are poor outcomes because of several systemic factors (samuels et al., 2015). for this study, two key factors require attention in order to address these inequalities that contribute to poor academic outcomes. firstly, the need for additional professional development of teachers and secondly, improved alignment between the curriculum and language policy (praesa, 2018; samuels et al., 2015). although grade r curricula encourages the development of literacy skills through play-based pedagogy (mohangi, krog, stephens, & nel, 2016), teachers struggle with practical implementation given that socialisation has occurred in an education system, which typically practices a didactic, transmission mode of teaching (kathard, pillay, & pillay, 2015). grade r classrooms are commonly attached to primary level schools, implying that teachers are likely to see grade r as formal learning in preparation for grade 1. while teachers focus on meeting curriculum goals, they can extend social learning opportunities to facilitate meaningful language and literacy learning (prinsloo & bloch, 1999). secondly, challenges with the implementation of the language-in-education policy (liep) are a key contributing factor to poor academic outcomes (jordaan, 2011). while the official policy promotes additive bilingualism, in practice, english language learning is actively promoted over african languages as it provides access to the economy (jordaan, 2011; probyn, 2018). the liep encourages children to be taught in their home languages from grade r to grade 3. however, in grade 4, 80% of children of black african home language backgrounds typically switch to english as the language of learning and teaching. in these cases, they are both taught and assessed in english from there onward. (heugh, 2013). classrooms have also become more linguistically diverse, with teachers having limited knowledge and support for how to support language learning, particularly for academic learning (jordaan, 2011). the curriculum, however, is premised on the assumption that children have acquired the language and literacy skills to reach curricular goals. the impact of the disjuncture between liep and curriculum practices is recognised in grade 4 when the medium of instruction switches from african home languages to english with no additional language support such as using visuals or allowing students adequate time to process (kirss, säälik, leijen, & pedaste, 2021). in a study of teachers’ perspectives of language challenges in intermediate phase classrooms (grades 4–7) in western cape, teachers were concerned that most learners were not meeting grade level outcomes for written language because of multiple systemic challenges as a result of apartheid-related lack of resources, amenities and infrastructure in historically black residential areas (navsaria, pascoe, & kathard, 2011). teachers in intermediate phase identified the need for early intervention to address language and literacy learning difficulties and the creation of communication supporting classrooms in the foundation phase, beginning in grade r. the persisting problem of low literacy levels in south africa strengthens the case for identifying other early supports, which may yield better literacy outcomes (govender & hugo, 2020; spaull, 2015). against this backdrop, the importance of communication supporting classrooms beginning in preschool (nurseries, crèches, grade r, etc.) is a critical part of improving learning outcomes. the large-scale challenge with language-literacy learning in south africa is becoming a priority for speech–language therapists who are focusing their support on partnerships with teachers, particularly in the foundation phase, as a strategy for classroom-based intervention (kathard & moonsamy, 2015; wium & louw, 2015). this approach of creating meaningful partnerships has the benefit of supporting the teachers to meet the communication learning outcomes required in the national curriculum and assessment policy (dbe, 2021). in addition, it allows slts the opportunity to gain a better understanding of classroom dynamics and curriculum. there is a restrictive therapist-to-population ratio (0.57:10 000) in south africa (pillay, tiwari, kathard, & chikte, 2020) with regard to communication professions (speech therapists, speech therapists and audiologists). therefore, the need to develop innovative population-focused primary level interventions which can support many teachers is vital to ensure the improvement of language-literacy learning (pillay & kathard, 2018). however, before interventions are considered, it is important to describe communication supports in grade r classrooms. communication supporting classrooms while children’s exposure to language-literacy learning may vary in home environments, the classroom is a structured everyday space to facilitate language-literacy learning. the playground also provides invaluable opportunities for language-literacy learning. teachers play a key role in in supporting communication by structuring the environment and facilitating interactions and shaping llos. therefore, optimising communication support in a school environment is important. while there has been a longstanding interest in communication in classrooms, using various assessment methods and tools, for example, the classroom assessment scoring tool (pianta, la paro, & hamre, 2008) and the classroom literacy observation schedule (louden, rohl, barratt-pugh, & brown, 2013) tools have been developed to support research and with a language teaching purpose. however, the communication supporting classroom observational tool (cscot) was developed and validated in the united kingdom in 2012 for clinical application by speech–language therapists (dockrell et al., 2012). the cscot is structured in three parts: language-learning environment the environment refers to the physical classroom environment and how it is organised and managed. it includes observing aspects such as sound levels, provision of learning material such as books and play materials, musical instruments and symbols and pictures to mark the various areas of the class. language-learning interaction the llis are regarded as the critical aspect of developing oral language as exchanges between teacher and learners is ongoing and provides opportunities for the teacher to be responsive. this interactional support during instruction includes a range of behaviour such as questioning, extending conversations, re-casts (task clarification) and feedback. these interactions are found to facilitate vocabulary development in monolingual speakers and children learning additional languages. language-learning opportunities language-learning opportunities assess the child’s (or children’s) opportunities for language learning and practice. these opportunities include small group work, interactive book readings and structured verbal conversations with adults and peers. these opportunities may be peer–peer or adult–learner dyads. the international body of literature confirms that children in contexts of poverty and social disadvantage require communication supporting classrooms as they may not have sufficient environment, stimulation and resources to develop their early communication skills (ellis & rowe, 2020; justice et al., 2010). environments supporting language-literacy learning are those that are print-rich, have materials and resources, display areas for children’s work and props, which support children’s interactions with each other (justice, 2004). there are a range of learning environments in south africa: some have minimal print-based resources, are unhygienic and disorganised; other classrooms are organised, with print-rich environments and a range of learning materials and play resources (nel, tlale, engelbrecht, & nel, 2016). language-learning opportunities are those opportunities that are created in everyday classrooms activities in large or small groups or through individual interaction that provide opportunities, which facilitate language learning. the activities include play-based activities, storytelling or reading and structured interactions (guo et al., 2010). the curriculum and assessment policy statement (caps) curriculum encourages a range of oral llos, peer conversations, role play, songs and poems (dbe, 2011). a study of teacher interactions with grade r children who were refugees (adams-obugjele & moletsane, 2019), found a general lack of quality social interactions with children, as the teacher and assistant were focused on classroom managed activities. nel et al. (2016) reported that when teachers who were required to provide instruction in english, which is not their home language, they read story books in a structured manner and did not ask questions to engage higher order thinking, hence limiting llo. these studies recommended teacher professional development to address teachers’ understanding of the caps curriculum, to strengthen social interaction skills and facilitate an improvement in the organisation of the learning environment. teachers are influenced by complex personal and contextual factors, which contribute to how they negotiate changes with instructional processes (kimathi & bertram, 2020). the area of lli has been the focus of research internationally as the interaction between the teacher and children is critical in language-literacy learning (swari, tantra, & pratiwi, 2020). rimm-kaufman et al. (2002). observed variation in activities in preschool classrooms environments across three states in the united states of america, with the most frequent activity being structured teacher-directed activity and whole group instruction. while more informal and play-based learning occurs in preschool classrooms, the early childhood classroom is teacher-led, with the teacher contributing to 93% of directive speech acts. this is for varied purposes including confirming ordering, explaining, requesting and telling (swari et al., 2020). in this same environment, children used speech acts mainly for the purpose of telling when prompted or initiated by a teacher (early, maxwell, ponder, & pan, 2016). wasik, bond, and hindman (2006) reported that when teachers were supported in their delivery of literacy intervention, they made positive changes in their interactions during book reading and other activities and practiced active listening, extended conversations, asked questions and provided feedback. children’s language development also benefitted through these interactions. in light of the death of research on grade r communication supporting classrooms, this study set out to describe lle, llo and lli grade r classrooms attached to public schools in the western cape, south africa. this knowledge will serve to inform slt practices in supporting grade r teachers. methodology aims and objectives the primary aim of the study was to describe how grade r classrooms scored on the domains of cscot tool, namely: language-learning environments language-learning interactions language-learning opportunities. the secondary aim of the study is to discuss the implications for speech–language therapy practice within the education or schooling system and as partners with teachers. methodology research design the study used a cross-sectional descriptive survey observational design whereby classrooms were observed using a criterion referenced tool – the cscot (fraenkel & wallen, 2000). the design was suited to collecting data from a large number of classrooms. the classroom and its teacher(s) and learners was the unit of data collection and analysis. criteria for inclusion of classrooms the following criteria were used for including classrooms in the study: public sector school following the national grade r curriculum classroom with a teacher who routinely taught the grade r class (i.e. no substitute teachers or locum teachers). criteria for exclusion classrooms attached to independent schools and early childhood development centres were excluded. sampling stratified adaptive cluster sampling was used to ensure a representative sample of schools in urban and rural or remote areas, as well classrooms from schools across the academic performance range, that is, higher and lower performance range. this sampling strategy allowed the schools in both rural and urban areas in the western cape equal opportunity for participation. within the schools selected, a cluster of grade r classrooms were selected. recruitment researchers first received permission from the western cape education department to conduct the study. thereafter, school principals were contacted to obtain their permission to conduct the study. after information was provided and it was established that the classrooms met the criteria for inclusion, arrangements were made for data collection to commence with teachers who consented to participate. method a structured observation method was employed, with the cscot used as the observational tool. prior to the study, research assistants were trained on conducting observations using the tool until they established a good inter-rater reliability (interclass correlation of 0.9). the research assistants chosen were students at the university of cape town in the field of linguistics, communications and other disciplines with a basic knowledge of communication. a total of 136 classrooms were observed for 1 h per classroom. where feasible, two raters were available per classroom, meaning that many classrooms had more than one observation. the total number of observations were 223, with 87 classrooms having multiple observations per classroom. each rater observed made independent observations. the observation occurred in the morning session of the school routine, which was typically a literacy or numeracy learning activity. the data were collated and entered into a spreadsheet, checked and verified by an independent researcher. research instrument communication supporting classroom observational tool the authors chose the cscot because it is a tool developed specifically to support slt practices in the early years – from grade r to grade 2 (dockrell et al., 2012). it was created to profile learning spaces or classroom environments and explore the various dimensions that supported the development of language skills (dockrell et al., 2012). furthermore, the south african school systems are similar in ethos, spirit and function to british educational contexts, sharing similar practices, that is, classrooms and education have a longstanding influence from british education system, which therefore makes the tool a good starting point to describe the south african classroom environment. furthermore, as part of an undergraduate research project that was conducted at the university of cape town (harty et al., 2013), the cscot was examined by a panel of experts to determine the face and content validity of the tool’s relevance and suitability in a south african context (harty et al., 2013). finally, the cscot used a comprehensive approach by examining the physical environment (lle – 18 items), lli (19 items) and llo (5 items) as the domains of the tool. for lle, the observer noted if the item was present or not. for lli and llo, the observer marked the number of times the behaviour was observed in the hour of observations – from 0 to a maximum of 5 observations. procedure the data were collected as two parts – one research team focused on the rural or remote schools while the other team collected data in urban areas. the teams arranged the daily schedules for observations. where feasible, two researchers entered a classroom and observed the classroom for an hour, usually during a morning routine followed by a language or mathematics lesson. each rater completed the cscot independently and the team head collected the hard copies of the data. the data per classroom observation was then captured independently by a researcher onto an excel spreadsheet. for each observation, the data were captured per item for each area of the cscot and were identified. the data entries were then verified by a research assistant. data analysis descriptive tables were produced to show the frequency of occurrence for each item in lle, lli and llo. scoring for lle, lli and llo items followed the same procedure suggested by the developer (dockrell et al., 2015). for lle items, a score of 1 was assigned for each item if the item was present and 0 if the item was absent. for lli items, scores were assigned on an ordinal scale of 5, with a score of 0 indicating the absence of an item, while a score from 1 to 5 indicates increasing presence of an item in the classroom. language-learning opportunities items followed the same scoring scheme as lli. for lle, the frequency and percentage that specific items scored a ‘1’ for each item was recorded in table 1. table 1: number of observations that indicated the presence of each item in the language-learning environment area (n = 223). for lli items, the frequency and percentage of individual observations that scored ≥ 3 were recorded in table 2. for llo items, the frequency and percentage of individual observations that scored ≤ 1 were recorded; this decision was made post hoc after examining the distribution of scores in the llo domain. table 2: number and proportion of observations that indicated a score ≥ 4 in each item of the language-learning interaction area (n = 223). validity and reliability the cscot was deemed to be reliable and valid (dockrell, bakopoulou, law, spencer, & lindsay, 2015) through extensive testing in united kingdom classrooms and further assessment for applicability in south africa (harty et al., 2013). furthermore, the reliability of the observations was strengthened by training of six research assistants who participated in three weekly training sessions. in these sessions, rater responses were compared with expert observations and this process was repeated until the researchers were satisfied with raters’ progress in training. then raters were required to watch an hour-long video of classroom interactions in english, afrikaans and xhosa classrooms and complete the tool. these results scores were used to determine inter-rater reliability, using the intraclass correlation coefficient (icc). for the english classroom the icc was 0.99; for the afrikaans classroom 0.93 and for the isixhosa classroom the icc was 0.91, which indicates a strong level of agreement between raters. the icc values indicated that language matching was not a necessity when observing a classroom. however, feedback from raters indicated that there was greater ease when they observed classrooms in a language that they were competent in. therefore, there was at least one rater per classroom who was competent in the language used in the classroom for instructional purposes. table 3: number and proportion of observations that indicated a score ≥ 3 in each item of the language-learning interaction area (n = 223). table 4: number and proportion of observations that indicated a score ≤ 1 in each item of the language-learning opportunity area (n = 223). ethical considerations the studies in the urban and rural contexts were approved by the university of cape town faculty of health sciences research ethics committee (hrec) (reference number: hrec 481/2014; 480/2014). results data from 136 classrooms with 223 observations were analysed and included schools in rural or remote and urban areas and across the academic performance range. the observations were conducted on 136 classrooms drawn from 43 schools (see figure 1). figure 1: number of schools, classroom and observations included. the teachers were all female, with an average age of 39.95 (s.d. = 11.2) years. the class size averaged 28 learners (s.d. = 6.7). the language of instruction across the western cape varied across classrooms where english (35%) and afrikaans (39.7%) were mainly spoken in urban areas, whereas isixhosa (7.4%) was mainly spoken in rural areas. the learners were of diverse language backgrounds and had multilingual exposure in english, afrikaans and isixhosa. teachers and learners shared a common language in 99 classrooms. in the other 37 classrooms, this was not the case, implying that children were learning in a language that was different from their home language (whether it be isixhosa, french or an additional african language). all teachers had formal training in education, and 86.8% teachers demonstrated additional training or qualification for teaching grade r children. on average, they had 8.86 years (s.d. = 8.6) of experience in grade r teaching specifically. overall, the items that were most commonly occurring were numbers 1 (adults use children’s names, draw attention of children), 5 (pausing: adult pauses expectantly and frequently during interactions with children to encourage their turn-taking and active participation) and 6 (pacing: adult uses a slow pace during conversation; give children plenty of time to respond and take turns in interacting with them) with a large majority of classrooms achieving scores for these items. the item least commonly occurring was item 14 (scripting: adult provides a routine to the child for representing an activity) with no classrooms demonstrating evidence of this strategy. this indicates that while teachers are using basic communication practices, the finer aspects of language that encourage children to practice language in interactions are missing in classrooms. this may indicate that teaching styles in most classrooms remain didactic. objective 1: language-learning environment the items occurring frequently (75% and greater) across classrooms indicated that the classrooms had adequate lighting, books and quality toys and natural resources for learning (e.g. shells, pebbles, pinecones). there were designated book and play areas with materials labelled with pictures or words. classrooms had displays that invited comments from children. the ambient sound levels were low while children’s work was labelled and displayed clearly. less frequently observed items (65% and less) were resources for free play and availability of nonfiction books. items that were observed 50% or fewer times included learning areas, which were clearly defined and labelled throughout the class, availability of music instruments and noisemakers and privacy spaces for downtime. there was minimal observation (less than 20%) of outdoor play, imaginary (role) play areas and literacy-specific areas (see figure 2). figure 2: frequency of items observed – language-learning environment. objective 2: language-learning interactions note that scores of 4 and 5 are considered clinically relevant as ‘good’ achievement in an lli and llo domain. this result indicates the number or percentage of observations, which had a score of 4 or greater than 4, meaning that these were well-established or commonly occurring (see figure 3). figure 3: frequency of items observed – language-learning interactions (> 4). the commonly occurring item was that the teacher used the child’s name (in 94.62% of classrooms), pausing and pacing while turn-taking in 56.5% of classrooms. less commonly occurring behaviours were teachers’ use of symbols, open questioning, labelling natural gestures and confirming. behaviours observed infrequently were commenting, extending, using adult models that the child is not using yet; adults use of contrasts, encouraging children to use new words, praising listening skills and nonverbal communication. there were no observations of scripting and choices for children. over 10 items on this scale did not occur commonly across classrooms, for example, praising of nonverbal communication, praising listening skills and encouraging children to use new words. as a less stringent criteria of a frequency of occurrence of the items 3 or more times indicated a similar pattern of analysis as 4 or more observations. sometimes the more complex interaction behaviours are observed across classrooms. these items relate to communication strategies used by teachers to scaffold the language learning of children and could be targeted in teacher training by slts. objective 3: language-learning opportunities this area of 5 items indicates that in general there were few observations of llo. these included attempts to include children in small group activity; opportunities to engage in interactive book reading facilitated by an adult; small group work facilitated by adults; opportunities to take three turns; and structured opportunities for developing conversations (see figure 4). figure 4: frequency of items observed – language-learning opportunities (scores ≤ 1). discussion overall results indicate that the lle was more robust than the lli and llo domains. this result indicates that while the environment had material resources to support communication in classrooms, the frequency of behaviours for lli and llo could be extended. furthermore, relative to the scoring and assumptions of the cscot, the results indicated that although there was basic equipment and structure, there were still a number of items which were not commonly observed in the classrooms in this study. clearly, contextual and resource issues continue to play a role in creating optimal environments for language-literacy learning. for example, many classrooms in rural areas (previous mixed race or black areas under apartheid) were created out of shipping containers, which placed resource and space constraints on the class. moreover, many schools in the rural areas had minimal access to additional resources such as musical instruments, books in many languages and a range of types of books and outdoor play areas. for many children in marginalised communities, outdoor play is restricted because of lack of resource and community safety concerns. globally, the expansion of physical environment to include creative, outdoor and free play is regarded as critical to early learning (shaari & ahmad, 2015). therefore, this is an important area to consider when looking to improve language learning. while there are aspects of lli that build engagement with learners, the less frequently observed were skills related to giving children time to engage in conversations with peers and other adults in the classroom. this observation indicates that opportunities for verbal interaction are restricted. it is likely that the teacher is structuring the classroom, relative to caps curriculum and getting children ‘school-ready’. didactic teaching methods and classroom structures observed in many traditional classroom set-ups may explain the less frequent interactive behaviours (kariippanon, cliff, lancaster, & okely, 2019). the observations of the researchers were that there was a formal delivery of a structured routine which teachers follow that may explain the common restrictive patterns across classrooms. for classrooms situated in contexts of social disadvantage in which children may not have access to enriched llos, it is essential that the teacher is supported – particularly when learning is occurring mediated in a second or additional language (jordaan, 2011; moonsamy & kathard, 2015). creating more interactive scaffolded conversations and llos are the main focus areas for supporting communication development is a key primary level support. implications building collaborative partnerships it should be noticed that the observations in this study were an etic or outsider view (from research observations) on what happens in the classroom using the cscot. while this study provides insights into classroom environments, it is acknowledged that the next step in the research process is to develop a deeper level of understanding that can be gained by further teacher–slt engagement to gain a more robust, contextualised understanding of classroom language-literacy learning culture prior to any intervention. this collaboration will serve to understand the teachers’ everyday context and constraints and to identify the key intervention priorities. the cscot was developed with intention to support teachers in self-assessment of their classroom communication supports and law, tulip, stringer, cockerill, and dockrell (2019) found that teachers across reception class, year 1 and 2 in north-east england found the tool easy to use and found llo helpful as it related to everyday classroom language learning, while lli was found to be helpful in scaffolding interactive language learning and thinking. the potential benefits and strategies for engaging with teachers to develop communication supporting environments are gaining momentum internationally. hamre, hatfield, pianta, and jamil (2014) confirmed that interventions with teachers add value as it facilitates responsive teaching and an emotionally sensitive environment. they provide various creative options for supporting teachers (hamre et al., 2014). these included in-class support and online support. a further study also confirmed that carefully planned teacher professional development interventions could have positive effects (early et al., 2016). justice et al. (2008) demonstrated the value of two things, namely the read it again (ria) strategy with preschool teachers supporting language-literacy learning and speech–language therapists providing curriculum-based supports. slts have a collaborative role to play in supporting teachers to create meaningful interactions in their classrooms and these interactions have a positive effect on several child communication outcomes. piasta, justice, mcginty, and kaderavek (2012) similarly demonstrated that preschool teachers benefit from support with conversational strategies but required more intensive support to the development of language developing strategies. piasta et al. (2020) in a randomised controlled trial study with 109 teachers and 726 children (children with disabilities and their peers) using the ria shared book reading intervention found that there was a significant increase in teachers’ provision of explicit instruction in print knowledge, vocabulary, phonological awareness and narrative. the study once again confirms that partnerships with teachers can support and change communication behaviour. expanding service delivery approaches the slts in south africa are considering how to serve population needs to deliver equitable services through expanding their service delivery approach from the traditional individual pullout model. initial evidence from small scale studies in south africa, wium, louw and eloff (2011) confirmed the value of working with teachers in supporting literacy learning in foundation phase. in a small-scale study, carolus and moonsamy (2019) demonstrated that collaboration between preschool teachers and slts highlighted the positive benefits as teachers changed their explicit instructional behaviour to support emergent literacy. the benefits of collaborative practices between teachers and slts were also found in a study which used environmental print to support emergent literacy in under-served communities (giacovazzi, moonsamy, & mophosho, 2021). all children, including children with specific communication disabilities stand to benefit from interventions that are teacher-led and can be practised on an everyday basis. importantly, the collaborative approach values the teacher as a professional with agency who has a close understanding of the context and therefore can decide how to implement newly learned behaviours. in south africa, the language-literacy crisis calls for the urgent scaling-up of primary level supports. to create such supports, slts must be politically conscious, viz. to address equality, equity and social justice as tools to transform practice (kathard & pillay, 2013), and skilled in advocating for expanding their practices in the education system from the traditional pull-out models and small group work. furthermore, they must be skilled to work in collaborative partnerships with teachers. the coronavirus disease 2019 (covid-19) pandemic has created opportunities for considering innovations in service delivery approach. a further avenue of support is for slts to work with the preservice teacher education programme. synergising communication supporting classrooms and curriculum goals the slts are more likely to find synergy with teachers when they make explicit the importance of communication support, which remains invisible, yet critical. tools such as the cscot make lle, lli and llo explicit and contribute to strengthening the curriculum in two ways. firstly, by supporting teachers in how to create a communication supporting classroom to reach their literacy goals. secondly, supporting teachers with how to embed communication skills to strengthen their pedagogy. one avenue currently being pursued in south africa is the use of play-based pedagogy in grade r. while play supports children’s learning (miller, 2000), aronstam and braund (2016) found that grade r teachers viewed play as a recreational activity, which is not beneficial to learning and meaningful interaction. they concluded that it was important to improve on the quality of play in grade r through facilitating teachers critical understanding of play as a pedagogy. harty, alant and uys (2007) demonstrated the utilisation of play-based activity in aided language stimulation (ails) in south africa. they implemented a two-phase training programme and coached six grade r teachers to improve interaction in the classroom using ails facilitator boards. data indicated that teachers improved in the areas of classroom management, ails strategy use and teacher interactions after a 6-week training programme. strengths and limitations the cscot was an appropriate tool to use given the exploratory nature of the research. it was simple and easy to use. it also provided training to other researchers with no background in education a fairly straightforward process. the comments area on the tool allowed researchers to make additional observations in each area, which allowed for in depth analysis. one notable shortcoming of the cscot is that there was little to compare the results to because of how new it was to the south african context. there is also no overall score that would allow researchers to give classrooms one score to represent the quality of the communication environment and subsequently use the scores of each area to indicate areas of strengths and weaknesses. furthermore, the area of llo was limited as a scale with few items with which to measure opportunities children have to practise language. as external observers, there was great opportunity to build relationships with teachers. they were receptive to having us in their classrooms and very willing to open up about the celebrations and challenges of their everyday life. conclusion while the lle in grade r classrooms were higher than the llo and lli scores, there is opportunity for improvement in all areas. the very low score on llo reflect the minimal llo provided in the period observed. similarly, critical lli items that support children’s language-literacy learning was observed infrequently. the study raises the awareness of the importance, and yet the invisibility, of the types of behaviours, which create communication supporting classrooms – everyday environments and exchanges that can potentially strengthen language-literacy learning. we argue for collaborative research and implementation practice partnerships between teachers and slts to create primary level supports to contribute to improving learning outcomes for children in grade r. acknowledgements the authors would like to acknowledge maaliyah orrie for her role in the process of data collection. they would also like to express their gratitude to the department of basic education in the western cape for allowing this study to be conducted and the teachers who welcomed them so openly into their classrooms to observe and learn from. in addition, the authors would like to acknowledge the funding support from the university of cape town and the south african national research foundation (nrf). competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions h.k. was the master’s supervisor and so she was involved at every stage of the study and this article. p.p. was the master’s student and was therefore involved in this study in all capacities. l.t. advised on methodology and analysis methods and drafts. m.p. advised on methodology and literature and drafts. z.j.h. analysed the data and was involved in reviewing drafts. j.l.r. was a research co-supervisor. m.h. was a master’s and research supervisor and was involved in all stages of the study. s.o.c. was involved as a co-supervisor. r.m. captured data, analysed data, managed the project administration and contributed to writing and editing of drafts. funding information funding was received from the uct knowledge co-op and harsha kathard’s nrf grant. data availability the data that support the findings of this study can by made available upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy and position of the author affiliations. references adams-ojugbele, r., & moletsane, r. 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(2011). evaluation of a programme to support foundation-phase teachers to facilitate literacy. south african journal of communication disorders, 58(2), 72–78. https://doi.org/10.4102/sajcd.v58i2.28 wium, a., & louw, b. (2013). revisiting the roles and responsibilities of speech-language therapists in south african schools. south african journal of communication disorders, 60(1), 31–37. https://doi.org/10.4102/sajcd.v60i1.8 wium, a.m., & louw, b. (2015). caps: implications for collaboration between teachers and speech-language therapists working in schools. south african journal of childhood education, 5(1), 19–41. https://doi.org/10.4102/sajce.v5i1.348 r e s e a r c h n e e d s i n s p e e c h p a t h o l o g y i n south africa s. b a u m a n , m . a . assistant director, speech, voice and hearing clinic; and lecturer in the department of logopedics, university of the witwatersrand m . a r o n , m . a . senior supervisor, speech, voice and hearing clinic, university of the witwatersrand although the field of logopedics can be regarded as a comparatively recent development in south africa, it is nevertheless a field that has twenty-five years behind it. this is a fairly considerable period and yet the research yield has been negligible. the natural curiosity which should have led workers in the field to investigate the incidence and nature of speech pathologies in south africa has been overshadowed by the immediate and urgent need for active therapists who have been given neither the time nor the facilities for research. therapy has been administered in the main centres for some years now, but there is an ignorance of the circumstances of the speech defective in this country. the material which presents itself for research in south africa is rich. conditions exist here that give rise to many different social strata, different racial and ethnic groups and the existence of many different languages, many of them remote from each other in construction. these facts must obviously play a major role in determining speech standards, the incidence of particular speech defects, attitudes towards the handicapped, etc. a further major aspect that would be most relevant to communication disorders concerns the rapid assimilation that groups are undergoing from a language, ethnic and social point of view. t h e emergence of new attitudes and standards would be important to study in order to get a clearer picture of how these are initiated and changed. on considering the type of person who has studied logopedics in south africa and the type of employment that has been offered it is not surprising that little research has been done. it is unfortunate that only women have studied in this field in south africa. this has caused a clinging to town life and usually an immediate break-away from logopedic practice after marriage. employment has been restricted to university and hospital clinics, education departments and special schools or institutions, all of which have emphasised therapeutic and training services rather than experimental investigations. we have therefore an unusual and undesirable situation where the cart has been placed before the horse. the logopedicians are working with groups about whom they know very little. they take for granted and rely uncritically on the research data from other countries and apply them here. this extends into the field of diagnostics and therapeutics. apart from the european population (english and afrikaans-speaking), the non-european peoples (coloured, indian and many groups of africans) present tremendous scope and difficulties as regards investigation and treatment. virtually no establishments exist for speech, voice and hearing handicapped non-europeans. t h e authors believe that work among the noneuropeans will probably soon be started and that it would be easy to commit the same errors again. therefore the plea here is for an initial understanding of the material with which we are to work before that material is manipulated therapeutically. time and space do not permit of the setting out of a complete scientific analysis of the research needs in south africa. the aspects which confront us in this field are so vast and complicated that in this article we will present only in a "stream of consciousness" some of the ideas which could be used as suggestions for areas of investigation. s u g g e s t i o n s for a r e a s of i n v e s t i g a t i o n 1. the influence of bilinguolism and polyglotism the data from studies on bilingualism and its relation to the incidence of speech defects are by no means conclusive. in the main the studies done in this direction have dealt with the contributory effects of bilingualism on articulatory errors and stuttering. i n south africa ideal conditions exist for an investigation into this factor for there are many languages spoken here, two of which are english and afrikaans, the official languages. the facets to this journal of the south african logopedic society december r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) problem must be many. however it is felt by the authors that any negative effects of bilingualism can only be brought to bear after the child has been introduced to the two languages for the purposes of expression. in the case of the european child the second official language is, in most cases, introduced after the age of about eight when the child is at school. this is beyond the age when speech can still be considered an inadequate function. it could be said that the greatest contributory cause of bilingualism on speech defects could be when the child is introduced to two languages from an early age as in the case of inter-marriage or newly arrived immigrants from europe. investigation here could provide data on the manner in which non-speech defective children acquire a new set of language symbols (taking into account the phonemic structure of the languages concerned). from objective study these errors then would be termed "normal" errors and the child need not necessarily be considered as having a speech defect. important also would be the data derived from studying the effects of the child experiencing a mixture of languages in the home and later the introduction of the second language in the school situation. t h e coloureds speak in the main afrikaans but their language is essentially a dialect which becomes a colourful and expressive admixture of afrikaans, english and slang. the indian child speaks his home language in addition to the two official languages that are taught in the schools, i.e. english and afrikaans. the bantu are usually able to speak more than one african language. in the elementry school he receives some of his instruction in his home language and in addition he is introduced to english and afrikaans. in the urban areas, particularly in their townships, the african tends to become familiar with a number of bantu languages and english and afrikaans. he becomes therefore, a polyglot. all the above groups provide an abundance of material for studying the polyglot individual in terms of the incidence and nature of speech defects directly or perhaps indirectly related to this factor. i 2 stuttering apart from the work of aron (1) concerning urban african stuttering children, no other information is available on this problem in any other group. the rural african;is completely unexplored in this direction. of particular interest would be the examination of data collected on the rural african child or adult who has not been introduced to any type of schooling or missionary influence. in the cases where stuttering is reported for such groups, it would be interesting to note the reasons why some adult rural africans "stopped" or "grew out of" stuttering, a factor very often reported by european adults who stuttered when younger. although we may assume, both from observation and from our records while servicing schools, that the incidence of stuttering among the europeans is the usual incidence reported overseas, it should nevertheless be ascertained objectively from studies. furthermore it would be interesting to note if there would be any differences in incidence and severity among european groups such as the english, afrikaans and jewish. from the work among european schools in johannesburg it is our impression that there tend to be more afrikaans stutterers than english, which is the converse of what weiss (2) found. an interesting, but also as yet unexplored field concerns the indians. therapists from the university speech clinic working in indian schools over a period of ten years have found that the incidence of stuttering tends to be higher than that for other groups (2.5 per cent — 3.5 per cent). we have little idea about the conditions of this disorder among the coloureds. for all these groups, cultural factors cannot be ignored and the symptom complex of this disorder should be studied in relation to differing cultural patterns. comparative therapeutic measures among these different groups might be difficult to apply but are necessary and information obtained from the reactions and results of these measures could prove most helpful in our understanding of this "will-othe wisp" problem. 3. anatomical and physiological disorders affecting speech and language a . cleft palate the incidence of cleft lip and palate among the various groups is unknown. we at the university speech clinic have never seen an african child with a cleft lip or palate or at least they have never beea brought to us. at the same time we believe that the number of coloured peoples with this condition appears to be high. if this impression is accurate and substantiated by research it could give rise to many speculations and research would be stimulated among the medical profession, geneticists, nutritionalists, etc. b. dysphonia professor p. de v. pienaar believes that the relationship between dysphonic conditions and proximity to gold-mine dumps should be explored. in journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) his experience, the fine yellow sand carried in the wind constitutes an irritant. some consideration should also be given to the fact that we have found a large number of dysphonic european school children, particularly in the poorer socio-economic areas. the africans appear to have habits not commonly found among other groups that could be related to voice problems among these people. it is quite usual for them to carry on a conversation over distances by shouting as long as the voice can still be heard. they frequently smoke harsh tobaccos and it is common practice to have smoke fires within their kraals. there are apparently voice quality changes depending on traditional cultural and social mores. when talking to authority figures the zulu, tshwana and other groups lower the voice. in the same way a wife must address her husband in a low tone which is considered to be respectful. this is accompanied by a bowing position of the body and a clasping of the hands. in tribal singing the women attempt to sing in as high a register as possible. it would be interesting also to study the singing voices of labourers who sing "work songs" while engaged in heavy labour. it is recognised that bantu languages have colourful tonal and inflectional patterns. to what degree this is carried over into the european languages that they learn and to what degree it influences their communication might be valuable to know. we have very little idea of the type of dysphonic conditions that might be prevalent among the coloured and indian communities. surveys should be done in this direction in order to supply some data concerning this problem. c. dysarthria and dysphasia the non-european government hospitals throughout the country admit large numbers of africans each year who are treated for injuries sustained in accidents and faction fights. patients with injuries affecting speech, voice or hearing mechanisms could furnish the profession with much valuable data concerning the adaptive and compensatory mechanisms which arc adopted by dysarthrics and dysphasics. related to the above there is much scope for exploring the recovery process in traumatic as compared with vascular aphasia. data concerning the nature of disturbed language function in dysphasics who are polyglot may lead to a clearer understanding of the language processes. aphasic therapy covers language in its spoken and written forms and therefore the treatment of the old generation of africans who could not read nor write prior to brain injury presents interesting problems. further interesting comparisons can be made with this group and with those aphasics who seek, on the basis of previous experience and memory to evoke and relate auditory, visual and kinesthetic imagery. similarly data concerning the recovery process of dysarthric conditions that are traumatic in origin could be of great importance. d. dysaudia there are many problems related to deaf and hardof-hearing persons that lend themselves to investigation. knowing that the african languages use a great deal of intonation variations related to meaning it would be interesting to study the difficulties confronting the african lip-reader. different methods of teaching lip-reading may be indicated for the different groups in the country. related to this would be the study of the melody, rhythm and accent found in the speech of deaf african children as compared with deaf european children. south africa is essentially a mining country and the effects of noise (pneumatic drills, etc.) in the mines on the workers could be ascertained for the artistic bookbinders t r a n s v a l i a b u i l d i n g s 21 s t i e m e n ' s & m e l l e street b r a a m f o n t e i n shop 8 in melle street phone 44-6584 h o w i m p o r t a n t a r e y o u r ® j o u r n a l s of s p e e c h a n d h e a r i n g disorders @ " s p e e c h " ® notes you can have these bound in attractive volumes to suit your needs w e specialize in binding your thesis according to your design and colour schemes to insure your success. ί journal of the south african logopedic society december r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) benefit of the many thousands of people employed in this field. 4 dyslexia defects of communication in its written forms such as the associated problems of reading and spelling and dyslexia should be investigated among the various groups in south africa. it should be established what percentage of children suffer from these problems and some attempt should be made to ascertain the factors that are operating causing this problem, whether it be poor teaching methods, poor background of experience, perceptual problems, etc. many therapists and other workers have reported that there are many more english children who demonstrate these problems compared to the afrikaans children and most are in agreement that this is because afrikaans is a phonetic language while english has many orthographic anomolies. it might be valuable to investigate the possibility of the influence in the spelling of a child who is introduced to the second official language in the school situation either in that language or in the previous and presumably home language. the existence of reading and spelling difficulties that may be present among ..bantu school-children in their own languages and in english and afrikaans is unknown. a study of their approach to these skills may open up new avenues in our understanding of these problems. biesheuvel (3) who demonstrated differences between the intelligence ratings of africans and europeans, found certain perceptual differences, namely manipulating the spatial relations, among african children which he attributed to cultural factors. this significant factor might be operative in their approach to reading. in relation to the bantu it would be interesting to see how the adult learns to read and write as distinct from the child and whether the difficulties and errors encountered are any different from those made by the child. 1 each language group in the country requires standardised | diagnostic tests, an analysis of the symptomotology and an investigation into vehicles for therapy for children exhibiting reading and spelling difficulties. ; 5 language^ development language development and the form which it takes in each of the different cultural groups could be studied. it would be important to see whether the forms of speech or language retardation in these groups reflects cultural or other factors. rich linguistic experience or poverty of experience might depend not only on cultural influence but also on the socio-economic standard of the group and in this respect rural and urban differences might be noted. the influence of european standards on african standards might be detected and in the same way the influence of the african nanny on the speech and language development of the young european child might be seen to be significant. c o n c l u s i o n the items discussed above constitute only a very small area in a very vast field. as research projects are undertaken they themselves will bring to the fore more specific problems and indicate the direction of future research. the research worker in this field faces many problems. financial assistance has u p to the present time not been forthcoming. perhaps the speech therapists themselves have been at fault here in that they have not impressed upon the authorities the need for this type of work. there are very few models on which this exploratory work could be based in south africa. language, social and cultural barriers would hamper the european investigator. at the same time these barriers have been in themselves a deterring factor. conditions are changing rapidly within the country and the time for research is now. approaches should be made to state, university and educational authorities, the council for scientific and industrial research and other allied organisations so that individual or team projects can go forward to lay the foundations of research. it is incumbent on speech therapists in south africa to realise this need and to work for the instigation of an active research programme. references 1 aron, m. l. " a n investigation of the nature and incidence of stuttering among a bantu group of school-going children." m . a . dissertation. university of the witwatersrand. 1958. 2 weiss, l. " a study of european speech defective school children in pretoria." m . a . dissertation. university of the witwatersrand. 1957. 3. biesheuvel, s. "african intelligence". s.a. institute of race relations, johannesburg. 1943. journal of the south african logopedic society r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) abstract background methods results and discussion conclusion acknowledgements references appendix 1 appendix 2 appendix 3 appendix 4 about the author(s) tasneem f. karani discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa mershen pillay discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa speech and language therapy,massey university, auckland, new zealand department of health professions, manchester metropolitan university, manchester, united kingdom citation karani, t.f., & pillay, m. (2021). it’s crunch time: exploring the sensibility of food textural acoustics for individuals with dysphagia. south african journal of communication disorders, 68(1), a806. https://doi.org/10.4102/sajcd.v68i1.806 original research it’s crunch time: exploring the sensibility of food textural acoustics for individuals with dysphagia tasneem f. karani, mershen pillay received: 17 dec. 2020; accepted: 10 may 2021; published: 30 june 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: various fields of study have alluded to food textural, and its associated acoustic, properties (i.e. food textural acoustics). however, because of the challenging nature of the inclusion of acoustic properties in diet textural modifications in dysphagia (swallowing disorders), this construct has not been sufficiently considered in the field. objective: to investigate the sensibility of food textural acoustics as a construct to understand eating for individuals with dysphagia. method: the study design was based on qualitative evidence synthesis methodologies. this involved revised scoping review methods (peer-reviewed published articles from 1980 to 2020 over seven databases), with an adapted consultation phase through online focus group discussions with six world experts. the data was analysed using frequency and thematic analysis, and ideology critique. results: a total of 11 articles were included in the revised scoping review analysis (seven research studies and four review articles). the analysis of these articles revealed a lack of diversity in geography, discipline and perspective exploring the construct of food textural acoustics. a total of three themes with three associated core arguments emerged from the revised scoping review and the consultation phase. these arguments highlighted (1) the need to study food textural acoustics because of its salience and pleasure responses, (2) possible methodological dilemmas in studying food textural acoustics due to the complexity of eating, and (3) considerations with regard to the approach and positioning adopted when studying the construct. conclusion: food textural acoustics may be a sensible construct to understand eating for individuals with dysphagia. as eating is a complex process, there is a need to challenge the methods we use when studying this construct of food textural acoustics. we hope that this article inspires researchers and practitioners to think differently by using textural, and its associated acoustic, properties as a way to reimagine dysphagia practice, especially for those from lowto middle-income contexts such as south africa and brazil. keywords: food acoustics; texture; perception; physiology; multisensory eating; dysphagia. background eating is one of the most multisensory human experiences (spence, 2017, 2020). the visual system is involved in the selection of foods, and the olfactory and gustatory systems make sense of the smell and taste of the food. the proprioceptive system assists in identifying textures and shapes of foods, while the auditory system plays a role in the sounds of biting and chewing of foods (spence, 2015; verhagen, 2007). practitioners in the field of dysphagia (swallowing disorders) primarily consider sensory stimuli such as chemical, tactile and thermal properties in the management of individuals with dysphagia (steele & miller, 2010; steele et al., 2015). despite the multisensory nature of eating, acoustic stimuli are not predominately used. this is due to the challenging nature of selecting the appropriate food textures, that have robust and consistently replicable acoustic properties, yet still safe for consumption for individuals with dysphagia. auditory properties are also not sufficiently foregrounded in comparison to the remaining senses in other fields such as cognitive neuropsychology and are often regarded as the neglected or ‘forgotten flavour sense’ (spence, 2015). the coronavirus disease 2019 (covid-19) pandemic has highlighted the vital role of the senses in eating. anosmia and ageusia (i.e. loss of the sense of smell and taste) are symptoms of the covid-19 virus, which can lead to diminished pleasure in eating (coppin, 2020; menni et al., 2020; parma et al., 2020). can one still eat and survive with the disabling effects of the loss of smell and taste? regardless of the temporary loss of these senses, an individual may rely on the role of texture and its associated acoustic properties for their hedonic or pleasure response when eating. this is as a result of the notion of auditory salience. evolutionarily, auditory salience has been understood as acoustic properties of food signifying freshness, pleasantness and enjoyment (spence, 2015; tunick et al., 2013; vickers, 1983). indeed, textural properties and acoustic properties are intimately connected. for instance, the force applied to a texturally hard food sample when biting into the food results in the production of vibrations that are transmitted to the ear as a wave via two pathways, namely, air-conduction and bone-conduction (duizer, 2001; vickers & bourne, 1976). we perceive these vibrations as sounds. for the purpose of this study, we will refer to the textural, and its associated acoustic, properties involved during eating as food textural acoustics. there are several fields of enquiry that have alluded to food textural acoustics. this includes the well-established fields of engineering and physical sciences, gastronomical sciences, cognitive neurosciences and dysphagia sciences (see appendix 1 for a review of the established fields that have made reference to food textural acoustics). this undeniable marriage of texture and acoustics was first recognised within the fields of engineering and physical sciences with the establishment of the notion of acoustic rheology (peleg, 2017; zadeike, jukonyte, juodeikiene, bartkiene, & valatkeviciene, 2018). we have borrowed from these fields and have chosen to use the term food textural acoustics. although it is well-known in the aforementioned fields that texturally hard foods produce auditory stimuli, for example, crispy or crunchy sounds, dysphagia studies of diet textural modifications tend to marginalise how texture and acoustic properties are closely connected. it is necessary to note that textural properties cannot be divorced from its acoustic properties when recommending the commonly used compensatory strategy of diet textural modifications in dysphagia rehabilitation (cichero, 2018; cichero et al., 2017; swan, speyer, heijnen, wagg, & cordier, 2015). other fields that are more recent and burgeoning such as the multisensory human–food interaction (mshfi) and multisensory eating frameworks have also alluded to food textural acoustics. the field of cognitive neuroscience has studied acoustic stimuli by foregrounding music and the environment and its influence on behaviour and perception (callan, callan, & ando, 2018; carvalho, wang, van ee, & spence, 2016; höchenberger & ohla, 2019; kantono et al., 2018; spence, 2015, 2017). however, there is still a gap present in the fields at large exploring the influence of acoustic stimuli on physiological responses. we have not sufficiently considered the physiological responses such as the notion of autophony. autophony refers to how the body generates and responds to internal sounds, for instance, sounds produced when eating and hearing one’s voice and breathing (harris 2015; mabaso, malinga, & paruk, 2018; tidball & fagelson, 2018). the various fields that have alluded to this construct of food textural acoustics, discussed above, speak to its overall construct validity or sensibility. we have chosen to use the notion of sensibility because of the complexity and marginality of the construct that we are studying. we have defined sensibility with reference to sensible knowledge and the judgement of the plausibility of a concept (strati, 2007). this study is part of a larger cluster of research projects under the thrive programme. thrive is an acronym for ‘tackling hunger by research and innovation in vulnerable environments’ (pillay, 2013; pillay & kathard, 2018). the thrive programme strives to reposition swallowing and feeding in a way that promotes transformative practitioners who are concerned with the food security and sovereignty of their patients. individuals with disabilities such as those with dysphagia may encounter difficulty in accessing food that is affordable and safe for consumption (pillay, 2013; pillay & kathard, 2018). this is prevalent particularly in lowto middle-income contexts such as south africa and brazil. low-to-middle income contexts may present with limited access to healthcare professionals, resources and equipment, where one can only target and invest in the food provided to these individuals. there is a specific thrive project that is motivated to develop more novel dysphagia interventions (pillay & kathard, 2018). in this study as part of this project, we would like to propose a transformation of the diets for patients with dysphagia (refer to appendix 2 for a history of the study that includes three phases). we would like to conceptualise alternative methods of developing foods that consider the multisensory nature of food and the potential therapeutic benefits of acoustic properties. this may drive us to connect diet textural modifications to food security from the perspective of food safety and the appropriate food textures. this includes developing and investing in more ‘sensory responsive’ foods that in addition to having a hedonic response, we hope that these foods will have a therapeutic benefit for individuals with dysphagia. it is vital to highlight that despite the documented research on the hedonic response to food textural acoustics, certain individuals may dislike or have unpleasant experiences to textural acoustic properties. sensory aversions and misophonia (i.e. a negative emotional reaction and dislike triggered by particular sounds such as eating and breathing) may also occur in both typical and atypical individuals (little, dean, tomchek, & dunn, 2017; palumbo, alsalman, ridder, song, & vanneste, 2018). objective to investigate the sensibility of food textural acoustics as a construct to understand eating for individuals with dysphagia. methods study design the underlying theory of this study originates from qualitative evidence synthesis (qes) methodologies with regard to creating evidence for a form of knowledge and practice. traditionally in healthcare, researching a theoretical basis of a construct and using the evidence from the scientific research may lead to the development of clinical practices (dodd, 2007; sackett & rosenberg, 1995). essentially, we are arguing that thoughts (theory) determine our practice (clinical practice). we used this broad qes methodologies framework in a way that engaged us reflexively as researchers. reflexivity refers to providing ‘attention to the complex relationship between the processes of knowledge production and the various contexts of such processes, as well as the involvement of the knowledge producer’ (alvesson & sköldberg, 2009:8). this qes methodology study design involved scoping review methods by arksey and o’malley (2005) and levac, colquhoun and o’brien (2010) with an optional adapted consultation phase through online focus group discussions (colquhoun et al., 2017). according to arksey and o’malley (2005), the consultation phase can be used in a variety of forms depending on the study aim. in this case, we have adapted and expanded the consultation phase by further exploiting it and more closely engaging with expert practitioners in the field. this has been used to dialogue the experts’ opinions with the published literature and scoping review findings regarding the construct of food textural acoustics in eating for typical adults. similar to other fields of enquiry, this information may be applied to individuals with dysphagia. data sources this study involved two main interconnected data sources: (1) published, peer-reviewed articles obtained via seven databases, detailed below, and (2) online focus group discussions with six world experts. we reviewed the published articles over a 40-year period (1980–2020). we also conducted focus group discussions with six world experts from several fields to gather their opinions on the construct of food textural acoustics in eating. this method will be expanded on in the next section. we hoped that this would inform a novel way of understanding the construct and its potential clinical application to the field of dysphagia. we have intentionally revealed the identities of the world experts, with their permission, to initiate a conversation and to develop a community of practice from a variety of fields regarding the construct of food textural acoustics. data collection we used the following methods to design the revised scoping review methodology; preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr) framework (schultz et al., 2018; tricco et al., 2018), and guidelines by joanna briggs institute (moola et al., 2015) for the search strategy. these methods were used to systematically and comprehensively map concepts and the distribution across the fields (levac et al., 2010). the revised scoping review included the following: (1) a pilot study that was conducted by an external reviewer to assist in planning the main study and analysing its validity (in, 2017), (2) a main study which involved a blind review by two reviewers to screen the titles and abstracts to ensure inter-rater consistency, and (3) conflict resolution through discussions between the two reviewers to finalise the selection of the full-text articles. figure 1 depicts the parameters used in the revised scoping review. figure 1: parameters of the revised scoping review. we consulted six world experts through online focus group discussions following the scoping review. the world experts represented various disciplines of study: (1) mechanical engineering (associate prof. ben hanson; university college london); (2) food science (prof. lisa duizer; university of guelph, canada); (3) audiology (prof. wayne wilson; university of queensland, brisbane); (4) cognitive neuropsychology (prof. massimiliano zampini; university of trento, italy); (5) a sommelier, (chef ferran centelles; director of bullipedia drinks elbullifoundation, barcelona), and (6) speech pathology and audiology (associate prof. mershen pillay; university of kwazulu-natal, south africa). these experts were purposefully selected based on their respective fields of expertise and the knowledge of them contributing collaboratively and constructively to the development of the study. pillay co-author of the article, was included in the study as he is an expert who has developed the thrive framework and provided a perspective from a lowto middle-income context on the matter. the expert consultations included self-developed semi-structured open-ended questions to promote dialogue between the experts. the questions focused on the experts’ opinions regarding food textural acoustics, its relevance to their respective fields and discussion relating to some of the published literature and scoping review findings. we also shared details of the methodology and results of phase 2 of our study. our analysis yielded core constructs and considerations when studying food textural acoustics, which will be presented under the ‘results and discussion’ section. data analysis we conducted two main data analyses: (1) frequency analysis and basic content analysis of the 11 included articles, and (2) thematic analysis of the 11 articles and the focus group discussions. we used mendeley with covidence for data management of the articles retrieved from the review. we identified the bibliographic coverage of the 11 included articles by conducting frequency analysis of author names, year, knowledge fields and affiliation (journal). we also conducted a basic content analysis to identify and tabulate the frequently occurring constructs, methodologies used and overall findings. the primary researcher transcribed the data verbatim from the consultation phase. we conducted member checking to improve the trustworthiness and validity of the data (birt, scott, cavers, campbell, & walter, 2016). this was performed by sending out the audio recordings and transcripts of the online focus group discussions to the experts via email. all the experts confirmed that the transcripts were a fair reflection of the focus group discussions. we employed thematic analysis by braun and clarke (2006) to analyse the 11 included articles and focus group discussions. thematic analysis was used to provide a rich account of the data and to develop themes. as per the process of thematic analysis, we conducted substantive and axial coding of the raw data using the computer analysis software nvivo 12 to reveal codes. subsequently, we formulated categories, concepts and developed themes. ethical considerations this study was approved by the university of kwazulu-natal biomedical research ethics committee (brec). ethical clearance number: bf152/19. results and discussion in relation to the stated objective, to investigate the sensibility of food textural acoustics as a construct to understand eating for individuals with dysphagia, the results and discussion will be presented under the following two headings: (1) prisma-scr results and bibliographic coverage findings of the 11 included articles, and (2) overview of core concepts and considerations related to food textural acoustics and eating. preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr) results and bibliographic coverage findings of the 11 included articles there were 1439 articles identified in the initial search across the seven databases. after 741 duplicates were removed, both reviewers independently screened 228 articles. appendix 3 depicts the results of the prisma-scr and the bibliographic information of the 11 included articles. the results revealed that there were seven research studies and four narrative reviews. the studies were conducted over 2004–2017, with the majority of the studies (seven out of 11) conducted in the united kingdom and the remaining studies conducted in italy, japan and netherlands. of the 11 articles, only one article was conducted in the field of speech and swallowing. spence (field of experimental psychology) conducted a majority of studies (six out of 11) independently or with other researchers specifically from the fields of psychology. these findings depict that food textural acoustics has predominantly been researched in the field of psychology, denoting that in addition to the lack of diversity in geography, there is a lack of diversity in discipline and perspective exploring this construct. overview of core concepts and considerations related to food textural acoustics and eating to understand these results and discussion, it is essential to note that in addition to the thematic analysis, we analysed the revised scoping review and focus group discussions data using the critical theory and ideology critique framework. we used the interrogative framework by guba and lincoln (1994), adapted by pillay (2003), and pillay and kathard (2018). this involved three assumptions that we used to formulate our three core arguments: ontological assumption: ontology is the nature of reality. realities are subjective and it is dependent on each person (parahoo, 2014). realities are shaped by social, political, cultural and economic values (guba & lincoln, 1994). epistemological assumption: epistemology is truth bases. this refers to how knowledge is created and communicated (denzin & lincoln, 2017). methodological assumption: this represents the research strategies used by researchers to confirm what they believe can be known (denzin & lincoln, 2017). the analysis of the revised scoping review and the online focus group discussions revealed the following three interconnected themes, which we will discuss as three core arguments: the sensibility of the acoustic sense. it does the ‘boom’ on your palate. the measurement texture-lemma. the sensibility of the acoustic sense eating involves multiple senses (velasco, carvalho, petit, & nijholt, 2016). however, acoustic properties are often overlooked and neglected in contributing to flavour perception (spence, 2015). there were three references made in the included articles (a) (article 5 (a5), a6 and a7) and four references during the focus group discussions regarding the neglect of the acoustic properties in comparison to the other senses. participant 1 (p1), hanson (a chemical engineer), referred to the auditory sense as the ‘hidden sense’. p4 (zampini, a cognitive neuropsychologist) also described the acoustic sense as ‘one of the most neglected modalities when it comes to food perception’. this correlates with the literature that depicts that there is a lack of focus on food textural acoustics and the common reference to the auditory sense as the ‘forgotten flavour sense’ (spence, 2015). there has been a recent renaissance of interest over the past 15–20 years in studying the acoustic sense in cognitive psychology, cognitive neuroscience, food science and gastronomical sciences (a5, a6, a7; spence, reinoso-carvalho, velasco, & wang, 2019). p4 further expressed that acoustic properties of food are rarely considered as influencing flavour perception. he believes that acoustics should be considered as the acoustic sense is a ‘relevant part of flavour experience’ and flavour involves more than smell and taste. articles 2, 3 and 4 and article 9 made reference to auditory salience. when the acoustic properties of the food were modified and the texture remained unaltered, participants of these studies reported that the auditory information was more salient to them. this improved the participants’ ‘oral feel’ or oral somatosensation, perceiving the foods as harder or crispier (spence & zampini, 2006). this phenomenon was also depicted by a study by masuda and okajima (2011). these studies highlight the possible sensible nature of food textural acoustics in eating through the need to foreground the auditory sense. this should not be surprising as evolutionary, food acoustics has always served as a highly salient cue of freshness and pleasantness of food (a6; tunick et al., 2013; vickers, 1983). this notion of auditory salience is a critical factor to consider in the overall experience of eating for individuals with dysphagia. it does the ‘boom’ on your palate the analysis of the expert consultations and the 11 articles demonstrates six main codes that highlight the hedonic responses to food textural acoustics (i.e. enjoyment, positive feelings, intraoral sounds, food enhancement, freshness and texture perception). these references to the hedonic response to food textural acoustics were made mainly by p5 (centelles, a sommelier). p5’s perspective predominantly focused on the need to build a dish that consists of auditory elements. he conveyed that this is needed as it ‘enhances’ the dish, ‘adds another dimension’, ‘flavours get more intense’ and is ‘something magical’ (figure 2). the positive hedonic responses to food textural acoustics correlate with what is evident in the literature (tunick et al., 2013; vickers, 1983). these studies have reported that the characteristic of crispiness most strongly relates to a food’s pleasantness and enjoyment. a6 and spence (2017) also depict that food acoustics improve the experience, pleasure and enjoyment of eating. figure 2: box display of an excerpt from the consultation with participant 5 depicting hedonic response to food textural acoustics. there are differing views and methods embraced to consider the hedonic influence of food acoustics. the analysis of the 11 articles and the vast literature shows that food textural acoustics has been focused on using a quasi-experimental orientation (a3, a4, a9 and a10; masuda & okajima, 2011). this involves subjectively evaluating hedonic responses related to the influence of food sounds on taste, freshness, feelings and texture perception using questionnaires (a3 and a4) and visual analogue scales (a1, a2 and a9). conversely, p5 admitted that his perspectives are based purely on considering the feedback from his restaurant customers and their pleasure experiences. he further declared that this is ‘not scientific at all’. in the real world, cooks and chefs are known to be driven by this intuition and the need to foreground hedonic interests to food acoustics for consumers’ food experience, , as shown in figure 2. this is also present in the creative dishes such as the sound of the sea by one of the world’s famous chefs heston blumenthal. the above argument depicts that similar to cooks and chefs, experts affiliated with the scientific fields also express the significance of the hedonic responses to food textural acoustics. p3, duizer (a food scientist), added that from a sensory perspective, sounds produced when eating indicates the freshness of food. despite experts from the scientific fields expressing the importance of the hedonic responses, their focus is more closely aligned with the literature related to how the construct of food textural acoustics can be studied rather than solely based on intuition. thus, a disparity exists between the varying perspectives of experts in the field, as well as the literature that portrays the reductionist nature adopted in the scientific fields. the reductionist approach does not admit into its purview sound because it is difficult to measure. there is also the opposing view that there is a need to focus on the body’s response and the hedonic value that sound has on the experience of eating. in relation to dysphagia management, in addition to considering the body’s response to food textural acoustics, it is essential to take into account premorbid food preferences and hedonic responses. food palatability or positive hedonic response to foods are known to increase food intake, appetite and overall nutrition (a4; mccrickerd & ford, 2016). the measurement texture-lemma dysphagia practitioners view food and drink using a textural or rheological lens when recommending diet textural modifications. traditionally in dysphagia science, dysphagia management has perpetuated a biomedical perspective. this perspective predominantly focuses on down modifications to make food safer for consumption to prevent choking and aspiration risks (i.e. moving from level 6 or 7 to level 3 or 4 based on the international dysphagia diet standardisation initiative framework) (cichero et al., 2013; cichero et al., 2017; iddsi, 2019). this is possibly to prevent litigation issues arising from patient fatalities. furthermore, the literature on dysphagia assessment and practice was mainly produced in the global north, promoting specific ontological viewpoints (nature of realities). this makes it difficult for the global south to adopt these viewpoints in practice as these contexts may be confounded by economic and social challenges such as reduced access to practitioner expertise and these assessment and management measures (andrews & pillay, 2017; ostrofsky & seedat, 2016). we acknowledge that rheology is vital to foreground in diet textural modification as rheological properties of food contribute to swallowing. for instance, studies by newman, vilardell, clavé and speyer (2016) and hadde, cichero, zhao chen and chen (2019) have depicted that rheological properties influence lingual pressure patterns, flow rate of the bolus, timing of the pharyngeal phase and swallow safety. despite the documented benefits of diet textural modification, it should be noted that when texture or rheological properties of food are modified, the sensory and proprioceptive properties (i.e. visual, olfactory, tactile and acoustic properties) are also modified. this may lead to reduced enjoyment of the overall experience of eating. this makes it necessary to consider the holistic and complex nature of eating (i.e. textural and its associated acoustic properties), even in the management of individuals with dysphagia. this will be further elaborated on below. multisensory and cross-modal nature of food: articles 2–11 and the expert consultations with p1, p4, p5 and p6 revealed two codes related to the complex nature of eating (i.e. multisensory and/or cross-modal integration) (knöeferle & spence, 2012). argument one (sensibility of the acoustic sense) points to the sensibility of food textural acoustics as a construct to understand eating. due to the complex nature of eating, it poses a methodological dilemma of measuring a specific sense like acoustics. p1, p4, p5 and p6 expressed that it will be challenging to study food acoustics as a single construct as ‘sound does not come alone…very tightly and close to texture and some other sensations…really complex topic’ (p5). p2, wilson (an audiologist), also highlighted the intricacy of the processing of auditory stimuli. he described, ‘it (auditory processing) is not linear or unidirectional’, and it involves complex processes (i.e. various pattern matching and neural responses). the articles and the experts are in agreement with the literature that promotes the ontological appreciation of the notion of the complexity of eating as multisensory. a total of five articles (a2, a5, a6, a7 and a9) and two experts (p3 and p4) stated that acoustic properties of food have both air-conduction and bone-conduction influences, which further compounds this methodological dilemma (christensen & vickers, 1991; dacremont, 1995; dacremont & colas, 1993; duizer, 2001) (figure 3). figure 3: diagram showing the complexity of eating and studying food textural acoustics. despite the acknowledgment of the complexity and interconnectedness of eating, empirical science and reductionist approaches have been adopted to study the auditory sense by isolating it (endo, ino, & fujisaki, 2016, 2017; masuda, yamaguchi, arai, & okajima, 2008). this includes the use of data collection tools such as microphones with headphones (a2, a3, a4, a8, a9 and a10) and surface electrodes to detect mastication behaviours (a3 and a4). this reductionist science pulls out and manipulates the auditory cues in terms of its components (i.e. pitch, loudness and/or frequency and temporal factors) and it utilises such methods to gather information regarding the body’s responses. p6, pillay (a speech pathologist and audiologist), expressed that isolating a sense is ‘artificial and sanitised that it actually takes away from the natural event (of eating) itself’. he further reported that using this type of approach becomes less pragmatic and less implementable in our work as practitioners. by virtue of the fact that eating is both multisensory and cross-modal, eating needs to be understood holistically. studying eating by isolating the various senses may be of value (such as those conducted by the studies described above); however, it is counteractive. we need to acknowledge this blind spot and rethink this paradigm when studying the construct. p6 voiced that he believes that the difficulty in measuring the construct ‘comes from the methodology we use, the science we use’. this will be discussed further below. the soundness of positioning: the results of the expert consultations exposed three primary codes related to positioning of food textural acoustics (i.e. bias, variety of perspectives and knowledge fields, and the culture of the science that we follow). varying perspectives emerged from the expert consultations and this illuminated the notion of memetics. memetics theoretically originates from the central concept of a meme (unit of cultural evolution and selection), conceptualised by richard dawkins in 1977 (tyler, 2011). we have operationalised the notion of memetics in this study as the way in which ideas have been generated across time and space (castaño díaz, 2013; dawkins, 1977). p4 stated that he felt ‘comfortable’ with the science that he uses. p2 and p6 had an overt discussion of the science. p2 indicated at the onset that his thoughts reflect his biases of understanding auditory processing from more of a bottom-up perspective (‘that goes from outer ear to middle ear to inner ear to cochlear nerve, to cochlear nucleus… station by station up the pathway’). this was because of his profession and retreat to topics that he is more comfortable with. this bottom-up perspective correlates with a5 and a7 which reviews highly controlled laboratory-based studies, and the literature that acknowledges more epistemological variations that come from quasi-experimental or positivistic frameworks (endo et al., 2016, 2017; masuda et al., 2008). despite p2’s stated professional bias, he questions certain scientific basis and encourages that auditory processing be understood from a more top-down perspective. this includes consideration of the influence of higher-order functions such as expectation and memory (spence, 2015; piqueras-fiszman, 2020; sakai, 2020). similarly, we need to consider these higher-order functions during eating and also for those with dysphagia (i.e. premorbid food preferences, and anticipation for consumption and subsequent memories of food experiences) (a6). it is crucial to acknowledge the methodological dilemma (i.e. the complexity of eating because of its multisensory and cross-modal nature) and approach used when studying the construct of food textural acoustics. this may assist in conceptualising and developing innovative methods of studying the construct. isolating a sense may not be the most ideal approach. p6, a south african–based practitioner proposed, ‘our mission is to look at inventing or imagining a new science that can help us take this (construct) forward’. the multisensory nature of eating with the consideration of the textural, and its associated acoustic, properties should be foregrounded in the assessment and management of individuals with dysphagia. p6 further expressed: ‘we work in a low socio-economic context. and a lot of the people we work with (individuals with dysphagia) do not have enough healthcare services to help… so we want to invest in developing foods that are in and of themselves maximally therapeutic… for its impact on the swallow mechanism. if sound is one of the other ingredients we can put into it (dysphagia diets), then that is why we want to develop it.’ (p6, pillay, speech pathologist and audiologist ) ‘illuminators’ and implications for the field of dysphagia the above three intersecting arguments illustrate that the construct of food textural acoustics may be sensible to investigate as it is supported from both a practice and theoretical perspective and from the focus of empirical-based and ecological studies. why have we not sufficiently researched and factored food textural acoustics and its potential therapeutic and hedonic benefits into dysphagia practice? we are more focused on diet textural modifications such as recommending softened foods and the use of commercial food thickeners. this often results in undernutrition, reduced quality of life, poor compliance and frequent hospitalisations because of recurrent aspiration pneumonia (o’keeffe, 2018; shune & namasivayam-macdonald, 2020; swan et al., 2015). are we solely concerned with food safety, rather than with rehabilitating swallowing and improving overall quality of life? are we treating the condition of dysphagia instead of the whole individual? the research across the fields of psychology, cognitive neuroscience, gastronomical sciences and marketing has depicted the influence of food acoustics on behaviour and perception (callan et al., 2018; carvalho et al., 2016; höchenberger & ohla, 2019; kantono et al., 2018; spence, 2015, 2017). how can we understand the influence of food textural acoustics on the body’s physiological response for dysphagia management? a few illuminators exist to connect this construct of food textural acoustics to dysphagia. however, two will be discussed below. studies by endo et al. (2016, 2017) have investigated the influence of altered auditory feedback of chewing sounds, which resembled a crunchy sound on the perception of food texture. the results revealed that in addition to positively influencing palatability and taste, this pseudo-chewing sound had an influence on the perception of food texture (i.e. perceiving the texture as stiff and rougher). this influence was present even in the absence of the actual crunchy oral sensation. this technique may be used to improve the texture perception and hedonic responses to texturally modified foods for individuals with dysphagia, without changing the actual texture of the foods. a second illuminator is the possible therapeutic benefit of ‘up-modifications’ (i.e. moving from lower level 4 to level 6 on the iddsi framework) (refer to pillay [2013] for further explanation). this involves the use of transitional foods for individuals with dysphagia. transitional foods (also known as solid meltable foods) refer to foods that change rapidly by melting when it comes into contact with body temperature, becoming easier to chew and swallow (cichero et al., 2017). an example in the south african context is the bakers blue label® marie biscuit. the most recent version of the iddsi framework includes transitional foods that span across the pyramid. research has shown the benefit of transitional foods in the paediatric populations, especially for those with less mature or underdeveloped sensorimotor systems for mastication (dovey, aldridge, & martin, 2013; gisel, 1991). this offers some promise for the adult population. a study by barewal, shune, ball and kosty (2020) demonstrated that it is necessary to consider the use of transitional foods like savorease and the eat-bar, which are two commercially available transitional foods. these transitional foods may provide improved eating pleasure and nutrition for individuals on texturally modified foods (barewal et al., 2020). snack foods and finger foods like the savorease require minimal chewing that may benefit masticatory muscle strength and cognition for individuals with dysphagia (barewal et al., 2020). these studies described above provide a strong evidence to support the development of more ‘sensory-responsive foods’, as per the thrive programme, because of their improved pleasure and potential therapeutic benefit. study critique we used multiple data sources (i.e. revised scoping review, online consultation phase and reference to published data) and data analysis methods. this was used as a means of triangulation to improve the credibility and trustworthiness of the study. the inclusion of a pilot study and a blind review prior to and during the scoping review aided with establishing data credibility. we acknowledge the limitations associated with the scoping review methodology. for instance, the search terms and databases chosen might have resulted in some relevant articles being overlooked. however, we used a rigorous method for data collection to alleviate this potential limitation. the co-author of this study acted as a supervisor and as an informant during the expert consultations. while this may appear to be bias, he was included as this study followed a hermeneutic paradigm (guba & lincoln, 1994). this involved including individuals’ opinions as a way of acknowledging that multiple realities exist and foregrounding and celebrating subjectivities (guba & lincoln, 1994; pillay & kathard, 2018). following the expert consultations, we also conducted member checking to promote trustworthy and credible data (birt et al., 2016; cope, 2014). conclusion this study has synthesised the literature, especially from 1980 to 2020, and views from world experts from various fields. the results of this study depict the possible sensibility of food textural acoustics as a construct to understand eating for individuals with dysphagia. we have highlighted auditory salience numerous times throughout the article with the need to change the rhetoric of sound the ‘forgotten flavour sense’ (spence, 2015) to the ‘celebrated flavour sense’. thoughts influence practice. we hope that this article inspires researchers and practitioners to think differently by using texture, and its associated acoustic, properties such as the use of transitional foods as a way to reimagine dysphagia practice. this study may drive us to develop novel ways of approaching this construct and to explore its potential clinical applicability for individuals with dysphagia. this may be particularly contextually responsive to those individuals with dysphagia from lowto middle-income contexts such as south africa and brazil, where food security and food sovereignty are a concern. acknowledgements the authors would like to thank the world experts for their invaluable contribution to this study. the authors would also like to gratefully acknowledge ms nazeera karani and ms maseeha bhobat (speech-language pathologists and/or audiologist) who assisted in the initial data collection phase of this study. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions t.k. drafted this manuscript. t.k. collected, analysed and interpreted the data under the supervision of m.p. both researchers reviewed and approved the final manuscript. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study are available from the corresponding author, t.k., upon reasonable request. disclaimer the views and opinions expressed in the submitted article are our own and not an official policy or position of any affiliated agency of the authors. references alvesson, m., & sköldberg, k. 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(2010). assessing the role of sound in the perception of food and drink. chemosensory perception, 3(1), 57–67. https://doi.org/10.1007/s12078-010-9064-2 appendix 1 table 1-a1: established fields that have alluded to food textural acoustics. appendix 2 history of the study figure 1-a2: the broader study involved three main phases (initial exploration, pilot study and sensibility exploration). phase 3 formed the primary focus of this article. figure 2-a2: self-developed protocols and tools associated with phase 2. appendix 3 figure 1-a3: preferred reporting items for systematic reviews and meta-analyses extension for scoping review (prisma-scr) flow diagram results. appendix 4 table 1-a4: bibliographic data of the 11 included articles. abstract introduction methods results discussion conclusion acknowledgements references about the author(s) ben sebothoma department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa minkhenso maluleke department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation sebothoma, b., & maluleke, m. (2022). middle ear pathologies in children living with hiv: a scoping review. south african journal of communication disorders, 69(1), a934. https://doi.org/10.4102/sajcd.v69i1.934 clinical perspective middle ear pathologies in children living with hiv: a scoping review ben sebothoma, minkhenso maluleke received: 02 apr. 2022; accepted: 08 sept. 2022; published: 28 nov. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: middle ear pathologies are associated with and persist in individuals living with human immunodeficiency virus (hiv). yet, limited research exists on middle ear pathologies in children living with human immunodeficiency viruses. objective: to systematically review evidence of middle ear pathologies in children living with hiv, how it is described, measures used to describe it and other relevant information. methods: this study was a scoping review. the data were collected from different electronic databases including pubmed, scopus, science direct, proquest, and web of science. the electronic database search was conducted for articles published between january 2010 and december 2020. keywords used for searching relevant articles included ‘middle ear pathology’, ‘middle ear disorder’, ‘children’, ‘hiv’, ‘otitis media (om)’, ‘hearing loss (hl)’, ‘hearing impairment’, ‘paediatric’, ‘minors’, ‘infants’ and ‘hiv/aids’. only articles that were published in english and reported on the middle ear function and pathologies of children living with hiv were considered. results: a total of 350 articles were extracted through databases, but only six studies were eligible and included for further analysis. studies reviewed suggested that middle ear pathologies in children living with hiv exist and are common. recurrent om, type b tympanogram, chronic om and hl with conductive element were common. tympanometry with a 226 hz probe tone and air bone gap were used commonly to establish the presence of middle ear pathology. conclusion: the findings of this study highlighted that despite the dearth of evidence in this area, available evidence indicates that children living with hiv are at increased risk of middle ear pathology. however, studies in this review have mostly used middle ear measures with poor sensitivity and specificity. therefore, the prevalence and nature of middle ear pathologies in studies reviewed may have been underreported. further research using sensitive measures such as wideband acoustic immittance is required. despite the paucity of evidence, the current findings raise important clinical implications for the assessment and management of middle ear pathologies in children living with hiv. contribution: this study makes a significant contribution to the literature regarding middle ear pathologies and hiv, particularly in children. keywords: children; hiv; middle ear function; middle ear pathologies; scoping review. introduction the human immunodeficiency virus (hiv) continues to be a public health challenge worldwide. in 2018, the prevalence of hiv was estimated to be approximately 37.9 million [32.7-44.0 million] globally, with sub-saharan countries accounting for the majority of the population living with hiv (mahy et al., 2019). in the same year, who estimated that there were approximately 1.7 million [1.3–2.2 million] children under the age of 15 years living with hiv (mahy et al., 2019). this is a significant increase from the 2005 data (joint united nations programme on hiv/aids [unaids], 2017). despite the preventative measures that are put in place to curb the spread, the prevalence of hiv in children seems to increase, with evidence of new infections annually. despite the efficacy of the antiretroviral therapy (art) that has been shown to reduce mortality rates of people living with hiv (gueler et al., 2017; samji et al., 2013), improve the immune system of people living with hiv, increase life expectancy and improve quality of life (achappa et al., 2013; izugbara & wekesa, 2011; oguntibeju, 2012), literature suggests that children living with hiv may be at a greater risk of middle ear pathologies (chao et al., 2012). evidence suggests that hiv incapacitates the ability of the immune system to fight pathogens and results in opportunistic infections such as middle ear pathologies (obasineke et al., 2014). given that children are known to have weaker immune systems and are more prone to ear infections compared with adults (ramma & sebothoma, 2016), hiv may have an additional effect on an already weak immune system. the existence of middle ear pathologies is concerning given that undetected, late detection and untreated middle ear pathologies may cause hearing impairment and other complications. the who has stipulated that approximately 50% of individuals with acute otitis media (aom) will develop chronic suppurative otitis media (csom) (mahy et al., 2019). further complications of untreated middle ear pathologies include permanent hearing impairment (hutz et al., 2018), meningitis (avnstorp et al., 2016), facial paralysis (lawler, 2018), and vestibular disturbances (rehagen et al., 2019). the impacts of these conditions in children can have far-reaching consequences. the impact of hearing impairments in children are well recorded in the literature. khoza-shangase and michal (2014) reported that children whose hearing loss (hl) is identified late are at a greater risk of developmental milestones. cole and flexer (2019) reported that children with hl have limited vocabulary, and often struggle to construct a sentence structure. furthermore, maluleke et al. (2019) indicated that children with hl have delayed language and inability to communicate, and they struggle to produce clear speech sounds. some children may experience listening fatigue (hornsby et al., 2014), especially in classrooms with poor acoustics such as those in lowand middle-income countries (lmics) (ramma, 2007), affecting their learning and overall academic achievement (abraham et al., 2018). based on the evidence presented, it is crucial to conduct a scoping review on middle ear pathologies in children living with hiv. although studies on hiv and other auditory pathologies exist (dawood et al., 2019), little is known about this current area of investigation, hence the rationale for conducting this scoping review. methods this scoping review followed a six-step framework proposed by arksey and o’malley (2005). the framework includes (1) identifying the research question, (2) identifying relevant publications, (3) study selection, (4) charting the data, (5) collating, summarising and reporting the results. there was agreement on the broad research questions between the two co-authors to be addressed by this scoping review and study protocol together with the identification of keywords and search terms, as well as the selection of databases to be searched. the aim of this study was to integrate the evidence that exists regarding middle ear pathologies in children living with hiv so as to map the literature and acquire an opportunity to find gaps in the evidence and types and sources of evidence to guide practice, policymaking, research and training (daudt et al., 2013). data sources and search strategy a search of relevant articles was conducted in the various electronic databases, including pubmed, scopus medline, science direct, proquest and web of science. the electronic databases were selected to be comprehensive and to cover the middle ear pathologies in children living with hiv. the search consisted of the following terms: ‘middle ear pathology’, ‘middle ear disorder’, ‘children’, ‘hiv’, ‘hiv/aids’, ‘otitis media (om)’, ‘hl’, ‘hearing impairment’, ‘paediatric’, ‘minors’ and ‘infants’. in line with previous research, the search covered the period from january 2010 to december 2020 (dawood et al., 2020). inclusion and exclusion criteria studies were included in this review if they were written in english, published in peer reviewed journals, and included paediatric population diagnosed with hiv. furthermore, studies were included if they reported middle ear pathologies in this population. title and abstract relevance screening during the first level of screening, the title and abstract citations were assessed, while the second level of screening included assessing the abstracts. lastly, the whole article was reviewed. in that manner, time was not wasted on articles that did not meet the minimum criteria for this scoping review. the titles, abstracts and whole articles were evaluated by both researchers. duplicates and articles without abstracts were excluded. data characterisation all the relevant papers or citations for the current scoping review on middle ear pathologies in children living with hiv were reviewed for full publication after the evaluation of titles and abstracts. a spreadsheet was developed by one of the researchers where appropriate publications were confirmed and where the details of publications such as authors, title, year of publication, country, population, methodology, results, conclusion and available data or gaps were recorded. data summary and synthesis data were organised in a single spreadsheet and inserted into microsoft excel 2016 for descriptive narrative analysis. ethical considerations this scoping review followed all ethical standards for a study that does not involve direct contact with human or animal participants. however, an ethical waiver (protocol: sta_2020_23) was obtained from the human research ethics committee (non-medical) university of the witwatersrand, johannesburg, south africa. results figure 1 is a preferred reporting items for systematic reviews and meta-analysis (prisma) diagram illustrating the process of the study selection. a total of 350 articles were extracted from different electronic databases. of these, 127 remained after the removal of the duplicates. the articles were screened based on title and abstract only and 93 were removed at this stage. the 34 remaining articles were included for full-text screening, after which 28 articles were excluded as they did not meet the minimum criteria for this scoping review. the remaining six articles were considered to be relevant to this study and therefore included for further analysis. figure 1: preferred reporting items for systematic reviews and meta-analysis flow diagram for included. characteristics of studies table 1 summarises the characteristics of the studies reviewed. three of the studies included in this review employed a case-control design (maro et al., 2016; taipale et al., 2011; torre et al., 2016), while the rest used a cross-sectional design (hrapcak et al., 2016), longitudinal design (mwambete & eulambius, 2018) and a scoping review (dawood et al., 2020). the total number of samples for all studies combined is 1053 with an age range of 0.8–18 years. all of the studies were conducted in four lmics countries, particularly in african countries. the researchers included children with hiv-infection and children without hiv-infection and compared the results between the two groups (maro et al., 2016; taipale et al., 2011; torre et al., 2016). table 1: studies with associated with middle ear pathologies in children living with human immunodeficiency virus. middle ear assessment methods used torre et al. (2016), maro et al. (2016), taipale et al. (2011) and hrapcak et al. (2016) used tympanometry with a 226 hz probe tone to determine the presence or absence of middle ear pathologies. ear canal volume (ecv), static compliance and tympanic peak pressure (tpp) were recorded to determine the types of tympanograms. mwambete and eulambius (2018) collected ear secretion specimens to identify the bacteria that cause middle ear pathologies. maro et al. (2016), taipale et al. (2011) and hrapcak et al. (2016) included pure tone audiometry (air and bone conduction) using an air or bone gap of 10 dbhl as an indicator to determine the type of hl. a scoping review by dawood et al. (2020) reported on different types of audiological testing measures including tympanometry and pure tone audiometry. an otoscopic examination was used by torre et al. (2016), taipale et al. (2011) and hrapcak et al. (2016) to rule out the presence of otorrohea because csom is characterised by drainage from middle ear (prabhu et al., 2018). middle ear pathologies torre et al. (2016) indicated that out of 37 children living with hiv, 6 (16.21%) presented with bilateral flat tympanograms (type b), while only 2 children without hiv (8.33%) presented with type b tympanograms. maro et al. (2016) also reported significantly high numbers of children living with hiv with abnormal tympanograms. about 25% of children with hiv presented with abnormal tympanograms, while only 12% of children without hiv had abnormal tympanograms. the prevalence of csom in children living with hiv was higher in 0–2-year-old children by 36% (taipale et al., 2011). studies by hrapcak et al. (2016) and dawood et al. (2020) show a high prevalence of conductive hearing loss (chl) in children with hiv. according to the study by hrapcak et al. (2016), 82% of children presented with chl and 4% presented with mixed hearing loss (mhl). dawood et al. (2020) reviewed 17 studies, 11 of which reported a high prevalence of chl. one study reported on the bacteria that causes middle ear pathologies (mwambete & eulambius, 2018) and 93.65% of participants with hiv were found to have bacterial flora, which is associated with middle ear pathologies. of the six studies reviewed, only three reported on peripheral hl (maro et al., 2016; taipale et al., 2011; torre et al., 2016). only two studies reported on chl (hrapcak et al., 2016; mwambete & eulambius, 2018) and one on conductive and mhl (hrapcak et al., 2016). out of these six articles, one study reported that chl is the second most common type of hl in children living with hiv (dawood et al., 2020). the degree of hl was reported by two studies (hrapcak et al., 2016; taipale et al., 2011). hrapcak et al. (2016) reported that mild, moderate, severe and profound hl are common, while taipale et al. (2011) only reported on moderate hl. all the articles reported on the hiv factors associated with hl. ear infection and low cd4 count were the most common factors for middle ear pathologies in children living with hiv. discussion the purpose of this review was to determine evidence that exists regarding middle ear pathologies in children living with hiv. according to the researchers’ knowledge, this is the first scoping review study that focuses on this particular area and the findings of this study revealed a clear paucity of evidence in this area. only six studies were relevant for this review, with one study being a review. this paucity of research in this area is concerning given the high prevalence of hiv in children (unaids, 2020) and the association between hiv and middle ear pathologies that have been established in the literature (khoza-shangase & anastasiou, 2020; sebothoma & khoza-shangase, 2020; tshifularo et al., 2013). the available research indicated that children living with hiv are at an increased risk of middle ear pathologies (maro et al., 2016; taipale et al., 2011; torre et al., 2016) and the prevalence of middle ear pathologies can be as high as 93.65% (mwambete & eulambius, 2018). the difference in these studies with regard to prevalence rates may be because of different sample sizes and the assessment methods used, among other factors. therefore, there is a need for further studies with large sample sizes to determine the prevalence of middle ear pathologies in children living with hiv. furthermore, while the studies reviewed indicated that the prevalence of middle ear pathologies is potentially high, all these studies used tympanometry with single probe tones such as 226 hz. literature has shown that tympanometry with a single probe tone has poor sensitivity and specificity in identifying middle ear pathologies (kaf, 2011; sebothoma & khoza-shangase, 2018). for example, hunter et al. (2017) found that tympanometry with a single probe tone missed approximately 20% of chl in children. these findings suggest that further research in children living with hiv must use measures that have high sensitivity and specificity in identifying middle ear pathologies. wideband acoustic immittance (wai) has emerged as the potential middle ear measure with higher sensitivity in identifying early signs of middle ear pathologies compared with the conventional tympanometry with single probe tone (kaf, 2011; sebothoma & khoza-shangase, 2018; shahnaz et al., 2009; terzi et al., 2015). while otomicroscopy is considered gold standard in identifying middle ear pathologies in some countries (sebothoma & khoza-shangase, 2018), the shortages of otolaryngologists in lmics (christopher et al., 2013), limit the practicality of this measure. consequently, video otoscopy used asynchronously has also been shown to be equally sensitive in identifying middle ear pathologies compared with otomicroscopy. martines et al. (2010) found a substantial agreement (k = 0.7) between the diagnoses made from video otoscopic images and those from onsite otomicroscopy. sebothoma and khoza-shangase (2018) also demonstrated that video otoscopy can produce accurate diagnosis of the middle ear pathology than the conventional tympanometry with single probe tone. it is therefore crucial that future studies include some of these sensitive tests to provide a more accurate picture of the prevalence and nature of middle ear pathologies in children living with hiv. in this review, hl with a conductive component was found to be the second most reported type of hl in children living with hiv (christopher et al., 2013). the prevalence of this type of hl was reported to be 36%, with the severity reaching moderate levels (christopher et al., 2013). given the fact that chl was the second most reported type of hl, dawood et al. (2020) suggest that this type of hl may be associated with otitis media with effusion (ome). in studies reviewed, the prevalence of ome was found to be 6.8% (martines et al., 2010). these findings are consistent with the study by christopher et al. (2013), who found that hl with a conductive component in children is likely because of ome, which is one of the common types of middle ear pathologies in children (vanneste & page, 2019). human immunodeficiency virus-positive children were shown to have more signs and symptoms related to middle ear pathologies compared with children without hiv. these symptoms or signs included otalgia, tympanic membrane perforation, otorrohea and impacted wax (hrapcak et al., 2016; maro et al., 2016; mwambete & eulambius, 2018; taipale et al., 2011; torre et al., 2016). of all these signs or symptoms, otorrohea, tympanic membrane perforation, history of ear infections, low immune system and who stage iv of hiv were associated with middle ear pathologies in children living with (dawood et al., 2020; hrapcak et al., 2016; maro et al., 2016; mwambete & eulambius, 2018; taipale et al., 2011; torre et al., 2016). studies on adults living with hiv also reported that middle ear pathologies result from opportunistic infections because of a low immune system resulting from a declined number of cd4 t cells (obasineke et al., 2014; van der westhuizen et al., 2013). however, in one study (torre et al., 2016), middle ear pathologies were only associated with flat tympanogram and otorrohea. the difference between previous studies and findings in this study by torre et al. (2016) may be because of different sample sizes. therefore, these conflicting results warrant further research in order to determine the contributing factors for middle ear pathologies. despite the paucity of evidence, this review suggests that middle ear pathologies exist in children living with hiv and may cause hl. therefore, there is a need for further research to identify the significant relationships or differences that exist between studies. conducting studies on middle ear pathologies will further enhance our knowledge regarding the middle ear function of children living with hiv and help to provide appropriate services for this population. early identification of middle ear pathologies is significant for all children, especially those with a compromised immune system. middle ear pathologies are known to have a negative impact on children’s language and quality of life (torre et al., 2016). for example, recurrent otitis media (rom) in children is associated with phonological delay (torre et al., 2016) and because children with hiv are at a high risk of rom, it is necessary to identify early signs of their middle ear pathologies so that timeous interventions can be implemented early. failure to implement early identification and intervention for children living with hiv may contribute to delays in schooling. for example, about 13% of children with hl and living with hiv never get a chance to attend school (hrapcak et al., 2016). while some children living with hiv already experience difficulty attending school because of constant sickness (hrapcak et al., 2016), very few of those who are able to attend school get to perform above average because of hl related to middle ear pathologies. therefore, it is crucial that children living with hiv receive early identification and intervention for middle ear pathologies. this is even more crucial in lmics where resources for assessing and managing middle ear pathologies are extremely limited (fagan & jacobs, 2009). conclusion the studies reviewed in this scoping review provided evidence that middle ear pathologies in children living with hiv exist and may be severe or chronic, causing hl to various degrees. however, because of the limited number of articles found during this scoping review, the findings must be interpreted with caution. while the studies reviewed provided some important information about middle ear pathologies in children living with hiv, all the studies used measures that have been shown to have poor sensitivity and specificity. further research using sensitive measures of middle ear pathologies such as wai and with large sample sizes must be conducted. furthermore, studies must use longitudinal designs in order to determine the change in middle ear function and pathologies (sebothoma & khoza-shangase, 2020). acknowledgements the authors would like to acknowledge professor katijah khoza-shangase and dr nomfundo moroe for their expertise, guidance and giving various seminars related to review this research. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions b.s. co-conceptualised the research project, supervised the study, contributed to the analysis and writing of this research project and edited the final version of this manuscript. m.m. co-conceptualised the study, collected the data, contributed to the writing and edited the final version of this manuscript. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data are available from the corresponding author upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references abraham, z.s., alawi, k., massawe, e.r., ntunaguzi, d., kahinga, a.a., & mapondella, k.b. 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(2018). a comparison between video otoscopy and standard tympanometry findings in adults living with human immunodeficiency virus (hiv) in south africa. south african journal of communication disorders, 65(1), 1–7. https://doi.org/10.4102/sajcd.v65i1.591 sebothoma, b., & khoza-shangase, k. (2020). middle ear pathologies in adults living with human immunodeficiency virus: a systematic review. annals of otology, rhinology & laryngology, 129(8) 821–828. shahnaz, n., bork, k., polka, l., longridge, n., bell, d., & westerberg, b.d. (2009). energy reflectance and tympanometry in normal and otosclerotic ears. ear and hearing, 30(2), 219–233. https://doi.org/10.1097/aud.0b013e3181976a14 taipale, a., pelkonen, t., taipale, m., roine, i., bernardino, l., peltola, h., & pitkäranta, a. (2011). otorhinolaryngological findings and hearing in hiv positive and hiv-negative children in a developing country. european archives of oto-rhino-laryngology, 268(10), 1527. https://doi.org/10.1007/s00405-011-1579-x terzi, s.u.a.t., özgür, a., erdivanli, ö.ç., coskun, z.ö., ogurlu, m., demirci, m., & dursun, e.n.g.i̇.n. (2015). diagnostic value of the wideband acoustic absorbance test in middle-ear effusion. the journal of laryngology and otology, 129(11), 1078. https://doi.org/10.1017/s0022215115002339 torre, p., iii, cook, a., elliott, h., dawood, g., & laughton, b. (2016). middle ear function in human immunodeficiency virus (hiv)-infected south african children. journal of pediatric care insight, 1(1), 13–17. https://doi.org/10.24218/jpci.2016.04 tshifularo, m., govender, l., & monama, g. (2013). otolaryngological and head and neck manifestations in hiv-infected patients seen at steve biko academic hospital in pretoria, south africa. south african medical journal, 103(7), 464–466. https://doi.org/10.7196/samj.6786 van der westhuizen, y., swanepoel, d.w., heinze, b., & hofmeyr, l.m. (2013). auditory and otological manifestations in adults with hiv/aids. international journal of audiology, 52(1), 37–43. https://doi.org/10.3109/14992027.2012.721935 vanneste, p., & page, c. (2019). otitis media with effusion in children: pathophysiology, diagnosis, and treatment. a review. journal of otology, 14(2), 33–39. https://doi.org/10.1016/j.joto.2019.01.005 claire penn, anniah mupawose and jennifer stein discussion forum from pillars to posts: some reflections on community service six years on claire penn, anniah mupawose and jennifer stein university of the witwatersrand abstract speech-language therapy and audiology graduates have worked in community service for 6 years. an evaluation of the impact of this strategy is now seen as important. in this discussion paper we report on the content and process of feed­ back sessions with 132 graduates from the university of the witwatersrand during their community service placements from 2003-2008. experiences and perceptions of these graduates are discussed in relation to a model as well as in rela­ tion to additional research conducted with our profession and other community service professions. themes discussed include professional and technical issues, systemic and managerial issues, interpersonal issues and ethical issues. per­ ceptions on the adequacy of training are also described. the overall goals of community service are considered as well as indices for measuring success. implications are considered for training institutions, for the department of health and for the profession. key words: community service, speech language therapy and audiology, perceptions, ethical distress i n this discussion paper we reflect on the first six years of community service from the perspective of graduates of the university of the witwatersrand (wits). in line with our title, we will reflect on how the pillars of primary health care have been addressed and how community service posts have helped our graduates achieve experience and competence in these areas. community service (cs) was first introduced into south africa for newly qualified doctors in 1998, followed by dentists in 2000 and pharmacists in 2001. in 2003, seven more professions, in­ cluding our own, started doing community service. the goal of cs was to "distribute health personnel throughout the country in an equitable manner” (department of health, 1997) and “to ensure' improved provision of service to all the citizens of our country”. the aim was also “to provide our young professionals with an opportunity to develop skills, acquire knowledge, behaviour pat­ terns and critical thinking that will help them in professional de­ velopment". a further implicit aim for cs was in counteracting (or at least delaying) emigration trends of health professionals (reid, 2 0 0 0 ). the history of cs has been well documented and published accounts suggest that it has generally been successful in achiev­ ing its goals (bateman, 2004). there has been ongoing debate, evaluation and feedback on the process and the pitfalls have been examined by a number of professional groups including doctors (bateman, 2004; nemutandani, malulueke & rudolph, 2006; reid, 2001), dieticians (paterson, green & maunder, 2007), dentists (naidoo & chitke, 2002) and pharmacists (e.g. khan, 2002). in view of the fact that over 700 graduates from our own professions of speech-language therapy and audiology (slt/a) have to date completed cs (department of health, fig­ ures retrieved from www.hst.org.za/search/basicresult.ohdv we believe that it is time to undertake such a review for our own pro­ fessions. some feedback on the process of cs for our professions has already occurred at various national and regional fora and through the website of the south african speech language hear­ ing association (saslha) (see for example the feedback from uct graduates claire roberts, sarah skeen and stellenbosch gradu­ ate katherine richardson on this website: roberts, no date). in this paper we intend to formalize the feedback we have received from our own graduates and propose a model of interpretation, while linking this with some formal research studies done on spe­ cific aspects of the experience (ellis, 2004; koorts, 2004; naidoo, 2006). the role of the department of speech pathology and audiology at wits in community work has a long history. not only did it host the first national conference on the topic (schneider, 1992) but it ran the diploma course for community speech and hearing ther­ apy for 10 years (bortz, schoub & mckenzie, 1992). in addition, the department was involved for a number of years in the training of community-based rehabilitation workers at iuphc site in alex­ andra as well as at tintswalo hospital in mpumalanga (schneider, 1992; rule, lorenzo & wolmarans, 2006). these experiences informed the content and methods of our undergraduate teach­ ing. for the past six years, aided by funding from an endowment, we have hosted a feedback session in the middle of the cs year for our graduates. this feedback session has (with the exception contact: prof claire penn, department of speech pathology and audiology university of the witwatersrand johannesburg south africa e-mail: claire.penn@wits.ac.za 8 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.hst.org.za/search/basicresult.ohdv mailto:claire.penn@wits.ac.za of one year) taken place either in late may or early june of the graduates’ community service year. the purpose of these feed­ back sessions has been’to gain insight into the issues of concern in practice and to ascertain graduates' views on their clinical and theoretical preparation for practice. this feedback has helped the department to modify and focus its syllabus where necessary in contextually relevant a re a s .,it has also provided feedback on content and methods of teaching which has informed the ongoing process of curriculum development. in this paper we aim to collate this feedback and to demon­ strate the outcome of this reflective process as well as to con­ sider trends in our profession, and how the experiences of our graduates match those of other health professionals undertaking cs. participants over the 6 years in which we have held this feedback session (2003-2008), we have had 132 cs graduates from wits partici­ pating in the sessions. this group represents approximately 74% of all our graduates over this period and constitutes just under a quarter of all slt/as who have been working in cs since its in­ ception. during this period they have worked in most provinces (gauteng, mpumalanga, limpopo, eastern cape, western cape, north west province, free state and kwazulu natal). about two thirds of the posts have been hospital based but each year there have been some regional posts (ranging from 6-12 per year). each participant attended the one day workshop and was asked to present some feedback to staff and final year students on their experience according to certain broad headings pertain­ ing to their caseloads, challenges, perceived obstacles and facili­ tators. they were also asked to comment on their perceived level i of, preparedness and the adequacy of their undergraduate train ' ing. participants had been liirged in advance to indicate areas in which they would like extra input and some workshops led by staff were also offered during the visits. at some of these feed­ back workshops, there were visitors, including representatives from the department of health (doh), members of the profesi sional board of the health professions council of south africa (hpcsa), hospital supervisors, other professionals undertaking cs (e.g. occupational therapists) and speech therapy graduates from other universities also undertaking cs. each feedback ses­ sion afforded a constructive opportunity for participants to share and discuss their experiences, to seek assistance and to prob lem-solve around common issues. the final year students in the department who also attended were thus provided with an oppor­ tunity to find out about their forthcoming positions. the role of the teaching staff and the visitors in these feedback sessions was supportive and students were provided with input supplemented by follow up phone calls and site visits on occasion. from pillars to posts: some reflections on community service six years on analysis of data during each feedback session, detailed auditing of the process took place. at least two staff members made notes on each occa­ sion and a permanent record was retained of the collated notes. these records were subsequently used as a basis for curriculum meetings, were discussed each year at the respective inter­ university meetings and were also used in feedback to relevant bodies such as the department of health and the hpcsa. it is these cumulative records which were used for the purpose of the present analysis. following the suggestions of patton (1990) and aronson (1994), a thematic content analysis was undertaken on the 6 sets of notes. in line with the areas broadly covered in each student presentation, various themes emerged. these themes have been aligned with other professions’ analyses of cs issues (see for example reid, 2002) and will be presented in the follow­ ing section. we will also highlight trends across the 6 year period. we will supplement this discussion with some direct quotations from the graduates. results the themes derived from the analysis have been presented in relation to the model portrayed in figure 1. fascination irritation depression stages of adjustment (after couper, 2002) adjustment figure 1 a diagrammatic representation of major themes and influences affecting community service for sltas the south african journal of communication disorders, vol 56, 2009 9 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) claire penn, anniah mupawose and jennifer stein this model is based on a similar model produced by the task team in department of health in 2001 (reid, 2002) but has been adapted specifically for our professions to include the recur­ rent major themes arising from our analysis. it highlights four major aspects of concern those relating to technical and profes­ sional aspects of service delivery, those related to system and management issues, those concerned with personal and interper­ sonal relations (what the above task team rather inappropriately, in our opinion, referred to as “soft skills”) and ethical aspects. each component of this model will now be discussed and illus­ trated. 1. technical and professional issues context of service as predicted, the range of responses was vastly diverse and depended a great deal on the placement of the graduate. in some cases, graduates were assigned to posts in departments which were already established and in which there were full time posts, as well as senior staff who were able to act as mentors and supervisors. in other cases, especially in the regional positions, the community therapists were the first ones from our profession servicing that particular community and they had to establish services from scratch, often without the benefit of a discipline related supervisor. most graduates indicated that they were doing both speech language therapy and audiology and they indicated that in most settings there was a strong demand for audiology services. at the beginning of cs (2003 and 2004) graduates reported the avail­ ability of very limited equipment. at some sites this improved. however even when equipment was ordered, it sometimes was “still in plastic" because of space restrictions. there was a strong feeling that the lack of equipment together with a lack of ent services hampered opportunities for doing audiology. these ob­ servations correlated with the findings of naidoo (2006) who in her survey of 278 audiologists in practice throughout south africa (including 9 in cs) in 2005, found that fewer than 25 % felt that they had the necessary access to equipment which would enable them to do more than basic audiological testing. similarly claire roberts, an audiologist from another programme, reported that during her cs year “about 30% of my time was spent doing audi ology" (roberts, no date). caseload and caseload management the size of caseloads varied according to site. during the initial years, some of the graduates in some sites reported that there was not enough work for them and they had to create it. some experienced initial problems with referrals in the context of new posts and reported on the implementation of awareness cam­ paigns. very high caseloads were reported at the regional clinics. recently some graduates in this setting have even complained about difficulties in prioritizing and in “over-referral": “everything is referred to speech therapy even if we can't do anything about it.” graduates consistently commented on the very high incidence of individuals with cerebral palsy and of multiple handicap. many graduates have seen patients with syndromes that they had not seen before. many were involved in early intervention and in pae­ diatric dysphagia. in some hospital settings graduates indicated that up to 80% of their inpatient caseloads had dysphagia. in a study conducted by koorts (2004) with 23 graduates (from two universities) undertaking their community service in 2004, the following aspects were found to reinforce these impressions: 92% of the slt/as in cs were working with clients with dysphagia and such patients constituted between 26-76% of their caseloads. the main etiologies in adults were stroke, traumatic brain injury (tbi) and head and neck cancer, and for children, developmental problems. only four reported using any measures other than bedside evaluation and many felt under-prepared for this aspect. 77% of the group indicated that they were entirely unsupervised in their dysphagia work. graduates also reported a high incidence of cva and tbi as well as chronic otitis media. the hiv /aids epidemic was a perva­ sive theme in the discussions of caseloads and all graduates have expressed how difficult this disease has been to handle, both professionally and personally. amongst themes identified in relation to hiv/aids were concerns about the attitudes of other professionals to some of the patients. they also felt that they did not know enough about the treatment of the disease. these find­ ings relate to the detailed analysis of benatar (2004) with regard to the impact of this disease on health care delivery in south africa. graduates commented on the value of group work in address­ ing caseload demands. several graduates reported on initiatives which included the starting of new clinics, kangaroo mother care, hearing screening at nursery schools, cerebral palsy schools, school-aged language groups, language stimulation groups, sign language groups, groups for caregivers, education for pregnant mothers, nurse training, educational talks for teachers and the development of a library for patients in a rehabilitation ward. co­ option by other professionals for counselling services and serving as sign language interpreters for other professionals working with deaf clients, were among the expanded roles reported. 'you are more than a speech therapist; you have a broader role get involved!" 2. system and management issues on the whole, feedback with regard to placement issues was positive. the graduates felt that they had been consulted and informed, and their choices had been taken into account. most of 10 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) from pillars to posts: some reflections on community service six years on them had their placements in good time (by september of the year before) and there was some flexibility which was appreci­ ated. although some early difficulties were reported, a positive change was noted over the years in this aspect with improved lines of communication as well as good organization and briefing. no major complaints were made regarding payment, leave condi­ tions, accommodation arrangements or allowances. administration a common theme was the perceived burden of administrative duties which many graduates initially found overwhelming. they also expressed a lack of preparation in this regard. ellis (2004), who undertook a survey of 15 wits sta graduates in 2004, pro­ vided some strong evidence of this in her telephonic interviews: “i was thrown in the deep end.” one of ellis informants’ also indicated that in retrospect, “i would be more systematic in record keeping”. resources and staff early graduates in cs described the challenges of having to set up services and departments “from scratch"some had “not even a desk". such graduates had to use their own equipment or bor­ row equipment from others. some reported making equipment from waste. for therapists in regional placements a particular and recurrent problem related to the use of transport. they re­ ported that much of their work time was spent travelling. further they reported that the government cars frequently broke down and were not repaired timeously. often multidisciplinary teams travelled together in one vehicle and there was a perception that time was wasted while waiting as a colleague from another disci­ pline was treating a patient. * space shortages were frequently commented on and concern / i ,̂.was expressed about the long waiting list for hearing aids, for example, and the adverse effects of budget cuts on the acquisi­ tion and supply of hearing ajds. generally, over the years we noticed a reported improvement in referral systems for underjresourced placements (e.g. regional centres) to better equipped hospitals. in some settings, gradu­ ates felt overburdened by referrals from other therapists in their region who, either because of their scope of practice (on single registers) or their lack of equipment, referred large caseloads for assessment. in the feedback many graduates reported on staff­ ing issues at their sites and the way in which such issues im­ pacted on their goals of service delivery. distressingly, many en­ countered obstacles which linked to poor morale of permanent and nursing staff and major staff shortages resulting in backlogs and inefficiencies. nevertheless, advice proffered included: “make friends with everybody in the hospital” and "build rap­ port with the nurse." i graduates reported many problems with referrals especially specialist referrals (including ent and neurology). supervision as reid (2002) reports in relation to doctors, the level of super­ vision has been very variable. all graduates reported the need for supervision, particularly for disorders such as dysphagia. they were often supervised by another profession (e.g. social work) who did have insight into the scope of our professions. “the work was extremely depressing and we were not offered any type of debriefing or counselling which i think is essential. ” each cohort of graduates relied a great deal on each other through telephonic and e-mail contact. interestingly the mid year feedback opportunity itself (on which this study is based) pro­ vided a very positive supervision for those who attended. the feedback we received each time was that it provided an opportu­ nity for debriefing and extra input which was highly valued, par­ ticularly by those who were at remote sites and who expressed frustration about the paucity of supervision. recent developments and emphasis on continuing professional development (cpd) in the profession were perceived as being very positive and graduates reported the benefit derived from attending courses and meetings which provided access not only to new materials and information, but also to a network of sup­ portive colleagues. 3. interpersonal issues interface with other professionals and with other slta/s all graduates have commented on the value of working in a team and of gaining further insight into the roles of the different team members in relation to the contexts and the disorders they worked with. several commented also on the importance of trans­ disciplinary work. “while the physiotherapist says ppp i measure for a wheel­ chair. ” a common theme with only one exception was on difficulties of interface with ents. there was a long waiting list for ent ser­ vices, poor follow up, lack of thorough examinations, poor referral patterns and very frustrating delays. graduates at the few sites which employed speech therapy assistants (stas) commented on difficulties with working with this category and they indicated that they found working with physiotherapy (ptas) and occupational therapy assistants (otas) easier. they did not see the need for stas and their experience was mostly negative. they also com­ mented that stas had expressed dissatisfaction with their role, as well as working their conditions and salaries. some graduates reported an interesting interface with community speech and hearing therapists, although they reported that the scope of prac­ tice of the latter was not always clear and in one instance the community speech and hearing therapist was in a supervisory the south african journal of communication disorders, vol 56, 2009 11 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) role. they also found that working with slp/a graduates from other universities enlightening and commented on the mutual benefit of this. some "turf battles” were reported with other professionals, for example on making diagnoses with, for example, psychologists, and some clashes with occupational therapists who were working on early intervention and who were fitting hearing aids. they re­ ported good relations with doctors but reported that at some sites there was an initial lack of respect. some commented on the negative effect of doctor rotations as relationships were estab­ lished and then the doctors moved on. in one hospital medical students observe speech therapy practice. at one site, dysphagia patients were referred to dieticians and not to speech therapy and a partnership had to be developed. generally there were no positive experiences reported with social workers and many expressed great difficulty and frustration with the process of acquiring disability grants on behalf of patients. language and cultural issues huge difficulties were initially reported in handling the linguistic diversity of caseloads and especially in dealing with foreign doc­ tors and foreign patients. no formal interpreting services were reported but the use of ad hoc interpreters was widely reported and included the following: otas and community-based rehabili­ tation workers (cbrs), cleaners, nurses, other patients, volun­ teers, stas, family members, ptas, secretaries, community speech and hearing workers and slt/as. those who had studied an african language as part of their course commented that it had not been particularly useful in practice and felt that the syllabus of that course needed revision. further there was no guarantee that their working context would be one in which that language would be used. all graduates felt that some training in african languages should continue in a modified format but reported that on-site language learning had been effective and quick, especially where there was a predomi­ nant language spoken (as in kwazulu-natal) or when they had attended extra language classes. in 2008 there were fewer graduates highlighting such language issues as a major barrier. hopefully this is a reflection of greater emphasis in the curriculum on addressing language diversity and working with interpreters (penn, 2000). the changing profile of our student body may be another explanation. another possibility exists: that some devel­ oped community placements now have more consistent and ef­ fective language strategies and services in place. personal attributes substantial discussion at each of the feedback meetings cen­ tred on the personal impact of cs and the individual influences on their development. many reported an initial sense of isolation and the feeling of being overwhelmed and unable to handle the politics of the work environment in addition to the administrative claire penn, anniah mupawose and jennifer stein demands: “the politics were terrible; i don't think that new graduates should be exposed to the sort of things that we were exposed to." several were very concerned about safety and security issues (particularly given the transport inadequacies described above) and started using their own, more reliable cars. some described their work as “heartbreaking” and expressed feelings of burnout and the need for debriefing and support. most of the graduates reported developing strong informal networks of support cs pro­ fessionals of other disciplines at their own sites, and through emails and telephonic contact and weekend visits with their fel­ low classmates and with other cs workers. very few however indicated that this was formalized or regular. many indicated that they had learned to take initiative and understood the notion of multitasking. “my clinical skills haven’t grown as much as i have as a per­ son." several expressed frustration, but in their report back showed qualities of energy, humour and resilience. “it's frustrating but challenging." there was a growing awareness of their professional and per­ sonal value as well as of the value of cs: “in kzn they want us, they love us, they welcome us!" “i got a job straight after graduating." a sense of purpose was also articulated: “it seemed like a place i would make a difference. ” ellis (2004): “once you ju st go there and be confident and learn from your mistakes." “trust your knowledge; you are well prepared and it's ok to say you don't know because when you do know your opinion will be trusted and appreciated". ( 4. ethical issues contextual issues including the overriding influence of poverty, vulnerability and the burden of disease particularly for patients with hiv/aids, were frequently raised as a backdrop to some of the ethical problems identified by graduates. “it was more kind of dealing with people who didn't have any money." particularly prior to the antiretroviral (arv) rollout at govern­ ment sites, graduates expressed considerable distress about the issues they were encountering and a sense of helplessness. though there has been some alleviation in this regard, the harsh reality of daily exposure to death and the ravages of this disease have had a huge impact. an analysis of the range of ethical issues described in the work­ shops revealed problems ranging on a continuum from what pur tilo (2006) describes as frank “moral distress” to issues which 12 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) from pillars to posts: some reflections on community service six years on offered the opportunity for some active intervention and resolu­ tion. these findings correlated with some recent work with new graduates in australia (kenny, lincoln, blyth and balandin, 2009). it became clear that in some cases graduates could iden­ tify the required course of action but were hampered from doing so and perceived that something harmful was ensuing. examples of major challenges linked to being required to operate beyond recommended scope of competence. they also expressed con­ cern about what they perceived as ethical violations on the part of other professionals, at managerial level and with nursing staff, and they were unsure as to how and to whom to “blow the whis­ tle". they felt vulnerable when raising such issues and wondered about the impact on working relationships all graduates com­ mented on the unique ethical demands of their placements and spoke about problem-solving strategies which had been devel­ oped. these problems further resulted in reported high levels of stress and burnout, confirming a study by swidler and ross (1993) and one by dhaniram (2002) with cs doctors. 5. perceptions of training all graduates were asked to comment on the training they had received and on their sense of preparedness for cs. the majority of graduates felt that their training had prepared them for most aspects of their jobs. “we know what we are doing.” “you are more qualified than you think. ” ■ “wits trains you well to think on your feet and make decisions." "trust the knowledge you have acquired at wits, but do con­ tinue reading.” they commented on the usefulness of lectures on counselling and community work, on the value of their hospital practical exi periences and the value of tiheir training and exposure to cultur/ ! ally diverse caseloads. those who had had rural clinical practice in their undergraduate training commented specifically on its value in preparing them for cs. they found handouts provided during their training very useful and many commented on how helpful their training in sign language had been. the 2007 cohort made specific comments about the value of the resource portfo­ lios which they had prepared over their studies (introduced after previous feedback from graduates). graduates also appeared to benefit from the service learning opportunity in their third year of study which involved the develop­ ment of a workshop within a community of their choice (see mo phosho and stein, 2009, for details of this component). some highlighted perceived gaps in their training: they felt the need for more input on budget writing, meeting protocol, develop­ ing home programmes, ent procedures including cerumen re­ moval and syringing, assertiveness skills, disability grants, how to write a motivational letter and a better understanding of legal issues around abuse, and of disability grants management. some reported difficulties in doing home visits especially for very se­ verely disabled patients. suggestions about additions to the cur­ riculum included a need for further input on aac and early inter­ vention, more practical opportunities in dysphagia, additional information about the management of motor neuron disease, specific information about arvs and more first aid experience. discussion for many of our graduates the cs became a life changing ex­ perience: “my outlook on life has changed.” in relation to community service for doctors, couper (2002) has described the stages in the process as one of “culture shock”: fascination, irritation, depression, adjustment. the feedback we have had from our own graduates suggests the validity of those phases, but it also suggests an even earlier “overwhelmed” stage which seemed to be a common feeling of our graduates. this is reflected in figure 1. interestingly in the one year (2006) when we had feedback at a slightly later stage of the year (august), we noticed a growth pat­ tern in the stages our graduates had reached and we were sur­ prised at the difference that even two months had made. these graduates seemed less overwhelmed, and there was pleasing evidence of adjustment, confidence and more proactive problem solving. most of our graduates themselves were able to describe these changes and growth across the year and were open about their early difficulties and their resolution towards the end of the year. they seemed aware of their limitations and described strategies to address them. “for the first half of the year, i tried to avoid dysphagia as much as i could. ” several of our graduates applied for permanent posts in the same setting where they had worked but were often disappointed by the lack of availability of permanent posts. in relation to the development of a process across the 6 years we have also seen positive changes. there appears to have been an improvement in equipment, referral systems and in recogni­ tion of the roles and function of the slt/a in the team. access to arvs has made an important difference to caseloads. feedback on the adequacy of our program and the cs gradu­ ates' level of preparedness is increasingly improving. our own curriculum has been modified substantially over the years to ad­ dress the perceived gaps in the training including larger mod­ ules on cerebral palsy, special input on working with interpreters (penn, 2000), specialized and case-based input on ethical prob­ lem-solving, to mention but a few. we have reinstituted a rural practical, though this is expensive. as a result of our graduates’ feedback, we have also strength­ ened our commitment to produce graduates who can register the south african journal of communication disorders, vol 56, 2009 13 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) both as speech language therapists and audiologists. according to the feedback we have had at this stage, there remain limited opportunities (and equipment) to employ singly qualified audiolo­ gists in the public sector and by far the majority of our graduates not only indicated a preference for a dual qualification, but also a level of preparedness for the type of problems they encountered, which they attributed to their training in both professions. this, however, should not detract from the urgent need to create an infrastructure supporting specialist qualifications in the future. the feedback sessions have been immensely useful serving as cathartic and informative opportunities and have helped us as educators to fine-tune our curriculum and methods. as a cpd service provider, our department has also implemented a series of workshops run in different provinces for multidisciplinary groups to address established needs: e.g. dysphagia, ethical problem solving for professionals, working with interpreters, hiv/ aids and communication disorders, and cerumen management. in relation to cs for doctors, reid (2001) suggested that the strategy of cs .should be reviewed after five years to examine whether it is achieving the goal for which it was instituted. six years on, our own profession also needs to take stock. for our recent graduates, how have the pillars of phc and the new posts created, met the goals of cs? what indices can be used to meas­ ure the success of this initiative? this is obviously a difficult challenge. one objective measure of success is to evaluate the proportion of recent graduates who stay in the country or people who are leaving because of commu­ nity service (reid, 2002). another index might be to estimate the proportion of those who stay active in the profession (as there is a large drop-out rate) and of those, who choose to remain in pub­ lic service. as price and weiner (2005) have pointed out in rela­ tion to the medical profession, the situation is complex. reporting on a survey conducted with wits medical graduates, they found that more graduates from the 1990s are working in the public sector than before (over 60%) and that more recent graduates had spent more time in the public sector especially in their early years. they highlight the methodological problems of such sur­ veys, but assert the importance of considering the longitudinal career path of graduates and influences such as gender on the process an important consideration in the case of our own pro­ fessions. in ellis’ (2004) cohort, 61% of the cs slt/as indicated that they would not choose to remain in their work setting if of­ fered a permanent job, for personal and professional reasons. we urge our own professional body to undertake a similar analysis of graduates by institution, province and decade, and to examine the number of individuals in this decade compared to the previous one, who have chosen not only to stay in the country but also to work in the public sector. such an analysis might be very illuminating and will require a correlation with available posts claire penn, anniah mupawose and jennifer stein for both speech-language therapists and audiologists. a further index of success and one which we consider critical, is research. pleasingly the benefit of cs has been an increase in the number of research projects at an undergraduate and postgradu­ ate level which have been motivated by cs placements and ex­ periences. this aspect is seen as a particularly important value of future enterprise, one apparently initially overlooked by the pro­ ponents of cs, but of vital importance to future status and sur­ vival of the profession (see penn, 2007). only through continued scientific research can our discipline hope to achieve due recog­ nition and significantly influence policy. most of the above indices of success can (and should) be analyzed by reference to data bases and by relevant quantitative methods. much harder, of course, is the measurement of the impact of cs on aspects such as development of confidence and competence, person skills, management skills, negotiation skills, team skills and ongoing evaluation of these aspects using suitable methods is important. we feel that the feedback process has provided significant in­ sights and provided some opportunity to examine such factors. surveys have some limitations, as price and weiner (2005) point out, but the focus group methods are useful in highlighting such aspects as paterson et al. (2007) have found in relation to dieti­ cians. one criticism that could be levelled at the present study is that it incorporated wits graduates only. however the presence of multiple auditors and independent observers at each meeting addresses issues regarding reliability to some extent. it is note­ worthy that the graduates were widely dispersed and represented approximately 22% of all those working in cs each year through­ out the country. at the time of the study, the wits programme was one of the three programmes in the country graduating students with the option of dual registration (in both disciplines). now there are only two such programmes. clearly, equivalent studies on the graduates of other institutions would be useful and will add sig­ nificantly to this body of preliminary evidence. further longitudinal follow-up of graduates will provide additional perspectives, as wheeler, cross and anthony (2000) have done in relation to nurs­ ing graduates. conclusions and recommendations we conclude with some suggestions for research and some challenges for our professions. community service has undoubt­ edly been one of the most important developments in the long history of the professions of speech language therapy and audi­ ology in south africa. the advent of cs has brought with it posts, novel employment opportunities and, as this paper suggests, a wealth of experience for new graduates. it has met the need of many hundreds-of individuals for whom no previous services ex­ isted and for our own graduates it seems to have served as a refining and consolidating year for knowledge, skills and atti14 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) from pillars to posts: some reflections on community service six years on tudes. happily, in many cases, it has reinforced career choice, country of residence and site of future practice. from our university’s perspective, these feedback sessions have been profoundly valuable and have created a regular oppor­ tunity for self reflection which is a critical element of effective and dynamic educational practice (mcallister & lincoln, 2004). more than any other influence, these feedback sessions have helped to highlight gaps, strengths and provided in some cases a shift of focus in the curriculum. the settings have provided a range of opportunities for research and have provided innovation to our professions in terms of methods and problem solving skills. how­ ever, not all the implications lie at the university level. much needs to happen at the doh level (see bateman, 2004). some of the experiences of graduates in remote rural areas need to be heeded. for some, the experience has been profoundly negative: “/ think anybody who speaks to me will find that my cs experi­ ence was rather a lot like hell.” the doh has a responsibility to take heed of such accounts and explore the reasons for these perceptions, and consider carefully the suitability of certain sites for the new graduate. without the necessary level of support, the intention of cs in developing and retaining staff will be fruitless. our results suggest that, especially for audiology services, there has to be more emphasis placed on ent services, better equipping of hospitals and other sites. the creation of permanent and senior posts at each site is im­ perative to provide continuity and supervisory opportunities which will sustain the initial impetus and the goals of cs. in addition, better and consistent language services should be a feature of all sites and provision should be made for on-site training. the doh should also encourage research as a relevant outcome of cs and support those wishing to do' such research. the subsidisation of a / in training would provide a helpful aid/ rural practical for students to preparedness. for our professions, the feedback from recent graduates serves i to provide evidence and impetus for a re-examination of scope and competency profiles for issues such as cerumen managei ment and the profession should pursue its commitment to recog­ nizing the need for specialist registers. the professional body should also continue to press for appropriate equipment, supervi­ sion, transport and support structures for members of its profes­ sion and explore interface with other professional bodies to en­ sure relevant referral opportunities. some attention should be paid to the issues surrounding the training and scope of stas. the profession has an ongoing ethical obligation to seek feed­ back from all graduates on the process and to undertake the relevant statistical analysis to understand better indices of suc­ cess, or lack thereof, in cs. such evidence is critical in formulat­ ing policy and changes of̂ direction. above all, the research as­ pect of our disciplines should not be neglected. the south one of bur graduates recently made the important observation that "community service is what you make of it”, but we believe that we can make it better and we remain committed to identify­ ing and facilitating mechanisms at university, professional and national levels which will enable the achievement of this goal. acknowledgements thanks are due to all those wits graduates who participated in our feedback sessions and whose ideas and voices form the ba­ sis of this article. we are deeply indebted to the simmonds hampton trust fund which has made this research possible. thanks are also due to heila jordaan, tanya klugman, dilys jones, nadine ellis and jennifer watermeyer for their input on this project. references aronson, j. 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(2006). community-based rehabilitation: new challenges. in b. watermeyer, l. swartz, t. lorenzo, m. schneider, & m. priestley (eds.), disability and so­ cial change: a south african agenda (pp. 273-290). cape town: hsrc press. schneider, m. (1992). the care and management of communica­ tion disorders in a rural area: the role of the community speech and hearing therapy worker. south african journal of communi­ cation disorders, 39, 55-61. swidler, m. & ross, e. (1993). burnout: a smouldering problem •amongst south african speech-language pathologists and audi­ ologists? south african journal of communication disorders, 40, 71-84. wheeler, h., cross, v. & anthony, d. (2000). limitations, frustra­ tions and opportunities: a follow-up study of nursing graduates from the university of birmingham, england. journal of ad­ vanced nursing, 32(4), 842-856. 16 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.hst.org.za/udloads/files/ http://www.hst.org.za/udloads/files/chapter8.pdf abstract introduction literature review methodology discussion conclusion and recommendations limitations acknowledgements references about the author(s) saira b. karrim discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa penelope s. flack discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa urisha naidoo discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa stephanie beagle discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa abigail pontin discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa citation karrim, s.b., flack, p.s., naidoo, u., beagle, s., & pontin, a. (2022). the experiences of speech-language therapists providing telerehabilitation services to children with autism spectrum disorder. south african journal of communication disorders, 69(2), a917. https://doi.org/10.4102/sajcd.v69i2.917 original research the experiences of speech-language therapists providing telerehabilitation services to children with autism spectrum disorder saira b. karrim, penelope s. flack, urisha naidoo, stephanie beagle, abigail pontin received: 31 jan. 2022; accepted: 12 may 2022; published: 31 aug. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: there has been an increased emergence of the use of telerehabilitation by speech-language therapists (slts) in south africa since the covid-19 pandemic in 2020. objectives: to explore the criteria that slts use when recommending telerehabilitation for children with autism spectrum disorder (asd), the technical skills required, strategies used by slts, the restrictions encountered when conducting telerehabilitation and the views of slts on telerehabilitation in comparison to face-to-face therapy for children with asd. method: a descriptive, phenomenological, qualitative study design was utilised. purposive and snowball sampling techniques were employed. six slts from the private sector, who had experience providing telerehabilitation to children with asd, were recruited from three provinces in south africa. data were gathered via semistructured online interviews and analysed using thematic analysis. results: two out of five themes that emerged from this study are presented in this paper, i.e. approaches to telerehabilitation and the benefits of telerehabilitation. results revealed that telerehabilitation was used to provide assessment and therapy during the covid-19 pandemic lockdowns as an alternative method of service delivery. assessment and treatment strategies included synchronous and asynchronous methods, family collaboration, social stories, frequent breaks and interactive sessions. telerehabilitation reduced the client’s and slt’s travel costs and increased caregiver and clinician satisfaction. client progress and increased awareness of slt were viewed as further benefits. conclusion: telerehabilitation was found to be beneficial to most children with asd, and in most cases, the benefits far outweighed the challenges encountered. clinical implications included the need for caregiver support in facilitating effective carryover, an increase in slts’ knowledge and the opportunity to provide services to a broader geographical range. limitations of the study are included. keywords: autism spectrum disorder; experiences; telerehabilitation; speech language therapist; south africa. introduction speech-language therapists (slts) are core members of the interprofessional team responsible for the management of children with autism spectrum disorder (asd), a neurodevelopmental disorder characterised by restrictive and repetitive behaviour, impaired social communication skills and sensory difficulties (lord et al., 2020). approximately 270 000 people in south africa are diagnosed with asd (van biljon, kritzinger, & geertsema, 2015), with a projected 5000 new cases per year (springer et al., 2013). children with asd may be able to access support services through specialised educational placements in either the public or private sectors. however, these are limited, resulting in significant numbers of children not having access to necessary support (bateman, 2013). in south africa, historical, social, political and economic factors hamper equitable access to care (malcolm-smith, hoogenhout, ing, thomas, & de vries, 2013). this is compounded by the extreme shortage of healthcare workers to serve a rapidly growing population, particularly in the field of speech-language pathology, where a 1:18 000 slt-to-patient ratio is likely (health professions council of south africa, 2018). one answer to expanding access to services is telerehabilitation (mars, 2011). this refers to the use of electronic information and telecommunication technologies to provide clinical services to patients who have difficulties in accessing health services or attending face-to-face therapy (bettger & resnik, 2020; wacker et al., 2013). telehealth, which is an umbrella term for modalities that include telerehabilitation (bettger & resnik, 2020), is becoming an increasingly viable alternative model of service delivery, especially to ensure access to healthcare in situations where traditional face-to-face visits are difficult. telecommunications technology is used to provide services, which can happen in real time (synchronously) or through prerecorded videos or voice notes (asynchronously) or through a hybrid approach (american speech and hearing association, 2019). this technology may include social media platforms and online meeting applications, typically requiring both audio and video technology (aggarwal, patel, & ravi, 2020). synchronous telerehabilitation is the most common method used by slts. the clinician and the client communicate and interact directly using videoconferencing via the phone, computer or laptop (khoza-shangase, moroe, & neille, 2021; simacek, elmquist, dimian, & reichle, 2021; solomon & soares, 2020). this allows for slts to provide the caregiver and child with instant feedback, instructions and positive reinforcement as the intervention is provided to the child (simacek et al., 2021). on the other hand, asynchronous telerehabilitation allows a caregiver to complete the therapy activity at a convenient time and send or e-mail images, recordings and monitoring charts to the slt for analysis and interpretation (hill & breslin, 2016). in the early months of 2020, the coronavirus disease 2019 (covid-19) pandemic swept across the globe, and efforts to contain the spread of the virus included various forms of lockdown. in south africa, the government declared a national lockdown at the end of march 2020. although people were allowed to shop for necessities and seek emergency medical care, all other forms of face-to-face contact were discouraged. even when the lockdowns eased, many people felt unsafe returning to face-to-face contact in schools and healthcare centres. alternative forms of service delivery then became paramount, and telerehabilitation was one solution. however, little was known about how slts could use telerehabilitation to provide health services to children who present with asd. literature review speech-language therapists play a critical role in the multidisciplinary team, both in terms of contributing to the differential diagnosis and in providing support to children with asd (dillenburger et al., 2014). early identification, followed by effective intervention, can reduce the burden of asd upon the child, the family and the community. the slt’s particular role is to support the development of skills that will help the children communicate their wants and needs in the most functional way, as well as exchange ideas and comprehend others’ intentions in various settings (parsons, cordier, munro, joosten, & speyer, 2017). the role of slts extends to supporting both verbal and nonverbal communication, providing augmentative and/or alternative forms of communication and training others involved in the care and education of children with asd. ongoing, consistent intervention is therefore crucial. the disruption to face-to-face interactions caused by the covid-19 pandemic resulted in slts rapidly exploring alternative forms of service delivery, such as telerehabilitation, to ensure continued access to service as far as possible (campbell & goldstein, 2021; elsami jahromi, farokhzadian, & ahmadian, 2021; kraljević, matić, & dokoza, 2020; sutherland et al., 2021; theodoros, 2008; tohidast, mansuri, bagheri, & azimi, 2020). although telerehabilitation (referred to as telehealth and telemedicine in some literature) has been gaining traction globally for the past few decades (law, dornstauder, charlton, & gréaux, 2021), it is a relatively new and still emergent method of service delivery for the slt in south africa (south african speech-language-hearing association, 2020). khoza-shangase et al. (2021) reported limited literature on telerehabilitation in africa. the health professions council of south africa (hpcsa) had provided guidelines for telerehabilitation as early as 2014 (health professions council of south africa, 2014). however, hlayisi (2016) found that although slts appeared to understand telerehabilitation, few were using this approach. prior to the covid-19 pandemic, service delivery in slt was typically one-on-one, in-person direct training and/or clinical service provision. reluctance to embrace telerehabilitation may have stemmed from both perceived and real barriers, such as poor telecommunications infrastructure in south africa, i.e. internet or network availability, access to appropriate devices for both clinician and client or caregiver, the health professionals’ attitude towards telerehabilitation, ethical and legal issues and the challenges of multilingualism and multiculturalism (chifamba, 2018; hlayisi, 2016; sinsky, jerzak, & hopkins, 2021). nevertheless, there are significant benefits of telerehabilitation in slt beyond the current focus on reduction of risk of infection through face-to-face contact, such as better access for people in rural and remote areas (grillo, 2017), more cost-effective service delivery (macoir et al., 2021) and more efficient use of time and resources (elsami jahromi et al., 2021; khoza-shangase et al., 2021); all are important considerations for the profession in south africa. speech-language therapists face a range of difficulties when providing services to children with asd through telerehabilitation, from accessibility to resources that are required for telerehabilitation, adequate training of slts and caregivers, active involvement of the caregiver and the child and the appropriateness of the environment where the therapy is conducted (edwards, stredler-brown, & houston, 2012). firstly, telerehabilitation requires the slt and caregiver to have compatible devices to facilitate communication during therapy. such devices may include laptops, computers, cell phones and telephones (edwards et al., 2012), any of which can be used to support telehealth. yet 5% of the south african population do not own or are not able to borrow a phone because of challenges such as theft, cost of the device and lack of sufficient literacy for the use of smartphones; high data costs and access to electricity also impact on access to telehealth services (mccrocklin, 2021). use of phones rather than laptops or ipads is not favoured by clinicians because of the small screens, which potentially compromise the quality of the image of the clinician and/or resources being presented (gibbs, cai, aldridge, & wong, 2021). secondly, the necessity for the caregiver to be able to troubleshoot the device, programme or connectivity problems should they arise requires some training and upskilling, particularly in south africa where it is not uncommon in rural and remote areas for the primary caregivers to be elderly grandparents, who are more likely to be illiterate and/or have poor technological literacy (gibbs, 2021; khuluvhe, 2021; le roux, 2020; rao, 2018). thirdly, the caregiver should ideally be actively involved in the sessions. this poses a challenge in terms of both appropriate training regarding the technology and the appropriate behaviour (for example, feedback and monitoring) during the session. parent training is particularly important when working with children with asd (burgoyne & cohn, 2020). parent training is one way for the slt to reduce cultural barriers associated with telerehabilitation in children with asd and their families (alkhalifah & aldhalaan, 2018). however, a challenge linked to this is the caregiver’s availability, which may limit times for synchronous sessions. reports from slts using telerehabilitation indicate that both quality and quantity of responses from the child are compromised (simacek, dimian, & mccomas, 2017). in synchronous sessions using zoom technology, for example, time lags because of poor connectivity or imbalances in the way multiple voices are amplified can result in a breakdown in communication or compromise the feedback. this feedback is necessary to assess the child’s receptiveness to the treatment plan and the strength of the cooperation (burgoyne & cohn, 2020). nonverbal behaviours and facial expressions are also more limited as these are impacted both by the technology and the equipment the child and the slt are using. camera positioning is critical to ensure the child is able to move around the chosen space without compromising the slt’s view or sound quality (burgoyne & cohn, 2020). young children with complex communication needs especially may have negative responses to equipment such as headphones (grogan johnson et al., 2013). johnsson and bulkeley (2021) suggest that children with asd usually present with behavioural difficulties which interfere with their ability to engage with telerehabilitation effectively. in contrast to the challenges and negative experiences reported earlier, gibbs et al. (2021) found that clinicians working with adults with asd and their families shared positive technology experiences. nevertheless, they too expressed concerns about how the technology negatively impacted their assessment experience. in a telerehabilitation assessment session, significant features of client behaviour may not be as noticeable to the clinician, with eye contact highlighted as the most challenging behaviour to observe whilst the easiest skills to assess were verbal and conversational skills (gibbs et al., 2021). strategies used in telerehabilitation recommendations for successful telerehabilitation are highlighted in the literature. having a flexible plan, a selection of toys and props, limiting session times and breaking sessions into therapeutic games have proven to be effective when working with children with asd and their families (burgoyne & cohn, 2020). shorter sessions also allow for additional time to work with the caregiver, whereas with older children the clinician can adapt games to the digital platform or make use of various applications where relevant (camden et al., 2020). therefore, caregivers need to be involved in the selection of the resources. the use of telerehabilitation allows for collaboration between the slt and the child’s family to develop appropriate therapy goals to be targeted, as well as activities tailored to the individual child. the use of auditory, verbal and visual strategies are considered the most effective strategies when providing services to children with asd (ngcobo, 2015), as this combination provides the slt, the caregiver and child with the most effective learning environment. camden et al. (2020) reported that telerehabilitation is usually found to be more successful with children older than 6 years of age. late diagnosis is particularly prevalent in south africa, and in rural communities the average age for a child diagnosed with asd is 7 years (solomon & soares, 2020). in south africa, early intervention services for children with asd are limited in the public sector because of the limited number of professionals and collaboration between professionals and families (guler, de vries, seris, shabalala, & franz, 2018). popich, louw and eloff (2006) found that 84% of parents of children with asd were aware of their children’s delayed communication abilities but reported that they did not have access to appropriate resources to target these delays. although this study was conducted more than 15 years ago, little has changed, and healthcare services currently provided to children using the face-to-face model are insufficient for the increasing number of children with asd and their families. thus, despite the current focus on telerehabilitation resulting from the covid-19 pandemic, even after all restrictions are lifted, there is likely to be a significant need for alternative forms of service delivery such as telerehabilitation for children with asd. rationale for the study there is insufficient information available in the literature regarding the use of telerehabilitation by slts when working with children with asd and even less focused on children in sub-saharan africa (goldstein, klaiman, & willliams, 2017; guler et al., 2018; khoza-shangase, 2021; sutherland et al., 2018). most of the studies conducted globally regarding the use of telerehabilitation and children with asd have not provided detailed information regarding the strategies and techniques used by slts when conducting assessment and intervention. these include strategies used to build rapport with the child and caregiver, assessment, providing comfort, showing empathy and monitoring skills that are impacted by physical and cognitive difficulties when co-occurring with asd (goldstein et al., 2017). this gap in the literature extends to resources and tools. tools used during asd evaluation have not been translated into telerehabilitation format, and some of the strategies used during telerehabilitation are not evidence-based. furthermore, there are currently inefficient policies guiding the use of telerehabilitation to manage behavioural difficulties in children with asd (johnsson & bulkeley, 2021; solomon & soares, 2020). a lack of evidence-based practice can result in slts not feeling confident enough to provide telerehabilitation services to children with asd, impacting their experience utilising it. over the past decade, telerehabilitation studies in slt have focused mainly on providing instructions to parents, caregivers and teachers. therefore, the focus of this study is on the experiences of slts providing telerehabilitation services to children with asd. methodology aim to explore the experiences of slts providing telerehabilitation services to children with autism spectrum disorder. objectives to explore factors that impact on the decision to recommend telerehabilitation for children with autism spectrum disorder. to describe the slt’s approach when conducting telerehabilitation for children with autism spectrum disorder. to describe the views of slts regarding the challenges and benefits of telerehabilitation for children with autism spectrum disorder. research design a qualitative descriptive phenomenological approach was used. according to pathak, jena and kalra (2013), researchers use the qualitative approach when they are gathering in-depth data or information about people’s daily life experiences. according to sutton and austin (2015), qualitative research allows the researchers to gain more insights and precise knowledge about the phenomenon that was the participants’ daily experiences using telerehabilitation with children with asd and their professional role of assessing and supporting children with asd. study setting speech-language therapists from anywhere in south africa could participate in this study. the online nature of the study did not restrict participation to a specific province. because of the covid-19 pandemic, this study was conducted online and ensured no direct contact between the researchers and the participants, maintaining safety and social distancing (dodds & hess, 2020). participants purposive, snowball sampling was used. initially requests for participants were sent to both the department of health and the department of education as well as online social media groups. as gatekeeper permission was not obtained timeously from the departments of health and education in time to complete data collection, only those participants who were recruited via online and personal social media groups were included. the groups were closed facebook groups for slts or speech-language audiologists and whatsapp groups of slts that served for sharing ideas, information and resources. six participants met the inclusion criteria, which were registration with the hpcsa as slts or speech-language therapists and audiologists, a minimum of 6 months of experience with telerehabilitation and experience using telerehabilitation as well as face-to-face therapy with children presenting with asd aged 2–12 years in south africa. all participants came from the private sector and had between 4 and 15 years of experience as slts; all but one started using telerehabilitation from february 2020. table 1 illustrates the description of the participants. table 1: description of the participants. procedures semistructured interviews were conducted with each participant online via zoom. this was an appropriate alternative to face-to-face interviews because of the restrictions on personal research interviews imposed by the covid-19 pandemic. owing to limited participants, the pilot study was done with a qualified slt who conducted telerehabilitation as a final year student at the university of kwazulu-natal and had 9 months of experience as a qualified professional at the time of the study. the purpose of the pilot study was to test the data collection tool and process, following which changes were made. therefore, data and participant information were excluded from the main study. the results of this pilot study revealed a need for frequent follow-up of participants to schedule interviews, and there were some minor adaptations to the interview schedule, such as rephrasing of some questions to facilitate better understanding of the questions. potential participants identified by the researchers were provided with an information letter about the nature of the study, benefits of the study, their role and details regarding data collection and distribution. this information letter, which covered confidentiality, provided participants with detailed information to allow them to make informed decisions about whether to participate in the study or not. participants’ rights to self-determination and withdrawal from the study were emphasised. an e-mail with screening questions was sent to interested participants to identify if they met the inclusion criteria. for example, ‘have you provided telerehabilitation services to children with asd?’ once the participants who met the inclusion criteria were identified, they were asked to complete the informed consent document. this was distributed and collected via e-mail. each interview lasted approximately 30–45 min. the interviews were recorded on zoom and on a dictaphone, uploaded and saved in password-protected electronic files on the researchers’ laptops immediately after the interview. participant identity was protected by assigning codes to all files. the semistructured interview schedule, containing five sections (general information, challenges of telerehabilitation, slt attitudes, telerehabilitation strategies and telerehabilitation versus face-to-face therapy), was developed from relevant literature using the kallio, pietilä, johnson and kangasniemi (2016) framework. data collection occurred from 02 november to 05 november 2021. data analysis the data were analysed according to the six phases of thematic analysis by braun and clarke (2012), which include familiarisation with the study, generating initial codes, searching for themes, reviewing of themes, naming of themes and reporting of results. the first phase required familiarisation with the transcribed data gathered from the interview. otter.ai was used to assist with the written transcription of the data. however, it was important that the researchers personally transcribed each interview to begin the familiarisation process of the data. the interesting initial ideas were noted as the data were cleaned and reread. the second phase required generating codes on the data collected. these codes were smaller ideas or themes that were identified in the data. the data were then grouped into related ideas or themes that later provided ease of analysis for the next phases. phase 3 required searching for themes by naming and interpreting the codes noted in the data. in this phase, the main overarching themes and subthemes within them were identified. phase 4 of this analysis process focused on reviewing and refining the themes further. the themes were compared to the codes, and a thematic table was developed to highlight the main areas of the research question. phase 5 focused on defining and naming the themes presented for the analysis. a supervisor review was conducted to confirm coding schemes and accurate analysis of the data, which resulted in the researchers editing the overarching themes of the research study. trustworthiness credibility was ensured through the use of a pilot interview; member checking was conducted at the end of the interview with participants, whereby participants were allowed to alter, affirm or remove any statements they had made (gibson & brown, 2009). the findings of the member checks revealed that the researchers accurately captured their ideas and responses appropriately with no removal of any statements made. during data analysis, the transcripts were checked against video recordings for accuracy by the researchers. dependability was ensured through the use of an audit trail to track decisions made at each stage of the research process. the researchers ensured confirmability by probing to gather richer data, participant screening and supervisor review of the transcripts to confirm coding schemes and accurate analysis of the data. transferability was ensured with the use of purposive sampling to obtain a broad range of information that is contextually diverse, which was achieved by including participants who work in both health and education departments and who are from different geographical areas. findings multiple themes emerged under each of the objectives of the study. figure 1 provides an overview of themes as they align to the objectives for the interest of the reader. however, only the themes linked to two of the objectives are discussed in this article, that is, objectives 2 and 3. the themes that are presented in this paper are strategies used in telerehabilitation and benefits of telerehabilitation. the themes linked to these two objectives were selected based on being the most relevant to slts providing or considering telerehabilitation. figure 1: overview of themes and subthemes that constitute the results of the study. strategies used in telerehabilitation this theme discusses the online assessment strategies used, treatment approaches useful for telerehabilitation, transitioning methods, family collaboration and maintenance of the client’s attention. online assessment strategies three participants indicated the use of informal assessment strategies online, together with face-to-face assessments. creative methods of getting as much information as possible included the use of video recordings. participant 2 requested caregivers to send video recordings of the client in multiple contexts during everyday interactions. thereafter, the childhood autism rating scale (cars; schopler et al. 1980, 1988) was used to analyse the videos. participant 6 mentioned collaborating with caregivers and other healthcare professionals to gather assessment information about the client, including the use of classroom-based assessments to determine how the client was performing, and then based their goals on that: ‘a lot of the assessment is classroom based, how much of the classroom work do they know, what can they do? what can’t they do? and then from there it’s based on … our goals are based on functional elements. ’ (p6, slt, gauteng) unlike the participants earlier, participant 4 conducted only synchronous telerehabilitation assessments. this participant reported using pictures presented on powerpoint, scanning copies of formal tests and displaying them on the screen and play-based observation with real objects. participant 4 further indicated that play was assessed in the same manner as face-to-face therapy, with the difference being that caregivers prepared the appropriate items and facilitated the assessment: ‘i get the parents to have matching toys and prepare spoons and plates. then i say, “oh the lion is hungry and asleep” and the child automatically wants to feed the lion. so you assess play the same way that you would by getting the parents to prepare items for you.’ (p4, slt, gauteng) treatment approaches the family-centred, functional and dir®/floortime™ approaches were used most frequently. all six participants applied the family-centred approach to their telerehabilitation sessions. a majority of the activities and techniques that participants mentioned using were parent-driven and involved the family’s active participation in the preparation and facilitation of sessions. participant 1 reported that being involved in the sessions improved caregiver understanding of their child’s challenges: ‘all my therapy sessions were parent driven. … i was having a conversation with a parent to instruct them on how to do certain activities and focus on something specific.’ (p1, slt, western cape) two participants used the functional approach to intervention (owens, 2012), which can be considered appropriate for children with asd. this approach helps clients apply the learnt skills to environments they are a part of in everyday life. one participant reported using the dir®/floortime™ approach (greenspan & wieder, 2008) with their clients and applying techniques such as mirroring and mediating finding solutions: ‘so the strategies that i used, so number one is floortime approach that we use. so it is those types of techniques. so mirroring, you know, shapes, problem-solving. so it’s nontraditional speech therapy.’ (p3, slt, kwazulu-natal) transitioning methods as mentioned in the introduction, the covid-19 pandemic resulted in the sudden transition from seeing clients face-to-face to conducting telerehabilitation. four participants prepared their asd clients for the transition by using social stories or discussing covid-19 with the client. two participants used show and tell as an interactive strategy for the client to welcome the participant into their home: ‘we did a social story for the kids themselves to explain what was happening with the lockdown, why therapy was no longer going to happen and why it would happen at home.’ (p2, slt, gauteng) all participants mentioned the importance of finding a suitable environment for telerehabilitation to be effective. two participants expressed the need to remove distractions whilst another two participants mentioned the importance of positioning to keep the client focused on the screen. this was required as most children with asd cannot shift their attention or focus on a specific task with multiple distractions. this is because of their inability to understand which task is more critical (mundy, kim, mcintyre, lerro, & jarrold, 2016). participants 2 and 6 determined appropriate spaces for therapy by conducting informal assessments of the house, either by requesting a video walkthrough of the house or by trial and error with each session to determine an appropriate spot: ‘the first thing that we asked for was a video walkthrough … reason being is we said we wanted to set up a space that a child specifically with autism then associates with therapy within the house.’ (p2, slt, gauteng) two participants reported the importance of keeping to a routine and using familiar songs. therefore, these participants kept the same session times as face-to-face therapy, as this facilitated a smooth transition to telerehabilitation: ‘i tried to keep like the same time of the day that i normally see them.’ (p4, slt, gauteng) ‘i think it was just a combination of still being able to see their teachers, still hearing their familiar transition songs or music songs and kind of their parents getting them into a routine.’ (p5, slt, kwazulu-natal) family collaboration all six participants mentioned working closely with the family when conducting telerehabilitation. for participants with younger asd clients (below the age of 4 years), the therapy sessions were more indirect and focused on parent coaching. the participants expressed positive experiences with parent coaching influencing the client’s generalisation and carrying over of the session’s aims: ‘they started using all therapy techniques every single day in those different areas, which allowed for stimulation to happen more often, and which in turn allowed for intervention to be more successful.’ (p2, slt, gauteng) in addition, all participants reported that their caregivers were sent videos and home programmes to implement the skills targeted during the week. caregivers played a more active role in telerehabilitation than in face-to-face sessions, as they were responsible for organising materials, facilitating the session and following up with the home programme between sessions: ‘being at school, we’re working mainly with the teachers and the kids. but when you’re online, you need parents to be able to facilitate the session. so i actually really enjoyed the combination of working with the kids and their parents.’ (p6, slt, gauteng) maintaining attention all participants incorporated the caregivers into their sessions to ensure that the clients maintained attention and concentration. participant 5 mentioned that they collaborated with other professionals, such as occupational therapists, for advice about maintaining the client’s attention. two participants mentioned using play-based activities with the clients as this kept them engaged: ‘so we use lots of game-based work play … always asked the mom and dad [to] leave a toy out that is their favourite. so, in the event that they lose attention, we grab that toy.’ (p6, slt, gauteng) benefits of telerehabilitation this section presents the subthemes that emerged related to the benefits of telerehabilitation. these include caregiver satisfaction and involvement, clinician satisfaction, the cost-effectiveness of telerehabilitation, accessibility to rural areas, clients’ progress in treatment and increased awareness of the role of the slt, each of which is discussed in the following. caregiver satisfaction and involvement all six participants reported a high level of caregiver satisfaction with telerehabilitation services. participant 2 conducted a satisfaction survey with caregivers as her practice felt uncertain about whether telerehabilitation was suitable for their children. the participant found the caregivers with whom she was working were satisfied with services; however, they preferred face-to-face therapy as they required more reassurance when they were overwhelmed or stressed during telerehabilitation. on the other hand, two participants measured caregiver satisfaction by the gratitude expressed by the caregivers. participant 4 reported caregivers felt grateful to have access to information and be involved in their child’s treatment during the pandemic. furthermore, participants 4 and 5 mentioned caregivers being grateful for reducing the accessibility difficulties. therefore, parents were less stressed with travel arrangements and attending different appointments across the city. the option of telerehabilitation was also viewed positively by parents as therapy could continue during the pandemic: ‘and then the kids that were unable to return continued online. … so i think that parents that continued online were really grateful that they had an option for educating their kids while they couldn’t come to school.’ (p5, slt, kwazulu-natal) two participants mentioned that the success of telerehabilitation depends on the involvement of the family. half the participants also noted that the caregiver’s involvement in telerehabilitation is greater than during face-to-face therapy: ‘it’s the same as you would have with the one-on-one therapy session, and i find that we end up with more parent involvement and understanding of therapy goals because they are there for each session.’ (p4, slt, gauteng) during face-to-face therapy, there are separate roles between caregiver and slt, and caregivers tend to observe instead of actively participating in the session. in telerehabilitation, the caregiver has to be engaged in the activities, prompt the child and apply the strategies learnt: ‘so it should be the same. but with face-to-face, families get away with a lot. or sometimes they … [are] just like, “it’s not my job. it’s my job to be mom; it’s your job to be therapists,” so they separated so much. whereas when you are in their home via screen, they just … have to get involved.’ (p4, slt, gauteng) interestingly, there were mixed emotions regarding caregiver involvement. participant 6 felt that occasionally caregivers would over-prompt the child, leading to difficulty determining whether the child is responding to the clinician’s prompt or the repetition of it: ‘i have a dad who would prompt the child every single time after i prompt the child. i think that also becomes challenging because they are getting over-prompted. then you don’t really know if they are responding to your prompt or the repetition of the prompt.’ (p6, slt, gauteng) this was supported by participant 3 who shared that ‘helicopter parenting’ impacted on the sessions because of the caregiver taking over and ignoring the importance of providing a reinforcement to the child after the prompt. ‘if you do have parents who are helicopter parenting, they tend to take over, so that can be a disadvantage, but you know, obviously you need to give them a little briefing beforehand to say, “fine, this is what i am planning.”’ (p3, slt, kwazulu-natal) in addition, participant 2 felt that too many family members involved in the session causes the child to experience difficulty concentrating and engaging with the clinician. the findings suggest that caregiver satisfaction and involvement are high with telerehabilitation as the caregivers are responsible for the session, and the clinician serves as a facilitator. ‘their own personal satisfaction of seeing that they had reached it with me just facilitating.’ (p3, slt, kwazulu-natal) however, there is a need for slts to set ground rules and provide training to avoid caregivers overstepping or applying ineffective communication strategies with their children. clinician satisfaction the slt’s views regarding telerehabilitation play a significant role in its success. all participants were satisfied with the opportunity to communicate with the caregivers and family. in addition, telerehabilitation provided the participants with the opportunity to observe the parent–child interaction in the home environment and provide meaningful real-time feedback to parents: ‘so i guess it opens up a nice opportunity to see how they live, what’s important to them, what they [are] keen on sharing with you. when you see them in your offices, it’s very different because they don’t always want to share certain things. when you [are] seeing them at home or online, you can see what’s important for their visual schedules.’ (p6, slt, gauteng) five participants agreed that they would continue providing telerehabilitation services as they were satisfied with the benefits. some of these reasons include accessibility to outlying areas, more caregiver involvement and flexible schedules: ‘look, telerehabilitation for me is the way of life; i’m one person and i have to travel between places that are 3 hours apart. so, for me, telerehabilitation brought another whole aspect to my practice. i can consult from two different places.’ (p6, slt, gauteng) in contrast, participant 5, who only used telerehabilitation during the lockdown period, did not agree that she would continue telerehabilitation despite identifying the benefits of using it: ‘i feel like it can be frustrating sometimes. when you get into it, and the kids are not responding, you’re not seeing the progress that you would face to face, then it can be quite disheartening. i think kids make it much more difficult.’ (p5, slt, kwazulu-natal) cost-effectiveness of telerehabilitation prior to the lockdown, most participants provided slt services at multiple sites such as schools, private practices and hospitals. this required the participants to incorporate travel costs and travel time into their monthly budget. thus, many slts describe the cost-efficiency of telerehabilitation, as it was evident that reduced travel time and costs were an advantage. ‘i don’t have to use petrol to get to my office; i can do it from home. it’s very convenient. i could actually do it from anywhere if i do it on whatsapp.’ (p1, slt, western cape) affordable rates were reported to be another cost-effective aspect of telerehabilitation. participants 2, 3 and 6 found that they could offer more affordable rates, thereby providing some financial ease for families. telerehabilitation has shorter sessions, thus more affordable rates, lack of face-to-face activities and limited clinician-led treatment. ‘it’s cheaper compared to our normal rates. a lot more people are able to afford it, which allows us to increase our caseload. our services are then given to people that need it and will generally not be able to afford it.’ (p2, slt, gauteng) it was found that participants 2 and 4 were able to provide services to clients in outlying rural areas via telerehabilitation. ‘the same thing with access in the rural areas. … there aren’t a lot of therapists over there, where teletherapy has then allowed us to access those areas and provide services in those settings.’ (p2, slt, gauteng) ‘[s]olving the access problem in south africa, as i think south africa has a big access problem between the haves and the have-nots.’ (p4, slt, gauteng) clients’ progress in treatment the findings demonstrate that telerehabilitation might be as effective as face-to-face interventions and a promising tool to consider utilising with children with asd. participant 4 reported progress seen in her clients; one client in particular has now become an effective communicator, and another has managed to continue mainstream schooling. this indicates that the shift to rehabilitation still resulted in significant progress: ‘i’ve had very good progress. and i think a lot of it has to do with the parents carrying through the home programs that we give because they are efficient, and they understand.’ (p4, slt, gauteng) in addition, participant 3 mentioned the clients with an already established relationship before telerehabilitation showed progress as much as they would have with face-to-face therapy: ‘i think it was more of the kids that i knew from their personality, because they didn’t need that one-on-one face time. that not only did they progress, but they progressed as much as versus seeing them.’ (p3, slt, kwazulu-natal) increased awareness of the role of the speech-language therapist telerehabilitation provides the opportunity for slts to create awareness about their role in assessment and treatment. participant 2 felt that caregivers often had a limited understanding of their child’s intervention goals and what needs to be prioritised in therapy, thus resulting in caregivers not identifying when their child with asd experiences dysregulation or is attempting to communicate a need or a want. participant 2 overcame this challenge by sitting down and discussing with caregivers the reasoning behind selecting short-term and long-term goals: ‘that’s why it is important to include the caregivers as well, because then you can sit down and explain the reasons as to why this needs to be focused on and why it is important.’ (p2, slt, gauteng) participant 4 reported that utilising telerehabilitation resulted in an increased awareness of the different healthcare professions. participant 4 explained that by providing explanations for their child’s behaviour, there was an improved understanding regarding what is conducted in intervention: ‘it’s allowing parents to also get an education and just an awareness about therapies that are not known or understood by most of our population … the public isn’t overly aware, or there’s misconceptions about what a speech therapist is or what’s an occupational [therapist] is. so i think telehealth, then, just gives direct access for parents to enquire.’ (p4, slt, gauteng) discussion a variety of online assessment strategies are used by slts during telerehabilitation (mashima & doarn, 2008). in this study the participants used asynchronous methods of telerehabilitation for assessment more than synchronous methods, whilst still incorporating collaboration with family and other healthcare professionals. informal assessments, including the use of videos, checklists and family reports were all favoured. the strategies follow those recommended by oberleitner, ball, gillette, naseef and stamm (2006). the above findings suggest that the family-centred approach applied in telerehabilitation played a significant role in developing treatment plans and goals that were functional for a child. this approach values the caregiver’s decision and places them in control with the slt as the provider. this means that the caregiver’s needs are considered when planning treatment goals (gibbs & toth-cohen, 2011). in addition to this, the functional approach (owens, 2012) and dir®/floortime™ (greenspan & wieder, 2008) are important in the development and carryover of skills. all of these approaches highlight the need for family inclusion and participation in telerehabilitation sessions. this not only provides the caregiver with insight into their child’s difficulties but also supports carryover (gibbs & toth-cohen, 2011). this is significant as poor awareness and knowledge regarding communication goals can lead to caregivers questioning the meaning of the treatment and may lead to them avoiding or adapting therapist-suggested activities (gibbs & toth-cohen, 2011). therefore, educating caregivers during sessions increased carryover in the child’s natural environment. coaching is another important part of family collaboration, particularly when working with younger clients and the only interaction between the slt and client is indirect via the parent (beiting & nicolet, 2020). in this approach, the slt is the planner and model, the caregivers are the implementers and the client is the participant. however, regardless of the approach, family involvement in speech-language therapy is important as caregivers can support speech-language intervention and improve their child’s quality of life by creating stimulating and rewarding environments outside the speech-language therapy clinic (cohn et al., 2000). family participation in therapy can also help keep children with asd engaged during telerehabilitation, as they have knowledge of favourite toys, songs and games. the use of familiar objects and routines, as well as animated singing of songs, can help maintain attention and focus (burgoyne & cohn, 2020), all of which was confirmed by the participants in this study. a child with asd is very attached to their familiar routines and will follow those routines; therefore, disruptions to the familiar routines can negatively affect their behaviour (mirzaie, jamshidian, & hosseini, 2018). it was therefore important to try and set aside a consistent space within the home that would be associated with therapy and to hold onto familiar resources and routines when transitioning to telerehabilitation. caregiver satisfaction is a crucial factor to consider during telerehabilitation, as it is an indicator of the quality of service delivery (kittredge, 2017) and influences the level of involvement a caregiver will have in their child’s treatment. caregivers’ views of treatment and perceived success are important to inform the slt’s decision-making on treatment methods and goals (ong, 2019). client satisfaction surveys opened a dialogue between caregivers and slts which show that the slts are listening and correcting issues, which contributes to the clinician–client relationship (cleave, 2017). high levels of parent satisfaction with speech-language therapy conducted via telerehabilitation in the paediatric population during the covid-19 pandemic were found by tenforde et al. (2020). grady (2002) found that telerehabilitation reduced general stress and saved time and money. the findings in this study are therefore consistent with the literature. oberleitner et al. (2006) found that healthcare professionals utilising telerehabilitation have a better understanding of what is happening to children in their natural environments at the time of their behavioural episode whilst simultaneously creating a need for family counselling. the benefits of seeing children in their own environment, albeit online, were confirmed by the participants of this study. given the widespread use of teletechnology since the covid-19 pandemic, it is likely that satisfaction with the usefulness of telerehabilitation will continue to improve with increased familiarity and use, as noted by the remaining five participants who continued using it in 2021. therefore, there are high levels of clinician satisfaction regarding the use of telerehabilitation with asd children. advantages such as scheduling efficiency, reduced travel time and reduced costs associated with both travel and visiting off-site clients are all cited in the literature (beiting & nicolet, 2020; blaiser, behl, callow-heusser, & white, 2013). it has been reported that telerehabilitation can increase access to therapy services for those who live in rural and remote areas (beiting & nicolet, 2020; cason, 2009). in south africa, there is a shortage of healthcare professionals as compared to the general population (health professions council of south africa, 2018), which makes telerehabilitation a good option. unfortunately, therapy services in south africa are unequally provided across its various socio-economic communities (pillay, tiwari, kathard, & chikte, 2020). the majority of slts practice in the gauteng and western cape provinces of south africa, despite these two provinces having the lowest percentage of persons with disabilities (5%) (statistics south africa, 2014). these services are still central. therefore, the option of telerehabilitation may be an effective option to solve the challenge of individuals with disabilities in south africa accessing healthcare. conclusion and recommendations in this sample in south africa, telerehabilitation was successfully utilised to provide an alternative method to continue speech-language therapy services for children with asd during the covid-19 lockdown. benefits to telerehabilitation were found to include caregiver satisfaction and involvement, clinician satisfaction, cost-effectiveness of telerehabilitation, accessibility to rural areas and increased awareness of the role of slt. this study has many clinical implications. firstly, the need to consistently provide information and support to caregivers to become facilitators during sessions is paramount. encouraging and incorporating caregivers into the session promotes the generalisation of skills learnt and carryover into the child’s natural environments, thereby improving the quality of intervention provided to the clients. information-sharing should include the reason for communication goals and the reasoning behind specific techniques. it is likely that telerehabilitation is here to stay. this warrants the need for slts to continue professional development in the area via reading, online courses and the use of social media platforms that serve as discussion groups to better prepare and support each other for alternative forms of service delivery. a further implication of this is the necessity to include telerehabilitation in undergraduate training programmes. future research should explore the use of telerehabilitation for assessment of children with asd, the use of telerehabilitation by therapists in the departments of education and health and the use of telerehabilitation by slts working in rural contexts. limitations participant recruitment was limited by not being able to gain permission from the departments of health and education, which resulted in slts being recruited from the private sector and data being representative of only one context. acknowledgements the authors would like to thank the students who conducted the research study, nkosivumile ndlovu, and nondumiso ntombela and dineo ndlela for their roles in the data collection process. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions a.p. was part of the initial research project. s.b. contributed to the initial drafts of the literature review, methodology and findings. all authors were involved in the writing of the manuscript. p.s.f., s.b.k. and u.n. also edited the manuscript. ethical considerations the researchers were guided by the relevant ethical principles to act responsibly and report findings honestly and accurately. the researchers obtained consent from the participants via email prior to their participation in the study. in an information letter, the participants were assured of their confidentiality and their right to withdraw from the study at any point without any penalty. approval to conduct this study was given by the university of kwazulu-natal biomedical research ethics committee, reference number: brec/00003040/21. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study are available from the corresponding author, s.b.k., upon request. disclaimer the views expressed in this article are those of the authors and do not necessarily reflect the view of any affiliated agency of the authors. references aggarwal, k., patel, r., & ravi, r. 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(2013). conducting functional communication training via telehealth to reduce the problem behavior of young children with autism. journal of developmental and physical disabilities, 25(1), 35–48. attitudes of children to unfamiliar peers using aac devices 45 attitudes of children towards augmentative and alternative communication systems margaret lilienfeld occupational therapist erna alant director centre for augmentative and alternative communication university of pretoria, south africa abstract the purpose of this study was to determine the impact of voice output, as a characteristic of a child's aac system, on the attitude of unfamiliar peers. the need to develop a suitable tool to measure the attitudes of peers led to the development of the communication aidldevice attitudinal questionnaire (cadaq). a descriptive survey design was used and the suitability of the cadaq was tested in a pilot study. one hundred and fifteen participants, aged 11 -13 years, viewed a videotape of a 13-year-old boy with cerebral palsy, communicating with the use of an aac device. attitudes were measured according to three dimensions: affectivelbehavioural, cognitivelbelief and communication competence. data were analysed with a 2 (group) x 2 (gender) x 3 (dimension) analysis of variance (anova) with dc =.05. an item analysis, cronbach alpha's and scale intercorrelations between the 3 dimensions of the cadaq were computed to determine the internal consistency of the cadaq. results reflected more favourable attitudes to the presence of voice output in comparison to the no voice option. girls held more positive attitudes to the peer with disabilities and little or no junctional speech (lnfs). good internal consistency of the cadaq was demonstrated. key words: attitudes, augmentative and alternative communication (aac), voice output, peers, interaction, communication. introduction the use of augmentative and alternative communication (aac) systems provides children with little or no functional speech (lnfs) the opportunity to engage in the communicative process. the attitudes of communication partners, particularly peers, have a significant influence on the success of aac intervention (kraat, 1987). the need to increase our knowledge, not only of the processes that occur when aac users interact with speaking partners but also of how features of various aac systems impact on the interaction has been highlighted (light, 1988). evidence that communication device characteristics e.g. voice output, have a significant effect on the attitude and perceptions of partners and their willingness to interact with the user has been widely described (gorenflo & gorenflo, 1991; hoag & bedrosian, 1992; o'keefe, brown & schuller, 1998). insufficient interaction between children who use aac and their peers is well documented as negatively affecting the formation of attitudes (beukelman & mirenda, 1992; goossens, crain & elder, 1994; kraat, 1987; lloyd, fuller & arvidson, 1997). peer attitudes die suid-afrikaanse tydskrifvir kommunikasieafivykings, vol. 48, 2001 and perceptions towards children using aac devices necessitate a more systematic understanding of factors that contribute to the formation of attitudes in children. as these factors may well differ from those of adults and adolescents , the variables that affect peer perceptions of the communicative competence of children who use aac need to be investigated empirically in order to develop successful intervention strategies. one of these variables, the impact of the aac device used and the way in which a device improves or diminishes the speaking partner's perception of the user, is of special interest (higginbotham, 1989; schepis & reid, 1995). o'keefe et al. (1998) found that the aac user is more likely to be favourably considered by peers when the aided message is highly intelligible, socially appropriate, and reflects the intelligence, age and gender of the user. use of intelligible voice output has major advantages for the communication partner (beukelman & mirenda, 1992). the views of aac users, on whether voice output has an effect on their interactions with peers, were elicited by the researcher (first author) through the medium of the acolug iistserve on the internet. aac users expressed the view that voice output r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) provided a natural, typical means of communication that had advantages over other methods of augmented communication (k. spivey, personal communication, november 19, 1998; m. a. merchen, personal communication, november 19, 1998). provision of voice output was perceived as allowing users to express their personalities and their sense of humour as well as allowing them to approach strangers (k. mcmaster, personal communication, november 19, 1998; m. a. merchen, personal communication, november 19, 1998). in addition, voice output was credited with improving the confidence and self-image of users (m. a. merchen, personal communication, november 19, 1998). the crucial issue is whether peers rate a child who uses an aac device that produces speech (voice output) as more competent than a child who uses a low technological device without voice output. evidence for this appears to be controversial. reports by aac users as highlighted by k. spivey (personal communication, november 19, 1998), k. mcmaster (personal communication, november 19, 1998) and m.a. merchen (personal communication, november 19, 1998) and the experience of clinicians suggest that voice output will have a positive effect on the attitudes of peers towards a child with disabilities who uses an aac device. research with adults in support of this hypothesis includes a study by schepis and reid (1995). in this study support staff increased their interactions with a 23-year-old adult with disabilities and lnfs in both adult education and residential settings when the young adult had access to a voice output communication aid (voca). in addition, results. of a study to assess the attitudes of undergraduate college students toward a peer with physical disabilities and lnfs indicated that when the voca was used, peer evaluations were more favourable than when unaided or alphabet board techniques were used (gorenflo & gorenno, 1991). conversely, the research of blockberger, armstrong, o'connor and freeman (1993) indicated that the attitudes of fourth-grade children (aged nine and 10 years) toward a child with lnfs was not more positive when an aided electronic technique (a voca) was used as opposed to when aided non-electronic or unaided techniques were used. similarly, the research of beck and dennis (1996) indicated that the type of augmentative aid (a non-electronic alphabet board vs. a voice output device) used by a child with physical disabilities and lnfs was not associated with a difference in fifth-grade peer attitudes. this finding was confirmed in a more recent study on attitudes of third to fifth-grade children towards their peers who use aac devices (beck et ai., 2000). no effects of physical status or aac technique (a voca vs. a picture communication board) on the attitudes of the peers were found (beck et ai., 2000). the authors suggested that a larger sample size as well as different stimulus material (for example, a .' videotape or a real-life exposure rather than a picture of a child in awheelchair) may have resulted in more differentiated reactions. with the adoption of educational policies that favour the inclusion of children with disabilities in schools (ncscet, 1997) in south africa, it is important that we investigate the attitudes of peers to children who use aac. social communicative abilities may have a greater impact than academic abilities on the success of inclusion margaret lilienfeld & eroa alant 46 of a child with disabilities (carter & maxwell, 1998). functional communication systems for children will impact significantly on their social as well as academic performance in the classroom. a survey by alant (1999) of students attending schools for children with severe mental disabilities in the pretoria area, south africa, indicated that approximately 39% of these children had lnfs. possible factors contributing to this high incidence included the lack of early intervention, little or no access to therapeutic services and the limited knowledge and insufficient training of teachers. the survey reflected a lack of access to augmentative and alternative communication (aac) systems by children with lnfs and low teacher expectations of students with lnfs (alant, 1999). in addition, both teachers and parents expressed concern about the attitudes of regular school students toward the children with lnfs (alant, 1999). even though educational policies in south africa support social inclusion, (ncscet, 1997) few students with lnfs are present~y included in mainstream schools. in order to facilitate the inclusion of children with lnfs in mainstream schools an in-depth understanding of the attitudes of regular students towards peers with lnfs seemed pivotal. negative attitudes of people in developing countries towards those with disabilities have been reported (goerdt, helander, mendis & nelson, 1989; kisanji, 1995). attitudes determirie with whom, about what, where and how individuals interact with others. this profound effect of attitudes on interactions highlights the need to determine the attitudes of non-disabled peers to children with disabilities, including those with lnfs. attitudes are, however, difficult to measure accurately and researchers have developed and employed many different methodologies and techniques in attempting to quantify attitudinal responses. researchers studying the perceptions and attitudes of adults and children toward aac users have used likert-type attitudinal questionnaires and rating scales (beck & dennis, 1996; bedrosian, hoag, calculator & molineux, 1992; gorenflo & gorenflo, 1991; gorenflo & gqrenflo, 1997; hoag, bedrosian, johnson, & molineux, 199,4). a theoretical construct appropriate to und~rstand children's attitudes to peers with a disability is th~ abc model of attitudes (feldman, 1993). the model suggests that. any attitude has three interrelated elements, riamely an affective, a behavioural and a cognitive component (feldman, 1993). although the potency of the link between an attitude and the resultant behaviour' does vary, people generally endeavour to maintain consistency between their attitudes and behaviour, which form a logical behavioural framework (feldman, 1993). the chedoke-mcmaster attitudes toward children with handicaps (catch) scale used by beck and dennis (1996) and blockberger et al. (1993) was based on the theoretical construct that attitudes have an affective, a behavioural and a cognitive (belief) component (rosenbaum, armstrong & king, 1986). however, factor analysis indicated that a two component model was more appropriate, namely affectivelbehavioural and cognitive (rosenbaum et ai., 1986). the sensitivity of the catch, which was developed for a more general purpose, was queried in terms of its suitability for differentiating attitudes the south african journal of communication disorders, vol 48 200] r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) attitudes of children to unfamiliar peers using aac devices towards various aac techniques used by children (beck & dennis, 1996). beck and dennis (1996) suggested that future research include the development of a scale designed to measure subtle differences in children's attitudes to aac users. in order to develop a scale, the attitudinal questionnaires and scales used by researchers to determine attitudes toward adult aac users were also considered. these included the attitudes toward nonspeaking persons scale (atnp) used by gorenflo and gorenflo (1991) and a questionnaire for use in their study on variables influencing perceptions of an adult aac user. factor analysis of the a tnp highlighted two meaningful attitudinal factors: a "general evaluation" corresponding to the cognitive component, and the "interactive/affective" factor corresponding to the affectivelbehavioural component of the catch (gorenflo & gorenflo, 1991). the questionnaire by bedrosian et ai. (1992), a likert-type scale, consisted of 30 items and was designed specifically to assess the perceived communicative competence of aac users. the recent study by beck et ai. (2000) describes the assessment of attitudes toward augmentative/alternative communication (aat aac), a new measuring instrument for determining attitudes of children towards aac users. although the aa t aac was not yet published or available at the time the present study was conducted, there are some interesting similarities and differences to the scale, the cadaq, used in this study. both the aataac and the cadaq are 5-point likert-type rating scales with some items positively and other items negatively worded, the former consisting of 26 and the latter 37 items. the aat aac contained 7 cognitive aspect items, 5 affective aspect items and 14 items to measure behavioural intents (beck et al., 2000). the first page of the aat aac also contained six pictures of facial expressions as a "supplemental, non-verbal measure of affective responses" (beck et a~., 2000, p.l6). possibly the most salient difference between the two scales is the inclusion , .' of a section of 13 items on the rating of the communication comp~tence of the aac user in addition to 13 affectivelbehavi6ural items and 11 cognitive items in the cadaq. i a further aspect of analysis of attitude to disability has been across age land gender. findings have been inconsistent. several s,tudies found that girls have more favourable attitudes to disabled peers than boys do (fiedler & simpson, 1987; rosenbaum et ai., 1986; voeltz, 1980). an exception was a study of children's ratings of peers presented as intellectually and physically disabled which reported that boys gave more favourable ratings than girls (wisely & morgan, 1981). although not a major aim of the study, the recent study by beck et al. (2000) suggested the attitude of peers (girls and boys), exposed to children with disabilities, towards children with lnfs may become less favourable' as they became older. research on the effect that voice output has on the attitudes of peers of children with disabilities is conflicting (beck & dennis, 1996; blockberger et ai., 1993; gorenflo & gorenflo, 1991; schepsis and reid, 1995). as children w~th lnfs may now be included in mainstream education in south africa it is imperative to investigate how this process may be facilitated. it is die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 200] 47 important to identify any variable that influences the initial attitudes of peers to a child who uses aac to ensure that initial perceptions are as affirmative as possible (beck et ai. 2000). the present study addressed the question of whether the variable of speech output, as a feature of the output mode of a communication device, has an effect on the attitudes of children towards a peer with disabilities and lnfs. methodology aims the primary aim was to develop a suitable tool, the communication aid/device attitudinal questionnaire (cadaq) to measure any difference in the attitudes toward children who are aac users, dependent on the output mode of the devices used. the following objectives were formulated: to establish the suitability of the cadaq by determining the internal consistency, content validity and construct validity. to use the cadaq to investigate whether voice output had an effect on the attitudes of children, 11-13 years of age, toward an unfamiliar peer with lnfs. to determine whether the attitudes of boys differed from girls towards a peer with physical disabilities and lnfs who uses an aac system. research design a descriptive survey design was used to compare children's responses to a peer, with physical disabilities and lnfs, depending on whether the peer used an aac device with voice output or not. purposive sampling, a non-probability sampling procedure, was utilised by the study (dooley, 1995) as the subjects were selected according to their age and grade level as well as for reasons of geographical convenience. this was in accordance with the characteristic of a descriptive survey that the population must be deliberately chosen, precisely defined and explicitly circumscribed to ensure precise parameters (leedy, 1985). subjects permission from parents and the educational authority was received for the participation of 115 children from a mainstream, suburban, co-educational (boys and girls) senior primary school in kwazulu-natal, south africa. the medium of instruction at the school was english. children with severe disabilities were not integrated into this school and pupils were generally from a middle class socio-economic background. although, only learners receiving their education in english were included, this criterion included learners of different home languages. ninety four percent of the children were from families whose home language was english and seven children (5.51%) were from families where the home language was not english. of these, five pupils came from zulu speaking families, one from an afrikaans speaking family and one from a family where polish was the home language. all subjects were between 11 years, 0 months and 13 years, 6 months of age, in grade 6 or 7, and were rated r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) by their teachers as having an adequate vocabulary and knowledge of language to understand the questionnaire statements. when the researcher inquired about previous exposure to people with disabilities, only one child reported having a family member with a significant disability. none of the other ,children reported knowing any person with significant disabilities. this was not surprising as no children with severe disabilities were included in the school. materials the videotapes videotapes of a child with lnfs using an aac device, a deltatalker™ in spell mode with a simple alphabet overlay were recorded. the videotape was filmed using a ns5 svhs panasonic™ camera on a techoni™ super high grade videotape. one videotape, videotape a, showed the child communicating with the device with synthetic voice output, the dectalk "perfect paul" option. a copy of this videotape was made without the voice output of the deltatalker™ and this was identified as videotape b. care was taken to ensure conformity between using an alphabet board and a voice output communication device (voca). conformity was achieved by using the deltatalker™ in spell mode for closer comparison to an alphabet board and to eliminate the variable of message encoding rate. a special overlay showing only the letters of the alphabet in qwerty arrangement and numbers 0-9 was used. the child with lnfs was a 13-year-old male with cerebral palsy whose home language was english. cognitively intact,. he was a competent communicator using a deltatalker™ and was proficient at spelling out his messages as he used an alphabet board prior to obtaining his device. "kim", the peer, was a 15-year-old female teenager who had previously met the aac user. her role was that of a conversational partner. the content of the videotape was that of a conversation between "alan", the aac user, and "kim". at the beginning of the videotape 'alan' was viewed from the front. he was not wearing his head pointer and smiled briefly at the camera. for the remainder of the videotape the camera was positioned above and behind 'alan's' left shoulder. in the videotape 'alan's' shoulder, the left side of his head and helmet, as well as the head pointer and the communication device were visible. the letters on the overlay and each letter selected by the user as hespelt out his messages, were clearly visible. unable to walk, he was seated in a manual wheelchair during the videotaping. the peer was not seen on the videotape, although her voice was heard. this strategy maintained the focus on the aac user and further reduced any possible variables due to "kim's" appearance. the ,speaking partner did not use re-auditorizations as the variable of voice (in the. no-voice option) would otherwise .be introduced. furthermore, videotape b more clearly reflects the reality of communication with an alphabet board user (an extract of the conversation is contained in appendix b). margaret lilienfeld & ema alant 48 . the development of the measuring instrument the cadaq was devised for children, 11-13 years (grades 6-7), to measure their attitudes towards the aac user. the questions were devised to measure the following three dimensions: • the affectivelbehavioural components of attitudes • the cognitive components of attitudes • the evaluation of communicative competence. fifteen of the twenty-four questions examining the affectivelbehavioural and cognitive dimensions of attitudes included in the cadaq were based on the catch. the catch was developed according to the three-dimensional model of attitude formation, that attitudes consist of interrelated affective, behavioural intent and cognitive components (rosenbaum et ai., 1986). 'several of the questions pertaining to communicative competence were re-worded from the questionnaire designed by bedrosian et al. (1992) to measure the communicative competence of adult aac users. in the cadaq, statements were written so that agreement represented either a favourable or unfavourable attitude with respect to the variable being assessed. to prevent the acquiescence type of response, half of the questions in the attitude scale were worded in a positive form and half in the negative form. short closed questions were used to facilitate ease of completion. items were arranged in a random order and participants were asked to rate each item using a fivepoint scale ranging from one, 'i strongly agree' to five, 'i strongly disagree'. scores from 1 to 5 were assigned for each item. as high scores on the scale indicated more positive attitudes and low scores more negative attitudes, positive responses to positive items as well as negative responses to negative items were assigned higher scores as was suggested by oppenheim (1973). validity and reliability of the questionnaire six teachers of grades 6 and 7 rated the statements as applicable and relevant to the experiences of children of that age group thereby providing information on th~ face validity of the measure. the teachers also rate? the vocabulary and grammar as appropriate but sugg~sted that the statements be read to the participants by the researcher because children with specific rdding i difficulties may be present in grade 6 and'7 classes. \ construct validity is the extent to which the scale measures the theoretical concept of interest (dobley, 1995). construct validity of the cadaq was establii~hed by predicting that girls would have more positive attitudes than boys would. this prediction was based on previous research indicating that girls have more positive attitudes to peers with disabilities (fiedler & simpson, 1987; rosenbaum et ai., 1986; voeltz 1980). ' pilot study a preliminary form of the cadaq consisting of40 items was tested in a pilot study: the objettive of the pilot study was to identify any potential problems with the practicality or feasibility of the" questionnaire, the videotapes and the proposed procedures. the 68 pilot study subjects consisted of equal numbers of boys and girls, aged between 11 years 0 months and 13 years 6 months, from grades 6 and 7 at a co-educational (girls and boys) english medium, senior primary school the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) attitudes of children to unfamiliar peers using aac devices situated in the inner west municipal area of durban, kwazulu-natal, south africa. these subjects were selected to ensure similar educational, home language, socio-economic and geographical status as the main study subjects. this was do,ne to facilitate the ide~tification of possible difficulties, as the pilot study subjects would have a similar understanding of questionnaire statements to the main study subjects. results of the pilot study modifications to the cadaq following the pilot study included the elimination of three statements and the order of some of the statements was changed to make, certain that rephrased pairs were widely spaced. the final questionnaire consisted of 37 items (see appendix a). in addition the videotapes were re-filmed in a quieter environment to eliminate extraneous noise. procedure four class groups, two grade 6 and two grade 7 classes were randomly selected to take part in the main study. thereafter, one grade 6 and one grade 7 class were randomly assigned to form group 1. the second grade 6 and the second grade 7 class were combined to form group 2. the groups were considered comparable in terms of gender and age. in group 1, 31 (54%) subjects were girls and 26 (46%) were boys and in group 2,32 (55%) were girls and 26 (45%) were boys. in group 1, twenty-six participants were ll-year-olds, twenty-six ~er~ 12~year-olds and five were 13 years old. the age dlstnbutlon of group 2 included twenty-nine ll-year-old subjects, twenty-six 12-year-old and three 13-year-old subjects. the class teachers and head of department for grade 7 rated the groups as comparable in terms of academic achievement based on grade tests and assignments. , ?roup 1 was assigned to view videotape a and group /2, videotape b. both groups completed the questionnaire on the same day before recess to minimise fatigue and to h d · . i ensure t at no iscusslon took place between the subjects. t" data collection; i the data was collected in the group teaching room, which easily accommodated' the two classes making up each group. the room had tiered seating and a large screen episcope to ensure excellent viewing of the video. the researcher gave identical instructions to each group of subjects before showing the videotapes. (see appendix c for the instructions). the questionnaires were then distributed and subjects given further instructions. the two trial items were then presented and the subjects indicated they understood what was required. one trial item was positively stated and one negatively stated. following the teachers' advice, each of the 37 statements of the questionnaire was read aloud prior· to the subjects completing it. after completion of the last statement the subjects were requested to make sure all statements had been responded to before the questionnaires were' collected. the subjects were then die suid-afrikaanse tydskrifvir kommunikasieafivykings, vol. 48,2001 49 thanked and their questions regarding peers with disabilities were addressed. data analysis the mean of the total scores on the cadaq and for each of the three dimensions was calculated for each group (voice and no voice) as was the mean for the total o~ the gi~ls' and the boys' scores within each group. to give an idea of the degree of variance from the mean, standard deviations for the total and the three dimensions were computed for both groups as well as for girls' and boys' scores. frequencies for each scoring category (is) were calculated for each individual variable. an analysis of variance (anov a) of the total scores and the three dimension scares was completed to determine if there were significant differences between the voice and no voice groups, girl's and boy's responses within groups, as well as to determine if there was any interaction between group and gender. item analysis, cronbach's alpha and correlations between the three dimensions of the scale were all calculated to determine the internal consistency and reliability of the cadaq. results scores from l(negative) to 5 (positive) were assigned for each of the 37 items on the cadaq. the three components tested were affectivelbehavioural, cognitive and communicative competence with 13, 11 and 13 items respectively. reliability implies consistency in differentiating ,among persons and can be gauged by the consistency of scores (dooley, 1995). one measure of reliability is internal consistency, which indicates both the degree to which the items concur with each other and the, conformity of items relative to overall performance on the questionnaire. the internal consistency of the cadaq with respect to the concurrence of items to each other was determined by item analysis using the iteman programme (assessment systems corporation). item scale co~elations for the affectivelbehavioural component vaned between .48 and .81, apart from item 26 ("i feel upset when i see how alan has to 'talk"'). 'this item was ambiguous and should have been eliminated" after the field test study. the item scale correlations are above .27, which is indicative of acceptable internal consistency for the13 items (owen & taljaard, 1995r as there were 11 items on the cognitive component item scale, correlations of .3 or higher reflect acceptable levels (owen & taljaard, 1995). the item scale correlations on the cognitive component varied between .42 and .79 indicating good internal consistency. the item scale correlations of the communicative competence items varied between .34 and .76 reflecting good internal consistency as item scale correlations of .27 or above indicate acceptable correlation for a 13 item subscale (owen & taljaard, 1995). ' reliability based upon the consistency of subjects' responses to all items in a subscale was determined by cronbach's coefficient alpha .. as this method is used most often for questionnaires in which items have 3 or more answer options to measure test reliability (dooley, 1995). an acceptable level for reliability is .80. the reliability for the affectivelbehavioural component was .89 for the r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) voice option and .85 for the no voice group. the reliability for the cognitive component was .81 and .77 for voice and no voice groups respectively. reliability for the communicative competence component was .84 for the voice group and .76 for the no voice group. as mentioned earlier, the deletion of item 26 in the affectivelbehavioural component would improve the reliability coefficient of this component. correlations between the three components of the scale (attitudelbehavioural, cognitive and communicative table 1: comparison of componentintercorrelations. voice (n=57) component 1 2 1 1.000 0.727 2 0.727 1.000 3 0.666 0.739 note: 1= affective/ behavioural component 2= cognitivelbelief component 3= communicative competence component 3 0.666 0.739 1.000 to determine whether group (voice or no voice) and gender influenced attitudes, 2 (group) x 2 (gender) analysis of variance (anov a) was conducted with the total scores and the scores of the three components of the cadaq as dependent variables. the group (voice output margaret lilienfeld & eroa alant 50 competence) were computed. all the correlations were positive and significant at the 5% level indicating that these components are closely related and do form integral subscales of the same attitudinal scale. the correlations are presented in table 1. notably, the correlation between the various components is not as high for the no voice option as for the voice option, indicating less consistency in the responses of the participants who watched the no voice option. no voice (n=58) component 1 2 3 1.000 0.591 0.491 0.591 1.000 0.562 0.491 0.562 1.000 or no voice output) and the gender (male or female) were the independent variables. the level of significance was dc = 0.05. significant effects were found for both group and gender as reflected in the table below. table 2: analysis of variance results for group (output mode) and gender group group 1 voice output group 2 no voice output group 57 ingrou~ 58 in group comparison standard standard mean deviation mean deviation p-value ! total scores on '116.44 20.51 104.91 16.29 .0008* cadaq affective/ 45.28 8.68 41.67 7.48 .0132* i behavioural \ i cognitive! belief 31.54 6.82 30.64 5.98 .4577 \ component communi -cative 39.61 7.33 32.60 6.01 .0001 * ; competence gender girls boys group comparison 63 in group 52 in group standard standard mean deviation mean deviation p-value total scores on 115.57 16.15 104.63 16.15 .0013* cadaq / affective/ 45.46 6.80 41.04 9.25 .0031 * behavioural cognitive/ belief 34.59 5.75 29.27 6.72 .0052* component , communicative 37.52 6.53 34.32 8.34 .0092* competence = slgmficant at the 5% level ./ the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) attitudes of children to unfamiliar peers using aac devices as reflected in table 2 the means of total scores of the cadaq and the scores on the affective, cognitive and communicative competence components indicate that girls expressed significantly more favourable attitudes to the disabled peer with lnfs than boys. statistically significant differences were evident in favour of the voice option in the total score as well as on the affectivelbehavioural and the communicative competence component scores. although not significant, the same tendency is reflected on the cognitive component scores. the interaction between gender and group was also investigated but was not found to be significant. discussion results indicated that the cadaq has good internal consistency, content validity and construct vaiidity. deletion of statement 26 would improve the internal consistency. the cadaq proved to be sensitive to differences in peers' attitudes towards a child with disabilities using an aac device with and without voice output. the research subjects readily understood and identified with the statements of the cadaq. peer attitudes as reflected in the results were more positive when voice output was used and this result correlates with the findings of gorenflo and gorenflo (1991). in their study peer evaluations of young adults were more favourable when a voca was used than when unaided or alphabet board techniques were used (gorenflo & gorenflo 1991). the current findings differ from those of investigations by blockberger et al. (1993) and beck and dennis (1996). blockberger et al. (1993) found the aac technique used (unaided, alphabet board and voca) had no perceivable impact on the attitudes of the fourth graders in their study. as in the current study, classes of children viewed videotapes of a peer with physical difficulties who had lnfs. the peers' attitudes were measured using the catch scale (blockberger et ai. 1993). beck and dendis (1996), in their research on the attitudes of fifth gradjrs towards a peer with physical , disabilities and lnfs who used aac, found no difference in ca tch ~cores between those who viewed i the videotape of the ch~ld using the non-electronic device and those who viewed! the child using the voca. the videotape subject in i their study, a boy, used a combination of gestur~s, verbalisations and pointing to an alphabet board' in'" the non-electronic (low technological) option and a combination of gestures, verbalisations and a touch talker ™ in the high technological option. it is difficult to substantiate the precise reason for the difference in outcomes between the studies, as there are several methodological differences which merit discussion. differences in the measuring instruments. the cadaq statements referred to the names (pseudonyms) of the videotape subjects whereas the catch refers to the more generic term of "handicapped" children (rosenbaum et ai., 1986). unlike the catch, the cadaq included 13 statements on the communication competence of the child using aac (see die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 51 appendix a). these differences may have helped the peers completing the cadaq to identify more closely with the aac user and his skill in communicating. differences in the videotapes. in an attempt to isolate the variable of voice output in the current study the first tape (videotape a) was dubbed sans the voice output of the voca, to create videotape b. the tapes were thus identical visually and in terms of topic of conversation and number and length of message turns. three separate videotapes were filmed corresponding to each aac technique (unaided, alphabet board and voca) (blockberger et ai. 1993). the strategies of using a scripted conversation and editing were employed to control discrepancies in topic and message selection rate. in the beck and dennis (1996) study, two videotapes were filmed and these were edited to form two 5-minute conversational samples that were as similar as possible. in the first tape the video subject gestured, verbalised and pointed to an alphabet board and in the second videotape he used a combination of gesturing, verbalising and using a voca (beck & dennis 1996). the physical appearance of the aac user could influence the initial .attitudes of peers (blockberger et ai. 1993). the videotape subjects were different for each of the studies. in the blockberger et al. (1993) study the child with lnfs was an attractive 9-year-old girl, in the beck and dennis (1996) study a 13-year-old boy who smiled, laughed and occasionally drooled and in the current study a 13-year-old boy who accessed his voca with a head pointer. in addition, the conversational partners in all three studies also varied. adult female therapists were used in both the blockberger et ai. (1993) and the beck and dennis (1996) studies whereas a teenage female peer was used in the current study. the intelligibility, ageand gender-appropriateness of synthetic voice output influences the attitude of listeners and negative attitudes may result when vocas are first introduced to peers (mirenda, eicher & beukelman 1989). different devices with diverse speech options were used in each of the studies during the high technology option. a prentke romich touch talker ™ was used in the beck and dennis study (1996), an acs epson hx-20tm in the blockberger et ai. (1993) study and a prentke romich deltatalker™ in the present study. a final aspect to consider with regard to the videotapes is that the strategy of re-auditorization was used in both the blockberger et al. (1993) and beck and dennis (1996) investigations but not in the current study and this could have impacted on the results obtained. umitations and future research there are several limitations to the present study. the subjects were from a limited urban geographical area and represented a narrow socio-economic group. accordingly results can only be generalised to this group. the small number of subjects (n=115) also limited the statistical procedures that could be applied. it was, for example, not possible to do a factor analysis of the items of the questionnaire. the study also used only one child with physical disabilities and lnfs, and different results r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) toward a different aac user may have possibly been revealed, as initial attitudes are influenced by factors such as physical attractiveness, gender and attire. directions for future research should include the interaction of the device used with other factors that are known to be important in the formation of initial attitudes of children to peers e.g. physical appearance (blockberger et al. 1993). the design and critical evaluation of peer training programmes to improve the interaction of peers with children with lnfs will enhance our understanding of peer attitudes and interactions with children who use aac. it is essential to 'include aac users and their views must be considered not only in determining appropriate intervention but also releva'nt research. conclusion a significant difference between the mean of total scores of the groups supported the hypothesis that the attitudes of children to peers with physical disabilities who have lnfs are significantly more positive when the communication device used has voice output. this result supports the provision of a device with voice output as a means of promoting more favourable initial peer attitudes towards a child with disabilities and lnfs. a device however, is only part of the equation to promote the interaction of a child with disabilities and lnfs with peers. the peer partners and the aac user should receive training and be taught strategies to promote successful interactions. facilitation of interaction between peers and the aac user should be continued until spontaneous, functional and independent communication readily takes place. peer perceptions and attitudes are important to the personal and educ'ational progress of all students including those with lnfs. the crucial role that peers can assume in the education of all pupils, disabled or not, through peer tutoring and support strategies is increasingly recognised (uditsky, 1993). as we progress towards inclusion of children with lnfs into community schools in south africa, an in-depth understanding of factors impacting on the process remain pertinent to enhance intervention efforts. acknowledgements this article is based on a master's dissertation entitled "the attitudes of children to unfamiliar peers using augmentative and alternative communication devices", written by the first author in partial fulfilment of the requirements for a master's degree in alternative and 'augmentative communication at the university of pretoria, south africa. the promoter of the degree was prof. e. alant. special thanks to mrs rina owen, department or' research support, at the university of pretoria for statistical support. references aiken, l. r. 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(1987). modifying the attitudes of nonhandicapped high school students toward handicapped peers. exceptional children, 53, 342-349. goossens, c., crain, s. s., & elder, p., s. (1994). engineering the preschool environment for interactive symbolic communication. birmingham, al.: southeast augmentative communication conference publications. gorenflo, c., w., & gorenflo, d. w. (1991). the effects of information and augmentative communication technique on attitudes ;toward nonspeaking individuals. journal of speec.h and hearing research, 34, 19-26. i gorenflo, d. w., & gorenflo, c. w. (1997). effects of synthetic speech, gender and perceived similarity on attitudes toward the augmented communicator. augmentative and alternative communication,' 13(2), 87-91. helander, e., mendis, p., nelson, g., & goerdt, a. (1989). training iij tfze community for people with disabilities.' geneva: world health organisation. higginbotham, d. j. (1989). the interplay of communication device output mode and interaction style between nonspeaking persons anq,their speaiang partners. journal of speech and hearing disorders, 54, 320-333. , hoag, l. a., & bedrosiim j; l. (1992). effects of speech output type,', message le'ngth and reauditorization on perceptions of the communicative competence of an adult aac user. journal of speech and hearing,research, 35, 1363-1366. ' , the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) attitudes of children to unfamiliar peers using aac devices hoag, l. a., bedrosian j. l., johnson, d. e., & molineux, b. (1994). variables affecting perceptions of social aspects of the communicative competence of an adult aac user. augmentative and alternative communication, 10(3), 129-137. horne, m.d. 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(1997). education for all~ appendix a cadaq statements affective behavioural items 6 i would worry if alan sat next to me in class. 9 i would be scared to talk to alan. 13 i would be embarrassed to communicate like alan does. 15 it would be fun to talk to alan. 26 i feel upset when i see how alan has to 'talk' . 10 i would like to talk to alan. 12 i would tell my secrets to alan. 16 alan would be unwelcome at my birthday party. 53 public discussion document. cape town: university of the western cape. o'keefe, b. m., brown, l., & schuller, r. (1998). identification and rankings of' communication aid features by five groups. augmentative and alternative communication, 14(1),37-50. oppenheim, a. n. (1973). questionnaire design and attitude measurement~ london: heinmann educational books ltd. oppenheim, a. n. (1994). questionnaire design, interviewing and attitude measurement~ london: printa publishers. owen, k., & taljaard j.j. (1995). handleiding vir die gebruik van sielkundige en skolastiese toetie van die rgn [manual of psychological and scholastic tests of the council for humanities research]. pretoria: hsrc. rosenbaum, p. l., armstrong, r. w., & king, s. m. (1986). children's attitudes toward disabled peers: a self-report measure. journal of pediatric psychology, 11(4),517-530. schepis, m. m., & reid, d. h. (1995). effects of a voice output communication aid on interactions between support personnel and an individual with multiple disabilities. journal of applied behavior analysis, 28(1),73-77. uditsky, b. (1993). from integration to inclusion: the canadian experience. in r. slee (ed.): is there a desk with my name on it? the politics of integration. london: the falmer press. voeltz, l. m. (1980). children's attitudes toward handicapped peers. american journal of mental deficiency, 84(5), 455-464. warrick, a. (1988). sociocommunicative considerations within augmentative and' alternative communication. augmentative and altern'ative communication, 4(1),45-51. wisely, d. w., & morgan, s. (1981). children's ratings of peers presented as mentally retarded and physically handicapped. american journal of mental deficiency, 86(3), 281-286. ' 18 if alan was in my class i would like to do a project with him, 21 i would try to stay away from alan if he came to my school. 28 alan would not be my best friend. 31 i would like tq go to 'the spur' with alan. 37 i would like alan to sit next to me in class. die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48,2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) margaret lilienfeld & erna alant 54 cognitive items 2. our class works too quickly for alan. 4. alan would find it difficult to make friends at my school. 8. i think alan has many friends. 17. alan would get teased in our class. 20. alan would be popular with the girls. 25. alan would need lots of help in the classroom. 29. alan had interesting things to say. 32. alan most likely comes last in class. 33. alan should be good with computers. 34. i do not think alan has much fun. 36. alan needs lots of help to tell a story . . communicative competence 1. alan took an active part in the conversation. 3. kim understood everything alan said. 5. if i couldn't speak i would like to communicate like this. 7. i found it easy to understand what alan meant. 11. there must be better ways for alan to communicate. 14. it was easy to understand what alan was 'saying'. 19. alan could not communicate quickly enough. 22. alan was frustrated communicating like that. 23. alan was unable to say what he really wanted to. 24. alan could answer kim's questions quickly enough. 27. kim did not always understand what alan wanted to say. 30. the way alan communicated with kim resulted in some misunderstanding. 35. alan could say exactly what he wanted to . . appendix b conversational extract of the videotape. kim: hello alan alan: hi, kim kim: what have you been doing on your computer lately? alan: making web-pages kim: what programme do you use? alan: frontpage alan: what do you look up on internet? kim: i look up information for school projects kim: how has school been lately? alan: o.k. but very busy appendix c instructions to participants prior to and after viewing videotape a or b. i i 'as part of your theme on disability awareness you are about to watch a 5 minute video of alan, a boy who has phhical disabilities and is in grade 6 at the school where i work. in the video, alan is chatting to his new friend, kim. due ito his disability alan is not able to speak clearly and he communicates in other ways. all i ask is that you do not discuss the video with your friends while we are watching it and remember to watch it carefully as you are going to answer some qu~stions when we have finished watching it' . the videotape was then screened. group 1 watched videotape a whereas group 2 watched videotape b and the participants were then given the following instructions: 'i am now going to hand out the questionnaires and pencils. please don't chat about the video until all the questions have been answered. you will then be able to ask me any questions you want to about alan. in the meantime you can tick the block next to your age and whether you are a boy or girl. please don't write your name on the questionnaires' and neither your teachers nor i will know which one is your questionnaire. remember there are no right.or wrong answers and this is not for marks. i want you to think about the video while you answer the questions. i will read each question and you must tick the answer that best shows how you feel. please make only one tick per question and don't.leave any questions out. let's start with the first example ... .' .' / the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) abstract introduction third-party disability methods and materials rigour data analysis results and discussion limitations conclusion acknowledgements references about the author(s) kim a. coutts department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa maxine solomon department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south afric citation coutts, k.a., & solomon, m. (2020). the use of diet modifications and third-party disability in adult dysphagia: the unforeseen burden of caregivers in an economically developing country. south african journal of communication disorders, 67(1), a777. https://doi.org/10.4102/sajcd.v67i1.777 original research the use of diet modifications and third-party disability in adult dysphagia: the unforeseen burden of caregivers in an economically developing country kim a. coutts, maxine solomon received: 29 apr. 2020; accepted: 30 aug. 2020; published: 25 nov. 2020 copyright: © 2020. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: one of the interventions for dysphagia is diet modifications, involving a variety of resources and consumables. in south africa, where 49% of the population live below the poverty line, the necessities for it are not always feasible for the patient and their family. this coupled with the responsibility of caring for a loved one with disability can culminate into caregivers experiencing third-party disability (tpd). objective: to describe the experiences of tpd of caregivers when implementing dysphagia management strategies at home within an economically developing country context. methods: this was a qualitative study using phenomenological principles. data were collected using a semi-structured self-developed interview tool at three tertiary level public sector hospitals. seven participants and six caregivers were interviewed. rigour was obtained through credibility, triangulation, transferability, dependability and confirmability. the data were analysed using a thematic content analysis technique following a top-down approach to coding. results: the use of diet modification is an appropriate management strategy if the patients’ access and contextual limitations have been taken into consideration. it was evident that the caregivers had multiple international classification of functioning, disability and health domains affected, which restricted their daily functioning including activities, participation and environmental and personal factors. conclusion: the management of dysphagia needs to be family centred and the caregiver’s role and needs have to be considered by all team members when determining long-term management plans. the specific area of how the caregiver’s quality of life was experienced also required further exploration. keywords: adult dysphagia; third-party disability; caregivers; food insecurity; economically developing context. introduction dysphagia (swallowing disorder) is heterogeneous in nature which can result in a variety of serious medical complications, including but not limited to malnutrition, dehydration, difficulty with pill swallowing, aspiration and aspiration pneumonia (takizawa, gemmell, kenworthy, & speyer, 2016). management of dysphagia is multifaceted but predominantly falls under the scope of the speech language pathologist (slp). management involves a variety of techniques broadly including non-oral feeding methods such as nasogastric and percutaneous endoscopic gastrostomy (peg) tubes for the more severe cases and swallowing manoeuvres and/or diet modifications (groher & crary, 2006) for the people who are able to tolerate some form of oral feeds. diet modifications involve altering the consistency of the food to something tolerable for the patient, so that it can be swallowed safely (o’keeffe, 2018). it broadly involves modifications using various techniques such as cooking food for longer, blending and/or using thickening agents (speyer, baijens, heijnen, & zwijnenberg, 2010) which require access to electricity, stoves, blenders and thickeners, which can be costly. in south africa, where approximately half of the population live below the poverty line (49.2%) (statssa, 2019), the use of this technique can become increasingly challenging because of resource scarcity and contextual constraints. these include lack of access to running water and electricity as well as kitchen items such as kettles and blenders. this scarcity coupled with the responsibility of needing to manage the dysphagia at home can create tension for both the patients and their caregivers. together with the interest of ensuring that slp practice patterns are responsive to the needs of the challenging south african context (moonsamy, mupawose, seedat, mophosho, & pillay, 2017), the necessity for this article became increasingly significant to bridge this contextual gap. this article stemmed from a larger study that had a focus of looking at food insecurity challenges related to adult patients with dysphagia who require the use of diet modifications at home. for the larger study, the caregivers were not the original participants; however, the researchers felt that as this theme of third-party disability (tpd) came across as highly pertinent amongst the caregivers during the data analysis process, it required to be its own article. third-party disability third-party disability is a consequence of a person’s impairment and how this affects the daily functioning of significant others (nund et al., 2014). this concept has been scarcely researched, but there is one study in hearing loss (scarinci, worrall, & hickson, 2009) and aphasia (grawburg, howe, worrall, & scarinci, 2013), respectively. only one study explored dysphagia in relation to patients with head and neck cancer (hnc) who were undergoing non-surgical therapy, and the findings will be discussed briefly below. the findings from those tpd studies are important for slps; however, in terms of understanding caregiver’s experiences in an economically developing context still remains unexplored. these tpd studies have all utilised the world health organization’s framework of the international classification of functioning, disability and health (icf) (world health organization, 2002) to understand the impact of it on caregivers. this well-known framework is shown in figure 1. figure 1: international classification of function and disability framework. threats (2007) used the icf framework to discuss the impact that dysphagia would have on an individual, using eating as the main activity (in the centre). these challenges include the ability to use utensils appropriately and being able to adequately get the food to the mouth for consumption as a body function. people who have dysphagia because of a neurological deficit may suffer from other comorbidities such as motor impairments, which will further impact on these activities. in terms of participation, threats (2007) describes these as daily meal preparation as well as actively being able to participate in family and social functions. people with neurogenic dysphagia will need to rely heavily on the assistance of others for both the activity and participatory aspects that surround eating. a challenge with the study of threats (2007) when needing to relate it to the current article is that the concepts around environmental factors are discussed but focuses solely on the perspective of the person with dysphagia and not the caregivers. some of the environmental factors that are mentioned include access to support and health care workers (hcws), as well as their living conditions being adapted to their needs. these findings are helpful but the exact experiences of the caregivers of a person with dysphagia in an economically developing context are yet to be explored. researchers who have explored hearing loss and tpd in relation to the icf found that experiences of caregivers related predominantly to the activities and participation domains followed by contextual factors (scarinci et al., 2009). in terms of aphasia (grawberg et al., 2013), these findings were echoed. more to the focus of dysphagia, the article by nund et al. (2009) that explored tpd in patients with dysphagia post non-surgical treatment of hnc found that the majority of caregiver experiences also correlated to limitations in the activity and participation domains, but there were some hindrances to contextual and personal factors as well. these factors include eating meals at family gatherings as an example. a challenge with these studies is that they have been predominantly conducted in economically developed contexts, such as australia. because of a variety of cultural, social, linguistic and economic circumstances of the south african population as well as the complexity of the healthcare system (coovadia, jewkes, barron, sanders, & mcintyre, 2009), the specific experiences of caregivers in this context need to be explored to be better understood and incorporated into the context-specific slp practice teachings, guidelines and policies. methods and materials this article aimed to describe the caregivers’ experiences in relation to tpd when accessing and fulfilling diet modifications at home. as mentioned, these experiences stemmed from the findings of a larger study that focused on food security challenges in relation to diet modifications at home. the participants for this article are described below in the results section. this was a qualitative study using phenomenological principles as the researchers were able to gain insights into lived human experiences (mills & birks, 2014). interviews were conducted at three tertiary public hospitals in an urban area. data were collected as part of the larger study focusing on food insecurity that used a semi-structured self-developed interview tool that was based on themes of the icf model domains, resource scarcity and diet modification usage. seven individual interviews were audio-recorded, with each of the participants and their caregivers in a private room when they attended their follow-up appointment at the speech therapy department. participants for the larger study needed to have been diagnosed with dysphagia and conducting diet modifications at home. there were no specific inclusion or exclusion criteria for the caregivers. the interviews were conducted in english and the duration varied between 10 and 20 min. rigour for reliability purposes, a pilot study was conducted on one participant to ensure the feasibility and the applicability of the tool and to make any necessary adjustments to the data collection procedure. there were no adjustments relating to the length or content of the tool that needed to be made. credibility the researchers used member checking and triangulation (birt, scott, cavers, campbell, & walter, 2016). the researcher achieved credibility through asking the participants to verify the information that was obtained at the end of the interview (given, 2015). environmental triangulation was used as data were collected from three sites (lichtman, 2011). theory triangulation was also used as there were multiple perspectives from the literature that were used to review the findings (lichtman, 2012). finally, method triangulation was used as data were collected from multiple sources, including patient hospital files, observations and discussions with family members, participants and therapists at the sites (korstjens & moster, 2018). transferability this was ensured by the researcher offering details regarding descriptions of the context, research sites and participant’s information to ensure that the findings were contextually relevant to an economically developing country context (chilisa & preece, 2005). dependability this was obtained by the researcher discussing the findings with her supervisor and other experts in the field. the data from the interviews were transcribed and checked by a research assistant who was not present during the interviews to ensure accuracy (litchman, 2012). confirmability the research supervisor assisted with the data analysis and interpretation of the findings (given, 2015). reflexivity the main researcher did this through checking her personal biases and keeping a reflective journal throughout the research process (korstejens & moser, 2018). data analysis the data were analysed using a thematic content analysis technique following a top-down approach to coding which involved taking some preset themes from the literature, which in this case was the icf framework, and then setting up the codes and defining them from the source, which in this case were the interviews (braun & clark, 2006). both authors checked and agreed upon the coding and analysis procedures and findings. results and discussion participant demographics the demographics of the caregivers and the patients with dysphagia, including their prescribed diet modifications, are described in table 1. table 1: participants with dysphagia and caregiver relationships demographics and description of diet modifications. four (57%) of the seven participants were female with an age range between 33 and 69 years. the mean age for this sample was 47. four (57%) of the seven participants presented with motor neuron disease (mnd). five participants (71%) were classified as h1 and therefore were receiving some form of income in the family. all (100%) the participants had their solid food intake modified in some manner and two participants (28%) were receiving thickened liquids. two participants (28%) required peg feeds. percutaneous endoscopic gastrostomy feeds are delivered through the tube via a syringe and are therefore required to be of more puree consistency rather than soft, for ease of delivery through the syringe and tube. all participants also reported that they had access to electricity at home. all the caregivers were members of the patient’s immediate family. there was an even distribution between female and male caregivers. objective 1: to describe the methods in which caregivers execute these modified diets at home to better understand the burden, it was important to describe the type of diet modifications that were being used by the caregivers. prior to this study, there was little to no available evidence on what caregivers were doing in terms of modifying diets at home, especially in an economically developing country context. three types of diet modifications used are as follows: two (28%) of the seven participants used thickened liquids, five (71%) of the seven participants used soft food and two (28%) of the seven participants require pureed peg food. table 2 describes the different methods that caregivers used to modify the soft food. table 2: soft diet preparation methods used at home. all the dysphagia participants who ate soft food meant that the caregiver made use of a stove or oven to overcook the food items so that they could be mashed. these participants did report having access to electricity; but in more rural areas, this may be challenging. participant 1 reported not having access to a blender but used the overcooking vegetables as an alternative. the majority of the participants (85%) reported eating food that was already soft, for example, porridge, custard or mageu (a popular sour milk drink in south africa). this is a convenient option but the considerations from a nutritional perspective for long-term use may need to be possibly investigated. there were only two participants (28%) who required the use of thickened liquids. participant 1 used the commercial thickening agent ‘nutilis’ and the other used a cereal ‘future life’ to achieve the same thickening effect. the cereal is more readily available at retail shops and comes at a much lower cost. both the participants 2 and 3, who used peg feeds, used blenders to soften the more solid food and they also used naturally soft foods such as mageu. for these participants, who live in an urban area and have adequate access to electricity, having access to a blender is of importance for managing this type of diet at home. in the broader south african context where access to electricity (statssa, 2019) and specialised kitchen equipment is difficult, this may not always be so easily managed. the use of these types of diet modifications for people who live in more rural areas needs to be considered for future research purposes. objective 2: to describe the impact of third-party disability on the caregivers when executing diet modifications at home as stated, these findings stemmed from a larger study and are described as they emerged from the data analysis from that larger study. tpd was described as being experienced by all the caregivers (n = 6) in the study. theme 1: the challenges five sub-themes emerged in relation to challenges that were identified relating to the use of diet modifications at home: the costs of managing a patient with a disability at home (5/7 participants, 71%), the dislike of the modified diets by the patients (1 participant, 14%), different cultural views related to the use of diet modifications (5/7 participants, 71%), increased dependency (2/7 participants, 28%) and caregiver fear (4/7 participants, 57%). sub-theme 1: costs: as the participants who had dysphagia were young and within working age, the caregivers had to bear the burden of being the primary breadwinner and had to run the household with one less income. this would already be a challenge for most households in south africa, but these families had to bear the extra costs involved in managing a disability with this reduced income. when using thickening liquids, the caregivers were required to purchase either commercial thickeners at a cost of approximately r200 for a 300 g tin or a cheaper box of non-commercial thickener such as a cereal. the caregiver of participant 7 stated: ‘i can’t afford but i must try and buy it’ (p6, 70). in a larger urban hospital setting, it is possible that these commercial thickeners are available but because of budget constraints within the healthcare sector, this is not always the case often leaving this cost up to the family. participant 7 experienced difficulty in accessing these resources from their hospital, whereas participant 1 was managed at a different hospital and had easier access to these because the hospital had adequate stock available. when caregivers need to supply their own resources, these expenses are a significant contributing factor in their financial decision-making as seen when participant 2 said: ‘… we are not feeding expensive food’ (p2, 51). participants 4, 5 and 6 expressed that having to use modified diets was more expensive than before. participant 1 also stated that the extra costs of medication to manage the main medical diagnosis were another significant expense and that also needs to be taken into consideration over and above the diet. the indirect costs were described by the caregivers as cost implications around attending multiple hospital appointments and the transport to get to these appointments that were often on different days in conjunction with the need to pay for the essential living costs. participant 4 reported: ‘i have cancelled some of my appointments’ (p4, 21), as he needed to cancel work appointments to attend required medical appointments with his loved one, thus preventing him from earning an income. this was further described by him as: ‘… causes me to lose out on job opportunities.’ (p4, 21) participant 4 reported that living costs are prioritised, for example, rent, and then buying food is secondary as seen in the quote: ‘… we buy food with change’ and ‘… money left is the money we use to buy food and all that’ (p4, 83). it can be confirmed that for these caregivers, the cost of living with a person who has a disability often further exacerbates pre-existing financial difficulties as described by the caregiver of participant 7 in the quote: ‘i think, can’t afford but i must try and buy it’ (p7, 42). sub-theme 2: dislike of modified diets by patients: this was strongly reported by the caregiver of participant 1, whose sister had suffered a traumatic brain injury (tbi). she was on a soft diet for her solid food intake and also required the use of thickened liquids. the caregiver reported that she: ‘… doesn’t want it …’ (p1, 12) and ‘… yoh, yoh, she complains’ (p1, 15). she further said that she ‘doesn’t finish it’ (p1, 59). sometimes the caregiver resorted to threatening the patient: ‘… i keep on telling her that we are going back to the hospital’ (p1, 17). as people who have undergone a tbi often display cognitive and pragmatics deficits (lee et al., 2016), thus having a patient disliking modified foods is a high probability that needs to be considered in slp management and the impact that this can have on the caregiver needs to be considered. sub-theme 3: different cultural views on diet modification: in all, 71% of the participants and their caregivers experienced challenges on differing cultural views regarding the management of their dysphagia. south africa’s population is diverse with many cultural views of health and illness and how these conditions can be managed (weber & kelley, 1998). participant 3, who has a peg because of mnd, was told by fellow community members that they must have the peg removed as it was associated with: ‘… evil and bad spirits’ (p3, 56). this creates a significant conflict for both the patient and the caregiver. participant 1 referred to other food as ‘some are normal’ such as ‘meat’ (p1, 53), implying that the modified diet was not ‘normal’ food as part of their daily meal. participant 6 refers to the patient having to eat more vegetables, and not meat, unlike the rest of the family. as south africa has a diverse population with multiple cultural and religious beliefs, it is inevitable that conflicts in ideologies regarding management will arise. speech language pathologists need to be more aware of the different beliefs that can impact on the decision-making of the family and patients alike. this is important for holistic and family-centred care (kenny, 2015). sub-theme 4: caregiver fear: this theme of fear emerged strongly from participants 2 and 3. participant 3 related her fear to the meal preparation itself and having to feed her loved one via a feeding tube. her experiences were: ‘… scary and emotional’ (p3, 4). there is a substantial amount of counselling and training that needs to be provided for peg feeding by the multidisciplinary team (mdt) (best & hitchings, 2010) before discharge to ensure that this is done correctly. despite this counselling being done, these caregivers still experienced this fear after going home. the second aspect of fear felt by caregivers was the potential consequences of the dysphagia and the nutritional management at home. the caregiver of participant 2 stated: ‘i can say it has been difficult. as i have told her that he sometimes vomits and when he vomits, he loses his breaths, he coughs non-stop. so that, that scares me. so yes, it is difficult.’ (p2, 12) and ‘yeah, it scares us, so it is difficult’ (p2, 24). as mentioned, the medical consequences of dysphagia are significant and as an inexperienced caregiver having to cope with potentially serious complications in an isolated environment clearly creates feelings of justified fear. the caregiver of participant 1 as mentioned earlier had to use threats occasionally for compliant feeding to be completed. this can lead to a variety of other emotions on the part of the caregiver and the person with dysphagia. despite this, the comment from caregiver of participant 1 indicated that: ‘… at the end of the day i have to follow the right instruction’ (p1, 62), despite these real feelings of fear and anxiety that they had to persevere and follow the instructions from the medical staff as they are aware of the consequences. the implications of this for the mdt are to conduct frequent, appropriate counselling and possible practice sessions prior to the family being discharged. these feelings of fear need to be acknowledged by treating mdt members at follow-up appointments. this led the researchers to question whether the effects of caregiver burden and depression have an impact on compliance during the rehabilitation journey. sub-theme 5: increased dependency: the patient of caregiver 4 depends fully on her husband for her care, and this results in him having to: ‘… cancel some of [his] appointments’ (p4, 21) for work, so that medical appointments can be attended. these circumstances were echoed in participants 2 and 3. participant 2 needed to be at home as she was the sole person responsible for preparing and administering the peg feeds. this has had a resultant impact on the sister as she had to move back home to assist with the running of the household. participant 3 also expressed the need to rely on family members for support. this situation has thus impacted multiple family members with their loss of independence and resulted in a shift of responsibility. participant 1, who suffered a tbi, had their caregiver report that: ‘… since the accident, i have been at home’ (p1, 41), which has been difficult for her. participant 1 also reported that: ‘i have to make separate food … it is a challenge’ (p1, 38), showing the significant responsibility in preparing modified diets for a family member. the caregivers expressed that the extra responsibility is something that: ‘it’s part of our life now … so we are getting used to it’ (p1, 70); this shows the resilience and adaptability on the part of the caregivers. in south africa, family structures and family members’ roles are impacted by culture, which are many. how tpd shifts in responsibilities and increased dependency impacts on these familial structures needs to be further explored. based on these findings, it can be said that the caregivers’ tpd affects the following icf domains: activities, participation and environmental and personal factors. from this study, the activities included the actual act of preparing the meals. participation included the effect on work-related tasks and how the increased dependency affects family roles and responsibilities. this is currently an under-researched area and a poorly reported topic, especially in terms of caregivers of adult patients with dysphagia. however, the findings from this study do echo some of the findings from the previous studies on tpd that are mentioned earlier by nund et al. (2009), grawberg et al. (2013) and scarinici et al. (2009). the caregivers from these previous studies also had the activities and participation factors of the icf framework mostly affected. uniquely, for this study, the environmental and personal factors revealed the repercussions of caregivers’ fear and how differing cultural views can affect the caregiver on a deeply personal level. these findings have not been reported in other studies that have focused on tpd and thus require further exploration. theme 2: the facilitators the following facilitators were described by caregivers: appropriate counselling (2/7 participants, 28%), provision of resources from healthcare sites (2/7 participants, 28%), access to state disability grants (4/7 participants, 57%) and family support (100%). sub-theme 1: appropriate counselling: participant 3 expressed gratitude that she was counselled early regarding the progression of mnd and how this would have financial implications later on, specifically relating to diet modifications. this counselling was done by the slp and the dietician. she stated that she ‘had time to get used to it’ as it was ‘scary’ being informed about the need for a peg. she was counselled about the different types of foods, supplements and specialised equipment that she would need for the peg feeds. interestingly, for this participant, she moved from private to public healthcare as she felt that private was too expensive. she mentioned that the resources were more readily available in the public healthcare sector as it supplied her with the necessary consumables, such as the thickening agents. the dietician produced a list of foods that were inexpensive and easily obtainable. in a country where the public healthcare sector has an unpopular reputation, this was a positive finding. this was similarly reflected by participant 2 who received counselling from both his slp and dietician as they were given a list in advance regarding food that would meet their requirements: ‘yeah, none of the list we given is anything expensive or whatever … no … it is something that we can do’ (p2, 39). for patients in a complex setting such as south africa, adequate pre-counselling is imperative for multiple reasons, including patient compliance and preparation for the rehabilitation journey going forward. there appears to be little published research regarding this, and the current south african policies (south african speech language and hearing association, 2012) also speak little of this aspect in terms of addressing these issues in slp scope of practice documents and dysphagia practice guidelines or policies. the hope is that this research can facilitate the start of this change to make our practices more contextually responsive. sub-theme 2: provisions of consumables from hospitals: as mentioned earlier, thickeners can be costly. the caregiver of participant 7 stated ‘[i] can’t afford but i must try and buy it’ (p7, 70). in an urban hospital setting, it is possible that these commercial thickeners are available but because of budget constraints within the healthcare sector, this is not always the case often leaving this cost up to the family. participant 7 experienced difficulty in accessing these resources from their hospital, whereas participant 1 was managed at a different hospital and had easier access to these because the hospital had adequate stock available. it can be suggested that hospitals that manage these types of patients need to account for this when developing their annual consumables budget. sub-theme 3: assistance from state disability grants: participant 4, who in the absence of financial support, stated that ‘it is just the grant helping’ (p4, 51), and this helps the family to purchase food. similar sentiments were echoed by participants 5 and 6. participant 7 expressed that ‘the disability grant is helping too much’ (p7, 40), in terms of buying food; however, when it comes to purchasing specialised kitchen equipment, ‘… is still too much’ (p7, 42). these socio-economic factors need to be considered by all team members when doing counselling with patients as well as for management recommendations. perhaps informing caregivers about disability grants should be an option for inclusion in the pre-counselling process as well as a consideration to referrals to social work to assist with this. sub-theme 4: family support: as six of the seven participants had caregivers who were present during the interviews, all of whom were close family members, it can be assumed that family support is imperative to the management of these patients in a home environment. in terms of the facilitators, the findings from this study are distinctive to the south african context, which is pertinent in terms of being able to translate these results into tangible transformative teaching practices and guidelines. limitations a significant limitation of this study is that the sample size was small. because of the structure of the south african healthcare services, the majority of long-term patients are referred down to a primary healthcare level for management or they return home to the rural areas after discharge. further investigations regarding patients’ experiences at the primary healthcare level and in rural settings are required. this study was conducted in an urban setting consisting of well-resourced tertiary hospitals where family members are often employed. this study needs to be replicated in a rural or semi-rural area as the experiences of caregivers in these settings are expected to be different. as this was also not the primary focus of the larger study, the specific duration of the dysphagia was not fully investigated because this may have an impact on the caregiver as well. this needs to be explored too. conclusion dysphagia management is a multifaceted and complex process as it involves not only the rehabilitation of the patient but also a deeper understanding of the role of the caregiver in this social process of eating within their living context. this process also involves multiple healthcare professionals. diet modification is a useful management strategy for this population; however, access and costs need to be taken into account prior to initiating any management strategy. the concept of tpd in adult dysphagia is complex, but this study made an attempt to understand it by linking it to the icf framework, as done in previous studies on the topic. the domains of caregivers that are affected are activities, participation and environmental and personal factors. how tpd impacts on the quality of life of the caregivers is also something that needs further investigation. the management of dysphagia needs to be family centred, and the impact of the caregiver’s role needs to be considered by all team members when determining long-term management plans. this study started to shed some light on this important topic and can serve as a springboard for future research and to start transforming current practices to ensure that slps become more contextually responsive. acknowledgements the authors would like to thank the sites for allowing them access to conduct this research. the authors would also like to thank the participants and their caregivers for sharing their stories with them. competing interests the authors have declared that no competing interests exist. authors’ contributions k.a.c.: conceptualisation of the study, sole supervisor of the project and article write up. m.s.: honours research project, data collection and analysis. ethical consideration ethical approval was obtained from the university of the witwatersrand human research ethics committee prior to the commencement of the study under the code m181107. approval was also obtained from each site and written consent was obtained from each participant prior to data collection. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references best, c., & hitchings, h. 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(2002). towards a common language for functioning, disability and health. retrieved from https://www.who.int/classifications/icf/en/ abstract introduction method findings discussion conclusion acknowledgements references appendix 1 about the author(s) elanie a. van schalkwyk department of speech, language and hearing therapy, faculty of medicine and health, stellenbosch university, cape town, south africa berna gerber department of speech, language and hearing therapy, faculty of medicine and health, stellenbosch university, cape town, south africa citation van schalkwyk, e.a., & gerber, b. (2021). vulnerable mothers’ experience of feeding their preterm infant in neonatal care. south african journal of communication disorders, 68(1), a842. https://doi.org/10.4102/sajcd.v68i1.842 project research registration: project number: 6706 original research vulnerable mothers’ experience of feeding their preterm infant in neonatal care elanie a. van schalkwyk, berna gerber received: 22 may 2021; accepted: 10 aug. 2021; published: 28 oct. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: worldwide, preterm birth is a rising threat to maternal and child health. the universal challenges of being the mother of a preterm infant, combined with context-specific challenges such as poverty and poor linguistic and cultural representation, bring about risks for both mother and infant. this includes poor maternal mental health; poor mother–infant bonding and attachment and potential suboptimal developmental outcomes for the infant. objective: this article describes how afrikaans-speaking mothers living in poverty experienced feeding their preterm infants in neonatal care. method: the study implemented a cross-sectional, qualitative design. mothers of preterm infants (chronological ages between 3 and 6 months) were selected through a purposive sampling method and participated in individual semi-structured interviews. nine interviews were thematically analysed. the participants were a vulnerable group, about whom little research literature was available. results: feeding was perceived as a progressive task that worked towards the goal of discharge from the hospital. it was stressful because of various factors, but insufficient breastmilk supply was a significant contributor. the hospital setting was perceived as something that added to the participants’ anxiety surrounding feeding, but at the same time, it had the potential to decrease their anxiety. when the mother–infant dyad was able to breastfeed successfully, it made the participants feel like mothers at last after an extended period of anticipation. conclusion: feeding their preterm infant was a prominent experience for the mothers, especially whilst in neonatal care. increased feeding support is required from the healthcare team providing neonatal care in order to optimally use the neonatal period. keywords: vulnerable mothers; experiences; feeding; breastfeeding; preterm infants; neonatal care. introduction an increasing number of infants in south africa are at risk of neurodevelopmental delays because of the high frequency of preterm birth (south african speech-language-hearing association [saslha], 2017). south africa presents various risk factors for preterm birth that also complicate caring for a preterm infant. these factors include the high burden of disease, resource constraints in various respects and on many levels and inequalities relating to social determinants of health (dawes, biersteker, & irvine, 2008). as modern technology and advances in neonatal care are ensuring the survival of preterm infants at younger gestational ages and with lower birthweights (world health organisation [who], 2017a), lowand middle-income countries are experiencing increased neonatal morbidity rates and challenges to already overburdened and poorly resourced health services (pusdekar et al., 2020). being the mother of a preterm infant is universally described as a challenging and stressful experience. preterm infants are at risk of various medical, neurological and developmental complications that may influence current and future feeding skills (crapnell et al., 2013). as a result of neurological, sensory and physiological immaturity, preterm infants often display neurobehavioral dysfunction and consequently, the achievement of skills fundamental for successful oral feeding is delayed or disordered (brown et al., 2009). these skills include: state regulation, motor organisation, rhythmical sucking and coordinating a suck-swallow-breath pattern (crapnell et al., 2013). the potential comorbidities of preterm babies may have physical, psychological, social and financial implications for their mothers in the short and/or long term (petrou, 2005). the mother of a preterm infant has a unique early parenting experience in caring for her infant (pascoe, bissessur, & mayers, 2016), which may potentially alter the nature of mother–infant interactions in the early months of life. mothers of preterm infants with low socio-economic status (ses) and from linguistic minority groups face additional challenges that make them especially vulnerable and may negatively influence their experience of caring for their preterm infant. in addition to the trials associated with poverty, they may have limited linguistic and cultural representation within the health system. in south africa, mothers with a low ses from all of the 11 indigenous south african languages, including afrikaans, are in such a situation. the focus of the current study was on poor afrikaans-speaking mothers of preterm infants. firstly, living in poverty means that they experience high levels of psychosocial stress in combination with limited access to social and economic resources (crapnell et al., 2013). secondly, despite afrikaans being one of south africa’s 11 indigenous languages, afrikaans mothers constitute a group that is poorly represented in a health system where english is the language of choice of many healthcare professionals (hcps) (penn & watermeyer, 2018). the universal challenges of being a mother of a preterm infant, combined with the context-specific challenges of belonging to an underserved and socially marginalised group, bring about risks for both mother and infant. this includes: poor maternal mental health, poor mother–infant bonding and attachment and potential sub-optimal feeding and communication development. existing early communication intervention (eci) guidelines emphasise the involvement of the mother (primary caregiver) in the intervention process (craig et al., 2015) as mothers’ perceptions and experiences of caring for their infant have a strong influence on the future communication and feeding development of the child. the eci services provided to vulnerable populations, such as afrikaans mothers of preterm infants with low ses, should not only be sensitive but also accommodate their unique perceptions and experiences. such an approach will allow speech-language therapists to utilise the neonatal period optimally, to support mothers in stimulating communication and feeding development and to prevent or timeously identify communication and feeding delays or disorders (saslha, 2017). not much research, either local or international, has been published on the experiences of mothers from linguistic minority groups who live in poverty in caring for a preterm infant. the poor representation of these vulnerable groups in the research literature and the consequent inadequate professional knowledge render them susceptible to healthcare that is neither contextually appropriate nor sensitive towards their unique realities. the aim of the study was to describe and explain how afrikaans mothers living in low socio-economic circumstances in the western cape province experience feeding their preterm infant in neonatal care. the goal was achieved by articulating the following research question: how do afrikaans mothers, living in low socio-economic circumstances in the western cape province, experience feeding their preterm infant in neonatal care? the answer to this question may allow south african speech-language therapists to determine more accurately ‘what works best for whom, when and how’ (saslha, 2017, p. 3) with regard to eci for at-risk neonates and mothers in our culturally and linguistically diverse context. method study design this study entailed a cross-sectional, qualitative design. a small group of participants were selected through a purposive sampling method, more specifically criterion sampling. they participated in individual in-depth interviews that were guided by a semi-structured discussion schedule. this study design was appropriate as it assisted in exploring and describing the ‘meaning for several individuals of their lived experiences of a concept or phenomenon’ (creswell & poth, 2016, p. 57). the initial phenomenon in question was maternal experiences of caring for a preterm infant in the first months of life. following data collection, the data-led decision was made to provide an in-depth account of a more specific phenomenon, namely maternal experiences of feeding their preterm infant whilst in neonatal care. this decision will be expanded upon in the data collection and analysis sections. study sampling strategy the sample frame entailed all afrikaans mothers of preterm infants with ages ranging from 3 to 6 months (chronological age) who attended follow-up appointments at a high-risk clinic at a paediatrics out-patient department of a public tertiary hospital. purposive sampling, more specifically criterion sampling, was used to select participants. the inclusion criteria stipulated that participants must be afrikaans first-language speakers, older than 18 years, have low ses and be the mother of a preterm infant. infant-specific criteria included that the infant must be born before 37 weeks (quinn et al., 2016), born with birthweight of less than 2500 g (quinn et al., 2016), aged 3–6 months (chronological age) at the time of data collection, medically stable at the time of data collection and with no diagnosed biological, physical, sensory, congenital, or neurological disorders at the time of data collection. low ses was determined by limited educational attainment (no post-matriculation degree of diploma) and financial income (bracket h0 – h1 on the patient income scale that represents household with a total annual income of r0 – r100 000). prematurity was classified as extremely preterm (< 28 weeks), very preterm (28 – < 32 weeks) and moderate or late preterm (32 – < 37 weeks) (quinn et al., 2016). birthweight was classified as low birthweight (< 2500 g), very low birthweight (< 1500 g) and extremely low birthweight (< 1000 g) (quinn et al., 2016). in addition to the inclusion criteria, specified characteristics pertaining to the participants and their infants were considered in order to ensure variation within the sample (as listed in table 1). this variation aimed to increase the transferability of the study. the characteristics included: the participant’s age, number of children, highest education level attained, employment status and relationship status. the infant’s degree of prematurity and birthweight were further considered. variation in the sample ensured that the participants were heterogeneous and provided diverse experiences of the phenomenon being explored (malterud, siersma, & guassora, 2016). table 1: characteristics of the nine study participants. mothers who met the inclusion criteria were identified by researcher one and the paediatrician responsible for the clinic and invited to participate in the study following their paediatric appointment. this process continued until data saturation was reached after 11 interviews conducted over 5 days. the selected sample was reviewed by the researcher for a second time to confirm that all the inclusion criteria were met and to ensure that the interviews were of sufficient quality for inclusion in the study. the final sample consisted of nine (n = 9) participants. the heterogeneous nature of the selected sample (as listed in table 1), the detail-rich narratives collected during the interviews, and the decision to use in-depth analysis strategies to provide a detailed account of this phenomenon, assisted in establishing when data saturation occurred (malterud et al., 2016). study context (population and setting) the study population entailed afrikaans-speaking mothers of preterm infants with low ses. this may be viewed as a vulnerable group that is at risk for poor healthcare outcomes with regard to three attributes (clark & preto, 2018), namely being the mother of a preterm infant (health attribute), low ses (economic attribute) and belonging to a linguistic minority group (cultural attribute). all participants attended a medical follow-up appointment at a high-risk clinic with their infant at the same public tertiary hospital. during their infant’s admission, all mothers lodged in with their infants and the infants received neonatal care from the same public tertiary hospital. mothers are thus considered to have had similar in-patient care, follow-up care, and support provided from hcps. the hospital adhered to the baby-friendly hospital initiative as outlined by the who and the united nations international children’s emergency fund (who, 2017b). this initiative promotes the provision of breastfeeding support to mothers, the use of expressed breastmilk whilst the infant is unable to breastfeed (as opposed to formula milk), exclusive breastfeeding (as opposed to bottle feeding); and rooming in of mothers and infants (who, 2017b ). whilst in neonatal care, mothers were provided with galactagogues as the need arose. the healthcare team typically included medical doctors, nursing staff and dieticians. all mothers in neonatal care did not receive routine feeding and/or swallowing intervention and support from speech-language therapists as these services were provided on a referral basis for infants with identified feeding difficulties. feeding support (whilst tube feeding, cup feeding and breastfeeding) was mostly the responsibility of the nursing staff. breast pumps were not available and mothers had to hand express breastmilk, except if they had personal access to a breast pump. the hospital is a large facility that employs hcps from various cultural and linguistic backgrounds although services are mostly delivered in english. culture and language differences were thus likely to exist between some of the participants and the hcps. data collection eleven interviews were conducted in a private consulting room near the clinic using a semi-structured discussion schedule. interviews were conducted 1–3 months after the mother–infant dyad was discharged from the hospital. an initial pilot study was completed with three participants to ensure the credibility of the discussion schedule and the interview process. following review and discussion of the pilot study between the authors and an external expert in the field, no changes were made to the discussion schedule and minimal changes were recommended for the interview process. two of the interviews from the pilot study were deemed suitable and formed part of the study data. a total of nine interviews were included in the study. the discussion schedule (see appendix 1) entailed a revised version of a semi-structured questionnaire compiled by buys (2020) who completed a similar study amongst isixhosa speaking mothers. buys’s (2020) questionnaire was translated into afrikaans, and the content was reviewed by the authors to facilitate an open-ended discussion. the discussion schedule explored seven key areas related to caring for a preterm infant, namely maternal perceptions regarding prematurity, caregiving, feeding, mother–infant interaction, maternal responsibilities, additional role-players in their infant’s care and development and information needs. the open-ended nature of the discussion schedule allowed participants to guide the discussion and aimed to increase the confirmability of the tool (ali & yusof, 2012). the participants spontaneously gravitated towards the topic of feeding their preterm infant whilst hospitalised. it was clear that feeding their preterm infant in neonatal care was a prominent experience and one that participants could recall vividly. the interviews were conducted in afrikaans, had a duration of approximately 45 min and were voice recorded. author one conducted the interviews and is an afrikaans first-language speaker. the voice recordings were transcribed verbatim by author one. to ensure dependability and confirmability of the transcripts, 22% of the data were externally audited by a speech-language pathology doctoral student. to ensure confirmability of the translation of the participants’ quotations from afrikaans to english, it was reviewed using a forward and back translation procedure involving author one and an external language editor. data analysis thematic analysis, as described by braun and clarke (2006), was used to analyse the data. analysis was aimed at providing a detailed account of one particular aspect (maternal experiences of feeding their preterm infant whilst in neonatal care) as opposed to an overview of the entire data set (maternal experiences of caring for their preterm infant in the early months of life). this decision aimed to increase the study’s credibility and confirmability as it became clear during data collection that certain aspects (feeding) and periods (neonatal care) were prominent experiences to the mothers of preterm infants. an inductive approach to thematic analysis was used by creating semantic codes and themes that focused on the explicit meaning of the collected data. author one familiarised herself with the data by conducting the interviews, transcribing the audio recordings, reading the transcripts repeatedly and documenting early analytical remarks. the transcripts were coded in an iterative fashion, and data extracts were grouped into six main themes. the computer-assisted qualitative data analysis software (caqdas) programme atlas.ti 8 windows was used to assist with managing and organising codes and themes. refined codes and themes were assigned following various reviews and discussions between the authors to increase the credibility of the study (ali & yusof, 2012). findings six themes (outlined in table 2) arose during data analysis and provide a detailed account of the participants’ experiences of feeding their preterm infants whilst in neonatal care. participants provided vivid descriptions of their experiences of feeding their preterm infants, especially concerning the period during which the infant was hospitalised. the length of an infant’s hospital stay differed according to infant-specific factors such as medical stability, gestational age and birthweight. the time infants spent in hospital ranged from 3 to 11 weeks. the term ‘feeding’ includes all aspects related to the task such as mothers having to express breastmilk, the environment in which the feeding task occurred, the various feeding methods the infant progressed through and the infant’s ability to participate in feeding tasks (sucking and swallowing skills). table 2: themes describing maternal experiences of feeding a preterm infant whilst hospitalised. feeding was a progressive task aimed at ‘going home’ ‘it was very stressful. very, very, very. because i knew the breast is what’s going to let her go home. and her weight was already 1.8 [kilograms] and then she still couldn’t go [home] because she couldn’t breast [breastfeed].’ (participant 1, grade 11, cleaner) ‘to me it just felt like i was never going to get there [referring to 1.8 kilograms] and it’s still far because they said he must be this certain weight before we can move [go home].’ (participant 8, grade 12, carer at retirement home) ‘in the beginning, the infant is not with you. he is in the incubator. for now, it must be like this because he is still too small. and then you start to feed, they [nursing staff] teach you how to feed the baby. cup feeding and after cup feeding, you go to another ward where your baby is with you. and from there you go home.’ (participant 9, grade 7, farmworker) feeding the infant was experienced as a constantly changing task that was closely tied to the goal of discharge. mothers described the following as prerequisites for attaining this goal: successful breastfeeding, and steady weight gain with a target weight of 1.8 kg or more. the mothers’ accounts reflected the feeding-related discharge criteria of the hospital namely that the infant should be able to take adequate oral feeds (preferably via breastfeeding) with no safety concerns such as cyanosis, apnoea or vomiting and demonstrate an upward weight gain trend. this may be an indication that these criteria were communicated clearly to the participants. the task itself was perceived to change with regard to two aspects, namely the method of feeding and the feeding volume. firstly, the method of feeding the infant entailed ‘something new’ on a frequent basis. mothers described their infant’s feeding journey as starting with tube feeding (orogastric or nasogastric tubes) whilst the infant was in the incubator. following this, infants progressed to cup feeding and occasionally syringe feeding. lastly, the mother–infant dyad was challenged to progress to breastfeeding. breastfeeding was associated with moving out of the high care ward and perceived as a big step towards discharge. these changes contributed to maternal stress, as the mother was repeatedly expected to rebuild her feeding skill and confidence using a new method. secondly, the feeding volumes always needed to be ‘more’. the millilitres of milk the infant was supposed to consume during a feed were perceived to go ‘higher and higher every day’. thirdly, the infant was expected to gain weight steadily and this was monitored and documented daily. this monitoring process often resulted in feelings of hopelessness, and the infant’s weight was perceived as a numerical indicator of the infant’s progress towards the eventual goal of discharge. feeding was a significant contributor to stress ‘in the beginning’ ‘in the beginning when he was born, i struggled with the milk and that stressed me out a bit because they [hcps] told me that he must get my milk because it will help him quicker.’ (participant 8, grade 12, carer at retirement home) ‘so to me it was okay in the beginning, it was just sad that i couldn’t breastfeed him. i cried a lot because i couldn’t breastfeed him because i thought my child is never going to take the breast.’ (participant 6, grade 10, admin clerk) the task of feeding their infant was a significant cause of stress for the participants and was especially prominent ‘in the beginning’ of the infant’s life. various factors related to feeding were described as contributors to the mothers’ anxiety, including concerns regarding poor weight gain and growth of the infant, messing during feeding times, insufficient breastmilk supply and difficulty with the task of breastfeeding itself. the progressive nature of the feeding task contributed significantly to maternal anxiety. mothers were striving towards the goal of discharge from the hospital and therefore any factor that interfered with the attainment of this goal added to maternal stress. breastmilk was ‘the biggest thing’ in hospital ‘that was such a big stress to me, the milk. and then they move it up, they move it up up up – at the end, it is so much milk that i can’t even almost give that total.’ (participant 7, grade 10, unemployed) ‘and they were just like you must express milk and i was like i can’t. even that where you must wake up every two hours to express, i had to do that even though i didn’t have milk and nothing comes!’ (participant 4, grade 12, unemployed) the mothers experienced their breastmilk supply as one of the biggest problems during the hospital stay. they preferred their infants to receive ‘my milk’ as they believed this would help their infant the ‘quickest’ by facilitating steady weight gain and, subsequently, an expedited discharge. firstly, mothers were concerned that they would not be able to meet the prescribed millilitres as the infant’s feeding volumes increased on a frequent basis. secondly, the process of expressing milk was hard for mothers as it was often novel, painful or fruitless. thirdly, mothers felt overwhelmingly bombarded with the message of expressing breastmilk and perceived nursing staff to ‘push’ and ‘force’ them to express their milk even though it was clear that they were struggling with lactation. it appears that breastmilk was perceived as an elixir in hospital. having a good supply made you rich whilst a limited supply left you poor and hopeless. the mothers of extremely or very preterm infants did feel hopeless during most of their hospital stay. breastfeeding was ‘amazing’ ‘the saturday when the sister told me i must breastfeed him it was such an amazing feeling that he was on my breasts… i can’t explain it to anyone that amazing feeling, it’s like butterflies that i felt inside of me when he drank from me the first time.’ (participant 4, grade 12, unemployed) ‘it made me feel good because now it feels to me like okay, now i am a mother at last (laughs). i am now a mother because he drinks from me.’ (participant 8, grade 12, carer at retirement home) mothers experienced breastfeeding their infant as an exceptionally positive experience which they thoroughly enjoyed. breastfeeding was described as advantageous to both mother and child. physiological advantages described by the mothers include increased breastmilk production, weight gain for the infant, a healthy infant, and lastly discharge from hospital. interaction-attachment advantages described include increased bonding, proximity and communication between the mother and the infant. after having had to rely on alternative methods to feed their infants, such as orogastric and nasogastric tube feeding, syringe feeding, and cup feeding, breastfeeding made the mothers feel like mothers for the first time. the hospital setting was both stressful and helpful ‘it was actually harder in hospital than it was at home… i think it’s because the hospital is very controlled like you must feed at this time, you must change the nappy when you feed her, you must do it… but at home, it’s more like they give signals when the nappy is wet or… like she will cry when she’s hungry.’ (participant 4, grade 12, unemployed) ‘if you must stay, you must stay – it is your child’s health. you can’t be against it.’ (participant 9, grade 7, farmworker) ‘it’s just sometimes the nurses were a little… when we feed. they were actually strict.’ (participant 1, grade 11, cleaner) the hospital setting was perceived as novel, controlled, and anxiety-provoking although mothers were willing to endure this context to ensure their infants received the intervention they required. the support offered by the hcps on how to complete caregiving tasks was valuable and appreciated although nursing staff were occasionally perceived to be impatient and strict. feeding became ‘easier’ as mother and infant ‘got used to it’ ‘i learned everything here. i didn’t know anything about premature. i learned everything day after day… observed the nurses, listened to what the doctors are talking, and then i also started watching her and this is how i learned.’ (participant 1, grade 11, cleaner) ‘their insides are almost like not fully developed… like where a full nine-month baby when you give birth, they give your baby to you and you put baby on the breast and the baby clicks immediately i must drink now and so on. the difference is with them that they can’t just drink when they come out, they are like they don’t know that they must drink.’ (participant 7, grade 10, unemployed) ‘she messed for the first few days – spit it [milk] out, didn’t really know how to swallow it. and then afterwards it got easier for me.’ (participant 5, grade 12, unemployed) the mothers felt that they became more comfortable with feeding their infants as they acquired the following skills: recognising the infant’s hunger cues, identifying the infant’s specific preferences, handling the infant and using feeding equipment. they described three methods whereby they learned these skills, namely observation, direct instructions from the hcps and self-guidance. with regard to their infants’ learning, they experienced that ‘in the beginning’ their infants didn’t immediately ‘click’ that they must suck and did not know how to suck because they were not as fully developed as a full-term infant. according to the mothers, their infants ‘got used to it’ with exposure and practice, and learned how to feed. discussion the participants experienced the task of feeding their infant as a significant stressor related to caring for their infants, especially whilst the infant was hospitalised. this finding frequently appears in the research literature (buys, 2020; ericson & palmér, 2019; flacking, ewald, nyqvist, & starrin, 2006; leonard & mayers, 2008; swift & scholten, 2009), and various factors are thought to contribute to feeding being a challenging task (van schalkwyk, gay, miller, matthee, & gerber, 2020). the most prominent contributor in this study was the strong association between successful oral feeding and discharge from the hospital. participants described feeding as a progressive task that worked towards one goal, namely ‘going home’. the mothers formulated a clear recipe for discharge from the hospital: present a breastfeeding infant with a weight of at least 1.8 kg. this strong association between successful oral feeding and discharge from the hospital is perhaps a major cause of the anxiety surrounding feeding. successful feeding results in discharge from the hospital, whilst difficulty with feeding results in an extended hospital stay. an important question to ask is why the mothers associated successful oral feeding so closely with discharge from the hospital. according to lubbe (2018), it is because of the volume-driven approach to feeding as well as the intense monitoring of oral feeding within the neonatal hospital context (thoyre, 2001). the participants in the current study felt bombarded with the message that they must express breastmilk and supply specified amounts of breastmilk for their infant as breastmilk is ‘the thing that is going to send us home the quickest’. the big focus and daily monitoring of the infant’s weight gain gave the participants a perception of the infant’s weight as a numerical measure of their progress towards discharge and had a strong influence on maternal emotions. the way that hcps package and convey messages regarding feeding to the mothers of preterm infants should be carefully considered. firstly, hcps need to adjust the packaging of their message to accommodate the hardships that vulnerable mothers of preterm infants encounter. the following hardships were highlighted in the current study and are also supported by literature: high stress levels (van schalkwyk et al., 2020), difficulty with initiating and maintaining lactation (ericson & palmér, 2019; lee & gould, 2009), reduced feeding abilities of the infant (crapnell et al., 2013), limited reciprocal interaction with their infant (pascoe et al., 2016) and being in an unfamiliar hospital environment for prolonged periods with limited support (swift & scholten, 2009). an important recommendation for health professions education is thus to focus on developing awareness of and sensitivity towards the hardships vulnerable mother–infant dyads from diverse backgrounds experience and skills in addressing them (penn, 2014). secondly, hcps should find creative ways to motivate mothers to use expressed breastmilk and to breastfeed their infants as prescribed by the who (2020). perhaps it is necessary to ask whether breastmilk is being promoted by focusing on all the advantages it entails for mother and infant or whether it is simply promoted as ‘the thing that is going to send us home the quickest’ and that may result in an expedited discharge. promoting the use of breastmilk and breastfeeding by focusing on the inherent advantages versus focusing on an expedited discharge may produce different long-term outcomes in adhering to these practices. the first option may increase internal motivation to follow the prescribed health behaviours. the second option runs the risk of producing an intense and likely unsustainable short-term motivation to use breastmilk and breastfeed as a means to an end (discharge from hospital). it is recommended that future research efforts explore ways in which the hcps can encourage mothers of preterm infants to use breastmilk or to breastfeed, in a way that is sensitive towards their realities, and ensures their long-term commitment to these practices. this recommendation becomes especially relevant if one considers that all study participants converted to bottle and formula feeding once they returned home. some of the participants explained that this shift was because of their return to work, whilst others stated that this was either the infant’s or their own preference. this finding corresponds with the findings of buys (2020) who conducted a similar study amongst isixhosa speaking mothers. the findings of this study have clinical implications for the way in which hcps involved in neonatal care are currently providing feeding support to mothers of preterm infants. firstly, the situation requires increased awareness and acknowledgement of the challenges the mothers of preterm infants from low socio-economic settings face. secondly, hcps should increase their focus on mothers as equally important receivers of intervention whilst the mother–infant dyad is hospitalised. thirdly, creative ways should be considered to provide emotional support and protect the emotional wellbeing of these mothers whilst their infants are hospitalised. potential support methods include in-hospital support groups, a system to flag and monitor mothers at risk of mental illness and access to mental health services if indicated. fourthly, bonding and the attainment of a maternal identity should be encouraged during all stages of the preterm infant’s hospital stay. this can be achieved by actively including mothers in all caregiving tasks, especially feeding, from the start of the infant’s journey. this can further be achieved by encouraging kangaroo mother care (kmc), as skin-to-skin contact is an evidence-based nursing intervention that offers benefits to preterm infants, their mothers and also the health system (pattinson, bergh, malan, & prinsloo, 2006). these benefits include the promotion of bonding, maternal sensitivity towards the infant’s cues, lactation and breastfeeding (kritzinger & van rooyen, 2014). lastly, whilst in neonatal care, hcps have the opportunity and obligation to counsel mothers regarding prematurity to ensure they comprehend their infant’s behaviour and needs during the maturation process. this should include discussions surrounding developmental stages, stress signs, communication cues, appropriate sensory stimulation and feeding support (pike, kritzinger, & krüger, 2017). a further necessary clinical recommendation is for the mothers of preterm infants to have increased access to feeding and swallowing intervention from speech-language therapists. preterm infants are known to have delays and/or difficulties in the establishment of oral feeding (crapnell et al., 2013), and speech-language therapists may provide effective intervention to the mother–infant dyad to facilitate the gradual progression to safe and adequate oral feeding. additionally, access to lactation consultants might be of further assistance to mothers as the findings highlighted that initiating and maintaining lactation was a significant challenge to the participants. it is important to mention that linguistic and cultural differences between the participants and the hcps were not frequently mentioned or vividly described by the participants. one participant explained that whilst she was in hospital, she was dependent on her husband or other mothers in the ward to convey hcps’ messages regarding the infant to her as she has limited comprehension of complex english conversations. it can be deduced that the participant had two options with regard to receiving counselling about her preterm infant’s condition, namely to wait until her husband was present (delaying receiving much anticipated information); or to ask a stranger to assist (potentially sharing sensitive and private information). this was the only instance where a participant mentioned language or culture as a barrier to receiving information and health care, albeit a powerful example of receiving ‘monolingual health services in a multilingual society’ (elkington & talbon, 2016). linguistic and cultural differences may be more prominent between hcps and participants who speak other indigenous languages (besides afrikaans). limitations of the study firstly, the infants’ birthweights were specified as ‘under 2500 g’ in the pilot study, whilst the exact birthweight was documented in the main study. the researcher is therefore able to provide only a limited description (gestational age only) of the preterm infants included in the pilot study and a more detailed description (gestational age and birth weight) of the preterm infants is included in the main study. secondly, the ses of the participants was determined by their financial income and educational attainment. information about participants’ housing was not collected and may have provided additional insight into the mothers’ economic situation. conclusion mothers of preterm infants with low ses and from linguistic minority groups, such as poor afrikaans-speaking mothers, are a vulnerable group with a challenging early parenting experience in caring for their infants. the findings of the study highlight some of the difficulties this population face whilst having to care, and specifically feed, their preterm infants during the hospitalisation period. this includes: high stress levels, difficulty with initiating and maintaining lactation, reduced feeding abilities of their infants, limited reciprocal interaction with their infants and being in an unfamiliar hospital environment for prolonged periods with limited support. the hcps working with preterm mother–infant dyads should be aware of and sensitive towards mothers’ realities, and accommodate these realities in their treatment programme. firstly, increased feeding support from hcps is required, and especially increased access to feeding intervention provided by speech-language therapists and lactation consultants. secondly, hcps involved in neonatal care should seek effective methods to promote the prescribed feeding practices. these methods should aim to develop internal motivation in the members of this vulnerable group to follow the prescribed feeding practices, whilst still accommodating the hardships they encounter. this will allow hcps to utilise the neonatal period optimally and to improve maternal wellbeing, mother–infant bonding and attachment, and the developmental outcomes of the infant. acknowledgements the researchers are grateful to all the stakeholders who made this study possible with their participation. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions e.a.v.s and b.g. conceptualised the study together. e.a.v.s. collected and analysed the data, and drafted the manuscript. b.g. supervised the process and critically reviewed the draft manuscript. ethical considerations ethical approval was obtained from the health research ethics committee of stellenbosch university (project id 6707, reference number s18/04068), the national health research committee and the national health research department. informed consent was obtained from all the participants in their language of choice. the participants’ true identities were protected at all times. transcribed interviews were stored as password protected microsoft word documents on a secure flash drive. funding information the authors received no financial support for the research, authorship and/or publication of this article. data availability the data that support the findings of this study are available from the corresponding author, e.a.v.s., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors, and the publishers. references ali, a.m., & yusof, h. 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(2020). infant and young child feeding. retrieved from https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding appendix 1 discussion schedule introduction question: general experience tell me more about your experience of being the mother of a preterm infant? section 1: prematurity your baby was born prematurely. what does this mean to you? prompt: reason/differences to term infants section 2: caregiving tell me more about your experience of having and caring for a preterm infant? prompt: initially/currently/adjustments required section 3: communication (interaction) tell me more about your interaction (talking, playing, exchanging messages) with your infant? prompt: mother’s attempts (when and how)/infant’s response/infant’s attempts (when and how)/mother’s response/differences to term infants/challenges (makes it hard to interact)/facilitators (makes it easy to interact) section 4: feeding tell me more about the experience of feeding your infant? prompt: method/experience: good, bad, easy, hard/differences to term baby section 5: maternal role/responsibilities you are the mother of this infant. what does this role mean to you? prompt: responsibilities (what must you do for the baby)/responsibilities that only you can fulfil section 6: additional stakeholders tell me more about the other important people in this infant’s life? prompt: responsibilities towards infant/responsibilities towards mother section 7: information needs if you think about the past couple of months since your infant’s birth – tell me more about the type of support or information that would have made the process easier for you? prompt: format of information/agent/current information sources (where, who, how) abstract introduction methodology results and discussion conclusion acknowledgements references about the author(s) katijah khoza-shangase department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa nomfundo monroe department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa ben sebothoma department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation khoza-shangase, k., monroe, n., & sebothoma, b. (2022). conducting clinical research in the era of the covid-19 pandemic: challenges and lessons for speech-language pathology and audiology research. south african journal of communication disorders, 69(2), a898. https://doi.org/10.4102/sajcd.v69i2.898 original research conducting clinical research in the era of the covid-19 pandemic: challenges and lessons for speech-language pathology and audiology research katijah khoza-shangase, nomfundo monroe, ben sebothoma received: 26 jan. 2022; accepted: 27 mar. 2022; published: 18 july 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the novel coronavirus disease 2019 (covid-19) presented new and unanticipated challenges to the academic training and performance of clinical research at undergraduate and postgraduate levels of training. this highlighted the need for reimagining research designs and methods to ensure continued generation of knowledge – a core function of a research-intensive university. whilst adhering to government regulations geared towards protecting both the research participants and researchers, innovative research methods are required. objective: the purpose of this scoping review is to explore published evidence on innovative clinical research methods and processes employed during covid-19 and to document challenges encountered and lessons that the fields of speech-language pathology and audiology can learn. methods: electronic bibliographic databases including science direct, pubmed, scopus, medline, proquest were searched to identify peer-reviewed publications, published in english, between 2019 and 2021, related to innovative clinical research methods and processes applied where in-person contact is regulated. results: significant challenges with conducting research in the covid-19 era were identified, with important lessons learned and numerous opportunities that have relevance for this pandemic era and beyond. these findings are presented under 10 themes that emerged that highlight important considerations for research methods and processes during a pandemic and beyond. the findings of this study also raise implications for telehealth from which lowand middle-income countries (lmics), where resource challenges exist, can benefit. conclusion: challenges and opportunities identified in this review have relevance for the field of speech-language pathology and audiology as far as current and future (beyond covid-19) clinical research planning is concerned. keywords: audiology; challenges; clinical research; covid-19; ethical considerations; lessons; speech-language pathology; south africa. introduction coronavirus disease 2019 (covid-19), originally recorded in wuhan, china in 2019, has become a global pandemic that has significantly impacted how the world lives and functions (perez, perez, & roman, 2020), as declared by the world health organization (who) on the 11th march 2020. within academia, the pandemic has impacted how teaching and learning and research activities are conducted, with challenges caused by the measures put in place to curb the spread of the virus influencing all decisions made (khoza-shangase, moroe, & neille, 2021; perez et al., 2020; sebothoma, khoza-shangase, masege, & mol, 2021). as far as research is concerned, significant challenges have been encountered in terms of the planning of clinical research designs, sourcing of funding for research as research priorities change, as well as significant questions around ethical clearance of studies conducted during the covid-19 pandemic. questions around ethical clearance have had ethical committees and institutional research review boards challenged by their mandate to facilitate ethical research whilst adhering to health and safety regulations implemented to protect and safeguard the safety of research participants and researchers (beach et al., 2020; lumeng et al., 2020; perez et al., 2020; sebothoma et al., 2021; wieten, burgart, & cho, 2020). weiner, balasubramaniam, shah and javier (2020) believed that the impact that the covid-19 pandemic had on general research and on research specific to the pandemic raises numerous important factors: (1) the significance of research, (2) challenges of research, especially during public health emergencies (phes) and (3) resources and opportunities towards improving research to become more efficient and cost effective. furthermore, bailey, black and swanton (2020) argued that the covid-19 pandemic provided an opportunity and renewed momentum for innovative approaches to research within a restrictive environment. evidence indicates that the pandemic has become a significant threat in lowand middle-income countries (lmics), with the african continent, not being spared from the negative impact (lone & ahmad, 2020). although africa was the last continent to be affected by covid-19, the world economic forum (2020) predicted that, as the most vulnerable continent, covid-19 will have major impacts in africa. as of 26/01/2022, the who reports that the 47 african countries are affected, with 10 633 981 cumulative cases and 236 399 deaths because of covid-19 – with south africa contributing the most to these numbers, with 3 585 888 confirmed cases and 94 625 deaths (who, 2022). with the new covid-19 variants, including the current omicron, that are continuously creating challenges for the healthcare, educational and economic sectors, innovative and proactive models of survival and productivity are required. this article focuses on conducting clinical research, which is one of the areas requiring deliberation. the large number of immunocompromised populations within a poor healthcare system, in the presence of poor social determinants of health and high burdens of diseases, place the african continent at a greater risk of severe covid-19 pandemic impact (lone & ahmad, 2020; the world economic forum, 2020). the world economic forum (2020) argued that these conditions could make controlling the pandemic and managing its consequences significantly challenging. with the general lack of access to vaccines coupled with vaccine hesitancy, as well as the absence of a treatment drug currently available for covid-19, application of non-pharmaceutical measures to contain the spread of the virus remains the only measure available. these measures include national lockdowns and travel restrictions, hand washing and sanitisation, social distancing, isolation and quarantine, as well as community containment. these measures – have a serious impact on teaching, learning, as well as the performance of research (khoza-shangase et al., 2021, maluleke & khoza-shangase submitted). soon after the national lockdowns were instituted, higher education programmes and their ethical committees and institutional research review boards had to make decisions about what and how research should be conducted as part of the required knowledge generation of higher education institutions. this was also done as part of collating evidence around the covid-19 pandemic as a disease. perez et al. (2020) highlighted that, as far as research is concerned, covid-19 has also inspired new studies that are aimed at learning about the virus and its effects, described and defined the affected patient populations and established the efficacy of available interventions (vaccines and treatment drugs). this necessitated a rapid response to newly submitted research proposals, where participant–researcher interactions had to be considered and where general research approaches had to be revised to suit the new normal conditions with the pandemic. in the united states, perez et al. (2020) reported that unexpected divergences to standard protocols became unescapable because of the inability of participants to attend research sites for data collection following lockdowns, travel restrictions, quarantine requirements, etc.. furthermore, some research studies were postponed to adhere to social distancing and to minimise costs linked to personal protection equipment (ppe), with research fellows and general research staff ordered to ‘work from home’ (remote work). the travel restrictions also impacted the access to research tools that are most often imported, particularly in lmics. lumeng et al. (2020) further reported on how covid-19 has had a significant effect on the academic research enterprise in the united states, with numerous research institutions shutting down their research laboratories, adjourning fieldwork and stopping a number of human research initiatives. this led to the cessation of over 80% of all on-site research activity – with research in the basic and natural sciences gradually resuming activities over the course of a few months (lumeng et al., 2020). the research activities that resumed are those that were deemed to present relatively low risk for virus transmission, under strict adherence to non-pharmaceutical covid-19 intervention measures (i.e. social distancing). within the south african context, the speech-language pathology and audiology professions, as healthcare professionals, were right in the middle of the previously outlined challenges as well, and thus innovative approaches were required to continue to conduct research under uncertain times, with an indefinite time period. thus, emergency clinical research plans and policies had to be formulated, alongside emergency online teaching methods. research plans that still allowed for research questions to be answered whilst adhering to ethical principles such as informed consent, data collection visits, assessments and evaluation procedures, health and safety monitoring, research design monitoring, etc., – whilst protecting researchers and participants in accordance with published and promulgated regulations of the country had to be implemented. as this was a novel situation with challenges and potential opportunities for learning for future innovative clinical research practice, the current scoping review aimed to explore published evidence on innovative clinical research methods employed during covid-19 to document challenges encountered and lessons that can be learned in the field of speech-language pathology and audiology. this study is also important because covid-19 may last longer and perhaps precede other pandemics (jayaweera et al., 2021). methodology levac, colquhoun and o’brien’s (2010) scoping review methodology was adopted for this study, with the research team consisting of three researchers working as researchers and research supervisors in speech-language pathology and audiology university training programmes in south africa. the researchers came to an agreement on a broad research question that was the focus of the scoping review and on the global study protocol, including specification of medical subject headings (mesh) terms, keywords, phrases and selection of databases to be searched. for this scoping review, the arksey and o’malley’s (2005) framework was adopted, thus following the five key phases of (1) identifying the research question, (2) isolating relevant publications, (3) study selection, (4) charting the data and (5) collating, summarising and reporting the results. research question the broad question that guided the current scoping review was, ‘what has been published about conducting clinical research during the covid-19 pandemic?’ this line of enquiry was directed by the challenges presented by covid-19 in conducting and supervising research in speech-language pathology and audiology during a time where non-pharmaceutical covid-19 interventions negatively impacted standard practice and where innovative methods had to be explored and re-imagining future (post-covid) research practice was called for. the researchers aimed to perform this review to document both challenges and opportunities presented by covid-19 to research practice, in a context that is resource constrained where opportunities might expand access to participants and indigenous knowledge that might currently be inaccessible within the south african speech-language pathology and audiology professions. in addition, guided by daudt, van mossel and scott’s (2013) definition of the value of scoping reviews, the current scoping review also discovered the kinds and sources of evidence obtainable on the stated research question with findings raising implications for conducting clinical research during the covid-19 pandemic, involving all stages of research including research reviews, ethical clearance and so on. data sources and search strategy the initial search was carried out in december 2021 in the following five electronic databases: medline, proquest, pubmed, science direct and scopus. these five databases were chosen as they are deemed to be comprehensive and cover publications considering conducting clinical research during covid-19 by healthcare practitioners. the selected studies were restricted to those published in english from the year of the covid-19 advent, 2019 onwards, with a focus on clinical research. the search consisted of the following terms: conducting research, clinical research, covid-19, challenges, opportunities and lessons. resources a total of 15 citations, as depicted in table 1, were finally included in the analysis. an additional final search of the five listed bibliographic databases was performed in january 2022 to make sure that any new publications post the initial search were also identified. no new hits were identified. table 1: summary of studies included in the scoping review documenting clinical research challenges and opportunities during covid-19. table 1 (continues...): summary of studies included in the scoping review documenting clinical research challenges and opportunities during covid-19. table 1 (continues...): summary of studies included in the scoping review documenting clinical research challenges and opportunities during covid-19. table 1 (continues...): summary of studies included in the scoping review documenting clinical research challenges and opportunities during covid-19. citation management importation of all citations into the web-based bibliographic manager endnote was performed. all duplicate citations were removed through the endnote functionality of identifying duplicates. eligibility criteria a two-stage screening process to assess the applicability of publications identified in the search was adopted. the first stage comprised the inclusion of publications containing keywords and phrases and those broadly describing conducting clinical research during covid-19 to establish and describe the existing evidence base on the challenges and opportunities. the second stage involved excluding from analysis the publications that described research during covid-19 in areas other than healthcare. however, reference lists from these publications were checked to identify additional relevant publications. as a result of lack of access to translation resources, only publications in english were included in the review. title and abstract relevance screening following arksey and o’malley’s (2005) efficient time management methodology, the following steps were consecutively adhered to: (1) reviewing only the titles of the manuscripts was carried out as first-level inspection; (2) reviewing of abstracts only was performed as second-level inspection and lastly (3) full manuscripts were reviewed (figure 1). the researchers utilised the research team’s previously developed and pretested abstract relevance screening spreadsheet, which had a reviewer agreement (overall kappa) greater than 0.8 – representative of a high level of agreement (viera & garrett, 2005). the titles, abstracts and full manuscripts were independently screened by all three researchers, with the process developed to facilitate triangulation during the process of data selection and analysis. where research titles did not have abstracts, these were all included in the full article review stage of the data characterisation phase. regular online communication between the researchers was maintained during the entire process to make sure that conflicts were resolved, with one author (bs) making the final decision when disagreements were found. a high level of agreement was found with the overall kappa of 0.81. post the data analysis, two independent reviewers, a phd fellow and a postdoc fellow were recruited to review the manuscript with its accompanying supportive data to validate the findings reported in the scoping review. figure 1: the prisma flow diagram describing the process of study selection. data characterisation following the completion of the title and abstract inspection stage, all relevant citations for this scoping review on the conduction of clinical research during covid-19 were acquired for later full articles review. the researchers developed a spreadsheet where the relevance of each publication was confirmed and where details of the article such as author and publication year, article title, context, challenges, recommendations or opportunities and conclusions were documented. the characteristics of each publication were extracted by all three researchers. publications that did not meet the minimum eligibility criteria were then excluded at this phase. open engagement between the researchers, in line with levac et al.’s (2010) framework, for internal consistency and for resolution of prevailing conflicts between them occurred. furthermore, the researchers also ensured that the articles included were consistent with the stated research question and purpose following their independent reviews. data summary and synthesis data were recorded in a spreadsheet and imported into microsoft excel 2016 (microsoft corporation, redmond, wa, usa) for descriptive narrative analysis. initially, a total of 189 articles were identified for potential analysis in this study. during the collation and organisation of the studies part of the scoping review, 14 studies were deleted as they were duplicates; consequently, only 175 studies were then considered. of the 175 studies that remained, 151 were eliminated based on the titles and abstracts that were considered to not be in line with the focus of this study. subsequently, 24 studies were evaluated for eligibility and from these 9 were omitted as they failed to meet the inclusion criteria of this study. ultimately, 15 articles were included for analysis in this study (see figure 1). ethical considerations this scoping review followed all ethical standards for a study that does not involve direct contact with human or animal participants, including reflexivity and informed subjectivity, audience-appropriate transparency and purposefully informed selective inclusivity (suri, 2020). due to the nature of this study being based on published articles (secondary data), there was no need to seek ethical clearance. results and discussion as depicted in table 1, 15 publications were included in this review following them to meet the inclusion criteria revealed significant challenges with conducting research in the covid-19 era, with important lessons learned and numerous opportunities that have relevance for this pandemic era and beyond. these publications were diverse because they included opinion pieces and commentaries, research reviews, as well as various types of empirical studies, for example, single group prospective, cross-sectional, clinical trials, etc., all engaging the research question. findings are presented and discussed under 10 major themes that were identified: (1) the importance of having processes in place to balance research priority, speed and high quality; (2) approval processes can be efficient without compromising the research integrity process; (3) need for flexibility in research protocols and designs currently and beyond covid-19; (4) need to interrogate participant recruitment, participant participation and informed consent within the realm of information and communication technology (ict) currently and beyond covid-19; (5) remote working practices for data collection unavoidable but highly recommended; (6) intensified efficient use of ict for research processes; (7) research informatics and ict use and innovation (telehealth) has its problems; (8) challenges with actual interventions; (9) challenges with data capturing, analysis and storage and (10) challenges with research findings sharing or publishing. findings under these 10 themes suggest an emergence of new approaches to conducting research since the start of covid-19 pandemic that the south african speech-language pathology and audiology professions can learn from. the significance of developing a sustained research infrastructure and research workforce that can continue research under phe contexts with efficient training and funding for researchers who are integrated into the healthcare workforce across the scopes of practice was highlighted. importance of having processes in place to balance research priority, speed and high quality during the covid-19 pandemic, obvious and inevitable prioritisation of all efforts towards curbing the spread and managing covid-19 was witnessed globally and this included prioritisation of research on this virus (jayaweera et al., 2021; wyatt et al., 2021). despite the prioritisation of covid-19 and research on it, weiner et al. (2020) highlighted that during phes, such as the covid-19 pandemic, several measures need to be in place to ensure that time and cost efficiency challenges are prevented and mitigated. these measures include (1) consideration of crisis standards for research along with the ongoing phe, with accompanying appropriate phe training for researchers; (2) consideration of dedicated funded core workforce of phe multidisciplinary researchers in the research site organogram, as well as funded research infrastructure, to plan, consult, review, monitor, interpret studies, guide appropriate clinical use of data and inform decisions regarding effective use of resources for phe research – in the midst of other ongoing research that is not covid-19 related; measures should be taken to include sufficiently prepared and remunerated research support professionals in training and funding plans to enhance the management of clinical trials and support the date collection processes (e.g. data manager or study coordinator); (3) consideration of research funding and appropriate infrastructure, with concreted efforts towards securing external private party funding, where transparent and less bureaucratic procedures for allocating and managing funds for investigators are well documented; (4) consideration around processes to be adopted where reduction in available research delivery staff because of redeployment to frontline care has to be carried out, with centrally organised prioritising covid-19 research and redeploying research staff recommended and (5) collaboration amongst national policymakers, the pharmaceutical industry, opinion leaders, patient advocacy groups and regulatory agencies for appropriate resource allocation. all these measures, along with the rest of the recommendations put forward in this article, would ensure that there is an efficient balancing of research priority, speed and high quality. roshan das et al. (2021) recommended that in developing the study team, it is important to (1) decide on the constituency of the team members – and that this should be multidisciplinary in nature as this makes the team stronger, but small enough to facilitate quick and efficient resolution of conflicts. therefore, these authors suggest that for efficient but diverse functioning and for succession planning, two people be appointed per role; (2) constitute an external study advisory board consisting of field experts, with clearly defined roles and responsibilities, as well as agreed-upon manner of accreditation in future publications emanating from the research group; (3) have a patient and public involvement (ppi) that is argued to ensure that researchers keep the needs of the patient at the forefront – and it is advised that ppi must occur early in the study as this facilitates the acquisition of the requisite training and experience and furthermore, ppi can aid with publicity for the study thus improving recruitment and (4) have written agreements drawn up about the roles and responsibilities of each team member. approval processes can be efficient without compromising the research integrity process with all the challenges to research created by covid-19, weiner et al. (2020) and wyatt et al. (2021) stressed the importance of having a well-established coordinated review and study process to make the best use of constraint resources. hashem et al. (2020) cautioned that regardless of the sense of urgency caused by the pandemic, the same core ethical principles that govern research on human subjects are still expected to be adhered to. the current scoping review revealed that the covid-19 era exposed that for such review and study activation processes, including ethics or research approvals and institutional review bodies (irbs), it is feasible to considerably reduce the administrative, regulatory and time costs that are involved in coordinating, registering and conducting research, specifically trials (bailey et al., 2020; cagnazzo et al., 2021; hashem et al., 2020). evidence revealed that simplified approval processes are possible and these streamlined approval procedures that were devised for covid-19 trials can be continued beyond this pandemic era. cagnazzo et al. (2021) argued that these procedures can be employed in different types of clinical research, over and above clinical trials. approval processes can be efficient without compromising the research integrity process through irbs: (1) ensuring that the standard of ethical review is not relaxed; (2) ensuring that informed consent is always secured, despite the phe, whilst ensuring efficient use of resources; (3) considering issues such as strict exclusion and inclusion criteria, participant compensation and reimbursements, as well as well-defined risks of the study to vulnerable participants; (4) improving their expediency during phes and (5) strengthening online processes such as placing template case report forms and ethics forms online for online entry and modification and being continuously informed of research progress (bailey et al., 2020; cagnazzo et al., 2021; hashem et al., 2020; rania et al., 2021; roshan das et al., 2021; shamsuddin et al., 2021; walker et al., 2021; waterhouse et al., 2020). current and beyond covid-19 need for flexibility in research protocols and designs as a result of the unpredictable nature of covid-19, with its numerous waves and ever-developing variants (lone & ahmad, 2020; the world economic forum, 2020) influencing research processes and timelines as well as intervention plans, research plans deviations are inevitable. this implies the need for flexibility in research protocols and designs as recommended by bailey et al. (2020). fleming et al. (2020) believed that protocol deviations may lead to increased flexibility in the design of new trials and hashem et al. (2020) further stated that during a pandemic, greater flexibility is needed for conducting clinical trials. these authors stress that, within this flexibility, research teams must have ‘appropriate study designs, collaboration, patient registries, automated data collection, artificial intelligence, data sharing and ongoing consideration of appropriate regulatory approval processes’ (weiner et al., 2020, pp. 148–149). they further recommended that researchers must consider hybrid models of conducting research, models that incorporate decentralised components (e.g. remote work practices, ict use, home visits, etc.) only during times of crisis, such as during a phe like covid-19. it is important to plan for possible changes to the research methods and design. for example, roshan das et al. (2021) gave an example of the manner in which a possibility of questionnaires requiring changing, researchers must be prepared for this change and contemplate on what measures or processes must be put in place to enable or facilitate the change at the appropriate time. another example these authors provide is planning ahead on methods that will be employed to code inevitable changes to study tools, such as surveys, as well as ensuring that all data are time-stamped, which will facilitate data cleaning and merging. current and beyond covid-19 need to investigate participant recruitment, participation and informed consent within the realm of information and communication technology numerous publications reviewed (bailey et al., 2020; cagnazzo et al., 2021; fleming et al., 2020; hashem et al., 2020; roshan das et al., 2021; rothwell et al., 2021; shamsuddin et al., 2021; waterhouse et al., 2020) highlighted significant gaps in standard processes involved in patient recruitment, participant participation and informed consent, under pre-covid-19 conditions, with these intensified within the ict realm created by remote working. these gaps that straddle between remote working practices and intensified use of ict for research processes raised an important theme that of a need to carefully scrutinise these research processes for current and future research. jayaweera et al. (2021) and cagnazzo et al. (2021) argued that constant review of evolving knowledge, in this case knowledge that emerged because of the covid-19 pandemic, must be utilised to refine and enhance research processes; thus, ensuring that the future of research centres on preparedness and on not repeating past or current errors. cagnazzo et al. (2021) highlighted that patient recruitment and participation require re-consideration to alternative measures that have the potential to enhance patient participation in research. four key considerations that these authors put forward that can serve as alternatives approaches are: (1) offering reimbursement of expenses incurred by participants and their families and caregiverss, such as travel, examinations, procedures, without limitation to rare disease clinical trials only; (2) facilitating remote participants visits (e.g. video, telemedicine, phone); (3) provide incentives for the possibility to conduct procedures at the participant’s home – home visits (e.g. drug administration, blood sample taking, administration of questionnaires and function tests, cochleovestibular monitoring, etc) whilst safeguarding the participant’s anonymity and (4) allow the use of healthcare facilities (e.g. laboratory for blood analyses) other than the reference centre, with strict study protocol monitoring. remote working practices for data collection unavoidable but highly recommended as part of non-pharmaceutical interventions to manage the spread of covid-19 (imai et al., 2020; perra, 2021), including the in-person interactions restrictions created significant challenges with research (bookman et al., 2021; fleming et al., 2020; walker et al., 2021). these challenges necessitated the need for remote working practices for research, practices that can be carried forward to beyond the covid-19 era. remote working practices were adopted to facilitate research planning, research review and approval (irb communications), participant recruitment, patient to participant contact, interventions and data collection, site visits and training (bailey et al., 2020; cagnazzo et al., 2021; hashem et al., 2020). for example, cagnazzo et al. (2021) encouraged the facilitation of remote patient visits, such as video conferencing, telehealth, use of telephones, etc. hashem et al. (2020) highlighted that to mitigate the likelihood of infection, although remote research processes, such as monitoring, through the use of ict in the form of video visits and telephone calls are crucial, it is important that this practice should be restricted to essential core data and maintained to an absolute minimal frequency in order to evade redundant workload on the research team. walker et al. (2021) argued that videoconferencing is a convenient, cost-effective and often user-friendly research method and recommend the use of online photovoice – as this facilitates real-time interactions amongst participants and researchers (building rapport). current reviewed studies highlighted the importance of identifying needs that can be addressed before conducting remote research, as well as establishing whether this form of data collection is suitable for the research question and population of interest (roshan das et al., 2021; walker et al., 2021). this includes the facilitation of remote monitoring of the research and verification of source data (cagnazzo et al., 2021; hashem et al., 2020). intensified efficient use of information and communication technology for research processes as a result of the enforced remote working practices, the use of ict for research processes had to be intensified during covid-19, however, these practices can be taken forward beyond this pandemic era (bailey et al., 2020; bookman et al., 2021; hashem et al., 2020; roshan das et al., 2021; rania et al., 2021; shamsuddin et al., 2021; walker et al., 2021). if adapted suitably, ict has been demonstrated and recommended to possess the potential to transform the entire research process, including increasing awareness of and access to clinical studies (bailey et al., 2020; shamsuddin et al., 2021; rothwell et al., 2021). through the use of remote interfaces and apps as well as telehealth technologies, be it synchronous, asynchronous or hybrid models (khoza-shangase et al., 2021; sebothoma et al., 2021), there have been significant research enhancing changes such as participant recruitment, communication with patients regarding eligibility for various studies and for informed consent and for monitoring symptoms and drug side effects for clinical trials (e.g. drug safety trials) and longitudinal studies (bailey et al., 2020; roshan das et al., 2021; rothwell et al., 2021). for example, covid-19 has raised awareness amongst key stakeholders involved in research about the limits of informed consent and offers the research community a rare opportunity to advance significant change that can meaningfully enhance informed decision-making for research and research access (hashem et al., 2020; rothwell et al., 2021; shamsuddin et al., 2021; waterhouse et al., 2020). as far as informed consent is concerned, hashem et al. (2020) and roshan das et al. (2021) stressed that during pandemics such as the covid-19, researchers must take into cognisance the strong risk of infection transmission through paperwork used in information sheets, consent forms, questionnaires etc. this risk can be mitigated through the application of data acquisition, capture and storage processes that are performed electronically, thus raising the value and challenges of electronic acquisition of informed consent. research informatics and information and communication technology use and innovation (telehealth) has its problems this review revealed numerous opportunities and challenges with informed consent that are linked to ict (bailey et al., 2020; walker et al., 2021). depending on how these are addressed, they can be challenges or opportunities: (1) increased use of e-consent and increased use of remote consent, (2) increase in participants who do not speak english – a language that is often used in research, (3) increase in challenges with obtaining signatures and increased use of waiver of signatures, (4) increased use of legally authorised representatives, (5) increased use of clinician team to consent and (6) increase in re-consenting when either participant capacity has returned following intervention interruption because of covid-19 or research disruption because of lockdowns, etc. (bailey et al., 2020; bookman et al., 2021; rothwell et al., 2021; waterhouse et al., 2020). the current researchers, as also recommended by rothwell et al. (2021), argue that during covid-19 and beyond, the practice of informed consent acquisition should place more emphasis on the process than the document itself. these authors suggest that this entails the exploration of alternative means for communicating information outside reading the text. alternative strategies include the use of verbal exchanges and visual images that foster more effective informed decision-making (rothwell et al., 2021). thus, it is important that resources should be made available to research teams to develop quality consent tools and methods that advance proper understanding and address literacy and linguistic concerns (khoza-shangase & mophosho, 2018, 2021; rothwell et al., 2021; hashem et al., 2020). rothwell et al. (2021) suggested that institutions provide resources that facilitate consent translation and context-relevant interpreters. resource allocation for this aspect should also take into consideration training of recruiters and the relevant research team members on cultural competency and implicit bias (roshan das et al., 2021; rothwell et al., 2021). roshan das et al. (2021) also recommended the use of ppi members in this role and argued that they can help with the development of appropriate research tools as they are intimate with the public and patient needs. lack of these resources significantly hinders the research process and may cause harm by creating a barrier to inclusive access to research and therapeutic interventions (rothwell et al., 2021). placing more emphasis on the informed consent process rather than the document itself also requires that interruptions brought about by covid-19 be considered during the development of the consent protocol. the fact that re-consent could be required following study interruptions, disruptions or stoppages – after capacity has been regained, rothwell et al. (2021) recommended that researchers should consider adding follow-up communication to the one-time consent encounter. further challenges with ict involve challenges with research informatics, ict use and innovation (e.g. telehealth, research virtual visits). key to these challenges, over and above-informed consent, is the well-documented bias of this model of research to those with internet access, thus excluding a significant part of individuals, particularly in lmics (shamsuddin et al., 2021; walker et al., 2021). linked to, but not exclusive to this access challenge, is familiarity with the internet and the e-world, including skills such as ability to log in to check e-mails for research deadlines and logging in to participate in videoconferencing or interviews, etc. for the researchers and all participants, familiarity with the internet has an influence in issues such as the number of participants who can be included in an e-interaction or visit, this affects the time allocation for each event because it has an impact on the time allotted for the activity (hashem et al., 2020; rania et al., 2021; walker et al., 2021; weiner et al., 2020). another important challenge with research informatics involves online data handling storage and destruction (bookman et al., 2021; hashem et al., 2020; shamsuddin et al., 2021); specifically (1) the ethical implications for recording online and this includes a private recording of the event by participants – particularly when it involves more than one participant as is the case with focus groups; (2) storage of recordings and destruction of data, as well as (3) challenges with the establishment of rapport amongst participants and between participants and researchers (hashem et al., 2020; shamsuddin et al., 2021; walker et al., 2021). challenges with actual interventions challenges with actual interventions because of factors such as potential delays or pause in enrolment of participants, challenges with monitoring adherence increase the risk of bias; later re-initiation of enrolment and its implications for the research protocol; interruption of intervention delivery and data collection, analytical issues in protecting research integrity, etc. (bailey et al., 2020; fleming et al., 2020; hashem et al., 2020; rothwell et al., 2021). findings from the review raise a need for home visits for intervention delivery and monitoring whilst in full personal protective equipment, as well as efficient maintenance of contact with research participants by the research team for participant retention for later re-initiation (bailey et al., 2020; cagnazzo et al., 2021; fleming et al., 2020). furthermore, cagnazzo et al., (2021) and hashem et al. (2020) suggested that the feasibility of interventions should be carefully evaluated before studies are conducted. these authors posit that priority should be given to interventions that reflect the explicit needs of the patient population where the studies are being conducted and interventions that are easily implementable. in lmics, current authors recommend that interventions should be rapidly available and affordable. challenges with data capturing, analysis and storage as a result of the challenges with data collection caused by interruptions, pauses, re-entering and adherence to monitoring because of covid-19, data capturing may reveal incomplete or missing data, and the consequent need for revision of the statistical methods planned are inevitable (fleming et al., 2020; roshan das et al., 2021). roshan das et al. (2021) and waterhouse et al. (2020) recommended that modifications to data collection and revisions to planned statistical procedures should be discussed with all relevant stakeholders including clinicians, operational staff, data management teams and statisticians and that these changes should be well documented and reviewed by appropriate authorities and committee, for example, irbs (bailey et al., 2020; hashem et al., 2020; waterhouse et al., 2020). as far as data storage is concerned, shamsuddin et al. (2021) raised critical considerations around the ethical implications for recording online, such as recording of sessions, as well as informed consent for recordings. these authors offer guidance on how to address these challenges. firstly, for addressing online recording, they suggest strict adherence to the ethical principles of justice, beneficence and respect for persons, whilst ensuring that all necessary precautions are in place for data collection, where participant confidentiality and privacy are respected and protected. furthermore, these authors suggest that suitable online recording tools should be utilised and the intention to record online be clearly communicated to the irb. secondly, to ensure informed consent for recordings, shamsuddin et al. (2021) suggested that researchers should make it clear during the process of obtaining consent that recordings cannot be removed after participation, thus limiting the chance of different consent for recording. in addition, a clear confidentiality statement must form part of the participant information sheets and consent forms and these information sheets should also disallow participant recording of the research session using their own recording devices. as far as storage and destruction of recordings is concerned, shamsuddin et al. (2021) offered numerous recommendations. firstly, researchers should make an informed choice about what type of software to use for storage, for example, whether to use the web conferencing system’s built-in function or to use software external to the web conferencing system used during data collection. secondly, researchers must be knowledgeable about the recording facility’s privacy policy, for example, some hosting platforms such as blackboard collaborate™ ultra and zoom™ store recordings on their platform (i.e. cloud storage), and such recordings can later be downloaded to the researcher’s computer for secure long-term storage. thirdly, researchers must strengthen their study data security for recordings stored on the host provider’s platform by having password protection that ensures that they have complete control over who has access to it. finally, researchers must decide on how long recordings should be stored and must also ensure that the methods for data destruction are appropriate. most importantly, they must make sure that data stored on these virtual host platforms are destroyed, so that this data does not get used for market research purposes. challenges with research findings sharing or publishing as a result of the emergency created by covid-19, sharing and publishing of research findings became critical as global evidence on prevalence or incidence, symptomatology, interventions and treatment outcomes was required. park et al. (2021) and bailey et al. (2020) emphasised the obvious advantages of preprint servers and the merits of a faster peer review process, resulting in quicker dissemination of findings that can be utilised to inform policies and fast track the research and development (r&d) process for covid-19 interventions and vaccines. this review indicates that research findings sharing or publishing can be faster, with most journals offering preprints. however, an identified challenge with this process was compromised poor quality of studies with many non-peer-reviewed preprints with reduced standards (bailey et al., 2020; park et al., 2021). park et al. (2021) and bailey et al. (2020) lamented that the differentiation between peer-reviewed publications and preprints with apposite oversight became distorted. this practise, these authors believe, has a significant impact on the scientific community and the public. thus, during and beyond covid-19, whilst facilitating fast speed of dissemination, processes should be in place to ensure that standards are maintained. bailey et al. (2020) stated that such a safeguarding process entails: (1) transparency in data sources and analysis procedures, (2) repeatability and reproducibility and (3) vigorous peer-review process. as far as the transparency is concerned, it is crucial that researchers inform journals of any changes to research protocols and statistical procedures that were because of covid-19-related impacts such as study commencement delays, interruptions, pauses, late re-enrolments and so on. fleming et al. (2020) suggested that these covid-19-induced modifications and so on must be described in detail in the methodology section of the publication, with any protocol amendments highlighted in the cover letter submitted at the time of the article submission to the journal (bailey et al., 2020). as a result of the changing nature of the covid-19 pandemic, the reviewed studies recommend that findings or data sharing and reporting should be ongoing, with very clear and simple messages. roshan das et al. (2021) suggested the importance of incorporating ppi input at this stage to ensure simplicity and clarity. this, it is highlighted, can only occur if research units have clear dissemination policies and plans for how, when and how frequently data or report findings will be released. furthermore, this process will be safeguarded by ensuring the protection of intellectual property and having clear copyright statements that provide contact details of key authors to respond to data sharing requests, with clear policies around authorship. roshan das et al. (2021) and bookman et al. (2021) recommended that data sharing and authorship policies should be in place at the commencement of research projects, whilst roshan das et al. (2021) recommended that researchers register their studies on an online study registry, such as clinicaltrials.gov, to protect intellectual property. furthermore, these authors recommend that pre-existing disease-specific national registers be utilised to host new studies where possible, but caution that researchers must remain awake to the possibility that their pre-existing workload may lead to delays to new studies. where pre-existing registers do not exist, these authors suggest developing local registries. furthermore, they recommend that where pre-existing registers exist, researchers should deliberate and query with relevant ethics committees if simply submitting amendments to earlier ethical approvals would be adequate for their new study, instead of re-applying for new ethical approval, thus, saving time. alternatively, emergency, fast-track ethical approval processes should be explored from universities and relevant institutions. in addition, roshan das et al. (2021) suggested that in such scenarios, researchers should also establish links with other researchers working in related studies to agree on common minimum standards or contents of research tools, such as questionnaires – which may be of benefit to everyone involved. conclusion the current scoping review aimed at answering the question ‘what has been published about conducting clinical research during the covid-19 pandemic?’ findings have revealed both challenges and significant opportunities spanning from the inception of research teams, setting up research protocols, obtaining institutional and ethical approval, all the way to actual interventions, data collection and analysis, data recording and storage, sharing research findings and publishing. these findings are all whilst considering remote working conditions as imposed by covid-19, with the use of ict for research revealed to have intensified. the findings of this study are presented under 10 themes that emerged from the data. the current findings not only highlight important considerations for research during a pandemic but also beyond, where ict and telehealth can play a significant role in increasing access to both research participants recruitment and participation and provision of interventions remotely, be it for research purposes or for clinical care – particularly in lmics where challenges with the healthcare workforce are well documented. lessons about access in research are important to take forward as they might facilitate access to larger and more diverse participants for clinical studies, affording researchers data that may be more relevant and findings that are more generalisable. these considerations are critical for the speech-language pathology and audiology professions to deliberate on for current and future (beyond covid-19) clinical research planning. regardless of the fact that some studies included in this review are from a purely medical perspective, the challenges and opportunities identified in those studies are similar to and are transferable to the field of speech-language pathology and audiology. acknowledgements competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions all authors co-conceptualised the idea for the research as well as the design and methodology adopted. k.k.s. was the lead author in writing up of the manuscript for publication with input from b.s. and n.m. all authors read and approved the final manuscript. funding information the authors thank the national institute for the humanities and social sciences (nihss) for providing financial assistance for the publication of this manuscript. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references arksey, h., & o’malley, l. 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(2022). coronavirus (covid-19) media briefings. retrieved from https://www.bing.com/search?q=coronavirus+(covid-19)+%7c+who+%7c+regional+office+for+africa&cvid=5037661c80b244b6bfda79f5e256c496&aqs=edge..69i57.397j0j4&form=anab01&pc=asts wyatt, d., faulkner-gurstein, r., cowan, h., & wolfe, c.d.a. (2021). impacts of covid-19 on clinical research in the uk: a multi-method qualitative case study. plos one, 16(8), e0256871. https://doi.org/10.1371/journal.pone.0256871 the south african journal o f communication disorders, vol. 54, 2007 editorial introduction this volume o f the south african journal o f communica­ tion disorders begins with a lead article written by the journal’s editorial board. several notable researcher practitioners were invited to write their responses to this article. these five authors have provided their views and opinions on the relevance o f professional research to the lives o f the people with whom we work. p r o f sally hartley, a uk based speech-language thera­ pist (slt) has worked in economically developed and economically developing countries, mainly in africa. she has a deep interest in the development o f slt and audio­ logy across geographical contexts. in presenting her inter actionist perspective o f research and practice, she does so with the reminder that the topic is important to consider across social and economic geographies. indeed, her re­ view is relevant not only for slt and audiology but for rehabilitation practice in itself. echoing similar senti­ ments, p ro f erna alant (centre for alternative and aug­ mentative communication, pretoria) has drawn on her long-standing involvement in addressing social and eco­ nomic concerns within rehabilitation practice. she has poignantly challenged the profession with the following question: when is our commitment to our profession more overtly going to focus on government support and liaisons to develop service and intervention mod­ els that could work fo r rehabilitation in our coun­ try? (page 12) similarly, prof. claire penn (university of the witwaters rand) asks us to consider several points in her rather chal­ lenging review. via her perspective, not only as an a rated scientist but also as recipient o f president mbeki’s order of the mapungubwe award (silver); penn has pro­ vided an astute, rich analysis o f the wide range o f research methodologies available to practitioners. however, as we foray into non-mainstream methodologies, penn cautions us about diminishing scientific rigour. o f the many chal­ lenges that she poses, i, on behalf o f the journal, echo penn when she asks: why do people think that research is only fo r those who are not clinically inclined? penn’s challenges and cautions are to be considered espe­ cially in relation to ideologies such as singh’s reference to distributive justice. prof. shajila singh, the chairperson o f the profession’s board on the health professions council o f sa, invites us to consider questions such as the racial and cultural profile o f our researchers, their research inter­ ests and importantly o f researchers’ foci not ju st on communities in sa that tend to be over-researched but of how we engage these communities in deciding research methodologies and the research process itself. in arguing that professional research should transcend political agendas, dr. d e wet swanepoel (university of pretoria) has positioned his perspective on the ideology that our professions need to transcend political ideology toward respecting aspects o f human dignity and respect for persons. swanepoel adds a very pragmatic slant to the research activity and agenda within the profession. in lamenting the l0w publication rate, he argues that “ ...whatever the research bein pursued, it must ultimately be published.” (page 11). the editorij board o f this journal could not agree more with this statement indeed, the decision to write this lead article is part o f the jour­ nal’s strategy to highlight the nature o f research, especially 0f relevant research, within the professions o f speech-language therapy and audiology. it is our attempt not only to stimulate interest but to encourage our readership into actively engaging the thoughts, challenges and recommendations published in the jour­ nal. the articles contained within this volume o f the journal may be in sync with your notion o f relevance in research/practice. al­ ternatively, you may disagree with the relevance o f authors’ ori­ entation, theoretical stance or methodology. as slt and audiol­ ogy practitioners, we may very well choose to make these issues o f relevance invisible. alternatively, we may choose to raise the visibility o f relevance in our professional research and practice toward dizzying heights. while ambitious, we think the latter is an honourable and necessary aim well worth confronting. mershen pillay editor-in-chief south african journal o f communication disorders now available in south africa after 10 years of success in the us! spend more tim e working with your clients instead of writing about them. finally! you can minimize repetitive report writing and still maintain the integrity of your reports with this state-of-the-art software program. * in a matter of minutes,you can produce a unique, personalized profile written in a rich narrative style for each individual client. * it is uniquely programmed to deliver semantically different but clinically equivalent reports when client profiles are similar. 77) e speech# language report writer makes it simple! * developed after 15 years of research by senior clinicians and programmers, this is the software system that can dramatically reduce your report writing time without sacrificing the quality of your reports. * for use in schools, agencies and individual practices. v e r s i o n 3 . 0 n o w a v a i l a b l e for more information, upgrade information,or a free 30-day trial, visit www.cllnidansinagidan.com po 8ox 426, bedford ny 10506, usa speech language report writer™ clinician's magician, ltd. • clinical software p u b l i s h e r s for more details on the speech and language report writer™ dial: (new york, usa) 00+1+914+2346752 or e-mail: clinmag@gmail.com die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.cllnidansinagidan.com mailto:clinmag@gmail.com abstract background emergent literacy development and literacy as a social practice in south africa benefits of shared book reading and the role of the speech-language therapists methodology materials research procedure findings and discussion conclusion acknowledgements references about the author(s) tarryn coetzee department of speech-language pathology and audiology, school of human and community development, university of the witwatersrand, johannesburg, south africa sharon moonsamy department of speech-language pathology and audiology, school of human and community development, university of the witwatersrand, johannesburg, south africa joanne neille department of speech-language pathology and audiology, school of human and community development, university of the witwatersrand, johannesburg, south africa citation coetzee, t., moonsamy, s., & neille, j. (2023). a shared reading intervention: changing perceptions of caregivers in a semi-rural township. south african journal of communication disorders, 70(1), a948. https://doi.org/10.4102/sajcd.v70i1.948 original research a shared reading intervention: changing perceptions of caregivers in a semi-rural township tarryn coetzee, sharon moonsamy, joanne neille received: 24 sept. 2022; accepted: 31 oct. 2022; published: 26 jan. 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: many caregivers from low-middle income (lmi) households consider that preschool children are too young for shared book reading. thus, many caregivers are unaware of their potentially powerful role in their children’s emergent literacy and communication. objectives: to describe (1) caregivers’ perceptions of shared reading, (2) caregivers’ perceptions of barriers to shared reading and (3) changes in these perceptions following a short intervention. method: a qualitative methodology was used to understand the perceptions of 40 caregivers from a semi-rural south african township. two semi-structured interviews were conducted before and after intervention. the intervention was a short training video about shared reading. results: caregivers described the unfamiliar reading culture and viewed reading as an educational activity that they knew little about. barriers to shared reading included lack of time, few reading materials and low levels of literacy or lack of exposure to this type of activity. following the intervention, they acknowledged the importance of shared reading, described growing confidence in their shared reading abilities and closer relationships with their children. conclusion: speech-language therapists (slts) have a pivotal role to play in caregiver training of emergent literacy skills and can make a marked impact in guiding caregivers’ shared reading. a short video-based intervention can alter caregiver perceptions and practices, which may be the first step in changing behaviours. contribution: the study provides an example of a simple and cost-effective intervention that changed caregiver perception and caregivers’ reported shared reading practice. keywords: literacy; shared-reading; early intervention; caregiver training; caregiver perceptions; south africa; emergent literacy development. background caregiver involvement in children’s early reading development plays a pivotal role in their later reading and scholastic success and usually depends on the parents’ own social, cultural and linguistic capital (coetzee et al., 2021; justice et al., 2020). international studies have highlighted the importance of parental involvement in the development of emergent literacy (e.g. coetzee et al., 2021; vally et al., 2015). there are many activities that can be utilised to promote emergent literacy and readiness for formal reading instruction, one of which being shared book reading between caregivers and children. based on such evidence, some south african initiatives have been implemented to promote shared book reading by providing families with books (e.g. book dash [www.bookdash.org] and the mikhulu trust [www.mikhulutrust.org]). the effective implementation of such initiatives is often encumbered by misconceptions about emergent literacy-related activities. south africa’s history of inequality and social injustice has resulted in many caregivers having limited access to education and thus presenting with low or absent levels of literacy (graven, 2016). research has also shown that many caregivers do not perceive themselves as central partners in their children’s emergent reading development and do not know how to share books with them (coetzee et al., 2021). this article describes an intervention undertaken with caregivers to promote their shared reading ability. the following sections provide context about children’s literacy development in south africa and the role of speech-language therapists (slts) in shared reading. emergent literacy development and literacy as a social practice in south africa the experience when a more knowledgeable other, such as a parent or a teacher uses a combination of targeted strategies, specifically aimed at improving a child’s early language and emergent literacy development, is termed shared book reading (vally, 2012). this interactive form of sharing books with children has been considered an essential cognitive stimulation activity, which varies widely among cultures and families (vally, 2012). it is less common in more disadvantaged communities (fletcher & reese, 2005; logan et al., 2019). a study by the south africa book development council (sabdc, 2011) revealed an absence of reading culture in most low-middle income (lmi) communities in south africa. oral literacy is culturally more familiar to many south african caregivers than print literacy and shared book reading. oral literacy refers to meaning, messages and teachings traditionally conveyed by songs, rituals and oral storytelling rather than by print (gardner-neblett & iruka, 2015). children’s learning experiences are enriched and enhanced by these forms of knowledge, which are generated within their cultures (gardner-neblett & iruka, 2015). although shared book reading may not be the sole predictor for emergent literacy development, it has been found to have a distinct facilitative effect on children’s acquisition of language and emergent literacy skills (cabrera et al., 2020). benefits of shared book reading and the role of the speech-language therapists the benefits of shared book reading for children’s early language and literacy development have been widely and extensively researched (coetzee et al., 2021; shahaeian et al., 2018; vally et al., 2015). book sharing in the first six years of a child’s life has been linked with promising (shahaeian et al., 2018). substantial enhancements in the language skills of 2-year-old children were observed in a study by whitehurst et al. (1988) after mothers from middle-class backgrounds had been taught and had improved upon their shared reading techniques. another study that was conducted by huebner and meltzoff (2005) established that a positive effect on children’s language could be attributed to the increase in their parents’ dialogic reading behaviour. parents who have received instruction and training on how to participate and effectively engage in shared reading strategies have been observed to make greater use of labelling, questioning, commenting and discussing pictures in a story, which ensures a greater chance for exposure to new vocabulary and concepts (mol et al., 2008). shared reading skills, experiences and confidence of adults facilitating and mediating literacy development vary greatly. many adults tend to refrain from sharing books with their children as they lack the knowledge to effectively do so (tayob & moonsamy, 2018). the importance of teaching caregivers skills in how to effectively engage in shared reading with young children, especially in settings where there may have been limited opportunity to acquire these skills, highlights the need for emergent literacy interventions that target specifically caregivers. despite it being well known that shared reading is an effective vehicle for the promotion of early language and literacy development, a paucity of research has examined the potential benefits of providing caregiver training to achieve this (dowdall et al., 2019). concerns surrounding the cost of training and other associated logistical challenges have resulted in few studies describing the effectiveness of these interventions in resource-constrained environments such as south africa. a study that was conducted by knauer et al. (2019) in a similar resource-constrained environment in kenya sets out to investigate the use of dialogic reading training to educate parents about book sharing. the implemented training programme improved the quality of parent–child reading and showed vocabulary gains in children of caregivers with no and/or low literacy. seven and goldstein (2020) used a multiple-baseline design to determine whether structured training in dialogic reading and conversational skills impacted upon child language development in four father-child dyads in a resource-poor setting in turkey. the authors reported interactions and decontextualised talk as study outcomes. a randomised book sharing intervention trial was conducted by vally et al. (2015) in a rural settlement in south africa. children’s early language and literacy development were found to benefit substantially from book sharing intervention, and vally et al. (2015) surmised that the positive effects that were observed in their study were attributable to improved parents’ mediation skills, which had been developed through training. a study by coetzee et al. (2021) investigated the impact of a short caregiver training video on the shared reading behaviours of caregivers and children and found a significant improvement in caregiver and children’s shared book reading behaviours after exposure to the training video. the use of training videos as effective and cost-effective intervention is supported by this and other studies (e.g., lloyd & robertson, 2012; hsin & cigas, 2013). the implementation of training videos as a population-based intervention to promote children’s emergent literacy is in majority world settings is, proves to be promising. the positive outcomes of developing an intervention delivered through the medium of videos demonstrated in these studies served as a scaffold for the current study. speech-language therapists are key contributors in promoting children’s emergent literacy because literacy is typically viewed as being built on a foundation of oral language skills. speech-language therapists facilitate and teach interactive reading behaviours to families, caregivers and teachers. one of their roles is to assist caregivers in creating many high-quality opportunities to participate in emergent literacy activities at home, in daycare and in preschool (chang & monaghan, 2019). speech-language therapists may serve as leaders in designing and implementing literacy programmes such as shared book reading interventions to teach parents and caregivers these interactive reading behaviours (kaderavek, 2015). thus, this study set out to understand caregivers’ views about shared reading and how slts can use cost-effective early interventions to change these perspectives to promote language and literacy development in south african pre-school children. the authors endeavoured to answer three research questions: what are caregivers’ pre-intervention perceptions of shared reading? what are the existing barriers to shared reading? does a training video aid in modifying these attitudes? methodology aim the study aimed to describe caregivers’ perceptions of shared reading, identify existing barriers to shared reading and determine the impact of a caregiver training video in altering these attitudes. research design the data for this article formed part of a larger data set for a study that used a non-randomised, comparison group, crossover repeated measures approach as part of a mixed-methods design (coetzee et al., 2021). in this article, we present the qualitative results obtained from semi-structured interviews with caregivers. all participants were interviewed individually before taking part in the intervention. they were then interviewed again afterwards. participants convenience sampling was used. an invitation to participate in the study was extended to caregivers at parent meetings that were held at three separate daycare centres in orange farm, gauteng. prospective participants had to be a caregiver of a child between 2 and 6 years of age, attending one of the three daycare centres and must have provided signed informed consent. caregivers with a known visual, cognitive or hearing impairment, as well as minor caregivers, younger than 18 years of age, who did not have signed informed consent from their primary caregiver to participate in the study, were excluded from the study. during the parent meetings at the respective daycare centres, 59 caregivers volunteered to participate. the study process was completed by 40 of these child-caregiver dyads who met the inclusion criteria by attending both appointments. the study comprised a total cohort of 40 participants (n = 40). children in this study ranged in age between 36 and 71 months of age (m = 50; s.d. = 9). the cohorts of children who participated in this study (n = 40) consisted of 25 who were female (62.5%). most caregivers were single mothers who reported they were heading their household either with the help of a grandmother or other female support, such as an aunt or an older child. table 1 provides an overview of the participants. table 1: demographic information of participating caregivers. site of data collection this study took place at three daycare centres in a semi-rural township called orange farm, located south of johannesburg in gauteng, south africa. orange farm is a large informal or peri-urban settlement, which is regarded as one of the most geographically isolated communities in johannesburg. the orange farm community is faced with a multitude of challenges including, but not limited to, poverty, high levels of violence, unemployment and crime, limited access to healthcare facilities and lack of basic services, as well as low levels of literacy. orange farm is termed semi-rural or peri-urban because of its limited facilities and high levels of unemployment and poverty. all three daycare centres were based in orange farm, and the roads leading to them were a combination of dirt roads and poorly maintained tarred roads. orange farm has only one small official library located near the orange farm community centre, which is situated within a 5 km – 10 km radius from each of the three daycare centres. many residents make use of horse or donkey-drawn carts as modes of transport. the three primary languages most commonly spoken in the orange farm area include english, isizulu and sesotho (statistics south africa, 2018). materials caregiver training video the 4 min and 30 s caregiver training video (https://www.youtube.com/watch?v=3slrfzqrkoa) was developed by one of the researchers in english, and a forward or background translation process was then used to translate the video content into isizulu and sesotho (regmi et al., 2010). this video inspired by the parent–teacher training dvd called ‘read together, talk together’ and was specifically developed and culturally adapted for this study (rttt; pearson early learning, 2003). the caregiver training video aimed to teach caregivers how to enhance attention to text, promote interactive reading and support comprehension and use literacy strategies effectively. a combination of edited video clips of one of the researchers modelling a shared reading behaviour with a child, narration or explanation and visual caricatures and written bullet points were all combined in the video to maximise the caregivers’ learning experience. the participants were not given access to the caregiver training video on their phones during the study and only watched the training video once during the data collection process. participants could watch the video more than once if they wished and requested to do so. other than the training video, no further training was provided by the researchers. books the books that were chosen for this study were developed by book dash. the books that were selected did not necessarily require the caregivers to be competent readers, as all the books primarily comprised colourful pictures and illustrations. both caregivers and children were thereby free to engage in a meaningful exchange in their own language, irrespective of the caregivers’ level of literacy. book dash storybook developers assisted the researchers with the appropriate selection of books and ensured that these were leveled to meet the requirements for the study population (i.e. diversity of languages spoken in south africa and the geographical context of the study, age of the participants, etc.). all the storybooks were provided in english, sesotho and isizulu. semi-structured interview schedules the researchers developed two interview schedules to include preand post-intervention information: the initial semi-structured interview and the semi-structured exit interview schedule. the initial semi-structured interview aimed to obtain demographic information from the participants including age and gender of the primary adult or minor caregiver, age and gender of the child, the caregiver’s highest level of education and occupation, the duration of time that the child has spent in a formal schooling environment, the book-sharing practices at home (if any), reasons for sharing or not sharing books and whether or not books were shared with the parent or caregivers as children. the semi-structured exit interview schedule was intended to obtain insight into the caregiver’s experiences during the project and whether or not they felt that the caregiver training video had changed the way they thought about sharing books with their child, the way that they shared books with their child or children at home and what they had found most beneficial about the intervention. research procedure the information presented here forms part of a larger study and only the qualitative findings from the interviews will be presented (coetzee et al., 2021). the larger study used an experimental intervention in the form of a caregiver training video. data collection took place over a 4-week period with a 2-week duration between the two appointments of each group. the existing perceptions of and barriers to shared reading among caregivers in south africa were probed in an initial semi-structured interview administered by the researcher in english during the first appointment. two weeks later, an exit interview was conducted post the caregivers viewing the caregiver training video to determine whether the training video had altered these perceptions. the effects of the video on the caregiver perceptions of shared reading were recorded and analysed. the results were thematically analysed and theoretically linked to the intervention (caregiver training video) being investigated in the study. data analysis the data were analysed using a combination of content and thematic analysis (creswell, 2009). themes were systematically formulated from the data. themes were tallied as often as the 40 participants mentioned their respective codes, regardless of how often one participant may have mentioned a theme. thematic analysis took place in three phases, namely coding, of which the purpose was to organise the data; categorisation, in order to distinguish between the various ideas in the data collected and finally, the identification of themes (braun & clarke, 2006). to ensure trustworthiness, the interviews were video recorded to allow for playback and review. the researcher and two trained research assistants alternated analysing and crosschecking each other’s analyses. trustworthiness to ensure trustworthiness, shenton’s (2004) strategies were implemented. the semi-structured interview questions were piloted in accordance with shenton’s (2004) strategies, to determine content and face validity. participants who participated in this study did so voluntary, and hence, only responses from caregivers whose verbal and written consent had been obtained were included in the analysis. collaborative coding was applied to mitigate any research bias and all authors provided descriptions of both the parameters and the limitations of the study. ethical considerations ethical clearance (protocol number: h19/05/04) was obtained from the university of the witwatersrand human research ethics committee (non-medical) and the gauteng department of education (gde) (8/4/4/1/2). all caregivers gave written permission and consent to participate in the study and for their responses to be used in the write up of this study. findings and discussion eight main themes emerged from the qualitative analysis. each of these is discussed in turn below, together with any subthemes that emerged. the themes and subthemes, with verbatim examples from the participants, are presented in table 2. themes and subthemes are arranged and discussed according to the aim of the study as well as their occurrence in the initial and exit interview. table 2: themes and subthemes, with verbatim examples from the participants. existing perceptions of book sharing absence of a culture of book sharing the majority of participants in this study stated that they did not share books with their 3to 6-year-old children, even those who indicated that they owned some form of reading material at home. most believed sharing and reading books was an activity that was the role of the school and schoolteachers and reserved for their older, school-going children rather than their pre-school child. research supports the observation that reading is not necessarily an activity that caregivers consider their responsibility and parents in lmi groups in south africa are often unaware of their potential roles in supporting emergent literacy development (seden, 2008). the few participants who reported sharing books with their children described sharing colouring books, tracing books, comics or school setwork books belonging to an older sibling. the most commonly mentioned reason for the absence of a culture of book sharing – leading to a subtheme that emerged from this study – was the absence of a culture of book sharing and reading experiences in their own homes when they were children. many participants reported that they had no recollection of a caregiver ever having shared a book or read a book with or to them. ‘i have no memories of [anyone] sharing books with me as a child. this was not done at home’ (participant 15, 20 years, mother). the absence of a culture of book sharing can, at least in part, be ascribed to the fact that most of the parents of the participants in this study were born and raised between 1948 and 1994 – the apartheid era in south africa. the capacity of primary caregivers in south africa (especially those living in rural communities) to provide reading materials for their children is often limited and adversely affected by poverty, limited knowledge and literacy skills (makunga et al., 2017). of the 40 caregivers who participated in this study, only two reported sharing books with their own caregivers during their childhood. children’s reading preferences are developed in social contexts and reinforced by people in their immediate environment. a study conducted by pfost et al. (2016) assessed the attitudes of 380-nineth grade students to reading. the mothers of these students were asked to provide comparable information about their own reading behaviours, attitudes and habits. results obtained from the study revealed that caregiver attitudes and reading behaviours do impact children’s attitudes towards reading and their reading behaviours. reading for education rather than recreation participants also mentioned that they viewed reading and book-related activities as educational rather than recreational. ‘i think that this [book sharing] is something that comes in older years, like grade 1.’ (participant 23, 29 years, mother). research suggests that this is a notion shared by many south africans (haese et al., 2018). when asked whether they shared books with their children at home, many caregivers mentioned that they would read religious texts to the children, which they would then be required to recite. existing barriers to book sharing lack of access to books and reading material and perceived limited book-sharing skills the most prominent barrier to sharing books with their children at home was the lack of access to books and reading materials. the sabdc (2007) national survey found that lmi households are less likely to have books. ninety-seven percent of households in sub-saharan africa has two (or fewer) children’s books (united nations international children’s emergency fund [unicef], 2017). limited access to resources in rural settlements, such as orange farm, is a daily reality for many families. books are considered a luxury and are not affordable in most households. ‘i don’t have children’s books. they are too expensive’ (participant 5, 43 years, mother). limited access to books adversely affects the development of a reading culture. only one participant mentioned having visited a library with her child on one or two occasions. according to pretorius (2015), an integral part of developing a culture of reading is access to age-appropriate books. children require access to books and a skillful model such as a parent or an older sibling to facilitate a love for reading (pretorius, 2015). many caregivers are not only unaware of their potential roles in supporting emerged literacy development but also often reported feeling ill-equipped or unskilled to perform this task. limited time many caregivers pinpointed a lack of time as being a significant factor that inhibited them from sharing books with their children. ‘i come home late from work. i work for long hours and then i am too tired when i come home’ (participant 26, 25 years, mother). another participant mentioned that she was often too tired after a long day at work. an estimated 40% of south african households are headed by a single parent, of which 40% are headed by a female. female-headed households face an increased risk of poverty as a result of their limited access to social and economic resources and the additional costs of childrearing (department of social development, 2013). the prioritisation of chores may therefore be a reason why many single-parent households rely on their eldest child to share some of the child-rearing responsibilities and why older siblings accompanied some of the children in this study. perceptions of shared reading post intervention shared reading as a vehicle for change and improved relationships the reading context and attitudes of caregivers after exposure to the caregiver training video appeared to change. most caregivers reported altered shared reading behaviours and that their view of sharing books with young children had shifted after watching the video. this change in attitude was multi-faceted – it applied to the caregivers’ attitudes regarding the importance of book sharing and their improved relationship with their children and new skills development: ‘it [the project] has changed the mind-set i once had of not having an interest of sharing a book with a young child and it made me eager to share books more with my young ones.’ (participant 12, 35 years, father). parental involvement at an early age is a critical component of reading skills development (sukhram & hsu, 2012). caregivers felt encouraged and positively reinforced by the positive responses they felt they elicited from their children during shared reading. research has shown that book sharing can promote a perceived improvement in parenting capabilities (seden, 2008). this coincides with the findings of lessing and odendaal (2004) that the aspects contributing to the success of such an intervention are the physical presence of the caregivers, the positive reinforcement from the caregivers, improved self-confidence among the children and the caregivers and quality time spent together. increased frequency of book sharing many participants emphasised that the frequency of book-sharing activities had increased within the household and that the children often initiated this: ‘we share books much more now. even when i forgot, she shows me that we haven’t read today. [i] did not think that i could make reading books with her so enjoyable and fun.’ (participant 15, 20 years, mother) many south africans consider reading as educational rather than recreational, and this perception was changed over the course of the study. participants admitted to having considered reading and sharing books to be a boring and difficult activity. they had not been aware of ways to make it more interesting and intriguing for the children. this observation supports the notion of transgenerational communication of assumptions regarding literacy in that the caregiver/s’ own attitudes towards schooling and literacy were affected by their own school experiences (reese et al., 2012). the child as an active participant in book sharing book sharing allows for – and encourages – both the caregiver and the child to actively participate in the reading process. both child and parent are encouraged to become equal contributors. several participants mentioned that their children had begun insisting on holding the book and leading the interaction after having observed their caregiver share a book with them. caregivers reported that, as they continued sharing books with their children, their children became more confident and would begin holding the books, turning the pages and narrating the story more independently: ‘before, i just read the words and i quickly turn the pages to finish the book. now, i take time and i don’t just read the words. i let her talk and point the pictures and talk about the pictures.’ (participant 2, 25 years, father) increased verbal output among children participants reported engaging more in collaborative talk. they learned to make use of this form of communication with their children to assist them with comprehension and, importantly, facilitate the enjoyment of the reading process. these findings relate to bandura’s (1977) social learning theory, which suggests that children observe their role models in their immediate environment and study their behaviours with the potential for later imitation. the children’s desire and resulting eagerness to engage in independent reading also indicate a sense of personal mastery that will ultimately aid in fostering an intrinsic motivation for reading (fawson & moore, 1999). responsive and reciprocal interaction between caregivers and young children promotes the acquisition of new vocabulary and the development of linguistic skills (knauer jakiela, ozier, aboud & fernald, 2018). many participants also mentioned that their children had become more verbal during the project: ‘she does not stop talking now. she asks me questions about everything and wants to know the reasons for everything that is happening in the book. sometimes i don’t know. we can sit for hours and speak about things that are happening in the book.’ (participant 11, 24 years, mother) the benefits of age-appropriate resources all participants reported that the picture books used in this study had an impact on the reading practices in their homes. participants repeatedly mentioned that the books were easy to read and contained plenty of pictures, which made it easy to tell a story even if they did not read the words: ‘i like that they [the books] have many pictures and they are child friendly. even though you don’t read all the words, you can grasp the story from the pictures or make your own story.’ (participant 3, 33 years, mother) the participants made use of the books in a multilingual fashion. although the researcher had provided each of the books in english, isizulu and sesotho, the written language or story text did not affect the language of narration during shared reading. all the participants were observed code-switching at least once during their interactive shared reading session with their child. along with isizulu, sesotho, isixhosa and sepedi, english was also used consistently during the interactions. many of the caregivers elected to share the english version of a book with their child but would narrate the entire book in their home language. the books allowed for the shared reading interactions between the caregivers and the children to take place in the language of the participant’s choice. this concept of scaffolding coincides with a growing body of work within south africa on ‘translanguaging’ (canagarajah, 2011; makalela, 2015). translanguaging assumes that language practice involves a complex inter-play of communicative strategies including, for example, code-switching between languages during an interactive reading activity. this form of scaffolding needs to be encouraged during these shared book-reading interactions to aid children’s expressive and receptive language development in english and the child’s home language. bilingual transitional models maintain that a child must first develop cognition in the medium of their first language before they are able to gain the necessary skills for the acquisition of a second language (canagarajah, 2011; makalela, 2015). these debates have implications for language policy in south africa, and evidence from this study suggests that home language has an important role to play in the development of early reading skills. vygotsky’s (1978) notion of zpd is also relevant to second language acquisition. if a child has not attained a comfortable level of oral language proficiency and does not comprehend the fundamental principles of emergent literacy in their first language, then academic mastery of a second language will be beyond the zpd. the use of multiple languages and ‘translanguaging’ during shared reading activities builds and strengthens the development of cognitive skills in children (peng & kievit, 2020). the effectiveness of the video intervention format several participants mentioned that they appreciated and enjoyed seeing the shared reading technique being modeled in the caregiver training video: ‘it [the video] guided me on how to interact. i have learned how now to wait and let her interact. so actually, if i did not see the video, i was going to be dominant from beginning to end.’ (participant 14, 33 years, mother) most caregivers emphasised that they had enjoyed the caregiver training video as a vehicle of learning and teaching. many reported that they felt comfortable learning via a video format, as this was perceived to be non-threatening, and they did not feel in danger of being judged by a teacher or instructor. conclusion this article explored caregivers’ perceptions of shared reading before and after an intervention to improve shared reading practices among caregivers. targeting early language and literacy development, and thereby contributing to reducing educational inequality, is a potential advantage of a parent-centred shared reading intervention. the overall changes elicited in attitudes towards shared reading and the increase in shared reading evident among caregiver suggest that this caregiver training video provides a promising and effective early intervention worth implementing in lmi households in countries like south africa. positive effects of a caregiver training video on the shared book reading practices and relationship between caregivers and their children are supported by this study. however, the cultural context of south africa is complex, and factors impacting emergent literacy development are multi-faceted. there is still a great deal of work to be done before an intervention model is developed that accommodates the diversity of cultures that exist in south africa. this study has some limitations in that the cohort recruited was relatively small, and results can therefore not easily be generalised as contextual factors will differ. furthermore, the children who participated in this study were of a large age range, which complicates the interpretation of findings about specific shared reading behaviours for specific age groups as emergent literacy skills develop across a continuum. similarly, the same applies to the large age range of caregivers as this introduced additional variables that necessitate cautious interpretation of results. however, this situation reflects typical communities in the majority world countries. the role of the reading partner, such as siblings versus parents, needs to be further researched as each group will bring a diversity of life experiences, strengths and weaknesses to their interactions and reading behaviours. the results obtained in this study report on the short-term perceptions of caregivers. further studies would need to investigate the sustainability of reported new behaviours and what minimum intervention dosage yields the most long-lasting results. the absence of book-sharing practices in south africa can be attributed to a myriad of barriers related to past and current challenges of lmi families in south africa today. however, results obtained also showed the promising change and impact that a caregiver training video can have on the attitudes of caregivers towards book sharing and the power to modify behaviour to improve the quality of caregiver-child shared reading interactions. making intervention and academic materials available in the 11 official languages spoken in south africa is therefore of critical importance and highly recommended. early interventionists play a pivotal role in the development, implementation and promotion of such training programmes. speech-language therapists have a key role in the promotion of early literacy skills particularly in children who may be at risk for developing literacy-related learning difficulties. speech-language therapists may help to prevent, identify and provide suitable interventions for these children and collaborate with families, caregivers and teachers to ensure that children are provided with opportunities to participate in emergent literacy activities within their immediate environments. speech-language therapists need to endeavour to incorporate existing cultural practices and foster a responsiveness to their context. speech-language therapists who are based in lmi countries such as south africa should be encouraged to contribute to the development of further emergent literacy interventions that are easily disseminated and cost-effective and require minimal trained personnel and expertise. speech-language therapist’s also need to recognise the importance of caregiver training to foster the development of emergent literacy skills. acknowledgements prof. michelle pascoe was a great help in the review and editorial process. her guidance was invaluable. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions t.c. was involved in the conceptualisation, data collection, data analysis and writing up of the article. s.m. and j.n. were involved in the conceptualisation of the article, writing up and editing of the article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data used in this study are available from the corresponding author, t.c., upon request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references bandura, a. 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(1988). accelerating language development through picture book reading. developmental psychology, 24(4), 552–559. https://doi.org/10.1037/0012-11649.24.4.552 abstract introduction methods results discussion conclusions acknowledgements references about the author(s) ben sebothoma department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa katijah khoza-shangase department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa duane mol department of otorhinolaryngology – head and neck surgery, the ear and eye clinic, alberton, south africa dipuo masege department of otorhinolaryngology – head and neck surgery, faculty of health science, university of the witwatersrand, johannesburg, south africa citation sebothoma, b., khoza-shangase, k., mol, d., & masege, d. (2021). the sensitivity and specificity of wideband absorbance measure in identifying pathologic middle ears in adults living with hiv. south african journal of communication disorders, 68(1), a820. https://doi.org/10.4102/sajcd.v68i1.820 original research the sensitivity and specificity of wideband absorbance measure in identifying pathologic middle ears in adults living with hiv ben sebothoma, katijah khoza-shangase, duane mol, dipuo masege received: 22 jan. 2021; accepted: 10 aug. 2021; published: 30 sept. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: limited research exists on the sensitivity and specificity of wideband acoustic immittance (wai) in adults living with human immunodeficiency virus (hiv). this study forms part of the bigger study titled ‘wideband acoustic immittance in adults living with hiv’. objectives: to determine the sensitivity and specificity of the wideband absorbance measure at tympanic peak pressure (tpp), as a screening tool for detecting middle ear pathologies in adults living with hiv. method: a prospective nonexperimental study comprising 99 adults living with hiv was performed. all participants underwent a basic audiological test battery which included case history, video otoscopy, tympanometry, wideband absorbance at tpp and pure tone audiometry. middle ear pathologies were established by two otorhinolaryngologists using asynchronous video otoscopic images analysis. the outcomes of the otorhinolaryngologists served as the gold standard against which the wideband absorbance at tpp and tympanometry were measured. the receiver operating characteristics (roc) curve was calculated. results: roc revealed the sensitivity of wideband absorbance at tpp to be higher in low to mid frequencies, but significantly lower in frequencies above 971.53 hz. the sensitivity of tympanometry was lower. however, there was no difference between the specificity of wideband absorbance at tpp and tympanometry, indicating that when there are no pathologies, tympanometry is equally accurate. conclusion: the current findings reveal that wideband absorbance at tpp can distinguish middle ear pathologies better than the tympanometry. incorporating wideband absorbance at tpp in clinical practice may improve early identification and intervention of middle ear pathologies. keywords: adults; hiv; middle ear pathologies; sensitivity; specificity; wideband absorbance at tpp. introduction although there have been global efforts to eradicate hiv using antiretroviral therapy (art) (mwaba, ngoma, kusanthan, & menon, 2015) and other preventative measures (williams et al., 2006), there has been a consistent pattern in the literature linking hiv with middle ear pathologies (sebothoma & khoza-shangase, 2020; tshifularo, govender, & monama, 2013; van der westhuizen, swanepoel, heinze, & hofmeyr, 2013). unfortunately, the persistence of middle ear pathologies in individuals living with hiv seems to occur despite the efficacy of art. therefore, there is a need for early identification measures for the prevention or reduction of the sequelae of middle ear pathologies associated with hiv. several middle ear pathologies have been reported in the literature. commonly reported middle ear pathologies in adults living with hiv range from acute otitis media (aom), recurrent otitis media (rom), otitis media with effusion (ome) to chronic suppurative otitis media (csom) (sebothoma & khoza-shangase, 2018; tshifularo et al., 2013). if middle ear pathologies are left undetected and untreated or detected late, they can invade other auditory compartments (e.g. inner ear), cause permanent auditory damage (kolo, salisu, yaro, & nwaorgu, 2012) and life-threatening conditions such as intracranial complications (ibrahim, cheang, & nunez, 2010). consequences of hearing impairment have been documented (anderson, paebery-clark, white-schwoch, drehobl, & kraus, 2013), which show perception of speech challenges in background noise that may continue despite amplification. consequently, this may affect overall communication and contribute to the development of psychosocial problems leading to a reduced quality of life (ciorba, berto, borgonzoni, grasso, & martini, 2007). permanent hearing loss may also have financial implications for individuals and the country (kuchkin, 2018). a systematic review indicates that permanent hearing loss is associated with billions of dollar in excess cost in the united states of america (huddle et al., 2017). early identification of middle ear pathologies is therefore crucial. while less severe forms of middle ear pathologies such as aom can be treated effectively with simple antibiotics at primary health care (phc) centres, chronic middle ear pathologies are often difficult to treat. these pathologies may require specialised services that are commonly found in tertiary hospitals or in the private healthcare sector, especially within the south african context (fagan & jacobs, 2009). access to such services is therefore limited because of capacity versus demand challenges (khoza-shangase, 2021). consequently, individuals may opt for ‘self-treatment’ using various hazardous methods (joubert, sebothoma, & kgare, 2017) that are known to cause or exacerbate auditory conditions. simple and affordable measures that can accurately identify early signs of middle ear pathologies are crucial. tympanometry with single probe tone frequency (e.g. 226 hz) remains a routine audiological measure for assessing middle ear pathologies (british society of audiology [bsa], 2013; macdonald & green, 2001; sebothoma & khoza-shangase, 2021) because it is easy to administer and produces objective results. however, several studies have demonstrated that tympanometry with a single probe tone is most likely to miss many middle ear pathologies or inaccurately detect them (kaf, 2011; sebothoma & khoza-shangase, 2018; shahnaz, bork, polka, longridge, & bell, 2009). subjective clinical examination technique are reported to have higher sensitivity and specificity than the standard tympanometry with a single probe tone frequency (khater, fahmy, shahat, & khater, 2015), and these measures require specialised skills currently only possessed by physicians such as otorhinolaryngologists. with the continued shortage of otorhinolaryngologists in developing countries such as south africa (fagan & jacobs, 2009), the use of subjective clinical examination technique can delay the diagnosis of middle ear pathologies and render early identification and management impossible. therefore, there is a need for measures that can combine simplicity, accessibility and high sensitivity and specificity in these contexts. wideband acoustic immittance (wai) has emerged as a potential measure that can accurately identify pathologic middle ears (hunter & shahnaz, 2014; sanford, hunter, feeney, & nakajima, 2013). all these studies have reported that wai is superior in identifying middle ear pathologies than the standard tympanometry with single probe tone. terzi et al. (2015) reported a sensitivity of 100% and 94% when wideband average (0.375 khz – 2.000 khz) is used. other studies have reported that wai can also predict conductive hearing loss (chl) (keefe, sanford, ellison, fitzpatrick, & gorga, 2012; prieve, feeney, stenfelt, & shahnaz, 2013). keefe et al. (2012) found that wai can predict the presence and magnitude of chl of air bone gap (abg) that ≥ 20 db at frequencies above 0.7 khz. the superiority of wai over standard tympanometry with single probe tone is attributed to its clinical parameters. wideband acoustic immittance uses stimuli with broad spectrum such as clicks assessed over a wide range of frequencies, typically from 220 hz to 11 000 hz to measure middle ear functioning (margolis, saly & keefe, 1999). unlike tympanometry with single probe tone, wai is also shown to be able to measure the resonance frequency (rf) of the middle ear system. this renders the measure more sensitive and specific and therefore arguably appropriate for early detection of middle ear pathologies in the population most at risk of these conditions. however, there is limited research on the sensitivity and specificity of wai in identifying middle ear pathologies in adults living with hiv. hence, the importance of this study, which intends to contribute to the existing body of knowledge regarding the sensitivity and specificity of wai. this is crucial in south africa where there is a high burden of hiv disease. therefore, the aim of this study was to determine the sensitivity and specificity of the wideband absorbance measure at tympanic peak pressure (tpp), as a screening tool for detecting middle ear pathologies in adults living with hiv. methods research design this study employed a prospective, non-experimental design (leedy & ormrod, 2013). data for this study was quantitative and variables of interests were described without any manipulation (irwin pannbacker, & lass, 2014). participants non-probability purposive sampling was employed to select and recruit potential participants (leedy & ormrod, 2013). purposive sampling was deemed appropriate as it allows the researcher to carefully select participants who exhibit the characteristics that are important and useful for the study (leedy & ormrod, 2013). in this study, for example, the inclusion criteria were that participants had to be adults diagnosed with hiv. several advantages of purposive sampling are documented in the literature. purposive sampling is a more convenient and cost-effective method to use than other sampling methods. participants were available at the hiv clinic and could be easily invited to participate in the study. the disadvantage was that non-probability sampling methods do not allow the researcher to generalise the findings to a larger population (leedy & ormrod, 2013). participants were adults aged 18 years and older diagnosed with hiv, attending the nmc. those who did not have otorrhoea on the day of testing, were invited, agreed and signed an informed consent form. all participants were black africans with similar socioeconomic backgrounds. this selection was performed because research has indicated that people from different ethnic groups (shahnaz & bork, 2006) and socioeconomic groups (siddartha, bhat, bhandary, shenoy, & rashmi, 2012) may have slightly different middle ear function. research context this study was conducted in one of the hiv clinics in the limpopo province in south africa. the clinic established an audiology clinic, which offers various audiological services. the clinic is one of the few in the country to have obtained an immittance machine, which can be used for wideband absorbance measurements. therefore, the choice of the study site was based on the availability of equipment and population being served at the clinic. procedure all participants underwent a basic audiological test battery, which included case history information using a self-developed abstraction sheet, video otoscopy using aurica otocam 300. tympanometry with 226 hz probe tone and wideband absorbance at tpp were performed using a titan interacoustic, denmark, version 3.3. pure tone audiometry was conducted using an ad 629 diagnostic interacoustics audiometer with sennheiser ha 200 supra-aural headphones and radio ear b-71 bone conductor. all these audiological equipment were calibrated 6 months prior the commencement of the study (jnaurary 2018). speech reception thresholds (srts) were performed using the south african spodaic (sas) wordlist (hanekom, soer, & pottas, 2015). the titan machine was connected to the acer laptop via a usb cable. an appropriate probe nub that provided a better hermetic seal was used to measure tympanometry using a 226 hz probe tone and wideband absorbance at tpp. a single low frequency probe tone of 226 hz at an intensity of 85 db sound pressure level (spl) was presented into the ear. to generate tympanograms, pressure was swept from +200 to –400 dapa. acoustic compliance, pressure (dapa) and ear canal volumes (ecvs) were analysed to determine the absence of a type a tympanogram or the presence of type as, ad, b or c indicative of middle ear pathologies. normative values that were used to determine the type of tympanogram were those of the bsa (2013). values that were within the normative range were coded as 1, indicating the absence of middle ear pathology; while values that were out of the normative range were coded 2, indicating the presence of middle ear pathology. wideband absorbance at tpp was conducted by changing the function on the titan equipment. wideband absorbance at tpp is conducted by varying pressure in the external auditory meatus from +200 to –300 dapa at the rate of 200 dapa/s. wideband absorbance measure was conducted at tpp because the tympanic membrane is at maximal mobility during tpp (feeney & sanford, 2012). data were collected at 107 frequencies from 0.226 khz to 8 khz. however, frequencies were reduced to 16 at 1/6th octave for statistical analysis purposes. the researchers used pure tone thresholds to determine the hearing sensitivity of each participant. air and bone conduction thresholds were measured across 250 hz – 8000 hz and 250 hz – 4000 hz frequencies, respectively. an abg of ≥ 10 db was used to determine the presence of middle ear pathology (e.g. chl or mixed hearing loss) (kramer & brown, 2019) all video otoscopic images were sent to two otorhinolaryngologists using asynchronous (save and forward) telepractice techniques (biagio, swanepoel, laurent, & lundberg, 2014). the roles of the otorhinolaryngologists were to analyse and make diagnoses of middle ear pathologies based on video otoscopic images. these results served as the gold standard against which to measure the sensitivity and specificity of the tympanometry with 226 hz probe tone and wideband absorbance at tpp. the motivation for utilising video otoscopic analysis through asynchronous telepractice method as a gold standard was based on clinical practice in south africa, where the diagnosis for middle ear diseases made by otorhinolaryngologists is considered to be the gold standard (biagio, swanepoel, adeyemo, hall, & vinck, 2013). the diagnoses of middle ear pathologies that were performed through the analysis of asynchronous video otoscopic images by the otorhinolaryngologists were found to be similar (k = 0.7) to those made via otomicroscopy (biagio et al., 2014). as a result of the scarcity of otorhinolaryngologists in south africa, a more convenient method, with a similar level of accuracy was chosen to serve as a gold standard. otorhinolaryngologists in this study were blinded on the demographic characteristics of the participants, recording and interpretation of the diagnoses. reliability and validity test–retest reliability was achieved by conducting a pilot study prior to the main study (satake, 2015). this pilot study was conducted with five adults who met the inclusion criteria of the main study (sebothoma & khoza-shangase, 2018). all the audiological tests were performed by the first author who is also an experienced clinical audiologist. each participant was tested individually in a sound treated room in the audiology department at nmc. calibration of all equipment was carried out before the commencement of the study, in line with the american national standards institute (ansi, 2004). daily biological calibration was also conducted everyday before testing participants (wilber & burkard, 2015). data analysis statistical analysis was performed using statistical package for social science (spss) version 24 (chicago, il). descriptive and inferential statistics were employed. the otorhinolaryngologists used a qualitative method to analyse the structure, thickness, colour and position of the tympanic membrane to make diagnoses of any middle ear pathology (biagio et al., 2013). for the purpose of this study, middle ear pathologies were not pre-defined; instead, were diagnosed by the otorhinolaryngologists using asynchronous video otoscopic images. cohen’s kappa was used to evaluate the agreement diagnosis between the two otorhinolaryngologists (sebothoma & khoza-shangase, 2018). the overall test performance of wideband absorbance at tpp and tympanometry with 226 hz probe tone was evaluated by using receiver operating characteristics (roc). the (auroc) curve and 95% confidence interval (ci) were calculated automatically on spss version 24. chi squared was also used to determine the association between the diagnosis made between the two otorhinolaryngologists and hearing loss with conductive component. ethical considerations this research project was approved by the human research ethics committee (hrec) (medical) (m160663) of the university of the witwatersrand, johannesburg. permission was granted by the provincial department of health (the limpopo province) and by the chief executive officer (ceo) of nmc. all participants gave written consent before commencing with the tests. results of the 198 ears included in the study, the two otorhinolaryngologists initially excluded 25 ears (13%) of the video otoscopic images because of poor visualisation of the tympanic membrane and wax. of the 173 ears, cohen’s kappa revealed a strong agreement between the diagnoses made by two otorhinolaryngologists (k = 0.7). another 12 ears (7%) were excluded from the study because the two otorhinolaryngologists were not in agreement with the diagnoses of the middle ear pathologies in these patients. therefore, a total of 161 ears were finally included in the study, 17 had abnormalities (11%) and 144 were normal (89%). middle ear pathologies that were diagnosed by the otorhinolaryngologists during analysis included ome (n = 5), retracted tympanic membrane (n = 4), tympanic membrane perforation (n = 3), csom (n = 2), tympanosclerosis (n = 1), tympanic membrane scarring (n = 1) and otitis externa (n = 1). table 1 indicates the diagnoses made by each otorhinolaryngologist. a total of 161 ears (87 adults) were finally analysed and diagnosed by the two otorhinolaryngologists. table 1: summary of video otoscopic diagnoses. table 2 and table 3 summarises the results indicated in the area under the curve that was used to determine the specific cut-off values to determine the sensitivity and specificity of wideband absorbance at tpp, tympanometry with 226 hz probe tone and pure tone audiometry. table 4 classifies the sensitivity and specificity of wideband absorbance measure in identifying middle ear pathologies in different frequencies. as the purpose of the study was to determine whether wideband absorbance at tpp has high sensitivity and specificity for identifying middle ear pathology, the criterion used to select cut-off values involves the use of the roc curve to select the point where the product of the two indices (sensitivity and specificity is maximum). these values were then used to determine the sensitivity and specificity of wideband absorbance at tpp. the procedure for determining the sensitivity and specificity of tympanometry using a 226 hz probe tone and pure tone audiometry was similar. table 2: area under the curve for wideband absorbance measure. table 3: area under the curve for tympanometry with 226 hz and pure tone audiometry. table 4: the sensitivity and specificity of wideband absorbance measurements. the sensitivity of wideband absorbance at tpp was higher (59% – 82%) in low to mid frequencies (226 hz – 971.43 hz), but significantly lower (23.5%) at frequencies above 971.43 hz (see table 3). the mann–whitney u test (nachar, 2008) revealed a statistically significant difference (p < 0.05) between the sensitivity of wideband absorbance at tpp and the sensitivity of tympanometry with 226 hz prone tone, especially in low to mid frequencies. the specificity of wideband absorbance at tpp was generally high across frequencies. there was no statistical difference between the specificity of wideband absorbance at tpp and the specificity of tympanometry using a 226 hz probe (93.8%). the sensitivity and specificity of pure tone audiometry in detecting middle ear pathologies were also established. the sensitivity of pure tone audiometry using the abg as an indicator was 17.6%, while the specificity of abg was 44%. the chi-squared analysis revealed that there was a statistically significant association (p = 0.62) between middle ear pathologies as identified by the otorhinolaryngologists analysis and actual diagnosed conductive pathology (conductive and mixed hearing loss). discussion this study evaluated the sensitivity and specificity of wideband absorbance at tpp compared with the standard tympanometry with 226 hz probe tone in adults living with hiv. to the knowledge of the authors these are the first results of wideband absorbance at tpp in adults living with hiv to date. although various types of middle ear pathologies may differentially influence the mass and compliance component of the middle ear system and may potentially be a major factor contributing to the difference in sensitivity and specificity, the prevalence of specific middle ear pathologies in this study was significantly low (n = 13). as a result, the sensitivity and specificity of wideband absorbance at tpp could not be linked to specific middle ear pathologies. instead, the researchers ended up with two categories, indicating ‘presence’ or ‘absence’ of middle ear pathologies. further studies are therefore required to investigate the sensitivity and specificity of wideband absorbance at tpp in adults living with hiv for specific middle ear pathologies. the sensitivity of wideband absorbance at tpp was generally higher than the sensitivity of tympanometry with 226 hz probe tone and pure tone audiometry in detecting middle ear pathologies. however, the specificity of wideband absorbance at tpp was comparable to the specificity of tympanometry with 226 hz probe tone. the findings of this study are consistent with previous studies, which indicated that wai absorbance or reflectance is superior in detecting middle ear pathologies compared with tympanometry with single probe tone (terzi et al., 2015). shahnaz et al. (2009) observed that tympanometry with a 226 hz probe tone is less sensitive to middle ear pathologies, which do not severely affect the mechanical properties of the tympanic membrane such as otosclerosis. often these pathologies alter the rf but may retain the normal functioning of the tympanic membrane (iacovou, vlastarakos, ferekidis, & nikolopoulos, 2013). while the sensitivity and specificity of wideband absorbance at tpp was generally higher in this study; it is lower compared with previous studies (beers, shahnaz, westerberg, & kozak, 2010; terzi et al., 2015). this variation may be attributed to various factors. firstly, the auroc values were obtained, which were used to generate cut-off values that were generally lower in this study compared with previous studies. for example, a minimum auroc of 0.56 and maximum of 0.98 across a frequency spectrum (0.25 hz – 8.00 khz) was found by terzi et al. (2015), which indicate a good diagnostic test in distinguishing pathologic ears from non-pathologic ones. however, in this study, auroc values of 0.41–0.64 were obtained across the frequency spectrum (0.25 hz – 8.00 khz). these auroc values have facilitated the selection of maximum sensitivity and specificity. the reasons for obtaining such small auroc values in this study are not clear. perhaps using the diagnoses and analyses of otorhinolaryngologist as a gold standard may have been a confounding factor. otorhinolaryngologists used video otoscopic images to analyse the structure and colour of the tympanic membrane to make the appropriate diagnoses. however, wideband absorbance at tpp as part of the acoustic immittance relies on the mechanical aspect of middle ear system (beers et al., 2010). literature suggests that there are certain middle ear pathologies that do not affect mechanical aspects of the middle ear system, and therefore acoustic immittance measures may miss these pathologies (kaf, 2011; sebothoma & khoza-shangase, 2018). despite this limitation, results have still indicated wideband absorbance at tpp to be a better measure of detecting middle ear pathologies than the standard tympanometry using a 226 hz probe tone. research suggests that there is an association between hiv and middle ear pathologies (sebothoma & khoza-shangase, 2018). unfortunately, these pathologies persist despite the effectiveness of art treatment. given the fact that hiv continues to increase, especially in developing countries (joint united nations programme on hiv/aids [unaids], 2018) combined with shortages of health professionals (mulwafu, ensink, kuper, & fagan, 2017), there is a need to use measures that have high sensitivity and specificity in identifying middle ear pathologies. wideband absorbance at tpp offers the possibility of accurately identifying pathologic middle ears that could not be identified through the use of tympanometry with 226 hz probe tone, thereby facilitating early intervention. these findings support evidence suggesting that wideband absorbance measures can improve early identification of middle ear pathologies (terzi et al., 2015), especially in individuals who are prone to infection. however, the pattern of sensitivities across frequencies in this study was different from other studies (beers et al., 2010; terzi et al., 2015). although the rf in this study was not calculated, the current findings suggest that wideband absorbance at tpp alone may also miss pathologies affecting the rf, which sometimes can be detectable above 971.43 hz (özgür et al., 2016). therefore, wideband absorbance at tpp may need to be used in conjunction with other measures in order to improve early identification in adults living with hiv. therefore, further studies are needed in this area. clinical implications the literature suggests that individuals living with hiv are at increased risk of middle ear pathologies compared with hiv negative control group (sebothoma & khoza-shangase, 2018; tshifularo et al., 2013). middle ear pathologies of these individuals vary depending on the number of cd4 cells in the body (obasineke, amdi, ibekwe, ezeanolue, & ogisi, 2014; van der westhuizen et al., 2013). some of these pathologies may be missed when using tympanometry using a 226 hz probe tone. sebothoma and khoza-shangase (2018) observed that the use of tympanometry using a 226 hz probe tone in identifying pathologic middle ears is ineffective in individuals living with hiv. despite the difference between the finding of this study and previous studies the recommendation is still made that wideband absorbance at tpp may be useful in clinical practice. audiologists may be able to identify early signs of middle ear pathologies and offer opportunities for timeous interventions. some middle ear pathologies can be successfully treated at phc centres with antibiotics. however, severe middle ear pathologies may require specialised services, which are limited in developing countries (fagan & jacobs, 2009). the utility of wai in clinical practice may potentially improve early identification and reduce these challenges. with the current proposed model of service delivery in resource-constrained environments, which involves the use of specialised technology (swanepoel & clark, 2018), wideband absorbance measure can be embedded in these programmes, increase access to hearing healthcare and thereby reduce costs associated with traveling long distances for treatment. although there is a promising prospect of using wai, especially for the identification of middle ear pathology in developing countries and can be carried out without otorhinolaryngologists and audiologists, it may not be considered because of its expense. while testing may take a couple of seconds to complete, trained audiologists are needed to conduct these tests, and the equipment for measuring wideband absorbance measure is considerably more expensive and more sophisticated to operate compared with conventional screening tympanometry. it is not yet known whether paraprofessionals can effectively conduct and interpret wideband absorbance measures. much work still needs to be carried out. increased sample sizes in wai studies may enable generalisability. furthermore, studies on wai must include an hiv negative control group in order to make a comparison of wideband absorbance patterns in adults living with hiv. as acoustic reflex thresholds were not conducted as part of the middle ear assessment, further studies need to include art in order to improve the accuracy of identifying middle ear pathologies. lastly, studies on wideband absorbance measure must also measure ambient pressure (hunter & shahnaz, 2014), which provides crucial information about the middle ear mechanics. conclusions the findings of this study reveal that wideband absorbance at tpp can show middle ear pathologies better than the conventional tympanometry with 226 hz probe tone. given the high prevalence of hiv in south africa, and its continued link to the development of middle ear pathologies, incorporating wideband absorbance measure in clinical practice may improve early identification of middle ear pathologies and offer these individuals the opportunity to receive timeous intervention. however, wideband absorbance measures may need to be used in conjunction with other measures, which are more sensitive to middle ear pathologies that have not yet affected the mechanical properties of the tympanic membrane. acknowledgements authors would like to thank all participants who volunteered to participate. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions b.s. and k.k.-s. contributed to the conceptualisation of the study, design, data collection, analysis and writing of the manuscript. k.k.-s. also supervised the study. d. mol and d. masege analysed the video otoscopic images. all authors have read and approved the final manuscript. funding information the authors thank the national institute for the humanities and social sciences (nihss) for providing financial assistance for the publication of this manuscript. data availability the data that support the findings of this study are available from the corresponding author, b.s., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references american national standards institute. 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(2013). auditory and otological manifestations in adults with hiv/aids. international journal of audiology, 52(1), 37–43. https://doi.org/10.3109/14992027.2012.721935 wilber, l.a., & burkard, r. (2015). calibration. in j. katz, m. chasin, k. english, l.j. hood, & k.l. tillery (eds.), handbook of clinical audiology (7th ed., pp. 9–27). philadelphia, pa: wolters kluwer health. williams, b.g., lloyd-smith, j.o., gouws, e., hankins, c., getz, w.m., hargrove, j., … auvert, b. (2006). the potential impact of male circumcision on hiv in sub-saharan africa. plos medicine, 3(7), 1032–1040. https://doi.org/10.1371/journal.pmed.0030262 t h e l i v e d e x p e r i e n c e o f b e i n g a s p e e c h l a n g u a g e t h e r a p i s t in t h e w e s t e r n c a p e p u b l i c h e a l t h servi ce jocelyn a. warden, patricia mayers and harsha kathard division of communication sciences and disorders, university of cape town, south africa abstract this study explores the lived experience o f being a speech-languagetherapist (s-l therapist) in the south african western cape public health service.the lived experience of seven s-ltherapists with varied clinical experience was illuminated using a qualitative phenomenological research design. s-ltherapists, working in the three western cape tertiary hospitals, provided an in-depth account of their experiences as s-lthera pists.theaudiorecorded interviews weretranscri bed verbatimandanalysedusinganadaptationofcolaizzi's (1978) method of analysis. the rigour and trustworthiness of the research process was informed by consid­ eration of issues of credibility, applicability, confirmability and dependability as they relate to phenomeno­ logical design. five main themes emerged from data analysis: expectations of practice and practice realities; being partofthe"underdog"profession:roledefinitionandstatus;beingconnected;theholisticnatureofthe s-ltherapist'spractice;anderosionorpromotion.theimplicationsfortrainingandsupportofs-ltherapists by managers and policymakers and peers are highlighted. k e y w o r d s : phenomenology, lived experience, western cape public health service, speech-language therapist. this study responds to the question: w h a t meet the needs o f communicatively impaired south is the essence o f the lived experience o f safricans (bortz, jardine, & tshule, 1996). interna­ls therapists in a rapidly changing public tional studies have researched issues such as the ef health system in the western cape? ‘lived experifeet o f extrinsic and intrinsic job satisfaction factors ence’ studies (phenomenology) examine human exon retention o f s -l therapists (randolph, 2 0 0 5 ), is perience through descriptions provided by the people sues o f gender imbalance in the profession (boyd 6c who have the experience o f the phenomenon under hewlett, 2 0 0 1 ; sheridan, 1999), the patient-profes investigation. phenomenology aims to describe how sional relationship (stone, 199 2 ), the effect o f per people experience a specific phenomenon, how they sonal and professional value imbalance on dissatis interpret those experiences and what meaning the faction (byng, cairns, 6c duchan, 2 0 0 2 ) . experiences hold for them. research o f this nature speech-language therapy (s -l therapy) serv uses the person’s description o f their experience to ices in the western cape are managed primarily “transform lived experience into a textual expression by the department o f health. the post-apartheid o f its essence” (van manen, 1990, p. 36). w hile pheservice provision for health care in general is under nomenological research in the field o f s -l therapy pinned by principles o f primary health care (van has focused primarily on people living with certain rensburg, 2 0 0 4 ) and implemented through the dis communication disorders such as aphasia and dysflutrict health system. since 1994, health service deliv ency, this study focuses on professional issues by exery in the western cape has undergone rapid change ploring the lived experience o f s-ltherapists them as accessibility o f services to indigent communities selves. has been extended. m ajor reorientation o f services research in south africa has focussed on burnhas occurred at primary, secondary and tertiary levels out amongst s-ltherapists (swidler 6cr oss, 1993), o f care across the health sector. despite this reori threats to the profession within the south african entation, s -l therapists have remained primarily in context (tuomi, 1994), quality assurance in speechthe three tertiary hospitals, namely red cross chil language pathology and audiology within the south drens w ar memorial hospital (r x h ), groote sch african context (tuomi, 1994), and training needs to uur hospital (g s h ) and tygerberg hospital (t b h ) the s o u t h a f r ic a n jo u r n a l o f c o m m u n ic a t io n d iso r d er s, v o l 55 2 0 0 8 | 49 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) jocelyn a. w a r d e n , patricia mayers a n d h a r sh a k ath ar d limiting service delivery at primary or secondary levels. as a consequence o f the imperatives for transformation o f service delivery in south africa, the demography o f the client population and variety o f settings in which south a f­ rican s l therapists provide services has changed and ex­ panded. significant theoretical, clinical and technological advances in the field o f s l therapy (aron, 1991) together with the social and political changes since 1994 have sig­ nificant implications for the training o f s l therapists. in the current context, s l therapists are challenged to meet new service delivery imperatives and, in this rapidly chang­ ing context, it is vital to understand their lived experience. tuom i reported that the profession and professionals were considered to be showing “signs o f strain” (1994, p. 6). challenges facing the profession were projected to be the management o f the diversity o f people, cultures and lan­ guage groups, a phenomenon also described by h enri and hallowell (2001) in respect o f the international context. even though historically s l therapists have had “little experience and often little inclination to participate in the arena o f political advocacy and lobbying” (lubinski 8c frat tali, 2 0 0 1 , p. 34 4 ), there has been a significant increase in the need for advocacy worldwide (lubinski 8c frattali, 2001). the predicted changes that aron and tuom i described are unravelling in the current context, providing impetus for this study. w h ile contextual influences present a challenge, the na­ ture o f the work o f s l therapists influences their reality. a s part o f a helping profession s l therapists are “first and foremost helpers” (purtilo, 1990, p. 18) as they benefit the individual in society, and patients’ lives are directly or indi­ rectly affected by their activities. another dimension o f s l therapy practice is one o f forging identity. “throughout history, the discipline o f hu­ man communication sciences and disorders as well as speech-language pathologists have worked aggressively to form an identity that is unique from other disciplines, and have earned a reputation o f being specialists in the field o f communication and related disorders” (frattali, 2 0 0 1 , p. 173). this, however, can lead to a professional identity so separate from other professions that it becomes a profes­ sional liability “i f pursued as propriety and at the exclusion o f other professionals” (p. 173). s l therapists are encouraged to adopt interdisciplinary or multidisciplinary approaches to treatment (frattali, 2 0 01). the focus on co-ordination and communication between members brings together diverse skills for the achievement o f goals. the centrality as well as the changing nature o f the clini­ cal relationship is a key element in effective service deliv­ ery in communication disorders and other helping profes­ sions (stone, 1992). s l therapy intervention as well as other healthcare interventions take place in a context o f an interaction between the patient and professional a rela­ tionship documented as early as 1 937 (bloom 8c summey, 1978). m odels o f the professional-patient relationship have changed significantly from distinctly asymmetrical models (parsons, as cited in bloom 8c summey, 1978) where the professional was assigned specific privileges such as profes­ sional self-regulation, access to physical and personal intima­ cy with the patient, autonomy and professional dominance. r ecent models describe a mutual participation (fadlon 8c werner, 1999) and an encounter o f cultures, background, families and aspirations. as the s l therapist-patient re­ lationship develops, it creates its own “dynamic quality that is affected by what the s l therapist and client bring to it” (flasher 8c fogle, 2 0 0 4 , p. 87). the trust which devel­ ops between the s tl therapists and their patients has been referred to as “professional closeness” (purtilo, 1990, p. 22) and the manner in which the client behaves toward the s l therapist is suggested to be directly linked to how the s l therapist thinks, feels and behaves towards the client (flasher 8c fogle, 20 0 4 , p. 88). the approach o f the medical profession to the manage­ ment o f illness, disease and disability has changed signif­ icantly over the last few decades (sahler, 2 0 02). as more medical professionals have begun to appreciate the patient s right and desire to participate in the management o f his or her illness, the patient is no longer seen as a passive recipi­ ent o f medical science and treatment. this has led to health professionals taking a more holistic approach described by engel (1977) as the biopsychosocial model o f healthcare. this model recognizes other aspects o f the person as possi­ ble contributing factors to the presenting problem. the shift in the management o f patients, illness and disease has im ­ pacted significantly on the s l therapy practice, particu­ larly at a relational level. the hybrid nature o f the s l therapy profession, which draws on fields such as neurology, psychology, anatomy, physiology, physics, education and computer science makes it a highly integrated profession that is not limited to one approach to the treatment o f patients and their disorders. this makes the profession consistent with the principles that guide the biopsychosocial model o f healthcare. as a consequence o f the complex range o f issues shap­ ing the work o f s l therapists, and those involved in “peo­ ple work” (farmer, m onahan, 8c hekeler, 1984, p. 43), many stress-related factors have been described. factors which are inherently stressful within human service professions in­ clude the complexity o f clients and their needs, the difficulty in evaluating success, the poor perceptions o f the helping re­ lationship by others, lack o f support from the organization, ambiguous decision-making processes, and tension o f client needs and organization demands (farmer et al., 1984, p. 45). m aslach (1982) stated o f health professions that “because by definition the recipients o f most helping relationships are people with problems, the health professional inevitably sees the part o f her patient that is negative or needing interven­ tion” (p. 18). a major source o f stress for s l therapy professionals is that o f conflicting priorities in settings where s l ther­ apy intervention is regarded as merely a supportive function within the hospital team (byng et al., 2 0 02). the only pub­ lished south african study on burnout among s l ther­ apists reported that, at the time o f this study, s l thera­ pists and audiologists were experiencing moderate levels o f emotional exhaustion, low levels o f depersonalization, and high levels o f personal accomplishment. hospital thera­ pists in particular perceived themselves as being under large amounts o f pressure and susceptible to burnout (swidler 8c ross, 1993). so | die su id -afr ika an se ty dsk r if vir k o m m u n ik a s ie -a fw y k in g s , vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t h e l iv e d e x p e r ie n c e o f b e in g a s p e e c h l a n g u a g e t h e r a p i s t organizations in which people work, create motivation through factors that are either intrinsic or extrinsic to the work itself (bratten, callinan, forshaw, 8c sawchuk, 2007). reporting on extrinsic and intrinsic factors which correlated with career satisfaction and desire to stay in the jo b amongst hospital-based occupational therapists, physiotherapists and s l therapists, barnes (as cited in randolph, 2 0 0 5 ) stat­ ed that the only significant positively correlating extrinsic factors were productivity expectations and a flexible work schedule (randolph, 2 0 0 5 ). intrinsic factors that positively correlated with jo b satisfaction an d desire to stay in the jo b were stable work environment, opportunity for professional growth, input into departmental decisions, and practising in an environment that was in line with the professionals values. intrinsic factors that positively correlated with jo b satisfaction only, were opportunities for direct patient care, feeling competent, accomplishing career objectives, and meaningful work. intrinsic factors that positively correlat­ ed with desire to stay in the jo b only were fair policies, and closeness with co-workers. harrison (1983, p. 2 2 4 ) stated “a sense o f competence and a feeling o f efficacy are the results o f being able to af­ fect the environment and meet its challenges”. i t has been proposed that significance is a core motive for all people, especially those engaged in a profession, and that people in the helping professions want to feel that they are making a difference in others’ lives (cherniss, 1995). professionals may develop positive affective responses to their jobs i f they believe that what they are doing is valuable and makes a d if­ ference to the lives o f their patient(s). harrison’s social competence model o f burnout (1983, p. 22 4 ), although developed over twenty years ago, illustrates clearly the nature o f transactions between the individual and his or her work environment. in relation to s l therapy and other healthcare professions, the model demonstrates that while the motivation to help and serve others is an impor­ tant pre-requisite for the professional, the presence o f sup­ portive aspects (helping factors) significantly affect the pro­ fessional’s sense o f competence and resultant motivational enhancement. similarly, the presence o f non-supportive aspects (barriers) significantly decreases the professional’s sense o f effectiveness, leading to burnout and a reduced m o­ tivation to help others. some cited supportive aspects include: participation in peer counselling and support from colleagues, feeling sup­ ported by managers, feeling training had prepared them for the working environment, feeling their expectations o f the jo b had been satisfied, feeling a sense o f pride and achieve­ ment when goals were attained, and experiencing work as interesting and rewarding (akroyd, w ilson, painter, 8c figuers, 1994; collings 8c murray, 1996; culbreth, scar­ borough, banks-johnson, 8c solomon, 2 0 0 5 ; hasselkus 8c d ickie, 1994; jenkins, 1991; jenkins 8c e lliott, 20 0 4 ; kil fedder, power, 8c w ells, 2 0 0 1 ; lloyd, king, 8c chenoweth, 2 0 0 2 ; lloyd 8c king, 2 0 0 1 ; m oore, cruikshank, 8c haas, 2006a; m oore, cruikshank, 8c haas, 2 0 06b ; reid et al., 1999; u m 8c harrison, 1998). non-supportive aspects (barriers) include high jo b de­ mands and work' overload; low supportive work relation­ ships with supervisors and co-workers; dealing with death and dying; lack o f essential resources; uncooperative family members and clients; time constraints; poor or unfair re­ muneration and disregard for professional worth (austin, shah, 8c muncer, 2 0 0 5 ; carson, w ood, w h ite, 8c tho­ mas, 1997; cheng, kawachi, coakley, schwart, 8c colditz, 2 0 0 0 ; decker, 1997; lloyd 8c king, 20 0 1 ; m cg ib bon , 1997; m oore, et al., 2006a; murray, 1998; sm ith 8cn ursten, 1998; pope, nel, 8c poggenpoel, 1998; van w ijk , 1997; w ebster 8c hackett, 1999). the literature has shown the multidimensional influenc­ es on s l therapy as a profession. it is a helping profes­ sion challenged by having to construct its identity in rapidly changing socio-political contexts, continuously shifting to­ wards a social model, questioning its practice, and practi­ tioners experiencing the same professional stress and burn­ out felt by other helping professionals. despite the depth and breadth o f the literature, the essence o f the experience o f being a s l therapist is an area which has not been suf­ ficiently explored. this study explores the lived experience o f the s l therapist, to contribute to the body o f knowledge in this area. methodology aim the aim o f this study was to explore and describe the lived experience o f being an s l therapist in the western cape public health service. research question: w h a t is the lived experience o f being an s l therapist in a rapidly changing public health service in the w estern cape? participant selection criteria participants were required to meet the following inclu­ sion selection criteria: a t least two years work experience as a s l thera­ pist in the w estern cape public health service (hospital or community) currently a full-tim e or part-tim e s l therapist in the w estern cape public health service (hospital or com ­ munity) i f on a dual register ( s -l therapy and audiology), 50% o f the participants’ weekly activities had to be dedicat­ ed to s l therapy. voluntary participation with openness to share ex­ periences participants who were at different stages o f their careers were selected as this was assumed to broaden the range o f experience which might emerge during interviews (patton, 2002). purposive sampling was used in order to select partic­ ipants (guba 8c lincoln, 1989; schofield and jamieson, 1999). purposive sampling is appropriate for small studies as the “logic and power o f purposive sampling lies in select­ ing information rich cases for study in depth” (patton, 2002, p. 230). the study was limited to the w estern cape as it was a context which was undergoing rapid change and there was a need to understand experiences within this context. the re­ searcher also had close knowledge o f the context which was a strength in an exploratory study o f this nature. the study was limited to this area to allow the researcher ease o f access th e s o u t h a f r ic a n j o u r n a l o f c o m m u n ic a t io n d iso rd er s, v o l . 55 2 0 0 8 | 51 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) jocelyn a. w a r d e n , patricia mayers a n d h a r s h a kath ar d to participants to enable personal communication. access to participants following approval from the university o f cape town faculty research ethics com m ittee, the medical superin­ tendents and speech therapy heads o f department o f the three tertiary hospitals were contacted. inform ation about the study aims and what participation would involve for staff members was provided. o nce permission was grant­ ed, all s l therapists in each hospital were individually e-mailed with the study information and participant re­ quirements, and requested to respond indicating either will­ ingness or unwillingness to participate. e ach s l therapist who agreed to participate was contacted telephonically in order to arrange an interview time and venue. participants were assured o f confidentiality and o f their right to with­ draw from the study at any time without penalty or preju­ dice. description of participants the sample group comprised seven female s l thera­ pists ranging in age from 26 to 52 years with a mean age o f 3 6 years. the number o f years work experience ranged be­ tween 3 and 2 7 years, with three participants holding b ach­ elor degrees and four holding m asters degrees from two universities in cape town. all, at the time o f data collection, worked at one o f the three tertiary hospitals in the western cape. five participants had dual registration as s l thera­ pists and audiologists while two had single s l therapy registration. five o f seven participants had a predominantly paediatric s l therapy caseload. ethical considerations e thical approval was obtained from the school o f health and rehabilitation sciences and the university o f cape town faculty research ethics committees. participation in the study was voluntary. s l therapists who declined to participate were not contacted again in connection with the study. w ritten informed consent was obtained from each participant. identifying information about the participating s -l therapists was kept confidential and participants were allo­ cated a number which appeared on all transcripts. identify­ ing information was removed from all direct quotes without changing the meaning o f the words. as s l therapy de­ partments in the w estern cape public service are small, all correspondence between the researcher and participant was conducted via personal e-mail which is password protected. issues in relation to interviewing colleagues as the researcher is herself a s l therapist, and in view o f the limited number o f s l therapists working in the w estern cape public health service, it was not possible to eliminate all s l therapists known to the researcher from the potential pool o f participants. advantages o f interview­ ing colleagues include shared language and shared level o f education, norms, and knowledge o f the participant work culture (holloway 8c w heeler, 1996). a potential disadvan­ tage, such as lack o f trust and privacy between participating s-l th erap ists and myself [the researcher], was minimised by avoiding face-to-face discussions with participating and non-participating s l therapists in the workplace and re­ questing that participants not discuss the content o f their interview with fellow colleagues. the danger o f me [the re­ searcher and a s l therapist] becoming over-involved and over-identifying with the participating s l therapists was minimised by formally assuring the participant that i was conducting the study from the point o f a researcher and not a s l therapist or colleague and that i would not be assuming or drawing on prior conversations we may have had. continuous researcher self-reflection and bracketing (creswell, 1998; holloway 8c w heeler, 1996) o f presuppo­ sitions and attitudes, and ongoing discussion between the researcher and study supervisor contributed to maintaining the integrity o f the research process. research procedure data collection d ata were generated through seven individual in-depth interviews (approximately 90 minutes in length); the keep­ ing o f field notes and reflective memoranda by the research­ er; and seven follow-up interviews (approximately 30 min­ utes in length) to discuss preliminary study findings. e ach interview commenced with an initial question “i would like you to tell me as fully as you are able, and draw­ ing from your experience, what it is like to be a s l thera­ pist in the public health service?”this question was followed with explorative questions and reflective responses by the researcher. phenomenological interviewing relies on skilled listening without prejudice by the interviewer, and encour­ aging and allowing the interviewee to describe their experi­ ence without interruption by questions from the interview­ er. as the participant is actively involved in the gathering process o f discovery and interpretation (van m anen, 1990, p. 98), and with interpretation taking place during and after the formal data gathering phase, interviews deliberately did not contain a set o f pre-formulated questions. this allowed the researcher to remain open to new and unexpected views and ideas. bracketing (creswell, 1998; holloway 8c w heeler 1996) was applied whereby the researcher’s beliefs about the phe­ nomenon were made explicit and temporarily suspended, enabling the researcher to be open to new understandings. interviews were recorded, dated and labelled with the par­ ticipant’s number, and transcribed verbatim to reliably rcr fleet the interviewees precise words including non-verbal and para-linguistic communication (hycner, 1985). | interviews were followed by the writing o f field notes which captured the “flavour o f the interview” (holloway 8c w heeler, 1996, p. 70) as well as participants’ behaviours, at-, titudes and non-verbal information (mason, 1996). reflec­ tive memoranda were not part o f the direct data collection process, but contributed to the analysis phase and enhanced rigour by describing the research process and capturing the researcher’s views, thoughts, feelings and opinions. individ7 ual follow-up conversations were held with each participant to clarify issues which were not clear in the original inter­ view. ^ data analysis the challenge o f qualitative data analysis is “making sense o f massive amounts o f data, reducing the volume o f raw in­ formation, identifying significant patterns, and constructing a framework o f communicating the essence o f what the data reveal” (patton, 2 0 0 2 , p. 432). the analytic frameworks sug­ gested by colaizzi (1978) and hycner (1985) were followed 52 die su id -afr ika an se ty dsk r if vir k o m m u n ik a s ie -a fw y k in g s , vol. 5 5, 2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t h e l iv e d e x p e r ie n c e o f b e in g a s p e e c h l a n g u a g e t h e r a p is t to analyse the verbatim transcriptions. the researcher read each transcript a number o f times and significant statements relating to the phenomenon were extracted. these were tabulated in an adjacent column with the statement re-written in the third person, which helped to personalise the statement (table 1). duplicate statements were eliminated. next, each significant statement was coded to bring out the meaning in the description (table 2). next, similar codes within each transcript were grouped togeth­ er into clusters. clusters were grouped across all transcripts into categories which were finally assigned to one o f five final themes. themes and categories were checked against each original transcript to ensure that all information from the transcript was contained in the themes and vice ver­ sa. findings from each theme were written as an exhaus­ tive thick description in paragraph form substantiating the analysis through the use o f interview excerpts, van m anen (1990) describes the identified themes as being “objects for further reflection in follow-up hermeneutic conversations in which both the researcher and the interviewee collaborate” (p. 99). this was achieved by returning the themes and a short description o f each to the participants to read, and then conducting a 3 0 4 0 minute discussion where each participant was given the opportunity to comment on the findings, clarify issues and expand on the interpretation. lastly, findings from all five themes were combined into an exhaustive description o f the phenomenon. rigour and trustworthiness in qualitative inquiry the credibility and legitimacy o f the study is dealt with under the broad framework o f trustwor­ thiness (patton, 2 0 0 2 ). credibility (in preference to inter­ nal validity) refers to the truthfulness and value o f the re­ searcher’s findings to represent the world as perceived by the participants (maxwell 8c satake, 2 0 0 6 ). the research­ er has provided a clear description o f the study setting and participants, the research process as well as describing the researcher’s personal experience o f being a s l therapist. shenton (2004) recommends the “development o f early fa­ miliarity with the culture o f participating organisations be­ fore data collection takes place” (p. 64). as a s l therapist, the researcher was 'familiar with the settings and facilities in which s l therapist participants worked. shenton (2004) offers further strategies for enhancing credibility: potential participants should be given the opportunity to refuse to participate, contending that this ensures that data are ob­ tained only from participants who are genuinely willing to take part in the study; frequent debriefing sessions between researcher and superiors/supervisors; peer scrutiny by col­ leagues, peer and academics; member checks (achieved by revisiting the participants after their interview to validate that the emerging categories and themes were consistent with the participants’ experiences);! researcher’s reflective commentary, and thick description o f the phenomenon un­ der scrutiny, all o f which were adhered to in this study. a pplicability/transferability is the degree to which the findings can be applied to other contexts, groups or gen­ eralised to the greater population although generalisability is not relevant in!many qualitative research projects (kref ting, 1991). “the results o f a qualitative study must be un­ derstood within the context o f the particular characteristics o f the organisation and perhaps the geographical area in which the fieldwork was conducted” (shenton, 20 0 4 , p. 70). participants with a range o f career experience were select­ ed to facilitate transferability judgments on the part o f s -l therapists in other public service settings (guba 8c lincoln, 1989). confirm ability (in preference to objectivity) shows that data are linked to their sources (guba 8c lincoln, 1989; holloway 8c w heeler, 1996). a n audit trail was used to ena­ ble the reader to understand and evaluate how methodolog­ ical, analytical and theoretical decisions were made (lincoln 8c guba, 1985), thus ascertaining whether the findings are “grounded in the data” (lincoln 8c guba, 1985, p. 32 3 ). in this study the researcher kept reflective memoranda o f ideas, thoughts, feelings, opinions and difficulties experienced, e.g. the researcher’s feelings during and following interviews. included was additional information about the participants themselves such as reactions to events and comments made. following transcription o f each interview, the researcher’s impression o f that participant’s experience along with the researcher’s knowledge o f that participant as a colleague was noted. this assisted to bracket out personal feelings in respect o f knowing some participants as colleagues. after each stage o f analysis progress notes were made and tables o f preliminary findings stored for comparison to the follow­ ing stage findings. this also contributed to the dependability (reliability) o f the research process and the findings. findings phenomenological analysis across all interview tran­ scripts resulted in five themes that represent the lived expe­ rience o f being a public health service s l therapist. each theme is supported by excerpts from participants’ interviews as quotes (in italics) which serve as exemplars o f the partici­ pants’ experience. theme one: expectations o f practice and practice re­ alities s l therapists begin their careers with the desire to make a significant difference to the lives o f their patients. they are motivated because “you're concerned about their speech a n d lan ­ gu age”-. “. . . i think, sort o f w an ting to be able to, to help people, um, you kn ow an underlying desire to, to be able to try a n d make a difference somewhere ... .you kn ow w e w an t to be able to, to help everyone m ake a big difference, m ake their lives better and, help them to cope a t school a n d help them to, be a success in life, a n d m ake their social circumstances easier... ’ w orking as an s l therapist is different to their antici­ pations and they soon realise that they are not able to help everyone they see. furthermore, they feel let down as the public health system is not as organised and efficient as it was portrayed during their training, and they struggle to gain the same level o f control they had as student thera­ pists: “. . . i think in, in the beginning i t ’s a b it harder 'cosyou, you come in into the profession a n d i t ’s very differen t to w h a t you w ere p rep ared f o r as a student. as a student, i mean every­ thing is like in order an d you kn ow it looks like there’s this w hole system in p lace to d ea l w ith people coming in w ith speech problems, w ith hearing problem s a n d you kn ow every­ t h e s o u t h a f r ic a n j o u r n a l o f c o m m u n ic a t io n disord er s, v o l. 55 2 0 0 8 | 5 3 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) jocelyn a. w a r d e n , patricia mayers a n d h a r s h a k ath ar d thing looks g ood on paper, but when you actually start, start working. . . i t ’s a lot messier than w h at i think you expect a n d i think that is a b it o f a, a let dow n in a way, um, a n d a b it fru stra tin g .. . ” the abovementioned progression is described by trys senaar and perkins (2001, p. 22) as the “transition stage” which is an eager “marking tim e” through a student’s final months in training; the “euphoria and angst stage” as the therapist begins professional practice with both excitement and trepidation; the “reality o f practice stage” where thera­ pists struggle through sometimes “unpleasant experiences” (p. 22) as s l therapists come to terms with the realities o f the job. research conducted with health, welfare and education professionals has identified issues consistent with the ex­ periences o f current study participants. curtis and m artin (1993) reported physiotherapy graduates as having had “un­ realistic expectations” (p. 588) on leaving student life and entering the professional world. expectations were not al­ ways met or were met in an unanticipated fashion. lloyd et al. (2002) reported that social workers have felt dissatisfied with the discrepancy between the ideals o f social work they were trained in and the reality o f day to day practice; par­ ticipants stated that their profession “has a very idealistic and reforming philosophy which is not met by many social workers in practice” (p. 262). in a study by madjar, m cm illan, sharke, and cadd (as cited in chang 8c hancock, 2 0 0 3 , p. 156) nurses stated that they experienced a significant gap between the theory they had learned in training and what was expected o f them in practice. school counsellors have been reported to experi­ ence a discrepancy between the ideal role and the role that interns (novice teachers) experience in practice (culbreth et al., 2 0 0 5 ). a current study participant described defining her role is a “continuous challenge”. communication disorders are seldom as clearly diagnosed and treated as many medical conditions, and the nature o f these disorders is such that a complete recovery following intervention is often not possible or realistic. residual defi­ cits may remain, and this may leave s l therapists feeling that their work is unfinished, unresolved and incomplete: “the nature o f language disorders, never, neverfixed, seldom, i t ’s, i t ’s a life-lon g disability... ” patients who attend the public service healthcare facility are mainly those with no medical insurance who often live in negative social contexts. for s l therapists this “perpetu­ ates the current situation” and is a barrier to progress. there are aspects o f s l therapists’ interventions which cannot be implemented without societal change: “...b u t sometimes the bitterness around the edge j a [yes], definitely, i guess th at w ould k in d o f represent the aspects o f society that are beyond me as an in d iv id u al to effect any change... ” to counteract these limitations, s l therapists acknowl­ edge the pressures their patients face and seek to use their skills and knowledge to “help people [patients] to understand h ow they [social elements] are related to the languageproblem"'. through examining the environmental stressors at play in a patient’s life, s l therapists attempt to understand fully the patient’s language/speech difficulty. they dedicate their time and energy to empowering and educating their patients and families about the role they can play in bringing about last­ ing change in their own lives and cope with future challeng­ es in a positive manner. .. um, but i think ultimately i f things in their hom e situa­ tion or community situation are affecting the specific speech a n d language difficulty, one needs to address them otherwise dealing w ith the underlying speech a n d language disability can be a b it o f a waste o f time... ” over time, as s l therapists come to terms with the re­ alisation that there is much that is beyond their personal ca­ pacity to change, they become less idealistic and more prag­ matic about what they can and cannot achieve. they begin to establish more realistic goals and expectations, adapting their therapy to the setting and patients: “. . . i ’m ju s t more realistic in my goals, an d my expectations, um, a n d i ’m more realistic about the population i w ork with, um, w h at they can, what, w h a t i can expect them to w an t to d o ... i mean you kn ow when you’re 20, you think you can change the world, now i kn ow i can ju s t change my corner o f the w orld!so th a t’sfine!... ” acceptance o f this reality enables s l therapists to be­ come more realistic about future experiences. b y being less idealistic about their work, their patients and therapeu­ tic outcome, s l therapists experience less anxiety about needing to f i x ” every patient’s problem. no longer solely responsible for every patient’s progress, and free from ideal­ istic expectations, s l therapists are better able to deal with difficulties which arise and view them as being part o f the jo b rather than crises. this adjustment to their profession is described by tryssenaar and perkins (2001, p. 22) as the “adaption stage” which is the last o f four distinct chronolog­ ic stages experienced by new therapists, marking the begin­ ning o f their “new world o f professional practice” (p. 22). theme two: being part of the “underdog” profession: role definition and status a great frustration for s l therapists’ is public and fel­ low health professionals’ misperceptions o f the profession and the nature o f their work. they feel that these attitudes and beliefs are uninformed; this makes them feel underes­ timated and underrated as professionals, as they know and understand their work to be far more complex and intricate than commonly understood: \ “...ja , [yes] there’s always the perception that you, you w ork mostly w ith children, th at you w ork in a school... th at you w ork w ith stutterers... they’re not aw are o f the diverse range in age groups th at w e see, i mean the diverse range o f disor­ ders a n d age groups, a n d u m ,ja [yes] types o f things th at w e d e a l w it h ... ” although the multidisciplinary team approach is a prinr ciple to which health professionals subscribe, s l thera­ pists often feel devalued as professionals, discouraged, disil­ lusioned and not consistently recognised as equal members ' o f the team: “. . . i think there’s a certain am ount o f frustration because i think the gen eral lack o f knowledge o f speech therapy as a profession in a community a n d especially at, you kn ow a t a community health level, nurses a n d doctors a n d other profes­ sionals i think are often not fu lly aw are o f w h at our role is w h a t w e do — who w e see, um why w e see them — w h at can 54 | die su id -afr ik a a n se ty d sk r if vir k o m m u n ik a s ie -a fw y k in g s , vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t h e l iv e d exp e r ie n c e of b e in g a s p e e c h -l a n g u a g e t h e r a p is t offer, you know all those types o f things... so there just isn’t a lot o f knowledge about speech therapy... ” in a study which explored how social workers experience their work, participants stated that their role is misinter­ preted as “just being nice or doing the common sense things that anyone can do” (dillon, as cited in lloyd et al., 2002, p. 257). occupational therapists have also reported feeling “devalued” (hasselkus 8c dickie, 1994, p. 147) and having their skills “unused” (p. 147) or “blocked” (p. 147) by certain team members. current study participants described simi­ lar experiences, in that talking and swallowing are viewed as automatic processes that everyone can do, and are less of a priority than other more obvious impairments. this is il­ lustrated in the words o f one participant who said “f o r many o f them, [stroke patients] it is about getting back to walking... sometimes much more than communication”. the specific expe­ rience o f having a skill “devalued” or “blocked” is reflected on by a participant in the current study. she related an o f­ ten-repeated situation in which a decision regarding place­ ment in a rehabilitation hospital seldom takes into consider­ ation the opinion o f the s -l therapist. her experience was that, should a stroke survivor be left with both a physical and communication deficit, rehabilitation would immedi­ ately be recommended, however if left only with a commu­ nication difficulty, the referral to rehabilitation would not be automatic. even after strong motivation, her opinion is usu­ ally disregarded, leaving her feeling disrespected as a profes­ sional. participants suggested that contributory factors to these misperceptions is the abstract nature o f the disorders treated by s -l therapists, the invisibility o f communication disor­ ders as compared with physical diseases, the historical lack o f advocacy by s -l therapists and the relatively low status o f people with communication difficulties in many commu­ nities: “...speech and communication disorders are not as concrete or as visible as more physical disorders, as treated by a phys­ io [physiotherapist] or an occupational therapist, um, you know i f someone’s got a, had a stroke and one side o f their body is weak, you '''can automatically see it, um, whereas speech and language is, not as visible... ’’ . .people with communication difficulties as i prefer to call them whatever they are, whatever their nature, is that be­ cause these difficulties are not visible, they’re not well un­ derstood um, people, the public think that people who can’t communicate properly are stupid are worthless are um, they become the butt-end o f jokes... ” continually having to explain what s -l therapists’work entails and the nature o f their role is exhausting. a further frustration is being referred to as an elocution coach or “someone who helps people to speak welt'. the ignorance sur­ rounding the profession is such that one study participant stated that she felt that it would have been much easier to have chosen a different career. the relative invisibility o f speech, language and communication disorders means the difficulty is not well understood or acknowledged. even within the subset o f patients with different communication disorders, s -l therapists are frustrated that more visible difficulties are prioritised. a patient is only likely to seek the s -l therapist’s help for a communication problem that is negatively affecting his or her occupation or quality o f life. it is hard to accept the relative complacency o f persons with a communication difficulty; as many are content to tolerate it as long as it does not interfere too much, thus seldom seek help in the early stage o f the disorder. patients with communication problems are also misun­ derstood. one participant described her experience: “the lay person’s attitude to people with communication disorders is one o f ridicule" and that in her work she has often been “a recipient o f the casualties o f the lay person’s attitude and actions towards them . patients may have explored numerous options before accessing the speech therapy services and have often en­ dured teasing and ridicule. s -l therapists experience their work environment as nurturing, a unique community which is almost “like home” which is contrary to the perceptions o f the public regarding state hospitals: . .ja [yes], i think they, people just don’t have any idea o f this context even that you’re working in or you know it, it, i think this hospital, it’s like a little world on it’s own, sort o f a community in a way a ndja [yes], i f you haven’t been here you don’t quite understand what its like... ” s -l therapists experience feeling secure and being nur­ tured by their environment which makes the tension be­ tween their experience and the public’s misperceptions dif­ ficult to reconcile: ".. .people just come in here, they see the, the dirt, everything peeling off the walls, the whatever!... the first impressions here are not very positive i think f o r many people ja [yes]...... .ja [yes], but it’s a home away from home sometimes in a way [laughs] now .... i think it’s, it’s, i f you’ve been here a long time, one, you, you know how things work here, so i think that’s just a negative perception we really have... ” unlike physiotherapy, occupational therapy and social work, s -l therapy services are under-represented at com­ munity health facility level, secondary hospital level and in mainstream education. as a result, patients’ only options are to access s -l therapy services at a tertiary level even i f it is geographically and logistically very difficult to do so: “... often clients can receive the medical help they need at a community level, but not the rehab at a community level... ” .. and i think that’s, that’s an area of, where our profession really needs to be to be working at is at a level of, um ... com­ munities, but also educators, doctors... ’’ w ithin the western cape, the hospitals with skilled and available medical personnel are geographically some dis­ tance from the majority o f their patients. this negatively af­ fects patient attendance and increases s -l therapists’ frus­ tration. w hile certain s -l therapy services require medical support which is offered by the hospital, a large proportion o f the services s -l therapists offer to both adults and chil­ dren are not suited to this setting and would be “f a r more effective i f offered at a community level or in mainstream class­ rooms”. s -l therapists are left feeling detached from their patients and misplaced as health professionals who provide decontextualised services. the lack o f s -l therapy services at community level ex­ acerbates the pressure to get through the large case load in a limited time, which, when added to the associated adminis­ tration, can result in reduced productivity and less time and the south african journal of c o m m u n ic atio n disorders, vol. 55 2008 | 55 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) jocelyn a. warden, patricia mayers a n d harsha kathard energy to focus on each individual patient. the lack o f suf­ ficient time for patient care is a consistent finding in other human service profession research. occupational therapists are reported to feel unable to serve clients adequately when coping with a large caseload (hasselkus 8c dickie, 1994) and to experience excessive paperwork and statistics as a major source o f stress (bailey, 1990; freda, 1992; pringle, 1996). the physiotherapy literature reveals similar findings in that “during periods o f high demand for physical therapy” (deckard 8c present, 1989, p.116) therapists felt pressured and complained about inadequate time in which to provide all their patients with adequate treatment. physiotherapists in the above study reported feeling “torn between providing service to everyone” (p. 116) which decreased the quality of care and amount o f time they were able to devote to each treatment. theme three: being connected s -l therapists engage in a broad range o f relationships with others. intervention is a collaborative process between s -l therapists and patients and their families and involves “a tremendous amount o f give and take”. they place the pa­ tients and their families at the centre o f the intervention process, giving them permission “ to state their priorities and expectations o f therapy". s -l therapists recognise them as important and useful resources for change and strategically look at what their patients and families are able to contrib­ ute to the treatment/rehabilitation process. s -l therapists’relationships with their patients are com­ plex and interactive (holland, 2001). current study partici­ pants described a real sense o f connectedness to their pa­ tients as they are intimately involved in a dynamic two-way helping relationship fuelled by a desire to help, remediate and improve the presenting communication or swallowing difficulty. worrall 8c frattali (2000) described s -l thera­ pists’ involvement with their patients as “entering into peo­ ple’s lives in a very real way and becoming involved in issues o f human living” (p. 193). all therapeutic endeavours occur in cultural context with cultural factors demanding aware­ ness and sensitivity (holland, 2001). the importance o f personal relationships is reflected in a person’s choice to enter the profession o f s -l therapy, for which helping other people is a primary motivation (byng et al., 2002). in line with the abovementioned two-way helping relationship, egan (2002, p. 7) presents two princi­ pal goals o f helping: the first being to help clients manage their problems in living more effectively and develop unused resources and missed opportunities more fully; and the sec­ ond being to help clients become better at helping them­ selves in their everyday lives. he further states that due to the nature o f helping others, helpers “are only successful to the degree to which their clients, through the client-helper interaction are better able to manage specific problems and develop specific unused resources and missed opportunities more effectively” (p. 7). collaborative partnerships with the healthcare team help s -l therapists offer more effective and holistic manage­ ment and reduces the pressure and expectation that they feel to try to meet all their patients’ needs: .. when we run multidisciplinary clinics we provide a much better service f o r a patient because it's one-stop-shop, it's less timefor them, it's less schlepping [walking] around less wait­ ing, less stress... everyone’s in one place, so that we work to­ gether at the same time with the parent and the child and we can give them feedback together and we have one p la n... which is just a more efficient way o f doing things... ” in the hospital setting, patients often require interventions in addition to that offered by s -l therapists. the multidis­ ciplinary team is a source o f information and support. this illustrates the team’s role in producing better quality serv­ ice and comprehensive approach than its individual mem­ bers working as solo practitioners. the professional is able to increase productivity and has a sense o f accomplishment (benierakis, 1995). current study participants described ex­ periencing great willingness from team members to work collaboratively, making their own work day more enjoyable. this is consistent with a study o f occupational therapists who reported that job satisfaction is derived from being part o f a multidisciplinary team and that good communica­ tion and co-operation among team members increased their sense o f fulfilment (de wesley 8c clemson, 1992). despite this positive experience o f teamwork, ignorance and misperceptions about s -l therapists’ professional roles continue to exist among colleagues. study participants de­ scribed feeling “side-lined’ compared to professionals from seemingly better-understood professions, and described not being recognised as equal members o f the team. for one par­ ticipant in particular, remarks and actions o f medical doctors in particular make her feel “stupid’ and that her interven­ tion techniques are not sufficiently academic. an australian study in the occupational therapy profession found that the underlying ignorance and misperception o f the profession is seen in both an absence o f referrals or inappropriate referrals to the profession (moore et al., 2006a). current study participants spoke o f poor collaboration with some educators, certain healthcare professionals, and some privately employed s -l therapists. this makes effec­ tive management very difficult and creates a barrier for the development and maintenance o f good working relation­ ships: “... we do get quite a lot o f negative comments, it’s, it’s, espe­ cially (name) and i who’ve been herefor many years, um, you go to any gathering o f therapists and they say ”oh, you’re still at (name) shame!” and it's kind o f like 'can’t you do any­ thing better f o r yourselves, that you, you’re still landed here’. i think that the perception is that you start off in the public sector when you don’t know very much, to learn and, which is true to a certain extent, it is a very good place to start but, um, it’s almost the perception that perhaps you graduate to private practice!..." theme four: the holistic nature of the speech-lan­ guage therapist’s practice the therapy process involves much more than direct therapeutic intervention. s -l therapists need to conscious­ ly engage with their patients in order to better understand their needs. they need to “...really get to know them beyond the superficial level, to just go a bit deeper... but it’s also about hearing them, it’s about having the humility to hear them with­ out judging them. ,. ” s -l therapists focus on more than the presenting com­ munication disorder and take a holistic approach to patients 56 die suid-afrikaansetydskrif vir kommunikasie-afwykings, vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t h e l iv e d exp e r ie n c e of b e in g a s p e e c h -l a n g u a g e t h e r a p is t and families, placing high value on the way their patients use speech and language functions, rather than individual grammatical structures, to gain communicative power. the aim is to assist their patients to use language as a tool for everyday life and to facilitate successful social integration: “. . . i mean i think one o f the most important things is not only focussing on sort o f specific language things but looking at more lifestyle communication and pragmatic skills which are going to help them later on in life as opposed to being able to say something that's syntactically correct! or whatever, and you know it might be more o f apriority to deal with, get them coping at a certain level which is functionally going to be use­ fu lfo r them as opposed to what would be perhaps ideal... " the presence o f a communication difficulty is the reason for the consultation, yet s -l therapists’ primary focus is on the ‘person’ and their role requires that they consciously ad­ dress their patients’ salient needs with the same respect and rapidity as they do their communication difficulty: .. it feels like you’re giving more than just that [therapy]... but you end up having to, to just make, make their lives neat and tidy from other aspects so you can actually — you know, i f all that is in a mess then somehow the therapy is not, they cantfocus on therapy because they too stressed about blah blah blah and something else, so it’s almost like you have tofocus on all the little bits and pieces as part o f like a like a holistic sort o f management that you're doing... ” s -l therapists understand how speech and language are used in the daily interactions between their patients, their patients’ significant others and community, and the severely limiting impact of the communication difficulty on their pa­ tient’s ability to interact effectively with his or her world: .. speech and language is a part o f interaction which is a part o f the child’sfamily, which is a part o f their society... ” there are times when s -l therapists’ roles entail not do­ ing anything, but just being there for their patients and con­ sciously assuming the role o f supporter, advisor, or counsel­ lor. one participant described how she regards herself as a committed friend a!nd support to her patients and families, needing to operate from a place o f “enormous empathy”. ".. .just to be supportive, i think it’s kind o f to acknowledge what you’refeeling, it is a process, it does take time... and cer­ tainly with my adults i f i cry with them, ijust think it adds a dimension, they do know that you feel, and why should i hide it? i f i ’m going to cry andfall apart and i can't help him, that’s a different story, but i f you're helping him andfeeling f o r him ... ” s -l therapists make personal investments into the lives o f their patients and families by offering themselves and their skills in the therapeutic process, with their own needs subservient to the greater needs o f their patients. they are fully present in sessions with their patients and conscious­ ly focus their minds, thoughts, attention and energy during that time, not allowing themselves to become distracted: “.. .you know you have to give them everything you know your all... i f like i assess a child i ’m not gonna, my whole heart is there ok, type o f thing, it’s not ok, i'm doing this but my mind is somewhere else, i don't know, i mean.. .you can't be.. .you are going to try to put 110% in so no matter how busy your day is, no matter what's happened before, no matter what’s coming, you have to, you just put on your ther­ apist’s hat and off you g o ... it’s like, you know a child comes running, smiling and you’ve got to, you've just pull out what you need and you know deliver the goods!... and sometimes that's a natural thing, other times you dig deep!...'' the therapeutic process involves more than specific activ­ ities; there is an emotional component to the therapy. help­ ing professions such as s -l therapy involve more than just helping, but require “an investment o f knowledge and skill blended with facilitating interpersonal qualities to effect change in another individual” (lubinski 8c frattali, 2001, p. 189). regardless o f personal feelings and circumstances and day-to-day pressures, participants described how the patient always comes first. s -l therapists are emotionally drained after a day o f making such intense investments into the lives o f their patients. a day at work is described by one participant as “much more than just a job”. the responsibility o f managing patients with serious communication difficul­ ties is onerous. the management o f even uncomplicated pa­ tients is like “trying to eat spaghetti” in that it is “hard to man­ age”. as they interact with their patients on a deeper level, an emotional bond develops with expectations o f them as therapists: "... they come to you with all this hope and i think because we are in a profession that gives people a little more time it’s not you know quick consultations, they have a lot o f one on one time with you and because it’s it’s not just so medi­ cal but so therapeutic there’s a lot o f counselling and stuff that goes on, that, i think it doesn'tjust affect the patient, you know somehow you also become involved, in their lives..., in what it means f o r them... you know it becomes your, your problem as well... ” s -l therapists share in the emotional journey o f their patients and families. one study participant described how in the past she had “hoped with the family” that test results would not return as suspected. other participants described the emotional journeys they have taken with patients and families as together they express grief and disappointment at the birth o f a disabled child, the diagnosis o f a terminal illness or life-altering procedure. taking on the responsibili­ ty o f managing patients with serious medical conditions and chronic disabilities requires emotional maturity and stami­ na. one participant described her experiences as requiring “staying power which takes more maturity than your years”. the repeated exposure to illness and suffering can make s -l therapists hardened, no longer as sensitive as they were to the shocking reality o f their first experience. certain sights, sounds and smells become so much a part o f their daily activities that they no longer have the impact they once did. they easily lose their sense o f what is regarded as normal, see disorders as the norm, and thus seldom ex­ pect anything more. they lose hope that miracles do hap­ pen and that recoveries can occur. s -l therapists may find themselves approaching their patients from the perspective o f “deficit", thinking only about what they cannot do, instead o f what they are still able to do: “. . . i mean i remember when i was a student, just seeing pic­ tures o f children with cleft lip andpalate thinking this is terrible, i mean now you think ‘oh is that all that’s wrong with you!’ 'oh, that’ll be fixed, i mean the brain’s working fin e and you’ve seen people with so much worse than that that your, you sort o f rate the south african journal of c o m m u n ic atio n disorders, vol. 55 2008 57 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) jocelyn a. warden, patricia mayers a n d harsha kathard your degree o f how bad something is... ” healthcare professional [s -l therapists] have have to deal with occupational stressors that are not part o f most other occupations in that they deal with people in situations involving death and suffering that have a profound effect on them (payne 8c frith-cozen, 1987). for this group o f s l therapists, the repeated exposure to illness and suffering with the common sights, sounds and smells makes it easy to become hardened to seeing people suffer “with even the most experienced professional feeling awkward and help­ less” (arbore, katz, therese 8c johnson, 2006, p. 17). seeing disorders as the norm and seldom expecting anything more was also described by arbore et al. (2006, p. 25) who state that in such cases, the professional is often left to feel that there is nothing he or she can do for the patient except to be with the patient in the situation. health professionals re­ act in different ways to seemingly hopeless situations. they either become overor under involved, which is described as unconscious countertransference feelings (arbore, et al., 2006, p. 22). one participant described her shock and sur­ prise at patients who, against all odds, make unbelievable recoveries. this makes her aware o f how pragmatic and mat­ ter-of-fact she has become. theme five: erosion or promotion the public service setting presents many challenges for s -l therapists: time pressure to complete their work, high patient caseloads, time-consuming reports, insufficient staff complement, changes in promotional possibilities (the abol­ ishment o f rank promotion based on work experience) and no financial incentives other than their monthly salary: "... and i think that especially being in the public service where there’s more, there’s more o f a rush to get things done, um, there’s numbers that you have to get through, there's waiting lists. . . i think i f there was time you could sort it out better; um, but you in a bit o f a hurry too, to sort out all the loose ends sort o f move on so it does, i think the time and the pressure on, on numbers and things like that does, does affect how much you can actually do..." “... now money’s an issue, but in the past the salaries were ad­ equate um, as the cost o f living increased so the salaries didn’t keep pace, but in the beginning it wasn’t as shocking a salary as it is now... ’’ a large caseload results in less time and energy to fo­ cus on each individual patient, especially with the time-con suming referrals and report writing: i think it also depends on your, your workload um, i think i f you’re really working hard you have less o f thatfor each patient... ’’ despite the many challenges which make s -l therapists question their decision to stay in the public service, this is countered by the predictability and security they experience in this setting. a guaranteed stable salary and benefits, rea­ sonable administrative support and a high level o f predict­ ability in the nature o f their work makes them feel settled, grounded and in control: “. . . i mean i ’ve always had a job, i ’m, i ’m in quite a secure environment, which is maybe also why i ’m staying here you reach a point where you, actually it’s too comfortable maybe to [both laugh], to move on now j a [yes], also j a [yes], my career has been fairly safe groundfor m e... ” “... the benefits o f staying here, o f staying here have been big­ ger than, the benefits of, o f private sector... ” s -l therapists receive consistent and predictable admin­ istrative support which enables them to focus on service de­ livery rather than on administrative duties. their familiarity with the way their environment functions, whether positive or negative, defuses much o f their frustration over everyday challenges. they are prepared for the common challenges o f a public health service and able to manage these. security, permanence o f employment, regular salary, pension benefits, together with, flexibility o f vacation leave and clearly defined sick leave benefits contribute towards the stability o f their roles. similar findings were reported in the responses o f participants from a study o f occupational therapists working in the british national health system who stated that they regarded themselves as having a job “for life” and reported valuing their pension and good con­ ditions o f service (pringle, 1996, p. 405). the diversity o f s -l therapists’ caseloads provides them with opportunities to grow and develop as therapists. this enables inexperienced therapists to develop a sound clinical foundation as they work in the tertiary service infrastruc­ ture and support networks. one participant described how the freedom she had to "find her feet" is rarely available in other settings, in which providing services to paying clients is the priority: "...initially you’re pretty much finding your feet in the pro­ fession, you’re doing, a little bit o f everything, figuring out what you like, what you do better, what you don’t do so well, so there’s that initial kind o f just almost testing the waters kind o f thing... ” working in a training hospital offers s -l therapists var­ ied patient exposure and the opportunity to manage patients with a wide variety o f communication disorders including those with multiple and / or rare conditions. this makes s -l therapists’ experiences dynamic, stimulating and challeng­ ing. it stretches them in terms o f the knowledge, clinical skills and expertise they require and demands flexibility, cre­ ativity and a sound knowledge and understanding o f dif­ ferent treatment approaches. the three tertiary hospitals! in this study are teaching hospitals, with the ethos o f learning, teaching, research and clinical advancement. they have ac­ cess to academic resources and staff which offers them edu­ cational and clinical development opportunities. the teach­ ing environment is stimulating, rewarding, and a source o f significant job satisfaction. . this expectation o f exposure to valuable learning op­ portunities in specific contexts is common to other health professions. in a study looking at career choice, 55 percent o f newly qualified canadian physiotherapists reported hav­ ing chosen a public service hospital setting due to the per­ ceived learning opportunities and the anticipation o f it be­ ing an appropriate environment to start as a novice therapist (ohman, solomon, 8c finch, 2002). in another study novice physiotherapists chose the hospital setting because o f the learning opportunities they believed it would offer them (miller, solomon, giacomini, 8c abelson, 2005). the hos­ pital setting, which facilitated the grounding o f their clini­ cal experience, was viewed as a “stepping stone” (p. 148) to other practice settings. this viewpoint was not described by current study participants; rather it was their belief that this 58 | die suid-afrikaansetydskrif vir kommunikasie-afwykings, vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t h e l iv e d exp e r ie n c e of b e in g a s p e e c h -l a n g u a g e t h e r a p is t was the opinion o f s -l therapists in private practice. study participants described privately-employed s -l therapists to most definitely have the perception that “you start o ff in the public sector when you don’t know very much, learn as it’s a very good place to start, and then graduate to private practice!”. even after many years o f working in the public service health setting, the opportunities that initially attracted s -l therapists to the public service continue to keep them mo­ tivated to stay: “...u m , and i think that’s also especially i f you work in the public sector, i don’t know i f it’s more so, that you can do that, whereas privately you kind o f working kind o f fo r yourself whereas here you know you’re working in the public sector, you’re doing your bitfor the community, um, you’re working, you know there’s, there's a bigger, you know there’s a bigger picture type o f thing...” s -l therapists who are socially motivated to work in this setting or who chose it because o f the role they wished to play in this context, experience it very differently to s -l therapists who did not have these same sentiments. even after years in this setting, those who described themselves to have “chosen it" are still committed to the public service. despite the ups and downs o f s -l therapists’ clinical work, the positive experiences and job satisfaction play a major role in their decisions to be a part o f the service: “.. .generally i can speak very positively about the, the public sector, and at the end o f the day i choose to be here... ” s -l therapists feel enriched by being exposed to the wide variety o f people around them and have learned to accept others more, judge them less, and understand them more deeply. engaging with patients and families on a daily ba­ sis requires them to go beyond a superficial level to “know­ ing where they’re coming from ” and “really understand the peo­ ple you’re working with". the daily interaction with people from diverse cultural and socio-economic groups enriches and deepens their understanding o f humanity: “. . . i f i hadn’t worked here, i would never have known much, as much about people who are not different, i mean we’re all the same basically,\live in different circumstances, have grown up differently, got\different priorities perhaps um, i think it’s made me more tolerant o f people, more understanding o f dif­ ferent ja \yts\just o f different belief systems and culture... ” being a part o f their patients’journeys towards recovery and rehabilitation is an enriching and validating experience. there is a sense o f accomplishment as they see their patients become empowered to succeed beyond the therapy setting. victory for a patient is translated into renewed passion for what s -l therapists do and why they do it: “.. .1 love it when i have a ‘happy client’. w hen i ’ve been able to make a difference... .. .my patients actually, because o f the, the, the type o f pa­ tients i see, i ’m humbled by them, i ’m, they, they, they make me feel good on a daily basis.. . ” s -l therapists’ patients’ successes are a personal victory, not because o f the role they have played, but due to the deep connection they feel to their patients and their rehabilita­ tive journeys: .. yes, obviously, i mean getting, um, being successful or get­ ting something right, or making some, making a difference in, in a patient’s life, it, yes, it reaffirms you and it makes youfeel, ok yes you want to do this again, you are making a difference... ” s-l therapists in this setting are greatly affected by their patients. two participants expressed their feelings: “ilove my patients”, “i love working with them” and “7 have had won­ derful experiences with patients". working and interacting with them on a daily basis humbles the s -l therapist. s -l therapists’experiences o f crying with patients, talking about their progress, how they have grown, or being thanked for help they have given, are all rewarding and affirming experi­ ences. a study investigating the satisfaction o f occupational therapists (moore et al., 2006a) reported that patient con­ tact and working with patients was a highly fulfilling part o f their work. one participant stated, “i don’t think there’s anything i ’d rather be doing” (p. 22). other participants described their relationships with patients as being mean­ ingful and rewarding. current study participants described feeling humbled by, and privileged to listen to the life sto­ ries and experiences o f their patients, their past experienc­ es and thoughts o f the future. as s -l therapists’ patients share their experiences, their dreams, fears and reflections, therapists feel honoured that they choose to allow them to enter their reality. s -l therapists feel enriched and validat­ ed as they realise the contribution they have made in their patients’ journeys. social workers, nurses and occupational therapists reported the opportunity to develop relationships with patients and see them progress as being a frequent source o f satisfaction (reid et al., 1999). for a current study participant, seeing patient achievements renew her passion for her work. s -l therapists experience patients’ successes as almost a personal victory, not because o f the role they played in it, but because o f the deep connection they feel to their patients and their rehabilitative journeys. a n occupa­ tional therapist stated, in a study by moore, et al. (2006a), how the role she is able to play in a patient’s life gives her a sense o f achievement and validates her as a person. s-l therapists describe their relationship with patients as being full o f “ups and downs”, being as joyful and fulfilling as lim­ iting and challenging and as “leading them to unexpected places” (byng et al., 2000, p. 93). limitations of the study the researcher is a s -l therapist at one o f the tertiary hospitals from which participants in the study were drawn. although there is a risk o f over-involvement and over-iden­ tification, especially in the interviewing phase, studying col­ leagues is also viewed as an advantage (holloway 8c w heel­ er, 1996). qualitative research calls for the researcher to “immerse and involve him or herself in the setting and the culture under study” (holloway 8c wheeler, 1996, p. 3) and to have a “close” (p. 3) relationship with participants. in or­ der to minimise this limitation, the researcher kept reflective memoranda throughout the process and tried as far as pos­ sible to ask participants for clarification o f their ideas and not assume to have a full understanding o f what participants said before clarifying it with them. a criticism o f qualitative research is that studies with small samples (such as this one) prevent the research from being generalisable to the general population. from the out­ set current findings were not anticipated to be generalisable. the nature o f the clinical work and the predominance of paediatric s -l therapists in the study may mean that the the south african journal of c o m m un ic atio n disorders, vol. 55 2008 59 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) jocelyn a. warden, patricia mayers a n d harsha kathard experiences o f s -l therapists who work in other fields may not be fully described. the present study findings reflect the description and analysis o f a reality experienced by s l therapists in this specific setting, taking into account the conditions and context. recommendations the absence o f s -l therapy services at community health centre level is a significant barrier to the provision of services to people who most require these. speech therapy departments from established hospitals should consider ini­ tiating outreach projects in the community i.e. district hos­ pitals. partnering with, and developing a good relationship with an outreach site, offers the opportunity to develop a much needed service and could lead to the establishment o f a permanent service, in line with the objectives o f the healthcare 2010 plan for the western cape public service. participants’ perceptions o f the public’s appreciation o f professional role and function o f the s -l therapist have highlighted the need for further development. marketing strategies which are sustainable and adequately portray the benefits o f s -l therapy and services need to be considered. for s -l therapists working with children in particular, there is a need to strengthen relationships and referral be­ tween educators and s -l therapists. outreach programmes and information sessions to schools could facilitate this. the education and training o f s -l therapists requires continual curriculum development to prepare and support new therapists in their role in a rapidly changing health service. s -l therapists will need to be pro-active, market their profession, lobby for the development o f appropriate, affordable and accessible services for underserved commu­ nities, and be creative in offering these within the budgetary constraints o f the public health service. conclusion this study has explicated the lived experience o f being a s -l therapist in the public service health setting, in a inquiry in which there is minimal published research. a l­ though the public service is only one area in which the s-l therapist may practise, the study highlights issues specific to this context as well as to the profession o f s -l therapy in general. the lived experience o f being a s -l therapist in a pub­ lic health service is one o f challenge, opportunity, security, predictability and connectedness through diverse and com­ plex relationships. the profession o f s -l therapy and the holistic nature o f the work impact on the therapist’s entire being physical, mental and emotional. the joy o f helping is contrasted with the exhaustion and despair where s -l therapists do not feel that they make a difference. despite this, however, sl therapists are committed to their chosen profession and to the clients and patients who need them. references akroyd, d ., w ilson, s., painter, j., 8c figuers, c . 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(e ds.). neurogenic commu­ nication disorders: a functional approach. new york: thieme. 62 | die suid-afrikaansetydskrif vir kommunikasie-afwykings,vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) article information authors: stephanie couch1 dominique zieba1 jeannie van der linde1 anita van der merwe1 affiliation: 1department of speech-language pathology, university of pretoria, south africa correspondence to: jeannie van der linde email: jeannie.vanderlinde@up.ac.za postal address: department of speech-language pathology and audiology, university of pretoria, pretoria 0002, south africa dates: received: 02 june 2014 accepted: 24 aug. 2014 published: 26 mar. 2015 how to cite this article: couch, s., zieba, d., van der linde, j., & van der merwe, a., 2015, ‘vocal effectiveness of speech-language pathology students: before and after voice use during service delivery’, south african journal of communication disorders, 62(1), art. #95, 7 pages. http://dx.doi.org/10.4102/sajcd.v62i1.95 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. vocal effectiveness of speech-language pathology students: before and after voice use during service delivery in this original research... open access • abstract • introduction • method    • research design       • participants    • protocol used for data collection    • procedures    • quantitative data analysis    • data processing • results    • perceptual results    • acoustic results • discussion    • changes in perceptual and acoustic features of voice    • participant characteristics and acoustic change    • effects of occupational voice use    • limitations and recommendations for future research • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ background: as a professional voice user, it is imperative that a speech-language pathologist's (slp) vocal effectiveness remain consistent throughout the day. many factors may contribute to reduced vocal effectiveness, including prolonged voice use, vocally abusive behaviours, poor vocal hygiene and environmental factors. objectives: to determine the effect of service delivery on the perceptual and acoustic features of voice. method: a quasi-experimental., pre-test–post-test research design was used. participants included thirdand final-year speech-language pathology students at the university of pretoria (south africa). voice parameters were evaluated in a pre-test measurement, after which the participants provided two consecutive hours of therapy. a post-test measurement was then completed. data analysis consisted of an instrumental analysis in which the multidimensional voice programme (mdvp) and the voice range profile (vrp) were used to measure vocal parameters and then calculate the dysphonia severity index (dsi). the grbasi scale was used to conduct a perceptual analysis of voice quality. data were processed using descriptive statistics to determine change in each measured parameter after service delivery. results: a change of clinical significance was observed in the acoustic and perceptual parameters of voice. conclusion: guidelines for slps in order to maintain optimal vocal effectiveness were suggested. introduction top ↑ the vocal health and voice management of professional voice users has gained increasing interest in recent years: professional voice users are considered to be at risk of developing voice problems and complaints (van lierde et al., 2008). since the professional voice users rely on their voices as the means to carry out their occupational duties, their voices can be described as a ‘primary tool of trade’ (warhurst, madill, mccabe, heard & yiu, 2010; titze, lemke & montequin, 1997). considering the importance of voice to professional voice users, it is imperative that their voices remain clear and stable throughout the day. less than optimal vocal effectiveness (pitch, loudness, quality and flexibility) may negatively influence the professional voice user's ability to carry out their daily occupational demands (hazlett, duffy & moorhead, 2009; roy, merril, thibeault, gray & smith, 2004). this highlights the need for the prevention, identification and treatment of voice problems before they become significant enough to influence occupational duties negatively. professional voice users are amongst the most likely individuals to develop vocal pathologies or voice disorders as a result of improper or excessive voice use (broaddus-lawrence et al., 2000). they often demonstrate excessive amounts of voice use in sometimes non-optimal environments as part of their occupational requirements or demands (colton, 2011). occasional vocal abuse or misuse may not have a significant impact on vocal parameters, however, the chronic use of vocally abusive behaviours may result in vocal problems such as hoarseness, reduced pitch range, vocal fatigue and the sensation of pressure, tightness or pain in the throat (ng, bailey & lippert, 2005). given the vocal demands placed on the professional voice user's voice, it is almost expected that vocal problems may manifest. pathologies on the vocal folds may occur as a result of vocal overuse, chronic voice abuse and misuse (johns, 2003). organic manifestations such as nodules, cysts and granuloma may develop after initial wounds have healed which resulted in the remodelling of the superficial layer of the lamina propria. lesions on the vocal folds, such as nodules, result in mucosal wave disruption during phonation (johns, 2003). this in turn may result in perturbation of the acoustic wave. in an attempt to overcome the resulting change in voice parameters, the individual may attempt to compensate by making use of excessive effort, abuse and misuse of the voice. subsequently, a vicious cycle of vocal misuse and abuse may ensue in order to compensate for the loss of vocal effectiveness. some of the most common consequences of voice problems may include a change in job performance and an absence from work (yiu, 2002; roy et al., 2004). the slp is a professional voice user with a very specialised set of voice use requirements. the occupational vocal demands that slps experience daily are profession-specific (warhurst et al., 2010). these demands may be a significant causal factor in the development of vocal difficulties. increasing vocal intensity or loudness whilst maintaining a clear voice quality, as well as maintaining appropriate vocal power, stamina and control are, amongst other conditions, categorised as vocal demands (timmermans, de bodt, wuyts & van de heyning, 2004; warhurst et al., 2010). slps may use an increasing number of vocally demanding behaviours to keep the client's attention in therapy; for instance, using auditory highlighting. voice therapy particularly requires not only the proper use of voice to be demonstrated to clients who are receiving therapy for their voice disorder but also incorrect vocal behaviours. slps use their voices in a variety of ways for a range of additional purposes. these purposes may include public speaking, counselling, conferencing, therapy and class presentations in the school context (gottliebson, lee, weinrich & sanders, 2006). therefore, as the profession that treats voice disorders and that has a role in advocating vocal health, it is essential that the speech-language pathologist prioritise vocal health and adequate vocal effectiveness. according to gottliebson et al. (2006), a lower prevalence of voice disorders occurs in slp students than in other students; however, a small number of slp students are still identified as having a voice disorder. for these students, the resolution of their difficulties will be essential to a ‘successful professional voice career’ (gottliebson et al., 2006, p. 704). the purpose of this study is to determine whether two hours of voice use during service delivery (e.g. providing therapy to an individual client) has an effect on the voice characteristics of a group of slp students. it is possible that both the perceptual and the acoustic features of voice will demonstrate a diminished effectiveness as a result of voice use during service delivery. method top ↑ research design a quasi-experimental, pre-test–post-test design was applied. participants purposive sampling was used and 12 participants (see table 1) were selected according to the pre-set selection criteria: participants were required to be female and between the ages of 18 and 30 years. participants were excluded if they were smokers and had a history of voice disorders or gastro-oesophageal reflux disease. the population included thirdand final-year slp students enrolled at a university in south africa. table 1: description of participants’ characteristics. information letters were provided to each participant and informed consent was given by all the participants in the study. no risks were involved in the study. protocol used for data collection a short case history was obtained and three assessment instruments were used. the data collected in the case history included a search for factors that may have a negative influence on vocal effectiveness. the assessment instruments included the grbasi 4-point scale (see table 2) to rate perceptual data (yamauchi, imaizumi, maruyama & haji, 2010), the dysphonia severity index (dsi) (wuyts et al., 2000), a quantitative correlate of vocal quality, maximum phonation time and the s/z ratio (shipley & mcafee, 2009). the voice range profile (vrp) and the multidimentional voice program (mdvp) software packages (kaypentax, 2008) were used to measure the vocal parameters necessary to calculating the dsi, including shimmer, jitter, highest frequency, lowest intensity, fundamental frequency and noise to harmonics ratio (see table 3). table 2: grbasi 4-point rating scale. table 3: vocal parameters measured. procedures each participant completed a case history. participants were instructed not to drink caffeinated drinks or alcoholic beverages 12 hours prior to the first assessment to ensure the use of these did not influence their voice quality. audio recordings of the voices of each participant were made. participants were instructed to hold the microphone at a fixed distance of 30 cm from the mouth to obtain the most consistent results across the different participants and to obtain optimal quality recordings (van lierde et al., 2008; timmermans et al., 2004). voice recordings for acoustic analysis were made in a sound-proof room. the recording facility of the computerised speech lab (or csl) (kaypentax, 2008) was used to make the recordings. participants were asked to sustain phonation of the /a/, /i/ and /u/ sounds three times each at a comfortable pitch and loudness. the /a/ vowel was used to record the highest and lowest frequency and the highest and lowest intensity using the vrp. the participant was instructed to produce highest and lowest pitch. a stop-watch was used to record the maximum phonation time of the participant using the /a/ sound. the s/z ratio was recorded by using the stop-watch. participants completed two hours of speech therapy individually in similar noise-controlled room conditions. the type of therapy provided varied between participants and included adults and children. noise levels in surrounding rooms and corridors were kept to a minimum to prevent this factor from negatively influencing the results. this helped to control the impact of treating adults and children. high noise levels in the environment may also negatively influence vocal parameters (lehto et al., 2006). the post-test was done once the participants had completed the experimental condition (providing two consecutive hours of therapy) and before any amount of voice rest was possible. voice rest may result in an improved quality of voice (van der merwe, 2004). the same procedures were performed as during the pre-test. quantitative data analysis the perceptual data of the participants’ voice quality was collected following the grbasi scale (table 2). a listener panel consisting of three judges took part in the analysis. to ensure reliable data all of them were experienced listeners (howard & lohmander, 2011). the sentence recordings were played back in random order to remove bias. each member of the panel of listeners gave a rating for each component of the grbasi scale. consensus was then reached by majority vote for each component. the dsi was calculated from the measurements collected by the mdvp, vrp and the maximum phonation time. the dsi is interpreted as follows: scores may range from –5 to +5. a score of +5 indicates a perceptually normal voice whereas a score of –5 indicates a voice that is severely dysphonic. the degree of dysphonia as measured by the dsi represents the optimal combination of independent variables to correspond with the g component of the grbasi scale (timmermans et al., 2004; wuyts et al., 2000). in table 3 the vocal parameters measured were presented. changes in the acoustic data were related to the presence or absence of participant characteristics (collected in the case history) that may have been contributors to reduced vocal effectiveness. data processing the perceptual data were processed by comparing the scores obtained for each participant in the preand post-tests. for each component within the grbasi scale, values may range from 0–3 (where 0 = normal, 1 = slight, 2 = moderate, 3 = severe). the acoustic data were analysed by means of descriptive statistics using stata 12. descriptive statistics consisted of calculations of medians and range for each acoustic value (shimmer, jitter, highest frequency, lowest intensity, fundamental frequency and noise to harmonics ratio) collected before and after the experimental condition. the sign test was used to determine whether the median for acoustic values differed from the pre-test to the post-test results (dixon & mood, 1946). a p-value was calculated for each parameter to determine whether change that occurred was statistically significant. results top ↑ perceptual results table 4 depicts the pre-test and post-test scores for each component of the grbasi scale, as well as the changes noted from preto post-test. the perceptual voice quality of 50% of the participants did not change from the pre-test to the post-test. the other 50% of the participants demonstrated a change in perceptual voice quality by no more than one point per parameter. table 4: perceptual analysis results: change in scores from preto post-test. of the 12 participants in this study, the grbasi scores (perceptual data) of six (50%) remained the same from the pre-test to the post-test. of the six participants (the other 50%) who did demonstrate changes in grbasi scores, three received an improved rating of one point (from slight to normal) in instability, but roughness remained the same (slight). one participant was rated normal for hoarseness and instability in the pre-test and was scored as slightly hoarse and unstable in the post-test. one participant received an improved rating of hoarseness and instability but scored as slightly rough in the post-test from a normal score of roughness in the pre-test. participant 12 was also rated as having slight roughness in the post-test from a normal rating of roughness in the pre-test. no change was noted in the parameters asthenia or strain and breathiness. two candidates who were rated as slightly breathy in the pre-test were scored the same degree of breathiness in the post-test. one of these participants was part of the 50% who did demonstrate change in grbasi ratings from pre-test to post-test, whereas the other participant was part of the 50% who demonstrated no change. acoustic results table 5 depicts the pre-test and post-test median values for each acoustic parameter measured. the change in median values from preto post-test for every parameter is presented. the direction of change is indicated, as is whether or not the direction of change was as expected. a p-value is presented, representing whether or not the results are statistically significant. table 5: acoustic analysis results across all participants. for all the measured acoustic parameters a p-value indicated that pre-test and post-test parameters did not differ significantly: lowest intensity, maximum phonation time, s/z ratio, highest frequency, shimmer, fundamental frequency and the dsi were parameters in which change occurred in the expected direction (the expected direction indicating a decreased effectiveness of voice from preto post-test). noise or harmonics ratio and jitter measurements resulted in a change in the direction that was not expected, indicating results which alluded to improved effectiveness of voice (see table 2 for a definition of the parameters). with regard to those parameters that changed in the expected direction (decreased effectiveness of voice), lowest intensity demonstrated an increase (i.e. lowest intensity range was reduced) after the experimental condition. maximum phonation time demonstrated a decrease after the experimental condition. the s/z ratio indicated poorer vocal effectiveness in the post-test. the highest frequency decreased from the preto the post-test as expected. an increase in shimmer and fundamental frequency was observed in the post-test measurements. the dsi results indicated that participants were more dysphonic in the post-test than in the pre-test, indicating a diminished voice quality. for the parameters that changed in the direction not expected, noise or harmonics ratio demonstrated a decrease in the post-test. since the values of jitter were in the region of 1%–2% and also decreased, this parameter was not responsible for the shift in the dsi. the implications of the values of jitter indicate that the other variables used to calculate the dsi (mpt, lowest intensity, highest frequency) were responsible for the shift to a more negative dsi value. discussion top ↑ changes in perceptual and acoustic features of voice although not statistically significant, change that was of clinical significance was observed in the acoustic and perceptual parameters of voice in the expected direction. the change in the s/z ratio and maximum phonation time indicated poorer vocal effectiveness in the post-test in comparison to the pre-test. this reflects a decrease in overall ‘phonatory ability’ and demonstrates a decreased efficiency in subglottic pressure, airflow resistance and vocal fold closure (wuyts et al., 2000, p. 803). the decrease in highest frequency noted in the results often indicates an increased vocal fold mass which hampers vocal fold vibration at higher rates. in addition, the increase in the shimmer value demonstrates the inability of the vocal folds to support a periodic vibration for a distinct period and indicates the existence of turbulent noise in the voice signal (kaypentax, 2008). vocal fatigue and vocal pathology are associated with a decrease in fundamental frequency following a period of voice use (stemple, stanley & lee, 1995; guimarães & abberton, 2005; altman, atkinson & lazarus, 2005), as seen in the results of the current study. the two participants who were rated as mildly breathy in the pre-test were scored as mildly breathy in the post-test. instability values changed in five participants: of all the parameters demonstrating change, it was the parameter that changed in the highest number of participants from the pre-test to the post-test. despite the fact that much of the change in the parameters of voice occurred in the expected direction for both perceptual and acoustic results, there were several unexpected changes in the opposite direction. for perceptual results, an improvement in hoarseness for one participant and in instability for four participants was noted. acoustic results revealed a decrease in jitter for seven participants, and a decrease in noise or harmonics ratio for seven participants. these changes suggest improved effectiveness of voice, which was not as expected. it is important to consider that the improvements noted may have resulted from a ‘warm-up’ effect. a study conducted by van lierde et al. (2011) revealed that vocal warm-ups of only 30 minutes significantly increased dsi values. voice use during the experimental condition may have acted as a form of warm up for voice use and therefore the functioning of the intrinsic and extrinsic laryngeal muscles may have improved. it is likely, then, that improvements in hoarseness and instability, and decreases in jitter and noise or harmonics ratio may have resulted from this warm-up effect. the improvements noted indicate that vocal warm-up exercises may be a tool that should be used by slps in conserving their voices. it should also be taken into consideration that participants’ performance in the post-test may have improved due to their having knowledge of the testing procedures. participants may have proceeded cautiously in the pre-test but more confidently and comfortably in the post-test. the results obtained for individual participants were found to coincide with specific participant characteristics that put them at risk for a voice disorder. poorer vocal effectiveness (as indicated by shimmer, fundamental frequency and highest frequency) was found to be associated with the presence of participant characteristics, including sinusitis, birth control measures, allergies and post-nasal drip. participant characteristics and acoustic change fundamental frequency, highest frequency and shimmer showed measurements that suggested decreased vocal effectiveness in a number of participants’ post-test results. in the case of fundamental frequency, seven of the 12 participants demonstrated scores in the post-test that indicated poorer vocal effectiveness. these participants presented with similar characteristics in that four of the seven suffered from sinusitis and were currently implementing birth control. the characteristics associated with poorer vocal effectiveness can be explained as follows: highest frequency was found to be poorer (reduced pitch range) in four of the 12 participants after voice use and this change coincided with the presence of allergies and sinusitis. a combination of sinusitis and post-nasal drip was found to coincide with poorer scores of shimmer for three participants in the post-test. these associations highlight the importance for slps to be aware of factors that may contribute to the development of a voice disorder. the treatment and control of these factors will be central to preventative strategies that these professionals may take to preserve their vocal effectiveness. effects of occupational voice use overall, the following symptoms were evident in the post-test after all the participants were exposed to the experimental condition: a decrease in vocal effectiveness and efficiency, decreased vocal fold vibration at higher frequencies, impaired ability to maintain periodicity in the amplitude of the voice, vocal fatigue and a diminished voice quality. although none of the change in any voice parameter was statistically significant, much of it was in the expected direction (decreased vocal effectiveness) and subsequently holds clinical significance. it must be taken into account that over a longer testing period or longer period of voice use, more pronounced results may be obtained. extended voice use resulting in vocal fatigue or reduced vocal effectiveness may lead to difficulties in controlling voice production and subsequently the voice may deteriorate more quickly or present with more severe dysphonia (stemple et al., 1995). periods of voice rest have also been found to improve the parameters of voice and have been found to be a valuable addition to voice therapy (van der merwe, 2004). the voice use of a professional voice user is not likely to be confined to a two-hour period in a day and typically spans the length of a working day. considering the change that occurred in vocal effectiveness after only two hours of voice use, it may be inferred that after a typical day of voice use, vocal effectiveness may be diminished to a much larger degree. a period of voice rest lasting 30–60 minutes, combined with appropriate hydration, may restore vocal effectiveness and assist in preventing the development of vocal pathologies (van der merwe, 2004; van lierde, claeys, de bodt & van cauwenberge, 2007) the implications of the results of this study suggest that the slp should consider a period of voice rest and hydration after two hours of service delivery. this strategy, consisting of two-hour sessions of service delivery, is consistent with specific guidelines developed for appropriate vocal hygiene and voice conservation such as those set out by deem and miller (2000). occupationally related voice dysfunction may have a significant impact on job performance, attendance and future career choices (roy et al., 2004). furthermore, economic burdens may be placed on the professional voice user who displays diminished vocal effectiveness, including costs related to sick leave, voice therapy or surgical management (roy et al., 2004). the implications of reduced effectiveness of voice point to the importance of developing effective prevention and management programmes for slps who are either experiencing or at risk of developing reduced effectiveness of voice. limitations and recommendations for future research this was an exploratory study and further research with this and other populations is necessary. the implications of the results obtained in this study underline the need for future research. further research into the effects of voice use during service delivery is necessary because of the importance of voice conservation. this research should be expanded to a larger number of participants in order for results to be more representative of the effects that occur in the real-life everyday use of the slp. the wide variety of measurements of vocal parameters collected in this study provided a multi-faceted picture of the voice before and after voice use. these measurements are not time consuming to collect and are also collected as a set by the software used. as a set, the measurements provide valuable data. future research can include the use of all the parameters and measurements used in this study. the experimental condition should be extended to the length of a working day for the effects of voice use to be more representative of typical voice use. experimental control should be tightened in future studies. more control over food and drink ingested before the experiment should occur as certain foods may have a negative effect on the parameters of voice (deem & miller, 2000). furthermore, future research should introduce a control group that does not allow hydration during the period of voice use. the amount and type of hydration permitted in the experimental group should be specified and closely monitored. the type of therapy provided by the participants should be more controlled and possibly limited to either adults or children with similar disorders. conclusion top ↑ this study has revealed both the positive and the negative effects of voice use during service delivery. the occupational use of voice in slp students demonstrated a change (whether positive or negative) in the parameters of voice. although no statistical significance was established, signs which are of clinical significance were observed. these changes may be indicative of the harmful effects of voice overuse, vocal abuse and vocal misuse that are often occupationally required by the slp. the importance of vocal hygiene programmes has been brought to light. a suggested strategy is two-hour sessions of service delivery, followed by a period of voice rest and hydration. vocal hygiene as part of voice conservation may result in prevention, identification and treatment of voice problems before they become significant enough to influence service delivery negatively. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions d.z. 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(2002). impact and prevention of voice problems in the teaching profession: embracing the consumer's view. journal of voice, 16(2), 215–228. http://dx.doi.org/10.1016/s0892-1997(02)00091-7 abstract introduction background research method and design results discussion conclusion acknowledgements references about the author(s) aimee flowers department of speech pathology and audiology, university of the witwatersrand, johannesburg, south africa dhanashree pillay department of speech pathology and audiology, university of the witwatersrand, johannesburg, south africa citation flowers, a., & pillay, d. (2021). sports audiology: ear hygiene practices of gym users who wear earphones. south african journal of communication disorders, 68(1), a794. https://doi.org/10.4102/sajcd.v68i1.794 original research sports audiology: ear hygiene practices of gym users who wear earphones aimee flowers, dhanashree pillay received: 04 sept. 2020; accepted: 10 may 2021; published: 28 july 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: technological advancements have facilitated the demand for electronic systems to track and measure progress during exercise activities. electronic devices with music applications, such as ipods and smartphones, are popular during gym sessions as they support the ambiance to one’s exercise programme. earphones are the popular choice for the transmission of music to the gym user’s ear. there is a direct correlation between the cardiovascular health and the aural health because of the effect of increased blood supply to the auditory system. therefore, this research study explores the ear hygiene of gym users. objectives: this study aimed at determining the ear hygiene and middle-ear status of gym users who wore earphones whilst exercising. method: a purposive sampling method was adopted. data were collected in two phases: phase 1 via a questionnaire and phase 2 included an otoscopic examination and tympanometry. qualitative and quantitative data were analysed. results: fifty-four participants were included. ear hygiene was not a priority for all gym users. the results revealed that 87% of the participants randomly cleaned their ears; however, 59% were cleaning their earphones. the middle ear assessment indicated that 17% of the participants presented with pathological indicators. participants requested for the implementation of educational programmes pertaining to infection control measures for proper ear hygiene. conclusion: there is a dearth of health and wellness educational programmes that include ear hygiene practices, necessitating the development of prevention and promotion programmes for this niche area in audiology. the need for guidelines pertaining to ear hygiene practices amongst gym users is vital to ensure that the auditory system is monitored and protected when individuals participate in exercise sessions. keywords: exercise; ear hygiene; noise induced hearing loss; gym; earphones. introduction the 19th century saw the first industrial revolution in the textile industry as new production methods were employed (crafts, 2011; de pleijt, nuvolari, & weisdorf, 2020; mohajan, 2019). the first, second and third industrial revolutions have created the foundation for the technological developments in the dynamic fourth industrial revolution in the 21st century. the fourth industrial revolution has begotten a human lifestyle that centres on the use of technologically advanced systems and devices in almost every area of life (schwab, 2017; xu, david, & kim, 2018). the world economic forum (2020) states that: the 4th industrial revolution is about more than just technology-driven change; it is an opportunity to help everyone, including leaders, policy-makers and people from all income groups and nations, to harness converging technologies in order to create an inclusive, human-centred future. economic, educational, social and political spheres depend on the technology to communicate, learn and live. individuals use technology connected to earpieces such as earphones and insert ear devices to socialise, to assist in health and wellness and to gain new knowledge. the world health organization describes good ear hygiene as follows (who, 2006:1): not using medication in the ear that is not prescribed for you not using dirty towels to clean one’s ears not putting anything into your ears not cleaning one’s ears with hairpins, toothpicks or anything else not putting water into one’s ears not leaving cotton wool in one’s ears unless directed by a healthcare worker. individuals who wear ear devices are advised to follow good ear hygiene practices, such as cleaning and disinfecting the ear devices regularly (gompa & anand, 2019; mazlan, thomas, saim, & liyab, 2002). focal areas in the field of audiology in the 21st century depend on the use of electronic ear devices for the assessment and management of hearing loss and ear care. auditory brainstem assessment, otoacoustic emission assessments and personal amplification systems are but a few technological advancements in the current century that has provided the opportunity to assess and manage auditory-related disorders in an effective, efficient and precise manner (iliadou et al., 2017). despite the electronic advancements for assessment and diagnosis of an auditory pathology, human-centredness and prevention are still at the forefront of care in audiology. ear-related electronic devices are popular in the 21st century, necessitating the promotion of ear care and the prevention of auditory pathologies. earphones are the most commonly used electronic ear device amongst the general population as individuals use earphones for various activities, such as listening to music, podcasts and audiobooks, watching movies, gaming, and making phone calls (hiipakka, 2015). earphones are most commonly used by people for enjoying music, especially during exercise sessions (barney, gust, & liguori, 2012; jones & ekkekakis, 2019). the earphones placed at the entrance of the ear canal poses a risk for developing otitis media (om), otitis externa (oe) and a noise-induced hearing loss (nihl) as the earphones are carriers of dust and microbial particles and they may emit excessive noise (mazlan et al., 2002). international studies identified that gym users are at a greater risk as exercise exacerbates the physiological changes and increases the ear’s susceptibility to auditory pathologies, such as om and oe (vittitow, windmill, yates, & cunningham, 1994). good ear hygiene practices are not limited to protecting one’s hearing, but it includes cleaning ear accessories, such as earphones (chadha, 2014; who, 2012). however, there is a dearth of research pertaining to the ear hygiene practices of the gym users who wear earphones. audiologists in south africa (sa) play an important role in the promotion of good ear hygiene practices and prevention of auditory pathologies. globally, the research study on sports audiology focuses on social and professional sports participants (du plessis, fothergill, gertner, hughes, & schwaller, 2008; inalsingh, 2012; pillay & dada, 2018; pillay & jardine, 2010); however, there is a lack of studies that focus on the ear hygiene practices of gym users. gym users may not be considered as sportsmen or women; however, gym users participate in training akin to sports people. therefore, a study pertaining to the ear hygiene practices and earphone usage amongst gym users would provide valuable evidence to support additional investigations in the area of sports audiology. background playing and watching sports are popular recreational activities globally. increased participation in sports can be attested to social connects that are created during the shared participation and enjoyment of the sport (department of sports and recreation, 2005). south africa has an emphasised interest in sports (department of sports & recreation, 2005), as south africans are those who take their sports seriously (eds. alegi & bolsmann, 2013). sports provide escapism and a healthy competitive atmosphere in sa (department of sports and recreation, 2005) as people are becoming more aware of the physical and mental well-being. exercise and physical training were synonymous with sportsmen and women; however, wellness and fitness are growing in their popularity with the general population. globally, individuals have become more attuned to a healthier lifestyle, and gyms have become spaces that are frequented by the average person on a daily basis. it is estimated that, globally, there are 58 000 000 individuals who utilise gyms, on average, two times per week (statistic brain, 2017). the number of people attending and exercising at gyms has also increased in sa (fitness and health, 2017) despite the insufficient statistics on gym attendance in sa. south african gyms earn r12.5 billion a year, which is the highest in the world (mapumulo, 2017), suggesting that a significant number of south africans attend gym on a regular basis. health professionals promote exercise to increase immunity and reduce stress levels (gleeson, 2005) as exercise releases endorphins. exercising demonstrates a positive impact on health; however, confounding variables whilst exercising can have negative impact on the health of the individual. gyms are designated spaces for exercise, which focus on a healthy physical lifestyle; however, there are situations and activities within the gym that have the potential to harm the gym user. exercise and training at a gym may have a negative impact on the individual because of an increase in blood pressure levels, thus increasing pressure to the auditory system and brain (delp et al., 2001), as well as increasing the risk of middle ear infections and hearing loss because of earphone usage. in addition to the straining, individuals may hold their breath to assist them when lifting the weights, resulting in an increased pressure within the auditory system. intense yoga poses, the loud noise level in group sessions and noise from crashing weights are incidental factors that can negatively impact the auditory system. abnormal pressure in the auditory system related to participation in sports and exercise may lead to the formation of a perilymphatic fistula, tinnitus, dizziness and hearing loss (assi, moore, ellemberg, & hébert, 2018; vavilala et al., 2018; vogel, 2014). gyms provide the user with the opportunity of participating in classes, such as boxing and swimming sessions (inalsingh, 2012), which could impact the auditory system if ear hygiene practices are ignored, thus, resulting in a possibility of increased ear infections and hearing loss. whilst there is a risk of harmful side-effects of exercise, it is evident that a healthy lifestyle requires exercise. wellness programmes reinforce the positive effects of exercise on the overall physical and mental aspects of human life. the technological advances of the fourth industrial revolution have brought with it health and wellness accessories and wearables, such as wristbands, watches and hearables. hearables are wireless in-ear computational devices that fit inside an individual’s ear canal and enhance the quality of listening (banks, 2015). hearables are supplemented with biometric personal identification information, vital sign tracking, activity tracking, augmented hearing and improved sound quality through the filtering of sound and a decrease in background sound interferences (banks, 2015). the design of hearables must ensure that a seal is created within the ear canal to limit sounds from escaping. the concern arises when high-intensity music is played through the hearables as reverberation increases with hearables when compared with a free-field environment (dobie & van hemel, 2005). determination of safe listening levels is based on free-field listening and not hearables, such as earphones (dobie & van hemel, 2005), highlighting the need for further research. a research study conducted on the effects of earphones focuses on call centre agents (trompette & chatillon, 2012) and young adults who use personal listening devices (sulaiman, husain, & seluakumaran, 2015). a healthy auditory system is linked to good ear hygiene practices, such as cleaning one’s ears, cleaning the devices used in one’s ears and decreasing noise exposure (american academy of otolaryngology–head and neck surgery, 2017; chadha, 2014; who, 2012). there is a dearth of research pertaining to ear hygiene practices. the studies conducted revealed that the majority of individuals are unaware of or are misinformed about the correct ear hygiene practices, and those with some knowledge choose to ignore the recommendations as they believe the harmful effects do not apply to them (punch, elfenbein, & james, 2011). the misperception that ear health refers to the removal of excess wax using earbuds (olaosun, 2014) can result in ear drum perforations and hearing loss (prusick, 2015). ear hygiene includes the cleaning of the pinna and the devices that are inserted into the ear canal, which is a common practice during a hearing assessment conducted by an audiologist as infection control is mandatory (bankaitis, 2015). audiologists have the knowledge to assist gym users in proper ear care and infection control practices, and hence, their role with gym users. the rationale for this study stemmed from the lack of specific educational infection control programmes available in sa targeting individuals who wear hearables on a social basis, despite the increased use of hearables during exercise programmes and at events, such as silent discos and secret sunrise exercise gatherings (secret sunrise, 2018; silent events, 2018). the lack of awareness programmes to support good ear health will lead to the lack of knowledge pertaining to ear hygiene practices, resulting in a possible diagnosis of om or oe (waitzman, 2017). the earliest study in 1985 illustrated the positive link between om and the use of airline headsets (brook, 1985). otitis media is directly caused by staphylococcus bacteria, and more recent studies have supported the evidence that unclean earphones carry these bacteria (mukhopadhyay, basak, gupta, chawla, & bairy, 2008). gym users who wear hearables are at a higher risk as their sweat from exercise creates a breeding ground for bacteria, as it creates a moist and warm environment that is ideal for staphylococcus to grow (bhatia & zahoor, 2007). individuals who were exposed to noise during exercise performed significantly worse when assessed for temporary threshold shifts when compared with those who were exposed to noise only and exercise only (lindgren & axelsson, 1988; vittitow et al., 1994). exercise causes an increase in heart rate and blood pressure, which may, in turn, affect the blood circulation to the cochlea (vittitow et al., 1994), and by wearing unclean earphones and listening to music at extreme intensities, the auditory system is at a greater risk for developing om and/or a hearing loss. therefore, it is crucial to document and profile the ear hygiene practices of gym users who wear earphones. the current study aimed at contributing to new knowledge within the area of sports audiology in sa, and it plays an integral role in building foundational information pertaining to ear hygiene practices of gym users. research method and design aims of the study to document any significant audiological case history information. to document the ear hygiene practices and earphone usage of gym users. to assess and document the tympanometry results of gym users who wear earphones. research design and instrumentation this study employed an exploratory, mixed method research design. the data were collected in two phases: phase 1 utilised a questionnaire that was developed by the researcher to obtain qualitative data, and phase 2 included an otoscopic examination and tympanometry assessment that yielded quantitative data. sampling and sample a purposive sampling method was undertaken to identify individuals who attended gyms. the sample comprised of individuals who were familiar with the researcher and individuals who were recruited via an advert on social media. fifty-four participants between the ages of 18 and 50 years were included in this study, 26 male and 28 female. participants met the following inclusion criteria: participants were required to attend and exercise at a gym for 3 days a week or more; they were required to own a pair of earphones, which they wear during the exercise sessions; they needed to be over the age of 18 years and could identify with any gender description or nationality. the data were collected at a location that was convenient for the participants and were then documented on a record sheet. the otoscopic examinations were performed by the researcher to ensure consistency and reliability of results. the researcher documented all findings onto the record sheet. the findings, such as impacted wax, abnormalities of the pinna and ear canal, were recorded. the middle-ear status was assessed via a calibrated tympanometer with a 226-hz probe tone, which is an appropriate choice for the adult participants in this study. the tympanogram classification was based on the jerger (1970) classification system for tympanometry, which utilises types of tympanograms as per the normative values. participants received the results of the middle ear assessment immediately, and were counselled and referred to the appropriate healthcare practitioners if needed. ethical considerations ethical clearance was granted by the university of the witwatersrand medical research ethics committee in 2018 (clearance number: m180216), and data were collected thereafter. potential participants were provided with an information sheet, detailing the research methods and requirements. individuals who agreed to participate were provided with an informed consent form. descriptive statistics were employed for the analysis of the quantitative data. results the results are presented as per the aims of the study. aim 1: to document any significant audiological case history information five participants experienced multiple ear infections during childhood, of which two had undergone surgery to insert grommets and the other three had a history of ear infections as a result of swimming. seven participants were experiencing ear problems at the time of data collection, which included an excessive wax build-up, tinnitus and hearing loss. eight participants experienced dizziness after exercising, and 11 participants experienced tinnitus. thirteen participants experienced a change in hearing ability after strenuous training sessions whilst listening to loud music via earphones. participants revealed that the loss of hearing lasted for 30 sec to an hour. aim 2: to document the ear hygiene practices and earphone usage of gym users forty-seven participants indicated that ear cleaning formed a part of their hygiene practices. the number of times that participants cleaned their ears varied from every day to every second month. twenty participants practised daily ear cleaning, 20 of them practised weekly ear cleaning, three practised monthly ear cleaning and four participants cleaned their ears at an interval of two or more months. ear cleaning methods and tools were identified as earbuds (29), water (10), soap and water (8), cloth (6), finger (4), tissue (1), waxsol (1), syringe (1) and bobby pin (1). participants’ earphone hygiene practices revealed that 32 participants cleaned their earphones; however, there were variations in the frequency of cleaning practices. three participants practised daily earphone cleaning, 15 practised weekly cleaning, six practised monthly cleaning and seven cleaned their earphones every few months when it became visibly dirty. methods of earphone cleaning varied between using a cloth (9) to using chemicals, such as dettol wipes (1), alcohol swabs (2), chlorohexidine (1), germicide (1), hand sanitizer (1), cologne (1) and surgical spirits (1). one of the participants used a safety pin to clean the earphones. forty-six participants indicated their willingness to participate in education programmes geared at ear hygiene practices. participant 4 stated that ‘the implementation of community programmes at the level of primary intervention would prevent future complications’. participants indicated that their understanding and perceptions surrounding ear hygiene were limited and poor. the average participant exercised three or four times a week and utilised earphones at every session. the mean volume level used by the participants to hearing music was at 70% of the maximum volume on the device. aim 3: to assess and document the tympanometry results of gym users who wear earphones the results are presented in terms of ears rather than participants. the otoscopic examination revealed that 90 ears were free from abnormalities, five ears presented with a partial wax occlusion, 11 ears were fully occluded with wax and two ears showed visible exostoses. the participant who presented with the exostoses indicated that he or she cycles outdoors on a regular basis. the tympanometry results revealed that 90 ears presented with type a tympanograms, two ears with type as tympanograms, two ears presented with type b tympanograms and three ears with type c tympanograms. discussion middle-ear factors eleven per cent of participants presented with a full wax occlusion and 4% with a partial wax occlusion. this number is quite large in relation to the sample size. the presence of wax is normal and healthy; however, it becomes problematic when it blocks the ear canal as it may decrease hearing thresholds (prusick, 2015). the use of earphones may result in a wax build-up and ear canal occlusion (beaudoin, davies, lee, & zalisk, 2020). the function of wax is to protect the ear from dust, harmful bacteria and infection. a research study shows that earphones are vectors for bacteria, and by placing them in the ear, the risk of infection increases (schwaab, gurr, neumann, dazert, & minovi, 2011). the findings from the current study suggest a relationship between the use of earphones, occluded ear canals and a hearing loss. an explanation for the increased wax production may be a protective mechanism to reduce the risk of ear infection (schwaab et al., 2011). a study conducted in 2002 by mazlan et al. exploring the relationship between ear infections and earphone users found that four participants presented with a wax impaction. therefore, the researcher concluded that it could not be attributed to the earphones. therefore, a larger, more detailed study would provide valuable evidence of the significant relationship between the three variables. additionally, the participant who presented with the exostoses indicated that he or she cycles early in the morning and often encounters cold conditions. the weather conditions play a role in the possible development of exostoses (mazza, 2016), which highlights a possible relationship between the presence of exostoses in the ear canals of individuals who cycles under the cold morning conditions. exostoses are benign bony growth that form in the outer ear canal, most commonly after repeated exposure to cold water (moore et al., 2010). however, exostoses can occur after a repeated exposure to extremely cold air (mazza, 2016). therefore, audiologists must be cognisant of the effects of weather conditions on sportswomen and men. type b and c tympanograms can be related to middle-ear pathologies, such as om (onusko, 2004; passali et al., 2014). otitis media and oe are reported in individuals who swim (jayakar, sanders, & jones, 2014; wiegand, berner, schneider, lundershausen, & dietz, 2019; wipperman, 2014), and as a result, there is a need for grommets to manage the middle-ear infections (stephen, leach, & morris, 2013). the current study found that two gym users utilised the pool facilities to exercise, and therefore, individuals who swim and have pre-existing ear pathologies should receive advice on ear care to protect the middle-ear system from further damage (wang, liu, shiao, & wang, 2005). the use of earphones during exercise sessions exposes the user to bacteria from the earphones (liaqat, tariq, jamil, & amin, 2015) and participants who have a hearing loss and who experience tinnitus are innately susceptible to further ear damage. a research study suggests that bacteria live on earphones in the form of biofilm, thus, creating a vector for causing ear infections (liaqat et al., 2015). noise levels participants who revealed that they have a hearing loss did not disclose the cause of the hearing loss; however, it is vital to monitor the noise levels when using earphones during exercise sessions in order to prevent further damage on the hearing mechanisms. the noise exposure in gyms may be because of loud music during group classes, weights crashing and general music noise within the gym. the current study highlights the need for a large-scale study that monitors the noise levels in gyms as exercising results in the auditory system being more sensitive to sound (vittitow et al., 1994). the experience of tinnitus and hearing loss after training may be attributed to loud music levels (ireland, 2017), and the results from participants in the current study revealed that music volume levels were 70% of the maximum volume. the temporary shift in thresholds after exposure to loud music is common (le prell et al., 2012; zhao, manchaiah, french, & price, 2010), which highlights the need for monitoring the hearing status of individuals who are exposed to loud music during gym sessions. a study by punch et al. (2011) suggested that the participants were aware of the dangers of listening to music at loud levels; however, they underestimate the damage of noise that was caused to the auditory system. educational programmes are suggested to deliver preventative measures in a more effective, long-lasting manner (punch et al., 2011). intense exercise intense workout sessions increase the susceptibility of developing audiological symptoms (ireland, 2017) as strenuous workouts, such as cardiovascular exercise, resistance training, strength and stretch training, and high-intensity workouts, increase the blood flow to the cochlea, resulting in an increased sensitivity whilst training (welch, law, & dirks, 2014). the negative effects of intense workout sessions include increased middle-ear pressure that results in a possible perilymphatic fistula (gurgel, 2014; magliulo, stasolla, colicchio, & gagliardi, 2010) the current study revealed that participants are experiencing audiological symptoms after training, and these symptoms may be warning signs of the hazardous effects of exercise on the auditory system. the negative effects of exercise on the auditory system may also be compounded because of the increase in middle-ear pressure (nall, 2017). therefore, education on the effects of illness on the auditory system and the compounding effect of exercise on a compromised auditory system is important. ear hygiene the ear is a self-cleaning mechanism, and it is, therefore, recommended that individuals do not need to clean their ears (prusick, 2015). however, individuals from the current study described various cleaning methods, some of which are harmful. these included the use of earbuds and a bobby pin. individuals are generally misinformed or are not aware of the correct ear hygiene practices (olaosun, 2014). the results of the current study correlated with those of a study exploring the ear cleaning habits amongst educated young adults in nigeria (olaosun, 2014). the current study and the study conducted by olaosun (2014) found that individuals are unaware of the correct manner in which to clean the ear. participant 2 stated that they felt that ‘there is not enough awareness surrounding aural hygiene’. therefore, it is important to educate the gym users on how to care for their ears and avoid further damage from using earphones. education provides individuals with the tools they need to identify problems and create solutions (zimmerman, woolf, & haley, 2015). educating the public about healthcare is extremely important in order to promote hygiene practices and prevent diseases. the current study revealed that there is a need to educate individuals about the status of their middle-ear health whilst exercising. the warning signs and symptoms of various audiological disorders should be displayed in gym sites to create awareness. it is evident that health and wellness programmes need to consider the inclusion of auditory assessments in order to ensure that aural health and communication are monitored. conclusion exercise is vital in the overall healthy lifestyle regime; therefore, one should be equipped with the knowledge of preventing the audiological abnormalities that could result during exercise sessions. various types of exercise activities have different effects on the audiological system and may cause audiological symptoms during and after training sessions. by providing the gym user with the required ear hygiene knowledge, the audiologist can promote good ear health and prevent ear damage. there is a need for aural hygiene awareness, especially in the gym setting, and the role of the audiologist is highlighted in this niche area. the audiologist can consider the following recommendations: lobby that medical aids create a mandatory hearing assessment within their health and vitality programmes, thus, promoting the monitoring of one’s hearing status. make requests to the gyms for posters that indicate the need to disinfectant surfaces, including one’s earphones. offer screening at gym sites to promote awareness of aural hygiene and hearing. petition the producers of hearables to request for a warning sign to be placed on hearables to prevent misuse at loud volumes. petition the producers of earphones and request that cleaning instructions are made available within the instruction manual. exercise is necessary for a healthy body and mind; therefore, one cannot stop exercising in order to decrease the risks of auditory damage. however, audiologists play a significant role in educating and equipping the gym users about ear hygiene and care. there is a niche area of sports audiology, which should be explored in a deeper manner. acknowledgements the authors thank all the participants who gave up their time to be a part of the study. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions both a.f. and d.p. contributed equally to this work. funding information this research work received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article. disclaimer the views and opinions expressed in this article are those of the authors and do not reflect the official policy or position of any affiliated agency of the authors. references alegi, p., & bolsmann, c. 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(2015). population health: behavioral and social science insights understanding the relationship between education and health. retrieved from https://www.ahrq.gov/professionals/education/curriculum-tools/population-health/zimmerman.html 61 perceptions of tinnitus in a group of senior citizens pamela mae sourgen and eleanor ross department of speech pathology and audiology university ofthe witwatersrand abstract although previous research has highlighted the debilitating effects of tinnitus on quality of life, most studies appear to have targeted the general population, with few researchers focusing specifically on elderly persons. hence, the purpose of this study was to investigate the perceptions of tinnitus in a group of 20 senior citizens. a questionnaire based on existing research instruments developed by stouffer and tyler (1990) and wilson et al. (1991) was used to elicit information regarding the auditory-perceptual characteristics of tinnitus, effects of tinnitus on lifestyle, perceived causes, factors aggravating or ameliorating tinnitus and coping strategies employed. results supported findings from earlier research and indicated that tinnitus did indeed exert an impact on respondents' lives with 65% avoiding noisy situations, 65% having difficulty relaxing, and 55% struggling to follow conversations. almost two-thirds, namely 70%, of respondents reported feelings of frustration, 60% and 55% mentioned feelings of tenseness and irritability respectively, while 50% experienced depression associated with the tinnitus. these findings are discussed in terms of their implications for the education of health care professionals, management of tinnitus patients in general, public and patient awareness campaigns, the establishment of tinnitus self help groups, and further research. opsomming alhoewel vorige navorsing die negatiewe gevolge van tinnitus op lewenskwaliteit aangetoon het, was die meeste studies klaarblyklik gemik op die algemene bevolking, en het min navorsing op bejaardes gefokus. derhalwe, was die doel van hierdie studie om die persepsies van tinnitus in 'n groep van 20 senior burgers te ondersoek. 'n vraelys, gebaseer op bestaande navorsingmiddels ontwikkel deur stouffer en tyler (1990) en wilson en andere (1991) is gebruik om inligting te verkry oor die ouditief-perseptuele kenmerke!van tinnitus op lewensstyl, waarnemende oorsake, faktore wat tinnitus vererger ofverbeter, en hanterings-strategiee wat gebf.uik word vir die verligting / vermindering van tinnitus. die resultate stem ooreen met die van vorige navorsing en het aange8-ui dat tinnitus wei 'n invloed het op respondente se lewens, met 65% wat lawaaierige situasies vermy, 65% wat dit moeilik ojdervind om te ontspan, en 55% wat sukkel om gesprekke te volg. amper twee-derdes, naamlik 70% van die respondente hetj gevoelens van frustrasie aangemeld, 60% en 50% respektiewelik, het melding gemaak van gevoelens van spanning en irritasie, terwyl 50% gevoelens van depressie as gevolg van die tinnitus ondervind het. hierdie bevindinge word bespreek in tkrme van hul implikasies vir die opleiding van gesondheidsorg-personeel, die behandeling van tinnitus-pasiente in die algemjen, veldtogte vir die bewusmaking van die publiek, die daarstelling van tinnitus-selfhelpgroepe, de . i en ver re navorsmg. i i . /' key words: tinnitus, senior citizens, quality oflife tinnitus is one of the most debilitating and disabling symptoms of auditory dysfunction, and despite the fact that the past 20 years have seen an enormous growth in clinical and research interest in this condition, there still appears to be no widely accepted treatment that is highly successful (tyler,aran & dauman, 1992: 41; tyler, 1997b). the term "tinnitus" is derived from the latin "tinnire" which means to ring or to tinkle (jackson, 1983:159), and is used to describe "the subjective perception of sound by an individual in the ear or head unrelated to an external sound" (o'connor & zappia, 1993: 25). hence, the sound which is produced involuntarily, does not have an external source. various ways of classifying tinnitus have been put forward, namely: middle ear and sensorineural tinnitus, pulsatile and non-pulsatile tinnitus and objective and subjective tinnitus (o'connor & zappia, 1993; tyler, 1997a). since middle-ear tinnitus is caused by myoclonic or vascular sources (tyler & babin, 1993) it has a pulsating quality. in view of the fact that the patient is hearing a part of their body external to the auditory system it is also known as objective tinnitus, which can sometimes be heard by the doctor as well (o'connor & zappia, 1993). sensorineural tinnitus, also known as non-pulsatile or subjective tinnitus, is commonly caused by noise exposure and aging which can result in either hair cell, chemical or neural abnormalities (tyler, 1997a). however, tyler and babin (1993) maintain that the distinction between subjective and objective tinnitus has limited usefulness as studies of cochlear emissions have demonstrated that a sound which can be heard by the examiner in the ear die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 62 canal, may not be heard by the patient and often originates in the inner ear (norton, schmidt & stover; 1990). the sensation of tinnitus has not only been perceptually located in one or both ears, but patients have also indicated the presence of tinnitus in the middle, back, side or front ofthe head (tyler & babin, 1993). the quality ofthe sound has frequently been described as buzzing or ringing, with other descriptions of rushing, roaring, whistling or pulsing also being indicated. some patients have reported two or more sounds which may differ in pitch (tyler & babin, 1993). high pitched tinnitus is more common (tyler & babin, 1993), and when combined with relatively loud tinnitus tends to make the sound more annoying (jakes, hallam, chambers & hinchcliffe, 1985; tyler et ai.,1992). a number of surveys performed in the usa, the united kingdom and sweden have indicated that tinnitus is fairly common. although there is a difference in the reported prevalence of tinnitus in each of the three countries, the results generally indicate that 6-20% of the population experiences tinnitus that can be bothersome, with 1% experiencing a severe tinnitus that interferes with daily activities (chung, gannon, & mason, 1984; coles, 1987; axelsson & ringdahl, 1989). tinnitus is not only a common condition, but often a debilitating one (stouffer & tyler, 1990) as it may be "associated with considerable psychological distress such as anxiety, depression, irritability, and sleep disturbance" (wilson, henry, bowen & haralambous, 1991:197). a number of studies have provided information on the psychosocial consequences of tinnitus. difficulty falling asleep, trouble concentrating, feelings of anxiety, difficulty understanding speech, depression, annoyance, confusion, dependence on drugs, emotional distress, auditoryperceptual difficulties, and a deleterious effect on the ability to lead a normal life have been reported (tyler & baker, 1983; coles in stouffer & tyler, 1990; tyler, 1997a). in order to investigate the experience of tinnitus from the patient's perspective, stouffer and tyler (1990) administered a questionnaire to 528 tinnitus sufferers who were representative ofa clinic population. these researchers reported that the tinnitus population they studied did not necessarily present with a hearing loss. perceptual characteristics of pitch and loudness were both rated as 7 on a visual analogue scale of 1 to 10 by 65% and 47% of the subjects respectively. patients whose primary complaint was tinnitus and those who were diagnosed as having meniere's disease reported the effects of tinnitus on daily life as more severe than those whose primary complaint was hearing loss. according to stouffer and tyler (1990), these results highlight the impact of tinnitus on people's lives. therefore, by knowing how people perceive their tinnitus the clinician is better able to understand the problems that the tinnitus sufferer experiences and provide relevant information and intervention. it is important to note that "each patient presents with his or her own personal responses to tinnitus" (tyler, 1997a: 10). it has been noted that some people are not distressed by their tinnitus while others find it highly distressing (dineen, doyle & bench, 1997a). according to tyler, aran and dauman (1992) two main factors contribute ,to the annoyance of tinnitus, namely, the tinnitus itself and psychological factors. the more unpleasant the quality of the tinnitus, the more annoying it is likely to be (tyler et ai., 1992) and the less people are able to cope with stressful situations, the more likely they pamela mae sourgen & eleanor ross are to be annoyed by the tinnitus (tyler et ai., 1992; dineen et ai., 1997a). axelsson and ringdahl (1989) noted that some of the disturbing qualities of tinnitus are greater in the older population. nevertheless, despite this finding, most studies appear to have targeted the general population oftinnitus patients, with few researchers focusing specifically on elderly persons. aging involves molecular, cellular and organ changes that when combined, result in a decrease in the body's ability to respond to disruptions in homeostatic equilibrium (chodzko-zajko & ringel in chodzko-zajko, 1997). these "normal" changes can be accompanied by secondary or pathological problems which are often associated with aging (lubinski & weiland, 1997). consequently, all elderly people undergo some degree of physical, mental and/or sensory function changes, yet not all are as successful as others in adapting to those changes (lubinski & weiland, 1997). the ability to adapt is usually influenced by the severity of the change, the ability of the person to access the internal assets accumulated throughout life, and the physical and social environmental resources available (lubinski & weiland, 1997). many older people are able to live their lives with considerable satisfaction and competence, with numerous surveys of life satisfaction demonstrating a general sense of well-being (maddox, 1978). however, good health, adequate finances and someone to confide in, often playa role in determining a person's overall perception of their quality oflife (botwinick, 1984). this status is defined as "the degree of emotional, intellectual, or cultural satisfaction in one's everyday life, as distinct from the degree of material comfort" (reader's digest, 1984:1381). with regard to good health, it is not only the person's objective health status that plays a role, but literature studies have shown that older adults' feelings of life satisfaction can be influenced by their subjective health status (spirduso & gilliammacrae, 1991). both the severity and prevalence oftinnitus have been found to increase with age (axelsson & ringdahl, 1989). tinnitus can therefore playa role in elderly people's subjective perception of their health status. in addition, if they perceive tinnitus as a threat to their health, their quality oflife could be affected. ': although there appears to belittle, if any, re~earch in the area of tinnitus currently being conducted ~in south africa, according to statistics ofthe prevalence oftinnitus in the usa, the uk and sweden, namely 6%-20%) it seems reasonable to assume that a relatively large n*mber of people in south africa probably suffer from this ~isorder. it would therefore seem important to highlight the presence and impact of tinnitus on people's qualib oflife so that intervention can be provided to decrease the level of distress and annoyance associated with this condition (dineen, doyle & bench, 1997b). many of the studies on the psychosocial aspects of tinnitus have used the university of iowa tinnitus questionnaire developed by stouffer and tyler (1990) or various tinnitus handicap scales (e.g., tyler & baker, 1983; hallam, jakes & hinchcliffe, 1988; kuk, ,tyler, russel & jordan, 1990). however, most of these--;:esearch instruments were designed for the generalpopulation oftinnitus sufferers and do not specifically target elderly persons. for example, the tinnitus questionnaire includes items not necessarily applicable to senior citizens, such as questions regarding menstruation, shooting guns, rifles and so forth, this particular research tool also presupposes the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) perceptions of tinnitus in a group of senior citizens a fairly sophisticated target group which is able to quantify percentage oftime that tinnitus is present on a scale from 1 to 100. for this reason, the present study endeavoured to adapt the university of iowa tinnitus questionnaire (stouffer & tyler, 1990) and the tinnitus reaction questionnaire (wilson et ai., 1991) to meet the needs of a group of senior citizens. the present study also falls within the framework of current health and welfare policy in this country. for example, the white paper for the transformation of the health system in south africa (1997:13) states that the "emphasis should be placed on reaching the poor, the under-served, the aged, women and children who are amongst the most vulnerable". the white paper for social welfare (1997:71) refers to older persons and states that "there needs to be a good balance between an emphasis on duration oflife and quality oflife". the effects of tinnitus need to be researched in the elderly population because this condition has the potential of adversely affecting quality of life (tyler & babin, 1993). methodology aim the overall aim of the study was to investigate the perceptions of tinnitus in a group of senior citizens. sub-aims (1) to assess respondents' perceptions of the auditory characteristics of tinnitus. (2) to determine the effect of tinnitus on quality of life. (3) to elicit information on the respondents' perceptions of the cause/s of their tinnitus. (4) to highlight factors perceived to aggravate or ameliorate the experience of tinnitus. (5) to explore the coping strategies employed. res~arch design i in order to investigate tje aims of the study, a survey design which involved the jdministration of a questionnaire was used. the purposejofthis design was "to provide a detailed inspection of tlie prevalence of conditions, practices, or attitudes in a given environment by asking people about them rather than observing them directly" (ventry & schiavetti, 1980:52). /' subjects a sample size of 20 persons presenting with tinnitus was used. subjects were recruited from three old-age homes in the gauteng area, using nonprobability snowball sampling techniques (baker, 1988). subject selection criteria (1) subjects were required to suffer from any type of tinnitus, as this was the phenomenon under investigation. (2) subjects needed to be 60 years of age or older, thereby falling into the category of senior citizen in which there is a higher prevalence of tinnitus (axelsson & ringdahl, 1989). .63 (3) subjects had to have no diagnosed psychiatric illness in which the person might experience auditory hallucinations, which could be confused with tinnitus, thus confounding the results (jackson, 1983:159). (4) subjects needed to have the cognitive-linguistic ability to understand and answer the questionnaire. (information on (3) and (4) was obtained from the health care personnel at the various old-age homes.) description of subjects the occurrence of tinnitus in relation to age, gender, previous occupation, hearing loss, primary diagnosis and primary complaint is set out in table 1. research instrumentation a tinnitus questionnaire based on an adaptation of the university of iowa tinnitus questionnaire (stouffer & tyler, 1990) and the tinnitus reaction questionnaire (wilson et ai., 1991) was used to quantify the data. these two research instruments were chosen because they covered areas targetted in the present study. the questionnaire is set out in appendix a, and comprised the following sections: covering letter a covering letter not included with the original research tools, provided subjects with a brief explanation of the purpose and usefulness of the research, what the session would entail, as well as an assurance of confidentiality and voluntary participation. biographical information subjects were required to provide details regarding their age, previous occupation and gender. previous occupation was important since patients exposed to occupational noise have a 70% risk of tinnitus (coles in stouffer & tyler, 1990). information on age was sought because within the population over 50 years of age approximately 40% have tinnitus (axelsson & ringdahl, 1989). this increase in prevalence with age is possibly due to the increase in hearing loss and accumulated noise exposure, both of which are implicated in sensorineural tinnitus (chung et ai., 1984; tyler, 1997a). perceptual characteristics this section was designed to gather information from respondents on the perceived location, sound quality, pitch and loudness oftheir tinnitus, as well as time since onset and how often the tinnitus bothered them. stouffer and tyler (1990) and tyler and babin (1993) have highlighted the importance of quantifying these perceptual characteristics of tinnitus. psychosocial effects the aim of this section was to determine the effects of tinnitus on the person's lifestyle, emotions and general health. information was elicited in order to highlight the presence and impact of tinnitus on people's quality oflife so that relevant intervention could be provided to decrease the level of distress and annoyance associated with it. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 64 etiology the rationale for including this section, was that an understanding of the possible causes of tinnitus could possibly serve to reduce the effects of the condition by eliminating the cause (stouffer & tyler, 1990). factors influencing tinnitus this section was designed to highlight factors that exacerbate or reduce a person's tinnitus. such information was felt to be useful in planning management strategies for tinnitus patients (o'connor & zappia, 1993). coping strategies this question explored how people coped with their tinnitus. it has been found that a person's ability to cope may influence the amount of distress associated with tinnitus (lindberg, scott, melin & lyttkens, 1987). additional comments additional views were targeted through an open-ended question which was placed toward the end of the questionnaire (de vaus, 1991) allowing respondents to elaborate on their general feelings and experience of tinnitus (singleton, straits & straits, 1993). audiological characteristics based on a similar section in stouffer and tyler's (1990) study, this section, filled in by the audiologist, provided table 1: description of subjects (n=20) demographic factor sample 1age 60-69 70-79 80-89 90-99 2. gender female male 3. previous home (quiet) occupation office (semi-quiet) other (semi-noise) factory (noise) 4. hearing loss slight (16-25db) (left ear) mild (26-40db) moderate( 41-65db) severe (66-95db) 5. hearing loss slight (16-25db) mild (26-40db) moderate(41-65db) severe (66-95db) 6. primary diagnosis noise-induced loss presbycusis middle ear disorder normal hearing other 7. primary complaint hearing loss tinnitus pamela mae sourgen & eleanor ross information on the subjects' primary diagnosis, primary complaint and hearing thresholds at 1000 and 4000hz. since tinnitus and hearing loss usually co-exist (tyler, 1997a) this information was included to illustrate the relationship between the tinnitus and hearing loss, particularly presbycusis in the elderly population. pre-test of the research instrument the tinnitus questionnaire adapted from the university of iowa tinnitus questionnaire (stouffer & tyler, 1990) and the tinnitus reaction questionnaire (wilson, et ai., 1991) was used in the pre-test on two subjects who were not included in the final study. on the basis of the pilot study the questionnaire was further adapted for senior citizens. namely, a larger font size was used to facilitate reading, and various questions were removed or modified. firstly, the questions requiring the percentage of time tinnitus was present and the number of days per month that tinnitus was bothersome were deleted. they were replaced with an open-ended question on how often tinnitus bothered the subject. this item was placed in the biographical details section. the questions targeting the effects of tinnitus on respondents' quality of life were changed from a percentage scale ranging from 1-100 (stouffer & tyler, 1990) to a four-point scale where l=never, 2=occasionally, 3=often, 4=all the time. the question on causation of tinnitus was modified from a choice of possible causes to an open-ended question as the pretest subjects circled a possible cause and the "i have no idea" item where only one answer was required. the no. percentage 6 30 10 50 3 15 1 5 12 60\ 8 40, , 3 15: i 8 40', 6 30 i 3 15 \ , 1 5 i 4 20 11 55 4 20 3 15 5 15, _. 10 50 2 10 4 / 20 12 60 1 5 2 ,/ 10 1/" 5 11 55 9 45 the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) perceptions of tinnitus in a group of senior citizens 65 item referring to "shooting guns, rifles" as well as the item on menstruation in the list of factors that make tinnitus worse, were removed as they were deemed irrelevant for the elderly population. the subjects used in the pilot study were not included in the final administration of the questionnaire. the researcher to obtain the hearing thresholds at 1000 and 4000hz as recommended by stouffer and tyler (1990). data analysis administration of the questionnaire the tinnitus questionnaire was administered individually to subjects in order to provide assistance or clarification where necessary, as opposed to a postal survey in which such assistance would not have been possible. while some subjects completed the questionnaire on their own, others requested the researchers' help in this regard because they had, for example, not brought with their reading glasses. the speech therapist at the one old-age home liaised between the researcher and patients and accessed the relevant audiological information set out in section h of the tinnitus questionnaire. since no audiological information was available for the subjects from the other two homes, a screening audiometer was used by the results were analysed using descriptive statistics, in which quantitative information or data are organized, summarized and described (mccall, 1994). content analysis was used to analyze qualitative data from the openended questions according to themes articulated by respondents (dooley, 1995). results and discussion the following results are discussed in accordance with the sub-aims of the study. auditory-perceptual characteristics the auditory-perceptual characteristics of place, quality, pitch, loudness, time since onset and how often respondents were bothered by tinnitus are set out in table 2. table 2: description of auditory-perceptual characteristics of tinnitus (n=20) tinni tus characteristic sample no. percentage 1. place left ear 6 30 right ear 2 10 both ears equally 4 20 both, left worse 2 10 both, right worse 1 5 head 4 20 head, right 1 5 2. quality' buzzing 10 23,8 hissing 7 16,7 humming 6 14,2 i ringing 4 9,5 other 3 7,1 cricket-like 3 7,1 whistling 2 4,8 clicking 2 4,8 crackling 1 2,4 popping 1 2,4 roaring 1 2,4 steam whistle 1 2,4 i whooshing 1 2,4 ; / 3. pitch mean 5,3 median 5,7 range 1-8 4. loudness • mean 5,7 • median 5,9 • range 1-10 5. time in years since onset of tinnitus • 0-8 10 50 • 9-16 1 5 • 17-24 3 15 • 25-32 4 20 • 33-40 2 10 6. how often tinnitus bothered them • sometimes 9 45 • often 6 30 i • all the time 5 25 * responses regarding quality do not add up to 20 as respondents reported more than one type of sound. die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 66 the responses indicated that the perceptual location of tinnitus could be in either ear (40%), both ears (35%) or in the head (25%) this phenomenon has been found by numerous other researchers (miekle & griest, 1987; axelsson & ringdahl, 1989; stouffer & tyler, 1990), all of whom have found a higher incidence of bilateral tinnitus as opposed to a unilateral location. in addition, a quarter of the respondents reporting unilateral tinnitus were male and three-quarters were female which reflects the apparent prevalence of unilateral tinnitus in females (erlandsson, hallberg &axelsson, 1992) and bilateral in males (axelsson & ringdahl, 1989). the present finding of a higher prevalence of left ear tinnitus (30%) corresponds with previous studies (lindberg et ai., 1984; axelsson & ringdahl, 1989; stouffer & tyler, 1990). numerous hypotheses have been suggested, namely handedness, asymmetric noise exposure, the predominance ofleft-sided vascular disease and the physiological asymmetry of the lower brainstem in humans (hallam, rachman & hinchcliffe, 1984; stouffer & tyler, 1990). according to axelsson and ringdahl (1989), a reason for the difference in laterality could be due to left-sided noiseinduced hearing loss being more common than right-sided. since unilateral tinnitus is more likely to be in the ear with greater hearing loss (chung et ai., 1984) left-sided tinnitus should be more common. this situation is reflected by the present findings in which 75% of respondents presented with a moderate to severe loss in the left ear, compared to 60% in the right ear. yet, in chung, gannon and mason's (1984) study no lateral difference in the prevalence of tinnitus was found. however, tyler and babin (1993) caution that the perceptual location may be misleading and is of limited diagnostic importance. most of the subjects provided more than one response item for the quality of the tinnitus with the three most common responses being buzzing (24%), hissing (17%) and humming (14%). these are different when compared to stouffer and tyler's (1990) finding of ringing (38%), buzzing (11 %), cricket-like sounds (9%) and hissing (8%). however, the ordering effect, with buzzing appearing first on the list, may have influenced the choice of response. in addition, these descriptions are dependent on the vocabulary of the respondent and their previous listening experience and therefore have limited diagnostic significance (tyler & 6 5 o+---.----.---.---.--~---.----r-~~ ___ 2 34567 8 9 10 (ratings (1=low/soft; 10=high/loud) ___ pitch ~ loudness figure 1. subjective ratings of pitch and loudness of tinnitus (n=20) pamela mae sourgen & eleanor ross babin, 1993). however, reports of pulsing or popping sounds, although they may occur in sensorineural tinnitus, should alert the physician or clinician to the presence of muscular or vascular tinnitus (tyler & babin, 1993). results in respect of respondents' perceptions ofthe pitch and loudness of their tinnitus are illustrated in figure l. respondents rated the relative pitch of their tinnitus on a subjective visual analogue scale ranging from 1 to 10 where 1 was very low and 10 very high. the mean pitch rating was 5,3 (sd=1,9) with a range of 1 to 8. it was observed that 50% of the respondents rated their pitch in a mid-range position of 5 and 6, with no difference between those reporting a higher pitch rating of 7 and above (25%) and those with a lower rating of 4 and less (25%). this finding is in contrast to previous observations that most tinnitus sufferers report a high-pitched tinnitus (stouffer & tyler, 1990) frequently matching their tinnitus at frequencies around or above 2000, 3000 and 4000hz (tyler & babin, 1993). however, many of the respondents in this study stated that they had difficulty rating their pitch as it varied and were unsure of what constituted a low or high pitch. this result is consistent with stouffer and tyler's (1990) finding that tinnitus pitch could vary daily. as a result, pitch matching reliability varies among patients (tyler & babin, 1993: 3037). although individuals do differ in regard to their perception of high and low pitch, which tends to make it difficult to compare values between subjects, scaled values have been found to be reliable within subjects (hellman & meiselman, 1988). loudness was rated on a similar scale resulting in a mean loudness rating of 5,7 (sd=2,25) and a range of 1-10. it was observed that 35% of the respondents rated their loudness in a mid-range position of 5 and 6, with the same number, namely 35%, reporting a higher loudness rating of 7 and above, while 30% recorded a lower rating of 4 and less. some patients indicated that the loudness of their tinnitus changed. this finding was also reported by stouffer and tyler (1990) with more than 50% of their respondents experiencing fluctuations in tinnitus loudness. it has been generally found that most patients match the loudness of their tinnitus to a few decibels above their hearing threshold (lindberg, lyttkens, melin & scott, 1984). however, tyler and babin (1993) point out that this sensation level is an intensity measure and not a measurement of 16udness (sones). therefore, with hearing threshold and 16udness recruitment taken into account, an increase in hearing threshold could result in tinnitus being perceived as exceptionally loud (tyler & babin, 1993). i a slight difference in pitch and loudness ratings between males and females was observed. for males the me~n pitch rating was 5,8 (range = 2-8) and loudness 6,4 (rarige = 410), with females giving a mean rating of 4,9 (range = 1-8) for pitch and 5,1 (range = 1-8) for loudness. these results do not reflect dineen, doyle and bench's (1997a) finding that female subjects perceived their tinnitus as louder and more annoying than their male counterparts. for 50% of respondents, tinnitus onset was within the past 8 years. in relation to stouffer and tyler:s (1990) result / ' of62%, 45% ofthe respondents in the present study reported the onset of tinnitus within the previous 5 years and 10% as opposed to 18% within the previous 6-10 years. although a fairly similar trend was noted between the two studies with a large percentage of respondents reporting a recent time since onset, the present study demonstrated a larger mean time since onset of 13,5 years (sd=13,4) as opposed ~/ the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) perceptions of tinni tus in a group of senior ci tizens to stouffer and tyler's (1990) mean of 7,6 years (sd=9,9). this finding may have been related to the fact that the study targeted senior citizens who had probably suffered from tinnitus for longer periods of time than members of the general population. the mean age for the onset of tinnitus was 58,4 years (sd=16,6) thus falling into the most common period for the onset of tinnitus, namely middle age (i.e., 50 to 60 years). this finding can be explained by the reduced metabolic responsiveness of the auditory system associated with aging 67 useful information that could aid in the design of therapeutic programmes (stouffer & tyler, 1990). according to tyler, stouffer and schum (1989), discussing the problems tinnitus patients generally experience and the difficulties they tend to encounter in describing the sounds they hear, can be a helpful and therapeutic strategy in counselling individual tinnitus clients and their families. effects of tinnitus on quality of life resulting in increased sensitivity to noise and drug stress approximately a third, namely 35%, of respondents (miller, dolan, raphael, altschuler, 1998). however, a range indicated that their overall enjoyment of life was affected of 25 to 85 'years was present in the sample. by their tinnitus. table 3 demonstrates the frequency with it was found that 45% of the respondents were only which tinnitus affected their quality of life. bothered by their tinnitus some ofthe time, while 25% were it was noted that respondents were most affected in noisy bothered all the time. the remaining 30% experienced situations (65%), in relation to their capacity to relax (65%), difficulty answering this question because of the variable in their ability to follow a conversation (55%) and in their nature of their tinnitus. moreover, due to the somewhat ability to concentrate (50%). one respondent provided ambiguous wording of the question, it cannot be determined further information on how her quality oflife was affected whether the time respondents were bothered by tinnitus by stating that she would no longer listen to music because corresponded to the time it was present or only to a part of she feared it would trigger her tinnitus. the weighted scores that time when they were bothered by their tinnitus. did not alter the rank order of the life functions/situations assuming that the information obtained was an indication according to the percentage of respondents that were of time tinnitus was present, on the basis that respondents' affected. instead the weighted scores served to distinguish tinnitus was variable, then this result does not correspond between life function categories those with the same with stouffer & tyler's (1990) finding that 68% of their percentage of respondents. for example, 65% of respondents respondents indicated that their tinnitus was present for were affected by noisy situations and experienced difficulty more than 80% of the time. nonetheless, the variability of relaxing, yet tinnitus was shown to affect noisy situations tinnitus did not necessarily reduce the annoyanceproduced more often than the ability to relax as demonstrated by the by the condition but, as explained by one respondent, was weighted score of 23 as compared to 18. however, it is not more irritating because it would come on suddenly. since . known whether tinnitus was the only cause of the tinnitus is a chronic condition, there is no direct relationship difficulties experienced in noise and the ability to follow a between the amount of impairment and the disabling and conversation since all of the respondents presented with handicapping effects of tinnitus (hallam et ai., 1984). co-occurring hearing losses. in summary, although the findings regarding the previous studies commonly report difficulties in sleep auditory-perceptual characteristics do not necessarily aid and ability to concentrate (tyler & baker, 1983; jakes et in diagnosing causation of tinnitus, they are nevertheless ai., 1985; slater & thrry, 1987; axelsson & ringdahl, 1989; important in that they enhance audiologists' understanding stouffer & tyler, 1990). moreover, it has been reported that of the condition from the client's perspective. in addition, females are more likely than males to report difficulty such ~ubjective descriptions i of tinnitus should provide falling asleep (stouffer & tyler, 1990; dineen et ai., 1997a). table 3: frequency with ~hich tinnitus affected various life functions/situations (n=20) life functions/situation~ no. weighted score . percentage , avoid noisy situations 13 23 65 ability to relax 13 18 65 / difficulty following a conversation 11 18 55 ability to concentrate 10 14 50 difficulty understanding speech 9 13 45 caused tiredness 8 12 40 enjoyment of life 7 11 35 difficulty with sleep 7 9 35 avoid social situations 5 8 25 avoid quiet situations 5 6 25 ability to work 3 5 15 interferes with relationships 3 4 15 * weighted scores were obtained by arbitrarily assigning the value of 1 to the response of 'sometimes', 2 to 'of ten'" and 3 to 'all the time'. each value jas multiplied by the number of responses, respectively. the sub-totals were combined to form the weighted score. die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 68 however, this finding was not obtained in the present study with 35% of respondents, 43% of whom were female and 57% male, reporting occasional interference with sleep. furthermore, axelsson and ringdahl (1989) found a significant relationship between the severity oftinnitus and difficulties in falling asleep. even if the amount of time that tinnitus is bothersome is regarded as an index of the severity of tinnitus it was still found that sleep was not disturbed in 64% of those respondents bothered by their tinnitus often or all the time. nevertheless, of the 7 respondents indicating loud tinnitus (rating of 7 or more) 43% indicated that tinnitus interfered to some degree with sleep. slater and terry (1987) found that tinnitus loudness and difficulty getting to sleep were significantly associated. however, although sleep is affected in some tinnitus patients, coles (in slater & terry, 1987) cautions that some individuals with severe tinnitus may not experience sleep difficulties. therefore sleep disturbance cannot be used as a clinical indicator of tinnitus severity. table 4 shows that 70% of respondents reported that their tinnitus caused them to be frustrated, 60% felt that it made them feel tense, 55% stated that the condition caused feelings of irritability and 50% reported depression. although more respondents, namely 45%, indicated that their tinnitus caused them to be confused compared to 40% reporting that the condition made them unhappy, unhappiness due to tinnitus occurred more frequently as indicated by the slightly stronger weighting of 11. depression, anxiety and annoyance have been highlighted as the common emotional reactions to tinnitus in previous studies (tyler & baker, 1983; tyler, 1997a; scott, lindberg, melin & lyttkens, 1990; stouffer & tyler, 1990;). this finding could simply be due to differences in terminology as, for example, tyler and baker (1983) combined despair, frustration and depression as one difficulty experienced by tinnitus patients, whereas the tinnitus reaction questionnaire (wilson et al., 1991), on pamela mae sourgen & eleanor ross which the present study's questionnaire was based, lists frustration and depression as separate entities. in addition, each tinnitus patient presents with his or her own responses to tinnitus, therefore, patients with similar descriptions of tinnitus may react very differently (tyler, 1997a). in the present study two respondents indicated that, in terms of the possible reactions listed, they were not affected by their tinnitus. for example, one respondent stated that she did not panic but simply took things as they came. tyler and baker (1983) comment that many tinnitus patients have only a few problems associated with their tinnitus, and either are not sufficiently troubled by it or have adjusted their lifestyle in order to cope. slater and terry (1987) explain this finding in terms of personality type, in which introverted individuals are more likely to be aware of their tinnitus and so be annoyed by it. nevertheless, the results also clearly indicate that tinnitus did affect the group of respondents surveyed, as seen by one person's comment that it was "highly irritating". one subject mentioned that the tinnitus would get so bad that it would drive her frantic. she explained that if it had not been for her children she would have thrown herself off the balcony of her flat on the third floor. another respondent who was boarded because of his tinnitus, stated "i am permanently on an antidepressant and intermittently on tranquilizers".scott, lindberg, melin and lyttkens (1990) found that tinnitus creates greater levels of insomnia, depression, anxiety and difficulties with concentration in tinnitus patients compared to patients with a hearing loss only. therefore, whether tinnitus is the sole cause of these reactions or certain individuals are predisposed to them, tinnitus does appear to result in diverse reactions, many of which cause serious problems for the patient (tyler & baker, 1983). in terms ofthe effects of tinnitus on general health, 23% of respondents indicated that tinnitus caused them to feel dizzy, while 19% reported losing their balance. the prevalence of balance problems, tinnitus and hearing table 4: frequency with which emotional responses to tinnitus were experienced(n=20) emotional responses no. weighted score . percentage i frustrated 14 20 70 i tense 12 17 60 irritable 11 13 5j i depressed 10 13 50 i confused 9 10 45 unhappy 8 11 40 ' ! annoyed 7 9 35 tormented 5 7 25 driven crazy 5 7 25 angry 5 6 25 helpless 5 6 25 hopeless 4 6 / 20 tearful 2 3 10 contemplated suicide 2 3 10 / * weighted scores were obtained by arbitrarily assigning the value of 1 to the response of 'sometimes', 2 to 'often' and 3 to 'all the time'. each value was multiplied by the number of responses, respectively. the sub~totals were combined to form the weighted score. the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) perceptions of tinnitus in a group of senior citizens threshold generally increase with an increase in age (chung et ai., 1984; shepard & telian, 1994). it is likely that, just as tinnitus is a symptom of auditory dysfunction (tyler, 1997a), balance difficulties along with tinnitus and a hearing loss indicate an underlying auditory system problem. for example, patients with meniere's disease present with symptoms of vertigo, low frequency hearing loss and roaring tinnitus (slater & terry, 1987). tyler and baker (1983) reported that 13,8% of their respondents experienced giddiness, balance or 'fuzzy head' problems. in addition, 40% of the respondents (making up 22% of the responses) indicated concern that tinnitus might cause them to become deaf. previous research has shown a range from 5% (slater & terry, 1987) to 55% of respondents (stouffer & tyler, 1990) expressing this concern. findings from the present study highlight the need for clinicians to adopt a holistic approach to the assessment and treatment of tinnitus. besides helping patients cope with the consequences oftinnitus on their daily lives, their families need to be involved in the management oftinnitus, as they are also indirectly affected (tyler & babin, 1993:3031). perceived causes of tinnitus an open-ended question was used to elicit respondents' perceptions of the cause of their tinnitus. a summary of the general themes articulated are presented in table 5. respondents provided a variety of explanations for the cause of their tinnitus. one couple explained that while in a neighbouring country, they and a few other south mricans suddenly developed tinnitus. the husband felt that this outcome was due to the high pitched hum produced by his tv screen once it was programmed to receive the zimbabwean television signal. two people felt that syringing was implicated. the one respondent explained that he had a problem with his ears in which wax formed, causing his ears to clog up so they had to be syringed every year. he was convinced that' the nozzle of the syringe actually penetrated the ear dtum, and reasoned that his tinnitus would get better as /the ear drum healed. the literature does report that some patients have indicated that ear syringing has been ~ precipitating factor in the onset oftinnitus (slater & ter~, 1987). one lady was under the impression that too much~ salt in her diet caused her tinnitus. although no systematic research appears to have been performed to determine the effects offood on tinnitus, i / table 5: perceived causes of tinnitus (n=20) cause sub-cause no idea noise-related • general • work , • tv • mter football ear-related • infection • syringe • deaf , other • food 69 slater and terry (1987) provide anecdotal evidence that dietary factors do playa role for some individuals. the largest proportion of respondents did not know what had caused their tinnitus. this finding of 40% was similar to 46% of respondents in stouffer and tyler's (1990) study who also had no idea what had caused the condition. one man in the present study mentioned that prior to being referred by the speech therapist to the researcher, he had not known that the condition he suffered from was called tinnitus, and was unaware of the cause of his tinnitus. middle ear tinnitus can be of vascular or muscular origin (slater & terry, 1987; stouffer & tyler, 1990; tyler & babin, 1993) resulting from vascular tumours or developmental arteriovenous malformations in the ear or head region, or muscle spasms of the palatal or middle ear muscles (tyler & babin, 1993). it is hypothesised that sensorineural tinnitus involves hyperactive hair cells or nerve fibres, or decoupling of hair cell steriocilia, due to damage to the auditory system (slater & terry, 1987; stouffer & tyler, 1990; tyler, 1997a). various causes are implicated, namely, meniere's disease, acoustic trauma, long-term noise exposure, aging, ototoxic drugs and certain diseases (slater & terry, 1987). however, the causes oftinnitus are largely unknown (tyler, 1997a). the implication of the findings from the present study, is that audiologists need to be involved in campaigns to create public awareness oftinnitus. audiologists also need to share their knowledge about tinnitus during counselling sessions with patients. this kind of information usually helps clients to realize that the audiologist recognises that their tinnitus is a real phenomenon and not merely an imaginary ailment. moreover, in cases of middle-ear tinnitus it is important for audiologists to make medical referrals in order to determine if medicallyor surgicallytreatable diseases, namely glomus tumours, arteriovenous malformations, meniere's disease and acoustic tumours, are present (stouffer & tyler, 1990). factors affecting tinnitus table 6 lists the factors perceived by respondents to aggravate their experience of tinnitus. being in a noisy place and mental/emotional stress were each identified by 45% of the respondents as being the main factors exacerbating their tinnitus. these two factors were also highly implicated in stouffer and tyler's (1990) study, with 31% and 29% of respondents indicating that responses percentage total 8 40 40 2 10 30 2 10 2 10 1 5 1 5 25 2 10 1 5 1 5 5 die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 70 their tinnitus was made worse by being in a noisy place and emotionavmental stress respectively. however, their results showed that the primary situation that exacerbated tinnitus for 36% ofresp~:mdents was being in a quiet place (stouffer & tyler,1990). many of the respondents in the present study mentioned that quiet situations made them more aware of their tinnitus but did not necessarily make it worse. slater and terry (1987) reported that 28% and 27% of respondents indicated that loud noises exacerbated tinnitus when they were present and when they had ceased respectively. fifteen percent of respondents in the present study indicated that drugs or medicine served to worsen tinnitus. this result is supported by findings in the literature that several antibiotics, especially the mycins, aspirin and anti-depressants are known to produce or exacerbate tinnitus (slater & terry, 1987). other nonmedically related factors that served to exacerbate tinnitus, namely caffeine, alcohol and nicotine, were each implicated by 5% of respondents. although the exact mechanisms of how tinnitus is influenced by these substances is not fully understood, anecdotal evidence (slater & terry, 1987) supports the finding that caffeine, alcohol and nicotine do make tinnitus worse for some individuals. table 7 lists the factors that reduce tinnitus severity. for 45% of respondents nothing reduced their tinn,itus. this figure is consistent with stouffer and tyler's (1990) finding of 41 % of respondents for whom nothing alleviated the condition. being in a quiet place was known to reduce tinnitus for 30% of the subjects. although two respondents indicated that being in a noisy environment helped to ameliorate their tinnitus, they explained that the noise they were referring to was conversational noise as it helped them be less aware of the tinnitus. very similar responses, although in a different rank order, were selected by pamela mae sourgen & eleanor ross respondents to stouffer and tyler's (1990) study. the only exception was "having just recently been in a quiet place" which replaced "wearing a hearing aid". an important implication of these findings involves the planning of effective treatment programmes for tinnitus patients. in order to record instances where tinnitus severity is increased or decreased, patients are required to keep a tinnitus diary (o'connor & zappia, 1993). this strategy is used to highlight situations which patients should either avoid or in which they should spend more time (stouffer & tyler, 1990). identifying associations or nothing 40.0% medication 8.0% figure 2.categories of coping strategies employed by respondents (n=25) (responses do not total 20 as respondents reported more than one way of coping) table 6: factors perceived to make tinnitus worse (n=61) factors that aggravate tinnitus no. of responses percentage of responses percentage of respondents being in a noisy place 9 14.8 45 emotionallmental stress 9 14.8 40 lack of sleep 5 8.2 25 on first waking up 5 8.2 25 excitement 4 6.5 15 physical tiredness 3 4.9 15 dru.gslmedicine 3 4.9 15 nothing 3 4.9 15 quiet place 3 4.9 15 change head position 2 3.3 10 recently in noise 2 3.3 10 relaxation 2 3.3 10 other 11 18.0 50 table 7: responses representing items selected that reduced tinnitus (n=25) factors that reduce the number of percentage of percentage of tinnitus responses responses respondents. / / nothing 9 36 45 being in a quiet place 6 24 / 30 sleep 3 12 1// 15 being in a noisy place 3 12 15 tv/radio 2 8 10 wearing a hearing aid 2 8 10 / the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) perceptions of tinnitus in a group of senior citizens possible cause and effect conditions, enables the patient to practically improve their quality of life and so contributes to their sense of control (o'connor & zappia, 1993). coping strategies the coping strategies were diverse with the main themes illustrated in figure 2. some respondents preferred slightly noisier environments and would therefore turn on the tv/radio (10%), wear their hearing aid (5%), or keep busy (5%). on the other hand, others preferred to relax or rest in a quiet environment (20%) or switch off their hearing aid (5%). however, although one respondent indicated that he tried to cope by relaxing, this strategy was often difficult so he tried to "channel my mind on pleasant thoughts". some respondents attempted more drastic measures such as trying to take wax out of their ear (5%), shaking their head or slamming it against a pillow (5%), or taking medication (10%), while the largest proportion of respondents, namely 45% reported doing nothing. as one person explained, "it is something you accept and learn to live with". it has been found that beliefs about tinnitus may affect a patient's motivation to use coping strategies to deal with this condition (erlandsson et ai., 1992) which in turn may influence the level of distress produced by tinnitus (lindberg, scott, melin & lyttkens, 1987). in their study, dineen, doyle and bench (1997a) found no relationship between tinnitus symptoms, the length oftime that tinnitus was present, beliefs about the nature and manageability of tinnitus and patients' perceived ability to cope with the condition. regardless of their perceived ability to cope, those who were more distressed by tinnitus tended to use a wider range of coping behaviours (george & kemp, 1991). this result is supported by dineen, doyle and bench's (1997a) finding that subjects who had previously sought help, used more coping behaviours than those who had not, suggesting that those who were emotionally distressed by their tinnitus were more likely to be more c,bnscious of their attempts to cope, resulting in higher reported levels of emotionand problem-focused coping beha{riours. the variability in copijg strategies employed by respondents indicate the imp6rtance of developing tinnitus rehabilitation programme~ that are sensitive to the variability amongst individu~ls (dineen et ai., 1997a). conclusions ! ./ the main finding that emerged from this study was that tinnitus impacted on respondents lives, although it varied from one individual to another. in general, tinnitus caused respondents to avoid noisy situations, have difficulty relaxing and have trouble in following conversations. it led to frustration, tenseness, irritability and depression. in addition, all respondents commented that tinnitus was variable. it was also found that tinnitus influenced respondents' health. the majority experienced dizziness and balance problems. there was also a concern that tinnitus would result in deafness. of the respondents who had previously sought medical advice, all had been told that there was nothing that could be done to alleviate the condition. although the majority of respondents had learned to accept and live with their tinnitus it still had psychosbcial consequences for them. this situation was highlighted by the finding that just under 71 half the respondents had no idea what had caused their tinnitus. in addition, respondents were desirous ofobtaining information regarding tinnitus. it should be noted that the study was conducted on a small, non-probability sample preventing generalisation of the findings to the broader tinnitus population. a further limitation of the study was the fact that, due to practical problems experienced in recruiting sufficient subjects, there was no upper ceiling level in terms of age of subjects selected. consequently respondents ranged in age from 60 to 93. de santi and obler (1991: 337) highlight the methodological problems inherent in including different sub-groups or cohorts such as the 'young old' and the 'old old' within the same research sample. nevertheless, despite these limitations, these findings are not only of relevance to the elderly population but have important implications for the education of health care professionals, management of tinnitus patients in general, public and patient awareness campaigns, the establishment of tinnitus self help groups, and further research. education of health care professionals according to sweetow (1987 a), tinnitus has largely been ignored or disregarded by members of the health professions, as they are uncomfortable in admitting their ignorance to patients who are desperately in need of knowledge. as a result many professionals h.ave turned away tinnitus patients with the comment that there was nothing they could do about it; and they just had to learn to live with it (sweetow, 1987a). greater knowledge and awareness of tinnitus is therefore needed (tyler, 1997b). professional education in such diverse fields as audiology, medicine, nursing, otology, psychology and psychiatry (shulman, 1987; tyler 1997b), should increase understanding regarding the nature of tinnitus. it is further recommended that particular emphasis be placed on etiology, prevention, effects and rehabilitation strategies in undergraduate curricula as well as in continuing education workshops and training programmes (tyler, 1997b). this knowledge could potentially assist in promoting appropriate referrals (sweetow, 1987b; tyler, 1997b), thereby ensuring better management ofthe patient. (tyler et ai., 1989). management of tinnitus patients in general a variety oftreatments have been attempted for tinnitus over the years, including electrical stimulation, masking, acupuncture, medication, cognitive behaviour modification therapy, biofeedback, habituation therapy and counselling (tyler & babin 1993). since tinnitus is complex and diverse, affecting other life functions in addition to the auditory system, clinical management needs to focus not only on the alleviation of the symptom, but on the associated problems as well (shulman, 1987; sweetow, 1987a; tyler et ai., 1989; o'connor & zappia, 1993). the aim should be tinnitus patient management as opposed to tinnitus management (sweetow, 1987a). in order to achieve this aim and facilitate proper diagnosis and appropriate treatment, a multidisciplinary team approach needs to be utilised (shulman, 1987). moreover, tinnitus rehabilitation needs to be flexible reflecting the specific needs of the individual tinnitus patient (o'connor & zappia, 1993; tyler & babin, 1993). die sllid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 72 public and patient awareness campaigns the educatio"n of the general public regarding tinnitus is necessary in order to raise awareness of the nature and effects of tinnitus on the lives of tinnitus sufferers. this information would hopefully increase understanding of some of the problems experienced by patients, increase their support of clinical and research efforts, and more importantly, prepare potential tinnitus sufferers for the impact of tinnitus on their lives (tyler, 1997b). beliefs about and attitudes toward tinnitus play an important role in rehabilitation (erlandsson et ai., 1992). for this reason, tinnitus patients require information to reduce their fears or provide reassurance that their tinnitus is not necessarily indicative of a life-threatening disease (tyler & babin, 1993). information about tinnitus would provide them with a realistic attitude concerning the condition and empower them to seek professional help (tyler, 1997b). most patients benefit from basic information on tinnitus as they come to realize that tinnitus is a real and common problem (tyler, 1997a). the establishment of tinnitus self-help groups in addition to the above clinical implications, the results suggest the need for the establishment of tinnitus selfhelp groups. self-help groups would enable patients to discuss the problems they experience as a result of tinnitus as well as the sounds they hear. such discussion is usually helpful (tyler & babin, 1993). family members could be included in these discussions enabling them to realise the validity and severity of the problem (tyler & babin, 1993). self-help groups could also playa role in increasing public awareness of tinnitus. further research according to tyler (1997b), if one considers the widespread and devastating nature of tinnitus, research remains meagre. this situation is especially true in the south african context in which little, if any, research in this area appears to have been conducted. until recently, tinnitus sufferers were generally told by their doctors that tinnitus was untreatable and that they simply have to live with it. although many persons have accepted this advice, the extent of the problem has actually been obscured (lindberg et ai.,1984). therefore, research is needed to determine the incidence of tinnitus in the south african population as well as its effect on quality oflife. hence there is a need to replicate the present study on larger samples more representative of sub-groups within the elderly population, different auditory pathologies, such as meniere's disease, as well as the general population. as there are as yet no highly effective treatments for the majority of tinnitus sufferers (george & kemp, 1991), " research could evaluate the effects of different intervention strategies, such as masking, biofeedback, habituation therapy, counselling and so forth, on the perceptions of distress experienced by the tinnitus patient. as mentioned previously, individual tinnitus patients react differently to their tinnitus, suggesting that personality might playa role in the perception of and reaction to tinnitus (house & house, 1987). thus, further research could investigate the relationship between pamela mae sourgen & eleanor ross personality and the subjective experience of tinnitus. largely anecdotal evidence exists regarding the effects of caffeine, alcohol and nicotine on tinnitus (slater & terry, 1987). hence there is a need for further empirical research in this area. in conclusion, this study has highlighted the psychosocial effects of tinnitus. tyler (1993) states that tinnitus cannot simply be regarded as a disorder resulting from an auditory system pathology, or an impairment due to the auditoryperceptual characteristics. tinnitus can cause a disability in terms of sleep, concentration and understanding of speech, resulting in a handicap as lifestyle is affected (tyler, 1993). hence, our understanding of the nature of tinnitus needs to include its often disabling and handicapping nature (tyler, 1993). references axelsson, a. & ringdahl, a. 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(1991). surveys in social research. london: allen & unwin. dineen, r, doyle, j. & bench, j. (1997a). audiological and psychological characteristics of a group of tinnitus sufferers, prior to tinnitus management training. british journal of audiology. 31, 27-38. dineen, r, doyle, j. & bench, j. (1997b). managing tinnitus: a comparison of different approaches to tinnitus management training. dooley, d. (1995). social research methods. (third ed.). englewood cliffs: prentice-hall. ' erlandsson, s. 1., hallberg, l. r m. & axelsson, a.: (1992). psychological and audiological correlates ofperceived:tinnitus severity. audiology. 31, 168-179. i george, r n. & kemp, s. 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(1991). tinnitus reaction questionnaire: psychometric properties of a measure of distress associated with tinnitus. journal of speech and ,hearing research. 34, 197-201. appendix a tinnitus questionnaire (adapted from stouffer & tyler, 1990 and wilson et at, 1991) a: biographical information j 1. please fill in the following information: • age i • previous occupation _+-___________ _ • gender _____ 1 b: the characteristics of your tinnitus i 2. where is your tinnitus? (please circle only one answer) • left ear i /" • in the head but no exact place • right ear • more in the right side of the head • both ears equally • more in the left side of the head • both ears, but worse in the left < • outside ofthe head • both ears, but worse in the right • middle of the head 3. which of these qualities best describes your tinnitus? • buzzing • humming • roaring • clanging • musical note • rushing • clicking • popping • steam whistle • crackling • pounding • throbbing • cricket-like • pulsing • whistling • hissing • ringing • whooshing other(pleasespecify) ________________________ ~ ___ _ if you hear more than onj sound or a different sound in each ear, answer the following questions with regard to the most annoying sound. die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 74 -pamela mae sourgen & eleanor ross 4. describe the most prominent pitch of your tinnitus by circling one ofthe numbers below. number 1 is like a very low deep male voice, and number 10 is like a very high pitched whistle. 1 234 (very low) pitch 5 6 7 8 9 10 (very high) 5. describe the loudness of your tinnitus by circling one ofthe numbers below. number 1 is very faint tinnitus, and number 10 is very loud tinnitus. 1 2 3 4 loudness 567 6. how many months / years have you had tinnitus? ________ _ 7. how often are you bothered by your tinnitus? __________ _ 8 c: the effects of tinnitus on your lifestyle 8. for the following items, please rate how tinnitus has affected your lifestyle. = never; 2 = sometimes; 3 = often; and 4 = all the time. • my tinnitus has interfered with my enjoyment of life. 1 • my tinnitus has caused me to avoid social situations. 1 • my tinnitus has caused me to avoid quiet situations. 1 • my tinnitus makes it hard for me to concentrate. 1 • my tinnitus makes it hard for me to relax. 1 • my tinnitus has interfered with my ability to work. 1 • my tinnitus has caused me to avoid noisy situations. 1 • my tinnitus has interfered with my sleep. 1 • my tinnitus makes it hard for me to follow a conversation. 1 • my tinnitus makes me feel tired. 1 • my tinnitus has interfered with the quality of my relationships. 1 • my tinnitus makes it hard for me to understand speech. 1 9 10 circle the relevant number where: 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 2 3 4 9. for the following items< please rate how tinnitus affects you. circle the relevant number where: 1 = never; 2 = sometimes; 3 = often; and 4 = never. • my tinnitus has made me feel depressed. 1 2 3 4 • my tinnitus has made me feel unhappy. 1 2 3 4 • my tinnitus has made me feel tense. 1 2 3 4 • my tinnitus has made me feel irritable. 1 2 3 4 • my tinnitus has made me feel angry. 1 2 3 4 • my tinnitus has made me feel annoyed. 1 2 3 4 • my tinnitus has made me feel confused. 1 2 3 4 • my tinnitus has made me feel helpless. 1 2 3 4 • my tinnitus has made me feel frustrated. 1 2 3 4 • my tinnitus has made me feel hopeless about the future. 1 2 3 4 • my tinnitus has made me feel tormented. 1 2 3 4 • my tinnitus has led me to cry. 1 2 3 4 • my tinnitus has "driven me crazy". 1 2 3 4 • my tinnitus has led me to think about suicide. 1 2 3 4 1 10. for the following items, please indicate how tinnitus has affected your general health by ticking all those that apply to you: • my tinnitus has caused me to become dependent on drugs. • my tinnitus causes me to experience pain / headaches. • my tinnitus makes me feel dizzy. • my tinnitus causes me to lose my balance. • i am concerned that my tinnitus is a symptom of a much worse disease. • i am concerned that i might go deaf because of my tinnitus. d: the cause/s of tinnitus 11. what do you think originally caused your tinnitus? ________________ --;-~ ________ _ the south african journal of communication disorders, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) perceptions of tinnitus in a group of senior citizens 75 e: factors influencing your tinnitus 12. when you have your tinnitus, which ofthe following makes it worse? tick all those that apply to you. • alcohol • smoking • being in a noisy place • coffee / tea • being in a quiet place • drugs / medicine • changing head position • sudden physical activity • having just recently been in a noisy place • when you are excited • having just recently worn a hearing aid • when you are tired from doing physical work • constipation • while you are wearing a hearing aid • emotional/mental stress • when you first wake up in the morning • lack of sleep • listening to the radio / tv • relaxation • nothing makes it worse • food • other (please specify) ________ _ 13. which of the following reduces your tinnitus? tick all of the answers that apply to you. • alcohol • having just recently been in a noisy place • being in a noisy place • having just recently worn a hearing aid • being in a quiet place • listening to the television or radio • coffee / tea • emotional/mental stress • drugs / medicine • sleep • smoking • food • nothing reduces my tinnitus • other (please specify) __________ _ f: coping strategies 14. what do you do to help you cope with your tinnitus? (i.e., what do you do when your tinnitus is bad?) _______ _ g: other 15. do you have any other comments you would like to make about your tinnitus? ________________ _ thank you very much for your cooperation. h: audiological information (to be filled in by the audiologist) 1. primary diagnosis (tick oilly one) • noise-induced hearing ross • presbycusis : • meniere's disease ! • middle ear disorder (ple~se specify) ________________________________ _ • retrocochlear (please specify)_' __________________________________ _ • normal hearing (please specify) ___________________ --------------• unknown • other (please specify) ___________________________________ _ 2. primary complaint (tick only one) • hearing loss • dizziness • tinnitus • pain or headaches • other (please specify) _____________________________________ _ 3. hearing thresholds left ear 1000hz ________ db hl 4000hz db hl right ear 1000hz ________ db hl 1000hz db hl die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 45, 1998 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) abstract background methodology results discussion conclusion acknowledgements references about the author(s) victor de andrade department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa rethabile r.m. landman department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation de andrade, v., & landman, r.r.m. (2022). ‘all of a sudden, you know, you can’t go to these services, because of the risk of infection’: audiological service considerations at residential care homes for older persons during covid-19. south african journal of communication disorders, 69(2), a904. https://doi.org/10.4102/sajcd.v69i2.904 original research ‘all of a sudden, you know, you can’t go to these services, because of the risk of infection’: audiological service considerations at residential care homes for older persons during covid-19 victor de andrade, rethabile r.m. landman received: 31 jan. 2022; accepted: 27 mar. 2022; published: 10 aug. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: residential care homes for older persons were especially affected during the coronavirus disease 2019 (covid-19) pandemic lockdowns which resulted in limited social interactions and service provision. communication became challenging due to the prophylactic use of masks and social distancing. objectives: this qualitative research study set out to explore audiological service considerations in residential care homes for older persons during the covid-19 restrictions. method: through purposive sampling, nine managers from residential care homes for older persons in johannesburg participated in semi-structured, online interviews. the transcriptions of these recorded interviews underwent thematic analysis. results: managers employed various strategies to attend to residents’ audiological needs, audiological health, hearing aid use, and hearing aid provision. furthermore, it transpired that other health related services were prioritised over audiological services in general, but especially during the pandemic lockdowns. managers reported that staff had to use various communication strategies due to covid-19 precautions and that masks and social distancing made communication more challenging for residents with hearing loss. moreover, isolation and modified service provision were extremely taxing on residents. conclusion: this study highlights the need for continued audiological services at residential care homes, but also the need to balance audiological needs with other health needs because these seem to be prioritised over hearing loss, especially in this population who may have limited agency and choice in the health care options available to them. furthermore, adapted strategies need to be considered to support communication considering covid-19 precautions so that communicative difficulties do not exacerbate lockdown isolation. keywords: residential care homes for older adults; audiological services; covid-19; hearing loss; south africa. background residential care homes for older persons in south africa manderson, harling and withem (2019) argue that, in south africa, care facilities such as residential care homes for older persons are usually a last resort for the older persons. nonetheless, it is estimated that there are approximately 1150 residential care homes for older persons in south africa, of which only 415 are registered with the department of social development (mahomedy, 2017). perold and muller (2000) suggest that residential care homes for older persons: [c]ame into existence in south africa within the social work domain because of various social problems including loneliness, economic and housing problems, deteriorating mobility of the older persons and lack of family and other support systems for them in the community. (p. 1) broadly, manderson et al. (2019) state that care for the elderly usually includes assisting with activities such as, bathing, getting dressed, eating, going to the toilet, among others. however, manderson et al. (2019) question whether these activities are enough to allow elderly persons to participate in society and that there are considerable shortcomings and a lack of formal care when it comes to caring for the elderly in south africa. lloyd-sherlock (2019) adds that the legacy of apartheid permeates into residential care homes for older people where older white people may have access to them while older black people may be cared for by their families. mahomedy (2021) predicts that the demand for care among older persons will escalate and that south africa is not prepared for this increasing demand. as stated earlier, because many homes are not registered with the department of social development, this may suggest that these homes do not comply with the older persons act, no. 13 of 2006, section 18, subsection 1a, which states that no one should operate a residential facility for the elderly unless it has been registered (mahomedy, 2017). furthermore, there is a shortage of trained staff who have the skills to take care of the elderly (mahomedy, 2017, 2021) which also raises questions about the training of the staff at residential care homes for older persons regarding audiological services, especially because staff at residential care homes for older persons may have very little knowledge about hearing services, especially hearing aids (pryce & gooberman-hill, 2012). finances appear stretched because the high levels of poverty and unemployment in the country add to the pressures on older persons and their children who support them financially (kang’ethe, 2018). the government’s social grant for older persons as well as the subsidies to homes are not enough to cover the costs of running the homes (mahomedy, 2021). although homes have tried to explore other fundraising to cope with the financial demands, the coronavirus disease 2019 (covid-19) pandemic interrupted such fundraising and resulted in more deficits and closures. (mahomedy, 2021). therefore, considering these financial constraints, although hearing amplification devices such as hearing aids are recommended for people with presbycusis (sprinzl & riechelmann, 2010), sooful, dijk and avenant (2009) found that hearing loss in south africa is considered a low priority because hearing amplification technologies are expensive for most south africans and people do not have money for transport to go for repairs and retubing, nor the money to buy hearing aid batteries (sooful et al., 2009). hearing and older persons in residential care homes residential care homes for older persons may not always be able to offer favourable communication environments for persons with a hearing loss. for example, residents in pryce and gooberman-hill’s (2012) study stated that they were unable to cope with background noise of music, television, other residents’ conversations, or the noise of crockery. boi et al. (2012) argue that hearing aids can improve the quality of life in clients who use them regularly and correctly and that a decline in depressive symptoms was noted, the burden on caregivers lessened, feelings of social isolation also declined in the participants of this study after they were fitted with hearing aids. however, in south africa, older persons do not seem to use hearing aids regularly and correctly (moroe & vazzana, 2019) which, consequently, could result in social isolation and diminished quality of life. furthermore, untreated hearing loss has been associated with incident dementia because of prolonged auditory deprivation, feelings of social isolation, and feelings of being unfamiliar with the environment (lin et al., 2011). covid-19 and the hearing of older persons in residential care homes due to covid-19, precautionary measures had to be taken to limit the spread of the virus, including social distancing, isolation, and the use of masks. dipa (2020) found that older persons in residential care homes in gauteng, south africa, felt lonely and depressed during the national lockdown of march 2020. families of residents were not allowed to visit, and residents were confined to their rooms with very little social interaction while also having to adapt to using smartphones and social media applications to communicate with their families. the american speech-language-hearing association (asha, 2020) states that masks muffle speech, making it difficult to hear and understand speech, especially for those with hearing difficulties. specifically, masks degrade speech because they act as low pass filters and attenuate high frequencies from 2000 hz to 7000 hz by between 4db and 12db, making it very difficult for people to hear, especially people who already have a hearing loss (goldin, weinstein, & shiman, 2020). to exacerbate matters, goldin et al. (2020) point out that when masks are used in environments with background noise and the absence of visual cues from facial expressions, speech is mostly perceived as unintelligible for many people. transparent masks have been offered as a potential opportunity to allow for lip-reading while still offering a barrier to mitigate for covid-19 spread (chodosh, weinstein, & blustein, 2020; correia & ferreira, 2021). despite the potential benefit, chodosh et al. (2020) point out that there are few manufacturers of these masks and, therefore, correia and ferreria (2021) advocate for more investment in transparent masks. however, as thibodeau, thibodeau-nielsen, tran and jacob (2021) point out, transparent masks can become fogged up by the warm breath on the inside of the mask, thereby obstructing the view of the speaker’s mouth. nonetheless, thibodeau et al. (2021) offer suggestions to minimise the fog and these suggestions include ‘simply applying a thin film of a liquid soap or bubbles to more expensive options of a product designed for antifog’ (p. 780). rationale of the study therefore, because older persons may be more susceptible to presbycusis and since hearing loss in older adults may result in isolation, reduced quality of life, communication challenges, depression, and dementia, it was deemed necessary to explore audiological service provision in residential care homes during a time when the focus was on mitigating for covid-19. furthermore, because audiological services may not have prominence (joubert, sebothoma, & kgare, 2017), these audiological services may have been relegated due to other competing demands. this study, therefore, sought to provide a description of the audiological service considerations at residential care homes for older persons in johannesburg during covid-19 restrictions in south africa. methodology a qualitative research design was employed to provide a description of the audiological service considerations at residential care homes for older persons in johannesburg during covid-19 restrictions by interviewing the managers of the homes. through purposive sampling, the managers of 30 residential care homes were invited, via phone calls and emails, to participate in the research project and nine agreed to participate. some of the managers who declined participation cited competing responsibilities such as covid-19 demands and the first rollout of vaccinations which was happening at the time of data collection. nine interviews were conducted, two of which were joint interviews while one participant was involved at two homes. table 1 presents information about the participants. table 1: participants’ profile. semi-structured interviews were conducted utilising an interview guide informed by the aim of the project and a review of the literature. the interviews were conducted between 25 may 2021 and 21 june 2021 when south africa was struggling with the delta variant of covid-19 and went from adjusted level one lockdown regulations to level four lockdown. these semi-structured interviews were conducted using whatsapp video call, zoom, and microsoft teams meetings. the interviews which were conducted on zoom and microsoft teams were successfully recorded using the recording options on the applications while the interviews from the whatsapp video calls were recorded on a secondary cellular phone. the interviews were conducted in participants’ preferred languages where code switching also occurred. the recordings were used to transcribe the interviews and where different languages were spoken, the transcriptions reflected those. for example, p1 preferred to speak a mixture of setswana and english and then the one author, r.r.m.l., transcribed the interview into english and setswana. after transcription, member checking was conducted by emailing transcriptions of the interviews to the participants so that they could comment on the accuracy of the transcriptions. thereafter, the transcriptions were analysed using thematic analysis. braun and clarke (2008) suggest flexibility without focussing on preconceived themes to welcome themes that arise in the data and therefore deductive and inductive approaches were employed. ethical considerations prior to conducting the interviews and after obtaining clearance from the university of the witwatersrand human research ethics committee (sta-2021-26), a pilot study was conducted. thereafter, letters of permission were sent to homes seeking permission from the management committee or board of the homes to interview the managers. participant information sheets were sent to the managers of the homes which had granted permission for participation and informed consent was received from them prior to commencement of the interviews. results the data analysis revealed that covid-19 affected communication and audiological service provision for older persons in residential care homes. seven themes emerged from the data analysis, namely, (1) audiological services were interrupted due to covid-19, (2) other health services were prioritised over audiological services due to covid-19, (3) covid-19 mask-wearing adversely impacted on communication with older persons in residential care homes, (4) communication had to be adjusted for residents who have hearing loss during covid-19 restrictions, (5) covid-19 increased the sense of isolation for residents, (6) financial constraints limited the provision of audiological services, and (7) covid-19 has impacted on the confidence in hospital attendance for audiological service provision. these themes are detailed hereafter. audiological services were interrupted due to covid-19 due to lockdowns and restricted access, there were limited opportunities for external audiological services as per p5 (female, manager). ‘pre-covid, once a month she’d [audiologist] come for general ear health checks and then make her recommendations thereafter. now, … uhm eight months maybe, six to eight months, i mean there was one time in between, you know, since the start of the pandemic.’ because of these interruptions, care staff at residential care homes were not able to continue offering services usually offered by audiologists. for example, p4 (female, nursing services manager) expressed that even though the audiologist had shown her and the staff how to take care of the hearing aids, she is the only one who helps residents with the hearing aids: ‘you know, these things are so small and so finicky, and uh you know, temperamental so if you put the batteries in the wrong side, up. you, you know, you might break, break the inside. we’ve had that with somebody tried to force something in there that shouldn’t be done. so normally when it’s you know, in pieces or that doesn’t want to work, or we’ve got a high pitch tone or something. the staff will bring it to me and say, there’s a problem here. so, it’s a box on my, on my table and they’ll leave it with a note to say whose is this, whose this is and then i just manage it from there ….’ the strict lockdown restrictions resulted in limited audiological service provision, especially because there were audiology practices and services which were closed during the stricter levels of lockdown. however, it seems as though the availability of audiological services diminished due to covid-19 as per this excerpt from p4 (female, nursing services manager): ‘quite bad, like i said, it’s like the industries uhm took a strain. i think most people became aware of the needs, the companies were, you know, because people were let off, uhm, companies were closed, couple of places that i phoned that told me they don’t have staff to send out to us. you know, you can see, it’s taken a knock and the availability shrunk.’ furthermore, access to audiological services was limited, even those which were still available during the covid-19 restrictions as p4 (female, nursing services manager) reported: ‘uh, yes, transport, getting there, we’re not allowed to transport people up and down, unless the audiologist can come to them…’. p7 (female, nursing services coordinator) offered strategies that were employed to address transport service interruptions: ‘but the problem with home r is, obviously with the transport, buses have been cut to get there, but now they know about uber and taxify, they’re fine, and then they help each other out to get to the appointment ….’ participants spoke of how residents’ attendance for audiological service provision became risky and therefore had to stop. p7 (female, nursing services coordinator), spoke of how having to go to an audiologist suddenly became a risk: ‘[… b]ecause all of a sudden, you know, you can’t go to these services, because of the risk of infection, you see, so it has, the fact that you just cannot, as an elderly person if you’re not vaccinated or fully vaccinated, you cannot go because there’s a risk when getting to these services, the access has been now blocked in a way….’ other health services were prioritised over audiological services due to covid-19 in addition to covid-19 health concerns, managers reported that residents had a variety of health concerns, including turner’s syndrome, diabetes, arthritis, hypertension and hypotension, stroke, parkinson’s disease, dementia, and huntington’s disease, which also needed to be balanced with other needs. the findings from this study revealed that survival strategies were prioritised during the pandemic. participants spoke of the need to focus on life threatening aspects as exemplified by p4 (female, nursing services manager) when she said: ‘sjoe, uhm it all goes as to what’s the basic need at that present moment. i first go with what’s the most important thing, if it’s life threatening or threatening a resident’s, social ability or inability. if it threatens somebody is able to you know, being to have a normal day for me that’s a priority, then i start there. uhm, you know, uh if it’s just something smaller, like a resident tells me i’ve got one hearing aid, but the other one is a little bit, you know, that one, i’ll leave a little bit later and just manage the one without the hearing aid first….’ p9 (female, resident social worker) stressed the prioritisation during covid-19 when she said: ‘so services are always prioritized in terms of medical and nursing and physical, emotional care…’ and p3 (female, nursing services manager) reinforced this notion of the relegation of audiological services ‘the audio and the speech cases, they are also important but now the focus is on the covid side and the and medical side, you see …’. even though participants expressed that other health concerns take priority, it seems as though dementia coupled with hearing loss has devastating effects on the elderly as per p5 (female, manager): ‘… i would say about 80% of them have hearing aids and use hearing aids. without them, they can’t really function…management of their dementia and alzheimer’s and anxiety. so, from a mental health perspective, that definitely takes absolute priority….’ and p8 (female, nursing manager): ‘[…t]hat is difficult because you have a combination, oftentimes in our home where, it is the natural decline of the body, so the residents feel like, i’m aging, and i have to accept it. plus, i have hearing loss, and oftentimes early onset dementia, which creates almost the perfect storm.’ participants referred to the limited provision of audiological services due to insufficient information and prominence of audiology, especially during a time when covid-19 was predominant. p9 (female, resident social worker) referred to the invisibility of audiology when she said: ‘… audiology is a field that is, honestly very fuzzy for us at the moment … i think there’s a lack of knowledge about audiology, about its delineation, the boundaries, the servicing, when it’s required, what to look for, i think a lot of education is required in most facilities., around, audiology, it’s about advocating, you know.’ p4 (female, nursing services manager) reinforced this idea when she said: ‘uhm, you know what, i think if maybe, if there’s maybe a little bit more pamphlets and things that’s rather a little bit more advertising, uhm making themselves visible to us….’ consequently, due to the reduced prominence, audiological services were not always foregrounded as p1 (female, nursing services manager) pointed out: ‘well, the thing is we never say that we are going out to check the hearing status of our patients. hore okay ha re kopeng doctor [that let’s ask the doctor] … lets check the ears of our residents and those types of things. errr to be honest, i don’t think … er … much as we know that progressive hearing loss is something that affects the elderly … it’s not something that we say … er guys … this week a ke re check’eng [let’s check] the hearing capacity of our residents … because we have noticed that nkgono y and nkgono x have got a problem when we speak to them.’ covid-19 mask-wearing adversely impacted on communication with older persons in residential care homes participants reported that covid-19 mask-wearing protocols made communication difficult. for example, p1 (female, nursing services manager) said: ‘it is a problem for them to keep their masks in situ besides it’s very difficult for a person, gore o moutlwehoreontsareng ha a kentse mask [for a person to hear what you are saying when you are wearing a] mask….’ p2.1 (female, manager) reported that ‘the mask, the mask, muffles your voice somehow’. p3 (female, nursing services manager) stated that sometimes carers had to take off their masks for residents to be able to understand them: ‘yoh, they can’t hear because now with a mask and the residents have got the masks, and the staff have got masks on, it’s so difficult to communicate, you know. so, at some stages we just take the mask off, i mean, what can we do, really?’ communication had to be adjusted for residents who have hearing loss during covid-19 restrictions coronavirus disease 2019 (covid-19) containment strategies have resulted in communication challenges for residents. participants said that prior to covid-19 mask-wearing obligations, face-to-face communication was reported to be very helpful, especially because then residents could lip-read. subsequently, due to mask-wearing, participants reported that carers have had to resort to speaking more loudly. despite the potential benefit of carers speaking more loudly, the participants said that this louder speech is not always ideal as it does not promote discretion as per p1 (female, nursing services manager) in this excerpt: ‘jah, jah like, we do talk loud buuut, but, you can’t do, you can’t do loud, you know. like for instance, when you’ve got an incontinent person not to embarrass them. you want them not to get off the chair and tell them to go with you to the room, so i’ll just tell them come please with us to the room, but you can’t you say, you wet the chair please follow me at your room, you know, then aaall of home n knows that chair is now wet, you know, so you need to be discreet … uhm jah, and sensitive. get the resident up, make sure nobody notices there’s been a glipsie, and then get the chair out of the equation and get the chair sorted and replace another chair there without anybody noticing, and then take the resident to be cleaned up, and you know not to make this you know like a whole big shpiel.’ due to these challenges, participants said that carers have had to find alternative ways of communicating with residents. for example, p9 (female, resident social worker) spoke of written and diagrammatic strategies when she said: ‘… as well as writing and drawing where possible. so, most residents, uhm, the problem is that it takes time and effort…’. p7 (female, nursing services coordinator) stated that carers use hand gestures, as depicted in the following excerpt, ‘…whether you do certain hand gestures with them, you find a way. like, i said, they’re creative in a way, they always find a way…’. furthermore, due to limitations placed on social interaction and visitors, p3 (female, nursing services manager) added that residential care homes were quieter during covid-19 restrictions: ‘…because there’s not too much noise with us here, it’s always quiet and uhm, it’s always quiet and we don’t have any social gatherings at the moment…’. covid-19 increased the sense of isolation for residents participants spoke of the isolation of residents due to covid-19, especially with protocols relating to self-isolating and quarantine. p9 (female, resident social worker) explained: ‘so, when, when, especially during the first wave, we had that we couldn’t even access the wards, and people were extremely isolated, they were. there were a few weeks where people were locked in their rooms, where they couldn’t even go out. so that was detrimental, it’s devastating, you know. you weigh up the physical safety, and you weigh everything else and nothing. i mean to do that to someone that feels cruel, we could see people withering, people were withering from lack of being able to socialize….’ concomitant challenges seemed to aggravate the already difficult situation as highlighted by p1 (female, nursing services manager) who spoke of how some residents, especially those who had dementia, struggled to adhere to the covid-19 protocols: ‘when it was obvious now that we had to go to level 5, we had to have isolation rooms and quarantine rooms, but it was very difficult because some of the patients, waitsi [you know] older people especially banaleng [that have] dementia o re o mokentse [you will send to] into isolation or quarantine o tlatswa [then they will go out], o tlainsist’ahorenikslenna [they will insist that they] want to sit with the other mogolos [residents].’ in order to alleviate isolation, p7 (female, nursing services coordinator) reported that they were able to make use of technology and virtual platforms such as whatsapp video call to facilitate communication between residents and their families and friends outside the residential care homes, as seen in the following excerpt: ‘[… b]ut social media, you know, social media like these platforms, helped a lot, we have assisted a lot of residents to get connected especially with whatsapp, so you can communicate with them.’ financial constraints limited the provision of audiological services stretched financial resources, especially in a time of competing demands due to covid-19, seemed to impact on audiological services. p1 (female, nursing services manager) said: ‘other institutions, tsona [they] can afford to have a full-time audiologist. at least maybe rona [we] we can use the services offered by the final year medical, i mean audio students to come and look at the hearing of our residents because we handle very poor and the low of the lowest socio-economic group, waitsi [you know]….’ p3 (female, nursing services manager) described the absence of services because of financial constraints when she said, ‘… jah no we don’t have those services. you know, our home is a subsidized by the government, so we don’t have all those resources here…’. it also seems as though private medical insurance is not a guarantee that audiological services can be provided as exemplified by p3 (female, nursing services manager) who said: ‘[… a]nd even for the people on medical aids, and the, the funds available for audiology is not sufficient enough, so finances definitely plays a massive role to the residents, whether they’re for medical aid or not….’ because of the redirecting of funds due to covid-19, hearing aid services were dependent on the availability of funds at that time as per p8 (female, nursing manager) who said that if residents need hearing aids but do not have funds to buy hearing aids, then they are referred to the local public hospital but that audiological services as not guaranteed, ‘jah, that will be literally dependent on whatever is happening in the government.’ also, because fundraising was limited due to covid-19, money that could have been used for hearing aids is not available as per the excerpt from the interview with p4 (female, nursing services manager): ‘uhm, we’ve got a couple of people that’s on the benevolent fund, but, you know, everyone has taken some strain’. consequently, older persons with hearing loss have had to endure communication difficulties as per p3 (female, nursing services manager): ‘sometimes they don’t, sometimes we don’t have money to buy the batteries. so, they will stay without, jah, they can’t hear anybody talking, and all that…’. covid-19 has impacted on the confidence in hospital attendance for audiological service provision residents seemed reluctant to go for audiological services at hospitals as exemplified by p8 (female, nursing manager): ‘i think the residents are more sceptical, about going to actually the clinic for anything, because they don’t want to go into isolation … as soon as it comes to the government facilities, there’s no social distancing, there’s no systems in place … they are also afraid that they might get exposed to the virus there … fear of either contracting covid or having to go into isolation.’ furthermore, the waiting times at hospitals increased residents’ reluctance as per the example offered by p3 (female, nursing services manager): ‘you know, the other thing, they don’t want to go to hospitals because they stay there for a long time. that’s why, that’s one of the things that they make, them not want to go. so, they think, i’m gonna go there and i’m gonna stay for the whole day there and all that so it’s better, it’s better to leave it. i’m not going.’ moreover, as managers, they themselves feared that residents would contract the virus at crowded hospitals, as per p7 (female, nursing services coordinator): ‘[… b]ut now (name) hospital is also full, and i don’t want them to go there, to be honest with you, i don’t want them going there and catching something or getting anything.’ participants therefore spoke of strategies which they adopted to address this interruption in audiological service provision. for example, p6.1 (female, manager) stated that they made arrangements for the hearing aids to be sent to the audiologist or for the audiologist to come in, be screened, and observe all the covid-19 protocols so as to provide the necessary audiological services: ‘…so, what we do is we do have, we either send the, the hearing aid to the audiologist and they then clean it and look at it, okay, but we have allowed some of the audiologists in and they have to then dress in, you know, their masks, visors and put their gloves on….’ discussion this qualitative study has offered insights into audiological service considerations at residential care homes for older persons in johannesburg during covid-19 restrictions in south africa. the results of this study showed that pre-covid-19 challenges in south african residential care homes, including a shortage of resources and equipment (maphumulo & bhengu, 2019) as well as poor audiological services (sooful et al., 2009) were amplified during the covid-19 crisis. participants reported that covid-19 precautions such as mask-wearing had a negative impact on communication because residents struggle to hear them. this finding is supported by goldin et al. (2020) who found that a simple medical mask reduced the sound by 3db to 4db, while the n95 medical masks reduce the sound by 12db, a sentiment shared by participants who, for example, said that the mask ‘muffles’ their voices which makes it very difficult for residents to hear them. the results also showed that sometimes staff at old age homes had to become noncompliant with the covid-19 precautions because, even though it is in everybody’s best interests to comply with the covid-19 regulations, they do sometimes pull down their mask to communicate effectively with residents because, with their masks on, residents struggle to hear them. participants spoke of communication strategies that had to be adopted when communicating with persons who have hearing loss during covid-19. the results revealed that staff speak louder to residents who have hearing loss, but participants also said that speaking louder could compromise residents’ privacy or cause embarrassment for residents, as per the example offered earlier relating to a resident who had urinated. similarly, newton and shah (2013) propose the need to speak clearly and not yell when communicating with persons who have a hearing loss because that might infringe on people’s privacy because others will hear what is being said. in addition to enhanced spoken communicative strategies, participants reported using other communication strategies which echo other literature where, for example, newton and shah (2013), encourage the use of pictures, cards, and writing down information. gestures and pointing were also mentioned by participants and these modes of communication are also encouraged by newton and shah (2013) when communicating with persons who have hearing loss. from the results of this study, it seems as though other services are prioritised over audiological services. it could be said that hearing loss is an invisible disability (mackenzie & smith, 2009) and even before the declaration of the pandemic, in our context, it is reported that hearing loss was not prioritised because of the burden of disease and the allocation of resources to, for example, human immunodeficiency virus (hiv), acquired immunodeficiency syndrome (aids), tuberculosis (tb), and malaria (sooful et al., 2009). furthermore, participants in this study said that audiological services did not have the same prominence as other services. joubert et al. (2017) state that there is a serious lack in the public awareness of audiology, regarding the profession itself and services offered by audiologists. the results confirmed this assertion at residential care homes, and it appears necessary to follow joubert et al.’s (2017) suggestion for collaboration between audiologists, universities, and the national department of health to implement strategies that will increase knowledge and awareness about audiology and audiological services. notwithstanding the prioritisation of covid-19 needs, the need for audiological services remained, especially because of the possible audiological sequelae of covid-19 (almufarrij & munro, 2021) but also because benefits associated with auditory stimuli, sound recognition, and sound discrimination as well as the social benefit and emotional well-being (noble & gatehouse, 2006) for people with hearing loss. dawes et al. (2015) point out that hearing loss can exacerbate dementia in the elderly and that addressing hearing loss can improve cognitive performance in the elderly. as evidenced in our study, when audiologists were not able to offer services during the interruption, residents could not benefit from their hearing aids and, therefore, could experience cognitive sequelae. this points to the audiological benefits of audiological services which ought to be considered a crucial service. moreover, participants spoke about the isolation experienced by residents at homes during covid-19. older persons who have hearing loss are already at risk of social isolation, social withdrawal, and poor quality of life (d’haese et al., 2019); thus, this current study showed that residents’ isolation due to covid-19 restrictions compounded their isolation. participants spoke of strategies such as using whatsapp video calls for residents to maintain contact between them and their families outside. it is proposed that through phone calls, social media, and the internet, residents can maintain contact with family and friends, especially to mitigate for ‘the mental health problems of the elderly caused by covid-19’ (lee, jeong, & yim, 2020, p. 3). the participants in this study spoke of the need for audiologists to offer audiological services at residential care homes because staff at the homes struggled to do so. in addition to limited access to health care, including audiological services and a lack of proper equipment used in audiology, there is a limited number of health professionals that can attend to matters pertaining to hearing loss (harris & dodson, 2017). also, as reported by participants in this study, there has been a reduction in audiological services because of covid-19. pillay, tiwari, kathard and chikte’s (2020) study found that there was already a shortage of audiologists in the workforce in south africa pre-covid-19, so this study reinforces the need for increased audiological service provision in our country due to the workforce consequences of the pandemic. financial challenges pervaded the results of this study. maphumulo and bhengu (2019) reinforce that the healthcare system in south africa has had problems since apartheid where the distribution of resources was unequal based on race and geographical location, especially prejudicing poorer and black communities and that, in general, there was a shortage of resources and shortage of skilled professionals. mhlanga and garidzirai (2020) further argue that even though south africa is almost 30 years into its full democracy, there is still inequality in the health sector. the findings of this study found that older persons were reluctant to attend health facilities due to concerns about covid-19 and, according to mhlanga and garidzirai (2020), approximately 70% of south africans depend on the public health system which suggests that many older persons who would otherwise be accessing these services, could not, or were reluctant to because of concerns about covid-19 safety at hospitals. even pre-covid-19, maphumulo and bengu (2019) found that there are several challenges such as poor hygiene and poor infection control measures at hospitals and these concerns seem to have extended to covid-19 matters. this current study suggests the need to attend to these concerns while also looking at improving service delivery to improve residents’ experiences of visiting health facilities. conclusion in conclusion, this research study has revealed that covid-19 restrictions have had a detrimental effect on audiological services, as well as communication, for people who live in residential care homes for older persons. managers reported on the effect of the restrictions as well as strategies to try address these challenges. it has been very difficult for staff at residential care homes to balance the life-sustaining and covid-19 protection needs with residents’ audiological service needs. furthermore, interruptions to an already strained audiological service, workforce challenges, as well as financial constraints are among the concerns. understandably, covid-19 containment took priority, but this study revealed the particular audiological challenges posed by the restrictions. furthermore, the study highlighted that, although audiological services may not get the same priority, the communicative challenges faced by older persons who have hearing loss can increase loneliness and isolation, mental health challenges, and cognitive health issues. the covid-19 pandemic appears to have added a level of complexity to the managers’ attendance to audiological needs. if services are interrupted, to maintain communication, enhanced communication strategies need to be included, for example, to compensate for mask-wearing. to account for masks, saunders, jackson and visram (2021) suggest transparent masks to facilitate lip-reading while thibodeau et al. (2021) provide options for transparent masks that do not fog up. furthermore, suggestions and guidelines have been provided on how audiologists can modify hearing aid programme settings and frequency responses to account for the specific frequencies which are degraded due to mask-wearing (saunders et al., 2021). furthermore, schlögl and jones (2020) suggest that when speaking to older persons during covid-19 restrictions, especially when wearing masks, it is important to attend mindfully when interacting with older persons and to maintain calm, despite communication frustrations and breakdowns. they specifically mention approaching older persons from the front so that, besides enhanced awareness and communication, it also shows respect for the older person by not catching them unaware. furthermore, for staff working with older persons at residential care homes, their advice for communicating with older persons during these covid-19 restrictions could be beneficial: [a]void noise and overwhelming stimulus and make surethe older person is wearing glasses or hearing aids, ifneeded, then slowly communicate one point at a time. useshort, simple sentences and underline your words with gestures.make your statement or ask your question and thenpause. keep your voice even, tone gentle, and speech slow. (schlögl & jones, 2020, p. e12) cognisant of the health and life-threatening aspects of covid-19, audiological services ought to continue as essential services with all the necessary precautions to reduce the sensory deprivation, cognitive risk, and socio-emotional difficulties which may arise from the combination of covid-19 restrictions and hearing loss. senescence may have effects on the whole body and, therefore, specific strategies need to be adopted at residential care homes to offer holistic care and a balanced service provision that includes audiology, even when there are competing needs as evidenced during the covid-19 restrictions, so that older residents can benefit from a well-rounded service provision. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions v.d.a. and r.r.m.l. both contributed equally to this work. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study are available on request from the corresponding author. the data are not publicly available due to privacy or ethical restrictions. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references almufarrij, i., & munro, k.j. 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(2010). current trends in treating hearing loss in elderly people: a review of the technology and treatment options – a mini-review. gerontology, 56, 351–358. https://doi.org/10.1159/000275062 thibodeau, l.m., thibodeau-nielsen, r.b., tran, c.m.q., & jacob, r.t. (2021). communicating during covid-19: the effect of transparent masks for speech recognition in noise. ear and hearing, 42(4), 772–781. https://doi.org/10.1097/aud.0000000000001065 t he persistence o f language d isorders in a g roup o f d isadvantaged g rade 3 l earners 59 the persistence of language disorders in a group of disadvantaged grade 3 learners daleen klop*, seppo k tuomi department speech-language-hearing therapy stellenbosch university abstract a strong correlation between early language impairment and academic failure has been suggested by p a st research. this follow up cohort study o f 25 monolingual, disadvantaged grade 3 learners investigated whether the language impairments diagnosed in their preschool year were still evident after 3 years o f school attendance, maturation and speech-language therapy. the results verified the persistence ofpreschool language impairments, which have been associated with poor reading and academic failure. introduction the attainment o f literacy and academic success is crucial for survival in a modem industrialised, knowledge-driven society. in south africa today a large percentage o f learners do not succeed academically and leave school without the necessary skills to ensure economic survival. the western cape educa­ tion department (wced) assessed the reading skills o f 34 487 grade 3 learners in 1, 093 schools in 2004 and found that only an average o f 39.5% o f learners passed the literacy test at grade 3 level (wced, 2005). explanations for the poor per­ formance vary from lack o f resources, crowded classrooms, shortage o f appropriately trained teachers and socio-economic factors to poor pre-literacy skills. one potential cause that has received less attention is the impact of poor entry level lan­ guage skills. bilingualism, multilingualism and learners who are edu­ cated in languages other than their mother tongue have also been suggested as potential causes and are highly contentious issues in south africa. in 1997 the government introduced the language in education policy based on non-discriminatory language use in the context o f a bilingual or multilingual framework. the stated aims were to secure mother-tongue maintenance, to promote proficiency in a second language and to strive for optimal cognitive development (heugh, 2002). the policy also recognised that]the mother tongue, or the language used most proficiently at home, is the most appropriate lan­ guage o f learning. in reality the majority of learners in south africa receive their education through the medium o f a second language and lack o f proficiency in the language of instruction poses major obstacles to education for both educators and learners (uys, van der walt, van den berg & botha, 2007). in the face o f the more investigated and therefore more evident language and learning problems experienced by second language learners, the language problems o f learners who re­ ceive instruction in their mother tongue by educators who are proficient in the same language, may easily be overlooked. speech-language therapists working in school environments often experience pressure from educators and parents to focus their intervention programmes on the language needs o f second language learners. this article aims firstly, to draw attention to the lan­ guage problems o f learners who are not second language leamd epartm ent speech-l anguage-h earing t herapy f acu lty o f h ealth sciences | s tellenbosch u niversity t ygerberg 7505 e-m ail: dk@ sun.ac.za ers but who are at risk for academic failure, because they come from disadvantaged backgrounds and lack the complex lan­ guage and literate language skills needed for academic success. secondly, it seeks to highlight the persistence o f the language problems exhibited by these learners despite speech-language therapy intervention programmes and formal education. there is a dearth o f research in south africa pertaining to the impact o f the often “atypical” language skills o f learners from lower socio-economic backgrounds and learners from different cultural groups on their academic progress. no large scale longitudinal studies have been done locally in the field of speech-language therapy to investigate how learners who enter school without the necessary emergent literacy and language skills cope with the academic curriculum. there is a lack of epidemiological data pertaining to the nature and extent of emergent literacy and language skills in different cultural groups at school entry. data and information relevant to the south african context is needed to guide best practice for this domain and to inform all the role-players involved in service delivery to enable them to provide appropriate and focused intervention where necessary. speech-language therapists are often the first professionals to encounter preschool children at risk for developing reading and learning problems, and should play a crucial role in early identification o f these learners and their subsequent intervention programmes. evidence from several longitudinal studies in the united states o f america showed that a large percentage o f children who fail to learn do not display disordered language, but rather a global language delay, characterized by a lack o f literate lan­ guage skills (catts, fey, tomblin & zhang, 2002; fazio, nare more & connell, 1996; tomblin, zhang, buckweiler & o ’brien, 2003). these longitudinal studies have shown that poor language skills at school entry not only predict poor read­ ing acquisition, but continue to negatively affect all aspects o f academic learning. learners who start school with delayed language never “catch up” and continue to fall even further behind (senechal, lefevre, smith-chant & colton, 2001; tomblin, et al., 2003). these children may not necessarily meet the diagnostic criteria for specific language impairment and parents and educators may not be concerned about their levels of language development. if they also resemble the ma­ jority o f their peers regarding language skills, it is highly unlikely that they will be referred for speech-language therapy or any form o f language remediation. the relationship between lower socio-economic status (ses) and academic failure is well documented, but linguistic and literacy variables associated with ses should be consid­ ered against the background of cultural and linguist diversity in the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:dk@sun.ac.za 60 d aleen k lop and seppo tuom i a multicultural society such as south africa. prinsloo and stein (2004) argue that early language and literacy development should be investigated against the background of the social community, classroom and institution, and warn against skills based models o f early literacy where the focus is on individual within-child attributes associated with literacy acquisition. the differences in quality, quantity and style o f child-directed speech, and exposure to literacy, associated with lower ses, may be the result o f different values and social practises regard­ ing language and early literacy exposure (dollaghan et al., 1999; fazio, et al., 1996). children from lower ses back­ grounds may grow up in environments that provide them with ample experience with language and functional literacy use in their social and cultural context, but fail to provide them with what is described by kaderavek and sulzby (2000) as the “written language register” (p. 35), or cognitive academic lan­ guage proficiency (calp). literate language used in textbooks and classrooms is de-contextualized, abstract, syntactically more complex and has more formal vocabulary than oral lan­ guage and is linked to a child’s ability to construct meaning and to re-contextualize a previously experienced event (westby, 2005). reading is a language-based skill requiring learners to use structural and conceptual linguistic knowledge to initially decode simple syntactical texts and later to extract meaning from complex and less familiar syntactical constructions in written texts (senechal, et al., 2001). knowledge o f the syntac­ tic rules governing the order and combination o f words enable children to construct well-formed sentences and to comprehend complex literate language. international research indicates that there is a positive correlation between measures o f syntax skills and reading performance. poor readers demonstrate reduced sentence length, more syntactical errors, and problems under­ standing and using complex sentences (westby, 2005). early identification and remediation o f poor language skills in children at risk for academic failure in the pre-school years is crucial. traditional diagnostic measures used by speech -language therapists are usually more focused on the identifica­ tion o f children with specific language impairments (sli), i.e. disordered language. socio-demographic variables, such as ses and culture may impact negatively on children’s performance on norm-referenced and spontaneous language production measures, because o f their different experiences with language. lower test scores may be caused by environmental and physio­ logical risk factors associated with lower ses, but may also reflect the cultural biases inherent in many standardised tests. there are only few standardized tests and assessment proce­ dures that take into account the diversity and complexity o f the experiential, cultural and socio-economic circumstances of south african learners. to overcome this problem, speech language therapists employ informal qualitative assessment procedures, such as analysing language samples obtained through children’s narratives to extract linguistic indicators that correlate with literacy failure. narratives can be described as a “form o f discourse initi­ ated and controlled by a person, organized in a predictive, cohe­ sive, rule-governed way, and representing causal and temporal patterns o f relating information” (owens, 2004, p. 213). bot ting (2002) considered narratives a valid way to investigate communicative competence and to distinguish between lan­ guage impairments and normal language development. the ability to tell a story links oral language skills and literacy, be­ cause it requires children to plan and produce de-contextualized and cohesive narratives. numerous studies have demonstrated the value o f children’s narratives to predict academic success die suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 and reading skills (botting, 2002; liles, 1993; kaderavek & sulzby, 2000; norbury & bishop, 2003). research in the united states o f america has highlighted the structural differences in narratives produced by children from different cultures and socio-economic groups. no similar research has been done in south africa, and the use o f narratives for diagnostic purposes should be undertaken with caution. depending on the goals o f the examiner, narratives can be analysed at macroor micro-levels in several ways, such as narrative levels, high point analysis, story grammars and cohe­ sive devices (owens, 2004). this study focused on micro-level analysis o f aspects o f productivity, lexical diversity and syntac­ tic complexity, which are linked to literate language and reading acquisition. macro-analysis o f schemas produced in narratives, usually story grammar schemas, provides information about skills mainly associated with reading comprehension. macro­ level analysis was not included in the results, because retelling a narrative does not require a person to generate and organize story schema content and is therefore not the best way to assess schema knowledge (westby, 2005). it is evident that, internationally, a strong correlation between early language impairment and academic failure has been indicated by past research. a high level o f academic fail­ ure, particularly in the form o f poor reading skills, is evident in south africa. the present study was designed to investigate the effect o f speech-language development programmes and formal academic training on a variety of linguistic variables in a group o f monolingual disadvantaged preschool children. on the basis o f past research from other countries, it was hypothesized that the children would still exhibit language delays. in addition to supplying preliminary data on the local situation, the results of this study are also important for south african speech-language therapists in evaluating the efficacy o f their services and the impact o f present academic and language intervention ap­ proaches. methodology aims the main aim o f the study was to assess the measure o f persis­ tence, if any, o f receptive and expressive language disorders in a small sample o f disadvantaged afrikaans mother tongue grade 3 learners, who were previously tested in preschool. j the specific aims were: j • to evaluate the learners’ receptive vocabulary skills; • to evaluate the learners’ expressive language skills [in story retell narratives, using measures o f productivity,1 lexical diversity and syntactical complexity; 1 • to assess the development of the learners’ language skills by comparing their present results with those gained three years earlier. participants the present study population (n=25) formed part of a previous cross-sectional study investigating the'precursors to literacy in a group o f disadvantaged preschool children (n=43). the original study had defined disadvantaged children as coming from a community “deprived o f some basic necessities o f life, such as adequate housing, medical care or educational facilities” (the american heritage dictionary o f the english language, 2000). the community consisted mainly o f farm workers and was char­ acterised by a high level o f adult illiteracy and unemployment. the original sample, consisting o f 43 children who met r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the persistence o f language d isorders in a g roup o f d isadvantaged g rade 3 learners 61 the selection criteria, was selected from three pre-primary afri­ kaans medium classes in a small rural community in the western cape. the selection criteria specified that children had to be afrikaans home language speakers, between the ages o f 6 years 5 months and 6 years 9 months, and normally developing ac­ cording to the class teachers. none o f the children had been re­ ferred for speech-language therapy and none of the parents, care­ givers or teachers considered any o f the children to have im­ paired language. it must be noted that these children had the advantage o f attending pre-primary classes, as opposed to the majority o f their peers in grade 1, who started formal schooling without any form o f preschool education. results o f the original study (klop & rumble, 2002) in­ dicated below-average receptive language scores on the afri kaanse reseptiewe woordeskattoets (arw) (buitendag, 1994) in the majority of the children that were assessed. precursors to literacy, namely print awareness, phonemic awareness, rapid serial naming and literate language features, were also develop mentally inappropriate and the majority o f the children were considered by the researcher to be at risk for reading failure. o f the original cohort o f 43 children, only 25 children were still attending the same school at the time o f the project in hand. the average age o f learners was 9 years 4 months (sd 2.7). the follow-up cohort consisted o f 11 boys and 14 girls. none o f the children was identified by the grade 3 teachers as specifically language impaired. since school entry all the chil­ dren had been enrolled for at least one year in a speech-language therapy development programme, as part o f a university student training programme. the programme had been conducted in groups of six learners by student speech-language therapists su­ pervised by clinical supervisors. the foci of the programme were phonemic awareness training and the improvement o f lan­ guage skills. procedures and materials the first data collection took place in october at the end o f their pre-primary year, just prior to the beginning o f their grade 1 year in the local primary school. the cohort was reassessed three years .later at the end o f grade 3. their language skills were measured again to determine the stability o f the previously noted delayed language features. prior to testing, informed written consent was obtained from | the education department, school principals and the parents. assent was obtained from the chil­ dren taking part in the study. participation was voluntary, and participants, teachers and parents were assured that confidential­ ity would be maintained and that their identities would be pro­ tected. ! learners in both cohorts were assessed by the same two qualified speech-language therapists using the same six linguis­ tic variables to measure linguistic growth. a formal test was used to measure the participants’ receptive vocabulary abilities. data for the other five variables were obtained by transcribing and analysing story retell narratives elicited from the participants and audio taped. a story retell procedure to elicit narratives was chosen as retold stories are considered easier than the construction o f an original story and result in longer and more grammatically com­ plete language samples (liles, 1993; schneider & dube, 2005). a story-retell format, in contrast to story generation, offers con­ trol over stimulus input, because all the subjects are presented with the same story and the retold narratives can therefore be compared over time and across subjects in a more valid and reli­ able way (gazella & stockman, 2003). to elicit a story retell narrative, a story {die d u if en die mier, smallman and nes­ tling, 1993), was told to the children with the aid o f 8 laminated colour pictures from the original storybook. the text was adapted to include more complex syntactic structures, such as subordination and elaborated noun phrases. another reason for the choice o f a retell narrative procedure was the resemblance between this task and classroom activities. teachers often ex­ pect children to display their understanding by retelling infor­ mation that was previously presented to them (fazio, naremore & connell, 1996). linguistic variables receptive vocabulary a formal test, the afrikaanse reseptiewe woordeskat­ toets (arw) (buitendag, 1994) provided a standardized meas­ ure to assess receptive language skills. the arw was devel­ oped and standardized in south africa for use in afrikaans speaking populations, but it is important to note that it was stan­ dardised on white afrikaans speaking children in a specific geo­ graphic region. it is therefore possible that the test may be bi­ ased against dialectal variations associated with specific geo­ graphic regions and ses. knowledge o f word meanings is cru­ cial for the comprehension o f written language and vocabulary skills are associated with fluent reading in grade 3 rather than reading acquisition. research has also indicated a direct link between vocabulary and phonological awareness skills, which in turn are crucial for early reading acquisition (senechal et al., 2001). the reciprocal relationship between reading and vocabu­ lary development is well documented. reading enhances vo­ cabulary growth, while increased vocabulary, in turn, leads to more efficient reading and word recognition. lower socio­ economic status has been found to be associated with poor vo­ cabulary skills in preschool children (dollaghan et al., 1999; fazio, et al., 1996). productivity this term refers to the amount o f language produced in response to a task and can be used to distinguish between lan­ guage impaired children and children with normal language development. the language o f language impaired children often resembles that o f younger children (scott & windsor, 2000). two measures, total number o f words (tnw) and total number of t-units, are often used to measure productivity. total number o f words (tnw) language impaired children tend to produce fewer words than children with normal language development, because their narratives are in general shorter and less complex (scott & win­ dsor, 2000). all the words in each narrative were counted as well as all additional morphemes, such as plural s and -e , past tense ge-. repetitions, hesitations, unintelligible utterances and comments, such as “ek weet nie ”, were excluded from the word count. contracted forms e.g. hy ’t and compound words e.g. gou gou were counted as single words. the tnw in the original narrative presented to the children was 288. number o f t-units (t-unitsj a t-unit comprises o f a main clause with all its subordi­ nate clauses and phrases, and is a more accurate reflection of syntactic complexity at utterance level than a sentence, because increased length o f sentences does not always imply increased complexity (nippold, 1998; scott & windsor, 2000). each nar­ rative was segmented into t-units, consisting o f the main clause and all its subordinate clauses and phrases. the total number of t-units in the original narrative presented to the children was the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 31. number o f different words (ndw) lexical diversity was measured by counting the number of different words (ndw) per narrative. ndw is strongly correlated with maturation and can be used to distinguish language impaired children from children with normal language at preschool level (scott & windsor, 2000). it also reflects a child’s expressive vo­ cabulary size and semantic proficiency (dethome, johnson & loeb, 2005). to control for differences in the length o f the narra­ tives ndw was calculated as a percentage o f the tnw produced in each individual narrative to make comparisons between subjects and between narratives possible. the ndw in the original narrative was 133. syntactic complexity mean length o f utterance (mlu) mlu is strongly correlated with age and language develop­ ment, and is an indicator of expressive syntactic complexity (dethome et al., 2005; scott & windsor, 2000). children aged 60 months are expected to produce a mlu o f 4.0 to 6.0 in a language sample and a mlu of 7.210.4 is expected at the age o f 108 months. owens (2004) questioned the reliability and validity of mlu as a diagnostic tool in older children, because of the inconsis­ tent relationship between the rate o f mlu change and age, and stated that a low mlu is not necessarily an indication o f language impairment. in the present study mlu was used to compare the variation o f mlu over time and not primarily in terms of language norms. the mlu was calculated by dividing the tnw produced by each participant by the number o f t-units. the mlu o f the original narrative presented to the children was 9.3. subordination (sub) subordination is an indication o f increasing syntactic com­ plexity. research has reported a gradual improvement in children’s understanding and use o f subordinating conjunctions as they ma­ ture. the use o f subordination is associated with exposure to a liter­ ate language style, because it occurs more frequently in written lan­ guage than in oral language (westby, 2005). a subordinating clause is a conjunctive device that cannot stand alone. it is either joined as a phrase to the main clause with a subordinate conjunction or embedded within the main clause to fulfil a grammatical function in the main clause (nippold, 1998). all the instances, where subordination occurred in the narratives were counted. in subordination, clauses are not added by linking with equal status, but by embedding a nominal clause or an adver­ bial clause within a main clause. subordination can also occur in the form of relative clauses post-modifying the head noun, adverb or adjective in noun phrases, adverb phrases or adjective phrases. the total number o f subordinations in the original narrative was 11. data analysis audiotape recordings o f the narratives elicited from the participants were independently transcribed and coded according to a specified format into the linguistic variables o f interest by two qualified speech-language therapists. the inter-judge reliability for the 100% sample transcribed, coded and analysed was 99% for transcription and 97% for analysis. discrepancies in the scores were discussed, and final decisions were made after consensus was reached. results receptive vocabulary test results are presented first followed by the various narrative measures. 62 the results o f the participants’ receptive vocabulary scores in grade r and grade 3 are presented in table 1. d aleen k lop and seppo tuomi receptive vocabulary skills t able 1: m eans, standard deviations and ranges o f tw o m eas­ ures o f the a frikaanse r eseptiew e w oordeskattoets (a rw ) variable mean sd range standard score: g rade r 75 12 58-102 g rade 3 6 8 a 1 4 a <50-95 language age: g rade r 5 3 b 1 0 b 3 5 -7 5 b g rade 3 7 5 b 1 3 b 5 6 -1 0 8 b n o te s: ’ standard scores fo r (n=13) only because the rest o f the participants obtained standard scores below 50. b a r w lan­ g uage age in months. in grade r only six participants obtained scores within 1 standard deviation (sd 12) o f the average standard score of 100, which is considered to be within the normal range of development. age equivalent scores indicated that the average language age of the grade r children was 53 months, which is 22 months below their average chronological age. retesting with the arw 3 years later in grade 3 indicated a drastic decline in receptive vo­ cabulary standard scores over time. the average grade 3 vocabulary standard score of 68 was about 3 standard deviations below the average (buitendag, 1994). only 12 participants obtained scores o f 50 and above and just one participant obtained a standard score within the nor­ mal developmental range. the average language age of 75 months was 37 months (3 years) below the average chronological age o f 112 months. productivity the results o f the participants’ scores on productivity measures in grade r and grade 3 are presented in table 2 . t able 2: m eans, standard deviations and ranges o f tw o m eas­ ures o f productivity elicited in story retell narratives ! variable mean sd j range standard score: g rade r 82 37 i '31-185 g rade 3 129 31 69-184 language age: g rade r 12 4 6-23 g rad e 3 21 4 31-185 the narratives of the grade 3 participants were markedly longer than the grade r samples, as indicated by the increase in the total number o f words (tnw) (129 vs. 82) and total number o f t-units (21 vs. 12). lexical diversity as seen in table 3, the number o f different words (ndw) in the two samples showed some increase from grade r to grade 3 from 40 to 63. / however, when corrected for the differences in length o f the narratives, there was little or no change in the number of different words produced by the partici­ pants from grade r to grade 3. die suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) t he p ersistence o f language d isorders in a g roup o f d isadvantaged g rade 3 l earners 63 t a b le 3: m eans, standard deviations and ranges o f num ber o f differ­ en t w ords (n dw ) elicited in story retell narratives variable mean sd range number of different words (ndw) g rade r 40 14 18-72 g rade 3 63 12 39-87 ndw correct fo r length 5 2 c 1 0 c 36-77c g rade r 4 9 c 4 ° 4 3 -5 7 c g rade 3 n ote: c ndw as a percentage o f tn w to correct fo r differences in length o f narratives. syntactic complexity as shown by table 4, the increased productivity did not reflect an increase in syntactic complexity. this was confirmed by the lack o f significant increase in the mean length o f utterances (mlu) in the grade 3 sample. no increase was seen in the number o f subordinating constructions produced in the narra­ tives o f the grade 3 participants, when compared to the grade 1 narratives. t a b le 4: m eans, standard deviations and ranges o f tw o m easures syn­ tactic com plexity elicited in story retell narratives variable mean sd range mean length o f utterance (mlu) g rade r g rade 3 no o f subordinating conjunctions (sub) g rade r g rade 3 6.8 6.4 0 0 1 1 1 1 4.7-8.8 4.9-9.0 0-2 0-2 discussion the chosen linguistic variables were investigated because they provide an accurate measure o f communicative competence, language development, and because of their specific associa­ tion with literacy acquisition and reading. poor performance on these variables has been proven by longitudinal studies to re­ sult in reading problems and academic failure (catts et al., 2002; johnson et al., 1999). the results o f this study confirmed previous research findings demonstrating the [persistence of language delays de­ spite maturation and intervention (johnson et al., 1999; catts et al., 2002). the results are also consistent with findings that children with non-specific language impairment, i.e. globally delayed language are even less likely to achieve normal lan­ guage status via maturational processes than children with spe­ cific language impairments (tomblin, et al., 2003). the majority of participants in the present study dis­ played impaired receptive vocabulary skills before they entered school. their mean language age equivalent o f 53 months was 22 months below their mean chronological age o f 75 months. this implies that they started their formal school careers with inadequate vocabulary and language comprehension skills to cope with a curriculum designed for children with age appropriate language development. none o f these children were identified by caregivers and educators as language im­ paired, probably because they did not display articulation prob­ lems or obviously disordered language structures, e.g. wrong use o f tense or word order. this is consistent with findings in other studies that children with non-specific language impair­ ment are unlikely to be identified as language impaired, and that they are therefore seldom referred for intervention or remediation (catts et al., 2002; fazio, et al., 1996; tomblin, et al., 2003). consistent with studies reporting the persistence o f language impairment despite maturation, the results o f re­ assessments three years later showed an even greater discrep­ ancy between chronological age and receptive language age, with an average delay o f 37 months. despite three years o f formal training and speech-language therapy intervention, the majority o f the participants in grade 3 displayed vocabulary skills expected o f normally-developing children at school en­ try. this implies that at the end o f grade 3, they could rea­ sonably be expected to comprehend written language at grade 1 level. the results also indicate that the formal training, even when combined with speech-language intervention, does not seem to help the learners catch up with their vocabulary skills. it might also suggest that the particular speech-language inter­ vention, in its present form, is not effective for learners with a non-specific language impairment and might need to change. the negative impact o f poor vocabulary skills on the acquisition o f literacy and academic skills should not be un­ derestimated. the reciprocal relationship between vocabulary and phonological awareness skills implies that poor vocabu­ lary at school entry will compromise early reading acquisition at decoding level and are predictive of poor later reading com­ prehension (senechal, et al., 2001). adequate vocabulary skills are crucial for the comprehension o f de-contextualized literate language, used in written texts and in the classroom environment. the ability to retell a narrative has been shown by sev­ eral studies to be a powerful predictor o f longer-term language and literacy skills, which paves the way for transition between oral language and literacy (botting, 2002; kaderavek & sulzby, 2000). story-retelling requires children to construct mental representations o f the meaning and structure o f a story and then to retrieve, reconstruct and produce it in such a way that the listener can also construct meaning. this task demands a degree o f meta-linguistic awareness and higher-order lan­ guage processing and is linked to the ability to understand and produce literate language (fazio et al., 1996; westby, 2005). given their poor receptive vocabulary skills it was an­ ticipated that the participants would produce poor retell narra­ tives. despite being provided with a well-constructed model narrative and visual aids, in an attempt to minimize the effect o f possible short term memory deficits, they were unable to produce narratives o f the same lexical and syntactical com­ plexity as the stimulus narrative. in terms of productivity, the grade 3 children produced much longer narratives, compared to their narratives at preschool level. the narratives contained more words and t-units, and they included more story detail. the increase in length did not, however, result in a corre­ sponding increase in the syntactic and lexical complexity o f the narratives. as shown in table 3, the number o f different words (ndw), when expressed as a percentage o f tnw to control for the different lengths o f narratives, decreased with age. the lack of improvement correlates with the severe delay in recep­ tive vocabulary skills demonstrated by participants’ arw scores. although the model narrative contained 133 different words, grade 3 participants produced on average only 63 dif­ ferent words and seemed unable to imitate or utilise the new words presented to them. research has shown that language impaired children do not learn novel words as quickly and the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 64 d aleen k lop and seppo tuom i incidentally as their normally-developing peers (oetting, rice & swank, 1995). this may account for the inability of partici­ pants to spontaneously produce a variety o f words or even to reproduce the words in the story presented to them. in terms o f syntactic complexity, no significant growth occurred in the narratives produced by the grade 3 partici­ pants. their mlu scores, an indicator o f language develop­ ment and increased complexity at sentence level, stayed at the level o f their preschool narratives. this is consistent with stud­ ies reporting that the mlu and syntactic complexity of narra­ tives of language impaired children often resemble those o f younger children (scott & windsor, 2000). according to westby (2005), difficulties with the syntactic component of retelling narratives may also indicate problems with the inte­ gration o f information and poor abstract reasoning abilities. no growth seems to have occurred at intra-sentence level, as demonstrated by the number of subordinations pro­ duced. the increasing use o f subordination indicates complex­ ity at clausal level, and is associated with a literate language style and the development of complex language structures (westby, 2005). although the model narrative contained 11 examples o f subordination, only 11 of the 25 participants used any form o f subordination, and no participant produced more than two subordinations. given that clausal subordination and embedding is prevalent in literate and written language, this does not augur well for the participants’ reading comprehen­ sion abilities. clinical implications although efforts were made to control as many variables as possible this study has several limitations which must be taken into account when the results are interpreted. a small, non randomly drawn sample from a specific socio-economic, cul­ tural, geographic and linguistic group was used, which may restrict the ability to generalize the results to other populations. the measures used to assess the language skills may not have been culturally and/or linguistically appropriate for the study population. it would have also been useful to compare these results with those o f similar age non-disadvantaged popula­ tion. despite these limitations the results o f this study have several practical implications. firstly, none o f the participants in the study were con­ sidered to be language disordered by their teachers, possibly because they displayed no speech production disorders or ob­ viously disordered language. their language impairments may also be less obvious than those o f second language learners in the same classrooms. another reason may be that in a commu­ nity where all the learners come from disadvantaged back­ grounds, their language abilities resembled those o f the major­ ity o f their peers. this raises the issue of whether these learn­ ers should be regarded as demonstrating delayed language at all, but rather that they lack proficiency in cognitive academic language, which has implications for assessment and interven­ tion. speech-language assessment at preschool level should include assessment o f literate language features and emergent literacy skills, and intervention programmes should provide explicit and targeted literacy support. the literacy learning programme content o f the re­ vised national curriculum focuses on language acquisition, language development and communication, and educational authorities and educators are aware of the crucial role o f lan­ guage in attaining academic success. awareness o f the role o f language in education is also reflected in the debate concern­ ing second language learning and mother tongue instruction. the educators involved in this study, both at preschool and at grade 3 level, were unaware o f the nature and extent o f the language problems o f the participants. the persistence o f the language problems in the participants also indicates that three years o f formal instruction within a curriculum with stated language and communication outcomes, had no or little impact on their language development. there is a need for educators to assess the cognitive academic language levels o f learners in their classrooms, because without awareness o f the learners’ levels o f language abilities no focused intervention can take place. classroom-based intervention should also focus on the aspects o f language development directly linked to reading acquisition and reading comprehension, e.g. vocabulary, narra­ tive skills, and acquisition o f complex syntax. secondly, a concerted effort needs to be focused on the identification and intensive intervention o f language problems during the preschool years to allow for early intervention in educational settings. the persistence o f the participants’ lan­ guage delays indicates that they did not out outgrow their lan­ guage impairments and continued to fall even further behind. the presence o f developmental language impairments is an established risk factor for reading failure. early identification o f at risk learners is crucial to allow for early intervention within programmes focused on the development o f language skills necessary for the development o f reading and literacy. thirdly, speech-language therapists, particularly those working in schools, need to perform an in depth evaluations of the format and content o f existing intervention approaches with preschool and early school age population to improve their effectiveness. all the participants in the study received small-group speech-language therapy on a weekly basis for at least one year. the foci o f the intervention programmes, in compliance with the grade 1 educators’ needs, were phonemic awareness training and general improvement o f language skills. the lack o f developmental progress in participants’ lan­ guage skills indicates that the intervention had not been effec­ tive. reasons for this may be that the intervention programmes were too short-term and not intensive enough for the learners to benefit from them. learners, who start school with delayed language and/or lack o f emergent literacy skills, need intensive intervention focused on specific language and literacy skills, e.g. vocabulary and complex syntax. more active collaboration with educators to enhance transfer and reinforcement o f ther­ apy targets to the classroom may improve the effectiveness o f speech-language therapy interventions. the participants’ might have benefited more, if the intervention had started earlier and’ i lasted longer. conclusions the study demonstrated that, despite the academic training and speech-language intervention, none o f the measured language skills showed significant improvement with age. at the end o f the foundation phase, the learners still functioned at a much younger age level. this is consistent with research reports from similar studies from the united states o f america. the low level o f language skills portents poorly on-the future aca­ demic learning of these individuals even though it is possible that the learners’ language skills are 9 ompletely adequate to cope with daily living within their own environment. die suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the persistence o f language d isorders in a g roup o f d isadvantaged 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(1993). n arra tiv e discourse in children w ith language disorders and children w ith norm al language: a critical review o f the literature. journal o f speech, language, and hearing research, 36, 868-882. | appendix i stimulus narrative presented with 8 colour prints illustrating the story i eendag w as daar 'n m ier w at in die veld geloop het. hy w as vreeslik dors en daarom stap hy na die dam toe d ie dam is vol w ater en die m ier kan daar lekker koel w ater drink die m ier buk vooroor om van die koel w ater te drink m aar toe val hy binne-in die koue w ater "help my! h elp my" roep die m ier bang, 1 w ant hy kan glad nie swem nie. "ek m oet die arm e m ier gaan help" se die duif. hy pluk vinnig 'n groot groen blaar a f en gooi dit vir die bang mier. die m ier klim blitsvinnig op die blaar en d ry f na die w al van die dam toe. "dankie tog" se hy bly. i 'ek het baie groot geskrik w ant ek w as baie bang dat ek gaan verdrink" n ippold, m .a . (1998). l ater language developm ent: the school-age and adolescent years. a ustin, t exas: pro-ed inc. n orbury, c .f. & bishop, d .v .m . (2003). n arrative skills o f children w ith co m m u n i­ cation im pairm ents. international journal o f language & communication disorders. 3 8 ,2 8 7 -3 1 3 . o etting, j.b ., r ice, m .l. & sw ank, l.k . (1995). q u ick incidental learning (q u il) o f w ords b y school-age children w ith and w ith o u t sli. journal o f speech, lan­ guage, and hearing research, 38, 434-445. o w ens, r.e. (2004). l anguage d isorders: a functional approach to assessment and intervention. (4 lh ed.) boston, ma: pearson e ducation inc. p rinsloo, m. & stein, p. (2004). w h a t’s in the b ox? c h ild re n ’s early encounters w ith literacy in south a frican classroom s. perspectives in education, 22 (2), 67 -84. s chneider, p. & d ube, r.v . (2005). s tory presentation effects on c h ild re n ’s retell content. american journal o f speech-language pathology, 14, 52-60. scott, c .m . & w indsor, j. (2000). g eneral language perform ance m easures in sp o ­ ken and w ritten narrative and expository discourse o f school-aged children w ith language learning disabilities. journal o f speech, language, and hearing r e­ search, 43, 324-339. senechal, m ., l efevre. j-a ., s m ith-c hant, b.l. & c olton, k.v. (2001). o n refining th eoretical m odels o f em ergent literacy: the role o f em pirical evidence. journal o f school psychology, 39, 439-460. sm allm an, s. & n estling, p. (1993). kom ons lees: die mier en die duif. b raam fon tein: m acm illan b olesw a. the a m erican heritage d ictionary o f the english language, (2 0 0 0 ),(4lh ed.). b oston: h oughton m ifflin co. t om blin, j.b ., z hang, x., b uckw alter, p. & o ’b rien, m. (2003). the s tability o f prim ary l anguage d isorder: f o u r y ears after k indergarten d iagnosis. journal o f speech, language, and hearing research, 4 6 , 1283-1296. u ys, m., v an d er w alt, j., v an den b erg, r. & b otha, s. (2007). english m edium o f instruction: a situation analysis. south african journal o f education, 27(1), 69 82. w c ed task team to drive num eracy and literacy strategies (2005). r etrieved june 24, 2006, from http://w ced.w cape.gov.za/com m s/press/2005/29_num lit.htm l w estby, c.e. (2005). a ssessing and rem ediating tex t com prehension problem s. in: g. kam hi & h .w . catts (eds.), reading disabilities: a developmental lan­ guage perspective. (2nd ed) n eedham h eights: a llyn and bacon. the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://wced.wcape.gov.za/comms/press/2005/29_numlit.html narratives produced by a participant at age 6years 6months (narrative 1) and at age 9years 6months (narrative 2) 6 6 d aleen k lop and seppo tuomi narrative 1 narrative 2 hy wou water gedrink het eendag was daar ‘n mier toe verdrink hy hy het water gaan drink toe kom die duif toe val hy in die water toe help die duif vir hom toe skree hy “help, help” toe kom daar ‘n man toe vlieg daar ‘n duif af toe wil hy die duif geskiet het toe pluk die mier vinnig-vinnig ‘n blaar af toe help die mier vir hom toe is hy blitsig op die blaar toe byt die mier vir die man toe klim hy a f toe se hy “ek is jou beste vriend” toe loop daar ‘n man met groot skoene toe wil hy die duif skiet toe lig hy sy geweer op toe byt die mier aan sy been toe val hy toe se die duif: “dankie dat jy my gehelp het” toe se die mier: “dankie dat jy vir my ook gehelp het” toe se die mier: “dis maar nog niks en ons is maar net vriende” die suid-afrikaanse tydskrif vir kommunikasieajwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) abstract introduction theoretical background methods results discussion limitations conclusion acknowledgements references appendix 1 appendix 2 about the author(s) thiani pillay discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa mershen pillay discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa speech and language therapy, massey university, auckland, new zealand department of health professions, manchester metropolitan university, manchester, united kingdom citation pillay, t., & pillay, m. (2021). contextualising clinical reasoning within the clinical swallow evaluation: a scoping review and expert consultation. south african journal of communication disorders, 68(1), a832. https://doi.org/10.4102/sajcd.v68i1.832 original research contextualising clinical reasoning within the clinical swallow evaluation: a scoping review and expert consultation thiani pillay, mershen pillay received: 18 mar. 2021; accepted: 02 june 2021; published: 29 july 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: this study explored the available literature on the phenomenon of clinical reasoning and described its influence on the clinical swallow evaluation. by exploring the relationship between clinical reasoning and the clinical swallow evaluation, it is possible to modernise the approach to dysphagia assessment. objectives: this study aimed to contextualise the available literature on clinical reasoning and the cse to low-middle income contexts through the use of a scoping review and expert consultation. method: a scoping review was performed based on the prisma-scr framework. the data was analysed using thematic analysis. articles were considered if they discussed the clinical swallow evaluation and clinical reasoning, and were published in the last 49 years. results: through rigorous electronic and manual searching, 12 articles were identified. this review made an argument for the value of clinical reasoning within the clinical swallow evaluation. the results of the study revealed three core themes related to the acquisition, variability and positive impact of clinical reasoning in the clinical swallow evaluation. conclusion: the results of this review showed that the clinical swallow evaluation is a complex process with significant levels of variability usually linked to the impact of context. this demonstrates that in order to deliver effective and relevant services, despite challenging conditions, healthcare practitioners must depend on clinical reasoning to make appropriate modifications to the assessment process that considers these salient factors. keywords: clinical reasoning; dysphagia; clinical swallow evaluation; speech-language pathology; contextualisation. introduction clinical reasoning is a decision-making process that is vital to clinical practice (higgs & jones, 2008; young et al., 2020). it has been understood as a complex and critical skill (doeltgen, attrill, & murray, 2019; findyartini, hawthorne, mccoll, & chiavaroli, 2016; miles, friary, jackson, sekula, & braakhuis, 2016), which allows healthcare practitioners (hcps) to provide services in a flexible manner that embraces uncertainty within the clinical encounter (greenhalgh, wherton, shaw, & morrison 2020). this is of particular importance to low-middle income contexts (lmics), such as south africa, where flexible and responsive reasoning is required to provide equitable and relevant healthcare services (sachs, 2012; saito et al., 2016). the value of clinical reasoning is well established within dysphagia practice. doeltgen et al. (2019), and many others (jones, cartwright, whitworth, & cocks, 2018; mathers-schmidt & kurlinski, 2003; mcallister et al., 2020; pettigrew & o’toole, 2007; rumbach, coombes, & doeltgen, 2018), have shown that sound clinical reasoning is vital within dysphagia assessment and management to prevent poor patient outcomes. however, almost all this research has emerged from higher income contexts which cannot always be generalised to lmics. the aim of our article, therefore, was to explore the nature of clinical reasoning within the clinical swallow evaluation (cse) in published literature over the last 49 years using a scoping review and expert consultation. this was achieved through two study objectives which included: (1) determining how clinical reasoning had been characterised within the cse regarding its explicitness, conceptual understanding, reported perceptions and perceived value in literature and, (2) determining the relevance of the scoping review findings to policy and practice in a south african context. theoretical background the theoretical background of this article rationalises and deconstructs the use of clinical reasoning within practice. clinical reasoning is a complex cognitive process used by hcps to decide on appropriate diagnoses and treatments for patients (gummesson, sundén, & fex, 2018; miles et al., 2016; young et al., 2020). this involves the use of cognitive tools like interpretation, association and evaluation to critically consider presenting clinical information to inform management plans (gummesson et al., 2018; young et al., 2020). levett-jones et al. (2010) describe clinical reasoning as a recursive and cyclic process to collect appropriate cues, establish goals and execute actions in an appropriate manner. clinical reasoning was initially hypothesised as a static skill which was applied verbatim to every situation (gruppen, 2017). however, márquez-álvarez, calvo-arenillas, talavera-valverde and moruno-millares (2019), young et al. (2020) and mcbee et al. (2018), have suggested the importance of accounting for the individualised nature of clinical reasoning which considers the patient, context, evidence and clinician in decision-making. this is valuable as it allows hcps to consider multiple sources of information when developing a working hypothesis regarding patients (boshuizen et al., 2018). in this article, we focus on the effect of clinician, context and assessment modality on clinical reasoning. clinician clinical reasoning is highly dependent on the practicing clinician (jessee, 2018; langridge, roberts, & pope, 2016). cognition, training and experience are unique to each clinician, but are all influential within the clinical reasoning process (norman et al., 2017). the role of these factors have informed various clinical reasoning models within the literature (norman et al., 2017), that are broadly classified within two categories. the subconscious and conscious (gummesson et al., 2018) models of clinical reasoning are discussed below. the subconscious or pattern-recognition model assumes clinical reasoning is influenced by knowledge acquired from experience and intuition (johansen & o’brien, 2016). this model is informed by the premise that hcps associate clinical problems presenting in current patients with problems seen previously and thus manages patients in a similar manner (benner, hughes, & sutphen, 2008; johansen & o’brien, 2016). according to this model, novice clinicians initially rely on training and established guidelines to make clinical decisions. progressively, they move towards intuitive reasoning as they become more experienced (benner & tanner, 1987; jessee, 2018). in contrast, the conscious model, the hypothetico-deductive model, states that hcps develop a hypothesis, based clinical information which is informed by training and experience (abdallah, 2020; trimble & hamilton, 2016). this hypothesis is then exhaustively tested through several stages such as cue recognition, hypothesis generation, cue interpretation and hypothesis evaluation, to develop a clear management strategy (abdallah, 2020; trimble & hamilton, 2016). context clinical reasoning is determined by various factors related to context and political consciousness (kathard & pillay, 2013; young et al., 2020). this is particularly true for lmics all over the world, who are haunted by political and economic injustices (browne et al., 2016; lavoie et al., 2018; umeh & feeley, 2017; ziltener & künzler, 2013). these injustices have resulted in several consequences such as severe inequity, high unemployment rates and insufficient health systems (baatiema et al., 2020; browne et al., 2016; ruelas, gómez-dantés, leatherman, fortune, & gay-molina, 2012). this in turn has caused unsurmountable personnel and resource constraints, high patient numbers, as well as a complex burden of disease (ludwick, morgan, kane, kelaher, & mcpake, 2020; mayosi et al., 2012; meng et al., 2020; puchalski ritchie et al., 2016). these constraints have forced hcps to practice in a creative and flexible manner to combat the effect of these inequities on their patients (baatiema et al., 2020; saito et al., 2016; van graan, williams, & koen, 2016). for perceived non-essential services such as speech therapy, these difficulties are often compounded because of their lack of priority when disseminating resources (andrews & pillay, 2017; bright, wallace, & kuper, 2018; rech, hugo, schmidt, goulart, & hilgert, 2019). as a result, according to andrews and pillay (2017), pierpoint and pillay (2020) and modi and ross (2000), many speech-language therapists (slts) chose to alter their practice patterns to cope with the demands of the contexts in which they work, to allow for best possible practice within challenging conditions (doeltgen et al., 2019; saito et al., 2016). according to kathard and pillay (2013), another facet of contextual influence is determined by political climates and historical biases. this accounts for how political, social, cultural and systemic structures impact clinical reasoning (kathard & pillay, 2013). for example, hcp’s clinical reasoning is informed by knowledge acquired from professional training (doeltgen et al., 2019). historically, academic instruction has subscribed to a privileged approach to knowledge which has been taught under the guise of universality (dawson, 2020; grosfoguel, 2013; kathard & pillay, 2013). this is problematic as a rigid approach to knowledge which gives deference to colonial ideals cannot account for the complex social, economic and historical realities of the rest of the world (dawson, 2020; ndlovu-gatsheni, 2018). therefore, it is important for us to understand the influence of these biases on clinical reasoning to assist in managing patients in a manner that is more relevant and socio-politically aware (findyartini et al., 2016; kathard & pillay, 2013; zahir, miles, hand, & ward, 2020). assessment in this article, we have chosen to foreground the cse given its subjective nature which relies on clinical reasoning (garand, mccullough, crary, arvedson, & dodrill, 2020). the cse is an assessment which evaluates patients to make inferences about the presence, nature and cause of dysphagia within the oral and pharyngeal phase of the swallow (carnaby-mann & lenius, 2008; garand, mccullough, crary, arvedson, & dodrill, 2020). this is achieved through chart reviews, patient observations, oral motor examinations and multiple swallow trials (doeltgen et al., 2019; garand et al., 2020). the cse is a detailed assessment which informs hypotheses regarding the anatomy and physiology of the swallow (rangarathnam & mccullough, 2016). this assessment is necessary as it allows slts to make decisions regarding oral intake and consistency, additional compensations and ultimately the need for instrumental assessments (namasivayam-macdonald & riquelme, 2019; virvidaki, nasios, kosmidou, giannopoulos, & milionis, 2018). there is significant controversy regarding the utility of the cse as a stand-alone assessment to guide dysphagia management (doeltgen, mcallister, murray, ward, & pretz, 2018; riquelme, 2015), given its reliance on perceptual information and varied practice patterns (riquelme, 2015). however, the cse is still the most commonly used form of dysphagia assessment (virvidaki et al., 2018). it is regarded as a time efficient, cost-effective and non-invasive assessment, which allows therapists to understand a patient’s dysphagia in relation to their medical history and displayed symptoms (carnaby-mann & lenius, 2008; riquelme, 2015; virvidaki et al., 2018). methods this study followed a scoping review design which aimed to collate and understand the evidence available on clinical reasoning (aromataris & munn, 2017). the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr) (tricco et al., 2018), framework was adapted to guide the study. although the prisma-scr is a novel framework, the clarity it provided for methodological quality and reporting styles made it appropriate to ensure a transparent and complete review could be carried out (chang, 2018; mueller et al., 2013). the 22-item checklist (appendix 1) was adapted for the needs of the study. given the nature of our second objective, we acknowledge that the methodology employed differs from traditional approaches to scoping reviews. however, this adapted methodology was instrumental to contextualising the findings to a south african context to account for global narratives on the utility of clinical reasoning. this study consisted of three phases namely: data preparation, collection and analysis. as preparation for the main study, the first phase involved a pilot study to test the developed research instruments (i.e. search protocols, screening protocols and tools) to establish internal validity (kinchin, ismail, & edwards, 2018). additionally, an expert reference group consisting of five dysphagia academics in south africa were consulted as per the joanna briggs institution (jbi) (peters mdj, godfrey c, mcinerney, munn, tricco & khalil, 2020) to assist in informing decisions regarding keywords, databases, search terms and strategies for searching the literature. the second phase involved the collection and review of the literature identified from various sources. peer-reviewed articles and grey literature published between 1970 and 2019 were considered. the researchers focused on the last 49 years as research published prior was considered outdated. within the third and final phase of the study, the data was analysed and a focus group was consulted to contextualise the results as per objective two. eligibility criteria the studies included were those which: were published between 1970 and 2019. assessed the swallowing function of human participants. were published by dysphagia practitioners in medically related fields (e.g. speech-pathology, dietetics, dentistry). evaluated the assessment of patients using the cse. referred to clinical reasoning or its associated terms. information sources information for this review was sourced from both electronic and physical journals. the electronic databases searched were: south african bibliographical network (sabinet), ebscohost, medline, pubmed, clinical key, google scholar and cochrane library. these databases were selected as they are highly reputable and extensive, which ensured that all the relevant literature was identified. furthermore, published conference papers of american speech and hearing association (asha), and south african association of speech, language and hearing association (saslha), as well as postgraduate dissertations available on researchspace were all searched to identify grey literature. the final electronic search was conducted on 03 june 2019. handsearching was performed at three south african university libraries. the biomedical journal, academic medicine, medical education, south african journal of communication disorders, international journal of speech and language, new england journal of medicine, and journal of medical research were searched from 1970 to 2019 for keywords via table of contents and subject indexes. the final manual search was conducted on 07 june 2019. search strategy the jbi’s (peters et al., 2020), three-step search strategy was utilised to guide a comprehensive search of the literature. this included searching two databases namely, google scholar and medline, for articles which related clinical reasoning to the cse to identify keywords contained within the title, abstract, and index (moola et al. 2015). the keywords identified through this strategy were: clinical reasoning, clinical decision-making, cse, dysphagia and speech therapy. following this, a second search was carried out to determine which combination of these keywords would yield the most relevant results across databases. the final combination of keywords used were: [clinical reasoning] or [decision-making] and [dysphagia assessment] or [swallow assessment]. these terms were placed into the databases using advanced searching options to filter articles by date and search terms. finally, reference lists of relevant articles were searched post data collection to ensure no relevant information was missed. study selection two reviewers blindly screened the titles, abstracts and full articles of the search results independently. reviewer 1 performed the manual search and screening, and reviewer 2 searched and reviewed the six electronic databases. upon completion of the screening processes, the reviewers met to discuss the eligibility of each article for the dataset. the suitability of each of the articles was evaluated based on the inclusion criteria. an agreement rate of 85.7% was achieved between the reviewers. in the two instances where the reviewers could not reach a consensus, a third reviewer was consulted to make the final decision. data charting and analysis the data extraction and charting process was iterative, allowing for the dataset to evolve as useful elements were identified (moola et al., 2015; schultz et al., 2018). the data charted included: author, year of publication, country, aims, study population and size, methodology, intervention type, outcomes and key findings. the extracted data served as a basic summary to help orient readers to the nature of the research collected. thematic analysis as described by braun and clarke (2006), was utilised to provide a rich and complex account of the data. braun and clarke (2006), described a six-step recursive method for thematic analysis which included: (1) familiarisation, (2) generation of initial codes, (3) searching for and (4) reviewing themes, (5) production of final themes, and (6) a report. furthermore, the computer analysis software nvivo 12 was used to support data coding processes by streamlining complex functions like syntactical word recognition, word frequency counting, coding and the creation of visual representations of the data in the form of word clouds, tree diagrams and word matrices. consultation finally, the researcher chose to include an optional consultation as described by colquhoun et al. (2017), within the third phase of this review. although largely unknown, the consultation phase is a historic (arksey & o’malley, 2005; levac, colquhoun, & o’brien, 2010) and current (faulkner, taylor, ferrence, munro, & selby, 2006; faulkner et al., 2011; khan et al., 2015; moore et al., 2019; myers, schaefer, & coudron, 2017; smartt et al., 2019; youssef, chaudhary, wiljer, mylopoulos, & sockalingam, 2019; zwiep et al., 2018) feature of scoping reviews which engages stakeholders to understand the implications of a review’s findings within practice. the aim of this consultation phase was to contextualise the data to south africa. the reliability, value and applicability of the results were addressed within the context of healthcare in south africa. four dysphagia practitioners were consulted through a focus group to allow for a multidimensional discussion around the collected data (nyumba, wilson, derrick, & mukherjee, 2018). the focus group was conducted using open-ended questions surrounding the applicability of the results to the south african context. upon completion, the focus group was transcribed and thematically analysed in relation to the themes of the literature search. this allowed the researchers to highlight the applicability of the results in the context of south africa. ethical considerations this study was approved by the biomedical research ethics committee (brec) of the university of kwazulu-natal (brec reference number: be275/19). results search results figure 1 depicts the data collected through both the electronic and manual searches. there were 49,000 articles identified in the initial searches across the six databases, however there were extensive numbers of duplicates between the searches. after the duplicate studies were removed, 8,800 studies were screened. of the total number of articles screened by title, only approximately 0.14% of the articles were included within the final review. this could demonstrate a poor focus within the literature on clinical reasoning within the cse. figure 1: prisma-scr flow diagram of results. characteristics of the included studies appendix 2 represents the characteristics of the 12 studies included in the study. each of the selected articles made explicit references to the use of clinical reasoning within the cse as per the eligibility criteria. the studies were published between the period 1999 and 2019. the methodologies of the study included: two literature reviews, seven descriptive survey-based studies, two intervention studies and one case study. all the included studies were conducted in largely urbanised, high-income countries. four studies were carried out in australia, two in ireland, four in the united states of america, one in canada, and one in england. this influenced the narratives which could be explored given the homogenous economic context of the dataset (see appendix 2). thematic results the results of the review revealed three main themes related to the value and use of clinical reasoning within the cse. the results of both the review and the consultation highlighted several key issues including: the importance of clinical reasoning, the impact of training and experience, the importance of individualised service delivery and the value of flexible and critical reasoning within dysphagia assessment. each of these themes will be elaborated on further in the discussion below. discussion the results of the literature search and consultation have been presented and discussed simultaneously. by presenting the results together, the researchers aimed to represent perspectives from both high-income and low-income contexts on clinical reasoning which correlates with the objectives of the study. through the thematic analysis, three core themes regarding clinical reasoning in the cse were revealed and will be elaborated in the following subsections. theme 1: experience matters in clinical reasoning the review highlighted the importance of knowledge acquired from training and experience in the clinical reasoning process. as expected, university training was described as influential in the development of clinical reasoning skills. as mentioned previously, training is the foundation on which all clinical knowledge is built and therefore impacts how all decisions are made (doeltgen et al., 2019). according to seven of the articles within the dataset, a solid theoretical understanding of assessment and management of dysphagia is needed to develop appropriate knowledge schemas to guide reasoning (brodsky, mayfield, & gross, 2019; doeltgen et al., 2018; jones et al., 2018; mathers-schmidt & kurlinski, 2003; mcallister, kruger, doeltgen, & tyler-boltrek, 2016; mccurtin & carter, 2015; mccurtin & healy, 2017). however, an interesting finding was the focus on experience rather than training as the guiding factor within clinical reasoning. several articles within the dataset referred to the level and quality of experience amongst slts as being the preferred factor to guide clinical reasoning (brodsky et al., 2019; doeltgen et al., 2018; jones et al., 2018; mathers-schmidt & kurlinski, 2003; mcallister et al., 2016; mccurtin & carter, 2015; mccurtin & healy, 2017; pettigrew & o’toole, 2007; rumbach et al., 2018; walshe, ryan, & regan, 2017). table 1 demonstrates this with several extracts from the dataset which support the use and preference of experience in clinical reasoning. experience was described in terms of the recognition-primed decision model (rpdm), which theorises that hcps make decisions through the recognition of patterns (klein, 1999). all 12 articles described pattern recognition as useful, as it allows hcps to quickly process information to develop a small number of plausible diagnoses. this preference for pattern-recognition was attributed to it being a resourceand time-efficient process whilst avoiding haphazard or inaccurate decisions. the rpdm relies heavily on intuition, which is described as ‘the immediate realisation of risk, usually learnt […] without conscious awareness’ (farr-wharton, brunetto, & shacklock, 2012, p. 1392). according to articles 1 (doeltgen et al., 2018), 7 (mccurtin & carter, 2015) and 11 (mccurtin & healy, 2017), intuition is developed through diverse and high-quality clinical experiences. article 1 (doeltgen et al., 2018) explains that these experiences help slts to develop complex networks of illness scripts and patterns of symptoms that are relied on to guide decision-making. furthermore, articles 1 (doeltgen et al., 2018) and 7 (mccurtin & carter, 2015) highlighted that the amount of experience which hcps have, impacts on both the speed and accuracy of their pattern-recognition approach. novice hcps have less information within their knowledge schemas to develop diagnoses at an intuitive level. therefore, they have to engage in an exhaustive conscious approach to make diagnoses (klein, 1999). table 1: extracts regarding the value of clinical experience. the sentiment that experience is arguably more influential than training was echoed in the results of the consultation phase. this was attributed to inconsistency and irrelevance of training of slts at tertiary institutions. the results showed that practitioners preferred to rely on their own experiences to guide their approach to dysphagia management. as seen in figure 2, the focus group felt that universities focused more on a theoretical understanding of dysphagia and trained clinicians in a linear outcome-based model which is inappropriate to the lmic contexts that they find themselves in. they reported that this inappropriateness of training was exacerbated by insufficiency in opportunities to develop these clinical skills in real-life scenarios. these sentiments are echoed in recent literature which describes the doubt and under-preparedness voiced by many novice slts in response to their training (caesar & kitila, 2020; coutts, 2019; singh et al., 2015). figure 2: word tree showing the conceptualisation of training in consultation phase by focus group, generated in nvivo 12. theme 2: clinical reasoning cannot be decontextualised globally, slts often work in a variety of settings as seen in figure 3. as a result of this diversity in setting, every article within the dataset highlighted contextual factors as a major contributing factor to clinical reasoning which should not be discounted. article 7 describes this by stating: ‘the clinical decisions [which] health professionals [make] are strongly influenced by the context in which they are made’ ( mccurtin & carter, 2015, p. 72). this makes sense given that context often determines resource availability, prioritised health goals, institutional policies and popularised assessment practices (schwarz,coccetti, & cardell, 2020). as a result of this increased variability, hcps are required to engage in assessment in a highly nuanced and complex manner. therefore, we can deduce that the decision which clinicians make cannot be removed from the context in which it occurs. for example, the data showed a discrepancy between acute/subacute and community-based settings as demonstrated in figure 4. slts favoured instrumental assessments within the acute/subacute settings. this higher frequency can be attributed to equipment usually being more accessible as well as the complex nature of the patient population. conversely, slts in community settings were more likely to rely on the cse to guide their decisions as instrumental assessments are considered costly and difficult to access. this is in line with the literature explored earlier by virvidaki et al. (2018) and namasivayam-macdonald and riquelme (2019). figure 3: word cloud of clinical setting, generated in nvivo 12. figure 4: word tree representing setting data, generated in nvivo 12. the results of the consultation frequently described how influential context was in making clinical decisions. the clinicians felt that clinical reasoning was imperative to ensure that the management of patients reflected both the needs of the population as well as best practice even in challenging conditions. there was consensus that because of the complex quadruple burden of disease, severe resource constraints and high patient loads which are mirrored in most lmics, slts have to alter the way in which they practice to cope with demands of their settings (andrews & pillay, 2017). this was described to be unique to lmics as often there are fewer confounding variables to consider within high income contexts. therefore, they felt that slts often relied on clinical reasoning when developing context-specific assessments which are crucial in effective and equitable service delivery. theme 3: focused clinical reasoning positively impacts patient outcomes the dataset (as seen in table 2) showed that slts have moved to a purposeful and process-driven approach to assessment which allows them to easily adapt to conditions. articles 1 (doeltgen et al., 2018), 4 (jones et al., 2018), 7 ( mccurtin & carter, 2015) and 12 (martino , pron, & diamant, 2004) suggested that this has occurred because slts have a network of core assessment components which are influenced by a hierarchical model. according to this hierarchy, slts begin with the most common cse components and then move on to less utilised components as required. this process continues until the clinician has developed a satisfactory diagnosis. gonzález-fernández, ottenstein, atanelov and christian (2013), corroborated this idea by stating that component omission by slts was purposeful and non-random. this suggests that component selection in the cse is reflective of the practice philosophy amongst slts who ‘[do] what works best for their patients, in their setting’ (jones et al., 2018, p. 73). in addition, it is clear to see the positive impact which clinical reasoning has on the utilisation of the cse. within complex cases better outcomes are reported when slts employ high-quality clinical reasoning processes to guide the selection of assessment components. this conclusion is supported by odderson, keaton and mckenna (1995), who state that: [r]egardless of the variability in slt cse practice, it has been demonstrated that slt involvement in the clinical management of dysphagia indeed contributes to better clinical outcomes and reduced healthcare expenditure. (p. 1132) table 2: data extracts on the impact of clinical reasoning. the positive impact of clinical reasoning includes assisting slts in guiding management decisions, considering multiple factors, preventing unnecessary assessment and synthesising information from multiple sources. this positive impact was extrapolated within the results of the consultation phase. the focus group agreed that there was substantive value in clinical reasoning especially within the complex socio-economic context of south africa as an example of an lmic. the participants reasoned that clinical reasoning was a key tool which clinicians used to adapt dysphagia assessment protocols to make them relevant to their context. they felt that this study was invaluable in creating a link between research, service delivery and training to meet the needs of the complex and diverse communities within lmics in an effective manner. limitations there were limitations to this study, given the nature of the methodology and the time-sensitive and resource-sensitive nature of data collection. firstly, the inclusion criteria were narrow to fit the scope of the research question which excluded studies that considered instrumental assessments or dysphagia management. however, given that the cse is so dependent on clinical reasoning skills, it was valuable to foreground this modality. secondly, the researchers acknowledge limitations regarding the implementation of the scoping review methodology. for example, the choice of search terms, databases and the nature of handsearching may have resulted in some relevant articles not being identified. however, the rigorous and transparent nature of the methodology has aided in mitigating these issues. furthermore, for the consultation phase the researchers chose to use south africa as the example of a lmic for convenience. whilst this could limit the applicability of the results, south africa is considered an effective illuminator of the impact of wealth disparity within a country. therefore, these results could be mirrored within many contexts globally. conclusion in conclusion, this study demonstrated that the cse is a highly complex process with significant levels of variability. this variability is evident because dysphagia treatment and management cannot be decontextualised. to deliver effective and relevant services despite challenging and complex conditions, hcps must depend on clinical reasoning as a key tool to make appropriate decisions within the assessment process. figure 5 is suggested to re-present the way in which we consider clinical reasoning based on the result of this review. it aims to account for the complex interaction between both internal and external factors which impact clinical reasoning skills. this review has highlighted the impact of both the clinician and context on clinical reasoning, particularly within lmics. so, how are these factors not sufficiently emphasised within practice? in the future, hcps have to better account for the effect of these factors within their clinical reasoning to provide equitable and effective services. figure 5: venn diagram representing clinical reasoning. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions both t.p. and m.p. contributed equally to this work. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references abdallah, a. 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(2018). impact of group practices on patients, physicians and healthcare systems: protocol for a scoping review. bmj open, 8(9), e022164. appendix 1 table 1-a1: preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr) checklist. appendix 2 table 1-a2: characteristics of included studies. abstract introduction research method and design results and discussion limitations of the study recommendations and conclusion acknowledgements references about the author(s) milka c. madahana school of electrical and information engineering, faculty of engineering and the built environment, university of the witwatersrand, johannesburg, south africa katijah khoza-shangase department of audiology, school of human and community development, university of the witwatersrand, johannesburg, south africa nomfundo moroe department of audiology, school of human and community development, university of the witwatersrand, johannesburg, south africa otis nyandoro school of electrical and information engineering, faculty of engineering and the built environment, university of the witwatersrand, johannesburg, south africa john ekoru school of electrical and information engineering, faculty of engineering and the built environment, university of the witwatersrand, johannesburg, south africa citation madahana, m.c., khoza-shangase, k., moroe, n., nyandoro, o., & ekoru, j. (2022). application of machine learning approaches to analyse student success for contact learning and emergency remote teaching and learning during the covid-19 era in speech–language pathology and audiology. south african journal of communication disorders, 69(2), a912. https://doi.org/10.4102/sajcd.v69i2.912 original research application of machine learning approaches to analyse student success for contact learning and emergency remote teaching and learning during the covid-19 era in speech–language pathology and audiology milka c. madahana, katijah khoza-shangase, nomfundo moroe, otis nyandoro, john ekoru received: 31 jan. 2022; accepted: 30 may 2022; published: 30 aug. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the onset of the covid-19 pandemic across the globe resulted in countries taking several measures to curb the spread of the disease. one of the measures taken was the locking down of countries, which entailed restriction of movement both locally and internationally. to ensure continuation of the academic year, emergency remote teaching and learning (ertl) was launched by several institutions of higher learning in south africa, where the norm was previously face-to-face or contact teaching and learning. the impact of this change is not known for the speech–language pathology and audiology (slpa) students. this motivated this study. objectives: this study aimed to evaluate the impact of the covid-19 pandemic on slpa undergraduate students during face-to-face teaching and learning, ertl and transitioning towards hybrid teaching and learning. method: using course marks for slpa undergraduate students, k means clustering and random forest classification were used to analyse students’ performance and to detect patterns between students’ performance and the attributes that impact student performance. results: analysis of the data set indicated that funding is one of the main attributes that contributed significantly to students’ performance; thus, it became one of the priority features in 2020 and 2021 during covid-19. conclusion: the clusters of students obtained during the analysis and their attributes can be used in identification of students that are at risk of not completing their studies in the minimum required time and early interventions can be provided to the students. keywords: artificial intelligence; audiology; hybrid learning; contact; covid-19; education; machine learning; emergency remote teaching; speech–language pathology; teaching; blended learning. introduction the coronavirus disease 2019 (covid-19) pandemic has produced a public health crisis worldwide that has severely affected the economic, health, academic and social fabric of the world community (khoza-shangase, moroe, & neille, 2021; maital & barzani, 2020; mckibbin & fernando, 2020; pawar, 2020; soni, 2020). the spread of covid-19 has been a catastrophe, and most governments in the world instituted measures to minimise the risks and spread of covid-19 (blankenberger & williams, 2020). some of the measures taken to curb the spread of the disease were and are not limited to wearing face masks, practising social distancing, isolation for individuals infected or exposed to covid-19 (who, 2021) and varying levels of lockdown where movement is restricted. most countries, including south africa, restricted gatherings, movement and also implemented curfews (south african government, 2021). one of the sectors that was significantly affected by the restrictions on movement was the education sector. covid-19 significantly reshaped the way education is conducted globally, dhawan (2020). in south africa, from the time of colonisation to the decolonisation period, most institutions of higher learning have been dependent on face-to-face teaching and learning (mgqwashu, 2017; mpungose, 2020). face-to-face teaching and learning usually occurs in the presence of an instructor or lecturer who transfers knowledge to students in a designated, demarcated classroom. the instructor or lecturer may use chalkboards, textbooks or any other traditional resource (mpungose, 2020). in the context of political unrests, student protests, the outbreak of a pandemic or any other emergency situation, the demarcated physical classrooms are not available. in addition to that, face-to-face learning is marked by real-time contact with resources at a specific contact time (mpungose, 2020; tularam, 2018). at the early stages of the covid-19 pandemic, most institutions of higher learning were completely closed in south africa, as part of national regulations forming the national state of emergency. to ensure that students completed the academic year successfully, most institutions transitioned to emergency remote teaching and learning (ertl), which may be defined as a temporary shift of instructional delivery to an alternate delivery mode because of crisis circumstances. emergency remote teaching and learning involves the use of various remote teaching strategies for education that would under normal circumstances be conducted face-to-face or as blended or as hybrid (mpungose, 2020). emergency remote teaching and learning applies aspects of both synchronous teaching –using video conferencing tools, for instance, zoom, teams and google meets (bond, bedenlier, marín, & händel, 2021) – and in some instances, utilising the asynchronous type of teaching approach, where students are provided with course material and lecture recordings and given flexibility to study in a self-paced fashion. some of the approaches used in ertl were virtual and digital teaching and learning strategies (mhlanga & moloi, 2020). emergency remote teaching and learning has played a huge role in ensuring that academic institutions in south africa continue to deliver on their mandates. however, considering the south african history of colonialism and apartheid, which was characterised by racial segregation and injustices, transitioning to ertl came with its own challenges (besser, flett, & zeigler-hill, 2020; khoza-shangase et al., 2021; mcquirter, 2020; neuwirth, jović, & mukherji, 2021; rajab, gazal, & alkattan, 2020). thaba-nkadimene (2020) highlighted that changing from face-to-face learning to ertl, using digital platforms and currently transitioning towards blended or hybrid teaching, is a change that cannot be easily carried out within a short period of time. this change, which has occurred over the last 24 months, has required institutions of higher learning to intensively invest in digital technologies and academic staff digital training (garcía-morales, garrido-moreno, & martín-rojas, 2021). covid-19 highlighted and exacerbated the already existing social and economic inequalities in south africa, and at the beginning of the ertl, some students did not have the resources required for learning; for example, they lacked the device(s) to access information on digital platforms which were being used as part of the ertl strategy, and they did not have connectivity access. thus, the department of higher education and training collaborated with universities to provide laptops for students (francis, valodia, & webster, 2020; mpungose, 2020). some students were faced with the dilemma of exorbitant costs of internet and connectivity interruption, especially students residing in remote areas (azionya & nhedzi, 2021). to overcome some of the challenges faced because of lack of access and internet interruption, universities responded by partnering with internet providers as a mitigating strategy, and a fixed amount of data were made available monthly for students to use in some of the universities (itweb, 2020). south african universities also negotiated for zero rating of educational sites, which is a solution that had previously been used during the students’ protests in 2015. zero rating is where mobile network providers and some internet service providers do not bill their clients for accessing specific sites, in this context, educational sites. zero rating means that the academic sites may be accessed without depletion of the student’s data bundle. however, the current reality of education is that pedagogically relevant content is no longer constrained to an institutional website or even to a limited number of websites. in ertl, students were sometimes required to access audio and visual communication tools, for instance, microsoft teams, zoom and google classroom. zero rating can therefore be perceived as having been narrowly interpreted, and there is a huge disconnect between sites that are zero rated and most sites that are pedagogically relevant to ertl (mhlanga, 2020; tenet, 2021). another challenge faced by students in navigating ertl was frequent power interruptions, which also affect internet connectivity (azionya & nhedzi, 2021; laher, bain, bemath, de andrade, & hassem, 2021; oyedotun, 2020). power interruption is a well-documented ongoing challenge in south africa, termed load-shedding, and it is currently still being resolved. students required flexibility to access academic material online and to participate in assessments that were conducted online to accommodate this instability in power supply (gedala & connie, 2021; motsepe foundation, 2021). the assessment of students during ertl was the most challenging aspect, both locally and internationally. the proposed assessment strategies that emerged either supported or disrupted the already existing inequalities that widened access to higher education by previously marginalised individuals (padayachee & matimolane, 2021). it is argued by padayachee and matimolane (2021) that challenges experienced during ertl originate from an ingrained perspective of an assessment as a measure of student competence and standard of teaching. the transition to ertl challenged how assessments have previously been viewed at institutions of higher learning. re-evaluating teaching and redesigning approaches to assessments seems to have triggered a shift in assessment ideology (padayachee & matimolane, 2021). although these strategies assisted students in coping with the ertl, both course instructors and students continued to face other challenges in completing the academic year (padayachee & matimolane, 2021). in most institutions of higher learning in south africa, bachelor of speech–language pathology and bachelor of audiology programmes are designed to be completed within a duration of 4 years. the practical or clinical courses may be held at the university’s speech and hearing clinics and at speech and hearing clinics at hospitals, schools, industries and care facilities, within the broader urban and rural context. south african training institutions for speech–language and hearing (slh) have predominantly applied the traditional and orthodox approach to teaching and learning through in-person contact. teletraining and telepractice have not been employed extensively (khoza-shangase et al., 2021). the covid-19 outbreak therefore brought to light the need for a paradigm shift in the manner in which clinical training for slh in south africa is viewed and conducted (chin et al., 2021; khoza-shangase et al., 2021; schmutz et al., 2021). in pursuit of solutions during ertl, application of simulations was presented as one of the ways students can conduct their clinical training (tabatabai, 2020). in a scoping review by nagdee, sebothoma, madahana, khoza-shangase and moroe (2022) on what has been documented about simulation as a mode of clinical training in health care professions, findings indicate the value and usefulness of simulation but only within a hybrid model of training where it is used in conjunction with traditional approaches to training. other challenges that were observed during the ertl were lack of effective peer-to-peer interaction, which is very instrumental in students being able to learn from each other (chandra & palvia, 2021). some students lacked conducive environments at home that would allow for effective ertl (gumede & badriparsad, 2022). these challenges were not restricted to students only, as staff members at institutions of higher learning were also faced with various challenges. lack of e-tech facilities was one of the setbacks (mpungose, 2020). lecturers who were used to only traditional ways of teaching were frustrated with online interactive learning digital technologies because of lack of digital skills or because of the new expectation to have to learn how to use new platforms in a very short period of time, whilst at the same time delivering quality lectures (engler, 2020). regardless of all these challenges faced by students and academic members of staff, there was still an expectation that students should excel in their academic work and the academic year be successfully completed. with the ease of the lockdown restrictions, most institutions of higher learning in south africa are transitioning to hybrid teaching and learning. hybrid teaching and learning in the current context of most south african universities may be defined as the thoughtful integration of classroom face-to-face learning experiences, ertl and online learning experiences (hrastinski, 2019). figure 1 is a visual representation of the modes of teaching and learning, ranging from face-to-face learning, ertl and the current transition to hybrid learning; the cohort of students in figure 1 change each year. figure 1: south african academic institution timelines as related to teaching and learning. amidst the covid-19 pandemic, academic success has remained one of the primary strategic objectives for most institutions of higher learning (zeineddine, braendle, & farah, 2021). with increasing operational costs and budget cuts from government subsidies, companies that sponsor students and general donors terminating their sponsorship contracts and general loss of income by guardians because of covid-19 (van schalkwyk, 2021), academic institutions need to pay more attention to clearly understanding factors that influence students’ performance and be able to address these in their planning and interventions. these interventions would facilitate throughput, thus institutions meeting their mandate. student retention in light of the covid-19 pandemic has also been a concern for institutions of higher learning; thus, enrolment and retention of enrolled students has also become a top priority for administrators of institutions of higher learning (zeineddine et al., 2021). high student dropout rates generally result in lower graduation rates and financial loss for both students and institutions. institutions that experience high dropout rates may also be ranked lower and their reputation amongst their peers be in disrepute (cardona, cudney, hoerl, & snyder, 2020). one of the main indicators and predictors of students’ success in academic institutions are the course marks that a student obtains at the end of the course. in south africa, most institutions of higher learning use both summative and formative assessments to arrive at course marks for students. the assessments are usually prepared by the lecturer and are moderated by both internal and external stakeholders. the examinations are usually administered by the university, and invigilators are selected by the university. the final course mark is made up of an accumulation of scores over the course period through various tests, practicals and the examination. the final mark is normally presented as a percentage mark, and in many institutions, it is released to the student by the faculty on behalf of the university. a mark of 50% and above in a course would generally be viewed as having passed the course and a mark below that would indicate failure. course marks are therefore one of the indicators of whether a student has completed a course successfully or not. institutions of higher learning currently have huge data sets collected over years that can be used to detect and understand unknown patterns and trends and other hidden variable relationships, using data mining techniques and tools. data mining has in the past been applied in various fields, for instance, health care, business and education. considering its success in prediction of various critical academic outcomes, performance, retention, success, satisfaction and achievement, data mining may also be applied in assessing the impact of covid-19 on students’ performance (alyahyan & düştegör, 2020). data mining and application of machine learning (ml) models for classification and analysis of data typically follow a data science approach, namely the cross industry standard process for data mining (crisp – dm), as shown in figure 2. figure 2: the cross-industry standard process for data mining (crisp – dm) approach to data mining. the first step in crisp-dm is business understanding, which refers to clearly understanding the problem and converting it to a well-defined analytics problem. the current dilemma in this research is to assess the effect of the covid-19 pandemic on speech–language pathology and audiology (slpa) undergraduate students under three predefined modes of learning, namely face-to-face teaching and learning, ertl and transitioning to hybrid teaching and learning. the second stage in this approach entails understanding of the data that are extracted or collected from the data warehouse that are essential in solving the identified problem. literature shows that prior academic achievements, student demographics, e-learning activities and psychological attributes and environment are the most commonly reported features or attributes that determine students’ success (alyahyan & düştegör, 2020). it is reported that 69% of literature articles focused on prior academic achievement and student demographics as a choice of attributes. to benchmark this study, demographic, financial and academic achievements were extracted. the third stage in the crisp-dm entails data preparation, where the decision of the data to be used for evaluation of the impact of covid-19 on students’ performance was made. existing literature (alyahyan & düştegör, 2020) was used in determining the criteria for the attributes (columns) and records (rows) that were suitable in answering the research question. the financial, academic and demographic data were merged for easy analysis and interpretation. the fourth stage is the modelling. the two common models used in student success models are predictive and descriptive. to generate patterns that define the basic structure and interconnectedness in students’ data, a descriptive model was firstly used. the most common techniques used are linear regression and logistic regression analysis. logistic regression is a simple and efficient technique for linear and binary classification models. it is a model that is easy to realise and provides good performance. logistic regression can be used for binary classification and class probability estimation (millar, 2011; tu, 1996). this analysis is commonly used to explain the relationship between a series of predicted variables and a binary variable, for example, whether a student passed or failed. logistic regression provides the best model that fits the correlation between dependent and independent variable sets (sinha et al., 2010; hashim, awadh, & hamoud, 2020). logistic regression is applied for a response variable (y) that tracks a binomial distribution (bielza, robles, & larrañaga, 2011). logistic regression output is defined generically by a probability distribution and has two values: 1 or 0 (madahana, ekoru, mashinini & nyandoro, 2019). clustering of students’ data applies to techniques such as k means clustering, which may be defined as one of the statistical and unsupervised analysis that can be performed on a huge data set. this method groups data into homogeneous classes; thus, hidden relationships and patterns can be observed and analysed from the data set. a cluster may be defined as a group of data objects with similar characteristics (shovon & haque, 2012). k means clustering is an unsupervised learning algorithm that groups data samples together depending on the attributes, also known as features, that they share. this results in a model that has data samples as inputs and the return groups or clusters that the new data point belongs to. the simplified algorithm is presented by shovon and haque (2012). the most commonly used classification algorithms are decision trees and random forest. decision trees are ml algorithms that apply the branching approach to demonstrate likely outcomes of a decision subject on determined parameters. a hierarchical arranged set of rules makes up the tree structure, which starts with the root attributes and ends with the leaf nodes. one or multiple outcomes from the original data sets represents each tree (guleria, thakur, & sood, 2014; hamoud, 2017). decision trees also have root nodes, internal nodes and terminal nodes (basu, basu, buckmire, & lal, 2019). on the other hand, random forest is a supervised ml algorithm that is constructed from decision trees. the random forest classifier is made up of a combination of tree classifiers, which are generated by using a random vector sampled independently (breiman, 2001). the other commonly used classification technique is the support vector machine (svm), which is a ml algorithm that is commonly used for regression and pattern classification (graf & wichmann, 2002). the basic operation of svms is obtaining an optimal linear hyperplane such that the error of unseen samples is reduced (chiu & huang, 2013; madahana et al., 2019). figure 3 shows the overall system diagram used for clustering the data sets and for building classification models. the raw data refer to the extracted students’ data, which then undergoes data cleaning, and then classification is conducted. evaluation is conducted to understand the data mining results. in this study, the patterns and trends observed in students’ performance are analysed. in the evaluation stage, the attributes that were excluded are discussed, as well as whether there is a need to use them in future. the final stage is the deployment where the model can be used. figure 3: clustering and classification of students’ data set. research method and design study design the research approach selected and applied to this study is a quantitative methodology utilising a correlational study design (creswell & creswell, 2017). the design was suitable because correlational studies attempt to establish the extent of a relationship between two or more variables using statistical methods. the chosen approach produces results that can be used in a predictive model, hence its appropriacy for this study. study population and sampling strategy data for 605 undergraduate students from the slpa departments were extracted from the university data warehouse. the data set consists of 95% (n = 576) female students and 4.8% (n = 29) male students, with age ranges from 18 to 36 years and a mean age of 24.8 in the sample. data collection raw data were obtained from an institution of higher learning in johannesburg, south africa. four years of institutional data for undergraduate students from 2018 to 2021 enrolled for sp&a degree programmes were extracted from the university data warehouse. variables were extracted that are typically cited in the literature to influence students’ performance, for example, financial, academic and demographic characteristics (alyahyan & düştegör, 2020). table 1 provides the definition of the attributes. the variable in table 1 includes the quantile ranking and different funding types. the quantile ranking system was implemented by the south african government to assist in redressing the past financial inequalities regarding educational funding in south africa. all south african public schools are placed into five categories, called quintiles, which are used for the application of financial resources. quintile 1 is the ‘poorest’ quintile whilst quintile 5 is the ‘least poor’. the quintile rankings are determined nationally according to the poverty of the community around the school and certain infrastructure factors (van dyk & white, 2019). a student may be self-funded or sponsored. self-funded students may be paying their own school fees, or their guardians may be paying the fees. students may be sponsored externally, for example, by a company or organisation. a student may also be sponsored internally, for example, through a staff bursary, faculty bursary or merit award that is sourced via the university’s financial aid and scholarship office. table 1: attributes extracted from students’ records. data analysis the data extracted from the university data warehouse had already undergone a thorough extraction, transformation and loading (etl) process. the data were loaded onto jupyter notebook in python, and the data cleaning process was conducted by deleting unusable columns of data, for example, incomplete columns of data sets from the biographical questionnaire. the extracted data were converted into a single file, with the columns representing the features and the rows representing students’ records. the attributes extracted and their definitions are given in table 1. the data consists of 5608 horizontal rows of data, also known as observations, of students’ performance for 4 years. the final course mark is known as the target feature, and it represents the feature that the researchers were interested in gaining a deeper understanding of, because it determines whether a student has passed or failed. a statistical approach to assess and compare learning algorithms by dividing data into segments (known as cross-validation) was used. a 10-fold cross-validation was run with a split of 80% and 20% randomly shuffled testing and training sets, respectively. the extracted data were analysed using k means clustering and random forest classification. the summarised data were presented in tables and graphs. ethical considerations this study involved the use of anonymised data to evaluate student performance. depersonalised attributes or features (for instance, course marks) were extracted from the database. the study followed all ethical standards of studies without direct contact with human or animal subjects. ethical clearance to conduct this study was obtained from the university of the witwatersrand, human research ethics committee (non-medical) (reference number: hrecnmw22/01/11). results and discussion in order to get general insights into the patterns and trends in the data set, a correlation matrix showing relationships between features in the data sets was drawn, as shown in figure 4. there is a need to understand the relationship between variables. each cell in figure 4 shows the correlation between two specific variables. features with a correlation number above 0.50 are considered to be strongly positive correlated, whilst features with negative numbers are weakly negative correlated, and numbers that are less than 0.006 are considered not to be correlated at all. the patterns observed on the correlation matrix indicated a correlation between students’ funding type and their final mark. there is also a positive correlation between self-funded students and the quintile. age was also observed to have a positive correlation with the final mark. therefore, from the correlation matrix, the students’ funding type, the courses registered by a student and age are viewed as important correlations. however, in the building of a student success or intervention model, features that introduce biases in the data set are not included. figure 4: correlation matrix indicating relationship between features. bar charts for overall students’ performance and performance per course were also drawn as shown in figures 5a to 5d. variations of average marks within the range of 5% are expected in student marks each year, because each cohort of students varies each year. the average performance of students can vary, even if the teaching practices remain the same. despite the sp&a courses being taught by qualified and experienced staff each year, variations in the course marks are still expected, because the cohorts of students are different each year. the p-value and the confidence interval may be used to determine whether the average marks variation are statistically significant or not. a p-value of less than 0.05 was considered as the threshold of whether the average marks were statistically significant or not. statistical significance does not imply practical significance; hence, further tests and interpretations are conducted for values deemed as statistically significant values. from 2018 to 2019, the average student performance was very similar for speech and hearing science (sppa1003a) and speech pathology and audiology (sppa1004a). there was then a slight increase in average marks for ertl and hybrid learning (2020 and 2021) for sppa1003 and sppa1004, as seen in figure 5a. figure 5: (a) first year students’ performance during face-to-face teaching and learning from 2018 to 2021, (b) course performance for second year, (c) students’ performance for third year and (d) students’ performance for fourth year. from figure 5b, audiology ii (sppa2001a) students’ average performance in 2020 and 2021 was lower compared with 2018 and 2019. there was also a slight drop in average performance for clinical practicals in audiology (sppa2005a) in 2020 and 2021. the sppa2004 was introduced in 2019, and sppa2002 was discontinued after 2018, hence the data are missing for those course codes. in third year, students performed better in clinical practicals in audiology (sppa3004a) in 2021 compared with 2018 to 2020. in speech–language pathology iii (sppa3005a), the highest performance was observed in 2020. the performance for sppa3005a dropped back to its usual average in 2021 (figure 5c). the sppa 3003 was discontinued after 2019; hence, there is no data on the course after 2019. finally, in fourth year, observations show an improvement in average marks for sppa4005 in 2020, as seen in figure 5d. the sppa4005 course was discontinued after 2020, hence the missing data in the year that follows. the sppa4007 course shows similar performance in 2018 and 2021, whereas in 2019 and 2020 average performance is similar. the variations could be because of factors other than the shift to ertl. the trends in the average marks plotted in the bar graphs (figures 5a to 5d) indicate an increase in average marks in 2020 and 2021 for courses with practical components, except for one second-year course (sppa2001) where there was a decrease in the average marks for a course with a practical component. whilst the obtained general information is instrumental in providing a general view of the class performance over the years, it does not provide enough details to account for the reasons for the increase or drop in marks. therefore, data are analysed further to obtain insights into students’ performance during face-to-face, ertl and hybrid learning by clustering the students using k means. clustering was conducted to determine the properties of the data set. the students were segmented into groups using k means. the elbow plot was used to determine the optimal cluster number that minimises the cost function, as shown in figure 6. from the elbow plot, the optimal cluster number is three. the vertical axis is labelled as within cluster sum of square (wcss) referring to wcss, which is defined as the sum of squared distance between each point and the centroid in a cluster. when the wcss is plotted with the k-value, the plot looks like an elbow. as the number of clusters increase, the wcss value will start to decrease. the wcss value is largest when k = 1, which is the optimal cluster selection. figure 6: the elbow plot for optimal cluster selection. each student in the entire data set was assigned to a cluster label. figure 7 shows the clusters that were obtained using third-year students as an example. figure 7: third-year clusters from 2018 to 2021. figure 7 shows three distinct priority classes in the students’ marks from 2018 to 2021. these priority classes are further broken down, as shown in table 2. table 2: students’ performance milestones. the change in students’ final course marks was the determining factor in classification into the level of priority. the classes in table 2 can be used in the prediction of whether a given student will be able to complete the academic year or not, depending on their classification. low-risk students are viewed to be generally performing well in their studies and they need minimal intervention; medium-risk students need intervention at a high level, which may be administered in a group setting. however, high-risk students are perceived to have various challenges with the courses and urgent intervention based on ‘one-on-one’ intervention may be required. at this point, the clusters still do not provide much information about the students’ attributes. in order to customise students’ interventions, it is important to understand the attributes that characterise each cluster. information within the cluster is obtained using the random forest classifier. figure 8 is an example of attribute extraction that was conducted using random forest. the main attributes that were found to affect students’ performance in the fourth year in 2021 are listed in order of priority starting with the age, quintile, sppa4006 and funding. the first four attributes will be considered to be significant. the attributes are important because they provide the state of ‘academic health’ for a student. for example, if a student is self-funded and from a lower high school quintile (1, 2, 3), the department of sp&a will need to closely monitor the performance of this student, because the student is likely not to perform well. one of the courses that can be used to monitor students’ performance in fourth year would be the observed performance in sppa4006a. the students’ performance in sppa4006 strongly influences the performance in the other courses and the performance in their entire fourth year. figure 8: fourth-year 2021 important attributes. classification of the data using random forest results is the ability to recognise the hidden patterns and trends in the data set, as shown in table 3. the attributes vary depending on the year of study. table 3: attributes in order of importance. the clusters were created using the attributes extracted and listed in table 1. random forest classifier was applied in order to understand the hidden information in each cluster for each year of study from 2018 to 2021. the observed patterns can be summarised as follows: self-funded students from lower quintile high schools (1, 2 and 3) generally performed poorly from 2018 to 2021. whereas, self-funded students from higher quintile schools (5, 6, 7) performed very well. this study does not consider whether the self-funded students paid their own tuition fees or if the tuition fees were paid by their guardians. to understand and illustrate this finding further, figure 9, is plotted to show the relationship between quintiles, funding and students’ performance. from 2018 to 2021, the age and high school quintile remained the priority factors for all the undergraduate students from first year to fourth year. funding was observed to have a very low priority from 2018 to 2019 in determining a student’s performance; however, from 2020 to 2021, funding increased in priority and it influenced students’ performance. in 2018 and 2019, sppa1003 had a lower priority; however, in 2020 and 2021, its priority increased and it became one of the key courses in first year that determined a student’s performance in first year. the sppa2001 course influenced students’ performance in 2018, 2020 and 2021. in fourth year, sppa4006a was a priority factor in 2018, 2019 and 2021. figure 9: relationship between self-funded students, the quintile and performance. these results indicate that one of the impacts of covid-19 on sp&a students was having the financial health status of a student becoming one of the priority attributes that determined their success. self-funded students from lower quintiles were affected more than self-funded students from higher quintiles. this is expected, because some of the effects of covid-19 in south africa were budget cuts and loss of income from different sectors. institutions of higher learning were not an exception. it is not clearly understood from the data why sppa1003 (speech and hearing science), sppa2001 (audiology) and sppa4006 (research report) became priority courses during the contact and blended learning. careful deliberation of the content of these courses is required to ensure that the teaching and learning approaches adopted are responsive, relevant and responsible. the general insights and the important attributes from the clusters may be used in development of sp&a undergraduate students’ performance tracking system. a comparative analysis was also carried out using various classification techniques to establish the model that is suitable for the students’ data set. the results are shown in table 4. table 4: model performance. the significance of the analytics in this study is that they can be used by various stakeholders to make predictions of student performance and be able to implement intervention strategies for students in a timely manner. the analytics indicate that each study approach has its own merits and demerits, and the different population groups of students are affected by the choice of one model of learning over the other. a hybrid type of learning would be more suitable because it is more flexible. although this study was prompted by the global negative effects of covid-19 on teaching and learning (maital & barzani, 2020), current findings raise important implications going beyond covid-19 if the hybrid model of teaching and learning remains part of standard practice. within the slpa programmes, where traditionally only face-to-face was the adopted model, the implications of these findings speak to areas requiring supportive measures for both access and success. the current findings were obtained using data from the slpa programmes, however, the results can also be applied as evidence of south african colonialismhigher learning institutions, as described by mgqwashu (2017) and mpungose (2020). if financial status in the form of self-funding is a critical factor in the performance of students during remote teaching and learning, as found in this study, it is important for institutions of higher learning to ensure that (1) students have funding; (2) they intensify their investment in digital technologies and digital literacy for both staff and students (garcía-morales et al., 2021); (3) the department of higher education and training engages in and solidifies intersectoral collaboration with other relevant departments such as the department of communications to facilitate students’ access to information and communication technology (ict) resources and support for learning (francis et al., 2020); (4) zero rating of all course material is negotiated as a standard nationally, without the current reported disconnect between sites that are zero rated and relevant etrl relevant course material (mhlanga, 2020; tenet, 2021); (5) considerations are always made around power supply challenges such that students are not disadvantaged by load-shedding, which also affects connectivity that is beyond their control during remote learning (azionya & nhedzi, 2021; laher et al., 2021; oyedotun, 2020); (6) models of training forming part of remote teaching and learning as part of hybrid methodology such as telepractice, teletraining and use of simulations (khoza-shangase et al., 2021; nagdee et al., in press) are carefully monitored for efficacy; and (7) psychosocial aspects such as gradual instead of abrupt change to remote teaching and learning (thaba-nkadimene, 2020), as well as provision of effective peer support and engagement platforms are considered (chandra & palvia, 2021). limitations of the study it is assumed that the average performance can vary even if the teaching practices remain the same. despite the sppa courses being taught by qualified and experienced staff each year, variations in the course marks are still expected because the cohorts of students are different each year; therefore, definitive conclusions based on current data are limited, thus raising implications for future confirmatory research in this area. some attributes (for instance, gender, disability, nationality and marital status) are analysed as attributes that affect student performance; however, in the future development of the ml model, these attributes are not included to avoid biases in the model. for self-funded students who have to work to pay their school fees, their specific performance based on this unique feature is not analysed in this study, which is thus an implication for future studies. the impact of race on student performance with respect to covid-19 has deliberately been left out of this publication, even though it is well documented that attributes such as financial health remain racially linked in south africa. this will be the focus in a future study. recommendations and conclusion according to the comprehensive analysis of the data sets, a novel approach in this field, both traditional methods of learning and online learning have their merits and demerits. amalgamating the merits of both types of learning would result in a system that is easy for both students and lecturers or course instructors to navigate. transitions towards blended or hybrid learning will require stakeholders to identify and merge the positive aspects from the online learning and face-to-face learning platforms. the covid-19 pandemic has accelerated south africa’s institutions of higher learning towards thinking about how to develop robust technological infrastructure that can be used alongside the traditional methods of teaching. the huge amount of data sets that institutions of higher learning have collected over the years can be used to analyse trends and patterns in students’ performance. this study has demonstrated how this can be done through ml, using slpa as a case study. with this in mind, some of the questions that the slpa programmes and institutions of higher learning generally will need to look at are: how can learning and teaching be improved to support student success? which approach would be suitable to ensure students’ academic success? which social, psychological and economic factors affect students, and what are the ways in which the students can work with the university to resolve the challenges? which learning approaches are better suited for students, and is there a difference in these based on year of study? the ml model can be used in implementation of an early warning and recommendation system that ensures that administrators provide early intervention to a student who is not performing well. however, it is important to note that features that would introduce biases in the data sets (for example, race, age, nationality, marital status and nationality) would not be included in the ml models. in future, the attributes that have been observed to have an influence on students’ performance will be used in the building of an early intervention model to help the course instructors and administrators in identifying students who are not coping with their workload and provide interventions. in the early intervention model, features that introduce biases in the data will not be included. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions m.c.m., k.k-s., n.m., o.n. and j.e. contributed equally to this work. funding information the authors thank the national institute for the humanities and social sciences for providing financial assistance for the publication of this manuscript. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references alyahyan, 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(2021). enhancing prediction of student success: automated machine learning approach. computers and electrical engineering, 89, 106903. https://doi.org/10.1016/j.compeleceng.2020.106903 abstract introduction research method and design results discussion conclusion acknowledgements references about the author(s) casey j. eslick department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa esedra krüger department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa alta kritzinger department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa citation eslick, c.j., krüger, e., & kritzinger, a. (2022). exploring swallowing, feeding and communication characteristics of toddlers with severe acute malnutrition. south african journal of communication disorders, 69(1), a874. https://doi.org/10.4102/sajcd.v69i1.874 note: additional supporting information may be found in the online version of this article as online appendix 1. original research exploring swallowing, feeding and communication characteristics of toddlers with severe acute malnutrition casey j. eslick, esedra krüger, alta kritzinger received: 22 nov. 2021; accepted: 01 aug. 2022; published: 31 oct. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: severe acute malnutrition (sam) is associated with cognitive and motor deficits. little is known about the swallowing, feeding and communication characteristics of hospitalised toddlers with sam, limiting the abilities of speech-language therapists to provide effective early intervention. objective: to explore the background, swallowing, feeding and communication characteristics of toddlers with sam during in-patient nutritional rehabilitation. method: an exploratory, prospective, collective case-study was conducted with three hospitalised toddlers who were 12–18 months old and independently diagnosed with sam, at least 1 week after transitioning to oral feeding. detailed case histories were compiled through medical file perusal and parent interviews. cross-sectional clinical bedside assessments were completed with the rossetti infant-toddler language scale and schedule for oral-motor assessment. results: all three participants had a history of feeding difficulties before admission. despite intact pharyngeal swallows, heterogeneous oral-sensorimotor dysfunction and disruptive feeding behaviours were identified. risk for oropharyngeal dysphagia indicates the need to modify dietary consistencies to prevent prolonging recovery or sam relapse. participants had mild-to-moderate language delays, particularly in interaction-attachment, play and language comprehension, with an atypical moderate receptive and mild expressive language delay profile. none of the participants were referred for speech-language therapy. conclusion: this exploratory research showed the oral-sensorimotor skills, swallowing and communication characteristics of children with sam. speech-language therapists could address oral-sensorimotor functioning, feeding difficulties and communication interaction delays before discharge to community-based management for sam. further investigation with a larger sample size is recommended. contribution: novel description of the oral-sensorimotor skills for feeding and the communication development of three severely malnourished toddlers with hiv and tuberculosis co-infection was presented. the complexity of the three cases is highlighted. keywords: communication difficulties; early identification; oral-sensorimotor dysfunction; oropharyngeal dysphagia; severe acute malnutrition; speech-language therapist; swallowing and feeding characteristics; toddler. introduction the pathophysiological response to severe acute malnutrition (sam) – the most severe form of undernutrition – reduces immunity, impairs growth and delays neurodevelopment, undermining children’s educational and economic potential (iannotti et al., 2016; world health organization [who] & united nations children’s fund [unicef], 2009). as a consequence of severe nutritional deficiency within a short period, structural brain changes disrupt neuro-cognitive development (bhargava & singh, 2020). research in sub-saharan africa identified delayed development of executive functioning, learning memory, motor and communication skills (prado & dewey, 2014; ruiseñor-escudero et al., 2016; sudfeld et al., 2015). timely medical management of sam according to who 10-step guidelines reduced case fatality rates in south africa from 30 to 40% to less than 15% (ashworth, khanum, jackson, & schofield, 2003; who, 2013). however, survivors experience long-lasting developmental delay, which has implications for rehabilitation services (iannotti et al., 2016). although motor and communication delays are reported (east et al., 2019), it is not known how swallowing, oral-sensorimotor function and language development are affected by sam in young children. further detailed description is needed to inform speech-language therapists (slts) service delivery for this vulnerable population. severe acute malnutrition is a preventable condition defined as a weight-for-height z-score (whz) below three standard deviations, mid-upper arm circumference less than 11.5 cm and/or presence of bilateral pitting oedema (who, 2013). commonly characterised by delayed growth, low weight, muscle wastage, poor appetite, recurrent illness, fatigue, vomiting, diarrhoea, dehydration and irritability in children (who, 2013), sam is the result of multiple cascading biological and psychosocial risk factors. akombi et al. (2017) summarised the risk factors including male gender, low birth weight and size, diarrhoea and illness, non-exclusive or short duration breastfeeding (bf) and young maternal age. there is, however, little research available regarding maternal pregnancy, maternal health and birth history of young children with sam. multisectoral causal factors at the household level are strongly associated with intergenerational poverty (itaka & omole, 2020; who & unicef, 2009). south african research identifies poor individual health, inappropriate feeding practices, poor access to healthcare, water, hygiene and sanitation services, inadequate maternal education and low socio-economic factors as risks for underweight-for-age in children (chopra, 2003; lesiapeto, smuts, hanekom, du plessis, & faber, 2010). furthermore, the coronavirus disease 2019 (covid-19) pandemic increased unemployment rates, reduced household income, heightened food insecurity and disrupted essential routine healthcare services (nyashanu, simbanegavi, & gibson, 2020). consequently, aggravated risk factors for undernutrition exacerbate challenges to address poor maternal and child health, communicable disease epidemics such as human immunodeficiency virus (hiv) and tuberculosis (tb), high prevalence of non-communicable diseases and trauma or injury (hofman & madhi, 2020). these factors are recognised as the quadruple burden of disease, which characterise the south african healthcare context. as both causes and consequences of malnutrition, a high prevalence of hiv and tb co-infection challenges the systematic treatment of sam and underlying conditions. a high hiv prevalence of 40–50% is reported among children treated for sam in south africa (de maayer & saloojee, 2011; muzigaba, sartorius, puoane, van wyk, & sanders, 2017). the majority of children only receive an hiv and/or tb diagnosis after admission for sam, and the similarities of symptomatic presentation between hiv, tb and sam challenge treatment initiation (de maayer & saloojee, 2011; muzigaba et al., 2017). this delay is concerning because delayed initiation of highly active antiretroviral therapy (haart) anti-tb medication can cause and/or exacerbate malnutrition (who, 2013). additionally, children with hiv or hiv exposure are shown to be at a higher risk of morbidity and mortality (de maayer & saloojee, 2011). furthermore, nutritional rehabilitation progress is shown to be impacted by hiv status and hiv disease stage (muzigaba et al., 2017). similar to the sequelae of sam, hiv poses a high risk of neurodevelopmental compromise, affecting physical growth, gross and fine motor, social and language domains in young children (gómez et al., 2018; ndiaye et al., 2021). severe acute malnutrition, hiv and tb co-infection can increase the risk of mortality (de maayer & saloojee, 2011). interaction of biological factors within the child and inappropriate feeding practices by the caregiver, play a role in sam, which may consequently delay maturation of feeding skills and increase the risk for oropharyngeal dysphagia (opd). early bf cessation and introduction of solids before 6 months, as well as insufficient quantities of food are associated with sam in south africa (itaka & omole, 2020). these poor feeding practices, in addition to inadequate dietary variety (food types and consistencies), indicate children’s environment may lack adequate oral-sensorimotor experiences for maturation of feeding and swallowing skills (arvedson, brodsky, & lefton-greif, 2020). respiratory rate changes in respiration-related illnesses such as bronchiolitis or tb, which commonly co-occur with sam, can further increase the risk of opd (barbosa, gomes, & fischer, 2014). furthermore, motor delays associated with sam may contribute to oral-sensorimotor dysfunction, thereby disrupting co-ordination of the swallowing sequence, compromising safety and efficiency and resulting in opd (dodrill & gosa, 2015). speech-language therapists play a central role in early in-patient management of swallowing and feeding difficulties to address possible opd when transitioning to oral feeds (arvedson et al., 2020; barbosa et al., 2014). speech-language therapists may therefore support the sam management team to prevent opd exacerbating challenges to achieve nutritional goals, shorten hospital stay and reduce the risk of relapse. children with sam are known to present as hypotonic, weak and lacking stamina during acute recovery (arvedson et al., 2020). however, there is a paucity of research on the swallowing and feeding characteristics of young children with sam during in-patient nutritional rehabilitation. the updated who treatment protocol for sam (who, 2013) calls for community-based management. in south africa, implementation of this sam management protocol means that out-patient toddlers with sam may have limited access to slt services, which are centralised at hospitals (nyashanu et al., 2020). hospital-based slts, therefore, require an in-depth understanding of the oral feeding and communication characteristics of toddlers with sam to render holistic services to affected families before discharge in areas where slt services are scarce. the following research question was proposed: what are the characteristics of the backgrounds, swallowing, feeding and communication of three toddlers with sam during in-patient nutritional rehabilitation? research method and design aim and design an exploratory, prospective, collective case-study design was used to describe the backgrounds, swallowing, feeding and communication characteristics of three toddlers with sam during in-patient nutritional rehabilitation. cross-sectional, quantitative, structured parent interviews and participant assessments are described for three cases. setting bedside assessments were conducted in the paediatric medical ward of a tertiary hospital in june 2021. along with doctors and nursing staff, a paediatric multidisciplinary team (mdt) is available including slts, audiologists, dieticians, physiotherapists, occupational therapists, social workers and psychologists. rehabilitation services before discharge include transitioning toddlers to ready-to-use therapeutic food (rutf) and modified family meals, co-ordination of a stimulation programme, structured play by an occupational therapist and/or physiotherapist, and involving the mother in feeding, childcare, and stimulation activities as recommended by guidelines (ashworth et al., 2003; department of health [doh], n.d.). participants the researcher visited the paediatric ward of the hospital, communicated and confirmed with the referred dietician to determine potential participants for the study. cases were utilised as presented at the time of investigation. three toddlers (mean age 1 year 4 months) with sam, independently diagnosed by paediatricians according to the who’s definition of the condition, were selected purposively (who & unicef, 2009). all three toddlers were in the rehabilitation phase – steps 8 to 10 of the who standard 10-step sam management guidelines (see online appendix 1; who, 2013), feeding orally for at least 1 week, with weight gain and discharge preparation being the priority. the managing paediatrician and dietician confirmed toddlers were medically fit to participate, meaning that toddlers were not in the acute phase and had moved to the rehabilitation phase of sam recovery (who, 2013) where there was no longer life-threatening risk. mothers of toddlers required english language proficiency to answer background information questions. characteristics of the participants are shown in table 1, including that participants had normal birth weight and were each diagnosed with hiv and tb co-infection. hiv infection was confirmed by medical practitioners using hiv pcr tests. all three participants were established as seropositive and received haart after their initial hospital admissions. in the toddlers’ road to health booklets, no notes indicated the prescription of nevirapine which is used to prevent mother-to-child transmission of hiv during bf. medical practitioners diagnosed tb using tuberculin skin tests and induced sputum or gastric washings for tb microscopy. according to participants’ medical files, based on parent report, all participants presented with delayed developmental milestones (table 1). clinical care and treatment procedures followed the who standard 10-step guidelines for management of sam (ashworth et al., 2003; who, 2013) (online appendix 1). feeding progressed with f75 formula, a therapeutic milk product low in protein and sodium and high in carbohydrates used during initial management of sam. at the time of data collection, all participants were drinking f100 formula by cup and were being prepared for discharge, including receiving frequent physiotherapy sessions. all participants were recently referred to occupational therapy and intervention was because pf begin the next week. speech-language therapist assessment was not conducted by hospital staff. table 1: toddler characteristics per case (n = 3). the three mothers were hiv positive, two of which defaulted arv treatment during pregnancy and are also tb co-infected (table 2). participant 3’s mother reported attending three antenatal visits. none of the mothers attended the prescribed number of antenatal appointments. participants 1 and 3 were born in april 2020 during south africa’s highest covid-19 lockdown measures. all mothers expressed they had sufficient support during pregnancy as well as to fulfil current child care responsibilities. table 2: maternal characteristics per case (n = 3). all participants reside with their mothers in informal houses with varying socio-economic status-related characteristics (table 3). despite monthly income levels above the lower-bound poverty line (pl), all mothers expressed experiencing regular food insecurity, which impacts their feeding practices. the mothers reported no substance use (smoking, alcohol or drugs) in their households. table 3: socio-economic status-related characteristics (n = 3). data collection materials and procedures background information sheet a structured background information sheet was used to extract relevant information as quantitative data, from medical file perusal and thereafter, parent interviews. compiled questions were adapted from fuls (2019), kritzinger (2012) and van der linde, swanepoel, glascoe, louw and vinck (2015), relating to demographics, ses, early developmental factors as well as feeding practices. further considerations of disruptive feeding behaviours were inferred from arvedson et al. (2020). mothers were shown a picture chart and asked to point out if they consider their ses to be low, middle or high, and to disclose their actual household income which was interpreted according to the 2021 national food poverty lines. detailed social work notes in medical files were used to corroborate social and demographic information. the schedule for oral motor assessment the schedule for oral motor assessment (soma) (reilly, skuse, mathisen, & wolke, 1995) was used. the tool has been shown to successfully assess oral-sensorimotor functioning across a variety of consistencies with south african infants (fuls, krüger, & van der linde, 2020; lalbahadur, 2018). strong content validity, adequate construct and predictive validity, intra-rater and test-retest reliability, with 85% sensitivity have shown that the soma is an appropriate tool to assess oral-sensorimotor functioning for feeding in children who are eight to 24 months old (barton, bickell, & fucile, 2018; reilly et al., 1995). since publication of the soma, which refers to oral-motor functioning, the term oral-sensorimotor functioning is used to holistically describe motor co-ordination and sensory integration required for feeding (arvedson et al., 2020). data were collected by an slt with experience in assessment of swallowing and feeding of young children. face-to-face ratings were used to assess feeding and swallowing skills, specifically, oral-sensorimotor function related to voluntary oral preparation – duration of bolus formation, bolus manipulation and oral transit, as well as initiation of pharyngeal swallow through tongue base propulsion. the following consistencies were rated using the food items specified: liquid (bottle, sippy-cup and/or open cup) – breastmilk, formula or water; puree – yoghurt; semi-solid – soft porridge; solid – butternut cubes; and cracker – ginger biscuits or nuttikrust biscuits. this research used the same food items for the soma as recommended by fuls et al. (2020), who adapted ‘unknown foods’ from the soma, to foods recognised in the south african setting. oral-sensorimotor functions such as upper and lower lip involvement for food removal, lip closure around food for removal and to prevent food loss, tongue protrusion, jaw stabilisation sufficiency and controlled sustained biting were observed. established clinical signs of aspiration such as increased respiratory rate, audible breathing, shallow breathing, coughing, throat clearing, drooling, watering eyes, ‘wet’ vocalisation or choking (arvedson et al., 2020) after pharyngeal swallow initiation were recorded. the rossetti infant-toddler language scale communication interaction, including pre-verbal and verbal skills, was assessed with the criterion-referenced rossetti infant-toddler language scale (ritls) (rossetti, 2006). the comprehensive tool was previously used with a south african population (van der linde et al., 2015) and is appropriate for children from birth to 36 months. the ritls identifies different developmental levels in 3-month intervals across the pragmatics, gesture, play, language comprehension, language expression and interaction-attachment domains. because of health and safety restrictions in the hospital during the covid-19 pandemic, the researcher relied on observation to identify communication interaction skills. parental reports and elicitation of communication interaction with the same set of toys were supplemented only when required. analysis information from the structured background information form was summarised descriptively and relevant data were tabulated. as per the soma protocol and scoring criteria, the researcher rated the swallowing behaviours of the second trial (bite) of each consistency as this is considered a more reliable presentation of oral-motor skills and swallowing behaviour (reilly et al., 1995). a cut-off score was used to categorise the behaviours per consistency as functional or oral-motor dysfunction. furthermore, oral-sensorimotor skills were considered across consistencies as well as discrete oral-sensorimotor behaviours for feeding. communication skills in each domain of the ritls were evaluated across 3-month intervals, working backwards from the participants’ age intervals to establish their developmental levels (when all skills are performed at that interval). if no developmental level was identified, existing skills were considered emerging. if the established developmental level of any domain is two intervals or more below the chronological age, the participant was considered to present with a communication delay categorised as mild (6 months), moderate (6–12 months) or severe (12–15 months). according to ritls guidelines (rossetti, 2006), typical language development is attributed to achievement of skill levels 3 months below or above the expected level of functioning for the participants’ age. the global basal communication level is interpreted as the highest level where all items of each domain are achieved. ethical considerations approval to conduct the study and collect the data was obtained from the university of pretoria, faculty of humanities, research ethics committee, reference number: hum009/0320 and the kalafong provincial tertiary hospital (kpth), reference number: kpth 17/2020. voluntary informed consent was obtained from mothers (≥ 18 years) to peruse medical files, conduct interviews and assess the toddlers. mothers were aware that they could refute questions and/or withdraw consent anytime without elucidation. results feeding history none of the participants received neonatal intensive care or tube feeding after birth. all had average birth weight and breastfed immediately. participant 2’s mother reported pain at the start of bf, which resolved when nursing staff proposed position changes during feeding. table 4 summarises the reported past and current feeding practices per case and maternal perceptions including reasons all mothers stopped exclusive bf. all mothers reported that participants’ feeding currently influences the family at mealtimes negatively because of disruptive feeding behaviours, which include food refusal, avoidance and moving away, slow eating, and use of distraction, and force-feeding. participants had two-to-three meals on average per day. no additional snacks were reported, indicating daily intake being inadequate for nutritional requirements to support typical child development. the dietician noted that all participants experience limited dietary diversity at home. table 4: reported feeding practices and maternal perceptions per case (n = 3). swallowing characteristics: schedule for oral motor assessment during the soma, and confirmed by an independent physiotherapy assessment, it was observed that participant 1 does not have sufficient postural control to sit independently (table 1), indicating a severe gross motor developmental delay. participants 1 and 3 reclined on their mother’s lap for support to feed while participant 2 sat independently throughout most of the evaluation. arvedson et al. (2020) describe that toddlers who are 13–18 months old should sit or stand independently to eat, predominantly self-feed, swallow with lip closure, demonstrate lateral and vertical tongue movements and gather food into a bolus with their tongue. appropriate lip movement with rotary chewing should be used with no anterior food loss and food should be cleared off lips independently (arvedson et al., 2020). furthermore, all food consistencies should be tolerated. the participants in this study were all diagnosed with heterogeneous oral-sensorimotor dysfunction affecting food acceptance, bolus preparation, formation and propulsion, across a variety of consistencies (table 5). all mothers were observed to clean participants’ lips and face frequently during feeding. table 5: observed feeding skills and behaviours according to the schedule for oral motor assessment per case (n = 3). despite intact pharyngeal swallow responses, all participants presented with oral-sensorimotor dysfunction in the oral preparatory phase of swallowing. difficulties with jaw opening and stabilisation, food removal with lips (particularly lower lip), sustained bite, tongue protrusion and lateralisation, bolus manipulation and mastication were observed. poor lip closure was observed during the pharyngeal phase of swallowing. participant 3 presented with oral-sensorimotor dysfunction when drinking from an open cup. difficulties included the absence of lower lip support to the cup resulting in uncoordinated swallows, anterior spillage, multiple swallows and the observable reaction of panic when milk enters the mouth. participants 1 and 3 presented with oral-sensorimotor dysfunction when eating purees and semi-solids, showing insufficient jaw opening, difficulty with regular chewing actions, tongue protrusion, anterior food loss and pocketing. participant 1 presented with a single cough and participant 3 presented with wet vocalisation soon after initiation of the pharyngeal swallow response with semi-solids, suggesting risk for aspiration. participants 1 and 3 swallowed small butternut cubes whole. all participants presented with oral-sensorimotor dysfunction in the oral preparatory phase when eating a cracker. participant 2 showed poorly graded jaw opening, insufficient strength to sustain the bite, anterior drooling, sucking and reliance on the cracker getting soft, difficulty lateralising tongue, poor lip control and rotary movements of the jaw during chewing and severe pocketing in the buccal sulci. in the pharyngeal phase, multiple swallows and anterior food loss were noted. mothers reported drooling onset between 1 and 3 months before hospital admission. during bedside assessment, drooling of mild-moderate severity was identified with all participants, particularly during feeding. this suggests poor lip closure, which may be associated with fatigue, limited endurance or delayed motor skills. participants’ observed disruptive feeding behaviours included food refusal, holding food in their mouth, slow eating, and combinations of distraction and force-feeding by the mothers. communication characteristics: rossetti infant-toddler language scale the ritls showed that all three participants experience mild-to-moderate receptive-expressive language delay (table 6). participants had the most difficulty with interaction-attachment, gestures, play and language comprehension. mothers of participants 2 and 3 explained that their children do not say many words because they are sick and ‘too small’. mothers of the participants reported that no newborn hearing screening was received. participants 1 and 3 reportedly experienced recurrent middle ear infections; however, they were discharged before hearing screening could be conducted. table 6: rossetti infant-toddler language scale results per case (n = 3). discussion this exploratory study provides a detailed description of swallowing, oral-sensorimotor function and communication development in a collective case-study of three hospitalised toddlers independently diagnosed with sam. the description is relevant for slts practising in early communication intervention as well as the multi-disciplinary team. the toddlers presented with a triad of sam, hiv and tb co-infection. because of multiple data collection tools, a rich data set for each case could be described. findings of heterogeneous oral-sensorimotor difficulties were identified with graded jaw opening, stabilisation, food removal, accurate tongue placement, lateralisation, and elevation for bolus manipulation, and sustained bite in the oral phase. additionally, poor lip closure with multiple swallows was observed in the pharyngeal phase of swallowing indicating a need for dietary consistency modifications. clinical signs of aspiration during the soma suggest risk for opd. disruptive feeding behaviours were also observed. mild-to-moderate language delays were identified in all domains of the ritls for all participants – except participant 2’s pragmatic skills, which should be monitored. an atypical receptive-expressive language delay profile is highlighted, with moderately delayed language comprehension and mild expressive language delay only (owens, 2020). background, feeding history and developmental considerations outstanding information available in the case histories of all participants was their diagnosis of hiv at their initial hospital admission as well as tb co-infection. prior south african research demonstrated that 54% of children in the sample were diagnosed with hiv at hospital admission (de maayer & saloojee, 2011). the late hiv-diagnosis is notable considering recent advances in south africa’s prevention of mother-to-child transmission (pmtct) campaign at clinics. prevention of mother-to-child transmission failure in participants may be attributed to social-behavioural strategies for the covid-19 pandemic as the need for social distancing, transport difficulties and stigma led to avoidance of health facilities (hofman & madhi, 2020; nyashanu et al., 2020). active tb and hiv, previously managed at clinics, were diagnosed for all participants during hospital stay. this delayed identification further highlights how covid-19 restrictions disrupted essential screenings at clinics to address south africa’s quadruple burden of disease (hofman & madhi, 2020). the effects of disrupted maternal and child healthcare services are further underscored as mothers of participants 1 and 3 missed immunisations and baby wellness appointments, which may have identified poor anthropometry earlier. although participants were initiated on bf, they were not currently breastfed. participants 2 and 3 stopped bf before 6 months old. short exclusive bf duration and suboptimal dietary diversity are known risks for sam, which may have played a role in participants’ poor anthropometry and nutrition (akombi et al., 2017; chopra, 2003). because research with hiv-exposed-uninfected infants shows that appropriate bf practices can modify poor infant growth associated with maternal risk factors (ndiaye et al., 2021), the low adherence to bf recommendations is concerning. improved clinic attendance may have prevented early bf cessation and increased dietary diversity through maternal education. the identified poor feeding practices are compounded by social risks including limited access to healthcare, hygiene and sanitation, and low maternal education and literacy, along with hiv and tb co-infection. these risk factors are congruent with established risks for undernutrition in south africa as well as sam internationally (chopra, 2003; lesiapeto et al., 2010; who & unicef, 2009). although risk factors for undernutrition are identified, it is important to understand how biological and environmental risks contribute to precipitating and perpetuating factors of sam in south africa’s context with quadruple burden of disease. further research is required to understand the interplay of mother and child individual health, burden of hiv and tb co-infection, and household socio-economic conditions, placing young children at risk of sam in south africa. delayed gross-motor skills of participants 1 and 3 resulted in poor postural control and alignment for feeding, contributing to coughing, wet vocalisations and a risk for aspiration (arvedson et al., 2020). prior research with wasted children (whz < -2) and children with sam (whz < -3) highlight motor delays, hypotonicity, limited endurance and observed disruptive feeding behaviours congruent with the current findings (saldan, demario, brecailo, ferriani, & mello, 2015; sudfeld et al., 2015). potentially progressive motor delays can limit environment exploration and inhibit sensory, cognitive and language stimulation (prado & dewey, 2014). the findings outline the importance of slt collaboration in the paediatric mdt (south african speech-language-hearing association [saslha], 2017) for the management of young children with sam’s swallowing, feeding and communication development. swallowing characteristics the heterogeneous oral-sensorimotor dysfunction affecting controlled jaw opening, stabilisation, tongue placement and co-ordination, sustained bite in the oral phase and poor lip closure in the pharyngeal phase, highlights participants’ low muscle tone and weakness known to be associated with sam (arvedson et al., 2020). as seen in this study, increased respiratory effort due to tb reduces endurance, and may contribute to delayed initiation of swallow, extended pauses, reduced lip closure for oral inspiration and increased respiratory rate while feeding (barbosa et al., 2014). participants appeared to experience extended feeding times, increasing energy use, which may prolong nutritional recovery. the description of oral-sensorimotor dysfunction contributes novel information that toddlers with sam are at risk for opd after transitions to oral feeding and possible aspiration pneumonia, which may extend hospital stay (dodrill & gosa, 2015). the findings indicate the importance of continued research to inform the role of slts in early intervention for this vulnerable population during hospitalisation. anterior drooling was identified and may be related to poor oral muscle tone and co-ordination, opd and/or open-mouth posture because of tb-related respiratory difficulties (montgomery et al., 2016). these difficulties impact swallowing and speech development (arvedson et al., 2020). drooling is therefore a characteristic that health care professionals can observe as an indicator to refer for slt assessment. low muscle tone contributing to oral-sensorimotor dysfunction and drooling may be attributed to neurological changes in the brain resulting from sam and hiv interactions, specifically impacting motor development and control (arvedson et al., 2020; bhargava & singh, 2020; ruiseñor-escudero et al., 2016). findings of oral-sensorimotor dysfunction and drooling indicate that risk for opd was not identified as a contributing factor. referral for specific slt management is thus required. the findings show that children with sam, hiv and tb co-infection can experience oral feeding difficulties after acute medical treatment, thus indicating the importance of early slt involvement. speech-language therapists should provide earliest holistic swallowing and oral-sensorimotor intervention (barbosa et al., 2014). in this collective case-study, none of the participants were referred for slt assessment at the time of data collection. consequently, oral-sensorimotor dysfunction contributing to feeding difficulties and disruptive feeding behaviours were not identified for early intervention. because of high slt caseloads children with sam may not be seen timeously by an slt during acute treatment. in tertiary hospitals where slt services are readily available, slts should typically be involved to assess safety of swallowing and feeding when transitioning patients to oral feeding. findings of this study show that late referral can result in missed opportunities to advance children’s development. referral to slt services for assessment and/or intervention should be included in sam management guidelines (doh, n.d.; who, 2013). communication characteristics all participants experienced mild-to-moderate language delays. central nervous system viral infection as a result of hiv infection, as well as sam (whz < -3) and wasting (whz < -2) in children impair cognitive, behavioural, language and motor development of young children who learn through play (gómez et al., 2018; ruiseñor-escudero et al., 2016; sudfeld et al., 2015). hiv infection significantly impairs development of executive function, working memory and recall for learning, thus impacting children’s abilities to acquire language knowledge (ruiseñor-escudero et al., 2016). poor motor development and fatigue limit play, environmental exploration and interaction opportunities with caregivers to develop receptive language (iannotti et al., 2016; prado & dewey, 2014). these limitations may contribute to the particpants’ uncommon profile of better expressive language skills. as a result of nutritional deficiency, toddlers may be functionally isolated. toddlers may not initiate interactions to receive language input and mothers initiate less because of toddlers’ lack of responsiveness (east et al., 2019). early communication intervention can successfully resolve functional isolation and repair mother-child interactions (itaka & omole, 2020). the pathophysiological effect of sam and hiv on neurodevelopment likely exacerbated delays shown in interaction-attachment and play subtests of the ritls through gross and fine-motor skills delay. recurrent middle ear infections are strongly associated with hearing loss and were reportedly experienced frequently by all participants, temporarily limiting their access to new sounds and language. emerging research shows that children with sam are predisposed to specific patterns of hearing loss, which may be temporary or permanent, with independent association of moderate-to-profound, more persistent, sensorineural and high-frequency hearing loss (close et al., 2020). future research should aim to describe hearing and middle ear functioning in prospective studies. implications for early childhood intervention although sam, hiv and/or tb are not new diagnoses for slts to address, this study highlights the complexity of their combined presentation in young children. novel detailed descriptions of the swallowing, feeding and communication profiles of young children with sam are presented. the profiles emphasise the need for early slt intervention. current standards of practice indicate that young children with uncomplicated sam should be managed as out-patients in clinics to decentralise care. distance to health facilities and the lack of transport remain an obstacle for continued follow-up and access to rehabilitative services for children with sam (hofman & madhi, 2020; nyashanu et al., 2020). research shows that pervasive neurodevelopmental effects of sam may be reversed through nutritional rehabilitation and effective stimulation (bhargava & singh, 2020). findings underscore the need for paediatric rehabilitation specialists such as slts to maximise opportunities to provide early intervention and caregiver coaching while toddlers are still hospitalised. limitations of analysis include the cross-sectional nature of the study as some observed behaviours may change as recovery progresses. longitudinal studies are therefore warranted. clinical assessments and observations can be furthered with instrumental assessments in future studies. this research presents in-depth descriptions of three cases, but generalisation of findings to other toddlers with sam is not possible. the exploratory nature of the investigation prevents determining associations between factors in these cases. findings therefore indicate a need to further investigate the swallowing, oral-sensorimotor and communication development of young children hospitalised with sam. future research endeavours may support sustained nutritional recovery and language development using larger-scale experimental, longitudinal or case-control study designs. the cases presented are presumed to be commonly part of the slt caseload in hospitals; therefore, further research is imperative. conclusion the complexity of sam, hiv and tb co-infection was a notable characteristic in all participants’ case histories and their presenting symptoms. despite nearing readiness for discharge to community-based management because of nutritional recovery (according to anthropometric measurements), participants in this collective case-study presented with oral-sensorimotor dysfunction and disruptive feeding behaviours. moreover, an atypical receptive-expressive language delay profile is highlighted with moderately delayed language comprehension and mild expressive language delay only, warranting early communication intervention. however, the three toddlers were not referred for slt services. the findings indicate that south african children with sam and simultaneous hiv and tb co-infection may experience synergistic detrimental effects requiring highly co-ordinated early mdt intervention. the early involvement of the hospital-based slt to support young children with sam, before they are dispersed to communities with limited services, is important. acknowledgements the authors express their thanks to the staff at the departments of paediatrics, dietetics, as well as speech therapy and audiology at the hospital. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions c.j.e. served as the principal investigator, collected data and drafted the article. e.k. and a.k. assisted to conceptualise the research, contributed to writing and editing the article and supervised the overall project. funding information c.j.e. discloses receipt of a doctoral research bursary from the university of pretoria. data availability the authors confirm that the data supporting the findings of this study are available within the article. data associated with this research study is stored at the university of pretoria for 15 years. data are not publicly available because of containing information that could compromise participant privacy and protection of personal information to maintain confidentiality. disclaimer the views expressed in this article are the authors’ own and not a position of the affiliated institution or hospital. references akombi, b.j., agho, k.e., hall, j.j., wali, n., renzaho, a.m.n., & merom, d. 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(2009). who child growth standards and the identification of severe acute malnutrition in infants and children: a joint statement by the world health organization and the united nations children’s fund. author. 83 a model of frequency coding in the central auditory nervous system j ohan j hanekom department of electrical and electronic engineering university of pretoria abstract a phenomenological model for neural coding in the central auditory system is presented. this model is based on average rateplace codes and the hypothesis is that the rate-place code present in the population of low spontaneous rate nerve fibres is adequate to account for frequency discrimination thresholds across the entire audible frequency range. the activity of a population of nerve fibres in response to an input pure tone is calculated and a neural spike train pattern is generated. an optimal central observer estimates the input frequency from the spike train pattern. the model output is the frequency difference limen at the specific input frequency, determined from the estimated input frequency. it is shown that a rate-place code can account for psychoacoustically observed frequency difference limens. the model also supports the hypothesis that a human listener does not make full use of all the information relevant to frequency that is available in auditory nerve spike trains. opsomming 'n fenomenologiese model vir neurale kodering in the sentrale gehoorstelsel word voorgestel. die model is gebaseer op gemiddelde-tempo plekkodering en die hipotese is dat die tempo-plekkode teenwoordig in die groep lae spontane vuurtempo senuvesels voldoende is om frekwensie-diskriminasiedrempels oor die hele hoorbare frekwensiebereik te verklaar. die aktiwiteit van 'n populasie van senuweevesels word bereken in reaksie op 'n enkeltoon-inset. 'n neurale aksiepotensiaalpatroon word hieruit genereer. die insetfrekwensie word deur 'n optimale sentrale waarnemer geskat vanuit die aksiepotensiaalpatroon: die modeluitset is die net-waarneembare frekwensieverskil vir die gegewe insetfrekwensie, bepaal uit die geskatte insetfrekwensie. daar word aangetoon dat 'n tempo-plekkode psigoakoesties-waargenome frekwensie-diskriminasiedrempels kan verklaar. die model ondersteun ook die hipotese dat mens like luisteraars nie ten volle gebruik maak van al die frekwensieinligting beskikbaar in die gehoorsenuwee se aksiepotensiaalpatrone nie. / ,/ key words: rate-place codes, population coding, central auditory system, frequency discrimination, modelling. introduction a sound stimulus received by the peripheral auditory system is transformed to neural spike train activity in a population of auditory nerve fibres (called a spike train pattern). the auditory system varies a number of parameters of the neural spike train pattern to accurately represent a sound, e.g. average spike rate, spread of excitation over a specific subset ofthe neural population and synchronization of spikes to the stimulus waveform (delgutte, 1995). this process of transformation of the original sound stimulus to an internal spike train pattern representation is called coding (bialek, 1991) and the internal.representation of a stimulus is referred to as the neural code for this stimulus (figure 1). two mechanisms known to be involved in frequency coding in the auditory system are rate-place coding and phase lock coding (delgutte, 1997; moore & sek, 1996). in rate-place coding, the auditory system may use the excitation pattern across the entire auditory nerve population to determine the stimulus frequency. rate-place coding operates over the entire stimulus frequency range, but is dominant for the coding of high frequencies (above about 5000 hz) (kim & parham, 1991; moore, 1973). phase lock coding, i.e., synchronization of neural firing rate to individual cycles of a periodic stimulus, is the primary cue used for determination of the frequency of a pure tone at low frequencies. phase locking is progressively lost as stimulus frequency increases above about 2500 hz (delgutte, 1995). both coding mechanisms probably operate in parallel over a large range of frequencies, but it is not clear yet to which extent the central auditory system uses either mechanism alone or both mechanisms simultaneously in the determination of the frequency ofa pure tone (johnson, 1980). it is, however, known that at increasingly higher auditory nerve centres more phase-locking is lost and the auditory system relies increasingly on rate-place codes alone (langner, 1992). shofner & sachs (1986), kim, chang & sirianni (1990) and kim, parham, sirianni & chang (1991) studied spatial response profiles of the discharges of populations of auditory nerve fibres. a "spatial response profile" or "rate response profile" is simply the spatial distribution ofneudie suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 84 ral responses (average neural firing rates) to single tone stimuli along the length of the cochlea. an earlier study by kim and molnar (1979) indicated that the rate response profiles become very broad and exhibit very little tuning at all but very low stimulation intensities (20 db spl). however, they did not clearly distinguish between low spontaneous rate and high spontaneous rate fibres in their study. low spontaneous rate (sr) fibres have wider dynamic range (shofner & sachs, 1986) and are more likely candidates for rate coding. shofner and sachs studied specifically the rate response profiles at low frequency for very low sr fibres (fibres with sr < one spike per second). these fibres ac~ count for about 15% of the afferent auditory nerve population. shofner & sachs found that the rate response profiles for these fibres exhibit clear peaks at the stimulation frequency (1500 hz in their experiments) over a wide range of sound pressure levels (in their experiments, from 34 db spl to 87 db spl). kim, chang and sirianni (1990) observed the same effect with a 1000 hz stimulus. these studinput: sound stim ulus , encoder (peripheral auditory system from outer ear to cochlear level) auditory nerve ,. central decoder (central auditory nervous system from cochlear nucleus level to higher auditory centres) figure 1. a simple model of the encoding of sound stimuli by the auditory system. the model presented hi ihis article describes the encoding process (which primarily takes place in the cochlea) and the decoding process (which takes place in the central auditory nervous system at the cochlear nucleus level and higher). the encoder output is the sound stimulus encoded as a neural spike train pattern. the decoder output is the estimation of the stimulus parameter, e.g., the frequency of the stimulus. johan hanekom ies suggested that the rate-place code operates not only at high frequencies, but also over a wide range of sound pressure levels at low frequencies. high sr fibres saturate at relatively low stimulation intensities (kim, chang & sirianni, 1990) and the peak in the excitation pattern at the stimulus frequency is quickly flattened as excitation begins to spread along the length of the cochlea at higher stimulation intensities. spread of excitation is a cue for loudness (smith, 1988) and it is therefore fair to assume (for the purposes of this article) that high sr fibres are primarily involved in intensity coding. of course, low and high sr fibres are involved in coding of frequency via phase locking as wel1. however, this article focusses on rate coding only and so only low sr fibres are considered. the articles by shofner & sachs (1986), and kim, chang & sirianni (1990) established that a pure tone stimulus is represented in the rate code, but it is not actually known whether the rate information is utilized by the central auditory system for the extraction of frequency, and if so, how this is achieved. in other words, how does the central auditory system go about extracting a single frequency tone from about 28000 (kim, 1984) nerve fibre spike trains? of course, the auditory system does not have to extract the tone explicitly, i.e., there need not be an explicit representation of the tone somewhere in the central auditory system. by this it is meant that it is not necessary that the auditory system has a representation where (for example) only a single neuron fires somewhere in the central auditory system when a 1000 hz tone at 60 db spl is heard. it is, however, known that pure tones are extracted and represented centrally in some form, as is demonstrated by (for example) the ability of subjects to discriminate between two frequencies and vocalize which was higher in pitch. this article presents a modelling study and proposes a mechanism for the extraction offrequency information from a population of nerve fibres. this model is phenomenological and does not reveal the complexity of the underlying biophysical processes. the intention ofthe model is to explain how a tone might be extracted from the activities of a population of nerve fibres (i.e., the tone is encoded by a population code), and this is achieved by demonstrating how: we can account for psychophysically observed frequency ~is­ crimination difference limens or just noticeable frequency differences (jndfs). : mathematical detail of the numerical model falls outside the scope of this article and is not included in the description. the philosophy was to elucidate the principles behlnd the model rather than to obscure them with mathematibl detai1. ' population coding in neural systems (including the auditory system), sensory information is represented in the activities of a population of nerve fibres. population coding models have been studied before in a more general context of parameter coding by neurophysiological systems (baldi & heiligenberg, 1988; shadlen & newsome, 1994). in population codip.g systems, input sensory information (in this article, auditory information in the form' of a single tone) is sanwled.by a limited number of receptors (the inner hair cells in this case). the receptors have rather wide tuning/profiles which overlap considerably. for the tuning profiles of the receptors of the auditory system, see, for example, kiang (1965) or ruggero the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) a model of frequency coding in the central auditory nervous system 85 (1992). because of the broadness of tuning, a large number of receptors will be activated by the stimulus. for example, if a listener hears a 1000 hz pure tone, not only are the fibres that have a characteristic frequency (cf) of 1000 hz activated, but so are many other fibres with cf in the vicinity of 1000 hz. however, the fibres with cf of 1000 hz are maximally activated and fibres not tuned to 1000 hz are activated less strongly. because the tuning profiles are so wide (see, for example, johnson, 1980 or kiang, 1965), even fibres an octave away from the stimulus may be activated, although weakly. by comparing the relative activity of all the different receptors, an internal picture may be formed by the central auditory system of the acoustic environment (i.e., the actual physical signal, the pure tone, in this article). activities of fibres in the neural population are in the form of trains of action potentials, or spike trains. in themodel described in this article, the viewpoint of an ideal central observer (bialek, 1991) is adopted. in other words, the central auditory system is imagined as being a central observer with no knowledge of the "outside world", except that which is reflected by the activity of the population of auditory nerve fibres. each nerve fibre forms an information channel. the central observer is a conceptual model of all the signal processing that takes place in the entire central auditory system. it has available an entire population of nerve fibres responding with different activities to the same stimulus. the reconstruction of the physical signal by the central observer can be much more precise than the spacing between adjoining receptors (snippe& koenderink, 1992). just noticeable differences are typically smaller than the tuning widths of the individual receptors. in the human auditory system, the central observer receives its only image of the acoustic environment by observing spike trains from about 28000 afferent auditory nerve fibres (kim, 1984; spoendlin & schrott, 1989). from these 28000 spike trains, it has to somehow extract the single tone (or tone in noise) which is presented to the listener in a frequency discrimination experiment. ,// point process description of spike trains the spikes (or action potetials) of a neural spike train are all very similar in shape ~nd size, but the informationbearing aspect of a spike traih is the times of occurrence of the spikes. furthermore, spikes are random in the sense that two identical presentations of the same stimulus do not lead to two identical spik~ trains. spike trains may dif.; fer in the number of spikes in a given time period and in different times of occurrence of spikes. spike trains can be described mathematically as point processes (johnson, 1996). the theory of point processes describes the occurrence of isolated events (in this case, individual neural spikes) with the mathematical tools of probability theory and statistics. the point process description can provide a basis for mathematical analysis of coding of information in spike trains. the point process having the simplest structure is the poisson process. here a poisson process is a train of spikes, such that the spikes have a poisson distribution. the poisson distribution is a mathematical function describing the probability of having exactly k spikes, placed at entirely random moments, in a time interval t. the poisson process is characterized by the intensity parameter a. the number of spikes (k) in ,/ an interval t is random, so that the exact number of spikes in the interval t is not known when a is known. however, for larger values of a, a larger number of spikes are expected in the time interval t. the expected number of spikes in an interval t is at. nerve fibres respond to the stimulus by modulating their firing rates (shadlen & newsome, 1994). every nerve fibre shows an increase in discharge rate over a specific range of pure tone frequency, but the spikes are randomly spaced over the duration of the stimulus and repetitions of the same stimulus do not produce the same number of spikes. this suggests that the poisson distribution provides an adequate description ofthe statistics of neural spike trains on the auditory nerve (keidel, kallert & korth, 1983; shadlen & newsome, 1994). after the occurrence of a spike, there is a short period (the refractory period) during which the nerve fibre is unable to produce another spike. the poisson process disregards refractory effects (johnson & swami, 1983) and is therefore not an entirely accurate model for neural spike trains. however, it was chosen for use in the model described in this article, as it is easy to manipulate mathematically as it has only one parameter (the intensity or rate parameter, a). the rate parameter a gives an indication of the instantaneous rate of spikes, and even though spikes occur at random times, a can under certain conditions be estimated in a straightforward way by counting the number of spikes n in a time period t and by then dividing n by t, i.e. a"'=ntr, where a" is an estimation or guess of the value ofa. this equation is only a good estimate for the value of a in the case where it is known that a. does not change during the time period t. the rate ofthe spike train, a, is the only parameter that the central observer needs to extract (johnson, 1996) in order to have complete knowledge of the stimulus. however, any estimation of a will never be entirely accurate because ofthe random nature ofthe poisson process. for example, if a time period oft seconds is observed, different numbers of spikes will be observed at each repetition ofthe same stimulus, although on average the number of spikes will equal at. thus, there will be variance in the spike count (as a result of the mathematical definition of a poisson process, both the average spike rate and the variance equal a). the central observer has to expect any normal speech or sound pattern as input and has no way of "knowing" that it is presented with a single pure tone only in a frequency discrimination experiment. so the central observer cannot assume that the a-parameter remains constant for a specific neural channel; it has to assume that the spike rate is driven by the normal acoustic environment and thus that the a-parameter is constantly changing. the a-parameter is a function of the external acoustic signal s( t). this signal is in general random (consider for example a speech signal) and so the random spike train described by a poisson process has a rate a driven by a random input signal. such a process is called a doubly stochastic (i.e., doubly random) poisson process. the task of the central observer in this general context is to estimate set) from the observed set of spike trains. in general, the estimation task of the central observer is extremely difficult. although the central observer may assume a constant rate a and use a¢ =ntr, this' will be an extremely poor estimation of the actual a. if, however, the statistics ofthe signal set) are known (for example, the average and the variance of set»~, it is possible to obtain better estimators for set) and a. the mathematical details are beyond the scope ofthis article and the point die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 86 of this discussion is that any estimator of a. or of set), even the best estimator, will have variance in the estimation. this variance leads to limitations in the discrimination performance of the auditory system (delgutte, 1995), because, as should be obvious, two frequencies may be confused if the estimation variance is large enough that tone a might sometimes produce the same estimated spike rate a." as tone b. the theory of signal detection (green & swets, 1966) describes how estimation variance (which may be regarded as an internal noise source) and external environmental noise influence signal detectability and discriminability. the standard deviation in estimation (the square root of the variance) can be shown to be equivalent to the just noticeable difference (jnd) for the parameter estimated (siebert, 1970), and this observation is used in the present model. for example, if the stimulus was a 100 hz pure tone, and the central auditory nervous system estimated this frequency with a standard deviation of 1 hz, the just noticeable difference in frequency will be 1 hz. so the task of our model of the central observer will be to observe the spike trains on the population of nerve fibres and (1) to estimate from this the rate a. of each neural channel and then (2) to combine this information to estimate the input frequency i. although the auditory system need not have any explicit representation of the extracted tone, it is fair to design'the central observer of the model to indeed exc tract the tone explicitly. the standard deviation of the estimated value of i is then calculated and this is used as the value for the frequency discrimination jnd. modelling and simulation a suitable model must be able to predict documented psychophysically measured frequency discrimination jnds (zwicker & fastl, 1990; sek & moore, 1995; moore, 1973). with an adequate number of neural channels, it is expected that the variance ofthe estimation should be reduced relative to an estimation of the tone frequency i made on the basis of a single nerve fibre spike train only. how many nerve fibres should be included in a population coding model and what should their extent be? for the model discussed here, the extent of the neural channels was restricted to one critical band. the critical band is a band offrequencies within which loudnesses of all constituent tones are integrated (moore, 1997). it is assumed that frequencies within one critical band are processed as a unit by the auditory system. it is known that the critical band is dynamically shifted to be symmetrical around the tone (zwicker & fastl, 1990). by restricting the model to one critical band, the following model of the signal processing at the auditory periphery is implicitly assumed: namely, that there is a preliminary coarse filtering of the input signal into critical bands, after which the auditory system performs a fine filtering process that extracts the frequency by decoding the population code in this critical band. there are around 3500 inner hair cells, which provide the· primary source of afferent information to the central auditory system. a total of around 28000 afferent nerve fibres innervate these hair cells (kim, 1984; spoendlin & schrott, 1989) so that each inner hair cell is innervated by about eight afferent nerve fibres. about 15% of these, i.e., around one nerve fibre per hair cell, have very low sr (shofner & sachs, 1986). as the model is restricted to these low sr nerve fibres, it will be assumed that only one or two johan hanekom nerve fibres per hair cell contribute to the rate-place coding ofthe input acoustic signal. by modelling one critical band, a range of around 150 hair cells (zwicker & fastl, 1990), spaced 9j.lm apart, is considered, i.e., a total range of about 1.3 mm along the basilar membrane. so there are 150 channels of spike trains from which the central observer has to estimate the tone frequency f. various techniques exist for combining the channels in a population coded model to decode the input signal (bialek, 1991; snippe & koenderink, 1992; pouget, zhang, deneve & latham, 1998), the most common of these being to find the centre of gravity of the activities of the population of nerve fibres (snippe & koenderink, 1992). this may be explained as follows. suppose a pure tone stimulus i is presented to the auditory system model. denote by r the "response" of the nth neuron in the auditory nerve population. the response may be the average spike rate of the neuron (for example) in response to the tone. each neuron has a characteristic frequency in' the stimulus frequency to which its response r,; is maximal. in centre-of-gravity estimation, the estimator judges the relative likelihood of all possible stimulus frequencies by using the response r of neuron n to weigh the contribution of a frequency at i: to the received stimulus. for example, if the stimulus frequency was 100 hz and neuron n had a characteri'stic frequency of 200 hz, the response rn would be lower than for a neuron with characteristic frequency of 100 hz. weighing is achieved by multiplying each characteristic frequency in by the response rn ofthe corresponding neuron. the centre of gravity estimate is then i'" = -----:::::---lr il il --50 --l a... j cj) i cd 40 e '0 \ i '0 \ \ 0 30 ..c: (/) cd .... ..c: 20 ~ 1\ -'0 cd \ ... , j i\! n 10 co e -'.: . .... ~\ ./e v 0 0 e' , e z 125 250 500 1000 2000 6000 frequency (hz) figure 2. model tuning curves (solid lines) superimposed on tuning curve data (circles) from kiang (1965). tuning curves are for three nerve fibres with characteristic frequencies (439 hz, 1328 hz and 5289 hz) close to the stimulation frequencies us'd in the model (500 hz, 1500 hz and 5000 hz), as. tuning curve data were available from kiang (1965) for nervefibres with these characteristic fre<luencies. tuning curves from kiang (1965) w~re normalized by substracting the threshold at the characteristic frequency from all the data points on the tuning curve. / the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) a model of frequency coding in the central auditory nervous system 87 where f is the estimate of f and the summations are over all the neurons in the auditory nerve population. it is not known how real neural systems combine information from populations of nerve fibres, but this is not important for the model discussed here. the present model has to combine the 150 channels in an optimal way, as we are interested in determining the optimal frequency discrimination capability of the auditory system, given the available information. because we are dealing with random variables, information is combined from the population of nerve fibres by calculating the most probable input frequency f using arguments from probability theory. this estimate f of the input tone frequency f is not necessarily the same as the estimate calculated by u'sing the more common centre of gravity method. methods the modelling process has two main steps (figure 3). in the first step, the activities of the population of 150 nerve fibres which the central observer receives are generated (le., the 150 spike trains are generated). in the second step, the best estimate f of the input tone frequency f is calculated from the 150 spike trains observed by the central observer. the mathematical details are outside the scope of this article and the discussion below is intended to elucidate the principles. the equations describing the model were coded in matlab, a computer language designed for doing mathematics. simulations were run on a pentium ii personal computer under the windows 95 operating system. step 1: generation of auditory spike trains in response to a pure tone stimulus 1. low frequency tones (500 hz, 1500 hz) and a high frequency tone (5000 hz) were used. the choice ofthe 1500 hz frequency was guided by the availability of data for the, population response~ profiles at this frequency (shofner & sachs, 1986). stimuli were always presented ~t 60 db spl. this intensity was chosen to be well above discrimination threshold pf low sr fibres (shofner & sachs, 1986) to ensure tha;t the peaks in the population response profiles were well-defined and because of the availability of data measjred at intensities in this vii cinity (shofner & sachs, 1~86). 2. the input tones were passed through a set of 150 filters which approximated isorb"te tuning curves measured for auditory nerve fibres (kiang, 1965). the isorate contours in figure 2 are plots of the intensity required at each frequency to achieve a given firing rate 20% above the spontaneous spike rate. the figure shows three representative isorate contours (plotted from data from kiang, 1965) for nerve fibres with characteristic frequencies close to the pure tone input frequencies used in the model. the tuning curves of three model nerve fibres are superimposed on the data. the output of each ofthe filters was a single value for the average firing rate, a, of the particular nerve fibre when the input was one of the three tones. the 150 filters were all placed within a range of one critical band, arranged symmetrically around the input tone. table 1 provides information about the range of frequencies for these filters. 3. with the activities of each nerve fibre in the neural population known, spike trains were then generated for a 200 ms interval for all the fiores in the population. the spike trains were series of spikes occurring at random times according to a poisson-distribution with rate parameter a. step 2: estimation of the input by a central observer 1. the first calculation that the central observer had to perform, was to find an estimation a"" of the rate a on each neural channel. this calculation is in general quite complex as explained previously. the rate estimator in the central observer had 150 inputs (the spike trains from the neural population) and 150 outputs (the estimated value a"' on each channel). 2. the second calculation was to combine the outputs from the 150 neural channels to form a single estimate f of the frequency f of the input tone. this was done in an optimal way as explained before. this estimate varies over the period of 200 ms of signal presentation. the standard deviation ofthis signal was calculated and this value was used as an approximation to the value ofthe frequency discrimination jnd at the specific input frequency f. results a typical nerve fibre spike train as simulated is shown in figure 4(a). the output a* of one channel of the estimator is shown in figure 4(b). the estimator had to estimate the value of a, but as can be seen from the figure, this is a quite difficult· task and relatively large estimation errors are made. figure 5 shows a typical estimate of the input frequency as a function of time of a 500 hz tone of 200 ms duration. this is the frequency estimate after combination ofthe spike rate estimates of each spike train. only a small fragment ofthe frequency axis is shown. the variance in estimation of the frequency of the tone over the 200 ms period can be seen clearly. fortunately the input tone is coded bya multiplicity of nerve fibres, arid the variance of the collective estimation of the tone frequency is far smaller than what table 1. ranges of critical bands around the input tones used in the model. input tone range of filters which rea~t to the number of filters physical spacing of fil ters input tone (1 critical band) in this range along the cochlea 500 hz 450 570 hz 150 9j.lm 1500 hz 1350 1650 hz 150 9j.lm 5000 hz 4500 5500 hz 150 9j.lm die suid-afrikaanse tydskrifuir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 88 input tone frequency: f duration: t encoder ------------1------------... --n cochlear filters spread over one critical band average rate generator compressive nonlinearity (spike rate saturation) ai 1,.2 a) .. ···· .... ··ai .............. an poisson-distributed spike train generator (spike train i has poisson intensity ai) ---deco der ... ------optimal estimator for poisson intensity of each spike train i of n spike trains a'" i 1,./ a" ) · .......... ·ai' ............ ·an• population code decoder optimal combini3.tion of n estimated intensities r~ frequency jnd determination calculate standard deviation of f' over interval t -------------~-----------4/ fig ure 3. schematic diagram of the neural encoding and decoding operations implemented in the model. the encoder encodes stimulus parameters (in this case, frequency) in the spike train pattern. the cochlear filters are used to calculate activities of a neural population ofn nerve fibres (e.g., 150 fibres) (centred approximately at the input tone frequency) in response to the input tone. the amount of activation of each cochlear filter is then used to calculate the appropriate average spike rate for each fibre, using parameters for low spontaneous rate fibres and taking spike rate saturation into account. the n spike trains now carry the neural code for the input frequency. the spike rate (poisson process intensity) is estimated separately for each spike train. these estimations are then combined to provide an estimate for the input frequency. the frequency jnd is determined by equating it to the standard deviation in estimated frequency over the duration of the stimulus. johan hanekom would have been expected from figure 4 for one nerve fibre alone. relative frequency discrimination jnds (jnd£lf) for humans as measured by sek & moore (1995) and moore (1973) (solid lines) are compared to the predictions from the model (markers) in figure 6. clearly, although the task of the central observer seems very difficult (figure 4), the population code is quite effective in representing information about the frequency of a single tone. as was observed by siebert (1970), we see here as well that, given enough channels in the population code, the ideal central observer does better than human observers in psychoacoustic frequency discrimination experiments. this is true when one or two low sr nerve fibres per hair cell were used and where it was assumed that the other nerve fibres do not contribute to frequency discrimination. when there is less than one low sr nerve fibre per hair cell, the central observer does not have enough information and fares worse than the human observer data of moore (1973). discussion characteristics of the model the central observer in the model presented here is a single black box which models all the signal processing tasks of the central auditory system from the input of the auditory nerve signals right through to the final decision that the listener has to make in a typical two-alternative forcedchoice psychoacoustical experiment. this model has a number of strengths, but also several shortcomings .. the trends in the predicted frequency discrimination just noticeable differences are correct. as frequency rises, the relative jndfs also rise. for a model with 150 nerve fibres representing the tone in a population code, the model pre11111 i1111111 ii ii cil u; q) 160 ..>:: 0.. !!!140 q) '§ 120 q) ..>:: 100 0.. cil q) 80 cl ~ 60 q) > ell 40 "c 2 20 ell e :.:::; 0 cil ul 0 50 100 150 200 time in milliseconds figure 4.a typical nerve fibre spike train as simulated is shown in (a). the frequency of the tone was 1500 hz and. the characteristic frequency of the nerve was 1503 hz. the average rate t.. was 125 spikes/second. the output ,t.. * of one channel of the estimator is shown in (b). the tone was presented for 200 ms. the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) a model of frequency coding in the central auditory nervous system 89 dicts values for frequency discrimination jnds close to the data of ,moore (1973) at lower frequencies. furthermore, when human nerve fibre density is taken into account (spoendlin & schrott, 1989), around 200 low sr nerve fibres are expected in a critical band centred at 500 hz, 300 fibres at 1500 hz and 150 fibres at 500 hz. a curve plotted through the relevant data points in figure 6 (the square at 500 hz, the circle at 1500 hz and the square at 5000 hz) has a bowl shape similar to human frequency jnd£lf data. it has to be taken into account that the choice of various model parameters influences the ability of the population code to present tonal information accurately. we completely ignored the role of the outer hair cells and also the role that the cochlear nucleus plays in sharpening tuning curtes (kim, parham, sirianni & chang, 1991). also, we assumed that high sr fibres do not contribute to the rate-place code. if they did, the predicted frequency discrimination jnds would decrease. furthermore, the role of phase-locking in coding the identity of a single tone was ignored in the present model. but phase-locking is ubiquitous in the peripheral auditory system and probably plays an important role in the coding of frequency. it was not the purpose of this article to prove the opposite, but rather to indicate how the rate-place code 502 500 n :r: -498 >, ()/ c/ /q) ::::j aq) -= "0 2 ro 496 e ~ uj / 494 o 50 100 150 200 time (ms) figure 5. estimated frequency as a function oftime for a 500 hz pure tone input of 200 ms duration. only a small fragment of the frequency axis is shown to show the variance in estimation of the frequency of the tone clearly. there is a slight bias in the . stimation as well, as the average of the estimated frequency is 498.3 hz. the standard deviation is 1.4 hz. may be interpreted. if the central observer uses phase-locking information as well, listeners should in theory be able to perform far better on frequency discrimination tasks than what has been observed in psychoacoustical experiments. this was also observed by siebert (1970). hair cell loss apart from indicating that the assumption of more nerve fibres contributing to the rate-place code leads to better frequency resolution, figure 6 can also be interpreted as showing the effect of hair cell loss. with a smaller number of available hair cells, the model leads us to expect that frequency discrimination jnds will rise. conclusions siebert (1970) predicted the best achievable frequency jnd by other methods, but did not indicate which signal processing the auditory system is required to do to achieve this discrimination threshold. the model presented in this paper proposes a mechanism for the signal processing required for frequency discrimination. the model clearly shows (as was also remarked by siebert, 1970), that the human observer does not make full use of all the information relevant to frequency which is available in the auditory nerve spike trains. the reasons for this are not clear. one possibility is that there are other sources of noise not taken into account in this model. it is concluded from the model that the rate-place code alone is adequate to account for frequency discrimination behaviour in humans. jndf/f 0.008 0.004 a 0.002 • 0.001 • 0.0005 • 500 1500 5000 frequency (hz) figure 6. just noticeable difference in frequency (jndf) is normalized by frequency (jndf/f) and plotted as a function of frequency. the solid lines are human frequency jndf/f data as measured by sek & moore (1995) (curve a) and moore (1973) (curve b). the squares are thejndflfvalues predicted by the model when a population of 150 nerve fibres is used. circles are for 300 fibres, triangles for 75 fibres and diamonds for 30 fibres. the datapoints for 75 fibres and 30 fibres coincide at 500 hz. in all cases the population of nerve fibres was spread over a range of one critical band around the tone. die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 90 references baldi, p. & heiligenberg, w. 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(1994). noise, neural codes and cortical organization. current opinion in neurobiology, 4, 569579. shofner, w.p. & sachs, m.b. (1986). representation of a low-frequency tone in the discharge rate of populations of auditory nerve fibers. hearing research, 21, 91-95. siebert, w.m. (1970). frequency discrimination in the auditory system: place or periodicity mechanisms? proceedings of the ieee, 58, 5, 723-730. smith, rl. (1988). encoding of sound intensity by auditory neurons. in g.m. edelman, w.e. gall & w.m. cowan (eds.), auditory function. neurobiological bases of hearing. san diego: college-hill press. snippe, h.p. & koenderink, j.j. (1992). discrimination thresholds for channel-coded systems. biological cybernetics, 66, 543551. spoendlin, h. & schrott, a. (1989). analysis of the human auditory nerve. hearing research, 43, 25-38. zwicker, e. & fastl, h. (1990). psychoacoustics. facts and models. berlin: springer-verlag. the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) e v i d e n c e based p r a c t i c e in speech l a n g u a g e p a t h o l o g y / a u d i o l o g y in i n d i a i g e e ta m u k u n d a n r ead er & h ead , d e p t, o f s p eech -l a n g u a g e p athology, a.y.j. n a tio n a l in s titu te fo r t h e h e a rin g h a n d ic a p p e d , m u m b a i, india a b s tra c t i t h is o p in io n a rtic le a d d re s s e s th e is s u e o fe b p in a c a d e m ic , re s e a rc h a n d c lin ic a ls e ttin g s in in d ia . e b p is n o ta n a lie n c o n c e p t fo rs p e e c h -l a n g u a g e p a th o lo g is ts /a u d io lo g is ts in th e c o u n try .m o s tp r o fe s s io n a ls in p ra c tic e a r e a c q u a in te d w ith th e id e a o f in te g ra tin g c u rre n t research e v id e n c e w ith clinical e x p e rtis e in th e c o n te x t o f th e client's o w n life s itu a tio n . w ith th e a im o fe lim in a tin g n o n s ta n d a rd p ractice p a tte rn s in b o th a s s e s s m e n ta n d in te r v e n tio n ,e x p e r ts in th e fie ld h a v e d e v e lo p e d g u id e lin e s fo r w o rk in g w ith a w id e r a n g e o f clinical p o p u la tio n s in in d ia . m o n o g ra p h s a n d jo u rn a ls a re b e in g p u b lis h e d p e ­ rio d ically b y a c a d e m ic in s titu tio n s a n d profession al b o d ie s in an e ffo r tto b r id g e th e r e s e a r c h -to -p r a c tic e g a p . this o p in io n a r tic le re v ie w s th e e b p im p le m e n ta tio n p r o b le m s u n iq u e to th e s u b c o n tin e n tin c lu d in g d iv e r s e la n g u a g e s a n d d ia le c ts ,la c k o fs ta n d a rd to o ls fo ra s s e s s m e n tin d iffe re n tla n g u a g e s ,fin a n c ia lc o n s tra in ts ,illite ra c y ,n o n a v a ila b ility o fs p e c ia liz e d c e n te rs a n d th e lack o f a m e c h a n is m to m o n ito r clinical practices in in d ia . the disciplines o f speech-language pathology and audiology have been in existence in india from the early 60s (nikam, 2003). the first speech and hear­ ing centre was established at mumbai and soon after a di­ ploma course in speech and hearing was started. this was followed by the establishment o f an institute at mysore in 1966 and commencement o f undergraduate and postgradu­ ate degrees in both speech-language pathology and audi­ ology. thus began a slow but steady increase in the number o f speech-language pathologists and audiologists in the country. the indian speech and hearing association (ish a ) was formed in 1967 (rathna, 1993). its inception marked the growth and interest in services rendered by the profes­ sion. i t has both regular members as well as associate mem­ bers. however, it is not mandatory for all professionals to be members o f is h a ' i t neither has powers to grant licenses nor to place strictures on professionals who indulge in mal­ practices. the indian perspective on evidence based practices evidence based !health care is a concept that is gaining ground steadily in india. the notion has found acceptance in the medical institutions and is being promoted by the professional bodies! the movement is currently catching on with a number o f training and awareness programs being conducted to improve skills and facilities fo r making such practice widespread among the medical fraternity. the term evidence based practice (e b p ) is used in speech-language pathology and audiology to refer to per­ spective on clinical decision making (a sh a , 2 0 04). it refers to the integration o f current best research evidence, clini­ cal expertise, and the client’s perspectives in making de­ cisions about the care o f individual patients (schlosser 8c raghavendra, 2 0 04). i t is acknowledged amongst academ­ ic speech-language pathologists and audiologists in in ­ dia that empirical evidence is crucial for decision making in routine clinical practice. there is a need to look to empirical evidence to support the assessments and interventions and determine the most efficacious, effective and efficient ways o f providing services (frattali 8c golper, 2 0 06). w ith the aim o f eliminating nonstandard practice pat­ terns in assessment, experts in the field have developed a set o f standard tests and procedures, known as the is h a b a t­ tery, for professionals working with different clinical pop­ ulations (kacker 8c basavaraj, 1990). additionally, mono­ graphs on topics o f interest as well as journals have been published periodically by is h a as well as other institutes. these are aimed towards bridging the research-to-practice gap in india. the framework o f e b p is not new to clinicians in in ­ dia except, perhaps, for those in non-academic work settings who graduated in the 1960s. m ost professionals in practice are acquainted with the idea o f integrating current research evidence with clinical expertise in the context o f the clients own life situation. the international classification o f func­ tioning, disability and health (w orld h ealth organization, 2001) is currently used by academic institutes and individual practitioners for profiling clients to determine the impact o f disability in the real world. w h ile there is the tendency to rely on old ways and rules o f thumb, this is giving way to application o f new and better information today. clinicians acknowledge their need for research database and hands-on training especially in areas that have assumed importance in the current scenario. in recognition o f the relevance o f ebp, the curriculum o f the m aster’s training program in speech-language pa­ thology and audiology includes topics on the subject. the is h a also encourages presentations to be made on the top­ ic at its annual conferences. as the domain o f speech-lan guage pathology has expanded to include dsyphagia and other upper aerodigestive disorders, practitioners constantly feel the need to acquaint themselves with new information and best possible assessments and interventions. author contact: dept, o f speech language pathology bandra reclamation(w) mumbai 400050 india e-mail: gmuk5@yahoo.com th e s o u t h a fr ic a n j o u r n a l of c o m m u n ic a t io n d iso rd er s, v o l 5 5 2 0 0 8 13 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:gmuk5@yahoo.com geeta m u k u n d a n opportunities offered via e b p for development of slp/audiology practices, professional education and/or research professionals in india are increasingly becoming aware o f the need to make decisions by identifying such evidence that there may be for a practice and rating /evaluating it ac­ cording to how scientifically sound it may be. this is done with an aim to eliminate unsound or risky practices in fa­ vor o f those that have better outcomes. a good number o f speech-language pathologists/audiologists do adopt the principles o f e b p in their work lives, although the term is not widely used. g reater emphasis on such an approach would encourage more professionals to search for best evi­ dences by reviewing the literature, thus inculcating the habit o f keeping in touch with libraries, subscribing to relevant publications or engaging in literature search on the internet. they perforce would need to hone their skills o f critical ap­ praisal and technical writing as well. the offshoot is that the professional life o f speech-language pathologists/audiol­ ogists would evolve which, in turn, would contribute to bet­ ter care for their clients. the professional body would also be in a position to bring out policy documents on e b p and also implement guidelines for clinical practice. however, unlike the w est, the demand for accountability is not often voiced as insurance companies and other payers do not play a large role in this sector. the majority o f research papers that are submitted for presentation at the annual conferences o f is h a and for publication in its journal, demonstrate that indian profes­ sionals do apply the e b p framework as a routine. however, most o f these authors are attached to academic or research institutions. such institutions provide good library facilities, access to internet resources and opportunities for attending seminars/ workshops. moreover, as a procedure, research proposals are screened by academic and ethics committees for approval, thus ensuring that they meet the standards. continued education programs for speech and hearing professionals have been a fervent endeavor o f is h a as well as lead institutions in the country. as e b p comes to center stage in india, it would mandate that the themes for such programs focus on the relevance o f summarizing research as well as guiding professionals on how to understand and apply research findings. for instance, as research outcomes encourage the use o f cochlear implants in young children, more clinicians sign in for such training programs to im ­ prove their knowledge o f research based evidence for appro­ priate decision making. speech language pathologists/audiologists working in india are required to be registered under the rehabilitation council o f india (r c i). for renewal o f their licenses every seven years, it is mandatory that they attend continued edu­ cation programmes (c e p ) so that they update themselves. such opportunities could be used to educate professionals on applying research data to clinical practices. also it serves as a platform for exchanging information on outcome meas­ ures, test selection considerations, and measures o f disabil­ ity. the weakest link in the process o f addressing e b p has been the non-availability o f standard assessment tools in the various indian languages. w ith 18 official languages and many hundreds o f dialects, the scenario is daunting even to the most diehard proponent o f ebp. however, while a be­ ginning has been made in some main languages, there is a need to develop similar tools for the others. lead institu­ tions have also made efforts to develop indigenous software and assessment kits to enable clinicians to measure out­ comes in clinical practice. as e b p becomes the approach o f choice, certainly greater priority would need to be given to this issue. researchers and administrators would then ad­ dress the problem with greater urgency. however, it is also important that the limitations o f the e b p framework be realized by the professionals. it would seem appropriate to use the e b p orientation mainly where there is uncertainty. w h en a condition is quite apparent and can be diagnosed quite accurately, the use o f elaborate testing would be unwarranted. in my opinion, most clini­ cians in india, by virtue o f their exposure to a large variety o f cases during training as well as in their work lives, have developed the skills o f making accurate diagnoses without resorting to extensive testing. potential problems/threats to professional develop­ ment in the country india is a vast country with a teeming population o f over one billion. the bulk o f its people live in the villages where basic facilities are far from adequate. its large and diverse population is a melting pot o f various beliefs and practices. superstitions and quackery are rife in certain areas o f the country especially where illiteracy predominates. n ot sur­ prisingly, clients/caregivers generally consult a speech-l an guage pathologist/audiologist long after the crucial years have been lost to such endeavours. a myriad o f problems are encountered by the speech language pathologists/audiologists in clinical practice. they grapple with large caseloads and frequently do not have the time for detailed record keeping and documenta­ tion. financial and time considerations may constrain oth­ ers in applying standard procedures and tests. o ftentim es, their decisions are made keeping in view the resources o f the clients or their parents, their location, availability o f profes­ sional/educational services, and ability to attend follow-up appointments. assessments are short circuited i f the client/caregiver is unable or unwilling to spend time or funds for detailed test­ ing or to make another visit to the centre. for instance, for a case with hoarse voice who cannot afford an endoscopy, the clinician may decide to make do with a perceptual assess­ ment and refer the client to an otolaryngologist. interven­ tion plans, too, may hinge on factors such as distance from the centre, availability o f transport as well as an escort to ac­ company the client to the session, follow-up o f hom e-pro grammes, and affordability o f the charges. it may be noted that services provided at government run hospitals are free or nominal while private establish­ ments levy higher charges. clients have to be able to meet the expenses involved as there is no insurance cover unless a policy has been purchased. w h ile government agencies provide hearing aids and some devices free o f cost for the needy, oftentimes clients would have to look out for them­ selves. professionals thus have to lim it themselves to options that are affordable for their clients. 14 | die su id -afr ik a a n se ty d sk r if vir k o m m u n ik a s ie -a fw y k in g s , vo l. 55, 2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) e v id e n c e b a s e d p r a c t ic e in s p e e c h -l a n g u a g e p a t h o l o g y /a u d io l o g y in in d i a i believe that clinicians deal with two main groups o f cli­ ents: the informed, literate and internet savvy on one hand and the uninformed, naive and gullible on the other hand. the former usually is willing to invest time and money in the endeavor to obtain precise and detailed evaluations o f their ward; o n the other hand, the latter would be inclined to give the procedures short shrift and look for quick and easy solutions. scheduling detailed evaluations would not be in the interest o f their child who would lose out should the caregiver decide that the process was too tedious and give up altogether. hence the professional would be forced to make compromises. in some settings, only one professional is available to deal with a big client load. t im e constraints dictate that evalu­ ations be cursory so that more clients could be examined and ensure that intervention programs, too, can be carried out. detailed client documentation would not be possible in such a scenario. however, qualitative and quantitative meas­ ures are frequently used. the effectiveness o f intervention is verified through such means and also through self assess­ ment by the client and his family. for professionals in private settings, attending seminars, conferences or workshops is not frequently encouraged. the management frowns on time lost in such activities and the loss o f revenue on account o f the absence o f the clinician. the practitioner thus has little opportunity for professional development and has to make extra efforts to keep abreast o f research and development in the field. the management, however, has to take cognizance o f the fact that the profes­ sional has to attend at least three c e p s in order to get his/ her license renewed by the r c i. t o their credit, the training programmes for speech language pathologists/audiologists in india provide great depth o f insight to students in dealing with a variety o f cli­ ents. students learn to do a thorough workup using exten­ sive documentation in an institutional setting, for example, but also learn how 'to conduct screening at camps where hundreds o f people gather to have their hearing, language or speech evaluated! they learn to carry out assessments and interventions using the cornerstones o f e b p ; yet they also learn about areas where e b p is not critical. the need to be flexible and to keep the client’s perspective in mind in decision making is encouraged in student training pro­ grams. reviewing current literature, making critical judg­ ments, weighing options with the concerns o f the clients in mind are emphasized during their clinical training. t o conclude, the e b p orientation is not alien to the in ­ dian system o f perception and thought. indian professionals generally subscribe to a broader perspective in terms o f re­ search and practice. they are naturally inclined to study hu­ man behavior as a whole rather than to look for specific rules o f behavior. further, given the time and other demands on practicing professionals, the application o f e b p is not con­ sidered appropriate in all settings, especially for busy clinics. however, there is little doubt that such an orientation has the potential to improve the quality o f evidence supporting clinical practice in speech—language pathology and audi­ ology and, ultimately, the quality o f services to patients with speech, language and hearing disorders (a sh a , 2 0 04). references american speech-language and hearing association (2004). evidence-based practice in communication disorders (techni­ cal report). retrieved july 16, 2008 from www.asha.org/nr/ rdonlyres. frattali, c.m. 8tgolper, l.a. (2006). evidence-based practice and outcome oriented approaches in speech-language pathology. in a.f. johnson and b.h. jacobson (eds.).medicalspeech-lan guage pathology: a practitioner's guide (2nd edition). new york: ihieme. kacker, s.a. 8c basavaraj, v. (1990). (eds.). indian speech, lan­ guage and hearing tests: the isha battery. mysore: indian speech and hearing association. nikam, s. (2003). hearing impairment. in c.l.kundu (ed.). dis­ ability status india. new delhi: rehabilitation council of in­ dia. rathna, n. (1993). speech and hearing in india: thirty years. my­ sore: indian speech and hearing association. schlosser, r.w. 8c raghavendra, p. (2004) evidence based practice in augmentative and alternative communication. augmenta­ tive and alternative communication, 2 0 , 1 , 1-21. world health organization (2001). international classification o f functioning, disability and health (icf). geneva: who. th e s o u t h a fr ic a n j o u r n a l of c o m m u n ic a t io n d iso rd er s, v o l . 55 2 0 0 8 | 15 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://www.asha.org/nr/ 25 sepedi -toets vir spraakverstaanbaar heid sunel fouche en anita van der merwe departement kommunikasiepatologie universtiteit van pretoria opsomming hierdie studie was daarop gemik om 'n sepedi-toets vir spraakverstaanbaarheid op te stel wat die spraakverstaanbaarheid van die klient objektief kan evalueer en fonetiese inligting sal gee oor die aard van die spraakfoute. die stzidie het voortgespruit uit die huidige behoefte aan evalueringshulpmiddels in die inheemse tale en dienslewering in die afrikatale. die woorde wat in die toets gebruik is, moes voldoen aan sekere fonetiese kriteria. woorde en sinne van verskillende lengtes is ingesluit die prosedures wat deur die toepasser gevolg ·word by die uitvoer van die toets; verskil by moedertaalsprekers en nie-moedertaalsprekers. nadat die toets sciamgestel is, is dit ook toegepas op vier disartriesprekers. by die uitvoer van die toets het dit geblyk. dat daar wel verskille voorkomtussen die beoordeling deur moedertaalsprekers en nie-moedertaalsprekers. bruikbare fonetiese inligting is verkry met die kwalitatie'we ontleding van die spraakproduksies. dit wil dus voorkom of die sepedi-toets vir spraakverstaanbaarheid wel in die kliniese opset gebruik kan word om evaluasie meer objektief uit te voer. . summary the aim of this study was to develop the "sepedi-toets vir spraakverstaanbaarheid" to objectively evaluate the' speech intelligibility of the client and to give appropriate phonetic information. this study evolved from the present need for evaluation mechanisms and therapeutic services in the indigenous african languages. the words used in the test had to conform to the requirements of certain phonetic criteria. words and sentences of differing lengths were included the procedures followed by the test administrator were different for mother tongue speakers than those for non-mother tongue speakers. after the compilation of the test it was applied to four dysarthria speakers. upon execution of the test it was evident that differences in judgment of speech intelligibility exist between mother tongue and non-mother tongue speakers. useful phonetic information was obtained through the qualitative analysis of the speech productions. it appears that the '~sepedi-toets vir spraakverstaanbaarheid" can be used in the clinical environment to obtain a more objective evaluation of the client. /' i sleutelwoorde: sepedi, spraakverstaanbaarheid, moedertaalspreker, nie-moedertaalspreker, woordelyste, sinslyste . i die spraak-taalterajeut wat werksaam is in suidafrika word daagliks gjkonfronteer met' die diversiteit van die land se bevolkingsamestelling. die minderheid van spraak-taalterapeu'te is 'n afrikataal magtig. die teendeel is egter dat 'n igroot aantal van die potensiele kliente slegs 'n afrikataal magtig is. die gevolg is dat so 'n per soon baie seide in sy moedertaal geevalueer kan word. 'n vraag wat kan ontstaan is. of resultate wat dan verkry word, betroubaar is en of die evaluasie objektief en geldig was. die vraag na hulpmiddels vir evaluasie en rehabilitasie vir gebruik deur die spraak-taalterapeut word al groter. klopper het in 1983 die mrikaanse toets vir spraakverstaanbaarheid opgestel, sodat die mrikaaanssprekende disartriespreker in sy moedertaal objektief gee val ueer kan word. die toets van klopper (1983) is opgestel na analogie van die "assessment of intelligibility of dysarthric speech" (yorkston & beukelman, 1981). beide hierdie toetse se ontwerp word in hierdie studie as riglyne gebruik vir die samestelling van 'n sepedi-toets vir spraakverstaanbaarheid. i verskeie argumente kan aangevoer word oor die insluiting van spraakverstaanbaarheid in die evaluering van disartrie. yorkston, beukelman en be1u1988) beskou verstaanbare spraak as die primere doel van die disartriespreker. dit is bekend dat disartrie, ongeag die onderliggende neuromotoriese oorsaak, verminderde spraakverstaanbaarheid en spraakspoed tot gevolg het (yorkston, beukelman & bell, 1988). evaluering van die spraakverstaanbaarheid verskaf inligting aangaande die graad van die afwyking en die fonetiese aard daarvan. yorkston en beukelman (1978) het bevind dat daar 'n noue verband is tussen die spraakverstaanbaarheidsmeting en die hoeveelheid inligting wat oorgedra word as be paling van die sukses van kommunikasie. volgens cannito en marquardt (1997) is die primere doel van terapie om die spreker se verstaanbaarheid te verbeter sodat hy funksioneel kan kommunikeer. vir effektiewe evaluering word 'n diagnostiese en prognostiese vorderingskaal vereis. dit is van praktiese waarde by die kwantifisering van 'n persoon se vordering. spraakverstaanbaarheidsmetings kan verstaan word sonder dat die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 26 gedetailleerde kennis van die fisiologie van die spraakmeganisme benodig word. die kwantitatiewe data kan dus baie maklik aan die persoon se familie oorgedra word met duidelike aanduidings van sy vordering (yorks ton & beukelman, 1978). 'n spraakverstaanbaarheidtoets kan op verskillende wyses saamgestel word. een wyse wat algemeen bekend is, is die transkripsiemetode. dit behels die transkripsie van enkelwoorde soos die lys van tikofsky (1970), asook die transkripsie van sinne. black en haagen (1963) het 'n veelvuldige keuse metode vir die meting van verstaanbaarheid, ontwikkel. yorkston en beukelman het ook in 1981 die toets " assessment of intelligibility of dysarthric speech" op hierdie die wyse opgestel. 'n vergelyking tussen verskillende verstaanbaarheidsmetings het aan die lig gebring dat daar 'n hierargie is in die verskillende metingsmetodes. die resultate verkry met die transkripsiemetode is aansienlik laer as die wat verkry word deur die veelvuldige keuse metode ( yorks ton & beukelman, 1980). klopper (1983) het die mrikaanse toets op dieselfde wyse as yorkston en beukelman (1981) opgestel, maar kyk addisioneel na die tipe fonetiese foute wat die persoon maak. 'n baie belangrike faktor wat die meting van spraakverstaanbaarheid kan belnvloed is luisteraarsbekendheid. daar moet gepoog word om oplossings te kry om hierdie faktor te kontroleer. pogings om luisteraarsbekendheid . met die spreker en inhoud te oorkom, word aangewend (darley, aronson & brown, 1975'; tikofsky, 1970; yorkston & beukelman, 1980; yorkston, beukelman & bell, 1988). die luisteraarstaak kan die meting belnvloed, omdat sekere opdragte kontekstuele leidrade verskaf (yorks ton & beukelman, 1978). die spraakverstaanbaarheidstoetse wat opgestel word in verskillende tale kan nie absoluut volgens homogene beginsels gedoen word nie, omdat die fonotaktiese en fonologiese reels van tale verskil. tydens die opstel van so 'n toets moet hierdie reels in aanmerking geneem word, omdat die taal die opsteller moet lei. die ernstige behoefte wat dus bestaan aan hulpmiddels in 'n afrikataal, leen hom tot verdere navorsing. in hierdie studie is 'n toets opgestel waarmee die spraakverstaanbaarheid van sepedi-sprekers objektief geevalueer kan word deur middel van 'n kwantitatiewe en moontlike kwalitatiewe meting van spraakverstaanbaarheid. metode hoofdoel die hoofdoel van hierdie studie is om 'n spraakverstaanbaarheidstoets in sepedi op te stel waarmee die spraaktaalterapeut spraakverstaanbaarheid objektief kan evalueer, wat fonetiese inligting sal gee en ook 'n aanduiding van spraakspoed by sepedi-sprekers sal gee (fase 1). 'n verdere doel is om die bruikbaarheid van die toets te evalueer deur dit toe te pas op enkele disartriese sp'rekers (fase 2). fase1 die doel van fase 1 was die opstel van kriteria vir die toetsmateriaal en die samestelling van 4 woorden sinslyste wat alternerend toegepas kan word om beoordeelaarsvertroudheid te voorkom. sunel fouche en anita van der merwe fase2 die hoofdoel in hierdie fase is die toepassing van die sepedi-toets vir spraakverstaanbaarheid op disartriesprekers en die beoordeling deur luisteraars om die betroubaarheid van die verskillende lyste te bepaal. . subdoelstellings van fase 2 • vergelyking van die resultate soos verkry deur twee groepe luisteraars, nl. nie-sepedi-sprekende luisteraars en 'n sepedi-sprekende luisteraar. • vergelyking van die resultate van die 4 verskillende lyste wat saamgestel is ten einde te bepaal of ooreenstemmende resultate verkry word. • aanpassings van die kriteria en toetsprosedures van die sepedi-toets vir spraakverstaanverbaarheid waar nodig. • evaluering van die bruikbaarheid van die sepedi-toets vir spraak-verstaanbaarheid om fonetiese foute uit te wys d.m.v. kwalitatiewe ontledings van die kenmerkende fonetiese foute wat by die spreker voorkom. fase 1: metode kriteria vir die sames telling van materiaal van die sepedi-toets vir spraakverstaanbaarheid die toetsmateriaal waaruit die sepedi-toets vir spraakverstaanbaarheid saamgestel is, voldoen aan die volgende kriteria: • tweelettergrepige woorde met en sonder konsonantkombinasies word ingesluit. • bekende woorde wat algemeen gebruik word deur sepedi -sprekers. • die fonetiese eienskappe van die klanke van die woorde word gekontroleer in 'n poging om 'n moontlike aanduiding van die fonetiese afwykings te verkry. • daar word van 'n veelvuldige keusemetode gebruik gemaak as beoordelingsmetode waar die luistera~r 'n keuse kan maak tussen minimale woordpare wat :p.an hom beskikbaar gestel word. • sinne van verskillende lengtes word ingesluit :ten einde die vermoe van die disartriespreker om lan'ger eenhede verstaanbaar te produseer, te evalueer. ; sames telling van die toetsmateriaal die toets bestaan uit twee tipes woorde, nl. tweelettergrepige woorde sonder konsonantkombinasies en tweelettergrepige woorde met konsonantkombinasies. in die toets is ook 'n aantal sinne ingesluit wat in die 4 lyste gebruik kan word om spraakverstaanbaarheid en spraakspoed te meet. elke lys bestaan uit 27 tweelettergrepige woorde en 32 sinne. die navorser het/tydens die samestelling van die toetsmateriaal verskillende bronne geraadpleeg vir die seleksie van die materiaal (joubert, 1996; kriel & van wyk, 1989; kock & kock,)991; kock & kock, 1992; kotze, 1990; van wyki groenewald, prinsloo, kock & taljard, 1990; pakendorf, 1996). / the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) sepedi.toets vir spraakverstaanbaarheid woordbou en moeilikheidsgraad die kvkv woorde maak die grootste gedeelte van die toets uit omdat dit 'n ruim persentasie van die mees algemene woorde in sepedi uitmaak. die woorde voldoen ook aan die kriteria vir die grade ring van die moeilikheidsgraad van die toetsitems. die grootste persentasie woorde in die toets bestaan dus uit kvkv (k=konsonant; v=vokaal;) woorde, maar daar is ook kkvkv woorde ingesluit om moeiliker eise aan die spreker te stel. altesaam word 18 kvkv woorde en 9 kkvkv woorde in elke lys getoets. die ideaal sou wees om meer woorde by die toets in te sluit, maar daar is egter nie genoeg woorde wat aan die seleksiekriteria voldoen nie. sekere groepe van die kvkv woorde is egter daarop gemik om spesifieke foute in plek van artikulasie uit te wys. die konsonante wissel tussen klanke wat bilabiaal en middelalveolerbladlinguaal is. die meeste van die konsonante in sepedi kom voor in hierdie gebied (kotze, 1990). vokale die tweelettergrepige woorde met kvkv-kombinasies maak die toetsing van vokaalproduksies moontlik by die sprekers. die volgende vokale is in hierdie studie gebruik: fa:, a, e, e, j, 0, u:, i f. die vokale f y, rn f is nie gebruik nie, omdat dit nie algemeen voorkom in sepedi nie. elk van die genoemde groepe bestaan uit subgroepe waarin elke keer 'n ander vokaal getoets word. die groepe soos bo genoem is soos volg saamgestel: in elk van die drie kolomme word 'n ander vokaal gebruik. elke ry in 'n subgroep is saamgestel uit minimale woordpare waar verskillende vokale in dieselfde konsonantomgewings voorkom. daar is 'n toetswoord vir elke lys in elke subgroep. die toetswoorde van elke subgroep kom uit dieselfde kolom. op die antwoordblad van die luisteraar verskyn daar 3 kolomme woorde wat gegroepeer is. die luisteraar het dus 'n keuse van woorde waaruit hy die een kan kies wat hy dink die persoon gese het. daar kan dus bepaal word of die disartriespreker spesifieke vokaalof konsonantver/*arrings toon. fonetiese,eienskappe wat bepaal kan word wanneer 'n foutanalise i van die spreker se produksies opgestel word, sluit in aspekte soos vokaalduur by. [a-a:] en vokaalvervanging bv.![e-e]. in groepe 7-9 het 'n ~nder kriterium ten opsigte van vokaalkeuse gegeld. di~ produksie van konsonantkombinasies word hoofsaaklik in hierdie afdelinggeevalueer en daarom is die vokale per spesifieke subgroep konstant gehou. daar is hoofsaaklik gebruik gemaak van konsonantkombinasies saam met fa:, e, j f. die kkvkv woorde in groep 9 word net eenmaal per lys gebruik in 'n spesifieke konsonantomgewing. die vokaal [u] word gebruik,omdat dit die enigste kombinasie was waaruit 'n volledige subgroep saamgestel kon word. konsonantomgewings die vokale wat getoets word in die kkvkv-woorde het elkeen 4 alternatiewe konsonantomgewings waarin die 'vokaal kan voorkom, nl. p vp v [pa:ta]; p vfv [pa:la]; fvp v [ba:ta]; fvfv [ma:na]. (p-plosief; f-frikatief) die konsonantomgewings word meer as een keer herhaal in elke lys, maar telkens saam met verskillende vokale. daar word dus in elke ry, in elke subgroep van dieselfde konsonantomgewings gjbruik gemaak. in groepe 4-6 word 27 daar spesifiek gekyk na die produksie van bilabiaie en middelalveoler-bladlinguale klanke, om inligting te verkry oor plek van artikulasiefoute. om patroonmatigheid van die produksie van konsonantomgewings uit te skakel, is die toetswoorde van elkelys uit verskillende rye binne die groep gekies, dus kom die vokale in verskillende konsonantomgewings per lys voor. stemgewing probleme met die korrekte produksie van stemhebbende en stemlose klanke kan voorkom by disartriesprekers en verminder sodoenfte die spraakverstaanbaarheid (gillmer,1982). in groep 1 is die woorde saamgestel uit woorde wat slegs verskil ten opsigte van stemgewing van die inisiele konsonant. in die eerste subgroep is spesifiek woorde geselekteer waar die inisiele konsonant stemloos is, by. "pepa". die woorde in die tweede subgroep het stemhebbende inisiele konsonante, by. "beka". in beide subgroepe is daar gebruik gemaak van verskillende konsonantomgewings. een woord per subgroep is vir elke lys geselekteer. konsonantkombinasies woorde waar konsonantkombinasies in die inisiele posisie staan, word gebruik om te bepaal watter konsonantkombinasies vir die disartriespreker moeilik is om korrek te produseer. hierdie woorde is in groepe 7-8. verskillende konsonantkombinasies is ingesluit, nl. pf-p, pf-f. ander konsonantkombinasies soos by. fp-p kom nie voor in sepedi nie. in groep 9 word gebruik gemaak van konsonantkombinasies waar geaspireerde eksplosiewe in die kombinasie voorkom nl. pf-p, pf-f, by. phaka en phala. die toetswoorde in 'n subgroep word gekies uit dieselfde kolom. in groepe 7-9 word die vokale gewissel om dit in soveel moontlik konsonantkombinasies te toets. sinne spraakverstaanbaarheid van disartriesprekers verskil by die produksie van woorde en sinne en daarom is daar ooksinne in die sepedi-toets ingesluit. volgens yorkston en beukelman (1978), behaal persone met erge disartrie beter tellings op enkelwoorde as by sinne, omdat enkelwoorde makliker produseerbaar is. die materiaal wat gebruik is vir die sinne is gegroepeer volgens die aantal lettergrepe per sin. die sinslengtes varieer van 3-10 lettergrepe per sin om daardeur ook 'n variasie in die moeilikheidsgraad te bewerkstellig. al die sinne voldoen aan die voorafbepaalde kriteria al verskil die inhoud van die verskillende sinslyste. daar kom 15 verskillende tipes sinne voor wat verskil in terme van die aantallettergrepe per sin en dan ook die woordlengtes. daar word 2 sinne van elke tipe per lys getoets. daar kom dus 32 sinne per lys voor wat 127 woorde bevat. samestelling van verskillende lyste met hierdie studie is daar na analogie van klopper (1983),4 verskiilende woorden-sinslyste saamgestel, as 'n poging om luisteraarsvertroudheid by die terapeut, wat die toets herhaaldelik moet toepas, te kontroleer. daar is gepoog om die verskille tussen die lyste te kontroleer sodat al 4 lyste dieselfde fonetiese eienskappe meet. elke lys is saamgestel uit 27 woorde wat verdeel kan word in 18 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 0 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 28 kvkv-woorde, 9 kkvkv-woorde en 32 sinne. in die bylae word twee van hierdie lyste aangegee (sien bylae a) • kvkv-woorde: in elke lys kom daar dieselfde aantal woorde uit 'n bepaalde groep voor, met ander woorde elke lys be vat 'n toetswoord uit elke subgroep. die toetswoorde van 'n spesifieke subgroep word uit dieselfde kolom gekies volgens die fonetiese eienskappe wat by 'n subgroep getoets word. die woorde word egter geselekteer uit verskillende rye wat dus impliseer dat daar verskillende konsonantomgewings rondom dieselfde vokaal is. indien daar dus by. 3 toetswoorde uit 'n groep vir ,; spesifieke lys gekies word, word die 3 woorde elk uit 'n ander kolom en 'n ander ry gekies. • kkvkv-woorde: elke lys bevat 'n toetswoord uit elke subgroep woorde. al die woorde word gekies uit dieselfde kolom, maar uit 'n ander ry. • sinne: die sinne is saamgestel uit 15 groepe sinne waar elke tipe sin, 2 keer verteenwoordig word in elke lys. elke lys bevat dus 32 sinne wat altesaam uit 127 woorde per lys bestaan. fase 2: toepassing van die voorlopige sepedi-toets vir spraakverstaanbaarheid. proefpersone kriteria vir die seleksie van die proefpersone • tipe spraakprobleem: disartrie as gevolg van enige letsel (die toets is gerig op aile tipes disartrie). ander toestande soos verbale apraksie ofafasie sal 'n invloed he op die tipe spraakprobleem en daarom moet daar nie enige sodanige toe stand teenwoordig wees nie. • ouderdom: die disartriespreker moet 'n adolessent of volwassene wees aangesien hierdie toets spesifiek gerig is op hierdie populasie. die kompleksiteit van baie van die sinne beperk die gebruik van die toets by kinders. • geletterdheid: die disartriespreker moet 'n vlak van geletterdheid he wat hom instaat stel om die woorden-sinslyste te lees. • taal: die persoon moet sepedi-sprekend wees, sonder addisionele taalprobleme soos bo genoem. • geslag: die proefpersoon kan van enige geslag wees aangesien dit nie 'n invloed op spraakverstaanbaarheid behoort te he nie. • gehoor: normale gehoor is 'n vereiste, omdat 'n gehoorverlies 'n persoon se spraakverstaanbaarheid kan belnvloed. tabel 1: inligting aangaande proefpersone sunel fouche en anita van der merwe seleksie van proefpersone geskikte proefpersone is gevind by die letaba skool/ inrigting vir fisies gestremdes in die n oordelike provinsie. al die proefpersone is serebraalgestremd en pas in by die seleksiekriteria. die inligting aangaande die proefpersone verskyn in tabel 1. . luisteraars kriteria vir die seleksie van luisteraars • persone wat voorheen alblootgestel is aan disartriespraak en dus oor kennis van disartrie beskik. • minstens een luisteraar wat 'n moedertaalspreker is. seleksie van luisteraars drie afrikaanssprekende vierdejaar b. kommunikasiepatologie studente van die universiteit van pretoria en een sepedi-moedertaalspreker en ook 'n b. kommunikasiepatologie student het opgetree as luisteraars. materiaal en apparaat materiaal die voorlopige materiaal vir die sepedi-toets vir spraakverstaanbaarheid is as toetsmateriaal gebruik. die toets bestaan uit: 4 woordlyste, 4 sinslyste, 1 luisteraarsantwoordblad, inligting aangaande die prosedure asook 'n foutanalisetabel. elke proefpersoon het al vier lyste gelees om sodoende vas te stel of daar betekenisvolle verskille tussen die lyste voorkom apparaat die spraakproduksies is op 'n hoekwaliteitkassetopnemer opgeneem, nl. die aiwa js 145. die kassetopnemer is met elektriese krag tydens die opnames aangedryf, sodat die kwaliteit van die opname deurgaans konstant gehou is. 'n tdk d 60 kasset is gebruik. prosedure fisiese opset die opnames is in 'n stil kantoor by die skool gemaak. die toetsafnemer en die proefpersoon het langs mekaar by 'n tafel gesit. die mikrofoon is vasgesit aan die lkpel van die proefpersoon se hemp, wat impliseer dati dit gemiddeld 10-15cm. van die spreker se mond was. die d,uur van die toets was ongeveer 40 minute per spreker,. die graad van aantasting het egter bygedra daartoe dat dit soms gevarieer het. proefpersoon etiologie plek van letsel ouderdom geslag gehoor s~reektaal 1 kongenitaal bmn-ietsel 18 vroulik normaal sepedi 2 kongenitaal bmn-ietsel 17 vroulik normaal. sepedi 3 kongenitaal serebeller 20 vroulik normaal sepedi 4 kongenitaal bilaterale 22 manlik normaal sepedi bmn-ietsel / o the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) sepedi-toets vir spraakverstaanbaarheid toetsprosedure die proefpersoon kon die toetsmateriaal eenmaal stillees om leesfoute uit te skakel. daarna moes hy dit hardop lees vol gens die intruksies wat aan hom gegee is daar is tussen die lyste elke keer 'n rusperiode van 3 minute gegee.om uitputting te voorkom. tussen elke gelese woord of sin is daar'n pouse gelaat van omtrent 5 sekondes, sodat die luisteraars geleentheid het om hulle optekening te maak. analise van die toetsresuitate die opnames is deurgaans afsonderlik aan die luisteraars gespeel, vanwee die beskikbaarheid van die oorfone en kassetopnemer. die luisteraars kon slegs eenmaal na elke woord luister waarna hulle dan 'n keuse moes maak uit die beskikbare keuses in die veelvuldige keusekolom. die prosedure van beoordeling van die sinne is verander nadat die nie-moedertaalsprekers baie probleme ondervind het met die transkripsie daarvan. as alternatief het die nie-moedertaalsprekende luisteraars die lys van gelese sinne voor hulle gehad en slegs die woorde wat as verkeerd gehoor is, gemerk. 29 verwerking van toetsresultate kwantitatiewe analise die verskillende tellings soos deur die onderskeie luisteraars aangeteken is met mekaar vergelyk. die volgende vergelykings is met behulp van kwantitatiewe ontledings getref: tellings verkry deur die verskillende luisteraars, verskillende woordlyste, verskillende sinslyste, woord -en -sinslyste. k walitatiewe analise die doel van die kwalitatiewe analise is om die fonetiese foute van die spreker te identifiseer. elke luisteraar se beoordeling van proefpersoon 4. (word gebruik omdat hy die meeste foute vertoon) is gebruik om fonetiese foute te identifiseer en vas te stel of die fonetiese indeling wei terapie leidrade kan verskaf. die foutiewe produksies van die proefpersoon is ontleed vol gens die tipe fonetiese fout, by. die proefpersoon se kuta maar die luisteraar hoor kila. dit is dus 'n vokaalvervanging. die aantal foute wat voorgekom het by elke fonetiese eienskap is bymekaar getel en aangeteken op die foutanalise-tabel. tabel 2: 'n uiteensetting van die kwalitatiewe analise van die produksies van proefpersoon 4, soos verkry deur die luisteraars doelwit woord geproduseerde woord tipe fonetiese fout dila tila stemhebbend --. stemloos padi pidi lang vokaal --. kort vokaal rufa rifa agtervokaal --. voorvokaal fira fura voorvokaal --. agtervokaal ripa ruoa voorvokaal --. agtervokaal gesa gasa voorvokaal --. middelvokaal padi pidi middelvokaal --. voorvokaal lota iota mid hoe vokaal --. mid lae vokaal / tepa tepa mid hoe vokaal --. mid lae vokaal / pona i mid lae vokaal --. mid hoe vokaal pona nepa i nepa mid lae vokaal --. mid hoe vokaal i bela i bula mid hoe vokaal --. hoe vokaal tab a i huba lae vokaal --. hoe vokaal ! mana' , nama bilabiaal --. middealveolerbladlinguaal . i (inisiele posisie) lama , middelal veolerbladlinguaal bilabiaal mama --. (inisiele posisie) mana nama middelalveolerbladlinguaal --. bilabiaal (finale posisie) peso beso eksplosief --. frikatief (inisiele posisie) taba huba eksplosief --. eksplosief (inisiele posisie) dita kita eksplosief --. eksplosief (inisiele posisie) dila tila eksplosief --. eksplosief (inisiele posisie) bata pata eksplosief --. eksplosief (inisiele posisie) b6ta pota frikatief --. eksplosief (inisiele posisie) gasa gasa frikatief --. frikatief (finale posisie) mana nama frikatief --. frikatief (inisiele posisie) tloka tioga pf-p --. pf-f tsama tsaka pf-f --. pf-p kgaka i gaka pf-p --. fop kgafa gafa pf-f --. f-f die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 30 resultate van fase 2 die resultate van die kwantitatiewe en kwalitatiewe analises wat verkry is tydens die toepassing van die sepedi-toets vir spraakverstaanbaarheid, word aan die hand van· die geformuleerde subdoelstellings, soos uiteengesit in die metodologie, bespreek. kwantitatiewe analise vergelyking van die resultate verkry van die twee groepe luisteraars elke spreker het by elk van die luisteraars vier lyspersentasiesbehaa1. vir elke spreker is 'n gemiddeld bepaal, vanuit sy vier lyspersentasies ten opsigte van 'n spesifieke luisteraar(sien figuur 1). die luisteraars word 'in twee groepe verdeel n1. die nie-moedertaalsprekers (nm1-nm3) en die moedertaalspreker (m1). uit hierdie resultatesoos in figuur 1 uiteengesit, blyk dit dat daar nie noemenswaardige verskille voorgekom het tussen die nie-moedertaalsprekende luisteraars (nm1-nm3) nie. die beoordelings wat deur die drie verskillende luisteraars gemaak is by proefpersoon 1 verskil met 1 %. die luisteraars se beoordelings van die verstaanbaarheid by die ander proefpersone verskil met 1 % tot 3%. die luisteraars se waarnemings verskil kenmerkend minder by die proefpersone wat uit "n subjektiewe oogpunt 'n geringer mate van aantasting het. dit wil dus voorkom of die beter verstaanbaarheid van 80% 75% 70% "'d 65% -~ "'d "'d ..... e 60% ~ c-' 55% 50% 45% 76% sunel fouche en anita van der merwe hierdie spreker, vir die nie-moedertaalsprekende luisteraar makliker was om korrek te beoordee1. tellings soos verkry uit die verskillende woordelyste die doel van hierdie vergelyking is om te bepaal of al vier die woordelyste ooreenstemmende resultate oplewer en dus ewe bruikbaar is. die gemiddeldes wat elke proefpersoon op al vier woordelyste by die 4 luisteraars behaal het word voorgestel in figuur 2. dit blyk duidelik dat die persentasies wat deur die verskillende proefpersone behaal is op die vier lyste in 'n groot mate ooreenstem. by proefpersoon 1 wissel die persentasies wathy behaal het by die verskillende lyste tussen 69%-71 % (figuur 2). die verskille tussen die lyste vir proefpersoon 1 is dus nie besonder groot nie. by proefpersoon 2 kom daar 'n verskil in persentasies tussen die verskillende lyste voor van 1 %-3%. dit is duidelik dat ook hier nie noemenswaardige verskille voorkom nie. 'n verskil van 1 %-3% het voorgekom by die persentasieswat deur proefpersoon 3 verkry is op die verskillende lyste. by proefpersoon 4 het daar 'n verskil van 1% voorgekom tussen die verskillende woordelyste. die ooreenstemming soos gesien in figuur 2, blyk hier selfs groter te wees. die proefpersone het nie konstant beter of swakker gevaar op spesifieke lyste nie, dit blyk dus dat daar nie . noemenswaardige verskille tussen die lyste bestaan nie. wanneer·hierdie resultate in ag gene em word, kan daar aanvaar word dat die verskillende lyste in 'n groot mate dieselfde eienskappe by 'n persoon evalueer. al vier die proefpersoon 1 proefpersoon 2 proefpersoon 3 .' /. proefpersoon 4 • luisteraar nmi 0 luisteraar nm 2 mil luisteraar nm3 itiii luisteraar ml figuuur 1: gemiddelde spraakverstaanbaarheid van elke proefpersoon soos behaal op al vier lyste beoordeel deur die vier luisteraars (persentasies afgerond na die naaste heelgetal) . . / the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) sepedi-toets vir spraakverstaanbaarheid 31 k()% 75% 74% 74% 70% "c ('5% ~ "c "c " .. s (,1"% <li c-' 55% 5()% 45% proefpersoon 1 proefpersoon 2 proefpersoon 3 proefpersoon 4 llii lys 1 dlys 2 bmlys"3 ~lys 4" figuuur 2: gemiddeld wat elke proefpersoon opelke woordelys behaal het soos deur die twee groepe luisteraars aangeteken ' " lyste is dus bruikbaar om die spraakverstaanbaarheid van die sepedi-spreker te evalueer. resultate soos verkry uit die verskillende sinslyste elke proefpersoon se gemiddeldes vir al vier lyste soos verkry by die vier luisteraars gesamentlik, is bereken. in figuur 3 word die gemiddeldes van die sinslyste soos bereken, weergegee. uit figuur 3 blyk dit duidelik dat daar nie groot verskille in die beoordeling van die verskillende sinslyste was nie. proefpersoon 1 behaal op drie uit die vier lyste dieselfde persentasie en behaal slegs 1% meer op die ander lys. by proefpersoon 2 kom daar ook nie groot verskille tussen die lyste voor nie. 'n verskil ivan 2% kom voor, maar proefpersoon 2 behaal elke keer vir twee lyste dieselfde persentasie. die persentakies vir die sinslyste wat verkry is by proefpersoon 3 wissel tussen 78%-80%. op twee van die lyste het hy egter di~selfde persentasiebehaal. die persentasies wat proefpersoon 4 behaal het op die verskillende lyste wissel van 77%-79%: dieselfde persentasies is behaal op lyste 1 en 2. die grootste variasie tussen die lyste kom dus voor by proefpersoon 2, die variasie herhaal homself egter nie by die andersprekers nie. die proefpersone presteer nie konstant beter of swakker op dieselfde lyste nie, daarom kan daar aanvaar word dat die moeilikheidsgraad'tussen die lyste konstant is. wanneer hierdie resultate van die verskillende sinslyste in ag geneem word, blyk dit dat die lyste in'n groot mate dieselfde eienskappe evalueer. ai vier die sinslyste kan dus gebruik word om die spraakverstaanbaarheid van die sepedispreker te evalueer. kwalitatiewe analise resultate soos verkry by proefpersoon 4 'n volledige uiteensetting van die kwalitatiewe foutanalise van die toetsresultate word in tabel 2 verskaf. die volgende fonetiese foute is by proefpersoon 4 deur middel van die kwalitatiewe foutanalise van die enkelwoorde uitgelig: • probleme met stemgewing • verandering van die plek van artikulasie van die vokale, by. agtervokaal (voorvokaal) • duurveranderinge by die vokale • konsonantveranderinge, by. eksplosief(p) ---. frikatief(f) • veranderinge en vereenvoudiging van konsonantkombinasies. die fonetiese foute wat cleur die luisteraars aangeteken is, gee 'n aanduiding dat die fonetiese kriteria vail die enkelwoorde voldoende is, sodat die toets hom kan leen tot kwalitatiewe foutanalises van sprekers. dit is belangrik om te meld dat enkele van: die foute wat deur die nie-sepedi sprekende luisteraars aangeteken is, nie deur die'moedertaalspreker wat as luisteraar opgetree het, aangeteken is nie. uit die kwantitatiewe analise 'van die resultate blyk dit dat daar minder foute deur laasgenoemde luisteraar aangeteken is. hierdie re~ultate korrelleer dus met die kleiner voorkoms van foute by die kwalitatiewe analise. daar bestaan wei ooreenkomste in die evaluering en telkens is dieselfde fonetiese' fout,wat deur die ander luisteraars opgemerk is, aangeteken. daar blyk egter sekere beperkinge te weesin die fonetiese kriteria waarvoor daar nie genoegsame voorsiening gemaak is in die veelvuldige keuse nie.die foute wat egter voorgekom het, is nie erkende woorde in sepedi nie, hoewel dit foneties bestaan, bv.pidi, die foute kan ook by ander sprekers verwag word. die proefpersoon het die konsonantkombinasies vereenvoudig, by. kgaka word uitgespreek as gaka, die prosessse kan ook verwag word by ander sprekers. meer woordgroepe blyk nodig te die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 32 90% 85% 80% 75% "'0 -~ 70% "'0 .~ 65% ~ 60% 55% 50% 45% sunel fouche en anita van der merwe proefpersoon 1 proefpersoon 2 proefpersoon 3 proefpersoon 4 1m lys 1 dlys2 ~lys3 iii lys 4 figuur 3: gemiddeld deur elke proefpersoon behaal vir al die sinslyste, soos beoordeel deur die twee groepe luisteraars gesamentlik wees om stemgewing meer suksesvol te evalueer. daar is egter nie nog groepe woorde wat aan die seleksiekriteria van die woorde vir die sepedi-toets vir spraakverstaanbaarheid voldoen nie. bespreking van resultate die hoofdoel van hierdie studie was om 'n sepedi-toets vir spraakverstaanbaarheid op te stel. die waarde van so 'n toets is dat 'n persoon se spraakverstaanbaarheid meer betroubaar in sy eie moedertaal geevalueer kan word. fonetiese inligting van die klient se spraakproduksies kan hierdeur verkry word en sodoende word die spraaktaalterapeut instaat gestel om verantwoordbare terapie aan die klient te gee. tydens die uitvoer van hierdie studie was dit duidelik dat dit moontlik is om na analogie van 'n bestaande toets (klopper, 1983), materiaal te wysig en kultureel aan te pas, sodat dit toepaslik is vir 'n ander taalgroep in suid-afrika. die sepedi-toets vir spraakverstaanbaarheid is verder ook uitgevoer op sepedidisartries·prekers. die resultate wat verkry is dui daarop dat die toets wei betroubaar is en in sy huidige vorm gebruik kan word. die struktuur van die sepedi-toets vir spraakverstaanbaarheid .' die sepedi-toets vir spraakverstaanbaarheid is opgestel na analogie van die afrikaanse toets vir spraakverstaanbaarheid van klopper (1983). tydens die opstel van die toets het dit egter duidelik geblyk dat sepedi wat 'n afrikataal is in 'n baie groot mate verskil van afrikaans wat ontwikkel het uit onder andere baie verskiilende europese en maleisiese tale. die fonetiese repertoire van sepedi verskil van die van afrikaans. daar kom klanke voor in sepedi wat geensins in afrikaans gebruik word nie soos by. die ih1l wat uitgespreek word as 1 cfi. in sepedi kom daar nie klusters voor waar die frikatiefvoor die eksplosief staan nie. die navorser moes die unieke eienskappe van sepedi in aanmerking neem en akkomodeer in 'n toets met hierdie spesifieke forma at. woorde met kvk-struktuur kon nie ingesluit word nie, omdat dit nie voorkom in sepedi nie. die verskille wat voorkom tussen die tale beklemtoon die noodsaaklikheid van 'n toets in 'n afrikataal soveel te meer. indien 'nafrikaanse of engelse toets toegepas word moet die persoon klanke produseer wat nie eie is aan sy taal nie. die aantal woordgroepe wat in die toets inge'sluit is, moes as gevolg van hierdie verskiile verminder word, omdat daar nie meer groepe gevorm kon word wat aaj: die fonetiese kriteria voldoen nie. die meerderheid klanke' wat in sepedi gebruik word, is egter in die toets ingesluit en dus word die toets nie nadelig geraak deur die beperkte getal groepe nie. 'n groot voordeel wat spruit uit die minder groepe, is die feit dat die toetsafnemer meer tyd bespaar met die afneem van die toets. ook vir die toetsling is die toets minder uitputtend; evaluasie deur die nie-moederta,alspreker in die suid-afrikaanse konteks word die spraaktaalterapeut byna daagliks gekonfro~teer met die kwessie van meertaligheid. dit bring mee dat die terapeut met 'n klient moet kommunikeer in 'n geradb~aakte tweede of selfs derde taal. dit wil ook voorkom asof daar slegs 'n klein persentasie van die spraak-taalterapeute in die land is, wat ook 'n afrikataal magtig is. nie net die spraaktaalterapeut word egter met meertaligheid gekonfronteer the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) sepedi-toets vir spraakverstaanbaarheid nie, maar ook die klient wat dalk nie in -sy moedertaal geevalueer kan word nie. uit hierdie stu die blyk dit dat die toetsafnemer se kennis van die taal waarin die toets is, wei 'n rol speel. die spreker kan benadeel word wanneer sy spraakverstaanbaarheid geevalueer word deur 'n niemoedertaalspreker. baie van die klanke wat in die repertoire van die afrikatale voorkom, word nie in afrikaans en engels gebruik nie, veral wat betref die konsonantklusters en is dusvreemd vir die luisteraars. dit is daarom vir die luisteraar moeilik om te onderskei tussen onverstaanbare spraak en duidelike, maar onbekende spraak. die luisteraar evalueer streng volgens dit wat op papier staan, maar selfs al is die klanke foneties geskryf op die antwoordblad, klink die uitspraak van die moedertaalspreker anders as die van die nie-moedertaalspreker. die rede hiervoor kan toegeskryfword aan die feit dat klanke in die volksmond verandering ondergaan en nie meer altyd klink soos dit wat geskryf staan nie. die sepedi wat in pretoria gepraat word, verskil ook weer van die sepedi wat in die noordelike streke gepraat word. die sepedi in pretoria kan beskou word as 'n koine-taal. volgens schuring (1984) is hierdie dialek 'n meer alledaagse gesproke taal. dit beteken dus dat daar wei variasies en strukturele vereenvoudigings van die taal voorkom. volgens schuring (1984) word die pretoria-sepedi beinvloed deur tale soos mrikaans, engels, pedi, kgatla en nog ander tale wat in die gebied gepraat word. die sepedi in die noordelike streke word weer beinvloed deur tale soos mrikaans, engels, sjangaan, tsonga en ander. die spraak-taalterapeut gaan dus te doen kry metdialekte en taalvariasie in die verskillende gebiede waar dieselfde taal gepraat word. die sepedi-toets vir spraakverstaanbaarheid verminder die probleem in 'n mate. die klient moet die woorde lees soos wat dit geskryf is. daar kan dus minder strukturele veranderings en variasies voorkom as wanneer die taal spontaan gepraat word. daar blyk nie werklik 'n oplossing vir hierdie probleem te wees nie, omdat die taalverskeidenheid in die land so groot is. meetinstrumente kan in elke amptelike taal oritwikkel word, maar die persone wat die intstrument moet / / gebruik, sal nie noodwendig moedertaalsprekers wees of oor enige kennis van die taal beskik nie. die ideaal sou wees om meetinstrumente te ohtwikkel wat universeel van aard is, en wat nie die terapejt of klient benadeel nie. 'n ander moontlikheid sou gewees het om die toets te kategoriseer om aan te pas by die persbon se dialek. die uitvoerbaarheid van so 'n taak sal egtet baie gekortwiek word deur die besondere hoe taalversk~idenheid in die land. gewysigde prosedures vir die evaluering deur die nie-moedertaalspreker. in die mrikaanse toets vir spraakverstaanbaarheid van disartriesprekers van klopper (1983) asook in die bestaande engels toets, nl. "assessment of intelligibility of dysarthric speech" van yorkston en beukelman (1981) word daar gebruik gemaak van die veelvuldige keuse metode asook die transkripsie-metode as beoordelingsmetodes. tydens die uitvoering van die sepedi-toets vir spraakverstaanbaarheid het dit egter geblyk dat die evaluasiemetodes gewysig moet word om die probleme wat voorkom as gevolg van die meertaligheid, te verminder. in die vorige gedeelte is reeds verwys na die feit dat daar van die klanke itt die klankrepertoire van sepedi 33 voorkom, wat nie in afrikaans of engels gebruik word nie. die gesproke taal klink dus baie vreemd vir die niemoedertaalspreker. sepedi is ook 'n toontaal (kotze, 1990), 'n eienskap wat totaal onbekend is aan die nie-moedertaalspreker. die eienskap is inherent aan die spraakproduksie van die moedertaalspreker. baie min persone wat die taal wei as derde taal magtig is, kan hierdie verskille in toon uitken (taljard, 1998). dit is van die aspekte wat transkripsie van sinne deur die terapeut baie bemoeilik. die spraak klink vir die luisteraar na baie vinnige, onverstaanbare jargon wat nie gevolg kan word nie. dit veroorsaak geweldige frustrasie aan die kant van die luisteraar, omdat dit nie net baie moeilik is om uit te voer nie, maar ook baie tydrowend is. op hierdie wyse veriaag die betroubaarheid van die resultate wat verkry word. die prosedure vir die evaluering van die sinne word dus gewysig vir die nie-moedertaalspreker. die wysiging vergemaklik die taak van die terapeut en verbeter die klient se kanse om beter te vaar op die toets. in die genoemde toetse van klopper (1983) en yorks ton en beukelman (1981) word daar ook gebruik gemaak van 'n subjektiew.e evaluasie van spraakverstaanbaarheid. uit hierdie studie het dit egter duidelik geblyk dat die gebruik van die subjektiewe evaluasie deur 'n nie-moedertaalspreker nie werkbaar is nie. die onbekendheid van die taal aan die luisteraar bring mee dat die subjektiewe evaluering van 'n per soon se spraakverstaanbaarheid negatief beinvloeld word. die subjektiewe evaluering van spraakverstaanbaarheid deur die nie--moedertaalspreker wat as luisteraar optree, word uitgelaat by die uitvoering van die sepedi-toets vir spraakverstaanbaarheid. daar word verder voorgestel dat groep 9 wat bestaan uit geaspireerde klusters, nie deur die nie-moedertaalspreker uitgevoer word nie. die geaspireerde klanke is baie moeilik om te onderskei van ander klanke as die luisteraar nie bekend is daarmee nie. die toetsresultate wat verkry word deur die niemoedertaalspreker en moedertaalsprekers wat optree as luisteraars moenie met meer as 10% verskil nie. indien die verskil groter is, kan die resultate nie as betroubaar geag word nie. dit is belangrik dat die spraak-taalterapeut wat die toets gebruik, soms gebruik moet maak van 'n tweede luisteraar wat 'n moedertaalspreker is. die aard van spraakverstaanbaarheidstoetse die grootste aantal spraakverstaanbaarheidstoetse wat beskikbaar is, vereis dat dietoetsling moet kan lees. wanneer die spraakverstaanbaarheidstoetse,van klopper (1983) en yorkston en beukelman (1981) uitgevoer word, word daar ook van die toetsling verwag om te kan lees. die spraak-taalterapeut in suid-afrika word nie net gekonfronteer met meertaligheid nie, maar ook met kliente wat nie altyd kan lees ofskryfnie. volgens statistiek, soos verkry van die central statistics (css), wat vrygestel is 1997 van die 1991 sensus (laaste beskikbare statistiek) was 82,16% van die totale bevolking op daardie stadium geletterd. die css definieer geletterdheid as volg: die persoon kan sy moedertaal lees, skryf en praat. die geletterdheid onder die swart suid-afrikaners is 76% en in gebiede waar die grootste konsentrasie van sepedi's is, is die totale geletterdheid van al die bevolkingsgroepe in die provinsies ongeveer 73%. daar is dus in suid-afrika 'n groot getal persone wat nog ongeletterd is. 'n totaal van die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) 34 2 864 000 volwassenes in suid-afrika is ongeletterd en daarvan is 2 640 000 persone van die swart bevolkingsgroepe. 'n groot dee i van hierdie persentasie persone bestaan uit persone van swart bevolkingsgroepe van veral die plattelandse gebiede. die gebiuik van die sepedi-toets vir spraakverstaanbaarheid word in 'n groot mate hierdeur geraak, omdat die klient die lyste moet kan lees. in die prosedure word daar wei aanbeveel dat die klient die woorde kan herhaal, maar dit verminder die waarde van die toets. 'n luisteraar hoor dus beide produksies en die beoordeling van prestasie is dus onbetroubaar. die navorser beveel nie hierdie prosedure aan, tensy dit onvermydelik is nie. verdere navorsing is nodig om te kyk of daar 'n addisionele afdeling by die toets gevoeg kan word wat die probleem van ongeletterdheid kan oorbrug. daar kan gekyk word na die gebruik van prente met of sonder toepaslike vrae, om die verwagte res pons te ontlok. die vrae wat gebruik word om die respons te ontlok moet nie so wyd wees dat dit meer as die vereiste respons ontlok nie. dit kan veroorsaak dat die persoon sinne, in plaas van woorde produseer. 'n belangrike aspek wat te voorskyn kan kom by die gebruik van prente is hie kwessie van die koine-taal. tydens die opstel van die sepedi-toets vir spraakverstaanbaarheid is daar gebruik gemaak van die standaardtaal, sodat die toets groter toepassingsmoontlikhede het. prente kan egter woorde by die spreker ontlok wat gebiedsgebonde is. dit is belangrik dat die aspek in ag gene em word wanneer die prente gebruik word. die spraak-taalterapeut kan self prente versamel om te gebruik. daar word egter aanbeveel dat die prente inpas by die milieu van die sepedi-spreker, sodat die toetsling die prente herken. prente vanuit die westerse kultuur sal nie altyd toepaslik wees nie, omdat baie van die gebruike nie in die afrika-kultuur voorkom nie. die prente moet eenvoudig en duidelik wees , sodat 'n persoon wat swak sien, die prent duidelik kan sien. te veel detail kan verwarrend wees en om slegs die vereiste woord te ontlok, moet daar so minmoontlik items op dieprent wees. slot die sepedi-toets vir spraakverstaanbaarheid kan baie effektiefin die suid-afrikaanse konteks gebruik word. dit vergemaklik die taak van die spraak-taalterapeut wat in 'n meertalige situasie werk en nie altyd die klient se taal kan besig nie. die probleem van meertaligheid sal nog vir baie lank in ons midde wee!:;, maar die spraak-taalterapeut kan dit beskou as 'n uitdaging wat aan haarlhom gestel word om te kompenseer vir die gebrek aan taalvaardighede. die uitdaging aan die spraak-taalterapeut wat in die opset werksaam is, is om steeds verantwoordbare dienste aan die klient te lewer en op so wyse by te dra tot die vooruitgang van die professie. sunel fouche en anita van der merwe verwysings black, j.w. & haagen, c.h. (1963). multiple choice intelligibility tests, forms a & b. journal of speech and hearing disorders, vol. 28, pp. 77 86. cannito, m.p. & marquardt, t.p. (1997). ataxic dysarthria. in mcneil m.r. (ed) clinical management of sensorimotor speech disorders. new york: thieme medical. central statistics (css). (1997). statistics in brief: rsa darley, f.l., aronson, ae. & brown, j.r. (1975). motor speech disorders. philadelphia: saunders. gillmer, e. (1982). 'n ondersoek na die stemaanvangstyd van apraktiese en disartriesprekers. ongepubliseerde b. log navorsingsverslag. pretoria: universiteit van pretoria. joubert, a m. (1996). die opstel en uitvoering van sepedi. artikulasietoets. ongepubliseerde b. kommunikasiepatologie navorsingsverslag. pretoria: universiteit van pretoria. klopper, k (1983). spraakverstaanbaarheid by alrikaanse disartriesprekers: 'n voorgestelde toets. ongepubliseerde b.log n avorsingsverslag. pretoria: u niversiteit van pretoria. kock, j.h.m., & kock, s. d. (1991). noord-sotho vir die nuwe era 6. kaapstad: nasionale opvoedkundige uitgewery beperk. kock, j.h.m., & kock, s. d. (1992). noord-sotho vir die nuwe era 7. kaapstad: nasionale opvoedkundige uitgewery beperk. kotze, a e. (1990). an introduction to northern sotho phonetics and phonology. houtbaai: marius lubbe publishers. kriel, t.j. & van wyk, e. b. (1989). pukuntsu woordeboek. pretoria: j.l. van schaik. pakendorf, c. (1996). the translation of the peabody picture vocabulary test: revised into northern sotho: a preliminary investigation. ongepubliseerde m. kommunikasiepatologie verhandeling. pretoria: universiteit van pretoria. schuring, g.k (1984). die omgangs sotho van die swart woongebiede van pretoria. ongepubliseerde d. litt. verhandeling. johannesburg: randse afrikaan se u niversiteit. taljard, e. (1998). persoonlike onderhoud: beskrywing van die nie-moedertaalspreker en die gebruik van die toontaal. universiteit van pretoria, pretoria, rsa. tikofsky, r.s. (1970). a revised list for the estimation of dysarthric speech. journal of speech and hearing research, vol, 13, pp. 59-64. van wyk, e.b., groenewald, p.s., prinsloo, d.j., kock, j.h.m. & taljard, e. (1990). noord sotho vir eerstejaars. pretoria: j.l. van schaik. yorkston, k.m. & beukelman, d.r. (1978). a comparison of techniques for measuring intelligibility of dysarthric speech. journal of speech and hearing research, vol. 11, pp. 499512. yorkston, km. & beukelman, d.r. (1980). a clinician-judged technique for quantifying dysarthric speech based on sirgle word intelligibility. journal of communication disorders, ivol. 13, pp. 15-31. : yorkston, km. & beukelman, d.r. (1980). influence of pass'age familiarity on intelligibility estimates of dysarthric spejch. journal of communication disorders, vol. 13, pp. 33-41. \ yorkston, k.m. & beukelman, d.r. (1981). communication efficiency of dysarthric speakers as measured by sentence intelligibility and speaking rate. journal ol speech a1nd hearing disorders, vol. 46, pp. 296 398. 'j yorkston, k m., beukelman, d.r. & bell, k r. (1988). clinical management of disarthric speakers. texas: pro-ed. ' the south african journal of communication disorders, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) sepedi-toets vir spraakverstaanbaarheid 35 bylaea voorbeeld van twee woordelyste lenaneo 1 (woordlys 1) 1. pepa 2. dila 3. fapa 4. gesa 5. kopa 6. pula 7. ripa 8. mela 9. poka 10. pala 11. meta 12. bona 13. tapa 14. tema 15. napa 16. lema 17. tupa 18. tima 19. kwata 20. tseka 21. kgopa 22. kwara 23. kw€ma 24. tsola 25.phaka 26. thata 27. khuma lenaneo 2 (woordlys 2) 1. peso 2. heka 3. gasa 4. peta 5. pona 6. ruta 7. fira 8. peka 9. kona 10. bata 11. bela 12.pota 13. taba 14. nepa 15.loba 16. tepa 17. tuba 18. rip a 19. tsaka 20.kgeka 21. tsoka 22. tsama 23. tsena 24.kgaga 25.phapa 26. thaba 27.khuna bylaeb voorbeeld van luisteraarsantwoordblad 1. pepa fepa lepa 5. kepa kapa kopa 9. poka peka paka [p£pa] [f£pa] [l£pa] [k£pa] [ka:pa] [k pal [poka] [peka] [pa:ka] peso beso meso pina pena pona kona kina kana [pelo] [belo] [melo] [pinal [pma] [p:ma] [kona] [kina] [ka:na] seka teka neka seka saka soka iota leta lata [s£ka] [t£ka] [n£ka] [s£ka] [sa:ka] [sfb ka] [lota] [leta] [la:ta] fefa hefa lefa sela sal a sola gosa gasa gesa [f£fa] [p£fa] [l£fa) [s£la] [sa:la] [s3 la] [xola] [xa:f a] [xef a] 2. kita dita tita 6. kupa kopa kapa 10. pota pata puta [kita] [dita] [tita) [kupa) [k( pal [ka:pa] [p( tal [pa:ta] [puta] tila dila kila pula pol a pala pola pala pula [,tila] [dila] [kila] [pula] [pola] [pa:la] [pola] [pa:la] [pula] 1/ seka heka feka ruta rota rata beta bata bita / [s£ka] [p£ka] [f£ka] [ruta] [rota] [ra:ta] weta] wa:ta] [pita] fase lase gase rufa rafa rifa mena mana mina [fa:se] [la:se] i [xa:se] [rufa] [ra:fa] [rifa] [mena] [ma:nal emina] 3. padi pedi : podi 7. kota kita kuta 11. p6ta puta peta [pa:di] [p£di] [podij [k:> tal [kita] [kuta] [rn tal [puta] [petal pala pela ,pola pana pina pena pola pala pela [pa:la] [pela] [pola] [p3 na] [pinal [pma] [pol a] [pa:la] [pela] fapa fepa fopa rap a rip a rupa mota mata meta [fa:pa] [f£pa] [fopa] [ra:pa] [ripa] [rupa] [mota] [ma:ta] [meta] gas a gesa gosa fura fira fora bula bala bela [xa:i a] [xda] [xola] [fura] [fira] [fora] wula] wa:la] [pela] 4. pata peta puta 8. puka poka peka 12. pota pata puta [pa:ta] [petal [puta] i [puka] [poka] [peka] [p:>tp] [pa:ta] [puta] poso peso puso pola pula pela pona pina pana [polo] [pdo] [pujol [polar [pula] [pel a] [p:>na] [pinal [pa:na] fapa £epa fopa saka soka seka bota beta bita [fa:pa] [f£pa] [fop a] [sa:ka] [soka] [seka] [13:> tal [petal [pita] gosa gesa i gasa mola mala mela bona bina buna [xola] [xda] [xa:fa) [molal [ma:la] [mela] [13:> na] [£pina] [puna] die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 46, 1999 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) abstract background methodology findings discussion how did the students perceive the written assignments? how did the students perceive the clinical course? what were the challenges experienced by students with the training programme? conclusion acknowledgements references about the author(s) khetsiwe p. masuku department of speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa anniah mupawose department of speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation masuku, k.p., & mupawose, a. (2022). students’ experiences of using a writing-intense programme to facilitate critical thinking skills on an online clinical training platform: a pilot study. south african journal of communication disorders, 69(2), a919. https://doi.org/10.4102/sajcd.v69i2.919 original research students’ experiences of using a writing-intense programme to facilitate critical thinking skills on an online clinical training platform: a pilot study khetsiwe p. masuku, anniah mupawose received: 01 feb. 2022; accepted: 30 may 2022; published: 22 aug. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: coronavirus disease 2019 (covid-19) and the subsequent lockdown altered traditional clinical training for speech language pathology students, thus forcing training institutions to implement innovative and responsive clinical training strategies in the midst of the pandemic. as such, a writing-intense programme was piloted in an online clinical training programme with second-year speech language pathology students. objectives: this study explored speech language pathology students’ experiences with a writing programme used during an online clinical training programme implemented during the covid-19 pandemic. method: the study used a qualitative survey design. purposive convenient sampling was used to recruit 29 second-year speech language pathology students. online student reflections guided by 10 open-ended questions were used to elicit responses from students. data were analysed using deductive thematic analysis. results: findings revealed that the written component of the programme facilitated the acquisition of clinical knowledge and improved clinical processes of writing among students. feedback that students received on their written tasks improved learning. the clinical component of the course enabled students to learn in a less stressful environment and helped them gain confidence in their knowledge and clinical skills. connectivity challenges and the lack of motivation from some students negatively impacted the programme. conclusion: using a writing programme to clinically train students can have positive effects in applying theory to clinical application because it affords students time to consolidate and process theory with practice as the jump from first year to second year can be cognitively taxing. a writing-intense programme can also improve students’ writing skills. keywords: covid-19; speech pathology; online clinical training; writing intensive; students. background speech language pathology is a degree that comprises a combined theoretical and clinical curriculum. the curriculum is set up to ensure that students can apply theoretical knowledge to a clinical context. for speech language pathology students to effectively apply what they know theoretically to a clinical context, they need to be able to transfer their learning of theory to a clinical context. the ability of students to transfer their learning skills requires developing and using appropriate thinking skills. writing as a tool promotes critical thinking if the writing assignments go beyond extrapolating the knowledge students have acquired from learning. extrapolation lends itself to lower-order thinking skills (as per bloom’s taxonomy), such as remembering, understanding and applying (cited in armstrong, 2016). when writing is instituted to help students learn the course content on a clinical platform, students are forced to engage in higher-order thinking skills (as per bloom’s taxonomy), such as analysis, evaluation and synthesis (cited in armstong, 2016). on a clinical learning platform these skills translate to the student in speech language pathology collating and analysing information, developing an understanding of clients’ needs, planning and implementing intervention and reflecting on client care (cronin & graebe, 2018). according to kamhi (2011) and coutts and pillay (2021), these critical thinking skills are the core skills that speech language pathology students need to foster early in the speech language pathology programme to be used in the provision of services and routinely in decision-making. in the context of the coronavirus disease 2019 (covid-19) pandemic, the clinical training of our speech language pathology students needed to move from the traditional face-to-face method to an online platform. so, the rationale for using a writing-intense programme was to address the clinical outcomes of the clinical course and improve the writing skills of speech language pathology students. because of the covid-19 pandemic, the department of speech language pathology, like all other departments in the university, had to develop innovative strategies to clinically train our students. we had to train the students in a manner that addressed their gaps in knowledge, addressed their clinical competencies, bridged the gap between theory and practice and improved the writing skills of the students. in our department, second-year students engaged in their first year of clinical training in underserved and under-resourced child language contexts. so, it was imperative that the second-year students obtain a solid foundation for assessing and treating paediatric clients who present with speech, language and literacy disorders. in order to establish a solid foundation as clinical educators we needed to develop an innovative teaching and learning approach that would develop the necessary critical thinking skills needed for clinical decision-making. we were forced to rethink and reimagine the way clinical training would occur (khoza-shangase, moroe, & neille, 2021), while still maintaining the integrity and continuity of the education process (ross, 2020) and achieving the required outcomes of the course. we did not want the students disadvantaged in terms of clinical competency and accumulating the necessary number of clinical hours required for students to graduate and register as therapists with the healthcare professionals council of south africa (hpcsa, 2017). previous research has demonstrated that critical thinking skills required for clinical practice can be developed through a number of activities, including simulation in speech language pathology (ellis, 2017; macbean, theodoros, davidson, & hill, 2013), questioning across disciplines (copes, guenther, adelung, & telesca, 2018), peer assessments, for example, in dentistry (tricio, woolford, & escudier, 2016) and using assessments that are culturally and contextually appropriate (coutts & pillay, 2021). literature examining clinical simulations and the development of critical thinking or reasoning skills in speech language pathology revealed that speech language pathology students enjoy simulated cases but need more guidance and feedback on how to interact with cases (ellis, 2017). macbean et al. (2013) reported that most australians find the use of simulated cases important, but the use of simulated cases is limited in speech language pathology programmes. another study conducted in south africa by coutts and pillay (2021) showed that cultural and contextual factors influence critical thinking skills (clinical decision-making) when conducting bedside dysphagia assessments. in fact, a study by hayden, smiley, alexander, kardong-edgren and jeffries (2014) in nursing showed that there is no significant difference in the development of skills between traditional face-to-face training and clinical simulations. copes et al. (2018) found that the use of questioning by clinical educators from various disciplines improved students’ critical thinking skills in relation to client management. although there are studies that have been conducted investigating critical thinking skills and clinical practice, few if any have incorporated the use of a writing-intense approach to develop critical thinking skills for clinical practice on an online platform. the authors argue that using a writing-intense programme facilitates the critical thinking skills required for learning clinical skills on an online platform. a writing-intense course is defined by nichols et al. (2019) as: [a]n existing course which is adapted to use writing to deliver course content, where the latter concept is understood as the particular critical thinking skills which the course is designed to teach. (p. 133) we utilised a writing-intense programme for several reasons. firstly, the profession of speech language pathology incorporates a great deal of writing. secondly, writing promotes critical thinking skills, especially if it is linked to the content or context of learning. thirdly, writing demands that students think ahead, consider their audience and rethink their wording or organisation to ensure that their writing tasks (assessment and intervention reports) meet a specific goal: to inform or explain, evaluate, intepret and/or integrate (çavdar & doe, 2012; nichols et al., 2019). lastly, writing improves academic literacy and cognitive academic language proficiency (calp) of students who are first language english and english additional language (eal) speakers (dinitz & harrington, 2014). academic literacy is the ability to handle the demands of academic language at a tertiary level (weideman, 2018) and calp refers to students’ ability to understand and express, in both oral and written forms, concepts and ideas that are relevant to academic success (cummins, 2008). english additional language students face additional difficulties and stress in academic writing largely because of a lag in their level of language proficiency (al fadda, 2012; dinitz & harrington, 2014). therefore, to deal with the difficulties students experience irrespective of language proficiency, in our programme an appropriate critical process of writing was utilised to improve their academic literacy. the language of learning and teaching in this speech language pathology programme was english. the writing-intense programme utilised in this study was based on the following principles: (1) the use of different types of writing, for example, therapy goals, paragraphs, assessment reports and home programmes; (2) students were given continuous feedback on written assignments from peers and clinical educators; (3) the programme used the jargon or terminology related to the discipline; (4) the written activities contributed significantly to the students’ clinical course mark; (5) the clinical course required a significant amount of writing; and (6) there was meaningful clinical educators–students interaction on each of the written weekly submissions (hilgers et al., 1995; nichols et al., 2019). the writing-intense approach is a non-linear activity in which students are required to plan, draft, revise and edit (hung & young, 2015). in the process of planning, drafting, revising and editing, students are required to engage in critical thinking skills (brock, sanchez, & sharpe, 2020). critical thinking skills, such as calculations, interpretations, analysis, synthesis, creating, evaluation, planning and reflection, which are the core skills that speech language pathologists need in the provision of services and decision-making, are required for client care (brock et al., 2020; cronin & graebe, 2018). the authors set out to answer the following research questions: how did the students experience the written assignments? how did the students experience the clinical course? what did the students experience as challenges of the clinical course? methodology aim the purpose of this study was to explore the experiences of second-year speech language pathology students on the writing-intense clinical training programme that was implemented during covid-19 (july–november 2020). methods consistent with the study aim, a qualitative survey design was used for the study (jansen, 2010). a qualitative approach was deemed appropriate because of its flexibility and allowance for a more detailed exploration of the students’ experiences (berg, 2009). in addition, a qualitative approach produced a broad spectrum of ideas and opinions and different perspectives among the different students (berg, 2009). participants a non-probability purposive convenient sampling strategy was utilised to recruit participants (cresswell & poth, 2018). a specific inclusion criterion was employed (leady & ormrod, 2013). in accordance with the sampling strategy and inclusion criteria, participants had to be registered as second-year speech pathology students, who had participated in the writing-intense online clinical training programme, which was in english. a total of 29 participants who were all women and between the ages of 18 and 20 years (mean age 19 years) participated in the study. the 29 students had done face-to-face clinical practicals at school placements between february and march 2020, and they had also participated in the online clinical training programme between july and november 2020. data collection and analysis at the end of the 14 weeks of the writing-intense training programme, students were requested to complete an online reflection report on their experiences of the clinical training programme. student reflections were guided by 10 key open-ended questions (table 1). students were given a period of 30 days to complete their reflections. weekly reminders were sent to students to complete the reflections. students were informed that their reflections may be used for research purposes, and they were requested to indicate through writing if they consented to their reflections being used for this study. the reflection questions were piloted with two clinical educators who are speech language pathologists. the aim of the pilot study was to determine the content as well as the face validity of the questionnaire, in particular whether the questions asked on the reflection report answered the research question and were ideal as a tool to guide a reflection (leedy & ormrod, 2013). the pilot study showed that the questions were appropriate. transcripts of the students’ responses to the reflection questions were downloaded from the online system and imported into nvivo 1.5.1 qualitative analysis research software and analysed using deductive thematic analysis, following braun and clarke’s six steps of thematic analysis (braun & clarke, 2006). themes were informed by the research questions. table 1: open-ended questions on which students’ reflections were based on. trustworthiness to ensure trustworthiness, shenton’s (2004) strategies were used. in accordance with the strategies, the 10 reflection questions were piloted to determine content and face validity. even though all students were invited to submit reflections, participation in the study was still voluntary and was not graded; thus, only responses from students who wanted to be part of the study are included in the analysis. collaborative coding was employed to mitigate any research bias. the authors have provided descriptions of the parameters of the study and have also stipulated its limitations. ethical considerations ethical clearance to conduct the study was obtained from relevant authorities (clearance number: h20/05/45). permission was requested from students to use their reflections as part of the study. all 29 students gave written permission and consent for their reflections to be used for this study. findings eight themes that describe how second-year speech pathology students in their first year of clinical practice experienced the writing-intensive clinical online training programme implemented during the covid-19 pandemic emerged from the data. the themes and quotes from students are presented in table 2 and further discussed in the discussion section. students reported that the written assignments improved their clinical knowledge. the feedback that students received from their peers and clinical educators as well as the discussions that they engaged in based on their written assignments improved students’ learning. written assignments further improved the students’ critical processes by teaching students the mechanics of academic writing. students reported that the clinical component of the writing-intense online training programme enabled them to learn clinical knowledge and skills and improved their confidence in a less stressful environment because it was simulated. the online nature of the programme presented with challenges such as connectivity (data and infrastructure) and inconsistent participation from students, which negatively affected the programme. table 2: themes from students’ reflections. discussion one of the outcomes of the speech language pathology degree is to develop the ability of students to acquire theoretical knowledge about communication disorders as well as to apply that knowledge clinically in the management of patients presenting with communication disorders. for students to be able to do this, they require critical thinking skills. critical thinking skills are fundamental to decision-making in the clinical service provision in speech language pathology (kamhi, 2011). one of the ways in which critical thinking skills can be promoted is through engaging students in writing-intense tasks that require them to use higher-order cognitive skills, such as collecting information; developing an understanding of clients’ needs; and then planning, directing, performing and reflecting on appropriate client care (cronin & graebe, 2018). during the lockdown instituted because of the covid-19 pandemic, face-to-face clinical teaching was suspended. therefore, a writing-intense online clinical programme was implemented with second-year speech language pathology students between july and november 2020. the study explored, through student reflections, how the 29 second-year speech language pathology students who were registered and participated in the course experienced the written assignments and the clinical component as well as what they experienced as challenges. findings (themes) from students’ reflections are presented in table 2 and are discussed below according to the different research questions. how did the students perceive the written assignments? findings from students’ reflections revealed that engaging in writing-intense tasks facilitated the students’ understanding of theoretical and clinical content. this finding supports the ‘writing to learn’ principle of writing-intense courses documented in mcleod and miraglia (2011) and thaiss et al. (2012), where the authors in the mentioned studies argue that the writing to learn principle of writing-intense courses assists students to learn discipline-specific course content through writing, therefore improving their learning and marks. although the study at hand is not reporting on grades, the positive effects of the writing activities on students’ learning came across strongly in the student responses. international studies on writing-intense programmes further present that using a writing-intense approach is an ideal method to promote students’ learning about difficult and unfamiliar course-related concepts (belting & lanninh, 2017; peters et al., 2019). students in the study also reported that the writing tasks promoted opportunities for engagements between students and clinical educators through peer and clinical educator feedback as well as through online discussions, which the students appreciated. feedback and discussions forced students to move from simplistic ways of understanding and interpreting content and clinical cases to a more nuanced and complex understanding, thus aligning with more deep as opposed to surface learning. findings from the study support the conclusion stated by brock et al. (2020) that feedback and discussion sessions derived from multiple drafts of writing on the same topic form an integral part of a writing-intense course. feedback and discussion in a writing-intense course not only facilitate the social aspect of learning, but also challenge students to opportunities to consider, develop and rethink initial responses, therefore facilitating integration and the development of critical thinking skills (bean, 2011; brock et al., 2020; cronin & graebe, 2018). students further perceived the writing assignments to have encouraged the critical processes of writing. students reported that the writing component of the clinical programme was significant in teaching them the structure of drafting a written academic piece and their ability to provide a critical and detailed reporting of clinical findings. the provision of a structure (e.g. a thesis statement, supporting details and conclusion), a marking rubric for written paragraphs and allowing multiple drafts of written work was a good way of scaffolding students’ written work. the findings of this study corroborate those of marshall and marr (2018) and peters et al. (2019), where the authors present that one of the benefits of writing-intense activities was to improve the writing skills of students, skills that are necessary for future academic careers as well as employment. written work is a crucial component in the speech language pathology profession, as speech pathology students and clinicians are required to write clinical assessment and intervention reports, research reports and clinical home programmes. how did the students perceive the clinical course? students in this study reported that the clinical component of the online training programme promoted the learning of clinical work in a less stressful environment. students found that having to start clinical work directly with real-life patients especially in their first year of clinical work caused them stress and anxiety. therefore, using the template of a simulated approach where the written activities are the focus is an option that could be used to ease students into clinical work, especially in their first year of clinical practicals. this theme corroborates that of mohammadi, tourdeh and ebrahimian (2019) in a study where they describe the effect of simulation-based training methods on the psychological health promotion of students during their educational internship. findings from mohammadi et al.’s (2019) study revealed that simulation is one of the strategies that is suggested and used to reduce stress and anxiety in clinical student education. tension and anxiety in clinical training should ideally be reduced as far as possible because they affect students’ proper clinical training efficiency, academic performance, critical thinking, learning outcomes and cognitive appraisal (saravanan & wilks, 2014). the clinical component of the training programme was reported to have facilitated confidence in the students’ knowledge and skills on assessing and managing clients with language and literacy difficulties. singh et al. (2020) in a study that looked at significant application of virtual reality cases during covid-19, albeit in the medical fraternity, highlighted an increase in self-confidence, positive psychological affects, improved teamwork, increased skills of students and overall performance, which are factors also mentioned by students in this study. improved knowledge and skills in assessing and managing language and literacy in paediatric populations were attributed to constructive feedback received from peers as well as from clinical educators. copes et al. (2018) argued that probing by clinical educators during student supervision enhanced students’ critical thinking skills with respect to client management. in another study by williams, dudding and ondo (2013), cited in ellis (2017), the authors evaluated the role of feedback in virtual human experiences in their graduate speech-language pathology courses. in williams et al.’s (2013) study cited in ellis (2017), students who had received constant feedback performed much better than those who did not. similarly, ellis et al. (2017) reported that speech language pathology students enjoy simulated cases but need more guidance and feedback on how to interact with cases. we suggest that using a writing-intense approach provides an alternative method of providing guidance and feedback to students. what were the challenges experienced by students with the training programme? even though the students had mostly positive feedback on the writing-intense clinical training programme, some students battled with keeping on track with tasks because of the online nature of the clinical training. some students in the course lived in remote areas with poor connectivity and limited access to data, which are factors that negatively influenced their participation. mishra, gupta and shree (2020) and pillay and agherdien (2021) conducted studies in lowand middle-income countries, india and south africa, respectively, and both acknowledged that in these contexts the digital divide is evident. while some students have the necessary resources to successfully engage in online teaching and learning, other students experience challenges because of interrupted electricity connection, intermittent signal issues and unaffordable data costs. commitment to participation in group activities was not the same for all students, therefore affecting the learning process. mishra et al. (2020) reported similar challenges, which they attributed to a certain degree a lack of motivation and commitment. conclusion this article only focuses on reflections of students to evaluate the programme. the voices of clinical educators and course coordinators are missing. however, as this study is a pilot study, starting with the experiences of students was deemed a good starting point. future research needs to include the perspectives of clinical educators in using a writing-intense programme on an online platform. there is an assumption that the academic literacy of the students improved on this platform. we did not particularly delve into the calp of the students, which is an issue that can be investigated in future research. lastly, the students may not have responded to all the questions and therefore inter-student or intra-student comparisons are not feasible (eadie et al., 2006). the strength of this study is that it provides an alternative method to the clinical training of speech language pathology students. the study strongly suggests that online writing-intense programmes can facilitate critical thinking skills that are important in decision-making in speech language pathology clinical practice. the structure of the writing-intense programme, for example, providing a thesis statement, supporting detail and conclusion, provides students with support and scaffolding for written tasks. this structure can be generalised to any clinical written work, for example, client reports and home programmes. the writing assignments, feedback from peers and clinical educators and the revision processes fostered more deep structures of writing (simon, 2013), as writing was not used to access knowledge but to rather encourage critical thinking. the writing assignments, feedback from peers and clinical educators and the revision processes also facilitated the learning of clinical knowledge and applying theory to clinical practice. incorporating an online clinical writing programme, which follows the template of simulated learning, gave an opportunity for students to consolidate and process theory with practice, as the move from first year to second year can be cognitively challenging for students. an online clinical writing programme presented before students see real-life patients decreases the anxiety and stress of treating real-life patients for the first time. when implementing an online programme, such as this one, consideration for access to resources, such as data, devices and electricity, should be done, so that all students can actively participate in the programme. lastly, in formulating the written assignments and activities, consideration needs to be done in a manner that does not overburden students but rather facilitates critical thinking. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions k.p.m. was involved in the conceptualisation, data collection, data analysis and writing up of the article. a.m. was involved in conceptialisation and writing up of the article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data used in this study are available from the corresponding author upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references al fadda, h. 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(2018). academic literacy: five new tests. bloemfontein: geronimo distribution. williams, s., dudding, c., & ondo, k. (2013). simulations & beyond: practical considerations for getting started. [convention handout]. retrieved from http://find.asha.org:8085/asha#q=stacy%20williams&sort=relevancy&f:@sysfiletype=[pdf] abstract introduction methodology results and discussion study limitations and strengths conclusion acknowledgements references about the author(s) kerusha bhojraj department of health, durban, south africa discipline of audiology, university of kwazulu-natal, durban, south africa vuyelwa z. peter discipline of audiology, university of kwazulu-natal, durban, south africa citation bhojraj, k., & peter, v.z. (2022). patient’s perceptions of presbycusis and associated tinnitus counselling practices within the kwazulu-natal province. south african journal of communication disorders, 69(1), a868. https://doi.org/10.4102/sajcd.v69i1.868 original research patient’s perceptions of presbycusis and associated tinnitus counselling practices within the kwazulu-natal province kerusha bhojraj, vuyelwa z. peter received: 20 oct. 2021; accepted: 14 apr. 2022; published: 07 sept. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: counselling manages the psychosocial effects of presbycusis and associated tinnitus, which is best conducted through patient-centred care (pcc). however, there is a paucity of research on implementing pcc within audiology and on patients’ perceptions of counselling practice, making the focus on patient benefit and satisfaction crucial. furthermore, pcc has been documented to be suitable in addressing the psychosocial effects of hearing loss and associated tinnitus, as it focuses on the adult patient playing an integral part of the management processes, providing improved patient outcomes. objectives: this study aimed to explore patients’ perceptions of presbycusis and associated tinnitus counselling practices by audiologists within kwazulu-natal (kzn). method: qualitative phenomenological semi-structured telephonic interviews were conducted through purposive sampling, consisting of seven patients with presbycusis and associated tinnitus who were recruited from private and public facilities in kzn. data were analysed through hybrid thematic analysis following braun and clark’s steps. results: six categories were identified: perceptions on counselling methods, efficacy and tools, audiological rehabilitative training, multicultural sensitivity, patient satisfaction and recommendations on improving counselling practices as pcc adaptation. themes were then extracted from these categories. the overall outcome of the study found that patients had positive perceptions of methods and tools, and audiologists were viewed as adequately trained. furthermore, they were satisfied and benefitted from counselling practices and found clinicians to be culturally sensitive in their practice. however, recommendations were made towards linguistic sensitivity and satisfaction evaluations. conclusion: therefore, implementing pcc into counselling practice may achieve positive patient perceptions, thus highlighting the need to identify barriers and improve the implementation of pcc into practice, especially in resource-constrained contexts. keywords: patient outcomes; recommendations; patient-centred care; presbycusis; tinnitus. introduction presbycusis is an age-related hearing loss, known as the most common cause of hearing loss in ageing adults (sogebi, olusoga-peters, & oluwapelumi, 2014). research has determined that presbycusis can start to manifest in adults as early as 30 years of age (kim & yeo, 2015). it directly and negatively impacts physical, cognitive, social and emotional functioning of patients, leading to lowered self-esteem, depression and social isolation (lee, 2013; sprinzl & riechelmann, 2010). apart from these psychosocial effects of presbycusis, a common side-effect is tinnitus, a noise in the ear that is described by patients as a ringing or buzzing sound (cunningham & tucci, 2017; lee, 2013; zhang, yu, & ruan, 2020). the effects of tinnitus are similar to presbycusis, ultimately leading to deterioration in quality of life (cunningham & tucci, 2017; ferreira, ramos, & mendes, 2009; sogebi et al., 2014). when zeroing in on presbycusis and tinnitus within the south african context, data is scarce. however, some research in public healthcare facilities revealed a hearing loss prevalence of 17.5%, with presbycusis being the predominating cause of hearing loss (louw, swanepoel, eikelboom, & hugo, 2018), causing a possibly significant prevalence of presbycusis in south africa (sa). furthermore, the world health organization (who) (2018) indicated that 4.57% of the population in sub-saharan africa (ssa) is affected by a disabling hearing loss, which is considered to be a loss of hearing greater than 35 decibels in the better hearing ear (who, 2018). furthermore, the who (2018) predicted a rapid increase in prevalence in the years to follow. sub-saharan africa and sa prevalence on hearing loss and the predicted increase (louw et al., 2018; who, 2018) indicates the necessity of exploring presbycusis and associated tinnitus management to better understand the impact on the population afflicted, thus allowing for improved and beneficial management strategies to be implemented. apart from ssa, presbycusis and associated tinnitus affect millions of adults worldwide (kidd & bao, 2012). a study conducted in india on 2695 adult patients in the age range of 60 and above revealed presbycusis as the predominant cause of hearing loss and a tinnitus prevalence of 16.81% (thirunavukkarasu & geetha, 2013). similar research conducted in japan on 14 423 adults between the ages of 49 and 79 presenting with hearing loss (predominantly presbycusis) revealed an 11.9% prevalence of tinnitus (fujii et al., 2011). therefore, these studies demonstrate a common trend of a coexisting relationship between presbycusis and associated tinnitus and an increase of prevalence with a corresponding increase of age (fujii et al., 2011; thirunavukkarasu & geetha, 2013). these reported studies are from asia and pacific, with a paucity of similar studies from ssa reflecting associations between presbycusis and tinnitus. this creates a gap in knowledge and further strengthens the need for exploration of presbycusis and associated tinnitus, in order to better understand the impact on the population afflicted for improved management strategies and to close knowledge gaps. current and most common management strategies for presbycusis and associated tinnitus include compensating for the hearing loss through the use of hearing assistive devices (swain, nayak, ravan, & sahu, 2016). whilst advances in technology have led to better management options for presbycusis and associated tinnitus, there is no cure (swain et al., 2016). this intensifies the need for further exploration on the management of presbycusis and associated tinnitus. over decades of research, it has been indicated that compensation through amplification alone does not adequately address the negative impacts of presbycusis and associated tinnitus on quality of life, as mentioned earlier. consequently, advantageous management of presbycusis and associated tinnitus goes beyond compensation to include counselling (boothroyd, 2007; chisolm & arnold, 2012; hawkins, 2005; parham, lin, coelho, sataloff, & gates, 2013). counselling is conducted post-assessment right up until discharge of the patient, which serves as a means of imparting knowledge to patients and assisting them in adjusting to their hearing loss and its impact on quality of life (american speech-hearing association [asha], 2012; british society of audiology [bsa], 2016). whilst counselling may be deemed a crucial part of management for presbycusis and associated tinnitus, there is a lack of research on the benefit of counselling practices within south africa. it has further been anecdotally discovered that counselling practices within south africa require exploration regarding appropriateness and patient outcomes. research in south africa has revealed unpleasant patient experiences during healthcare delivery, resulting from communication breakdowns and lack of respect for patient preferences, autonomy and socio-economical discriminatory experiences from healthcare providers (de man et al., 2016; peltzer, 2009). although research on patient outcomes within the field of audiology in south africa is limited, with the known undesirable patient experiences from generalised healthcare delivery, providing counselling practices beneficial to patients within the patient-centred care (pcc) approach is crucial. patient-centred care is a framework that proposes that the patient’s individual needs should be the point of focus when providing services and promoting patient satisfaction (nkrumah & abekah-nkrumah, 2019). over the years, pcc has been advocated in healthcare delivery and intends to improve patient outcomes by offering services that are both meaningful and valuable to the individual patient (epstein & street, 2011; nkrumah & abekah-nkrumah, 2019; rathert, wyrwich, & boren, 2013). therefore, the effectiveness of pcc in practice may be represented by patient satisfaction by focusing on the patient’s perceptions (smith & dunham-taylor, 2018). substantiated by sladdin, chaboyer, and ball (2018), who conducted a study exploring 11 patients’ perceptions of pcc by focusing on their experiences from dietetic services, it was found that adopting pcc into practice improved patient satisfaction. based on suggestions by sladdin et al. (2018), implementing pcc during counselling practices may be the favoured approach in improving patient satisfaction. this suggestion can further be considered for presbycusis and associated tinnitus in the sa context, as there is already limited documented evidence of pcc application. however, research has indicated that in ssa, pcc was found to be poorly implemented in healthcare because of strained resources, poor interpersonal interactions between patients and healthcare providers and a lack of focus on training healthcare providers regarding psychosocial dimensions of illnesses (de man et al., 2016). this is no exception in south africa, with research indicating that patients experience poor quality of care (maphumulo & bhengu, 2019). more specifically, research suggests that audiologists in south africa reported that time constraints, language barriers, lack of training and limited resources have negatively impacted their service provision (makhoba & joseph, 2016). these are contributing factors that hinder pcc implementation amongst audiologists in south africa, leading to dissatisfied patient outcomes. there is still a paucity of research on pcc implementation within the field of audiology, with literature accounting for audiologists’ first-hand descriptions of patient outcomes and satisfaction from presbycusis and associated tinnitus counselling. meibos, muñoz and twohig (2019) suggested that to improve counselling practice or skills, audiologists should better understand patients. therefore, exploring patients’ perceptions on presbycusis and associated tinnitus counselling practices may improve patient outcomes. dilollo and neimeyer (2020) described counselling practice in audiology in terms of components of a clinician–client framework, a term used interchangeably with pcc. the audiologist’s main focus is on the individual needs of the patient and the patient’s significant others in order to facilitate patient participation, assisting patients to adjust and cope with the psychosocial impacts of hearing loss (dilollo & neimeyer, 2020). consequently, pcc serves as a fundamental influence in beneficial counselling practices amongst audiologists. however, there is a gap in literature on the nature and outcomes of pcc in audiologists’ counselling practices and a need to conceptualise pcc within audiology (grenness, hickson, laplante-lévesque, & davidson, 2014). therefore, focusing on patients’ perceptions and conceptualising pcc is crucial in closing these research gaps. to conceptualise pcc into counselling practices, components of pcc need to be focused upon. patient-centred care components are based on the eight picker principles: respect for the patient’s values, preferences and expressed needs; coordination and integration of care; information sharing; comfort and support to the patient and significant others; involvement of significant others; continuity; and access to care (picker institute europe, 2020). therefore, this study conceptualised a framework as depicted in figure 1, focusing on components of pcc in counselling practices. the framework is described in various aspects excerpted as: counselling methods: the forms or procedures used by audiologists during counselling practices, which include informational or adjustment counselling (asha, 2012) counselling efficacy and tools: the benefits or helpfulness of counselling practices measured through measurement tools (bsa, 2016) audiological rehabilitative training: the audiologist’s training, skills and exposure to counselling practices multi-cultural sensitivity: diverse cultural and linguistic backgrounds of patients that should be considered whilst delivering services patient satisfaction: the patient’s overall benefit and satisfaction from counselling practices figure 1: conceptual framework adapted from patient-centred care, depicting aspects of counselling practices guided by patient-centred care that have been adopted for this study. a scoping review of 18 articles found that audiologists have limited knowledge of patients’ perceptions of counselling practices because of the paucity of research and require better knowledge and training for improved counselling practice (meibos et al., 2017). furthermore, pcc may be poorly implemented in ssa, despite review literature asserting increased patient satisfaction with its implementation (de man et al., 2016). there is a gap in research regarding the above-discussed aspects of pcc being implemented in counselling sessions of patients with presbycusis and associated tinnitus. this gap may have a direct impact on the patient’s perception of the service they have received. furthermore, research on patients’ perceptions of counselling practices specific to the south african context is scarce. thus, this study would explore patients’ perceptions of audiologists’ practices of presbycusis and associated tinnitus counselling, in order to improve on practices within a pcc framework. methodology aims this study aims to explore patients’ perceptions of presbycusis and associated tinnitus counselling practices offered by audiologists, within kwazulu-natal (kzn). study design and context the study followed a qualitative, phenomenological design concerned with the participants’ lived experience, using semi-structured telephonic interviews developed by the researcher to describe patients’ perceptions of counselling practices. furthermore, the phenomenological design allowed for in-depth perspectives of patients receiving presbycusis and tinnitus counselling by exploring their experiences (brink, van der walt, & van rensburg, 2012). the phenomenological design allowed for in-depth perspectives of the patients receiving presbycusis and associated tinnitus counselling by exploring their experience through information (brink et al., 2012). telephonic interviews provide an effective and economical method of gathering data for a wide geographic sampling population (fox, hunn, & mathers, 2009), making it a suitable design for this study. in addition, the study was conducted during the covid-19 pandemic; therefore, telephonic interviews reduced the risk and spread of infections. study site, population and sampling technique participants were sourced from both public and private sectors within four districts of kzn. these districts were a mix of rural and urban, with urban districts being ethekwini and umgungundlovu and rural being zululand and king cetshwayo. languages predominant in kzn are english and isizulu, with other african languages also spoken within this province (pillay, tiwari, kathard, & chikte, 2020). however, patients are seen by audiologists in kzn that are predominantly english-speaking (pillay et al., 2020). seven participants were interviewed. of these seven participants, one was isizulu-speaking and seen by an isizulu-speaking clinician. this participant had a good knowledge of english; however, a trained isizulu interpreter was sought throughout the data collection process. the other six participants were english-speaking and were seen by clinicians speaking english. furthermore, all participants were literate. the sample size of seven participants was decided upon after consulting a statistician, which allowed for a sample large enough to gain insight into the phenomenon yet small enough to gain in-depth data (vasileiou, barnett, thorpe, & young, 2018). the participants had to meet the inclusion criteria that required them to be adults within kzn, diagnosed with tinnitus and presbycusis, with severity between mild to profound. participant demographics are represented in table 1. table 1: participant demographics. furthermore, purposive sampling was used to ensure that participants were representative of the phenomena-based research (brink et al., 2012). data collection tool semi-structured telephonic interviews were conducted to minimise contact with patients because of the covid-19 pandemic that restricted physical contact with participants. therefore, telephonic interviews allowed for an in-depth conversation whilst reducing chances of covid-19 transmission. furthermore, telephonic interviews were conducted with patients using open-ended questions that were guided by the structure and nature of the hearing handicap inventory for the elderly (hhie) and the who disability assessment schedule (whodas) questionnaires, in order to derive information on self-care, participation, interpersonal and life activities (bsa, 2016). the interview was focused on counselling based on interaction between audiologist and patient from the post-assessment stage until the point of discharge. the interview schedule was guided by the picker patient experience questionnaire, which explores patients’ experiences with hearing loss (jenkinson, coulter, & bruster, 2002). the picker principles provide a guideline for pcc and are included in the pcc framework utilised for this study. the semi-structured interview schedule included a biographical section to obtain patient information, followed by sections to obtain patients’ perceptions of counselling practices: these included counselling methods, counselling efficacy and tools, audiological rehabilitative training of audiologists, multicultural sensitivity of audiologists and patient satisfaction. the interview schedule ended with a section focusing on patients’ recommendations on improving counselling practices. furthermore, al-abri and al-balushi (2014) described patient satisfaction as the patient’s emotions, feelings and perceptions of health services rendered, whilst other researchers (ahmad, nawaz, khan, khan, & rashid, 2015) described patient satisfaction as the relationship between the patient’s expectations of health services and their perceptions of services received. therefore, the interview schedule was developed to obtain information to cover both these descriptions of patient satisfaction. data collection procedure gatekeeper permission was obtained from kzn department of health (doh) and clinicians in private practice. private and public audiologists practising in kzn were contacted to obtain details of patients who met the stipulated criteria, after receiving patients’ consent to participate in the study. information and consent forms were sent to patients through their respective audiologists and then shared directly with the patient via a document link after they agreed to participate. once patients agreed to participate, the date and time were set to conduct the telephonic interviews that focused on counselling, based on interaction between audiologist and patient from the post-assessment stage until the point of discharge. the interview was audio-recorded and verbatim transcription was carried out. data analysis this study used a hybrid approach of thematic analysis of data that includes both inductive and deductive measures (swain, 2018). the hybrid thematic analysis allowed the researcher to obtain rich data on patients’ perceptions of counselling practices whilst focusing on the theoretical framework providing for an analysis of the phenomenon researched (swain, 2018). this approach allowed for the analysis for identifying, analysing and reporting themes from the data collected using nvivo12 software. transcription of audio recordings of seven participants was conducted to arrive at a written document useful for qualitative data analysis (swain, 2018). the transcriptions were imported onto nvivo12 software for coding, analysis, management and representation of themes. thematic analysis was conducted to derive insight into the phenomena studied (swain, 2018). rigour and trustworthiness rigour was assessed using a four-dimensional criterion: building of a research team, data collection preparations, participation in the research and consistency of the study (forero et al., 2018). this was performed by ensuring that the researcher completed an ethics course, adapting data collection tools from the existing literature where reliability and validity have already been established (jenkinson et al., 2002; picker institute europe, 2020), consulting a statistician during planning phases of participants involved in this study and maintaining consistency throughout the study by following ethics discussed later (forero et al., 2018). therefore, rigour was ensured through the four-dimensional criterion that assisted the researcher in reaching objectives through informed data analysis whilst being sensitive towards interpretation bias. rigour was further demonstrated by developing a code manual, summarising data, identifying initial themes, applying template of codes, connecting codes, identifying themes, corroborating and legitimating coded themes (fereday, 2006). rigour was further ensured by developing the data collection tools with guidance from already existing literature where reliability and validity have already been established (picker institute europe, 2020) and conducting a pilot study prior to the main study. furthermore, the pilot study ensured adequacy, ordering and comprehensiveness of the research tools used (regmi, waithaka, paudyal, simkhada, & van teijlingen, 2017). trustworthiness was maintained throughout the study through transparency and by ensuring that participants fully understood and consented to the study before data collection (fereday, 2006). to enhance the authenticity of data findings, a member check was conducted, all participants of the study were provided with the written transcript of their interview (fereday, 2006) and all participants were further invited to approach the researcher if there were any disagreements on transcriptions and interpretations. ethical considerations ethical clearance was obtained from the humanities and social sciences ethics committee of the university of kwazulu-natal (ukzn) with reference number hssrec/00002114/2020. the study adhered to the declaration of helsinki code of conduct for ethical research (goodyear, krleza-jeric, & lemmens, 2007). results and discussion the study focused on a framework based on the fundamental components of pcc during counselling sessions offered by the audiologist, as discussed earlier in the article. aspects of counselling practices framed the study. six main categories were then identified during analysis: perceptions on counselling methods, efficacy and tools, audiological rehabilitative training, multicultural sensitivity, patient satisfaction and recommendations on improving counselling practices. these themes are depicted in the given developed concept map. the concept map given in figure 2 identifies the categories generated from the study, closely linked to the study’s conceptual framework. an overview of results from the study is depicted in table 2. figure 2: concept map depicting themes developed within this study. table 2: representation of categories and themes found in the study. category 1: perceptions on counselling methods english and archbold (2014) described informational counselling as a form of teaching in which the audiologist imparts knowledge to the patient and significant others related to the hearing diagnosis. all participants (n = 7) reported an overall positive perception of counselling methods used by audiologist to manage presbycusis and associated tinnitus. these participants had positive regard for audiologists who addressed their need for information and provided them with skills to cope with their problem. all participants reported that they were provided with information on their hearing impairment and assistive device. however, despite this overall positive perception of audiologists meeting their need for information on presbycusis and associated tinnitus, all patients struggled to confidently explain the type of hearing loss and assistive devices that they used. it is speculated that this may be attributed to some insufficiencies of providing information during informational counselling in terms of information that is exchanged or the manner in which information is exchanged. research has revealed that insufficiencies during informational counselling can infringe upon a patient’s decision-making (shezi & joseph, 2021). therefore, audiologists need to utilise counselling strategies to ensure that information provided is understood and internalised for patient’s informed decision-making (shezi & joseph, 2021). apart from informational counselling, the bsa (2016) described adjustment counselling as exploring the patient’s experiences and identifying the conflicts and emotions they go through to deal with the diagnosis. the most common adjustment or lifestyle change experienced by a majority (6) of participants was based on the use and maintenance of the hearing device: ‘the only lifestyle changes would be to take care of the equipment, the cleansing part of it, the looking after it, how to deal, how to manage it. working with the battery and how long the batteries last. that aspect of giving attention to the hearing aid is somewhat of a small bracket of lifestyle changes.’ (participant 1, 67, male) apart from this, two out of seven participants reported communication strategies and repairs being discussed in their adjustment counselling session. therefore, five out of seven participants did not report on lifestyle changes to accommodate or adjust to their life with tinnitus. therefore, these were interpreted as undesirable responses, as the primary need for a majority of participants (five), adjusting to presbycusis and associated tinnitus with lifestyle changes required to deal with the disabling hearing loss, was not fulfilled for the patient: ‘if i can’t hear when the person speaks then i must switch off everything and turn my full attention to the person speaking to me, also she told me if i’m speaking to someone that i should tell them to speak slowly and clearly so that i may understand them.’ (participant 2, 45, female) the narrative from participants 1 and 2 demonstrates that whilst audiologists are providing some level of adjustment information to the assistive device counselling, the patient’s perceived benefits are based mainly on adjusting their lives to accommodate the hearing device. whilst this may provide for adjustment to an extent, it is not adhering fully to patients’ experiences or adjustments to the psychosocial impacts of presbycusis, which go beyond just compensating for a hearing loss (parham et al., 2013). similar studies in medicine revealed patients’ experiences of inefficiency from adjustment counselling because of follow-up dialogue, rushed time or lack of follow-up sessions, which this study suggests being similar practice within kzn (walseth, abildsnes, & schei, 2011). these insufficiencies have been noted in previous audiological research conducted in south africa, revealing that audiologists’ inefficiency of counselling was because of audiologist bias, lack of information provided to patients and turning a deaf ear to the individual needs of the patient (shezi & joseph, 2021). shezi and joseph’s (2021) findings on the inefficiency of counselling are corroborated in this study. this study asserts that audiologists therefore need to include improved information exchange during counselling to ensure that patients can confidently apply and participate in informed decision-making during the rehabilitation process (shezi & joseph, 2021). this will improve the perceived benefit of counselling offered by audiologists to patients. the similarities in inefficiency from methods of counselling experienced by participants may be improved by adopting pcc into practice, which will provide information-sharing, educate patients, ensure respect of patients’ preferences and emotional support and include patients’ significant others (picker institute europe, 2020). further methods of counselling are the delivery through individual or group sessions (bsa, 2016). none of the participants interviewed reported participating in group counselling, and all participants described a preference for individual or family counselling over group counselling. furthermore, one out of seven participants reported that they were advised by the audiologist to attend group counselling. the remaining six participants were not offered the option of group counselling. however, despite the limited offering of group counselling sessions, none of the participants showed preference for group counselling over individual or family counselling, as seen by the narrative of participants 2 and 3. this was similar to the initial study, with audiologists stating an inclination towards individual sessions and lacking group counselling. participant 2 (45, female) stated, ‘i preferred one on one it was more private’. participant 3 (55, female) said, ‘it was individual, yes [preferred it that way], because it’s one on one and she [the audiologist] could answer my questions’. research conducted in australia suggests that the most commonly used approach for conducting counselling is through group sessions (ekberg, meyer, scarinci, grenness, & hickson, 2015), as it allows for sharing of experiences, addressing coping strategies and counselling more than a single individual in one sitting. contrary to that study, however, it was found in this study that none of the participants interviewed reported being part of group counselling or showed a preference for group counselling. this study perceives it as placing them at a disadvantage, as they are missing out on the many documented benefits of group counselling. furthermore, most participants interviewed were not offered the option of group counselling; it could be possibly attributed to the covid-19 pandemic causing disruptions to traditional service delivery, as measures to curb the spread of the disease required minimising contact (pfattheicher, nockur, böhm, sassenrath, & petersen, 2020). despite the covid-19 pandemic, anecdotally it does not appear that audiologists are providing options for group counselling for patients as part of counselling practice in kzn. this study advocates that those audiologists should consider offering group counselling sessions whilst adhering to safety protocols, allowing patients the opportunity to opt out, in line with the pcc principle of offering a variety of counselling methods. furthermore, this preference of individual or family counselling over group counselling was attributed to patient privacy concerns and fear of embarrassment or judgement, as depicted in the following narrative: ‘well, i don’t suppose you ever want everybody else to know, because people are always inquisitive and curious to know your business, and they’re just sitting there not minding their own business.’ (participant 1, 67, male) participant 1 (67, male) showed preference towards individual or family counselling, as did other participants as seen by the narrative of participant 4 (57, female), who said, ‘i can manage on my own. i’m a very private person. i don’t like discussing my private life’. participants’ negative perception towards group counselling may be influenced by insufficiencies of information given to the patient from audiologists, impacting their informed decision-making (shezi & joseph, 2021) and causing patients to opt out of group counselling. therefore, a link is created with the patient’s inclination to individual or family counselling and informational counselling. this link is suggestive that a lack of information may contribute to a patient’s negative perceptions of group counselling. these negative perceptions by patients may be influenced by providing patients with additional information on the benefits and impacts of group counselling whilst assuring patients of their privacy. this article recommends further investigation in terms of research to benchmark group counselling practices specific to the south african context that may improve patient outcomes as depicted in literature (ekberg et al., 2015). apart from group sessions, most participants reported a lack of family or significant others being present during counselling and reported negative perceptions on the lack of involvement of significant others during counselling. ekberg et al. (2015) surveyed the involvement of family during the audiological rehabilitation process that included audiologists, patients and patients’ families. this study reported that families present at sessions were not invited into conversations between patient and audiologist; only 12% had family participation, despite family members’ willingness to actively participate and show support. despite literature by ekberg et al. (2015) and patients who prefer family or significant others’ involvement during counselling, it is not fully offered to patients within kzn by audiologists, as seen in the following narrative: ‘it makes a great impact because i feel if they [family or significant others] are there and if something happens, they can guide me if i don’t hear anything. makes me feel safer.’ (participant 7, 45, female) this lack of involvement from family or significant others of patients may impact pcc dimensions and patient benefits because pcc ideals advocate for patients’ active participation and involvement of significant others (picker institute europe, 2020). ekberg et al. (2015), further revealed that audiologists do not have a full appreciation of how to incorporate and successfully use significant others in the counselling session for patient benefit. this study shares similar sentiments with these authors, because the lack of inclusion and appropriate use of significant others in counselling sessions has been seen in its findings. this needs to be considered in practice as most participants (n = 4) showed an inclination towards family counselling over group counselling, as they reported feeling supported emotionally, safe to express themselves and certain that information was not missed or misunderstood, as explained by participant 7 in the given narrative. however, none of the four participants were given the option to bring a family member for future sessions. lack of an option for family or significant others’ involvement may also impact counselling efficacy. therefore, audiologists are urged to encourage inclusion and invite the significant other to the sessions (ekberg et al., 2015). furthermore, for effective carry-over of counselling strategies shared with the patient, the significant other can be a facilitator in the patient’s natural environment (ekberg et al., 2015). for further effective carry-over to be facilitated, appropriate tools such as measurement scales are required during the counselling session to improve the value of intervention. category 2: perceptions on counselling efficacy and tools for the purposes of this study, efficacy of counselling refers to the benefits or helpfulness of counselling practices measured by tools such as checklists or questionnaires (bsa, 2016). to assess the efficacy of presbycusis and associated tinnitus counselling practices, audiologists must ensure the use of appropriate measurement tools, with the most common in use for adults being the hhie, the tinnitus handicap inventory and the whodas ii (bsa, 2016). all seven participants demonstrated positive inclination towards the use of tools to rate the efficacy of the counselling practice. however, despite the positive perception, all participants mainly commented on audiology booths as a tool used by the audiologists, as can be seen in the given narrative. none of the participants reported use of questionnaires or checklists during the session to assess effectiveness of counselling, as is also portrayed in the given the following narrative: ‘they used a silent room and they had headphones and stuff that they put on different ways and then there was sounds that they registered on a machine computer and then programmed it, they used charts and then she actually had the physical stuff here. they had the hearing aid and the batteries and then demonstrated how it needed to be used.’ (participant 1, 67, male) it was found that participants described the equipment used during assessment of hearing as the tools or resources used during counselling practices. this misunderstanding by patients of tools or resources may be attributed to insufficiencies during the counselling process in informing patients of respective tools or resources used and their purpose during practice. this study identified desynchrony in counselling practice between audiologists and patient perceptions in terms of understanding the tools, their use and efficacy, which may be because of time constraints. however, such insufficiencies may impact patient satisfaction and benefit. this study speculates that audiologists in kzn do not routinely use checklists or questionnaires to measure the impact or validation of presbycusis and associated tinnitus on a patient’s quality of life. whilst the reasons are unknown, it could be attributed to lack of access to tools or resources. the lack of using measurement scales may impact patient benefit from counselling, as there is no full appreciation of the psychosocial impact on quality of life because measures that foreground the severity that may be used to guide counselling practice are hardly used (parham et al., 2013). further impacting on and linking to adjustment counselling practices, since the psychosocial impacts of presbycusis and associated tinnitus are not fully undertsood and measured, therefore, patients may not be appropriately adjusting to the impacts of hearing loss and tinnitus. the use of these validation tools during counselling practice is imperative as it affects patients’ overall progress towards goals of improved quality of life and implements integrated care amongst audiologists (bsa, 2016), in line with pcc components. furthermore, all participants reported counselling to be effective based on the fitting of hearing devices, placing the patient at a disadvantage because of insufficient information or knowledge on what they expect to achieve from counselling, which goes beyond just compensating for a hearing loss but also includes dealing with the psychosocial impacts (parham et al., 2013). audiologists’ insufficiently effective use of validation tools may negatively impact the patient’s outcomes or satisfaction. a study conducted in south africa by makhoba and joseph (2016) shared similar sentiments, as it found that audiologists’ perceived limitations during undergraduate training might contribute to a waning, inefficient use of tools in counselling practices (makhoba & joseph, 2016). this can be evident in counselling practice where validation tools are not used. in addition, accessibility of the tools is another concern, as they can be costly and may have linguistic limitations as they are manufactured in developed countries (makhoba & joseph, 2016). when probed further, participants described the audiologist’s efficacy during counselling to be attributed to an ultimate diagnosis of their hearing loss alone, which allowed for management options such as compensating for the loss but lacked in management of psychosocial impacts of presbycusis and associated tinnitus. this may be attributed to the patient’s limited understanding of counselling outcomes, which may be linked to insufficiencies during information exchange with audiologists (shezi & joseph, 2021). this may further be associated with audiologists’ undergraduate training and exposure, impacting their management practice. category 3: perceptions on audiological rehabilitative training audiologists have indicated that limitations in training negatively impact their counselling practices (makhoba & joseph, 2016). therefore, training focused on counselling skills may have a positive impact on audiologist counselling practices. all (n = 7) participants in this category expressed their perceptions of audiologists to be well trained and capable of counselling, with the main attributes being kindness, understanding and patience, as is portrayed in the given narrative. participant 1 said, ‘we were treated with the highest respect and honour and decency and kindness’. this study speculates the limited offering of adjustment counselling and use of validation tools can be attributed to similar training exposure. the patients’ perceptions are based on their experiences with services rendered to end-users, which might be conflated with audiologists’ adequate training and exposure. the researcher was mindful and appreciated that the participants’ perceptions of audiologists in terms of training competence are different based on differing levels of knowledge of the participants. therefore, for the purpose of this study, the study reported on how patients perceive audiologists’ competence. furthermore, there is an appreciation that audiologists’ competence measurement criteria are different for the patients and audiologists. as supported by epstein and street (2011), who suggested that if audiologists show mindfulness and empathy whilst being informative to patients, their role in the patient–audiologist dynamic will change from audiologists being viewed as authority figures to forming a partnership with patients, bringing about collaboration and improved patient participation. audiologists require a set of micro-skills that will allow them to show mindfulness and empathy (asha, 2012); such micro-skills, amongst others, include listening, empathy and responding to patients (beck & kulzer, 2018). these skills are used subjectively with patients and may be developed over time with practice and training (beck & kulzer, 2018). furthermore, beck and kulzer (2018) suggested audiologists’ skills may impact shared decision-making between patient and clinician. shared decision-making is critical within the pcc framework (picker institute europe, 2020). this study found that the majority of participants (six), felt that they were a part of the decision-making process during counselling. the practice of including patients in the decision-making process for assistive devices is appreciated as it is supported by makhoba and joseph (2016), who found that if patients are part of the selection of the device then there are high chances of acceptance. however, one participant reported to have not been involved in the decision-making process and attributed this to being treated at a public facility, as portrayed in the given narrative. participant 5 (69, female) stated, ‘i wasn’t there when they were making the decisions for my hearing aid; this is a government hospital’. therefore, this study found that whilst a majority of participants reported having been included in shared decision-making, these were decisions solely on their hearing device, and there are different practices between private and public sectors based on shared decision-making. studies have suggested that audiologists demonstrate varied activities during counselling practises by utilising closed or open-ended questions, taking charge as authoritative figures during the counselling session or allowing the patient to lead the session (pryce et al., 2018), depending on their training and skill level (pryce et al., 2018). however, literature focused on this study advocates for pcc that allows patients to become active participants in shared decision-making (picker institute europe, 2020). therefore, pryce et al. (2018) suggested that clinicians should better adapt their therapeutic skills to improve shared decision-making. (picker institute europe, 2020). a participant from the public sector reported to have not been involved in the decision-making process, as can be seen in the narrative from participant 5 depicted here, whereas patients from the private sector reported positively on being a part of the decision-making process. therefore, patients in the public sector may not be afforded the same opportunity during decision-making as compared with patients in the private sector. this disparity in activities and actions creates a perception of the private sector better adhering to pcc than the public sector. this is supported by kayyali, marques gomes, mason, and naik (2016), suggesting the need for improved counselling skills is required to better meet patients’ needs and expectations. therefore, it can be deduced, improving these skills amongst audiologists may prove to increase patient benefit through shared decision-making, whilst adhering to pcc dimensions. category 4: perceptions on multicultural sensitivity patients seeking audiological services have diverse cultural and linguistic backgrounds that should be considered whilst delivering services (asha, 2012). this is substantiated by owen et al. (2016), reporting that patients who perceived their therapist as less culturally sensitive showed negative outcomes from services. this is further substantiated by khoza-shangase and mophosho (2018), who conducted research focusing on audiology services offered in south africa, revealing a need to africanise services to ultimately improve patient benefit and outcomes. however, despite the documented need to africanise services, all participants in this study described a positive perception of cultural sensitivity. all seven participants described audiologists to be multiculturally sensitive, which is appreciated as south africa is a multicultural society. the participants attributed the audiologists’ multicultural sensitivity to understanding and respect of their culture as well as the diversity of patients seen in waiting rooms. this study speculates that this positive response demonstrates that audiologists’ undergraduate training on cultural sensitivity is being applied by graduates in their clinical practice. furthermore, participants 1 and 2 report on the compassionate bedside manner of the audiologist, which is positive. participant 2 (45, female) said, ‘i like that she respected the fact that i was covered and she didn’t show any irritation when i took my time to remove my scarf’. all participants further attributed their audiologists’ multicultural sensitivity to showing kindness and respect for their customs during practice; in turn, all participants described their experience of counselling to be pleasant, possibly attributed to their understanding of multicultural sensitivity, which this study appreciated. this is substantiated by owen et al. (2016), who reported that patients who perceived their therapist as less culturally sensitive showed adverse outcomes from services. this was further verified by this study, where the perception of cultural sensitivity by the patient was positive as portrayed in the following narrative. participant 1 said, ‘i think we were treated with the highest respect and honour and decency and kindness’. the patient’s positive perceptions of multicultural sensitivity is supported by literature, advocating for multicultural sensitivity in providing holistic management for patients for increased patient benefit (de man et al., 2016). this is substantiated by de man et al. (2016), generating a link between patient satisfaction from pcc approaches and multicultural service delivery. in addition, the participant’s perception of cultural sensitivity differs from that of the audiologist, as issues of their own cultural beliefs were not considered to be part of cultural sensitivity. cultural beliefs play an integral part in multicultural sensitivity, as supported by govender and khan (2017) documenting that patients have cultural beliefs related to the cause of hearing loss and suggesting further training and need for audiologists to demonstrate improved cultural competence, suggesting that audiology training on cultural sensitivity is different from how these patients perceive cultural sensitivity. another disjuncture between audiologists and patients in terms of cultural sensitivity is identified in this study, as with the initial study. both studies have found that there is no similar understanding of the definition and application of cultural sensitivity. however, finding a consensus is not the focus of this study. furthermore, de man et al. (2016) suggested that the ability of audiologists to include and respect multicultural services aids in promoting patient satisfaction. category 5: perceptions on patient satisfaction all participants positively described their overall benefit and satisfaction from counselling practices. participants attributed this to the skill set of the audiologists, as they were described as kind, patient and understanding. all participants reported to have benefited from counselling and attributed this benefit to their understanding of their hearing impairments as seen in the given narrative. furthermore, they expressed satisfaction with the services received: ‘it did [meet expectations], with my understanding and acceptance of the hearing loss, i’m still a bit scared about it. the counselling session did help me with accepting my hearing loss.’ (participant 6, 34, female) apart from understanding their hearing loss, all participants reported satisfaction from their counselling as it led to compensating through hearing devices, which has improved their quality of life (parham et al., 2013). this is laudable as it demonstrated that audiology practice for patients with presbycusis and associated tinnitus is meeting their expectations, which has a positive impact on their outcomes. moreover, participants reported satisfaction based on the audiologist’s skills as seen in the given narrative. participant 2 (45, female) said, ‘i don’t have any complaints. i felt that i was comfortable. i was at ease, i don’t have any complaints, she was sweet, she was polite, she was patient’. the given narrative indicates that the patient reported satisfaction because the audiologist’s demeanour was demonstrated during counselling, which is supported by literature noting audiologists with essential skills conducive to counselling will increase patient satisfaction (alex et al., 2019). this finding is further substantiated by english and archbold (2014), based on a study in the united kingdom on a group of 20 audiologists attending a programme to expand their knowledge on counselling. the study concluded that pcc may improve patient–audiologist dynamics and patient satisfaction, which is inherent with findings from this study. the initial study on audiologists’ counselling practices coupled with this study has found that evaluation of patient satisfaction is not routinely performed, which is concerning within the pcc framework as the patient’s perception and satisfaction has not been extensively incorporated. category 6: recommendations to improve counselling practices patient-centred care dimensions focus on the patient’s individual needs and preferences, which are used to drive services to improve patient benefit and satisfaction (balachandran, 2020). therefore, heeding patients’ recommendations may lead to improved counselling practices specific to the context of kzn. participants provided recommendations towards improving counselling practice in the following points. firstly, participants’ recommendations were to extend the time of sessions to better understand their patients, as can be seen in the following narrative: ‘the counselling session was a little bit pressurised and maybe there were many patients and the time is short and the audiologist it is not sensitive to the particular needs and just wants to rush through things and get the job done, it is in those constraints, they may not necessarily pick up deeper-lying issues it won’t surface unless time is given to hear the person out and they might just jump to conclusions they make on just thinking that they understand the situation and then act accordingly.’ (participant 1, 67, male) increasing the number of sessions or split sessions may help to avoid overwhelming a patient with volumes of information: ‘i would’ve broken it down, i would seat the patient down and explain what’s wrong firstly and do what my audiologists did and tell them there is no medication to help the problem that i have and then tell the patient that these are your options i can fit you with a hearing aid and see how that goes and things like that and then do it on another day.’ (participant 2, 45, female) secondly, participants recommend including a significant other in the counselling session as well as an interpreter in case of language differences: ‘i would like when a patient is being seen and there is a language barrier, i would like when that patients is seen thats not speaking english to have an isizulu speaking translator during the appointment.’ (participant 5, 69, female) thirdly, participants recommend providing more information on hearing impairment or vocational possibilities for those with a hearing loss that may be shared with others out of the counselling session. participant 6 (34, female) said, ‘i think they need to add more advice or information about what jobs we can do with a hearing loss or what jobs we can go into’. these recommendations by participants provide audiologists with insight into first-hand perceptions of patients to better implement pcc in practice. study limitations and strengths this study provides a perspective from a group of participants with presbycusis and associated tinnitus from different districts that are inclusive of urban and rural areas with different stratification of the population. furthermore, the inclusion of private and public sectors provides for different perspectives and lived experiences by the participants. views of a smaller sample population cannot represent the entire population as the sample was limited in terms of diversity. conclusion there is limited research on patients’ perceptions of counselling practices in audiology (meibos et al., 2017), thus creating a knowledge gap that has contributed to the insufficiencies of implementing pcc into audiology counselling practices, inadvertently impacting patient outcomes. this study found positive perceptions where information counselling was dominant over adjustment counselling. there is a need for audiologists to increase focus on adjustment counselling to address the needs of the patients towards adjusting and living with presbycusis and associated tinnitus. there is concern related to patient confidence and ability to relate their diagnosis and assistive device; it was found to be limited, suggesting gaps in informational counselling practice by audiologists. this creates a need for improvement in informational exchange during counselling. positive perception and preference for individual over group counselling sessions was reported; however, audiologist are urged to discuss the benefit of group sessions and offer the option as part of the service package. positive perceptions towards tools to assess efficacy were observed, but there are diverse levels of knowledge and use of efficacy tools between audiologists and patients, suggesting desynchrony in the understanding of tools between audiologist and their patients related to tool use during counselling. therefore, further research is required to explore the efficacy and patient benefit from these tools. furthermore, as part of their practice, audiologists need to explain the tools and their benefit to patients and conduct verification based on objective tools. there was a positive regard for and confidence in the audiologists’ training and perceived competence, with caution on the disparity between the competency as rated by the audiologist versus the patients; this needs further exploration. patients considered their audiologists to have adequate training and competence if they demonstrated empathy and shared decision-making. the patient’s perceptions were inclined to show satisfaction and benefit towards counselling practices currently being conducted by audiologists within kzn. these practices when exploring patients’ perceptions suggested that audiologists are implementing pcc dimensions into practice. however, further research can assist in identifying barriers and subsequently evaluate and improve implementation of pcc in the field of audiology holistically. however, this study’s findings on patients’ recommendations on improving counselling closely resembled pcc dimensions and the conceptual framework depicted in this study in terms of implementing the eight picker principles. these recommendations made by participants further assist in closing the knowlegde gap in practice. however, further research if requried on effective ways of implementing pcc into practice (meibos wt al., 2017). however, further research is needed to provide quantitative evidence on the efficacy of counselling practices in line with pcc, as this study provided the qualitative aspect. acknowledgements the authors would like to extend their thanks to all participants of this study, the department of health kwazulu-natal, south african association of audiologists, south african speech-language-hearing association and the consulting statistician. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions the author k.b. conceptualised the study, conducted the data collection and wrote the manuscript. v.z.p. supervised the research process, provided input into conceptualising the study and approved the final manuscript. ethical consideration ethical clearance was obtained from the humanities and social sciences ethics committee of the university of kwazulu-natal (ukzn) with the reference number hssrec/00002114/2020. permission to conduct research was also obtained from the kwazulu-natal directorate of disability and rehabilitation and the kwazulu-natal health research committee (no. kz_202011_036). the study adhered to the declaration of helsinki code of conduct for ethical research (goodyear, krleza-jeric, & lemmens, 2007). funding information this research received no specific grant from any funding agency in the public, 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(2020). presbycusis-related tinnitus and cognitive impairment: gender differences and common mechanisms. in sevgi akarsu (ed.), multiple chronic conditions-overview and management of chronic disease clusters. london, uk: intechopen. abstract introduction methods results discussion conclusion acknowledgements references about the author(s) nyasa e. groenewald department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa maria du toit department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa marien a. graham department of science, mathematics and technology education, faculty of education, university of pretoria, pretoria, south africa carl swanepoel lcm voice clinic, medical centre, groenkloof life hospital, pretoria, south africa giselle maartens lcm voice clinic, medical centre, groenkloof life hospital, pretoria, south africa jeannie van der linde department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa citation groenewald, n.e., du toit, m., graham, m.a., swanepoel, c., maartens, g., & van der linde, j. (2022). reflux symptoms and vocal characteristics in adults with non-organic voice disorders. south african journal of communication disorders, 69(1), a935. https://doi.org/10.4102/sajcd.v69i1.935 original research reflux symptoms and vocal characteristics in adults with non-organic voice disorders nyasa e. groenewald, maria du toit, marien a. graham, carl swanepoel, giselle maartens, jeannie van der linde received: 06 apr. 2022; accepted: 08 sept. 2022; published: 26 oct. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: laryngopharyngeal reflux (lpr) is prevalent and can lead to voice disorders, but its diagnosis is difficult, because of limited correlations between clinical symptoms and organic pathology. various tools and methods have been explored to aid a diagnosis of lpr. objective: to investigate associations between reflux symptoms, acoustic-, perceptual-, and physical vocal characteristics, glottal function index (gfi), and vocal handicap index (vhi) in adults with non-organic voice disorders. methods: data of 51 adults with non-organic voice disorders were collected, using a retrospective cohort explorative research design, at a private ear, nose and throat specialist practice in gauteng, south africa. quantitative outcomes were compared between reflux symptom index (rsi), acoustic characteristics (jitter, shimmer and fundamental frequency [f0]), maximum phonation time, perceptual(grbasi) and physical vocal characteristics, gfi and vhi. results: the rsi showed positive fair correlations against gfi, vhip and caffeine intake, indicating an increase in reflux symptoms with higher scores on the various measures. moderate correlations were also found between gfi and vhip, grade of hoarseness and jitter, strain and vhip, strain and vhi total (vhit) and between asthenia and jitter. very strong correlations were found within the various subsections of the vhi as well as between jitter and shimmer and between f0-male and physical symptoms of the vhi (vhip). conclusion: results indicated associations between reflux symptoms, vocal characteristics, the gfi and the vhi. based on the correlations found these tools used in conjunction could improve clinical diagnosis of lpr. implications of these findings are promising, but further research is recommended. contribution: this study contributes to the body of knowledge to support the accurate clinical diagnosis of lpr using subjective measures to determine lpr symptoms, as well as acoustic analysis. keywords: acoustic characteristics; laryngopharyngeal reflux; rsi, vocal characteristics; vhi; voice disorders. introduction approximately 30% of the global adult population present with a chronic voice disorder (roy et al., 2005), and more than 50% of patients with voice disorders also present with a form of reflux, more specifically, laryngopharyngeal reflux (lpr) (kaplan et al., 2014; koufman et al., 2000, 2002). another frequent form of reflux, which may be confused with lpr, gastroesophageal reflux disease (gerd), is found in 15% of the global population (eusebi et al., 2018). a study conducted amongst ear, nose and throat specialists in private healthcare in gauteng, south africa reported an lpr incidence rate of 15% (fourie et al., 2017). although south african statistics from all healthcare contexts are unavailable, the global prevalence of reflux-related voice disorders supports the need for investigation into this population. voice disorders are diagnosed when voice quality, pitch and/or loudness are inappropriate in comparison with individual’s peers of similar age, gender and cultural group (aronson, 1990; aronson & bless, 2009; boone et al., 2020), and can be classified as organic or non-organic (voerman et al., 2009). organic voice disorders are caused by neurological or structural abnormalities. a non-organic voice disorder, on the other hand, is defined as a voice with impaired sound in the absence of causal organic laryngeal pathology (aronson, 1990; seifert & kollbrunner, 2005; van thal, 1961; voerman et al., 2009). non-organic voice disorders are also frequently referred to as ‘psychogenic’ or ‘functional’ voice disorders (seifert & kollbrunner, 2005). these terms are not necessarily interchangeable, but rather fall under the term non-organic voice disorders (voerman et al., 2009). certain voice disorders can be caused or worsened by reflux-related disorders, such as lpr (belafsky et al., 2001; khan et al., 2006; ulualp & toohill, 2009). initially, lpr was thought to be a manifestation of gerd (oyer et al., 2009), but in 1991, it was described for the first time as a disease distinct from gerd (koufman, 1991). gerd refers to the backflow of contents from the stomach into the oesophagus, whereas lpr refers to the backflow of contents from the stomach, past the oesophagus, into the laryngopharynx (koufman et al., 2002). lpr and gerd also have distinct clinical differences in terms of patient characteristics, pathophysiology and symptomatology (belafsky et al., 2002; johnston et al., 2013). individuals with gerd experience heartburn, have dysmotility of the oesophagus, are often obese, and while in the supine position their reflux mainly takes place at night (belafsky et al., 2002). in contrast, individuals with lpr do not experience heartburn, have normal oesophageal motility, and do not tend to be obese, and their reflux occurs mainly during the day (belafsky et al., 2002). because of these clinical differences, the outcome measures and diagnostic methods used for gerd are not always suitable for lpr (belafsky et al., 2002; johnston et al., 2013). even though a distinction has been made between lpr and gerd, lpr is still not well-understood, which complicates its diagnosis and the use of outcome measures (johnston et al., 2013). the dubiety regarding lpr is partly because of a lack of correlation between the severity of patient symptoms and the severity of the organic pathologies found in the larynx (belafsky et al., 2001). this discrepancy is caused by vocal symptoms, such as hoarseness and vocal fatigue, being resolved more quickly during treatment than the laryngoscopic findings, such as oedema and mucosal hypertrophy (belafsky et al., 2001). to further complicate diagnosis, differentiation between lpr and other laryngeal pathologies with the same presentation, as well as the co-occurrence of these conditions, must also be made. diagnosing both gerd and lpr can be divided into two approaches: investigation-based and symptom-based. the investigation-based approach is expensive, time-consuming, invasive, not globally available and has certain limitations (kaplan et al., 2014). investigation-based diagnosis uses proton pump inhibitor (ppi), endoscopy and ph testing. the investigation-based ppi test used for diagnosing gerd has been found to be controversial for diagnosing lpr (johnston et al., 2013). endoscopy methods are limited because of their inability to detect lpr cases, where there are laryngeal lesions without visually perceptible oesophageal involvement (kaplan et al., 2014). ph monitoring methods are limited as well because of the diagnostic criteria for many ph probe studies having excluded patients who experience acid reflux but lack endoscopic evidence of acid reflux, thus only representing a segment of the range of patients with reflux and resulting in limited accuracy and low sensitivity (60%) of 24 h ph monitoring for these patients (reynolds, 2007). the symptom-based approach relies on interviews and structured questionnaires (vakil, 2013); however, up to 50% of patients with extraesophageal symptoms of gerd do not present with typical esophageal symptoms, such as heartburn (johnston et al., 2013; vakil, 2013). therefore, because of the limitations of the investigation-based approach and the uncertainty of symptom-based diagnosis results, new diagnostic methods are needed for lpr. in an effort to aid the accurate diagnosis of lpr, belafsky et al. (2002) developed the reflux symptom index (rsi). the rsi showed good criterion-based validity, as it accurately documents symptoms and improvement in patients with lpr (belafsky et al., 2002). contradictory findings on the reliability and validity of the rsi have, however, been reported (hoon park et al., 2006). to further improve the diagnosis of lpr using the rsi, some researchers have started exploring the possible relationships between the rsi and other vocal characteristics, including hoarseness, breathiness, strain and instability (lechien et al., 2016; mesallam et al., 2007). it has also been suggested that the relationship between the rsi and different subgroups of voice disorders should be investigated in order to further improve the precision of its use in diagnosis (watson et al., 2013). if associations are found between the rsi and certain subgroups of voice disorders, its value as a diagnostic tool may increase. in additional attempts to develop new diagnostic methods, studies have explored the preand post-test treatment outcomes in adults with lpr (karkos et al., 2007; lechien et al., 2016; watson et al., 2013). these studies indicated that significant correlations exist between lpr and acoustic and perceptual vocal characteristics, with a significant decrease in jitter, shimmer, vocal handicap index (vhi) and perceptual characteristics (grbasi) scores 3 month post-treatment of lpr (lechien et al., 2016; watson et al., 2013). another study found an association between lpr and functional dysphonia (a non-organic voice disorder) for two ph parameters (the longest reflux episode in a supine position and the fraction of time the ph was less than four in a supine position) – recommending larger studies on the link between lpr and functional dysphonia (karkos et al., 2007). this substantiates the need for research to explore the relationships between acoustic, perceptual and physical vocal characteristics (lechien et al., 2016; watson et al., 2013) in patients with lpr and non-organic voice disorders. thus, the research question posed in this study is as follows: what are the associations between reflux symptoms and vocal characteristics (voice quality and voice handicap, as well as patient stroboscopy reports) in adults with non-organic voice disorders? methods study design a retrospective cohort explorative research design (sedgwick, 2014) was employed to investigate data sets, case histories, self-rating assessment questionnaires regarding perceived lpr symptoms, voice quality and voice handicap as well as patient stroboscopy reports. setting data collection took place from april to july 2019 and was obtained from the existing database of an established clinical ent, specialising in voice disorders, at a private hospital in gauteng, south africa. study population and sampling strategy participants were adults aged 18 and older. individuals with organic pathologies and underlying neurological causes were excluded to ascertain that changes in vocal characteristics were not because of any physical factors. in addition, research has shown that treatment can cause a ‘suggestive effect’ by causing an improvement in one tool (subjective rsi scores) while not in the other (objective reflux finding scores (rfs) [e.g. oedema, oroand hypopharyngeal erythema and laryngeal keratosis]) (lechien et al., 2018). reassessment data could thus affect the correlations and associations between the rsi and other assessment tools. consequently, to avoid confounding variables, reassessment data sets were excluded and only the data of initial assessments were collected. only data sets containing a primary diagnosis, vocal fold edge data, a complete rsi, and at least one other complete assessment measure, were included. some participant data sets included up to three diagnoses – classified as primary, secondary and tertiary – where secondary and tertiary diagnoses specify coexisting conditions other than the main condition affecting the participant’s voice. for example, a participant may have a primary diagnosis of hyperfunctional dysphonia with a secondary diagnosis of lpr. the main diagnoses that were given to participants, based on physical examination, acoustic and perceptual voice analysis as well as self-rating scales, were functional dysphonia, hyperfunctional dysphonia and muscle tension dysphonia (mtd). hyperfunctional dysphonia and mtd both fall under functional dysphonia, but have progressed enough so as to warrant more specific diagnoses. hyperfunctional dysphonia is specific to the misuse and abuse of the voice, whereas mtd is specific to a functional dysphonia that specifically involves muscle tension (van houtte et al., 2011). from a database of more than 800 clients, 143 met the inclusion criteria, of which 68 were excluded because of missing or incomplete rsi data sets, and six because of the multi dimensional voice programme (mdvp) having been used with them instead of the praat programme. praat is a programme used to analyse and reconstruct recorded speech signals (boersma & weenink, 2022). the mdvp and praat programmes are similar programmes used for the analysis of voice, but individual numerical values obtained by each programme have been shown to vary greatly, making the combined use of results from these programmes inadvisable (amir et al., 2009). thus, the data of 51 participants with non-organic voice disorders were analysed. materials and apparatus the dependent variable was the rsi which measured the subjective reflux symptoms of each patient. the independent variables were gender, age, caffeine intake, physical vocal characteristics, glottal function index (gfi), vhi, jitter, shimmer, fundamental frequency (f0), maximum phonation time (mpt) and perceptual characteristics (grbasi). the rsi is a likert-scale questionnaire consisting of nine questions, as outlined in table 1 (belafsky et al., 2002; lee et al., 2018). each question is answered by selecting a number from zero to five, ranging from no problem to severe, respectively (johnston et al., 2013). the total score can be any number between 0 and 45 (johnston et al., 2013), with a score greater than 13 being considered as abnormal (belafsky et al., 2002). table 1: reflux symptom index. this study looked at the following physical vocal characteristics: vocal fold edge, glottic closure, mucosal wave, periodicity, phase closure, phase symmetry and vertical level of approximation. the physical vocal characteristics were observed by means of a fibreoptic flexible distal chip optic camera stroboscopy examination. a fibreoptic stroboscopy examination is considered to be the clinical ‘gold standard’ for assessing vocal fold function (bonilha et al., 2015). acoustic characteristics, such as jitter, shimmer and f0, were also analysed. jitter is the measure of the variation of periodicity in the fundamental frequency of the vibratory characteristics of the vocal folds. a jitter score higher than one is considered abnormal (schwartz, 2004; teixeira & fernandes, 2014). shimmer is the measure of the variation of periodicity in the amplitude of the vibratory characteristics of the vocal folds, with an abnormal score being anything higher than 5 (schwartz, 2004; teixeira & fernandes, 2014). f0 is the lowest frequency of the voice which correlates with a physical measure of vocal fold vibration, with a score lower than 175 or higher than 230 being considered abnormal for females, and a score lower than 110 or higher than 160 being considered abnormal for males (ferrand, 2012; teixeira & fernandes, 2014). the grbasi 4-point rating scale (yamauchi et al., 2010) is a measurement for the perceptual evaluation of voice quality and is widely used because of its brevity and user-friendliness. it looks at six characteristics of voice quality, including grade of hoarseness (g), roughness (r), breathiness (b), asthenia (a), strain (s) and instability (i). the vhi is a likert-scale questionnaire which measures the perceived psychosocial effect of voice disorders and consists of 30 items, each of which can be scored between zero and four, with a maximum total score of 120 (johnston et al., 2013). vhi abnormal scores vary for each subsection. the symptom-focused vocal impairment of each participant was measured using the gfi. the gfi is a self-administered likert-scale questionnaire which has four questions and is answered by selecting a number from zero to five, with a possible score ranging from 0 to 20 (johnston et al., 2013), with a score higher than four being considered as abnormal (bach et al., 2005). data collection data collection took place at the voice clinic, where data dating from 2015 to 2019 were extracted from electronic assessment reports and then manually inserted into an ms excel spreadsheet. the data were then manually coded. the rsi, vhi, gfi and case history were completed subjectively by each client. flexible distal chip stroboscopy examinations were used by the ent to conduct objective patient evaluations. in addition, the speech-language therapist (slt) used the grbasi and the praat computer programme to evaluate the patients’ perceptual and acoustic vocal characteristics, respectively. the ent and the slt who conducted the assessments both had more than 10 years of experience in treating voice disorders, ensuring reliable outcomes (ajmi & aase, 2021). the cross-check principle was used to ensure the accuracy of measurements. this principle is used to improve accurate diagnosis by cross-checking the results of a single test, in this study the rsi, against an independent test measure; in this case, the reported stroboscopy evaluation outcomes, thus confirming the results of the first test (hall, 2016; jerger & hayes, 1976). this principle was used to account for the reported contradictory findings regarding the rsi’s validity and reliability (hoon park et al., 2006). the ent and slt reached consensus with the classification (mild, moderate or excessive) of caffeine intake. in addition, bias of evaluation may have influenced grbasi scores, as the rater had prior knowledge of the patient’s symptoms and history and was, therefore, not blinded during the scoring of the grbasi. data analysis the statistical package for social sciences v24 was used by a statistician to analyse data. descriptive statistics were calculated for the different variables. for continuous variables, the shapiro–wilk test showed a lack of normality; thus, nonparametric tests were used (field, 2018). the spearman correlation coefficient (rs) was used for correlations between continuous variables; the chi-square test was used to test for associations between nominal categorical variables. because of a small cohort and sparse data, the p-value of the fisher’s exact test was used to determine associations instead of the p-value of the chi-square test. the ad hoc tests – phi coefficient and cramer’s v – were used following the chi-square test to determine the strength of association. a statistically significant correlation (or association) exists if the p-value is less than 0.05 (field, 2018). correlations range from -1 to +1; the categorisations of their strength (i.e. poor, fair, moderate, very strong and perfect) were done as per the recommendations of a 2018 user’s guide to correlation coefficients (akoglu, 2018). a positive correlation indicates that as one variable increases, so does the other, and vice versa, whereas a negative correlation indicates that as one variable increases, the other decreases and vice versa. phi coefficients and cramer’s v range from 0 to 1; categorisations of their strength were again done as per the guidelines in the 2018 user guide (akoglu, 2018). only statistically significant correlations and associations are reported on. the level of significance and the power of this study are 0.05 and 0.9685, respectively. it should be noted that a statistical power of 0.8 or higher indicates that the sample size was large enough to ensure statistical power. this being said that, prior to data collection, an a priori power analysis was conducted using g*power version 3.1.9.4 (faul et al., 2007) to compute the required sample size needed for a power of at least 0.8. for conciseness, details are omitted here, as the achieved power was greater than 0.8, indicating that the sample size was sufficient for the tests conducted. ethical considerations an application for full ethical approval was made to the institutional review board (university of pretoria faculty of health sciences research ethics committee), and ethics consent was received on 27 march 2019, reference number: 1/2019. all data sets used, had previously signed voluntary informed consent forms, giving permission for future research projects to use the data. a permission letter was also obtained from the ent of the private voice clinic to analyse the existing database. the study was conducted in accordance with the helsinki declaration as revised in 2013 (world medical association, 2013). results the data of 51 participants with non-organic voice disorders were analysed, of which 33% were male and 67% were female. ages ranged from 18 to 77 years (mean = 45.61; standard deviation [sd] = 15.430). no gender or age effect was found. the most prevalent primary diagnoses were mtd (29%) and lpr (28%). many participants (63%) had either primary, secondary or tertiary diagnosis of lpr, of which 94% had abnormal rsi scores. only 10% were smokers and 70% were excessive caffeine drinkers (more than 15 cups per week) (table 2). table 2: associations of reflux symptom index with demographics of participants. table 3 summarises the abnormal descriptive values and results of the rsi, gfi, vhi, jitter, shimmer, mpt and fundamental frequency (f0). because of separate f0 normative data for males and females, f0 data were analysed according to gender. f0-male showed a positive correlation with the vhip (rs = 0.874 [very strong]; p = 0.005) (table 3). positive correlations were found between the rsi and the gfi (rs = 0.366 [fair]; p = 0.008), and the rsi and the vhip subsection (rs = 0.302 [fair]; p = 0.035) (table 3); thus, as the score increased on the gfi or the vhip subsection, the rsi score also increased. a positive correlation was found between the rsi and caffeine intake (rs = 0.322 [fair]; p = 0.043) (table 2). most participants with excessive caffeine intake (70%) had abnormal rsi scores (96%). table 3: abnormal outcomes and spearman correlations between self-rating and acoustic variables. all the correlations between jitter, shimmer, mpt, gfi and vhi were positive, except for correlations with mpt, which were negative (table 3). the strongest of these correlations were between: vhip and vhie (rs = 0.926 [very strong]; p < 0.001), vhif and vhie (rs = 0.906 [very strong]; p < 0.001), vhif and vhip (rs = 0.875 [very strong]; p < 0.001), jitter and shimmer (rs = 0.888 [very strong]; p < 0.001) and between gfi and vhip (rs = 0.761 [moderate]; p < 0.001). the mean for each of the grbasi sections ranged from 0.76 to 1.29 (0 = normal; 1 = slight pathology). all correlations between the grbasi and rsi, gfi, vhi, jitter, shimmer and mpt can be found in table 4. the strongest correlations were: g and jitter (rs = 0.755 [moderate]; p < 0.001), s and vhip (rs = 0.754 [moderate]; p < 0.001), s and vhit (rs = 0.714 [moderate]; p < 0.001) and a and jitter (rs = 0.704 [moderate]; p < 0.001) (table 4). table 4: spearman correlations of the grbasi (n = 41)† with self-rating and acoustic variables. according to physical examination results, 16% showed open phase predominates for phase closure, whereas 84% showed normal phase closure. a positive correlation was found between the rsi and phase closure (rs = 0.424 [fair]; p = 0.035), indicating that patients with normal phase closure scored low on the rsi and those with abnormal phase closure scored high on the rsi (table 5). table 5: associations of rsi with physical vocal characteristics. discussion comparisons with other studies this study explored the associations between lpr symptoms, vocal characteristics and patient-completed questionnaires, to better understand the characteristics and diagnosis of lpr. more than half of the participants (63%) had a primary, secondary or tertiary diagnosis of lpr. the analysis of the associations between rsi, mpt, vhi, gfi, acoustic-, perceptual-, and physical vocal characteristics produced various significant correlations. correlations between the grbasi and other variables varied from fair to moderate. the strongest of these was between g and jitter (rs = 0.755 [moderate]; p < 0.001). other studies have found similar results, and the correlation between jitter and g is the most constant finding when comparing acoustic variables with grbasi (lechien et al., 2016; ziwei et al., 2014). this might be explained by the close relationship between jitter and the stability of mucosal movement of the vocal cords, which is also affected by airflow and amount of mucous on the vocal cords, which in turn is linked to hoarseness of voice (jin et al., 2008). thus, an improvement in hoarseness of voice should reflect in the jitter. other correlations with jitter were all fair except between jitter and shimmer (rs = 0.888 [very strong]; p = 0.005). these results confirm recent findings for correlations between jitter and shimmer (karlsen et al., 2018; ziwei et al., 2014), and between jitter and vhip (dehqan et al., 2017; karlsen et al., 2018; ziwei et al., 2014). the correlations, between perturbation (jitter and shimmer) and vhip, indicate that there is a common underlying entity, that is, vocal fatigue associated with functional voice disorders, between them (karlsen et al., 2018; ziwei et al., 2014). a positive correlation was found between rsi scores and caffeine intake vhip and f0-male (rs = 0.874 [very strong]; p = 0.005), but all other significant correlations between the vhi and acoustic variables were fair. this may be because of the non-organic selection criteria of this study, as research has indicated that associations are not strong between vhi scores and acoustic parameters in participants without direct vocal cord disease (dehqan et al., 2017; karlsen et al., 2018; schindler et al., 2009). further research, exploring acoustic scores and subjective parameters across populations with specific vocal pathologies, is needed (karlsen et al., 2018; ziwei et al., 2014). a positive correlation was found between high rsi scores and excessive caffeine intake (rs = 0.322 [fair]; p = 0.043), indicating that participants with excessive caffeine intake had higher rsi scores. although some studies have shown that caffeine intake may be related to reflux (pehl et al., 1997), more recent literature has found this data weak (katz et al., 2013; kroch & madanick, 2017). the relationship between caffeine and the rsi specifically has not been explored to the authors’ knowledge. the analysis of the associations between reflux symptoms and acoustic-, perceptual-, and physical vocal characteristics, gfi and vhi produced three statistically significant fair correlations. correlation between the rsi and physical vocal characteristic phase closure was positive, indicating that patients with abnormal phase closure were more likely to have reflux than those with normal phase closure (rs = 0.424 [fair]; p = 0.035). no other studies have explored this relationship and further research is, therefore, necessary. the correlation between rsi and vhip was positive (rs = 0.302 [fair]; p = 0.035), indicating a link between patients’ perception of their physical voice symptoms and of their reflux symptoms. similar correlations were reported, showing a positive correlation between improved rsi and vhi scores after treatment (belafsky et al., 2002). in addition, a positive correlation was found between the rsi and the gfi (rs = 0.366 [fair]; p = 0.008), indicating a link between glottal dysfunction and increased reflux. this presents the possibility of the rsi being used in conjunction with the gfi when evaluating lpr. this relationship has also not been explored in the past, perhaps because of the gfi having been created to assess glottal dysfunction and not specifically lpr (bach et al., 2005). thus, if further research confirms these correlations as meaningful, the rsi may be used with the gfi and vhi for more reliable diagnosis of reflux-related voice disorders. in future studies, objective clinical testing should be included so as to ensure that unbiased results are obtained for comparison. currently, however, empirical treatment is considered best practice for the diagnostic confirmation of reflux-related voice disorders (falk & vivian, 2016). reported associations between the rsi and vocal characteristics may be an indicator of the individuals who would benefit from empirical diagnostic testing. correlations of moderate strength were found between the gfi and the vhip, vhit, vhie and the vhif. little research is available on the relationship between the gfi and vhi other than that by bach et al. (2005), who found a correlation of 0.61 (p < 0.001) between total gfi and vhi scores, which significantly reduced post-therapy for organic voice disorders. however, albeit not the aim of the current study, these significant correlations indicate that although these are two distinct clinical tools, they may both be used in conjunction with the rsi to increase reliability in monitoring vocal pathology. as significant correlations were found between the rsi and vhip and between the vhi and gfi, these relationships should be further explored to establish whether the rsi, gfi and vhi have meaningful significant relationships, which could make the diagnosis of lpr using subjective-based instruments more certain. clinical applicability of the study the results of this study indicate that associations exist between reflux symptoms and vocal characteristics, but further research is necessary to determine whether these results hold any true value for improving the diagnostic criteria for lpr. strengths and limitations because of the strict exclusion criteria, confounding variables were limited and results were very specific. all data measures that were included are applicable to the typical voice practice. in addition, this study also has a high achieved power (0.9685) with a high power (typically 0.8 or greater), indicating that there is a large chance of a significance test detecting a true correlation or association. limitations of the study include the strict exclusion criteria and retrospective nature of this study made it necessary to exclude participants who met the requirements, but did not have complete rsi forms, and may have led to selection bias. the cohort size (n = 51) of this study was smaller than expected. only a minority of people seek private healthcare services for their voice disorders, even though its subjective impact on their lifestyles may be significant in terms of vocational demands and social interaction (bhattacharyya, 2014). furthermore, fourie et al. (2017) found that the incidence of voice disorders amongst private practices in gauteng specifically was only 5.2% (fourie et al., 2017). it can be expected that the prevalence of voice disorders is much higher than the incidence rate but that very few people seek treatment (fourie et al., 2017), often because of time and leave constraints, as well as a lack of awareness of when to seek help and whom to seek help from (da costa et al., 2012). an international study reported that people often seek help only when it severely affects their ability to perform their vocational duties (roy et al., 2005). this, together with the strict exclusion criteria, may explain the small cohort, which limited the types of statistical tests that could be used for data analysis. conclusion this study found significant correlations between the rsi and phase closure, gfi, vhip and caffeine intake. these correlations, however, were not very strong and require further exploration. various correlations between the jitter, shimmer, f0-male, grbasi, mpt, gfi and vhi were found, varying from poor to very strong. these results support existing research and indicate that there are underlying associations between reflux symptoms and vocal characteristics in adults with non-organic voice disorders. further investigation is needed to establish the degree of significance of these findings. to determine whether the rsi, phase closure, the gfi and vhip would improve the accuracy of the diagnosis of lpr, future research would have to compare these parameters within different subgroups of voice disorders, such as functional dysphonia, instead of within the broad group of non-organic voice disorders. this would allow the researcher to determine whether results are specific to certain voice disorders, improving the precision of its use in diagnosis. the manner of diagnosis of lpr for the study would also have to exclude the rsi entirely, so that correlations would not be biased towards the rsi. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions j.l., m.t., g.m. and c.s. conceived the presented idea. n.g. compiled the theory. m.g. verified and conducted analytical methods. all authors supervised the findings and editorial care of this work. all authors discussed the results and contributed to the final manuscript. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data are securely stored on the university of pretoria data repository and can be accessed once ethical clearance and permission have been obtained. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references ajmi, s.c., & aase, k. 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(2014). multiparameter voice assessment for voice disorder patients: a correlation analysis between objective and subjective parameters. journal of voice, 28(6), 770–774. https://doi.org/10.1016/j.jvoice.2014.03.014 sajcd_v69_i1&2_2022_contents.indd http://www.sajcd.org.za open access table of contents original research the influence of screen time on children’s language development: a scoping review nazeera f. karani, jenna sher, munyane mophosho south african journal of communication disorders | vol 69, no 1 | a825 | 09 february 2022 original research the lived experiences and psychosocial impact of hearing loss on the quality of life of adults with multidrug-resistant tuberculosis amanda b. thusi, jessica paken south african journal of communication disorders | vol 69, no 1 | a823 | 14 february 2022 original research systemic support for learners with developmental language disorders in zimbabwe and south africa nettie n. ndou, margaret f. omidire south african journal of communication disorders | vol 69, no 1 | a850 | 16 february 2022 original research a longitudinal community-based ototoxicity monitoring programme and treatment effects for drug-resistant tuberculosis treatment, western cape lucia j. stevenson, leigh biagio-de jager, marien a. graham, de wet swanepoel south african journal of communication disorders | vol 69, no 1 | a886 | 31 march 2022 original research communication experiences of healthcare students whilst managing adults with communication disorders vrinda rathiram, lauren o. neilson, azraa syed kassim, winnie t. mokone, caitlin c. green south african journal of communication disorders | vol 69, no 1 | a870 | 31 may 2022 original research patient’s perceptions of presbycusis and associated tinnitus counselling practices within the kwazulu-natal province kerusha bhojraj, vuyelwa z. peter south african journal of communication disorders | vol 69, no 1 | a868 | 07 september 2022 original research audiologists’ presbycusis and associated tinnitus counselling practices within the kwazulu-natal province kerusha bhojraj, vuyelwa z. peter south african journal of communication disorders | vol 69, no 1 | a869 | 08 september 2022 original research reflux symptoms and vocal characteristics in adults with non-organic voice disorders nyasa e. groenewald, maria du toit, marien a. graham, carl swanepoel, giselle maartens, jeannie van der linde south african journal of communication disorders | vol 69, no 1 | a935 | 26 october 2022 57 64 77 90 103 112 124 135 page i of iii table of contents editorial in pursuit of best practice through contextually relevant, accountable and responsive research anita edwards, faheema mahomed-asmail, anna-mari olivier, jeannie van der linde, katijah khoza-shangase, nomfundo moroe, joanne neille south african journal of communication disorders | vol 69, no 1 | a945 | 15 december 2022 opinion paper triage and dysphagia: are hospitals in the south african public health sector ready? kelly-ann kater south african journal of communication disorders | vol 69, no 1 | a852 | 30 june 2022 clinical perspective analysis of barriers and facilitators to early hearing detection and intervention in kwazulu-natal, south africa naedene naidoo, nasim b. khan south african journal of communication disorders | vol 69, no 1 | a839 | 31 january 2022 clinical perspective stitching a new garment: considering the future of the speech–language therapy profession globally bea staley, marise fernandes, ellen hickey, helen barrett, karen wylie, julie marshall, mershen pillay, harsha kathard, ryann sowden, david rochus, carol e. westby, t. rosario roman, sally d. hartley south african journal of communication disorders | vol 69, no 1 | a932 | 21 november 2022 clinical perspective middle ear pathologies in children living with hiv: a scoping review ben sebothoma, minkhenso maluleke south african journal of communication disorders | vol 69, no 1 | a934 | 28 november 2022 original research ototoxicity monitoring in south african cancer facilities: a national survey katerina ehlert, barbara heinze, de wet swanepoel south african journal of communication disorders | vol 69, no 1 | a846 | 19 january 2022 original research audiologists’ phenomenographic experiences of professional development during community service in kwazulu-natal, south africa sphilile mbhele, musa makhoba south african journal of communication disorders | vol 69, no 1 | a844 | 21 january 2022 original research newborn and infant hearing screening at primary healthcare clinics in south africa designated as national health insurance pilot sites: an exploratory study amisha kanji south african journal of communication disorders | vol 69, no 1 | a840 | 26 january 2022 1 3 7 19 24 31 41 50 vol 69, no 1 (2022) issn: 0379-8046 (print) | issn: 2225-4765 (online)south african journal of communication disorders http://www.sajcd.org.za open access table of contents original research a survey of communication supports in grade r classrooms in the western cape, south africa harsha kathard, prianka parusnath, lehana thabane, mershen pillay, zheng jing hu, jane le roux, michal harty, shelley o carrol, rizwana b. mallick south african journal of communication disorders | vol 69, no 1 | a871 | 28 october 2022 original research exploring swallowing, feeding and communication characteristics of toddlers with severe acute malnutrition casey j. eslick, esedra krüger, alta kritzinger south african journal of communication disorders | vol 69, no 1 | a874 | 31 october 2022 144 157 original research contralateral suppression of transient evoked otoacoustic emissions in adults: a normative study simone zevenster, alida naudé south african journal of communication disorders | vol 69, no 1 | a929 | 08 december 2022 original research south african speech-language therapists’ practices regarding feeding tube placement in people with advanced dementia mariaan cloete, esedra krüger, jeannie van der linde, marien a. graham, sarveshvari b. pillay south african journal of communication disorders | vol 69, no 1 | a927 | 09 december 2022 167 175 page ii of iii original research conducting clinical research in the era of the covid-19 pandemic: challenges and lessons for speech-language pathology and audiology research katijah khoza-shangase, nomfundo monroe, ben sebothoma south african journal of communication disorders | vol 69, no 2 | a898 | 18 july 2022 original research in pursuit of increasing the application of tele-audiology in south africa: covid-19 puts on the alert for patient site facilitator training katijah khoza-shangase south african journal of communication disorders | vol 69, no 2 | a900 | 20 july 2022 original research feeding practices in public hospitals’ neonatal intensive care units: an exploration into the ways in which covid-19 affected the best practice in gauteng kim a. coutts, joanne neille, nicole louw south african journal of communication disorders | vol 69, no 2 | a921 | 22 july 2022 original research middle ear status – structure, function and pathology: a scoping review on middle ear status of covid-19 positive patients ben sebothoma, katijah khoza-shangase south african journal of communication disorders | vol 69, no 2 | a910 | 25 july 2022 original research health sciences students’ perception of the communicative impacts of face coverings during the covid-19 pandemic at a south african university nasim b. khan, nolwazi mthembu, aishwarya narothan, zamahlase sibisi, qiniso vilane south african journal of communication disorders | vol 69, no 2 | a890 | 27 july 2022 original research exploring the online learning experience of first-year speech–language pathology students in a johannesburg-based university nancy barber, jenna sher south african journal of communication disorders | vol 69, no 2 | a914 | 29 july 2022 185 199 209 217 224 238 original research increasing unemployment rate amongst health professionals: will there be jobs for newly graduated south african audiologists post-covid-19? vera-genevey hlayisi south african journal of communication disorders | vol 69, no 2 | a909 | 01 august 2022 original research simulations as a mode of clinical training in healthcare professions: a scoping review to guide planning in speech-language pathology and audiology during the covid-19 pandemic and beyond nabeelah nagdee, ben sebothoma, milka madahana, katijah khozashangase, nomfundo moroe south african journal of communication disorders | vol 69, no 2 | a905 | 02 august 2022 original research challenges to infection control in early communication intervention: a scoping review bilqees achmat, berna gerber south african journal of communication disorders | vol 69, no 2 | a911 | 03 august 2022 original research the effects of covid-19 on the rehabilitation of persons with aphasia: a scoping review khetsiwe p. masuku, gift khumalo, nontokozo shabangu south african journal of communication disorders | vol 69, no 2 | a920 | 04 august 2022 original research when uncertainty becomes the norm: the chris hani baragwanath academic hospital’s speech therapy and audiology department’s response to the covid-19 pandemic sadna balton, annika l. vallabhjee, stephanie c. pillay south african journal of communication disorders | vol 69, no 2 | a913 | 08 august 2022 original research ‘all of a sudden, you know, you can’t go to these services, because of the risk of infection’: audiological service considerations at residential care homes for older persons during covid-19 victor de andrade, rethabile r.m. landman south african journal of communication disorders | vol 69, no 2 | a904 | 10 august 2022 247 255 268 282 291 302 vol 69, no 2 (2022) special collection: the impact of covid-19 in slh professions in lmics: challenges and opportunities explored sub-edited by katijah khoza-shangase (wits), nomfundo moroe (wits) and joanne neille (wits) http://www.sajcd.org.za open access table of contents original research the perspectives of speech–language pathologists: providing teletherapy to patients with speech, language and swallowing difficulties during a covid-19 context zahraa tar-mahomed, kelly-ann kater south african journal of communication disorders | vol 69, no 2 | a902 | 11 august 2022 original research cochleovestibular findings linked to covid-19: a scoping review for clinical care planning in south africa katijah khoza-shangase south african journal of communication disorders | vol 69, no 2 | a899 | 12 august 2022 original research a descriptive case report of telesupervision and online case-based learning for speech and language therapy students in vietnam during the covid-19 pandemic lindy l. mcallister, marie atherton, alison winkworth, stephanie wells, dien k. le, karina sandweg, thuy t.t nguyen, natalia henderson-faranda, sharon broadmore south african journal of communication disorders | vol 69, no 2 | a897 | 15 august 2022 original research is a hybrid of online and face-to-face services feasible for audiological rehabilitation post covid-19? findings from three public health patients nuha khatib, vera-genevey hlayisi south african journal of communication disorders | vol 69, no 2 | a907 | 17 august 2022 original research a proposed artificial intelligence-based real-time speech-to-text to sign language translator for south african official languages for the covid-19 era and beyond: in pursuit of solutions for the hearing impaired milka c. madahana, katijah khoza-shangase, nomfundo moroe, daniel mayombo, otis nyandoro, john ekoru south african journal of communication disorders | vol 69, no 2 | a915 | 19 august 2022 311 318 330 336 347 original research students’ experiences of using a writing-intense programme to facilitate critical thinking skills on an online clinical training platform: a pilot study khetsiwe p. masuku, anniah mupawose south african journal of communication disorders | vol 69, no 2 | a919 | 22 august 2022 original research application of machine learning approaches to analyse student success for contact learning and emergency remote teaching and learning during the covid-19 era in speech–language pathology and audiology milka c. madahana, katijah khoza-shangase, nomfundo moroe, otis nyandoro, john ekoru south african journal of communication disorders | vol 69, no 2 | a912 | 30 august 2022 original research the experiences of speech-language therapists providing telerehabilitation services to children with autism spectrum disorder saira b. karrim, penelope s. flack, urisha naidoo, stephanie beagle, abigail pontin south african journal of communication disorders | vol 69, no 2 | a917 | 31 august 2022 original research speech–language therapy educator reflections on the planning and implementation of education and training during the covid-19 pandemic urisha naidoo, penelope s. flack, vrinda rathiram, legini moodley, saira b. karrim, nomfundo buthelezi, vuledzani ndanganeni south african journal of communication disorders | vol 69, no 2 | a908 | 09 september 2022 original research the impact of covid-19 on speech–language and hearing professions in lowand middle-income countries: challenges and opportunities explored katijah khoza-shangase, nomfundo moroe, joanne neille, anita edwards south african journal of communication disorders | vol 69, no 2 | a937 | 09 september 2022 reviewer acknowledgement south african journal of communication disorders | vol 69, no 1 | a952 | 19 december 2022 358 365 378 390 400 415 page iii of iii abstract introduction methodology results discussion conclusion and recommendations acknowledgements references about the author(s) sphilile mbhele department of audiology, faculty of health sciences, university of kwazulu-natal, durban, south africa musa makhoba department of audiology, faculty of health sciences, university of kwazulu-natal, durban, south africa citation mbhele, s., & makhoba, m. (2022). audiologists’ phenomenographic experiences of professional development during community service in kwazulu-natal, south africa. south african journal of communication disorders, 69(1), a844. https://doi.org/10.4102/sajcd.v69i1.844 original research audiologists’ phenomenographic experiences of professional development during community service in kwazulu-natal, south africa sphilile mbhele, musa makhoba received: 28 june 2021; accepted: 27 sept. 2021; published: 21 jan. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the compulsory community service programme (csp) was implemented to improve access to healthcare and arguably facilitate the transition of graduates into independent professionals. however, its role and outcomes as a developmental platform for audiology graduates remains unclear and scant in literature. objective: to explore the qualitative differences in the experiences of professional development among new audiology graduates during their community service year at their fixed-placements in kwazulu-natal, south africa. methods: within a phenomenographic design and framework, semi-structured interviews were conducted with 12 purposively sampled community service officers (csos) of the year 2017, after obtaining ethical clearance, gatekeeper permission and participant’s consent. results: the findings were interpreted according to the tenets of phenomenography. an outcome space based on the participants’ reported experiences, revealed three categories of description: transitioning from graduate to professional, learning in the workplace during community service and professional development. the findings reflected that the work environment, supervision, resource allocation, socialisation and infrastructure contributed to qualitatively different developmental experiences of the csp. conclusion: the current model of fixed-placement of the csos exposes them to qualitatively different developmental experiences, resulting in them attaining different developmental outcomes despite being in the same programme at the same time. hence, we argue for an urgent csp review, with the aim of standardising and redefining its intended outcomes and pertinent criteria for the attainment of the independent practitioner status. keywords: professional development; community service; work-based learning; phenomenography; graduate to professional transition. introduction mandatory community service programmes (csps) are used globally by over 70 countries as an effective mode of providing healthcare services to underprivileged communities (dlamini, sekoli, & bresser, 2019; frehywot, mullan, & payne, 2010). in africa, countries such as mozambique and zambia are cases in point. in southern african countries such as lesotho and south africa, a 12-month period of community service is mandatory before graduates can be recognised as independent practitioners (frehywot et al., 2010; health professions council of south africa [hpcsa], 2021). the increased burden of disease in lowand middle-income countries, shortage of qualified healthcare professionals and the uneven distribution of resources was the impetus for the csp (mulwafu, ensink, kuper, & fagan, 2017; olusanya, neumann, & saunders, 2014). in south africa, the csp was introduced by the department of health (doh) in 1998 for medical professions such as dentistry, medicine and pharmacy, followed by the allied health professions in 2003 including audiology and speech therapy; physiotherapy, and occupational therapy (khan, knight, & esterhuizen, 2009; reid, peacocke, kornik, & wolvaardt, 2018). this was shortly followed by nursing in 2008 (govender, brysiewicz, & bhengu, 2015). this programme aimed to broaden access to healthcare services whilst facilitating professional development for new graduates (reid et al., 2018). however, the latter has not received much attention in research and the field of practice; thus, the noticeable knowledge gap in this area. this study addresses this void by providing a base on which further research can be developed regarding the csp as a developmental platform for new graduates. through this article, we respond to this question: what are audiologists’ phenomenographic experiences of professional development during community service at their fixed-placement in kwazulu-natal (kzn), south africa? in this article, we focus on the csp in south africa, yet we acknowledge that issues discussed may relate to csps in other countries. thus, this article contributes to what should be an international and global discussion regarding the values of the csps in the refinement of fit-for-purpose professionals. the year-long csp serves as a foundation for healthcare professionals to practice and refine their professional skills and knowledge (beyers, 2013; frehywot et al., 2010; reid et al., 2018). on the contrary, reid (2018) reported a lack of standardised guidelines for the implementation of the csp from the national department of health within the south african context. the infrastructural inadequacies including poor supervision and large caseloads in public hospitals contributed to a growing dissatisfaction with the structure of the csp (ross, naidoo, & dlamini, 2018; van niekerk, 2012). the available literature on the csp in south africa (khan et al., 2009; reid, 2018; ross et al., 2018; van niekerk, 2012) does not seem to discuss the significance of, and the need to standardise the minimum competencies for graduates to be certified as independent practitioners at the end of the csp, particularly in audiology. the key soft and hard skills, attitudes and knowledge required for audiologists to be considered fit for independent practice seems unclear and predominantly overlooked (reid, 2018). thus, the supervisors of community service officers (cso’s) are likely to be left to make discretionary judgements on the readiness of the csos for independent practice owing to the vague community service guidelines as observed by frehywot et al., (2010). despite these notable shortfalls, each cso is awarded the same certificate of independence. the csp ideally, should play a pivotal role in graduate development. however, the concerns regarding its unclear minimum target outcomes and indistinct guidelines are justifiable. this was the inspiration behind this study, as the authors ought to contribute an audiology perspective of such concerns. we thus, intend to facilitate a better understanding of the audiologists’ experiences of professional development during the csp, which has been a largely neglected area of audiology. whilst literature reports on professional development, as seen in a 15-year review study by reid et al. (2018) on cps for medical doctors in south africa, it is limited in its exploration of the qualitative differences in professional development and their respective impact on readiness for independence practice. the fixed-placement model of csos in south africa does not allow csos to rotate across different sites, which according to ross et al. (2018) brings about risks of inconsistency of experiences, skills and knowledge gained by the medical interns. the absence of a similar study in the field of audiology, arguably, suggested that the impact of the fixed-placement model of audiology csos on their developmental experiences compared with that of rotating across different csp sites remained a mystery. this was our primary concern. in medicine, the hpcsa extended the internship period and stipulated that rotations between clinical sites were mandatory to ensure adequate preparedness and competency in graduates (nkabinde, ross, reid, & nkwanyana, 2013). therefore, we argued that the consequences of the fixed-model of placement in audiology needed to be well researched and critically reviewed in order to devise appropriate, field-specific interventions in response to the aforementioned challenges. this article is the first of two based on a masters research project (mbhele, 2019). through this article, we report on csos’ experiences of community service in kzn within the year 2017. we also discuss the differences and the factors that contributed to those differences in their experiences. we thus, present an audiology perspective to the challenges of the csp fixed-placement model, to supplement those observed by the aforementioned disciplines. the subsequent article builds on this study’s findings as a foundation to propose possible changes to the current model of cso placement, to address the reported challenges. methodology design and framework phenomenography was adopted as the study framework and design. it guided the conceptual understanding of csos’ experiences and the adopted study methods. phenomenography is a study of qualitatively different ways in which people can experience and understand the same phenomena (marton, 1981). it is located within an interpretive paradigm as it is underpinned by the assumption that the world exists as perceived by those who live in it, and two or more individuals exposed to the same phenomenon, will have qualitatively different experiences of it (han & ellis, 2019; ireland, neofa, & harding, 2009; marton, 1981). therefore, as a study frame, phenomenography provided a lens through which the audiology csos’ developmental experiences during their community services (cs) were explored. phenomenographic experiences as they exist in the consciousness of those who lived them are either referential or structural (marton & pong, 2005). the former refers to the meaning attributed to the experiences, whilst the later refers to the aspects of the experience (han & ellis, 2019; marton & pong, 2005). applied to this study, the referential aspects pertained to what the experiences of community service meant to the csos. the structural aspect pertained to the elements of the csp that impacted the different experiences. the structural aspect comprised an internal horizon, referring to the relationship between the phenomenon and its various parts and an external horizon, which refers to the foundation of the experience (yates, partridge, & bruce, 2012). in this study, the undergraduate audiology programme at the respective universities was the foundation of the experiences and was largely supported by work-integrated learning methods. as csos’ interacted with the work context, which is inclusive of hospital staff, patients, clinical procedures and the administrative processes, their experiences of the programme were shaped. the methods of data generation and processing were developed within the aforementioned frame. methods the study was conducted in kzn, south africa because of convenience and feasibility of the data generation process that did not compromise the quality of data generation. gatekeeper permission to conduct the study in kzn was sought via email from the directorate of health research and knowledge management, the assistant director of disability and rehabilitation online application for the gatekeeper permission. the study commenced following the attainment of full ethical clearance from the university the researcher was registered with. all 28 audiology graduates, placed in kzn across the different municipalities in 2017 (table 1) were invited telephonically to participate in the study. they were contacted through their institution contact numbers, which were publicly available. the list of all csos was publicly accessible from the department of health website. a total of 12 csos agreed to participate; a participant number that was sufficient and consistent with the phenomenolgraphy design (tight, 2016). each participant had qualified with a bachelor’s degree in audiology in the year 2016. two of the 12 participants participated in the pilot study, their responses were included in the main study as minimal amendments were made to the pilot study, rendering their response relevant in the main study. the participants’ biographical information is presented in table 1. table 1: participants’ biographical information and placement in various districts in kwazulu-natal. the participants were predominately female, and they all completed their cs in rural communities. this was consistent with the demographics of the csos at the time of the study, as the profession was and is still female dominated (du plessis, 2018). targeting representative participants contributed to strengthening the contextual validity of the study’s finding (dikilitaş & griffiths, 2017). data generation and tools an interview schedule was developed by the researcher, informed by relevant literature (åkerlind, 2005; rands & gansemer-topf, 2016; reed, 2006; strydom, 2013). the interview schedule comprises three sections, including the background, experiences of cs and professional development, supplemented by probing questions. all these elements allowed for the generation of phenomenographic data that focused on the holistic and qualitatively different experiences (han & ellis, 2019; marton & pong, 2005). key information about the participants’ role and rights were discussed, then shared through the information document before each participant signed the informed consent form. all interviews were conducted in english and each interview ranged from 25 min to 60 min, which all participants were comfortable with. data analysis each audio-recorded interview was transcribed verbatim (stuckey, 2014) and uploaded into nvivo (version 11) for analysis. through content analysis, data were manually organised into key units of meaning in the form of words or phrases related to the phenomenon and the tenants of the adopted conceptual frame (erlingsson & brysiewicz, 2017). the codes were collated into themes, reflecting the different ways in which csos experienced development during their cs year (reed, 2006; ireland et al., 2009). the participants’ conceptions were arranged according to their similarities and differences and then placed into categories according to their core meaning (categories of description) (han & ellis, 2019). an outcome space was then constructed, where the conceptions were categorised and the relationships between the categories were defined (barnard, mccosker, & gerber, 1999; yates et al., 2012). therefore, in this article, the outcome space represents the qualitatively different ways professional development was experienced by csos in 2017. quality of the data the aforementioned ethics committees’ approvals of the study ensured that it would be ethically and scientifically sound. trustworthiness of the research findings was maintained through ensuring credibility, dependability and transparency (anney, 2014). selection of representative sample ensured that the data were contextually valid (dikilitaş & griffiths, 2017). the excerpts from the interviews were shared to ensure transparency (anney, 2014). the pilot study allowed for the necessary refinements in the data generation processes that could compromise the quality of the study (malmqvist, hellberg, möllås, rose, & shevlin, 2019). all possible challenges were resolved, eliminating ambiguities between researchers and participants. methodological rigour allowed for an in-depth exploration of the qualitative differences in cs enhanced transparency, ensuring that the findings are dependable (anney, 2014). ethical considerations the ethical approval and gatekeeper permission were sought and granted by the university of kwazulu-natal’s human and social sciences ethics committee (hss/1040/108m), and the department of health (kz-201809-023), respectively, before the study commenced. participants signed informed consent forms before participating. the researcher abided by the world medical association’s helsinki declaration of research ethical principles for medical research involving human subjects (world medical association, 2013). results the findings are organised according to the conceptual framework (figure 1) and presented in the outcome space (table 2), which illustrates the categories of descriptions, conceptions and key differences of how csos conceptualised their lived experiences of cs. figure 1: illustration of the characteristics of an experience. table 2: outcome space of the participants’ experiences. the findings indicate that there are differences in the cs experiences and the conceptions of csp amongst participants. participants expressed differences in the work context, supervision support and space of professional development. these results have been reported on a masters research project conducted by mbhele (2019), therefore, a brief overview will be presented in this section to illustrate the variations in the developmental outcomes stemming from one programme. transitioning from graduate to professional (the referential aspect) there were no noticeable qualitative differences in the experiences of transitioning from graduate to professional during the cs year. however, the participants’ experiences were significant in understanding the developmental role of cs, thus it is worth reporting. participants expressed that transitioning into the csp was initially difficult, as they had to deal with a surge of emotions, constructing a professional identity and the pressures of the work environment. specifically, the conceptions of transition and adaptation to the workplace were identified for this category, as discussed in the next subsection. conceptions of transition and adaptation to the workplace participants reported experiencing emotions such as anxiety, stress, frustration and exhaustion related to transitioning to a working place. some of these feelings were further exacerbated by factors such as large patient caseloads, relocation, work conflict and not having supervisors. these are amongst the external factors that contributed to the qualitative differences in experiences. from the responses, it was evident that the participants were able to develop emotional maturity and coping mechanisms during their cs in order to effectively adjust to their work environment. they reported feeling more resilient and more self-motivated as the year progressed. this is seen in the following excerpts: ‘so, i think, as i said i was very nervous at first and then you got to a point where you were bit more confident, a bit more relaxed.’ (participant 6, 25 years old, female) the participants also reported that their transitional experiences were also influenced by the noticeable differences between their previous learning environment and the workplace. they described their undergraduate training as a support-rich environment that provides ample resources for learning. conversely, other participants felt that cs gave more opportunity for learning and development than their previous tertiary institution as detailed in the following excerpts: ‘i think in terms of knowledge of different diagnosis, different pathologies that’s much better. also, just skills like i picked up much better. like in campus i had hardly done any ear moulds. i did like 2 the whole year, i only did like 3 for my whole 4 years and now i did like 20 or 30, i don’t know how many. so, things like that […].’ (participant 9, 24 years old, female) ‘yeah, because in varsity it was more following the rules whereas in comm-serve i got to do my own thing and i got to understand how i work and the people that i saw who developed my own style of doing things.’ (participant 2, 24 years old, female) the given excerpts are some of many examples indicating the effectiveness of the csp as a developmental platform for new audiology graduates. thus, participants learnt a lot about different aspects of working as a professional, as indicated in the following section, which added to their professional development as an outcome of being through the csp. learning in the workplace during cs (structural aspect-external horizon) according to strode (2010) the work context has influence over professional learning and development; be it negative or positive. thus, the explored conception of cs as a work context provides a deeper understanding into factors that affect professional development of coss. key differences in the work environments, supervision and the availability of resources amongst csos were identified and are further discussed in relation to the participants’ conceptions. work environment there were variations in the participants’ conceptions of the impact of their work environment in their development. half of the participants indicated their work environment had a positive impact on their learning and this was facilitated by availability of supervision, feeling welcomed and socialisation as seen in this excerpt: ‘my supervisor was like probably, one of the most amazing, most amazing woman i ever met and her co-worker um also she xhosa, also incredible people. […]. you know that type of … so, she also kind of made it relaxed and you know, i remember i used to offer to clean all the probes. you know like i’ll clean all the probes for you…. she was like “sit down, we’re all in this together. we are a team. like, i can learn from you as well”.’ (participant 10, 26 years old, female) others reported starting up an audiology department without supervision and work conflict to have negatively impacted their development in the workplace. furthermore, they indicated that challenges with hospital management and negative attitudes towards audiology services posed as limitations to their practice of audiology as seen in these excerpts: ‘[y]eah as much and it might have to do with limited understanding and yeah that teamwork within the tb clinic wasn’t very good. but other than that (site where participant worked) did actually have quite good resources in terms of audiology, we had a big budget for hearing aids and yeah, it was a good experience despite, yeah. management within the hospital didn’t always make it easy, that and how the whole hospital is managed also the things like ordering equipment or ordering stock or staff like that.’ (participant 7, 25 years old, female) equally, some participants observed that it was such challenges that facilitated the development of leadership skills, self-assurance and independence, as explained by the following excerpt: ‘[…] sometimes it is something that you have to, i’m trying to find right words to explain this, like you get patients that you see that okay, if i’m going to do this, this and this according to what i was taught in varsity, it won’t work. so, you get to find your own way of doing things but which doesn’t violate the rules but you get to find your own way of dealing with situations.’ (participant 4, 25 years old, male) these findings highlight the differences in the experiences of the csos, which supports the key point of concern and further necessitates the argument for change as expressed in the discussion section. the impact of resources in the practice of audiology participants were exposed to a new clinical environment that is notably different from their tertiary institutions. they reported the importance of resource availability in their experiences of professional development. they reported experiences that indicated variations in what csos considered as limited resources. factors such as staffing, equipment, management and finances were observed as resources, which were viewed as unevenly distributed within the healthcare context. some participants reported a lack of audiological equipment in the department whilst some reported limited budget allocation for equipment acquisitions. for others, the available equipment was uncalibrated, thus limiting its use. some participants only had access to basic audiometric testing equipment whilst others only lacked the advanced (electrophysiological) equipment. this and other challenges such as restricted work space impacted negatively their development, limiting their learning and clinical practice as seen in the following excerpts: participant 6: ‘and i think better in the sense that also equipment related because our abr (auditory brainstem responses, objective test of auditory function, katz et al., 2015) was broken in the first three quarters of the year. so, if that (the abr equipment) was working…, well i don’t do abr now so that would have been an amazing experience.’ (participant 6, 25 years old, female) ‘audiometry i could have developed but i couldn’t because of equipment, resources shortage and as much as we were kind of exposed to screening in a noisy environment, how to reduce the noise to signal ratios and all that what you learn in varsity. i could have as well there because we had clinics which were very busy and had limited space.’ (participant 3, 24 years old, female) conversely, some participants expressed that they had sufficient resources to foster their learning as seen in these excerpts: ‘its just me. ok…like i said, it (site where the participant worked) was well resourced. i got the opportunity to use most of the theory that i learnt and used it theoretically, practically….’ (participant 12, 24 years old, female) these findings indicate how the differences in the availability of resources contributed in shaping the level of exposure to different audiological practices. this brings to question the extent of variation in the csp contribution towards developing and refining the clinical and professional skills of the new graduates, particularly across different placement sites. support and supervision this aspect of the finding highlights the discrepancy in support and supervision received by csos in the various healthcare institutions. some participants indicated receiving adequate supervision, which facilitated independence, confidence and clinical skills as seen in this excerpt: ‘[y]eah so my supervisors were always very helpful and very nice to me and understanding so that was, that was nice and i think that made the difference, that if you have nice supervisors the experience there is much different. so if they sort of… they…, you know that’s your supervisor but they kind of treat you like equals. that’s what i’m saying. they respect you and you respect them. so that’s what i like […].’ (participant 9, 24 years old, female) other participants expressed limited or no supervision, which facilitated the need to learn discipline, self-reliance and operational and patient management skills. this affected their development throughout the year as seen in this excerpt: ‘it was a good and bad experience in that i learnt to be more independent and i learnt to be more motivated because i didn’t have anybody to rely on so i was always trying to push myself to do better and it was negative because i didn’t have anybody i could rely on so and whenever i wanted to do something different i didn’t have anybody backing me up so i was always just alone.’ (participant 2, 24 years old, female) a few of the participants reported receiving intermittent supervision, which alleviated feelings of stress during cs. this was observed as a significant hindrance to their development. ‘[u]hm, more likely of mixed emotions because earlier i had a supervisor and you know in areas where i wasn’t sure, i would run to my supervisor all the time. and then as time went on and then i didn’t have a supervisor because she was sick and then i got this one incident i got a very stressful patient and then i was very emotional and i couldn’t handle it […].’ (participant 11, 25 years old, female) again, this brings to question the extent to which availability of supervision is regulated in order to have it relatively standardised across the different cs placement sites. however, the findings have indicated room for improvement in this regard. professional development (structural aspect-internal horizon) the work environment afforded by the csp was developmental to csos, as previously observed by wranz (2011) and beyers (2013). the participants in this study reported having experienced practical and experiential knowledge in various areas of clinical practice and professional conduct during their cs year, including audiological skills such as cerumen management, basic audiometry, ototoxicity monitoring and patient-management. they indicated that daily repetition of procedures, high caseload and variety of cases improved their clinical judgement, confidence and decision-making skills, as seen in the next excerpt: ‘i think it increases your confidence quite a bit and i was quite fortunate that last year to have seen quite a large patient load and it does certainly give you confidence in your testing procedures, more confidence in your ability to diagnose hearing and related disorders […].’ (participant 1, 30 years old, male) however, other participants felt there was not much improvement in their theoretical knowledge and cs served to cement theory obtained during their undergraduate training. theoretical knowledge was reported to have been an overlooked part of cs. however, activities such as presentations, journal clubs and workshops were used by csos to develop their theoretical knowledge as expressed in the following excerpt: ‘i won’t lie. i think because there was no supervisor involved from my side, there was no learning or reading up on anything new in terms of theory so i can’t…anything stands out that i can say i learnt. […] in terms of workshops and cpd courses, it was a very neglected area.’ (participant 12, 24 years old, female) granted, all participants experienced professional development, as previously indicated, differences were observed in the type of knowledge developed and the extent of the professional development. the different contextual factors identified in the participants’ conceptions were noticed to have contributed to the qualitative differences in the csos’ experiences of audiology in 2017. discussion guided by the phenomenography as a framework, the primary focus of this study was to highlight the key variations in audiology csos’ developmental experiences. the identified referential aspect of the phenomenographic experiences indicated transitional challenges experienced by all participants, which was predominantly emotionally challenging, as the findings indicated. these findings were consistent with previous research (de villiers, van heerden, & van schalkwyk, 2018). de villiers et al. (2018) qualitative, longitudinal study explored medical intern supervisors’ views on internship training in south africa. the study found that transitional challenges were common amongst medical interns, including difficulties with applying theory to practice and heeding the work environment demands such as long hour shifts, which are emotionally stressful. this study’s findings suggest that there are three qualitatively different ways in which the professional development can be conceived and that the outcomes of csp are largely affected by factors such as cso site placement and work environment, the transition into the workplace and availability of both human and clinical resources. currently, it appears that the main focus of csp is for service delivery, where professional development has not been largely prioritised. as a compulsory developmental platform prior to certification for independent practice, it is, arguably, fair to expect the csp to provide a conducive environment for csos to develop in all areas related to their scope of practice. however, the findings indicate that this was not the case. the fixed-placement of csos at the doh sites facilitated the heterogeneity of experiences as there were csos who received minimum exposure and those who had exposure to a wide spectrum of audiological practices. furthermore, supervision was another key factor where some participants had onsite audiology supervisors whilst others did not. support and resource availability have been reported as paramount contributing factors in service provision and the development of cso in dentistry (machete, makwakwa, moipolai, & motloba, 2021). these were reported by these authors in a correctional study conducted with dentists who had completed their community service in south africa. in audiology, similar challenges were reported over a decade ago by khan et al. (2009), and yet, for some participants, this was still a challenge in the year 2017. the community service supervisors have a significant influence in the kind of experiences each cso is exposed to shezi (2014). at least this was the case in nursing, according to shezi (2014). ross et al. (2018) evaluating the medical internship programme at a public hospital in south africa in 2016, revealed that the level of supervision, consistency of mentorship and training received by interns at public institutions were a cause for concern. this was further confirmed by the hpcsa internship subcommittee that identified gaps in supervision and training of graduates (ross et al., 2018). the availability of an onsite cs supervisor has not been a full requirement of the cs placement criteria (reid, 2001), even though it appears to be a strong consideration since 2018 according to the internship and community service placement guidelines for 2017–2018 (south african national department of health, 2018). availability of resources is another crucial factor that plays a role in developing competencies for audiological practice. some participants reported lack of basic audiological equipment, availability of broken and uncalibrated equipment and ultimately, inadequate infrastructure for clinical practice, which poses limitations on the clinical skills developed during the csp. similar concerns were raised by matlhaba, pienaar and sehularo (2019) studying the nurse’s clinical competence in some hospitals in the north west province, south africa. regardless of these factors, the assumption is that the certification of independent practice at the end of cs should signify competency in all or most of audiology areas of practice. thus, we remain concerned with the variations in the cs experiences and possible implications it could have on the effectiveness of the same csp in preparing different csos for independent practice. this concern is worsened by the absence of any board exams or competency assessment measures that would at least document the level of or preparedness for independent practice or lack thereof at the end of the csp for each cso. whilst the audiology undergraduate programme offers intensive clinical exposure, one could argue that it does not negate the need for further professional development that takes place during an in-service or csp. the findings of this study indicated that csp does facilitates professional development post-graduation as was indicated by govender et al. (2015), and van stormbroek and buchanan (2016). however, the development of csos seems to occur haphazardly with little support and structure in practice to ensure that standardised developmental outcomes are met across the programme. similarly, we recognise the developmental value of infrastructural constraints within the context of csp. reid et al. (2018) stated that the human, financial, equipment and other resource constraints contribute to the development of resilient and adaptable professionals. our key concern is the degree of variation in developmental experiences in the same group of csos resulting from these constraints. this concern is not new in audiology as khan and colleagues reported similar concern with resource constraints in health sciences rehabilitation fields, including audiology (khan et al., 2009). perhaps to remediate the present challenges in the programme, strong considerations for the introduction of an in-service training and internships programme in audiology followed by a formalised standardised assessment of competency, need to be made. similar strategies have been utilised in undergraduate healthcare programmes such as pharmacy and medicine, whilst others don’t (opoku, van niekerk, & jacobs-nzuzi khuabi, 2020). audiology, occupational therapy, physiotherapy and optometry are a case in point. it is not clear if the csp negates the need for in-service training in these fields. in pharmacy, graduates are required to complete 1 year of internship, submit continuing professional development (cpd) portfolio, their supervisor submit a progress report with areas of competence and they are then required to successfully complete a pre-registration examination prior to being registered as a pharmacist (the south african pharmacy council, 2020). furthermore, they are required to involve themselves in community work and community outreach to gain experience and interpersonal skills (farzadeh, 2019). similarly, the medicine profession has a 2-year internship programme, to allow for graduates to acquire all the necessary skills prior to starting with the csp (van niekerk, 2012). this incorporates clinical rotations, which optimised each intern’s exposure across different areas of practice, enhancing their knowledge and skills (nkabinde et al., 2013; reid et al., 2018). the cs programme was viewed by the majority of the medical csos as an effective developmental platform in the study conducted in south africa. in practice the guidelines, including the outcome measures of the csp, as a developmental platform remain unclear (reid, 2018). we, therefore, argue that seemingly subjective, discretionary judgement of the csos readiness to practice independently requires a review. the differences in csos experiences suggests that if the benchmark for minimum criteria of independent practice skills outcome exists in audiology, its use differs across the cs sites, and that there is likely too much reliance, in practice, on the subjectivity of the cs supervisors. we thus, argue that the lack of, or limited (practical application of the) standardisation and benchmarking of the csp, should be amongst the highly prioritised concerns and reasons for the review of the current csp. we elaborate on this argument in the subsequent article. limitations methodologically, the participants’ reflection has to be taken as true, without the necessity to control for untruthful reflections. it is possible that the participants’ reflections could have left out some important aspects of their experiences, despite extensive probing. it would have been of benefit to conduct member checking and reflections to verify the accuracy of the interpretation of the participants’ responses. however, time and other challenges did not allow for this aspect to be realised. lastly whilst the trustworthiness of the findings remains strong, in our opinion, it would have been even stronger had the findings been analysed by two or more researchers initially. but the study being at a master’s level limited us from doing so. conclusion and recommendations the csos experiences of professional development demonstrate the various ways in which they interacted with work environment, staff and the community as a whole through the csp. the conceptions discovered in this study reveal the close relationship between the nature of csp context and the developmental outcomes it intends on producing as it influences the development of skills, knowledge and professional autonomy. this research study further highlights the limitations of using the fixed-placement model within the csp as optimises variations in developmental outcomes and demonstrates a lack of standardisation in the evaluation criteria that declares the readiness for independent practice. the study argued for an urgent review of this model and majority of the challenges within the programme warrant an urgent response. thus, we provide suggestions for improvements in the subsequent article. in addition, the variations of experiences reflected in this study should serve as a foundation for further research and a broader discussion for the improvement of the programme and its intended outcomes. acknowledgements the authors would like to thank all audiologists who took part in the study. they provided a valuable insight into the audiologists’ qualitatively differently developmental experiences of the community service programme. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions sphilile mbhele conducted the original research as a requirement for the master’s degree under the sole supervision of musa makhoba. both authors contributed to the writing of the manuscript from conceptualisation to finalisation. both authors read and edited the manuscript according to the manuscript guidelines of the sajcd. funding information a postgrad scholarship grant was received for the running costs of the original research from the university of kwazulu-natal’s college of health sciences. data availability the data that support the findings of this study are available from the corresponding author, upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references åkerlind, g.s. 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(2012). exploring information experiences through phenomenography. library and information research, 36, 96–119. abstract introduction rationale methodology results ethical consideration discussion conclusion acknowledgements references appendix 1 appendix 2 appendix 3 about the author(s) fareeaa abdoola discipline of speech-language pathology, university of kwazulu-natal, south africa penelope s. flack discipline of speech-language pathology, university of kwazulu-natal, south africa saira b. karrim discipline of speech-language pathology, university of kwazulu-natal, south africa citation abdoola, f., flack, p.s., & karrim, s.b. (2017). facilitating pragmatic skills through role-play in learners with language learning disability. south african journal of communication disorders, 64(1), a187. https://doi.org/10.4102/sajcd.v64i1.187 original research facilitating pragmatic skills through role-play in learners with language learning disability fareeaa abdoola, penelope s. flack, saira b. karrim received: 29 sept. 2016; accepted: 09 apr. 2017; published: 26 july 2017 copyright: © 2017. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: role-based learning involves the process whereby learners acquire skills, knowledge and understanding through the assumption of roles within real-life settings. role-play holds potential as an effective learning strategy for children; however, there is limited research on the use of role-play as a therapy method within the field of speech-language pathology. children with language learning disability (lld) typically present with difficulties in social communication, which can negatively affect their social and academic achievement. aim: the aim of this study was to determine the effectiveness of role-play as a therapy approach targeting the pragmatic skills of stylistic variation and requesting for clarification in learners with lld. method: the use of combined positivist and interpretivist paradigms allowed for the implementation of an embedded mixed methods design. an experimental pretest-posttest design was implemented. eight participants, who were learners with a diagnosis of lld, were purposefully selected. data collection was conducted over five phases, utilising the clinical evaluation of language fundamentals (4th ed.) pragmatics profile, discourse completion tasks, session plans and session records. quantitative data were analysed using descriptive statistics and were supplemented by qualitative data from session records. results: results revealed improvements in stylistic variation and requesting for clarification post role-play intervention, with minimal changes in the control group. limitations of the study have been reported for consideration when interpreting results. conclusion: role-play as a therapy approach targeting two pragmatic skills, stylistic variation and requesting for clarification, was found to be beneficial for learners with lld. recommendations for the implementation of role-play as a therapy approach were made. introduction one often sees children playing ‘make believe’ and taking on the role of a schoolteacher, mother or doctor. children generally have experience of taking on the role of another person in a different situation from a young age. literature suggests that role-play is a natural method adopted by children to learn, as all children engage in some form of socio-dramatic play (goldstein & cisar, 1992; mcsharry & jones, 2000). in the field of speech-language pathology, therapists seek out evidence-based methods of learning to facilitate language development in children who require such intervention. role-play holds potential as an effective method of learning for children (clarke & wales, 2005; greenwood, horton & utley, 2002; killen, 2006; mason, 2006; purvis, 2008). its effectiveness as an approach to targeting pragmatic skills in children with language learning disability (lld) was investigated in this research study. literature review role-play role-play can be defined as a technique using simulated communication scenarios to elicit specific or spontaneous responses (purvis, 2008). clinically, simulation aims to provide experience in a safe and secure environment through the imitation of reality (theodoros, davidson, hill & macbean, 2010). in role-based learning settings, the learner is a participant in the setting that simulates a real-life scenario. the role of the therapist in this setting is that of a facilitator who guides and creates learning opportunities (killen, 2006; oliver, harper, hedberg, wills & agostinho, 2002). the implementation therefore requires purposeful preparation on the part of the facilitator to develop scenarios that provide learning opportunities in accordance with the objectives (oliver et al., 2002). in this study, literature on the use of role-play as a learning strategy has been sourced primarily from the field of education and applied to speech-language pathology. in the field of speech-language pathology, role-play has been used along with other methods to target social communication skills; however, there is no study that investigates the effectiveness of role-play itself as an intervention approach (gerber, brice, capone, fujiki & timler, 2012). a recent study found that theatre-based intervention with children with autism spectrum disorder resulted in improvements in social cognition, social interaction and social communication (corbett et al., 2015). this randomised trial made use of peer-mediated learning and acting in a theatre context to target social competence and has provided initial evidence supporting theatre-based intervention (corbett et al., 2015). this relates closely to the use of role-play as a therapy approach as it required the participants to take on the role of another in a given scenario, thereby providing a naturalistic context for learning social skills. pragmatics the term ‘pragmatics’ is typically used to refer to the ways in which speakers and listeners use language in social interaction (goldstein, kaczmarek & english, 2002). asha (2015) defines pragmatics as the system combining language components (phonology, morphology, syntax and semantics) to generate functional and socially appropriate communication. this definition illustrates the complex nature of pragmatics, as it relies on and comprises of multiple language skills (adams, 2002). another aspect of pragmatics, which adds to its complex nature, is that it is culturally and linguistically diverse (asha, 2015). in the south african context, caseloads are largely multilingual and multicultural; speech-language therapists must therefore be aware of the cultural differences in pragmatics when assessing and providing intervention to individuals with social communication deficits (mcleod, 2014; perry, 2012). two specific pragmatic skills were selected and targeted in the role-play intervention for this study. these were requesting for clarification and stylistic variation (register). requesting for clarification refers to making a request to repair or clarify the message when communication breakdown occurs. this involves identifying that you have not understood the message and then making the speaker aware that you have not received the message. a request for clarification can involve verbally telling the speaker that you do not understand, asking them to repeat themselves or even giving a non-verbal cue such as an enquiring look. as children develop language, they typically first learn to respond to requests for clarification from others around two years of age (fletcher, o’ toole & fourie, 2015). however, as their language develops they learn to independently make requests for clarification at around four to five years of age (fletcher et al., 2015). stylistic variation refers to the ability to shift from one register to another, according to the communication partner and context. for example, one would use an informal register while interacting with friends at break time, but will have to switch to a formal register if asked to meet with the principal or boss. register is also context sensitive, as one may use a less formal register if speaking to the principal or boss at a social event, and a more formal register if speaking to the principal or boss regarding school or work. children begin to appropriately alter their register from as early as 4 years of age (paul, 2007). language learning disability the diagnostic and statistical manual of mental disorders, fourth edition, (dsm-iv) of the american psychiatric association (2000) provides acknowledged guidelines to establishing a diagnosis of a language disability. the dsm-iv defines learning disability as follows: ‘learning disorders are diagnosed when the individual’s achievement on individually administered tests of reading, mathematics or written expression is substantially below that expected for age, schooling and level of intelligence’. the dsm-v (american psychiatric association, 2013) introduces a change in terminology by referring to ‘specific language disorder’. this term combines the dsm-iv diagnosis of reading disorder, mathematics disorder, disorder of written expression and learning disorder not otherwise specified. children with lld, therefore, fall under this category. in this study, the dsm-iv would have been utilised to diagnose participants. literature suggests that difficulties experienced by children with learning disabilities affect not only their academic performance, but also their ability to use language appropriately in social contexts (funderburk, schwartz & nye, 2009; hallahan & kauffman, 2003; vaughn, elbaum & boardman, 2001). it is imperative that these difficulties are addressed in intervention, as they have the potential to affect the individual’s ability to become an integrated member of society. poor pragmatic skills can result in peer rejection, decreased likability and difficulty forming friendships (cordier, munro, gillan & docking, 2013). this in turn increases the risk of low self-esteem, long-term emotional difficulties and social isolation (brinton & fujiki, 2006). effective approaches to address pragmatic difficulties are therefore necessary. rationale the rationale for this study stems from personal clinical experience and observation, where it was noted that children in a special needs classroom were more involved in the therapy session and more easily retained new vocabulary when role-play was used. this exemplified literature regarding learners requiring more explicit intervention that supports generalisation and provides immediate feedback (greenwood et al., 2002). investigation into role-play as a learning strategy dates back at least 30 years (ladousse, 1987; van ments, 1983), where the use of role-play was found to be effective in the education context. a recent change in approach to teaching and learning strategies has seen a rise in focus given to constructivism and active learning. these concepts are based on the tenet that effective learning occurs when the learner is actively involved in the construction of knowledge, as opposed to receiving knowledge from a third party (brady, 2004). various studies in the field of education advocate for the use of role-play as an active learning strategy (brady & skully, 2005; clarke & wales, 2005; killen, 2006; yehuda, 2006). a problem often encountered by speech-language therapists is that of a lack of generalisation of therapy aims to contexts outside the therapy environment. role-play allows the therapy context to closely approximate natural interactions, and therefore results in more functional outcomes and increased generalisation (killen, 2006). even though role-play is used in certain areas of speech-language pathology, there is sparse literature documenting its method of implementation and effectiveness. methodology aim and objectives the aim of this study was to determine the effectiveness of role-play as a therapy approach targeting pragmatic skills in learners with lld. the objectives focused on determining the effectiveness of role-play in improving the two pragmatic skills being targeted to achieve the aim, that is, stylistic variation and requesting for clarification. research design the combined use of positivist and interpretivist paradigms allowed the researcher to logically analyse the research data, while still considering the holistic view through observation and interpretation (coolican, 2004; weaver & olsen, 2006). this was achieved through the use of an embedded mixed methods design. qualitative data were used to support quantitative data, in order to view a complete picture and achieve data triangulation. the dominant quantitative component made use of an experimental pretest-posttest design. this method controlled for many threats to internal validity, while showing that change occurred following the treatment. eight participants, between the ages of 10 and 12, who were learners with a diagnosis of lld, were purposefully selected (appendix 1). all the participants attended a school for learners with special educational needs in ethekwini (kwazulu-natal) and resided in surrounding areas. all participants spoke english as their dominant language. intervention focused on two specific pragmatic skills: stylistic variation and requesting for clarification. data collection was conducted over five phases (see figure 1 below). phase 1 involved pragmatic assessment of each of the participants. phase 2 consisted of the role-play intervention being implemented with the experimental group. phase 3 served as the posttest, and thus involved a reassessment of all of the participants (experimental and control group). an additional step was then added to the traditional pretest-posttest design. during phase 4, the control group received intervention targeting the same pragmatic skills; however, no role-play was used. thereafter, all participants received a final reassessment in phase 5. this final step allowed the researcher to compare the effects of the intervention with and without the inclusion of role-play. figure 1: structure of the experimental pretest-posttest design. procedure an assessment of each participant was conducted using the clinical evaluation of language fundamentals, fourth edition, pragmatics profile (celf-4 pp) and discourse completion tasks (dcts). assessment was conducted through observation in various contexts (classroom and playground) and one-on-one interaction with the participants. when using pragmatic skills as an outcome measure, it is recommended that assessments allow for documentation across various contexts and communication partners (gerber et al., 2012; norbury, 2014). the dcts were designed by the researcher based on research studies that made use of dcts (archer, aijmer & wichmann, 2012; chen & rau, 2013; jernigan, 2007; kasper & dahl, 1991; kasper & roever, 2005; martínez-flor & uso-juan, 2011). the situations presented in the tasks all included the following information: the setting, social distance and social status (alemi, rasekh & razanjad, 2014; aufa, 2014; chen & rua, 2013; kasper & roever, 2005; martínez-flor & uso-juan, 2011). the scoring of the dcts was conducted by a third party in an effort to avoid researcher bias. the intervention phases of the study involved the implementation of group therapy. literature provides limited guidelines for best practice in social skills group interventions (reichow & volkmar, 2010). group therapy sessions were therefore designed and implemented by the researcher using guidelines for implementing role-play as a learning strategy described in literature (brady & skully, 2005; cherif, verma & somervill, 1998; clarke & wales, 2005; killen, 2006; ladousse, 2004; mcdaniel, 2000; milroy, 1982, yehuda, 2006). each session comprised five components: introduction, narrative, discussion, role-play and reflection. the narratives were written by the researcher based on the criteria of a social story (gray, 2000) (appendix 2). narratives were designed to be linguistically and culturally appropriate while addressing the target pragmatic skill. interaction with the participants during the selection and assessment process allowed the researcher time to gauge information on the participant’s linguistic abilities and cultural background prior to formulating the narratives. the narrative served the purpose of providing the learners with a foundation on which to practice the skill (duncan & klinger, 2010; stanton-chapman & snell, 2011). a structured record form was completed for each participant following every group session (appendix 3). the form allowed for documentation of the session in general, as well as record-keeping of each participant’s performance. the purpose of documentation was to achieve data triangulation and so that the variables (e.g. lack of interest of the participant) could be accounted for during interpretation and discussion of results. data analysis in keeping with the research design, the qualitative data were embedded in the quantitative data in the analysis and discussion of results. integration of the two sets of data was conducted at the reporting level, using a weaving approach (fetters, curry & creswell, 2013). this was achieved by first tabulating and presenting each set of data and thereafter integrating the results in a written analysis or narrative (fetters et al., 2013). the qualitative data served to enrich, support (data triangulation) and provide explanations for the quantitative data. because of the small sample size, quantitative data were analysed with the use of only descriptive statistics. assessment scores were analysed by calculating and comparing the mean, standard deviation and gain in scores. the reliability of these descriptive statistic scores when using a small sample depends directly on the reliability of the pre and posttest scores (salkind, 2010; zimmerman, 2009). the purpose of these measures was simply to provide a means of drawing comparisons across phases and groups. analysis of results was separated into analysis of the experimental group and analysis of the control group. the initial step in the group analysis was to provide an overview of each participant’s response to the intervention; this allowed for the documentation of clinically significant findings that may be masked with statistical analysis of combined group scores alone (adams, 2003). the second step was to conduct a statistical analysis of the groups’ preand post-assessment scores, and analyse this information in conjunction with qualitative data. this provided the information needed to conduct the last step of analysis. the last step involved comparison of the experimental and control group, in order to determine the effectiveness of role-play as a therapy approach targeting pragmatic skills (stylistic variation and requesting for clarification) in learners with lld. for the purpose of this article, only the combined group scores and a comparison thereof are presented. trustworthiness reliability in this study was ensured by the researcher administering the data collection instruments herself or himself, the utilisation of user-friendly data collection instruments, a portion of the assessment being conducted by a third party and by conducting a pilot study. validity in this study was ensured by the use of an instrument that is based on literature and criterion referenced (celf-4 pp) (semel, wiig & secord, 2003), conducting a pilot study prior to the main study, and the use of a control group to provide as a comparative measure. validity of results was also achieved by controlling for extraneous variables, for example, participants received no other intervention for pragmatic skills during the duration of the study. results the experimental group received intervention during phase 2, with the preand post-intervention assessments occurring in phases 1 and 3 (see figure 1). results from phases 1 and 3 were analysed and presented in tables 1 and 2 below. table 1: experimental group: statistical analysis of assessment scores (phases 1 and 3). table 2: control group: statistical analysis of assessment scores (phases 1 and 3). with regard to the control group, results from phases 1 and 3 were analysed first (table 2), and thereafter results from phases 3 and 5 were analysed (table 3). the control group received no intervention during phase 2 and received intervention excluding role-play (the session plan included only the introduction, narrative, discussion and reflection) in phase 4. table 3: control group: statistical analysis of assessment scores (phases 3 and 5). session records for each participant were reviewed and summarised in the table below (table 4). data from session records were used to supplement and support quantitative data findings. table 4: summary of qualitative data as per session records. results from phases 1 and 3 revealed that the average increase in the mean of the experimental group for both assessment measures was greater than that of the control group. the celf-4 pp and dct scores of the experimental group increased by an average of 11 and 3.5, respectively (table 1), while the control group celf-4 pp and dct scores increased by an average of 0.5 and 0, respectively (table 2). improvements in the experimental group post-intervention were further supported by participant-specific data from session records (table 4). it was found that improvements were noted post-intervention for both requesting for clarification and stylistic variation. requesting for clarification was targeted for the first six group sessions and stylistic variation was targeted during the second six group sessions. improvements in both these skills were more apparent in performance on the dct, which assessed them directly. it was found that participants were able to grasp and apply the concept of requesting for clarification more easily than stylistic variation. even though participants were already familiar with the facilitator and the components of the session, they took longer to independently identify pragmatically appropriate and inappropriate behaviour with regard to stylistic variation. this may be because stylistic variation is context specific, and is therefore more cognitively and linguistically demanding. it was also found that generalisation occurred to untrained skills as well, which was more apparent in participants who were actively involved in group sessions (participants 2 and 3). phases 3–5 of the study involved the control group receiving intervention, while the experimental group received no intervention. however, the control group received the intervention without the role-play. the purpose of this was to allow the researcher to compare the effects of the intervention with and without the role-play component, thus establishing if it is in fact the use of role-play that is effective. results indicated that the experimental group presented with a higher average increase in scores on the celf-4 pp post-intervention (mean increase: 11), as compared with the control group (mean increase: 0.25). however, the control group presented with a higher average increase in score on the dct assessment compared with the experimental group. the low increase in dct scores of the experimental group appears to be as a result of two of the participants already achieving a high score on the dct assessment pre-intervention. analysis of session records revealed that the control group did make progress in therapy without the role-play component (table 4). this progress appears to have reflected in their post-intervention dct assessment. the progress, however, did not reflect in the post-intervention pragmatic profile assessment. the reason for this could be that progress was made in the therapy context, but did not generalise, and was therefore not observed when completing the profile during classroom and break time observation. ethical consideration ethical clearance was obtained from the university of kwazulu-natal, humanities and social sciences research ethics committee (reference number: hss/0334/014m). informed consent was obtained, as learners became participants in the study only if they provided verbal consent and their parent or caregiver provided written consent. right to privacy or confidentiality was ensured by assigning a pseudonym to each participant for reference throughout the study and by not revealing any information about the participants and organisations involved. the raw data collected from the study are stored in password-protected electronic files and will be kept for at least 5 years. only the researcher and supervisors have access to these data. discussion this study aimed to determine the effectiveness of role-play as a therapy approach to target stylistic variation and requesting for clarification in learners with lld. it was found that there is limited research into effective methods of addressing pragmatic difficulties of learners with lld. the need for such research is evident in the fact that learners with lld typically present with difficulties in social communication (funderburk et al., 2009; hallahan & kauffman, 2003), which negatively affects their social relationships, inclusion and quality of life (diken, 2014). results from both quantitative and qualitative data revealed that improvements in stylistic variation and requesting for clarification were observed post role-play intervention in the experimental group, with minimal changes in the control group. role-play as a therapy approach targeting pragmatic skills (stylistic variation and requesting for clarification) in learners with lld was found to have a number of benefits that supported its effectiveness. these included that participants displayed increased interest and involvement when role-play was used; participants reported to enjoy the ‘acting’ and would enthusiastically decide who should play which role when it came to the role-play component of the session. during intervention with the control group (which excluded role-play), even learners who participated well began to lose interest and concentration before the end of the session. research shows that if learners are not actively involved in the process of knowledge acquisition, they are less likely to make the necessary connections that make learning meaningful (cuthrell & yates, 2007). role-play also allowed for peer learning to take place. it was found that stronger participants supported weaker participants, by offering prompts, modelling and giving examples and suggestions. this was noted during the role-play and reflection components of the group session. participants responded well to support from their fellow learners and generally responded to the prompt or suggestion. lastly, it was found that skills learnt appeared to generalise to outside the therapy context and were maintained after a period of 6 weeks of no intervention. qualitative analysis of the celf-4 pp (semel et al., 2003) pre and post-intervention revealed that generalisation occurred to untrained skills as well as target skills. role-play creates a ‘real-life’ type context for the learner (killen, 2006; van ments, 1999), and practising a skill in realistic contexts increases the likelihood of generalisation of the target skill (stewart, carr & leblanc, 2007). parent and teacher input during the preand post-assessment process, in the form of questionnaires or rating scales, is recommended to validate findings in future studies (see gerber et al., 2012). limitations of the approach were also identified. during role-play intervention, it was found that the responsibility of creating an environment that supports active learning relies on the facilitator. the facilitator needs to maintain a role that is supporting and flexible (killen, 2006; mcdaniel, 2000), while ensuring support is graded according to the needs of each participant. the effectiveness of the intervention is therefore dependent on the facilitators’ skill in supporting child-centred learning. role-play intervention can also be time consuming to plan and implement, and it relies on learner participation. it can be concluded that all of the components in the session plan in role-play-based therapy were found to be necessary and beneficial for effective implementation of the intervention. however, further research is needed to fine-tune each component, in order to achieve the best outcomes. the recommendations for the implementation of role-play as a therapy approach derived from this study has been consolidated and presented in figure 2 below. the figure presents the steps recommended in planning and implementation of a session, as well as the facilitator’s role in the process. figure 2: recommended steps for planning and implementing role-play as a therapy approach. clinical implications speech-language therapists should seek evidence-based methods for addressing the pragmatic difficulties of learners with lld. the findings of the study can be used to inform clinical practice and decision-making when implementing role-play intervention. therapists should be aware of and implement all the components of a role-play session. appropriate knowledge of the process of active learning will ensure maximum benefit being derived from role-play. therapists should also be aware of using narratives that are relatable, functional and culturally appropriate. strategies to support and ensure the participation of weaker learners, such as peer learning, should be supported during role-play intervention. limitations the following were identified as limitations of the study: the small sample size (eight participants) in this study limits the extent to which results can be generalised; all the participants were from the same school; participants were limited to learners whose dominant language is english; assessments of pragmatic skills pre and post-intervention were conducted only in relation to the school context; a portion of the assessment was conducted by the researcher (researcher bias); and random assignment of participants resulted in unequal distribution of abilities in the control and experimental groups. furthermore, data collection was conducted over a period of two and a half months; participant maturation could therefore be a possible confounding variable. research implications future research in the area of role-play as a therapy approach should investigate its effectiveness in targeting pragmatic skills in learners with lld, using a larger sample size, and with learners with other developmental communication disorders. given the multilingual, multicultural clientele found in south africa (jordaan, 2011), and the cultural nature of pragmatic skills, the effectiveness of role-play as a therapy approach targeting pragmatic skills in learners with lld, who are english second language learners, should be researched. the scope of the use of role-play can also be expanded by exploring its effectiveness across age groups, pragmatic skills and other areas of language. the development of standardised guidelines and principles for planning and implementation of role-play intervention will ensure evidence-based practice. conclusion role-play is an active learning strategy that closely mimics natural interactions, and therefore results in improved generalisation of skills (killen, 2006). the combined use of positivist and interpretivist paradigms allowed the researcher to logically analyse the research data, while still considering the holistic view through observation and interpretation (coolican, 2004; weaver & olsen, 2006). this was achieved through the use of an embedded mixed methods design. qualitative data were used to support quantitative data, in order to view a complete picture and achieve data triangulation. the method of implementing role-play intervention was sourced from education literature and was found to be effective in its use as an intervention approach in speech-language pathology. it can be concluded that in this study role-play was found to be an effective approach to target stylistic variation and requesting for clarification in learners with lld. role-play as an approach to intervention may therefore be the way forward in ensuring generalisation of pragmatic skills. however, results of the study should be interpreted with the limitations in mind. the results of this study have also identified further areas of research regarding the use of role-play as a therapy approach and provided therapists with recommendations to inform their clinical practice. the results of this study have laid the foundation for future research and implementation of role-play as a therapy approach in speech-language pathology. acknowledgements the authors extend their gratitude to the university of kwazulu-natal (ukzn) for assisting with funding for this study, and to the principal and staff at the school where the study was conducted for generously allowing the research to be conducted. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions this 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(2009). the reliability of difference scores in populations and samples. journal of educational measurement, 46(1), 19–42. https://doi.org/10.1111/j.1745-3984.2009.01067.x appendix 1 table 1-a1: description of participants. appendix 2 table 2-a2: example of narrative reflecting application of the principles of social stories. appendix 3 session record form date: time: venue: group therapy session no.: pragmatic skill targeted: description of therapy environment: researcher’s personal reflection: researcher’s assessment of session recommendations for next session participant general conduct: motivation and participation in session: performance in session: progress noted (if applicable): abstract introduction methodology results and discussion conclusion acknowledgements references about the author(s) katijah khoza-shangase department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation khoza-shangase, k. (2022). cochleovestibular findings linked to covid-19: a scoping review for clinical care planning in south africa. south african journal of communication disorders, 69(2), a899. https://doi.org/10.4102/sajcd.v69i2.899 original research cochleovestibular findings linked to covid-19: a scoping review for clinical care planning in south africa katijah khoza-shangase received: 26 jan. 2022; accepted: 30 june 2022; published: 12 aug. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: on 30 january 2020, the world health organization (who) officially declared an outbreak of the coronavirus disease 2019 (covid-19) to be a global health emergency. research has focused on the impact and response to life-threatening symptoms of covid-19 across the lifespan; however, there is a need to investigate the effects of covid-19 on the cochleovestibular system, as viral infections are known to impact this system. this is particularly important for contexts where resources are limited and prioritisation of resources requires strong risk versus benefit evaluations. objective: therefore, the purpose of this scoping review was to investigate published evidence on the impact of covid-19 on the cochleovestibular system across the lifespan in order to allow for strategic clinical care planning in south africa, where capacity versus demand challenges exist. methods: electronic bibliographic databases such as cinahl, ebscohost, medline, proquest, pubmed, scopus and sciencedirect were searched for peer-reviewed publications between january 2020 and january 2022. these had to be published in english and related to the impact of covid-19 on the cochleovestibular system, where the question was: ‘what evidence has been published on the impact of covid-19 on the cochleovestibular system?’ review selection and characterisation was performed by the researcher with an independent review by a colleague using pretested forms. results: of a total of 24 studies that met the inclusion criteria, the current scoping review revealed limited conclusive published evidence linking covid-19 to permanent hearing function symptoms. current evidence supports the possibility of covid-19, similar to other viral infections in adults, impacting the cochleovestibular system and causing tinnitus, vertigo and sudden sensorineural hearing loss (ssnhl), with the symptoms being generally temporary and resolving either partially or completely following therapy with steroids, with very inconclusive findings in the paediatric population. conclusion: these findings raise global implications for properly designed studies, which include longitudinal follow-up of cases across the lifespan, examining this link with some focus on establishing the pathophysiologic mechanisms at play as well. in the meanwhile, current findings raise the value of polymerase chain reaction (pcr) testing for all patients presenting with unexplained cochleovestibular symptoms during the pandemic, as these may be the only presenting symptoms indicating covid-19, thus requiring careful treatment and management. keywords: audiology; cochleovestibular; clinical; covid-19; hearing loss; planning; south africa; steroids; tinnitus; vertigo. introduction since the advent of coronavirus disease 2019 (covid-19), which was first reported in wuhan, china, the world health organization (who) officially declared this novel coronavirus outbreak an international global public health emergency on 30 january 2020 and finally a pandemic on 11 march 2020 (who, 2020a, 2020b). as of 21 june 2022, the total global number of confirmed cases has escalated to 540 million with over 6.32 million deaths, with south africa registering a cumulative total of 3.99 million cases and 102 000 total official deaths (who, 2022). these numbers were regardless of all the global efforts to contain the virus (hui et al., 2020; who, 2022). thus, prevention and control of the covid-19 infection, including during research, as well as provision of clinical care and training, is a key strategy to save lives and livelihoods, while safeguarding the safety of healthcare professionals and patients (beach et al., 2020; khoza-shangase, moroe, & neille, 2021; wieten, burgart & cho, 2020; who, 2022). during the current covid-19 pandemic, the wearing of face coverings globally is one of the key prevention strategies recommended and in some countries mandated. community-wide face covering wearing, particularly in public areas, as is the requirement in south africa (balkaran & lukman, 2021), is aimed at decreasing possible symptomatic or pre-symptomatic transmission of covid-19 to others, along with adhering to physical distancing and handwashing or sanitising (ten hulzen & fabry, 2020). logically, wearing of face coverings impacts aspects of communication such as visual cues (lip reading, facial expressions) during communication – particularly for those who rely on this compensatory strategy because of a hearing impairment (chodosh, weinstein, & blustein 2020; homans & vroegop, 2021; kataoka, maeda, sugaya, omichi, & kariya, 2021; maru, stancel-lewis, easton, & leverton, 2021). evidence suggests that universal wearing of face coverings and adherence to physical distancing during covid-19 has a serious negative impact on communication for the hearing impaired (naylor, burke, & holman, 2020; saunders, jackson, & visram, 2021; ten hulzen & fabry, 2020). goldin, weinstein and shiman (2020) found that masks lead to an attenuation of the speaker’s voice in the 2000 hz – 7000 hz frequency range because of a low-pass filter effect. furthermore, a reduction in sound intensity of 3 db to 4 db for medical mask to approximately 12 db for the n95 mask (respirator or ffp) was found. this, coupled with physical distancing, exacerbates the deleterious impact of covid-19 on communication, particularly for the hearing impaired (ten hulzen & fabry, 2020). if covid-19 directly impacts hearing function, a real hearing impairment may be overlooked by the patient and their family if these documented effects of mask wearing and physical distancing are taken into consideration. in a recent online survey within the united kingdom, where the goal was to explore experiences of interactions where face masks were worn and how these masks affected communication, saunders et al. (2021, p. 495) found that face masks had a negative impact on ‘hearing, understanding, engagement and feelings of connection with the speaker’ with this impact being more pronounced in hearing-impaired individuals. similar findings were reported by naylor et al. (2020). researchers such as gallus et al. (2021) and almufarrij and munro (2021) reported on dizziness, rotatory vertigo, dynamic imbalance and static imbalance that is transitory in nature, without any solid evidence of clinically significant permanent vestibular damage post covid-19 infection. this evidence has important implications for early identification of real cochleovestibular symptoms that might be linked to covid-19 so that they are not lost in these ‘perceived’ temporary subjective impacts, hence the importance of careful documentation of the possible impact of covid-19 on the cochleovestibular system. vestibular symptoms may be more obvious and easier to identify and report, particularly in the absence of accompanying major covid-19 symptoms, but hearing symptoms might remain hidden. viral infections such as cytomegalovirus, measles, herpes simplex virus, hiv, rubella and others have been associated with hearing loss (assuiti et al., 2013; caroça et al., 2017; cohen, durstenfeld, & roehm, 2014; dunmade, segun-busari, olajide, & ologe, 2007; goderis et al., 2014; khoza-shangase, 2010; khoza-shangase & anastasiou, 2020). cohen et al. (2014) reported that viral infections impact cochleovestibular function by either directly causing damage to inner ear structures, such as the inner hair cells and the organ of corti, or by stimulating an inflammatory response on the auditory system. it is thus not surprising to anticipate that covid-19, as a viral infection, might also impact hearing and balance function, although cochleovestibular symptoms have not been reported as part of the core symptoms of the disease. mustafa (2020) argued that covid-19, as a new pandemic that is viral in nature, requires scrutiny insofar as its possible impact on the audiological system. the commonly documented clinical features of covid-19 include dry cough, sore throat, headache, fever, fatigue, loss of taste, loss of sense of smell and shortness of breath (alimohamadi, sepandi, taghdir, & hosamirudsari, 2020; lai, shih, ko, tang, & hsueh, 2020; tian et al., 2020). there is, however, a growing and solidifying body of evidence reporting on cochleovestibular signs and symptoms, such as sudden sensorineural hearing loss (ssnhl), tinnitus and vertigo in adults with covid-19, and refer findings on hearing screening in neonates whose mothers were covid-19 infected (fancello et al., 2021; jacob, flannery, & mostert, 2020; karimi-galougahi, naeini, raad, mikaniki, & ghorbani, 2020; koumpa, forde, & manjaly, 2020; parrino et al., 2022). jacob et al. (2020) reported on the novel ear, nose and throat triad of hearing loss, anosmia and ageusia, which brings a closer relationship of the commonly reported symptoms of covid-19 and hearing loss to the fore. munro, uus, almufarrij, chaudhuri and yioe (2020) maintained that more than 1 in 10 adults with covid-19 complain about changes in their hearing status when interviewed 2 months post hospital discharge. this is while parrino et al. (2022) reported on overall significantly higher incidence of ssnhl and combined acute cochleovestibular involvement during the pandemic than before. if covid-19 impacts cochleovestibular function in a similar manner to other viruses such as hiv, that is, either directly (virus itself) or indirectly (iatrogenic causes because of the medications prescribed to treat it) (khoza-shangase, 2020), implications for ear and hearing care in lowand middle-income countries (lmics) such as south africa are significant. this concern is driven by the numbers of infections that have and continue to be high in the african context – with minimal success from vaccination drives because of vaccine hesitancy (cooper, van rooyen, & wiysonge, 2021; hughes, mbamalu, okonji, & puoane, 2021). with the numbers of infection and the documented capacity versus demand challenges insofar as provision of ear and hearing care services is concerned in south africa (pillay, tiwari, kathard, & chikte, 2020), it becomes crucial that clear definition of morbidity, including cochleovestibular symptoms, in order to facilitate proper planning at all levels of preventive audiology from primordial to tertiary (khoza-shangase, 2022). this clear categorisation of symptomatology is important because of numerous reasons that are risk factors for cochleovestibular pathology and would impact ear and hearing care in the south african context, including (1) the unique circumstances presenting in south africa when compared with china or various other regions such as north america and europe in terms of quadruple burden of disease (khoza-shangase, 2021; mukandavire et al., 2020; pillay-van wyk et al., 2020), with most of these cases not on treatment (hansoti et al., 2019); (2) the risk factors for covid-19 infection and its consequent mortality, for example, comorbid conditions such as hypertension, diabetes and chronic pulmonary disease are documented to be highly prevalent in south africa (chutel & dahir, 2020); and (3) vaccine access and hesitancy (cooper et al., 2021; pepperrell et al., 2021) and poor healthcare infrastructure (mezue et al., 2020; ogbolosingha & singh, 2020), as well as the prevailing poor social determinants of health (ataguba & ataguba, 2020; khoza-shangase & mophosho, 2021). these factors highlight the need for extending the covid-19 discussions from mortality-focused deliberations only to acute and long-term effects of covid-19 as part of both prevention of the disease and efficient management of those infected (kilic et al., 2020). at the initial stages of the covid-19 pandemic, understandably, significant focus was placed on life-threatening symptoms of the disease; however, with increasing numbers of infections and more evidence becoming available, new symptoms are being reported and scrutinised as the virus presents deleterious effects on particular organs and structures of the body. these innumerable other symptoms that are constantly documented indicate involvement of multiple systems by covid-19 (eravci et al., 2020; savtale, hippargekar, bhise, & kothule, 2021). with covid-19 being a viral infection with direct cytopathic effects (eravci et al., 2020; kaur, bherwani, gulia, vijay, & kumar, 2020), which munro et al. (2020) argued may contribute to hearing or balance disorders, the importance of this study is highlighted. furthermore, as covid-19 is a viral infection, prompt diagnosis of hearing impairment is critical because prompt treatment of viral-induced hearing loss has been proven to yield positive outcomes, while unidentified or late-identified permanent hearing impairment has well-documented negative impacts on the quality of life of the individuals affected (saniasiaya, 2021). interestingly, jin et al. (2021) also reported that quality of life has been impacted by covid-19 by raising mental-related disease patients of the otolaryngology department (e.g. panic, anxiety, depression and sleep disorders). while other rapid and systematic reviews have been conducted on this topic (almufarrij & munro, 2021; jafari, kolb, & mohajerani, 2021; saniasiaya, 2021), albeit with different questions being explored, the nature of the pandemic, confirmatory studies such as this study are justified by covid-19’s presentation and its management, as illustrated by (1) the rapid evolution of the virus along with new variants and subvariants; (2) the impact of individual and heard immunity developments; (3) the available covid-19 treatments, including the different vaccines available to prevent it; and (4) the evolving nature of the clinical features from the initially reported to currently reported (aleem & slenker, 2021; cascella, rajnik, aleem, dulebohn, & di napoli, 2022; wang et al., 2020; zhou et al., 2020), among other things. in the context of a pandemic where the urgency of knowledge sharing is high, certain research and publication protocols that ensure research integrity may be relaxed (fleming, labriola, & wittes, 2020; park et al., 2021; vindrola-padros et al., 2020), thus replication of exploratory studies for confirmation of findings is arguably valuable, hence the importance of this study. therefore, the purpose of this scoping review is to investigate published evidence, including case reports, on the impact of covid-19 on the cochleovestibular system across the lifespan. methodology aim this scoping review aimed to analyse published evidence on the impact of covid-19 on the cochleovestibular system in line with the pandemic changes. review approach the arksey and o’malley’s (2005) framework for performing scoping reviews was utilised, as detailed next, with the guidelines of the preferred reporting items for systematic reviews and meta-analysis (prisma) followed during the screening process and for illustrating the process. stage 1: identification of the research question the population (covid-19 infected and/or exposed), concept (cochleovestibular symptoms or effects) and context (globally) (pcc) framework by the joanna briggs institute was used to formulate the research question. for this review, the following question was formulated, ‘what evidence has been published on the impact of covid-19 on the cochleovestibular system?’ stage 2: data sources and search strategy levac, colquhoun and o’brien (2010) recommended that the search strategy should follow a transparent format that can be reviewed and it should be comprehensive, without compromising feasibility. therefore, in this review, the literature search was conducted in december 2021 on databases including cinahl, ebscohost, medline, proquest, pubmed, scopus and sciencedirect. the following terms and combination of keywords were devised and used for the search based on the research question and to ensure congruency between the research question, search terms and inclusion criteria. these terms included ‘covid-19’ or ‘sars-cov-2,’ or ‘audiological effects of covid-19’ or ‘hearing loss and covid-19’ or ‘impact of covid-19 on audiovestibular system’ or ‘covid-19 and cochleovestibular effects’, ‘auditory dysfunction’, ‘dizziness’, ‘hearing loss’, ‘vertigo’, ‘vestibular dysfunction’ and ‘otologic symptoms’. ghalibaf et al. (2017) advised that utilising a combination of keywords enhances the search strategy to lead to an increased likelihood of finding more relevant articles while eliminates eliminating irrelevant articles. inclusion criteria to yield contemporary evidence, the search was restricted to peer-reviewed studies published in english during the covid-19 era (between january 2020 and january 2022). to be part of the scoping review, the studies had to report on cochleovestibular symptoms or effects of covid-19. exclusion criteria review studies and studies not published in english were not eligible for inclusion. studies were excluded if they did not address the research question, and if they did not include the combination of the search keywords. studies that spoke about tinnitus on its own were excluded because of the limited objective evaluation of tinnitus in such studies and the multiple possible causal factors in the absence of hearing loss. studies across the lifespan were included to ensure that findings assist with clinical planning across the lifespan, although it was obvious that identification of vestibular symptoms in the paediatric population would be challenging; however, hearing function findings would be valuable. stage 3: study selection all in all, the database search from all databases identified 114 articles. all identified database citations were exported to a web-based bibliography manager, endnote. through this bibliography manager, duplicate studies were identified and removed. following removal of duplicate studies, 79 studies remained, and these were brought down to 45 after title screening, where 34 articles were eliminated. the 45 abstracts were consequently screened, guided by the search question, and 5 studies were excluded because they did not report on cochleovestibular effects of covid-19. a total of 40 studies were then assessed for eligibility, and of these, 15 were excluded because they did not meet the inclusion criteria. ultimately, a full-text screening resulted in 24 studies meeting the inclusion criteria and being included in this scoping review. figure 1 shows a prisma flowchart for the literature search, retrieval and inclusion process of this scoping review. figure 1: preferred reporting items for systematic reviews and meta-analysis flow diagram for the current scoping review. stage 4: data extraction and charting following peters et al.’s (2015) recommendation that the data must be charted in line with the objectives of the review, the charting was conducted. after the reference search, a total of 24 studies formed part of this review, and these are tabulated in table 1. the table reflects the following data that were extracted from the included articles, with detailed analysis and discussion of the contents of the table presented next: researcher(s) and the year of publication title of the study country of publication aim of the article signs and symptoms reported conclusions recommendations. table 1: summary of studies included in the scoping review documenting cochleovestibular impact of coronavirus disease 2019. data analysis was carried out through descriptive analysis, as the last step set out by arksey and o’malley (2005), with implications of the findings focusing on three broad categories: implications for teaching, research and practice – highlighting planning needs (peters et al., 2015). ethical considerations this scoping review followed all ethical standards for a study that does not involve direct contact with human or animal participants, including reflexivity and informed subjectivity, audience-appropriate transparency and purposefully informed selective inclusivity (suri, 2020). results and discussion the characteristics and main cochleovestibular findings documented in the 24 studies that met the eligibility criteria are depicted in table 1. these articles varied in terms of type of study, including case reports, single group prospective, case-control prospective, retrospective or cross-sectional studies on the cochleovestibular impact of covid-19. the articles are from both lmics and high-income countries (hics), with no evidence from africa as a continent, except for some from transcontinental egypt (mustafa, 2020; rhman & wahid, 2020). the majority of the evidence was on adults, with minimal but emerging evidence from the paediatric population (alan & alan, 2021; oskovi-kaplan et al., 2022; yıldız et al., 2021). the current findings are valuable for the south african context as they seem to flag a need for preventive ear and hearing measures planning, because they indicate the possibility of cochleovestibular presentation in covid-19. furthermore, current findings bring forward significant implications not only for therapeutic interventions insofar as prompt otorhinolaryngological management is concerned but they also highlight such implications for patient isolation should cochleovestibular symptoms be the first and only symptom, as well as for audiological service provision and human resource planning within this resource-constrained context. as far as the cochleovestibular symptoms are concerned, there is no conclusive published evidence of cochlear or vestibular damage that is persistent and clinically relevant following covid-19 recovery (gallus et al., 2021). however, the current review appears to indicate a strong possibility of covid-19 impacting cochleovestibular function in various ways across the lifespan (alan & alan, 2021; gallus et al., 2021; korkmaz et al., 2021); however, this evidence is not strong, and it remains difficult to confirm because of two key factors: (1) poor quality of studies and evidence that is based mainly on case studies (almufarrij, uus, & munro, 2020; munro et al., 2020), and (2) occurrence of other possible causes of cochleovestibular symptoms in these patients (munro et al., 2020). although in the current scoping review, the quality of the studies was not formally assessed, a scoping overview indicates the following features of the studies: (1) mostly case reports where other possible causes are a possibility; (2) limited use of objective audiological measures, but rather reports and complaints by patients were used; (3) where control groups are included, there is limited clarity provided on inclusion criteria for the control group participants, and so on. these limitations are, however, arguably expected during a new public health emergency where everything is new and novel and exploratory research is what is feasible. nonetheless, notwithstanding this research quality challenge, the limited evidence that exists seems to warrant the need for careful audiological assessment and monitoring and polymerase chain reaction (pcr) testing for covid-19 diagnosis in patients with sudden unexplained cochleovestibular features during covid-19 (beckers et al., 2021; jafari et al., 2021; koparal & yılmazer, 2021) and children born to mothers who were covid-19 positive during pregnancy (alan & alan, 2021; oskovi-kaplan et al., 2022; yıldız et al., 2021). this is particularly important as definitive evidence is required to ensure that appropriate treatment is provided that takes into cognisance the therapeutic dilemmas surrounding the use of steroids in this population, as raised by karimi-galougahi et al. (2020), the need for patient isolation and the possibilities of monitoring for late onset hearing loss in children born to mothers who were covid-19 positive during pregnancy. the south african healthcare system and the audiology community would need to carefully plan around how to effectively manage these cases within the already resource-constrained context (pillay et al., 2020), possibly within already existing programmes, adopting a programmatic approach to care (khoza-shangase, 2022). analysis in this review leads the current author to conclude that generally, cochleovestibular symptoms that have been reported in adults include sudden onset sensorineural hearing loss with varying severity levels, which can be unilateral or bilateral, mostly high-frequency configuration, with or without tinnitus and vertigo, with the presentation in the paediatric population remaining relatively obscure. the occurrence of cochleovestibular symptoms is reported to vary, with some patients presenting with ssnhl as a leading symptom of covid-19, while in others the symptoms occur greater than 6 days after the covid-19 diagnosis or long after recovery from the infection (kilic et al., 2020; munro et al., 2020; pokharel et al., 2021; ricciardiello et al., 2021). even if some patients present with cochleovestibular symptoms, some evidence seems to indicate that these are mainly temporary in nature (gallus et al., 2021; munro et al., 2020). in paediatrics, refer findings have been documented during neonatal or newborn hearing screening (nhs) in neonates whose mothers were infected with covid-19, particularly in the second trimester. in most of the cases, the symptoms are temporary and resolve either partially or completely following treatment with steroids, thus highlighting the importance of clear categorisation and identification of these symptoms for early intervention. the possibility of late onset of hearing loss in the paediatric population has not been eliminated by current data and warrants closer monitoring of these patients, thus raising implications for longitudinal follow-up of these children for early intervention to be instituted should the need arise, within the south african context. the type of onset of the cochleovestibular symptoms is reported to be acute (gallus et al., 2021; koumpa et al., 2020; savtale et al., 2021), with most of the patients reported to have achieved partial or complete resolution of symptoms after therapy with steroids (bhatta et al., 2021; chern et al., 2021; koumpa et al., 2020; ricciardiello et al., 2021). for example, pokharel et al. (2021) reported on significant improvement in hearing following treatment with steroids. early detection and diagnosis of ssnhl and other less familiar symptoms in this population provides patients with the prospect to receive early intervention (koumpa et al., 2020; ricciardiello et al., 2021). koumpa et al. (2020) argued that this prompt screening and diagnosis of cochleovestibular symptoms post-covid-19 facilitates prescription of an early course of steroids, thus providing the patient with the best chance of symptom resolution. koparal and yılmazer (2021) stressed that in cases presenting with unexplained hearing loss or vestibular dysfunction, it is critical to prioritise pcr testing to determine the possibility of covid-19 causing the symptoms because of two important reasons: (1) prevention of virus spread (patient isolation) and (2) offering the patient therapy for acute hearing loss with steroids while taking into cognisance the therapeutic dilemmas surrounding the use of steroids in this population (karimi-galougahi et al., 2020), thus affording the infected patient an opportunity to recover from the symptoms. from their review, almufarrij et al. (2020) concluded that significantly few cochleovestibular symptoms can be confirmed to be covid-19 related, with most of the cases presenting with minor symptoms. mustafa (2020), however, highlighted that the lack of significant covid-19 symptoms does not necessarily provide assurance that cochlear function is healthy and safe. several studies reviewed indicate the presence of ssnhl with or without tinnitus and vertigo (beckers et al., 2021; chern et al., 2021; gallus et al., 2021; jin et al., 2021; kimura et al., 2021; korkmaz et al., 2021; koumpa et al., 2020; munro et al., 2020; ricciardiello et al., 2021) with nonspecific symptoms such as ssnhl being reported as possibly being the sole feature that could be used to identify a covid-19 case (kilic et al., 2020). the reported rate of otological or vestibular symptoms varied significantly. for example, korkmaz et al. (2021) reported the rate of hearing impairment (5.1%), tinnitus (11%), dizziness (31.8%) and true vertigo (6%); gallus et al. (2021) documented their rate at 8.3% for hearing loss, 4.2% for tinnitus and 8.3% for dizziness; bhatta et al. (2021) reported hearing loss in 3.9%, tinnitus in 1.8%, earache in 1.8% and aural fullness in 1.4% of their patients with covid-19; and munro et al. (2020) reported a change in hearing and tinnitus in 13.2% of their covid-19 diagnosed patients. munro et al. (2020) reported that testing showed vestibular symptoms, with beckers et al. (2021) reporting a deficit of the anterior semicircular canals and chern et al. (2021) documenting bilateral intralabyrinthine haemorrhage. ricciardiello et al. (2021) reported that both ears can equally be affected, and the impairment could be unilateral or bilateral, and if bilateral, the symptoms can be symmetrical or nonsymmetrical (karimi-galougahi et al., 2020; koparal & yılmazer, 2021; koumpa et al., 2020; sriwijitalai & wiwanitkit, 2020), with the severity of the hearing loss documented to range from mild loss to profound hearing loss (beckers et al., 2021; chern et al., 2021; koparal & yılmazer, 2021; koumpa et al., 2020; pokharel et al., 2021) and some evidence of pure-tone average being substantially worse in patients with covid-19 when compared with healthy control groups, particularly in the high frequencies (koparal & yılmazer, 2021). mustafa (2020) found that pure-tone hearing thresholds in high frequencies and amplitudes of transient evoked otoacoustic emissions (teoae) were significantly worse in this population, thus concluding that covid-19 infection potentially has adverse effects on cochlear hair cell function even when infected individuals are asymptomatic for the cardinal disease symptoms. similar findings were reported by dharmarajan et al. (2021), while daher et al. (2022) only found the hearing loss in the ultra-high frequencies, thus highlighting the need for inclusion of sensitive audiological measures such as ultra-high frequency audiometry and distortion product oaes (dpoaes). among the paediatric population, covid-19 positivity in pregnancy has been associated with an increased risk of refer screening results during nhs (alan & alan, 2021; oskovi-kaplan et al., 2022; yıldız et al., 2021). alan and alan (2021) reported that pcr positivity during the second trimester of pregnancy may be associated with abnormal nhs findings, although these refer findings resolve on repeat screening later and results become similar to those of the control group (alan & alan, 2021; yıldız et al., 2021; oskovi-kaplan et al., 2022). in fact, oskovi-kaplan et al. (2022), based on the lack of differences they found between the study and control groups at final screening, conclude that covid-19 infection during pregnancy does not appear to be a risk factor for hearing loss – a sentiment not shared by alan and alan (2021), who asserted that maternal covid-19 infection could potentially be a risk factor for hearing impairment, albeit the effect being temporary in nature. on the other hand, yıldız et al. (2021) suggested that for conclusive findings about hearing loss because of covid-19 in this population, larger patient series in newborns should be evaluated and that late onset hearing loss is also a possibility in this population. oskovi-kaplan et al. (2022) supports this suggestion by recommending that large-scale, multicentre studies of pregnant women be conducted to support current evidence and to make a definitive judgment regarding neonatal hearing outcomes post-covid-19-exposure and infection. this raises research and clinical follow-up implications for the south african research and audiology communities. findings from the review reveal uncertainty and inconsistency regarding the underlying pathophysiology of the cochleovestibular symptoms in covid-19 positive patients, with pokharel et al. (2021) maintaining that the absence of a clear pathophysiologic mechanism linking covid-19 to ssnhl creates a vague association. therefore, koparal and yılmazer’s (2021) recommended more research to examine the impact of covid-19 on hearing, including the underlying pathophysiology. so far, current evidence suggests that otologic features found in this population are potentially because of (1) direct viral invasion of the labyrinth or cochlear nerve and intralabyrinthine haemorrhage from covid-19-associated coagulopathy (chern et al., 2021); (2) an inflammatory process in the cochlea (virus-triggered, immune-mediated inflammation), as observed in mri findings (degen et al., 2020); (3) the possibility of covid-19 invading the neural pathways involved in hearing and balance (karimi-galougahi et al., 2020); and (4) in neonates, delayed neuromaturation because of factors such as preterm birth, foetal growth restriction and perinatal mortality (alan & alan, 2021). on the other hand, kimura et al. (2021) argued that differentiating symptoms in covid-19 from those of bacterial infections is difficult, while munro et al. (2020) highlighted that many other potential causes of hearing loss linked to critical care such as auto-immune disease, systematic or local infections, ototoxic medications and vascular disorders should also be considered. numerous recommendations were found in the studies reviewed regarding establishment and assessment and management of cochleovestibular symptoms in patients with covid-19. key to the recommendations is one by karimi-galougahi et al. (2020) and parrino et al. (2022), who argue that epidemiological correlations and bio-pathological mechanisms involved in cochleovestibular presentation of covid-19 require further investigations. linked to this recommendation, is ensuring that studies should not be of poor quality (almufarrij et al., 2020; fancello et al., 2021; munro et al., 2020), with almufarrij et al. (2020) suggesting that future high-quality studies be conducted once the life-threatening nature of the pandemic is under control. such high-quality studies would ensure that the distinction between premorbid and current changes in hearing, balance and tinnitus is clear and that the possibility that environmental surroundings changes associated with use of masks and hospitalisation is not what may have caused recognition of pre-existing tinnitus and hearing loss (munro et al., 2020). jafari et al. (2021) suggested future directions including follow-up assessments utilising reliable objective measures, as well as studies with properly constituted research designs. fancello et al. (2021) believed that despite the fact that the quality of the current evidence is poor, there is sufficient support for cochleovestibular disorders to be included as possible important features of covid-19. such heightened awareness of cochleovestibular disorders as part of the nonspecific presentation of covid-19 is important, as it facilitates prevention of the spread of this infectious pandemic through patient isolation and provision of and early covid-19 specific interventions (kilic et al., 2020; koumpa et al., 2020). pokharel et al. (2021) recommended a comprehensive history and diagnostic assessment for past or recent covid-19 infection in individuals with ssnhl, because ssnhl could be a sequela of covid-19 (ricciardiello et al., 2021), with beckers et al. (2021) recommending inclusion of pcr testing in the diagnostic evaluation of these patients with ssnhl during covid-19. furthermore, munro et al. (2020) recommended meticulous following up of covid-19 patients for establishment of its long-term consequences on cochleovestibular function. conclusion the current scoping review aimed at answering the question ‘what evidence has been published on the impact of covid-19 on the cochleovestibular system?’ revealed findings that highlight a need for high-quality research in the area so that definitive answers can be provided. current evidence suggesting the possibility of cochleovestibular impact of covid-19 across the lifespan is not strong enough; however, it does show that tinnitus, vertigo and ssnhl of mostly high frequencies occur either singly or in combination in adults and refer findings in neonatal hearing screening, albeit temporary. these cochleovestibular symptoms occur sometimes as the only symptom of covid-19 in the absence of the standardly reported core symptoms, and these are generally temporary and resolve either partially or completely following treatment with steroids. the pathophysiologic mechanism for the cochleovestibular symptoms in this population remains obscure. this lack of clarity and definitiveness is the same in the adult and paediatric populations, thus raising a need for caution around assessment and management of patients presenting with unexplained cochleovestibular symptoms during this pandemic and a need for possible longitudinal monitoring of children born to mothers who were covid-19 positive during pregnancy. recommendations for pcr testing have been made to allow for accurate and safe treatment of these patients – including isolation should pcr come back positive for covid-19, with safety and possible value around the use of steroids for treatment of ssnhl in this population being highlighted. these findings have important implications for clinical care planning and evidence development within the south african context, as detailed in the results and discussion section of this article. considerations around preventive approaches from primordial to tertiary prevention levels are crucial for this context, with implications for resource allocation taken careful cognisance of. acknowledgements competing interests the author declares that she has no financial or personal relationships that may have inappropriately influenced her in writing this article. author’s contributions k.k.-s. declares that she is the sole author of this research article. funding information the author thanks the national institute for the humanities and social sciences (nihss) for providing financial assistance for the publication of this manuscript. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of any affiliated agency of the author. references alan, m.a., & alan, c. 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(2020). clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. the lancet, 395(10229), 1054–1062. https://doi.org/10.1016/s0140-6736(20)30566-3 sajcd 117 costs involved in using a cochlear implant in south africa g kerr, s tuomi, a müller   division of speech language and hearing therapy, stellenbosch university gillian kerr seppo tuomi alida müller corresponding author: g kerr (gill.kerr@westerncape.gov.za) since the introduction of multichannel cochlear implants in 1984 (eisen, 2009), the potential hearing and speech outcomes of individuals with a severe-to-profound hearing loss have been revolutionised (mccormick, 2003; niparko, 2009; peters, wyss & manrique, 2010). the effectiveness of cochlear implants in providing increased sound perception for this population is well documented. they result in improved auditory performance and speech perception for adults and children, with benefits extending to improvements in education, occupation and quality of life (carpenter, 2009; chute & nevins, 2006; ramsden et al., 2012). cochlear implants have become the treatment of choice for many individuals with severe or profound sensorineural hearing loss (chute & nevins, 2006; carpenter, 2009).  cochlear implants are also cost-effective (lin, niparko & francis, 2009; o’neill, 2002; palmer, niparko, wyatt, rothman & delissovoy, 1997; sach, 2002; wyatt, niparko, rothman & delissovoy, 1995). despite this, they are used in low volumes (khan, mukhtar, safeed & ramsden, 2007). as of december 2010, approximately 219 000 individuals had received cochlear implants worldwide (nidcd, 2011). the relatively low volume used is probably due to the high cost of the implant system (retailing in the $30 000 range), as well as the costs of hospital admission, surgical fees and post-implant rehabilitation. these expenses keep cochlear implants out of reach for many individuals with profound hearing loss, especially in poor and socio-economically developing countries (glasscock, 2011). without access to such technology the potential choice of access to developing spoken language (congenital profound losses) or to retaining access to spoken language (acquired profound hearing loss) is denied for these individuals. although some individuals with severe or profound hearing loss may choose to follow a manual communication system, without potential access to cochlear implants, such a choice may be forced upon others. obtaining a cochlear implant commits an individual to a lifetime use of such a device. in countries like south africa, where implants are not provided by the national department of health (ndoh), individuals using a cochlear implant need to have adequate finances to be able to access the rapidly developing technology for the rest of their lives. for the purpose of economic evaluation, the process and costs of cochlear implantation can be divided into assessment, implantation, rehabilitation and maintenance (hutton & politi, 1995). in addition, the individual must be able to access a specialist facility, where cochlear implantation is offered. in south africa, reaching one of the facilities in six main city centres could involve additional costs of travelling long distances. although the initial costs of surgery and the implant system are available, little information is available in south africa about either the overall costs over time or individual cost categories. the high cost of the implant system itself frequently receives the primary focus, with less consideration given to the ongoing financial burden of using and maintaining the implant system, and of the rehabilitation. previous cost studies most studies have considered costs from the perspective of a third-party payer (e.g. medical aid or insurance) or society at large rather than from the perspective of the individual using the cochlear implant. studies which have investigated costs incurred by individuals or their families include those conducted in the uk (barton, fortnum, stacey & summerfield, 2006; sach, whynes, archbold & o’donaghue, 2005), the usa (cheng et al., 2000) and canada (fitzpatrick et al., 2006). most of these studies have been in developed countries, where a number of the direct costs are not paid for by the individuals using the cochlear implant. in the uk, for example, the tax-funded national health service meets the costs of the entire cochlear implant service (sach, whynes, o’neill, o’donaghue & archbold, 2004). the individuals and their families carry no direct costs for the service. in contrast, cochlear implants are mostly self-funded in many developing countries, necessitating consideration of a patient’s financial resources to fund both the implant system and the subsequent rehabilitation at the outset of pre-assessment (khan et al., 2007). no previous cost studies related to cochlear implantation have been conducted in south africa. applying the results of one country’s costs studies to other countries is difficult because of differences in healthcare systems, costs of services, and health and educational service delivery methods (fitzpatrick et al., 2006). each country’s unique funding and economic situation needs to be considered. the south african context in june 2010 south africa had an estimated population of 49.99 million people (statistics south africa, 2010). the country has a dichotomised health system. eighty-three per cent of the population is mainly reliant on the public health sector, which lacks sufficient systems, skills and resources to deliver healthcare services efficiently and operate health facilities optimally. this runs parallel with a well-resourced private health sector, which serves a minority of the population. eight million (17%) south africans are covered by private medical schemes (blecher, kollipara, dejager & zulu, 2011). although the private-public differential reveals a narrowing trend in recent years, inequity in health access, quality of care and spending remain a major challenge. despite south africa spending around 8.6% of gross domestic product on health, overall health outcomes of south africans remain inadequate (blecher et al., 2011). the ministry of health has committed to the negotiated service delivery agreement (nsda) (2010 2014), focusing on improving health outcomes by targeting four key outputs, viz. to increase life expectancy, decrease maternal and child mortality, combat hiv and aids and decrease the burden of disease from tuberculosis, and to strengthen the effectiveness of the health systems (blecher et al., 2011). against the backdrop of life-threatening disease and a prioritisation towards primary healthcare, specialised rehabilitative approaches, such as cochlear implantation, essentially a quaternary level of care, are not seen as a priority for ndoh spending. it is also unlikely that they will become so in the foreseeable future. the costs of the procedure have to be met by the individuals who receive a cochlear implant and their families, who may, or may not, have access to some funding from a private medical aid. the first multichannel cochlear implantation in south africa took place at the tygerberg hospital-university of stellenbosch cochlear implant unit (hereafter referred to as the tygerberg hospital cochlear implant unit) in november 1986. by june 2010 almost 1 000 individuals had been implanted in the country (j. wiegman, personal communication, 10 august 2010). wagenfeld and müller (1994), who pioneered the work in the field of cochlear implantation in south africa, cautioned that the financial implications of lifetime maintenance of an implant, rather than the supply of the implant hardware itself, represent the biggest financial obstacle for individuals requiring and using cochlear implants. as more individuals continue to be implanted in the country, it is important to use the experience gained from 25 years of implantation to guide further intervention. it is necessary to be able to detail the long-term costs borne by the individuals receiving a cochlear implant, as well as to examine and anticipate their course over time. this information is needed to provide realistic guidance regarding the financial implications of implantation to individuals who are considering obtaining a cochlear implant. it is also needed to help guide individuals already using an implant and clinicians working in the field. methodology aims the current study investigated the costs incurred by the existing population using a cochlear implant at the tygerberg hospital cochlear implant unit. the aim of the study was to determine the shortand long-term costs of using a cochlear implant system for this population. study design the study employed a non-experimental ex post facto research design (bailey, 1997; hegde, 2003). individuals, who had received a cochlear implant at the tygerberg hospital cochlear implant unit between november 1986 and march 2010, were surveyed by means of a questionnaire and examination of patient records. the survey contained two different types of questions designed to elicit different types of information from participants. some questions tapped quantitative data, which were analysed using descriptive statistics. other questions were open-ended, which allowed participants freedom to respond and include issues they thought important. the qualitative data yielded by these latter questions were subjected to theme analysis. costs investigated the following costs were investigated: short-term costs • initial acquisition • the implant system long-term costs • maintenance and use • upgrades of the processor • batteries • spare parts • repairs • travel and accommodation associated with visits to the implant unit • support services • rehabilitation for children • optional costs • insurance • hearing aid in non-implanted ear • personal frequency modulation (fm) system in addition, the manner of funding and development of costs over time were monitored. advice from participants to individuals considering using a cochlear implant in the future regarding costs was solicited and analysed. the costs of radiological investigations, consultations with the ear, nose and throat surgeon, surgery and hospitalisation were excluded from this study. these costs tend to be either covered by medical aids, for individuals accessing private healthcare, or are highly subsidised for state patients. although expensive, these costs to the individuals themselves are often minimised. they are also more variable than the other costs investigated as they take place at a number of different facilities, and are not standardised, making comparisons difficult. participants inclusion criteria the participants were required to be living in south africa, and actively using their cochlear implants. they had to have been using their implant for a minimum period of 3 months at the time of the data collection, in order for them to be able to contribute meaningful information regarding the use of an implant, in addition to the purchase of it. exclusion criteria individuals who were implanted at other centres and subsequently managed at the tygerberg hospital cochlear implant unit, those living in other countries, deceased individuals who had used a cochlear implant and those no longer using their cochlear implants were not included in the study. sampling the population consisted of all the individuals who had received a cochlear implant from the tygerberg hospital cochlear implant unit. the unit retains contact with all individuals implanted there, as they require lifelong audiological follow-up. it is a closed population where contact details are known for all, enabling access to all potential subjects. the questionnaire was sent to all individuals who met the inclusion criteria. such probability sampling, which includes the entire defined study population, is considered the ideal random method of participant selection (drummond, 1996; hegde, 2003). all individuals had an equal chance of being included in the study. while the consent process in the study would have resulted in a degree of volunteerism, allowing each individual in the population an equal chance to participate reduced the potential effect of subject selection on the internal validity of the study (bailey, 1997; hegde, 2003). description of participants three hundred and ten individuals met the inclusion criteria and were sent the questionnaire. one hundred and sixty-four responded. ten chose not to participate as a result of a variety of reasons including illness, time constraints and lack of records. one hundred and fifty-four individuals (50%) participated. they consisted of 80 females and 74 males. • age at implantation. the average age of participants at implantation was 22 years, with a range of 6 months to 84 years. eighty-two participants (53%) were implanted as children (average age 4 years 5 months). a small number of participants (8) were implanted as teenagers (average age 15 years 9 months) and 64 (42%) were implanted as adults (average age 45 years 2 months). • duration of implant use. the average duration of use of an implant was 7 years 4 months (range: 3 months to 22 years 7 months).those implanted as children had, on average, used their implants for 8 years (range: 3 months to 21 years 2 months). the teenagers’ average duration of use was 6 years 2 months (range: 1 year to 15 years 3 months). the adults had, on average, used their implants for 6 years 8 months (range: 4 months to 22 years 7 months). income status the tygerberg hospital’s income classification system was used to determine the current income status of the participants (see table 1), which in turn determines the cost of visits to the implant unit. this classification is based on the patients’ (or family’s) monthly income, ranging from those earning least (unemployed, on grants or non-private children under 6 years) to those on medical aids. ninety-six participants (62%) were members of medical aids (charged the highest price for hospital visits, regardless of actual income level). two participants were non-private children under 6 years of age, who qualified for free hospital appointments. the income distribution of the remaining 56 participants ranged from less than r4 166 to more than r8 334 per month. table 1. monthly family income classification of participants monthly family income non-private <6 years old ≤r4 166 r4 167-r8 333 ≥r8 334 medical aid number of participants 2 (1%) 27 (18%) 12 (8%) 17 (11%) 96 (62%) ethics permission to conduct the study was granted by the health research ethics committee of the stellenbosch university and the medical superintendent of tygerberg hospital. information and consent forms were distributed to all subjects. all participants returned a written signed consent form indicating their willingness to participate, and their understanding of the nature of the study. in the case of children, parents/caregivers were required to provide the written consent and complete the questionnaire. data collection questionnaire a questionnaire (appendix a), relevant for the south african context, was developed for the study. the questionnaire consisted of nine question areas. eight asked for estimates of various costs and provided the participants with option ranges to choose from. the questions included: forced alternatives (yes/no type questions) and, where possible, presented closed set options for participants’ responses. this structure was chosen to aid the speed and ease of completion for participants (creative research systems, 2012; drummond, 1996). one question (question 8) was open-ended. this question probed advice which participants would give others regarding costs. the open-ended structure afforded participants an opportunity to respond more freely, and to include information which they felt was relevant to the question (creative research systems, 2012; drummond, 1996). the participants were instructed to fill in as much information as possible. if they could not remember or did not have access to exact amounts they were asked to give estimated costs. provision was also made for participants who did not remember a particular cost to indicate this on the questionnaire. in order to gain an idea of the different costs incurred at different time periods in the implantation process, the questionnaire requested the information according to time periods. these included: initial evaluation, 1 2 years, 3 5 years, 6 10 years, 11 15 years, 15 20 years and more than 20 years after receiving a cochlear implant. as the length of time the individuals had been using their cochlear implants varied, they completed only those time periods relevant to them. questions 1, 2 and 3 collected data related to visits to the cochlear implant unit. question 4 probed information regarding the number of post-warranty repairs needed for the speech processor. question 5 gathered information about the insurance of the speech processor. question 6 investigated the purchase of a personal fm system and the costs involved. question 7 extracted information about the use of a hearing aid in the contralateral ear (the ear not implanted), i.e. the purchase of the aid and monthly battery cost. question 8 gave participants an opportunity to advise those considering an implant about costs and planning for costs, involved in obtaining and maintaining a cochlear implant based on their own experience. question 9 examined rehabilitation costs for children (those who were implanted below the age of 13 years). the content, as well as the phrasing of the questions, was carefully considered to ensure that only questions relevant to the study were asked in a way which did not lead the subject (creative research systems, 2012; drummond, 1996). the questionnaire was designed by the investigator, an audiologist with 10 years’ experience working in cochlear implantation, and the founding co-ordinator of the unit, an audiologist with 25 years’ experience working in the field of cochlear implantation in south africa. the questions were judged to not include any cultural, racial, intelligence or language bias, which could have influenced the results. care taken in the design of the questionnaire helped to ensure the internal validity of the study (bailey, 1997; creative research systems, 2012). the questionnaire was developed in english and translated into afrikaans, the two main languages spoken by individuals using a cochlear implant at the tygerberg hospital cochlear implant unit. the accuracy of the translation was assessed by a bilingual english-afrikaans speaking speech-language therapist and audiologist employed in an academic post at the department of speech-language and hearing therapy, stellenbosch university. the questionnaire was made available to participants in english or afrikaans depending on their known preference. only the cost information for one cochlear implant per individual was collected. this was done in order to try to determine the minimum necessary costs which would need to be covered if an individual were to receive a cochlear implant. currently most individuals still use one implant, though bilateral implantation is becoming the treatment of choice, especially for children (johnston, durieux-smith, angus, o’connor & fitzpatrick, 2009; ramsden et al., 2012; summerfield, lovett, bellenger & batten, 2010). in this study, 30 participants (19%) were bilaterally implanted. pilot study of the questionnaire prior to being used in the study the questionnaire was piloted on three individuals who used a cochlear implant, who were not included in the study, to ensure that participants would understand the questionnaire, and to help plan the procedures which would be used in the data collection (creative research systems, 2012; doehring, 2003). it was also used to determine whether the questions elicited the desired information and to evaluate whether the survey was too long or too short (bailey, 1997). all three individuals indicated that they could follow all the instructions easily and that they understood all the questions as asked. minor modifications to the reply format were made on the basis of their responses and suggestions. distribution of the questionnaires the questionnaires together with information sheets and consent forms were distributed to subjects via email, post or in person, when the individuals using a cochlear implant attended their follow-up appointments at the unit. three hundred and ten questionnaires were distributed. one hundred and fifty-four completed questionnaires were returned, via email, fax, post (using a pre-paid envelope provided) or by hand directly to the unit. email and telephone reminders were used to help improve the return rate of the questionnaires. the 50% return rate obtained was considered acceptable as it was in keeping with the general findings of response rates to postal questionnaires, which are usually between 40% and 60% (oppenheim (1996) cited in drummond, 1996). patient records the information supplied by the questionnaire was supplemented with and checked against information from patient and distributor records to increase the accuracy of data and to verify costs associated with implantation and maintenance. where data were readily available in patient records, information was obtained from these sources rather than from the participants themselves to reduce possible potential inaccuracies related to participants’ recall. information from patient records was extracted from databases at the tygerberg hospital cochlear implant unit and southern ent pty (ltd), the tygerberg hospital income classification system and the tygerberg hospital cochlear implant unit follow-up protocol. analysis of data the raw data were analysed to establish the relationships, trends and patterns of all the costs incurred by individuals using a cochlear implant, or their families, from the time of their initial assessment up to june 2010. all costs were converted into south african rand values as at june 2010, using the consumer price index (cpi), so that they could be compared in real terms. descriptive statistics were used. means were used as a measure of central tendency and ranges as a measure of variability (heffner, 2004; stein & cutler, 1996). where ranges of costs were provided, the midpoint of the range was used in the calculations. where the participant’s responses fell into an open-ended interval (i.e. top limit unbound), the investigator estimated the most likely value to be used in the calculations. very few responses were noted in the open-ended ranges, so this did not have a significant effect on the analysis. the probability of occurrences of various costs in the different time periods following implantation was statistically determined, using contingency tables, based on the relative actual frequencies of occurrences for participants in the study. these included the occurrences of spares purchases, repairs and upgrades. frequency distribution tables were constructed to analyse this information (stein & cutler, 1996). the responses to the open-ended question 8 were subjected to a theme analysis (aronson, 1994; braun & clark, 2006). responses were coded by participant number and analysed independently by the investigator and another experienced cochlear implant audiologist. the main themes were independently extracted from each participant’s answer by the two analysers and compared. a 92% correlation between the two analysers’ themes was obtained, indicating high inter-rater reliability (doehring, 2003; hegde, 2003).the few discrepancies were discussed to reach a consensus. the main themes were analysed for all participants to extract the most frequently occurring themes in the group and trends were extracted. results and discussion total average costs the total average costs were calculated for the first 5 and 10 years post implantation (table 2). ten years represented the maximum time period for which complete records of spares and repair costs were available from the current south african distributor of the nucleus products used at the tygerberg hospital cochlear implant unit. this grouping of costs allowed for the comparison of shorterand longer-term costs incurred. these costs were calculated for private individuals living within 50 km of the unit. the costs of a hearing aid and an fm system were not included in these figures, as they are not costs essential to the use of a cochlear implant, or routinely encountered by all individuals using a cochlear implant. in this study only a third of the participants were using a hearing aid in the non-implanted ear, and only 15% had purchased an fm system. as seen in table 2, during the first 5-year period, the implant system cost was 74% of the total costs for children and 86% of the total costs for adults. during the first 10-year period these percentages dropped to 49% for children and 58% for adults, reflecting the increased costs over and above the initial purchase of the system itself encountered in the longer time period. the total costs for children (i.e. those implanted under 13 years) were significantly higher than for adults, mostly because of the additional rehabilitation costs (primarily speech-language therapy). electrode programming costs for children were also higher as a result of the increased number of appointments needed, and on average spares costs were 40 50% greater for them. the difference in the costs between the first 5 and 10 years post implantation reflected the greater likelihood that repair and upgrade costs would occur in the longer term. findings from the study showed that, on average, participants upgraded their processor after 7 years of using their cochlear implant, and had their processor repaired once during the first 10 years of use, usually after at least 6 years of use. individuals using a cochlear implant who lived further than 50 km from the unit, bore greater travel costs than those indicated in table 2 and may also have had additional accommodation costs. table 2.total costs for first 5 and 10 years post implantation (june 2010)   1st 5 years (child) 1st 5 years (adult) 1st 10 years (child) 1st 10 years (adult) implant system r221 000 r221 000 r221 000 r221 000 batteries (ci) r11 400 r11 400 r22 800 r22 800 spares r1 849 r738 r2 795 r1 444 repairs     r2 950 r2 950 travel (<50 km)* r2 093 r688 r2 746 r752 electrode programming† r5 240 r3 930 r6 550 r5 240 insurance r20 220 r20 200 r40 440 r40 440 upgrade‡     r85 000 r85 000 total r261 802 r257 956 r384 281 r379 626 speech therapy r37 159   r70 944   total r298 961 r257 956 r455 225 r379 626 *travel cost: cost per patient as estimated by participants. †average cost was used. this will be higher for younger children and lower for older children because of the increased number of appointments needed for younger individuals using a cochlear implant. ‡upgrade price. initial acquisition: implant system costs cochlear implant system costs over time the costs of the cochlear implant system from november 1986 to june 2010 are shown in figure 1. all costs are in constant rands, as at june 2010. the cost of the implant system is the same for children and adults. the cochlear implant system was the greatest single cost involved in the implantation process. this result was similar to the findings in a recent french study, which also reported the cost of the device as the main cost in implantation (molinier, bocquet, bongard & frayesse, 2009). in that study the cost of the device represented 64.4% and 68.8% of the total cost for children and adults respectively. this was lower than that noted for participants in this study during the first 5 years, and higher than that noted for participants during the first 10 years. figure 1 shows the rising trend for the average system cost over the 24-year period, with a peak in average cost occurring between 2001 and 2005. the highest and lowest average costs varied by almost r100 000. the average cost of implants increased steadily from r152 026 in the earliest period to r246 589 during the 2001 2005 period, with a decline in the latest period. the average implant system in the most recent time period (2006 2010) cost almost r55 000 (r54 950) more than in the earliest time period (1986 1990). as the implant systems are manufactured outside of south africa and imported for use, a major reason for their cost fluctuations and increase may be exchange rate changes. fig. 1. cochlear implant system costs between november 1986 and june 2010. funding of implant systems although the cochlear implant system was the greatest single cost in the implantation process, the amount which participants themselves had to pay varied. figure 2 shows the sources participants used to fund their implant systems. seventy per cent of the participants (35% + 34% + 1%) were members of a medical aid at the time they were implanted. there was considerable variation in the medical aids’ contribution towards the cost of the implant system. half had the system fully funded by their medical aid while the other half received only partial funding and had to pay from 5% to 95% of the cost. the average partial contribution from the medical aids was 50% of the system cost. thirty per cent of the participants were not members of a medical aid when they were implanted. twelve per cent of these individuals had to fully fund the system themselves. another 12% were fully assisted by sponsors. six per cent of the participants funded their implant system using a combination of their own funds and those from a sponsor. fig. 2. funding sources for cochlear implant system. maintenance costs upgrades the cost of upgrading the sound processor was the second highest cost involved, adding up to almost 40% of the initial system cost (r85 000 at june 2010). on average the participants had upgraded every 7 years (range: 1 year to 14 years). participants from one particular medical aid upgraded more regularly, as a result of their medical aid’s funding policy. many individuals on other medical aids, and all those not on medical aid, had to fund the upgrades themselves. upgrades among the participants were less frequent than the current practice in the uk, where sound processors are upgraded free of charge on average every 4 5 years of use (s. thomas, personal communication, 18 november 2010). an increasing upgrading percentage, as well as multiple upgrades, was noted for those implanted the longest. all the participants implanted for more than 20 years had upgraded at least twice, with 2 individuals having upgraded 3 times, and 1 having upgraded 4 times. more than half the participants implanted for 15 20 years had upgraded twice. all the participants implanted for longer than 15 years had upgraded at least once. most of the participants implanted for between 11 and 15 years had upgraded at least once, with more than a quarter upgrading twice. more than half the participants implanted for between 6 and 10 years had upgraded their sound processor, most of them once, and a small number twice. most of the participants using their sound processor for less than 5 years had not upgraded. batteries the monthly battery costs for the sound processor are shown in appendix b. on average battery costs varied from r1 200 to r3 372 per year (r100 to r281 per month). the costs were influenced by the sound processor being used. battery costs were generally lower for body-worn devices than for ear-level sound processors. rechargeable batteries for the ear-level processors appeared to be more expensive than disposable batteries. spare parts the analysis of spare parts included costs of ear-hooks, magnets, drying kits, snug-fits, cables and coils. those implanted for more than 2 years had spent on average r276 per year on spares. there was, however, great individual variation, with some participants having no expenses, and others spending r916 per year. on average spares costs were greater for the children, especially during the 3 5-year period following implantation. the average cost of cables and coils over 10 years was r2 838 for those participants who had had to replace them. these purchases occurred sporadically at different time intervals post implantation. most participants only started replacing cables and coils from 4 years post implantation. clustering of purchases occurred for a few individuals, especially some children. repair costs the average repair cost of the sound processor was r3 000 per repair. the percentage of devices needing repair increased with longer duration of use, and especially after 6 years. most participants had only had one repair in the 10-year time period reviewed. there were, however, a few notable exceptions, e.g. one individual, who had 4 repairs in 7 years 8 months of use. travel and accommodation associated with visits to the implant unit travel costs the highest travel costs were noted for all participants during the first 2 years after implantation. on average those living within 50 km of tygerberg hospital spent r1 024 on travel in the first 2 years. those living more than 1 000 km away spent an average of r8 645 during the same time period. accommodation costs one-third of the participants needed accommodation in order to attend implant-related appointments. there was a peak in accommodation costs during the first 2 years post implantation for those who lived more than 100 km from the unit. the average total accommodation cost for these participants was r3 390 for the first 2 years after implantation. support services rehabilitation services for children the cost of rehabilitation services received by children was influenced by the frequency of therapy, length of time, number of therapies involved (single or multiple) and whether participants were seen at private or government facilities. most participants (93%) received speech-language therapy in the first 2 years following implantation, at an average cost of r7 070 per year. as shown in figure 3, a significant, though declining, percentage of children continued receiving speech-language therapy over 3 5 years and 6 10 years following implantation. the continued need for speech-language therapy for over 40% of the participants 6 10 years post implantation may have been a reflection of the relatively late average age of implantation of the children in this study (4 years 5 months). it is estimated that 40% of children will present with an identified disorder in addition to their hearing loss (perigoe & perigoe, 2004; picard, 2004), which will necessitate additional intervention. the children in this study were no exception. figure 3 shows that, in addition to speech-language therapy, some of the children also required occupational therapy and physiotherapy. the number of children receiving these services was highest in the first 2 years after implantation, and declined over time. fig. 3. rehabilitation services received by children at different time intervals following implantation. optional costs associated with implant use insurance twenty-seven per cent of the participants had insured their sound processors. some who wanted to insure their sound processors found the monthly premiums too costly to afford. insurance premiums were on average r4 044 per year (r337 per month). they varied widely from r600 to r9 600 per year (r50 to r800 per month). cost of hearing aid in the non-implanted ear one-third of the participants used a hearing aid in their non-implanted ear. the cost of a hearing aid varied from r3 534 to r29 750. half of these participants had purchased the hearing aid themselves and a quarter had received funding from their medical aid. participants paid, on average, r31 a month for batteries. this was a fraction of the average monthly battery costs noted for the processor. personal frequency modulated (fm) system the cost of an fm system varied from r9 964 to r21 750. fifteen per cent of the participants had purchased an fm system. most were purchased for children to use. two-thirds of these participants paid for the device themselves. the rest were funded partially or in full by their medical aid. advice from participants participants were asked to provide advice about the costs involved in cochlear implantation to individuals who would potentially use a cochlear implant in the future. the following six themes were identified from the analysis of the participants’ advice: 1. need to budget carefully, plan and save for costs (46% of participants). 2. importance of belonging to a medical aid that assisted with implant costs (44% of participants). 3. use of multiple financial sources to purchase implant system (39% of participants). 4. high cost of batteries for sound processor (23% of participants). 5. importance of insuring sound processor (17% of participants). 6. meticulous care of the sound processor to increase its lifespan (16% of participants). limitations the findings of this study are based on information collected from half the individuals using a cochlear implant at one implanting unit in south africa, which utilises only one make of implant system. despite the relatively large sample size obtained, the findings may not be fully representative of the situation in the country as a whole. while these limitations should be heeded, the types of costs identified in the study are thought to hold relevance for all patients and implanting units in the country. the actual costs in the study are tied to a particular time and product and will need to be adjusted accordingly when applying the information in the future. conclusion the findings of this study suggest that in order to meet the cost requirements of cochlear implantation in south africa individuals using a cochlear implant need to make plans to meet the following shortand long-term costs: • obtain the funds for the initial purchase of the cochlear implant system (june 2010: r221 000). • pay for upgrading the sound processor (june 2010: r85 000) on average every 7 years. alternatively every 10 15 years once their sound processor becomes obsolete, or approximately every 3 5 years, if they want to stay abreast of the latest technology. • afford between r1 200 and r3 372 per year (r100 r281 per month) for batteries. • purchase spare parts immediately as needed, and be prepared to spend on average r276 on spares per year (more for children). • pay sound processor repair cost of r3 000. • afford the travel (and accommodation) expenses to access the implant unit for appointments. the costs are greatest in the first 2 years following implantation but remain ongoing. • afford the programming of the sound processor. the number of appointments will be dependent on age at onset of hearing loss, age at implantation, and duration of use. • purchase and maintain a hearing aid for the non-implanted ear if indicated. these costs could range from r3 534 to r29 750. • insure the sound processor to avoid significant expenses should it become lost or stolen. insurance could cost r600 r9 600 per year (r50 r800 per month). • in addition parents or caretakers of children must be able to: • access and afford the rehabilitation required. the type, frequency and duration of required therapies are child-specific. the most likely is at least speech-language therapy (average r7 070 for 1 year). • purchase and maintain a personal fm system at an average cost of approximately r16 000 (range: r9 964 r21 750; june 2010). individuals, who meet all the selection criteria and are considering a cochlear implant, as well as those already using one, should be informed about these expected costs, and the likely time periods post implantation they will be incurred. this knowledge will assist them in assessing the affordability of the intervention and planning for the costs to enable them to continue using their implant system successfully in the long term. clinicians engaged in candidate selection in south africa will also benefit from the findings obtained. they must realistically consider an individual’s ability to afford a cochlear implant, so that limited resources are not wasted and patients are not unintentionally financially burdened beyond their means and ability to achieve good outcomes. making a decision regarding an individual’s or a family’s ability to meet the potential long-term costs for candidates who may be able to meet the initial cost requirements may lead to an ethical dilemma for clinicians. the findings of this research could assist them in helping individuals consider their ability to meet the implementation costs of their intervention of choice more realistically. implications for further research to expand the knowledge base of cost factors involved for individuals using a cochlear implant in south africa, future studies could investigate: (i) the economic impact of bilateral implantation on individuals or their families; (ii) the economic impact on individuals or their families of the increasing trend towards younger implantation of congenitally deaf children; (iii) the effect of financial factors on non-use in the south african context; (iv) the indirect costs borne by individuals using a cochlear implant (e.g. time away from work to attend appointments and loss of earnings); and (v) the cost of appropriate education for children using a cochlear implant in south africa. acknowledgements. the authors thank all those individuals who took part in this study and southern ent pty (ltd) for access to their patient records. thanks also to professors servaas berger, martin kidd and hannelie nel at stellenbosch university for their assistance in the data analysis, and jenny perold for assistance with the theme 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(1995). cost effectiveness of the multichannel cochlear implant. the american journal of otology,16(1), 52-62.   appendix a. cochlear implant cost questionnaire instructions: please complete the following questionnaire. the information is important, please try and fill in all the questions. if you don’t know the exact data please give as close an approximation as you can. for those who have two cochlear implants please answer all questions with regard to the first cochlear implant (ci). date completed: _____________________________________ name of implant user: _________________________________ date of birth: ________________________________________ question 1. distance to the cochlear implant centre 1.1. how far did you live from the ci centre while you were being evaluated for the cochlear implant? (mark one block) within 50 km 51 100 km 101 500 km 501 1 000 km more than 1 000 km           1.2. how far did you live from the ci centre during the first 2 years after receiving the implant? (mark one block) no change within 50 km 51 100 km 101 500 km 501 1 000 km more than 1 000 km             1.3. how far did you live from the ci centre during years 3 5 after receiving the implant? (mark one block) no change within 50 km 51 100 km 101 500 km 501 1 000 km more than 1 000 km             1.4. how far did you live from the ci centre during years 6 10 after you received the implant? (mark one block) no change within 50 km 51 100 km 101 500 km 501 1 000 km more than 1 000 km             1.5. how far did you live from the ci centre during years 11 15 after the implant? (mark one block) no change within 50 km 51 100 km 101 500 km 501 1 000 km more than 1 000 km             1.6. how far did you live from the ci centre during years 15 20 after the implant? (mark one block) no change within 50 km 51 100 km 101 500 km 501 1 000 km more than 1 000 km             1.7. how far did you live from the ci centre from 20 years after the implant? (mark one block) no change within 50 km 51 100 km 101 500 km 501 1 000 km more than 1 000 km             1.8. did you move to be closer to the ci centre? yes_________ no__________   if yes please explain the reason(s): ___________________________________________________________________________________________________________________________________________________________________________________________________________________________   1.9. did you transfer to another cochlear implant program because of costs? yes_________ no _________ question 2. transport to the ci centre 2.1. how did you get to the ci centre at different points in time? (mark all relevant blocks) evaluation own transport public transport air travel + other first 2 years own transport public transport air travel + other year 3 5 own transport public transport air travel + other year 6 10 own transport public transport air travel + other year 11 15 own transport public transport air travel + other year 15 20 own transport public transport air travel + other years 20 + own transport public transport air travel + other 2.2. what was the total transport cost during each time period? (mark relevant blocks) evaluation r0 r100 r101 r500 r501 r1 000 r1 001 r5 000 more than r5 000 first 2 years r0 r100 r101 r500 r501 r1 000 r1 001 r5 000 more than r5 000 year 3 5 r0 r100 r101 r500 r501 r1 000 r1 001 r5 000 more than r5 000 year 6 10 r0 r100 r101 r500 r501 r1 000 r1 001 r5 000 more than r5 000 year 11 15 r0 r100 r101 r500 r501 r1 000 r1 001 r5 000 more than r5 000 year 15 20 r0 r100 r101 r500 r501 r1 000 r1 001 r5 000 more than r5 000 years 20 + r0 r100 r101 r500 r501 r1 000 r1 001 r5 000 more than r5 000   question 3. accommodation to attend appointments 3.1. did you ever have to stay away from home overnight as a result of attending appointments for your/your child’s cochlear implant? yes _______________ no ________________ if yes, please indicate: did you stay with friends/relatives _____________ or did you pay for accommodation ____________ ?   if you paid for accommodation please complete the following table: indicate the total accommodation cost during each time period. (mark relevant blocks) evaluation less than r500 r501 r1 000 r1 001 r2 000 r2 001 r5 000 more than r5 000 first 2 years less than r500 r501 r1 000 r1 001 r2 000 r2 001 r5 000 more than r5 000 year 3 5 less than r500 r501 r1 000 r1 001 r2 000 r2 001 r5 000 more than r5 000 year 6 10 less than r500 r501 r1 000 r1 001 r2 000 r2 001 r5 000 more than r5 000 year 11 15 less than r500 r501 r1 000 r1 001 r2 000 r2 001 r5 000 more than r5 000 year 15 20 less than r500 r501 r1 000 r1 001 r2 000 r2 001 r5 000 more than r5 000 years 20+ less than r500 r501 r1 000 r1 001 r2 000 r2 001 r5 000 more than r5 000 question 4. repair of speech processor 4.1. how many times did your speech processor have to be repaired after its warranty expired? _____________________ question 5. insurance is your speech processor insured? yes___________ no ___________ if yes, please indicate: monthly premium: r_________________________________ how long has it been insured for? _______________________ question 6. the use of an fm system have you bought an fm system to use with the ci? yes ____________no ______________ if yes, please indicate: cost: r_____________________________________ how did you pay for it? self_____________ medical aid________________ question 7. the ear without the implant do you/your child use a hearing aid in the ear that is not implanted? yes _____________no _______________ if yes, please indicate: cost: r______________________________ how did you pay for it? self_____________ medical aid___________ monthly cost of batteries: ______________ question 8. advice to others from your own experience with a cochlear implant, what advice would you give potential patients with regard to costs and planning for costs involved in obtaining and maintaining a cochlear implant? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ if you/your child were/was implanted before the age of 13 years please continue to question 9. if you/your child were/was implanted after the age of 13 years you have now completed the questionnaire. thank you very much for taking the time to complete the questionnaire. question 9. rehabilitation services for children with cochlear implants please only answer this question if you/your child were/was implanted before the age of 13 years. what extra costs did you have in the first year after implantation as a result of extra rehabilitation needed? (mark relevant blocks) therapy how often? cost per year how did you pay? speech therapy daily r________ self   weekly can’t remember __________ medical aid   monthly   included in school fees occupational therapy daily r________ self   weekly can’t remember _________ medical aid   monthly   included in school fees physiotherapy daily r________ self   weekly can’t remember __________ medical aid   monthly   included in school fees clinical psychology daily r________ self   weekly can’t remember __________ medical aid   monthly   included in school fees other: please specify daily r________ self   weekly can’t remember ________ medical aid   monthly   included in school fees if you continued any of these services after the first year please complete the following table (mark relevant blocks)   therapy (tick all relevant) estimate total cost of therapies how did you pay? year 2 3 after ci none r____________ self   speech therapy can’t remember ________ medical aid   occupational therapy   included in school fees   physiotherapy       clinical psychology       other:     year 3 5 after ci none r____________ self   speech therapy can’t remember ________ medical aid   occupational therapy   included in school fees   physiotherapy       clinical psychology       other:     please only answer this question if you/your child were/was implanted before the age of 13 years. if you continued any of these services after the first year please complete the following table (mark relevant blocks) year 5 10 after ci none r____________ self   speech therapy can’t remember ________ medical aid   occupational therapy   included in school fees   physiotherapy       clinical psychology       other:       thank you very much for taking the time to complete this questionnaire. appendix b. monthly battery costs for sound processor sound processor percentage of participants’ current sound processor body-worn or ear-level type of battery used average monthly battery cost (2010) range of monthly battery cost (2010) spectra/sprint™ 1% body worn penlight r100 r50 r150 esprit™/esprit™22 1% ear-level 2 disposables (size 675) r125 r100 r150 esprit™ 3g (22/24) 24% ear-level 3 disposables (size 675) r161 r126 r196 freedom® 64% ear-level 3 disposables (size 675) or lithium-ion (rechargeable), based on 2 years’ use (charger + 2 batteries included) r180   r281   r110 r146 cp810 4% ear-level lithium-ion (rechargeable), based on 2 years’ use (charger + 2 batteries included) r240   opvoedkundige oudiologie: medekonsuitasie vir optimalisering van kinders met gehoorverlies in die kiaskamer 55 opvoedkundige oudiologie: medekonsultasie in spesialiseringsonderwys lidia pottas en rene hugo departement kommunikasiepatologie, universiteit van pretoria abstract the aim of this study was to determine the value of educational audiology in the in-service training of teachers of children with hearing loss, in the south african context. two questionnaires were developed which teachers and headmasters of schools for the deaflhard of hearing in the gquteng and northwest provinces completed. the aim of the first questionnaire was to obtain background information regarding the 10 schools included in this study. the purpose of the second questionnaire was to determine the knowledge of 211 teachers regarding the child with a hearing loss. the background information obtained from the first questionnaire made it possible for the researchers to compare the knowledge of two different groups of teachers on the basis of in-service training. the results indicated definite limitations in the knowledge of the teachers, which must be viewed in light of the specific audiological needs of the child with a hearing loss, who may thus not fulfill hislher potential in the school setting. in spite of in-service training there was no significant difference between the two groups of teachers, which questions the value of existing training. opsomming die doel van hierdie studie was om die waarde van opvoedkundige oudiologie in die indiensopleiding van die onderwysers van kinders met gehoorverlies in suid-afrika te ondersoek. twee vraelyste is saamgestel wat deur die onderwysers en skoolhoofde van skole vir doweslhardhorendes in die gauteng provinsie asook by nabygelee skole in die noordwes provinsie voltooi is. die eerste vraelys is gebruik om agtergrondinligting aangaande die 10 skole wat in die studie ingesluit is, in t~ win. die tweede vraelys se doel was om 'n beeld van die 211 onderwysers se kennis van die kind met 'n gehoorverlies te ve~kry. agtergrondinligting verkry uit hierdie vraelys het die navorser instaat gestel om 'n vergelyking te treftussen die kennis van twee verskillende groepe onderwysers op grond van indiensopleiding. resultate het definitiewe leemtes in die kennis jan die onderwysers aangedui. hierdie tekortkominge in kennis moet in noue verband met die besondere oudiologiele behoeftes van die kind met gehoorverlies beskou word, aangesien dit daartoe kan lei dat die kind i nie sy.volle potensiaal in die onderrigsituasie kan verwesenlik nie. voorts is bevind dat indiensopleiding nie 'n wesenlike verskil in die kennis vbn die twee groepe onderwysers tot gevolg het nie, wat die waarde van bestaande indiensopleiding bevraagteken. i ' i sleutel woorde: opvoedkundige oudiologie, indiensopleiding, gehoor-gestremdheid, onderwysersopleiding, gehoorgestremde kind. . inleiding "the word inservice1 typically is used within the field of ... education to refer to training or education provided to school personnel after they have accepted or are already working in a specific job. inservice usually targets job-specific information or skills related to needs in the present job situation, which were not adequately addressed in the employee's preservice education, that is, that which took place before the individual was hired" (de conde johnson, benson, & seaton, 1997, p. 166). dit is v~ral die onderwyser in 1 eie beklemtoning die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48,2001 spesialiseringsonderwys wat 'n besondere taak en roeping het waarvoor gespesialiseerde kennis en insig nodig is (marais, 1988). spesialisasie in die onderwysersopleiding is nie noodwendig daarop gemik om die effek van die gestremdheid uit te skakel nie, maar behoort eerder ge"interpreteer te word as 'n verdieping· van die onderwyser se insig met betrekking tot spesifieke hulpverlening aan sulke kinders (marais, 1988). in die huidige suid afrika'anse konteks wil dit voorkom asof hierdie aspek veral relevant is ten opsigte . van die kind met 'n gehoorverlies, wat tans nog grootliks in die spesiale onderwysstroom gehuisves word. bier is dit duidelik dat oudiologie as vakgebied, 'n vakvreemde dissipline vir die algemene onderwyser, 'n uitgesproke rol r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) lidia pottas & rene hugo 56 speel in. die onderrigsituasie en dat die onderwyser van enige kind wat 'n gehoorprobleem het, oor die nodige kennis en vaardigheid moet beskik om in die opvoedingsbehoeftes van die kind met 'n gehoorverlies te kan voorsien. the realisation of the auditory potential of the hearing impaired child requires constant audiological surveillance, carried out in everyday situations in which the child needs to use hearing. many of the communication difficulties experienced by hearing-impaired children can be resolved, either panly or wholly, by attention to audiological factors that requires initiation by audiologically aware teachers. it cannot be done at a distance by a hospital technician or audiologist" (harrison, 1993, p. 30). literatuur rakende die besondere behoeftes van die onderwyser in spesialiseringsonderwys is beperk. tog het hierdie onderwyser 'n primere verantwoordelikheid as "advokaat" van elke kind met 'n gehoorverlies (harrison, 1993). vanwee hul besondere noue kontak met die kind met 'n gehoorverlies, moet die onderwyser die kind as't ware verteenwoordig in alle situasies en teenobr aile persone. dit veronderstel egter met inbegrip van verskeie vaardighede 'n besondere kennis van en begrip vir die kind met 'n gehoorverlies. die besondere oudiologiese behoeftes van die kind vereis bepaalde kennis en vaardighede van die onderwyser (vgl. tabel 1). tabell: veronderstelde kennis en vaardighede van die onderwyser rakende sekere aspekte van oudiologie. die rol van die onderwyser aard van kennis/vaardigheid die kind met 'n gehoorverlies in die klaskamer • kennis van die basiese anatomie en fisiologie van die gehoorsisteem; oudiometriese toetsprosedures en interpretasie van resultate asook die etiologie van gehoorverlies (lass, tecca en woodford, 1987) .. kennis van die kenmerke/gevolge van in gehoorverlies (flexer, 1993) • kennis van die verskillende teoriee en filosofiese orientasies in die onderrig van die kind met in gehoorverlies (easterbrooks & radaszewski-byme, 1995) nagaan en hantering van gehoorapparate • kennis van gehoorapparaattegnologie, funksie en werking van gehoorapparate en versterkingsisteme (harrison, 1993; berg, 1992). • vermoe tot die daaglikse nagaan en toepaslike gebruik van klankversterkingsapparaat (berry, 1992) aanpassing en beheer van die akoestiese • kennis van die akoestiese omgewing in die klaskamer en omgewing die faktore wat dit be'invloed (flexer, 1993) • vermoe tot die daarstelling van in optimale luisteromgewing (easterbrooks & radaszewski-byrne, 1995) evaluasie en opleiding van spraak en taal • kennis van normale taalen spraakontwikkeling (grant, 1983) • vermoe om die kind met in gehoorverlies se kommunikasie, spraak en taal te evalueer (sass-lehrer, 1986) • vermoe om inligting soos verkry tydens die evaluasie te interpreteer, toepaslike doelwitte en doelstellings te formuleer en die nodige aanpassings in die onderrigsituasie te maak (sass-lehrer, 1986). • kennis van en vaardigheid in toepaslike stimulasie van spraak en taal in die onderrigsituasie (grissom & cochran, 1986). evaluasie en opleiding van luistervermoens • kennis van die doel, aard en wyse vanouditiewe en spraakleesvaardighede opleiding (berg, 1992) / / • kennis van die doel, aard en wyse van spraakleesopleiding (berry, 1992) die probleem is egter dat hierdie kennis en vaardighede nie vanselfsprekend deel van die onderwyser se mondering is nie, maar verwerf moet word deur verdere opleiding (hegarty, pocklington & lucas, i990). die opleiding van die onderwyser blyk dus onontbeerlik te wees ten einde~hom toe te rus vir sy taak. the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) t:1 ;:;;. c,., :;:: is..: ~ .... ~ i:l 'i; '" ~ t;. ::; '!:;; "" ::;. ~ ~ ;::: ~ '"' ;:;;. ~ '< ?;s· (}q -'"' ~ :""_co n 8 ....... skool provinsie getal getal getal spraakterapeute fases in skool missie van die skool leerlinge onderwysers loudioloe ~i " i noordwes 55 8 0 sekonder die voorsiening van 'n hoe standaard van sekondere onderwys aan dowe leerlinge, ongeag ras, kleur, geslag, tegnies taal of godsdiens, ten einde die grondslag te ie vir verdere onderwys en opleiding. 2 gauteng 195 23 i vakante pos preprimer primer om so goed as moontlik die dowe kind op te voed en te onderrig in 'n christen (katolieke) agtergrond om op -------·-sekonder __ tegnies 'n gelykwaardige grondslag met "normale mense" mee te ding. 3 noordwes 400 (t) 58 (ti) i \ sekonder to provide effective education to all the pupils in the school. 67 (g) 14(gi) 4 gauteng 176 27 2 preprimer primer to educate deaf and hard of hearing pupils in an environment which fosters human dignity and mutual sekonder respect and enable the pupils to take their rightful place in both the hearing and the deaf world with beroepsopleiding confidence. 5 noordwes 269 41 i primer to strive for and maintain effective teaching, learning and educational excellence in an environment pre-primer conducive to learning and so develop a responsible, independent, self-reliant person who can communicate, beroepsopleiding reckon, realize and develop to his potential to take hislher rightful place in society. 6 noordwes 349 42 0 preprimer primer to develop the deaf to be independent adults who will occupy their place as responsible adults in the sekonder tegnies community_ beroepsopleiding 7 gauteng 290(t) 34 (ti) 0 preprimer, primer offering quality education and adapting the curriculum to meet the needs and demands of the industrial 244 (g) 34(gi) sekonder world. this is in line :-vith the inclusion policy. 8 gauteng 278 44 4 preprimer primer nie beskibaar sekonder 9 gauteng 317 51 3 preprimer primer nie beskikbaar sekonder tegnies beroepsopleiding 10 gauteng 147 18 i preprimer we are committed to provide excellent and relevant educational programmes to our pupils that embraces primer academic, vocational achievement and personal growth and esteem of multicultural deaf students sekonder incorporating respect for culture and heritage. in our belief that the deaf are valuable, capable and beroepsopleiding responsible we pledge to render services of the highest professional skills and attitudes exemplifying tegnies dedication and excellence. l__ . __ ----'--t == totale getal kinders in skool; g == kinders met gehoorverlies; tl == totale aantal onderwysers; g 1 == onderwysers betrokke by kinders met gehoorverlies i ~ q; '=' ~ ~ ~ /i) '" ~ ., '< ~ /i) ::i q. /i) a: riq' c; ::i ijq <l q; ::i '" ~ 0 is'' s· ijq /i) '" 5. -s· '" -c q. ;. 0 ~ -< 0 /i) q. ~ c ::s q. 1iq' /i) 0 c q. o· 0ijq ~. ~ /i) q. /i) ~ 0 ::s '" c ;:; ql '" (:d' -< :;. 0 ~ -3' e:.. (ii' /i) :!. ::s ijq -< ql ::s ~ ::s q. /i) ., '" 3 /i) -~ /i) ::i'" 0 0 ., -< /i) :l. (:d' '" 5' q. (:do ~ ql 'il ~ ql 3 /i) ., vi -....l r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) navorsing met die doel om die rol van oudiologie as vakgebied in die indiensopleiding van onderwysers van individue met gehoorverlies te motiveer, is beperk. kennis in hierdie verband kan bydra tot voorstelle ten opsigte van die toepaslike verdere opleiding van die onderwysers. metode doel van die stuoie die hoofdoelstelling van die empiriese ondersoek was om die rol van sekere aspekte van oudiologie as vakgebied in die opleiding (en meer spesifiek indiensopleiding) van die onderwysers van kinders met gehoorverlies in spesialiseringsonderwys in die rsa te ondersoek. die hoofdoelstelling word gerealiseer in die volgende subdoelstellings: 1. om die onderwysers se stand van kennis oor sekere aspekte van oudiologie te bepaal. 2. om 'n vergelyking te lief tussen die kennis van sekere aspekte van oudiologie van twee verskillende groepe onderwysers, naamlik die onderwysers wat indiensopleiding ontvang met diegene wat geen indiensopleiding ontvang het nie. navorsingsontwerp in hierdie stu die het die klem geval op 'n in diepte lidia pottas & rene hugo 58 beskrywing van die kennis van sekere aspekte van oudiologie van 'n spesifieke groep, nl. die onderwysers wat kinders met gehoorverlies onderrig in spesialiseringsonderwys in die rsa. die navorser het dit ten doe! gestel om "dit wat is" op die een of ander wyse "akkuraat en noukeurig te beskryf' (mouton & marais, 1992, p. 46). vol gens die riglyne soos neergele deur mouton en marais (1992, p. 46-47) is daar van 'n beskrywende opnamestudie in die vorm van vraelyste gebruik gemaak met kwantifisering waar moontlik. die kwalitatiewe-kwantitatiewe aard van hierdie navorsing verseker die realisering van die doelstellings (mouton & marais, 1992). ondersoekgroep skole ingesluit in die studie weens die feit dat vraelyste persooonlik by skole gelewer en afgheaal is is besluit om slegs skole in die gauteng provinsie asook nabygelee skole in die noordwes provinsie by die projek in te skakel. slegs skole vir doweslhardhorendes is ingesluit in die studie, gesien in die lig daarvan dat hierdie studie fokus op die kind met 'n gehoorverlies in spesialiseringsonderwys. inligting oor die skole wat ingesluit is, word vervolgens verskaf. beskrywende inligting oor die tien deelnemende skole word aangebied in tabel 2. 'n uiteensetting van die kommunikasiesisteme en taalaanleermetodes is uiteengesit in tabel 3 en tabel 4 verskaf 'n beeld van die bestaande indiensopleidingsprogramme iii die skole. tabel 3: kommunikasiesisteme en taalaanleermetodes in gebruik in die skole skool tipe tipe taalaanleermetode kommunikasiesisteem 1 gebare natuurlik totale kommunikasie struktureel 2 gebare natuurlik (sekondere fase) 3 totale kommunikasie natuurlik totale kommunikasie struktureel (primere fase) 4 gebare aangepaste taalkurrikulum (sekonder) totale kommunikasie struktureel 5 gebare totale kommunikasie struktureel 6 gebare 7 totale kommunikasie struktureel 8 oraal/ouraal natuurlik oraal/ouraal 9 totale kommunikasie natuurlik gebare 10 totale kommunikasie natuurlik / the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) opvoedkundige oudiologie: medekonsultasie vir optimalisering van kinders met gehoorverlies in die k1askamer 59 tabel 4: indiensopleiding in die skole skool indiensopfrekwensi doel verantwoordelike aard leiding? e . persoonlsone 1 nee 2 nee 3 nee om onderwysers toe te interpretasie van 4 ja onbekend rus vir hul taak in die oudioloe oudiogramme. klaskamer gehoorapparate 5 nee on die onderwysers op bestuur en gehoorapparate 6 ja maandeliks hoogte te hou van die konsulterende gebaretaal nuutste ontwikkelin~e oudioloe 7 nee om onderwysers toe te rus vir hul taak 8 ja jaarliks spesifiek met verwysing onbekend onbekend na gehooren leergestremde leerders. oudioloe, toerusting van die opvoedkundige 9 ja maandeliks opvoeders vir hul taak hulpdienste, bestuur onbekend en senior 10 nee ondersoekgroep van onderwysers ingesluit in die studie al die onderwysers van die geselekteerde skole is in die studie ingesluit. 'n totaal van 300 vraelyste is uitgedeel en 211 (70o/j) vraelyste is terugontvang. die j 30% nie-repondente /'was onderwysers wat op die spesifieke dae waarop die vraelyste uitgedeel is afwesig was, terreindiens moes doen of nie aan die projek wou deelneem nie. volgensjdie literatuur (babbie, 1992) kan 70% deelname as i,n verteenwoordigende respons beskou word. die onderwysers sel biografiese inligting asook daardie aspekte wat verklarend~ inligting bevat ten opsigte van die vraelys kan soos volg opges6m word. • die meerderheid (167) onderwysers is vroulik en 44 mans is in die studie ingesluit. 85 van die onderwysers is tussen 31 40 jaar oud. 74 onderwysers se ouderdomme strek tussen 41 50 jaar, terwyl 24 onderwysers ouer as 50 jaar is. • engels en gebaretaal word deur 148 onderwysers as onderrigmedium gebruik. 35 onderwysers gebruik afrikaans en gebaretaal terwyl 28 onderwysers afrikaans en engels as onderrigmedium gebruik. • ten opsigte van verdere opleiding beskik 199 van die onderwysers oor 'n naskoolse kwalifikasie, waarvan 143 onderwysers 4 en meer jare opleiding ontvang het. 56 onderwysers beskik oor 2-3 jaar opleiding na skool, terwyl 11 ondenyysers slegs oor 'n seniorsertifikaat beskik. 72 onderwysers het indiensopleiding ontvang. die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 onderwysers • die meerderheid (120) van die onderwysers het 7-12 leerlinge in hul registerklasse: 30 onderwysers het 1-6 leerlinge in die registerklas terwyl 31 onderwysers slegs roterende klasse onderrig waarvan die getaile varieer van 7-18 leerlinge. 23 onderwysers het 13-18 leerlinge in hulregisterklasse en 7 onderwysers het meer as 19 leerlinge in hul registerklasse. die getai kinders in die klasse in laasgenoemde twee gevalle is baie hoog, veral as daar in gedagte gehou word dat die ideale getal 6-8 leerlinge per onderwyser behoort te wees (hugo, 1987). • ten opsigte van gehoorapparate het 77 onderwysers aangetoon dat nie een van die leerlinge in hu} klasse oor gehoorapparate beskik nie. 78 onderwysers het 1-6 leerlinge in hul klasse .met gehoorapparate, terwyl 51 onderwysers 7-12 leerlinge met gehoorapparate in hul klasse het. 5 onderwysers het 13-18 leerlinge met gehoorapparate in hul klasse. na vorsingsapparaat en -materiaal vanwee die feit dat daar gepoog is om al die onderwysers van kinders met gehoorverlies in spesiale onderwys in die gauteng provinsie en nabygelee skole in die noordwes provinsie te betrek, is daar besluit om in die lig van voorsiene praktiese probleme eerder gebruik te maak van vraelyste as formele/infonnele onderhoude. daarbenewens bied vraelyste die voordeel dat proefpersone maklik bereikbaar is, dat detail inligting vinnig en maklik bekom kan word en dat die r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) lidia pottas & rene hugo 60 anonimiteit van deelnemers hierdeur verseker kan word (van der merwe, 1994). in nadeel is egter dat die publiek oor die algemeen in negatiewe ingesteldheid teenoor in vraelys het (statomet, 1994) en di t gevolglik nie voltooi en terugstuur nie. ten einde hierdie' tendens te voorkom, is die vraelyste persoonlik uitgedeel aan die skoolhoofde en al die onderwysers verbonde aan die deelnemende skole. die navorser was dus teenwoordig tydens die voltooiing van die vraelyste en daar was genoegsaam tyd vir verduideliking in geval van enige onduidelikheid. mag vir die respondent totaal vreemd wees (steenekamp, 1984). met die konstruksie en finalisering van die vraelyste, is dit deurentyd in gedagte gehou dat in groot aantal van die ptoefpersone in hierdie studie nie afrikaans of engels as eerste taal gebruik nie. deur middel van in voorstudie is die vraelyste aan in praktiese toets onderwerp ten einde die bruikbaarheid en praktiese uitvoerbaarheid daarvan te bepaal in terme van (bornman, 1995): • verstaanbaarheidlduidelikheid van terrninologie; twee afsonderlike vraelyste is in die studie gebruik (sien bylae a). • ondubbelsinnigheid van afsonderlike vrae; • relevansie en toepaslikheid van inhoud; • verstaanbaarheid van instruksies; • gemak van kodering; • tyd benodig vir voltooiing; • voorgenome strategiee vir ontleding. vraelys 1 het bestaan uit agtergrondvrae oor die skool met die oog op omskrywing en korrelasies. dit was gerig aan die skoolhoofde van die betrokke skole om inligting te verkry ten opsigte van die algemene kenmerke van die skool, sy missie en struktuur van funksionering. vraelys 2 het bestaan uit biografiese sowel as kennisvrae en is ontwikkel uit relevante literatuur (berg, 1992; easterbrooks en radaszewski-byrne, 1995; flexer, 1993; harrison, 1993; lass et al., 1987; ross, 1991; sass lehrer, 1986) ten opsigte van die veronderstelde kennis van oudiologie van die onderwyser van die kind met in gehoorverlies. kennisvrae is hoofsaaklik gebruik, nie so seer net om te bepaal of die respondent oor bepaalde kennis beskik nie, maar omdat kennis die grondslag vorm van bepaalde gedrag of bydra om houdings te vorm (steenekamp, 1984). die inligting en terugvoer wat die loodsstudie verskaf het, is gebruik om die vraelyste in die finale vorm te formuleer. data verwerkingsprosedures abe data soos aangeteken op vraelys 2 is in in toepaslike koderingskolom aangeteken vir statistiese verwerking. dit is verwerk met in ibm 370-rekenaar en die statistical packages for social sciences program, universiteit van pretoria, is gebruik tydens die prosessering van die data. volgens schoeman (1994) is dit ook van uiterste belang dat die navorser aspekte soos die ervaringswereld, sosiale status en die opvoedkundige peil van die proefpersone moet verreken. sekere begrippe wat vir die navorser bekend is, in tabel 5 word in opsomrning van die statistiese prosedures ooreenkomstig die onderskeie subdoelstellings verskaf. tabel 5: statistiese prosedure gebruik in die studie subdoelstelling beskrywing: sta tistiese verwysings prosedure 1. om die onderwysers se stand frekwensietabelle is gebruik om die prestasie de vos & fouche, van kennis oor sekerer aspekte van die steekproef op die meervoudige 1998. van oudiologie te bepaal. keusevrae te bepaal. beskrywende statistiek, wat bestaan uit die tabellering van die data en die berekening van , beskrywende groothede op sodanige wyse dat die ten dense en eienskappe van die : waargenome data duidelik na yore kom, is ! gebruik. die resultate is as in geheel saamgevat en bespreek. indien die oorgrote meerderheid (meer as 70%) van die onderwysers in item korrek beantwoord het, is daar aanvaar dat hul oor voldoende kennis van die aspek beskik, d.w.s die antwoord is as korrek aanvaar. 70% dui dus op die rekenkundige meerderheid eri nie 'n statistiese meederheid nie. 2. om 'n vergelyking te tref die t-toets vir onafhanklike groepe is gebruik de vos & fouche, tussen die kennis van oudiologie om te bepaal of daar telkens in beduidende 1998. van twee groepe onderwyseis, verskil tussen die resultate van die twee groepe owen, owen, / nilarlllik die onderwysers wat is. pannbacker & indiensopleiding ontvang het met die chi-kwadraatverdeling (j;verdeling) is middelton, 1994 diegene wat geen gebruik om te toets vir die onafhanklikheid van' indiensopleiding ontvang het nie. veranderlikes binne in kruistabel oop vrae is d.m.v 'n kwalitatiewe inhoudsontleding ontleed / the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) opvoedkundige oudiologie: medekonsultasie vir optimalisering van kinders met gehoorverlies in die k1askamer 61 resultate en bespreking kennis van die onderwysers die resultate is as 'n geheel saarngevat en bespreek. indien die oorgrote meerderheid (meer as 70%) van die onderwysers 'n item korrek beantwoord het, is daar 120% 100% 100% gi iv .. 80% > , gi 'iii 60% s c:: gi til 40% .. gi il. 20% 0% aanvaar dat hul oor voldoende kennis van die aspek beskik, d.w.s die antwoord is as korrek aanvaar. sewentig persent dui dus op die rekenkundige meerderheid en nie 'n statistiese meederheid nie. die voorafgaande resultate van subdoelstelling 1 kan dus as volg saamgevat word. --+-'')'':;t('---+-=c:c~--+----i ikorrek 1 subafdelings vraelys 2 figuur 1: opsommende beeld van kennis van onderwysers t.o.v sekere aspekte van oudiologie , die bevindinge van hierdie stu die dui op bepaalde tekortkorninge in die kbnnis van die onderwysers met betrekking tot verskeie asbekte. i kennis aangaande ikommunikasie: spraaken taalontwikkeling i wat die onderwysers ise kennis rakende kommunikasie: spraak-en taalontwikkeling betref, blyk dit dat die meerderheid onderwysers oor voldoende kennis beskik. kennis in hierdie verband is onontbeeriik vir die onderwyser van die kind met 'n gehoorverlies. dit stel nie net die onderwyser in staat om op grond van sylhaar kennis van normale spraaken taalontwikkeling die kind se kommunikasie, spraak en taal te evalueer nie, maar ie ook die basis vir toepaslike taalverryking, taalstirnulasie en spraakopleiding, wat 'n prirnere behoefte van die kind met 'n gehoorverlies is (grant, 1983). volgens israelite en hammermeister (1986) het 80% van die opleidingsprogramme vir onderwysers van kinders met gehoorverlies die belangrikheid van kennis van spraak en taalontwikkeling aangetoon. hierdie belangrikheid kan inderdaad toegeskryf word aan . die feit dat 'n goeie taalbasis, en in 'n mindere mate verstaanbare spraak, die basis vorm vir alle ander akaderniese vakke en die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 opvoedkundige prestasies van die kind met 'n gehoorverlies (bader, 1992). kennis van gehoormeganisme / oudiometriese toetsing / oorsake van gehoorverlies kennis van die gehoormeganisme, oudiometriese toetsing en interpretasie van oudiograrnme, asook die etiologie (oorsake) van gehoorverlies is van belang (easterbrooks en radaszewski-byrne, 1995) ten einde die besondere behoeftes van die kind met 'n gehoorverlies, wat spruit uit die aard, graad en etiologie van die gehoorverlies te bevredig in die onderrigsituasie. 'n studie uitgevoer deur martin, bernstein, daly en cody, (1988) oor die soortgelyke kennis van onderwysers in die hoofstroom, het getoon dat die onderwysers 57% van die vrae oor hul kennis van gehoorprobleme korrek beantwoord het, terwyl die onderwysers betrokke in hierdie studie ook 57% van die vrae in verband met gehoorprobleme korrek beantwoord het. wat die vrae oor die gehoormeganisme asook die oudiometriese toetsing van gehoorverlies betref, het die onderwysers onderskeidelik 60% en 33% van die vrae korrek beantwoord. dit dui daarop dat die kennis van die onderwysers in die hoofstoom in ontwikkelde lande ongeveer op dieselfde vlak is as die kennis van die r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) ondeiwysers in spesialiseringsondeiwys in 'n ontwikkelende land. 'n soortgelyke tendens is ook waargeneem in 'n studie van lass et al. (1987) deurdat daar slegs 'n verskil van 2% tussen die prestasie van ondeiwysers in spesialiseringsondeiwys en diegene in hoofstroomondeiwys in die vsa gevind is. verskeie faktore kan egter ter verklaring aangebied word vir die rsa konteks. alhoewel die ondeiwysers in die hoofstroom in ontwikkelde lande nie werklik oor kwalifikasies in gehoorprobleme beskik nie, word hulle bygestaan deur opvoedkundige oudioloe asook gekwalifiseerde onderwysers vir kinders met gehoorverlies (luckner, 1991). die ondeiwysers in die rsa konteks word in 'n groot mate vanwee 'n gebrek aan voldoende opleiding asook ontoereikende ondersteuningsdienste, veral 'n tekort aan oudioloe, uitgelewer aan hulself. kennis aangaande die kenmerke/gevolge van gehoorverlies wat die ondeiwysers se kennis van die kenmerkelgevolge van in gehoorverlies betref, is slegs 33% van die vrae korrek beantwoord. die kind in sy totaliteit (emosioneel, sosiaal, intellektueel, ens.) noop die ondeiwyser om oor kennis in hierdie verband te beskik (marais, 1988), aangesien dit van kardinale belang is in die beplanning en implementering van enige akademiese aktiwiteit (sanders, 1988). kennis van gehoorapparate verskeie outeurs (harrison, 1993; lass et al., 1987; maxon & smaldino, 1991) is dit eens dat kennis van gehoorapparate van wesenlike belang is in die onderrigsituasie. dit spruit uit die feit dat die akoestiese omgewing in die klaskamer nie ideaal is nie en dat die kind met 'n gehoorverlies in staatgestel moet word om optimaal voordeel te trek uit ouditiewe-lingulstiese invoer (maxon & smaldino, 1991). om 'n kind in staat te stel om sy/haar lidia pottas & rene hugo 62 residuele gehoor optimaal te benut, moet die ondeiwyser nie net oor kennis van die optimalisering van die akoestiese omgewing beskik nie (flexer, 1993), maar ook van gehoorapparaattegnologie, funksie en werking van gehoorapparate en versterkingsisteme en die instandhouding daarvan (harrison, 1993; berg, 1992). die feit dat die meerderheid ondeiwysers in hierdie studie slegs 26% van die vrae korrek kon beantwoord, kan moontlik toegeskryf word daaraan dat die meeste van hulle skoliere nie gepas is met gehoorapparate nie. in vergelyking met 'n soortgelyke studie (lass et al., 1987) uitgevoer op ondeiwysers in die hoofstroom, beskik die ondeiwysers in die rsa konteks oor beperkte kennis in hierdie verband, aangesien die meerderheid ondeiwysers in die hoofstroom 78% van die vrae oor gehoorapparate korrek kon beantwoord. kenn~ aangaande ouditiewe opleiding en spraakleesopleiding slegs 17% van die vrae oor ouditiewe opleiding en spraakleesopleiding is korrek beantwoord. kennis hiervan is van belang, aangesien luistervaardighede en spraakleesverrnoens die kommunikasieproses ten grondslag ie. luistervaardighede speel onder andere 'n kritieke rol in die ontwikkeling van lees-en skryfvaardighede (berg, 1992) en dit word versterk deur spraakleesverrnoens, aangesien laasgenoemde die ouditiewe sein aanvul (sanders, 1982). die beperkte kennis van die ondeiwysers kan moontlik toegeskryf word aan die feit dat die minimum aantal leerlinge gepas is met gehoorapparate. die mening dat ouditiewe opleiding geen doel dien as die kind nie blootgestel word aan versterkte klank nie, kan dan ontstaan. die ondeiwysers maak ook grootliks staat op gebaretaal as kommunikasiesisteem en skenk gevolglik nie werklik aandag aan spraakleesverrnoens nie, vanwee die feit dat hul nie oor die kennis van die doel, aard en wyse van spraakleesopleiding beskik nie. 120%r---~~~'---------'----------r---------.---------'---------'--------~ .. 100%· ~ 80% .~ 60% j!! c: ~ ~ 40% 20% 0% . subafdellngs • vraelys 2 figuur 2: indiensopleiding: vergelyking van onderwysers se kennis /' iii beduidende verskil1 / • geen verskil ' / the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) opvoedkundige oudiologie: medekonsultasie vir optimalisering van kinders met gehoorverlies in die k1askamer 63 die resultate van subdoelstelling 1 soos bespreek, dui duidelik daarop dat die ondeiwysers bepaalde leemtes in hul kennis van sekere aspekte van oudiologie het. die waarde van indiensopleiding die volgende vraag wat beantwoord moes word is of die bestaande indiensopleiding wat hul ontvang wei vir die ondeiwysers van waarde was. in figuur 2 word aangetoon hoe die kennis van die ondeiwysers wat indiensopleiding ontvang het vergelyk met die van ondeiwysers wat nie sodanige opleiding ontvang het nie. die resultate word aangebied in terme van die mate waartoe daar 'n beduidende verskil in die kennis van die twee groepe ondeiwysers voorgekom het. vit die voorafgaande figuur is dit duidelik dat daar slegs met betrekking tot die vrae oor "gehoorapparate" 'n beduidende verskil in die kennis van die twee groepe onderwysers verkry is. wat alle ander aspekte betref, kon geen duidelike verskil tussen die twee groepe se kennis aangetoon word nie. die doel van indiensopleidingsprogramme is juis om die potensiaal van ondeiwysers verder te ontwikkel deur voortgesette opleiding, sodat hulle te alle tye diensbaar kan wees (van heerden, 1991). dit spruit uit die besef dat aanvanklike opleiding in 'n vinnnig ontwikkelende wereld nie meer voldoende is nie (van heerden, 1991). indiensopleiding is 'n forme ie poging om te verseker dat die aanvanklike onderwysstudent in die werksopset tot 'n lewenslange leer-program oorgaan. met betrekking tot oudiologie impliseer dit dus dat oudiologie as wetenskap geplaas word binne die unieke skoolkonteks. laasgenoemde aspek maak dit juis verskillend van formele opleiding aangesien leerervarings binne die relevante konteks daargestel kan word. dit sluit ook aan by volwassene leer in die sin dat volwassenes probleemgesentreerde leerervarings verkies, wat betekenisvol en van toepassing is op die onmiddellike omgewing (english, 1995~ i 'n verdere motiveri~g vir indiensopleiding is dat beperkte kennis van g~hoor en gehoorverlies by die ondeiwyser kan lei tot bdperkte groei in die ontwikkeling van opvoedkundige pro~edures vir die hantering van kinders met gehoorverli~s (ross, 1991 in flexer,1993). ten aansien van die on~eiwyser in die hoofstroom, sal indiensopleiding nie net bydra tot kennisverryking en die verandering van inge~teldheid teenoor inklusiewe ondeiwys nie, maar is dit !tans/die enigste opsie vir verdere opleiding, weens die feit dat daar nog nie eintlik formele onderrigprogramme vir liierdie ondeiwysers bestaan nie (ross, 1991). wat die ondeiwyser in die rsa konteks aanbetref, is indiensopleiding 'n aspek wat dringende aandag verg. tot dusver was ondersteuningsdienste, wat ook die aspek van indiensopleiding betref, onvoldoende en ontoepaslik, veral in verafgelee gebiede. baie skole beskik nie oor die dienste van 'n oudioloog nie en waar daar wei dienslewering is, is dit in baie gevalle ontoepaslik in die sin dat dit fokus op die probleme van die leerder (kind) en nie op die sis teem nie (department of education, 1997). dit kan toegeskryf word aan onvoldoende en gefragmenteerde ontwikkeling van mens like hulpbrorine (department of education, 1997) en het 'n direkte invloed op kennis en vaardigheid wat daartoe lei dat die sisteem ontoereikend is om te voorsien in die diverse die suid-afrikaanse tydskrifvir kommunikasieajwykings, vol. 48,2001 behoeftes van die kind. die sisteem is dus gevolglik 'n "barrier to learning" vir die kind wat reeds 'n struikelblok as gevolg van 'n gehoorverlies ervaar. hierdie vraagstuk kan alleenlik met tyd en laterale denke hanteer word. indien daar nie 'nbeskikbare oudioloog as deel van die personeel is wat verantwoordelik kan wees vir die indiensopleiding nie, kan ander altematiewe oorweeg word. een moolitlikheid is die gebruik van 'n sogenaamde "rondreisende model van dienslewering". altematiewelik kan aktiewe konsultasie met oudioloe in privaatpraktyk ooiweeg word. hoe meer inligting na die onderwysers in die skoolkonteks gebring word, hoe meer kan die groot behoefte aan kennis oor oudiologie in skole gedemonstreer word. dit kan sodoende die basis vorm vir die ontwikkeling van 'n behoefte aan 'n meer permanente postestruktuur vir 'n oudioloog in die onderwyskonteks wat opvoedkundige oudiologie 'n lewende werklikheid kan maak. die voordeel hiervan is dat s6 'n oudioloog nie net die sterk en swak hoedanighede van die skool en personeel sal ken nie, maar ook werklike individuele kennis het van die spesifieke kinders met gehoorverlies (ross, 1991). indiensopleiding is egter nie 'n aspek wat ligtelik opgeneem moet word nie. die sukses daarvan berus volgens verskeie outeurs (allen, 1994; jones, 1993; ross, 1991) op noukeurige beplanning, met inagnerning van die volgende aspekte: • behoeftes en veiwagtinge van die ondeiwysers; • kenmerke en behoeftes van die kind met gehoorverlies; • die spesifieke onderrigsituasie, by. spesialiseringsondeiwys; • aanpasbaarheid en relevansie van inhoud vrr die klaskamersituasie; • die persepsies, agtergrond en opleiding van die ondeiwysers; • betrokkenheid van ondeiwysers by die beplanning van indiensopleiding; • aard van die ondersteuningsdienste beskikbaar. die genoemde faktore, of die afwesigheid daarvan, kan enige indiensopleidingsprogram benadeelen daartoe lei dat dit nie die beplande trefkrag het nie . ' die leerplan van inqiensopleidingsprogramme, oor oudiologie as vakgebied, behoort volgens die literatuur (flexer, 1993; ross, 1991) ten rninste die volgende aspekte in te sluit: • kenmerke/gevolge van gehoorverlies; • gehoorapparate en fm-sisteme; • spraakakoestiek en persepsie; • klaskamerakoestiek; • ouditiewe opleiding; • spraakopleiding; • taalevaluasie en -opleiding. soos uiteengesit in tabel 4 word daar slegs by 4 van' die skole, betrokke in hierdie studie, indiensopleiding gedoen en dit blyk uit die resultate (figuur 2) dat hierdie indiensopleidingsprogramme veral aspekte oor gehoorapparate beklemtoon. die werklike inhoud van die indiensopleidingsprogramme in hierdie skole is egter nie aan die navorser bekend nie. elke indiensopleidingsprogram behoort aan die hand van die voorgenoemde aspekte geevalueer te word, om te verseker dat alle aspekte met betrekking tot oudiologie in die klaskamer ingesluit is. volgens jones (1993) is 'n r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) .. aanvankiike behoeftebepaling van kardinale belang, aangesien die onderwysers se verwagtinge en behoeftes kan verskil van die inhoud soos beplan deur die oudioloog. nuwe navorsingsbevindinge, die ontwikkeling in tegnologie en die aanstelling van nuwe personeel noodsaak indiensopleiding om 'n voortdurende, volgehoue proses te wees wat die onderwyser instaat sal stel om by nuwe omstandighede en vereistes aan te pas en sodoende te alle tye diensbaar te kan wees (van heerden, 1991). ev aluasie van die studie hierdie studie was 'n oorspronklike studie en op grond van die resultaat is riglyne neergele vir indiensopleiding van die onderwysers om sodoende te voorsien in die besondere behoeftes van die kind met 'n gehoorverlies. soos met enige navorsing is bepaalde beperkinge in hierdie studie gei"dentifiseer, nl. die grootste beperking van hierdie studie is dat daar slegs skole in die gauteng en noordwes provinsies ingesluit is. die studie kan uitgebrei word na ander provinsies om sodoende 'n meer verteenwoordigende beeld van die kennis van die onderwysers te verkry. enkele oop vrae is in die vraelys ingesluit, aangesien daar nie met voorafgaande antwoordkategoriee voorsiening gemaak kon word vir al die moontlike response op die vrae nie. dit stel egter hoe eise aan respondente en dit kan gevolglik hul motivering nade1ig bei"nvloed (steenekamp, 1984). in die lig daarvan dat dit ook tydrowend is om te kodeer, moet dit slegs by uitsondering gebruik word. slot die professionele implikasies van hierdie studie motiveer die bevordering van opvoedkundige oudiologie in die rsa-konteks, asook die daarstelling van poste vir oudioloe in skole. deur verder die nodige aandag te skenk aan indiensopleiding en konsultasie met oudioloe, sal daar nie net in die leemtes van kennis en behoeftes van die onderwysers voorsien word nie, maar kan die oudiologiese behoeftes van die kind in die klaskamer daadwerklik bevredig word deur die daarstellling van 'n meer dinamiese, ondersteunende onderrigsituasie. bibliografie allen, b.m. 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(ed.), research at grass roots a· primer for the caring professions.. pretoria: j.l. van schaik. 3 enige identifiserende inligting sal uit die finale verslag verwyder word. algemene inligting ten opsigte van die skool: naam van skool: 2 getalleerlinge: 3 getal onderwysers; i ----~---------------------------.4 , getal spraakterapeuteloudiolo. ! 5 oor watter fase(s) beskik u skool? preprimer i primer sekonder 6 wat is u skool se missie? 7 7 'k ' . t rn/' t k i b 'k? a er ommunl aslesls ee sis erne wor in u 5 001 ge rui d' w tt k , oraavouraal totale kommunikasie i enige opmerkings in hierdie verband: die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 8eroepsopleiding tegnies. gebare r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) lidia pottas & rene hugo 66 8 watter tipe taalaanleermetode word primer in u skool gebruik? natuurlik struktureel (bv. fitzgerald sleutel) ander indien ander gemerk, spesifiseer asseblief: enige opmerkings in hierdie verband: 9 ontvang u onderwysers enige indiensopleiding ten aansien van oudiologie? ja nee 9.1 indien ja, dui aan hoe gereeld dit plaasvind. jaarliks elke ses elke drie elke maand ander maande maande indien ander gemerk, spesifiseer asseblief: 9.2 wat is die doel van indiensopleiding in u skool? 9.3 wie is verantwoordelik vir indiensopleiding in u skool? 9.4 wat behels die indiensopleiding? (indien moontlik, heg asseblief 'n jaarprogram of uiteensetting aan van die aspekte wat aandag geniet). vrael ys 2 aan onderwysers antwoord aile vrae. 2 antwoord vrae so volledig as moontlik. 3 merk die toepaslike antwoord met in kruisie in die aangewese blok waar van toepassing. 4 aile inligting sal as hoogsvertroulik beskou word. 5 enige identifiserende inligting sal uit die finaleverslag verwyder word. the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) opvoedkundige oudioiogie: medekonsuitasie vir optimaiisering van kinders met gehoorverlies in die k1askamer 67 a biografiese inligting: geslag manlik vroulik 2 ouderdom 31-40 jaar 41-50 jaar 51 en ouer . 3 taal afrikaans 2 engels 3 sotho 4 zoeloe 5 xhosa 6 gebaretaal 7 ander: 4 hoogste opvoedkundige kwalifikasies verwerf: i 5 het u enige spesi~le opleiding ontvang in die hantering van gehoorgestremde kinders? i : ja nee indien ja, spesifiseer asseblief: tipe opleiding ja nee 1 indiensopleiding 2 spesiale diplomaisertifikaat , 3 spesiale graad die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) ." lidia pottas & rene hugo 68 6 hoe lank is u reeds betrokke by die ondemg van gehoorgestremde kinders? 1 minder as 1 jaar 2 minder as 2 jaar 3 minder as 5 jaar 4 meer as 5 jaar 7 persoonlike ervaring met gehoorgestremdheid 7.1 het u se~ 'n gehoorverlies? ja nee 7.2 ken u iemand met 'n gehoorverlies? ja nee indien ja. spesifiseer asseblief: 1 familie 2 vriende 3 ander 8 kinders in klas 8.1 hoeveel kinders is daar tans in u registerklas? 8.2 hoeveel kinders in u klas dra 'n gehoorapparaat? b kommunikasie : spraaken taalontwikkellng: 9 'n persoon met normale gehoor kommunikeer slegs deur middel van spraak. waar onwaar geen kennis 10 nie-verbale gedrag bv. gesigsuitdrukkings en natuurlike gebare is 'n belangrike deel van kommunikasie tussen persone met normale gehoor. waar onwaar geen kennis the south african journal o/communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) opvoedkundige oudiologie: medekonsultasie vir optimalisering van kinders met gehoorverlies in die klaskamer 69 11 tydens taalonlwikkeling sal die baba eers taal verstaan voordat hy dit gebruik m.a.w reseptiewe taal onlwikkel v66r ekspressiewe taal. waar onwaar geen kennis 12 die graad / erns van in gehoorverlies is verwant aan die tipe taalprobleme wat 'n gehoorgestremde kind ondervind. waar onwaar geen kennis 13 kommunikasie met mense in die omgewing is noodsaaklik vir die kind om taal te onlwikkel. waar onwaar 14 gebaretaal is in taal in.sy eie reg net soos afrikaans/ engels! sotho' ens. waar onwaar geen i<ennis ii 15 "total communication" is die gelyktydige gebruik van spraak en gebare. waar onwaar geen kennis c die gehoormeganisme 16 'n gehoorverlies a.g.v. van 'n probleem in die middeloor kan medies behandel word. waar onwaar geen kennis ii 17 middeloorontsteking (otitis media) gaan nooit gepaard met in gehoorverlies nie. ; waar onwaar geenkenrlls ii 18 'n gehoorverlies ~.g.v. skade in die binne-oor en gehoorsenuwee kan medies reggestel word. i waar ! onwaar geen kennis 19 in gebarste oordrom kan in gehoorverlies tot gevolg he. waar onwaar geen kennis 20 die funksie (werking) van die binneoor kan soos volg omskryf word: 1 konduktiewe (geleidings) funksie 2 sensoriese funksie 3 neurale of elektriese funksie , 4 geen kennis die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) lidia pottas & rene hugo 70 d oudiometriese toetsing van gehoorverlles: 21. oudiometriese toetse word uitgevoer om: 21.1 die graad (ems) van die verlies te bepaal. waar onwaar geen kennis 21.2 die moontlike plek van die probleem in die gehoonneganisme te bepaal. ' waar onwaar geen ken.nis 21.3 in aanduiding te kry van die oorsaak van die verlies. waar onwaar 21.4 inligting te verkry wat belangrik is vir plasing en rehabilitasie. waar onwaar geen kennis 22. kies die korrekte een: in oudiogram is .... 1 die persoon wat 'n mens se gehoor toets 2 in diagram/figuur wat in aanduiding gee van in individu se luistervaardighede 3 die instrument wat gebruik word om gehoor te toets 4 'n diagram/figuur wat 'n aanduiding gee van 'n individu se gehoorvennoens 5 . geen kennis 23. kies die korrekte: 23.1 in konduktiewe gehoorverlies word veroorsaak deur 'n probleem in: 1 die buite-oor en/of middeloor 2 die binne-oor en/of senuwee 3 albei bogenoemde 4 geen kennis the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) opvoedkundige oudiologie: medekonsuitasie vir optimalisering van kinders met gehoorverlies in die klaskamer 23 .. 2 in sensories-neurale gehoorverlies word veroorsaak deur 'n probleem in: 1 die buite-oor en/of middeloor 2 die binne-oor en/of senuwee 3 albei bogenoemde 4 geen kennis 24. die graad (ems) van die gehoorverlies is die enigste faktor wat die vordering van die kind bepaal. waar onwaar geen kennis indien onwaar: watter faktor(e) speel volgens u ook 'n rol? 25. persone wat in hoe frekwensie gehoorverlies het, kan soms spraak hoor, maar kan nie verstaan wat gese word nie. waar onwaar geen kennis e oorsake van gehoorverlles: 26 herhaaldelike blootstelling aan harde lawaai kan lei tot 'n permanente gehoorverlies. waar onwaar geen kennis 27 'n swanger vrou wat duitse masels kry kan geboorte skenk aan in baba met in gehoorverlies. , 28 waar ii onwaar geen kennis sekere tipes medis~ne kan in gehoorverlies veroorsaak. i onwaar 29 in gehoorverlies kan veroorsaak word deur 'n kombinasie vanfaktore. waar onwaar geen kennis die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 71 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) lidia pottas & rene hugo 72 30 wat is na u mening die twee grootste oorsake van in gehoorverlies by 'n kind? dui met kruisies u keuse aan. 1 onbekend 2 oorerwing 3 meningitis / breinvleisontsteking 4 middeloorontsteking 5 koors 6 geboortebeserings 7 geen kennis 31 in tekort aan suurstof tydens geboorte kan in gehoorverlies tot gevolg he. waar onwaar geen kennis 32 pampoentjies (kindersiekte) kan in emstige gehoorverlies in een oor tot gevolg he. waar onwaar geen kennis f kenmerkeigevolge van 'n gehoorverlles: 33 in gehoorgestremde persoon het probleme om sekere klanke uit te spreek. 'waar onwaar geen kennis 34 kinders met in gehoorverlies van tot 70 db kan met die regte gehoorapparaat en opleiding suksesvolleer in die hoofstroom. waar onwaar geen kennis wat is u mening oor plasing van die gehoorgestremde kind in die hoofstroom? 35 wat is na u mening die grootste gevolg van in gehoorprobleem. kies slegs een. 1 'n taalprobleem 2 in spraakprobleem ' 3 in denkprobleem 4 in sosiale probleem 5 in emosionele probleem ./ 6 in opvoedkundige probleem 7 in beroepsprobleem 8 geen kennis / the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) opvoedkundige oudiologie: medekonsultasie vir optimalisering van kinders met gehoorverlies in die k1askamer g gehoorapparate: 36 in gehoorapparaat norrnaliseer gehoor net soos in bril sig norrnaliseer. waar onwaar geen kennis ·11 37 die kragbron van die g~hoorapparaat is: 1 die versterker 2 die mikrofoon 3 die battery 4 geen kennis 38 benoem die volgende dele van die apparaat: indien u nie weet nie, trek slegs 'n kruisie ( x ) 2 3 4 5 -------------------------------------------------------6 39 hoe kan 'n battery getoets word sonder 'n batterytoetser? , i 40 as die apparaat fluit in 'n kind se oor is dit 'n aanduiding dat: i , 41 in gehoorapparaat maak klanke harder, maar nie duideliker nie. waar onwaar . 1 geen kennis ~ 'fa 42 in persoon wat 'n gehoorapparaat kry moet geleidelik gewoond word aan die versterkte klank. waar onwaar geen kennis die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 73 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) lidia pottas & rene hugo 74 43 hoe gereeld, sou u s9 moet 'n gehoorapparaat nagegaan word? 1 daagliks 2 ai om die ander dag 3 weekliks 4 elke twee (2) weke 5 maandeliks 6 geen kenis 44 wat word bedoel met die "roetine nagaan van 'n gehoorapparaat"? 1 noukeurige inspeksie van die apparaat en oorstuk. 2 luisterinspeksie van die klank van die apparaat. 3 toets van die battery. 4 skoonmaak van die oorstuk 5 ai bogenoemde 6 geen kennis 45 die nadeellbeperking van 'n fm-sisteem is dat die gehoorgestremde kind nie sy eie stem of die van sy maats kan hoor nie. waar onwaar geen kennis h ouditiewe opleiding en spraakleesopleiding: 46 watter een van die volgende prosesse ontwikkel eerste tydens die ontwikkeling van die kind se luistervermoens? 1 .identifikasie identifiseer die verskillende klanke 2 deteksie word bewus van aanjafwesigheid van klank 3 diskriminasie word bewus van die verskil in klanke 4 beg rip betekenisvolle interpretasie van klank 5 geen kennis 47 die doel van 'n opleidingsprogram in luistervaardighede is om te verseker dat die kind wat 'n gehoorapparaat het, leer. om sy oorgeblewe gehoor maksimaal te gebruik. /' waar onwaar geen kennis the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) opvoedkundige oudiologie: medekonsultasie vir optimalisering van kinders met gehoorverlies in die klaskamer 48 watter van die volgende faktore in die klaskamer het vol gens u 'n beperkende invloed op die kind se vermoe om te luister. 1 weerkaatsing van klank 2 agtergrondsgeraas 3 afstand tussen die onderwyser en die kind 4 geraas buite die klaskamer 5 ai bogenoemde 6 geen kennis 49 wat is volgens u die eerste stap in 'n ouditiewe opleidingsprogram met 'n jong kind: (kies slegs .een) 1 klankherhaling 2 die bewustheid van klank 3 klankdiskriminasie 4 klankproduksie 5 nie een van bogenoemde nie 6 geen kennis indien nie een van bogenoemde nie, waar sou u begin met ouditiewe opleiding? 50 die spraaksein wat die moeilikste is om te liplees is: (kies een) 1 vokale i 2 i konsonante i i 3 woorde in konteks i 4 s. i innej 5 geen kennis die suid-afrikaanse tydskrifvir kommunikasieafwykings, vol. 48, 2001 75 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) lidia pottas & rene hugo 76 51 die vermoe om te liplees word be'invloed deur: (kies een) 1 beskikbare lig (beligting) 2 die afstand tussen die spreker kind 3 die spraakspoed 4 ai bogenoemde 5 geen kennis verdere opleiding: 52 het u enige besondere opleidingsbehoeftes ten opsigte van oudiologie met ander woorde: waarvan sou u graag meer te wete wou kom? 53 het u enige voorstelle ten opsigte van verdere opleiding? the south african journal of communication disorders, vol 48 2001 r ep ro du ce d b y sa bi ne t g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r ( da te d 20 12 ) abstract introduction research methodology results discussion conclusion acknowledgements references about the author(s) nuha khatib department of health and rehabilitation sciences, faculty of health sciences, university of cape town, cape town, south africa vera-genevey hlayisi department of health and rehabilitation sciences, faculty of health sciences, university of cape town, cape town, south africa citation khatib, n., & hlayisi, v. (2022). is a hybrid of online and face-to-face services feasible for audiological rehabilitation post covid-19? findings from three public health patients. south african journal of communication disorders, 69(2), a907. https://doi.org/10.4102/sajcd.v69i2.907 original research is a hybrid of online and face-to-face services feasible for audiological rehabilitation post covid-19? findings from three public health patients nuha khatib, vera-genevey hlayisi received: 31 jan. 2022; accepted: 01 july 2022; published: 17 aug. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the global coronavirus disease 2019 (covid-19) pandemic has pushed many audiologists to incorporate remote service delivery methods to adhere to mandatory health and safety protocols. the use of tele-audiology for audiological rehabilitation may provide a sustainable, cost-effective modality to suit the existing need, particularly in low-resourced countries. objectives: this study aimed to investigate the feasibility of implementing a hybrid tele-rehabilitation programme in a south african public health context. an online auditory training (at) programme was used to determine (1) compliance, (2) clinical benefit, (3) participant experience and (4) costs. method: a convergent mixed methods design with a feasibility approach was utilised. data collection was done through questionnaires, in-booth assessments, online at, and face-to-face interviewing. participants undertook online at over 4 weeks. for preand post-online at, the abbreviated profile of hearing aid benefit (aphab), quicksin, entrance and exit questionnaires, interviews and a system usability scale were administered. results: key findings of this study included (1) a high compliance rate (84.82%) with minimal clinician contact time at 3 h 25 min over 5–6-weeks; (2) improvement in perceived hearing aid (ha) benefit, and improvement in listening skills; (3) reported positive experiences; and (4) minimal programme costs at an average of r1350.00 per participant. conclusion: the results showed positive indicators that the use of hybrid tele-rehabilitative strategies may provide a viable alternative to the traditional face-to-face modality. the hybrid approach showed clinical benefits, cost-effectiveness, minimal contact time as well as covid-19 compliance. further large-scale research is still needed. keywords: tele-audiology; hybrid; covid-19; public health; auditory training; hearing aids; adult; south africa. introduction one of the negative effects of the coronavirus disease 2019 (covid-19) lockdown protocol in south africa was the temporary halting of nonessential services, with essential services referring mainly to hospital care, police forces and grocery store operation (banerjee, robinson, sathian, & van teijlingen, 2020). many audiologists sought alternative service delivery modalities to protect their patients and themselves against covid-19, while providing a high standard of care that ensured ethical testing, rehabilitation and treatment of audiology patients. the adoption of hybrid (online and face-to-face) tele-audiology was a way for audiologists to do this. many audiologists globally already use hybrid methods to provide hearing healthcare to a larger population (ballachanda, 2019; bush, thompson, irungu, & ayugi, 2016; havenga, swanepoel, le roux, & schmid, 2017; ratanjee-vanmali, swanepoel, & laplante-lévesque, 2020). the successful implementation of audiological services using online methods lowers the risk of covid-19 infection. this is particularly pertinent given the fact that a large proportion of the general audiology patient population is of geriatric age with probable comorbidities (e.g. high blood pressure and chronic respiratory disease) (ko et al., 2020). the use of a hybrid model may also provide long-term benefits to practices (in relation to costs, clinician time and patient benefits) (reis, boisvert, beedell, & mumford, 2019; tye-murray, spehar, barcroft, & sommers, 2017). some of the challenges of online services, such as technology limitations (e.g. internet-capable device access and technological incompatibility of older hearing aids [has]), patient readiness and the reliability of some online assessments (ratanjee-vanmali, swanepoel, & laplante-lévesque, 2019; ravi, gunjawate, yerraguntla, & driscoll, 2018; rutherford & petersen, 2019), all of which may restrict many from taking full advantage of the opportunities. feasibility of a hybrid tele-audiology model a recent review by tao et al. (2018) included international tele-audiology studies focusing on adult ha users and found that remote ha fittings and subsequent follow-ups were indeed feasible. however, they highlighted the need for further tele-audiology research, particularly including the delivery of rehabilitative strategies such as auditory training (at). the current feasibility study aimed to contribute to the knowledge base on tele-rehabilitation applications involving at provision for adult ha users. abrams, bock and irey (2015), evaluating internet-based at on new ha users, showed that the online platform presents a promising model for at delivery for audiological rehabilitation but that using internet-based at to provide audiological rehabilitation still implied considerable administrative time and clinician contact with the patient. this is important to consider for the south african public health context, as clinician time is one of the limitations or barriers currently preventing the provision of comprehensive audiological rehabilitation beyond ha fitting such as at (chisolm et al., 2013; dubno, 2013; ferguson & henshaw, 2015; sweetow & palmer, 2005). the cost and workload aspects are important factors to consider with tele-audiology applications, together with the patient experience and satisfaction with the services provided, which should also be considered. a study conducted in south africa concluded that the hybrid model has great potential and importance in influencing patient satisfaction and compliance (ratanjee-vanmali et al., 2020). furthermore, some of their key findings indicated that patient satisfaction with hybrid services was very high (97%), and patients preferred some online services compared to traditional face-to-face services (ratanjee-vanmali et al., 2020). they also found that patients were highly likely to recommend hybrid services to friends and family (ratanjee-vanmali et al., 2020). strategies such as perceptual training (e.g. at) after ha fitting are considered a critical aspect in comprehensive audiological rehabilitation. many studies have shown that at improves auditory skills in people with hearing loss (humes et al., 2019; santos, marangoni, andrade, prestes, & gil, 2014; tye-murray et al., 2017). the training of cognitive skills which underlie successful speech perception may provide more generalisable outcomes and benefits for ha users, such as more effective communication (ferguson & henshaw, 2015). furthermore, a recent systematic review showed that some at programmes may have positive effects on overall cognition in older adults with hearing loss (lawrence et al., 2018). south african hearing healthcare provision for public health patients with hearing loss is marred with challenges, which include a lack of qualified audiologists, a lack of contextually relevant rehabilitative tools and limited provision of specialised rehabilitation such as at. the lack of resources combined with the large patient load has resulted in a delay of service provision and hindered the successful implementation of comprehensive audiological rehabilitation in the public health sector (pascoe, rogers, & norman, 2013; pienaar, stearn, & swanepoel, 2010; rutherford & petersen, 2019). there is a need for the investigation of tele-rehabilitation in south african public healthcare to assist in the limited comprehensive audiological rehabilitation provision (ratanjee-vanmali et al., 2019; scott & mars, 2015; swanepoel, 2016). study rationale with the growing impact of tele-audiology on healthcare in low-resource contexts, there is a great need for investigation into feasibility of tele-rehabilitation to assist in the limited hearing healthcare provision (which currently does not typically include at) and provide covid-19 safe services. this study was, to the knowledge of the researcher, the first to address the research question: ‘is the implementation of a tele-rehabilitation programme for adult ha users feasible in a south african public health context?’. research methodology aim to investigate the feasibility of implementing an online at programme within a south african public health context. objectives the objectives of the study were to: determine participants’ compliance to an online at programme over 4 weeks with respect to the: number of sessions spent on the programme per week frequency of interactions and contact time between clinician and each participant number of participants who complete the prescribed sessions versus any withdrawals determine the effect of the online at programme on participants’ speech perception in noise (preand post-administration of the online at programme) assess participants’ experience and benefit of online at through interviewing and self-report questionnaires estimate the costs around online at programme implementation (online access, participant data usage, travel costs). research design a feasibility study using a convergent mixed methods design (quantitative and qualitative) was utilised. feasibility studies allow the investigation and inclusion of data from different aspects of an intervention modality (e.g. patient performance, patient experience, clinical benefit and intervention expenses) (orsmond & cohn, 2015). the quantitative methods included assessments of auditory skills (speech perception and online at tasks) and likert questionnaires and were used within a single group pretest–post-test design. the qualitative methods included semistructured interviews and were used within a generic qualitative research design. study setting the current study was conducted in cape town at groote schuur hospital (gsh). the hospital has ear, nose and throat (ent) and audiology departments. the audiology clinic provides services to both paediatric and adult patients. services include diagnostic audiology testing, rehabilitative services and ha fittings. in alignment with the public health protocol, adult audiology patients at gsh usually receive one ha even with a bilateral hearing loss. participants sampling a nonprobability purposive sampling method was used. this sampling strategy was used to specifically select the participants, firstly, with a sensorineural hearing loss – because this specific patient was targeted by at intervention (brouns, el refaie, & pryce, 2011; bryck & fisher, 2012). secondly, the method of at delivery in the current study required participants to have access to an internet-capable device. finally, the language restriction on the selected at programme was english. the full participant criteria are presented next. inclusion criteria hearing aid users: aged 19–59 years. with a mild to severe sensorineural hearing loss (unilateral or bilateral) with access to a smartphone, laptop, computer or tablet who could communicate in english who had at least 1 month experience of ha use (monaural or binaural). exclusion criteria the following individuals were excluded from the study if they: were already receiving at had a known cognitive impairment had a known literacy impairment had a bilateral flat profound sensorineural hearing loss. recruitment the recruitment methods included both direct (telephonic calls) and indirect (recruitment posters) methods. direct recruitment involved the researcher reviewing the audiology department’s ha patient folders to identify those who met the superficial study criteria – for example, age, hearing loss and language criteria. this was followed by telephonic contact to invite eligible participants. the eligible participants were firstly given an overview of the study and then the opportunity to ask questions, and if they were interested, matters regarding participation and consent were explained to them. confidentiality was kept throughout the recruitment and data collection process as per research ethical guidelines (which included no sharing of medical results, training performance or any personal details of participants to parties outside of the research study). a total of 26 patients were identified and passed the initial eligibility criteria (e.g. age, hearing loss, ha fitting, language and device access) for recruitment to this study. an in-person screening was conducted on those who agreed to participate in order to determine their full eligibility. the screening included a cognitive screener and a brief technological task ability questionnaire (details are given under the ‘study materials’ section). after the screening and eligibility determination, there were initially five eligible participants. however, because of two participants not arriving for appointments, three participants were included in this feasibility study (see figure 1). all included participants were women between the ages of 35 and 55 years, diagnosed with a bilateral hearing loss and fitted monaurally. the participants’ aided period (duration since fitting) ranged from 6 to 24 months. figure 1: participant recruitment. study materials mini-cog (screening tool 1): paper-based standardised test used to distinguish between persons with dementia and persons without dementia (borson, scanlan, brush, vitaliano, & dokmak, 2000). used in the current study to screen for undetected cognitive impairment. task ability questionnaire (screening tool 2): designed by the researchers to assess participants’ ability to perform the basic technological functions to use the online at programme (intervention) (e.g. navigate to a website independently). listening and communication enhancement (intervention): listening and communication enhancement (lace) online training platform (defauw & henderson-sabes, 2014). the lace online includes four different types of activities (e.g. word memory, rapid speech, speech in noise and competing speaker). the lace is available in american and british english, which limits its applicability to south africa. however, future south african at tele-rehabilitation programmes may use the lace online platform design to build a more contextually relevant programme as it is the most user-friendly. the lace online includes a clinician monitoring function and a shorter programme moulded from years of research and ha user feedback to provide similar benefit as the original lace, however, at a more accessible level (defauw & henderson-sabes, 2014). the lace online consists of 11 sessions, each approximately 25–45 min in length. each session contains a combination of listening exercises. as patients progress through the 11 sessions, the difficulty of the level changes depending on their scoring. for example, if patients improve in their scores, the tasks become more challenging (lower signal-to-noise ratio [snr]). the inverse is that if patients struggle, then tasks become easier (higher snr). the lace online also administers the quicksin in the middle and at the end of the programme. quick speech in noise (quicksin): a standardised test used to determine patients’ ability of understanding speech in noise. patients are tested in an audiometric booth and presented with sentences in one speaker and white noise in the other. they are expected to repeat each sentence in the presence of the noise. according to the quicksin development team, etymōtic research (2001), the score obtained in the quicksin test is accurate to 2.7 decibels (db) at a 95% confidence level. although a quicksin assessment is included in the lace online programme, it was also conducted by the researcher in the current study in an audiometric booth preand post-intervention. in order to minimise the influence of the learning effect, the in-booth quicksin was administered with different wordlists for the preand postassessments. abbreviated profile of hearing aid benefit (aphab): likert-scale questionnaire which includes questions based on the ha user’s experience in specific listening situations (cox & alexander, 1995). the aphab is separated into four subscales: ease of communication (ec), reverberation (rv), background noise (bn) and aversiveness (av). each statement or item in the aphab is scored in a percentage. in all subscales an increase in percentage score indicates an improvement in perceived benefit. the aphab was used as a formal means to measure perceived ha benefit preand post-intervention. entrance questionnaire: likert-scale questionnaire designed by the researchers to determine previous exposure to at; anticipated motivation to complete the at; preferred internet-capable device; and preferred method of contact. exit questionnaire: likert-scale questionnaire designed by the researchers and questions were framed around programme accessibility and interface. system usability scale (sus): the sus (brooke, 1996), is a 10-item likert-scale questionnaire used to assess participants’ perceived usability of a programme (i.e. lace online). according to brooke (1996), measuring usability should include (1) the effectiveness of the programme or system – the ability of participants to complete the programme; (2) efficiency – the resources needed and used to complete the programme; and (3) satisfaction – participants’ opinion and experience. the sus was included because it is a simple standardised scale that has been widely used in research and is considered an intrinsic tool when assessing perceived usability (lewis, 2018). interviews: the inclusion of semistructured interviews (before and after at) in the current feasibility study served to allow comprehensive inclusion of participant experiences and opinions, as well as to enable the researcher to build rapport with participants. entrance interviews determined participants’ case history, hearing concerns, technological knowledge and expectations of online at. exit interviews allowed participants the opportunity to provide responses to questions surrounding the online programme, delivery, accessibility and clinician contact. they were also asked questions pertaining to what they enjoyed and did not enjoy about the online at. the participants were also encouraged to provide any other feedback or comments. data collection screening: potential participants were given consent forms, and after signing the forms they were screened using the mini-cog and the task ability questionnaire. pre-intervention: eligible participants were pre-assessed using the aphab and quicksin. the entrance questionnaire was also administered. entrance interviews were conducted and an introductory session including programme demonstration was done to ensure participants knew how to navigate the at programme. intervention: the at programme was then completed by all participants at their own convenience over 4 weeks, with the researcher monitoring their progress through the lace online cloud server. participants were given a brief overview of their progress weekly through whatsapp messages (one participant did not have a cell phone; therefore, their results were consented to be sent to their communication partner). post-intervention: upon the completion of the programme each participant was re-assessed using the aphab and quicksin. the sus and exit questionnaires were administered, and the exit interviews were conducted. the at programme was completed while the participants were wearing their has. the quicksin was conducted in an audiometric booth through free field speakers while the participants were wearing their has. the quicksin was also conducted as part of the at programme, and the results were captured. all questionnaires and screening tests were conducted under the supervision of the researcher. the complete hybrid tele-rehabilitation programme ran over 6 weeks. data analysis quantitative data descriptive statistics were used for the quantitative data. descriptive statistics were advantageous as they provided meaningful summaries of the findings, which allowed the intervention modality to be analysed from different aspects (mishra et al., 2019) (see table 1 for a brief overview). table 1: summary of quantitative data analysis. qualitative data thematic analysis of the qualitative data was conducted to determine any commonality between participant interviews. the thematic analysis in the current study adopted a systematic phased process outlined by nowell, norris, white and moules (2017). the analysis process included: familiarisation with the data: researcher reviewing transcripts. generating initial codes: coding of data and researcher reflexive writing of initial thoughts and impressions of the data. searching for themes: identification of possible themes based on common participant experiences. reviewing themes: determination of link between themes and participant experience. defining and naming themes: definition and clarification of themes and subthemes. producing report: write-up of common themes and subthemes with raw data (participant quotes) embedded within report. ethical considerations this study followed the ethical principles outlined by the world medical association (wma) in the declaration of helsinki to guide researchers in protecting the rights, mental and physical well-being of human participants (world medical association 2013). notable ethical points of the current study included the following: participants were given the study overview in the early stages of recruitment as well as during the first in-person appointment so that they understood what the research entailed, thus allowing them to give informed consent. no one was forced to participate. participants were also able to withdraw from the study at any time without penalty. all participants received the same intervention and were assessed with the same tests. each participant received 1.0 gigabytes (gb) – 1.5 gb of mobile data to allow internet access. participants received intervention that would have only improved their listening abilities, and there was no risk of further hearing damage. ethical approval was obtained from the human research and ethics committee (hrec) of the university of cape town (uct) (reference number: 642/2018). results the results are presented according to the objectives of this feasibility study: (1) participant compliance, (2) clinical benefit, (3) participant experience and (4) estimation of costs around hybrid tele-rehabilitation programme implementation. participant compliance compliance was determined from (1) the number of sessions completed, (2) contact time between the clinician and participant and (3) the number of participants who withdrew from the programme. the average total completed at sessions was 9 out of 11 (84.82%). the average total contact time for each participant was 3 h and 25 min, and the weekly average was 22.5 min for each participant. the average number of online interactions was 9, and there were no withdrawals in this study. see table 2 for the results of (1) and (2). table 2: compliance factors. participant benefit (clinical and perceived) clinical benefit – online auditory training results and speech in noise perception scores the results of the at and quicksin showed evidence of clinical benefit with an overall improvement in participants’ listening skills. table 3 describes each participant’s at scores for each subtest included in the programme, from the first session compared to the last session. table 3 also describes the quicksin results obtained from participants through the online at programme and in the audiometric booth (preand post-intervention). table 4 describes the overall mean (at and quicksin scores). table 3: assessment and intervention results. table 4: assessment and intervention results (mean). perceived benefit – abbreviated profile of hearing aid benefit in this feasibility study, the results of the aphab showed that with all the participants, there was an overall improvement in perceived ha benefit in three of the four subscales. the average benefit of the rv items improved by 21.3%, bn items improved by 21.2% and av items improved by 16.4%. the ec average benefit decreased by 1.1%. table 5 depicts the results of the aphab. table 5: abbreviated profile of hearing aid benefit results. participant experience of hybrid tele-rehabilitation entrance questionnaire responses from the entrance questionnaire showed that two participants had not had any form of at before and had also never heard of the concept. once the concept of the at included in this study was explained, all participants indicated that they believed they would benefit from it and would also be able to make time for it during their own weekly schedule. all participants indicated whatsapp to be their preferred method of contact over e-mail, short message service (sms) and phone call. exit questionnaire according to the results obtained from the exit questionnaire, the device most used for the at was a laptop. the main reason given by participants preferring the laptop was that it was easier to read the text of the programme on the laptop screen compared to the smartphone screen. exit interviews the responses from the exit interviews were analysed and formed three different themes and several categories, as depicted in table 6. table 6: thematic analysis. usability of hybrid tele-rehabilitation programme a notable finding from the sus was that all participants indicated that they believed people would need initial technical assistance to be able to learn to use the programme quickly. figure 2 depicts the responses. figure 2: system usability scale responses. hybrid tele-rehabilitation programme associated costs the estimated cost of the implementation of the hybrid tele-rehabilitation programme was calculated by including the following costs for each participant: lace online access – $79.00 (r1200.80) mobile data – r80.00 – r100.00 travel – r28.00 – r30.00. table 7 describes the breakdown in costs of the hybrid tele-rehabilitation programme implementation. table 7: breakdown of costs. discussion this study was, to the knowledge of the researchers, the first to investigate the feasibility of hybrid tele-rehabilitation implementation in south african public hearing healthcare using a hybrid tele-audiology model. even though the sample size was limited, the feasibility intent of the study sought to investigate the initial findings from a hybrid tele-rehabilitation programme. thus, the findings from this feasibility study may be seen as initial positive indicators that audiological rehabilitation of disabling hearing loss could be administered using a hybrid model in a low-resourced context. key findings of this feasibility study indicated a high compliance rate (84.82%) to hybrid tele-rehabilitation, minimal clinician contact time at 3 h 25 min over a 5–6-week period, clinical benefit and positive feedback from participants and programme costs at an estimated r1350.00 per person. moving forward in the context of covid-19, using hybrid tele-rehabilitation may be a reality for most audiologists where the relevant resources (e.g. device access) are available. hybrid tele-rehabilitation compliance and clinician contact the compliance rate for the hybrid tele-rehabilitation programme for this feasibility study was high (84.82%), and this is comparable to the compliance rates noted by chisolm et al. (2013) (84%) and tye-murray et al. (2012) (> 90%). the high compliance rate in this study may be attributed to the hybrid tele-audiology model used where there was regular clinician support. this is an important finding to consider as it implies that tele-rehabilitation should not fully replace clinician contact; in fact, clinician contact (through a hybrid model of delivery) is pertinent to positive patient compliance. a similar finding of clinician contact positively impacting patient compliance was also reported by chisolm et al. (2013) and tye-murray et al. (2012). the total clinician time in this feasibility study was at an average 3 h and 25 min over 6 weeks for a full at programme. in a usual audiology clinic, 3 h would equate to 3–4 diagnostic tests or initial ha fittings. this indicates that a hybrid model of tele-rehabilitation delivery may be introduced into the existing audiology clinics in low-resource contexts without adding a significant workload burden for the clinicians. although the at programme was explained in detail, and participants were given a document summarising how to log in; patients required further reassurance and support in week 1. this finding is similar to a crucial point made by nemes (2010), who suggested that tele-audiology methods should be applied, without disregarding duties towards patient support in the form of clinician contact. in addition, sweetow and henderson-sabes (2010) highlighted that compliance with home-based at has been reported by many audiologists to have improved with an initial face-to-face introductory session with the clinician. considering these previous findings and the findings of the current study, it can be said that hybrid tele-rehabilitation has shown to improve (1) compliance, (2) patient trust and (3) patient empowerment (nemes, 2010; sweetow & henderson-sabes, 2010; tye-murray et al., 2012). a hybrid model may also address issues with low follow-up rate, as noted by previous studies (chisolm et al., 2013; ramkumar, hall, nagarajan, shankarnarayan, & kumaravelu, 2013; scott & mars, 2015). the findings of this feasibility study suggest that adult ha patients may comply with online at as it is convenient and does not require regular travel to the hospital, which implies, for most low-resourced countries, taking a day off work. furthermore, the high compliance rate of this feasibility study is in line with recent research in south africa (ratanjee-vanmali et al., 2020). clinical benefit and participant experience clinical benefit the communication skills of ha users are multifaceted and need comprehensive assessment which assists in measuring improvements and establishing communication goals (sweetow & henderson-sabes, 2010). measuring self-perceived benefit should be considered important when administering at – as seen with the results of the aphab in the current study, which aligned with the at training effects. the results of the aphab showed that the bn subscale was one of the most improved subscales overall. this is an important result, as one of the key training tasks of the lace programme is speech-in-noise training. even with the results of the ec subscale of the aphab failing to improve post-intervention shows that it could be attributed to the at. this is because at focuses on improving listening in noise skills and the ec items all address quiet situations, and therefore the perceived benefit could have been more perceptible in the other subscales which deal with complex noisy situations. an improvement in listening in noise skills would then determine how the participants scored their listening skills in noisy environments (e.g. bn subscale) compared to quiet environments (ec subscale). this finding suggests that the results of an at programme should be cross-checked with a self-perceived benefit scale, such as the aphab. participant experience participants responded positively to the hybrid tele-rehabilitation according to the interviews, which was a promising indicator that south african public health patients may be open and willing to engage in tele-rehabilitation. all participants indicated that at should be included in audiological rehabilitation. some stated that patients should, at least, be informed about it, citing that they had never heard of at before this research. the lack of information and implementation of further hearing rehabilitation could be because public health audiologists are challenged with attending to back-to-back patients and the diagnosing and fitting of patients leaves little time for further services (e.g. at) (makhoba & joseph, 2016; pienaar et al., 2010). makhoba and joseph (2016) noted that the inclusion of communication strategies was the only form of further audiological rehabilitation after ha fitting, and it was only reported to be included by 69.8% of their sample. the lack of at inclusion is further corroborated by other international studies which have reported that at is a vital yet underutilised tool in the field of audiology (chisolm et al., 2013; dubno, 2013; ferguson & henshaw, 2015; sweetow & palmer, 2005). therefore, the use of online at whereby the patients receive a self-explanatory document (e.g. instruction pamphlet) may afford public health patients the opportunity to receive at, without placing a burden on public health audiologists. as found in the current study, it would not require a substantial amount of time to explain at and introduce patients to an online programme (approximately 15 min) during their first obligatory ha follow-up. hybrid tele-rehabilitation costs a factor in assessing the feasibility of the hybrid tele-rehabilitation programme is the determination of associated costs. these costs generally include the costs of resources (e.g. assessments, programme access, etc.), health facility costs (e.g. equipment and health professionals) and patient costs (e.g. travel expenses and internet data costs). the current study reviewed the costs of the hybrid tele-rehabilitation programme from a health provider perspective and included the costs of the american product (lace online), which was influenced by the dollar to rand exchange rate, mobile internet data and patient travel expenses. the total costs for this feasibility study were r6352.00, and the average cost per participant was r1350.00. internet-capable device access in low-resource contexts another important factor to consider with tele-rehabilitation is patient access to internet-capable devices. it is worth noting that internet connectivity and device access in previous literature was anticipated to be a challenge in implementation and compliance to tele-audiology methods in low-resourced contexts (clarke & mars, 2015; monica et al., 2017; ramkumar et al., 2013). however, this feasibility study highlighted that even though most patients who seek public healthcare may be presumed to be from low socio-economic backgrounds, their access to technology and an internet-capable device was not observed to be limited. internet connectivity and device access is increasing in low-resource contexts, and rutherford and petersen (2019) noted that the penetration of the smartphone market in south africa is 73%, which is arguably significant and holds promise for tele-audiology applications. the covid-19 safety benefits of hybrid tele-rehabilitation physical distancing and mandatory face coverings decrease the risk of infection but increase breakdowns in communication, which is comparatively more severe in those living with hearing loss because they are unable to read lips or facial cues (naylor, burke, & holman, 2020). to counter these affects, some audiologists adopted transparent masks or face shields where in-person appointments are a necessity. however, current national laws and social responsibility noted that where services could be provided using socially distant tele-audiology methods, audiologists were encouraged to do so. the dilemma which many audiologists faced was the uncertainty around tele-audiology methods; this included which services to provide using online methods, efficiency of services and, most importantly, the question of patient benefit (nemes, 2010). a recent international survey showed that audiologists’ attitude towards telehealth during covid-19 was overall positive, with some hesitancy around certain factors – mainly, time and financial constraints, patient technology access and technology knowledge (eikelboom et al., 2021). the previously outlined patient and clinician benefits from the current study, which included time and cost savings, are some of the possible broader advantageous factors of implementing hybrid tele-rehabilitation. when considering the current covid-19 pandemic and its impact on everyday practices, the benefits may be expanded to include that it is a covid-19 safe option which minimises close contact and thus reduces the risk of infection. study strengths original research the current study was, to the knowledge of the researcher, the first to investigate the feasibility of implementing tele-rehabilitation through an online at programme in a south african public health context. with regard to tele-audiology research in south africa (and globally), most studies aim to include screening or diagnostic testing in the scope of hearing healthcare service provision. this feasibility study on tele-rehabilitation presented research on a topic that is not widely researched in the field of audiology and would therefore add value to the larger pool of audiology research. relevant research with the growing influence of telehealth applications in the field of audiology, the current feasibility study presents a relevant topic. south africa is seen as one of the leading countries in tele-audiology research and application because of the significant need for cost-effective, efficient solutions for its current public health system. in terms of audiological rehabilitation service provision in south africa, research efforts need to be directed at looking into methods that can provide more comprehensive services to public health patients in a manner that would not additionally burden the current patient load. mixed methods the current study included both quantitative and qualitative measures. it is important to include patient experience when considering the feasibility of a new service delivery model for patients as the quantitative factors can be limited in its means to show patient satisfaction and self-perceived benefit. also, mixed methods allowed for comprehensive data collection from different aspects of the intervention modalities. study limitations sample size the main limitation of this feasibility study was the sample size. the sample size in the current study was mostly influenced by the design of previous research, recruitment challenges and the objectives of this feasibility study. regarding previous research with at and given the nature of at, small sample sizes have been preferred (dubno, 2013; ferguson & henshaw, 2015; santos et al., 2014; sweetow & henderson-sabes, 2004). a lack of control group as well as the nonrandomisation of the sample was a bias threat. however, the feasibility approach of the current study was not suitable for participant randomisation. the intention of including inferential statistics alongside the descriptive statistics could not be accomplished because of the sample size. statistical inferences would not have been valid with the current sample size. the exclusion of inferential statistics implied a limitation on the interpretation of the results and no concrete conclusions could be made to generalise or make inferences of the study findings; however, the results of the current study may be used as a foundation for comparison to future large-scale research. conclusion the results of the current study indicated that the use of a hybrid tele-audiology model to provide audiological rehabilitation (such as online at) may be feasible for implementation in low-resourced contexts like south africa, with minimal additional costs, workload and time (face-to-face clinical contact) implied in current services. however, limitations of this study included the sample size which restricted generalisability. therefore, the findings of this study can be seen as positive indicators for the use of hybrid telehealth as a modality for the delivery of audiological rehabilitation in low-resourced contexts during and after the covid-19 pandemic, but further large-scale research is still needed. acknowledgements the authors would like to thank the audiology department at groote schuur hospital as well as the participants for their cooperation in this study. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions n.k. and v.h. were responsible for the study conception and design. n.k. contributed towards data collection and analysis and interpretation of results. n.k. and v.h. drafted the manuscript. both authors reviewed the results and approved the final version of the manuscript to be published. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the authors confirm that the data supporting the findings of this study are available within the article and/or its supplementary materials. disclaimer the views and opinions expressed in this articles are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references abrams, h.b., bock, k., & irey, r.l. 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(2013). world medical association declaration of helsinki: ethical principles for medical research involving human subjects. jama, 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 abstract introduction methods results discussion conclusion acknowledgements references about the author(s) khetsiwe p. masuku department of speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa gift khumalo department of speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa nontokozo shabangu department of speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation masuku, k.p., khumalo, g., & shabangu, n. (2022). the effects of covid-19 on the rehabilitation of persons with aphasia: a scoping review. south african journal of communication disorders, 69(2), a920. https://doi.org/10.4102/sajcd.v69i2.920 original research the effects of covid-19 on the rehabilitation of persons with aphasia: a scoping review khetsiwe p. masuku, gift khumalo, nontokozo shabangu received: 01 feb. 2022; accepted: 12 may 2022; published: 04 aug. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the impact of the coronavirus disease 2019 (covid-19) pandemic was more pronounced on the well-being of persons with disabilities, especially in lowand middle-income countries. there is documented evidence of the rippling effects of covid-19 on persons with disabilities. however, not much is known about the impact of covid-19 on the rehabilitation of persons with aphasia. objective: the scoping review explores how covid-19 affected the rehabilitation of persons living with aphasia. method: a scoping review was conducted using arksey and o’malley’s framework. a search was conducted on science direct, pubmed, medline, scopus, proquest and google scholar, to identify relevant studies published between 2019 and 2022. data were analysed using thematic analysis. results: most studies regarding the effects of covid-19 on persons living with aphasia were conducted in the united kingdom. five themes emerged from the data, namely, (1) negative impact on rehabilitative care, (2) telehealth and its limitations, (3) impact on social participation, (4) compromised caregiver involvement and (5) mental health challenges. conclusions: findings highlight the need for healthcare professionals to pursue innovative ways in which aphasia rehabilitation and conversational support programmes can be made accessible to persons with aphasia, despite the limitations brought about by a pandemic. telerehabilitation programmes need to be tailored to the needs of persons with aphasia if they are to be successful. this study highlights the importance and need for the prioritisation of mental health services for persons with aphasia and their caregivers during a pandemic. keywords: aphasia; covid-19 pandemic; rehabilitation; telehealth; social participation. introduction globally, stroke is a leading cause of mortality and disability (akinyemi et al., 2021; johnson et al., 2019). the prevalence of people living with the effects of stroke has increased because of the growing and ageing population (johnson et al., 2019). stroke is a leading public health issue especially in lowand middle-income countries (lmics) (mendis, 2010). stroke causes more death in lmics than in high-income countries (hics) because lmics are more susceptible to most of the causes of stroke, such as diabetes mellitus, hypertension, human immunodeficiency virus or acquired immunodeficiency syndrome (hiv and aids), traumatic aphasia that is caused by interpersonal violence and motor vehicle accidents (duff, ntsiea, & mudzi, 2014; johnson et al., 2019; ntsiea, 2019; sambo & kirigia, 2014). akinyemi et al. (2021), johnson et al. (2019) and ntsiea (2019) further submit that in lmics, stroke occurs in younger people with calamitous psychological, social and economic consequences on the individual with a stroke, their family and society. stroke is the most common cause of aphasia (khedr et al., 2020). approximately a third of stroke survivors experience aphasia (van oers et al., 2018). aphasia is an acquired adult language impairment that affects spoken language expression, spoken language comprehension, written expression, reading and reading comprehension and cognitive nonlinguistic skills (brady et al., 2016). language impairments have a significant impact on an individual’s quality of life because of their effect on communication, which is not only a basic human need and right but also a human power (jokel et al., 2014; williams, 2000). ultimately, aphasia has an impact on participation. communication intervention becomes imperative in this population (persons with aphasia) because when communication is affected, vocational, family as well as social relations are affected, often leading to frustration, isolation, hopelessness and depression (hilari et al., 2010; masuku, mophosho, & tshabalala, 2018). the surviving stroke population is increasing, and subsequently there is also an increase in the number of persons living with aphasia. the effects of a language impairment are devastating on the quality of life of both the person with aphasia and their families, thus creating a greater demand for preventive, therapeutic and rehabilitation services at different levels of care (akinyemi et al., 2021; stinear, lang, zeiler, & byblow, 2020). in addition to the linguistic challenges, persons with aphasia will experience physical, emotional, psychological and social challenges (doogan et al., 2018). thus, a multidisciplinary approach to their rehabilitation is required to holistically address their needs. the rehabilitation teams usually consist of speech language therapists, occupational therapists and physiotherapists (doogan et al., 2018). persons with aphasia may also require psychological intervention, as they are likely to suffer from clinical depression and emotional distress as a result of communication difficulties (santo pietro et al., 2019). research has shown that rehabilitation intervention for aphasia is important because it increases psychosocial well-being (hilari et al., 2010), communication success (johansson, carlsson, & sonnander, 2012) and participation in everyday life (johansson et al., 2012). rehabilitation programmes for persons with aphasia also provide an opportunity for social networks and peer support to persons with disabilities and their families. the world health organisation (2017, p. 21) defines rehabilitation as ‘a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment’. the british society of rehabilitation medicine (2003) further present that for stroke patients, rehabilitation is a process of active change by which a person who lives with a disability acquires the knowledge and skills needed for optimal physical, psychological and social function. the authors of this study therefore conceptualise rehabilitation using the above-mentioned definitions. rehabilitation is thus all-encompassing and extends beyond that of addressing body structure and function and activity limitations (ntsiea, 2019) and should address or alleviate factors that hinder full social integration of the patients, including return to work and improving carer support. the world health organisation (2017), in their 2030 strategy which was implemented in 2017, declares rehabilitation as an essential component of integrated healthcare and further states that to achieve sustainable development goal 3 (that of universal health coverage), access to rehabilitation services is necessary. in a south african study sample, all patients who had suffered a stroke received physiotherapy, and only patients from 16 of the 21 health centres received speech therapy and occupational therapy in addition to physiotherapy (ntsiea, 2019). although extensive research shows that rehabilitation is an essential part of the care continuum and positively impacts physical, psychological and social functioning of persons with aphasia, studies suggest that rehabilitation needs remain unmet globally (akinyemi et al., 2021; masuku et al., 2018; ntsiea, 2019; rhoda et al., 2014; sherry, 2014; world health organisation, 2017). rehabilitation is still not a health priority, especially in lmics (morris et al., 2021). the unmet rehabilitation needs are further compounded in lmics (ntsiea, 2019; rhoda et al., 2014; world health organisation, 2017). global research on aphasia and rehabilitation shows that unmet rehabilitation needs of persons with aphasia may be attributed to various factors. the factors include the shortage of rehabilitation healthcare professionals such as physiotherapists, occupational therapists and speech language therapists (bernhardt, urimubenshi, gandhi, & eng, 2020; khoza-shangase & mophosho, 2018). context-specific factors include the cost of travelling to healthcare facilities to access services (masuku et al., 2018), cultural interpretations of aphasia which influence health-seeking behaviours (masuku et al., 2018; penn & armstrong, 2017), spiritual beliefs (masuku & khoza-shangase, 2018), limited knowledge of rehabilitation services (aenishanslin, amara, & magnusson, 2020; masuku et al., 2018), limited number of stroke units which are almost exclusively situated in urban areas (taylor & ntusi, 2019) and the cost of rehabilitation and transportation to reach rehabilitation services (aenishanslin et al., 2020; masuku et al., 2018). persons with aphasia may have difficulty accessing health care, support groups and intervention programmes that meet their needs (worrall et al., 2016). in march 2020, lmics as well as hics declared a national state of disaster, as the covid-19 pandemic continued to spread globally. since the beginning of the lockdown in march 2020, life as we know it changed drastically. the pandemic and the national lockdown affected the movements of people across different sectors, including healthcare and social welfare (spinelli & pellino, 2020). for example, in healthcare, outpatient clinics were suspended, the wearing of masks became mandatory, caregivers accompanying patients for hospital visits were no longer allowed in the hospital and patients were asked not to come in if they presented with covid-19 symptoms (spinelli & pellino, 2020). the covid-19 pandemic has also caused multidisciplinary team meetings to be suspended or reduced and has further caused a shortage in healthcare resources, which compromises the potential high standard of care given to patients (spinelli & pellino, 2020). telehealth approaches were implemented to facilitate access to aphasia rehabilitation (jacobs et al., 2021). given the healthcare, social, psychological and other needs of persons with aphasia, the above-mentioned changes and restrictions that were brought about by the covid-19 pandemic were therefore bound to compound the already-existing barriers to rehabilitation healthcare services experienced by persons with aphasia and their families. although persons with aphasia are typically the elderly, aphasia also affects adults, making them vulnerable to the covid-19 pandemic. the covid-19 pandemic can prolong the recovery process of persons with aphasia because of the pandemic’s negative influence on aphasia rehabilitation, such as making it difficult for persons with aphasia to start or continue with therapy. it was therefore important to establish how covid-19 impacted the rehabilitation of persons with aphasia globally. it has been shown that persons with disabilities have been significantly affected and threatened by the evolving health, social and political dimensions of the pandemic (goggin & ellis, 2020). aim the aim of this study is to provide a scoping review of current literature regarding the effect of the covid-19 pandemic on aphasia rehabilitation. methods a scoping review was selected because the intention was to synthesise and map out emerging evidence on the rehabilitation of persons with aphasia in the context of compounding circumstances such as covid-19, which is relatively new (arksy & o’malley, 2005; levac, colquhoun, & o’brien, 2010; pham et al., 2014). the intention of a scoping review in this area is to provide an overview of existing literature, to identify existing gaps for further research and for the findings of the review to influence public policy and guide clinical practice. findings may also contribute to the strengthening of rehabilitation services in the context of a pandemic and inform the improvement of new adapted methods of rehabilitation that may have been implemented because of covid-19. design and steps followed in the review process an interpretive scoping literature review employing arksey and o’malley’s (2005) scoping review methodology was used. in accordance with this framework, the following steps were followed: the initial research question was developed by k.m., g.k. and n.s. relevant studies that answer the research question were identified using various search strategies and databases to avoid bias (schlosser et al., 2005). relevant studies that met the inclusion and exclusion criteria were included in the analysis. data were charted using a narrative descriptive analytical framework. data were then collated and summarised. levac et al. (2010) state that a scoping review is broad in nature, as the focus is more on the breadth than it is on the depth of literature, and thus it becomes necessary to clearly define the scope of the inquiry through a clearly defined population (aphasia patients), a clearly stated concept or interest (rehabilitation) and specified context (covid-19) to ensure a successful search strategy. in addition to the above, a clear inclusion and exclusion criteria was set and agreed upon by all three reviewers to prevent selection bias (gough et al., 2012). table 1 presents the inclusion and exclusion criteria for articles. table 1: criteria for selecting studies. data sources and search strategy a systematic search was conducted in january 2022 by three reviewers who are all rehabilitation healthcare professionals. two of the reviewers are speech language therapists who manage and conduct research on and with persons with aphasia and one reviewer is a social worker who has an interest in disability research. levac et al. (2010) advise that ideally, experts in the research subject and the scoping research methodology should be involved in scoping reviews to increase rigour. three search strategies were used to ensure that all available literature on the subject were included (davis, drey, & gould, 2009), namely (1) online database searches, (2) general internet browser via google scholar and (3) hand searches. multiple electronic databases were utilised during the search (bramer 2016). a total of seven electronic databases accessible through the university of the witwatersrand library were included in the search, namely science direct, pubmed, scopus, proquest, web of science, ebscohost and google scholar. google scholar often reports a very high number of hits compared to other databases (bramer, 2016). therefore, based on the feasibility and time required to screen each hit and because the authors believed that screening further would not produce articles relevant to the study, a theoretically informed decision was made to screen only the first 100 hits as sorted by relevance, as proposed by haddaway, collins, coughlin and kirk (2015). an additional hand search, where the two reviewers screened through the reference lists of the identified studies, was conducted to make sure that no relevant studies were missed (gough et al., 2012). the electronic databases and university library websites contained similar search terms and publication requirements. the boolean search conducted in each individual database and university website used the following search terms: ‘aphasia patients’ and ‘rehabilitation’ and ‘covid’. figure 1, an adapted preferred reporting items for systematic reviews and meta-analyses (prisma) (moher et al., 2010), illustrates the search and article selection process followed during the study. figure 1: preferred reporting items for systematic reviews and meta-analysis flow diagram for included publications. citation management and article screening all publications were imported into mendeley, a web-based reference management programme. the mendeley web-based reference management programme was used to facilitate a rigorous process of data management (king et al., 2011). the authors k.m. and g.k. were responsible for searching and screening the articles. once the articles were imported onto mendeley, duplicates were removed manually by k.m. and g.k. from there, the screening of the remaining publications was conducted collaboratively by k.m. and g.k., a process that ensured that the screening process was conducted by at least two authors (blanco et al., 2019). articles that did not met the minimum inclusion and exclusion criteria were removed first at title and then at abstract level. at both the title and abstract level, the inter-rater agreement was 100%. where discrepancies of the saved publications from the collaborative screening arose, they were discussed by the two authors until consensus was reached. full-text articles that were deemed relevant for the study post the title and abstract level were then again reviewed collaboratively by k.m. and g.k. inter-rater agreement at the article screening level was 80%, a percentage that is deemed acceptable by graham, milanowski and miller (2012). disagreements were discussed by k.m., g.k. and an independent reviewer who is well versed on review methodologies until consensus was reached. data from the full-text articles were characterised into a spreadsheet and charted according to the following headings: author and year of publications, title, focus, aims, methodology and results. once data were charted, inductive thematic analysis was employed. the analysis followed the steps proposed by braun and clarke (2006). an overview of the characteristics of the seven articles that are included in the review is provided in table 2. table 2: studies with implications for rehabilitation of persons with aphasia. ethical considerations ethical clearance to conduct this study was obtained from the human research ethics committee (nonmedical), reference number: sta_2021_41. the articles accessed and reviewed are in the public domain and thus the authors did not need permission to conduct the review. this study did, however, follow all ethical standards for a research without direct contact with human or animal subjects. results descriptive information on the studies that were included methodologies used in the seven studies included one qualitative (14%), one mixed methods study (14%), one case presentation (14%) and four opinion and position statements (58%). the qualitative design consisted of one single-subject design (n = 1), whilst the mixed methods design consisted of two surveys conducted at two different periods. the first survey was with (n = 544) speech language therapists whilst the second was with (n = 413) speech language therapists. geographically, three (43%) of the studies were conducted solely or in collaboration with researchers from the united kingdom, 29% (n = 2) were situated in the usa, 14% (n = 1) in italy and 14% (n = 1) in malaysia. thematic analysis of the seven studies included in the current study revealed that because of the inability to access full rehabilitation services as a result of the strained healthcare system, lockdown and social distancing restrictions, the rehabilitation and clinical progress of persons with aphasia was compromised (table 3). the restrictions related to covid-19 also compromised the social participation of persons with aphasia, some of which is facilitated through aphasia conversational support groups during rehabilitation therapy. caregiver involvement, which is crucial to aphasia patient care, was also limited because of social distancing restrictions. telehealth became the preferred alternative of providing face-to-face rehabilitation clinical services. however, even though telehealth facilitated the provision of rehabilitation services during the pandemic, telehealth presented with challenges as a result of patients’ physical limitations, clinicians’ knowledge and skills of using online platforms to conduct therapy and the social isolation of patients. the covid-19 pandemic affected the mental health of both patients and rehabilitation healthcare professionals, which in turn negatively influenced rehabilitation healthcare services. table 3: themes and subthemes that emerged from an analysis of the studies included in the review. discussion findings of the scoping review revealed a scarcity of literature pertaining to the influence of covid-19 on the rehabilitation of persons with aphasia in hics as well as lmics. there was evident dearth of literature on this subject in the african context, despite the high prevalence of stroke and aphasia, exacerbated by constrained access to rehabilitation and strained healthcare resources (johnson et al., 2019; ntsiea, 2019; sherry, 2014). of the publications that were deemed relevant for the study, a few discussed rehabilitation and aphasia independent of stroke, and the emphasis is on multidisciplinary rehabilitation as opposed to just reporting on speech language pathology. this is because of the close association of stroke and aphasia (khedr et al., 2020). by its nature, a stroke usually affects different areas including motor, communication, psychological and cognitive abilities, often impacting on participation and quality of life of the stroke survivor and their facilities. therefore, a team approach to rehabilitation is key. an analysis of literature revealed that covid-19 negatively impacted on the rehabilitation and the therapy progress of persons with aphasia, both at the acute and chronic stages, because of regulations imposed by states to curb the spread of the virus. regulations related to lockdown and social distancing resulted in the inability of persons with aphasia to travel to healthcare facilities to access healthcare. the number of rehabilitation sessions as well as the number of team members making up the multidisciplinary team were significantly reduced to ensure social distancing and to decrease the exposure to the virus. some healthcare facilities abruptly suspended speech therapy services. chadd, moyse and enderby (2021) agree with the findings of this study that the number of sessions were reduced in that the number of referrals to speech language therapists during the period of 2019 and 2020 in the united kingdom drastically went down as a result of disruptions to the provision of rehabilitation services by the covid-19 lockdown. although there is evidence of an exponential increase in the use of telerehabilitation as an alternative to physical rehabilitation during covid-19 (fu, burger, arjadi, & bockting, 2020), online therapy with persons with aphasia was not always successful. prior to covid-19, even though teletherapy was an available option, not all clinicians were using teletherapy. therefore, when covid-19 struck, not all rehabilitation healthcare professionals (including speech language therapists) had the necessary knowledge and skills to conduct therapy on an online platform. the success of telerehabilitation services is dependent not only on the client and type of rehabilitation therapy provided, but also on the therapists conducting the intervention (ebrahim et al., 2021). therefore, it not surprising that the lack of knowledge and skills of therapists could negatively influence access to rehabilitation for aphasia patients. this finding is also consistent with the findings from a study that was conducted by eikelboom and swanepoel (2016) where it was revealed that less than a quarter of healthcare professionals in the study had used teletherapy to conduct therapy with clients. as previously mentioned, persons with aphasia may present with hemiparesis or other motor difficulties, and they may also present with co-existing age and cognition-related problems. therefore, to ensure the success of telerehabilitation, therapists must take into consideration the recommendations by hall, boisvert and steele (2012), who propose that before assigning patients to telerehabilitation, therapists need to be aware of factors such as their communication and motor abilities, severity, chronicity and symptoms of aphasia. a study conducted by neate, kladouchou, wilson and shams (2022) agrees with the finding of this study regarding online therapy as not always being successful. neate et al. (2022) found that persons with aphasia were often distressed in online sessions for numerous reasons, including experiencing fatigue when they had to speak, challenges around framing of props and videoconferencing platforms putting group members in small tiles making it difficult to read other members’ facial expressions and turn-taking challenges. one of the key outcomes of aphasia therapy is to facilitate communication and increase participation, which is usually facilitated through group-based therapy because it provides natural and social communication (fama, baron, hatfield, & turkeltaub, 2016). group therapy also facilitated peer support networks for both the persons with aphasia and their caregivers. findings in the study, however, reveal that covid-19 restrictions negatively impacted on support groups, which resulted in patients and caregivers being isolated because they lacked opportunities to engage with others. lucas et al. (2021) support the findings of this study in that persons with aphasia were unable to access local support groups for peers, thus impacting on their ability to create peer support networks. additionally, this finding is also supported by a study conducted by hack (2021) where persons with aphasia expressed feeling lonely, missing their aphasia group therapy, having difficulties with communication and worrying about losing their group members to covid-19 after the abrupt end to their group therapy sessions. shafer, shafer and haley (2019, p. 635) submit that ‘caregivers are an integral part of the recovery process for people with aphasia, helping them to navigate outpatient rehabilitative care and reintegrate into the community after hospitalization’. however, findings of this study suggest that during covid-19, in the acute phase, covid-19 regulations may have not always allowed caregivers to be physically present during the treatment of persons with aphasia, with some caregivers required to join sessions remotely via telehealth. where caregivers were involved, they took up multiple roles and as a result they felt overwhelmed, which may have had a negative impact on their mental health. lucas et al. (2021) agree with this finding in that hospital visitations by caregivers of persons with aphasia were suspended and that the caregivers were therefore unable to be involved in the rehabilitation process of the patients. this affected the functioning of the caregivers as they felt isolated and unable to observe the progress made by their loved ones. in a study conducted in the usa with caregivers of stroke survivors in an inpatient rehabilitation where visitations were suspended (sutter-leve, passint, ness, & rindflesch, 2021), it was revealed that caregivers were concerned about the rehabilitation of their loved ones in their absence and expressed uncertainty about their loved ones’ rehabilitation progress and being unable to observe them during therapy and nursing care. additionally, the restrictions of the covid-19 pandemic put strain on the caregivers and their loved ones’ relationships (bakas & commiskey, 2021). this finding is further agreed upon in a study by lee et al. (2021) in that the caregivers expressed that they were physically exhausted and were experiencing psychological distress because of concerns about exposing their loved ones to covid-19, the additional workload and taking up the role of rehabilitation therapists during the pandemic. conclusion findings from the study suggest the need for rehabilitation healthcare professionals to pursue innovative ways in which aphasia rehabilitation support and conversational programmes can still be made accessible to persons with aphasia despite the limitations brought about by covid-19 or any other pandemic or circumstance that may hinder face-to-face patient contact. group rehabilitation therapy is important for facilitating conversations as well as overcoming conversational barriers that persons with aphasia and their families experience. conversational groups create a social interactive environment which is ideal for practising communication and participation, which are good for the emotional and mental well-being of persons with aphasia and their families. telerehabilitation provides an alternative means to continue patient rehabilitation care, including online aphasia intervention and conversational groups. however, in order for telerehabilitation to be successful, special consideration need to be made for the physical and communicational needs of the person with aphasia and their family. the authors would go as far as to argue for contextual relevant consideration such as data costs, connectivity challenges because of poor infrastructure, health and digital literacy, which are mostly experienced in lmics. the above-mentioned factors mostly experienced in lmics may not have come through in the results of this study because of the paucity of literature of the subject as it pertains to aphasia rehabilitation during the pandemic. however, they are a reality in these contexts, and they have the potential to impede the delivery of rehabilitation services. studies on the subject from lmics are needed so as to shed some light onto the current telerehabilitation trends when managing persons with aphasia so that context-specific solutions can be forged. as the global need for telerehabilitation continues to increase, it is therefore necessary to have a rehabilitation healthcare workforce that possess the necessary knowledge, skills and experience, in telerehabilitation. there is a need for renewed and deliberate efforts to integrate telerehabilitation into the academic curriculum for current and future rehabilitation healthcare students. current rehabilitation healthcare professionals can enhance their telerehabilitation skills through continued professional development activities. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions k.m. and g.k. were involved in the conceptualisation, data collection, data analysis and writing up. n.s. was involved in conceptualisation and data extraction. funding information the authors thank the national institute for the humanities and social sciences (nihss) for providing financial assistance for the publication of this manuscript. data availability the data that support the findings of this study can by made available by the corresponding author, k.m., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references aenishänslin, j., amara, a., & magnusson, l. 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(2020). malaysia stroke council guide on acute stroke care service during covid-19 pandemic. medical journal of malaysia, 75(3), 311. abstract background and rationale a framework for revisioning speech language therapy services research questions method results discussion conclusion acknowledgements references about the author(s) bea staley college of indigenous futures, education and the arts, charles darwin university, darwin, australia ellen hickey school of communication sciences and disorders, dalhousie university, halifax, canada david rochus yellow house health and outreach services, kisumu, kenya duncan musasizi yellow house health and outreach services, kisumu, kenya rachael gibson yellow house health and outreach services, kisumu, kenya citation staley, b., hickey, e., rochus, d., musasizi, d., & gibson, r. (2021). successes and challenges of speech language therapy service provision in western kenya: three case studies. south african journal of communication disorders, 68(1), a838. https://doi.org/10.4102/sajcd.v68i1.838 original research successes and challenges of speech language therapy service provision in western kenya: three case studies bea staley, ellen hickey, david rochus, duncan musasizi, rachael gibson received: 29 apr. 2021; accepted: 18 july 2021; published: 27 sept. 2021 copyright: © 2021. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: the need for communication-related services in sub-saharan africa to support individuals experiencing communication disability is a longstanding and well-documented situation. we posit the inequities highlighted by coronavirus disease 2019 (covid-19) make this a relevant time for speech language therapists and the professional bodies that govern us to broadly consider our roles and practices in education, health and disability in local, national and global contexts. objective: to illustrate what services developed with local knowledge can look like in kenya in order to promote dialogue around alternative speech language therapy models, particularly in contexts where there are insufficient services, few trained speech language therapists and limited structures to support the emerging profession. method: this article examines three clinical case studies from western kenya, using a conceptual framework for responsive global engagement. results: service needs in western kenya well exceed a direct one-on-one model of care that is common in the minority world. the service delivery models described here emphasise training, skills sharing and engaging the myriad of communication partners available to individuals with communication disabilities. conclusion: we offer up these case studies of collaborative practice as contextual realities that may be present in any speech language therapy programming in under-resourced communities. we dispel the idea that success in this work has been linear, progressed on planned time frames or come to fruition with targeted goal attainment. the fact that our relationships have endured in these communities since 2007 is our primary success. keywords: speech language therapy, kenya, collaboration, service delivery, sustainability. background and rationale the world report on disability (who, 2011) estimates that more than a billion people live with disability, including 95 million children, and that disability prevalence figures are increasing due to chronic health conditions. hartley and wirz (2002) estimated that the proportion of people with communication disability is somewhere between 25% and 49% of this population, while olusanya and okolo (2006) inferred that about 40 million of the estimated 115 million children not attending school globally have communication disorders and other disabilities. there is a notable discrepancy between the prevalence figures for individuals with disability and the rehabilitation services available (who, 2011). the dearth of speech language therapy (slt) services in sub-saharan africa in relation to the region’s population, however, is certain (bunning et al., 2014; wylie et al., 2016b), as khoza-shangase and mophosho (2021) state we have a ‘known demand versus capacity challenge’ (p. 1). this remains despite the knowledge that communication access is a stated human right (mcleod, 2018; united nations general assembly, 1948). the global covid-19 pandemic has made explicit the interconnected nature of the planet. we have seen and felt local impacts on our own well-being and communities due to global events and decision-making. how international governments responded and reacted to the covid-19 outbreak had a palpable effect on our daily lives. we have also seen, via the media, the inequity of healthcare service availability and accessibility in both minority and majority world contexts (e.g. roy, 2020; yashadhana, pollard-wharton, zwi, & biles, 2020). it is a relevant time for speech language therapists and the professional bodies that govern us to broadly consider our roles and practices in education, health and disability in local, national and global contexts. if communication is a human right, and speech language therapists possess the skills to meet the needs of individuals with communication difficulties, there is surely an obligation to critically engage in conversations to ameliorate the service disparities in our communities and around the world (hartley, 1998) to re-imagine and re-vision the possibilities for the profession (khoza-shangase & mophosho, 2021). as mcleod (2018) notes, ‘the importance of communication rights goes beyond just enabling freedom of opinion, expression and language. once these rights are realised, people are more readily able to realise other human rights’ (p. 4). the development of more communication-related services in sub-saharan africa to meet the needs of individuals with communication disability is a longstanding, documented need (hartley & newton, 2009; olusanya, ruben, & parving, 2006; pillay & kathard, 2018; wylie, mcallister, davidson, & marshall, 2013). this need is currently being met in various ways, including the visible growth and presence of the profession in countries like zambia (bright & selemani, 2017), uganda (barrett & marshall, 2013; marshall & wickenden, 2018), kenya (e.g. staley et al., 2019), rwanda (mukara et al., 2017) and ghana (wylie et al., 2016a, 2017). the provision of services is also being met through a proliferation of minority world – majority world partnerships (e.g. staley et al., 2019, 2021; wylie et al., 2016a). however, authors such as khoza-shangase and mophosho (2021) and pillay and kathard (2018) urge us to critically consider how slt services are provided to better meet the needs of individuals experiencing communication disabilities in african contexts. they highlight that many of the services currently offered are colonising: a reduplication of minority world cultural ideals, structural racism, language socialisation and practices delivered in transported models of ‘service exportation’ (hartley, 1998, p. 278). the purpose of this article is to illustrate what services developed with local knowledge can look like in kenya. the aim of this article is to promote dialogue around slt practices, particularly in contexts where there are scant services, few trained speech language therapists and limited structures to support the emerging profession. a framework for revisioning speech language therapy services pillay and kathard (2018) as well as hyter (2014) propose frameworks for the slt profession, challenging traditional conceptualisations of the field, which are based on epistemologies and theories developed around white middle class experiences and understandings of the world. here, the authorship team describe our ongoing clinical collaboration between minority and majority world speech language therapists. we use hyter’s framework (2014) for responsive global engagement to share work that occurred in western kenya between 2007 and 2020. hyter’s (2014) framework guides speech language therapists to consider social structure factors that influence the availability of and access to slt services and to be aware of and to consider diverse worldviews in our clinical practice. hyter (2014) provides a structure for thinking about the contextual factors that impact the outcomes of our services, particularly for clients from culturally and linguistically diverse backgrounds, and to consider the factors that impact availability and sustainability of slt services in global contexts or marginalised groups in our own countries (hyter, 2014; pillay & kathard, 2018). hyter (2014) posits that in order to develop sustainable and culturally relevant slt services with groups of people from culturally and linguistically diverse backgrounds, we must develop a better understanding of the macro level social structures that impact people (e.g. historical, cultural, economic, and political factors). this broader understanding, or world literacy, allows clinicians to take a broader view of clients’ and families’ contexts. the result is responsive global engagement, which is ‘an ongoing process of self-reflection and reciprocity’ (hyter, 2014, p. 115) that involves collaborative and sustainable work with communities from different parts of the world. furthermore, there are four constructs associated with the process of responsive global engagement: global humility, global self-awareness, global knowledge and global reciprocity (hyter, 2014). these constructs promote self-awareness of our own cultural assumptions and views, as well as an openness to learning about other cultures, knowledge and the contextual conditions of our clients and families. they guide us in modifying our practices to better match the client and family’s beliefs and values, to build more relevant and sustainable slt services. that said, it is necessary to understand that responsive global engagement is a process rather than an endpoint and depends on the iterative work of theory, collective direct action, critical reflection, creation of new knowledge and practice change and so on in cyclical fashion (hyter, 2014). this article examines three clinical case studies, using hyter’s conceptual framework for responsive global engagement (see hyter, 2014; hyter & salas-provance, 2019) to elucidate our thinking about the local context, practices and key elements in our ways of working. this framework supports explicit thinking about power, epistemology of practice and the best ways to meet the needs of children and families in western kenya’s given macrostructural factors within the context. these case studies were generated from our collective memory of each project and a narrative lens where ‘meaning is constructed through story’ (ely, vinz, downing, & anzul, 1997, p. 63). we understand that through the iterative process of reflecting, writing and editing this narrative together as a group of collaborators with varying viewpoints and worldviews, we make deeper meaning of our work and understand better our working relationships as clinicians and authors. thus, this article is a co-construction of local and global knowledge that came out of conversations and work among the authors. through writing, we understand better each other’s perspectives, goals and intentions (ely et al., 1997). research questions although qualitative in nature, this work intended to answer the following questions: what do we learn about the successes and failures of our slt work in western kenya by analysing case studies of our practice? how can we use this information to improve clinical practices? how do we ensure that the resources, perspectives and knowledge of all partners is being fully utilised to benefit individuals’ experiencing communication disability? method case study design a qualitative case study design (stake, 2005) was used to examine the three different types of work being engaged in by one non-governmental organisation (ngo) in western kenya. case study is not ‘a methodological choice but a choice of what is to be studied’ (stake, 2005, p. 443). cases are necessarily bound by time, place and activity (stake, 2005). we explored these three slt cases, which describe collaborations between one ngo that supports slt development and three government-funded health and education institutions that took place between 2007 and 2020 (see table 1). we describe the locales, projects and their trajectories to date and share our experiences as collaborators in slt service provision over the years. the case studies of collaborative practice presented here were developed to both contribute to the literature on what slt practices can look like in situ as well as provide the authorship team with an opportunity for reflection, discussion and improvement. table 1: characteristics of case studies. this case study approach (stake, 2005) paired with hyter’s (2014) conceptual framework for responsive global engagement were used to explore the collaborative partnerships for developing slt services in western kenya. this approach was used because (1) we could not control or manipulate the cases studied; indeed these cases are presented in retrospect and (2) we aim to describe the contextual conditions and how/why each of the projects was more or less successful in developing slt services (baxter & jack, 2008; yin, 2003). qualitative data from these reflections were triangulated with data from email communication, files, organisational records and conversations amongst the clinicians and researchers about the slt projects over the past 13 years. as we created the case descriptions, reviewed documents and recollections, we came to better understand the impact of collaboration on our activities. furthermore, this collaborative writing process was an opportunity for bi-directional, culturally responsive learning (hyter, 2014). ethical considerations this article followed all ethical standards for research without direct contact with human or animal subjects. results case 1: collaborating with government funded education services kilima children’s community centre (all place names are pseudonyms) was a project grounded in a prior working relationship between a foreign but locally based speech language therapist (the first author on this article) and a community professional trained to work in the kenyan disability sector. the team at the government-funded education centre wanted to expand their centre’s service capabilities based on the community’s needs. specifically, they wanted a space that caregivers and their children could comfortably gather for therapy services and information sharing. in 2007, this team led the process to renovate an onsite government building that was being used intermittently to store grain. the team identified a grant opportunity from a kenyan telecommunication company to fund the refurbishment and led the application process, while the speech language therapist’s role was encouragement and editorial. the grant provided usd $20 000 to repair the roof, windows and doors to transform the building into a community therapy centre for children with disabilities. a second grant was obtained by the speech language therapist from a consulate in nairobi to build two wheelchair accessible pit latrines, as well as to buy resources, therapeutic equipment and furniture. the building was then used for a cerebral palsy clinic, occupational therapy (ot) services and, later, slt services. because of the funding needed to support the new services, a local community based organisation (cbo) was established to run the project. the cbo worked in partnership with an international ngo that was set up in the united states to fund monthly operating costs, including utilities for the building, salaries for the occupational and speech-language therapists, fuel for the motorbike for community outreach and funds for parent trainings. though the funding for the kilima project has largely come from overseas fundraising, the way services have been provided has always been informed by the needs of the community and within the boundaries of a collaborative relationship. this has not always worked, however, in terms of continuity of care. in 2012, a change in leadership at the district level resulted in a change in local administrative staffing and the collaboration ended swiftly and with tension. then in 2017, the partnership was restoked tentatively when local administrative staffing changed once again. during the interim, when allied health services were not available, parents who lived in the area reportedly kept requesting the services that they had seen emerging in their district between 2012 and 2017 prior to the dissolution of the collaboration. the relationship between the speech language therapists working for the ngo and colleagues working at kilima children’s community centre was rekindled when the slt team approached the kilima team and requested the use of the centre to see an adult client who was unable to make the long trip from their home to the speech language therapist’s practice. the team willingly agreed and requested that slt services be made available for any clients on the centre’s waiting list. since that time, the ngo provides 1 day of slt services at the centre per week under a memorandum of understanding. ongoing stigma and shame around disability in kilima present as a challenge for kilima children’s centre. however, this community has a strong network of involved parents, and the physical location of kilima children’s community centre and access to public transport makes it an ideal place for clinical service provision and trainings. the staff at the centre have been working to shift local attitudes to reduce shame associated with having a child with a disability. in the years that this collaboration has both worked and not worked, there have been notable impacts at the client/family and community levels, including a growing awareness about the slt profession and the scope of slt services. kilima children’s community centre staff reported several improvements, as follows. at the client/family level, more families coming to the centre for assessment and families receiving services have reported increased confidence in their ability to support their child’s development. at the community level, improvements were made for data keeping for children with disability in the county by centre staff. stigma and shame around disability appear to have reduced in the community per staff report, though no measurable indicators for this are available. recent cooperation from county officials in education has been unprecedented, enabling teachers to attend trainings around communication disability and extending slt education support for street connected children with special education needs and communication disabilities. further, word has travelled, and children are often referred from neighbouring counties. the partnership is far from perfect, however. one difficulty is finding ongoing funding to support the community-based work that speech language therapists and the kilima children’s centre staff used to do jointly. further, for a variety of reasons (e.g. less time available for meeting, increased caseloads), there is less collaboration between the two organisations with individual clients, so families no longer receive an interprofessional rehabilitation approach. case 2: collaborating with hospital services in 2007–2008, a foreign-locally-based speech language therapist (b.s.) and a local hospital-based occupational therapist initiated a transdisciplinary relationship that allowed for slt service provision within the ot department at the provincial hospital in ziwa. in return for slt service provision for their outpatient referrals, the ot department provided a small room to serve as a therapy room and office. the presence of a speech language therapist presented opportunities for in-house professional development about communication disabilities and slt practices. the ngo’s involvement in hospitals grew over time, driven by speech language therapists (d.r., d.m. and r.g), who provided slt trainings and clinical services in the hospital 1 day per week. working inter-professionally with occupational therapists afforded an opportunity to build awareness of the slt scope of practice and the services that could be offered appropriately to patients. since late 2015, the ngo has funded an slt position within ziwa hospital 2 days per week. however, increase in referrals has caused staffing pressures, as the ngo has a finite number of clinical days assigned to cover both inand out-patient units, and this impacts the dosage and intensity of service provision available for clients. the inter-professional partnership between the slt and ot departments has been mutually beneficial, providing for collaborative management of children with a variety of diagnoses, creation of a support group for stroke patients with aphasia and management of swallowing and feeding difficulties. over time, this collaboration has extended to supporting ot and clinical psychology students from the training college on their rotation through the ot department. in turn, the hospital occupational therapists have provided similar individualised support to international slt students on clinical placement with the ngo. another neighbouring hospital collaboration was successful to start, but not successful in the long term. between 2012 and 2016, the ngo worked in kijiji, a rural district hospital. in its prime, this inter-professional collaboration allowed speech language therapists the opportunity to liaise with hospital-based occupational therapists, physical therapists, nurses, nutritionists, doctors, clinical officers, the orthopaedic technologists and biomedical engineers. the speech language therapists developed relationships with individual nurses, who over time learned what speech language therapists do and started referring in-patients with feeding difficulties or those experiencing communication disability. the speech language therapists were able to leave feeding plans for nurses or the family to follow. they were also able to work with nutritionists around dietary needs and types of food clients would eat. the speech language therapists also referred clients for malnutrition and later the nutritionists referred clients with feeding difficulties. moreover, speech language therapists referred clients who presented with epilepsy, fevers or acute medical conditions to the doctors and clinical officers on site. a parent liaison officer (employed by the ngo) would follow up on these referrals with parents, alleviating any anxiety about the appointment and serving as a case manager for the family. the parent liaison officer also supported the parents to implement any recommendations and strategies and reminded families of upcoming appointments. this partnership ended unceremoniously when the space allocated to slt services was reallocated to a county government official, and the clinic equipment and furniture were found piled up in the hospital corridor. although this work involves three government hospitals in the region (two relationships described here), the work is funded by international donations. this is due to national issues around the development of the slt profession in kenya and lack of government recognition while the association of speech and language therapists kenya works towards a scheme of slt service, or an agreement around the inclusion of slt services into the hospital’s patient billing system. because the work does not generate revenue or cover staffing costs, resourcing a hospital-based service remains an ongoing challenge. that said, the benefits of hospital-based relationships are undeniable. speech language therapists’ contributions to a rehabilitation team are contextualised, resulting in increased awareness and referrals for slt services. communication between the speech language therapists and the hospital administrators improved over time, allowing access to wards and clinical space, resulting in invitations to continued medical education meetings attended by most medical and rehab staff. this increased professional visibility of speech language therapists and consequently increased awareness of communication and swallowing disabilities and an increase in appropriate referrals to slt services. ward nurses and doctors directly started referring in-patients to speech language therapists. case 3: collaborating with the community two elements of the clinical slt work that have developed successfully and innovatively in the past few years are the creation of a position of parent liaison officer and the implementation of a community-based service model known as communication camps (chance for childhood, 2015). these are presented as a third case study because they are co-occurring practices. both the position of parent liaison officer and the communication camps have positively impacted the community relationships and case studies already described in this article. parent liaison officer the creation of a parent liaison officer position evolved out of a relationship between the ngo’s speech language therapists and a parent of a child with disabilities who had been receiving slt services. the parent was hired as a parent liaison officer to work with parents alongside the team’s speech language therapists. the parent liaison officer’s many roles were designed for a person who could speak to first-hand experience with slt services. the parent liaison officer works with parents who are referred for slt services and she attends slt clinics to support parents and answer their questions. the parent liaison officer runs parent support groups for parents of children experiencing communication disability and uses her social capital, community connections and networks to reduce the stigma around communication disability. she also case manages for families engaged with hospital-based services and helps to identify children that may have been overlooked for referral. perhaps most importantly, the parent liaison officer engages in the crucial work of expectation management. caregivers are often looking for a cure and expect that the speech language therapist will be able to ‘fix’ their child, make them talk or promote the immediate recovery of a child’s speech. when this does not happen, there can be confusion about the purpose and process of slt practices. this parent liaison officer role has been transformative for the organisation by increasing parent buy-in and the number of return appointments and new referrals. communication camps the ngo has also begun training parents of children with disabilities through a service delivery model called communication camps (chance for childhood, 2015). communication camps are for parents and children with severe communication disability and/or eating and swallowing difficulties. families are invited to participate when they have limited access to health and therapy services, have not had a similar training before and have a willingness to learn more about their child’s disability and associated difficulties. often the children are identified through community extension health volunteers, kilima children’s community centre, the out-patient department of kijiji hospital and word of mouth. referrals often exceed the capacity of the team. the communication camp training curriculum was developed by and is continually refined by the speech language therapists and the parent liaison officer based on experiences and stakeholder feedback. communication camps are funded through international grants and attended by parents, children, two speech language therapists and the parent liaison officer. communication camps cost usd $150 per family. this cost includes the 2-day camp costs, initial identification of the child and family and 20 follow-up visits of the child and parent as part of a support group. to date, the teams have run 15 communication camps for 107 caregivers of children with disabilities. after the communication camp, caregivers are provided follow-up support by the parent liaison officer. follow-ups are home visits, support group visits or phone calls. the speech language therapist work with the family intermittently, providing strategies that supported the child’s progress. the communication camps have been one of the most successful and innovative programmes trialled by the ngo to meet the needs of children experiencing communication disability in the community. feedback from the communication camps and parent support group is that parents are better able to view their child as more than their disability, as well as understand their child’s disability and how this impacts their child’s participation in the community. the success of the ngo funded camps has been due to the multifaceted approach from the kilima children’s community centre team, the parent liaison officer who works with the parent support group and the speech language therapists provided by the partnering ngo. discussion service needs in western kenya well exceed a direct one-on-one model of care that is common in the minority world (hyter, 2014; pillay & kathard, 2018). the community contexts described here necessitate service delivery models that emphasise training, skills sharing and engaging the myriad of communication partners available to individuals experiencing communication disabilities. optimally, all slt clinical service models are developed in response to community context and need (barrett, 2016; hyter, 2014) ‘or ‘contextual realities’ (khoza-shangase & mophosho, 2021, p. 4). locally developed service delivery can account for the structural factors in place, including historical, political, economic and cultural structures that present barriers or supports for development of slt services (hyter, 2014; khoza-shangase & mophosho, 2021). these case studies describe some of the successes and failures in developing slt services in western kenya and have been interpreted using hyter’s (2014) framework of responsive global engagement. we structure the discussion by answering our research questions: 1. what do we learn about the successes and failures of our work in western kenya by analysing case studies of our practice? at the kilima children’s community center, clinical services evolved over time, in response to varying factors. a need was identified within the local context and services developed based on the preferences of the client group (families of children with disabilities), taking into account the social factors that made this a desirable context for services (hyter, 2014). despite strong relationships in the community and an understanding of the historical and socio-cultural context, however, the slt services at the kilima children’s community centre stumbled. changing political landscapes and administrative positions will always be a challenge when working outside of governmental health and education structures. even when collaborative interprofessional practice is working well, economic and political factors can impact the sustainability of clinical work. local social structures supported the growth, the demise and then the redevelopment of this collaborative project. kilima is an optimistic case study for our team, as it demonstrates that over time some projects may cease then later resume, possibly in a new format and with new stakeholders. as an ngo and partnering organisation, staff report that they could not have foreseen the varying dynamics that ended the partnership between the organisations in 2012. but, political factors, such as changes in governmental positions at district and regional levels, can completely shift the context, so that active and viable projects become untenable. the demise of the collaboration at kijiji hospital was also related to macrostructural or institutional administrative changes outside of the collaboration and largely unrelated to the clinical work. hospitals are highly contextualised and bureaucratic places and support within the administrative structures is essential for the development and continuation of any successful partnership. 2. how can we use this information to improve clinical practices? our noted successes and failures, big and small, are a part of an ongoing and somewhat cyclical story as per responsive global engagement (hyter, 2014). a programme went well until it no longer did; changes were made, and things improved, or they did not. we explore both aspects of the work, so that the lessons learned and the processes we engaged with can inform not only ourselves, but other practicing clinicians working in similar contexts. these case studies demonstrate the need to build flexibility into the way service models emerge. developing slt services in rural east african contexts depends on the skills, attitudes and motivations of the individuals available in a community at any one time. in these cases, local context was imperative and slt options were determined by the available space, expertise, support and overall energy for slt service provision in the community. the need in the region is extensive, but the reason this ngo continues to work in these distinct locales is because of these situated collaborations, partnerships and people. there have been other communities where projects were initiated, but there were not enough vital ingredients for service delivery to get traction. the case studies illustrate that different slt services will eventuate in different localities, and that positive, reciprocal relationships based on professional respect and valuing of differing stakeholder knowledge and values is imperative (but no guarantee) for successful and ongoing projects. innovation for the sake of novelty is unnecessary. we described a parent liaison model developed by a parent advocate who identified how she could improve the quality of service by supporting parents in accessing and understanding slt service delivery. we also described cases of hospital work and community centre work that evolved alongside functioning therapeutic services and teams. slt was a value-added rather than a new or separate service. while case 3 works as a model of service delivery, both case 1 and case 2 illustrate that the long-term viability of slt service provision by an outside provider is questionable. the slt needs of a hospital would be best met by an integrated slt department. however, the identified needs of patients must be met to justify the professional presence of speech language therapists on site. we optimistically believe that by demonstrating the need for and benefits of slt services in hospitals to hospital administrators, other health care professionals will support crucial upward pressure to create a scheme of service for slts nationally and create billing structures locally. in kenya, despite the initiation of slt training programmes, increased awareness of the need for slt services and ongoing slt service provision by african trained and foreign trained speech language therapists, these 13 years have not seen the development of government funding for slt positions or services. professional traction that can allow for growth of slt service provision to the broader rural kenyan population is difficult to see. funding does not drive programme development or service delivery in these collaborations but does place constraints on what is feasible for ongoing growth. 3. how do we ensure that the resources, perspectives and knowledge of all partners is being fully utilised to benefit individuals’ experiencing communication disability? in these cases, allied health professionals (speech language therapists, occupational therapists) and non-professionals have engaged in models of practice that grew from local understanding about community needs and reciprocal relationships that developed trust over time. the local innovations of communication camps and the role of the parent liaison officer demonstrate responsive global engagement by considering the local structural factors and approaching problem solving with global reciprocity. this allowed parents and families to be the experts of their children and their needs and gave them a realistic ability to engage in services in ways that supported their child while accounting for their access to resources and their other responsibilities. that clinical services exist, have sustained and have developed in ziwa speaks to the ways that the arrangement is mutually beneficial (e.g. hospital patients receive services, slt students have placement opportunities). the sustained nature of the partnerships where services are developed alongside each other allows for conversations that interrogate decision-making around practices and necessitate justification of service provision. this is an opportunity to question assumptions and draw on research literature about best practice as part of the cyclical process of acting, reflecting, creating knowledge and changing practice (hyter, 2014). the kilima partnership was able to regroup because there were relationships to rekindle. both organisations had continued to work in parallel until it was possible to work together again. solutions come to light in understandings developed during conversations among educators, occupational therapists and speech language therapists, with all team members being willing to respect multiple perspectives to come to collaborative decisions. the team described here is used to considering the resources, time and energy available to explore feasible options for expanding their work. they have moved well beyond any notion of a ‘right way’. we believe that the development of services in the majority world should be focused on local knowledge, including language and culture. in places like kenya where slt services are relatively new and the professionals (even when local or from the region) have been trained by foreigners, the curriculum is often disconnected from local language(s), culture and norms. for example, in the past, the clinical teams described here spent much time talking with parents about play and encouraging dyadic parent-child play, although this is not a typical interaction for kenyan parents. the east african clinicians believed that if they just kept showing parents the importance of play (as had been taught to them in their training programme), parents would change their behaviour, which led to frustration on both sides. duplicating socially and culturally embedded ideas from the minority world about language, interaction and play, and the role of the parent in their child’s early development and education does not result in culturally responsive practice (hyter, 2014). speech and language therapists and communication partners of individuals experiencing communication disability need to recognise and acknowledge there are differences across cultural contexts (e.g. rogoff, 2003) and adapt their recommendations accordingly. as the clinical team described in this article moves along the path from global humility and self-awareness towards global knowledge and reciprocity (hyter, 2014), they continue to observe and listen to their families, to be able to better adapt and develop more culturally responsive services. now the team takes a more parent led approach with a focus on daily routines unless the parent indicates a specific interest in engaging their child in play. our key message in this work is that to begin to meet the needs of individuals experiencing communication disability in under resourced communities, we need to initiate more creative, nuanced and progressive service models. as aptly stated by khoza-shangase and mophosho (2018), we need to consider ‘next practice’ not just ‘best practice’ (p. 6). as colleagues, we have chosen to take nuanced perspectives of the situation, and each other’s realities, to deeply consider issues of power and control in decision-making. we are not always in agreement about the way to proceed. we work, live and write not from a dichotomous place of right and wrong, good and bad but a space of differing cultures, worldviews and ways of knowing. we strive for global reciprocity, empathy and understanding (and to realise what we do not understand and may never understand) with each other, clients and their families as a way of being together. experience and stakeholder feedback have shifted the clinical approaches we have taken over time to attempt more sustainable and locally responsive practices. these case studies provide an opportunity to reflect and to examine the lessons learned from multiple perspectives in real-world contexts (hyter, 2014) and are not intended to be replicated. that said, we expect that the clinical experiences described here will resonate with speech language therapists in sub-saharan african contexts and anticipate that the learnings might be fruitful for thinking about service delivery possibilities in these settings. for this collaborative team of clinicians, writing together enables us to articulate our current practice and consider what works and what does not. it is a work of knowledge production that has occurred over 13 years. our lives as an authorship team have changed in large and small ways over this time, as have our clinical skills and our global humility and knowledge (hyter, 2014) about the lives of families with children experiencing communication disability in kenya. while our goal is to develop sustainable slt services for the region, this article is in some ways a small celebration of what is currently being achieved given the limited resources. the collaborations described here have enabled more children and adults experiencing communication disabilities to access services, and those services are now better tailored to meet their needs than they were in the past. conclusion we need change in the slt profession to meet the needs of individuals experiencing communication disability globally. equitable health and education provision, particularly in post-colonial countries where people were historically exploited and/or marginalised to suit those in power, present us with complicated contemporary contexts and situations that have been termed as ‘wicked problems’ (gwynne & cairnduff, 2017). the epistemologies, research and curriculums that lay the foundation for slt practice do not reflect the multilingualism or multiculturalism of the communities many of us work in. thus, challenges in establishing sustainable, culturally responsive service delivery models are inevitable. disappointments, failures and struggles are guaranteed, but these too are a part of the story. knowledge of both the successes and failures is necessary if we seek innovation in service delivery globally. we offer up these case studies of collaborative practice as contextual realities that may be present in any slt programming in under-resourced communities. we dispel the idea that success in this work has been linear, progressed on planned timeframes or come to fruition with targeted goal attainment. the fact that our relationships have endured in these communities since 2007 is our primary success. in our work together and our collective histories, there have been notable disappointments, major stumbling blocks and the occasional win. that said, we have impacted individual lives. we have delivered services, organised parent and teacher trainings, provided education about communication disability and alleviated difficulty. however, the positives should not be overstated. if the goal is to provide culturally and linguistically responsive slt services to every individual experiencing communication disabilities, then we all have a long way to go. acknowledgements the authors would like to acknowledge the collegiality, collaboration and contributions of wilson lugalia and wellington manyola to this work. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions overall, this article was produced through a collaborative writing process, which was an opportunity for bi-directional, culturally responsive learning between the authorship team. this writing of this article was led by b.s., while e.h. helped frame the case studies. d.r., d.m., and r.g. contributed at each stage to the conceptualising, writing, and editing of the article. funding information the work described in this manuscript has been funded by various volunteers, agencies and individuals over the past 13 years. none of this funding came with ‘strings attached’ or academic obligations. data availability the data that support the findings of this study are available from the corresponding author, b.s., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and reflect the position of the authors in the work that they do. references barrett, h. 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(2020). indigenous australians at increased risk of covid-19 due to existing health and socioeconomic inequities. the lancet regional health – western pacific, 1, 100007. https://doi.org/10.1016/j.lanwpc.2020.100007 yin, r.k. (2003). case study research: design and methods (3rd ed.). thousand oaks, ca: sage. article information authors: natalie schellack2 anna m. wium1 katerina ehlert1 yolande van aswegen2 andries gous2 affiliations: 1discipline of speech-language pathology and audiology, sefako makgatho health sciences university, south africa 2department of pharmacy, sefako makgatho health sciences university, south africa correspondence to: natalie schellack email: natalie.schellack@ul.ac.za postal address: po box 195, medunsa 0204, south africa dates: received: 26 june 2014 accepted: 04 apr. 2015 published: 17 june 2015 how to cite this article: schellack, n., wium, a.m., ehlert, k., van aswegen, y., & gous, a. (2015). establishing a pharmacotherapy induced ototoxicity programme within a service-learning approach. south african journal of communication disorders 62(1), art. #96, 7 pages. http://dx.doi.org/10.4102/sajcd.v62i1.96 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. establishing a pharmacotherapy induced ototoxicity programme within a service-learning approach in this original research... open access • abstract • introduction • ototoxicity: the need for monitoring • what is ototoxicity? • establishing an ototoxicity clinic as service-learning context • challenges and strengths       • experiences of the stakeholders       • content taught • role of the facilitators • attendance, and learning and teaching opportunities • logistics • conclusion • acknowledgements    • competing interests    • authors’ contributions • references abstract top ↑ pharmacotherapy-induced ototoxicity is growing, especially in developing countries such as south africa. this highlights the importance of ototoxicity monitoring and management of hearing loss. this article focuses on the establishment of an ototoxicity clinic as a site for the implementation of a service-learning module in the audiology programme. the clinic offers a unique opportunity of collaboration between pharmacists and an audiologist where pharmacotherapy-induced ototoxicity is uniquely monitored. the sefako makgatho health sciences university (smu) provides training to both the disciplines audiology and pharmacy. the main aim of this article is to describe how ototoxicity monitoring is implemented in the curriculum within such an academic service-learning approach. through service learning students develop a deeper understanding of course content, acquire new knowledge and engage in civic activity. it simultaneously provides a unique opportunity for interdisciplinary collaboration between the disciplines of audiology and pharmacy. the objectives for this programme are therefore to facilitate learning and to provide a service to the local community by identifying, preventing and monitoring medicine-induced hearing loss in in-hospital and out-patients; as well as to establish inter-disciplinary collaboration between the disciplines and stakeholders for more effective service delivery. the constant interdisciplinary teamwork between the audiologist, pharmacist, physician and nursing staff in the wards results in best practice and management of patients with ototoxic damage. introduction top ↑ the creation of competent and caring professionals who contribute to the welfare of the country is the ultimate aim of higher education institutions (stevens, 2009). traditionally students were taught professionalism through their clinical training (scudder, 2006). it is important that students not only obtain their clinical competence through the training of splinter skills that are based on theoretical knowledge, but that they learn by applying their knowledge, and to further become competent in analysing, synthesising, and evaluating what they have learnt in the classroom (stevens, 2009). the past decade has seen several changes in teaching and learning practices. one of the paths to facilitating professional competence of audiologists is though service-learning experiences. academic service-learning (asl) is a ‘valued pedagogy for engaged campuses’ (bringle & hatcher, 2009, p. 37) and is a methodology for teaching and learning that facilitates the application of knowledge and reflecting on it, while simultaneously addressing community needs. through asl, students develop a deeper understanding of course content, acquire new knowledge and engage in civic activity (colby, ehrlich, beaumont & stephens, 2003). this article focuses on a newly established ototoxicity clinic in a semi-rural context where students obtain hands-on learning experiences in ototoxicity monitoring by simultaneously providing a service to the community. the main aim of this article is to describe the collaboration between two disciplines (smu – department of pharmacy and the discipline of speech-language pathology and audiology) in the initiation of a pharmacotherapy induced ototoxicity clinic within a service-learning approach. ototoxicity: the need for monitoring top ↑ south africa is faced with a major challenge in terms of tuberculosis (tb), human immunodeficiency virus (hiv) (achkar, kasprowicz & wilson, 2011) and malaria (department of health, 2014). in all three of these conditions, hearing loss can be induced by the treating agents. dr george mukhari academic hospital (dgmah) specifically encounters the challenges in treating tb and hiv. one of the challenges posed by these statistics lies in the fact that multi-drug resistant tb (mdr-tb) requires the use of an aminoglycoside for an extended period of time (department of health, 2014). aminoglycoside-related ototoxicity has been well described in literature and is known to be irreversible (cheng, huth & ricci, 2011). therefore the tb burden in sa also accounts for an additional burden on the health care system of pharmacotherapy-induced ototoxicity and the resulting hearing loss in patients with tb. specific attention should further be paid to patients who are treated with ototoxic medications, as they are at risk for hearing loss. patients suffering from multi-drug resistant tuberculosis, renal failure (schacht, talaska & xie, 2011), oncology patients (handelsman, 2011), and neonates with severe infections or sepsis who are treated in the neonatal intensive care unit (cheng et al., 2011) can be classified as high-risk patient populations for possible ototoxicity. according to bratt et al., (2005) the best way to detect ototoxicity is by assessing auditory and vestibular function directly. early detection of ototoxic damage can improve the treatment outcome through minimising hearing loss progression and by counselling and rehabilitation of the patient. it also provides the physicians the opportunity to adjust the therapeutic regimen to the benefit of the patient. an effective ototoxicity monitoring programme should consist of various aspects, including specific criteria to identify ototoxicity, timely identification of the at-risk population, pre-treatment counselling regarding the potential ototoxic effect of the drug treatment, valid baseline measurements and on-going monitoring during and after the completion of the drug treatment (asha, 1994). what is ototoxicity? top ↑ ototoxicity can broadly be defined as the tendency of certain substances, either systemic or topical, to cause functional impairment and cellular damage to the tissues of the inner ear and especially to the end organs of the cochlear and vestibular divisions of the eight cranial nerves (roland & rutka, 2004). medications that may lead to ototoxicity can either cause cochleotoxicity or vestibulotoxicity, depending on their mechanism of action in terms of the ototoxicity. certain medications, e.g. aminoglycosides, have the tendency to cause both (selimoglu, 2007). cochleotoxicity may present as reversible or irreversible hearing loss, tinnitus, hyperacusis, as well as the difficulty in system may present as disequilibrium, unsteadiness when walking or ataxia, oscillopsia, nystagmus and/or vertigo (selimoglu, 2007). blockman and sinxadi (2009) consider a drug to be ototoxic if it has any toxic effects on the structures of the inner ear, such as the cochlea, vestibule, semi-circular canals and the otoliths. hearing problems can start within minutes to several days after the administration of an ototoxic drug, or it is possible that it can only start presenting several years after treatment with ototoxic medicine (de andrade, hajat & khoza-shangase, 2009). depending on the type of medicine being used as part of the patient’s specific treatment regimen, hearing loss may be reversible or permanent (irreversible). examples of drugs causing irreversible hearing loss are aminoglycosides, platinum compounds and quinine. reversible hearing loss can occur as a result of loop diuretics, salicylates and non-steroidal anti-inflammatories (blockman & sinxadi, 2009). considering that most primary care clinicians and clinical pharmacists have seen patients who have suffered from ototoxicity at some point in their career, it makes sense that audiologists should be more involved in a collaborative patient education effort with physicians, nurses and pharmacists concerning ototoxic medications (banotai, 2004). pharmacists can play an active role in identifying and monitoring ototoxicity agents, and can subsequently, where applicable, perform therapeutic drug monitoring to reduce ototoxicity (schellack & naude, 2013). audiologists often only become involved in ototoxicity-related problems after the patients stop taking medication or leave the hospital and experience hearing or vestibular problems. establishing an ototoxicity clinic as service-learning context top ↑ the establishment of the pharmacotherapy-induced ototoxicity programme ensures that there is a team approach from the clinical pharmacist, audiologist, nurse and physician in managing the patient. this service to the local community (i.e. the hospital) created a platform for an academic service-learning approach (asl), which is a form of experiential learning. a service-learning approach places equal emphasis on student learning and service to the community (bringle & hatcher, 2009). simultaneously, it aims to facilitate social responsibility. it is a process through which students develop knowledge, skills and values from direct experiences outside a traditional academic setting. well-planned supervised and assessed service-learning programmes promotes interdisciplinary learning, facilitates social responsibility, career development, cultural awareness, leadership and other professional and intellectual skills. smu provides training to both the disciplines audiology and pharmacy, and is attached to the dr george mukhari academic hospital (dgmah), which is adjacent to the campus. previously, there were no accepted clinical protocols or criteria for ototoxic change using objective measures of ototoxicity at dgmah. to this effect, two academic departments at smu (department of pharmacy and the discipline of speech-language pathology and audiology) and one clinical department (speech-language and audiology department of dr george mukhari academic hospital) initiated an ototoxicity clinic. the establishment of a programme with medicinal and audiological monitoring for ototoxicity provided the basis for developing objective protocols for monitoring ototoxic damage. the aim of the collaboration was to engage in service-learning at the dr george mukhari academic hospital by establishing a clinic to monitor pharmacotherapy-induced ototoxicity. through such a clinic a service could be provided to the patients at dgmah by identifying, preventing and monitoring medicine-induced hearing loss to in-hospital and out-patients. the objectives for this project were aligned with the criteria for asl (stacey, rice & langer, 2001) as follows: the service provided is relevant and meaningful to the hospital community, the students and the academic staff. ototoxic monitoring services have not been available to this hospital prior to the establishment of the ototoxicity clinic, and have now become an integral and necessary part of more effective service delivery. during regular staff-student meetings in the clinic, the nurses and doctors in the various units value the contribution of the students and consider their role as necessary. effective service delivery requires effective inter-disciplinary collaboration between the disciplines and stakeholders in order to provide more effective service delivery in health care. literature states that audiologists should collaborate with doctors, nursing staff and other health care professionals when monitoring a patient presenting with ototoxicity, but in current practises and existing programmes audiologists work on their own and only provide results and reports to other professionals in an inter-disciplinary approach. (dille et al., 2011). the experience enhances academic learning as it strengthens the accomplishment of module outcomes. the objectives related to patients are considered service-learning (s-l) outcomes in the curriculum. this experience facilitates interdisciplinary learning between students in the disciplines audiology and pharmacology, to obtain competence (knowledge and skills) in managing pharmacotherapy induced ototoxicity. this allows audiology students the opportunity to apply their knowledge regarding ototoxicity monitoring and to reflect on it (bender, daniels, lazarus, naude & sattar, 2006). the rotation in the ototoxicity clinic fosters students’ social responsibility as the knowledge, skills and values obtained prepare students for active involvement in future communities (bender et al., 2006) the students engage in structured reflection by completing their reflection journals to think critically about what happened at the service site and their experiences at the end of each day. they need to do this in order to plan for the next session. through this reflection they examine their own feelings, attitudes and beliefs. they further relate their learning to the module outcomes and apply their prior knowledge to conduct a more effective service in future. at the conclusion of the rotation block they complete a course evaluation sheet to evaluate the entire experience. considering the health professions act 56 of 1974 for clinical training of students in audiology, it was necessary to include aspects of prevention and identification; assessment; and management of ototoxicity. this early detection of ototoxicity will make it possible to prevent the progression of hearing loss to lower frequencies where speech perception can be greatly impaired. the department of pharmacy provides a service of evaluation and possible identification of medicines that has the potential of causing ototoxicity; with subsequent monitoring of the medicine in terms of dose, duration, levels (peak and trough) where indicated, and renal function. where appropriate, dosage adjustments are made and medicines are stopped or changed for less toxic agents. the department also developed a short course that is available on line to promote education in the monitoring of ototoxicity. pharmacy postgraduate students are also enrolled to investigate pharmacotherapy-induced ototoxicity. to this effect they collaborate with the discipline of speech-language pathology and audiology for audiological monitoring with possible identification of hearing loss. educational activities need to be evaluated to ensure that trainees will professionally benefit from them. monitoring is achieved through interdisciplinary team meetings and patient feedback. reflective journals kept by students facilitate higher level learning as they are expected to analyse and synthesise the information learnt within ototoxicity as well as prior knowledge needed from other audiological modules. the criterion for judging programmes is the extent to which it can be used to make decisions that improve the programme, which implies that the findings are valued and credible. students engage in the service-learning activity in a rotation format and the process consists of several phases: preparation, acting (service), reflecting, and lastly evaluating whether the learning outcomes and service goals were met (bender et al., 2006). the latter contributes to the effectiveness of the service provided. students are initially orientated for their asl experience firstly in the classroom by the pharmacists on the topics of pharmacotherapy and ototoxicity. secondly they are prepared by their supervisors at the clinic to become familiarised with learning outcomes and the assessment procedures. several aspects had to be considered in the establishment of such a clinic as a service-learning context (ginsberg, 2007): firstly, the learning goals in the curriculum from which students could benefit from hands-on learning experience had to be considered. these included those goals where direct interaction with clients was concerned. secondly, the specific context where these goals could be realised had to be identified. in this case, an academic hospital in a rural context that was within easy access for students appeared to be the most suitable choice. as no ototoxicity monitoring services have previously been available in this context, the patients in specific wards (nicu, paediatrics, renal, tb and oncology) could certainly benefit from such an incentive. in establishing this clinic as a vehicle for service-learning, it was further necessary to consider the types of activities that the students had to perform. with regards to ototoxicity, these include identification of the medicines prescribed and the basic mechanisms through which certain medicines can cause ototoxicity, case history, employing an audiology protocol to assess hearing abilities with regards to baseline testing and serial monitoring, designing and implementing a management plan, report writing, ethical decision-making, counselling appropriate to a variety of audiences with different levels of knowledge and collaboration with the pharmacist, physician and nurse. knowledge from other audiology modules within the audiology curriculum is needed to achieve the outcomes in ototoxicity monitoring. the critical cross-field outcomes within the curriculum need to be applied and integrated. these include: identifying and solving problems through responsible decision-making and creative, critical thinking. working effectively with others as a member of a team, group, organisation and community. organising and managing oneself and one’s activities responsibly and effectively collecting, analysing, organising and critically evaluating information. communicating effectively using visual, mathematical and/or language skills in the modes of oral and/or written persuasion. demonstrating and understanding of the world as a set of related systems by recognising that problem-solving contexts do not exist in isolation (inter-disciplinary collaboration). using science and technology effectively and critically, showing responsibility toward the environment and health of others. developing entrepreneurial opportunities. contributing to the full personal development of each learner and the social and economic development of the society at large, by making it the underlying intention of any programme of learning to make an individual aware of the importance of: reflecting on and exploring a variety of strategies to learn more effectively participating as responsible citizens in the life of local, national and global communities being culturally and aesthetically sensitive across a range of social contexts. looking into a variety of educational and professional opportunities. these activities could not only provide a service to the wards in the hospital, the patients and their significant others, but also provide students with an opportunity to learn (altosino & armstrong, 2014). the process of establishing the ototoxicity clinic required the following: human resources: staff from both the pharmacy and speech-language pathology and audiology departments are involved in the clinical training. one supervisor from the discipline of speech-language pathology and audiology manages the clinic on a weekly basis. whenever the students are not available (e.g. during examination periods and recess), this role is taken over by the staff from the dgmah speech therapy and audiology department. site and physical space: the clinic is situated in the skills-lab at medunsa campus and testing is conducted in the paediatric oncology and renal wards at dgmah. the clinic is situated in an ideal quiet environment for audiology testing procedures. challenges are experienced when hearing screening takes place in the wards due to noise levels. air-conditioning is available in the clinic, which improves infection control, as infections spread quicker in a heated environment (hicpac, 2003). technology and protocol: baseline and serial monitoring of pure-tone hearing thresholds (with a frequency range of 250 to 8000 hz) using serial audiograms are the most effective indicators of hearing loss, especially when ultra-high frequency testing is included (bratt et al., 2005). extended high-frequency (ehf) and otoacoustic emissions (oaes) are audiologic tests that are sensitive to primary ototoxic damage. ehf and oaes can detect any changes in the auditory function before ototoxicity affects the hearing at such frequencies where speech recognition can be affected (kraemer, knight, neuwelt & winter, 2007). oaes evaluate the cochlear outer hair cell system. early changes in oae may reflect on cochlear damage that could progress to further hearing loss if the ototoxic medication is continued. the audiological services available at the clinic provide baseline and serial monitoring of pure-tone thresholds (with a frequency range of 250 to 8000 hz) in a soundproof booth, tympanometry, as well as distortion product (dpoae) and transient evoked oto-acoustic emissions (teoae). unfortunately, ehf audiometry is not available due to a lack of appropriate equipment in the clinic which is due to a lack of funding. when testing is done in the wards at dgmah, only oae testing and tympanometry is done, as equipment used for baseline and serial monitoring of pure-tone hearing thresholds is not mobile. often, hospital treatment protocols have specific time points for performing audiological assessments. these times points are based on several factors, such as diagnosis, treatment plan, patient age and ototoxicity risk (bass, white & jones, 2013). at the smu clinic the patients are evaluated at any time during or after therapy if a noticeable change in hearing occurs. bass et al. (2013) is of the opinion that patients diagnosed with severe or fluctuating hearing loss should be followed up more frequently than the ototoxicity protocol indicates, at least until hearing loss stabilises. in the medunsa clinic ototoxicity monitoring is not concluded at the end of therapy, as delayed onset and progressive hearing loss has been documented in patients treated with ototoxic medication (bass et al., 2013). to date no accepted clinical techniques for vestibulotoxicity exist despite reported cases of possible effects thereof (jones, 2008). patients that display symptoms such as dizziness and unsteady gate associated with ototoxic therapy are referred for a complete vestibular evaluation at smu vestibular clinic. needs of stakeholders: funding is a major need for the clinic, as no funds were available at the onset of the programme. up to the present, existing equipment from the discipline of speech-language pathology and audiology had to be utilised. this aspect poses occasional challenges, as the equipment is also needed at several other student training sites. although ehf audiometry is a vital test to be administered in an ototoxicity monitoring programme (kraemer et al., 2007), this equipment is not available at present. challenges and strengths top ↑ oaes are successfully used for evaluating cochlear outer hair cell function (kraemer et al., 2007). many adults with normal hearing present with low-level oaes. therefore, in ototoxicity, the ability to detect low-level oaes and small oae changes over time is required. achieving valid and reliable measurements of low-level oaes pushes the limits of standard oae equipment, which invariably has been designed with infant screening in mind, as infants with normal hearing usually present with large oaes and are easy to elicit. eliciting low-level oaes are also more affected by environmental noise or noise generated from a restless patient. despite these challenges, oaes can be successfully used in ototoxicity programmes (marshall & miller, 2007). another challenge is that some patients (e.g. the paediatric oncology patients) are too ill and immunocompromised to attend the clinic. this results in only oaes being conducted, as baseline and serial measures are not possible in the wards due to immobile equipment and noise levels. therefore, pure-tone thresholds, which is considered as the most effective measure of hearing loss is not possible. oaes are conducted at the patient’s bedside or in a section of the ward. the acoustic climate of the wards is noisy, which makes is difficult to obtain reliable results on a repeated basis. nursing staff also do not always realise the importance of a quiet environment during oae testing. the collaborations allows for the following strengths and weaknesses: in terms of the former, a definite strength of this ototoxicity programme is the constant interdisciplinary teamwork between the audiologist, pharmacist, physician and nursing staff in the wards. effective teamwork based on evidence based practices may enhance better practices and management of patients with ototoxic and vestibulotoxic damage. in addition, there is a close proximity by providing easy and frequent access to the ototoxicity clinic; there is a clear communication and trust between the two disciplines; the patient sees both disciplines at once, which proved to be more effective than seeing the patient one after the other, and this increases the communication between the disciplines and the patient. the patient receives more effective treatment because the concerns are addressed immediately and ototoxic effects can be minimised and/or prevented if possible. state of the art equipment that is frequently calibrated is available to increase reliability. student training is also taking place within a service-learning context. the hospital staff is also involved, which ensures the continuation of the ototoxicity clinic services when the university is closed for recess. in terms of weaknesses, the student schedule causes the clinic to run according to the university calendar, which causes an increased workload for the hospital staff. testing often occurs in the wards due to the patients being immunocompromised. the noise levels in the wards are high, which makes the testing challenging and often creates unreliable results. there is a lack of equipment for high-frequency audiometry at present, which ideally should be part of the protocol. experiences of the stakeholders at present there is no formal evidence of the experiences of the stakeholders, as this matter currently is being researched. the staff from the hospital departments expressed appreciation for the service and continues to send patients for screening. the clinical pharmacists have established working relationships with the physicians and audiologists and have become familiar with the type of hearing impairment caused by the different drugs. the audiologists performing the monitoring find the wards to be too noisy at times and struggle to obtain reliable oae results. although a quiet environment is the ideal for efficient testing, this is not necessarily the case. in reality the noise levels are high, which often cause the results to be unreliable and patients have to be re-assessed. in addition, the procedure takes much longer than it usually should. patients who are not too ill are transported to the ototoxicity clinic where the environment is more conducive to testing. student training has been successful, as students perform well in conducting the assessment procedures. students attend on a rotation basis and block review reports and reflective journals have shown a positive result in terms of student self-review of competencies. content taught the ototoxicity clinic at smu provides a platform for student teaching and learning within a service-learning approach. audiology students have the opportunity to work within an interdisciplinary team with pharmacists, nurses and physicians, and to interact with a diverse group of patients. the department of pharmacy provides the students with the background information on pharmacology and drugs that cause ototoxicity in the classroom prior to the onset of their rotation. on clinic days the students provide ototoxicity-monitoring services, including counselling to adult and paediatric patients affected by ototoxic and vestibulotoxic medications. students are also required to develop a management plan for patients identified with ototoxic and vestibulotoxic damage. these plans are also submitted for assessment. report writing is a collaborative effort between the clinical pharmacist and the audiologist. reports are based on a discussion of results and planning of the way forward for each patient. while providing a vital service to the community, students are able to meet their learning outcomes related to ototoxicity monitoring within a hospital setting. summative and formative assessment procedures are applied throughout the clinical block. at the end of the module, the students are able to conduct an age and case-appropriate interview through the selection of appropriate questions from a case history form, display well-developed information retrieval skills together with the ability to critically analyse and synthesise information obtained from the assessment. students are also expected to conduct and apply ageand case-appropriate protocols during the conduction of the basic audiometric test battery, critically analyse and synthesise information and interpret accurately. additionally, students are able to conduct and apply age and case-appropriate procedures during the determination of diagnostic oaes displaying logical and critical thinking; as well as demonstrate engaged participation during discussion of results. students are expected to summarise audiometric results and explain it in a well-structured comprehensible manner during feedback and in the diagnostic report to the client, the parents, caregivers and/or significant others. reflective journals allow analysis and synthesis of information learnt. when working with nurses, doctors, pharmacists and patients in the clinic, the students are exposed to multidisciplinary teamwork. role of the facilitators top ↑ one staff member from the pharmacy and audiology department, assisted by a masters student, provides consultations with regard to the ototoxic medication. they also brief the students in speech-language pathology and audiology regarding ototoxicity, pharmacotherapy and the clinic protocol. demonstrations in the use of the equipment for students training in audiology are offered and supervision is provided, whilst students gain hands-on testing experience. the entire process of learning and serving is monitored through structured assessment instruments by the facilitators. attendance, and learning and teaching opportunities top ↑ from the initiation of the clinic in february 2013 up until april 2014, a total of 52 patients with 102 patient visits (an average of 1.9 visits per patient) attended the clinic. some patients visited the clinic more than once depending on the recommendations by the team. all of these patients had a regimen containing either one or two medicines that may cause ototoxicity. to date 48 students have been trained in the clinic, and from their course evaluations and reflections on the module it appears as if they consider their training as good or excellent. logistics top ↑ the clinic is conducted on friday mornings between 08h00 and 12h00. currently patients are referred by the paediatric oncology unit, nicu, renal and internal medicine wards. the clinical pharmacist identifies patients from other unit’s e.g. internal medicine. the programme intends to extend to other departments, e.g. adult oncology. patients with pharmacotherapy that may cause ototoxicity are either identified by the clinical pharmacist or referred to the service department (which is the hospital department of pharmacy or speech-language and audiology). the clinical pharmacist then provides a description of the type of toxicity to be expected (i.e. vestibular/cochleotoxic and reversible/irreversible toxicity). the audiologist then assesses the patient and a full report is written from both disciplines with recommendations for alteration of therapy to the treating physician. the current regimen of prescription contains either one or two medicines that may cause ototoxicity. the medicines mostly implicated include amikacin, gentamicin, cisplatin and furosemide (at high dosages and used orally for extended periods of time in patients within the renal unit). these medicines might have been used alone or in combination. additional details on the type of ototoxicity seen with these agents will be included as part of a master’s degree study currently being conducted at the clinic. conclusion top ↑ through a service-learning approach, it is possible to form partnerships with the hospital staff and other stakeholders in order to meet the hospital community’s needs, but also to meet the specific learning outcomes, of which inter-professional collaboration and teamwork is but one. through asl a reciprocal relationship is established in which both parties benefit. the establishment of this service-learning programme has created a unique opportunity for interdisciplinary collaboration between audiologists and pharmacists. such collaboration provides an opportunity for early identification of medicines that may cause hearing impairment in vulnerable patients. early identification affords early intervention for both the clinical pharmacist and the audiologist. future research should further explore the nature and extent of hearing loss caused by the various agents and the experiences of stakeholders. a service-learning approach seems to contribute to the quality of their training. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this article. authors’ contributions n.s. (sefako makgatho health sciences university) conceptualisation and drafting of manuscript; a.m.w. (sefako makgatho health sciences university) – conceptualisation and drafting of manuscript; k.e. (sefako makgatho health sciences university) – conceptualisation and drafting of manuscript; y.v.a. (sefako makgatho health sciences university) conceptualisation and clinical implementation; a.g. (sefako makgatho health sciences university) review of final document. references top ↑ achkar, j.m., kasprowicz, v.o., & wilson, d. (2011). the tuberculosis and hiv epidemic in south africa and the kwazulu-natal research institute for tuberculosis and hiv. the journal of infectious diseases, 204, 1099–1101. http://dx.doi.org/10.1093/infdis/jir414 altosino, a., & armstrong, j.l. (2014). the effects of a service learning workshop on the intellectual life of graduate students in communication disorders. http://dx.doi.org/10.1044/aihe17.1.27 american speech-language-hearing association (asha). 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(2009). journey to professional competency in speech-language patholgy. the scholarship of teaching and learning at emu, 1, article 4. retrieved october 06, 2014, from http://commons.emich.edu/sotl/vol1/iss1/4 article information authors: frenette southwood1 ondene van dulm1, 2 affiliations: 1department of general linguistics, stellenbosch university, south africa 2department of communication disorders, canterbury university, new zealand correspondence to: frenette southwood email: fs@sun.ac.za postal address: private bag x1, matieland, 7602, south africa dates: received: 27 feb. 2014 accepted: 31 aug. 2014 published: 10 feb. 2015 how to cite this article: southwood, f., & van dulm, o. (2015). the challenge of linguistic and cultural diversity: does length of experience affect south african speech-language therapists’ management of children with language impairment? south african journal of communication disorders 62(1), art. #71, 14 pages. http://dx.doi.org/10.4102/sajcd.v62i1.71 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. the challenge of linguistic and cultural diversity: does length of experience affect south african speech-language therapists’ management of children with language impairment? in this original research... open access • abstract • introduction    • the problem    • potential solutions • research question • methodology    • aims and objectives    • research design    • materials    • respondents    • data analysis • findings and discussion • summary of the findings • discussion    • limitations of the study    • clinical implications • conclusion • acknowledgements    • competing interests    • authors’ contributions • references • appendix 1    • national survey: child language assessment and therapy abstract top ↑ background: south african speech-language therapists (slts) currently do not reflect the country's linguistic and cultural diversity. the question arises as to who might be better equipped currently to provide services to multilingual populations: slts with more clinical experience in such contexts, or recently trained slts who are themselves linguistically and culturally diverse and whose training programmes deliberately focused on multilingualism and multiculturalism? aims: to investigate whether length of clinical experience influenced: number of bilingual children treated, languages spoken by these children, languages in which assessment and remediation can be offered, assessment instrument(s) favoured, and languages in which therapy material is required. method: from questionnaires completed by 243 health professions council of south africa (hpcsa)-registered slts who treat children with language problems, two groups were drawn: 71 more experienced (me) respondents (20+ years of experience) and 79 less experienced (le) respondents (maximum 5 years of experience). results: the groups did not differ significantly with regard to (1) number of children (monolingual or bilingual) with language difficulties seen, (2) number of respondents seeing child clients who have afrikaans or an african language as home language, (3) number of respondents who can offer intervention in afrikaans or english and (4) number of respondents who reported needing therapy material in afrikaans or english. however, significantly more me than le respondents reported seeing first language child speakers of english, whereas significantly more le than me respondents could provide services, and required therapy material, in african languages. conclusion: more le than me slts could offer remediation in an african language, but there were few other significant differences between the two groups. there is still an absence of appropriate assessment and remediation material for afrikaans and african languages, but the increased number of african language speakers entering the profession may contribute to better service delivery to the diverse south african population. introduction top ↑ south african speech-language therapists (slts) working in the context of cultural and linguistic diversity face immense challenges in their efforts to provide equitable services to all of their clients (barratt, khoza-shangase & msimang, 2012). this is in part because the political policies and practices of the past have affected the profession of speech-language therapy and audiology in a negative manner. a discriminatory education policy resulted in few south africans of colour entering tertiary education and obtaining professional qualifications (evans, 1990), and thus few persons of colour entered the profession. furthermore, research was (and remains) dominated by white intellectuals. because so-called ‘black universities’ were originally intended to be training centres rather than research centres, few black researchers emerged (evans, 1990). furthermore, the group areas act (no 41 of 1950, no 77 of 1957, no 36 of 1966) led to residential separation of different racial groups, thereby preventing sustained and integrated contact amongst them. economic conditions in south africa have also led to disparity between different ethnic groups. these factors have contributed to a corps of predominantly white slts who do not necessarily have in-depth knowledge of the cultural practices of the majority of the country's residents. there is thus a lack of academics and practicing slts of colour who might be in a position to offer solutions to practices that perpetuate inequality in access to linguistically and culturally appropriate services. in south africa, the challenges that slts face in rendering equitable services to all their clients are inherent in every aspect of the intervention process. in this article, we discuss the findings of a national survey pertaining to the practices of south african slts during child language assessment and remediation. the survey took the form of a questionnaire sent to all registered slts in south africa, asking them, amongst others, about the languages spoken by their child clients, the language in which they can offer their services, and the assessment material they use. based on the answers to our questions, we consider whether there is a relationship between length of work experience and the slt's ability to deal with a culturally and linguistically diverse clientele. poorly developed language skills and language impairment can have adverse effects on academic performance (conti-ramsden, knox, botting & simkin, 2002). children whose language problems have been resolved before they enter school may still have poor phonological processing and literacy skills (stothard, snowling, bishop & chipchase, 1998). those children who enter school with unresolved language problems experience significant difficulties in all aspects of spoken and written language. increasingly, over time, they fall further behind their typically developing peers in vocabulary growth (stothard et al. 1998). this is also the case for children from low socioeconomic backgrounds, which is of particular concern in south africa. these children form a significant percentage of the school-going population, given that 47% of south africans are living in poverty (armstrong, lekezwa & siebrits, 2008). such children generally enter school with less well developed language skills in comparison to their middle-class peers (see raizada, richards, meltzoff & kuhl, 2008), and they often fall behind as they progress through school grades, with the gap between poor and middle-class children ever widening (cunningham & stanovich, 1997). because of the critical influence of language skills on academic success, the nature of the language assessment and remediation services offered to the child population by south african slts warrants investigation. the problem beginning at the most basic level of slt service provision, pascoe and norman (2011) pointed out that the number of qualified slts in south africa is simply too small to adequately service the population. furthermore, the existing body of slts does not reflect the linguistic and cultural diversity of the population it serves, because most slts are mother tongue speakers of english or afrikaans with little or no knowledge of other official languages and/or of the cultural backgrounds of many of their clients (barratt et al. 2012; pascoe & norman, 2011). the royal college of speech and language therapists (1996) guidelines advised that language assessment be carried out in both (or preferably all) languages spoken by a bilingual client. given that a diagnosis of language impairment cannot be made by assessing a child in his or her second language only (jordaan & yelland, 2003), such mismatch between the languages of south african slts and their clientele can negatively influence clinical practice. the shortage of slts fluent in and knowledgeable about african languages also has implications for the protection of the language rights of south africans and for language policy implementation (barratt et al. 2012). this study investigated, amongst other things, whether there is a difference in the extent to which more and less recently trained slts can offer language assessment and remediation in their clients’ first languages. with child language assessment, the first step in the intervention process, south african slts face a lack of linguistically and culturally appropriate assessment instruments (pascoe & norman, 2011; penn, 1998). for many languages and language varieties spoken in south africa, no standardised assessment instruments are available. most of the available assessment instruments are not locally developed and thus contain language structures, cultural references and visual material inappropriate for the local population. the problem might, in some contexts, be partly solved by using informal and dynamic assessment methods, but this is hindered by (1) a lack of knowledge on typical development in many of the mother tongues spoken by the south african clinical population, and (2) a lack of local norms against which a child's performance can be compared (pascoe et al. 2010; pascoe & norman, 2011). valid and reliable assessment is widely acknowledged to be the cornerstone of effective intervention. as such, this lack of linguistically appropriate and culturally unbiased assessment instruments would leave an slt with limited indications for therapy, even if she or he were able to deliver slt services in the client's language. ethical principles argue against excluding from treatment a client whose language differs from that of the clinician (pascoe & norman, 2011). however, in the case of slt services, a clinician who is not competent in the language and/or does not have linguistically appropriate resources at hand runs the risk of doing more harm to a client than good, amongst others by increasing the risk of underor over-diagnosis (gould, 2008). potential solutions a number of reports have appeared in the literature on steps taken by south african slts to address the challenges presented by language barriers in the clinical context. the first is the translation and adaptation of assessment instruments. whilst a number of authors reported certain levels of success in test translation and adaptation (e.g., barratt, 2012; mosdell, 2010; o'toole & hickey, 2013), it is a complex process fraught with problems. test item translation is generally not straightforward because of syntactic, semantic, pragmatic, and/or phonological differences between the two languages. direct translation may render either, (1) an item which does not target the same structure or skill as in the original language, or (2) an item which is not of the same level of difficulty as the original item. the intricacies of item translation are also often hidden. for example, a change necessitated by a syntactic difference between the languages concerned may lead to the use of a lexical item which has a higher level of difficulty in some dialects than in others. logistical problems also interfere with the success of test translation. firstly, it is a decidedly costly process, amongst other reasons because of the need to standardise the translated instrument on a representative sample of the target population. there is a need to re-standardise untranslated english-medium assessment instruments developed elsewhere when used with speakers of south african english (wilson & moodly, 2000), and this is also a case for translated instruments. secondly, despite mutual intelligibility of, and structural similarity between, certain african languages spoken in south africa, the translation of an adequate range of assessment instruments into each of these languages will be a lengthy and costly task. this is as a result of the number of different languages spoken in south africa and therefore the number of different languages for which assessment instruments may be needed. the use of interpreters during assessment and remediation is a second solution often applied in the south african slt context. whereas the use of an interpreter is arguably preferable to having no communication at all between client and slt, it raises its own set of problems. it can also lead to either underor over-identification of language impairment if the interpreter is not thoroughly knowledgeable about dialectal differences that impact the targets of the intervention. furthermore, an interpreter may make errors of interpretation that affect either what is communicated or how it is communicated. the slt remains unaware of any such error and cannot control for its effects (barratt et al. 2012). a further problem with regard to the use of interpreters is a lack of availability. penn, mupawosa, and stein (2009) reported that recently qualified slts from the university of the witwatersrand had no access to formal interpreting services during their community service year, although they did report making frequent use of ad hoc interpreters. such use of untrained interpreters exacerbates the problems already pointed out above. a third solution may lie in appropriate language training for undergraduate slt students. a brief examination by the authors of the curricula of south african slt training programs as specified in their online prospectuses indicates that there is some awareness of the need to equip slt students with knowledge about linguistic and cultural diversity in clinical practice, and with the skills required to cope with such diversity. for instance, some training programmes include course content on issues around multiculturalism and multilingualism. some cover these topics in clinical speech pathology modules. slt students who have (applied) linguistics as a subject also study bi-/multilingualism as a psycholinguistic and/or sociolinguistic phenomenon. furthermore, the psychology modules offered to slt students at the various universities appear to deal with themes related to core social issues and challenges facing south african society. regarding slt students’ linguistic proficiency, at least four training institutions require those who do not have an african language as mother tongue to take an african language as subject, usually for one year. some institutions also require afrikaans as subject for those students who have no, or limited, proficiency in afrikaans. one institution includes the topic xhosa communication competence in the clinical context in its clinical speech pathology modules. for most of the institutions, the prospectuses do not state that an african language is taught or that explicit instruction is given on multilingualism and multiculturalism. the apparent absence of such modules is not necessarily cause for alarm, because (1) relevant content might be inherent in certain speech-language pathology or therapy modules, and (2) students may have the opportunity to acquire some competence in a language other than their mother tongue and some understanding of other cultures naturally during the course of their four years of study. the limited and non-uniform focus on multilingual abilities may, however, indicate that the mismatch between the language backgrounds of south african slts and those of their clients is only just beginning to be addressed. the above discussion suggests that training institutions are taking steps toward addressing the fact that the vast majority of south african slts are white speakers of english and/or afrikaans with little knowledge of other south african languages and cultures. note, however, that, at feedback sessions in the middle of their community service year, recently qualified slts who had graduated from the university of the witwatersrand and who had studied an african language as part of their undergraduate training reported that such training had not been ‘particularly useful in practice’ (penn et al. 2009). the slts stated that formal training in an african language should continue, but that ‘on-site language learning had been effective and quick, especially where there was a predominant language spoken (as in kwazulu-natal) or when they had attended extra language classes’ (penn et al. 2009). research question top ↑ globally, slt service delivery to multilingual and multicultural populations is deemed by slts to be less than satisfactory (asha, 2011a). as stated above, our training institutions are not yet producing large numbers of multilingual and culturally knowledgeable slts, and other solutions to effective service delivery to our multilingual population (e.g. test translation and the use of interpreters) are not satisfactory. in light of these facts, the following research question arose: are slts with more years of clinical service or are more recently trained slts better equipped to deal with the multilingual and multicultural south african population? on the one hand, the former may be better equipped because they have had a longer time to gain clinical experience in multilingual and multicultural contexts. on the other hand, the latter may be better equipped because (1) they themselves are possibly more diverse in language and culture and (2) they have benefitted from training programmes that deliberately focus on multilingual and multicultural issues. in this regard, it should be noted that we consulted the current prospectuses of the various training institutions and did not conduct an historical overview of their academic and clinical programmes on offer. these prospectuses relate only to the training of the more recently qualified slts; we did not systematically investigate the nature of the multilingual and multicultural matters included in previous curricula. methodology top ↑ aims and objectives the aim of this study was to investigate whether length of clinical experience as an slt had an influence on aspects of child language intervention practices, this field being particularly challenging in the multilingual and multicultural context of south africa. specific objectives were to analyse data from a survey to ascertain whether there were differences between more experienced (me) slts and less experienced (le) slts with regard to: the number of child clients treated (including bilingual child clients), the primary causes of the children's language problems, and the languages spoken by these clients the language(s) in which assessment and remediation can be carried out the assessment instrument(s) favoured and the reasons for this factors taken into account when selecting an assessment instrument the language(s) in which therapy material is required. research design the study took the form of an exploratory and descriptive questionnaire-based survey. ethical clearance for conducting the research was granted by the ethics committee of the faculty of arts and social sciences at stellenbosch university. respondents who completed and returned the questionnaire indicated thereby their consent for participation in the survey. materials data to inform the above research question were collected by means of a questionnaire devised by the authors (see appendix). the first section of the questionnaire requested respondents to indicate their clinical setting(s), their length of service delivery, and their language skills, particularly the language(s) in which they were able to assess and treat clients. the second section posed questions about respondents’ clientele, particularly on how many children with language problems typically existed on respondents’ caseloads, the main cause(s) of the language problems, the ages and first languages of the children, the proportion of the children who were bilingual, and how many of the bilingual children received remediation in their first language. the third section focused on the assessment and remediation of language problems, specifically the assessment instruments used and respondents’ ratings of these with regard to various factors, the factors considered by respondents when selecting an assessment instrument, and the language(s) in which therapy material is required. the questionnaire contained two different types of questions. content questions required written answers, such as the number of years spent working as an slt in south africa. response selection questions offered a number of possible response categories, of which a respondent could tick either one or more than one. for example, when indicating the average number of children with language problems on his or her caseload, a respondent could tick only one of several categories (1–5; 6–10; 11–15; 16–20; 20+), but when indicating causes of the language problems, a respondent could tick one or more categories (e.g. language delay, neurological impairment, insufficient exposure to literacy practices, etc.). for questions with an ‘other’ option, respondents were requested to supply further written information. in order to increase the validity of the questionnaire, care was taken to phrase questions in a simple yet precise manner, to keep questions strictly related to the topic at hand (kazi & khalid, 2012), and to include questions that would allow the researchers to answer the research questions. completion of the questionnaire took approximately 10 minutes. respondents paper copies of the questionnaire were posted at the end of january 2012 to every one of the 1915 slts registered with the health professions council of south africa (hpcsa). total population sampling thus took place. these slts excluded community service graduates. fifty-eight questionnaires were returned undelivered and 272 completed questionnaires were returned in the stamped self-addressed envelopes provided. this comprises a return rate of 15%, with representation from all nine provinces. we acknowledge a possible sample bias, in the sense that possibly only those therapists interested in the topics covered in the survey completed the survey. such a bias would have influenced the results and limited the generalizability of the findings. of the 272 respondents, 243 were south africa-based slts who had children with language problems on their caseloads. two groups of participants (those with more and those with less experience) were drawn from these 243 completed questionnaires. to ensure two distinctly different groups, those respondents with 20 or more years of experience (average 28 years 9 months; median 30 years 0 months; sd = 5 years 8 months) and those with five or less years were selected. the more experienced (me) group comprised 71 respondents and the less experienced (le) group 79. the two groups differed significantly in the time they had practiced in south africa (p = 0.000) but not in the time they had practiced abroad (p = 0.398). regarding their service-delivery setting, 30 of the 79 respondents (38.0%) in the le group and 54 of the 71 in the me group (76.1%) worked in private practice. this difference between proportions of each of the two groups working in private vs. public institutions was significant (p = 0.000) and should be borne in mind when interpreting the findings. data analysis data were transferred from the paper versions of the selected returned questionnaires to a microsoft® office excel file. total responses of each of the two groups on various questions were tallied. comparisons between two binary or categorical variables were made using pearson chi square, where a p-value < 0.05 was taken to imply a significant association between the two variables, i.e. that there was a difference in proportions between the way in which the two groups responded to the question. findings and discussion top ↑ there were no significant differences between the two groups regarding the number of children slts had on their caseloads (chi square 1.591 (df = 4), p = .810), or average number of children with language difficulties (chi square 5.100 (df = 4), p = .404). there were also no significant differences between the two groups regarding the primary causes of their child clients’ language problems in the given options (viz. language delay, language disorder, incomplete second language acquisition, hearing impairment, neuro-logical impairment, insufficient exposure to literacy pra-ctices, under-stimulation), or any other cause mentioned (see table 1). the only exception was insufficient exposure to school-type language. more le than me respondents indicated this as a primary cause of the language difficulties of their child clients. table 1: primary causes of language problems of child clients on south african speech-language therapists caseloads. turning to the languages spoken by the child clients with language problems: there were no significant differences between the two groups with regard to the number of slts who reported seeing child clients who speak afrikaans or an african language as home language (see table 2). considering individual african languages, significantly more me than le respondents reported seeing isizulu-speaking children, but there were no significant differences between the groups for the other african languages reported (this could be related to the fact that isizulu is the language with the largest number of home language speakers in south africa; statistics south africa, 2012). significantly more me respondents than le respondents reported seeing child clients who speak english as their home language. considering bilingual children, the difference between the two groups approached significance, with more le respondents (47.9% of the 76 respondents who answered the question; median 40%; sd 31.4) than me respondents (36.8% of the 69 respondents who answered the question; median 30%; sd 27.4) seeing bilingual child clients (mann-whitney u = 2133.5; p = .05336). table 2: languages of child clients on south african speech-language therapists caseloads. there were no statistically significant differences between the two groups of respondents regarding ability to evaluate children with language impairments in afrikaans or english. there were, however, limited indications that le respondents are better equipped than me respondents in evaluating such children in languages other than afrikaans or english: more le respondents than me respondents indicated being able to evaluate in an african language (either with or without the use of interpreters). as far as assessment in specific languages is concerned, only the finding for isizulu was statistically significant – more le than me respondents reported being able to evaluate clients in isizulu (see table 3). table 3: languages in which assessment can be carried out. with regard to treatment, similar results were obtained as for assessment. again, there were no statistically significant differences between the two groups regarding ability to remediate in afrikaans or english. there were, again, some indications that le respondents are better equipped than me respondents in treating children with language impairments in other languages: more le than me respondents indicated being able to treat in an african language (either with or without the use of interpreters). as was the case for assessment, the only significant finding was for isizulu, with more le than me respondents being able to offer remediation in isizulu (see table 4). the average percentage of bilingual children with language problems receiving remediation in their first language did not differ significantly between the le respondents (47.8% of the bilingual clients; median 50%; sd 34.0) and the me respondents (42.2% of the bilingual clients; median 35%; sd 33.9), mann-whitney u = 2158.0; p = .25261. table 4: languages in which remediation can occur. table 5 summarises the findings for the le and me groups’ choices of assessment instruments. twenty-six instruments were reportedly used with afrikaans-speaking children and 49 with english-speaking children, excluding slts’ own, informal assessment material. table 5 includes those instruments mentioned for either afrikaans-speaking or english-speaking children by at least 5% of either the le or the me group. as can be seen from this table, the only significant differences between the two groups were the following: when assessing afrikaans-speaking as well as english-speaking children, more me than le respondents frequently used the illinois test of psycholinguistic abilities (itpa-3; hammill, mather & roberts, 2001) and the peabody picture vocabulary test (ppvt-4; dunn & dunn, 2007) (note that the latest versions of instruments are cited here, but respondents did not always indicate which version they use). when assessing english-speaking children, more me than le respondents frequently used the test of language development (told-4; newcomer & hammill, 2008); the renfrew language scales (rls; renfrew, 1997) (without specifying whether they use the whole battery or selected subtests) and the renfrew bus story; the language assessment, remediation and screening procedure (larsp; crystal, fletcher & garman, 1981); the test for reception of grammar (trog-2; bishop, 2003); and the british picture vocabulary scale (bpvs; dunn, dunn, sewell & styles, 2009). note that more le than me respondents used the renfrew action picture test (renfrew apt) when assessing english-speaking children. more le than me respondents also used an afrikaans translation of the test of auditory comprehension of language (tacl-3; carrow-woolfolk, 1998) when assessing afrikaans-speaking children. the reverse held true for an afrikaans translation of the preschool language scales (pls-5; zimmerman, steiner & pond, 2011) and the afrikaanse semantiese taalevaluasiemedium (ast, ‘afrikaans semantic language evaluation medium’; pretorius, 1989). table 5: assessment instruments used with englishand afrikaans-speaking children. the instruments used by the most respondents were the celf, tacl, itpa, renfrew apt, and ppvt. the reasons why slts favoured these, as well as the afrikaanse reseptiewe woordeskattoets (arw, ‘afrikaans receptive vocabulary test’; buitendag, 1994) and ast, and the aspects of these instruments preferred by the respondents, are discussed below. the celf was found by the vast majority of respondents to be either fair, good or excellent in its efficacy in diagnosis and its ability to provide therapy guidelines – in both cases, by all 27 of the le respondents who answered this question and by 22 of the 23 me respondents (95.7%) who answered this question. furthermore, most respondents regarded the celf to be a comprehensive assessment instrument (all 27 le respondents; 17 of the 23 me respondents [73.9%]). the tacl received similar ratings: it was judged to be either fair or good in its efficacy in diagnosis (all 41 le respondents; 18 of the 20 me respondents [90.0%]) and to have either a fair, good or excellent ability to provide therapy guidelines (40 of the 41 le respondents [97.6%]; 19 of the 20 me respondents [95.0%]). furthermore, respondents generally found the tacl easy to score (28 of the 41 le respondents [68.3%]; 15 of the 20 me respondents [75.0%]). all respondents (9 le and 15 me) found the itpa to be fair, good or excellent regarding its efficacy in diagnosis and its ability to provide therapy guidelines. amongst the le respondents, 6 of the 9 (66.7%) judged the itpa to be quick to administer, whereas only 8 of the 15 me respondents (53.3%) responded likewise. regarding ease of scoring, the itpa also received positive ratings (from 6 of the 9 le respondents (66.7%) and 11 of the 15 me respondents (73.3%)). the instrument was judged to be comprehensive by 6 of the 9 le respondents (66.7%), but by only 4 of the 15 me respondents (26.7%). the apt was the mostly frequently used subtest of the renfrew. this subtest was judged fair, good or excellent with regard to its efficacy in diagnosis by 29 of the 30 le respondents (96.7%) and by all 7 me respondents. all respondents (30 le and 7 me) judged the ability of the renfrew apt to provide therapy guidelines as fair, good or excellent. furthermore, 29 of the 30 le respondents (96.7%) and all 7 me respondents judged the renfrew apt to be quick to administer. all 7 le respondents and 23 of the 24 me respondents (96%) regarded the ppvt to be fair, good or excellent with regard to diagnostic efficacy. it was also judged favourably in its ability to provide therapy guidelines: all 7 of the le respondents reported it to be fair or good, and 22 of the 24 me respondents (92%) reported it to be fair, good or excellent. furthermore, the ppvt was rated quick to administer by 5 of the 7 le respondents (75%) and by 19 of the 24 me respondents (80%), and easy to score by 5 of the 7 le respondents (75%) and by 14 of the 24 me respondents (60%). regarding the afrikaans-medium instruments, the arw was judged as having either fair or good diagnostic efficacy (by 11 of the 12 le respondents (91.7%) and by all 7 me respondents). the ast was judged as fair, good or excellent (by 5 of the 6 le respondents (83.3%) and by all 14 me respondents). both instruments’ ability to provide therapy guidelines was judged as fair, good or excellent (by 9 of the 11 le respondents (75.0%) and 6 of the 7 me respondents (85.7%) for the arw, and by 5 of the 6 le respondents (83.3%) and all 14 me respondents for the ast). furthermore, many respondents judged the arw to be easy to score (8 of the 12 le respondents [66.7%] and 6 of the 7 me respondents [85.7%]). regarding factors taken into account when selecting an assessment instrument, significantly more le (53.2%; 42 of 79) than me (36.6%; 26 of 71) respondents considered logistical matters such as purchase price and availability (chi square 4.130; p = .042). there were no statistically significant differences for other considerations listed on the questionnaire. it is notable, however, that 63.3% of le (50 of 79) and 69.0% of me (49 of 71) respondents reported considering the underlying linguistic base of the instrument when selecting an assessment instrument (chi square .546; p = .460). in contrast, only 5.1% of le (4 of 79) and 1.4% (1 of 71) of me respondents reported considering an instrument's cultural and linguistic appropriateness when used in the south african context (chi square 1.550; p = .213). this suggests a severe lack of attention to these aspects, which may be regarded as particularly important in our multilingual and multicultural society. finally, it is clear that although there were no statistically significant differences between the two groups regarding the types of therapy material used (commercially available vs. self-devised; chi square 1.490 (df = 4; p = .828), more le than me respondents reported being in need of therapy materials in languages other than english and afrikaans (see table 6). also, more than twice as many le than me respondents indicated that they require therapy material in an african language. this was especially the case for isizulu, isixhosa, and sesotho. as in the case of the pascoe et al. (2010) survey on slts’ practices regarding children with speech difficulties, some of the present respondents commented on the lack of appropriate material for use in the south african context. table 6: languages in which therapy material is needed. summary of the findings top ↑ in summary, the more and less experienced groups of slts did not differ significantly in the number of children and the number and ages of those with language difficulties on their caseloads. moreover, the number of slts who saw child clients with afrikaans or an african language as home language did not differ significantly (the single exception here was that significantly more le than me slts saw first language child speakers of isizulu). significantly more me than le slts reported seeing first language child speakers of english, but there was no significant difference between the numbers of bilingual children on their caseloads. regarding the languages in which the slts could provide their services, there were no significant differences between the groups for assessment and remediation taking place in afrikaans or english, but more of the le slts could render these services in an african language, and in isizulu in particular. the participating slts reported making use of a wide range of assessment instruments. those instruments used significantly more frequently by the me than by the le slts are the ast, bpvs, itpa, larsp, pls, ppvt, renfrew (where no subtest was specified), renfrew bus story, told, and trog. significantly more le than me slts routinely use the renfrew apt and the tacl. regarding language therapy material, there were no significant differences between the groups in the number of slts who reported needing such material in english or afrikaans. however, significantly more le than me slts needed material in african languages, particularly in isixhosa, isizulu, and sesotho. most therapists, regardless of level of experience, were aware of the need to consider the underlying linguistic base of the assessment instruments they consider for use, but few considered the cultural and linguistic appropriateness of these instruments. thus, with regard to linguistic and cultural awareness during assessment instrument selection, level of experience did not bring about a change. level of experience, furthermore, influenced few other slt practices asked about in the present survey. discussion top ↑ the research question posed in this study was whether slts with more years of clinical service are better equipped than slts with fewer years of service to deal with the multilingual and multicultural south african population. the data indicate that more of the less experienced than the more experienced slts are able to assess and remediate children in isizulu (but not in any other african language). this selective increase in ability to assess and remediate in languages other than afrikaans and english may be as a result of a diversification of the profession regarding slt ethnicity. the diversification is, however, not yet sufficient to render an slt corps representative of the linguistic and cultural diversity of the country (barratt et al. 2012; pascoe & norman, 2011). the slow rate of diversification could be because of a lack of awareness of the slt profession. in a study conducted with 651 ethnically diverse male and female learners and students in the united kingdom, greenwood, wright, and bithell (2006) found that one-third of respondents were totally unaware of speech-language therapy, and minority ethnic respondents were significantly less likely than majority ethnic respondents to know that speech-language therapy is a degree course. asha (1997–2014) provided an overview of the challenges pertaining to the recruitment and retention of ethnic minorities in a wide range of professions in the united states of america (usa). there are thus indications that the diversification of the slt profession is a challenge in countries other than south africa. the selective increase in ability of our respondents to assess and remediate in languages other than afrikaans and english may also indicate (1) that more people who had an african language as additional language at school are entering the profession, or (2) that those slt training programmes offering an african language as part of its curriculum are successful at rendering linguistically more diverse graduates. this finding could be interpreted as an indication that the less experienced group (those who were trained more recently) are better equipped to deal with multilingual clients, or with clients who do not speak afrikaans or english. however, such an interpretation does not take into account the possibility that slts with more experience may have had more time to acquaint themselves with the range of cultural traditions, customs, values, and beliefs within the multicultural south african population. such experience-based knowledge may make the latter group of slts culturally better equipped, despite being linguistically less so. the slts’ relevant cultural knowledge was not investigated in the present study, and so it is not possible to conclude that the less experienced group is necessarily better than the more experienced group at dealing with the multilingual and multicultural south african population. in short, knowing a language sufficiently to assess and remediate in that language speaks of linguistic competence (which is required for accurate diagnosis), but not of cultural competence (which is required for interpreting test behaviour and rendering appropriate therapy services). cultural competence is given increasing prominence in both research studies (leadbeater & litosseliti, 2014; and others) and policies of professional bodies (asha, 2004, 2011b; royal college of speech and language therapists specific interest group in bilingualism, 2007; and others). given the importance of a basic understanding of the theoretical foundations of an assessment instrument, it is encouraging that most respondents, regardless of level of experience, were aware of the need to consider the underlying linguistic base of an assessment instrument. however, the finding that few respondents considered the cultural and linguistic appropriateness of such instruments is disconcerting multilingual and multicultural context. the implications of such findings deserve consideration by those responsible for slts’ undergraduate training and in continuing professional development programs. turning to assessment and remediation practices: more recently trained than more experienced slts could offer their services in an african language, but there were few other significant differences between the two groups. there were some differences in the assessment instruments preferred, but not in the use of informal assessment material. there was widespread use of british and american assessment instruments. this included widespread use of afrikaans translations of these instruments, despite the problems associated with the use of translated instruments, especially those that have not been renormed. these findings indicate a need for linguistically and culturally appropriate child language assessment instruments in afrikaans, south african english, and the african languages spoken in south africa. penn (1998, p. 266) reviewed the assessment instruments available in the languages spoken in south africa. she concluded that ‘development of specialised assessment and intervention protocols for diverse languages and cultures … needs to be expanded’. penn referred to test translations and adaptations carried out prior to 1998 (chiefly into afrikaans, but also into isixhosa and sepedi). she also referred to test development, notably that of the afrikaanse reseptiewe woordeskattoets (buitendag, 1994), which was developed precisely because of the: need for the acknowledgement of cultural and linguistic diversity in south africa, and the … unavailability of non-biased standardised norm-referenced language tests for the identification of language pathology in children who speak a non-standard language. (buitendag, 1997, p. vii) since the publication of the penn (1998) survey, these efforts have indeed been expanded by researchers such as barratt (2012), mosdell (2010), pakendorf and alant (1997), van dulm and southwood (2008), and southwood and van dulm (2012). in addition, research into typically developing language development amongst speakers of languages spoken in south africa has continued. such research has been ongoing since at least the 1980s. for example, kunene (1979) studied siswati, connelly (1984) and demuth (1984) sesotho, tsonope (1987) setswana, and suzman (1991, 1996) isizulu. more recently, pascoe and smouse (2012) reviewed research on isixhosa acquisition (by, amongst others, gxilishe, de villiers & de villiers, 2007); bortz (2012) investigated grammatical aspects of setswana acquisition; southwood and van dulm (2012) focused on afrikaans and south african english; klop, visser, and oosthuizen (2012) studied afrikaans-english bilingual language skills; and nel (in press) and potgieter (in press) studied grammatical aspects of afrikaans-english-isixhosa trilingual language acquisition. such developmental data will inform the development of appropriate assessment and remediation material that will reduce the reliance of south african slts on instruments developed in other countries for other speaker groups. the existence of a range of linguistically and culturally fair assessment and remediation instruments will assist south african slts (regardless of their level of experience) in providing equitable services to their multilingual and multicultural clientele. limitations of the study this was a small scale study in the sense that the data obtained from only 150 slts in south africa were considered. those slts who did complete the questionnaire might, furthermore, have been biased towards the topic under investigation. these two factors limit the generalizability of the findings. respondents did not always complete each question, and some questions were answered ambiguously. for instance, more than one response category were selected where only one was possible, e.g., some respondents indicated that they use mostly commercially available assessment instruments as well as mostly self-devised informal assessment instruments. whereas these matters complicated statistical analyses, they did not deduct from overall conclusions drawn on the basis of the findings. another major limitation was that respondents were not asked about the training they received on multilingual and multicultural matters whilst they were students (as was done in the survey of scheffner-hammer et al. 2004). respondents were also not asked about their level of confidence in treating multilingual children. pascoe et al. (2010) asked this of their respondents to a questionnaire on treating speech difficulties. they found that many of the south african slts who rated themselves ‘not very confident’ or ‘not confident at all’ when managing multilingual children had more than 10 years of clinical experience. it would have been of value to ask the present respondents this question regarding their multilingual child clients with language problems. clinical implications because of their specific language repertoire (consisting primarily of english only or english and afrikaans), the majority of south african slts are at present still underprepared to provide appropriate language assessment and remediation services to our multilingual population. this lack of slts who are proficient in an african language is exacerbated by a lack of culturally and linguistically appropriate assessment instruments for use with our child population. it is furthermore exacerbated by a general absence of contextually relevant language therapy material. slts’ responses to the survey discussed here indicated that they are aware of the limitations of their current assessment and remediation practices. several requests were made by the respondents for the development of appropriate instruments that would improve the quality of child language-related services rendered to our diverse population. whereas more speakers of african languages (first, second, or additional language speakers) entering the profession will contribute to better service delivery, the absence of appropriate assessment instruments and remediation material will necessarily limit this contribution. conclusion top ↑ from the findings of the survey, it appears that the language competencies (as far as delivering services in african languages) of the slt fraternity in south africa are changing: more slts who entered the field in the past five years are able to assess and remediate children with language impairments in an african language than are slts who have been delivering their services for two decades or longer. pascoe and smouse (2012) stated that: clinicians within the slt profession have an ethical responsibility to effectively assess and manage their clients in the client's first language, even where a language mismatch between client and clinician exists. even though more slts who can work in african languages are entering the profession now than in earlier years, the findings presented here suggest that the majority of child speakers of african languages will still receive language assessment and remediation in a language other than their first. this will make it difficult to disentangle those speakers of african languages who are typically developing but still in the process of acquiring english (or afrikaans) from those who have underlying language impairment. this is because such a differential diagnosis requires knowledge of the status of the child's language skills in his or her first language. that said it appears that recruiting first or other language speakers of african languages into slt training programmes will change levels of service delivery more than will specialised training or maturation as an slt. such recruitment and the appropriate training of non-mother-tongue speakers of african languages will increase the linguistic and cultural competencies of slts. these slts will still need linguistically and culturally appropriate assessment and remediation materials if south african children with language impairments are to receive the contextually relevant evidence-based intervention to which they are entitled. therefore, the said recruitment and training needs to go hand in hand with research that will provide slts with the appropriate means of assessment and remediation. acknowledgements top ↑ competing interests the authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article. authors’ contributions f.s. 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(2011). preschool language scales. san antonio, tx: pearson. appendix 1 top ↑ national survey: child language assessment and therapy listeners'attitudes: speech supplementa­ tion strategies for improving effective­ ness of speakers with mixed dysarthria as a result of motor neuron disease natalie toy and karin joubert department of speech pathology and audiology, university of the witwatersrand, south africa abstract this study examined unfamiliar and familiar listener attitudes towards the use of combined alphabet-topic cues and a control condition (habitual speech with no cues) associated with the speech of three individuals with severe mixed dysarthria. two listenergroups (n=36) were shown experimentally imposed visual imag esofthecombinedalphabet-topiccuestrategyinconjunction with recorded auditory presentationswiththe habitual speech of three individuals with mixed dysarthria. using a 7-point likert scale, listeners were asked toratehoweffectivetheythoughtthespeakerscommunicated;howcomfortabletheywerecommunicating with the speakers; and how persistent they were in trying to understand the speakers. the results revealed thattherewerenosignificantdifferencesintheattituderatingsoffamiliarlistenersascomparedtounfamiliar listeners. however, resultsrevealedthatratingofcommunicativeeffectiveness, comfort communicatingwith speakers and listener persistence were each more favourable when using the combined cue condition than purelyhabitualspeech.theresultssuggestthataugmentativeandalternativecommunicationstrategiespro viding frequent and specific cues regarding the content and constituent words of a message may enhance the attitudes of listeners. keywords: dysarthria, intelligibility, listener attitudes, speech supplementation, augmentative and alternative communication. s peech, one ,bf the pre-dominant forms o f com suits from damage to the peripheral or central nervmunicatiori is used in every facet o f our lives, ous system and is characterized by slowness in cowhether for the purpose o f expressing our baordination and imprecision o f the movement o f the sic needs, social j interaction or vocational purposes speech musculature. reduced speech intelligibility (light, m cnaughton, gulens, kresman, williams is a hallmark characteristic o f most dysarthrias and 8c cohen, 1999), the inability to communicate via has a significant impact on an individual’s ability to speech has significant psychosocial consequences on communicate, thus ultimately affecting an individuan individual’s functioning and role in society, such as al’s quality o f life (hustad 8c beukelman, 2 0 0 1 ). it alterations in social and family roles, as well as family has been estimated that dysarthria accounts for up to interactions (fox, sohlberg 8c fried-oken, 1999). 54% o f all communication disorders associated with in addition, britnell, madill, montgomerie and stroke, traumatic brain injury and progressive neurostewin (1 9 9 2 ) found that individuals with a dislogical disorders such as m n d , parkinson’s disease ability reported decreased participation in occupaand multiple sclerosis (duffy, 2005). tional roles and recreational activities. individuals m n d , also known as lou gehrigs disease or with m otor neuron disease (m n d ) reported that amyotrophic lateral sclerosis, is a progressive neuas a result o f a reduction in their motor abilities and rological disease, which usually results in severe physspeech intelligibility, attitudes changed from kindical disability involving all four limbs, speech, swalness to awkwardness and avoidance (mathy, y o r k _________________________________________________ston 8c g u tm ann, 2 0 0 0 ), contributing to decreased author contact: department o f speech pathology and audiology participation in various social activities and eventuprivate bag 3, ally isolation. i wits, 2050, south africa dysarthria, a deficit o f speech production, ree-mail: karin.joubert@wits.ac.za the south african journal of c o m m u n ic atio n disorders, vol. 55 2008 | 63 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:karin.joubert@wits.ac.za natalie toy a n d karin joubert lowing and breathing (young 8cmcnicoll, 1998).the cause o f m n d is unknown and is said to occur in 1.5 per 100,000 o f the population worldwide with the average age o f onset at 65 years and a greater incidence in males (freed, 2000). patients with m n d usually do not show any changes in cognitive abilities (young 8cm cn icoll, 1998). the disorder is characterized by deficits in either the lower motor neuron or the upper motor neuron, but usually results from a com­ bination o f both (freed, 2000). the type o f dysarthria that occurs in individuals with m n d depends on which motor neurons are affected. in the initial, mild stages, individuals with lower motor neuron in­ volvement will present with flaccid dysarthria, where as those with upper motor involvement present with spastic dysar­ thria. however, as the disease progresses to involve both the upper and lower motor neurons, patients will present with mixed dysarthria that will predominate throughout most o f the disorder (freed, 2000). in a progressive neurological disorder such as m n d, ap­ proximately 75% o f the patients will reach a point where in­ telligible verbal communication is no longer possible (freed, 2000). the rapid decline o f speech function in patients with m n d is common, but is not inevitable. mathy et al. (2000) identified and documented the progression o f dysarthria in individuals with m n d (appendix a). in the early stage (stage 1), there are no obvious deficits noticed in an indi­ vidual’s speech, but as the disease progresses, the individu­ al’s speech intelligibility becomes more compromised until at the final 5th stage, individuals with m n d lose all speech function. communication by nature requires the involvement of two communication partners who take turns playing the roles o f the listener and speaker throughout the course o f in­ teraction (hustad &. beukelman, 2002). speech intelligibil­ ity can be defined as the extent to which a spoken utterance is understood by the listener (yunusova, weismer, kent 8c rusche, 2005) and is seen as a significant factor in deter­ mining whether an individual is an effective communicator within a conversation (depaul 8c kent, 2000). intelligibil­ ity is therefore a central concept in the field o f speech-lan­ guage pathology, particularly for speakers with dysarthria, whose compromised intelligibility may impair their abili­ ty to communicate effectively in their daily lives (hustad, jones 8c dailey, 2003). sentence intelligibility measures are often used for clini­ cal purposes such as quantifying the severity o f dysarthria, measuring progress throughout the intervention process and in determining a speaker’s communicative effectiveness (hustad 8c cahill, 2003). in addition, intelligibility meas­ ures are also used for basing decisions on the implementa­ tion o f alternative and augmentative communication (aac) strategies (depaul 8c kent, 2000). speech intelligibility is an interactive process that fluc­ tuates for any given speaker and is dependent on a host of variables pertaining not only to the speaker, but also to var­ iables associated with the listener and the communicative context (hustad 8c cahill, 2003). relatively few o f these variables that are thought to have an influence on intelli­ gibility, have been systematically studied. however, recent research is beginning to demonstrate the importance of “signal-independent information” extrinsic variables on in­ telligibility (hustad 8c cahill, 2003). these extrinsic vari­ ables are not dependent on the acoustic signal produced by the speaker, but focus on factors that influence intelligibility for the listener. there is a growing body o f experimental research sug­ gesting that aac strategies designed to supplement dys arthric speech can significantly increase speech intelligibil­ ity for individuals with dysarthria (beukelman 8c yorkston, 1977; crow 8c enderby, 1989; hunter, pring 8c martin, 1991; hustad 8c beukelman, 2001). the use o f low technol­ ogy aac strategies in progressive diseases such as m n d has received significant attention in recent years (beliveau, hodge 8c hagler, 1995; dongilli, 1994; garcia 8c cannito, 1996; hustad 8cbeukelman, 2001).these strategies include alphabet supplementation, topic supplementation and com­ bined supplementation. the alphabet supplementation strategy involves the use o f an alphabet board that speakers point to, to indicate the first letter o f each word while simultaneously speaking it (beukelman 8c yorkston, 1977; crow 8c enderby, 1989; hustad 8c beukelman, 2001; yorkston, beukelman, strand 8c bell, 1999). this strategy aims to improve intelligibili­ ty by providing the listener with knowledge regarding the phonetic content o f a word. in alphabet cues, the listener receives first-letter-of-word orthographic information that serves to limit the number o f possible word choices and therefore improve the chances o f correct word identifica­ tion (hustad, 2001a; hustad 8c beukelman, 2001; hustad 8c garcia, 2005). several studies have demonstrated that al­ phabet supplementation can lead to sentence intelligibility scores that average approximately 35% higher than intelligi­ bility scores associated with habitual speech (beukelman 8c yorkston, 1977; beukelman et al., 2000; crow 8c enderby, 1989; hustad et al., 2003). w ith topic supplementation strategies, the use o f a com­ munication board containing key words or phrases that rep­ resent topics or contexts in the speaker’s life is used (hustad, 2001a). topics are represented orthographically or through the use o f picture symbols. the speaker would point to the topic o f his/her message before producing it verbally (beuke­ lman et al., 2002; hustad, 2001b). hustad and beukelman (2001,2002) suggest that this strategy assists the listener to narrow the expectations o f the semantic content o f the mes­ sage. the topic supplementation strategy has been shown;to produce sentence intelligibility scores ranging from 3%' to 16% higher than habitual speech (beukelman 8c yorkston, 1977; beukelman et al., 2002; crow 8c enderby, 1989; hus­ tad et al., 2003). the combined supplementation strategy involves the in­ tegration o f both alphabet and topic supplementation strat­ egies. in this scenario, the speaker first presents the listener with a topic cue followed by a first-letter cue for each word spoken. this strategy has been shown to provide the high­ est sentence intelligibility scores, yielding as much as 35% to 40% higher scores than habitual speech (beukelman 8c yorkston, 1977; beukelman et al., 2000; crow 8c enderby, 1989; hustad et al., 2003). the concept o f ‘attitude’ has important social implica­ tions for individuals who use speech supplementation strat­ 64 | die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) s t r a t e g i e s for im p r o v i n g e f f e c t i v e n e s s of s p e a k e r s with m ix ed d y s a r t h r i a egies to enhance their intelligibility. attitudes have been a topic o f interest within the disability literature for the past five decades (hustad 8c gearhart, 2 0 0 4 ).the widely accept­ ed notion o f the aac acceptance model states that attitude is a concept made up o f three different components, namely affective, cognitive and behavioural components (antonak 8c livneh, 1988; eiser, 1986; greenwald, brock 8c ostrom, 1968; lasker 8c bedrosian, 2000; triandis, adamopoulos 8c brinberg, 1984). the affective component o f attitude in­ volves emotional and physiological reactions to aac such as comfort level or frustration. the behavioural component relates to the willingness to use aac or to interact with someone using aac, whilst the cognitive component o f at­ titude relates to both the speaker and partner’s perceptions o f communication skills (hustad, 2001b). the attitudes o f potential communication partners may be influenced by factors such as rate, intelligibility, personali­ ty characteristics and their view on disability. these attitudes in turn, may impact on a speaker’s desire or motivation to adopt one o f the previously mentioned speech supplemen­ tation strategies and hence provides valuable information to support clinical decisions (hustad 8c gearhart, 2004). hustad and gearhart (2004) investigated 168 listeners’ attitudes towards 7 dysarthric speakers who implemented three different supplementation strategies (topic/subject cues, alphabet cues and combined topic-alphabet cues) by measuring ratings relating to cognitive, affective and behav­ ioural components o f attitude. the results showed that rat­ ings for the behavioural component were the highest for all but one speaker. the study concluded that there is strong evidence o f a positive relationship between intelligibility scores and attitude ratings, with attitude ratings increasing linearly with intelligibility scores. in addition the study yielded important clinical impli­ cations for individuals who supplement their speech with aac strategies. the implementation o f combined cues or alphabet cues resulted in higher attitude ratings relative to topic cues and habitual speech. these strategies also resulted in the greatest intelligibility gains (hustad et al., 2003). as listeners appeared to be more willing to communicate with speakers who implemented alphabet or the combined cues strategies, the use o f strategies aimed at enhancing intelli­ gibility will likely serve to particularly enhance the behav­ ioural attitude o f listeners. also o f particular interest in recent studies is the means o f defining the optimal listener-speaker pair. familiarity has been among one o f the many factors used in explaining variations in listener performance (depaul 8c kent, 2000). familiarity is however a vague and abstract concept, and for research purposes needs to be usable and measurable based on definable characteristics.' in a longitudinal case study, depaul and kent (2000) studied the effect o f listener familiarity and proficiency on intelligibility judgements o f individuals with m n d . the results indicated better per­ formances for familiar listeners as opposed to unfamiliar lis­ teners. familiar listeners were defined as individuals who had experience in communicating, on a daily basis with a person with a communication disorder. unfamiliar listeners were defined as individuals that had no more than inciden­ tal experience listening to and communicating with persons having communication disorders. the results o f this study suggest that speech-language pathologists should use listen­ er training as part of their practice standards in dysarthria treatment. the components should include: (i) establish­ ing pre-treatment listener’s proficiency, (ii) training listen­ ers through familiarization techniques, and (iii) re-assessing intelligibility using these trained listeners. additional research examining familiarity with dysar­ thric speech is required in order to obtain conclusive results regarding the influence o f familiarity on the speech intelli­ gibility o f individuals with dysarthria. this study is largely based on the previous work conduct­ ed by hustad (2001b), which investigated 68 unfamiliar lis­ teners’ evaluation o f speech supplementation strategies used for severely dysarthric speech. as communication is dyad­ ic (hustad 8c beukelman, 2002), requiring interaction be­ tween the speaker and listener in communicative exchanges, speech intelligibility and listener attitude is a central con­ struct in the area o f aac (hustad, 2001a,b). it is there­ fore o f significance to determine listeners’ attitudes towards aac and in particular speech supplementation strategies, as this can greatly influence the acceptance o f aac systems and strategies by the user. method aim the primary aim o f the study was to compare unfamiliar and familiar listeners’ attitudes towards the use o f speech supplementation strategies (combined topic and alphabet cues) by speakers with mixed dysarthria. three sub-aims delineate the means by which the primary aim o f the study was realised: • to describe the effects o f speech supplementation strate­ gies on listeners ’perception o f communication effectiveness. • to describe the effects o f speech supplementation strate­ gies on listeners’ "willingness to interact with speakers. • to describe the effects o f speech supplementation strat­ egies on listeners’ ratings o f persistence in trying to under­ stand speakers. research hypotheses as the research investigated the influence o f two factors (familiarity and cues vs. no cues) on listener attitudes to­ wards speakers with dysarthric speech, two hypotheses were formulated. firstly, familiar listeners will have significant­ ly higher ratings pertaining to their attitudes towards com­ municating with dysarthric speakers on the cognitive, af­ fective and behavioural components o f attitude. secondly, it is hypothesized that the use o f speech supplementation strategies will yield higher ratings on the cognitive, affec­ tive and behavioural components o f attitude, than the use o f no cues. research design a comparative research design was employed for the study (schiavetti 8c metz, 2006). this design was selected as it was appropriate to investigate the differences between the attitudes o f the two groups o f listener participants (fa­ miliar vs. unfamiliar) towards speakers with mixed dysar­ thria who use speech supplementation strategies. participants the study involved the use o f two participant groups. the south african journal of c o m m u n ic atio n disorders, vol. 55 2008 | 65 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) natalie toy a n d karin joubert the speakers were individuals with m n d that presented with mixed dysarthria who produced speech samples. the second participant group included listeners that were either familiar or unfamiliar with communicating with a person with communication disorders. speakers with dysarthria three individuals with m n d that presented with mixed dysarthria participated in the study. using a non-probabil­ ity, purposive sampling strategy (schiavetti 8c metz, 2006), speakers that met the following selection criteria were re­ cruited with the assistance from the motor neuron disease association (gauteng): (i) diagnosis o f m n d made by a certified neurologist; (ii) used speech as their primary mode o f communication; (iii) english first language speaker; (iv) reading ability at or above the 5 th grade level; (v) presented with mixed dysarthria and in the 3rd or 4th stage o f dysarthria (mathy et al., 2000) (appendix a); (vi) speech intelligibility scores between 30 70% as measured by the sentence in ­ telligibility test (s it ) (yorkston, beukelman 8ctice, 1996), and; (vi) able to produce at least eight consecutive words in connected speech. see table 1 for detailed information re­ garding each speaker. table 1. d em ographic inform ation f o r the speakers •with dysarthria vanable speaker sit b sit sit judge judge 2 judge judge 2 judge ____ 1 1 1 judge 2 age (years) gender medical diagnosis primary mode of communication staging of dysarthria sit score (%) rate of speech (wpm)* 68 male mnd speech stage 3 51 male mnd speech stage 3 52 male mnd speech stage 4 62.73% 61.75% 67.27% 68.21% 30.91% 31.96% 67.92 79.46 55.68 wpm = words per minute listener participant group the primary participants in this study were the listen­ ers. a total o f 36 participants were recruited for the study. a non-probability sampling strategy, ‘purposive sampling’ was employed to recruit the 18 familiar listeners (fl), and ‘convenience sampling’ to recruit the 18 unfamiliar listen­ ers (ul). the listener participant groups met the following criteria: (i) aged 30 75 years; (ii) english first language speaker; (iii) no self-reported hearing loss; (iv) no identi­ fied language, learning, cognitive or visual disabilities per ‘self report. familiar listeners were defined as individuals (family member/friend/care worker) who had experience in communicating, on a daily basis with a person with a com­ munication disorder (hustad, 2001a,b). unfamiliar listen­ ers were defined as individuals that had no more than in­ cidental experience listening to and communicating with persons having communication disorders. the two listener groups were matched for gender and mean age. the unfa­ miliar listener group comprised o f 18 participants (14 fe­ male, 4 male). their average age was 58.0 years (range 32 to 75; sd=10.3). the familiar listener group recruited through the parkinson’s disease association support group o f south africa, comprised o f 18 listeners (14 female, 4 male). their average age was 50.7 years (range 32 to 79; sd=14.8). d e­ mographic information regarding listeners assigned to each listener group is provided in table 2. t able 2 . d em ographic in fo rm a tio n fo r the listen er groups g roup participant fam iliar listener unfam iliar listeneri ages g ender age gender 1 56 fem ale 53 female 2 56 fem ale 73 fem ale 3 58 fem ale 55 female 4 66 fem ale 42 fem ale 5 65 fem ale 40 male 6 71 fem ale 69 female 7 62 fem ale 71 female 8 38 fem ale 62 female 9 57 fem ale 38 fem ale 10 54 fem ale 79 fem ale 11 56 fem ale 37 fem ale 12 32 fem ale 61 fem ale 13 58 male 42 fem ale 14 68 f em ale 32 male 15 55 male 38 female 16 57 male 36 male 17 60 fem ale 44 female 18 75 male 42 male materials speech stimuli four narrative passages, each consisting o f 10 sentences were employed as speech stimuli. narratives (appendix b) representing situational information common to first lan­ guage english speakers were developed based on linguis­ tic characteristics specified in a study conducted by hustad (2001b). the length and content o f the stimulus material were equalised across the following linguistic parameters: (i) sentences per narrative; (ii) topic per narrative; (iii) words per narrative; (iv) number o f words per sentence; and (v) reading level. summary statistics for stimulus material are presented in table 3. , table 3. linguistic characteristics o f narratives __________ characteristic___________ number sentences per narrative 10 topics per narrative 1 w ords per narrative 65 5-word sentences per narrative 2 6 word sentences per narrative 3 7 word sentences per narrative 3 8 word sentences per narrative 2 reading level for each narrative 5 66 questionnaire a questionnaire (appendix g) to measure the primary dependant variables was developed, and included demo­ graphic information and three statements probing listener die suid-afrikaansetydskrif vir kommunikasie-afwykings, vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) s t r a t e g i e s for im p r o v i n g e f f e c t i v e n e s s of s p e a k e r s with m ix ed d y s a r t h r i a attitudes in the cognitive, behavioural and affective domains. these statements were selected as they directly address the three components o f attitude and were the same as those employed in the other studies (hustad, 2001b; hustad 8c gearhart, 2004). each o f the three variables were measured using a 7-point ordinal likert scale, with 1 = strongly disa­ gree and 7 = strongly agree. listeners were required to circle the number which most closely represented their perception o f each speaker. the statements were: (i) i think this person is an effective communicator using this strategy; (ii) i would feel comfortable communicating with this person in a class or at work if s/he used this strategy; and (iii) i would be will­ ing to communicate with this person in a class or at work if s/he used this strategy. in addition a qualitative question (“w hat feelings would you experience i f you were to com­ municate with the speakers?”) was included to obtain infor­ mation regarding the listener’s feelings/emotions towards the speaker after hearing the speaker. data collection procedures ethical considerations various ethical considerations were implemented throughout the research study. the researcher obtained ethi­ cal clearance from the human research ethics committee (medical) of the university o f the witwatersrand before this research study was implemented. written informed consent was obtained from the m n d association, parkinson’s dis­ ease association and all participants, using established and approved methods. all participants in the study were fully informed o f the nature o f the study and were assured o f an­ onymity and confidentiality. each participant was required to sign a consent form, providing proof o f his/her willing­ ness to partake in the study and had the right to withdraw from the study at any time, without suffering any negative consequences. data collection from the speakers with dysarthria: re­ cording speech samples the recording o f narrative samples took place in a qui­ et room in the speakers’ homes, and were obtained using a sony m ini-disc walkman (m z -r 900) digital audio re­ corder and a head mounted sennheiser microphone to limit disturbance noises during the recording as a result o f micro­ phone movement. jthe head mounted microphone helped to maintain a constant distance from the speaker’s mouth so as to obtain correct! sound levels during the recording. each speaker was instructed to read all four narrative passages, printed in font size 20 and presented directly in front o f the speaker, as naturally as possible to emulate a typical communication situation. the rate and prosody o f the speakers was not controlled. constructing the stimuli (audio-visual footage) the recorded speech samples were transferred digitally to a toshiba satellite (a100-519) laptop via the onboard sound card. the recordings were edited using digital audio editing software (acoustica v4.0).the speech samples were edited to remove extraneous comments, and the amplitude o f all the samples normalized to a -5 db setting using the sound editing software to ensure that all the speech samples were at a similar volume level. the edited speech samples were then combined with vis­ ual information to implement the combined topic-alphabet cue strategy using windows movie maker software (version 6, windows vista os). the visual orthographic information took the form of a text presentation on the screen showing the narrative topic cue, and the display o f the first alphabet letter o f each word spoken during the narrative. the display o f the alphabet cue visuals was synchronized to the actual speech sample, so that as the speaker produced each word, the first letter was displayed simultaneously in real-time. for the stimuli where no cues were used, a blank screen was dis­ played in the background whilst the audio speech sample was played. presentation of stimuli to the listeners the final step involved the presentation of the compiled stimuli to the unfamiliar (ul) and familiar (fl) groups. the audio-visual recordings containing the narrative samples of the three speakers associated with the combined cue con­ dition and the no cues condition were presented to the 36 listeners. all 36 listeners viewed the audio-visual footage in a quiet room at their place o f residence. all the listeners were seat­ ed during the viewing with the laptop positioned directly (0.5m) in front o f them. the volume was normalized at the maximum output o f the laptop for each listener, so that all the listeners listened to the stimuli at the same sound level. listeners were instructed that they would hear two speakers each reading a narrative, one purely auditory with­ out any supplementation cues and the other with the com­ bined alphabet and topic cue. the listener was briefed prior to the presentation on how the combined supplementation strategy worked and how it would appear on the screen. following the completion o f the listening task, all partic­ ipants were requested to independently complete the ques­ tionnaires after receiving verbal and written instructions on the requirements o f the questionnaire. randomization to prevent the possibility o f order and learning effect of cue conditions during the presenting o f the narrative audio­ visual stimuli to the listeners, the sequence o f the cue/no cue narratives shown to each listener was alternated. different sequences and combinations o f possible presentation orders for cues condition, speakers (3 speakers) and narratives (4 narratives) was used in the study. each listener in the unfa­ miliar listener group was matched to one o f the 18 in the fa­ miliar listener group. therefore 18 sequences were displayed in total, ensuring that no two listeners were exposed to the same speaker, narrative, and cue combination. data analysis the values obtained from the likert-type scales were re­ corded and collated for statistical analysis. descriptive sta­ tistics were utilized to summarize and organize the data col­ lected. a two-way repeated measure analysis of variance (anova) design was used (one-factor repetition) to de­ termine the effect o f the two experimental (‘familiarity’ and ‘cue/no cue’) factors on the listeners’ attitudes. the design used a within-subjects repeated measure for the ‘cues/no cues’ factor in the design, since the listener at­ titude rating measurements for both the cues and no-cues condition were obtained from the same listener participants. two different sample groups for the familiar and non-fa­ miliar listeners were used, and therefore repeated-measures the south african journal of c o m m u n ic atio n disorders, vol. 55 2008 | 67 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) natalie toy a n d karin joubert were not used for the ‘familiarity’ factor o f the listeners in the research design. the research design was employed for each o f the three listener attitude components measured in the study. the three dependant variables were the listener ratings o f com­ munication effectiveness (cognitive); listener feelings and emotions (affective); and willingness/persistence to com­ municate and understand the speaker (behavioural). results and discussion the results o f the study will be described and discussed in this section in relation to the aims o f the research. the results from the research data indicated mean listener at­ titude ratings across all listener and cue conditions (com­ bined cues and no-cue strategy) o f m = 3.241(sd = 1.852) for the cognitive component; m = 3.612(sd = 1.936) for the af­ fective component; and m = 4.00(sd = 1.933) for the behav­ ioural component. listener attitude ratings communicative effectiveness the mean attitude ratings for the communicative effec­ tiveness o f listener attitude are shown in figure 1 below. the figure shows a difference in the cognitive attitude rat^ & / o n o visual cues 13 c o m b in e d c u e s s t r a t e g y f a m ilia r l iste n e rs ( f t ) u n fa m ilia r l i s t e n e r s ( u l ) ustenergroups f igu re 1. m ean attitude (cognitive component) ratings f o r the listener groups (familiar, unfamiliar) with combined ings (mean) for the familiar listener group (combined cues: m =4.77, s d = 1.47;n o cues:m =2.88, sd =1.52) and the un­ familiar listener group ( combined cues: m =3.42, sd =1.55; no cues: m 1 .5 7 , s d -1 .5 0 ). the difference exists for both □ n o v isual cues b c o m b in ed cues stra te g y f a m ilia r lis te n e r s ( f l) u nfa m ilia r l isteners ( u l) ustenergroups the combined cues and no cues condition. listener emotions and feelings (affective) the mean attitude ratings for the affective attitude com­ ponent (see figure 2) show similar results to those observed for communication effectiveness, with a slight difference observed in the ratings between the familiar listener ( com­ bined cues: m = 5.00 sd =1.47; no cues: m = 2.88 sd=1.52) and unfamiliar listener group ( combined cues: m =4.21 sd = 1.55; no cues: m = 2.143 sd =1.50). again this differ­ ence is observed for both the cue conditions. listener willingness and persistence to communicate (behavioural) the results for the behavioural component (figure 3) o f the listener attitudes showed slightly higher mean ratings than the other attitude components. as observed in the pref igu re 2. mean attitude (affective component) ratings f o r the listener groups (familiar, unfamiliar) with combined cues, no cues condition 68 | die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol. 5 5 ,2 0 0 8 f ig u re 3. mean attitude (behavioral component) ratings f o r the listener groups (familiar, unfamiliar) with combined cues, no cues condition vious attitude component results, the behavioural attitude results show a slight difference between the familiar lis­ tener ( combined cues: m =5.3 8 sd =1.47; no cues: m = 3.056 sd =1.52) and unfamiliar listener groups ( combined cues: m = 4 .5 sd =1.55; no cues:m =2.85 sd=1.50). a two-way repeated measure analysis o f variance (anova) test with one factor repetition for the ‘cues/no cues’treatment was performed for each o f the three depend­ ant measures. the test assumes that the treatment factors have equal variances (this assumption was confirmed for each set o f dependent measure data by performing an equal variance test). the results o f the test are described for each treatment factor (‘familiarity’ and ‘cues condition) in the following section. listener familiarity hypothesis 1 stated that familiar listeners will have significantly higher ratings than unfamiliar listeners, per­ taining to their attitudes towards the speech o f dysarthric speakers, measured for the cognitive, affective and behav­ ioural components o f attitude. the results o f this hypothesis, when tested using a two-way repeated measure anova to compare the mean difference on the attitude ratings for f l as compared to u l is presented in table 4. results o f testing hypothesis 1 the two-way repeated measure anova tests applied to all 3 dependent measures (table 4) indicates that the differ­ ences observed in mean values for the ‘listener familiarity’ r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) s t r a t e g i e s f or im p r o v in g e f f e c t i v e n e s s of s p e a k e r s with m ix ed d y s a r t h r i a table 4. two way repeated measure a n o va (one factor repetition) results f o r listener attitude (cognitive, affective & behavioral components) dependent variable listener attitude(c ognitive) c om m unicative effectiveness ( equal variance test: passed (p = 0.596) source of vsnatios ss f p power/ test sensitivity familiarity 0.374 0.121 0.730 0.050 cue/no cue 68.881 29.796 < 0.001 1.000 fam iliarity x cue/no cue 0.00620 0.00268 0.959 0.050 dom o a riso n s fcir fa cto r^ * (overall sianificance level = 0.05) difference of means unadjusted p c ritical level s ig nificant fl vs. ul 0.444 0.730 0.050 no com bined cues vs. no cues 2.091 0.0169 0.050 yes listener attitude(affective) listener's c om fort, em otions equal variance test: source.of variation passed (p = 0.757) ss f p power/ test sensitivity fam iliarity 0.211 0.0761 0.785 0.050 cue/no cue 55.254 30.278 < 0.001 1.000 fam iliarity x cue/no cue 0.00397 0.00217 0.963 0.050 (io m b a riso ns for fa c to ri * (overall sianificance level = 0.05) difference o f means unadjusted p critical level s ig nificant fl vs. ul 0.333 0.785 0.050 no c om bined cues vs. no cues 1.673 0.0161 0.050 yes ¥ ' listener attitude(behavioral)-listener's willingness to communicate equal variance test: passed (p =1.000) source o f variation" ss f p power/ test sensitivity familiarity 0.988 0.294 0.592 0.050 cue/no cue 100.829 27.624 < 0.001 1.000 fam iliarity x cue/no cue 62.252 0.833 0.369 0.050 fcomoarisons for factors' * (overall sianificance level = 0.05) difference o f means unadjusted p c ritical level s ig nificant fl vs. ul 0.722 0.592 0.050 no com bined cues vs. i■jo cues 1.988 0.0210 0.050 yes type i, a = 0.050 * pair wise multiple comparison procedures (holm-sidak method): factor is not sufficiently.large to exclude the possibility that the difference is due to random sampling variance, when the effects o f the other factor (combined cues versus no cues strategy) is taken into account. comparison o f the f l and u l groups yielded mean differences between the groups of 0 .4 4 4 for the cognitive component (p=0.7 3 0 ); 0 .3 3 3 for the affective component (p=0.785); and 0 .7 2 2 for the behav­ ioural component (p=0.592). therefore there is no statisti­ cally significant difference in the scores o f the f l sample group as compared to the u l sample group, across all 3 lis­ tener attitudes. the study results therefore conclude that the hypothesis stating that ‘familiarity’ plays an influencing factor on the attitude ratings (all three components) o f listeners is not valid. the effect o f familiarization o f the listener in influenc­ ing their attitudes towards dysarthric speakers would there­ in contrast to the results indi­ cated by the longitudinal study carried out by de paul and kent (2000), which concluded that a familiar listener had superior performance over unfamiliar lis­ teners. according to their study, the performance was significant­ ly improved especially during the individuals’ second year o f pro­ gression o f m n d when their speech intelligibility decreased markedly. several factors may have con­ tributed to the current results. the familiar listener participant group was defined as listeners who had experience in commu­ nicating on a daily basis with persons with a communication disorder. however, it did not specify the degree o f the dysar­ thria o f the person that these fa­ miliar listener individuals com­ municated with or had contact with. in this study, the familiar listener participants were ‘fa­ miliar’ with individuals who had parkinson’s disease. it was noted that many o f the familiar listen­ ers communicated with individ­ uals in the early stages o f parkin­ son’s disease, where their speech was only mildly impaired. these ‘familiar’ listener participants would therefore not have any substantial experience in com­ municating with speakers who had severe dysarthria. in this study the duration o f interaction between the famil­ iar listener and speaker was not specified and this variability of exposure was not taken into ac­ count. the familiar listener may have interacted with the in­ dividual for a month or a few years. this is in contrast to the longitudinal case study done by de paul and kent (2000). therefore, the researchers’ selection criteria had to be stricter in specifying the frequency and length o f exposure to an in­ dividual with dysarthria, as well as the severity of dysarthria. however the researchers were unable to define the selection criteria to include exposure and stricter familiarity require­ ments for the study due to the nature and time limitations o f the research. speech supplementation strategy (combined cues vs. no cues) hypothesis 2: the use o f a speech supplementation strategy, in this case the combined topic and alphabet cues will yield higher ratings, than the use o f no cues pertain­ ing to listeners’ attitudes towards the speech o f dysarthricfore appear to play no significant role. this result is however the south african journal of communication disorders, vol. 55 2008 69 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) natalie toy a n d karin joubert speakers. results o f testing hypothesis 2 the results o f the two-way repeated measure anova (one factor repetition) analysis are presented in table 4 in the previous section. this analysis compared the mean dif­ ference on the listener attitude ratings for the use o f the combined topic and alphabet cue, as compared to the use o f no cues pertaining to their attitudes towards the speech o f dysarthric speakers. three components o f attitude were measured namely, cognitive, affective and behavioural. c om m unicative effectiven ess (cogn itive); the two-way repeated measure anova. determined that there was a statistically significant difference (p=<0.001) in the mean values among the different levels o f cues. the difference in the mean values among the different levels o f cues is greater than would be expected by chance after allowing for the ef­ fects o f differences in familiarity. the two-way repeated measure revealed ratings o f effec­ tiveness that were significantly higher for combined cues than for the no cue condition. all the statistical findings for ratings o f communication effectiveness in this study are consistent with intelligibility data obtained in previous studies (hustad, 2003; hustad &beukelman, 2003; hustad et al., 2003). the indication is that the combined topic and alphabet cue results in more favourable ratings o f effective­ ness and intelligibility than the no cue condition. according to hustad (2001b), a reason for the positive effect o f the combined cue on effectiveness rating may be that all the listeners recognized attempts to enhance speech via the strategy presentation and they equated the use of the multiple supplementation strategies as trying “harder” to compensate to a greater extent for the communication difficulties. l isten er com fort an d em otion (affectiv e): similarly, the two-way repeated measure anova determined that there was a statistically significant difference (p=< 0.001) in the mean values among the different levels o f cues. as was the case for listener effectiveness combined cues yielded more favourable affective attitude ratings than the no cue con­ ditions. the results suggest that the more information the listener has about a topic the more comfortable they would be to interact with the speakers. participants stated that be­ cause they were provided with the topic o f the narrative, as well as the alphabet cues, they were able to anticipate and understand more o f what the speaker was saying. l isten er persisten ce (behaviou ral): again, the two-way repeated measure anova determined that there was a sta­ tistically significant difference (p= <0.001) in the mean be­ havioural rating. listeners are therefore more persistent to interact with speakers that employed the combined topic and alphabet cue supplementation strategy in conjunction with their habitual speech, as compared to the no cue con­ dition. the overall results o f the present study showed that the u l and f l sample groups were from the same population group and therefore listener familiarity was not a favourable indicator o f increased intelligibility and listener attitude rat­ ings. however, the present study did show that the com­ bined alphabet and combined cue supplementation strategy used in conjunction with habitual speech, resulted in sig­ nificantly higher ratings o f listeners’perceptions o f the com­ munication o f speakers with dysarthria ranging from 33% 67% intelligibility. it is however important to consider these findings in light o f the limitations o f the research. the study employed a traditional experimental paradigm which differs significant­ ly from naturalistic, real life communication situations. as the speakers and listeners did not converse and interact with one another in communicative exchanges, extra-linguistic factors such as gesture, body language and facial expression used in conjunction with verbal communication were omit­ ted. the listeners were also not able to directly interject and ask for clarification from the speaker. the content, form and use o f messages produced by the speaker were also scripted, and the environment in which the listeners heard the audio recordings was manipulated for an ideal listening and viewing condition. the audio-visual material presented to the listeners for viewing and listen­ ing was digitally enhanced, so that all the cues used were clearly and readily visible. in a real life situation and im­ plementation o f these supplementation strategies, the com­ municative partner does not have the advantage o f this type o f digital enhancement. the communicative partner would have to deal with the effects o f lighting, distance from the speaker and the angle at which the partner is facing towards the speaker. in addition the speech patterns o f the speaker may have been different if they were directly implementing the supplementation strategy, for example slowing down of their speech rate as they point to the various alphabet cues, thus affecting their overall speech intelligibility as perceived by the listener. these factors need to be considered in light o f the current research. the sample size o f the study involved only 3 speakers with dysarthria and 36 listener participants; therefore this relatively small sample size may have an influence on the reliability and validity o f the study. in addition the partici­ pants in the study were restricted to a specified age range. the results indicated by the study may not be fully repre­ sentative o f the general population. ' in this study, only three likert-type questions were used to gather information regarding listener attitudes. although the construct o f attitude and its constituent components (cognitive, affective and behavioural) are well grounded in literature (hustad 8c gearhart, 2004), measurement of these constituents in a research study is more complex. the measurement o f listener attitudes based on three questions cannot fully account for the many different facets o f a listen­ er’s attitude and it is suggested that future research should aim to adapt or develop a more comprehensive instrument with well-described psychometric properties to explore lis­ tener attitudes. the results o f the qualitative question: “w hat feelings would you experience if you were to communicate with the ■■ speakers?”indicated a few general trends across all 36 listen­ ers’emotional reactions towards the 3 speakers. the majority o f listeners felt a great sense o f empathy and awkwardness towards the speakers because they acknowledge the speak­ ers’ intent to communicate, but still struggled to understand them. listeners stated a great sense o f awkwardness in not knowing what the speaker is saying and not being able to re­ 7 0 | die suid-afrikaansetydskrif vir kommunikasie-afwykings, vol. 55, 2008 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) s t r a t e g i e s for im pr o v in g e f f e c t i v e n e s s of s p e a k e r s with m ix e d d y s a r t h r i a spond appropriately during a communicative exchange. listeners also stated becoming highly frustrated with the speakers and frequently becoming quite impatient. most of the participants stated that it would have been easier to un­ derstand what the speaker was saying, if they were face-to face with the speaker in comparison to only being able to listen to a recording o f their speech. the majority o f the participants did indicate that they found the cues beneficial in helping them to understand the speaker. however, a few listener participants did state that they found the visual cues misleading, stating they had difficulty in focusing on the cues and integrating the visual and auditory stimuli (this was particularly evident when the speaker spoke at a fast rate). conclusion the overall aim o f the study was to determine the influ­ ence o f familiarity on a listener’s attitude towards speakers with mixed dysarthria. the findings of this study concluded that familiarity has no statistically significant influence on their attitudes towards speakers with mixed dysarthria. the results, however did suggest that speakers whose speech intelligibility is severely reduced may benefit mark­ edly from using a combined topic-alphabet cue strategy, as within this experimental research paradigm, the combined cue strategy resulted in more favourable listener attitudes. in addition, listeners appeared to be more comfortable and persistent in communicating with speakers who implement­ ed the combined cues. although many variables are likely to influence listener attitudes, there is strong evidence to sug­ gest that listener attitudes are closely linked to intelligibility (hustad 8c gearhart, 2004). the findings o f the influence o f familiarity on the listener attitudes may possibly have been affected by the time con­ straints imposed on the study and an insufficient definition o f the familiar listener. it is suggested that the definition o f a familiar listener include specific detail on the duration and frequency o f interaction with the person with dysarthria as well as the severity o f the reduction in the speaker’s intelli­ gibility. other studies (depaul 8c kent, 2000) indicated that familiarity does lead to significant performances on speech intelligibility and therefore listener attitudes. it further in­ dicated that an advantage o f familiarity evolved over time and reached a maximum level when the speech impairment was significantly reduced in intelligibility (depaul 8c kent, 2000). the results o f the study should be interpreted in light of the experimental nature o f the study where the listeners did not communicate in a real communicative exchange and it therefore does not permit generalisation to ecologically val­ id communication situations. this study however has important implications in the clinical management o f individuals with motor speech dis­ orders, such as dysarthria. the implementation o f speech supplementation strategies such as the use o f combined al phabet-topic cues can improve the communicative effective­ ness and lead to more favourable interactions with listeners. future research should address the attitudes o f unfamil­ iar and familiar listeners towards individuals with different severity levels and speech characteristics, using more natu­ ralistic speech samples. it is important that future research should take intra-rater reliability into account by repeating a small proportion o f speech samples. in addition, a quali­ tative approach could be employed to investigate how aac strategies affect listener attitudes to provide information re­ garding what listeners think, feel and believe when faced with speakers using aac. references antonak, r., 8c livneh, h . (1988). the measurement o f atti­ tudes towards people with disabilities. charles c. thomas: springfield, il . beliveau, c., hodge, m ., 8c hagler, p. (1995). effects of supplemental linguistic cues on the intelligibility o f se­ verely dysarthric speakers. augmentative and alternative communications, 1 1 , 176-186. beukelman, d. r., yorkston, m ., 8c reichle, j. (2000). a ug­ mentative and alternative communication fo r adults with acquired neurological disorders. brooks publishing co.: baltimore. beukelman, d ., 8c yorkston, k. (1977). a communication system for the severely dysarthric speaker with an intact language system .journal o f speech and hearing disorders, 4 2 , 265-270. britnell, e. s., madill, h. m ., montgomerie,t. c., 8c stew in, l. l. (1992). work and family after injury: do female and male client perspectives differ? career development quarterly, 4 1 , 145-160. crow, e ., 8c enderby, p. 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(1998). against all odds: posi­ tive life experiences o f people with advanced amyotroph ic lateral sclerosis. health and social work, 2 3 (1), 35-43. yunusova, y., weismer, g ., kent, r. d., 8c rusche, n. m . (2005). breath-group intelligibiity in dysarthria: charac­ teristics and underlying correlates.journal o f speech, l an ­ guage and hearing research, 4 8 (6), 1294-1310. 72 | die suid-afrikaansetydskrif vir kommunikasie-afwykings, vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) appendix a stages of dysarthria (mathy, yorkston, & gutmann, 2000) s t r a t e g i e s for im p r o v in g e f f e c t i v e n e s s of s p e a k e r s with m ix e d d y s a r t h r i a stage 1: no detectable speech disorder __ _______________________________________ • speech of individuals with a spinal presentation of als sounds normal. • speaker notices a change in function. • listeners note no changes in speaking rate, precision or loudness.____________________________ stage 2: o bvious speech disorder w ith intelligible speech_______________________________________ • changes in speech are apparent. • changes may be more apparent with stress or fatigue. most speakers compensate unconsciously for articulator or respiratory impairment by decreasing their speaking rate and the length of their breath groups. speech at this stage remains easy to understand, although voice quality maybe harsh or breathy ______ or mild articulator problems may be present._________________________________________________ stage 3: reduction in speech in te llig ib ility__________________________ ___________________________ • speaking rate, articulation and resonance are impaired and may make speech difficult to understand, depending on the communication environment. • helpful strategies include maintaining a slower speaking rate, conserving energy, increasing the precision of speech production and developing strategies to resolve communication breakdowns. individuals can do with modifying their speech production (kennedy, strand, & yorkston, 1994). • some speakers begin to use aac techniques to resolve breakdowns. when speaking rate is 50% or less, aac assessment and intervention should be initiated. • helpful strategies include maintaining a slow speaking rate, conserving energy, increasing ______ precision of speech production, and developing strategies to resolve communication breakdown. stage 4: natural speech supplemented w ith augmentative com m unication_______________________ speech must be combined with aac approaches (kazandijan, 1997). • natural speech may be limited to highly predictable messages, such as responses to questions and greetings. • the speaker must supplement natural speech by writing key words or pointing to the first letter of each word he or she speaks. • intervention for speakers at this stage may include alphabet supplementation, changing communication modes for different situations, an alerting signal for gaining attention, augmented ______ telephone communication, and portable writing systems (hustad, 1999)_______________________ stage 5: no useful speech_____________________________________________________________________ • speakers with advanced bulbar als lose speech function. some individuals at this stage may vocalize for emotional expression or with extreme effort but do not produce understandable speech. ■ intervention for speakers at this stage may include establishing reliable yes/no system, eye-gaze systems and communication systems for speaker’s dependant on ventilators, and integrated ______ multipurpose aac systems________________________________________________________________ the south african journal of c o m m u n ic atio n disorders, v o l 55 2008 73 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) appendix b natalie toy a n d karin joubert narrative stimuli narrative 1: a holiday it was an amazing holiday (5). we gathered shells on the beach (6). we also saw dolphins swimming in the sea (8). we spent hours lying in the warm sun (8). one day we hiked up table mountain (7). the view was so magnificent and peaceful (7).lt was the best experience ever (6). we have a beautiful country (5).the week had come to an end (7). my fun holiday had officially ended (6). narrative 2: a sporting event the two batsmen walked onto the cricket field (8). the crowd was cheering wildly (5). everyone was standing and clapping their hands (7). the sun was shining directly overhead (6). the umpires briefly spoke to each other (7). they asked the players to begin the match (8). each player went to their position (6). the crowd started a mexican wave (6). it went round and round the stadium (7). it was a great game (5). narrative 3: my wedding day the special day had arrived (5). finally, my eldest daughter was leaving home (7). it was an exciting day (5). the church hall was decorated with red roses (8). the bridesmaids wore pink satin dresses 6). the groom and his best man wore white tuxedo’s (8). a silver limo arrived at twelve o’ clock (7). the wedding music started to play (6). we walked together down the aisle(6). then my daughter looked at me and smiled (7). narrative 4: the trip to the doctor i woke up with a fever and headache (8). i could barely sit up (5). i was in such pain and discomfort (7). the whole night i could not sleep (7). my grandmother took me to the doctor’s office (8). i waited there for 40 minutes (6). my grandmother was angry and frustrated (6). finally, i went into the doctor’s office (7). i hated going to the doctor (6). i went home and slept (5). 74 | die suid-afrikaanse tydskrif vir kommunikasie-afwykings, v o l 55, 2008 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) date: a pp en d ix c attitude questionnaire code: ____ s t r a t e g i e s for im p r o v in g e f f e c t i v e n e s s of s p e a k e r s with m ix ed d y s a r t h r i a highest level of education: date of birth: _________________________________ sex: male/ female age: _________________________ ;________________ first language:_________________________________ relationship to the person with parkinson’s disease: spouse/ parent/ caregiver/ family friend/other if other, please describe:____________________________ do you have any hearing problems? if yes, please describe:_________________________________ do you have any language, learning or cognitive problems? if yes, please describe:_________________________________ the south african journal of c o m m u n ic atio n disorders, v o l 55 2008 | 75 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) natalie toy and karin joubert appendix c (continued) i th in k this person is an effective com m unicator using this strategy disagree agree strongly strongly ■ j. w ould fee[ com fortable com m unicating w ith this person in a cjass or at w ork if he/she used this strategy 1 2 3 4 5 6 7 disagree agree strongly strongly i w ould be w illing to com m unicate w ith this person in a class or at w ork if he/she used this strategy. 1 2 3 4 5 6 7 ; disagree agree ! strongly strongly ; section b please com plete the follow ing questions tru th fu lly and to the best o f your knowledge: what feelings would you experience if you were com m unicating to the tw o previous speak76 | die suid-afrikaansetydskrif vir kommunikasie-afwykings,vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) abstract introduction materials and method results discussion conclusion acknowledgements references about the author(s) lucia j. stevenson department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa leigh biagio-de jager department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa marien a. graham department of science, mathematics and technology education, faculty of education, university of pretoria, pretoria, south africa de wet swanepoel department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa ear science institute australia, perth, australia citation stevenson, l.j., biagio-de jager, l., graham, m.a., & swanepoel, d.w. (2022). a longitudinal community-based ototoxicity monitoring programme and treatment effects for drug-resistant tuberculosis treatment, western cape. south african journal of communication disorders, 69(1), a886. https://doi.org/10.4102/sajcd.v69i1.886 project registration number: project research number: 23051592 (gw20161128hs) original research a longitudinal community-based ototoxicity monitoring programme and treatment effects for drug-resistant tuberculosis treatment, western cape lucia j. stevenson, leigh biagio-de jager, marien a. graham, de wet swanepoel received: 09 dec. 2021; accepted: 06 feb. 2022; published: 31 mar. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: south africa has a high burden of drug-resistant tuberculosis (drtb) and until recently, ototoxic aminoglycosides were predominant in treatment regimens. community-based ototoxicity monitoring programmes (omps) have been implemented for early detection of hearing loss and increased patient access. objectives: a longitudinal study was conducted to describe the service delivery characteristics of a community-based omp for drtb patients facilitated by chws as well as observed ototoxic hearing loss in this population. method: a descriptive retrospective record review of longitudinal ototoxicity monitoring of 194 drtb patients undergoing treatment at community-based clinics in the city of cape town between 2013 and 2017. results: follow-up rates between consecutive monitoring assessments reached as high as 80.6% for patients assessed by chws. few patients (14.2% – 32.6%) were assessed with the regularity (≥ 6 assessments) and frequency required for effective ototoxicity monitoring, with assessments conducted, on average, every 53.4–64.3 days. following drtb treatment, 51.5% of patients presented with a significant ototoxic shift meeting one or more of the american speech-language-hearing association (asha) criteria. deterioration in hearing thresholds was bilateral and most pronounced at high frequencies (4 khz – 8 khz). the presence of pre-existing hearing loss, human immunodeficiency virus co-infection and a history of noise exposure were significant predictors of ototoxicity in patients. conclusion: drtb treatment with kanamycin resulted in significant deterioration of hearing longitudinally, predominantly at high frequencies. with ongoing training and supportive supervision, chws can facilitate community-based ototoxicity monitoring of drtb patients. current protocols and guidelines may require reassessment for appropriate community-based ototoxicity monitoring. keywords: community-based services; community health workers; decentralised services; tuberculosis; drug-resistant tuberculosis; hearing loss; ototoxicity monitoring; audiometry; south africa. introduction tuberculosis (tb) is a communicable disease spread when people who are sick expel the tb-causing bacteria into the air (world health organisation [who], 2020a). although tb can be successfully prevented and treated (cox et al., 2019), it is the leading infectious disease and one of the top 10 causes of death globally (who, 2020a). africa accounted for 25% of the 10 million people globally who developed tb in 2019, with south africa being identified by the who as a high-burden tb country (who, 2020a). furthermore, south africa has a high prevalence rate (19.5%) of human immunodeficiency virus (hiv) infection for adults aged 15–49 years (republic of south africa statistics department, 2021; wells et al., 2007). in 2019, 209 000 people in the country were afflicted with tb and hiv (who, 2020a). tuberculosis may accelerate the course of hiv infection, which may contribute to the increase in the prevalence of drug-resistant tb (drtb) in patients with tb (wells et al., 2007). tuberculosis that is resistant to at least two of the most effective anti-tb drugs, rifampicin and isoniazid, is known as drtb (centers for disease control and prevention [cdc], 2016). rifampicin-resistant tb (rrtb) and multidrug-resistant tb (mdrtb), which are different types of drtb, continue to be a public health threat (who, 2020a) that jeopardises the control of tb (horsburgh, mitnick, & lange, 2019). close to half a million people developed rrtb globally in 2019, 78% of whom had mdrtb (who, 2020a). south africa has the highest number of patients with mdrtb on the african continent (lange et al., 2019), with an estimated 23 out of every 100 000 people being infected with rr/mdrtb (who, 2020a). treatment of drtb takes longer and requires drugs that are more expensive and more toxic than those used for the treatment of tb (who, 2020a). before 2018, the who and the south african department of health (department health republic of south africa [doh], 2013) included the use of a second-line injectable antibiotic (either an aminoglycoside such as kanamycin, or a polypeptide) in the drtb treatment regimen (wrohan, redwood, ho, velen, & fox, 2021). aminoglycoside antibiotics are known to affect hearing and balance, or both, through ototoxicity in the cochleovestibular organ (campbell & le prell, 2018). outer hair cell damage starts at the basal coil and progresses to the apex of the cochlea, resulting in a permanent high-frequency hearing loss, progressing to the lower frequencies (de jager & van altena, 2002). damage to the outer hair cells is followed by progressive loss of the inner hair cells in more severe cases (xie, talaska, & schacht, 2011). the prevalence rate of aminoglycoside-induced ototoxicity in drtb patients, which is estimated as 63% of patients (who, 2021b), is dependent on the drug, drug dosage, treatment duration (huth, ricci, cheng, & pearson, 2011; schacht, talaska, & rybak, 2012; xie et al., 2011) and patients’ demographic profile (ramma, heinze, & schellack, 2019). in the western cape, it has been reported that around 47% – 57% of drtb patients have developed aminoglycoside-induced hearing loss (melchionda et al., 2013; petersen & rogers, 2015; ramma et al., 2019). concerns regarding the ototoxic nature of injectable antibiotics and the availability of novel, less toxic, more effective drugs led to an update of the south african department of health (doh, 2018) and who drtb treatment guidelines in 2018 and 2019, respectively (who, 2020b; wrohan et al., 2021). the latest drtb treatment guidelines recommend a shorter, all-oral regimen containing bedaquiline for the treatment of rr/mdrtb (doh, 2018; who, 2020b). bedaquiline has fewer side effects than the other drugs used to treat drtb (medicins sans frontieres [msf], 2020) and does not appear to be associated with hearing loss, unlike kanamycin (khoza-shangase & prodromos, 2021). however, an all-oral regimen may not be suitable for all patients, and therefore the guidelines continue to include the use of amikacin, which is associated with an estimated hearing loss prevalence of 38.9% (dillard et al., 2021; evans et al., 2015; who, 2020b; wrohan et al., 2021). furthermore, access to novel drugs has remained limited (msf, 2020). between 2015 and 2019, only one in nine people across 36 countries who could benefit from bedaquiline received the medication (cox et al., 2018; msf, 2020). despite their adverse effects, aminoglycoside antibiotics are used in high-burden tb countries because they are easily accessible and inexpensive, leading to an increased burden of aminoglycoside induced hearing loss (bardien et al., 2009; campbell & le prell, 2018). almost half (46%; 17/37) of the countries whose national policies and practices were surveyed in 2019 (msf, 2020) reported still using kanamycin or capreomycin in the treatment of drtb, contrary to the latest recommendations (who, 2020a). in addition, the coronavirus disease 2019 (covid-19) pandemic threatens to undo the progress made in tb control as it causes major disruptions to essential tb services and threatens to increase the burden of tb disease (who, 2020a). as a result, a substantial number of patients may develop ototoxic hearing loss and require hearing loss prevention strategies, including audiological ototoxicity monitoring (dillard et al., 2021). when the use of injectable ototoxic medications is unavoidable, audiological ototoxicity monitoring is essential to optimise hearing-related outcomes (who, 2021b; wrohan et al., 2021). audiological ototoxicity monitoring encompasses the regular assessment of patients’ hearing thresholds during treatment to detect early changes in hearing, so that treatment regimens can be adjusted and disabling hearing loss can be avoided (who, 2021b). in response to the high prevalence of ototoxic hearing loss associated with drtb treatment, the south african national tb control programme implemented the national ototoxicity prevention programme to improve the access to audiological monitoring and reduce the prevalence of ototoxic hearing loss (who, 2021b). as part of this programme, portable audiometers and training were offered to selected decentralised health facilities, including primary healthcare (phc) facilities (who, 2021b). patients with drtb were able to access ototoxicity monitoring services outside centralised tb hospitals, increasing access to care (doh, 2013; ndjeka et al., 2020; the south african national aids council, 2017). the south african department of health has committed to addressing the disparity in human resources for health by prioritising the integration of 50 000 community health workers (chws) into the phc system by 2024 (doh, 2020). community health workers are individuals working in the community in which they reside who are selected and trained to broaden the access and coverage of health care services in remote areas (who, 2007). community health workers engage in task-sharing, which involves the shifting of health care tasks from highly skilled professionals such as audiologists to workers with shorter training, such as chws (dillard et al., 2021; doh, 2020). task shifting (mulwafu, ensink, kuper, & fagan, 2017) and incorporating ototoxicity monitoring into existing service delivery models, such as community-based health care services, have been proposed to address the barriers to ototoxicity monitoring (dillard et al., 2021). to improve the efficacy and efficiency for early detection of hearing changes, existing ototoxicity monitoring programmes (omps) and treatment effects should be evaluated so that ototoxicity monitoring guidelines can be adapted to specific settings (dillard et al., 2021; health professions council of south africa [hpcsa], 2018). the current study, therefore, aimed to describe the service delivery characteristics of a community-based omp for patients with drtb, facilitated by chws and phc audiologists using conventional audiometry (0.25 khz – 8 khz) for ototoxicity monitoring according to the timing, frequency and follow-up rates of ototoxicity monitoring assessments. in addition, this study aimed to describe the ototoxic hearing loss observed in drtb patients over time. to our knowledge, this is the first study to report on observed longitudinal treatment effects for drtb and ototoxicity monitoring conducted by chws in a decentralised community-based model of care for increased patient access. materials and method this study was part of a larger, longitudinal descriptive retrospective record review of a decentralised community-based omp for patients with drtb facilitated by chws between 2013 and 2017. this specific omp was selected for investigation as it offers a novel approach to ototoxicity monitoring for drtb patients with a timeframe allowing for as many study participants as possible. the data were collected at community health centres and phc clinics in two sub-districts of the city of cape town (coct), namely the [location masked for blind review] and [location masked for blind review] sub-districts. at the time of data collection, the sub-districts were characterised by a predominantly coloured (30% – 50%) and black african (19% – 46%) population who mostly resided in formal dwellings (68% – 87%) (coct, 2013a, 2013b, 2013c, 2013d). most people living in the sub-districts included in this study were employed (68% – 87%), with 32% – 60% of people having completed high school education (grade 12) (coct, 2013a, 2013b, 2013c, 2013d). this study aimed to supplement the findings of a larger study by describing the service delivery characteristics of a community-based omp for drtb patients facilitated by chws and phc audiologists and the ototoxic hearing loss observed in this population over time. participants this study included patients from a larger study who met the following selection criteria: patients who (1) received kanamycin, (2) were tested using conventional audiometry (0.25 khz – 8 khz), (3) had a baseline assessment conducted before, on the same day, or within 2 weeks of initiation of medication, and (4) had one or more follow-up monitoring assessments using conventional audiometry thereafter. the selection criteria were based on the omp protocol and guidelines for ototoxicity monitoring (hpcsa, 2018) to allow for comparability. non-probability purposive sampling was used to select all patients with drtb, regardless of age, gender or hearing status. of the 831 patients included in the parent study, 194 patients met all the selection criteria and were eligible for inclusion in this study (figure 1). the patient interviews and ototoxicity monitoring assessments were conducted by six chws and two phc audiologists at 19 of the sub-districts’ phc clinics and community health centres. in 2012, the western cape department of health, in collaboration with the university of cape town, initiated a pilot project in which 30 chws underwent a year-long certificate training programme to become members of the phc team (clark, 2015; gamiet & rowe, 2019). the chws were provided with skills and knowledge in community-based rehabilitation to support people with disabilities in two underserved communities in the western cape (gamiet & rowe, 2019). to facilitate ototoxicity monitoring for drtb in a community-based setting, six chws received additional training from the phc audiologist responsible for the mitchells plain/klipfontein sub-district. the six chws were also trained to conduct home-based hearing screening and hearing screening of school-aged children and patients attending a phc clinic. figure 1: patient selection procedure. data collection procedure the data collection procedure for this study was the same as for the larger study (stevenson et al., 2021). the omp protocol implemented at the time of data collection was as follows: all patients who received ototoxic medication for treatment of drtb were identified and referred by their managing doctor and included in the omp as part of the package of care. patients visited a clinic or centre daily for the first 6 months of treatment to receive their medication from a nurse. after the initial 6-month treatment period, medication was continued for 18 months, with patients visiting a clinic weekly to obtain their medication, and monthly to consult with their managing doctor. at the time of data collection, the official south african ototoxicity monitoring guidelines had not yet been published, thus the omp developers relied on adapting the international guidelines of the american speech-language-hearing association (asha) (asha, 1994) and the american academy of audiology (aaa) (aaa, 2009) when developing the omp protocol. an unpublished draft of the hpcsa ototoxicity monitoring guideline was, however, available to the omp developers to assist them in applying the international guidelines to the south african context. community health workers and phc audiologists travelled to the clinics in each sub-district with portable audiological equipment. community health workers and phc audiologists were testers in the mitchells plain/klipfontein sub-district, whereas only phc audiologists were testers in the western or southern sub-district. at the time of a patient’s baseline assessment, identifying information including the patient’s name, date of birth, gender and medical history pertaining to hiv status, drtb medication/s, comorbidities and adverse effects were recorded manually on a paper data collection form by chws and phc audiologists. this information was obtained from the patient’s medical records in a clinic file and/or verbally reported to the chws and phc audiologists during the patient interview. the kuduwave portable audiometer (emoyo, south africa) was used by chws and phc audiologists in this study. the kudu wave is a pc (dell laptop) controlled clinical diagnostic audiometer, and integrated supra-aural ear-cup and insert earphone headset, with an electronic response button for use without a soundproof booth. automated and manual programmes conduct audiometry up to 16 khz. results are stored electronically and store-and-forward for printing. the protocol for baseline and monitoring audiological ototoxicity monitoring assessments followed by the omp at the time of data collection was as follows: a bilateral otoscopic examination was conducted followed by air-conduction pure-tone audiometry, and the findings recorded on the data collection form. if outer or middle ear pathology was suspected following otoscopy, the patient was referred to the managing doctor or nurse for appropriate treatment and referred for audiometry, according to the omp protocol. baseline assessments were conducted at the clinics prior to, on the same day or within 2 weeks of drtb treatment initiation. monitoring assessments were conducted once a month during the initial 6-month treatment regimen and then at 3, 6 and 18 months thereafter. where an ototoxic shift meeting predetermined criteria (asha, 1994) was evident, the managing doctor was informed, and monitoring assessments were then conducted every 2 weeks until no change in hearing thresholds was detected. assessments were conducted in a quiet environment using conventional audiometry (0.25 khz – 8 khz). typically, manual testing would have been done; however, an automatic mode of threshold determination may also have been used in some instances. the equipment required to conduct both conventional audiometry and extended high-frequency (ehf) audiometry became available in november 2015 for use in the [location masked for blind review], and in july 2016 for use in the [location masked for blind review] sub-district. before this, only conventional audiometry was available for ototoxicity monitoring. each patient’s descriptive and audiological data were recorded manually by the chws and phc audiologists on paper data collection forms and stored in the patient’s clinic file. a copy of each patient’s data collection form was kept with the chws and phc audiologists and regularly made available for review to the managing phc audiologist responsible for each sub-district. upon completion of a patient’s drtb treatment and ototoxicity monitoring, the form was stored permanently with the phc audiologist responsible for each sub-district. the researchers collected the hardcopies of the patients’ data collection forms from the managing phc audiologists in each sub-district for analysis, and these were returned upon completion of this study. data analysis data were imported from excel into statistical package for social sciences (spss) software (version 27), after which descriptive statistics such as frequency distributions, measures of central tendency and measures of variability were used to present and interpret the data in a meaningful way. data cleaning was performed where data erroneously captured by the chws, phc audiologists and/or the researcher, such as dates, were corrected to be in a uniform format. in cases where data was accidentally not captured by the researcher, the data collection forms were re-examined to supplement any missing data. because the data differed significantly from normality (shapiro–wilk p < 0.05), nonparametric tests were used (field, 2018). the wilcoxon signed-rank (w) test was used to compare significant differences between dependent groups (baseline assessment and exit assessment). the mann–whitney u (u) test was used to determine whether there was a difference in the variables (timing of baseline assessments and the number of monitoring assessments attended by patients) for independent groups (patients assessed by chws and patients assessed by phc audiologists). in order to determine significant predictors for hearing deterioration, multiple linear regression models with many assumptions were run initially; one of these assumptions is that the error terms must be normally distributed. the error terms in this study were not normally distributed. therefore, quantile regression models, which are robust to outliers and do not require the assumptions of normally distributed error terms, were used instead. for inferential statistics, a 5% level of significance was used throughout. the omp used paper data collection forms, which were manually completed by the chws and phc audiologists for each patient. where important data were missing, this was because data were not recorded on the data collection forms by the testers, and were therefore unavailable for inclusion in this retrospective study. ethical considerations the study was conducted according to the guidelines of the declaration of helsinki and was approved by the institutional review board (or ethics committee) of the university of pretoria (gw20161128hs; 63/2017), the coct (7788) and the western cape department of health (wc_2017rp22_896). owing to the retrospective nature of this study, consent to access the existing data collection forms on behalf of the patients was granted by the western cape department of health and the coct health department. all patient identifying information was kept confidential as patient records were given a numerical code in order to ensure anonymity during data collection and analysis. data from the data collection forms were recorded on a password-protected excel spreadsheet for later analysis by the researchers. results participants of the 831 patients included in the parent study, 201 met the participant selection criteria and were eligible for inclusion in this study. seven patients with results indicating technical or procedural issues related to their baseline and exit assessment audiograms (i.e. improved thresholds [> 50 db hl] across all frequencies) were excluded. a final sample of 194 patients (figure 1) was included, as presented in table 1. the mean age of patients was 36.2 years (standard deviation [sd] = 11.3; range = 15.0 – 65.1 years). the gender of 33.0% (64/194) of the patients was not recorded by chws and phc audiologists on the data collection forms and was thus unavailable for inclusion in this retrospective study. at the time of the baseline assessment, 24.7% (48/194) of patients reported having drtb and hiv co-infection, 20.6% (40/194) reported a history of excessive noise exposure and 18.0% (35/194) reported experiencing tinnitus. patients’ baseline assessments were conducted, on average, 16.8 days (sd = 86.5; range = –494 to 14 days) before treatment initiation. table 1: participant description at the time of the baseline assessment (n = 194). ototoxicity monitoring programme characteristics timing and frequency of ototoxicity monitoring assessments community health workers tested 76.3% (148/194) of the patients in the study. there was a statistically significant difference (p = 0.003; u = 2406.5) between the timing of baseline assessments by chws and by phc audiologists. patients assessed by phc audiologists had a baseline assessment conducted on average 52.0 days (sd = 134.9) before treatment initiation, while the patients assessed by chws had a baseline assessment conducted on average 5.9 days (sd = 61.2) before treatment initiation. there was a statistically significant (p = 0.019; u = 2637.0) difference between the average number of follow-up visits made by patients between chws and phc audiologists; excluding the baseline assessment, patients assessed by phc audiologists attended, on average, 4.3 (sd = 2.5; 46/194) monitoring assessments, while patients assessed by chws attended, on average, 3.3 (sd = 2.1; 148/194) monitoring assessments. only 14.2% (21/148) of patients assessed by chws attended six or more monitoring assessments as recommended by the hpcsa (hpcsa, 2018) and the omp protocol (figure 2), compared with 32.6% (15/46) of patients assessed by phc audiologists. figure 2: percentage of patients attending assessments following the baseline assessment according to tester. ototoxicity monitoring programme follow-up rates the follow-up rates of the first six monitoring assessments for patients assessed by phc audiologists (69.2% – 87.0%) were higher than for those assessed by chws (51.2% – 80.6%) (table 2). the average days elapsed between monitoring assessments were fewer for patients assessed by chws (53.4 days; sd = 10.3) than for patients assessed by phc audiologists (64.3 days; sd = 19.3) (table 2). both groups exceeded the 14–30 days between monitoring assessments recommended by the hpcsa (hpcsa, 2018) and the omp protocol. table 2: follow-up return rates and average days between consecutive pure tone audiometry assessments according to tester type. ototoxicity characteristics treatment effects on hearing more than half (51.5%; 100/194) of the patients presented with a pre-existing hearing loss at the time of the baseline assessment, where a hearing loss was defined as one or more hearing threshold > 25db hl in one or both ears across all frequencies, increasing to 66.5% (129/194) at the time of the exit assessment. on average, a decline in hearing thresholds from the baseline to exit assessment was evident across all frequencies bilaterally, with the deterioration most pronounced at the high frequencies (figure 3 and table 3). the mean hearing threshold deterioration was statistically significant at the high frequencies 4 khz (p = 0.006; w = −2.744), 6 khz (p < 0.001; w = −3.897) and 8 khz (p < 0.001; w = −4.371) of the left ear, and at the frequencies 500 hz (p = 0.021; w = −2.309), 1 khz (p = 0.029; w = −2.178), 2 khz (p = 0.005; w = −2.248), 4 khz (p < 0.001; w = −3.573), 6 khz (p < 0.001; w = −4.456) and 8 khz (p < 0.001, w = −5.322) in the right ear (table 3). figure 3: mean hearing thresholds and deterioration of the left (a) and right (b) ears from baseline to exit assessment (n = 194) (error bars = standard error). table 3: mean baseline and exit assessment hearing threshold values and hearing deterioration for the left and right ears (n = 194). the patients’ hearing thresholds were compared according to various pure tone averages (ptas) in table 4 as follows: overall pta (0.5 khz – 4 khz), low-frequency pta (0.25 and 0.5 khz), mid frequency pta (1 and 2 khz) and high frequency pta (3 khz – 8 khz). hearing deterioration was evident across all pta groups bilaterally; however, deterioration was most pronounced at high frequencies (table 4 and figure 4). the results indicated statistically significant deterioration in the mean high-frequency pta for the left (p < 0.001; w = −4.125) and right (p < 0.001; w = −5.247) ears. the mean overall pta deterioration (p = 0.001; w = −3.426) and the mid-frequency pta deterioration (p = 0.017; w = −2.381) of the right ear from baseline to exit assessment was statistically significant (table 4). there was no statistically significant difference in the mean hearing threshold deterioration at each frequency (p > 0.05; w = −1.499 – 0.240) or mean pta deterioration between the left and right ears (p > 0.05; w = –1.675–0.637). figure 4: mean baseline and exit assessment pure tone averages of the left and right ears (n = 194) (error bars = standard error). table 4: mean pure tone average values and hearing deterioration for the left and right ears (n = 194). description of ototoxic hearing loss the presence of an ototoxic shift was determined according to the three criteria developed by asha (1994), the most widely used and validated criteria (aaa, 2009), as indicated in table 5. following drtb treatment, more than half of the patients (51.5%; 100/194) presented with a significant ototoxic shift meeting one or more of the asha criteria. ototoxic shifts occurred most often at high frequencies (4 khz – 8 khz). there was no statistically significant difference (p = 0.114; w = −1.581) in ototoxic shifts (meeting one or more of the asha criteria) between the left and the right ears. table 5: distribution of patients presenting with an ototoxic shift at the time of exit assessment. the prevalence of hearing loss severity according to the revised who grades of hearing impairment is presented in table 6. from the baseline to the exit assessment, the prevalence of patients presenting with hearing loss meeting any category of hearing loss severity increased from 22.2% (39/194) to 25.8% (50/194). for the left and right ears, from the baseline to the exit assessment, the prevalence of patients presenting with hearing loss meeting any category of hearing loss severity increased from 32% (62/194) to 39.7% (77/194), and from 27.3% (52/193) to 33.5% (66/193), respectively. following drtb treatment with kanamycin, there was an increase in patients presenting with a hearing loss meeting each category of hearing loss, excepting mild hearing loss, most notably for the moderate (4.9%; 9/194), total (1.5%; 3/194) and unilateral (9.8%; 19/194) categories of hearing loss severity. table 6: prevalence of hearing loss severity for the left (n = 194) and right (n = 193) ears at the baseline and the exit assessment according to the revised world health organization grades of hearing loss. predictors of hearing loss the presence of a pre-existing hearing loss at the time of the baseline assessment was a significant predictor of the deterioration of the overall pta (0.5 khz – 4 khz) of the left (β = −8.750; 95% confidence interval [ci] [−14.953; −2.547]; p = 0.006) and right (β = −13.750; 95% ci [−19.063; −8.437]; p < 0.001) ears over time. patients presenting with a pre-existing hearing loss had an increase in deterioration of 8.75 and 13.75 times more for the left and right ear, respectively, than those with no pre-existing hearing loss. a history of noise exposure was a second significant predictor of the deterioration for overall pta (0.5 khz – 4 khz) of the right ear (β = −3.750; 95% ci [−6.682; −0.818]; p = 0.012), with patients who indicated exposure to noise having an increase in deterioration of 3.75 times more than those with no history of exposure to noise. significant predictors of the deterioration of the high frequency pta (3 khz – 8 khz) of the right ear, where hearing deterioration was most prominent, included drtb and hiv co-infection (β = −5.833; 95% ci [−10.711; −0.956]; p = 0.019) and the presence of a pre-existing hearing loss (β = −26.667; 95% ci [−35.521; −17.812]; p < 0.001). quantile regression models showed that gender, age, duration of administration of medication, history of tinnitus and tester (chw or phc audiologist) were not significant predictors of hearing deterioration (p > 0.05). discussion ototoxicity monitoring programme characteristics community health workers as facilitators of decentralised community-based ototoxicity monitoring the majority (76.3%) of patients in this study were assessed by chws, possibly because there were more chws (six) acting as testers than phc audiologists (two). the follow-up rates between consecutive monitoring assessments for patients assessed by chws reached as high as 80.6%. in addition, the average number of days between assessments was lower for patients assessed by chws (53.4 days) than for those assessed by phc audiologists (64.3 days). the follow-up rate of patients assessed by chws is better than the rate of a community-based drtb treatment programme that included ototoxicity monitoring, where the loss to follow-up was reported as being high as 38% (moyo et al., 2015). increased usage of ototoxicity monitoring and drtb treatment services has been associated with older age (> 26 years) (moyo et al., 2015), timing of baseline assessments (within 1 month of treatment initiation), the presence of pre-existing hearing loss and the development of ototoxic hearing loss following treatment (ramma, nhokwara, & rogers, 2019). the high follow-up rate (80.6%) and the shorter timing between monitoring assessments (53.4 days) for patients assessed by chws in the present study may therefore be attributed to the average age of patients (36.2 years), the timing of baseline assessments (5.9 days before treatment duration), the high prevalence (51.5%) of pre-existing hearing loss and the development of ototoxic hearing loss in patients (51.5%) according to one or more of the asha criteria following drtb treatment. in addition, the decentralised community-based nature of the omp, offered in a phc framework of care and integrated into drtb treatments services for increased patient access to care may have attributed to the higher follow-up rates and timing between ototoxicity monitoring assessments for patients assessed by chws evident in this study. numerous challenges to the implementation of ototoxicity monitoring exist, including a shortage of trained health care professionals and a lack of resources to conduct serial monitoring (dillard et al., 2021; khoza-shangase & masondo, 2021). sub-saharan africa has an extremely low coverage of ear, nose and throat, audiology and speech therapy services, and the availability of equipment remains poor (mulwafu et al., 2017). the covid-19 pandemic has had a severely negative impact on the provision and access to tb services for patients in many countries (migliori et al., 2021; who, 2020c, 2021a, 2021b) exacerbating the existing challenges in treating tb and monitoring associated with ototoxicity. world health organization guidelines promote the establishment of community-based tb services primarily delivered by chws, and in the context of the covid-19 pandemic such programmes may mitigate the additional strain on healthcare services and the delivery of essential tb services (who, 2020a), including ototoxicity monitoring. the employment of chw for community-based hearing screening has been shown to provide increased access to hearing services (bright et al., 2019; eksteen et al., 2019; mulwafu et al., 2017) and may offer a solution to the shortage of human resources synonymous with ototoxicity monitoring in south africa (o’donovan, verkerk, winters, chadha, & bhutta, 2019). in addition, integrating ototoxicity monitoring into existing community-based drtb treatment services in phc allows for a patient-centred approach that can increase patients’ access to services (cox et al., 2014). the findings of the current study indicating high follow-up rates and shorter number of days between assessments for patients assessed by chws, support the feasibility of a community-based model of care for ototoxicity monitoring facilitated by chws as a widely used service. frequency and timing of ototoxicity monitoring assessments and ototoxicity monitoring programmes data management procedures although there were positive outcomes for community-based ototoxicity monitoring facilitated by chws, the omp failed to meet some quality benchmarks pertaining to the frequency and timing of ototoxicity monitoring assessments, as stated in the guidelines (hpcsa, 2018) and the omp protocol. a few patients (14.2% – 32.6%) were assessed with the regularity required by the omp protocol and the hpcsa. ideally, ototoxicity monitoring should be conducted every 14 (hpcsa, 2018) to 30 days (omp protocol); however, the omp was unable to assess patients with the frequency recommended, with assessments being conducted, on average every 2 months or more (53.4–64.3 days). this demonstrates a missed opportunity for the early detection of hearing loss that could support preventative actions through a change in treatment regimens (crundwell, gomersall, & baguley, 2016). a previous report has also indicated that audiologists conducting ototoxicity monitoring in south africa do not conduct monitoring assessments with the frequency recommended by the national guidelines (khoza-shangase & masondo, 2020). significant differences in the frequency of ototoxicity monitoring by chws and by phc audiologists were identified in this study. the number of monitoring assessments attended by patients assessed by phc audiologists (mean 4.3) was higher than for those assessed by chws (mean 3.3). in addition, almost a third (32.6%) of patients assessed by phc audiologists attended the recommended six follow-up assessments, compared to 14.2% of patients assessed by chws. the reasons for patients assessed by phc audiologists attending monitoring assessments with more frequency than those assessed by chws could not be established in this study. however, a possible reason may be the supervision and quality control provided by omp managers of ototoxicity monitoring conducted by chws. for chws to fulfil their role successfully, regular training and supervision are required (who, 2007). reports from sub-saharan africa indicate that the current provision of training for chws is not sufficient to improve the quality of care in this region (o’donovan, o’donovan, kuhn, sachs, & winters, 2018). possible suggestions to facilitate ongoing training and supervision for chws include the use of tools such as smartphone technology and applications like whatsapp (o’donovan et al., 2018). in addition to ototoxicity monitoring for drtb, chws were tasked with conducting home-based, school-based and phc clinic-based hearing screening services at various locations across the mitchells plain/klipfontein sub-district. this may have affected the ability of chws to visit phc and community health clinics with the frequency required to conduct regular ototoxicity monitoring assessments. furthermore, patient retention to services during the long and arduous drtb treatment regimen is known to be difficult, even in a well-resourced programme (moyo et al., 2015; ramma et al., 2019); however, the patient variables influencing the frequency of ototoxicity monitoring assessments could not be determined because of the retrospective nature of this study. the current omp used paper data collection forms that were manually completed by chws and phc audiologists. however, important demographic information, such as patient gender (33%), was not recorded by chws and phc audiologists, and was, therefore, unavailable for analysis owing to the retrospective nature of this study. an effective omp data management system enables the comparison of serial monitoring through reliable data recording; this is more efficiently achieved using an electronic data management system (khoza-shangase & masondo, 2021). the use of smartphone technology and cloud-based data management has been shown to offer effective data management for large-scale screening purposes (eksteen et al., 2019) and is recommended for south african omps. integrating secure data sharing with national health repositories should be considered in an effort to improve the data management procedures of omps in south africa (swanepoel, 2020). ototoxicity characteristics treatment effects on hearing and predictors of hearing loss in resource-limited countries such as south africa, baseline audiometric assessments are often not conducted within the recommended timeframe, before ototoxic damage is likely to occur (ganesan et al., 2018; govender & paken, 2015; khoza-shangase & masondo, 2020) and pre-existing hearing loss is consequently underdiagnosed (hong et al., 2020). as a result, there are limited data on the prevalence of pre-existing hearing loss in drtb patients, apart from a recent study by hong et al. (2020). in the current study, where patients had a baseline assessment conducted on average 16.8 days before treatment initiation, more than half (51.5%) presented with a pre-existing hearing loss. the findings of this study support recently published reports that found that pre-existing hearing loss is prevalent in south african drtb patients, with 60% of patients assessed using conventional audiometry presenting with a pre-existing hearing loss prior to treatment (hong et al., 2020). the prevalence of pre-existing hearing loss is an important consideration for south african omps, as patients presenting with a pre-existing hearing loss prior to drtb treatment initiation are at particular risk of developing further hearing loss following the use of aminoglycoside (hong et al., 2020; petersen & rogers, 2015). the increased risk of aminoglycoside-induced hearing loss in drtb patients with a pre-existing hearing loss is confirmed by the results of the current study, which indicated that patients presenting with a pre-existing hearing loss at the time of the baseline assessment had an increase in hearing deterioration up to 13.75 times higher than those with no pre-existing hearing loss. a history of noise exposure was a significant predictor of hearing deterioration in the current study, with patients who reported previous exposure to noise presenting with 3.75 times the deterioration in hearing sensitivity compared with those with no history of noise exposure. a previous report concurred, indicating that patients with a history of noise exposure and aminoglycoside treatment had poorer high-frequency hearing thresholds than those exposed to noise without a history of aminoglycoside treatment (khoza-shangase, 2020). the findings of this study emphasise the importance of counselling for drtb patients so that they avoid excessive noise exposure during and after aminoglycoside treatment (campbell & le prell, 2018). in addition, where hearing deterioration was most prominent at the high frequencies (3 khz–8 khz), a significant predictor of hearing loss was drtb and hiv co-infection. the current study supports previous findings that hiv-infected drtb patients are more likely to develop an aminoglycoside-induced hearing loss than their non-infected peers (harris et al., 2012; hong, budhathoki, & farley, 2018). several significant predictors of hearing loss in drtb patients were observed, including the presence of a pre-existing hearing loss, hiv co-infection, and a history of exposure to noise. the findings of the current study have important implications for omps as they highlight the need for omps to identify and prioritise drtb patients presenting with pre-existing hearing loss, hiv co-infection, and noise exposure for all-oral treatment regimens, together with more vigilant audiological ototoxicity monitoring for early management of hearing deterioration. patients presenting with these conditions should be identified by omps for closer supervision of attendance of ototoxicity monitoring assessments, through direct communication with patients using, for example, smartphone technology and applications like whatsapp. description of hearing loss the reported prevalence of ototoxicity varies widely and depends on various factors, including drug type and dosage, and patients’ demographic profile, such as age (> 60 years), the presence of mitochondrial mutations and exposure to loud noises (ramma et al., 2019). in addition, a lack of standardised research methodology and the use of different criteria to grade and classify hearing loss has influenced the estimates of hearing loss prevalence (campbell & le prell, 2018; dillard et al., 2021; ganesan et al., 2018). in the current study, it was found that following drtb treatment with kanamycin, more than half of the patients (51.5%) presented with a significant ototoxic shift meeting one or more of the asha criteria, with ototoxic shifts most often occurring at high frequencies. the finding of this study concurs with a recent hearing loss prevalence estimation, using asha criteria, of 49.7% following kanamycin use (dillard et al., 2021). at the time of the baseline assessment, 51.5% of patients in the current study presented with one of more elevated hearing thresholds (> 25db hl) in one or both ears across all frequencies; this increased to 66.5% (129/194) at the time of the exit assessment. in order to report on the severity of hearing loss following drtb treatment among the patients in this study, and to describe the functional consequences for communication associated with each category of severity, the prevalence of hearing loss severity was presented according to the revised who grades of hearing impairment. in the current study, following drtb treatment with kanamycin, there was a notable increase in patients presenting with hearing loss meeting the moderate (4.9%), total (1.5%) and unilateral (9.8%) categories of hearing loss severity (olusanya et al., 2019; who, 2021b). patients with untreated moderate or unilateral hearing loss following drtb treatment may experience difficulties hearing speech in the presence of background noise, while patients presenting with total hearing loss will be profoundly deaf, resulting in a devastating impact on the quality of life (who, 2021b). patients in this study presented with a bilateral decline in hearing thresholds in all pta groups, with the most pronounced deterioration at high frequencies at the time of the exit assessment. drug-resistant tb treatment using kanamycin therefore had a negative effect on the hearing status of the patients in this study, with clinically and statistically significant deterioration of hearing thresholds, most markedly in the high frequencies. the findings of the current study, therefore, support the implementation of omps for drtb patients who are administered aminoglycosides, particularly as the latest who drtb treatment guidelines (who, 2020b) continue to include amikacin, which is known to be ototoxic. the occurrence of high-frequency hearing deterioration measured in this study further supports the recommendation (hpcsa, 2018) of the use of ehf audiometry for ototoxicity monitoring in drtb patients, particularly for those most at risk for developing ototoxic hearing loss. extended high-frequency audiometry, which assesses air conduction hearing thresholds above 8 khz, is considered to be the most sensitive behavioural method for detecting early cochlear outer hair cell damage (campbell & le prell, 2018; harris, peer, & fagan, 2012; petersen & rogers, 2015) before it affects hearing functionality, and is therefore recommended for the monitoring of ototoxicity (hpcsa, 2018). there have been significant advances in point of care testing and mobile health technologies in hearing assessment (garinis et al., 2021), which should be considered for ototoxicity monitoring in south africa. in particular, the use of smartphone technology with automated ehf audiometry hearing assessment applications and cloud-based capabilities for integrated data management should be considered for community-based ototoxicity monitoring (bornman, swanepoel, de jager, & eikelboom, 2019; eksteen et al., 2019; who, 2021b; yousuf hussein, swanepoel, mahomed, & biagio de jager, 2018). the limitations of this study included the absence of quality indicators for audiometry conducted by chws and phc audiologists. in addition, the prevalence of adverse side effects experienced by patients was not established by testers at the time of exit assessment. immittance measures were not included as part of omp protocol, and therefore, the prevalence of ototoxic hearing loss may have been influenced by the inclusion of patients presenting with middle-ear disorders. important data pertaining to patient description and treatment were at times not recorded by testers and were, therefore, unavailable for inclusion in this retrospective study, and thus, may have caused research bias. researcher and analysis triangulation were applied to reduce the effects of research bias. the use of a non-probability sampling method may limit the generalisability of the results of this study. conclusion the findings of this study support the employment of chws to facilitate community-based ototoxicity monitoring of patients with drtb. however, the findings reveal that over time, community-based omps for drtb show gaps in service delivery practices, most notably in the frequency and timing of ototoxicity monitoring assessments. the possible reasons for this may highlight the need for ongoing training and supervision of chws using novel tools, such as smartphone technology and applications like whatsapp. drug-resistant tb treatment with kanamycin caused clinically and statistically significant deterioration of hearing thresholds in patients, most prominently at high frequencies. in this study, the patients co-infected with hiv, those with a pre-existing hearing loss and those exposed to excessive noise were at higher risk for developing ototoxicity-induced hearing deterioration. patients presenting with these conditions should be identified and prioritised by omps for more vigilant ototoxicity monitoring and all-oral treatment regimens. south african omps need support and novel approaches for community-based ototoxicity monitoring, with revision of the current recommendations to best suit the south african context. these may include the widespread integration of ototoxicity monitoring services facilitated by chws into the existing decentralised, community-based phc service delivery frameworks using a portable, automated technology with integrated data-sharing capabilities. acknowledgements the authors acknowledge and thank the key role players who made this study possible through their support and participation. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions l.j.s. and d.s. were responsible for conceptualisation and contributed towards the methodology. l.j.s., d.s. and m.a.g contributed towards the validation and visualisation. m.a.g conducted the formal analysis. l.j.s. was responsible for the investigation. resources were provided by the western cape department of health and city of cape town health department. l.j.s., d.s. and m.a.g. prepared and wrote the original draft and l.b.d.j assisted with reviewing and editing the manuscript. l.j.s. was responsible for project administration, while d.s, l.b.d.j. and m.a.g. provided supervision for the study. all authors have read and agreed to the published version of the manuscript. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability statement the data that support the findings of this study are available on request from the corresponding author, l.j.s., for ethical reasons. the data are not publicly available as they contain information that could compromise the privacy of the research participants. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references american academy of audiology (aaa). 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(2018). community-based hearing screening for young children using an mhealth service-delivery model. global health action, 11(1), 1467077. https://doi.org/10.1080/16549716.2018.1467077 abstract background method results discussion conclusion acknowledgements references about the author(s) katerina ehlert department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africadepartment of speech-language pathology and audiology, faculty of healthcare sciences, sefako makgatho health sciences university, pretoria, south africa barbara heinze department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa de wet swanepoel department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa citation ehlert, k., heinze, b., & swanepoel, d.w. (2022). ototoxicity monitoring in south african cancer facilities: a national survey. south african journal of communication disorders, 69(1), a846. https://doi.org/10.4102/sajcd.v69i1.846 original research ototoxicity monitoring in south african cancer facilities: a national survey katerina ehlert, barbara heinze, de wet swanepoel received: 05 july 2021; accepted: 27 sept. 2021; published: 19 jan. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: national information regarding ototoxicity monitoring practices are limited for patients undergoing chemotherapy in south africa. objectives: to determine (1) the national status of ototoxicity monitoring implemented in private and public cancer facilities, (2) the knowledge and ototoxicity monitoring approaches implemented, and (3) reported challenges. method: a descriptive quantitative survey was conducted in public and private oncology units and audiology referral clinics. private (60%) and public (43%) oncology units that provide platinum-based chemotherapy in south africa and audiology referral units (54%) were: (1) surveyed telephonically to determine if ototoxicity monitoring takes place; and (2) a self-administered survey was sent to qualifying oncology units and audiology referral clinics. results: all public oncology units reported that ototoxicity monitoring only occurs on referral and is not standard practice. all private oncology units indicated that monitoring is on a patient self-referral basis when symptoms occur. poor awareness of ototoxicity monitoring best practice guidelines was reported by all oncology units and 14% of audiology referral clinics. audiology referral clinics reported adequate knowledge of ototoxicity protocols although they are not widely used with only 43% following best practice guidelines. the most prominent challenges reported by participants was referral system (67% oncology units; 57% audiology referral clinics), environmental noise (83% oncology units; 86% audiology referral clinics) and the compromised status of cancer patients (67% oncology units; 57% audiology referral clinics). conclusion: ototoxicity monitoring is not routinely implemented across oncology units in south africa. multidisciplinary teamwork and a simplified national ototoxicity monitoring protocol may improve hearing outcomes for patients. keywords: ototoxicity; ototoxicity monitoring; ototoxicity monitoring protocols; cancer; oncology; hearing loss; chemotherapy; platinum-based compounds. background cancer is known to be one of the world’s most life-threatening diseases, resulting in approximately 19.3 million new cases and 10 million deaths in 2020 (sylla & wild, 2012; world health organization, 2020). the projected increase of cancer rates and the progress in cancer therapeutics over the past 40 years, which has remarkably improved survival rates, reveals the need to shift the focus to adverse drug effects and their impact on quality of life (qol). ototoxicity is known to have an adverse effect in platinum-based cancer chemotherapeutic agents (rybak & ramkumar, 2007; silver, baima & mayer, 2013). susceptibility to ototoxicity increases with dose and duration of therapy, infusion rate and cumulative lifetime dose, impaired kidney function, which can lead to rapid accumulation of the ototoxic drug, concurrent administration of another ototoxic drug (e.g. aminoglycosides and loop diuretics), anaemia; hypoalbuminaemia; age, pre-existing sensorineural hearing loss, exposure during pregnancy, previous exposure to head and neck radiation, genetic susceptibility and family history of ototoxicity. this in turn has a significant impact on qol in a cancer survivor’s life (baguley, rybak & ramkumar, 2017; ferlay et al., 2015; pearson, taylor, patel, & baguley 2019; silver et al., 2013). platinum-based chemotherapy such as cisplatin is a widely used chemotherapeutic agent for the treatment of numerous malignancies, including testicular, ovarian, bladder, cervical, head and neck and non-small cell lung cancers (rybak & ramkumar, 2007). ototoxicity results in tinnitus and sensorineural hearing loss, which can be severe to profound after high-dose chemotherapy (rybak & ramkumar, 2007). for patients with life-threatening illnesses that necessitate treatment with ototoxic drugs, communication ability is a central qol issue. hearing loss and tinnitus are both associated with a greater risk of social isolation, depression, anxiety (nordvik et al., 2018) and development of dementia (deal et al., 2017). there is also a substantial risk for cochleotoxicity to be followed by vestibulotoxicity in patients receiving platinum-based chemotherapy (prayuenyong et al., 2018). vestibular dysfunction may have a major effect on the qol as balance and mobility impairment are more predominant in cancer survivors, which also increases the risk of falls (sun, ward, semenov, carey, & della santina, 2014; wildes et al., 2015). therefore, identifying ototoxic damage early can improve treatment outcomes by minimising hearing loss progression and vestibular dysfunction and providing early aural and vestibular rehabilitation where ototoxicity is inevitable (konrad-martin et al., 2018). although platinum-based chemotherapy ototoxicity is a common adverse occurrence, there are varying incidence rates reported in both adults and children, which is partly because of the variability of audiological tests employed in the identification and monitoring of the cancer patient’s hearing status (paken, govender, pillay, & sewram, 2020). considering these challenges, international bodies such as the american-speech-language-hearing-association (asha) and american academy of audiology (aaa) have guidelines that provide flexibility for shortened screening protocols to be used for ototoxicity monitoring (aaa, 2009; asha, 1994; health professions council of south africa [hpcsa], 2018). although audiologic evaluation is ideally conducted in a sound treated room, the asha guidelines recognise that, even with shortened protocols, full booth-based audiometric monitoring is not always feasible in all clinical environments (brungart et al., 2018), which contributes to the ineffectiveness of existing screening programmes. it is currently unknown what proportion of patients undergoing chemotherapy with platinum-based agents are systematically identified and monitored for signs of ototoxicity in south africa. too often, audiological testing is arranged only once debilitating hearing loss is already apparent to the patient or multidisciplinary team (paken et al., 2020). serial audiological monitoring is critical in ototoxicity monitoring protocols to achieve the desired outcomes (brungart et al., 2018; hpcsa, 2018). another challenge is that, whilst much chemotherapy practice is protocol based, divergence from protocols is common as treatments may be delayed, modified or added to in particular circumstances (baguley et al., 2017). this often affects the audiological monitoring schedules, highlighting that set protocols cannot be followed for all patients receiving chemotherapy. thus, the identification of a truly homogeneous treatment group may be difficult. whilst empirical evidence of compliance with such guidelines has not been identified, indications are that the implementation of audiometric monitoring is sporadic (paken et al., 2020). in lowand middle-income countries (lmics) like those in sub-saharan africa, there is a lack of hearing care and appropriate equipment in order to successfully implement hearing screening and monitoring programmes (chadha, cieza, & krug, 2018; mulwafu, kuper, & ensink, 2016). the number of audiologists within the african continent has been reported to be one of the lowest, with an estimate of one audiologist for every million people in sub-saharan africa (mulwafu et al., 2016). moreover, the high costs associated with screening equipment and the necessity for the equipment to be operated by trained personnel such as audiologists further burden the implementation of effective screening programmes for early detection and intervention (louw, swanepoel, eikelboom, & myburgh, 2017). furthermore, the mechanisms for tracking patients throughout the system need to be explored in order to ensure patients receive the audiological services they may need at various stages of cancer treatment and survivorship (konrad-martin et al., 2018). studies in south africa (andrade, khoza-shangase, & hajat, 2009; khoza-shangase & jina, 2013) revealed that the effects of ototoxicity, the role of audiologists and need for their expertise were not fully recognised by the oncologists. furthermore, most general practitioners (gp) also do not appear to carry out ototoxicity monitoring strategies despite being aware of their own role within an ototoxicity monitoring programme (andrade et al., 2009; garinis et al., 2018; khoza-shangase & jina, 2013). early identification of ototoxic effects on hearing ability because of platinum-based therapy provides physicians with an opportunity to adjust the drug therapy in order to minimise or prevent hearing loss and provide early hearing intervention services (garinis et al., 2018; hpcsa, 2018). an ototoxicity monitoring programme should be context sensitive without increasing the already over-burdened treatment schedule of cancer patients, identify ototoxic effects early and include a team of healthcare professionals (ganesan et al., 2018). studies conducted in south africa indicated that there was neither provision for ototoxicity monitoring in the chemotherapy protocols nor any ototoxicity monitoring programmes in place and only half of the participants reported referring patients for audiological management during the chemotherapeutic process (khoza-shangase & jina, 2013; paken et al., 2020). the studies that have been performed in south africa are limited to certain geographical areas and national data on ototoxicity monitoring practices in south africa is lacking. this study therefore aimed to describe ototoxicity monitoring practices in south africa in both the private and public healthcare sectors. method the survey aimed to (1) describe the national status of ototoxicity monitoring implemented in private and public cancer facilities in south africa, (2) describe knowledge and ototoxicity monitoring approaches implemented and (3) identify challenges to ototoxicity monitoring. data collection sites, population and sampling probability sampling was applied. the participants included healthcare professionals (gps, oncologists, nurses, pharmacists and audiologists) working in private and public healthcare oncology units and audiology referral clinics in south africa. all public hospitals were accessed via the national department of health website http://www.health.gov.za/ (department of health, 2019). private oncology units were accessed via www.medpages.co.za (medpages, 2018) and the independent clinical oncology network (icon) (icon, 2017). public provincial tertiary and central or academic hospitals were included as these hospitals consist of specialised referral units, which together provide an environment for multi-specialty clinical services, innovation and research, such as oncology. there are 29 tertiary hospitals and 10 major teaching hospitals in south africa; however, not all hospitals provide platinum-based oncology treatment or were able to participate in the research. there were 55 private oncology units identified in south africa. oncology units were contacted telephonically to confirm eligibility and willingness to participate. information was obtained from the practice manager or nurse in charge. once consent for participation was obtained, questionnaires were sent to the oncology units where a healthcare professional (gps, oncologists, nurses or pharmacists) representing the oncology units completed the questionnaire. audiology referral clinics (n = 13) in the same hospital as oncology units were contacted for participation in the study. participants therefore included an audiologist representing the audiology referral clinics in the private and public sector across south africa and mentioned by oncology units as referral centres. questionnaires were sent to the audiology referral clinics for completion. figure 1 illustrates the research sites, participant description and sampling procedure. figure 1: research sites, participant description and sampling procedure. data collection procedure before commencing with the study, ethical clearance was obtained from a university in south africa. firstly, private oncology units (n = 55) and public hospitals (n = 29) with cancer units were contacted telephonically to determine whether platinum-based chemotherapy is being offered as a treatment option. oncology units who offered platinum-based chemotherapy and were willing to participate in the study were surveyed telephonically. during the telephonic survey, nursing managers and oncologists in the units provided information regarding ototoxicity monitoring practices within the cancer units. the telephonic survey confirmed (1) if platinum-based chemotherapy agents are offered in the unit, (2) if ototoxicity monitoring is performed as standard practice for all patients receiving ototoxic chemotherapy, if ototoxicity monitoring is only performed when referred by a healthcare professional or if patients arrange their own hearing evaluation when ototoxicity symptoms or hearing loss is apparent and (3) where patients are referred for ototoxicity monitoring. the second part of the research study included a self-administered questionnaire. an electronic questionnaire was sent to the oncology units to determine the knowledge, monitoring approaches, protocols and challenges of implementing ototoxicity monitoring. nurses, oncologists, gp and pharmacists were some of the healthcare professionals who completed the electronic questionnaires on behalf of the oncology units. audiology departments in public hospitals with cancer units and private practice audiologists in close proximity to private oncology units and those mentioned as referral centres were contacted for information on ototoxicity monitoring practices. the telephonic survey confirmed if ototoxicity monitoring is performed for patients receiving ototoxic chemotherapy. the electronic questionnaire was sent to the identified audiology referral clinics for completion. audiologists completed the questionnaire on behalf of the audiology referral centres. description of electronic questionnaire a structured, self-administered questionnaire was used for both oncology units and audiology referral clinics. the questionnaire was administered as a single attempt to determine the characteristics of the ototoxicity monitoring protocols currently implemented in oncology units and audiology referral clinics in south africa and the challenges experienced. the same questionnaire was used for all healthcare professionals as the questionnaire included general aspects regarding ototoxicity, ototoxicity monitoring and challenges. there was a section only to be completed by audiologists that included aspects such as testing protocols and procedures followed during ototoxicity monitoring. the questionnaire was adapted from steffens et al. (2014) by adding answer options to choose from, resulting in more closed-ended questions with an option of providing additional information. the original study (steffens et al., 2014) had only open-ended questions, which were interview based. the questionnaire included a range of openand closed-ended questions (multiple choice format) in three broad categories: (1) demographic information, (2) knowledge and general perceptions towards ototoxicity monitoring, (3) challenges, (4) ototoxicity monitoring protocols (only to be completed by audiology referral clinics) and (5) views on potential improvements to ototoxicity monitoring. qualtrics survey platform was used for ease of completion and automatic data storage (refer to questionnaire in online appendix 1). data analysis data collected from the (1) telephonic surveys and (2) electronic questionnaires with private and public oncology units and audiology referral clinics were integrated. the data were analysed to yield percentages and frequency distributions nationally and across provinces. thematic content analysis was used for open-ended questions. results from the 39 hospitals in the public sector that provide chemotherapy oncology services, 44% (n = 17) were willing to participate in the research following the telephonic survey. from the 55 private oncology units, 60% (n = 33) were surveyed telephonically and provided platinum-based chemotherapy; some units only provide radiation or were unwilling to participate. a lower response rate was received for the questionnaire compared with the telephonic survey as some of the units did not perform ototoxicity monitoring and did not consent to complete the questionnaire. furthermore, some oncology units also have several branches, and responses were only obtained from one branch as similar ototoxicity monitoring practices are followed at the branches. the electronic questionnaire was completed by 26 (46%, n = 57) participants; however, only n = 19 (33%, n = 57) could be included in the study as they complied with the inclusion criteria. questionnaires completed by healthcare professionals that are not involved in ototoxicity monitoring and working with oncology units were excluded from the study. therefore, only 36% (n = 12) questionnaires were completed and returned by healthcare professionals representing the oncology units. the questionnaires were completed by 54% (n = 7) audiologists representing the audiology units. overall a response rate of > 25% for completion of questionnaires was achieved, which is considered acceptable for mailed surveys (baruch & holtom, 2008). telephonic survey: ototoxicity monitoring coverage telephonic surveys of ototoxicity monitoring at private and public oncology units demonstrated that it was not a standard practice. cancer patients with ototoxicity complaints, such as hearing loss and tinnitus, were either referred for an audiological evaluation by a healthcare professional or patients had to arrange for audiological evaluations on their own initiative. table 1 provides a breakdown of the ototoxicity monitoring approaches followed. table 1: distribution of oncology units and ototoxicity monitoring approaches (n = 50) across public and private facilities. self-administered questionnaire: ototoxicity perceptions, challenges and testing approaches table 2 summarises the demographic information of the participants (healthcare professionals representing the oncology units and referral audiology centres). table 2: demographic information of the participants. multiple-choice questions were used to determine general knowledge and perceptions of ototoxicity monitoring. overall, poor awareness of ototoxicity monitoring protocols or best practice guidelines were reported, as no oncology units were reported to have knowledge about protocols. amongst the audiology referral clinics, 14% (n = 1) had knowledge of best practice guidelines and 86% (n = 6) had no knowledge. all participants (100%) from the oncology units and audiology referral clinics described ototoxicity as ‘a side effect of medicine resulting in auditory and vestibular dysfunction resulting in hearing loss and disequilibrium’. the purpose of ototoxicity monitoring was reported as early identification of hearing loss (83%, n = 10 oncology units; 86%, n = 6 audiology referral clinics), to terminate ototoxic treatment (0%, n = 0 oncology units; 14.3%, n = 1 audiology referral clinics), to adjust treatment dosages (67%, n = 8 oncology units; 86%, n = 6 audiology referral clinics), to improve qol post-treatment (25%, n = 3 oncology units; 57%, n = 4 oncology referral clinics) and to provide appropriate and timely intervention (83%, n = 10 oncology units; 86%, n = 6 audiology referral clinics). in contrast, the benefits of providing ototoxic monitoring to the patient was reported as patient knowledge of ototoxic hearing loss (58%, n = 7 oncology units; 43%, n = 3 audiology referral clinics) and early identification (100%, n = 12 oncology units; 100%, n = 7 audiology referral clinics) and intervention (83%, n = 10 oncology units, 100%, n = 7 audiology referral clinics) of hearing loss. table 3 describes participants’ knowledge of ototoxicity. table 3: participant’s general knowledge and perceptions of ototoxicity monitoring. participants reported on the severity of the possible impact (tinnitus, hearing loss and vestibular problems) of ototoxicity on cancer patients’ daily life as presented in figure 2. figure 2: participant’s perception of the impact of ototoxicity symptoms on daily life (n = 12 healthcare professionals representing the oncology units, n = 7 audiologists representing the audiology referral clinics). the questionnaire probed the ototoxicity monitoring protocols followed when cancer patients attend hearing evaluations and the importance of baseline testing. baseline testing in ototoxicity monitoring was deemed important as 60% (n = 7 oncology referral units), 100% (n = 7 audiology referral clinics) reported extremely important and 42% (n = 5 oncology units) said very important. however, this does not seem to reflect in practice as the audiology referral clinics reported that only 29% (n = 2) of oncology patients receive baseline assessments. all participants (100%, n = 12 oncology units; n = 7 audiology referral clinics) reported that only patients referred receive baseline assessments and 17% (n = 2 oncology units) reported that baseline assessments were not performed. section 4 (refer to the appendix) of the electronic questionnaire (refer to online appendix 1) was completed by audiologists only (n = 7 audiology referral clinics). table 4 describes the battery of audiological tests included in ototoxic monitoring when patients are referred or self-refer for audiological testing. table 4: battery of audiological tests included in ototoxic monitoring by audiology referral clinics (n = 7 audiologists). the participants were asked how informed patients were regarding the ototoxic effects of chemotherapy: 0% (n = 0 oncology units) and 71% (n = 5 audiology referral clinics) reported patients were uninformed, 8% (n = 1 oncology units) and 29% (n = 2 audiology referral clinics) reported slightly informed, 83% (n = 10 oncology units) reported moderately informed and 8% (n = 1 oncology units) reported well informed. the participants reported that patients receive this information from oncologists (50%, n = 6 oncology units; 57%, n = 4 audiology referral clinics), nurses (42%, n = 5 oncology units; 71%, n = 5 audiology referral clinics), audiologists (25%, n = 3 oncology units; 100%, n = 7 audiology referral clinics), pharmacists (25%, n = 3 oncology units; 14.3%, n = 1 audiology referral clinics) and gps (8%, n = 1 oncology units; 14.3% n = 1 audiology referral clinics). the majority of participants agreed that oncologists (92%, n = 11 oncology units; 86%, n = 6 audiology referral clinics) and nurses (83%, n = 10 oncology units; 86%, n = 6 audiology referral clinics) are responsible for informing patients. audiologists (58%, n = 7 oncology units; 57%, n = 4 audiology referral clinics), gps (58%, n = 7 oncology units; 57% audiology referral clinics) and pharmacists (50%, n = 6 oncology units; 43%, n = 3 audiology referral clinics) also have a responsibility to inform patients. although ototoxicity monitoring is not a standard practice, but rather based on a referral basis, provision of ototoxicity monitoring services was reported by 25% (n = 3 oncology units) and 29% (n = 2 audiology referral clinics; 42% [n = 5 oncology units] and 43% (n = 3 audiology referral clinics) stated no ototoxicity monitoring was provided and 33% (n = 4 oncology units) and 29% (n = 2 audiology referral clinics) reported to be unsure. from the responses completed only by audiology referral clinics (n = 7), only 43% (n = 3) reported that the ototoxicity monitoring protocols are documented, and it is the hospital’s protocol of unknown origin, 43% (n = 3) were unsure and 14% (n = 1) reported protocols are not documented. only 14% (n = 1) reported that the protocols are compulsory and always followed, 29% (n = 2) said it was only a guideline and sometimes followed and 57% (n = 4) were unsure if protocols are followed. the factors that influence the protocols followed were reported as follows: 29% (n = 2) stated testing was performed according to clinical necessity and doctor referrals, 43% (n = 3) reported best practice guidelines are followed, 57% (n = 4) mentioned availability of equipment, 29% (n = 2) stated appointment availability and 57% (n = 4) mentioned audiologist training and knowledge as a contributing factor. audiologist referral units (n = 7) reported sending ototoxicity testing and monitoring results to oncologists (71%, n = 5) and nurses (14%, n = 1) and to the patient (29%, n = 2). the results provided were believed to influence dosage choices (86%, n = 6), influence treatment choices (57%, n = 5), results in otoprotective agents being prescribed (29%, n = 2) and all audiology referral clinics (100%, n = 7) agreed that it ensures follow-up appointments and frequent visits to the audiologist. the length of monitoring varied as 50% (n = 6 oncology units) and 43% (n = 3 audiology referral clinics) reported that monitoring should continue for 12 months whilst 42% (n = 5 oncology units) and 43% (n = 3 audiology referral clinics) were of the opinion that it should continue for the patient’s lifespan and only 8.3% (n = 1 oncology units) and 14.3% (n = 1 audiology referral clinics) indicated that 6 months of monitoring is sufficient. most participants (83%, n = 10 oncology units; 100%; n = 7 audiology referral clinics) agreed that the audiologist should decide how long monitoring is needed, whilst 17% (n = 2 oncology units) indicated the oncologist should decide. challenges to implementation of ototoxicity monitoring the final section of the questionnaire surveyed the challenges of implementing ototoxicity monitoring in cancer patients. all (100%, n = 12 oncology units and n = 7 audiology referral clinics) of the participants reported a greater awareness needed amongst health professionals; however, 25% (n = 3 oncology units) reported that awareness amongst oncologists is not needed. participants were asked if improvements are needed in ototoxicity monitoring in their workplace, 50% (n = 6 oncology units) and 57% (n = 4 audiology referral clinics) reported ‘yes’, 17% (n = 2 oncology units) and 14% (n = 1 audiology referral clinics) reported ‘no’ and 33% (n = 4 oncology units) and 29% (n = 2 audiology referral clinics) reported ‘unsure’. participants were asked if the referral process for ototoxic monitoring posed a challenge, 8% (n = 1 oncology units) and 14% (n = 1 audiology referral clinics) reported ‘yes’, 33% (n = 4 oncology units) and 29% (n = 2 audiology referral clinics) reported ‘no’ and 58% (n = 7 oncology units) and 57% (n = 4) reported ‘unsure’. open-ended responses in the questionnaire from a referral audiology clinic in the public sector (14%, n = 1) reported that ‘an attempt was made to implement a strict ototoxicity monitoring system for all qualifying chemotherapy patients, however this was unsuccessful’. oncology referral units indicated that ‘at-risk patients or patients with hearing loss complaints, rather than all patients are identified for possible ototoxicity monitoring’. it was also reported that ‘hearing loss does not seem to be a main complaint in patients seen’. the patient challenges experienced were as follows: too ill to attend the audiology clinic (67%, n = 8 oncology units; 57%, n = 4 audiology referral clinics), patients tested in wards because of poor immunity and isolation (33%, n = 4 oncology units; 57%, n = 4 audiology referral clinics), which results in environmental noise (83%, n = 10 oncology units; 86%, n = 6 audiology referral clinics) and unfavourable testing conditions and financial considerations (25%, n = 3 oncology units). an open-ended response from the private oncology units was ‘the patients are put through a lot very quickly and it is extremely stressful to them. cost is a big factor’. as it is clear that there is a lack of ototoxicity monitoring protocols followed, 83% (n = 10 oncology units; 86%; n = 6 audiology referral clinics) were in favour of a national ototoxicity monitoring protocol to be implemented in hospitals; however, 43% (n = 3 audiology referral clinics) indicated that they would modify the protocol to be suited to their setting. a national ototoxicity protocol may also assist with lobbying for equipment in hospitals (57%, n = 4 audiology referral clinics); however, 43% (n = 3 audiology referral clinics) were unsure if this would help. from the audiology referral clinics (n = 7), 57% (n = 4) were in favour of a novel approach to monitoring such as automated smartphone audiometry, 14% (n = 1) were not in favour and 29% (n = 2) were unsure. an open-ended response from the audiology referral clinics stated that there is ‘a need for mobile testing equipment’. discussion this survey is the first to report the national status of ototoxicity monitoring in cancer patients in the public and private healthcare sector in south africa. both in the private and public healthcare sectors, ototoxicity monitoring protocols are not followed. in the public sector, hearing tests are performed according to clinician referrals. clinicians refer if patients complain about hearing-related problems. some hospitals attempted to implement a strict protocol to see all qualifying chemotherapy patients; however, the constant rotation of doctors did not allow for a smooth working system between audiology and oncology. awareness campaigns result in a temporary influx of referrals but do not remain consistent (maru & malky, 2018). in the private sector, patients mostly refer themselves. often, by this time, a hearing loss is already noticeable and likely irreversible. similarly, a study in the united states of america reported that the physicians differed in their approaches to ototoxicity monitoring, from habitual referrals to audiology, to relying on patient self-referral (garinis et al., 2018). the feedback from the private sector was that the oncology units do not give as much attention to hearing loss as they should. oncology units claim that it is not a lack of awareness of ototoxicity but rather because of the cancer diagnosis, advanced disease, other oncologic emergencies, emotional, financial and physical constraints that are prioritised (carrera, kantarjian, & blinder, 2018; oun, moussa, & wheate, 2018). although platinum-based treatment is an ototoxicity risk in itself and risk-prediction models for platinum-related ototoxicity, based on age and cumulative dose, have been developed, these models do not accurately predict risk for individual patients (landier, 2016). patient risks such as younger age (particularly <5 years) at the time of therapy, diagnosis of a central nervous system tumour, diminished renal function, rapid intravenous administration and treatment with multiple potentially ototoxic agents (oun et al., 2018) are identified as increased risks for ototoxicity. the private oncology units are of the opinion that identifying a patient who has a high risk is more valuable than identifying just anyone on platinum-based treatments as hearing loss does not seem to be a main complaint in patients seen. this was also reported in a south african study, where oncologists reported that patients do not complain of the ‘subtle’ symptoms of cisplatin ototoxicity, such as tinnitus (paken et al., 2020; whitehorn et al., 2014). this study indicated a comprehensive understanding of ototoxicity across all disciplines; however, there is limited familiarity with implementing ototoxicity monitoring and referral pathways and greater awareness amongst healthcare professionals is needed. these findings were similar to previous studies internationally and in south africa stating that professionals involved in the care and management of cancer patients need to improve their awareness of ototoxicity and refer timeously for audiological evaluation (landier, 2016; paken et al., 2020; steffens et al., 2014). all participants in this study stated that platinum-based chemotherapy can cause hearing loss, tinnitus and vestibular problems, which has a moderate to severe impact on daily life. this corresponds with findings in similar research performed in south africa and internationally (ganesan et al., 2018; landier, 2016; oun et al., 2018; paken et al., 2020; whitehorn et al., 2014). cancer patients, however, undergo significantly variable ototoxicity monitoring, and practices range from no baseline testing and routine monitoring to some form of testing in some patients, which seems to be a common phenomenon in current ototoxicity monitoring practices (ganesan et al., 2018; paken et al., 2020). although survival rates remain the priority in cancer treatment, there needs to be more emphasis on the importance of remaining side effects and long-term symptoms such as hearing loss and tinnitus (pearson et al., 2019). as the survival rate increases and it becomes clear that there will be a life beyond cancer, qol becomes increasingly important. all audiology referral clinics in this study described appropriate ototoxicity protocols that should be followed, but implementation remains a challenge, despite the presence of substantial evidence supporting the significance of early identification of ototoxic-induced hearing loss (ganeson et al., 2018; hpcsa, 2018; paken et al., 2020). pure tone audiometry (pt), extended high frequency audiometry (ehf) audiometry and distortion product otoacoustic emissions (dpoaes) were cited as the most crucial tests, as suggested in ototoxicity monitoring guidelines (ganesan et al., 2018; landier, 2016; paken et al., 2020; pearson et al., 2019). although participants reported that vestibular problems may be caused by platinum-based chemotherapy, vestibular assessments are not typically included in monitoring protocols in both this study and internationally (landier, 2016; paken et al., 2020; steffens et al., 2014). no widely accepted guidelines for vestibulotoxicity monitoring exist (ganesan et al., 2018). the major challenge in vestibulotoxicity monitoring is the identification of these symptoms, which is only apparent when patients are mobilised and may often be incorrectly attributed to the patient’s debilitated state. vestibular diagnostic procedures are also often impractical because of the patient’s compromised health status. furthermore, because of the complex nature of the vestibular system, there is no single test that can identify vestibulotoxicity (pearson et al., 2019). ototoxic testing was reported to continue 6–12 months post-treatment, with some suggesting follow-up for an entire person’s lifespan. existing protocols suggest 6 months post-treatment and annually for at least 10 years (landier, 2016; pearson et al., 2019; steffens et al., 2014). more than half of participants in this study indicated that patients were uninformed about ototoxic effects of chemotherapy. research suggests that oncologists and nurses should be the custodians for providing this information (paken et al., 2020; pearson et al., 2019). a multidisciplinary team and patient-centred approach to ototoxicity is essential as effective communication amongst healthcare professionals and greater insight of information about adverse effects and monitoring is needed (ganesan et al., 2018; landier, 2016; pearson et al., 2019). monitoring outcomes are believed to influence dosage and treatment choices, result in otoprotective agents being prescribed, and it ensures follow-up appointments and frequent visits to the audiologist. this is in agreement with the purpose of ototoxicity monitoring protocols (konrad-martin et al., 2018; landier, 2016; maru & malky, 2018; pearson et al., 2019; steffens et al., 2014). the most prominent challenges reported by participants in this study were referral system, environmental noise, multidisciplinary teamwork, lack of equipment, staff availability and the often compromised status of cancer patients (konrad-martin et al., 2018). more than half of audiology referral clinics in this study were in favour of a novel approach to ototoxicity monitoring. considering the challenges identified in ototoxicity monitoring, the integration of mobile health (mhealth) tools such as smartphone audiometry is a novel approach, which can improve the effectiveness and efficiency of ototoxicity monitoring in cancer patients. mhealth tools have proved to be effective in primary healthcare settings (sandström, swanepoel, myburgh, & laurent, 2016) and infectious disease clinics (brittz, heinze, mahomed-asmail, swanepoel, & stoltz, 2019); however, applications specifically for ototoxicity monitoring in cancer patients require further investigation. an mhealth hearing screening application with automated test sequences, integrated noise monitoring, data capturing and data sharing (sandström et al., 2016; yousuf hussein et al., 2016) makes asynchronous ototoxicity monitoring possible, which will minimise the already overburdened schedule of cancer patients as monitoring can take place during inor out-patient chemotherapy treatments. conclusion there is significant discrepancy in how ototoxicity monitoring is conducted across south africa in both the private and public sectors, and implementation of a national ototoxicity monitoring protocol may improve audiological outcomes for patients receiving ototoxic chemotherapy. health professions council of south africa (2018) ototoxicity monitoring guidelines have been developed and should be used as a guide when implementing ototoxicity monitoring programmes. furthermore, effective scheduling and test location are key to a successful monitoring programme. finally, the need to simplify ototoxic monitoring of hearing and vestibular function to reduce test time and make it less stressful and tiresome on the patient should be considered. ototoxic monitoring programmes need to become standard of care for all patients receiving treatment with ototoxic medications. although a multidisciplinary team approach is vital, audiologists must take the lead to implement programmes that are thorough, efficient and accurate and based on patient-centred care. audiologists need to be proactive and develop exceptional working relationships with oncologists and nursing staff within the oncology units, ensuring that appropriate referrals are made for ototoxicity monitoring. including ototoxicity monitoring in the oncology treatment programme may also limit the overwhelming costs involved in oncology treatment. a deeper understanding of how long-term toxicities, such as hearing loss, tinnitus and vestibular dysfunction, can affect qol, needs to be incorporated into clinical practice for audiology referral centres and oncology units. by raising awareness, the risk of these long-term effects being overlooked will reduce. once enrolled in ototoxicity monitoring, cancer patients ought to be guided through the treatment journey and can be provided with pertinent and individualised support and intervention for hearing loss, tinnitus and vestibular dysfunction. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions k.e. conceived of the presented idea. k.e. developed the theory and performed the computations. d.s. and b.h. verified the analytical methods and encouraged k.e. to investigate (a specific aspect) and supervised the findings of this work. all authors discussed the results and contributed to the final manuscript. ethical considerations this article followed all ethical standards for research without direct contact with human or animal subjects. funding information the authors disclosed receipt of the following financial support for the research, authorship and publication of this article: this work was supported by the sefako makgatho health sciences university research support grant (grant number d200). data availability the data that support the findings of this study are available from the corresponding author, k.e., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references american academy of audiology (aaa). 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(2016). smartphone hearing screening in mhealth assisted community-based primary care. journal of telemedicine and telecare, 22(7), 405–412. https://doi.org/10.1177/1357633x15610721 abstract introduction method results and discussion limitations conclusion acknowledgements references about the author(s) katijah khoza-shangase department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa nomfundo moroe department of audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa joanne neille department of speech–language pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa anita edwards africa health research institute, mtubatuba, south africa citation khoza-shangase, k., moroe, n., neille, j., & edwards, a. (2022). the impact of covid-19 on speech–language and hearing professions in lowand middle-income countries: challenges and opportunities explored. south african journal of communication disorders, 69(2), a937. https://doi.org/10.4102/sajcd.v69i2.937 original research the impact of covid-19 on speech–language and hearing professions in lowand middle-income countries: challenges and opportunities explored katijah khoza-shangase, nomfundo moroe, joanne neille, anita edwards received: 28 may 2022; accepted: 15 july 2022; published: 09 sept. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: since the advent of the coronavirus disease 2019 (covid-19), the speech–language and hearing (slh) professions globally have been confronted with novel and unexpected challenges. objective: the aim of this article was to explore the impact of covid-19 on slh professions in lowand middle-income countries (lmics) as presented in the special issue of the south african journal of communication disorders in the year 2022. method: divergent from the standard editorial writing style, this editorial adopted a research approach where a qualitative, descriptive scoping review design was conducted to meet the objectives of the study. three specific objectives were targeted: (1) exploring the challenges to slh research, teaching and practice; (2) establishing evidence-based solutions available for these challenges that can be used to improve the professions’ response in the post-pandemic era; and (3) determining the areas that require further investigation, alternative solutions and innovation for improved readiness for future pandemics. a total of 21 manuscripts were reviewed that covered three predetermined themes – research, teaching and practice – that were constructed through a deductive approach as part of the call for papers for the special issue. these manuscripts were from academics, researchers and clinicians from various institutions in lmics. the review is presented using thematic analysis. results: the review raised important challenges, presented under various subthemes, to the three key themes. these challenges reflect on the impact of covid-19 on the slh professions in terms of research, teaching, service provision and ethical challenges, as well as its impact on speech language, hearing, swallowing and balance functions. the review also advanced solutions and future directions during and beyond covid-19. conclusion: these findings raise global implications for research, teaching and practice that are not only relevant to the slh professions. keywords: audiology; covid-19; teaching and learning; practice; speech–language pathology; clinical research; hearing professions. introduction no country, sector or profession has been spared from the impact of the global health emergency, the coronavirus disease 2019 (covid-19) pandemic, that has gripped the world since it was first identified and reported in wuhan, china (world health organization [who], 2020a, 2020b). global statistics, as of 27 may 2022, indicate that the total number of confirmed cases in the world has escalated to approximately 528 million, with over 6.28 million deaths. africa is currently recording 12 122 000 cases, with south africa registering the highest number of cases at a cumulative total of 3.94 million cases and over 101 000 total official deaths (who, 2022). despite all efforts to curb the spread of the virus and its consequent mortality and morbidity, the reported infection numbers remain high, although the mortality rate is seen to be declining where vaccination roll-out is successful (cooper, van rooyen, & wiysonge, 2021; who, 2022). however, africa’s vaccination drive has confronted numerous challenges, including resource constraints as well as vaccine access and hesitancy, with south africa at the end of the fifth wave of the pandemic in this second quarter of the year. this reality, therefore, has necessitated continued use of nonpharmaceutical prevention and control of the covid-19 infection measures, such as wearing of face coverings and physical distancing, in an effort to save lives and livelihoods, while preserving the health and safety of health care practitioners and their patients and students (beach et al., 2020; who, 2022; wieten, burgart, & cho, 2020), with these regulations very recently (june 2022) having been completely scrapped by the south african national department of health. the implementation of these measures has presented challenges to the provision of services within the scope of practice of the speech–language and hearing (slh) professions, including clinical practice, teaching and training, as well as research (khoza-shangase et al. 2021). a considerable aspect of the measures aimed at preventing the spread of covid-19 concentrated on the application of different public health measures for reducing transmission (kamerlin & kasson, 2020). these prevention measures have been classified as ‘suppressive approaches, which aim to arrest transmission, and mitigation approaches, which aim to slow spread and shield vulnerable populations without truncating transmission’ (kamerlin & kasson, 2020, p. 1). strategies such as ventilation, wearing of face coverings and physical distancing are aimed at curbing the spread of the virus, because close contact has been identified as a mode of virus transmission via droplet and airborne routes through respiratory activities (sun & zhai, 2020). such strategies of reducing transmission, especially within the slh professions where the patient population falls under the vulnerable groups (kuy et al., 2020), highlighted noteworthy challenges while raising the need for innovative solutions in clinical practice, training and research in these fields. thus, there is the need for the current special issue of south african journal of communication disorders (sajcd) in 2022 on the impact of covid-19 in slh professions in lowand middle-income countries (lmics). besides the obvious impact on the ability to provide clinical care for persons with communication impairments who rely on face-to-face communication (tohidast, mansuri, bagheri, & azimi, 2020), as well as the potential cognitive-communicative, hearing and balance impairments caused by covid-19 (fancello et al., 2021; jacob, flannery, & mostert, 2020; ramage, 2020), evidence also suggests that the use of masks majorly impacts communication in at least two ways. the wearing of masks and adherence to physical distancing is believed to affect the scope of slh practice by (1) reducing important features such as visual cues (chodosh, weinstein, & blustein, 2020; homans & vroegop, 2021; kataoka, maeda, sugaya, omichi, & kariya, 2021) and (2) lowering speech sound intensity and clarity, which affects individuals who depend on this compensatory strategy, such as the hearing impaired (saunders, jackson, & visram, 2021; ten hulzen & fabry, 2020). research indicates that masks cause a 3 db – 4 db (medical masks) reduction to approximately 12 db (n95 mask) reduction in sound intensity and a low-pass filter effect attenuating 2000 hz – 7000 hz of the speaker’s voice (goldin, weinstein, & shiman, 2020). exploration of the impact of covid-19 in lmics has substantial implications for slh professionals. it archives challenges encountered within these resource-constrained contexts. furthermore, it documents innovative solutions that were applied to overcome these challenges. this will allow for careful future planning, not only for future public health emergencies, but also for re-imagined service provision in these contexts. this exploration further highlights challenges of capacity versus demand as far as slh human resources are concerned, in contexts where this is an additional pressure for speech, language, swallowing, hearing and balance care (khoza-shangase, 2021; pillay, tiwari, kathard, & chikte, 2020). within the south african context, such careful future planning, as well as re-imagined slh research, teaching and practice, requires an evidence base that can help facilitate service delivery models that are culturally, linguistically and contextually compatible with the population and context (khoza-shangase, 2020). it is against this backdrop that the authors, professors katijah khoza-shangase, nomfundo moroe and joanne neille, all of whom are academics and researchers in the departments of audiology and speech–language pathology at the university of the witwatersrand, initiated the concept of, and acted as guest editors, on this special issue of the sajcd, entitled ‘the impact of covid-19 in slh professions in low and middle-income countries: challenges and opportunities explored’, by inviting research papers from academics, clinicians and researchers. the current article therefore serves as both the editorial for the special issue and original research in its own right. method aim instead of the standard editorial that provides an overview of papers included in the special issue of sajcd in 2022, the editorial team adopted a research approach that aimed at exploring the collated views and findings on the impact of covid-19 on slh professions in lmics, as reported in papers accepted for publication in the current special issue of the sajcd, with very specific objectives. objectives this study had the following objectives: to explore the challenges to slh research, teaching and practice during the covid-19 pandemic to describe evidence-based solutions for slh research, teaching and practice in the post-pandemic era to identify the issues that require further investigation for improved readiness for future pandemics. research questions the specific research questions asked by the authors were as follows: what were the challenges to slh research, teaching and practice during a pandemic like covid-19 reported by authors of the articles in the sajcd special issue (2022)? what evidence-based solutions were recommended for slh research, teaching and practice that can be used to improve the professions’ response in the post-pandemic era? what areas of research require further investigation and alternative solutions and innovation for improved readiness for future pandemics? study design because of the fact that a limited comprehensive body of literature existed on covid-19 and its potential impact on slh in lmics at the time of the special issue, as well as the fact that the paper was exploring evidence specific to time (during covid-19), location (lmics), source (peer-reviewed articles included in the special issue) and origin (academics, researchers and clinicians), a qualitative descriptive scoping review design was deemed an appropriate approach to adopt (peters et al., 2022). this design allowed for an overview of the complex impact that the covid-19 public health emergency had on the slh professions. the research design was chosen to facilitate recommendations for improved health care decision-making processes and quality of health care services in the slh professions (bae, 2014; butina, 2015; green, johnson, & adams, 2006). sources of data sources of data for the current study included all manuscripts accepted for publication in the special issue of the sajcd in 2022 after a blinded peer review process. a public call for submissions to the special issue of sajcd in 2022 was made and the guest editors encouraged those in the slh professions in lmics known to be involved in aspects related to the topic from among academics, researchers and clinicians to submit manuscripts. the special issue aimed to collate current contextually relevant and responsive evidence that fills the gap in innovative practices and re-imagines future practice in slh professions, as well as different models of service delivery. the goal of the special issue was to reflect on the impact of covid-19 on the slh professions in terms of research, teaching, service provision and ethical challenges as well as its impact on speech–language, hearing, swallowing and balance functions. selection criteria all manuscripts accepted for publication in the special issue of sajcd in 2022 were included in this qualitative narrative review. for inclusion in the special issue, manuscripts had to meet the following criteria: must be written in english consider the impact of covid-19 on one or more of the following areas: impact on training of slh professions; impact on research on slh professions; impact on speech–language, hearing, swallowing and balance functions; contextual factors influencing slh professions’ clinical response to covid-19; policy and legislation in slh professions’ response to covid-19; and impact on service delivery by slh professionals. data analysis a narrative thematic data analysis process was used, consisting of the following stages (creswell & creswell, 2017): arrangement and organisation of the data gaining an overall appreciation of the information identifying themes aligned to the research questions interpretation of the data. the analysis of data also included the qualitative narrative review approach of reflection on relevant evidence of the authors’ findings in the 21 articles included in the special issue (butina, 2015). analysis was further enhanced by using the framework of ‘ask – acquire – appraise – apply – assess’ or the 5a process, proposed by green et al. (2006) to facilitate critique and to summarise the contents of the findings of the articles. succinctly summarised data relevant to the specific objectives of the study were extracted and are presented in table 1 and table 2. readers are referred to the individual specific articles in the special issue of sajcd in 2022 for more specific details on the findings, as these could not be detailed in this article. the tables reflect the following information extracted from the reviewed manuscripts: author(s) and the year of publication title of the study challenges reported in terms of research, teaching and practice (table 1) solutions and future research directions recommended in terms of research, teaching and practice (table 2). table 1: summary of studies included in the scoping review documenting challenges presented by the covid-19 pandemic to practice, teaching and research. table 1 (continues...): summary of studies included in the scoping review documenting challenges presented by the covid-19 pandemic to practice, teaching and research. table 1 (continues...): summary of studies included in the scoping review documenting challenges presented by the covid-19 pandemic to practice, teaching and research. table 2: summary of studies included in the scoping review documenting solutions and future research directions for covid-19. table 2 (continues...) : summary of studies included in the scoping review documenting solutions and future research directions for covid-19. table 2 (continues...) : summary of studies included in the scoping review documenting solutions and future research directions for covid-19. the analysis was conducted by three of the authors, who paid particular attention to the information that offered insight into the stated research questions (butina, 2015). manuscript (member)-checking (the sajcd’s independent review process), confirmability between all researchers and transferability and dependability were all carried out to promote credibility. data management the guest editors and the sajcd editor-in-chief, as well as the administrative staff working for the publishing company, had access to the submitted manuscripts and the blinded peer review process used by the publishing company. an electronic audit trail was ensured by saving all the manuscripts reviewed and notes for data collection and analysis in password-protected information and communications technology (ict) systems (butina, 2015; creswell & creswell, 2017). ethical considerations the nature of the current study based on secondary data (articles in the special issue of sajcd in 2022) precluded the need for ethical clearance. however, this scoping review followed all ethical standards for a study that does not involve direct contact with human or animal subjects. this included reflexivity and informed subjectivity, audience-appropriate transparency and purposefully informed selective inclusivity (suri, 2020). results and discussion this special issue contains 21 papers that accurately responded to the specified call and thus met the eligibility criteria. these papers are depicted in table 1 and table 2. these papers, although unequally, addressed the three key themes that formed part of the open call for papers for the sajcd special issue (2022): (1) research, (2) teaching and (3) practice in slh in lmics. these three themes were established through a deductive approach. nuanced analysis of the focus on the evidence provided by the papers revealed a clear preponderance of papers focusing on practice challenges, possible solutions and future directions for clinical practice in slh (11 of the 21 papers). six papers specifically focused on teaching and learning challenges as well as solutions and future directions. the papers, which are all published in the sajcd special issue (2022), were all listed by the authors as reviews or original research articles. the papers are from lmics, as per the open call. south africa is the most represented country, possibly because the journal is owned and supported by the south african speech language and hearing association and is therefore most known to south african professionals and researchers. published articles are from more than half (four of seven) of the south african universities where slh training occurs. the reader is referred to the special issue of sajcd in 2022 for details from individual articles. inductive thematic analysis findings are presented and discussed under the specific study objectives, covering all three predetermined major themes, under specifically labelled subtitles. challenges to speech-language and hearing research, teaching and practice during the covid-19 pandemic research the inductive thematic analysis of the extracted data, as presented in table 1 and table 2, found that the challenges encountered by slh researchers during the covid-19 pandemic could be categorised into three subthemes: (1) paucity in research, (2) a lack of rigorous scientific standards as reflected in the research design and (3) adherence to cumbersome, inflexible and bureaucratic processes for research from research conceptualisation to publishing. the included papers highlighted a general lack of research during covid-19 as well as limited research on covid-19 and its impact on slh professions. furthermore, solutions towards provision of services during this public health emergency were also identified as lacking (barber & sher, 2022; khoza-shangase, 2022a; khoza-shangase et al., 2022; madahana et al., 2022b; tar-mahomed & kater, 2022;). for example, madahana et al. (2022b) lamented on the paucity of evidence as well as focused research into artificial intelligence (ai) as a machine learning (ml) option, particularly for the hearing-impaired population. this gap is especially pronounced in the african continent. such a lacuna became intensely obvious during the covid-19 pandemic, where the use of masks negatively impacted communication. consequently, a need for ai for clinical application as well as real-time speech captioning in african languages to assist hearing-impaired individuals was highlighted. additionally, tar-mahomed and kater (2022) raised another challenge regarding the lack of research on the utilisation of telepractice with slh patients. their research focused on evidence for the use of this modality in the provision of therapy to patients with speech, language and swallowing difficulties after a stroke. for this special issue of sajcd in 2022, no submissions of manuscripts on research into any other areas of communication disorders, many of which must have become relevant during the pandemic, were received. moreover, barber and sher (2022) identified a challenge with limited research evidence into understanding how to facilitate throughput of slh students during the pandemic. in their review, khoza-shangase et al. (2022) performed a scoping review specifically on challenges encountered by health care researchers in conducting research during the covid-19 pandemic, while highlighting lessons learnt for slh research. their review, which echoes challenges also reflected in the other articles included in the sajcd special issue (2022), found the following: (1) an absence of processes that can be used to balance quality, priority and speed of research conducted during this time; (2) an overall need for research protocols and designs to be flexible during the pandemic, as well as the importance of this flexibility in participant recruitment and participation; (3) difficulties with securing informed consent from research participants remotely – where remote working had become the standard practice; (4) ict challenges where telefunctioning had to be adopted because of a need to adhere to covid-19 regulations; (5) significant difficulties with provision of research interventions during the research; (6) challenges with data capturing, analysis and storage; and (7) challenges with sharing and publishing research findings. these challenges seem to have an influence on the amount, type and quality of research conducted, produced and shared (khoza-shangase, 2022a; khoza-shangase et al., 2022). khoza-shangase (2022a), for example, specifically highlighted the lack of rigorous scientific standards as reflected in the research designs in studies on cochleovestibular features of covid-19. the above-mentioned challenges are important to archive to allow for anticipatory strategies to be put in place for future planning. teaching and learning as far as teaching and learning challenges during the covid-19 pandemic were concerned, over and above the impact that masks and shields had on communication (khan et al., 2022), four themes emerged from the papers reviewed. khan et al. (2022) highlight the impact of masks and shields as obscuring facial expressions, affecting sound transmission, creating a barrier to accessing visual cues, making hearing speech challenging and listening more effortful and thus increasing feelings of anxiety when communicating during teaching and learning activities. these challenges would obviously not be experienced when teaching occurs online, as shields and masks are not utilised in that modality. therefore, the four themes that emerged were (1) a general lack of support for students, (2) heightened gaps in skills and knowledge, (3) limited knowledge and skills of educators for emergency remote teaching and learning (ertl) and (4) exceptionally increased workload for educators. coronavirus disease 2019 presented unprecedented challenges with traditional methods of teaching and learning, and these required innovative approaches and unconventional solutions. however, institutions of higher learning faced challenges with providing timely support for students to be able to navigate and cope with these institutional changes. naidoo et al. (2022), in their speech–language therapy educator reflections on the planning and implementation of clinical education during the covid-19 pandemic, reported that teaching and learning challenges were common across all students but were, however, more pronounced with first-year students. barber and sher (2022) observed that the challenges to teaching and learning indicated the need for varied types of support for students from different demographics to succeed. this timely institutional support that students require to be able to traverse the complex institutional changes was deemed crucial during the pandemic. this was particularly because challenges with in-person targeting of gaps in knowledge, clinical reasoning skills and competencies, as well as academic writing skills as part of clinical training, were impacted by covid-19 restrictions (masuku & mupawose, 2022). moreover, as far as teaching and learning challenges were concerned, covid-19-induced ertl did not only create challenges for students, but for educators as well. key to the challenges to educators was their limited knowledge and skills of ertl (naidoo et al., 2022). naidoo et al. (2022) reported that ertl was overwhelming and intimidating for educators, even with training, thus leading to uncertainty. these authors believed that although ertl training was valuable, it was lacking in practical application and was more knowledge focused with poor theoretical coherence. these challenges with ertl for educators had a substantial impact on their workload, which became exceptionally increased (hlayisi, 2022; khatib & hlayisi, 2022; naidoo et al., 2022). naidoo et al. (2022) found that educators experienced substantial challenges in coping with the extra demands brought on by the ertl student-centred approach that covid-19 was demanding. practice as far as challenges to practice were concerned, five themes were identified in the current review of papers in the sajcd special issue (2022): (1) lack of sufficient knowledge and skills in telepractice and the use of advances in ict for clinical practice by practising clinicians and students; (2) access and infrastructure challenges, for example, lack of appropriate equipment and limited access to data for connectivity; (3) high costs linked to telepractice; (4) increased or high workload; and (5) lack of and/or poor application of policies and regulations, for example, covid-19 regulations that do not consider patients with special needs. because of the covid-19 regulations that were put in place to prevent the spread of the virus, as well as to manage those infected, important challenges were encountered with the traditional in-person models of service delivery. for clinical care to continue, adoption of innovative and mostly remote service delivery models became inevitable. thus, telepractice became placed at the forefront of these models – therefore requiring knowledge and skills in this model. khoza-shangase (2022b) reported on the lack of sufficient knowledge and skills in telepractice by audiologists, while madahana et al. (2022b) highlighted the lack of utilisation of ai for clinical application. this knowledge and application gap is a missed opportunity for clinical care in these fields during and beyond covid-19. additionally, karrim et al. (2022) raised challenges with criteria, strategies and technical skills required for the utilisation of telerehabilitation by speech–language therapists and audiologists. for example, challenges were highlighted on telerehabilitation in children with autism spectrum disorder; middle ear assessments (sebothoma & khoza-shangase, 2022); therapy for speech, language and swallowing following stroke (tar-mahomed & kater, 2022); early communication intervention (achmat & gerber, 2022); neonatal feeding in neonatal intensive care units (coutts et al., 2022); and geriatric audiology service provision in old age homes (de andrade & landman, 2022). challenges to practice created by covid-19 were worsened by access and infrastructure challenges, as well as the related high infrastructural costs. over and above infrastructure and system challenges directly related to curbing the spread of covid-19 in the form of personal protective equipment (ppe) and infection prevention and control (ipc) measures (achmat & gerber, 2022), noteworthy other infrastructure and costrelated challenges were experienced by both professionals and patients (khoza-shangase, 2022b; mcallister et al., 2022; tar-mahomed & kater, 2022). access to the technology and its infrastructural support for innovative clinical service provision was raised as a serious barrier. this included (1) access to technological devices (e.g. computers, laptops, tablets and smartphones), with a lack of resources reported by coutts et al. (2022); (2) connectivity in the form of access to internet with good bandwidth; (3) stable power supply; and (4) technology-associated costs, including data costs (khatib & hlayisi, 2022; khoza-shangase, 2022a, 2022b; mcallister et al., 2022; tar-mahomed & kater, 2022). in south africa, a major challenge was maintaining a stable power supply with load-shedding, which is scheduled national electricity supply interruption. khatib and hlayisi (2022) raised limitations regarding available technologies such as technological compatibility of older hearing aids, while khoza-shangase (2022b) reported on challenges around technological abilities of patients, clinicians as well as patient-site facilitators (psfs). khatib and hlayisi (2022) reported that patients were not ready for this model of service delivery, thus requiring deliberations around reliability of some online assessments. tar-mahomed and kater (2022) highlighted that within the south african context, these challenges of technological access and supportive infrastructure are not the same across the health care sector. these authors reported that the private health care sector is better resourced than the public sector. however, regardless of the sector, in general, other health care services were prioritised over audiological services such as covid-19, with financial constraints limiting the provision of audiological services during covid-19 (de andrade & landman, 2022). furthermore, as far as challenges to practice are concerned, covid-19 significantly increased the workload of clinicians (balton et al., 2022; hlayisi, 2022; khatib & hlayisi, 2022). over and above the core function of providing clinical care, time devoted to establishing innovative modes of service provision, sourcing required resources that would allow for continuity of service provision during the pandemic, training and upskilling everyone on alternative service provision methods, as well as engagement in the national covid-19 pandemic management were all added to clinicians’ workloads (achmat & gerber, 2022; balton et al., 2022; hlayisi, 2022; karrim et al., 2022; khatib & hlayisi, 2022; khoza-shangase, 2022b; nagdee et al., 2022). balton et al. (2022) highlighted how such workload challenges were possibly influenced by a lack of or poor application of policies and regulations within the south african context. these authors argued that the response of the south african health care system to covid-19 highlighted that the needs of vulnerable populations were not clearly taken into cognisance when regulations and policies to curb the pandemic were developed. khoza-shangase (2022b) underscored how regulations around reimbursement and registration to practice were barriers to the provision of clinical care during covid-19 internationally and how these regulations require careful engagement. karrim et al. (2022) raised restrictions around policies regarding the use of telepractice for assessment and treatment as another challenge. khoza-shangase (2022b) highlighted this challenge around policies and regulations as it relates to the use of psfs, their training and their regulation as part of telepractice. this challenge stresses an urgent need for regularisation, standardisation and structurisation of psfs in current training programmes as well as in the south african national health department’s human resource strategy. evidence-based solutions for speech–language and hearing research, teaching and practice in the post-pandemic era valuable evidence-based solutions and future directions were identified from the papers included in the sajcd special issue (2022). research as far as research is concerned, the solutions emerged under four themes: (1) need for new and innovative approaches to research, (2) heightened focus on technological advances, (3) contextually relevant and responsive large-scale research in lmics to address the key needs and (4) development and/or implementation of relevant policies. khoza-shangase et al. (2022) argued for new approaches to research that accommodate national public health emergencies. these authors also raised the importance of development of research infrastructure and workforce that will facilitate and sustain knowledge generation during and beyond pandemics. furthermore, these authors highlighted maximising opportunities for remote working practices, which require improved use of ict for research processes. such approaches will enhance the quality of research designs (khoza-shangase, 2022a), including contextually relevant and responsive longitudinal as well as large-scale studies required in lmics to address key needs for evidence-based practice (coutts et al., 2022; khan et al., 2022; khatib & hlayisi, 2022; khoza-shangase, 2022b; masuku et al., 2022). solutions must include considerations of, development and/or implementation of relevant policies so that researchers and participants are not harmed, research is supported and sustained, researchers are protected as employees and their mental health is looked after by research managers and research institutes. details on the methods of support can be obtained in the individual articles of the special issue of sajcd in 2022. teaching and learning solutions that were suggested to address teaching challenges fell under eight themes: (1) careful interrogation of core aspects of telepractice and inclusion of them in the undergraduate curriculum; (2) need for flexibility in terms of access to academic material; (3) need for robust technical infrastructure to support innovative teaching and learning; (4) comprehensive and enhanced student support across the years of study; (5) exploration of opportunities for international telesupervision; (6) need for advances in clinical training (ict, fourth industrial revolution [4ir] and ai); (7) enhanced hybrid models for teaching and learning; and (8) deliberate reflection on personal challenges and contextual influences to build resilience and coping mechanisms (khoza-shangase, 2022b; madahana et al., 2022a, 2022b; naidoo et al., 2022). with the overall recommendation of hybrid models of teaching and learning that include the use of ict, simulations, teletraining and telesupervision (barber & sher, 2022; masuku & mupawose, 2022; mcallister et al., 2022; nagdee et al., 2022), naidoo et al. (2022) stressed that online platforms will facilitate closer and increased collaboration. this collaboration is between students and between students and educators, with increased opportunities for local and international collaborations. these authors further believed that online platforms for teaching and learning may raise opportunities to support students through social media platforms, thus increasing the amount of immediate and individual support offered to them. from their experience with telesupervision and online case-based learning for speech and language therapy students in vietnam, mcallister et al. (2022) recommended telesupervision, where international therapists, working remotely and in partnership with local therapists, provide on-site supervision for students. this recommendation includes online case-based discussions as part of clinical training and online student group discussions, using case simulations with videos or avatars. practice clinical practice-related solution themes to covid-19 that emerged from the articles in the special issue of sajcd in 2022 were the following: (1) intensified research into contextually relevant and responsive solutions to guide best practice, (2) technologically intelligent clinical skills training, (3) the need to explore and/or formalise and regulate the use of task-shifting and psfs during telepractice, (4) robust technical infrastructure to support telepractice, (5) use of hybrid rehabilitation models, (6) prioritisation of mental health services for both patients and their caregivers as well as health care workers and (7) the need for quality standards and best-practice models to be maintained (coutts et al., 2022; de andrade & landman, 2022; karrim et al., 2022; khatib & hlayisi, 2022; khoza-shangase, 2022a, 2022b; madahana et al., 2022a, 2022b; naidoo et al., 2022; tar-mahomed & kater, 2022). some specific solutions emanating from the foci of the articles in the special issue of sajcd in 2022 included (1) an increased need for careful audiological assessment as well as polymerase chain reaction testing for covid-19 diagnosis in patients presenting with sudden unexplained cochleovestibular symptoms during covid-19 (khoza-shangase, 2022a); (2) paradigm shift towards inclusion of ai and ml concepts in the current technologies being developed in south africa as solutions for the slh professions as the country transitions towards 4ir, such as the ml-linked solutions that are targeted towards bridging the communication gap between the normally hearing and people with hearing impairment (madahana et al., 2022a, 2022b); (3) provision of and access to robust technical infrastructure to support all activities (madahana et al., 2022a); and (4) the use of a hybrid approach to clinical service delivery (khatib & hlayisi, 2022). khatib and hlayisi (2022) highlighted that the utilisation of a hybrid approach including telepractice can lead to increased patient compliance, positive clinical benefits and positive participant experience, as well as cost-effective slh services. karrim et al. (2022) supported this approach and argued that despite the implementation difficulties associated with telepractice, the benefits far outweigh the challenges encountered. moreover, as far as practice solutions are concerned, tar-mahomed and kater (2022) stressed the importance of considering factors such as linguistic and cultural diversity and socio-economic status. the socio-economic status issues include income, educational level and stable power supply, as well as access to ict and its associated infrastructure as part of key solutions for practice challenges for both patients and service providers. khoza-shangase (2022b) added to these factors the crucial potential role of psfs during telepractice within the south african context. this author argued that this solution carries the potential of enhancing contextual relevance in clinical service provision, if the psfs are linguistically and culturally diverse and come from the communities where the patients reside. furthermore, this solution, if properly planned and appropriately managed and regulated, can potentially create employment opportunities where paraprofessionals are employed in task-shifting roles as psfs. however, this would require careful deliberations and planning around who can serve as psfs, who will provide the training and the content and nature of the training they would require, as well as regulations around the quality standards and best-practice models that must be maintained. all the solutions presented thus far call for careful planning, research to establish evidence for best practice and proper and accurate record-keeping. balton et al. (2022) raised the value of adaptability, becoming comfortable with uncertainty and maintaining open and transparent communication in clinical practice during and beyond covid-19. such qualities also require close collaboration within the various levels of the south african health care system to facilitate an appropriately response to the needs of patients during such a public health emergency. according to balton et al. (2022), this hinges on commitment to compassionate leadership and staff well-being. issues that require further investigation for improved readiness for future pandemics current evidence emerging from the special issue of sajcd in 2022 reviewed articles suggests a clear need for research in the following areas: research is needed on the potential impact of remote (online) teaching and learning, as well as telepractice. studies should be conducted on the use of simulations as well as writing-intensive approaches to teaching for clinical training. rigorous scientific investigation of the effects of covid-19 on slh services that includes specific evaluation of the many different areas of communication disorders that are clinically diagnosed and treated by slh professionals. research into the use of and development of ai and ml technologies in slh research, teaching and clinical practice. research into technologies for speech-to-text conversion in south african languages other than english. exploration of remote international clinical supervision. research into hearing health care human resource policies and planning, hearing health care labour market needs and capacity, as well as hearing health care service delivery and potential for growth in the south african context after covid-19. reviews of policies and regulations around covid-19 and similar public health emergencies and how these affect slh professions and the vulnerable populations they serve. efficacy studies on the use of telepractice in slh service provision.the effect of ppe and ipc on slh services. the above-listed areas of future research direction and recommendations in this covid-19-themed special issue of sajcd in 2022 raise important concerns for future enquiry and developments for the slh professions from lmics, which may also have global relevance. each manuscript provides specific, more detailed future research implications, contextualised within each paper. limitations although the qualitative scoping review approach adopted in the current review was appropriate for the purpose and questions of the current study, findings are limited to data presented in the manuscripts included in the special issue of sajcd in 2022 on covid-19 research. this limitation must therefore be considered when interpreting the findings presented, as findings cannot be generalised and cannot be assumed to represent the comprehensive body of knowledge in the area that the special issue of sajcd in 2022 specifically focused on, and challenges, solutions and areas for further investigation presented in this article are only reflective of those covered in the 21 manuscripts included in this special issue of sajcd in 2022. conclusion this special issue entitled ‘the impact of covid-19 in slh professions in lmics: challenges and opportunities explored’ revealed important challenges encountered by lmics in terms of research, teaching and practice. although specific to the slh professions, findings presented in this article may have global applicability within broader health care research, teaching and training. the challenges identified, as presented under themes, call for strategic planning, innovative and flexible solutions and sensitivity to contextual realities in slh research, teaching and practice. these solutions must be driven by evidence developed from research that adheres to rigorous scientific standards, with enhanced appreciation of what ict, ai and 4ir have to offer to these professions. some of the issues highlighted by the special issue of sajcd in 2022 that require further investigation for improved readiness for future pandemics, which have been detailed in this article, require engagement and deliberate planning for slh professions to be better prepared not only for public health emergencies but also for re-imagining slh practice within lmics. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions k.k.-s. was responsible for the conceptualisation, methodology, formal analysis, investigation, writing of the original draft, project administration, data curation, resources, review and editing of the article and funding acquisition. n.m. was responsible for the methodology, investigation, data curation, resources and funding acquisition. j.n. and a.e. were responsible for the methodology, investigation, data curation and resources. funding information the authors thank the national institute for the humanities and social sciences (nihss) and the national research foundation (nrf) for providing financial assistance for the publication of this manuscript. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily 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(2020b). global leaders unite to ensure everyone everywhere can access new vaccines, tests and treatments for covid-19. retrieved from https://www.who.int/news/item/24-04-2020-global-leaders-unite-to-ensure-everyone-everywhere-can-access-new-vaccines-tests-and-treatments-for-covid-19 world health organization (who) (2022). coronavirus (covid-19) media briefings. retrieved from https://www.bing.com/search?q=coronavirus+(covid-19)+%7c+who+%7c+regional+office+for+africa&cvid=5037661c80b244b6bfda79f5e256c496&aqs=edge..69i57.397j0j4&form=anab01&pc=asts abstract introduction methodology findings and discussion conclusion acknowledgements references about the author(s) sadna balton department of speech therapy and audiology, chris hani baragwanath academic hospital, johannesburg, south africa annika l. vallabhjee department of speech therapy and audiology, chris hani baragwanath academic hospital, johannesburg, south africa stephanie c. pillay department of speech therapy and audiology, chris hani baragwanath academic hospital, johannesburg, south africa citation balton, s., vallabhjee, a.l., & pillay, s.c. (2022). when uncertainty becomes the norm: the chris hani baragwanath academic hospital’s speech therapy and audiology department’s response to the covid-19 pandemic. south african journal of communication disorders, 69(2), a913. https://doi.org/10.4102/sajcd.v69i2.913 original research when uncertainty becomes the norm: the chris hani baragwanath academic hospital’s speech therapy and audiology department’s response to the covid-19 pandemic sadna balton, annika l. vallabhjee, stephanie c. pillay received: 31 jan. 2022; accepted: 12 apr. 2022; published: 08 aug. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: in march 2020 the world health organization declared the coronavirus disease 2019 (covid-19) a pandemic. management of this pandemic had significant implications for clinical departments across the world. healthcare systems were urgently required to reorganise and redesign patient care as well as repurpose staff. objectives: we will share the lived experience of our response as speech therapy and audiology (sta) clinicians to the covid-19 pandemic. method: this study adopted an autoethnographic approach within bronfenbrenner’s bioecological model to describe sta clinicians’ response to the covid-19 pandemic. results: adaptations to practice were made to continue service provision whilst adhering to covid-19 regulations. we assisted in other areas to meet the immediate needs of the hospital. service delivery strategies consisted of a review of clinical and quality assurance protocols. we developed a telehealth service package which included a hybrid approach, within a context of digital poverty. we created resources to ensure continuity of care. collaboration within our systems facilitated innovative solutions. mental health and well-being of staff members were key to the response developed. conclusion: south african healthcare systems’ inequalities were highlighted by the pandemic. the response showed that the needs of vulnerable populations were not accounted for when developing this public health response. lessons learnt included the importance of adaptability, becoming comfortable with uncertainty and maintaining open and transparent communication. consultation and collaboration within various levels of our healthcare system were critical in responding to the needs of patients. commitment to compassionate leadership and staff well-being were crucial. keywords: covid-19; adaptations; autoethnography; bioecological framework; collaboration; microsystem; speech therapy and audiology; south africa; solutions; telehealth; well-being. introduction south africa detected its first case of the coronavirus disease 2019 (covid-19) in march 2020 (moonasar et al., 2021), and this was the onset of uncertainty, fear, anxiety and confusion. the president of south africa declared a national state of disaster on 15 march 2020, followed by varied levels of lockdown as part of the measures to control and/or minimise the spread of this novel virus (dlamini zuma, 2020). access to in-person healthcare and rehabilitation services was severely limited, and people avoided seeking services for fear of contracting and spreading covid-19 (banks, davey, shakespeare, & kuper, 2020; de biase, cook, skelton, witham, & hove, 2020; pillay, pienaar, barron, & zondi, 2021; wilson, crouch, schuh, shinn, & bush, 2021). all outpatient services in the speech therapy and audiology (sta) department at chris hani baragwanath academic hospital were immediately stopped and inpatient care was directed towards covid-19 services. outpatients who had been booked up to three months in advance had appointments cancelled. the pandemic exacerbated existing problems and concerns for people with and affected by hearing, balance, communication and swallowing disorders (clegg, o’flynn, & just, 2021; tohidas, masuri, bagher, & azimi, 2020; wilson et al., 2021). the needs of our patients required us to address the challenges that covid-19 presented by reframing our model of care. this period of uncertainty also led to innovation, adaptation and a need for transparency and compassion amongst healthcare professionals. methodology our response to the covid-19 pandemic within a tertiary academic hospital’s sta department in south africa is narrated using an autoethnographic approach (dercon et al., 2021; jackson & mazzei, 2008; marechal, 2010) within the theoretical framework of bronfenbrenner’s bioecological model (bronfenbrenner, 2005; tudge, mokrova, hatlfield, & karnik, 2009). autoethnography is a reflexive consideration of the personal narrative of a group about an aspect of their experience which is embedded within a particular environment (dercon et al., 2021; marechal, 2010; mendez, 2013). an autoethnographic approach, for us, facilitates a better understanding of the larger political, social and cultural phenomena experienced during the covid-19 pandemic (marechal, 2010; mendez, 2013; wall, 2008). roy and uekusa (2020) asserted that covid-19 has allowed groups a unique opportunity to turn their everyday experiences, daily routines, activities and emotions into rich qualitative data in a collaborative and systemic way. many studies published during the covid-19 pandemic have utilised an autoethnographic approach to reflect on the lived experience of various healthcare professionals and patient groups (das nair et al., 2021; hannam-swain & baily, 2021; perumal et al., 2021; wasdan, 2021; zheng, 2021). in fact, roy and uekusa (2020) argued that researchers should explore innovative, unconventional strategies to provide new insights and understanding. the authors consist of the head of the sta department and the therapists who were leading the speech therapy clinical teams during the pandemic. as current authors of this manuscript, we have deliberately chosen to write in the first person to capture and share our story as a group experience where the emphasis on self purposefully moves away from conventional and hierarchical forms of writing (jackson & mazzei, 2008). the decision to use the ‘i’ narrative challenges the colonial perspective which ‘creates barriers between people, places and things’ (pillay & kathard, 2015, p. 199). the use of ‘i’ also facilitates new ways of thinking and being (khoza-shangase & mophosho, 2018). the information used to tell our story was gathered from our review of statistics, departmental reports, revised protocols and a retrospective review of personal and departmental records. bronfenbrenner’s bioecological model provides a systemic, integrated approach that facilitates the understanding of the individual’s experience in a specific context and time within an interdependent system (bronfenbrenner, 2005; cala & soriano, 2014; eriksson, ghazinour, & hammarstrom, 2018). the covid-19 pandemic has highlighted the interconnectedness of varied systems which has affected all domains of life (hassan et al., 2020). it also exposed structural health inequities with increased risks to already vulnerable groups, such as the elderly and people living with disabilities (paremoer, nandi, serag, & baum, 2021; the lancet, 2020). a systemic response to covid-19 provided an opportunity for new knowledge to be acquired, interpreted, disseminated and applied contextually in order to build and strengthen relationships between individuals and organisations (zięba, 2021). figure 1 outlines bronfenbrenner’s process-person-context-time (ppct) model (bronfenbrenner, 2005; rosa & tudge, 2013; tudge et al., 2009), which frames our discussion in this article. figure 1: outline of bronfenbrenner’s process-person-context-time model. person the sta department had a staff complement of 47 therapists and 10 auxiliary staff members during this period. the staff profile within our department consisted of white therapists, african therapists, indian therapists and coloured therapists, with only four men in the group. more than 55% of staff members had less than five years’ experience, with 13 members having just started their community service year. fifty-three per cent of staff members lived away from their families who resided in other provinces. our immediate microsystem during the covid-19 pandemic consisted of a diverse group of people who did not have extensive experience within the public healthcare sector. process the reciprocal interactions between people within the sta department and the environment within which they function are connected through these various processes (barach & johnson, 2006). the sta department is organised into five clinical teams, where each team has a designated team leader and clinic coordinators who ensure the smooth flow of services at an operational level. inpatient and outpatient services across the lifespan are provided to patients with communication, hearing, balance and swallowing disorders. statistics from 2019 indicated that there were a total of 35 019 contact sessions for sta. contact sessions refer to clinical contact with patients. the head of department and team leaders form an executive leadership committee that engages in strategic decision-making, planning and monitoring. our department’s functioning is guided by a strategic plan, a comprehensive annual performance plan, departmental protocols, clinical guidelines and hospital and provincial policies. quality assurance roles, responsibilities and activities in these protocols are outlined to ensure that service standards are upheld. this includes areas such as infection control and occupational health and safety. the sta department facilitates various activities to build a dynamic, transformative, committed and well-cared-for team with a strong sense of purpose. context microsystems co-exist within a macrosystem (tudge et al., 2009). the macrosystem includes legislature, government departments, social policies, economic systems, media and cultural values that influence social contexts (newman & newman, 2020). our hospital is classified as a central hospital in the public healthcare sector where highly specialised, multispeciality clinical services are offered by multidisciplinary teams in an environment that fosters innovation and research (department of health, 2017). there are seven business units in the hospital, each under the management of a senior clinical executive who reports to the hospital’s chief executive officer. speech therapy and audiology falls under allied health with occupational therapy, physiotherapy, dietetics, podiatry, social work and orthotics. the heads of these departments, who are not directly involved in hospital management structures, meet monthly and mainly discuss operational issues. the sta department is interconnected with the broader healthcare system within the province. at a provincial level, we are represented on the executive committee for sta as well as the rehabilitation forum which has representation from occupational therapy, physiotherapy and sta. these structures fall under the directorate for oral health and therapeutic services in gauteng. the sta department is therefore integrally linked and accountable to broader structures within the hospital and province. furthermore, the sta department provides a clinical platform for sta students from the university of the witwatersrand and hosts students doing their electives or observations from other universities in the country. our microsystem is therefore extensive, with our mesosystem consisting of varied levels of interaction and engagement. at a macrosystem, services are informed and planned in accordance with the burden of disease, sociodemographic conditions (pillay, tiwari, kathard, & chiktay, 2020) and the linguistic and cultural diversity of our patients (khoza-shangase & mophosho, 2018). time time as defined within the ppct model will be highlighted in our discussion through identifying the activities that took place within a specific time period, march 2020 to december 2021. the continuous adaptations to processes within the microsystem were also defined by changes within the macrosystem at a particular time, e.g., adapting to the changes in legislature and its impact on services. findings and discussion the clinical microsystem assessment tool in table 1 (johnson, 2010) identifies the characteristics of high-performing microsystems (barach & johnson, 2013). table 1: clinical microsystem assessment tool. adhering to table 1, the discussion of our response to the covid-19 pandemic focuses on leadership, staff and patients with performance and information integrated into these areas. leadership a crisis requires ‘positive leadership amid unprecedented change, to lead and function as active, authentic, aware, adaptive, flexible, as well as trusted, engaged and compassionate communicators’ (hill, butnoris, dowling, macolino, & patel, 2020, p. 294). at the onset of level 5 lockdown, we were instructed by hospital management to stop all nonessential services, which included all outpatient sta services. this sudden change in operations required us to rethink our purpose and function within the hospital. mather (2020) recommended that leaders should go back to their core values and purpose at a time of crisis. our vision and mission as a department, as displayed in table 2, therefore guided our decision-making during this period. table 2: vision, mission and values of the speech therapy and audiology department. according to heath, sommerfield and von ungern-sternberg (2020), keeping staff informed serves the purpose of building resilience through a sense of increased control over one’s environment and displays a commitment to engage and support staff directly. an urgent staff meeting was called by the head of department to relay information about the directive received and its impact on services and staff. staff members communicated their fears about covid-19 in this meeting but added that they wanted to contribute to the hospital’s response. unfortunately, at this initial stage the hospital’s response was not clearly communicated by management. organisational support in the hospital (barach & johnson, 2013) was activated only a few weeks later through the development of a steering committee under the leadership of the head of internal medicine. this committee met biweekly via the microsoft teams platform. statistics on the number of covid-19 admissions, staff positivity rates, logistical challenges, personal protective equipment (ppe) and ward reallocations were some of the areas discussed. these meetings facilitated improved relations with various stakeholders within the hospital and continued to build the identity of rehabilitation. the head of the sta department attended these meetings and provided feedback to staff members on a regular basis. these sessions provided an opportunity for staff to be informed and to participate in decision-making. in a crisis, employees depend on organisational leaders for information, and effective communication of critical decisions (sanders, ngugen, boukenogne, rafferty, & schwarz, 2020). initially, all information received through various platforms was shared with staff members to reduce the anxiety associated with covid-19. however, this influx of information became very overwhelming. we refined our communication strategy as our knowledge, skills and understanding of covid-19 improved. we agreed on a set of principles to guide our communication in terms of the nature, frequency, time and platforms that would be used. mather (2020) and bronfenbrenner (2005) stated that during a crisis or a specific historical event, there is a need to act with urgency as wasted time and delays can be damaging. during this period there was no communication received from the national and provincial rehabilitation directorates about the role of rehabilitation personnel in and during covid-19. it was therefore critical for decisions to be made at an sta departmental level to ensure that we continued functioning with a sense of purpose within the health system. we engaged with our exosystem to review material generated by international and national associations and the health professions council of south africa. this facilitated the development of standard operating procedures, adaptation of protocols and creation of resources to guide clinical practice. because of the urgency of this response, our protocols were developed in a silo and did not include consultation with other disciplines in the hospital. upon reflection, it was evident that to ensure a unified approach, this process should have been guided by the leadership of national and provincial rehabilitation structures to ensure a more comprehensive and integrated response. adaptable, transparent and compassionate leadership (de zulueta, 2016; poorvakos, 2016) was key in helping us lead during a period marked with uncertainty. person (staff) research has shown an increase in levels of stress, anxiety and depression of healthcare professionals during the covid-19 pandemic (feijt, de kort, bongers, bierbooms, westerink, & ijsselsteijn, 2020; prasad et al., 2021; zhang et al., 2020). a valued member of the microsystem is one that feels that their needs are taken into consideration by the organisation (johnson, 2010). the sta department therefore focused on the well-being of our staff. this was achieved through training and development, creation of a supportive and safe environment and a culture that facilitated trust, transparency, empathy, open-communication and teamwork (barach & johnson, 2006). training and development healthcare professionals should be provided with evidence-based knowledge and tools to cope with the impact of covid-19 (rana, mukhtar, & mukhtar, 2020). a systematic review by cag et al. (2020) reported that supportive learning environments facilitate resilience and support mental health of healthcare professionals, during and after a pandemic. training that was done in our department focused on understanding covid-19 and its impact on speech, language, eating and drinking, balance and hearing. infection control, occupational health and safety procedures and well-being strategies were also included. the details of our training programme are presented in table 3. table 3: speech therapy and audiology training and development programme. staff safety providing a safe work environment is a matter of social justice, and healthcare professionals need to be safe to provide care for others (zungu et al., 2021). recommendations made by the world health organization (who) (2021) and the south african department of employment and labour (2020) included the implementation of work shifts and alternating work weeks to limit interactions across coworkers as part of measures towards reducing infections (carnevale & hatak, 2020; sanchez-taltavull, castelo-szekely, candinas, roldan, & beldi, 2021; who, 2021). however, there was inconsistency and a lack of specificity in recommendations about which organisational strategies would be most suitable within a hospital setting (sanchez-taltavull et al., 2021; who, 2021). we developed an alternate working model which proposed shift work and alternating teams for our department, but our proposal was rejected by management, and we were required to continue with a full staff complement on-site daily. promoting a safety culture through the development of organisational policies is important for contributing to a better mental health in the workplace (devaraj, 2020; hamouche, 2020; yassi et al., 2007). various protocols were introduced in our department to improve staff safety and ensure our adherence to infection control and safety compliance measures. adherence was regularly monitored through audits by the sta department’s infection control team, and continuous feedback was provided on improvement strategies. signage was placed around our department to indicate the number of people per room to ensure adequate social distancing. most of our meetings and activities were moved to a virtual platform in order to adhere to regulations and to keep staff members safe. during the pandemic, a shortage of sanitisers, medical masks and toilet paper and the absence of guidelines on the use of ppe increased anxiety-related behaviours amongst healthcare professionals (corkery & maheshwari, 2020; shigemura, ursano, morganstein, kurosawa, & benedek, 2020). initially, ppe was provided according to our own risk assessment and availability of stock. at the early stages of the pandemic, there was a severe shortage of ppe (le roux & dramowski, 2020; zungu et al., 2021) and staff had to either purchase their own masks or wear the same mask for a few days. this was very distressing as we felt unsafe and uncared for within the health system. once the hospital’s ppe committee was constituted and guidelines were developed according to the level of risk and exposure, the stress and anxiety experienced were reduced. staff well-being research has highlighted that the pandemic will have far-reaching psychological impacts including burnout, fatigue, moral injury, depression, increased anxiety and post-traumatic stress for healthcare professionals (blake, bermingham, johnson, & tabner, 2020; robertson, maposa, somaroo, & johnson, 2020; sovold et al., 2021; wong, olusanya, parulekar, & highfield, 2021). implementing and exploring the value of evidence-based self-care strategies empowers healthcare professionals to protect their well-being (cocchiara et al., 2019; sovold et al., 2021; walton, murray, & christian, 2020). staff activities focused on building resilience, offering support and implementing strategies to maintain mental well-being. research has shown the importance of providing access to mental health support for healthcare professionals during a pandemic (walton et al., 2020). information was shared on free mental health support services, online applications and resources for healthcare professionals (e.g. healthcare workers care network and south african depression and anxiety group and care pathways). debriefing was organised for individuals and groups with the hospital’s psychology department. support for covid-positive staff members was provided through daily check-ins and sharing of resources on managing covid-19 symptoms. an individualised response was developed for those who experienced loss. discussions were held within the department on how to keep in touch with family and friends and how to minimise cross-infection to family members (adams & walls, 2020). we created a space to share information on events such as online music festivals and ideas on self-care activities, movies, recipes and reading lists. our well-being activities included mindfulness practice such as adult colouring, beadwork and gratitude practice by making gratitude jars, practising meditation and yoga. a graduation ceremony was hosted for our community service therapists who were denied this opportunity because of covid-19. research by teo et al. (2021) found that teamwork and feeling appreciated at work were protective factors and assisted in mitigating the anxiety and stress associated with covid-19. stigmatisation of healthcare professionals by their colleagues was rife during the early stages of covid-19 (grover, singh, sahoo, & mehra, 2020). regular and transparent communication about covid-positive staff members, as well as patients, was important to decrease anxiety and fear associated with the unknown. three of our staff members who tested positive in wave 1 shared their story in a video produced by the gauteng department of health. the aim of this video was to destigmatise being covid-positive amongst healthcare professionals. interdependence of staff within a system interdependence within the clinical microsystem refers to the interaction of staff, characterised by collaboration, a willingness to help and a recognition that all contribute individually to a shared purpose (johnson, 2010). as hospitals struggled with high patient loads during the pandemic, many healthcare professionals needed to act out of their scope of practice (adams, seedat, coutts, & kater, 2021; bodiat & rogers, 2020). we were called on to assist with swabbing patients and staff at designated points in the hospital. we assisted with packing ppe for staff and setting up a database for hospital staff covid-19 infections. in addition, we were requested to accommodate the staff occupational health and safety service in our department. this consisted of telephonic risk assessments and follow-ups with positive staff members. the head of department was seconded onto the hospital’s vaccine committee to organise the vaccine roll-out for healthcare professionals. she also assisted with vaccine education and training sessions for staff and acted as a media liaison for the hospital. the sta department assisted with queue management and registration for the vaccine roll-out. this intensive process took up our time, personnel and resources but was important within the timing of the overall development of the hospital’s response to the pandemic. our collaborative approach assisted in relationship-building, networking and contributing to a historical event. an integrated approach to feeling valued needs to include training and development, maintaining staff safety and creating a psychologically safe space where every member feels a sense of belonging and purpose. patients our services were aligned to the different levels of lockdown as indicated on the timeline in figure 2. rehabilitation is a human right (united nations, 2006) and is identified as a key health strategy by the who (2019). the rehabilitation needs of persons with disabilities were not considered in many countries’ responses to the covid-19 pandemic (eskytė, lawson, orchad, & andrews, 2020), as services were either stopped or curtailed (negrini et al., 2020). vulnerable people became even more vulnerable during this pandemic (castelyn, viljoen, dhai, & pepper, 2020). our outpatient services were immediately stopped after the state of disaster was declared in march 2020 (dlamini zuma, 2020; moonasar et al., 2021). our inpatient load was affected by the hospital’s decision to discharge all medically stable patients in order to free beds and increase staff availability for covid-19 patients. this reprioritisation within the hospital for covid-19 patients necessitated a meeting with medical heads of units to clarify referrals, discharge procedures and plan the clinical management of patients already in the hospital. communication channels between teams were also discussed to improve the understanding of expectations and patient flow within and through the various units. our protocols were adjusted to include prioritisation criteria and risk reduction strategies for the inpatient population. the criteria were based on guidelines developed by the royal college of speech and language therapists (2020) and recommendations made by west, kevin and welling (2020). three levels of priority as indicated in table 4 were developed and instituted to guide decision-making in levels 5 and 4 of lockdown. figure 2: sta department timeline. table 4: initial prioritisation guideline. the above guidelines were continuously reviewed and adjusted according to emerging evidence and levels of lockdown. risk reduction strategies included stopping high-risk procedures like speech-valve trials and modified evans blue-dye tests (cameron, reynolds, & zuidema, 1973 as cited in swigert, 2003). the time spent with inpatients was reduced and the frequency of treatment was determined by the risk of transmission. all multidisciplinary joint treatment sessions were stopped to maintain social distancing. other adjustments included the positioning of the therapist and ensuring that the appropriate ppe was used. initially, the staff entering covid-19 wards was restricted because of ppe and uncertainty about treatment protocols. screening algorithms and augmentative and alternative communication boards were developed for doctors and nurses to facilitate communication with patients and safe eating and drinking practices. note-writing templates were developed to reduce the time spent in wards. research has shown that there was an increased need for information from family members of patients during this period as the levels of worry and uncertainty were high (hugelius, harada, & marutani, 2021). limited family contact because of visiting restrictions impacted family and caregiver training, education and counselling and obtaining relevant patient information. despite the barriers discussed above, the sta department continued clinical care and maintained a total of 17 310 contact sessions with speech and audiology inpatients. outpatient care was severely restricted because of lockdown regulations; however, our commitment to patient-centred care continued to motivate us to investigate other means of reaching our patients. the team regrouped to strategise approaches on how we could identify and meet the urgent needs of patients to maintain function in their home environments. we developed a proposal to obtain permission from the hospital to conduct home visits. however, because of the level of lockdown and concerns around staff safety, our request was denied. missed opportunities to engage and partner with communities during covid-19 were also reported by rispel, marshall, matiwane and tenza (2021). a non-governmental organisation was contacted to enquire if they were able to conduct the visits on our behalf. care packages were developed for patients who required consumables and equipment to facilitate continued access. these included home programmes, batteries for patients with hearing aids, consumables for patients with head and neck cancer, transpore tape and specialised feeding equipment for children with cleft lip and/or palate. information for families and caregivers on how to stimulate communication at home, pamphlets on covid-19 and mindfulness activities were included in the packs. the non-governmental organisation reported that they were well-received by patients who expressed their gratitude for the visit. numerous research studies have shown that people with disabilities have lower incomes and are at a heightened risk of food insecurity compared to people without disabilities (banks et al., 2020; park, kim, kim, jeoung, & park, 2020; the lancet, 2020). lockdown was especially difficult for already vulnerable groups (abrahams, boisits, schneider, prince, & lund, 2021); some of the adult patients reported that they had limited access to food and others lived alone without familial support. the non-governmental organisation arranged food parcels for these patients and placed them on their database for follow-up visits. feyisayo, olufunke and lambert (2021) found that an increasing number of south africans became dependent on food parcels during the pandemic. whilst the gauteng provincial government identified social relief as a key response, it is evident that this may have been inaccessible to more vulnerable groups (gauteng provincial government, 2020). the elderly and people with disabilities were expected to compete with others for limited resources within a context of restricted movement (de groot & lemanski, 2021). children’s exposure to formal and informal learning opportunities was limited because of lockdown restrictions (murray, 2021). the disruption of rehabilitation services for children with disabilities negatively impacted their physical and mental well-being as well as their behavioural development (allison & levac, 2021; rao, 2021). because of these identified risks, we collaborated with soweto tv to run a segment on how to stimulate language, literacy and play in the home during covid-19. the segment was aired as part of the news bulletin of the day. covid-19 required us to investigate new and additional methods of service provision (cacciante et al., 2021; dixit et al., 2021). our service package included face-to-face intervention, telehealth (asynchronous, synchronous and remote monitoring) or a hybrid model of incorporating the two. a study conducted by camden and silva (2021) across 76 countries showed that the use of telehealth by therapists had increased from 4% pre-covid-19 to 70% by may 2020. the sta department’s overall use of telehealth increased from 0% pre-covid to 46% in 2021. speech therapy for hearing-impaired children reached 88% during level 5 lockdown and maintained 70% in 2021, with many patients electing to follow a hybrid model. a total of 520 synchronous and 632 asynchronous interventions were conducted from june 2020 until december 2021. an upward trend was noted in all other clinical areas in the sta department. many studies have identified digital poverty as a barrier to the implementation of telehealth (baker-smith, sood, prospero, zadokar, & srivastava, 2016; clare, 2021; the lancet, 2020). barriers include internal factors such as the lack of awareness and scepticism about change, technical readiness and external challenges such as costs, limited technical resources, data privacy issues and unclear liability of rehabilitation providers (camden & silva, 2021). furthermore, dixit et al. (2021) identified limited access to telehealth in patients with low income, limited english proficiency, low health, computer literacy and those accessing public healthcare. to understand our patients’ needs and preferences, we conducted a telehealth access questionnaire. this included questions related to data and internet access, availability of smartphones, laptops and tablets as well as establishing if patients were interested in telehealth. these interviews highlighted the reality of digital poverty within our context, as most patients indicated their lack of data and internet. whilst the identified barriers were overwhelming, we continued to look for solutions to overcome these. internet access for both staff members and patients was the main challenge. we developed funding proposals to various private organisations but received no response. we also developed a comprehensive motivation to the hospital for improved internet access as well as supporting equipment. our proposal was rejected; however, this did not deter us. the high level of motivation and drive amongst staff members ensured that other creative solutions were developed; this included the use of personal resources and a mapping exercise to identify community centres and places that offered free wi-fi. we developed a roster for staff members to conduct telehealth sessions from home. relevant accountability mechanisms were introduced to ensure transparency (e.g. the use of google calendars) and appropriate use of time. the health professionals council of south africa was contacted to discuss our plan to ensure compliance with the ethical rules and regulations. we developed telehealth record-keeping forms and created password-protected storage for videos sent in by patients for asynchronous sessions as well as recorded therapy sessions. logistical issues such as patient payment for these sessions were discussed with our finance and patient affairs department. a study conducted by signal, martin, leys, maloney and bright (2020) found that most patients were unfamiliar with telehealth and sceptical of its value, but their attitudes changed once they received telehealth services. we are still refining our skills in providing synchronous telehealth sessions; however, many lessons have already been learnt, which have assisted in improving services. we have learnt that presession planning is important. this includes setting up the device, checking internet stability, ensuring that all therapy resources are within the reach, communicating with patients and families on expectations for the session as well as what material would be required. correct positioning and lighting are crucial and family routines and schedules must be accommodated. patient and family feedback after each session is critical for continuity of care and achievement of goals. effective implementation of telehealth requires organisational change and support (james et al., 2021). sustainable telehealth implementation in the public health sector requires commitment of resources and logistical support from the department of health. we should continue to fine-tune, monitor and evaluate the implementation of telehealth (abdel-wahab, rosenblatt, prajogi, zubizarretta, & mikhail, 2020) in the public health sector. asynchronous intervention has an advantage over synchronous intervention by removing scheduling issues (hill & breslin, 2016). the efficiency of therapy can also be improved within a context of infrastructure limitations and language variability (bhat, kant, vachhani, rautara, & kopparapu, 2020). our asynchronous sessions required the development of digital learning resources, therapy programmes and educational material. we consulted an expert in digital health literacy who provided us with critical feedback on health literacy, high-impact messaging and technical aspects to improve the quality of our videos. these resources were shared through whatsapp, email and short message service (sms). our overall goal of service delivery was to maintain patient-centred care in a safe environment for patients and therapists. a strategic planning session with staff members identified the resources, processes and support that were required to provide services to patients who indicated a preference for face-to-face sessions. the adherence to non-pharmaceutical interventions to reduce the risk of infections was critical. these measures included patient screening, hand hygiene, booking fewer patients and increasing the time between patients to allow for cleaning. the number of people per room was limited and disinfection protocols were strictly followed (agarwal et al., 2020; cho et al., 2020). it was imperative that these infection control measures become a part of our routine clinical practice. conclusion at a macro level, the needs of people with disabilities should be visibly accounted for when planning a country’s response to a pandemic (de biase et al., 2020). leadership from the national and provincial rehabilitation directorate needs to step in early to provide guidance to professionals to help facilitate their roles, responsibilities, priorities and functions in a pandemic to avoid the siloed response that was seen during the current pandemic (maccarone & masiero, 2021). working in a pandemic requires adaptation, flexibility and innovation of healthcare models to enable service delivery (pearlman, tabaee, sclafini, sulica, & selesnic, 2021). these advocated models need to be supported to guide implementation. regular consultation and transparent and frequent communication with patients, families, healthcare professionals and communities are essential from the onset. this article provided us with an opportunity to tell our story of adaptation, teamwork and resilience in a period of uncertainty. storytelling allowed us to understand the meaning of our actions, our values and principles, ‘our fears and vulnerability, and the connective tissue that binds us together’ (kumagia & baruch, 2021, p. 1095). our initial discomfort, confusion, fears and doubts about our role led us to redefine our purpose as healthcare professionals within an unprecedented and changing context. research has found that healthcare professionals expressed a need to continue working and feeling a strong sense of purpose during the pandemic (aughterson, mckinlay, fancourt, & burton, 2021). our shared vision and collaborative decision-making provided a strong foundation in navigating the uncertainty. it was difficult when our ideas were not supported at higher levels, but we remained committed to finding innovative solutions within our context that aligned to our purpose and allowed us to continue patient care. according to kumagia and baruch (2021, p. 1095), stories ‘help us form empathic connections and focus on collective values and goals’. networking and collaborating within our microsystem and mesosystem strengthened our response to staff and patient needs. the pandemic reminded us of the importance of compassionate leadership and responding to the socio-emotional needs within a team. whilst we functioned as part of a broader, holistic system, it was important for us to remain ‘whole’ by focusing on our well-being. stories are being increasingly recognised for their potential as creators of change as they guide small, everyday decisions and practices (essebo, 2021). we hope that our story will encourage others to tell theirs so that we could strengthen the narrative of practice within context. it was through this journey of storytelling that we gained a bird’s eye perspective of everything we had accomplished as a department in our response to covid-19. this led us to submitting our application for the 7th annual batho pele awards, where we were placed jointly in first position in the category of best responsive government institution. this recognition by the ministry of the department of public service and administration has further increased the platforms on which we are able to continue telling our story. acknowledgements the authors acknowledge the dedication, commitment and passion of their colleagues at the speech therapy and audiology department at chris hani baragawanath academic hospital. a special thanks to everyone who discussed, read and reviewed their work in progress. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions s.b., a.l.v. and s.c.p. all conceptualised the idea for this research, wrote the first draft and made the editorial input, with s.b. as the main author. ethical considerations this article followed all ethical standards for research without direct contact with human or animal subjects. funding information the authors thank the national institute for the humanities and social sciences (nihss) for providing financial assistance for the publication of this article. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references abdel-wahab, m., rosenblatt, e., prajogi, b., zubizarretta, e., & mikhail, m. 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(2021). quarantine life is stillness and dialogue: a reflective autoethnography during a global pandemic. qualitative inquiry, 27(7), 829–834. https://doi.org/10.1177/1077800420960170 zięba, k. (2021). how can systems thinking help us in the covid-19 crisis? wiley online, 1–10. https://doi.org/10.1002/kpm.1680 zungu, m., voyi, k., mlangeni, n., moodley, s.v., ramodike, j., claassen, n., … malotle, m. (2021). organizational factors associated with health worker protection during the covid-19 pandemic in four provinces of south africa. bmc health services research, 21(1080). https://doi.org/10.1186/s12913-021-07077-w abstract introduction research methods and design results discussion conclusion acknowledgements references appendix 1 about the author(s) jaishika seedat department of speech pathology and audiology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation seedat, j. (2023). ‘the knowledge-to-action process model for knowledge translation in oral care in south africa’. south african journal of communication disorders, 70(1), a951. https://doi.org/10.4102/sajcd.v70i1.951 original research the knowledge-to-action process model for knowledge translation in oral care in south africa jaishika seedat received: 06 oct. 2022; accepted: 12 june 2023; published: 31 july 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: literature supports the mismatch between empirical evidence and service delivery. given this knowledge gap, it is important that research undertaken has a theoretical foundation, considers the context and stakeholders to confirm its need and that it can be feasibly implemented and sustained. objectives: the study aimed to facilitate knowledge translation in oral care using the knowledge-to-action (k2a) process model among nurses. method: the study was completed in an acute hospital in south africa. a qualitative design with ethnography incorporating video-recordings and semi-structured interviews were used. a total of 139 nurses were recruited using random purposive sampling and received training on oral care, which was monitored. inductive thematic analysis was completed. results: the model facilitated information transfer and implementation of oral care by nurses. conclusion: with clear directions for use and theoretical underpinning, the k2a model was well-suited to the needs of the study and stakeholders, and the complexity of the context. for challenging contexts such as public healthcare institutions in south africa, this was ideal and critical to the success of the intervention. contribution: when nursing managers show interest and recognise nurses for their role in implementation of interventions, the buy-in, support and sustained use of that intervention is enhanced. a model such as the k2a promotes involvement of all stakeholders (e.g. nurses and their managers) in the design and planning for implementation of an intervention, and these are critical for the successful and feasible use of the intervention. keywords: knowledge-to-action process model; oral care; nursing; acute; south africa. introduction knowledge translation provides a means of merging existing knowledge and new evidence to close the gap between research and practice. barriers to knowledge translation in south africa (sa) and other similar contexts, range from being structural and resource related, to systemic rules and regulations as well as human traits of attitudes, perceptions, and assumptions (grimshaw et al., 2012). ultimately, contextual considerations are fundamental to any change in healthcare service delivery. internationally, healthcare practitioners struggle to translate empirical evidence into intervention while facilitating optimal and timeous outcomes (field et al., 2014). the mismatch that exists between research findings and implementation thereof confirms that change is not automatic and if it happens, sustainability must not be assumed. the national health service institute for innovation and improvement has estimated that up to 70% of all organisational change is not sustained over time (ilott et al., 2013a). selecting an appropriate framework, theory or model would provide the necessary interface to address the diverse and dynamic variables that hinder knowledge translation (damschroder et al., 2009) and once selected should elucidate and ensure sustainability of the intervention with measures to monitor the variables that are likely to influence the intervention over time (chambers et al., 2013). this study reveals how the knowledge-to-action (k2a) framework devised by graham and colleagues (2006), facilitated implementation of oral care among nurses working in an acute hospital in sa. following a review of the literature, different models to facilitate implementation of research, that is, knowledge translation have been described in the literature (davis & conti, 2003). insufficient attention given to the patient in the model by pathman and colleagues (1996) and the minimisation of context in the model by green and colleagues (1980) made both these models unsuitable for the requirements of this study. variables such as persons involved in the intervention (e.g., nurses), the recipients of the intervention (i.e., the patient), as well as the systemic parameters operating within the context (e.g., a hospital) cannot be divorced from the how, who or why of the actual process or intervention (i.e., oral care) that requires changing. graham et al. (2006) conceptualised the k2a model as a synthesis of available evidence on knowledge translation (figure 1). this model was applicable for this study context in the sense that the process of knowledge creation is dynamic and starts from what is known. of relevance is the focus for knowledge to be adapted to the needs and circumstances of the local context, thereby addressing feasibility of the intervention for the context. the k2a model offered an inclusive framework to consider the variables that contribute to the challenges that nurses faced working in public healthcare in sa. figure 1: the knowledge-to-action (k2a) process model. graham et al. (2006) suggest that knowledge is derived from an empirical and experiential basis. as there is movement of knowledge through the funnel, it becomes more distilled and refined (graham et al., 2006, p. 18). knowledge inquiry is first generation knowledge that is in its natural state and largely unrefined. knowledge synthesis represents the aggregation of existing knowledge. this process involves feedback, discussion and critique to understand the needs of the stakeholders and context to formulate the research questions and aims of the planned intervention. the third tier represents knowledge tools or products. the purpose of the tools is to present knowledge in a clear, concise and user friendly way with explicit meanings to facilitate uptake and application of knowledge (graham et al., 2006). the action cycle frames the knowledge creation funnel and represents the activities that are necessary to apply the knowledge. graham et al. (2006) recommend the identification of facilitators or supports that may prove beneficial in implementation of the intervention. the next phase of the model represents the dissemination, planning and execution of the intervention to facilitate and promote awareness and implementation of knowledge. identifying barriers and facilitators is crucial for this phase to proceed effectively. once the implementation initiatives commence monitoring the use of knowledge begins and proceeds into the next phase. for this, graham et al. (2006) notices the importance of defining what constitutes knowledge use to allow measurement. it is important to monitor knowledge use to assess the extent to which it is translated into action. the role of the intervention in bringing about the desired change is also evaluated at this phase. it is thereafter necessary to define the impact of using the knowledge in the next phase, that is, whether the efforts to improve the uptake of knowledge were successful or not. the last phase considers sustainability to ensure continuity of the intervention that has been shown to be effective. with a population of 60.6 million (stats sa, 2022) and approximately 84% of the population relying on public health services (national treasury fiscal review, 2017), holistic patient care is a challenge in sa. one aspect of care often compromised is oral care, which falls within the remit of nurses. given this statistics, public healthcare institutions in sa are stressed and overburdened, with those working in the system dealing with the ramifications (khamisa et al., 2017; manyisa & van aswegen, 2017). nurses being frontline workers in hospitals shoulder the burden of inundated wards; insufficient nurses to cope with the numbers of patients accessing health services, poor to no recognition for nurse contribution to patient care and so forth. high workloads for nurses have culminated in emotional and psychological burnout (rispel, 2015). having to cope with high patient numbers, non-essential routines such as oral care are compromised. this has adverse implications for the patient as more studies continue to document the positive outcomes of oral care for atrial fibrillation and heart failure (chang et al., 2020), a lower incidence of pneumonia among frail individuals (manger et al., 2017) and improved oral health with type 2 diabetes mellitus (simon et al., 2019). a study of nurses working in intensive care unit (icu) in sa found that despite knowledge of aspiration and contaminated secretions, nurses did not complete oral care (perrie & scribante, 2011). participants reported seeing no evidence of the benefit of oral care to patient outcome. oral hygiene when compared with other nursing routines is least enjoyed by nurses (hanne et al., 2012). medication dispensing, monitoring of vital signs and feeding are understandably considered priority nursing routines. this article contends that it is equally important for nurses to be equipped with the necessary knowledge and clinical skills to perform oral care efficiently given its documented contribution to patient well-being and recovery (hanne et al., 2012). considering the context described, it appeared that the k2a model could offer a solution to address the needs of the context and the implementation of oral hygiene and oral care by nurses. this was explored in this study. research methods and design the aim was to explore the use of the k2a model to facilitate knowledge translation in oral care among nurses working in an acute general medical ward in sa. a qualitative design with ethnography was employed. ethnography provided direct access to what nurses did, as well as what they say they did. oral care in terms of frequency and the routine was observed as part of the ethnography. ethnography including video-recordings, semi-structured and informal interviews were the tools used in the study. the research was undertaken within the medical wards in an acute, adult intake government hospital in johannesburg, sa. a total of 139 nurses were recruited using random purposive sampling. nurses from different categories as detailed here, were included as participants (subedar, 2005): enrolled nursing auxiliary or assistant nurse: a 1-year programme at college or exited after completing the first year of the university 4-year programme and competent to practice elementary nursing. enrolled nurse: a 2-year programme at a nursing college or exited after completing 2 years of the 4-year-programme at university and competent to practice basic nursing. professional or registered nurse: a 4-year-programme at university or a nursing college and competent to practice comprehensive nursing and midwifery. all participants provided written consent to participate in the study. consent from hospital management was obtained and was followed by ethnography of the medical wards over a 5-month period (january 2013 – end may 2013) and proceeded with once weekly in january 2013 – april 2013 to daily 6-h daily observations. the aim and content of the observations did not change. any activity related to oral care was observed. following training, the oral care routine itself that used by nurse participants was observed in terms of how it was performed, utensils used, time it took, and level of participation from the patient. over the weeks, changes in these aspects were observed. a needs analysis discussion with nurses followed the ethnography. a pilot study was conducted (described below) followed by data collection for the main study (which involved training and monitoring of oral care implementation). data were analysed using inductive thematic analysis. analysis was data-driven to avoid bias given the volumes of published work (nationally and internationally) that provide a negative and unfavourable view on nurses, nursing culture, and nursing as a profession (aikman, 2019; crawford et al., 2019; drennan & ross, 2019). data from the ethnography, semi-structured and informal interviews as well as video and audio recordings (of nurse training, nurse implementation of oral care and at mealtimes) were compared and checked against each other. the video and audio recordings were conducted before, during and after mealtimes, but with no set schedule. flexibility in terms of when recordings were completed was necessary to accommodate the nurses and how they worked. all video recordings were completed by the author. the oral care routine was reviewed and completed using a checklist (appendix 1). respondent validation occurred during the course of the interviews. the oral care protocol was self-developed as a synthesis of existing standard hospital oral care protocols (in sa) and that developed by brady et al. (2006). frequency of oral care provision, use of equipment (toothbrush, oral suctioning unit), and resources (toothpaste, mouth rinse, lip care, dental floss) were observed. ethical considerations ethical clearance to conduct this study was obtained from the university of the witwatersrand human research ethics committee (no. m091166). results literature concedes that process, context and sustainability are core components of any intervention study such as the one reported in this article (grimshaw et al., 2012; pinnock et al., 2017; shepperd et al., 2009). pinnock et al. (2017) highlight the importance of the reporting format and content thereof to ensure that effects of the intervention can be reasonably translated into clinical practice for the benefit of the individuals from that context. the results cover these aspects commencing with identification of the practice gap to implementation and finally sustainability of the intervention as per the k2a model. problem identification – the gap in practice (figure 1): the ethnography provided the researcher with an overview of oral care implementation in wards. inconsistent to no oral care before breakfast and no rinsing of mouth after any meal was observed. independent patient tooth-brushing was observed for a minority of patients with toothbrushes. the observations were unpacked in a needs analysis discussion with hospital management, the senior nurses, that is, nurse sister, and the nurses caring directly for patients. all stakeholders acknowledged oral care as a low priority routine (the gap in practice), resulting in poor to no implementation thereof. contextual needs – adapt knowledge to local context (figure 1): the ethnography and needs analysis discussion concluded the following: less than ideal working conditions for nurses. limitations in inter-professional communication between nurses and medical and allied health professionals. a gap in oral care for patients. a consensus was reached on the need for oral care training for nurses. the format and structure of the training were explored and confirmed as part of the pilot study, taking into account the variables within the context (i.e., number of nurses in a ward at any given time, nurse to patient ratio, and time availability). pilot study (part of adapt knowledge to local context): the pilot study aimed to confirm the length of the training session, the content validity of the information, and that the materials to be used for training were appropriate. the training format and structure were also confirmed. altering the context to suit the needs of the study was not considered as per the k2a model. training had to support the context. results of the pilot study confirmed that one-on-one training at the patient bedside was most feasible as: there was less need for planning, preparation, and coordination there was no need to consider logistical variables such as venue, time for training, or audience participation the one-on-one model facilitated understanding with increased opportunity to address concerns and provide clarification it guaranteed hands-on experience by participant with opportunity for constructive feedback it did not impact nursing routine or compromise service delivery to any patient from a time perspective. this training format addressed the requirements of the context, and was acceptable to hospital managers, nurse managers, and nurses. the materials used in the training, that is, the posters, booklet on oral care and pictures (all developed by the author specifically for the intervention) as well as the resources used, that is, gauze, forceps and mouthwash solution, were acceptable to the nurses and available within the wards. adapting to the needs of the context supported the k2a model and contributed towards sustainability of the intervention, that is, oral care training. it also facilitated capacity building for nurses with maintenance of skills for use with all patients after completion of the study. following consent from the patient and nurse, training was conducted at the patient bedside. the trained nurse subsequently implemented oral care (appendix 1: oral care protocol) until patient’s discharge. the k2a model acknowledged the continuous movement and interaction between knowledge creation and the surrounding action cycle, highlighting that knowledge is continuously changing and that this in turn required action (practice) to change accordingly. the information and tools were therefore purposefully selected to ensure that they would be acceptable and useful to nurses to facilitate change in practice (ilott et al., 2013b). adapting knowledge and assessing barriers to knowledge use (figure 1): in view of the context of oral care in the hospital described here, careful consideration of barriers and facilitators to implementation and involvement of the nurses was critical. to enhance inclusivity, nurse managers, nursing sisters, and nurses were involved in the design, content and delivery of the training to prevent disconnection between the drivers of the intervention and those implementing the intervention (gruen et al., 2008). barriers that emerged from the ethnography included: poor to lack of monitoring of routines carried out by nurses: ‘sad to say but she [indicating nursing sister] doesn’t even know what i do for sure …’ (participant 23, female, enrolled nurse) time-consuming routines. unknown benefit for nurses. ‘… doctors act like they only should be thanked for getting the patient better. what do we do? [pause] nothing?’ (participant 51, female, enrolled nurse) attitude and behaviour. modelling and demonstration, direct one-on-one feedback and individually tailoring the level of information provision was implemented to accommodate the different levels of qualification of the nurse participants. adopting an interactive and participatory model as opposed to a didactic model of instruction produced favourable nurse participation and transfer of clinical skills (tryssenaar & gray, 2004). provision of a continuing professional development certificate to recognise the training on oral care and opportunity for professional responsibility facilitated this process. select, tailor, and implement interventions (figure 1): oral care training was collaborative involving the nurse participants, researcher, as well as nurse and hospital management. there was consensus in the design of how the training would happen, the content of the training, the duration and manner of training. based on the barriers identified here, the aids to training were selected. table 1 provides a list of supplementary materials used. table 1: supplementary material used during training. the involvement and collaboration with all stakeholders aligned with requirements of the k2a model (graham et al., 2006). monitor knowledge use (figure 1): all nurse participants recorded each oral care session that was completed. oral care was completed in the morning before breakfast; mouth rinsing after breakfast, lunch and dinner; and mouth rinsing had to precede any consumption of water (appendix 1). furthermore, nurses were required to record each completed mouth care session. recordings were reviewed daily and incomplete records were brought to the attention of the nurse participant. randomly timed video recordings of the nurses completing the oral care routine were captured. cross checking the written records, the video recordings and information from the interviews completed the triad of data collection sources. the use of multiple sources allowed verification of information from one source against information from a different source. recordings indicated that oral care was implemented 99.7% of the time. three ‘no recordings’ were identified. table 2 captures some comments from the nurses under their recording of mouth care. table 2: examples of nurse’s notes for mouth care. video recordings provided evidence that nurses were correctly implementing oral care in line with the training and schedule. the protocol presented with some challenges for patients who required suctioning largely because of contextual shortcomings where suction equipment at the patient’s bedside was not always in working condition. however, when the suction equipment was working, oral care for the patient requiring suctioning was in fact shorter by 3 min – 4 min on average. the video recordings confirmed that less patient compliance and cooperation was needed as the patient was not required to spit out or rinse their mouth. the nurse was able to accomplish this using the suctioning equipment. evaluate outcomes (figure 1): the outcomes of the study aligned with the following objectives that were achieved: (1) feasible and accepted training method and strategies for knowledge transfer of oral care, (2) regular implementation of oral care and (3) sustained implementation of oral care. as observed, one-on-one training was cost-effective, time-effective, and enhanced knowledge translation of the content. the outcome of the training was positive. themes identified from the interviews were: learning opportunity ‘i am glad i got to learn the procedure for mouth care. i can see it is important and it is helping the patients’. (participant 3, female, assistant nurse) ‘mouth care is a new thing that i learnt. i can now do with all my patients. i can see how it is helping mrs y, so i will continue’. (participant 11, male, nurse assistant) improved patient care and service provision ‘the training for the mouth care was really good. i learnt something new and now i can use it for other patients …’ (participant 27, female, nurse assistant). opportunity for certification ‘i love it. the training we got now was lovely and to get a certificate to show that you have learnt it and are doing the mouth care correctly is lovely. it’s also good for my cv because other people can see exactly what you have been trained in’. (participant 62, male, nurse assistant) improved knowledge of other professions ‘i think the training and working together goes together. i’ve seen how by working together i understand better what’s happening with the patient and why certain things need to be done. i am sure it is the same for you. i think it is important to work together’. (participant 14, female, enrolled nurse) mouth care: it was practical, facilitated knowledge translation to other patients, and patient improvement was noted. recordings of oral care were reviewed for consistency, completion, and content. facilitating sustainability of the intervention (figure 1): sustainability was ensured via these measures: the research assistant was a speech pathologist and obtained a permanent position of employment at the research site, where she remained for 5 years after the completion of the study. this facilitated institutionalising of oral care. the nurse manager within each medical ward supplied the newly appointed speech pathologist who was previously the research assistant, with a list of the new nurses rotating through the ward and who required training on oral care. institutionalising of the training was the goal. a review of training records 1-year post-completion of the study indicated regular weekly training sessions (on average eight training sessions per week). these training sessions were offered by the research assistant or speech pathologist on an individual basis (as per the study), to any new nurse or nurse from any ward who approached her for training. the oral care provision therefore expanded and was implemented to any in-patient in the hospital by the nurse who received training and was caring for that patient. while training was initially to nurses in the wards that the research assistant or speech pathologist worked as part of her patient management, knowledge and awareness of the training spread by word-of-mouth, hence nurses from wards with patients not requiring speech pathology intervention approached the research assistant or speech pathologist for training. presentation of the findings of the study to the hospital and nursing management at the end of the study and a report on the continued training on oral care was provided 1-year post-completion of the study. discussion this study confirmed the value of extensive stakeholder consultation to alleviate misfit between stakeholder and facility needs and implementation of intervention strategies (wensing & grol, 2019). macleod et al. (2014) elaborated on the financial, patient and societal ramifications of failure to act on research findings. it was against this backdrop and in considering the harmful consequences of poor knowledge translation, specifically in the area of oral care that this study was undertaken. the study highlighted the following barriers: barriers between staff from different professions (e.g. limited communication and information exchange between nurse and speech pathologist impacting service delivery) systemic barriers (e.g. poor monitoring of nurse services by nurses perceived as a lack of interest) organisational and structural barriers (e.g. a lack of incentive and poor acknowledgement of nurse contribution to patient care). similar barriers, that is, professional, systemic and organisational were noticed by grimshaw et al. (2012). thus, the intervention was tailored to address these barriers. consultation, active engagement, and hands-on involvement from all the listed stakeholders at each step of the research process promoted more communication exchange, patient discussion, and consultation. the value of health managers, health administrators and on the ground healthcare practitioners in the conceptualisation, design and implementation of interventions was clear (morsiani et al., 2017; wensing & grol, 2019). the k2a model addressed the issue of a lack of monitoring by management and consequent feelings of disregard felt by the nurses. the buy-in, understanding and commitment from managers and nurses from the conceptualisation of the study to the implementation was key to the success of the intervention. interlinked to the context, was behaviour and attitude. typically, professionals work in silos albeit for the same patient. as noticed here, high patient numbers and poor working conditions adversely impacted work morale and job satisfaction among nurses in sa (mayosi & benatar, 2014; nesengani et al., 2019). behaviour and attitude are recognised as two of the greatest challenges in knowledge translation historically (mallidou et al., 2018). the training platform prescribed to a collaborative model of patient care that required frequent and direct communication between the nurse and other health professionals. implications of holistic patient care are implicit within a collaborative model, and this was attained in this study. knowledge translation to address a knowledge-to-action gap requires active collaboration between the researcher and knowledge-users and when achieved, the benefits of knowledge translation are results that extend beyond the lifetime of the research project. there was evidence to support that oral care for patients continued after completion of the project. the k2a model offered the researcher clear direction and directives on considerations for the project. it enabled use and practice of strategies and techniques in an efficient and effective manner thereby avoiding additional burden on already overstretched services and staff. regarding the outcome of collaboration, a lesson learned was ensuring that the benefits of collaboration were not gained at the cost of further levels of stress and frustration for the nurse. effective communication enhanced implementation of oral care with provision of direct support, one-on-one training, and monitoring structures (wensing & grol, 2019). the study confirmed that a linear, unidirectional and passive flow of information from research to practice was incongruent with attaining knowledge translation as observed by weiss (1979). the need for face-to-face contact with and involvement of the nurses in the process improved collaboration when caring for patients. the findings of the study echoed the sentiments of cornwall and jewkes (1995) ‘research strategies that emphasize participation are gaining greater respectability and attention within mainstream health research in developed and developing countries’. nurse participation reinforced their active contribution to patient-related decisions and this in turn enhanced nurses’ autonomy. this study was deemed successful in the sense that nurses implemented oral care with minimal prompting and evidence in the form of positive outcomes for the patient. the benefit of the study for nurses within the sa context was also made explicit by one nurse participant: ‘if we don’t push ourselves to learn new things, other people are going to take over and the nurses will continue to have a bad name. if we start and we show the doctors and the families that we know what we are doing and we care, then even the matrons will see it. we must all remember why we chose to do nursing’. (participant 67, female, registered nurse) conclusion the k2a model provided the theoretical and clinical framework for the study as it facilitated information transfer on oral care among a group of nurses working in an acute government hospital in sa and enabled practical implementation of oral care by the nurses who received the training. this had relevance for sa and health professional researchers such as speech pathologists, given the healthcare challenges and resource constraints. the model was applicable to the needs of the study, the complexity of the context, and stakeholders. importantly, it promoted adaptation of the required knowledge to suit the context and not vice versa. for contexts that offer unique challenges such as those faced by government healthcare institutions in sa, this was ideal and critical to the success of the intervention. in closing the existing gaps in clinical practice in sa, the importance of engagement and consultation with the end-users of the intervention cannot be over-emphasised. edwards et al. (2019) emphasise the critical need to identify viable methods for knowledge translation in developing contexts such as africa, to capitalise on shared-learning given that research funding, research initiatives and research capacity are often limited in these contexts. efforts in research initiatives with appropriate theoretical frameworks may provide a platform to address gaps in practice and enhance patient care and inter-professional partnerships while managing patients. while sustainability was tracked and monitored from a qualitative perspective, clearer quantitative measures were not completed. thus, this component of the action cycle was acknowledged as a limitation of the study. although measures such as journaling and debriefing were completed throughout the research process for the researcher, it is possible that elements of subjectivity resulted in a more favourable perspective of nursing by the researcher. implications for nursing management recognition of nursing staff for their role in patient recovery. involvement of nursing staff in patient management decisions and interventions. need for evidence to align with implementation of interventions. implementation of research findings into clinical practice must consider context, nurse buy-in and input, and sustainability. implications for healthcare professionals as the requirement for contextually relevant research to underpin clinical practice is increasingly expected in sa, with the systemic, financial and capacity challenges within healthcare, shared-learning offers an advantage. this study provides a theoretical framework that works in public healthcare and could be used to underpin future intervention studies by speech pathologists. improvement in professional practice, patient service provision and patient outcomes continues to be challenging in developing contexts. barriers to improvement and change are multifaceted. understanding and involving the stakeholders, that is, staff and patients is an initial step in facilitating change that may be sustained. empirical research to underpin speech therapy practice is necessary. however, when the parameters of research become too strict and exclusionary, implementation of research findings is compromised. speech pathologists engaging in research in healthcare facilities must be cognisant of the balance between stakeholder and patient directed needs, rigour and integrity of findings, feasibility of interventions, as well as implementation of research findings. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. author’s contributions j.s. is the sole author of this article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article as no new data were created or analysed in this study. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references aikman, n. 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(2019). knowledge translation in health: how implementation science could contribute more. bmc medicine, 17(1), 1–6. https://doi.org/10.1186/s12916-019-1322-9 appendix 1 oral care protocol and checklist patient name/number: ______________________________ date: _____________________________________________ please note: oral care must be provided before breakfast. the patient must rinse out their mouth after every meal. a visual inspection of the oral cavity must be completed by the nurse. abstract introduction methodology results discussion study’s limitation and strengths conclusion acknowledgements references about the author(s) kerusha bhojraj department of health, durban, south africa discipline of audiology, university of kwazulu-natal, durban, south africa vuyelwa z. peter discipline of audiology, university of kwazulu-natal, durban, south africa citation bhojraj, k., & peter, v.z. (2022). audiologists’ presbycusis and associated tinnitus counselling practices within the kwazulu-natal province. south african journal of communication disorders, 69(1), a869. https://doi.org/10.4102/sajcd.v69i1.869 original research audiologists’ presbycusis and associated tinnitus counselling practices within the kwazulu-natal province kerusha bhojraj, vuyelwa z. peter received: 20 oct. 2021; accepted: 14 apr. 2022; published: 08 sept. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: counselling plays an integral part in the management of presbycusis and tinnitus. counselling can be conducted by implementing patient-centred care (pcc), showing improved patient outcomes; however, it has been poorly implemented in healthcare in south africa (sa), particularly in the field of audiology for this condition. objectives: this study aimed to report on audiologists’ presbycusis and tinnitus counselling practices as guided by the pcc framework within kwazulu-natal (kzn). method: quantitative semi-structured online surveys were conducted using purposive sampling of 41 audiologists practising in both the public and private sectors within kzn. results: this study revealed that 7.3% (n = 3) of participants provided only compensation for hearing loss without counselling, and only 2.4% (n = 1) of participants offered group counselling. apart from this, 7.9% (n = 3) reported that tools and resources in counselling were not useful, whilst 12.5% (n = 5) reported that counselling was not multiculturally sensitive. furthermore, a p = 0.044 suggests the public sector reported a dire need for improved training in counselling as compared with the private sector. conclusion: audiologists have been providing services within pcc to the best of their capabilities and their environments; however, there is still room to better implement pcc for improved patient outcomes. pcc has not been fully implemented into counselling practices in terms of patient preferences, emotional support, involvement of significant others, integrated care and education. keywords: presbycusis; tinnitus; counselling; patient-centred care; counselling practices; multi-cultural. introduction the global burden of disease (gbd) established that hearing impairment is one of the top five leading causes of disability worldwide (global burden of disease et al., 2017). in 2019, an estimated 1.57 billion people globally presented with a hearing impairment (global burden of disease, 2021). whilst prevalence data of hearing loss in south africa are scarce, sub-saharan africa was ranked as the third-highest region affected by this disabling hearing impairment, with an estimated prevalence of 4.55% within its population (world health organization, 2018). the gbd further predicts an increase in the number of the hearing-impaired population over the years because of an increase in lifespan, as derived from data indicating that 62.1% of those with hearing impairment were older than 50 years (global burden of disease, 2021). based on the nature of hearing impairment, a possible amelioration is to improve healthcare provision (global burden of disease, 2021), focusing on presbycusis as it is the leading cause of hearing impairment in adults. presbycusis is an age-related hearing loss, documented as the leading cause of hearing loss within the adult population; it is accompanied by many symptoms, primarily tinnitus, a perception of noise in the ears (cunningham & tucci, 2017; jafari, kolb, & mohajerani, 2019; lee, 2013; sogebi, olusoga-peters, & oluwapelumi, 2014; zhang, yu, & ruan, 2020). exploring audiologist practices for presbycusis and tinnitus is therefore crucial for improved services and patient satisfaction, especially in resource-constrained contexts with cultural and linguistic diversity within south africa. presbycusis is a complex phenomenon because of its associated symptoms (zhang et al., 2020). research has determined that presbycusis starts to manifest as early as 30 years and can lead to cognitive decline in adults, communication difficulty, isolation and depression, causing psychosocial effects that negatively impact the quality of life (kim & yeo, 2015). similarly, tinnitus that tends to co-occur with presbycusis is a debilitating symptom with similar psychosocial effects and impact on quality of life (chari & limb, 2018). sogebi et al. (2014), supported this claim through research conducted in nigeria by exploring the symptoms of presbycusis in 69 patients. they found that 79.7% of participants reported tinnitus, thereby indicating that tinnitus is associated with presbycusis and thus suggesting an early onset of presbycusis and high co-existence of tinnitus. research indicates that there is currently no medical cure for presbycusis and tinnitus (swain, nayak, ravan, & sahu, 2016). current treatment options in the literature include pharmacological drug administration for tinnitus and non-pharmacological forms of treatment for tinnitus and presbycusis (han, lee, kim, lim, & shin, 2009). whilst studies found that patients with tinnitus showed a preference for pharmacological treatments (swain et al., 2016), a combination of both forms may be identified as the most effective management of presbycusis and tinnitus (british society of audiology, 2016; parham, lin, coelho, sataloff, & gates, 2013). however, the most common management strategy comprises compensating for the hearing loss (parham et al., 2013). whilst this may provide amplification and mask the tinnitus, it does not adequately address the patient’s psychosocial needs (parham et al., 2013). these differing views emphasise the need for a management approach that can embrace and allow for holistic management to ensure patient benefit, which includes the best of both worlds (british society of audiology, 2016; parham et al., 2013; swain et al., 2016). holistic management is therefore suggested to include counselling as a crucial aspect to improve the management of presbycusis and tinnitus (parham et al., 2013). this goes beyond just compensation for hearing loss, addressing the life-long impact of presbycusis and tinnitus, thus improving the patient’s quality of life and outcomes from services (parham et al., 2013). as part of the services offered, counselling is an integral component of the audiologist’s scope of practice to inform and assist patients in adjusting to the psychosocial effects of hearing impairment. it is conducted post-audiological assessment, with differing counselling practices based on the patient’s audiological needs and underlying pathology (american speech hearing association, 2012). these counselling practices as excerpted from the literature utilise counselling methods, counselling efficacy tools and audiological rehabilitative training, ensuring multicultural sensitivity and patient satisfaction (american speech hearing association, 2012). research on counselling practices within the field of audiology is scarce (meibos et al., 2017), particularly within developing countries with diverse cultures, languages and needs. whilst reasons for the paucity of research are unknown, audiologists’ inclination to focus on compensation for hearing impairment rather than on the psychosocial aspects may be an anecdotal attribution. moreover, the literature supports service provision that is sensitive and inclusive of patient needs (parham et al., 2013). audiologists have advocated that counselling practices should be customised to the patient’s individual needs (hoare, gander, collins, smith, & hall, 2012). this requires an approach that focuses on the patient’s individual needs. the patient-centred care (pcc) approach fits such a requirement as it focuses on the patient’s individual needs and encourages active participation in the decision-making process regarding treatment whilst addressing medical needs (nkrumah & abekah-nkrumah, 2019). within the field of audiology, pcc must be implemented to ensure appropriate counselling, as some sectors of the literature suggest that power dynamics between the audiologist and patient need to be carefully considered during management to improve patient–clinician dynamics and increase shared decision-making (elwyn et al., 2014). other sectors of literature proposed that patients may be inclined to take the back seat in decision-making, allowing their clinicians to lead (schoenfeld et al., 2018). research has indicated that audiologists present as dominating during the management of patients (shah, 2020), without allowing patients to fully express themselves or acknowledging their preferences (shah, 2020). it can be speculated that this is the case with presbycusis and tinnitus counselling. to allow patients to fully express themselves and their preferences during management, the authors advocate audiological counselling practices to be delivered through adopting and implementing pcc (elwyn et al., 2014). the pcc framework was first introduced in 1964, based on the eight picker principles (picker institute europe, 2020), namely (1) respect for patients’ values, (2) preferences and expressed needs, (3) coordination and integration of care, (4) information sharing, (5) comfort and support for the patient and significant others, (6) involvement of significant others, (7) continuity and (8) access to care (picker institute europe, 2020). patient-centred care proposes that the patient’s individual psychological needs should be the point of focus when providing health services (epstein & street, 2011). this framework advocates for the involvement and inclusion of the patient’s significant others and the patient’s active participation in shared decision-making during the management process (picker institute europe, 2020). dilollo and neimeyer (2020) suggested that patient-focused healthcare services improve patient satisfaction. therefore, pcc serves as an ideal influence in audiology counselling practices. patient-centred care advocates that the patients’ beliefs, preferences and perspectives serve as an integral part of healthcare delivery and may be utilised to improve counselling practice guidelines (montori, brito, & murad, 2013). these are critical aspects in a culturally and linguistically diverse context such as south africa. patient-centred care has gained much popularity in the healthcare system, both locally and internationally. however, research on audiologists’ presbycusis and tinnitus counselling practices require further study to investigate implementation of pcc. although the benefits of pcc are explored in literature, research on the implementation during counselling practice in audiology is limited. boisvert et al. (2017) found that although there is an awareness of pcc within the field of audiology, it is not effectively being implemented in practice in sub-saharan africa. this poor implementation is attributed to strained resources, poor interpersonal patient–healthcare provider interaction, and lack of focus on psychosocial impacts of illnesses in healthcare training (de man et al., 2016). therefore, research on pcc during audiology counselling practices for presbycusis and tinnitus counselling is crucial in closing the knowledge gap and aiding in conceptualising pcc implementation in a developing context. hence, this study aims to explore presbycusis and associated tinnitus counselling practices in this context by answering the following research question: what are the presbycusis and tinnitus counselling practices offered by audiologists within kzn? methodology aim and objectives this study aims to report on audiologists’ presbycusis and associated tinnitus counselling practices, guided by the pcc framework within kzn. study design and context this non-experimental descriptive study was conducted with self-administered online surveys developed by the researcher to best explore audiologists’ presbycusis and tinnitus counselling practices. the online self-administered survey had been adopted from the picker principles in pcc (picker institute europe, 2020), serving as the following fundamental components of counselling practices: information, education, coordinate-integrated care, respect for patient preference, access to care, emotional support and involvement of significant others. this allowed for information to be gathered on current counselling practice, skills and challenges audiologists are faced with whilst conducting presbycusis and tinnitus counselling. a descriptive design helps to collect information based on a specific field; it can be used to gather information on matters related to current practices or to determine practices amongst healthcare professionals (brink, van der walt, & van rensburg, 2012). this enabled the authors to obtain information on current counselling practices conducted by audiologists. furthermore, the online survey efficiently covered a wide geographic sample, whilst ensuring ethical advantages (fox, hunn, & mathers, 2009). it allowed for efficient data collection around kwazulu-natal during the worldwide pandemic of covid-19 and provided a safer method of obtaining data. data collection tool this study used self-administered online surveys with open-ended questions to enable quantitative data to be collected over a wide geographical area (brink et al., 2012). the survey was guided by the picker principles (picker institute europe, 2020). in addition, the researcher adopted certain sections from the tool aligned with this study (picker institute europe, 2020). the survey was approximately 20–30 min long and efficiently covered a broad geographic sample (fox et al., 2009). questions included likert scales, close-ended questions and an option to elaborate on questions. in addition, the tool included the following sections: biographical data, counselling methods, counselling efficacy and tools, audiological rehabilitative training, multicultural sensitivity and patient satisfaction. study site, population and sampling technique purposive sampling was conducted that ensured participants were representative of the phenomena under research (brink et al., 2012). the survey was conducted on 41 audiologists practising within the 11 districts of kzn. this ensured that the sample is heterogeneous and representative of the general population (leedy & ormrod, 2013). the inclusion criteria were based on audiologists registered with the health professions council of south africa, practising within kzn in both public or private sectors that provide presbycusis and tinnitus counselling to adults. data collection procedure once ethical clearance was obtained, the relevant gatekeepers from the public and private sectors were contacted to allow the progress of the study. these gatekeepers included the provincial department of health, owners of private practices, hospital management and professional associations’ body chairpersons. gatekeepers serve as mediators for accessing study participants to obtain data required for research (andoh-arthur, 2019). once gatekeeper permission was obtained, the public speech language therapists and audiologists forum and private regulatory boards such as the south african speech-language and hearing association and south african audiology association (saaa) were contacted via email to obtain permission to progress with the study and obtain participant details. representatives from saaa shared the invitation to participate in the study request via email to the database of private audiologists in kzn. audiologists who wanted to participate then read the invitation letter and information and consent form. the information and consent form with the link to the self-administered survey was then sent via email to all audiologists within the private sector in kzn. once gatekeeper permission was received from the public sector, the information and consent form and the link to the self-administered survey were shared with the audiologists in kzn via email addresses obtained from the speech language therapists and audiologists forum. the information and consent form was sent to all participating audiologists in both public and private sectors to inform them of the study and that clicking on the link to the online survey meant that they consented to participating in the study. the information and consent form and survey link were therefore circulated to 53 private audiologists via saaa’s contact database and 83 audiologists within the public sector. three weeks later, the researcher sent out a gentle reminder via e-mail for participants to complete the survey. three weeks after the first reminder, the researcher sent a second gentle reminder to all participants via email to complete the survey. a total of two reminders were sent, encouraging participants to complete the online survey to improve the response rate. the participants were given a 2-month timeframe to complete the survey before closing the responses. data analysis data collected were then coded onto a microsoft excel spreadsheet before using the statistical package for social sciences version 27 to capture and analyse data. descriptive statistics (mean, standard deviations and range) and inferential statistics, pearson’s chi-square and fisher’s test were used to analyse the data. chi-square testing was selected because of the robustness regarding data distribution, detailed information and convenience of computing data (mchugh, 2013). it was used to compare variables for statistical significance. a significance level of p < 0.05 was set for data analysis that indicated a 5% risk of concluding an association between the variables exists when there is no actual association (mchugh, 2013). a statistician was consulted on the selection of statistical tests that best suited the study, taking into consideration sample size and the nature of research, to ensure the increased quality of data analysis. reliability and validity a pilot study was conducted prior to ensure reliability and validity of data collected during the main study, which provided adequacy, ordering and comprehensiveness of research tools used (regmi, waithaka, paudyal, simkhada, & van teijlingen, 2017). the pilot study identified possible challenges or problems that would be encountered during the study. the study was then altered and modified, ensuring that results remained valid and reliable (leedy & ormrod, 2013). the pilot study provided testing of data collection recruitment methods and determining the proficiency of the data collection instrument. in addition, it aided in identifying any modifications that were made. the pilot study was conducted with two audiologists within the kzn region. two audiologists completed the online surveys; these audiologists were practising within the public sector of kzn, both being female, one with 31–40 years of experience and the other with between 41 and 50 years of experience. all participants included in the pilot study were not included in the main study. however, the pilot study followed the same data collection methods stipulated in the main study’s methodology section, following the same inclusion and exclusion criteria. furthermore, a statistician was consulted to ensure the reliability of statistical tests and data. ethical considerations ethical clearance was obtained from the humanities and social sciences ethics committee of the university of kwazulu-natal (ukzn) with the reference number hssrec/00002114/2020. the study adhered to the declaration of helsinki code of conduct for ethical research (goodyear, krleza-jeric, & lemmens, 2007). the declaration of helsinki is a code of ethical principles used during human research in which the researcher ensures that the well-being and respect of participants takes precedence throughout the study process, mainly through informed consent, autonomy and anonymity (goodyear et al., 2007). results the survey link was sent out to 136 audiologists in kzn from both public and private sectors; from these audiologists, with guidance from a statistician, a sample of 50 audiologists who met the required criteria was created. this was concluded to be an adequate size for statistical analysis from a population of an estimated 136 audiologists. from these audiologists, taking into account the sample size, 41 (82%) responses were obtained from audiologists with differing demographics as shown in table 1. table 1: description of participants (n = 41), in relation to years of experience. table 1 shows that participants were mostly female (80.5%) and showed no significant differences with years of experience. most participants fell within the age range of 30 and below, which accounted for 63.4% (n = 26), and a significant relationship between age and years of experience amongst participants was observed; this was because of the younger age of participants showing fewer years of experience. furthermore, 30% (n = 12) participants were practising in the private sector and 70% (n = 28) were in the public sector, and a significant relationship was observed between sector of employment and years of experience (p = 0.003). this is further detailed in table 2. table 2: participants’ years of experience in relation to sector of employment. whilst one participant did not state his or her sector of employment, table 2 indicates that the majority of n = 40 participants (51.2%) attained between 5 and 10 years of experience and consisted mostly of participants from the public sector. furthermore, participants with more than 30 years of experience, n = 3, are exclusively practicing in the private sector. results were further presented in a suite of counselling practices excerpted from literature as (1) counselling methods, (2) counselling efficacy and tools, (3) audiological rehabilitative training, (4) multicultural sensitivity and (5) patient satisfaction. these are derived from the underpinning theoretical framework that guides the study. furthermore, participants’ sectors of employment and years of experience were analysed as variables of interest and were closely inspected when significant relationships were established. counselling methods counselling methods used by audiologists include management through hearing assistive devices, counselling conducted through informational or adjustment counselling and methods of delivery such as individual, group or family counselling (american speech hearing association, 2012). amongst 41 audiologists, 34 (82.9%) managed presbycusis and tinnitus through compensation for the hearing loss with an assistive device and provided counselling services, whilst four (9.8%) participants were provided only counselling and three (7.3%) provided only compensation for hearing loss with an assistive device, without counselling. there was no significance with years of practice (p = 0.072) or sector of employment (p = 0.968) impacting a management course. apart from management, counselling was conducted through informational and adjustment counselling. the majority of audiologists 75.6% (n = 31) offered both informational and adjustment counselling whilst 24.4% (n = 10) offered only informational counselling during presbycusis and tinnitus counselling. there was no significant relationship between informational and adjustment counselling and years of practice (p = 0.0718) or sector of employment (p = 0.426). the study further focused on delivery methods used during counselling as depicted in figure 1. figure 1: delivery methods used during counselling. figure 1 revealed that 87.8% (n = 36) of participants offered counselling through individual counselling, whilst 53.7% (n = 22) offered family counselling, 9.8% (n = 4) offered all methods of delivery and only 2.4% (n = 1) offered group counselling; all participants offering group counselling practised within the public sector. there was no significant relationship between delivery methods and years of experience (p = 0.343) or sector of development (p = 0.322). a total of 24 participants (n = 24) reported on reasons for the implementation of chosen methods of delivering counselling. the study found that 8.33% of participants (n = 2) reported that individual counselling was attributed to the covid-19 pandemic preventing group counselling. furthermore, 20.8% (n = 5) stated that individual counselling allowed discretion and additional time spent focused on the patient to accommodate specific needs. however, 4.16% (n = 1) reported that the private sector prefers individual counselling over group and family counselling, possibly because of telehealth only allowing for individual counselling. counselling efficacy and tools within this study, the efficacy of counselling refers to the benefits or helpfulness of counselling practices (parham et al., 2013). to assure the efficacy of presbycusis and tinnitus counselling practices, audiologists must ensure the use of appropriate measurement scales (british society of audiology, 2016), which for this study are considered as tools or resources. this aspect of counselling practices therefore focuses on the tools and resources used by audiologists. participants reported use of the following tools and resources when counselling patients with presbycusis and tinnitus: abbreviated profile of hearing aid benefit, tinnitus handicap inventory (thi), self-assessment of communication hearing handicap scale for the elderly (schhse), questionnaires, models and pamphlets. from 38 responses, 92.1% (n = 35) found these tools useful during practice whilst 7.9% (n = 3) reported it not useful; although participants were allowed to elaborate on the tools’ usefulness or otherwise, there were no reasons stipulated for tools being not useful during counselling practices. significant relationships were found between the efficacy of tools used during counselling practices, as depicted in table 3. table 3: relationship between the efficacy of tools and resources to years of experience and sector of employment. there is a significant relationship between the efficacy of tools and resources and participants’ years of experience, resulting in a p = 0.049; 75% of responses disagreed on current tools and resources being of efficacy during counselling practices, and these participants fell within the group with 5–10 years of experience. there was no significant relationship between the efficacy of tools and resources and sectors of employment. whilst there was no relationship between the multicultural sensitivity of tools and resources and years of experience (p = 0.643) and sector of employment (p = 0.805), a relationship of significance was observed regarding participants’ understanding of tools and resources and sector of employment, indicating 100% of responses that disagreed on having a good understanding of tools and resources fell within the private sector. audiological rehabilitative training audiologists play an integral role during the counselling process, which highlights the importance of ensuring that audiologists are well equipped with the appropriate training in audiological rehabilitation (meibos, muñoz, & twohig, 2019). presently, there are five tertiary institutions within south africa offering the degree at undergraduate and postgraduate levels. results in this study revealed that of the 41 participants (n = 41), 68.3% of the participants (n = 28) obtained their degrees in kzn, whilst 29.3% (n = 12) obtained their degrees outside of kzn and 2.4% (n = 1) obtained their degrees from both kzn and outside the province. of all respondents, 72.5% (n = 29) participants reported that their institution provided them with training for both informational and adjustment counselling, whilst 22.5% (n = 9) reported only being offered training in informational counselling and 5% (n = 2) reported a lack of training in counselling. a significant relationship was observed between participants who felt they could have been better trained for counselling by their respective institutions and sectors of employment, with a p-value = 0.044, suggesting public sector audiologists presenting views of the need for improved training in counselling. multicultural sensitivity the american speech hearing association (2012) advocated for the education of audiologists to ensure their capacity for multicultural sensitivity during counselling practices. most participants 75.6% (n = 31) reported accommodating a multicultural population whilst 24.4% (n = 10), reported not accommodating for multicultural sensitivity. there were 29 responses explaining how multicultural sensitivity was adhered to or not adhered to during practice, a majority of 17 respondents reported that adhereing to multicultural sensitivity was attributed to inclusion of bilinguism during practice, while 3 respondents attributed not adhering to multicultural sensitivity to language barriers and tools which did not fit the context of the population managed. whilst 50% (n = 20) of participants agreed on tools used for presbycusis and tinnitus counselling being multiculturally sensitive, 12.5% (n = 5) of participants disagreed and a further 7.5% (n = 3) strongly disagreed. there were no significant relationships established around multicultural sensitivity and sectors of employment and years of experience. patient satisfaction audiologists with essential skills conducive to counselling increase patient satisfaction. audiologists reported on their ability to ensure patient satisfaction through counselling practices (de man et al., 2016). all 41 participants conducted a satisfaction survey based on how they perceived their patients to be satisfied with their services. most audiologists n = 33 (80%) agreed that their counselling practices provided benefits to their patients. there was no significant relationship between audiologists viewing their patients’ benefits from counselling practices and years of experience (p = 0.753) or sectors of employment (p = 0.915). furthermore, 39 out of 41 audiologists agreed that the patient’s perceptions could provide input on improving counselling practices. discussion patient-centred care can be implemented into audiology practice by focusing on pcc dimensions suitable for counselling, these being the picker principles mentioned earlier (picker institute europe, 2020). literature indicates select dimensions of pcc being related to the specific context of services provided (berghout, van exel, leensvaart, & cramm, 2015), those services being counselling in this study. furthermore, there is a need for conceptualising pcc implementation in current audiology practices (grenness, hickson, laplante-lévesque, & davidson, 2014). the following five components of counselling practice were focused on during this study: counselling methods, counselling efficacy and tools, audiological rehabilitative training, multicultural sensitivity and patient satisfaction, as depicted in figure 2. figure 2: adapted framework on implementing patient-centred care into counselling practices. the researchers adapted the picker principles to form the framework focusing on implementing pcc within audiology counselling practices. this assisted in understanding how a practice can be investigated using these five constructs. counselling methods counselling methods assist in informing and educating patients. this can be conducted in various ways that involve information, communication and education, which are viewed as the most important dimensions of pcc (berghout et al., 2015). counselling methods utilised by audiologists can thus serve as a medium for implementing ppc dimensions into practice. common management of presbycusis is compensating for the hearing loss with assistive hearing devices, placing little attention on counselling (parham et al., 2013). management for tinnitus include pharmacological drug administration typical in developed countries and non-pharmacological forms of treatment that include counselling (han et al., 2009). results from this study revealed that a majority of audiologists (82.9%) managed presbycusis and tinnitus using both methods, compensating for the hearing loss with a hearing device and providing counselling services. a minority provided only compensation for hearing loss through an assistive hearing device, which is still laudable; however, a shift towards a combination of compensation and counselling is required to address the psychosocial aspects of presbycusis and associated tinnitus for improved quality of life (parham et al., 2013). the study related the findings of audiologists concentrating more on compensating for the hearing loss; whilst this may benefit patients, it does not adequately address all aspects of quality of life (parham et al., 2013). implementing pcc into presbycusis and associated tinnitus counselling practices should therefore be a major aspect of treatment as this would ensure holistic management for patients, as previously advocated in the literature. counselling is thus a necessity during the management process and should be provided through appropriate methods. appropriate counselling methods used by audiologists include informational and adjustment counselling (american speech hearing association, 2012). both methods provide for information-sharing, patient education, respect for patient preferences, emotional support of patients and inclusion of the patient’s significant others, all of which are aspects of the eight picker principles (picker institute europe, 2020) falling within the context of pcc. the american speech hearing association (2012) describes informational counselling as a form of teaching, in which the audiologist imparts knowledge related to the hearing diagnosis to the patient and significant others, whereas adjustment counselling explores the experiences of the patient, identifying the conflicts and emotions they go through (british society of audiology, 2016) to deal with the diagnosis. whilst a majority of audiologists (75.6%) offered both informational and adjustment counselling, the minority (24.4%) of audiologists solely provided informational counselling. it was further revealed that there was no significant relationship between years of experience and informational and adjustment counselling. this supports previous research that has shown audiologists are more inclined towards informational counselling (meibos et al., 2017); this study suggests that this inclination is irrespective of the audiologists’ years of experience. the inclination in favouring informational counselling may be attributed to higher confidence levels amongst audiologists, obtained through training, and increased knowledge on informational counselling as opposed to adjustment counselling (meibos et al., 2017). this insignificant relationship between years of experience and informational and adjustment counselling may further indicate that currently audiologists are not receiving the necessary training required to improve their confidence levels in adjustment counselling. this is substantiated by a study conducted in south africa that found audiologists showed difficulty in facilitating adjustment counselling and attributed it to a lack of knowledge, training and confidence (makhoba & joseph, 2016). this is further perceived by patients who are discussed at length in a subsequent article, exploring patients’ perceptions of counselling practices. similarly, this study speculates that the preference towards informational counselling may be attributed to a lack of training and skill in adjustment counselling, indicating the need for further training of already practising audiologists or improved training for undergraduate audiology students. to support the recommendation for increased and improved counselling training, an exploratory study conducted by meibos et al. (2017) focused on training in counselling. findings revealed improvement in counselling practices post-training and concluded that further training is needed for audiologists. apart from informational and adjustment counselling, this study reported on methods of counselling through individuals, families or groups (american speech hearing association, 2012). patient-centred care is characterised by the inclusion of the patient’s family and friends in shared decision-making and involvement (smith, saunders, stuckhardt, & mcginnis, 2013). delivery of these various options for counselling therefore ensures the implementation of pcc in practice. it was found that more than half of audiologists offered individual counselling (87.8%), followed by those who offered family counselling (53.7%), and the least number of audiologists offered group counselling (2.4%). literature indicates a preference for group counselling but cautions that it should be dictated by patients’ context, resources and cultural practices (meibos et al., 2019). however, this study indicated that audiologists showed an inclination towards individual (87.8%) and family (53.7%) counselling as compared with group counselling (2.4%). this was observed in both the private and public sectors. this was mainly attributed to the covid-19 pandemic and patient preferences that were listed as contributing factors to inclination towards individual and family counselling over group counselling. this is supported by studies based on the south african healthcare system, revealing various disadvantages within the south african context, notably resource and time constraints and high patient loads (maphumulo & bhengu, 2019). therefore, the preferences of the patient must be considered. counselling methods can thus better adhere to pcc dimensions, ultimately improving other aspects of counselling practices, which include efficacy and tools. counselling efficacy and tools efficacy of counselling describes the benefits or helpfulness of counselling practices. in assessing the efficacy of presbycusis and tinnitus counselling practices, audiologists must use appropriate measurement scales (british society of audiology, 2016). this study found that a majority of audiologists commonly used measurement scales during counselling practices, such as the abbreviated profile of hearing aid benefit, thi and schhse (british society of audiology, 2016). literature suggests that these tools used during counselling practices assist in determining the patient’s overall progress towards goals of improved quality of life and implement integrated care amongst audiologists (british society of audiology, 2016). however, measurement scales such as the client-oriented scale of improvement, communication scale for older adults and the who disability assessment schedule ii were not found to be used in practice, for unknown reasons. supporting studies reporting audiologists not monitoring their counselling efficacy or appropriateness with the use of measurement scales (de man et al., 2016) therefore prove to be evident in current practice. this was further corroborated in the subsequent study focusing on patients’ perceptions of tools and resources. however, a minority of audiologists did not find tools and resources to be helpful during counselling practice, which they attributed to context specificity and language barriers. this may be the main contributing factor as to why certain measurement scales are not included in practice. furthermore, it may have a negative impact on services, as contrary literature suggests that these tools have proved to be internationally efficient in measuring counselling efficacy and providing guidance to audiologists regarding counselling practices (american speech hearing association, 2012; british society of audiology, 2016). thus, there are measurement scales that serve as tools for counselling and may be used as a guideline to counselling practices that improve efficacy and patient outcome. this study revealed that there are tools that are not being used in current practice, even though they are widely available. this may be attributed to availability of these tools to audiologists and context-specificity of tools and resources; audiologists reported that tools were not context-specific in terms of linguistic significance, which impacts their use. audiologists with 5–10 years of experience felt that the use of tools and resources showed no significant impact in ensuring the efficacy of counselling practices; however, these tools have been documented to focus on the patient’s individual needs and improve patient satisfaction (british society of audiology, 2016), complementing the dimensions of pcc. therefore, this study suggests that audiologists with 5–10 years of experience who participated in this study might be underestimating the impact of tools and resources on counselling efficacy, and this may be a contributing factor to the disuse of these tools and resources. it was further discovered that audiologists have been including resources during counselling practices such as pamphlets that may remain with the patient. such practice is in line with the pcc dimension of patient information and education, as sharing written information that has been proven to assist patients with hearing loss is admirable (balachandran, 2020). therefore, whilst measurement tools and resources suggested for counselling practices are advantageous internationally, there are still limitations that are encountered through context specificity. this may be improved by refining tools and resources to fit the context and improve the training of audiologists in implementing such tools to improve outcomes. audiological rehabilitative training meibos et al. (2019), found that an audiologist’s competency in counselling acquired through training contributes to counselling efficacy. investigating audiological rehabilitative training was thus crucial in gaining knowledge about audiologist training in counselling practices. the study found that whilst a majority of audiologists reported having been trained in both informational and adjustment counselling, a minority of audiologists reported having been trained only in informational counselling or to have received no training in counselling at all. this is related to the inclination towards informational counselling over other options of counselling delivery, which has been noticed in the past research based in south africa (makhoba & joseph, 2016). this was further corroborated by patients’ perceiving and recommending improved adjustment counselling to be included in practice, which is focused on in the subsequent study. this further indicates that in a span of 5 years, audiologists within a similar context may still have limitations in skill development because of institutional training that may impact providing emotional support to patients, thereby negatively impacting pcc dimensions. furthermore, audiologists who reported on not receiving any training in either informational or adjustment counselling reported not having a good understanding of the use of tools and resources during counselling, indicating that audiologists’ lack of skills training may strain their ability to efficiently counsel patients. this is supported by literature revealing that audiologists’ skills or training in counselling impact their preparedness to counsel (meibos et al., 2017). these sentiments add to the notion that to provide appropriate counselling practices, audiologists need to be trained to reach a point of preparedness that allows them to counsel patients using pcc. this study further found that that there is a significant relationship of p = 0.044 between audiologists employed in the public sector reporting an increased need for improved training in counselling as compared with audiologists in the private sector. this can be attributed to differing requirements of counselling based on resource constraints and barriers between sectors. this is supported by studies specific to south africa, indicating that audiologists tend to reflect differing practices based on their training and skills (makhoba & joseph, 2016). this may suggest that the training of audiologists may not be sufficient for public sector requirements. a common report that has recurred throughout the study is that language barriers impact counselling practices; this indicates the need to ensure that institutions provide context-specific training to better equip audiologists in overcoming certain factors faced in the public sector, as supported by khoza-shangase & mophosho (2018), suggesting that context-specific training may impact service delivery. a study by pillay and kathard (2018) suggests that improvement in training is imperative in impacting service delivery. apart from service delivery, the inclusion of context-specific training may improve audiologists’ multicultural sensitivity during counselling practices. multicultural sensitivity healthcare providers indicated patient preferences and values to be the most important dimensions of pcc (berghout et al., 2015). they further indicated that a focus on patients’ preferences and listening to their needs according to their values would improve shared decision-making and patient outcomes (berghout et al., 2015), indicating the necessity of multicultural sensitivity in practice. within the field of audiology, respecting patients’ preferences leads to the understanding of the patient’s individual needs that aid in the development of management to improve their quality of life (balachandran, 2020). therefore, patient preferences and values may be taken into consideration by placing a focus on multicultural sensitivity. this study found that the majority of audiologists reported demonstrating multicultural sensitivity during counselling practices; however, a minority of audiologists reported not adhering to such trends, which is mainly attributed to language barriers faced during the counselling process between audiologists and patients. this is consistent with research based in a similar context that reported the impact of language barriers affecting audiological services (makhoba & joseph, 2016), which is important as the health professionals council of south africa (health professions council of south africa) recommends that audiologists ensure appropriate management in a culturally and linguistically diverse south africa (health professions council of south africa, 2019). furthermore, counselling practices that does not provide for a multicultural population may not be fully adhering to pcc dimensions. substantiated by research that focused on 271 psychologists registered in south africa who explored multicultural counselling competencies, the themes derived from data analysis included competencies in understanding patients’ respect, tolerance and trust (ngcobo & edwards, 2008), suggesting that multicultural sensitivity can be implemented through various paths such as empathy, respect, tolerance and trust. this correlates with a study conducted by de man et al. (2016) that explored the current state and barriers to the implementation of pcc in sub-saharan africa; participants described their satisfaction with culturally sensitive service delivery with reports of therapists’ understanding, respect and tolerance. this emphasises the relevance of patient preferences during counselling and the positive impacts on patient satisfaction. however, it is also critical for audiologists and patients to share the same definition of multicultural sensitivity; patients’ perceptions of multicultural sensitivity are therefore focused on in the subsequent study, further impacting patient satisfaction. patient satisfaction the majority of audiologists reported their counselling practices as beneficial to their patients. audiologists’ sentiments are consistent with literature advocating the significance of counselling and pcc in patient satisfaction (de man et al., 2016). furthermore, the majority of audiologists reported positively on patients’ input in improving counselling practices. by encouraging and accepting patients’ input, audiologists will be adhering to pcc dimensions. supporting these sentiments is a cross-sectional survey on healthcare delivery, conducted on 216 patients with a mean age of 47–94, revealing that pcc showed positive patient satisfaction (kuipers, cramm, & nieboer, 2019). this study highlights and strengthens the implementation of pcc into counselling practices that will improve patient satisfaction. this study supports the assertion that counselling should incorporate a component of patient satisfaction evaluation to improve the implementation of pcc within the south african (sa) context. study’s limitation and strengths this quantitative study included some open questions to get further insight into counselling practices that allowed for a holistic view. furthermore, there was an inclusion of public and private sectors that provided a balanced view of the study, using pcc to guide the evaluation of responses, providing for a neutral standard. however, the study sample is limited to kzn; therefore, the generalisation of findings is only for kzn. conclusion this study has found that audiologists have been implementing pcc into current counselling practices as discussed here in terms of the picker principle; however, they are not fully adhering to all dimensions of pcc in those aspects of counselling practices excerpted as counselling methods, counselling efficacy and tools, audiological rehabilitative training, multicultural sensitivity and patient satisfaction. therefore, current counselling practises show room for improvement. within counselling methods, audiologists have been adhering to pcc given their resource constraints, those mainly being language barriers and the covid-19 pandemic. however, there is room to better implement pcc through adhering to education, information and patient preferences. the insight into counselling efficacy and tools indicates that although audiologists have reported the use of tools and resources, it has not been fully adhered to as literature suggests, which is mainly attributed to language barriers and context specificity. audiologists further reported on the need to improve training to better prepare themselves for counselling patients, supporting literature that advocates similar sentiments (makhoba & joseph, 2016). with improved training, audiologists can expect improved skills to better prepare themselves in ensuring multicultural sensitivity when in conjunction with other above-mentioned aspects of counselling practices, thus improving patient satisfaction. therefore, patient satisfaction may be improved by the implementation of pcc in practice, specific to the context of services (berghout et al., 2015). whilst the conceptual framework depicted in this study will aid in the evaluation and implementation of pcc into practice, further research into the implementation and effectiveness of pcc in audiology practices within the kzn context is crucial for the field to move closer to adhering to pcc. there is a lack of evidence-based research on the relationship between pcc and patient outcomes (rathert, wyrwich, & boren, 2013), which contributes to the knowledge gap in south africa on pcc implementation in audiology practice. this necessitates the need for further research within this field of study. acknowledgements the author would like to extend thanks to all participants of this study, the department of health kwazulu-natal, south african association of audiologists, south african speech-language-hearing association and the consulting statistician. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions the author, k.b., conceptualised the study, conducted the data collection and wrote the manuscript. v.z.p. supervised the research process, provided input into conceptualising the study and approved the final manuscript. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study can by made available by the corresponding author, k.b., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references american speech hearing association. 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(2020). presbycusis-related tinnitus and cognitive impairment: gender differences and common mechanisms. in s. akarsu (ed.), multiple chronic conditions-overview and management of chronic disease clusters (pp. 1–4). london, uk: intechopen. a cquired d ysarthria w ithin the c ontext o f the four-level fram ew ork o f speech sensorim otor control 67 acquired dysarthria within the context of the four-level framework of speech sensorimotor control alexandra stipinovich and anita van der merwe department o f communication pathology university o f pretoria abstract the four-level framework o f speech sensorimotor control (van der merwe, 1997) complicates the traditional view o f dysarthria as a purely motor execution disorder. according to this framework, hypokinetic, hyperkinetic and ataxic dysarthria are program ming-execution dysarthrias, while fla ccid dysarthria is the only execution dysarthria. this preliminary study aimed to differentiate programming-execution dysarthria from execution dysarthria by examining variability o f the temporal control o f speech. six p a r­ ticipants and fiv e control participants repeated 15 stimulus words ten times. voice onset time, vowel duration, vowel steady state duration and vowel form ant transition duration were measured acoustically. the coefficient o f variation o f the temporal parame­ ters, and the correlation coefficient between the durational parameters, were calculated and analysed using descriptive statistics. the coefficient o f variation revealed that the speakers with dysarthria were more variable than the control speakers. all partici­ pants, except those with fla ccid dysarthria, showed similar patterns o f intra-subject variability. those with fla ccid dysarthria ex­ hibited greater intra-subject variability o f voice onset time. the correlation analysis did not reveal differences between dysarthria type, or between the dysarthric speakers and the controls. differences fo u n d in the patterns o f variability may support the hy­ pothesis that individuals with programming-execution dysarthria resort to a different level o f control than those with execution dysarthria. further research in this fie ld is necessary. key words: flaccid dysarthria, hypokinetic dysarthria, ataxic dysarthria, temporal variability, motor programming, motor execu­ tion, four-level framework o f speech sensorimotor control. introduction the traditional classification of dysarthria as a motor execution disorder (darley, aronson & brown, 1975) is challenged by recent advances in theoretical models o f the sensorimotor con­ trol o f speech. one such model is the flf of speech sensorimo­ tor control (van der merwe, 1997; 2007). this framework has recently been described as ‘possibly the most detailed and com­ prehensive attempt to explain impairments in the speech pro­ duction process, relating sub-components to underlying neural structures, diagnosis of motor speech disorders, and principled development o f treatment strategies for such disor­ ders’ (ballard, granier & kobin, 2000 p. 972). according to the flf (van der merwe, 1)997; 2007), neural structures such as the basal ganglia (implicated in hypokinetic and hyperkinetic dysarthria), and the lateral1 cerebellum (implicated in ataxic dysarthria), are involved inj both the programming of move­ ments and the execution o f movements. areas o f the cerebel­ lum other than the lateral cerebellum, as well as the lower mo­ tor neurons, are involved in motor execution. dysarthrias asso­ ciated with damage to the basal ganglia or lateral cerebellum are thus likely to show signs of both programming and execu­ tion difficulties and may therefore exhibit similar trends that would differentiate them from pure motor execution disorders. thus, when viewed within the context of the flf (van der merwe, 1997; 2007), the traditional classification o f dysarthria as a disorder of motor execution may need to be revised. in a recent publication, duffy and kent (2001) acknowledged the challenges that the flf (van der merwe, 1997) poses to future research and the classification o f dysarthria. models based on the normal process of language and speech production should guide the classification and under­ standing of the underlying nature o f communication disorders. until recently, the most accepted model o f speech production has been a three-level model proposed by various authors (e.g. darley et al., 1975; itoh & sasanuma, 1984). the origin o f this three-level model may be traced back to the three hierarchical stages involved in motor skill, namely the planning (encoding), programming and execution of movements (brooks, 1986; magill, 2007). while speech production is a motor act and therefore likely to entail the same phases o f motor planning, programming and execution as other forms o f movement, ver­ bal communication also entails the linguistic planning of the utterance to be made. a pre-motor phase therefore needs to be distinguished from the three motor phases o f planning, pro­ gramming and execution. according to van der merwe (1997), linguistic planning is equated with motor planning for speech by the three-level model o f speech production. this lack of differentiation between linguistic planning and the three phases involved in the preparation and production of the speech act has led to an inadequate formulation o f the true nature of the motor planning, motor programming and execution of speech (van der merwe, 1997). in view of the above-mentioned limi­ tations of the three-level model, van der merwe proposed the flf o f speech sensorimotor control in 1997. this framework consists o f one pre-motor stage, namely linguistic-symbolic planning, and three motor stages, namely motor planning, mo­ tor programming and motor execution. according to the flf (van der merwe, 1997; 2007), aphasia constitutes a breakdown in linguistic-symbolic planning. apraxia of speech is consid­ ered to reflect a breakdown primarily in speech motor plan­ ning, although motor programming may also be compromised. the dysarthrias constitute a breakdown in programming and execution, or in execution only (van der merwe, 1997; 2007). according to the flf (van der merwe, 1997; 2007), a coalition o f neural structures is involved in the control o f ver­ bal communication, many of which are active during more than one stage o f processing. for example, the temporal-parietal areas and broca’s area are involved in linguistic-symbolic planning. broca’s area, together with other cortical motor ar­ the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 68 a lexandra stipinovich and a nita van der m erwe eas, is also involved in speech motor planning. furthermore, speech motor programming is controlled by the basal ganglia, the lateral cerebellum, the supplementary motor area (sma), the motor cortex and the fronto-limbic system. however, the cerebellum, sma and basal ganglia are also involved in the control o f speech execution (van der merwe, 1997). this co­ involvement o f neural structures on more than one level of processing complicates the accurate differentiation of break­ down on the various levels. the current study is a first attempt to differentiate between disorders on both a speech motor pro­ gramming and execution level, from disorders in speech execu­ tion only. given the above description of the involvement o f neu­ ral structures such as the basal ganglia and lateral cerebellum in both the programming and execution of speech movements, the possibility o f dual symptomatology in dysarthrias such as hy­ pokinetic dysarthria and ataxic dysarthria is strong. only those dysarthrias caused by damage to the areas of the cerebellum other than the lateral cerebellum, as well as due to lower motor neuron disorders, are seen to display pure deficits in motor execution and are termed flaccid dysarthria (van der merwe, 1997). hypokinetic dysarthria and ataxic dysarthria may there­ fore constitute programming-execution dysarthrias, while flac­ cid dysarthria may constitute execution dysarthria. motor programming for speech is defined in the flf (van der merwe, 1997; 2007) as the specification and sequenc­ ing of motor programmes for the movements o f the muscles of the articulatory structures. motor programmes specify muscle tone, velocity, direction and range o f movement (brooks, 1986). according to the flf (van der merwe, 1997; 2007), a disorder at the level o f motor programming would result in the impairment of muscle tone, velocity, direction and range of movements. the repeated initiation and feed-forward of co­ occurring and successive motor programmes to the lower mo­ tor centers would also be impaired. speech symptoms associ­ ated with such deficits may include sound distortion, abnor­ malities in speech rate, and/or problems with the initiation of movements for speech. motor programming difficulties may occur in the absence of hypoor hypertonia or involuntary movements which are traditionally associated with dysarthria and which cause the breakdown in execution (van der merwe, 1997; 2007). the execution o f movement is mediated at the lowest level of the motor hierarchy and is set in motion by sub programmes that are conveyed from the middle levels to the lower motor centres, namely the spinal levels (brooks, 1986). flaccid paralysis is caused by damage to the nuclei, the axons or the neuromuscular junctions that make up the lower motor neuron (duffy, 2005). all signals to produce movement arising in the central nervous system must pass through the final com­ mon pathway (which includes the lower motor neuron). as a result, all types o f movement (voluntary, automatic and reflex­ ive) are impaired in the case o f motor execution difficulties (hageman, 1997). four issues complicate the differentiation between the signs associated with a pure motor execution disorder and a programming-execution disorder. firstly, it is to be expected that all types o f dysarthria (flaccid, spastic, ataxic etc.) will differ in terms of their signs and speech motor characteristics as the underlying nature of the associated neuromotor disorder and its effect on muscle tone and movement characteristics differs. secondly, there is likely to be some similarity between the signs and motor speech characteristics of the different types o f dysarthria as velocity, direction and range o f movements are affected to some degree in all types of dysarthria. thirdly, the possibility of certain motor characteristics, such as spasticity, masking a programming disorder must also be taken into ac­ count when attempting to differentiate between a pure execu­ tion difficulty and a programming-execution difficulty (van der merwe, 1997). finally, the study of neuromotor speech disorders is complicated by the interaction o f motor impair­ ment and motor control compensations in response to that im­ pairment (kent, netsell & abbs, 1991). symptoms of dy sarthric speech may thus not solely reflect the role o f the disor­ dered neurological area in the regulation o f speech, but also what the speech motor control system can do in the face of such damage. signs exhibited by dysarthric speakers may thus be the result o f compensatory techniques that have involved the adjustment o f motor programmes (hixon, putnam & sharp, 1983). from the above discussion it is clear that, to differenti­ ate between a speech motor programming-execution disorder and a speech motor execution disorder, an index or parameter of motor control, which will reveal any possible differences between these two types of dysarthria, needs to be identified. variability o f motor speech performance is frequently regarded as a key to the nature o f the speech disturbance (seddoh, robin, sim, hageman, moon & folkins, 1996). ac­ cording to mchenry (2004), the implications of variability for speech production are not yet clear. for example, the complex­ ity o f most skilled behaviours requires the ability to accomplish a goal in different ways. this capacity of a motor system to accomplish the same final product despite considerable varia­ tion in the individual components is referred to as motor equivalence (hughes & abbs in abbs, 1986). however, should the variation within the individual components exceed the boundaries o f equivalence, the end product will be speech that is perceived as unstable or inconsistent and distorted (van der merwe, 1997). thus, on the one hand, variability may reflect inherent flexibility o f a motor system. on the other hand, tem­ poral variability in motor performance is seen to suggest insta­ bility in motor control (e.g. gerratt, 1983; mchenry, 2004; munhall, 1989; seddoh et al., 1996). if the latter is true, then the nature of variability o f the temporal control o f speech may reveal the underlying motor control disorder. acoustic and physiological investigations have sug­ gested that in communicatively impaired individuals, disrup­ tions in temporal control reflect a disrupted motor control sys­ tem (duffy, 2005; seddoh et al., 1996). temporal aspects of speech include voice onset time, vowel duration, vowel steady state duration, vowel formant transition duration, and speech rate. all of these are potential sources of variation' in speech (forest & weismer, 1997; pols, 1986). vowel duration and vowel steady state duration may be representative of what levelt (1989) refers to as intrinsic timing. according to levelt (1989), ‘segment durations are in some way globally speci­ fied’ (p. 442) and ‘such syllable-specific durational properties are part o f the stored syllable program’ (p. 442). intrinsic dura­ tion is thus determined before execution starts, when viewed within the context of the flf (van der merwe, 1997; 2007). levelt (1989) also distinguishes extrinsic timing. according to levelt (1989, p.436), ‘the duration o f moving from one pho­ netic target to the next depends only on the mechanical proper­ ties of the musculature involved’, i.e. on executive factors be­ yond the phonetic plan. when viewed within the context of the flf (van der merwe, 1997; 2007), vowel steady state duration and vowel duration may be determined by the planning and programming levels while vowel formant transition duration (extrinsic timing) may be determined on the execution level. due to the possible differential breakdown in the durational parameters of vowels, both these aspects o f duration were ex­ die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) a cquired d ysarthria w ithin the c ontext o f the four-level fram ew ork o f speech sensorim otor c ontrol 69 amined in this study. voice onset time is an index of the temporal coordina­ tion o f the movements of the vocal folds and the oral structures and thus reflects interarticulatory synchronization (van der merwe, 1997). increased variability of voice onset time may reflect a disruption o f this aspect of temporal control o f speech movements and was therefore also examined in this study. ac­ cording to the flf (van der merwe, 1997; 2007), the potential for interarticulatory synchronization is created on the motor planning level o f the speech production process, before motor programming and execution occur. although abnormalities of vot may result from disorders of planning, programming and execution, the possibility exists that the nature o f the distur­ bance o f vot may differ for the different types o f dysarthria. in describing variability of movement, the form or type o f variability must be taken into account in addition to the amount or magnitude of variability (munhall, 1989). for skilled activities, such as speech, there must be some stability in the internal timing relations between the muscle events that underlie the phonetic percept (harris, tuller & kelso, 1986). the nature o f the correlation between the durational parameters may reflect the speaker’s ability to maintain the internal timing relations between the durational parameters in order to achieve accurate production of the target words. thus, in addition to measuring the degree o f variability of the above temporal pa­ rameters, the correlation between the durational parameters was also calculated. variability of motor speech control has been examined in different types of dysarthria. for example, according to her trich and ackerman (1999), individuals with ataxic dysarthria are expected to exhibit increased variability of target positions and segmental durations. according to reed and franks (1998), individuals with parkinson’s disease (and associated hypokinetic dysarthria) display increased on-line adjustments to movement as movement complexity increases, leading to increased variability in motor performance. turner and tjaden (2000) found that individuals with spastic-flaccid dysarthria caused by amyotrophic lateral sclerosis (als) display longer and more variable vowel durations than normal speakers. previ­ ous research has also established that variability o f speech pro­ duction depends on the severity of the dysarthria under investi­ gation (mchenry, 2003). however, despite previous research into the variability o f the temporal control o f speech exhibited by individuals with dysarthria, the nature of these differences has not been compared across the different dysarthria types. this is a preliminary study] which aimed to differentiate be­ tween programming-execution dysarthria and execution dy­ sarthria by examining variability of the temporal control of speech. different patterns o f temporal control errors exhibited by the participants with programming-execution dysarthria as opposed to the participants with execution dysarthria may strengthen the hypothesis presented by the flf (van der merwe, 1997; 2007) that programming-execution dysarthria should be differentiated from pure execution dysarthria. on the other hand, similar patterns o f errors for the different dyarthrias under investigation may suggest that the level o f impairment contributing to the timing disturbance in the three populations is the same. method aims i the aim of this study was to examine the variability of tempo­ ral parameters during speech production of participants with flaccid dysarthria, representative of execution dysarthria, and participants with hypokinetic dysarthria and ataxic dysarthria, representative o f programming-execution dysarthria. the following sub-aims were formulated to facilitate achievement o f the main aim of this study: • to determine and compare the degree o f variability of the temporal control of voice onset time (vot) as well as the durational parameters o f vowel duration (vd), vowel steady state duration (vssd), and vowel formant transition duration (vftd) of the speech o f participants with flaccid dysarthria, hypokinetic dysarthria and ataxic dysarthria and their matched control participants across repeated produc­ tion of stimulus words • to determine and compare the nature of the correlation be­ tween the durational parameters (vd, vssd, vftd) ex­ hibited by participants with flaccid dysarthria, hypokinetic dysarthria, ataxic dysarthria and their matched control par­ ticipants across repeated production o f the stimulus words as an index to the nature of the internal timing relations between the durational parameters research design a descriptive, non-experimental quantitative research design was selected for this study (leedy, 1997). this type of research involves making careful descriptions o f observed phenomena, as well as the exploration o f possible relationships between these phenomena (leedy, 1997). in achieving the first sub-aim of the study, the focus o f observation was on the variability of the temporal parameters of speech. in the second sub-aim, the extent to which differences in one durational parameter (e.g. duration of vssd) were related to differences in another dur­ ational parameter was determined. participants the participants were required to present with acquired flaccid dysarthria, hypokinetic dysarthria or ataxic dysarthria. the locus of the disease or damage was to be restricted to a single neurological structure so that the results obtained would reflect the pathology under investigation. the disease process dis­ played by each participant was required to have been diagnosed by a neurologist and the presence o f dysarthria confirmed by a qualified speech-language therapist experienced in the field of neuromotor speech disorders. the minimum and maximum age criteria were based on the processes related to the effects of age on the motor performance. the minimum age criterion was set at 18 years. a maximum age criterion o f 75 years was set. this study was not confined to members of a specific gender. the participants were required to be either first-language english or afrikaans speakers as these are the languages in which the re­ searcher is proficient. the participants were required to have no abnormalities of the oral-facial structures other than those associated with the disease process responsible for dysarthria. all participants were to have a negative history of previous neurological, respiratory, speech or voice disorders. all partici­ pants were required to present with adequate comprehension, as determined through spontaneous conversation, so as to un­ derstand the instructions given, as well as adequate vision so as to be able to read the target phrases. six individuals were selected, by means o f non­ probability sampling (leedy & ormrod, 2005) to participate in this study. the sample was confined to six participants owing to the limited availability o f individuals with pure ataxic, hy­ pokinetic or flaccid dysarthria; and also due to the detailed data the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 70 a lexandra stipinovich and a nita van der m erwe collection and analysis procedures followed. the participants are referred to as fd1, fd2, hd1, hd2, adi and ad2, re­ spectively; where fd refers to flaccid dysarthria, ad to ataxic dysarthria and hd to hypokinetic dysarthria. a description o f the participants is provided in table 1. included in table 1 is a description o f the perceptual speech characteristics o f each participant and an indication o f which participant from each dysarthria group presented perceptually with the more severe dysarthria. as indicated in table 1, participant fd1 was diag­ nosed with amyotrophic lateral sclerosis (als). als is a form o f motor neuron disease and is associated with damage to the upper motor neurons and lower motor neurons, typically resulting in a mixed form of dysarthria with bulbar (flaccid) and pseudobulbar (spastic) features (duffy, 2005). participant fd1 was included in this study as he presented with predomi­ nantly lower motor neuron signs. the muscle tone o f partici­ pant f d l's speech structures was reduced and he exhibited decreased reflexes. the mixed nature o f als was, however, taken into consideration during the interpretation o f results. t a b le 1: d escription o f participants not one of the participants was receiving speech therapy at the time o f data collection. each participant was asked to list the medications he or she was taking as well as the dosage thereof. the possible side-effects o f this medication were taken into account in the interpretation o f the results. five matched control participants were used to control for the effects o f age, gender and language. the control partici­ pants presented with perceptually normal speech, no structural or functional abnormalities of the oral-facial structures, and no history o f neurological, respiratory, speech, hearing and voice problems. the controls are referred to as cfd1, cfd2, chd1, chd2, cadi and cad2. cfd1 and chd1 is the same person as he could be matched with both participant fd1 and partici­ pant hd1. the matching o f one control participant to two par­ ticipants was not deemed problematic, as in no instances were the results o f the participants or control participants grouped together. instead, the performance o f each of the participant was compared to that o f a matched control. fd1 fd2 hd1 hd2 ad1 ad2 etiology a m yo tro p h ic lat­ eral sclerosis ideopathic atro p h y o f low er m otor neuron n xii and nx ideopathic parkin­ son’s d isease post-encephalitic parkinson’s dis­ ease a ssa u lt to head w ith dam age to cerebellum . g unshot w ound: occipi­ tal and cerebel­ lar atrophy. age 72 years 73 years 81 years 67 years 20 years 39 years 1 1 age at onset 64 years 72 years 68 years 55 years 19 years 38 years gender male m ale male fem ale male fem ale language english afrikaans english afrikaans english a frikaans oral-facial examination | g eneral w eakness. predom inant low er m otor neuron sym ptom s. re­ duced oral reflexes d eviation o f tongue to left. a tro p hy and fasciculations o f left side o f tongue. re­ duced range and rate of tongue m ovem ent. mild right-sided facial and tongue w eakness. involun­ ta ry grim acing and spasm s o f the face. mouth breathing. normal sym m etry. popping o f tm joint. t re m ulou s­ ness and mild de­ viation o f tongue to right. right-sided facial and tongue w eakness. pop­ ping o f tm joint. associated ja w m ovem ents dur­ ing lateralization o f tongue. r ate jof tongue and lip m ove­ m ents m ildly reduced. i perceptual characteristics poor intelligibility. slow ed, laboured speech. d istorted consonants and vow els. h yperna­ sal. low-pitched, harsh voice. m ono­ pitch and m ono­ loudness. pro­ longed phonem es. inappropriate si­ lences. less dysarthric than f d 1. im precise lingual conso­ nants. mild distortion o f velar consonants. voice soft and breathy. r educed stress. a ccelerated, dys fluent speech. im precise conso­ nants. bilabial plosives produced as labiodental fricatives. m ono­ pitch and m ono­ loudness. un­ steady, breathy voice. mild flu ctu at­ ing nasality. less dysarthric than hd1. m ono­ pitch and m ono­ loudness and re­ duced stress. breathy, trem ulous voice. rapid rate. t endency to speak on residual air. s low rate. harsh vocal quality. periods o f apho­ nia. m ono-pitch and m ono­ loudness. ex­ cess and equal stress. im precise consonants. a rticulatory breakdown. fluc­ tuating n a s a l i t y / less dysarthric th a n a d i. excess and equal stress. s low speech rate. prolonged phonem es. c on so n an t and vowel distor­ tions. medication, dosage and time taken prior to data collection lanzor: 15mg daily (m ornings: 1 hour before data collec­ tion) xanor: 0.5 mg and c ipram il 20mg da ily (evenings) c o-d iovan: 80mg, lipitor: 10 mg and disprin: 150mg daily (m ornings: 1 hour before data collection) diovan: 80m g, aricpet: 5 10mg and hytrin: 5-1 omg daily (evenings) m adopar: (levadopa 200m g; benserazide hci 50m g) vi tablet every tw o hours. (taken 30 m inutes before data collec­ tion) sinem et: 100mg 3x per day (taken 1 hour before d a t a ' collection) none none. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) a cquired d ysarthria w ithin the c ontext o f the four-level fram ew ork o f speech sensorim otor control 71 ethical considerations the study was cleared by the faculty research proposal and ethics committee o f the university o f pretoria. a letter ex­ plaining the aims and nature o f the study was presented to the potential participants. this letter was supplemented with a ver­ bal explanation o f the nature o f the study and the procedures involved in data collection. an informed consent form was at­ tached to the letter. the participants were asked either to sign this form, or to give verbal consent if unable to sign due to mo­ tor involvement. material used for data collection the test material consisted o f 15 consonant-vowel-consonant (cvc) words embedded within the carrier phrase. ‘it’s a ....’ for english and, ‘dit is ‘n ...’ for afrikaans to accommodate speak­ ers o f both languages. by matching the participants with control participants, the impact o f possible differences in language was minimized to a large extent. carrier phrases made it possible to elicit the target words in continuous speech while at the same time controlling the phonetic and phonological context. each o f the target words had either a voiceless bilabial, alveolar or velar stop consonant in word-initial position so that variability o f the temporal parameters o f vot and vftd could be determined. the vowels /a, a, i, e, ae, u, o and a1 were included within the target words and represented the nucleus o f the stressed syllable of the utterance. each sentence was printed on white cardboard in size 22 font. the form in which these words were presented to each subject is presented in table 2. the meaning o f the afri­ kaans words is indicated in brackets. a cp 430 stereo marantz tape recorder and an akg d 1200 e short distance, directional microphone were used to record the speech of the subjects. tdk iec 1 / type 1 cassettes were used for the recordings. apparatus used for data analysis the cp 430 stereo marantz tape recorder was used to send the speech signal to the computerized speech laboratory (csl 4300b) from the kay elemetrics corporation. this signal was captured and analyzed by the digital signal processor. the speech signal was monitored with two jbl pro 3 loudspeakers. the speech signal was presented on a nec multisync 2 display screen, where the time cursors and time axes were used to obtain the measurements on a dual display o f soundwave and wideband spectrogram. data collection procedures recordings were made by the first author in a soundproof envi­ ronment. the akg d 1200 e short distance, directional micro­ phone was positioned within 15 cm of the participant’s mouth. the sentences were presented and read to the participants to fa­ miliarize them with the words and to answer any questions that they may have had. the participants were asked to read each sen­ tence 10 times at a comfortable rate, pausing between repetitions so that the final energy o f the target word did not run into the initial energy o f the first word of the next sentence. the utter­ ances were thus self-initiated and not imitated. each sentence was held in front o f the participant. the researcher counted the number o f repetitions and indicated to the participant when ten repetitions were reached. i acoustic analysis procedures acoustic analysis o f voice onset time voice onset time (vot) is defined as the interval be­ tween the release burst of the stop consonant and the appearance o f periodic modulation for a following sound (kent & read, 1992). vot was thus measured from the start o f the energy burst (indicating release of the stop closure) to the start o f the first full glottal (periodic) pulse of the vowel o f the target utterance. forrest and weismer (1997) define the first full glottal pulse o f a vowel as showing energy through at least the first two formants. acoustic analysis o f vowel formant transition duration vowel formant transition duration (vftd) was measured after vot was measured. a formant transition is defined as the segment o f the formant beginning at the burst release, and ending at the onset o f the steady state portion o f the vowel (forrest & weismer, 1997). in this study, the transition o f the vowel for­ mants was measured from the onset o f the vowel to the steady state portion o f the vowel. only information pertaining to the vowel was obtained from this measurement. thus, the term ‘vowel formant transition duration’ is used in this study, and not ‘consonant-vowel transition duration’. both formant 1 (f i) and f2 were taken into consideration when measuring the vftd. specific attention was paid to f2 transitions, as this formant ap­ pears to be most sensitive to the changes in the shape o f the vocal cavities (gerratt, 1983). in certain cases where it was difficult to establish vftd based on fi and f2, f3 was considered as well. acoustic analysis o f vowel steady state duration vowel steady state duration (vssd) was measured from the end o f the fi and f2 transition to the onset o f the vc-formant transition at the end o f the target word. according to kewley port (1982), the onset of the steady state begins in that frame where frequency change falls to less than 10hz per 5 millisecond frame. t able 2: t arget phrases used in data collection e n g lis h p h ra s e s a frik a a n s p h ra s e s it’s a pet d it is ‘n pet (it is a cap) it’s a pit d it is ‘n pit (it is a pip) it’s a puck i d it is ‘n pak (it is a packet / suit) it’s'a pup ’d it is pap (it is porridge) it’s a putt d it is ‘n pad (it is a road) it’s a tack jdit is ‘n tek (short for technical college) it’s a tick :dit is ‘n tiek (it is a tic) it’s a tip •dit is ’n tip (it is a tip) it’s a top d it is ‘n top (it is a top) it’s a tuck dit is ‘n tak (it is a branch) it’s a cook d it is ‘n koek (it is a cake) it’s a cop d it is ‘n kop (it is a head) it’s a cu ff dit is kaf (it is nonsense) it’s a cup d it is ‘n kap (it is a hood) it’s a cut d it is ‘n kat (it is a cat) apparatus used for data collection the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 72 a lexandra stipinovich and a nita van der merwe acoustic analysis o f vowel duration vowel duration (vd) was measured from the onset o f the vowel, (from the first full glottal pulse) to the last full glottal pulse. this final glottal pulse showed periodic energy through the first and second formants as suggested by forrest and weis mer (1997). reliability and validity to ensure reliability, 15% (every third repetition) o f the data was re-analyzed by the first author. according to seddoh et al. (1996), a difference o f 3 msecs between the original value and the value obtained during the reliability check is considered reli­ able. in a study performed by smith and kenney (1994), an av­ erage difference o f 4 msecs (with a range o f 2 msecs to. 10 msecs) was considered acceptable. in this study, a difference o f 10 msecs or less was considered reliable for the durational meas­ urements. a difference of 5 msecs or less was deemed reliable for the temporal parameter o f vot. the following formula was used to calculate the reliability o f data analysis for each partici­ pant (shriberg & kent, 1982): n um ber o f units scored similarly percentage o f agreem ent = total num ber o f units scored overall, 93% (range: 88% 99%) agreement was ob­ tained. a researcher who has a master’s degree in the field of acoustic analyses was consulted for assistance whenever prob­ lematic analyses arose and, in so doing, functioned as the second analyser. controlling the environment in which data collection took place enhanced the internal validity of the study. in addition, all possible factors, which may have influenced the results obtained (for example the use o f medication by certain participants and the relative severity o f the dysarthria), were taken into account in the interpretation o f the results (leedy & ormrod, 2005). partici­ pants who were representative o f individuals with ataxic, hy­ pokinetic and flaccid dysarthria were selected ensure external validity o f the study (leedy & ormrod, 2005). participant fd1 presented with a mixed form o f dysarthira. however, he was selected to participate in this study, as his symptoms were pre­ dominantly flaccid in nature. participant f d 1 was therefore con­ sidered representative o f individuals with execution dysarthria. data analysis procedures in this study, the degree o f variability o f speech, as well as the correlation between the durational parameters o f speech were determined by means o f descriptive statistics (leedy & ormrod, 2005). data analysis procedure f o r sub-aim 1 the purpose of sub-aim 1 was to determine the degree o f variability o f motor speech performance o f the participants and their matched controls. a measure o f dispersion, the coefficient o f variation, was used to determine the degree o f variability of each temporal parameter. the coefficient of variation, which is the standard deviation squared, is a dimensionless index, allow­ ing measures o f different sizes and units to be compared (leedy, 1997; leedy & ormrod, 2005). the coefficient o f variation was calculated for each temporal parameter across the first nine repe­ titions of each o f the 15 stimulus words produced by the partici­ pants and control participants. the tenth repetition o f each stimulus word was omitted as most participants uttered the final repetition with greater emphasis as if to indicate that this was the final word o f the series. this change in emphasis would not be representative o f the former nine repetitions. the 15 coefficients o f variation for each temporal parameter were then averaged for each participant and control participant. in this way, the overall degree of variability o f speech was determined for each dy­ sarthric participant and control participant. a comparison was then made o f the overall degree o f variability o f speech between the dysarthric speakers and the control participants, and between the different types o f dysarthria. data analysis procedure f o r sub-aim 2 the purpose o f sub-aim 2 was to determine the correla­ tion between vd and vssd, between vd and vftd and be­ tween vssd and vftd across repeated production o f the stimu­ lus words by the participants. a pearson product moment corre­ lation (leedy & ormrod, 2005) was applied to calculate the cor­ relation coefficient between the durational parameters. only the correlation between the durational parameters was calculated. the correlation coefficient was calculated for each durational parameter across all the words produced by the participants with dysarthria as well as their matched control participants. a com­ parison of the correlation between the durational parameters of the dysarthric speakers and the control participants, and between the different types o f dysarthria was performed through subjec­ tive inspection o f the data. results degree o f variability of the temporal parameters the coefficients o f variation calculated for each temporal pa­ rameter across repeated production of the 15 stimulus words are presented in table 3 for each participant as well as each matched control participant. ' as indicated in table 3, all o f the dysarthric speakers, excluding participant fd2, exhibited greater variability of the temporal control of speech than their matched controls. partici­ pant fd2 (who represented execution dysarthria), exhibited less variability than his matched control with regard to all the tempo­ ral parameters with the exception of vot (28.13). participant fd2 also exhibited the lowest degree o f variability o f vd (6.91) and vssd (9.13) when compared with the other dysarthric speakers. in contrast to the relatively low degree o f variability of t a b le 3: c oefficients o f variation o f the tem poral param eters o f vow el duration, vow el steady state duration, vow el form ant transition duration and voice onset time temporal parameters fd1 cfd1 fd 2 cfd2 hd1 chd1 hd2 chd2 ad1 cad1 ad2 cad2 vd 22.95 7.09 6.91 7.07 9.95 7.09 10.81 6.01 9.81 9.07 9.94 7.19 vssd 21.73 7.40 9.13 9.86 12.75 7.40 14.28 8.78 13.9 9'' 10.04 10.47 9.73 vftd 39.38 21.37 28.58 29.07 41.77 21.37 29.99 27.72 37.60 36.97 28.35 29.06 vot 63.01 12.73 28.13 20.63 18.89 12.73 21.84 13.37 25.43 16.38 26.54 17.08 die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) acquired d ysarthria w ithin the c ontext o f the four-level fram ew ork o f speech sensorim otor control the temporal control o f speech exhibited by participant fd2, participant fd1 (who also represented execution dysarthria) showed the highest degree o f variability for each of the tempo­ ral parameters, excluding vftd when compared with the con­ trols and the other dysarthric speakers. the possible influence o f upper motor neuron involvement in participant fd1 may have contributed to the high degrees o f variability exhibited by this participant. participant hd1 exhibited the highest overall degree o f variability o f vftd (41.77). from the information presented in table 3 it would therefore appear that program­ ming-execution dysarthria cannot be distinguished from execu­ tion dysarthria on the basis o f the overall degree o f variability o f speech alone. a comparison o f the degree o f intra-subject variability o f each o f the temporal parameters (table 3) reveals differ­ ences in performance between the participants with program­ ming-execution dysarthria and participants with execution dy­ sarthria. for each o f the control participants as well as the par­ ticipants with programming-execution dysarthria, variability o f vot (which reflects interarticulatory synchronization) was greater than the durational parameters o f vd and vssd, but less variable than vftd. the participants with programming execution dysarthria thus followed the same pattern o f variabil­ ity as the control participants with regard to intra-subject vari­ ability o f the temporal parameters o f speech. in contrast, par­ ticipant fd1 (representing execution dysarthria), exhibited greater variability o f vot (63.01) than any o f the durational parameters (vd: 22.95; vssd: 21.73 and vftd: 39.38). par­ ticipant fd2, who is considered to be a more true reflection o f a lower motor neuron lesion than participant fd1, obtained coefficients of variation o f 28.13 for vot and 28.58 for vftd. thus, while participant fd2, like the other dysarthric speakers and control participants exhibited greater intra-subject variabil­ ity o f vftd than vot, the difference in variability was not as great. in summary, it would appear that the participants with programming-execution dysarthria followed the same pattern o f variability as the control participants with regard to the intra­ subject variability of the temporal parameters, while the partici­ pants with execution dysarthria did not. correlation between durational parameters the averages o f the correlation coefficients between the dur­ ational parameters o f vd, vssd and vftd exhibited by each participant and control participant across repeated production of the stimulus word are indicated in table 4. according to the information presented in table 4, each o f the dysarthric speakers achieved the highest correlation between the durational parameters o f vd and vssd. thus, for each o f the dysarthric speakers, an increase in milliseconds o f vd was accompanied by a concomitant increase in millisec­ onds o f vssd. the same appears to be true for each o f the con­ trol participants with the exception of cad2 who achieved a higher correlation coefficient (0.43) between vd and vftd than between vd and vssd (0,40). furthermore, for each o f the dysarthric speakers, as well as their matched control partici­ pants, the correlation between vd and vftd was also posi­ tive. finally, the lowest correlation exhibited by each o f the dysarthric speakers as well as their matched controls was found between vssd and vftd. it would thus appear that each of the dysarthric speakers followed the same trends as the normal speakers with regard to the nature o f the correlations between the durational parameters. it was therefore not possible to dif­ ferentiate between programming-execution dysarthria and exe­ cution dysarthria based on the nature o f the correlation between the durational parameters. discussion variability o f temporal parameters the results regarding the degree o f variability o f the temporal control o f speech revealed that each o f the dysarthric speakers, with the exception o f participant fd2, exhibited greater vari­ ability than the control participants. participant fd2 exhibited less variability o f vowel duration, vowel steady state duration and vowel formant transition duration, but greater variability of voice onset time than his matched control participant. the find­ ing that the dysarthric speakers were more variable than the controls is in agreement with previous research investigating variability o f dysarthric speech. for example, increased vari­ ability o f vowel durations in individuals with als has been reported (turner & tjaden, 2000; weismer, tjaden & kent, 1996). increased variability o f motor speech performance in hypokinetic dysarthria associated with parkinson’s disease (reed & franks, 1998) as well as in ataxic dysarthria (hertrich & ackermann, 1999) has also been reported. if temporal vari­ ability o f speech is indeed an indication o f the precision or reli­ ability o f motor control (kent et al., 1991), then it is to be ex­ pected that dysarthric speakers would show greater variability of the temporal control o f speech than the control participants. all the dysarthric speakers, with the exception o f participant fd2 (excluding voice onset time) confirmed this prediction. however, it was not possible, in this study, to differentiate pro­ gramming-execution dysarthria from execution dysarthria on the basis o f the overall degree o f variability o f speech. for ex­ ample, in contrast to the relatively low degrees of variability exhibited by participant fd2, participant fd1 (representing the same dysarthria group as participant fd2) exhibited the highest overall degree of variability o f vowel duration, vowel steady state duration and voice onset time. the possibility exists that variables such as age, medication, the presence o f involuntary movements (gerratt, 1983), speech rate (kent et al., 1991; mchenry, 2003) and the severity o f dysarthria (kent et al., 1979; mchenry, 2003) contribute in a particular way to the overall degree o f variability exhibited by dysarthric speakers. differences due to these factors thus complicate the differentia­ tion between the levels o f breakdown in dysarthria. 73 t able 4: correlation coefficients between the durational parameters of vowel duration, vowel teady state duration and vowel formant transition duration fd1 cfd1 fd2 cfd2 hd1 chd1 hd2 chd2 ad1 cad1 ad2 cad2 correlation between vd and vssd 0.76 0.82 0.69 0.80 0.85 0.82 0.70 0.88 0.80 0.73 0.80 0.40 correlation between vd and vftd 0.64 0.79 0.47 0.24 0.29 0.79 0.60 0.44 0.4 0.22 0.37 0.43 correlation between vssd and vftd 0.32 0.48 0.12 -0.26 -0.06 0.48 0.25 0.31 0.00 -0.04 0.15 -0.07 the south african journal o f communication disorders, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) 74 a lexandra stipinovich and a nita van d er m erwe a comparison o f the temporal parameters showing the highest degrees o f variability revealed differences between pro­ gramming-execution dysarthria and execution dysarthria. for each o f the dysarthric speakers as well as each o f the control speakers, voice onset time was more variable than vowel dura­ tion and vowel steady state duration, but less variable than vowel formant transition duration. in contrast, participant fd1 (representing execution dysarthria) exhibited greatest variability o f voice onset time. similarly, participant fd2 (also represent­ ing execution dysarthria) showed relatively high degrees o f in­ tra-subject variability o f vot when compared with the other temporal parameters. it would therefore appear that the indi­ viduals with programming-execution dysarthria followed the same patterns o f variability as the control participants, despite showing a higher overall degree of variability o f motor speech control. the individuals with execution dysarthria, on the other hand, do not appear to have followed the same trends as the normal speakers or the participants from the programming execution dysarthria group with regard to intra-subject variabil­ ity o f the temporal parameters. the similar performance o f the individuals with pro gramming-execution dysarthria to that o f the control partici­ pants regarding intra-subject variability o f the temporal parame­ ters may be explained by the possibility o f the participants with hypokinetic dysarthria and ataxic dysarthria resorting to em­ ploying cortical mechanisms to control motor performance (brooks, 1986). while this is likely to take longer and move­ ments are likely to be executed less automatically, the possible cortical control over movements in individuals with basal gan­ glia or cerebellar involvement may reflect greater movement control than that seen in an individual with flaccid dysarthria who has intact motor planning and motor programming abili­ ties, but an inability to execute movements according to the specifications o f these plans and programmes due to impaired lower motor neurons (von gruenewaldt, 2003). the relatively high degrees o f intra-subject variability o f voice onset time exhibited by participants fd1 and fd2 may be interpreted within the context o f the flf (van der merwe, 1997; 2007). voice onset time reflects inter-articulatory syn­ chronization (van der merwe, 1997) and assesses the temporal coordination o f the vocal folds and the oral articulators. accord­ ing to the flf (van der merwe, 1997; 2007), the potential for inter-articulatory synchronization is created on the motor plan­ ning level o f the speech production process. if this is true, then participants fd1 and fd2 (each representing execution dy­ sarthria) possess the potential to plan the synchronization be­ tween the oral and laryngeal articulators for voice onset time. in addition, they possess the ability to specify motor programmes for the muscles o f the necessary articulators. however, the coor­ dinated execution o f the movements o f the articulators accord­ ing to the specifications o f the motor plan and programme is likely to be impaired in these speakers. the degree to which the execution o f movements required for voice onset time is im­ paired, is likely to be related to the extent to which the motor neurons are impaired. the finding that participant fd2 was less variable with regard to voice onset time than participant fd1 may therefore be because participant fd2 only needed to coor­ dinate weak tongue and velar movements with intact laryngeal articulators. in als, the articulatory structures are not all af­ fected to the same degree (depaul & brooks, 1993). the coor­ dinated execution o f movements of the oral and laryngeal ar­ ticulators was thus likely to have been more difficult for partici­ pant fd1. in summary, each o f the dysarthric speakers, with the exception o f participant fd2 (excluding voice onset time), ex­ hibited greater overall variability o f the temporal control of speech than their matched control participants. the individuals with programming-execution dysarthria followed similar pat­ terns o f variability to the control group. in contrast, the partici­ pants with execution dysarthria differed with regard to the pat­ tern o f variability exhibited when compared with the partici­ pants with programming-execution dysarthria and the control group. this is a possible indication that individuals with pro­ gramming-execution dysarthria resort to a different level of control than individuals with execution dysarthria. interactive control of durational parameters the results o f the correlation analysis showed that all the par­ ticipants (with the exception o f cad2) achieved the highest correlation between the durational parameters o f vowel dura­ tion and vowel steady state duration. the correlation between vowel duration and vowel formant transition duration was also positive (again, with the exception o f cad2). for each o f the participants, the lowest correlation was found between vowel steady state duration and vowel formant transition duration. in summary, the general trend o f the current research results sug­ gests that the dysarthric speakers performed in a similar way to the control participants with regard to the nature o f the correla­ tion between the durational parameters. the implication of these results is that the dysarthric speakers, regardless o f fac­ tors such as the degree o f variability o f motor speech perform­ ance, age, medication, the presence of involuntary movements, speech rate, and severity o f dysarthria, were able to maintain the internal timing relations between the durational parameters. the positive correlation between vowel duration and vowel steady state duration and between vowel duration and vowel formant transition duration exhibited by the control par­ ticipants is not unexpected. given that there can be consider­ able changes in absolute duration and magnitude o f individual muscle events, there must be some stability in the internal rela­ tions between muscle events that underlie the phonetic percept (harris et al., 1986). thus, for many skilled activities, it is the internal timing relations that are preserved over such transfor­ mations as rate and force changes. the reason for the ability o f the dysarthric speakers to maintain the internal timing relation between the i durational parameters is unclear. in addition, there is no existing data with which the correlation coefficients reported in this study may be compared. the possibility exists that, despite the higher de­ grees o f variability o f the individual temporal parameters ex­ hibited by the dysarthric speakers (with the exception o f fd2) when compared with the control participants, the dysarthric speakers may have been able to consciously control the relative duration o f the movements executed, thereby preserving the perceptual identity o f the words produced. alternatively, the dysarthric speakers may have implemented compensatory tech­ niques to preserve the perceptual identity o f words. for exam­ ple, individuals with als exhibit consistently greater weakness in the tongue as compared to the jaw and lower lip (depaul & brooks, 1993). increasing the range o f jaw opening (particularly during the production o f vowels) is seen to be a strategy to compensate for reduced tongue movement (depaul & brooks, 1993; turner & tjaden, 2000) and is achieved by adjusting the motor programmes of the muscles o f the jaw. if this is the case, the jaw may become the primary articulator in an individual with als, resulting in the jaw, lower lip and tongue moving together as a single mass. if this is so, then one could expect to see a linear relationship between vowel dura­ tion and vowel steady state duration and between vowel steady die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) a q u ir e d d ysarthria w ithin the c ontext o f the four-level fram ew ork o f speech sensorim otor c ontrol 75 state duration and vowel formant transition duration in a s p e a k e r w i t h a l s . whatever the reason may be for the maintenance o f the internal timing relations between the durational parameters by the dysarthric speakers, it was not possi­ ble on the basis o f the correlation analysis, to differen­ tiate between programming-execution dysarthria and execution dysarthria. it was also not possible, however, to differentiate the dysarthric speakers from the normal speakers on the basis of the correlation analysis. the internal timing relations between the durational pa­ rameters of words may therefore not be a sensitive in­ dex of pathology. additional indeces o f variability which may further explore the hypothesis set by the flf (van der merwe, 1997; 2007), namely that pro­ gramming-execution dysarthria differs from execution dysarthria must be investigated. conclusion this study was a preliminary exploration o f the vari­ ability o f motor speech performance o f individuals with flaccid dysarthria, hypokinetic dysarthria and ataxic dysarthria in an attempt to differentiate between pro­ gramming-execution dysarthria and execution dy­ sarthria. the flf (van der merwe, 1997; 2007) was used as the conceptual framework for this study. the degree o f variability o f motor speech performance, and the correlations between the durational parameters of speech were investigated as possible indeces to differ­ entiate between the dysarthria types. the dysarthric speakers performed in a similar way to the control participants regarding the correla­ tions between the durational parameters. it was there­ fore neither possible to differentiate between the control participants and the dysarthric speakers, nor between the participants with programming-execution dysarthria and the participants with execution dysarthria, on the basis o f the correlation analysis. investigation o f corre­ lation between the durational parameters may therefore not have been an accurate index to pathology. examination o f the degree o f variability of the temporal parameters of speech showedjthat the participants with hypokinetic and ataxic dysarthria (representing pro­ gramming-execution dysarthria) exhibited the same patterns o f variability as the | controls regarding intra­ subject variability of the temporal parameters. in con­ trast, the participants representing execution dysarthria exhibited relatively higher degrees o f intra-subject vari­ ability o f voice onset time. these differences found in the patterns o f variability support the hypothesis pre­ sented by the flf (van der merwe, 1997; 2007), that individuals with programming-execution dysarthria resort to a different level o f control than those with exe­ cution dysarthria. it is recommended that more exten­ sive research be performed on the variability o f motor speech performance normal speakers. in addition, it is recommended that future research investigating vari­ ability o f motor speech performance in dysarthria be performed using larger speaker groups in which speak­ ers are matched for severity o f dysarthria. additional indeces o f variability should be explored to further in­ vestigate the hypotheses set by the flf (van der merwe, 1997; 2007). references ballard, k.j., g ranier, j.p ., & r obin, d.a. 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(2003). a cq u ired dysarthria w ithin the context o f the four level fram ew ork o f speech se nsorim otor control. u npublished m asters m ini­ dissertation, u niversity o f p retoria, south africa. w eism er, g. t jaden, k. & k ent, r .d (1995). can articulatory behaviour in m otor speech disorders be accounted for by theories o f norm al speech production? journal o f phonetics, 23, 149-164. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 54, 2007 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) article information author: hillary k. sang1 affiliation: 1department of linguistics, moi university, kenya correspondence to: hillary sang email: hillarysang@yahoo.com postal address: po box 3900, eldoret, moi university, department of linguistics, kenya dates: received: 16 apr. 2014 accepted: 22 mar. 2015 published: 08 june 2015 how to cite this article: sang, h.k., 2015, ‘agrammatic aphasia verb and argument patterns in kiswahili-english spontaneous language’, south african journal of communication disorders 62(1), art. #89, 10 pages. http://dx.doi.org/10.4102/sajcd.v62i1.89 copyright notice: © 2015. the authors. licensee: aosis openjournals. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. agrammatic aphasia verb and argument patterns in kiswahili-english spontaneous language in this original research... open access • abstract • introduction    • sociolinguistic situation in kenya    • brief description of kiswahili       • verb paradigm       • copula and auxiliary verbs    • aphasiological perspective    • theoretical perspective    • aims    • purpose    • research questions    • method       • ethical considerations       • participants       • materials       • procedure       • scoring       • statistical analysis    • data analysis    • results       • mean length of utterance       • inflectional errors       • verb types and tokens    • lexical verbs, copulas and auxiliary verbs       • verb argument structure    • general discussion    • conclusion    • issues for future research • acknowledgements    • competing interests • references abstract top ↑ background: the spontaneous and narrative language of kiswahili agrammatic aphasic and non-brain-damaged speakers was analysed. the bilingual participants were also tested in english to enable comparisons of verb production in the two languages. the significance of this study was to characterise bilingual kiswahili-english spontaneous agrammatic output. this was done by describing kiswahili-english bilingual output data with a specific focus on the production of verbs. the description involves comparison of verb and argument production in kiswahili and english. methods and procedures: the participants recruited for this study were drawn from two groups of participants (six non-fluent aphasic/agrammatic speakers and six non-brain-damaged). from each participant, a sample of spontaneous output was tape-recorded in english and kiswahili based on the description and narration of the flood rescue picture’ and the ‘cookie theft picture’. the data elicited were compared for each subject and between the participants and relevant verb parameters have been analysed. the variables that were studied included mean length of utterance (mlu), inflectional errors, verb tokens and types, copulas and auxiliaries. further, all verbs produced were classified as per their argument structure. results: the results from english data supported previous findings on agrammatic output. the agrammatic participants produced utterances with shorter mlu and simpler sentence structure. however, kiswahili data surprisingly showed reversed results, with agrammatic speakers producing longer utterances than non-brain-damaged (nbd) controls. the results also revealed selective impairment in some agrammatic speakers who made inflectional errors. the verb argument structure showed contrasting results, with agrammatic speakers preferring transitive verbs whilst the nbd speakers used more intransitive verbs. conclusions: the study attempts for the first time to characterise english-kiswahili bilingual spontaneous and narrative output. a quantitative analysis of verb and argument production is conducted. the results of the english data are consistent with those in the literature; agrammatic speakers produce utterances with shorter mlu and simpler sentence structure. however, kiswahili data reveals a surprisingly reversed pattern most notably with respect to mlu with agrammatics producing longer utterances than nbd controls. argument structure analysis revealed that agrammatics used more transitive verbs than intransitives. introduction top ↑ aphasia is caused by a focal brain injury after language acquisition due to a stroke, traumatic brain injury or tumour. this may lead to agrammatism, traditionally defined as a disorder of language production that is a clinical syndrome of broca's aphasia. globally, the world health organization (who) estimated as far back as 2004 that 15 million people worldwide suffered from a stroke annually. out of these, 5 million die, whilst another 5 million become permanently disabled. the burden of care is placed on families and communities. africa accounts for 8% of all first-ever strokes and an estimated 5% of stroke survivors worldwide live in africa according to who. feigin, lawes, bennett, barker-collo and parag (2009) predict that the prevalence of stroke might rise in future due to increased exposure to risk factors such as sedentary lifestyles. in kenya, the centre for disease control (cdc) lists stroke among the top ten causes of death in the country. this study takes a linguistic perspective on the manifestation of aphasia due to stroke. kiswahili-english language therapists need this kind of information to correctly assess and determine whether their patients present with agrammatism (cdc-kenya 2010). agrammatism is an acquired language disorder resulting from left hemisphere brain damage, which is characterised by simplification of structure and the omission and/or substitution of inflectional morphemes (e.g. goodglass, 1968; marshall, 1986). studies on agrammatic output in the literature (for example, thompson, shapiro, li & schendel, 1994; vermeulen, bastiaanse & van zonneveld, 1998) typically compare production of nouns and verbs showing that the former are less problematic for agrammatic individuals. however, there are very few studies of this kind on other languages. several other studies looking specifically at the verb (e.g., bastiaanse, jonkers & moltmaker-osinga, 1996; saffran, berndt & schwartz, 1989; thompson, shapiro, li & schendel, 1994; thompson, lange, schneider & shapiro 1997) have found that agrammatic speakers are impaired in verb production. the production of verbs and their diversity are significantly reduced, whilst verb inflections and auxiliaries are often omitted. grodzinsky (1984) observed that the pattern of omission or substitution is morphologically driven and depends on whether the stem can be a free-standing morpheme or not. rossi & bastiaanse (2008) investigated verb production in a group of italian agrammatic speakers. they found that agrammatic speakers are impaired in verb production with omission of verbs and inflectional errors characterising their output. in comparison to non-brain-damaged speakers, their agrammatic speakers produced fewer lexical verbs, fewer modal verbs and fewer auxiliaries. however, they found that copula production was similar in the two groups. in conclusion, they hypothesised that agrammatic speakers have a deficit in grammatical encoding as shown by their patterns of omissions and inflectional mistakes of verbs. also, agrammatic speakers overuse verbs without internal arguments, whereas the proportion of verbs with internal arguments is reduced compared to output of healthy people (thompson, 2003). recent studies by abuom and colleagues on kiswahili-english agrammatism have shown a distinct selective deficit for production and comprehension of verb forms (abuom & bastiaanse, 2013; abuom, obler & bastiaanse, 2011). the same finding is reported in their study that analysed spontaneous output of agrammatic aphasic. they found that the impairment was more severe in english despite its simpler verb paradigm than kiswahili. their results further demonstrated that kiswahili-english agrammatic aphasics had difficulty comprehending passive sentences. this study builds on these findings by looking at features of the verb as well as the argument structure of kiswahili-english agrammatic speakers’ language. the main focus in this study, like in rossi & bastiaanse (2008) was on verb and argument production, but unlike their monolingual italian speakers, the present study analysed the spontaneous and narrative output of the english-kiswahili bilinguals, both agrammatic and age and education-matched non-brain-damaged speakers. previous studies have unanimously found that verbs produced by agrammatic speakers are simpler in argument structure in comparison to those produced by non-brain-damaged speakers. the current study hypothesises that the same results will be found, at least in english. the following parameters of the verb paradigm were analysed: verb omissions and inflection verb tokens and types use of copulas, modals, and auxiliaries verb argument structure. the comparison of bilingual agrammatic and non-brain-damaged speakers of english and kiswahili was based on the parameters outlined above. similarities and differences between the two groups are of particular interest. this was important in the determination of the severity of verb production problems in the agrammatic group. the structural and morphological differences between the two languages imply that differences were likely to be observed. the next section discusses the language situation in kenya, followed by a description of the relevant aspect of the kiswahili language and its grammar. subsequently, some relevant issues with respect to bilingualism and aphasia will be explored briefly. finally, the purpose, aims and research questions for the present study will be presented. sociolinguistic situation in kenya kenya is a multilingual country in which over 40 languages are spoken. however, english and kiswahili dominate in that they are given official recognition, whilst other indigenous languages are not. english is used in education, for official purposes and international communication, whilst kiswahili is the national language and is used in the political arena, parliament, and as a language of political unity and national identity (kembo-sure, ogechi & mwangi, 2006). this study investigates agrammatic and non-brain-damaged speakers of kiswahili and english to find out the differences in verb production in these two languages with strikingly different verb morphology. in the kenyan context, the languages being studied here are acquired at the same time (kindergarten level), effectively making the speakers bilingual. however, strictly speaking, the participants are trilingual given that their native languages all belong to one of the more than 40 ethnic languages spoken in kenya. it is only kiswahili and english that are taught as school subjects from kindergarten to university, therefore proficiency levels can be assumed to be at par. brief description of kiswahili whiteley (1974) classifies kiswahili as belonging to the large family of bantu languages and as native to the peoples who live on the east coast of africa that stretches from the south of somalia to the north of mozambique, including the islands of pate, lamu, pemba, zanzibar and mafia. from east to west, the area of influence of kiswahili extends from tanzania and kenya through the interior of congo up to uganda, burundi, zambia and malawi. the present study attempts to characterise the production of verbs in english-kiswahili speakers. these languages are very different with respect to their verb inflection paradigms. however, there are some similarities between kiswahili and english, mainly in sentence structure configuration; both have a basic subject-verb-object (svo) configuration (for example, ‘the boy (s) kicked (v) the ball (o)’). both languages also allow inverted constructions such as passives, wh-questions, relative and object clefts that change the argument structure of the verb. the main characteristic of the kiswahili verb that differentiates it from its english counterpart is its agglutinative aspect. agglutinative languages are those that have affixes representing various grammatical markers glued to the verb root (see example 2 in section 1.3.1 below). according to omondi (1999), the verb becomes a functional part of the sentence, when a certain number of affixes are attached to it: prefixes, infixes and suffixes, according to the situation. all these affixes possess a precise position and function. the general position schema of these affixes in relation to the verb radical is as follows: verb paradigm pre-prefix + subject prefix + tense marker + object infix + root + derivation + suffix + post-suffix there are however very few verbs which contain this full representation of the verb paradigm. example: a –   li– m–  pig-a subject prefix pst   obj root + final vowel/derivation (verb stem) (i)      (him) (beat) the verbal morphology of kiswahili is clearly more complex than that of english, involving numerous inflectional and derivational morphemes. verbal prefixes are associated with inflection: the main ones are subject and object agreement markers, and tense (relative clauses and reflexives are expressed by means of special object markers). the verbal suffixes are derivational morphemes. the most frequent are the causative, passive, stative, applicative, and reciprocal. the subject and object markers agree in gender and number with the appropriate argument. subject agreement is almost always mandatory for finite verbs, but the use of the object marker is optional. object marking is possible with every semantic class of objects, although it is more frequent with animate objects. copula and auxiliary verbs universally, copulas are not regarded as verbs in the strict sense but as lexicalisations of inflection. unlike lexical verbs, copulas and auxiliaries in general are indeed assumed to be base-generated (projecting from the inflectional phraseip) rather than being generated in the verb node. copulas in kiswahili have little independent meaning and mainly function to relate sentential elements of clause structure, especially subject and complement. examples of copula verbs are; ni, si, ndi-, -li-, -po, -ko,-mo,-na,yu, u and wa. (ashton, 1982). in kiswahili, auxiliary verbs accompany main verbs to express a special aspect of an action, for example: 3. a  li kuwa  anakunywa chai   subject prefix pst cop subject prefix prest stem   obj   (he   was    drinking tea) 4. kijana  a ta-  taka kuenda nyumbani   subject (subject prefix)  futt cop inf  loc   (the boy       will  want to go home) in example 3, the –limarker in the auxiliary kuwa (to be) indicates that the activity started in the past, whilst in example 4, the –tamarker in the auxiliary taka indicates that the activity will take place in future. auxiliary verbs are used to make distinctions in relation to mood, aspect, voice and so on. examples of auxiliary verbs are: kuwa (be), weza (can), pata (get) and wahi (be in time). aphasiological perspective fabbro (2001) observes that grammatical deficits in aphasia depend on the structure of the language system. this means that problems with verb production and argument structure faced by agrammatic speakers are a reflection of the complexity (or lack of it) in the morphosyntactic structures of their languages. although english and kiswahili have the same sentence configuration (svo), their verbal paradigms as discussed earlier, differ significantly. in the context of this study, the factor of bilingualism is also important in describing the aphasiological manifestations of the agrammatic speakers investigated. there is considerable literature on bilingual aphasia (see albert & obler, 1978; fabbro, 1999; paradis, 1995), and a growing number of published work in kiswahili and other bantu language family. one such study, abuom et al. (2011) tests explanations of agrammatism using kiswahili and english. they investigated the patterns and degree of severity of time reference impairments in bilingual agrammatic speakers of kiswahili and english. however, time reference is not a concern for the present study. the studies on bilingual aphasia have shown that bilingual aphasic speakers do not necessarily manifest the same language disorders with the same degree of severity in both languages. according to paradis (1995), bilingual aphasic speakers should be assessed not only in one of their languages, but in both. hence, this study tests bilingual agrammatic speakers in english and kiswahili languages to determine the nature of impairment with respect to verb production. theoretical perspective thompson et al. (1994) in their description of spontaneous output from agrammatic speakers reported the production of fewer verbs than non-brain-damaged speakers. they also found that agrammatic speakers tended to produce verbs with no internal arguments or, if any, just one internal argument. this, together with experimental results, led to the formulation of the argument structure hypothesis (asch) (thompson, 2003), which proposes that the increased complexity of verbal argument structure precludes more difficulty for agrammatic speakers. the current study describes verb production in kiswahili, which has a more complex way of expressing argument structure than english. we hypothesise that at least english data will show results similar to those found by previous studies (e.g. thompson, 2003). a comparison of the languages is expected to further affirm the asch, with agrammatic speakers showing more difficulty in kiswahili than english. aims the main aim of the study is to describe kiswahili-english bilingual output data with a specific focus on the production of verbs. the description therefore involved comparison of verb production in kiswahili as well as in english. purpose the specific motivation for the study is: to describe kiswahili spontaneous and narrative output data with respect to verb production. to compare the data with the analysis of english spontaneous and narrative output. research questions in characterising verb and argument production in kiswahili-english bilingual agrammatics, the following issues are addressed: are kiswahili agrammatic speakers impaired in verb and argument production? do they omit verbs in obligatory contexts? do they make inflectional errors? is the diversity of verbs produced limited? is production of lexical verbs, copulas and auxiliaries different from normal? do they prefer simpler or more complex argument structures compared to non-brain-damaged speakers? method ethical considerations the graduate research ethics committee of moi university approved the study. in granting permission for the study, the ethics committee emphasised the need to maintain confidentiality and anonymity of participants and information collected from them. although all participants could read and understand consent forms, they were read to the participants in the presence of an adult family member whom they selected as a witness. there was no need to translate consent forms, since all the participants were proficient in english and kiswahili. all the participants understood what entailed their participation in the study and appended their signatures. to ensure confidentiality of participants, codes were used on the form and on interview transcripts instead of names. there was no disclosure whatsoever of the participants specific locations to avoid identification by unauthorised parties. participants the participants recruited for this study were drawn from two groups of participants (six non-fluent aphasic/agrammatic speakers and six non-brain-damaged). they were matched on age and education level which was kept at a minimum of o-level qualification. in the kenyan school system, these are graduates who have gone through kindergarten, elementary (primary school) and high school tiers of the education system, which means 12 years of uninterrupted exposure to english and kiswahili. all participants are right-handed and without any history of psychiatric or developmental output or language disorders or any other neurological conditions. the agrammatic speakers produced telegraphic output in both languages confirmed by a practicing output therapist. unfortunately, there are no tests available to establish the aphasia syndrome, but all agrammatic speakers had good comprehension in both languages on an adapted version of the subtask for auditory comprehension of single words (boston diagnostic aphasia examination [bdae]-word comprehension test goodglass & kaplan, 1983). their details are shown in the table 1. table 1: details of agrammatic speakers. materials participants were recruited through purposive sampling at aga khan university and nairobi hospitals in collaboration with resident output and language therapists. the therapists were given a language profile of agrammatism and asked to recommend patients who exhibited the following characteristics: non-fluent language production, words produced limited to content words (nouns, verbs and adjectives), telegraphic output and articulation problems. from each participant, a sample of narrative output was tape-recorded in english and kiswahili based on the description and narration of the ‘cookie theft picture’ from the boston diagnostic aphasia examination (bdae) (goodglass & kaplan, 1972) and the pulitzer prize winning photograph by annie wells, ‘flood rescue picture’. these assessment tools were chosen, since kenya does not have any test for identification of the aphasia syndrome. the elicitation method adopted was in the format of a semi-structured interview that involved the interviewer showing the participants the pictures and asking them, ‘can you tell me what is happening in this picture?’ narration involved participants being asked to tell a story from the pictures with ‘a beginning, middle and an end’ for both pictures. in both description and narration, participants were encouraged to tell as much as possible about the pictures. a further tape-recording of spontaneous output was done to elicit the number of utterances required for analysis. agrammatic participants were asked the following questions: can you tell me about your stroke? can you tell me about your work before the stroke? can you tell me about your family? can you tell me about your hobby? for comparison purposes, questions 1 and 2 were slightly modified for the non-brain-damaged participants to ‘can you tell me something about your last illness??’ and ‘can you tell me about your past work?’ respectively. procedure previous studies have used varied sample sizes in their analyses of spontaneous output. vermeulen et al. (1989) drew 300 words from the spontaneous output of their aphasic patients, whilst berndt, haendiges, mitchum & sandson (1997) did their analysis on samples of 150 words. rossi & bastiaanse (2008) used all spontaneous output materials elicited from every participant in their study. the present study ran analyses on samples of 200 words. however, since kiswahili is an agglutinative language and english is not, comparisons on the basis of the number of words do not seem to be appropriate. for example, to express the past perfect in english, four words are need (e.g. ‘he had been writing’), whereas only two words are used in kiswahili (‘amekuwa akiandika’). this study therefore based analyses on utterances extracted from the 200 word samples recorded from the participants. utterances were defined as those clauses containing a verb meaning (i.e. verb, copula, modal or auxiliary) for purposes of comparison. doing this, provided a similar number of utterances for both english and kiswahili, thus enabling comparisons to be done statistically. so, from the 200 word samples in both english and kiswahili, we had an average of 64 utterances. in essence the comparison between the two languages done in this study was based on the number of utterances and not the number of words. the illustration below shows that whereas words are variable, utterances tend to be more stable as units of analysis. this is the reason why utterances as opposed to words were used for comparison between the two languages. the calculation of mean length of utterance (mlu) was done by dividing the number of words per utterance by the number of utterances. kiswahili: alimpiga  - 1 word 1 utterance (mlu=1) english: he beat him  - 3 words  1 utterance (mlu=3) kiswahili: amekuwa akiandika 2 words  1 utterance (mlu=2) english: he had been writing 4 words 1 utterance (mlu=4) nb: english has more words per utterance. recording sessions were held in a quiet setting for each of the participants using a digital audio recorder. the participants were asked to describe the pictures and then to tell a story, also based on the pictures, with a beginning, middle and an end. the samples collected were orthographically transcribed verbatim and then segmented into sentences. hartmann and stork's definition (1972) of a clause as a grammatical unit that includes, at minimum, a predicate and an explicit or implied subject and expresses a proposition, informed the criterion of segmentation. thus, well-formed sentences with the elimination of repetitions and hesitation phenomena (e.g. eeeh, uum, well…) were of particular consideration. scoring an utterance considered to be a unit of output bounded by breaths or pauses (aronoff & rees-miller, 2001) was the unit of analysis critical in scoring. however, for the present study focus was on clauses that contained a verb, meaning that utterances containing verb, copula, modal, or auxiliary were analysed. the analyses were carried out on agrammatic and non-brain-damaged speakers’ samples with each lexical verb, auxiliary, copula, and modal verb being counted and scored. the finiteness of the verbs was also taken into account as well as inflectional errors. all these variables were counted and divided by the number of utterances for each speaker. further, the argument structure for each verb produced (following rossi & bastiaanse, 2008) was analysed for the number of internal arguments. in this respect, three verb argument structures were examined: intransitives, transitives and ditransitives. for all the analyses described here, comparisons were done within and between groups for both english and kiswahili data. the data of the agrammatic speakers were compared to those of non-brain-damaged speakers for both languages. statistical analysis statistical analysis involved all the participants (agrammatic and non-brain-damaged speakers). the two sample groups were treated as being independent of each other in the obvious sense that they are separate samples coming from different sets of individual speakers. the individual measures in the agrammatic group are in no way linked with or related to any of the individual measures in the non-brain-damaged group, and vice versa. the version of the statistical ttest that was applied was therefore the one assuming ‘unequal sample variances.’ the measures of dispersion used to describe results were the mean and standard deviation. data analysis the results reported here are for six agrammatic and six non-brained-damaged bilingual speakers of english and kiswahili. all analyses were done on the basis of the utterance as the primary unit in which all grammatical elements are contained. this means that all variables were analysed in relation to the number of utterances for each subject. the implication is that the total number of a given grammatical element (e.g. copula or auxiliary) produced by a subject was divided by the total number of utterances produced by that subject. it was therefore possible to do direct comparisons within and between participants for english and kiswahili on a proportional basis. the following variables were counted and divided by the number of utterances for each subject: mean length of utterance (mlu): the mean number of words per utterance. it is predictable that kiswahili, being agglutinative, yielded more words per utterance than english. inflectional errors: verb inflection omissions and substitution. verb tokens and types. verb tokens: the total number of lexical verbs, copulas, modals and auxiliaries verb types: the number of different verbs per sample of 200 words in order to compute lexical diversity. copulas and auxiliaries were counted. verb argument structure: bastiaanse & jonkers (1998) analysed 300 consecutive words from their participants’ samples. for the present study, however, 200 words were extracted and the number and nature of realised internal arguments scored. this was necessitated by the fact that some of the agrammatic speakers could not reach the 300-word threshold. there were three possible verb-argument structures considered: verbs without internal arguments (intransitives), verbs with one internal argument (transitives) and verbs with two internal arguments (ditransitives). results mean length of utterance mean length of utterance was calculated for both agrammatic and non-brain-damaged speakers and a difference in mlu between english and kiswahili computed for each group. the data for both groups showed variation in mlu, implying that both sets of participants produced longer utterances in english (m = 6.45, sd = 1.0) than in kiswahili (m = 3.8, sd = 0.5) for nbd. this was predictable as illustrated earlier, given the different configurations of the languages. a t-test however revealed that the difference in mlu between the two languages was not significant for both groups. for non-brain-damaged participants, english showed a higher level of mlu (m = 6.8, sd = 2.5) than kiswahili (m = 3.8, sd = 1.6). this difference was also not significant (t (8) = 12.6, p > 0.05). for agrammatics, english showed a higher level of mlu (m = 6.05, sd = 2.0) than kiswahili (m = 4.3, sd = 1.6). this difference was also not significant (t (9) = 3.4, p > 0.05). the mlu of participant ea was the lowest in both languages (english = 4.2, kiswahili = 3.1). his utterances consisted of short and simple sentences that fell far short of those produced by a control subject of his age, education and professional background. he scored 2.5 sd below the mean of the mlu of the control participants in english, whereas all the other agrammatic speakers fell within the normal range. in kiswahili, however, agrammatic speakers had longer utterances (m = 4.3) than non-brain-damaged speakers (m = 3.8). this can be attributed to a tendency by the former group to use circumlocutions hence making their utterances longer. inflectional errors the non-brain-damaged speakers do not make inflectional errors in either language. there were no omissions or substitutions of verbs in obligatory contexts and therefore no analysis of inflectional errors was done. the patterns observed in agrammatic speakers reveal some variation, but most of them show errorless performances comparable to their non-brain-damaged counterparts. some agrammatic speakers omitted inflectional endings in obligatory contexts. the worst performer in this respect was participant ea, whose majority of verbs lacked inflections of any kind. he simply produced the stem of the requisite verb in both english (69% error rate) and an even higher percentage in kiswahili (92% error rate). participants hj (31%) and sw (3%) had fewer inflectional errors in english, whilst mm (12%) and sw (3%) had this error rate in kiswahili. these results are shown in table 4. table 2: differences in mean length of utterance (mlu) values between english and swahili. table 3: error analysis: agrammatic speakers. table 4: verb production. verb types and tokens the non-brained-damaged participants produced fewer verb tokens in english (m = 46.67) than kiswahili (m = 62.3) in a sample of 200 words. the lexical verb types in the two languages are, however, similar in english (m =29.8) and kiswahili (m = 30.5). a similar trend was found in the agrammatic group, although the margin of difference in means for this group was reduced: verb tokens in english (m = 33.5) and kiswahili (m = 36.7); verb types in english (m = 20.5) and kiswahili (m = 20.3). this implies that, whereas in kiswahili more verbs (verb tokens) are produced, the diversity of verbs (verb types) is decreased. the type-token ration (ttr) was calculated by dividing the number of different verbs (the types) by the number of tokens giving a ratio (between 1.00 and 0.00) that indicated the rate of diversity: a high ratio means a great diversity, whilst a low ratio implies poor diversity and hence low lexical content (vermeulen et al. 1989). the ttr values for english are higher for both groups (non-brain-damaged = 0.64; agrammatic = 0.62) than kiswahili (non-brain-damaged = 0.51; agrammatic = 0.57) indicating that diversity is lower in kiswahili spontaneous output. this is shown in tables 5–6. table 5: raw numbers and proportion of lexical verbs, copulas and auxiliary verbs in 200 words. table 6: verb argument structure. lexical verbs, copulas and auxiliary verbs the raw numbers of different kinds of verbs per utterance in 200 word samples for each group is shown in tables 7–8. the results reveal that participants produced more lexical verbs in kiswahili (m = 62.3) than in english (m = 46.7) for non-brain-damaged speakers. agrammatic speakers also produced more lexical verbs in kiswahili (mean = 36.7) than in english (m = 33.5), albeit with a smaller margin in comparison to their non-brain-damaged counterparts. copulas in kiswahili were marginally higher (m = 25.2) than english (m = 18.2) and so were auxiliaries: kiswahili (m = 24.3); english (m = 18.5) for nbd participants. in comparison with non-brain-damaged speakers, the production of copulas and auxiliaries by agrammatic speakers was significantly reduced: copulas in english (m = 9.2) and kiswahili (m = 7.2) and auxiliaries in english (m = 13) and kiswahili (m = 6.2). verb argument structure the argument structures of verbs produced in the two languages was analysed in a sample of 200 words for each subject. the analyses shown in percentages in tables 9 and 10 reveal that non-brain-damaged participants produced more verbs without internal arguments in english (m = 63) and kiswahili (m = 63.2). the verbs with one internal argument (transitive) were the second highest produced in both english (m = 45.3) and kiswahili (m = 22.6). the analyses also show that there was very limited use of ditransitive verbs in both languages with percentage production of below 5%. results from agrammatic speakers with respect to argument structure were surprisingly the opposite of non-brain-damaged controls. they produced more verbs with one internal argument (transitive verbs; m = 50.4%) in english and kiswahili (m = 55.6) than those without internal arguments (intransitive verbs; m = 23.9) in english and kiswahili (31.7). however, verbs with two internal arguments (ditransitive verbs) were also hardly produced. general discussion the variables selected in this study provided a basis to compare linguistic structures of the languages investigated. it was possible to ascertain differences between the spontaneous and narrative output of agrammatic speakers and that of non-brain-damaged participants. the analysis presented in this chapter describes and quantifies verb and argument production, and are therefore a good reflection of how agrammatism is manifested in bilingual speakers of english and kiswahili. as mentioned earlier, with respect to spontaneous output in bilingual speakers of these languages, this is the first such attempt, hence opening up scope for more research. all participants had a first language (their mother tongue) prior to the acquisition of english and kiswahili. the results show a pattern of consistency in verb production between non-brain-damaged speakers and agrammatic speakers in both languages under investigation. the only exception is the agrammatic subject ea, who produced many errors and fell significantly below the normal range. non-brain-damaged and agrammatic speakers produced longer utterances in english than in kiswahili, although the difference was not significant. this could possibly be attributable to the differences in the configurations of the languages: kiswahili is highly agglutinative, meaning that grammatical elements are attached to the verb, whilst english is more analytical. in kiswahili, several morphemes are added to the verb to denote case, number, gender, person, and tense. words are a combination of roots and stems, whilst in english, which is described as fairly analytic (bickford, albert & daly, 1996) the vast majority of morphemes are free morphemes, that is, they are considered to be full-fledged ‘words’. another explanation is the fact that in kiswahili, units that were counted as words are sentences when translated to english. for example, in english the three-word sentence ‘he beat him’ would be translated in kiswahili as ‘alimpiga’. this was counted as a single word in this study and also as a one utterance. the unit of analysis was chosen as ‘utterance’ as described earlier, thus making comparisons between kiswahili and english viable. results of mlu analyses describe agrammatic output in english and kiswahili. the findings were expected to be comparable to agrammatic spontaneous output research in indo-european languages that showed short sentences are produced by agrammatic speakers of those languages (e.g. for english, goodglass, 1976; thompson, shapiro, li & schendel, 1994; for italian, rossi & bastiaanse, 2008). the same characteristics were found in the present study: shorter mlu in words and proportionately more simple sentences produced by agrammatic speakers. as anticipated, the non-brain-damaged speakers did not omit or substitute verbs in obligatory contexts. however, verb production in agrammatic speakers showed a reduced number of lexical verbs, as reported by thompson et al. (1994) for english, and bastiaanse, jonkers & moltmaker-osinga (1996) for dutch. auxiliaries were also reduced in agrammatic speakers in comparison with non-brain-damaged participants, supporting findings by bastiaanse, hugen, kos & van zonneveld (2002) for dutch and miceli, silveri, romani & caramazza (1983) for italian. the present data revealed that both groups produced more verb tokens in kiswahili than in english, although the verb diversity was relatively higher in english. this means that kiswahili spontaneous language produced by the participants had low lexical content in comparison to english. this could be explained by the use of compensation and adaptive strategies for kiswahili due to the context of use. whilst english is mainly used in formal situations in kenya, kiswahili is used in everyday conversation. so speakers tend to use verbs in obligatory conditions in english but not in kiswahili, as long as they are understood by other interlocutors. the production of copulas and auxiliaries in english and kiswahili was found to be similar for non-brain-damaged participants in the two languages relative to the number of utterances. however, agrammatic speakers’ output was characterised by low levels of these linguistic units generally. the analysis concerning verb argument structure surprisingly showed sharply dissimilar trends in production between the two groups of participants for both languages. previous studies on argument production in spontaneous output, for example thompson et al. (1997) who distinguished one (intransitive), two (transitive) and three (ditransitive) place verbs and counted the frequency of each, found that agrammatic speakers use relatively fewer two and three-place verbs than non-brain-damaged speakers. rossi & bastiaanse (2008), in their analysis of italian agrammatic output, counted the number of internal arguments produced and found that agrammatic speakers produce significantly more verbs without internal arguments (one-place verbs) than agrammatic speakers and that there was no significant difference in the production of verbs with one or two internal arguments between the two groups. the results of the present study were comparable to those of rossi & bastiaanse (2008) with respect to non-brain-damaged speakers. the use of one-place verbs (intransitives) was higher than transitives for non-brain-damaged participants, whilst an opposite pattern was observed for their agrammatic counterparts who produced more transitive than intransitive verbs. the only similarity between the groups was found in the use of ditransitives, which was very minimal for both groups. conclusion this study reports findings of analyses conducted on the spontaneous and narrative output of english-kiswahili bilingual agrammatic and age and education-matched non-brain-damaged speakers. it is the first effort as far as existing literature is concerned and hence provides novel data in verb and argument structure production in kiswahili. the data elicited from picture description and narration in english and kiswahili were compared for each group and between the groups. the results revealed a remarkable consistency among the participants in their verb production in both languages. the pattern of use of lexical verbs (token and types), copulas and auxiliaries was similar in the two languages for the participants. this suggests that they are well balanced bilinguals and hence suitable for this kind of cross-linguistic comparative study. the overall finding in this study is consistent with results from similar studies in indo-european languages. the output of agrammatic speakers is characterised by short, simple utterances with proportionately fewer grammatical morphemes. inasmuch as the performances of most of the participants were comparable to those of non-brain-damaged controls, they still fell short in certain respects. this was especially observed in the total sample size recorded which averaged more than 500 words for non-brain-damaged participants and 200 for agrammatic speakers. this meant that for purposes of analysis (pegged at 200 words), entire samples were analysed from agrammatic speakers, whilst those from non-brain-damaged speakers were proportionally selected. inflectional errors were found in samples from three agrammatic speakers, with ea particularly showing selective impairment. he had very high levels of omission of inflection morphemes in both languages. the differences in variables found between the two languages were largely attributable to the contrast in the syntactic structures of the languages studied. english is described as being ‘fairly analytical’, whilst kiswahili is classified as agglutinative (bickford et al., 1996). the contrast was clearly shown by the significance in difference of the mean lengths of utterance produced by the participants in english and kiswahili. the study was found to be suitable for analysing verb and argument production in the spontaneous output of english-kiswahili bilingual agrammatic speakers in kenya. it provided insight on patterns of language storage in the brain with respect to participants who can be characterised as balanced bilinguals. issues for future research the agglutinative nature of the kiswahili language as pointed out in the present study means that several affixes are glued together, essentially resulting in ‘single-word’ sentences. this study avoided the possible problems this structural aspect would have on the results by basing analyses on ‘the utterance’. however, it is the recommendation of this study that there is need for research to identify the demarcation of a word in kiswahili as compared to english. the question of ‘what is a word?’ in kiswahili is crucial in the comparison of verb production with other languages like english since this kind of studies use word samples in analyses. the other challenge observed in kiswahili-english spontaneous data was the propensity of participants to code-switch. we tried to avoid this pitfall by doing recordings for this study on different dates for the two languages, and even though this helped to a large extent, there were still quite a few code-switched data in the final transcripts. for analysis purposes for this study, these data were excluded and therefore did not have any effect on the results reported. however, future research can analyse the impact of code-switching in agrammatic spontaneous output, given that there are several studies on code-switching in output of non-brain-damaged individuals in the literature. finally, the kiswahili narrative output revealed the use of what can be characterised as a narrative marker ‘ka’. both non-brain-damaged and agrammatic individuals used this marker in telling stories depicted in the pictures. the past narrative marker (the -katense) is used for narration, but it is often preceded in output by a first verb in the simple past. the past narrative exists only in the affirmative. the infix -kais placed between the affirmative subject prefix and the verb radical. this tense accommodates object infixes, but cannot be used in relative constructions. it was observed that participants used this marker frequently in narration and this could have had an impact on tense (time reference). this was beyond the scope of the present study and therefore we recommend studies focusing on the impact of this marker on time reference in kiswahili narrative output. acknowledgements top ↑ competing 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(ed.), language in kenya. nairobi: oxford university press. who. disease and injury regional estimates for 2004. retrieved august 18, 2014, from http://www.who.int/healthinfo/global_burden_disease/estimates_regional/en/index.html http://www.sajcd.org.za open access page 1 of 1 reviewer acknowledgement acknowledgement to reviewers in an effort to facilitate the selection of appropriate peer reviewers for the south african journal of communication disorders, we ask that you take a moment to update your electronic portfolio on https://sajcd.org.za for our files, allowing us better access to your areas of interest and expertise, in order to match reviewers with submitted manuscripts. if you would like to become a reviewer, please visit the journal website and register as a reviewer. to access your details on the website, you will need to follow these steps: 1. log into the online journal at https://sajcd. org.za 2. in your ‘user home’ [https://sajcd.org.za/ index.php/sajcd/user] select ‘edit my profile’ under the heading ‘my account’ and insert all relevant details, bio statement and reviewing interest(s). 3. it is good practice as a reviewer to update your personal details regularly to ensure contact with you throughout your professional term as reviewer to the south african journal of communication disorders. please do not hesitate to contact us if you require assistance in performing this task. publisher: publishing@aosis.co.za tel: +27 21 975 2602 tel: 086 1000 381 the editorial team of the south african journal of communication disorders recognises the value and importance of the peer reviewer in the overall publication process – not only in shaping the individual manuscript, but also in shaping the credibility and reputation of our journal. we are committed to the timely publication of all original, innovative contributions submitted for publication. as such, the identification and selection of reviewers who have expertise and interest in the topics appropriate to each manuscript are essential elements in ensuring a timely, productive peer review process. we would like to take this opportunity to thank all reviewers who participated in shaping this volume of the south african journal of communication disorders. we appreciate the time taken to perform your review(s) successfully. alida naude alta kritzinger anniah mupawose barbara heinze berna gerber bradley mcpherson caitlin wakefield christine rogers erika bostock gouwa dawood harsha kathard heidi allen hlologelo ramatsoma husmita ratanjee-vanmali jaishika seedat janet whitehouse jennifer watermeyer jenny pahl kathryn schie katijah khoza-shangase kerstin tonsing kim coutts lauraine giacovazzi leanie engelbrecht legini moodley maggi soer marguerite de jongh maureen o’meara melissa bortz mianda van zyl michelle pascoe monique visser mpilo booi nasim khan neethie joseph nola chambers nondumiso gina ntsako maluleke ondene van dulm rujeko chidawanyika sadna bolton selvarani moodley shabnam abdoola silva kuschke simone zevenster tarryn reddy tommie robinson vera hlayisi victor de andrade yvette hyter zenzo chakara http://www.sajcd.org.za� https://sajcd.org.za� https://sajcd.org.za� https://sajcd.org.za� https://sajcd.org.za/index.php/sajcd/user https://sajcd.org.za/index.php/sajcd/user mailto:publishing@aosis.co.za abstract introduction method results discussion recommendations acknowledgements references about the author(s) silva kuschke department of audiology, faculty of rehabilitation sciences, red cross war memorial children’s hospital cape town, western cape, south africa department of health and rehabilitation sciences faculty of communication sciences and disorders, university of cape town, cape town, south africa christine rogers department of health and rehabilitation sciences faculty of communication sciences and disorders, university of cape town, cape town, south africa estie meyer department of otorhinolaryngology, faculty of health sciences, university of cape town, cape town, south africa citation kuschke, s., rogers, c., & meyer, e. (2023). ten years’ experience with bone conduction hearing aids in the western cape, south africa. south african journal of communication disorders, 70(1), a940. https://doi.org/10.4102/sajcd.v70i1.940 clinical perspective ten years’ experience with bone conduction hearing aids in the western cape, south africa silva kuschke, christine rogers, estie meyer received: 13 july 2022; accepted: 09 nov. 2022; published: 27 jan. 2023 copyright: © 2023. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract untreated conductive and mixed hearing losses as a result of middle ear pathology or congenital ear malformations can lead to poor speech, language and academic outcomes in children. lack of access to centralised hearing healthcare in resource-constrained environments limits opportunities for children with hearing loss. red cross war memorial children’s hospital (rcwmch) is one of only two dedicated paediatric hospitals in sub-saharan africa. between 2016 and 2021, 29 children received implanted bone conduction hearing devices, and 104 children were fitted with bone conduction devices on softbands. the authors’ experience at rcwmch suggests that bone-anchored hearing devices, either fitted on softbands or on implanted abutments, can provide solutions in settings where patients have limited access to hearing healthcare and optimal classroom environments. hearing healthcare should be accessible and delivered at the appropriate level of care to mitigate the adverse effects of hearing loss in children. contribution: this article describes strategies employed at rcwmch such as fitting bone conduction hearing devices on a softband immediately after hearing loss diagnosis and conducting follow-up via remote technology to make hearing healthcare more accessible to vulnerable populations. keywords: bone conduction hearing aids; hearing loss; softband; abutment; accessible hearing healthcare. introduction preventable childhood hearing loss in lowto middle-income countries the world health organization (who, 2021) estimates that more than 60% of hearing loss in children under the age of 15 years is preventable, with this figure being substantially higher in lowto middle-income countries (lmics). the dramatic increase in preventable hearing loss in under-resourced countries may be attributed to limited access to resources such as vaccines, as well as a possible predisposition to infections such as otitis media and associated hearing loss (olusanya et al., 2019; who, 2021). the most common causes of childhood conductive hearing loss (chl) are related to infection or structural abnormalities of the outer and/or middle ear (kesser et al., 2013). otitis media occurs in approximately 50% of children under the age of one year and 60% of children under the age of two years (simon et al., 2018). although episodic acute cases of otitis media are common during childhood, recurrent otitis media can affect hearing throughout childhood, with the associated degree of chl generally correlating with the severity of the infection (jensen et al., 2013). the resultant hearing loss is often caused by persistent fluid in the middle ear cavity, tympanic membrane perforations or corrosion of the ossicular chain (hunter & choo, 2017). single-sided hearing loss is defined as unilateral hearing loss which is characterised by a severe-to-profound hearing loss in one ear (pure-tone average threshold ≥ 65 dbhl) and normal hearing (pure-tone average threshold < 30 dbhl) in the contralateral ear (who, 2021). children with single-sided hearing loss have difficulty with sound localisation, as well as understanding speech, especially with background noise. there are several causes for single-sided hearing loss in children, including idiopathic sudden sensorineural hearing loss, congenital cytomegalovirus, meningitis and head trauma (usami et al., 2017). management of childhood hearing loss in lowto middle-income countries the adverse effects of hearing loss, irrespective of its aetiology, on childhood development manifest as delays in speech and language development (gouma et al., 2011). furthermore, behavioural problems (such as attention deficits, failure to engage and respond during conversational discourse and a lack of interest in communication) could lead to social maladaptation and poor academic performance (gouma et al., 2011). internalised behavioural problems such as anxiety and depression have been reported in children with chl (bush, 2019). thus, the desire to manage hearing loss as early as practicable and as holistically as possible is essential, particularly in paediatric populations. certain syndromes, which are more likely to occur in lmics, may predispose children to conductive or mixed hearing loss (kesser et al., 2013). these syndromes include down syndrome, crouzon syndrome and goldenhar syndrome. congenital structural conditions of the pinna and outer ear such as atresia and microtia might prevent prescription of conventional behind-the-ear hearing aids. in addition, children with chronic otorrhoea are not candidates for air conduction hearing aids, and bone conduction devices may be a more suitable option. bone conduction hearing devices implantable bone conduction hearing devices were pioneered in the seventies (faber et al., 2015). bone conduction hearing aids are amplification devices that conduct sound to the cochlea through the transmission of vibrations from a sound processor to the mastoid (westerkull, 2018). the device bypasses the middle ear and is traditionally used in patients with chl who are unable to use air conduction hearing aids (liu et al., 2017). bone conduction hearing aids can transmit sound transcutaneously if the sound processor is anchored to the head by an external fabric headband (commonly referred to as a softband) or percutaneously if the sound processor is attached to a titanium fixture which is surgically implanted in the skull (mejia et al., 2015). in developed countries, bone conduction devices can be implanted in two stages in patients as young as four years (davids et al., 2007; humitz, 2016; westerkull, 2018). in lmics such as south africa, operating time is often limited, and theatre waiting lists are long, especially following the devastating impact of the coronavirus disease 2019 (covid-19) pandemic (klazura et al., 2022). therefore, permanent bone conduction implants are performed at eight years for typically developing children and at 10 years for syndromic children with thinner skull measurements. in the meantime, children continue to wear their bone conduction device on a softband to have access to sound. figure 1 shows a schematic representation of the abutment and device on the left and a softband worn by a child with a malformed pinna on the right. figure 1: percutaneous bone conduction device (a) and transcutaneous bone conduction device on a softband (b). current paediatric guidelines in the western cape province for the management of persistent conductive, mixed or single-sided hearing losses include medical or surgical treatment, as well as the use of bone conduction hearing devices. the next section of this article presents data from red cross war memorial children’s hospital (rcwmch) in the western cape province of south africa over six years, followed by recommendations for accessible service delivery in resource-constrained settings. method red cross war memorial children’s hospital is one of only two dedicated paediatric tertiary-level academic hospital in sub-saharan africa and serves as a central referral hospital for patients across the entire western cape who require specialised healthcare services. the audiology department at rcwmch provides diagnostic audiology and intervention services to children from birth to 13 years from the public healthcare sector. study design and sampling a retrospective review of clinical data, using an electronic departmental database, was conducted. purposive sampling was used by the primary investigator to identify children between 0 and 13 years, who were fitted with bone conduction hearing devices, either on a softband or implantable abutment, between january 2016 and december 2021. the departmental database was established in 2016; therefore, data were reviewed from 2016 to 2021 to include a wide lens of records. data collection and analysis participants were identified retrospectively using an electronic departmental database from which their demographic and clinical information was recorded. data were anonymised by assigning an alphanumeric code to each participant. all data were captured on an excel spreadsheet, using microsoft excel 2022 (microsoft corporation, redmond, washington, united states). the data were analysed using spss 27, version 27.0 (ibm corporation, armonk, new york, united states). descriptive analysis was used to report on the findings. ethical considerations this article followed all ethical standards for research without direct contact with human or animal subjects. results the retrospective departmental database review indicated that a total of 9215 children were seen by the audiology department at rcwmch during january 2016 and december 2021. of these, 498 children were fitted with amplification devices, of which 133 were bone conduction hearing devices on softbands (n = 104) and permanent implanted abutments (n = 29). table 1 details recipients of bone conduction devices. table 1: profile of patients fitted with implanted and softband bone conduction devices at red cross war memorial children’s hospital from 2016 to 2021. the majority of patients who received either implanted or softband bone conduction hearing devices during 2016 – 2021 presented with chl (53.4%; n = 71). nearly one-third of our sample (27.1%; n = 36) presented with single-sided hearing loss. it is notable that during 2020, when the covid-19 pandemic was at a peak globally, the number of bone conduction implants and devices issued on softbands decreased. the decrease was likely because of audiology outpatient services de-escalating and patients having restricted access to nonemergency healthcare services. discussion success in many areas of healthcare in lmics speaks directly to how accessible and patient-centred services are. for example, patients in lmics often travel great distances to access centralised hearing services (olusanya, 2015), and upon receiving them, they might struggle to return for regular follow-up. the audiology service at rcwmch has addressed these challenges in the following ways: patients are fitted with bone conduction devices on softbands prior to abutment implantation, and device usage (measured in average hours per day) is documented via data logging software in the device. patients who present with chl caused by tympanic membrane perforations or chronically leaking ears, and who are too young for surgical intervention, are fitted with bone conduction devices on a softband until they are old enough for surgery. the bone conduction processor fitted to a softband means that the device can be issued on the day of diagnosis. this rapid response speaks to the principles of primary healthcare in terms of accessibility and acceptability. functional hearing outcomes are measured by validated parent–teacher feedback questionnaires, such as the parents’ evaluation of aural/oral performance of children (peach) and the teachers’ evaluation of aural/oral performance of children (teach) (ching & hill, 2005; national deaf children’s society, [no date]). the peach and teach are measures of everyday functional auditory and communication performance and can be used to identify situations that could negatively impact a child’s regular amplification use (ching & hill, 2005). both questionnaires require the caregiver or teacher to observe and rate both the child’s listening and communication skills in quiet and noisy real-life situations and were designed for use for children of all ages (ching & hill, 2005). affordability is crucial in primary healthcare. in this instance, funding for 20 bone conduction hearing devices per annum was secured by the western cape provincial department of health in 2014, so that no end-user point of payment is necessary. the authors acknowledge that access to funding has greatly accelerated programme rollout and are grateful that the political will to provide such care is present in the region. wound care follow-up for patients who received permanent abutment implants is optionally facilitated by the use of technology. whatsapp pictures of abutment complications (such as skin infection around the implanted site) can be sent to the ear, nose and throat (ent) surgeon, who can refer the patient directly to the appropriate level of care (primary-level general practitioner). patients’ travelling distance to a centralised tertiary service can be reduced in this way, and infections that arise as a complication of the abutment surgery can be treated timeously. for patients who do not have access to a smartphone or mobile data, written information on wound care is given, and they are advised to come to the hospital immediately if any postoperative wound complications (such as skin redness or crusting) are observed. south african classrooms are often large and noisy, and resources such as fm systems and remedial support are not routinely available in many public schools. in order to facilitate inclusivity within the south african public education sector, bone conduction devices are offered to children with single-sided hearing loss, where the bone conduction device acts as a cross-router for better localisation. bone conduction devices are often issued for children with single-sided hearing loss based on teacher feedback of poor scholastic performance. functional listening progress (especially in noise) is measured by the teach questionnaire, as described earlier. such a strategy manages the often-overlooked issue of unilateral hearing loss, which has a negative impact on children’s social and academic advancement. recommendations the above description of a system to manage hearing healthcare in a resource-constrained environment has implications for planning and policy in similar settings in south africa and other sub-saharan african facilities. a review of the guidelines for medical and audiological treatment of conductive, mixed or single-sided hearing loss in children is necessary, especially when delayed speech development and poor scholastic performance are reported. acknowledgements we are grateful to all the referring practitioners in the western cape, as well as the audiologists at red cross war memorial children’s hospital who provide excellent hearing healthcare to the patients we serve. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions s.k. was responsible for the conceptualisation, project administration, data curation and writing the original the draft, the review and the editing thereof. c.r. and e.m. were supervisors of the study and contributed to the conceptualisation and the review and editing. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability data sharing is not applicable to this article, as no new data were created or analysed in this study. disclaimer the views expressed in the submitted article are his or her own and not an official position of the institution or funder. references bush, m.l. (2019). behavioral disorders in children with hearing loss. the hearing journal, 72(1), 34. https://doi.org/10.1097/01.hj.0000552753.74488.4e ching, t., & hill, m. (2005). parents’ evaluation of aural/oral performance of children (p.e.a.c.h.). australian hearing. retrieved from https://www.grapevineaudiology.com/wp-content/uploads/sites/84/2016/07/peach-questionnaire.pdf davids, t., gordon, k.a., clutton, d., & papsin, b.c. (2007). bone-anchored hearing aids in infants and children younger than 5 years. archives of otolaryngology – head & neck surgery, 133(1), 51–55. https://doi.org/10.1001/archotol.133.1.51 faber, h.t., nelissen, r.c., kramer, s.e., cremers, c.w., snik, a.f., & hol, m.k. (2015). boneanchored hearing implants in single-sided deafness patients: long-term use and satisfaction by gender. the laryngoscope, 125(12), 2790–2795. https://doi.org/10.1002/lary.25423 gouma, p., mallis, a., daniilidis, v., gouveris, h., armenakis, n., & naxakis, s. 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(2015). bone-conduction hearing aids: into the (near) future. the hearing journal, 68(8), 30–32. https://doi.org/10.1097/01.hj.0000470894.83693.cf national deaf children’s society. (no date). teachers’ evaluation of aural/oral performance of children and ease of listening (teach). retrieved from https://www.ndcs.org.uk/information-and-support/being-deaf-friendly/information-for-professionals/assessments-for-deaf-children-and-young-people/listening-skills/teachers-evaluation-of-auraloral-performance-of-children-and-ease-of-listening-teach/ olusanya, b.o. (2015). screening for neonatal deafness in resource-poor countries: challenges and solutions. research and reports in neonatology, 5, 51–64. https://doi.org/10.2147/rrn.s61862 olusanya, b.o., davis, a.c., & hoffman, h.j. (2019). hearing loss: rising prevalence and impact. bulletin of the world health organization, 97(10), 646–646a. https://doi.org/10.2471/blt.19.224683 simon, f., haggard, m., rosenfeld, r.m., jia, h., peer, s., calmels, m.n., couloigner, v., & teissier, n. (2018). international consensus (icon) on management of otitis media with effusion in children. european annals of otorhinolaryngology, head and neck diseases, 135(1), s55–s57. https://doi.org/10.1016/j.anorl.2017.11.009 usami, s.i., kitoh, r., moteki, h., nishio, s.y., kitano, t., kobayashi, m., shinagawa, j., yokota, y., sugiyama, k., & watanabe, k. (2017). etiology of single-sided deafness and asymmetrical hearing loss. acta oto-laryngologica, 137(s565), s2–s7. https://doi.org/10.1080/00016489.2017.1300321 westerkull, p. (2018). an adhesive bone conduction system, adhear: a new treatment option for conductive hearing losses. journal of hearing science, 8(2), 35–43. https://doi.org/10.17430/1003045 world health organization (who). (2021). world report on hearing: executive summary. licence: cc by-nc-sa 3.0 igo. abstract background methods findings and discussion conclusion acknowledgements references about the author(s) kim a. coutts department of speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa joanne neille department of speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa nicole louw department of speech pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation coutts, k.a., neille, j., & louw, n. (2022). feeding practices in public hospitals’ neonatal intensive care units: an exploration into the ways in which covid-19 affected the best practice in gauteng. south african journal of communication disorders, 69(2), a921. https://doi.org/10.4102/sajcd.v69i2.921 original research feeding practices in public hospitals’ neonatal intensive care units: an exploration into the ways in which covid-19 affected the best practice in gauteng kim a. coutts, joanne neille, nicole louw received: 01 feb. 2022; accepted: 27 mar. 2022; published: 22 july 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: south africa’s healthcare system has a multitude of pre-existing challenges prior to the onset of the coronavirus disease 2019 (covid-19) pandemic, ranging from reduced number of staff, lack of resources and units being at overcapacity both in the adult and paediatric populations. the neonatal intensive care units (nicus) require a team approach to ensure best practice with vulnerable infants, but little is known about how the onset of the covid-19 pandemic and the resultant lockdown restrictions impacted the feeding practices within the nicu. objectives: this study aimed to explore the impact that covid-19 had on the feeding practices within the nicu settings in public hospitals in gauteng. methods: a qualitative design was employed with data collected in two nicus in gauteng. data were collected in the form of observations and semi-structured interviews with healthcare workers (hcws) in the nicu. data were analysed using inductive thematic analysis. results: although the sample size of participants was limited, social distancing proved to be a challenge resulting in mothers and healthcare workers being given restricted access. this had effects on the ability to provide adequate feeding practices and resulted in anxiety for the mothers and mental health challenges for the hcws when feeding these at-risk infants. a limitation of this study was the use of only two sites. conclusion: covid-19 amplified the existing challenges in the nicu. a multidisciplinary and family-centred approach to address feeding challenges is required to offset the challenges resulting from the pandemic and subsequent lockdown. keywords: covid-19; feeding practices; nicu; speech-language pathologists; gauteng. background the coronavirus disease 2019 (covid-19) pandemic has had a significant impact on healthcare, service provision and the experiences of patients and their families across the globe (singh & singh, 2020). whilst research has emerged pertaining to the impact that the covid-19 pandemic has had on healthcare, education, financial security and society at large, little is known about the impact that the covid-19 pandemic has had on feeding practices within the neonatal intensive care unit (nicu). this article strives to explore the impact that the covid-19 pandemic has had on the implementation of best practice in terms of feeding practices within the nicu from the perspective of the multidisciplinary team (mdt). the first case of covid-19 in south africa (sa) was identified on 05 march 2020, with a national state of disaster being declared on 15 march 2020. on 26 march 2020, sa entered ‘alert level 5’, resulting in many social restrictions, including limiting numbers of people in any form of social gathering, the necessity for the wearing of masks, a restriction on public movement and limited access to public transport. whilst these measures were necessary to ensure slowing down the spread of the disease and allowing healthcare facilities an opportunity to prepare, they did magnify social inequality (naidu, 2020) and may have had a negative influence in the feeding practices, bonding and attachment of mothers and neonates born during this period. global health policies highlight the importance of the first 1000 days of a child’s life (world health organization [who], 2002). whilst this is true for all children, prematurity, birth complications, medical complications, feeding difficulties, challenges to bonding and attachment and admission to the nicu pose significant risks to development and to the establishment of adequate feeding skills, which are necessary to sustain growth and development (altimeter & philips, 2016). where an infant is admitted to the nicu, caregivers may require significant support from the developmental team to bond with their baby and in order to learn to read their communicative signs and signals, as well as to establish good feeding patterns. it is also vital that appropriate feeding practices based on international guidelines are developed and adhered to during this time (arumigum et al., 2015). south africa has an overall neonatal mortality rate of 21 per 1000 live births, with most of these being deaths attributed to pneumonia, diarrhoea and malnutrition (department of health, 2013). rhoda et al. (2018) suggested that some of these deaths may be preventable by ensuring that feeding guidelines, including breastfeeding and safe feeding methods, are explained and demonstrated to caregivers prior to discharge from the hospital. furthermore, local research suggests that infants return to medical facilities post-discharge with feeding difficulties, which can result in serious complications such as aspiration, poor weight gain and malnutrition (da costa et al., 2019). this highlights the need for a coordinated and comprehensive approach to screening, assessment and intervention. local studies support the need for screening tools to be used in the local nicus in order to identify at-risk infants (viviers, kritzinger, & vinck, 2016). given the complexity of cases and the nicu environment, it is vital to adopt a multidisciplinary approach to assessment and intervention, with caregivers at the centre of the team (barbosa, 2013; da costa et al., 2019). other team members include but are not limited to doctors, neonatal nurses and other developmental professionals including physiotherapists, occupational therapists, dieticians, social workers, psychologists and speech-language therapists (slts). each team member plays a critical role during the infant’s admission to the nicu; however, there is little research available on the unique role of each team member in establishing optimal feeding practices within the nicus in the south african public healthcare system (hardy, govender, & naidoo, 2021; lloyd & de witt, 2018) and how these roles may have been affected by the covid-19 pandemic. whilst the covid-19 pandemic necessitated social distancing and at times separation of patients, healthcare providers and family members, the who advises against the separation of a mother from her infant, with emphasis placed on the importance of rooming-in and the continuation of the mother providing care to her own newborn infant, which includes maintaining breastfeeding when the mother is able to do so (calil, krebs, & de carvalho, 2020). whilst research suggests that the chances of transmission of covid-19 through breastfeeding is minimal (ahmad et al., 2020; de miranda et al., 2020), the constant presence of mothers in nicus is not always possible because of social distancing restrictions. the impact that these restrictions had on infants and their caregivers is yet to be determined. given the limited research into the impact that the covid-19 pandemic has had on infant feeding practices in the nicu, this study aimed to explore the feeding practices in public sector hospital nicus in the gauteng province during the covid-19 pandemic. methods this article reports on research conducted within two nicus in tertiary level public hospitals in gauteng. an exploratory, descriptive design was employed underpinned by structured observations of the nicu and semi-structured interviews with the medical team working in the nicu. in addition, the admissions book was reviewed at both sites to determine the number of admissions relative to the number of nurses working in the nicu, medical diagnoses of infants admitted to the nicu and nature of prescribed feeds. participants all healthcare workers (hcws) at both sites were observed during the structured observations and were invited to take part in the interviews. in total, 23 hcws across both research sites agreed to participate in the semi-structured interviews. participants are detailed in the table 1. table 1: participants included in the study. inclusion criteria stipulated that participants needed to be working in the nicu and involved in the feeding of infants at the time of data collection. mothers were excluded from the study because of the nature of the research question and given ethical considerations regarding their vulnerability. data collection data were collected over a period of 12 days at site 1 and 5 days at site 2, at which point data saturation was reached. observations were initially performed and then 14 interviews were conducted at site 1 and eight at site 2, resulting in a total of 23 interviews. interviews were conducted in a private room or section in close proximity to the nicu, and the length of interviews ranged from 9 min to 38 min. two self-developed instruments were used as a guide for the structured observation and the semi-structured interviews. these instruments were created around the themes identified in the literature review and the aims set out for the study. the observational tool was performed following emerson, fretz and shaw’s (2011) guidelines on ethnographic observation. this process involved jotting down notes, building on these to provide elaborate descriptions, thematic analysis of what was observed and reflection on the researchers’ thoughts, feelings, responses and reactions to the observations. the researcher included observations of the following aspects in the tool as described in table 2. table 2: themes in the observation tool. the researcher constructed a diagram based on these observations that were conducted over a period of a few days. the interview schedule was based on internationally and locally recognised feeding policies (e.g. department of health, 2013; unicef/who, 2016; who, 2002) and guided by observations conducted at the two research sites. the nature of questions differed slightly when interviewing the diverse disciplines of professionals because their roles and responsibilities within the nicu all involved different aspects and the interviews maintained a semi-structured approach. themes for interviews included their description of the nicu and the admitted infants, the unit’s feeding policies and practices, their perceptions on the role of the team and specifically the slt and lastly, the impact of covid-19 on the unit and subsequent feeding of infants. rigour was ensured through a range of methods including conducting a pilot study prior to beginning data collection, ensuring a sustained presence in the nicu during data collection, triangulation of data collection methods, including a range of professionals in the participant sample and ensuring reliability of thematic analysis with each researcher conducting independent analyses of the observational notes and interview transcripts. no changes needed to be made to the tools based on the pilot study. observations took place throughout the day during the period of data collection, with a focus on feeding practices. by focusing on feeding times, it was possible to establish the feeding practices and routines surrounding feeding times and simultaneously identify the team members involved and their dynamics during lockdown restrictions. the diagrams were then completed and the data from the admissions book were recorded. individual interviews were carried out face to face and recorded, as this allowed the researcher to listen to all answers and information was provided repeatedly during the process of transcription and analysis. data obtained from the admission books were entered into a microsoft excel spreadsheet, which was stored on an acer laptop. analysis data were analysed using inductive thematic analysis (braun & clark, 2006). the transcribed interviews and information on the observational data collection sheets were analysed numerous times to identify the usable data under the codes, and themes were set out. most of the transcriptions were checked by the second and third authors to ensure reliability. ethical considerations ethical clearance was granted through the university of the witwatersrand medical ethics committee (clearance number: m200220), and from the chief executive officers and unit managers at the two sites. data collection, analysis and write-up of findings were performed in accordance with the standards stipulated in the declaration of helsinki (world medical association, 2008). individual consent was obtained from all participants and assent was obtained from the caregivers. findings and discussion the findings highlight the ways in which the covid-19 pandemic amplified existing challenges within the nicu. findings related specifically to the ways in which the pandemic impacted the nicu environment and the impact of lockdown restrictions on caregivers, staff and logistical arrangements. these themes and subthemes are detailed in table 3. table 3: themes and subthemes. the neonatal intensive care unit environment the setting during our presence in the nicu, the environment was observed to be busy and overstimulating. this was confirmed during the interviews where one nurse (participant 3) described it as: ‘loud, bright, overcrowded and busy’, and another nurse (participant 5) said, ‘it should definitely be quiet, more calm and lights down, and less noise, but it’s obviously not’. the nicus were often at overcapacity during the data collection period for both sites. research site 2 was 16% overcapacity at the time of data collection. as observed in the admission books during the observations, which indicated that the ward could take 49 infants, there were over 52 babies admitted. it was also observed during the observations and was confirmed in the interviews by two participants, a nurse (participant 7) and a slt (participant 11), who said ‘because of the influx (overload of infants admitted on a daily), it’s very difficult to follow in the daily routine especially having these very sick babies’ and ‘it is no longer safe, it is overcrowded most of the time. we no longer have a quality set-up that we used to before the overcrowding’ (participant 7). ‘it’s very busy, uhm, i think everybody works very hard. i think there is not enough staff for all the babies that need to be seen [to]’ (participant 8, dietician). this impacted the care that was given to the infants. feeding routines it was observed that both research sites followed a strict three-hourly feeding routine that started with daily care and monitoring activities. this was confirmed in the interviews by dieticians and nurses. a dietician (participant 8) mentioned, ‘all babies will be fed three-hourly’. care activities surrounding feeding times, was explained by a nurse (participant 1), ‘in that three-hourly routine we change nappies, we feed babies, we do observations, suction if necessary, carry out doctor’s orders and give treatment’. most other nurses at both sites also mentioned that they do suctioning and check aspirates before every feeding time commences, which is recommended as a feeding tolerance assessment (yin et al., 2015). feeding policies it was observed during the observations that both research sites had a feeding policy on the wall and that the baby friendly initiative (bfi) was followed. however, during the interviews, the hcws had varying views on feeding policies despite the doctors having a protocol book with the various policies and procedures that were developed by the mdt. these views specifically influenced the transitioning from enteral to oral feeding in terms of when to start and then what to start feeding infants. this was because only 22% of the participants agreed that babies should start breastfeeding prior to discharge. feeding methods and practices regarding the methods of feeding, 40% of infants were fed non-orally during the period of data collection, with the majority of infants at both sites being tube-fed. this was based on the 52 infants observed at the time. these included orogastric and nasogastric tubes. additional feeding methods included syringe feeding, bottle feeding and intravenous drips. the majority of infants who were fed orally appeared to be fed mixed feeds, consisting of a combination of breast milk and formula feeds, followed by breast milk only, formula milk only and donated breast milk. as a result of the nature of the covid-19 restrictions, the units were understaffed and at overcapacity during data collection. this resulted in babies being frequently moved around and being discharged, so it was challenging for the researcher to get specific feeding information for each baby based on the observations alone. whilst, for most hcws, the goal was to transition infants who were being fed non-orally onto oral feeds, the restrictions imposed by lockdown regulations, together with reduced capacity and time restrictions, served as the barriers. as a result of social distancing regulations, caregivers were allowed into the nicu on a rotational basis, resulting in feeding becoming the primary responsibility of the nurses as mothers were unavailable. the nurses were observed to have developed feeding methods where they could feed more than one infant at a time because of staff shortages and the units often suffering from overcapacity. each nurse was responsible for feeding up to 10–15 babies per mealtime as observed during the observations. these feeding strategies involved hanging syringes from drip stands and holding two babies simultaneously as seen during the observations. the long-term impact of these restrictions may have had a negative impact on caregivers being able to exclusively breastfeed, given that the babies were discharged on alternative feeding methods including syringe, cup and bottle feeds. babies who were being transitioned onto oral feeds were done so primarily using cup feeding, thus following the bfi as confirmed in the interviews and observations. some babies were being syringe fed and that was because of resource restrictions. if the mother was present, breastfeeding was encouraged. the impact of lockdown restrictions on practices within the neonatal intensive care unit social distancing in the unit the nicu has always been a setting that follows strict hygiene protocols because of the vulnerability of the infants (naylor et al., 2020), but as a result of covid-19 the implementation of distancing between the beds presented a significant challenge. as a result of overcapacity, the recommended 2–3 m distancing between beds could not always be adhered to. figure 1 and figure 2 depict the layout of the nicus in the two different sites. figure 1: research site 1 layout. figure 2: layout of site 2. it is evident from these two diagrams that space is limited within these units, and the implementation of social distancing requirements in a unit that is already at overcapacity presented as a significant challenge. the need for social distancing within the unit also reduced the presence of caregivers and limited staffing capacity. this subsequently impacted the care provided to these infants, especially in terms of how they were being fed. these findings were echoed in a study by mahoney et al. (2020), who stated that the limitations of parents being involved in the nicu had subsequent impact on the hcws and the discharge outcomes of these infants. this is problematic because discharged infants would then return to these units for more complications that perhaps could have been avoided. in sa, where the units are already at overcapacity, this needs to be avoided. the effect of covid-19 on breastfeeding research during the pandemic indicated that mothers who tested positive for covid-19 are still encouraged to breastfeed (calil et al., 2020). however, as mothers were not allowed into the nicus where the study was conducted during the harder lockdowns, their breastmilk needed to be expressed so that it could be given to their infants using alternate methods, such as syringe feeding. this was observed during the interviews, where a doctor (participant 13) said, ‘the mothers will come in to bring in expressed milk. a covid-19 positive mom, we still allow breast milk to be dropped’. furthermore, a slt (participant 11) observed: ‘moms were so involved in every part of our therapy, and coming from having moms one day to having practically no moms – only moms that could express and then leave their milk, or moms that eventually when they were lodging were allowed to be here.’ mothers were not allowed into the nicus for prolonged periods of time, and many experienced difficulties in accessing the hospital in order to deliver breastmilk because of financial and transport difficulties. it was observed on some occasions that doctors even went to mother’s house to collect the milk, as evidenced where a doctor (participant 12) said, ‘we had doctors driving from their houses to fetch milk during covid-19’. by doing so, this placed further pressure on the already overwhelmed medical staff in the overall management of these infants. family involvement pre-covid-19, both parents and grandparents were allowed into the nicu (mckechnie et al., 2020); however, this changed rapidly at the start of the pandemic. the different sites had varying protocols on who was allowed into the nicu through visiting hours during lockdown. research site 1 allowed mothers who were breastfeeding their child, but research site 2 allowed all mothers during visiting hours. no other family members, including fathers, were allowed into the nicu at both sites. during an already stressful period, the lack of support for the mothers from their family created further anxiety as described by one of the occupational therapists (participant 20): ‘the moms are not having the support, i would say. uhm, because they obviously have to come in but then the dads are not allowed in the hospital grounds at all.’ this was a new finding and requires reflection on how to manage this when moving forward in the pandemic. this lack of family involvement affected not only the medical staff but also had a direct impact on the family as well. these feelings were shared by parents of infants in the nicu in both the netherlands (meesters et al., 2021) and in the united states (vance et al., 2021). both these studies found that the parents were upset with the decision that the healthcare systems made and that parents needed to be consulted as part of this process. based on the findings from the study by meesters et al. (2020) and vance et al. (2021), a more family-centred approach is required when making important decisions that affect the care of vulnerable infants and their families. effect of the covid-19 pandemic on healthcare workers during lockdown, hcws were put onto rotations to reduce the number of people present to decrease transmission rates (mahoney et al., 2020). this was observed in the two research sites. this approach placed pressure on the present hcws to treat all infants in a unit that was already at overcapacity, as suggested when a dietician (participant 8) said, ‘in the first wave we had a lot of (covid-19) positive nurses, and it affected the feeding of the babies and stuff a lot’. furthermore, when a staff member tested positive, the whole team was required to quarantine, which affected access to services as revealed when a slt (participant 21) said: ‘for us specifically as a department, we had a positive covid-19 case with one of our audiologists, and so our whole department was shut down for 3 days. as a result there was no one in such a small department to see any of our babies in the nicu.’ this situation resulted in new and often undertrained staff working in highly specialised settings, which affected infant care and hcw performance. the impact of the pandemic also had a significant impact on staff mental health and performance. this was evident where a doctor (participant 17) stated, ‘the staff are burnt out and exhausted. and when you are exhausted and burnt out your productivity and functional levels are not as good as, you know, you would’ and where a nurse said: ‘so, we were only three on duty on that day and there were with only two, uhm, what can i say, sessional. imagine the cubicle with only one nurse and only one assistant in the cubicle.’ ‘i was extremely exhausted; my energy level was very low.’ in addition, a slt (participant 21) commented: ‘i think the nurses became a lot more stressed and stretched. i think their whole routines were thrown out the window.’ the ways in which the pandemic affected service delivery in the nicu highlights the need for reflection and planning for both the immediate future and long-term in order to ensure that staff mental health is maintained whilst not compromising on service delivery. these findings are supported in other local and international studies (mahwasane et al., 2020; pieterse, 2017). a study set in sa specifically highlighted the negative impact of lockdown restrictions had on slts and their inability to sufficiently manage patients, especially at an outpatient level in both the private and public sector (adams, seedat, coutts, & kater, 2021). from this study, the inability to train parents adequately on feeding practices prior to discharge is a significant problem. an inability to train caregivers could result in infants returning to the hospital with other complications (assad et al., 2016). the information that is required by the family prior to discharge is often missed because hcws are overworked and are unable to visit the family as often as not. carry-over of information our findings suggest that training on feeding that was performed by various hcws within the nicu with both parents and nurses was commonplace during pre-covid-19. the training was performed by multiple members of the mdt. however, with the lockdown restrictions, these services were interrupted as observed in the interviews. a slt (participant 11) stated, ‘we also provide training to the nurses. uhm, it had to stop during covid-19’, whilst a physiotherapist (participant 9) added: ‘obviously we have a role in nurses’ education and obviously with parent education – so parent education came to a halt with covid-19 and even now we need to be careful of groups.’ the inability to provide the individual treatment plan to the parents and to provide the ongoing guidance and support that parents needed during the nicu stay was a significant finding. a physiotherapist (participant 9) explained: ‘i think we have missed having the mothers, because if you have a more sort of a long-term baby, we would rely on the mom to carry over what we have been doing. it not only affects the treatment here but the fact that i don’t have a mom to give input to means that when she goes home or when this baby goes home, so she will then just come and get her baby in order to go home. and so she hasn’t had those two or three bits of input. part of early intervention is actually connecting with the moms. so when covid-19 hit and the moms were no longer coming in, i would say yes, our practice changed a lot.’ this finding is important and can have lasting effects for when the infant is discharged. the impact of hcws not being able to have consistent contact with the family resulted in more post-discharge complications as seen by meesters et al. (2020). a long-term study on the impact of covid-19 on infants during this time in sa is perhaps warranted. these findings suggest that existing challenges in the nicu prior to the covid-19 pandemic were mostly related to the units being at overcapacity, understaffing of hcws in the unit and limited resources as reflected in figure 3. figure 3: feeding challenges within the neonatal intensive care unit prior to covid-19. these ongoing challenges as depicted in figure 3 were amplified during the pandemic. there were also new challenges found, such as the impact that new policies had on hcws and families. this study further supports the notion that feeding is a complex and multifaceted process that, despite lockdown restrictions, requires mdt input within a family-centred approach to ensure ongoing support and reduced complications (green et al., 2021; pike et al., 2016; younesian, yadegari, & soleimani, 2015). in the case where restrictions limit the number of hcws present, the need for relying on other hcws becomes important to assist in certain areas in terms of method of feeding. this suggests the need for considering a revision on practice patterns, such as a transdisciplinary approach, is required to offset these challenges in the nicu. this type of approach has been suggested in adult dysphagia cases in a variety of settings to offset certain resource challenges (coutts, 2021). the types of feeds that infants are receiving, whether it be formula or mixed feeds, was because of the decreased presence of mothers and the transport challenges that they experienced in needing to get their expressed milk to the hospital. this could lead to intolerances if mothers wanted to change types of feeds at home (assad et al., 2016). this is a potential challenge that can lead to infants returning post discharge for more care. in the sa setting, this needs to be avoided. overall, family members should be involved more consistently, despite the level of lockdown restrictions, and should be supported throughout the process. this can assist with reducing the load on hcws, reduce parental anxiety and possibly reduce the number of infants that might return with complications. conclusion this study proved that covid-19 had a significant negative influence on the already burdensome public healthcare sector in sa. it confirmed that nicus are at overcapacity and the shortage of hcws influenced staff’s mental health and the subsequent care provided in terms of feeding to both the infants and their parents. prior to covid-19, support to mothers was already a challenge due to limited staff and wards being at their maximum capacity, and the covid-19 merely exacerbated these challenges, which created potential complications when infants were being discharged. these environments need an increase in hcws to provide the services needed by the number of infants in this setting, when it comes to adequate feeding practices of these at-risk infants. with more dedicated hcws within the nicu, the feeding development of infants can be supported optimally. infants can also be guided safely to discharge successfully, even during lockdown restrictions. another possible solution and research recommendation would be to implement a more transdisciplinary approach to the management of feeding with the nicus during these circumstances, and how to better utilise mothers within the nicu environment to assist with feeding. further investigation on the longer effects that covid-19 has had on this setting, the hcws, infants and families is also required. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions k.a.c. and j.n. contributed to conceptualisation, formal analysis and writing the original draft supervising the study. j.n. also contributed to the writing in reviewing and editing. n.l. contributed to the formal analysis and investigation. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study can by made available by the corresponding author, k.a.c., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references adams, s., seedat, j., coutts, k., & kater, k. 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(2015). impact of oral sensory motor stimulation on feeding performance, length of hospital stay, and weight gain of preterm infants in nicu. iranian red crescent medical journal, 17(7), e13515. impact of the telephone assistive device (tad) on stuttering severity while speaking on the telephone impact of the telephone assistive device (tad) on stuttering severity while speaking on the telephone nola chambers university of the witwatersrand abstract there is extensive experimental evidence that altered auditory feedback (aaf) can have a clinically significant effect on the severity of speech symptoms in people who stutter. however, there is less evidence regarding whether these experimental effects can be observed in naturalistic everyday settings particularly when using the telephone. this study aimed to investigate the effectiveness of the tele­ phone assistive device® (tad), which is designed to provide aaf on the telephone to people who stutter, on reducing stuttering severity. nine adults participated in a quasi-experimental study. stuttering severity was measured first without and then with the device in partici­ pants’ naturalistic settings while making and receiving telephone calls (immediate benefit). participants were then allowed a week of repeated use of the device following which all measurements were repeated (delayed benefit). overall, results revealed significant im­ mediate benefits from the tad in all call conditions. delayed benefits in received and total calls were also significant. there was sub­ stantial individual variability in response to the tad but none of the demographic or speech-related factors measured in the study were found to significantly impact the benefit (immediate or delayed) derived from the tad. results have implications for clinical decision making for adults who stutter. key words: altered auditory feedback (aaf), telephone use, adults who stutter, telephone assistive device (tad) a ltered auditory feedback (aaf) is an umbrella term used to refer to manipulations of auditory feedback in the form of frequency (frequency altered feedback or faf) or timing (delayed auditory feedback or daf). both types of aaf have been shown to produce immediate reductions in stuttering for a majority of adults who stutter in experimental settings, par­ ticularly in oral reading (kalinowski, armson, mieszkowski, stuart & gracco, 1993; kalinowski, stuart, sark & armson, 1996; macleod, kalinowski, stuart & armson, 1995; sparks, grant, millay, walker-baston & hynan, 2002; stuart, kalinowski & rastatter, 1997), and to a lesser extent, in monologues (antipova, purdy, blakely &j williams, 2008) and scripted conver­ sations (armson, kiefte, mason & decroos, 2006; pollard, ellis, finan & ramig, 2009). ! the exact mechanism of how aaf reduces stuttering is not well understood. however, the general consensus is that aaf repro­ duces the choral effect, where adults who stutter tend to show immediate and dramatic reductions in stuttering when speaking chorally, or in unison with another speaker (kiefte & armson, 2008). theories differ regarding the mechanisms underlying both the choral speech effect, and by extension, aaf. early theories attributed the positive effects of choral speech and aaf to changes in the motor production of speech (wingate, 1969; 1970) such as more active control of vocalization, reduced rate of speech, and changes in vocal intensity. recent studies, how­ ever, have suggested that this motor hypothesis is over-simplistic and does not account for benefits derived under conditions of aaf even at rapid speech rates (kalinowski et al., 1993, 1996; mcleod et al., 1995; sparks et al., 2002). more recent theories have attributed the effects of aaf to reducing auditory perceptual anomalies in those who stutter, particularly related to anatomical anomalies of the auditory temporal cortex (i.e., atypical rightward asymmetry of the planum temporale (pt); foundas et al., 2004). based on their physiological findings, foundas and colleagues have proposed two subgroups within the stuttering population, those with typical (leftward) pt asymmetry, which they consider adaptive and therefore may respond to motor speech techniques alone, and those with atypical (rightward) pt asymmetry, which is a significant risk factor for developmental stuttering, which may be more responsive to treatment via aaf as demonstrated in their study. all studies conducted to date with aaf have found significant individual variation in the benefits derived from aaf. however, it is not clear what factors contribute to this variation. one impor­ tant potential factor is that of severity of stuttering. it is not yet clear what factors underlie the ultimate severity of stuttering in individuals who stutter, but these factors are no doubt varied and consist of a complex interaction between biological, emotional, and environmental variables. given this complexity, researchers correspondence to: dr nola chambers department of speech pathology and audiology university of the witwatersrand johannesburg south africa email: nola.chambers@wits.ac.za the south african journal of communication disorders, vol 56, 2009 23 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:nola.chambers@wits.ac.za have employed various measures of severity, which may include more or fewer of these variables in quantifying severity. percent­ age syllables stuttered (%ss) is frequently used as it simply quan­ tifies the behavioural severity of stuttering. behavioural studies investigating the relationship between aaf and stuttering severity have found conflicting findings. sparks et al. (2002) demon­ strated greater improvements in fluency under daf in people with severe versus mild presentations of stuttering when reading at both normal and fast speech rates. in contrast, armson et al. (2006) found greater benefits from aaf in formulated speech (i.e., not reading) in adults with mild stuttering compared to those with more severe stuttering at baseline. foundas et al. (2004) found that in their stuttering group, only those with atypical pt asymmetry demonstrated significant reduc­ tions in stuttering severity under conditions of daf and that these participants were also the ones with the most severe presenta­ tions of stuttering at baseline. this finding could suggest that the atypical pt asymmetry is directly responsible for both the initial severity of stuttering as well as the ability of daf to induce flu­ ency. the authors acknowledge that it is also possible that the difference between pt asymmetry groups is evidence of a ceiling effect in the ability of daf to induce fluency (i.e., that daf simply can improve severe stuttering more than mild stuttering). a sec­ ond factor that is related to stuttering severity, that could affect an individual’s response to aaf, may be the type of stuttering symptoms a person presents with. for instance, it is possible that those whose stuttering is characterised predominantly by silent blocks may derive less benefit from a device that can only alter feedback from an audible source. in addition, related to the dis­ cussion above, silent blocks tend to be associated with more severe presentations of stuttering and the length of blocks is directly factored into severity calculations of clinical measures of severity such as the stuttering severity instrument 3 (ssi-3; riley, 1994). no studies appear to have examined this potential variable. a third factor affecting one's response to aaf may be the de­ gree of language proficiency or language familiarity in multilingual speakers. a clear language familiarity effect in fluent biand mul­ tilingual speakers under daf has been demonstrated (van borsel, sunaert & engelen, 2005) with participants demonstrat­ ing significantly slower speech rate and more speech disruptions when reading their less familiar languages under daf. van borsel and colleagues relate this finding to increased reliance on audi­ tory feedback when reading in less familiar languages. hence, if the auditory feedback system is disrupted under conditions of daf, greater disfluencies result. the authors go on to hypothesise that the corollary may be true in adults who stutter, that is, that daf may be most beneficial for adults who stutter in their less nola chambers familiar language where problems in auditory feedback may be most pronounced. it is possible that daf might assist in normalis­ ing the auditory feedback system, thus reducing stuttering sever­ ity more in less familiar languages in those who stutter. it is im­ portant to note that language proficiency in bilingual adults who stutter is not independent from stuttering severity, with severity often reported to increase in less familiar languages (jankelowits & bortz, 1996; watt, 2000). the potentially beneficial effects of aaf on speakers’ less familiar language is intriguing to consider in south africa where many clients are treated in their second or third languages. there appears to be no literature to this author’s knowledge regarding responses to aaf in multilingual speakers who stutter. in their seminal review of the literature regarding the impact of aaf on stuttering severity, lincoln and colleagues (2006) stated that more research regarding the impact of aaf devices in natu­ ralistic, as opposed to experimental settings was essential for the field. in addition, armson et al. (2006) have suggested that it is important to examine the effects of aaf, not only in naturalistic settings, but also using commercially available devices as specific devices may not have the capabilities of devices that are used in experimental studies. one naturalistic speaking context which many adults who stutter report to be extremely stress-provoking is the use of the telephone. james, brumfitt and cudd (1999) sampled the perceptions of 223 adults who stuttered regarding telephone use and found that the majority of their sam ple're­ ported particular difficulty using the telephone. their results suggested that an inability to use the telephone effectively, constituted considerable restrictions in daily life activi­ ties for adults who stutter, restricting participation in both social and career-related activities. interestingly, those participants with self-reported severe stuttering found telephone use to be more difficult than those with mild stuttering. it is important to consider reasons why the telephone presents such challenges to people who stutter. james et al. (1999) found that the most frequently cited reason for difficulty speaking on the telephone as opposed to “face-to-face” conversations was the total reliance on speech to convey information, leading to an actual or perceived pressure to speak fluently and keep the con­ versation going. the inability to use nonverbal communication both to assist in conveying messages and gauging listener’s re­ sponses, was also reported as being problematic and was re­ ported to result in telephone partners being less understanding than face-to-face conversational partners. finally, the fact that telephone conversations frequently required introductions and/or the exchange of specific information was also cited as a particu­ lar source of difficulty for respondents. there are only a few studies to date that have addressed the 24 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) impact of the telephone assistive device (tad) on stuttering severity while speaking on the telephone potential therapeutic effects of aaf when speaking on the tele­ phone and these have all been conducted using commercially available devices. the earliest documented study was conducted by zimmerman, kalinowski, stuart and rastatter (1997). their study examined the effect of aaf during scripted, 300 syllable telephone conversations to various local businesses by nine participants. aaf with a 50milli-second (ms) delay and half octave downward shift was provided by the commercially avail­ able casa futura fluency system, and was presented binaurally via a headset. the results showed a remarkable decrease in stut­ tering, on average 55% under faf and 60% under daf. some participants reached near-zero stuttering frequency. the scripted nature of the telephone calls and the fact that telephone calls were made from a laboratory detract from the naturalistic condi­ tions under which telephone calls are typically made and may have enhanced the reductions of stuttering severity. a second study that included the use of an aaf device in a more naturalistic or therapeutic manner was conducted by van borsel, reunes, and van den bergh (2003). in that study, nine adults were exposed to aaf in a variety of speaking situations also using the portable casa futura school daf device for three months. included in this exposure, the participants were required to use the telephone to make two telephone calls, one to another participant and one to a stranger in response to a newspaper advertisement, and to receive four telephone calls a month from the researchers who enquired about compliance. several of the participants reported that using the device had reduced their fear of speaking on the phone and this had lead to its more frequent use. however, objective data relating to stuttering severity while talking on the telephone was not collected. j h e authors noted that in other speaking conditions, specifically /"automatic speech, conversation, picture description and repeat­ ing, stuttering in the non-feedback conditions had markedly re­ duced following the three months of repeated exposure to aaf, suggesting carryover of benefit from exposure to aaf to speech without aaf. it is unknown if a similar carryover effect may occur with telephone calls. o’donnell, armson and keifte (2008) recently investigated the effectiveness of the in-the-ear speecheasy device on stuttering severity in situations of daily living, including the telephone. seven participants took part in the study which included assess­ ments incorporating laboratory and naturalistic measures of stut­ tering severity, both before and after 9-16 weeks of repeated exposure to the speecheasy in everyday situations. for the tele­ phone conversations, weekly calls were made to the participants by one of the authors, who became familiar to the participants over the course of the study, as well as by unfamiliar research assistants. thus all calls recorded and analysed were received by the par­ ticipants. results indicated that all seven participants demon­ strated reductions in percentage syllables stuttered (%ss) when speaking on the telephone with the device, with individual mean reductions ranging from 20% to 94.4% when speaking to the experimenter (group mean 64.5%; sd = 22.9), and 7.5% to 74.4% when speaking to the unfamiliar research assistants (group mean 55.1%; sd = 22.3). finally, bray and james (2009) recently published preliminary data on 5 participants who used the telephone assistive device (tad), the device investigated in the current study, in naturalistic telephone conversations. descriptive data suggested a decreas­ ing trend in %ss between naturalistic phone calls made without the device and phone calls made with the device, although the responses were highly variable among participants. in addition, more positive feelings related to using the telephone were re­ ported by most participants, even when limited benefit in terms of reductions of stuttering frequency was noted. it is important to note that no attempt was made to assess the effect of repeated practice making telephone calls versus the effect of the device itself on stuttering severity. however, the results of this study provide preliminary data to warrant further research with the tad. this study aimed to investigate the effects of the va609 tad developed by a south african company known as voiceamp®. the tad incorporates the already existing technological architec­ ture of the va601i fluency system, which is a portable unit that provides monaural or binaural aaf to people who stutter. this existing technology has been housed in a unique unit that con­ nects to the telephone and delivers aaf monaurally through the telephone handset. this new platform has a variety of additional capabilities to the va601i portable system, such as a word prompting feature that is designed to assist those who present with severe blocks on initial sounds to initiate voicing when speaking on the telephone. the overall aim of the study reported here, was to assess the effec­ tiveness of the tad in a sample of adults who stutter when talk­ ing on the telephone in their natural environments. this aim was operationalised into the following objectives to determine: (1) the immediate and delayed benefit from the tad following a week of repeated use (as well as the relationship between this delayed benefit and the amount of time spent using the device during that week); (2) the difference, if any, in the benefit derived from the tad between making telephone calls versus receiving telephone calls; (3) the carryover of benefit, if any, from using the tad to telephone calls without using the tad; (4) the impact of initial speech variables (stuttering severity and type of symptoms) and demographic variables (first versus second language use and self-reported restrictions in telephone use prior to the study) on the immediate and delayed benefit derived from the tad and, (5) the participants’ perceptions of the tad following a week’s re­ peated use of the device. the south african journal of communication disorders, vol 56, 2009 25 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) nola chambers method design a quasi-experimental design was used for this study. all partici­ pants were assessed both without and then with the tad while making and receiving telephone calls before and after one week’s repeated use of the tad in their natural environments. there was hence no control group and all participants took part in all parts of the study. participants nine participants were recruited from the pietermaritzburg (pmb) and surrounding areas of kwa-zulu natal (kzn). inclusion criteria included the presence of developmental stuttering as determined by clinical interview and speech evaluation, no hear­ ing difficulties by self-report, and access to a land-line on a regu­ lar, if not daily, basis. there were no exclusionary criteria based on gender, age, severity of stuttering, number of languages spo­ ken, history of speech therapy, or previous exposure to aaf de­ vices. this inclusive approach to participant recruitment resulted in a highly diverse participant pool, which is helpful when at­ tempting to identify relationships between variables (such as language spoken on the telephone and benefit derived) but also reduces experimental control over extraneous variables. three participants who took part in the study were receiving therapy. the majority of participants were not receiving therapy and were ultimately recruited via a newspaper advertisement with distributable 1. demographic characteristics of participants participant age (years) gender lan­ guage used ethnicity education occupation recruitment source 1 28 male second zulu grade 12 hospital orderly therapist 2 41 male first indian mba marketing man­ ager word of mouth 3 25 female first indian computer di­ ploma admin clerk advertise­ ment 4 34 male first indian bsc engineerengineer therapist 5 24 male second zulu student student therapist 6 46 male first indian grade 9 rural tuck shop manager advertise­ ment 7 26 male first indian grade 12 machine opera­ tor advertise­ ment 8 21 male first white student student advertise­ ment 9 24 male first indian bcom it it assistant advertise­ ment 26 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 liuii local to pmb (n=6). one other participant was recruited by word of mouth. ten participants volunteered to take part in the study; however, one was ultimately excluded on the basis of hav­ ing additional communication problems associated with cerebral palsy and developmental delays. as a result of these concomitant difficulties, his data proved to be very difficult to score reliably and were therefore excluded from the analyses. the fact that hearing could not be objectively screened is considered a limita­ tion of the study. the general demographic characteristics of the nine partici­ pants are presented in table 1 while stuttering characteristics and information related to therapy history and telephone use are presented in table 2. the mean age of participants was 29.89 years (sd = 8.59), with a range from 21 to 46 years of age. a wide range of educational levels was represented among the participants, from those without high school qualifications (p6) through to those with post-graduate degrees (p2). a range of oc­ cupations was reported, though it must be noted that occupa­ tions for some participants were severely constrained by their stuttering and did not reflect their educational ability or potential. two participants (p3 and p7), both had the capacity and financial opportunity to attend university, but chose not to and were report­ edly not in their preferred occupations. two participants spoke english as a second language. r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) impact of the telephone assistive device (tad) on stuttering severity while speaking on the telephone table 2. stuttering characteristics of participants participant ssi* ssi severity predominant speech symptoms therapy history telephone use 1 38 very severe sound, syllable and word repetitions current, none as child social and voca­ tional 2 19 mild syllable and word repetitions, interjec­ tions brief as child social and voca­ tional 3 45 very severe silent blocks, interjections brief as child family only 4 16 very mild sound, word and phrase repetitions brief as child social and voca­ tional 5 23 mild sound, syllable and word repetitions, prolongations current, none as child social and voca­ tional 6 20 mild sound, syllable and word repetitions, interjections brief as child social and voca­ tional 7 39 very severe silent blocks, interjections brief as child social only 8 10 very mild word repetitions, interjections brief as child social only 9 42 very severe audible blocks, sound repetitions brief as child some social, vo­ cational a stuttering severity instrument-3 (riley, 1994) total score it is clear from the data in table 2 that the severity of stuttering, as measured by the ssi-3 (riley, 1994), was bimodally distrib­ uted, with five participants presenting with mild to very mild stut­ tering in conversational speech and reading and four presenting with very severe stuttering. only two participants were currently receiving therapy, and this was reported to be of brief duration, approximately 3-4 months prior to the start of the study. one of these (p5) had previous exposure to -aaf via the voiceamp va601i portable device. no others were receiving therapy at the time of the study, despite frequent severe presentations of stut­ tering. most reported having received therapy as children, but few reported any positive gains from this therapy and they were un­ able to describe the nature [of the intervention received. based on self-report, thejparticipants could be categorised into those who demonstrated little to no restrictions in telephone use, defined as using the telephone in all aspects of their lives, includ­ ing social and vocational spheres (n=5) and those that reported severe restrictions in telephone use that were long-standing (i.e., for at least the previous ten years; n=4). these participants re­ ported only using the telephone to call friends, or in an even more restricted fashion, only family (p3). they also reported never an­ swering the phone unless they knew the caller, and never making enquiry calls to strangers. the level of restriction in telephone use did not always correspond with stuttering severity in that one adult with mild stuttering fell into the severe restriction category, while one adult with severe stuttering fell into the no restriction category. the significant restrictions participants placed on their own telephone use also had implications for the procedures of this study, as these participants would not have been able to i make any ‘cold’ enquiry calls for the purpose of the study as in the zimmerman et al. (1997) study. all calls made during the study needed to therefore be individualised to each participant’s comfort level and typical pattern of usage. apparatus and setting the apparatus used was the va609 tad as this is the device most accessible to the south african population. there is also only one previous, preliminary study documenting its potential effectiveness with adults who stutter (bray & james, 2009). the tad is a unique device that connects directly to the telephone handset, where the handset microphone receives the user’s voice signal. once altered by the device, the signal is delivered monau rally through the earpiece of the handset to the user. the feed­ back is not heard by the telephone conversational partners. in addition, the voices of the telephone partners are not altered in any way. during the telephone tasks, the default settings of 56ms delay and 304hz upward frequency shift characteristic of pro­ gramme 1 were used in order to assess the effectiveness of the device’s standard settings. if participants expressed dissatisfac­ tion with these settings, they were also exposed to programme 2, characterised by a 90ms delay and 530hz upward frequency shift. all participants chose to use programme 1. procedures took place in the participants’ natural environments. table 3 lists the venues for data collection for each participant. four participants chose to collect data primarily at their places of work, five at home, and one at his university, where he was a residential stu­ dent. venues for data collection were chosen by the participants based on where their most frequent telephone use occurred, permission from employers, and where they had access to a land line, which was necessary for tad connection. all calls were videoed for further analyses using measures described below. the south african journal of communication disorders, vol 56, 2009 27 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) nola chambers measures three measures were used in this study: i. stuttering severity instrument-3 (ssi-3; riley, 1994). the ssi-3 is a clinical measure used to quantify and characterise stuttering se­ verity of each participant at the start of the study. the ssi-3 em­ ploys analysis of both a conversational speech sample of at least 300 syllables and a reading passage. stuttering severity was calcu­ lated using the composite measures of percentage syllables stut­ tered (%ss), average duration of the three longest blocks, and physical concomitants according to the standard scoring proce­ dures of the ssi-3. //. percentage syllables stuttered (%ss). commensurate with previous studies of aaf devices, the primary dependent variable used to quantify stuttering during the telephone tasks and to calculate the benefit derived from the tad was %ss. this meas­ ure has value as it provides a clear metric for comparison to pre­ vious studies. however, it must be noted that it is limited to quan­ tifying the frequency of stutters and has no value in quantifying other aspects of severity such as type of symptom, length of blocks, which is captured by measures such as the ssi. all speech samples from the telephone calls were transcribed for analysis. stuttered syllables were defined as silent blocks, sound, sylla­ ble or word repetitions, prolongations or interjections (armson et al., 2006). if more than one type of dysfluency occurred on a syllable (e.g., interjection + block + sound repetition at the begin­ ning of a word), this was counted as one stuttered moment. the number of syllables in the intended message was calculated and %ss was calculated individually for made and received calls. a total %ss was calculated to hi. participant log and questionnaire. a participant log sheet and questionnaire was developed specifically for this study. dur­ ing the week of repeated use of the tad, participants were asked to use the log to document the number of calls made and re­ ceived using the tad, the approximate number of minutes of each telephone call, and to rate their speech for each call on a 5 point scale where 3 = typical for that situation; 4 a little better, and 5 much better for that situation; 2 a little worse and 1 much worse for that situation. at the end of the week, participants were also asked to give an evaluation of the device in terms of the following parameters: ease of use, comfort of use, whether they would recommend the device to others, and whether they would support further development of the device. they were asked to give suggestions for further development and any other general comments in an open-ended written questionnaire. procedures ethical approval for this study was granted prior to the start of the study from the university of the witwatersrand, human re­ search ethics committee (hrec) non-medical (protocol number h080103). devices were loaned to the researcher at no cost for use in this study by the manufacturing company voiceamp. the company did not dictate any conditions or expectations regarding the study in exchange for this loan and provided no financial sup­ port or compensation related to the study. all devices were re­ turned to the company at the end of the study. the following procedures were implemented for each participant: /. stuttering severity evaluation. each participant received an initial stuttering severity evaluation. included in this evaluation table 3. venue and telephone partners for each participant reflect a combination of the made and received calls, which was calculated by add­ ing the total number of stut­ tered syllables in each of the made and received calls and dividing by the sum of the syllables in each call, in order to control for differences in the length of samples. benefit derived from the tad was quantified as a mean percentage change value and was calculated as the differ­ ence in %ss without and with the tad within each condition as a percentage of the value in the no tad condition. telephone partner initial assessment final assessment without tad with tad without tad with tad partici­ pant venue made received made received made received made received 1 work therapist therapist therapist supervi­ sor physio­ therapist re­ searcher physio­ therapist researcher 2 work enquiry re­ searcher enquiry . a business . a business i business 3 home father . a brother father brother, father . a mother, brother researcher 4 home friend, enquiry re­ searcher sister enquiry friend friend friend researcher 5 univer­ sity re­ searcher re­ searcher re­ searcher re­ searcher . a re­ searcher . a researcher 6 work enquiry re­ searcher friend re­ searcher business re­ searcher business researcher 7 home friend re­ searcher friend re­ searcher friend re­ searcher friend researcher 8 home gran re­ searcher sister re­ searcher enquiry gran enquiry ^unt 9 work gran, mother re­ searcher . a re­ searcher re searcher business re­ searcher researcher 3 dashes indicate missing data 28 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) impact of the telephone assistive device (tad) on stuttering severity while speaking on the telephone was an interview that tapped information regarding stuttering development and therapy history, and questions related to the frequency of typical telephone use. this information was there­ fore gained only by self-report. ii. baseline telephone tasks without the tad. for a baseline measure, participants were asked to make and receive a tele­ phone call without the tad. because each participant varied so much in terms of whom they would normally speak to on the tele­ phone, they were at liberty to choose who they wanted to speak to within the limitations of the venue of data collection and time of day. table 3 lists to whom and from whom the calls were made and received during the telephone tasks both before and after the week of repeated use. where data collection took place at work;some participants were limited to calling within their organi­ sation to limit telephone costs to the company. when it came to receiving calls, the researcher typically called the participant from another room or extension, or made use of serendipitous phone calls that took place during the data collection period. the lack of uniformity in terms of listener familiarity in this procedure may have affected the internal validity of the study. however, many of the participants with severely restricted telephone use would not have had the willingness or capacity to call a stranger or even a non-family member, particularly at the start of the study. ili. orientation to the tad. following the baseline telephone calls, participants were oriented to the tad with a brief descrip­ tion of the principle behind the technology. the choral effect was explained and then demonstrated by reading or counting along with the participant and comparing this to their solo performance. following this, each participant was given the opportunity to listen to the feedback provided by the tad in a series of graded tasks including: counting, automatic speech, reading, giving their name / i yand address, and answering some general questions regarding their family while holding the handset of the phone to their ear. iv. telephone tasks with the tad. following the orientation, participants were again required to make and receive at least one i call using the tad. similar instructions to the baseline calls were given. v. repeated use in naturalistic environment. the tad device was left in the participants’ home or office environments for a week of repeated use. participants were instructed to make and receive calls using the tad in the normal course of their days and to complete the log sheet. as with the other self-report measures, the accuracy of this measure was not verified independently. vi. telephone tasks following the week o f repeated use. at the end of the week, all telephone tasks were repeated (i.e., partici­ pants were required to make and receive a telephone call without the device and again with the device). inter-rater reliability i all telephone samples were videotaped and transcribed for analysis. twenty-five percent of the telephone samples were ran­ domly selected and analysed by a second coder in order to deter­ mine inter-rater reliability. the reliability coder was a qualified speech therapist who was blind both to the condition of each telephone call coded (i.e., with or without the tad) and to whether it took place before or after the week’s repeated use. cohen’s kappa (cohen, 1960) was used to quantify agreement. cohen’s kappa assesses the reliability of a categorical scale while correct­ ing for chance agreement and has values ranging from 0 to 1. values from .60 to .75 are regarded as good and values over .75 as excellent (fleiss, 1981). a mean kappa of .80 (range .59 to .93) was obtained, indicating excellent agreement overall, de­ spite a range of kappas between samples. data analysis data were analysed according to the aims of the study. due to the small sample size, non-parametric statistical procedures were used for all analyses (siegel & castellan, 1988). aims 1 to 3 re­ quired tests for related pairs and hence wilcoxon signed rank tests for related pairs were used to determine whether changes or differences in %ss were significant for immediate benefit, de­ layed benefit, differences in made versus received calls and carryover of delayed benefit with the tad to calls without the tad. in order to determine whether the total number of minutes of tad use during the week of repeated use had any effect on the de­ layed benefit derived, spearman’s correlation coefficient between the total number of minutes and overall change in %ss was cal­ culated. for aim 4, the sample was divided into the appropriate independent groups (mild vs severe stuttering, presence or ab­ sence of silent blocks, low vs high restriction in telephone use, and first vs second language used) and %ss was then compared across groups using a series of mann-whitney u tests for both immediate and delayed benefit. participants’ perceptions of the tad (aim 5) collected via the questionnaire were analysed through content analysis. in addition to the group statistics, indi­ vidual trends were also examined in order to understand individ­ ual performances and differences more fully. results group results immediate benefit from the tad. the individual and mean %ss and standard deviations for each condition (made or received, with or without the tad) both before and after the week of re­ peated use are presented in table 4. on average, %ss for the made calls during the initial evaluation decreased by 35%, re­ ceived calls by 36%, and total calls by 32%. according to the wil­ coxon signed ranks test for related samples, these changes were all statistically significant (made calls: z=2.21; p<.027; n=8; re­ ceived calls: z=2.02; p<.043; n=6; total calls: z=2.31; p<.021; n=9). following the week’s use of the tad, only the made calls condition showing a significant immediate decrease in %ss when the south african journal of communication disorders, vol 56, 2009 29 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) the tad was used compared to the no tad condition (z=2.21; p<.027; n=8), but not for received (z=l .79; p<.074; n=7) or total calls (z = l.90; p<.058; n=9). nola c h a m b e rs table 4. mean (sd) percentage syllables stuttered in each condition before and after week's use participant made received total no tad tad %changea no tad tad %changea no tad tad %changea before repeated use 1 19 11 42 19 _ b _ b 19 11 42 2 16 12 25 8 _ b _ b 11 12 -9 3 24 11 54 _ b 6 _ b 24 8 67 4 16 7 56 21 8 62 18 8 56 5 14 10 29 17 11 35 16 11 31 6 10 3 70 13 5 62 12 4 67 7 9 9 0 18 13 28 13 11 15 8 8 8 0 15 15 0 12 13 -8 9 29 _ b _b 27 20 26 27 20 26 mean 16.11 8.88 34.50* 17.25 11.14 35.50* 16.89 10.89 31.89* sd 7.03 2.90 25.80 5.63 5.34 23.71 5.67 4.37 29.01 after repeated use 1 20 16 20 23 11 52 22 15 32 2 11 2 82 _ b 7 _b 11 4 64 3 13 14 -8 _ b 16 _ b 13 15 -15 4 12 8 33 15 15 0 13 11 15 ; 5 _ b _ b _ b 15 5 67 15 5 i 67 6 16 4 75 19 3 84 18 4 i 78 7 7 5 29 11 9 18 8 7 13 8 16 14 13 9 13 -44 10 13 -30 9 31 31 0 28 18 36 29 23 21 mean 15.75 11.75 30.50* 17.14 10.78 30.43 15.44 10.78 27.22 sd 7.29 9.36 32.67 6.69 5.17 43.44 6.62 6.42 37.05 * p < .05 a % change is calculated as the difference in conditions as a percentage of initial value without tad b dashes indicate missing data 30 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) impact of the telephone assistive device (tad) on stuttering severity while speaking on the telephone delayed benefit from the tad. to determine the delayed benefit of the tad following the week’s repeated use, changes in %ss for each condition were examined from the initial assessment with­ out the tad to the final assessment with the tad. results are presented in table 5. wilcoxon signed ranks tests indicated that the delayed benefit was statistically significant for the received calls (z=2.52; p<.012; n=8), and total call conditions (z=2.55; p<.011; n=9) but not for the made calls (z=1.75; p<.080; n=8). on average, there was a 39% decrease in %ss in delayed benefit for all calls. significant individual variation is also evident in table 5 and decreases in %ss ranged from -75% (stuttering frequency increased) to +88% for the made calls condition, 13% to 77% for the received condition, and -8% to 69% for the total condition. table 5. delayed benefit from tad: from initial assessment (no tad) to final (tad) assessment made received total no tad tad %cha ngea no tad tad %cha ngea no tad tad %change a 1 19 16 16 19 11 42 19 15 21 2 16 2 88 8 7 13 11 4 64 3 24 14 42 _ b 16 _ b 24 15 38 4 16 8 50 21 15 29 18 11 39 5 14 . b _b 17 5 71 16 5 69 6 10 4 60 13 3 77 12 4 67 7 9 5 44 18 9 50 13 7 46 8 8 14 -75 15 13 13 12 13 -8 9 29 31 -7 27 18 33 27 23 15 mean 16.11 11.75 27.2 5 17.25 10.78 41.0 0* 16.89 10.78 39.00* sd 7.03 9.36 50.0 5 1 15.63 5.17 24.0 7 5.67 6.42 26.14 * p < .05 3 %change is calculated as percentage of initial value the difference in conditions as a without tad ! b dashes indicate missing data the mean number of minutes spent using the tad during the week of repeated use was 31.61 (sd= 63.31) for made calls, 4.67 (sd=2.60) for received calls, and 36.33 (sd=64.48) for total calls. the large standard deviations are as a result of one participant, p4, who used the tad for substantially longer than the other participants, 208 minutes in total (200 for made calls and 8 minutes for received calls during the week of repeated use). this participant was particularly interested in knowing whether the tad would improve his fluency on the telephone and used his phone extensively for personal and vocational use prior to the study. without his data, the mean time spent using the tad for the group was fairly low, only 10.56 (sd=4.85) for made calls, 4.25 (sd=2.44) for received calls, and 14.88 (sd=3.91) for total calls across the whole week. reasons for this were cited as ill­ ness, lack of consistent access to a landline in the evenings, gen­ eral dissatisfaction toward the end of the week with the tad, and the general restriction in telephone use evident in many partici­ pants’ lives. no significant relationships were observed between the minutes spent making calls with the tad and benefit for made calls (r/io=.24; p<.57; n=8); minutes spent receiving calls and benefit for received calls (rho=.08\ p<.85; n=8) or total min­ utes spent using the tad and total benefit (r/io=.36; p<.34; n=9). table 6. impact of speech and demographic variables on immediate and delayed benefit variable immediate benefit delayed benefit za p za p initial stuttering sever­ ity: mild (n=5) vs severe (n -4 ) 0.87 0.39 0.74 0.46 silent blocks: present (n=6) vs absent (n=3) 0.39 0.7 0.52 0.6 first (n=7) vs second (n=2) language speaker 0.15 0.88 0.44 0.66 restriction in telephone use: low (n=5] vs high (n=4) 0.37 0.71 1.11 0.27 amann-whitney test for two independent sam­ ples carryover o f benefit to telephone calls without the tad. wil­ coxon signed ranks tests indicated no significant benefit in calls made without the tad following the week of repeated use for made calls (z=.21; p< .83; n=8), received calls (z=.85; p<.40, n=7), or total calls (z=.63; p<.53; n=9). this suggests that there was no carryover of benefit from using the tad during the week to calls made without the tad at the end of that week. impact o f speech and demographic variables on benefit de­ rived from the tad. aim 4 was concerned with the impact of speech variables (stuttering severity and presence of silent blocks at the initial evaluation) and demographic variables (use of first or second language on the telephone, and level of tele­ phone use restriction reported by participants at the start of the study) on the immediate and delayed benefit derived from the tad. a series of mann-whitney u tests were calculated to investi­ gate this aim, and the results are summarised in table 6 above. none of the speech or demographic variables was significantly related to either immediate or delayed impact derived from the tad. the south african journal of communication disorders, vol 56, 2009 31 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) participants’ perceptions of the tad. all the participants re­ ported that the device was easy to use. on the 5-point likert scale, participants tended to rate their speech with the tad as the same or slightly better than usual with a mean of 3.93 (sd=.38) and a range of 3.50 to 4.60. despite these largely posi­ tive ratings of telephone calls made with the tad, three partici­ pants also reported that they found the device uncomfortable to use, with the predominant complaint being that the feedback was very distracting to them. three participants also reported that they would not recommend the device to another person who stutters. however, most reported that they would support further , development of the device. the most common developments suggested were adaptations for the device to be compatible with cordless and cellular phones, and voice prompts to assist with silent blocks. voice prompting is technologically possible with the tad, but was not assessed in this study. summary of group data. in summary, the group results suggest immediate benefits for the group as a whole in using the device for made, received, and total calls, despite clear individual varia­ tion. delayed benefits were noted for received and total calls. the extent of benefit derived from the tad appeared to bear no rela­ tionship with initial severity of stuttering, predominance of silent blocks, use of first or second language on the telephone, or level of restriction in telephone use reported by the participants at the start of the study. this complicates clinical decision making in the assessment of individual clients and in attempting to make prog­ noses as to who might benefit from the device. the individual profiles of three participants are described below in order to illus­ trate this individual variation more clearly. individual profiles individual profiles of three participants who represent the het­ erogeneity in results are described to illustrate possible interac­ tions between the variables examined in this study. p5 and p6 both demonstrated marked immediate benefit from the tad de­ vice as well as the largest total percentage improvements in de­ layed benefits over the course of the study of 69% and 67% re­ spectively (see table 5). as expected from the group results above, however, these two participants differed markedly in nearly all aspects assessed in this study, including age (24 vs. 46 years), education (master’s level student vs. grade 9), language used on the telephone (first vs. second), history of therapy, and previous exposure to aaf devices. however, p5 and p6 were simi­ lar in initial stuttering severity (mild), types of symptoms (sound, syllable and word repetitions, no silent blocks), and level of re­ striction in phone use (low). it is possible that an ideal response to the aaf provided by the tad is to be found in a combination of variables rather than in any one variable in isolation. at the very least, the large disparity in the two participants who appeared to derive the greatest gains from the tad would preclude clinicians from excluding any potential candidates from a trial period with nola chambers the device, particularly based on any one of the demographic or speech variables considered in this study. one other individual participant (ps) is worth mentioning as he appeared to gain no benefit from the tad in either the immediate or delayed conditions. p8 presented with mild stuttering on the ssi-3 at his initial evaluation. during this evaluation, he reported that he considered his stuttering “cured" in conversational speech but that his stuttering was more severe when talking on the telephone and hence he demonstrated a significantly re­ stricted use of the telephone at the start of the study. during the telephone tasks, it was observed that his stuttering was qualita­ tively more severe and was characterised by long silent blocks of up to 60 seconds as noted when calculating his %ss. very few other core behaviours other than these silent blocks were noted when he used the telephone. as mentioned, without any sound from the speaker, such as during a silent block, the tad is unable to provide any feedback to assist in reducing stuttering. it is pos­ sible that for a client such as this, the voice prompting feature of the tad would be beneficial. discussion overall, the results of this study suggest that the tad was effec­ tive in reducing stuttering severity as measured by %ss for this group of adults who stutter while talking on the telephone. partici­ pants’ severity of stuttering decreased on average by 32% imme­ diately using the tad and by 39% after a week’s repeated use with the tad. these results are more modest than those reported by o’donnell et al. (2008) who reported mean improvements in % ss of 64.5% (sd=22.9) during calls received from the familiar experimenter and 55.1% (sd=22.3) during calls received by an unfamiliar research assistant. the results of the present study are also more modest than those of zimmerman et al. (1997) who found immediate reductions in %ss of 55% for faf and 60% for daf in scripted telephone conversations in 9 participants. methodological differences between these three studies could account for the differences in magnitude of benefit. one main difference was the instrumentation used. participants in the zim­ merman et al. study were provided with binaural aaf provided through a headset with a boom microphone rather than a typical telephone handset. stuart et al. (1997) have found greater bene­ fits for binaural aaf than monaural aaf in experimental reading tasks. however, similar to the present study, participants in the o’donnell study received monaural feedback through the in-the ear portable speecheasy device. participants in the o’donnell study were, however, also using their devices in jrio re speaking situations than the telephone and hence were being exposed to aaf through this device for much longer periods than the partici­ pants in this study. with regard to participant characteristics, those in the zimmer­ man et al. (1997) study had apparently all attended or been as32 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) impact of the telephone assistive device (tad) on stuttering severity while speaking on the telephone sociated with the total immersion fluency training program, sug­ gesting a more extensive history of therapy than the participants in the present study. similarly, the majority of participants in the o’donnell study had previous exposure to aaf devices and the remaining two were referred from speech therapists, again sug­ gesting a greater involvement in intervention than the current study’s participants. as a result, it is possible that the participants in both these previous studies had less active avoidance of the telephone and less overall restriction in daily use of the tele­ phone. the one week’s use of the tad in this study possibly did little to address the accumulated years of avoidance and anxiety associated with the telephone in a manner that would allow for the full fluency-enhancing benefits of the device to be seen. this study found no carryover of the effects of tad to calls made without the tad in the final evaluation. this finding con­ trasts with that of van borsel et al. (2003) who found significant decreases in stuttered words in non-feedback conditions follow­ ing three month’s exposure to aaf compared to initial measures. it is possible that the discrepancy in findings is due to the shorter period of exposure in this study. nonetheless, the present find­ ings lend some weight to the assertion by antipova et al. (2008) that aaf devices may be limited to use as prosthetics as opposed to a more permanent management strategy. a finding in this study that is common to previous studies of aaf, was the presence of substantial individual variation in the participant's responses to aaf. this study found no explanation for this individual variation in initial stuttering severity, types of stuttering symptoms, initial level of restriction in telephone use, or use of first or second language on the telephone. it is likely that a combination of factors will ultimately predict who will bene­ fit most from such a device. it is possible that only further neuroi/ i / m a g in g studies will shed light on possible subtypes of stuttering that respond more or less optimally to aaf (foundas et al., 2004) to explain this individual variation. ! implications. these findings, have important clinical implica­ tions. due to the heterogeneity in responses to the tad device reflected in this study, it seems important for clinicians not to exclude any potential client expressing an interest in such a de­ vice from a fitting and trial period based on any one factor meas­ ured in this study, such as stuttering severity, or presence of si­ lent blocks, alone. similarly, however, it seems equally important to inform potential clients of the variability in responses to aaf and not to make undue promises. the benefits of the tad may be enhanced if it is introduced along with other management strategies. these could include behavioural strategies for slowly increasing the length of time using the tad or grading telephone tasks to increase the likeli­ hood of success and systematically desensitising participants to using the telephone. in addition, speech motor strategies could be given to assist participants in situations where the tad would not be useful, for example, with silent blocks at the beginning of utterances. it is certainly worthy of future research to investigate whether a more supported and systematic introduction of the tad within a comprehensive therapy programme addressing tele­ phone avoidances, anxiety, and speech motor techniques would yield more favourable results than those obtained in the present study. this call has been made by other researchers who have found that aaf users tend to combine speech therapy techniques with their aaf devices (lincoln & walker, 2007). future research is also warranted to investigate the effectiveness of the voice prompting feature of the tad to assist clients presenting predomi­ nantly with silent blocks while talking on the telephone. acknowledgements the author extends grateful thanks to the dominic barker trust for funding this study, and to voiceamp for supplying, on loan, the telephone devices and equipment used by the participants. thanks also go to penelope littlejohns for her assistance in cod­ ing, paul hackney and pary kazantzas for assistance in the initial stages of the study, dilys jones for helpful discussion of the manuscript, and all the participants, who gave of their time to take part in the study. references antipova, e.a., purdy, s.c., blakely, m„ & williams, s. (2008). effects of altered auditory feedback (aaf) on stuttering fre­ quency during monologue speech production. journal of flu­ ency disorders. d0l:10.1016/jfludis.2008.09.002. armson, j., kiefte, m., mason, j.,& de croos, d. (2006). the effect of speecheasy on stuttering frequency in laboratory conditions. journal o f fluency disorders, 31, 137-152. bray, m. & james, s. (2009). an evaluation of a telephone assis­ tive device (tad) for people who stutter. international journal of speech-language pathology, 11, 54-60. cohen, j. (1960). a coefficient of agreement for nominal scales. educational and psychological measurement, 20, 37-46. fleiss, j.l. (1981). statistical methods for rates and proportions. new york: wiley. foundas, a.l., bollich, a.m., feldman, j., corey, d.m., hurley, m., lemen, l.c., et al. (2004). aberrant auditory processing and atypical planum temporale in developmental stuttering. neurol­ ogy, 63, 1640-1646. james, s.e., brumfitt, s.m. & cudd, p.a. (1999). communicating by telephone: views of a group of people with stuttering impair­ ment. journal o f fluency disorders, 24, 299-317. jankelowitz, d. & bortz, m. (1996). the interaction of bilingualism and stuttering in an adult. journal o f communication disorders, 29, 223-234. kalinowski, j. armson, j., mieszkowski, m. r., stuart, a., & gracco, v. l. (1993). effects of alterations in auditory feedback and speech rate on stuttering frequency. language and speech, 36, 1 -16. kalinowski, j., stuart, a., sark, s., & armson, j. (1996). stuttering the south african journal of communication disorders, vol 56, 2009 33 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) amelioration at various auditory feedback delays and speech rates. european journal of disorders of communication, 31, 259-269. kiefte, m. & armson, j. (2008). dissecting choral speech: proper­ ties of the accompanist critical to stuttering reduction. journal of communication disorders, 41, 33-48. lincoln, m., packman, a. & onslow, m. (2006). altered auditory feedback and the treatment of stuttering: a review. journal of fluency disorders, 31, 71-89. lincoln, m. & walker, c. (2007). a survey of australian adult users of altered auditory feedback devices for stuttering: use pattern, perceived effectiveness and satisfaction. disability and reha­ bilitation, 29, 1510-1517. macleod, j., kalinowski, j., stuart, a., & armson, j. (1995). effect of single and combined auditory feedback on stuttering fre­ quency at two speech rates. journal of communication disor­ ders, 28, 217-228. o’donnell, j.j., armson, j. & kiefte, m. (2008). the effectiveness of speecheasy during situations of daily living. journal of flu­ ency disorders, 33, 99-119. pollard, r., ellis, j., finan, d„ & ramig, p. (2009). effects of speecheasy on objective and perceived aspects of stuttering: a 6-month phase i clinical trial in naturalistic environments. jour­ nal o f speech, language and hearing research, 52, 516-533. riley, g.d. (1994). stuttering severity instrument-3. austin, texas: pro-ed. siegel, s. & castellan, n.j. (1988). nonparametric statistics for the behavioral sciences. (2nd ed.). boston, ma: mcgraw-hill. sparks, g., grant, d., millay, k., walker-baston, d., & hynan, l. (2002). the effect of fast speech rate on stuttering frequency during delayed auditory feedback. journal of fluency disorders, 27, 187-201. stuart, a., kalinowski, j. & rastatter, m. p. (1997). effect of mon­ aural and binaural altered auditory feedback. journal of the acoustical society of america, 101, 3806-3809. van borsel, j., reunes, g. & van den bergh, n. (2003). delayed auditory feedback in the treatment of stuttering: clients as consumers. international journal of language and communication disorders, 38,119-129. van borsel, j., sunaert, r. & engelen, s. (2005). speech disrup­ tion under delayed auditory feedback in multilingual speakers. journal o f fluency disorders, 30, 201-217. watt, n. (2000). analysis of language factors in a multilingual stutterer. south african journal of communication disorders, 47, special edition, 5-12. wingate, m.e. (1969). sound and pattern in artificial fluency. journal of speech and hearing research, 12, 677-686. wingate, m.e. (1970). stuttering and audition. journal of speech and hearing research, 13, 861-873. zimmerman, s., kalinowski, j., stuart, a. & rastatter, m. (1997). effect of altered auditory feedback on people who stutter during scripted telephone conversations. journal of speech, lan­ guage, and hearing research, 40, 1130-1134. nola chambers 34 die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol, 56, 2009 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) abstract background aim objectives methodology results and discussion online learning journey critical incident themes critical incident trends across the year conclusion and implications of the study acknowledgements references appendix 1: likert scale to measure the first-year students’ experience appendix 2: timeline template for students to complete about the author(s) nancy barber department of speech-language pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa jenna sher department of speech-language pathology, faculty of humanities, university of the witwatersrand, johannesburg, south africa citation barber, n., & sher, j. (2022). exploring the online learning experience of first-year speech–language pathology students in a johannesburg-based university. south african journal of communication disorders, 69(2), a914. https://doi.org/10.4102/sajcd.v69i2.914 original research exploring the online learning experience of first-year speech–language pathology students in a johannesburg-based university nancy barber, jenna sher received: 31 jan. 2022; accepted: 25 apr. 2022; published: 29 july 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: understanding the learning experiences of first-year speech–language pathology (slp) students during the coronavirus disease 2019 (covid-19) pandemic is essential to ensure that academic staff are able to support and enhance the transition from secondary to tertiary education. an understanding of the student experience could lead to improved support strategies that could be beneficial for the blended learning environment that the university of the witwatersrand will be entering from 2022. objectives: this research explored the experiences of first-year slp students in online learning during the covid-19 pandemic. method: an exploratory mixed-method concurrent triangulation design was employed. quantitative data were collected from likert scales. qualitative data were collected from critical incident timelines. themes were identified from both the likert scales as well as the critical incident timelines using bottom-up thematic analysis. results: the majority of participants reflected that their online learning through the pandemic in 2021 was successful. the themes that emerged from this year pertain to 2021 and the specific participants however, it provides an important insight that the students’ needs change during a year. as a lecturer, one needs to consider these evolving needs to ensure students have the support that they require to be successful in their learning. conclusion: this research provided insights into the evolving nature of the support first-year slp students require in the online learning space during the covid-19 pandemic. keywords: covid-19; online learning; pedagogy; first-year; resilience; educator; support; johannesburg. background it has been established in research that the adjustment from secondary school to tertiary education can be challenging for students (lekena & bayaga, 2018). it is reported that dropout rates in the first year of university are high worldwide (van rooij, jansen, & van de grift, 2017). it has also been found that a smooth transition from secondary school to university can increase the chances of students’ success, specifically in achievement and persistence (lowe & cook 2003; rienties, beausaert, grohnert, niemantsverdriet, & kommers, 2012). lekena and bayaga (2018) identified that one needs to understand the first-year students’ perspectives so that their needs can be met to ensure that their potential is not wasted (lekena & bayaga, 2018). although it is acknowledged that the first year of university is an important transition period for students, there is a paucity of understanding as to how to enhance success and persistence in tertiary education (lekena & bayaga, 2018). there is also limited knowledge as to how best to promote a positive first-year experience in order to facilitate the transition to tertiary education. there is a well-known history in south africa of marginalised populations who have not been provided with equitable educational services. to facilitate transformation, the university of the witwatersrand has emphasised the need to transform the student demographics in terms of gender, race, socio-economic status and prior education so that students from more varied demographics have access to tertiary education and are supported appropriately to be able to obtain their degrees (university of the witwatersrand senior executive team, 2015). this transformation has led to students requiring different types of support to succeed. the transformation in the student body at the university of the witwatersrand, especially in the speech–language pathology (slp) department, has led to the need to transform the pedagogies employed. there have been several papers written highlighting the need to transform and decolonise the slp curriculum in the south african context, and thus this is required for the context of the university of the witwatersrand slp department (adams, mupawose, kelly, & moonsamy, 2021; kathard & pillay, 2013; khoza-shangase & mophosho, 2018, 2021; moonsamy, mupawose, seedat, mophosho, & pillay, 2017; morreira, luckett, kumalo, & ramgotra, 2020; pillay & kathard, 2015, 2018). the covid-19 pandemic has been termed a disruptor of traditional education (adedoyin & soykar, 2020; thurston, 2021). online learning with synchronous and asynchronous tasks has been employed at the university of the witwatersrand for the year 2021. this online learning environment needs to be considered for the first-year student who traditionally may find the adjustment to tertiary education challenging. thus, for academic staff, the need to support the transition to tertiary education in the current state of learning is essential. the covid-19 pandemic as an educational disruptor seems to have advanced the change in pedagogy more swiftly than in previous years (thurston, 2021). within education, there are a variety of pedagogies employed. traditional educational pedagogy refers to teacher-centred pedagogy (khalaf & zin, 2018; patel et al., 2021). the teacher is seen as the source of knowledge and students are seen as passive vessels that absorb knowledge (patel et al., 2021). behaviourism underpins the traditional educational pedagogy and suggests that learning occurs because of the influence of the teacher on students (khalaf & zin, 2018). traditional educational pedagogy that is influenced by behaviourism has been criticised by constructivist learning theories (khalaf & zin, 2018). constructivist learning theory emphasises that students construct knowledge during the learning process (khalaf & zin, 2018). cognitive and constructivist approaches to learning are therefore student-centred (khalaf & zin, 2018). given the current circumstances of remote online learning in which education is occurring, educators have been challenged to integrate constructivist learning theory within the online learning space and assist students as they transition from secondary school to tertiary education via online learning. understanding the learning experiences of first-year slp students during the covid-19 pandemic is essential to ensure that academic staff can support and enhance the transition from secondary to tertiary education. an understanding of the student experience could lead to improved support strategies that could be beneficial for the hybrid learning environment that the university of witwatersrand will be entering from 2022. aim to explore the experiences of first-year slp students in online learning during the covid-19 pandemic. objectives to explore the experiences of first-year slp students in online learning during the covid-19 pandemic using a likert scale and focus group. to explore the critical incidents that occurred throughout the first year that impacted the slp students’ experience of online learning during the pandemic, by means of a timeline. to gain an understanding of when first-year slp students require the most support during their first year of study. methodology this study was an exploratory mixed methods concurrent triangulation design. quantitative data were collected from likert scales. qualitative data were collected from the critical incidents recorded on the timelines. this research study employed purposive sampling of first-year slp students from 2021 at the university of the witwatersrand. twelve of 36 first-year slp students completed the likert scale and critical incident timeline. it must be noted that because of the small sample size, this study may not be representative of the learning experiences of the full cohort of students. at the end of the academic year, all the students in the sample completed the likert scale and the timeline reflecting the critical incidents retrospectively for all four academic blocks. students completed a likert scale reflecting on their online learning experience in the first-year curriculum specifically in speech–language pathology i (sppa1004a) (see appendix 1). a timeline using the critical incident technique (cit) was then completed. critical incident technique includes reflecting on critical incidents, which are events that were positive or negative that occurred and made an impact on the student (cunningham, de brún, & mcauliffe, 2020). critical incident technique is known to be a good reflection tool that can provide in-depth information regarding a participant’s experience (cunningham et al., 2020). students were instructed to plot any incidents (academic or personal) that occurred in each block that they felt had a significant impact on themselves as students, and they had to reflect on the reason that each incident was important to them (cunningham et al., 2020). a timeline format can support reflection as it provides a visual structure that allows a participant to reconstruct an experience or incident and thus can enable comparison and evaluation of experiences (kristiansen, storlien, mora, krogstie, & divitini, 2012). the students were provided with the instructions and timeline template in appendix 2 as a framework for their reflection. the data from the timelines were analysed using a bottom-up approach by employing the six steps of reflexive thematic analysis (ta) as described by braun and clarke (2021), which include generating codes, grouping them together, identifying patterns in the data and thus inferring the themes that are reflected in the patterns (braun & clarke, 2021). the trustworthiness of the research was established using the four pillars of lincoln and guba (1985). the trustworthiness may be impacted by students completing the likert scale and critical incident timelines retrospectively at the end of the year because of recall bias. credibility was promoted through methodological and data triangulation. transferability was established through purposive sampling and thick descriptions (stahl & king, 2020). the dependability of the research was established through a peer debriefer and reflexive auditing, by means of the two researchers analysing the data separately and then reviewing and confirming the themes identified. the researchers were cognisant to adopt an attitude that reflected their own backgrounds and positionality, remaining aware of how this could influence the research process. this was achieved through detailed note-taking and reflective discourse. ethical considerations ethical clearance to complete the research was obtained from the university of the witwatersrand hrec (nonmedical) committee with the protocol number h21/11/47. results and discussion the results from the study will be discussed with regard to the themes that emerged from the likert scale, and then these will be integrated with the themes from the critical incidents reported in the timelines. online learning journey results from the likert scale are illustrated in figure 1 using descriptive statistics. figure 1: visual representation of the likert scale responses from the first-year speech–language pathology students. these results identified that students felt that their year of online learning was successful, and they felt confident that they had learnt a lot through the sppa1004a course even though it was online, as reflected by responses in statement 1 and statement 10. the results also highlighted that students found prerecorded lectures beneficial in their learning journey (statement 3), that weekly engagement tasks helped them to learn better (statement 4) and that participating in weekly engagement tasks was not overwhelming (statement 7). live lectures and microsoft teams breakout rooms seemed to be beneficial but with minimally less impact than the aforementioned teaching and learning strategies, as can be observed in statements 2 and 6. positively, students also reflected that they felt generally supported by staff throughout the year (statement 8) and that not meeting their lecturers face to face did not hinder their learning experience (statement 5). in addition, students reflected that they had sufficient time management skills (statement 9). these results provide insight that students feel that they can learn successfully through online learning platforms when there are prerecorded lectures with engaging tasks to support their active learning. this insight is supported by adult learning principles, which validate that active learning pedagogies need to be carefully considered and employed to promote learning (noffs & wilson, 2021), and thus as educators we need to be mindful of designing and structuring our course to promote active learning. critical incident themes the thematic results from the timelines submitted were constructed based on the bottom-up thematic analysis of each academic block. at the university of the witwatersrand, the academic year comprises four blocks of 7 weeks per block, block 1 being the first block of the year and progressing to block 4 at the end of the academic year. after block 2 is the mid-year exam period, and after block 4 is the final year exam period. during the analysis of critical incidents reported in the timelines, it was noted that there were specific themes that were inherent to each block, and the themes did not appear to be generalised across the entire year. thus, when reporting these themes, they will be reported per block. reporting them per block also provides insight for educators as to the changing support required by students across the academic year, as well as the variety of support that is possibly required by first-year students engaging in online learning. figure 2 reflects the changing themes across the blocks of the 2021 academic year. figure 2: the themes per block for the academic year of 2021. themes for block 1 period of adjustment and support strategies two main themes emerged from the first academic block of study. students identified a period of adjustment and supportive strategies as the most significant incidents of that block. the theme ‘period of adjustment’ included the following statements: ‘i was overwhelmed by the new environment’ (student 4), ‘first few weeks of block were very difficult’ (student 11) and ‘i was not familiarised with the way things are done on the university level and also struggled a bit navigating on an online platform’ (student 12). interestingly, the same students subsequently included statements that contributed to the theme of ‘supportive strategies’. they reported, respectively, that ‘it took some time for me to adjust and understand what was required’, ‘i was able to adapt quickly’ and ‘lectures gave tips on how to tackle each course productively, prioritise and use time wisely’. whilst students initially struggled with the transition into tertiary education, they were able to overcome these obstacles by means of their own resilience and support from peers and university staff. this is consistent with results from the likert scale where students reflected that they felt generally supported by staff through the year. similarly, a study by picton and kahu (2021) reported that students who utilised academic support services found them helpful and that support services positively influenced their self-efficacy and ultimately improved their academic performance. support was also reported to positively influence students’ emotions and increase their sense of belonging to the university community (picton & kahu, 2021). block 2 themes contextual influences and coping mechanisms and strategies the main themes that emerged from block 2 of the academic year were ‘contextual influences’ and ‘coping mechanisms and strategies’. students described novel incidents associated with events that were specific to that particular point in time, as demonstrated by the following responses: ‘my whole family contracted covid during the holiday’ (student 9); ‘block 2 was when we would start writing exams … for the first time’ (student 11);’ and ‘load shedding occurred when i was writing my online exam’ (student 12). the second block of the academic year coincided with the june/july examination period. during this period in south africa, there was the advent of the third wave of covid-19 infections, from 01 june 2021 to 23 june 2021, driven mainly by the dominant delta variant (maslo et al., 2021). furthermore, the implementation of load shedding during this time further complicated the students’ ability to engage in online learning. similarly, a study conducted by mavhandu-mudzusi, mudau, shandu and ndou (2021) reported that intermittent power supply as a result of load shedding led to an unstable internet connection and failure to power up their devices, preventing them from engaging in online learning. whilst the students reported difficulties because of contextual influences, they were able to employ coping mechanisms and strategies to overcome these obstacles. student 9 reported that ‘[contracting covid] set me back a little bit, but luckily i have completed my hours now’, whilst student 12 commented on the lecturer’s supportive response to load shedding: ‘i emailed the lecturer to tell them about my issue; they were so calm about it and reassured me that there is nothing to worry about’. successful student strategies can improve well-being, counter negative emotions and help foster positive ones, all of which facilitate students engaging more deeply with their learning (picton & kahu, 2021). block 3 theme new challenges the main theme reflected in block 3 was termed ‘new challenges’. the challenges presented in block 3 were not related to the challenges reflected in the period of adjustment in block 1, nor were they related to the contextual influences that were identified in block 2. the theme of new challenges incorporated the type of learning strategies employed (case studies and group work) as well as students being tired. educators in sppa1004a employ a variety of pedagogies to engage students in the coursework and to facilitate active learning of the curriculum. the use of case studies and group work are tools that facilitate deep learning, as evidenced by increased reasoning and academic results when these pedagogies are employed (chang & brickman, 2018; puri, 2020). the use of case studies facilitates student-centred learning that promotes a deeper understanding of real-life complexities for a particular case, therefore assisting with bridging the theory-practice gap (puri, 2020). speech–language pathology students must be able to apply their learned knowledge to make and justify clinical decisions in novel situations (mok, whitehill, & dodd, 2014). exposing students to case studies in the first year may be complex, as student 4 reported: ‘[block 3] seemed a bit more complicated with the case studies – but i nonetheless enjoyed it’. however, as puri (2020) explains, this pedagogy allows the development of skills required for understanding the real-life complexities of the cases that students will one day assess and treat. group work is also a useful pedagogy to increase the depth of learning (chang & brickman, 2018). however, in the study by chang and brickman (2018), students reflected that group work could be difficult because of the unequal contributions by group members, even though they found the cognitive and social support beneficial. peer reviews and group contracts did not seem to assist with equal group member contribution in the study by chang and brickman (2018). similar challenges were faced by our participants, as stated by student 2: ‘in block 3 i did not quite enjoy our assignment task. … group work became exceedingly challenging due to group members not cooperating’. the challenges of online group work are important to consider when designing learning for students in online learning during the covid-19 pandemic. one needs to ensure the support for case studies and group work are consolidated so that students can use these pedagogies as deep learning experiences. another aspect of the theme of new challenges that emerged was fatigue. student 12 stated that they were ‘starting to get emotionally, mentally and physically tired, but i kept pushing and reminded myself that i can do this and giving up is not worth it’. tertiary online learning requires that students are psychologically and physically prepared to receive large volumes of information and to be able to successfully participate in self-regulated learning (tugtekin, 2022). the use of online learning during the covid-19 pandemic has led to psychological and physical fatigue in students because of factors such as excessive technology use, unconscious use of technology and low technology literacy (tugtekin, barut tugtekin, kurt, & demir, 2020). educators need to be aware of the psychological and physical exertion that online learning places on students to best support them during times of fatigue. block 4 themes personal challenges and building resilience the main themes reflected in block 4 were ‘personal challenges’ and ‘building resilience’. the theme of personal challenges was made evident through critical incidents shared. student 5 shared: ‘i fell behind with many of my assignments and work because i had lost my cousin to suicide and i struggled to process it’. student 10 shared: ‘my uncle passed away … this had a negative impact on my mood’. student 11 reported that ‘block 4 was an emotional rollercoaster for me, personally’. student 12 also reflected that ‘final [end of] year anxiety was getting to me’. these participants’ experiences are corroborated by research conducted by cénat et al. (2020). this research identified that the covid-19 pandemic had impacted students’ lives in a diverse number of areas but that the main consequence of these impacts was fear, worry, anxiety and exacerbated stress (cénat et al., 2020). this same concept can be seen in the aforementioned quotes from the participants. the covid-19 pandemic has impacted the participants’ lives in diverse ways that have led to negative emotions. cénat et al. (2020) identified a humanistic approach to sharing covid-19 traumas based on caring, empathy and sharing of experiences that led to the development of coping strategies and resilience. this humanistic approach identified by cénat et al. (2020) leads to the second main theme of ‘building resilience’ that was identified in block 4. resilience is generally defined as the effective adaptation to stress, change or adversity (flinchbaugh, luth, & li, 2015). delany et al. (2015) described resilience as occurring when an individual is positively transformed by the adversity that they have experienced. during the covid-19 pandemic, there has been considerable stress, change and adversity for first-year slp students, as reflected in the personal challenges theme and the themes of the other blocks. however, participants reflected that they were able to overcome the challenges of online learning during the covid-19 pandemic and be positively transformed by the challenges that they experienced. student 11 stated: ‘[l]ooking back just makes me really emotional, but i managed to get through the block – even obtained distinctions. i believe what happened to me in block 1, realising my potential as a student, played a huge role in how i dealt with block 4.’ student 9 reflected: ‘i was lucky enough to reach some of my academic goals and my hard work throughout the year paid off’. participants reflected on the importance of a caring, empathetic, humanistic approach to their teaching and learning experience. student 12 stated that ‘there were support groups and lecturers … [and] also a support system to help us with any topics of the course that we were struggling with’. student 3 reported that ‘lecturers were also incredibly supportive and showed recognition and attention to the concerns of students’. a supportive environment assisted with the development of the participants’ resilience. the impact of a supportive environment corroborates the findings of a scoping review of resilience in higher education students by brewer et al. (2019). the scoping review revealed the need for educators to be aware of the organisational context, as this impacts the development of resilience in students (brewer et al., 2019). critical incident trends across the year it was observed that the critical incidents reported over the blocks seemed to decrease across the year. table 1 reflects the number of incidents reported per block that impact the students’ teaching and learning. the number of students reporting that a critical incident did not occur increased from block 1 to block 3, indicating that the students had fewer incidents that affected their learning as the year progressed. however, in block 4, the students had more critical incidents occurring. this trend highlights that students appear to require more support at the beginning and at the end of an academic year. with the transition from high school to university, the beginning of the first-year experience is dotted with unexpected challenges and the transition towards becoming more mature (lee, ang, & dipology-ubanan, 2019). towards the end of the first-year experience, students have a developed a new level of awareness and maturity that allows them to identify their difficulties with more ease and, at the same time, develop an expectation for a better learning environment (lee et al., 2019). this is important for educators facilitating teaching and learning at those stages of the academic year to be mindful of. table 1: number of students reporting critical incidents per block. conclusion and implications of the study the experience of first-year slp students engaging in teaching and learning through online platforms during the covid-19 has been described. the majority of participants reflected that their online learning through the pandemic in 2021 was successful and that they did learn a lot during the year. participants indicated that prerecorded lectures, weekly active engagement tasks and having supportive educators impacted their learning journey positively. these learning tasks are consistent with constructivist learning theory, as they promote students constructing their knowledge during the learning process (khalaf & zin, 2018). it is important for educators to consider how to integrate constuctivist learning theory prinicples when designing their courses to ensure the use of strategies that promote active learning and yet do not overwhelm students who are experiencing a great deal of adversity, stress and changes as a result of studying via online learning in a pandemic. this awareness will assist in transforming the pedagogies employed in teaching and learning so that a diverse group of students can be supported through the hybrid learning approach that the university of the witwatersrand will be embarking on in 2022, as learning continues in a pandemic with all of its stress, changes, adversities and uncertainties. it is also essential to consider the evolving support required from students across a year. the themes that emerged from this year pertained to 2021 and the specific participants; however, they provide an important insight – that students’ needs change. as a lecturer, one needs to consider these evolving needs to ensure students have the support that they require to be successful in their learning. it is also important to note that for each block, although there were challenges because of online learning during a pandemic, students reflected on support strategies, coping mechanisms and building resilience that supported them to experience successful learning and academic success during the specific block. educators should foster a humanistic, caring, empathetic environment, as suggested by cénat et al. (2020), one that can allow students to develop support strategies, coping mechanisms and ultimately resilience so that they can be successful learners navigating online learning in a pandemic. developing their support strategies, coping mechanisms and resilience could support them in their adjustment to first-year tertiary education as well as for their future years of study. whilst this study provided valuable information regarding first-year students’ experiences of online learning, it would be valuable to study these experiences with a different cohort of first-year students to look for any commonalities or differences, as well as studying the different learning needs of students across the years of study. acknowledgements competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions n.b. conceptualised the work, developed the data analysis tools, analysed and interpreted the data, drafted the article and engaged in critical revision of the article. j.s. developed the data analysis tools, analysed and interpreted the data, drafted the article and engaged in critical revision of the article. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. however, the article processing charges have been funded by the university of the witwatersrand, faculty of humanities early career researchers publication grant. data availability the data that supports the finding of this study are available from the corresponding author upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references adams, s.n, mupawose, a., kelly, c., & moonsamy, s. 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(2018). first-year university students’ academic success: the importance of academic adjustment. european journal of psychology of education, 33(4), 749–767. https://doi.org/10.1007/s10212-017-0347-8 appendix 1: likert scale to measure the first-year students’ experience this likert scale was developed based on the aims of the research to investigate the first-year students’ experience. the scale was sent to them via google forms. instructions: please reflect on the past year and specifically the sppa1004a course when selecting the term on the scale that describes your perceived level of agreement with the statement. the terms will be the same for each item and will be organised as a scale under each statement. the terms are: strongly agree, agree, neutral, disagree and strongly disagree. remember this will be anonymous and will not be linked to you or your results, so please be as honest as possible. statements: i feel that online learning during my first year as an slp student was successful. live lectures were beneficial in my learning journey. watching prerecorded lectures was beneficial in my learning journey. engaging weekly with structured tasks such as discussions, reflections and questions helped me learn better. not being able to meet my lecturers face to face hindered my learning journey. engaging in small group activities on microsoft teams breakout rooms did not support my learning journey. engaging in weekly activities was overwhelming. i generally felt supported by my lecturers in sppa1004a throughout the year. i was able to manage my time so that i could complete all the work necessary. i am confident that i learned a lot during my first year through the course sppa1004a. appendix 2: timeline template for students to complete instructions for students: dear students, below is a template of a timeline. please reflect over the past year and think of any incidents (academic or personal) that occurred in each block. these incidents should be things that occurred that had a significant positive or negative impact on you as a student. please write in some detail as to what led up to that incident, and then write what was the consequence of that incident. please also reflect on the reason that each of the incidents was important to you. abstract introduction methodology findings discussion conclusion and recommendations acknowledgements references about the author(s) urisha naidoo discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa penelope s. flack discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa vrinda rathiram discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa legini moodley discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa saira b. karrim discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa nomfundo buthelezi discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa vuledzani ndanganeni discipline of speech-language pathology, school of health sciences, university of kwazulu-natal, durban, south africa citation naidoo, u., flack, p.s., rathiram, v., moodley, l., karrim, s.b., buthelezi, n., & ndanganeni, v. (2022). speech–language therapy educator reflections on the planning and implementation of education and training during the covid-19 pandemic. south african journal of communication disorders, 69(2), a908. https://doi.org/10.4102/sajcd.v69i2.908 original research speech–language therapy educator reflections on the planning and implementation of education and training during the covid-19 pandemic urisha naidoo, penelope s. flack, vrinda rathiram, legini moodley, saira b. karrim, nomfundo buthelezi, vuledzani ndanganeni received: 31 jan. 2022; accepted: 30 may 2022; published: 09 sept. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: universities across the world experienced lockdown and closure of all learning institutions around march 2020 because of the advent of the coronavirus disease 2019 (covid-19). this lockdown and closure presented challenges to the traditional pedagogical approaches in the health sciences, which typically include both campus-based and clinical site-focused activities involving face-to-face interactions and work integrated learning. the onset of the covid-19 pandemic resulted in a shift to emergency remote teaching (ert) and learning. objectives: this study aimed to explore speech–language pathology (slp) educators’ experiences of the planning and implementation of ert and learning during the covid-19 pandemic. method: a qualitative, descriptive narrative design was adopted to meet the objectives of the study. seven slp educators from a single university in south africa participated in this study by constructing narratives on their experiences. the narratives were analysed using thematic analysis. results: five themes emerged from the data analysis, and these included (1) uncertainty, (2) educator feelings, (3) capacity development, (4) influence of circumstances on teaching, learning and assessment and (5) troubleshooting. current findings provide insight into the challenges encountered and strategies utilised by educators in planning and implementing ert and learning. conclusion: beyond the covid-19 pandemic, most educators believe that a hybrid model would address some concerns identified, such as that of missing face-to-face contact, but that it would still allow for the full exploitation of online activities for teaching, learning and assessment required during clinical training. keywords: covid-19; emergency remote teaching and learning; narrative research; south africa; speech–language pathology; speech–language therapy educators. introduction ten days after the first patient was diagnosed with coronavirus disease 2019 (covid-19) in south africa, the south african government declared a national state of disaster and on 27 march 2020 placed the country under lockdown (adams, seedat, coutts, & kater, 2021). as part of measures to control the spread of this novel virus and manage infections, nonpharmaceutical measures were implemented, and these included prohibition of public gatherings, implementation of bans on national and international travel, adherence to regulated social distancing, enforcement of stringent infection control measures, as well as the closure of schools and higher education institutions where large gatherings could serve as super-spreader events (du plessis et al., 2022). in south africa, a national high-level advisory committee was established to provide advice to the minister of health and to establish evidence-based policy guidelines (abdool karim, 2020). the south african minister of higher education and training, dr blade nzimande, in a press briefing expressed the need for academic institutions of higher learning to successfully complete the 2020 academic year. to do this, universities transitioned to emergency online remote teaching (czerniewicz et al., 2020). the format, timing and method of roll-out varied across institutions; the university where the current study was conducted adopted a trial period of online learning on 18 may 2020 and an official commencement on 01 june 2020 (s. songca, personal communication, 06 april 2020). traditional pedagogical approaches in the health sciences typically include both campus-based and clinical site-focused activities, involving face-to-face interactions and work-integrated learning (kumar et al., 2021). however, with the onset of the covid-19 pandemic and the temporary halting of all in-person learning opportunities in training platforms such as schools, hospitals and other clinical sites (kumar et al., 2021), concerns were raised regarding appropriate clinical practice and even whether this could be successfully performed using online delivery. therefore, the proposed move to online teaching was daunting, as most academic and clinical educators were unfamiliar with online teaching principles, theories and strategies (al-yateem et al., 2021). however, khoza-shangase, moroe and neille (2021) highlight the need for the south african speech–language pathology (slp) profession to seriously consider this mode of delivery for the provision of clinical services, as well as for education and supervision even beyond the covid-19 pandemic. for the current study, ‘education and training’ refers to teaching methods and activities for both theory and clinical modules in the undergraduate programme. global, south african and institutional response to emergency remote online teaching and learning universities and schools across the world experienced lockdown and total closure of learning institutions around march 2020, impacting more than 94% of the world’s student population (al-yateem et al., 2021; pokhrel & chhetri, 2021). thus, they had to discontinue face-to-face teaching to slow down the rise in numbers of new infections and deaths (pokhrel & chhetri, 2021). the decision paved the way for universities to introduce digital learning (ferri, grifoni, & guzzo, 2020; pokhrel & chhetri, 2021), which raised both planning and implementation challenges for both students and educators (oyedotun, 2020). challenges experienced by students psychological distress when working from home affected productivity (pokhrel & chhetri, 2021). this was compounded by factors such as taking care of sick family members, as well as worry about loss of income that paid for fees when parents lost jobs due to lockdown (statistics south africa, 2020). other exacerbating factors to student engagement included mental health and challenges regarding domestic affairs. a department of higher education and training (dhet) survey conducted in 2020 on 13 000 students in south africa reported that 40% of respondents could not buy food during the pandemic, whilst 30% did not have a suitable study space, 6% did not have electricity and more than 40% felt socially isolated (krull & de klerk, 2021). whilst these realities are not new, emergency remote learning has brought them to the fore and required monitoring of students’ performance, health and participation by support and teaching staff (al-yateem et al., 2021; oyedotun, 2020). stress factors such as minimal direction, especially for learners who usually struggled even in face-to face teaching and learning, and limited exposure to information and communication technologies (ict) also exacerbated the struggle to access remote teaching and learning (pokhrel & chhetri, 2021). these challenges were particularly prevalent for students from disadvantaged backgrounds and communities, where even something as simple as connectivity was not guaranteed, and access not only to devices but also to data was limited (pokhrel & chhetri, 2021). in addition to these challenges in accessing learning resources, students in lowand middle-income countries (lmics) such as bhutan in south asia had to work and assist on farms attending to cattle, doing home chores and other farming, and they often had no time for accessing learning in their home environments (pokhrel & chhetri, 2021). in south africa, several factors contributed to students’ capacity to move to remote learning, not least of which was the inequity of access to resources for students (czerniewicz et al., 2020). at the university in which the study was conducted, most of the students come from disadvantaged backgrounds. this is in line with public universities’ policy to target the enrolment of students from disadvantaged communities (those in quintile 1 and quintile 2 schools) in south africa (white & van dyk, 2019) to facilitate transformation and redress educational inequalities (mestry & ndhlovu, 2014). quintile 1 schools in each province cater for the poorest 20% of learners, whilst quintile 2 schools cater for the next poorest 20% of learners (department of education, 2004). a sizeable portion of students are therefore recipients of the national student financial aid scheme (nsfas) by the south african government or other external sources of funding. soon after the announcement of the national lockdown in 2020, the dhet communicated an adjusted budget for the provision of laptops for students funded by nsfas (songca, ndebele, & mbodila, 2021). however, there were delays in students receiving their laptops from nsfas because of shipment challenges resulting from the national lockdown (shoba, 2020). these students therefore had no laptops, which are a requirement for accessing resources and remote lectures and assessments. furthermore, first-year students were doubly disadvantaged as their computer skills training did not happen during their orientation period as a result of student protests on campus and suspension of the academic programme at the beginning of the 2020 academic year, prior to the pandemic shutdown. coronavirus disease 2019 in this case added an additional layer to historical disadvantage and unrest (czerniewicz et al., 2020). challenges experienced by educators many educators required upskilling to be able to use ict more effectively to transfer knowledge to their students. thus, capacity development for remote teaching, learning and assessment (tla) became an immediate focus for university leadership (pokhrel & chhetri, 2021). educators felt ill-equipped to encourage student participation in an online environment where they were aware that students had limited use of ict for the purpose of learning (al-yateem et al., 2021; kumar, et al., 2021), and they were suddenly required to develop an online presence and engage with students (mcgill, turrietta, & lal, 2021). the educators tended to describe students as unresponsive during online teaching and learning (yakar, 2021). common methods to facilitate engagement included online quizzes and interactive class sessions encouraging group work (al-yateem et al., 2021). training for emergency remote teaching and learning (ertl) for educators was sudden and covered copious amounts of content over a limited amount of time. training was delivered online and required the use of multiple and often unfamiliar internet-based programmes (al-yateem et al., 2021). in addition, digital inequalities, internet inaccessibility, the lack of hardware such as laptops and the lack of adequate training for educators for online teaching were cited as resource constraints (songca et al., 2021). there is conflicting evidence regarding the impact of emergency remote teaching (ert) on learning. al-yateem et al. (2021) compared end-of-term results for 2019–2020 to those of 2020–2021 – in other words, for the period where teaching was all conducted face-to-face versus the period where online teaching and assessments was adopted. these researchers found higher scores for ert than for face-to-face. on the other hand, halilić and tinjić (2020) found that scores for face-to-face assessments were higher than ert assessments. however, yakar (2021) found that despite the high scores achieved, educators agreed that the scores for ert did not reflect the actual learning levels of students. these results should be interpreted with caution, as many variables could account for these differing findings. the reliability and quality of online assessments, cybersecurity issues leading to breaches and hacks, as well as a need for appropriate measures of checking for plagiarism are some of the concerns raised in the literature as possible influencing factors (al-yateem et al., 2021; oyedotun, 2020; pokhrel & chhetri, 2021). in addition, the onset of online teaching found educators taking on more technical, managerial and social roles. educators encouraged students to develop an online learning community for peer support. managing course designs, deadline extensions and creating engaging activities whilst remaining fair to both educators and students and maintaining academic integrity were seen as additional challenges that educators were required to navigate (al-yateem et al., 2021). as a health science profession, it was important for slp programmes to ensure the development of clinical skills through various online activities such as the use of videos and simulation software. the teaching of clinical skills in an online platform remained the most significant shift in the training of healthcare professionals (al-yateem et al., 2021). transitioning to a different pedagogical approach the higher education sector needed a strategy that would ensure reliable, fast, efficient and effective continuation of educational programmes. thus began the unexpected shift to ‘ert’ (karakose, 2021). emergency remote teaching is defined by hodges and fowler (2020, p. 119) as ‘a temporary shift of instructional delivery to an alternative delivery mode due to crisis circumstances’. for the purposes of the current study, ertl has been used to include reference to teaching and learning, after czerniewicz et al. (2020). reference to ertl includes both theory and clinical modules in the bachelor of slp programme. much of the literature around ertl focuses on theory, traditional lectures and tutorials. however, the practical aspects of the programme, including the clinical practicum, also had to be reimagined for ertl. typically, developing an online course or module could take many months (hodges & fowler, 2020). therefore, ertl is not to be confused with online courses, which are specifically planned and designed to be delivered virtually (hodges & fowler, 2020; mohmmed, khidhir, nazeer, & vijayan, 2020; petersen, n.d.). the covid-19 pandemic circumstances required educators and students to transition quickly from face-to-face tla to some form of ertl. as a result, both educators and students were underprepared (karakose, 2021; jelinska & paradowski, 2021). upskilling needed to be fast (mohmmed et al., 2021), and institutions rolled out online courses, webinars and self-study materials for educators and students to support this upskilling, and this all happened simultaneously to the actual tla. the reference to the quick transition should not imply poor pedagogy or inferior quality. it is imperative to ensure that even though delivery methods may change, the quality of the learning outcomes is not compromised, and outcomes are still met (hodges & fowler, 2020; petersen, n.d.). although the focus of the current study is on the ertl as a response to the covid-19 pandemic at the university, it is likely that online learning in some form or another is here to stay (jelinska & paradowski, 2021; karakose, 2021). lessons learned from current experiences can therefore inform curriculum development for the future. opportunities created by emergency remote teaching and learning despite the significant challenges experienced in the transition to ertl, literature also recognised opportunities that the pandemic created. pokhrel and chhetri (2021) highlighted the following opportunities: building strong connections whilst navigating through ertl, as well as exploration of the use of online platforms (e.g. google classroom and zoom) and social media group forums (e.g. whatsapp and messenger) as additional resources to strengthen teaching and learning programmes. there was also opportunity for increased collaboration between educators and students in finding creative solutions to overcome the restrictions of ertl (pokhrel & chhetri, 2021). karakose (2021) identified the prospects of reassessing and restructuring higher education systems from a reformist perspective to combine technology-supported digital learning together with traditional face-to-face in a hybrid model to facilitate tla, particularly for socially disadvantaged students who may find the cost of attending university face-to-face prohibitive. online opportunities could also be explored to increase digital literacy, provide psychological support for both educators and students and identify fun online strategies to increase student motivation (karakose, 2021). the review literature has presented the global, south african and institutional response to ertl with particular focus on the challenges experienced by students and educators whilst also acknowledging the opportunities created by ertl. the relevant literature substantiates the importance of the current study, which aimed to explore the slp educators’ experiences of the planning and implementation of ertl during the covid-19 pandemic in a south african university. methodology research question how did slp educators experience the planning and implementation of ertl during the covid-19 pandemic in a south african university? aim to explore the educators’ experiences of the planning and implementation of ertl during the covid-19 pandemic in a south african university. objectives to explore the educators’ experiences of the planning of ertl during the covid-19 pandemic. to explore the educators’ experiences of the implementation of ertl during the covid-19 pandemic. study design a qualitative, descriptive narrative design (edmonds & kennedy, 2017) was used to explore the experiences of educators who engaged in ertl during the covid-19 pandemic. this approach was most suitable as it allowed for the unravelling of ‘consequential stories of people’s lives as told by them in their own words and worlds’ (ntinda, 2018, p. 1). a narrative design presented an opportunity for educators to document and reflect on their practice to support, evaluate and improve teaching and learning. setting the study was conducted at a university in south africa that offers education and training in slp. study population and sampling strategy a purposive nonprobability sampling technique was utilised to recruit full-time, permanent educators in the discipline of slp. an invitation was e-mailed to all potential educators who met the inclusion criteria, and seven agreed to participate in the study. the inclusion criteria required participants to be slp educators and to have been involved in the planning and implementation of education and training in the undergraduate programme through ertl during the covid-19 pandemic in 2020. procedures and data collection the invitation that was emailed outlined the study title, aim and objectives. educators were required to use the research objectives as prompts to reflect on their experiences and produce a reflective narrative. all narratives were submitted in english, as all participants were proficient in english. submissions were e-mailed to the research coordinator (i.e., first author in this article who is also an educator). the narratives were coded by the research coordinator in the first level of analysis to ensure anonymity and confidentiality. once the narratives were received and coded, they were stored in a password-protected file on microsoft (ms) teams. the file was accessible to the seven members of the research team for data analysis. the coding process is described in figure 1. figure 1: process followed in coding the narratives. data analysis an inductive thematic analysis of the narratives was guided by braun and clarke’s (2012) six-step process. in the first step, six researchers familiarised themselves with one narrative and developed the preliminary codebook. all codes were named by consensus in second step. the balance of the narratives was then coded by a smaller cohort of three researchers, and the codebook was expanded. the coded transcripts were shared with all participants for member checking to ensure credibility of the data. in the third step, themes were identified by consensus in a group meeting. themes were represented diagrammatically and circulated for review (fourth step) and naming, which was again done by consensus (fifth step). the report was then finalised (sixth step). trustworthiness guba (1981) proposed four criteria to ensure trustworthiness in a qualitative study. (1) credibility was ensured by carrying out member checking. (2) transferability was ensured by detailing all the procedures. (3) confirmability was ensured by involving three coders during data analysis. (4) dependability was ensured in this study by describing the procedures undertaken for study (i.e. data collection and data analysis). an audit trail was ensured by storing all the data and notes for data collection and analysis in password-protected documents. ethical considerations ethical clearance was obtained from the university’s research ethics committee (reference number: hssrec/00003784/2022). all ethical considerations such as informed consent, confidentiality, beneficence and non-maleficence were adhered to when this study was conducted. additionally, the raw data is kept in password-protected microsoft word 2019 documents which only the research team has access to. findings seven participants were included in the study. participants were all female, representing a diverse cultural profile, with clinical and/or educator experience ranging from less than 5 years to over 20 years, within the age range of 35–65 years. during the process of data analysis, it became clear that presenting findings for objectives separately would potentially compromise the richness of the data. the iterative nature of the process made it difficult to differentiate experiences of planning and implementation. thus, the themes presented below therefore include both phases, and the findings are presented as a composite of objectives 1 and 2. five dominant themes emerged from the data gathered and are illustrated in figure 2. the five themes included uncertainty, educator feelings, capacity development, influence of circumstances on tla and troubleshooting. figure 2 further illustrates the relationship amongst the themes. throughout the planning and implementation process, the adaptations to and reimagining of the tla were shaped by multiple influences. these included institutional influences such as guidelines, the need to cater to the uniqueness of the university student, as well as educators’ awareness of and sensitivity to the students’ needs, all of which were impacted on and by the educators’ feelings and emotions. capacity development was ongoing and iterative, as educators made amendments to the programme and continued to develop new skills. through this process, educators grew in confidence and competence but have not yet reached a point of certainty. figure 2: themes dominant in the study. theme 1: uncertainty (context) uncertainty is presented and discussed as the backdrop or context in which all other themes are embedded. this was an unprecedented time, globally, in which educators found themselves. there was a lack of clarity around the covid-19 disease progression, prevention and its effects on all sectors, including education. the global move to ertl was an inevitable consequence and a change from familiar pedagogies. the only ‘certainty’ was that change was necessary and inevitable. uncertainty permeated through all sectors, including education. information poured in from various media, some credible, some not. confusion reigned. decisions were being made by scientists, politicians and legal experts that would impact the lives of millions, without a clear idea of how the pandemic would play out: ‘we were so uncertain, you know. we were hoping maybe by a certain date or after the initial hard lockdown that students would return. at the time, i think the uncertainty of not even knowing how to treat covid-19, which contributed to the reluctance or caution on the side of the university…’ (slp07) ‘as we started focusing on the academic programme, it was a feeling of, “where do we start in continuing with the programme?” students were now at home (including those who lived at university residences). initially, departments were left to figure things out on their own – which was very stressful. communication from the school and university leadership was initially slow – whilst they themselves were trying to plan.’ (slp03) the decisions about ensuring continuity of education at a national or institutional level provided the initial impetus regarding programme adaptation for ertl. however, there was a sense of confusion as information from various sources was contradictory, and guidance on clinical training was absent, with institutional guidance being slow. there was uncertainty about physical student contact and resumption of the programme, even if online. it was even uncertain whether all students had access to devices that would enable the educators to use ertl: ‘the discussion amongst staff centred around what it would be like, are we really in a pandemic, what would happen in south africa, how would we teach? there was so much uncertainty of what was going to happen. … [the students] were frantic that they had to take what they could and leave; some were worried about not having their own laptops and how they were going to cope. they wanted to know plans, and at that stage, we had not received specific plans regarding teaching and learning from management.’ (slp07) theme 2: educator feelings a feeling of being anxious and overwhelmed at the onset of the pandemic immediately followed student protest action at the university in march 2020. the focus at the start of the pandemic was not on the academic programme but on learning about the covid-19 virus, its global impact and managing a household that was in lockdown. the focus on educator training to upskill and migrate to an online training platform within a short space of time left educators feeling exhausted, with some feeling ambushed by the magnitude of the content covered during training: ‘development of online clinical training activities as well as online activities for theory modules can be quite time consuming and overwhelming for staff, as it requires a shift in teaching pedagogy, creativity and ensuring that you are presenting content to cater for various students.’ (slp 05) other educators were not previously ‘tech savvy’, and the sudden move to ertl left them uncomfortable. feelings of discomfort were lessened by learning from colleagues and listening to their experiences. planning of modules, especially clinical modules, left educators feeling anxious and stressed as clinical sites closed their doors to student training, prioritising the management of patients with covid-19: ‘but what about academic staff? if no student is to be left behind, then surely someone must lead? was that supposed to be us? me? those feelings of being overwhelmed returned.’ (slp 02) exacerbating the feelings of anxiety was educator awareness that students were experiencing their own stressors, including managing domestic, technological, infrastructure and load-shedding challenges. emergency remote teaching and learning left educators feeling isolated and disconnected from their students and colleagues, with limited human contact whilst dealing with ertl challenges: ‘i did not have human contact – the sense of community from my peers and students.’ (slp 02) the laptop screen was viewed as both a physical and social barrier. whilst an educator support network was available in the form of staff meetings, due to data and connectivity challenges, laptop mics were often muted and cameras switched off, making the experience a faceless exchange. despite these negative feelings, many educators were excited to reimagine their teaching and were eager to learn. educator confidence improved as the ideas and resources to develop online teaching activities were shared with them. theme 3: capacity development this theme refers to educators undertaking in-service training and self-directed learning to upskill for the shift to ertl. institutional audits supported the need for capacity development of educators. in this theme, educators’ experiences of methods to enhance digital literacy for ertl are explored. at the outset, educators realised that their current understanding and implementation of blended learning was limited, and they lacked the requisite competence for an immediate shift to ertl: ‘[…u]niversity had an online teaching platform, but we used it … scarcely … more a repository for documents and quizzes prior to 2020. our skills in using the online teaching platform were not excellent … it was not something we were dependent on with face-to-face lectures. our previous teaching was very much a traditional approach. … we had to ensure that we had the technical skills to now transfer our teaching onto the online platform.’ (slp07) ‘staff were required to not only learn about and establish for themselves the online teaching pedagogy for their modules but also to navigate the various platforms such as moodle, zoom and simucase that we would use to deliver training and assessments.’ (slp05) although educators did benefit from in-service training, there were challenges. training demands increased rapidly, but the training did not follow a meaningful, developmental format that would have facilitated educators’ understanding. educators felt that the training focused more on knowledge rather than skills: ‘there was too much training going on from the university. they were trying to overload us with knowledge without skills in a short space of time. i feel that everything was a mess. …’ (slp06) whilst educators were trained to transition to ertl for theory modules, a similar focus for online clinical intervention methods such as telerehabilitation was absent. this was a significant challenge for educators in the department, because these intervention methods had not been previously routinely utilised, and therefore curriculum focus was limited: ‘i have never done telerehab ever before in my practice, and now i must speak from a point of authority on the subject. this is where the added pressure comes in. as a profession[al], i have not come across courses or webinars addressing this issue. i just listen to others or read [on social media] what others are doing. it is very much trial and error.’ (slp02) theme 4: influence of circumstances on teaching, learning and assessment this theme refers to how circumstances guided decisions regarding adaptations of the curriculum for ertl. in this theme, the researchers present how the designing of tla methods and strategies was informed by awareness of and sensitivity to the student challenges within this context. the university’s focus on redressing inequities of the past by allocating a greater number of first-entry admissions to students from quintile 1 and 2 schools. this implies that most students come from significantly disadvantaged backgrounds. the educators reflected on the student circumstances and challenges that informed their tla. this included data affordability, poor infrastructure affecting connectivity, access to water and power, limited access to devices that may be used for learning and assessment, learning environments that may not be conducive and the need to participate in household chores: ‘the socio-economic backgrounds our students came from, the geographical areas that the students would have gone back to was to think about access and where the students were. from those perspectives, we tried to conduct a quick online survey to see where students were, what devices they had and whether they had access to the internet.’ (slp07) coronavirus disease 2019 itself was a challenge, as students were either infected or affected in some way by the virus. groupwork during this time was challenging, as students were unable to find common times to work and when they did, connectivity was unstable, impacting on completion time. lower data costs meant students preferred working at night. students in their first year of study were under-prepared for learning, as they had only arrived at university before its closure: ‘because we were so aware of data costs, access, nature of devices students had access to and living conditions, very little contact was made with videos on, particularly for students.’ (slp 01) decisions about tla were guided by the different regulatory bodies such as the health professions council of south africa (hpcsa) and the university teaching and learning committee. decisions included the transition to ertl, the use of various online methodologies for clinical training and a flipped classroom–hybrid model of tla. lecture content was modified to include easily accessible and downloadable texts to all students, most of whom were using their smartphones with limited data. the reading material for the flipped classroom approach needed to be user-friendly, as most students are second-language english learners who needed to engage with the content in their own time, with pertinent issues discussed during ‘live’ synchronous lectures: ‘[…r]eading material that was going to be user-friendly, accessible online, downloadable even on cell phones, so that students didn’t waste data.’ (slp07) ‘the students reflected before the lesson and made the lesson easier to facilitate as they had prior knowledge.’ (slp06) the migration to ertl meant that teaching methods needed to be adapted. planning throughout was necessary for theory and clinical modules. for clinical practice, simulated cases, paper-based cases and videos were developed for students. as most venues closed their doors and others had restricted access to clients, clinic planning from an administrative focus took much effort: ‘planning therefore developed from the areas that i felt could be covered well by simulated cases, within the limits of the hours allowed, and then i explored other ways of meeting remaining outcomes…’ (slp01) the directive from the university was that ‘live’ synchronous teaching for theory modules needed to be reduced, allowing students to engage with learning materials and lectures in a time that was convenient for them, considering data costs and infrastructure issues. educators prerecorded lectures, did voiceover powerpoints, uploaded readings and selected appropriate videos for students. however, a challenge was that student engagement was reduced during lectures: ‘students were mostly unresponsive, and it was so easy to go back to our familiar way of lecturing during live zoom or send prerecorded slides.’ (slp04) an ongoing concern was whether students were meeting module outcomes. the lack of active student engagement during lectures made this difficult to discern. one way in which this was managed was through ongoing assessment in modules, whether developmental or formative. clinical practice has traditionally followed a continuous assessment format. this did not change, but the activities for assessment were varied to include simulations, role play, case studies and telerehabilitation sessions (synchronous and asynchronous): ‘[…s]tudents were provided with real-life clinical scenarios whilst also ensuring that all module outcomes (assessment, management, screening, prevention, promotion, counselling and education) were met within the different online clinical activities allowed, i.e. simulations, case studies, role play and telerehab.’ (slp05) a generic fourth-year module was also developed to facilitate consolidation of skills: ‘[…s]taff prioritised fourth-year and used the time to analyse and identify gaps in knowledge and skills – which could be addressed though online teaching….’ (slp03) despite all the adaptations, educators still felt that assessment remained problematic: ‘we have yet to learn ways of creating online assessments that ensure that students do not copy. we have trialled some changes with time, shuffling questions, etc., but still need other ways to ensure results are not compromised. the students’ final marks were extremely high[er] than average; this can be attributed to weak systems that can stop plagiarism and copying.’ (slp04) theme 5: troubleshooting it was clear that challenges occurred before the planning phase was started, and many more arose thereafter. at times these overwhelmed both educators and students. however every effort was made to ‘troubleshoot’ as each situation arose. the theme ‘troubleshooting’ therefore refers to attempts to address challenges experienced by educators and students during ertl and solutions. communication was of particular concern as students returned to their homes, often in rural and remote areas. the exiting (fourth-level) students were prioritised to ensure they met the requisite competencies within the (disrupted) academic year. student support was therefore key, and efficient communication was necessary. however, concerns about connectivity and data costs resulted in quick, simple and cost-effective communication methods. most educators and students found whatsapp the most reliable solution. it was also used to support students who were unable to log into zoom sessions, by using speaker-phone to allow full participation: ‘communication was difficult. whatsapp was used to set up chat groups with class reps. this was used to ascertain information about the class – regarding who had access to e-mail [and] whatsapp and who didn’t. eventually chats groups were created for modules with those students who had access, but there were many who didn’t – since many students at the university came from socio-economically disadvantaged backgrounds (selected from quintile 1–3 schools) – university’s admissions policy addressing inequities in the majority students’ access to university.’ (slp03) ‘whatsapp access meant i was often contacted well out of office hours, over weekends or late at night, and despite the temptation to wait until the appropriate time to read the messages, i tried to be sensitive to students’ need for reassurance or to deal with queries quickly.’ (slp01) the second quote indicates how at times the ‘solutions’ in themselves potentially became problems. discussion the findings of this study provided insight to the challenges encountered and strategies utilised by educators in planning and implementing ertl. although ertl was introduced at the university, which was already using hybrid models of training, it was still daunting for educators because of limited knowledge and skills of ertl, which led to uncertainty. the use of learning management systems (lmss) in tla requires both computer and digital literacy (mohammadyari & singh, 2015). limited digital literacy might have resulted in apprehensiveness, because adapting and accepting recent technology can be challenging. it was crucial that educators attended training to enhance their knowledge and skills to effectively use the lms and other online tools for teaching theory and clinical modules. whilst this training was useful, it lacked theoretical coherence and focused more on knowledge than skills. this prevented immediate application, thereby exacerbating the uncertainty. the emotional response by educators within the department of slp is indicative of the uncertain circumstances around the delivery of ertl within a pandemic and the challenges of the university context. whilst mixed feelings were a common thread through the initial planning and implementation phases, educators developed confidence and a sense of security as they resolved the challenges arising from ertl and supported each other. these sentiments are similar to the findings in a study by meishar-tal and levenberg (2021), which indicated that lecturers experienced ‘threat’ and ‘failure’ more intensely at the start of ertl, as they lacked any formal training or competency in this method of delivery. their anxiety was heightened due to having to provide ertl during the pandemic. however, as their competency in ertl increased, more positive emotions of success were evoked. educators collaborated around evidence-based solutions to facilitate clinical training. clinical competencies were met by including simulations, telerehabilitation and case studies. these strategies were used to supplement clinical training due to limited access to sites. educators and students engaged in collaborative teamwork to solve problems, forging ahead to save the academic programme. subsequently, the department had to report back to other bodies for approval of these strategies. low-tech communication tools such as whatsapp and e-mail were mostly used between educators and students, similar to the findings in studies by alawamleh et al. (2021), al-yateem et al. (2021) and oyedotun (2020). teaching platforms like zoom and moodle (the learning management system [lms] used at the university) were used in the current study. alawamleh et al. (2021) reported students feeling disconnected from educators and classmates, whereas in the current study educators felt that these platforms, particularly whatsapp, helped with human contact. collaboration and communication occurred amongst educators and students within and amongst institutions, which helped navigate through the uncertainty. similar findings were reported at other universities nationally and internationally (czerniewicz et al., 2020; pokhrel & chhetri, 2021). in this study, social media and technology that were easily available were used initially (i.e. whatsapp, e-mail) with other methods incorporated later as knowledge and skills increased (e.g. zoom). the perceived circumstances and challenges encountered by slp students at the university were not different from those of students from other lmics (oyedotun, 2020). issues were related to data affordability, poor connectivity, lack of devices and limited time for learning due to domestic chores (matsilele, 2021; pokhrel & chhetri, 2021). this resulted in students opting to complete assessments and catch up on recorded lecture content at night when data costs were lower and/or chores were done (pokhrel & chhetri, 2021), indicating the resilience and perseverance of students. challenges were common across students, which was more evident with first-year students due to the lack of timely institutional support resulting from protest action at the university in the weeks preceding lockdown. the inequalities that existed before covid-19 were further emphasised by erlt (czerniewicz et al., 2020; krull & de klerk, 2021). educator sensitivity to students from lower socio-economic backgrounds when planning and implementing the move to ertl was required (al-yateem et al., 2021; pokhrel & chhetri, 2021). the results highlighted educator challenges in ensuring that ertl was student-centred so that no student was left behind. this made planning and implementing ertl difficult. whilst the institution adopted a student-centred approach from the outset, educators struggled to cope with the additional demands that came with student support and capacity development. it was important for the institution to meet the needs of both educators and students simultaneously. karakose (2021) stresses the need for educators to receive relevant psychosocial support as well. conclusion and recommendations the university’s imperative that no student be left behind illuminated the inequities in the student body. educators could not make assumptions that students had access to devices and conducive environments to support ertl. decisions about tla had to be made with sensitivity to and an awareness of student circumstances. whilst educators acknowledged several challenges, feeling overwhelmed, stressed and anxious, these feelings dissipated to some extent as they became more skilled and therefore comfortable in an online environment. it is recommended that the ertl response for a time of crisis should be designed beforehand from a preparedness approach rather than a reactionary one, which is what happened during the start of the covid-19 pandemic. organisational communication in times of crisis should also be planned and implemented effectively to reduce feelings of uncertainty and anxiety. the opportunity for educators to enhance their digital literacy means that improved confidence and competence will result in a hybrid model and continued use of online tla, regardless of the return to face-to-face teaching. online platforms have also facilitated more collaboration between students, between students and educators and between educators within the department and internationally. there is a need for building educators’ capacity to navigate the learning management systems more efficiently, especially as technologies evolve. furthermore, opportunities to support students through social media platforms could result in students receiving more immediate and individual support. acknowledgements the authors would like to thank mrs jenny pahl for her review of the manuscript. competing interests the authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article. authors’ contributions u.n. conceptualised the research project. u.n., p.s.f., v.r., l.m., s.b.k., n.b. and v.n. all carried out the research, discussed the results and contributed to the final manuscript. funding information this research did not receive funding from any funding agency in the public, commercial or not-for-profit sector. data availability the data that support the findings of this study are available from the corresponding author, u.n., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references abdool karim, s.s. 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(2021). the effect of emergency remote teaching on the university students’ end-of-term achievement. journal of educational technology and online learning, 4(3), 373–390. https://doi.org/10.31681/jetol.957433 abstract introduction methods results the perceived role of the speech-language therapists in people with dementia discussion conclusion acknowledgements references about the author(s) mariaan cloete department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa esedra krüger department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa jeannie van der linde department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa marien a. graham department of science, mathematics and technology education, faculty of education, university of pretoria, pretoria, south africa sarveshvari b. pillay department of speech-language pathology and audiology, faculty of humanities, university of pretoria, pretoria, south africa citation cloete, m., krüger, e., van der linde, j., graham, m.a., & pillay, s.b. (2022). south african speech-language therapists’ practices regarding feeding tube placement in people with advanced dementia. south african journal of communication disorders, 69(1), a927. https://doi.org/10.4102/sajcd.v69i1.927 original research south african speech-language therapists’ practices regarding feeding tube placement in people with advanced dementia mariaan cloete, esedra krüger, jeannie van der linde, marien a. graham, sarveshvari b. pillay received: 09 feb. 2022; accepted: 08 june 2022; published: 09 dec. 2022 copyright: © 2022. the author(s). licensee: aosis. this is an open access article distributed under the terms of the creative commons attribution license, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. abstract background: studies related to tube feeding in people with dementia (pwd) remain a contested topic, neglecting the importance of speech-language therapists’ (slts) role in dysphagia management. furthermore, slt practices and beliefs regarding tube feeding in people with advanced dementia in an upper-middle-income country, such as south africa, are unexplored. objective: this study aimed to determine the practices and beliefs of slts in south africa regarding tube feeding placement in pwd. method: a self-compiled online survey was distributed using social media platforms and was completed by 83 south african slts with experience in swallowing and feeding management of pwd. results: most slts (78.8%) strongly believed they play a vital role in the decision-making regarding feeding tube insertion in pwd. this role is often met with several challenges, such as limited support from other healthcare professionals. speech-language therapists with more experience and increased involvement in palliative care appeared to be more confident in supporting and counselling families of pwd on tube feeding. many slts still recommend tube feeding despite its known negative consequences for pwd. conclusion: the findings indicate a need for continued professional development for south african slts on feeding decisions in advanced dementia to increase knowledge and confidence in clinical practice. speech-language therapists require guidelines by professional bodies and further dialogue amongst healthcare professionals to guide difficult feeding decisions in people with advanced dementia. keywords: tube feeding; advanced dementia; speech-language therapists; dysphagia; beliefs; practices; south africa; electronic survey. introduction approximately 86% of people with dementia (pwd) will experience swallowing and eating difficulties during the last 6 months of life (gieniusz et al., 2018; newman, ray, woodward, & glass, 2020) because of progressive underlying neurodegeneration of the swallowing system (rösler et al., 2015; rumbach, coombes, & doeltgen, 2018). if left undiagnosed or untreated, oro-pharyngeal dysphagia (opd) leads to aspiration pneumonia, a leading cause of death in pwd (chen et al., 2018; manabe et al., 2017; rogus-pulia et al., 2018). complex feeding decisions arise when advanced dementia is reached, and oral feeding is considered unsafe or does not meet nutritional needs (chen et al., 2018; payne & morley, 2018; schwartz, 2018). advanced dementia is a state wherein a person’s mental and physical abilities deteriorate to a complete dependence on daily living tasks, such as personal care needs, including eating and swallowing, and severe constraints in verbal communication (ijaopo & ijaopo, 2019). healthcare professionals often rely on speech-language therapists (slts) for their expertise in assessing and managing swallowing and feeding disorders to provide evidence-based judgement regarding enteral nutrition (berkman, ahronheim, & vitale, 2019; schofield, dittborn, huxtable, brangan, & selman, 2021). speech-language therapists may adopt an alternative approach, recommending feeding tubes (ft) because of the risk of opd and the perceived advantages of ft, namely improved nutrition and hydration, decreased risk of aspiration-pneumonia, sarcopenia and frailty in pwd (berkman et al., 2019; newman et al., 2020). tube feeding is an alternative method for people who have difficulty swallowing and obtaining adequate oral intake to meet their body’s energy requirements (ijaopo & ijaopo, 2019). there is a dearth of evidence regarding ft placement in pwd in south africa. clinical practice requires direction from international guidelines. the consensus amongst european professional organisations (european society of parenteral and enteral nutrition [espen], 2016; national institute of health and care excellence [nice], 2006) advises avoiding tube feeding in pwd (american geriatrics society ethics, clinical, & models of care, 2014; nice, 2006). tube feeding has been shown not to improve quality of life, nutritional status or comfort in end-of-life care (faraday et al., 2021; mori, naito, nakane & tohara, 2019). carers often rely on advance care plans (acp) to guide decision-making for a person with dementia. the health professions council of south africa’s (hpcsa) palliative care ethical guideline document encourages patients to write down their treatment preferences in an advanced directive (ad), which is similar to a living will (hpcsa, 2019). this document serves as a written nomination of a surrogate in accordance with the national health act, which requires a person to make decisions on their behalf if they become incapacitated. however, ad or acp remains controversial as the documentation could be revised. the implementation of acp, particularly regarding swallowing and feeding, remains a topic of discussion in geriatric clinical practice (schofield et al., 2021; sellars et al., 2019). there are also considerations of harm versus benefit. people with dementia who do not require end-of-life care may benefit from ft placement; this practice might seem futile in the case of those with advanced dementia (chen et al., 2018). some authors (coutts, 2019; newman et al., 2020) have highlighted that ft insertion does not harm the patient but may contribute to a higher mortality risk after insertion (kenny & singh, 2015). the main disagreement exists because of the mismatch between clinical practice and evidence-based guidelines, as withholding artificial nutrition and hydration can evoke a controversial response when candidacy for ft placement is questioned (kochovska et al., 2020). the decision to forego ft placement is preferably directed by an acp (berkman et al., 2019; douglas et al., 2018). forty per cent of pwd face decisions regarding intensive procedures, such as tube insertion (kelly, cumming, kenny, smith-merry, & bogaardt, 2018; torke et al., 2020), and the need to make these decisions typically occurs when advanced dementia symptoms are severe, and decision-making capacity has deteriorated (manabe et al., 2017). less than 50% of newly diagnosed pwd initiate the acp. without acps, preferences of pwd are unknown, and family members are left overwhelmed with life-limiting decisions (douglas et al., 2018). consequently, families tend to rely on the assessment findings and clinical skills, such as slts, to decide on feeding measures for pwd (american geriatrics society ethics et al., 2014; berkman et al., 2019). speech-language therapists’ beliefs and practices regarding feeding decisions for pwd warrant further investigation (douglas et al., 2018). beliefs and practices about decisions regarding tube feeding are often morally and ethically driven by an intricate and implicit value system, including healthcare professionals’ age, gender, and culture, and their knowledge of evidence-based practice, ethnic background, and religious views (chen et al., 2018; douglas et al., 2018). external perspectives on the decision to commence with tube insertion are available, but little is known regarding slts’ practices and beliefs concerning the implementation of ft (schwartz, 2018). there is a growing need to examine the state of practice, specifically in an upper-middle-income country with lower-income settings, such as south africa (kelly et al., 2018). seventy-eight per cent of older adults requiring alternative approaches, such as tube feeding, live in lower-to-middle-income countries (lmic). the absence of position statements may leave a gap for error in judgement (connor, 2014; vose, kesneck, sunday, plowman, & humbert, 2018). speech-language therapists in south africa face limited resources and overwhelming caseloads (hpcsa, 2018). the hpcsa and the south african speech, language and hearing association of south africa (saslha) do not currently have resources, such as policies or guidelines available for slts outlining the feeding practices for persons with advanced dementia. pillay (2020) explored the current state of service provision in 2018 and found that 86% of slts worked in private practice whilst 14% worked in the public sector, emphasising the disparities between service delivery in different contexts. according to the hpcsa, the slt to patient ratio is 1:18 000 (coutts, 2019). this staggering population ratio mostly consists of vulnerable citizens presenting with concomitant and non-communicable diseases (audain, carr, dikmen, zotor, & ellahi, 2017). south africa faces a quadruple burden of disease exacerbated by poverty, high unemployment, socioeconomic disparity and an inefficient health system (modjadji, 2021). consequently, south african slts are increasingly faced with pwd with additional diseases, such as hiv and tuberculosis, which affect treatment and prognosis (andrews & pillay, 2017). as a result, the south african environment can be complicated and demanding for slts (coutts, 2019). further investigation is warranted to gain insight into the factors influencing the decision-making of slts. this study aimed to determine the current beliefs and practices of slts in south africa when considering ft placement in pwd. by probing slts’ perspectives, the study may provide insight and contribute to evidence-based practice for slts and other healthcare professionals regarding tube feeding in pwd in lower-to-middle-income settings (druml et al., 2016). methods study design and setting a prospective mixed-methods descriptive survey design was employed. an online social platform advertised the survey, accompanied by an electronic link. electronic surveys may render valuable information seeing as it reaches a broad audience who may be dispersed across a large geographic area (leedy & ormrod, 2016). process a self-compiled electronic survey was compiled based on the published work of shega et al. (2003), sharp and shega (2009), o’reilly and walshe (2015) and vitale et al. (2011). the survey comprised 32 questions, of which 2 were mandatory and determined eligibility for participation in the questionnaire. the survey consisted of qualitative and quantitative data. participants had to be english-proficient, qualified slts with current experience of, or have managed feeding and swallowing disorders in pwd in the last 5 years. qualtrics™ xm software was used to distribute the self-compiled electronic survey to slts on social media platforms, and the survey was open for 1 month. purposeful sampling was used. the questionnaire was distributed to respondents with a particular interest in pwd and dysphagia, known to currently serve or who have experience with the pwd population (leedy & ormrod, 2016). purposive sampling allowed the researcher to select knowledgeable and reliable respondents, from the authors’ network base of slts, to provide information that would answer the research question. a sample of 83 respondents was recruited prospectively. a pilot study was conducted by requesting two qualified experienced slts who fit the inclusion criteria, to evaluate the survey’s content and scrutinise the phrasing of the questions and the clarity of questions to prevent any ambiguity. ambiguous questions might confuse respondents, resulting in misleading data (leedy & ormrod, 2016). feedback was received from the slts regarding ease of completion, avoiding ambiguity and overpowering information provided during the survey, which might result in vague responses. the questionnaire was adjusted, adapted and amended to be sent out as a pilot study to an independent slt who fit the inclusion criteria. data analysis data were analysed using the statistical package for social sciences (spss) version 26.0 in collaboration with a statistician. open-ended questions were coded thematically using qualitative content analysis (vaismoradi et al., 2013). an exploratory factor analysis (efa) was conducted, and cronbach alpha values were calculated to determine the internal consistency of items in the questionnaire. the survey’s reliability was determined using cronbach alpha values. the generally agreed-upon lower limit for cronbach alpha is 0.70, although some researchers advocate that a value as low as 0.60 is acceptable in general (daud, khidzir, ismail, & abdullah, 2018; zhan, wei, & hong, 2021) and in exploratory research (hair, black, babin & anderson, 2009). firstly, an efa was conducted, and four factors were identified. the kaiser–meyer–olkin measure of sampling adequacy (kmo) and bartlett’s test of sphericity were performed to determine whether the data were suitable for factor analysis. the kmo (which should ideally be above 0.5) and bartlett’s test of sphericity (of which the p-value should ideally be less than 0.05) showed evidence that dimension reduction could be achieved (kmo = 0.686, bartlett’s test of sphericity p < 0.001). each factor was named, and the cronbach alpha value was computed for each factor (table 1). the cronbach alpha values indicate reliability for factors 1–3 but not for factor 4. although the cronbach alpha value of factor 4 is below 0.6, it is well-known that the more items a factor has, the higher the cronbach alpha. authors (briggs & cheek, 1986; pallant, 2001) have suggested that inter-item correlations be used to establish reliability when the factor has few items; factor 4 has only two items. the recommendation is that an inter-item correlation should be between 0.1 and 0.5 because values lower than 0.1 indicate that a single total score could not adequately represent the complexity of the items, and higher than 0.5 means the items on the factor tend to be overly redundant. the inter-item correlation between the two items of factor 4 equals 0.465 with a p < 0.001, indicating the correlation is statistically significant, establishing reliability for factor 4. furthermore, to establish construct validity, convergent validity (items belonging to the same factor should correlate highly) and discriminant validity (items not belonging to the same factor should have low correlations) should be established (heale & twycross, 2015). although not all details are shown here for conciseness, convergent and discriminant validity have been established as items belonging to the same factors correlate stronger than items belonging to different factors. table 1: factors and corresponding cronbach alpha coefficients. the frequency distribution allowed further exploration of how different groups responded to the various factors. differences between two independent groups were analysed using the mann–whitney (mw) test, and differences between three or more independent groups were tested using the kruskal–wallis test. p-values less than 0.05 indicated a statistical significance between these groups, and an ad hoc mw test was used following the kruskal–wallis test. for missing values, pairwise deletion was used over listwise deletion. the latter leads to smaller sample size and lower statistical power as the entire record is excluded from analysis if a single value is missing (raaijmakers, 1999). ethical considerations the study obtained institutional ethical clearance from the faculty of humanities’ research ethics committee at the university of pretoria for the study protocol hum004/1219 on 20 march 2020. voluntary informed consent was obtained from respondents by providing a hyperlink of the informed consent document in the questionnaire. results one hundred and eighty-two potential respondents received an invite-over-email for the individuals who did not have social media access; only 42.2% (n = 35) agreed to participate. a total of 83 responses were recorded and statistically analysed. respondents were 21–50 years of age, and of the 47 who answered the specific question regarding services to pwd, 85.1% (n = 40) currently provided services to pwd (table 2). interestingly, two participants, a doctor and a healthcare professional, also participated in the survey. however, these results were excluded based on the inclusion criteria. the largest number of respondents, 30.1% (n = 25), worked in private practice, followed closely by 28.9% (n = 24) respondents working in private hospitals providing inand out-patient services to pwd, residential care facilities, 20.5% (n = 17), and 19.3% (n = 16) worked in rehabilitation facilities. almost half of the respondents, 44.7% (n = 21), graduated 5 or less than 5 years ago. table 2: respondents’ characteristics (n = 83). the perceived role of the speech-language therapists in people with dementia specific role in feeding tube placement from the total of 83 respondents, 36.1% (n = 30) identified their current role in assessing and treating pwd who might have dysphagia. the largest proportion of slts (37/47, 78.7%) strongly agreed that they have a role in decision-making for pwd who might require tube feeding assistance. most slts (46/47, 97.9%) agreed that their scope of practice includes swallowing and feeding management in pwd and felt that their regulatory body specified this role. two areas in the multiple-answer question indicated the most pertinent roles of the slt in treating pwd: consulting with the individual, family and caregivers involved in the care of the pwd 54.2% (n = 45) and 54.2% (n = 45) agreed to assessing the individual’s swallowing and feeding ability. from the multiple answer question, 49.4% (n = 41) of slts believe the slts’ primary role in their current professional setting was perceived as providing diagnosis and assessment of feeding and swallowing abilities. beliefs and practices in the professional setting in this section, the open-ended responses were analysed using thematic analysis from which themes emerged. the slts’ beliefs and practices were based on two identified themes that influenced ft placement in pwd: best practice for the pwd and the decision to implement tube feeding remains patient dependent. most slts indicated they would recommend ft placement, but concerns were raised regarding the maintenance of tube feeding post-insertion. these concerns led to a feeling of uncertainty in palliative care practices, as seen by the following: ‘unfortunately, palliative care practices are loosely defined in south africa, and we do not have access to palliative care specialists at the hospital’. (respondent 1, slt, qualified within the past 5 years) table 3 outlines the roles of the speech-language therapists. interestingly, more than half of the slts believed ft placement remains the most viable option for pwd and would recommend tube feeding to a family member. however, contrary to evidence-based practices (ayman et al., 2017; gieniusz et al., 2018), slts often succumb to external pressures and are often confronted or contested by three common aspects that often challenge ft placement decisions. these aspects are listed below, together with respondents’ corroborative statements: families’ insight, perception, and culture: ‘families would do anything to keep a family member alive, even if tube feeding is not the optimal medical decision. the unrealistic expectation of families.’ (respondent 2, slt, qualified within the past 5 years) speech-language therapists’ bio-ethical concerns and belief system of the necessity for ft placement: ‘ethical dilemmas when a poor prognosis is given. upon discharge, the families often [feel] emotional and traumatised, with limited to no optimal care facilities upon discharge.’ (respondent 3, slt, experienced) the lack of support from other healthcare professionals: ‘i think different allied health professionals have different opinions. the physicians only consider certain factors and not always look at the client holistically.’ (respondent 2, slt, qualified within the past 5 years) table 3: roles of the speech-language therapists (n = 83). table 4 summarises responses that were statistically significantly different (p < 0.05) per factor (identified in table 1). table 4: statistically significant differences between responses per factor (n = 83). question 3 showed a statistically significant difference between whether an slt currently renders any swallowing and feeding services to pwd and their score for factor 1 (area of practices [p = 0.014]) and factor 2 (frequency of involvement and level of confidence) [p = 0.026]), respectively. respondents who provided feeding and swallowing services to pwd had statistically significantly higher scores for factor 1 and factor 2 than those who did not. current clinical practice and frequency in treating swallowing and feeding challenges contribute to higher confidence in rendering services to pwd. respondents aged 31–40 years agreed more strongly (p = 0.017) than those aged 21–30 years, with statements formed by factor 4 (counselling and support). when investigating the context in which these services were delivered, respondents working in private hospitals providing inand out-patient services to pwd (p = 0.035) and in rehabilitation facilities agreed significantly (p = 0.008) more strongly with statements forming factor 1 (area of practices) than those respondents who did not render services at these hospitals and facilities. in contrast, the group of respondents from secondary level hospitals, that is, district hospitals and regional hospitals, tended to be significantly less in agreement with these statements forming factor 1 (p = 0.045). when investigating clinical time, respondents who indicated 6 or more hours per week (p = 0.008) and those who indicated 3–5 h per week (p = 0.037) agreed significantly more strongly with statements that formed factor 2 (frequency of involvement and the level of confidence) than those who indicated 0–2 h of clinical time per week. respondents who have undergone further education and training agreed more strongly with the statements forming factor 1 (area of practices [p = 0.028]) and those forming factor 2 (frequency of involvement and level of confidence [p = 0.041]) than respondents who have not had further training. team members involved the level of involvement from other multidisciplinary team (mdt) members and slts’ satisfaction with mdt participation when caring for pwd were examined (table 5). most respondents, 87.2% (n = 41), are part of an mdt. the multiple-answer question identified that the three most frequently nominated team members were the slt, 54.2% (n = 45); dietician, 54.2% (n = 45); and physiotherapist, 51.8% (n = 43). of those respondents who are part of mdt teams, less than half (20/42, 47.6%) are satisfied with their own level of involvement. table 5: level of involvement of team members (n = 83). open-ended questions revealed two related themes: inconsistent involvement of other healthcare professionals, and limited inclusion in the decision-making of alternative feeding methods. the identified themes highlighted the need for more collaboration between healthcare professionals treating pwd because most slts feel excluded when decisions regarding ft placement are taken, as demonstrated by the following statement: ‘treating physicians do not always value our input and make their own decision, which is often uninformed. the extent to which i am involved depends on the referring doctor.’ (respondent 4, slt, experienced) continuous professional development approximately 55.3% (n = 26) of respondents had invested in pwd-related continuous professional development activities (cpd) prior to this survey. qualitative information gathered from open-ended questions in table 6 revealed the following themes: the need for increased cpd opportunities or events, clear guidelines in the healthcare context and online training. interestingly, evidence-based research was the main focal point, followed by information regarding ethical concerns relating to ft placement in pwd, as seen in the following statement: ‘it is ethically an exceedingly difficult decision. i would appreciate more training and discussion regarding the right decision based on international guidelines and research.’ (respondent 4, slt, experienced) table 6: further education (n = 83). discussion the study found that the perceived role of the slt is to assess, diagnose and treat opd in pwd, followed by providing appropriate ongoing and alternative feeding within slts’ specific area of expertise and scope of practice. speech-language therapists tend to focus on person-centred care in deciding what pwd want to eat and drink, but with limited systematic support to direct decision-making. similarly, whilst most slts mentioned that decision-making mechanisms would help with nuanced feeding decisions, official guidelines remain absent. speech-language therapists spending more clinical time (6+ h per week) rendering services to pwd appeared to have more confidence in ft placement decisions than those who indicated less clinical time (andrews & pillay, 2017; schwarz, coccetti, & cardell, 2020). speech-language therapists with more experience and a higher frequency of involvement in managing pwd appeared to be more confident in supporting and counselling families of pwd on ft. speech-language therapists who are sporadically involved in decision-making practices regarding ft placement in pwd may submit to external influences, such as emotional responses from families (coutts, 2019; schwarz et al., 2020), or input from other healthcare professionals, because of their undefined role within the mdt (hawksley, ludlow, buttimer, & bloch, 2017; kelly et al., 2018; krikheli, mathisen, & carey 2018). speech-language therapists rely less on their clinical expertise (schwarz et al., 2020), and the tendency to succumb to pressure may be exacerbated by limited physical and human resources and a lack of clinical experience. speech-language therapists mentioned that the pwd’s age and cognitive status and the severity and progression of dementia play a role in ft placement. a further consideration is slts’ bio-ethical concerns and the legal implications of ft placement (kelly et al., 2018). speech-language therapists’ expertise helps them act as intercessors between the pwd, other healthcare professionals and family members to reach a consensus regarding ft placement for pwd (chahda, mathisen, & carey, 2017). a lack of other healthcare professionals’ support in this decision-making is evident, further highlighting the additional pressure slts face in daily clinical practice. mdt involvement in ft decisions is often complicated by families’ insights, perceptions and cultural values (berkman et al., 2019; mchutchison, miles, spriggs, & jayathissa 2018). family involvement is crucial as they remain the primary decision-makers but tend to favour tube feeding even when it is discouraged by healthcare teams (rumbach et al., 2018). because of the unique linguistic and cultural diversity in local settings, misunderstandings regarding care might compel patients’ families to consult alternative medical practitioners accepted according to cultural beliefs (druml et al., 2016; pascoe, klop, mdlalo, & ndhambi, 2018; salifu, almack, & caswell, 2021). in a multicultural and multilingual setting, such as south africa, clear communication between families and healthcare providers is essential (pascoe et al., 2018). south african slts appear to rely more on clinical experience than research-based information (andrews & pillay, 2017). speech-language therapists in this study believed that their roles are congruent with their professional healthcare settings’ expectations of the role of the slt. the slt’s decision to agree to ft placement would be accepted amongst healthcare professionals if clear guidelines were available to inform practice, which is the case for neither south africa nor high-income countries (andrews & pillay, 2017; mchutchison et al., 2018). new zealand and the united kingdom are the only countries currently developing supportive documents to assist in making decisions regarding ft placement (kelly et al., 2018; schwarz et al., 2020). inconsistency exists in slts’ clinical practice because of a mismatch between slts’ belief systems and the policies of the slts’ governing bodies (berkman et al., 2019). there is currently no guideline provided by the south african speech-language and hearing association regarding ft placement decision making for slts in south africa. the national department of health (2017) has a current policy that states there is no structure or formal mechanism in the public health sector for introducing a multidisciplinary team of health workers, healthcare professionals and social workers to implement better palliative care procedures. this context of the survey confirms the slts’ perceived limited interaction between multi-disciplinary team setups. however, hpcsa’s palliative care ethical guidelines (2019) state that only treatment options that are scientifically supported and reasonably expected to yield the intended benefits should be recommended and provided by healthcare practitioners providing palliative care. a clinical void seems to exist, and slts may discard their clinical knowledge of the best practice (schwarz et al., 2020) to accommodate pwd’s family members’ wishes (schwarz et al., 2020) and other healthcare professionals’ opinions, resulting in sub-optimal decision making (berkman et al., 2019; vose et al., 2018). although the hpcsa’s palliative care ethical guidelines (2019) advise healthcare professionals to consider the possible benefits versus the risks of palliative care in subsequent interventions, formal guidelines for slts may assist in decision making for ft insertion in the later stages of dementia or serve as a preventative guide in the earlier stages (kochovska et al., 2020; sellars et al., 2019). further research is thus warranted. providing alternative feeding options to patients with advanced dementia is an ethical obligation, and such provision is a fundamental human right (vose et al., 2018). south africa has the highest inequality of health services amongst all lmics, which further highlights the need for guidelines to ensure best practices concerning pwd (andrews & pillay, 2017; pillay, tiwari, kathard, & chikte, 2020). graduate slts expressed a need for further evidence-based education consisting of events, workshops or online cpd activities. continued research using focus groups may provide insight regarding ft decisions and address ethical issues in the advanced stage of dementia in a resource-constrained setting, such as south africa (coutts, 2019). in this study, most slts indicated that they provided services in the private sector. therefore, responses are more reflective of this sector and less representative of slts in the public healthcare sector. regrettably, slts’ service delivery to individuals with advanced dementia and their families accessing public healthcare services could not be comprehensively described, and this topic warrants further exploration. one respondent’s response to the question exploring decision-making challenges regarding tube feeding was as follows: ‘in the public sector: no access to pegs, catheter tubes are placed, poor amenities at home, for example, no access to clean running water, and education levels/ language barrier/ understanding of the care of peg tubes.’ (respondent 4, slt, experienced) although most respondents graduated 5 or fewer years ago and could therefore be expected to have a broader perspective, they still believed that ft placement for pwd remains the most viable option and would recommend ft placement to a family member. the significant decrease in the number of survey participants as their years since qualification increased could indicate a number of factors, possibly being less active on social media platforms or fewer slts providing this specialised service to people with advanced dementia. comfort feeding or pleasure feeding was not mentioned as an option to consider in the quality of life of pwd. although these practices pose some challenges, they are patient-dependent and currently regarded by many as best practices for pwd (schwarz et al., 2020). a patient-centred approach with individualised decision-making is ideal (orlandoni et al., 2020). further research should investigate local slts’ implementation of comfort feeding with pwd (andrews & pillay, 2017; kelly et al., 2018). knowledge gained from this study could be used in undergraduate training and continued professional development of slts. conclusion the use of ft in pwd remains a matter of contention. speech-language therapists need further research to drive contextually specific guideline development that may aid decision making in the case of pwd to ensure high-quality patient-centred care. the findings of this study may guide undergraduate training and continued professional development of south african slts. future research endeavours may include conceptualising guidelines by professional bodies to aid healthcare professionals, such as slts in decision making about ft placement in pwd. strengths and limitations it may be that the slts who participated in this study most likely had a firm opinion, interest or belief in this topic. recall bias might have occurred and influenced responses because of personal experience with a pwd. to the researchers’ knowledge, this survey was the first performed in a country encompassing both upper-middle-income and lower-income settings, and therefore the findings are valuable. awareness about ft placement in pwd was raised, and slts may have recognised the need for further professional development regarding this matter. a substantial sample yielded valuable responses from slts from various south african settings, but missing data limit the findings. acknowledgements the authors would like to thank all the study participants who contributed to this study. competing interests the authors declared no potential conflicts of interest concerning the research, authorship and/or publication of this article. the research was completed for an ma degree for m.c. authors’ contributions m.c., e.k., s.b.p. and j.v.d.l. conceptualised the study and co-wrote the article. m.c. collected the data. m.a.g. assisted with statistical analysis. all authors have approved the release of the final version and have contributed sufficiently to the project to accept public responsibility for the publication of its content. funding information this research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. data availability the data that support the findings of this study are available from the corresponding author, s.b.p., upon reasonable request. disclaimer the views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors. references american geriatrics society ethics, c., clinical, p., & models of care, c. 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(2021). cellphone addiction during the covid-19 outbreak: how online social anxiety and cyber danger belief mediate the influence of personality. computers in human behavior, 121(8), 106790. https://doi.org/10.1016/j.chb.2021.106790 problem based learning a n d t h e construction of an slp curriculum robert fourie dept. speech and hearing sciences, college of medicine and health, university college, cork, ireland j... ....................................................................................................................................................................' w ~ rn r ..... w ......w \ abstract i problem based learning (pbl)isa learner-centered,smallgrouplearningpedagogythat emphasizesknowl edgeas an emergent and socially constructed property of learners'relationships to information; and which is thought to bridge some of the issues related to the theory-practice gap in professional education. the current paperaimstoexplore the philosophical groundings ofthis method, some ofthe research pertaining to its use in slp curricula;and practical suggestionsfor its application, based on the author's experiences of implementing this method in a new slp curriculum at university college cork (ucc), republic of ireland. morespecifically,thispaperexaminesthetheoreticalbasisforpbl,problemconstructionandsuggestionsfor how the method can be incorporated into an slp curriculum at tertiary level. keywords: problem based learning (pbl), teaching and learning, curriculum development. background and philosophical groundings of pbl t here is too much information out there and our students are being overloaded with more facts than they will ever be able to remember in practice. this sentiment was expressed in the medical community as early as 1913 when osier noted that medical curricula were growing at a phenomenal rate (osier, 1913). following osier’s comments, it became widely recognized that learners simply memorized facts for examinations, but then soon afterwards, iforgot this information (w ood, 2 0 0 4 ). moreover,(traditional models o f education in the w est were at this time influenced by behaviourist accounts o f learning such as those o f thorndike (1906) that focuseid on modelling, demonstration and reinforcement o f jcloser attempts to match an ideal fixed fact or skill (saettler, 1990). such an approach assumed that reality was knowable, and that the learner’s response could be objectively judged as right or wrong according to clear criteria. this epistemology was reflective o f the philosophy o f realism that dominated much of the 2 0 th century. realism focused on the universal elements that constitute reality; but more importantly, stressed that these universals existed independent o f the linguistic, cognitive and social practices o f people (miller, 200 5 ). influenced by platonic thought, realism assumed that information was “particulate” in nature and that these “particles” o f knowledge could be delivered to learners, bit by bit. accordingly, the sign o f someone who had learned sufficiently was their ability to return this information in an examination. this was proof that the learner’s “inner reality” reflected the outer truth o f reality. the implications o f such an epistemology were that instruction should focus on clear transmission o f information; and that learning constituted successful memorization o f facts (bonk & cunningham, 1998). also heavily influenced by descartes, who believed that any complex problem could be understood by reducing it to its elemental constituents, realist epistemologies have generally promoted the study o f ever smaller, or specialist segments for the purposes o f constructing an understanding o f the natural world. to date, slp departments have generally reflected this epistemology, by providing a modular, subject-based approach to delivering a curriculum. this distributed approach to curricular design is illustrated by taught subjects being situated across the university, with learners attending courses in linguistics, anatomy, physiology, audiology and education, in departments unaware o f the curricular goals o f s l p departments; and with limited explicit integration o f these courses into a coherent whole. consequently, it has been left up to slp learners to somehow assimilate and synthesize these units of information into a meaningful gestalt for themselves; and then apply this to clinical situations. symbolic interactionism on the other hand, as an author contact: dept. speech and hearing sciences, university college cork, brookfield health sciences complex, college road, cork, ireland tel: + 3 5 3 2 1 4 9 0 1 5 3 8 e-mail: r.fourie@ucc.ie the south african journal of c o m m u n ic atio n disorders, v o l 55 2008 77 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) mailto:r.fourie@ucc.ie robert fourie alternative epistemology, developed in opposition to realism (blumer, 1969); and formed the basis o f many qualitative research methodologies. this humanistic philosophy presented humans as intersubjective; constructing their identities by using their imaginations to make meaningful interpretations o f events, with each other, through language, and within a social context. such a philosophy applied to learning, implied that knowledge was relational and dependent on how well the learner was able to interact with information and other people to generate knowledge. symbolic interactionism was reminiscent and influenced by john dewey who argued for the active participation of learners in the process o f learning (dewey, 1929). the implication o f symbolic interactionism, as applied to learning, was that knowledge represented iterative relationships to socially mediated information; and that the goal o f education, rather than to feed learners with “particles” o f information, might be to foster a relationship in the learner to facts and information. consequently, symbolic interactionism seeded the constructivist approach to teaching and learning (palincsar, 1998). from this perspective, learning was a process o f entering into an active relationship with information which occurred in a network o f social and cultural contexts (palincsar, 1998). constructivists therefore rejected the view that knowledge is situated in the learner; instead holding that knowledge could be better conceived o f as arising from interaction with information in a social context. carl rogers, in the early 1950’s, enlarged on this concept by applying his client-centred theories to the arena of education and advocated for university learners to become more active in the acquisition o f knowledge (rogers, 1961). rogers advocated a system in which learners collaborated on what they needed to know, worked together to attain that knowledge, and used it to accomplish something. from this constructivist perspective, knowledge was more relational; knowledge was actively pursued and constructed; and was conceived o f as a field o f interaction, rather than an object that can be consumed and known. like all relationships, knowledge could grow and change; it was dynamic and challenging to the individual, rather than being static, unchanging and merely additive in nature. a relational understanding o f knowledge allowed for change and dynamic growth o f information, in the sense that learning was not simply the acquisition o f a fact. from the constructivist perspective, the learner was not a passive consumer o f information (palincsar, 1998). instead, the learner had an attitude to a fact; was not uncritical in the understanding o f a fact; and evaluated a fact from the perspective o f previous information and relationships with other bodies o f knowledge, within a social context (savery 8c duffy, 2001). for this reason, learners were seen to need opportunities to apply information within a community o f practice. knowledge was negotiated and tested in context; and knowledge and learning were seen as social (palincsar, 1998). moreover, explaining one’s thought and understanding o f a topic in an interactive situation enabled a deeper processing o f information (bereiter 8c scardamalia, 1989). and thus, the social dimensions o f communication therefore facilitate the growth o f deep knowledge (palincsar, 1998). problem based learning (p b l ) p b l endorses a constructivist epistemology inasmuch as the learner constructs knowledge in a social context, rather than having it passed on to them (haith-cooper, 2 0 0 0 ). the development o f p b l occurred in reaction to discontent with how medical learners were taught in canada (barrows, 1996). barrows explains that teachers at mcmaster university medical school in hamilton ontario in the 1960s decided to experiment with new methods of teaching that incorporated ideas from various previous theorists. accordingly, p b l developed with a number o f core characteristics as follows: (i) learner centeredness (ii) small group learning (iii) facilitation by tutors (iv) interacting with iconic problems (v) problems facilitate knowledge and skills (vi) self-directed learning (barrows, 1996). in addition, p b l as a method, recognized the relational and discursive nature o f learning. firstly, from the perspective o f the relationship between the learner and information and secondly, from the perspective o f the social relationships in which such knowledge was constructed. moreover, p b l allowed learners to actively: (i) create meanings from evidence, facts and information, (ii) negotiate the meanings these facts had in relation to a specific learning outcome, (iii) co-construct meanings in a social milieu (hmelo-silver 8c barrows, 2006). this meant that learners provided the power for the process o f learning; learning was owned by learners; and learning occurred in a realistic social context that better emulated a real-life work environment than the classroom lecture, in which the learner was a passive and uncritical recipient o f the lecturer’s dictated notes. it therefore located the learner in a particular active relationship to information which was dynamic and ever-changing. in this student driven learning, learners drive the discussion, while the p b l facilitator scaffolds the process o f learning (collins, brown 8c newman, 1989). more specifically, p b l is a methodology for teaching and learning that involves active, small group learning that focuses on investigating and explaining a meaningful problem (barrows, 2000). learners meet in small groups o f seven to nine individuals and are facilitated by a p b l facilitator. essentially, a problem is a narrative or artefact that triggers enquiry and the growth o f knowledge. on analyzing the problem, learners identify the relevant information provided in the problem; and this allows the learners to meaningfully represent the problem, so that a process o f hypothesizing can ensue (hmelo-silver, 2004). this means that learners try to predict what the issues and consequences o f the problem might be, prior to formal study. this process o f hypothesizing leads naturally to defining knowledge deficiencies which 78 | die suid-afrikaansetydskrif vir kommunikasie-afwykings, v o l 55, 2008 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) p r o b l e m b a s e d l e a r n in g a n d t h e c o n s t r u c t io n of a n slp c u r r ic u l u m become the learners’ “learning issues”, and which fuel the process o f self-directed learning (hmelo-silver,2004). once learning issues have been set, learners leave the tutorial and access literature over the next few days. this literature may provide solutions to the learning issues and may help the learners confirm or disconfirm their hypotheses (hmelo silver, 2004). on reconvening a few days later in a tutorial, learners are provided with opportunities for in-depth discussions o f their findings. these discussions foster the application o f their new-found knowledge to the problem trigger, their hypotheses and their learning issues (barrows, 2000). during this process, notes are taken on a blackboard and learners make attempts to answer their learning issues. finally, at the completion o f a problem, learners hand in academic journals which are essentially short essays that reflect the synthesis o f knowledge that occur in tutorials and which demonstrate the learners’ practical application of their learning to the characters and elements in the problem. these partly replace lecture notes on the topic in question. p b l therefore achieves a number o f goals in relation to learning: 0) the development o f a professional knowledge base (ii) problem solving skills (iii) life long self-directed learning (iv) social collaboration (v) motivation to learn (barrows 8c kelson, 1995). in an slp curriculum,a set o f problems elicits a part, but preferably the entire curriculum. this means that the faculty involved in the delivery o f such a curriculum, need to decide in consultation with statutory professional bodies and other departments, how widely the p b l curriculum can be incorporated into the overall slp curriculum. ideally, all aspects o f an slp curriculum could be delivered using an integrated pblj approach. this means that psychology, linguistics, communication disorders, audiology, education, neurology and physiology might all be delivered as a series o f coherent problem triggers that are integrated to form a complete curriculum. this may not be entirely achievable; but in the author’s 'experience it is sufficient to incorporate some o f the disciplinesj -and parts o f the essential aspects of others. however, when a discipline other than slp, such as psychology is involved in such an approach, then its modules should reflect this inclusion within the slp curriculum; and therefore, an associated reduction in formal psychology lecturing contact. in other words, p b l should not double student workload or contact. in line with a constructivist epistemology o f learning, each problem would incorporate a number o f subject areas simultaneously, rather than simply embodying a different subject area in each problem. according to barrows (1998), p b l should aim to facilitate the acquisition o f knowledge on a deep level thus developing clinical problem solving; and that this could be attained by integrating various disciplines into each problem. curriculum developers should work collaboratively with other disciplines to incorporate the relevant aspects into the slp curriculum. thus, p b l is essentially an interdisciplinary venture involving the social collaboration o f lecturing staff, adjunct lecturers (p b l facilitators), learners and different faculties. such collaboration can have positive spin offs such as interdisciplinary research and community development. research in p b l for sl p curricula there are only a few studies evaluating the utility o f p b l in the field o f slp; but these are mostly related to the student experience. for example, murphy (2004) studied 1st and 2nd year slp learners’ experiences o f p b l in the context o f a psychology curriculum using a questionnaire. murphy reported that learners experiencing this curriculum, valued both the team work and involvement in in-depth learning; but perceived the method as increasing their expected workload. this finding by murphy might be explained by learners being used to passive learning as experienced in other more traditional courses or an unreported addition o f p b l to a standard psychology lecturing curriculum. in addition, murphy’s participants felt that interpersonal communication was somewhat awkward between some learners new to this method (murphy, 2004). leahy, dodd, walshe 8c murphy (2006) conducted a similar attitudes study with 2nd, 3rd and 4th year students in addition to m sc learners in slp curricula in two centres; one in ireland and another in the uk. these researchers reported descriptive statistics indicating 71% o f their two participant samples believed that p b l was relevant to practice, but only 58% believed that p b l was sufficient for preparation to practice. it is not clear from these studies how various disciplines were integrated into the p b l curriculum; or if this method was incorporated only into a single module. fourie and fletcher (2006) conducted a questionnaire study to evaluate learners’ attitudes to p b l following a foundation year in a newly formed slp curriculum, in which communication disorders, psychology and linguistics were mostly delivered in an integrated p b l format; with a few supplementary workshop-type lectures for practical skills such as phonetic transcription and language analysis. twenty three respondents completed an anonymous questionnaire indicating agreement or disagreement on visual analogue scales (vas) eliciting attitudinal constructs in relation to their experience o f p b l . participants in this study generally agreed that they enjoyed group sharing and discussion and agreed that p b l engendered critical and clearer thinking, self-directed learning and the improvement o f communication skills in a group context. however, participants were equivocal with regards to their attitudes to the differential contributions o f members in a group, mutual support and resource sharing. in summary, most o f the slp studies assessing learner experiences, generally seem to agree that learners perceive benefits and some shortcomings o f the p b l method. furthermore, as colliver (2002) notes, widely reported student satisfaction and preference for p b l in the field o f medicine, does not guarantee practitioner competence. there are no extant studies in the field o f slp education clearly differentiating the academic and clinical outcomes o f traditional learning versus p b l . relevant research outside o f the discipline, mainly focuses on knowledge competency following exposure to p b l (koh, khoo, wong and koh, the south african journal of c o m m u n ic atio n disorders, vol. 55 2008 | 79 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) robert fourie 2008); and there have been controversies in relation to whether p b l results in a weaker knowledge base in medical students (colliver, 2002; vernon 8c blake, 1993). koh and colleagues (2008), in a recent systematic review assessing 15 controlled studies meeting their inclusion criteria, determined that while learners graduating from p b l curricula perceive themselves as having less knowledge than their non-pbl schooled peers, that there was no evidence to support this. moreover, their study provided evidence that p b l had positive effects on both the social and cognitive dimensions o f physician practice. readers are referred to koh and colleagues’ interesting analysis o f pre-existing literature on p b l outcomes in the medical education literature (koh, et al., 2008). constructing a p b l curriculum the following description is based on the author’s experience and understanding o f developing a p b l curriculum for a cork-based slp programme in ireland, which was based on an earlier university o f hong kong curriculum, modified and “hibernosized” for the irish context. these ideas for constructing a p b l curriculum are not intended to be prescriptive; but instead to provide suggestions for how p b l might be incorporated, in whole or in part, into an slp curriculum. the curriculum matrix a departmental curriculum committee, prior to developing a set o f problems for an slp curriculum, needs to develop a curriculum matrix that will help organize and systematize the curricular content o f a course (barrows, 1994). a curriculum matrix is a set o f carefully defined learning areas for each year o f the entire slp curriculum. learning areas for the entire curriculum need to be decided upon prior to devising problems; and these learning areas need to be associated into similar ‘knowledge groups’. for example, phonology and motor speech disorders in childhood could be grouped into a family o f learning areas relating to expressive problems in the paediatric population. in this way, a taxonomy o f learning areas should be devised by a curriculum committee. learning areas in slp are the major subdivisions o f the core topics o f slp. in some slp curricula, the first year consists o f a general introduction to communication disorders, while the second and third years incorporate paediatric and adult areas o f an slp curriculum respectively. devising a curriculum matrix should be based on the general topics pertinent to slp that accrediting bodies have determined to be the main areas o f learning for the profession. essentially, a curriculum committee, based on local norms, can decide exactly what areas o f knowledge need to be accessed by learners, so that they can become slps. often, such information may already exist in documents pertaining to the curricular goals o f an slp programme; or they can be distilled from lists o f learning outcomes based on bloom’s (1956) taxonomy, appropriate to a particular programme. the following is a sample o f a core topic and its associated learning areas in year one. 1) phonology (year 1): normal development o f speech during pre-school years relationship between speech and social development in early years phonological processes risk factors for delayed and disordered speech in addition, a number o f learning outcomes, based on bloom’s original (1956) taxonomy, can be stipulated for these learning areas. for example, the following learning outcomes are associated with the above topic and learning areas: learners should be able to: describe the typical development o f speech sounds, explain, with examples what is a phonological process, distinguish between typical and atypical phonological processes, appreciate the psychosocial effects o f speech impairment in an affected child. the above learning areas and learning outcomes are appropriate for an introductory level course. however, at a second year level, further learning areas might be added to a topic in a way that reflects the developmental level o f the learner: phonology (year 2): intelligibility analysis o f child phonology relationships between child and adult phonology contribution o f vowel errors to intelligibility assessment and treatment o f consonant and vowel processes the associated learning outcomes for these learning areas in the second year might include: i perform a consonantal relational analysis o f a paediatric speech sample. interpret phonological analyses for the purpose of designing intervention. ' | calculate percentage consonants correct (pcc) in a speech sample calculate percentage words correct (pw c) in a speech sample classify vowels into their various phonetic and phonological categories calculate percentage vowels correct (pvc) in a speech sample compare summary measures to normative data. / each program may differ according to the specific emphasis it has. also, learning areas should not include only communication disorders. learning areas should incorporate cognate areas pertinent to communication disorders. the following are examples o f such learning areas: 80 | die suid-afrikaansetydskrif vir kommunikasie-afwykings, v o l 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) p r o b l e m b a s e d l e a r n in g a n d th e c o n s t r u c t io n of a n slp c u r r ic u l u m the scientific method linguistic theories o f child language development psycholinguistic models o f speech and language processing developmental theories in psychology phonetics and ipa transcription grammatical analysis learning, memory and cognition the neurology o f speech, language and hearing once a comprehensive set o f learning areas and associated learning outcomes have been determined for each year o f a curriculum, the learning areas can be distributed throughout a number o f problems that will form the focus for learning during the academic semester. the curriculum committee needs to decide what learning areas should be contained in each problem; and these learning areas need to be clustered in plausible ways. however, it is important that there is some unexpected pairing o f learning areas in order to create surprise and to reflect the unpredictability o f clinical practice in slp. so for example, a problem on “neurogenic voice disorders” may be paired with “the construction and enactment o f intervention”. a problem on closed head injury might contain learning issues pertaining to the “social and psychological consequences o f closed head injury” together with the learning issue o f “evidence based practice”. thus problems have content which is related in a non-linear and often surprising way, which may reflect the realities o f practice. examples o f plausible pairings include attention deficit disorders and medical anthropology stammering and personality theory specific language impairment and measurement o f intelligence , personal adjustment counselling & neurogenic voice j laryngeal cancer and lifespan psychology o f late middle-age i . cleft palate and the psychology o f disfigurement on a more practical level, once learning areas have been outlined, a curriculum committee needs to know how many problems they need for each year o f study and how those problems will be divided into the semester structure o f the college. some slp programs incorporating p b l , include more learning areas in fewer problems, while other programs have more problems with fewer learning areas in each. i f the curriculum committee decides for example, to have fifteen problems per year, they need to decide what the focus o f each year will be. so for example, first year may be a general introduction to paediatric and adult communication and development; with second year focusing on paediatric disorders o f communication; and third year focussing on adult disorders o f communication. this depends on how the faculty understands the developmental sequence o f learning for their learners. typically, each, member o f a curriculum committee becomes a “case manager” and is assigned a number o f problems to devise, manage and regularly update, according to their general areas o f expertise. part-time staff or independent consultants can also be involved in this process with responsibility for possibly fewer cases in more specialized topics. in addition, case managers can work together to incorporate different aspects o f a complex topic into a single problem. it is important however, that case managers have some experience in the areas covered in the problem, so that the problem trigger can be written from experience and therefore have ecological validity; or can be taken from a real case, and made anonymous for the purposes o f confidentiality. also, if the case manager has experience in the learning areas covered in the problem, it is more likely that he or she will have access to data and artefacts relevant to the problems. so for example, a problem containing reference to acquired profound hearing loss in adulthood may need to include audiograms and other electrophysiological data. once case managers have been assigned, it is their responsibility to construct a problem or problems that relates to the learning areas they have been allocated. however, problems need to be carefully constructed and it is therefore necessary to examine what a problem is in a little closer detail. w hat is a problem? before entering into definitions o f the problem in the context o f p b l , it is relevant to examine the notion of “problem” generically. essentially, a problem is an anomaly that calls for explanation or response; and is therefore a challenge to responsibility. accordingly, a problem presents an opportunity to apply old knowledge and in the process, synthesize new knowledge. thus a problem carries within it the potential for transformation. however, a problem implies an expenditure o f energy: effort is required to create a transformation. i f something did not involve effort, or was properly understood then it would not be a problem. therefore, a problem can also be seen as a kind o f gateway to knowledge and personal transformation that involves personal effort. a significant portion o f what is discussed in a p b l tutorial involves conversation around a textual trigger or problem; although videos, live clients and other artefactual objects can also be used. a problem is usually a state or an event, and its structure can be easily reflected within a narrative framework. in the context o f pb l , a problem is for all intents and purposes, an interesting, meaningful and educationally relevant narrative and it consists o f events that need to be explained (norman & schmidt, 1992). problems should be “ill-defined”, complex and reflective o f the real world. carder, willingham and bibb (2001) explain that “ill defined” means that a problem does not have a specific single solution; thus reflecting the reality o f practice. however, it is a trigger that is amenable to discussion and the making o f meaning. such discussions mostly involve the analysis of text and it is therefore important to understand what makes various aspects o f such narrative texts meaningful or salient to learners. in the context o f communication disorders, a problem is a plausible and ecologically valid story about either a client with a communication or swallowing disorder; and/or about an slp, with the purpose o f bringing to the learner’s attention, experiences that might be salient to the practice the south african journal of c o m m u n ic atio n disorders, v o l 55 2008 81 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) robert fourie o f slp. therefore, a problem has an explicit purpose: it enables learners to construct the various facets o f what it means to be an slp, in a particular context. it is therefore designed to evoke the meanings, professional values and knowledge that slps need to set in motion to perform their profession. the problem is therefore an exemplar o f an slp issue relevant to becoming an slp, told as a story or part o f a story. in p b l , such contexts for learning are stories that are constructed as a “problem”. the problem as narrative the work o f the slp is transformative and therefore involves stories o f change. thus, the problem trigger may be identified as a meaning-generating narrative and as a narrative, it will follow the laws o f narrative discourse. thus, every problem is framed as a story and is constructed according to a story grammar: it has a beginning, a middle and an end, like any good story does. it is necessary to understand what makes these stories meaningful to learners. stories are complex and non-linear, reflecting the complex nature o f society. it is this complexity that makes humans love stories. this is evidenced by the value we place on television, cinema, radio, the reading o f novels. thus it makes sense to present information and a context for learning in the framework o f a story. symbolic interactionism (blumer, 1969) predicts that we are relational beings, looking for patterns o f information in order to construct our own stories and to make meanings o f the things we experience. story grammars for problem construction the construction o f a story is not that straightforward, particularly when that story is textual. thorndyke (1977) argued for a propositional-structural model o f stories: that stories have their own grammar and consistent internal structures. thorndyke outlined the structure o f a story as consisting o f a setting, which is the character list located in time and space; a theme, which is an event with a goal; a plot, which is a problem or a series o f problems containing attempts to solve problems; and finally a resolution which is a specific event/state. these components were stated as rules in the format: story => setting + theme + plot + resolution thorndyke described his narrative schema as a “frame” with its abstract components instantiated by specific details. stein and glenn (1979) has a slightly different way o f formalizing the story grammar. their story was structured according to the following format: story=>setting + in itiatin g event + internal response + a ttem p t + consequence in this grammar, which is framed slightly differently to thorndyke’s frame, the plot is subsumed by greater specification from the perspective o f the actors in the story and the theme o f the story is absorbed into the setting. there are a number o f other story grammars, but these two represent the most commonly referenced story grammars and would be familiar to slps working on discourse in language therapy. it is not sufficient to specify the abstract components of a story. it is also important that these components are held together in a coherent manner (carroll, 1994). therefore, sentences need to “tie” together sufficiently and make appropriate anaphoric reference to indexed members of the narrative. indeed, the degree to which the reader will appropriately assimilate information in a text, will depend in part on how the reader processes that informational content (chambliss, 1995). the adequate processing of information will depend on a number o f factors, some o f which are intrinsic to the learner and others o f which will be dependent on the text presented to the learner. textual narrative considerations before engaging with text, there are a number o f attributes o f learners that will determine how they interact with textual problems. firstly, it is necessary that learners have a need for cognition which can be defined as a “tendency to engage in and enjoy thinking” (cacioppo 8c petty, 1982, p. 116). secondly, topic interest refers to how likely a learner will have positive affect in relation to particular content (renninger, 2000); and thus the significance o f such material is probably mediated by the learner’s value system and affective experience (hidi 8c baird, 1988). moreover, learners who have personal interest in the topic, are more likely to process information in text (hidi, 1990). these intrinsic factors intervene in the likelihood o f learners to engage with text. on the other hand, factors extrinsic to the learner and located within the structure o f text also have a mediating role in how textual problems are processed. “interestingness” refers to how well learners will respond to a text (hidi 8c baird, 1988). for example, textual information which is highly interesting is more easily recalled than text o f less interest (shirey 8c reynolds, 1988). schank (1979) was one o f the first researchers to discuss interestingness in the context o f discourse processing. according to schank, material is more interesting when it is non-normative, such as when things don’t go according to expectation; when there is missing information which causes puzzlement and when the themes elicit “absolute interest”, i.e. they are o f an archetypal nature, such as death1, sex and power (schank, 1979). however, it is important to recognise that while text can be made artificially interesting; this may not necessarily facilitate important generalizations;1 instead it may detract from such important processes, (garner, alexander, gillingham, kulikowich 8c brown,, 1991). therefore, when constructing problems, the author needs to make problems interesting; but not in a manner that may detract from their meaningfulness, in relation to communication disorders. dole and sinatra (1998) state that motivation in learners to engage with text is determined by their dissatisfaction with their current state o f knowledge, the personal relevance the information has for them, its social context and their own need for cognition. these researchers hypothesize that there is an interaction between learner characteristics and with characteristics o f the text that result in meaningful engagement with the text. they suggest that text should be coherent, plausible, interesting and rhetorically compelling. dissatisfaction with the current state o f knowledge is referred to as cognitive dissonance (festinger, 1957; 82 | die suid-afrikaansetydskrifvir kommunikasie-afwykings, vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) p r o b l e m b a s e d l e a r n in g a n d t h e c o n s t r u c t io n of a n slp c u r r ic u l u m neighbour, 1992). in the context o f learning, cognitive dissonance is a psychological state in which the learner feels dissatisfaction at not knowing. savery and duffy (2001) call this cognitive “conflict”and state that this conflict determines what the learner will focus on and what prior knowledge the learner will invoke as relevant to constructing new knowledge. the problem should therefore induce in learners a need to want to find out. an individual experiencing cognitive dissonance, feels motivated to reduce it and to engage in behaviours reducing this dissonance. therefore, an incongruity between the learner’s previous understanding and current experience are what drives learning (palincsar, 1998). therefore, cognitive dissonance prompts the learner to find out; and it is essential for the accommodation o f new ideas and information. cognitive dissonance is similar to a need for cognition, in that it motivates behaviour, but is more goal-directed. w hile a need for cognition is an intrinsic individual trait that probably cannot be modified externally, cognitive dissonance is a state which can be induced in the learner by providing the learner with information that challenges understanding or creates a sense o f puzzlement or questioning. according to perret-clermont, (1980) it is this “cognitive conflict created by social interaction” (p. 12) where intellectual strides are made. this cognitive dissonance results in pertinent questions; and it is this questioning that is made explicit in the inventory o f learning issues which learners formulate prior to accessing literature and making enquiry. w ithout this invoked sense o f needing to know, the self-directed learning process is rudderless. relevance and ecological validity the case manager should devise a problem that is ecologically valid. this refers to whether a problem is plausible, structured and coherent (gonzalez 8c salmoni, 2008). this means that the problem should be interesting, but not full o f distracting facts; it should be relevant to the curriculum; and it should contain supporting data and artefacts to corroborate and accentuate the ideas it aims to draw out in the learner. the problem is written in such a way that it will create a series o f cognitive dissonances in learners that will inevitably lead them to ask relevant questions to answer their uncertainties. in order to write a plausible problem, the case manager needs not only to have some experience in that particular field, but also to be guided by evidence and literature in the fields covered by the learning areas. the professional socialization o f learners through narrative i f problems are not very carefully constructed to show faithfulness to complex issues in the life o f clients and patients, they can inadvertently transmit unwanted assumptions, values and beliefs to learners (kenny 8cbeagan, 2004), that are neither advantageous to the profession o f slp, nor effective for the multifaceted treatment of clients and patients. w hile learners need to be exposed to problems that will closely resemble their future occupational situation (dolmans, 1997), problems and case histories can depersonalize the client, reducing and separating the client into a list o f symptoms (anspach, 1988). such a list may be useful to the practitioner as the end o f a process o f interview and assessment, but is not representative o f what learners will encounter when dealing with clients (kenny 8c beagan, 2004). in fact, narratives presenting clients as a distilled list of symptoms may effectively distort the client’s life by situating them out o f time and context. in addition, the use o f certain linguistic features may create further problems. for example, the use o f the passive voice, imbues authoritative and factual status to the omitted practitioner (anspach, 1988); for example: “the client was assessed”, and “the palpa was administered”. other linguistic markers might encode scepticism regarding client narratives, for example: “the client claims”, or “the client reports”. passive sentences used together with such sceptical descriptors transmit an attitude that the practitioner is in control and that the client’s story is not to be trusted. kenny 8c beagan illustrate the power o f language in a problem statement from a medical curriculum: for example, in one case, after a patient “was referred to a respirologist”, he “underwent bronchoscopy”. shortly afterwards a “chest x-ray showed a 50% pneumothorax” so “a chest tube was inserted”. he “was admitted to hospital” where “the chest tube continued to bubble”. here no one performed the bronchoscopy (let alone cleaned the bronchoscope, wheeled the patient into the room, or cleaned up afterward); no one took the x-ray, or read it; no one inserted the chest tube; no one admitted the patient, nor did the patient enter the hospital himself. the most active agents here were the x-ray showing, and the chest tube bubbling! (kenny 8c beagan, 2004, pp. 1073 1074). kenny and beagan (2004) further point out that the presence o f the client as an actual real person who experiences impact is often omitted in problems and they further imply that such characterizations may ultimately erode the learners’ ethical sensitivities. they recommend the use o f live clients where possible, the use o f dense texts (containing richly detailed information about the client), the use o f video, web technologies, photographs, transcripts and diary entries, among other things, to more richly portray the complexities o f real live clients. professional and inter-disciplinary issues in addition to issues regarding the self-directed learning process o f learners and how the problem should be structured, there are other issues to consider in the development of problem triggers for an sl p curriculum. the fact that slp is practice-oriented and governed by statutory bodies and legal parameters in most countries, means that the set o f problems in an entire curriculum should be reflective of the typical principles and practices an slp would need in the field as outlined by the statutory bodies. however, no curriculum can ever cover every aspect o f knowledge pertinent to the field o f slp. this is because the fields o f communication disorders, psychology, linguistics and physiology pertinent to speech disorders is so vast and ever-expanding. this is partly due to the explosion o f available information in an information age dominated by the internet. indeed, the drive to attempt to cover every possible piece o f information the south african journal of c o m m u n ic atio n disorders, vol. 55 2008 | 83 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) robert fourie relevant to a topic is part o f a realist epistemology. but, it is not possible to cover everything. nevertheless, it is possible to expose learners to core exemplars o f essential knowledge pertinent to the practice o f slp that might facilitate an intelligent and critical evaluation o f available information. there is therefore, to some extent, a tension between compulsory components o f a curriculum and the facilitation o f an intelligent and critical attitude to knowledge that is the essence o f the slp; and which facilitates life long learning. unfortunately, a curriculum committee can become divided along realist/constructivist epistemologies and it is therefore important that p b l does not become divisive in the delivery o f slp curricula. to this end, it is important to find a middle ground between process and content. the role o f the p b l curriculum designers is therefore to devise problems that will simultaneously serve as core exemplars o f factual knowledge, while evoking the principled attitudes, cognitions and activities o f the slp working in a field which is not always typical or linear; and indeed changing rapidly. evaluating current suitable literature in a pure p b l approach, learners are left to find appropriate literature pertinent to their learning issues, themselves. w hile this is basic to the spirit o f enquiry based learning, it may not always be appropriate for professional courses, particularly i f there is not excellent library support. although p b l is loosely based on principles o f adult learning, many professional undergraduate programs deliver curricula to 17 and 18 year old learners. such individuals may have achieved legal adulthood in most countries, but most individuals at this age are still teenagers. although they may be cognitively mature, they may not have the adult experience or affective maturity to properly evaluate the level o f reading that would be expected o f them. in addition, learners from certain secondary schools may have been over-coached into graduation; resulting in learners who despite high achievement on final leaving certificate examinations, find it difficult to responsibly source, evaluate and apply academic information. for this reason, the current author recommends that first and second year learners be recommended prescribed texts to evaluate and read, while simultaneously be encouraged to bring their own researched material to tutorials. later in third or fourth year, learners should know the level o f reading required, and will also have matured into adulthood proper. they can then be at least partly expected to find the appropriate literature for achieving their academic goals. therefore, each case manager needs to prescribe appropriate texts, and this involves evaluating current literature relevant to the learning areas. case mangers can recommend academic papers and expository texts that either cover the individual learning areas or the specific combination o f learning areas, or both. this entails a robust attempt to assess the current available literature and to make decisions on what literature would be suitable to the learners’ developmental level. to this end, the case manager has to find relevant scientific literature that illuminates the learning areas contained in the problem. this can be time-consuming, but is absolutely essential to not only present a plausible problem for learners, but one that will highlight current issues in the field pertaining to the problem. the implication o f this is that problems can become stale or dated, as new evidence is produced in the scientific literature. accordingly, one o f the duties o f the case manager is to continually evaluate the relevance and up-to-datedness o f the problems he or she manages and this can be achieved by annual intra-faculty curricular committee meetings. such meetings, while labour intensive also serve to enable departments to continually revise and improve their curriculum annually. in this way, problems remain fresh and will elicit issues that are current and relevant to the learner. introductory text-book chapters and secondary sources are often more digestible to first year learners who may need simpler and easier expository texts. similarly, case managers need to consider that learners may be second language users o f english, in which most slp texts are published. the issue o f cognitive academic language proficiency (calp) is particularly important in this regard (cummins, 1984, 1986); and case managers need to carefully select texts that are not too difficult for second language users; as this may be disempowering within any learning process. however, the p b l process allows students to express their difficulties with texts and allows those within the group, with a better grasp o f a particular text, to share their insights and understanding with other members o f the p b l group. as learners progress, texts which are a little more advanced can be prescribed. also, there is no harm in presenting learners with texts which are a little beyond their current developmental level. vygotsy (1978) discusses the principle o f working within the learner’s zone o f proximal development (zpd ). z pd is a level o f difficulty just a litde advanced from the learner’s current state o f understanding. i f material is presented that is too easy, learners will lose interest (particularly if they have a strong need for cognition) and conversely, if the material is too advanced for the learner, they will not feel capable o f understanding and will give up on the text. it is therefore important that the case manager carefully select texts which will challenge learners but neither bore them nor over-challenge them. a list o f recommended (or compulsory) readings for each problem can then be provided to learners for evaluating and informing the learning issues raised in p b l tutorials. the devising o f a coherent set o f problems is the first step in devising a p b l curriculum. j problem sample the following is an example o f a problem written by the current author, according to this schema. it is situated in a third year curriculum focussing on adult communication disorders and has been “south africanised” to suit local contexts: voice spasms, or “after ukufa komyeni warni.” case manager: dr. r. fourie ^ lhandi was a 2 7 -year-old postal clerk who worked in randburg. thandi had a personal tragedy in which her beloved husband had been killed in an mva; and which some professionals believed had resulted in a voice problem. an e n t referred thandi to an slp. 84 | die suid-afrikaansetydskrif vir kommunikasie-afwykings, vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) p r o b l e m b a s e d l e a r n in g a n d t h e c o n s t r u c t io n of a n slp c u r r ic u l u m it also had become obvious to ihandi and her family that her voice had deteriorated quite severely after her loss because they kept having to ask her to repeat herself due to her weak and strained voice. a psychologist's report stated that besides the death o f her husband\ there were no other obvious psychopathological factors at play in ihandis case. since there were no obvious causal factors besides ihandi's husband's death, and the report from the e n t stating that there was no evidence o f any kind o f physiological pathology, dr. mary nthebe, an slp practicing near ihandi in randburg, diagnosed afunctional voice disorder. ihandi then commencedfor voice therapy with d r nthebe, fou r months after her husband’s death. but dr. nthebe realized after three sessions that ihandi’s voice problem seemed intractable. a t first the voice was weak and intermittent, and ihandi complained that she felt there was "something stuck in her throat like a “small ifishbone kanje. after ukufa komyeni wami”. throat clearing did not release her voice and gradually the voice became more strained and started showing an intermittent strangled harsh quality. d r nthebe referred back to the e n t who again, couldfind no obvious organic causes. it was at this time that the e n t diagnosed, with the assistance o f a specialist slp trained in electroglottography (egg), the presence o f adductor spasmodic dysphonia (see data). ihandi went back to dr. nthebe, feeling very demoralised after the new diagnosis because firstly, she believed her family “thought it was all in her head” and this was upsetting f o r her: “do they think l a m a hypochondriac? awu ngiphe amandla, nkosi yami”. she felt nobody understood what it was like f o r her. secondly, she wanted to know why the doctors wanted her to try botulism as a medicine. "surely that will kill me”, said ihandi, “but maybe that will be good. i can join my beloved husband ezulwini. akekho onjengaye”. d r nthebe understood that ihandi meant botulinum toxin (botox) treatment fo r spasmodic dysphonia, and felt worried aboutlhandi’s mental health. dr. nthebe looked down at her report from the specialist slp and wondered how his report could possibly have any real meaning in relation to ihandi’s suffering. this is what she looked at: e g g dear dr. nthebe the peaks o f the waves in this e g g represent the closure part o f the vibratory cycle o f the vocal folds; while the "valleys” represent the open part o f the vibratory cycle. by using standard measurements o f the e g g graph above, and using the formula cq = t c / ( t c + to) i have determined that ihandi’s vocal folds have a 0 .7 closed quotient, indicating possible adductor spasmodic dysphonia. k in d regards fannie vermeulen, slp dr. nthebe decided to make some rooibos tea to share with her client, to help calm ihandi’s mind, before explaining the issues to her distressed client. product: role play dr. nthebe’s conversation with thandi. learning issues in the above problem, the following may represent questions or learning issues learners might come up with as pertinent to the problem: w hat is spasmodic dysphonia? w hat is a functional voice disorder? w hy did the slp first think the problem was functional? how can an slp differentiate between two types o f voice disorder? how does a functional voice disorder differ from spasmodic dysphonia? w hat is electroglottography and how does it work? w hat is the significance o f the closed quotient and the e g g graph? w hat is the role o f the e n t in the diagnosis o f voice disorders and how do these two professions work together? w hat, if any, are the neurological bases o f spasmodic dysphonia? w hy is b o t o x used with spasmodic dysphonia? how can the slp answer the client’s concerns about the problem being “all in her head”? w hat is the role o f the psychologist in voice disorders? w hat is the role o f the slp in relation to counselling the client? once hypotheses have been made about the problem and learning areas have been formulated, learners can access the literature in a meaningful way. reading alleviates the cognitive dissonances learners experience as they resolve the questions raised in the learning issues. once learners have accessed online resources and relevant expository texts available in the campus libraries (or provided by the department), the learners are ready to discuss what they have learned with each other. learners evaluate the literature and find resources to be brought to the tutorial for discussion. it is at this point that the p b l facilitator could help the learners evaluate the quality o f the information in relation to the requirements o f the profession. evaluating the problem prior to learner exposure once case managers have completed designing a problem, they might want to ask the following questions o f the problem, to determine whether it is suitable for the program: the south african journal of c o m m un ic atio n disorders, vol. 55 2008 | 85 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) robert fourie does this problem represent a recognized core area or field in the profession o f slp? does the problem have ecological validity, i.e. does it seem plausible from the perspective o f a practitioner? have i seen a similar case myself? does the problem have good narrative structure and connectivity? does the problem take account o f the complexity and non-linearity o f practice? does this problem promote conceptual thinking and development? does this problem engage the reader affectively in some manner? does this problem allow the possibility o f relating theory to appropriate practice? does this problem have any data or artefactual information for the learner to grapple with and process? does this problem elicit current thinking on the topic? is their sufficient recommended literature that takes into account the learners’ developmental level? is the problem narrative culturally appropriate? does the narrative reflect a changing multi-cultural society? are there too many red herrings or distracting pieces o f information in the problem? the structure o f the p b l session according to barrows (1994), p b l tutorials should progress in the following order: ideas & h ypotheses »> facts => l earn in g issues => a ction plan various problems structure p b l programs loosely according to this structure. for example, the maastricht university program consists o f a process which manifests barrows’ (1994) sequence in seven steps. at university college cork, where the current author is situated, p b l sessions are structured as follows: 1. assignment o f roles, in which a chairperson and secretary are elected by learners; 2. analyzing the problem by defining its content; 3. remembering and discussing what is already known, either formally, informally or both; 4. making hypotheses and imagining implications of hypotheses; 5. structuring question as learning issues and ranking their relative importance; 6. distributing academic work in which learners decide on who will research what; 7. doing the work o f resolving learning issues by accessing literature; 8. reconvening, sharing and synthesizing knowledge in note form; 9. clarifying knowledge by constructing concept maps or devising products related to the problem; 10. re-reading the problem in the light o f new found knowledge and relating these to the curriculum matrix; 11. reflecting, giving feedback and making suggestions for the future. products and concept maps at stage nine o f the eleven point process, learners can clarify their knowledge by constructing visual summaries o f their new-found understanding and knowledge in the form o f concept maps. these concept maps, invented by novak (1990) are a tool for organising and representing knowledge and are ideal for summarising a process o f learning. the example below in f ig .l, is a concept map devised by first year learners pertaining to voice and laryngeal cancer, and is borrowed with permission from o ’toole (2006). constructing concept maps allows learners to develop a taxonomy o f knowledge and allows them to understand how differing sets o f information relate to each other. mok, w hitehill, and dodd (2008, in press) discuss how concept maps relate to critical thinking in pbl. similarly, the learner could be asked to construct a product in relation to the problem. for example, in the sample problem provided above, learners were asked to role play a conversation together; or learners could be asked to write a short letter to a medical professional detailing issues in relation to a client. similarly, learners can construct as a product, an information leaflet relating to the problem trigger. learners can either construct products as a group, or produce these in preparation for tutorials, individually. learners can be evaluated on the effort and meaningfulness o f their products and concept maps. reading forms and academic journaling in addition to concept maps and products, learner’s knowledge and synthesis o f knowledge can be evaluated by setting them the task o f writing short essays at the end o f each problem, in which they apply their knowledge to the problem at hand. this involves either summarizing information i f they are first year learners, or demonstrating their ability to apply relevant knowledge by applying academic content in relation to characters in a problem, i f they are in second or third year. this permits the p b l facilitator, who marks these, to evaluate how deeply the learner was able to make sense and meaning o f the literature; and provides the learner with an opportunity to formally demonstrate their relationship to knowledge. in addition, it provides the learner with opportunities to develop written skills. it is particularly valuable to learners when p b l facilitators provide feedback pertaining to the content and style o f these reading forms. the writing o f such applied summaries form one o f the bases o f continual assessment for the p b l curriculum. ; in addition to reading forms, learners can submit an academic journal once a semester. this journal provides the p b l facilitator with a personal account o f the learners’ experiences o f learning and their individual processes o f academic development. alternatively, such journals can be incorporated in the structure o f the reading form. the role o f the p b l facilitator faculty lecturers, post-qualification phd students, clinical tutors and other contracted speech and language therapists in the community can serve as p b l facilitators. year co-ordinators divide up a year cohort into groups of 7 to 9 learners, who are allocated to a p b l facilitator for a semester at a time. each group meets with their p b l facilitator for two to three-hour sessions in lieu o f lectures; or with a few focused lectures pertinent to the problem under study. according to caplow and colleagues (1997), the effectiveness o f the p b l facilitator’s role can have a major 8 6 j die suid-afrikaanse tydskrif vir kommunikasie-afwykings, vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) p r o b l e m b a s e d l e a r n in g a n d t h e c o n s t r u c t io n of a n slp c u r r ic u l u m difficulty swallowing lymphatic system ottiier organs staging system . ; speech j teryiw 1 laryngonasopliw yhgolaryngascopy neck exam « mai scans, --------------; is sy ste m ) therapy i(dnht; i [laryngectom y] 'twcivm bclfl \ ratfation therapy &ctiemotherapy f ig 1. example o f concept map, used with permission from o’toole (2006). impact on the success o f p b l outcomes in learners (caplow, donaldson, kardash, 8c hosokawa, 1997). the skills employed in p b l are counter-intuitive and not often used in traditional pedagogies. therefore, it is important that each p b l facilitator undergo some form o f formal training in the facilitation o f p b l tutorials. frost (1996) believes that the role o f the p b l facilitator is to foster learner ’̂ exploration and reflection and thus enable them to achieve learning objectives. w hile some authors such as wilkerson and maxwell (1988) advocate that p b l facilitators remain silent for long periods, some p b l programs encourage facilitators to take an active role in guiding learners to explore learning areas. at university college cork, p b l facilitators use non-directive methods in facilitating learners by providing stimulating questions (katz, 1995); providing alternate views and presenting learners with the consequences o f their ideas (schmidt, 1990). in addition, p b l facilitators can ask learners to justify their ideas, imagine the implications o f their ideas and hypotheses, develop metacognitive skills (thinking about the learning process), apply concepts to learning issues and ensure that all learning issues are covered in sufficient depth. also, the p b l facilitators concentrate on understanding the dynamics o f the group (hughes 8c lucas, 1997) and intervene when conflict hinders the process of learning (wilkerson, hafler, liu, schmidt, van der arend, moust, koyx, 8c boon, 1992). therefore p b l facilitators need to be trained to facilitate such groups; but the skill is easily learned and readily transmissible to others in the current author’s experience. p b l facilitators also evaluate individual students’ engagement with the learning process from tutorial to tutorial, such as contribution to discussion and enquiry, and the demonstration o f having read relevant texts, from tutorial to tutorial. this then represents another component o f continual assessment in a p b l course. iterative evaluation o f problems during the course o f tutorials, p b l facilitators should keep notes on among other things, how the learners responded to the problem. this includes whether they identified all the learning issues as identified by the case manager; how they responded to the recommended literature; their affective response to the problem; and their overall interest in the problem. learners often will provide criticisms o f the problem; particularly if it is not ecologically valid; or if the recommended readings are above their developmental level. learners can also be a source o f ideas for changing the problem in terms o f suggestions for learning areas and may sometimes identify sources o f information, more relevant readings or websites that were useful to them. these can be fed back to case managers for future iterations o f the problem. case managers, p b l facilitators and year co­ coordinators can then review facilitators’ notes at an annual curriculum committee meeting; and use such feedback to modify, extend or change problems to better reflect clinical practice and reasoning, available literature, learners’ actual elicited learning issues, as well as new developments in the literature. following this meeting, case managers make their modifications and submit their re-written problems to the year co-ordinators who then compile the revised problems into a book o f problems which is published in anticipation o f the next year of upcoming learners. listening to learners’ ideas is an extremely valuable way o f improving the quality and educational value o f the problems. problems themselves the south african journal of communication disorders, vol. 55 2008 | 87 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) robert fourie are therefore dynamic and ever-changing; reflecting the changing nature o f the field o f communication disorders, the changes in available information, the changing needs of clients and the changing needs o f slp learners. situating problems in semester times a set o f problems needs to be divided into the semester structure o f an slp course. how much time is spent on each problem, depends on its complexity, the amount of recommended reading and how many learning areas are covered in the problem. some slp curricula cover one problem per week or week and a half, while other curricula cover two very detailed problems over a whole semester. it is up to the curriculum committee to determine how much o f the course will be covered in p b l tutorials. table 1. below is a visual representation o f p b l tutorials structured over four times based on a curriculum framework in which the majority o f the curriculum is delivered by p b l tutorials. in this curriculum, there are between ten and fifteen problems per year. i f in the first year, fourteen problems are covered over two twelve-week semesters the problems can be structured as in table 1, below. typically, learners meet four times per problem in this time structure. however, time 1 and time 4 involve the end o f one problem and the beginning o f another. thus problems are staggered over periods that last approximately a week and a half. table 1. a visual representation o f tutorials structured over fo u r times the relationship o f the p b l curriculum to the rest o f the ytriifi 1 eg. (moncfayls 1 i f time 2 e.q. (thursday; n tln'ift 3 i h e . q . (mondays wsm ti.n»4 buie.g. end of previous problem (reflection etc see time 4) i reconvening & presentation of concepts s a 5 ; | a c w9 8u01 tjc reconvening & presentation of . £ concepts r ! 1 i 3 c completing problem (see time 1) « £ ou. o£ break i break (8 ' w break !> break s ! i i § 1 dc hypothesizing i < 1 0 u. 1 < next probism ami learning answering • qi• 5 answering (hypothesizing issues for new i learning 1 learning and learningproblem (see issues & issues 1 ! issues etc see ! time 4) j i umg 11 ; iff! curriculum it is probably unrealistic to expect that the entire academic content o f any program could be delivered by p b l alone. in addition to conceptual and affective learning, learners need to be able to do things relating to a profession. these activities are referred to as psychomotor skills. in slp curricula, this could refer to learning how to use instrumentation to analyze voice; or it may involve being shown how to administer a psycholinguistic assessment; or it may involve being shown how to work with a client in therapy. all o f these skills require procedural knowledge that are not necessarily accessibly from a p b l curriculum or a traditional curriculum. therefore, in addition to a p b l curriculum, the faculty needs to consider that learners may need supporting workshops and lectures which generally coincide with and elucidate the topics covered in p b l ; and can therefore present learners with an opportunity to apply theoretical knowledge in practice. evaluation and examination o f p b l learners various p b l programs assess students in different ways. at the slp programme at u c c, assessment is ongoing, and learners are evaluated on the basis of: (i) contributions to p b l tutorials; (ii) evidence o f having engaged in reading for the problem; (iii) reading forms and academic journals; (iv) formal examinations. as (i) to (iii) above have already been discussed in this paper, a process o f p b l examination is outlined below. a week prior to the examination date, learners are individually provided with an examination problem. this problem is a new learning opportunity that provides content not necessarily, or partly covered in previous p b l problems. in addition, learners are provided with appropriate references or readings pertaining to the problem. learners are expected to read all references in addition to their own further reading. during the examination, which is typically three hours in duration, learners may make reference to all unmarked readings, which they are permitted to bring to the examination. they may not bring in additional texts or any notes pertaining to the problem. the examination questions are devised from a constructivist perspective, i.e., they are written in such a way as to provide learners with an opportunity to demonstrate their ability to apply information and clinical reasoning appropriately to the examination problem statement. therefore, factual information is elicited; but the focus in examinations is on how students can use various sources o f information to construct coherent and meaningful applications to a clinical problem; thus demonstrating their knowledge in relation to information. consequently, memorisation o f factual information is less important than reasoning, application and a coherent discussion o f the learner’s learning issues.1 an example o f an examination questionl relevant to the problem, “voice spasm”,; cited above may be: , (1) explain why differential diagnosis o f spasmodic dysphonia was so difficult for the professionals involved in thandi’s case. in addition, provide a reasoned discussion of how d r nthebe’s evaluation ofthandi’s lack o f improvement led to a more accurate diagnosis; and what implications this might have for the general practice o f slp. such an examination question requires learners to think, reason and apply information to an iconic clinical situation and reflects the ethos o f the p b l format o f teaching and learning. o f course, faculty members can devise their own methods o f assessment that honour the p b l format, but these should consider the learners’ developmental level and the time implications o f such assessments; and should not focus on the learners’ abilities to memorize facts. in the 88 current author’s experience, many existing slp programmes die suid-afrikaansetydskrif vir kommunikasie-afwykings, vol. 55, 2008 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) p r o b l e m b a s e d l e a r n in g a n d t h e c o n s t r u c t io n of a n slp c u r r ic u l u m already structure examination questions in such a format. conclusion the current paper provides only a brief introduction to p b l ; and the interested reader is referred to a plethora o f available literature on the implementation o f a p b l curriculum. constructing a p b l curriculum involves a good deal o f planning and curricular consideration on the part o f academic staff. however, there are a number o f benefits to this, not least the promotion o f life-long, active learning in both learners and in faculty staff. academic staff tend to be more aware o f the overall curriculum and how lecturing serves the purpose o f elucidating on problems and learning issues formulated by learners themselves, in response to problem triggers. moreover, learners are keen to learn because they are invested and involved in the curriculum and this in itself is highly psychologically motivating and satisfying for curriculum designers and faculty staff. accordingly, it motivates faculty staff to update their curriculum, provide better exemplars o f learning and to keep abreast with current developments in a particular learning area or topic. by working together in small groups, academic staff and learners get to know each other, thus facilitating professional socialization. moreover, the work environment becomes rich in feedback loops thus improving communication as a whole within an slp programme. in conclusion, the following quote from w .b. yeats summarizes the current authors thoughts about the use o f pbl: “education is not thefilling o f a bucket, but the lighting o f afire. ” w b yeats references anspach, r. r. 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(2004). problem based learning, acta biochimica po lonica, 51(2), 2 1 -2 6 . j 90 die suid-afrikaansetydskrif vir kommunikasie-afwykings, vol. 5 5 ,2 0 0 8 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2. ) http://plato.%e2%80%a8stanford.edu/archives/fall2005/entries/realism/ http://plato.%e2%80%a8stanford.edu/archives/fall2005/entries/realism/ a single case study of the communication development of a high-risk neonate, from birth to discharge from an nicu 25 a single case study of the communication development of a high-risk neonate, from birth to discharge from a neonatal intensive care unit alethea mclnroy and alta kritzinger clinic for high risk babies (chrib) centre for early intervention in communication pathology department of communication pathology university of pretoria, south africa abstract since preterm and low birth weight infants display a high-risk for communication disorders or delays, the neonatal intensive care unit (nicu) provides the earliest opportunity where family-centered early communication intervention (eci) services can be initiated. extensive knowledge about high-risk neonates exists, but there appears to be limited knowledge about the emergence of early communication skills in these neonates. the aim of the study was to provide a systematic description of the successive communication developmental steps of a high-risk neonate on a weekly basis, from birth to discharge from a nicu, in order to guide further research on a larger scale. an α-type single case study design was used to collect prospective data over 14 sessions during the participant's 51-day stay in the nicu. using a comprehensive data-collection protocol, rich data sets were gleaned over time. the results are described as a chronology of events contributing to the participant's risk status and influencing his early communication development. the successive emergence of the different components of language skills in the participant provided new insights into the communication development of a preterm neonate and should be further investigated. an eci programme and guidelines for implementation in the nicu are discussed as a treatment option. key words: high-risk neonates, neonatal intensive care unit, neonatal communication development, early communication intervention, parent-centered approach introduction preterm and low birth weight neonates demonstrate a high-risk for developmental disorders and more specifically communication delays and disorders (rossetti, 2001). the neonatal intensive care unit (nicu) provides the earliest opportunity where family-centered early communication intervention (eci) services can be initiated (rossetti, 2001). in the south african context where preterm birth and low birth weight are the primary causes of death during the perinatal period (pattinson, 2002), initiatives.to start eci from birth onwards are warranted in order to / i minimize the effects of developmental disorders or prevent potential communication developmental delays in those infants who survive. j eci services in the form of developmentally appropriate care have been implemented in the nicu for some years and the efficacy of parent training, staff training and interventions directed at the neonates, such as appropriate oral-motor, tactile, vestibular, kinesthetic, visual and auditory stimulation, has been established (rossetti, 2001). in addition to numerous studies on developmental interventions in the nicu and outcomes of highrisk neonates (als, 1997; kritzinger, 1994; rossetti, 2001) various theoretical frameworks are offered to describe the neurobehavioral characteristics and associated environmental factors impacting on the high-risk neonate (als, 1999; brazelton, 1984; cioni, ferrari, einspieler, paolicelli, barbani & prechtl, 1997; klaus & kennell, 2001; samerhoff & fiese, 2000; young, 1997). despite in-depth descriptions of high-risk neonates, their associated medical conditions and early neurobehavioral development (als, 1999; als, 1997; rossetti, 2001; young, 1997), there appears to be limited knowledge of neonatal communication development in the nicu. references to high-risk neonatal communication behaviours are mostly based on typical development or integrated in descriptions of early mother-infant interaction patterns or neurobehavioural development (asha, 2004). it appears that no systematic chronology of the earliest communication development of high-risk infants can be found in the literature. an ordered description of the successive communication developmental steps of high-risk neonates in the nicu, may be an important source of information to identify developmentally appropriate intervention needs of the neonate and the family in the nicu. according to rossetti (2001) regular serial assessments of high-risk infants are the only means to describe developmental patterns, to measure developmental rates and change, to identify new problems, to provide information about the effects of intervention and to guide decision making during eci. informed decisions regarding developmentally appropriate care options in the nicu require a specialized knowledge base of fetal and newborn brain development, medical conditions of high-risk neonates and the subsequent neuro-developmental sequelae, different aspects of developmental and neurobehavioural patterns of high-risk neonates, the nicu environment and parenting in the nicu (rossetti, 2001). the preterm neonate is in reality a fetus developing in an extra-uterine environment and the demands of this unnatural environment may lead to maladjusted neurobehavioural development in the nicu (als, 1999). during the critical period of rapid brain development and the development of other organ systems the preterm infant is exposed to an environment characterized by inappropriate patterns of stimulation (young, 1997), far removed from the dark, peaceful and protected environment of the mother's uterus (als, 1997). eci efforts in the nicu can therefore only attempt to compensate for the infant's untimely start of extra-uterine communication development. birth weight and gestational age are considered the most important indicators of an infant's risk status, and later developmental disorders and delays in the child are strongly associated with these two biological risk factors (rossetti, 2001). various the south african journal of communication disorders, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 26 alethea mclnroy and alta kritzinger complications in the perinatal period, lengthened hospitalizations and separation from the primary caregivers may contribute to delayed development, and more specifically, delayed communication development (rossetti, 2001). developmentally appropriate ec i goals should therefore aim to create the most ideal environment viable to support the infant's development from the earliest possible time. consequently, family-centered eci services are advocated, since human relationships are essential for the survival and development of high-risk neonates (als, 1997; klaus & kennell, 2001; rossetti, 2001). a family-centered intervention approach in the nicu is essential as the parent-infant attachment process, initiated before conception and disrupted by preterm birth, needs to be restored and continued in the first days and weeks of the neonate's life (klaus & kennell, 2001). optimum attachment is important as the caregiver and neonate's abilities to establish ideal patterns of interaction increase the potential for appropriate communication development in the neonate (rossetti, 2001). parents' stressful experiences of caring for the neonate in the nicu may have a negative influence on their subsequent interaction with the preterm infant (klaus & kennell, 2001). interventions aimed at supporting the family are most important since parents are the primary mediators between the neonate and the healthcare system (young, 1997). due to unique circumstances every high-risk neonate and family has individual needs, which emphasizes the provision of individualized eci programmes (als, 1999). the basis of a developmental! y appropriate intervention programme rests on the premise that the neonate communicates through behavioural changes in response to physiological changes, handling or the environment (ziev, 1999). by rendering services to the high-risk neonate, the family and the nicu staff, long-term risks for the neonate's communication development may be decreased (rossetti, 2001). due to the high prevalence of preterm and low birth weight infants in south africa it is important that speechlanguage therapists play an active role in the nicu. knowledge about the chronology of early communication development of infants while in the nicu, may guide developmen tally appropriate eci programmes and facilitate best practice in the nicu. the research question for the study was stated as follows: how may serial assessment data of a high-risk neonate's communication developmental progress in the nicu be used to identify the changing needs of the neonate and parents and provide guidelines for an individualized developmentally appropriate eci programme? although the findings of a single case study cannot be generalized to other cases or contexts, it may be used as a basis for a larger scale study and a treatment option for eci services in the nicu. method aims the main aim of the study was to provide a systematic description of the communication development of a high-risk neonate, from birth to discharge from a nicu in order to identify changing developmental needs in the infant and parents. specific sub-aims were identified to track and describe the following aspects regarding the participant from birth to discharge from the nicu: • the cascading effect of biological risk factors identified in relation to the participant ο the changing physiological states, feeding behaviour, development of neurobehavioral states and the participant's changing ability to organize himself in the nicu environment ο the participant's emerging communication development ο the process of attachment and parent-neonate interaction ο the changing needs of the participant and his parents with regards to eci based on the outcomes of the sub-aims a developmentally appropriate eci programme was applied during the neonate's stay in the nicu, and will be described together with guidelines for further intervention. research design an α-type single case study research design was selected, since it is a descriptive research design that describes one participant's behaviour as it occurs in the natural environment (mcreynolds & kearns, 1983). a longitudinal design was used since information related to a specific situation was gathered over time (leedy & ormrod, 2001), mainly by means of successive prospective observations (mcreynolds & kearns, 1983). participants participant selection criteria ο the participant had to be a patient in a nicu for the duration of the data collection period, ο the participant had to be extremely premature, i.e. < 30 weeks (southgate & pittard, 2001) as these infants are usually cared for in a nicu for a considerable amount of time (young, 1997) so that sufficient changes could be observed over time to allow a rich description of the case (leedy & ormrod, 2001). participant description the characteristics of the participant are described in table 1. table 1. characteristics of participant at birth. characteristic description 1. age of mother 33 years ; (ideal age 18-37 years, rossetti, 2001) j 2. mother's educational level tertiary education j i 3. position of participant in family t second child 4. mother's antenatal care sufficient: 3 visits before 24 weeks (ideal: 5 visits before 35 weeks, rossetti, 2001) 5. duration of pregnancy 29 weeks (extremely premature, southgate & pittard, 2001) 6. reason for preterm birth premature rupture of membranes 7. means of birth caesarian section 8. birth-weight 1040g (ideal: 3400-3800g) (very low birth weight, southgate & pittard, 2001 9. apgar score: 1 min and 5 min 4/10 and 6/10 (ideal 7/10 10/10) (moderate asphyxia, rossetti, 2001) 10. weight for gestational age small-for-gestational age (ideal 1175g for 29 weeks, rossetti, 2001) die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a single case study of the communication development of a high-risk neonate, from birth to discharge from an nicu 27 according to table 1 the participant, who is male, presented with various risk factors for communication disorders and sensorineural hearing loss at birth. these factors include very low birth weight (<1 500g), extremely preterm birth (<30 weeks gestation), small-for-gestational age and moderate birth asphyxia (joint committee on infant hearing, 1994; rossetti, 2001; southgate & pittard, 2001). protective factors for the participant's development were the mother's age, educational level, sufficient antenatal care and the fact that the participant was the parents' second child. the participant's parents were setswana speaking, lived in a rural area 50 km from the nicu and the mother was a teacher and the father a policeman. the risks appeared to be mainly biological conditions with the participant's environment providing various protective factors that would support further development. materials a comprehensive data-collection protocol, comprising of ten different developmental areas and related aspects, was compiled. firstly, the risk assessment (kritzinger, 1994) was used to compile a risk profile and secondly, the genetic screening checklist (louw & kritzinger, 1998) was used to describe any possible physical anomalies. thirdly, the developmental assessment (willemse, 2003) was used to describe neonatal state transitions over time as well as the increased ability of the participant to organize himself. the neonatal communication assessment instrument (kritzinger & louw, 2003) was used to describe the following four areas of development, i.e. the participant's earliest stages of prelinguistic communication development (precursors of language use, content and form) and precursors of cognition. components of the oral-motor/feeding rating scale (jelm, 1990) and the feeding evaluation form for at-risk infants (fefari, uys, 2000) were used to assess feeding behaviour from birth to discharge from the nicu. the ninth component of the data collection protocol was a description of the physical environment of the nicu. a component of the neonatal communication assessment guide (swanepoel, 2000) was used for this purpose. lastly,' the observation of communication interaction (klein & briggs, 1987) was used to describe the development of communication interaction between the parents and the participant over time'. procedures i pilot study j a pilot study was carried out to determine the effectiveness of the data-collection protocol in the nicu. permission was obtained from the hospital authority to conduct the research. the selection criteria stipulated for the main study were used to select a single participant for the pilot study. informed consent was obtained from the participant's parents. the complete datacollection protocol was administered when the participant was thirteen days old. the age of the participant ensured that a range of neonatal behaviours could already be observed. the results of the pilot study were used to adjust the protocol as follows, thereby contributing to its validity and reliability. (leedy & ormrod, 2001). ® a description of the routine activities that nurses performed on the participant while data collection took place, was added to the protocol. routine care may elicit certain physiological and behavioural responses in a neonate (young, 1997) and must therefore be considered when interpreting neonatal behaviour, ο the pilot study enabled the researcher to plan the duration of the data collection sessions and interview with the parents. « recurrent items in the data collection protocol were removed, ο the pilot study gave the researcher the opportunity to meet the nicu staff and become familiar with the routines and cultural patterns in the nicu (rossetti, 2001; ziev, 1999). reliability and validity of the study reliability the following measures were taken to increase the reliability of the data-collection protocol: ο the data-collection protocol was subdivided into ten different sections so that every section could be observed and recorded separately. reliability could be increased since the researcher could focus on a single component of the data collection protocol at a time. ο a pilot study was carried out in order to refine the data collection protocol. ο the participant for the main study was observed 14 times at regular intervals of three to four days apart and an hour was set aside for data collection, ο only the head nurse of the nicu and another senior nurse were aware of the research project. the staff were therefore not biased to adjust their routine care-giving activities and pay special attention to the participant. validity the following types of validity were considered in the study: face validity refers to the appearance of the instrument and the question is whether the appearance confirms those variables which the data collection protocol must measure (de vos, 1998). to improve the face validity the protocol was given to a nurse with extensive experience in developmental care in the nicu for comments and her recommendations were integrated into the protocol. internal validity refers to the researcher's ability to make accurate deductions concerning the data collected (leedy & ormrod, 2001). the researcher ensured that deductions were based only on the data that was collected (leedy & ormrod, 2001) and that it could be compared to other research findings. ethics the research proposal of the study was approved by the research ethics committee of the department of communication pathology, university of pretoria. ethical issues taken into consideration during this study can be categorized as follows (de vos, 1998; leedy & ormrod, 2001): non-maleficence: care-giving routines were not interfered with, the participant was not handled and hospital regulations concerning control of infection were observed. recommendations were made to test the participant's hearing and to obtain eci services for the family. informed consent for both the pilot and the research study were obtained from the participants' parents. the right to privacy: the participants' parents maintained their rights about any personal information to be included in the study. the south african journal of communication disorders, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 28 alethea mclnroy and alta kritzinger making results known: the researcher made the results known in an accurate and honest manner by means of the following: • naming shortcomings and further research possibilities. • results were made known in an accurate, objective and distinct way. ® all resources were acknowledged. • upon request the results were made known to the hospital and the participant's parents in the main study. confidentiality: no identifying information about the participants or parents was included in the final report. data collection and data analysis data was recorded twice per week over 14 sessions, from the participant's birth to discharge from the nicu, using the complete data-collection protocol for every session. data was obtained from the participant's medical file, an interview with the parents and direct observation of the participant and parents. the mother-infant interaction was observed eight times, while two opportunities arose to observe father-infant interaction. the observation of parent-infant interaction depended on the availability of the participant's parents to visit him at times that were also convenient for the researcher. the successive data sets of the single participant were organized into different categories based on themes, concepts and corresponding characteristics (de vos, 1998). objective measurements were obtained by calculating frequencies and averages of the participant's functioning on the different components of the data collection protocol, which were represented in tables, graphs and figures. the mother's pregnancy, leading to the participant's preterm birth and subsequent stay of 51 days in the nicu is presented in figure 1. according to figure 1, and also indicated earlier in table 1, a series of biological events prenatally, lead to the participant's highrisk status. it is well known that extremely preterm birth and very low birth weight in a neonate may lead to the conditions which also occurred in the participant. the participant experienced respiratory distress syndrome, sepsis and anaemia, and subsequent medical interventions and medications, some of which could be damaging to developing organs such as the cochlea (joint committee on infant hearing, 1994). it appears that a risk assessment represented as a chronology of events in figure 1 may serve as a useful technique for speech-language therapists working in nicu's to keep track of conditions that may have long-term developmental implications for their clients. instead of viewing the different risk factors as separate events in the mother and the infant, a chronology serves to provide a multidimensional perspective on the inter-relatedness of the different risk conditions. according to shprintzen (1997) the trajectory of early biological events over time, expressed as the cascading effect of gene expression and incidents early in life, may be used to gain insight into the causes of genetic syndromes and developmental disabilities in children. the concept of continuum of risk, described by rossetti (2001) expresses the same principle, but extends into the postnatal period and further in life. this concept may assist clinicians in eci to consider retrospective factors relating to the currently identifiable causes of, and contributing factors to the communication disorders or delays in their clients. the different events determining the participant's risk status in figure 1 were used as a framework to analyze and interpret data about the participant's physiological states, feeding behaviour, and developmental stages in the nicu. figure 1. the cascading effect of the biological risk factors of the participant resulting in the 51 day stay in the nicu. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a single case study of the communication development of a high-risk neonate, from birth to discharge from an nicu 29 the changing physiological states, feeding behaviour and developmental stages of the participant while nursed in the nicu environment a detailed analysis of the chronology of the different developmental aspects underlying the participant's communication development is provided in table 2. table 2. the physiological states, feeding behaviour and states of the participant in the nicu environment. age 3 days 6 days 10 days 13 days 17 days 20 days 24 days 28 days 31 days 34 days 38 days 41 days 45 days 48 days age 30 weeks 31 weeks 32 weeks 34 weeks 35 weeks 36 weeks p hy si ol og ic al s ta te s medication amikacin vancomycin vancomycin p hy si ol og ic al s ta te s pulse ecg (s/m) 145 148 153 144 147 157 151 160 163 165 166 164 155 161 p hy si ol og ic al s ta te s sc body temperature 37 36.8 36.9 36.4 36.7 36.8 36.9 36.9 37 36.9 37 37 36.8 37 p hy si ol og ic al s ta te s % oxygen saturation 95 96 96 95 95 96 97 97 94 96 94 96 96 > 9 0 p hy si ol og ic al s ta te s ventilation cpap* nose cannula nose cannula & room air room air p hy si ol og ic al s ta te s % oxygen <40 1/21 1/21 1/41 1/41 1/41 1/21 1/41 1/41 1/41 1/41 nose cannula & room air room air fe ed in g feeding (ml) 156 150 180 180 192 216 232 232 246 288 305 273 368 276 fe ed in g aspiration (mi) 0 0 0 0.5 5.54 0 1.3 0 8.3 2.6 0 0 0 0.5 fe ed in g feeding method day 2 to 38: nasogastric tube feeding day 1: intravenous feeding combination of nasogastric tube feeding and breast-feeding f ee di ng weight (g) 1040 1040 1120 1120 1250 1280 1290 1400 1400 1660 1720 1720 2000 2008 s ta te s an d th e ne on at e' s ab ili ty t o o rg an iz e it se lf development stage turning-in stage (rossetti, 2001) coming out stage reciprocit y stage s ta te s an d th e ne on at e' s ab ili ty t o o rg an iz e it se lf states observed deep sleep & active sleep deep sleep active sleep deep sleep & active sleep active sleep deep sleep & active sleep deep sleep active sleep & quiet alert active sleep, drowsy & quiet alert deep sleep, active sleep, drowsy & crying deep, sleep active sleep & drowsy s ta te s an d th e ne on at e' s ab ili ty t o o rg an iz e it se lf regulation of subsystems i motor disorganization motor organization s ta te s an d th e ne on at e' s ab ili ty t o o rg an iz e it se lf regulation of subsystems self-requlation s ta te s an d th e ne on at e' s ab ili ty t o o rg an iz e it se lf regulation of subsystems states organized s ta te s an d th e ne on at e' s ab ili ty t o o rg an iz e it se lf regulation of subsystems attention/interaction subsystem organized c ο ε c ο "5 c β 3 lighting light on infant | dim lights, except for care giving routines light in environment c ο ε c ο "5 c β 3 noise moderat e noise quiet moderate noise quiet moderate noise quiet moderate noise quiet high levels of noise moderate noise quiet moderate noise c ο ε c ο "5 c β 3 stay in nicu warm table incubator lncubator& crib crib ζ development water mattress sheep skin ζ appropriate positioning with towel or blanket rolls and silicon cushions; pacifier ζ care strategies ι towel on incubator to decrease noise; covering to decrease light note: *continuous positive airway pressure the south african journal of communication disorders, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 30 the results suggest that the participant, even though extremely premature, was kept physiologically stable from birth to discharge by the life support interventions that have increased the survival rates of high-risk infants in the nicu in recent years (als, 1997). as indicated in table 2 the participant's body temperature was stable and oxygen saturation levels were above the recommended 90% levels (zaichkin, 1996). the participant's physiological stability resulted in maturation that could be observed in the successful transition from nasogastric tube feeding to breast-feeding during the last 13 days of his stay in the nicu. fairly consistent weight gain in relation to the amount of fluid taken per day was also observed in the participant. upon close inspection of table 2 it can be seen that a pacifier was provided to facilitate nutritive sucking in the participant, but since no further feeding intervention was implemented by the nursing staff, an opportunity for feeding therapy guidelines was missed. since the participant was physiologically stable, guidelines for optimal positioning and oral stimulation and the early introduction of kangaroo mother care may have facilitated successful breast-feeding at an earlier stage in the participant (van rooyen, pullen, pattinson & delport, 2002). as depicted in table 2 the participant went through the neuro-developmental stages described by gorski, davidson and brazelton in 1979 (in rossetti, 2001). the turning-in stage usually occurs in infants less than 32 weeks gestation age, and the participant's state of awareness typically fluctuated between deep and active sleep and he was easily startled by environmental stimuli such as noises, which could be observed as motor disorganization (rossetti, 2001). characteristics of motor disorganization displayed by the participant included jerky movements, large movements away from the body, hyperextension, repetitive uncoordinated movements and poor sucking (gardner & lubchenco, 1998). the participant's physiological state was mechanically maintained and he displayed no self-regulatory behaviour during the turning-in period of data collection. no regulation of the other subsystems, such as the attention/interaction, motor and state regulatory subsystems occurred (gardner & lubchenco, 1998; willemse, 2003). the participant reached the coming-out stage at 38 weeks gestation age, a stage typically reached after 35 weeks alethea mclnroy and alta kritzinger (rossetti, 2001). although delayed, the coming-out stage was characterized by a greater variety of awareness states in the participant, thereby demonstrating his increased ability to regulate and organize himself in the extra-uterine environment. during the coming-out and reciprocity stages the participant experienced five of the six states of awareness, from deep and active sleep, to drowsy, quiet alert and crying (rossetti, 2001). no active alert state was observed during any of the data collection sessions. the nicu environment appeared to provide some support to the participant's development since lights were mostly dimmed, coverings were used to decrease light, and developmentally supportive equipment such as a water mattress, a sheep skin, blanket rolls, silicon cushions and a pacifier was provided (zaichkin, 1996). the participant's mother was encouraged to practice kangaroo mother care by the nursing staff when the participant was no longer receiving continuous positive airway pressure. it is not known to what extent the mother received training to sustain this excellent technique, now considered as best practice for high-risks neonates (power, 2002). the moderate to high noise levels occurring regularly during datacollection times (swanepoel, 2000) appear to be typical of descriptions of nicu environments in the literature (gardner & lubchenco, 1998) and are considered as a major source of physiological stress for preterm infants (rossetti, 2001). knowledge regarding nicu environmental stressors, the medical and developmentally appropriate interventions implemented in the nicu is essential to guide the speech-language therapist in designing comprehensive eci programmes (rossetti, 2001). eci programmes must include strategies to protect highrisk neonates from noise bombardment, facilitate their communication development, involve their parents from the beginning and compensate for the separation from their primary caregivers. the participant's communication development in the nicu the tracking of the participant's communication development, described in terms of precursors of language content, form, use and cognition, was carried out as serial assessments, using the neonatal communication assessment instrument (kritzinger & louw, 2003). the results are presented in figure 2. ο q) o) <b c a> ο a> a. q) o> <b a> > < 90 80 70 60 50 40 30 20 10 0 4j l 10 13 17 20 24 28 31 34 38 41 45 48 age of subject in days • precursors to language content • precursors to language use ^precursors to language form • precursors to cognition figure 2. the communication development of the participant during his stay in the nicu. die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a single case study of the communication development of a high-risk neonate, from birth to discharge from an nicu 31 according to figure 2 the participant's communication development gradually unfolded as the different components of language skills emerged. precursors of language content appeared first on day 12, when the participant started to respond reflexively to sound during the turning-in neurodevelopmental stage (see table 2). during the participant's turning-in stage on day 24, the second component of language to emerge were the precursors of language form, characterized by the emergence of differentiated cries, crying in response to another infant's cry, and discomfort sounds. after day 38 the participant progressed to the coming-out stage, displaying increased levels of motor organization, self-regulation and feeding skills (see table 2), concurrently with the emergence of precursors of language use and cognition. at this stage the participant made fleeting eye contact with caregivers, accepted cuddling, displayed adapting behaviours after repetitive stimuli, and demonstrated selfcomforting responses. upon discharge from the nicu after 51 days the participant did not yet exhibit all the communication ι interaction skills typical of a full-term newborn infant (kritzinger, 1994), thereby displaying a risk for a communication disorder or delay. the successive emergence of the different components of language skills in the participant provided new insights into the communication development of a preterm neonate and should be further investigated in a representative sample so that reliable inferences can be made. the emergence of hearing responses only on day 12, followed by differentiated vocal expressions several days later, and interactive communication skills at a later stage in the participant, appear to correspond with certain fetal developmental patterns as described by lecanuet, granier-derferre and busnel (1995) and gottlieb (1971, in asha, 2004). hearing responses and prenatal auditory learning are present in fetuses during the last trimester of pregnancy (lecanuet, et al., 1995), the first vocal expression occurs only at birth with the birth cry, and interactive communication behaviours are characteristic of newborn communication capabilities. gottlieb (1971, in asha, 2004) describes the successive development of sensory systems as a process where the tactile system develops first during the fetal period, followed by the vestibular, auditory and visual systems. the implication is that the auditory system functions before the visual system, which indicates the same sequence of sensory functioning and language development observed in the participant of the present study. j the results of the successive development of communication skills in the participant provide guidelines for the gradual introduction of sensory experiences in the individualized eci programme for the participant. avoiding noise exposure i and replacing inappropriate auditory stimulation with gradual exposure to human voices, preferably the voices of the participant's primary caregivers, appear to be developmentally appropriate. the interactive component of language development, i. e. language use, should only be introduced when the infant's physiological subsystems display readiness for reciprocity. self-quieting behaviours and the ability to respond to caregivers are indicators that the infant is ready for reciprocal interaction (rossetti, 2001). according to rossetti (2001) sensory over-stimulation may prolong the duration of an infant's time in the turning-in stage. eci strategies and techniques to promote high-risk neonates' progress through the different stages and the key role that their parents can play in early communication development, should therefore be investigated. progress of parent-infant interaction during the participant's stay in the nicu the observation of communication interaction (klein & briggs, 1987) was used to measure the quality of the interactions between the parents and the participant. since the parents lived 50 km from the hospital, they could not visit the participant regularly. the results are depicted in figure 3. figure 3. parent-infant interaction during the participant's stay in the nicu. note: parent-infant interaction values: 1= never; 2= sometimes; 3= often; 4= optimally as indicated in figure 3 the participant's parents both displayed limited interaction with their infant during the first observation sessions, despite the nurses' encouragement to talk to the infant and to provide appropriate tactile stimulation. both parents read the information file provided by the nicu staff to encourage parental participation in the care-giving routines of the infants, and read the eci plans provided weekly by the researcher. when the participant was 28 days old the frequency of the mother's interaction with the participant during data collection could be described as "often" (see figure 3, key to parent-infant interaction measurement), even though he was still in the turning-in stage and not responding actively to her interest shown in him. no specific reason for the mother's increased interaction on that day with the participant can be offered, except that both the nicu staff and the researcher continuously encouraged her involvement in the participant. according to the results there was an increase in parent-infant interaction over time, but could only be described as "sometimes" and did not change when the participant emerged from his turning-in stage. although the neonate's level of arousal increased according to the corresponding developmental stage, the type and amount of input given to the infant by the parents was not increased. consequently, appropriate interaction between the participant and his parents was not facilitated. the quality of the parent-infant interaction sessions must be viewed against the extremely stressful experiences of parents while their infants are in the nicu (guldenpfennig, 2000). the normal attachment process that already starts during pregnancy and must be continued after birth so that interaction can develop, is interrupted by the participant's preterm birth and need for immediate medical care (klaus & kennell, 2001). apart from the delayed attachment process, parents must adapt to the strange environment of the nicu, lack of privacy and often experience feelings of anxiety, fear, concern, guilt, aggression, denial, helplessness and depression (guldenpfennig, 2000). these feelings contribute to the parents' uncertainty about their role in the nicu. feelings of helplessness may ι» a 1 4 η > c • 1 3 — ο cd 1 2 τη η η η ρ ι r y c co 4 " τ ί — γ τ ί — — — — ~~ — ~ c 0 "h—' 1 —1 1 i 1 1 ! — 1 1 i — j-lj— 2 3 6 28 34 38 41 45 48 age of participant in days • mother-neonate interaction • father-neonate interaction the south african journal of communication disorders, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) 32 alethea mclnroy and alta kritzinger disempower parents which may limit their involvement with their infant (guldenpfennig, 2000). it is clear that insight into parental emotions and experiences are essential so that valid interpretations of the participant's parents' lack of interaction with him can be made. parental perceptions of the role of professionals and their respect for those professionals are culturally based and may influence their involvement in eci (louw & avenant, 2002). it could also be that the parents were not treated as autonomous members of the decision making team in the nicu, which could influence the power balance between professionals and parents. the participant's parents were experienced caregivers, since he was their second child, but they required a sensitive family-centered approach to support them through the process of having a medically fragile infant in the nicu and they needed training to appropriately stimulate the development of the infant. the changing needs of the high-risk neonate and parents form birth to discharge form the nicu the results of the study were integrated in an overview of the changing needs and opportunities for developmentally appropriate care strategies that will also enhance the early communication development of the participant. the participant advanced through the different neurodevelopmental stages of turning-in, coming out and reciprocity as described in the literature (rossetti, 2001). each of these stages requires distinct changes that should be reflected in the individualized eci programme for the participant and his parents. the parents of the participant displayed the following needs: β emotional support, especially when the participant was in the turning-in stage of development. the parents required counseling from professionals in the nicu, information on their infant's conditions and capabilities, and training to improve their interaction skills with the participant and to gain confidence. β encouragement to visit the participant more often, since they lived far from the hospital, β development of skills to interact with the participant according to his developmental stages. since the parents displayed limited interaction with their infant despite continued guidance, demonstration and direct modeling of appropriate interaction with the participant by the nurses and the speechlanguage therapist is recommended. factors hampering their full participation should be considered. . use of kangaroo mother care and breast-feeding times for communication interaction between mother and infant. the mother should gain insight into the fine balance between over-stimulation and appropriate stimulation techniques, ο discharge planning in order to facilitate the take over of complete care of the participant in a developmentally appropriate way. eci service delivery in the nicu is guided by the development of the high-risk neonate, which in turn impacts on the parents, staff and regulation of the environment. based on the results of the study an example of a developmentally appropriate communication intervention programme in the nicu, that may be used as a treatment option, is provided in appendix a. the different developmental areas and stages to be considered in the compilation of such a programme are summarized in figure 4. figure 4. the interrelationship between the developmental areas and stages of the participant which may guide the nicu intervention programme die suid-afrikaanse tydskrif vir kommunikasieafwykings, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) case study of the communication development of a high-risk neonate, from birth to discharge from an nicu 3 3 the eci programme presented in appendix a is based on the p r i n c i p l e s 0 f individualized care and a family-centered approach (als, 1997; rossetti, 2001), with the aim to ensure the best possible outcomes for the infant and family. the guidelines include a wide variety of topics to provide parents with information to become more familiar with the highly technical environment of the nicu, their infant's medical conditions and behaviour patterns. the information is mainly provided as handouts, but may be discussed with the parents as well. finally, the eci programme is holistic and interventions are directed at the infant, parents and the staff of the nicu. as indicated by gottlieb (1971, in asha, 2004) and lecanuet, et al. (1995), and emphasized by the results of the study, direct intervention with the high-risk neonate involves the successive introduction of sensory stimuli as the infant moves through the turning-in, coming out and reciprocity stages of development. conclusion the description of the early successive communication development of a single high-risk neonate provided rich and new information that should be further investigated. due to the limitations of a single case study the results cannot be generalized, but may serve as an example of a case that may be encountered in clinical practice. the results describing the effect of the preterm birth and nicu experience on the participant's parents should alert clinicians to the sensitive approach and skills required when working with parents, without whose full participation eci efforts cannot be effective (rossetti, 2001). the developmentally appropriate communication intervention programme may be adapted to suit the unique needs of high-risk neonates and their families in private and public health settings in south africa. the results also serve to alert speechlanguage therapists and audiologists of the set of events that contributed to the communication development of an infant or child and family who spent time in an nicu and who now requires their services. the urgency for knowledge about highrisk neonates and their families is now more important than ever in south africa since poverty and the increased incidence of low birth weight and preterm' infants among pregnant women witli hiv/aids (van rooyen, et al., 2002) requires the attention of all involved in early intervention efforts. references als, h. (1997). earliest intervention for preterm infants in the newborn intensive care unit. in m. j. guralnick, (ed.), the effectiveness of early intervention (2n d ed., pp. 4776). baltimore: paul h. brooks publishing co. als, h. (1999). reading the premature infant. in e. goldson (ed.), developmental interventions in the neonatal intensive care nursery (pp. 18-85). new york: oxford university press. asha, (2004). roles of speech-language pathologists in the neonatal intensive care unit: technical report. retrieved september 1, 2004, from http://www.asha.org/members/ deskrefjournals/deskref/default brazelton, t.b. (1984). neonatal behavioural assessment scale (2n d ed.). london: spastics international medical publications. cioni, g., ferrari, f., einspieler, c., paolicelli, p.b., barbara, m.t., & prechtl, h.f.r. (1997). comparison between observation of spontaneous movements and neurologic examination in preterm infants. the journal of pediatrics, 130(5), 704-711. de vos, a.s. (1998). research at grass roots. a primer for the caring professions (pp. 76-94). pretoria: j.l. van schaik academic. gardner, s.l., & lubchenco, l.o. (1998). the neonate and the environment: impact on development. in g.b. merenstein, & s.l. gardner (eds.), handbook of neonatal intensive care. (4th ed., pp. 197-242). st louis: mosby, inc. giildenpfennig, d. (2000). early intervention for parents of low birth weight premature babies: development of a programme from an educational psychological perspective. unpublished doctoral dissertation, university of pretoria, gauteng, south africa. joint committee on infant hearing. (1994). 1994 position statement. audiology today, 6(6), 6-9. jelm, j.m. (1990). oral-motor/ feeding rating scale. tucson: therapy skill builders. klaus, m.h., & kennell, j.h. (2001). care of parents. in m.h. klaus, & a.a. fanaroff (eds.), care of the high-risk neonate (5th ed., pp. 195-222). philadelphia: w. b. saunders company. klein, m.d., & briggs, m.h. (1987). observation of communicative interaction. journal of childhood communication disorders, 10, 95-106. kritzinger, a. m. (1994). vroee kommunikasieontwikkeling van biologiese risikobabas. unpublished masters thesis, university of pretoria, gauteng, south africa. kritzinger, a. (2003). risk assessment. department of communication pathology, university of pretoria, gauteng, south africa. kritzinger, α., & louw, b. (2003). clinical training of undergraduate communication pathology students in neonatal assessment and neonate-caregiver interaction in south africa. the south african journal of communication disorders, 5, 5-14. lecanuet, j., granier-deferre, c., & busnel, m. (1995). human fetal auditory perception. in j. lecanuet, w.p. fifer, n.a. krasnegor, & w.p. smotherman (eds.), fetal development. a psychobiological perspective (pp. 239-262). new jersey: lawrence erlbaum associates, inc. leedy, p.d., & ormrod, j.e. (2001). practical research. planning and design. new jersey: prentice-hall, inc. louw, b., & avenant, c. (2002). culture as context for intervention: developing a culturally congruent early intervention program. international pediatrics, 17(3), 145150. louw, b., & kritzinger, a. (1998). genetically based communication disorders: technological advances relevant to the speech-language therapist and audiologist [monograph]. clinica: applications in chmcal pracuce of communication pathology, 3, u-26. mcreynolds, l.v., & kearns, k.p. (1983* « " perimental designs in communicatee disorders. baltimore: university park press. the south african journal of communication disorders, vo 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) http://www.asha.org/members/ 34 alethea mclnroy and alta kritzinger pattinson, r.c. (2003). perinatal care surveys 2000-2002: an overview of the challenges. in saving babies 2002. third perinatal care survey of south africa (pp. 1-4). pretoria: the mrc unit for maternal and infant health care strategies. power, d. (2002, december). opening address. fourth international workshop on kangaroo mother care, cape town, south africa. rossetti, l.m. (2001). communication intervention. birth to three. canada: singular thomson learning. samerhoff, a.j., & fiese, b.h. (2000). transactional regulation: the developmental ecology of early intervention. in j.p. shonkoff, & s.j. meisels, (eds.), handbook of early childhood intervention (2n d ed., pp. 135-159). cambridge: cambridge university press. shprintzen, r.j. (1997). genetics, syndromes and communication disorders. san diego: singular publishing group, inc. southgate, w.m., & pittard, w.b. (2001). classification and physical examination of the newborn infant. in klaus, m.h., & fanaroff, a.a. (eds.), care of the high-risk neonate. (5th ed., pp.100-129). philadelphia: w. b. saunders company. swanepoel, d. (2000). compilation and formative evaluation of a preliminary transdisciplinary neonatal communication assessment tool. unpublished bachelors thesis, university of pretoria, gauteng, south africa. uys, k.j. (2000). oral feeding skills of premature infants. unpublished masters thesis, university of pretoria, gauteng, south africa. van rooyen, e., pullen, a.e., pattinson, r.c., & delport, s. d. (2002, april). the value of the kangaroo mother care unit at kalafong hospital. geneeskunde. the medicine journal, 6-10. willemse, s. (2003). developmental care plan. medforum hospital, pretoria. young, j. (1997). developmental care of the premature baby. london: bailliere tindall. zaichkin, j. (1996). newborn intensive care. what every parent needs to know. santa rosa: nicu ink book publishers. ziev, m.s.r. (1999, may/june). earliest intervention: speechlanguage pathology services in the neonatal intensive care unit. asha, pp.32-36. appendix a developmentally appropriate communication intervention programme in the nicu compiled by alethea mclnroy and alta kritzinger, 2003 principles of the programme (willemse, 2003) ο individualized care of the neonate in order to improve the developmental outcomes, to support growth and development and to facilitate the stabilization of physiological functioning and behaviour ο family-centered care that views the neonate within the family context and that involves the parents in the care of the neonate from birth to discharge from the nicu aims of the programme (willemse, 2003) ο to protect and promote the developmental progress of each neonate ο to avoid harmful environmental stimulation ο to ensure the best possible outcomes for the neonate and the family these aims can be accomplished by supporting the neonate, the family and the nicu staff. guidelines for implementing the communication intervention programme ι i guidelines were explained in a file provided to the parents. the participant's parents had access to the following information in the file that was kept at the participant's incubator: ! i ο individualized care plan: these care plans were compiled weekly and provided information on (rossetti, 2001; willemse, 2003): how the participant demonstrates that he is content which activities and handling patterns increase the participant's stress levels and should be avoided which observable behaviours demonstrate signs of stress in the participant which techniques may be used to comfort the participant and facilitate his growth and development suggested developmentally appropriate activities to include in the participant's schedule ο a pamphlet on the hearing abilities of high-risk neonates, risks for hearing impairment in the nicu and information on hearing testing after'discharge ο guidelines on handling the high-risk neonate for the primary caregivers and family ο phases of adaptation of the family of the high-risk neonate ο information brochure: who is the high-risk infant? ο information about the physical nicu environment ο the nature of the nicu as a social environment: handout about kangaroo mother care and a handout about the stimulation of early speech, language and listening skills (handouts may be obtained from the second author) ο guidelines on "swaddling bathing" ο discharge criteria ο guidelines for caring of the high-risk neonate at home r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2) a single case study of the communication development of a high-risk neonate, from birth to discharge from an nicu 35 guidelines for eci in the nicu based on the results of the study and rossetti (2001) and willemse (2003) the following guidelines for eci in the nicu are proposed: 1. intervention directed at the neonate appropriate positioning and handling calming techniques regulation of developmental subsystems socio-communicative interaction appropriate and graded tactile, auditory and visual stimulation: provide auditory stimulation only when the infant is in the turning-in and coming out stages. the visual component of communication interaction may be added when the infant enters the reciprocity stage of development. rationale for intervention activities directed at the neonate to reduce stress experienced by the neonate activities can assist in conserving the neonate's energy for growth to respond appropriately to the neonate's behaviour to understand the neonate's current level of organization to modify care according to the neonate's behaviour and ability to organize himself to adapt to the neonate's developing individual needs 2. intervention directed at the parents (rossetti, 2001; guldenpfennig, 2000) strategies for intervention determine the parents' specific circumstances establish a relationship with the parents, accept their diversity and support them determine the parents' knowledge and experience about preterm birth train parents to develop skills to respond appropriately to the neonate, keep a journal, reflect on their own feelings and use available resources guide parents during the stages of attachment focus on parental and,family strengths χ provide information about developmental expectations and the need for serial developmental assessments after discharge / _ i rationale for intervention activities directed at the parents to reduce the stressful impact of the nicu on the neonate and family to facilitate adaptive parenting and overcome difficulties with attachment to the neonate to respect personal, social and cultural influences on the family to ensure independent home care after discharge from the nicu 3. intervention directed at the nicu staff (rossetti, 2001) to be aware of the environment in terms of noise, lighting, handling and positioning of the neonates to identify stress signs in the neonates and respond appropriately to identify neonatal developmental stages and promote self regulating behaviour in infants to implement developmental care effectively to apply new strategies and trends in developmental care, such as kangaroo mother care to integrate services provided by different disciplines to promote the social environment in the nicu the south african journal of communication disorders, vol. 52, 2005 r ep ro du ce d by s ab in et g at ew ay u nd er li ce nc e gr an te d by th e p ub lis he r (d at ed 2 01 2)